Falconer Debbie, Yousfani Sariha, Herrey Anna S, Lambiase Pier, Captur Gabriella
Royal Free Hospital, Pond Street, London NW3 2QG, UK.
Barts Heart Centre, W Smithfield, London EC1A 7BE, UK.
Case Rep Cardiol. 2022 Apr 11;2022:8148241. doi: 10.1155/2022/8148241. eCollection 2022.
. Myocardial bridges are congenital abnormalities, where a segment of coronary artery travels intramyocardially, rather than the typical epicardial course. The overlying muscle segment is termed "the bridge". Most myocardial bridges are asymptomatic, but some can result in myocardial ischaemia, arrhythmias, and sudden cardiac death. . A 31-year-old male with no past medical history presented to our tertiary cardiac centre following an out-of-hospital ventricular fibrillation arrest. Coronary angiography and computed tomography of the coronary arteries revealed a 2 cm myocardial bridge overlying the left anterior descending (LAD) artery. An exercise echocardiogram demonstrated severe apical ballooning and hypokinesis during peak exercise, with corresponding ST-segment elevation, resolving on rest. Options for medical therapy of a symptomatic myocardial bridge include beta blockers, calcium channel blockers, ivabradine, or a combination thereof. Surgical interventions include deroofing the bridge and revascularisation of the affected region with bypass grafting. However, a lack of trial data comparing medical regimens and surgical interventions makes it difficult to ascertain the most effective management strategy for each patient. There was disagreement between experts at different tertiary centres over the optimal management of this patient. He was treated with multiple regimes of medical therapy with ongoing ischaemia on stress testing, before undergoing a negative stress test on amlodipine, diltiazem, and isosorbide mononitrate. It was felt that no further intervention was necessary at this time given his exercise test was now negative for ischaemia. However, after seeking a second opinion, he underwent surgical intervention with bypass grafting of his left anterior descending artery, followed by implantation of an implantable cardiac defibrillator. Subsequently, an angiogram postsurgery demonstrated concomitant spasm of the LAD and he was resumed on medical therapy with calcium channel blockers and nitrates. . Without randomised trials, it is impossible to determine the optimal management strategy for each patient. It is possible that some patients with myocardial bridges are not being trialled on optimal medical therapy prior to undergoing invasive and irreversible interventions.
心肌桥是一种先天性异常，即冠状动脉的一段走行于心肌内，而非典型的心外膜走行。覆盖其上的肌段称为“桥”。大多数心肌桥无症状，但有些可导致心肌缺血、心律失常和心源性猝死。一名31岁无既往病史的男性在院外发生心室颤动骤停后被送至我们的三级心脏中心。冠状动脉造影和冠状动脉计算机断层扫描显示左前降支（LAD）动脉上方有一段2厘米长的心肌桥。运动超声心动图显示运动高峰时严重的心尖部气球样变和运动减弱，伴有相应的ST段抬高，休息时缓解。有症状心肌桥的药物治疗选择包括β受体阻滞剂、钙通道阻滞剂、伊伐布雷定或它们的联合使用。手术干预包括心肌桥松解术和用旁路移植术对受影响区域进行血运重建。然而，由于缺乏比较药物治疗方案和手术干预的试验数据，难以确定针对每个患者的最有效管理策略。不同三级中心的专家对该患者的最佳管理存在分歧。他接受了多种药物治疗方案，但在压力测试时仍有缺血，之后在氨氯地平、地尔硫䓬和单硝酸异山梨酯治疗下压力测试结果为阴性。鉴于他现在的运动测试结果显示无缺血，当时认为无需进一步干预。然而，在寻求第二种意见后，他接受了左前降支动脉旁路移植手术干预，随后植入了植入式心脏除颤器。术后血管造影显示LAD同时存在痉挛，他恢复使用钙通道阻滞剂和硝酸盐进行药物治疗。没有随机试验，就不可能确定针对每个患者的最佳管理策略。有可能一些有心肌桥的患者在接受侵入性和不可逆转的干预之前没有接受最佳药物治疗试验。
