Transmyocardial Revascularization Using CO2 Lasers in Ischemic Heart Disease

  • Andrew C. W. Baldwin
  • O. H. FrazierEmail author


While the modern armamentarium for the treatment of ischemic heart disease includes ever-improving pharmaceutical therapies, percutaneous interventions, and coronary artery bypass grafting, standard modalities are not always sufficient in the treatment of advanced disease. Indeed, the number of patients with symptomatic chronic disease continues to rise in the United States – likely due to advancements in medical therapy. As a result of this challenge, researchers have long sought to develop alternative strategies to more traditional revascularization techniques. In the 1990s transmyocardial laser revascularization (TMLR) emerged as an effective treatment modality for patients with severe coronary disease not amenable to conventional therapy. Although the specific mechanisms leading to reperfusion and symptom relief remain controversial, studies have shown laser therapy to significantly improve angina in select patient groups, rendering it an important therapeutic option in the treatment of severe coronary artery disease.


Transmyocardial laser revascularization Coronary artery disease CO2 lasers Angiogenesis 


  1. 1.
    Mannheimer C, Camici P, Chester MR, Collins A, DeJongste M, Eliasson T, Follath F, Hellemans I, Herlitz J, Luscher T, Pasic M, Thelle D. The problem of chronic refractory angina; report from the ESC Joint Study Group on the Treatment of Refractory Angina. Eur Heart J. 2002;23:355–70.CrossRefPubMedGoogle Scholar
  2. 2.
    Osswald BR, Blackstone EH, Tochtermann U, Schweiger P, Thomas G, Vahl CF, Hagl S. Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients? Eur J Cardiothorac Surg. 2001;20:120–5, discussion 125–126.CrossRefPubMedGoogle Scholar
  3. 3.
    Weintraub WS, Jones EL, Craver JM, Guyton RA. Frequency of repeat coronary bypass or coronary angioplasty after coronary artery bypass surgery using saphenous venous grafts. Am J Cardiol. 1994;73:103–12.CrossRefPubMedGoogle Scholar
  4. 4.
    Thebesius AC. De circulo sanguinis in corde. Leiden: Apud Abrahamum Elzevier; 1708.Google Scholar
  5. 5.
    Wearn JT, Mettier SR, Klumpp TG, Zschiesche LJ. The nature of the vascular communications between the coronary arteries and the chambers of the heart. Am Heart J. 1933;9:147–64.CrossRefGoogle Scholar
  6. 6.
    Sen PK, Udwadia TE, Kinare SG, Parulkar GB. Transmyocardial acupuncture: a new approach to myocardial revascularization. J Thorac Cardiovasc Surg. 1965;50:181–9.PubMedGoogle Scholar
  7. 7.
    Beck CS, Leighninger DS. Scientific basis for the surgical treatment of coronary artery disease. JAMA. 1955;159:1264–71.CrossRefGoogle Scholar
  8. 8.
    Goldman A, Greenstone SM, Preuss FS, Strauss SH, Chang ES. Experimental methods for producing a collateral circulation to the heart directly from the left ventricular. J Thorac Surg. 1956;31:364–74.PubMedGoogle Scholar
  9. 9.
    Massimo C, Boffi L. Myocardial revascularization by a new method of carrying blood directly from the left ventricular cavity into the coronary circulation. J Thorac Surg. 1957;34:257–64.PubMedGoogle Scholar
  10. 10.
    Mittal CM. Profulla Kumar Sen: his contributions to cardiovascular surgery. Tex Heart Inst J. 2002;29:17–25.PubMedCentralPubMedGoogle Scholar
  11. 11.
    Walter P, Hundeshagen H, Borst HG. Treatment of acute myocardial infarction by transmural blood supply from the ventricular cavity. Eur Surg Res. 1971;3:130–8.CrossRefPubMedGoogle Scholar
  12. 12.
    Mirhoseini M, Muckerheide M, Cayton MM. Transventricular revascularization by laser. Lasers Surg Med. 1982;2:187–98.CrossRefPubMedGoogle Scholar
  13. 13.
    Okada M, Ikuta H, Shimizu K, Horii H, Nakamura K. Alternatives method of myocardial revascularization by laser: experimental and clinical study. Kobe J Med Sci. 1986;32:151–61.PubMedGoogle Scholar
  14. 14.
    Mirhoseini M, Shelgikar S, Cayton MM. New concepts in revascularization of the myocardium. Ann Thorac Surg. 1988;45:415–20.CrossRefPubMedGoogle Scholar
  15. 15.
    Mirhoseini M, Cayton MM, Shelgikar S. Transmyocardial laser revascularization. J Am Coll Cardiol. 1994;1A:484.Google Scholar
  16. 16.
    Frazier OH, Cooley DA, Kadipasaoglu KA, Pehlivanoglu S, Lindenmeir M, Barasch E, Conger JL, Wilansky S, Moore WH. Myocardial revascularization with laser. Preliminary findings. Circulation. 1995;92:II58–65.CrossRefPubMedGoogle Scholar
  17. 17.
    Josefson D. FDA approves heart laser treatment. BMJ. 1998;316:1409.PubMedGoogle Scholar
  18. 18.
    Dietz U, Darius H, Eick O, Buerke M, Ed Odeh R. Transmyocardial revascularization using temperature controlled HF energy creates reproducible intramyocardial channels. Circulation. 1998;98:3770.Google Scholar
  19. 19.
    Khairy P, Dubuc M, Gallo R. Cryoapplication induces neovascularization: a novel approach to percutaneous myocardial revascularization. J Am Coll Cardiol. 2000;35:5A–6.Google Scholar
  20. 20.
    Smith NB, Hynynen K. The feasibility of using focused ultrasound for transmyocardial revascularization. Ultrasound Med Biol. 1998;24:1045–54.CrossRefPubMedGoogle Scholar
  21. 21.
    Whittaker P, Rakusan K, Kloner RA. Transmural channels can protect ischemic tissue. Assessment of long-term myocardial response to laser- and needle-made channels. Circulation. 1996;93:143–52.CrossRefPubMedGoogle Scholar
  22. 22.
    Yamamoto N, Gu A, DeRosa CM, Shimizu J, Zwas DR, Smith CR, Burkhoff D. Radio frequency transmyocardial revascularization enhances angiogenesis and causes myocardial denervation in canine model. Lasers Surg Med. 2000;27:18–28.CrossRefPubMedGoogle Scholar
  23. 23.
    Genyk IA, Frenz M, Ott B, Walpoth BH, Schaffner T, Carrel TP. Acute and chronic effects of transmyocardial laser revascularization in the nonischemic pig myocardium by using three laser systems. Lasers Surg Med. 2000;27:438–50.CrossRefPubMedGoogle Scholar
  24. 24.
    Hughes GC, Kypson AP, Annex BH, Yin B, St Louis JD, Biswas SS, Coleman RE, DeGrado TR, Donovan CL, Landolfo KP, Lowe JE. Induction of angiogenesis after TMR: a comparison of holmium: YAG, CO2, and excimer lasers. Ann Thorac Surg. 2000;70:504–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Jeevanandam V, Auteri JS, Oz MC, Watkins J, Rose EA, Smith CR. Myocardial revascularization by laser-induced channels. Surg Forum. 1994;41:225–7.Google Scholar
  26. 26.
    Kadipasaoglu KA, Frazier OH. Transmyocardial laser revascularization: effect of laser parameters on tissue ablation and cardiac perfusion. Semin Thorac Cardiovasc Surg. 1999;11:4–11.CrossRefPubMedGoogle Scholar
  27. 27.
    Kadipasaoglu KA, Sartori M, Masai T, Cihan HB, Clubb Jr FJ, Conger JL, Frazier OH. Intraoperative arrhythmias and tissue damage during transmyocardial laser revascularization. Ann Thorac Surg. 1999;67:423–31.CrossRefPubMedGoogle Scholar
  28. 28.
    Cooley DA, Frazier OH, Kadipasaoglu KA, Pehlivanoglu S, Shannon RL, Angelini P. Transmyocardial laser revascularization. Anatomic evidence of long-term channel patency. Tex Heart Inst J. 1994;21:220–4.PubMedCentralPubMedGoogle Scholar
  29. 29.
    Burkhoff D, Fisher PE, Apfelbaum M, Kohmoto T, DeRosa CM, Smith CR. Histologic appearance of transmyocardial laser channels after 4 1/2 weeks. Ann Thorac Surg. 1996;61:1532–4; discussion 1534–1535.CrossRefPubMedGoogle Scholar
  30. 30.
    Gassler N, Wintzer HO, Stubbe HM, Wullbrand A, Helmchen U. Transmyocardial laser revascularization. Histological features in human nonresponder myocardium. Circulation. 1997;95:371–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Berwing K, Bauer EP, Strasser R, Klovekorn WP, Reuthebuch O, Bertschmann W. Functional evidence of long-term channel patency after transmyocardial laser revascularization (abstract). Circulation. 1997;96:I-564.Google Scholar
  32. 32.
    Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanoglu S, Kolff JW, Wilansky S, Moore WH. Transmyocardial laser revascularization: clinical experience with twelve-month follow-up. J Thorac Cardiovasc Surg. 1996;111:791–7;discussion 797–799.CrossRefPubMedGoogle Scholar
  33. 33.
    Kwong KF, Kanellopoulos GK, Nickols JC, Pogwizd SM, Saffitz JE, Schuessler RB, Sundt 3rd TM. Transmyocardial laser treatment denervates canine myocardium. J Thorac Cardiovasc Surg. 1997;114:883–9; discussion 889–890.CrossRefPubMedGoogle Scholar
  34. 34.
    Hirsch GM, Thompson GW, Arora RC, Hirsch KJ, Sullivan JA, Armour JA. Transmyocardial laser revascularization does not denervate the canine heart. Ann Thorac Surg. 1999;68:460–8; discussion 468–469.CrossRefPubMedGoogle Scholar
  35. 35.
    Minisi AJ, Topaz O, Quinn MS, Mohanty LB. Cardiac nociceptive reflexes after transmyocardial laser revascularization: implications for the neural hypothesis of angina relief. J Thorac Cardiovasc Surg. 2001;122:712–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Al-Sheikh T, Allen KB, Straka SP, Heimansohn DA, Fain RL, Hutchins GD, Sawada SG, Zipes DP, Engelstein ED. Cardiac sympathetic denervation after transmyocardial laser revascularization. Circulation. 1999;100:135–40.CrossRefPubMedGoogle Scholar
  37. 37.
    Hughes GC, Lowe JE, Kypson AP, St Louis JD, Pippen AM, Peters KG, Coleman RE, DeGrado TR, Donovan CL, Annex BH, Landolfo KP. Neovascularization after transmyocardial laser revascularization in a model of chronic ischemia. Ann Thorac Surg. 1998;66:2029–36.CrossRefPubMedGoogle Scholar
  38. 38.
    Kohmoto T, Fisher PE, DeRosa C, Smith CR, Burkhoff D. Evidence of angiogenesis in regions treated with transmyocardial laser revascularization. Circulation. 1996;94:I-294.Google Scholar
  39. 39.
    Malekan R, Reynolds CA, Kelly ST, Suzuki Y, Bridges CR. Angiogenesis in transmyocardial laser revascularization: a nonspecific response to injury. Circulation. 1997;96:I-483.Google Scholar
  40. 40.
    Yamamoto N, Kohmoto T, Gu A, Derosa C, Smith CR, Burkhoff D. Transmyocardial revascularization enhances angiogenesis in a canine model of chronic ischemia. Circulation. 1997;96:I-563.Google Scholar
  41. 41.
    Nakagawa K. Direct observation of laser generated free radicals from a myocardium target site. Free Radic Biol Med. 1992;12:241–2.CrossRefPubMedGoogle Scholar
  42. 42.
    Horvath KA, Chiu E, Maun DC, Lomasney JW, Greene R, Pearce WH, Fullerton DA. Up-regulation of vascular endothelial growth factor mRNA and angiogenesis after transmyocardial laser revascularization. Ann Thorac Surg. 1999;68:825–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Li W, Chiba Y, Kimura T, Morioka K, Uesaka T, Ihaya A, Muraoka R. Transmyocardial laser revascularization induced angiogenesis correlated with the expression of matrix metalloproteinases and platelet-derived endothelial cell growth factor. Eur J Cardiothorac Surg. 2001;19:156–63.CrossRefPubMedGoogle Scholar
  44. 44.
    Pelletier MP, Giaid A, Sivaraman S, Dorfman J, Li CM, Philip A, Chiu RC. Angiogenesis and growth factor expression in a model of transmyocardial revascularization. Ann Thorac Surg. 1998;66:12–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Chu VF, Giaid A, Kuang JQ, McGinn AN, Li CM, Pelletier MP, Chiu RC. Thoracic Surgery Directors Association Award. Angiogenesis in transmyocardial revascularization: comparison of laser versus mechanical punctures. Ann Thorac Surg. 1999;68:301–7; discussion 307–308.CrossRefPubMedGoogle Scholar
  46. 46.
    Horvath KA, Belkind N, Wu I, Greene R, Doukas J, Lomasney JW, McPherson DD, Fullerton DA. Functional comparison of transmyocardial revascularization by mechanical and laser means. Ann Thorac Surg. 2001;72:1997–2002.CrossRefPubMedGoogle Scholar
  47. 47.
    Malekan R, Reynolds C, Narula N, Kelley ST, Suzuki Y, Bridges CR. Angiogenesis in transmyocardial laser revascularization. A nonspecific response to injury. Circulation. 1998;98:II62–5; discussion II66.PubMedGoogle Scholar
  48. 48.
    Horvath KA. Thoracoscopic transmyocardial laser revascularization. Ann Thorac Surg. 1998;65:1439–41.CrossRefPubMedGoogle Scholar
  49. 49.
    Saatvedt K, Dragsund M, Nordstrand K. Transmyocardial laser revascularization and coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg. 1996;62:323–4.CrossRefPubMedGoogle Scholar
  50. 50.
    Agarwal S, Kamath MV, Castresana MR. Transesophageal echocardiography for transmyocardial laser revascularization. Anesth Analg. 2014;118:1146–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Horvath KA, Cohn LH, Cooley DA, Crew JR, Frazier OH, Griffith BP, Kadipasaoglu K, Lansing A, Mannting F, March R, Mirhoseini MR, Smith C. Transmyocardial laser revascularization: results of a multicenter trial with transmyocardial laser revascularization used as sole therapy for end-stage coronary artery disease. J Thorac Cardiovasc Surg. 1997;113:645–54.CrossRefPubMedGoogle Scholar
  52. 52.
    Aaberge L, Nordstrand K, Dragsund M, Saatvedt K, Endresen K, Golf S, Geiran O, Abdelnoor M, Forfang K. Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris. Clinical results from the Norwegian randomized trial. J Am Coll Cardiol. 2000;35:1170–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Allen KB, Dowling RD, Fudge TL, Schoettle GP, Selinger SL, Gangahar DM, Angell WW, Petracek MR, Shaar CJ, O’Neill WW. Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med. 1999;341:1029–36.CrossRefPubMedGoogle Scholar
  54. 54.
    Burkhoff D, Schmidt S, Schulman SP, Myers J, Resar J, Becker LC, Weiss J, Jones JW. Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison. Lancet. 1999;354:885–90.CrossRefPubMedGoogle Scholar
  55. 55.
    Frazier OH, March RJ, Horvath KA. Transmyocardial revascularization with a carbon dioxide laser in patients with end-stage coronary artery disease. N Engl J Med. 1999;341:1021–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T, Buxton M, Wallwork J. Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial. Lancet. 1999;353:519–24.CrossRefPubMedGoogle Scholar
  57. 57.
    Aaberge L, Rootwelt K, Blomhoff S, Saatvedt K, Abdelnoor M, Forfang K. Continued symptomatic improvement three to five years after transmyocardial revascularization with CO(2) laser: a late clinical follow-up of the Norwegian Randomized trial with transmyocardial revascularization. J Am Coll Cardiol. 2002;39:1588–93.CrossRefPubMedGoogle Scholar
  58. 58.
    Allen KB, Dowling RD, Angell WW, Gangahar DM, Fudge TL, Richenbacher W, Selinger SL, Petracek MR, Murphy D. Transmyocardial revascularization: 5-year follow-up of a prospective, randomized multicenter trial. Ann Thorac Surg. 2004;77:1228–34.CrossRefPubMedGoogle Scholar
  59. 59.
    Cheng D, Diegeler A, Allen K, Weisel R, Lutter G, Sartori M, Asai T, Aaberge L, Horvath K, Martin J. Transmyocardial laser revascularization: a meta-analysis and systematic review of controlled trials. Innovations (Phila). 2006;1:295–313.CrossRefGoogle Scholar
  60. 60.
    Horvath KA. Transmyocardial laser revascularization. J Card Surg. 2008;23:266–76.PubMedCentralCrossRefPubMedGoogle Scholar
  61. 61.
    Bridges CR, Horvath KA, Nugent WC, Shahian DM, Haan CK, Shemin RJ, Allen KB, Edwards FH, Society of Thoracic Surgeons. The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization. Ann Thorac Surg. 2004;77:1494–502.CrossRefPubMedGoogle Scholar
  62. 62.
    Horvath KA, Ferguson Jr TB, Guyton RA, Edwards FH. Impact of unstable angina on outcomes of transmyocardial laser revascularization combined with coronary artery bypass grafting. Ann Thorac Surg. 2005;80:2082–5.CrossRefPubMedGoogle Scholar
  63. 63.
    Peterson ED, Kaul P, Kaczmarek RG, Hammill BG, Armstrong PW, Bridges CR, Ferguson Jr TB, Society of Thoracic Surgeons. From controlled trials to clinical practice: monitoring transmyocardial revascularization use and outcomes. J Am Coll Cardiol. 2003;42:1611–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Allen KB, Dowling RD, DelRossi AJ, Realyvasques F, Lefrak EA, Pfeffer TA, Fudge TL, Mostovych M, Schuch D, Szentpetery S, Shaar CJ. Transmyocardial laser revascularization combined with coronary artery bypass grafting: a multicenter, blinded, prospective, randomized, controlled trial. J Thorac Cardiovasc Surg. 2000;119:540–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Frazier OH, Boyce SW, Griffith BP, Hattler BG, Kadipasaoglu KA, Lansing AM, March RJ. Transmyocardial revascularization using a synchronized CO2 laser as adjunct to coronary artery bypass grafting: results of a prospective, randomized, multicenter trial with 12-month follow-up (abstract). Circulation. 1999;100:I-248.Google Scholar
  66. 66.
    Eldaif SM, Lattouf OM, Kilgo P, Guyton RA, Puskas JD, Thourani VH. Long-term outcomes after CABG with concomitant CO2 transmyocardial revascularization in comparison with CABG alone. Innovations (Phila). 2010;5:103–8.CrossRefGoogle Scholar
  67. 67.
    Kim CB, Oesterle SN. Percutaneous transmyocardial revascularization. J Clin Laser Med Surg. 1997;15:293–8.PubMedGoogle Scholar
  68. 68.
    Leon MB, Kornowski R, Downey WE, Weisz G, Baim DS, Bonow RO, Hendel RC, Cohen DJ, Gervino E, Laham R, Lembo NJ, Moses JW, Kuntz RE. A blinded, randomized, placebo-controlled trial of percutaneous laser myocardial revascularization to improve angina symptoms in patients with severe coronary disease. J Am Coll Cardiol. 2005;46:1812–9.CrossRefPubMedGoogle Scholar
  69. 69.
    Oesterle SN, Sanborn TA, Ali N, Resar J, Ramee SR, Heuser R, Dean L, Knopf W, Schofield P, Schaer GL, Reeder G, Masden R, Yeung AC, Burkhoff D. Percutaneous transmyocardial laser revascularisation for severe angina: the PACIFIC randomised trial. Potential Class Improvement From Intramyocardial Channels. Lancet. 2000;356:1705–10.CrossRefPubMedGoogle Scholar
  70. 70.
    Stone GW, Teirstein PS, Rubenstein R, Schmidt D, Whitlow PL, Kosinski EJ, Mishkel G, Power JA. A prospective, multicenter, randomized trial of percutaneous transmyocardial laser revascularization in patients with nonrecanalizable chronic total occlusions. J Am Coll Cardiol. 2002;39:1581–7.CrossRefPubMedGoogle Scholar
  71. 71.
    Frazier OH, Kadipasaoglu KA, Radovancevic B, Cihan HB, March RJ, Mirhoseini M, Cooley DA. Transmyocardial laser revascularization in allograft coronary artery disease. Ann Thorac Surg. 1998;65:1138–41.CrossRefPubMedGoogle Scholar
  72. 72.
    Gregoric ID, Nolen MT, Ksela J, Chandler LB, Messner GN, Cervera RD, Smart FW, Delgado 3rd RM, Frazier OH. Posttransplant off-pump coronary bypass and laser revascularization in a Jehovah’s Witness. Tex Heart Inst J. 2005;32:434–6.PubMedCentralPubMedGoogle Scholar
  73. 73.
    Patel AN, Spadaccio C, Kuzman M, Park E, Fischer DW, Stice SL, Mullangi C, Toma C. Improved cell survival in infarcted myocardium using a novel combination transmyocardial laser and cell delivery system. Cell Transplant. 2007;16:899–905.CrossRefPubMedGoogle Scholar
  74. 74.
    Shahzad U, Li G, Zhang Y, Yau TM. Transmyocardial revascularization induces mesenchymal stem cell engraftment in infarcted hearts. Ann Thorac Surg. 2012;94:556–62.CrossRefPubMedGoogle Scholar
  75. 75.
    Gowdak LH, Schettert IT, Rochitte CE, Lisboa LA, Dallan LA, Cesar LA, Krieger JE, Ramires JA, Oliveira SA. Cell therapy plus transmyocardial laser revascularization for refractory angina. Ann Thorac Surg. 2005;80:712–4.CrossRefPubMedGoogle Scholar
  76. 76.
    Gowdak LH, Schettert IT, Rochitte CE, Rienzo M, Lisboa LA, Dallan LA, Cesar LA, Krieger JE, Ramires JA, de Oliveira SA. Transmyocardial laser revascularization plus cell therapy for refractory angina. Int J Cardiol. 2008;127:295–7.CrossRefPubMedGoogle Scholar
  77. 77.
    Reyes G, Allen KB, Alvarez P, Alegre A, Aguado B, Olivera M, Caballero P, Rodriguez J, Duarte J. Mid term results after bone marrow laser revascularization for treating refractory angina. BMC Cardiovasc Disord. 2010;10:42.PubMedCentralCrossRefPubMedGoogle Scholar
  78. 78.
    Horvath KA, Zhou Y. Transmyocardial laser revascularization and extravascular angiogenetic techniques to increase myocardial blood flow. In: Cohn LH, editor. Cardiac surgery in the adult. 4th ed. New York: McGraw-Hill Professional; 2012.Google Scholar

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© Springer-Verlag London 2015

Authors and Affiliations

  1. 1.Department of Cardiopulmonary TransplantationCenter for Cardiac Support, Texas Heart InstituteHoustonUSA

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