Revascularization Strategy of Myocardial Bridge under FFR

Guidance

Dr. Wang Yue ， Dr. Li Changling ， Dr Wang Jian-an

the Second Affiliated Hospital Zhejiang University School of
Medicine
Myocardial Bridge
INTRODUCTION
 Coronary arteries that tunnel through the myocardium are seen
in as many as 40% to 80% of cases on autopsy
 functional myocardial bridging (0.5% to 16.0%) and can range
from 4 to 80 mm in length.
 67% to 98% occur in the LAD.
 they range from 0.3 to 28 mm in depth
 anatomically they consist of either superficial myocardial fibers
that traverse over the LAD or deep fibers that encircle the LAD.
 The hemodynamic impact of myocardial bridging depends on the
thickness and length of the bridge, the orientation of the bridge
relative to myocardial fibers, and the presence of loose connective
or adipose tissue around the bridged segment.
 Clinical Presentation

myocardial ischemia

ACS

coronary spasm

Exercise induced dysrhythmias such as SVT, VT or AVB

myocardial stunning

Transient ventricular dysfunction

syncope

sudden death
Aging on the Myocardial Bridge
Aging on the Myocardial Bridge

ventricular
hypertrophy

diastolic
dysfunction

plaque progression
proximal to the
bridge
negative
remodeling of the
vessel with
decreased lumen
diameter
Milking Effect
Systolic Narrowing at the Myocardial Bridge Accentuated by
Intracoronary Nitroglycerin
Intravascular
Ultrasound
“Half-Moon”
Sign
Myocardial Bridge
THERAPY
 Schwarz Classification for Myocardial
Bridges and Treatment
Objective
Schwarz
Criteria Signs Treatment
Type
of Ischemia

A Incidental finding on angiography − None

B Ischemia on stress test + BB or CCB

Altered intracoronary hemodynamics

BB or CCB
quantitative coronary angiography
C +/− and/or
coronary flow reserve
revascularization
Doppler
 Revascularization

• Stent
• Surgical myotomy
• CABG
 IMA
 Saphenous vein graft
Author Study Cohort Intervent Follow Results
ion Up
Haager et al. MB (n=11) BMS 2 years 45% ISR (7 weeks)

Kursaklioglu MB (n=12) BMS 6 ISR 67% in MB

months
Kunamneni MB (n=12) 4 BMS 1 year ISR 75% in BMS
8 DES ISR 25% in DES

Tsujita et al. MB (n=70) 4 BMS 1 year MB Stent Group: 33%

34% of stents 66 DES MACE
covering MB non-MB Stent Group: 11%
66% of stents not MACE
covering MB

Ernst et al. MB (n=15) DES 5 years 1 perforation during stent

implantation
19% ISR (6 months)
Myotomy Procedure
 Myotomy Complication
First
Procedur Follow-Up Immediate Post-Operative
Author Follow-Up Results
size e Period Results

2 with right ventricular

Iversen perforation
et al. 9 Myotomy In-hospital All survived operation None
1992 Post-operative studies showed
flow restoration
1 patient had post-operative
7–81 angina with angiography
Rezaya
months showing narrowing in the LAD 2 with angina were treated medically
t et al. 26 Myotomy
(mean 34.2 coronary artery and No MACE
2006
months) subsequently underwent CABG
with LIMA graft

3–115 21 of 31 (11 CABG 10 myotomy)

Wu 16 CABG 1 patient with right ventricular
months underwent follow-up angiography
and Xu 31 15 perforation was successfully
(mean 31 showing restoration of flow
2007 myotomy converted to CABG
months) No MACE

8 CABG
6–120
Huang with LIMA 1 patient with right ventricular
months 2 experienced atypical chest pain and
et al. 11 graft perforation was successfully
(median 35.3 were treated medicallyNo MACE
2007 3 converted to CABG
months)
myotomy
 CABG graft selection

• Bockeria et al. 2013 CABG for MB ： 39 cases

 20 with LIMA graft
 19 with SVG

• 6 of 39 had recurrent angina ， angiography at 12

months
 occlusions in 12 LIMA grafts

 occlusions in 3 SVGs Grafts

Myocardial Bridge
MODIFIED SURGICAL THERAPY
 Case

• Male ， 51 years old

• Angina for 2 years ， progress and syncope in
half month
• Medical therapy with CCB and beta-blocker
CAG
FFR
Surgical procedure
Postoperative FFR
Postoperative CAG
 Summery
• Q=(P1-P2)/R
• R=8ηL/πr4
• P1 Higher graft proximal pressure
• L Shorter graft length
• r4 Enlarged anastomotic diameter
• LIMA Better graft material
• Middle and long term result need further observation
Thanks for listening