iT’ll be alright on the night
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Transcript of iT’ll be alright on the night
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.