Myocardial bridges at multiple sites over the left coronary artery in a patient with hypertrophic cardiomyopathy

258

InternatlonalJournulof Cardmlogv,

23 (1989)258-260 Elsevier

IJC 08563

Myocardial bridges at multiple sites over the left coronary in a patient with hypertrophic cardiomyopathy Wolfram

Voelker,

Klaus

D. Schick

artery

and Karl R. Karsch

of Medrcine, Diuision of Cardiologv, Tuebingen University, F. R.G.

Department

(Received 11 July 1988; revision accepted 18 October 1988)

In a 47-year-old associated

with

demonstrated Thus,

male

with hypertrophic

significant

cardiomyopathy,

systolic

narrowing

no sign of myocardial

ischemia.

the prognosis

of myocardial

coronary

of the left coronary Ten-year

bridges,

follow-up

even when located

angiography

artery.

revealed

Measurements

three during

myocardial pacing

bridges

and exercise

was uneventful. at multiple

sites across

the left coronary

artery,

seems

benign. Key words:

Hypertrophic

cardiomyopathy;

Myocardial

bridge;

Introduction Systolic graphic an

narrowing

intramural

myocardium.

or “bridging” documenting segment

by

the

bridges

are

usually

are

almost

exclusively

third of the left anterior a patient

at three

of

overriding single

located

descending

is presented

different

angio-

the compression

coronary

this case report dial bridges

is a rare

Myocardial

which

middle

at

artery

the

[I]. In

who had myocar-

sites of the left coronary

artery. Case

A 47-year-old

patient

1977

because

of

gram

showed

abnormal

avF

consistent

vealed vocative

ventricle

inferior

testing

(68%).

a high

Simultaneous

an outflow

gradient

maneuvers

electrocardio-

was

II,

III.

myocardial negative

and into a

Left heart catheteriza-

Angiography with

in September

The in leads

work load of 100 watts.

left

fraction

Q-waves

exercise

tion was performed. mal

angina.

with a previous

Stepwise

maximal

was hospitalized

recurrent

demonstrated left ventricular

pressure

a norejection

measurements

re-

of 30 mm Hg during

pro-

and a Brockenbrough

phenomenon

The left coronary

during

diastole

Otfried-Miiller-Str.

Voelker.

M.D.,

10. 7400 Tuebingen,

F.R.G.

to:

W.

Med.

Klinik.

(Figs.

a

second

diagonal

rowing

of 95%

Two

septal

section, distal

2/3

1). Furthermore,

the first

To

the hemodynamic

myocardial

bridges

metabolic pulmonary

arterial

measurements. artery

ercise

testing.

duced

ischemia

No

evidence

was found.

no indication

proved

under continuous

low-up

(March

metric septum.

rapid

sinus capillary

echocardiography of the basal

portion

for and

during

ex-

or exercise

in-

The

symp-

resection

patient

im-

At lo-year

fol-

complained

appearing

2).

blood

atria1 pacing

for surgical

beta-blockade.

angina

had a

of these

the disabling

was seen.

1988) the patient

hypertrophy

consequences

Despite

bridges

cross-sectional

branch

of 1 cm (Fig.

for pacing

myocardial

this

in the

was com-

were registered

toms of the patient

atypical

diagonal

and coronary

of the

infrequent

branch

Also, pulmonary

pressures

from

over a length of 1.5 cm

over a length

at rest and during

nar-

1 and 2).

obstruction

A marginal systole

narrowing

was sampled

systolic

originated

systolic

70% systolic examine

a severe

of 3 cm (Figs.

which

a complete during

normal

the middle

the origin of the first and the

perforations, of the vessel.

coronary

was completely

showed

over a length

obstructed

Coronary

right

1 and 2). In systole

branch

showed

normal

artery

part of this artery between

and Correspondence

cardiomyopathy.

demonstrated

artery.

(Fig.

Report

of hypertrophic

angiography

pletely

farction.

angiography

as a sign

phenomenon

findings,

Coronary

only about

at rest. revealed

M-mode asym-

of the anterior

Fig. 1. Diastolic and systolic frames of the selective coronary arteriogram in the left anterior oblique position. In diastole the vessel appears normal. while in systole the left anterior descending artery reveals an almost complete narrowing in the middle third (1-J). Additionally, a first marginal branch shows a proximal systolic occlusion ( J ).

Discussion

Multiple myocardial bridges involving different sites of the left or the right coronary artery are a very rare

Fig. 2. Diastolic and systolic frames of the coronary arteriogram in the right anterior oblique position. In this projection the systolic narrowing of the anterior descending artery ( tt ) and the first diagonal branch is documented ( t ).

angiographic finding. Two myocardial bridges ing the left anterior descending artery and a branch were described [2,3]. Additionally, 2 myocardial bridges located in the left anterior ing artery and the right coronary artery were t1.41.

concerndiagonal cases of descendreported

260 In our patient with hypertrophic cardiomyopathy severe systolic h.nninal narrowing could be detected at three different sites of the left coronary artery. Despite the severe systolic compression myocardial &hernia could not be documented, thus, conservative treatment was preferred. In contrast, other groups recommended resection of myocardial bridges in patients with hypertrophic cardiomyopathy even in the presence of only atypical symptoms [5]. The lo-year follow-up of our patient, however, revealed no cardiac event, and symptoms improved under continuous beta blockade. Thus, the rare presence of several significant myocardial bridges of the left coronary artery does not necessarily result in myocardial ischemia during rapid atria1 pacing or exercise. The prognosis of patients with myocardial bridges resulting in high-graded systolic compression of the underlying arteries without objective evidence of myocardial ischemia seems to be benign.

International Elsevier

Further prospective long-term tient populations are necessary, this finding.

studies with larger panonetheless, to confirm

References 1 Angelini P, Trivellato M. Donis J, Lea&man RD. Myocardial bridges. A Review. Prog Cardiovasc Dis 1983;26:75-88. 2 Faruqui AMA, Malay WC, Felner JM, Schlant RC, Logan WD. Symbas P. Symptomatic myocardial bridging of coronary artery. Am J Cardiol 1978;41:1305-1310. 3 Kitazume H, Kramer JR. Krauthamer D. Tobgi SE, Proudfit WL, Sones FM. Myocardial bridges in obstructive hypertrophic cardiomyopathy. Am Heart J 1983;106:131-135. 4 Rossi L, Dander B, Nidasio GP, et al. Myocardial bridges and ischemic heart disease. Em Heart J 1980;1:239-245. 5 Pey J. deDios M, Epeldegui A. Myocardial bridging and hypertrophic cardiomyopathy: relief of ischemia by surgery. Int J Cardiol 1985;8:327-330.

Journal of Cardiology, 23 (1989) 260-264

IJC 08564

Balloon pulmonary valvuloplasty in a child with Ebstein’s anomaly and valvar pulmonary stenosis Monica L. Garrick, Donald R. Fischer and James R. Zuberbuhler Department

of Pediatric Cardiology, Children’s Hospital

of Pittsburgh, Pittsburgh, Pennsylvania,

(Received 1 August 1988; revision accepted

20 October

U.S.A

1988)

We performed a balloon pulmonary valvuloplasty in a child with Ebstein’s anomaly using the standard technique. The procedure reportedly has not been performed in the face of this defect and, although difficult, was safely and successfully accomplished. In patients with Ebstein’s anomaly and right ventricular oufflow obstruction compounded by pulmonary valve stenosis, application of this technique may delay the need for surgical intervention. Key

words:

Ebstein’s

anomaly:

Valvuloplasty;

Pulmonary

stenosis

Introduction Correspondence to: M.L. Garrick M.D.. Dept. of Pediatric Cardiology, Children’s Hospital of Pittsburgh. 3705 Fifth at DeSoto, Pittsburgh. PA 15213, U.S.A.

Ebstein’s the

anatomic

anomaly

of the tricuspid

displacement

of the

valve origin

is defined of the

as

septal