CT coronary angiographic approach to delineate terrible triad of coronary-cameral microfistulae, myocardial bridge and hypertrophic obstructive cardiomyopathy presenting with angina: a case report.

BACKGROUND & OBJECTIVE: Association of multiple coronary arterial microfistulae and myocardial bridge together with concentric diffuse hypertrophic obstructive cardiomyopathy is considerably rare and we aim to highlight a similar unusual but clinically significant association in a young adult female patient with hypertrophic cardiomyopathy, presenting with progressively worsening angina on exertion.

CASE FINDINGS

A young 38-year-old female presented to the cardiology clinic of our institute with complaints of angina on exertion New York Heart Association (NYHA) class III for 2 years. An electrocardiogram showed left ventricular enlargement and echocardiography showed diffuse hypertrophic obstructive cardiomyopathy with the systolic anterior motion of the mitral valve and left ventricular outflow tract gradient of 40 mm Hg on Valsalva. CT coronary angiography revealed a diffuse concentric hypertrophic left ventricular myocardium with no regional wall motion abnormality, a mid-left anterior descending artery myocardial bridge, multiple coronary arterial microfistulae from distal left anterior descending (LAD) and right coronary artery (RCA) emptying to the right ventricle and dilated pulmonary artery trunk.

CONCLUSION

In patients with hypertrophic obstructive cardiomyopathy, angina can be rarely due to coronary artery fistula and or myocardial bridge in addition to myocardial perfusion mismatch owing to hypertrophy or a combination of all. CT coronary angiography seems to be the ideal first noninvasive modality for screening and pre-intervention planning.