ANSWER: ISOLATED RV INFARCTION - MIMICKING ANTERIOR OR ANTERO-SEPTAL INFARCTION

RV infarction

• Associates with inferior-posterior wall myocardial infarction in 30 to 50%, depends on criteria and methods used to make the diagnosis.
• Isolated right ventricular infarction is rare. This case may represent one of them (See below)
• Right ventricle blood supply: Dominant RCA - acute marginal branch - RV lateral wall; dominant Cx - postero-lateral branch; conus branch and branch from LAD - RV anterior wall; non or codominant RCA - RV wall except the infero-posterior wall.
• Hemodynamic changes are the results from decreased RV systolic and diastolic function, RV dilatation and pericardial constrain.
• Electrical complication: High grade AV block, atrial fibrillation, arrhythmogenic during cardiac catheterization.
• Diagnosis:
  • Clinical
    • Hypotension, occasional cardiogenic shock
    • Elevated jugular veneous pulse, positive Kussmaul sign.
    • Clear lung.
    • AV block.
  • Laboratories
    • St segment elevation (>1 mm) in right precordial lead (V4R), early and transient, in %.
    • Echocardiogram
    • Radionuclide, technetium study
    • Hemodynamic.
• Treatment:
  • Adequate volume, may require large amount.
  • Inotropic, dobutamine is most used.
  • Preserve AV synchrony, in case of complete AV block.
  • Early reperfusion
  • Unload the left ventricle, if necessary.
• Prognosis:
  • Has higher morbidity and mortality than inferior-posterior myocardial infarction without right ventricular infarction.
  • For those survive, complete recovery from right ventricular infarction is common over a period of weeks to months.

   

Isolated RV infarction

• St segment elevation in V1 to V4.
  • No opposition electrical force from infero-posterior MI to cancel out these changes.
  • Seen in cases of occluded proximal dominant and co-dominant RCA without or with small infero-posterior MI and in cases of occluded non-dominant RCA.
  • St segment elevation has characteristic of higher in V1 and V2, then decrease towards mid precordial leads, with some exception.
  • R wave does not decrease or Q wave does not develop in these leads.
  • Have been reported in acute isolated RV infarction (ischemia), complication of RCA intervention treatment, and during exercise test.

 

REFERENCES

Logeart D, Himbert D, Cohen-Solal A.
ST-segment elevation in precordial leads: anterior or right ventricular myocardial infarction?
Chest. 2001 Jan;119(1):290-2. (can get full text)

Cafri C, Orlov G, Weinstein JM, Kobal S, Ilia R.
ST elevation in the anterior precordial leads during right ventricular infarction: lessons learned during primary coronary angioplasty--a case report.
Angiology. 2001 Jun;52(6):417-20.

Vives MA, Bonet LA, Soriano JR, Lalaguna LA, Saez AO, de Arellano AR, Perez MP.
Right ventricular infarction mimicking anterior infarction: a case report.
J Electrocardiol. 1999 Oct;32(4):359-63. Review.

Mikdadi G, Wadgaonkar SU, Dhurandhar RW, Quintal RE.
Right ventricular infarction complicating right coronary angioplasty.
Catheter Cardiovasc Interv. 1999 Jul;47(3):327-30.

Saw J, Amin H, Kiess M.
Right ventricular ischemia mimicking acute anterior myocardial infarction.
Can J Cardiol. 1999 Oct;15(10):1143-6.

Porter A, Herz I, Strasberg B.
Isolated right ventricular infarction presenting as anterior wall myocardial infarction on electrocardiography.
Clin Cardiol. 1997 Nov;20(11):971-3.

Khan ZU, Chou TC.
Right ventricular infarction mimicking acute anteroseptal left ventricular infarction.
Am Heart J. 1996 Nov;132(5):1089-93.

van der Bolt CL, Vermeersch PH, Plokker HW.
Isolated acute occlusion of a large right ventricular branch of the right coronary artery following coronary balloon angioplasty. The only true 'model' to study ECG changes in acute, isolated right ventricular infarction.
Eur Heart J. 1996 Feb;17(2):247-50.

Fernandez AR, deMarchena EJ, Sequeira RF, Kessler KM.
Acute right ventricular infarction mimicking extensive anterolateral wall injury.
Chest. 1993 Sep;104(3):965-7.

Krueger DW, Lesnefsky EJ, Groves BM, Lindenfeld J.
Right ventricular ischemia and proximal right coronary artery narrowing indicated by exercise ST-segment elevation in lead V1.
Am J Cardiol. 1989 Jan 1;63(1):107-9.

Kataoka H, Kanzaki K, Mikuriya Y.
Massive ST-segment elevation in precordial and inferior leads in right ventricular myocardial infarction.
J Electrocardiol. 1988 Apr;21(2):115-20. Review.

Fujita M, Sasayama S, Sakurai T, Nonogi H. Related Articles
Intracoronary thrombolysis in evolving isolated right ventricular infarction.
Cathet Cardiovasc Diagn. 1987 Jan-Feb;13(1):54-6.

Ilia R, Margulis G, Goldfarb B, Katz A, Rudnik L, Ovsyshcher IA.
ST elevation in leads V1 to V4 caused by isolated right ventricular ischemia and infarction.
Cardiology. 1987;74(5):396-9.

Halkett JA, Commerford PJ, Millar RS.
Right ventricular infarction mimicking extensive anterior infarction.
Chest. 1986 Oct;90(4):617-9.

Lew AS, Prigent F, Maddahi J.
Exercise-induced precordial ST segment elevation due to right ventricular ischemia.
Am Heart J. 1986 Jan;111(1):172-4.

Geft IL, Shah PK, Rodriguez L, Hulse S, Maddahi J, Berman DS, Ganz W.
ST elevations in leads V1 to V5 may be caused by right coronary artery occlusion and acute right ventricular infarction.
Am J Cardiol. 1984 Apr 1;53(8):991-6.

 

GENERAL REFERENCES FOR RV INFARCTION

Kinch, J, Ryan, TJ (1994)
Right ventricular infarction.
N Engl J Med 330,1211-1217 (can get full text)

Haji SA, Movahed A.
Right ventricular infarction--diagnosis and treatment.
Clin Cardiol. 2000 Jul;23(7):473-82. Review.

Cohn JN, Guiha NH, Broder MI, Limas CJ.
Right ventricular infarction. Clinical and hemodynamic features.
Am J Cardiol. 1974 Feb;33(2):209-14.

Kozakova M, Palombo C, Distante A.
Right ventricular infarction: the role of echocardiography.
Echocardiography. 2001 Nov;18(8):701-7. Review.