Images in Cardiovascular Medicine
When the Atheromatous Culprit Coronary Plaque Melts Like Snow in the Sun
2025 年 7 巻 8 号 p. 695-696
詳細
2025 年 7 巻 8 号 p. 695-696
A 43-year-old smoker was admitted for inferior ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed proximal occlusion of the right coronary artery. After thrombus aspiration, chest pain and ST-segment elevation resolved and coronary TIMI 3 grade flow was obtained. A deferred approach without immediate stenting was adopted because of substantial thrombus burden (Figure). Medical treatment was continued (heparin, dual antiplatelet therapy (DAPT) and glycoprotein IIb-IIIa inhibitors), but 3 days later, systematic angiographic follow-up suggested the persistence of an extended thrombus. Optical coherence tomography (OCT) revealed an erythrocyte-rich thrombus without definite evidence of plaque rupture (Figure), so a plaque erosion was suspected. The low-density lipoprotein (LDL) cholesterol level was measured as 135 mg/dL. Medical therapy including DAPT and statins was continued.
Serial angiography and optical coherence tomography (OCT). OCT performed at the same sites: culprit lesion (A), atheromatous plaque beside the collateral branch (B), downstream atheromatous free segment (C) at different times: Day-3 (thrombus=red arrows), Month-1 (large plaque burden=yellow dots, intraplaque microchannels=white asterisk), Year-1 and Year-12 (plaque and microchannel regression).
One month later, the patient was asymptomatic and he had quit smoking. A non-stenotic lesion remained on planned angiography. OCT confirmed resolution of the thrombus, revealing a large fibrolipidic plaque with intraplaque microchannels, supporting the hypothesis of plaque erosion (Figure).
Two similar follow-up assessments were conducted at 12 months and 12 years. His LDL level reduced to 59 mg/dL. Angiography found mild improvement in the lumen diameter and OCT revealed a significant reduction in the lipidic plaque burden and numbers of microchannels (Figure).
This case highlights that favorable long-term outcomes can be achieved with exclusive medical management of plaque erosion under OCT guidance, as already reported.1,2 OCT can also demonstrate plaque regression and stabilization.3
Patient has given informed consent for publication.
P.M. and G.S. declare consulting fees from Terumo and from Abbott. N.C. declares consulting fees from Medtronic.
