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
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
V Tachyarrhythmias occurring in first 24-48hrs do not imply continuing risk over time Primary therapy should be coronary revascularisation
No further VT as inpatient CMR No LV inducible ischaemia No LV scar Culprit lesion revacsularised
Discharged with some memory issues OPD March NRH assessment Cardiac Rehab Repeat CMR Reassess for ICD
Sanders AO. Coronary thrombosis with complete heart-block and relative ventricular tachycardia: a case report. Am Heart J 1930;6:
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.
Clinical signs ECG Echo
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
Isolated RVMI relatively rare presentation Non-Dominant RCA lesions not benign & innocuous Value of CMRI Limited data on value of AICD
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
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.