Alejandro González Veliz: Can Increasing Venous Pressure Improve Myocardial Perfusion?
Alejandro González Veliz, Interventional Cardiologist at Institute of Cardiology and Cardiovascular Surgery, shared a post on LinkedIn:
“Can increasing venous pressure improve myocardial perfusion?
For years, the Coronary Sinus Reducer was considered one of the most innovative options for patients with refractory angina who had exhausted conventional revascularization strategies.
Early studies, particularly COSIRA, reported meaningful improvements in angina symptoms and quality of life.
The physiological rationale seemed compelling: increase coronary sinus pressure to redistribute blood flow toward ischemic subendocardial regions.
However, more recent evidence has challenged this paradigm.
ORBITA-COSMIC, a randomized, sham-controlled trial using quantitative cardiac MRI, failed to demonstrate significant improvements in myocardial perfusion, raising important questions about the device’s mechanism of action.
Likewise, a 2025 meta-analysis found that although the procedure appears safe, the magnitude of benefit is considerably smaller in randomized trials than in observational studies, underscoring the importance of placebo effects in angina research.
Today, the Coronary Sinus Reducer remains a Class IIb option for carefully selected patients with refractory angina who are not candidates for PCI or CABG.
The cardiology community now awaits the results of COSIRA-II, which may ultimately determine the device’s role in clinical practice.
Key message: Promising physiology does not always translate into meaningful clinical benefit – and only rigorous sham-controlled trials can reveal the true effect.”
Title: Efficacy of a Device to Narrow the Coronary Sinus in Refractory Angina
Authors: Stefan Verheye, E Marc Jolicœur, Miles W Behan, Thomas Pettersson, Paul Sainsbury, Jonathan Hill, Mathias Vrolix, Pierfrancesco Agostoni, Thomas Engstrom, Marino Labinaz, Ranil de Silva, Marc Schwartz, Nathalie Meyten, Neal G Uren, Serge Doucet, Jean-François Tanguay, Steven Lindsay, Timothy D Henry, Christopher J White, Elazer R Edelman, Shmuel Banai
Title: Coronary sinus reducer for the treatment of refractory angina (ORBITA-COSMIC): a randomised, placebo-controlled trial
Authors: Michael J Foley, Christopher A Rajkumar, Fiyyaz Ahmed-Jushuf, Florentina A Simader, Shayna Chotai, Rachel H Pathimagaraj, Muhammad Mohsin, Ahmed Salih, Danqi Wang, Prithvi Dixit, John R Davies, Tom R Keeble, Claudia Cosgrove, James C Spratt, Peter D O’Kane, Ranil De Silva, Jonathan M Hill, Sukhjinder S Nijjer, Sayan Sen, Ricardo Petraco, Ghada W Mikhail, Ramzi Khamis, Tushar Kotecha, Frank E Harrell, Peter Kellman, Darrel P Francis, James P Howard, Graham D Cole, Matthew J Shun-Shin, Rasha K Al-Lamee
Title: Safety, Efficacy, and Effectiveness of Coronary Sinus Reducer Implantation in Refractory Angina: A Meta-Analysis
Authors: Utkarsh Ojha, Muhammad Mohsin, Krzysztof Macierzanka, Fiyyaz Ahmed-Jushuf, Christopher A. Rajkumar, Shayna Chotai, Florentina A. Simader, Matthew J. Shun-Shin, Michael J. Foley, and Rasha K. Al-Lamee
Title: 2024 ESC Guidelines for the management of chronic coronary syndromes: Developed by the task force for the management of chronic coronary syndromes of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS)
Authors: Christiaan Vrints, Felicita Andreotti, Konstantinos C Koskinas, Xavier Rossello, Marianna Adamo, James Ainslie, Adrian Paul Banning, Andrzej Budaj, Ronny R Buechel, Giovanni Alfonso Chiariello, Alaide Chieffo, Ruxandra Maria Christodorescu, Christi Deaton, Torsten Doenst, Hywel W Jones, Vijay Kunadian, Julinda Mehilli, Milan Milojevic, Jan J Piek, Francesca Pugliese, Andrea Rubboli, Anne Grete Semb, Roxy Senior, Jurrien M ten Berg, Eric Van Belle, Emeline M Van Craenenbroeck, Rafael Vidal-Perez, Simon Winther
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