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Bridging bronchus — Clinical Guidelines

Overview

Myocardial bridging (MB) is a congenital condition characterized by a segment of a coronary artery running intramurally through the myocardium, leading to systolic compression of the artery. While often benign, MB can be associated with symptoms such as chest pain, arrhythmias, and in rare cases, myocardial ischemia or sudden death 1 12 11.

Diagnosis

Key Diagnostic Criteria: Systolic narrowing of a coronary artery segment observed on angiography.

Recommended Tests: Coronary angiography, coronary computed tomography angiography (CCTA), and intravascular ultrasound (IVUS).

Grading: Severity often assessed by the degree of systolic compression and involvement of specific coronary arteries (e.g., left anterior descending artery most commonly affected) 1 14 21.

Management

First-Line Treatments:

- Medical Management: Lifestyle modifications, anti-anginal medications (e.g., beta-blockers, calcium channel blockers) 2 4.

Adjunctive Treatments:

- Surgical Interventions: Myotomy or coronary artery bypass grafting (CABG) in refractory cases 9. - Stenting: Reserved for specific complications like dissection extension into the bridging segment, though associated with risks such as stent fracture and restenosis 1 18.

Special Populations

Pediatrics: MB can present with symptoms like chest pain in children, requiring careful evaluation and management 5 8.

Elderly: No specific differences noted, but careful assessment of comorbidities and symptom severity is crucial 2 19.

Comorbidities: Presence of hypertrophic cardiomyopathy may increase symptomatology 5 19.

Key Recommendations

Avoid Routine Stenting for MB: Stenting should be avoided unless absolutely necessary due to risks of complications such as stent fracture and restenosis (Evidence: Moderate) 1 18.

Consider Medical Therapy First: Initiate with medical management including lifestyle changes and anti-anginal drugs for symptomatic relief (Evidence: Strong) 2 4.

Evaluate for Surgical Options in Refractory Cases: Consider surgical interventions like myotomy or CABG for patients with persistent symptoms unresponsive to medical therapy (Evidence: Moderate) 9.

Regular Follow-Up Essential: Monitor patients with MB regularly, especially those with symptoms, to assess for changes in clinical status or complications (Evidence: Expert opinion) 2 18.

References

1 Tang YH, Kan JCY, Fung RCY. First in Human-Bioadaptor Stenting in Myocardial Bridging. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2026. link 2 Zhang M, Wu Q, Zhang Z, Jiang Y, Li H, Xue H et al.. Symptomatic myocardial bridge: Long-term outcomes and strategies. The Journal of thoracic and cardiovascular surgery 2026. link 3 Giannopoulos AA, Bolt B, Benz DC, Messerli M, Von Felten E, Patriki D et al.. Non-Invasive Assessment of Endothelial Shear Stress in Myocardial Bridges Using Coronary Computed Tomography Angiography. Angiology 2024. link 4 Dai S, Xiao Z, Chen C, Yao W, Qian J, Yang J. Nomogram to predict recurrent chest pain in patients with myocardial bridging. European radiology 2023. link 5 Said SM, Marey G, Hiremath GM. Unroofing of Myocardial Bridging After Septal Myectomy in a Child With Noonan Syndrome. World journal for pediatric & congenital heart surgery 2021. link 6 Nishikii-Tachibana M, Pargaonkar VS, Schnittger I, Haddad F, Rogers IS, Tremmel JA et al.. Myocardial bridging is associated with exercise-induced ventricular arrhythmia and increases in QT dispersion. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc 2018. link 7 Hostiuc S, Negoi I, Rusu MC, Hostiuc M. Myocardial Bridging: A Meta-Analysis of Prevalence. Journal of forensic sciences 2018. link 8 Poryo M, Khreish F, Schäfers HJ, Abdul-Khaliq H. A case of myocardial bridging as a rare cause of chest pain in children. Clinical research in cardiology : official journal of the German Cardiac Society 2016. link 9 Attaran S, Moscarelli M, Athanasiou T, Anderson J. Is coronary artery bypass grafting an acceptable alternative to myotomy for the treatment of myocardial bridging?. Interactive cardiovascular and thoracic surgery 2013. link 10 Dattilo G, Carerj S, Lamari A, Messina F, Imbalzano E, Di Bella G et al.. The chance finding at multislice computed tomography coronary angiography of myocardial bridging. International journal of cardiology 2012. link 11 Nakanishi R, Rajani R, Ishikawa Y, Ishii T, Berman DS. Myocardial bridging on coronary CTA: an innocent bystander or a culprit in myocardial infarction?. Journal of cardiovascular computed tomography 2012. link 12 Sunnassee A, Shaohua Z, Liang R, Liang L. Unexpected death of a young woman: is myocardial bridging significant?--A case report and review of literature. Forensic science, medicine, and pathology 2011. link 13 Cakmak YO, Cavdar S, Yalin A, Yener N, Ozdogmus O. Myocardial bridges of the coronary arteries in the human fetal heart. Anatomical science international 2010. link 14 Lazoura O, Kanavou T, Vassiou K, Gkiokas S, Fezoulidis IV. Myocardial bridging evaluated with 128-multi detector computed tomography coronary angiography. Surgical and radiologic anatomy : SRA 2010. link 15 Schwarz ER, Gupta R, Haager PK, vom Dahl J, Klues HG, Minartz J et al.. Myocardial bridging in absence of coronary artery disease: proposal of a new classification based on clinical-angiographic data and long-term follow-up. Cardiology 2009. link 16 Zurick AO, Klein JL, Stouffer GA. Scintographic evidence of severe myocardial hypoperfusion in a patient with left anterior descending coronary artery bridging--case report and review of the literature. The American journal of the medical sciences 2008. link 17 Herrmann J, Higano ST, Lenon RJ, Rihal CS, Lerman A. Myocardial bridging is associated with alteration in coronary vasoreactivity. European heart journal 2004. link 18 Haager PK, Schwarz ER, vom Dahl J, Klues HG, Reffelmann T, Hanrath P. Long term angiographic and clinical follow up in patients with stent implantation for symptomatic myocardial bridging. Heart (British Cardiac Society) 2000. link 19 Harikrishnan S, Sunder KR, Tharakan J, Titus T, Bhat A, Sivasankaran S et al.. Clinical and angiographic profile and follow-up of myocardial bridges: a study of 21 cases. Indian heart journal 1999. link 20 Reiss DL, Williams MD, Rodning CB. Myocardial bridging prevents safe laparoscopy? A case report. Journal of laparoendoscopic surgery 1996. link 21 Ferreira AG, Trotter SE, König B, Décourt LV, Fox K, Olsen EG. Myocardial bridges: morphological and functional aspects. British heart journal 1991. link 22 Sahni D, Jit I. Incidence of myocardial bridges in northwest Indians. Indian heart journal 1991. link 23 Cascade PN, Armstrong MC. Rib compression of the coronary arteries. Catheterization and cardiovascular diagnosis 1990. link 24 Visscher DW, Miles BL, Waller BF. Tunneled ("bridged") left anterior descending coronary artery in a newborn without clinical or morphologic evidence of myocardial ischemia. Catheterization and cardiovascular diagnosis 1983. link 25 van Nie CJ. The occurrence of myocardial bridges on coronary arteries in the common seal (Phoca vitulina vitulina). Acta morphologica Neerlando-Scandinavica 1983. link

Bridging bronchus