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Introduction: Wellens’ syndrome represents an important, at times overlooked, spectrum of left anterior descending (LAD) coronary artery occlusion, spontaneous reperfusion, and impending reocclusion. Once considered pathognomonic for a thromboembolic coronary event, an increasing number of clinical scenarios have been demonstrated to result in pseudo-Wellens’ syndrome, each requiring unique forms of assessment and management. Case Report: We describe two clinical presentations in which myocardial bridging (MB) of the LAD led to clinical and electrophysiologic presentations of a pseudo-Wellens’ syndrome. Conclusion: These reports represent a rare cause of pseudo-Wellens’ syndrome attributed to MB of the LAD. Transient ischemia secondary to myocardial compression of the traversing LAD leads to intermittent angina and electrocardiogram changes that are typical in patients presenting with Wellens’ syndrome secondary to an occlusive coronary event. As with other previously reported pathophysiologic mechanisms that have been shown to mimic Wellens’ syndrome, myocardial bridging should be considered in patients presenting with a pseudo-Wellens’ syndrome.

Myocardial bridge (MB) is the most frequent inborn coronary artery variant in which a portion of the myocardium overlies an epicardial coronary artery segment. Although MB has long been considered a benign entity, a growing body of evidence has suggested its association with angina and adverse cardiac events. However, to date, no data on long-term prognosis are available, nor on therapies improving cardiovascular outcomes. We are currently conducting an ambispective, observational, multicentre, study in which we enrol patients with a clinical indication to undergo coronary angiography (CA) and evidence of MB, aiming to describe the incidence of symptoms and cardiovascular events at baseline and at long-term follow-up (FUP). The role of invasive full-physiology assessment in modifying the discharge therapy and eventually the perceived quality of life and the incidence of major cardiovascular events will be analysed. Basal clinical-instrumental data of eligible and consenting patients have been acquired after CA; FUP was performed 6, 12, and 24 months after the angiographic diagnosis of MB. The primary endpoint of the study is the incidence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction, cardiac hospitalization, and target vessel revascularization; the secondary endpoints are the rate of patients with Seattle Angina Questionnaire (SAQ) summary score <70 and the incidence of MACE in patients undergoing invasive intracoronary assessment. Among patients undergone FUP visits, we recorded 31 MACE at 6 months (11.6%), 16 MACE at 12 months (6.5%), and 26 MACE at 24 months (13.5%). The rate of patients with SAQ <70 is 18.8% at 6 months, 20.6% at 12 months, and 21.8% at 24 months. To evaluate the prognostic role of invasive intracoronary assessment, we compared MB patients who underwent only angiographic evaluation (Angio group) to those who underwent acetylcholine (ACH) provocative test with indication to

Introduction When the coronary artery, located subepicardially, submerges into the myocardium and appears again subepicardially after a short intramural course, it represents an embedded coronary artery, while the part of the myocardium above is a myocardial bridge. Objective We investigated the frequency of the embedded left coronary artery (LAD) in the autopsy material considering the descending branch of the LAD to be the most important one in the nourishment of the myocardium and myocardial bridges to be the most frequent in its area, as well as clinically important. Methods A prospective autopsy study of 975 cases was performed, including both, natural (21.33%) and violent (78.67%) deaths. The sample consisted of 74.56% males and 25.44% females. In order to discover myocardyal bridges and their characteristics, the hearts were examined by both transverse cuts and longitudinal openings of the LAD. Results Myocardial bridge was found in 78 cases (8.00%), more commonly in males (9.35%) than females (4.03%). The average length of the myocardial bridge was 21.85±16.10mm and thickness 3.744±1.48 mm. The common localization of the myocardial bridge was the proximal half of the LAD (89.74%). The upper part of the artery, proximal to the bridge, was a common site of atherosclerotic changes. Myocardial bridge was found in 12.50% of natural deaths, but in 13.38% out of all cases of sudden cardiac deaths. Conclusion Therefore, the presence of the myocardial bridge by itself is not predominant, but it is certainly a contributing factor to a sudden cardiac death., Uvod 'Poniruća koronarna arterija' je pojam koji se odnosi na slučaj kada koronarna arterija - inače lokalizovana subepikardno - ponire u miokard i ponovo se pojavljuje subepikardno, posle kratkog puta kroz mišić, pri čemu se mišić iznad nje naziva 'miokardni most'. Cilj rada Istraživali smo učestalost poniruće descendentne grane leve koronarne arterije u autopsijskom materijalu imajući u vidu da je ona najvažnija u ishrani srčanog mišića, da najčešće ponire u srčani mišić i da je vrlo značajna i s kliničkog aspekta. Metode rada Urađena je prospektivna autopsijska studija 975 slučajeva prirodnih (21,33%) i nasilnih smrti (78,67%). Uzorak je obuhvatio 74,56% osoba muškog i 25,44% ženskog pola. Radi otkrivanja miokardnog mosta i analize njegovih osobenosti, nishodna grana leve koronarne arterije otvarana je uzdužnim i poprečnim obdukcionim rezovima. Rezultati Miokardni most je utvrđen u 78 slučajeva (8,00%), češće kod muškaraca (9,35%) nego kod žena (4,03%). Prosečna dužina miokardnog mosta bila je 21,85±16,10 mm, a debljina 3,744±1,48 mm. Najčešća lokalizacija miokardnog mosta bila je u predelu proksimalne polovine descendentne grane leve koronarne arterije (89,74%), a aterosklerotske promene su najčešće ustanovljene ushodno od miokardnog mosta. Miokardni most je postojao u 12,50% slučajeva prirodnih smrti, odnosno u 13,38% slučajeva tzv. naprasnih srčanih smrti. Zaključak Postojanje miokardnog mosta nije predominantni činilac za pojavu naprasne srčane smrti, ali je njegovo postojanje faktor rizika za njen nastanak.

総説, 心筋架橋(myocardial bridge:MB)は,冠状動脈の走行途中の一部を心筋組織が被覆する解剖学的亜型である.MB は左冠状動脈前下行枝(left anterior descending coronary artery:LAD)に多く,その解剖学的特性(厚さ・長さ・開始位置)には個体差がある.心収縮期には,MB 自体の収縮によりLAD が圧迫され,血液の逆流が生じ,LAD 内血流の血行力学的変貌をまねき,同動脈の内膜硬化性病変の発生分布に影響する.すなわち,MB 開始位置より近位のLAD 内膜には粥状動脈硬化症の進展をみるが,MB 被覆部のLAD では逆にその発生・進展が抑制される.さらに,LAD 支配域の心筋梗塞剖検例の解析によると,MB は非梗塞例に比して有意に厚く長い傾向を示し,MB 入口より近位2 cm の位置のLAD 内膜に高度な内膜硬化性病変の集中が生じ,厚く長いMB は心筋梗塞発生の責任病変形成に寄与していることが判明した.本稿ではMB による心筋梗塞発生の機構について概説する.

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