A myocardial bridge refers to the partial or complete encasement of coronary arteries by the myocardium.¹ In contrast, the myocardial venous bridge is less well-known and has only been identified in cadaver studies.² Its clinical relevance remains unclear. Watanabe et al.² described two forms of myocardial bridge: one involving the artery and another involving both the artery and the vein, with both structures enveloped by myocardial tissue in the latter type. Coronary artery disease (CAD) continues to be the leading cause of death globally. However, coronary venous disorders have received significantly less attention in research compared to CAD. Coronary veins-particularly the coronary sinus-are frequently utilized for guiding ablation procedures.³ These veins have been the focus of anatomical and imaging studies, with several anomalies in the coronary venous system reported.^4-6 A better understanding of the microvascular and coronary venous physiology may help clarify some unresolved aspects of cardiology. For instance, the pathophysiology of Takotsubo syndrome remains not fully understood.⁷ Advances in imaging technology, which have enhanced the study of coronary arteries, could similarly be applied to investigating diseases of the coronary venous system.⁸

The three myocardial venous bridge images discussed in this article should be categorized as anomalies of the coronary venous system. Since coronary angiography is performed more frequently than venography, and venographic imaging typically lacks comprehensive multi-projection views, myocardial venous bridges have likely gone unrecognized. Even if observed, they may not have been reported in scientific literature. This may be because during coronary angiography, the focus is usually on detecting CAD, while during venography, the aim is usually often to identify a suitable coronary sinus branch for lead placement in cardiac resynchronization therapy. To our knowledge, this article presents the first clear conventional angiography and venography images of myocardial venous bridges in the literature (Figure 1). Informed written and verbal consent was obtained from the patients.

Treatment strategies for myocardial bridges are not yet well-defined enough to be included in clinical guidelines. Stent implantation raises concerns due to the increased risk of stent fracture, vessel perforation, and thrombosis.⁹ Since stents are placed within arteries, they are not effective for treating myocardial venous bridges. In surgical management, saphenous vein grafts are preferred for bypass procedures because the left internal mammary artery may compete with the left anterior descending artery and become occluded.⁹ Myotomy has shown more favorable midterm outcomes and angiographic results compared to bypass surgery.¹⁰ If future studies confirm that myocardial venous bridges are linked to negative cardiac outcomes, myotomy may become the preferred treatment option for bridges involving both the coronary artery and vein.

Informed Consent: Informed written and verbal consent was obtained from the patients.

Authorship Contributions: Concept- E.A.; Design- E.A.; Supervision- G.T., U.K., B.K.; Data Collection or Processing- E.A., G.T., U.K., B.K.; Analysis or Interpretation- E.A., G.T., U.K., B.K.; Literature Search- G.T., U.K., B.K.; Writing- E.A.; Critical Review- B.K.

Conflict of Interest: No conflict of interest was declared by the authors.

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