Myocardial bridge - a variant of normal anatomy or pathology? Case report

Myocardial (muscle) bridges are considered a variant of the normal anatomy of the coronary arteries, but there are some reports of their clinical significance: their presence is associated with angina pectoris, myocardial infarction, ventricular tachycardia, and sudden cardiac death. In this study, using a clinical case as an example, the significance of the problem, approaches to assessing perioperative risk and methods for identifying risk factors at the preoperative stage in a patient with abnormal coronary arteries are presented. At stydiyng clinical case according to the results of coronary angiography in the 7th segment of the anterior interventricular artery, a myocardial bridge with stenosis in systole up to 95% was revealed, which, against the background of hemorrhagic shock, could provoke the development of acute coronary syndrome. An analysis of a clinical case, a review of the literature on assessing the risks of patients with myocardial bridges demonstrates an insufficient assessment of this morphological feature for patients with a non-cardiac surgery profile. In the studied case, the patient underwent elective orthopedic surgery and emergency surgery aimed at stopping bleeding. Surgery with concomitant trauma, systemic inflammatory response, anesthesia and analgesia, pain, hypothermia, bleeding, anemia, and nutritional deficiencies is similar to an extreme stress test. The combination of these factors provokes inflammatory, hypercoagulable, stressful and hypoxic conditions, which are associated with a perioperative increase in troponin levels, arterial thrombosis and, as a consequence, a high risk of mortality. The authors suggest that current clinical guidelines for assessing perioperative risks need to be improved. With such a refinement, it is necessary to rely not only on the existing international recommendations, but also on the results of the latest meta-analyzes devoted to the prognostic role of preventive myocardial recanalization before surgery. Thus, in summary, it can be noted that the existing clinical guidelines and risk assessment scales do not contain ready-made solutions for all clinical cases, but can only be the basis for making decisions in specific situations and do not provide sufficient guarantees of the success of surgical interventions.