Can a minimally invasive surgery be performed for unroofing a Left Anterior Descending (LAD) myocardial bridge in a patient with an Implantable Cardioverter-Defibrillator (ICD)?

Minimally Invasive Surgery for LAD Myocardial Bridge Unroofing in Patients with ICDs

Minimally invasive surgery can be safely performed for unroofing a Left Anterior Descending (LAD) myocardial bridge in patients with an Implantable Cardioverter-Defibrillator (ICD). This approach is reasonable as an alternative to traditional sternotomy, particularly in carefully selected patients.

Evidence for Minimally Invasive Approach

Recent evidence strongly supports minimally invasive approaches for myocardial bridge unroofing:

• Off-pump minithoracotomy has been demonstrated as a safe and effective approach for LAD myocardial bridge unroofing with shorter hospital stays compared to sternotomy (3.0 vs 4.0 days) 1
• Minimally invasive coronary artery bypass techniques are appropriate alternatives for managing symptomatic myocardial bridging 2
• Robotic totally endoscopic off-pump unroofing of LAD myocardial bridges has been successfully performed with complete symptom relief 3

ICD Considerations

The presence of an ICD does not contraindicate minimally invasive cardiac surgery:

• Guidelines do not specifically prohibit minimally invasive cardiac procedures in patients with ICDs 4
• The ACC/AHA guidelines recognize that "minimally invasive" surgical approaches can avoid both the risk of cardiopulmonary bypass and repeat median sternotomy 4
• Hybrid procedures combining minimally invasive approaches with other interventions are considered reasonable in selected patients 4

Surgical Planning and Precautions

When planning minimally invasive myocardial bridge unroofing in patients with ICDs:

1. Pre-operative ICD management:

   • The device should be interrogated before surgery
   • Tachyarrhythmia therapies should be temporarily deactivated during surgery to prevent inappropriate shocks
   • External defibrillation capability must be immediately available

2. Surgical approach:

   • Off-pump techniques are preferred to minimize electromagnetic interference with the ICD 1
   • Minithoracotomy or robotic approaches provide excellent access to the LAD 1, 3
   • Careful surgical planning is needed to avoid ICD lead displacement or damage

3. Post-operative care:

   • ICD should be interrogated and reprogrammed after surgery
   • Monitor for potential lead dislodgement or malfunction

Clinical Outcomes

Surgical unroofing of myocardial bridges has demonstrated excellent outcomes:

• Significant improvement in angina symptoms across all dimensions of the Seattle Angina Questionnaire 5
• No major complications or deaths reported in multiple series 1, 5
• Dramatic improvements in physical limitation, angina stability, frequency, treatment satisfaction, and quality of life 5

Potential Pitfalls and Caveats

1. Patient selection is critical:

   • Ensure the myocardial bridge is hemodynamically significant and symptomatic despite maximal medical therapy
   • Approximately 63% of patients report complete resolution of chest pain after unroofing, but some may have persistent non-ischemic chest pain 6

2. Technical considerations:

   • Electrocautery during surgery may interfere with ICD function if not properly managed
   • The surgical field may be more restricted in minimally invasive approaches
   • Conversion to sternotomy should remain an option if technical difficulties arise

3. Post-procedure management:

   • Some patients may require continued medical therapy despite successful unroofing 6
   • Regular follow-up with both cardiac surgery and electrophysiology is essential

In conclusion, minimally invasive surgical approaches for LAD myocardial bridge unroofing can be safely and effectively performed in patients with ICDs when appropriate precautions are taken. This approach offers the benefits of less invasive surgery while effectively treating the myocardial bridge.