There is a less invasive, catheter-based procedure for performing transmyocardial revascularization (TMR). In this procedure, a laser-tipped catheter is fed through the femoral artery in the groin and all the way to the heart. There, it can create the channels in the heart. By inserting the laser into the body via a catheter instead of an incision between the ribs, the following advantages are gained:

Researchers are also studying the use of needles to drill holes in the heart wall to have the same effect as either of the TMR procedures. In addition to these alternatives to TMR, there is also a noninvasive treatment for angina called enhanced external counterpulsation (EECP). The treatment involves air (pneumatic) cuffs that are wrapped around the legs at three places and inflated between heartbeats. The inflated cuffs gently compress the blood vessels in the leg, forcing blood back into the heart. Like TMR, this can help to relieve angina. However, it is not appropriate for people who have conditions such as:

• Unpredictable chest pain (unstable angina)
• Heart failure
• Major damage to the heart muscle
• Serious valvular heart diseases (e.g., aortic regurgitation)
• Atrial fibrillation or frequent extra heartbeats
• Uncontrolled high blood pressure (hypertension)
• Severe artery or vein disease in the legs
• Tendency to bleed excessively (including those with ulcers)
• Pregnancy

EECP is also not advised for people with pacemakers, implantable defibrillators or patients taking anticoagulants.

Ultimately, however, the use of TMR is limited by the increasing sophistication of both conventional coronary artery bypass graft surgery (CABG) and angioplasty/stent procedures. In recent years, these techniques have been refined and applied to ever-sicker and older patients, thus narrowing the pool of prospective patients that might have been recommended for TMR. As a result of these limitations, TMR is generally used today as an adjunct to CABG surgery for parts of the heart that are severely lacking oxygen-rich blood.