IMAGING IN CARDIOLOGY
Myocardial bridging
S.C.A.M. Bekkers, F.W.H.M. Bar, H.J.G.M. Crijns
Figure 1. ECG on
admission.
A49-year-old male patient with a two-year history of episodic chest pain was seen at the Heart Emergency Department because of acute onset of squeezing epigastric pain radiating to his chest. His risk factors for coronary artery disease were a positive family history, hypertension and he was an ex-smoker. Physical examination was normal. The electrocardiogram showed a sinus rhythm with a left anterior hemiblock and abnormal repolarisation (figure 1). Repeat troponin levels were normal. Because of recurrent chest pain, accompanied with minor ECG
S.C.A.M. Bekkers. F.W.H.M. Bir. H.J.G.M. CrIljns. Department of Cardiology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht. Address for correspondence: S.C.A.M. Bekkers. E-mail: [email protected]
26
changes and after inconclusive exercise testing, a coronary angiogram was performed. Obstructive atherosclerotic lesions were not found but systolic squeezing ofthe left anterior descending branch was seen over a long section (figure 2). Beta-blocking agents did not relieve the symptoms. Jaundice gradually developed with a rise of cholestatic liver enzymes. Cholelithiasis was confirmed by a CT scan and he was successftilly treated with a cholecystectomy, after which he remained free of symptoms. In myocardial bridging, a short segment of a superficial muscular band runs across a predominantly epicardially located coronary artery that is angiographically characterised by systolic squeezing. The left anterior descending artery is most commonly involved.'13 It is seen in 0.5 to 16% of angiographic studies and still has controversial clinical relevance, since normal myocardial perfusion is diastolic. However, abnormal flow patterns can be detected in the bridging coronary artery segment with decreased coronary flow reserve.4 Nuclear exercise testing has a Netherlands Heart Journal, Volume 12, Number 1, January 2004
IMAGING IN CARDIOLOGY
Figure 2k Systolic squeezing of mid segment ofthe LAD (arrows).
Figure2A Sytoiesqueezing ofmid sge,"nt ofthe LAD (arrows). low sensitivity and specificity in determining the clinical significance of myocardial bridging. Prognosis is generally excellent and evidence concerning adverse cardiac events has been inconclusive.5-7 Rare cases of myocardial infarction, ventricular tachycardia, syncope and atrioventricular block have been reported. Although myocardial bridges are mostly asymptomatic, good results have been reported with [-blocking agents as a first line of treatment, while calcium antagonists are an alternative in symptomatic patients. Surgical myotomy or stenting is rarely indicated.5 8 U
Figure 2B. Same segment as in figure 2A during diastole. 6
7
8
Greenspan M, Iskandrian AS, Catherwood E, Kimbiris D, Bemis CE, Segal BL. Myocardial bridging ofthe left anterior descending artery: evaluation using exercise thallium-201 myocardial scintigraphy. Cathet Cardiovasc Diagn 1980;6:173-80. JuilliereY, BerderV, Suty-Selton C, Buffet P, Danchin N, Cherrier F. Isolated myocardial bridges with angiographic milking ofthe left anterior descending coronary artery: a long-term follow-up study. Am HeartJ 1995;129:663-5. Hill RC, Chitwood WR Jr, Bashore TM, Sink JD, Cox JL, WechslerAS. Coronary flow and regional function before and after supraarterial myotomy for myocardial bridging. Ann Thorac Sur,g 1981;31:176-81.
Rferences Noble J, Bourassa MG, Petitclerc R, Dyrda I. Myocardial bridging and milking effect of the left anterior descending coronary artery: normal variant or obstruction? AmJCardiol 1976;37:993-9. 2 Reyman H. Dissertatio de vasis cordis propriis. BiblAnat 1737;2: 366. 3. Angelini P, Trivellato M, Donis J, Leachman RD. Myocardial bridges: a review. Prog Cardiovasc Dis 1983;26:75-88. 4 Ge J, Erbel R, Rupprecht HJ, Koch L, Kearney P, Gorge G, et al. Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging. Circulation 1994;89:1725-32. 5 Haager PK, Schwarz ER, Dahl J vom, Klues HG, Reffelmann T, Hanrath P. Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging. Heart2000;84:403-8. 1
Netherlands Heart Joural, Volunm 12, Number 1, January 2004
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer.
27
Myocardial bridging
S.C.A.M. Bekkers, F.W.H.M. Bar, H.J.G.M. Crijns
Figure 1. ECG on
admission.
A49-year-old male patient with a two-year history of episodic chest pain was seen at the Heart Emergency Department because of acute onset of squeezing epigastric pain radiating to his chest. His risk factors for coronary artery disease were a positive family history, hypertension and he was an ex-smoker. Physical examination was normal. The electrocardiogram showed a sinus rhythm with a left anterior hemiblock and abnormal repolarisation (figure 1). Repeat troponin levels were normal. Because of recurrent chest pain, accompanied with minor ECG
S.C.A.M. Bekkers. F.W.H.M. Bir. H.J.G.M. CrIljns. Department of Cardiology, University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht. Address for correspondence: S.C.A.M. Bekkers. E-mail: [email protected]
26
changes and after inconclusive exercise testing, a coronary angiogram was performed. Obstructive atherosclerotic lesions were not found but systolic squeezing ofthe left anterior descending branch was seen over a long section (figure 2). Beta-blocking agents did not relieve the symptoms. Jaundice gradually developed with a rise of cholestatic liver enzymes. Cholelithiasis was confirmed by a CT scan and he was successftilly treated with a cholecystectomy, after which he remained free of symptoms. In myocardial bridging, a short segment of a superficial muscular band runs across a predominantly epicardially located coronary artery that is angiographically characterised by systolic squeezing. The left anterior descending artery is most commonly involved.'13 It is seen in 0.5 to 16% of angiographic studies and still has controversial clinical relevance, since normal myocardial perfusion is diastolic. However, abnormal flow patterns can be detected in the bridging coronary artery segment with decreased coronary flow reserve.4 Nuclear exercise testing has a Netherlands Heart Journal, Volume 12, Number 1, January 2004
IMAGING IN CARDIOLOGY
Figure 2k Systolic squeezing of mid segment ofthe LAD (arrows).
Figure2A Sytoiesqueezing ofmid sge,"nt ofthe LAD (arrows). low sensitivity and specificity in determining the clinical significance of myocardial bridging. Prognosis is generally excellent and evidence concerning adverse cardiac events has been inconclusive.5-7 Rare cases of myocardial infarction, ventricular tachycardia, syncope and atrioventricular block have been reported. Although myocardial bridges are mostly asymptomatic, good results have been reported with [-blocking agents as a first line of treatment, while calcium antagonists are an alternative in symptomatic patients. Surgical myotomy or stenting is rarely indicated.5 8 U
Figure 2B. Same segment as in figure 2A during diastole. 6
7
8
Greenspan M, Iskandrian AS, Catherwood E, Kimbiris D, Bemis CE, Segal BL. Myocardial bridging ofthe left anterior descending artery: evaluation using exercise thallium-201 myocardial scintigraphy. Cathet Cardiovasc Diagn 1980;6:173-80. JuilliereY, BerderV, Suty-Selton C, Buffet P, Danchin N, Cherrier F. Isolated myocardial bridges with angiographic milking ofthe left anterior descending coronary artery: a long-term follow-up study. Am HeartJ 1995;129:663-5. Hill RC, Chitwood WR Jr, Bashore TM, Sink JD, Cox JL, WechslerAS. Coronary flow and regional function before and after supraarterial myotomy for myocardial bridging. Ann Thorac Sur,g 1981;31:176-81.
Rferences Noble J, Bourassa MG, Petitclerc R, Dyrda I. Myocardial bridging and milking effect of the left anterior descending coronary artery: normal variant or obstruction? AmJCardiol 1976;37:993-9. 2 Reyman H. Dissertatio de vasis cordis propriis. BiblAnat 1737;2: 366. 3. Angelini P, Trivellato M, Donis J, Leachman RD. Myocardial bridges: a review. Prog Cardiovasc Dis 1983;26:75-88. 4 Ge J, Erbel R, Rupprecht HJ, Koch L, Kearney P, Gorge G, et al. Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging. Circulation 1994;89:1725-32. 5 Haager PK, Schwarz ER, Dahl J vom, Klues HG, Reffelmann T, Hanrath P. Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging. Heart2000;84:403-8. 1
Netherlands Heart Joural, Volunm 12, Number 1, January 2004
In this section a remarkable 'image' is presented and a short comment is given. We invite you to send in images (in triplicate) with a short comment (one to two pages at the most) to Mediselect bv, Editorial Office Netherlands Heart Journal, PO Box 63, 3830 AB Leusden, the Netherlands. This section is edited by M.J.M. Cramer.
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