Author + information
- Received January 30, 2014
- Accepted February 13, 2014
- Published online October 1, 2014.
- Mohit D. Gupta, MD, DM∗ (, )
- Meenahalli Palleda Girish, MD, DM,
- Vijay Trehan, MD, DM and
- Sanjay Tyagi, MD, DM
- Department of Cardiology, GB Pant Hospital and Associated Maulana Azad Medical College, New Delhi, India
- ↵∗Reprint requests and correspondence:
Dr. Mohit D. Gupta, First Floor Department of Cardiology, GB Pant Hospital, Room 125, Academic Block, New Delhi-110002, India.
A 40-year-old man, nonsmoker, presented with chronic stable angina for the past 1 year. The electrocardiogram showed left ventricular hypertrophy, and echocardiography revealed severe concentric left ventricular hypertrophy suggestive of hypertrophic cardiomyopathy. He was taken up for coronary angiography, which showed severe myocardial bridging (MB) in all 3 coronary arteries (left anterior descending coronary artery [LAD], left circumflex artery, and posterior descending artery) (Figures 1, 2, and 3⇓⇓⇓, Online Videos 1, 2, and 3) and an occluded obtuse marginal branch.
MB is defined as a segment of a major epicardial coronary artery that goes intramurally through the myocardium beneath the muscle bridge (1). Angiographically, MB is almost exclusively seen in the LAD (2). Angiographic observation of bridging in all coronary arteries is extremely rare. It has only been described in some autopsy reports (3). The typical angiographic finding in MB is systolic narrowing of an epicardial artery. Occurrence of coronary heart disease in such cases is caused by direct compression of the LAD by MB contraction and/or by enhancement of the natural history of coronary atherosclerosis in the LAD segment proximal to the MB (3). Use of intracoronary nitrates shows resolution of coronary spasms and often increased contractility, thereby unmasking the MB (4). Common clinical presentation of MB ranges from an asymptomatic patient to angina, myocardial ischemia, and, rarely, infarction and sudden cardiac death (3). Coronary angiography, the current gold standard, typically shows a “milking effect” and a “step-down step-up” phenomenon induced by systolic compression of the tunneled segment (3), as seen in this case. The intracoronary Doppler ultrasound reveals a characteristic flow pattern, the “fingertip phenomenon” or “spike-and-dome pattern” (4). Management of MB aims to improve quality of life by relief of symptoms by pharmacotherapy, surgery, or catheter intervention. In conclusion, MB in all 3 coronary arteries as in the present case is extremely rare. This is the first report, to our knowledge, to document MB angiographically in all 3 coronary arteries.
For supplemental videos, please see the online version of this paper.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 30, 2014.
- Accepted February 13, 2014.
- American College of Cardiology Foundation