title: The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization.
abstract: BACKGROUND
  Patients with chronic severe angina refractory to medical therapy who cannot be completely revascularized with either percutaneous catheter intervention or coronary artery bypass graft surgery present clinical challenges. Transmyocardial laser revascularization, either as sole therapy or as an adjunct to coronary artery bypass graft surgery, may be appropriate for some of these patients. Although transmyocardial revascularization has consistently been demonstrated as an efficacious means of relieving angina, the mechanism of its effects are still debated, and criteria for the selection of patients for this novel therapy have not been adequately defined.
  
  
  METHODS
  We reviewed the available evidence to allow us to make recommendations for the appropriate therapeutic applications of transmyocardial revascularization following the format of the American Heart Association and the American College of Cardiology guidelines for diagnostic and therapeutic procedures. Our recommendations were classified as class I, IIA, IIB, or III. For each recommendation we defined the level of supporting evidence as A, B, or C.
  
  
  RESULTS
  We identified class I indications for transmyocardial revascularization as sole therapy and class IIA indications for transmyocardial revascularization as an adjunct to coronary artery bypass graft surgery with levels of evidence A and B, respectively.
  
  
  CONCLUSIONS
  Transmyocardial laser revascularization may be an acceptable form of therapy for selected patients: as sole therapy for a subset of patients with refractory angina and as an adjunct to coronary artery bypass graft surgery for a subset of patients with angina who cannot be completely revascularized surgically.
authors.affiliation: Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA. cbridges@pahosp.com
authors.forename: Charles R
authors.initials: CR
authors.lastname: Bridges
authors.forename: Keith A
authors.initials: KA
authors.lastname: Horvath
authors.forename: William C
authors.initials: WC
authors.lastname: Nugent
authors.forename: David M
authors.initials: DM
authors.lastname: Shahian
authors.forename: Constance K
authors.initials: CK
authors.lastname: Haan
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Shemin
authors.forename: Keith B
authors.initials: KB
authors.lastname: Allen
authors.forename: Fred H
authors.initials: FH
authors.lastname: Edwards
mesh_terms: D000787:Angina Pectoris / Q000601:surgery*; D001026:Coronary Artery Bypass; D006801:Humans; D053685:Laser Therapy / Q000009:adverse effects / Q000379:methods / Q000592:standards; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000379:methods / Q000592:standards