LETTER TO THE EDITOR
Some questions regarding myocardial bridges still require answers: Reply
Martial G. Bourassa, MD* and
Gary L. Tardif, MD
* Montreal Heart Institute, 5000 Belanger Street East, Montreal, QC, Canada H1T 1C8
bourassa{at}icm.umontreal.ca
In his comments on our recent state-of-the-art study (1), Dr. Angelini implies that our literature review on symptomatic myocardial bridges failed to define the incidence, natural history, and pathophysiology of this clinical entity. Although we also believe that the study of the incidence and natural history of myocardial bridges should be restricted to specific patient populations, namely those with typical symptoms and objective signs of ischemia, we agree that the follow-up of patients with any type of bridging has not been helpful in the past (2,3). We do not share his view that, overall, myocardial bridges are unlikely to produce ischemia (4). Typical angina, exercise-induced ST-segment depression, positive myocardial scintigraphy, and abnormal intracoronary Doppler flow velocities are recognized manifestations of ischemia. The mechanism of this ischemia has recently been clarified and consists of significant diastolic coronary diameter reduction, in addition to phasic systolic compression. We share Dr. Angelini’s concern about the correct management of patients with symptomatic bridges. As we have stated, medical therapy must be the first and principal strategy, and interventions should be limited to patients with refractory angina despite medical therapy. Then coronary stenting and cardiac surgery, especially mammary artery implantation, can achieve long-lasting relief of angina. We are not aware of cases of crushing of a metallic stent in the presence of a muscular bridge nor was this mentioned in the investigators’ previous report (4). Finally, it is well known that mammary graft failure can occur whenever anterograde flow is unimpaired, underscoring the importance of careful patient selection.
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1. Bourassa MG, Butnaru A, Lespérance J, Tardif JC. Symptomatic myocardial bridges: overview of ischemic mechanisms and current diagnostic and treatment strategies. J Am Coll Cardiol. 2003;41:351–359[Abstract/Free Full Text]
2. Kramer JR, Kitazume H, Proudfit WL, Sones FM Jr. Clinical significance of isolated coronary bridges: benign and frequent condition involving the left anterior descending artery. Am Heart J. 1982;103:283–288[CrossRef][Medline]
3. Angelini P, Trivellato M, Donis J, Leachman RD. Myocardial bridges: a review. Prog Cardiovasc Dis. 1983;26:75–88[CrossRef][Medline]
4. Angelini P, Velasco JA, Flamm S. Coronary anomalies. Incidence, pathophysiology, and clinical relevance. Circulation. 2002;105:2449–2454[Free Full Text]
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