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The Society of Thoracic Surgeons practice guideline series: transmyocardial laser revascularization
Charles R Bridges1, Keith A Horvath, William C Nugent
1Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA. cbridges@pahosp.com
Insights
Transmyocardial laser revascularization (TMLR) is effective for refractory angina patients. It is recommended as sole therapy (Class I) or adjunct to bypass surgery (Class IIA) when complete revascularization is not possible.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Procedures
- Interventional Cardiology
Background:
- Chronic severe angina refractory to medical therapy poses significant clinical challenges.
- Patients unsuitable for complete percutaneous catheter intervention or coronary artery bypass graft surgery require alternative treatment options.
- Transmyocardial laser revascularization (TMLR) is an emerging therapy for refractory angina, but its mechanisms and patient selection criteria require further definition.
Framework:
- Evidence-based guideline development for TMLR.
- Classification of recommendations using American Heart Association and American College of Cardiology formats (Class I, IIA, IIB, III).
- Grading of supporting evidence levels (A, B, C).
Implementation:
- Systematic review of existing evidence on TMLR efficacy and safety.
- Formulation of therapeutic recommendations based on reviewed evidence.
- Classification of TMLR indications as sole therapy or adjunct to coronary artery bypass graft surgery.
Implications:
- TMLR is identified as a Class I indication for sole therapy in selected refractory angina patients.
- TMLR is identified as a Class IIA indication when used as an adjunct to coronary artery bypass graft surgery.
- These recommendations provide guidance for the appropriate therapeutic application of TMLR in complex cardiovascular cases.
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.
