Abstract
BACKGROUND: Myocardial bridging is an anatomical variant in which coronary arteries course within the myocardium rather than on the epicardial surface. Complete intramyocardial coronary systems are extremely rare and can lead to significant clinical consequences. CASE SUMMARY: An 18-year-old man with left ventricular noncompaction cardiomyopathy experienced chest pain and syncope while playing basketball, and was subsequently diagnosed with ST-segment elevation myocardial infarction. Coronary imaging revealed a completely intramyocardial coronary system. Despite medical management and placement of implantable cardioverter-defibrillator, he developed heart failure requiring heart transplant evaluation. DISCUSSION: This case underscores the complexity of managing extensive intramyocardial coronary anatomy, in which conventional revascularization strategies may not be viable and individualized, multidisciplinary approaches are essential. TAKE-HOME MESSAGES: Extensive myocardial bridging involving the entire coronary system is a rare anatomical anomaly that can precipitate exertional ischemia, arrhythmias, and even sudden cardiac events. Management of complete intramyocardial coronary anatomy requires individualized, multidisciplinary assessment, as traditional revascularization strategies may be unfeasible.