Introduction

Every tissue and organ in our body needs oxygen to survive. However, what happens when the heart muscle doesn't receive enough oxygen due to clogged arteries, a condition known as (CAD) coronary artery disease?¹ This can lead to a lack of oxygen, called myocardial ischemia², and severe pain in the form of angina.³

A medical procedure called Transmyocardial Laser Revascularization (TMLR) is performed to remedy this. This procedure creates tiny holes in the heart muscle's left ventricle, responsible for carrying oxygen. Doing so stimulates the muscle, improves blood flow, and increases oxygen supply to the heart muscle. Ultimately, this helps the heart function to normal.

Purpose and significance of TMLR in cardiac care

Transmyocardial Laser Revascularization is a specialised technique not widely used in all coronary artery disease or myocardial ischemia cases. However, it can be a crucial option for individuals who have not experienced any improvement through traditional medical treatments for their chest pain. This advanced procedure involves the creation of tiny channels in the heart muscle using a laser, which allows the growth of new blood vessels and improves blood flow to the heart through angiogenesis.⁴ 

Besides TMR, other advanced techniques are available, such as cell/gene therapy or transcutaneous electric nerve stimulation, that can be used in combination to enhance the effectiveness of the treatment. These advanced options have significantly improved the prognosis for individuals with coronary artery disease or myocardial ischemia who have not responded to traditional therapies.

How is it performed?

Laser therapy, a pivotal component of Transmyocardial Laser Revascularization (TMLR), harnesses the power of advanced laser technology, employing two primary types of lasers: the Ho: YAG laser system and a specialized CO2 laser emitting infrared light. Each laser system serves a unique purpose in the TMLR procedure, allowing surgeons to choose the most suitable option based on individual patient needs and the specifics of the heart condition being addressed.

The Ho: YAG laser system operates by emitting a specific wavelength of light that is readily absorbed by heart tissue. This laser's precision enables surgeons to create precise channels within the heart muscle, fostering improved blood flow and oxygenation to the compromised areas. On the other hand, the specialized CO2 laser, generating infrared light, offers a distinct approach in creating microchannels within the heart muscle, aiding in the enhancement of blood perfusion to alleviate angina symptoms.

The overarching goal of laser therapy in TMLR extends beyond mere procedural intervention. It seeks to repair damaged heart muscle by strategically creating these microchannels, prompting the heart to receive an increased supply of oxygen-rich blood. By enhancing blood flow to areas where it's most needed, laser therapy aims to alleviate chest pain (angina), thereby fostering improved heart function and overall well-being for individuals grappling with severe coronary artery disease.

This advanced therapeutic approach is a testament to the continual evolution of medical technology, offering a ray of hope for individuals for whom traditional treatments have been insufficient. As research and technological advancements persist, the refinement of laser therapy in TMLR holds promise for further improvements in cardiac care, shaping the landscape of heart disease management toward more effective and tailored interventions.

Who can undergo this treatment?

Individuals who might benefit from Transmyocardial Laser Revascularization (TMLR) are typically those facing significant chest pain (angina) caused by limited blood flow to the heart muscle despite trying other treatments like medications or surgeries to open up blocked arteries. Candidates for TMLR often fall into these categories:

• Severe angina: People experiencing frequent and intense chest pain that isn't adequately controlled by medications or other procedures
• Blocked arteries: When other treatments like stents or bypass surgery aren't suitable due to multiple blockages
• High risk for surgery: Individuals at increased risk for conventional surgeries due to various health conditions might be candidates for TMLR, as it's considered less invasive than some other procedures
• Not Responding to medication: Those whose chest pain isn't responding well to medications or who cannot tolerate these medications due to side effects

However, the decision about whether someone is suitable for TMLR is made after careful evaluation by a medical team. They consider a person's overall health, the severity of their heart condition, and other factors before determining if TMLR is the right choice.

How is it diagnosed?

Candidates considered for Transmyocardial Laser Revascularization (TMLR) undergo a thorough evaluation by the cardiologist⁵ team to determine if the procedure suits them. The evaluation process involves several steps:

• Medical history review: Doctors assess the individual's medical history, including any heart conditions, past surgeries, medications taken, and overall health status
• Physical examination: A comprehensive physical exam is conducted to assess the heart's current condition and overall health
• Diagnostic tests: Various tests are performed to gather detailed information about the heart's structure and function. These tests may include electrocardiogram (ECG), echocardiogram, stress tests, cardiac catheterisation⁶, and imaging scans like MRI or CT scans
• Assessment of angina severity: Doctors evaluate the frequency, duration, and intensity of chest pain (angina) experienced by the individual to determine its impact on their daily life and activities
• Response to previous treatments: The effectiveness of prior treatments, such as medications or other heart procedures, in relieving angina symptoms is assessed. If these treatments haven't provided sufficient relief, TMLR may be considered
• Overall health status: Factors such as age, presence of other medical conditions, and general fitness level are considered to assess the individual's ability to undergo and recover from the procedure

Based on the information gathered from these evaluations, the cardiologist team collaborates to determine whether TMLR suits the candidate. The decision considers the potential benefits of the procedure weighed against the individual's overall health condition and the likelihood of achieving improved heart function and reduced angina symptoms.

What should we expect after finding TMLR as the treatment of choice?

Following the essential pre-operative assessments, the surgeon provides specific guidelines to enhance the success of the upcoming Transmyocardial Laser Revascularization (TMLR) procedure. Among these instructions, the surgeon advises discontinuing smoking and ceasing the use of aspirin tablets at least two days before the surgery. The reasoning behind this advice lies in the impact these substances have on blood coagulation; aspirin, in particular, affects the clotting process, and smoking can interfere with the body's ability to heal optimally post-surgery.

Upon admission, typically the night before or the morning of the surgery, the individual is instructed to fast—refraining from eating and drinking. This fasting period helps minimise the risk of complications during the procedure and ensures a safer anaesthesia⁷ administration.

Throughout this process, guidance from both the cardiologist and surgeon is paramount. The cardiologist may provide additional recommendations or medications to stabilise the heart condition before the procedure. Meanwhile, the surgeon may offer specific directives regarding pre-operative preparations, detailing any other medications that should be paused or taken differently, and instructions on preparing for the surgical intervention.

During the actual TMLR procedure, the entire operation is performed under anaesthesia. This ensures the individual is comfortably asleep and pain-free while the surgical team meticulously executes the necessary steps. The anaesthesia allows for a painless experience, promoting a smooth and controlled environment for the successful completion of the surgery.

What are the benefits and risks involved in undergoing this procedure?

Benefits:

• Reduce angina symptoms in their frequency and duration, thus enhancing patients' quality of life
• Improving blood-flow. These micro-channels act as alternative pathways for blood, delivering oxygen-rich blood directly to the heart muscle
• Enhancing heart function by inducing a healing response, encouraging new blood vessel formation and improving the heart's ability to pump blood efficiently
• Most importantly, it is a less invasive technique than other procedures

Risks:

• Bleeding and infection: There's a risk of bleeding during or after the procedure. Additionally, like any surgery, there's a potential risk of infection at the incision site
• Heart rhythm issues: TMLR might cause irregular heart rhythms (arrhythmias) in some individuals, which may require treatment to regulate the heartbeat
• Puncture of heart: The laser used during the procedure could inadvertently cause a puncture in the heart muscle, leading to complications that might require immediate medical intervention
• Chest pain or discomfort: Some people may experience continued or increased chest pain after TMLR, although this often improves

It's important to note that the likelihood of these risks varies among individuals and depends on various factors, including overall health, the severity of the heart condition, and any pre-existing medical conditions.

FAQs

What is the recovery time for laser heart surgery?

Your doctor will likely limit your activities for several weeks after transmyocardial laser revascularization. It can take three months or more for a complete recovery. It's vitally important to follow heart-healthy guidelines for life. Most people are able to return to activities that once caused chest pain.

How long is hospital stay after minimally invasive heart surgery?

From there, you may go to a special care unit or a regular room. The hospital stay after minimally invasive heart surgery varies. But it's often 3 to 5 days.

How painful is heart surgery recovery?

You may have some brief, sharp pains on either side of your chest. Your chest, shoulders, and upper back may ache. These symptoms usually get better after 4 to 6 weeks. The incision in your chest and the area where the healthy blood vessel was taken may be sore or swollen.

What is the fastest way to recover from bypass surgery?

Help your body heal properly: Eating a heart-healthy diet, being active, reducing your stress, getting enough sleep and avoiding smoking are all important lifestyle choices that will help you heal and get back to your daily routine.

Summary

TMLR is a medical procedure that aims to improve blood supply to the heart to reduce angina symptoms and enhance the heart's overall function. This is particularly useful for patients who have not had success with traditional treatments like medications or surgeries to open blocked arteries. 

During the procedure, precise and controlled laser incisions are made in the heart muscle under anaesthesia to ensure the patient's comfort and pain-free experience. Patients are carefully evaluated based on their medical history, angina severity, response to prior treatments, and overall health status to determine their eligibility for the procedure. 

Although TMLR presents as a promising solution, it's not without potential risks, including bleeding, infection, heart rhythm disturbances, and incomplete relief of symptoms for some patients. However, for many patients, TMLR can significantly alleviate chest pain and improve their quality of life by enhancing blood flow to the heart muscle. 

The decision to pursue TMLR involves collaborative discussions between the patient and their cardiologist. As an evolving procedure, ongoing advancements in technology and research continue to refine TMLR's effectiveness and safety, offering hope for those struggling with severe angina and limited blood supply to the heart.