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Włodarczak S, Rola P, Jastrzębski A, Turkiewicz K, Korda A, Włodarczak P, Barycki M, Kulczycki JJ, Furtan Ł, Włodarczak A, Lesiak M. Safety and Effectiveness of Coronary Sinus Reducer in the Therapy of Refractory Angina Pectoris-Mid-Term Results of the Real-Life Cohort. J Clin Med 2024; 13:4413. [PMID: 39124680 PMCID: PMC11313317 DOI: 10.3390/jcm13154413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/07/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Despite continuous improvements in revascularization techniques, refractory angina without potential revascularization options remains a relevant clinical issue with significant impact on the patient's quality of life. Recently, a novel device, the Coronary Sinus Reducer (CSR), has been introduced into clinical practice as a therapeutic option for patients with disabling angina pectoris. In this single-center, observational study, we evaluated the mid-term (3-month) safety and efficacy of the CSR in a real-world cohort. Methods: The study population consisted of 55 patients with refractory angina without potential revascularization options, who were predominantly men (87.3%) with a high cardiovascular risk factor burden and advanced angina (baseline CCS angina class 3.15 ± 0.6). In terms of procedure safety, all patients underwent successful device deployment with only one periprocedural complication. Results: At the 3-month follow-up, we observed a statistically significant improvement in angina control measured CCS class and SAQ-7 total questionnaire along with increased abolition of physical limitation-6-MWT (233.3 ± 107.1 vs. 305.2 ± 126.8; p < 0.0001). Additionally, we observed significant improvement in terms of quality of life measurements SF-36, the EQ-5D-5L questionnaire, and the EQ-VAS. Conclusions: Our real-world data suggest that CSR implantation is a relatively safe procedure and appears to be particularly effective in relieving angina symptoms and improving quality of life in subjects with refractory angina.
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Affiliation(s)
- Szymon Włodarczak
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Piotr Rola
- Department of Cardiology, Provincial Specialized Hospital, 59-200 Legnica, Poland; (P.R.); (M.B.); (Ł.F.)
| | - Artur Jastrzębski
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Karol Turkiewicz
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Andrzej Korda
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Piotr Włodarczak
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Mateusz Barycki
- Department of Cardiology, Provincial Specialized Hospital, 59-200 Legnica, Poland; (P.R.); (M.B.); (Ł.F.)
| | - Jan Jakub Kulczycki
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Łukasz Furtan
- Department of Cardiology, Provincial Specialized Hospital, 59-200 Legnica, Poland; (P.R.); (M.B.); (Ł.F.)
| | - Adrian Włodarczak
- Department of Cardiology, Copper Health Centre (MCZ), 59-300 Lubin, Poland; (A.J.); (K.T.); (A.K.); (P.W.); (J.J.K.); (A.W.)
| | - Maciej Lesiak
- 1st Department of Cardiology, University of Medical Sciences, 61-701 Poznan, Poland;
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Ong P, Rudolph TK, Wiebe J, Berger R, Woitek F, Landmesser U. [Angina and no obstruction on coronary angiography : New approaches to the diagnosis and treatment of vasomotor disorders]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:495-502. [PMID: 38517528 DOI: 10.1007/s00108-024-01690-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Clinical management of patients with angina and no obstructive coronary artery disease (ANOCA) is still challenging. This scenario affects up to 50% of patients undergoing diagnostic coronary angiography due to suspected coronary artery disease. Many patients report a long and debilitating history before adequate diagnostics and management are initiated. OBJECTIVES This article describes the current recommendations for diagnostic assessments and treatment in patients with ANOCA. Focus is placed on invasive diagnostics in the catheter laboratory, pharmacological/interventional treatment as well as the patient journey. RESULTS In patients with ANOCA, the current European Society of Cardiology (ESC) guidelines suggest that invasive assessments using acetylcholine and adenosine for the diagnosis of an underlying coronary vasomotor disorder should be considered. Acetylcholine is used to diagnose coronary spasm, whereas adenosine is used in conjunction with a wire-based assessment for the measurement of coronary flow reserve and microvascular resistance. The invasive assessments allow the determination of what are referred to as endotypes (coronary spasm, impaired coronary flow reserve, enhanced microvascular resistance or a combination thereof). Establishing a diagnosis is helpful to: (a) initiate targeted treatment to improve quality of life, (b) reassure the patient that a cardiac cause is found and (c) to assess individual prognosis. CONCLUSIONS Currently, patients with ANOCA are often not adequately managed. Referral to specialised centres is recommended to prevent long and debilitating patient histories until expertise in diagnosis and treatment becomes more widespread.
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Affiliation(s)
- Peter Ong
- Abteilung für Kardiologie und Angiologie, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Deutschland.
| | - Tanja K Rudolph
- Klinik für Allgemeine und Interventionelle Kardiologie/Angiologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Jens Wiebe
- Deutsches Herzzentrum München, Klinik an der Technischen Universität München, Lazarettstr. 36, 80636, München, Deutschland
| | - Rudolf Berger
- Abteilung für Kardiologie und Nephrologie, Innere Medizin I, Krankenhaus der Barmherzigen Brüder, Johannes von Gott Platz 1, 7000, Eisenstadt, Österreich
| | - Felix Woitek
- Herzzentrum Dresden GmbH, Universitätsklinik, Fetscherstraße 76, 01307, Dresden, Deutschland
| | - Ulf Landmesser
- Klinik für Kardiologie, Angiologie und Intensivmedizin, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
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3
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Wang H, Fan L, Choy JS, Kassab GS, Lee LC. Mechanisms of coronary sinus reducer for treatment of myocardial ischemia: in silico study. J Appl Physiol (1985) 2024; 136:1157-1169. [PMID: 38511210 DOI: 10.1152/japplphysiol.00910.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/22/2024] Open
Abstract
The coronary sinus reducer (CSR) is an emerging medical device for treating patients with refractory angina, often associated with myocardial ischemia. Patients implanted with CSR have shown positive outcomes, but the underlying mechanisms are unclear. This study sought to understand the mechanisms of CSR by investigating its effects on coronary microcirculation hemodynamics that may help explain the therapy's efficacy. We applied a validated computer model of the coronary microcirculation to investigate how CSR affects hemodynamics under different degrees of coronary artery stenosis. With moderate coronary stenosis, an increase in capillary transit time (CTT) [up to 69% with near-complete coronary sinus (CS) occlusion] is the key change associated with CSR. Because capillaries in the microcirculation can still receive oxygenated blood from the upstream artery with moderate stenosis, the increase in CTT allows more time for the exchange of gases and nutrients, aiding tissue oxygenation. With severe coronary stenosis; however, the redistribution of blood draining from the nonischemic region to the ischemic region (up to 96% with near-complete CS occlusion) and the reduction in capillary flow heterogeneity are the key changes associated with CSR. Because blood draining from the nonischemic region is not completely devoid of O2, the redistribution of blood to the capillaries in the ischemic region by CSR is beneficial especially when little or no oxygenated blood reaches these capillaries. This simulation study provides insights into the mechanisms of CSR in improving clinical symptoms. The mechanisms differ with the severity of the upstream stenosis.NEW & NOTEWORTHY Emerging coronary venous retroperfusion treatments, particularly coronary sinus reducer (CSR) for refractory angina linked to myocardial ischemia, show promise; however, their mechanisms of action are not well understood. We find that CSR's effectiveness varies with the severity of coronary stenosis. In moderate stenosis, CSR improves tissue oxygenation by increasing capillary transit time, whereas in severe stenosis, it redistributes blood from nonischemic to ischemic regions and reduces capillary flow heterogeneity.
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Affiliation(s)
- Haifeng Wang
- Department of Mechanical Engineering, Michigan State University, East Lansing, Michigan, United States
| | - Lei Fan
- Joint Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, Wisconsin, United States
| | - Jenny S Choy
- California Medical Innovations Institute, San Diego, California, United States
| | - Ghassan S Kassab
- California Medical Innovations Institute, San Diego, California, United States
| | - Lik Chuan Lee
- Department of Mechanical Engineering, Michigan State University, East Lansing, Michigan, United States
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Foley MJ, Rajkumar CA, Ahmed-Jushuf F, Simader FA, Chotai S, Pathimagaraj RH, Mohsin M, Salih A, Wang D, Dixit P, Davies JR, Keeble TR, Cosgrove C, Spratt JC, O'Kane PD, De Silva R, Hill JM, Nijjer SS, Sen S, Petraco R, Mikhail GW, Khamis R, Kotecha T, Harrell FE, Kellman P, Francis DP, Howard JP, Cole GD, Shun-Shin MJ, Al-Lamee RK. Coronary sinus reducer for the treatment of refractory angina (ORBITA-COSMIC): a randomised, placebo-controlled trial. Lancet 2024; 403:1543-1553. [PMID: 38604209 DOI: 10.1016/s0140-6736(24)00256-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The coronary sinus reducer (CSR) is proposed to reduce angina in patients with stable coronary artery disease by improving myocardial perfusion. We aimed to measure its efficacy, compared with placebo, on myocardial ischaemia reduction and symptom improvement. METHODS ORBITA-COSMIC was a double-blind, randomised, placebo-controlled trial conducted at six UK hospitals. Patients aged 18 years or older with angina, stable coronary artery disease, ischaemia, and no further options for treatment were eligible. All patients completed a quantitative adenosine-stress perfusion cardiac magnetic resonance scan, symptom and quality-of-life questionnaires, and a treadmill exercise test before entering a 2-week symptom assessment phase, in which patients reported their angina symptoms using a smartphone application (ORBITA-app). Patients were randomly assigned (1:1) to receive either CSR or placebo. Both participants and investigators were masked to study assignment. After the CSR implantation or placebo procedure, patients entered a 6-month blinded follow-up phase in which they reported their daily symptoms in the ORBITA-app. At 6 months, all assessments were repeated. The primary outcome was myocardial blood flow in segments designated ischaemic at enrolment during the adenosine-stress perfusion cardiac magnetic resonance scan. The primary symptom outcome was the number of daily angina episodes. Analysis was done by intention-to-treat and followed Bayesian methodology. The study is registered with ClinicalTrials.gov, NCT04892537, and completed. FINDINGS Between May 26, 2021, and June 28, 2023, 61 patients were enrolled, of whom 51 (44 [86%] male; seven [14%] female) were randomly assigned to either the CSR group (n=25) or the placebo group (n=26). Of these, 50 patients were included in the intention-to-treat analysis (24 in the CSR group and 26 in the placebo group). 454 (57%) of 800 imaged cardiac segments were ischaemic at enrolment, with a median stress myocardial blood flow of 1·08 mL/min per g (IQR 0·77-1·41). Myocardial blood flow in ischaemic segments did not improve with CSR compared with placebo (difference 0·06 mL/min per g [95% CrI -0·09 to 0·20]; Pr(Benefit)=78·8%). The number of daily angina episodes was reduced with CSR compared with placebo (OR 1·40 [95% CrI 1·08 to 1·83]; Pr(Benefit)=99·4%). There were two CSR embolisation events in the CSR group, and no acute coronary syndrome events or deaths in either group. INTERPRETATION ORBITA-COSMIC found no evidence that the CSR improved transmural myocardial perfusion, but the CSR did improve angina compared with placebo. These findings provide evidence for the use of CSR as a further antianginal option for patients with stable coronary artery disease. FUNDING Medical Research Council, Imperial College Healthcare Charity, National Institute for Health and Care Research Imperial Biomedical Research Centre, St Mary's Coronary Flow Trust, British Heart Foundation.
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Affiliation(s)
- Michael J Foley
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Shayna Chotai
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Rachel H Pathimagaraj
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Muhammad Mohsin
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ahmed Salih
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Danqi Wang
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Prithvi Dixit
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John R Davies
- Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, UK; Medical Technology Research Centre, Anglia Ruskin University School of Medicine, Chelmsford, UK
| | - Tom R Keeble
- Essex Cardiothoracic Centre, Mid and South Essex NHS Foundation Trust, Basildon, UK; Medical Technology Research Centre, Anglia Ruskin University School of Medicine, Chelmsford, UK
| | - Claudia Cosgrove
- St George's University Hospitals NHS Foundation Trust, London, UK; St George's, University of London, London, UK
| | - James C Spratt
- St George's University Hospitals NHS Foundation Trust, London, UK; St George's, University of London, London, UK
| | - Peter D O'Kane
- University Hospitals of Dorset NHS Foundation Trust, Bournemouth, UK
| | - Ranil De Silva
- The Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan M Hill
- The Royal Brompton Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Sayan Sen
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Ramzi Khamis
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Frank E Harrell
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Peter Kellman
- Department of Health and Human Services, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Rasha K Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
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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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Foley MJ, Rajkumar CA, Ahmed-Jushuf F, Simader F, Pathimagaraj RH, Nijjer S, Sen S, Petraco R, Clesham G, Johnson T, Harrell FE, Kellman P, Francis D, Shun-Shin M, Howard J, Cole GD, Al-Lamee R. A double-blind, randomised, placebo-controlled trial of the coronary sinus Reducer in refractory angina: design and rationale of the ORBITA-COSMIC trial. EUROINTERVENTION 2024; 20:e216-e223. [PMID: 38214677 PMCID: PMC10836388 DOI: 10.4244/eij-d-23-00567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/12/2023] [Indexed: 01/13/2024]
Abstract
The coronary sinus Reducer (CSR) is an hourglass-shaped device which creates an artificial stenosis in the coronary sinus. Whilst placebo-controlled data show an improvement in angina, these results are unreplicated and are the subject of further confirmatory research. The mechanism of action of this unintuitive therapy is unknown. The Coronary Sinus Reducer Objective Impact on Symptoms, MRI Ischaemia, and Microvascular Resistance (ORBITA-COSMIC) trial is a randomised, placebo-controlled, double-blind trial investigating the efficacy of the CSR. Patients with (i) established epicardial coronary artery disease, (ii) angina on maximally tolerated antianginal medication, (iii) evidence of myocardial ischaemia and (iv) no further options for percutaneous coronary intervention or coronary artery bypass grafting will be enrolled. Upon enrolment, angina and quality-of-life questionnaires, treadmill exercise testing and quantitative stress perfusion cardiac magnetic resonance (CMR) imaging will be performed. Participants will record their symptoms daily on a smartphone application throughout the trial. After a 2-week symptom assessment phase, participants will be randomised in the cardiac catheterisation laboratory to CSR or a placebo procedure. After 6 months of blinded follow-up, all prerandomisation tests will be repeated. A prespecified subgroup will undergo invasive coronary physiology assessment at prerandomisation and follow-up. The primary outcome is stress myocardial blood flow on CMR. Secondary outcomes include angina frequency, quality of life and treadmill exercise time. (ClinicalTrials.gov: NCT04892537).
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Affiliation(s)
- Michael J Foley
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fiyyaz Ahmed-Jushuf
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Florentina Simader
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rachel H Pathimagaraj
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sukhjinder Nijjer
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Thomas Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Frank E Harrell
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Darrel Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - James Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, London, United Kingdom
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Ford TJ, Redwood E, Chuah E. Coronary Sinus Reduction: Can Device-Based Therapy Improve Coronary Microvascular Function? Circ Cardiovasc Interv 2024; 17:e013831. [PMID: 38227698 DOI: 10.1161/circinterventions.123.013831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Thomas J Ford
- Department of Cardiology, Gosford Hospital, NSW, Australia (T.J.F., E.R., E.C.)
- Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia (T.J.F.)
- British Heart Foundation (BHF) Cardiovascular Research Centre, The Institute of Cardiovascular & Medical Sciences (ICAMS), University of Glasgow, United Kingdom (T.J.F.)
| | - Eleanor Redwood
- Department of Cardiology, Gosford Hospital, NSW, Australia (T.J.F., E.R., E.C.)
| | - Eunice Chuah
- Department of Cardiology, Gosford Hospital, NSW, Australia (T.J.F., E.R., E.C.)
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Dimitriadis K, Iliakis P, Pyrpyris N, Beneki E, Tsioufis P, Aznaouridis K, Aggeli K, Tsioufis K. Coronary sinus narrowing therapy: A "Reducer" for angina and beyond. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 57:96-105. [PMID: 37573172 DOI: 10.1016/j.carrev.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/01/2023] [Accepted: 07/18/2023] [Indexed: 08/14/2023]
Abstract
Refractory Angina (RA) is an increasingly common clinical diagnosis, in which patients unsuitable for further percutaneous or surgical procedures experience anginal symptoms, despite receiving optimal medical therapy. This clinical condition challenges the everyday activities and diminishes the quality of life of these patients. A wide variety of novel therapies for this type of angina are being investigated for clinical use. One of them is coronary sinus narrowing, which is performed as a percutaneous interventional procedure using catheter-delivered device, the Reducer. The device is implanted in the coronary sinus creating a physical narrowing and a pressure gradient in the sinus. This intervention improves the impaired blood flow in the ischemic regions of the heart leading to the relief of the anginal symptoms and, therefore, the overall clinical improvement of these patients. Several clinical trials have established both the safety and efficacy of the coronary sinus Reducer, while ongoing trials are aiming to further establish the procedure's safety and efficiency in both RA and other cardiovascular diseases, such as coronary microvascular dysfunction. This review aims to discuss the pathophysiology and the role of the coronary sinus Reducer in RA, the clinical trials documenting its safety and efficacy, as well as the future perspectives of this procedure among cardiovascular diseases.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
| | - Panagiotis Iliakis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Nikolaos Pyrpyris
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Eirini Beneki
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Panagiotis Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Konstantinos Aznaouridis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
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9
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Périer DM, Haidar DHA, Munnich DB, Huang DF, Benamer DH. [Coronary sinus reducer : Literature review and issues surrounding the France Reducer registry]. Ann Cardiol Angeiol (Paris) 2023; 72:101683. [PMID: 37918330 DOI: 10.1016/j.ancard.2023.101683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 10/09/2023] [Indexed: 11/04/2023]
Abstract
Coronary sinus Reducer implantation is a percutaneous technique used to treat patients suffering from refractory angina pectoris. The device narrows the coronary sinus, increases the back pressure in the myocardial venous system and forces redistribution of coronary blood flow from less ischemic subepicardium to the more ischemic subendocardium. Multiple clinical studies had proven its efficacy to alleviate myocardial ischemia and related symptoms, and to improve the quality of life of patients with refractory symptomatic chronic coronary artery disease for whom coronary revascularization is deemed unsuitable. This literature review aims to expose the device design, its mechanisms of action, and the clinical data supporting its use. Since November 2021 Reducer's reimbursement has been granted in France by the national health authority. It is the first device to be approved under a newly established reimbursement approval process. A transitional coverage is provided with opportunities for renewal before applying for full-time reimbursement. To fulfill the requirements of the National Commission for Evaluation of Medical Devices and Health Technologies, the French Society of Cardiology has been creating the France Reducer registry. This clinical registry has been collecting data from patients undergoing coronary sinus Reducer implantation regarding their clinical situation, periprocedural information, and one-year follow-up. It is crucial for the future of this emerging therapeutic option in France. To date, 215 patients from 28 centers have been included between June 2022 and September 2023.
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Affiliation(s)
| | | | | | | | - Docteur Hakim Benamer
- Service de cardiologie, Hôpital Foch, 40, rue Worth, 92150 Suresnes, France, Institut Jacques Cartier, Institut cardiovasculaire Paris Sud (ICPS) Ramsay Générale de santé, 6, avenue du Noyer-Lambert, 91300 Massy, France, Membre du Collège de Médecine des Hôpitaux de Paris, France
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10
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Elimelech C, Zornitzki L, Konigstein M, Rozenbaum Z, Arnold JH, Havakuk O, Revivo M, Flint N, Khoury S, Topilsky Y, Banai S, Laufer-Perl M. Baseline Left Ventricle Longitudinal Strain as a Predictor for Clinical Improvement Following Coronary Sinus Reducer Implantation. Am J Cardiol 2023; 204:77-83. [PMID: 37541151 DOI: 10.1016/j.amjcard.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/11/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023]
Abstract
Coronary sinus narrowing device (reducer) implantation has emerged as an effective treatment to improve the quality of life and functional capacity in patients suffering from disabling refractory angina. Left ventricle global longitudinal strain (LV-GLS) is a useful tool for early diagnosis of subclinical cardiac injury and an independent predictor for coronary artery disease. We aimed to investigate whether LV-GLS could help predict clinical improvement after coronary sinus reducer implantation. LV-GLS assessments were performed at baseline and 6 months after reducer implantation in consecutive patients treated for refractory angina. Patients were divided into 2 groups based on reduced (<17% absolute value) or preserved baseline LV-GLS. Clinical improvement was defined as an increase of ≥25 m in the 6-minute walk test (6MWT) at follow-up. Overall, 41 patients were included, 31 in the reduced LV-GLS group and 10 in the preserved LV-GLS group. The mean age was 68 ± 8 years, with only 2 female patients (5%). Baseline characteristics did not differ significantly between the 2 groups. Univariable analysis revealed that LV-GLS was the only significant predictor for 6MWT improvement. Baseline preserved LV-GLS reduced the likelihood of 6MWT improvement by 82% (odds ratio 0.18 [0.04 to 0.83], p = 0.029). A significant increase in 6MWT (307 ± 97 m to 343 ± 92 m, p = 0.017) was observed in the reduced LV-GLS group, compared with a decrease in the preserved LV-GLS group (378 ± 86 m to 361 ± 123 m, p = 0.651). In conclusion, reduced LV-GLS may serve as a marker for potential clinical improvement in patients with refractory angina treated with reducer. Larger clinical trials are needed to establish its role.
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Affiliation(s)
- Chen Elimelech
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Lior Zornitzki
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Maayan Konigstein
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zach Rozenbaum
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiology, Tulane University, New Orleans, Louisiana
| | - Joshua H Arnold
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ofer Havakuk
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Miri Revivo
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Flint
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shafik Khoury
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yan Topilsky
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shmuel Banai
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Laufer-Perl
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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11
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Tsiachris D, Giannini F, Antoniou CK, Dimitriadis K, Stefanadis C, Tsioufis K. First-in-man parallel implantation of a coronary sinus Reducer and biventricular pacemaker. J Cardiovasc Med (Hagerstown) 2023; 24:778-780. [PMID: 37577865 DOI: 10.2459/jcm.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Affiliation(s)
- Dimitris Tsiachris
- Athens Heart Center, Athens Medical Center, Marousi, Attica
- First University Department of Cardiology, Athens Medical School, Hippokration General Hospital, Athens, Greece
| | | | - Christos-Konstantinos Antoniou
- Athens Heart Center, Athens Medical Center, Marousi, Attica
- First University Department of Cardiology, Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Kyriakos Dimitriadis
- First University Department of Cardiology, Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Christodoulos Stefanadis
- Athens Heart Center, Athens Medical Center, Marousi, Attica
- First University Department of Cardiology, Athens Medical School, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First University Department of Cardiology, Athens Medical School, Hippokration General Hospital, Athens, Greece
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12
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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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13
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Chen Y, Ge Y, Chao T, Huan N, Liu W, Chu G, Wang C. Refractory angina pectoris: a 20-year (2003-2022) bibliometric analysis. Front Cardiovasc Med 2023; 10:1228201. [PMID: 37692051 PMCID: PMC10484221 DOI: 10.3389/fcvm.2023.1228201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Background The increasing number of patients with refractory angina pectoris, combined with the aging population and improved survival rates among coronary heart disease patients, presents a significant challenge in contemporary cardiovascular medicine. The treatment of refractory angina has been an ongoing area of exploration, yet a comprehensive analysis of the existing literature on this topic is currently lacking. Therefore, this study aims to provide the first bibliometric analysis of publications related to refractory angina. Methods A systematic search was conducted in the Web of Science database to identify articles related to refractory angina published between 2003 and 2022. The inclusion criteria were limited to articles and reviews written in English. CiteSpace software was utilized to conduct a collaborative network analysis of countries/regions, institutions and authors, co-occurrence analysis of keywords, and co-citation analysis of authors and references. Results A total of 1,386 publications were identified, with an annual publication volume exhibiting fluctuation over time. American and European countries and institutions demonstrated a leading position in terms of research output. Henry TD emerged as the most prolific researcher in the field, while Mannheimer C received the highest number of citations. The primary research hotspot within this field focused on the treatment of refractory angina, with recent emphasis on emerging treatments such as stem cell therapy and the coronary sinus reducer. A significant number of clinical trials have been conducted, with a continuous focus on patient benefits, quality of life, and survival prognosis. Conclusion Significant progress has been made in the field of refractory angina pectoris in recent years. Novel treatment methods, including spinal cord stimulation, enhanced external counterpulsation, stem cell therapy, and the coronary sinus reducer, hold promising therapeutic prospects. However, further high-quality evidence-based research is essential to support these emerging interventions. Additionally, the development of comprehensive evidence-based guidelines for refractory angina treatment is crucial. Such guidelines would provide clinicians with a framework to navigate the complexities of treatment choices and optimize patient care in this challenging condition.
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Affiliation(s)
| | | | | | | | | | | | - Chenglong Wang
- Center for Cardiovascular Disease, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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14
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da Silveira JB. Percutaneous treatment for refractory angina with the coronary sinus Reducer: A multicenter initial experience. Rev Port Cardiol 2023; 42:421-422. [PMID: 36828181 DOI: 10.1016/j.repc.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Affiliation(s)
- João Brum da Silveira
- Centro Hospitalar e Universitário do Porto, Hospital de Santo António, Porto, Portugal.
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15
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Reis JF, Brízido C, Madeira S, Ramos R, Almeida M, Cacela D. Coronary sinus Reducer device for the treatment of refractory angina: A multicenter initial experience. Rev Port Cardiol 2023; 42:413-420. [PMID: 36828185 DOI: 10.1016/j.repc.2022.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 05/23/2022] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION The coronary sinus Reducer (CSR) device has emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSR in a real-world setting. METHODS Twenty-six patients with refractory angina (RA) and evidence of myocardial ischemia attributable to the left coronary artery considered unsuitable for revascularization were treated with the CSR at two centers between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at six-month follow-up, were reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7), and reduction in antianginal therapy. RESULTS Twenty-three patients had end-stage coronary artery disease without revascularization targets and three had microvascular disease without epicardial stenosis. Procedural success was achieved in 23 patients, with two device/procedure-related complications and one anatomically-related failure to deliver the device. A total of 25 patients had the device implanted and entered the efficacy analysis. Eighteen patients (75.0%) had a reduction of at least one CCS class, 41.7% had a reduction of at least two classes, and 16.7% became asymptomatic, with a mean reduction in CCS class of 1.3±0.2 (p=0.001) at six-month follow-up. All SAQ-7 domains improved, notably physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction in anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010). CONCLUSION In this real-world, multicenter experience, implantation of the CSR was associated with improvement in angina and QoL in patients with RA.
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Affiliation(s)
- João Ferreira Reis
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal.
| | - Catarina Brízido
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Sérgio Madeira
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Rúben Ramos
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
| | - Manuel Almeida
- Department of Cardiology, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Duarte Cacela
- Department of Cardiology, Hospital de Santa Marta, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
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16
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Ullrich H, Olschewski M, Münzel T, Gori T. Randomized, crossover, controlled trial on the modulation of cardiac coronary sinus hemodynamics to develop a new treatment for microvascular disease: Protocol of the MACCUS trial. Front Cardiovasc Med 2023; 10:1133014. [PMID: 36873411 PMCID: PMC9978109 DOI: 10.3389/fcvm.2023.1133014] [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: 12/28/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Background Microvascular angina (MVA) is a frequent condition for which our understanding of the disease pathophysiology and therapeutic perspectives remain unsatisfactory. The current study is designed to test whether an improvement in microvascular resistances could be achieved by elevating backward pressure in the coronary venous system, based on the hypothesis that an increase in hydrostatic pressure could cause a dilatation of the myocardial arterioles, resulting in a reduction of vascular resistances. This approach might have potential clinical implications, as it might suggest that interventions aimed at increasing coronary sinus (CS) pressure might result in a decrease in angina in this subset of patients. The aim of our single-center, sham-controlled, crossover randomized trial is to investigate the effect of an acute increase in CS pressure on a number of parameters of coronary physiology, including parameters of coronary microvascular resistance and conductance. Methods and analysis A total of 20 consecutive patients with angina pectoris and coronary microvascular dysfunction (CMD) will be enrolled in the study. Hemodynamic parameters including aortic and distal coronary pressure, CS and right atrial pressure, and the coronary microvascular resistance index will be measured at rest and during hyperemia in a randomized crossover design during incomplete balloon occlusion ("balloon") and with the deflated balloon in the right atrium ("sham"). The primary end point of the study is the change in index of microvascular resistances (IMR) after acute modulation of CS pressure, while key secondary end points include changes in the other parameters. Discussion The aim of the study is to investigate whether occlusion of the CS is associated with a decrease in IMR. The results will provide mechanistic evidence for the development of a treatment for patients with MVA. Clinical trial registration https://clinicaltrials.gov/, identifier NCT05034224.
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Affiliation(s)
- Helen Ullrich
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany.,German Centre for Cardiovascular Research, Standort RheinMain, Mainz, Germany
| | - Maximilian Olschewski
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany.,German Centre for Cardiovascular Research, Standort RheinMain, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany.,German Centre for Cardiovascular Research, Standort RheinMain, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany.,German Centre for Cardiovascular Research, Standort RheinMain, Mainz, Germany
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Ponticelli F, Giannini F. Coronary sinus reducer for the treatment of chronic refractory angina pectoris. Future Cardiol 2022; 18:523-537. [PMID: 35758146 DOI: 10.2217/fca-2021-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Refractory angina represents the final stage of chronic coronary artery disease, where anginal symptoms persist despite complete epicardial coronary artery revascularization and maximally tolerated pharmacological therapy. Percutaneous narrowing of the coronary sinus with the Coronary Sinus Reducer® device was first attempted in humans in 2005 and has been shown to improve angina symptoms and the quality of life of patients suffering chronic refractory angina. It was recently included in the European guidelines for the management of chronic coronary syndrome and is progressively gaining popularity. The authors hereby provide a review of current literature on the topic, intending to facilitate insights and to promote further research on this device and its clinical applications.
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Affiliation(s)
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Via Madonna di Genova 1, Cotignola, RA, 48033, Italy
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18
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Abstract
Management of stable coronary artery disease (CAD) centers on medication to prevent myocardial infarction and death. Many anti-anginal medications also have benefit for reducing symptoms, and have been proven to be effective against placebo control. Before effective preventive medications were available, patients with stable CAD often underwent revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), on the plausible assumption that these procedures would prevent adverse events and reduce symptoms. However, recent randomized controlled trials have cast doubt on these assumptions.Considering results from the recent ISCHEMIA trial, we discuss the evidence base that underpins revascularization for stable CAD in contemporary practice. We also focus on patient groups at high risk of myocardial infarction and death, for whom revascularization is often recommended. We outline the areas of uncertainty, unanswered research questions, and key areas of potential miscommunication in doctor-patient consultations.
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Affiliation(s)
- Rasha K Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
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19
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Mann TD, Kofman N, Katz A, Konigstein M, Perl ML, Zuzut ME, Revivo M, Topilsky Y, Banai S, Havakuk O. Coronary Sinus Narrowing Improves Right Ventricular Function. JACC: ASIA 2022; 2:385-387. [PMID: 36338412 PMCID: PMC9627899 DOI: 10.1016/j.jacasi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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20
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Gindi R, Gorgis S, Raad M, O'Neill W, Koenig G. The use of coronary sinus reducer for refractory angina in the U.S.: A case series. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40S:267-271. [DOI: 10.1016/j.carrev.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/31/2021] [Accepted: 01/05/2022] [Indexed: 01/29/2023]
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21
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Hochstadt A, Itach T, Merdler I, Ghantous E, Ziv-Baran T, Leshno M, Banai S, Konigstein M. The Effectiveness of CS Reducer for the treatment of Refractory Angina - a Meta-Analysis. Can J Cardiol 2021; 38:376-383. [PMID: 34968714 DOI: 10.1016/j.cjca.2021.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Refractory angina is a debilitating condition that affects quality of life of patients worldwide, that after exhausting standard available therapies are regarded as "no option" patients. Recently, coronary sinus (CS) Reducer implantation became available and is gaining popularity in the treatment of refractory angina. The effectiveness of this therapy was demonstrated in one randomized sham-control trial and numerous uncontrolled prospective studies entailing altogether several hundred patients. We performed a meta-analysis to incorporate the data and elucidate its efficacy and safety. METHODS A meta-analysis of prospective studies assessing the effects of CS narrowing published in English until June 2021 was performed. The primary outcome was the proportion of patients improving ≥1 class in the Canadian Cardiovascular Society (CSS) angina score. Other endpoints included proportion of patients improving ≥2 CCS classes, procedural success, periprocedural complications, changes in Seattle Angina Questionnaire (SAQ) scores, and six-minute walk test (6MWT). RESULTS Data from 9 studies, including 846 patients was included. An improvement of ≥1 CSS class occurred in 76% [95% CI 73%- 80%] of patients. Improvement of ≥2 CSS classes was observed in 40% of patients (95% CI of 35-46%). Procedure success was 98%, with no major and 3% of non-major periprocedural complications. Post procedural SAQ scores and 6MWT distance were significantly improved. CONCLUSIONS In patients suffering from angina refractory to medical and interventional therapies, CS narrowing implantation improves symptoms and quality of life, with a low complication rate. These results are consistent in one randomized trial and in multiple prospective, uncontrolled studies.
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22
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Savarimuthu S, Philip B, Harky A. Coronary Sinus Reducer: A Solution for patients with Refractory Angina. Curr Probl Cardiol 2021; 47:101085. [PMID: 34936909 DOI: 10.1016/j.cpcardiol.2021.101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022]
Abstract
Refractory Angina (RA) places a great burden on patients and the healthcare system, with reduced quality of life (QOL), increased hospital admissions, polypharmacy, and psychological effects. Patients with RA are limited in options for management and with the introduction of the coronary sinus reducer (CSR), a safe and effective option may be available for this group of patients. This review article seeks to understand the efficacy of coronary sinus implantation in the current literature.
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Affiliation(s)
| | - Bejoy Philip
- Department of Cardiothoracic surgery, Liverpool Heart and Chest hospital, Liverpool, UK
| | - Amer Harky
- Department of Cardiothoracic surgery, Liverpool Heart and Chest hospital, Liverpool, UK.
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23
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Bertero E, Heusch G, Münzel T, Maack C. A pathophysiological compass to personalize antianginal drug treatment. Nat Rev Cardiol 2021; 18:838-852. [PMID: 34234310 DOI: 10.1038/s41569-021-00573-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/06/2023]
Abstract
Myocardial ischaemia results from coronary macrovascular or microvascular dysfunction compromising the supply of oxygen and nutrients to the myocardium. The underlying pathophysiological processes are manifold and encompass atherosclerosis of epicardial coronary arteries, vasospasm of large or small vessels and microvascular dysfunction - the clinical relevance of which is increasingly being appreciated. Myocardial ischaemia can have a broad spectrum of clinical manifestations, together denoted as chronic coronary syndromes. The most common antianginal medications relieve symptoms by eliciting coronary vasodilatation and modulating the determinants of myocardial oxygen consumption, that is, heart rate, myocardial wall stress and ventricular contractility. In addition, cardiac substrate metabolism can be altered to alleviate ischaemia by modulating the efficiency of myocardial oxygen use. Although a universal agreement exists on the prognostic importance of lifestyle interventions and event prevention with aspirin and statin therapy, the optimal antianginal treatment for patients with chronic coronary syndromes is less well defined. The 2019 guidelines of the ESC recommend a personalized approach, in which antianginal medications are tailored towards an individual patient's comorbidities and haemodynamic profile. Although no antianginal medication improves survival, their efficacy for reducing symptoms profoundly depends on the underlying mechanism of the angina. In this Review, we provide clinicians with a rationale for when to use which compound or combination of drugs on the basis of the pathophysiology of the angina and the mode of action of antianginal medications.
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Affiliation(s)
- Edoardo Bertero
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- German Center for Cardiovascular Research (DZHK), Partner site Rhine-Main, Mainz, Germany.
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC), University Clinic Würzburg, Würzburg, Germany.
- Department of Internal Medicine 1, University Clinic Würzburg, Würzburg, Germany.
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Khalaph M, Bergau L, Vanezi M, Rudolph TK, Sommer P, Sohns C. Beneficial effects of atrial fibrillation ablation in patients with angina pectoris and coronary sinus reducer. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:149-153. [PMID: 34564879 DOI: 10.1111/pace.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 11/30/2022]
Abstract
Limited data exists about the effectiveness of the coronary sinus reducer (CSR) device in patients with angina pectoris and atrial fibrillation (AF). This case demonstrates beneficial effects of AF ablation in a patient with CSR. We report four major findings: Rhythm control has a relevant effect on angina pectoris symptoms in patients with coronary artery disease and AF. In these patients, AF ablation should be considered at an early stage. Patients with persistent angina pectoris and CSR may require sinus rhythm for an optimal effect of the device. Selected coronary sinus (CS) interventions can still be performed through the mesh of the CSR device.
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Affiliation(s)
- Moneeb Khalaph
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Leonard Bergau
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Maria Vanezi
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Tanja K Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Philipp Sommer
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christian Sohns
- Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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25
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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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26
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Verheye S, Agostoni P, Giannini F, Hill JM, Jensen C, Lindsay S, Stella P, Redwood SR, Banai S, Konigstein M. Coronary sinus narrowing for the treatment of refractory angina: a multicentre prospective open-label clinical study (the REDUCER-I study). EUROINTERVENTION 2021; 17:561-568. [PMID: 33319762 PMCID: PMC9724967 DOI: 10.4244/eij-d-20-00873] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The REDUCER-I study is a prospective (with a retrospective component), open-label, multi-centre, international, post-market study, which collects long-term data of patients with refractory angina treated with the Reducer. Here we present the overall clinical outcomes of the first 228 patients enrolled. AIMS The aim of this study is to examine the safety and efficacy of the coronary sinus (CS) Reducer in improving angina severity and quality of life in patients suffering from angina pectoris, refractory to medical and interventional therapies. METHODS REDUCER-I is a multicentre, non-randomised observational study. Enrolled patients had refractory angina pectoris Canadian Cardiovascular Society (CCS) class II-IV and were treated with Reducer implantation. RESULTS In the first 228 patients (81% male, 68.3±9.6 years), the procedural success rate was 99%, with only one adjudicated possible procedural or device-related MACE. Mean CCS class decreased from 2.8±0.6 at baseline, to 1.8±0.7 at two years. Improvement in ≥1 CCS class was observed in 82%, and in ≥2 CCS classes in 31% of patients at two years. At baseline, 70% of the cohort were reported to be in CCS class III-IV; this portion was reduced to 15% at follow-up. Additional measured parameters of functional class and quality of life were also improved. CONCLUSIONS Interim results from the ongoing REDUCER-I study confirm the high safety profile of this therapy in patients suffering from refractory angina. The results also demonstrate sustained improvement in angina severity and in quality of life up to two years.
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Affiliation(s)
- Stefan Verheye
- Cardiovascular Center, ZNA Middelheim Hospital, Lindendreef Antwerp, Belgium
| | | | | | | | | | - Steven Lindsay
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | | | - Simon R. Redwood
- St Thomas’ Hospital Cardiothoracic Centre, London, United Kingdom
| | - Shmuel Banai
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906, Israel
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27
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Efficacy of coronary sinus Reducer in patients with refractory angina and diabetes mellitus. Heart Vessels 2021; 37:194-199. [PMID: 34374824 DOI: 10.1007/s00380-021-01909-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Coronary sinus Reducer (CSR) implantation is currently recommended to relieve angina in patients with refractory symptoms despite optimal medical therapy and maximally achievable revascularization. The impact of diabetes mellitus on outcome after CSR implantation is at present unknown. We aimed to explore the impact of CSR in refractory angina patients with diabetes mellitus. Data from consecutive patients undergoing CSR implantation at four different centres between 2014 and 2018 were included. Patients were divided according to the presence or absence of diabetes mellitus. Primary objective of this analysis was to evaluate the clinical response to CSR implantation defined as an improvement of ≥ 1 classes of the Canadian Cardiovascular Society (CCS) Classification. A total of 219 patients were included, 116 (53%) of whom had diabetes mellitus. The median age of the population was 69 years and 167 patients (76%) were male. There were no significant differences between groups of patients with and without diabetes mellitus with respect to CCS class at baseline (p value = 0.32) and at follow-up (p = 0.75). Over a median follow-up of 393 [224-1004] days, 84 (72%) of the patients with diabetes mellitus met the primary outcome, similarly to those without diabetes mellitus (p = 0.28). Fifty-three patients (24%) did not have an improvement in CCS class and no one experienced worsening of angina. CSR implantation was equally effective in improving angina symptoms among patients with refractory angina and diabetes mellitus compared to patients without diabetes mellitus.
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28
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Traverse JH. The coronary sinus reducer - Where modern technology meets old school physiology! Int J Cardiol 2021; 342:31-32. [PMID: 34371031 DOI: 10.1016/j.ijcard.2021.07.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/30/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jay H Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, The University of Minnesota, School of Medicine, Cardiovascular Division, Minneapolis, MN, United States of America.
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29
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Abstract
PURPOSE OF THE REVIEW Ischemic heart disease is among the most common causes of morbidity and mortality worldwide. In its stable manifestation, obstructing coronary artery stenoses prevent myocardial blood flow from matching metabolic needs of the heart under exercise conditions, which manifests clinically as dyspnea or chest pain. Prolonged bouts of ischemia may result in permanent myocardial dysfunction, heart failure, and eventually reduced survival. The aim of the present work is to review currently available approaches to provide relief of ischemia in stable coronary artery disease (CAD). RECENT FINDINGS Several pharmacological and interventional approaches have proven effectiveness in reducing the burden of ischemia in stable CAD and allow for symptom control and quality of life improvement. However, substantial evidence in favor of improved survival with ischemia relief is lacking, and recently published randomized controlled trial suggests that only selected groups of patients may substantially benefit from this approach. Pharmacological treatments aimed at reducing ischemia were shown to significantly reduce ischemic symptoms but failed to provide prognostic benefit. Myocardial revascularization is able to re-establish adequate coronary artery flow and was shown to improve survival in selected groups of patients, i.e., those with significant left main CAD or severe left ventricular dysfunction in multivessel CAD. Outside the previously mentioned categories, revascularization appears to improve symptoms control over medical therapy, but does not confer prognostic advantage. More studies are needed to elucidate the role of systematic invasive functional testing to identify individuals more likely to benefit from revascularization and to evaluate the prognostic role of chronic total occlusion recanalization.
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30
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Wilgenhof A, Zivelonghi C, Verheye S, Vermeersch P, Scott B, Convens C, Timmers L, Leenders G, Kuijk JPV, Stella P, Agostoni P. Coronary sinus anatomical features: Description and procedural implications during coronary sinus Reducer implantation. Catheter Cardiovasc Interv 2021; 97:E929-E935. [PMID: 33211373 DOI: 10.1002/ccd.29398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/14/2020] [Accepted: 11/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES We hypothesized that some coronary sinus (CS) anatomies allow a more straightforward CS Reducer (CSR) implantation. BACKGROUND Recent decades have seen a rise in patients with chronic angina. When complete revascularization and maximal medical therapy fail to reduce symptoms, CSR has become a new therapeutic option. METHODS We identified a classical C-shape-a near horizontal course of the proximal portion of a circular CS-in a retrospective analysis of 47 CSR implantations and compared the procedural time, fluoroscopic time, contrast use, presence of valves or bifurcations and procedural complications with the non-C-shape CS anatomy. RESULTS We found a significant difference in procedural (20.0 [19.0-24.7] min vs. 24.5 [20.7-51.0] min; p = .028 and fluoroscopic time (9.5 [7.5-14.5] min vs. 11.0 [7.9-30.0] min; p = .016). There was no significant difference in contrast use. The presence of bifurcations or valves along the CS course did not influence the procedural timings. CONCLUSION This study is the first systematic evaluation of CS anatomy and its procedural implications. We identified a favorable C-shape anatomy which allows for a more straightforward implantation. Operators should be aware of the different implications of CS anatomy, their influence on guiding catheter stability and overall procedure complexity.
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Affiliation(s)
- Adriaan Wilgenhof
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carlo Zivelonghi
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Stefan Verheye
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Paul Vermeersch
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Benjamin Scott
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Carl Convens
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Leo Timmers
- Cardiology Department, Sint Antonius hospital, Nieuwegein, The Netherlands
| | - Geert Leenders
- Cardiology Department, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pieter Stella
- Cardiology Department, University Medical Center Utrecht, Utrecht, The Netherlands
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31
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Davies A, Fox K, Galassi AR, Banai S, Ylä-Herttuala S, Lüscher TF. Management of refractory angina: an update. Eur Heart J 2021; 42:269-283. [PMID: 33367764 DOI: 10.1093/eurheartj/ehaa820] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/17/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.
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Affiliation(s)
- Allan Davies
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK
| | | | - Shmuel Banai
- Slezak Super Centre for Cardiac Research, Tel Aviv University, Tel Aviv, Israel.,Tel Aviv Medical Centre, Tel Aviv, Israel
| | | | - Thomas F Lüscher
- National Heart and Lung Institute, Imperial College, Guy Scadding Building, Dovehouse Street, London SW3 6LY, UK.,Royal Brompton & Harefield Hospitals, London, UK.,University of Zurich, Center for Molecular Cardiology, University of Zurich, Switzerland
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32
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Ponticelli F, Khokhar AA, Leenders G, Konigstein M, Zivelonghi C, Agostoni P, van Kuijk JP, Ajmi I, Lindsay S, Bunc M, Tebaldi M, Cafaro A, Cheng K, Ielasi A, Patterson T, Wolter JS, Sgura F, De Marco F, Ioanes D, D'Amico G, Ciardetti M, Berti S, Guarracini S, Di Mauro M, Gallone G, Dekker M, Silvis MJM, Tarantini G, Redwood S, Colombo A, Liebetrau C, de Silva R, Rapezzi C, Ferrari R, Campo G, Schnupp S, Timmers L, Verheye S, Stella P, Banai S, Giannini F. Safety and efficacy of coronary sinus narrowing in chronic refractory angina: Insights from the RESOURCE study. Int J Cardiol 2021; 337:29-37. [PMID: 34029618 DOI: 10.1016/j.ijcard.2021.05.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/06/2021] [Accepted: 05/17/2021] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Refractory angina (RA) is considered the end-stage of coronary artery disease, and often has no interventional treatment options. Coronary sinus Reducer (CSR) is a recent addition to the therapeutic arsenal, but its efficacy has only been evaluated on small populations. The RESOURCE registry provides further insights into this therapy. METHODS The RESOURCE is an observational, retrospective registry that includes 658 patients with RA from 20 centers in Europe, United Kingdom and Israel. Prespecified endpoints were the amelioration of anginal symptoms evaluated with the Canadian Cardiovascular Society (CCS) score, the rates of procedural success and complications, and MACEs as composite of all-cause mortality, acute coronary syndromes, and stroke. RESULTS At a median follow-up of 502 days (IQR 225-1091) after CSR implantation, 39.7% of patients improved by ≥2 CCS classes (primary endpoint), and 76% by ≥1 class. Procedural success was achieved in 96.7% of attempts, with 3% of procedures aborted mostly for unsuitable coronary sinus anatomy. Any complication occurred in 5.7% of procedures, but never required bailout surgery nor resulted in intra- or periprocedural death or myocardial infarction. One patient developed periprocedural stroke after inadvertent carotid artery puncture. At the last available follow-up, overall mortality and MACE were 10.4% and 14.6% respectively. At one, three and five years, mortality rate at Kaplan-Meier analysis was 4%, 13.7%, and 23.4% respectively. CONCLUSIONS CSR implantation is safe and reduces angina in patients with refractory angina.
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Affiliation(s)
- Francesco Ponticelli
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Arif A Khokhar
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Geert Leenders
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maayan Konigstein
- Division of Cardiology, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv, Israel
| | - Carlo Zivelonghi
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Pierfrancesco Agostoni
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Jan-Peter van Kuijk
- Department of Cardiology, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Issameddine Ajmi
- Department of Cardiology, Angiology and Pulmonology, Coburg Hospital, Coburg, Germany
| | - Steven Lindsay
- Department of Cardiology, Bradford Royal Infirmary, Bradford, United Kingdom
| | - Matjaž Bunc
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Alessandro Cafaro
- Department of Cardiology, General Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Kevin Cheng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alfonso Ielasi
- U.O. di Cardiologia Clinica ed Interventistica, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Tiffany Patterson
- Cardiothoracic Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jan Sebastian Wolter
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany; DZHK (German Centre for Cardiovascular Research), partner site Rhine-Main, Frankfurt am Main, Germany
| | - Fabio Sgura
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
| | - Federico De Marco
- Department of Cardiology, IRCCS Policlinico S. Donato, San Donato Milanese, Italy
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gianpiero D'Amico
- Department of Cardiology Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Marco Ciardetti
- Fondazione Toscana G. Monasterio - Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | - Sergio Berti
- Fondazione Toscana G. Monasterio - Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | | | - Michele Di Mauro
- Cardiovascular Department, Casa di cura Pierangeli, Pescara, Italy
| | | | - Mirthe Dekker
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Max J M Silvis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Giuseppe Tarantini
- Department of Cardiology Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Simon Redwood
- Cardiothoracic Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Ranil de Silva
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Claudio Rapezzi
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy; Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Roberto Ferrari
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy; Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona (FE), Italy
| | - Steffen Schnupp
- Department of Cardiology, Angiology and Pulmonology, Coburg Hospital, Coburg, Germany
| | - Leo Timmers
- Department of Cardiology, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Stefan Verheye
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Pieter Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Shmuel Banai
- Division of Cardiology, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel-Aviv, Israel
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy.
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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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34
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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: 34187640 DOI: 10.1016/j.repce.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] 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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Zivelonghi C, Konigstein M, Azzano A, Agostoni P, Topilski Y, Banai S, Verheye S. Effects of coronary sinus Reducer implantation on oxygen kinetics in patients with refractory angina. EUROINTERVENTION 2021; 16:e1511-e1517. [PMID: 32091397 PMCID: PMC9724877 DOI: 10.4244/eij-d-19-00766] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Refractory angina is still a major public health problem. The coronary sinus Reducer (CSR) has recently been introduced as an alternative treatment to reduce symptoms in these patients. The aim of this study was to investigate objective improvements in effort tolerance and oxygen kinetics as assessed by cardiopulmonary exercise testing (CPET) in patients suffering from refractory angina undergoing CSR implantation. METHODS AND RESULTS In this multicentre prospective study, patients with chronic refractory angina undergoing CSR implantation were scheduled for CPET before the index procedure and at six-month follow-up. The main endpoints of this analysis were improvements in VO2 max and in VO2 at the anaerobic threshold (AT). Clinical events and improvements in symptoms were also recorded. A total of 37 patients formed the study population. The CSR implantation procedure was successful and without complications in all. At follow-up CPET, significant improvement in VO2 max (+0.97 ml/kg/min [+11.3%]; 12.2±3.6 ml/kg/min at baseline vs 13.2±3.7 ml/kg/min, p=0.026), and workload (+12.9 [+34%]; 68±28 W vs 81±49 W, p=0.05) were observed, with non-significant differences in VO2 at the AT (9.84±3.4 ml/kg/min vs 10.74±3.05 ml/kg/min, p=0.06). Canadian Cardiovascular Society (CCS) grade improved from a mean of 3.2±0.5 to 1.6±0.8 (p<0.01), and significant benefits in all Seattle Angina Questionnaire variables were shown. CONCLUSIONS In patients with obstructive coronary artery disease suffering from refractory angina, the implantation of a CSR was associated with objective improvement in exercise capacity and oxygen kinetics at CPET, suggesting a possible reduction of myocardial ischaemia.
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Affiliation(s)
- Carlo Zivelonghi
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Maayan Konigstein
- Tel Aviv Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Alessia Azzano
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Pierfrancesco Agostoni
- Antwerp Cardiovascular Center, Ziekenhuis Netwerk Antwerpen Middelheim, Antwerp, Belgium
| | - Yan Topilski
- Tel Aviv Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Shmuel Banai
- Tel Aviv Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Stefan Verheye
- Interventional Cardiology, Cardiovascular Center, ZNA Middelheim, Lindendreef 1, 2020 Antwerp, Belgium
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Akşit E, Altay S, Altun A. The importance of evaluating coronary sinus blood flow during the coronary sinus reducer treatment. Int J Cardiol 2021; 332:38. [PMID: 33812947 DOI: 10.1016/j.ijcard.2021.03.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Ercan Akşit
- Çanakkale Onsekiz Mart University Faculty of Medicine, Department of Cardiology, Çanakkale, Turkey.
| | - Servet Altay
- Trakya University Faculty of Medicine, Department of Cardiology, Edirne, Turkey
| | - Armağan Altun
- Başkent University Istanbul Hospital, Department of Cardiology, Istanbul, Turkey
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Alfonso F, Gonzalo N, Rivero F, Escaned J. The year in cardiovascular medicine 2020: interventional cardiology. Eur Heart J 2021; 42:985-1003. [PMID: 33448291 PMCID: PMC7928953 DOI: 10.1093/eurheartj/ehaa1096] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Fernando Alfonso
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Nieves Gonzalo
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
| | - Fernando Rivero
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Javier Escaned
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
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Vescovo GM, Zivelonghi C, Bellamoli M, Vermeersch P, Verheye S, Agostoni P. Coronary Sinus Reducer for the Treatment of Chronic Refractory Angina: Will This Challenge the Treatment of Coronary Chronic Total Occlusions? Curr Cardiol Rep 2021; 23:31. [PMID: 33655425 DOI: 10.1007/s11886-021-01463-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW The prevalence of angina despite optimal medical therapy is high among patients with coronary chronic total occlusions. Despite advancements in techniques and operator's experience, percutaneous revascularization of coronary chronic total occlusions is still associated with a not negligible risk of failures and complications. The Coronary Sinus Reducer, a new device developed to improve angina, has shown promising results in terms of efficacy and safety in patients with refractory symptoms. The aim of this review is to summarize the evidence so far available and to guide clinicians in the selection of patients with chronic total occlusions that could benefit more from Coronary Sinus Reducer implantation. RECENT FINDINGS A recently published study suggests a clear value of this device in patients with chronic total occlusions. This is likely to be related to the presence of a well-developed collateral circulation. A careful evaluation of risks and benefits of both myocardial revascularization and Coronary Sinus Reducer implantation should be done in all the cases in order to better define the optimal strategy for the patient. The Coronary Sinus Reducer implantation has a rationale in patients with chronic total occlusion as an alternative or additional therapy to myocardial revascularization.
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Affiliation(s)
| | - Carlo Zivelonghi
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Michele Bellamoli
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Paul Vermeersch
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
| | - Stefan Verheye
- HartCentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium
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Konigstein M, Ponticelli F, Zivelonghi C, Merdler I, Revivo M, Verheye S, Giannini F, Banai S. Long-term outcomes of patients undergoing coronary sinus reducer implantation - A multicenter study. Clin Cardiol 2021; 44:424-428. [PMID: 33605473 PMCID: PMC7943892 DOI: 10.1002/clc.23566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/22/2021] [Accepted: 02/01/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Coronary sinus (CS) narrowing by reducer implantation has emerged as a safe and effective therapy for patients suffering from refractory angina. However, data regarding the clinical benefit of this treatment over time is lacking. METHODS Patients undergoing successful reducer implantation were enrolled prospectively to clinical registries at three medical centers. Those with more than 2-years of follow-up were included in the present analysis. Peri-procedural data, data regarding adverse events, and current evaluation of angina severity (Canadian Cardiovascular Society [CCS] class) were collected. RESULTS Overall, 99 consecutive patients (77% males, mean age 69.8 ± 9.4) with severe angina were enrolled between September 2010 and October 2017 and included in the present analysis. No procedure-related complications were recorded. During a median follow up time of 3.38 years (IQR 2.95-4.40), 15.1% of the patients died, 9% experienced myocardial infarction (MI) and 21% underwent percutaneous coronary intervention (PCI). Mean CCS class was 3.1 ± 0.5 at baseline, improved to 1.66 ± 0.8 at 1 year (p < .001), and remained low through 2-years and at last follow up (1.72 ± 0.8 and 1.71 ± 0.8, p > 0.5 for both, in comparison to 1 year). At baseline 91% of patients reported severe disabling angina (CCS class 3-4), at 1 year only 17.9% suffered from disabling angina, p < .001, and this portion remained low overtime (19% at last follow up). CONCLUSION Long-term mortality of patients undergoing reducer implantation is similar to that reported for patients with stable coronary artery disease. The previously reported short-term efficacy of the reducer, reflected by significant improvement of angina symptoms, is maintained over time.
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Affiliation(s)
- Maayan Konigstein
- Tel Aviv Medical Center and Sackler School of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Francesco Ponticelli
- Cardiovascular CenterInterventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital CotignolaItaly
| | - Carlo Zivelonghi
- Division of Heart CenterZNA Middelheim Hospital, Lindendreef AntwerpAntwerpBelgium
| | - Ilan Merdler
- Tel Aviv Medical Center and Sackler School of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Miri Revivo
- Tel Aviv Medical Center and Sackler School of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
| | - Stefan Verheye
- Division of Heart CenterZNA Middelheim Hospital, Lindendreef AntwerpAntwerpBelgium
| | - Francesco Giannini
- Cardiovascular CenterInterventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital CotignolaItaly
| | - Shmuel Banai
- Tel Aviv Medical Center and Sackler School of MedicineTel Aviv UniversityTel Aviv‐YafoIsrael
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40
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Abstract
The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.
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Affiliation(s)
- Thomas J Povsic
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - E Magnus Ohman
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
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41
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Usefulness of Coronary Sinus Reducer Implantation for the Treatment of Chronic Refractory Angina Pectoris. Am J Cardiol 2021; 139:22-27. [PMID: 32998007 DOI: 10.1016/j.amjcard.2020.09.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 01/16/2023]
Abstract
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.
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42
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Bunc M, Sustersic M, Langel C, Kuhelj D, Banai S. Coronary sinus reducer transfemoral extraction after intraprocedural device migration: A case report. Clin Case Rep 2021; 9:386-390. [PMID: 33489187 PMCID: PMC7813095 DOI: 10.1002/ccr3.3538] [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: 08/09/2020] [Revised: 09/18/2020] [Accepted: 10/03/2020] [Indexed: 11/18/2022] Open
Abstract
The coronary sinus reducer migration during implantation procedure is a rare complication with no standard bailout strategy. Transfemoral extraction of the reducer can be a safe and successful method, as demonstrated by this case report.
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Affiliation(s)
- Matjaz Bunc
- Division of Internal Medicine, Clinical Department of CardiologyUniversity Medical Center LjubljanaLjubljanaSlovenia
| | - Miha Sustersic
- Division of Internal Medicine, Clinical Department of CardiologyUniversity Medical Center LjubljanaLjubljanaSlovenia
| | - Crt Langel
- Institute of RadiologyUniversity Medical Center LjubljanaLjubljanaSlovenia
| | - Dimitrij Kuhelj
- Institute of RadiologyUniversity Medical Center LjubljanaLjubljanaSlovenia
| | - Shmuel Banai
- Tel‐Aviv Medical CenterSackler School of MedicineTel‐Aviv UniversityTel‐AvivIsrael
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43
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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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Gallone G, Baldetti L, Tzanis G, Gramegna M, Latib A, Colombo A, Henry TD, Giannini F. Refractory Angina: From Pathophysiology to New Therapeutic Nonpharmacological Technologies. JACC Cardiovasc Interv 2020; 13:1-19. [PMID: 31918927 DOI: 10.1016/j.jcin.2019.08.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
Abstract
Despite optimal combination of guideline-directed anti-ischemic therapies and myocardial revascularization, a substantial proportion of patients with stable coronary artery disease continues to experience disabling symptoms and is often referred as "no-option." The appraisal of the pathways linking ischemia to symptom perception indicates a complex model of heart-brain interactions in the generation of the subjective anginal experience and inspired novel approaches that may be clinically effective in alleviating the angina burden of this population. Conversely, the prevailing ischemia-centered view of angina, with the focus on traditional myocardial revascularization as the sole option to address ischemia on top of medical therapy, hinders the experimental characterization and broad-scale clinical implementation of strongly needed therapeutic options. The interventionist, often the first physician to establish the diagnosis of refractory angina pectoris (RAP) following coronary angiography, should be aware of the numerous emerging technologies with the potential to improve quality of life in the growing population of RAP patients. This review describes the current landscape and the future perspectives on nonpharmacological treatment technologies for patients with RAP, with a view on the underlying physiopathological rationale and current clinical evidence.
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Affiliation(s)
- Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, Città della Scienza e della Salute Hospital, University of Turin, Turin, Italy
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Georgios Tzanis
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Bronx, New York. https://twitter.com/azeemlatib
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center / The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio; University of Florida, Gainesville, Florida
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research Maria Cecilia Hospital, Cotignola, Italy.
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Stanak M, Rothschedl E, Szymanski P. Coronary Sinus Reducing Stent for the Treatment of Refractory Angina Pectoris: A Health Technology Assessment. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:259-276. [PMID: 32982492 PMCID: PMC7508028 DOI: 10.2147/mder.s255440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/23/2020] [Indexed: 11/25/2022] Open
Abstract
Aim To summarize the evidence on the clinical effectiveness and safety of coronary sinus reducing stent (CSRS) therapy in refractory angina pectoris (AP) patients. Methods We performed a systematic literature search in common databases (n=4). The evidence obtained was summarized according to GRADE methodology. A health technology assessment (HTA) was conducted using the HTA Core Model® for Rapid Relative Effectiveness Assessment. Primary outcomes for the clinical effectiveness domain were the proportion of patients with improvement in two or more Canadian Cardiovascular Society (CCS) angina score classes, overall mean reduction of CCS class, and Seattle Angina Questionnaire (SAQ) quality of life (QoL) score improvement. Outcomes for the safety domain were adverse device effects (ADEs) and serious adverse device effects (SADEs). Results One randomized controlled trial (RCT) was identified. Outcomes that showed statistically significant differences between CSRS and sham treatment (in favor of CSRS) were CCS angina score improvement of one or two classes, overall mean reduction of CCS class, and SAQ QoL score improvement. Concerning safety, the sham-controlled trial data indicate that there were fewer SADEs in the intervention group (19%) than in the control group (46%). SADEs reported in observation studies ranged from none to 30%. The most frequently reported SADEs were death and stable angina. In the RCT, the only case of death occurred in the control group. Concerning clinical effectiveness, the risk of bias (RoB) was rated to be low, and concerning safety, the RoB was rated to range from low to moderate. As assessed by GRADE, the overall strength of evidence for effectiveness and safety was moderate. Internal and external validity of the evidence base were low. Conclusion Even though the current evidence indicates that the assessed technology, CSRS, is potentially more effective than sham intervention for refractory AP patients, the lack of internal validity of the studies undermines the partially positive results.
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Affiliation(s)
- Michal Stanak
- Austrian Institute for Health Technology Assessment (AIHTA), Vienna, Austria
| | - Eleen Rothschedl
- Austrian Institute for Health Technology Assessment (AIHTA), Vienna, Austria
| | - Piotr Szymanski
- MSWiA Central Clinical Hospital, Centre of Postgraduate Medical Education, Warsaw, Poland
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46
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Rakhimov K, Gori T. Non-pharmacological Treatment of Refractory Angina and Microvascular Angina. Biomedicines 2020; 8:biomedicines8080285. [PMID: 32823683 PMCID: PMC7460172 DOI: 10.3390/biomedicines8080285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/16/2022] Open
Abstract
Refractory angina (RA) is defined as debilitating anginal symptoms despite the optimal guideline-directed combination of medical, percutaneous, and surgical therapies. Often referred to as “no option”, these patients represent a significant unmet clinical need for healthcare institutions. Due to the ageing of the population, and increased survival from coronary artery disease, the number of patients with RA is expected to rise exponentially. Despite the developments of novel technologies for the treatment of RA, none of them found wide clinical application (to date). Microvascular dysfunction, alone or in combination with epicardial coronary disease, is thought to contribute significantly to refractory angina. However, most of the techniques developed to improve RA symptoms have not been tested specifically on patients with microvascular dysfunction. This review discusses the recent developments in the treatment of RA, and gives some perspectives on the future of these techniques.
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Affiliation(s)
- Kudrat Rakhimov
- Department of Cardiology, University Medical Center Mainz Langenbeckstr 1, 55131 Mainz, Germany
- Correspondence: (K.R.); (T.G.); Tel.: +49-6131-172829 (T.G.); Fax: +49-6131-176428 (T.G.)
| | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz and Deutsches Zentrum für Herz und Kreislauf Forschung, Standort Rhein-Main, Langenbeckstr 1, 55131 Mainz, Germany
- Correspondence: (K.R.); (T.G.); Tel.: +49-6131-172829 (T.G.); Fax: +49-6131-176428 (T.G.)
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47
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Efficacy of Coronary Sinus Reducer in Patients With Non-revascularized Chronic Total Occlusions. Am J Cardiol 2020; 126:1-7. [PMID: 32345474 DOI: 10.1016/j.amjcard.2020.03.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/27/2020] [Accepted: 03/27/2020] [Indexed: 01/10/2023]
Abstract
The coronary sinus reducer (CSR) has been introduced as therapy for patients with refractory angina with no other treatment options. Aim of this study is to investigate the efficacy of the CSR in patients with refractory angina and presence of coronary chronic total occlusions (CTO). In this multicentre, international retrospective study, patients undergoing CSR implantation were screened and divided in 2 groups according to the presence/absence of CTO lesions. Baseline and clinical characteristics were analyzed in the 2 groups. Primary-outcome consisted of the variation in Canadian Cardiovascular Society (CCS) class at 6-month follow-up. Between January 2014 and December 2018, 205 patients with refractory angina were consecutively treated with the study device in the participating centers, 103 (50.2%) of which had a CTO lesion at coronary angiogram and formed the CTO-group. Baseline characteristics of the study population were well balanced between the 2 groups. CSR was successfully implanted in all cases. Baseline CCS class was 3 ± 0.5 in the CTO-group versus 3.1 ± 0.6 in the non-CTO group (p = 0.45), and improved at follow-up to 1.6 ± 0.9 versus 2 ± 1.1 respectively (p <0.01), with a significantly higher improvement in CCS class in the CTO-group (1.4 ± 0.9 vs 1.1 ± 1 respectively, p = 0.01). Any improvement in CCS class was registered in 79 (80.6%) CTO-patients, while a significantly lower percentage (65 patients, 66.3%) of the non-CTO patients reported benefits in CCS class (p = 0.03). In conclusions, patients suffering from refractory angina with non-revascularized CTO lesions have a better response to CSR implantation than patients without CTOs. CSR implantation should be considered a valid complementary therapy to CTO-PCI in these patients.
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Jolicoeur EM, Henry TD. The Robin Hood effect! Catheter Cardiovasc Interv 2020; 95:1109-1110. [DOI: 10.1002/ccd.28923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 11/11/2022]
Affiliation(s)
- E. Marc Jolicoeur
- Department of Medicine, Montreal Heart InstituteUniversité de Montréal Québec Canada
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and EducationThe Christ Hospital Cincinnati Ohio United States
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Coronary Sinus Reducer and Left Ventricular Function. Can J Cardiol 2020; 36:474-475. [DOI: 10.1016/j.cjca.2019.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/18/2019] [Accepted: 12/18/2019] [Indexed: 11/18/2022] Open
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Cheng K, de Silva R. Implantation of a Coronary Sinus Reducer to Treat Refractory Angina in a 38-Year-Old with an Anomalous Left Coronary Artery and No Revascularization Options. Cardiology 2020; 145:126-129. [PMID: 32007999 DOI: 10.1159/000505261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 11/28/2019] [Indexed: 11/19/2022]
Abstract
A 38-year-old female with anomalous left coronary artery from the pulmonary artery presented with refractory angina (Canadian Cardiovascular Society [CCS] class 4). Having failed two previous internal mammary artery grafts to the left anterior descending artery and with no percutaneous revascularization options, she underwent coronary sinus reducer implantation, which improved her symptoms (CCS 0), quality of life, and corresponded to an improvement in ischemia on myocardial perfusion scanning. This case report describes an unusual case of refractory angina in the context of congenital heart disease, illustrates the benefit of this novel hourglass-shaped stent in improving ischemia, quality of life, depression and anxiety, and highlights the importance of managing these patients in multidisciplinary teams.
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Affiliation(s)
- Kevin Cheng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom, .,Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom,
| | - Ranil de Silva
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Specialist Angina Service, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
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