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The influence of image quality on diagnostic performance of a machine learning-based fractional flow reserve derived from coronary CT angiography. Eur Radiol 2020; 30:2525-2534. [PMID: 32006167 DOI: 10.1007/s00330-019-06571-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the effect of image quality of coronary CT angiography (CCTA) on the diagnostic performance of a machine learning-based CT-derived fractional flow reserve (FFRCT). METHODS This nationwide retrospective study enrolled participants from 10 individual centers across China. FFRCT analysis was performed in 570 vessels in 437 patients. Invasive FFR and FFRCT values ≤ 0.80 were considered ischemia-specific. Four-score subjective assessment based on image quality and objective measurement of vessel enhancement was performed on a per-vessel basis. The effects of body mass index (BMI), sex, heart rate, and coronary calcium score on the diagnostic performance of FFRCT were studied. RESULTS Among 570 vessels, 216 were considered ischemia-specific by invasive FFR and 198 by FFRCT. Sensitivity and specificity of FFRCT for detecting lesion-specific ischemia were 0.82 and 0.93, respectively. Area under the curve (AUC) of high-quality images (0.93, n = 159) was found to be superior to low-quality images (0.80, n = 92, p = 0.02). Objective image quality and heart rate were also associated with diagnostic performance of FFRCT, whereas there was no statistical difference in diagnostic performance among different BMI, sex, and calcium score groups (all p > 0.05, Bonferroni correction). CONCLUSIONS This retrospective multicenter study supported the FFRCT as a noninvasive test in evaluating lesion-specific ischemia. Subjective image quality, vessel enhancement, and heart rate affect the diagnostic performance of FFRCT. KEY POINTS • FFRCTcan be used to evaluate lesion-specific ischemia. • Poor image quality negatively affects the diagnostic performance of FFRCT. • CCTA with ≥ score 3, intracoronary enhancement degree of 300-400 HU, and heart rate below 70 bpm at scanning could be of great benefit to more accurate FFRCTanalysis.
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Qi Q, Liu G, Yuan Z, Liu L, Tu S, Zhao Q. Quantitative flow ratio-guided surgical intervention in symptomatic myocardial bridging. Cardiol J 2020; 27:685-692. [PMID: 31909471 DOI: 10.5603/cj.a2019.0113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/26/2019] [Accepted: 11/30/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients with myocardial bridging (MB) are associated with adverse cardiovascular events, but a decision to perform surgical intervention, especially for patients with systolic intermediate stenosis, is a difficult clinical issue. Fractional flow reserve (FFR) represents a novel method for the functional evaluation of coronary stenosis, but the relationship between FFR and MB remains controversial because of the cyclic dynamic stenosis of MB. Quantitative flow ratio (QFR) is a novel index allowing fast assessment of FFR from a diagnostic coronary angiography. This study aimed to investigate the relationship between QFR and MB patients and to further develop a prediction model of QFR-guided surgical intervention for these patients. METHODS Forty-five symptomatic lone MB patients who had undergone coronary angiography were consecutively enrolled in this study. MB was located in the middle of left anterior descending artery with intermediate stenosis during systole. The patients were retrospectively divided into a medical therapy group or a surgical therapy group. Systolic geometry based QFR (SG-QFR) and diastolic geometry based QFR (DG-QFR) were calculated based on three-dimensional quantitative coronary angiography and patient-specific flow velocity. Subsequently, time-averaged QFR (TA-QFR) is defined as the average of SG-QFR and DG-QFR. RESULTS Receiver operating characteristic curve analysis revealed that TA-QFR (AUC = 0.91; 95% CI: 0.79-0.98) was found to be the best pre-operative index for surgical intervention to MB, when compared with DG-QFR (AUC = 0.69; 95% CI: 0.53-0.82; difference: 0.22; 95% CI: 0.04-0.41; p = 0.02) and SG-QFR (AUC = 0.87; 95% CI: 0.74-0.95; difference: 0.04; 95% CI: 0.00-0.08; p = 0.03). CONCLUSIONS TA-QFR improved the performance of functional evaluation in MB patients with intermediate stenosis during systole and is useful for guiding surgical intervention.
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Affiliation(s)
- Quan Qi
- First Hospital of Lanzhou University.
| | - Gang Liu
- Department of Cardiology, Yuyao People's Hospital
| | - Zhize Yuan
- Department of Cardiac Surgery, RuiJin Hospital
| | - Lili Liu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University
| | - Shengxian Tu
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University
| | - Qiang Zhao
- Department of Cardiac Surgery, RuiJin Hospital
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McCray LC, Fogwe DT, Aggarwal K, Karuparthi PR. Novel Assessment of Ischemia in Patients With Anomalous Right Coronary Artery. JACC Case Rep 2019; 1:819-822. [PMID: 34316939 PMCID: PMC8289109 DOI: 10.1016/j.jaccas.2019.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/25/2022]
Abstract
Anomalous right coronary arteries are usually benign; however, sudden death owing to myocardial ischemia, especially during exertion, have been reported in patients with intramural or interarterial course, which is likely due to dynamic obstruction. We propose a novel method of physiological evaluation with instantaneous wave-free ratio with dobutamine infusion to simulate controlled dynamic obstruction in anomalous right coronary arteries. (Level of Difficulty: Intermediate.)
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Schnittger I, Boyd JH, Tremmel JA. A Step Back in the Diagnosis and Management of Myocardial Bridging. Ann Thorac Surg 2019; 109:1950. [PMID: 31706871 DOI: 10.1016/j.athoracsur.2019.09.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 09/14/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford School of Medicine, 300 Pasteur Dr, Rm H2157, MC 5233, Stanford, CA 94305.
| | - Jack H Boyd
- Department of Cardio-Thoracic Surgery, Stanford University Medical Center, Stanford, California
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California
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Zhou F, Wang YN, Schoepf UJ, Tesche C, Tang CX, Zhou CS, Xu L, Hou Y, Zheng MW, Yan J, Lu MJ, Lu GM, Zhang DM, Zhang B, Zhang JY, Zhang LJ. Diagnostic Performance of Machine Learning Based CT-FFR in Detecting Ischemia in Myocardial Bridging and Concomitant Proximal Atherosclerotic Disease. Can J Cardiol 2019; 35:1523-1533. [PMID: 31679622 DOI: 10.1016/j.cjca.2019.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The diagnostic performance of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) in detecting ischemia in myocardial bridging (MB) has not been investigated to date. METHODS This retrospective multicentre study included 104 patients with left anterior descending MBs. MB was classified as either superficial or deep, short, or long, whereas all MB vessels were further divided into <50%, 50% to 69%, and ≥70% groups, according to proximal lumen stenosis on invasive coronary angiography. Diagnostic performance and receiver operating characteristics (ROC) of CT-FFR to detect lesion-specific ischemia was assessed on a per-vessel level, using invasive FFR as reference standard. Intraclass correlation coefficient (ICC) and Bland-Altman plots were used for agreement measurement. RESULTS Forty-eight MB vessels (46.2%) showed ischemia by invasive FFR (≤0.80). Sensitivity, specificity, and accuracy of CT-FFR to detect functional ischemia were 0.96 (0.85 to 0.99), 0.84 (0.71 to 0.92), and 0.89 (0.81 to 0.94), respectively, in all MB vessels. There were no differences in diagnostic performance between superficial and deep MB or between short and long MB (all P > 0.05). The accuracy of CT-FFR was 0.96 (0.85 to 0.99) in ≥70% stenosis, 0.82 (0.67 to 0.91) in 50% to 69% stenosis, and 0.89 (0.51 to 0.99) in <50% stenosis (P = 0.081). Bland-Altman analysis showed a slight mean difference between CT-FFR and invasive FFR of 0.014 (95% limit of agreement, -0.117 to 0.145). The ICC was 0.775 (95% confidence interval, 0.685-0.842, P < 0.001). CONCLUSIONS CT-FFR demonstrated high diagnostic performance for identifying functional ischemia in vessels with MB and concomitant proximal atherosclerotic disease when compared with invasive FFR. However, the clinical use of CT-FFR in patients with MB needs further study for stronger and more robust results.
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Affiliation(s)
- Fan Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yi Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - U Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China; Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA; Department of Cardiology and Intensive Care Medicine, Heart Center Munich-Bogenhausen, Munich, Germany
| | - Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Chang Sheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Lei Xu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Hou
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Min Wen Zheng
- Department of Radiology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Jing Yan
- Siemens Healthcare Ltd., Shanghai, China
| | - Meng Jie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Dai Min Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bo Zhang
- Department of Radiology, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Jia Yin Zhang
- Institute of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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Waterbury TM, Tarantini G, Vogel B, Mehran R, Gersh BJ, Gulati R. Non-atherosclerotic causes of acute coronary syndromes. Nat Rev Cardiol 2019; 17:229-241. [DOI: 10.1038/s41569-019-0273-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2019] [Indexed: 12/15/2022]
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Tarantini G, Barioli A, Nai Fovino L, Fraccaro C, Masiero G, Iliceto S, Napodano M. Unmasking Myocardial Bridge-Related Ischemia by Intracoronary Functional Evaluation. Circ Cardiovasc Interv 2019; 11:e006247. [PMID: 29903715 DOI: 10.1161/circinterventions.117.006247] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 05/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Invasive physiological assessment of myocardial bridges (MBs) is largely unsettled. Unlike fractional flow reserve (FFR), instantaneous wave-free ratio (iFR) is a diastole-specific index. As such, its value might not be hampered by systolic pressure overshooting and negative systolic pressure gradient caused by the compression of the tunneled coronary artery. METHODS AND RESULTS We prospectively enrolled 20 patients with angina and/or positive noninvasive stress test, absence of significant coronary artery stenosis, and angiographic suspicion/evidence of MB in the left anterior descending artery. According to a prespecified protocol, all patients underwent functional intracoronary evaluation with FFR at rest and after dobutamine (up to 20 μg kg-1 min-1) and atropine (1 mg) intravenous infusion. iFR at baseline and dobutamine-induced hyperemic wave-free period pressure ratio were also recorded. FFR values ≤0.80 and iFR values ≤0.89 were considered indicative of hemodynamic significance of MB. At baseline, no MB was hemodynamically significant according to FFR, whereas iFR was below the cutoff value in all but 7 patients. During inotropic challenge, median FFR did not change significantly (0.87-0.86, P=0.59). CONCLUSIONS Physiological evaluation of MBs with iFR seems to be more consistent with patients' symptoms and noninvasive test results compared with FFR.
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Affiliation(s)
- Giuseppe Tarantini
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy.
| | - Alberto Barioli
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Luca Nai Fovino
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Chiara Fraccaro
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Giulia Masiero
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Sabino Iliceto
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
| | - Massimo Napodano
- From the Department of Cardiac, Thoracic and Vascular Sciences, Padova University Hospital, Italy
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Teragawa H, Oshita C, Ueda T. The Myocardial Bridge: Potential Influences on the Coronary Artery Vasculature. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2019; 13:1179546819846493. [PMID: 31068756 PMCID: PMC6495429 DOI: 10.1177/1179546819846493] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 04/03/2019] [Indexed: 12/18/2022]
Abstract
A myocardial bridge (MB) is an anatomical abnormality of the coronary artery and is characterized by the systolic narrowing of the epicardial coronary artery caused by myocardial compression during systole. An MB is frequently observed on cardiac computed tomography or coronary angiography and generally appears to be harmless in the majority of patients. However, the presence of MB is reportedly associated with abnormalities of the cardiovascular system, including coronary artery diseases, arrhythmia, certain types of cardiomyopathy, and cardiac death, indicating that MB serves a pivotal role in the occurrence and/or development of such cardiovascular events. Recently, there has been an increasing interest in the coexistence of MB and coronary spasm in research due to opposing aspects regarding their treatments. For example, monotherapy using β-blockers, which are effective in patients with MB, may worsen symptoms in patients with coronary spasm. By contrast, nitroglycerin, which is an effective treatment option for coronary spasm, may worsen symptoms in patients with MB. This review focuses on the pathophysiology and diagnosis of MB and MB-related cardiovascular diseases, including coronary spasm, and on the treatment strategies for MB.
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Affiliation(s)
- Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Tomohiro Ueda
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
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Monroy-Gonzalez AG, Alexanderson-Rosas E, Prakken NHJ, Juarez-Orozco LE, Walls-Laguarda L, Berrios-Barcenas EA, Meave-Gonzalez A, Groot JC, Slart RHJA, Tio RA. Myocardial bridging of the left anterior descending coronary artery is associated with reduced myocardial perfusion reserve: a 13N-ammonia PET study. Int J Cardiovasc Imaging 2019; 35:375-382. [PMID: 30267168 PMCID: PMC6428791 DOI: 10.1007/s10554-018-1460-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/20/2018] [Indexed: 12/30/2022]
Abstract
Myocardial Bridging (MB) refers to the band of myocardium that abnormally overlies a segment of a coronary artery. This paper quantitatively evaluates the influence of MB of the left anterior descending artery (LAD) on myocardial perfusion of the entire left ventricle. We studied 131 consecutive patients who underwent hybrid rest/stress 13N-ammonia positron emission tomography (PET) and coronary computed tomography angiography (CCTA) due to suspected myocardial ischemia. Patients with previous myocardial infarction and/or significant coronary artery disease (≥ 50% stenosis) were excluded. Myocardial perfusion measurements were compared between patients with and without LAD-MB. Additionally, we evaluated the relationship between anatomical characteristics (length and depth) of LAD-MB and myocardial perfusion measurements. 17 (13%) patients presented a single LAD-MB. Global myocardial perfusion reserve (MPR) was lower in patients with LAD-MB than in patients without LAD-MB (1.9 ± 0.5 vs. 2.3 ± 0.6, p < 0.01). Global stress myocardial blood flow (MBF) was similar in patients with and without LAD-MB (2.2 ± 0.4 vs. 2.3 ± 0.7 ml/g/min, p = 0.40). Global rest MBF was higher in patients with LAD-MB than in patients without LAD-MB (1.2 ± 0.3 vs. 1.0 ± 0.2 ml/g/min, p < 0.01). Global rest MBF, stress MBF, and MPR quantifications were similar in patients with superficial and deep LAD-MB (all p = NS). We did not find any correlation between length and global rest MBF, stress MBF nor MPR (r = - 0.14, p = 0.59; r = 0.44, p = 0.07; and r = 0.45, p = 0.07 respectively). Quantitative myocardial perfusion suggests that LAD-MB may be related to impaired perfusion reserve, an indicator of microvascular dysfunction. Anatomical characteristics of LAD-MB were not related to changes in myocardial perfusion.
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Affiliation(s)
- Andrea G. Monroy-Gonzalez
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erick Alexanderson-Rosas
- National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
- Department of Physiology, National Autonomous University of Mexico, Mexico City, Mexico
| | - Niek H. J. Prakken
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Luis E. Juarez-Orozco
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Jan C. Groot
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Rene A. Tio
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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Mok S, Majdalany D, Pettersson GB. Extensive unroofing of myocardial bridge: A case report and literature review. SAGE Open Med Case Rep 2019; 7:2050313X18823380. [PMID: 30719302 PMCID: PMC6349980 DOI: 10.1177/2050313x18823380] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 12/13/2018] [Indexed: 01/29/2023] Open
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.
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Affiliation(s)
- Salvior Mok
- Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - David Majdalany
- Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Fractional flow reserve derived from CCTA may have a prognostic role in myocardial bridging. Eur Radiol 2018; 29:3017-3026. [DOI: 10.1007/s00330-018-5811-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 09/12/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
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Agrawal H, Qureshi AM, Alam M, Mery CM, Molossi S. Anomalous aortic origin of a coronary artery with an intraseptal course: novel techniques in haemodynamic assessment. BMJ Case Rep 2018; 2018:bcr-2018-225707. [PMID: 29960972 DOI: 10.1136/bcr-2018-225707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Athar M Qureshi
- Department of Cardiology, CHI St. Luke's Health, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mahboob Alam
- Department of Cardiology, CHI St. Luke's Health, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Carlos M Mery
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Silvana Molossi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Houston, Texas, USA
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Maeda K, Schnittger I, Murphy DJ, Tremmel JA, Boyd JH, Peng L, Okada K, Pargaonkar VS, Hanley FL, Mitchell RS, Rogers IS. Surgical unroofing of hemodynamically significant myocardial bridges in a pediatric population. J Thorac Cardiovasc Surg 2018; 156:1618-1626. [PMID: 30005887 DOI: 10.1016/j.jtcvs.2018.01.081] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 12/22/2017] [Accepted: 01/09/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although myocardial bridges (MBs) are traditionally regarded as incidental findings, it has been reported that adult patients with symptomatic MBs refractory to medical therapy benefit from unroofing. However, there is limited literature in the pediatric population. The aim of our study was to evaluate the indications and outcomes for unroofing in pediatric patients. METHODS We retrospectively reviewed all pediatric patients with MB in our institution who underwent surgical relief. Clinical characteristics, relevant diagnostic data, intraoperative findings, and postoperative outcomes were evaluated. RESULTS Between 2012 and 2016, 14 pediatric patients underwent surgical unroofing of left anterior descending artery MBs. Thirteen patients had anginal symptoms refractory to medical therapy, and 1 patient was asymptomatic until experiencing aborted sudden cardiac arrest during exercise. Thirteen patients underwent exercise stress echocardiography, all of which showed mid-septal dys-synergy. Coronary computed tomography imaging confirmed the presence of MBs in all patients. Intravascular ultrasound imaging confirmed the length of MBs: 28.2 ± 16.3 mm, halo thickness: 0.59 ± 0.24 mm, and compression of left anterior descending artery at resting heart rate: 33.0 ± 11.6%. Invasive hemodynamic assessment with dobutamine confirmed the physiologic significance of the MBs with diastolic fractional flow reserve: 0.59 ± 0.13. Unroofing was performed with the patient under cardiopulmonary bypass (CPB) in the initial 9 cases and without CPB in the subsequent 5 cases. All patients were discharged without complications. The 13 symptomatic patients reported resolution of symptoms on follow-up, and improvement in symptoms and quality of life was documented using the Seattle Angina Questionnaire version 7. CONCLUSIONS Unroofing of MBs can be safely performed in pediatric patients, with or without use of CPB. In symptomatic patients, unroofing can provide relief of symptoms refractory to medical therapy.
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Affiliation(s)
- Katsuhide Maeda
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
| | - Ingela Schnittger
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
| | - Daniel J Murphy
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
| | - Jennifer A Tremmel
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
| | - Jack H Boyd
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Lynn Peng
- Department of Pediatric Cardiology, Stanford University, Stanford, Calif
| | - Kozo Okada
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
| | | | - Frank L Hanley
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | | | - Ian S Rogers
- Department of Cardiovascular Medicine, Stanford University, Stanford, Calif
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Cerrato E, Barbero U, D'Ascenzo F, Taha S, Biondi-Zoccai G, Omedè P, Bianco M, Echavarria-Pinto M, Escaned J, Gaita F, Varbella F. What is the optimal treatment for symptomatic patients with isolated coronary myocardial bridge? A systematic review and pooled analysis. J Cardiovasc Med (Hagerstown) 2018; 18:758-770. [PMID: 28834785 DOI: 10.2459/jcm.0000000000000551] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Myocardial bridging is a common coronary anomaly, with few severe adverse events but a relevant symptom burden. Myocardial bridging treatment, however, remains uncertain because of the lack of randomized trials. MATERIAL MEDLINE/PubMed was systematically screened for studies reporting on isolated myocardial bridging diagnosed at coronary angiography or with coronary computed tomography in patients admitted for suspected angina or with an acute coronary syndrome. Baseline, treatment and outcome data were appraised and pooled according to treatment (medical therapy, bypass surgery/myotomy or stenting). RESULTS A total of 899 patients in 18 studies were included with a low prevalence of traditional risk factors, especially diabetes (15.6%, interquartile range 2.5-21.5). After a median of 31.0 months (interquartile range 12.4-37.1), major cardiovascular events (composite of death, myocardial infarction or target vessel revascularization) occurred in only 3.4% of the study patients and 78.7% [70.5-86.9; 95% confidence intervals (CI)] were managed conservatively and free of symptoms. When an invasive strategy was planned, freedom from angina was higher in patients treated with surgery [84.5% (78.4-90.7; 95% CI)] than in those treated with stenting [54.7% (38.9-70.6; 95% CI)]. Patients in the stenting group experienced a high incidence of major cardiovascular events related to target vessel revascularization [40.07% (19.83-60.32; 95% CI)]. Meta-regression showed that patients treated with beta-blockers or with a history of hypertension were more likely to remain free from angina (B -0.6, P = 0.013; B -0.66, P = 0.006). CONCLUSION Patients with symptomatic isolated myocardial bridging generally have a good long-term prognosis. Pharmacological treatment alone, especially with beta-blockers, is able to improve angina in most cases. Surgical treatment appears to be more effective than stenting in nonresponders.
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Affiliation(s)
- Enrico Cerrato
- aInterventional Cardiology, San Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi Hospital bDivision of Cardiology, Città della Salute e della Scienza, University of Turin, Turin cDepartment of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina and Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli dDivision of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy eDepartment of Cardiology, Hospital General ISSSTE, Querétaro, México fHospital Clinico San Carlos, Madrid, Spain
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66
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Benenati S, De Maria GL, Scarsini R, Porto I, Banning AP. Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:362-372. [DOI: 10.1016/j.carrev.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 01/16/2018] [Indexed: 02/08/2023]
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Nishikii-Tachibana M, Pargaonkar VS, Schnittger I, Haddad F, Rogers IS, Tremmel JA, Wang PJ. Myocardial bridging is associated with exercise-induced ventricular arrhythmia and increases in QT dispersion. Ann Noninvasive Electrocardiol 2017; 23:e12492. [PMID: 28921787 PMCID: PMC6931813 DOI: 10.1111/anec.12492] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 07/27/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A myocardial bridge (MB) has been associated with ventricular arrhythmia and sudden death during exercise. QT dispersion (QTd) is a measure of abnormal repolarization and may predict ventricular arrhythmia. We investigated the frequency of ventricular arrhythmias during exercise and the QTd at rest and after exercise, in patients with an MB compared to a normal cohort. METHODS We studied the rest and stress ECG tracings of patients with an MB suspected by focal septal buckling on exercise echocardiography (EE) (Echo-MB group, N = 510), those with an MB confirmed by another examination (MB group, N = 110), and healthy controls (Control group, N = 198). RESULTS The frequency of exercise-induced premature ventricular contractions (PVCs) was significantly higher in the Echo-MB and MB groups compared with the Control group (both p < .001). In all, 25 patients (4.9%) in the Echo-MB group, seven patients (6.4%) in the MB group and no patients in the Control group had exercise-induced non-sustained ventricular tachycardia (NSVT). There was no difference in the baseline QTd between the groups. In the Echo-MB and MB groups, QTd postexercise increased significantly when compared with baseline (both p < .001). Patients with NSVT had a higher frequency of male gender and an even greater increase in QTd with exercise compared with the non-NSVT group. DISCUSSION There is an increased frequency of exercise-induced PVCs and NSVT in patients with MBs. Exercise significantly increases QTd in MB patients, with an even greater increase in QTd in MB patients with NSVT. Exercise in MB patients results in ventricular arrhythmias and abnormalities in repolarization.
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Affiliation(s)
- Makiko Nishikii-Tachibana
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Vedant S Pargaonkar
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ingela Schnittger
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ian S Rogers
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer A Tremmel
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul J Wang
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
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68
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Forsdahl SH, Rogers IS, Schnittger I, Tanaka S, Kimura T, Pargaonkar VS, Chan FP, Fleischmann D, Tremmel JA, Becker HC. Myocardial Bridges on Coronary Computed Tomography Angiography - Correlation With Intravascular Ultrasound and Fractional Flow Reserve. Circ J 2017; 81:1894-1900. [PMID: 28690285 DOI: 10.1253/circj.cj-17-0284] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Myocardial bridges (MB) are commonly seen on coronary CT angiography (CCTA) in asymptomatic individuals, but in patients with recurrent typical angina symptoms, yet no obstructive coronary artery disease (CAD), evaluation of their potential hemodynamic significance is clinically relevant. The aim of this study was to compare CCTA to invasive coronary angiography (ICA), including intravascular ultrasound (IVUS), to confirm MB morphology and estimate their functional significance in symptomatic patients.Methods and Results:We retrospectively identified 59 patients from our clinical databases between 2009 and 2014 in whom the suspicion for MB was raised by symptoms of recurrent typical angina in the absence of significant obstructive CAD on ICA. All patients underwent CCTA, ICA and IVUS. MB length and depth by CCTA agreed well with length (0.6±23.7 mm) and depth (CT coverage) as seen on IVUS. The product of CT length and depth (CT coverage), (MB muscle index (MMI)), ≥31 predicted an abnormal diastolic fractional flow reserve (dFFR) ≤0.76 with a sensitivity and specificity of 74% and 62% respectively (area under the curve=0.722). CONCLUSIONS In patients with recurrent symptoms of typical angina yet no obstructive CAD, clinicians should consider dynamic ischemia from an MB in the differential diagnosis. The product of length and depth (i.e., MMI) by CCTA may provide some non-invasive insight into the hemodynamic significance of a myocardial bridge, as compared with invasive assessment with dFFR.
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Affiliation(s)
| | - Ian S Rogers
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Shigemitsu Tanaka
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | - Takumi Kimura
- Division of Cardiovascular Medicine, Stanford University School of Medicine
| | | | - Frandics P Chan
- Department of Radiology, Stanford University School of Medicine
| | | | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University School of Medicine
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69
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Rogers IS, Tremmel JA, Schnittger I. Myocardial bridges: Overview of diagnosis and management. CONGENIT HEART DIS 2017; 12:619-623. [PMID: 28675696 DOI: 10.1111/chd.12499] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 05/20/2017] [Indexed: 12/30/2022]
Abstract
A myocardial bridge is a segment of a coronary artery that travels into the myocardium instead of the normal epicardial course. Although it is general perception that myocardial bridges are normal variants, patients with myocardial bridges can present with symptoms, such as exertional chest pain, that cannot be explained by a secondary etiology. Such patients may benefit from individualized medical/surgical therapy. This article describes the prevalence, clinical presentation, classification, evaluation, and management of children and adults with symptomatic myocardial bridges.
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Affiliation(s)
- Ian S Rogers
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA.,Division of Pediatric Cardiology, Stanford University, Stanford, California, USA
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
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Yacoub MH, Afifi A, Saad H, Aguib H, ElGuindy A. Current state of the art and future of myectomy. Ann Cardiothorac Surg 2017; 6:307-317. [PMID: 28944171 DOI: 10.21037/acs.2017.06.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical relief of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) requires more than septal myectomy. The procedure is currently the gold standard for all symptomatic HCM patients except those with comorbidities. The operation requires an individualized approach to restore the sophisticated functions of the left ventricular outflow tract (LVOT) without injury to the surrounding vital structures. The procedure should be tailored to deal with all the varied components of the obstruction including fibrous trigones, accessory tissues, and papillary muscle fusion. Preoperative multimodality imaging and numerical modeling combined with intraoperative transesophageal echocardiography (TEE) are essential to define existing anomalies as well as assess the adequacy of the repair. The mitral valve can be conserved in virtually all patients. The operation can be conducted with very low mortality and morbidity with predictable good outcomes both in the short and long term. Nevertheless, surgical relief of LVOTO is still grossly underused.
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Affiliation(s)
- Magdi H Yacoub
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed Afifi
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Hesham Saad
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Heba Aguib
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed ElGuindy
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
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71
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Tarantini G, Migliore F, Cademartiri F, Fraccaro C, Iliceto S. Left Anterior Descending Artery Myocardial Bridging: A Clinical Approach. J Am Coll Cardiol 2017; 68:2887-2899. [PMID: 28007148 DOI: 10.1016/j.jacc.2016.09.973] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 08/28/2016] [Accepted: 09/27/2016] [Indexed: 02/08/2023]
Abstract
A myocardial bridge (MB) is the term for the muscle overlying the intramyocardial segment of the epicardial coronary artery (referred to as a tunneled artery). Although MBs can be found in any epicardial artery, most of them involve the left anterior descending artery. These congenital coronary anomalies have long been recognized anatomically, and are traditionally considered a benign condition; however, the association between myocardial ischemia and MBs has increased their clinical relevance. This review summarizes the prevalence, pathophysiology, and diagnostic findings, including morphological, functional assessment, and treatment of patients with MB involving the left anterior descending artery, suggesting a pragmatic clinical approach to this entity.
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Affiliation(s)
- Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy.
| | - Federico Migliore
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Filippo Cademartiri
- Department of Radiology, Erasmus Medical Center University, Rotterdam, the Netherlands; Department of Radiology, Montréal Heart Institute, Universitè de Montréal, Montreal, Quebec, Canada
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padova, Italy
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72
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Agrawal H, Molossi S, Alam M, Sexson-Tejtel SK, Mery CM, McKenzie ED, Fraser CD, Qureshi AM. Anomalous Coronary Arteries and Myocardial Bridges: Risk Stratification in Children Using Novel Cardiac Catheterization Techniques. Pediatr Cardiol 2017; 38:624-630. [PMID: 28214966 DOI: 10.1007/s00246-016-1559-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/29/2016] [Indexed: 11/24/2022]
Abstract
The evaluation of the vast majority of children with anomalous aortic origin of a coronary artery (AAOCA) and/or myocardial bridges is performed with non-invasive testing. However, a subset of these patients may benefit from invasive testing for risk stratification. All patients included in the Coronary Anomalies Program (CAP) at Texas Children's Hospital who underwent cardiac catheterization were included. Techniques included selective coronary angiograms (SCA), intravascular ultrasound (IVUS), and fractional flow reserve (FFR) measurements with provocative testing using adenosine and/or dobutamine infusions. Out of the 131 patients followed by the CAP between 12/12-4/16, 8 (6%) patients underwent 9 cath investigations at median age 13.1 (2.6-18.7) years and median weight 49.5 (11.4-142.7) kg. Six patients presented with cardiac signs/symptoms. Four patients had myocardial bridges of the left anterior descending (LAD) coronary artery, 2 patients had isolated AAOCA, and 2 patients had an anomalous left coronary artery (LCA) with an intramyocardial course of the LAD. SCA was performed in all patients. FFR was positive in 4/6 patients: IVUS showed >70% intraluminal narrowing in 3/5 patients. One patient had hemodynamic instability that reversed with catheter removal from the coronary ostium. Based on the catheterization data obtained, findings were reassuring in three patients, surgery was performed in three patients, and two patients are being medically managed/restricted from competitive sports. In our small cohort of patients, we demonstrated that IVUS and FFR can safely be performed in children and may help to risk stratify some patients with AAOCA and myocardial bridges.
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Affiliation(s)
- Hitesh Agrawal
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Silvana Molossi
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Mahboob Alam
- Section of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - S Kristen Sexson-Tejtel
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Carlos M Mery
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - E Dean McKenzie
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Charles D Fraser
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA.,Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Athar M Qureshi
- Coronary Anomalies Program, Texas Children's Hospital, Houston, TX, USA. .,The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA. .,CE Mullins Cardiac Catheterization Laboratories, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin Street, West Tower, 19th Floor, Suite 19345-C, Houston, TX, 77030, USA.
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73
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Duygu H. Ischemia evaluation in patients with myocardial bridging: It's a tough situation? Int J Cardiol 2017; 229:63. [DOI: 10.1016/j.ijcard.2016.11.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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74
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Abudayyeh I, Tran BG, Tobis JM. Optimizing Coronary Angioplasty with FFR and Intravascular Imaging. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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75
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Boyd JH, Pargaonkar VS, Scoville DH, Rogers IS, Kimura T, Tanaka S, Yamada R, Fischbein MP, Tremmel JA, Mitchell RS, Schnittger I. Surgical Unroofing of Hemodynamically Significant Left Anterior Descending Myocardial Bridges. Ann Thorac Surg 2016; 103:1443-1450. [PMID: 27745841 DOI: 10.1016/j.athoracsur.2016.08.035] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/13/2016] [Accepted: 08/11/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Left anterior descending artery myocardial bridges (MBs) range from clinically insignificant incidental angiographic findings to a potential cause of sudden cardiac death. Within this spectrum, a group of patients with isolated, symptomatic, and hemodynamically significant MBs despite maximally tolerated medical therapy exist for whom the optimal treatment is controversial. We evaluated supraarterial myotomy, or surgical unroofing, of the left anterior descending MBs as an isolated procedure in these patients. METHODS In 50 adult patients, we prospectively evaluated baseline clinical characteristics, risk factors, and medications for coronary artery disease, relevant diagnostic data (stress echocardiography, computed tomography angiography, stress coronary angiogram with dobutamine challenge for measurement of diastolic fractional flow reserve, and intravascular ultrasonography), and anginal symptoms using the Seattle Angina Questionnaire. These patients then underwent surgical unroofing of their left anterior descending artery MBs followed by readministration of the Seattle Angina Questionnaire at 6.6-month (range, 2 to 13) follow-up after surgery. RESULTS Dramatic improvements were noted in physical limitation due to angina (52.0 versus 87.1, p < 0.001), anginal stability (29.6 versus 66.4, p < 0.001), anginal frequency (52.1 versus 84.7, p < 0.001), treatment satisfaction (76.1 versus 93.9, p < 0.001), and quality of life (25.0 versus 78.9, p < 0.001), all five dimensions of the Seattle Angina Questionnaire. There were no major complications or deaths. CONCLUSIONS Surgical unroofing of carefully selected patients with MBs can be performed safely as an independent procedure with significant improvement in symptoms postoperatively. It is the optimal treatment for isolated, symptomatic, and hemodynamically significant MBs resistant to maximally tolerated medical therapy.
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Affiliation(s)
- Jack H Boyd
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
| | - Vedant S Pargaonkar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - David H Scoville
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Ian S Rogers
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Takumi Kimura
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Shigemitsu Tanaka
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Ryotaro Yamada
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jennifer A Tremmel
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Robert Scott Mitchell
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Aleksandric S, Djordjevic-Dikic A, Beleslin B, Parapid B, Teofilovski-Parapid G, Stepanovic J, Simic D, Nedeljkovic I, Petrovic M, Dobric M, Tomasevic M, Banovic M, Nedeljkovic M, Ostojic M. Noninvasive assessment of myocardial bridging by coronary flow velocity reserve with transthoracic Doppler echocardiography: vasodilator vs. inotropic stimulation. Int J Cardiol 2016; 225:37-45. [PMID: 27710800 DOI: 10.1016/j.ijcard.2016.09.101] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Accepted: 09/25/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND To consider hemodynamic assessment of myocardial bridging (MB) adequate, it is believed that inotropic stimulation with dobutamine should be estimated because its dynamic nature depends on the degree of extravascular coronary compression. This study evaluated comparative assessment of hemodynamic relevance of MB using coronary flow velocity reserve (CFVR) measurements by transthoracic Doppler echocardiography (TTDE) with vasodilatative and inotropic challenges. METHODS This prospective study included forty-four patients with angiographic evidence of isolated MB of the left anterior descending coronary artery (LAD) and systolic compression of ≥50% diameter stenosis. All patients were evaluated by exercise stress-echocardiography (ExSE) test for signs of myocardial ischemia, and CFVR of the distal segment of LAD during iv.infusion of adenosine (ADO:140μg/kg/min) and iv.infusion of dobutamine (DOB:10-40μg/kg/min), separately. RESULTS Exercise-SE was positive for myocardial ischemia in 8/44 (18%) of patients. CFVR during ADO was significantly higher than CFVR during peak DOB (2.85±0.68 vs. 2.44±0.48, p=0.002). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (2.01±0.16 vs. 2.54±0.47, p<0.001), but not for ADO (2.47±0.51 vs. 2.89±0.70, p=0.168), respectively. Multivariable logistic analysis showed that CFVR peak DOB was the most significant predictor of functional significant MB (OR 0.011, 95%CI: 0.001-0.507, p=0.021). Receiver-operating characteristic curves have shown that TTDE-CFVR obtained by high-dose of dobutamine infusion is better than those by adenosine regarding to functional status of MB (AUC 0.861, p=0.004; AUC 0.674, p=0.179, respectively). CONCLUSIONS Non-invasive CFVR measurement by TTDE during inotropic stimulation, in comparison to vasodilation, provides more reliable functional evaluation of MB.
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Affiliation(s)
| | - Ana Djordjevic-Dikic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Branko Beleslin
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Biljana Parapid
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | | | - Jelena Stepanovic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Dragan Simic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Ivana Nedeljkovic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Milan Petrovic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Milan Dobric
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Miloje Tomasevic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Kragujevac, School of Medicine, Kragujevac, Serbia
| | - Marko Banovic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Milan Nedeljkovic
- Division of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Miodrag Ostojic
- University of Belgrade, School of Medicine, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
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77
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Gould KL, Johnson NP. Myocardial Bridges: Lessons in Clinical Coronary Pathophysiology. JACC Cardiovasc Imaging 2016; 8:705-9. [PMID: 26068287 DOI: 10.1016/j.jcmg.2015.02.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 02/10/2015] [Indexed: 11/29/2022]
Affiliation(s)
- K Lance Gould
- Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, University of Texas Medical School at Houston and Memorial Hermann Hospital, Houston, Texas.
| | - Nils P Johnson
- Weatherhead PET Center for Preventing and Reversing Atherosclerosis, Division of Cardiology, Department of Medicine, University of Texas Medical School at Houston and Memorial Hermann Hospital, Houston, Texas
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78
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A bridge over troubled water: Functional assessment of a myocardial bridge by Gili S Taha S, Omedé P et al. Int J Cardiol 2016; 203:1135. [PMID: 26608009 DOI: 10.1016/j.ijcard.2015.08.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 08/26/2015] [Indexed: 11/21/2022]
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79
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Uusitalo V, Saraste A, Knuuti J. Multimodality Imaging in the Assessment of the Physiological Significance of Myocardial Bridging. Curr Cardiol Rep 2015; 18:2. [PMID: 26694724 DOI: 10.1007/s11886-015-0685-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
In myocardial bridging (MB) a segment of the coronary artery is covered by the myocardium. MB can be seen as a systolic compression by invasive coronary angiography (ICA) or as an intramural course by computed tomography angiography (CTA). Intramural course is a common incidental finding in CTA studies. Only minority of the bridging segments are associated with systolic compression causing a possible impairment of myocardial perfusion. The relationship between myocardial blood flow and MB is complex and poorly evaluated by anatomic imaging. Furthermore, provocation tests are frequently needed to uncover systolic compression. Fractional flow reserve can be used to assess the hemodynamic significance of MB. Nuclear perfusion imaging can demonstrate flow abnormalities associated with MB. Stress echocardiography can demonstrate ischemic wall motion abnormalities. They can be complemented by hybrid imaging with CTA to distinguish epicardial coronary artery disease and MB. This article will review different imaging modalities for the evaluation of the physiologic significance of MB.
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Affiliation(s)
- Valtteri Uusitalo
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Antti Saraste
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.,Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.,Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, University of Turku, Turku, Finland
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80
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Gili S, Taha S, Omedé P, Moretti C. A bridge over troubled water: Functional assessment of a myocardial bridge. Int J Cardiol 2015; 201:285-7. [DOI: 10.1016/j.ijcard.2015.08.092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/08/2015] [Indexed: 02/08/2023]
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81
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Lee SE, Yu CW, Park K, Park KW, Suh JW, Cho YS, Youn TJ, Chae IH, Choi DJ, Jang HJ, Park JS, Na SH, Kim HS, Kim KB, Koo BK. Physiological and clinical relevance of anomalous right coronary artery originating from left sinus of Valsalva in adults. Heart 2015; 102:114-9. [DOI: 10.1136/heartjnl-2015-308488] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/14/2015] [Indexed: 11/03/2022] Open
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Kobayashi Y, Tremmel JA, Kobayashi Y, Amsallem M, Tanaka S, Yamada R, Rogers IS, Haddad F, Schnittger I. Exercise Strain Echocardiography in Patients With a Hemodynamically Significant Myocardial Bridge Assessed by Physiological Study. J Am Heart Assoc 2015; 4:e002496. [PMID: 26581225 PMCID: PMC4845237 DOI: 10.1161/jaha.115.002496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 09/21/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although a myocardial bridge (MB) is often regarded as a benign coronary variant, recent studies have associated MB with focal myocardial ischemia. The physiological consequences of MB on ventricular function during stress have not been well established. METHODS AND RESULTS We enrolled 58 patients with MB of the left anterior descending artery, diagnosed by intravascular ultrasound. Patients underwent invasive physiological evaluation of the MB by diastolic fractional flow reserve during dobutamine challenge and exercise echocardiography. Septal and lateral longitudinal strain (LS) were assessed at rest and immediately after exercise and compared with strain of matched controls. Absolute and relative changes in strain were also calculated. The mean age was 42.5±16.0 years. Fifty-five patients had a diastolic fractional flow reserve ≤0.76. At rest, there was no significant difference between the 2 groups in septal LS (19.0±1.8% for patients with MB versus 19.2±1.5% for control, P=0.53) and lateral LS (20.1±2.0% versus 20.0±1.6%, P=0.83). With stress, compared with controls, patients with MB had a lower peak septal LS (18.9±2.6% versus 21.7±1.6%, P<0.001) and lower absolute (-0.1±2.1% versus 2.5±1.3%, P<0.001) and relative change (-0.6±11.2% versus 13.1±7.8%, P<0.001) in septal LS, whereas there was no significant difference in lateral LS. In multivariate analysis, diastolic fractional flow reserve and length were independent determinants of lower changes in septal LS. CONCLUSIONS Patients with a hemodynamically significant MB, determined by invasive diastolic fractional flow reserve, have significantly lower change in septal LS on exercise echocardiography, suggesting that septal LS may be useful for noninvasively assessing the hemodynamic significance of an MB.
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Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Jennifer A. Tremmel
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Yuhei Kobayashi
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Myriam Amsallem
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Shigemitsu Tanaka
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Ryotaro Yamada
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Ian S. Rogers
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Division of Pediatric CardiologyStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Francois Haddad
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
| | - Ingela Schnittger
- Division of Cardiovascular MedicineStanford University School of MedicineStanfordCA
- Stanford Cardiovascular InstituteStanfordCA
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83
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Invasive physiologic and anatomic multimodality assessment of myocardial bridging. Coron Artery Dis 2015; 26 Suppl 1:e38-40. [PMID: 26247269 DOI: 10.1097/mca.0000000000000206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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84
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The Functional Effects of Intramural Course of Coronary Arteries and its Relation to Coronary Atherosclerosis. JACC Cardiovasc Imaging 2015; 8:697-704. [DOI: 10.1016/j.jcmg.2015.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 03/24/2015] [Accepted: 04/02/2015] [Indexed: 12/31/2022]
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85
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Response to letter by Hendrik Bonnemeier: Is it coronary kinking or vasospasm induced myocardial ischemia? Int J Cardiol 2015; 184:486. [DOI: 10.1016/j.ijcard.2015.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/02/2015] [Indexed: 11/17/2022]
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86
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Corban MT, Hung OY, Timmins LH, Samady H. Reply: Myocardial bridging. J Am Coll Cardiol 2014; 64:2179-81. [PMID: 25457409 DOI: 10.1016/j.jacc.2014.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 09/08/2014] [Indexed: 02/08/2023]
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87
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Indolfi C, Mongiardo A, Spaccarotella C, Torella D, Caiazzo G, Polimeni A, Sorrentino S, Micieli M, Sabatino J, Curcio A, De Rosa S. The instantaneous wave-free ratio (iFR) for evaluation of non-culprit lesions in patients with acute coronary syndrome and multivessel disease. Int J Cardiol 2014; 178:46-54. [PMID: 25464218 DOI: 10.1016/j.ijcard.2014.03.210] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND Adenosine administration is currently required for evaluation of stenosis severity with fractional flow reserve (FFR). The instantaneous wave-free ratio (iFR) was recently introduced as an adenosine-free alternative in patients with stable CAD. The aim of the present study was to replicate the findings of previous iFR studies using an independent calculation algorithm and to evaluate the iFR for the assessment of non-culprit vessels in patients with acute coronary syndrome (ACS). METHODS AND RESULTS 53 patients with ACS (65%) and at least one non-culprit intermediate lesion and 29 (35%) with stable CAD were included. A total of 123 stenoses were evaluated with both FFR and iFR. Classification match of iFR in ACS was not inferior to stable CAD (79.5% in ACS and 84.4% in CAD; p=0.497). Accordingly, no difference was observed in iFR/FFR correlation between ACS and stable CAD (r=0.66 in ACS vs. r=0.69 in CAD). Overall, a significant correlation was found between iFR and FFR (r=0.68; p<0.001) with a good diagnostic efficiency at ROC analysis (area under the curve: 0.87). In addition, neither the localization of the stenosis within the coronary tree (p=0.147) nor the time interval from the acute event (p=0.550) significantly influenced the concordance of iFR with FFR. CONCLUSIONS The iFR is a promising method for the assessment of non-culprit lesion severity in patients with acute coronary syndrome.
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Affiliation(s)
- Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy; URT-CNR, Magna Graecia University, Catanzaro, Italy.
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Daniele Torella
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Gianluca Caiazzo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Mariella Micieli
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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88
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Aparci M, Ozturk C, Balta S, Okutucu S, Isilak Z. Hypercholesterolemia is Accounted for Atherosclerosis at the Proximal Arterial Segments of Myocardial Bridging. Clin Appl Thromb Hemost 2014; 22:297-302. [DOI: 10.1177/1076029614554995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Arterial shear stress was generally implicated in the development of atherosclerotic plaque (AP). Atherosclerotic plaque may be associated with myocardial bridging (MB). We evaluated the metabolic abnormalities which could determine the localization of AP at the proximal coronary segment of MB. We analyzed the patients with MB, AP&MB, and AP on left anterior descending (LAD) artery who were diagnosed by multislice computed tomography coronary angiography. Serum levels of metabolic parameters were compared among study groups. Patients with MB&AP and AP were significantly older than those in the MB group. Patients with MB&AP had AP and MB at the proximal and middle segments of LAD artery, respectively. Total cholesterol, low-density lipoprotein (LDL) cholesterol and very LDL, and triglyceride levels were significantly higher in patients with MB&AP and AP compared to only MB. Low-density lipoprotein cholesterol was significantly correlated with the type of coronary artery disease in multiple regression analysis. Myocardial bridging may be an anatomical determinant for the localization of AP proximal to itself in the presence of hypercholesterolemia.
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Affiliation(s)
- Mustafa Aparci
- Department of Cardiology, Etimesgut Military Hospital, Ankara, Turkey
| | - Cengiz Ozturk
- Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey
| | - Sevket Balta
- Department of Cardiology, Eskisehir Military Hospital, Ankara, Turkey
| | - Sercan Okutucu
- Department of Cardiology, Etimesgut Military Hospital, Ankara, Turkey
| | - Zafer Isilak
- Department of Cardiology, Haydarpasa Training Medicine, Istanbul, Turkey
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89
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Corban MT, Hung OY, Eshtehardi P, Rasoul-Arzrumly E, McDaniel M, Mekonnen G, Timmins LH, Lutz J, Guyton RA, Samady H. Myocardial bridging: contemporary understanding of pathophysiology with implications for diagnostic and therapeutic strategies. J Am Coll Cardiol 2014; 63:2346-2355. [PMID: 24583304 DOI: 10.1016/j.jacc.2014.01.049] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/24/2014] [Accepted: 01/28/2014] [Indexed: 12/30/2022]
Abstract
Patients with myocardial bridging are often asymptomatic, but this anomaly may be associated with exertional angina, acute coronary syndromes, cardiac arrhythmias, syncope, or even sudden cardiac death. This review presents our understanding of the pathophysiology of myocardial bridging and describes prevailing diagnostic modalities and therapeutic options for this challenging clinical entity.
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Affiliation(s)
- Michel T Corban
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Olivia Y Hung
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Parham Eshtehardi
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Emad Rasoul-Arzrumly
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Michael McDaniel
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Girum Mekonnen
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Lucas H Timmins
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA
| | - Jerre Lutz
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Robert A Guyton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Habib Samady
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
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90
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Chalyan DA, Zhang Z, Takarada S, Molloi S. End-diastolic fractional flow reserve: comparison with conventional full-cardiac cycle fractional flow reserve. Circ Cardiovasc Interv 2014; 7:28-34. [PMID: 24496240 DOI: 10.1161/circinterventions.113.000327] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Diastolic fractional flow reserve (dFFR) has been shown to be highly sensitive for detection of inducible myocardial ischemia. However, its reliance on measurement of left-ventricular pressure for zero-flow pressure correction, as well as manual extraction of the diastolic interval, has been its major limitation. Given previous reports of minimal zero-flow pressure at end-diastole, we compared instantaneous ECG-gated end-diastolic FFR with conventional full-cardiac cycle FFR and other diastolic indices in the porcine model. METHODS AND RESULTS Measurements of FFR in the left anterior descending and left circumflex arteries were performed in an open-chest swine model with an external occluder device on the coronary artery used to produce varying degrees of epicardial stenosis. An ultrasound flow-probe that was placed proximal to the occluder measured absolute blood flow in ml/min, and it was used as a gold standard for FFR measurement. A total of 17 measurements at maximal hyperemia were acquired in 5 animals. Correlation coefficient between conventional mean hyperemic FFR with pressure-wire and directly measured FFR with flow-probe was 0.876 (standard error estimate=0.069; P<0.0001). The hyperemic end-diastolic FFR with pressure-wire correlated better with FFR measured directly with flow-probe (r=0.941, standard error estimate=0.050; P<0.0001). CONCLUSIONS Instantaneous hyperemic ECG-gated FFR acquired at end-diastole, as compared with conventional full-cardiac cycle FFR, has an improved correlation with FFR measured directly with ultrasound flow-probe.
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Affiliation(s)
- David A Chalyan
- From the Department of Radiological Sciences, University of California-Irvine, Irvine, CA (D.A.C., Z.Z., S.M.); Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA (D.A.C.); Department of Radiology, Tianjin Medical University General Hospital, Tianjin, China (Z.Z.); Division of Cardiology, University of California-Irvine, Orange, CA (S.T.)
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91
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Yoshino S, Cassar A, Matsuo Y, Herrmann J, Gulati R, Prasad A, Lennon RJ, Lerman LO, Lerman A. Fractional flow reserve with dobutamine challenge and coronary microvascular endothelial dysfunction in symptomatic myocardial bridging. Circ J 2014; 78:685-92. [PMID: 24463708 DOI: 10.1253/circj.cj-13-0846] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Myocardial bridging (MB) results in compression of the coronary artery lumen in systole, extending into diastole with resultant hemodynamic alternation as reflected by fractional flow reserve (FFR). MB has also been associated with coronary endothelial dysfunction. The objective of this study was to investigate relationship between FFR with dobutamine challenge and coronary microvascular endothelial dysfunction in symptomatic MB. METHODS AND RESULTS Seventeen consecutive patients who had cardiac catheterization assessment of MB were enrolled. The patients were divided into 2 groups according to normal (% increase in coronary blood flow [%CBF] ≥50%, n=7) or impaired (%CBF <50%, n=10) coronary microvascular endothelial function assessed on vasoreactivity in the coronary artery with intracoronary infusion of acetylcholine (Ach). Myocardial ischemia was then assessed using FFR at rest and during i.v. dobutamine infusion challenge across the MB with intracoronary pressure wires. FFR was significantly decreased at peak dobutamine infusion compared to at rest in the impaired group (0.85±0.06 vs. 0.91±0.05, P=0.001), but not in the normal group (0.93±0.05 vs. 0.91±0.07, P=0.618). Both FFR at rest and at peak dobutamine infusion had a positive correlation with %CBF by Ach in the impaired group (r(2)=0.46, P=0.030; r(2)=0.52, P=0.018, respectively). CONCLUSIONS Microvascular endothelial dysfunction was associated with decreased FFR at peak dobutamine stress in patients with symptomatic MB.
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Affiliation(s)
- Satoshi Yoshino
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and College of Medicine
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92
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Lin S, Tremmel JA, Yamada R, Rogers IS, Yong CM, Turcott R, McConnell MV, Dash R, Schnittger I. A novel stress echocardiography pattern for myocardial bridge with invasive structural and hemodynamic correlation. J Am Heart Assoc 2013; 2:e000097. [PMID: 23591827 PMCID: PMC3647262 DOI: 10.1161/jaha.113.000097] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Background Patients with a myocardial bridge (MB) and no significant obstructive coronary artery disease (CAD) may experience angina presumably from ischemia, but noninvasive assessment has been limited and the underlying mechanism poorly understood. This study seeks to correlate a novel exercise echocardiography (EE) finding for MBs with invasive structural and hemodynamic measurements. Methods and Results Eighteen patients with angina and an EE pattern of focal end‐systolic to early‐diastolic buckling in the septum with apical sparing were prospectively enrolled for invasive assessment. This included coronary angiography, left anterior descending artery (LAD) intravascular ultrasound (IVUS), and intracoronary pressure and Doppler measurements at rest and during dobutamine stress. All patients were found to have an LAD MB on IVUS. The ratios of diastolic intracoronary pressure divided by aortic pressure at rest (Pd/Pa) and during dobutamine stress (diastolic fractional flow reserve [dFFR]) and peak Doppler flow velocity recordings at rest and with stress were successfully performed in 14 patients. All had abnormal dFFR (≤0.75) at stress within the bridge, distally or in both positions, and on average showed a more than doubling in peak Doppler flow velocity inside the MB at stress. Seventy‐five percent of patients had normalization of dFFR distal to the MB, with partial pressure recovery and a decrease in peak Doppler flow velocity. Conclusions A distinctive septal wall motion abnormality with apical sparing on EE is associated with a documented MB by IVUS and a decreased dFFR. We posit that the septal wall motion abnormality on EE is due to dynamic ischemia local to the compressed segment of the LAD from the increase in velocity and decrease in perfusion pressure, consistent with the Venturi effect.
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Affiliation(s)
- Shin Lin
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
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93
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Rubinshtein R, Gaspar T, Lewis BS, Prasad A, Peled N, Halon DA. Long-term prognosis and outcome in patients with a chest pain syndrome and myocardial bridging: a 64-slice coronary computed tomography angiography study. Eur Heart J Cardiovasc Imaging 2013; 14:579-85. [DOI: 10.1093/ehjci/jet010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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94
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Oh JH, Lee HW, Cha KS. Hemodynamic significance of coronary cameral fistula assessed by fractional flow reserve. Korean Circ J 2012; 42:845-8. [PMID: 23323123 PMCID: PMC3539051 DOI: 10.4070/kcj.2012.42.12.845] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 04/30/2012] [Accepted: 05/12/2012] [Indexed: 12/29/2022] Open
Abstract
Coronary cameral fistula (CCF) is a rare anomaly, where a communication exists between an epicardial coronary artery and a cardiac chamber. Assessing the hemodynamic significance of the fistula is crucial to make a decision concerning the management process. We present two cases of CCF, draining into the left ventricle, in which the hemodynamic significance was assessed by a fractional flow reserve.
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Affiliation(s)
- Jun-Hyok Oh
- Department of Cardiology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
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95
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Tanaka N. Fractional flow reserve for guidance in intervention of multiple sequential lesions. J Cardiol Cases 2012; 6:e183-e184. [PMID: 30533101 PMCID: PMC6269414 DOI: 10.1016/j.jccase.2012.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Indexed: 11/29/2022] Open
Affiliation(s)
- Nobuhiro Tanaka
- Tokyo Medical University, Department of Cardiology, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
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96
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Cai W, Dong Y, Zhou X, Chen SB, Zhao JH, Jiang TM, Li YM. Left ventricular systolic dyssynchrony in patients with isolated symptomatic myocardial bridge. SCAND CARDIOVASC J 2012; 47:11-9. [PMID: 23036109 DOI: 10.3109/14017431.2012.736635] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The impact of myocardial bridge (MB) on left ventricular (LV) systolic synchrony is insufficiently understood. DESIGN Thirty-five subjects with isolated mid-left, anterior, descending artery (LAD) MB, preserved LV ejection fraction (LVEF > 50%), and otherwise, normal coronary angiogram were identified from 3607 patients who underwent diagnostic coronary angiography and were evaluated by tissue Doppler imaging and real-time three-dimensional echocardiography (RT3DE). Control subjects consisted of 26 age and sex-matched coronary angiographically "normal" subjects. RESULTS MB patients were characterized by reduced, early, diastolic strain rate in LAD-supplied apical segments (lateral and anterior), with prevalence of LV systolic dyssynchrony of 25.7% (9/35). MB patients were further classified by the medians of MB stenosis and length. For MB stenosis < 52.5%, Class I: length < 17 mm (n = 7), Class II: length ≥ 17 mm (n = 10); for stenosis ≥ 52.5%, Class III: length < 17 mm (n = 10), Class IV: length ≥ 17 mm (n = 8). Binary Logistic regression model revealed that higher MB lesion classification (odds ratio: 4.944, 95%CI 1.174-20.82, P < 0.05) and hypertension (odds ratio: 15.32, 95%CI: 1.252-187.6, P < 0.05) are statistically associated with LV systolic dyssynchrony, which was independent of LV mass. CONCLUSIONS MB in the mid LAD is associated with myocardial dyssynchrony. Hypertensive individuals and those with more severe bridging (determined by length and stenosis) tend to have an increased incidence of dyssynchrony.
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Affiliation(s)
- Wei Cai
- Institute of Cardiovascular Disease and Heart Center, Pingjin Hospital, Logistics University of Chinese People's Armed Police Forces, Tianjin, PR China
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Park K, Youn TJ, Park KW, Na SH, Lee HY, Kang HJ, Chung WY, Koo BK, Chae IH, Choi DJ, Kim HS, Oh BH, Park YB. Physiologic evaluation of myocardial bridging: a new analysis for an old disease. Can J Cardiol 2011; 27:596-600. [PMID: 21641176 DOI: 10.1016/j.cjca.2011.01.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 01/11/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Myocardial bridging (MB) is the most common congenital coronary anomaly. However, the functional relevance of MB is not well understood. METHODS Eighteen patients with lone MB were consecutively enrolled. Fractional flow reserve (FFR) was measured before and after dobutamine infusion. Diastolic FFR was calculated by offline analysis. Cutoff values for functional significance of FFR and diastolic FFR were 0.75 and 0.76, respectively. RESULTS Baseline systolic percent diameter stenosis and lesion length of MB were 70 ± 16% and 24 ± 7 mm. FFR and diastolic FFR were 0.92 ± 0.05 and 0.89 ± 0.07 at maximal hyperemia induced by adenosine, respectively (P = 0.006). Despite the angiographic stenosis, only 1 lesion was functionally significant. After dobutamine infusion, percent diameter stenosis (84 ± 11%, P = 0.002) and lesion length (26 ± 6 mm, P = 0.019) were aggravated and diastolic FFR was lowered (0.84 ± 0.10, P = 0.006). Two additional lesions became functionally significant after dobutamine infusion. Angiographic percent diameter stenosis at diastole was correlated with dobutamine diastolic FFR (R = -0.58, P = 0.04), but stenosis at systole was not. During median follow-up of 54 months, 2 patients underwent target-lesion revascularization. CONCLUSIONS Dobutamine increased the morphologic and functional severity of MB. Dobutamine-FFR seems to be helpful in the functional assessment of MB.
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Affiliation(s)
- Kyungil Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
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98
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Sen S, Escaned J, Malik IS, Mikhail GW, Foale RA, Mila R, Tarkin J, Petraco R, Broyd C, Jabbour R, Sethi A, Baker CS, Bellamy M, Al-Bustami M, Hackett D, Khan M, Lefroy D, Parker KH, Hughes AD, Francis DP, Di Mario C, Mayet J, Davies JE. Development and validation of a new adenosine-independent index of stenosis severity from coronary wave-intensity analysis: results of the ADVISE (ADenosine Vasodilator Independent Stenosis Evaluation) study. J Am Coll Cardiol 2011; 59:1392-402. [PMID: 22154731 DOI: 10.1016/j.jacc.2011.11.003] [Citation(s) in RCA: 499] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 11/03/2011] [Accepted: 11/03/2011] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The purpose of this study was to develop an adenosine-independent, pressure-derived index of coronary stenosis severity. BACKGROUND Assessment of stenosis severity with fractional flow reserve (FFR) requires that coronary resistance is stable and minimized. This is usually achieved by administration of pharmacological agents such as adenosine. In this 2-part study, we determine whether there is a time when resistance is naturally minimized at rest and assess the diagnostic efficiency, compared with FFR, of a new pressure-derived adenosine-free index of stenosis severity over that time. METHODS A total of 157 stenoses were assessed. In part 1 (39 stenoses), intracoronary pressure and flow velocity were measured distal to the stenosis; in part 2 (118 stenoses), intracoronary pressure alone was measured. Measurements were made at baseline and under pharmacologic vasodilation with adenosine. RESULTS Wave-intensity analysis identified a wave-free period in which intracoronary resistance at rest is similar in variability and magnitude (coefficient of variation: 0.08 ± 0.06 and 284 ± 147 mm Hg s/m) to those during FFR (coefficient of variation: 0.08 ± 0.06 and 302 ± 315 mm Hg s/m; p = NS for both). The resting distal-to-proximal pressure ratio during this period, the instantaneous wave-free ratio (iFR), correlated closely with FFR (r = 0.9, p < 0.001) with excellent diagnostic efficiency (receiver-operating characteristic area under the curve of 93%, at FFR <0.8), specificity, sensitivity, negative and positive predictive values of 91%, 85%, 85%, and 91%, respectively. CONCLUSIONS Intracoronary resistance is naturally constant and minimized during the wave-free period. The instantaneous wave-free ratio calculated over this period produces a drug-free index of stenosis severity comparable to FFR. (Vasodilator Free Measure of Fractional Flow Reserve [ADVISE]; NCT01118481).
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Affiliation(s)
- Sayan Sen
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, UK.
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99
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Galbraith EM, Eshtehardi P, Samady H. SPECT perfusion imaging and myocardial bridges: bridging the gap of diagnostic uncertainty. J Nucl Cardiol 2011; 18:1000-2. [PMID: 21842329 DOI: 10.1007/s12350-011-9443-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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100
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Jhi JH, Cho KI, Ha JK, Jung CW, kim BJ, Park SO, Jo AR, Kim SM, Lee HG, Kim TI. Alteration of left ventricular function with dobutamine challenge in patients with myocardial bridge. Korean J Intern Med 2011; 26:410-20. [PMID: 22205841 PMCID: PMC3245389 DOI: 10.3904/kjim.2011.26.4.410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/18/2011] [Accepted: 06/17/2011] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND/AIMS The aim of this study was to identify changes in left ventricular (LV) performance in patients with a myocardial bridge (MB) in the left anterior descending coronary artery during resting and in an inotropic state. METHODS Myocardial strain measurement by speckle-tracking echocardiography and conventional LV wall-motion scoring was performed in 18 patients with MB (mean age, 48.1 ± 1.7 years, eight female) during resting and intravenous dobutamine challenge (10 and 20 µg/kg/min). RESULTS Conventional LV wall-motion scoring was normal in all patients during resting and in an inotropic state. Peak regional circumferential strain increased dose dependently upon dobutamine challenge. Longitudinal strains of the anterior and anteroseptal segments were, however, reduced at 20 µg/kg/min and showed a dyssynchronous pattern at 20 µg/kg/min. Although there were no significant differences in radial strain and displacement of all segments at rest compared with under 10 µg/kg/min challenge, radial strain and displacement of anterior segments at 20 µg/kg/min were significantly reduced compared with posterior segments at the papillary muscle level (44.8 ± 14.9% vs. 78.4 ± 20.1% and 5.3 ± 2.3 mm vs. 8.5 ± 1.8 mm, respectively; all p < 0.001), and showed plateau (40%) or biphasic (62%) patterns. CONCLUSIONS Reduced LV strain of patients with MB after inotropic stimulation was identified. Speckle-tracking strain echocardiography identified a LV myocardial dyssynchrony that was not demonstrated by conventional echocardiography in patients with MB.
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Affiliation(s)
- Joon-Hyung Jhi
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Kyoung-Im Cho
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Jong-kun Ha
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Chan-Woo Jung
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Bong-Jae kim
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Seong-Oh Park
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - A-Ra Jo
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Seong-Man Kim
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Hyeon-Gook Lee
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
| | - Tae-Ik Kim
- Division of Cardiology, Department of Internal Medicine, Maryknoll Medical Center, Busan, Korea
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