Impact of Right Ventricular Dysfunction in Morbidity and Mortality in Patients with Inferior Wall Myocardial Infarction Presenting to a Tertiary Care Center of Nepal

Introduction: In comparison to anterior wall myocardial infarction, inferior wall myocardial infarction is generally regarded as a low risk event. The aim of this study was to evaluate the prognostic impact of right ventricular (RV) myocardial involvement in patients with inferior wall myocardial infarction (IWMI). Methods: This is an observational study of 82 consecutive IWMI patients admitted and treated in Manmohan Cardiothoracic, Vascular and Transplant Center (MCVTC) from May 15 2018 to June 15 2019. The clinical characteristics, risk factors profile, electrocardiographic, echocardiographic, including RV function and angiographic characteristics, complications and in-hospital deaths were analyzed. Results: The mean age of patients presenting with IMWI was 64.8 ± 13.8 years with predominance of male (67%). Right ventricular myocardial infarction was present in 34.1% of patient with RV dysfunction in 25.6% patients. Mean Tricuspid Annular Plane Systolic Excursion (TAPSE), RV tricuspid annulus (S') and RV Fractional area change (FAC) in patients with RV dysfunction vs patients without RV dysfunction were 12.2 ± 3.3 mm vs 22.5 ± 3.5 mm (p < 0.001), 7.54 ± 0.91 cm/s vs. 12.79 ± 2.16 cm/s respectively (p Conclusion: In inferior wall myocardial infarction, RV involvement with RV dysfunction is an independent risk factor for in-hospital mortality along with advanced age, complete atrioventricular block, higher Killip class, delayed hospital presentation, left ventricular ejection fraction < 40% and angiographic evidence of triple vessel disease.

Primary angioplasty for infarction due to isolated right ventricular artery occlusion

We report an unusual case of an isolated right ventricular infarction with haemodynamic compromise caused by spontaneous isolated proximal occlusion of the right ventricular branch of the right coronary artery(RCA), successfully treated by balloon angioplasty. A 58-yearold gentleman presented with epigastric pain radiating into both arms. Electrocardiograph with right ventricular leads confirmed ST elevation in V4 R and a diagnosis of isolated right ventricular infarction was made. Urgent primary percutaneous intervention was performed which revealed occlusion of the right ventricular branch of the RCA. During the procedure, the patient's blood pressure dropped to 80/40 mm Hg, and echocardiography showed impaired right ventricular systolic function. Despite aggressive fluid resuscitation, the patient remained hypotensive, continued to have chest pain and persistent electrocardiograph changes, and hence balloon angioplasty was performed on the proximal right ventricular branch which restored flow to the vessel and revealed a severe ostial stenosis. This was treated with further balloon angioplasty which restored TIMI 3 flow with resolution of patient's symptoms. Repeat echocardiography showed complete resolution of theST-elevation in leads V4 R and V5 R and partial resolution in V1. Subsequent dobutamine-stress echocardiography at 4 wk showed good left and right ventricular contractions. The patient was discharged after a 3-d inpatient stay without any complications.

Intraoperative Right Ventricular Myocardial Infarction in a Geriatric Patient with Hip Fracture： a Case Report

HIP fracture is becoming a global public health issue due to increased longevity and the in-creased incidence of osteoporosis.1,2 Patients who underwent surgery experience high rates of mortality and disability, with approximately 5% death rate before discharge and 10% death rate within 30 days after discharge.3,4 Intraoperative cardiac arrest （IOCA） complicates up to 43 per 100,000 surgeries.5 Even with resuscitation by eligible professionals in a well-equipped operating room, IOCA is still associated with 35% imme-diate mortality and 65.5% in-hospital mortality.6,7 The main causes may be related to patient conditions, preoperative complications, anesthesia or surgical procedures.7,8 Age- associated changes in cardiovascular and other systems especially increase the risk of IOCA, which may explains why geriatric patients are the majority who experience asystole during surgery.

Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion:A case report

BACKGROUND Typically,right coronary artery(RCA)occlusion causes ST-segment elevation in inferior leads.However,it is rarely observed that RCA occlusion causes STsegment elevation only in precordial leads.In general,an electrocardiogram is considered to be the most important method for determining the infarct-related artery,and recognizing this is helpful for timely discrimination of the culprit artery for reperfusion therapy.In this case,an elderly woman presented with chest pain showing dynamic changes in precordial ST-segment elevation with RCA occlusion.CASE SUMMARY A 96-year-old woman presented with acute chest pain showing precordial STsegment elevation with dynamic changes.Myocardial injury markers became positive.Coronary angiography indicated acute total occlusion of the proximal nondominant RCA,mild atherosclerosis of left anterior descending artery and 75%stenosis in the left circumflex coronary artery.Percutaneous coronary intervention was conducted for the RCA.Repeated manual thrombus aspiration was performed,and fresh thrombus was aspirated.A 2 mm×15 mm balloon was used to dilate the RCA with an acceptable angiographic result.The patient’s chest pain was relieved immediately.A postprocedural electrocardiogram showed alleviation of precordial ST-segment elevation.The diagnosis of acute isolated right ventricular infarction caused by proximal nondominant RCA occlusion was confirmed.Echocardiography indicated normal motion of the left ventricular anterior wall and interventricular septum(ejection fraction of 54%),and the right ventricle was slightly dilated.The patient was asymptomatic during the 9-mo follow-up period.CONCLUSION Cardiologists should be conscious that precordial ST-segment elevation may be caused by occlusion of the nondominant RCA.