ORIGINAL RESEARCH ARTICLE

INTERNATIONAL JOURNAL OF ANATOMY

PHYSIOLOGY AND BIOCHEMISTRY
http://www.eternalpublication.com

IJAPB: Volume: 2; Issue: 3; March 2015

ISSN(Online):2394-3440

A Cadaveric study on Muscle Bridges in human hearts

Published online on 1st March 2015www.eternalpublication.com

DR. CHANDRASEKHAR KT 1
DR. HARSHA BR 2
1
Assistant Professor, Department of Anatomy,
MMC&RI, Mysore, Karnataka.
2
Assistant Professor, Department of Anatomy,
CIMS, Chamarajanagar, Karnataka.
Corresponding Author:
Dr. Chandrasekhar KT.
Assistant Professor
Department of Anatomy
MMC&RI
Mysore-570001(Karnataka,
India)
+91drktcsanat@gmail.com
Received: 6th Feb 2015; Accepted: 18th Feb 2015

How to cite this article: Chandrasekhar KT,

Harsha BR. A cadaveric study on muscle bridges in
human hearts. International Journal of Anatomy
Physiology and Biochemistry 2015; 2(3):1-6.

Introduction:

Abstract:
Background: Muscle bridge/ myocardial bridge are structures consisting
of heart muscle tissue which pass above the coronary arteries and their
branches. The frequency of myocardial bridging varies widely.
Myocardial bridge has been considered a benign condition, but the
various complications have been reported. Thus in view of its
complication, myocardial bridge should be considered an anatomical risk
factor in evaluating coronary artery disease. There is a wide variation in
percent of hearts showing myocardial bridges in every study reported.
All these factors made to take up the present study, and perform detailed
anatomical study of myocardial bridge in human heart.
Materials and Methods: Study was carried out on 50 normal formalin
fixed human heart specimens. Dissection was performed according to
standard techniques. The percentage of hearts showing myocardial
bridges, the distribution of myocardial bridges over the different
branches of the coronary arteries were observed and documented.
Results: Myocardial bridges (MB) were found in 35 (70%) of the hearts
with a total of 46 bridges. Single bridge was found in 25 of these hearts
and multiple bridges were observed in 10 (9 with double bridges and 1
with triple bridges).They were most often found over the anterior
interventricular artery (28 MB), on its middle third (20 MB). Bridges were
also found over the diagonal branch (4 MB) and over the left marginal
branch (3 MB) branch of the left coronary artery. Out of 11MB found over
the right coronary artery, 5 MB was found over the first segment and 6
MB over the posterior interventricular branch of the right coronary
artery.
Conclusion: The present study adds up the information regarding the
prevalence, relationship of myocardial bridges to coronary arteries.. The
possibility of myocardial bridges should be borne in mind in individuals
with ischemia but no evidence of coronary atherosclerosis.
Keywords: anterior interventricular artery, coronary artery, left anterior
descending artery, myocardial bridge

Human heart is one of the vital organs of our body.

The blood supply to the heart is always of interest to
1

IJAPB: Volume: 2; Issue: 3; March 2015

Original Article

every medical person, as in the present clinical

scenario, most of the disease process affects the
arteries directly or indirectly. The first description
of myocardial bridge dates from 1737 Reymann1
who observed that segments of the left coronary
artery can be covered with a thin layer of heart
muscle fiber.
Muscle bridge/ myocardial bridge are structures
consisting of heart muscle tissue which pass above
the coronary arteries and their branches. The
coronary arteries and their major branches travel
along the surface of heart under the epicardium.
However occasionally a portion of these arteries
may be embedded in muscle, finding that has been
variously described as a mural coronary artery,
submerged coronary artery, tunneled artery or more
frequently myocardial bridge.2,3
The epicardial cells undergo epithelial-tomesenchymal transition controlled by factors from
the myocardium. The mesenchymal cells thus
formed migrate through the spaces generated in the
developing myocardium finally forming the
coronary arterial system. This migration of these
mesenchymal cells through the developing
myocardium could explain the embryogenesis of
myocardial bridges over the portions of coronary
arteries.4
Myocardial bridge is a congenital anomaly
characterised by narrowing during systole and some
of epicardial arterial segment running in the
myocardium.5
Myocardial bridge has been considered a benign
condition, but the following complications have
been reported: ischemia and acute coronary
syndrome, coronary spasm, ventricular septal
rupture, arrhythmias (including supraventricular
tachycardia and ventricular tachycardia), exercise
induced atrio-ventricular conduction block,
stunning, transient ventricular dysfunction, early
death after cardiac transplantation and sudden
death.6

ISSN(Online):2394-3440

Bridging of coronary arteries in otherwise

angiographically normal arteries generally is not
hazardous to the patient. However strenuous
physical exertion results in compression of a portion
of a coronary artery by a myocardial bridge.7
The degree of coronary obstruction by a myocardial
bridge depends on factors such as location,
thickness, length of muscle bridge, and degree of
contractility. Thus in view of its above
complication, myocardial bridge should be
considered an anatomical risk factor in evaluating
coronary artery disease. There is a wide variation in
percent of hearts showing myocardial bridges in
every study reported. All these factors made to take
up the present study, and perform detailed
anatomical study of myocardial bridge in human
heart by dissection method.

Materials and Methods:

The study was carried out on 50 formalin fixed
human hearts from patients who had died of nonvascular causes and were autopsied. Specimens
with injury or underwent any surgical procedure on
coronary arteries and with gross abnormality were
rejected. After exploring the pericardial cavity, the
heart was detached from the major venous channels
(superior vena cava and inferior vena cava) and the
aorta was cut 3 centimetres above the level of the
coronary sinus and then the heart was extracted with
intact epicardium and coronary vessels. The
specimens were stored in 10% formalin solution.
The right and left coronary arteries were traced
carefully from its origin to its most distal end by
cleaning the epicardium and fat piecemeal using
blunt and pointed forceps. The left coronary artery
along with its branches was dissected as it passed
between the auricle and pulmonary trunk and was
followed to its most distal end. The right coronary
artery along with its branches were also dissected
and followed to its distal end. The presence,
location and the length of myocardial bridges was
noted with the part of the artery and or its branch it
was crossing. Specimens showing the myocardial
2

IJAPB: Volume: 2; Issue: 3; March 2015

Original Article

ISSN(Online):2394-3440

bridges were photographed from various angles and

were numbered.

Observations and Results:

Out of 50 heart specimens, 35 heart specimens
(70%) showed the presence of myocardial bridges.
In which Twenty five (71.43%) hearts showed
single bridge, nine (25.71%) hearts presented with
double bridge and one heart (2.86) had triple bridge
out of 35 hearts. Thus out of 35 hearts 46
myocardial bridges (MB) were present. Out of total
35 hearts with myocardial bridges, 6 (17.14%)
showed MB on the right coronary artery only, 24
(68.57%) showed MB on the left coronary artery
only and 5 (14.29%) showed MB on both the right
and left coronary artery. Out of 46 total myocardial
bridges, maximum number 20 (43.49%) of MB
were present in middle segment of anterior
interventricular branch of left coronary artery, 7
(15.23%) MB was present on the proximal segment
of anterior interventricular branch of left coronary
artery, 4 (8.69%) MB was present on the left
diagonal and 3 (6.52%) MB was present on the left
marginal branch of left coronary artery. On the first
segment of right coronary artery 5 (10.87%) MB
and on the posterior interventricular branch of right
coronary artery 6 (13.04%) MB was present. Least
number of MB were noted on distal 1/3rd of anterior
interventricular branch of left coronary artery which
was 2.17% (1 out of 46).Out of 28 MB on,
maximum number of MB were present on the
middle 1/3rd i.e. 20 (71.43%), 7 (25%) MB were
present on the proximal 1/3rd and 1 (3.57%) MB
was present on the distal 1/3rd of anterior
interventricular branch of LCA which was
statistically significant (p value < 0.0001).

Figure 1: Single Myocardial bridge (MB) in the

anterior interventricular (AIV) branch of left
coronary artery (LCA).

Figure 2: Showing double MB over AIV branch of

LCA

Figure 3: Showing triple MB, two MB over AIV

branch of LCA.

IJAPB: Volume: 2; Issue: 3; March 2015

Original Article
10

Figure 4: Showing triple MB, one MB over

posterior interventricular (PIV) branch of right
coronary artery (RCA).

Discussion:
Table 1: The Prevalence of Muscular bridges
Sr
No

Study

Sample
Size

Prevalence
of MB (%)

Comment

AUTOPSY
METHOD
1

Geiringer E6

100

23

AIV

Polacek7

70

86

AIV- 60%

Lee and Wu9

108

58

AIV

Ferreira
Jr et al8

AG

90

56

All
coronaries

Baptista
DiDio11

&

82

54

All
coronaries,
35% in AIV

Mavi
al14

ISSN(Online):2394-3440
A

et

7200

0.4

All patients

The prevalence varies substantially among studies

with a much higher rate at autopsy versus
angiography. Variation at autopsy may in part be
attributable to the care taken at preparation and the
selection of hearts. Polacek7 who included
myocardial loops, reports the highest rate with
bridges or loops in 86% of cases. The prevalence of
myocardial bridges in the present study is 70%
which is less than Polacek10 but more than other
studies.
Myocardial bridges were more frequently found on
male hearts in the present study which is even
supported by Ferreira AG Jr8 1991, Kosinski A2
2004, Loukas15 2006.
Observation was made on the number of myocardial
bridges on the hearts in the present study.
Geiringer6 1951 did not observe double and triple
MB, the analyses of majority of investigators
tabulated below and our own observation confirms
that these can potentially occur either over one or
more coronary arteries.
Table 2: Comparison of number of myocardial
bridges in the hearts with other studies
S Studies
r
N
o

No. of
hearts
studie
d

No.
of
heart
s with
MB
(%)

Total
no. of
bridge
s

Hearts with myocardial

bridges (MB)
Single

Double

Triple

Kosinski &
Grzybiak2

300

31

All
coronaries

Present
study
ANGIOGRA
PHIC
METHOD

50

70

All
coronaries

1 Present
study

50

35
(70%
)

46

25
(50%)

9
(18%)

1
(2%)

90

5
(5.5%)

1100

4.5

All patients

35
(38.9
%)

10
(11.1%)

Angelini
al12

50
(55.6
%)

70

2 Ferreira
AG et
al8

3200

0.6

All patients

94
(33.3
%)

114

Harikrishnan
et al13

3 Kosinsk
i A et
al2

300

75
(24.9
%)

18
(5.9%)

1
(0.3%)

et

Original Article

IJAPB: Volume: 2; Issue: 3; March 2015

4 Loukas
M
et
al15

200

69
(34.5
%)

81

59
(29.5
%)

8 (4%)

2 (1%)

All the studies tabulated above showed the single

MB in majority of cases followed by double and
triple MB. But the percentages of MB are high in
the present study when compared with others.
Apart from the studies above, authors like Bapista
and Didio11 found double MB in 6 hearts but related
only to anterior interventricular branch of left
coronary artery. Voelkar et al17 observed 3 MB in
one heart which was over anterior interventricular
artery, left diagonal and left marginal branch of left
coronary artery during coronary angiography. In the
present study we observed double MB in 9 hearts,
out of which 1 heart had MB over same artery (AIV
branch of left coronary artery) and other 8 hearts
had MB over different branches of coronary
arteries. We also observed triple MB in 1 heart over
posterior interventricular branch of right coronary
artery, proximal 1/3rd and distal 1/3rd of AIV branch
of left coronary artery.
In the light of previous studies by Ferreira AG8
1991, Vanildo Junior de Melo Lima18 2002,
Kosinski A2 2004, AyferMavi et al14 2008, MB are
most often associated with the left coronary artery
on AIV, mainly the middle 1/3rd of this. These
results are consistent with our observation. The
searching for the nature of this coexistence should
probably focus on analysis of the processes
connected with the development of the coronary
vessels during foetal life. The formation of
superficial arterial system begins between 5 and 6
weeks after fertilization and before the development
of the myocardium has been completed. It is likely
that the coincidence of these processes is a
prerequisite for a MB arising. The earlier
development of the artery leads to a greater
probability of some fibres of the myocardium
forming a MB over it. Initially arteries occur in
grooves along the places with maximum
concentration of connective tissue. The AIV stands

ISSN(Online):2394-3440

apart as the first and MB are observed most

frequently over this artery.
Vanildo Junior de Melo Lima18 2002 also did not
found MB on distal 1/3rd of AIV but we observed
MB over this in our study.
The current study found that the next most common
sites of myocardial bridges were over the proximal
1/3rd of anterior interventricular artery (15%)
followed by posterior interventricular branch of
right coronary artery (13.04%), Ist segment of right
coronary artery (10.87%), the diagonal branch of
the left coronary artery (8.69%), the left marginal
branch (6.52%). However, whereas Kosinski A et
al2 (2004) reported the AIV as the most common
site for bridges in a study of 300 specimens, he also
reported that the diagonal branch of the left
coronary artery was the second most common site
and the posterior interventricular branch of the right
coronary artery the third most common.
We have showed the distribution of hearts having
MB in both RCA and LCA which was not
commented in the study of these authors.

Conclusion:
Muscle bridges are still an open issue. The
discussion whether it is pathology or a variation of
physiology is still ongoing. It is known that their
existence is congenital. In the present study, we
have tried to find out the prevalence, over coronary
arteries and the relationship of myocardial bridges
to coronary artery dominance in the adult human
hearts. In most of the individuals they do not cause
symptoms but particularly in those with long and
deep myocardial bridges, the anatomical relation of
the myocardial fibres can distort the artery that can
be identified angiographically. The possibility of
myocardial bridges should be borne in mind in
individuals with ischaemia but no evidence of
coronary atherosclerosis.

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IJAPB: Volume: 2; Issue: 3; March 2015

Original Article

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