Abstract 20382: A Case of Severe Myocardial Bridging: Usefulness of Diastolic Fractional Flow Reserve
A case of 72-year-old female presented with progressive exertional angina. Her past medical history included PCI for LCx lesion. She had recurrent angina on a light exertion in 18 months after PCI.
Initial Diagnostic Tests: Treadmill exercise test revealed angina with significant ST-segment depression in leads II, III and aVF. Stress myocardial perfusion imaging showed overall ischemia with reduced EF at stress. CAG revealed no relevant stenosis in main vessels, however, after administration of intra-coronary isosorbide dinitrate, more progressive vessel squeezing with myocardial bridge (MB) at mid LAD was noticed, compared with previous angiogram. We proceeded with β-blocker.
Medical Treatment: Of Carvedilol 10mg showed no effect, the threshold of angina had gradually decreased in her daily life during 2 months periods. Nitroglycerin use resulted in a worsening of symptoms.
Proof of Ischemia and Intervention: Invasive examinations were performed to obtain the proof for ischemia with MB. IVUS revealed a severe compression (compression rate: 39-43%) under MB. Pull back IVUS image also showed moderate organic stenosis at proximal to the MB (MLA 2.4 squ.mm). Although conventional FFR did not show a significant decrease at distal to MB (0.85), diastolic FFR showed a value of 0.70. Dobutamine provocation revealed further decrease of diastolic FFR (0.67). Finally, It was decided to carry out the treatments with stents for both MB lesion and proximal organic stenosis utilizing Nobori (BES) stent in the next admission. After stenting for MB lesion, diastolic FFR improved sufficiently. Adding with 2nd stent for organic lesion, diastolic FFR was not changed compered with just after 1st stenting (Figure). Treadmill test was done without any symptoms or EKG changes. The patient has been fully released from angina in daily life.
Conclusions: Diastolic FFR was useful in assessing subjective myocardial ischemia and therapeutic effect of coronary stenting for angina with MB.
Author Disclosures: T. Mitsuse: None. K. Sakamoto: None. K. Tsujita: None. N. Komura: None. K. Yamanaga: None. T. Akasaka: None. T. Miyazaki: None. N. Tabata: None. M. Ishii: None. Y. Arima: None. S. Kojima: None. K. Kaikita: None. S. Nakamura: None. S. Hokimoto: None. H. Ogawa: Other Research Support; Modest; AstraZeneca, Astellas, Boehringer lngelheim, Bristol-Myers Squibb, Daiichi Sankyo, Dainippon Sumitomo Pharma, Kowa, MSD, Novartis, Pfizer, Sanofi, Takeda. Other Research Support; Significant; Bayer, Chugai, Otsuka. Honoraria; Modest; AstraZeneca, Bayer, Pfizer, Sanofi, Takeda. Honoraria; Significant; Daiichi Sankyo, MSD.
- © 2014 by American Heart Association, Inc.