International Journal of Cardiology 187 (2015) 97–98
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Different optical coherence tomography findings for intracoronary stripe-like filling defects on coronary angiogram in patients with acute coronary syndrome Hyung Joon Joo, Cheol Woong Yu ⁎, Do Sun Lim Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, Republic of Korea
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Article history: Received 18 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Optical coherence tomography Acute coronary syndrome Longitudinal filling defect
red thrombus in the moderately stenosed coronary artery (Fig. 1B and C). We performed aspiration thrombectomy using a thrombus aspiration catheter (Eliminate; Terumo Corporation, Tokyo, Japan) and retrieved a long, stripe-like red thrombus (Fig. 1D). Subsequent CAG showed that the previously observed stripe-like filling defect had completely disappeared (Fig. 1E), and OCT demonstrated a ruptured plaque in the moderately stenosed coronary artery (Fig. 1F and G). The patient became stabilized without chest pain after thrombus removal. A 3.0 × 28-mm Nobori drug-eluting stent (Terumo) was later implanted into the culprit lesion. 2. Case 2
Stripe-like radiolucent filling defects visualized by a conventional coronary angiogram (CAG) usually suggest coronary artery dissection. However, recent endovascular imaging technique with high resolution power such as optical coherence tomography (OCT) makes more detailed intraluminal lesion characterization possible, compared with the conventional CAG, and attests to possibilities of being different clinical situations [1]. We report that stripe-like radiolucent filling defects on CAG proved to have different pathophysiologies by OCT in patients with acute coronary syndrome.
1. Case 1 A 50-year-old man presented with severe continuous chest pain. This patient was taking medication for hypertension, diabetes mellitus, end-stage renal disease, and dyslipidemia. Electrocardiography revealed ST-segment elevation at V2–V4 and T wave inversion at V5–V6, I, and aVL; initial cardiac enzyme levels were also elevated (CK-MB, 8.84 ng/mL and troponin I, 0.4 ng/mL). CAG revealed a long, stripe-like intraluminal filling defect proximal to the mid-left anterior descending artery (Fig. 1A). OCT revealed a free-floating, longitudinally growing
⁎ Corresponding author at: Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, 126-1, 5ka, Anam-dong, Sungbuk-ku, Seoul 136-705, Republic of Korea. E-mail address:
[email protected] (C.W. Yu).
http://dx.doi.org/10.1016/j.ijcard.2015.03.218 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
A 50-year-old man was referred with previous history of acute coronary syndrome accompanied by abnormal intraluminal filling defects on CAG. The patient was taking medication for hypertension. Electrocardiography revealed a normal sinus rhythm, and the initial cardiac enzyme levels were within normal ranges (CK-MB, 1.45 ng/mL and troponin I, 0.121 ng/mL). A treadmill test showed no inducible ST-segment changes without effort-related chest pain. CAG demonstrated multiple stripe-like intraluminal filling defects proximal to the mid-left anterior descending artery (Fig. 2A). OCT revealed multiple intraluminal communicating channels suggestive of a recanalized organized thrombus [2] (Fig. 2B and C). The patient was prescribed oral anticoagulation therapy and discharged. To summarize the present cases, OCT confirmed the different intraluminal lesion types in each case with similar intraluminal filling defect on CAG: stripe-like longitudinal red thrombi and recanalized organized thrombus. The treatment strategy for each case differed completely based on different pathophysiologies defined by OCT. The longitudinally growing red thrombus was removed via manual thrombectomy with a thrombus aspiration catheter. The recanalized organized thrombus was treated medically with oral anticoagulation therapy. These cases suggest that OCT can give us valuable information such as underlying pathophysiologic mechanisms in patients with stripe-like filling defect on CAG. Intraluminal filling defects are common on CAG [3] and the stripe-like longitudinal defects are often considered for coronary arterial dissection. However, other conditions including coronary thrombi could present with the similar angiographic findings and might cause diagnostic uncertainty. Three disease entities should be included in the list of differential diagnoses in patients with stripe-like
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H.J. Joo et al. / International Journal of Cardiology 187 (2015) 97–98
Fig. 2. Coronary angiography (CAG) and optical computed tomography (OCT) findings of recanalized organized thrombi. (A) CAG image of the stripe-like filling defects (arrowheads). (B and C) OCT images showing the “honeycomb” appearance caused by multiple intraluminal communicating channels separated by septa with high signal intensities.
Conflict of interest All authors declare that they have no conflicts of interest.
References
Fig. 1. Coronary angiography (CAG) and optical computed tomography (OCT) findings of stripe-like red thrombi. (A) CAG image of the stripe-like filling defects (arrowheads). (B and C) OCT images showing intraluminal masses with signal attenuation, suggesting red thrombi. (D) Gross appearance of a large, longitudinally grown red thrombus obtained via thrombus aspiration. (E) The consecutive CAG image after thrombus aspiration. (F and G) OCT images showing rupture (arrows) of a fibrous plaque with cholesterol crystal deposition in the culprit lesion.
filling defect on CAG. For planning the medical, endovascular and surgical treatment strategies for patients with those lesions, the accurate characterization of those angiographic filling defects might be critical [4].
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