Extensive unroofing of myocardial bridge: A case report and literature review

Background: Myocardial bridge is defined as a segment of a coronary artery that takes an intramyocardial course. The presence of myocardial bridge has been observed in as many as 40%–80% of cases on autopsy, angiographically from 0.5% to 16.0%, and often asymptomatic. However, it has been associated with angina, coronary spasm, myocardial infarction, arrhythmias, syncope, sudden cardiac arrest, and death. Conflicting opinions exist on the timing of surgical intervention for myocardial bridge. Methods: We present an unusual case of a young female, with prior aortic surgery, who had refractory chest pain despite optimal medical therapy. Stress testing revealed anterior ischemia. Cardiac catherization showed myocardial bridge of the left anterior descending artery with significant compromise of blood flow (fractional flow reserve = 0.75 with adenosine). We proceeded with surgery. Intraoperatively, we found an unusually long (10-cm) intramyocardial segment of the left anterior descending artery which was managed by surgically unroofing. Our patient felt better post procedure. Repeat cardiac catheterization showed no further narrowing of the left anterior descending artery with a fractional flow reserve of 0.87 in its distal segment. Results/discussion: Myocardial bridge is present mostly in female patients (74.5%), with median age at 56.2 years and mostly involving the left anterior descending artery (77.2%). The average length of myocardial bridge is 21.85 ± 16.10 mm (range: 5–70 mm). Our case is unique as the involved myocardial bridge was 10 cm in length, the longest ever reported. Multiple imaging modality revealed significant coronary insufficiency, with a subsequent clinical and angiographic improvement upon unroofing of the culprit coronary vessel. Conclusion: Management decision on myocardial bridge remains controversial. This is a case of the longest symptomatic myocardial bridge, with a subsequent improvement post unroofing.

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Fractional flow reserve and instantaneous wave-free ratio discordance in patients with severe aortic valve stenosis

European Heart Journal ◽

10.1093/ehjci/ehaa946.1276 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

F Yamanaka ◽

K Shishido ◽

S Yokota ◽

N Moriyama ◽

Y Mashimo ◽

...

Keyword(s):

Coronary Artery ◽

Aortic Valve ◽

Aortic Valve Stenosis ◽

Fractional Flow Reserve ◽

Coronary Artery Stenosis ◽

Artery Stenosis ◽

Aortic Valve Area ◽

Fractional Flow ◽

Left Anterior Descending Artery ◽

Flow Reserve

Abstract Background It has been reported that discordance between fractional flow reserve (FFR) and Instantaneous Wave-Free Ratio (iFR) could occur in up to 20% of cases. However, there are no reports regarding discordance between FFR and iFR in patients with severe aortic valve stenosis (AS). Purpose We aimed to investigate the discordance between FFR and iFR in patients with severe AS. Methods Severe AS was defined as an aortic-valve area of ≤1.0 cm2, a mean aortic-valve gradient of 40mmHg or more, or a peak aortic-jet velocity of 4.0 m/s or more. Intermediate coronary artery stenosis was defined as 30% to 70% stenosis (visual estimation). FFR and iFR were calculated in 4 quadrants based on values of FFR ≤0.8 and iFR ≤0.89 (positive discordance; low FFR and high iFR, negative discordance; high FFR and low iFR). Results We examined consecutive 140 patients (164 intermediate coronary artery stenosis vessels). Mean FFR and iFR ± standard deviation was 0.82±0.09 and 0.82±0.14, respectively. The discordance was observed in 48 vessels (29.3%). In the discordant group, most of cases were negative discordance (45 cases, 93.6%). Binary logistic regression analysis showed that left anterior descending artery (Hazard Ratio 3.80; 1.55 to 9.31, p=0.0036) was independently associated with negative discordance. Conclusions In patients with severe AS, the discordance between FFR and iFR could be observed in 29.3% of the vessels, mostly negative discordance. The left anterior descending artery is an independent predictor for negative discordance. Funding Acknowledgement Type of funding source: None

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Computed Tomographic Angiography–Based Fractional Flow Reserve Compared With Catheter-Based Dobutamine-Stress Diastolic Fractional Flow Reserve in Symptomatic Patients With a Myocardial Bridge and No Obstructive Coronary Artery Disease

Circulation Cardiovascular Imaging ◽

10.1161/circimaging.119.009576 ◽

2020 ◽

Vol 13 (2) ◽

Author(s):

Ayman Jubran ◽

Ingela Schnittger ◽

Jennifer Tremmel ◽

Vedant Pargaonkar ◽

Ian Rogers ◽

...

Keyword(s):

Fractional Flow Reserve ◽

Obstructive Coronary Artery Disease ◽

Dobutamine Stress ◽

Computed Tomographic Angiography ◽

Fractional Flow ◽

Myocardial Bridge ◽

Computed Tomographic ◽

Flow Reserve ◽

Artery Disease ◽

Tomographic Angiography

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P3575Clinical importance of fractional flow reserve in patients with organic coronary stenosis and vasospastic angina

European Heart Journal ◽

10.1093/eurheartj/ehz745.0436 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K Hao ◽

J Takahashi ◽

A Suda ◽

K Sato ◽

J Sugisawa ◽

...

Keyword(s):

Clinical Outcomes ◽

Fractional Flow Reserve ◽

Coronary Stenosis ◽

Coronary Spasm ◽

Provocation Test ◽

Vasospastic Angina ◽

Prognostic Impact ◽

Fractional Flow ◽

Flow Reserve

Abstract Background Vasospastic angina (VSA), which is one of the important functional cardiac disorders, may also play a role in the pathogenesis of atherosclerosis. Conversely, organic coronary stenosis is also known as an independent predictor for poor clinical outcomes in VSA patients. Although VSA patients have a variable degree of organic coronary stenosis in clinical setting, the functional importance of organic stenosis in those patients remains to be elucidated. Purpose The aim of this study was to examine the clinical importance and prognostic impact of fractional flow reserve (FFR) in patients with VSA and organic coronary stenosis. Methods We enrolled 236 consecutive patients with suspected vasospastic angina who underwent acetylcholine provocation test for coronary spasm (M/F 148/88, 63.6±12.0 [SD] yrs.). Among them, 175 patients (74.1%) were diagnosed as having VSA, while the remaining non-VSA patients were regarded as controls (Group-C, n=61). We divided the VSA patients into 3 groups based on angiographical findings and FFR values; VSA with no organic stenosis (>50% luminal stenosis) (Group-N, n=110), organic stenosis and high FFR (≥0.80) (Group-H, FFR 0.87±0.05, n=36), and organic stenosis and low FFR (<0.80) (Group-L, FFR 0.71±0.07, n=29). We evaluated the incidence of major adverse cardiovascular events (MACE), including cardiovascular death (CVD), non-fatal myocardial infarction (MI), urgent percutaneous coronary intervention (PCI), and hospitalization due to unstable angina pectoris (UAP) during the median follow-up period of 656 days. Results The groups with organic stenosis (Groups H and L) were characterized by higher prevalence of diabetes mellitus (Group-C/N/H/L, 23.0/20.9/44.4/34.5%, P=0.03) and dyslipidemia (Group-C/N/H/L, 37.7/39.1/50.0/65.5%, P=0.03) as compared with Group-C. After provocation test, all VSA patients received calcium channel blockers (CCBs). In addition, 20 days (median) after provocation test, 26 patients (92.9%) in Group-L underwent elective PCI with coronary stents, while no patient underwent PCI in Groups N or H. The incidence of MACE during follow-up was significantly higher in Group-L (Group-C/N/H/L; 1.6/3.6/5.6/27.6%, log-rank P<0.001), whereas clinical outcomes were comparable among the remaining 3 groups (Figure). Importantly, all 8 patients with MACE in Group-L had poor outcomes (CVD/MI/urgent PCI/UAP; 2/1/3/2) despite complete revascularization and the prevention of coronary spasm with CCBs, indicating that they might be resistant to standard contemporary therapies. They were characterized by less frequent use of angiotensin convert enzyme inhibitor (0 vs. 47.6%, P=0.02) and higher prevalence of multi-vessel organic lesions (37.5 vs. 4.8%, P=0.052) compared with those without MACE. Figure 1 Conclusions These results provide the first evidence that evaluation of coronary functional abnormalities with FFR is useful for making therapeutic strategies in VSA patients with organic coronary stenosis.

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