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Angina and left ventricular dysfunction: can we 'reduce' it?
Simone Biscaglia1, Matteo Tebaldi1, Donato Mele1
1Department of Medical Sciences Ferrara University, Ferrara, Italy.
Insights
Refractory angina, a persistent issue despite medical and device advancements, can be effectively managed with coronary sinus Reducer implantation. This innovative treatment offers significant symptom relief for patients with difficult-to-treat angina.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Recurrent and persistent angina remains a significant clinical challenge despite advances in pharmacology and interventional cardiology.
- Existing treatments, including beta-blockers and ivabradine, may not fully resolve symptoms in all patients, leading to refractory angina.
- A history of complex cardiac interventions, including aortic valve replacement and percutaneous coronary intervention (PCI), can complicate angina management.
Purpose of the Study:
- To evaluate the efficacy of coronary sinus Reducer implantation in a patient with refractory angina following multiple cardiac interventions.
- To assess the impact of the Reducer device on Canadian Cardiovascular Society (CCS) angina class and overall symptom burden.
Main Methods:
- A case report detailing the treatment of a 69-year-old female patient with a history of severe aortic stenosis, bioprosthetic valve degeneration, and coronary artery disease.
- The patient underwent aortic valve-in-valve implantation and PCI for in-stent restenosis, but continued to experience refractory angina.
- A coronary sinus Reducer device was implanted to address persistent angina symptoms.
Main Results:
- Following Reducer implantation, the patient experienced a gradual improvement in angina symptoms.
- The patient became angina-free within two months of the procedure, indicating successful symptom management.
- This outcome suggests the potential of the coronary sinus Reducer as a therapeutic option for refractory angina.
Conclusions:
- Coronary sinus Reducer implantation can provide significant relief for patients suffering from refractory angina, even after extensive prior treatments.
- The COSIRA trial findings support the use of the coronary sinus Reducer as a valuable addition to the therapeutic armamentarium for angina management.
- This case highlights the potential of novel device-based therapies in addressing unmet needs in cardiovascular symptom control.
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.