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STATE-OF-THE-ART PAPER

Symptomatic myocardial bridges: overview of ischemic mechanisms and current diagnostic and treatment strategies

^* Department of Medicine and Research Center, Montreal Heart Institute, Montreal, Quebec, Canada

Manuscript received September 11, 2002; accepted October 17, 2002.

^* Reprint requests and correspondence: Dr. Martial G. Bourassa, Research Center, Montreal Heart Institute, 5000 Belanger Street East, Montreal, QC, Canada, H1T 1C8.
bourassa{at}icm.umontreal.ca

This review article focuses on the morphological and functional alterations that characterize patients with myocardial bridges (MB) as well as the currently available diagnostic and treatment strategies. Because of incomplete understanding of the pathophysiology of MB, their clinical significance has been the subject of debate for the last quarter century. Investigational tools now available in the cardiac catheterization laboratory have helped clarify why symptoms and signs of ischemia can occur in such patients, especially when the only angiographic finding appears to be systolic compression or milking effect of a coronary vessel. Quantitative coronary angiography and intravascular ultrasound (IVUS) clearly demonstrate that the phasic systolic vessel compression visualized on the angiogram is coupled with a persistent diastolic diameter reduction. Intracoronary Doppler reveals increased flow velocities, retrograde systolic flow, and reduced coronary flow reserve. The clinical diagnosis can be established by significant percent lumen diameter and area narrowing, increased flow velocity, and by characteristic patterns such as the "half moon" phenomenon on IVUS and the early diastolic "finger tip" phenomenon on intracoronary Doppler. Successful medical, interventional, or surgical therapy leads not only to marked improvement or normalization of these alterations but also relief of angina and ischemia.

Abbreviations and Acronyms   AMI   acute myocardial infarction   ADPV   average diastolic peak flow velocity   APV   average peak flow velocity   ASPV   average systolic peak flow velocity   CFR   coronary flow reserve   DSVR   diastolic/systolic flow velocity ratio   IVUS   intravascular ultrasound   LAD   left anterior descending coronary artery   MB   myocardial bridge(s)   MLD   mean lumen diameter   MPV   maximal peak flow velocity   PCI   percutaneous coronary intervention   QCA   quantitative coronary angiography

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