Right Ventricular Infarction Associated with Pulmonary Embolism

Mohammed Al-Sadawi¹, Rishard Abdul¹ and Samy I. McFarlane^1,

¹Department of Internal Medicine, State University of New York: Downstate Medical Center, Brooklyn, New York, United States- 11203

Cite this paper

Mohammed Al-Sadawi, Rishard Abdul and Samy I. McFarlane. Right Ventricular Infarction Associated with Pulmonary Embolism. American Journal of Medical Case Reports. 2019; 7(7):151-157. doi: 10.12691/AJMCR-7-7-9

Abstract

Background: Since the introduction of heparin as part of the management of acute coronary syndrome, the occurrence of pulmonary embolism (PE) as a complication of myocardial infarction (MI) have somewhat been unheard of. Given this rarity, its recognition is now a formidable challenge. Case Description: We present a case of a previously well 56-year-old male who presented with typical chest pain radiating to the left arm and dizziness. Initial vital signs revealed a blood pressure of 95/65 mmHg and his heart rate was 42 bpm. Physical exam revealed a middle-aged male in no acute distress with cool extremities, normal heart sounds, no murmurs and flat neck veins. His chest was clear to auscultation, abdomen benign and clinically, he was euvolemic. His first electrocardiogram (EKG) was significant for bradycardia with heart block and junctional escape rhythm and ST depressions in the anteroseptal leads. Subsequent right sided EKG showed sinus bradycardia with ST segment elevations in leads II, III and aVF. Troponin I was 0.95 ng/L [normal <0.04 ng/L] and initial transthoracic echo (TTE) was unremarkable with an ejection fraction (EF) of 55-60%. He was given loading doses of aspirin and clopidogrel, heparin drip initiated, and he proceeded to cardiac catheterization which revealed a 60 % stenotic lesion of the mid LAD and a large filling defect with 100% stenosis of the mid RCA consistent with thrombus. Post procedure TTE revealed an EF of 40%, septal and posterior hypokinesis, right ventricular regional wall motion abnormality of the basal and mid free wall with apical hypercontractility (McConnell's sign) suggestive of PE. CT pulmonary angiography revealed bilateral pulmonary emboli and anticoagulation therapy was initiated. Conclusion: This case illustrates that pulmonary embolism is a potential complication of RV infarction and its early identification is critical for implementation of anticoagulation therapy for this potentially fatal condition if left undiagnosed and untreated.

Keywords

right ventricular infarction, pulmonary embolism, coronary intervention

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	McConnell, M., Solomon, S., Rayan, M., Come, P., Goldhaber, S. and Lee, R. (1996). Regional Right Ventricular Dysfunction Detected by Echocardiography in Acute Pulmonary Embolism. The American Journal of Cardiology, 78(4), pp.469-473.
[2]	Oh, S., Bang, S. and Kim, M. (2015). McConnell’s sign; a distinctive echocardiographic finding for diagnosing acute pulmonary embolism in emergency department. Critical Ultrasound Journal, 7(Suppl 1), p.A20.
[3]	Kuno, T., Imaeda, S., Hashimoto, K., Ryuzaki, T., Saito, T., Yamazaki, H., Tabei, R., Kodaira, M., Hase, M. and Numasawa, Y. (2018). Recent Inferior Myocardial Infarction Complicated with a Right Ventricular Thrombus Detected by Three Cardiac Imaging Modalities. Internal Medicine, 57(5), pp.693-695.
[4]	Boukantar, M., Lim, P. and Mitchell-Heggs, L. (2010). Right ventricular thrombus and pulmonary embolism in patient with anterior myocardial infarction. European Heart Journal, 31(23), pp.2870-2870.
[5]	Labana, S., Hussein, M., Saha, S. and Khan, M. (2017). Double Trouble: Acute Pulmonary Embolism in a Patient With Acute Inferior Wall Stemi. Chest, 152(4), p.A1024.
[6]	Smith, J., Koul, S., Roijer, A., Holmqvist, J., Keussen, I., Cwikiel, W., Öhlin, B. and Erlinge, D. (2013). Acute right ventricular failure caused by concomitant coronary and pulmonary embolism: successful treatment with endovascular coronary and pulmonary thrombectomy. European Heart Journal: Acute Cardiovascular Care, 2(2), pp.131-136.
[7]	Miller, R., Jordan, R., Parker, R. and Edwards, J. (1952). Thrombo-embolism in Acute and in Healed Myocardial Infarction. Circulation, 6(1), pp.7-15.
[8]	Ögren, M., Bergqvist, D., Eriksson, H., Lindblad, B. and Sternby, N. (2005). Prevalence and risk of pulmonary embolism in patients with intracardiac thrombosis: a population-based study of 23, 796 consecutive autopsies. European Heart Journal, 26(11), pp.1108-1114.
[9]	Kearon, C., Akl, E., Ornelas, J., Blaivas, A., Jimenez, D., Bounameaux, H., Huisman, M., King, C., Morris, T., Sood, N., Stevens, S., Vintch, J., Wells, P., Woller, S. and Moores, L. (2016). Antithrombotic Therapy for VTE Disease. Chest, 149(2), pp.315-352.
[10]	Chen, Z., Li, C., Li, Y., Tang, H., Rao, L. and Wang, M. (2019). Concomitant coronary and pulmonary embolism associated with patent foramen ovale.