Coronary Venous Interventions

Abstract

C oronary revascularization can salvage ischemic myocardium, relieve symptoms, and prolong life in patients with high-risk acute coronary syndrome and in patients with severe coronary artery disease. It is no wonder that coronary artery bypass surgery and percutaneous coronary interventions (PCI) were preformed on nearly 900 000 patients in the United States in 2010.1 Despite the advances with both revascularization techniques, there are many situations where improvement is still needed. For instance, myocardial salvage in ST-segmentelevation myocardial infarction with primary PCI averages only 40% to 50% of the area at risk despite timely reperfusion and many patients with multivessel disease continue to have severe angina and ischemia because of anatomy that is not amenable to revascularization. As many as 7% or 1.8 million individuals are estimated to be unrevascularizable and the treatment options for these patients are limited and often unsuccessful.2,3 Recently, several articles have been published suggesting that retrograde perfusion via the coronary sinus may have promise as a treatment option for these patients.In a study by Verheye et al, 4 104 patients with severe angina who were not candidates for revascularization were randomized to partial coronary venous occlusion accomplished by placement of an hourglass stent in the coronary sinus or to a sham operation. The stent partially obstructs the coronary sinus leading to increased retrograde flow into the ischemic territory. At 6 months, angina and quality-of-life measures were significantly improved during exercise time and wall motion index during dobutamine stress imaging were not. The study demonstrated feasibility and safety accompanied by symptomatic improvement but it failed to show improvement on functional testing. Given the small size of the study, major adverse clinical outcomes were infrequent.In a small pilot study, van de Hoef et al 5 showed that in 15 patients with stable angina undergoing PCI of the left anterior descending artery (LAD), intermittent occlusion of the coronary sinus with a balloon catheter (pressure-controlled intermittent coronary sinus occlusion [PICSO]) was safe. The goal of this technique is to increase coronary sinus pressure to its maximum with balloon occlusion and then to allow complete washout after deflation. During PCI, PICSO increased distal LAD coronary wedge pressure and reduced ST segment changes consistent with reduction in acute ischemia. In an initial feasibility study by the same authors, 30 patients with anterior ST-segment-elevation myocardial infarction undergoing primary PCI were studied with PICSO. 6 Only 19 had successful PICSO for 90 minutes and 1 patient developed tamponade. When compared with historical patients, magnetic resonance imaging infarct size was not significantly different between PICSO and controls but in those with high quality PICSO, late improvement in infarct size was seen. Further studies are planned to validate these preliminary findings.The rationale for considering coronary ...

Signs and signals limiting myocardial damage using PICSO: a scoping review decoding paradigm shifts toward a new encounter

“…In agreement with these clinical observations are additional molecular consequences in porcine hearts subjected to experimental myocardial infarction and PICSO complementing this narrative ( 18 ). Reinitiating scientific interest, especially in the primary mechanism of PICSO, expanded the potential therapy for patients with heart failure ( 19 – 23 ). Consequently, a significant improvement in cardiac function in patients after open-heart surgery with acute failing hearts highlights the PICSO therapy in the most challenging situation of cardiogenic shock ( 24 ).…”