Abstract
The prevalence of myocardial bridging is reported to range from 0.5% to 30% and is more frequently found in patients with hypertrophic obstructive cardiomyopathy (HCM) [1Marshall M.E. Headley R.N. Intramural coronary artery as a cause of unstable angina pectoris.South Med J. 1978; 71: 1304-1306Crossref PubMed Scopus (22) Google Scholar]. The “milking effect” seen on angiography during systole is considered a benign condition because arteries are irrigated during diastole. However, some groups have shown that this narrowing effect could be extended to diastole [2Bourassa M.G. Butnaru A. Lesperance J. Tardif J.C. Symptomatic myocardial bridges: overview of ischemic mechanisms and current diagnostic and treatment strategies.J Am Coll Cardiol. 2003; 41: 351-359Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar]. Clinically, myocardial bridging may be associated with myocardial ischemia, tachycardia-induced ischemia, conduction abnormalities, myocardial infarction, and even sudden death [3Bestetti R.B. Costa R.S. Zucolotto S. Oliveira J.S. Fatal outcome associated with autopsy proven myocardial bridging of the left anterior descending coronary artery.Eur Heart J. 1989; 10: 573-576PubMed Google Scholar]. Although clinical studies have shown that myocardial bridging is an independent risk factor for developing myocardial ischemia and interstitial fibrosis [4Brodsky S.V. Roh L. Ashar K. Braun A. Ramaswamy G. Myocardial bridging of coronary arteries: a risk factor for myocardial fibrosis?.Int J Cardiol. 2008; 124: 391-392Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar], prognostic data are limited. Because the severity of the wall thickness is more important in patients with HCM, Kunkala and associates [5Kunkala M.R. Schaff H.V. Burkhart H. et al.Outcome of repair of myocardial bridging at the time of septal myectomy.Ann Thorac Surg. 2014; 97: 118-123Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] evaluated the clinical outcome of muscular bridge unroofing of the left anterior descending artery at the time of septal myomectomy in patients with HCM. This retrospective study compared three groups of patients: group 1, myomectomy and unroofing; group 2, myomectomy alone; and group 3, no surgical intervention. The results showed that myocardial unroofing can be performed safely. Angina was improved in group 1 but no difference was found in terms of late survival. This group reported their experience of myocardial unroofing during septal myomectomy as guidance to clinical decision management. Myocardial bridging is still controversial in the literature even on the pathophysiologic side and on the symptomatic relief and clinical prognosis of this intervention. This paper by Kunkala and colleagues [5Kunkala M.R. Schaff H.V. Burkhart H. et al.Outcome of repair of myocardial bridging at the time of septal myectomy.Ann Thorac Surg. 2014; 97: 118-123Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] is of some interest because of the rarity of the condition, but there are many shortcomings inherent to the nature of the study that prevent us from obtaining definitive answers. In particular, very few data are given concerning the physiopathologic consequences of bridging in these patients or in patients without HCM and bridging. There is no documentation of ischemia in the anterior territory, no explanation for recurrence of angina. Numerous details are lacking concerning anatomy of the bridge, findings at angiography, and medical management of patients. The risks of unroofing being small, perhaps it should be recommended for all (with or without angina) at the time of myomectomy. Further studies should be considered to reinforce the link between the clinical symptoms and the pathophysiologic mechanism, because the paradox remains. Outcome of Repair of Myocardial Bridging at the Time of Septal MyectomyThe Annals of Thoracic SurgeryVol. 97Issue 1PreviewMyocardial bridging describes systolic compression of the muscular investment of a portion of an epicardial coronary artery. We evaluated the outcome of muscular bridge unroofing of the left anterior descending artery at the time of septal myectomy in patients with hypertrophic cardiomyopathy. Full-Text PDF
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