The number of patients with refractory angina without revascularization options is increasing. The prognosis and the quality of life in these patients is poor and maximal medical therapy is not enough for symptoms relieve. 

64-years-old male patient with coronary artery disease debuted in 2002 with an anterior ST-elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention (PCI) on medial left anterior descending artery (LAD) with implantation of a Bare Metal Stent (BMS).

In 2004, for the evidence of the stenosis of the bicuspid aortic valve and an ascending aorta aneurysm, substitution of the aortic valve and the ascending aorta with a mechanical valve attached to a Dacron tube graft (St. Jude 25mm + 28 mm) was performed.

In 2011, for new evidence of stress angina, PCI with a drug eluting stent (DES) implantation of the proximal RCA was performed.

In 2013, for stress angina recurrence, a myocardial single-photon emission computed tomography (SPECT) with pharmacological stress (Dipyridamole) was performed, with the evidence of modest inducible ischemia in inferior cardiac wall (SRS 3, SSS 9, SDS 6), without CAD progression at the coronary angiography.

For this reason, in 2014, we decided to treat the patient with shockwaves therapy.

We locate the area to treat by documenting inducible ischemia at the stress myocardial SPECT. The ESMR were applicated with a commercially available cardiac shock wave generator system (Cardiospect TM, Medispec, Germantown, MD) under echocardiographic guidance (Figure 1.A and B): through a cardiac ultrasound imaging system, we look at this area and these measurements are calibrated into the shockwave applicator head to ensure the position of the focal treatment zone, so using an electrocardiographic R-wave gating, shockwaves are delivered through the applicator to the sub-endocardial myocardium of the ischemic area. We applied a low energy of shockwaves (0.09 mJ/mm2, ≈10% of the energy for the lithotripsy treatment).

Figure 1. The methodology of cardiac shock wave therapy.A. Shock wave generator system (Medispec, Germantown, MD, USA).
B. Shock wave focal zone alignment: Position of the sub-segment on the 2-dimensional image determined by X and Y coordinates. The shockwave applicator position is identically adjusted along. X- and Y-axes corresponding to the X and Y coordinates of the ultrasound image

The ischemic area was divided into 3 zones, corresponding to the three sessions of treatments. The treatment was divided into three sessions with 3 treatments for week every 4 weeks. 100 pulses gated by R wave trigger was performed for each target spotted (up to a total of 1000 pulses) at each individual session. Each session lasted about 20 minutes. During the treatment, symptoms and vital signs were continuously monitored.

 A regular echocardiographic follow-up was performed, without evidence of malfunction or complications about the mechanical prosthetic aortic valve and tube:

In 2013, before ESMR therapy, prosthetic valve had a normal function and position, pressure gradient (PG) was 13/6 mmHg, Aortic Valve Area (AVA) measured by Velocity Time integral (VTi) was 2.3 cm2 and Doppler Velocity index (DVi) was 0.56. Prosthetic tub was regular without dehiscence.

-In 2014 prosthetic valve had a normal function and position, PG was 15/8 mmHg, V max was 2 m/sec and DVi was 0.30. Prosthetic tub was regular without dehiscence (Figure 2).

Figure 2. Echocardiography performed in 2014, before ESMR.
 

Last echocardiographic study was performed in January 2018 and showed a prosthetic valve with a normal function and position, PG was 12/8 mmHg, V max was 1.7 m/sec. Prosthetic tub was regular without dehiscence (Figure 3).

Figure 3. Echocardiography performed in 2018, three years after ESMR.

The number of patients with refractory angina without revascularization options is increasing. The prognosis and the quality of life in these patients is poor and maximal medical therapy is not enough for symptoms relieve. 

According to the last American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of chronic stable angina, the objective of the treatment should be the resolution of angina attacks, the reduction of the numbers of hospitalizations and the carrying out of normal daily activities without symptoms [1-6].

Extracorporeal Shockwave Myocardial Revascularization therapy (ESMR) is a non-invasive treatment and several studies have demonstrated its safety and its efficacy in patients with refractory angina (RA) to improve myocardial perfusion and exercise capacity reducing symptoms by the application shockwaves (SW) on the culprit ischemic area of the heart under echocardiographic guidance [7-26]. Shockwaves consist of low-intensive acoustic energy artificially generated by discharging of a high voltage spark under water by a generator designed to address the clinical anatomical requirements of the chest cavity. Several treatment sessions are required. The aim of this treatment is former to induce vasodilatation and latter to induce neovascularization from the healthy area to the ischemic area [27-37].

But, actually, there are no data about the safety of ESMR in patients with a mechanical prosthetic valve.

We would report about a 64-year-old man with coronary artery disease (CAD) and refractory angina pectoris despite maximally tolerated medical therapy and after percutaneous coronary intervention (PCI) and with a prosthetic aortic valve and aortic tube.

The patient received extracorporeal shockwave myocardial revascularization therapy without any complication during or after treatment.

We locate the area to treat by documenting inducible ischemia at the stress myocardial SPECT. The ESMR were applicated with a commercially available cardiac shock wave generator system (Cardiospect TM, Medispec, Germantown, MD) under echocardiographic guidance (Figure 1.A and B): through a cardiac ultrasound imaging system, we look at this area and these measurements are calibrated into the shockwave applicator head to ensure the position of the focal treatment zone, so using an electrocardiographic R-wave gating, shockwaves are delivered through the applicator to the sub-endocardial myocardium of the ischemic area. We applied a low energy of shockwaves (0.09 mJ/mm2, ≈10% of the energy for the lithotripsy treatment).

In conclusion, we treated by ESMR a patient with refractory angina and with mechanical prosthetic aortic valve and tube, without any sign of complication or malfunction of the cardiac device in acute or in further years.