from controlled trials to clinical practice monitoring transmyocardial revascularization use and outcomes objectives we sought to examine trends in the use and outcomes of transmyocardial revascularization tmr in community practice we also identified important risk factors for tmr and compared outcomes of tmr combined with coronary artery bypass graft surgery tmr cabg versus bypass alone in patients receiving incomplete revascularizationbackground although it is approved for use as a standalone procedure there are limited data on the outcomes of tmr cabgmethods we identified 3717 patients receiving tmr at 173 us hospitals participating in the society of thoracic surgeons sts national cardiac database baseline characteristics and outcomes in these patients were compared with those from six published randomized tmr trials multivariable logistic regression was used to identify clinical risk factors for mortality with tmr riskadjusted mortality was also compared for tmr cabg relative to cabg only in patients not amenable to complete traditional revascularizationresults between january 1998 and december 2001 the number of sts hospitals performing tmr and total procedural counts increased markedly driven predominately by more tmr cabg cases overall mortality rates for tmralone and tmr cabg were 64 and 42 respectively operative risks were significantly higher in those patients with recent myocardial infarction unstable angina and depressed ventricular function among patients receiving incomplete revascularization tmr cabg was not associated with decreased mortality risk compared with cabg alone adjusted odds ratio 111 95 confidence interval 074 to 167conclusions the use of tmr and in particular tmr cabg is expanding in community practice although procedural risks are high there is room for optimization through improved patient selection and timing of the procedure further studies of tmr cabg are needed given its growing use and unclear benefits