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Extensive unroofing of myocardial bridge: A case report and literature review.

ABSTRACT: Background:Myocardial bridge is defined as a segment of a coronary artery that takes an intramyocardial course. The presence of myocardial bridge has been observed in as many as 40%-80% of cases on autopsy, angiographically from 0.5% to 16.0%, and often asymptomatic. However, it has been associated with angina, coronary spasm, myocardial infarction, arrhythmias, syncope, sudden cardiac arrest, and death. Conflicting opinions exist on the timing of surgical intervention for myocardial bridge. Methods:We present an unusual case of a young female, with prior aortic surgery, who had refractory chest pain despite optimal medical therapy. Stress testing revealed anterior ischemia. Cardiac catherization showed myocardial bridge of the left anterior descending artery with significant compromise of blood flow (fractional flow reserve = 0.75 with adenosine). We proceeded with surgery. Intraoperatively, we found an unusually long (10-cm) intramyocardial segment of the left anterior descending artery which was managed by surgically unroofing. Our patient felt better post procedure. Repeat cardiac catheterization showed no further narrowing of the left anterior descending artery with a fractional flow reserve of 0.87 in its distal segment. Results/discussion:Myocardial bridge is present mostly in female patients (74.5%), with median age at 56.2 years and mostly involving the left anterior descending artery (77.2%). The average length of myocardial bridge is 21.85 ± 16.10 mm (range: 5-70 mm). Our case is unique as the involved myocardial bridge was 10 cm in length, the longest ever reported. Multiple imaging modality revealed significant coronary insufficiency, with a subsequent clinical and angiographic improvement upon unroofing of the culprit coronary vessel. Conclusion:Management decision on myocardial bridge remains controversial. This is a case of the longest symptomatic myocardial bridge, with a subsequent improvement post unroofing.

SUBMITTER: Mok S

PROVIDER: S-EPMC6349980 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Carcinomas composed predominantly or purely of malignant Paneth cells were rarely reported in gastrointestinal system. They have not been reported at gastroesophageal junction nor has the association with Barrett esophagus been explored. None of the previous studies has mentioned any peculiar histologic features other than typical adenocarcinoma containing neoplastic Paneth cells. The Her2/neu status and the expression of beta-catenin in Paneth cell carcinoma at gastroesophageal junction have not been studied although the activated beta-catenin pathway was recently demonstrated in neoplastic Paneth cells in colon. CASE PRESENTATION:A 70-year-old Caucasian male who initially presented in the emergency room due to upper gastrointestinal bleeding was subsequently found to have a submucosal nodule at gastroesophageal junction. A diagnosis of adenocarcinoma was rendered on biopsy. Histologic examination of the subsequent endoscopic mucosal resection revealed an adenocarcinoma with various levels of differentiation which are zonally distributed. The deeper portion of the tumor showed well-differentiated bland-appearing glands with extensive cystic and secretory changes. The cytoplasm of tumor cells and secretion demonstrated marked reactivity with lysozyme antibody on immunohistochemical stain. The tumor had a peculiar Her2/neu staining pattern with cytoplasmic and nuclear stain in poorly-differentiated area and no stain in well-differentiated area. Only membranous stain was detected with beta-catenin antibody. CONCLUSION:We reported the first case of Paneth cell carcinoma at gastroesophageal junction. The tumor had well-differentiated area which, when sampled in small biopsies, can mimic benign lesions including those related to proton pump inhibitor therapy. Lysozyme immunohistochemical stain may be helpful when difficulty in diagnosis arises. Her-2/neu was negative but showed a distinct staining pattern. In contrast to neoplastic Paneth cells in colon, beta-catenin pathway did not seem to be activated. More studies are needed for the etiology, pathogenesis, clinical course, prognosis and treatment of Paneth cell carcinoma.

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Extensive unroofing of myocardial bridge: A case report and literature review.

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