Transmyocardial revascularization (TMR): current status and future directions

  • Keith B. AllenEmail author
  • Amy Mahoney
  • Sanjeev Aggarwal
  • John Russell Davis
  • Eric Thompson
  • Alex F. Pak
  • Jessica Heimes
  • A. Michael Borkon
Review Article



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.


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.


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.


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.


Transmyocardial revascularization TMR Laser 


Compliance with ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflicts of interest

Dr. Keith Allen has had prior research support from CryoLife, Inc., as national PI for TMR studies (none currently) and currently serves in the speaker’s bureau. Amy Mahoney is employed by CryoLife, Inc. All other authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was not necessary for the review article.


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Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  1. 1.Saint Luke’s Mid America Heart InstituteKansas CityUSA
  2. 2.CryoLife, Inc.KennesawUSA

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