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Myocardial bridging of the ramus intermedius coronary artery
International Journal of Cardiology 89 (2003) 295–296 www.elsevier.com / locate / ijcard
Letter to the Editor
Myocardial bridging of the ramus intermedius coronary artery a a b, Ramesh M. Gowda , Syed I. Rahmatullah , Ijaz A. Khan * b
a Division of Cardiology, Long Island College Hospital, Brooklyn, NY, USA Cardiac Center, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131 -2044, USA
Received 30 May 2002; accepted 22 July 2002
Keywords: Myocardial bridging; Myocardial ischemia; Coronary anomaly; Cardiac catheterization; Myocardial infarction; Coronary angiography
Myocardial bridging of coronary arteries in systole was long considered as an incidental finding, but now there is ample literature to document its association with compromised coronary flow causing clinical symptoms including angina, myocardial infarction, and sudden death [1–4]. In a 35-year-old woman with a history of angina pectoris of Canadian Cardiovascular Society functional class III for about 3 months, the exercise stress testing with thallium myocardial perfusion scintigraphy revealed mild to moderate reversible perfusion defect. Coronary arteriography showed the coronary arteries to be normal in diastole (Fig. 1). In systole, however, a muscle bridge occluding the mid portion of the ramus intermedius coronary artery was observed (Fig. 2). Left ventriculography revealed normal left ventricular systolic function with no wall motion abnormalities. She has been symptom free with optimal medical therapy at 6-month follow-up. The intramural course of the coronary arteries may be crossed by a band of abnormal muscle fibers, which may cause compression. Muscle bridging with systolic compression of the coronary arteries involves predominantly the left anterior descending coronary
artery. Although intramural course has been demonstrated for the left circumflex and right coronary arteries on autopsy or by angiography, the most cases recognized to have bridging of these coronary arteries have also demonstrated bridging of the left anterior
*Corresponding author. Tel.: 11-402-280-4573; fax: 11-402-2804938. E-mail address: [email protected] (I.A. Khan).
Fig. 1. Coronary angiogram of the left coronary system in right anterior oblique view during diastole showing normal ramus intermedius coronary artery.
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(02)00465-5
296
R.M. Gowda et al. / International Journal of Cardiology 89 (2003) 295–296
ing, obstructive coronary artery disease may eventually appear at the bridging point causing angina, acute myocardial infarction or sudden death [3]. Majority of the patients continue doing well on regular treatment with anti-anginal agents, and only in a small percentage of patients, percutaneous coronary intervention is a consideration [1].
Acknowledgements No financial support was received for this paper.
References
Fig. 2. Coronary angiogram of the left coronary system in right anterior oblique view during systole showing compression of the mid portion the ramus intermedius coronary artery with near complete obliteration of the lumen.
descending coronary artery [1]. Angiographic demonstration of myocardial bridging and systolic milking of the ramus intermedius coronary artery has not been reported before. In a few cases of myocardial bridg-
[1] Berry JF, von Mering GO, Schmalfuss C, Hill JA, Kerensky RA. Systolic compression of the left anterior descending coronary artery: a case series, review of literature, and therapeutic options including stenting. Catheter Cardiovasc Interv 2002;56:58–63. [2] Chiappa E, Vineis C. Sudden death during a game of soccer in a young adolescent with a myocardial muscle bridge. G Ital Cardiol 1993;23:473–7. [3] Arjomand H, Al Salman J, Azain J, Amin D. Myocardial bridging of left circumflex coronary artery associated with acute myocardial infarction. J Invasive Cardiol 2000;12:431–4. [4] Garg S, Brodison A, Chauhan A. Occlusive systolic bridging of circumflex artery. Catheter Cardiovasc Interv 2000;51:477–8.
Letter to the Editor
Myocardial bridging of the ramus intermedius coronary artery a a b, Ramesh M. Gowda , Syed I. Rahmatullah , Ijaz A. Khan * b
a Division of Cardiology, Long Island College Hospital, Brooklyn, NY, USA Cardiac Center, Creighton University School of Medicine, 3006 Webster Street, Omaha, NE 68131 -2044, USA
Received 30 May 2002; accepted 22 July 2002
Keywords: Myocardial bridging; Myocardial ischemia; Coronary anomaly; Cardiac catheterization; Myocardial infarction; Coronary angiography
Myocardial bridging of coronary arteries in systole was long considered as an incidental finding, but now there is ample literature to document its association with compromised coronary flow causing clinical symptoms including angina, myocardial infarction, and sudden death [1–4]. In a 35-year-old woman with a history of angina pectoris of Canadian Cardiovascular Society functional class III for about 3 months, the exercise stress testing with thallium myocardial perfusion scintigraphy revealed mild to moderate reversible perfusion defect. Coronary arteriography showed the coronary arteries to be normal in diastole (Fig. 1). In systole, however, a muscle bridge occluding the mid portion of the ramus intermedius coronary artery was observed (Fig. 2). Left ventriculography revealed normal left ventricular systolic function with no wall motion abnormalities. She has been symptom free with optimal medical therapy at 6-month follow-up. The intramural course of the coronary arteries may be crossed by a band of abnormal muscle fibers, which may cause compression. Muscle bridging with systolic compression of the coronary arteries involves predominantly the left anterior descending coronary
artery. Although intramural course has been demonstrated for the left circumflex and right coronary arteries on autopsy or by angiography, the most cases recognized to have bridging of these coronary arteries have also demonstrated bridging of the left anterior
*Corresponding author. Tel.: 11-402-280-4573; fax: 11-402-2804938. E-mail address: [email protected] (I.A. Khan).
Fig. 1. Coronary angiogram of the left coronary system in right anterior oblique view during diastole showing normal ramus intermedius coronary artery.
0167-5273 / 02 / $ – see front matter 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0167-5273(02)00465-5
296
R.M. Gowda et al. / International Journal of Cardiology 89 (2003) 295–296
ing, obstructive coronary artery disease may eventually appear at the bridging point causing angina, acute myocardial infarction or sudden death [3]. Majority of the patients continue doing well on regular treatment with anti-anginal agents, and only in a small percentage of patients, percutaneous coronary intervention is a consideration [1].
Acknowledgements No financial support was received for this paper.
References
Fig. 2. Coronary angiogram of the left coronary system in right anterior oblique view during systole showing compression of the mid portion the ramus intermedius coronary artery with near complete obliteration of the lumen.
descending coronary artery [1]. Angiographic demonstration of myocardial bridging and systolic milking of the ramus intermedius coronary artery has not been reported before. In a few cases of myocardial bridg-
[1] Berry JF, von Mering GO, Schmalfuss C, Hill JA, Kerensky RA. Systolic compression of the left anterior descending coronary artery: a case series, review of literature, and therapeutic options including stenting. Catheter Cardiovasc Interv 2002;56:58–63. [2] Chiappa E, Vineis C. Sudden death during a game of soccer in a young adolescent with a myocardial muscle bridge. G Ital Cardiol 1993;23:473–7. [3] Arjomand H, Al Salman J, Azain J, Amin D. Myocardial bridging of left circumflex coronary artery associated with acute myocardial infarction. J Invasive Cardiol 2000;12:431–4. [4] Garg S, Brodison A, Chauhan A. Occlusive systolic bridging of circumflex artery. Catheter Cardiovasc Interv 2000;51:477–8.