Excimer Laser Atherectomy in Acute Myocardial Infarction-Evidence-based Treatment Approach

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US Cardiology 2004;2004:1(1):1-5

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The last three years have seen the application of percutaneous excimer laser atherectomy in patients sustaining acute myocardial infarction (AMI) gaining momentum. Current efforts in the US are concentrated toward identification of the best technologies for efficacious restoration of flow in the infarct-related vessel1 and toward shortening the time lag between the presentation of AMI patients to the emergency department and the subsequent percutaneous coronary intervention at the cardiac catheterization suite for revascularization of the infarct-related vessels.2With this in mind, the interest of interventionalists and medical centers alike in excimer laser atherectomy as a reliable and efficient revascularization modality is justified.3,4

In August 2003, the US Food and Drug Administration (FDA) removed a decade-old set of contraindications for excimer laser use, that were originally imposed by the laser industry as a cautionary measure. Thus, the following clinical conditions are no longer considered contraindications and are currently available for the interventionalist discretions:AMI, acute thrombosis, and depressed left ventricular ejection fraction. The FDA decision and the noted growing recognition of the role of excimer laser atherectomy in AMI are based on discoveries from basic research projects that illuminate the special interaction of excimer laser with thrombus and on clinical evidence from numerous multicenter and single center studies that analyzed excimer laser utilization in coronary and peripheral revascularization.

Thrombolytic pharmacologic therapy and/or balloon angioplasty with adjunct stenting continue to be considered standard of care in the management of patients with Q-wave and non-Q-wave AMI alike. The pharmacologic approach is limited by restoration of adequate antegrade flow in only 50% to 60% of patients and by 20% to 30% post-treatment reocclusion of the infarct-related artery. Although balloon angioplasty has commonly and successfully been used in AMI, it carries significant limitations, especially in dealing with vessels and lesions that contain intracoronary thrombus. Since thrombus is highly prevalent in AMI, its presence within the infarct-related vessel is associated with a higher risk for complications during and after standard balloon angioplasty. Notably, thrombus disruption by balloon inflations or by direct stenting can increase local thrombosis, enhances platelet aggregation, and results in distal embolization. Hence, the application of 308nm ultraviolet pulsed-wave excimer laser energy is intriguing.

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