Stenting a myocardial bridge: a wrong decision in STEMI?

In a STEMI setting, stent implantation for a myocardial bridge (MB) with significant systolic compression in the mid LAD, is a challenging issue.The risk of coronary rupture during stent implantation arises from: (i) a thin intima of the bridged artery; (ii) a thin myocardial layer toward the right ventricle; (iii) a smaller LAD diameter in the MB; (iv) high inflation pressure in the balloon. Perforation with a coronary fistula resolving spontaneously within several months is one of the possible scenarios. We report a case of a coronary fistula between mid LAD and right ventricle after MB stenting in a patient with STEMI, with spontaneous angiographic deterioration after several days. Stent graft implantation in case of a coronary fistula with increasing flow is an effective therapeutic concept.