Myocardial Bridge Treatment in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Symptomatic patients (angina CCS Class II–IV, dyspnoea, palpitations, syncope) despite ≥3 months of optimised beta-blocker or non-dihydropyridine CCB therapy

• Objective haemodynamic significance confirmed by FFR ≤ 0.80 or diastolic FFR ≤ 0.76 under adenosine, or iFR ≤ 0.89

• Documented inducible ischaemia on non-invasive imaging: stress cardiac MRI, adenosine stress SPECT/PET-CT showing ≥10% ischaemic myocardium, or stress ECHO with wall-motion abnormalities in the LAD territory

• Bridge length ≥ 20 mm or depth ≥ 5 mm on IVUS/CTCA, predictive of surgical feasibility of unroofing myotomy

• Patients with exercise-induced ventricular tachycardia or documented aborted sudden cardiac death attributable to bridge-related ischaemia

• Young patients (typically <50 years) without significant proximal atherosclerosis, where unroofing is preferred over CABG to preserve native coronary anatomy

• REQUIRED DIAGNOSTIC WORK-UP BEFORE TREATMENT:

• 64-slice or higher Dual-Source CTCA with cardiac gating — to measure bridge length, depth, and angulation, and assess proximal atherosclerosis

• Invasive coronary angiography with pharmacological provocation (ergometrine or acetylcholine) to demonstrate milking effect and exclude significant fixed obstructive disease

• Resting and adenosine-stress FFR / iFR measurement across the bridge segment

• IVUS or Optical Coherence Tomography (OCT) to assess plaque, vessel remodelling, and peri-bridge anatomy

• Adenosine stress cardiac MRI (preferred) OR Rb-82 / N-13 ammonia PET-CT for absolute myocardial blood flow and CFR quantification

• 12-lead ECG, 24–72-hour Holter monitor (to exclude ventricular arrhythmia burden)

• Transthoracic echocardiogram (ECHO) — LV function, regional wall motion, haemodynamic baseline

• Full pre-operative labs: CBC, BMP, coagulation panel, HbA1c, thyroid panel, lipid profile

• CONTRAINDICATIONS / RELATIVE EXCLUSIONS:

• Asymptomatic incidental bridge with normal CFR and negative stress imaging (medical observation only)

• EF < 30% with diffuse LV dysfunction not attributable to bridge ischaemia

• Significant co-morbidities precluding surgery (STS/EuroSCORE II > 10% without multidisciplinary heart team consensus)

• Prior CABG with patent grafts to the LAD territory (re-operation risk outweighs benefit in most cases)

• Coagulopathy or severe thrombocytopaenia uncorrectable pre-operatively

TIER 1 — OPTIMISED PHARMACOLOGICAL MANAGEMENT (First-Line): Beta-1 selective adrenergic blockade is the pharmacological cornerstone. Bisoprolol (2.5–10 mg/day) or metoprolol succinate (25–200 mg/day) reduce resting and peak-exercise heart rate, prolonging diastole and thereby increasing the effective coronary perfusion window. Target resting HR 55–65 bpm. For patients with beta-blocker intolerance or predominantly vasospastic phenotype, non-dihydropyridine CCBs — verapamil (240–480 mg/day SR) or diltiazem (120–360 mg/day SR) — are used. Ivabradine (5–7.5 mg BID) can be added as an adjunct for rate control without negative inotropy, particularly valuable in patients with borderline LV function. Antiplatelet therapy (aspirin 75–100 mg/day) is considered where proximal plaque is detected. Sublingual and long-acting nitrates are specifically contraindicated.

TIER 2 — SURGICAL UNROOFING MYOTOMY (Definitive Surgical Standard): Surgical unroofing (supracoronary myotomy) is the treatment of choice for symptomatic patients refractory to medical therapy, with bridge lengths amenable to dissection. The procedure involves cardiopulmonary bypass (CPB) with cardioplegic arrest; the myocardial fibres overlying the tunnelled coronary segment are sharply incised and excised, releasing the artery to an epicardial position. Operating time for the unroofing component is typically 15–45 minutes once CPB is established. Published case series (Iversen et al., Mohlenkamp, Alegria) report 88–95% freedom from angina at 2-year follow-up, normalisation of FFR post-procedure, and regression of stress-perfusion defects. Contemporary centres are now performing unroofing via minimally invasive right anterolateral mini-thoracotomy or robotic-assisted thoracoscopic approach (da Vinci Surgical System), reducing ICU stay to 24–48 hours and total hospital stay to 5–7 days versus 8–12 days for conventional sternotomy.

TIER 3 — CORONARY ARTERY BYPASS GRAFTING (CABG) — Selected Cases: CABG is preferred when: (a) significant proximal atherosclerosis co-exists and unroofing would not address the obstructive disease, (b) bridge anatomy precludes safe surgical unroofing (deep intramyocardial course, short segment with unfavourable angulation), or (c) prior unroofing has failed. Off-pump CABG (OPCAB) using the left internal mammary artery (LIMA) to the distal LAD — with or without sequential grafts — is favoured to avoid CPB-related morbidity. In patients with isolated bridge and no atherosclerosis, CABG provides competitive myocardial blood flow but creates a 'competitive flow' scenario that may reduce graft patency long-term; this is weighed carefully by the heart team. Total arterial revascularisation strategies using bilateral IMA or radial artery grafts are employed in younger patients.

TIER 4 — PERCUTANEOUS CORONARY INTERVENTION (PCI) — Exceptional and Discouraged: Percutaneous stenting of the bridged segment is generally contraindicated due to high stent fracture rates (reported 20–30% at 2 years), neo-atherosclerosis, ISR, and risk of perforation. Bare metal or drug-eluting stents placed within the bridge are associated with significant long-term failure. PCI is only considered in extreme high-surgical-risk cases as a bridge-to-decision strategy, with full patient counselling regarding inferior durability.

TIER 5 — ELECTROPHYSIOLOGY INTERVENTION (Adjunctive): Patients presenting with ventricular tachycardia or fibrillation attributable to bridge ischaemia may require ICD implantation concurrent with or following surgical unroofing, pending arrhythmia substrate elimination confirmed by post-operative electrophysiological study.

PHASE 1 — REMOTE PRE-CONSULTATION (Weeks 1–2, From Home Country):

• Patient submits medical records, coronary angiogram reports, CTCA images, and stress test results to GAF Healthcare's dedicated cardiology coordination team via secure portal

• GAF assigns a subspecialist interventional cardiologist or cardiothoracic surgeon for a telemedicine second opinion within 48–72 hours

• GAF provides a written treatment plan, itemised cost estimate, and destination recommendation (India or UAE) based on case complexity, urgency, and patient preference

• e-Medical visa application process initiated for India (typically approved in 3–5 business days); UAE visit/medical visa facilitated via sponsor letter

PHASE 2 — ARRIVAL AND DIAGNOSTIC WORK-UP (Days 1–4 In-Country):

• Day 1: Airport pickup by dedicated GAF medical concierge; hotel/hospital accommodation check-in; orientation briefing with assigned patient coordinator

• Days 2–3: Comprehensive cardiac diagnostic protocol — fasting bloodwork, 12-lead ECG, transthoracic ECHO, adenosine-stress cardiac MRI or PET-CT, Holter monitoring

• Day 3–4: Invasive coronary angiography with FFR/iFR assessment and IVUS under conscious sedation (day-case or overnight admission); CTCA review by interventional cardiologist and cardiothoracic surgeon jointly

• Heart Team Conference: Cardiologist, cardiothoracic surgeon, electrophysiologist, and anaesthesiologist meet to confirm treatment plan, obtain informed consent, and schedule procedure

PHASE 3 — PROCEDURE DAY (Day 5–6):

• Medical management patients: Pharmacological optimisation initiated; monitored 24–48 hours; no procedure required

• Surgical unroofing (conventional or robotic): General anaesthesia with TEE monitoring; CPB established (or robotic port placement); unroofing myotomy performed; haemostasis confirmed; repeat intraoperative FFR/IVUS to confirm anatomical success; chest closure; transfer to cardiac ICU

• CABG patients: OPCAB or on-pump CABG with LIMA-to-LAD anastomosis; transit-time flow measurement (TTFM) to verify graft patency before chest closure; ICU transfer

PHASE 4 — ICU AND STEP-DOWN RECOVERY (Days 1–5 Post-Procedure):

• ICU: Typically 24–48 hours (robotic/minimally invasive) to 48–72 hours (sternotomy); haemodynamic monitoring, early extubation protocol, chest drain management

• Days 2–4: Transfer to monitored step-down ward; early ambulation protocol initiated (sitting up Day 1, standing Day 2, corridor walking Day 3); respiratory physiotherapy; wound care

• Day 4–5: Removal of chest drains; repeat ECHO to assess LV function and exclude pericardial effusion; repeat ECG

• Beta-blocker and antiplatelet therapy commenced or continued; statin therapy initiated if atherosclerosis present

PHASE 5 — HOSPITAL DISCHARGE AND IN-COUNTRY RECOVERY (Days 7–14 Post-Procedure):

• Discharge criteria: Afebrile, haemodynamically stable, ambulatory, wound healing, no arrhythmia burden on telemetry

• GAF-arranged recovery accommodation (serviced apartment or hospital-affiliated guest house) for patient and attendant

• Outpatient cardiology review at Day 10–12: wound inspection, Holter monitoring, repeat ECHO, exercise tolerance assessment

• Cardiac rehabilitation sessions (supervised, 3×/week) initiated at Day 10 for surgical patients

• Stress perfusion imaging (nuclear or MRI) recommended at 4–6 weeks post-discharge to confirm resolution of ischaemia

PHASE 6 — FIT-TO-FLY CLEARANCE AND DEPARTURE (Weeks 5–8 Post-Procedure):

• Medical management patients: Fit to fly in 2–3 weeks after pharmacological optimisation and stable Holter

• Post-surgical patients: Conventional sternotomy — fit to fly typically at 6–8 weeks; minimally invasive/robotic — 4–6 weeks

• GAF provides a formal fit-to-fly medical letter, summary discharge report, and digital imaging archive for the patient's home cardiologist

• Remote 3-month and 12-month virtual cardiology follow-up arranged through GAF's telehealth platform