Myocardial bridge is a congenital cardiac abnormality (present at birth) in which a portion of the myocardium (heart muscle) has grown over a coronary artery. The affected coronary artery dips down slightly below the surface with a thin layer of myocardium covering it, during that course, then arises back to continue on the surface of the myocardium.
Occurrence
The incidence of myocardial bridging in healthy children and young adults is unknown, although some studies have estimated up to 10%. Myocardial bridges are usually benign and do not cause symptoms. However, in some cases, patient’s may have symptoms and signs concerning for myocardial ischemia (low blood flow to the heart muscle). In such cases, surgical intervention may be indicated to open the bridge and relieve the compromised portion of the coronary artery.
Clinical presentation
Most of the population with myocardial bridges do not have symptoms. However, there are some who do. Of those who do, some common signs and symptoms are the following:
Chest pain during or immediately following exertion
Heart palpitations during or immediately following exertion
Shortness of breath/difficulty breathing during or immediately following exertion
Dizziness during or immediately following exertion
Fainting during or immediately following exertion
Cardiogenic shock
SCA (sudden cardiac arrest)
SCD (sudden cardiac death)
Management for myocardial bridge is controversial among health care professionals. The most common approaches (at the discretion of the surgeon and cardiologist) are exercise restriction and surgical procedures, depending on several factors following careful evaluation with experts and studies performed.
Exercise Restriction
Exercise restriction is used to decrease the risk of SCD, however it is unknown if this truly has an impact. Moreover, this can be difficult:
Children and teens are competitive in nature.
There is still a possibility of SCD with minimal activity that would not necessarily be prevented with exercise restriction.
Exercise is both a physical activity and a way to connect with peers. Asking a child or teen to refrain from activities can create psychological and emotional consequences.
In the long term, exercise is important for overall cardiac health, and exercise restriction may increase the risk of cardiac events in the future.
Our Approach
Our team at Texas Children’s Hospital looks at each patient as an individual and formulates the best plan of care/recommendations. This may be surgical intervention, or clinically monitoring the patient regularly in the cardiology clinic, with the goal of returning to full exercise activities, without restrictions, whenever possible.
Surgery
In some patients, surgery is used to decrease risk of myocardial ischemia (low or no blood flow to heart muscle) and the risk of SCD that is associated with the myocardial bridge. The presenting symptoms and the studies performed are essential to help in the careful decision-making, a process shared between patients/families and the CAAP multidisciplinary team.
Myectomy of Myocardial Bridge
In the case of myocardial bridges, the thin layer of muscle that is overlying the affected coronary artery is excised. This relieves any existing restriction to the blood flow in that specific area.
Results
All patients continue to be followed longitudinally, regardless of undergoing surgery or not (if not indicated).
Non-surgical patients
The majority of patients with myocardial bridges, that do not show signs of ischemia during evaluation and testing, are clinically monitored. After careful evaluation by the CAAP team, your provider may release the patient to full exercise activities and continue to be followed clinically.
For those followed clinically, repeating studies is usually not needed for at least 3-5 years from the initial assessment, unless clinical concerns arise, and the great majority of patients are allowed to continue with exercise/sports activities with no restrictions.
Surgical patients
For those undergoing surgical intervention, a complete evaluation with testing, as done on the initial presentation, is repeated at 3 months after surgery. This is to determine readiness to return to exercise/sports activities with no restrictions. Continued longitudinal follow up is also recommended and repeating studies is usually not needed for at least 3-5 years, unless clinical concerns arise. There have been rare reports of SCD after undergoing myectomy surgery, possibly related to incomplete resolution of the anatomical issues at surgery.
High risk anatomy, no surgical option
A very small subset of patients may have a high-risk anatomy of deep myocardial bridges or unusual location that makes surgical intervention very challenging, with no optimal options or carrying a high-risk of complications. These patients may be offered a specific medication, exercise restrictions from exercise/sports activities, and followed clinically. Repeat studies may be considered in about 3-5 years from initial assessment, or sooner if indicated.
Follow-up Care
The CAAP at Texas Children’s Hospital has developed a clinical algorithm to standardize the evaluation and management of patients with coronary anomalies, including myocardial bridge. This algorithm is refined during Quality Assurance multidisciplinary meetings every 1.5-2 years when the data acquired is analyzed meticulously and changes to the algorithm, if needed, are made.
Non-Surgical follow-up:
Pediatric cardiology follow-up every year
ECG every year
Echocardiogram every two years (optional)
Exercise stress test every 2 years (optional)
Stress cardiac MRI every 3-5 years (optional)
After surgery follow-up:
Postoperative Short-term Follow-up may include:
1 week: cardiovascular surgery follow-up
1 month: cardiology visit with ECG, echocardiogram
3 months: cardiology visit with ECG, CTA and stress cardiac MRI. If cardiac cath was performed as part of the evaluation prior to surgery, it will be repeated again at this time. Exercise restrictions may be lifted after third month visit if studies are acceptable.
6 months: cardiology visit with ECG
12 months: cardiology visit with ECG
Long-term Follow-up
Pediatric cardiology follow-up every year
ECG every year
Echocardiogram every two years (optional)
Exercise stress test every 2 years (optional)
Stress cardiac MRI every 3-5 years (optional)
Lifestyle Changes
Patients awaiting surgical intervention or who refuse surgical intervention are restricted from exercise/sports activities.
Patients undergoing surgical intervention cannot exercise until 3 months after surgery, after which they can return to exercise/sports activities as long as they meet the following requirements:
They are asymptomatic
All the test findings are acceptable/negative
Patients with low risk lesions that do not warrant surgical intervention are allowed to continue exercising without limitations.
Physical activities and exercise is important to cardiovascular health. Our aim is for patients to maintain physical activity throughout their lives.
Quality of Life
Patients and families affected with this diagnosis often experience increased anxiety and this may alter their lives. Texas Children’s Heart Center has psychology support for our patients. All patients in the CAAP program are referred to psychology as part of our program.
Resuming exercise activities might be an important goal to achieve normalcy following a diagnosis of myocardial bridge, whether undergoing surgery or not.
Providing education and information about emerging data related to this condition may positively impact patients and families and continues to be our impetus to acquire prospective, longitudinal data through our Registry.
Psychological Adjustment
A diagnosis of myocardial bridge brings significant anxiety and stress to patients in families. Some of the reasons include results of surgery and the risk of SCD, safety of continuing to exercise with no surgical intervention, uncertainties on the best options for management, restriction from exercise/sports participation, among others.
Therefore, our CAAP has included an experienced psychologist who meets with patients and families to provide help in coping with this new diagnosis. The hope is that this encounter will facilitate the expression of sentiments and identification of tools to better deal with myocardial bridge.
