What is the clinical evidence from this study?

Study design: Observational. Population: Spontaneously recanalized coronary thrombus (SRCT) (n=33). Intervention: Optical Coherence Tomography (OCT). Primary outcome: Major adverse cardiac and cerebral events (MACCE).

November 30, 2017Open Access

Diagnosis and Management of Spontaneously Recanalized Coronary Thrombus Guided by Optical Coherence Tomography　― Lessons From the French “Lotus Root” Registry ―

GSGéraud SouteyrandCentre National de la Recherche Scientifique MVMathieu ValladierUniversité Clermont Auvergne NANicolas AmabileInterventional Cardiology

Key Result

Optical coherence tomography-guided management of spontaneously recanalized coronary thrombus, primarily via stenting, was associated with a 9.1% rate of major adverse cardiac and cerebral events over 17 months.

Study Design

Type

Observational (n=33)

Multicenter

Yes

Structured PICO

Population

33 patients (median age 56, 30.3% female) with spontaneously recanalized coronary thrombus confirmed on OCT, followed for a median of 17 months.

Exposure

Optical coherence tomography (OCT)-guided diagnosis and management (stenting performed in 91% of cases).

Outcome

Major adverse cardiac and cerebral events (MACCE), a composite of death from cardiac causes, ischemic or hemorrhagic stroke, myocardial infarction, or need for myocardial revascularization at median 17 months follow-up.composite

OCT is superior to angiography for diagnosing spontaneously recanalized coronary thrombus, and OCT-guided stenting is feasible and associated with good mid-term clinical outcomes.

Limitations

Selection bias due to inclusion of only lesions suggestive or ambiguous on angiography where OCT instrumentation was feasible.
Optic fiber passage and flush may mechanically increase lumen area, underestimating lumen reduction.
Fractional flow reserve (FFR) was implemented in only 1 case, limiting the assessment of ischemic status for each lesion.

Abstract

BACKGROUND: Spontaneous reanalyzed coronary thrombus (SRCT) has been reported in autopsy series, but little is known about SRCT, and it is potentially under-diagnosed in clinical practice. METHODS AND RESULTS: SRCT identified on OCT were included in a French multicenter series, the Lotus Root French Registry. A total of 34 SRCT were identified on OCT in 33 patients (23 male; median age, 56 years; IQR, 52-65 years); 23/33 patients (70%) presented with angina pectoris and/or dyspnea. Three angiographic aspects were distinguished retrospectively: braided, pseudo-dissected, and hazy. Stenosis severity on quantitative coronary analysis varied between 11% and 100% (median, 45%), whereas the reduction in lumen area on OCT varied between 20% and 92% (median, 68%). A typical "lotus root" aspect was confirmed on OCT, consisting of multiple circular concave-edged channels of varying size, numbering between 3 and 12 depending on the slice, separated by smooth-edged septa of high luminosity without posterior attenuation. OCT also served to guide treatment, with stenting in 91% of cases. During the 17-month follow-up 91% of patients had excellent evolution. One death and 3 ACS events occurred. CONCLUSIONS: In this large SRCT cohort, angiography had limited diagnostic value whereas OCT could be used to define disease characteristics and guide treatment of lesions inducing angina pectoris and/or silent myocardial ischemia. OCT-guided management was associated with good prognosis.

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