Background Although the salutary effects of reperfusion in patientswith left ventricular infarction are well documented, the benefitsin patients with acute right ventricular infarction are lessclear.
Methods To determine whether primary angioplasty improves rightventricular function and the clinical outcome in patients withright ventricular infarction, we performed echocardiographicstudies before and after angioplasty in 53 patients with acuteright ventricular infarction.
Results Complete reperfusion, defined as normal flow in theright main coronary artery and its major right ventricular branches,was achieved in 41 patients (77 percent), leading to promptand striking recovery of right ventricular function (mean [±SE]score for free-wall motion, 3.0±0.4 at base line and1.4±0.1 at three days; P<0.001). Twelve patients (23percent) had unsuccessful reperfusion, defined as the failureto restore right ventricular branch flow, with or without patencyof the right main coronary artery. Unsuccessful reperfusionwas associated with lack of recovery of right ventricular function(score for free-wall motion, 3.2±0.6 at base line and3.0±0.9 at three days; P = 0.55), as well as persistenthypotension and low cardiac output (in 83 percent of the patients,vs. 12 percent of those with successful reperfusion; P = 0.002)and a high mortality rate (58 percent, vs. 2 percent for thosewith successful reperfusion; P = 0.001).
Conclusions In patients with right ventricular infarction, completereperfusion of the right coronary artery by angioplasty resultsin the dramatic recovery of right ventricular performance andan excellent clinical outcome. In contrast, unsuccessful reperfusionis associated with impaired recovery of right ventricular function,persistent hemodynamic compromise, and a high mortality rate.
Right ventricular infarction is common in patients with acuteinferior–posterior left ventricular myocardial infarctionand may depress right ventricular function, resulting in right-heartfailure and low cardiac output.1,2,3,4,5,6,7 Despite the potentiallylife-threatening acute hemodynamic effects, however, most patientswith ischemic right ventricular dysfunction have spontaneousearly hemodynamic improvement and subsequent recovery of rightventricular function, regardless of the patency of the infarct-relatedartery.5,6,7,8,9,10,11,12,13,14 This resilience of the rightventricle is in marked contrast to the effects of coronary occlusionon regional and global left ventricular function.15,16,17 Nevertheless,right ventricular infarction is associated with increased ratesof morbidity and mortality.5,6,18,19,20,21,22,23 Furthermore,spontaneous recovery of right ventricular function and hemodynamicand clinical improvement may be slow9,10,11,12,13,14,24 andin some cases incomplete.25
Although the salutary effects of timely reperfusion in patientswith left ventricular infarction are well documented,26,27,28,29,30the benefits in patients with ischemic right ventricular dysfunctionare less clear. Some studies suggest that right ventricularfunction is recovered only after successful reperfusion,11,12,22,31,32whereas others report improvement even in the absence of a patentinfarct-related artery.5,8,9,13,14 Unfortunately, it is difficultto draw firm conclusions from these studies because of the smallnumbers of patients or the lack of serial measurements of rightventricular performance. Recent studies in laboratory animalshave shown that reperfusion of the right coronary artery enhancesthe recovery of right ventricular function, even after prolongedischemia.33,34 If reperfusion improves right ventricular performancein patients with ischemic right ventricular dysfunction, theclinical benefits may be substantial. We performed a study designedto assess the effect of primary percutaneous transluminal coronaryangioplasty (PTCA) of the occluded right coronary artery onright ventricular function and clinical outcome in patientswith acute ischemic right ventricular dysfunction.
Methods
The study group consisted of 53 patients who presented to WilliamBeaumont Hospital, Royal Oak, Michigan, between September 1994and December 1996 with acute inferior myocardial infarction(defined as chest pain with an ST elevation >1 mm in leadsII, III, and aVF), and ischemic right ventricular dysfunction(defined as the combined presence of right ventricular free-walldysfunction, dilatation, and depressed global performance) ontransthoracic two-dimensional echocardiography. A total of 290patients with inferior myocardial infarction were screened.Of these patients, 125 were excluded because a base-line echocardiogramcould not be obtained without an unacceptable delay, and 41were excluded because of technically inadequate images at baseline (38 patients) or follow-up (3). Of the 124 remaining patients,53 with echocardiographic evidence of right ventricular infarctionwere enrolled in the study and underwent emergency cardiac catheterizationand primary PTCA according to standard techniques.29,32
Assessment of Ventricular Function
Serial echocardiograms were obtained to assess right and leftventricular function before and 1 hour, 24 hours, three to fivedays, and one month after PTCA. The echocardiograms were analyzedaccording to previously described methods.24,33,34 From theapical four-chamber view, right ventricular performance wasassessed by measuring the ventricular area at end diastole andend systole and calculating the fractional change in area. Theright ventricular free wall was divided into three segments,and the motion of each segment was scored on a scale of 1 to4 (1, normal; 2, hypokinetic; 3, akinetic; and 4, dyskinetic).The overall score for right ventricular free-wall motion wascalculated as the average score for the three segments. Leftventricular dimensions and the change in the fractional areawere also calculated. The left ventricular inferoposterior wallwas divided into apical, middle, and posterior segments, andthe overall score for left ventricular inferior-wall motionwas calculated as the average score for the three segments.The left ventricular ejection fraction was determined by cineangiography.
Assessment of Perfusion
Coronary angiograms were analyzed to determine the severityof stenosis and the extent of flow, which was graded accordingto the Thrombolysis in Myocardial Infarction (TIMI) classification.28,29,30Previous studies of reperfusion in patients with right-coronary-arteryocclusion have focused on the restoration of flow in the rightmain coronary artery and its left ventricular branches, largelyignoring flow in the right ventricular branches.11,12,13,14,17,28,29,30,31,32In our study, we defined successful reperfusion of the rightcoronary artery as less than 50 percent residual stenosis andrestoration of TIMI grade 3 flow in the right main coronaryartery, its left ventricular branches, and all major (>1mm) right ventricular branches. To assess right ventricularfree-wall reperfusion, we calculated an overall grade for branchflow by averaging the flow grades for all major right ventricularbranches. Similarly, an overall grade for left ventricular inferior-wallperfusion was calculated by averaging the flow grades for theposterior descending artery and posterolateral left ventricularbranches.
In-Hospital Outcome
Adverse clinical events were recorded, including recurrent ischemia(defined as recurrent chest pain with new electrocardiographicchanges or recurrent myonecrosis as indicated by enzyme tests),high-grade atrioventricular block, the need for a pacemakerfor more than one hour, ventricular arrhythmias requiring treatment,hemodynamic abnormalities (elevated right atrial pressure, lowcardiac output, or hypotension for more than one hour), anddeath.
Statistical Analysis
All data are expressed as means ±SD, except the resultsof paired comparisons, which are reported as means ±SE.Comparisons were made with use of the chi-square test for categoricalvariables and a two-tailed Student t-test for continuous variables.A paired t-test was used to compare base-line and subsequentvalues in each patient. Analysis of variance was used to compareserial echocardiographic wall-motion data, including right andleft ventricular wall-motion scores, within each group overtime, and a paired t-test was used for comparisons at each interval.Comparisons between groups at the same point in time were madewith a two-tailed Student t-test.
Results
Base-Line Characteristics
The 53 patients with acute inferior infarction and ischemicright ventricular dysfunction had a mean age of 63±10years. Eight patients had had previous myocardial infarctions,12 had undergone PTCA, and 1 had undergone bypass surgery. Thepatients presented a mean of 2.2±3.4 hours (range, 1.3to 12.5) after the onset of symptoms.
Before PTCA was performed, bradyarrhythmias occurred in 21 patients(40 percent). Ventricular tachyarrhythmias, defined as recurrentventricular tachycardia (>15 beats) or ventricular fibrillationor both, occurred in 16 patients (30 percent). Twenty-threepatients (43 percent) had hypotension (aortic systolic pressure,<90 mm Hg), which responded to volume infusion, treatmentof bradycardia, or both in 12 patients but required inotropicor vasopressor support in 11.
Angiographic Findings and Perfusion Status
Coronary angiography documented single-vessel disease in 29patients, two-vessel disease in 22, and three-vessel diseasein 2. The right coronary artery was the infarct-related arteryin all cases, and the culprit lesion (initial stenosis, 97±7percent; TIMI flow grade, 0.8±1.2) was proximal to themajor right ventricular branches in 50 patients (94 percent)(Figure 1A, Figure 1B, Figure 1C, and Figure 1D). Perfusionof the right ventricular free wall and the left ventricularinferior wall was severely reduced (flow grades, 0.5±0.8and 0.8±1.2, respectively).
Figure 1. Angiograms Showing Successful and Unsuccessful Reperfusion in Patients with Right Ventricular Infarction Who Underwent Primary Angioplasty.
Panel A shows total occlusion of the right coronary artery proximal to the right ventricular branches (arrow) in a patient before angioplasty, and Panel B shows complete reperfusion after angioplasty, with a Thrombolysis in Myocardial Infarction grade 3 flow in the right main coronary artery and its major right ventricular branches (arrowheads). Panel C shows the complete failure of reperfusion in another patient, with impaired flow in the right main coronary artery, left ventricular branches, and right ventricular branches (arrowhead), attributable to refractory dissection and thrombus (arrows). Panel D shows partial reperfusion in a third patient, with an absence of flow in the right ventricular branches, despite successful reperfusion of the right main coronary artery and its left ventricular branches.
According to the traditional criteria (i.e., regardless of theflow in the right ventricular branches), reperfusion of theright main coronary artery and its left ventricular brancheswas successful in 48 patients (91 percent): residual stenosis,19±13 percent a mean of 3.4±3.0 hours after theonset of symptoms and 1.3±0.8 hours after presentation.According to our criteria, however, which included restorationof flow in the major right ventricular branches (Figure 1A,Figure 1B, Figure 1C, and Figure 1D), reperfusion was successfulin 41 patients (77 percent) (16 of whom received stents). Successfulreperfusion improved right ventricular perfusion (flow index,0.5±0.8 at base line and 2.9±0.5 after angioplasty;P<0.001), with the restoration of left ventricular inferior-wallperfusion (flow grade, 0.8±1.2 at base line and 3.0±0.1after angioplasty; P<0.001).
The 12 patients with incomplete reperfusion had persistentlyimpaired right ventricular flow (flow grade, 0.6±1.0at base line and 1.3±0.9 after angioplasty; P = 0.10).In 5 of these 12 patients (2 of whom received stents), flowwas not restored in the right main coronary artery or in itsleft ventricular branches (flow grade, 0.6±0.8 at baseline and 1.0±1.0 after angioplasty; P = 0.50) or rightventricular branches (flow grade, 0.6±1.0 at base lineand 1.0±1.0 after angioplasty; P = 0.54). The failureof PTCA to restore perfusion was attributable to recurrent intracoronarythrombus in three patients and refractory flow-limiting dissectionsin two. In the seven patients with partial reperfusion (threeof whom received stents), normal flow was restored in the rightmain coronary artery and its left ventricular branches (flowgrade, 0.8±1.0 at base line and 3.0±0.1 afterangioplasty; P<0.001) but not in one or more major rightventricular branches (flow grade, 0.8±1.0 at base lineand 1.4±0.5 after angioplasty; P = 0.18). The impairedflow in the right ventricular branches was attributable to the"no reflow" phenomenon (in which there is flow into the epicardialvessels but diminished flow into the myocardium) in five patientsand severe residual branch stenoses in two.
Ventricular Performance
Before PTCA, all the patients had severe inferior left ventriculardysfunction (motion score, 2.9±0.4), but overall leftventricular performance was preserved (fractional change inarea, 38±5 percent; ejection fraction, 50±8 percent).In all cases, there was severe right ventricular dysfunction(motion score, 3.1±0.6; fractional change in area, 25±8percent), with paradoxical septal motion reflecting compensatorysystolic interactions.24,33,34,35,36 Right ventricular diastolicdysfunction was indicated by right ventricular dilatation (Figure 2),reversed septal curvature, and elevated right-heart diastolicpressures (mean atrial pressure, 14.0±4.3 mm Hg). In80 percent of the patients, a right ventricular dip-and-plateaupattern and equalized diastolic filling pressures indicatedadverse diastolic interactions.3,6,33,34,35,36,37
Figure 2. Echocardiographic Images from a Patient with Acute Inferior Myocardial Infarction and Right Ventricular Ischemia in Whom Angioplasty Was Successful.
Images at end diastole and end systole were obtained from the transthoracic apical four-chamber view. At base line, there was severe right ventricular dilatation with reduced left ventricular diastolic size at end diastole. At end systole, there was right ventricular free-wall dyskinesis (arrows), intact left ventricular function, and compensatory paradoxical septal motion. One hour after angioplasty, there was a striking recovery of right ventricular free-wall contraction (arrows), resulting in marked improvement in global right ventricular performance, with a markedly reduced right ventricular size and an increased left ventricular size at end diastole. At one day, there was further improvement in right ventricular function (arrows), and at one month right ventricular size and function (arrows) were normal. RV denotes right ventricle, and LV left ventricle.
In all cases of successful right-coronary-artery reperfusion,right ventricular function recovered dramatically at one hour(wall-motion score, 3.0±0.6 at base line and 2.0±0.5at one hour, P<0.01; change in the fractional area, 25±4percent at base line and 32±5 percent at one hour, P<0.001)(Figure 2 and Figure 3). As in laboratory models,32,33 successfulreperfusion led to lower right-heart filling pressures (rightatrial pressure, 12.4±1.9 at base line and 10.3±1.6mm Hg at one hour; P = 0.05), reduced right ventricular dilatation(Figure 2), and resolution of the right ventricular dip-and-plateaupattern and equalized diastolic pressures. As right ventricularsystolic and diastolic function recovered, left ventricularfilling was enhanced, and systemic cardiac output improved (3.6±0.7liters per minute at base line and 5.6±1.1 liters perminute at one hour, P = 0.04). There was further recovery ofright ventricular function during the next 23 hours, and at3 to 5 days, right ventricular performance was normal in 95percent of the patients (Figure 2 and Figure 3). Remarkably,even though flows in the right and left ventricular brancheswere restored to similar levels after successful reperfusion,the recovery of right ventricular function was greater and morerapid than the recovery of left ventricular function (Figure 4).Immediately after PTCA, there was demonstrable improvementin right ventricular contraction in 76 percent of the patientswith successful reperfusion, whereas left ventricular wall motionimproved in only 2 percent (P = 0.001). At one month, rightventricular wall motion was completely normal in 98 percentof the patients with successful reperfusion, whereas left ventricularinferior wall motion recovered completely in only 8 percent(P = 0.001).
Figure 3. Mean (±SD) Changes over Time in the Score for Right Ventricular Free-Wall Motion in Patients with Successful Reperfusion and Those with Unsuccessful Reperfusion.
An asterisk denotes P0.01 for the comparison with the most recent score in the same group. A dagger denotes P0.02 for the comparison between groups at one point in time.
Figure 4. Mean (±SD) Changes over Time in the Score for Right Ventricular (RV) Free-Wall Motion and Left Ventricular (LV) Inferior-Wall Motion in the Patients with Complete Reperfusion.
An asterisk denotes P0.01 for the comparison with the most recent score for the same ventricle. A dagger denotes P0.003 for the comparison between the scores for the right and left ventricles at one point in time.
In contrast, the patients with unsuccessful reperfusion hadimpaired recovery of right ventricular function, regardlessof whether reperfusion was achieved in part or not at all. Lackof complete reperfusion was associated with persistent, severeright ventricular dysfunction at 24 hours (wall-motion score,3.2±0.6 at base line and 2.8±1.0 at 24 hours,P = 0.26; fractional change in area, 24±7 percent and27±8 percent, respectively, P = 0.34) (Figure 3). Unsuccessfulreperfusion was associated with persistently elevated right-heartfilling pressures (atrial pressure, 16.4±4.7 mm Hg atbase line and 15.6±4.5 mm Hg at 24 hours; P = 0.67) anddepressed cardiac output (2.8±0.8 liters per minute atbase line and 3.6±1.0 liters per minute at 24 hours,P = 0.16). However, although unsuccessful reperfusion led toa higher rate of in-hospital mortality (see below), patientssurviving to discharge ultimately had complete recovery of rightventricular function, although the recovery was slower thanin those with successful reperfusion (Figure 3).
Clinical Outcome
Adverse in-hospital events were infrequent in the patients withsuccessful reperfusion. Sustained hypotension occurred in fivepatients (12 percent), with inotropic support for more than24 hours required in one. Ventricular arrhythmias occurred in10 patients (24 percent). Most important, 40 of the patientswith successful reperfusion (98 percent) survived and were dischargedfrom the hospital after a mean stay of 8.7±7.7 days (range,3 to 45). At one month, all 40 were alive and had no evidenceof right-heart failure.
Conversely, the 12 patients with unsuccessful reperfusion hada poor clinical outcome. Lack of recovery of right ventricularfunction in these patients was associated with persistent severehemodynamic compromise, and 10 of the 12 patients (83 percent)required high-dose inotropic support and intraaortic balloonpumping to maintain blood pressure (P = 0.002 for the comparisonwith the successful-reperfusion group). Although these supportivemeasures initially stabilized blood pressure, seven patients(58 percent) had progressively reduced output leading to refractoryhypotension and death (P = 0.001 for the comparison with thesuccessful-reperfusion group), despite intact left ventricularfunction (ejection fraction, 49.3±6.7 percent). Of theseven patients who died, four had no reperfusion, and threehad partial reperfusion. Ventricular arrhythmias were more commonin these patients, occurring in 6 of 12 (50 percent, P = 0.09for the comparison with the successful-reperfusion group). Thefive patients with unsuccessful reperfusion who survived todischarge had prolonged hospital stays (11.8±6.2 days;range, 6 to 24), but at 1 month, all five were alive and hadno evidence of right-heart failure.
Discussion
The results of our study document the effect of right ventricularreperfusion on the clinical outcome and survival and demonstratethe disparate responses of the ischemic ventricles to reperfusion.In our study, as in previous studies in animals and humans,the detrimental effects of right ventricular free-wall ischemiaon right-heart function were striking.1,2,3,4,5,6,24,33,34,35,36,37Right-coronary-artery occlusion proximal to the major rightventricular branches resulted in severe right ventricular dysfunction.Previous studies have defined successful reperfusion of theright coronary artery on the basis of the restoration of flowto the left ventricular branches only, largely ignoring thestatus of the right ventricular branches.1,2,3,4,5,6,7,8,9,10,11,12,13,14,17,28,29,30,31,32Our study, in which we used new criteria for reperfusion ofthe occluded right coronary artery, suggests that complete reperfusion(including reperfusion of the major right ventricular branches)improves right ventricular function and the clinical outcome.In our study, complete reperfusion led to a striking immediateimprovement in right ventricular function followed by completerecovery — findings consistent with the results of studiesin animals33,34 and the few available data from clinical studies.11,12,31,32Recovery of right ventricular function was associated with improvedhemodynamic status, which is consonant with reperfusion-mediatedattenuation of adverse diastolic interactions,6,24,33,34,37since prompt recovery of right ventricular function reducesright ventricular dilatation and the constraining effects ofthe pericardium and enhanced right ventricular systolic performanceaugments left ventricular filling and improves cardiac output.Most important, unlike prior studies of right ventricular infarction,18,19,20,21,22,23our study suggests that successful reperfusion is associatedwith an uneventful clinical course and a high rate of survival.
In contrast to the benefits of successful reperfusion, failureto restore complete flow to the main right coronary artery andits major right ventricular branches was associated with impairedrecovery of right ventricular function, persistent hemodynamiccompromise, and a high rate of in-hospital mortality. Sincethe initial depression in right ventricular function was nogreater in the patients with unsuccessful reperfusion than inthose with successful reperfusion and since global left ventricularperformance was intact in the patients with unsuccessful perfusion,their poor clinical outcome must be predominantly attributableto persistent, severe right ventricular dysfunction. These observationsemphasize the importance of complete right-coronary-artery reperfusion,since the failure to restore flow in the right ventricular brancheswas associated with adverse outcomes even if the main rightcoronary artery and its left ventricular branches were reperfused.
There are scant and conflicting clinical data on the effectsof interventions designed to achieve reperfusion in ischemicright ventricular myocardium. Some authors suggest that rightventricular function improves only after successful thrombolysis,11,12,22,31whereas others report recovery even in the absence of earlyrecanalization.5,9,13,14 There is a paucity of data on the effectsof primary PTCA in patients with acute ischemic right ventriculardysfunction. Our findings are consistent with those of a recentstudy at our institution, which reported rapid hemodynamic improvementand an excellent clinical outcome after reperfusion in patientswith right ventricular infarction who underwent primary angioplasty.32Our observations are also consonant with prior studies of rightventricular infarction that have documented increased ratesof morbidity and mortality attributable to arrhythmias and cardiogenicshock,18,19,20,21,22,23 particularly in patients with unsuccessfulreperfusion.31,38 We can only speculate about whether the adverseoutcomes previously observed were related to unsuccessful reperfusionof the right ventricular branches and whether selective PTCAin unsuccessfully recanalized right ventricular branches willimprove the clinical outcome.
It should be noted that our conclusions are based on a studyof a limited number of nonconsecutive patients undergoing primaryPTCA. Therefore, caution should be used when extrapolating theresults of this study to reperfusion interventions in the broadpopulation of patients with right ventricular infarction ingeneral and in those undergoing primary thrombolysis in particular.
Previous studies support the concept that the right ventricleis more resistant to infarction than the left ventricle.8,9,10,11,12,24,33,34However, previous studies of reperfusion have not correlatedthe mechanical responses of the ischemic ventricles over timewith perfusion in the coronary branches. In our study, the dramaticrecovery of right ventricular function contrasted sharply withthe response of the left ventricle to equivalent ischemic insults.Remarkably, recovery of right ventricular function ultimatelyoccurred even in the patients with unsuccessful reperfusionwho survived. The superior recovery of the right ventricle isprobably attributable, at least in part, to more favorable oxygensupply–demand characteristics, in general, and a greatercapacity for rapid development of a functional collateral vascularsupply, in particular.24,33,34,39,40 It is possible that othermechanisms underlie the different responses of the ventricles,such as different patterns of ventricular injury potentiallymediated by a disproportionate distal distribution of embolito the left and right ventricular branches, differences in theresponses of myocytes to ischemia and reperfusion, and differencesin recovery from stunning. In the aggregate, however, our observationssuggest that the term "right ventricular infarction" is largelya misnomer, because acute ischemic right ventricular dysfunctionappears to represent predominantly viable myocardium that respondsfavorably to reperfusion.
Presented in part at the Scientific Session of the AmericanCollege of Cardiology, March 16–18, 1997.
Source Information
From the Division of Cardiology, William Beaumont Hospital, 3601 W. Thirteen Mile Rd., Royal Oak, MI 48073-6769, where reprint requests should be addressed to Dr. Goldstein.
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0.01 for the comparison with the most recent score in the same group. A dagger denotes P