Background. The purpose of the this investigation was to assess postoperative survival and quality of life with transmyocardial laser revascularization (TMR) in high-risk patients. Methods. During a 24-month period, 81 consecutive patients underwent either sole therapy TMR (n = 34) or TMR with coronary artery bypass grafting (n = 47) using a holmium:yttrium-aluminum-garnet (YAG) laser. Outcomes were assessed in three high-risk groups, including patients with left ventricular dysfunction (ejection fraction ≤ 0.40) (n = 37), unstable angina (n = 30), and congestive heart failure (n = 33). Disease-specific quality of life was assessed using the Seattle Angina Questionnaire in 58 late survivors and compared with an age-matched cohort undergoing coronary artery bypass grafting only (no TMR) (n = 20). Results. Overall mortality was 6% ± 3% (±70% confidence limit) and appeared higher with left ventricular dysfunction (11% ± 5% vs 2% ± 2%), but the difference did not reach statistical significance (p = 0.17; power = 0.16). There was also no statistical difference with unstable angina (10% ± 6% vs 4% ± 3%;p > 0.53) or congestive failure (9% ± 5% vs 4% ± 3%; p > 0.66). However, survival at 18 months was significantly lower with left ventricular dysfunction (62% ± 9% vs 90% ± 5%; p < 0.003) and congestive failure (48% ± 10% vs 96% ± 3%; p < 0.001). For sole therapy TMR, quality of life was diminished comparing TMR with coronary artery bypass grafting (p < 0.004) and coronary artery bypass grafting only (p < 0.002). Conclusions. Transmyocardial laser revascularization can be performed in high-risk patients, but survival is significantly impaired in patients with left ventricular dysfunction and congestive failure, and quality of life is diminished without some degree of direct revascularization.