This is the current release of the guideline.

The levels of evidence (A-C) and classification of recommendations (I-III) are defined at the end of the "Major Recommendations" field.

Recommendations for Transmyocardial Laser Revascularization (TMR) as Sole Therapy

Class I

1. Patients with an ejection fraction greater than 30% and Canadian Cardiovascular Class III or IV angina that is refractory to maximal medical therapy. These patients should have reversible ischemia of the left ventricular free wall and coronary artery disease corresponding to the region of myocardial ischemia. In all regions of the myocardium, the coronary disease must not be amenable to coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA), either due to a) severe diffuse disease, b) lack of suitable targets for complete revascularization, c) lack of suitable conduits for complete revascularization. (Level of Evidence: A)

Class IIB

1. Patients who otherwise have Class I indications for TMR but who have either
   1. Ejection fraction less than 30 percent with or without insertion of an intraaortic balloon pump. (Level of Evidence: C)
   2. Unstable angina/acute ischemia necessitating intravenous antianginal therapy. (Level of Evidence: B)
   3. Patients with Class II angina. (Level of Evidence: C)

Class III

1. Patients without angina or with Class I angina. (Level of Evidence: C)
2. Acute evolving myocardial infarction or recent transmural or nontransmural myocardial infarction. (Level of Evidence: C)
3. Cardiogenic shock defined as a systolic blood pressure less than 80 mm/Hg or a cardiac index of less than 1.8L/min/m2. (Level of Evidence: C)
4. Uncontrolled ventricular or supraventricular tachyarrhythmias. (Level of Evidence: C)
5. Decompensated congestive heart failure. (Level of Evidence: C)

Recommendations for TMR as an Adjunct to CABG

Class IIa

1. Patients with angina (Class I - IV) in whom CABG is the standard of care who also have at least one accessible and viable ischemic region with demonstrable coronary artery disease which cannot be bypassed, either due to a) severe diffuse disease, b) lack of suitable targets for complete revascularization, or c) lack of suitable conduits for complete revascularization. (Level of Evidence: B)

Class IIb

1. Patients without angina in whom CABG is the standard of care who also have at least one accessible and viable ischemic region with demonstrable coronary artery disease which cannot be bypassed, either due to a) severe diffuse disease, b) lack of suitable targets for complete revascularization, or c) lack of suitable conduits for complete revascularization. (Level of Evidence: C)

Class III

Patients in whom CABG is not the standard of care (Level of Evidence: C)

Definitions

Level of Evidence

Level A: Data derived from multiple randomized clinical trials

Level B: Data derived from a single randomized trial or from several nonrandomized trials

Level C: Consensus expert opinion

Classification of Recommendations

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment

II.a.: Weight of evidence/opinion is in favor of usefulness/efficacy

II.b.: Usefulness/efficacy is less well established by evidence or opinion

Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful and in some cases may be harmful

None provided

The type of evidence supporting the recommendations is specifically stated for each recommendation (see 'Major Recommendations' field).

Not applicable: The guideline was not adapted from another source.

2003

Society of Thoracic Surgeons - Medical Specialty Society

Society of Thoracic Surgeons

Workforce on Evidence-Based Medicine

Workforce Members: Charles R. Bridges, MD (TMR Taskforce Chair), ScD; Keith A. Horvath, MD; William C. Nugent, M.D; David M. Shahian, MD; Constance K. Haan, MD; Richard J. Shemin, MD; Keith B. Allen, MD; Fred H. Edwards, MD

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on March 30, 2005. The information was verified by the guideline developer on May 3, 2005.

© 2003 The Society of Thoracic Surgeons
The Society of Thoracic Surgeons Practice Guidelines may be printed or downloaded for individual and personal use only. Guidelines may not be reproduced in any print or electronic publication or offered for sale or distribution in any format without the express written permission of the Society of thoracic Surgeons.