Comprehensive functional and anatomic assessment of myocardial bridging: Unlocking the Gordian Knot

Giuseppe Ciliberti, Renzo Laborante, Marco Di Francesco, Attilio Restivo, Gaetano Rizzo, Mattia Galli, Francesco Canonico, Andrea Zito, Giuseppe Princi, Rocco Vergallo, Antonio Maria Leone, Francesco Burzotta, Carlo Trani, Vincenzo Palmieri, Paolo Zeppilli, Filippo Crea, Domenico D'Amario, Giuseppe Ciliberti, Renzo Laborante, Marco Di Francesco, Attilio Restivo, Gaetano Rizzo, Mattia Galli, Francesco Canonico, Andrea Zito, Giuseppe Princi, Rocco Vergallo, Antonio Maria Leone, Francesco Burzotta, Carlo Trani, Vincenzo Palmieri, Paolo Zeppilli, Filippo Crea, Domenico D'Amario

Abstract

Myocardial bridging (MB) is the most frequent congenital coronary anomaly in which a segment of an epicardial coronary artery takes a tunneled course under a bridge of the myocardium. This segment is compressed during systole, resulting in the so-called "milking effect" at coronary angiography. As coronary blood flow occurs primarily during diastole, the clinical relevance of MB is heterogeneous, being usually considered an asymptomatic bystander. However, many studies have suggested its association with myocardial ischemia, anginal symptoms, and adverse cardiac events. The advent of contemporary non-invasive and invasive imaging modalities and the standardization of intracoronary functional assessment tools have remarkably improved our understanding of MB-related ischemia, suggesting the role of atherosclerotic lesions proximal to MB, vasomotor disorders and microvascular dysfunction as possible pathophysiological substrates. The aim of this review is to provide a contemporary overview of the pathophysiology and of the non-invasive and invasive assessment of MB, in the attempt to implement a case-by-case therapeutic approach according to the specific endotype of MB-related ischemia.

Keywords: intracoronary imaging; intracoronary physiology; invasive intracoronary assessment; myocardial bridging; myocardial ischemia; non-invasive tests; tailored therapy.

Conflict of interest statement

Author MG declares that he has received consulting fees or honoraria from Terumo, outside the present work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Ciliberti, Laborante, Di Francesco, Restivo, Rizzo, Galli, Canonico, Zito, Princi, Vergallo, Leone, Burzotta, Trani, Palmieri, Zeppilli, Crea and D’Amario.

Figures

FIGURE 1
FIGURE 1
Myocardial ischemia is not purely related to vessel systolic compression in patients with MB. Several mechanisms may account for the occurrence of symptoms and may be detected though invasive and non-invasive modalities. MB, myocardial bridging.
FIGURE 2
FIGURE 2
Hyperemic and non-hyperemic pressure ratios (FFR, dFFR, iFR, RFR, dPR) proposed for the invasive functional assessment of patients with myocardial bridging. Pa, aortic pressure; Pd, distal pressure; FFR, fractional flow reserve; dFFR, diastolic-fractional flow reserve; iFR, instantaneous wave-free pressure ratio; RFR, resting full-cycle ratio dPR, diastolic pressure ratio.
FIGURE 3
FIGURE 3
Flow diagram with proposed strategy for the management of symptomatic patients with myocardial bridging. ACE-I, Angiotensin-converting enzyme-inhibitors; Ach, acetylcholine; ARB, Angiotensin receptor blocker; BBs, beta-blockers; CAD, coronary artery disease; CFR, coronary flow reserve; FFR, fractional flow reserve; iFR, instantaneous wave-free ratio; IMR, index of microvascular resistance IVUS, intravascular ultrasound; MB, myocardial bridging; OCT, optical coherence tomography; PCI, percutaneous coronary intervention.

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