International Journal of Cardiology 173 (2014) e70–e71
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
First observation of acute coronary syndrome triggered by calcified nodules. Angiographic and optical coherence assessment Ramón Rodríguez-Olivares a, Arturo García-Touchard b,⁎, Roberto Diletti a, Juan Francisco Oteo b, Jose Antonio Fernández-Díaz b, Jose Ramón Domínguez-Domínguez b, Javier Goicolea Ruigómez b a b
Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Department of Interventional Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
a r t i c l e
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Article history: Received 10 February 2014 Accepted 22 March 2014 Available online 28 March 2014 Keywords: Calcified nodules Acute coronary syndrome Thrombosis Optical coherence tomography
A 68-year-old man with a history of chronic ischemic heart disease was admitted due to a Non-ST-elevation myocardial infarction.
Coronary angiogram showed three discrete regions of haziness located at the mid segment of the circumflex. These findings were initially interpreted as indicative of thrombotic material. In order to further investigate this lesion, an OCT was performed, revealing three calcified eccentric and irregular protuberances compatible with calcified nodules. A moderate amount of thrombotic material was observed to be attached to those calcified lesions (asterisk). The presence of thrombus at the site of the calcified nodules is supportive of the unstable nature of these structures in the present case (Fig. 1). A percutaneous coronary intervention was therefore performed with the implantation of a drug eluting stent with a good angiographic result. The real incidence of in vivo calcified nodules is still unclear. In pathological studies, 2% of all sudden coronary deaths were attributed to acute thrombi caused by complicated calcified nodules [1]. IVUS
Fig. 1. Right image shows a coronary angiogram of a patient admitted with an acute coronary syndrome. Three regions with hazy appearance were observed in the mid circumflex (A, B and C). At the left an OCT of the mid circumflex artery showing longitudinal and cross-section images of three calcified nodules (A, B and C). Thrombus is observed on the calcified lesion surface (asterisks). ⁎ Corresponding author at: Department of Interventional Cardiology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain. E-mail address: [email protected] (A. García-Touchard).
http://dx.doi.org/10.1016/j.ijcard.2014.03.164 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
R. Rodríguez-Olivares et al. / International Journal of Cardiology 173 (2014) e70–e71
based investigations, reported lesions likely to be calcified nodules as a common finding in non-culprit vessels [2]. However this is the first demonstration of the fact that calcified structures protruding into the lumen could be associate in vivo with thrombus formation and acute coronary syndrome. References [1] Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol 2000;20:1262–75.
e71
[2] Xu Y, Mintz G, Tam A, et al. Prevalence, distribution, predictors, and outcomes of patients with calcified nodules in native coronary arteries: a 3-vessel intravascular ultrasound analysis from Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT). Circulation 2004;126:537–45.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
First observation of acute coronary syndrome triggered by calcified nodules. Angiographic and optical coherence assessment Ramón Rodríguez-Olivares a, Arturo García-Touchard b,⁎, Roberto Diletti a, Juan Francisco Oteo b, Jose Antonio Fernández-Díaz b, Jose Ramón Domínguez-Domínguez b, Javier Goicolea Ruigómez b a b
Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Department of Interventional Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 10 February 2014 Accepted 22 March 2014 Available online 28 March 2014 Keywords: Calcified nodules Acute coronary syndrome Thrombosis Optical coherence tomography
A 68-year-old man with a history of chronic ischemic heart disease was admitted due to a Non-ST-elevation myocardial infarction.
Coronary angiogram showed three discrete regions of haziness located at the mid segment of the circumflex. These findings were initially interpreted as indicative of thrombotic material. In order to further investigate this lesion, an OCT was performed, revealing three calcified eccentric and irregular protuberances compatible with calcified nodules. A moderate amount of thrombotic material was observed to be attached to those calcified lesions (asterisk). The presence of thrombus at the site of the calcified nodules is supportive of the unstable nature of these structures in the present case (Fig. 1). A percutaneous coronary intervention was therefore performed with the implantation of a drug eluting stent with a good angiographic result. The real incidence of in vivo calcified nodules is still unclear. In pathological studies, 2% of all sudden coronary deaths were attributed to acute thrombi caused by complicated calcified nodules [1]. IVUS
Fig. 1. Right image shows a coronary angiogram of a patient admitted with an acute coronary syndrome. Three regions with hazy appearance were observed in the mid circumflex (A, B and C). At the left an OCT of the mid circumflex artery showing longitudinal and cross-section images of three calcified nodules (A, B and C). Thrombus is observed on the calcified lesion surface (asterisks). ⁎ Corresponding author at: Department of Interventional Cardiology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain. E-mail address: [email protected] (A. García-Touchard).
http://dx.doi.org/10.1016/j.ijcard.2014.03.164 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
R. Rodríguez-Olivares et al. / International Journal of Cardiology 173 (2014) e70–e71
based investigations, reported lesions likely to be calcified nodules as a common finding in non-culprit vessels [2]. However this is the first demonstration of the fact that calcified structures protruding into the lumen could be associate in vivo with thrombus formation and acute coronary syndrome. References [1] Virmani R, Kolodgie FD, Burke AP, Farb A, Schwartz SM. Lessons from sudden coronary death: a comprehensive morphological classification scheme for atherosclerotic lesions. Arterioscler Thromb Vasc Biol 2000;20:1262–75.
e71
[2] Xu Y, Mintz G, Tam A, et al. Prevalence, distribution, predictors, and outcomes of patients with calcified nodules in native coronary arteries: a 3-vessel intravascular ultrasound analysis from Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT). Circulation 2004;126:537–45.
