Coronary Sinus Reduction for the Treatment of Refractory Angina: What Have We Learned after 70 Years of the Beck Surgery?

With the increasing prevalence of chronic coronary syndromes, many patients with extensive atherosclerosis experience uncontrolled angina, even while receiving optimal medical therapy. This is especially true for patients who are not suitable candidates for surgical or percutaneous revascularization. Numerous treatments have been investigated for managing angina pectoris, and in this context, the coronary sinus reducer has emerged as a promising therapeutic option. Since the 1950s, beginning with Beck's surgery, the coronary venous sinus has been a focal point of research in anti-ischemic therapies. Significant scientific advances have been made in narrowing the venous sinus in the past two decades. Thanks to technological improvements in minimally invasive procedures and better methods for assessing myocardial blood flow, a new therapeutic option has become available for patients suffering from refractory angina and, possibly, for microvascular dysfunction. In this review, we aim to examine key concepts related to angina pectoris and myocardial ischemia, highlighting the historical background, pathophysiological rationale, and technical aspects of coronary sinus reduction as a therapy for refractory angina. Additionally, we will explore the scientific evidence from recent decades, as well as identify existing gaps and outline future research directions concerning this emerging treatment.