Myocardial laser revascularization.

Some patients with severe angina have coronary artery disease which is unsuitable for conventional forms of revascularization — coronary angioplasty/ stenting or coronary artery bypass surgery. These patients have usually undergone previous revascularization procedures and have disease which is diffuse and affects the distal part of the coronary circulation. Transmyocardial laser revascularization, a technique which uses laser ablation to create transmural channels in the ischaemic myocardium usually via a left anterolateral thoracotomy, has been used in recent years to treat such patients. More recently, laser ablation has been carried out from within the left ventricular cavity using a catheter-based approach— percutaneous myocardial laser revascularization. The first reports of transmyocardial laser revascularization using a high-energy carbon dioxide laser were encouraging. A multicentre uncontrolled trial in the U.S.A. recruited 200 patients with advanced coronary artery disease. They reported an improvement in angina score by two Canadian Cardiovascular Society classes in 75% of patients at 3 months. Peri-operative mortality was 9% with a further 9% mortality after a mean of 10 months of follow-up. In an uncontrolled European and Asian registry involving 967 patients there was an improvement in two Canadian Cardiovascular Society classes in 47% of patients. The peri-operative mortality was 9·7% and the peri-operative morbidity included chest/wound infections, transient arrhythmia (usually artrial fibrillation) and left ventricular dysfunction. Clearly, the symptomatic benefits of transmyocardial laser revascularization need to be weighed against the risks of mortality and morbidity. We have recently reported the first prospective randomized controlled trial to assess the effectiveness of transmyocardial laser revascularization compared with medical management in patients with coronary artery disease not amenable to conventional revascularization techniques. One hundred and eighty-eight patients were randomized to either transmyocardial laser revascularization plus their usual medication (94 patients) or to continue with medical therapy alone (94 patients). All patients were required to have a left ventricular ejection fraction of at least 30% and have evidence of reversible myocardial ischaemia on