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 RT, 42 year old man  BIBA following OOHCA  Collateral from wife  Driving, c/o headache, chest and bilateral arm pain  LOC, shaking  PMHx: PUD,

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Presentation on theme: " RT, 42 year old man  BIBA following OOHCA  Collateral from wife  Driving, c/o headache, chest and bilateral arm pain  LOC, shaking  PMHx: PUD,"— Presentation transcript:

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2  RT, 42 year old man  BIBA following OOHCA  Collateral from wife  Driving, c/o headache, chest and bilateral arm pain  LOC, shaking  PMHx: PUD, cannabis smoking, coryzal symptoms

3  minutes downtime  CPR  V Fib  Shocked x 13  Adrenaline x 5, Amiodarone 300mg, MgSO 4  ROSC 45 minutes after CPR was commenced

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7  Globally reduced LV and RV function  EF 30-35%  No definite RWMA  No significant AR or AS  No effusion

8  V Fib Arrest  Young, male, no significant history  Flu-like illness  No consistent ST elevation  No marked RWMA on Echo  Haemodynamically stable

9  ICU  Cooling  DAPT, LMWH  Amiodarone infusion  Coronary Angiogram

10  Pressors not required initially  Induced Hypothermia 72Hrs  Troponin I: 8.17, (<0.06)  CK 5670 (0-210)  Pulmonary oedema  Co-amoxiclav, clarithromycin, oseltamivir  Influenza A/H3 on throat swab  Extubated 3 days later

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19  PCI?  ICD?

20  Right guide SH  Sian and Sian blue wires to RCA and RV branch  Pre dilated with Emerge balloon dilation catheter  2.5x20mm Promus PREMIER™ Everolimus- Eluting Platinum Chromium Coronary Stent placed in main RCA  Post dilated with kissing balloons for RV branch protection

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24  V Tachyarrhythmias occurring in first 24-48hrs do not imply continuing risk over time  Primary therapy should be coronary revascularisation

25  No further VT as inpatient  CMR  No LV inducible ischaemia  No LV scar  Culprit lesion revacsularised

26  Discharged with some memory issues  OPD March  NRH assessment  Cardiac Rehab  Repeat CMR  Reassess for ICD

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28 Sanders AO. Coronary thrombosis with complete heart-block and relative ventricular tachycardia: a case report. Am Heart J 1930;6:

29  Malignant ventricular arrhythmias occurred in up to 38% of patients and tended to be associated with larger infarct size (measured by peak CPK).  Concomitant RVMI occurs in 30–50% of cases of patients with acute inferior MI  Isolated right ventricular infarction accounts for less than 3% of all cases of infarction. Ricci, S.R. Dukkipati, M.C. Pica, D.E. Haines, J.A. Goldstein Malignant ventricular arrhythmias in patients with acute right ventricular infarction undergoing mechanical reperfusion Am J Cardiol, 104 (12) (2009), pp. 1678–1683 Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am Coll Cardiol 1987;10: AJ.M.

30  Clinical signs  ECG  Echo

31  DE-CMR more sensitively identifies RVMI in patients presenting with acute inferior MI than  ECG  physical exam  echocardiography A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M. Gross, R. Dietz, M.G. Friedrich Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am Coll Cardiol, 48 (10) (2006), pp. 1969– 1976

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33  Isolated RVMI relatively rare presentation  Non-Dominant RCA lesions not benign & innocuous  Value of CMRI  Limited data on value of AICD

34  Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med. 1994;330:1211–1217.  Haji SA, Movahed A. Right ventricular infarction-diagnosis and treatment. Clin Cardiol. 2000;23:473–482.  A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M. Gross, R. Dietz, M.G. FriedrichContrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am Coll Cardiol, 48 (10) (2006), pp. 1969–1976  Cavalcante JL, Al-Mallah M, Hudson M. Isolated right ventricular infarct presenting as ventricular fibrillation arrest and confirmed by delayed-enhancement cardiac MRI. Heart Lung Circ 2010; 19:  Hurst JW, editor. The heart, 4th ed. New York: McGraw- Hill; p 409

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39  AV block  RBBB  Atrial Fibrillation  Ventricular Arrhythmias

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41  LV: normal size, volume, function.  RV: increased ESV & hypokinesis of the inferior & anterior walls at the base & mid segments with mildly reduced global systolic function, EF 40%  Perfusion: Evidence of matched/fixed perfusion defects in septum & inferoseptum from mid wall to base  Tissue: mild oedema in basal segments of the RV anterior & inferior wall on dark blood T2 weighted STIR images. DE- abnormal signal in basal & mid segments of inferior and anterior wall of RV, indication infarction.


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