In Vivo Optical Coherence Tomography Detection of Repetitive Plaque Erosion Leading to Healed Plaques and Lesion Progression

Plaque erosion is the second most common cause of acute coronary syndromes (ACS). Small studies using optical coherence tomography (OCT) have shown favorable outcomes in select patients with plaque erosion treated conservatively without stent implantation. Unlike plaque rupture, the role of plaque erosion in the formation of healed plaques and subsequent flow-limiting coronary stenoses is less certain. We present the case of a medically managed anterior ST-segment elevation myocardial infarction (STEMI) in a 53-year-old man, secondary to plaque erosion in the mid-left anterior descending (LAD) artery. Repeat OCT at 2 weeks demonstrated adequate resolution of intraluminal thrombus along with plaque layering with varying optical densities and negative invasive physiological testing. This case provides unique in vivo evidence of plaque erosion healing leading to the development of further plaque layering. We hypothesize that the multilayered plaque appearance after erosion is representative of repetitive episodes of plaque instability at the same coronary location, which may eventually lead to progression of plaque and reduction of lumen. Finally, there is mounting evidence that healed plaques represent an important predictor of future adverse events, raising important questions regarding the preconceived notion that plaque erosion has a benign course when treated conservatively.