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Goldstein JA, Lerakis S, Moreno PR. Right Ventricular Myocardial Infarction-A Tale of Two Ventricles: JACC Focus Seminar 1/5. J Am Coll Cardiol 2024; 83:1779-1798. [PMID: 38692829 DOI: 10.1016/j.jacc.2023.09.839] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 05/03/2024]
Abstract
Right ventricular infarction (RVI) complicates 50% of cases of acute inferior ST-segment elevation myocardial infarction, and is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. RV systolic performance is generated by left ventricular contractile contributions mediated by the septum. Augmented right atrial contraction optimizes RV performance, whereas very proximal occlusions induce right atrial ischemia exacerbating hemodynamic compromise. RVI is associated with vagal mediated bradyarrhythmias, both during acute occlusion and abruptly with reperfusion. The ischemic dilated RV is also prone to malignant ventricular arrhythmias. Nevertheless, RV is remarkably resistant to infarction. Reperfusion facilitates RV recovery, even after prolonged occlusion and in patients with severe shock. However, in some cases hemodynamic compromise persists, necessitating pharmacological and mechanical circulatory support with dedicated RV assist devices as a "bridge to recovery."
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Affiliation(s)
- James A Goldstein
- Department of Cardiovascular Medicine, Beaumont University Hospital, Corewell Health, Royal Oak, Michigan, USA.
| | - Stamatios Lerakis
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pedro R Moreno
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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2
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Jha AK, Jha N, Malik V. Perioperative Decision-Making in Pulmonary Hypertension. Heart Lung Circ 2023; 32:454-466. [PMID: 36841637 DOI: 10.1016/j.hlc.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 02/27/2023]
Abstract
Pulmonary hypertension (PH) is a haemodynamic manifestation of cardiorespiratory and non-cardiorespiratory pathologies. Cardiorespiratory pathologies account for nearly three-fourths of patients with PH. It is now increasingly being recognised due to routine requests for transthoracic echocardiographic examination in the perioperative setting in patients undergoing intermediate- to high-risk non-cardiac surgery. The increased risks of perioperative morbidity and mortality attributed to PH have been widely acknowledged in the literature. The importance of PH in perioperative decision-making and postoperative outcomes has had little mention in all the guidelines. Understanding the complexity of the pathophysiology of PH may help in anaesthetic and surgical decision-making. Preoperative evaluation and risk assessment are guided by the nature, extent, invasiveness, and duration of surgery. Surgical decision-making and anaesthetic management involve preoperative risk stratification, understanding the interactions between surgical procedures and PH, and understanding the interactions between anaesthetic procedures, PH, and cardiopulmonary interactions. Intraoperative and postoperative monitoring is crucial for maintaining the haemodynamic parameters and helps titrate anaesthetic agents and medication. This narrative review focusses on all issues related to anaesthetic and surgical challenges in patients with PH. This review aimed to suggest a preoperative evaluation plan, surgical decision-making, anaesthetic plan, and anaesthetic management based on the evidence available in the literature.
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Affiliation(s)
- Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
| | - Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Vishwas Malik
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Haloot J, Mahmoud M, Prasad A, Anderson AS, Aslam MI. Management of Post-Myocardial Infarction Right Ventricular Failure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100526. [PMID: 39132546 PMCID: PMC11308243 DOI: 10.1016/j.jscai.2022.100526] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/05/2022] [Accepted: 10/11/2022] [Indexed: 08/13/2024]
Abstract
Right ventricular failure (RVF) due to an acute myocardial infarction (MI) has been associated with high morbidity and mortality. Initial treatment is guided by early recognition and prompt revascularization. Current management of post-MI RVF is built upon expert consensus and is also informed by RVF from other etiologies, including massive pulmonary embolism, left ventricular assist device-associated right ventricular dysfunction, postcardiotomy shock, etc.; this speaks to the limited data available on the specific management of RVF in acute MI. The goal of this review is to discuss the current literature on the pathophysiology, general management considerations, interventional management, hemodynamic monitoring, medical management, and mechanical circulatory support of MI-induced RVF.
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Affiliation(s)
- Justin Haloot
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Mohamed Mahmoud
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Anand Prasad
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Allen S. Anderson
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - M. Imran Aslam
- Division of Cardiology, Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
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Abstract
Isolated right ventricular (RV) infarction is extremely rare and its diagnosis may be challenging, because RV infarction most often occurs simultaneously with infarction of the inferior wall of the left ventricle. A 66-year-old man with a history of diabetes mellitus presented with cold sweat and general malaise. Although his symptoms were atypical for myocardial infarction, he was quickly diagnosed with RV infarction and successfully underwent urgent percutaneous coronary intervention. He was definitely diagnosed with isolated RV infarction by a scintigram and cardiac magnetic resonance imaging. Our review showed the importance of the combined assessment in the diagnosis of isolated RV infarction.
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Affiliation(s)
- Daigo Hiraya
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Akira Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Hiroaki Watabe
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Tomoya Hoshi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan
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Adamson C, Rocchiccioli P, Brogan R, Berry C, Ford TJ. Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-6. [PMID: 32123801 PMCID: PMC7042144 DOI: 10.1093/ehjcr/ytz181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/17/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022]
Abstract
Background Coronary ostial stenosis is an uncommon but potentially lethal complication following aortic root replacement with or without aortic valve replacement (including Bentall and David procedures). This manifests clinically as acute myocardial ischaemia in the early or late post-operative period. Traditionally, this might be managed with redo open-heart surgery. Case summary This case series describes two presentations where urgent percutaneous coronary intervention was used to manage myocardial infarction complicating aortic root surgery with coronary reimplantation. Discussion This series highlights the risk of acute myocardial infarction after cardiac surgery involving coronary reimplantation. Emergency percutaneous coronary intervention is feasible and illustrates the importance of shared post-operative care involving the cardiac surgeons and the cardiology team.
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Affiliation(s)
- Carly Adamson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Richard Brogan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK.,Department of Cardiology, Gosford Hospital, NSW, Australia.,University of New South Wales, Sydney, Australia
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Albulushi A, Giannopoulos A, Kafkas N, Dragasis S, Pavlides G, Chatzizisis YS. Acute right ventricular myocardial infarction. Expert Rev Cardiovasc Ther 2018; 16:455-464. [PMID: 29902098 DOI: 10.1080/14779072.2018.1489234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Acute right ventricular myocardial infarction (RVMI) is observed in 30-50% of patients presenting with inferior wall myocardial infarction (MI) and, occasionally, with anterior wall MI. The clinical consequences vary from no hemodynamic compromise to severe hypotension and cardiogenic shock depending on the extent of RV ischemia. Areas covered: The pathophysiological mechanisms, diagnostic steps, and novel therapeutic approaches of acute RVMI are described. Expert commentary: Diagnosis of acute RVMI is based on physical examination, cardiac biomarkers, electrocardiography, and coronary angiography, whereas noninvasive imaging modalities (echocardiography, cardiac magnetic resonance imaging) play a complementary role. Early revascularization, percutaneous or pharmacological, represents key step in the management of RMVI. Maintenance of reasonable heart rate and atrioventricular synchrony is essential to sustain adequate cardiac output in these patients. When conventional treatment is not successful, mechanical circulatory support, including right ventricle assist devices, percutaneous cardiopulmonary support, and intra-aortic balloon pump, might be considered. The prognosis associated with RVMI is worse in the short term, compared to non-RVMI, but those patients who survive hospitalization have a relatively good long-term prognosis.
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Affiliation(s)
- Arif Albulushi
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Andreas Giannopoulos
- b Cardiac Imaging, Department of Nuclear Medicine , University Hospital Zurich , Zurich , Switzerland
| | - Nikolaos Kafkas
- c Cardiology Department , General Hospital KAT , Athens , Greece
| | | | - Gregory Pavlides
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
| | - Yiannis S Chatzizisis
- a Cardiovascular Division , University of Nebraska Medical Center , Omaha , NE , USA
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Hanzel GS, Dixon S, Goldstein JA. Prioritizing and Combining Therapies for Heart Failure in the Era of Mechanical Support Devices. Interv Cardiol Clin 2017; 6:465-480. [PMID: 28600098 DOI: 10.1016/j.iccl.2017.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Technological advances have promoted challenges to prioritizing and combining therapies for heart failure. The concept of prioritization implies distinct but inextricably linked considerations. They may be viewed from pathophysiologic, clinical, and procedural perspectives, encompassing analysis of hemodynamic status, anatomic considerations, and technical challenges. It is essential to consider factors, including conduction disease, renal and pulmonary function, hematological derangements, and so forth. These considerations allow determination of clinical goals, which determine prioritization and interventional strategies. These considerations then facilitate goal setting for medical and interventional therapies as definitive/destination, preservation/salvage, stepwise, bridge, or palliation.
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Affiliation(s)
- George S Hanzel
- Cardiac Catheterization Laboratory, Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA
| | - Simon Dixon
- Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA
| | - James A Goldstein
- Cardiovascular Research and Education, Department of Cardiovascular Medicine, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA.
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Left ventricular systolic dysfunction is associated with adverse outcomes in acute right ventricular infarction. Coron Artery Dis 2016; 27:277-86. [DOI: 10.1097/mca.0000000000000358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vieira C, Santa Cruz A, Arantes C, Rocha S. Isolated right ventricular infarction: a diagnostic challenge. BMJ Case Rep 2016; 2016:bcr-2016-215338. [PMID: 27143166 DOI: 10.1136/bcr-2016-215338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 73-year-old woman was admitted to the emergency room due to sudden-onset dyspnoea, altered mental status and haemodynamic instability. ECG showed a junctional rhythm, T-wave inversion in I, aVL and V2-V6 (present in a previous ECG), and no ST/T changes in the right precordial leads. Transthoracic echocardiography, however, revealed a severe depression of global systolic function of right ventricle with akinesia of free wall and a normal left ventricular function. Coronary angiography showed an occlusion of the proximal segment of the right coronary artery, which was treated with balloon angioplasty, and a chronic lesion of the anterior descending artery. The patient had a good recovery and was discharged on the 14th day. Myocardial perfusion scintigraphy (stress and rest) was performed a month later, showing a fixed perfusion defect in the apex and anterior wall (medium-apical), with no signs of ischaemia.
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Affiliation(s)
| | - Andre Santa Cruz
- Department of Internal Medicine, Braga Hospital, Braga, Portugal Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - Carina Arantes
- Department of Cardiology, Braga Hospital, Braga, Portugal
| | - Sérgia Rocha
- Department of Cardiology, Braga Hospital, Braga, Portugal
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Webb CAJ, Weyker PD, Flynn BC. Management of Intra-Aortic Balloon Pumps. Semin Cardiothorac Vasc Anesth 2014; 19:106-21. [DOI: 10.1177/1089253214555026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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