Real-world presentation of myocardial bridging in the cath-lab: a case series

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2026
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Abstract
Abstract Background Myocardial bridging (MB), an intramyocardial course of an epicardial coronary segment, is common yet frequently underrecognized on angiography, and can provoke ischemia via multiple, overlapping mechanisms. High-resolution optical coherence tomography (OCT), paired with targeted physiological testing, may improve in-vivo characterization and clinical decision-making. Case Summary We report eight contemporary, catheterization-lab cases illustrating the heterogeneous anatomy, physiology, and clinical expression of MB. Clinical presentation ranged from myocardial infarction with/without ST-elevation to acute heart failure. OCT consistently revealed recurrent morphologies, namely: homogeneous “media-like” bands abutting the adventitia, sharp-bordered fusiform or “moon-shaped” perivascular areas, or dynamic and asymmetric vessel distortion tracking with the muscular cuff. Management was individualized: i) medical therapy with β-blockers when ischemia was attributable to MB alone; ii) OCT-guided PCI for adjacent atherosclerotic disease with precise landing-zone selection; iii) in one case, integrated functional assessment, including dobutamine and acetylcholine testing, to unmask epicardial hemodynamic significance, microvascular dysfunction, and vasospasm, informing agent selection. Clinical outcomes were favorable, with symptom resolution and preserved or improved LV function over follow-up intervals up to two years. Discussion MB modulates coronary flow, atherogenesis, and procedural risk. An integrated approach that combines structural definition with intravascular imaging, stress state physiology, and vasoreactivity testing is essential to clarify mechanisms, tailor therapy, and mitigate the pitfalls of stenting near tunneled segments. This real-world series offers a pragmatic roadmap for decoding MB related ischemia and for translating concordance between imaging and physiology into optimized, individualized management.
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Authors D D'amario, Rocco Vergallo, Stefano Elia, Gaetano Rizzo, Alfredo Ricchiuto, Giuseppe Ciliberti, Italo Porto, Giuseppe Patti
Journal European Heart Journal - Case Reports
Year 2026
DOI
10.1093/ehjcr/ytag357
URL
https://doi.org/10.1093/ehjcr/ytag357
Keywords Keywords not found

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