Right Ventricular Infarction

Isolated right ventricular infarction is extremely rare and it is usually seen as a complication or other infarction. The right ventricle most commonly receives its blood supply from the right coronary artery. In patients with left dominant systems, the blood supply may come from the left circumflex. The anterior portion of the right ventricle is supplied by branches of the left anterior diagonal artery. Approximately 30 percent of inferior wall myocardial infarctions involve the right ventricle. The presence of right ventricular infarction is associated with a significant increase in mortality and cardiovascular complications. Right ventricular infarction can be diagnosed by the presence of ST-segment elevation in the right precordial lead V 4 (rV4), in the setting of an inferior wall myocardial infarction. The presence of elevated neck veins or hypotension in response to nitroglycerin is also suggestive. Echocardiography or nuclear imaging can be diagnostic, but they are less readily available in the ED.

The most serious complication of right ventricular infarction is shock. 24 The severity of the hemodynamic derangement in the setting of right ventricular infarction is related to the extent of right ventricular dysfunction, the interaction between the ventricles (the right and left ventricle share the interventricular septum), and the interaction between the pericardium and the right ventricle. Right ventricular infarction results in a reduction in right ventricular end-systolic pressure, left ventricular end-diastolic size, cardiac output, and aortic pressure as the right ventricle becomes more of a passive conduit to blood flow. Left ventricular contraction causes bulging of the interventricular septum into the right ventricle, with resultant ejection of blood into the pulmonary circulation. As a result, right ventricular infarction with concurrent left ventricular infarction has a particularly devastating effect on hemodynamic function. Fluid balance and maintenance of adequate preload is critical in the treatment of right ventricular infarction. Treatment of right ventricular infarction is discussed in Chap 48,

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