Rapid Hemodynamic Improvement in Right Ventricular Infarction After Coronary AngioplastyRight ventricular infarction is a common association of acute inferior myocardial infarction and usually is not associated with adverse consequences. Isolated right ventricular infarction is rare and has been described as being associated with occlusion of side branches of the right coronary artery2 or with a non-dominant right coronary artery. Acute necrosis of a large part of the right ventricle may cause a hemodynamic picture characterized by a disproportionate elevation of right atrial pressure, compared to pulmonary artery wedge pressure, and systemic hypotension. To correct this hemodynamic derangement, routine treatment is to administer an appropriate intravenous load. We present a patient in whom the hemodynamic disturbance caused by a right ventricular infarction was corrected promptly after flow to a large marginal branch was reestablished by coronary angioplasty. http://www.travoprosteyedrops.com/

Case Report
A 53-year old white man presented to the Emergency Room of Robert Wood Johnson University Hospital complaining of substernal chest pain for approximately 30 minutes, accompanied by diaphoresis, and lightheadedness. He denied previous history of chest pain or other cardiac history. He had had hypertension for ten years and a 35 pack-year history of smoking. His medications included metoprolol, 100 mg daily and thiazide, 25 mg daily. On arrival, an electrocardiogram showed ST-segment elevation in the inferior leads, as well as in the anterior precordial leads (Fig 1). Heart rate was 60 beats/min, blood pressure was 80/50 mm Hg, there was mild jugular venous distention, the lungs were clear, and heart sounds normal. Results of initial laboratory analyses were normal. CPK peaked at 1,012 U with 11 percent MB fraction 8 hours after admission. After informed consent was obtained, the patient was taken to the cardiac laboratory within 60 minutes of onset of chest pain. Hemodynamic measurements were: right atrium, 14 mm Hg; right ventricle, 32/16 mm Hg; pulmonary artery, 30/16 mm Hg (mean 22); pulmonary artery “wedge” 16 mm Hg; left ventricle systolic, 80/16 mm Hg; aorta, 80/60 mm Hg (mean 72) (Fig 2). Cardiac output 4.47 L/min, cardiac index was 2.6 L/min/m2. Coronary arteriography disclosed a normal left coronary artery and total occlusion of the right coronary artery in its proximal third (Fig 3). There was retrograde collateral flow from the left coronary artery to the distal segments of the right coronary artery. Left ventriculography showed an akinetic segment located in the infero-basal segment (Fig 4).
This procedure was followed by successful percutaneous transluminal coronary angioplasty (PTCA) to the proximal right coronary artery. Visualization of the distal segments showed a co-dominant right coronary system with a small posterior descending branch, as well as a large right ventricular branch (Fig 3). Normal saline solution infused at 150 ml per hour was maintained during and for one hour after the procedure (total 120 min). Thereafter, blood pressure normalized (RA 7 mm Hg, PA 20/12 mm Hg, PA wedge 10 mm Hg, Ao 118/78 mm Hg), and no further volume expansion was necessary. The patient had an uneventful course. Repeat cardiac catheterization on day 9 post-infarction showed an entirely patent right coronary artery and normal left ventricular function with segmental improvement of the inferior wall (Fig 4). Right and left heart hemodynamics were normal (Fig 2). Cardiac output was 5.77 L/min and cardiac index 3.4 L/min/m2.

Figure 1. Admission electrocardiogram.

Figure 1. Admission electrocardiogram.

Figure 2. RA: right atrium; RV: right ventricle; PA: pulmonary artery; “W": pulmonary artery wedge; LV: left ventricle; Ao: aorta. Upper: admission; Lower: nine days post-PTCA.

Figure 2. RA: right atrium; RV: right ventricle; PA: pulmonary artery; “W”: pulmonary artery wedge; LV: left ventricle; Ao: aorta. Upper: admission; Lower: nine days post-PTCA.

Figure 3. Upper: Right coronary artery, right anterior oblique view before PTCA. Lower: Right coronary artery after PTCA.

Figure 3. Upper: Right coronary artery, right anterior oblique view before PTCA. Lower: Right coronary artery after PTCA.

Figure 4. Left ventricular wall motion analysis. Upper: before PTCA; lower: nine days post-PTCA.

Figure 4. Left ventricular wall motion analysis. Upper: before PTCA; lower: nine days post-PTCA.