Unmanageable unstable angina patients undergoing transmyocardial laser revascularization (TMR), in whom conventional revascularization was not possible form the basis of this study. Patients were classified in the unmanageable unstable angina group, when they had been admitted to the CCU with unstable angina for seven days, with three failed attempts at weaning them off intravenous antianginal medications. Ninety-seven routine protocol patients, undergoing TMR for chronic angina not amenable to standard revascularization, were compared with thirty-five patients in the unmanageable unstable angina group. The procedure was performed through a left thoracotomy without cardiopulmonary bypass. These patients were followed for twelve months after the TMR procedure.

Unmanageable unstable angina group patients had a higher rate of diabetes, reduced ejection fractions, and female patients. Early and late mortality were higher in the unmanageable unstable angina group. All adverse events in the unmanageable unstable angina group occurred in the first 3 months. Patients surviving this interval did well with angina reduced by at least two classes occurring in 85% and 90% of the unmanageable unstable angina group at 3 months and 6 months, respectively. This was accompanied by a reduction in antianginal medications of at least two drugs. The unmanageable unstable angina group patients (40%) demonstrated improvement in their thallium perfusion scans. In conclusion, TMR carries a higher risk in unmanageable unstable angina. There was no difference however between the protcol and unmanageable unstable groups in the follow-up interval, after three months. The procedure can be cautiously recommended in this end-stage group of patients, who otherwise have no recourse to effective therapy in the control of their angina.