Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Indian Journal of Thoracic and Cardiovascular Surgery
Published in: Indian Journal of Thoracic and Cardiovascular Surgery 3/2018

01-12-2018 | Review Article

Transmyocardial revascularization (TMR): current status and future directions

Authors: Keith B. Allen, Amy Mahoney, Sanjeev Aggarwal, John Russell Davis, Eric Thompson, Alex F. Pak, Jessica Heimes, A. Michael Borkon

Published in: Indian Journal of Thoracic and Cardiovascular Surgery | Special Issue 3/2018

Login to get access

Abstract

Purpose

Cardiac surgeons are increasingly faced with a more complex patient who has developed a pattern of diffuse coronary artery disease (CAD), which is refractory to medical, percutaneous, and surgical interventions. This paper will review the clinical science surrounding transmyocardial revascularization (TMR) with an emphasis on the results from randomized controlled trials.

Methods

Randomized controlled trials which evaluated TMR used as sole therapy and when combined with coronary artery bypass grafting were reviewed. Pertinent basic science papers exploring TMR’s possible mechanism of action along with future directions, including the synergism between TMR and cell-based therapies were reviewed.

Results

Two laser-based systems have been approved by the United States Food and Drug Administration (FDA) to deliver laser therapy to targeted areas of the left ventricle (LV) that cannot be revascularized using conventional methods: the holmium:yttrium-aluminum-garnet (Ho:YAG) laser system (CryoLife, Inc., Kennesaw, GA) and the carbon dioxide (CO2) Heart Laser System (Novadaq Technologies Inc., (Mississauga, Canada). TMR can be performed either as a stand-alone procedure (sole therapy) or in conjunction with coronary artery bypass graft (CABG) surgery in patients who would be incompletely revascularized by CABG alone. Societal practice guidelines have been established and are supportive of using TMR in the difficult population of patients with diffuse CAD.

Conclusions

Patients with diffuse CAD have increased operative and long-term cardiac risks predicted by incomplete revascularization. The documented operative and long-term benefits associated with sole therapy and adjunctive TMR in randomized trials supports TMR’s increased use in this difficult patient population.
Literature
1.
Muhkerjee D, Bhatt DL, Roe MT, Patel V, Ellis SG. Direct myocardial revascularization and angiogenesis – how many patients might be eligible? Am J Cardiol. 1999;84:598–600.CrossRef
2.
Weintraub WS, Jones EL, Craver JM, Guyton RA. Frequency of repeat coronary bypass or coronary angiogplasty after coronary artery bypass surgery using saphenous venous grafts. Am J Cardiol. 1994;73:103–12.CrossRefPubMed
3.
Osswald BR, Blackstone EH, Tochtermann U, et al. Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients? Eur J Cardiothorac Surg. 2001;20:120–6.CrossRefPubMed
4.
Mohr FW, Rastan AJ, Serruys PW, et al. Complex coronary anatomy in coronary artery bypass graft surgery: impact of complex coronary anatomy in modern bypass surgery? Lessons learned from the SYNTAX trial after two years. J Thorac Cardiovasc Surg. 2011;141:130–40.CrossRefPubMed
5.
Allen KB. Holmium:YAG laser system for transmyocardial revascularization. Expert Rev Med Devices. 2006;3:137–46.CrossRefPubMed
6.
Schaff H, Gersh BJ, Pluth J, et al. Survival and functional status after coronary artery bypass grafting: results 10 to 12 years after surgery in 500 patients. Circulation. 1983;68:II200–4.
7.
Lawrie GM, Morris GC, Silvers A, et al. The influence of residual disease after coronary bypass on the 5-year survival rate of 1274 men with coronary artery disease. Circulation. 1982;66:717–23.CrossRefPubMed
8.
Bell MR, Gersh BJ, Schaff HV, et al. Effect of completeness of revascularization on long-term outcome of patients with three-vessel disease undergoing coronary artery bypass surgery. A report from the Coronary Artery Surgery (CASS) Registery. Circulation. 1992;86:446–57.CrossRefPubMed
9.
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;119:540–9.
10.
Lopes RD, Hafley GE, Allen KB, et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med. 2009;361:235–44.
11.
Allen KB, Dowling RD, Heimansohn DA, Reitsma E, Didelot G, Shaar CJ. Transmyocardial revascularization utilizing a holmium:YAG laser. Eur J Cardiothorac Surg. 1998;14:S100–4.CrossRefPubMed
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;341:1029–36.CrossRefPubMed
13.
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;341:1021–8.CrossRefPubMed
14.
Burkhoff D, Schmidt S, Schulman SP, et al. Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomized trial. Lancet. 1999;354:885–90.CrossRefPubMed
15.
Schofield PM, Sharples LD, Caine N, et al. Transmyocardial laser revascularization in patients with refractory angina: a randomised controlled trial. Lancet. 1999;353:519–24.CrossRefPubMed
16.
Aaberge L, Nordstrand K, Dragsund M, et al. Transmyocardial revascualrization with CO2 laser in patients with refractory angina pectoris: clinical results from the Norwegian randomized trial. J Am Coll Cardiol. 2000;35:1170–7.CrossRefPubMed
17.
Allen KB, Dowling RD, Angell WW, et al. Transmyocardial revascularization: five-year follow-up of a prospective, randomized, multicenter trial. Ann Thorac Surg. 2004;77:1228–34.CrossRefPubMed
18.
Horvath KA, Aranki SF, Cohn LH, et al. Sustained angina relief 5 years after transmyocardial laser revascularization with a CO2 laser. Circulation. 2001;104:I-81–4.CrossRef
19.
Cheng D, Diegeler A, Allen K, et al. Transmyocardial laser revascularization: a meta-analysis and systematic review of controlled trials. Innovations. 2006;1:295–313.CrossRefPubMed
20.
Myers J, Oesterle S, Jones J, Burkhoff D. Do transmyocardial and percutaneous laser revascularization induce silent ischemia? An assessment by exercise testing. Am Heart J. 2002;143:1052–7.CrossRefPubMed
21.
Bridges CR, Horvath KA, Nugent B, Shahian DM, Haan CK, Shemin RJ. Society of Thoracic Surgeons practice guideline: transmyocardial laser revascularization. Ann Thorac Surg. 2004;77:1484–502.CrossRef
22.
Diegeler A, Cheng D, Allen K, et al. Transmyocardial laser revascularization: a consensus statement of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) 2006. Innovations. 2006;1:314–22.CrossRefPubMed
23.
Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation. 2003;107:149–58.CrossRefPubMed
24.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126:3097–137.CrossRefPubMed
25.
Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124:2610–42.CrossRefPubMed
26.
Wehberg KE, Julian JS, Todd JC, Ogburn N, Klopp E, Buchness M. Improved patient outcomes when transmyocardial revascularization is used as adjunctive revascularization. Heart Surg Forum. 2003;6:328–30.PubMed
27.
Peterson ED, Kaul P, Kaczmarek RG, et al. From controlled trials to clinical practice: monitoring transmyocardial revascularization use and outcomes. J Am Coll Cardiol. 2003;42:1611–6.CrossRefPubMed
28.
Allen KB, Dowling RD, Richenbacher W. From controlled trial to clinical practice: monitoring transmyocardial revascularization use and outcomes. J Am Coll Cardiol. 2004;43:2364–5.CrossRefPubMed
29.
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;119:540–9.
30.
Allen KB, Dowling RD, Schuch DR, et al. Adjunctive transmyocardial revascularization: five-year follow-up of a prospective, randomized, trial. Ann Thorac Surg. 2004;78:458–65.CrossRefPubMed
31.
Frazier OH, Boyce SW, Griffith BP, et al. Transmyocardial revascularization using a synchronized CO2 laser as adjunct to coronary artery bypass grafting: results of a prospective, randomized multi-center trial with 12 month follow-up. Circulation. 1999:100:I248.
32.
Frazier OH, Tuzun E, Eichstadt A, et al. Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter study with 4-year follow-up. Tex Heart J. 2004;31:231–9.
33.
Diamond EG, Kittle CF, Crockett JE. Evaluation of internal mammary artery ligation and sham procedure in angina pectoris. Circulation. 1958;18:712–3.
34.
Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA. An evaluation of internal- mammary- artery ligation by a double-blind technic. N Engl J Med. 1959;260:1115–8.CrossRefPubMed
35.
Kwong KF, Kanellopoulos GK, Nickols JC, et al. Transmyocardial laser treatment denervates canine myocardium. J Thorac Cardiovasc Surg. 1997;114:883–90.CrossRefPubMed
36.
Al-Sheikh T, Allen KB, Straka SP, et al. Cardiac sympathetic denervation after transmyocardial laser revascularization. Circulation. 1999;100:135–40.CrossRefPubMed
37.
Beek JF, van der Sloot JA, Huikeshoven M, et al. Cardiac denervation after clinical transmyocardial laser revascularization: short-term and long-term iodine 123-labeled meta-iodobenzylguanide scintigraphic evidence. J Thorac Cardiovasc Surg. 2004;127:517–24.CrossRefPubMed
38.
Muxi A, Magrina J, Martin F, et al. Technetium 99m-labeled tetrofosmin and iodine 123-labeled metaiodobenzylguanide scintigraphy in the assessment of transmyocardial laser revascularization. J Thorac Cardiovasc Surg. 2003;125:1493–8.CrossRefPubMed
39.
Hughes GC, Baklanov DV, Biswas SS, et al. Regional cardiac sympathetic innervation early and late after transmyocardial laser revascularization. J Card Surg. 2004;19:21–7.CrossRefPubMed
40.
Tran R, Brazio PS, Kallam S, Gu J, Poston RS. Transmyocardial laser revascularization enhances blood flow within bypass grafts. Innovations. 2007;2:226–30.CrossRefPubMed
41.
Yamamoto N, Kohmoto T, Gu A, DeRosa C, Smith CR, Burkhoff D. Angiogenesis is enhanced in ischemic canine myocardium by transmyocardial laser revascularization.JACC.1998;31:1426–33.
42.
Kohmoto T, DeRosa CM, Yamamoto N, et al. Evidence of vascular growth associated with laser treatment of normal canine myocardium. Ann Thorac Surg. 1998;65:1360–7.CrossRefPubMed
43.
Malekan R, Reynolds CF, Narula N, Kelley ST, Suzuki Y, Bridges CR. Angiogenesis in transmyocardial laser revascularization. A nonspecific response to injury. Circulation. 1998;98:II62–5.PubMed
44.
Huikeshoven M, Belien J, Tukkie R, Beek JF. The vascular response induced by transmyocardial laser revascularization is determined by the size of the channel scar: results of CO2, holmium and excimer lasers. Lasers Surg Med. 2004;35:35–40.CrossRefPubMed
45.
Hughes GC, Lowe JE, Kypson AP, et al. Neovascularization after transmyocardial laser revascularization in a model of chronic ischemia. Ann Thorac Surg. 1998;66:2029–36.CrossRefPubMed
46.
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;70:504–9.CrossRefPubMed
47.
Hughes GC, Biswas SS, Yin B, et al. A comparison of mechanical and laser transmyocardial revascularization for induction of angiogenesis and arteriogenesis in chronically ischemic myocardium. J Am Coll Cardiol2002;39:1220–28.CrossRefPubMed
48.
Domkowski PW, Biswas SS, Steenbergen C, Lowe JE. Histological evidence of angiogenesis 9 months after transmyocardial laser revascularization. Circulation. 2001;103:469–71.CrossRefPubMed
49.
Hughes GC, Lowe JE. Revascularization versus denervation: what are the mechanisms of symptom relief? In: Abela GS, editor. Myocardial revascularization: novel percutaneous approaches. New York: Wiley-Liss; 2002. p. 63–79.
50.
Allen KB, Kelly J, Borkon AM, et al. TMR: from randomized trials to clinical practice. a review of techniques, evidence based outcomes, and future directions. Anesthesiol Clin. 2008;26:501–19.CrossRefPubMed
51.
Atluri P, Suarez EE, Liao GP, et al. Transmyocardial revascularization to enhance myocardial vasculogenesis and hemodynamic function. J Thorac Cardiovasc Surg. 2008;135:283–91.CrossRefPubMed
52.
Horvath KA, Chiu E, Maun D, et al. Up-regulation of vascular endothelial growth factor mRNA and angiogenesis after transmyocardial laser revascularization. Ann Thorac Surg. 1999;68:825–9.CrossRefPubMed
53.
Selke FW, Ruel M. Vascular growth factors and angiogenesis in cardiac surgery. Ann Thorac Surg. 2003;75:S685–90.CrossRef
54.
Losordo DW, Schatz RA, White CJ, et al. Intramyocardial transplantation of autologous CD34+ stem cells for intractable angina: a phase I/IIa double-blind, randomized controlled trial. Circulation. 2007;115:3165–72.CrossRefPubMed
55.
Pompillo G, Steinhoff G, Liebold A, et al. Direct minimally invasive intramyocardial injection of bone marrow -derived AC133+ stem cells in patients with refractory ischemia: preliminary results. Thorac Cardiovasc Surg. 2008;56:71–6.CrossRef
56.
Orlic D, Kajstura J, Chimenti S, et al. Bone marrow cells regenerate infarcted myocardium. Nature. 2001;410:701–5.CrossRefPubMed
57.
Abdel-Latif A, Bolli R, Tleyjeh IM, et al. Adult bone marrow-derived cells for cardiac repair: a systematic review and meta-analysis. Arch Intern Med. 2007;167:989–97.CrossRefPubMed
58.
Patel AN, Spadaccio C, Kuzman M, et al. Improved cell survival in infarcted myocardium using a novel combination transmyocardial laser and cell delivery system. Cell Transplant. 2007;16:899–905.CrossRefPubMed
59.
Rosenzweig A. Cardiac cell therapy – mixed results from mixed cells. N Engl J Med. 2006;355:1274–7.CrossRefPubMed
60.
Reyes G, Allen KB, Aguado B, et al. Bone marrow laser revascularisation for treating refractory angina due to diffuse coronary heart disease. Eur J Cardiothorac Surg. 2009;36:192–4.CrossRefPubMed
Metadata
Title
Transmyocardial revascularization (TMR): current status and future directions
Authors
Keith B. Allen
Amy Mahoney
Sanjeev Aggarwal
John Russell Davis
Eric Thompson
Alex F. Pak
Jessica Heimes
A. Michael Borkon
Publication date
01-12-2018
Publisher
Springer Singapore
Published in
Indian Journal of Thoracic and Cardiovascular Surgery / Issue Special Issue 3/2018
Print ISSN: 0970-9134
Electronic ISSN: 0973-7723
DOI
https://doi.org/10.1007/s12055-018-0702-7

Other articles of this Special Issue 3/2018

Indian Journal of Thoracic and Cardiovascular Surgery 3/2018 Go to the issue

Review Article

Bilateral internal thoracic artery use in coronary bypass surgery: is there a benefit?

Review Article

The role of stem cells in treating coronary artery disease in 2018

Review Article

Current role of saphenous vein graft in coronary artery bypass grafting

Review Article

Hybrid myocardial revascularization

REVIEW ARTICLE

The radial artery in coronary surgery, 2018

Review Article

Minimally invasive coronary artery bypass grafting