IT’LL BE ALRIGHT ON THE NIGHT

RT, 42 year old man BIBA following OOHCA Collateral from wife

Driving, c/o headache, chest and bilateral arm pain

LOC, shaking PMHx: PUD, cannabis smoking, coryzal

symptoms

10-15 minutes downtime CPR V Fib Shocked x 13 Adrenaline x 5, Amiodarone 300mg,

MgSO4 ROSC 45 minutes after CPR was

commenced

ECGs

Echo Globally reduced LV and RV function EF 30-35% No definite RWMA No significant AR or AS No effusion

Urgent Cath? V Fib Arrest Young, male, no significant history Flu-like illness No consistent ST elevation No marked RWMA on Echo Haemodynamically stable

Initial Management Plan ICU Cooling DAPT, LMWH Amiodarone infusion

Coronary Angiogram

ICU

Pressors not required initially Induced Hypothermia 72Hrs Troponin I: 8.17, 10.48 (<0.06) CK 5670 (0-210) Pulmonary oedema Co-amoxiclav, clarithromycin, oseltamivir Influenza A/H3 on throat swab Extubated 3 days later

Coronary Angiogram

Cardiac MRI

Dark blood T2 weighted STIR images

Late Gadolinium Enhancement

What now?

PCI? ICD?

PCI Right guide SH Sian and Sian blue wires to RCA and RV

branch Pre dilated with Emerge balloon dilation

catheter 2.5x20mm Promus PREMIER™

Everolimus-Eluting Platinum Chromium Coronary Stent placed in main RCA

Post dilated with kissing balloons for RV branch protection

ICD?

ICD

V Tachyarrhythmias occurring in first 24-48hrs do not imply continuing risk over time

Primary therapy should be coronary revascularisation

ICD? No further VT as inpatient CMR

No LV inducible ischaemia No LV scar

Culprit lesion revacsularised

Follow Up Discharged with some memory issues OPD March NRH assessment Cardiac Rehab Repeat CMR Reassess for ICD

Discussion

Sanders AO. Coronary thrombosis with complete heart-block and relative ventricular tachycardia: a case report. Am Heart J 1930;6:820-823

RVMI Malignant ventricular arrhythmias

occurred in up to 38% of patients and tended to be associated with larger infarct size (measured by peak CPK).

Concomitant RVMI occurs in 30–50% of cases of patients with acute inferior MI

Isolated right ventricular infarction accounts for less than 3% of all cases of infarction.

Ricci, S.R. Dukkipati, M.C. Pica, D.E. Haines, J.A. Goldstein Malignant ventricular arrhythmias in patients with acute right ventricular infarction undergoing mechanical reperfusionAm J Cardiol, 104 (12) (2009), pp. 1678–1683Andersen 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 1987;10:1223-1232AJ.M.

Diagnosis Clinical signs ECG Echo

CMR DE-CMR more sensitively identifies RVMI

in patients presenting with acute inferior MI than ECG physical exam echocardiography 

A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M. Gross, R. Dietz, M.G. Friedrich Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am Coll Cardiol, 48 (10) (2006), pp. 1969–1976

ICD

Conclusion Isolated RVMI relatively rare presentation Non-Dominant RCA lesions not benign &

innocuous Value of CMRI Limited data on value of AICD

References Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med.

1994;330:1211–1217. Haji SA, Movahed A. Right ventricular infarction-diagnosis

and treatment. Clin Cardiol. 2000;23:473–482. A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M.

Gross, R. Dietz, M.G. FriedrichContrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am Coll Cardiol, 48 (10) (2006), pp. 1969–1976

Cavalcante JL, Al-Mallah M, Hudson M. Isolated right ventricular infarct presenting as ventricular fibrillation arrest and confirmed by delayed-enhancement cardiac MRI. Heart Lung Circ 2010; 19: 620-623.

Hurst JW, editor. The heart, 4th ed. New York: McGraw-Hill; 1978. p 409

Thank you

complications AV block RBBB Atrial Fibrillation Ventricular Arrhythmias

CMR LV: normal size, volume, function. RV: increased ESV & hypokinesis of the inferior &

anterior walls at the base & mid segments with mildly reduced global systolic function, EF 40%

Perfusion: Evidence of matched/fixed perfusion defects in septum & inferoseptum from mid wall to base

Tissue: mild oedema in basal segments of the RV anterior & inferior wall on dark blood T2 weighted STIR images. DE- abnormal signal in basal & mid segments of inferior and anterior wall of RV, indication infarction.