Pathophysiology and ECG patterns of isolated right ventricular infarction with nondominant right coronary artery

Abstract

The prevalence of isolated right ventricular infarction is 0.4-2.4% in autopsy series and may occur by at least three different mechanisms, of which occlusion of a nondominant right coronary artery is reviewed here. Although rare, as oxygen demand/supply of the right is lower than that of the left ventricle, due to the smaller muscular mass, and it has a good prognosis, sudden death and cardiac rupture have been reported. Differential diagnosis with anterior infarction is needed. ECG may help but specific criteria should be adopted: dome-like and decreasing ST segment elevation from V1 to V3 leads; rapid ST segment normalization and no Q wave evolution from V1 to V3 leads, either accompanied or not by modest ST segment elevation in DIII (but not aVF) evolving in no Q wave; ST segment elevation in right-sided leads which should be explored; absence of ST segment depression in aVL; absent concomitant ST segment elevation in all inferior leads (DII, DIII, aVF). Applying these criteria may prevent erroneous management of right ventricular infarction if it is confused with left ventricular infarction. Right ventricular function evaluation should always be performed by echocardiography. Magnetic resonance imaging should be useful. An illustrative case and an ECG flow-chart are presented.

Acute Isolated Right Ventricular Infarction: Unusual Presentation of Anterior ST-Segment-Elevation Myocardial Infarction

“…8 Another group reported that decreasing STE from lead V 1 to lead V 3 is a pattern specific to isolated RV myocardial infarction. 9 We observed this pattern in Patient 2, but not in Patient 1. The cases that we have described illustrate the rare occurrence of isolated anterior STE correlated with acute RV marginal branch or proximal nondominant RCA occlusion causing acute RV myocardial infarction.…”

Diagnostic Traps—Noteworthy Electrocardiogram Patterns

“…The second main pattern is STE in anterior leads. This ECG pattern includes decreasing STE from V 1 /V 2 to V 4 /V 5 with no apparent Q waves and no reciprocal STD in inferior leads . When IRVMI leads to RV enlargement, there will be clockwise transposition of the heart, resulting in STE in anterior leads.…”

“…This ECG pattern includes decreasing STE from V 1 /V 2 to V 4 /V 5 with no apparent Q waves and no reciprocal STD in inferior leads. 5,6 When IRVMI leads to RV enlargement, there will be clockwise transposition of the heart, resulting in STE in anterior leads. Because V 1 is located directly over the RV, STE in V 1 is greater than that in V 2 and V 3 .…”

Pendekatan Diagnosis dan Tatalaksana Infark Ventrikel Kanan

“…Kejadian tersebut dapat terjadi akibat: 1) penyumbatan proksimal RCA dominan dengan adanya aliran darah kolateral dari arteri koroner kiri ke kanan; 2) sumbatan terisolasi dari arteri cabang marginal setelah intervensi koroner primer perkutan; dan 3) sumbatan pada arteri koroner kanan (RCA) non-dominan. 14…”

“…Keduanya dapat muncul sebagai elevasi segmen ST pada sadapan anterior. 14 Parameter elektrokardiografi spesifik diperlukan untuk diagnosis infark ventrikel kanan tunggal/terisolasi pada RCA nondominan, meliputi: 1) ST elevasi berbentuk kubah (dome-like) dan menurun dari V1 hingga V3; 2) normalisasi cepat segmen ST dan tidak terdapat evolusi gelombang Q dari V1 hingga V3; 3) ST elevasi pada sadapan kanan yang butuh dieksplorasi; 3) tidak adanya ST depresi pada aVL; dan 4) tidak adanya ST elevasi pada sadapan inferior (II, III, aVF).…”