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iT’ll be alright on the night

iT’ll be alright on the night. RT, 42 year old man B IBA following OOHCA Collateral from wife Driving, c/o headache, chest and bilateral arm pain LOC, shaking PMHx: PUD , cannabis smoking, coryzal symptoms. 10-15 minutes downtime CPR V Fib S hocked x 13

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iT’ll be alright on the night

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  1. iT’ll be alright on the night

  2. RT, 42 year old man • BIBA following OOHCA • Collateral from wife • Driving, c/o headache, chest and bilateral arm pain • LOC, shaking • PMHx: PUD, cannabis smoking, coryzal symptoms

  3. 10-15 minutes downtime • CPR • V Fib • Shocked x 13 • Adrenaline x 5, Amiodarone 300mg, MgSO4 • ROSC 45 minutes after CPR was commenced

  4. ECGs

  5. Echo • Globally reduced LV and RV function • EF 30-35% • No definite RWMA • No significant AR or AS • No effusion

  6. Urgent Cath? • V Fib Arrest • Young, male, no significant history • Flu-like illness • No consistent ST elevation • No marked RWMA on Echo • Haemodynamically stable

  7. Initial Management Plan • ICU • Cooling • DAPT, LMWH • Amiodarone infusion • Coronary Angiogram

  8. ICU • Pressors not required initially • Induced Hypothermia 72Hrs • Troponin I: 8.17, 10.48 (<0.06) • CK 5670 (0-210) • Pulmonary oedema • Co-amoxiclav, clarithromycin, oseltamivir • Influenza A/H3 on throat swab • Extubated 3 days later

  9. Coronary Angiogram

  10. Cardiac MRI

  11. Dark blood T2 weighted STIR images

  12. Late Gadolinium Enhancement

  13. What now?

  14. PCI? • ICD?

  15. PCI • Right guide SH • Sian and Sian blue wires to RCA and RV branch • Pre dilated with Emerge balloon dilation catheter • 2.5x20mm Promus PREMIER™ Everolimus-Eluting Platinum Chromium Coronary Stent placed in main RCA • Post dilated with kissing balloons for RV branch protection

  16. ICD?

  17. ICD

  18. V Tachyarrhythmias occurring in first 24-48hrs do not imply continuing risk over time • Primary therapy should be coronary revascularisation

  19. ICD? • No further VT as inpatient • CMR • No LV inducible ischaemia • No LV scar • Culprit lesion revacsularised

  20. Follow Up • Discharged with some memory issues • OPD March • NRH assessment • Cardiac Rehab • Repeat CMR • Reassess for ICD

  21. Discussion

  22. Sanders AO. Coronary thrombosis with complete heart-block and relative ventricular tachycardia: a case report. Am Heart J 1930;6:820-823

  23. RVMI • Malignant ventricular arrhythmias occurred in up to 38% of patients and tended to be associated with larger infarct size (measured by peak CPK). • Concomitant RVMI occurs in 30–50% of cases of patients with acute inferior MI • Isolated right ventricular infarction accounts for less than 3% of all cases of infarction. Ricci, S.R. Dukkipati, M.C. Pica, D.E. Haines, J.A. Goldstein Malignant ventricular arrhythmias in patients with acute right ventricular infarction undergoing mechanical reperfusion Am J Cardiol, 104 (12) (2009), pp. 1678–1683 Andersen HR, Falk E, Nielsen D. Right ventricular infarction: frequency, size and topography in coronary heart disease: a prospective study comprising 107 consecutive autopsies from a coronary care unit. J Am CollCardiol 1987;10:1223-1232AJ.M.

  24. Diagnosis • Clinical signs • ECG • Echo

  25. CMR • DE-CMR more sensitively identifies RVMI in patients presenting with acute inferior MI than • ECG • physical exam • echocardiography  A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M. Gross, R. Dietz, M.G. Friedrich Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am CollCardiol, 48 (10) (2006), pp. 1969–1976

  26. ICD

  27. Conclusion • Isolated RVMI relatively rare presentation • Non-Dominant RCA lesions not benign & innocuous • Value of CMRI • Limited data on value of AICD

  28. References • Kinch JW, Ryan TJ. Right ventricular infarction. N Engl J Med. 1994;330:1211–1217. • Haji SA, Movahed A. Right ventricular infarction-diagnosis and treatment. ClinCardiol. 2000;23:473–482. • A. Kumar, H. Abdel-Aty, I. Kriedemann, J. Schulz-Menger, C.M. Gross, R. Dietz, M.G. FriedrichContrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction J Am CollCardiol, 48 (10) (2006), pp. 1969–1976 • Cavalcante JL, Al-Mallah M, Hudson M. Isolated right ventricular infarct presenting as ventricular fibrillation arrest and confirmed by delayed-enhancement cardiac MRI. Heart Lung Circ 2010; 19: 620-623. • Hurst JW, editor. The heart, 4th ed. New York: McGraw-Hill; 1978. p 409

  29. Thank you

  30. complications • AV block • RBBB • Atrial Fibrillation • Ventricular Arrhythmias

  31. CMR • LV: normal size, volume, function. • RV: increased ESV & hypokinesis of the inferior & anterior walls at the base & mid segments with mildly reduced global systolic function, EF 40% • Perfusion: Evidence of matched/fixed perfusion defects in septum & inferoseptum from mid wall to base • Tissue: mild oedema in basal segments of the RV anterior & inferior wall on dark blood T2 weighted STIR images. DE- abnormal signal in basal & mid segments of inferior and anterior wall of RV, indication infarction.

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