Coronary sinus reducer implantation in the middle cardiac vein for the treatment of refractory angina

Double Reducer implantation in the coronary venous system for treatment of refractory angina: a case report

Background

The coronary sinus (CS) Reducer can be considered for the treatment of refractory angina in patients unsuitable for coronary revascularization, but its effect can be influenced by the significant heterogeneity in the anatomy of the cardiac venous system.

Case summary

We report the case of a 70-year-old woman with recurrent episodes of rest angina refractory to optimal medical therapy [Canadian Cardiovascular Society (CCS) Class IV] and inducible ischaemia in a large myocardial territory. Given the diffuse and peripheral nature of the coronary disease, the patient was considered ineligible for percutaneous or surgical revascularization and she was regarded as a good candidate for a CS occluder. Since coronary venous angiography showed the middle cardiac vein (MCV) to be at least as relevant as the CS, successful implantation of two devices, one in the CS and the second in the MCV, was performed. At 6-month follow-up, the patient reported a significant improvement in angina, resulting in a reduction of the CCS class from Grades IV to III.

Discussion

In patients affected by refractory angina and regarded as good candidates for Reducer implantation, a thorough comprehension of the cardiac venous pathway drainage is of pivotal importance to guarantee the therapeutic success of the procedure. In this patient, since the CS and the MCV seemed to contribute equally to coronary venous drainage, Reducer implantation in both vessels allowed to obtain a significant improvement of symptoms. The clinical effectiveness of this strategy needs to be validated in randomized clinical trials.

Usefulness of Coronary Sinus Reducer Implantation for the Treatment of Chronic Refractory Angina Pectoris

The coronary sinus (CS) Reducer is a novel device designed for the management of patients with severe angina symptoms refractory to optimal medical therapy and not amenable to further revascularization. Aim of this study was to investigate the efficacy and the safety of the CS Reducer device in a real-world, multicenter, and country-level cohort of patients presenting with refractory angina pectoris. The study included patients affected by refractory angina pectoris who underwent CS Reducer implantation in 16 centers. Clinical follow-up was carried as per each center's protocol. One hundred eighty-seven patients were included. Technical and procedural success were achieved in 98% and 95%, respectively. Minor peri-procedural complications were recorded in 8 patients. During a median follow-up of 18.4 months, 135 (82.8%) patients demonstrated at least 1 CCS class reduction after Reducer implantation, and 80 (49%) patients at least 2 CCS class reduction. Mean CCS class improved from 3.05 ± 0.53 at baseline to 1.63 ± 0.98 at follow-up (p < 0.001). Treatment benefit was also reflected in a significant improvement in quality of life scores and in a reduction of the mean number of anti-ischemic drugs prescribed for patient. In conclusion, in this multicenter, country-level study, the implantation of CS Reducer in patients with refractory angina pectoris resulted to be safe and effective in reducing of angina pectoris and improving quality of life.