Despite the success of current medical and surgical management of ischemic heart disease, a growing number of patients have diffuse obstructive coronary artery disease that is not amenable to coronary artery bypass grafting or catheter based interventions. This problem has stimulated interest in developing alternative therapeutic approaches. The construction of subendocardial channels to perfuse ischemic areas of the myocardium has been investigated since the 1950s. Before coronary artery bypass grafting, PTCA, and transmyocardial laser revascularization, mechanical methods to create transmural channels and thereby to revascularize the myocardium were reported. Early attempts at indirect myocardial revascularization had limited success. Transmyocardial laser revascularization is a new procedure for the treatment of angina pectoris. This article reviews the historical background of transmyocardial laser revascularization and possible mechanisms by which it may work, and discusses existing evidences for and against the procedure and how it may be applied in the future. The most important experimental studies and randomized prospective clinical trials from 1996 to 2001 were examined. The literature review concluded that transmyocardial laser revascularization does not have a life-saving effect, nor does it improve myocardial function. However, the method has a considerable short-term symptomatic effects, the mechanism of which is not understood. Neoangiogenesis, myocardial inflammation, denervation and placebo may play a role. Therefore, transmyocardial laser revascularization is potentially indicated for patients with severe angina that is refractory to medical therapy and who have contraindications for more traditional therapies (coronary artery bypass grafting, PTCA and heart transplantation). More expert groups recommend further research to clarify the mechanisms of transmyocardial laser revascularization treatment.