Extensive unroofing of myocardial bridge: A case report and literature review

Abstract

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.

Left Anterior Descending Artery Bridging and Atypical Chest Pain in a Young Woman

“…A retrospective review of 31 patients who underwent surgical myotomy for significant MB has reported that all patients became symptom-free following the surgical procedure, with an improvement in the New York Heart Association class from I-III to I-II [ 9 ]. Our patient was very symptomatic and was treated medically for approximately six months.…”

Combined Myocardial Bridge and Coronary Vessel Disease Requiring Coronary Artery Bypass Grafting and Myotomy of the Myocardial Bridge

“…It is believed that in patients with severe bridging and concomitant CAD who are undergoing CABG, myotomy improves flow to branches proximal to the anastomosis and distal to the coronary arterial lesion [15-16]. Retrograde perfusion of the branches proximal to the distal anastomosis was visually obvious perioperatively while administrating of cardioplegic blood through the graft to the native coronary artery to evaluate flow, patency, and the integrity of the anastomosis.…”

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“…Therefore, clinical features may manifest as angina-like chest pain, coronary spasm, acute coronary syndromes, left ventricular dysfunction, ventricular arrhythmias, and even sudden cardiac death. [42][43][44][45][46][47][48][49] Serious cardiac events are not common in the clinical setting. In addition, it is still arguable and uncertain whether MB can be directly attributable as the cause of the events.…”