Transmyocardial laser revascularization (TMLR) applies laser energy directly to areas in the heart where blockage has occurred, creating 10 to 50 tiny channels. TMLR can be performed in high-risk patients who do not respond to other treatments. Patients report improved symptoms and exercise tolerance.
A variant called percutaneous transmyocardial laser revascularization uses a small laser (a holmium YAG laser), which is smaller than the device used in TMLR and does not require open chest surgery and a general anesthetic.
Both procedures carry risks for serious complications, however, including some that can be life-threatening. It is not clear if either TMLR procedure improves survival, and, in one study, the quality of life afterwards was less than with standard heart surgeries.
Enhanced External Counterpulsation (EECP)
A noninvasive technique called enhanced external counterpulsation (EECP) has been used successfully by over a million people in China. The technique uses an air pump that inflates and deflates pressurized cuffs around the legs, causing blood to be pushed into the heart. In different studies, it has relieved angina in over 75% of patients who used it. The benefits persist, and there is some evidence that it produces actual cellular changes that benefit the heart. It may also improve depression and anxiety. Some experts now recommend it for patients with angina that do not respond to standard therapies. Those with three diseased vessels, however, do less well, and the procedure is not appropriate for those with heart failure or blood clots in the legs. EECP will not be likely to replace angioplasty or bypass, but it may reduce the need for nitrates.
Atherectomy procedures clear the narrowed arteries by using an approach called debulking. All these procedures use a catheter (a thin tube) that is inserted into the thigh and threaded up to the blockage. Devices are inserted through the tube to remove the plaque. They include:
- Rotational atherectomy, which uses a tiny cutter spinning at 2,500 rpm
- Extractional atherectomy, which "shaves" the plaque
- Directional atherectomy, which slices the plaques
Although they are successful in opening arteries, they offer no advantages over standard angioplasty and are used only for special cases.
Review Date: 04/12/2006
Reviewed By: Harvey Simon, M.D., Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital