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Percutaneous myocardial laser revascularisation
  1. SARAH C CLARKE,
  2. PETER M SCHOFIELD
  1. Regional Cardiac Unit
  2. Papworth Hospital
  3. Cambridge CB3 8RE, UK

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In the vast majority of patients with angina pectoris caused by underlying coronary artery disease, effective treatment is available. Most patients respond to antianginal medication, and for the remainder either percutaneous coronary revascularisation or coronary artery bypass grafting can be performed. There are, however, an increasing number of patients who have angina which is not controlled by medical treatment and have disease which is not suitable for conventional revascularisation techniques. Typically, such patients have atherosclerotic disease throughout their coronary arterial tree, with no “target” lesions for angioplasty and no “target” vessels for surgery. In recent years, transmyocardial laser revascularisation (TMLR) has been evaluated as a treatment option in this patient population. This technique, which is usually performed through a left anterolateral thoracotomy, uses laser energy to create transmural channels in the ischaemic myocardium. The initial experience with TMLR used a high energy carbon dioxide laser. As a result of developments in fibreoptic technology and by using a Holmium-YAG energy source, it is now possible to produce laser ablation from the endocardial surface of the left ventricle. This technique of percutaneous myocardial revascularisation has been investigated in randomised clinical trials.

Transmyocardial laser revascularisation

In the 1980s Mirhoseini reported the early experience with TMLR.1 ,2 The laser probe is placed on the surface of the ischaemic part of the left ventricle and activated. This creates a transmural channel into the left ventricular cavity. In an uncontrolled trial of TMLR in patients with refractory angina and coronary artery disease which was unsuitable for conventional revascularisation, three quarters had an improvement in symptoms of two angina classes.3 The findings from uncontrolled registry data, involving over 900 patients, showed that almost 50% experienced an improvement in angina …

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