Myocardial revascularization is an alternative procedure for patients with ischemic heart disease that are not able to get percutaneous coronary intervention or coronary artery bypass graft procedures because of failure of procedures, diffuse coronary artery disease, small coronary arteries, or stenosis.  There are two types of myocardial revascularization: transmyocardial revascularization (TMR) and the newer percutaneous myocardial revascularization (PMR).  Both use high-energy lasers to create holes in the heart between the epicardium (outer layer) and the endocardium (inner layer) to allow blood to flow directly from the left ventricle into the myocardium (middle muscular layer).  

Pre-Operative Details:

Your surgeon will give specific instructions before the surgery, including risks (i.e. bleeding, infection, adverse reaction to anesthesia, etc.).  Please make sure to contact your insurance company for coverage.  You will also meet with the anesthesiologist prior to the surgery to go over your medical history.  Please do not eat after midnight the night before your surgery.  On the day of surgery, you will arrive at the hospital, get registered, and get changed into a hospital gown.  A nurse will then review your chart to make sure there are no problems and then get all the paperwork in order for surgery.  The anesthesiologist will then start an IV and you will be taken to the operating room, where the surgeon will verify your name and procedure before any medication is given.  Once you are under anesthesia, surgery will begin.

Operative Details:

• TMR - The surgeon will do a thoracotomy to get to the heart.  This means an incision will be made in between the ribs and then the ribs will be spread along one side to allow access to the heart.  The patient will not be on cardiopulmonary bypass as the procedure is tolerated with the heart still beating.  A high-energy laser beam is then applied to the left ventricle area and will burrow a hole through the heart muscle layers to allow oxygenated blood to come directly out of the left ventricle to the myocardium, therefore "doing the work" of the obstructed coronary artery.  Then, he will finish up and use stitches to close the initial incision.  
• PMR - The surgeon will use a local anesthetic to the groin area and then make a tiny incision to allow a catheter (thin tube) to be placed in the femoral artery.  A fiberoptic catheter is then placed inside the first catheter and guided through the vasculature to the heart.  A high-energy laser beam is then emitted from the catheter through the endocardium of the left ventricle to the myocardium (NOTE: in TMR, the laser burns a hole through all 3 layers from outside-in whereas in PMR, the laser burns a hole through 2 layers from inside out).  Once completed, the catheters will be removed and the incision will be closed.  

Post-Operative Details:

After the surgery, you will be taken to the post-operative/recovery area or the intensive care unit and be monitored.  You will likely experience pain and will given pain medication appropriately.  It is important to keep the incision areas clean and dry.  The length of your hospital stay depends on how quickly you are able to recover and perform some physical activity.  If you experience fevers, severe pain, redness/swelling/warmth where the incisions were made, or drainage from the incisions, please let your doctor know immediately.  Your surgeon will give specific instructions about recovery time.