Objective: To compare the planned and actual revascularisation techniques used in patients undergoing cardiac surgery for refractory angina when excimer transmyocardial laser revascularisation (TMR) is available. Methods: Observational series of 31 patients (mean age 65 years) with severe angina [mean CCS score (SD) 3.8 (0.4)] and three-vessel coronary artery disease judged unsuitable for conventional bypass surgery alone. All patients underwent cardiac surgery: revascularisation techniques were determined by the operative findings. Results: Pre-operative strategy was altered by the intra-operative findings in 13 patients (42%). In 5 (16%), the coronary vessels proved graftable and TMR was unnecessary. Conversely, in 6 patients (19%) an anticipated graft could not be performed and TMR was used as an alternative. In 2 patients (7%), neither strategy was possible. Overall, TMR was performed as a stand-alone procedure in 9 (29%) and combined with CABG in 17 (55%). Operative mortality was low: 0% at 30 days and 6% at 6 months. Mean CCS class (SD) improved post-operatively from 3.8 (0.4) to 1.7 (1.1) (p < 0.01). Conclusions: The pre-operative coronary angiogram is an imperfect predictor of which coronary vessels are suitable for grafting. The availability of laser TMR allows the cardiac surgeon to accept cases which would otherwise be considered inoperable and to respond better to intraoperative findings. The combination of laser TMR and bypass grafts provides good short- and medium-term symptomatic improvement with a low post-operative mortality.