Right Ventricular Myocardial Infarction Research Articles

Right Ventricular Myocardial Infarction and Adverse Events from Nitrates: A Narrative Review

Introduction There is ubiquitous belief that right ventricular myocardial infarction (RVMI) patients are pre-load dependent, and that administering nitrates to this cohort may cause adverse events – most notably hypotension. This article charts a narrative history of RVMI and nitrates: from the initial recognition of RVMI and early support of the use of nitrates, through the spread of the view against nitrates, and to the recent publication of evidence once again supporting their use. Methods Four databases were systematically searched (PubMed, Embase, Medline, Web of Science) and results screened by title, then abstract, and finally full text. Results were presented using a chronological narrative structure. Results The view against the use of nitrates during RVMI can be traced back to a single 1989 cohort study of 28 patients, then later being adopted by a series of influential secondary evidence papers, and ultimately by international guidelines. In 2016, 2017 and 2019, new cohort studies totalling 1046 patients were presented, all of which concluded that nitrates are safe to administer during RVMI. Conclusion This article charts how a single retrospective cohort study with low statistical power came to form the dominant narrative on best practice despite complex and conflicting primary evidence.

Right ventricular myocardial infarction: pathophysiology, clinical implications and management.

Right ventricular myocardial infarction (RVMI) and right ventricular (RV) failure are complications from an acute occlusion of a dominant right coronary artery (RCA) or left anterior descending (LAD) artery. Although some patients have good long-term RV recovery, RVMI is associated with high rates of in-hospital morbidity and mortality driven by hemodynamic compromise, cardiogenic shock, and electrical complications. As such, it is important to identify specific clinical signs and symptoms, initiate resuscitation and commence reperfusion therapy with fibrinolytic therapy or percutaneous coronary intervention. This review will discuss RVMI pathophysiology, describe the current diagnostic measures, highlight current therapies, and explore future management options.

Трудности диагностики инфаркта миокарда нижней стенки левого желудочка с вовлечением правого желудочка

The article presents a clinical observation of myocardial infarction (MI) of the inferior wall of the left ventricle (LV) with ST-segment elevation in combination with damage to the right ventricle (RV). Unfortunately, there is often a delay in the timely diagnosis of RV involvement in the process. This is because, at the beginning of the symptoms, it may not differ clinically from the typical manifestations of MI of the inferior-diaphragmatic region of the LV. However, the combination of LV inferior wall MI with RV MI is an important, negative predictor of increased mortality in these patients. In this case, RV MI was diagnosed after stenting of the right coronary artery, only when signs of hypotension and increased pressure of the jugular veins appeared. Based on the analysis of this clinical case, the authors discuss the need to record an ECG of the right heart in most patients with inferior MI, especially in the presence of hypotension without signs of acute left ventricular failure.

Isolated right ventricular myocardial infarction: a case report.

BackgroundIsolated right ventricular myocardial infarction (RVMI) due to a recessive right coronary artery (RCA) occlusion is a rare presentation. It is typically caused by right ventricle (RV) branch occlusion complicating percutaneous coronary intervention. We report a case of an isolated RVMI due to flush RCA occlusion presenting via our primary percutaneous coronary intervention ST-elevation myocardial infarction pathway.Case summaryA 61-year-old female smoker with a history of hypercholesterolaemia presented via the primary percutaneous coronary intervention pathway with sudden onset of shortness of breath, dizziness, and chest pain while walking. Transradial coronary angiography revealed a normal left main coronary artery, large left anterior descending artery that wrapped around the apex and dominant left circumflex artery with the non-obstructive disease. The RCA was not selectively entered despite multiple attempts. The left ventriculogram showed normal left ventricle (LV) systolic function. She was in cardiogenic shock with a persistent ectopic atrial rhythm with retrograde p-waves and stabilized with intravenous dobutamine thus avoiding the need for a transcutaneous venous pacing system. A computed tomography pulmonary angiogram demonstrated no evidence of pulmonary embolism while an urgent cardiac gated computed tomography revealed a recessive RCA with ostial occlusive lesion. A cardiac magnetic resonance imaging confirmed RV free wall infarction. She was managed conservatively and discharged to her local district general hospital after 5th day of hospitalization at the tertiary centre.DiscussionThis case describes a relatively rare myocardial infarction presentation that can present with many disease mimics which can require as in this case, a multi-modality imaging approach to establish the diagnosis.

Right Ventricular Longitudinal Strain in Acute Pulmonary Embolism and Right Ventricular Myocardial Infarction in Patients with McConnell's Sign.

Aim To study the right ventricular (RV) myocardial longitudinal systolic strain in patient with RV myocardial infarction (MI), and pulmonary embolism (PE) with and without McConnell' phenomenon.Material and methods This study included 53 patients with PE (mean age, 59.0±15.1 years; men, 58.5 %) and 30 patients with RVMI (mean age, 61.8±10.9 years; men, 90 %). Longitudinal strain of basal, medial and apical segments of the RV free wall (RVFW) and the interventricular septum (IVS) was determined in the mode of two-dimensional speckle tracking. Ratio of the IVS apical strain to the RVFW strain (apical ratio) was calculated. Systolic excursion of the RVFW apical segment (apical excursion) was measured in the anatomical M-mode from the apical four-chamber view.Results The McConnell's sign was observed in 23 (43.4 %) of 53 patients with PE and in 16 (53.3 %) of 30 patients with RVMI (p>0.05). Irrespective of the cause for the RV damage, patients with the McConnell's sign had higher values of the apical ratio (1.69±0.50 vs. 0.95±0.22; p<0.001; cutoff point, 1.18) and apical excursion (7.9±1.7 vs. 2.6±1.4 mm; p<0.001; cutoff point, 5.0 mm). Apical excursion closely correlated with the value of apical ratio (r=0.65; p<0.001) but not with the RVFW apical segment strain (r= -0.07; p>0.05).Conclusion Incidence of the McConnell's sign was similar in patients with PE and RVMI. McConnell's sign is based on a passive systolic shift of the RVFW apical segment, which develops during contraction of the IVS apical segment. The greater the ratio of IVS apical segment to RBFW global strain the greater the amplitude of this shift. With the ratio value of 1.18 or more, the systolic shift of RVFW apical segment was >5 mm, which was visually perceived as the McConnell's sign.

Right Ventricular Cardiogenic Shock Caused by Myocardial Infarction: A Review

Left ventricular inferior wall acute myocardial infarction is associated with right ventricular myocardial infarction (RVMI) in up to 50% of cases. The worse prognosis of RVMI is due to the greater propensity for refractory cardiogenic shock (CS) when compared to isolated inferior wall myocardial infarction (IWMI). The diagnosis is based on the clinic, biomarkers, electrocardiogram (ECG) and coronary angiography. Meanwhile, imaging modalities, such as transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) play a complementary role.

P111: Kussmaul's sign for the diagnosis of right ventricular myocardial infarction

Introduction: Kussmaul's sign, the absence of a drop in JVP or a paradoxical increase in JVP on inspiration, can be elicited clinically as an indicator of right ventricular myocardial infarction (RVMI). RVMI poses unique diagnostic and management challenges. It complicates 30-50% of inferior MI and is associated with increased mortality when compared to inferior MI without RV involvement. Early recognition allows maintenance of preload by avoiding use of nitroglycerin, diuretic and narcotic medication, and treatment with fluids and vasopressors. We reviewed the evidence for Kussmaul's sign for diagnosis of RVMI. Methods: We conducted a librarian assisted search using PubMed, Medline, Embase, the Cochrane database, relevant conference abstracts from 1965 to October 2019. No restrictions for language or study type were imposed. All studies with patients presenting with acute myocardial infarction were reviewed. Two independent reviewers extracted data from relevant studies. Studies were combined when similar study populations were present. Study quality was assessed using the QUADAS-2 tool. Random effects meta-analysis was performed using metaprop in Stata for the 3 reference standards combined. Subset analysis for each of the 3 reference standards was completed. Results: We identified 122 studies: 10 were selected for full text review. Eight studies had comparable populations with a total of 469 consecutive patients admitted to the coronary care unit with acute inferior myocardial infarction and were included in the analysis. Prevalence of RVMI was 36% (CI 95% 31.8–40.5). References standards for the diagnosis of RVMI included echocardiography, 16 lead ECG and haemodynamic studies. A gold standard for diagnosis of RVMI is lacking and thus the reference standards were combined. Kussmaul's sign had a sensitivity of 69.3% (CI 95% 46.3 - 85.5, I2- 86.7%), specificity of 95.1% (CI 95% 75.6 - 99.2, I2- 89.3%) and LR + 14.1 (CI 95% 2.6-73.2). Subset analysis of echocardiography, ECG and haemodynamic studies revealed sensitivity of 45%, 77% and 82% (I2- 62%, N/A, 70%) respectively and specificity of 92%, 84% and 92% (I2- 86%, N/A, 86%). Conclusion: Kussmaul's sign is specific for acute right ventricular myocardial infarction and may serve as an important clinical sign of right ventricular dysfunction requiring preload preserving management.

Cardiac strain in right ventricular myocardial infarction and pulmonary embolism

Aim. To study the prospects of using parameters of right ventricle (RV) longitudinal strain (LS) during systole for the differential diagnosis of RV myocardial infarction (RVMI) and pulmonary embolism (PE).Material and methods. The study included 83 patients who were hospitalized with RVMI or PE in the period from December 2017 to May 2019. The study of RV LS using the two-dimensional speckle-tracking echocardiography was carried out in 30 patients with RVMI (group 1), 15 patients with high-risk PE (group 2), and 38 patients with intermediate-risk PE (group 3).Results. The mean values of RV global LS in patients of groups 1 and 2 did not differ (12,8±2,69 and 12,0±2,56%, respectively) and were significantly lower than in patients of group 3 (15,9±3,03%). The ratio of the interventricular septum (IVS) LS to the RV free wall (FW) LS in the group 1 (1,04±0,43) was significantly lower than in the groups 2 (1,61±0,52) and 3 (1,29±0,38). The ratio of the LS of the RVFW basal segment to the apical segment in group 1 (0,60±0,37) was also significantly lower than in groups 2 (1,69±1,57) and 3 (1,67±1,33).Conclusion. In patients with RVMI, there is a comparable decrease in the LS of the RVFW and IVS, and the LS of the basal segment decreases to a greater extent than the apical one. In patients with PE, the decrease in the LS of the RVFW is more pronounced than in IVS, and the LS of the apical segment decreases to a greater extent than the basal one. These differences can be used for the differential diagnosis of RVMI and PE.

RESPECTING THE RIGHT VENTRICLE: RIGHT VENTRICLE MYOCARDIAL INFARCTION REQUIRING MECHANICAL CIRCULATORY SUPPORT

Right ventricular myocardial infarction (RVMI) affects up to 33% of inferior STEMIs. Clinical presentation depends on the extent of RV ischemia. Early recognition and risk stratification is imperative. This has led to the implementation of standardized protocols for the management of RVMI. A 59

Impact of concurrent right ventricular myocardial infarction on outcomes among patients with left ventricular myocardial infarction

To compare in-hospital outcomes between left ventricular myocardial infarction (LVMI) patients with and without right ventricular myocardial infarction (RVMI). Patients with acute ST-segment elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) were enrolled and divided into LVMI with and without RVMI groups. Between-group differences and in-hospital outcomes were compared. Compared to patients without RVMI, patients with RVMI were more likely to be male, have higher body mass index, serum levels of C-reactive protein (8.9 ± 2.4 vs 6.2 ± 2.1 mg/dL), B-type natriuretic peptide (1295 ± 340 vs 872 ± 166 pg/mL) and cardiac troponin-I (8.6 ± 2.9 vs 5.2 ± 2.1 ng/mL), and have diabetes (36.3% vs 3.4%) and dyslipidemia (53.4% vs 48.1%). Patients with RVMI had lower left and right ventricular ejection fraction (50.5 ± 5.6% vs 53.4 ± 3.8% and 33.6 ± 2.9% vs 45.7 ± 2.0%), but had higher mean pulmonary artery pressure (30.6 ± 3.3 vs 23.8 ± 3.1 mm Hg). Compared to patients without RVMI, patients with RVMI had higher odds of in-hospital all-cause mortality (4.1% vs 1.0%) and new onset acute heart failure (3.4% vs 1.0%). After adjusted for confounding factors, LVMI with RVMI remained independently associated with composite outcomes, with odds ratio 1.66 (95% confidence interval 1.39–2.04). Compared to isolated LVMI patients, those with concomitant RVMI have higher odds of in-hospital complications, particularly all-cause mortality and new onset acute heart failure.

Correlation between Cardiac Biomarkers and Right Ventricular Dysfunction in Acute Inferior Wall Myocardial Infarction with and without Right Ventricular Myocardial Infarction

Introduction: Right Ventricular Myocardial Infarction (RVMI) along with inferior wall left ventricular (LV) dysfunction or Inferior Wall Myocardial Infarction (IWMI) is found in 30-50% of the cases. Isolated Right Ventricular (RV) dysfunction or infarction is rare except in iatrogenic (interventional) procedures. RVMI is being more commonly diagnosed retrospectively in the era of primary angioplasty, when these patients post-procedure fail to improve satisfactorily as compared to isolated IWMI patients. Clues to identify early RV involvement in acute IWMI patients will help in better management and less morbidity in this group of patients. Aim: The study was undertaken to search for any correlation between cardiac biomarkers {Troponin I (Trop I), Creatinine Kinase-MB (CK-MB), Brain Natriuretic Peptide (BNP)} and RV involvement using echocardiographic parameters in inferior Acute Myocardial Infarction (AMI), with and without associated RVMI, in patients who underwent primary Percutaneous Coronary Intervention (PCI). Materials and Methods: This was a cross-sectional study, conducted from September, 2018 to August, 2019, in the Cardiology Department of ABVIMS and Dr. Ram Manohar Hospital. A total of 294 patients, presenting with acute IWMI, were included in the study. Samples for Trop-I, CK-MB and BNP were taken immediately after admission. One hundred and thirty two patients had an associated RVMI. Two-dimensional Echocardiography was done within the first 12 hours of admission. Electrocardiography (ECG) and Echocardiography (EEG) assessments were used to determine RV involvement. Comparison was done first between patients with and without RV involvement, followed by comparison among groups for quantitative parameters, especially biomarkers, for finding correlation between biomarker levels and echocardiographic parameters (both RV and LV functions). Results: Patients presenting with IWMI with an associated RVMI had increased LV E/E’ ratio. Also, as predicted, they had a low Tricuspid Annulus Plane Systolic Excursion (TAPSE) and a low RV fractional area change, as well, due to stunning of right ventricle in the acute phase. In the group with higher BNP levels (≥400 pg/mL), the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/E’) was increased; on the other hand LV ejection fraction and TAPSE were decreased. There was negative correlation between RSm (RV systolic wave), TAPSE and BNP levels. BNP, Trop I and CK-MB levels showed a positive correlation with E/E’ at higher levels. Hypotension was more in patients presenting with RVMI, but it did not reach statistical significance. The mortality was 4.5% in the inferior Myocardial Infarction (MI) with RV involvement group versus 1.8% in isolated inferior MI group (during hospital stay). Conclusion: In acute Inferior wall MI, higher levels of BNP, CK-MB, Trop I, alone or in combination, might be used for prediction of RV involvement. BNP levels ≥400 pg/mL, Trop I levels ≥1.1 ng/mL, and CK-MB levels ≥4.5 ng/mL, along with hypotension and higher E/E’ ratio were observed in such cases and were associated with RV dysfunction and increased mortality.

P716 Acute chest pain and new onset severe and asymmetric functional tricuspid regurgitation: What is going on?

Abstract Acute inferior myocardial infarction can be complicated by conduction disorders and/or by extension to the right ventricle (RV). Both situations can resolve with an early percutaneous revascularization. We report a case of a 73-year-old woman, with arterial hypertension, dyslipidemia, and studied by cardiology for atypical chest pain, with several negative ischemia detection tests. She was brought to the Emergency Department due to oppressive chest pain irradiated to the left upper extremity. An electrocardiogram was performed, highlighting a complete atrioventricular block with suprahisian escape and ST segment elevation in inferior leads. Tendency to arterial hypotension and multiple episodes of asymptomatic non-sustained monomorphic ventricular tachycardias as well as self-limiting Torsade de Pointes were registered. The transthoracic echocardiogram (TTE) showed an akinesia circumscribed to the basal segment of the inferior left ventricle wall, a non-dilated RV with akinesia of its anterior wall and a new onset functional and asymmetric severe tricuspid regurgitation (TR) by tethering of the anterior leaflet. It was not possible to estimate the RV-RA gradient by obtaining a dense triangular doppler continuous wave jet contour with early peak. Vena contracta was 7 mm long. An urgent coronary angiography was performed in which the presence of an acute thrombotic occlusion of the proximal segment of the right coronary artery was confirmed. A drug-eluting stent was implanted, with good result. With all this, it was possible to stabilize the patient"s electrical and hemodynamic situation. A TTE was repeated one week after, in which mild to moderate tricuspid regurgitation was observed, coinciding with improvement of the RV systolic function and better mobility of the anterior tricuspid leaflet. Anatomically, the tricuspid valve consists of anterior, septal, and posterior leaflets. Each leaflet is connected via chordae tendineae to the anterior, posterior, and septal papillary muscles of the right ventricle, respectively. The cause of functional TR appears to be tricuspid annular dilatation and tethering of the tricuspid valve leaflets (because of LV failure, pulmonary hypertension, left-to-right shunt, or RV infarction). Primary disorders of the tricuspid valve causing TR are less common. RV myocardial infarction may involve the wall supporting the papillary muscle with resulting tension on the chordae causing TR. The 2D TTE demonstrates incomplete and often asymmetric closure of the tricuspid leaflets with apical displacement of the coaptation point. This phenomenon is similar to that seen with LV myocardial infarction with resulting loss of support of mitral papillary muscle and ischemic mitral regurgitation. We report a case of acute inferior myocardial infarction involving the RV that caused a transient dysfunction of the papillary muscle of the anterior tricuspid leaflet, generating a severe TR that resolved by early revascularization. Abstract P716 Figure. A: severe acute TR. B: few days after

Clinical profiling of right ventricular infarction in patients with acute inferior wall myocardial infarction

Background: Incidence of Right Ventricular Myocardial Infarction (RVMI) associated with Inferior Wall Myocardial Infarction (IWMI) is reported to be quite high (30%-50%). To diagnose coexisting RVMI is important, since its early recognition and proper treatment reduces overall morbidity and mortality in IWMI. Author assessed the incidence and clinically profiled patients with right ventricular infarction in acute inferior wall myocardial infarction and analysed the effects of RVMI on clinical outcome of IWMI.Methods: A total of 150 patients of IWMI were evaluated in the present hospital based prospective observational study over duration of two years. They were evaluated for coronary risk factors like diabetes mellitus, hypertension, smoking, obesity, alcohol and dyslipidemia. Twelve-lead ECG, cardiac enzyme assay and echocardiography were undertaken in all the participants.Results: Of the total 150 patients, 45 (30%) patients had right ventricular myocardial infarction (RVMI). Complications were significantly lower in patients with isolated IWMI as compared to patients with IWMI and associated RVMI except pulmonary edema (p<0.05). Of the total 22 (14.67%) deaths in the present study, 18 (12%) had associated RVMI and 4 (2.66%) isolated IWMI, the difference being statistically significant.Conclusions: Involvement of right ventricle increases rate of complications as well as the mortality rate in patients with inferior wall myocardial infarction.

Predictors of complications among patients with acute inferior and right myocardial infarction

Introduction: Early recognition of acute right ventricular myocardial infarction (RVMI) is very crucial for the initiation of treatment to avoid complications. Objective: The objective of this study is to assess the predictors of complications in patients with acute inferior and RVMI. Patients and Methods: This prospective, single-center study included 100 patients with acute inferior and RVMI presented within 6 h of symptoms onset. All patients received streptokinase as thrombolytic therapy. The patients had undergone conventional two-dimensional echocardiography to assess LVEF, RVEF, RVFAC, and tricuspid annular plane systolic excursion (TAPSE), tissue Doppler to assess s', e', a' waves and myocardial performance index (MPI), and speckle tracking echocardiography to assess RV global longitudinal strain. All echocardiographic parameters were done within the first 12 h of admission and 2 months later. Results: Of 100 patients with acute RVMI; 27 patients had complications, the most common complication was atrioventricular block followed by cardiogenic shock. Mortality occurred in only one patient. On comparing the complicated and noncomplicated groups on admission, we revealed that; as regarding the clinical data, the female gender, presence of diabetes, lower systolic and diastolic blood pressure, and lower pulse were independent risk factors for occurrence of complications in RVMI with P

Right Ventricular Myocardial Infarction as an Independent Predictor of Prognosis in Acute Inferior Myocardial Infarction

Background: Acute inferior myocardial Infarction frequently involves the right ventricle and associated with significant morbidity and mortality. We hypothesized that right ventricular involvement may affect the prognosis of patients with inferior myocardial infarctions.Methodology: In 100 consecutive patients admitted to the hospital with acute inferior myocardial infarction, we assessed the incidence and prognostic factors for in-hospital outcome. RVMI (Right ventricular myocardial infarction) was diagnosed by ≥1mm ST elevation in lead V4R in right sided electrocardiogram.Result: RVMI was found in 31(31%) of patients of acute inferior myocardial infarctions. Major complications as hypotension and cardiogenic shock occurred in 96.7% and 64.5% patients respectively and in-hospital mortality was 41.9%. Whereas major complications as hypotension and cardiogenic shock occurred in 10.1% and 2.8% patients respectively and in hospital mortality was 2.8% of patients without right ventricular infarction among the inferior myocardial infarction. Multiple logistic regression analysis showed right ventricular infarction to be independent of and superior to all other clinical variables available on admission for the prediction of in hospital mortality (relative risk 88.37 percent, 95% confidence interval 7.33 to 1064.80; p=0.000) and major complications as hypotension (relative risk 394.22, 95% confidence interval 32.04 to 4849.07; p=0.000) and cardiogenic shock (relative risk 272.36, 95% confidence interval, 16.38 to 4526.35; p=0.000).Conclusion: RVMI commonly occurs in inferior myocardial infarction. It is a strong and independent predictor of major complications and in-hospital mortality. Early detection and appropriate monitoring can reduce its high mortality rate.TAJ 2013; 26: 8-13

Impact of type 2 diabetes mellitus in the course of acute myocardial infarction of the left ventricle with involvement to the right ventricle

The aim. To evaluate the effect of diabetes mellitus (DM) on the clinical course of the acute period of myocardial infarction (MI) of the left ventricle (LV) and the biventricular MI.Materials and methods. 309 patients with Q-MI age 65.5±4.42 years were examined. Patients were divided into 3 groups: the 1st group – 155 patients with MI of the right ventricle (RV) on the background of Q-MI of the posterior wall of the LV, the 2nd group – 53 patients with RV MI due the Q-MI of the LV circular localization, and the 3rd group – 101 patients with Q-MI of the LV posterior wall. Patients with DM were 41 (26.5 %) in the 1st group, 22 (41.5 %) - in the 2nd group, and 26 (25.7 %) patients in the third group. The hospital treatment period was 16.8±2.7 days.Results. Patients with DM in all groups had late admission, usually within 12-24 hours (p <0.05) and after the first day of the MI (p <0.05). Among patients with DM there were more women (p <0.05). The presence of DM was associated with a significantly greater number of ventricular arrhythmias and ventricular fibrillation (p <0.05). The clinical course of the acute MI in patients with DM often complicated of early postinfarction angina (p <0.05), recurrent MI and the LV aneurysms in the 2nd group (p <0.05). The acute heart failure (HF) was more severe in patients with DM with prevalence of the number of cases with Killip II-III (p <0.05) and a higher frequency of cardiogenic shock (p <0.05). Patients with DM had more severe manifestations of chronic HF with greater frequency of the HF IIA, IIB and III NYHA in the total group of patients with MI (p <0.05).Conclusion. The DM in patients with Q-ІМ of the LV and the biventricular MI is accompanied by late admission and is more common in women. The presence of the DM in patients with MI is associated with a higher frequency of ventricular extrasystoles, ventricular tachycardias and ventricular fibrillation, cases of early post-MI angina, the development of recurrent MI and the LV aneurysms. Patients with DM have a high frequency of cardiogenic shock and worse manifestations of acute and chronic HF

Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association.

The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF. The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations. Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking. RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.

THE DIAGNOSTIC AND PROGNOSTIC VALUE OF RIGHT VENTRICLE SYSTOLIC AND DIASTOLIC FUNCTION IN INFERIOR MYOCARDIAL INFARCTION

Right ventricular (RV) involvement increases mortality and morbidity in inferior myocardial infarction (MI). There are sparse data on the usefulness of pulsed tissue Doppler imaging (TDI) in the diagnosis of RV dysfunction in ST segment elevation MI (STEMI). This study evaluate the diagnostic and prognostic significance of RV systolic and diastolic function compared to classical electrocardiographic RVMI diagnostic criteria in this group of patients. Consecutive patients with first, acute, inferior STEMI were prospectively assessed. The RVMI was defined as an ST-segment elevation ≥ 0.1 mV in lead V4R. Echocardiography with TDI was performed within24 h of the onset of symptoms. Out of 31 patients (mean age 56.39 ± 9.02 years), RVMI was found in 18 (37%). Multivariate analysis showed that two variables—RV systolic and diastolic function, were independent predictors of in-hospital prognosis. Sensitivity and specificity the RV systolic function were 94,4% and 69,2%, respectively. While RV diastolic function were 44% and 76,9%, respectively. RV systolic function predict ECG diagnosis of RVMI with relatively high sensitivity and specificity. RV diastolic function predict ECG diagnosis of RVMI with relatively low sensitivity but with high specificity.Keywords: tissue Doppler imaging, RV myocardial infarction, inferior myocardial infarction

High-risk inferior myocardial infarction: Can speckle tracking predict proximal right coronary lesions?

It is important to diagnose right ventricular (RV) infarction in the setting of acute inferior myocardial infarction (MI). We aimed to improve the diagnostic accuracy of RV infarction and identify a high-risk subset of inferior MI patients with proximal RCA lesions. We tried to find the link between speckle tracking and coronaries in high risk inferior infarction METHODS: This study included 68 patients within 24 hours of first acute inferior MI. Group 1 (n = 49) isolated inferior MI; group 2 (n = 19) inferior and RV MI. echocardiography for RV free wall longitudinal strain (FWLS), RV fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), RV myocardial performance index (MPI) and peak systolic velocity (S'). Group 2 had higher MPI by tissue Doppler and 2D-RV average FWLS, whereas RV FAC, S', and TAPSE were lower (P < 0.001). In group 1, 14.4% had a significant proximal RCA lesion with impaired RV function. RV average FWLS at a cutoff value ≥ - 19.7% can predict proximal RCA culprit lesion with 91.7% sensitivity and 70.5% specificity, which was detected as an independent predictor in multivariate logistic regression (odds ratio: 37.75, P = 0.036). 2D RV average FWLS at a cutoff of ≥ - 19.7% is a useful added tool for diagnosis of RV involvement and an independent predictor to rule in proximal RCA culprit lesion in inferior-wall MI patients in the emergency department.

Impact of right ventricular diastolic dysfunction on clinical outcomes in inferior STEMI.

The aim of this study was to investigate the prognostic value of restrictive right ventricular filling pattern (RRVFP) in patients with the first acute inferior wall myocardial infarction (IWMI) complicated by right ventricular myocardial infarction (RVMI) undergoing primary percutaneous coronary intervention (p-PCI). A total of 152 patients with acute IWMI complicated by RVMI undergoing p‑PCI were divided into two groups according to the presence of RRVFP. RRVFP was defined as tricuspid diastolic early/late flow velocities (Et/At)> 2 and Et deceleration time (DT)< 120ms. There were 23patients with RRVFP in the study cohort. At, DTt, isovolumetric relaxation time (IVRT), and tissue Doppler tricuspid annular late velocity (A't) were reduced significantly in patients with RRVFP than in those without RRVFP (At 19.6± 2.7 vs. 39.1± 7.4 cm/s, p< 0.001; DTt 106± 13 vs.156± 21 ms, p= 0.001; IVRT 59± 6.7 vs. 62± 7.4 ms, p= 0.01; A't 4.6± 1.1 vs. 8.6± 1.05, p= 0.001). Et/At ratios were higher in patients with RRVFP than in those without RRVFP (Et/At 2.20± 0.2 vs. 1.15± 0.37, p< 0.001). Et, tissue Doppler tricuspid annular early velocity (E't), E't/A't ratio, and Et/E't ratio were not significantly different between groups (Et 43.3± 5.4 vs. 40.7± 9.2 cm/s p= 0.18; E't 8.8± 1.4 vs. 9.5± 2.3, p= 0.15; E't/A't 1.08± 0.24 vs. 1.13± 0.30, p= 0.52; Et/E't ratio 5.0± 1.1 vs. 4.5± 1.5 p= 0.09). Presence of E't/A't> 2, short DTt, RRVFP, unsuccessful p‑PCI, and cardiogenic shock on admission were independent predictors of in-hospital mortality (p< 0.05) in multivariable logistic regression analysis. Presence of RRVFP is associated with in-hospital mortality in patients presenting with their first IWMI complicated by RVMI.