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Wu B, Kheiwa A, Swamy P, Mamas MA, Tedford RJ, Alasnag M, Parwani P, Abramov D. Clinical Significance of Coronary Arterial Dominance: A Review of the Literature. J Am Heart Assoc 2024; 13:e032851. [PMID: 38639360 PMCID: PMC11179863 DOI: 10.1161/jaha.123.032851] [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] [Indexed: 04/20/2024]
Abstract
Coronary dominance describes the anatomic variation of coronary arterial supply, notably as it relates to perfusion of the inferior cardiac territories. Differences in the development and outcome in select disease states between coronary dominance patterns are increasingly recognized. In particular, observational studies have identified higher prevalence of poor outcomes in left coronary dominance in the setting of ischemic, conduction, and valvular disease. In this qualitative literature review, we summarize anatomic, physiologic, and clinical implications of differences in coronary dominance to highlight current understanding and gaps in the literature that should warrant further studies.
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Affiliation(s)
- Bovey Wu
- Department of MedicineLoma Linda University Medical CenterLoma LindaCAUSA
| | - Ahmed Kheiwa
- Department of CardiologyLoma Linda University Medical CenterLoma LindaCAUSA
| | - Pooja Swamy
- Department of CardiologyLoma Linda University Medical CenterLoma LindaCAUSA
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis ResearchKeele UniversityStoke‐on‐TrentUnited Kingdom
| | - Ryan J. Tedford
- Department of Medicine, Division of CardiologyMedical University of South CarolinaCharlestonSCUSA
| | - Mirvat Alasnag
- Cardiac CenterKing Fahd Armed Forces HospitalJeddahSaudi Arabia
| | - Purvi Parwani
- Department of CardiologyLoma Linda University Medical CenterLoma LindaCAUSA
| | - Dmitry Abramov
- Department of CardiologyLoma Linda University Medical CenterLoma LindaCAUSA
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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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Foley MJ, Rajkumar CA, Ahmed-Jushuf F, Nowbar AN, Simader F, Bello O, Al-Lamee R. Why Does a Cardiologist Believe in a Therapy? The Role of Intuitiveness and Understanding the Mechanism. Circ Cardiovasc Qual Outcomes 2024; 17:e010664. [PMID: 38362766 PMCID: PMC10949971 DOI: 10.1161/circoutcomes.123.010664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Affiliation(s)
- Michael J. Foley
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (M.J.F., C.A.R., R.A.-L.)
| | - Christopher A. Rajkumar
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (M.J.F., C.A.R., R.A.-L.)
| | - Fiyyaz Ahmed-Jushuf
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
| | - Alexandra N. Nowbar
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
| | - Florentina Simader
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
| | - Olamide Bello
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, United Kingdom (M.J.F., C.A.R., F.A.-J., A.N.N., F.S., O.B., R.A.-L.)
- Imperial College Healthcare NHS Trust, London, United Kingdom (M.J.F., C.A.R., R.A.-L.)
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6
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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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Rodriguez-Rivera GJ, Post A, John M, Buchan S, Bernard D, Razavi M, Cosgriff-Hernandez E. Injectable hydrogel electrodes as conduction highways to restore native pacing. Nat Commun 2024; 15:64. [PMID: 38167848 PMCID: PMC10762156 DOI: 10.1038/s41467-023-44419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
There is an urgent clinical need for a treatment regimen that addresses the underlying pathophysiology of ventricular arrhythmias, the leading cause of sudden cardiac death. The current report describes the design of an injectable hydrogel electrode and successful deployment in a pig model with access far more refined than any current pacing modalities allow. In addition to successful cardiac capture and pacing, analysis of surface ECG tracings and three-dimensional electroanatomic mapping revealed a QRS morphology comparable to native sinus rhythm, strongly suggesting the hydrogel electrode captures the deep septal bundle branches and Purkinje fibers. In an ablation model, electroanatomic mapping data demonstrated that the activation wavefront from the hydrogel reaches the mid-myocardium and endocardium much earlier than current single-point pacing modalities. Such uniform activation of broad swaths of tissue enables an opportunity to minimize the delayed myocardial conduction of heterogeneous tissue that underpins re-entry. Collectively, these studies demonstrate the feasibility of a new pacing modality that most closely resembles native conduction with the potential to eliminate lethal re-entrant arrhythmias and provide painless defibrillation.
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Affiliation(s)
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, TX, 77030, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, TX, 77030, USA
| | - Skylar Buchan
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, TX, 77030, USA
| | - Drew Bernard
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, TX, 77030, USA
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, TX, 77030, USA.
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
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Zhang H, Hu H, Zhai C, Jing L, Tian H. Cardioprotective Strategies After Ischemia-Reperfusion Injury. Am J Cardiovasc Drugs 2024; 24:5-18. [PMID: 37815758 PMCID: PMC10806044 DOI: 10.1007/s40256-023-00614-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/11/2023]
Abstract
Acute myocardial infarction (AMI) is associated with high morbidity and mortality worldwide. Although early reperfusion is the most effective strategy to salvage ischemic myocardium, reperfusion injury can develop with the restoration of blood flow. Therefore, it is important to identify protection mechanisms and strategies for the heart after myocardial infarction. Recent studies have shown that multiple intracellular molecules and signaling pathways are involved in cardioprotection. Meanwhile, device-based cardioprotective modalities such as cardiac left ventricular unloading, hypothermia, coronary sinus intervention, supersaturated oxygen (SSO2), and remote ischemic conditioning (RIC) have become important areas of research. Herein, we review the molecular mechanisms of cardioprotection and cardioprotective modalities after ischemia-reperfusion injury (IRI) to identify potential approaches to reduce mortality and improve prognosis in patients with AMI.
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Affiliation(s)
- Honghong Zhang
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Huilin Hu
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China.
| | - Changlin Zhai
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Lele Jing
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
| | - Hongen Tian
- Department of Cardiology, Affiliated Hospital of Jiaxing University: First Hospital of Jiaxing, No. 1882 Zhonghuan South Road, Jiaxing, 314000, Zhejiang, People's Republic of China
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9
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Tebaldi M, Campo G, Ugo F, Guarracini S, Marrone A, Clò S, Abdirashid M, Di Mauro M, Rametta F, Di Marco M, Cocco M, Marchini F, Penzo C, Erriquez A, Banai S, Biscaglia S. Coronary Sinus Narrowing Improves Coronary Microcirculation Function in Patients With Refractory Angina: A Multicenter Prospective INROAD Study. Circ Cardiovasc Interv 2024; 17:e013481. [PMID: 38227697 DOI: 10.1161/circinterventions.123.013481] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/10/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND The underlying mechanisms responsible for the clinical benefits following coronary sinus narrowing and pressure elevation remain unclear. The present study aims to investigate whether coronary sinus narrowing improves the indexes of coronary microcirculatory function. METHODS Patients with refractory angina who had a clinical indication for reducer implantation underwent invasive physiological assessments before and 4 months after the procedure. The primary outcome was the change in the values of the index of microcirculatory resistance. Secondary end points included changes in coronary flow reserve and the resistive resistance ratio values. Angina status was assessed with the Canadian Cardiology Society class and the Seattle Angina Questionnaire. RESULTS Twenty-four patients with a history of obstructive coronary artery disease and prior coronary revascularization (surgical and percutaneous) treated with reducer implantation were enrolled, and 21 of them (87%) underwent repeated invasive coronary physiological assessment after 4 months. The index of microcirculatory resistance values decreased from 33.35±19.88 at baseline to 15.42±11.36 at 4-month follow-up (P<0.001; mean difference, -17.90 [95% CI, -26.16 to -9.64]). A significant (≥20% from baseline) reduction of the index of microcirculatory resistance was observed in 15 (71.4% [95% CI, 47.8%-88.7%]) patients. The number of patients with abnormal index of microcirculatory resistance (≥25) decreased from 12 (57%) to 4 (19%; P=0.016). Coronary flow reserve increased from 2.46±1.52 to 4.20±2.52 (mean difference, 1.73 [95% CI, 0.51-2.96]). Similar findings were observed for resistive resistance ratio values. Overall, 16 patients (76.1%) had an improvement of 1 Canadian Cardiology Society class. Seattle Angina Questionnaire summary score increase of around 3 points (3.01 [95% CI, 1.39-4.61]). CONCLUSIONS Coronary sinus reduction implantation is associated with a significant improvement in the parameters of coronary microcirculatory function. These findings provide insights into the improvement of angina symptoms and may have implications for the treatment of coronary microvascular dysfunction. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05174572.
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Affiliation(s)
- Matteo Tebaldi
- Cardiology Unit, Ospedale degli Infermi, Faenza (RA), Italy (M.T.)
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Fabrizio Ugo
- Cardiology Unit, Ospedale S. Andrea, Vercelli, VC, Italy (F.U., M.A., F.R.)
| | | | - Andrea Marrone
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Stefano Clò
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Mohamed Abdirashid
- Cardiology Unit, Ospedale S. Andrea, Vercelli, VC, Italy (F.U., M.A., F.R.)
| | - Michele Di Mauro
- Cardiology Unit, Casa di Cura Pierangeli, Pescara, Italy (S.G., M.D.M.)
| | - Francesco Rametta
- Cardiology Unit, Ospedale S. Andrea, Vercelli, VC, Italy (F.U., M.A., F.R.)
| | - Massimo Di Marco
- Cardiology Unit, Ospedale Santo Spirito, Pescara, Italy (M. Di Marco)
| | - Marta Cocco
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Federico Marchini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Carlo Penzo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Andrea Erriquez
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
| | - Shmuel Banai
- Division of Cardiology, Tel Aviv Medical Center, Israel (S. Banai)
| | - Simone Biscaglia
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy (G.C., A.M., S.C., M.C., F.M., C.P., A.E., S.B.)
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10
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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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11
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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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12
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Grebmer C, Bossard M, Attinger-Toller A, Kobza R, Hilfiker G, Berte B, Cuculi F. Cardiac resynchronization therapy in patients with a coronary sinus reducer: a case series. Eur Heart J Case Rep 2023; 7:ytad455. [PMID: 37743902 PMCID: PMC10516338 DOI: 10.1093/ehjcr/ytad455] [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: 03/23/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/26/2023]
Abstract
Background Reducing venous drainage of the coronary sinus is a promising intervention for refractory angina. Coronary Sinus Reducer (CSR) System™ effectively treats patients with refractory angina, possibly by increasing coronary collateral circulation, and leads to an improvement in their symptoms and quality of life. In patients with impaired left ventricular function and electrocardiographic dyssynchrony, cardiac resynchronization therapy (CRT) is an established treatment. However, there is only one published case report of CRT in a patient implanted with a CSR system. We present the first case series of CRT in patients implanted with the CSR system. Case summary This case series describes three patients. The first case demonstrated that CRT is feasible in patients implanted with a CSR system. The second case is the first report of a left ventricular lead extraction after CSR, and the third case was complicated due to the patient's medical history; however, CSR system implantation was feasible without major complications. Discussion Our results suggest that CRT is feasible in patients implanted with a CSR system, and lead extraction after CSR system implantation is possible. However, lead extraction in cases of severe adhesions around the CSR system and the coronary sinus may be associated with a high risk of complications; alternative options should be discussed at an early stage.
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Affiliation(s)
- Christian Grebmer
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Matthias Bossard
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Adrian Attinger-Toller
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Richard Kobza
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Gabriela Hilfiker
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Benjamin Berte
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
| | - Florim Cuculi
- Department of Cardiology, Heart Center Lucerne, Luzerner Kantonsspital, Spitalstrasse 16, 6002 Luzern, Switzerland
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13
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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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14
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Paz Y, Grosman-Rimon L, Levy Y, Shinfeld A. The Coronary Sinus Reducer Stent for the Treatment of Refractory Angina Pectoris: From the Conception of Innovation to Clinical Application. Cardiol Rev 2022; Publish Ahead of Print:00045415-990000000-00061. [PMID: 36728718 DOI: 10.1097/crd.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The Neovasc Coronary Sinus Reducer Stent (CSRS) was developed for the treatment of patients who continue to suffer from disabling symptoms despite optimal medical therapy. This patient population with refractory angina symptoms is expected to grow, since life expectancy of individuals with atherosclerotic coronary artery disease is increasing. In this paper, we discussed the development of a novel device the CSRS and the upside-down strategy to rebuild a retrograde coronary pressure that was attenuated by the atherosclerotic disease.
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Affiliation(s)
- Yoav Paz
- From the General Intensive Care Unit, Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liza Grosman-Rimon
- The Academic College at Wingate, Wingate Institute, Netanya, Israel Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Levy
- Department of Internal Medicine, Meir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amihay Shinfeld
- Department of Internal Medicine, Meir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Gibson CM, Ajmi I, von Koenig CL, Turco MA, Stone GW. Pressure-Controlled Intermittent Coronary Sinus Occlusion: A Novel Approach to Improve Microvascular Flow and Reduce Infarct Size in STEMI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 45:9-14. [PMID: 35918254 DOI: 10.1016/j.carrev.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/21/2022] [Accepted: 07/19/2022] [Indexed: 01/04/2023]
Abstract
Despite successful primary percutaneous coronary intervention (PCI) for treatment of ST-segment elevation myocardial infarction (STEMI), myocardial salvage is frequently suboptimal resulting in large infarctions with increased rates of heart failure and death. Microvascular dysfunction after the procedure is frequently present and contributes directly to poor outcomes in STEMI. Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) is a novel technology designed to mitigate microvascular dysfunction in STEMI. Non-randomized studies have suggested that PiCSO use during primary PCI in STEMI is safe, improves microvascular perfusion and reduces infarct size. Randomized trials are ongoing to investigate the safety and effectiveness of PiCSO in high-risk patients with anterior STEMI undergoing primary PCI.
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Affiliation(s)
- C Michael Gibson
- Beth Israel Lahey, USA; Baim Institute for Clinical Research (FKA Harvard Clinical Research Institute), USA; Harvard Medical School, USA
| | - Issameddine Ajmi
- Helios Frankenwaldklinik Kronach, Freisener Strasse 41, 96317 Kronach, Germany
| | - Cajetan L von Koenig
- Miracor Medical SA, E40 Business Park, Rue de Bruxelles, 174, 4340 Awans, Belgium.
| | | | - Gregg W Stone
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
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16
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Cheng K, Keramida G, Baksi AJ, de Silva R. Implantation of the coronary sinus reducer for refractory angina due to coronary microvascular dysfunction in the context of apical hypertrophic cardiomyopathy-a case report. Eur Heart J Case Rep 2022; 6:ytac440. [PMID: 36415685 PMCID: PMC9675594 DOI: 10.1093/ehjcr/ytac440] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/23/2022] [Accepted: 11/02/2022] [Indexed: 02/15/2024]
Abstract
Background Refractory angina leads to a poor quality of life and increased healthcare resource utilization. In this growing population of patients, multiple mechanism(s) of ischaemia may co-exist, including functional disorders of the coronary microcirculation. There are few evidence-based effective therapies resulting in a large unmet clinical need. Case summary A 38-year-old woman with refractory angina was referred with daily chest pain despite multiple anti-anginal medications and previous percutaneous coronary intervention. Cardiac magnetic resonance imaging demonstrated apical hypertrophic cardiomyopathy (HCM). Rubidium-82 positron emission tomography (PET) with regadenoson stress confirmed significant myocardial ischaemia in the apex and apical regions (16% of total myocardium) with a global myocardial perfusion reserve (MPR) of 1.23. Coronary angiography confirmed patent stents and no epicardial coronary artery disease. Therefore, the mechanism of ischaemia was thought attributable to coronary microvascular dysfunction (CMD) in the context of HCM. In view of her significant symptoms and large burden of left-sided myocardial ischaemia, a Coronary Sinus Reducer (CSR) was implanted. Repeat PET imaging at 6 months showed a marked reduction in ischaemia (<5% burden), improvement in global MPR (1.58), symptoms, and quality of life. Conclusion In refractory angina, ischaemia may be due to disorders of both the epicardial and coronary microcirculations. The CSR is a potential therapy for these patients, but its mechanism of action has not been confirmed. This report suggests that CSR implantation may reduce myocardial ischaemia and improve symptoms by acting on the coronary microcirculation. The efficacy of CSR in patients with CMD and its mechanism of action on the coronary microcirculation warrant further investigation.
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Affiliation(s)
- Kevin Cheng
- Vascular Science, National Heart and Lung Institute, Imperial College London, Cale Street, London SW3 6LY, UK
- Royal Brompton Hospital, Sydney Street, Chelsea SW3 6NP, London, UK
| | - Georgia Keramida
- Royal Brompton Hospital, Sydney Street, Chelsea SW3 6NP, London, UK
| | - A John Baksi
- Royal Brompton Hospital, Sydney Street, Chelsea SW3 6NP, London, UK
| | - Ranil de Silva
- Vascular Science, National Heart and Lung Institute, Imperial College London, Cale Street, London SW3 6LY, UK
- Royal Brompton Hospital, Sydney Street, Chelsea SW3 6NP, London, UK
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17
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Novel therapeutic strategies to reduce reperfusion injury after acute myocardial infarction. Curr Probl Cardiol 2022; 47:101398. [PMID: 36108813 DOI: 10.1016/j.cpcardiol.2022.101398] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023]
Abstract
For almost 30 years, urgent revascularization termed primary percutaneous coronary intervention (pPCI) has been a cornerstone of modern care for acute myocardial infarction (AMI). It lowers mortality and improved cardiovascular outcome compared to conservative therapy including thrombolysis. Reperfusion injury, which occurs after successful re-opening of the formerly occluded coronary artery, had been exploited as a potential therapeutic target. When revascularisation became faster and pPCI was successfully performed within 60-90 minutes of symptom onset, the interest in a potential additive effect of targeting reperfusion injury vanished. More recently, several meta-analyses indicated that limiting reperfusion injury prevents microvascular obstruction and reduces final infarct size, thereby lowering the probability of heart failure events and improving quality of life in AMI survivors. Here, we describe the current strategies to limit reperfusion injury and to improve post-AMI outcomes such as systemic or intracoronary hypothermia, left-ventricular unloading, intracoronary infusion of super-saturated oxygen, intermittent coronary sinus occlusion, and C-reactive protein apharesis.
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18
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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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19
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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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20
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Foley M, Al-Lamee RK. Coronary sinus reducer therapy for refractory angina: is it ready for prime time? EUROINTERVENTION 2021; 17:530-531. [PMID: 34554093 PMCID: PMC9707434 DOI: 10.4244/eijv17i7a94] [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] [Indexed: 11/23/2022]
Affiliation(s)
- Michael Foley
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rasha K. Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, United Kingdom
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21
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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: 15] [Impact Index Per Article: 5.0] [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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22
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Abstract
The coronary circulation is a complex system in which vascular resistances are determined by an interplay of forces in at least three compartments: the epicardial, the microvascular, and the venous district. Cardiologists, and particularly interventional cardiologists, normallly place the focus of their attention on diseases of the epicardial coronary circulation as possible causes of coronary syndromes and neglect the importance of the other two compartments of coronary circulation. The study of the coronary microcirculation, an increasingly recognized source of ischemia, has long been disregarded, but is witnessing a revival since the (re-)introduction of diagnostic tools in the better equipped catheterization laboratories. Unfortunately, to date our understanding of coronary microvascular disease remains incomplete and the numerous proposed classifications fail to reflect its complexity. Further, no specific therapy for these disorders is available. The coronary venous circulation is an even more neglected third vascular district. Its role in regulating coronary resistances is almost completely unexplored, but inital evidence suggests that the modulation of venous pressure might help improve coronary perfusion. Coronary sinus interventions are a group of invasive techniques (both surgical and catheter-based) that are designed to treat ischaemic heart disease by increasing coronary venous pressure and therefore redistributing coronary blood flow towards the endocardium. In this review paper, we revise the role of these interventions with particular focus on acute and chronic coronary microvascular disease.
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Affiliation(s)
- T Gori
- Kardiologie 1, Zentrum für Kardiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz and DZHK Standort Rhein Main, Germany
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23
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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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24
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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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25
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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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26
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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: 10] [Impact Index Per Article: 3.3] [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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27
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de Silva R, Cheng K. Reducing refractory angina. EUROINTERVENTION 2021; 16:e1466-e1467. [PMID: 33792542 PMCID: PMC9707452 DOI: 10.4244/eijv16i18a265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Ranil de Silva
- NHLI (Brompton Campus), Imperial College London, Sydney Street, London, SW3 6NP, United Kingdom
| | - Kevin Cheng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom,Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
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28
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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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Abstract
The article discusses pharmacologic and interventional therapeutic options for patients with refractory angina. Refractory angina refers to long-lasting symptoms (≥3 months) due to established reversible ischemia in the presence of obstructive coronary artery disease, which cannot be controlled by escalating medical therapy with second-line and third-line pharmacologic agents, bypass grafting, or stenting. Due to an aging population, increased number of comorbidities, and advances in coronary artery disease treatment, incidence of refractory angina is growing. Although the number of therapeutic options is increasing, there is a lack of randomized clinical trials that could help create recommendations for this group of patients.
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Affiliation(s)
- Marcin Makowski
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland.
| | | | - Marzenna Zielińska
- Department of Interventional Cardiology, Medical University of Lodz, Central Clinical Hospital, ul. Pomorska 251, Lodz 92-213, Poland
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30
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Palmisano A, Giannini F, Rancoita P, Gallone G, Benedetti G, Baldetti L, Tzanis G, Vignale D, Monti C, Ponticelli F, Ancona M, Montorfano M, Del Maschio A, De Cobelli F, Colombo A, Esposito A. Feature tracking and mapping analysis of myocardial response to improved perfusion reserve in patients with refractory angina treated by coronary sinus Reducer implantation: a CMR study. Int J Cardiovasc Imaging 2020; 37:291-303. [PMID: 32860122 DOI: 10.1007/s10554-020-01964-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/06/2020] [Indexed: 01/06/2023]
Abstract
Coronary sinus (CS) Reducer implantation improves myocardial perfusion and symptoms in patients with debilitating refractory angina. Its impact on myocardial remodeling remain uncertain. Aim of the present study was to assess possible impact of CS Reducer on myocardial systolic-diastolic deformation and microstructural remodeling, as assessed through cardiac magnetic resonance (CMR) feature tracking and mapping analysis. Twenty-eight consecutive patients with refractory angina underwent multiparametric stress CMR before and 4 months after CS Reducer implantation. Eight patients were excluded (6 for absence of inducible ischemia, 2 for artifacts). Modifications in 3D systo-diastolic myocardial deformation were evaluated using feature tracking analysis on rest cine images. Myocardial microstructural remodeling was assessed by native T1 mapping, cellular and matrix volume and extracellular volume fraction (ECV). Collaterally, the percentage of ischemic myocardium (ischemic burden %) and the myocardial perfusion reserve index (MPRI) were measured. After CS Reducer implantation, myocardial contractility improved (ejection fraction rose from 61 to 67%; p = 0.0079), along with longitudinal (from - 16 to - 19%; p = 0.0192) and circumferential strain (from - 18 to - 21%; p = 0.0017). Peak diastolic radial, circumferential and longitudinal strain rate did not change (p > 0.05), and no changes in native T1, ECV, cellular and matrix volume were observed. Myocardial perfusion improved, with a reduction of ischemic burden (13-11%; p = 0.0135), and recovery of intramural perfusion balance in segments with baseline ischemia (MPRi endocardial/epicardial ratio from 0.67 to 0.96; p = 0.0107). CS Reducer improves myocardial longitudinal and circumferential strain, without microstructural remodeling and no impact on diastolic proprieties.
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Affiliation(s)
- Anna Palmisano
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| | - Francesco Giannini
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Paola Rancoita
- Department University Centre for Statistics in the Biomedical Sciences (CUSSB), Vita-Salute San Raffaele University, Milan, Italy
| | - Guglielmo Gallone
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Division of Cardiology, Department of Medical Sciences, Città della Scienza e della Salute Hospital, University of Turin, Turin, Italy
| | - Giulia Benedetti
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,Radiology Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - 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
| | - Davide Vignale
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| | - Caterina Monti
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Francesco Ponticelli
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Marco Ancona
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Del Maschio
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesco De Cobelli
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Antonio Esposito
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. .,School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy.
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31
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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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32
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Jolicoeur EM, Verheye S, Henry TD, Joseph L, Doucet S, White CJ, Edelman E, Banai S. A novel method to interpret early phase trials shows how the narrowing of the coronary sinus concordantly improves symptoms, functional status and quality of life in refractory angina. Heart 2020; 107:41-46. [PMID: 32719097 DOI: 10.1136/heartjnl-2020-316644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Reduction of the coronary sinus was shown to improve angina in patients unsuitable for revascularisation. We assessed whether a percutaneous device that reduces the diameter of the coronary sinus improved outcomes across multiple endpoints in a phase II trial. METHODS We conducted a novel analysis performed as a post hoc efficacy analysis of the COSIRA (Coronary Sinus Reducer for Treatment of Refractory Angina) trial, which enrolled patients with Canadian Cardiovascular Society (CCS) class 3-4 refractory angina. We used four domains: symptoms (CCS Angina Scale), functionality (total exercise duration), ischaemia (imaging) and health-related quality of life. For all domains, we specified a meaningful threshold for change. The primary endpoint was defined as a probability of ≥80% that the reducer exceeded the meaningful threshold on two or more domains (group-level analysis) or that the average efficacy score in the reducer group exceeded the sham control group by at least two points (patient-level analysis). RESULTS We randomised 104 participants to either a device that narrows to coronary sinus (n=52) or a sham implantation (n=52). The reducer group met the prespecified criteria for concordance at the group level and demonstrated improvement in symptoms (0.59 CCS grade, 95% credible interval (CrI)=0.22 to 0.95), total exercise duration (+27.9%, 95% CrI=2.8% to 59.8%) and quality of life (stability +11.2 points, 95% CrI=3.3 to 19.1; perception +11.0, 95% CrI=3.3 to 18.7). CONCLUSIONS The reducer concordantly improved symptoms, functionality and quality of life compared with a sham intervention in patients with angina unsuitable for coronary revascularisation. Concordant analysis such as this one can help interpret early phase trials and guide the decision to pursue a clinical programme into a larger confirmatory trial. TRAIL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT01205893.
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Affiliation(s)
- E Marc Jolicoeur
- Department of Medicine, Interventional Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Stefan Verheye
- Antwerp Cardiovascular Institute, ZNA Middelheim Hospital, Antwerpen, Belgium
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Lawrence Joseph
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Serge Doucet
- Department of Medicine, Interventional Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Christopher J White
- The John Ochsner Heart & Vascular Institute, Ochsner Clinical School, University of Queensland, New Orleans, Louisiana, USA
| | - Elazer Edelman
- Institute for Medical Engineering and Science, Cambridge, Massachusetts, USA.,Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shmuel Banai
- The Tel Aviv Medical Center, The Tel Aviv University Medical School, Tel Aviv, Israel
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33
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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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34
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Zivelonghi C, Verheye S. The Coronary Sinus Reducer – Clinical Evidence and New Perspectives On An Emerging Tool in the Treatment of Refractory Angina. Heart Int 2020; 14:29-33. [DOI: 10.17925/hi.2020.14.1.29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
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35
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Konigstein M, Giannini F, Banai S. The Reducer device in patients with angina pectoris: mechanisms, indications, and perspectives. Eur Heart J 2019; 39:925-933. [PMID: 29020417 DOI: 10.1093/eurheartj/ehx486] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 08/21/2017] [Indexed: 11/13/2022] Open
Abstract
Despite available pharmacological and interventional therapies, refractory angina is a common and disabling clinical condition, and a major public health problem, which affects patients' quality-of-life, and has a significant impact upon health care resources. Persistent angina is common not only in patients who are not good candidates for revascularization, but also in patients following successful revascularization. Clearly, there is a need for additional treatment options for refractory angina beyond currently available pharmacological and interventional therapies. It is of pivotal importance, in this condition, to practice a patient-centred health assessment approach, measuring success of a new therapy by its effects on patients' symptoms, functional status, and quality-of-life, rather than hard clinical endpoints as used in clinical studies. The coronary sinus Reducer is a novel technology designed to reduce disabling symptoms and improve quality-of-life of patients suffering from refractory angina. This review serves to update the clinician as to current evidence and future perspectives of the optimal utilization of this innovative technology.
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Affiliation(s)
- Maayan Konigstein
- Department of Cardiology, Tel-Aviv Medical Center, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, Tel Aviv 64239, Israel
| | - Francesco Giannini
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Via Olgettina Milano 60, 20132, Milan, Italy
| | - Shmuel Banai
- Department of Cardiology, Tel-Aviv Medical Center, Tel-Aviv, Israel and the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizman Street, Tel Aviv 64239, Israel
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36
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The impact of coronary sinus narrowing on diastolic function in patients with refractory angina. Int J Cardiol 2019; 291:8-12. [DOI: 10.1016/j.ijcard.2019.03.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 01/20/2023]
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37
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Giannini F, Palmisano A, Baldetti L, Benedetti G, Ponticelli F, Rancoita PMV, Ruparelia N, Gallone G, Ancona M, Mangieri A, Tzanis G, De Cobelli F, Del Maschio A, Colombo A, Esposito A. Patterns of Regional Myocardial Perfusion Following Coronary Sinus Reducer Implantation: Insights by Stress Cardiac Magnetic Resonance. Circ Cardiovasc Imaging 2019; 12:e009148. [PMID: 31451003 DOI: 10.1161/circimaging.119.009148] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy (F.G., A.M., A.C.)
| | - Anna Palmisano
- Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.P., G.B., F.D.C., A.D.M., A.E.)
| | - Luca Baldetti
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Giulia Benedetti
- Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.P., G.B., F.D.C., A.D.M., A.E.)
| | - Francesco Ponticelli
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Paola M V Rancoita
- University Centre for Statistics in the Biomedical Sciences (CUSSB), Vita-Salute San Raffaele University, Milan, Italy (P.M.V.R.)
| | - Neil Ruparelia
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Guglielmo Gallone
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Marco Ancona
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Antonio Mangieri
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy (F.G., A.M., A.C.).,Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Georgios Tzanis
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Francesco De Cobelli
- Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.P., G.B., F.D.C., A.D.M., A.E.)
| | - Alessandro Del Maschio
- Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.P., G.B., F.D.C., A.D.M., A.E.)
| | - Antonio Colombo
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy (F.G., A.M., A.C.).,Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (L.B., F.P., N.R., G.G., M.A., A.M., G.T., A.C.)
| | - Antonio Esposito
- Department of Radiology and Experimental Imaging Centre, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.P., G.B., F.D.C., A.D.M., A.E.)
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38
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Biscaglia S, Tebaldi M, Mele D, Balla C, Ferrari R. Angina and left ventricular dysfunction: can we 'reduce' it? Eur Heart J Suppl 2019; 21:C28-C31. [PMID: 30996705 PMCID: PMC6456877 DOI: 10.1093/eurheartj/suz045] [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] [Indexed: 11/18/2022]
Abstract
Despite the evolution in pharmacology and devices, recurrent and persistent angina still represent a frequent issue in clinical practice. A 69-year-old Caucasian female patient has history of surgical aortic valve replacement with a bioprosthesis for severe aortic stenosis with subsequent transcatheter valve-in-valve implantation for bioprosthesis degeneration and single coronary artery bypass graft with left internal mammary artery on left anterior descending (LAD). After transcatheter aortic valve implantation, she started to complain angina [Canadian Cardiovascular Society (CCS) Class III], effectively treated with bisoprolol uptitration and ivabradine 5 b.i.d. addition. After 6 months, she had a non-ST segment elevated myocardial infarction with evidence of left main occlusion and good functioning aortic bioprosthesis. A retrograde drug-eluting balloon percutaneous coronary intervention (PCI) on LAD (in-stent restenosis) was performed. However, the patient continued to complain angina (CCS Class II–III), even after further ivabradine increase to 7.5 mg b.i.d. After 4 months, the patient underwent Reducer implantation. After 2 months, angina started to improve and the patient is currently angina free. In the last decades, PCI materials and stents greatly improved. Medical therapy (such as β-blockers) has been shown not only to improve symptoms but also to add a prognostic benefit in patients with reduced ejection fraction (EF). Ivabradine showed additional benefits in patients with angina and reduced EF. However, still a relevant portion of patients complain refractory angina. The COSIRA trial showed that a coronary sinus Reducer was associated with greater angina relief than the sham procedure and could be a further step in angina treatment.
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Affiliation(s)
- Simone Biscaglia
- Department of Medical Sciences Ferrara University, Ferrara, Italy
| | - Matteo Tebaldi
- Department of Medical Sciences Ferrara University, Ferrara, Italy
| | - Donato Mele
- Department of Medical Sciences Ferrara University, Ferrara, Italy
| | - Cristina Balla
- Department of Medical Sciences Ferrara University, Ferrara, Italy
| | - Roberto Ferrari
- Department of Medical Sciences Ferrara University, Ferrara, Italy.,E.S: Health Science Foundation, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
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39
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Konigstein M, Shofti R, Schwartz M, Banai S. Coronary sinus reducer for the treatment of chronic refractory angina pectoris‐results of the preclinical safety and feasibility study. Catheter Cardiovasc Interv 2018; 92:1274-1282. [DOI: 10.1002/ccd.27709] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 04/06/2018] [Accepted: 05/30/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Maayan Konigstein
- Department of Cardiology, Sackler Faculty of Medicine, Tel‐Aviv Medical CenterTel‐Aviv University Tel Aviv Israel
| | - Rona Shofti
- Pre‐Clinical Research AuthorityTechnion Haifa Israel
| | | | - Shmuel Banai
- Department of Cardiology, Sackler Faculty of Medicine, Tel‐Aviv Medical CenterTel‐Aviv University Tel Aviv Israel
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40
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Montone RA, Russo M, Giannini F, Niccoli G. The coronary sinus Reducer device for refractory chronic angina: rationale, clinical evidence and future perspectives. Expert Rev Med Devices 2018; 15:611-613. [PMID: 30179051 DOI: 10.1080/17434440.2018.1511422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Rocco A Montone
- a Department of Cardiovascular and Thoracic Sciences , Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
| | - Michele Russo
- a Department of Cardiovascular and Thoracic Sciences , Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
| | - Francesco Giannini
- b Unit of Cardiovascular Interventions , IRCCS San Raffaele Scientific Institute , Milan , Italy
| | - Giampaolo Niccoli
- a Department of Cardiovascular and Thoracic Sciences , Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome , Italy
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41
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Konigstein M, Bazan S, Revivo M, Banai S. Coronary Sinus Reducer implantation improves symptoms, ischaemia and physical capacity in patients with refractory angina unsuitable for myocardial revascularisation: a single-centre experience. EUROINTERVENTION 2018; 14:e452-e458. [DOI: 10.4244/eij-d-18-00102] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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42
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Mechanical Therapies for Refractory Angina: The Current Evidence. Am J Ther 2018. [PMID: 29543611 DOI: 10.1097/mjt.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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43
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44
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Piek JJ. Sneaking in through the back door. Neth Heart J 2017; 25:155-156. [PMID: 28168511 PMCID: PMC5313454 DOI: 10.1007/s12471-017-0954-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- J J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, The Netherlands.
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45
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Wu H, Kassab GS, Tan W, Huo Y. Flow velocity is relatively uniform in the coronary sinusal venous tree: structure-function relation. J Appl Physiol (1985) 2017; 122:60-67. [PMID: 27789767 DOI: 10.1152/japplphysiol.00295.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 10/06/2016] [Accepted: 10/23/2016] [Indexed: 11/22/2022] Open
Abstract
The structure and function of coronary venous vessels are different from those of coronary arteries and are much less understood despite the therapeutic significance of coronary sinus interventions. Here we aimed to perform a hemodynamic analysis in the entire coronary sinusal venous tree, which enhances the understanding of coronary venous circulation. A hemodynamic model was developed in the entire coronary sinusal venous tree reconstructed from casts and histological data of five swine hearts. Various morphometric and hemodynamic parameters were determined in each vessel and analyzed in the diameter-defined Strahler system. The findings demonstrate an area preservation between the branches of the coronary venous system that leads to relatively uniform flow velocity in different orders of the venous tree. Pressure and circumferential and wall shear stresses decreased abruptly from the smallest venules toward vessels of order -5 (80.4 ± 39.1 µm) but showed a more modest change toward the coronary sinus. The results suggest that vessels of order -5 denote a hemodynamic transition from the venular bed to the transmural subnetwork. In contrast with the coronary arterial tree, which obeys the minimum energy hypothesis, the coronary sinusal venous system complies with the area-preserving rule for efficient venous return, i.e., da Vinci's rule. The morphometric and hemodynamic model serves as a physiological reference state to test various therapeutic rationales through the venous route. NEW & NOTEWORTHY A hemodynamic model is developed in the entire coronary sinusal venous tree of the swine heart. A key finding is that the coronary sinusal venous system complies with the area preservation rule for efficient venous return while the coronary arterial tree obeys the minimum energy hypothesis. This model can also serve as a physiological reference state to test various therapeutic rationales through the venous route.
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Affiliation(s)
- Hao Wu
- Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, People's Republic of China.,State Key Laboratory for Turbulence and Complex Systems, College of Engineering, Peking University, Beijing, People's Republic of China
| | | | - Wenchang Tan
- Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, People's Republic of China; .,State Key Laboratory for Turbulence and Complex Systems, College of Engineering, Peking University, Beijing, People's Republic of China.,Shenzhen Graduate School, Peking University, Shenzhen, People's Republic of China; and
| | - Yunlong Huo
- Department of Mechanics and Engineering Science, College of Engineering, Peking University, Beijing, People's Republic of China.,State Key Laboratory for Turbulence and Complex Systems, College of Engineering, Peking University, Beijing, People's Republic of China.,College of Medicine, Hebei University, Baoding, People's Republic of China
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46
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Giannini F, Aurelio A, Jabbour RJ, Ferri L, Colombo A, Latib A. The coronary sinus reducer: clinical evidence and technical aspects. Expert Rev Cardiovasc Ther 2016; 15:47-58. [DOI: 10.1080/14779072.2017.1270755] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco Giannini
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Andrea Aurelio
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Cardiovascular Department, Casa di Cura Villa Verde, Taranto, Italy
| | - Richard J. Jabbour
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Luca Ferri
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Cardiovascular Department, Ospedale A. Manzoni, Lecco, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Azeem Latib
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
- Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
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47
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Benedetto D, Abawi M, Stella PR, Nijhoff F, Lakemeier MDM, Kortlandt F, Doevendans PA, Agostoni P. Percutaneous Device to Narrow the Coronary Sinus: Shifting Paradigm in the Treatment of Refractory Angina? A Review of the Literature. Front Cardiovasc Med 2016; 3:42. [PMID: 27818991 PMCID: PMC5073123 DOI: 10.3389/fcvm.2016.00042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/07/2016] [Indexed: 11/23/2022] Open
Abstract
Refractory angina pectoris is defined as a chronic debilitating condition characterized by the presence of chronic anginal symptoms due to a severe obstructive and/or diffuse coronary artery disease that cannot be controlled by the combination of medical therapy and/or revascularization (percutaneous or surgical). In addition, the presence of myocardial ischemia as a cause of the symptoms must have been documented. The coronary sinus reducer (CSR) is a recently introduced percutaneous device to treat patients with severe anginal symptoms refractory to optimal medical therapy and not amenable to conventional revascularization. The purpose of this review is to describe the current evidence from available studies measuring the clinical effect of the CSR implantation on the health and well-being of patients with refractory angina.
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Affiliation(s)
- Daniela Benedetto
- University Medical Centre Utrecht, Utrecht, Netherlands; University of Milan, Milan, Italy
| | - Masieh Abawi
- University Medical Centre Utrecht , Utrecht , Netherlands
| | | | - Freek Nijhoff
- University Medical Centre Utrecht , Utrecht , Netherlands
| | | | | | | | - Pierfrancesco Agostoni
- University Medical Centre Utrecht, Utrecht, Netherlands; St. Antonius Hospital, Nieuwegein, Netherlands
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48
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Abawi M, Nijhoff F, Stella PR, Voskuil M, Benedetto D, Doevendans PA, Agostoni P. Safety and efficacy of a device to narrow the coronary sinus for the treatment of refractory angina: A single-centre real-world experience. Neth Heart J 2016; 24:544-51. [PMID: 27299456 PMCID: PMC5005194 DOI: 10.1007/s12471-016-0862-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective The coronary sinus Reducer is a recently introduced device to treat patients with severe angina symptoms refractory to optimal medical therapy and not amenable for conventional revascularisation. We aimed to assess the safety and efficacy of the Reducer in a real-world cohort of patients with refractory angina. Methods This is a single-centre retrospective registry. Patients with severe angina symptoms, objective evidence of myocardial ischaemia using any adequate non-invasive modality and without options for conventional revascularisation were regarded eligible for Reducer implantation. Results Twenty-three patients (74 % male, mean age 70 ± 8 years, 91.3 % previous bypass surgery, 82.6 % previous percutaneous intervention, 47.8 % previous myocardial infarction, 52.2 % diabetes mellitus) underwent Reducer implantation. The safety endpoint (successful implantation of the first device without device-related adverse events) was met in all patients. After a median follow-up of 9 (8–14) months the efficacy (any reduction in Canadian Cardiovascular Society (CCS) class and revascularisation-free survival) was reached in 17 patients (74 %): 8 patients (34.8 %) improved by 1 CCS class, 7 (30.4 %) by 2 CCS classes and 2 (8.7 %) by 3 CCS classes. One patient died 4 months after implantation because of progressive heart failure (not associated with Reducer implantation). Conclusion In this single-centre real-world experience, Reducer implantation was safe and demonstrated excellent clinical efficacy in the treatment of refractory angina at mid-term follow-up.
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Affiliation(s)
- M Abawi
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - F Nijhoff
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P R Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - P A Doevendans
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Agostoni
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
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50
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De Maria GL, Kassimis G, Raina T, Banning AP. Reconsidering the back door approach by targeting the coronary sinus in ischaemic heart disease. Heart 2016; 102:1263-9. [DOI: 10.1136/heartjnl-2016-309642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/09/2016] [Indexed: 01/14/2023] Open
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