Primary angioplasty for isolated right ventricular infarction.

We describe a case of isolated right ventricular infarction that has rarely been diagnosed antemortem. Electrocardiogram showed ST segment elevation in left precordial chest, right precordial chest, and inferior leads, which mimicked those of anterior and inferior left ventricular infarction. Coronary angiography revealed that culprit lesion was totally occluded right coronary artery. Infarcted artery was nondominant right coronary artery with branches supplying only right ventricular wall. Restoration of coronary blood flow was obtained by primary stenting and resulted in prompt ST segment normalization in all leads. Despite extensive right ventricular wall motion abnormality, subsequent right ventricular dysfunction was not observed.     

Nonischemic changes in right ventricular function on exercise. Do normal volunteers differ from patients with normal coronary arteries?

Factors other than ischemia may alter right ventricular function both at rest and on exercise. Normal volunteers differ from cardiac patients with normal coronary arteries with regard to their left ventricular response to exercise. This study examined changes in right ventricular function on exercise in 21 normal volunteers and 13 patients with normal coronary arteries, using first-pass radionuclide angiography. There were large ranges of right ventricular ejection fraction in the two groups, both at rest and on exercise. Resting right ventricular ejection fraction was 40.2 +/- 10.6% (mean +/- SD) in the volunteers and 38.6 +/- 9.7% in the patients, p = not significant, and on exercise rose significantly in both groups to 46.1 +/- 9.9% and 45.8 +/- 9.7%, respectively. The difference between the groups was not significant. In both groups some subjects with high resting values showed large decreases in ejection fraction on exercise, and there were significant negative correlations between resting ejection fraction and the change on exercise, r = -0.59 (p less than 0.01) in volunteers, and r = -0.66 (p less than 0.05) in patients. Older volunteers tended to have lower rest and exercise ejection fractions, but there was no difference between normotensive and hypertensive patients in their rest or exercise values. In conclusion, changes in right ventricular function on exercise are similar in normal volunteers and in patients with normal coronary arteries. Some subjects show decreases in right ventricular ejection fraction on exercise which do not appear to be related to ischemia.     

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

An isolated right ventricular infarction occurs rarely and dataon its electrocardiographic appearance and underlying angiographicallyproven cause are scarce. The electrocardiographic response ofacute right ventricular ischaemia is often obscured by the coexistingforces of the ischaemic mass of the inferior wall of the leftventricle when the right coronary artery itself becomes occluded.Percutaneous transluminal coronary angioplasty of the rightcoronary artery may cause an isolated occlusion of a right ventricularbranch. We encountered this phenomenon in nine patients. Inall, it led to acute isolated right ventricular ischaemia withST elevations in the right precordial leads (V₁–V₃, V₃Rand V₄R on the electrocardiogram. We conclude that the ECG pattern of pure right ventricular ischaemiacan be seen when an isolated occlusion of a large right ventricularbranch occurs, for example as a complication of percutaneoustranslummal coronary angioplasty.     

Single coronary artery with the right coronary artery arising from the first septal perforator

A 50-year-old woman with chest pain and an exercise thallium-201 scintigram positive for focal ischemia was found on coronary arteriography to have a heretofore unreported variant of single left coronary artery with the right coronary artery originating as a branch from the first septal perforator. Proximally, the aberrent vessel coursed through the ventricular septum at the level of the right ventricular outflow tract. A conus artery was absent and this is a possible basis for the focal basal ventricular ischemia and the patient's symptoms.     

Incidence of exertional right ventricular wall motion abnormalities in patients with coronary artery disease

To evaluate the role of analysis of right ventricular function with exercise in patients with presumed coronary artery disease referred for radionuclide ventriculography, the records of 55 patients referred to our laboratory over a 19-month period were reviewed. All underwent rest and exercise first-pass radionuclide stress testing and cardiac catheterization within a period of four months. Three groups were identified: (1) patients with normal exercise right ventricular function (n = 24); (2) patients with exercise-induced right ventricular regional wall motion abnormalities (n = 15); and, (3) patients with abnormal resting right ventricular function without new exercise abnormalities (n = 16). Patients in each group were similar in age, sex, baseline left ventricular function, medication usage, and indication for study. The incidence of right coronary artery disease was identical in the three groups, as was the incidence of left ventricular functional abnormalities with exercise. Patients with proximal right coronary artery disease were more likely to have reduced left ventricular ejection fraction and more extensive coronary artery disease than those without disease at this site. We conclude that: (1) analysis of rest and exercise right ventricular function does not allow prediction of coronary anatomy in an unselected group of patients; (2) normal right ventricular function with exercise is compatible with extensive coronary artery disease, including proximal right coronary artery disease; and (3) abnormal exercise right ventricular function may be due to exertional left ventricular dysfunction in the absence of proximal right coronary artery disease.     

Stress long-axis function in coronary artery spasm.

In a patient with prior myocardial infarction who had complained of frequent angina repeat arteriograms proved normal coronary arteries. Both ECG exercise testing and thallium scanning excluded ischemia. Resting echocardiogram showed increased distal septal and right ventricular apical myocardial echo intensity. Dobutamine stress echo demonstrated right ventricular and posteroseptal abnormalities consistent with ischemia. Repeat angiogram with ergonovine confirmed distal right coronary spasm.     

The impact of right atrial ischemia on inferior myocardial infarction with extension to right ventricle: transesophageal echocardiographic examination

BACKGROUND: The role of the right atrium in adaptation to the hemodynamic changes produced by extension of myocardial infarction (MI) of the left ventricular inferior wall to the right ventricle is fundamental. HYPOTHESIS: The aim of this study was analyze a group of patients with MI with extension of right chambers, and particularly right atrial alterations, by transesophageal echocardiography and to correlate it with clinical and angiographic variables. METHODS: Thirty patients with right ventricular (RV) MI involving obstruction of the right coronary artery without stenosis of the left coronary artery were included; 18 underwent early reperfusion. Transesophageal echocardiography was performed on all within 5 days of coronary angiography. Follow-up was continued from hospitalization to the present. RESULTS: When patients with right atrial ischemia were compared with those with normal right atrium, the RV wall movement score was significantly greater in the group with right atrial ischemia, severe RV dilatation was more frequent, and association with proximal occlusion of the artery responsible for the MI, as well as absence of right atrial branches and poor collateral circulation, were significant. Hospitalization was more prolonged in this group, and there was a higher incidence of arrhythmias, complete atrioventricular block, and mortality. CONCLUSIONS: Right atrial ischemia associated with RV infarction leads to a higher incidence of complications and higher mortality. Transesophageal echocardiography is a safe, reproducible technique that provides detailed anatomic information about right chambers and aids in the determination of prognosis and therapeutic decisions.     

Anomalous right coronary artery from the main pulmonary artery in a patient with double-chambered right ventricle

We describe a rare case of double-chambered right ventricle (DCRV) in a 32-year-old female presenting to the echocardiography lab for evaluation of congenital heart disease. We identified a unique constellation of findings, including the DCRV, a perimembranous ventricular septal defect, aortic valve prolapse, patent foramen ovale, and an anomalous right coronary artery coming off the main pulmonary artery. To the best of our knowledge, this is the first reported case describing the association of an anomalous right coronary artery coming off the main pulmonary artery in a patient with DCRV.     

Importance of a non-dominant right coronary artery occlusion presenting as sudden cardiac death with prolonged right ventricular dysfunction and malignant arrhythmias

We report a case of a patient who presented with sudden cardiac death secondary to a subtotal occlusion of a small non-dominant right coronary system. Catheterization several weeks following the initial episode revealed persistent severe right ventricular dysfunction with moderate hemodynamic compensation. Continued unstable arrhythmogenic potential at this point led to placement of an AICD device. The case highlights the potential hazard and often complacency involved in dealing with benign appearing lesions as this one. © 1995 Wiley-Liss, Inc.     

ST segment elevation in leads V1 to V3 due to isolated right ventricular branch occlusion during primary right coronary angioplasty.

It is rare to observe ST elevation in anterior derivations caused by isolated right ventricular branch occlusion. We described the case with acute inferior and right ventricular myocardial infarction (MI) who developed ST segment elevation in precordial leads V(1) to V(3) due to isolated right ventricular branch occlusion during primary right coronary angioplasty.     

Right ventricular outflow tract obstruction caused by a right coronary cusp prolapse: An unusual finding

Patients with large sub-pulmonic ventricular septal defect (VSD) present early as a results of their complications. Some present late, due to the restriction of VSD by the right coronary cusp (RCC) due to its prolapse. In this report, we present a rare case of sub-pulmonic VSD in a 33-year-old man who developed a sub-pulmonic stenosis due to the prolapse of the RCC into the right ventricular outflow tract.     

Nondominant right coronary artery occlusion and ventricular tachyarrythmias.

It is usually considered that occlusion of a nondominant right coronary artery is not associated with significant consequences. We report two cases of nondominant right coronary artery occlusion that presented with sudden cardiac death. Timely intervention resulted in complete resolution of the ventricular arrhythmias. This highlights the need for greater vigilance in the recognition and treatment of these lesions.     

Double right coronary artery arising from the left main stem and right coronary sinus associated with ventricular septal defect in an adult: an extremely rare case

Anomalies of the coronary arteries are often asymptomatic and uncommon in general population. In this report we describe a case of a 48-year-old male patient with ventricular septal defect and double right coronary artery originating from the left main coronary artery and the right coronary sinus.     

ST elevation in leads V1 to V4 caused by isolated right ventricular ischemia and infarction

A patient with isolated right ventricular ischemia and infarction is presented. ST elevation in leads V1 to V4 mimicking anteroseptal myocardial infarction was recorded at admission and during episodes of chest pain later on. Noninvasive and invasive workup suggested isolated right ventricular infarction and ischemia due to an occluded small and nondominant right coronary artery.     

先天性右冠状动脉缺如一例并文献复习

目的探索先天性右冠状动脉缺如的变异现象及其临床意义。方法分析我科诊治的1例和国内外文献报道的51例先天性右冠状动脉缺如患者的临床资料,并结合相关文献进行讨论。结果冠状动脉造影术诊断44例,冠状动脉CT血管成像诊断6例,外科探查诊断2例。25例患者表现为心肌缺血症状,合并左冠状动脉明显病变时可出现严重心脏症状,约1/3患者可出现心律失常,其中病态窦房结综合征3例,心房颤动6例,Ⅲ度房室传导阻滞1例。治疗上,10例行冠状动脉血运重建术,2例行心脏起搏器植入术,12例予药物治疗。结论单纯先天性右冠状动脉缺如多表现为良性临床过程,但在心律失常方面有潜在的危险性,故需保持随访与治疗,一旦合并左冠状动脉病变应早期积极治疗。MDCT可作为检测冠状动脉变异的筛查手段。     

Transient but marked ST elevation in precordial leads caused by ischemia of the isolated right ventricular branch

The present case is a 64 year-old man in whom transient but marked ST elevation was confirmed in the contralateral precordial leads (V1-3) during percutaneous transluminal coronary angioplasty (PTCA) of the proximal right coronary artery, suggesting that the patient had anteroseptal ischemia. The ST elevation persisted even after the balloon was deflated, and no changes in the left coronary artery were detected. In addition, blood flow in the affected area of the right coronary artery was favorable and there was a transient delay only in the right ventricular branch. Once blood flow in the right ventricular branch improved, ST returned to baseline, and when the right ventricular branch was again occluded by the balloon, ST elevation occurred in a reproducible manner. Hence, the electrocardiographic changes in the precordial leads were caused by occlusion of the right ventricular branch. It is rare to observe ST elevation caused by isolated right ventricular branch ischemia.     

用多普勒组织成像评价冠状动脉狭窄患者右室舒张功能

目的 :应用多普勒组织成像 （DTI）技术评价冠状动脉狭窄患者右室整体舒张功能的变化。方法 :测定三尖瓣环的运动速度及各舒张功能参数。结果 :单纯左冠状动脉狭窄组右室舒张功能均减低 ,混合支冠状动脉狭窄组右室舒张功能较单纯左支冠脉狭窄组进一步减低。结论 :DTI评估冠状动脉狭窄患者的右室舒张功能有一定的临床应用价值     

Aberrant right coronary artery origin from the left aortic sinus with interarterial course manifesting acute myocardial infarction

A 43-year-old patient was admitted to hospital because of an inferior-posterior myocardial infarction. The admission electrocardiogram was suggestive of a right coronary artery (RCA) culprit lesion. Coronary angiography following successful thrombolysis revealed a normal left system and mild intraluminal disease of the dominant RCA, which arose from the left aortic sinus and travelled an interarterial course; the latter was depicted in a subsequent computed tomographic angiogram. The lack of ST segment elevation in V4R and the absence of right ventricular wall motion abnormalities on echocardiography precluded the proximal ectopic vessel from being the culprit. The patient was managed medically; one year following discharge, he is asymptomatic. In cases of aberrant anomalous origin of a coronary artery from the opposite sinus with interarterial course, the proximal ectopic vessel is intussuscepted within the aortic wall, potentially leading to ischemia. The present article highlights that, although medical treatment in cases of such an aberrant RCA without apparent ischemia-driven sequelae may be valid, the need for interventional treatment could be substantiated following investigation of the anatomofunctional features of the intussuscepted proximal ectopic segment with intravascular ultrasound.     

Use of a coronary sinus lead and biventricular ICD to correct a sensing abnormality in a patient with arrhythmogenic right ventricular dysplasia/cardiomyopathy

Implantable cardioverter defibrillators (ICDs) are frequently offered to patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C). Yet ICDs in these patients may be complicated by poor sensed amplitudes resulting from fatty and fibrous tissue replacement of right ventricular myocardium. We present the case of a patient with ARVD/C who had inappropriate detection of ventricular tachycardia with a single-chamber ICD due to poor sensed right ventricular amplitudes. We discuss how the use of a bipolar coronary sinus lead and a biventricular ICD generator with a novel header configuration solved the problem.     

Influence of right ventricular ischemia on septal Q waves determined by coronary angioplasty.

The aim of this study is to evaluate the influence of right ventricular ischemia on the amplitude of septal Q waves. Twenty-two patients without previous myocardial infarction who underwent isolated right coronary artery angioplasty were studied. The criterion for right ventricular ischemia was defined as ST elevation of 0.1 mV or more in lead V4R during angioplasty. The patients were divided into two groups: those with (group A, n = 12) and those without (group B, n = 10) right ventricular ischemia. There was no significant difference in the amplitude of septal Q waves in any lead before angioplasty between the two groups. During angioplasty, group A showed a reduction in the amplitude of septal Q waves in leads V5 and V6 but no change in the amplitude of septal Q waves in leads I and aVL. Group B had no significant reduction in the amplitude of septal Q waves in any lead. During angioplasty group A had a higher incidence of reduction of at least 0.05 mV of the septal Q wave amplitude in any lead (58% vs 10%). These results indicate that the amplitude of septal Q waves is occasionally reduced by right coronary occlusion and most such cases are accompanied by right ventricular ischemia. Therefore reduction of the amplitude of septal Q waves during right coronary occlusion appears to be caused by reduction of the electrical force derived from the right ventricular myocardium.