Unroofing of Extensive Myocardial Bridge Compressing the Left Anterior Descending Artery

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Myocardial bridging is a rare congenital anomaly presenting a segment of a coronary artery, most commonly the left anterior descending (LAD), covered by a bridge of myocardium that produces dynamic compression resulting in intermittent myocardial ischemia with eliciting symptoms of angina. The condition affects men twice as often as women and clinically manifests during the fourth or fifth decade of life. When conservative medical management fails, surgical unroofing is prompted. Currently, identification of the coronary artery deep in the myocardium can be challenging, and no standard method for documentation of myocardial ischemia has been described. This video demonstrates the intraoperative application of indocyanine green (ICG) angiography to document myocardial ischemia and identify the precise location of a large intramyocardial LAD segment during a myocardial bridge unroofing procedure.



The Patient

A twenty-nine-year-old man with a myocardial bridge was evaluated for recurrent angina and syncope episodes. A preoperative angiogram showed extensive compression of the middle and distal segments of the LAD. Furthermore, a three-dimensional CT reconstruction confirmed the segment of the myocardial bridge.

The Surgery

The patient underwent elective open-heart surgery for coronary repair. Upon performance of a median sternotomy and extensive exposure of the heart, an initial peripheral intravenous administration of 3 cc of ICG revealed the full area of the myocardial bridge and the extent of myocardial ischemia. Following target tissue identification, the operation proceeded with extensive dissection of the myocardial bridge and unroofing of the intramyocardial LAD with ICG angiography guidance. 

A postoperative ICG angiography revealed complete reperfusion and relief of the compromised myocardium toward the apex of the left ventricle. The patient tolerated the procedure well with no postoperative complications.

The authors concluded that indocyanine green angiography allows for intraoperative assessment of myocardial ischemia, and provides the precise location of intramyocardial coronary arterial segments and under-perfused myocardium. Moreover, this technique allows for an intraoperative evaluation of complete restoration of myocardial perfusion followed by an extensive dissection of the myocardium.

References

1. Mok S, Majdalany D, Pettersson GB. Extensive unroofing of myocardial bridge: A case report and literature review. SAGE Open Med Case Rep. 2019 Jan 16;7:2050313X18823380. doi: 10.1177/2050313X18823380. PMID: 30719302; PMCID: PMC6349980.
2. Ahmed M, Hassan K, Mustafa ME. Left Anterior Descending Artery Bridging and Atypical Chest Pain in a Young Woman. Cureus. 2020 Sep 20;12(9):e10550. doi: 10.7759/cureus.10550. PMID: 33101798; PMCID: PMC7575310.
3. Weis F, Kilger E, Beiras-Fernandez A, et al. Indocyanine green clearance as an outcome prediction tool in cardiac surgery: a prospective study. J Crit Care. 2014;29(2):224-229. doi:10.1016/j.jcrc.2013.10.023

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