Abstract
Background:
Drug-coated balloons (DCB) represent a novel therapeutic approach for treating native coronary artery disease. However, the clinical outcomes of DCB in patients with left anterior descending (LAD) artery stenosis proximal to a myocardial bridge (MB) remain unclear. This study aims to investigate the effects of DCB in patients with LAD artery stenosis proximal to MB.
Method:
This retrospective cohort study included consecutive patients with LAD artery stenosis proximal to MB who underwent DCB or drug-eluting stent (DES) procedures between January 2020 and July 2021. The DCB group comprised 30 patients treated with DCB alone, while the DES group included 105 patients treated with DES alone. Major adverse cardiac events (MACEs) during a median follow-up of 507 days (IQR 391.5–622.0 days) were defined as a composite of unstable angina requiring hospitalization, acute myocardial infarction, cardiac death, and target lesion revascularization (TLR).
Results:
Both groups exhibited generally comparable baseline clinical and lesion characteristics, except for age and MB systolic compression. Over a median follow-up of 507 days (IQR 391.5–622.0 days), Kaplan–Meier survival analysis revealed no statistically significant difference in MACE-free survival rates between the two groups (73.96%, 95% CI 55.8–98.0 vs. 82.49%, 95% CI 73.9–90.8; Log-rank P = 0.678). Cox proportional regression analysis showed no statistically significant difference in MACEs between DCB and DES patients (HR = 1.58, 95% CI = 0.56–4.45, P = 0.383).
Conclusion:
In this exploratory retrospective study, we did not detect a statistically significant advantage of DCB over DES in treating LAD stenosis proximal to MB. Given the limited sample size, these findings should be considered preliminary and do not support DCB as a reasonable alternative to DES. Larger prospective studies are warranted to validate the potential role of DCB in this specific anatomical setting.
1 Introduction
Myocardial bridge (MB) is a congenital coronary artery anomaly characterized by a segment of an epicardial coronary artery passing through the myocardial tissue (). The left anterior descending artery (LAD) has the highest incidence of MB, with most cases having a positive prognosis. However, some patients experience adverse cardiovascular events, such as acute coronary syndrome (, ). Severe pathological stenosis can develop in the proximal segment of the MB due to blood flow shear forces, necessitating further interventional therapy (, ). The primary treatment for stenosis proximal to a MB is stent implantation; however, complications such as in-stent restenosis are challenging to avoid due to the proximity of the lesion to the MB (, ).
Drug-coated balloons (DCB) have gained popularity in clinical practice. Unlike drug-eluting stents (DES), DCBs leave no polymer matrix or metal mesh behind, reducing the risk of intimal inflammation and thrombosis while avoiding metal implants in the body. This has a positive clinical impact on treating lesions, including bifurcated coronary lesions and small coronary vessels (, ). However, the clinical outcomes of DCB for stenosis proximal to a MB remain unclear. Given the limitations of DES in this challenging anatomical subset, this study aimed to compare clinical outcomes between DCB and DES in patients with LAD stenosis proximal to an MB.
2 Material and methods
2.1 Study population
This study included patients from Beijing Chao-Yang Hospital with LAD artery stenosis proximal to a MB from January 2020 to July 2021. Diagnosis of MB was based on a segment being compressed during systole by surrounding muscle contraction and recovering fully or partially during diastole (). Proximal atherosclerotic lesions of MB were defined as significant stenosis (over 70%), as assessed by quantitative coronary angiography (QCA). Patients aged ≤85 years and with a target vessel diameter >2.0 mm were included, while those with left main vessel lesions or prior coronary artery bypass graft surgery were excluded. This human study was approved by the Institutional Review Board (2020-KY025), conducted in accordance with the Declaration of Helsinki, and registered in the Chinese Clinical Research Registry (No. ChiCTR2200066421).
2.2 Procedures and medication
Before coronary angiography (CAG) and percutaneous coronary intervention (PCI), all patients received 300 mg of aspirin and a loading dose of either 300 mg of clopidogrel or 180 mg of ticagrelor. The radial artery was initially evaluated, and the surgeon decided on the use of glycoprotein IIb/IIIa receptor inhibitors. After discharge, dual antiplatelet therapy followed global recommendations (). The interventional technique (DCB or DES) was chosen by an experienced interventionist team following diagnostic coronary angiography. The DCB group received routine pre-dilatation using a standard balloon. Cutting balloons or non-compliant scoring balloons [non-slip element (NSE)] were utilized at the operators’ discretion to obtain an acceptable lumen increase. DCB diameter was selected with a 1:1 ratio to the reference vessel diameter as determined by QCA. All percentage stenoses were measured by quantitative coronary angiography (QCA) as described in Section 2.3. After pre-expansion processing, the applicable conditions of DCB are:(a) TIMI blood flow grade III; (b) Residual stenosis ≤30% (c) Dissection below Type C. Specifically: TIMI < III means grades 0, I, or II (no flow, minimal flow with stagnation, slow flow). Residual stenosis >30% is diameter stenosis >30%. Dissection type C - F includes transmural (C), spiral (D), persistent filling defect (E), or occlusion (F). Bailout stenting with DES was performed if any of these occurred. DCB should be delivered to the lesion within 2 min and given sufficient dilation time (≥30 s) and nominal pressure (7–8 atm). Applicable conditions for DES-alone or bailout stenting were: (a) TIMI flow < grade III; (b) Residual stenosis >30%; (c) Dissection type C-F. All decisions were independently evaluated by two senior interventional physicians. Patients were implanted with Paclitaxel-Coated Balloons (PCB, SeQuent Please, B. Braun, Melsungen, Germany) during PCI in DCB group. In DES group, patients were implanted with new generation DES, such as, Zotarolimus-eluting stent (ZES, Resolute Integrity, Medtronic, Galway, Ireland), Everolimus-eluting stent (EES, Promus PREMIER, Boston Scientific, Galway, Ireland). In the DCB group, dual antiplatelet therapy (DAPT) was de-escalated to single antiplatelet therapy after 3 months. Conversely, DES patients received DAPT for 1 year before transitioning to monotherapy. Based on medical records and follow-up interviews, no patient was found to have deviated from the planned DAPT regimen.
2.3 Quantitative coronary angiographic analysis
The percentage of diameter stenosis, percentage of MB compression, MB length and lesion length were analysed by automated edge-detection system (Allura Xper FD20, Philips, Netherlands) before and after angiography.
2.4 Clinical follow-up and study end points
Patients were followed up via phone or outpatient clinic interviews every three months after PCI until the administrative censoring date of May 22, 2022. Follow-up was conducted for major adverse cardiac events (MACEs), defined as unstable angina requiring hospitalization, acute myocardial infarction, cardiac death, and target lesion revascularization (TLR). MACE-free survival was defined as the time from the index procedure to the first occurrence of any of these events. MACEs were adjudicated by two cardiologists based on hospital medical records and follow-up telephone interviews. Due to the retrospective design, a blinded independent endpoint committee was not used.
2.5 Statistical analysis
The analysis was performed using R programming language (version 3.6.1) and EmpowerStats (version 4.0). Normality of continuous variables was assessed using the Shapiro-Wilk test. Normally distributed variables are presented as mean ± standard deviation (SD) and were compared using the unpaired Student's t test. Non-normally distributed variables are presented as median (interquartile range, IQR) and were compared using the Mann-Whitney U test. Categorical variables were compared using the chi-square test. Kaplan-Meier survival analysis was used to generate cumulative event-free survival curves. Cox proportional regression analysis, adjusted for confounding baseline variables, was used to evaluate the potential impact of intervention on MACEs, with hazard ratios (HRs) and 95% confidence intervals (CIs). Multivariate Cox regression was chosen for covariate adjustment instead of propensity-score-based methods, given the small sample size. A two-sided P value < 0.05 was considered statistically significant.
3 Results
From January 2020 to July 2021, a total of 135 consecutive patients were enrolled, with 30 receiving DCB and 105 receiving DES (Figure 1). No patient in the DCB group required bailout stenting. The average age was 63.38 ± 9.57 years, with 103 (76.3%) being male. Baseline characteristics were generally comparable between the two groups, although the DCB group was older (66.40 ± 9.07 vs. 62.51 ± 9.58 years). Table 1 displays baseline demographic and clinical information.
Figure 1
Table 1
| Characteristic | DCB group (n = 30 ) | DES group (n = 105 ) | P |
|---|---|---|---|
| Male | 22 (73.33%) | 81 (77.14%) | 0.665 |
| Age (years) | 66.40 ± 9.07 | 62.51 ± 9.58 | 0.050 |
| BMI (kg/m2) | 26.22 ± 2.04 | 25.33 ± 3.23 | 0.158 |
| Smoking | 16 (53.33%) | 60 (57.14%) | 0.711 |
| Hypertension | 22 (73.33%) | 60 (57.14%) | 0.109 |
| Prior PCI | 5 (16.67%) | 28 (26.67%) | 0.261 |
| Stroke | 1 (3.33%) | 15 (14.29%) | 0.102 |
| LDL-C (mmol/L) | 2 (1.53, 2.88) | 2.26 (1.67, 2.85) | 0.604 |
| ALT (U/L) | 21 (16.00, 35.25) | 19 (14.00, 32.00) | 0.217 |
| Cr (umol/L) | 68.05 (56.75, 73.58) | 70.30 (58.55, 79.40) | 0.440 |
| HsCRP (mg/L) | 1.12 (0.40, 5.06) | 1.3 (0.50, 3.48) | 0.749 |
| HbA1c (%) | 6.05 (5.55, 7.65) | 6.1 (5.7, 7.15) | 0.769 |
| LVEF (%) | 66 (58.00, 73.00) | 66 (61.00, 70.50) | 1.000 |
| Admission diagnosis | |||
| UA | 22 (73.33%) | 68 (64.76%) | 0.500* |
| NSTEMI | 5 (16.67%) | 19 (18.10%) | |
| STEMI | 3 (10.00%) | 18 (17.14%) |
Baseline patient characteristics.
*P value obtained from Fisher's exact test.
ALT, alanine aminotransferase; BMI, body mass index; Cr, creatinine; DCB, drug-coated balloon; DES, drug-eluting stent; LDL-C, low-density lipoprotein cholesterol; LVEF, left ventricular ejection fraction; NSTEMI, non-ST elevated myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST elevated myocardial infarction; UA, unstable angina pectoris.
The lesion length in the DCB group was 26.5 (18.0, 29.35) mm, while in the DES group it was24.0 (17.5, 35.0) mm (P = 0.605). There was no significant difference in MB length between the two groups 20.8 (13.73, 30.28)mm for DCB vs. 20.87 (17.08, 28.06) mm for DES, P = 0.797), nor in the distance from stenosis to MB [7.42 (5.13, 9.29) for DCB vs. 7.16 (4.39, 9.48) for DES, P = 0.935]. However, the DES group exhibited more severe stenosis [90 (80.0, 95.0)% vs. 90 (85.0, 97.0)%, P = 0.153] and less MB systolic compression [50 (47.5, 72.5)% vs. 50 (40.0, 55.0)%, P = 0.015] (Table 2).
Table 2
| Characteristic | DCB group (n = 30 ) | DES group (n = 105 ) | P |
|---|---|---|---|
| Lesion stenosis (%) | 90 (80.00,95.00) | 90 (85.00,97.00) | 0.153 |
| Lesion length (mm) | 26.5 (18.00,29.35) | 24 (17.50,35.00) | 0.605 |
| MB length (mm) | 20.8 (13.73,30.28) | 20.87 (17.08,28.06) | 0.797 |
| MB systolic oppression (%) | 50 (47.50,72.50) | 50 (40.00,55.00) | 0.015 |
| Distance from stenosis to MB (mm) | 7.42 (5.13,9.29) | 7.16 (4.39,9.48) | 0.935 |
| DES diameter (mm) | — | 3.22 ± 0.38 | — |
| DES length (mm) | — | 30.64 ± 13.57 | — |
| DCB diameter (mm) | 2.80 ± 0.35 | — | — |
| DCB length (mm) | 28.57 ± 11.75 | — | — |
Angiographic characteristics.
DCB, drug-coated balloon; DES, drug-eluting stent; MB, myocardial bridge.
During a median follow-up of 507.0 days (IQR 391.5–622.0 days; censored as of May 22, 2022), 21 (15.6%) patients experienced composite outcomes. Kaplan–Meier survival analysis revealed no statistically significant difference in MACE-free survival rates between the two groups (DCB: 73.96%, 95% CI 55.8–98.0; DES: 82.49%, 95% CI 73.9–90.8; Log-rank P = 0.678, Figure 2).No statistically significant differences were observed in composite endpoints such as acute myocardial infarction, acute heart failure, or unstable angina between the two groups. Table 3 lists the clinical events. A multivariate Cox proportional regression model was employed to adjust for potential confounders (Table 4) and outcomes showed no statistically significant differences, indicated that DCB did not impact MACEs.
Figure 2
Table 3
| Characteristic | DCB group (n = 30 ) | DES group (n = 105 ) | P |
|---|---|---|---|
| MACE | 6 (20.00) | 15 (14.29) | 0.446 |
| Cardiac death | 0 (0.00) | 0 (0.00) | — |
| AMI | 1 (3.33) | 1 (0.95) | 0.341 |
| UA | 5 (16.67) | 14 (13.33) | 0.643 |
| TLR | 0 (0.00) | 0 (0.00) | — |
Clinical events.
Values are n (%).
AMI, acute myocardial infarction; DCB, drug-coated balloon; DES, drug-eluting stent; MACE, major adverse cardiac events; TLR, target lesion revascularization; UA, unstable angina.
Table 4
| Variables | Hazard ratio (95%CI) | P |
|---|---|---|
| DCB (vs. DES) | 1.58 (0.56–4.45) | 0.383 |
| Age | 1.00 (0.95–1.05) | 0.963 |
| Male | 0.55 (0.21–1.45) | 0.225 |
| BMI | 0.94 (0.81–1.08) | 0.368 |
| Stroke | 1.93 (0.51–7.27) | 0.330 |
| LDL-C | 1.19 (0.75–1.91) | 0.459 |
| HbA1c | 0.77 (0.50–1.17) | 0.214 |
Multivariate cox regression analyses of MACE.
Model fit: likelihood ratio test χ2 = 14.2, P = 0.05; Harrell's C-index = 0.74 (SE = 0.05). In a sensitivity analysis adjusting for additional angiographic covariates, the HR for DCB vs. DES remained non-significant (HR = 1.27, 95% CI 0.44–3.68, P = 0.665).
BMI, body mass index; CI, confidence interval; DCB, drug-coated balloon; DES, drug-eluting stent; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac events. PCI, percutaneous coronary intervention.
4 Discussion
MB is a prevalent congenital abnormality found in approximately one-third of adults, often diagnosed through coronary angiography and computed tomography. Previous studies indicate that about 82% of MBs occur in the LAD, primarily in the proximal and middle segments (, ). While many patients remain asymptomatic, others may experience coronary heart disease due to the effects of direct compression and atherosclerosis in the LAD segment proximal to MB (, ). A meta-analysis, which involved 4,556 subjects (30.5% presented MB), showed that MB was associated with an increased risk of adverse cardiac events (OR = 1.71, 95% CI = 1.29–2.26, P = 0.0002), non-fatal myocardial infarction (OR = 3.17, 95% CI = 1.21–8.31; P = 0.02), and angina requiring hospitalization (OR = 2.31, 95% CI = 1.55–3.45; P < 0.0001), respectively, compared with subjects without MB ().
Treating stenosis in the proximal segment of MB presents a clinical challenge, as coronary anatomy must be carefully considered. PCI with DES is a common approach, but it carries risks such as in-stent restenosis and other cardiovascular events. Studies have shown higher incidences of MACEs in patients receiving DES for significant stenosis proximal to MB compared with those without MB. According to one study by Zhang et al. (), DES implantation for significant atherosclerosis stenosis in the segments proximal to MB have higher incidence of MACEs (HR = 1.781, 95% CI = 1.108–2.863; P = 0.017). Lee's study observed 551 patients with DES implantation, which were divided into MB group (proximal segment stenosis to MB) and non-MB group (). The results showed that MACEs in MB group was significantly higher than that in non-MB group (18.1 vs. 9.8%, P = 0.024). These observations shows that MACEs of DES were likely to occur on stenosis at proximal to MB, and the mechanism may be related to endothelial dysfunction (, ).
DCBs have been increasingly used in treating stent restenosis, small-vessel disease and bifurcated disease recent years, and new indications are expanding, such as large-vessel disease, chronic total occlusion (CTO) lesions, diffuse coronary lesions, and acute coronary syndromes (–), which presents an opportunity for the management of stenosis at proximal to MB.
Myocardial bridges impose cyclic mechanical compression on the adjacent coronary segment, which may increase the risk of stent fracture, in-stent restenosis, and endothelial dysfunction when a rigid metal stent is implanted across or near the bridge (, , ). By leaving no metallic implant behind (, ), drug-coated balloons avoid the mechanical mismatch between a rigid stent and the dynamically contracting myocardial bridge, potentially reducing shear stress abnormalities and vessel wall irritation. Furthermore, the absence of a permanent polymer and metal platform may lower the risk of local inflammation and late thrombosis (). Although direct evidence on drug uptake in segments proximal to MB is limited, studies have shown that paclitaxel can be effectively transferred to the vessel wall with a short exposure time (), which may be sufficient to inhibit neointimal proliferation in such complex lesions. These mechanistic considerations provide a theoretical rationale for exploring DCB in this setting, but clinical evidence from our study does not support its advantage over DES.
In recent years, accumulating evidence has supported the clinical application of drug-coated balloons (DCB) for de novo coronary macrovascular lesions (≥3.0 mm) (). The ongoing REVERSE trial (NCT05846893) is further evaluating DCB versus drug-eluting stents (DES) for macrovascular disease, with results anticipated to provide critical guidance for clinical practice. In our cohort, proximal MB lesions had vessel diameters of 2.80 ± 0.35 mm, and no statistically significant difference outcomes during a median follow-up of 507 days (IQR 391.5–622.0 days) was observed between DCB and DES. However, the REC-CAGEFREE I trial revealed that DCB with bailout stenting failed to achieve non-inferiority to DES for the 2-year device-oriented composite endpoint (DoCE) in uncomplicated coronary disease, underscoring remaining challenges for DCB in large-vessel interventions ().
While intravascular imaging (IVUS/OCT) significantly optimizes procedural strategy and prognosis (, ), its utilization in this study was limited (8.89%, n = 12) due to resource constraints—consistent with China's national averages (IVUS: 8.1%; OCT: 1.5%, Statistics of the China Cardiovascular Health and Disease Report 2023). Nevertheless, our DCB approach for proximal MB lesions represented an early exploratory effort in China. Chinese Expert Consensus on the Clinical Application of Drug-Coated Balloons was updated in 2023, which also added the indication of DCB in Denovo lesions ().
Several limitations should be acknowledged. First, the wide confidence interval and limited sample size preclude definitive conclusions despite the absence of a statistically significant difference. This was a retrospective, single-center study with a small sample size, particularly the DCB group (n = 30), which may have introduced potential selection bias. No a priori power calculation was performed; therefore, the study is underpowered to detect a 10% absolute difference in MACE-free survival during a median follow-up of 507 days (e.g., with 80% power, α=0.05), and the absence of a statistically significant difference should not be interpreted as equivalence. Baseline imbalances existed (older age and higher MB systolic compression in the DCB group). Although we adjusted for age and other covariates in the multivariate Cox regression model, residual confounding due to unmeasured or imprecisely measured variables may still exist. The rate of intravascular imaging was low (8.9%), mainly due to operator discretion and patient economic constraints, which may have introduced bias in lesion preparation and outcome assessment. Additionally, the examination of multiple secondary endpoints increases the risk of type I error. In addition, detailed DAPT adherence data were not systematically recorded due to the retrospective design, which is another limitation. Given these limitations, our findings are hypothesis-generating, suggesting that DCB may offer similar short-term clinical outcomes to DES in this lesion subset, but whether it confers any long-term advantage or benefits specific patient subgroups requires confirmation in larger prospective studies.
In conclusion, in this exploratory retrospective study, DCB did not demonstrate an advantage over DES in terms of MACE-free survival during a median follow-up of 507 days for treating LAD stenosis proximal to MB (HR = 1.58, 95% CI = 0.56–4.45). Based on these findings, there is no evidence to support DCB as a reasonable alternative to DES in this specific lesion subset. Future large-scale prospective studies are needed to further evaluate the potential role of DCB in this challenging anatomical setting.
Statements
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Ethics statement
This study was approved by the Institutional Review Board of Beijing Chao-Yang Hospital (approval No. 2020-KY025) and was conducted in accordance with the Declaration of Helsinki. The study protocol was registered in the Chinese Clinical Research Registry (No. ChiCTR2200066421). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
YJ: Writing – original draft, Data curation, Formal analysis. yx: Formal analysis, Data curation, Writing – original draft. yl: Data curation, Writing – original draft. hz: Data curation, Writing – original draft. yl: Data curation, Writing – original draft. wl: Data curation, Writing – original draft. CL: Data curation, Writing – original draft. YY: Data curation, Writing – original draft. WJ: Data curation, Writing – original draft. WH: Writing – review & editing, Writing – original draft, Data curation.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This study was supported by the Medical and Health Science and Technology Development Program of Shandong Province (No.202003010359), the Start-up Fund for New Faculty of Beijing University of Chinese Medicine (No. 2021-JYB-XJSJJ-076), and the Natural Science Foundation Cultivation Project of The Third Affiliated Hospital, Beijing University of Chinese Medicine (No. 2025-YJKT-ZRJJ-20).
Acknowledgments
The authors are grateful to all individuals who participated in this research.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1.
SternheimDPowerDASamtaniRKiniAFusterVSharmaS. Myocardial bridging: diagnosis, functional assessment, and management: JACC state-of-the-art review. J Am Coll Cardiol. (2021) 78:2196–212. 10.1016/j.jacc.2021.09.859
2.
ZhuCWangSCuiHTangBWangS. Associations of myocardial bridging with adverse cardiac events: a meta-analysis of published observational cohort studies involving 4,556 individuals. Ann Transl Med. (2020) 8:369. 10.21037/atm.2020.02.24
3.
MattaANaderVCanitrotRDelmasCBouissetFLhermusierTet al. Myocardial bridging is significantly associated to myocardial infarction with non-obstructive coronary arteries. Eur Heart J Acute Cardiovasc Care. (2022) 11:501–7. 10.1093/ehjacc/zuac047
4.
IshikawaYKawawaYKohdaEShimadaKIshiiT. Significance of the anatomical properties of a myocardial bridge in coronary heart disease. Circ J. (2011) 75:1559–66. 10.1253/circj.cj-10-1278
5.
IshikawaYAkasakaYSuzukiKFujiwaraMOgawaTYamazakiKet al. Anatomic properties of myocardial bridge predisposing to myocardial infarction. Circulation. (2009) 120:376–83. 10.1161/CIRCULATIONAHA.108.820720
6.
LeeCHEKimUParkJSKimYJ. Impact of myocardial bridging on the long-term clinical outcomes of patients with left anterior descending coronary artery disease treated with a drug-eluting stent. Heart Lung Circ. (2014) 23:758–63. 10.1016/j.hlc.2014.02.021
7.
HaoZXinweiJAhmedZHuanjunPZhanqiWYanfeiWet al. The outcome of percutaneous coronary intervention for significant atherosclerotic lesions in segment proximal to myocardial bridge at left anterior descending coronary artery. Int Heart J. (2018) 59:467–73. 10.1536/ihj.17-179
8.
López MínguezJRNogales AsensioJMDoncel VecinoLJSandovalJRomanySMartínez RomeroPet al. A prospective randomised study of the paclitaxel-coated balloon catheter in bifurcated coronary lesions (BABILON trial): 24-month clinical and angiographic results. EuroIntervention. (2014) 10:50–7. 10.4244/EIJV10I1A10
9.
CorteseBMicheliAPicchiACoppolaroABandinelliLSeveriSet al. Paclitaxel-coated balloon versus drug-eluting stent during PCI of small coronary vessels, a prospective randomised clinical trial. The PICCOLETO study. Heart. (2010) 96:1291–6. 10.1136/hrt.2010.195057
10.
AmplatzKAndersonR. Angiographic appearance of myocardial bridging of the coronary artery. Invest Radiol. (1968) 3:213–5. 10.1097/00004424-196805000-00009
11.
ValgimigliMBuenoHByrneRAColletJ-PCostaFJeppssonAet al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg. (2018) 53:34–78. 10.1093/ejcts/ezx334
12.
HostiucSNegoiIRusuMCHostiucM. Myocardial bridging: a meta-analysis of prevalence. J Forensic Sci. (2018) 63:1176–85. 10.1111/1556-4029.13665
13.
RajendranRHegdeM. The prevalence of myocardial bridging on multidetector computed tomography and its relation to coronary plaques. Pol J Radiol. (2019) 84:e478–83. 10.5114/pjr.2019.90370
14.
MattaARoncalliJCarriéD. Update review on myocardial bridging: new insights. Trends Cardiovasc Med. (2024) 34:10–5. 10.1016/j.tcm.2022.06.002
15.
AgirbasliMHillegassWBJChapmanGDBrottBC. Stent procedure complicated by thrombus formation distal to the lesion within a muscle bridge. Cathet Cardiovasc Diagn. (1998) 43:73–6. 10.1002/(sici)1097-0304(199801)43:1<73::aid-ccd22>3.0.co;2-t
16.
JavadzadeganAMoshfeghAQianYKritharidesLYongASC. Myocardial bridging and endothelial dysfunction - computational fluid dynamics study. J Biomech. (2019) 85:92–100. 10.1016/j.jbiomech.2019.01.021
17.
JegerRVEccleshallSWan AhmadWAGeJPoernerTCShinE-Set al. Drug-coated balloons for coronary artery disease: third report of the international DCB consensus group. JACC Cardiovasc Interv. (2020) 13:1391–402. 10.1016/j.jcin.2020.02.043
18.
YangXLuWPanLHanZPanSWangXet al. Long-term outcomes of drug-coated balloons in patients with diffuse coronary lesions. Front Cardiovasc Med. (2022) 9:935263. 10.3389/fcvm.2022.935263
19.
YerasiCCaseBCForrestalBJTorgusonRWeintraubWSGarcia-GarciaHMet al. Drug-coated balloon for de novo coronary artery disease: jACC state-of-the-art review. J Am Coll Cardiol. (2020) 75:1061–73. 10.1016/j.jacc.2019.12.046
20.
HanciKAcarBCakirOBarisOOmayOUralE. Stent fracture due to myocardial bridging causes cockboat deformity with large ischaemic myocardium. Postepy Kardiol Interwencyjnej. (2024) 20:227–31. 10.5114/aic.2024.139970
21.
MaJGustafsonGMDaiX. Plaque herniation after stenting the culprit lesion with myocardial bridging in ST elevation myocardial infarction: a case report. World J Cardiol. (2020) 12:91–6. 10.4330/wjc.v12.i2.91
22.
ChioncelVGherasieFIancuAAvramANMRAG. Coronary angioplasty with drug-coated balloons: pharmacological foundations, clinical efficacy, and future directions. Medicina (Kaunas). (2025) 61:1470. 10.3390/medicina61081470
23.
HerA-YAhmadWAWBangLHKiamOTNuruddinAAHsiehI-Cet al. Drug-coated balloons-based intervention for coronary artery disease: the second report of Asia-Pacific consensus group. JACC Asia. (2025) 5:701–17. 10.1016/j.jacasi.2025.02.017
24.
BarbashIMWaksmanR. Current status, challenges and future directions of drug-eluting balloons. Future Cardiol. (2011) 7:765–74. 10.2217/fca.11.56
25.
XiongGMAngHLinJLuiYSPhuaJLChanJNet al. Materials technology in drug eluting balloons: current and future perspectives. J Control Release. (2016) 239:92–106. 10.1016/j.jconrel.2016.08.018
26.
GaoCHeXOuyangFZhangZShenGWuMet al. Drug-coated balloon angioplasty with rescue stenting versus intended stenting for the treatment of patients with de novo coronary artery lesions (REC-CAGEFREE i): an open-label, randomised, non-inferiority trial. Lancet. (2024) 404:1040–50. 10.1016/S0140-6736(24)01594-0
27.
HongS-JLeeS-JLeeS-HLeeJ-YChoD-KKimJWet al. Optical coherence tomography-guided versus angiography-guided percutaneous coronary intervention for patients with complex lesions (OCCUPI): an investigator-initiated, multicentre, randomised, open-label, superiority trial in South Korea. Lancet. (2024) 404:1029–39. 10.1016/S0140-6736(24)01454-5
28.
VrintsCAndreottiFKoskinasKCRosselloXAdamoMAinslieJet al. 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J. (2024) 45:3415–537. 10.1093/eurheartj/ehae177
29.
ExpertWCOTGeJBChenYD. Chinese Expert consensus on the clinical application of drug-coated balloon (2nd) edition). J Geriatr Cardiol. (2024) 21:135–52. 10.26599/1671-5411.2024.02.001
Summary
Keywords
coronary heart disease, de novo lesion, drug-coated balloon, myocardial bridge, percutaneous coronary intervention
Citation
Jia Y, Xie Y, Li Y, Zhang H, Li Y, Li W, Li C, Yang Y, Jia W and Han W (2026) Impact of drug coated balloon on left anterior descending artery stenosis at proximal to myocardial bridge. Front. Cardiovasc. Med. 13:1830690. doi: 10.3389/fcvm.2026.1830690
Received
14 March 2026
Revised
04 August 2026
Accepted
06 August 2026
Published
24 August 2026
Volume
13 - 2026
Edited by
Masaaki Okutsu, Tokai University Hachioji Hospital, Japan
Reviewed by
Liang Pan, The First Affiliated Hospital of Zhengzhou University, China
Vedran Radonic, Klinička bolnica Merkur, Croatia
Updates
Copyright
© 2026 Jia, Xie, Li, Zhang, Li, Li, Li, Yang, Jia and Han.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Wenbo Han hanwenbo2014@126.com
† These authors have contributed equally to this work
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.