Optical Coherence Tomography in the Setting of an Acute Anterior Myocardial Infarction
An 82-year-old man presented with an acute anterior myocardial infarction and was treated with intravenous reteplase with successful reperfusion. Forty-eight hours later, however, he developed further chest pain and ST-segment elevation. He was referred for salvage percutaneous coronary intervention.
The left anterior descending artery was completely occluded proximally (Figure, A) with no detectable collateral flow, and the remainder of the coronary circulation showed diffuse nonsignificant disease. The left anterior descending artery was engaged with a JL4 guide catheter and wired with a Whisper J wire. The lesion was predilated with a 1.5-mm noncompliant balloon that restored flow to the left anterior descending artery and demonstrated a tight culprit lesion in the left anterior descending artery (Figure, B). This was then imaged with optical coherence tomography (OCT), which was facilitated by bolus contrast injection instead of proximal vessel occlusion. Panel C of the Figure demonstrates the composition of the plaque, which was disrupted with fibrocalcific material in the wall and thrombus in the vessel lumen. The lesion was then further dilated with a 2.5/12-mm balloon, stented with a 3.5/12-mm drug-eluting stent, and finally postdilated with a 3.5/9-mm balloon with an excellent angiographic result (Figure, D). OCT was then performed with proximal balloon occlusion at the end of the case, which showed a widely patent vessel, good stent apposition, and no luminal thrombus (Figure, E).
OCT is a novel, high-resolution, intravascular imaging modality that provides “optical biopsies” of the vascular wall.1,2 Because blood interferes with the imaging capabilities of the OCT probe, vessel occlusion followed by saline injection is generally performed to permit viewing. An alternative strategy is concurrent imaging during the injection of a contrast bolus to displace blood; this alternative technique was adopted in the present case during the initial sequence of imaging, when blood flow was diminished as a result of the recently ruptured plaque. Adequate images were obtained with no significant delay using this procedure. The present case shows the OCT images of a ruptured plaque detected during salvage percutaneous coronary intervention after an anterior myocardial infarction, which was performed in a hemodynamically stable patient with failed thrombolysis, to characterize the culprit lesion. Such an approach could potentially be used to broaden the application of OCT.
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