OFDI-Guided Stentless PCI for Erosion-Related STEMI Unmasking Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) accounts for 2.8% to 5.5% of acute myocardial infarctions in young adults, yet it is often unrecognized at presentation.

A 25-year-old man presented with anterior ST-segment elevation myocardial infarction, ventricular fibrillation, and cardiogenic shock. Angiography revealed a 99% proximal left anterior descending artery stenosis. Intracoronary imaging revealed an organized thrombus-dominant lesion without plaque rupture, suggestive of plaque erosion. Given his young age and large diagonal branch at risk, a prolonged perfusion-balloon inflation was used to achieve TIMI flow grade 3. Persistent antiphospholipid antibody positivity at ≥12 weeks confirmed definite APS; warfarin monotherapy was initiated.

Post hoc confirmation of APS guided long-term vitamin K antagonist therapy, underscoring the value of thrombophilia screening in young-onset myocardial infarction.

Stentless revascularization is a reasonable option in young patients with myocardial infarction and imaging features of plaque erosion. APS should be screened to guide appropriate anticoagulation therapy.