Stent-Free Sirolimus DCB for Left Main STEMI: Acute and Long-Term OCT Follow-Up.

BACKGROUND: Left main (LM) ST-elevation myocardial infarction (STEMI) is typically managed with urgent stent implantation according to current guidelines. Yet intravascular imaging has shown that plaque erosion may permit alternative strategies. CASE SUMMARY: A 43-year-old man with anterior STEMI and hypotension underwent angiography, revealing distal LM thrombus extending into the left anterior descending/left circumflex arteries. Postaspiration optical coherence tomography (OCT) confirmed plaque erosion without rupture. Following lesion preparation, a drug-coated balloon-only strategy was applied to all 3 vessels. Follow-ups at 20 days and 15 months confirmed vessel patency, satisfactory healing, and no recoil or neoatherosclerosis. DISCUSSION: Current guidelines lack support for stent-free LM STEMI intervention. However, OCT-guided management allows for individualized treatment in young patients by characterizing lesion biology. Long-term follow-up demonstrates successful vessel healing, suggesting that avoiding permanent metallic scaffolds in selected cases may mitigate lifelong stenting risks. TAKE-HOME-MESSAGE: OCT can identify plaque erosion and guide stent-free percutaneous coronary intervention in select left main STEMI cases, offering durable healing and flexibility in antithrombotic therapy.