Carcassoa
Carcassoa
Carcassoa
DOI 10.1080/02841850802199825 # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
Intramyocardial course, an inborn coronary anom- branch block (LBBB) in 12 patients. No alteration
aly, is defined as a segment of a major epicardial of troponin was found in any patient.
coronary artery that runs intramurally through the All MDCT examinations were performed with a
myocardium; the intramyocardial coronary arterial 16-detector-row scanner (Aquilion 16 CFX;
segment is termed a tunneled segment (1). In Toshiba Medical System, Tokyo, Japan). Patients
particular, we distinguish myocardial bridging, in with heart rate above 65 bpm received 50 mg
which the vessel returns to an epicardial position atenolol orally for 3 days before scanning, or they
after the muscle bridge, and intramyocardial course, increased their usual therapy with beta-blockers, in
which is described as a vessel running and ending in order to obtain a prescan heart rate B60 bpm.
the myocardium. Arterial enhancement was obtained by intrave-
Major discrepancies exist between pathological nous administration in an antecubital vein of 130
series, in which the incidence of intramyocardial 140 ml of nonionic iodinated contrast material
course has varied from 5% to 86% (25), and (iomeprol 400 mg I/ml, Iomeron 400; Bracco,
angiographic series, in which it is reported as being Milan, Italy) at an injection rate of 5 ml/s followed
between 0.5% and 33% (69). Although conven- by 40 ml of saline solution at the same rate. The
tional angiography is the gold standard, other contrast material was injected with a dual-syringe
imaging techniques have been used, such as intra- automatic injector (Stellant; MedRad, Pittsburgh,
Pa., USA).
vascular sonography and multidetector computed
Synchronization of the scan with the arterial
tomography (MDCT) (1012). Recent advances in
passage of the contrast material was performed
CT techniques, such as MDCT scanners, allow
with the bolus-tracking technique in real time
visualization of the coronary arteries (13).
(Sure Start). The region of interest was placed in
The aim of this study was to evaluate the
the ascending aorta with a scan-trigger threshold
prevalence of myocardial bridging in 242 consecu- of 150 HU. Transverse images were reconstructed
tive patients who underwent MDCT coronary retrospectively with a soft-tissue algorithm from the
angiography at our institution. raw MDCT data. The reconstruction was gated at
090% of the RR interval of each cardiac cycle.
Material and Methods Effective section thickness and reconstruction in-
crement were 0.5 and 0.3 mm, respectively.
The study population consisted of 242 patients (211 MDCT data were analyzed in consensus by two
men, 31 women; mean age 5996 years) with readers who were both blinded to the patients’
atypical chest pain admitted between December clinical history. First, the reconstruction interval
2004 and September 2006. Clinical characteristics with the smallest degree of motion artifacts was
of the study population are shown in Table 1. identified for each patient. This best data set of axial
All patients had atypical chest pain. No patient images was chosen to generate curved multiplanar
had severe arterial hypertension, anemia, valvular and 3D color reconstructions. Evaluation of the
lesions, or ventriculographic signs of cardiomyo- coronary arteries was then performed according to
pathy; mild hypertension (i.e., diastolic blood the classification of the American Heart Association
pressure of 95100 mmHg) was present in 189 (14). Coronary artery segments with a luminal
cases. Electrocardiogram (ECG) showed left bundle diameter of less than 1.5 mm at their origin were
excluded from the analysis.
Table 1. Clinical characteristics of study population
The diagnosis of intramyocardial course was
established on the basis of the cross-sectional,
Patients scheduled, n 242 thin-slab maximum intensity projection (MIP) and
Patients examined, n 235 (97%) multiplanar reformatting (MPR) images and the
Patients excluded, n 7 (3%) axial source images. Multiplanar and curved planar
Age, years 5996
Men/women 211/31
reformations were used for depiction of intramyo-
Body-mass index (BMI), kg/m2 2693 cardial course in at least two planes*one parallel
Hypertension, n 189/242 (78%) and one perpendicular to the course of the vessel.
Hypercholesterolemia, n 165/242 (68%) Intramyocardial course was defined as when part of
Smoking (current), n 171/242 (71%) a coronary artery was completely surrounded by
Diabetes, n 22/242 (9%)
Beta-blocker, n 143/242 (59%)
myocardium. In particular, we distinguished myo-
cardial bridging, in which the vessel returns to an
Values are mean9SD. epicardial position after the muscle bridge, and
Results
Fig. 4. Volume-rendering 3D (A), axial (B), and coronal (C) images show intramyocardial course of the distal third of the marginal branch.
AO: aorta; LM: left main artery; LA: left atrium; LV: left ventricle; MB: myocardial bridging.
Discussion
few patients present symptoms that do not usually proximal to the bridge, whereas the tunneled
develop before the third decade; the explanation for segment was always spared.
this is not clear, but prognosis of this anomaly is Coronary MDCT offers several potential advan-
excellent, with a reported 5-year survival rate tages. It is a noninvasive imaging modality that
greater than 95% (7). Nevertheless, myocardial shows the coronary artery lumen, wall, and sur-
bridging in particular is thought to be the first rounding myocardium, and data regarding the
responsible cause in some patients with myocardial length, depth, precise location, and presence or
infarction that have no evidence of coronary absence of atherosclerosis are easily obtained. This
atherosclerosis on angiography or at autopsy (17). information is crucial in planning possible bypass
Normally, only 15% of coronary blood flow interventions in patients with coronary stenosis/
occurs during systole, and the compression of occlusions, which can be accomplished with a single
intramyocardial segments is a systolic event. Its breath-hold, short scan. MDCT, on the other hand,
clinical significance and relevance have been ques- has greater difficulty in demonstrating lumen varia-
tioned. Ischemia in these patients could probably be tions in the systolic phase (030% of the RR
attributed to one or a combination of the following interval), because these phases have more move-
factors: increased heart rate compromising the ment artifacts. Risks include intravenous contrast
diastolic filling of coronary arteries, exercise indu- administration and radiation exposure, which is a
cing spasm of the coronary arteries, systolic kinking limitation of the technique (11, 19, 28).
of the blood vessel that may cause trauma to the In our study, we were easily able to recognize the
intimal layer and damage the endothelium with length and depth of myocardial bridging and
platelet activation and thrombus formation (18). intramyocardial course on multiplanar reconstruc-
The likelihood of ischemia increases with the tion images, even when only a few muscle fibers
intramyocardial depth and length of the segment, caused this anomaly. In the literature, myocardial
and sudden death has been reported in association bridging is mostly confined to the LAD (29). In our
with deep segments (19, 20). study, we also assessed intramyocardial course
The current imaging standard of reference for the located at the distal third of the LAD, in D1, in
diagnosis of myocardial bridging is coronary cathe- marginal branches, and in the intermediate branch
ter angiography, which demonstrates the classic of the left coronary artery. We found no significant
‘‘milking effect’’ and a ‘‘step downstep up’’ phe- diameter variation of the coronary arteries between
nomenon induced by systolic compression of the different phases, probably because all segments
tunneled segment (11), but cannot demonstrate were superficial and of small caliber. Even if the
muscle tissue and thereby myocardial bridging. significance of lumen variations demonstrated by
There is a discrepancy between the extremely low angiography has more clinical significance for the
reported prevalence according to catheter angiogra- presence of myocardial bridges, MDCT can better
phy and the relatively high prevalence reported at demonstrate the muscle bundles tunneling the
autopsy (29) because often there is no clear, exact artery. MDCT can therefore provide complemen-
definition of intramyocardial course and myocar- tary information to establish correct therapy, parti-
dial bridging. This might be part of the explanation cularly in surgical approaches such as minimally
for the highly variable incidence rates in different invasive coronary artery bypass grafting (CABG)
papers based on different techniques. and surgical myotomy (30, 31).
Regarding the occurrence of atherosclerotic pla- Our study had limitations. First, our measure-
ques in the tunneled coronary segment, GEIRINGER ments of systolic compression with CT may be
(21) and other investigators (2227) have reported inaccurate because we chose a variable systolic
that tunneled segments are rarely affected by phase (030%) in different patients with the smal-
atherosclerosis, unlike epicardial segments, in which lest degree of motion artifacts that did not corre-
atherosclerotic plaques are commonly found. A spond in all cases to the real systolic phase. Our
study by ISHIKAWA et al. (17) found the segments measurements should therefore be considered an
proximal to the bridge significantly narrowed, approximation of the real systolic compression of
whereas the tunneled segment itself was free of the tunneled segments. Second, our study did not
atherosclerotic lesions. This phenomenon has been completely investigate the relationship between
confirmed by our study, in which six atherosclerotic myocardial bridging and clinical symptoms, which
lesions were found mainly in the coronary arteries limits the clinical relevance of the results.
In conclusion, because of advances in CT tech- 11. Goitein O, Lacomis JM. Myocardial bridging: noninva-
nology, radiologists now have a noninvasive sive diagnosis with multidetector CT. J Comput Assist
Tomogr 2005;29:23840.
method to evaluate the location, depth, and length
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alterations are not rare and can cause important 13. Pannu HK, Flohr TG, Corl FM, Fishman EK. Current
complications (19). In routine practice, we also concepts in multi-detector row CT evaluation of the
coronary arteries: principles, techniques, and anatomy.
recommend including ECG-gated reconstructions Radiographics 2003;23:11125.
during different phases. A careful comparison of
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conflicts of interest. The authors alone are respon- 17. Rosencrance G, Deer TR, Lee KC, Warren SG.
Coronary artery muscle bridging causing class III
sible for the content and writing of the paper. angina in a patient with no coronary atherosclerosis.
W V Med J 1995;91:1967. / /
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