Minimally Invasive Myocardial Bridge Unroofing

Myocardial bridge refers to the intramuscular course of portion of the LAD, resulting to its luminal compromise during systole, and therefore symptoms of myocardial ischemia. Patients with myocardial bridge present with atypical angina, persistent over months or years, and are aggravated by a strong psychological component. Often, patients symptoms cannot be objectified, and they feel they are not taken seriously. For this reason, they have even formed an international community, seeking help in various advanced programs, including the authors'. Surgeons are reluctant to operate, unless all medical means have been exhausted (b-blockers, Vasodilators), and even then the warranted surgical approach is equivocal: to stent, to bypass, or to do nothing. Over the years, the most favored and physiologically efficient method is the so called LAD-unroofing (or de-roofing) procedure, whereby the muscle covering the LAD is dissected, hence removing the “squeeze” around the vessel during systole. Again, there is controversy as to how best to de-roof: through a median sternotomy, minimally invasively, on the beating heart, or on the arrested heart? It is not even clear which imaging/diagnostic modality is decisive for the diagnosis: exercise tolerance test, exercise-ECG/Echo, CT Angiography, or MRI.

The utility of FFR or IFR is still highly disputed. Now, due to the fact that the patients’ suffering of this condition is frustrating, they are psychosomatically affected, and they are very well-read on their condition. Due to the fact that the outcome is not always optimal (little symptomatic relief), surgeons find themselves medicolegally at risk, and hesitant to take on such cases. Needless to say, the consent process is extremely important and should not spare any detail. Based on the authors’ experience, they provide this video which presents such a controversial case, its diagnostic analysis, and most importantly, their surgical approach to LAD de-roofing, which is minimally invasive but uncompromising.

Reference

Michael S. Lee, Cheng-Han Chen. Myocardial bridging: an up-to-date review. J Invasive Cardiol. 2015 Nov;27(11):521–528.