Sneaking in through the back door

Over recent decades, the numerous coronary revascularisation procedures performed either by percutaneous coronary intervention (PCI), or coronary bypass surgery has led to an increasing number of patients who are no longer eligible for additional revascularisation procedures. This number of patients is expected to rise even further in view of an increase in life expectancy in patients with coronary artery disease. In a recent issue of the Netherlands Heart Journal, the investigators from the University Medical Center Utrecht report interesting findings on the use of a coronary sinus device in patients with refractory angina in whom there were no options for conventional revascularisation procedures [1]. This device is a balloon expandable stainless steel stent that creates a focal stenosis in the coronary sinus leading to an increase in coronary venous pressure. The principle of improving myocardial perfusion by elevating coronary venous pressure was introduced as early as 1954 when the coronary sinus was partially ligated in patients with angina pectoris [2]. The publication of the COSIRA trial has rekindled interest in the principle of enhancing coronary venous pressure for relief of angina by means of a stent implantation. This prospective multicentre double-blind sham-controlled trial evaluated coronary sinus stent implantation in patients with refractory angina and demonstrated both symptomatic improvement and an improvement in quality of life over a six-month follow-up period [3]. The study from Abawi et al. [1] evaluated the same coronary sinus stent device as in the COSIRA trial. It is