1. Primary Transmyocardial Laser Revascularization for End-Stage Coronary Artery Disease 
Thoralf M. Sundt, Marc R. Moon 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 6, Issue 3, Pages (August 2001)
DOI: /otct
Copyright © 2001 Elsevier Inc. Terms and Conditions

2. 1
TMR may be performed as a “stand alone” procedure or in combination with conventional CABG. Either may be performed via a median sternotomy or a thoracotomy approach, depending on the territories to be treated. The most frequent indication for the combined procedure in our practice has been after previous CABG, often in the presence of a patent internal thoracic artery graft to the left anterior descending artery and with occluded vein grafts to the inferior and lateral walls. Occasionally an individual will present with lateral wall or lateral and inferior wall ischemia alone, in which cases we have used a lateral thoracotomy approach most often. When a bypass graft must be performed, this provides access to the descending thoracic aorta for a proximal anastomosis. When no grafts are required, the procedure may be performed via a limited anterior thoracotomy.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

3. 2
When a full posterolateral thoracotomy is performed, we enter the fifth intercostal space and “shingle” the sixth rib posteriorly.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

4. 3
The chest retractor is positioned with the crossbar anteriorly for ultimate attachment of the tissue stabilizer. The inferior pulmonary ligament is taken down with electrocautery.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

5. 4
The pericardium may be entered either anterior or posterior to the phrenic nerve, or through both routes. This provides easy access to virtually the entire left ventricle. When approaching a circumflex marginal vessel for concomitant CABG, we most often start with an incision posterior to the phrenic, providing access right down to the atrioventricular groove.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

6. 5
Stay sutures in the pericardium may be passed through the subcutaneous tissue (as shown for clarity) or, more commonly, directly through the chest wall by directing the tails through a 14-gauge peripheral venous catheter inserted at the location of choice and secured in place with snaps. This provides maximum traction at the optimal angle while keeping the strings out of the wound.
With the pericardium retracted in this manner, distal vessels are evaluated for their adequacy. If none are found, then TMR can be carried out at this point. If a candidate vessel is identified, a partial occlusion clamp is placed on the descending thoracic aorta for creation of the proximal anastomosis.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

7. 6
Proximal anastomosis of a vein graft or radial artery to the aorta may be performed directly on the aorta if it is of good quality. Frequently, however, there will be thickening of the wall or local plaque. This may be overcome by creating a larger defect and patching it with a disc of pericardium (A). The proximal anastomosis is then created to this patch (B).
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

8. 7
Once the proximal anastomosis has been completed, a tissue stabilizer is positioned appropriately.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

9. 8
The distal anastomosis is carried out in the usual manner, with control achieved proximally or both proximally and distally using elastic tapes.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

10. 9
After the bypass graft is completed, the inferior and lateral walls may be accessed by elevating the apex of the heart. Channels are created at approximately one-cm intervals beginning at the base and moving toward the apex. Most often, four or five channels may be made in rapid succession. Hemostasis is then achieved by providing digital pressure or by applying a sponge over the entire treatment area.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

11. 10
If the anterior wall requires treatment, then it is easily accessed by depressing the apex.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions

12. 11
If stand-alone TMR is planned, access can be achieved via a small anterior thoracotomy in the fifth intercostal space. The pericardium is then opened anterior to the phrenic nerve. Access to the base of the heart is limited, but the inferior, lateral, and anterior walls can be accessed simply by deflecting the ventricle as needed. The malleable TMR wand can be shaped as needed to access all portions of the ventricle.
Operative Techniques in Thoracic and Cardiovascular Surgery 2001 6, DOI: ( /otct )
Copyright © 2001 Elsevier Inc. Terms and Conditions