Pericardial Adhesions Simulating Myocardial Bridging
Shahid M Khan, MD,
Walid Hassan, MD,
Aly Al Sanei, MD,
Zohair Y Al-Halees, MD
King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
Walid Hassan, MD, Tel: +966 1 464 7272, Ext 32058, Fax: +966 442 7482, Email: hassanw{at}kfshrc.edu.sa, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, MBC #16, PO Box 3354, Riyadh, Saudi Arabia 11211.
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ABSTRACT
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A 48-year-old man with aortic valve disease was diagnosed to have myocardial bridging on preoperative coronary angiography. During surgical exploration, only pericardial adhesions were found, with a normal epicardial coronary course.
Key Words: Adhesions • Coronory Angiography • Myocardial Bridging
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INTRODUCTION
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The major coronary arteries normally course along the epicardial surface of the heart, with occasional intra-myocardial segments. During systole, the intramyocardial segments can be compressed, a phenomenon known as myocardial bridging. Compression of an intramyocardial segment during systole results in narrowing that reverses during diastole. The dynamic and phasic nature of the obstruction differentiates bridging from fixed coronary artery stenosis. This has been recognized angiographically since 1960. We describe a case of aortic valve disease, which was diagnosed to have myocardial bridging on preoperative coronary angiography.
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CASE REPORT
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A 48-year-old man, who had undergone aortic valve repair using autologous pericardium 15 years previously, presented with chest pain, easy fatigability, and increasing shortness of breath. An echocardiogram showed a trileaflet aortic valve with thickened leaflets and fusion of the commissures. This caused severe aortic stenosis with a peak aortic gradient of 102 mm Hg and a mean aortic gradient of 54 mm Hg. Coronary angiography showed quite significant myocardial bridging of 2 segments in the distal half of the left anterior descending artery (LAD; Figure 1
). The patient was referred for redo aortic valve surgery. Possible intervention in the form of relief of myocardial bridging, a coronary bypass graft, or insertion of a coronary stent was also discussed. A repeat median sternotomy was performed. Pericardial adhesions were dissected free to establish cardiopulmonary bypass, and the heart was decompressed. Adhesions were freed from the ventricular surface of the heart and the LAD area. The LAD was found to be an epicardial vessel along its entire length up to the apex of the heart. All adhesions in this area were dissected free, and it looked a normal vessel with no intramyocardial segment. The aortic valve was replaced with a 23-mm Carbomedics mechanical valve. The procedure went smoothly, and the patient recovered uneventfully. Follow-up coronary angiography was performed on the 5th postoperative day before discharge. This showed a normal appearance of the LAD with none of the features of myocardial bridging noted preoperatively (Figure 2). It was quite apparent that the radiographic appearance of intramyocardial bridging in this patient had been due to pericardial adhesions.
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Figure 1. Coronary angiography in right anterior oblique and caudal views showing (A) quite significant myocardial bridging of 2 segments in the distal half of the left anterior descending artery, and (B) significant myocardial bridging of the distal left anterior descending artery.
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Figure 2. Postoperative coronary angiography in right anterior oblique and caudal views (A & B) showing a wide patent distal LAD.
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DISCUSSION
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Myocardial bridging is known to produce the radiographic appearance of a coronary artery lesion that usually has no physiological significance. However, there are reports indicating that severe bridging of the LAD can produce myocardial ischemia or sudden death.1–3 Such patients usually do not require any intervention, but if symptomatic, various treatment modalities can be used. The reported prevalence of myocardial bridging varies between pathologic and angiographic series. Angiographic studies have reported a prevalence of myocardial bridging involving the LAD of 1.7% (range, 0.5%–16%).2,4–8 Other vessels may be involved, but with a lower frequency. A higher prevalence has been reported in patients with hypertrophic cardiomyopathy and recipients of cardiac transplants.1 This variation reflects the fact that angiographic appearance depends on a variety of factors including myocardial thickness, length of bridged segment, orientation of the coronary artery to the myocardial fibers, and the nature of interposed tissue between the coronary artery and myocardium. Hypertrophic cardiomyopathy is associated with an increased incidence of bridging of the coronary arteries, in particular, the LAD. A literature search did not show any previous report of pericardial adhesions simulating the angiographic appearance a myocardial bridge.
With an increasing number of post-cardiac surgical patients, whether for congenital or acquired heart diseases, it becomes extremely important that this etiologic diagnosis is kept in mind while evaluating such findings. Not recognizing this fact might result in some unnecessary percutaneous coronary intervention or a concomitant coronary artery bypass graft.
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REFERENCES
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Asian Cardiovasc Thorac Ann 2009;
17:188-190
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103312
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ABSTRACT
INTRODUCTION
