Recurrent attack of acute myocardial infarction complicated with ventricular fibrillation due to coronary vasospasm within a myocardial bridge: a case report

Abstract

Background: Myocardial bridge (MB) often an inoffensive condition that goes in one or more of the coronary arteries through the heart muscle instead of lying on its surface. MBs sometimes leads to myocardial ischemic symptoms such as chest pain, even an occurrence of myocardial infarction. However, reports of severe and recurrent cardiac adverse events related to the MBs are rare. Case presentation: A 44-year-old male patient who suffered from a four-hour crushing chest pain ten years ago, was diagnosed as acute anterior ST-elevation myocardial infarction (STEMI). The initial findings of coronary angiography (CAG) showed MB was located in the middle part of the left anterior descending coronary artery (LAD). The patient was managed medically. Another re-attack of similar previous chest pain characteristics occured just after 3 days of discharge. Supra-arterial myotomy and CABG were the next adopted management. Postoperative progression was uneventful. However, 32 months after surgical treatment, the patient experienced an abrupt onset of chest pain accompanied by loss of consciousness. The ECG showed ventricular fibrillation (VF). After electrical cardioversion, an immediate CAG followed by CTA was performed which excluded thrombus or acute occlusion in the native coronary artery and an occlusion was observed at the end of the left internal mammary artery. An implantable cardioverter-defibrillator (ICD) was successfully performed for prevention of malignant arrhythmia. During ten years of follow-up, no complications have been identified. Conclusions: Although MB is mostly benign, it may lead to significant cardiovascular consequences. Supra-arterial myotomy is an appropriate treatment option for this patient who failed to optimal medical therapy. Furthermore, ICD implantation must be considered in order to prevent malignant ventricular arrhythmia caused by continuous spasm resulting in ischemia. Further investigations are required to confirm the clinical effectiveness of these procedures.

Myotomy for myocardial bridge utilizing harmonic scalpel

“…However, recurrent anginal symptoms due to in-stent restenosis, in-stent thrombosis, perforation, and stent fracture are reported, thus stent placement for medically refractory patients should be utilized only in poor surgical candidates [ [9] , [10] , [11] , [12] , [13] , [14] , [15] ]. Surgical intervention has consisted of myotomy, coronary artery bypass grafts, or a combination of the two [ [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] ]. Coronary bypass grafting has been described, but with inferior results due to competitive flow and subsequent graft failure.…”

“…Medical management is often successful, however when that fails, intervention may be indicated [ 7 , 8 ]. Stenting or bypass are generally not as successful as surgical myotomy [ [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] ]. We report our experience using the ultrasonic scalpel (Harmonic Scalpel, Ethicon End of Surgery, Raritan, New Jersey) as a safe, surgically efficient, and effective surgical technique to establish myotomy of MB.…”

Myocardial bridging phenomenon is not invariable: A case report

“…Therefore, it is generally considered benign and does not have clinical significance. However, adverse events caused by MB have still been widely reported and have relevance with the depth of the MB; MB may result in severe cardiovascular events[ 2 , 6 ]. Additionally, sudden cardiac death in young people who lack of any high-risk cardiovascular factors and underlying diseases has received increasing attention in recent years, which reminds us to give attention to congenital coronary malformations, such as MB[ 7 , 8 ].…”

Case Report: A Case of Unusual Combination of Hypothyroidism, Myocardial Bridging, and Myocardial Infarction-Induced Left Ventricular Aneurysm

“…This led to myocardial infarction and formation of left ventricular apical aneurysm. The mechanisms by which MB causes chest pain include reduced coronary blood flow and abnormal endothelial function, thrombosis, and coronary spasm ( 7 ). MB can induce coronary heart disease.…”