Assess the safety and effectiveness of stem cell application with regard to improvement in regional myocardial function in patients receiving Trans-Myocardial Laser Revascularization (TMR) and stem cells.

Multiple case experiences and studies have been published reviewing clinical experiences with Carbon Dioxide Trans-Myocardial Laser Revascularization (TMR) and autologous bone marrow derived cell application. These experiences have demonstrated perfusion improvements, ejection fraction improvements and improvements in angina or heart failure symptoms. The investigators elected to examine the use of CD133 positive (CD133+) BM-derived stem cells because of their pluripotent nature and the fact that during the CD133 selection process inflammatory cells present in the bone marrow are being discarded. CD133+ is a recently discovered marker for more primitive bone marrow derived multipotent stem and endothelial progenitor cells and is of particular interest in studies directed to therapeutic angiogenesis, as these cells have been shown to differentiate into endothelial and myogenic cell lines. Multiple studies have utilized BM derived cells for myocardial regeneration. Patients who received CD133+ cells showed improved perfusion at injection sites of stem cells leading to a significant increase in volume of left ventricular ejection fraction, regional wall motion in the infarct zone, and a reduction in end systolic left ventricular volume.

Inclusion Criteria:

• Presence of at least two vessel coronary artery disease not amenable to direct revascularization
• Area of interest defined as part of free left ventricular vall with reduced contractility
• Demonstration of reduced perfusion in the area of interest (>30% of free wall)
• Global ejection fraction 30-45% with symptoms class >_ II on the NYHA scale
• Significant refractory angina defined as symptoms class >_ III that are refractory to maximal medical and anti-angina therapy
• Expected survival of at least two years

Exclusion Criteria:

• Any condition that prevents successful stem cell collection or application, e.g. systemic infection, puncture for stem cell collection impossible
• Any condition that may adversely affect bone marrow such as malignancy or prior irradiation to the pelvic bone
• Mitral valve insufficiency > moderate grade
• History of ventricular arrhythmias not controlled by medication and/or AICD
• Need for additional heart surgery (i.e. valve replacement)
• Emergency or salvage operation defined as within 48 hours of diagnosis
• Evidence of left ventricular thrombus
• Previous heart surgery within the last 6 months
• Increased Troponin T (> 3X ULN) in patients with unstable angina at time of intervention
• History of symptomatic carotid disease within the last 3 months prior to study intervention
• Ejection fraction < 30%
• End stage renal disease
• Untreatable cancer, current or within preceding 5 years
• Severe COPD

to be determined per principal investigator and statistician