RIGHT VENTRICULAR INFARCTION - CLINICAL, HAEMODYNAMIC, ECHOCARDIOGRAPHIC AND THERAPEUTIC CONSIDERATIONS

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1 RIGHT VENTRICULAR INFARCTION - CLINICAL, HAEMODYNAMIC, ECHOCARDIOGRAPHIC AND THERAPEUTIC CONSIDERATIONS A T H Tan B L Chia B K H Ee M Choo SYNOPSIS Right venticula infaction complicating infaction of the infeio wall of the left venticle occus in a significant numbe of patients The syndome that is poduced is chaacteised by an elevated jugula venous pulse, clea lung fields and in some instances hypotension Diagnosis can be confimed eithe by haemodynamic pessue measuement of the ight side of the heat, by technetium pyophosphate scintigaphic scan and lastly by M mode o 2 dimensional echocadiogaphythe diagno sis of ight venticula infaction has theapeutic impotance because diuetics ae containdicated in this condition and fluid loading instead should be instituted A patient with ight venticula infaction is descibed INTRODUCTION Univesity Depatment of Medicine II Singapoe Geneal Hospital Outam Road Singapoe 0316 A T H Tan, MBBS, AM, M Med, FRACP B L Chia, MBBS, AM, FRACP, FACC Pofesso and Head M Choo, MBBS, M Med, MRCP Univesity Depatment of Medicine I Singapoe Geneal Hospital B K H Ee, MBBS, AM, M Med, MRCP Myocadial infaction has taditionally been egaded as involving pedominantly the left venticle of the heat in the geat majoity of instances Hypotension o cadiogenic shock complicates myocadial infaction in about 15% of cases and have until ecently been believed to be always due to sevee left venticula dysfunction (1) In ecent yeas, a unique syndome whee ight sided heat failue accompanied sometimes by hypotension but without left heat failue occuing as a esult of ight venticula infaction is being inceasingly ecognised Since no case of ight venticula infaction has been epoted fom Singapoe to date, we would like to descibe such a patient with a plea fo a wide ecognition of this syndome CASE REPORT A 48 -yea -old Chinese male was admitted to the Coonay Cae Unit of the Univesity Depatment of Medicine at Singapoe Geneal Hospital with an acute tansmual infeio myocadial infact The patient suffeed an anteoseptal myocadial infact fou yeas ago but had been symptom fee since His isk factos fo ischaemic heat disease included hypetension and being a heavy cigaette smoke On admission, he was geneally well with a blood pessue of 120/80 mm Hg Clinical examination evealed that the jugula venous pessue was elevated to 10 cm above the stenal angle The apex beat was not displaced and the heat sounds wee dual and egula without any cadiac mumus The lungs wee clea The electocadiogam showed acute tansmual infeio infact with O waves and T wave invesion in Leads II, Ill and AVF (Figue 1) The peak seum ceatinine kinase was makedly elevated at 102

2 VOLUME 24, No 2 APRIL 1982 CCH ' AVR V V4 j; 11 AVL V uuw ibsä 1111H _1b1 V AV V3 V6 Fig 1 Twelve lead ECG showing tansmual infeio myocadial infaction ñ N E Fig 2 Chest Xay showing minimal cadiomegaly and clea lung fields 9 N 968íU/lite The chest x-ay showed mild cadiomegaly with clea lung fields (Fig 2) and the outine blood biochemisty was nomal In view of the aised jugula venous pessue and clea lung fields, he was diagnosed as having ight venticula infaction in addition to infeio myocadial infaction of the left venticle A Swan -Ganz cathete was theefoe inseted and the pessues in the ight heat was measued The mean ight atial pessue was elevated to 13 mmhg and a pominent "V" wave and "y" descent wee noted The capillay wedge pessue was 14 mm Hg (Fig 3) The atio of the mean ight atial pessue to the mean pulmonay capillay wedge pessue was 092 M mode and coss sectional echocadiogaphy wee then pefomed In the M mode study the end diastolic ight venticula dimension was 22 mm and that of the left venticle was 48 mm giving an end diastolic ight venticula to end diastolic left venticula dimension atio of 52% (Fig 4) The coss sectional echocadiogaphic study using the subxiphoid appoach evealed a dilated ight venticle with akinesia of its fee wall (Fig 5) The patient made an uneventful ecovey fom the myocadial infaction and was subsequently dischaged fom hospital When eviewed in the outpatient's clinic 6 months late he was found to be well DISCUSSION In the majoity of instances myocadial infaction involves pedominantly the left venticle of the heat In the cases which ae complicated by pump failue, haemodynamic monitoing has been shown to be invaluable fo optimal management (2, 3) In ecent yeas, this pocedue has led to the detection of the syndome of pedominant ight venticula failue esulting fom ight venticula infaction occuing in some patients with tansmual infeio myocadial infaction of the left venticle (4) Clinically, these patients have signs of ight venticula failue with little o no evidence of left venticula failue in maked contast to the usual clinical situation whee ight venticle failue is seconday to left venticula failue In these patients, the ight atial pessue is elevated with eithe nomal o slightly elevated pulmonay capillay wedge pessue (4) A mean ight atial pessue to a mean pulmonay capillay wedge pessue atio of 065 o moe as was seen in ou patient has been used as a diagnostic citeia fo ight venticula infaction (5) In patients with extensive ight venticula infaction, the ight atial and ight venticula pessue wave foms may be identical suggesting absence of any effective ight venticula contaction (6) This haemodynamic pofile esembles that of constictive peicaditis Howeve, in the pesence of hypovolemia the haemodynamic featues of ight venticula infaction may be masked (5, 6) Right venticula infaction can also be diagnosed employing non invasive investigative techniques such as scintigaphy and echocadiogaphy Shape and co-wokes have found that technetium pyophosphate scintigaphy and gated adioangiogaphy with 99m technetium albumin can both detect the occuence of ight venticula infaction accuately (5) Using M mode echocadiogaphy, these same 103

3 RA=13mm Hg PCW=14mmHg PA=20mmHg Fig 3 Pessue tacings of ight atium, pulmonay atey and pulmonay capillay wedge RA = ight atium POW = pulmonay capillay wedge PA = pulmonay atey» _ J : t t ' 1 :+ i _ -;,--- n 't'if s,:: iì:yí' ^ : >-;_ ' _-+Ç C ' ' +_ a -- a4i:: y RV Dd, _:-: ^'' LVS ' -u-- y , `w1'= _=,o LVIDd n ; :* ` - LVVI 1 1, -),:,, I 1 wi 4,1p! _ "ti,ij sle-' s ``1 `E7 I I o,, 4 `,' Fig 4 M mode echocadiogam showing ight and left'venticula dimensions LVIDd = left venticula intenal dimension in end diastole RVIDd = ight venticula intenal dimension in end diastole IVS = inteventicula septum LVW = posteio wall of left venticle 104

4 VOLUME 24, No 2 APRIL 1982 lf+_f "" = ) T i- - q ` EF] a Je s ea -%2 4^1-_ A- - 4;30, - - Fig 5 Two dimensional echocadiogam fom the subxiphoid view showing dilated ight venticle In eal time the whole of the fee wall of the ight venticle (indicated by the 2 white aows) was noticed to be akinetic except fo the apex RV = ight venticle LV = left venticle RA = ight atium goup of wokes have found a significantly geate ight venticula end diastolic dimension ìn patients with infeio myocadial infaction associated with ight venticula infaction\they also noted that in this goup of patients with infeio myocadial infaction, 4 out of 5 cases associated with ight venticula infaction had a ight venticula end diastolic diamete to left venticula end diastolic diamete atio geate than 051 as was seen in ou patient In contast, only 1 out of 9 patients without ight venticula infaction had a atio geate than this We also confimed dilatation of the ight venticle employing coss sectional echocadiogaphy using the subxiphoid appoach In addition akinesia of the ight venticula fee wall pesumably coesponding to the infacted aea was clealy seen fom the eal time coss sectional study As fa as we ae awae, coss sectional echocadiogaphy has not been widely employed fo the diagnosis of ight venticula infac tion, but this study clealy indicates that this technique deseves futhe evaluation In addition to the infeio suface of the left venticle as well as the posteobasal inteventicula septum, the ight coonay atey also supplies the ight venticle It is theefoe not supising that autopsy studies (8) and technetium pyophosphate scintigaphic studies (5, 9) have shown that ight venticula infaction occus commonly in association with infaction of the infeio and septal walls of the left venticle The incidence of ight venticula infaction in association with infeio o posteio myo- cadial infaction is 24% in autopsy studies (8) and 375% in technetium pyophosphate studies (9) Howeve, clinical evidence of this condition is much lowe (11), suggesting that clinical manifestations of ight venticula dysfunction afte ight venticula infaction is lagely dependent on the impedance to ight venticula emptying viz pulmonay vascula esistance and left venticula compliance This is consistent with data showing nea nomal systemic venous pessues despite expeimental destuction of the ight venticle (12-14) The diagnosis of ight venticula infaction has impotant theapeutic implications The pesence of systemic venous engogement fequently leads to the inappopiate use of diuetics Afte ight venticula infaction, many patients, despite elevated ight venticula filling pessues, may have low left venticula filling pessues esulting in a low cadiac output and hypotension Injudicious use of diuetics will aggavate the situation futhe by loweing the left venticula filling pessue Awaeness of the haemodynamic consequences of ight venticula infaction enables optimal management of this condition In extensive ight venticula infaction, thee may be no effective ight venticula contaction Filling of the left venticle will then depend on ight atial to left atial pessue gadient (4) Theapy should be diected towads maintaining optimal left venticula filling pessues Despite elevated systemic venous pessues, fluids should be given to maintain left venticula filling pessues and this has coected 105

5 hypotension in seveal cases (11) It has been postulated that vasodilatos may also impove the clinical situation by educing pulmonay and systemic vascula esistances (11, 15) but the actual efficacy of this fom of teatment must await futue studies If the coect theapy is given, patients with hypotension associated with ight venticula infaction geneally have a much bette pognosis compaed to patients with cadiogenic shock due to sevee left venticula dysfunction (4) Because of this, the ecognition of ight venticula infaction is of cucial impotance in ode to enable coect theapeutic decisions to be made Addendum Since the publication of this pape, a study egading the value of using lead V4R in addition to the standad 12 lead ECG has been descibed as being of geat value in the diagnosis of ight venticula infaction (16) In this study, the ST segment in V4R was found to be elevated in patients with this condition If this finding is subsequently confimed, this would be a consideable aid to the diagnosis of ight venticula infaction REFERENCES 1 Hanoch P, Cohn JH: Left venticula function in acute myocadial infaction J Clin Invest 1971; 50: Russel RD J, Rackley CE, Pombo J et al: Effects of inceasing left venticula filling pessue in patients with acute myocadial infaction J Clin Invest 1970; 49: Bode MI, Cohn JN: Evolution of abnomalities in left venticula function afte acute myocadial infaction Ciculation 1972; 46: Cohn JN, Guiha NH, Bode MI, Constantinos JL: Right venticula infaction, clinical and haemodynamic featues Am J Cadiol 1974; 33: Shape ND, Botvinik EH, Shames DM et al: The noninvasive diagnosis of ight venticula infaction Ciculation 1978; 57: Raabe DS, Cheste AC: Right venticula infaction Chest 1978; 73: Loell B, Leinbach RC, Pohost GM et al: Right venticula infaction Am J Cadiol 1979; 43: Isne JM, Robets WC: Right venticula infaction complicating left venticula infaction seconday to coonay heat disease AM J Cadiol 1978; 42: Wackes FJ, Lie KI, Sokole EB et al: Pevalence of ight venticula involvement in anteio wall infaction assessed with myocadial imaging with thallium -201 and techneticum-49 pyophosphate Am J Cadiol 1978; 42: Rigo P, Muay M, Taylo DR et al: Right venticula dysfunction detected by gated scintiphotogaphy in patients with acute infeio myocadial infaction Ciculation 1975; 52: Cohn JN: Right venticula infaction Revisited Am J Cadiol 1979; 43: Sta I, Jeffes WA, Meade RH J: The absence of auspicuous incements of venous pessue afte sevee damage to the ight venticle of the dog, with a discussion of the elation between clinical congestive failue and heat disease Am Heat J 1943; 26: Kagan A: Dynamic esponses of the ight venticle following extensive damage by cauteisation Ciculation 1952 V: Guiha N, Limas CJ, Cohn JN: Pedominant ight venticula dysfunction afte ight venticula destuction in the dog Am J Cadiol 1974; 33: Rowe GG, Hendeson RH: Systemic and coonay haemodynamic effects of sodium nitopusside Am Heat J 1974; 87: Cadell-Riea J, Fiquees J, Valle V et al: Right venticula infaction: Relationship between ST segment elevation in V4R and haemodynamic, scintigaphic and echocadiogaphic findings in patients with acute infeio myocadial infaction Am Heat J 1981; 101: