Abstract
BACKGROUND: Myocardial bridging is a congenital coronary anomaly in which a segment of an epicardial artery is tunneled within the myocardium. Although many cases remain asymptomatic, hemodynamically significant bridges may require surgical intervention. CASE SUMMARY: A 57-year-old man with a history of an unrepaired ventricular septal defect presented with recurrent chest pain. Initial imaging identified a 4.7-cm myocardial bridge in the left anterior descending artery. Functional testing with fractional flow reserve, instantaneous wave-free ratio, and diastolic hyperemia-free ratio confirmed hemodynamic significance. Optical coherence tomography was performed to further visualize the segment. The patient underwent successful surgical unroofing, resulting in complete symptom resolution. DISCUSSION: This case highlights a multimodal intracoronary approach incorporating intracoronary anatomical and physiological testing to determine the hemodynamic significance of myocardial bridging. TAKE-HOME MESSAGE: Multimodal intracoronary anatomical and physiological testing is imperative for diagnosing myocardial bridges in patients presenting with undifferentiated angina, thereby influencing management.