TMR as an Adjunct to CABG TMR has been used on occasion in patients with severe angina refractory to GDMT in whom complete revascular- ization cannot be achieved with PCI and/or CABG. Although the mechanism by which TMR might be efficacious in these patients is unknown,502,503 several RCTs of TMR as sole therapy demonstrated a reduction in anginal symptoms com- pared with intensive medical therapy alone.397 399,504 506 A single randomized multicenter comparison of TMR (with a holmium:YAG laser) plus CABG and CABG alone in sub- jects in whom some myocardial segments were perfused by arteries considered not amenable to grafting showed a signif- icant reduction in perioperative mortality rate (1.5% versus 7.6%, respectively), and the survival benefit of the TMR CABG combination was present after 1 year of follow-up.400 At the same time, a large retrospective analysis of data from the STS National Cardiac Database, as well as a study of 169 patients from the Washington Hospital Center who under- went combined TMR CABG, showed no difference in ad- justed mortality rate compared with CABG alone.401,507 In short, a TMR CABG combination does not appear to im- prove survival compared with CABG alone. In selected patients, however, such a combination may be superior to CABG alone in relieving angina. 3.11. Hybrid Coronary Revascularization: Recommendations Class IIa 1. Hybrid coronary revascularization (defined as the planned combination of LIMA-to-LAD artery graft- ing and PCI of >1 non-LAD coronary arteries) is reasonable in patients with 1 or more of the follow- ing508 516 (Level of Evidence: B): a. Limitations to traditional CABG, such as heavily calcified proximal aorta or poor target vessels for CABG (but amenable to PCI); b. Lack of suitable graft conduits; c. Unfavorable LAD artery for PCI (ie, excessive vessel tortuosity or chronic total occlusion). Class IIb 1. 