Myocardial infarction remains a leading cause of morbidity and mortality. Restoration of coronary blood flow by percutaneous coronary intervention (PCI) is lifesaving but may trigger ischaemia-reperfusion arrhythmias (IRA). In previous experimental and computational studies, we identified a new mechanism of IRA-perivascular excitation tunnelling (PVET) — arising along the main branch of the reperfused vessel, where myocardial excitability recovers first. A “two-step reperfusion” strategy, in which distal tissue is reperfused before proximal regions, effectively prevented re-entrant arrhythmias in rabbit and pig hearts.
To translate these findings toward clinical relevance, we developed SHIELD-EP, a novel catheter-based approach designed to mitigate PVET-associated arrhythmias during reperfusion. In ex vivo Langendorff-perfused pig hearts, we combined selective coronary perfusion with optical mapping to characterise excitation recovery patterns under different reperfusion strategies. When the entire ischaemic zone was reperfused at once (“1-step”), PVET occurred in 11/12 hearts, producing re-entrant arrhythmias in 7 cases. By contrast, in the “2-step” protocol, PVET occurred in 4/6 hearts, but no re-entrant arrhythmias were observed, supporting the concept that temporally and spatially staggered reperfusion can electrically shield the myocardium.
Building on this principle, we have filed a European patent (EP4218625A1 & EP4501387A1) for a dual-balloon / dual-irrigation-zone catheter that enables simultaneous reperfusion of distal and proximal coronary territories with independently controlled perfusates. The distal balloon delivers oxygenated physiological solution to accelerate recovery of distal tissue excitability, while the proximal balloon maintains transient oxygenated cardioplegia to prevent premature re-entry formation. We are currently manufacturing and testing these dual-balloon, dual-irrigation catheters in collaboration with OSYPKA AG in an ex vivo Langendorff-perfused pig heart model. This work aims to optimise zone sizes, flow rates, and timing parameters to balance rapid metabolic recovery with electrical stability during reperfusion.
By reconciling the competing goals of fast re-oxygenation and arrhythmia prevention, SHIELD-EP provides a mechanistic and translational pathway to improve safety during PCI. Considering that approximately 300,000 PCI procedures are performed annually in Germany, with IRA incidence reported between 5–23%, the potential clinical impact is substantial—up to 70,000 patients per year could benefit from arrhythmia-preventive reperfusion protocols.
Future work will integrate computational modelling with advanced imaging to refine dual-zone perfusion strategies and enable risk stratification for PVET susceptibility. These efforts aim to bridge experimental electrophysiology and interventional cardiology, ultimately improving outcomes after myocardial infarction.
