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A myocardial bridge (MB) is a condition where a segment of an epicardial coronary artery passes through the myocardial muscle. While traditionally regarded as benign, MBs have been associated with various cardiovascular conditions. Therefore, assessing their hemodynamic impact is crucial for informed treatment decisions. Intracoronary functional assessments, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), have proven useful, especially under inotropic stimulation. However, their invasive nature limits their widespread clinical application. The Quantitative Flow Ratio (QFR) has emerged as a minimally invasive alternative for functional evaluation of MBs, though data on its use are still limited. This study aims to compare the diagnostic efficacy of FFR, iFR, and QFR for evaluating MBs both at rest and under stress conditions. Patients with confirmed MB on the LAD and typical angina (or abnormal noninvasive tests indicating myocardial ischemia) were included. According to a prespecified protocol, all patients underwent functional intracoronary evaluation with FFR and iFR at rest and after dobutamine and atropine intravenous infusion. QFR was also calculated for all cases both at rest and during dobutamine infusion. FFR values ≤0.80, iFR values ≤0.89 and QFR values ≤0.84 were considered indicative of significant myocardial ischemia. A total of 21 patients were included. Median FFR remained unchanged from rest (0.85) to stress (0.85), with only 1 patient showing a positive stress-FFR. In contrast, median iFR significantly decreased from 0.91 to 0.79 (p <0.001), with stress-iFR ≤0.89 in 18 patients. Resting QFR did not indicate significant hemodynamic impact of the MB (median 0.90), but under inotropic stimulation, ischemia was detected in 18 patients (median 0.79, p <0.001). QFR and iFR were concordant during stress in 19 patients, showing a significant positive correlation (Spearman’s ρ = 0.702, p = 0.037) and comparable sensitivity (0.86). QFR, computed during inotropic infusion, shows high sensitivity for detecting MB-related ischemia, comparable to stress-iFR and superior to stress-FFR. The correlation between stress-induced iFR and QFR suggests QFR as a reliable, minimally invasive alternative for functional lesion-specific evaluation in MB patients. Larger studies are necessary to confirm these preliminary findings and standardize QFR use in dynamic coronary stenosis assessments. Central Illustration. Diagnostic work-up example. [Display omitted]

PurposeMyocardial bridges (MB) have traditionally been considered a benign condition, but recent studies have demonstrated that the clinical complications can be dangerous. The transluminal attenuation gradient (TAG) obtained from coronary computed tomography angiography (CCTA) data (Retrospective ECG-triggered method) has been used in detecting significant stenosis in coronary artery caused by atherosclerosis. Contrast opacification difference (COD) was the parameters calculated as the change between attenuation of mural artery and the median attenuation of presumptive vessel segment; it was evaluated along with TAGstandardized (TAGs) and MB length for predicting MB with systolic compression (MB-SC) in patients diagnosed as MB in left anterior descending coronary artery (LAD) by CCTA or invasive coronary angiograph (ICA).MethodsA total of 107 MB patients were divided into three groups based on systolic compression (SC), including: Group 1 (MB without SC); Group 2 (MB with mild SC); and Group 3 (MB with significant SC). ANOVA and Kruskal–Wallis analysis indicated TAGs showed the most significant differences for MB identification.ResultsThis study revealed that TAGs decreasing and COD increasing were dominated in MB with significant SC.ConclusionsCOD had a higher sensitivity and a higher negative predictive value for detecting MB with significant SC than TAGs.

Combined congenital heart defects in adults are very rare, and knowledge of their diagnostic-therapeutic approach is of interest to specialists. Subaortic stenosis (SAS) is a heart disease of unclear etiology and variable clinical manifestation. In some cases, SAS is described in combination with a congenital bicuspid aortic valve, but a real rarity is the combination of the listed lesions with the non-obstructive coronary stenosis caused by a myocardial bridge. A middle-aged woman with chest pain and dyspnea during minimal physical exertion, that subsides after rest, was referred for surgery. Two-dimensional transthoracic echocardiography demonstrated left ventricular hypertrophy with preserved systolic function without anomalies of cardiac wall motion. A dynamic gradient was observed in the left ventricular outflow tract reaching up to 90 mmHg. Bicuspid aortic valve was presented with high-grade regurgitation. The picture of myocardial ischemia was complemented by selective coronary angiography demonstrating a rarely presented myocardial bridge over the left anterior descending coronary artery. The diagnostic approach and surgical corrections performed are the subject of this report.

Purpose of Review This review investigates the relationship between myocardial bridges (MBs), intimal thickening in coronary arteries, and Atherosclerotic cardiovascular disease. It focuses on the role of mechanical forces, such as circumferential strain, in arterial wall remodeling and aims to clarify how MBs affect coronary artery pathology. Review Findings MBs have been identified as influential in modulating coronary artery intimal thickness, demonstrating a protective effect against thickening within the MB segment and an increase in thickness proximal to the MB. This is attributed to changes in mechanical stress and hemodynamics. Research involving arterial hypertension models and vein graft disease has underscored the importance of circumferential strain in vascular remodeling and intimal hyperplasia. Summary Understanding the complex dynamics between MBs, mechanical strain, and vascular remodeling is crucial for advancing our knowledge of coronary artery disease mechanisms. This could lead to improved management strategies for cardiovascular diseases, highlighting the need for further research into MB-related vascular changes.

Myocardial bridging (MB) is a common anatomic variant in coronary arteries with unclear functional significance. We evaluated regional myocardial strain by speckle tracking during dobutamine stress echocardiography (DSE) in patients with MB in the left anterior descending coronary artery (LAD). We studied 11 patients with MB in the LAD and no obstructive coronary artery disease (CAD), 7 patients without MB, but obstructive CAD in the LAD, and 12 controls without MB or obstructive CAD. MB was defined as either > 1 mm (superficial) or > 2 mm (deep) intramyocardial course of the LAD in coronary CT angiography. Regional longitudinal, radial and circumferential strains and strain rates as well as post-systolic strain index (PSI) were measured at rest, peak stress, and early recovery (1 min after stress). Strain parameters during DSE were similar in the myocardium distal to MB and other myocardial regions of the same patients as well as the LAD territory in controls. However, patients with obstructive CAD showed impaired LS and strain rate as well as increased PSI at peak stress. None of the MB was associated with systolic compression in invasive coronary angiography and strain parameters were similar between superficial and deep MB. Stress myocardial blood flow by positron emission tomography correlated with LS and RS at peak stress in the myocardium distal to MB (r = − 0.73, p = 0.03, and r = 0.64, p = 0.04, respectively). Myocardial strain is not reduced during DSE in patients with MB in the LAD and no significant systolic compression.

Background Myocardial bridge (MB) often an inoffensive condition that goes in one or more of the coronary arteries through the heart muscle instead of lying on its surface. MBs sometimes leads to myocardial ischemic symptoms such as chest pain, even an occurrence of myocardial infarction. However, reports of severe and recurrent cardiac adverse events related to the MBs are rare. Case presentation A 44-year-old male patient who suffered from a four-hour crushing chest pain ten years ago, was diagnosed as acute anterior ST-elevation myocardial infarction (STEMI). The initial findings of coronary angiography (CAG) showed MB was located in the middle part of the left anterior descending coronary artery (LAD). The patient was managed medically. Another re-attack of similar previous chest pain characteristics occured just after 3 days of discharge. Supra-arterial myotomy and CABG were the next adopted management. Postoperative progression was uneventful. However, 32 months after surgical treatment, the patient experienced an abrupt onset of chest pain accompanied by loss of consciousness. The ECG showed ventricular fibrillation (VF). After electrical cardioversion, an immediate CAG followed by CTA was performed which excluded thrombus or acute occlusion in the native coronary artery and an occlusion was observed at the end of the left internal mammary artery. An implantable cardioverter-defibrillator (ICD) was successfully performed for prevention of malignant arrhythmia. During ten years of follow-up, no complications have been identified. Conclusions Although MB is mostly benign, it may lead to significant cardiovascular consequences. Supra-arterial myotomy is an appropriate treatment option for this patient who failed to optimal medical therapy. Furthermore, ICD implantation must be considered in order to prevent malignant ventricular arrhythmia caused by continuous spasm resulting in ischemia. Further investigations are required to confirm the clinical effectiveness of these procedures.

Chest pain complicated with electrocardiographic changes is not an uncommon scenario in emergency departments, which should be examined cautiously. We describe a 51-years-old man with a myocardial bridge of coronary artery presenting with simultaneous Mobitz type I atrioventricular block on electrocardiography. Echocardiography excluded valvular abnormality and systolic/diastolic dysfunction. Coronary angiography confirmed the diagnosis of a myocardial bridge at the middle segment of the left anterior descending artery, involving the most dominant septal perforator branch with marked systolic compression. The patient underwent coronary artery bypass grafting surgery and was followed up uneventfully at the outpatient department with medical treatment of diltiazem and clopidogrel. The present case is being reported to highlight that clinicians should be alert to such a congenital abnormality as a potential cause of repeated myocardial infarction and conduction abnormality.

Ectasia is the term used to describe the dilation of a coronary artery when its diameter is 1.5 times that of a normal artery. Myocardial bridge (MB) is a congenital coronary abnormality where a coronary artery segment tunnels across myocardial tissue, with coronary angiography (CAG) is the gold standard method for diagnosis. Here, we describe a case of an Afghan man who had both coronary artery ectasia and MB in the same segment of his left anterior descending artery (LAD).

Introduction: Wellens’ syndrome represents an important, at times overlooked, spectrum of left anterior descending (LAD) coronary artery occlusion, spontaneous reperfusion, and impending reocclusion. Once considered pathognomonic for a thromboembolic coronary event, an increasing number of clinical scenarios have been demonstrated to result in pseudo-Wellens’ syndrome, each requiring unique forms of assessment and management. Case Report: We describe two clinical presentations in which myocardial bridging (MB) of the LAD led to clinical and electrophysiologic presentations of a pseudo-Wellens’ syndrome. Conclusion: These reports represent a rare cause of pseudo-Wellens’ syndrome attributed to MB of the LAD. Transient ischemia secondary to myocardial compression of the traversing LAD leads to intermittent angina and electrocardiogram changes that are typical in patients presenting with Wellens’ syndrome secondary to an occlusive coronary event. As with other previously reported pathophysiologic mechanisms that have been shown to mimic Wellens’ syndrome, myocardial bridging should be considered in patients presenting with a pseudo-Wellens’ syndrome.

Objective To assess the diagnostic and clinical value of 64-slice CT coronary angiography (64SCTCA) for evaluation of myocardial bridge (MB) and mural coronary artery (MCA). Methods A total of 527 patients underwent 64SCTCA. The CT data was reconstructed and post-processed in the work-station. All the cases with MB were submitted to coronary angiography (CAG) studies observing the existence, length and thickness of MB as well as the stenosis of MCA. The results of CT and CAG were compared and analysed in the end. Results The 118 of 527 cases with MB segments were found through 64SCTCA. The detection rate is 22.4%. The 45 of 118 cases which were detected by 64SCTCA were found MB positive by CAG. The detection rate is 9.1%. The dates represent significant difference from 64SCTCA and CAG. Statistical significance was established at the p<0.05 level. The MB cases were found by 64SCTCA with the mean length of (6.1±2.5) mm, the mean thickness of (2.5±1.6) mm and the mean stenosis rate of MC of (47.3±11.3)%. The length and the stenosis rate of MB measured by CAG represent significant differences from those dates by 64SCTCA (p<0.05). Conclusion The 64SCTCA can clearly characterise MB and MC, and has important clinical values.