Myocardial bridging: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
(Shankar Kumar moved page Myocardial bridge to PCI in the bridge lesion)
 
No edit summary
Line 1: Line 1:
#REDIRECT [[PCI in the bridge lesion]]
__NOTOC__
{{PCI}}
{{CMG}}; {{AOEIC}} {{CZ}}; {{LG}}; '''Assistant Editor-In-Chief:''' Meagan Doherty, B.S.
 
==Overview==
A myocardial bridge or MB is defined as a segment of a major [[coronary artery|coronary]] [[epicardial]] [[artery]] that "tunnels" or passes intramurally through the [[myocardium]] beneath the muscle bridge during [[systole]].<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref><ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref> Myocardial bridges are generally located in the distribution of the [[left anterior descending artery]] ([[LAD]]) and its [[diagonal branch]]es.
==Historical Perspective==
[[Angiographic]]ally, myocardial bridging was first recognized in the 1960's.<ref>Reyman, HC. Disertatis de vasis cordis propiis. Bibl Anat. 1737; 2:366.</ref>
==Pathophysiology==
====Variants====
There are two basic morphologic variants:
*Deep variant
*[[Superficial]] variant
====Extent====
Majority of the cases, [[systolic]] bridging is usually not severe or extensive and completely reverses during [[diastole]]; except in patients with [[HOCM]], wherein severe [[systolic]] bridging of the [[septal]] perforators may be a predisposing factor to the development of [[myocardial ischemia]].<ref name="pmid307341">{{cite journal |author=Faruqui AM, Maloy WC, Felner JM, Schlant RC, Logan WD, Symbas P |title=Symptomatic myocardial bridging of coronary artery |journal=[[The American Journal of Cardiology]] |volume=41 |issue=7 |pages=1305–10 |year=1978 |month=June |pmid=307341 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid7397963">{{cite journal |author=Morales AR, Romanelli R, Boucek RJ |title=The mural left anterior descending coronary artery, strenuous exercise and sudden death |journal=[[Circulation]] |volume=62 |issue=2 |pages=230–7 |year=1980 |month=August |pmid=7397963 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7397963 |accessdate=2012-07-01}}</ref><ref name="pmid19620504">{{cite journal |author=Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K, Niino H, Tanaka M, Ogata K, Morinaga S, Ebihara Y, Kawahara Y, Sugiura H, Takimoto T, Komatsu A, Shinagawa T, Taki K, Satoh H, Yamada K, Yanagida-Iida M, Shimokawa R, Shimada K, Nishimura C, Ito K, Ishii T |title=Anatomic properties of myocardial bridge predisposing to myocardial infarction |journal=[[Circulation]] |volume=120 |issue=5 |pages=376–83 |year=2009 |month=August |pmid=19620504 |doi=10.1161/CIRCULATIONAHA.108.820720 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=19620504 |accessdate=2012-07-01}}</ref><ref name="pmid19914131">{{cite journal |author=Utuk O, Bilge A, Bayturan O, Tikiz H, Tavli T, Tezcan U |title=Thrombosis of a coronary artery related to the myocardial bridging |journal=[[Heart, Lung & Circulation]] |volume=19 |issue=8 |pages=481–2 |year=2010 |month=August |pmid=19914131 |doi=10.1016/j.hlc.2009.08.006 |url=http://linkinghub.elsevier.com/retrieve/pii/S1443-9506(09)01052-X |accessdate=2012-07-01}}</ref><ref name="pmid21448858">{{cite journal |author=Hostiuc S, Curca GC, Dermengiu D, Dermengiu S, Hostiuc M, Rusu MC |title=Morphological changes associated with hemodynamically significant myocardial bridges in sudden cardiac death |journal=[[The Thoracic and Cardiovascular Surgeon]] |volume=59 |issue=7 |pages=393–8 |year=2011 |month=October |pmid=21448858 |doi=10.1055/s-0030-1270703 |url=http://www.thieme-connect.com/DOI/DOI?10.1055/s-0030-1270703 |accessdate=2012-07-01}}</ref><ref name="pmid21123275">{{cite journal |author=Husmann L, Nkoulou R, Wolfrum M, Kaufmann PA |title=Myocardial bridging causing infarction and ischaemia |journal=[[European Heart Journal]] |volume=32 |issue=7 |pages=790 |year=2011 |month=April |pmid=21123275 |doi=10.1093/eurheartj/ehq423 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=21123275 |accessdate=2012-07-01}}</ref>
 
==Epidemiology and Demographics==
The reported [[frequency]] varies with different modalities used to identify [[myocardial]] bridges. Generally, with [[coronary angiography]], the reported frequent ranges from 0.5-16% <ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref><ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref><ref name="pmid10562478">{{cite journal |author=Ge J, Jeremias A, Rupp A, Abels M, Baumgart D, Liu F, Haude M, Görge G, von Birgelen C, Sack S, Erbel R |title=New signs characteristic of myocardial bridging demonstrated by intracoronary ultrasound and Doppler |journal=[[European Heart Journal]] |volume=20 |issue=23 |pages=1707–16 |year=1999 |month=December |pmid=10562478 |doi=10.1053/euhj.1999.1661 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10562478 |accessdate=2012-07-01}}</ref><ref name="pmid307341">{{cite journal |author=Faruqui AM, Maloy WC, Felner JM, Schlant RC, Logan WD, Symbas P |title=Symptomatic myocardial bridging of coronary artery |journal=[[The American Journal of Cardiology]] |volume=41 |issue=7 |pages=1305–10 |year=1978 |month=June |pmid=307341 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid8149538">{{cite journal |author=Ge J, Erbel R, Rupprecht HJ, Koch L, Kearney P, Görge G, Haude M, Meyer J |title=Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging |journal=[[Circulation]] |volume=89 |issue=4 |pages=1725–32 |year=1994 |month=April |pmid=8149538 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8149538 |accessdate=2012-07-01}}</ref><ref name="pmid12021235">{{cite journal |author=Angelini P, Velasco JA, Flamm S |title=Coronary anomalies: incidence, pathophysiology, and clinical relevance |journal=[[Circulation]] |volume=105 |issue=20 |pages=2449–54 |year=2002 |month=May |pmid=12021235 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12021235 |accessdate=2012-07-01}}</ref><ref name="pmid7055058">{{cite journal |author=Kramer JR, Kitazume H, Proudfit WL, Sones FM |title=Clinical significance of isolated coronary bridges: benign and frequent condition involving the left anterior descending artery |journal=[[American Heart Journal]] |volume=103 |issue=2 |pages=283–8 |year=1982 |month=February |pmid=7055058 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-8703(82)90500-2 |accessdate=2012-07-01}}</ref><ref name="pmid12957438">{{cite journal |author=Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Tajik AJ, Holmes DR |title=Myocardial bridging in adult patients with hypertrophic cardiomyopathy |journal=[[Journal of the American College of Cardiology]] |volume=42 |issue=5 |pages=889–94 |year=2003 |month=September |pmid=12957438 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703008544 |accessdate=2012-07-01}}</ref> and with [[pathological]] or [[coronary artery|coronary]] [[CT]], the [[frequency]] is between 5-86%.<ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref><ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref><ref name="pmid10426850">{{cite journal |author=Hongo Y, Tada H, Ito K, Yasumura Y, Miyatake K, Yamagishi M |title=Augmentation of vessel squeezing at coronary-myocardial bridge by nitroglycerin: study by quantitative coronary angiography and intravascular ultrasound |journal=[[American Heart Journal]] |volume=138 |issue=2 Pt 1 |pages=345–50 |year=1999 |month=August |pmid=10426850 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid8902676">{{cite journal |author=Iskandrian AE, Nallamothu N, Heo J |title=Nonatherosclerotic causes of myocardial ischemia |journal=[[Journal of Nuclear Cardiology : Official Publication of the American Society of Nuclear Cardiology]] |volume=3 |issue=5 |pages=428–35 |year=1996 |pmid=8902676 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid19697102">{{cite journal |author=La Grutta L, Runza G, Lo Re G, Galia M, Alaimo V, Grassedonio E, Bartolotta TV, Malagò R, Tedeschi C, Cademartiri F, De Maria M, Cardinale AE, Lagalla R, Midiri M |title=Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography |journal=[[La Radiologia Medica]] |volume=114 |issue=7 |pages=1024–36 |year=2009 |month=October |pmid=19697102 |doi=10.1007/s11547-009-0446-y |url=http://dx.doi.org/10.1007/s11547-009-0446-y |accessdate=2012-07-01}}</ref><ref name="pmid20808694">{{cite journal |author=Hwang JH, Ko SM, Roh HG, Song MG, Shin JK, Chee HK, Kim JS |title=Myocardial bridging of the left anterior descending coronary artery: depiction rate and morphologic features by dual-source CT coronary angiography |journal=[[Korean Journal of Radiology : Official Journal of the Korean Radiological Society]] |volume=11 |issue=5 |pages=514–21 |year=2010 |pmid=20808694 |pmc=2930159 |doi=10.3348/kjr.2010.11.5.514 |url=http://www.kjronline.org/DOIx.php?id=10.3348/kjr.2010.11.5.514 |accessdate=2012-07-01}}</ref>
 
Irrespective of the modality used, the [[LAD|left anterior descending coronary artery]] is most commonly involved and a higher [[incidence]] is observed in patients with [[HOCM|hypertrophic coronary artery]] and [[cardiac transplant]]s.<ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref><ref name="pmid12957438">{{cite journal |author=Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Tajik AJ, Holmes DR |title=Myocardial bridging in adult patients with hypertrophic cardiomyopathy |journal=[[Journal of the American College of Cardiology]] |volume=42 |issue=5 |pages=889–94 |year=2003 |month=September |pmid=12957438 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109703008544 |accessdate=2012-07-01}}</ref> Among the [[pediatric]] age group, the occurrence of [[myocardial]] bridging is rare but an increased [[incidence]] may be observed in association with [[hypertrophic cardiomyopathy]].
 
==Natural History, Complications and Prognosis==
===Complications===
[[Complication]]s of [[myocardial]] bridging include the following:
*[[Ischemia]] and [[acute coronary syndromes]],
*[[Coronary artery spasm]],
*[[Ventricular septal rupture]],
*[[Arrythmias]],
*Exercise-induced [[AV block|atrioventricular conduction block]],
*[[Myocardial stunning]],
*Transient [[ventricular dysfunction]],
*Early death after [[cardiac transplantation]] and
*[[Sudden cardiac death]].
 
===Prognosis===
The combined presence of [[hypertrophic cardiomyopathy]] and [[myocardial]] bridging is associated with a worse [[prognosis]] as compared to [[hypertrophic cardiomyopathy]] alone<ref name="pmid9780340">{{cite journal |author=Yetman AT, McCrindle BW, MacDonald C, Freedom RM, Gow R |title=Myocardial bridging in children with hypertrophic cardiomyopathy--a risk factor for sudden death |journal=[[The New England Journal of Medicine]] |volume=339 |issue=17 |pages=1201–9 |year=1998 |month=October |pmid=9780340 |doi=10.1056/NEJM199810223391704 |url=http://dx.doi.org/10.1056/NEJM199810223391704 |accessdate=2012-07-01}}</ref>.
 
==Diagnosis==
===Coronary Angiography===
*[[Systolic]] narrowing of the [[epicardial]] [[artery]] with complete reversal during [[diasole]].<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref>
*[[Angiographic]] manifestation depends on:<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref>
**Thickness and length of [[myocardial]] bridge,
**Reciprocal orientation of the [[coronary artery]] and [[myocardial]] fibers,
**Presence of loose [[connective tissue]] or [[adipose tissue]] around the bridged segment,
**Presence of an [[left ventricular outflow tract obstruction|aortic outflow tract obstruction]],
**Intrinsic tone of the wall of the [[coronary artery]],
**Presence of a [[proximal]] [[coronary artery|coronary]] fixed obstruction and
**State of [[myocardial]] [[contractility]].
*[[Nitroglycerine]] provocation to demonstrate [[systolic]] bridging may be employed in patients with [[exertional angina]]. 
 
=====Examples of Myocardial Bridging=====
[[Image:Myocardial bridge.gif]]
<br clear="left"/>
[[C. Michael Gibson|Copyleft Image courtesy of C. Michael Gibson MS. MD.]]
<br clear="left"/>
 
{{#ev:youtube|PJKPpgKMN2s}}
<br clear="left"/>
 
===Intracoronary ultrasound===
*Half moon phenomenon: caused by [[adipose tissue]] that is surrounding the bridged segment of the [[artery]] <ref>Möhlenkamp S, Hort W, Ge J, Erbel R. Update on myocardial bridging.Circulation. 2002;106:2616 –2622. </ref>
*[[Ultrasound]] images have shown that in patients with [[myocardial]] bridging there is delayed relaxation of the [[artery]] in early [[diastole]].<ref> Erbel R, Rupprecht HJ, Ge J, Gerber T, Görge G, Meyer J. Coronary artery shape and flow changes induced by myocardial bridging. Echocardiography. 1993;1:71–77.]</ref>. This may reduce [[coronary artery|coronary]] [[vasodilator]] reserve.<ref>Rouleau JL, Chuck LH, Hollosi G, Kidd P, Sievers RE, Wikman Coffelt J, Parmley WW. Verapamil preserves myocardial contractility in the hereditary cardiomyopathy of the Syrian hamster. Circ Res. 1982;50:405–412. </ref>
*An impaired [[coronary flow reserve]] has also been noted in patients with [[myocardial]] bridging. This can be corrected with [[Intracoronary Stenting|intracoronary stent implantation]].<ref> Klues HG, Schwarz ER, vom Dahl J, Reffelmann T, Reul H, Potthast K, Schmitz C, Minartz J, Krebs W, Hanrath P. Disturbed intracoronary hemodynamics in myocardial bridging: early normalization by intracoronary stent placement. Circulation. 1997;96:2905–2913.</ref><ref> Jeremias A, Haude M, Ge J, Görge G, Liu F, Konorza T, Erbel R. Emergency stent implantation in the area of extensive muscle bridging of the anterior interventricular ramus after post-interventional dissection [in German]. Z Kardiol. 1997;86:367–372. </ref>
*[[Intracoronary ultrasound]] demonstrates that although many times the bridged section of the [[artery]] was free of disease, [[plaque]]s were found next to the bridged fragment of the [[artery]].<ref> Ge J, Erbel R, Görge G, Haude M, Meyer J. High wall shear stress proximal to myocardial bridging and atherosclerosis: intracoronary ultrasound and pressure measurements. Br Heart J. 1995;73:462– 465.] </ref>
*Echolucent half moon phenomenon over the bridge segment.
*[[Systolic]] compression of the bridge segment of the [[coronary artery]].
*Retrograde flow in the [[proximal]] segment ([[systolic]] flow reversal).
*Accelerated flow velocity at early [[diastole]] (Finger-tip phenomenon).
*No or reduced [[systolic]] antegrade flow.
*Decreased [[diastolic]]/[[systolic]] velocity ratio.
 
==Treatment==
===Medical Treatment===
* [[Beta Blocker]]s.
* [[Calcium channel blocker]]s (preferably non-[[dihydropyridine]]s).
* [[Nitrates]] are contra-indicated because reduction in [[preload]] causes reflex [[sympathetic]] stimulation.<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref>
===PCI/Stenting===
*[[Stenting]] can abolish [[hemodynamic]] abnormalities associated with [[myocardial]] bridging and may improve clinical [[symptom]]s in patients with [[myocardial]] bridges.<ref name="pmid9386156">{{cite journal |author=Klues HG, Schwarz ER, vom Dahl J, Reffelmann T, Reul H, Potthast K, Schmitz C, Minartz J, Krebs W, Hanrath P |title=Disturbed intracoronary hemodynamics in myocardial bridging: early normalization by intracoronary stent placement |journal=[[Circulation]] |volume=96 |issue=9 |pages=2905–13 |year=1997 |month=November |pmid=9386156 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9386156 |accessdate=2012-07-01}}</ref><ref name="pmid10814636">{{cite journal |author=Prendergast BD, Kerr F, Starkey IR |title=Normalisation of abnormal coronary fractional flow reserve associated with myocardial bridging using an intracoronary stent |journal=[[Heart (British Cardiac Society)]] |volume=83 |issue=6 |pages=705–7 |year=2000 |month=June |pmid=10814636 |pmc=1760858 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=10814636 |accessdate=2012-07-01}}</ref>
*Care must be exercised in [[stent]] placement to assure that the bridge is not just moved upstream or downstream of the [[stent]].
*Of note, there have been reports of [[coronary artery perforation]]<ref name="pmid9417754">{{cite journal |author=Hering D, Horstkotte D, Schwimmbeck P, Piper C, Bilger J, Schultheiss HP |title=[Acute myocardial infarct caused by a muscle bridge of the anterior interventricular ramus: complicated course with vascular perforation after stent implantation] |language=German |journal=[[Zeitschrift Für Kardiologie]] |volume=86 |issue=8 |pages=630–8 |year=1997 |month=August |pmid=9417754 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid20339502">{{cite journal |author=Zhang M, Kang WC, Moon CI, Han SH, Ahn TH, Shin EK |title=Coronary artery perforation following implantation of a drug-eluting stent rescued by deployment of a covered stent in symptomatic myocardial bridging |journal=[[Korean Circulation Journal]] |volume=40 |issue=3 |pages=148–51 |year=2010 |month=March |pmid=20339502 |pmc=2844983 |doi=10.4070/kcj.2010.40.3.148 |url=http://www.koreancircj.kr/DOIx.php?id=10.4070/kcj.2010.40.3.148 |accessdate=2012-07-01}}</ref> and target vessel revascularization<ref name="pmid19427426">{{cite journal |author=Tsujita K, Maehara A, Mintz GS, Doi H, Kubo T, Castellanos C, Liu J, Yang J, Oviedo C, Franklin-Bond T, Sugirtharaj DD, Dangas GD, Lansky AJ, Stone GW, Moses JW, Leon MB, Mehran R |title=Impact of myocardial bridge on clinical outcome after coronary stent placement |journal=[[The American Journal of Cardiology]] |volume=103 |issue=10 |pages=1344–8 |year=2009 |month=May |pmid=19427426 |doi=10.1016/j.amjcard.2009.01.340 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(09)00457-3 |accessdate=2012-07-01}}</ref><ref name="pmid10995410">{{cite journal |author=Haager PK, Schwarz ER, vom Dahl J, Klues HG, Reffelmann T, Hanrath P |title=Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging |journal=[[Heart (British Cardiac Society)]] |volume=84 |issue=4 |pages=403–8 |year=2000 |month=October |pmid=10995410 |pmc=1729426 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=10995410 |accessdate=2012-07-01}}</ref> in patients with [[myocardial]] bridging during/following [[stent]] placement, respectively.
===Surgery===
[[Surgery]] is limited to patients with [[symptom]]s that persist despite medical treatment.
=====1. CABG=====
Minimally invasive [[CABG]] with placement of a [[left internal mammary artery]] to the distal [[left anterior descending artery]] is one option.
=====2. Myectomy=====
Myectomy can be performed on the [[myocardium]] surrounding the [[coronary artery]]. The procedure involves [[surgery|surgical]] division (unroofing) of the [[coronary artery]]. [[surgery|Surgical]] unroofing of the [[myocardial]] bridge often results in clinical improvement.<ref name="pmid9780340">{{cite journal |author=Yetman AT, McCrindle BW, MacDonald C, Freedom RM, Gow R |title=Myocardial bridging in children with hypertrophic cardiomyopathy--a risk factor for sudden death |journal=[[The New England Journal of Medicine]] |volume=339 |issue=17 |pages=1201–9 |year=1998 |month=October |pmid=9780340 |doi=10.1056/NEJM199810223391704 |url=http://dx.doi.org/10.1056/NEJM199810223391704 |accessdate=2012-07-01}}</ref><ref name="pmid8935519">{{cite journal |author=Katznelson Y, Petchenko P, Knobel B, Cohen AJ, Kishon Y, Schachner A |title=Myocardial bridging: surgical technique and operative results |journal=[[Military Medicine]] |volume=161 |issue=4 |pages=248–50 |year=1996 |month=April |pmid=8935519 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid7458489">{{cite journal |author=Hill RC, Chitwood WR, Bashore TM, Sink JD, Cox JL, Wechsler AS |title=Coronary flow and regional function before and after supraarterial myotomy for myocardial bridging |journal=[[The Annals of Thoracic Surgery]] |volume=31 |issue=2 |pages=176–81 |year=1981 |month=February |pmid=7458489 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid1439639">{{cite journal |author=Iversen S, Hake U, Mayer E, Erbel R, Diefenbach C, Oelert H |title=Surgical treatment of myocardial bridging causing coronary artery obstruction |journal=[[Scandinavian Journal of Thoracic and Cardiovascular Surgery]] |volume=26 |issue=2 |pages=107–11 |year=1992 |pmid=1439639 |doi= |url= |accessdate=2012-07-01}}</ref><ref name="pmid6385889">{{cite journal |author=Ochsner JL, Mills NL |title=Surgical management of diseased intracavitary coronary arteries |journal=[[The Annals of Thoracic Surgery]] |volume=38 |issue=4 |pages=356–62 |year=1984 |month=October |pmid=6385889 |doi= |url= |accessdate=2012-07-01}}</ref> Potential [[complication]]s include [[right ventricular perforation]] and left [[ventricular aneurysm]] which can be avoided with the use of [[echocardiography]] to follow the course of the [[vessel]].<ref>Hiratzka LF, McPherson DD, Brandt B 3d, Lamberth WC Jr, Marcus ML, Kerber RE. Intraoperative high-frequency epicardial echocardiography in coronary revascularization: locating deeply embedded coronary arteries. Ann Thorac Surg 1986 Dec;42(6 Suppl):S9-11</ref>
 
=====Surgery Contra-Indication=====
[[Cardiac surgery]] is not indicated for [[hypertrophic cardiomyopathy]] associated [[myocardial]] bridging, and medical [[therapy]] may provide adequate anti-[[ischemic]] [[therapy]].<ref name="pmid11127472">{{cite journal |author=Mohiddin SA, Begley D, Shih J, Fananapazir L |title=Myocardial bridging does not predict sudden death in children with hypertrophic cardiomyopathy but is associated with more severe cardiac disease |journal=[[Journal of the American College of Cardiology]] |volume=36 |issue=7 |pages=2270–8 |year=2000 |month=December |pmid=11127472 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(00)00987-6 |accessdate=2012-07-01}}</ref>
 
==References==
{{Reflist|2}}
 
{{WikiDoc Help Menu}}
{{WikiDoc Sources}}
[[Category:Cardiology]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

Revision as of 16:34, 22 January 2013

Percutaneous coronary intervention Microchapters

Home

Patient Information

Overview

Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI approaches

PCI Complications

Factors Associated with Complications
Vessel Perforation
Dissection
Distal Embolization
No-reflow
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Restenosis
Renal Failure
Thrombocytopenia
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
Vasospasm
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

Myocardial bridging On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Myocardial bridging

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Myocardial bridging

CDC on Myocardial bridging

Myocardial bridging in the news

Blogs on Myocardial bridging

Directions to Hospitals Treating Percutaneous coronary intervention

Risk calculators and risk factors for Myocardial bridging

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Lakshmi Gopalakrishnan, M.B.B.S. [3]; Assistant Editor-In-Chief: Meagan Doherty, B.S.

Overview

A myocardial bridge or MB is defined as a segment of a major coronary epicardial artery that "tunnels" or passes intramurally through the myocardium beneath the muscle bridge during systole.[1][2] Myocardial bridges are generally located in the distribution of the left anterior descending artery (LAD) and its diagonal branches.

Historical Perspective

Angiographically, myocardial bridging was first recognized in the 1960's.[3]

Pathophysiology

Variants

There are two basic morphologic variants:

Extent

Majority of the cases, systolic bridging is usually not severe or extensive and completely reverses during diastole; except in patients with HOCM, wherein severe systolic bridging of the septal perforators may be a predisposing factor to the development of myocardial ischemia.[4][5][6][7][8][9]

Epidemiology and Demographics

The reported frequency varies with different modalities used to identify myocardial bridges. Generally, with coronary angiography, the reported frequent ranges from 0.5-16% [2][1][10][4][11][12][13][14] and with pathological or coronary CT, the frequency is between 5-86%.[2][1][15][16][17][18]

Irrespective of the modality used, the left anterior descending coronary artery is most commonly involved and a higher incidence is observed in patients with hypertrophic coronary artery and cardiac transplants.[2][14] Among the pediatric age group, the occurrence of myocardial bridging is rare but an increased incidence may be observed in association with hypertrophic cardiomyopathy.

Natural History, Complications and Prognosis

Complications

Complications of myocardial bridging include the following:

Prognosis

The combined presence of hypertrophic cardiomyopathy and myocardial bridging is associated with a worse prognosis as compared to hypertrophic cardiomyopathy alone[19].

Diagnosis

Coronary Angiography

Examples of Myocardial Bridging


Copyleft Image courtesy of C. Michael Gibson MS. MD.

{{#ev:youtube|PJKPpgKMN2s}}

Intracoronary ultrasound

Treatment

Medical Treatment

PCI/Stenting

Surgery

Surgery is limited to patients with symptoms that persist despite medical treatment.

1. CABG

Minimally invasive CABG with placement of a left internal mammary artery to the distal left anterior descending artery is one option.

2. Myectomy

Myectomy can be performed on the myocardium surrounding the coronary artery. The procedure involves surgical division (unroofing) of the coronary artery. Surgical unroofing of the myocardial bridge often results in clinical improvement.[19][32][33][34][35] Potential complications include right ventricular perforation and left ventricular aneurysm which can be avoided with the use of echocardiography to follow the course of the vessel.[36]

Surgery Contra-Indication

Cardiac surgery is not indicated for hypertrophic cardiomyopathy associated myocardial bridging, and medical therapy may provide adequate anti-ischemic therapy.[37]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS (2005). "Myocardial bridging". European Heart Journal. 26 (12): 1159–68. doi:10.1093/eurheartj/ehi203. PMID 15764618. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 2.2 2.3 Möhlenkamp S, Hort W, Ge J, Erbel R (2002). "Update on myocardial bridging". Circulation. 106 (20): 2616–22. PMID 12427660. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  3. ↑ Reyman, HC. Disertatis de vasis cordis propiis. Bibl Anat. 1737; 2:366.
  4. ↑ 4.0 4.1 Faruqui AM, Maloy WC, Felner JM, Schlant RC, Logan WD, Symbas P (1978). "Symptomatic myocardial bridging of coronary artery". The American Journal of Cardiology. 41 (7): 1305–10. PMID 307341. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  5. ↑ Morales AR, Romanelli R, Boucek RJ (1980). "The mural left anterior descending coronary artery, strenuous exercise and sudden death". Circulation. 62 (2): 230–7. PMID 7397963. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  6. ↑ Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K, Niino H, Tanaka M, Ogata K, Morinaga S, Ebihara Y, Kawahara Y, Sugiura H, Takimoto T, Komatsu A, Shinagawa T, Taki K, Satoh H, Yamada K, Yanagida-Iida M, Shimokawa R, Shimada K, Nishimura C, Ito K, Ishii T (2009). "Anatomic properties of myocardial bridge predisposing to myocardial infarction". Circulation. 120 (5): 376–83. doi:10.1161/CIRCULATIONAHA.108.820720. PMID 19620504. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  7. ↑ Utuk O, Bilge A, Bayturan O, Tikiz H, Tavli T, Tezcan U (2010). "Thrombosis of a coronary artery related to the myocardial bridging". Heart, Lung & Circulation. 19 (8): 481–2. doi:10.1016/j.hlc.2009.08.006. PMID 19914131. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  8. ↑ Hostiuc S, Curca GC, Dermengiu D, Dermengiu S, Hostiuc M, Rusu MC (2011). "Morphological changes associated with hemodynamically significant myocardial bridges in sudden cardiac death". The Thoracic and Cardiovascular Surgeon. 59 (7): 393–8. doi:10.1055/s-0030-1270703. PMID 21448858. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  9. ↑ Husmann L, Nkoulou R, Wolfrum M, Kaufmann PA (2011). "Myocardial bridging causing infarction and ischaemia". European Heart Journal. 32 (7): 790. doi:10.1093/eurheartj/ehq423. PMID 21123275. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  10. ↑ Ge J, Jeremias A, Rupp A, Abels M, Baumgart D, Liu F, Haude M, Görge G, von Birgelen C, Sack S, Erbel R (1999). "New signs characteristic of myocardial bridging demonstrated by intracoronary ultrasound and Doppler". European Heart Journal. 20 (23): 1707–16. doi:10.1053/euhj.1999.1661. PMID 10562478. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  11. ↑ Ge J, Erbel R, Rupprecht HJ, Koch L, Kearney P, Görge G, Haude M, Meyer J (1994). "Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging". Circulation. 89 (4): 1725–32. PMID 8149538. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  12. ↑ Angelini P, Velasco JA, Flamm S (2002). "Coronary anomalies: incidence, pathophysiology, and clinical relevance". Circulation. 105 (20): 2449–54. PMID 12021235. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  13. ↑ Kramer JR, Kitazume H, Proudfit WL, Sones FM (1982). "Clinical significance of isolated coronary bridges: benign and frequent condition involving the left anterior descending artery". American Heart Journal. 103 (2): 283–8. PMID 7055058. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  14. ↑ 14.0 14.1 Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Tajik AJ, Holmes DR (2003). "Myocardial bridging in adult patients with hypertrophic cardiomyopathy". Journal of the American College of Cardiology. 42 (5): 889–94. PMID 12957438. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  15. ↑ Hongo Y, Tada H, Ito K, Yasumura Y, Miyatake K, Yamagishi M (1999). "Augmentation of vessel squeezing at coronary-myocardial bridge by nitroglycerin: study by quantitative coronary angiography and intravascular ultrasound". American Heart Journal. 138 (2 Pt 1): 345–50. PMID 10426850. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  16. ↑ Iskandrian AE, Nallamothu N, Heo J (1996). "Nonatherosclerotic causes of myocardial ischemia". Journal of Nuclear Cardiology : Official Publication of the American Society of Nuclear Cardiology. 3 (5): 428–35. PMID 8902676. |access-date= requires |url= (help)
  17. ↑ La Grutta L, Runza G, Lo Re G, Galia M, Alaimo V, Grassedonio E, Bartolotta TV, Malagò R, Tedeschi C, Cademartiri F, De Maria M, Cardinale AE, Lagalla R, Midiri M (2009). "Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography". La Radiologia Medica. 114 (7): 1024–36. doi:10.1007/s11547-009-0446-y. PMID 19697102. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  18. ↑ Hwang JH, Ko SM, Roh HG, Song MG, Shin JK, Chee HK, Kim JS (2010). "Myocardial bridging of the left anterior descending coronary artery: depiction rate and morphologic features by dual-source CT coronary angiography". Korean Journal of Radiology : Official Journal of the Korean Radiological Society. 11 (5): 514–21. doi:10.3348/kjr.2010.11.5.514. PMC 2930159. PMID 20808694. Retrieved 2012-07-01.
  19. ↑ 19.0 19.1 Yetman AT, McCrindle BW, MacDonald C, Freedom RM, Gow R (1998). "Myocardial bridging in children with hypertrophic cardiomyopathy--a risk factor for sudden death". The New England Journal of Medicine. 339 (17): 1201–9. doi:10.1056/NEJM199810223391704. PMID 9780340. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  20. ↑ Möhlenkamp S, Hort W, Ge J, Erbel R. Update on myocardial bridging.Circulation. 2002;106:2616 –2622.
  21. ↑ Erbel R, Rupprecht HJ, Ge J, Gerber T, Görge G, Meyer J. Coronary artery shape and flow changes induced by myocardial bridging. Echocardiography. 1993;1:71–77.]
  22. ↑ Rouleau JL, Chuck LH, Hollosi G, Kidd P, Sievers RE, Wikman Coffelt J, Parmley WW. Verapamil preserves myocardial contractility in the hereditary cardiomyopathy of the Syrian hamster. Circ Res. 1982;50:405–412.
  23. ↑ Klues HG, Schwarz ER, vom Dahl J, Reffelmann T, Reul H, Potthast K, Schmitz C, Minartz J, Krebs W, Hanrath P. Disturbed intracoronary hemodynamics in myocardial bridging: early normalization by intracoronary stent placement. Circulation. 1997;96:2905–2913.
  24. ↑ Jeremias A, Haude M, Ge J, Görge G, Liu F, Konorza T, Erbel R. Emergency stent implantation in the area of extensive muscle bridging of the anterior interventricular ramus after post-interventional dissection [in German]. Z Kardiol. 1997;86:367–372.
  25. ↑ Ge J, Erbel R, Görge G, Haude M, Meyer J. High wall shear stress proximal to myocardial bridging and atherosclerosis: intracoronary ultrasound and pressure measurements. Br Heart J. 1995;73:462– 465.]
  26. ↑ Klues HG, Schwarz ER, vom Dahl J, Reffelmann T, Reul H, Potthast K, Schmitz C, Minartz J, Krebs W, Hanrath P (1997). "Disturbed intracoronary hemodynamics in myocardial bridging: early normalization by intracoronary stent placement". Circulation. 96 (9): 2905–13. PMID 9386156. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  27. ↑ Prendergast BD, Kerr F, Starkey IR (2000). "Normalisation of abnormal coronary fractional flow reserve associated with myocardial bridging using an intracoronary stent". Heart (British Cardiac Society). 83 (6): 705–7. PMC 1760858. PMID 10814636. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  28. ↑ Hering D, Horstkotte D, Schwimmbeck P, Piper C, Bilger J, Schultheiss HP (1997). "[Acute myocardial infarct caused by a muscle bridge of the anterior interventricular ramus: complicated course with vascular perforation after stent implantation]". Zeitschrift Für Kardiologie (in German). 86 (8): 630–8. PMID 9417754. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  29. ↑ Zhang M, Kang WC, Moon CI, Han SH, Ahn TH, Shin EK (2010). "Coronary artery perforation following implantation of a drug-eluting stent rescued by deployment of a covered stent in symptomatic myocardial bridging". Korean Circulation Journal. 40 (3): 148–51. doi:10.4070/kcj.2010.40.3.148. PMC 2844983. PMID 20339502. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  30. ↑ Tsujita K, Maehara A, Mintz GS, Doi H, Kubo T, Castellanos C, Liu J, Yang J, Oviedo C, Franklin-Bond T, Sugirtharaj DD, Dangas GD, Lansky AJ, Stone GW, Moses JW, Leon MB, Mehran R (2009). "Impact of myocardial bridge on clinical outcome after coronary stent placement". The American Journal of Cardiology. 103 (10): 1344–8. doi:10.1016/j.amjcard.2009.01.340. PMID 19427426. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  31. ↑ Haager PK, Schwarz ER, vom Dahl J, Klues HG, Reffelmann T, Hanrath P (2000). "Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging". Heart (British Cardiac Society). 84 (4): 403–8. PMC 1729426. PMID 10995410. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  32. ↑ Katznelson Y, Petchenko P, Knobel B, Cohen AJ, Kishon Y, Schachner A (1996). "Myocardial bridging: surgical technique and operative results". Military Medicine. 161 (4): 248–50. PMID 8935519. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  33. ↑ Hill RC, Chitwood WR, Bashore TM, Sink JD, Cox JL, Wechsler AS (1981). "Coronary flow and regional function before and after supraarterial myotomy for myocardial bridging". The Annals of Thoracic Surgery. 31 (2): 176–81. PMID 7458489. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  34. ↑ Iversen S, Hake U, Mayer E, Erbel R, Diefenbach C, Oelert H (1992). "Surgical treatment of myocardial bridging causing coronary artery obstruction". Scandinavian Journal of Thoracic and Cardiovascular Surgery. 26 (2): 107–11. PMID 1439639. |access-date= requires |url= (help)
  35. ↑ Ochsner JL, Mills NL (1984). "Surgical management of diseased intracavitary coronary arteries". The Annals of Thoracic Surgery. 38 (4): 356–62. PMID 6385889. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  36. ↑ Hiratzka LF, McPherson DD, Brandt B 3d, Lamberth WC Jr, Marcus ML, Kerber RE. Intraoperative high-frequency epicardial echocardiography in coronary revascularization: locating deeply embedded coronary arteries. Ann Thorac Surg 1986 Dec;42(6 Suppl):S9-11
  37. ↑ Mohiddin SA, Begley D, Shih J, Fananapazir L (2000). "Myocardial bridging does not predict sudden death in children with hypertrophic cardiomyopathy but is associated with more severe cardiac disease". Journal of the American College of Cardiology. 36 (7): 2270–8. PMID 11127472. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)


Template:WikiDoc Sources

Retrieved from "https://www.wikidoc.org/index.php?title=Myocardial_bridging&oldid=833290"