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Ann Thorac Surg 1999;68:246
© 1999 The Society of Thoracic Surgeons

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Invited Commentaries

^a Division of Pediatric Cardiology, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87131-5311 USA

e-mail: dwaldman{at}salud.unm.edu.

Invited commentary

Occasionally, the simple case report can have implications out of proportion to the single patient reported. This may be true of the paper by Hillman and associates from Children’s Memorial in Chicago. They report a 10-year-old with chest pain, abnormal ECG, and echocardiogram, then demonstration of contraction-induced coronary constriction. A myocardial bridge over the left coronary artery was suspected, confirmed at surgery, and repaired by supraarterial decompression myotomy.

Myocardial bridges have been recognized for over 250 years. Myocardial loops—atrial myocardium surrounding coronary arteries—were added to the knowledge base in 1961 [1]. Grondin reported supraarterial myotomy in this journal in 1977 [2]. In concert with Kramer’s 1982 paper, the historical wisdom has been that myocardial overbridging is not a source of myocardial ischemia [3]. However, as shown now by Hillman, Cutler and Wallace [5], and Schwarz and colleagues [6] as well as by Yetman and associates [4], we need to rethink that view.

If myocardial overbridging can cause ischemia with infarction and/or arrhythmias, and sudden death, a safe, curative surgical procedure is available. One must therefore ask two questions: (1) should we reconsider the significance of myocardial overbridging in people who die "for no apparent reason?" and (2) how should one work up the child with chest pain? With the plethora of diagnostic modalities available from ECG and echocardiogram through stress tests with and without echo to catheterization studies, the permutations are endless. An increased number of surgical referrals—many possibly unnecessary—would follow "as the night follows the day." Cost of medical care would escalate even further.

Given the magnitude of the medical problem as well as the financial implications, I believe the best answer is a national collaborative study funded by NIH. In this way, we can: (1) quickly acquire a large enough patient population to provide statistical power, (2) answer the clinical questions, (3) not require the individual patient to pay for the necessary studies, and (4) identify risk factors that will allow an appropriately stratified work up of the child with chest pain[7].

References

1. Polacek P., Kralove H. Relation of myocardial bridges and loops on the coronary arteries to coronary occlusions. Am Heart J 1961;61:44-52.[Medline]
2. Grondin P., Bourassa M.G., Noble J., Petitclerc R., Dydra I. Successful course after supraarterial myotomy for myocardial bridging and milking effect of the left anterior descending artery. Ann Thorac Surg 1977;24:422.[Abstract]
3. Kramer J.R., Kitazume H., Proudfit W.L., Stones F.M. Clinical significance of isolated coronary bridges. Am Heart J 1982;103:283-288.[Medline]
4. Hillman N.D., Mavroudis C., Backer C.L., Duffy E. Supraarterial decompression myotomy for myocardial bridging in a child. Ann Thorac Surg 1999;68:244-246.[Abstract/Free Full Text]
5. Cutler D., Wallace J.M. Myocardial Bridging in a Young Patient with Sudden Death. Clin Cardiol 1997;20:581-583.[Medline]
6. Schwarz E.R., Klues H.G., vom Dahl J., Klein I., Krebs W., Hanrath P. Functional characteristics of myocardial bridging. European Heart Journal 1997;18:434-442.[Abstract/Free Full Text]
7. Yetman A.T., McCrindle B.W., MacDonald C., Freedom R.M., Gow R. Myocardian bridging in children with hypertrophic cardiomyopathy—A risk factor for sudden death. New Engl J Med 1998;339:1201-1209.[Abstract/Free Full Text]

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