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

BACKGROUND

myocardial bridging (MB), an intramyocardial course of an epicardial coronary segment, is common yet frequently underrecognized on angiography, and can provoke ischaemia 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 ischaemia was attributable to MB alone; (ii) OCT-guided percutaneous coronary intervention for adjacent atherosclerotic disease with precise landing-zone selection; (iii) in one case, integrated functional assessment, including dobutamine and acetylcholine testing, to unmask epicardial haemodynamic significance, microvascular dysfunction, and vasospasm, informing agent selection. Clinical outcomes were favourable, with symptom resolution and preserved or improved LV function over follow-up intervals up to 2 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 tunnelled segments. This real-world series offers a pragmatic roadmap for decoding MB related ischaemia and for translating concordance between imaging and physiology into optimized, individualized management.