CPT® Code 33140

1. Indications

The transmyocardial laser revascularization (TMR) procedure is indicated for patients who have significant coronary artery disease and are experiencing angina or other symptoms related to inadequate blood flow to the heart muscle. The following conditions may warrant the performance of TMR:

• Severe Coronary Artery Disease Patients with advanced coronary artery disease that is not amenable to traditional revascularization techniques such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI).
• Refractory Angina Individuals suffering from chronic angina that persists despite optimal medical therapy, indicating a need for alternative revascularization options.
• Left Ventricular Dysfunction Patients with impaired left ventricular function due to ischemic heart disease, where improving blood flow may enhance cardiac performance.

2. Procedure

The transmyocardial laser revascularization procedure involves several critical steps to ensure successful revascularization of the myocardium. The following outlines the procedural steps:

• Step 1: Anesthesia and Preparation The patient is placed under general anesthesia to ensure they are unconscious and pain-free during the procedure. A double lumen endotracheal tube is inserted to facilitate ventilation of the right lung, which allows for better exposure of the heart during the operation.
• Step 2: Accessing the Heart The surgical team performs either a midline sternotomy or an anterolateral thoracotomy to access the heart. The pericardium, the protective sac surrounding the heart, is then incised to provide direct access to the heart muscle.
• Step 3: Laser Setup The energy level and pulse duration of the laser are set according to the specific requirements of the procedure. This calibration is crucial for ensuring the laser operates effectively and safely.
• Step 4: Positioning the Laser Probe The laser probe is positioned over the left ventricle, making contact with the epicardium. This positioning is essential for targeting the appropriate areas of the heart for revascularization.
• Step 5: Laser Application Utilizing a computer, the laser beam is directed to the predetermined areas of the heart. The laser is activated between heartbeats to minimize damage to surrounding tissues, creating small channels approximately one millimeter in diameter that extend from the surface of the heart into the internal ventricular chamber.
• Step 6: Repetition of Laser Application The laser application is repeated 20 to 40 times, depending on the specific needs of the patient and the extent of revascularization required.
• Step 7: Managing Bleeding After the channels are created, the external surface of the heart typically closes quickly. If there is ongoing bleeding from the epicardial surface, local pressure or sutures are applied to control it.
• Step 8: Finalizing the Procedure The channels within the left ventricle remain open, allowing oxygen-rich blood to flow through them as the left ventricle pumps blood into the aorta. Following the completion of TMR, the pericardium is reapproximated, and one or more chest tubes are placed in the pericardial cavity to facilitate drainage and prevent fluid accumulation.

3. Post-Procedure

After the transmyocardial laser revascularization procedure, patients are typically monitored in a recovery area for any immediate complications. The placement of chest tubes allows for the drainage of any excess fluid or blood that may accumulate in the pericardial cavity. Patients may experience some discomfort or pain at the incision site, which can be managed with appropriate analgesics. The expected recovery period may vary, but patients are generally advised to follow up with their healthcare provider for ongoing assessment of heart function and to monitor for any potential complications. Rehabilitation and gradual return to normal activities are often recommended as part of the recovery process.