A Minus That Makes the Difference

Background: Acute Coronary Syndromes include a wide variety of clinical scenarios. Coronary Angiography (CA) is a low-resolution imaging technique and its inability to provide a satisfactory tissue characterization of culprit lesions could be a concern in some cases. Optical Coherence Tomography (OCT) is an emergent intravascular high-resolution imaging modality which could be complementary to CA in challenging cases. We report a case of a young man in whom OCT had been determinant to understand the pathology of culprit lesion and to formulate a tailored therapy. Case presentation: We report a case of a 28-years-old man, presenting to the emergency department and complaining of acute chest pain lasting about 30 minutes. Cardiovascular risk factors were cigarette smoking and familial history of Coronary Artery Disease. At admission both EKG and echocardiogram were unremarkable; a mild positivization of high sensitive troponine T was detected. The next day CA was performed showing a “minus” image in the proximal Left Anterior Descendent Artery (LAD), highly suspicious for a pedunculated, non-stenosing, adherent wall thrombus which prompted adequate antithrombotic and anticoagulant therapy. At control angiography we performed an OCT study which showed a thin-capped eccentric vulnerable plaque. We therefore decided to implant a bioresorbable scaffold on the proximal LAD. Subsequent thrombophilia screening showed severe hyperhomocysteinemia and homozygous C677T Methylenetetrahydrofolate Reductase mutation. The patient was discharged home 2 days later on aspirin, ticagrelor, folic acid and vitamins B6 and B12. At 6-month follow-up, a new OCT image acquisition showed satisfactory apposition of the bioresorbable scaffold. Conclusions: OCT is a promising high-resolution intravascular imaging modality able to provide a comprehensive tissue characterization of unstable coronary plaques. OCT should be used as a complementary technique in challenging clinical scenarios.