Abstract
BACKGROUND: A 17-year-old male athlete experienced out-of-hospital cardiac arrest due to ventricular fibrillation during exercise. Myocardial bridging (MB) and vasospasm were identified as potential contributors to the event. CASE SUMMARY: Initial imaging revealed MB of the mid-left anterior descending artery embedded within hypertrophic myocardium. Physiological assessment demonstrated significant ischemia, and acetylcholine provocation testing induced epicardial spasm, confirming MB-induced ischemia with vasospasm. Fluorodeoxyglucose positron emission tomography showed increased tracer uptake, initially suggesting malignancy, but histopathology attributed this to ischemia-related metabolic changes. The patient underwent surgical unroofing with intraoperative confirmation of arterial decompression. Postoperatively, he was treated with diltiazem and bisoprolol. DISCUSSION: This case underscores the interplay between MB and vasospasm in exercise-induced cardiac arrest and highlights surgical unroofing as a definitive treatment. TAKE-HOME MESSAGES: MB can contribute to life-threatening arrhythmias, particularly when complicated by vasospasm. Surgical unroofing with targeted medical therapy may optimize outcomes.