Correspondence

Right Ventricular Infarction

N Engl J Med 1998; 339:479-480August 13, 1998

Article

To the Editor:

Bowers et al. (April 2 issue)1 report that complete reperfusion of the right coronary artery by angioplasty resulted in significant improvement of right ventricular function and outcome. We were not surprised by the fact that among 165 patients with inferior-wall myocardial infarction who underwent two-dimensional echocardiography, the images were technically inadequate in 41 (25 percent). In fact, recent studies have shown that two-dimensional echocardiography is not feasible in approximately 15 percent of cases.2 In addition, two-dimensional echocardiography does not provide hemodynamic information about right ventricular filling and pressures, which can be derived from Doppler echocardiographic studies. Finally, the detection of right ventricular wall-motion abnormalities or dilatation may have a low sensitivity, although the specificity is high, in consecutive patients.3

Continuous-wave Doppler flow studies of physiologic pulmonary regurgitation are directly related to the pressure gradient between the pulmonary artery and the right ventricle through the Bernoulli equation.3 Thus, the Doppler pattern of pulmonary regurgitation depends mainly on the pattern of diastolic right ventricular pressure, which is altered during right ventricular ischemia and characterized by a disproportionate increase in right ventricular end-diastolic pressure.4 We recorded continuous-wave Doppler tracings and right-heart hemodynamic data in 48 consecutive patients with acute inferior myocardial infarction and pulmonary regurgitation.3 In the 29 patients (60 percent) with hemodynamically confirmed right ventricular involvement, the pulmonary-regurgitation flow pattern was characterized by a rapid rise in flow velocity to a peak level, followed by an abrupt deceleration in mid-diastole before the A wave, whereas in patients without right ventricular involvement, the deceleration in mid-diastole was gradual. The pressure half-time of pulmonary regurgitation and the ratio of the lowest mid-diastolic velocity to the peak early diastolic velocity (V_min:V_max) were significantly lower in patients with right ventricular involvement than in those without such involvement. The best diagnostic accuracy (95 percent) was obtained with cutoff values of ≤150 msec for the pressure half-time of pulmonary regurgitation and ≤0.5 for Vmin:Vmax: sensitivity, 100 percent; specificity, 89 percent; positive predictive value, 94 percent; and negative predictive value, 100 percent. We have also shown that these Doppler-derived values were the strongest predictors of overall in-hospital complications in a consecutive series of 126 patients.5

Pulmonary-regurgitation flow can easily be determined in more than 80 to 90 percent of patients.3,5 Systematic detection and characterization of physiologic pulmonary-regurgitation tracings could help clinicians recognize right ventricular infarction at the bedside, especially in patients with inadequate two-dimensional echocardiographic images.

Ariel Cohen, M.D., Ph.D.
Damien Logeart, M.D.
Christophe Chauvel, M.D.
Saint-Antoine University Hospital, 75571 Paris CEDEX 12, France

5 References

1. 1

   Bowers TR, O'Neill WW, Grines C, Pica MC, Safian RD, Goldstein JA. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998;338:933-940
   Full Text | Web of Science | Medline

2. 2

   Bueno H, Lopez-Palop R, Bermejo J, Lopez-Sendon JL, Delcan JL. In-hospital outcome of elderly patients with acute inferior myocardial infarction and right ventricular involvement. Circulation 1997;96:436-441
   Web of Science | Medline

3. 3

   Cohen A, Guyon P, Chauvel C, et al. Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction. Am J Cardiol 1995;75:425-430
   CrossRef | Web of Science | Medline

4. 4

   Cohen A, Guyon P, Johnson N, et al. Hemodynamic criteria for diagnosis of right ventricular ischemia associated with inferior wall left ventricular acute myocardial infarction. Am J Cardiol 1995;76:220-225
   CrossRef | Web of Science | Medline

5. 5

   Cohen A, Logeart D, Costagliola D, et al. Usefulness of pulmonary regurgitation Doppler tracings in predicting in-hospital and long-term outcome in patients with inferior wall acute myocardial infarction. Am J Cardiol 1998;81:276-281
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: As Cohen et al. point out, the Doppler pulmonary-regurgitation pattern reflects abnormalities of right ventricular diastolic dysfunction and may therefore indirectly indicate the presence of right ventricular ischemic dysfunction. However, an elevation in right ventricular diastolic pressure is a nonspecific response to diastolic dysfunction, which may result from primary right ventricular pressure or volume overload or from cardiomyopathic processes (ischemic or nonischemic) and may be influenced as well by an elevation in the left-heart pressure through septum-mediated diastolic ventricular interactions.1-3 Therefore, Doppler pulmonary-regurgitation patterns are nonspecific indicators of right ventricular dysfunction.

Studies have shown that two-dimensional echocardiographic evidence of right ventricular free-wall dysfunction, dilatation, and depressed global ejection fraction are the most useful indicators of the presence and severity of ischemic right-heart dysfunction.1-5 Although in our study of patients with acute inferior myocardial infarction and right ventricular ischemic dysfunction, some patients were excluded because of an inability to obtain the high-resolution echocardiographic images necessary for a detailed analysis of right ventricular free-wall motion, in over 95 percent of cases, the quality of the ultrasonographic study was easily sufficient to detect ischemic right ventricular dysfunction. Therefore, although Doppler patterns of pulmonary regurgitation may add hemodynamic insights to the overall evaluation of patients with ischemic right ventricular dysfunction, two-dimensional echocardiographic delineation of right ventricular size and function provides the most crucial information about the presence of right ventricular ischemia and its effect on global right ventricular performance.

James A. Goldstein, M.D.
Terry Bowers, M.D.
William Beaumont Hospital, Royal Oak, MI 48073-6769

5 References

1. 1

   Bowers TR, O'Neill WW, Grines C, Pica MC, Safian RD, Goldstein JA. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998;338:933-940
   Full Text | Web of Science | Medline

2. 2

   Goldstein JA, Barzilai B, Rosamond TL, Eisenberg PR, Jaffe AS. Determinants of hemodynamic compromise with severe right ventricular infarction. Circulation 1990;82:359-368
   CrossRef | Web of Science | Medline

3. 3

   Goldstein JA. Right heart ischemia: pathophysiology, natural history, and clinical management. Prog Cardiovasc Dis 1998;40:325-341
   CrossRef | Web of Science | Medline

4. 4

   Bellamy GR, Rasmussen HH, Nasser FN, Wiseman JC, Cooper RA. Value of two-dimensional echocardiography, electrocardiography, and clinical signs in detecting right ventricular infarction. Am Heart J 1986;112:304-309
   CrossRef | Web of Science | Medline

5. 5

   Yasuda T, Okada RD, Leinbach RC, et al. Serial evaluation of right ventricular dysfunction associated with acute inferior myocardial infarction. Am Heart J 1990;119:816-822
   CrossRef | Web of Science | Medline

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