Infarction Due to Myocardial Bridging

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     A 45-year-old man with dyslipidemia had a sudden onset of retrosternal chest pain and presented to the emergency department. Findings on the physical examination were unremarkable. His electrocardiogram showed ST-segment elevation in the anterior leads (Panel A). Coronary angiography was immediately performed. The left anterior descending (LAD) coronary artery and two large diagonal branches appeared to be normal during diastole (Panel B) but were severely compressed during systole (Panel C), suggesting compression by myocardial bridging. A rate of flow classified as grade 2 (according to the criteria of the Thrombolysis in Myocardial Infarction [TIMI] trial) was observed in these three arteries. The other coronary arteries were normal. Direct stenting of the intramyocardial segment of the LAD artery and the second large diagonal branch restored TIMI grade 3 flow and relieved the chest pain, with normalization of the electrocardiogram. The creatine kinase and troponin levels were elevated, at 483 U per liter (normal range, <185 U per liter) and 2.63 μg per liter (normal range, <0.10 μg per liter), respectively. Left ventriculography showed a normal ejection fraction with mildly impaired motion of the anterior wall. Administration of aspirin, clopidogrel, atorvastatin, and metoprolol was initiated. A follow-up electrocardiogram showed resolution of the ST-segment elevation (Panel D). Three years later, the patient remained asymptomatic and achieved his target heart rate during a treadmill test.

    Karam Souibri, M.D.

    Gilles Grollier, M.D.

    Centre Hospitalier Universitaire de Caen

    14033 Caen CEDEX, France

    http://www.100md.com/html/DirDu/2007/01/01/32/91/26.htm