Coronary Sinus Interventions: From Concept to Clinics

Abstract

For almost 100 years the coronary venous system has attracted researchers as an access route to deprived myocardium. Different concepts have been tried and numerous experimental studies have been performed to evaluate whether coronary sinus occlusion, retroinfusion, and retroperfusion of arterial blood via the coronary sinus represent an effective treatment of myocardial ischemia. The early successful studies of Drs. Gregg, Eckstein, Beck and others led to the application of the Beck II procedure, a permanent retroperfusion technique used in the early 1950s to revascularize patients with diffuse atherosclerosis. The coronary sinus route was also used to retroperfuse blood intraoperatively during opening of the heart to keep the heart beating. Excessive mortality and severe side effects, such as myocardial edema and hemorrhage, and an insufficiently advanced technology resulted in the temporary demise of the coronary sinus approaches. Recently, however, the need to improve myocardial protection, despite enormous advances in coronary bypass surgery and interventional cardiology, has resulted in renewed interest in the coronary sinus as an access route to deprived myocardium. Advances in technology such as percutaneous catheter techniques have improved access to the coronary venous system and allowed for a physiological adaptation of coronary sinus retroperfusion techniques. Today the three major coronary sinus techniques, i.e., sychronized retroperfusion (SRP), retroinfusion of cardioplegia during cardiac arrest and retroinfusion of pharmaceutical agents in the normal working heart, and pressure-controlled intermittent coronary sinus occlusion (PICSO) have been documented as providing superior protection of jeopardized myocardium in selected subsets of patients. All of these techniques currently are under clinical consideration; the retroinfusion of cardioplegia has already found wide clinical acceptance, SRP and PICSO have only recently been tested in first clinical trials. Due to a vast resurgence in interest, it is desirable to survey the results obtained with each of these techniques, to discuss the pathophysiology and mode of action of coronary sinus interventions, and to assign them a place in the perspective of conventional therapies. Furthermore, an attempt will be made to weigh individual coronary sinus techniques against each other, discuss in which clinical settings each of them may be most effective, and define issues facing current development.

Synchronized Retroperfusion Combined With Coronary Sinus Occlusion: Experimental Measurements Compared With Simulation Results and Model Predictions

“…(2)) fitted to the envelopes of venous pressure is designed such that a plateau is reached assymptotically for sufficiently long coronary sinus occlusion times (Schreiner et al, 1987). The height of the plateau can be calculated analytically from the regression coefficients of the fitted function: Downloaded by [University of Arizona] at 07:12 03 February 2015 It has been suggested that the height of the plateau of coronary venous pressure is the essential parameter that provides the hemodynamic impetus for retrograde flow and upon which the automatic control of coronary sinus interventions could be based (Mohl, 1987(Mohl, , 1988. In light of its importance, Fig.…”

Reconsidering the back door approach by targeting the coronary sinus in ischaemic heart disease

“…Three main categories of CSI have been described and adopted over the last century: retroperfusion, retroinfusion and coronary sinus occlusion2 (figure 1). Retroperfusion technique aimed to provide arterialised blood to the ischaemic myocardium via the coronary vein system 2.…”

“…Retroperfusion technique aimed to provide arterialised blood to the ischaemic myocardium via the coronary vein system 2. Retroinfusion technique aimed to deliver drugs to the myocardium essentially for cardioprotection, by a retrograde approach involving the access to the coronary sinus 2.…”

“…Retroperfusion technique aimed to provide arterialised blood to the ischaemic myocardium via the coronary vein system 2. Retroinfusion technique aimed to deliver drugs to the myocardium essentially for cardioprotection, by a retrograde approach involving the access to the coronary sinus 2. Coronary sinus occlusion techniques aimed to support myocardium perfusion without active infusion of arterialised blood or drugs, but essentially slowing down the outflow of arterialised blood from the heart, obeying the principle ‘if you cannot increase coronary input, let's decrease its output’ 2.…”

“…Retroinfusion technique aimed to deliver drugs to the myocardium essentially for cardioprotection, by a retrograde approach involving the access to the coronary sinus 2. Coronary sinus occlusion techniques aimed to support myocardium perfusion without active infusion of arterialised blood or drugs, but essentially slowing down the outflow of arterialised blood from the heart, obeying the principle ‘if you cannot increase coronary input, let's decrease its output’ 2. Coronary sinus occlusion techniques can be categorised as balloon-based or ‘temporary coronary sinus occlusion techniques’ and non-balloon-based or ‘permanent coronary sinus occlusion techniques’.…”