Unusual Implantation of a Coronary Sinus Reducer in the Middle Cardiac Vein

J INVASIVE CARDIOL 2018;30(8):E69-E70.

Key words: cardiac imaging, coronary sinus reducer

A 75-year-old man with history of coronary artery bypass graft surgery, multiple percutaneous coronary interventions, and failed recanalization of an in-stent chronic total occlusion of the circumflex artery (Figures 1A and 1B) was referred to our department for refractory Canadian Cardiovascular Society (CCS) class IV angina, despite optimal medical therapy. Coronary sinus (CS) reducer implantation seemed the optimal therapeutic option. Preprocedural venography of the CS showed an unusual anatomy with a small CS (Figure 1C) and a large middle cardiac vein (MCV) (Figure 1D), suitable for CS reducer implantation. Stress echocardiography with dipyridamole was positive early after 1 minute of drug infusion (total dose, 0.84 mg/kg in 6 minutes) in the inferolateral wall, consistently with the MCV drainage. Implantation of the CS reducer in an atypical position was planned. After engagement of the CS and wiring of the MCV, the delivery was advanced to the proximal tract, then the CS reducer was released at the desired site (Figure 1E). Postimplantation angiography ensured appropriate implantation and reduction of the lumen’s diameter and excluded perforation or dissection of the MCV (Figure 1F). At 3-month follow-up the patient reported a definite improvement of symptoms (CCS class II). Similarly, dipyridamole stress echocardiography was markedly improved, as it turned positive only after the full dose of dipyridamole.

In this patient, the apparently unfavorable CS anatomy seemed to preclude CS reducer implantation; nevertheless, we decided to implant the CS reducer in the atypical site of MCV, which was of a suitable size for device implantation. The finding of inducible ischemia in the inferolateral wall consistently with the MCV drainage provided the rationale to implant the device in this atypical position. 

To our knowledge, this is the first such case and it could be speculated that in patients with small or unfavorable CS anatomies, implantation of a CS reducer in atypical sites might still be considered, if the target vein is of appropriate size and provides the venous drainage of the ischemic territory responsible for the patient’s symptoms.

From the ¹Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato, Italy; and ²Department of Interventional Cardiology, IRCCS San Raffaele hospital, Milan, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted March 22, 2018. 

Address for correspondence: Riccardo Gorla, MD, PhD, Department of Cardiology and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy. Email: r.gorla@hotmail.it