# Extension of interval between adjacent pulse delivery cycles to deal with myocardial ischemia by intravascular lithotripsy: case report

## TL;DR

A case report shows that extending the pulse delivery interval during intravascular lithotripsy can help manage myocardial ischemia in a patient with coronary calcification.

## Contribution

This case introduces extending pulse emission intervals as a novel strategy to mitigate myocardial ischemia during intravascular lithotripsy.

## Key findings

- Extending the pulse emission interval to 30 seconds eliminated chest pain and ST-segment changes in the patient.
- Intravascular ultrasound confirmed successful calcification rupture after adjusting the pulse delivery interval.
- Suspending pulse delivery may improve myocardial blood supply in certain clinical scenarios.

## Abstract

Intravascular lithotripsy (IVL) represents a novel approach in the management of coronary calcification. This technique employs acoustic pressure waves, generated by a shockwave balloon, to effectively fracture both superficial and deep calcification in situ. The efficacy and safety of IVL have been convincingly demonstrated through the Disrupt CAD I-IV studies. While IVL is associated with the occurrence of atrial and ventricular arrhythmias, there is no evidence to indicate it causes myocardial ischemia.

A 71-year-old man was admitted presenting with chest pain. His previous coronary angiography revealed stenosis and calcification in the left anterior descending branch. An attempt to predilate the lesion using two Lacrosse non-slip element balloons was unsuccessful. Ventricular premature beats and transient ST-segment depression were captured during the utilization of IVL. The operator gradually extended the pulse emission interval across two consecutive cycles to mitigate myocardial ischemia. Notably, when the interval reached 30s, the patient had no chest pain or ST-segment changes. Subsequent images of intravascular ultrasound confirmed calcification ruptures. Therapeutic intervention included the placement of a stent and the application of a drug-coated balloon in the left anterior descending branch. A telephonic follow-up six months later indicated the patient had no discomfort.

This case underscores the effectiveness of gradually extending the pulse emission interval as a strategic complement to the clinical application of IVL. In certain clinical scenarios, it may become imperative to suspend the pulse delivery to improve myocardial blood supply.

The online version contains supplementary material available at 10.1186/s13019-024-02782-z.