Young ST-Segment Elevation Myocardial Infarction With Autolysis: Survival of the Blessed

Many times, young patients with ST-segment elevation myocardial infarction (STEMI) are angina free during primary percutaneous coronary intervention and have patent infarct-related artery with TIMI flow grade 3 due to the process of autolysis. These cases pose a great challenge to the interventionist mind. This case series provides a new perspective to the management of such patients.

Patient 1 is a 31-year-old man who presented with STEMI. During primary percutaneous coronary intervention (PPCI), thrombus laden left anterior descending artery (LAD) with TIMI flow grade 3 was noted. Stenting was deferred and repeat coronary angiogram (CAG) after 4 weeks showed resolved thrombus and optical coherence tomography (OCT) showed healed plaque rupture. Patient 2 is a 29-year-old man who presented with STEMI of 12 hours' duration. During PPCI, mid-LAD had thrombus and TIMI flow grade 3. Stenting was deferred, and antithrombotic therapy was given. Repeat CAG showed complete resolution of thrombus, and OCT showed features of plaque erosion with adequate luminal areas. Patient 3 is a 31-year-old man undergoing treatment for nonseminomatous germinal cell tumor who presented with STEMI. During PPCI, LAD had nonocclusive thrombus with TIMI flow grade 3. Stenting was deferred and managed medically. CAG 4 weeks later showed resolution of thrombus and adequate luminal areas with a healing intramural hematoma on OCT.

Young STEMIs with features of autolysis during PPCI may be managed without stent placement if they have a favorable autolysis profile. OCT in these patients helped to understand the underlying pathophysiological mechanism of STEMI.