1
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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 2024; 32:448-452. [PMID: 36728718 DOI: 10.1097/crd.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [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
| | | | - 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 Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Elimelech C, Zornitzki L, Konigstein M, Rozenbaum Z, Arnold JH, Havakuk O, Revivo M, Flint N, Khoury S, Topilsky Y, Banai S, Laufer-Perl M. Baseline Left Ventricle Longitudinal Strain as a Predictor for Clinical Improvement Following Coronary Sinus Reducer Implantation. Am J Cardiol 2023; 204:77-83. [PMID: 37541151 DOI: 10.1016/j.amjcard.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/11/2023] [Accepted: 07/10/2023] [Indexed: 08/06/2023]
Abstract
Coronary sinus narrowing device (reducer) implantation has emerged as an effective treatment to improve the quality of life and functional capacity in patients suffering from disabling refractory angina. Left ventricle global longitudinal strain (LV-GLS) is a useful tool for early diagnosis of subclinical cardiac injury and an independent predictor for coronary artery disease. We aimed to investigate whether LV-GLS could help predict clinical improvement after coronary sinus reducer implantation. LV-GLS assessments were performed at baseline and 6 months after reducer implantation in consecutive patients treated for refractory angina. Patients were divided into 2 groups based on reduced (<17% absolute value) or preserved baseline LV-GLS. Clinical improvement was defined as an increase of ≥25 m in the 6-minute walk test (6MWT) at follow-up. Overall, 41 patients were included, 31 in the reduced LV-GLS group and 10 in the preserved LV-GLS group. The mean age was 68 ± 8 years, with only 2 female patients (5%). Baseline characteristics did not differ significantly between the 2 groups. Univariable analysis revealed that LV-GLS was the only significant predictor for 6MWT improvement. Baseline preserved LV-GLS reduced the likelihood of 6MWT improvement by 82% (odds ratio 0.18 [0.04 to 0.83], p = 0.029). A significant increase in 6MWT (307 ± 97 m to 343 ± 92 m, p = 0.017) was observed in the reduced LV-GLS group, compared with a decrease in the preserved LV-GLS group (378 ± 86 m to 361 ± 123 m, p = 0.651). In conclusion, reduced LV-GLS may serve as a marker for potential clinical improvement in patients with refractory angina treated with reducer. Larger clinical trials are needed to establish its role.
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Affiliation(s)
- Chen Elimelech
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Lior Zornitzki
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Maayan Konigstein
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Zach Rozenbaum
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Department of Cardiology, Tulane University, New Orleans, Louisiana
| | - Joshua H Arnold
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Ofer Havakuk
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Miri Revivo
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Flint
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shafik Khoury
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yan Topilsky
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shmuel Banai
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Michal Laufer-Perl
- Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel; Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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3
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Verheye S, Agostoni P, Giannini F, Hill JM, Jensen C, Lindsay S, Stella P, Redwood SR, Banai S, Konigstein M. Coronary sinus narrowing for the treatment of refractory angina: a multicentre prospective open-label clinical study (the REDUCER-I study). EUROINTERVENTION 2021; 17:561-568. [PMID: 33319762 PMCID: PMC9724967 DOI: 10.4244/eij-d-20-00873] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The REDUCER-I study is a prospective (with a retrospective component), open-label, multi-centre, international, post-market study, which collects long-term data of patients with refractory angina treated with the Reducer. Here we present the overall clinical outcomes of the first 228 patients enrolled. AIMS The aim of this study is to examine the safety and efficacy of the coronary sinus (CS) Reducer in improving angina severity and quality of life in patients suffering from angina pectoris, refractory to medical and interventional therapies. METHODS REDUCER-I is a multicentre, non-randomised observational study. Enrolled patients had refractory angina pectoris Canadian Cardiovascular Society (CCS) class II-IV and were treated with Reducer implantation. RESULTS In the first 228 patients (81% male, 68.3±9.6 years), the procedural success rate was 99%, with only one adjudicated possible procedural or device-related MACE. Mean CCS class decreased from 2.8±0.6 at baseline, to 1.8±0.7 at two years. Improvement in ≥1 CCS class was observed in 82%, and in ≥2 CCS classes in 31% of patients at two years. At baseline, 70% of the cohort were reported to be in CCS class III-IV; this portion was reduced to 15% at follow-up. Additional measured parameters of functional class and quality of life were also improved. CONCLUSIONS Interim results from the ongoing REDUCER-I study confirm the high safety profile of this therapy in patients suffering from refractory angina. The results also demonstrate sustained improvement in angina severity and in quality of life up to two years.
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Affiliation(s)
- Stefan Verheye
- Cardiovascular Center, ZNA Middelheim Hospital, Lindendreef Antwerp, Belgium
| | | | | | | | | | - Steven Lindsay
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | | | - Simon R. Redwood
- St Thomas’ Hospital Cardiothoracic Centre, London, United Kingdom
| | - Shmuel Banai
- Tel Aviv Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, 6423906, Israel
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4
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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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5
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Abstract
Myocardial ischemia is a metabolic problem involving reduced delivery of oxygen to cardiac mitochondria, resulting in less ATP formation, acceleration of glycolysis and production of lactate and H+ by the cell. Traditional therapies for ischemia aim at restoring the balance between mitochondrial ATP production and breakdown by reducing the need for ATP via suppression of heart rate, blood pressure and cardiac contractility, or by increasing oxygen delivery via increased myocardial blood flow. Despite optimal treatment with traditional hemodynamically oriented drugs (beta-adrenergic receptor antagonist, Ca2+ channel antagonist and nitrates), many patients continue to suffer from angina. Thus, there is a need for anti-anginal drugs that act directly on cardiomyocytes to lessen the metabolic abnormalities induced by ischemia and reduce the symptoms (chest pain and exercise intolerance). Ranolazine has been demonstrated to improve exercise time to angina or 1 mm of ST-segment depression in a manner similar to currently approved drugs, but without any significant effects on heart rate or blood pressure at rest or during exercise. In two Phase III trials, ranolazine improved exercise tolerance and reduced the frequency of angina attacks in chronic severe angina patients when administered either as monotherapy or on a background of atenolol, amlodinine or diltiazem. At present, ranolazine is under review for US Food and Drug Administration approval and, if approved, it will represent the first drug of its class in the USA.
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Affiliation(s)
- William C Stanley
- Department of Physiology and Biophysics, School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4970, USA.
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6
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Giusti II, Rodrigues CG, Salles FB, Sant'Anna RT, Eibel B, Han SW, Ludwig E, Grossman G, Prates PRL, Sant'Anna JRM, Filho GFT, Markoski MM, Nesralla IA, Nardi NB, Kalil RA. High Doses of Vascular Endothelial Growth Factor 165 Safely, but Transiently, Improve Myocardial Perfusion in No-Option Ischemic Disease. Hum Gene Ther Methods 2013; 24:298-306. [DOI: 10.1089/hgtb.2012.221] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Imarilde I. Giusti
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Clarissa G. Rodrigues
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
- Department of Surgery, Duke University, Durham, NC 27710
| | - Felipe B. Salles
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Roberto T. Sant'Anna
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Bruna Eibel
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Sang W. Han
- Universidade Federal de São Paulo, São Paulo, 04021-001 Brazil
| | - Eduardo Ludwig
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Gabriel Grossman
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Paulo Roberto L. Prates
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | | | | | - Melissa M. Markoski
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Ivo A. Nesralla
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Nance B. Nardi
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
| | - Renato A.K. Kalil
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, 90620-000 Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, 90050-170 Brazil
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7
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Rodrigues CG, Plentz RD, Dipp T, Salles FB, Giusti II, Sant'Anna RT, Eibel B, Nesralla IA, Markoski M, Beyer NN, Kalil RAK. VEGF 165 gene therapy for patients with refractory angina: mobilization of endothelial progenitor cells. Arq Bras Cardiol 2013; 101:149-53. [PMID: 23842797 PMCID: PMC3998152 DOI: 10.5935/abc.20130128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 03/14/2013] [Indexed: 11/20/2022] Open
Abstract
Background Vascular endothelial growth factor (VEGF) induces mobilization of endothelial
progenitor cells (EPCs) with the capacity for proliferation and differentiation
into mature endothelial cells, thus contributing to the angiogenic process. Objective We sought to assess the behavior of EPCs in patients with ischemic heart disease
and refractory angina who received an intramyocardial injections of 2000 µg of
VEGF 165 as the sole therapy. Methods The study was a subanalysis of a clinical trial. Patients with advanced ischemic
heart disease and refractory angina were assessed for eligibility. Inclusion
criteria were as follows: signs and symptoms of angina and/or heart failure
despite maximum medical treatment and a myocardial ischemic area of at least 5% as
assessed by single-photon emission computed tomography (SPECT). Exclusion criteria
were as follows: age > 65 years, left ventricular ejection fraction < 25%,
and a diagnosis of cancer. Patients whose EPC levels were assessed were included.
The intervention was 2000 µg of VEGF 165 plasmid injected into the ischemic
myocardium. The frequency of CD34+/KDR+ cells was analyzed by flow cytometry
before and 3, 9, and 27 days after the intervention. Results A total of 9 patients were included, 8 males, mean age 59.4 years, mean left
ventricular ejection fraction of 59.3% and predominant class III angina. The
number of EPCs on day 3 was significantly higher than that at baseline (p = 0.03);
however, that on days 9th and 27th was comparable to that at
baseline. Conclusion We identified a transient mobilization of EPCs, which peaked on the 3th day after
VEGF 165 gene therapy in patients with refractory angina and returned to near
baseline levels on 9th and 27thdays.
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Affiliation(s)
- Clarissa G. Rodrigues
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
- Duke University Medical Center, Durham, North Carolina, USA
| | - Rodrigo D.M. Plentz
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto
Alegre, RS - Brazil
| | - Thiago Dipp
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Felipe B. Salles
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto
Alegre, RS - Brazil
| | - Imarilde I. Giusti
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Roberto T. Sant'Anna
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Bruna Eibel
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Ivo A. Nesralla
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Melissa Markoski
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
| | - Nance N. Beyer
- Instituto de Cardiologia/Fundação Universitária de Cardiologia -
Programa de Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS -
Brazil
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS -
Brazil
| | - Renato A. K. Kalil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto
Alegre, RS - Brazil
- Mailing Address: Renato Abdala Karam Kalil, Av. Princesa Isabel, 370,
Santana, Postal Code 90620-000, Porto Alegre, RS - Brazil, E-mail:
,
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8
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Richter A, Cederholm I, Fredrikson M, Mucchiano C, Träff S, Janerot-Sjoberg B. Effect of Long-Term Thoracic Epidural Analgesia on Refractory Angina Pectoris: A 10-Year Experience. J Cardiothorac Vasc Anesth 2012; 26:822-8. [DOI: 10.1053/j.jvca.2012.01.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Indexed: 11/11/2022]
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9
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Cohen MG, Ohman EM. Therapeutic Goals in Patients with Refractory Angina. Coron Artery Dis 2012. [DOI: 10.1007/978-1-84628-712-1_4] [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: 11/29/2022]
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10
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Ryabov VV, Oyunarov EO, Markov VA. Refractory post-infarction myocardial ischemia: treatment potential. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2011. [DOI: 10.15829/1728-8800-2011-4-121-127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The treatment of recurrent, refractory post-infarction myocardial ischemia remains an unresolved clinical problem. Aggressive pharmaceutical therapy has limited effectiveness, while percutaneous coronary intervention or coronary artery bypass graft surgery are not possible in these patients, due to various reasons. Currently, alternative methods for refractory angina treatment are being developed for patients with chronic stable angina. The potential of these methods in patients with acute coronary syndrome should be investigated in the future studies.
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Affiliation(s)
| | - E. O. Oyunarov
- Research Institute of Cardiology, Siberian Division of the Russian Academy of Medical Sciences
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11
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Wang J, Peng X, Lassance-Soares RM, Najafi AH, Alderman LO, Sood S, Xue Z, Chan R, Faber JE, Epstein SE, Burnett MS. Aging-induced collateral dysfunction: impaired responsiveness of collaterals and susceptibility to apoptosis via dysfunctional eNOS signaling. J Cardiovasc Transl Res 2011; 4:779-89. [PMID: 21538183 DOI: 10.1007/s12265-011-9280-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 04/13/2011] [Indexed: 12/14/2022]
Abstract
Despite positive animal studies, clinical angiogenesis trials have been disappointing, possibly due to risk factors present in humans but usually unexplored in animals. We recently demonstrated aging causes impaired collateral remodeling and collateral dropout; here, we investigate potential mechanisms responsible for these findings. Four-, 10-, and 18-month-C57BL/6J mice were subjected to femoral artery ligation; flow was measured using laser Doppler perfusion imaging. Endothelial nitric oxide synthase (eNOS) and phosphorylated eNOS were measured in calf muscle. Apoptosis was assessed in endothelial (EC) and smooth muscle (SMC) cells isolated from young and old mice. Angiogenesis was measured using a Matrigel plug assay. Lethally irradiated young and old mice received bone marrow cells (BMC) from either young or old donors and were subjected to femoral artery ligation (FAL). BMC mobilization and homing were assessed. Flow recovery was impaired and less eNOS and phosphorylated eNOS was present in older vs. young mice (p < 0.001 and p = 0.015, respectively). ECs and SMCs from older mice were more sensitive to an apoptotic stimulus, but were rescued by NO-enhancing drugs. In older mice, angiogenesis (Matrigel plug assay) was impaired, as was mobilization and homing of BM progenitor cells following FAL. Although both mobilization and homing improved when older mice received BMC transplantation from young donors, flow recovery failed to improve. Aging impairs BMC mobilization and homing, collateral responsiveness to angiogenic stimuli, and increases EC and SMC susceptibility to apoptosis via dysfunctional eNOS signaling. The latter could contribute to impaired remodeling and collateral dropout. These finding identify potential obstacles to therapeutic interventions in elderly patients.
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MESH Headings
- Age Factors
- Aging/metabolism
- Aging/pathology
- Animals
- Aorta/enzymology
- Aorta/pathology
- Aorta/physiopathology
- Apoptosis
- Arterial Occlusive Diseases/enzymology
- Arterial Occlusive Diseases/pathology
- Arterial Occlusive Diseases/physiopathology
- Blotting, Western
- Bone Marrow Transplantation
- Cell Movement
- Cells, Cultured
- Collateral Circulation
- Cyclic Nucleotide Phosphodiesterases, Type 5/metabolism
- Disease Models, Animal
- Endothelial Cells/enzymology
- Female
- Femoral Artery/surgery
- Laser-Doppler Flowmetry
- Ligation
- Lower Extremity/blood supply
- Mice
- Mice, Inbred C57BL
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/physiopathology
- Myocytes, Smooth Muscle/enzymology
- Neovascularization, Physiologic
- Nitric Oxide Synthase Type III/metabolism
- Perfusion Imaging/methods
- Phosphorylation
- Regional Blood Flow
- Signal Transduction
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Affiliation(s)
- Jinsong Wang
- Cardiovascular Research Institute, MedStar Health Research Institute, Washington, DC 20010, USA
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12
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Rodrigues CG, Moraes MA, Sauer JM, Kalil RAK, de Souza EN. Nursing Diagnosis of Activity Intolerance: Clinical Validation in Patients With Refractory Angina. ACTA ACUST UNITED AC 2011; 22:117-22. [DOI: 10.1111/j.1744-618x.2011.01182.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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van Ramshorst J, Rodrigo SF, Schalij MJ, Beeres SLMA, Bax JJ, Atsma DE. Bone marrow cell injection for chronic myocardial ischemia: the past and the future. J Cardiovasc Transl Res 2011; 4:182-91. [PMID: 21213093 PMCID: PMC3047688 DOI: 10.1007/s12265-010-9249-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2010] [Accepted: 11/17/2010] [Indexed: 01/12/2023]
Abstract
Intramyocardial bone marrow cell injection is currently being investigated as a new therapeutic option for the treatment of chronic myocardial ischemia. Experimental studies and early phase clinical trials established a favorable safety profile of this approach and suggested that bone marrow cell injection was associated with clinical and functional improvements. Recently, a randomized, double-blind, placebo-controlled trial demonstrated that intramyocardial bone marrow cell injection was associated with beneficial effects on myocardial perfusion and anginal symptoms. However, the mechanisms by which bone marrow cells may improve myocardial perfusion are only partially understood, and several issues remain to be addressed. This review aims to provide a summary of the current experience with bone marrow cell therapy as a novel treatment option for patients with chronic myocardial ischemia. Therefore, the most frequently used cell types will be reviewed along with the mechanisms through which bone marrow cells may improve myocardial perfusion and function. In addition, possible routes of delivery are compared, and the results of currently available experimental and clinical studies are discussed.
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Affiliation(s)
- Jan van Ramshorst
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Sander F. Rodrigo
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Martin J. Schalij
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Saskia L. M. A. Beeres
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Douwe E. Atsma
- Department of Cardiology, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands
- Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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14
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Colivicchi F, Tubaro M, Mocini D, Genovesi Ebert A, Strano S, Melina G, Uguccioni M, Santini M. Full-dose atorvastatin versus conventional medical therapy after non-ST-elevation acute myocardial infarction in patients with advanced non-revascularisable coronary artery disease. Curr Med Res Opin 2010; 26:1277-84. [PMID: 20367555 DOI: 10.1185/03007991003751496] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS This study tested the hypothesis that the addition of full-dose atorvastatin (80 mg/day) to conventional medical treatment could reduce ischaemic recurrences after non-ST-elevation acute myocardial infarction (NSTE-AMI) in patients with severe and diffuse coronary artery disease (CAD) not amenable to any form of mechanical revascularisation. METHODS AND RESULTS The study was an open-label, randomised, controlled, blinded end-point classification trial, employing the PROBE (Prospective Open Treatment and Blinded End Point Evaluation) design. A total of 290 patients (mean age 74.6 +/- 9.6 years) with NSTE-AMI and angiographic evidence of severe and diffuse CAD, not amenable to revascularisation by either coronary surgery or angioplasty, were randomised to atorvastatin 80 mg/day (n = 144) or conventional medical treatment (n = 146). A primary end point event (combination of cardiovascular death, non-fatal acute myocardial reinfarction and disabling stroke within 12 months of randomisation) occurred in 16.0% of patients treated with atorvastatin 80 mg/day and in 26.7% of patients receiving conventional treatment (HR 0.56; 95% CI 0.33-0.93, p = 0.027). The study was not blinded. Consequently, a bias in the assessment of clinical outcome cannot be completely excluded. CONCLUSIONS In conclusion, when compared with a conventional treatment strategy, full-dose therapy with atorvastatin 80 mg/day provides greater protection against ischaemic recurrences after NSTE-AMI in patients with severe, diffuse, non-revascularisable CAD.
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Affiliation(s)
- Furio Colivicchi
- Cardiology Division, Cardiovascular Department, San Filippo Neri Hospital, Rome, Italy.
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15
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Cohen MG, Pascual M, Scirica BM, Magnus Ohman E. Therapeutic goals in patients with refractory chronic angina. Rev Esp Cardiol 2010; 63:571-82. [PMID: 20450851 DOI: 10.1016/s1885-5857(10)70119-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Refractory angina presents a major clinical challenge for everyday medical practice. Despite the widespread use of statins and improvements in revascularization techniques, a substantial proportion of patients with preserved left ventricular function and no life-threatening arrhythmias remain symptomatic, with severe debilitating angina. Because the rate of major cardiac events in this population is relatively low, the major aim of therapy should be not only to prolong survival but also to improve quality of life. The cornerstone of therapy for all these patients should be the aggressive modification of risk factors using evidence-based treatment, with the aim of stabilizing the disease process and improving overall survival. No opportunity for revascularization should be overlooked. Complementary approaches should be implemented to raise the angina threshold by either reducing oxygen demand or improving hemodynamics to increase myocardial oxygen supply. This review provides an update on therapeutic techniques and goals, and reinforces the need for a multidisciplinary approach to the management of patients with refractory angina.
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16
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Cohen MG, Pascual M, Scirica BM, Magnus Ohman E. Metas terapéuticas en pacientes con angina refractaria crónica. Rev Esp Cardiol (Engl Ed) 2010. [DOI: 10.1016/s0300-8932(10)70119-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Spinal Cord Stimulation for Refractory Angina. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00070-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Abstract
Refractory angina as a result of chronic myocardial ischemia is a common and disabling condition. Adult progenitor cells have emerged as a potential revolutionary treatment for cardiovascular disease. Locally administered adult progenitor cells with particular vasculogenic potential may offer treatment hope for those with chronic ischemia; however, the optimal cell type, dose, delivery mode, and target patient population has not been defined. Preclinical cell therapy studies have shown safety and efficacy sufficient to warrant human trials. Early, small-scale human trials exploring various cell types and delivery modes have shown that most approaches are safe, with modest early efficacy. This overview discusses the rationale and early results for ongoing larger cardiovascular disease trials, with a special emphasis on refractory angina and chronic myocardial ischemia.
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Affiliation(s)
- Amish N Raval
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53792-3248, USA.
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19
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Affiliation(s)
- Itsik Ben-Dor
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
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20
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Losordo DW, Schatz RA, White CJ, Udelson JE, Veereshwarayya V, Durgin M, Poh KK, Weinstein R, Kearney M, Chaudhry M, Burg A, Eaton L, Heyd L, Thorne T, Shturman L, Hoffmeister P, Story K, Zak V, Dowling D, Traverse JH, Olson RE, Flanagan J, Sodano D, Murayama T, Kawamoto A, Kusano KF, Wollins J, Welt F, Shah P, Soukas P, Asahara T, Henry TD. Intramyocardial Transplantation of Autologous CD34
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Stem Cells for Intractable Angina. Circulation 2007; 115:3165-72. [PMID: 17562958 DOI: 10.1161/circulationaha.106.687376] [Citation(s) in RCA: 446] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A growing population of patients with coronary artery disease experiences angina that is not amenable to revascularization and is refractory to medical therapy. Preclinical studies have indicated that human CD34+ stem cells induce neovascularization in ischemic myocardium, which enhances perfusion and function. METHODS AND RESULTS Twenty-four patients (19 men and 5 women aged 48 to 84 years) with Canadian Cardiovascular Society class 3 or 4 angina who were undergoing optimal medical treatment and who were not candidates for mechanical revascularization were enrolled in a double-blind, randomized (3:1), placebo-controlled dose-escalating study. Patients received granulocyte colony-stimulating factor 5 microg x kg(-1) x d(-1) for 5 days with leukapheresis on the fifth day. Selection of CD34+ cells was performed with a Food and Drug Administration-approved device. Electromechanical mapping was performed to identify ischemic but viable regions of myocardium for injection of cells (versus saline). The total dose of cells was distributed in 10 intramyocardial, transendocardial injections. Patients were required to have an implantable cardioverter-defibrillator or to temporarily wear a LifeVest wearable defibrillator. No incidence was observed of myocardial infarction induced by mobilization or intramyocardial injection. The intramyocardial injection of cells or saline did not result in cardiac enzyme elevation, perforation, or pericardial effusion. No incidence of ventricular tachycardia or ventricular fibrillation occurred during the administration of granulocyte colony-stimulating factor or intramyocardial injections. One patient with a history of sudden cardiac death/ventricular tachycardia/ventricular fibrillation had catheter-induced ventricular tachycardia during mapping that required cardioversion. Serious adverse events were evenly distributed. Efficacy parameters including angina frequency, nitroglycerine usage, exercise time, and Canadian Cardiovascular Society class showed trends that favored CD34+ cell-treated patients versus control subjects given placebo. CONCLUSIONS A randomized trial of intramyocardial injection of autologous CD34+ cells in patients with intractable angina was completed that provides evidence for feasibility, safety, and bioactivity. A larger phase IIb study is currently under way to further evaluate this therapy.
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Affiliation(s)
- Douglas W Losordo
- Feinberg Cardiovascular Research Institute, and Department of Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, IL 60611, USA.
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21
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Fox K, García MAA, Ardissino D, Buszman P, Camici PG, Crea F, Daly C, de Backer G, Hjemdahl P, López-Sendón J, Morais J, Pepper J, Sechtem U, Simoons M, Thygesen K. [Guidelines on the management of stable angina pectoris. Executive summary]. Rev Esp Cardiol 2007; 59:919-70. [PMID: 17162834 DOI: 10.1157/13092800] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Kim Fox
- Sociedad europea de cardiologia
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22
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Abstract
Viable treatment options are becoming available for the 'no-option' patient with chronic ischaemic heart disease. Instead of revascularising the highly diseased epicardial coronary arteries, scientists and clinicians have been looking at augmenting mother nature's way of providing biological bypass in an attempt to provide symptomatic relief in these patients. The novel use of gene and cell therapies for myocardial neovascularisation has exploded into a flurry of early clinical trials. This translational research has been motivated by an improved understanding of the biological mechanisms involved in tissue repair after ischaemic injury. While safety concerns will be top in priority in these trials, different types or combination of therapies, dose and route of delivery are being tested before further optimisation and establishment. With cautious optimism, a new era in the treatment of ischaemic heart disease is being entered. This article reviews the present state in gene and cell therapies for ischaemic heart disease, the modalities of their delivery, novel imaging techniques and future perspectives.
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Affiliation(s)
- Kian-Keong Poh
- Caritas St Elizabeth's Medical Center and Tufts University School of Medicine, Boston, MA, USA.
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23
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Zenovich AG, Davis BH, Taylor DA. Comparison of intracardiac cell transplantation: autologous skeletal myoblasts versus bone marrow cells. Handb Exp Pharmacol 2007:117-65. [PMID: 17554507 DOI: 10.1007/978-3-540-68976-8_6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
An increasing number of patients living with cardiovascular disease (CVD) and still unacceptably high mortality created an urgent need to effectively treat and prevent disease-related events. Within the past 5 years, skeletal myoblasts (SKMBs) and bone marrow (or blood)-derived mononuclear cells (BMNCs) have demonstrated preclinical efficacy in reducing ischemia and salvaging already injured myocardium, and in preventing left ventricular (LV) remodeling, respectively. These findings have been translated into clinical trials, so far totaling over 200 patients for SKMBs and over 800 patients for BMNCs. These safety/feasibility and early phase II studies showed promising but somewhat conflicting symptomatic and functional improvements, and some safety concerns have arisen. However, the patient population, cell type, dose, time and mode of delivery, and outcome measures differed, making comparisons problematic. In addition, the mechanisms through which cells engraft and deliver their beneficial effects remain to be fully elucidated. It is now time to critically evaluate progress made and challenges encountered in order to select not only the most suitable cells for cardiac repair but also to define appropriate patient populations and outcome measures. Reiterations between bench and bedside will increase the likelihood of cell therapy success, reduce the time to development of combined of drug- and cell-based disease management algorithms, and offer these therapies to patients to achieve a greater reduction of symptoms and allow for a sustained improvement of quality of life.
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Affiliation(s)
- A G Zenovich
- Center for Cardiovascular Repair, 312 Church Street SE, NHH 7-105A, Minneapolis, MN 55455, USA
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24
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Panse P, Klassen C, Panse N, Siuciak A, Rickers C, Jerosch-Herold M, Wilke NM. Magnetic resonance quantitative myocardial perfusion reserve demonstrates improved myocardial blood flow after angiogenic implant therapy. Int J Cardiovasc Imaging 2006; 23:217-24. [PMID: 16855858 DOI: 10.1007/s10554-006-9105-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Accepted: 05/13/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study is to follow myocardial angiogenesis temporally using quantitative magnetic resonance first pass perfusion imaging and compare this with the "gold standard" of radioactive microspheres in a random subset of animals. MATERIALS AND METHODS Ameriod constrictors were placed around the left circumflex in 15 pigs to induce an ischemic area. Two groups were randomized to receive either a sham operation or treatment with angiogenic implants inserted into myocardium in the distribution of the left circumflex artery (LCX). These implants are designed to induce myocardial angiogenesis. Magnetic resonance first pass perfusion imaging was performed at baseline and also after treatment with either sham or implant therapy by using first pass perfusion imaging with a TurboFLASH sequence. Absolute myocardial blood flow was derived by applying a quantitative Fermi function model. Radioactive microspheres were also injected into a random subset of animals to measure myocardial blood flow. RESULTS Angiogenic implant therapy increased absolute myocardial blood flow in the left circumflex territory relative to baseline and sham treated groups during adenosine infusion. Myocardial blood flows measured with radioactive microspheres was increased significantly in both the LCX and LAD territories during stress. Myocardial Perfusion reserve was also significantly increased in both the LCX and left anterior descending territories relative to baseline. Ejection Fraction during stress with dobutamine infusion increased significantly in the implant therapy group while that in the sham group was not affected. CONCLUSION Quantitative MR myocardial first pass perfusion imaging can be used to track the development of angiogenesis as corroborated by radioactive microspheres. Angiogenic implant therapy is a new device based therapy that has potential to protect an ischemic region by accelerating angiogenesis although further research is necessary with this device.
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Affiliation(s)
- Prasad Panse
- Health Science Center, University of Florida Jacksonville, Jacksonville, FL 32209, USA
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25
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Pettersson T, Bondesson S, Cojocaru D, Ohlsson O, Wackenfors A, Edvinsson L. One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation. BMC Cardiovasc Disord 2006; 6:28. [PMID: 16776842 PMCID: PMC1513599 DOI: 10.1186/1471-2261-6-28] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 06/15/2006] [Indexed: 11/19/2022] Open
Abstract
Background Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to be effective in reducing both angina and myocardial ischemia in patients not responding to medical therapy and without revascularization alternatives. The aim of the present study was to assess the long-term outcome of EECP treatment at a Scandinavian centre, in relieving angina in patients with chronic refractory angina pectoris. Methods 55 patients were treated with EECP. Canadian cardiovascular society (CCS) class, antianginal medication and adverse clinical events were collected prior to EECP, at the end of the treatment, and at six and 12 months after EECP treatment. Clinical signs and symptoms were recorded. Results EECP treatment significantly improved the CCS class in 79 ± 6% of the patients with chronic angina pectoris (p < 0.001). The reduction in CCS angina class was seen in patients with CCS class III and IV and persisted 12 months after EECP treatment. There was no significant relief in angina in patients with CCS class II prior to EECP treatment. 73 ± 7% of the patients with a reduction in CCS class after EECP treatment improved one CCS class, and 22 ± 7% of the patients improved two CCS classes. The improvement of two CCS classes could progress over a six months period and tended to be more prominent in patients with CCS class IV. In accordance with the reduction in CCS classes there was a significant decrease in the weekly nitroglycerin usage (p < 0.05). Conclusion The results from the present study show that EECP is a safe treatment for highly symptomatic patients with refractory angina. The beneficial effects were sustained during a 12-months follow-up period.
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Affiliation(s)
| | | | | | - Ola Ohlsson
- Department of Medicine, Kristianstad, Sweden
| | - Angelica Wackenfors
- Department of Emergency Medicine, Clinical Sciences Lund, Lund University, Sweden
| | - Lars Edvinsson
- Department of Emergency Medicine, Clinical Sciences Lund, Lund University, Sweden
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26
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Abstract
One of the first signs of ischemic heart disease may manifest as chronic stable angina, a mismatch between oxygen supply and demand. With more than approximately 16.5 million people each year having stable angina, development of new therapies to help control this disease state are warranted. Ranolazine, a novel agent exerting its effect through a partial fatty oxidase inhibitor, is one of the first new drugs in more than 20 years to be developed for chronic stable angina. Working through enzymatic modulation, instead of altering myocardial hemodynamics, ranolazine appears to be effective. An overview of chronic stable angina is provided, the American College of Cardiology-American Heart Association (ACC-AHA) current pharmacologic treatment guidelines are reviewed, and the mechanism of action of ranolazine is explored. Finally, the major clinical trials supporting its place in medical therapy are discussed. Additional clinical trials are under way to further elucidate ranolazine's exact role in the treatment of chronic stable angina. From results of the existing phase III clinical trials, however, the most beneficial potential role of ranolazine in the treatment algorithm of chronic stable angina appears to be as adjunctive therapy to the recommended ACC-AHA treatment modalities.
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Affiliation(s)
- Sarah M Gaffney
- Department of Pharmacy, Greenville Hospital System University Medical Center, 701 Grove Road, Greenville, SC 29605, USA
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27
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Abstract
Chronic refractory angina is a term used to describe patients who, despite optimal medical therapy, have both angina and objective evidence of ischaemia. It is estimated that 5-15% of the 12 million patients with chronic angina in the US meet the criteria for having refractory angina. This review focuses on the following evolving pharmacological therapies for chronic refractory angina: L-arginine, ivabradine, ranolazine, nicorandil and trimetazidine. Evolving devices and invasive procedures including enhanced external counterpulsation, spinal cord stimulation, and transmyocardial revascularisation are also briefly discussed.
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Affiliation(s)
- Eric H Yang
- Division of Cardiovascular Diseases and Internal Medicine, Mayo College of Medicine, Rochester, MN 55905, USA
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