DS 22/01/1983

We describe a case of a 38 y male with diabetes and effort angina (CCS 3) that was recovered immediately after severely positive exercise test (Fig.1.a-b.). His echocardiography shoed no wall motion abnormalities and normal ejection fraction (Fig.1.b-c.). Angiography shoed severe ostial left main stenosis (Fig.2.) that was treated with provisional LM-LAD stenting with good angiographic (Fig.3.a-b) and IVUS (Fig.3.c.) result. After 3 months he came back to us for persistence of effort angina.

The patient was hypotensive and with bad compliance to the medical therapy, so there was no more option for optimization of the medical treatment. Echocardiography was again normal. We performed the same type of exercise test that was interrupted at 6^th minute for chest pain with doubtful changes in the ECG. The patient had optimal lipids level but still desired optimization of blood sugar (Fig.4). He was recovered for coronary angiography.

Angiography shoed good result of LM stent (Fig.5.a-b) with normal instantaneous free wave ratio (iFR) on LAD iFR = 0,99 and LCx iFR = 0,98 (Fig. c-d), but pathologic values on small (<1,5 mm) diffusely diseased RI iFR = 0,89 and marginal branches (OM iFR = 0,88) (Fig.5.e-f); both not amenable for angioplasty. As there were no interventional or medical options, the only way to improve his quality of life according to us was implantation of Reducer system in his coronary venous sinus.

Thus, the next day after adequate hydratation to increase the venous pressure through the right jugular vein we cannulated his coronary sinus and using the child in mother technique we were able to implant successfully Neovasc coronary reducer system (Fig.6). The procedure was free of complications. The patient was discharged asymptomatic and in optimal medical therapy. At third month the patient was completely asymptomatic. His exercise stress test with duration of 7 minutes was negative for clinical end ECG criteria and also his echo stress with dobutamine was completely negative and at his clinical labs he was in optimal lipid ad glucose control (Fig. 7).

This case, together with our experience in the implantation of the Reducer system, confirms the clinical benefit of reducing coronary venous flow in patients with refractory angina and without options for percutaneous intervention or further modification of drug therapy.