The document discusses a case of refractory angina in a 56-year-old female patient unresponsive to maximal medical therapy, highlighting the challenges in managing her severe symptoms despite comprehensive treatments. It introduces the cs-reducer device as a potential novel approach for symptom relief and quality of life improvement in patients with end-stage angina not amenable to conventional therapies. The summary emphasizes the importance of balancing treatment benefits and risks while addressing refractory angina's debilitating nature.

1. REFRACTORY ANGINA…
NOVEL APPROACH ….
FOR BETTER QUALITY OF LIFE
AHMED T. ABDELWAHED, MD, EHRA-C
HEART CENTER, DEPARTMENT OF CARDIOLOGY, TAMPERE UNIVERSITY HOSPITAL, AND SCHOOL
OF MEDICINE,
UNIVERSITY OF TAMPERE, FINLAND;
DEPARTMENT OF CARDIOLOGY, FACULTY OF MEDICINE,
ZAGAZIG UNIVERSITY, EGYPT

2. REFRACTORY ANGINA
Novel therapeutic approach

3. HISTORY
• Female patient 56 y old , known DM, HTN chronic IHD with
previous CABG 10 y ago.
• presented by refractory angina CCS class III-IV in the last 2
years with on and off symptoms.
• Patient is receiving maximal intensive medical therapy trying
to control her refractory anginal pain.
• Including NICORANDIL, nitrates, BB, ivabradine, DAPT.
• Controlled her BP and Diabetic status.
• In the last 1 year, her anginal pain is intractable with multiple
hospitalization.

4. IMAGING
• CT-angiography :
chronically totally occluded both saphenous venous
grafts to OM1, and RCA.
Chronic Totally occluded RCA and LCX.
Patent LIMA to LAD.
Trial of Coronary intervention to the CTO
failed to open the vessels.

5. ECG
No dynamic ECG changes

6. ECHOCARDIOGRAPGHY
Normal LV dimensions and
preserved systolic function

8. RV FUNCTION PRESERVED

9. REFRACTOR ANGINA
Clinical condition characterized by the presence of:
1-long-lasting symptoms (≥3 months) due to objectively reversible
ischemia “evidence of ischemia as demonstrated by exercise treadmill
testing, stress imaging studies or coronary physiologic studies”
2-unmanageable by optimal medical therapy and surgical or percutaneous
revascularization,
3-including percutaneous coronary intervention (PCI) of chronic total
occlusions
--------------
Patients with refractory angina have either marked limitation of ordinary
physical activity or are unable to perform any ordinary physical activity
without discomfort (Canadian Cardiovascular Society [CCS] functional class
III or IV).
Knuuti J, et al, 2019Eur Heart J.
2020;14;41(3):407–77

10. Refractory angina pectoris according to Age distribution
Gowdak L, Heart Metab. 2017;72:4-

11. MANAGEMENT APPROACH
CS-reducer
device

13. CS-REDUCER
DEVICE

15. DEVICE
IMPLANTATIO
N
STEP BY STEP
NEW TECHNIQUE
NEW APPROACH

16. CS cannulation using Quadricapolar EP catheter

17. Exchange the EP catheter by CS 9 fr. Sheath

18. CS contrast to measure the size and optimize the position of the device

20. Inserting the CS reducer device through the sheath

21. Unsheathing and optimizing the position of the device

22. Device implantation by balloon inflation @ 2.5 atm for 1 minute
Special setting of the contrast used in balloon inflation 20% contrast

23. Confirming the optimal sealing of the device during full inflation

24. Full maximal deflation of the balloon using the sheath for stability

25. Confirming optimal position and sealing of the device post implantation

27. Post implantation in LAO and RAO view
LAO RAO

28. FOLLOW UP
Echocardiography

29. Apical 4 chamber view

30. TAKE HOME MESSAGE
• End-stage angina pectoris refractory to conventional medical therapy and not
amenable to either CABG or PCI medical therapy represents a truly desperate and
frustrating condition.
• There is no suggestion that any of the alternative treatments for refractory angina may
improve prognosis.
• The choice of treatment should be mainly based on a careful assessment of the
balance between the benefits for the disabling symptoms of patients and the risk
associated with the different treatment options.
• CS-reducer device may be a novel approach for reduction of symptoms and improve
the quality of life.
• CS-reducer device provides new approach for neovascularization and redistribution of
capillary circulation system especially subendocardial.

32. THANK YOU