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Not Everyone Agrees Laser Holes Ease Chest Pain

Heart: Some doctors sing the procedure's praises. Others call it an expensive surgical placebo.


CHICAGO — The surgeon took aim at his patient's naked beating heart with a bent plastic nozzle. The thing looked like something borrowed from a water faucet.

But it was a laser gun, the hot end of a 2,000-pound machine, and the surgeon was about to burn a hole clear through the woman's left ventricle, the main pumping chamber of her heart.

"Arm laser!" he ordered.

A red dot of light showed exactly where the laser beam would hit. He held the gun against the fat-streaked heart, pulsing like a nervous animal inside the open chest.

The surgeon stepped on a foot pedal. Thud. Gray-white smoke puffed from an exquisitely round hole, followed by a little geyser of blood.

"Hit?" the surgeon asked. An anesthesiologist watched the result on an ultrasound screen. A dark cloud blossomed inside the heart. Vaporized blood. "Yes," came the reply.

Until that moment, the operation had been an ordinary coronary bypass, much like 600,000 others done in the United States each year. Dr. Keith Horvath, the surgeon, had spent three hours stitching wormlike strands of vein and artery onto the woman's heart, detouring blood around her clogged blood vessels.

The laser, however, was something new. Horvath moved the gun a fraction of an inch and fired again. Ten minutes and 17 holes later, he was done.

What the surgeon accomplished with this final flourish--so elegant, yet crude--is something no one can say beyond a doubt.

Horvath hoped that he improved his patients' chances of escaping bad chest pain, that he increased the flow of blood to parts of the heart muscle that would not be helped by the bypass operation.

But did he? Or had he just added several thousand dollars to the patient's hospital bill for no good reason?

The questions are the core of a debate over an unusual piece of medical technology. Those who believe in the laser say it can profoundly relieve otherwise unmanageable angina. But even if people feel better--and they clearly often do--some wonder if the laser is simply an expensive placebo, a surgical version of the sugar pill.

Two competing versions of the laser have been on the market for more than two years, and many thought it would be used more widely by now. But the technology has been held back in part by a public relations problem: Drilling holes through the heart is an odd thing to do, and no one can explain with certainty why it works. If, in fact, it does.

"The technology is not intuitive," concedes Mark Tauscher, head of PLC Medical Systems, one of the two companies selling the lasers. "When you tell people that you burn a hole in people's hearts and make them feel better, they don't say, 'Aha! I understand.' "

The idea of drilling holes through the heart has been around since the 1980s. Early advocates supposed the holes would act like new blood vessels, bringing blood directly from the pumping chambers into the oxygen-starved muscle that surrounds them.

But this theory has been largely refuted. It turns out the holes quickly fill up with clots and then heal. Within a few months, they disappear.

Nevertheless, drilling holes in the heart does something. Between half and three-quarters of patients studied have dramatic relief from chest pain.

"In 20 years of medicine, I have never seen anything that gives as much symptomatic benefit for patients," says Dr. William O'Neill of William Beaumont Hospital in Royal Oak, Mich.

Testimonies of Recoveries

O'Neill is a cardiologist, a nonsurgical heart specialist, and he has tested a still-experimental form of heart laser that is delivered into the heart through a tube called a catheter. Instead of burning holes from the outside in, as the surgeons do, this technique burns notches into the walls of the heart from the inside.

Practically every doctor who has tried the laser--whether the surgical or catheter variety--tells stories of almost unbelievable recoveries. Among O'Neill's patients is Frank Warren, 41, an auto worker from Sterling Heights, Mich.

Warren suffered with heart problems for almost 10 years. Sometimes it was a burning sensation, other times a pain that came on even while he was resting. He had no energy. The slightest exercise was exhausting. Over the years, he underwent eight angioplasties, but nothing helped.

"After the laser, I felt immediate results," says Warren. "I felt a warmth in my face. My color seemed to change. I made a decision right there on the table that if this thing worked, I would begin to try to run."

He started out in rehab. He walked and eventually took up running, first a half mile and then longer. Almost a year to the day after his laser, Warren ran a marathon and finished in a respectable 4 hours, 29 minutes.

Most laser patients are too old to run marathons, but substantial and even complete relief of angina is common. Often they are able to give up nitroglycerin, the medicine they take, often in large quantities, for chest pain.

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