Myocardial Bridging as a Cause of Acute Transient Left Heart Dysfunction

doi:10.1378/chest.116.2.574

Chest

Volume 116, Issue 2, August 1999, Pages 574-580

https://doi.org/10.1378/chest.116.2.574 Get rights and content

The significance of myocardial bridging is still a matter of debate, and although several reports have underlined its pathologic potential, myocardial bridging is often considered to be a benign phenomenon. We present here the case of a 63-year-old woman with a history of acute left heart failure and ECG evidence of ischemia, and whose primary abnormality on extensive workup was myocardial bridging. This case further underlines that myocardial bridging can lead to significant cardiac events.

Section snippets

Case Report

A 63-year-old woman was admitted to our Cardiology Department a few days after she received intensive care treatment for acute pulmonary edema, preceded by angina pectoris without myocardial infarction. Her medical history was limited to atrial fibrillation, known since 1991, that was treated with digoxin. In 1995, she began complaining of typical rest angina and showed no evidence of myocardial ischemia by dipyridamole single-photon emission CT (SPECT). On admission, the clinical examination

Discussion

Most reports³¹⁵ on myocardial bridging have emphasized its good prognosis. Various arguments support this analysis. First, the high frequency of myocardial bridges in autopsy studies stands in contrast to the rarity of symptomatic cases. Second, symptoms usually start in patients > 30 years old.¹⁶¹⁷Nevertheless, this point of view has been challenged in several reports, and serious ischemic events have been linked with myocardial bridges.⁶⁷⁸⁹¹⁰¹¹¹²¹³¹⁸¹⁹ Induction of ischemia solely by a

Conclusion

Myocardial bridging-induced ischemia can be severe enough to generate clinical signs of acute left heart dysfunction, which is reversible after debridging in the absence of evolving myocardial infarction and/or myocardial stunning. Even in the presence of localized LVH, myocardial bridging-induced ischemia might favor further diastolic dysfunction, which can fully explain acute left heart dysfunction. This report, together with those previously published, suggests that myocardial bridging can

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Cited by (44)

Myocardial bridging: Contemporary understanding of pathophysiology with implications for diagnostic and therapeutic strategies
2014, Journal of the American College of Cardiology
Citation Excerpt :
These data suggest that both systolic and diastolic flow impairment contribute to myocardial supply-demand mismatch in patients with myocardial bridging. Although myocardial bridging can be an incidental finding on angiography or autopsy, symptomatic patients who have myocardial bridges as their only cardiac abnormality may present with myocardial ischemia (21), acute coronary syndromes (22–24), coronary spasm (21,25), exercise-induced dysrhythmias such as supraventricular tachycardia (24), ventricular tachycardia (26,27) or atrioventricular conduction block (28), myocardial stunning (29), transient ventricular dysfunction (30), syncope (24,27), or even sudden death (31,32). A number of diagnostic modalities have been used to investigate the anatomic and physiological significance of myocardial bridging (Table 1).
Myocardial bridging as a common phenotype of hypertrophic cardiomyopathy has no effect on prognosis
2014, American Journal of the Medical Sciences
The prognostic significance of myocardial bridging in hypertrophic cardiomyopathy (HCM) remains controversial. This investigation sought to evaluate the impact of myocardial bridging on prognosis of patients with HCM.
A total of 298 adult patients (73% male, mean age, 53 ± 12 years) with HCM were retrospectively enrolled at Fuwai Hospital from 1999 to 2011. Myocardial bridging was evaluated by coronary angiography. Follow-up data were collected by telephone interviews and mailed questionnaires.
Thirty-four (11%, 34/298) patients were determined with myocardial bridging and the middle of left anterior descending artery was the most frequently involved segment (77%, 26/34). Patients with myocardial bridging were younger than those without bridging (48 ± 9 versus 54 ± 12 years, P = 0.001). During the follow-up of 4.2 ± 2.3 years (range, 0.7-12.2 years), the presence of myocardial bridging was not evidently associated with increased risk for all-cause death (P = 0.54), cardiovascular death (P = 0.60), sudden cardiac death (P = 0.53) and deterioration of heart failure (P = 0.84).
Myocardial bridging was a relatively common morphological component of HCM but not a predictor for adverse clinical outcomes.
Myocardial bridging assessed by multidetector computed tomography: Likely cause of chest pain in younger patients with low prevalence of dyslipidemia
2012, Revista Espanola de Cardiologia
La relación entre los puentes miocárdicos y el dolor torácico todavía no está bien definida. El objetivo de nuestro estudio es evaluar la relación entre los puentes miocárdicos detectados mediante tomografía computarizada multidetectores y los síntomas de una población de pacientes evaluados por dolor torácico.
Se incluyó a 393 pacientes consecutivos sin enfermedad coronaria previa, estudiados por dolor torácico y remitidos para tomografía computarizada multidetectores entre enero de 2007 y diciembre de 2010. Se les realizó una coronariografía no invasiva mediante tomografía computarizada multidetectores. Se definió puente miocárdico como una parte de una arteria coronaria completamente rodeada por el miocardio en las imágenes axiales y las reconstrucciones multiplanares.
La media de edad fue 64,6 ± 12,4 años; el 44,8% de los pacientes eran varones. La tomografía computarizada multidetectores mostró 86 puentes miocárdicos en 82 de los 393 pacientes (20,9%). La descendente anterior izquierda fue la arteria coronaria afectada con mayor frecuencia (87,2%). La prevalencia de puente miocárdico fue significativamente superior entre los pacientes sin estenosis coronaria aterosclerótica significativa según la tomografía computarizada multidetectores (el 24,9 frente al 15,0%; p = 0,02). Los pacientes con puente miocárdico eran más jóvenes (60,3 ± 13,8 frente a 65,8 ± 11,9 años; p < 0,001), tenían menor prevalencia de hiperlipemia (el 29,3 frente al 41,8%; p = 0,03) y mayor prevalencia de miocardiopatía (el 6,1 frente al 1,6%; p = 0,02) que los pacientes sin puente miocárdico observado en la tomografía computarizada multidetectores.
La tomografía computarizada multidetectores es una herramienta fácil y fiable para diagnosticar los puentes miocárdicos in vivo. Los resultados del presente estudio indican que los puentes miocárdicos son la causa del dolor torácico en un subgrupo de pacientes más jóvenes, con menor prevalencia de hiperlipemia y mayor prevalencia de miocardiopatía que los pacientes en que se observa ateroesclerosis coronaria significativa en la tomografía computarizada multidetectores.
The relationship between myocardial bridging and symptoms is still unclear. The purpose of our study was to assess the relationship between myocardial bridging detected by multidetector computed tomography and symptoms in a patient population with chest pain syndrome.
The study enrolled 393 consecutive patients wihout previous coronary artery disease studied for chest pain and referred to multidetector computed tomography between January 2007 and December 2010. Noninvasive coronary angiography was performed using multidetector computed tomography. Myocardial bridging was defined as part of a coronary artery completely surrounded by myocardium on axial and multiplanar reformatted images.
Mean age was 64.6 (12.4) years and 44.8% were male. Multidetector computed tomography detected 86 myocardial bridging images in 82 of the 393 patients (20.9%). Left anterior descending was the most frequent coronary artery involved (87.2%). The prevalence of myocardial bridging was significantly higher in patients without significant atherosclerotic coronary stenosis on multidetector computed tomography (24.9% vs 15.0%; P = .02). Patients with myocardial bridging were younger (60.3 [13.8] vs 65.8 [11.9]; P<.001), had less prevalence of hyperlipidemia (29.3% vs 41.8%; P=.03), and more prevalence of cardiomyopathy (6.1% vs 1.6%, P=.02) compared with patients without myocardial bridging on multidetector computed tomography.
Multidetector computed tomography is an easy and reliable tool for comprehensive in vivo diagnosis of myocardial bridging. The results of the present study suggest myocardial bridging is the cause of chest pain in a subgroup of younger aged patients with less prevalence of hyperlipidemia and more prevalence of cardiomyopathy than patients with significant atherosclerotic coronary artery disease on multidetector computed tomography.
Full English text available from: www.revespcardiol.org
Incidence, clinical characteristics, and 4-year follow-up of patients with isolated myocardial bridge: A retrospective, single-center, epidemiologic, coronary arteriographic follow-up study in southern Turkey
2011, Cardiovascular Revascularization Medicine
Citation Excerpt :
The estimated frequency that has been reported varies from 1.5% to 16% when assessed by coronary angiography, but in some autopsy series, it is as high as 80% [10–13]. Traditionally, MB has been considered a benign condition, but the following complications have been reported: ischemia and acute coronary syndromes [14–18], coronary spasm [19], ventricular septal rupture [20], arrhythmias [21], exercise-induced atrioventricular conduction block [22], stunning [23], transient ventricular dysfunction [24], early death after cardiac transplantation [25], and sudden death [26]. In this trial, we aim to find the prevalence and prognosis of isolated MB patients who underwent coronary angiography for any reason as well as their clinical characteristics in the southern part of Turkey.
Myocardial bridge is a rare coronary anomaly that is generally considered to be benign. The true incidence and long-term prognosis are still under debate. Therefore, we investigated the prevalence and prognosis of patients with isolated myocardial bridge in our center.
This study is a retrospective, angiographic follow-up which includes 14,250 patients. Median follow-up was 4 years. The typical angiographic finding of myocardial bridging (MB) is systolic narrowing of an epicardial artery. Exclusion criterion was myocardial bridge with coronary artery disease (CAD). The primary end point was major cardiac events (death, myocardial infarction, and revascularization).
Myocardial bridge was observed in 118 (0.83%) patients without CAD. The median age was 56.2. There were 30 (25.5%) male and 88 (74.5%) female patients. The arterial segment that was most frequently involved was the left anterior descending artery, as evident in 91 patients (77.2%). Most of the myocardial bridge produces a systolic narrowing between 30% and 50%. There was no major adverse cardiac event nor a need for any revascularization in the follow-up period with medical treatment.
Isolated myocardial bridge is a benign and rare coronary anomaly. However, further studies are needed to detect long-term prognosis.
Myocardial bridging on dual-source computed tomography: degree of systolic compression of mural coronary artery correlating with length and depth of the myocardial bridge
2010, Clinical Imaging
Citation Excerpt :
The myocardial bridge can compress the tunneled segment and make the lumen narrow as a stenosis during the systolic phase; therefore, MB and MCA can be taken as a functional complex. In the past, MB was considered to be a normal anatomic variation, but many recent reports have implied that MB can impact the coronary flow and cause angina, myocardial infarction, life-threatening arrhythmias, and even sudden death [3–7]. The current gold standard for the detection of MB in vivo is conventional coronary angiography (CAG); however, its depiction rate is lower (0.5–16%) than that from autopsy (15–85%) [1,8,9].
To investigate the correlation between the degree of systolic compression of mural coronary artery (MCA) and the length and depth of myocardial bridging (MB) with dual-source computed tomography (DSCT).
The length and depth of MB were measured from diastolic phase. All datasets were reconstructed in 5% steps of R-R interval. The optimum phases were chosen where the maximal and minimal diameters were shown. The degree of systolic compression of MCA was calculated. The correlation between length and depth of MB and the degree of systolic compression of MCA were analyzed by Pearson test.
The minimal diameters were found in 27 sites (90.0%) from 30% to 35% R-R interval, and the maximal diameters were found in 27 sites (90.0%) from 70% to 80% R-R interval. The correlation between systolic compression of MCA and length of MB was not significant (r=0.096, P=.613); however, the correlation between systolic compression of MCA and the depth of MB was significant (r=0.675, P<.01).
The minimal and maximal diameters of MCA are usually demonstrated in 30–35% and 70–80% R-R reconstruction interval, respectively. The degree of systolic compression of MCA correlates well with the depth of MB.
Myocardial bridging as evaluated by 16 row MDCT
2009, European Journal of Radiology
Citation Excerpt :
Despite the fact that it is a congenital anomaly, the patients are usually symptomless until the third decade [3]. Although this phenomenon has generally been considered a benign process, it may also cause myocardial ischemia, myocardial infarction, myocardial stunning, left ventricular dysfunction, ventricular septal rupture, premature death after cardiac transplantation, ventricular tachycardia and sudden cardiac death [6–14]. An autopsy study by Ferreira et al. classified MBs into two categories: superficial bridges (75% of cases) which cross the artery perpendicularly or at an acute angle toward the apex, and deep bridges in which muscle bundles arise from the right ventricular apical trabeculae (25% of cases) crossing the LAD transversely, obliquely, or helically before terminating in the interventricular septum [15].
The purpose of this study is to find out the prevalence, appearance and clinical symptoms of myocardial bridging (MB) by MDCT coronary angiography (CTA).
A total of 280 (50 females) consecutive patients followed with coronary artery disease or postoperative stent and bypass control, underwent CTA performed by 16-MDCT scanner between January 2006 and April 2006. Short axis multiplanar reformatted images were evaluated. MBs were classified as complete and incomplete bridges with respect to continuity of the myocardium over the tunneled segment of left anterior descending artery (LAD) in interventricular groove and the cut-off value is 1.3 mm. Patients diagnosed with MB on CTA who had prior catheter angiography studies were re-evaluated for the presence of MB.
One hundred and twenty MBs [98 (81.6%) on LAD, 2 (1.6%) on diagonal branch, 11 (9.1%) on obtuse marginal, 4 (3.3%) on right coronary artery, 5 (4.1%) on ramus intermedius artery] were detected in 108 (38.5%) patients. Eighty-five (70.8%) of bridged segments in 79 (28.2%) patients were complete and the rest [35 (29.2%) in 34 (12.1%) patients] were incomplete. In 12 patients two MBs (either on different arteries or on the same artery) were detected. The length of bridged segments in patients with complete and incomplete MBs varied between 4–50.9 mm (mean 18 mm) and 4–37.3 mm (mean 13.6 mm), respectively, and the depth of myocardium over the artery ranged between 1–6.4 mm (mean 2.3 mm) and 1–1.2 mm (mean 1 mm), respectively. Thirty (27.7%) out of 108 patients, in whom MB was detected on CTA, were found to have correlative catheter angiography studies, retrospectively and MB was detected only in 4 (13.3%) out of 30 patients.
MDCT coronary angiography is a non-invasive, efficient method in the diagnosis of MB avoiding the procedural risks that catheter angiography carries. MDCT coronary angiography allows direct visualization of the bridge itself and may thus give the opportunity to differentiate between complete and incomplete myocardial bridges.

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Chest

Selected ReportsMyocardial Bridging as a Cause of Acute Transient Left Heart Dysfunction

Section snippets

Case Report

Discussion

Conclusion

Clin Radiol

Chest

Am Heart J

Chest

Am Heart J

Am Heart J

Int J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

Am Heart J

Ann Thorac Surg

Ann Thorac Surg

The incidence of myocardial bridges in heart transplants

Cardiovasc Intervent Radiol

Incidence and clinical significance of bridges of myocardium over the coronary arteries and their branches

Surg Radiol Anat

Myocardial bridges: morphological and functional aspects

Br Heart J

Fatal outcome associated with autopsy-proven myocardial bridging of the left anterior descending coronary artery

Eur Heart J

Myocardial bridging in a survivor of sudden cardiac near-death: role of intracoronary doppler flow measurements and angiography during dobutamine stress in the clinical evaluation

Heart

Myocardial bridge as a cause of thrombus formation and myocardial infarction in a young athlete

Clin Cardiol

Myocardial bridging in a young patient with sudden death

Clin Cardiol

Myocardial bridging as a cause of paroxysmal atrioventricular block

J Am Coll Cardiol

Coronary stenting in the management of myocardial ischemia caused by muscle bridging

Br Heart J

Functional, angiographic and intracoronary Doppler flow characteristics in symptomatic patients with myocardial bridging: effect of short-term intravenous beta-blocker medication

J Am Coll Cardiol

Endothelial dysfunction of the non-infarct related, angiographically normal, coronary artery in patients with an acute myocardial infarction

Eur Heart J

Selected Reports
Myocardial Bridging as a Cause of Acute Transient Left Heart Dysfunction