An evolutive phenotype of calcified nodule - from silence to noise: A case report

Calcified nodules constitute a significant burden to successful percutaneous coronary interventions, and are associated with high recurrences. This article describes a rare case in which a previously identified non-eruptive calcified nodule was later observed to have an eruptive phenotype in the setting of acute coronary syndrome. A 65-year-old female presented with chest pain and subsequently underwent intra-aortic balloon pump and optical coherence tomography -assisted high-risk percutaneous coronary intervention of the left main artery, which demonstrated an unusually developed eruptive calcified nodule at the location of a previously recognized non-eruptive calcified nodule. Despite procedural success, the patient later suffered a non-ST-elevation myocardial infarction, secondary to plaque fragments re-protrusion into the stent lumen requiring subsequent intervention. Calcified nodules typically become stable, non-eruptive lesions, forming from either healing of a prior eruptive calcified nodule or through progressive lipidic or calcific remodeling. However, this case highlights the atypical progression from a non-eruptive to an eruptive phenotype, underscoring the need for increased vigilance and long-term monitoring of these lesions. • Non-eruptive calcified nodules have potential to transform into the eruptive state. • Eruptive nodules are among the most challenging lesions to manage. • Calcium re-protrusion through stent struts poses a high-risk complication. • Long-term surveillance is essential for patients with calcified nodules.