Introduction: In our clinical practice, even with the indications provided by the guidelines and the myocardial revascularization scores, there are some cases of severe ischemic heart disease in which the patients prove to be non-revascularizable. Furthermore, these patients may develop severe left ventricular dysfunction causing chronic heart failure with reduced-ejection fraction (CHF-REF), with limited therapeutic choices.

Objective: In this clinical case presentation we aim to emphasize the importance of emerging therapies for these patients, presenting a guideline-conducted therapeutic strategy completed by non-invasive myocardial revascularization through extracorporeal shockwave therapy (ESWT) and vagus nerve stimulation (VNS).

Case presentation: A 47-year old gentleman was transferred in our clinic for low cardiac output syndrome. At presentation we noticed severe dyspnea, marked fatigability and nonproductive cough. The clinical exam showed a syndrome of acute respiratory distress, low blood pressure and sinus tachycardia. After clinical, ECG and echocardiography examination a diagnosis of acute cardiogenic pulmonary edema was made, in the presence of a dilated cardiopathy of unknown etiology. After stabilization, the patient underwent coronary angiography, which revealed severe multi-vessel lesions with heavy calcifications. The choice of myocardial re-vascularization therapy was challenging, and the patient finally received 3 drug-eluting stents, with failure to treat all the coronary lesions and an ICD implant. After 3 months of optimal guideline-conducted medical treatment, the patient remained highly symptomatic, with an ejection fraction of 27%. Due to completion of eligibility criteria, he benefited from extracorporeal shockwave myocardial revascularization in a 9-week treatment course accompanied by medical treatment, with slight amelioration of functional class and echocardiographic parameters. With constantly high NT-proBNP values, the patient received an implant of a vagus nerve stimulation device in a clinical trial of ba-roreflex activation therapy in CHF-REF.

Particularity of the case: Our case is individualized by the acute and severe presentation of acute heart failure due to dilated ischemic cardiopathy in a relatively young patient with severely calcified multi-vessel disease and limited options for revascularization. The novelty in terms of therapy is the non-invasive myocardial re-vascularization by ESWT, a promising therapeutic option for non-revascularizable patients and the completion of therapeutic strategy with an implant of a device for vagus nerve stimulation.