Extensive unroofing of myocardial bridge: A case report and literature review
Salvior Mok1, David Majdalany1, Gosta B Pettersson1
1Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
Insights
This study reports the longest symptomatic myocardial bridge case, a condition where a coronary artery segment runs within the heart muscle. Surgical unroofing led to significant symptom improvement, offering a potential treatment for this rare condition.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Cardiac Surgery
Background:
- Myocardial bridge, a coronary artery segment with an intramyocardial course, is often asymptomatic but can cause severe cardiac events.
- Prevalence varies significantly, from 0.5% angiographically to 80% on autopsy, with conflicting views on surgical intervention timing.
- Associated symptoms include angina, myocardial infarction, arrhythmias, and sudden cardiac death.
Observation:
- A young female with refractory chest pain and prior aortic surgery presented with significant left anterior descending artery compromise due to a myocardial bridge.
- Stress testing indicated anterior ischemia, confirmed by cardiac catheterization showing a fractional flow reserve of 0.75.
- Intraoperative findings revealed an exceptionally long 10-cm myocardial bridge segment.
Findings:
- Surgical unroofing of the 10-cm myocardial bridge resulted in immediate patient improvement.
- Post-procedure, repeat catheterization showed no residual narrowing and improved fractional flow reserve (0.87).
- This case represents the longest reported symptomatic myocardial bridge, highlighting its potential for severe coronary insufficiency.
Implications:
- The management of symptomatic myocardial bridges, particularly long segments, may benefit from surgical unroofing.
- This case underscores the importance of considering myocardial bridge in patients with refractory angina and ischemic findings.
- Further research is warranted to establish definitive guidelines for surgical intervention in myocardial bridge cases.
Background:
Myocardial bridge is defined as a segment of a coronary artery that takes an intramyocardial course. The presence of myocardial bridge has been observed in as many as 40%-80% of cases on autopsy, angiographically from 0.5% to 16.0%, and often asymptomatic. However, it has been associated with angina, coronary spasm, myocardial infarction, arrhythmias, syncope, sudden cardiac arrest, and death. Conflicting opinions exist on the timing of surgical intervention for myocardial bridge.
Methods:
We present an unusual case of a young female, with prior aortic surgery, who had refractory chest pain despite optimal medical therapy. Stress testing revealed anterior ischemia. Cardiac catherization showed myocardial bridge of the left anterior descending artery with significant compromise of blood flow (fractional flow reserve = 0.75 with adenosine). We proceeded with surgery. Intraoperatively, we found an unusually long (10-cm) intramyocardial segment of the left anterior descending artery which was managed by surgically unroofing. Our patient felt better post procedure. Repeat cardiac catheterization showed no further narrowing of the left anterior descending artery with a fractional flow reserve of 0.87 in its distal segment.
Results/Discussion:
Myocardial bridge is present mostly in female patients (74.5%), with median age at 56.2 years and mostly involving the left anterior descending artery (77.2%). The average length of myocardial bridge is 21.85 ± 16.10 mm (range: 5-70 mm). Our case is unique as the involved myocardial bridge was 10 cm in length, the longest ever reported. Multiple imaging modality revealed significant coronary insufficiency, with a subsequent clinical and angiographic improvement upon unroofing of the culprit coronary vessel.
Conclusion:
Management decision on myocardial bridge remains controversial. This is a case of the longest symptomatic myocardial bridge, with a subsequent improvement post unroofing.
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