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Creating myocardial venous congestion to relieve refractory angina !

Posted Mar 22 2011 10:56am

When LV fails the  lung gets congested and flooded with blood . Similarly when coronary sinus  ,  the major draining outlet of coronary  circulation resists  the incoming blood  flow . . .  myocardium  will  get congested !

This is  the concept  of  retrograde perfusion  in treating refractory CAD with angina . It is a double-edged concept. If the coronary  sinus  pressure is  excessive it may interrupt even  the normal  flow .It should be optimal so that it prolongs coronary micro-circulation time without compromising ante-grade flow. .

Picture courtesy : http://www.dartmouth.edu

Clinical example

We know cardiac failure patients rarely complain of  angina .

Why ? . . The myocardial congestion due to coronary sinus pressure is the most likely explanation.This goes well with the back flow concept in treating refractory angina.

While surgeons tried to link artery to vein  , Interventional cardiologists were smart enough to occlude the coronary sinus partially , that will result in stasis of blood in coronary micro-circulation and hence facilitates oxygen extraction .

Final message

God is a master craftsman. Do not think  there is only  one access to coronary micro circulation.Apart form LCA and RCA there is  a vast network of coronary  veins  traversing  the delicate surfaces and grooves of the heart .

Remember ,they also reach the same micro vascular  bed but in a different direction !

If we  can exploit  them  for myocardial arterial  perfusion we have a real breakthrough   in our hands. . After all , why should we take a vein  from a far way from legs (saphenous veins )  for by-pass surgery  when venous channels are  simply there beside  every branch of a  coronary  artery !

Let us be quixotic , we shall attempt to   congest the myocardium with blood for refractory angina by whatever means ! Mean while let us also remember  what happened to  TMR (Trans myocardial laser  revascularisation ) the biggest technology failure in cardiology in recent times !

Reference


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