Impact of right ventricular failure on the outcomes of acute inferior wall myocardial infarction.

Aim: Right ventricular failure (RVF) complicates 30-50% of cases with inferior wall myocardial infarctions (IWMI). Large-scale studies exploring the recent trends in morbidity and mortality of IWMI with RVF in the context of improved reperfusion strategies are currently lacking.Materials & methods: The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to query the National Inpatient Sample of 2018-2019 to yield IWMI admissions and stratified based on presence of RVF. The primary outcome was in-hospital mortality.Results: Out of the 182,485 weighed hospital admissions for IWMI, 1005 patients (0.6%) also had RVF. Patients with both IWMI and RVF had significantly higher mortality than patients with IWMI and no RVF (p < 0.001).Conclusion: RVF in patients with IWMI is an independent predictor of poor outcomes.

What is this article about? Right ventricular failure (RVF) refers to a condition in which the right ventricle is unable to pump blood to the left side of the heart. Up to 30­50% of patients with heart attacks, commonly known as acute myocardial infarction, affecting the back or the inferior wall of the heart (IWMI) can develop RVF. Research studies assessing the outcomes of patients with IWMI and RVF were done either in a small number of patients or done during the time when the current standard of acute myocardial infarction care was not the standard of care. Therefore, we conducted a study to assess the clinical outcomes of patients with IWMI and RVF in contemporary times.What are the results? We found that among all patients with IWMI, only about 0.6% had evidence of RVF. However, these patients were older and much more likely to have a higher burden of chronic medical problems and were less likely to have received angioplasty to open blocked arteries when compared with patients with IWMI and no RVF. Patients with IWMI and RVF were noticed to have a higher rate of death during hospitalization.What do the results mean? Patients with IWMI and RVF, when compared with patients with IWMI and no RVF, had significantly higher rates of various complications and death.

Abnormal ST-segment changes in anterior and inferior leads during acute inferior myocardial infarction.

Anterior and inferior ST elevation on electrocardiography (ECG) in patients with acute myocardial infarction is uncommon. ST-segment elevation due to right ventricular infarction induced by right coronary occlusion may extend from V1 to V3/V4, resembling the pattern of transmural ischemia of the anterior wall of the left ventricle. In addition, a wraparound left anterior descending (LAD) artery can produce ischemia manifesting as ST-segment elevation in the anterior and inferior leads. Our case report reveals dynamic ST-segment changes in acute inferior myocardial infarction, including the appearance of the shark fin ECG pattern, unlike what has been reported before.

Clinical significance of R-wave amplitude in lead V1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction.

OBJECTIVE: To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h. METHODS: Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9. RESULTS: Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset. CONCLUSIONS: For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.

A rare case of concurrent left ventricular aneurysm and ventricular septal rupture complicating an inferior myocardial infarction: a case report.

Complications following acute myocardial infarction (MI) such as ventricular septal rupture (VSR) and left ventricular (LV) aneurysm are rare and can be dreadful. Their simultaneous presence in the same patient is extremely rare. We aimed to present a rare case of concomitant association of ventricular aneurysm and VSR complicating an inferior myocardial infarction. We report the unusual case of Mr. A. D, a 63-year-old, active smoker, with a history of diabetes mellitus and hypertension, admitted for the management of inferior MI within 6 days. The MI was complicated by an LV aneurysm in the inferoposterior and the inferoseptal walls associated with a VSR in the inferoseptal wall. The patient had only signs of right heart failure on admission. This observation illustrates on the one hand the rarity of the association of VSR and LV aneurysm after an inferior myocardial infarction, and on the other hand the possibility of founding them at an early stage of MI without any signs of cardiogenic shock.

Acute inferior myocardial infarction combined with papillary muscle rupture: A case report. / 急性下壁心肌梗死合并乳头肌断裂1例.

The incidence of acute myocardial infarction (AMI) is increasing. Acute papillary muscle rupture is one of the serious and rare mechanical complications of AMI, which occurs mostly in inferior and posterior myocardial infarction. A patient with acute inferior myocardial infarction developed pulmonary edema and refractory shock, followed by cardiac arrest. After cardiopulmonary resuscitation (CPR), revascularization of criminal vessels was carried out by emergency percutaneous transluminal coronary angioplasty (PTCA) under the support of intra-aortic balloon pump (IABP) and extra corporeal membrane oxygenation (ECMO). Although the patient was given a chance for surgery, his family gave up treatment due to unsuccessful brain resuscitation. It reminds that mechanical complications such as acute papillary muscle rupture, valvular dysfunction and rupture of the heart should be highly suspected when cardiogenic pulmonary edema and cardiogenic shock are difficult to correct in acute inferior myocardial infarction. Echocardiogram and surgery should be put forward when revascularization of criminal vessels is available.

Successful percutaneous coronary intervention with extracorporeal membrane oxygenation in a patient with acute inferior wall myocardial infarction complicated by electrical storm, cardiogenic shock, and cardiac arrest: a case report.

BACKGROUND: High-risk patients with coronary heart disease who develop acute myocardial infarction (AMI) have severe coronary lesions. If severe complications occur, such as malignant ventricular arrhythmia, cardiogenic shock, and cardiac arrest, implementation of emergency percutaneous coronary intervention (PCI) may be hindered, leading to a higher perioperative mortality rate. Extracorporeal membrane oxygenation (ECMO) can pave the way for rapid myocardial reperfusion therapy. When cardiac arrest occurs, hemodynamic support with ECMO can facilitate revascularization with PCI, which can increase the time available for further salvage and treatment and reduce intraoperative risk during PCI. CASE PRESENTATION: Herein, we report a case of a 61-year-old man with AMI who suffered electrical storm of sustained malignant ventricular fibrillation, cardiogenic shock, and cardiac arrest and was successfully treated with PCI with ECMO support. During PCI, repeated aspiration and removal of the right coronary artery thrombus were performed, and blood flow was restored after right coronary artery balloon dilation. One episode of defibrillation was delivered to restore sinus rhythm. Then, stents were implanted in the distal and proximal right coronary artery lesions to achieve revascularization. After PCI with ECMO support, irreversible malignant arrhythmia returned to sinus rhythm through coronary perfusion, which prevented death following unsuccessful cardiopulmonary resuscitation. After applying active treatments, including anti-shock, mechanical ventilation, anti-inflammation, and organ support, the patient was discharged after his condition and vital signs stabilized. The patient was followed up once a week after hospital discharge, and his cardiopulmonary function recovered well. CONCLUSIONS: With ECMO support, PCI should be performed immediately in patients with inferior wall AMI complicated by electrical storm of sustained ventricular fibrillation, cardiogenic shock, and cardiac arrest to facilitate stent placement, achieve complete revascularization, restore coronary perfusion, and avoid death.

Acute inferior occlusion myocardial infarction with a solitary ST-elevation in lead III: A case report.

The ST-segment elevation myocardial infarction (STEMI) paradigm requires ST-segment elevation (STE) in contiguous leads on electrocardiography (ECG). STEMI criteria overlook numerous patients with acute coronary occlusion (ACO). The Aslanger pattern describes an ECG without contiguous STE, indicating acute inferior occlusion myocardial infarction (OMI) with concomitant multi-vessel disease. We describe one case of inferior OMI with one STE in lead III on initial ECG; however acute inferior STEMI was later identified. Coronary angiography showed thrombosis in the proximal right coronary artery and severe stenosis in non-infarct-related arteries. Awareness of the limitations of current STEMI criteria is crucial for timely intervention.

Transcatheter closure of ventricular septal rupture with prolonged support of intra-aortic balloon pump after primary PCI: a case report.

BACKGROUND: Ventricular septal rupture (VSR) is a rare but severe complication of acute myocardial infarction (AMI). For such cases, surgical repair is recommended by major guidelines, but not always possible for such cases. CASE PRESENTATION: A 72-year-old man presented to the emergency room. ECG showed the ST-segment was elevated by 2-3 mm in lead II, III, and aVF, with Q-waves. Coronary angiography (CAG) showed multi-vessel disease with a total occlusion of the right coronary artery (RCA) and severe stenosis of the left anterior descending artery (LAD). A diagnosis of acute inferior myocardial infarction was made. VSR occurred immediately after percutaneous coronary intervention (a 2.5 × 20 mm drug-eluting stent implanted in RCA), and the patient developed cardiogenic shock. An intra-aortic balloon pump (IABP) was used to stabilize the hemodynamics. Transthoracic echocardiography (TTE) revealed an 11.4-mm left-to-right shunt in the interventricular septum. An attempt was made to reduce the IABP augmentation ratio for weaning on day 12 but failed. Transcatheter closure was conducted using a 24-mm double-umbrella occluder on day 28. The patient was weaned from IABP on day 31 and underwent secondary PCI for LAD lesions on day 35. The patient was discharged on day 41. Upon the last follow-up 6 years later, CAG and TTE revealed no in-stent restenosis, no left-to-right shunt, and 51% left ventricular ejection fraction. CONCLUSIONS: Prolonged implementation of IABP can be a viable option to allow deferred closure of VSR in AMI patients, and transcatheter closure may be considered as a second choice for the selected senior and vulnerable patients, but the risk is still high.

Acute Dyspnea After Inferior-Wall Myocardial Infarction.

A 57-year-old woman presented with acute-onset dyspea with a duration of more than 2 days. Four days earlier, she had been thrombolyzed with streptokinase for inferior wall myocardial infarction in a nearby hospital. On examination, we found that the patient had elevated jugular venous pressure and systolic murmur in left lower parasternal region. In addition, there was a ventricular septal rupture in the posterobasal interventricular septum, with at least 2 exit points into the right ventricle. Timely identification of ventricular septal rupture before PCI is of paramount importance, as it has major implications in management of the patient.

Two Novel Mutations (G774A and A1685G) Causing Coagulation Factor XII Deficiency in a Patient with Acute Inferior Myocardial Infarction.

OBJECTIVE: To identify the gene mutation of the coagulation factor XII (FXII) in a patient with FXII deficiency and acute inferior myocardial infarction. METHODS: The proband was a 51-year-old Chinese man who was diagnosed with acute inferior myocardial infarction and had a history of FXII deficiency. The patient presented with a prolonged activated partial thromboplastin time (160 s) and decreased FXII activity (2.3%) and FXII antigen (1%). DNA sequence analysis of the FXII gene was performed by next generation sequencing. The mutant FXII cDNAs were constructed in an expression plasmid vector and transfected into 293T cells. The expression of FXII antigen was detected by western blot. RESULTS: Sequencing of the FXII gene revealed two novel heterozygous mutations, one at exon 8 (G774A; p: W258X) and the other at exon 14 (A1685G; p: D562G). Western blot showed that the FXII antigens were detected only in the supernatant and whole cell lysate of the wild-type and A1685G mutant type, but not in G774A or G774A plus the A1685G mutant type. In addition, the results showed that secretion but not synthesis of A1685G mutant protein was markedly reduced compared to the wild type. CONCLUSION: The present study indicated that the G774A mutation might impair the secretion and synthesis of FXII protein, while the A1685G mutation only influences the secretion of FXII protein. The definition of these new mutations could be useful tools for analyzing the intracellular protein transport and structure-function relationship of FXII protein transport in the future.

Case Report Detailing an Inferior Myocardial Infarction, Third-Degree Heart Block, and Cardiogenic Shock.

An infarction in the right coronary artery affects the inferior wall of the heart and can also cause impedance to the cardiac conduction system. The right coronary artery perfuses the sinoatrial and atrioventricular nodes, and a loss of blood flow contributes to a breakdown in the communication system within the heart, causing associated bradycardias, heart blocks, and arrhythmias. This case report details the prehospital and emergency care of a middle-aged man who experienced an inferior myocardial infarction, concomitant third-degree heart block, and subsequent cardiogenic shock, with successful revascularization. This case is informative for emergency clinicians to review symptoms of acute coronary syndrome, rapid lifesaving diagnostics and intervention, and the unique treatment and monitoring considerations associated with right ventricular involvement and third-degree heart block.

Inferior Wall Myocardial Infarction in Severe COVID-19 Infection: A Case Report.

BACKGROUND The novel coronavirus disease (COVID-19) has been declared a pandemic. With the ever-increasing number of COVID-19 patients, it is imperative to explore the factors related to the disease to aid patient management until a definitive vaccine is ready, as the disease is not limited to the respiratory system alone. COVID-19 has been associated with various cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. The infection is severe in patients with pre-existing cardiovascular disease, and a systemic inflammatory response due to a cytokine storm in severe COVID-19 cases can lead to acute myocardial infarction. CASE REPORT We present the case of a 56-year-old man with cardiovascular risk factors including coronary artery disease, hypertension, ischemic cardiomyopathy, and hyperlipidemia, who had COVID-19-induced pneumonia complicated with acute respiratory distress syndrome. He subsequently developed myocardial infarction during his hospitalization at our facility. He had a significant contact history for COVID-19. He was managed with emergent cardiac revascularization after COVID-19 was confirmed by real-time reverse transcription-polymerase chain reaction testing from a nasopharyngeal swab as per hospital policy for admitted patients. Apart from dual antiplatelet therapy, tocilizumab therapy was initiated due to the high interleukin-6 levels. His hospitalization was complicated by hemodialysis and failed extubation and intubation, resulting in a tracheostomy. Upon improvement, he was discharged to a long-term facility with a plan for outpatient follow-up. CONCLUSIONS In high-risk patients with COVID-19-induced pneumonia and cardiovascular risk factors, a severe systemic inflammatory response can lead to atherosclerotic plaque rupture, which can manifest as acute coronary syndrome.

Evaluation of right ventricular dyssynchrony in patients with acute inferior myocardial infarction and its relation with mortality.

PURPOSE: The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle-tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI). METHODS: One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention, and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation >1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for 3 years to determine the cardiovascular mortality. RESULTS: Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS, and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within 2 years. RVMI was more prevalent in mortality group, and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. Receiver operating characteristics (ROC) analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8% in IMI patients. CONCLUSIONS: Intra- and inter-ventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.

Clinical, procedural and long-term outcome of ischemic VT ablation in patients with previous anterior versus inferior myocardial infarction.

BACKGROUND: Outcome of ischemic VT ablation may differ between patients with previous myocardial infarction (MI) in relation to infarct localization. METHODS: We analyzed procedural data, acute and long-term outcomes of 152 consecutive patients (139 men, mean age 67 ± 9 years) with previous anterior or inferior MI who underwent ischemic VT ablation at our institution between January 2010 and October 2015. RESULTS: More patients had a history of inferior MI (58%). Mean ejection fraction was significantly lower in anterior MI patients (28 ± 10% vs. 34 ± 10%, p < 0.001). NYHA class and presence of comorbidities were not different between the groups. Indication for the procedure was electrical storm in 43% of patients, and frequent implantable cardioverter defibrillator (ICD) therapies in 57%, and did not differ significantly between anterior and inferior MI patients. A mean of 3 ± 2 VT morphologies were inducible, with a trend towards more VT in the anterior MI group (3.1 ± 2.2 vs. 2.6 ± 1.9, p = 0.18). Procedural parameters and acute success did not differ between the groups. During a mean follow-up of 3 ± 2 years, more anterior MI patients had undergone a re-ablation (49% vs. 33%, p = 0.09, Chi-square test). There was a trend towards more ICD shocks in patients with previous anterior MI (46% vs. 34%). After adjusting for risk factors and ejection fraction, multivariable Cox regression analyses showed no significant difference in mortality (p = 0.78) and cardiovascular mortality between infarct localizations (p = 0.6). CONCLUSION: Clinical characteristics of patients with anterior and inferior MI are similar except for ejection fraction. Patients with inferior MI appear to have better outcome regarding survival, ICD shocks and re-ablation, but this appears to be related to better ejection fraction when compared with anterior MI.

Late Post- Infarction Left Ventricular Pseudoaneurysm: A Case Report.

We present a case of a 90 year-old-patient who presented with syncope. She had previous inferior acute myocardial infarction 10 years ago. Coronary angiography revealed left ventricular pseudoaneurysm, which was confirmed on cardiac computed tomography. The patient refused surgical repair and implantable cardioverter defibrillator insertion and was discharged from the hospital alive. This case demonstrates the possibility of long-term survival with left ventricular pseudoaneurysm and the increasing detection of 'incidental' left ventricular pseudoaneurysm with more frequent use of imaging.

Ventricular septal rupture with right ventricular wall dissection after inferior ventricular infarction: A case report and literature review.

Right ventricular (RV) wall dissection following ventricular septal rupture related to inferior myocardial infarction (MI) is an extremely rare complication with a high mortality rate. We report the case of a 61-year-old man who was admitted to our hospital because of syncope and intermittent chest pain with a precordial murmur. Transthoracic echocardiography showed a rupture at the basal infero-posterior septum and RV free-wall dissection forming an echolucent cavity that extended beyond the septum and subsequently re-entered into RV chamber. The patient's overall cardiac and renal functions deteriorated and he died 24 days after the diagnosis. We present a literature review of the published cases of complex dissecting tracts through the septum and RV wall in ischemic context.