Mok Salvior, Majdalany David, Pettersson Gosta B
Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
SAGE Open Med Case Rep. 2019 Jan 16;7:2050313X18823380. doi: 10.1177/2050313X18823380. eCollection 2019.
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.
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.
Management decision on myocardial bridge remains controversial. This is a case of the longest symptomatic myocardial bridge, with a subsequent improvement post unroofing.
心肌桥被定义为走行于心肌内的一段冠状动脉。尸检发现心肌桥的存在率高达40%-80%，血管造影显示为0.5%-16.0%，且通常无症状。然而，它与心绞痛、冠状动脉痉挛、心肌梗死、心律失常、晕厥、心脏骤停及死亡有关。对于心肌桥手术干预的时机存在相互矛盾的观点。
我们报告一例年轻女性的罕见病例，该患者曾接受主动脉手术，尽管接受了最佳药物治疗仍有难治性胸痛。负荷试验显示前壁缺血。心脏导管检查显示左前降支心肌桥，血流明显受限（腺苷激发下血流储备分数=0.75）。我们进行了手术。术中，我们发现左前降支有一段异常长（10厘米）的心肌内节段，通过手术松解进行处理。术后患者感觉好转。重复心脏导管检查显示左前降支无进一步狭窄，其远端节段血流储备分数为0.87。
结果/讨论：心肌桥多见于女性患者（74.5%），中位年龄为56.2岁，主要累及左前降支（77.2%）。心肌桥的平均长度为21.85±16.10毫米（范围：5-70毫米）。我们的病例独特之处在于受累心肌桥长度为10厘米，是有报道以来最长的。多种影像学检查显示冠状动脉严重供血不足，在松解罪犯冠状动脉后临床及血管造影结果均有改善。
心肌桥的治疗决策仍存在争议。这是一例有症状的最长心肌桥病例，松解术后病情得到改善。
