ST segment elevation in leads V1 to V3 due to isolated right ventricular branch occlusion during primary right coronary angioplasty

Isolated right ventricular myocardial infarction caused by occlusion of an anomalous non-dominant right coronary artery: successful management with percutaneous coronary intervention

Isolated right ventricular myocardial infarction (RVMI) is a rare clinical presentation of acute coronary syndrome. A high index of suspicion is needed for its timely diagnosis and management to prevent serious complications like heart failure, cardiogenic shock, ventricular arrythmias or sudden cardiac death. Coronary anomalies are rare entities with a varied clinical presentation. We report an interesting case of a middle-aged female who presented with isolated RVMI, with a borderline blood pressure and sinus node dysfunction resulting from occlusion of an anomalous right coronary artery. The successful management of this patient with percutaneous coronary intervention using coronary stenting is also discussed.

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 ST-segment 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 ST-segment 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.

Isolated right ventricular myocardial infarction: a case report

Background

Isolated 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 summary

A 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.

Discussion

This 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.

Cardiac arrest due to an unexpected acute myocardial infarction during head and neck surgery: A case report

Major cardiac complication such as acute myocardial infarction can occur unexpectedly in patients without risk factors. We experienced cardiac arrest due to an unexpected acute myocardial infarction in a patient without any risk factors during head and neck reconstructive surgery. The patient was diagnosed with acute myocardial infarction after return of spontaneous circulation. With immediate percutaneous coronary intervention, the patient recovered without complications.

Proximal RCA occlusion producing anterior ST segment elevation, Q waves, and T wave inversion

An ST segment elevation myocardial infarction (STEMI) that produces anterior ST segment elevation (STE) is typically caused by acute occlusion of the left anterior descending (LAD) artery. Anterior STE, however, may also be caused by acute occlusion of either the proximal right coronary artery (RCA) or the right ventricular marginal branch (RVB). It has been thought that, in contrast to occlusions of the LAD, proximal RCA/RVB occlusion rarely causes Q waves in the right precordial leads. We present a case where a proximal RCA occlusion produced not only anterior STE, but also anterior T wave inversions and anterior Q waves.

Proximal complete occlusion of right coronary artery presenting with precordial ST-segment elevation: A case report

BACKGROUND

It is well known that cardiologists empirically judge the culprit lesion of acute ST-segment elevation myocardial infarction (STEMI) according to the corresponding electrocardiographic leads. However, In addition to the obstruction of left anterior descending (LAD) coronary artery, rare cases with the occlusion of proximal right coronary artery (RCA) and/or isolated right ventricular (RV) branch showed the ST-segment elevation in precordial leads V1-V3 as well.

CASE SUMMARY

We reported a patient complaining of acute chest pain and suffering ventricular fibrillation (VF) on admission. The electrocardiogram (ECG) showed mild ST-segment elevation in precordial leads V1-V3 and V4R. Bedside echocardiography displayed normal left ventricular ejection fraction and slight RV dilation. Proximal occlusion of nondominant RCA was confirmed by coronary angiography and urgent percutaneous coronary intervention (PCI) to RCA successfully resolved the chest pain and ST-segment elevation.

CONCLUSION

Undoubtedly, coronary angiography is usually the definite measurement for the diagnosis of culprit lesion. However, bedside echocardiography, ST-segment features in left and right precordial leads, and heart rate will be the additional information for judging ST-segment elevation in precordial leads V1-V3 resulting from occlusion of RCA or LAD.

Acute Complications of Myocardial Infarction in the Current Era: Diagnosis and Management

Coronary heart disease is a major cause of mortality and morbidity worldwide. The incidence of mechanical complications of acute myocardial infarction (AMI) has gone down to less than 1% since the advent of percutaneous coronary intervention, but although mortality resulting from AMI has gone down in recent years, the burden remains high. Mechanical complications of AMI include cardiogenic shock, free wall rupture, ventricular septal rupture, acute mitral regurgitation, and right ventricular infarction. Detailed knowledge of the complications and their risk factors can help clinicians in making an early diagnosis. Prompt diagnosis with appropriate medical therapy and timely surgical intervention are necessary for favorable outcomes.

Acute anterior ST-elevation myocardial infarction and electrical storm secondary to nondominant right coronary artery occlusion

A 42-year-old man emergently presented with chest pain and anterior ST elevation. Refractory ventricular arrhythmias and shock developed rapidly. A coronary angiogram revealed the acute occlusion of a nondominant right coronary artery. After percutaneous coronary intervention, the anterior ST elevation and ventricular arrhythmias resolved. The electrocardiographic pattern was a result of isolated right ventricular infarction that in turn caused profound electrical and hemodynamic instability. We discuss the cause and pathophysiology of this patient's case, and we recommend that interventional and general cardiologists be aware that anterior ST elevation can be caused by the occlusion of a nondominant right coronary artery.

Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: exclusion of left coronary obstruction with transoesophageal echocardiography

One of the most troublesome complications of percutaneous coronary intervention (PCI) or angiography is retrograde dissection of the artery into the aortic root. We report a case involving the right coronary artery (RCA) which was treated with prompt deployment of stents. Recurrent chest pain and ST segment elevation in V(2-4) mimicked the ECG appearance of acute anterior infarction and prompted concern that the dissection had extended to impair flow in the left coronary artery (LCA). Transoesophageal echocardiography (TOE) demonstrated that the aortic root dissection had been contained and that the LCA was not compromised.

Acute Myocardial Infarction by Right Coronary Artery Occlusion Presenting as Precordial ST Elevation on Electrocardiography

It is rare to observe ST-segment elevation in only the anterior leads and not the inferior leads during right coronary artery occlusion. We describe a case with acute myocardial infarction (MI) by right coronary artery occlusion who developed ST-segment elevation only in the precordial leads V1 to V3.

[Right ventricular infarction caused by isolated right ventricular branch occlusion: a case report]

It is rare to observe right ventricular infarction caused by isolated right ventricular branch occlusion. Isolated right ventricular infarction accounts for less than three percent of all cases of infarction. Generally, it is associated with occlusion of a non dominant right coronary artery or of a right ventricular branch. ECG can be misleading with ST segment elevation in anterior leads. We describe a patient admitted for chest pain with ST segment elevation in leads V1 to V3 associated with ST segment elevation in leads V3R and V4R. Coronary angiography demonstrated isolated total occlusion of the right ventricular branch. Thus, right precordial leads need to be done in every patient presenting with ST segment elevation in precordial leads V1 to V3 and not only in inferior myocardial infarction.

Isolated right ventricular infarction due to occlusion of the right ventricular branch in the absence of percutaneous coronary intervention

Isolated right ventricular myocardial infarction accounts for only 3% of all infarctions. It has previously been reported as a complication of percutaneous coronary intervention involving the right coronary artery secondary to occlusion of the right ventricular branch. In the present report, a patient is described in whom isolated right ventricular myocardial infarction developed due to occlusion of the right ventricular branch of the right coronary artery in the absence of percutaneous intervention.

Precordial ST-segment elevation in acute occlusion of the proximal right coronary artery

Isolated right ventricular myocardial infarction (RVMI) rarely occurs and accounts for only 3% of all myocardial infarction cases. In the literature, there are several reported isolated RVMI cases with precordial ST-segment elevation. We describe a 45-year-old man with marked ST-segment elevations in leads V1 through V4 accompanied by slight ST-segment elevations in the inferior leads (III, aVF) caused by acute occlusion of a nondominant small right coronary artery proximal to the conus branch causing isolated RVMI.

Right ventricular infarction mimicking anterior infarction

It is rare to observe ST elevation in anterior derivations caused by right ventricular branch occlusion. We described the case of a patient with unstable angina who developed acute right ventricular myocardial infarction with ST-segment elevation in anterior precordial leads (V(1)-V(4)) shortly after coronary angiography. Coronary angiogram revealed total occlusion of the right coronary artery (RCA) proximally to the right ventricular branch. This reminds us that the presence of diffuse ST-segment elevation in the precordial leads could be due to acute RCA occlusion. The differentiation of these two entities is important, as their therapies are quite different.