Safety of Extracorporeal Shockwave Myocardial Revascularization (ESMR) in Patient with a Mechanical Prosthetic Valve.

Safety of Extracorporeal Shockwave Myocardial Revascularization (ESMR) in Patient with a Mechanical Prosthetic Valve: A Case Report. Gianluca Alunni 1*, Salvatore D'amico 1, Dario Celentani1, Carlo Alberto Biolè 1, Alessandro Andreis1, Mauro Rinaldi Prof1, Marra Sebastiano2 1Department of Cardiology, City of Health and Science of Turin, Turin, Italy 2Villa Maria Hospital, Turin, Italy. *Corresponding Author: Gianluca Alunni, City of Health and Science, 10100 Turin, Italy. Tel: +390116335945 Email: a.gianluca1@virgilio.it Received date: July 13, 2018; Accepted date: Augest 03, 2018; Published date: August 08, 2018. Citation this Article: Gianluca Alunni , Salvatore D'amico , Dario Celentani, Carlo Alberto Biolè , Alessandro Andreis , Marra Sebastiano, Mauro Rinaldi. (2018) Safety of Extracorporeal shockwave myocardial revascularization (ESMR) in patient with a mechanical prosthetic valve: a case report. J Clinical Cardiology and Cardiovascular Interventions. Doi:10.31579/2641-0419/009 Copyright: ©2018. Gianluca Alunni. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction and highlights
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][2][3][4][5][6].
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.

Case presentation
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.

ESMR protocol
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/mm 2 , ≈10% of the energy for the lithotripsy treatment).
A B 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 Yaxes 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.

Echocardiographic prosthesis control
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 cm 2 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). 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).

Conclusion
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. The Author(s) declare(s) that there is no conflict of interest.