Article Text

Download PDFPDF
NICE evaluation of transmyocardial laser revascularisation and percutaneous laser revascularisation for refractory angina
  1. P M Schofield,
  2. D McNab
  1. Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE, UK
  1. Correspondence to Dr D McNab, Consultant Cardiologist, UK; duncan.mcnab{at}

Statistics from

The vast majority of patients with angina due to underlying coronary artery disease can have their symptoms adequately controlled by anti-anginal drugs, percutaneous coronary intervention or coronary artery bypass surgery. There is, however, a cohort of patients with extensive coronary artery disease whose angina persists despite medical treatment and who are not suitable for conventional revascularisation procedures. A variety of treatments have been used in this patient group, including cognitive behavioural therapy, precordial transcutaneous electrical nerve stimulation, spinal cord stimulator implantation, intermittent local anaesthetic, sympathectomy, opioids, external enhanced counter pulsation, percutaneous myocardial laser revascularisation (PMR) and transmyocardial laser revascularisation (TMR). The last two treatments have recently been evaluated by the National Institute for Health and Clinical Excellence (NICE).

TMR is a surgical procedure carried out under general anaesthesia and was first described in 1983. High-energy lasers are used to create channels within the wall of the left ventricular myocardium. The original theory was that these channels carried blood from the ventricular cavity into the myocardium, thereby relieving the symptoms of myocardial ischaemia. This was based on the model of the reptilian heart, in which the left ventricle is directly perfused from endothelium-lined channels which radiate out from the cavity of the left ventricle. This mechanism of action is unlikely, since the channels have been shown to occlude in the weeks following surgery. Other theories on the mechanism of action include the development of new blood vessels (angiogenesis) and also damage to the nerve supply of the heart (denervation). It is possible that there may be a placebo effect which contributes to the improvement in patient's symptoms.

The area to be treated …

View Full Text


  • Competing interests None.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.