Complex MINOCA With Myocardial Bridge, Vasospasm, and Microvascular Dysfunction in an HCM Patient

Figures

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  Figure 1. Coronary Angiogram From Coronary Function Testing (A) Baseline coronary angiogram showing long segment of myocardial bridge in the mid-distal left anterior descending artery with obliteration of flow in systole (red bracket). (B) Coronary angiogram after 100 μg of acetylcholine showing severe mid left anterior descending arterial vasospasm (red arrows). (C) Angiogram after administration of intracoronary nitroglycerine with reversal of vasospasm.

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  Figure 2. Intravascular Ultrasound of Distal Left Anterior Descending Artery Screenshot from the intravascular ultrasound run of the distal left anterior artery descending beyond the bridge showing it is a small-caliber vessel (1.49 × 1.52 mm, area of 1.76 mm2) with mild atherosclerosis.

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  Visual Summary. Reverse Pd/PA Waveform (A) Screen capture of RFR measurement with the pressure wire positioned beyond the intramyocardial bridge in the left anterior descending artery measuring a left ventricular pressure waveform (green waveform) with abnormal RFR of 0.64. The red waveform is the aortic pressure. Note, Pd/Pa measurement would not be accurate because the Pd pressure is up to 40 to 50 mm Hg higher than Pa and results in a number > 1.0. (B) Screen capture of RFR pullback measurement with distal pressure positioned proximal to intramyocardial bridge with normal RFR, fractional flow reserve, and Pd/Pa of 0.92. RFR = resting full-cycle ratio.