Journal Mobile Options
Table of Contents
Vol. 101, No. 1-3, 2004
Issue release date: February 2004

Mechanisms and Results of Transmyocardial Laser Revascularization

Horvath K.A.
To view the fulltext, log in and/or choose pay-per-view option

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Transmyocardial laser revascularization (TMR) is a technique that has been performed on over 10,000 patients around the world. Most of the patients were not suffering from heart failure. TMR is principally used for the treatment of angina, but in patients with significant reversible ischemia that is not amenable to conventional therapy, TMR may also improve myocardial function. The results of using TMR as a treatment for angina show a dramatic improvement in symptoms and quality of life. This paper reviews the current status of TMR techniques, mechanisms and results.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. Mirhoseini M, Muckerheide M, Cayton MM: Transventricular revascularization by laser. Lasers Surg Med 1982;2:187–198.
  2. Mirhoseini M, Fisher JC, Cayton M: Myocardial revascularization by laser: A clinical report. Lasers Surg Med 1983;3:241–245.
  3. Okada M, Ikuta H, Shimizu OK, Horii H, Nakamura K: Alternative method of myocardial revascularization by laser: Experimental and clinical study. Kobe J Med Sci 1986;32:151–161.
  4. Okada M, Shimizu K, Ikuta H, Horii H, Nakamura K: A new method of myocardial revascularization by laser. Thorac Cardiovasc Surg 1991;39:1–4.
  5. Horvath KA, Mannting F, Cummings N, Shernan SK, Cohn LH: Transmyocardial laser revascularization: Operative techniques and clinical results at two years. J Thorac Cardiovasc Surg 1996;111:1047–1053.
  6. Cooley DA, Frazier OH, Kadipasaoglu KA, et al: Transmyocardial laser revascularization: Clinical experience with twelve-month follow-up. J Thorac Cardiovasc Surg 1996;111:791–797.
  7. Horvath KA, Cohn LC, Cooley DA, Crew JR, Frazier OH, Griffith BP, Kadipasaoglu K, Lansing A, Mannting FR, March R, Mirhoseini MR, Smith C: Transmyocardial laser revascularization: Results of a multi-center trial using TLR as sole therapy for end stage coronary artery disease. J Thorac Cardiovasc Surg 1997;113:645–654.
  8. Krabatsch T, Tambeur L, Lieback E, Shaper F, Hetzer R: Transmyocardial laser revascularization in the treatment of end-stage coronary artery disease. Ann Thorac Cardiovasc Surg 1998;4:64–71.
  9. Hattler BG, Griffith BP, Zenati MA, et al: Transmyocardial laser revascularization in the patient with unmanageable unstable angina. Ann Thorac Surg 1999;68:1203–1209.
  10. Milano A, Pratali S, Tartarini G, et al: Early results of transmyocardial revascularization with a holmium laser. Ann Thorac Surg 1998;65:700–704.
  11. Dowling RD, Petracek MR, Selinger SL, et al: Transmyocardial revascularization in patients with refractory, unstable angina. Circulation 1998;98(suppl II):II73–II75.
  12. Allen KB, Dowling RD, Fudge TL, et al: Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina. N Engl J Med 1999;341:1029–1036.
  13. Burkhoff D, Schmidt S, Schulman SP, et al: Transmyocardial laser revascularization compared with continued medical therapy for treatment of refractory angina pectoris: A prospective randomized trial. Lancet 1999;354:885–890.
  14. Jones JW, Schmidt SE, Richman BW, Miller CC, Sapire KJ, Burkhoff D, Baldwin JC: Holmium:YAG laser transmyocardial revascularization relieves angina and improves functional status. Ann Thorac Surg 1999;67:1596–1602.
  15. 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;341:1021–1028.
  16. Schofield PM, Sharples LD, Caine N, Burns S, Tait S, Wistow T: Transmyocardial laser revascularization in patients with refractory angina: A randomized controlled trial. Lancet 1999;353:519–524.
  17. Aaberge L, Nordstrand K, Dragsund M, et al: Transmyocardial revascularization with CO2 laser in patients with refractory angina pectoris. Clinical results from the Norwegian randomized trial. J Am Coll Cardiol 2000;35:1170–1177.
  18. Agarwal R, Ajit M, Kurian VM, Rajan S, Arumugam SB, Cherian KM: Transmyocardial laser revascularization: Early results and 1-year follow-up. Ann Thorac Surg 2000;69:1993–1995.
  19. Horvath KA: Results of prospective randomized controlled trials of transmyocardial laser revascularization. Heart Surg Forum 2002;5:33–40.
  20. De Carlo M, Milano AD, Pratali S, Levantino M, Mariotti R, Bortolotti U: Symptomatic improvement after transmyocardial laser revascularization: How long does it last? Ann Thorac Surg 2000;70:1130–1133.
  21. Schneider J, Diegeler A, Krakor R, Walther T, Kluge R, Mohr FW: Transmyocardial laser revascularization with the holmium:YAG laser: Loss of symptomatic improvement after 2 years. Eur J Cardiothorac Surg 2001;19:164–169.
  22. Horvath KA, Aranki SF, Cohn LH, et al: Sustained angina relief 5 years after transmyocardial laser revascularization with a CO2 laser. Circulation 2001;104(suppl I):I81–I84.
  23. Aaberge L, Rootwelt K, Blomhoff S, Saatvedt K, Abdelnoor M, Forfang K: Continued symptomatic improvement three to five years after transmyocardial revascularization with CO2 laser: A late clinical follow-up of the Norwegian Randomized trial with transmyocardial revascularization. J Am Coll Cardiol 2002;39:1588–1593.
  24. Shawl FA, Kaul U, Saadat V: Percutaneous myocardial revascularization using a myocardial channeling device: First human experience using the AngioTrax system. J Am Coll Cardiol 2000;35:61A.
  25. 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(19 suppl):II62–II66.
  26. Smith NB, Hynynen K: The feasibility of using focused ultrasound for transmyocardial revascularization. Ultrasound Med Biol 1998;24:1045–1054.
  27. Khairy P, Dubuc M, Gallo R: Cryoapplication induces neovascularization: A novel approach to percutaneous myocardial revascularization. J Am Coll Cardiol 2000;35:5A–6A.
  28. Yamamoto N, Gu AG, Derosa CM, et al: Radio frequency transmyocardial revascularization enhances angiogenesis and causes myocardial denervation in a canine model. Lasers Surg Med 2000;27:18–28.
  29. 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.
  30. Horvath KA, Belkind N, Wu I, Greene R, Lomasney JW, McPherson DD, Fullerton DA: Functional comparison of transmyocardial revascularization by mechanical and laser means. Ann Thorac Surg 2001;72:1997–2002.
  31. 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;93:143–152.
  32. Hughes GC, Kypson AP, Annex BH, et al: Induction of angiogenesis after TMR: A comparison of holmium: YAG, CO2, and excimer lasers. Ann Thorac Surg 2000;70:504–509.
  33. Martin JS, Sayeed-Shah U, Byrne JG, et al: Excimer versus carbon dioxide transmyocardial laser revascularization: Effects on regional left ventricular function and perfusion. Ann Thorac Surg 2000;69:1811–1816.
  34. Whittaker P, Spariosu K, Ho ZZ: Success of transmyocardial laser revascularization is determined by the amount and organization of scar tissue produced in response to initial injury: Results of ultraviolet laser treatment. Lasers Surg Med 1999;24:253–260.
  35. Genyk IA, Frenz M, Ott B, et al: Acute and chronic effects of transmyocardial laser revascularization in the nonischemic pig myocardium by using three laser systems. Lasers Surg Med 2000;27:438–450.
  36. Jeevanandam V, Auteri JS, Oz MC, Watkins J, Rose EA, Smith CR: Myocardial revascularization by laser-induced channels. Surg Forum 1990;41:225–227.
  37. Kadipasaoglu K, Frazier OH: Transmyocardial laser revascularization: Effect of laser parameters on tissue ablation and cardiac perfusion. Semin Thorac Cardiovasc Surg 1999;11:4–11.
  38. Kadipasaoglu KA, Sartori M, Masai T, et al: Intraoperative arrhythmias and tissue damage during transmyocardial laser revascularization. Ann Thorac Surg 1999;67:423–431.
  39. 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;21:220–224.
  40. Mirhoseini M, Shelgikar S, Cayton M: Clinical and histological evaluation of laser myocardial revascularization. J Clin Laser Med Surg 1990;8:73–77.
  41. Hardy RI, James FW, Millard RW, Kaplan S: Regional myocardial blood flow and cardiac mechanics in dog hearts with CO2 laser-induced intramyocardial revascularization. Basic Res Cardiol 1990;85:179–197.
  42. Horvath KA, Smith WJ, Laurence RG, Schoen FJ, Appleyard RF, Cohn LH: Recovery and viability of an acute myocardial infarct after transmyocardial laser revascularization. J Am Coll Cardiol 1995;25:258–263.
  43. Krabatsch T, Schaper F, Leder C, Tulsner J, Thalmann U, Hetzer R: Histologic findings after transmyocardial laser revascularization. J Card Surg 1996;11:326–331.
  44. Lutter G, Martin J, von Samson P, Heilmann C, Sarai K, Beyersdorf F: Microperfusion enhancement after TMLR in chronically ischemic porcine hearts. Cardiovasc Surg 2001;9:281–291.
  45. Gassler N, Wintzer HO, Stubbe HM, Wullbrand A, Helmchen U: Transmyocardial laser revascularization: Histological features in human nonresponder myocardium. Circulation 1997;95:371–375.
  46. Khomoto T, Fisher PE, Gu A, Smith CR, De Rosa C, Burkhoff D: Physiology, histology, and two week morphology of acute myocardial channels made with a CO2 laser. Ann Thorac Surg 1997;63:1275–1283.
  47. Kohmoto T, Fisher PE, Gu A, et al: Does blood flow through holmium:YAG transmyocardial laser channels? Ann Thorac Surg 1996;61:861–868.
  48. Burkhoff D, Fisher PE, Apfelbaum M, Kohmoto T, DeRosa CM, Smith CR: Histologic appearance of transmyocardial laser channels after 4 ½ weeks. Ann Thorac Surg 1996;61:1532–1535.
  49. Sigel JE, Abramovitch CM, Lytle BW, Ratliff NB: Transmyocardial laser revascularization: Three sequential autopsy cases. J Thorac Cardiovasc Surg 1998;115:1381–1385.
  50. Kwong KF, Kanellopoulos GK, Nikols JC, Sundt TR III: Transmyocardial laser treatment denervates canine myocardium. J Thorac Cardiovasc Surg 1997;114:883–890.
  51. Kwong KF, Schuessler RB, Kanellopoulos GK, Saffitz JE, Sundt TM: Nontransmural laser treatment incompletely denervates canine myocardium. Circulation 1998;98:1167–1171.
  52. 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;68:460–468.
  53. 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;122:712–719.
  54. Al-Sheikh T, Allen KB, Straka SP, et al: Cardiac sympathetic denervation after transmyocardial laser revascularization. Circulation 1999;100:135–140.
  55. Yamamoto N, Kohmoto T, Gu A, DeRosa C, Smith CR, Burkhoff D: Angiogenesis is enhanced in ischemic canine myocardium by transmyocardial laser revascularization. J Am Coll Cardiol 1998;31:1426–1433.
  56. Fisher PE, Khomoto T, DeRosa CM, Spotnitz HM, Smith CR, Burkhoff D: Histologic analysis of transmyocardial channels: Comparison of CO2 and holmium:YAG lasers. Ann Thorac Surg 1997;64:466–472.
  57. Zlotnick AY, Ahmad RM, Reul RM: Neovascularization occurs at the site of closed laser channels after transmyocardial laser revascularization. Surg Forum 1996;48:286–287.
  58. Kohmoto T, Fisher PE, DeRosa C, Smith CR, Burkhoff D: Evidence of angiogenesis in regions treated with transmyocardial laser revascularization. Circulation 1996;94:1294.
  59. Spanier T, Smith CR, Burkhoff D: Angiogenesis. A possible mechanism underlying the clinical benefits of transmyocardial laser revascularization. J Clin Laser Med Surg 1997;15:269–273.
  60. Mueller XM, Tevaearai HT, Chaubert P, Genton CY, von Segesser LK: Does laser injury induce a different neovascularization pattern from mechanical or ischemic injuries? Heart 2001;85:697–701.

    External Resources

  61. Hughes GC, Lowe JE, Kypson AP, et al: Neovascularization after transmyocardial laser revascularization in a model of chronic ischemia. Ann Thorac Surg 1998;66:2029–2036.
  62. Horvath KA, Chiu E, Maun DC, Lomasney JW, Greene R, Pearce WH, Fullerton DA: Up-regulation of VEGF mRNA and angiogenesis after transmyocardial laser revascularization. Ann Thorac Surg 1999;68:825–829.
  63. Li W, Chiba Y, Kimura T, et al: Transmyocardial laser revascularization induced angiogenesis correlated with the expression of matrix metalloproteinase and platelet-derived endothelial cell growth factor. Eur J Cardiothorac Surg 2001;19:156–163.
  64. Pelletier MP, Giaid A, Sivaraman S, et al: Angiogenesis and growth factor expression in a model of transmyocardial revascularization. Ann Thorac Surg 1998;66:12–18.
  65. Chu V, Kuang J, McGinn A, Giai A, Korkola S, Chiu RC: Angiogenic response induced by mechanical transmyocardial revascularization. J Thorac Cardiovasc Surg 1999;118:849–856.
  66. Chu VF, Giaid A, Kuagn JQ, et al: Angiogenesis in transmyocardial revascularization: Comparison of laser versus mechanical punctures. Ann Thorac Surg 1999;68:301–307.
  67. Donovan CL, Landolfo KP, Lowe JE, Clements F, Coleman RB, Ryan T: Improvement in inducible ischemia during dobutamine stress echocardiography after transmyocardial laser revascularization in patients with refractory angina pectoris. J Am Coll Cardiol 1997;30:607–612.
  68. Frazier OH, Cooley DA, Kadipasaoglu KA, et al: Myocardial revascularization with laser. Preliminary findings. Circulation 1995;92(suppl):II58–II65.
  69. Laham RJ, Simons M, Pearlman JD, Ho KKL, Baim DS: Magnetic resonance imaging demonstrates improved regional systolic wall motion and thickening and myocardial perfusion of myocardial territories treated by laser myocardial revascularization. J Am Coll Cardiol 2002;39:1–8.
  70. Kim RJ, Rafael A, Chen E, Wu E, Parker MA, Horvath KA, Simonetti O, Finn P, Bonow RO, Klocke FJ, Judd RM: Contrast-enhanced MRI predicts wall motion improvement after coronary revascularization. Circulation 1999;100(suppl):I-797.
  71. Horvath KA, Greene R, Belkind N, Kane B, McPherson D, Fullerton DA: Left ventricular functional improvement after transmyocardial laser revascularization. Ann Thorac Surg 1998;66:721–725.
  72. Hughes GC, Kypson AP, St Louis JD, et al: Improved perfusion and contractile reserve after transmyocardial laser revascularization in a model of hibernating myocardium. Ann Thorac Surg 1999;67:1714–1720.
  73. Krabatsch T, Modersohn D, Konertz W, Hetzer R: Acute changes in functional and metabolic parameters following transmyocardial laser revascularization: An experimental study. Ann Thorac Cardiovasc Surg 2000;6:383–388.
  74. Oesterle SN, Sanborn TA, Ali N, et al: Percutaneous transmyocardial laser revascularization for severe angina: The PACIFIC randomised trial. Potential Class Improvement From Intramyocardial Channels. Lancet 2000;356:1705–1710.
  75. Stone GW, Teirstein PS, Rubenstein R, et al: A prospective, multicenter, randomized trial of percutaneous transmyocardial laser revascularization in patients with nonrecanalizable chronic total occlusions. J Am Coll Cardiol 2002;39:1581–1587.
  76. Leon MB, Baim DS, Moses JW, et al: A randomized blinded clinical trial comparing percutaneous laser myocardial revascularization vs. placebo in patients with refractory coronary ischemia. Circulation 2000;102:II-565.
  77. Horvath KA: Thoracoscopic transmyocardial laser revascularization. Ann Thorac Surg 1998;65:1439–1441.
  78. Allen KB, Dowling RD, DelRossi AJ, et al: Transmyocardial laser revascularization combined with coronary artery bypass grafting: A multicenter, blinded, prospective, randomized, controlled trial. J Thorac Cardiovasc Surg 2000;119:540–549.
  79. Trehan N, Mishra Y, Mehta Y, et al: Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization. Ann Thorac Surg 1998;66:1113–1118.
  80. Stamou SC, Boyce SW, Cooke RH, et al: One-year outcome after combined coronary artery bypass grafting and transmyocardial laser revascularization for refractory angina pectoris. Am J Cardiol 2002;89:1365–1368.
  81. Mehra MR, Uber PA, Prasad AK, et al: Long-term outcome of cardiac allograft vasculopathy treated by transmyocardial laser revascularization: Early rewards, late losses. J Heart Lung Transplant 2000;19:801–804.
  82. Frazier OH, Kadipasaoglu KA, Radovancevic B, et al: Transmyocardial laser revascularization in allograft coronary artery disease. Ann Thorac Surg 1998;65:1138–1141.
  83. Fleischer KJ, Goldschmidt-Clermont PJ, Fonger JD, et al: One-month histologic response of transmyocardial laser channels with molecular intervention. Ann Thorac Surg 1996;62:1051–1058.
  84. Sayeed-Shah U, Mann MJ, Martin J, et al: Complete reversal of ischemic wall motion abnormalities by combined use of gene therapy with transmyocardial laser revascularization. J Thorac Cardiovasc Surg 1998;116:763–768.
  85. Doukas J, Ma CL, Craig D, et al: Therapeutic angiogenesis induced by FGF-2 gene delivery combined with laser transmyocardial revascularization. Circulation 2000;102:1214.
  86. Lutter G, Dern P, Attmann T, et al: Combined use of transmyocardial laser revascularization with basic fibroblastic growth factor in chronically ischemic porcine hearts. Circulation 2000;102:3693.
  87. Horvath KA, Doukas J, Lu CJ, Belkind N, Greene R, Pierce GF, Fullerton DA: Myocardial functional recovery after fibroblast growth factor 2 gene therapy as assessed by echocardiography and MRI. Ann Thorac Surg 2002;74:481–487.

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50