Professional Society Practice Guidelines

Despite multiple randomized controlled trials showing safety and efficacy, society guidelines have change overtime. This is possibly due to confusion with Direct Myocardial Revascularization (DMR), which was a different procedure1.

Year Recommendations Evidence Rating
2003 ACC/AHA Guideline for Management of Patients with Chronic Stable Angina2
Surgical TMR as alternative therapy for chronic stable angina in patients:

  • Refractory to medical therapy
  • Not candidates for percutaneous intervention or revascularization
Class IIa, Level A
2004 STS Practice Guideline for Transmyocardial Laser Revascularization3
TMR sole therapy for patients with:

  • Ejection fraction >30%
  • Class III-IV angina refractory to maximal medical therapy
  • Reversible ischemia of left ventricular free wall and CAD in region of myocardial ischemia
  • CAD not amenable to CABG or PTCA, due to either:
    • Severe diffuse disease, or
    • Lack of suitable targets or conduits for complete revascularization

TMR adjunctive to CABG for patients with:

  • Angina Class I-IV in whom CABG is the standard of care, with at least one accessible and viable ischemic region with CAD that cannot be bypassed, due to either:
    • Severe diffuse disease, or
    • Lack of suitable targets or conduits for complete revascularization
Class I, Level A

Class IIa, Level B

2006 ISMICS Consensus Statement for Transmyocardial Laser Revascularization4
TMR sole therapy for stable patients with refractory severe angina not amenable to conventional revascularization, to:

  • Improve sustained angina relief
  • Reduce MACE and improve exercise performance
  • Reduce readmissions and reinterventions

TMR adjunctive to CABG for patients with diffuse CAD who cannot be completely revascularized by CABG alone, to:

  • Improve long term angina relief
  • Reduce 30-day mortality and MACE
Class I, Level A

Class I, Level A

Class IIa, Level B


Class IIa, Level B

Class IIa, Level A/B

2011 ACC/AHA Guideline Update for Coronary Artery Bypass Graft Surgery5
Surgical TMR, either alone or in combination with CABG, is reasonable in patients:

  • With angina refractory to medical therapy
  • Not candidates for PCI or surgical revascularization
Class IIb, Level A
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management
of Patients with Stable Ischemic Heart Disease6

  • Standalone TMR for the relief of refractory angina in patients with stable ischemic heart disease (SIHD)
  • TMR Performed as an adjunct to CABG to improve symptoms in patients with viable ischemic myocardium that is perfused by arteries that are not amenable to grafting
Class IIb, Level A

Class IIb, Level B

TMR Case Study Kit

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Learn from three case studies about how TMR can reduce or eliminate angina pain by these patients' five- or six-month follow up.

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  1. Leon, M. et al. , J Am Coll Cardiol. 2005 Nov 15;46(10):1812-9. Epub 2005 Oct 19.
  2. Gibbons RJ, et al. Circulation 2003;107:00-00.
  3. Bridges CR, et al. Ann of Thorac Surg 2004;77:1494-1502.
  4. Diegeler A, et al. Innovations 2006;1:314-322.
  5. Hillis LD, et al. Circulation 2011;124:2610-2642
  6. Fihn, SD, et al. Circulation. 2012; 126(25): e354-347

Clinical Applications

Learn how to perform TMR as a sole therapy or adjunctive with CABG and the clinical outcomes when treating angina.