ORIGINAL ARTICLE ACTA RADIOLOGICA

Prevalence of Coronary Artery Intramyocardial Course in a Large

Population of Clinical Patients Detected by Multislice Computed
Tomography Coronary Angiography
R. DE ROSA, M. SACCO, C. TEDESCHI, R. PEPE, P. CAPOGROSSO, E. MONTEMARANO, A. ROTONDO,
G. RUNZA, M. MIDIRI & F. CADEMARTIRI
UO di Radiologia, Ospedale San Gennaro, Napoli, Italy; UO di Cardiologia, Ospedale San Gennaro, Napoli, Italy;
Seconda Universita’ Degli Studi Di Napoli, Facolta’ Di Medicina E Chirurgia Dipartimento Universitatrio di
Internistica Clinica E Sperimentale ‘‘F. Magrassi
A. Lanzara’’ Sezione Scientifica Di Diagnostica Per Immagini,
Napoli, Italy; Dipartimento di Radiologia, DI.BI.ME.L, Università di Palermo, Palermo, Italy; Dipartimento di
Radiologia e Cardiologia, Azienda Ospedaliero-Universitaria, Parma, Italy

De Rosa R, Sacco M, Tedeschi C, Pepe R, Caporosso P, Montemarano E, Rotondo A,

Runza G, Midiri M, Cademartiri F. Prevalence of coronary artery intramyocardial
course in a large population of clinical patients detected by multislice computed
tomography coronary angiography. Acta Radiol 2008;49:895
901.
Background: Intramyocardial course, an inborn coronary anomaly, is defined as a
segment of a major epicardial coronary artery that runs intramurally through the
myocardium; in particular, we distinguish myocardial bridging, in which the vessel
returns to an epicardial position after the muscle bridge, and intramyocardial course,
which is described as a vessel running and ending in the myocardium.
Purpose: To evaluate the prevalence of myocardial bridging and intramyocardial course
of coronary arteries as defined by multidetector computed tomography (MDCT)
angiography.
Material and Methods: The study population consisted of 242 consecutive patients (211
men, 31 women; mean age 5996 years) with atypical chest pain admitted to our hospital
between December 2004 and September 2006. All MDCT examinations were performed
using a 16-detector-row scanner (Aquilion 16 CFX; Toshiba Medical System, Tokyo,
Japan). Patients with heart rate above 65 bpm received 50 mg atenolol orally for 3 days
prior to the MDCT scan, or they increased their usual therapy with beta-blockers, in
order to obtain a prescan heart rate B60 bpm. Curved multiplanar and 3D volume
reconstructions were performed to explore coronary anatomy.
Results: In 235 patients, the CT scan was successful and images were appropriate for
evaluation. The prevalence of myocardial bridging and intramyocardial course of
coronary arteries was 18.7% (47 cases) in our patient population. In 30 segments
(63.8%), the vessels ran and ended in the myocardium. In the remaining 17 segments
(36.2%), the vessels returned to an epicardial position after the muscle bridge. We found
no difference in the prevalence of this inborn coronary anomaly when comparing
different clinical characteristics of the study population (sex, age, body-mass index
[BMI], etc.). The mean length of the subepicardial artery was 7 mm (range 5
12 mm),
and the mean depth in the diastolic phase was 1.9 mm (range 1.2
2.3 mm). There was no
significant difference of diameter in these segments between the different R
R phases
examined.
Conclusion: Our study is in agreement with major angiographic literature reporting a
prevalence of myocardial bridging and intramyocardial course between 0.5% and 33%.
MDCT technology represents a useful, noninvasive imaging method to assess and
evaluate the location, depth, and length of this anatomical variation.
Key words: Anatomy; coronary artery disease; CT; intramyocardial course; X-ray
Roberto De Rosa, Via Colli Aminei 279, 80131
Napoli, Italy (tel./fax. 39 081
19577286, e-mail. robertoderosa@libero.it)
Accepted for publication May 2, 2008

DOI 10.1080/02841850802199825 # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)

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896 R. De Rosa et al.
Intramyocardial course, an inborn coronary anom-
aly, is defined as a segment of a major epicardial
coronary artery that runs intramurally through the
myocardium; the intramyocardial coronary arterial
segment is termed a tunneled segment (1). In
particular, we distinguish myocardial bridging, in
which the vessel returns to an epicardial position
after the muscle bridge, and intramyocardial course,
which is described as a vessel running and ending in
the myocardium.
Major discrepancies exist between pathological
series, in which the incidence of intramyocardial
course has varied from 5% to 86% (2
5), and
angiographic series, in which it is reported as being
between 0.5% and 33% (6
9). Although conven-
tional angiography is the gold standard, other
imaging techniques have been used, such as intra-
vascular sonography and multidetector computed
tomography (MDCT) (10
12). Recent advances in
CT techniques, such as MDCT scanners, allow
visualization of the coronary arteries (13).
The aim of this study was to evaluate the
prevalence of myocardial bridging in 242 consecu-
tive patients who underwent MDCT coronary
angiography at our institution.
Material and Methods
The study population consisted of 242 patients (211
men, 31 women; mean age 5996 years) with
atypical chest pain admitted between December
2004 and September 2006. Clinical characteristics
of the study population are shown in Table 1.
All patients had atypical chest pain. No patient
had severe arterial hypertension, anemia, valvular
lesions, or ventriculographic signs of cardiomyo-
pathy; mild hypertension (i.e., diastolic blood
pressure of 95
100 mmHg) was present in 189
cases. Electrocardiogram (ECG) showed left bundle
Table 1. Clinical characteristics of study population
Patients scheduled, n 242
Patients examined, n 235
Patients excluded, n 7 (3%)
Age, years 5996
Men/women 211/31
Body-mass index (BMI), kg/m2 2693
Hypertension, n 189/242
Hypercholesterolemia, n 165/242
Smoking (current), n 171/242
Diabetes, n 22/242
Beta-blocker, n 143/242
Values are mean9SD.
Acta Radiol 2008 (8)
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branch block (LBBB) in 12 patients. No alteration
of troponin was found in any patient.
All MDCT examinations were performed with a
16-detector-row scanner (Aquilion 16 CFX;
Toshiba Medical System, Tokyo, Japan). Patients
with heart rate above 65 bpm received 50 mg
atenolol orally for 3 days before scanning, or they
increased their usual therapy with beta-blockers, in
order to obtain a prescan heart rate B60 bpm.
Arterial enhancement was obtained by intrave-
nous administration in an antecubital vein of 130

140 ml of nonionic iodinated contrast material
(iomeprol 400 mg I/ml, Iomeron 400; Bracco,
Milan, Italy) at an injection rate of 5 ml/s followed
by 40 ml of saline solution at the same rate. The
contrast material was injected with a dual-syringe
automatic injector (Stellant; MedRad, Pittsburgh,
Pa., USA).
Synchronization of the scan with the arterial
passage of the contrast material was performed
with the bolus-tracking technique in real time
(Sure Start). The region of interest was placed in
the ascending aorta with a scan-trigger threshold
of 150 HU. Transverse images were reconstructed
retrospectively with a soft-tissue algorithm from the
raw MDCT data. The reconstruction was gated at
0
90% of the R
R interval of each cardiac cycle.
Effective section thickness and reconstruction in-
crement were 0.5 and 0.3 mm, respectively.
MDCT data were analyzed in consensus by two
readers who were both blinded to the patients’
clinical history. First, the reconstruction interval
with the smallest degree of motion artifacts was
identified for each patient. This best data set of axial
images was chosen to generate curved multiplanar
and 3D color reconstructions. Evaluation of the
coronary arteries was then performed according to
the classification of the American Heart Association
(14). Coronary artery segments with a luminal
diameter of less than 1.5 mm at their origin were
excluded from the analysis.
The diagnosis of intramyocardial course was
established on the basis of the cross-sectional,
thin-slab maximum intensity projection (MIP) and
(97%) multiplanar reformatting (MPR) images and the
axial source images. Multiplanar and curved planar
reformations were used for depiction of intramyo-
cardial course in at least two planes*one parallel
(78%) and one perpendicular to the course of the vessel.
(68%) Intramyocardial course was defined as when part of
(71%) a coronary artery was completely surrounded by
(9%)
(59%)
myocardium. In particular, we distinguished myo-
cardial bridging, in which the vessel returns to an
epicardial position after the muscle bridge, and
 Prevalence of Intramyocardial Course Detected by MDCT Angiography 897

intramyocardial course, which is described as a

vessel running and ending in the myocardium.
The diameter of each tunneled segment was
obtained in the curved multiplanar reconstruction
in two different R
R phases: in the end-diastolic
phase and in a phase close to the end systole with
the smallest degree of motion artifacts. The degree
of systolic compression was given as a percentage
and calculated from the mean of four measurements
in two different phases.

Results

All coronary MDCT examinations were performed

in 235 patients without complications. Image qual-
ity was good, and all involved segments were
considered to be assessable.
Scanning lasted 19
29 s for each patient. Patient
heart rates ranged from 51 to 65 bpm, with a mean
of 6099 bpm.
Tunneled segments were detected in 44 (17%) of
the 235 subjects, in total 47 tunneled segments. In 30
segments (63.8%), the vessels ran and ended in the
myocardium. In the remaining 17 segments
(36.2%), the vessel returned to an epicardial posi-
tion after the muscle bridge. We found no difference
in the prevalence of this inborn coronary anomaly
when comparing different clinical characteristics of
the study population (sex, age, body-mass index
[BMI], etc.).
Nine cases of myocardial bridging and one case
of intramyocardial course (21.3%) were located at
the distal third of the left anterior descending artery
(LAD) (Figs. 1 and 2). Seven cases of myocardial
Fig. 2. In the same patient as Fig. 1, volume-rendering 3D image
shows myocardial bridging at the middle third of the left anterior
descending artery (LAD). LM: left main artery; MB: myocardial
bridging; LV: left ventricle.
bridging and 10 cases of intramyocardial course
(36.2%) were located at the diagonal branches. One
case of myocardial bridging and 10 cases of
intramyocardial course (23.4%) were located at
the distal third of the marginal branches and nine
cases of intramyocardial course (19.1%) at the left
intermediate artery (Figs. 3 and 4). The mean length
of the tunneled artery was 7.492.7 mm (range 5
12
mm). The mean depth of the tunneled segment
artery in the diastolic phase was 1.990.5 mm (range
1.2
2.3 mm). The mean systolic compression of the
tunneled segment, as assessed with MDCT, was
11.499.6%. In six cases (7.3%), atherosclerotic

Fig. 1. Curved multiplanar reconstruction image shows intramyo-

cardial course and shifting into myocardium of the middle left Fig. 3. Curved multiplanar reconstruction image shows intramyo-
anterior descending artery (LAD). MB: myocardial bridging; LV: cardial course and shifting into myocardium of the left intermediate
left ventricle. artery (INT). MB: myocardial bridging; LV: left ventricle.

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898 R. De Rosa et al.

Fig. 4. Volume-rendering 3D (A), axial (B), and coronal (C) images show intramyocardial course of the distal third of the marginal branch.
AO: aorta; LM: left main artery; LA: left atrium; LV: left ventricle; MB: myocardial bridging.

lesions were found in the coronary arteries proximal

to the bridge (five LAD, one diagonal branch) with
a stenosis B50% of the lumen. In three cases we
found calcified plaques, in two cases non-calcified
plaques and in one case mixed plaque (Fig. 5).

Discussion

According to our study, the most common coronary

arteries involved in myocardial bridging are at the
diagonal branches (23.4%), the LAD at the midpor-
tion (21.3%), and the marginal branches (19.1%).
Intramyocardial course and myocardial bridging
may be characterized by systolic compression of the
tunneled segment. This anomaly remains clinically
silent in most cases. It was recognized at autopsy by
REYMAN in 1737 (15) and first described angiogra- Fig. 5. Curved multiplanar reconstruction image shows intramyo-
cardial course of the middle segment of the left anterior descending
phically by PORSTMANN and IWIG in 1960 (16). artery (LAD) and the presence of a mixed plaque in the proximal
Although this anomaly is present at birth, only a tract. LM: left main artery; MB: myocardial bridging.

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 Prevalence of Intramyocardial Course Detected by MDCT Angiography
few patients present symptoms that do not usually
develop before the third decade; the explanation for
this is not clear, but prognosis of this anomaly is
excellent, with a reported 5-year survival rate
greater than 95% (7). Nevertheless, myocardial
bridging in particular is thought to be the first
responsible cause in some patients with myocardial
infarction that have no evidence of coronary
atherosclerosis on angiography or at autopsy (17).
Normally, only 15% of coronary blood flow
occurs during systole, and the compression of
intramyocardial segments is a systolic event. Its
clinical significance and relevance have been ques-
tioned. Ischemia in these patients could probably be
attributed to one or a combination of the following
factors: increased heart rate compromising the
diastolic filling of coronary arteries, exercise indu-
cing spasm of the coronary arteries, systolic kinking
of the blood vessel that may cause trauma to the
intimal layer and damage the endothelium with
platelet activation and thrombus formation (18).
The likelihood of ischemia increases with the
intramyocardial depth and length of the segment,
and sudden death has been reported in association
with deep segments (19, 20).
The current imaging standard of reference for the
diagnosis of myocardial bridging is coronary cathe-
ter angiography, which demonstrates the classic
‘‘milking effect’’ and a ‘‘step down
step up’’ phe-
nomenon induced by systolic compression of the
tunneled segment (11), but cannot demonstrate
muscle tissue and thereby myocardial bridging.
There is a discrepancy between the extremely low
reported prevalence according to catheter angiogra-
phy and the relatively high prevalence reported at
autopsy (2
9) because often there is no clear, exact
definition of intramyocardial course and myocar-
dial bridging. This might be part of the explanation
for the highly variable incidence rates in different
papers based on different techniques.
Regarding the occurrence of atherosclerotic pla-
ques in the tunneled coronary segment, GEIRINGER
(21) and other investigators (22
27) have reported
that tunneled segments are rarely affected by
atherosclerosis, unlike epicardial segments, in which
atherosclerotic plaques are commonly found. A
study by ISHIKAWA et al. (17) found the segments
proximal to the bridge significantly narrowed,
whereas the tunneled segment itself was free of
atherosclerotic lesions. This phenomenon has been
confirmed by our study, in which six atherosclerotic
lesions were found mainly in the coronary arteries
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899
proximal to the bridge, whereas the tunneled
segment was always spared.
Coronary MDCT offers several potential advan-
tages. It is a noninvasive imaging modality that
shows the coronary artery lumen, wall, and sur-
rounding myocardium, and data regarding the
length, depth, precise location, and presence or
absence of atherosclerosis are easily obtained. This
information is crucial in planning possible bypass
interventions in patients with coronary stenosis/
occlusions, which can be accomplished with a single
breath-hold, short scan. MDCT, on the other hand,
has greater difficulty in demonstrating lumen varia-
tions in the systolic phase (0
30% of the R
R
interval), because these phases have more move-
ment artifacts. Risks include intravenous contrast
administration and radiation exposure, which is a
limitation of the technique (11, 19, 28).
In our study, we were easily able to recognize the
length and depth of myocardial bridging and
intramyocardial course on multiplanar reconstruc-
tion images, even when only a few muscle fibers
caused this anomaly. In the literature, myocardial
bridging is mostly confined to the LAD (29). In our
study, we also assessed intramyocardial course
located at the distal third of the LAD, in D1, in
marginal branches, and in the intermediate branch
of the left coronary artery. We found no significant
diameter variation of the coronary arteries between
different phases, probably because all segments
were superficial and of small caliber. Even if the
significance of lumen variations demonstrated by
angiography has more clinical significance for the
presence of myocardial bridges, MDCT can better
demonstrate the muscle bundles tunneling the
artery. MDCT can therefore provide complemen-
tary information to establish correct therapy, parti-
cularly in surgical approaches such as minimally
invasive coronary artery bypass grafting (CABG)
and surgical myotomy (30, 31).
Our study had limitations. First, our measure-
ments of systolic compression with CT may be
inaccurate because we chose a variable systolic
phase (0
30%) in different patients with the smal-
lest degree of motion artifacts that did not corre-
spond in all cases to the real systolic phase. Our
measurements should therefore be considered an
approximation of the real systolic compression of
the tunneled segments. Second, our study did not
completely investigate the relationship between
myocardial bridging and clinical symptoms, which
limits the clinical relevance of the results.
Acta Radiol 2008 (8)
900 R. De Rosa et al.
In conclusion, because of advances in CT tech-
nology, radiologists now have a noninvasive
method to evaluate the location, depth, and length
of a myocardial bridge and any concomitant
atherosclerotic changes in an in-vivo setting; these
alterations are not rare and can cause important
complications (19). In routine practice, we also
recommend including ECG-gated reconstructions
during different phases. A careful comparison of
different R
R phases will allow the assessment of
intermittent lumen narrowing (28).
Acknowledgements
We are grateful to Serena Tedeschi for helping us
with the linguistic editing of the manuscript.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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