Right Ventricular Infarction 

  • Author: Claudia Dima, MD; Chief Editor: Eric H Yang, MD   more...
 
Updated: Mar 29, 2011
 

Background

Right ventricular infarction was first recognized in a subgroup of patients with inferior wall myocardial infarctions who demonstrated right ventricular failure and elevated right ventricular filling pressures despite relatively normal left ventricular filling pressures. Increasing recognition of right ventricular infarction, either in association with left ventricular infarction or as an isolated event, emphasizes the clinical significance of the right ventricle to total cardiac function.

Interest in recognizing right ventricular infarction noninvasively has grown because of the therapeutic implications of distinguishing patients with right ventricular dysfunction from those with the more usual clinical presentation of left ventricular dysfunction. Patients with right ventricular infarctions associated with inferior infarctions have much higher rates of significant hypotension, bradycardia requiring pacing support, and in-hospital mortality than isolated inferior infarctions.[1]

For more information, see Myocardial Infarction.

Next

Pathophysiology

The right ventricle is a thin-walled chamber that functions at low oxygen demands and pressure. It is perfused throughout the cardiac cycle in both systole and diastole, and its ability to extract oxygen is increased during hemodynamic stress. All of these factors make the right ventricle less susceptible to infarction than the left ventricle.

The posterior descending branch of the right coronary artery usually supplies the inferior and posterior walls of the right ventricle. The marginal branches of the right coronary artery supply the lateral wall of the right ventricle. The anterior wall of the right ventricle has a dual blood supply: the conus branch of the right coronary artery and the moderator branch artery, which courses from the left anterior descending artery.[2]

Interestingly, right ventricular infarction noted at necropsy usually involves the posterior septum and posterior wall rather than the right free wall. The relative sparing of the right ventricular anterior wall apparently arises from a high degree of collateralization. This collateral blood flow is thought to be derived from the thebesian veins and diffusion of oxygen directly from the ventricular cavity. A direct correlation exists between the anatomic site of right coronary artery occlusion and the extent of right ventricular infarction. Studies have demonstrated that more proximal right coronary artery occlusions result in larger right ventricular infarctions.[3] On occasion, the right ventricle can be subjected to infarction from occlusion of the left circumflex coronary artery.[4]

Because the right ventricle is considered a low-pressure volume pump, its contractility is highly dependent on diastolic pressure. Hence, when contractility and associated diastolic dysfunction are impaired attendant to right ventricular infarction, the right ventricular diastolic pressure increases substantially and systolic pressure decreases. In such a scenario, concomitant left ventricular dysfunction, with increase in right ventricular afterload, is possible. In such a setting, right ventricular output can decrease dramatically, and the only driving force remaining is elevated right atrial pressure. In such a circumstance, the right ventricle serves as a poorly functioning conduit between the right atrium and the pulmonary artery.

Elevation of right atrial pressure secondary to right ventricular infarction has been noted to serve as a stimulus for secretion of atrial natriuretic factor. Increased levels of this polypeptide can be detrimental to normal left ventricular filling pressures. This occurs by virtue of the potent vasodilating, natriuretic, diuretic, and aldosterone-inhibiting properties of atrial natriuretic factor. Inappropriately elevated levels of atrial natriuretic factor may worsen the clinical syndrome of right ventricular infarction.[5] The potential hemodynamic derangements associated with right ventricular infarction render the afflicted patient unusually sensitive to diminished preload (ie, volume) and loss of atrioventricular synchrony. These 2 circumstances can result in a severe decrease in right and, secondarily, left, ventricular output.[6, 7, 8]

Early thrombolysis or mechanical reperfusion of an occluded coronary artery resulting in right ventricular infarction is associated with prompt reduction in right atrial pressure. This is extremely important because persistently elevated right atrial pressure has been associated with increased in-hospital mortality when associated with myocardial infarction. The extent of right ventricular infarction varies greatly and is dependent on the site of occlusion of the right ventricular arterial supply. If occlusion occurs before the right ventricular marginal branches and if collateral blood flow from the left anterior descending coronary artery is absent, then the size of infarction generally is greater. Extent of infarction depends somewhat on flow through the thebesian veins.[9, 10] In general, any major reduction in blood supply to the right ventricular free wall portends an adverse prognosis in association with this disorder.

Previous
Next

Epidemiology

Isolated infarction of the right ventricle is extremely rare; right ventricular infarction usually is noted in association with inferior wall myocardial infarction. The incidence of right ventricular infarction in such cases ranges from 10-50%, depending on the series.[11]

The frequency of right ventricular infarction, which can be detected by right-sided precordial leads, in association with non–ST-segment elevation or non–Q-wave myocardial infarction, is not known and currently is being investigated. Although right ventricular infarction is clinically evident in a sizable number of cases, the incidence is considerably less than that found at autopsy.[12, 13, 10, 14] A major reason for the discrepancy is the difficulty in establishing the presence of right ventricular infarction in living subjects. Additionally, right ventricular dysfunction and stunning frequently are of a transient nature, such that estimation of its true incidence is even more difficult.

Criteria have been set forth to diagnose right ventricular infarction; even when strictly employed, however, the criteria lead to underestimation of the true incidence of right ventricular infarction.[15, 16, 17]

Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Claudia Dima, MD  Fellow in Interventional Cardiology, Department of Cardiology, Banner Good Samaritan Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

David L Coven, MD, PhD  Assistant Professor of Medicine, Columbia University College of Physicians and Surgeons; Attending Physician in Interventional Cardiology, St Luke's-Roosevelt Hospital Center

David L Coven, MD, PhD is a member of the following medical societies: American College of Physicians, American Medical Association, and Massachusetts Medical Society

Disclosure: Nothing to disclose.

Kenneth B Desser, MD  Clinical Professor, Director of Cardiology Fellowship, Banner Good Samaritan Medical Center, Phoenix, Arizona

Disclosure: Nothing to disclose.

Ashish Pershad, MD  Consulting Staff, Heart and Vascular Center of Arizona

Ashish Pershad, MD is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

George A Stouffer III, MD  Henry A Foscue Distinguished Professor of Medicine and Cardiology, Director of Interventional Cardiology, Cardiac Catheterization Laboratory, Chief of Clinical Cardiology, Division of Cardiology, University of North Carolina Medical Center

George A Stouffer III, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, Phi Beta Kappa, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Eric H Yang, MD  Associate Professor of Medicine, Director of Interventional Cardiology Fellowship Program, Henry Ford Hospital

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Rex C Liu, MD, to the development and writing of the source article.

References

  1. Chockalingam A, Gnanavelu G, Subramaniam T, Dorairajan S, Chockalingam V. Right ventricular myocardial infarction: presentation and acute outcomes. Angiology. Jul-Aug 2005;56(4):371-6. [Medline].

  2. Forman MB, Goodin J, Phelan B, Kopelman H, Virmani R. Electrocardiographic changes associated with isolated right ventricular infarction. J Am Coll Cardiol. Sep 1984;4(3):640-3. [Medline].

  3. Garty I, Barzilay J, Bloch L, Antonelli D, Koltun B. The diagnosis and early complications of right ventricular infarction. Eur J Nucl Med. 1984;9(10):453-60. [Medline].

  4. Giannitsis E, Potratz J, Wiegand U, Stierle U, Djonlagic H, Sheikhzadeh A. Impact of early accelerated dose tissue plasminogen activator on in-hospital patency of the infarcted vessel in patients with acute right ventricular infarction. Heart. Jun 1997;77(6):512-6. [Medline]. [Full Text].

  5. Haupt HM, Hutchins GM, Moore GW. Right ventricular infarction: role of the moderator band artery in determining infarct size. Circulation. Jun 1983;67(6):1268-72. [Medline].

  6. Hirsowitz GS, Lakier JB, Goldstein S. Right ventricular function evaluated by radionuclide angiography in acute myocardial infarction. Am Heart J. Oct 1984;108(4 Pt 1):949-54. [Medline].

  7. Hurst JW. Comments about the electrocardiographic signs of right ventricular infarction. Clin Cardiol. Apr 1998;21(4):289-91. [Medline].

  8. Iqbal MZ, Liebson PR. Counterpulsation and dobutamine. Their use in treatment of cardiogenic shock due to right ventricular infarct. Arch Intern Med. Feb 1981;141(2):247-9. [Medline].

  9. Kinn JW, Ajluni SC, Samyn JG, Bates ER, Grines CL, O'Neill W. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol. Nov 1 1995;26(5):1230-4. [Medline].

  10. Bates ER. Revisiting reperfusion therapy in inferior myocardial infarction. J Am Coll Cardiol. Aug 1997;30(2):334-42. [Medline].

  11. Andersen HR, Nielsen D, Falk E. Right ventricular infarction: larger enzyme release with posterior than with anterior involvement. Int J Cardiol. Mar 1989;22(3):347-55. [Medline].

  12. 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. Dec 1987;10(6):1223-32. [Medline].

  13. Andersen HR, Nielsen D, Lund O, Falk E. Prognostic significance of right ventricular infarction diagnosed by ST elevation in right chest leads V3R to V7R. Int J Cardiol. Jun 1989;23(3):349-56. [Medline].

  14. Birnbaum Y, Wagner GS, Barbash GI, Gates K, Criger DA, Sclarovsky S, et al. Correlation of angiographic findings and right (V1 to V3) versus left (V4 to V6) precordial ST-segment depression in inferior wall acute myocardial infarction. Am J Cardiol. Jan 15 1999;83(2):143-8. [Medline].

  15. Braat SH, Brugada P, den Dulk K, van Ommen V, Wellens HJ. Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction. Am J Cardiol. Jun 1 1984;53(11):1538-41. [Medline].

  16. Braat SH, Brugada P, de Zwaan C, Coenegracht JM, Wellens HJ. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J. Apr 1983;49(4):368-72. [Medline]. [Full Text].

  17. Elkayam U, Halprin SL, Frishman W, Strom J, Cohen MN. Echocardiographic findings in cardiogenic shock due to right ventricular myocardial infarction. Cathet Cardiovasc Diagn. 1979;5(3):289-94. [Medline].

  18. Lisbona R, Sniderman A, Derbekyan V, Lande I, Boudreau R. Phase and amplitude imaging in the diagnosis of acute right ventricular damage in inferior infarction. Clin Nucl Med. Nov 1983;8(11):517-20. [Medline].

  19. Martin W, Tweddel A, McGhie I, Hutton I. The evaluation of right ventricular function in acute myocardial infarction by xenon-133. Nucl Med Commun. Jan 1989;10(1):35-43. [Medline].

  20. Mittal SR. Isolated right ventricular infarction. Int J Cardiol. Aug 1994;46(1):53-60. [Medline].

  21. Silverman BD, Carabajal NR, Chorches MA, Taranto AI. Tricuspid regurgitation and acute myocardial infarction. Arch Intern Med. Jul 1982;142(7):1394-5. [Medline].

  22. Nader DA, Ceretto WJ, Vieweg WV. Atrial pacing in the management of right ventricular infarction. South Med J. Mar 1981;74(3):362-3. [Medline].

  23. Pfisterer M, Emmenegger H, Müller-Brand J, Burkart F. Prevalence and extent of right ventricular dysfunction after myocardial infarction--relation to location and extent of infarction and left ventricular function. Int J Cardiol. Sep 1990;28(3):325-32. [Medline].

  24. Sugimoto T, Ogawa K, Asada T, Mukohara N, Higami T, Obo H, et al. Surgical treatment of ventricular septal perforation with right ventricular infarction. J Cardiovasc Surg (Torino). Feb 1996;37(1):71-4. [Medline].

  25. Mavric Z, Zaputovic L, Matana A, Kucic J, Roje J, Marinovic D, et al. Prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarction with and without right ventricular involvement. Am Heart J. Apr 1990;119(4):823-8. [Medline].

  26. Singhal AM, Ilangovan S, Mehta S, Portaluppi F. Isolated right ventricular infarction followed by posterior left ventricular infarction after a few days. Acta Cardiol. 1984;39(4):307-12. [Medline].

  27. Strauss HD, Sobel BE, Roberts R. The influence of occult right ventricular infarction on enzymatically estimated infarct size, hemodynamics and prognosis. Circulation. Sep 1980;62(3):503-8. [Medline].

  28. Dokainish H, Abbey H, Gin K, Ramanathan K, Lee PK, Jue J. Usefulness of tissue Doppler imaging in the diagnosis and prognosis of acute right ventricular infarction with inferior wall acute left ventricular infarction. Am J Cardiol. May 1 2005;95(9):1039-42. [Medline].

  29. Chockalingam A, Gnanavelu G, Alagesan R, Subramaniam T. Myocardial performance index in evaluation of acute right ventricular myocardial infarction. Echocardiography. Aug 2004;21(6):487-94. [Medline].

  30. Lahm T, McCaslin CA, Wozniak TC, Ghumman W, Fadl YY, Obeidat OS, et al. Medical and surgical treatment of acute right ventricular failure. J Am Coll Cardiol. Oct 26 2010;56(18):1435-46. [Medline].

  31. Robalino BD, Petrella RW, Jubran FY, Bravo EL, Healy BP, Whitlow PL. Atrial natriuretic factor in patients with right ventricular infarction. J Am Coll Cardiol. Mar 1 1990;15(3):546-53. [Medline].

  32. Roth A, Miller HI, Kaluski E, Keren G, Shargorodsky B, Krakover R, et al. Early thrombolytic therapy does not enhance the recovery of the right ventricle in patients with acute inferior myocardial infarction and predominant right ventricular involvement. Cardiology. 1990;77(1):40-9. [Medline].

  33. Schuler G, Hofmann M, Schwarz F, Mehmel H, Manthey J, Tillmanns H, et al. Effect of successful thrombolytic therapy on right ventricular function in acute inferior wall myocardial infarction. Am J Cardiol. Nov 1 1984;54(8):951-7. [Medline].

  34. Sharpe DN, Botvinick EH, Shames DM, Schiller NB, Massie BM, Chatterjee K, et al. The noninvasive diagnosis of right ventricular infarction. Circulation. Mar 1978;57(3):483-90. [Medline].

  35. Zorio E, Arnau MA, Rueda J, Almenar L, Osa A, Martínez-Dolz L, et al. The presence of epsilon waves in a patient with acute right ventricular infarction. Pacing Clin Electrophysiol. Mar 2005;28(3):245-7. [Medline].

  36. Sugiura T, Iwasaka T, Shiomi K, Nagahama Y, Takehana K, Inada M. Clinical significance of right ventricular dilatation in patients with right ventricular infarction. Coron Artery Dis. Dec 1994;5(12):955-9. [Medline].

  37. Tan HC, Yeo TC, Lim YT, Chia BL. A case of unusual electrocardiographic presentation of right ventricular myocardial infarction. Ann Acad Med Singapore. Nov 1997;26(6):844-7. [Medline].

  38. Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation. Feb 5 2008;117(5):686-97. [Medline].

  39. Tobinick E, Schelbert HR, Henning H, LeWinter M, Taylor A, Ashburn WL, et al. Right ventricular ejection fraction in patients with acute anterior and inferior myocardial infarction assessed by radionuclide angiography. Circulation. Jun 1978;57(6):1078-84. [Medline].

  40. Vesterby A, Steen M. Isolated right ventricular myocardial infarction. A case report. Acta Med Scand. 1984;216(2):233-5. [Medline].

  41. Yoshino H, Udagawa H, Shimizu H, Kachi E, Kajiwara T, Yano K, et al. ST-segment elevation in right precordial leads implies depressed right ventricular function after acute inferior myocardial infarction. Am Heart J. Apr 1998;135(4):689-95. [Medline].

  42. Zeymer U, Neuhaus KL, Wegscheider K, Tebbe U, Molhoek P, Schröder R. Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement. HIT-4 Trial Group. Hirudin for Improvement of Thrombolysis. J Am Coll Cardiol. Oct 1998;32(4):876-81. [Medline].

  43. Inglessis I, Shin JT, Lepore JJ, Palacios IF, Zapol WM, Bloch KD, et al. Hemodynamic effects of inhaled nitric oxide in right ventricular myocardial infarction and cardiogenic shock. J Am Coll Cardiol. Aug 18 2004;44(4):793-8. [Medline].

 
Previous
Next
 
Table. Sensitivity and Specificity of More Than 1 mm of ST-Segment Elevation in V1, V3 R, and V4 R
Leads Sensitivity (%) Specificity (%)
V12892
V3 R6997
V4 R9395
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.