Case Presentation:
A 52-year-old man presented to our institution with a one year history of intermittent, progressive chest tightness. Past medical history was notable for hypertension, hyperlipidemia, post-traumatic stress disorder and family history of coronary artery disease (CAD). Prior to developing symptoms, he was quite physically active; however, became less so prior to presentation due to symptomatic limitations.
He underwent an exercise stress test that showed good functional capacity (exercise time of 9 min 47 seconds) but demonstrated 2-3 mm ST depressions starting in Stage 2 of the bruce protocol in leads II, III, aVF and V4-V6. The patient also expressed dypnea with exercise that resolved 5 minutes into recovery. Coronary angiography was then performed, demonstrating non-obstructive CAD . However, a long segment myocardial bridge in the mid-LAD was observed (Figure 1) Transthoracic echocardiogram (TTE) demonstrated normal left ventricular size, normal systolic function and an estimated left ventricular ejection fraction of 60-65%.
Initially, the patient was trialed on maximal medical therapy for symptomatic relief, including amlodipine, aspirin and rosuvastatin. His symptoms persisted.  He was subsequently referred for cardiac surgical evaluation.  He was deemed an appropriate operative candidate, and was brought to the operating room for surgical unroofing of the myocardial bridge on April, 2020.
Standard aortic and dual stage venous cannulation was performed. The aorta was cross clamped and the heart was arrested with antegrade Del Nido cardioplegia. Upon surface inspection, a long segment of intramyocardial LAD was easily identified (Figure 2).  The LAD was unroofed with the use of a 15-c blade over the course of 10 mm.  The aortic cross clamp was removed and the patient was easily separated from cardiopulmonary bypass. He underwent coronary angiography on post-operative day one to evaluate the results of the surgery radiographically. Angiography revealed that the myocardial bridge had been entirely relieved (Figure 3). The patient had an uneventful post-operative course and was discharged home on postoperative day number four. He was seen in follow-up one and two months post procedure and is doing well without recurrence of symptoms.