International Journal of Cardiology, 37 (1992)
11l- 112
111
0 1992 Elsevier Science Publishers B.V. All rights reserved 0167-5273/92/$05.00
CARD10 15381
Brief Reports
Hypertrophic
cardiomyopathy
and myocardial bridging
H. Achrafi Cardiologic Section, St. Francois Clinic, Chartres. France
(Received 7 July 1991: accepted 25 March 1992)
Two patients are reported in whom hypertrophic cardiomyopathy was associated with myocardial bridging of the left anterior descending coronary artery. One had a history of angina and recurrent syncope, the other had chest pain and exertional dyspnoea. In each case the diagnosis was made by cross-sectional echocardiography and coronary angiography. Key words:
Hypertrophic
cardiomyopathy;
Myocardial
Introduction Myocardial bridging of an epicardial coronary artery with transient narrowing or occlusion of the vessel is not uncommon. The anterior descending, diagonal or marginal branches of the left coronary artery dip intramyocardially, and the overlying myocardium may compress the artery during systole, creating a functional stenosis. This phenomenon may, in some patients, be associated with hypertrophic cardiomyopathy. We report here two cases of such an association, one with and one without obstruction of left ventricular outflow. Case Reports
bridging;
Syncope
Cross-sectional echocardiography revealed asymmetric septal hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and premature aortic cusp closure. Doppler studies demonstrated an intraventricular pressure gradient of 75 mmHg, and impaired ventricular diastolic compliance. Cardiac catheterisation and coronary angiography confirmed the diagnosis of hypertrophic cardiomyopathy, and revealed the presence of a myocardial bridge in the mid portion of the left anterior descending coronary artery.
Patient 2. A 68-yr-old woman was seen with complaints of exertional dyspnoea and atypical chest pain. Physical examination was unremarkable, the ECG showed nonspecific ST-T wave changes with left ventricular hypertrophy. Cross-sectional echocardiography revealed symmetrical left ventricular hypertrophy, without obstruction of the outflow tract. Coronary angiography confirmed the diagnosis of concentric hypertrophic cardiomyopathy, and revealed a myocardial bridge across the proximal anterior descending coronary artery.
Patient I. A 49-yr-old man was seen with a 3-month history of syncope and angina, occurring particularly on exercise. Physical examination was unremarkable, but there was a midsystolic murmur in the apical region which increased with the Valsalva manoeuvre. The ECG showed sinus rhythm at 70/min, left ventricular hypertrophy and first-degree atrioventricular block.
Discussion
Correspondence to: Dr. H. Achrafi. Chartres 28000, France.
Myocardial bridging of epicardial coronary arteries is a congenital variant first described by Crainicianu in 1922 [l]. Geiringer [2] has estimated its prevalence to be about 23% of cases seen at necropsy. Its frequency
16 Place des Epars,
112
at angiography is between 0.5 and 1%. The coronary artery is embedded in the myocardial muscle for a variable distance, resulting in systolic narrowing or a “milking effect” in the absence of fixed atheromatous stenosis. Clinical symptoms attributed to myocardial bridging are chest pain, exertional dyspnoea and myocardial infarction. Morales and colleagues [3] reported cases of sudden death on exercise in patients with myocardial bridging. The degree of systolic narrowing of the arterial lumen may vary from 30% to more than 75%. An association with hypertrophic cardiomyopathy may aggravate myocardial ischaemia. Treatment of this disease, in isolation or associated with hypertrophic cardiomyopathy, may be medical or surgical. Beta-adrenoceptor antagonists have been claimed to help, and Raizner and colleagues [4] reported relief of ischaemia by surgery, in the form of bypass grafting or surgical unroofing which sometimes reveals unrecognised compression of septal perforators. The association of myocardial bridging and hypertrophic cardiomyopathy should be borne in mind because of the possibly increased risk of sudden death.
Morales A, Romanelli R. Boucek R. The mural left anterior descending coronary artery, strenuous exercise and sudden death. Circulation 1980;62:230-237. Raizner A, Ishimori T, Verani M. Surgical relief of ischaemia due to myocardial bridges (abstract). Am J Cardiol 1980;47:417.
Editorial comment Myocardial
References
I Crainicianu A. Anatomische Studien iiber Coronarterien und experimentelle Untersuchungen iiber ihre Durchgangkeit. Virchow’s Arch Pathol Anat 1922:238:1-8. 2 Geiringer E. The mural coronary artery. Am Heart 1951;41:359-368.
bridges
seen
at angiography
certainly
look spectacular, but what is their functional significance? We now know, from intracoronary Doppler studies, that flow in the large epicardial coronary arteries is virtually entirely diastolic, so compression during systole need not necessarily impair myocardial perfusion. This is in agreement with clinical observations that myocardial bridging is frequently seen in patients without evidence of ischaemia. Reports of surgical “cure” should be treated with scepticism, as other procedures are frequently combined with de-bridging, and controlled trial data are not available. Beta-adrenoceptor blockers are, of course, standard treatment for hypertrophic cardiomyopathy, and their effect on systolic compression may be irrelevant. It is certainly true that the increased mechanical stress on the vessel wall could help to induce spasm, or even rupture of a small atheromatous plaque, and this may be the mechanism for the cases of sudden death described. Until we have more information, however, it may be premature to recognise muscle bridging as a “disease”.
J
D. de Bono
International Journal of Cardiology, 37 (1992) 112-l 14 0 1992 Elsevier
CARD10
Science Publishers B.V. All rights reserved
0167-5273/92/$05.00
15382
Mycotic aneurysm of the descending aorta diagnosed by echocardiography Siiheyla Gzkutlu, Nazan Gzbarlas, Arman Bilgis and Ilhan Pasaoglu Department of Pediatric Cardiology, Hacettepe Unillersi@, Institute of Child Heath, Ankara, Turkey (Received
18 March
1992; revision
accepted
17 May 1992)
We present a 3-yr-old girl with coarctation of aorta and patent ductus arteriosus in whom mycotic aneurysm and bacterial endarteritis developed postoperatively and was diagnosed by two-dimensional and Doppler echocardiograCorrespondence to: Siiheyla Ankara, Turkey.
&kutlu,
M.D.,
Dept.
of Pediatric
Cardiology,
Hacettepe
University,
School
of Medicine,
00100
11l- 112
111
0 1992 Elsevier Science Publishers B.V. All rights reserved 0167-5273/92/$05.00
CARD10 15381
Brief Reports
Hypertrophic
cardiomyopathy
and myocardial bridging
H. Achrafi Cardiologic Section, St. Francois Clinic, Chartres. France
(Received 7 July 1991: accepted 25 March 1992)
Two patients are reported in whom hypertrophic cardiomyopathy was associated with myocardial bridging of the left anterior descending coronary artery. One had a history of angina and recurrent syncope, the other had chest pain and exertional dyspnoea. In each case the diagnosis was made by cross-sectional echocardiography and coronary angiography. Key words:
Hypertrophic
cardiomyopathy;
Myocardial
Introduction Myocardial bridging of an epicardial coronary artery with transient narrowing or occlusion of the vessel is not uncommon. The anterior descending, diagonal or marginal branches of the left coronary artery dip intramyocardially, and the overlying myocardium may compress the artery during systole, creating a functional stenosis. This phenomenon may, in some patients, be associated with hypertrophic cardiomyopathy. We report here two cases of such an association, one with and one without obstruction of left ventricular outflow. Case Reports
bridging;
Syncope
Cross-sectional echocardiography revealed asymmetric septal hypertrophy, systolic anterior motion of the anterior mitral valve leaflet, and premature aortic cusp closure. Doppler studies demonstrated an intraventricular pressure gradient of 75 mmHg, and impaired ventricular diastolic compliance. Cardiac catheterisation and coronary angiography confirmed the diagnosis of hypertrophic cardiomyopathy, and revealed the presence of a myocardial bridge in the mid portion of the left anterior descending coronary artery.
Patient 2. A 68-yr-old woman was seen with complaints of exertional dyspnoea and atypical chest pain. Physical examination was unremarkable, the ECG showed nonspecific ST-T wave changes with left ventricular hypertrophy. Cross-sectional echocardiography revealed symmetrical left ventricular hypertrophy, without obstruction of the outflow tract. Coronary angiography confirmed the diagnosis of concentric hypertrophic cardiomyopathy, and revealed a myocardial bridge across the proximal anterior descending coronary artery.
Patient I. A 49-yr-old man was seen with a 3-month history of syncope and angina, occurring particularly on exercise. Physical examination was unremarkable, but there was a midsystolic murmur in the apical region which increased with the Valsalva manoeuvre. The ECG showed sinus rhythm at 70/min, left ventricular hypertrophy and first-degree atrioventricular block.
Discussion
Correspondence to: Dr. H. Achrafi. Chartres 28000, France.
Myocardial bridging of epicardial coronary arteries is a congenital variant first described by Crainicianu in 1922 [l]. Geiringer [2] has estimated its prevalence to be about 23% of cases seen at necropsy. Its frequency
16 Place des Epars,
112
at angiography is between 0.5 and 1%. The coronary artery is embedded in the myocardial muscle for a variable distance, resulting in systolic narrowing or a “milking effect” in the absence of fixed atheromatous stenosis. Clinical symptoms attributed to myocardial bridging are chest pain, exertional dyspnoea and myocardial infarction. Morales and colleagues [3] reported cases of sudden death on exercise in patients with myocardial bridging. The degree of systolic narrowing of the arterial lumen may vary from 30% to more than 75%. An association with hypertrophic cardiomyopathy may aggravate myocardial ischaemia. Treatment of this disease, in isolation or associated with hypertrophic cardiomyopathy, may be medical or surgical. Beta-adrenoceptor antagonists have been claimed to help, and Raizner and colleagues [4] reported relief of ischaemia by surgery, in the form of bypass grafting or surgical unroofing which sometimes reveals unrecognised compression of septal perforators. The association of myocardial bridging and hypertrophic cardiomyopathy should be borne in mind because of the possibly increased risk of sudden death.
Morales A, Romanelli R. Boucek R. The mural left anterior descending coronary artery, strenuous exercise and sudden death. Circulation 1980;62:230-237. Raizner A, Ishimori T, Verani M. Surgical relief of ischaemia due to myocardial bridges (abstract). Am J Cardiol 1980;47:417.
Editorial comment Myocardial
References
I Crainicianu A. Anatomische Studien iiber Coronarterien und experimentelle Untersuchungen iiber ihre Durchgangkeit. Virchow’s Arch Pathol Anat 1922:238:1-8. 2 Geiringer E. The mural coronary artery. Am Heart 1951;41:359-368.
bridges
seen
at angiography
certainly
look spectacular, but what is their functional significance? We now know, from intracoronary Doppler studies, that flow in the large epicardial coronary arteries is virtually entirely diastolic, so compression during systole need not necessarily impair myocardial perfusion. This is in agreement with clinical observations that myocardial bridging is frequently seen in patients without evidence of ischaemia. Reports of surgical “cure” should be treated with scepticism, as other procedures are frequently combined with de-bridging, and controlled trial data are not available. Beta-adrenoceptor blockers are, of course, standard treatment for hypertrophic cardiomyopathy, and their effect on systolic compression may be irrelevant. It is certainly true that the increased mechanical stress on the vessel wall could help to induce spasm, or even rupture of a small atheromatous plaque, and this may be the mechanism for the cases of sudden death described. Until we have more information, however, it may be premature to recognise muscle bridging as a “disease”.
J
D. de Bono
International Journal of Cardiology, 37 (1992) 112-l 14 0 1992 Elsevier
CARD10
Science Publishers B.V. All rights reserved
0167-5273/92/$05.00
15382
Mycotic aneurysm of the descending aorta diagnosed by echocardiography Siiheyla Gzkutlu, Nazan Gzbarlas, Arman Bilgis and Ilhan Pasaoglu Department of Pediatric Cardiology, Hacettepe Unillersi@, Institute of Child Heath, Ankara, Turkey (Received
18 March
1992; revision
accepted
17 May 1992)
We present a 3-yr-old girl with coarctation of aorta and patent ductus arteriosus in whom mycotic aneurysm and bacterial endarteritis developed postoperatively and was diagnosed by two-dimensional and Doppler echocardiograCorrespondence to: Siiheyla Ankara, Turkey.
&kutlu,
M.D.,
Dept.
of Pediatric
Cardiology,
Hacettepe
University,
School
of Medicine,
00100
