Acute Myocardial Infarction Due to Myocardial Bridge Treated With Surgery: a Case Report.

Myocardial bridging is congenital anomaly characterized by segment of epicardial coronary arteries passing through the myocardium. Various ischemic conditions are related with this pathology. We report a case of myocardial bridging that was complicated with acute anterior myocardial infarction and a review of the literature. The patient was treated successfully with coronary bypass graft surgery after unsuccessful percutaneous intervention.

Surgical Angioplasty for a Single Coronary Artery With Myocardial Bridging.

Single coronary artery with myocardial bridging is rare but associated with the risk of sudden cardiac death in children, yet there is no standardized treatment approach. We report a 6-year-old girl with chest pain having a single coronary artery with complete myocardial bridging of the left main coronary artery (modified Lipton type RII-S) branching from the right coronary artery at an acute angle. Coronary angioplasty using an in situ aortic flap and an autologous pulmonary arterial patch combined with myocardial unroofing was successfully performed for the left main coronary artery. The patient remains healthy for over 3 years without any exercise restriction.

[Surgical treatment of obstructive hypertrophic cardiomyopathy combined with muscle bridging of the left anterior descending artery]. / Khirurgicheskoe lechenie obstruktivnoi gipertroficheskoi kardiomiopatii v sochetanii s miokardial'nym mostikom perednei niskhodyashchei arterii.

Myocardial bridging is often detected during diagnostic coronary angiography in patients with congenital and acquired heart defects. In most cases, muscle bridging does not require surgical treatment. Myocardial bridging and tunnels causing compression of one or more major coronary arteries is a potential cause of myocardial ischemia in patients with hypertrophic cardiomyopathy. The authors report surgical treatment of a patient with obstructive hypertrophic cardiomyopathy and myocardial bridging of the left anterior descending artery.

Surgical intervention and outcome for treatment of myocardial bridging refractory to medication.

INTRODUCTION: Myocardial bridging (MB) is a common and usually benign inborn coronary abnormality that may lead to anginal symptoms, acute coronary syndrome, arrhythmias, and rarely sudden cardiac death. MB are most commonly localized in the middle segment of the left anterior descending coronary artery (LAD). The treatment of LAD-MB is still challenging. Our objective was to assess the short- and long-term results of surgical procedures in patients with LAD-MB who had chest pain refractory to medical therapy. METHODS: Between March 2005 and January 2020, 26 patients (19 males and 7 females; mean 55.8 ± 12.4 years) with MB underwent surgery. All MB was located in the mid-segment of the LAD with a mean length of 4.2 ± 1.7 cm. Coronary angiography before surgery demonstrated LAD-MB with systolic compression more than or equal to 70% in all patients. RESULTS: Twenty-five patients underwent myotomy and one patient underwent coronary artery bypass grafting (CABG). All patients survived and recovered uneventfully. Neither hospital or late death nor major complications occurred. Follow-up time was 3-173 months (mean 55.7 months). Follow-up of coronary angiography or computed tomography scan performed in 16 patients demonstrated restoration of coronary blood flow and myocardial perfusion without significant residual compression of the artery. All patients were symptom-free and are currently in NYHA Class I. CONCLUSION: The symptomatic LAD-MB patients who are refractory to medication should actively undergo the surgical intervention such as myotomy and CABG to eliminate the clinical symptoms and achieve satisfactory results by follow-up findings. Myotomy is a preferred procedure because of its safety and satisfactory results.

Midterm results of different treatment methods for myocardial bridging in patients after septal myectomy.

BACKGROUND: Myocardial bridging (MB) is commonly treated in patients with hypertrophic cardiomyopathy. However, whether and how MB should be treated in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal myectomy remain unclear. METHODS: A total of 823 adults with HOCM who underwent septal myectomy at the Fuwai Hospital from 2011 to 2017 were retrospectively studied. RESULTS: Overall, 31 events occurred: 24 patients died and 7 had nonfatal myocardial infarction (MI). The 3-year cumulative event-free survival of all-cause death (97.9% vs. 100% vs. 100% vs. 98.4%, p = .89) and cardiovascular death (98.3% vs. 100% vs. 100% vs. 98.4%, p = .63) were similar among the four groups (non-MB, coronary artery bypass grafting [CABG], unroofing, untreated, respectively). However, the 3-year cumulative event-free survival of nonfatal MI (100% vs. 97.5% vs. 98.0% vs. 89.9%, p < .001) and combined endpoints (97.9% vs. 97.5% vs. 98.0% vs. 88.4%, p = .02) were significantly lowest in untreated MB (non-MB, CABG, unroofing, untreated, respectively). Cox regression analysis indicated that untreated MB was a significant independent predictor of combined endpoints (hazard ratio: 4.06, 95% confidence interval: 1.60-10.32, p < .001). Moreover, 49 patients underwent coronary artery computed tomography 1 year after surgery. The patency rate of the saphenous vein graft was significantly higher than that of the left internal mammary artery (13.3% vs. 84.2%, p < .001). No MB was detected in the unroofing group. CONCLUSIONS: Surgical MB treatment could be beneficial and performed safely during septal myectomy. Myocardial unroofing is the recommended treatment for MB, and unroofing when technically possible may be preferable for long-term outcomes.

Epicardial ultrasound in a case of myocardial bridge and apical hypertrophic cardiomyopathy.

A 59-year-old male with a history of unstable angina was diagnosed with a myocardial bridge of the left anterior descending artery (LAD) and apical variant hypertrophic cardiomyopathy (AHCM). He underwent unroofing of the myocardial bridge and a left ventricular apical myectomy. Intraoperatively, epicardial ultrasound was used to identify the myocardial bridge with systolic compression of the LAD and confirm resolution of this compression postoperatively. Furthermore, epicardial ultrasound was used for guiding the degree of apical resection of the decompressed heart. This novel use of intraoperative epicardial ultrasound can help guide surgeons preoperatively and confirm results immediately after an operation.

Quantitative flow ratio-guided surgical intervention in symptomatic myocardial bridging.

BACKGROUND: Patients with myocardial bridging (MB) are associated with adverse cardiovascular events, but a decision to perform surgical intervention, especially for patients with systolic intermediate stenosis, is a difficult clinical issue. Fractional flow reserve (FFR) represents a novel method for the functional evaluation of coronary stenosis, but the relationship between FFR and MB remains controversial because of the cyclic dynamic stenosis of MB. Quantitative flow ratio (QFR) is a novel index allowing fast assessment of FFR from a diagnostic coronary angiography. This study aimed to investigate the relationship between QFR and MB patients and to further develop a prediction model of QFR-guided surgical intervention for these patients. METHODS: Forty-five symptomatic lone MB patients who had undergone coronary angiography were consecutively enrolled in this study. MB was located in the middle of left anterior descending artery with intermediate stenosis during systole. The patients were retrospectively divided into a medical therapy group or a surgical therapy group. Systolic geometry based QFR (SG-QFR) and diastolic geometry based QFR (DG-QFR) were calculated based on three-dimensional quantitative coronary angiography and patient-specific flow velocity. Subsequently, time-averaged QFR (TA-QFR) is defined as the average of SG-QFR and DG-QFR. RESULTS: Receiver operating characteristic curve analysis revealed that TA-QFR (AUC = 0.91; 95% CI: 0.79-0.98) was found to be the best pre-operative index for surgical intervention to MB, when compared with DG-QFR (AUC = 0.69; 95% CI: 0.53-0.82; difference: 0.22; 95% CI: 0.04-0.41; p = 0.02) and SG-QFR (AUC = 0.87; 95% CI: 0.74-0.95; difference: 0.04; 95% CI: 0.00-0.08; p = 0.03). CONCLUSIONS: TA-QFR improved the performance of functional evaluation in MB patients with intermediate stenosis during systole and is useful for guiding surgical intervention.

Clinical Outcomes of Surgical Unroofing of Myocardial Bridging in Symptomatic Patients.

BACKGROUND: There is a paucity of data regarding results of surgical management of myocardial bridging. Our objective was to evaluate the clinical outcomes of unroofing procedures in patients with myocardial bridging of the left anterior descending (LAD) coronary artery who had chest pain refractory to medical therapy. METHODS: Among 274 adult patients diagnosed with myocardial bridging at our institution (1996-2017), 71 underwent surgical intervention. To understand the potential benefit of unroofing, we excluded patients with concomitant operations for other diagnoses or known obstructive coronary disease. The study included 35 patients with preoperative chest pain and isolated LAD coronary artery bridging who underwent surgical unroofing. We analyzed recurrent symptoms, postoperative medication use, and mortality. RESULTS: Mean age was 48.2 ± 11.2 years (18 men [51%]). All patients underwent preoperative coronary angiography. Endothelial dysfunction in the LAD coronary artery bridged segment was confirmed in 20 of 24 patients (83%). Mean cardiopulmonary bypass and cross-clamp times were 47.6 ± 29.8 minutes and 33.7 ± 22.2 minutes, respectively. Median lengths of hospital and intensive care unit stay were 5 days and 1 day, respectively. During follow-up (median, 31 months; 95% confidence interval, 18-49) there were no cardiac-related deaths, and 22 patients (63%) reported no chest pain. Among 13 symptomatic patients, 10 underwent postoperative noninvasive testing, which was negative for ischemia in all cases. CONCLUSIONS: Myocardial unroofing can be performed safely in patients with chest pain and isolated LAD coronary artery myocardial bridging. However, patients should be aware of the potential for recurrent nonischemic chest pain and continued medical therapy despite relief of coronary compression.

Undiagnosed Systemic Mastocytosis Presenting as Postoperative Distributive Shock: A Case Report.

Systemic mastocytosis (SM) is a rare clinical condition resulting from a clonal proliferation of abnormal mast cells. The clinical presentation may vary from mild cutaneous manifestations to aggressive systemic symptoms including intermittent episodes of anaphylaxis. We present a case of a 69-year-old male with abrupt and recurrent episodes of anaphylaxis with refractory distributive shock following cardiac surgery with cardiopulmonary bypass. Following a complex postoperative course, a bone marrow biopsy ultimately confirmed the diagnosis. Although rare, SM should be considered in the differential diagnosis of postoperative patients with unexplained and recurrent episodes of distributive shock.

Role of flowmetry in tactics of bypass grafting for myocardial bridge of the anterior descending artery. / Rol' floumetrii v taktike shuntirovaniia miokardial'nogo mosta perednei niskhodiashchei arterii.

The purpose of the study was to analyse the remote results of bypass grafting for myocardial bridges. Our retrospective single-centre study included a total of 17 patients subjected to coronary bypass grafting of the anterior descending artery (ADA) in connection with a detected myocardial bridge (MB). All patients underwent assessment of the coronary bypass grafts (CBG) by means of intraoperative flowmetry - transit time flow measurement (TTFM), as well as angiographic control of the CBGs in the remote period. The duration of follow up amounted to 72 months. Six patients were found to have pronounced retrograde blood flow accompanied by an elevated index of peripheral resistance (Pi) and decreased mean volumetric blood flow velocity (Qmean) below the threshold values. Compression of the ADA proximal to the anastomosis appeared to be followed by improvement of blood flow parameters, in connection with which the shunted artery was ligated with monofilament polypropylene suture 4/0. According to the findings of coronary bypass angiography (CBA) the following results were obtained: 4 occluded grafts were revealed in the group of patients in whom ligation of the ADA was not performed. In patients subjected to ADA ligation in connection with pronounced retrograde blood flow, all bypass grafts were competent. The cumulative probability of freedom from graft occlusion was significantly higher in the group of patients subjected ADA ligation proximal to the anastomosis (Log Rank=0.032).

Surgical unroofing of hemodynamically significant myocardial bridges in a pediatric population.

BACKGROUND: Although myocardial bridges (MBs) are traditionally regarded as incidental findings, it has been reported that adult patients with symptomatic MBs refractory to medical therapy benefit from unroofing. However, there is limited literature in the pediatric population. The aim of our study was to evaluate the indications and outcomes for unroofing in pediatric patients. METHODS: We retrospectively reviewed all pediatric patients with MB in our institution who underwent surgical relief. Clinical characteristics, relevant diagnostic data, intraoperative findings, and postoperative outcomes were evaluated. RESULTS: Between 2012 and 2016, 14 pediatric patients underwent surgical unroofing of left anterior descending artery MBs. Thirteen patients had anginal symptoms refractory to medical therapy, and 1 patient was asymptomatic until experiencing aborted sudden cardiac arrest during exercise. Thirteen patients underwent exercise stress echocardiography, all of which showed mid-septal dys-synergy. Coronary computed tomography imaging confirmed the presence of MBs in all patients. Intravascular ultrasound imaging confirmed the length of MBs: 28.2 ± 16.3 mm, halo thickness: 0.59 ± 0.24 mm, and compression of left anterior descending artery at resting heart rate: 33.0 ± 11.6%. Invasive hemodynamic assessment with dobutamine confirmed the physiologic significance of the MBs with diastolic fractional flow reserve: 0.59 ± 0.13. Unroofing was performed with the patient under cardiopulmonary bypass (CPB) in the initial 9 cases and without CPB in the subsequent 5 cases. All patients were discharged without complications. The 13 symptomatic patients reported resolution of symptoms on follow-up, and improvement in symptoms and quality of life was documented using the Seattle Angina Questionnaire version 7. CONCLUSIONS: Unroofing of MBs can be safely performed in pediatric patients, with or without use of CPB. In symptomatic patients, unroofing can provide relief of symptoms refractory to medical therapy.

Surgical Unroofing of Hemodynamically Significant Left Anterior Descending Myocardial Bridges.

BACKGROUND: Left anterior descending artery myocardial bridges (MBs) range from clinically insignificant incidental angiographic findings to a potential cause of sudden cardiac death. Within this spectrum, a group of patients with isolated, symptomatic, and hemodynamically significant MBs despite maximally tolerated medical therapy exist for whom the optimal treatment is controversial. We evaluated supraarterial myotomy, or surgical unroofing, of the left anterior descending MBs as an isolated procedure in these patients. METHODS: In 50 adult patients, we prospectively evaluated baseline clinical characteristics, risk factors, and medications for coronary artery disease, relevant diagnostic data (stress echocardiography, computed tomography angiography, stress coronary angiogram with dobutamine challenge for measurement of diastolic fractional flow reserve, and intravascular ultrasonography), and anginal symptoms using the Seattle Angina Questionnaire. These patients then underwent surgical unroofing of their left anterior descending artery MBs followed by readministration of the Seattle Angina Questionnaire at 6.6-month (range, 2 to 13) follow-up after surgery. RESULTS: Dramatic improvements were noted in physical limitation due to angina (52.0 versus 87.1, p < 0.001), anginal stability (29.6 versus 66.4, p < 0.001), anginal frequency (52.1 versus 84.7, p < 0.001), treatment satisfaction (76.1 versus 93.9, p < 0.001), and quality of life (25.0 versus 78.9, p < 0.001), all five dimensions of the Seattle Angina Questionnaire. There were no major complications or deaths. CONCLUSIONS: Surgical unroofing of carefully selected patients with MBs can be performed safely as an independent procedure with significant improvement in symptoms postoperatively. It is the optimal treatment for isolated, symptomatic, and hemodynamically significant MBs resistant to maximally tolerated medical therapy.

Left Anterior Descending Artery Myocardial Bridging: A Clinical Approach.

A myocardial bridge (MB) is the term for the muscle overlying the intramyocardial segment of the epicardial coronary artery (referred to as a tunneled artery). Although MBs can be found in any epicardial artery, most of them involve the left anterior descending artery. These congenital coronary anomalies have long been recognized anatomically, and are traditionally considered a benign condition; however, the association between myocardial ischemia and MBs has increased their clinical relevance. This review summarizes the prevalence, pathophysiology, and diagnostic findings, including morphological, functional assessment, and treatment of patients with MB involving the left anterior descending artery, suggesting a pragmatic clinical approach to this entity.

Myocardial Bridging.

Myocardial bridging is rare. Myocardial bridges are most commonly localized in the middle segment of the left anterior descending coronary artery. The anatomic features of the bridges vary significantly. Alterations of the endothelial morphology and the vasoactive agents impact on the progression of atherosclerosis of myocardial bridging. Patients may present with chest pain, myocardial infarction, arrhythmia and even sudden death. Patients who respond poorly to the medical treatment with ß-blockers warrant a surgical intervention. Myotomy is a preferred surgical procedure for the symptomatic patients. Coronary stent deployment has been in limited use due to the unsatisfactory long-term results.

Myocardial bridging

Abstract Myocardial bridging is rare. Myocardial bridges are most commonly localized in the middle segment of the left anterior descending coronary artery. The anatomic features of the bridges vary significantly. Alterations of the endothelial morphology and the vasoactive agents impact on the progression of atherosclerosis of myocardial bridging. Patients may present with chest pain, myocardial infarction, arrhythmia and even sudden death. Patients who respond poorly to the medical treatment with β-blockers warrant a surgical intervention. Myotomy is a preferred surgical procedure for the symptomatic patients. Coronary stent deployment has been in limited use due to the unsatisfactory long-term results.

A case of myocardial bridging as a rare cause of chest pain in children.

Asymptomatic myocardial bridging is a frequently seen pathology in adult patients, often in association with hypertrophic cardiomyopathy. Left anterior descending coronary artery is mostly affected. We report on a 14-year-old boy with repeated angina-like pain, disturbances of repolarization in the ECG and elevated values for Troponin T. After exclusion of a myocarditis in the MRI, myocardial bridging was detectable in coronary angiography and confirmed by myocardial perfusion imaging with 430 MBq (99m)Tc-Tetrofosmin at rest and under physical stress. After surgical myotomy, improvement of the cardiac symptoms could be noted and myocardial perfusion imaging studies at rest and under stress demonstrated reversal of the myocardial ischemia. Myocardial bridging is a rare and important differential diagnosis for angina-like pain in childhood without hypertrophic cardiomyopathy.