First report of lotus root-like appearance at the site of coronary spasm in a patient with acute coronary syndrome

摘要

A 65-year-old man without coronary risk factors was hospitalized due to frequent chest pain at rest in the early morning. Although electrocardiography showed no significant findings of myocardial ischaemia, his serum troponin I level was elevated at 0.3303 ng/mL (the normal level: <0.032 ng/mL). He was diagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS) and underwent cardiac catheterization. Coronary angiography revealed severe stenosis in the middle left anterior descending (LAD) coronary artery (Panels A1 and A2). Optical coherence tomography (OCT) imaging for detailed evaluation of the bifurcation lesion showed mural thrombus (Panel B1, asterisk) and multiple channels called a ‘lotus root-like appearance’ without atherosclerosis (Panels B2–B4). The lesion was dilated successfully using a cutting balloon (as the first choice) and a drug-coated balloon (Panel A3). Since vasospastic angina was suspected due to his medical history and absence of atherosclerotic changes around the lesion on OCT imaging, we performed a spasm provocation test 1 month after coronary intervention. After intracoronary injection of ergonovine which causes vascular smooth muscle contraction mainly via activation of serotonergic receptors, he complained of chest pain, and electrocardiography showed ST-segment elevation (Panel C). Coronary angiography demonstrated total occlusion of LAD (Panel D, arrowhead). Thus, he was diagnosed with vasospastic angina.