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Myocardial Bridging: Diagnosis, Functional Assessment, and Management: JACC State-of-the-Art Review.Journal of the American College of... Nov 2021Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of the epicardial coronary artery traverses through the myocardium for a portion of its... (Review)
Review
Myocardial bridging (MB) is a congenital coronary anomaly in which a segment of the epicardial coronary artery traverses through the myocardium for a portion of its length. The muscle overlying the artery is termed a myocardial bridge, and the intramyocardial segment is referred to as a tunneled artery. MB can occur in any coronary artery, although is most commonly seen in the left anterior descending artery. Although traditionally considered benign in nature, increasing attention is being given to specific subsets of MB associated with ischemic symptomatology. The advent of contemporary functional and anatomic imaging modalities, both invasive and noninvasive, have dramatically improved our understanding of dynamic pathophysiology associated with MBs. This review provides a contemporary overview of epidemiology, pathobiology, diagnosis, functional assessment, and management of MBs.
Topics: Computed Tomography Angiography; Coronary Angiography; Coronary Circulation; Coronary Vessels; Disease Management; Humans; Myocardial Bridging; Ultrasonography, Interventional
PubMed: 34823663
DOI: 10.1016/j.jacc.2021.09.859 -
Journal of the American College of... Sep 2023Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for... (Review)
Review
Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.
Topics: Humans; Microcirculation; Myocardial Bridging; Myocardial Ischemia; Angina Pectoris; Coronary Angiography
PubMed: 37704315
DOI: 10.1016/j.jacc.2023.06.043 -
Clinical Research in Cardiology :... Apr 2023Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation... (Review)
Review
Cardiogenic shock and cardiac arrest contribute pre-dominantly to mortality in acute cardiovascular care. Here, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as an established therapeutic option for patients suffering from these life-threatening entities. VA-ECMO provides temporary circulatory support until causative treatments are effective and enables recovery or serves as a bridging strategy to surgical ventricular assist devices, heart transplantation or decision-making. However, in-hospital mortality rate in this treatment population is still around 60%. In the recently published ARREST trial, VA-ECMO treatment lowered mortality rate in patients with ongoing cardiac arrest due to therapy refractory ventricular fibrillation compared to standard advanced cardiac life support in selected patients. Whether VA-ECMO can reduce mortality compared to standard of care in cardiogenic shock has to be evaluated in the ongoing prospective randomized studies EURO-SHOCK (NCT03813134) and ECLS-SHOCK (NCT03637205). As an innate drawback of VA-ECMO treatment, the retrograde aortic flow could lead to an elevation of left ventricular (LV) afterload, increase in LV filling pressure, mitral regurgitation, and elevated left atrial pressure. This may compromise myocardial function and recovery, pulmonary hemodynamics-possibly with concomitant pulmonary congestion and even lung failure-and contribute to poor outcomes in a relevant proportion of treated patients. To overcome these detrimental effects, a multitude of venting strategies are currently engaged for both preventive and emergent unloading. This review aims to provide a comprehensive and structured synopsis of existing venting modalities and their specific hemodynamic characteristics. We discuss in detail the available data on outcome categories and complication rates related to the respective venting option.
Topics: Humans; Shock, Cardiogenic; Extracorporeal Membrane Oxygenation; Prospective Studies; Heart Transplantation; Heart Arrest; Heart-Assist Devices
PubMed: 35986750
DOI: 10.1007/s00392-022-02069-0 -
Journal of the American College of... Sep 2023Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary... (Review)
Review
Centers specializing in coronary function testing are critical to ensure a systematic approach to the diagnosis and treatment of angina with nonobstructive coronary arteries (ANOCA). Management leveraging lifestyle, pharmacology, and device-based therapeutic options for ANOCA can improve angina burden and quality of life in affected patients. Multidisciplinary care teams that can tailor and titrate therapies based on individual patient needs are critical to the success of comprehensive programs. As coronary function testing for ANOCA is more widely adopted, collaborative research initiatives will be fundamental to improve ANOCA care. These efforts will require standardized symptom assessments and data collection, which will propel future large-scale clinical trials.
Topics: Humans; Program Development; Quality of Life; Angina Pectoris; Coronary Vessels; Life Style
PubMed: 37704316
DOI: 10.1016/j.jacc.2023.06.044 -
Heart (British Cardiac Society) Dec 2023Myocardial bridging is a common anatomical variant in which a major epicardial coronary artery takes an intramyocardial course, leading to dynamic systolic compression.... (Review)
Review
Myocardial bridging is a common anatomical variant in which a major epicardial coronary artery takes an intramyocardial course, leading to dynamic systolic compression. Because coronary perfusion occurs primarily during diastole, most patients with this anatomical variant have no associated perfusion abnormalities or symptoms. Despite this, there is a subset of patients with myocardial bridging who experience ischaemic symptoms. Determining which anatomical variants are benign and which are clinically relevant remains a challenge. Further complicating the picture, functional factors such as diastolic dysfunction and coronary vasospasm may exacerbate myocardial bridging-related ischaemia. In patients with ischaemic symptoms in the absence of alternative explanations, a detailed assessment of myocardial bridging with invasive physiology should be performed to define the significance of the lesion and guide tailored medical therapy. Patients with refractory symptoms despite maximally tolerated medical therapy should be considered for surgical coronary unroofing.
Topics: Humans; Myocardial Bridging; Heart; Coronary Angiography
PubMed: 37344169
DOI: 10.1136/heartjnl-2022-321586 -
Folia Morphologica 2020Myocardial bridging (MB) is an anatomical variant in which an epicardial coronary artery passes under a bridge of myocardium. The most commonly affected vessel is the...
Myocardial bridging (MB) is an anatomical variant in which an epicardial coronary artery passes under a bridge of myocardium. The most commonly affected vessel is the left anterior descending coronary artery, although other branches such as the marginal branches, diagonal branches and posterior descending right coronary artery may be occasionally involved. Technological advances in radiological techniques have enabled better diagnosis of myocardial bridges especially coronary angiography and coronary computed tomographic angiography (CCTA). During a routine angiography by means of CCTA in a 60-year-old male patient with arrhythmia, a case of MB was found in two segments of the posterior interventricular artery and a small segment of the right coronary artery. Although most cases of myocardial bridges are asymptomatic, knowledge of its pathophysiology is of great clinical importance as some cases of MBs have been associated with acute coronary syndromes, ischaemia, arrhythmias and even sudden death.
Topics: Computed Tomography Angiography; Coronary Angiography; Humans; Male; Middle Aged; Myocardial Bridging
PubMed: 31448810
DOI: 10.5603/FM.a2019.0080 -
BMJ (Clinical Research Ed.) Jun 2021To determine the efficacy and safety of dalteparin postoperative bridging treatment versus placebo for patients with atrial fibrillation or mechanical heart valves when... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To determine the efficacy and safety of dalteparin postoperative bridging treatment versus placebo for patients with atrial fibrillation or mechanical heart valves when warfarin is temporarily interrupted for a planned procedure.
DESIGN
Prospective, double blind, randomised controlled trial.
SETTING
10 thrombosis research sites in Canada and India between February 2007 and March 2016.
PARTICIPANTS
1471 patients aged 18 years or older with atrial fibrillation or mechanical heart valves who required temporary interruption of warfarin for a procedure.
INTERVENTION
Random assignment to dalteparin (n=821; one patient withdrew consent immediately after randomisation) or placebo (n=650) after the procedure.
MAIN OUTCOME MEASURES
Major thromboembolism (stroke, transient ischaemic attack, proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, peripheral embolism, or vascular death) and major bleeding according to the International Society on Thrombosis and Haemostasis criteria within 90 days of the procedure.
RESULTS
The rate of major thromboembolism within 90 days was 1.2% (eight events in 650 patients) for placebo and 1.0% (eight events in 820 patients) for dalteparin (P=0.64, risk difference -0.3%, 95% confidence interval -1.3 to 0.8). The rate of major bleeding was 2.0% (13 events in 650 patients) for placebo and 1.3% (11 events in 820 patients) for dalteparin (P=0.32, risk difference -0.7, 95% confidence interval -2.0 to 0.7). The results were consistent for the atrial fibrillation and mechanical heart valves groups.
CONCLUSIONS
In patients with atrial fibrillation or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postoperative dalteparin bridging to prevent major thromboembolism.
TRIAL REGISTRATION
Clinicaltrials.gov NCT00432796.
Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Dalteparin; Double-Blind Method; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Period; Prospective Studies; Surgical Procedures, Operative; Thromboembolism; Warfarin
PubMed: 34108229
DOI: 10.1136/bmj.n1205 -
The New England Journal of Medicine Feb 2024
Topics: Humans; Coronary Angiography; Myocardial Bridging; Risk Factors
PubMed: 38294977
DOI: 10.1056/NEJMicm2307383 -
Clinical Anatomy (New York, N.Y.) Jul 2021Myocardial bridges are anatomical entities characterized by myocardium covering segments of coronary arteries. In some patients, the presence of a myocardial bridge is... (Meta-Analysis)
Meta-Analysis
Myocardial bridges are anatomical entities characterized by myocardium covering segments of coronary arteries. In some patients, the presence of a myocardial bridge is benign and is only incidentally found on autopsy. In other patients, however, myocardial bridges can lead to compression of the coronary artery during systolic contraction and delayed diastolic relaxation, resulting in myocardial ischemia. This ischemia in turn can lead to myocardial infarction, ventricular arrhythmias and sudden cardiac death. Myocardial bridges have also been linked to an increased incidence of atherosclerosis, which has been attributed to increased shear stress and the presence of vasoactive factors. Other studies however, demonstrated the protective roles of myocardial bridges. In this study, using systematic review and a meta-analytical approach we investigate the prevalence and morphology of myocardial bridges in both clinical imaging and cadaveric dissections. We also discuss the pathophysiology, clinical significance, and management of these anatomical entities.
Topics: Animals; Cadaver; Humans; Myocardial Bridging; Prevalence
PubMed: 33078444
DOI: 10.1002/ca.23697 -
Cardiovascular Revascularization... Sep 2020Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The... (Review)
Review
Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.
Topics: Coronary Angiography; Death, Sudden, Cardiac; Humans; Myocardial Bridging; Myocardial Ischemia
PubMed: 32173330
DOI: 10.1016/j.carrev.2020.02.014