Real-World Invasive Evaluation of Myocardial Bridging: A Multicenter Italian Survey of Interventional Cardiologists' Practices

Background: Myocardial bridging (MB) is increasingly recognized as a potential cause of ischemia through heterogeneous mechanisms, yet real-world management remains heterogeneous. We surveyed interventional cardiologists to describe contemporary MB practice, focusing on functional assessments, perceived value, and barriers to the “full-physiology” approach, and priorities for standardization and research. Aims: To characterize contemporary MB management among interventional cardiologists, focusing on physiology approaches, imaging strategies, and perceived barriers to implementation and treatment. Methods: An anonymized online survey was conducted among interventional cardiologists from 28 Italian centers. Items covered MB-specific functional assessment strategies, therapies, implementation barriers, operational infrastructure, and research interest. Results: Ninety-three cardiologists responded (mean age 38.8 ± 8.6 years; 82.8% male). Pressure-based indices were widely used for epicardial CAD, but phenotyping in MB was uncommon: 57.0% performed physiology in < 10% of MB cases, and 19.4% never did. Epicardial MB assessment relied mainly on adenosine-FFR (33.3%) or iFR (31.2%), whereas stress-enhanced protocols were rarely used. Although intracoronary acetylcholine testing was commonly used in general practice (79.6%), only 49.5% of respondents reported using it to assess MB-related coronary spasm, and most did so in only a small proportion of cases. CMD testing in MB was rare (< 10% in 66.7%). Despite this, most respondents (87.1%) endorsed “full-physiology” as useful for mechanism identification and personalized therapy, but cited evidence uncertainty, procedural time, and limited experience as key barriers. Operational readiness was low (dedicated protocols: 26.9%; registries: 39.8%; routine capture: 34.4%). Willingness to join a randomized trial was high (93.5%). Conclusions: Despite the widespread availability of invasive functional assessment tools and operators' recognition of their relevance, their use in MB remains limited and heterogeneous, reflecting the lack of evidence-based guidance and underscoring the need for dedicated mechanistic studies and standardized invasive workflows.