Trans Myocardial laser re vascularisation (TMLR) : Patients who have severe angina and diffuse coronary artery disease with no graftable vessels are at limes subjected to TMLR. In this procedure target areas of myocardium are marked based on pre-operative studies. On a beating heart with special laser equipment, laser channels are created one cm npa1.1 on selected areas of niyocnrdium of left vcntriclc. 10-12. such channels arc created on the anterior anti lateral walls of LV as required. These should be away from major coronary artery branches. At times there may be one or two graftable vessels and large areas of myocardium that cannot be revascularised. A hybrid procedure is done for these cases. TMLR is done first and after haemostasis patient is heparinised and grafting is done either on or off bypass. This procedure has been described ant1 popularized from Escorts hospital india by Dr. Naresh Trehan.