Abstract
Right ventricular (RV) infarction is commonly associated with left ventricular (LV) myocardial infarction. Isolated RV infarction is a rare entity and the diagnosis is challenging. We present a case of a 65-year-old man with non-ST elevation myocardial infarction without obvious culprit obstructive coronary artery disease on coronary angiogram. There was late gadolinium enhancement (LGE) of RV free wall without LGE of the LV in magnetic resonance imaging (MRI) which helped in diagnosing isolated RV infarction. On follow up, the patient’s RV dysfunction normalized on echocardiogram. Our case shows the importance of cardiac MRI in the diagnosis of isolated RV infarction and that it can have a good prognosis.
Learning objectives
Diagnosis of isolated right ventricular (RV) infarction needs high degree of suspicion especially in absence of hemodynamic findings. Late gadolinium enhancement in cardiac magnetic resonance imaging can help diagnose RV infarction when there is diagnostic uncertainty. Early therapy helps in RV recovery.
Introduction
Right ventricular (RV) infarction encompasses a range from asymptomatic RV dysfunction, transient ischemic RV dysfunction, to myocardial necrosis with or without involvement of the left ventricle (LV) [ ]. Isolated RV infarction involves RV myocardial infarction without LV infarction and is thought to involve <3 % of all cases [ ]. Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) can help in the diagnosis of RV infarction with or without LV involvement together with coronary angiogram, intracoronary imaging, and clinical presentation [ ]. Coexisting RV infarction is associated with increased morbidity and mortality [ , ]. When detected early, patients can fully recover and early diagnosis is therefore important. We report a case of a non-ST segment elevation myocardial infarction (NSTEMI) from isolated RV infarction with RV dysfunction that eventually recovered, highlighting the importance of appropriate and timely diagnostic work up.
Case report
History and examination
A 65-year-old man presented with subsiding chest pain and was diagnosed with NSTEMI at another hospital. Initial examination including electrocardiogram (ECG) was unremarkable. Subsequent ECGs were mostly unremarkable except for some T-wave changes in V1 and V2 leads (Online Fig. 1, right-sided electrocardiogram not conducted). High-sensitivity troponin I peaked at 9245 pg/ml.
An echocardiogram demonstrated dilated RV, and akinesis of mid-distal RV free wall ( Videos 1, 2 ). The LV was normal in structure and function. Coronary angiogram performed after 24 h of onset of chest pain showed a non-obstructive mid left anterior descending artery lesion and a small but obstructive distal right posterior descending artery lesion ( Fig. 1 A, B), with a relative paucity of marginal branches. Right heart catheterization performed on day 4 showed mean right atrial, pulmonary artery, and pulmonary capillary wedge pressures of 5, 17, and 8 mmHg, respectively and normal cardiac index.
A cardiac MRI performed on day 2 of symptom onset showed dilated right atrium and RV with indexed RV end diastolic volume 94 ml/m 2 , ejection fraction 40 %, akinesis of mid-distal RV free wall, and accompanying transmural LGE without LV involvement ( Fig. 1 C-F). Given these findings, particularly RV LGE without a clear culprit vessel and without LGE of the LV, we diagnosed isolated RV infarction.
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