Primary percutaneous transluminal coronary angioplasty in the acute infarction of the right ventricle

BackgrouTld. Predilection sire for the acute myocardial ill/arclion of the right ventricle, (AMI-RV) is the upper third of the rig/II corollary artery and for this reason sitch an infarction is followed by numerous complications, primarily by conduction disorders and very often by suddell and rapid cardiogenic shock developme1lf. Methods. Primary percwafleolls trans/uminal coronary oll8ioplasry (PPTCA) was performed 011 three patiellts, ill whom the acllfe infarction of the right \'ell(ricular \Vas diagnosed and who had been hospitalized six hours after the beginning 0/ chest pain. /n all three patiellls ill(racoronary stell( was implanted. 0" the admission potiell(s had been in the threatening cardiogenic shock, with the prominent chest pain and with the elevation oj ST-segmelll in V4R>2 m V. /n the course of i"ten1entioll patients were administered low-molecular intracoronary heparin, witli direct platelet glycoprotein lib/II/a illhibitors (abciximab), according to the established procedure applied ill such cases. Results. The complete dilatation of the inJarcted artery lVas established with tile signs 0/ reperfusion alld the further clinical course was completely nonnal. there was no heart Jail//re and patients had 110 sI/bjectil'e difficulties. Conclusion. Invasive approach in the trealmem ofAMI-RV is justifiable. alld possibly the therapy oj choice a/these patients, providing well trained and equipped team is available.


Introduction
The goal of the current therapy of myocardial infarclion of the right ventricle (AMI•RV) is rapid, and if possible, complete patency achievement of the infarction artery in order to reduce the size of necro~is, establish the reperfusion of the affected area and at the same time prevent other possible complications, and reduce mortality rdte (I, 2).The extensive necrosis is affecting inferoposterior segment of the right ven• tricle associated with the infarction extension to the free wall of the right ventricle (RV), distal half of interventricular sep-IUm.papillary muscles.valvular apparatus with cardiac con-dUClioll system.Owing (0 these facts prognosis and early clinical course within the first 24 hours are quite uncertain.and the mortality rale is from 20 do 50% (3-5).Parallel wilh fibrinolytic therapy administration, there is a growing interest for mechanical reperfusion by using primary or delayed (life saving or rescue) balloon dilatation (6)(7)(8).

Conclusion
Patients with AMI~RV represent a subgroup with the very high risk within the scope of inferoposlerior engaging or the left ventricle with numerous and hardly predictable complications resulting in high mortality ralC.Our initial experience in the treatment of these patients by PPTCA complelely confirmed that this thernpcutic approach was absolutely justifiable in patients with cardiogenic shock, if there were comraindications for fibrinolytic therapy.or if 6poj I the optimal period of 6 hours after the onset of infarction had passed.Complete recovery of our paticnrs and their normal clinical course within the first three months after being discharged from Ihe hospilal showed Ihal Ihe invasive approach in Ihe Irealmem of AMI-RV was juslifiable and the possible therapy of choice of these paticnls.providing both trained personnel, including a (cam of inrcrvenlional cardiologists.and technical equipment.

REFERENCES
. All patients received abciximab, glycoprotein UbJUla inhibitor 10 mg before and 10 mg after the stent implantation into the right coronary anery.The therapy wall continued with enoxaparin I mglkg subcutanously (s.c.) every 12 hours and with 10 mg of abciximab in Female patient, 60 years of age.first infarction: on the admission there was a slow atrial fibrilation with ventricular response 60/min, logetner with the signs of inferoposterior infarction of the right ventricle.Blood pressure was 80/40 mmHg.Risk factors were smoking and the in-creased cholesterol level.Ultrasound of the hean performed immediately after admission showed dilated right ventricle associated with tricuspid failure and RV pressure of 40 mmHg.Three hours after the onset of AMI-RV.PPTCA and intracoronary stent implantation were performed.ECG taken immediately after PPTCA showed the rapid resolution of ST segment for more than 70% with the early formation of the negative T-wave (signs of the early mechanical reperfusion).Control echocardiography before discharging still showed dilated right ventricle and RV pressure was still 40 mmHg.After the discharge clinical finding was normal and there were no subjective difficulties during the four months follow-up period.Fig. I) ECG on the admission.Fig.

For
this reason modified PPTCA was introduced and direct glycoprotein inhibitors (abciximab) in combination wilh antiaggrcgation agents and low-molecular heparin were included into the Iherapeutic protocol.A great number of foHowing studies, as well as several randomized ones, showed thai thcrapy modified in this way and administered within the first 12 hours from the onsel of AMI reduced the mortality rate, myocardial reinfarction, urgent revascularization and postinfarction angina for 48% in comparison with the patients underwent PTeA, but without glycoprotein inhibitors (J 4, 15).This is the first rcpon in our medical hterature or the successrul lrC3lJnem or AMI-RV by PPTCA in combination with abciximab and low~molccular weight heparin together with intracoronary Slent implanlation in all 3 patients and is in accordance with ACClAI-IA recommendations (16).Patients who displayed the threatening cardiogenie shock confirmed by ECG, with eonduclion disorders in the rorm or AV block grade IO_mo and who Came within the first 6 hours rrom the onset of AMI~RV were urgClllly selll to catheterizalion room due to lheir serious condition.where pacemaker wa.~imp lamed and urgent coronarography with PPTCA was perr omled in the same act.Rapid clinical recovery, ST clevation regression ror more than 50% within the first 6 hours arler the intervention and the maximum increase of cardiospecific enzymes within lhe first 12 hours from the onset of AMI conṽ incingly confirmed ravourable clinical course.TIle SPECf performed within two weeks after the intervention confirmed sueeessrul rcperrusion in the area or the inrareted artery.Only in one case cchocardiographic finding showed slower course of the right ventricle recovery with persisting tricuspid failure and right ventricle pressure of 40 mmHg, bUI all other clinical indicators were nonnal.Our experience in lhe treallnel1l of patients with PPTCA was also confirmed by other studies which undoubtedly upholded our altitude that invasive approach wilh urgent coronarography was the only hope ror survival or thesc patients and Lhat it should be performed whenever possible, if personnel and technical equipment are provided (17-20).

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