Acute right ventricular infarction: insights for the interventional era

Acute right ventricular infarction is associated with higher in-hospital morbidity and mortality related to life-threatening hemodynamic compromise and arrhythmias during acute occlusion and abruptly with reperfusion, complications which have implications for interventional management. Acute right coronary artery occlusion proximal to the right ventricular (RV) branches results in depressed RV systolic function, leading to diminished transpulmonary delivery of left ventricular preload and resulting in low-output hypotension. Under these conditions, RV pressure generation and output are dependent on left ventricular-septal contraction via paradoxical septal motion. With culprit lesions distal to the right atrial (RA) branches, augmented RA contractility enhances RV performance and cardiac output, whereas proximal occlusions induce RA ischemia, which exacerbates hemodynamic compromise. Hypotension may respond to volume resuscitation and restoration of a physiologic rhythm. Refractory cases usually respond to parenteral inotropes, though in some cases mechanical support is required. The right ventricle is relatively resistant to infarction and usually recovers even after prolonged occlusion. Acute percutaneous mechanical reperfusion enhances recovery of RV performance and improves the clinical course and survival of patients with right ventricular infarction.