angiogenesis in the heart. While these initial efforts were promising, more convincing results have emerged recently by using the patient’s own stem cells, injected directly into the heart, to stimulate the growth of collateral vessels, bypassing the diseased segment of the heart and increasing its blood supply. Unfortunately, much of the media coverage regarding stem cells has focused on ethical and political concerns related to use of embryonic stem cells. In the meantime, cardiology research with adult stem cells has progressed dramatically, using both autologous (patient’s own cells) and allogeneic (cells from young, healthy donors) stem cells. Nearly 300 patients have been treated at the Minneapolis Heart Institute at Abbott Northwestern (one of five National Institutes of Healthsupported Cardiovascular Stem Cell Centers) using a wide variety of cells and methods of delivery for refractory angina, acute myocardial infarction, CHF, and peripheral arterial disease. In particular, the use of CD 34+ stem cells in patients with refractory angina have yielded very positive results. In a double-blind, placebocontrolled trial published in Circulation Research (August 2011), patients treated with CD 34+ stem cells had an improvement of more than two minutes in the time they were able to spend exercising on a treadmill, and had nearly 15 fewer episodes of chest pain a week. These positive results were sustained for at least two years. Based on these promising results, several new clinical trials are under way to illuminate the best approach for stem cell therapy in these challenging patients. Neurostimulation
Spinal cord stimulation (SCS) uses a percutaneously implanted electrical stimulator to deliver mild electrical signals to the
Improving symptoms, quality of life
FIGURE 1: Mechanism of action of enhanced external counterpulsation (EECP). (With permission from www.iprogressivemed.com/therapies/eecp.html)
area of the spinal cord that corresponds to the location of a patient’s angina. By modulating the pain pathways in the spinal cord, SCS can improve control of the pain symptoms, including angina. With this therapy, patients have fewer episodes of angina pectoris, as well as improved blood flow. It is believed that through modulation of the neural pathways, the autonomic trafficking of the heart will shift in favor of reducing the myocardial oxygen consumption. This approach has been successfully tested in patients with refractory angina. Currently, it is an approved therapy in these patients in Europe.
from nonischemic to ischemic territories. The coronary sinus occluder is a percutaneous implantable device designed to establish coronary sinus narrowing and to elevate coronary sinus pressure. The results of small, randomized, open-label trials are promising, and a larger phase II trial is underway.
In summary, patients are living longer despite severe blockages in their coronary arteries. Despite their high risk and complex heart disease, only about 3 percent of OPTIMIST patients die per year— a rate similar to agematched patients without heart disease. Therefore, the major focus is to improve the patient’s symptoms and quality of life. Fortunately, the number of options for “no-option” patients is growing and provides renewed hope for patients with severe CAD. Mohammad Sarraf, MD, is a cardiology fellow at the University of Minnesota, Minneapolis; Rachel E. Olson, RN, and Theresa L. Arndt, RN, are staff at the Minneapolis Heart Institute Foundation, Minneapolis; and Jay H. Traverse, MD, and Timothy D. Henry, MD, are staff at the Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis.
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Transmyocardial revascularization (TMR)
TMR is a surgical technique that creates tiny channels in the myocardium with a specialized laser. The idea is that formation of small channels may stimulate angiogenesis and also decrease the sensation of pain from the nerve endings of the heart. Although TMR has been approved by the FDA both alone and in conjunction with CABG, the complexity of patient selection has limited its widespread use. Recently we began using minimally invasive TMR delivered robotically.
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OFFICE - MEDICAL
Coronary sinus occluder
Increased coronary sinus pressure can reduce myocardial ischemia by redistributing blood
R.A. (Rob) Kost, CCIM Vice President of Commercial 612-604-0869 Direct Dial rkost@sherman-associates.com FEBRUARY 2012
MINNESOTA PHYSICIAN
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