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Minimally Invasive Surgical Unroofing of Left Anterior Descending Myocardial Bridges via Left Anterior Thoracotomy
Hanjay Wang, MD1, Vedant S. Pargaonkar, MD2, Chad J. Abbot, BSc3, Ian S. Rogers, MD, MPH2, Takumi Kimura, MD, PhD2, Kozo Okada, MD, PhD2, Jennifer A. Tremmel, MD, MS2, Robert S. Mitchell, MD1, Ingela Schnittger, MD2, Jack H. Boyd, MD1.
1Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA, 2Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA, 3Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.

Myocardial bridges, in which the left anterior descending artery courses within contractile myocardium, can result in severe angina, acute coronary syndromes, and sudden cardiac death. For patients who have failed medical management, myocardial bridge unroofing via median sternotomy may yield significant symptomatic improvement. Here, we present our technique and early outcomes for myocardial bridge unroofing via a minimally invasive left anterior thoracotomy approach.
Fifteen adult patients with refractory symptoms and intolerable quality of life due to a left anterior descending myocardial bridge underwent minimally invasive surgical unroofing as an isolated procedure. A double lumen endotracheal tube was placed for left lung isolation, and a left anterior thoracotomy was made in the fourth intercostal space over the midclavicular line. The left anterior descending artery was identified where it resumes an epicardial course after exiting the myocardial bridge distally. The observed anatomy of the myocardial bridge relative to diagonal coronary artery branches was correlated to preoperative imaging including computed tomography angiography, stress coronary angiography, and intravascular ultrasonography. A minimally invasive off-pump epicardial tissue stabilizer was introduced through a subxiphoid counter-incision. The epicardium overlying the left anterior descending artery at its distal emergence from the myocardial bridge was divided using a Beaver blade. The full length of the myocardial bridge was then released incrementally in a distal-to-proximal direction using tenotomy scissors. Angina symptoms pre- and post-surgery were assessed using the Seattle Angina Questionnaire.
Minimally invasive myocardial bridge unroofing was performed successfully in all 15 cases without need for cardiopulmonary bypass, conversion to sternotomy, transfusion, or occurrence of any significant complications or death. Seattle Angina Questionnaire scores were obtained for 9 patients at 6.1 months after surgery (range 4.5-10.2), revealing significant improvements compared to preoperative assessment (Figure).
Minimally invasive myocardial bridge unroofing is a safe and effective option for improving physical limitations, angina symptoms, and overall quality of life in carefully selected patients with symptomatic left anterior descending myocardial bridges who have failed medical management.

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Endorsed by:
The Society of Thoracic Surgeons

Co-sponsored by:
Association of Physician Assistants in Cardiovascular Surgery (APACVS) The International Society for Minimally Invasive Cardiothoracic Surgery Japanese Association for Coronary Artery Surgery
Brazilian Society of Cardiovascular Surgery Fu-Wai Hospital of Beijing Indian Association of Cardiovascular-Thoracic Surgeons
Society for Cardiothoracic Surgery in Great Britain & Ireland