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About ESMR

ESMR stands for Extracorporeal Shockwave Myocardial Revascularization. ESMR can also be termed Non invasive Cardiac Angiogenesis therapy (Ni-CATh).

ESMR therapy is a new non invasive therapy approach using Extracorporeal Shockwave technology for Myocardial Revascularization (i.e. to improve the blood supply to heart muscles). Ischemic myocardial areas no longer accessible by conventional revascularization therapies like Bypass surgery or Balloon Angioplasty and stent, could be treated with the ESMR therapy to relieve symptoms resulted from the myocardial ischemia.


  Chronic chest pain ( Refractory Angina) even after Bypass surgery or Angioplasty.

  Having 70 % -100 % blockages in angiogram

  Reblocks after Bypass surgery or Angioplasty

  Chronic Renal disease with heart attack problem

  High risk cases medically unfit for Bypass surgery

  Patients coronary anatomy not readily amenable for Bypass surgery

  Inability to perform angioplasty because the target lesion is inaccessible

  Patients not willing for surgical procedures.



ESMR was developed by Essen Institute of Cardiology, Essen University, Germany.


ESMR Treatment

The treatment is performed using a shock wave generator that is designed to address the unique
Clinical-anatomical requirements of the chest cavity. A cardiac ultrasound imaging system is used to locate the treatment area and to map the exact position and extent of the ischemic zone. Shock waves are then delivered via the anatomical acoustic window to the treatment area under E.C.G. R-wave gating. Several treatment sessions are required to obtain optimal results.

The therapeutic effect of shock waves is attributed to the mechanical pressure and tension that the acoustic wave exerts on the cardiac tissue. Delivery of low intensity Shock waves causes sheer stress on the vessel wall. This stimulates angiogenesis related growth factors-( eNOS,VEGF and PCNA) initiating the angiogenesis process.


Treatment Regimen


The whole treatment duration is 20-30 minutes and the patient should undergo a series of nine treatment sessions during a nine week period.(3 treatments at first week of each month- 1st week , 5th week, 9th week). At each treatment session shockwaves are delivered to the border of the ischemic area.


Clinical benefits of ESMR

  • Patient can walk more distance without chest pain
  • Patient would have fewer or no angina
  • Episodes of angina would be less painful
  • Patient need for anti anginal medications can be reduced
  • Patient can return to work and can participate in their active life style once again
  • Patient would be more energetic and confident.

Typical SPECT Data Pre and Post Shock Wave Application results show:

Frequently Asked Questions


Why ESMR ?

Patients with advanced CAD frequently have recurrent Angina. Surgical and interventional options for these patients typically have been exhausted or will result in only partial revascularization. The ESMR therapy offers new hope for these patients and provides therapy which complement existing treatment procedures.

How Would You Feel During The ESMR Treatment ?

During the treatment you might feel a local tickling in the treatment area, accompanied by a certain degree of noise.


What Are The Distinct Advantages Of ESMR Over Surgery ?

Unlike Bypass surgery, Angioplasty and stenting procedures, ESMR is non-invasive, carries no risk, painless, no anaesthesia or sedatives required, no re-treatment limitations and is an outpatient procedure.

What Are The Risks Or Side Effects Of ESMR ?

No acute or long term side effects were reported.


What Are Shockwaves ?

Shock waves are a kind of sound waves (like ultrasound) with high intensity and short duration. The sound waves are generated by an underwater high voltage spark, which are delivered non-invasively, focused by a special ellipsoid reflector. The reflector is coupled to the patient’s skin near the affected area with a water cushion. The focal zone distance into the patient’s body is adjusted according to the linical requirements.

What Is Angiogenesis ?

Angiogenesis or Neo-vascularisation means formation or growth of new blood vessels (otherwise called coronary collateral formation) naturally which in turn increases the blood supply to the ischemic of the heart and improves the myocardial perfusion. Hence coronary collateral angiogenesis can also be called NATURAL BYPASS.

What Is The Purpose Of The ESMR Treatment?

The purpose of this innovative non surgical treatment is to produce new pathways around the blocked arteries in Ischemic zone of the heart by expanding networks of tiny blood vessels called collaterals that help increase and normalize the blood flow to heart muscle thereby reducing or relieving angina.

Why ESMR Treatment Is Called Non-Invasive Or Non- Surgical Bypass Treatment ?

ESMR treatment forms new natural blood vessels which improve the oxygenated blood supply to the affected portion of the heart non- surgically or non-pharmaceutically. For this reason it is called Non-Invasive or Non- surgical Bypass treatment or Non-Invasive Cardiac Angiogenesis therapy (Ni-Cath).

Is Shock Wave Technology Used In Other Fields Of Medicine?

Shock wave technology is presently being used in the field of Urology for breaking Kidney stones and in Orthopaedics for bone and soft tissue injuries.