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Carpenter HJ, Gholipour A, Ghayesh MH, Zander AC, Psaltis PJ. In Vivo Based Fluid-Structure Interaction Biomechanics of the Left Anterior Descending Coronary Artery. J Biomech Eng 2021; 143:081001. [PMID: 33729476 DOI: 10.1115/1.4050540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Indexed: 12/25/2022]
Abstract
A fluid-structure interaction-based biomechanical model of the entire left anterior descending coronary artery is developed from in vivo imaging via the finite element method in this paper. Included in this investigation is ventricle contraction, three-dimensional motion, all angiographically visible side branches, hyper/viscoelastic artery layers, non-Newtonian and pulsatile blood flow, and the out-of-phase nature of blood velocity and pressure. The fluid-structure interaction model is based on in vivo angiography of an elite athlete's entire left anterior descending coronary artery where the influence of including all alternating side branches and the dynamical contraction of the ventricle is investigated for the first time. Results show the omission of side branches result in a 350% increase in peak wall shear stress and a 54% decrease in von Mises stress. Peak von Mises stress is underestimated by up to 80% when excluding ventricle contraction and further alterations in oscillatory shear indices are seen, which provide an indication of flow reversal and has been linked to atherosclerosis localization. Animations of key results are also provided within a video abstract. We anticipate that this model and results can be used as a basis for our understanding of the interaction between coronary and myocardium biomechanics. It is hoped that further investigations could include the passive and active components of the myocardium to further replicate in vivo mechanics and lead to an understanding of the influence of cardiac abnormalities, such as arrythmia, on coronary biomechanical responses.
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Affiliation(s)
- Harry J Carpenter
- School of Mechanical Engineering, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Alireza Gholipour
- School of Mechanical Engineering, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Mergen H Ghayesh
- School of Mechanical Engineering, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Anthony C Zander
- School of Mechanical Engineering, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia 5000, Australia; Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia 5000, Australia
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52
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Montone RA, Gurgoglione FL, Del Buono MG, Rinaldi R, Meucci MC, Iannaccone G, La Vecchia G, Camilli M, D’Amario D, Leone AM, Vergallo R, Aurigemma C, Buffon A, Romagnoli E, Burzotta F, Trani C, Crea F, Niccoli G. Interplay Between Myocardial Bridging and Coronary Spasm in Patients With Myocardial Ischemia and Non-Obstructive Coronary Arteries: Pathogenic and Prognostic Implications. J Am Heart Assoc 2021; 10:e020535. [PMID: 34259010 PMCID: PMC8483499 DOI: 10.1161/jaha.120.020535] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/21/2021] [Indexed: 12/04/2022]
Abstract
Background Myocardial bridging (MB) may represent a cause of myocardial ischemia in patients with non-obstructive coronary artery disease (NOCAD). Herein, we assessed the interplay between MB and coronary vasomotor disorders, also evaluating their prognostic relevance in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA) or stable NOCAD. Methods and Results We prospectively enrolled patients with NOCAD undergoing intracoronary acetylcholine provocative test. The incidence of major adverse cardiac events, defined as the composite of cardiac death, non-fatal myocardial infarction, and rehospitalization for unstable angina, was assessed at follow-up. We also assessed angina status using Seattle Angina Questionnaires summary score. We enrolled 310 patients (mean age, 60.6±11.9; 136 [43.9%] men; 169 [54.5%] stable NOCAD and 141 [45.5%] MINOCA). MB was found in 53 (17.1%) patients. MB and a positive acetylcholine test coexisted more frequently in patients with MINOCA versus stable NOCAD. MB was an independent predictor of positive acetylcholine test and MINOCA. At follow-up (median, 22 months; interquartile range, 13-32), patients with MB had a higher rate of major adverse cardiac events, mainly driven by a higher rate of hospitalization attributable to angina, and a lower Seattle Angina Questionnaires summary score (all P<0.001) compared with patients without MB. In particular, the group of patients with MB and a positive acetylcholine test had the worst prognosis. Conclusions Among patients with NOCAD, coronary spasm associated with MB may predict a worse clinical presentation with MINOCA and a higher rate of hospitalization attributable to angina at long-term follow-up with a low rate of hard events.
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Affiliation(s)
- Rocco A. Montone
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Filippo Luca Gurgoglione
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Maria Chiara Meucci
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Giulia Iannaccone
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Massimiliano Camilli
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Domenico D’Amario
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Antonio Maria Leone
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Rocco Vergallo
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Cristina Aurigemma
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Antonino Buffon
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Enrico Romagnoli
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Francesco Burzotta
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Carlo Trani
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Filippo Crea
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Giampaolo Niccoli
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Department of Medicine and SurgeryUniversity of ParmaItaly
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53
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Myocardial Bridging Unmasks as an Acute Coronary Syndrome from Dehydration. Case Rep Cardiol 2021; 2021:5589776. [PMID: 34336298 PMCID: PMC8292064 DOI: 10.1155/2021/5589776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
A 50-year-old male presented for loss of consciousness. He was initially treated with intravenous epinephrine and fluids, and an electrocardiogram (ECG) displayed an ST-segment elevation in lead aVR with global ST-segment depressions. A subsequent left heart catheterization revealed that the middle segment of the left anterior descending artery (LAD) demonstrated severe stenosis during systole but would become patent during diastole, which was suggestive of myocardial bridging. After stopping the epinephrine and increasing the fluid infusion, the ECG changes rapidly resolved. The patient had later admitted to significant dehydration all day. Myocardial bridging is a congenital anomaly in which a coronary artery segment courses through the myocardium instead of the usual epicardial surface. Occasionally, myocardial bridging may present similarly to acute coronary syndrome in severe dehydration or hyperadrenergic states. The diagnosis can be made through coronary angiography, which reveals a dynamic vessel obstruction pattern corresponding with the cardiac cycle. Long-term effects may also include accelerated atherosclerosis. Treatment consists of reversing precipitating causes during acute presentations and decreasing the risk of coronary artery disease on a chronic basis.
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54
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Evaluation of the morphological and clinical features of left anterior descending myocardial bridging with multi-detector computed tomography. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:87-91. [PMID: 34386049 PMCID: PMC8340642 DOI: 10.5114/kitp.2021.107469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/14/2021] [Indexed: 12/03/2022]
Abstract
Aim The aim of the study was to assess the incidence, localization, depth, length of myocardial bridging (MB) with left anterior descending (LAD), systolic compression ratio, atherosclerotic plaque localization and degree of stenosis by 256-slice multi-detector computed tomography (MDCT). Material and methods Computed tomography (CT) scans from a total of 3947 patients who underwent MDCT were reviewed retrospectively for LAD MB. A diastolic and systolic dataset with the best image quality was selected. Myocardial bridge was defined as a coronary artery with an intra-myocardial course. Myocardial bridging was divided into “deep” or “superficial”. The length and depth of the bridging segment were calculated. For each bridging segment, the presence of atherosclerosis was saved in a 2-cm-long segment proximal to the entry of the bridging segment. The degree of stenosis made by atherosclerotic plaques was determined. Results LAD myocardial bridging was detected in 410 (10.4%) patients. Among these, 97 (23.7%) patients had a deep and 313 (76.3%) patients had a superficial course. The mean LAD MB length was 20.28 ±9.63 mm and the depth was 1.72 ±1.11 mm. The systolic and diastolic mean diameter difference was 0.193 mm and the average compression ratio was 9.44%. Atherosclerotic plaques were found in 167 (40.7%) of 410 LAD MB. Atherosclerotic plaques were found in 50.5% of deep MB and 37.7% of superficial MB. Conclusions 256-slice MDCT coronary angiography has a high sensitivity to show myocardial bridging in LAD localization, to determine length, depth, compression ratio, atherosclerotic plaque localization and degree of stenosis.
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55
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Matta A, Canitrot R, Nader V, Blanco S, Campelo-Parada F, Bouisset F, Lhermusier T, Elbaz M, Carrie D, Roncalli J. Left anterior descending myocardial bridge: Angiographic prevalence and its association to atherosclerosis. Indian Heart J 2021; 73:429-433. [PMID: 34474753 PMCID: PMC8424261 DOI: 10.1016/j.ihj.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 11/24/2020] [Accepted: 01/14/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Left anterior descending Myocardial Bridge (LADMB) is considered a benign condition and actually becomes a forgotten cause of serious cardiac events. This study was conducted to estimate the prevalence of LADMB and its association to atherosclerosis. METHODS An observational retrospective study was conducted on patients referred for coronary angiography between June 2012 and June 2020. Coronary angiography database was revisedand studied population was divided into 2 groups: LADMB group versus Non-LADMB group. RESULTS LADMB was detected in 510 patients out of 35813 included in the study resulting in a prevalence at 1.42%. The mean age was 66.5 years. Male gender was more common than female (70vs30%). The prevalence of significant atherosclerotic LAD disease was more than two times higher in the non-LADMB group compared to the LADMB group. Statistical analysis revealed a significant negative association between LADMB and atherosclerosis (p < 0.001). A significant greater rate of MINOCA cases was observed in acute coronary syndrome LADMB patients. CONCLUSIONS LADMB is an inborn anatomic variation associated to atherosclerotic risk reduction in LAD. Physicians must be aware about the potential complications and pay attention to those classified at high risk for cardiovascular events.
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Affiliation(s)
- Anthony Matta
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France; Faculty of Medicine, Holy Spirit University of Kaslik, Kaslik, Lebanon
| | - Ronan Canitrot
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Vanessa Nader
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France; Faculty of Pharmacy, Lebanese University, Beirut, Lebanon
| | - Stephanie Blanco
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Francesco Campelo-Parada
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Frederic Bouisset
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Thibault Lhermusier
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Meyer Elbaz
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Didier Carrie
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France
| | - Jerome Roncalli
- Department of Cardiology, Institute CARDIOMET, University Hospital of Toulouse, Toulouse, France.
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Aleksandric SB, Djordjevic-Dikic AD, Dobric MR, Giga VL, Soldatovic IA, Vukcevic V, Tomasevic MV, Stojkovic SM, Orlic DN, Saponjski JD, Tesic MB, Banovic MD, Petrovic MT, Juricic SA, Nedeljkovic MA, Stankovic G, Ostojic MC, Beleslin BD. Functional Assessment of Myocardial Bridging With Conventional and Diastolic Fractional Flow Reserve: Vasodilator Versus Inotropic Provocation. J Am Heart Assoc 2021; 10:e020597. [PMID: 34151580 PMCID: PMC8403296 DOI: 10.1161/jaha.120.020597] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Functional assessment of myocardial bridging (MB) remains clinically challenging because of the dynamic nature of the extravascular coronary compression with a certain degree of intraluminal coronary reduction. The aim of our study was to assess performance and diagnostic value of diastolic‐fractional flow reserve (d‐FFR) during dobutamine provocation versus conventional‐FFR during adenosine provocation with exercise‐induced myocardial ischemia as reference. Methods and Results This prospective study includes 60 symptomatic patients (45 men, mean age 57±9 years) with MB on the left anterior descending artery and systolic compression ≥50% diameter stenosis. Patients were evaluated by exercise stress‐echocardiography test, and both conventional‐FFR and d‐FFR in the distal segment of left anterior descending artery during intravenous infusion of adenosine (140 μg/kg per minute) and dobutamine (10–50 μg/kg per minute), separately. Exercise–stress‐echocardiography test was positive for myocardial ischemia in 19/60 patients (32%). Conventional‐FFR during adenosine and peak dobutamine had similar values (0.84±0.04 versus 0.84±0.06, P=0.852), but d‐FFR during peak dobutamine was significantly lower than d‐FFR during adenosine (0.76±0.08 versus 0.79±0.08, P=0.018). Diastolic‐FFR during peak dobutamine was significantly lower in the exercise‐stress‐echocardiography test –positive group compared with the exercise‐ stress‐echocardiography test –negative group (0.70±0.07 versus 0.79±0.06, P<0.001), but not during adenosine (0.79±0.07 versus 0.78±0.09, P=0.613). Among physiological indices, d‐FFR during peak dobutamine was the only independent predictor of functionally significant MB (odds ratio, 0.870; 95% CI, 0.767–0.986, P=0.03). Receiver‐operating characteristics curve analysis identifies the optimal d‐FFR during peak dobutamine cut‐off ≤0.76 (area under curve, 0.927; 95% CI, 0.833–1.000; P<0.001) with a sensitivity, specificity, and positive and negative predictive value of 95%, 95%, 90%, and 98%, respectively, for identifying MB associated with stress‐induced ischemia. Conclusions Diastolic‐FFR, but not conventional‐FFR, during inotropic stimulation with high‐dose dobutamine, in comparison to vasodilatation with adenosine, provides more reliable functional significance of MB in relation to stress‐induced myocardial ischemia.
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Affiliation(s)
- Srdjan B Aleksandric
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Ana D Djordjevic-Dikic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Milan R Dobric
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Vojislav L Giga
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Ivan A Soldatovic
- Faculty of Medicine University of Belgrade Serbia.,Institute of Medical Statistics and Informatics Faculty of Medicine University of Belgrade Serbia
| | - Vladan Vukcevic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Miloje V Tomasevic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Department of Internal Medicine Faculty of Medical Sciences University of Kragujevac Serbia
| | - Sinisa M Stojkovic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Dejan N Orlic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Jovica D Saponjski
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Milorad B Tesic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Marko D Banovic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Marija T Petrovic
- Mount Sinai HeartIcahn School of Medicine at Mount Sinai Hospital New York NY.,James J. Peters Veterans Administration Medical Center Bronx NY
| | - Stefan A Juricic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia
| | - Milan A Nedeljkovic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Goran Stankovic
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
| | - Miodrag C Ostojic
- Faculty of Medicine University of Belgrade Serbia.,Institute for Cardiovascular Diseases Dedinje Belgrade Serbia
| | - Branko D Beleslin
- Cardiology Clinic University Clinical Center of Serbia Belgrade Serbia.,Faculty of Medicine University of Belgrade Serbia
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Ye Z, Dong XF, Yan YM, Luo YK. Coronary artery aneurysm combined with myocardial bridge: A case report. World J Clin Cases 2021; 9:3996-4000. [PMID: 34141758 PMCID: PMC8180216 DOI: 10.12998/wjcc.v9.i16.3996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/27/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronary artery aneurysm combined with myocardial bridge is a very rare clinical situation. The prognosis of this clinical situation is not yet clear.
CASE SUMMARY A coronary artery aneurysm and myocardial bridge in the same segment of the coronary artery were found in a 54-year-old female patient who underwent coronary angiography and intravascular ultrasound examination. Through conservative treatment, the patient was discharged from the hospital smoothly, and she was in good condition during 5 mo of follow-up.
CONCLUSION Coronary artery aneurysm combined with myocardial bridge seems to have a good prognosis, but due to the rarity of this clinical situation, further research and follow-up are needed.
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Affiliation(s)
- Zhen Ye
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
- Fujian Institute of Coronary Artery Disease, Fuzhou 350001, Fujian Province, China
- Fujian Heart Medical Center, Fuzhou 350001, Fujian Province, China
| | - Xian-Feng Dong
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
- Fujian Institute of Coronary Artery Disease, Fuzhou 350001, Fujian Province, China
- Fujian Heart Medical Center, Fuzhou 350001, Fujian Province, China
| | - Yuan-Ming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
- Fujian Institute of Coronary Artery Disease, Fuzhou 350001, Fujian Province, China
- Fujian Heart Medical Center, Fuzhou 350001, Fujian Province, China
| | - Yu-Kun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian Province, China
- Fujian Institute of Coronary Artery Disease, Fuzhou 350001, Fujian Province, China
- Fujian Heart Medical Center, Fuzhou 350001, Fujian Province, China
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Ganga KP, Goyal A, Ojha V, Deepti S, Sharma S, Kumar S. Prevalence Rates of Congenital Coronary Anomalies and Coronary Variations in Adult Indian Population Using Dual-Source Computed Tomography Coronary Angiography: Analysis of Regional Distribution of Coronary Anomalies and the Need for Standardized Reporting Formats. Indian J Radiol Imaging 2021; 31:138-149. [PMID: 34316122 PMCID: PMC8299496 DOI: 10.1055/s-0041-1730135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background
Congenital coronary artery anomalies (CCAA) are predominantly discovered as incidental findings on computed tomography coronary angiography (CTCA) of adults. They are rare but significant, considering their importance during endovascular or surgical interventions. This study describes the prevalence of CCAA and coronary variants (CV) in adults as identified by CTCA.
Methods
It is a retrospective evaluation of 7,694 CTCAs of adults performed in a tertiary care facility in North India.
Results
CCAA and CV were observed in a total of 9.6% of patients. The most common CV was myocardial bridging, observed in 7.1%. Anomalies of origin and course were detected in 2.3% of the patients. The frequency of these anomalies in the right coronary artery, left main, left circumflex artery, and the left anterior descending artery arteries were 1.06, 0.41, 0.03, and 0.38%, respectively. The single coronary pattern was seen in 0.05% and coronary artery fistulas in 0.03%. Scrutiny of data on Indian regional distribution revealed differing definitions and inclusion and exclusion criteria, making comparisons difficult, highlighting the need for uniform definitions as well as the need to adopt a standardized reporting template and format.
Conclusion
The prevalence of CCAA and CV is 9.6% in adult Indian patients undergoing CTCA. Prior knowledge of these anatomical finding can prevent a catastrophe during surgery or endovascular interventions. Hence, it is important that clinicians, as well as radiologists, are aware of these entities.
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Affiliation(s)
- Kartik P Ganga
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Aayush Goyal
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Vineeta Ojha
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Siddharthan Deepti
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjiv Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Bianco F, Bucciarelli V, Surace FC, Iezzi FV, Berton E, Baldinelli A, Piva T, Maolo A, Schicchi N, Colaneri M, Pozzi M, Gallina S. Echocardiographic changes and quality of life after surgical unroofing of myocardial bridges. J Int Med Res 2021; 49:3000605211014847. [PMID: 34013761 PMCID: PMC8150422 DOI: 10.1177/03000605211014847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the echocardiographic changes and quality of life (QoL) after surgical unroofing of myocardial bridges (MBs) involving the left anterior descending (LAD) coronary artery compared with optimal medical therapy (OMT). METHODS Twenty-two patients (median age, 24 years; interquartile range, 16-40 years) with MBs of the LAD artery and exertional angina from 2018 to 2019 were retrospectively analyzed. Twelve patients underwent OMT and 10 underwent surgery. Both groups underwent clinical and echocardiographic examinations during hospitalization and follow-up (mean, 1.0 ± 0.8 years). QoL was assessed with the Seattle Angina Questionnaire, short version (SAQ-7). RESULTS Surgery resulted in significantly better QoL than OMT, with a significant improvement in left ventricular global longitudinal strain (GLS) [mean (standard error): 19% (0.19) to 22% (0.34) and 19% (0.15) to 20% (0.24), respectively; delta-change (delta-GLS) of 0.15 vs. 0.067]. In the univariate and multivariable analyses, delta-GLS was positively correlated with the SAQ-7 score and MB length (rho = 0.64 and 0.71, respectively), with a significant interaction between MB length and surgical treatment (beta coefficient, 1.95; 95% confidence interval, 0.14-3.77). CONCLUSIONS MB unroofing surgery provided benefits in terms of QoL and left ventricular GLS improvement compared with 1 year of OMT.
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Affiliation(s)
- Francesco Bianco
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy.,Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio," University of Chieti, Italy
| | - Valentina Bucciarelli
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio," University of Chieti, Italy.,Department of Pharmacy, "G. d'Annunzio," University of Chieti, Italy
| | - Francesca Chiara Surace
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Federica Valentina Iezzi
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Emanuela Berton
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Alessandra Baldinelli
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Tommaso Piva
- Interventional Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Alessandro Maolo
- Interventional Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Nicolo' Schicchi
- Radiology Department, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Massimo Colaneri
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Marco Pozzi
- Department of Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio," University of Chieti, Italy
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Morphological analysis of myocardial bridges and coronary arterial dominance in northeast Brazil. Morphologie 2021; 106:92-97. [PMID: 33775545 DOI: 10.1016/j.morpho.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Coronary arterial dominance and myocardial bridges have clinical implications, since a left dominant pattern associated to the presence of myocardial bridges is often associated to a higher incidence of arteriosclerosis and higher mortality by myocardial infarction. OBJECTIVE To determine the presence and position of myocardial bridges and their relation with coronary arterial dominance. METHODS Fifty-seven human cadaveric hearts were analyzed into three groups, as follows: right dominance; left dominance; codominance. Each group was then divided into two subgroups: with or without myocardial bridges. Finally, each subgroup with myocardial bridges was classified according to the position of the myocardial bridge according to the main axis of the heart (proximal, middle and distal third). RESULTS The right dominance occurred in most hearts (30 hearts-52,6%). Twenty-three myocardial bridges (40,3%) were identified and mostly occurred on left dominant hearts (22,8%). The pattern of coronary dominance presented a statistically significant correlation with the presence of myocardial bridges (P=0.048). The middle third of the heart axis showed the highest occurrence of myocardial bridges. CONCLUSION These findings suggest there is a clear relationship between the presence of myocardial bridges and left dominant pattern. Middle third of the heart axis present the higher occurrence of myocardial bridges. Knowledge of the myocardial bridges morphology is of great clinical significance, improving patient care.
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Cardiac-CT with the newest CT scanners: An incoming screening tool for competitive athletes? Clin Imaging 2021; 78:74-92. [PMID: 33773447 DOI: 10.1016/j.clinimag.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 02/18/2021] [Accepted: 03/05/2021] [Indexed: 11/20/2022]
Abstract
Competitive athletes of all skill levels are at risk of sudden cardiac death (SCD) due to certain heart conditions. Prior to engagement in high-intensity athletics, it is necessary to screen for these conditions in order to prevent sudden cardiac death. Cardiac-CT angiography (CCTA) is a reliable tool to rule out the leading causes of SCD by providing an exceptional overview of vascular and cardiac morphology. This allows CCTA to be a powerful resource in identifying cardiac anomalies in selected patients (i.e. unclear symptoms or findings at ECG or echocardiography) as well as to exclude significant coronary artery disease (CAD). With the advancement of technology over the last few years, the latest generations of computed tomography (CT) scanners provide better image quality at lower radiation exposures. With the amount of radiation exposure per scan now reaching the sub-millisievert range, the number of CT examinations it is supposed to increase greatly, also in the athlete's population. It is thus necessary for radiologists to have a clear understanding of how to make and interpret a CCTA examination so that these studies may be performed in a responsible and radiation conscious manner especially when used in the younger populations. Our work aims to illustrate the main radiological findings of CCTAs and highlight their clinical impact with some case studies. We also briefly describe critical features of state-of-the-art CT scanners that optimize different acquisitions to obtain the best quality at the lowest possible dose.
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62
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Sharzehee M, Seddighi Y, Sprague EA, Finol EA, Han HC. A Hemodynamic Comparison of Myocardial Bridging and Coronary Atherosclerotic Stenosis: A Computational Model With Experimental Evaluation. J Biomech Eng 2021; 143:031013. [PMID: 33269788 DOI: 10.1115/1.4049221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 11/08/2022]
Abstract
Myocardial bridging (MB) and coronary atherosclerotic stenosis can impair coronary blood flow and may cause myocardial ischemia or even heart attack. It remains unclear how MB and stenosis are similar or different regarding their impacts on coronary hemodynamics. The purpose of this study was to compare the hemodynamic effects of coronary stenosis and MB using experimental and computational fluid dynamics (CFD) approaches. For CFD modeling, three MB patients with different levels of lumen obstruction, mild, moderate, and severe were selected. Patient-specific left anterior descending (LAD) coronary artery models were reconstructed from biplane angiograms. For each MB patient, the virtually healthy and stenotic models were also simulated for comparison. In addition, an in vitro flow-loop was developed, and the pressure drop was measured for comparison. The CFD simulations results demonstrated that the difference between MB and stenosis increased with increasing MB/stenosis severity and flowrate. Experimental results showed that increasing the MB length (by 140%) only had significant impact on the pressure drop in the severe MB (39% increase at the exercise), but increasing the stenosis length dramatically increased the pressure drop in both moderate and severe stenoses at all flow rates (31% and 93% increase at the exercise, respectively). Both CFD and experimental results confirmed that the MB had a higher maximum and a lower mean pressure drop in comparison with the stenosis, regardless of the degree of lumen obstruction. A better understanding of MB and atherosclerotic stenosis may improve the therapeutic strategies in coronary disease patients and prevent acute coronary syndromes.
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Affiliation(s)
- Mohammadali Sharzehee
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Yasamin Seddighi
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Eugene A Sprague
- Department of Medicine, University of Texas Health San Antonio, San Antonio, TX 78229
| | - Ender A Finol
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249
| | - Hai-Chao Han
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249
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63
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Erol N. Challenges in Evaluation and Management of Children with Myocardial Bridging. Cardiology 2021; 146:273-280. [PMID: 33631747 DOI: 10.1159/000513900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 12/10/2020] [Indexed: 11/19/2022]
Abstract
Myocardial bridging (MB) is a congenital anomaly where a coronary artery branch or group of branches extends inside a tunnel consisting of myocardium. Although it is mostly considered "benign," it is reported that MB may lead to significant cardiac problems and sudden cardiac deaths. While it is a congenital anomaly, its symptoms usually arise at further ages rather than childhood. The literature on MB in children is in the form of case reports or small case series. This is why pediatric cases are assessed in the light of information obtained from adults. This review compiled the literature on MB in adults and children and compared it, as well as discussing questions arising regarding the clinic, diagnosis, and treatment of MB.
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Affiliation(s)
- Nurdan Erol
- Pediatric Clinics, Zeynep Kamil Gynecology and Pediatrics Training and Research Hospital, Health Sciences University, Uskudar/Istanbul, Turkey,
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64
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Roberts W, Charles SM, Ang C, Holda MK, Walocha J, Lachman N, Tubbs RS, Loukas M. Myocardial bridges: A meta-analysis. Clin Anat 2021; 34:685-709. [PMID: 33078444 DOI: 10.1002/ca.23697] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/11/2022]
Abstract
Myocardial bridges are anatomical entities characterized by myocardium covering segments of coronary arteries. In some patients, the presence of a myocardial bridge is benign and is only incidentally found on autopsy. In other patients, however, myocardial bridges can lead to compression of the coronary artery during systolic contraction and delayed diastolic relaxation, resulting in myocardial ischemia. This ischemia in turn can lead to myocardial infarction, ventricular arrhythmias and sudden cardiac death. Myocardial bridges have also been linked to an increased incidence of atherosclerosis, which has been attributed to increased shear stress and the presence of vasoactive factors. Other studies however, demonstrated the protective roles of myocardial bridges. In this study, using systematic review and a meta-analytical approach we investigate the prevalence and morphology of myocardial bridges in both clinical imaging and cadaveric dissections. We also discuss the pathophysiology, clinical significance, and management of these anatomical entities.
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Affiliation(s)
- Wallisa Roberts
- Department of Medicine, Princess Royal Hospital, Apley Castle, Telford Shropshire, UK
| | - Stacey M Charles
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies
| | - Cassandra Ang
- Department of Medicine, Princess Royal Hospital, Apley Castle, Telford Shropshire, UK
| | - Mateusz K Holda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, England, UK
| | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University, Medical College, Krakow, Poland
| | - Nirusha Lachman
- Department of Clinical Anatomy and Department of Plastic Surgery, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota, USA
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies.,Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, School of Medicine, Grenada, West Indies.,Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
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65
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Khadke S, Vidovic J, Patel V. Bridging the Gap in a Rare Cause of Angina. Eur Cardiol 2021; 16:e05. [PMID: 33737959 PMCID: PMC7967818 DOI: 10.15420/ecr.2020.33] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/26/2020] [Indexed: 11/09/2022] Open
Abstract
Myocardial bridging occurs when coronary arteries run intramurally. Episodes of tachycardia can cause a dynamic obstruction that extends into diastole, compromising coronary filling time, and subsequently leading to ischaemia. Myocardial ischaemia, acute coronary syndrome, coronary spasm, myocardial stunning, arrhythmia, takotsubo cardiomyopathy, and sudden cardiac death have all been reported with bridging. Atherosclerotic plaques develop proximally in the bridge due to low shear stress and high oscillatory wall-flow. Factors affecting atherosclerotic build-up include disrupted flow patterns (particularly flow recirculation, which exacerbates LDL internalisation), cell adhesion and monocyte adhesion to the endothelium. Endothelial health depends on arterial flow patterns, given that the vessel reacts differently to various flow types, as confirmed in 3D simulations. Medication is the first-line therapy, while surgical de-roofing and coronary bypass are reserved for severe stenosis. Distinguishing physiological arterial compression from pathological stenosis is essential. Deeper bridges correlating with recurrent angina with an instantaneous wave-free ratio ≤0.89 or fractional flow reserve ≤0.80 are treated.
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Affiliation(s)
- Sumanth Khadke
- Our Lady of Fatima University, Fatima College of MedicineManila, Philippines
| | | | - Vinod Patel
- Division of Cardiology, Mount Sinai HospitalsNew York, NY, US
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66
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Okada K, Hibi K, Ogino Y, Maejima N, Kikuchi S, Kirigaya H, Kirigaya J, Sato R, Nakahashi H, Minamimoto Y, Kimura Y, Akiyama E, Matsuzawa Y, Iwahashi N, Kosuge M, Ebina T, Tamura K, Kimura K. Impact of Myocardial Bridge on Life‐Threatening Ventricular Arrhythmia in Patients With Implantable Cardioverter Defibrillator. J Am Heart Assoc 2020; 9:e017455. [PMID: 33094668 PMCID: PMC7763400 DOI: 10.1161/jaha.120.017455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Myocardial bridge (MB), common anatomic variant, is generally considered benign, while previous studies have shown associations between MB and various cardiovascular pathologies. This study aimed to investigate for the first time possible impact of MB on long‐term outcomes in patients with implantable cardioverter defibrillator, focusing on life‐threatening ventricular arrhythmia (LTVA).
Methods and Results
This retrospective analysis included 140 patients with implantable cardioverter defibrillator implantation for primary (n=23) or secondary (n=117) prevention of sudden cardiac death. Angiographically apparent MB was identified on coronary angiography as systolic milking appearance with significant arterial compression. The primary end point was the first episode(s) of LTVA defined as appropriate implantable cardioverter defibrillator treatments (antitachyarrhythmia pacing and/or shock) or sudden cardiac death, assessed for a median of 4.5 (2.2–7.1) years. During the follow‐up period, LTVA occurred in 37.9% of patients. Angiographically apparent MB was present in 22.1% of patients; this group showed younger age, lower rates of coronary risk factors and ischemic cardiomyopathy, higher prevalence of vasospastic angina and greater left ventricular ejection fraction compared with those without. Despite its lower risk profiles above, Kaplan–Meier analysis revealed significantly lower event‐free rates in patients with versus without angiographically apparent MB. In multivariate analysis, presence of angiographically apparent MB was independently associated with LTVA (hazard ratio, 4.24; 95% CI, 2.39–7.55;
P
<0.0001).
Conclusions
Angiographically apparent MB was the independent determinant of LTVA in patients with implantable cardioverter defibrillator. Although further studies will need to confirm our findings, assessment of MB appears to enhance identification of high‐risk patients who may benefit from closer follow‐up and targeted therapies.
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Affiliation(s)
- Kozo Okada
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Kiyoshi Hibi
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Yutaka Ogino
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Nobuhiko Maejima
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Shinnosuke Kikuchi
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Hidekuni Kirigaya
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Jin Kirigaya
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Ryosuke Sato
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Hidefumi Nakahashi
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Yugo Minamimoto
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Yuichiro Kimura
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Eiichi Akiyama
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Yasushi Matsuzawa
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Noriaki Iwahashi
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Masami Kosuge
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Toshiaki Ebina
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
| | - Kouichi Tamura
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
- Department of Medical Science and Cardiorenal Medicine Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Kazuo Kimura
- Division of Cardiology Yokohama City University Medical Center Yokohama Japan
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67
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Avram A, Chioncel V, Guberna S, Cuciureanu I, Brezeanu RC, Andrei CL, Sinescu C. Myocardial bridging-an unusual cause of Wellens syndrome: A case report. Medicine (Baltimore) 2020; 99:e22491. [PMID: 33031283 PMCID: PMC7544376 DOI: 10.1097/md.0000000000022491] [Citation(s) in RCA: 8] [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: 02/22/2020] [Revised: 07/06/2020] [Accepted: 09/01/2020] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death. PATIENT CONCERNS We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal. DIAGNOSES The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points. INTERVENTIONS The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB. OUTCOMES The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup. LESSONS MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.
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Affiliation(s)
- Anamaria Avram
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Valentin Chioncel
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Suzana Guberna
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Irina Cuciureanu
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Radu Constantin Brezeanu
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Catalina Liliana Andrei
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
| | - Crina Sinescu
- Carol Davila University of Medicine and Pharmacy
- Bagdasar-Arseni Emergency Clinical Hospital, Bucharest, Romania
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68
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Gulmez N, Sah H. The relationships between the myocardial bridge and ramus interventricularis paraconalis characteristics in lamb and sheep. Anat Histol Embryol 2020; 50:260-265. [PMID: 33009861 DOI: 10.1111/ahe.12623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 08/12/2020] [Accepted: 09/11/2020] [Indexed: 11/30/2022]
Abstract
The myocardial bridge (MB) is an anomaly that the myocardial fibres cover on a segment of the subepicardial coronary arteries or their branches in domestic animals and humans. The aim of the present study was to determine the relationships between the characteristics of the MB and ramus interventricularis paraconalis at three levels in lambs and adult sheep. Thirty-three hearts (16 lambs and 17 sheep) were used to determine the MB (length, angle and thickness) and vessel (vessel diameter and thicknesses of tunica intima et media of ramus interventricularis paraconalis) characteristics. Independent-samples t test was applied to compare variables between lambs and sheep. Spearman's correlation analysis was conducted to evaluate the relationships between bridge and vessel characteristics at three bridge levels. Length, angle and thickness of myocardial bridges were not significantly different between the lambs and sheep (p > .05). The mean length, angle and thickness were 24.9 ± 16.1 mm, 113.7 ± 11.2° and 1,098 ± 555 µm in 33 hearts, respectively. In lambs, the mean vessel diameters were 1,930 ± 742 µm (1,534-2,325 µm), 1,247 ± 665 µm (893-1,601 µm) and 865 ± 172 µm (774-957 µm) at the pre-bridge, bridge and post-bridge levels, respectively. In sheep, the mean vessel diameters in the same order were 1,861 ± 1,068 µm, 1,337 ± 308 µm and 1,287 ± 549 µm. The bridge prevalence was 100% in the samples examined. In conclusion, coronary arterial diseases related to myocardial bridge should not be expected in sheep for veterinary cardiology practice. It may also be concluded that the cross-breeds of the Awassi and Chios sheep may be useful in experimental studies related to myocardial bridge surgery.
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Affiliation(s)
- Nurhayat Gulmez
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Near East University, Nicosia, Cyprus
| | - Huseyin Sah
- Department of Histology and Embryology, Faculty of Veterinary Medicine, Near East University, Nicosia, Cyprus
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69
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Ahmed M, Hassan K, Mustafa ME. Left Anterior Descending Artery Bridging and Atypical Chest Pain in a Young Woman. Cureus 2020; 12:e10550. [PMID: 33101798 PMCID: PMC7575310 DOI: 10.7759/cureus.10550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Cardiac-related chest pain is a frequent cause of morbidity and mortality and should be carefully assessed due to its burden on patient health. Its etiology can sometimes prove challenging to discover because of atypical presentations or rare causes of chest pain like myocardial bridging (MB). MB requires a high index of suspicion to be diagnosed. MB is a rare congenital anomaly that occurs due to the passage of a segment of a coronary artery inside the myocardium, causing chest pain due to compression during systole. MB usually has no clinical significance in most cases. However, when severe bridging occurs in the major coronary arteries, patients can experience myocardial ischemia, coronary thrombosis, myocardial infarction, and stress cardiomyopathy, leading to arrhythmias and sudden death. We present the case of a young woman who presented with atypical (rather than ischemic) chest pain due to MB.
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70
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Gao W, Zhang J, Duan F, Guo S, Chen C, Du L, Zhao J, Zhou Z. Clinical characteristics and factors associated with coronary stenosis proximal to a myocardial bridge: a retrospective study. BMC Cardiovasc Disord 2020; 20:371. [PMID: 32795253 PMCID: PMC7427715 DOI: 10.1186/s12872-020-01655-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/04/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The association of myocardial bridge (MB) with cardiovascular risk and the possible cardiovascular risk factors remain unclear. This study aimed to explore the clinical characteristics and related factors of coronary stenosis proximal to an MB. METHODS This was a retrospective study of patients with symptoms of coronary atherosclerotic heart disease admitted between 10/2011 and 12/2014 to the Emergency and Cardiology Department of Bayannur Hospital, who underwent selective coronary angiography (SCAG). The patients were assigned to the non-stenosis and stenosis groups according to whether coronary stenosis was proximal to the MB. RESULTS Among 244 patients with MB and cardiovascular symptoms, 91 (37.3%) had stenosis proximal to the MB. Compared with the non-stenosis group, there were more males (80.2% vs. 55.6%, P < 0.001) and smokers (including those who had quit smoking) (P < 0.001) in the stenosis group. There were no significant differences in blood lipid-related indexes (TG, TC, HDL-C, LDL-C, and VLDL-C) between the two groups. Multivariable analysis suggested that MB location in the middle distal or distal segment of the left anterior descending artery (LAD) increased the odds of coronary stenosis proximal to the MB (OR = 0.439, 95% CI: 1.57-7.532, P = 0.002), which was then considered an independent factor associated with coronary stenosis proximal to the MB. CONCLUSIONS In patients diagnosed with an MB by SCAG, only MB located in the middle distal or distal segment of the LAD is independently associated with coronary stenosis proximal to the MB.
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Affiliation(s)
- Wen Gao
- First Department of Cardiology, Bayannaoer City Hospital, No. 98 Wulan Buhe Road, Linhe District, Bayannaoer City, 015000 Inner Mongolia Autonomous Region China
| | - Jiaxi Zhang
- Department of Cardiac Rehabilitation, Bayannaoer City Hospital, Bayannaoer City, Inner Mongolia Autonomous Region China
| | - Fei Duan
- Department of Vascular Abdominal Wall Hernia Surgery, Bayannaoer City Hospital, Bayannaoer City, Inner Mongolia Autonomous Region China
| | - Shujun Guo
- First Department of Cardiology, Bayannaoer City Hospital, No. 98 Wulan Buhe Road, Linhe District, Bayannaoer City, 015000 Inner Mongolia Autonomous Region China
| | - Chun Chen
- Department of Cardiac Rehabilitation, Bayannaoer City Hospital, Bayannaoer City, Inner Mongolia Autonomous Region China
| | - Liping Du
- First Department of Cardiology, Bayannaoer City Hospital, No. 98 Wulan Buhe Road, Linhe District, Bayannaoer City, 015000 Inner Mongolia Autonomous Region China
| | - Jianquan Zhao
- First Department of Cardiology, Bayannaoer City Hospital, No. 98 Wulan Buhe Road, Linhe District, Bayannaoer City, 015000 Inner Mongolia Autonomous Region China
| | - Zhihong Zhou
- First Department of Cardiology, Bayannaoer City Hospital, No. 98 Wulan Buhe Road, Linhe District, Bayannaoer City, 015000 Inner Mongolia Autonomous Region China
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71
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Zerbo S, Lanzarone A, Raimondi M, Martino LD, Malta G, Cappello F, Argo A. Myocardial bridge pathology and preventable accidents during physical activity of healthy subjects: A case report and a literature review. Med Leg J 2020; 88:209-214. [PMID: 32437236 DOI: 10.1177/0025817220923638] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Myocardial bridging is a congenital coronary pathology described as a segment of coronary artery which courses through the myocardial wall under the muscle bridge. Although the prognosis of myocardial bridging is benign, sports medicine recognises myocardial bridging as a leading cause of sudden death among young basketball, football and soccer players. The authors report a case of a 42-year-old man who collapsed while playing football. He died notwithstanding prompt medical assistance and cardiopulmonary resuscitation. At autopsy, gross examination of the heart revealed the intramural course of the left anterior descending coronary artery to be 2 cm from its coronary ostial origin. Histological examination of ventricular septal and left myocardium showed early signs of ischaemic injury without disease of small coronary vessels and hypertrophic cardiomyopathy. The cause of the death was due to malignant ventricular arrhythmia during intense physical activity.
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Affiliation(s)
- Stefania Zerbo
- Department Pro.Mi.Se, Legal Medicine, School of Medicine, University of Palermo, Palermo, Italy
| | - Antonietta Lanzarone
- Department Pro.Mi.Se, Legal Medicine, School of Medicine, University of Palermo, Palermo, Italy
| | - Marco Raimondi
- Department Pro.Mi.Se, Legal Medicine, School of Medicine, University of Palermo, Palermo, Italy
| | - Lorena De Martino
- Department of Experimental Biomedicine and Clinical Neuroscience, School of Medicine, University of Palermo, Palermo, Italy
| | - Ginevra Malta
- Department Pro.Mi.Se, Legal Medicine, School of Medicine, University of Palermo, Palermo, Italy
| | - Francesco Cappello
- Department of Experimental Biomedicine and Clinical Neuroscience, School of Medicine, University of Palermo, Palermo, Italy
| | - Antonina Argo
- Department Pro.Mi.Se, Legal Medicine, School of Medicine, University of Palermo, Palermo, Italy
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72
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Zhou L, Sheng-yu L, Dong-bao L, Chen H. A case of myocardial infarction due to myocardial bridging alone. Clin Med (Lond) 2020; 20:304-307. [DOI: 10.7861/clinmed.2019-0460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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73
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El-Sabawi B, Shadrin IS, Sandhu GS, Crestanello JA, Jaffe AS. Acute Myocardial Infarction Due to Fixed Coronary Artery Stenosis From Myocardial Bridging. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:91-93. [PMID: 32448775 DOI: 10.1016/j.carrev.2020.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/04/2020] [Accepted: 04/16/2020] [Indexed: 10/24/2022]
Abstract
Myocardial bridging is a common coronary abnormality often associated with left ventricular hypertrophy. It can be noted incidentally on coronary angiography by findings of systolic narrowing of the involved coronary artery. We present the case of a 59-year-old woman that presented with a non-ST elevation myocardial infarction. She had a history of angina and workup 9-months prior with CT coronary angiography that revealed an intra-myocardial course of the left anterior descending coronary artery (LAD) with minimal stenosis and no concomitant coronary artery disease. Invasive coronary angiography now demonstrated apparent myocardial bridging associated with a severe fixed stenosis of the LAD without change in diameter with nitroglycerin injection. Due to persistent symptoms, surgical myotomy was attempted and then aborted because of difficulty unroofing the LAD due to surrounding fibrosis. Coronary artery bypass grafting (CABG) was then successfully performed using a left internal mammary artery graft. The patient had complete resolution of her chest pain and was without functional limitation at 3-month follow-up. This case highlights possible sequelae of myocardial bridging and suggests that, in rare cases, fixed obstruction of the involved coronary artery may occur in the setting of fibrosis of the bridged segment. In such cases, surgical myotomy may not be feasible and CABG may be required.
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Affiliation(s)
| | - Ilya S Shadrin
- Department of Medicine, Mayo Clinic, United States of America
| | - Gurpreet S Sandhu
- Department of Cardiovascular Diseases, Mayo Clinic, United States of America
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, United States of America
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, United States of America; Department of Laboratory Medicine and Pathology, Mayo Clinic, United States of America.
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Zhu C, Wang S, Cui H, Tang B, Wang S. Associations of myocardial bridging with adverse cardiac events: a meta-analysis of published observational cohort studies involving 4,556 individuals. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:369. [PMID: 32355813 PMCID: PMC7186699 DOI: 10.21037/atm.2020.02.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Data derived from small series have demonstrated an association of myocardial bridge (MB) with adverse cardiac events, while MB has been traditionally considered as a benign condition. Hence, the precise clinical implications of MB on prognosis remains inconsistent. Our purpose is to perform a meta-analysis to assess the clinical implications of MB on prognosis. Methods We performed an extensive search of PubMed and reference lists of relevant articles. Studies which compared prognosis between subjects with and without MB were identified from 1960 to 31 March 2018. Studies selection was limited to human data and restricted to English language. Results Six eligible studies were included in current meta-analysis. Of 4,556 subjects, 1,389 (30.5%) presented MB. MB was associated with an increased risk of adverse cardiac events [odds ratio (OR), 1.71; 95% confidence interval (CI): 1.29 to 2.26; P=0.0002], non-fatal myocardial infarction (OR: 3.17; 95% CI: 1.21 to 8.31; P=0.02), and angina requiring hospitalization (OR: 2.31; 95% CI: 1.55 to 3.45; P<0.0001), respectively, compared with subjects without MB. Conclusions This meta-analysis of currently available observational cohort studies suggests that MB has an association with adverse cardiac events. Further prospective multicenter studies with large sample size are needed to confirm current findings. Moreover, studies refining the impact of different types of MB on cardiac events, myocardial ischemia, and symptoms requiring therapy, may provide more insights to this issue.
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Affiliation(s)
- Changsheng Zhu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Hao Cui
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bing Tang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shengwei Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Hemmati P, Schaff HV, Dearani JA, Daly RC, Lahr BD, Lerman A. Clinical Outcomes of Surgical Unroofing of Myocardial Bridging in Symptomatic Patients. Ann Thorac Surg 2020; 109:452-457. [DOI: 10.1016/j.athoracsur.2019.07.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/16/2019] [Accepted: 06/03/2019] [Indexed: 01/04/2023]
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76
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Al-Musawi M, Marsh A, Yi S, AlOmaishi S, Rubay D. Combined Myocardial Bridge and Coronary Vessel Disease Requiring Coronary Artery Bypass Grafting and Myotomy of the Myocardial Bridge. Cureus 2019; 11:e6486. [PMID: 31903314 PMCID: PMC6935739 DOI: 10.7759/cureus.6486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Myocardial bridging (MB) describes a band of myocardium that covers the epicardial surface of the coronary artery. This band can vary both in thickness and distance to which it covers the artery. It is broadly classified as superficial or deep, depending on the thickness of the covering muscle layer. It can be asymptomatic, or it could present with different complications. Reported complications have included ischemia and acute coronary syndromes, coronary spasm, ventricular septal rupture, and arrhythmias. MB is most commonly found in the middle segment of the left anterior descending (LAD) coronary artery. There is controversy with regard to therapy for symptomatic patients who are refractory to medical management. Percutaneous coronary intervention and surgical myotomy (unroofing) have been proposed; yet, each one has its pros and cons. MB can be associated with the development of atherosclerosis proximal to the MB segment in the involved coronary artery, and patients can present having both pathologies. We present a case series of six patients with atherosclerotic coronary lesions requiring coronary artery bypass grafting (CABG) with an accidental perioperative finding of MB, which required myotomy.
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Affiliation(s)
| | - Amanda Marsh
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Slee Yi
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
| | - Suhad AlOmaishi
- Internal Medicine, Life Alliance Organ Recovery Agency, University of Miami, Miami, USA
| | - David Rubay
- Surgery, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, USA
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77
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Secinaro A, Curione D, Mortensen KH, Santangelo TP, Ciancarella P, Napolitano C, Del Pasqua A, Taylor AM, Ciliberti P. Dual-source computed tomography coronary artery imaging in children. Pediatr Radiol 2019; 49:1823-1839. [PMID: 31440884 DOI: 10.1007/s00247-019-04494-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 06/11/2019] [Accepted: 08/01/2019] [Indexed: 12/17/2022]
Abstract
Computed tomography (CT) has a well-established diagnostic role in the assessment of coronary arteries in adults. However, its application in a pediatric setting is still limited and often impaired by several technical issues, such as high heart rates, poor patient cooperation, and radiation dose exposure. Nonetheless, CT is becoming crucial in the noninvasive approach of children affected by coronary abnormalities and congenital heart disease. In some circumstances, CT might be preferred to other noninvasive techniques such as echocardiography and MRI for its lack of acoustic window influence, shorter acquisition time, and high spatial resolution. The introduction of dual-source CT has expanded the role of CT in the evaluation of pediatric cardiovascular anatomy and pathology. Furthermore, technical advances in the optimization of low-dose protocols represent an attractive innovation. Dual-source CT can play a key role in several clinical settings in children, namely in the evaluation of children with suspected congenital coronary artery anomalies, both isolated and in association with congenital heart disease. Moreover, it can be used to assess acquired coronary artery abnormalities, as in children with Kawasaki disease and after surgical manipulation, especially in case of transposition of the great arteries treated with arterial switch operation and in case of coronary re-implantation.
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Affiliation(s)
- Aurelio Secinaro
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Davide Curione
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Teresa Pia Santangelo
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmela Napolitano
- Advanced Cardiovascular Imaging Unit - Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessia Del Pasqua
- Pediatric Cardiology and Cardiac Surgery Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrew Mayall Taylor
- UCL Centre for Cardiovascular Imaging, Institute of Cardiovascular Science, University College of London, Great Ormond Street Hospital for Children, London, UK
| | - Paolo Ciliberti
- Pediatric Cardiology and Cardiac Surgery Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Nassar M, Arow Z, Monakier D, Zusman O, Shafir G, Kornowski R, Hamdan A. Effect of Intramural Course of Coronary Arteries Assessed by Computed Tomography Angiography in Patients With Hypertrophic Cardiomyopathy. Am J Cardiol 2019; 124:1279-1285. [PMID: 31439279 DOI: 10.1016/j.amjcard.2019.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 12/17/2022]
Abstract
This study evaluated the prevalence, anatomical pattern, and prognostic implications of an intramural course of the coronary arteries in patients with hypertrophic cardiomyopathy (HC). The study population consisted of 92 patients with HC and 100 patients without HC. The presence of an intramural course of the coronary arteries was evaluated by coronary computed tomography angiography (CTA), and its length and depth were measured. During follow-up, the occurrence of unstable angina requiring hospitalization, myocardial infarction, and all-cause mortality was evaluated. An intramural course of the coronary arteries was more common in patients with HC than patients without HC (62% vs 25%, p <0.001). In the patients with an intramural coronary artery course, those with HC had a longer course (29.1 ± 15.3 mm vs 23.0 ± 13.0 mm; p = 0.037) with deeper penetration into the left ventricular myocardium (2.8 ± 1.2 mm vs 2.1 ± 0.8 mm; p = 0.007) and more involvement of multiple coronary arteries (38% vs 4%; p <0.001). During follow-up (mean 5.5 ± 3.5 years), cardiac events occurred in 17 of 57 patients (29.8%) with an intramural course and 11 of 35 (31.4%) without an intramural course (p = 0.87). On Kaplan-Meier survival analysis, there was no difference in cumulative event rate between HC patients with or without an intramural course (p = 0.89, log rank test). In conclusion, patients with HC have a high rate of an intramural course of the coronary arteries on CTA. The number of involved arteries and the length and depth of the intramural course differ between patients with and without HC, but apparently have no association with worse clinical outcomes.
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79
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Eftekhar-Vaghefi SH, Pourhoseini S, Movahedi M, Hooshmand S, Ostovan MA, Dehghani P, Ostovan N. Comparison of detection percentage and morphology of myocardial bridge between conventional coronary angiography and coronary CT angiography. J Cardiovasc Thorac Res 2019; 11:203-208. [PMID: 31579460 PMCID: PMC6759614 DOI: 10.15171/jcvtr.2019.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 08/02/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction: Myocardial bridge (MB) is a congenital anomaly in which a segment of a coronary artery is surrounded by myocardium. In our study, we want to use conventional coronary angiography (CCA) to describe morphologic characteristics of MB (unidentified or identified) in the patients with documented evidence of MB in coronary computed tomography angiography (CCTA). Methods: The present study was designed as cross-sectional and was conducted on 47 patients with documented evidence of MB in CCTA, who were referred to Nemazee and Faghihi hospitals for performing coronary angiography during a one year period. We compared the morphologic characteristics of tunneled segments, which were missed at CCA (unidentified), and the tunneled segments which were identified with CCA. Results: In sum, MB was found in 16 (34%) patients at CCA (identified), and it was not found in 31 (66%) patients (unidentified) based on compression sign. No significant correlation was found between the percentage of systolic compression and the length and depth of the tunneled segment in identified group (r=0.73, P = 0.18; r=1.09, P = 0.15; respectively). Degree of atherosclerotic plaque formation (diameter stenosis, percentage) (mean, 0.25 (25%) ±0.29; range, 0-0.98) of the tunneled segments in unidentified group was significantly more than the same degree (mean, 0.07 (7%) ±0.13; range, 0-0.41) of the identified group (P = 0.03). The measurement of the trapezoid area under the tunneled segment with this formula [(MB length+ intramyocardial segment) ×depth/2] had significant relation with systolic compression (r=0.304, P = 0.03) and defined the cut-off value of 250 mm2 as the value of significant difference in detecting myocardial bridging with CCA. Conclusion: Our results showed that in most of identified MBs in CCA the tunneled segment area was equal and more than 250 mm2. In addition, the degree of atherosclerotic plaque of the tunneled segments at CCA was significantly more in unidentified group.
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Affiliation(s)
| | - Somayeh Pourhoseini
- Department of Anatomy, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Movahedi
- Department of Cardiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shohre Hooshmand
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Ali Ostovan
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pooyan Dehghani
- Department of Cardiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nikan Ostovan
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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80
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Trisvetova EL. Modern Concepts of Fibromuscular Dysplasia of the Coronary Arteries. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2019-15-3-431-438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Fibromuscular dysplasia of the coronary arteries is a rare non-atherosclerotic and non-inflammatory vascular lesion that is asymptomatic until serious complications develop: stenosis, dissection, rupture, sudden cardiac death. Since there are no long-term numerous clinical observations of patients with fibromuscular dysplasia of the coronary arteries, recommendations have not been developed for diagnosing and treating the disease, which often manifests with acute coronary syndrome. In 2014, the European Consensus was published, and in 2019, the first international consensus document on the diagnosis and treatment of fibromuscular dysplasia with lesions of vessels from different regions (renal, cerebrovascular, coronary, and others). The documents state that the development of fibromuscular dysplasia of the coronary arteries considers the participation of the PHACTR1 gene mutation and the transcriptional activity of the EDN1 gene, smoking, prolonged exertion of the vascular wall, and possibly female sex hormones. In the case of acute coronary syndrome, the most informative diagnostic method is computed tomography with angiography, which reveals a smooth narrowing of the lumen in the middle or distal section in the epicardial artery, often due to intramural hematoma, and also finds dissection, spasm, and tortuous vessel. Additional diagnostic methods ‒ intravascular ultrasound and optical coherence tomography allow differentiation of fibromuscular dysplasia with atherosclerosis of the coronary artery, vasculitis, and other diseases. The choice of treatment tactics for fibromuscular dysplasia of the coronary arteries depends on the severity of the clinical manifestations ‒ conservative medical treatment and interventional methods are used.
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81
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Javadzadegan A, Moshfegh A, Mohammadi M, Askarian M, Mohammadi M. Haemodynamic impacts of myocardial bridge length: A congenital heart disease. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 175:25-33. [PMID: 31104712 DOI: 10.1016/j.cmpb.2019.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/09/2019] [Accepted: 03/27/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES There is an association between long and thick myocardial bridging (MB), haemodynamic perturbations and increased risk of myocardial infarction. This study aims to investigate the alteration in coronary haemodynamics with increasing the length of MB. METHODS Angiography and intravascular ultrasound were performed in 10 patients with varying length of MB in the left anterior descending (LAD) artery. In silico models of MB were developed based on the reconstructed three-dimensional model of the LAD. The entire LAD was divided into 3 segments, proximal (pre-bridge), bridge and distal (post-bridge). Transient computational fluid dynamics simulations were performed to derive distribution of blood residence time and wall shear stress (WSS) over entire vessel including proximal, bridge and distal segments. RESULTS With increasing the length of MB, a decreasing trend was observed in the WSS over proximal segment whereas an increasing trend was found in the WSS over bridge segment. When patients were divided into 2 groups based on the average length of MB in the whole cohort (Lave = 23.92 mm), patients with bridges longer than Lave had smaller WSS and higher residence time in the proximal segment compared to those with bridges shorter than Lave (0.59 ± 0.31 vs 0.21 ± 0.14 Pa and 0.0021 ± 0.0015 vs 0.0045 ± 0.0021 s). In contrast, patients with bridges longer than Lave had greater WSS in the bridge segment compared to those with bridges shorter than Lave (1.37 ± 1.66 vs 2.53 ± 3.14 Pa). No significant difference was found in the distal WSS of patients with short and long bridges. CONCLUSION Our findings revealed a direct relationship between the length of MB and haemodynamic perturbations in the proximal segment such that the increased length of MB is associated with decreased WSS and increased residence time.
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Affiliation(s)
- Ashkan Javadzadegan
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia; ANZAC Research Institute, The University of Sydney, Sydney, NSW 2139, Australia
| | - Abouzar Moshfegh
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia; ANZAC Research Institute, The University of Sydney, Sydney, NSW 2139, Australia.
| | - Maryam Mohammadi
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW 2109, Australia
| | - Mahsa Askarian
- Department of Community Health, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Mohammadi
- Department of Medicinal Chemistry, Pharmaceutical Sciences Research Center, Pharmaceutical Sciences Branch, Azad University, Tehran, Iran
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Zhang M, Yang J, Ma C, Liu M. Longitudinal strain measured by two-dimensional speckle tracking echocardiography to evaluate left ventricular function in patients with myocardial bridging of the left anterior descending coronary artery. Echocardiography 2019; 36:1066-1073. [PMID: 31087389 DOI: 10.1111/echo.14357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/30/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Myocardial bridging (MB) can cause myocardial ischemia, myocardial infarction, or even sudden cardiac death. We aimed to evaluate the left ventricular function in patients with MB of the left anterior descending coronary artery (LAD) using longitudinal strain (LS) measured by two-dimensional speckle tracking echocardiography. METHODS We enrolled 46 subjects with MB in the LAD diagnosed by coronary angiography. Patients were categorized into two groups according to the severity of tunneled artery stenosis: <50% as group I (23 patients) and ≥50% as group II (23 patients). Twenty-five gender- and age-matched subjects without MB confirmed by coronary angiography or with normal results on treadmill exercise test were included as controls. Two-dimensional strain software was applied to measure the territories systolic average peak LS of the LAD coronary artery (LAD-TPLS), right coronary artery (RCA-TPLS), and left circumflex coronary artery (LCX-TPLS) and to measure the global systolic peak LS of left ventricle (LV-GPLS). RESULTS The ratio of mitral peak early (E) and late (A) filling velocity (E/A) and the average mitral annular velocity (e') were lower, and the mitral E/e' ratio was higher in group II than in group I and controls (P < 0.05). LV-GPLS and LAD-TPLS were significantly less negative in group II than in group I and controls (LV-GPLS: -19.77 ± 1.60% vs -21.10 ± 1.91% and -21.76 ± 1.23%; LAD-TPLS: -19.24 ± 2.22% vs -22.00 ± 2.22% and -22.74 ± 1.82%, P < 0.001). The systolic compression severity of the tunneled artery was significantly correlated with LAD-TPLS (r = -0.56, P < 0.001), but less strongly correlated with LV-GPLS (r = -0.40, P < 0.05). The area under the curves of LAD-TPLS was larger than that of LV-GPLS; a cutoff value for LAD-TPLS of -21.68% had 91.3% sensitivity and 73.9% specificity for detection of ≥50% of the tunneled artery stenosis. CONCLUSIONS In patients with ≥50% systolic narrowing of the tunneled artery, left ventricular systolic function and diastolic function were impaired, and the LAD-TPLS is an excellent predictor of ≥50% systolic narrowing of the tunneled artery in patients with MB of the LAD.
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Affiliation(s)
- Minping Zhang
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jun Yang
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shen Yang, China
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, The First Hospital of China Medical University, Shen Yang, China
| | - Minghui Liu
- Department of Ultrasound Diagnosis, The Second Xiangya Hospital, Central South University, Changsha, China
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Spontaneous coronary artery dissection and associated myocardial bridging: Current evidence from cohort study and case reports. Med Hypotheses 2019; 128:50-53. [PMID: 31203908 DOI: 10.1016/j.mehy.2019.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/05/2019] [Accepted: 05/12/2019] [Indexed: 01/10/2023]
Abstract
Spontaneous coronary artery dissection (SCAD) is a relatively uncommon and under-diagnosed disease characterized by the dissociation of intima and media of coronary artery wall due to an intimal tear or intramural hemorrhage. The exact pathophysiology of SCAD remains elusive and may involve multiple predisposing or precipitating factors including genetic abnormalities, inherited or acquired vasculopathies, hormonal influences, inflammation, intense exercise, emotional stress, and recreational drugs. Accruing reports, including five case reports and one cohort study, have recently addressed the concurrence of SCAD and myocardial bridging (MB), an anatomic variant in which a segment of the epicardial coronary descends and traverses in the myocardium. Among the patients with coexisting MB and SCAD, the left anterior descending artery was the only artery that harbors both pathologies, with SCAD locating either within the tunneled segment or distal to the MB. No other predisposing factors or precipitating stressors for SCAD were noted. It is hypothesized that the predilection for vasospasm, impaired endothelial function, and disturbed coronary flow dynamics associated with MB bridging could collectively contribute to the development of SCAD. Future studies are warranted to explore the mechanistic implications of MB in patients with SCAD.
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84
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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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Javadzadegan A, Moshfegh A, Hassanzadeh Afrouzi H. Relationship between myocardial bridge compression severity and haemodynamic perturbations. Comput Methods Biomech Biomed Engin 2019; 22:752-763. [DOI: 10.1080/10255842.2019.1589458] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ashkan Javadzadegan
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- ANZAC Research Institute, The University of Sydney, Sydney, NSW, Australia
| | - Abouzar Moshfegh
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
- ANZAC Research Institute, The University of Sydney, Sydney, NSW, Australia
- Sydney Local Health District, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Hamid Hassanzadeh Afrouzi
- Faculty of Mechanical Engineering, Babol Noshirvani University of Technology, Babol, Iran
- Tehran Heart Center, Medical Sciences/University of Tehran, Tehran, Iran
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Almeida AR, Pereira AR, Morgado G, Loureiro MJ, Ferreira F, Cruz I, Lopes LR, Pereira H. Three-vessel myocardial bridging: A possible cause of myocardial stunning. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Shin YJ, Lee JH, Yoo JY, Kim JA, Jeon Y, Yoon YE, Chun EJ. Clinical significance of evaluating coronary atherosclerosis in adult patients with hypertrophic cardiomyopathy who have chest pain. Eur Radiol 2019; 29:4593-4602. [DOI: 10.1007/s00330-018-5951-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/03/2018] [Accepted: 12/04/2018] [Indexed: 12/24/2022]
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Anatomical variants and coronary anomalies detected by dual-source coronary computed tomography angiography in North-eastern Thailand. Pol J Radiol 2018; 83:e372-e378. [PMID: 30655913 PMCID: PMC6334062 DOI: 10.5114/pjr.2018.78420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 12/18/2022] Open
Abstract
Purpose Congenital coronary anomalies are uncommon, with an incidence ranging from 0.17% in autopsy cases to 1.2% in angiographically evaluated cases. The recent development of dual-source coronary computed tomography angiography (coronary CTA) allows accurate and noninvasive depiction of coronary artery anomalies. Material and methods A retrospective study included a total of 924 patients who underwent coronary CTA because of known or suspected coronary artery disease. In each study, coronary artery anomalies (CAs) were investigated. Results A total of 924 patients (mean age 51.2 ± 12.8 years), who underwent dual-source coronary CTA, were studied. The overall prevalence of CAs in our study was 3.7%, with the following distribution: four single coronary artery, 14 anomalous origin from opposite sinus of Valsalva, three absent left main, four high take-off coronary artery, three anomalous left coronary artery from pulmonary artery, and eight coronary artery fistulas. Conclusions The present study supports the use of coronary CTA as a reliable noninvasive tool for defining anomalous coronary arteries in an appropriate clinical setting and provides detailed three-dimensional anatomic information that may be difficult to obtain with invasive coronary angiography.
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89
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Almeida AR, Pereira AR, Morgado G, Loureiro MJ, Ferreira F, Cruz I, Lopes LR, Pereira H. Three-vessel myocardial bridging: A possible cause of myocardial stunning. Rev Port Cardiol 2018; 38:225.e1-225.e5. [PMID: 30031629 DOI: 10.1016/j.repc.2017.09.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 07/24/2017] [Accepted: 09/02/2017] [Indexed: 11/19/2022] Open
Abstract
The authors report a rare clinical case of myocardial bridging of the three major coronary arteries, which manifested in an unusual way with severe biventricular dysfunction in the context of tachycardia. For the diagnosis, the authors relied on non-invasive multimodality cardiac imaging, including cardiac magnetic resonance, computed tomography angiography and myocardial perfusion scintigraphy. The implementation of targeted medical and neurohormonal therapy resulted in the recovery of ventricular function and clinical improvement.
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Affiliation(s)
- Ana Rita Almeida
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Ana Rita Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Gonçalo Morgado
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Inês Cruz
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Luís Rocha Lopes
- Barts Heart Centre, Barts Health NHS Trust, London, England, United Kingdom; Institute of Cardiovascular Science, University College London, London, England, United Kingdom; Centro Cardiovascular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
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90
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A. DP, Avadhani R, K. S. Myocardial bridging ‘a double-edged sword’: Analysis and significance. J ANAT SOC INDIA 2018. [DOI: 10.1016/j.jasi.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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91
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Hao Z, Xinwei J, Ahmed Z, Huanjun P, Zhanqi W, Yanfei W, Chunhong C, Chan Z, Liqiang F. The Outcome of Percutaneous Coronary Intervention for Significant Atherosclerotic Lesions in Segment Proximal to Myocardial Bridge at Left Anterior Descending Coronary Artery. Int Heart J 2018; 59:467-473. [PMID: 29681571 DOI: 10.1536/ihj.17-179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aimed to evaluate the efficacy of percutaneous coronary intervention (PCI) for significant atherosclerosis lesions proximal to myocardial bridge (MB) at left anterior descending coronary artery (LAD).A total of 330 consecutive patients with LAD significant stenosis, diagnosed as acute coronary syndrome (ACS), were included. Based on whether combined with MB, the patients were divided into the MB group (MB, n = 48) and non-MB group (NMB, n = 282). Drug eluting stents (DES) were successfully implanted in the stenostic segments prior to MB. All patients were followed up during the hospital stay, 30 days and 12 months after PCI, to evaluate the major adverse cardiac events (MACEs).There was no difference in the incidence of MACEs between the two groups (6.2% versus 2.1%, P = 0.254) when in the hospital. During the follow-up of 30 days and 12 months after PCI, the rate of MACEs was significantly higher in the MB group than in the NMB group (18.2% versus 6.4% and 43.8% versus 17.0%, respectively, P < 0.001). Stent restenosis occurred in four patients in the MB group; whereas, in five patients in the NMB group, the rate of stent restenosis was higher in the MB group than in the NMB group (8.3% versus 1.8%, P = 0.036). Cox proportional hazards regression analysis revealed that the presence of MB was an independent predictor of MACEs (hazard ratio (HR) = 1.781, 95% confidence intervals (95% CI) = 1.108-2.863, P = 0.017).DES implantation for significant atherosclerosis stenosis in the segments proximal to MB have higher incidence of MACEs. MB appears to be associated with a higher incidence of stent restenosis after PCI and is a significant factor in the occurrence of MACEs.
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Affiliation(s)
- Zhang Hao
- Physical Examination Center, Affiliated Hospital of Hebei University
| | - Jia Xinwei
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Zakarya Ahmed
- Physical Examination Center, Affiliated Hospital of Hebei University
| | - Pan Huanjun
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Wang Zhanqi
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Wang Yanfei
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Chen Chunhong
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Zhang Chan
- Division of Cardiology, Affiliated Hospital of Hebei University
| | - Fu Liqiang
- Division of Cardiology, Affiliated Hospital of Hebei University
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92
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Jiang L, Zhang M, Zhang H, Shen L, Shao Q, Shen L, He B. A potential protective element of myocardial bridge against severe obstructive atherosclerosis in the whole coronary system. BMC Cardiovasc Disord 2018; 18:105. [PMID: 29843607 PMCID: PMC5975619 DOI: 10.1186/s12872-018-0847-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial bridge (MB) is generally described as a congenital benign variation. Previous studies have suggested that MB prevents atherosclerotic plaques from accumulating within the bridge segment but promotes coronary stenosis in the proximal segment adjacent to MB. However, it is still not clear whether MB has positive or negative effects on severe obstructive atherosclerosis in the whole coronary artery system. METHODS In this study, 6774 patients with symptoms of angina who were clinically diagnosed coronary artery disease (CAD) or suspected CAD underwent coronary angiography (CAG) in our center. The presence of MB was diagnosed, and a retrospective analysis was performed between MB and severe obstructive CAD requiring percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in the whole coronary system. RESULTS Among 6774 patients, 3583 (52.89%) were diagnosed with severe obstructive CAD (SOCAD) requiring a treatment of PCI or CABG and enrolled into the SOCAD group; and 3191 (47.11%) without SOCAD into the non-SOCAD group. Non-SOCAD and SOCAD groups had 512(16.05%) and 66(1.84%) patients with MB, respectively (P < 0.0001). The rate of SOCAD requiring PCI or CABG in patients with MB was much lower than that in patients without MB (11.42% vs. 56.76%, P < 0.0001). After adjusting for sex, age, diabetes mellitus, hypertension, and other risk factors, MB still had some positive role in preventing severe obstructive CAD (log-OR = - 2.134, p-value < 0.0001) through logistic regression. CONCLUSIONS Our results provided a clue that MB might act as a potential protective element against severe obstructive atherosclerosis in the whole coronary artery system.
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Affiliation(s)
- Lisheng Jiang
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China. .,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
| | - Min Zhang
- Department of Clinical Medicine, Shanghai Medical School, Fudan University, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hong Zhang
- Institution of Biostatistics, School of Life Science, Fudan University, Shanghai, China
| | - Lan Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qin Shao
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Linghong Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China.,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Chest Hospital, Shanghai, China. .,Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.
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93
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Javadzadegan A, Moshfegh A, Fulker D, Barber T, Qian Y, Kritharides L, Yong ASC. Development of a Computational Fluid Dynamics Model for Myocardial Bridging. J Biomech Eng 2018; 140:2681003. [DOI: 10.1115/1.4040127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 01/08/2023]
Abstract
Computational fluid dynamics (CFD) modeling of myocardial bridging (MB) remains challenging due to its dynamic and phasic nature. This study aims to develop a patient-specific CFD model of MB. There were two parts to this study. The first part consisted of developing an in silico model of the left anterior descending (LAD) coronary artery of a patient with MB. In this regard, a moving-boundary CFD algorithm was developed to simulate the patient-specific muscle compression caused by MB. A second simulation was also performed with the bridge artificially removed to determine the hemodynamics in the same vessel in the absence of MB. The second part of the study consisted of hemodynamic analysis of three patients with mild and moderate and severe MB in their LAD by means of the developed in silico model in the first part. The average shear stress in the proximal and bridge segments for model with MB were significantly different from those for model without MB (proximal segment: 0.32 ± 0.14 Pa (with MB) versus 0.97 ± 0.39 Pa (without MB), P < 0.0001 — bridge segment: 2.60 ± 0.94 Pa (with MB) versus 1.50 ± 0.64 Pa (without MB), P < 0.0001). When all three patients were evaluated, increasing the degree of vessel compression shear stress in the proximal segment decreased, whereas the shear stress in the bridge segment increased. The presence of MB resulted in hemodynamic abnormalities in the proximal segment, whereas segments within the bridge exhibited hemodynamic patterns which tend to discourage atheroma development.
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Affiliation(s)
- Ashkan Javadzadegan
- Faculty of Medicine and Health Sciences, Macquarie University, Level 1, 75 Talavera Road, Sydney 2109, NSW, Australia
- ANZAC Research Institute, The University of Sydney, Sydney 2139, NSW, Australia e-mail:
| | - Abouzar Moshfegh
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney 2109, NSW, Australia
- ANZAC Research Institute, The University of Sydney, Sydney 2139, NSW, Australia
| | - David Fulker
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney 2052, Australia
| | - Tracie Barber
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Sydney 2052, Australia
| | - Yi Qian
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney 2109, NSW, Australia
| | - Leonard Kritharides
- ANZAC Research Institute, The University of Sydney, Sydney 2139, NSW, Australia
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney 2139, NSW, Australia
| | - Andy S. C. Yong
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney 2109, NSW, Australia
- ANZAC Research Institute, The University of Sydney, Sydney 2139, NSW, Australia
- Department of Cardiology, Concord Hospital, The University of Sydney, Sydney 2139, NSW, Australia
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94
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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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95
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The incremental clinical value of cardiac hybrid SPECT/CTA imaging in coronary artery disease. Nucl Med Commun 2018; 39:469-478. [PMID: 29652747 DOI: 10.1097/mnm.0000000000000838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Coronary artery disease (CAD) is a major cause of death worldwide. It is significantly important to assess the coronary lesion and its pathophysiological relevance comprehensively. Coronary computed tomography angiography (CTA) or myocardial perfusion imaging alone suffers from some limitations in the evaluation of CAD. Through the integration and spatial colocalization of complementary morphological and functional information, the results of published hybrid single-photon emission computed tomography (SPECT)/CTA studies in patients with CAD are promising for detecting functionally relevant coronary artery lesion and evaluating the relationship between diseased coronary artery, coronary artery anomaly, myocardial bridging, or coronary calcification and myocardial ischemia. Compared with other diagnostic procedures, such as CTA, myocardial perfusion imaging alone, and side-by-side SPECT-CTA analysis, SPECT/CTA imaging has incremental value in the evaluation of CAD. Hybrid SPECT/CTA imaging can provide the physicians with more clinical evidence that helps with the treatment strategy decision-making process, thus acting as a gatekeeper to reduce unnecessary invasive examinations and revascularization procedures. In addition, follow-up SPECT/CTA fusion imaging plays a role in predicting prognosis by displaying clearly the relationship between postoperative vessel and myocardial blood supply. However, several limitations should be considered, including the increased radiation exposure, the limited number of patients, and the lack of a uniform gold standard. More data are needed to better specify the role of hybrid SPECT/CTA imaging in the management of CAD.
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96
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Abstract
PURPOSE OF REVIEW There is a broad spectrum of coronary artery anomalies that cardiologists may encounter either incidentally or during evaluation for cardiac symptoms. These anomalies include anomalous coronary arteries arising from the opposite sinus of Valsalva (ACAOS), coronary fistulae, and coronary artery aneurysms. This manuscript outlines the unique features, diagnostic characteristics, and treatment considerations for these lesions. RECENT FINDINGS Intravenous ultrasound (IVUS), computed tomographic angiography (CTA), and magnetic resonance imaging (MRI) are becoming more sophisticated and will be increasingly used to facilitate the optimal treatment approach for coronary anomalies. There are a wide variety of coronary artery anomalies and their clinical ramifications range from benign to potentially fatal. Coronary anomalies often have complex anatomy and require advanced imaging modalities for comprehensive characterization. Due to the heterogeneity in lesion characteristics and outcomes, physicians should consider clinical and imaging features to create individualized management plans, along with referral to adult congenital heart disease centers.
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Affiliation(s)
- Ajar Kochar
- Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA.
- , 2400 Pratt Street, Durham, NC, 27705, USA.
| | - Todd Kiefer
- Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
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97
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Paraskevas G, Koutsouflianiotis K, Iliou K. Myocardial bridge over the left anterior descending coronary artery: A case report and review of the literature. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 22:113. [PMID: 29184571 PMCID: PMC5680658 DOI: 10.4103/jrms.jrms_775_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 05/27/2017] [Accepted: 09/18/2017] [Indexed: 11/11/2022]
Abstract
Myocardial bridging (MB) is considered as a topic of high interest since its occurrence in different studies is statistically significant, and the clinical manifestations of this phenomenon are complicated with cardiovascular diseases. Whether the MB participates in heart diseases and has a decisive effect to life-threatening situations is still under research, and many studies have been conducted to clarify the abovementioned question. A case report with a MB on the left anterior descending coronary artery is presented in the current study, and a review of the literature is provided as well. Cardiologists as well thoracic surgeons and radiologists should bear in their mind the potential presence of such variant during interpretation of angiographies and multidetector-computed tomography.
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Affiliation(s)
- George Paraskevas
- Department of Anatomy, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Kalliopi Iliou
- Department of Anatomy, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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98
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Abuarqoub A, Naranjo M, Shamoon F. Myocardial bridging with left ventricular hypertrophy presenting as Wellens pattern. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:401. [PMID: 29152501 DOI: 10.21037/atm.2017.07.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The course of epicardial coronary arteries into a muscular tunnel under a bridge of myocardium is known as myocardial bridging (MB). This could be a benign anomaly, nevertheless, it could have a great impact on the quality of life in the setting of severe anginal symptoms. The clinical presentation and diagnosis could be challenging in those patients. The treatment options start from simple medical therapy to surgical intervention in refractory cases, the role of percutaneous coronary intervention (PCI) is limited in MB. We are describing a case of severe MB presenting as Wellens pattern with underlying left ventricular hypertrophy (LVH).
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Affiliation(s)
- Ahmad Abuarqoub
- Department of Cardiology, Saint Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Maria Naranjo
- Department of Cardiology, Saint Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Fayez Shamoon
- Department of Cardiology, Saint Joseph's Regional Medical Center, Paterson, NJ, USA
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99
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Hostiuc S, Rusu MC, Hostiuc M, Negoi RI, Negoi I. Cardiovascular consequences of myocardial bridging: A meta-analysis and meta-regression. Sci Rep 2017; 7:14644. [PMID: 29116137 PMCID: PMC5677117 DOI: 10.1038/s41598-017-13958-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/02/2017] [Indexed: 01/18/2023] Open
Abstract
Myocardial bridging, a congenital abnormality in which a coronary artery tunnels through the myocardial fibres was usually considered a benign condition. Many studies suggested a potential hemodynamic significance of myocardial bridging and some, usually case reports, implied a possible correlation between it and various cardiovascular pathologies like acute myocardial infarction, ventricular rupture, life-threatening arrhythmias, hypertrophic cardiomyopathy, apical ballooning syndrome or sudden death. The main objective of this article is to evaluate whether myocardial bridging may be associated with significant cardiac effects or if it is strictly a benign anatomical variation. To this purpose, we performed a meta-analysis (performed using the inverse variance heterogeneity model) and meta-regression, on scientific articles selected from three main databases (Scopus, Web of Science, Pubmed). The study included 21 articles. MB was associated with major adverse cardiac events - OR = 1.52 (1.01–2.30), and myocardial ischemia OR = 3.00 (1.02–8.82) but not with acute myocardial infarction, cardiovascular death, ischemia identified using imaging techniques, or positive exercise stress testing. Overall, myocardial bridging may have significant cardiovascular consequences (MACE, myocardial ischemia). More studies are needed to reveal/refute a clear association with MI, sudden death or other cardiovascular pathologies.
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Affiliation(s)
- Sorin Hostiuc
- Department of Legal Medicine and Bioethics, Department 2 Morphological Sciences, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Mugurel Constantin Rusu
- Division of Anatomy, Faculty of Dental Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,MEDCENTER, Centre of Excellence in Laboratory Medicine and Pathology, Bucharest, Romania
| | - Mihaela Hostiuc
- Department of Internal Medicine and Gastroenterology, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ruxandra Irina Negoi
- Department of Anatomy, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ionuț Negoi
- Department of Surgery, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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100
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Saling LJ, Raptis DA, Parekh K, Rockefeller TA, Sheybani EF, Bhalla S. Abnormalities of the Coronary Arteries in Children: Looking beyond the Origins. Radiographics 2017; 37:1665-1678. [PMID: 29019754 DOI: 10.1148/rg.2017170018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Coronary arterial abnormalities are uncommon findings in children that have profound clinical implications. Although anomalies of the coronary origins are well described, there are many other disease processes that affect the coronary arteries. Immune system-mediated diseases (eg, Kawasaki disease, polyarteritis nodosa, and other vasculiditides) can result in coronary arterial aneurysms, strictures, and abnormal tapering of the vessels. Because findings at imaging are an important component of diagnosis in these diseases, the radiologist's understanding of them is essential. Congenital anomalies may present at varying ages, and findings in hemodynamically significant anomalies, such as fistulas, are key for both diagnosis and preoperative planning. Pediatric heart surgery can result in wide-ranging postoperative imaging appearances of the coronary arteries and also predisposes patients to a multitude of complications affecting the heart and coronary arteries. In addition, although rare, accidental trauma can lead to injury of the coronary arteries, and awareness and detection of these conditions are important for diagnosis in the acute setting. Patients with coronary arterial conditions at presentation may range from being asymptomatic to having findings of myocardial infarction. Recognition of the imaging findings is essential to direct appropriate treatment. ©RSNA, 2017.
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Affiliation(s)
- Lauren J Saling
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
| | - Demetrios A Raptis
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
| | - Keyur Parekh
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
| | - Toby A Rockefeller
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
| | - Elizabeth F Sheybani
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (L.J.S., D.A.R., S.B.); Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, Ill (K.P.); Department of Cardiology, St Louis Children's Hospital, St Louis, Mo (T.A.R.); and Department of Radiology, Mercy Hospital, St Louis, Mo (E.F.S.)
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