Reporte de un caso de puente intramiocárdico en arteria coronaria derecha / A case report of intramyocardial bridge on right coronary artery

Los puentes intramiocárdicos son una anomalía de la circulación coronaria. Estos suelen presentarse en el trayecto de la arteria descendente anterior y se clasifican en superficiales o profundos. Reportamos el hallazgo de un puente intramiocárdico en el trayecto de la arteria coronaria derecha, incluida su rama sinoauricular y descendente posterior durante la disección de rutina de un cadáver. El paciente al parecer no presentó signos relativos a insuficiencia coronaria y falleció debido a una insuficiencia respiratoria aguda causada por neumonía aspirativa. Debido a la presencia limitada de casos sobre puente intramiocárdico de la arteria coronaria derecha, realizamos una revisión de la literatura al respecto y planteamos algunas conclusiones.

Intramyocardial bridges are a coronary circulation anomaly. They usually occur on the path of the anterior descending artery and are classified as superficial or deep. During a routine autopsy, we found­and report­an intramyocardial bridge in large part of the right coronary artery pathway, including the sinoatrial and posterior descending branch. The patient did not show signs of coronary insufficiency, and died from an acute respiratory failure caused by aspiration pneumonia. Due to the infrequency of cases of intramyocardial bridges of the right coronary artery without concomitant clinical symptoms or signs, we conducted a literature review in this regard.

Ponte miocárdica: revisão de literatura / Myocardial bridging: literature review

A ponte miocárdica é uma anomalia congênita das artérias coronárias em que feixes de miocárdio envolvemum segmento de artéria coronária epicárdica, levando a compressão de um segmento na sístole ventricular, serevertendo na diástole. Ela constitui um dos principais diagnósticos diferenciais de doença arterial coronariana, podendo se manifestar como dor torácica, infarto agudo do miocárdio ou morte súbita, mas na maioria das vezesé assintomática. Sua fisiopatologia ainda é controversa. Seu diagnóstico clínico deve ser considerado em pacientes com dor no peito e sem fatores de risco para doenças cardiovasculares. Nos exames complementares, o achado mais comum na cineangiocoronariografia é a compressão de um segmento coronário durante a sístole, revertido na diástole. A conduta de primeira linha no tratamento da ponte miocárdica sintomática é o uso de medicamentos para reduzir sintomas de isquemia e minimizar o risco de futuros eventoscardíacos. Na persistência da sintomatologia ao tratamento clínico, a intervenção percutânea com o uso de stents ou o tratamento cirúrgico estão indicados. O prognóstico a longo prazo em geral é bom. Embora seja um achado anatômico geralmente assintomático, em raros casos pode causar complicações importantes, inclusive morte súbita. Portanto, a ponte miocárdia deve ser considerada em pacientes jovens, com baixo risco para doenças cardiovasculares e sem evidências de isquemia miocárdica, porém com dor torácica ou sintomas não condizentes com a severidade dadoença arterial coronariana.

The myocardial bridging is a congenitalanomaly of the coronary arteries in which bundles of myocardial involve a segment of the epicardial coronary artery, leading to compression of a segment in the ventricular systole, reversing itself during diastole. It’s oneof the main differential diagnosis of coronary artery disease and may manifest as chest pain, myocardial infarction or sudden death, but in most cases are asymptomatic. Its pathophysiology is still controversial. His clinical diagnosis should be considered in patients with chest pain and no risk factors for cardiovascular disease. In laboratory exams, the most common finding in coronary angiography is the compression of a coronary segment during systole,reversed during diastole. The first treatment of symptomatic myocardial bridging is medications to reduce symptoms of ischemia and minimize the risk of future cardiac events. In the persistence of clinical symptomatology, percutaneous intervention using stents or surgical treatment are types of threatment. The long-term prognosis is usually good. Although an anatomical finding is usually asymptomatic, in rare cases can cause major complications, including sudden death. Therefore, the myocardial bridge should be considered in young patients at low risk for cardiovascular disease and no evidence of myocardial ischemia, but with no chest pain or symptoms consistent with the severity of coronary artery disease.

Infarto agudo do miocárdio associado a ponte miocárdica / Acute myocardial infarction associated to myocardial bridging

Paciente do sexo masculino, 73 anos, hipertenso, dislipidêmico e ex-tabagista, internado com quadro de infarto agudo do miocárdio sem supradesnivelamento do segmento ST. Cineangiocoronariografia demonstrou ponte miocárdica em artéria descendente anterior, sem lesões obstrutivas em outros territórios da circulação coronária. Em decorrência da elevação de marcadores de necrose miocárdica e do surgimento de supradesnivelamento transitório do segmento ST em parede anterior, na vigência de tratamento clínico otimizado, realizou-se ultrassom intracoronário, que evidenciou lesão ulcerada no território da ponte miocárdica, seguido de angioplastia com implante de stent, com sucesso. A evolução foi satisfatória após o procedimento e o paciente recebeu alta hospitalar.

We report the case of a 73-year-old man, with a history of hypertension, dyslipidemia, and previous smoking, admitted with a non-ST segment elevation myocardial infarction. Coronary angiography showed a myocardial bridge in the left anterior descending artery, with no obstructive lesions in other coronary arteries. Because of the raise in serum markers of myocardial necrosis and the development of transient ST segment elevation in the anterior wall, despite optimized medical treatment, we performed intravascular ultrasound, which showed an ulcerated lesion in the myocardial bridge territory, which was followed by a successful coronary angioplasty with stent implantation. The patient had a favorable course and was discharged from the hospital.

Myocardial Bridge in association with fixed atherosclerotic lesions treated with drug-eluting stents: a follow-up report with quantitative coronary analysis.

Stenting of muscle bridge is still a controversial issue with concerns regarding high restenosis rates, plaque prolapse and stent fracture. We report a case with significant atherosclerotic disease of right coronary artery and left anterior descending artery associated with a muscle bridge, proximal to the diseased segment which became more prominent after stenting the fixed lesion. This was managed by implanting another drug eluting stent, covering the bridge. Angiographic follow-up at 9 months revealed no difference in quantitative coronary angiography parameters in the stented segment of the bridge, as compared to other stented segments.