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Robotic-assisted surgical myotomy in a 27-year-old man with myocardial bridging of the left anterior descending coronary artery

DOI:10.1510/icvts.2009.221473
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Mai Bol Alima
Mai Bol Alima
Mai Bol Alima
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Frédéric Vanden Eynden at Université Libre de Bruxelles
Frédéric Vanden Eynden
Nicolas Preumont at Université Libre de Bruxelles
Nicolas Preumont
Jean-Luc Jansens at Université Libre de Bruxelles
Jean-Luc Jansens
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Abstract

Myocardial bridging (MB) is a frequent condition usually considered benign but it may be associated with myocardial ischemia. When bridging is symptomatic, therapeutic options are numerous and in the absence of guidelines all options are conceivable. This is a case of a 27-year-old man who benefited from a new surgical approach: myotomy for MB of the left anterior descending coronary artery with the help of left robotic thoracoscopy. ©2010 Published by European Association for Cardio-Thoracic Surgery.
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doi:10.1510/icvts.2009.221473
Interactive CardioVascular and Thoracic Surgery 11 (2010) 185–187
䊚2010 Published by European Association for Cardio-Thoracic Surgery
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Case report - Coronary
Robotic-assisted surgical myotomy in a 27-year-old man with
myocardial bridging of the left anterior descending coronary artery夞
Mai Bol Alima , Fre´de´ric Vanden Eynden , Nicolas Preumont , Jean-Luc Jansens *
baca,
Department of Cardiac Surgery, Erasme Hospital, Free University of Brussels, 808, Route de Lennik, 1070 Brussels, Belgium
a
Department of General Surgery, Erasme Hospital, Free University of Brussels, Belgium
b
Department of Cardiology, Erasme Hospital, Free University of Brussels, Belgium
c
Received 11 November 2009; received in revised form 17 March 2010; accepted 21 March 2010
Abstract
Myocardial bridging (MB)is a frequent condition usually considered benign but it may be associated with myocardial ischemia. When
bridging is symptomatic, therapeutic options are numerous and in the absence of guidelines all options are conceivable. This is a case of a
27-year-old man who benefited from a new surgical approach: myotomy for MB of the left anterior descending coronary artery with the
help of left robotic thoracoscopy.
䊚2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Myocardial bridging; Robotic surgery
1. Clinical summary
A 27-year-old man was admitted in an emergency depart-
ment with violent retrosternal chest pain at rest. The
patient reported that two days prior to admission he also
had intermittent chest pain at rest during 15 min, disap-
pearing spontaneously. His examination was unremarkable
and he had no cardiovascular risk factors. The electrocar-
diogram showed a sinus rhythm with significant ST segment
depression in the anterior leads. Blood tests were remark-
able for elevated troponin I up to 7.52 ngyml on the 1st
day and 15.38 ngyml on the 2nd day after admission (nor-
mal values: 0.00–0.25 ngyml)and elevated myocardial
bridging (MB)fraction of creatine kinase at 50 Uyl(normal
values: 0–25 Uyl). Chest X-ray was normal and cardiac
echography showed no segmental anomaly.
The patient was treated with intravenous molsidomine,
clopidrogel, ASA and enoxaparin and transferred to our
institution. A coronary angiography was performed (Fig. 1)
and showed a preserved left ventricular function associated
with a MB of the left anterior descending (LAD) coronary
artery. No other vessel abnormality was noted. After four
days without pain the patient was discharged and schedul-
ed for a surgical robot-assisted myotomy; discharge treat-
ment consisted of ASA and calcium channel blockers.
The procedure was performed using the ‘Da Vinci’ S
surgical system (Intuitive surgical, Sunnyvale, CA, USA)
with a camera port inserted in the fifth intercostal space
(ICS). Three working ports were inserted under direct vision
夞This work has been supported by a grant from Fonds pour la chirurgie
cardiaque.
*Corresponding author. Tel.: q32 2-5555534; fax: q32 2-5556652.
E-mail address: jjansens@ulb.ac.be (J.-L. Jansens).
in the second, seventh and under the rib cage on the left
side (Fig. 2). The LAD was stabilized and a beaver scapel
was used to dissect the pericardial fat and the myocardium,
exposing the LAD which was further released off some
adventitia (Video 1). Chest tube drainage of the left pleura
was used for 24 h. The patient was admitted to the
intensive care unit, and artificial ventilation was continued
for -2 h. He was returned to the ward on the first
postoperative day and was discharged four days after
surgery. A month later the patient was asymptomatic and
had a computed tomography coronary angiogram which
showed no LAD abnormality.
2. Discussion
First recognized by Reyman in 1737, MB occurs when an
epicardial vessel has a limited intramyocardial segment.
Although all coronary vessels can be affected, the mid LAD
segment is usually implicated w1, 2x.
In pathological series MB has an incidence as high as 80%,
whereas angiographic studies report incidences ranging
from 1.5% to 16% w2x.
It has been shown that MB is associated with systolic
compression and diminished coronary flow reserve, the
exact clinical implication of these is not well established
and while case studies report angina and infarction, con-
duction disturbances, ventricular tachycardia and sudden
death, retrospective follow-up of symptomatic MB showed
good prognosis but at the moment no definitive conclusions
can be drawn w2x.
The medical approach for symptomatic MB is the first line
therapy using drugs, such as b-blockers and calcium channel
blockers. When symptoms persist some advocate intraco-
ARTICLE IN PRESS
186 M. Bol Alima et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 185–187
Fig. 1. Coronary angiogram. On the left picture the two white arrows show
no abnormalities during diastole along the left anterior descending artery.
On the right picture, during systole there is a reduction in the diameter of
the LAD between the two white arrows.
Video 1. Robotically-assisted endoscopic release of a myocardial bridge on
the LAD.
Fig. 2. Port placement. 1 and 3: Right and left ports for the working arms,
respectively on the 2nd and 7th left intercostal spaces at the anterior axillary
line; 2: camera port; 4: left subcostal port for the stabilizing arm; 5: acces-
sory port (not used for MB).
ronary stenting as a successful means of treatment. Haager
et al. w3xstudied 11 patients stented for MB, the follow-up
period was two years and no major cardiac events were
reported, but at seven weeks post-stenting 50% of the
patients had mild to moderate or moderate to severe
restenosis and 36% required target vessel revascularization.
Moreover, the procedure is at risk owing to the thinner wall
of the bridged artery prone to perforation requiring exper-
imented operators.
First reported by Binet, direct surgical myotomy seems a
logical approach, by eliminating the cause of compression.
The high operative risks associated with open heart surgery
as well as the advances in coronary stenting have limited
its use, especially when no other coronary vessel abnor-
malities are found w4x.
Less invasive surgical approaches of MB, such as beating
heart surgery through sternotomy or through a less invasive
incision, such as a left minithoracotomy could be an option
for patients resistant to medical therapy in centers with no
robotic capabilities. In centers with robotic devices, such
as the Da Vinci system, we would advise treating a mechan-
ical problem by mechanical means. Since our conversion
rate in bypass for single-vessel disease is -5% in conven-
tional beating heart totally endoscopic artery bypass (BHTE-
CAB) we were comfortable offering the procedure to the
patient whose first episode was a myocardial infarction and
we had no clue of how protected he would have been with
medical treatment alone. The procedure performed with
the help of a robotic device initially developed for off-
pump CABG w5xhas no complication related to sternal
splitting, permits a total removal of the myocardial bridge
and even adventitial webs if needed. Adverse events of
this technique can be divided into two categories: the first
is related to the robot technology and port placements,
the second is related to myocardial maneuvers. In our
experience of more than 200 BHTECAB we had only one
conversion due to technical reasons of robot malfunction.
Conversion for port misplacement is also rare, in conven-
tional VATS surgery it is reported in 3% of the cases while
in BHTECAB although no large series have been reported
yet, it is probably lower owing to the very conventional
manner of port placement. In thin patients, the coronary
vessels are easily identified on the myocardium and bridg-
ing is often obvious as it is in open-chest surgery. The
stabilizator used for BHTECAB is very reliable and permits
precise suture on coronary arteries on the beating heart,
myocardial fibers dissection bridging an artery is even
deemed easier.
3. Conclusion
Surgery of MB through a left thoracoscopic approach,
robotically assisted, is feasible and safe, and it might be
an elegant therapeutic option in a symptomatic patient
resistant to optimal medical therapy.
References
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w2xAlegria JR, Herrmann J, Holmes DR Jr, Lerman A, Rihal CS. Myocardial
bridging. Eur Heart J 2005;26:1159–1168.
ARTICLE IN PRESS
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New Ideas Institutional
Report
Work in
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Article
Negative
Results State-of-the-art Best Evidence
Topic
Brief
Communication Case Report
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Paper
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out Procedure Nomenclature Historical
Pages
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... These prospective studies, though including relatively small numbers, demonstrated a lack of any major surgical complications from the robot assisted procedures and a near 100% success rate for both cohorts. A larger comparative study has demonstrated shorter ICU and total hospital length of stays, as well as lower requirement for blood transfusions with robotic ASD closures when compared to a traditional sternotomy approach [50]. ...
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It has been over two decades since the very first robotic cardiac surgery was performed. Over the years, there has been an increase in the demand for less invasive cardiac surgical techniques. Developments in technology and engineering have provided an opportunity for robotic surgery to be applied to a variety of cardiac procedures, including coronary revascularisation, mitral valve surgery, atrial fibrillation ablation, and others. In coronary revascularisation, it is becoming more widely used in single vessel, as well as hybrid coronary artery approaches. Currently, several international centres are specialising in a totally endoscopic coronary artery bypass surgery involving multiple vessels. Mitral valve and other intracardiac pathologies such as atrial septal defect and intracardiac tumour are also increasingly being addressed robotically. Even though some studies have shown good results with robot-assisted cardiac surgery, there are still concerns about safety, cost and clinical efficacy. There are also limitations and additional challenges with the management of cardiopulmonary bypass and myocardial protection during robotic surgery. Implementing novel strategies to manage these challenges, together with careful patient selection can go a long way to producing satisfactory results. This review examines the current evidence behind robotic surgery in various aspects of cardiac surgery.
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... 39 Unroofing definitively corrects the anatomic defect, thereby improving flow and relieving the source of myocardial ischemia, 40 and can be performed via sternotomy on or off cardiopulmonary bypass or via a minimally invasive approach. [41][42][43][44][45] CONFLICT OF INTEREST None. ...
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A myocardial bridge is a segment of a coronary artery that travels into the myocardium instead of the normal epicardial course. Although it is general perception that myocardial bridges are normal variants, patients with myocardial bridges can present with symptoms, such as exertional chest pain, that cannot be explained by a secondary etiology. Such patients may benefit from individualized medical/surgical therapy. This article describes the prevalence, clinical presentation, classification, evaluation, and management of children and adults with symptomatic myocardial bridges.
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... Robotic excision of aortic valve papillary fibroelastoma has also been reported. 44,72,73 Other robotic procedures Case reports have been published describing technique for approaching various other cardiac pathologies robotically, including aortic valve replacement, 74 apico-aortic conduit surgery, 75 myotomy for myocardial bridging of the LAD, 76 and right internal mammary to right coronary artery bypass for aberrant origin of the right coronary artery. 77 ...
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Since robotic cardiac surgery was first described nearly 2 decades ago, technological advance along with a growing demand for less invasive procedures have given way to increased development and adoption of robot-assisted cardiac surgery. Coronary revascularization is now being performed with varying degrees of robotic assistance. Robot-assisted single vessel and hybrid coronary artery revascularization is gaining popularity, and multivessel totally endoscopic coronary artery bypass surgery is being performed safely in select highly specialized centers. Intracardiac robot-assisted surgery has also become an attractive alternative to midline sterno-tomy and thoracoscopic approaches for mitral and tricuspid valve disease, atrial septal defect repair, and intracardiac tumors. This review will describe the current state of robotic cardiac surgery and offer some insight into future advancement.
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... It can be conventionally done through a median sternotomy. Minimally-invasive myotomy through mini-thoracotomy and robotic approach have also been reported [4,5]. Alternatively, the tunnelled segment, which usually involves LAD, is bypassed with a conduit. ...
Is coronary artery bypass grafting an acceptable alternative to myotomy for the treatment of myocardial bridging?
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Full-text available
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is CABG an effective alternative for the treatment of myocardial bridging?' Altogether, only six papers were identified using the reported search that represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers are tabulated; these studies reported the outcome of myotomy and coronary artery bypass grafting (CABG) for myocardial bridging. All of these studies were retrospective reports of the results of surgical intervention in patients with myocardial bridging. They showed that the incidence of myocardial bridging was less than 1-1.5% in patients with angina requiring angiography, and 7-9% of these patients had refractory angina despite medical treatment and required surgery. The evidence on the treatment of this congenital condition that mainly affects the middle segment of left anterior descending artery is limited, and there are no treatment guidelines currently available. Stenting of the tunnelled segment has shown high failure rates in approximately half of the cases. Current evidence in the literature suggests that surgery is the mainstay treatment for myocardial bridging. Surgery is performed either as supra-arterial myotomy and de-roofing of the muscle bands on- or off-pump, or as coronary artery bypass grafting of the affected coronary artery beyond the tunnelled segment. Although no mortality was reported with either of these operations, surgical myotomy on deep and extensive myocardial bridges carries the risk of entering the right ventricle, bleeding and aneurysm formation. In addition, in a small percentage of the patients undergoing myotomy, angina recurred. Despite the possibility of competitive flow in the native coronary artery after CABG for myocardial bridging, we did not identify any evidence demonstrating graft occlusion after CABG for myocardial bridging. In conclusion, in extensive and deep myocardial bridgings, CABG may be the treatment of choice that carries low risk, limited complications and excellent symptomatic relief.
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Off-Pump Mini Thoracotomy Versus Sternotomy for Left Anterior Descending Myocardial Bridge Unroofing
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Purpose: To compare the effects of myotomy and bypass surgery for treating myocardial bridges (MBs) over the left anterior descending artery (LAD) in a single-center observation study. Methods: Fifty-four eligible patients (34 males, median age of 60 years old) with symptomatic LAD-MBs who underwent myotomy (31 patients) or bypass surgery (23 patients) were included in this study. The primary endpoints were the occurrence of major adverse cardiac events (MACEs) and angiographic demonstration of adverse angiographic results. Results: No surgical death was observed. During a median follow-up of 26 months, 11 patients developed MACEs (7.4% for myotomy vs. 40.9% for bypass surgery, p = 0.007). Surgical strategy (bypass surgery vs. myotomy) was an independent risk factor for MACEs (odds ratio = 3.681, 95% confidence interval 1.814-8.685, p = 0.011). Myotomy compared with bypass surgery had a significantly lower incidence of adverse angiographic results (3.7% of residual compression vs. 40.9% of LIMA graft failure, p = 0.003). Among ten patients suffering from LAD-MBs with concomitant proximal coronary stenosis who underwent bypass surgery, only one reported transient recurrent exertional chest pain, and all LIMA grafts were patent. Conclusions: Myotomy of symptomatic LAD-MBs may be associated with encouraging midterm results. Bypass surgery may be recommended for treating symptomatic LAD-MBs with concomitant proximal coronary stenosis.
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Surgical outcome and clinical follow-up in patients with symptomatic myocardial bridging
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Myocardial bridging with systolic compression of the left anterior descending coronary artery (LAD) may be associated with myocardial ischaemia. The clinical outcome in patients with surgical treatment for symptomatic myocardial bridging remains undetermined. This study assessed the middle- and long-term results of surgical treatment for symptomatic myocardial bridging. From 1997 to 2006, 37,463 patients received selective coronary angiography in the Fuwai Cardiovascular Hospital, Beijing, China. Of these, 484 patients had angiographic diagnosis of myocardial bridging. Of the 484 patients, 35 underwent surgery for treatment of myocardial bridging with significant systolic arterial compression. Among the surgical treatment patients, 24 presented with other cardiac disorders, and the remaining 11 symptomatic patients with isolated myocardial bridging were included in the follow-up study. The angiographic prevalence of myocardial bridging was 1.3% in this study. The coronary angiographies of the 11 patients revealed myocardial bridging in the middle segment of LAD causing systolic compression > or = 75% (ranging from 75% to 90%). The mean age of patients was 48.4 years. Surgical myotomy was performed in 3 patients and coronary artery bypass grafting (CABG) in 8 patients. Eight patients were operated on with an off-pump approach and 3 with a cardiopulmonary bypass technique after median sternotomy. Conversion to on-pump CABG surgery was necessary in 1 patient because of perforation of the right ventricle. The left internal mammary artery was used in all patients with CABG. The acute clinical success rate was 100% with respect to the absence of myocardial infarction, death or other major in-hospital complications. All of the patients were followed up clinically. The median follow-up was 35.3 months (range: 6 to 120 months). Nine patients were free from symptoms and one of them continued taking beta blockers. The remaining 2 patients with myotomy had atypical chest pain. One received coronary angiography again and no stenosis was found two years after operation; while exercise testing was performed in the other patient and revealed no evidence of myocardial ischaemia. None of the patients sustained a myocardial infarction or other major adverse cardiac events (death or vessel revascularization) during follow-up. Myocardial bridging is a relatively common angiographic finding. Surgical myotomy or CABG should be limited to patients who are refractory to oral medication. Surgical relief of myocardial ischaemia due to systolic compression of intramyocardial coronary arteries can be accomplished with low operative risk and excellent middle- and long-term results.
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