Case Presentation:
A 52-year-old man presented to our institution with a one year history
of intermittent, progressive chest tightness. Past medical history was
notable for hypertension, hyperlipidemia, post-traumatic stress disorder
and family history of coronary artery disease (CAD). Prior to developing
symptoms, he was quite physically active; however, became less so prior
to presentation due to symptomatic limitations.
He underwent an exercise stress test that showed good functional
capacity (exercise time of 9 min 47 seconds) but demonstrated 2-3 mm ST
depressions starting in Stage 2 of the bruce protocol in leads II, III,
aVF and V4-V6. The patient also expressed dypnea with exercise that
resolved 5 minutes into recovery. Coronary angiography was then
performed, demonstrating non-obstructive CAD . However, a long segment
myocardial bridge in the mid-LAD was observed (Figure 1) Transthoracic
echocardiogram (TTE) demonstrated normal left ventricular size, normal
systolic function and an estimated left ventricular ejection fraction of
60-65%.
Initially, the patient was trialed on maximal medical therapy for
symptomatic relief, including amlodipine, aspirin and rosuvastatin. His
symptoms persisted. He was subsequently referred for cardiac surgical
evaluation. He was deemed an appropriate operative candidate, and was
brought to the operating room for surgical unroofing of the myocardial
bridge on April, 2020.
Standard aortic and dual stage venous cannulation was performed. The
aorta was cross clamped and the heart was arrested with antegrade Del
Nido cardioplegia. Upon surface inspection, a long segment of
intramyocardial LAD was easily identified (Figure 2). The LAD was
unroofed with the use of a 15-c blade over the course of 10 mm. The
aortic cross clamp was removed and the patient was easily separated from
cardiopulmonary bypass. He underwent coronary angiography on
post-operative day one to evaluate the results of the surgery
radiographically. Angiography revealed that the myocardial bridge had
been entirely relieved (Figure 3). The patient had an uneventful
post-operative course and was discharged home on postoperative day
number four. He was seen in follow-up one and two months post procedure
and is doing well without recurrence of symptoms.