Abstract
Although myocardial bridging (MB) is a common coronary anomaly, its cardiovascular consequences are still disputed. A positive link between sudden cardiac death (SCD) and myocardial bridging has not yet been definitively proved, even though many case reports and small scale studies support this association. For myocardial bridging to be associated with sudden cardiac death it must exhibit certain specific characteristics involving coronary or myocardial changes sufficient to explain a terminal cardiac event. In this study we aimed to analyze the morphological changes (both myocardial and coronary) associated with hemodynamically significant myocardial bridging and the morphological differences between hemodynamically significant MB and MB considered to be non-hemodynamically significant. Material and Method: We analyzed 53 cases of sudden cardiac death, of which 21 cases had hemodynamically significant myocardial bridging, 14 had non-hemodynamically significant myocardial bridging and 20 cases suffered sudden cardiac death without myocardial bridging, using a morphological score with seven histological parameters. Results: Myocardial fibrosis and interstitial edema were found to be highly correlated with hemodynamically significant myocardial bridging (HSMB), as were interstitial edema and interstitial fibrosis. Conclusions: Hemodynamically significant myocardial bridging can be discovered during heart dissection by analyzing a series of morphological markers (width, distribution of atherosclerosis, distal hypoplasia). Our study showed that MB was associated with increased myocardial fibrosis and edema, both of which have an increased risk of electrical instability. Compared to non-hemodynamically significant myocardial bridging, HSMB shows a distinct histological pattern, with increased myocardial fibrosis and edema. The main cause of SCD in association with HSMB seems to be electrical due to increased electrical myocardial heterogeneity, but large scale studies are needed to test this.
Key words
myocardial bridging - atherosclerosis - cardiac anatomy/pathological anatomy - congenital heart disease - CHD - interstitial fibrosis - interstitial edema
References
-
1
Cakmak Y O, Cavdar S, Yalin A, Yener N, Ozdogmus O.
Myocardial bridges of the coronary arteries in the human fetal heart.
Anat Sci Int.
2009;
89
140-144
-
2
Somanath H, Reddy K, Gupta S et al.
Myocardial bridge (MB): an angiographic curiosity?.
Indian Heart J.
1989;
41
296-300
-
3
Ge J, Erbel R, Rupprecht H J et al.
Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging.
Circulation.
1994;
89
1725-1732
-
4
Juillière Y, Berder V, Suty-Selton C et al.
Isolated myocardial bridges with angiographic milking of the left anterior descending coronary artery: a long-term follow-up study.
Am Heart J.
1995;
129
663-665
-
5
Polácek P.
Relation of myocardial bridges and loops on the coronary arteries to coronary occlusions.
Am Heart J.
1961;
61
44-52
-
6
Buja L M.
Modulation of the myocardial response to ischemia.
Lab Invest.
1998;
78
1345-1373
-
7
Barna B.
Incidence of sudden cardiac death in clinical and forensic context.
Rom J Leg Med.
2008;
16
305-312
-
8
Cristian C G, Mihai C, Dan D, Paul P.
Delayed sudden death determined by right atrial contusion – case report and literature review.
Rom J Leg Med.
2008;
16
253-260
-
9
Dermengiu D, Vovolis I, Hostiuc S et al.
Morphological features in myocardial bridging.
Rom J Leg Med.
2010;
18
163-170
-
10
Curca G C, Drugescu N, Ardeleanu C, Ceausu M.
Investigative protocole of sudden cardiac death in young adults.
Rom J Leg Med.
2008;
16
57-66
-
11 Dermengiu D. Medicina Legala.. Bucuresti: Tehnoplast; 2001
-
12
Mays A, McHale P, Greenfield J.
Transmural myocardial blood flow in a canine model of coronary artery bridging.
Circulation.
1981;
49
726-732
-
13
Ferreira A G, Trotter S E, König B et al.
Myocardial bridges: morphological and functional aspects.
Br Heart J.
1991;
66
364-367
-
14
Jodocy D, Aglan I, Friedrich G et al.
Left anterior descending coronary artery myocardial bridging by multislice computed tomography: correlation with clinical findings.
Eur J Radiol.
2010;
73
89-95
-
15
Möhlenkamp S, Hort W, Ge J, Erbel R.
Update on myocardial bridging.
Circulation.
2002;
106
2616-2622
-
16
Morales A, Romanelli R, Boucek R.
The mural left anterior descending coronary artery, strenuous exercise and sudden death.
Circulation.
1980;
62
230-237
-
17
Virmani R, Farb A, Burke A P.
Ischemia from myocardial coronary bridging: fact or fancy?.
Hum Pathol.
1993;
24
687-688
-
18
Feldman R L, Nichols W W, Pepine C J, Conti C R.
Hemodynamic significance of the length of a coronary arterial narrowing.
Am J Cardiol.
1978;
41
865-871
-
19
Ishikawa Y, Akasaka Y, Ito K et al.
Significance of anatomical properties of myocardial bridge on atherosclerosis evolution in the left anterior descending coronary artery.
Atherosclerosis.
2006;
186
380-389
-
20
Mohiddin S A, Begley D, Shih J, Fananapazir L.
Myocardial bridging does not predict sudden death in children with hypertrophic cardiomyopathy but is associated with more severe cardiac disease.
J Am Coll Cardiol.
2000;
36
2270-2278
-
21
Baptista C A C, Didio L J A.
The relationship between the directions of myocardial bridges and of the branches of the coronary arteries in the human heart.
Surg Radiol Anat.
1992;
14
137-140
-
22
Basso C, Thiene G, Mackey-Bojack S et al.
Myocardial bridging, a frequent component of the hypertrophic cardiomyopathy phenotype, lacks systematic association with sudden cardiac death.
Eur Heart J.
2009;
30
1627-1634
-
23
Curca G C, Sarbu N, Dermengiu D et al.
Coronary fibromuscular dysplasia and sudden death – case report and literature review.
Rom J Leg Med.
2009;
17
165-172
-
24
Bache R, Cobb F.
Effect of maximal coronary vasodilation on transmural myocardial perfusion during tachycardia in the awake dog.
Circ Res.
1977;
41
648-653
-
25
Feld H, Guadanino V, Hollander G et al.
Exercise-induced ventricular tachycardia in association with a myocardial bridge.
Chest.
1991;
99
1295-1296
-
26
De Giorgio F, Abbate A, Stigliano E, Capelli A, Arena V.
Hypoplastic coronary artery disease causing sudden death. Report of two cases and review of the literature.
Cardiovasc Pathol.
2010;
19 (4)
e107-111
-
27
Geiringer E.
The mural coronary.
Am Heart J.
1951;
41
359-368
-
28
Arora P, Bhatia V, Parida A K, Kaul U.
Myocardial Bridge in association with fixed atherosclerotic lesions treated with drug-eluting stents: a follow-up report with quantitative coronary analysis.
Indian Heart J.
2008;
60
594-596
-
29
Chatzizisis T S, Giannoglou G D.
Myocardial bridges are free from atherosclerosis: Overview of the underlying mechanisms.
Can J Cardiol.
2009;
25
219-222
-
30
Duygu H, Zoghi M, Nalbantgil S et al.
Myocardial bridge: a bridge to atherosclerosis.
Anadolu Kardiyol Derg.
2007;
7
17-18
-
31
Ge J, Erbel R, Gorge G, Haude M, Meyer J.
High wall shear stress proximal to myocardial bridging and atherosclerosis: intracoronary ultrasound and pressure measurements.
Br Heart J.
1995;
73
462-465
-
32
Ishii T, Hosoda Y, Osaka T.
The significance of myocardial bridge upon atherosclerosis in the left anterior descending coronary artery.
J Pathol.
1986;
148
279-291
-
33
La Grutta L, Runza G, Lo Re G et al.
Prevalence of myocardial bridging and correlation with coronary atherosclerosis studied with 64-slice CT coronary angiography.
Radiol Med.
2009;
114
1024-1036
-
34
Lee S S, Wu T L.
The role of the mural coronary artery in prevention of coronary atherosclerosis.
Arch Pathol.
1972;
93
32-35
-
35
Rusu M C, Cuzino D, Dermengiu D et al.
Coronary artery calcium scoring in postmortem specimens. Method report.
Rom J Leg Med.
2009;
17
271-276
-
36
Shimony A, Romem A, Horowitz S, Boehm R, Horowitz J.
Acute coronary syndrome associated with myocardial bridging due to ergotamine treatment for migraine.
Int J Cardiol.
2006;
113
E7-E8
-
37
Riezzo I, Monciotti F, Pomara C, Fineschi V.
Myocardial bridging of the right coronary artery and emotional stress: a fatal link?.
Int J Cardiol.
2007;
115
e99-e101
-
38
Yano K, Yoshino H, Taniuchi M et al.
Myocardial bridging of the left anterior descending coronary artery in acute inferior wall myocardial infarction.
Clin Cardiol.
2001;
24
202-208
-
39
Barr C S, Naas A, Freeman M, Lang C C, Struthers A D.
QT dispersion and sudden unexpected death in chronic heart-failure.
Lancet.
1994;
343
327-329
-
40
Barutcu I, Sezgin A T, Gullu H et al.
Exercise-induced changes in QT interval duration and dispersion in patients with isolated myocardial bridging.
Int J Cardiol.
2004;
94
177-180
-
41
Schouten E, Dekker J, Meppelink P et al.
QT-interval prolongation predicts cardiovascular mortality in an apparently healthy population.
Circulation.
1991;
84
1516-1523
-
42
Yi G, Elliott P, McKenna W J et al.
QT dispersion and risk factors for sudden cardiac death in patients with hypertrophic cardiomyopathy.
Am J Cardiol.
1998;
82
1514-1519
-
43
Brodsky S V, Roh L, Ashar K, Braun A, Ramaswamy G.
Myocardial bridging of coronary arteries: A risk factor for myocardial fibrosis?.
Int J Cardiol.
2008;
124
391-392
-
44
Dongaonkar R M, Stewart R H, Geissler H J, Laine G A.
Myocardial microvascular permeability, interstitial oedema, and compromised cardiac function.
Cardiovasc Res.
2010;
87
331-339
-
45
Waldenström A, Martinussen H, Gerdin B, Hällgren R.
Accumulation of hyaluronan and tissue edema in experimental myocardial infarction.
J Clin Invest.
1991;
88
1622-1628
-
46
Davis K L, Laine G A, Geissler H J et al.
Effects of myocardial edema on the development of myocardial interstitial fibrosis.
Microcirculation.
2000;
7
269-280
-
47
Iversen S, Dahm M, Diefenbach C et al.
Surgery for coronary obstruction caused by myocardial bridging.
Thorac Cardiovasc Surg.
1987;
35
62-63
-
48
Canyigit M, Turkbey B, Hazirolan T, Peynircioglu B, Aytemir K.
Magnetic resonance imaging first-pass myocardial perfusion in evaluation of hemodynamic effects of myocardial bridging.
J Comput Assist Tomogr.
2008;
32
274-275
-
49
Kim R J, Fieno D S, Parrish T B et al.
Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function.
Circulation.
1999;
100
1992-2002
-
50
Choudhury L, Mahrholdt H, Wagner A et al.
Myocardial scarring in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy.
J Am Coll Cardiol.
2002;
40
2156-2164
-
51
Lotz J, Kivelitz D, Fischbach R, Beer M, Miller S.
Recommendations for the use of computer tomography and magnet resonance tomography in heart diagnostics. Part 2: Magnetic resonance tomography.
Rofo.
2009;
181
800-814
-
52
Debl K, Djavidani B, Buchner S et al.
Delayed hyperenhancement in magnetic resonance imaging of left ventricular hypertrophy caused by aortic stenosis and hypertrophic cardiomyopathy: visualisation of focal fibrosis.
Heart.
2006;
92
1447-1451
-
53
Bourassa M G, Butnaru A, Lespérance J, Tardif J-C.
Symptomatic myocardial bridges: overview of ischemic mechanisms and current diagnostic and treatment strategies.
J Am Coll Cardiol.
2003;
41
351-359
-
54
Hongo Y, Tada H, Ito K et al.
Augmentation of vessel squeezing at coronary-myocardial bridge by nitroglycerin: study by quantitative coronary angiography and intravascular ultrasound.
Am Heart J.
1999;
138
345-350
-
55
Haager P K, Schwarz E R, vom Dahl J et al.
Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging.
Heart.
2000;
84
403-408
-
56
Ahmed S H, Khawaja S N, Husain N M, Panayiotou H.
Self-expanding intracoronary stent for symptomatic myocardial bridging.
Catheter Cardiovasc Interv.
2007;
69
984-987
-
57
Pereira A B, Castro D S P, Menegotto E T, Amaral W M, Castro G S P.
Ponte miocárdica: evolução clínica e terapêutica.
Arq Bras Cardiol.
2010;
94
188-194
Sorin Hostiuc
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