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Cheng K, Hill JM, de Silva R. Coronary Sinus Reducer Therapy for Refractory Angina and its Role in Modern Interventional Practice: A Contemporary Review. Interv Cardiol 2024; 19:e11. [PMID: 39145119 PMCID: PMC11322950 DOI: 10.15420/icr.2023.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/30/2024] [Indexed: 08/16/2024] Open
Abstract
Coronary sinus reducer (CSR) implantation is an emerging treatment option for patients with refractory angina. This condition represents a major global cardiovascular healthcare challenge, with patients experiencing chronic anginal symptoms that significantly impair their quality of life and for whom few effective treatments exist. The clinical burden of refractory angina is only set to grow because of improved survival from coronary artery disease, increased life expectancy and the presence of residual angina after percutaneous or surgical coronary revascularisation. Therefore, new, effective, evidence-based therapies are urgently needed. In this review, we highlight the unmet clinical needs of patients with refractory angina, discuss the development of the CSR device and review the preclinical and clinical evidence base underlying CSR implantation. In addition, we discuss the current role of CSR implantation in contemporary interventional practice, highlighting knowledge gaps and discussing areas of on-going research.
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Affiliation(s)
- Kevin Cheng
- National Heart and Lung Institute, Imperial College LondonLondon, UK
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondon, UK
| | - Jonathan M Hill
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondon, UK
| | - Ranil de Silva
- National Heart and Lung Institute, Imperial College LondonLondon, UK
- Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondon, UK
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2
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Fortunato A, Valentini I, Rumi F, Antonini D, Siviero L, Di Brino E, Basile M, Cicchetti A. A budget impact model and a cost-utility analysis of reducer device (Neovasc) in patients with refractory angina. Front Cardiovasc Med 2024; 11:1307534. [PMID: 38562187 PMCID: PMC10982321 DOI: 10.3389/fcvm.2024.1307534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
Background Refractory angina (RA) is a chronic condition characterized by the presence of debilitating angina symptoms due to established reversible ischemia in the presence of obstructive coronary artery disease (CAD). Treatments for this condition have undergone major developments in recent decades; however, the treatment for RA remains a challenge for medicine. In this sense, the Coronary Sinus Reducer System (CSRS) stands as the last line of therapy for ineligible patients for revascularization with reversible ischemia. The purpose of this report is to evaluate the potential burden on the National Health Service (NHS) and measure the health effects in terms of both quantity (life years) and quality-of-life aspects related to the reducer. Methods Two different economic evaluation models were developed as part of the analysis. The budget impact was developed to estimate the potential burden on the NHS from incremental uptake of the use of the reducer in the target population. The utility cost analysis compares and evaluates the quality of life and health resource use and costs between the two alternatives, based on the research of Gallone et al. A deterministic and probabilistic sensitivity analysis was carried out to characterize the uncertainty around the parameters of the model. Results In the budget impact analysis (BIA), the reducer is shown to be more expensive in the first 2 years of the model, due to the gradual uptake in the market and the cost of the device. Starting from the third year, assuming maintenance of effectiveness, there are savings in terms of resource absorption in direct healthcare costs arising from hospitalizations, emergency department accesses, coronarography, and visits avoided. Conclusion The BIA and cost-effectiveness model show that the reducer device, despite an increase in resources absorbed in the first years of implementation and use, has the potential to result in increased quality of life in patients with RA. These costs are largely offset in the short term by the improved clinical outcomes achievable leading to savings from the third year onward in the BIA and a dominance ratio in the cost-utility analysis.
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Affiliation(s)
- Agostino Fortunato
- Alta Scuola di Economia e Management dei Sistemi Sanitari (ALTEMS) - Università Cattolica del Sacro Cuore, Roma, Italy
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3
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Choy JS, Hubbard T, Golts EM, Bhatt DL, Navia JA, Kassab GS. Pre-arterialization of coronary veins prior to retroperfusion of ischemic myocardium: percutaneous closure device. Front Cardiovasc Med 2023; 10:1208903. [PMID: 37790598 PMCID: PMC10543752 DOI: 10.3389/fcvm.2023.1208903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background Chronic coronary retroperfusion to treat myocardial ischemia has previously failed due to edema and hemorrhage of coronary veins suddenly exposed to arterial pressures. The objective of this study was to selectively adapt the coronary veins to become arterialized prior to coronary venous retroperfusion to avoid vascular edema and hemorrhage. Methods and results In 32 animals (Group I = 19 and Group II = 13), the left anterior descending (LAD) artery was occluded using an ameroid occlusion model. In Group I, the great cardiac vein was blocked with suture ligation (Group IA = 11) or with occlusion device (Group IB = 8) to arterialize the venous system within 2 weeks at intermediate pressure (between arterial and venous levels) before a coronary venous bypass graft (CVBG) was implemented through a left internal mammary artery (LIMA) anastomosis. Group II only received the LAD artery occlusion and served as control. Serial echocardiograms showed recovery of left ventricular (LV) function with this adaptation-arterialization approach, with an increase in ejection fraction (EF) in Group I from 38% ± 5% after coronary occlusion to 53% ± 7% eight weeks after CVBG, whereas in Group II the EF never recovered (41% ± 2%-33% ± 7%). The remodeling of the venous system not only allowed restoration of myocardial function when CVBG was implemented but possibly promoted a novel form of "collateralization" between the native arterioles and the newly arterialized venules, which revascularized the ischemic myocardium. Conclusions These findings form a potential rationale for a venous arterialization-revascularization treatment for the refractory angina and the "no-option" patients using a hybrid percutaneous (closure device for arterialization)/surgical approach (CVBG) to revascularize the myocardium.
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Affiliation(s)
- Jenny S. Choy
- Department of Biomedical Engineering, California Medical Innovations Institute, San Diego, CA, United States
| | | | - Eugene M. Golts
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, CA, United States
| | - Deepak L. Bhatt
- Icahn School of Medicine at Mount Sinai Health System, New York, NY, United States
| | - José A. Navia
- Department of Cardiac Surgery, Austral University, Pilar, Buenos Aires, Argentina
| | - Ghassan S. Kassab
- Department of Biomedical Engineering, California Medical Innovations Institute, San Diego, CA, United States
- 3DT Holdings, LLC, San Diego, CA, United States
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4
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Fujita Y, Kawamoto A. Therapeutic Angiogenesis Using Autologous CD34-Positive Cells for Vascular Diseases. Ann Vasc Dis 2022; 15:241-252. [PMID: 36644256 PMCID: PMC9816028 DOI: 10.3400/avd.ra.22-00086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/13/2022] [Indexed: 12/25/2022] Open
Abstract
CD34 is a cell surface marker, which is expressed in various somatic stem/progenitor cells such as bone marrow (BM)-derived hematopoietic stem cells and endothelial progenitor cells (EPCs), skeletal muscle satellite cells, epithelial hair follicle stem cells, and adipose tissue mesenchymal stem cells. CD34+ cells in BM and peripheral blood are known as a rich source of EPCs. Thus, vascular regeneration therapy using granulocyte colony stimulating factor (G-CSF) mobilized- or BM CD34+ cells has been carried out in patients with various vascular diseases such as chronic severe lower limb ischemia, acute myocardial infarction, refractory angina, ischemic cardiomyopathy, and dilated cardiomyopathy as well as ischemic stroke. Pilot and randomized clinical trials demonstrated the safety, feasibility, and effectiveness of the CD34+ cell therapy in peripheral arterial, cardiovascular, and cerebrovascular diseases. This review provides an overview of the preclinical and clinical reports of CD34+ cell therapy for vascular regeneration.
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Affiliation(s)
- Yasuyuki Fujita
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan
| | - Atsuhiko Kawamoto
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan,Corresponding author: Atsuhiko Kawamoto, MD, PhD. Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, 1-5-4 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan Tel: +81-78-304-5772, Fax: +81-78-304-5263, E-mail:
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Bassetti B, Rurali E, Gambini E, Pompilio G. Son of a Lesser God: The Case of Cell Therapy for Refractory Angina. Front Cardiovasc Med 2021; 8:709795. [PMID: 34552966 PMCID: PMC8450394 DOI: 10.3389/fcvm.2021.709795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/02/2021] [Indexed: 11/20/2022] Open
Abstract
In the last decades, various non-pharmacological solutions have been tested on top of medical therapy for the treatment of patients affected by refractory angina (RA). Among these therapeutics, neuromodulation, external counter-pulsation and coronary sinus constriction have been recently introduced in the guidelines for the management of RA in United States and Europe. Notably and paradoxically, although a consistent body of evidence has proposed cell-based therapies (CT) as safe and salutary for RA outcome, CT has not been conversely incorporated into current international guidelines yet. As a matter of fact, published randomized controlled trials (RCT) and meta-analyses (MTA) cumulatively indicated that CT can effectively increase perfusion, physical function and well-being, thus reducing angina symptoms and drug assumption in RA patients. In this review, we (i) provide an updated overview of novel non-pharmacological therapeutics included in current guidelines for the management of patients with RA, (ii) discuss the Level of Evidence stemmed from available clinical trials for each recommended treatment, and (iii) focus on evidence-based CT application for the management of RA.
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Affiliation(s)
- Beatrice Bassetti
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Erica Rurali
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Elisa Gambini
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Oloker Therapeutics S.r.l., Bari, Italy
| | - Giulio Pompilio
- Unità di Biologia Vascolare e Medicina Rigenerativa, Centro Cardiologico Monzino-Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Milan, Italy
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6
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Pravian D, Soesanto AM, Ambari AM, Kuncoro BRMAS, Dwiputra B, Muliawan HS, Sukmawan R. The effect of external counterpulsation on intrinsic myocardial function evaluated by speckle tracking echocardiography in refractory angina patients: a randomized controlled trial. Int J Cardiovasc Imaging 2021; 37:2483-2490. [PMID: 34037889 DOI: 10.1007/s10554-021-02289-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/15/2021] [Indexed: 01/12/2023]
Abstract
External Counterpulsation (ECP) is one of the therapeutic options in patients with refractory angina inadequately controlled by medical, interventional, or surgical therapy. The 2D Speckle Tracking Echocardiography (2D-STE) method is considered superior in assessing clinical improvement. We would like to evaluate any improvement of myocardial intrinsic function using 2D-STE in patients underwent standard ECP protocol (35 sessions). We conducted a double-blind randomized controlled trial. Patients with refractory angina who could not be revascularized conventionally were randomized into two groups: (1) the ECP group (300 mmHg) and (2) the Sham/control group (75 mmHg). ECP standard therapy was given for 35 sessions (1 h/day/session). The 2D-STE data, including longitudinal strain and post systolic index (PSI) were obtained before and after therapy. 43 subjects were analyzed, with 22 subjects in ECP group and 21 control subjects (Sham group). A homogenous baseline strain was found either globally (12.42 ± 4.55 vs 12.00 ± 4.92 [- %]; P = 0.774) or segmentally/regionally (12.63 (0.01-25.16) vs 12.43 (0.01-27.20) [- %]; P = 0.570). There was no statistically significant improvement between groups in the left ventricle longitudinal strain globally (P = 0.535) and segmentally/regionally (P = 0.434). PSI parameters showed improvement in the ECP group (P = 0.049), and segments with PSI ≥ 20% seemed to improve longitudinal strains in the ECP group after therapy (P = 0.042). In conclusion, 35 ECP therapy sessions did not improve either global or segmental/regional left ventricular mechanical function in patients with refractory angina. However, the mechanical function of myocardial segments with PSS tends to improve after ECP therapy.
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Affiliation(s)
- Dexanda Pravian
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Amiliana M Soesanto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.
| | - Ade M Ambari
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - B R M Ario S Kuncoro
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Bambang Dwiputra
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Hary S Muliawan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Renan Sukmawan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia/National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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7
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Madeira S, Brízido C, Raposo L, Brito J, Vale N, Leal S, Gonçalves PDA, Gabriel HM, Teles RC, Almeida M. Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block. Rev Port Cardiol 2021; 40:371-382. [PMID: 33879377 DOI: 10.1016/j.repc.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/28/2020] [Accepted: 09/07/2020] [Indexed: 12/28/2022] Open
Abstract
Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.
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Affiliation(s)
- Sérgio Madeira
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal.
| | - Catarina Brízido
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Luís Raposo
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - João Brito
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Nélson Vale
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sílvio Leal
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro de Araújo Gonçalves
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Henrique Mesquita Gabriel
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Rui Campante Teles
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Manuel Almeida
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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8
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Silvis MJM, Dekker M, Zivelonghi C, Agostoni P, Stella PR, Doevendans PA, de Kleijn DPV, van Kuijk JP, Leenders GE, Timmers L. The Coronary Sinus Reducer; 5-year Dutch experience. Neth Heart J 2020; 29:215-223. [PMID: 33284421 PMCID: PMC7991026 DOI: 10.1007/s12471-020-01525-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 11/29/2022] Open
Abstract
Background Refractory angina is a growing and major health-care problem affecting millions of patients with coronary artery disease worldwide. The Coronary Sinus Reducer (CSR) is a device that may be considered for the relief of symptoms of refractory angina. It causes increased venous pressure leading to a dilatation of arterioles and reduced arterial vascular resistance in the sub-endocardium. This study describes the 5‑year Dutch experience regarding safety and efficacy of the CSR. Methods One hundred and thirty-two patients with refractory angina were treated with the CSR. The primary efficacy endpoint of the study was Canadian Cardiovascular Society (CCS) class improvement between baseline and 6‑month follow-up. The primary safety endpoint was successful CSR implantation in the absence of any device-related events. Results Eighty-five patients (67%) showed improvement of at least 1 CCS class and 43 patients (34%) of at least 2 classes. Mean CCS class improved from 3.17 ± 0.61 to 2.12 ± 1.07 after implantation (P < 0.001). The CSR was successfully implanted in 99% of the patients and only minor complications during implantation were reported. Conclusion The CSR is a simple, safe, and effective option for most patients with refractory angina. However, approximately thirty percent of the patients showed no benefit after implantation. Future studies should focus on the exact underlying mechanisms of action and reasons for non-response to better identify patients that could benefit most from this therapy. Electronic supplementary material The online version of this article (10.1007/s12471-020-01525-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M J M Silvis
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M Dekker
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - C Zivelonghi
- Hart Centrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerpen, Belgium
| | - P Agostoni
- Hart Centrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerpen, Belgium
| | - P R Stella
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - P A Doevendans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - D P V de Kleijn
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - J P van Kuijk
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - G E Leenders
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - L Timmers
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
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Li D, Guo P, Chen L, Wu Y, Wang G, Xiao C. Outcomes of Surgical Patch Angioplasty of The Coronary Artery for Diffuse Coronary Artery Disease. Braz J Cardiovasc Surg 2020; 35:706-712. [PMID: 33118736 PMCID: PMC7598967 DOI: 10.21470/1678-9741-2019-0390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Diffuse coronary artery disease (CAD) has a poor prognosis and many patients are ineligible for conventional coronary artery bypass grafting (CABG). This study evaluated the 12-month outcomes of coronary artery reconstruction and surgical patch angioplasty of the coronary artery for diffuse CAD. Methods A retrospective cohort study of patients who underwent CABG with surgical patch angioplasty of the coronary artery (reconstruction group) or standard CABG alone (standard group) at the Cardiovascular Surgery Department of the local Hospital between January 2014 and January 2016. Follow-up was censored at 12 months after surgery. Results Cardiopulmonary bypass and aortic cross-clamping durations were longer in the reconstruction group (n=32) than in the standard group (n=125) (P<0.05). There were no differences in graft blood flow and postoperative levels of cardiac markers between the two groups (P>0.05). In the reconstruction group, one patient died; a vein graft showed occlusion. In the standard group, two patients died; one left internal mammary artery graft and three vein grafts showed occlusion. There were no significant differences in mortality, major adverse cardiovascular and cerebrovascular events, and patency between the two groups (P>0.05). Conclusion Coronary artery reconstruction and surgical patch angioplasty of the coronary artery can be performed for diffuse CAD. Patient outcomes were not significantly different from those of patients who underwent standard CABG.
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Affiliation(s)
- Dong Li
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Pengfei Guo
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Lei Chen
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Yang Wu
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Gang Wang
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Cangsong Xiao
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
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10
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Zhou YS, Mao S, Guo LH, Gao XY, Zou X, Zhang MZ. Effect of Tongguan Capsules () on Restenosis after Coronary Stent Implantation: Study Protocol for A Randomized Controlled Trial. Chin J Integr Med 2020; 27:16-23. [PMID: 32335860 DOI: 10.1007/s11655-020-2722-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although percutaneous coronary intervention (PCI) had become widely employed therapeutic procedure for coronary artery disease, stent restenosis limited the benefits of this revascularization and the question how to prevent such events remained unresolved. While numerous empirical observations suggested Tongguan Capsules (), a patented Chinese Medicine, could decrease frequency and duration of angina pectoris attacks, evidence supporting its efficacy on restenosis remained inadequate. OBJECTIVE This trial was designed to determine whether Tongguan Capsules would reduce restenosis rate in patients after successful stent implantation. METHODS Approximately 400 patients undergoing percutaneous coronary stent deployment were enrolled and randomized to control group or Tongguan Capsules (4.5 g/d) for 3 months. All patients received standard anti-platelet, anti-coagulation and lipid-decreasing treatments, concurrently. The primary clinical endpoint was the 12-month incidence of the major adverse cardiovascular events (defined as cardiac death, myocardial infarction, and recurrence of symptoms requiring additional revascularization). The angiographic end point was restenosis rate at 6 months. CONCLUSION This study would provide important evidence for the use of Tongguan Capsules in patients after stent implantation in combination with routine therapies, which may significantly reduce incidence of the restenosis so as to potentially improve the clinical outcomes. (registration number: ChiCTR-TRC- ChiCTR-IIR-17011407).
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Affiliation(s)
- Yuan-Shen Zhou
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China.,Doctoral Candidate of Guanzhou University of Chinese Medicine, Guangzhou, 510006, China
| | - Shuai Mao
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Li-Heng Guo
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Xiong-Yi Gao
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Xu Zou
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China.,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Min-Zhou Zhang
- Key Discipline of Integrated Traditional Chinese and Western Medicine, Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China. .,Department of Critical Care Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China.
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11
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Wei Z, Volkova E, Blatchley MR, Gerecht S. Hydrogel vehicles for sequential delivery of protein drugs to promote vascular regeneration. Adv Drug Deliv Rev 2019; 149-150:95-106. [PMID: 31421149 PMCID: PMC6889011 DOI: 10.1016/j.addr.2019.08.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 07/04/2019] [Accepted: 08/12/2019] [Indexed: 12/12/2022]
Abstract
In recent years, as the mechanisms of vasculogenesis and angiogenesis have been uncovered, the functions of various pro-angiogenic growth factors (GFs) and cytokines have been identified. Therefore, therapeutic angiogenesis, by delivery of GFs, has been sought as a treatment for many vascular diseases. However, direct injection of these protein drugs has proven to have limited clinical success due to their short half-lives and systemic off-target effects. To overcome this, hydrogel carriers have been developed to conjugate single or multiple GFs with controllable, sustained, and localized delivery. However, these attempts have failed to account for the temporal complexity of natural angiogenic pathways, resulting in limited therapeutic effects. Recently, the emerging ideas of optimal sequential delivery of multiple GFs have been suggested to better mimic the biological processes and to enhance therapeutic angiogenesis. Incorporating sequential release into drug delivery platforms will likely promote the formation of neovasculature and generate vast therapeutic potential.
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Affiliation(s)
- Zhao Wei
- Department of Chemical and Biomolecular Engineering, The Institute for NanoBioTechnology Physical-Sciences Oncology Center, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Eugenia Volkova
- Department of Chemical and Biomolecular Engineering, The Institute for NanoBioTechnology Physical-Sciences Oncology Center, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Michael R Blatchley
- Department of Chemical and Biomolecular Engineering, The Institute for NanoBioTechnology Physical-Sciences Oncology Center, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Sharon Gerecht
- Department of Chemical and Biomolecular Engineering, The Institute for NanoBioTechnology Physical-Sciences Oncology Center, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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12
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The Human Coronary Collateral Circulation, Its Extracardiac Anastomoses and Their Therapeutic Promotion. Int J Mol Sci 2019; 20:ijms20153726. [PMID: 31366096 PMCID: PMC6696371 DOI: 10.3390/ijms20153726] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/04/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023] Open
Abstract
Cardiovascular disease remains the leading global cause of death, and the number of patients with coronary artery disease (CAD) and exhausted therapeutic options (i.e., percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical treatment) is on the rise. Therefore, the evaluation of new therapeutic approaches to offer an alternative treatment strategy for these patients is necessary. A promising research field is the promotion of the coronary collateral circulation, an arterio-arterial network able to prevent or reduce myocardial ischemia in CAD. This review summarizes the basic principles of the human coronary collateral circulation, its extracardiac anastomoses as well as the different therapeutic approaches, especially that of stimulating the extracardiac collateral circulation via permanent occlusion of the internal mammary arteries.
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Čelutkienė J, Burneikaitė G, Shkolnik E, Jakutis G, Vajauskas D, Čerlinskaitė K, Zuozienė G, Petrauskienė B, Puronaitė R, Komiagienė R, Butkuvienė I, Steponėnienė R, Misiūra J, Laucevičius A. The effect of cardiac shock wave therapy on myocardial function and perfusion in the randomized, triple-blind, sham-procedure controlled study. Cardiovasc Ultrasound 2019; 17:13. [PMID: 31272465 PMCID: PMC6610956 DOI: 10.1186/s12947-019-0163-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/12/2019] [Indexed: 01/09/2023] Open
Abstract
Background Recent triple-blind sham procedure-controlled study revealed neutral effects of the cardiac shock wave therapy (CSWT) on exercise tolerance and symptoms in patients with stable angina. Current data about the effects of CSWT on global and regional myocardial contractility and perfusion is limited. Hereby we report the results of an imaging sub-study that evaluated the capacity of CSWT to ameliorate myocardial ischemia induced during dobutamine stress echocardiography (DSE) and cardiac single photon emission computed tomography (SPECT). Methods Prospective, randomized, triple-blind, sham procedure-controlled study enrolled 72 adult subjects who complied with defined inclusion criteria. The subjects were assigned to the OMT + CSWT and the OMT + sham procedure study groups with 1:1 ratio. Application of the CSWT covered all segments of the left ventricle. Imaging ischemia tests were performed in 59 study patients: DSE and SPECT before the CSWT treatment and after 6 months, with DSE carried out additionally at 3 months after randomization. Co-primary endpoints of the study were: change in wall motion score index (WMSI), representing the stress-induced impairment of regional myocardial function, and change in summed difference score (SDS), representing the amount of perfusion defect. Results OMT + CSWT and OMT + sham procedure study groups included 30 and 29 patients, respectively. Regional myocardial contractility during DSE significantly improved at 3 months follow-up in OMT + CSWT group compared to baseline as shown by WMSI at stress (1.4 ± 0.4 vs 1.6 ± 0.4, p = 0.001), but not in OMT + sham procedure group (1.5 ± 0.3 vs 1.6 ± 0.4, p = 0.136). The difference in stress DSE results between both study groups disappeared after 6 months. SPECT results demonstrated a significant reduction of inducible ischemia in OMT + CSWT group compared to OMT + sham procedure group at 6 months follow-up (SDS dropped from 5.4 ± 3.7 to 3.6 ± 3.8 vs 6.4 ± 5.9 to 6.2 ± 5 respectively, p = 0.034). Conclusions Cardiac shock wave treatment showed the ability to reduce stress-induced myocardial ischemia, as assessed by wall motion abnormalities and perfusion defects, compared to sham procedure. Trial registration Clinicaltrials.gov (NCT02339454). The trial was registered retrospectively on 12 January 2015.
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Affiliation(s)
- Jelena Čelutkienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania.
| | - Greta Burneikaitė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Evgeny Shkolnik
- Yale-New Haven Health Bridgeport Hospital, 267 Grant St, Bridgeport, 06610, CT, USA
| | - Gabrielius Jakutis
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Donatas Vajauskas
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Gitana Zuozienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Birutė Petrauskienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Roma Puronaitė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Renata Komiagienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Irena Butkuvienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Rima Steponėnienė
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Jonas Misiūra
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
| | - Aleksandras Laucevičius
- Institute of Clinical Medicine of the Faculty of Medicine of Vilnius University, Santariskiu St. 2, 08661, Vilnius, Lithuania
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Bennett NM, Rutten-Ramos S, Arndt TL, Garberich RF, Traverse JH, Poulose AK, Mitchell P, Storey KM, Henry TD. Health Status and Quality of Life of Patients Enrolled in a Specialized Refractory Angina Clinic. ACTA ACUST UNITED AC 2019. [DOI: 10.21925/mplsheartjournal-d-18-00008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
As the mortality of coronary artery disease improves and the population ages, an increasing number of patients with refractory angina are not candidates for percutaneous or surgical revascularization. We evaluated the impact of a dedicated refractory angina clinic on quality of life. In 76 patients who completed the Medical Outcomes Study 36-Item Short-Form Health Survey and Seattle Angina Questionnaire at baseline and 1 year, the Medical Outcomes Study results showed the proportion of patients who rated their health as “good” or “excellent” more than doubled from baseline to 1 year (15.8% vs. 42.2%; P < .001). Similarly, the Seattle Angina Questionnaire score was significantly improved at 1 year compared to baseline (P = .025), as were angina stability (P = 0.017) and angina frequency (P = .010). In conclusion, treatment in a dedicated clinic is associated with improved quality of life in patients with refractory angina.
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Affiliation(s)
- Noel M. Bennett
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Stephanie Rutten-Ramos
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Theresa L. Arndt
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Ross F. Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Jay H. Traverse
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Anil K. Poulose
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Patricia Mitchell
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Katelyn M. Storey
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
| | - Timothy D. Henry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN; Cedars-Sinai Heart Institute, Los Angeles, CA
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15
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Efficacy of cardiac shock wave therapy in patients with stable angina: The design of randomized, triple blind, sham-procedure controlled study. Anatol J Cardiol 2019; 19:100-109. [PMID: 29424731 PMCID: PMC5864803 DOI: 10.14744/anatoljcardiol.2017.8023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Despite revascularization and optimal medical treatment (OMT), patients with angina often have a reduced quality of life due to inadequate relief from symptoms. Recent studies have shown that the application of shock waves may reduce angina symptoms and improve quality of life, exercise capacity, and myocardial perfusion due to the stimulation of angiogenesis. However, there is limited evidence due to small, single-arm, single-center studies of low to moderate quality. The purpose of this study is to evaluate the impact of cardiac shock wave therapy (CSWT) on exercise tolerance and angina symptoms in patients with coronary artery disease and objective evidence of myocardial ischemia who cannot undergo traditional revascularization and experience angina despite OMT in comparison to sham procedure. Methods: We designed a randomized, triple-blind, placebo-controlled, multicentre trial (NCT02339454) to assess the efficacy of CSWT in addition to OMT in patients with stable angina and myocardial ischemia documented by exercise treadmill test (ETT). All patients were treated with stable doses of standard medical treatment 4 weeks before screening. An increase in the total exercise duration on ETT by ≥90 s from the baseline at the end of the study was set as the primary endpoint. Secondary endpoints included angina class, Seattle angina questionnaire scores, symptoms, and ECG changes during stress test. Patients underwent nine sessions of CSWT or corresponding sham procedure applied to all segments of the left ventricle, within 9 weeks. Endpoint assessments were performed at 6-month follow-up. The imaging substudies assessed the potential of CSWT to reduce stress-induced myocardial ischemia detected by dobutamine stress echocardiography, cardiac single-photon emission computed tomography, and cardiac magnetic resonance imaging. Results: At two centers, 72 of the 323 screened patients were randomized in two groups (ratio 1:1): active treatment and placebo control. Study patients were predominantly males (70.8%); the mean age of the patients was 68.4±8.3 years. Of these, 44 patients had angina Canadian Cardiovascular Society class III, and 66.7% of the patients had a history of myocardial infarction. Conclusion: Using sham applicators, blinding study participants, investigators, and endpoints assessors to the study data as well as centralized randomization ensures rigorous methodology and low risk of bias in this large randomized controlled CSWT study.
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Sharma R, Tradewell M, Kohl LP, Garberich RF, Traverse JH, Poulose A, Brilakis ES, Arndt T, Henry TD. Revascularization in "no option" patients with refractory angina: Frequency, etiology and outcomes. Catheter Cardiovasc Interv 2018; 92:1215-1219. [PMID: 30079551 DOI: 10.1002/ccd.27707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/16/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND A significant proportion of patients with complex, advanced coronary artery disease have refractory angina (RA) despite maximal pharmacological therapy and are deemed suboptimal candidates for revascularization. These patients are frequently termed "no-option" patients. However, despite this designation, many subsequently undergo coronary revascularization. We sought to determine the incidence, etiology and outcome of revascularization in "no-option" patients. METHODS AND RESULTS We examined a comprehensive, prospective RA database to identify 342 of 1363 (25.1%) patients who subsequently underwent revascularization after a median interval of 2.2 years from the "no-option" diagnosis. Coronary revascularization was achieved by percutaneous coronary intervention (PCI) (n = 274, 20.1%), coronary bypass graft surgery (n = 44, 3.2%) or both (n = 24, 1.8%). During a median follow-up of 5.1 years, patients who underwent revascularization had lower annual mortality (2% vs. 4.4%, P < .001). Detailed paired angiographic records were available for 181 PCI patients with a combined 302 lesions. Of these interventions, 48% were for a new lesion, 31% for an existing lesion and 21% for restenosis. The location was a native vessel in 77% and a bypass graft in 23%. CONCLUSIONS The "no-option" or non-revascularizable designation is frequently based on angiography at a single time-point. However, coronary artery disease is a progressive and dynamic process and new lesions often develop in such patients. Given the association between revascularization and better survival, careful consideration should be given to repeat revascularization in patients with refractory angina previously classified as "no-option".
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Affiliation(s)
- Rahul Sharma
- Cedars-Sinai Heart Institute, Los Angeles, California
| | - Michael Tradewell
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Louis P Kohl
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota.,Hennepin County Medical Center, Minneapolis, Minnesota
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Jay H Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Anil Poulose
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Theresa Arndt
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
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Kikuchi Y, Ito K, Shindo T, Hao K, Shiroto T, Matsumoto Y, Takahashi J, Matsubara T, Yamada A, Ozaki Y, Hiroe M, Misumi K, Ota H, Takanami K, Hiraide T, Takase K, Tanji F, Tomata Y, Tsuji I, Shimokawa H. A multicenter trial of extracorporeal cardiac shock wave therapy for refractory angina pectoris: report of the highly advanced medical treatment in Japan. Heart Vessels 2018; 34:104-113. [PMID: 29942978 DOI: 10.1007/s00380-018-1215-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/22/2018] [Indexed: 01/09/2023]
Abstract
We have previously demonstrated that cardiac shock wave therapy (CSWT) effectively improves myocardial ischemia through coronary neovascularization both in a porcine model of chronic myocardial ischemia and in patients with refractory angina pectoris (AP). In this study, we further addressed the efficacy and safety of CSWT in a single-arm multicenter study approved as a highly advanced medical treatment by the Japanese Ministry of Health, Labour and Welfare. Fifty patients with refractory AP [mean age 70.9 ± 12.6 (SD) years, M/F 38/12] without the indications of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were enrolled in 4 institutes in Japan. Ischemic myocardial regions in the left ventricle (LV) were identified by drug-induced stress myocardial perfusion imaging (MPI). Shock waves (200 shots/spot at 0.09 mJ/mm2) were applied to 40-60 spots in the ischemic myocardium 3 times in the first week. The patients were followed up for 3 months thereafter. Forty-one patients underwent CSWT and completed the follow-up at 3 months. CSWT markedly improved weekly nitroglycerin use [from 3.5 (IQR 2 to 6) to 0 (IQR 0 to 1)] and the symptoms [Canadian Cardiovascular Society functional class score, from 2 (IQR 2 to 3) to 1 (IQR 1 to 2)] (both P < 0.001). CSWT also significantly improved 6-min walking distance (from 384 ± 91 to 435 ± 122 m, P < 0.05). There were no significant changes in LV ejection fraction evaluated by echocardiography and LV stroke volume evaluated by cardiac magnetic resonance imaging (from 56.3 ± 14.7 to 58.8 ± 12.8%, P = 0.10, and from 52.3 ± 17.4 to 55.6 ± 15.7 mL, P = 0.15, respectively). Percent myocardium ischemia assessed by drug-induced stress MPI tended to be improved only in the treated segments (from 16.0 ± 11.1 to 12.1 ± 16.2%, P = 0.06), although no change was noted in the whole LV. No procedural complications or adverse effects related to the CSWT were noted. These results of the multicenter trial further indicate that CSWT is a useful and safe non-invasive strategy for patients with refractory AP with no options of PCI or CABG.
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Affiliation(s)
- Yoku Kikuchi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenta Ito
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomohiko Shindo
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kiyotaka Hao
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takashi Shiroto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuharu Matsumoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takao Matsubara
- Department of Cardiovascular Medicine, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Akira Yamada
- Department of Cardiovascular Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Yukio Ozaki
- Department of Cardiovascular Medicine, Fujita Health University Hospital, Toyoake, Japan
| | - Michiaki Hiroe
- Department of Cardiovascular Medicine, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Kazuo Misumi
- Department of Cardiovascular Medicine, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Hideki Ota
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kentaro Takanami
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomomichi Hiraide
- Department of Radiology, Miyagi Cardiovascular and Respiratory Center, Kurihara, Japan
| | - Kei Takase
- Department of Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Fumiya Tanji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Yasutake Tomata
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Health Informatics and Public Health, Tohoku University School of Public Health, Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
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Stoller M, Seiler C. Effect of Permanent Right Internal Mammary Artery Closure on Coronary Collateral Function and Myocardial Ischemia. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.116.004990. [PMID: 28566292 PMCID: PMC5482561 DOI: 10.1161/circinterventions.116.004990] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/07/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND The objective of this study is to test the effect of permanent right internal mammary artery device closure on coronary collateral function and myocardial ischemia. METHODS AND RESULTS This was a prospective, open-label clinical trial in 50 patients with coronary artery disease. The primary study end point was coronary collateral flow index as obtained during a 1-minute proximal right coronary artery (RCA) and left coronary artery balloon occlusion at baseline before and at follow-up examination 6 weeks after distal right internal mammary artery device closure. Collateral flow index is the ratio between simultaneously recorded mean coronary occlusive pressure divided by mean aortic pressure, both subtracted by central venous pressure. Secondary study end points were fractional flow reserve during vessel patency, the quantitative intracoronary ECG ST-segment elevation, and angina pectoris during the same 1-minute coronary occlusion. Collateral flow index in the untreated RCA and left coronary artery changed from 0.071±0.082 at baseline to 0.132±0.117 (P<0.0001) at follow-up examination and from 0.106±0.092 to 0.081±0.079 (P=0.29), respectively. RCA fractional flow reserve increased significantly (P=0.0029) from baseline to follow-up examination, despite deferral of coronary intervention in all patients. There was a decrease in intracoronary ECG ST-elevation during RCA occlusion from baseline to follow-up examination (P=0.0015); it did not change in the left coronary artery. Angina pectoris during RCA occlusion tended to occur in fewer patients at follow-up versus baseline examination (P=0.06). CONCLUSIONS Permanent right internal mammary artery device closure seems to augment extracardiac ipsilateral coronary supply to the effect of reducing ischemia in the dependent myocardial region. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02475408.
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Affiliation(s)
- Michael Stoller
- From the Department of Cardiology, Bern University Hospital, Switzerland
| | - Christian Seiler
- From the Department of Cardiology, Bern University Hospital, Switzerland.
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Tian PP, Li J, Gao J, Li Y. Efficacy and safety of the Shexiang Baoxin Pill for the treatment of coronary artery disease not amenable to revascularisation: study protocol for a randomised, placebo-controlled, double-blinded trial. BMJ Open 2018; 8:e018052. [PMID: 29444778 PMCID: PMC5829656 DOI: 10.1136/bmjopen-2017-018052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Coronary artery disease (CAD) not amenable to revascularisation indicates that the coronary arteries have severe diffuse lesions or calcifications, or that CAD is complicated with severe multiple-organ disease. Currently, Western medicines available for the treatment of CAD not amenable to revascularisation are limited. Shexiang Baoxin Pill (SBP), a type of Chinese patent medicine, has been widely used to treat CAD in China for many years. Previous studies have shown that long-term administration of SBP (1-2 pills three times daily, for at least 6 months) for treatment of CAD is effective and safe, with a significant, long-term effect. This study aims to evaluate the efficacy and safety of SBP in patients with CAD not amenable to revascularisation. METHODS AND ANALYSIS This is a multicentre, randomised, double-blinded, placebo-controlled clinical trial. A total of 440 participants will be randomly allocated to two groups: the intervention group and the placebo group. Based on conventional treatment with Western medicine, the intervention group will be treated with SBP and the placebo group will be treated with SBP placebo. The primary outcomes include major adverse cardiovascular events (including angina, acute myocardial infarction, pulmonary embolism and aortic dissection). The secondary outcomes include C reactive protein, B-type natriuretic peptide, ECG, echocardiographic parameters (ejection fraction percentage and the E/A ratio) and hospital readmission rates due to CAD. Assessments will be performed at baseline (before randomisation) and at 24 weeks after randomisation. ETHICS AND DISSEMINATION The protocol has been approved by the Research Ethics Committee of Guang'anmen Hospital, China Academy of Chinese Medical Sciences in Beijing, China (reference: 2016-129-KY-01). The results of this study will be published in a peer-reviewed journal and will be used as a basis for a multisite trial. TRIAL REGISTRATION NUMBER NCT03072121; Pre-results.
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Affiliation(s)
- Pan-pan Tian
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School Department, Beijing University of Chinese Medicine, Beijing, China
| | - Jun Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jian Gao
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School Department, Beijing University of Chinese Medicine, Beijing, China
| | - Ying Li
- Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- Graduate School Department, Beijing University of Chinese Medicine, Beijing, China
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Desperak P, Hawranek M, Gąsior P, Desperak A, Lekston A, Gąsior M. Long-term outcomes of patients with multivessel coronary artery disease presenting non-ST-segment elevation acute coronary syndromes. Cardiol J 2017; 26:157-168. [PMID: 28980282 DOI: 10.5603/cj.a2017.0110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 09/10/2017] [Accepted: 09/10/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There is paucity of data concerning the optimal revascularization in patients with mul- tivessel coronary artery disease (CAD) presenting non-ST-segment elevation acute coronary syndrome (NSTE-ACS). The aim was to evaluate long-term outcomes of patients with multivessel CAD presenting NSTE-ACS depending on the management after coronary angiography. METHODS 3,166 patients with NSTE-ACS hospitalized between 2006 and 2014 were screened. After ex- clusions, 1,342 patients were enrolled with multivessel CAD and were divided depending on their man- agement after coronary angiography; the medical-only therapy group (n = 91), the percutaneous coronary intervention (PCI) group (n = 1,122), the coronary artery bypass grafting (CABG) group (n = 129). Propensity scores matching was used to adjust for differences in patient baseline characteristics. RESULTS After propensity score analysis, 273 well-matched patients were chosen. Both before and after matching, patients treated with a medical-only therapy were burdened with the highest percentage of 24-month all-cause death and non-fatal MI in comparison to PCI and CABG groups, respectively. In the CABG group, ACS-driven revascularization rate was lowest. In the overall population, PCI (HR 0.33; 95% CI 0.20-0.53; p < 0.0001) and CABG (HR 0.54; 95% CI 0.31-0.93; p = 0.028) were independent factors associated with favorable 24-month prognosis. However, in a matched population only PCI was an independent predictor of long-term prognosis with a 63% decrease of 24-month mortal- ity (HR 0.37; 95% CI 0.19-0.69; p = 0.0020). CONCLUSIONS In patients with multivessel CAD presenting with NSTE-ACS, medical-only man- agement is related with adverse long-term prognosis in contrast to revascularization, which reduces 24-month mortality, especially among patients undergoing percutaneous intervention. Performance of PCI is an independent factor for improving long-term prognosis.
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Affiliation(s)
- Piotr Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Michał Hawranek
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Paweł Gąsior
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia in Katowice, Katowice, Poland
| | - Aneta Desperak
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Andrzej Lekston
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Chair and Department of Cardiology, Medical University of Silesia in Katowice, School of Medicine with the Division of Dentistry in Zabrze, Silesian Centre for Heart Diseases, Zabrze, Poland
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Burneikaitė G, Shkolnik E, Čelutkienė J, Zuozienė G, Butkuvienė I, Petrauskienė B, Šerpytis P, Laucevičius A, Lerman A. Cardiac shock-wave therapy in the treatment of coronary artery disease: systematic review and meta-analysis. Cardiovasc Ultrasound 2017; 15:11. [PMID: 28403861 PMCID: PMC5389112 DOI: 10.1186/s12947-017-0102-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/30/2017] [Indexed: 12/31/2022] Open
Abstract
AIM To systematically review currently available cardiac shock-wave therapy (CSWT) studies in humans and perform meta-analysis regarding anti-anginal efficacy of CSWT. METHODS The Cochrane Controlled Trials Register, Medline, Medscape, Research Gate, Science Direct, and Web of Science databases were explored. In total 39 studies evaluating the efficacy of CSWT in patients with stable angina were identified including single arm, non- and randomized trials. Information on study design, subject's characteristics, clinical data and endpoints were obtained. Assessment of publication risk of bias was performed and heterogeneity across the studies was calculated by using random effects model. RESULTS Totally, 1189 patients were included in 39 reviewed studies, with 1006 patients treated with CSWT. The largest patient sample of single arm study consisted of 111 patients. All selected studies demonstrated significant improvement in subjective measures of angina symptoms and/or quality of life, in the majority of studies left ventricular function and myocardial perfusion improved. In 12 controlled studies with 483 patients included (183 controls) angina class, Seattle Angina Questionnaire (SAQ) score, nitrates consumption were significantly improved after the treatment. In 593 participants across 22 studies the exercise capacity was significantly improved after CSWT, as compared with the baseline values (in meta-analysis standardized mean difference SMD = -0.74; 95% CI, -0.97 to -0.5; p < 0.001). CONCLUSIONS Systematic review of CSWT studies in stable coronary artery disease (CAD) demonstrated consistent improvement of clinical variables. Meta-analysis showed a moderate improvement of exercise capacity. Overall, CSWT is a promising non-invasive option for patients with end-stage CAD, but evidence is limited to small sample single-center studies. Multi-center adequately powered randomised double blind studies are warranted.
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Affiliation(s)
- Greta Burneikaitė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
- Room No A311, Santariskiu str. 2, 08661 Vilnius, Lithuania
| | - Evgeny Shkolnik
- Moscow State University of Medicine and Dentistry, Moscow, Russia
- Yale- New Haven Health Bridgeport Hospital, Connecticut, United States of America
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Gitana Zuozienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Irena Butkuvienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Birutė Petrauskienė
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Pranas Šerpytis
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Aleksandras Laucevičius
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Centre of Innovative Medicine, Vilnius, Lithuania
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota United States of America
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Abstract
Improvements in the care of patients with ischemic cardiovascular disease have led to improved survival but also a burgeoning population of patients with advanced ischemic heart disease. Cell therapies offer a novel approach toward cardiac "rejuvenation" via stimulation of new blood vessel growth, enhancing tissue perfusion, and via preservation or even regeneration of myocardial tissue, leading to improvements in cardiac performance after myocardial infarction and in patients with advanced heart failure. Here, we summarize and offer some thoughts on the state of the field of cell therapy for ischemic heart disease, targeting three separate conditions that have been the subject of significant clinical research: enhancing left ventricular recovery after MI, improving outcomes and symptoms in patients with congestive heart failure (CHF), and treatment of patients with refractory angina, despite maximal medical therapy.
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Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, 27708, USA.
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24
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Benedetto D, Abawi M, Stella PR, Nijhoff F, Lakemeier MDM, Kortlandt F, Doevendans PA, Agostoni P. Percutaneous Device to Narrow the Coronary Sinus: Shifting Paradigm in the Treatment of Refractory Angina? A Review of the Literature. Front Cardiovasc Med 2016; 3:42. [PMID: 27818991 PMCID: PMC5073123 DOI: 10.3389/fcvm.2016.00042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/07/2016] [Indexed: 11/23/2022] Open
Abstract
Refractory angina pectoris is defined as a chronic debilitating condition characterized by the presence of chronic anginal symptoms due to a severe obstructive and/or diffuse coronary artery disease that cannot be controlled by the combination of medical therapy and/or revascularization (percutaneous or surgical). In addition, the presence of myocardial ischemia as a cause of the symptoms must have been documented. The coronary sinus reducer (CSR) is a recently introduced percutaneous device to treat patients with severe anginal symptoms refractory to optimal medical therapy and not amenable to conventional revascularization. The purpose of this review is to describe the current evidence from available studies measuring the clinical effect of the CSR implantation on the health and well-being of patients with refractory angina.
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Affiliation(s)
- Daniela Benedetto
- University Medical Centre Utrecht, Utrecht, Netherlands; University of Milan, Milan, Italy
| | - Masieh Abawi
- University Medical Centre Utrecht , Utrecht , Netherlands
| | | | - Freek Nijhoff
- University Medical Centre Utrecht , Utrecht , Netherlands
| | | | | | | | - Pierfrancesco Agostoni
- University Medical Centre Utrecht, Utrecht, Netherlands; St. Antonius Hospital, Nieuwegein, Netherlands
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25
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Poppi NT, Gowdak LHW, Dourado LOC, Adam EL, Leite TNP, Mioto BM, Krieger JE, César LAM, Pereira AC. A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T. Clin Cardiol 2016; 40:11-17. [PMID: 27754552 DOI: 10.1002/clc.22599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/26/2016] [Accepted: 08/31/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The predictors of cardiovascular events in patients with chronic refractory angina are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are biomarkers that may be used to determine the prognosis of patients with stable coronary artery disease. HYPOTHESIS Hs-cTnT is a predictor of death and nonfatal myocardial infarction (MI) in patients with refractory angina. METHODS We prospectively enrolled 117 consecutive patients in this study. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms; evidence of myocardial ischemia served as an inclusion criterion. Optimal medical therapy was encouraged via outpatient visits every 6 months; plasma hs-cTnT levels were determined at baseline. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS During a median follow-up period of 28.0 months (interquartile range, 18.0-47.5 months), an estimated 28.0-month cumulative event rate of 13.4% was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were hs-cTnT levels and LV dysfunction. Following a multivariate analysis, only hs-cTnT was independently associated with the events in question, either as a continuous variable (hazard ratio per unit increase in the natural logarithm: 2.83, 95% confidence interval: 1.62-4.92, P < 0.001) or as a categorical variable (hazard ratio for concentrations above the 99th percentile: 5.14, 95% confidence interval: 2.05-12.91, P < 0.001). CONCLUSIONS In patients with chronic refractory angina, plasma concentration of hs-cTnT is the strongest predictor of death and nonfatal MI. Notably, none of the outcomes in question occurred in patients with baseline plasma levels <5.0 ng/L.
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Affiliation(s)
- Nilson T Poppi
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Luís H W Gowdak
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
| | - Luciana O C Dourado
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Eduardo L Adam
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Thiago N P Leite
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Bruno M Mioto
- Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - José E Krieger
- Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
| | - Luiz A M César
- Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
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26
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Abawi M, Nijhoff F, Stella PR, Voskuil M, Benedetto D, Doevendans PA, Agostoni P. Safety and efficacy of a device to narrow the coronary sinus for the treatment of refractory angina: A single-centre real-world experience. Neth Heart J 2016; 24:544-51. [PMID: 27299456 PMCID: PMC5005194 DOI: 10.1007/s12471-016-0862-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective The coronary sinus Reducer is a recently introduced device to treat patients with severe angina symptoms refractory to optimal medical therapy and not amenable for conventional revascularisation. We aimed to assess the safety and efficacy of the Reducer in a real-world cohort of patients with refractory angina. Methods This is a single-centre retrospective registry. Patients with severe angina symptoms, objective evidence of myocardial ischaemia using any adequate non-invasive modality and without options for conventional revascularisation were regarded eligible for Reducer implantation. Results Twenty-three patients (74 % male, mean age 70 ± 8 years, 91.3 % previous bypass surgery, 82.6 % previous percutaneous intervention, 47.8 % previous myocardial infarction, 52.2 % diabetes mellitus) underwent Reducer implantation. The safety endpoint (successful implantation of the first device without device-related adverse events) was met in all patients. After a median follow-up of 9 (8–14) months the efficacy (any reduction in Canadian Cardiovascular Society (CCS) class and revascularisation-free survival) was reached in 17 patients (74 %): 8 patients (34.8 %) improved by 1 CCS class, 7 (30.4 %) by 2 CCS classes and 2 (8.7 %) by 3 CCS classes. One patient died 4 months after implantation because of progressive heart failure (not associated with Reducer implantation). Conclusion In this single-centre real-world experience, Reducer implantation was safe and demonstrated excellent clinical efficacy in the treatment of refractory angina at mid-term follow-up.
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Affiliation(s)
- M Abawi
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Nijhoff
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - P A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Agostoni
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
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27
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Khan AR, Farid TA, Pathan A, Tripathi A, Ghafghazi S, Wysoczynski M, Bolli R. Impact of Cell Therapy on Myocardial Perfusion and Cardiovascular Outcomes in Patients With Angina Refractory to Medical Therapy: A Systematic Review and Meta-Analysis. Circ Res 2016; 118:984-93. [PMID: 26838794 DOI: 10.1161/circresaha.115.308056] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 01/13/2016] [Indexed: 12/15/2022]
Abstract
RATIONALE The effect of stem/progenitor cells on myocardial perfusion and clinical outcomes in patients with refractory angina remains unclear because studies published to date have been small phase I-II trials. OBJECTIVE We performed a meta-analysis of randomized controlled trials to evaluate the effect of cell-based therapy in patients with refractory angina who were ineligible for coronary revascularization. METHODS AND RESULTS Several data sources were searched from inception to September 2015, which yielded 6 studies. The outcomes pooled were indices of angina (anginal episodes, Canadian Cardiovascular Society angina class, exercise tolerance, and antianginal medications), myocardial perfusion, and clinical end points. We combined the reported clinical outcomes (myocardial infarction, cardiac-related hospitalization, and mortality) into a composite end point (major adverse cardiac events). Mean difference (MD), standardized mean differences, or odds ratio were calculated to assess relevant outcomes. Our analysis shows an improvement in anginal episodes (MD, -7.81; 95% confidence interval [CI], -15.22 to -0.41), use of antianginal medications (standardized MD, -0.59; 95% CI, -1.03 to -0.14), Canadian Cardiovascular Society class (MD, -0.58; 95% CI, -1.00 to -0.16), exercise tolerance (standardized MD, 0.331; 95% CI, 0.08 to 0.55), and myocardial perfusion (standardized MD, -0.49; 95% CI, -0.76 to -0.21) and a decreased risk of major adverse cardiac events (odds ratio, 0.49; 95% CI, 0.25 to 0.98) and arrhythmias (odds ratio, 0.25; 95% CI, 0.06 to 0.98) in cell-treated patients when compared with patients on maximal medical therapy. CONCLUSIONS The present meta-analysis indicates that cell-based therapies are not only safe but also lead to an improvement in indices of angina, relevant clinical outcomes, and myocardial perfusion in patients with refractory angina. These encouraging results suggest that larger, phase III randomized controlled trials are in order to conclusively determine the effect of stem/progenitor cells in refractory angina.
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Affiliation(s)
- Abdur Rahman Khan
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Talha A Farid
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Asif Pathan
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Avnish Tripathi
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Shahab Ghafghazi
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Marcin Wysoczynski
- From the Institute of Molecular Cardiology, University of Louisville, KY
| | - Roberto Bolli
- From the Institute of Molecular Cardiology, University of Louisville, KY.
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28
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Abstract
With improvements in survival from coronary artery disease (CAD) and an ageing population, refractory angina (RA) is becoming an increasingly common clinical problem facing clinicians in routine clinical practice. These patients experience chronic symptoms in the context of CAD, characterised by angina-type pain, which is uncontrolled despite optimal pharmacological, interventional and surgical therapy. Although mortality rates are no worse in this cohort, patients experience a significantly impaired quality of life with disproportionately high utilisation of healthcare services. It has been increasingly recognised that the needs of RA patients are multifactorial and best provided by specialist multi-disciplinary units. In this review, we consider the variety of therapies available to clinicians in the management of RA and discuss the promise of novel treatments.
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Affiliation(s)
- Kevin Cheng
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Heart Science, National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Sainsbury
- Department of Cardiology, Bradford Royal Infirmary, Bradford, UK
| | - Michael Fisher
- Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital NHS Trust and Royal Liverpool and Broadgreen NHS Trust, Liverpool, UK
| | - Ranil de Silva
- Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Vascular Science, National Heart and Lung Institute, Imperial College London, London, UK
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29
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Picichè M. Noncoronary Collateral Myocardial Blood Flow: The Human Heart's Forgotten Blood Supply. Open Cardiovasc Med J 2015; 9:105-13. [PMID: 27006713 PMCID: PMC4768666 DOI: 10.2174/1874192401509010105] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 03/20/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
The “noncoronary collateral circulation” (NCCC) or “noncoronary collateral myocardial blood flow”
(NCCMBF), reaches the heart through a micro-vascular network arising from the bronchial, esophageal, pericardial,
diaphragmatic, and aortic arteries. The left and right internal thoracic arteries (ITAs) along with their collateral branches
also serve as a source of NCCMBF-a feature seen in other mammals. Under certain circumstances the ITAs have a high
potential for developing collateral branches. In the case of severe Leriche syndrome or with chronic obstruction of the
abdominal aorta, the ITAs can serve as the main or even sole source of blood supply to the lower limbs. It is also possible
for the ITAs to develop angiographically visible branches that directly connect with the coronary arteries. In ischemic
conditions there is a functional, ischemia-reducing extracardiac coronary artery supply via natural ipsilateral ITA
anastomosis. To date we know little about NCCMBF and its potential benefits in clinical applications, which makes this a
challenging and intriguing field of research. This paper reviews all available data on noncoronary collateral blood supply
to the human heart.
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Affiliation(s)
- Marco Picichè
- Cardiac Surgery Department, San Filippo Neri Hospital, Via Martinotti 20, 00135, Rome, Italy
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30
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Current approaches for the diagnosis, risk stratification and interventional treatment of patients with acute coronary syndromes without st-segment elevation. КЛИНИЧЕСКАЯ ПРАКТИКА 2015. [DOI: 10.17816/clinpract83255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This article reviews current approaches to diagnosis and determination of the individual risk of patients with acute coronary syndrome without ST-segment elevation. Guidelines for determining the choice of treatment strategy and the time slots for its implementation are discussed. We describe the technical features of the implementation of interventional treatment in this group of patients; the choice of methods of myocardial revascularization is discussed.
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31
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Moore SM, Zhang H, Maeda N, Doerschuk CM, Faber JE. Cardiovascular risk factors cause premature rarefaction of the collateral circulation and greater ischemic tissue injury. Angiogenesis 2015; 18:265-81. [PMID: 25862671 DOI: 10.1007/s10456-015-9465-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 04/06/2015] [Indexed: 01/09/2023]
Abstract
RATIONALE Collaterals lessen tissue injury in occlusive disease. However, aging causes progressive decline in their number and smaller diameters in those that remain (collateral rarefaction), beginning at 16 months of age in mice (i.e., middle age), and worse ischemic injury-effects that are accelerated in even 3-month-old eNOS(-/-) mice. These findings have found indirect support in recent human studies. OBJECTIVE We sought to determine whether other cardiovascular risk factors (CVRFs) associated with endothelial dysfunction cause collateral rarefaction, investigate possible mechanisms, and test strategies for prevention. METHODS AND RESULTS Mice with nine different models of CVRFs of 4-12 months of age were assessed for number and diameter of native collaterals in skeletal muscle and brain and for collateral-dependent perfusion and ischemic injury after arterial occlusion. Hypertension caused collateral rarefaction whose severity increased with duration and level of hypertension, accompanied by greater hindlimb ischemia and cerebral infarct volume. Chronic treatment of wild-type mice with L-N (G)-nitro-arginine methylester caused similar rarefaction and worse ischemic injury which were not prevented by lowering arterial pressure with hydralazine. Metabolic syndrome, hypercholesterolemia, diabetes mellitus, and obesity also caused collateral rarefaction. Neither chronic statin treatment nor exercise training lessened hypertension-induced rarefaction. CONCLUSION Chronic CVRF presence caused collateral rarefaction and worse ischemic injury, even at relatively young ages. Rarefaction was associated with increased proliferation rate of collateral endothelial cells, effects that may promote accelerated endothelial cell senescence.
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Affiliation(s)
- Scott M Moore
- Department of Cell Biology and Physiology, 6309 MBRB, University of North Carolina, Chapel Hill, NC, 27599-7545, USA
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32
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Verheye S, Jolicœur EM, Behan MW, Pettersson T, Sainsbury P, Hill J, Vrolix M, Agostoni P, Engstrom T, Labinaz M, de Silva R, Schwartz M, Meyten N, Uren NG, Doucet S, Tanguay JF, Lindsay S, Henry TD, White CJ, Edelman ER, Banai S. Efficacy of a device to narrow the coronary sinus in refractory angina. N Engl J Med 2015; 372:519-27. [PMID: 25651246 PMCID: PMC6647842 DOI: 10.1056/nejmoa1402556] [Citation(s) in RCA: 189] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Many patients with coronary artery disease who are not candidates for revascularization have refractory angina despite standard medical therapy. The balloon-expandable, stainless steel, hourglass-shaped, coronary-sinus reducing device creates a focal narrowing and increases pressure in the coronary sinus, thus redistributing blood into ischemic myocardium. METHODS We randomly assigned 104 patients with Canadian Cardiovascular Society (CCS) class III or IV angina (on a scale from I to IV, with higher classes indicating greater limitations on physical activity owing to angina) and myocardial ischemia, who were not candidates for revascularization, to implantation of the device (treatment group) or to a sham procedure (control group). The primary end point was the proportion of patients with an improvement of at least two CCS angina classes at 6 months. RESULTS A total of 35% of the patients in the treatment group (18 of 52 patients), as compared with 15% of those in the control group (8 of 52), had an improvement of at least two CCS angina classes at 6 months (P=0.02). The device was also associated with improvement of at least one CCS angina class in 71% of the patients in the treatment group (37 of 52 patients), as compared with 42% of those in the control group (22 of 52) (P=0.003). Quality of life as assessed with the use of the Seattle Angina Questionnaire was significantly improved in the treatment group, as compared with the control group (improvement on a 100-point scale, 17.6 vs. 7.6 points; P=0.03). There were no significant between-group differences in improvement in exercise time or in the mean change in the wall-motion index as assessed by means of dobutamine echocardiography. At 6 months, 1 patient in the treatment group had had a myocardial infarction; in the control group, 1 patient had died and 3 had had a myocardial infarction. CONCLUSIONS In this small clinical trial, implantation of the coronary-sinus reducing device was associated with significant improvement in symptoms and quality of life in patients with refractory angina who were not candidates for revascularization. (Funded by Neovasc; COSIRA ClinicalTrials.gov number, NCT01205893.).
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Affiliation(s)
- Stefan Verheye
- Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | | | | | | | | | | | | | | | | | | | - Ranil de Silva
- National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust. London, UK
| | | | - Nathalie Meyten
- Antwerp Cardiovascular Center, ZNA Middelheim, Antwerp, Belgium
| | | | | | | | | | | | - Christopher J. White
- The John Ochsner Heart & Vascular Institute, Ochsner Clinical School, University of Queensland, New Orleans, LA, USA
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, MIT, Cambridge, MA USA, and Cardiovascular Division Brigham and Women’s Hospital, Harvard Medical School, Boston MA
| | - Shmuel Banai
- Tel Aviv Medical Center, The Tel Aviv University Medical School, Tel Aviv, Israel
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33
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Povsic TJ, Broderick S, Anstrom KJ, Shaw LK, Ohman EM, Eisenstein EL, Smith PK, Alexander JH. Predictors of long-term clinical endpoints in patients with refractory angina. J Am Heart Assoc 2015; 4:jah3765. [PMID: 25637344 PMCID: PMC4345862 DOI: 10.1161/jaha.114.001287] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Clinical outcomes in patients with refractory angina (RA) are poorly characterized and variably described. Using the Duke Database for Cardiovascular Disease (DDCD), we explored characteristics that drive clinical endpoints in patients with class II to IV angina stabilized on medical therapy. Methods and Results We explored clinical endpoints and associated costs of patients who underwent catheterization at Duke University Medical Center from 1997 to 2010 for evaluation of coronary artery disease (CAD) and were found to have advanced CAD ineligible for additional revascularization, and were clinically stable for a minimum of 60 days. Of 77 257 cardiac catheterizations performed, 1908 patients met entry criteria. The 3‐year incidence of death; cardiac rehospitalization; and a composite of death, myocardial infarction, stroke, cardiac rehospitalization, and revascularization were 13.0%, 43.5%, and 52.2%, respectively. Predictors of mortality included age, ejection fraction (EF), low body mass index, multivessel CAD, low heart rate, diabetes, diastolic blood pressure, history of coronary artery bypass graft surgery, cigarette smoking, history of congestive heart failure (CHF), and race. Multivessel CAD, EF<45%, and history of CHF increased risk of mortality; angina class and prior revascularization did not. Total rehospitalization costs over a 3‐year period per patient were $10 185 (95% CI 8458, 11912) in 2012 US dollars. Conclusions Clinically stable patients with RA who are medically managed have a modest mortality, but a high incidence of hospitalization and resource use over 3 years. These findings point to the need for novel therapies aimed at symptom mitigation in this population and their potential impact on health care utilization and costs.
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Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - Samuel Broderick
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - Linda K Shaw
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.) Program for Advanced Coronary Disease, Duke Medicine, Durham, NC (M.O.)
| | - Eric L Eisenstein
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - Peter K Smith
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
| | - John H Alexander
- Duke Clinical Research Institute, Durham, NC (T.J.P., S.B., K.J.A., L.K.S., M.O., E.L.E., P.K.S., J.H.A.)
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Henry TD, Williams B, Satran D. Rebuttal: Response to severe coronary disease not amenable to revascularization—Are the series clearly defined? Catheter Cardiovasc Interv 2014; 84:E2-3. [DOI: 10.1002/ccd.22733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 07/13/2010] [Indexed: 11/08/2022]
Affiliation(s)
| | | | - Daniel Satran
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
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Lozano I, Carro A, Lee D. Severe coronary disease not amenable to revascularization: are the series clearly defined? Catheter Cardiovasc Interv 2014; 84:E1. [PMID: 20824745 DOI: 10.1002/ccd.22739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 07/13/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Iñigo Lozano
- Hospital Universitario Central de Asturias, Oviedo, Spain
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Cassar A, Prasad M, Rodriguez-Porcel M, Reeder GS, Karia D, DeMaria AN, Lerman A. Safety and efficacy of extracorporeal shock wave myocardial revascularization therapy for refractory angina pectoris. Mayo Clin Proc 2014; 89:346-54. [PMID: 24582193 PMCID: PMC6124893 DOI: 10.1016/j.mayocp.2013.11.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/02/2013] [Accepted: 11/14/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of extracorporeal shockwave myocardial revascularization (ESMR) therapy in treating patients with refractory angina pectoris. PATIENTS AND METHODS A single-arm multicenter prospective trial to assess safety and efficacy of the ESMR therapy in patients with refractory angina (class III/IV angina) was performed. Screening exercise treadmill tests and pharmacological single-photon emission computed tomography (SPECT) were performed for all patients to assess exercise capacity and ischemic burden. Patients were treated with 9 sessions of ESMR to ischemic areas over 9 weeks. Efficacy end points were exercise capacity by using treadmill test as well as ischemic burden on pharmacological SPECT at 4 months after the last ESMR treatment. Safety measures included electrocardiography, echocardiography, troponin, creatine kinase, and brain natriuretic peptide testing, and pain questionnaires. RESULTS Fifteen patients with medically refractory angina and no revascularization options were enrolled. There was a statistically significant mean increase of 122.3±156.9 seconds (38% increase compared with baseline; P=.01) in exercise treadmill time from baseline (319.8±157.2 seconds) to last follow-up after the ESMR treatment (422.1±183.3 seconds). There was no improvement in the summed stress perfusion scores after pharmacologically induced stress SPECT at 4 months after the last ESMR treatment in comparison to that at screening; however, SPECT summed stress score revealed that untreated areas had greater progression in ischemic burden vs treated areas (3.69±6.2 vs 0.31±4.5; P=.03). There was no significant change in the mean summed echo score from baseline to posttreatment (0.4±5.1; P=.70). The ESMR therapy was performed safely without any adverse events in electrocardiography, echocardiography, troponins, creatine kinase, or brain natriuretic peptide. Pain during the ESMR treatment was minimal (a score of 0.5±1.2 to 1.1±1.2 out of 10). CONCLUSION In this multicenter feasibility study, ESMR seems to be a safe and efficacious treatment for patients with refractory angina pectoris. However, larger sham-controlled trials will be required to confirm these findings.
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Affiliation(s)
- Andrew Cassar
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Megha Prasad
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Guy S Reeder
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Darshak Karia
- Division of Cardiovascular Diseases, Albert Einstein Medical Center, Philadelphia, PA
| | - Anthony N DeMaria
- Division of Cardiovascular Diseases, University of California, San Diego, La Jolla
| | - Amir Lerman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Inaba Y, Davidson BP, Kim S, Liu YN, Packwood W, Belcik JT, Xie A, Lindner JR. Echocardiographic evaluation of the effects of stem cell therapy on perfusion and function in ischemic cardiomyopathy. J Am Soc Echocardiogr 2014; 27:192-9. [PMID: 24315764 PMCID: PMC3946830 DOI: 10.1016/j.echo.2013.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Small animal models of ischemic left ventricular (LV) dysfunction are important for the preclinical optimization of stem cell therapy. The aim of this study was to test the hypothesis that temporal changes in LV function and regional perfusion after cell therapy can be assessed in mice using echocardiographic imaging. METHODS Wild-type mice (n = 25) were studied 7 and 28 days after permanent ligation of the left anterior descending coronary artery. Animals were randomized to receive closed-chest ultrasound-guided intramyocardial delivery of saline (n = 13) or 5 × 10(5) multipotential adult progenitor cells (MAPCs; n = 12) on day 7. LV end-diastolic and end-systolic volumes, LV ejection fraction, and stroke volume were measured using high-frequency echocardiography. Multiplanar assessments of perfusion and defect area size were made using myocardial contrast echocardiography. RESULTS Between days 7 and 28, MAPC-treated animals had 40% to 50% reductions in defect size (P < .001) and 20% to 30% increases in total perfusion (P < .01). Perfusion did not change in nontreated controls. Both LV end-diastolic and end-systolic volumes increased between days 7 and 28 in both groups, but LV end-systolic volume increased to a lesser degree in MAPC-treated compared with control mice (+4.2 ± 7.9 vs +19.2 ± 22.0 μL, P < .05). LV ejection fraction increased in the MAPC-treated mice and decreased in control mice (+3.0 ± 4.3% vs -5.6 ± 5.9%, P < .01). There was a significant linear relation between the change in LV ejection fraction and the change in either defect area size or total perfusion. CONCLUSIONS High-frequency echocardiography and myocardial contrast echocardiography in murine models of ischemic LV dysfunction can be used to assess the response to stem cell therapy and to characterize the relationship among spatial flow, ventricular function, and ventricular remodeling.
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Affiliation(s)
- Yoichi Inaba
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Brian P Davidson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Sajeevani Kim
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Ya Ni Liu
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - William Packwood
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - J Todd Belcik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Aris Xie
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon.
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Lavine KJ, Kovacs A, Weinheimer C, Mann DL. Repetitive myocardial ischemia promotes coronary growth in the adult mammalian heart. J Am Heart Assoc 2013; 2:e000343. [PMID: 24080909 PMCID: PMC3835243 DOI: 10.1161/jaha.113.000343] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Coronary artery disease and ischemic cardiomyopathy represent the leading cause of heart failure and continue to grow at exponential rates. Despite widespread availability of coronary bypass surgery and percutaneous coronary intervention, subsequent ischemic events and progression to heart failure continue to be common occurrences. Previous studies have shown that a subgroup of patients develop collateral blood vessels that serve to connect patent and occluded arteries and restore perfusion to ischemic territories. The presence of coronary collaterals has been correlated with improved clinical outcomes; however, the molecular mechanisms governing this process remain largely unknown. METHODS AND RESULTS To date, no mouse models of coronary arterial growth have been described. Using a closed-chest model of myocardial ischemia, we have demonstrated that brief episodes of repetitive ischemia are sufficient to promote the growth of both large coronary arteries and the microvasculature. Induction of large coronary artery and microvascular growth resulted in improvements in myocardial perfusion after prolonged ischemia and protected from subsequent myocardial infarction. We further show that repetitive ischemia did not lead to increased expression of classic proangiogenic factors but instead resulted in activation of the innate immune system and recruitment of macrophages to growing blood vessels. CONCLUSIONS These studies describe a novel model of coronary angiogenesis and implicate the cardiac macrophage as a potential mediator of ischemia-driven coronary growth.
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Affiliation(s)
- Kory J Lavine
- Center for Cardiovascular Research, Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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Jolicœur EM, Banai S, Henry TD, Schwartz M, Doucet S, White CJ, Edelman E, Verheye S. A phase II, sham-controlled, double-blinded study testing the safety and efficacy of the coronary sinus reducer in patients with refractory angina: study protocol for a randomized controlled trial. Trials 2013; 14:46. [PMID: 23413981 PMCID: PMC3599995 DOI: 10.1186/1745-6215-14-46] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 01/21/2013] [Indexed: 01/06/2023] Open
Abstract
Background A growing population of patients lives with severe coronary artery disease not amenable to coronary revascularization and with refractory angina despite optimal medical therapy. Percutaneous reduction of the coronary sinus is an emerging treatment for myocardial ischemia that increases coronary sinus pressure to promote a transcollateral redistribution of coronary artery in-flow from nonischemic to ischemic subendocardial territories. A first-in-man study has demonstrated that the percutaneous reduction of the coronary sinus can be performed safely in such patients. The COSIRA trial seeks to assess whether a percutaneous reduction of the coronary sinus can improve the symptoms of refractory angina in patients with limited revascularization options. Methods/Design The COSIRA trial is a phase II double-blind, sham-controlled, randomized parallel trial comparing the percutaneously implanted coronary sinus Reducer (Neovasc Inc, Richmond, BC, Canada) to a sham implantation in 124 patients enrolled in Canada, Belgium, England, Scotland, Sweden and Denmark. All patients need to have stable Canadian Cardiovascular Society (CCS) class III or IV angina despite optimal medical therapy, with evidence of reversible ischemia related to disease in the left coronary artery, and a left ventricular ejection fraction >25%. Participants experiencing an improvement in their angina ≥2 CCS classes six months after the randomization will meet the primary efficacy endpoint. The secondary objective of this trial is to test whether coronary sinus Reducer implantation will improve left ventricular ischemia, as measured by the improvement in dobutamine echocardiogram wall motion score index and in time to 1 mm ST-segment depression from baseline to six-month post-implantation. Discussion Based on previous observations, the COSIRA is expected to provide a significant positive result or an informative null result upon which rational development decisions can be based. Patient safety is a central concern and extensive monitoring should allow an appropriate investigation of the safety related to the coronary sinus Reducer. Trial registration ClinicalTrials.gov identifier - NCT01205893.
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Affiliation(s)
- E Marc Jolicœur
- Montreal Heart Institute, Université de Montréal, 5000 Bélanger Street East, Montréal, Québec Q H1T 1C8, Canada.
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Incomplete revascularization in the drug eluting stent era permits meaningful long-term (12-78 months) outcomes in patients ≥ 75 years with acute coronary syndrome. J Geriatr Cardiol 2013; 9:336-43. [PMID: 23341837 PMCID: PMC3545249 DOI: 10.3724/sp.j.1263.2012.05021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 07/11/2012] [Accepted: 09/24/2012] [Indexed: 11/25/2022] Open
Abstract
Objective To compare long-term prognosis between complete revascularization (CR) and incomplete revascularization (IR) in elderly patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Methods We prospectively enrolled patients ≥ 75 years with ACS and multi-lesion disease between January 2005 and December 2010 at our center (Institute of Geriatric Cardiology, Chinese PLA General Hospital). Baseline clinical characteristics, PCI parameters and long-term (12 to 78 months) outcomes including main adverse cardiac and cerebral events (MACCE) were compared between CR and IR groups. We used the Kaplan-Meier curve to describe the survival rates, and variables reported to be associated with prognosis were included in Cox regression. Results Of the 502 patients, 230 patients obtained CR, and the other 272 patients underwent IR. Higher SYNTAX score was an independent predictor of IR [Odds ratio (OR): 1.141, 95% confidence interval (95% CI): 1.066–1.221, P = 0.000]. A total of 429 patients (85.5%) were followed with a duration ranging from 12 months to 78 months. There were no significant differences in cumulative survival rates and event free survival rates between the two groups, even for patients with multi-vessel disease. Older age (OR: 1.079, 95% CI: 1.007–1.157, P = 0.032), prior myocardial infarction (OR: 1.440, 95% CI: 1.268–2.723, P = 0.001) and hypertension (OR: 1. 653, 95% CI: 1.010-2.734, P = 0.050) were significant independent predictors of long-term MACCE. Conclusions Given that both clinical and coronary lesion characteristics are much more complex in patients ≥75 years with ACS and multi-lesion disease, IR may be an option allowing low risk hospital results and meaningful long-term (12 to 78 months) outcomes.
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Carboni GP. Depressed Exercise Peak Ejection Rate Detected on Ambulatory Radionuclide Monitoring Reflects End-Stage Cardiac Inotropic Reserve and Predicts Mortality in Ischaemic Cardiomyopathy. Cardiol Res 2012; 3:164-171. [PMID: 28348682 PMCID: PMC5358208 DOI: 10.4021/cr203w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2012] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Fifteen patients with ischaemic cardiomyopathy and inducible ischaemia were studied to determine the mechanisms of mortality. Failure of the contractile reserve during daily life activities may reflect a prognostic index. METHODS Single photon emission cardiac tomography and radionuclide ambulatory monitoring (Vest) data were analysed in all patients with a 7-year follow-up. RESULTS At peak exercise on Vest, the 7 non-survivors (N-SURV) showed worse peak ejection rates (PERs) and ejection fractions (EFs) compared with the 8 survivors (SURV), (2 ± 0.6 vs. 3.3 ± 0.7; end-diastolic volumes (EDVs), P < 0.003), and (34 ± 10% vs. 50 ± 13%; P < 0.02), respectively. However, exercise peak filling rates (PFRs) (1.9 ± 0.6 vs. 2.7 ± 0.9; EDVs/s) and exercise heart rates (HRs), (97 ± 17 vs. 106 ± 10), did not differ between the two groups (P > 0.05). In SURV, exercise PERs, which represented rapid left ventricular (LV) emptying, were significantly correlated with exercise PFRs, representing rapid LV filling, (r = 0.71, P < 0.04) but not in N-SURV (r = 0.66, P > 0.05). Among SURV, the Frank-Starling mechanism was thus preserved but not in N-SURV. Upon Cox analysis, overall LV function parameters, exercise PER was the only predictive measure associated with mortality (b = - 0.018, relative hazard ratio = 0.98, P = 0.02). CONCLUSIONS Exercise PER reduced values reflected failure of the Frank-Starling mechanism, the incapacity of the heart to perform rapid contractile adaptations to daily life activities and a poor prognosis.
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Affiliation(s)
- Gian Piero Carboni
- Consultant in Cardiology. Director of the Nuclear Cardiology Service, Universita Campus-Bio Medico di Roma. Via Alvaro del Portillo, 200, 00124 Roma, Italy.
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Stolen CM, Lam YM, Siu CW, Lau CP, Parker JA, Hauser TH, Tse HF. Pacing to reduce refractory angina in patients with severe coronary artery disease: a crossover pilot trial. J Cardiovasc Transl Res 2011; 5:84-91. [PMID: 22038623 DOI: 10.1007/s12265-011-9326-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 10/12/2011] [Indexed: 11/27/2022]
Abstract
Biventricular pacing (BiV) has been shown to reduce wall stress and workload in regions near the pacing sites. This trial investigated if BiV near the ischemic region would reduce chest pain in patients with refractory angina due to severe coronary artery disease (CAD). Eleven patients were implanted with BiV devices with leads positioned at or adjacent to their ischemic regions as detected by single-photon emission computed tomography (SPECT) and randomized to either pacing turned ON or OFF for 3 months, and then crossed over for 3 months. With pacing turned ON, a Dynamic atrioventricular (AV) delay was set for approximately 90% and 70% of the intrinsic AV delay at the resting heart rate and at the onset of symptoms, respectively. One patient was excluded from the analysis due to a large amount of RV pacing during the OFF periods (24-64%) and due to an inability to properly deliver therapy because of an excessive number of ventricular premature complexes. Overall, with the device ON vs. OFF, the number of angina episodes (0.8 ± 0.4 vs. 1.2 ± 0.7 per week, P = 0.03) and amount of nitroglycerin used (0.2 ± 0.1 vs. 1.0 ± 0.7 per week, P = 0.11) was lower with BiV pacing. Furthermore, the treadmill exercise time to symptoms trended higher (427 ± 65 vs. 408 ± 64 s, P = 0.19), and the sum of fluorodeoxyglucose-positron emission tomography (FDG-PET) scores trended lower (7.9 ± 3.5 vs. 12.0 ± 4.0, P = 0.11) with the device ON vs. OFF. Nevertheless, there were no significant differences in SPECT myocardial perfusion scores, left ventricle ejection fraction, wall motion score index, and quality of life scores with device programmed ON vs. OFF (all P > 0.05). In conclusion, this pilot study demonstrated that BiV-P at or near the ischemic region was feasible and associated with significant reductions in angina in patients with severe CAD. Adequately powered prospective studies are needed to confirm these findings.
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