**Author details**

it will cause bleeding which may be problematic. Detection of transmural penetration is

Mortality following TMR ranges from 1% to 5%; however, this low rate of mortality is primarily generalized to patients who are electively taken to the operating room and are hemodynami‐ cally stable. When these patients are taken to the operating room emergently, mortality is reported to be 10-20%. One-year survival following TMR ranges from 79% to 96% and is not significantly different from patients who undergo medical therapy. The primary advantage of TMR over medical therapy and the principal indication for intervention is the reduction in symptomatology; studies have found that 25%-76% of patients will achieve a decrease of 2 or more angina classes following intervention, which is not the case of patients undergoing medical intervention. Review of the randomized controlled study suggests improvement in perfusion for CO2 TMR treated patients. [45 46] Long term results suggest improved angina

However, the benefit of TMR is controversial. Cochrane review published it data after reviewing seven studies (1137 participants of which 559 randomized to TMR). Overall, 43.8 % of patients in the treatment group decreased two angina classes as compared with 14.8 % in the control group. Mortality at both 30 days (4.0 % in the TMR group and 3.5 % in the control group) and 1 year (12.2 % in the TMR group and 11.9 % in the control group) was similar in both groups. The 30-days mortality as treated was 6.8% in TMLR group and 0.8% in the control group, showing a statistically significant difference. Their conclusion was there is insufficient evidence to conclude that the clinical benefits of TMLR outweigh the potential risks and the

TMR is used in conjunction with CABG as well. One randomized controlled study have found that TMR combined with CABG may confer excellent perioperative and survival rates, including decreased opeartive mortality, inotropic support, and intensive care unit stay, while prolonging 1-year survival compared to those patients undergoing CABG alone. [49] Further‐ more, patients who undergo both procedures appear to be less symptomatic at follow-up.

In conclusion application of TMR in selected group for the treatment with severe angina due

Complex CAD remains a challenge for cardiac surgeons; however, evolving techniques and strategies can be used to overcome this challenge. Although reoperative CABG is a high-risk procedure, proper preoperative assessment and surgical planning has yielded excellent results. Patients who are not candidates for CABG or percutaneous coronary interventions due to diffusely diseased vessels can be offered coronary endarterectomy. Calcified aorta encoun‐ tered during surgery can be managed by aortic replacement, endarterectomy, using no touch

to diffuse disease can be used achieves a more complete revascularization.

primarily by tactile and auditory feedback.

symptoms and decreased hospitalization in five years. [47]

procedure is associated with a significant early mortality. [48]

**5.2. Outcome**

182 Artery Bypass

**6. Conclusion**

Tsuyoshi Kaneko and Sary Aranki\*

Brigham and Women's Hospital, Harvard Medical School, USA
