TRANSMYOCARDIAL LASER REVASCULARIZATION - DOES IT HAVE A ROLE IN THE TREATMENT OF ISCHEMIC-HEART-DISEASE

Transmyocardial laser revascularization, with or without coronary arte ry bypass grafting, is an alternative modality for complete revascular ization in selected patients with coronary artery disease. Arguably, t his modality works by shunting left ventricular blood directly into th e ischemic myocardium via laser-mediated transmural channels. in clini cal trials drilling of laser channels has been strongly correlated wit h long-term improvement of angina, but a causal relationship has not y et been documented. For now, the usefulness of transmyocardial laser r evascularization and the nature of its mechanism remain controversial. Some researchers question the existence of myocardial sinusoids altog ether. Others question the physiologic possibility of moving blood fro m the left ventricular cavity into the myocardium against a pressure g radient. Further questions concern the possible routes through which t he additional blood gains access to the myocardium; the difficulty of objectively documenting improved myocardial perfusion after transmyoca rdial laser revascularization, and the nature of the mechanism respons ible for the observed clinical benefit. This article examines the diff erent aspects of this controversy and discusses the current status of transmyocardial laser revascularization, as well as possible future di rections.