Richard Sohn MD

Interventional cardiology, CTO & CHIP operator. Coronary microvascular dysfunction (CMD), vasospasm angina (VSA) & myocardial bridge (MB) #ANOCA #INOCA #MINOCA

[Richard Sohn MD @RSohnMD]

Doing solo-operator ROTAPRO
(rotational atherectomy)

STARTING POSITION (after testing & adjusting burr speed):

Dynaglide ON, wire inside clip inside “brake defeat slot” (make sure to insert clip while pressing black button)

#RadialFirst

[Richard Sohn MD @RSohnMD]

@LAzzaliniMD Still, there’s something abnl going on

Slow resting coronary flow (by angio) is confirmed by the broad blue TD curves ➡️ long transit time = 2.4 sec (usu ~ 1.0 s)

Hence, rest IMR very high… but normalizes w/ adenosine. No CMD, but something telling microvasc to vasoconstrict

[Richard Sohn MD @RSohnMD]

@Iqbal48 @Umair2017 @imi_haf @DrHilal24718843 @mirvatalasnag @DrRajeshVijay @toreyj01 @aayshacader @IntervnCardio @sajannarayanan @PCRonline Focal hematoma between media & adventitia causing compression of lumen. Either SCAD (classic compartment in vessel wall, but unusual coronary location) but more likely guide trauma

[Richard Sohn MD @RSohnMD]

#ANOCA — Best medical therapy ??

See these 👇🏼 fantastic references

1️⃣ Toleva et al, JSCAI 2025

2️⃣ Miner et al, Eur Heart J 2026

* I routinely copy👇🏼 into my reports

#vasospasm @Hragy #MicrovascularDysfunction #MyocardialBridge @mirvatalasnag

[Richard Sohn MD @RSohnMD]

@IhabFathiSulima @Abdul_alkindy Great example of a mid-LAD myocardial bridge. Usually not clinically important, but can in some patients be symptomatic. Also, many bridges cause diastolic restriction as can be seen subtly in your first screenshot 👀

More info 👇🏼

[Richard Sohn MD @RSohnMD]

1/ MYOCARDIAL BRIDGES (MBs)

ANOCA mechanisms:

- Slow early diast relaxation
- Diast vessel restriction +/- neg remodeling
- Branch steal (Venturi effect)
- Proximal atherosclerosis
- Associated vasospasm, CMD (common!)

(see next for MINOCA)

[Richard Sohn MD @RSohnMD]

Do any of you do SuperSaturated O2 (SSO2) for anterior STEMI?

➡️ What are your thoughts on this therapy?

[Richard Sohn MD @RSohnMD]

@HeartOTXHeartMD @DocSavageTJU @iamritu @CannanCharles @Hragy @Obisht @jedicath @BaoGTran @saraceciliamtz @minhaskh @fischman_david @djc795 @mmamas1973 @DLBHATTMD @mirvatalasnag @SrihariNaiduMD @LeivaOrly @DrMarthaGulati @realarainmd @FaroucJaffer @rajivxgulati @DougDrachmanMD @ccijournal @aymanka @aayshacader @sbrugaletta @_radikalek @KardiologieHH @Pooh_Velagapudi @aspergian1 @timir_paul @SABOURETCardio LM spasm that didn’t resolve with NTG?

[Richard Sohn MD @RSohnMD]

Young woman w/ VF arrest

This 👇🏼 angiogram after ROSC 👀
Hemos stable, no CP

What is the etiology, and what next?

[Richard Sohn MD @RSohnMD]

@DocSavageTJU @CannanCharles @Hragy @Obisht @jedicath @BaoGTran @saraceciliamtz @minhaskh @fischman_david @djc795 @mmamas1973 @DLBHATTMD @mirvatalasnag @SrihariNaiduMD @LeivaOrly @DrMarthaGulati @realarainmd @FaroucJaffer @rajivxgulati @DougDrachmanMD @ccijournal @aymanka @aayshacader @sbrugaletta @_radikalek @KardiologieHH @Pooh_Velagapudi @aspergian1 @timir_paul @SABOURETCardio Perfect reference for this case — thank you @DocSavageTJU !
Importantly, you found 50-50 split between genders, reinforcing that men too can have spasm

[Richard Sohn MD @RSohnMD]

@BaoGTran @CannanCharles @Hragy @Obisht @jedicath @DocSavageTJU @saraceciliamtz @minhaskh No imaging done given the diagnosis

[Richard Sohn MD @RSohnMD]

@baijazvascular @evandrofilhobr @ShariqShamimMD @JayMathewsMD @SCAI Playing around w/ #heartflow app can be insightful. Watch this video 👇🏼 I made while scrolling around (angles displayed at bottom)

➡️ L-CRAN confirmed as best, and shows how caudal can be problematic

[Richard Sohn MD @RSohnMD]

@realarainmd @AsherElad https://t.co/0fvYLpofMq

[Richard Sohn MD @RSohnMD]

#CUBISM by SHOCKWAVE

Remarkably circumferential coronary calcium (1.4 mm thick!) 👀

➡️ Beautifully fractured by #Shockwave IVL alone

“Violin and Candlestick” by Georges #Braque

#CardioTwitter #OCT

[Richard Sohn MD @RSohnMD]

@jbspadoni Fantastic case 👏👏

Btw, your #IVUS is another great example supporting “mechano-cardiac” (@rajivxgulati) causes for SCAD, eg takosubo, #myocardialbridge. Your patient’s bridge is exactly at proximal end of hematoma (bridges are not only found in LAD!):

[Richard Sohn MD @RSohnMD]

@MichaelMegalyMD @MichaelMegalyMD So do you not modify your use of contrast in CKD patients, e.g limiting numbers of angiographic views, tending away from OCT, staging PCIs, etc?

[Richard Sohn MD @RSohnMD]

1/ MYOCARDIAL BRIDGES (MBs)

ANOCA mechanisms:

- Slow early diast relaxation
- Diast vessel restriction +/- neg remodeling
- Branch steal (Venturi effect)
- Proximal atherosclerosis
- Associated vasospasm, CMD (common!)

(see next for MINOCA)

[Richard Sohn MD @RSohnMD]

@DocSavageTJU @ChangeAtHeart @AlexandraLansky @HenrytTimothy @mmamas1973 @MyJSCAI @djc795 @TCTConference @crfheart @NishithChandra @ShariqShamimMD @heart_spasms @InocaInternati1 @Hragy @aymanka @aayshacader @AnastasiaSMihai @DrMarthaGulati @saraceciliamtz Such great work by @ChangeAtHeart, @samitshahmd and all the registry investigators! This should help reassure apprehensive ICs to begin their own #ANOCA programs.

No doubt a great presentation— wait, that’s me in the headphones!

[Richard Sohn MD @RSohnMD]

@mmamas1973 Can’t wait for the 5-year superiority data!

[Richard Sohn MD @RSohnMD]

@SarahFairley7 @mmamas1973 17%

[Richard Sohn MD @RSohnMD]

@jbspadoni Hmm, doesn’t look like bridge or SCAD / hematoma to me. Maybe a vein coursing around the coronary?

@jbspadoni do you know what this is? (Why was IVUS done in this otw normal looking coronary?)

[Richard Sohn MD @RSohnMD]

@sbrugaletta @AntonioMariaLe2 @ehj_ed @ESC_Journals @escardio Our current terminology is problematic for these reasons but also because these same entities (ie vasospasm, microvascular dysfunction, myocardial bridges, etc) can often cause angina / ischemia in pts who ALSO have epicardial CAD, eg those who don’t improve with PCI / CABG