Myocardial perfusion after transmyocardial laser revascularization.

Laser Revascularization To the Editor: I read with interest the report of Iskandrian et al.1 The authors described a case of improvement of perfusion in the right coronary artery territories (after transmyocardial revascularization), as well as in the territory of the left anterior descending artery and the circumflex artery (after CABG surgery). I’d like to ask the authors why they were sure that the improvement in the inferior territory was due to the laser. Because they did not show the preoperative angiography of the patient, we imagine that the right coronary artery was occluded and only small vessels were present, with collateral circulation coming from the other coronary branches, which were stenosed but patent. If this is true, an improvement in the inferior territory could be a result of the normalization of the flow in the other coronary arteries, which also supply the inferior territory. If the right coronary artery was not occluded but the distal vessels were small (without any evidence of collateral circulation from other coronary branches), why weren’t these vessels grafted? Small-vessel disease is very well known, and its treatment, even if technically demanding, is feasible by the average surgeon. Moreover, the right coronary artery system was not grafted “because of poor distal runoff.” This doesn’t seem to be true, because the territory in that area was viable, as demonstrated by the improvement in perfusion, whatever the cause. Basically, the indication to the laser doesn’t seem clear to me. In any case, mixing surgery with the laser makes it difficult to draw any concrete conclusion, as the authors have tried to do.