title: Tunneled left anterior descending artery in a child with hypertrophic cardiomyopathy.
abstract: BACKGROUND
  A 10-year-old boy presented with a history of severe angina on exertion. A two-dimensional echocardiogram showed mild asymmetric left ventricular (LV) hypertrophy localized to the interventricular septum, consistent with nonobstructive hypertrophic cardiomyopathy. A maximal treadmill exercise test was terminated early owing to marked downsloping of the ST-T segment on all precordial leads, associated with mild chest discomfort. Cardiac MRI and coronary angiography showed that the left anterior descending (LAD) artery was 'tunneled' from its origin to the junction of the middle and lower segments, causing systolic obliteration. PET showed diffusely blunted myocardial blood flow after dipyridamole infusion. A beating-heart technique was used to perform surgical mobilization of the superficial and lateral surfaces of the LAD artery. The patient was free from angina at 6 months after surgery. A repeat exercise test showed considerable improvement in exercise tolerance, which was associated with a marked decrease in ST-T changes on exertion.
  
  
  METHODS
  Physical examination, laboratory tests, 12-lead electrocardiography, two-dimensional echocardiography, exercise testing, cardiac MRI, coronary angiography, PET, Holter electrocardiographic monitoring.
  
  
  METHODS
  Angina caused by extensive myocardial tunneling of the LAD artery in nonobstructive hypertrophic cardiomyopathy.
  
  
  RESULTS
  Bisoprolol therapy and surgical mobilization of the tunneled LAD artery.
authors.affiliation: Referral Center for Cardiomyopathies, Cardiology Department, Careggi University Hospital, Florence, Italy. olivottoi@aou-careggi.toscana.it
authors.forename: Iacopo
authors.initials: I
authors.lastname: Olivotto
authors.forename: Franco
authors.initials: F
authors.lastname: Cecchi
authors.forename: Roberta
authors.initials: R
authors.lastname: Bini
authors.forename: Silvia
authors.initials: S
authors.lastname: Favilli
authors.forename: Bruno
authors.initials: B
authors.lastname: Murzi
authors.forename: Ismail
authors.initials: I
authors.lastname: El-Hamamsy
authors.forename: Magdi H
authors.initials: MH
authors.lastname: Yacoub
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000787:Angina Pectoris / Q000188:drug therapy / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D017298:Bisoprolol / Q000627:therapeutic use; D006348:Cardiac Surgical Procedures; D002312:Cardiomyopathy, Hypertrophic / Q000150:complications* / Q000188:drug therapy / Q000473:pathology; D002648:Child; D017023:Coronary Angiography; D004562:Electrocardiography; D005080:Exercise Test; D017079:Exercise Tolerance; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D054084:Myocardial Bridging / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D049268:Positron-Emission Tomography; D016896:Treatment Outcome
chemical_list: D000319:Adrenergic beta-Antagonists; D017298:Bisoprolol