Stent fracture following stenting of a myocardial bridge: Report of two cases

Tandar, Anwar; Whisenant, Brian; Michaels, Andrew D.

doi:10.1002/ccd.21365

Cited by 52 publications

(34 citation statements)

References 48 publications

(49 reference statements)

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“…5 Stent fracture under the MB probably occurs due to mechanical compression by the MB contraction during systole, which may lead to in-stent restenosis and/or in-stent thrombosis. 72 In-stent restenosis under the MB occurs more frequently than in cases with no MB. 74 Although the coronary intima beneath the MB is usually free from atherosclerosis, stent implantation causes mechanical stretch and an intimal/ medial injury at the bridged segment, leading to the development of in-stent neointima.…”

Section: Stent Placementmentioning

confidence: 99%

Significance of the Anatomical Properties of a Myocardial Bridge in Coronary Heart Disease

Ishikawa

Kawawa

Kohda

et al. 2011

Circ J

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he myocardial bridge (MB) is an anatomical variant that often covers part of the left anterior descending coronary artery (LAD). 1 It occurs almost exclusively in the mid-portion of the LAD (Figure 1). 2,3 Muscular contraction of the MB itself alters blood flow within the LAD, as demonstrated by coronary angiography, and influences the distribution of hemodynamic stress. [3][4][5] It is widely accepted that an MB sometimes causes coronary heart disease (CHD), 2,5,6 either from direct compression of the MB at cardiac systole or by enhancement of the natural progression of coronary atherosclerosis in the LAD segment proximal to the MB. 2,5,7 Both mechanisms are closely associated with changes in hemodynamic stress driven by the force of the MB contraction through a combination of anatomical properties, such as the location, length, and thickness of the MB. 3,7,8 This review focuses on the relationship between the presence of an MB in the LAD and the occurrence of CHD, specifically addressing the importance of the anatomical properties of the MB as the common root for the 2 distinct mechanisms. In addition, therapeutic approaches to CHD caused by an MB are summarized, along with their outcomes. A myocardial bridge (MB), partially covering the coronary artery, is a congenital anatomical variant usually present in the left anterior descending coronary artery (LAD). MB causes coronary heart disease (CHD) by 2 distinct mechanisms influenced by the anatomical properties of the MB, such as its length, thickness, and location. One is direct MB compression of the LAD at cardiac systole, resulting in delayed arterial relaxation at diastole, reduced blood flow reserve, and decreased blood perfusion. The other is enhancement of coronary atherosclerosis causing stenosis of the LAD proximal to the MB, occurring because of endothelial injury arising from the abnormal hemodynamics provoked by retrograde blood flow up toward the left coronary ostium at cardiac systole. The magnitude of the effect of the 2 distinct mechanisms of the MB on LAD blood flow is prescribed by a common root of the MB-muscle mass volume generated by those properties. Furthermore, the anatomical properties of the MB are closely associated with the choice of treatment and therapeutic outcome in CHD patients having an MB. Thus, the anatomical properties of an MB should be considered in the diagnosis and management of CHD patients with this anomaly. (Circ J 2011; 75: 1559 - 1566

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Section: Stent Placementmentioning

confidence: 99%

Significance of the Anatomical Properties of a Myocardial Bridge in Coronary Heart Disease

Ishikawa

Kawawa

Kohda

et al. 2011

Circ J

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“…Stent implantation in symptomatic patients with myocardial bridges can ameliorate peak intracoronary systolic pressure and vessel compression, normalize flow and abolish symptoms (42); however, concerns regarding perforation during stent deployment (21,43), stent fracture (44), in-stent restenosis (44-48) and stent thrombosis (49) have limited their use in this condition. Investigations focusing on in-stent restenosis are summarized in Table 3 and suggest two conclusions: 1) stent implantation in patients with symptomatic myocardial bridges result in high rates of early in-stent restenosis which may be related to bridge-associated decreased lumen area and 2) compared to PCI with bare metal stents (BMS), PCI with drug-eluting stents (DES) have lower rates of target vessel revascularization (TVR).…”

Section: Managementmentioning

confidence: 99%

Myocardial Bridging

Corban

Hung

Eshtehardi

et al. 2014

Journal of the American College of Cardiology

236

128

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“…However, stenting should not be recommended in MB because of the risk of stent thrombosis and restenosis. 3 Moreover, although CABG is also an effective treatment of MB and LIMA as the first choice of autogenous graft has the best long-term patency rate, the procedure cannot cure the MB and remains the possibility of graft restenosis and spasm resulting in recurrent angina. Surgical myotomy is a radical correction and suitable for every patient with persistent ischemic symptoms despite intensive medication.…”

mentioning

confidence: 99%

Myotomy After Previous Coronary Artery Bypass Grafting for Treatment of Myocardial Bridging

et al. 2011

Circulation

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A 57-year-old man with a long history of frequent chest pain was admitted to our cardiac center. Four years ago, he underwent coronary artery bypass grafting (CABG) with the left internal mammary artery (LIMA) to the distal segment of the left anterior descending coronary artery (LAD) grafting for myocardial bridging (MB) in LAD despite having ␤-blockers and calcium channel blockers. However, the patient still had recurrent angina within 3 months after the operation. ECG showed negative T wave in leads V1 and V2. On echocardiography, left ventricular ejection fraction was 60% with normal regional wall motion. The repeat coronary angiography showed a MB in the proximal LAD about 3 cm in length with 90% systolic narrowing of the LAD, and the LIMA graft was totally occluded ( Figure 1A through 1C). The angiographic manifestation of MB was the same as that of the coronary angiography ( Figure 2A through 2B) before the previous CABG operation.Through a remedian sternotomy, a tight fibrous adhesion was dissected and the anterior wall of the heart was exposed. The location of the LAD was difficultly identified and was carefully confirmed by excising epicardial adipose tissue and epicardium. Surgical myotomy was performed during cardioplegic arrest under cardiopulmonary bypass. The proximal LAD was completely unroofed of MB to eliminate the phasic compression of the coronary vessel ( Figure 1D).The patient had an uneventful postoperative course and is asymptomatic at 22 months of follow-up. Four-months' follow-up catheterization was performed: No systolic narrowing of the LAD could be visualized ( Figure 1E).MB is a congenital anomaly, most common in the middle segment of the LAD, that may cause myocardial ischemia and infarction, cardiac arrhythmias, and sudden cardiac death. 1 The current gold standard for diagnosing MB is coronary angiography with the typical systolic compression of the epicardial coronary vessel (milking effect). Recent studies have shown that coronary narrowing by MB may not only occur in systole but also result in a delayed and incomplete vessel diameter gain during mid-to-late diastole, thereby affecting the predominant phase of the coronary perfusion. 2 In symptomatic MB that is unresponsive to medication, intracoronary stenting and surgical interventions may be adopted as an alternative treatment. However, stenting should not be recommended in MB because of the risk of stent thrombosis and restenosis. 3 Moreover, although CABG is also an effective treatment of MB and LIMA as the first choice of autogenous graft has the best long-term patency rate, the procedure cannot cure the MB and remains the possibility of graft restenosis and spasm resulting in recurrent angina. Surgical myotomy is a radical correction and suitable for every patient with persistent ischemic symptoms despite intensive medication. It can not only treat the physiological abnormality of MB, but also can correct the congenital anatomical defect 4 without the risk of graft restenosis and thrombosis. The key points during the int...

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Stent fracture following stenting of a myocardial bridge: Report of two cases

Cited by 52 publications

References 48 publications

Significance of the Anatomical Properties of a Myocardial Bridge in Coronary Heart Disease

Significance of the Anatomical Properties of a Myocardial Bridge in Coronary Heart Disease

Myocardial Bridging

Myotomy After Previous Coronary Artery Bypass Grafting for Treatment of Myocardial Bridging

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