“Under the Bridge”: Looking for Ischemia in a Patient with Intramyocardial Coronary Artery Course—The Role of the Cardiopulmonary Exercise Test

Figures

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  Figure 1. Case presentation. A 74-year-old man with no cardiovascular history who performs high-load physical activity (multiple ski mountaineering trips) was referred for CPET following episodes of atypical chest pain. Abbreviations: CPET = Cardiopulmonary Exercise Testing.

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  Figure 2. Serial CPETs. The figure shows the exercise-induced ECG changes (A) and the metabolic changes in both the baseline CPET (B) and in the post-PCI CPET (C) with a clear flattening/downsloping of the O2-pulse and VO2/Work (arrows). Panel (D) shows the normalization of the metabolic behavior after the introduction of Verapamil in the medical therapyAbbreviations: CPET = Cardiopulmonary Exercise Testing; PCI = Percutaneous Coronary Intervention; VO2 = Oxygen Intake.

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  Figure 3. Stress CMR. A stress CMR was performed to exclude MI, showing normal biventricular volumes and systolic function (a–d). No LGE was detected (e,f), and a normal dynamic response was observed after dypiridamole with no signs of MI. Abbreviations: CMR = Cardiac Magnetic Resonance; MI = Myocardial Ischemia; LGE = Late Gadolinium Enhancement.

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  Figure 4. CA and PCI. CA shows stenosis of the RCA undergoing successful PCI without complications (upper panel, (A)) and the presence of a MB of the LAD (lower panel, (B)). MB is showed by yellow arrows. Abbreviations: CA = Coronary Angiography; RCA = Right Coronary Artery; PCI = Percutaneous Coronary Intervention; MB = Myocardial Bridging; LAD = Left Descending Artery.