From Allegheny University of the Health Sciences, MCP–Hahnemann
School of Medicine, Philadelphia, Pa.
A69 -year-old
man with severe angina had severe 3-vessel disease by coronary
angiography. At the time of coronary
revascularization, he had left internal mammary
artery implantation to the left anterior descending artery, a vein
graft to the diagonal branch, and a vein graft to the marginal branch
of the left circumflex artery. Transmyocardial laser
revascularization was performed in the territory of
the right coronary artery (because of poor distal runoff) with
a xenon chloride excimer laser (under an investigational device
exemption sponsored by United States Surgical Corp). The postoperative
course was uneventful. The patient experienced improvement of
symptoms.
The patient had an exercise treadmill test by the Bruce protocol
before and
Before surgery, exercise single photon emission CT (SPECT)
99mTc-sestamibi myocardial images revealed
extensive reversible perfusion defects consistent with 3-vessel
ischemia. After surgery, the exercise SPECT perfusion images
were almost normal (Figure
Footnotes
Reprint requests to Ami E. Iskandrian, MD, William Penn Snyder III Professor of Medicine, Director, Cardiovascular Research Center, Allegheny University of the Health Sciences, MCP–Hahnemann School of Medicine, Division of Cardiology, Department of Medicine, and Division of Cardiothoracic Surgery, 230 N Broad St, Philadelphia, PA 19102.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1–267, Houston, TX 77030.
© 1998 American Heart Association, Inc.
Images in Cardiovascular Medicine
Improvement of Myocardial Perfusion After Transmyocardial Laser Revascularization and Coronary Artery Bypass Graft Surgery
3 months after surgery. Before surgery, he developed
angina during exercise with ST-segment depression at 75% of maximum
predicted heart rate. After surgery, he exercised to 87% of maximum
predicted heart rate with no angina or ST-segment depression. 
). The improvement in the perfusion pattern
during exercise was equally remarkable in the vascular area treated
with laser and the vascular territories treated with bypass surgery.
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Figure 1. Exercise 99mTc-sestamibi images obtained before
(upper row) and after (lower row) surgery. Top left panel, Short-axis
slices; middle left panel, vertical long-axis slices; top right panel,
horizontal long-axis slices. Polar maps are shown in right middle panel
(before surgery, left; after surgery, right). Gated three-dimensional
perfusion images at end diastole (left) and end systole
(right) before surgery are shown in the left lower panel and after
surgery in the lower right panel. Preoperative images reveal extensive
perfusion defects involving the 3 vascular territories. Rest images
(not shown) reveal almost complete redistribution. Postoperative images
reveal almost complete normalization of perfusion pattern. Of note,
improvement in perfusion pattern in territory of right coronary
artery (area of transmyocardial laser
revascularization) is comparable to improvement in
territories of left anterior descending and left circumflex
coronary arteries (areas revascularized with bypass
grafting).
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