Presentation
Dyspnea on exertion. Hypercholesterolemia. Family history of CAD. ST-segment depression in II, II, V5-6, less in aVF during the recovery phase of treadmill test
Patient Data
Technique
patient premedication: beta blockers and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
standard image reconstruction
Findings
normal coronary origins and proximal courses
balanced coronary arterial dominance
Plaque burden:
coronary calcium score: <100
segment involvement score (SIS): two segments
Right coronary artery (RCA): gives rise to a small duplicate posterior descending artery
ostial non-stenotic calcified plaque
otherwise no stenoses in the proximal, middle, and distal segments
posterior descending artery (PDA): no plaques or stenosis
Left main (LM): inconspicuous
Left anterior descending artery (LAD): two diagonal branches
mixed plaque with spotty calcifications and minimal stenosis (D: <25%) near the origin of the first diagonal branch
no plaques or stenoses of the diagonal branches (D1 & D2)
Ramus intermedius: strong
long and deep myocardial bridge (length: ~3-4 cm; depth: ~5mm)
Circumflex artery (CX): obtuse marginal branch and left posterolateral branches
no plaques or stenoses in the main epicardial vessel
no plaques or stenosis of the obtuse marginal (OM) and left posterolateral branch
Impression
long and thick myocardial bridge of the strong ramus intermedius artery
small mixed non-obstructing coronary plaque with high-risk features of the LAD and calcified eccentric non-obstructing ostial plaque of the RCA
mild plaque burden
CAD-RADS 1/P2/E
Exam courtesy: Yvonne Kühn (radiographer)
MonoE at 40 keV and 80 keV
virtual monoenergetic images, synthesized at a level of 40 and 80 keV
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reconstructions in a soft tissue algorithm with the following window settings:
monoE 80: C:800 W:2000
monoE 80: C:400 W:1000
Conventional + MonoE 40 overlay
conventional images, reconstructed with a standard soft tissue filter and supplemented with a color-coded MonoE 40 overlay ranging from -600 to 1400 (C:400 W:2000)
Conventional + MonoE 80 overlay
conventional images, reconstructed with a standard soft tissue filter and supplemented with a color-coded MonoE 80 overlay ranging from -100 to 900 (C:400 W:1000)
this setting can be also used to illustrate calcium but is less ideal for depicting spotty calcification
Z-effective
the effective atomic number Zeff calculated by dual-energy analysis
Case Discussion
A myocardial bridge is a coronary anomaly or rather a variant of intrinsic coronary arterial anatomy where a tunneled length of an epicardial artery dives through the myocardium. Most myocardial bridges have been considered 'benign' and not associated with symptoms especially if short and superficial (<2 mm). However, in this case, we have a very deep (~5 mm) and long (>25 mm) tunneling of a strong ramus intermedius artery which could indeed explain this patient's symptoms due to systolic compression and subsequent early diastolic delay also known as milking effect.
There are no clear guideline recommendations with regard to the management of this entity 1. As proposed in a recent state-of-the-art review 1 we recommended close clinical follow-up and medical therapy with beta-blockers or calcium channel blockers as worthy consideration in addition to risk factor modification and preventive therapy, which she should get for her non-obstructive coronary artery disease anyway 2, as well as further stress testing preferably with a dobutamine stress test 3 in the setting of persisting symptoms.
Courtesy: Dr Waltraud Ibe
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