Isolated right ventricular infarction after modified Cabrol operation

We report the case of a 27-year-old woman with a rare presentation of right ventricular failure secondary to isolated right ventricular myocardial infarction, 3 weeks after an uncommon surgical procedure, the modified Cabrol operation. Her medical history also included a Ross procedure at the age of 12 years. On the basis of her subacute presentation and a consultation with cardiac surgeons, we decided on medical management. Follow-up echocardiography at 6 months revealed that the right ventricular systolic function remained severely impaired, but the patient was asymptomatic with excellent functional capacity.We review the surgical techniques of aortic graft replacement and their respective complications. We also discuss the impact of conservative and reperfusion strategies on prognosis and long-term outcomes in the setting of right ventricular infarction.     

Isolated right ventricular aneurysm following right ventricular infarction

A 78-year-old man with atherosclerotic heart disease developed extensive right ventricular infarction fibrosis with aneurysm formation following right coronary artery occlusion. No symptoms of right-sided heart failure were present. Postmortem examination revealed that 40% of the right ventricle, 11% of the septum and 7% of the left ventricular free wall were infarcted due to right coronary artery occlusion. This is the first documented case of isolated aneurysm of the right ventricle following infarction and it demonstrates that even extensive right ventricular destruction may be present without symptoms.     

Isolated right ventricular infarction followed by posterior left ventricular infarction after a few days

This report presents a rare case of isolated right ventricular infarction complicated by bilateral occlusive pulmonary embolism apparently due to right ventricular mural thrombus. Only 2 to 3 weeks later an infarct of the posterior wall of the left ventricle finally occurred. The clinical, pathological and electrocardiographic features of the case are discussed. This case shows that right ventricular infarct can occur without a preceding or simultaneous infarct of the left ventricle.     

Acute right ventricular infarction

This article reviews the pathophysiology, hemodynamics, natural history, and management of patients with inferior myocardial infarction complicated by right ventricular infarction. Five key areas are highlighted in which advances may impact catheterization and laboratory management of these acutely ill patients.     

Pure right ventricular infarction

The case is reported of a patient with chronic emphysema andcor pulmonale who developed the signs of acute myocardial infarctionwhich were initially interpreted as being localized in the postero-inferiorwall of the left ventricle. The patient rapidly developed thefeatures of massive right heart failure in the absence of pulmonarycongestion, a condition thought to be due to pulmonary emboli.The autopsy, however, revealed a pure right ventricular infarct,which covered more than half of the pre-existent right ventricularmyocardium, in the setting of marked right ventricular hypertrophyinfraction. The case furthermore shows that the possibilityof pure right ventricular infarction should be evaluated inall patients with puzzling right heart failure, in the courseof what initially is thought to be an acute left ventricularinfraction, is important since therapy with plasma volume expandersshould be used with great caution in such patients     

Assessment of right ventricular function after successful revascularization for acute anterior myocardial infarction without right ventricular infarction by echocardiography

BackgroundRight ventricular (RV) involvement in acute left ventricular (LV) myocardial infarction (MI) is frequently underestimated in the clinical setting owing to the diagnostic limitations of the electrocardiogram and echocardiography.ObjectiveTo assess RV function in patients presented with first acute anterior ST elevation myocardial infarction (STEMI) who underwent successful primary percutaneous coronary intervention (PCI) and factors affecting it.MethodsForty consecutive patients with anterior STEMI who underwent successful primary PCI were enrolled in the study. Presence of a coexisting clinical condition that might affect RV function, patients with RV infarction or those having significant stenosis (>50%) affecting RV branch or right coronary artery proximal to RV branch were excluded. Echocardiography was performed during the hospital stay to assess the LV and RV systolic and diastolic function with special focus on tricuspid annular plane systolic excursion, RV end-diastolic dimension, right atrial area, RV fractional area change, and tissue Doppler-derived myocardial performance index.Results and ConclusionRV dysfunction according to our definition in the first anterior MI occurred in (55%) of the study population. Independent predictors for abnormal RV function were left circumflex artery mid or proximal affection, eventful procedure, occurrence of no reflow, glucose level, LV end-systolic dimension, LV end-diastolic dimension, and LV ejection fraction.     

Acute right ventricular infarction without infero-posterior left ventricular infarction

Two cases of acute right ventricular infarction associated with acute extensive anterior myocardial infarction in the absence of inferior and/or posterior left ventricular infarction are presented. Such a combination is likely to occur from acute occlusion of the left anterior descending artery in the face of severe narrowing of the infundibular (conus) artery rather than from acute occlusion of the right coronary artery.     

Rapid hemodynamic improvement in right ventricular infarction after coronary angioplasty

A patient is described where the hemodynamic disturbance caused by a right ventricular infarction was promptly corrected after coronary angioplasty (PTCA). This indicates that reperfusion may be useful in managing hypotension due to predominant right ventricular infarction.     

Right ventricular aneurysm complicating right ventricular infarction

Right ventricular (RV) involvement commonly occurs in patients with acute inferior myocardial infarction and is associated with high mortality and morbidity. RV dysfunction and dilatation commonly recover in survivors; chronic RV dyskinesia and failure are rare complications. This case report presents a patient in whom an isolated RV aneurysm complicates a RV involvement of acute inferior-posterior myocardial infarction.     

Collateral vessel development after right ventricular infarction in the pig

Although the right coronary artery supplies both ventricles in the pig, a gradual proximal right coronary occlusion produces infarction in the left ventricle, whereas the right ventricle is usually spared. This study evaluates the influence of right ventricular hypertension and hypertrophy (RVHH) on the occurrence of right ventricular infarction and the difference in the rate and extent of collateral vessel development after gradual right coronary occlusion in pigs with (RVHH group) and without (control group) increased right ventricular pressure and mass. Right ventricular hypertension and hypertrophy were induced by pulmonary arterial banding which raised right ventricular systolic pressure from 24 to 74 mm Hg and doubled right ventricular mass in 4 weeks. Right coronary occlusion was produced with an ameroid constrictor in 24 control group pigs and 15 RVHH pigs. Serial selective coronary cineangiograms on days 4, 8, 14, 21 and 28 after ameroid constrictor placement showed no difference in first appearance of collateralization to the occluded right coronary artery. Total collateralization, which was present in all pigs studied in the control group by days 21 and 28, was present in only 57 percent of the RVHH group at the same time. Although left ventricular infarction occurred in all animals in both groups, right ventricular infarction was not found in the control group but was seen in 80 percent of the RVHH group. There was no correlation between the degree of collateralization seen and the size of the right ventricular infarction found. Experimentally induced right ventricular hypertrophy and hypertension make the right ventricle susceptible to infarction and impeded total collateral filling of the occluded right coronary artery in some of the animals studied.     

Isolated right ventricular infarction.

The literature on isolated right ventricular infarction is reviewed and local experience is reported. Chronic lung disease is an important risk factor. Chest pain and breathlessness are common. Syncope and sudden collapse can also occur. Rhythm disorders include sinus bradycardia, atrial fibrillation and ventricular tachycardia or fibrillation. Atrioventricular block is rare. Hypotension and a right-sided fourth heart sound are common. Cautious use of slow-release nitroglycerin is not hazardous in the absence of hypotension. High doses of steroids and anticoagulants can be helpful. The prognosis is usually good, although sudden collapse can occur due to ventricular fibrillation, rupture of the right ventricular free wall or massive pulmonary embolism.     

Pure right ventricular infarction.

A 76-year-old man with chest pain was admitted to hospital where electrocardiography (ECG) showed ST-segment elevation in leads V1-4, indicative of acute anterior myocardial infarction. ST-segment elevation was also present in the right precordial leads V4R-6R. Emergency coronary angiography revealed that the left coronary artery was dominant and did not have significant stenosis. Aortography showed ostial occlusion of the right coronary artery (RCA). Left ventriculography showed normal function and right ventriculography showed a dilated right ventricle and severe hypokinesis of the right ventricular free wall. Conservative treatment was selected because the patient's symptoms soon ameliorated and his hemodynamics was stable. 99mTc-pyrophosphate and 201Tl dual single-photon emission computed tomography showed uptake of 99mTc-pyrophosphate in only the right ventricular free wall, but no uptake of 99mTc-pyrophosphate and no perfusion defect of 201Tl in the left ventricle. The peak creatine kinase (CK) and CK-MB were 1,381 IU/L and 127 IU/L, respectively. His natural course was favorable and the chest pain disappeared under medication. Two months after the onset, the ECG showed poor R progression in leads V1-4 indicating an old anterior infarction. Coronary angiography confirmed the ostial stenosis of the hypoplastic RCA. This was a case of pure right ventricular free wall infarction because of the occlusion of the ostium of the hypoplastic RCA, but not of the right ventricular branch. Because the electrocardiographic findings resemble those of an acute anterior infarction, it is important to consider pure right ventricular infarction in the differential diagnosis.