Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: a prospective randomised trial

Standard treatments for angina pectoris are effective for most patients. Some patients with advanced disease, however, become less responsive to medication but are not candidates for percutaneous transluminal coronary angioplasty or coronary-artery bypass grafting because the atherosclerotic lesions are too diffuse. These patients have frequent angina, limited exercise tolerance, and poor quality of life. Transmyocardial revascularisation (TMR) was developed to treat such patients.1 TMR is a surgical procedure that uses a laser to create channels through the myocardial wall to the ventricular chamber. Although there is controversy about the mechanism of action, early clinical trials of TMR in the USA with carbon-dioxide lasers showed encouraging results. However, these results have been challenged because of high crossover rates and lack of masked assessment of symptoms. A subsequent study that used a carbon-dioxide laser but did not allow for crossover in the study design showed limited clinical benefits in patients with predominantly class III angina. We designed the Angina Treatments—Lasers and Normal Therapies in Comparison (ATLANTIC) prospective randomised study to compare TMR with continued medical therapy in patients with medically refractory angina.