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Myocardial Bridges a Forgotten Condition: a Review Martín Ibarrola, MD*

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Myocardial Bridges a Forgotten Condition: a Review Martín Ibarrola, MD* ISSN: 2474-3682 Ibarrola. Clin Med Img Lib 2021, 7:162 DOI: 10.23937/2474-3682/1510162 Volume 7 | Issue 1 Clinical Medical Image Library Open Access IMAGE ARTICLE Myocardial Bridges a Forgotten Condition: A Review Martín Ibarrola, MD* Centro Cardiovascular BV, General Cardiology, Argentina Check for updates *Corresponding author: Martín Ibarrola, MD, Centro Cardiovascular BV, General Cardiology, Argentina Abstract Introduction Myocardial Bridging (MB) is a congenital anomaly in which The first reference of MB was Reymann, H, the an- a segment of a coronary artery takes a “tunneled” intramus- atomically description Published in the Dissertationem cular course under a “bridge” of overlying myocardium. The inauguralem De Vasis Cordis Propriis, written in Latin, first reference of MB in coronary arteries, the association with angina and anatomically as referred by Reyman in described anatomically the presence of MB in a descrip- 1737. Considered a “benign” finding since the myocardi- tion and their relationship with angina in 1937. When al bridge causes coronary artery narrowing during systole noted this anatomy in human heart. Described was a therefore myocardial bridges should not compromise blood congenital variant of a coronary artery in which a por- supply to the musculature during diastole. The Left Anterior Descending coronary (LAD) is the most frequently affected tion of an epicardial coronary artery (most frequently vessel (70% in an autopsy series) and in some cases hearts the middle segment of the LAD takes an intramuscular contain more than one bridge, affecting the same vessel or course [1]. The relation of MB in coronary arteries and different coronaries. presence of angina was described by Black S in 1796 [2]. MB also has been associated with angina, myocardial infarc- An in-depth analysis of autopsy samples was presented tion, arrhythmia, depressed left ventricular function, left bun- by Geiringer E, et al. in 1951 [3]. In 1960 Porstmann W dle branch block, myocardial stunning, apical ballooning syn- drome, early death after cardiac transplantation, and sudden publish “The mural coronary” described abnormal find- death. The MB is a clinical condition with several possible ing of MB in the angiographic study [4]. In 1961, Po- manifestations, and its clinical relevance is debated. lacek was the first to use the term “myocardial bridge” The classification used for decision making proposal for when described these formations calling them as MB, Schwarz based on Clinical-Angiographic Data and Long- referred occur in 85.7% of all hearts; the occurrence is Term Follow-Up, with angiographic finding and relationship more frequent in the region of the left coronary artery with symptoms only in MB over the LAD. The new technolo- gies as intravascular ultrasound and valuation in Fractional in a study of 70 patients [5] (Figure 1). flow reserve or Cardiac Computed Tomography Angiogra- The MB in a study of is a clinical condition with sev- phy (CCTA) they allow to visualize the coronary anatomy with more precision and better visualization of MB not only eral possible manifestations, and its clinical relevance in LAD besides that study in another arteries (branch arter- is debated. Kramer J described in 1974 the clinical sig- ies), not only in LAD and correlate the symptoms with these nificance of isolated coronary MB such has benign and findings. frequent condition involving the left anterior descend- Congenital coronary anomalies detected by CCTA com- ing artery in asymptomatic patients without angina and pared to invasive coronary angiography are evidenced in presence of MB in angiographic study [6]. studies. A new terminology and assessment to studies are necessary according to current technologies. The assess- In a study of coronary angiograms of 64 heart trans- ment and implications of MB not only in the main arteries plant patients were reviewed by Wymore P to deter- (LAD), but also in the branches of the coronary arteries. mine the incidence of myocardial bridges. Only in 33% Keywords of these patients, myocardial bridges were detected, al- Myocardial bridging, Tunneled artery, Coronary angiography, most exclusively across the mid portion of the left ante- Ultrasound, Cardiac computed tomography angiography rior descending coronary artery. This is an evidence for Citation: Ibarrola M (2021) Myocardial Bridges a Forgotten Condition: A Review. Clin Med Img Lib 7:162. doi.org/10.23937/2474-3682/1510162 Accepted: January 28, 2021; Published: January 30, 2021 Copyright: © 2021 Ibarrola M. This is an open-access content distributed under the terms of the Cre- ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Ibarrola. Clin Med Img Lib 2021, 7:162 • Page 1 of 8 • DOI: 10.23937/2474-3682/1510162 ISSN: 2474-3682 Figure 1: Illustration depicting normal coronary artery anatomy in LAD, deep MB and shallow MB in LAD. LAD: Left Anterior Descendent Artery; MB: Myocardial Bridge. In a meta-analysis in MB were included 2519 ar- ticles and analyzed 21 articles of these. The presence of MB led to a significantly increased risk for Major Ad- verse Coronary Events (MACE) - OR = 1.53(1.01-2.30), p < 0.001 and myocardial ischemia [15]. Morphology MB represent an anomaly of coronary artery flow in which the branches flowing subepicardial descend into the myocardium more shallow or deeper, and after a shorter or longer intramyocardial flow, it reappears in the subepicardial tissue. Bundles of myocardial fibers, which in the form of small bridges, pass over the cor- responding part of the coronary artery (“tunnel” seg- ment), are marked as the MB [16]. Myocardial bridges are most commonly localized in the middle segment of the LAD, in other reports the anatomical variant of ra- mus intermedius artery presents MB [6,11]. Diagonal Figure 2: Cardiac computed tomography angiography. and marginal branches may be involved in 18% and 40% LMA, without lesions; LAD artery, without atherosclerotic of cases [17]. Also has reported the presence of multiple lesions, with a deep intramyocardial course up to 16.6 myocardial bridges and left ventricular dysfunction and mm (MB); Fist DB, with intramyocardial course (MB); LCx, first diagonal without lesions with intramyocardial left bundle branch block, in a patient with angina and course in distal third (MB). RI, of moderate size with two positive stress test [11] (Figure 2). rams intramyocardial course (MB) in middle third. RCA, dominant without lesions. These are distinguished between two types of bridg- ing: Superficial bridges (75% of cases) crossing the ar- LMA: Indicates Left Main Coronary Artery; LAD: Left Anterior Descending; DB: Diagonal Branch; LCx, left tery perpendicularly or at an acute angle toward the circumflex; RI: Ramus Intermedius; RCA: Right Coronary apex, and muscle bundles arising from the right ventric- Artery. MB: Myocardial Bridge. ular apical trabeculae (25% of cases) that cross the LAD transversely, obliquely, or helically before terminating the poor angiography for the diagnostic of MB except in in the interventricular septum [18] Figure 3. the LAD [7]. Pathophysiology and Relationship with Ath- The MB is a clinical condition with several possible erosclerosis manifestations. Also has been associated with angina, Only 15% of coronary blood flow occurs during sys- [8] myocardial infarction, [9] arrhythmia, [10] depressed tole, and because myocardial bridging is a systolic find- left ventricular function, left bundle branch block, [11] ing in angiography. Obviously, this allows only to recog- myocardial stunning, [12], apical ballooning syndrome, nize the muscle bridges in the main coronary arteries. In [13] early death after cardiac transplantation, and sud- coronary angiograms MB are to be detected indirectly, den death [14]. based on the systolic reduction of lumen. The tachy- Ibarrola. Clin Med Img Lib 2021, 7:162 • Page 2 of 8 • DOI: 10.23937/2474-3682/1510162 ISSN: 2474-3682 Figure 3: Additional analysis of the LAD MB in Figure 2 with CTTA. a) Cross-sectional view of intramyocardial course in LAD and View of an intramyocardial course in LAD (16.6 mm); Longitudinal view of intramyocardial course in LAD. LAD: Left anterior descending; MB: Myocardial bridge; CCTA: Cardiac computed tomography angiography. cardia may worsen ischemia because of a decrease in mid-LAD. The presence of MB significantly contributes diastolic filling time and in coronary flow reserve [19]. to low wall shear stress and endothelial dysfunction re- MB have been described as superficial or deep on the lationship. It recognized the relation in alteration in va- basis of: a) They range from 0.3 to 28 mm in depth, b) soactive agent and wall shear stress in endothelial dys- Anatomically they consist of either superficial myocar- function and development of atherosclerotic lesions by dial fibers that traverse over the LAD or deep fibers that abnormal function in the endothelium of coronary ves- encircle the LAD [5,7], and c) Bridges > 5 mm deep are sel and promotes the vasospasm artery and presence of less amenable to surgical myotomy. The hemodynamic angina without atherosclerotic lesions [24]. impact of myocardial bridging depends on the thickness The segment proximal to the bridge in LAD frequent- and length of the bridge, the orientation of the bridge ly shows atherosclerotic plaque formation, although the relative to myocardial fibers, and the presence of loose tunneled segment is typically spared [16]. Because low connective or adipose tissue around the bridged seg- shear stress may contribute to atherosclerotic plaque ment [18,20]. formation proximal to the bridge, whereas high shear Coronary artery spasm, first described by Prinzmet- stress may have a protective role within the tunneled al, is not an uncommon and has been recognized as an segment [25]. Plaque formation is related to the fac- important cause of chest pain in patients with normal or tors described, but additionally to the atherogenic risk non- significant obstructive coronary artery and the as- factors of the patient.
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