Jack H. Boyd, MD, Vedant S. Pargaonkar, MD, David H

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Presentation transcript:

Surgical Unroofing of Hemodynamically Significant Left Anterior Descending Myocardial Bridges Jack H. Boyd, MD, Vedant S. Pargaonkar, MD, David H. Scoville, MD, Ian S. Rogers, MD, MPH, Takumi Kimura, MD, PhD, Shigemitsu Tanaka, MD, PhD, Ryotaro Yamada, MD, PhD, Michael P. Fischbein, MD, PhD, Jennifer A. Tremmel, MD, MS, Robert Scott Mitchell, MD, Ingela Schnittger, MD The Annals of Thoracic Surgery Volume 103, Issue 5, Pages 1443-1450 (May 2017) DOI: 10.1016/j.athoracsur.2016.08.035 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Schematic representation of the detailed evaluation performed for diagnosing a hemodynamically significant myocardial bridge (MB) suitable for surgical unroofing. (CT = computed tomography; dFFR = diastolic fractional flow reserve; IVUS = intravascular ultrasonography.) The Annals of Thoracic Surgery 2017 103, 1443-1450DOI: (10.1016/j.athoracsur.2016.08.035) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Left anterior descending artery (LAD) with a myocardial bridge (MB) shown on a still frame of a coronary angiogram and corresponding intravascular ultrasonogram (IVUS). The upper panel represents a still frame of the LAD from the coronary angiogram. The MB is identified by the green dotted line; S1 to S4 are the septal perforators; D1 and D2 are the diagonal branches. The lower panel shows the entire distance of the IVUS catheter pullback (73.51 mm), marking the distal and proximal end of the MB, the MB length (22.84 mm), and its relationship to other branches. (LCX = left circumflex artery.) (B) Demonstrative examples of arterial compression, maximum plaque burden, and halo thickness on IVUS. The upper panel shows an end-diastolic and an end-systolic still frame from a manual IVUS pull back, demonstrating 47.5% arterial compression. The middle panel demonstrates, to the left, a maximal plaque burden (Max PB) of 49%, which is located 24.1 mm upstream from the MB entrance. This plaque was not appreciated on the coronary angiogram. To the right is shown the maximal MB halo thickness (characteristic half-moon sign) measured at 0.48 mm. (VA = vessel area.) The Annals of Thoracic Surgery 2017 103, 1443-1450DOI: (10.1016/j.athoracsur.2016.08.035) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Pressure tracings from proximal to the myocardial bridge (MB), within the MB, and distal to the MB at rest and peak stress during dobutamine stress testing. The red tracings are the aortic pressure and the yellow tracings are the intracoronary pressure. The numbers to the left in each row represent the pressure (mm Hg). At rest, there was no significant difference in pressures between the aorta and the coronary artery either proximal to, within the MB, or distal to the MB. At peak stress, there was a moderate difference in pressures distal to the MB, a significant difference in pressures within the MB, and no significant difference in pressures proximal to the MB. The purple arrow points to the site of greatest separation during peak stress between the curves in diastole (within the MB), yielding a diastolic fractional flow reserve of 0.46. The Annals of Thoracic Surgery 2017 103, 1443-1450DOI: (10.1016/j.athoracsur.2016.08.035) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Intraoperative image showing on-pump unroofing of a left anterior descending artery myocardial bridge. Arrow points to the unroofed segment of the bridged artery. Patient head oriented to top of figure. (B) Intraoperative image showing off-pump unroofing of a left anterior descending artery myocardial bridge. Arrow points to the unroofed segment of the bridged artery. Patient head oriented to top of figure. The Annals of Thoracic Surgery 2017 103, 1443-1450DOI: (10.1016/j.athoracsur.2016.08.035) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Seattle Angina Questionnaire scores before (preoperative [blue bars]) and after (postoperative [red bars]) surgical unroofing of a myocardial bridge. Data available for 38 patients; higher scores represent better outcome. The p value was less than 0.001 for all five categories. The Annals of Thoracic Surgery 2017 103, 1443-1450DOI: (10.1016/j.athoracsur.2016.08.035) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions