Organized thrombus is a frequent underlying feature in culprit lesion morphology in non-ST-elevation myocardial infarction. A study using optical coherence tomography and magnetic resonance imaging

Fig. 1. Thrombus healing stages. Histological thrombus healing stages: left panels. Reprinted with permission and adapted from Kramer et al. [3] and Shimokado et al. [14]. Histological early stage (A) and early healing stage thrombi (C) [3]. Late thrombus healing stage and healed/layered plaque visualised on histology (E) and OCT (F) [14].OCT-defined thrombus healing stages: right panels. B Acute thrombus: white thrombus with homogenous light intensity. A mass floating in the lumen or attached to the surface (arrow). Irregular, protruding with clear demarcation from the underlying tissue with irregular lateral delineation. D Organising thrombus: regular, rounded mass with a more concave surface and clear demarcation from underlying tissue (asterisk). The lateral delineation is more regular with a homogenous signal density (arrow) with layered appearance. F Healed/layered plaque: the surface is regular and rounded with a smooth lateral delineation (arrow F). The plaques are heterogenous; there is a clear demarcation to the underlying tissue. There is a signal-rich, bright light intensity compared with the underlying tissue (arrows E)

Fig. 2. OCT flowchart. Patient level: of 90 patients with an angiographic culprit, OCT was performed in 65 patients who were included in this study. Of these, 49 had an OCT culprit. Lesion level: In 65 patients with OCT, 133 coronary artery lesions were identified on angiography. In 23 patients full OCT of all lesions was not possible in a total of 40 (30%) stenoses. Of the 93 angiographically lesions visualized with OCT, 4 double lesions were identified adding to a total of 97 lesions visualized with OCT. Full OCT was possible in 42 (65%) of the 65 patients

Fig. 3. Hierarchical culprit identifiers. Occurrence of the main hierarchical culprit identifiers. Of note, several criteria could be present simultaneously. Numbers represents total number of cases and percentages refers to the number of culprit lesions

Fig. 4. Organizing thrombus as the culprit in NSTEMI. Angiography of proximal LCX including OCT showing a 40% stenosis (A) and corresponding cross-sectional OCT (B) image shows an organizing thrombus due to a darker gradient towards the underlying luminal surface. Complementary CMR images (C; LGE image and D; T2-weighted image) of a single mid-ventricular short-axis slice: A large hyperenhanced area laterally (C, arrows) with a small black core indicating a large infarction with microvascular obstruction. The corresponding T2-weighted image (D) shows a hyperenhanced area with oedema laterally indicating acute infarction