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(Chest. 2003;124:219-226.)
© 2003 American College of Chest Physicians

New Parameters in Identification of Right Ventricular Myocardial Infarction and Proximal Right Coronary Artery Lesion*

Kurtulus Özdemir, MD; Bülent B. Altunkeser, MD; Abdullah Içli, MD; Hüseyin Özdil, MD and Hasan Gök, MD

* From the Cardiology Department, Selçuk University Medical Faculty, Konya, Turkey.

Correspondence to: Kurtulus Özdemir, MD, Kiliçarslan mah, Rauf Denktas Cad, Aybüke sitesi B2 Blok 83/4, 42080 Selçuklu, Konya, Turkey; e-mail: kurt33{at}hotmail.com


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Objective: The diagnosis of right ventricular myocardial infarction (RVMI) accompanied by acute inferior myocardial infarction (MI) is still a problem that we encounter. This study was designed to find out the usefulness both of peak myocardial systolic velocity (Sm) and of the myocardial performance index (MPI) of the right ventricle measured by pulsed-wave tissue Doppler imaging (TDI) in assessing right ventricular function.

Methods: Sixty patients who experienced a first acute inferior MI (mean [± SD] age, 57 ± 9 years) were prospectively assessed. An ST-segment elevation of >= 0.1 mV in V4-V6R lead derivations was defined as an RVMI. From the echocardiographic apical four-chamber view, the Sm, the peak early diastolic velocity, peak late diastolic velocity, the ejection time, the isovolumetric relaxation time, and the contraction time of the right ventricle were recorded at the level of the tricuspid annulus by using TDI. Then, the MPI was calculated. The patients were classified into the following three groups, according to the localization of the infarct-related artery (IRA) detected using coronary angiography: group I, proximal right coronary artery; group II, distal right coronary artery; and group III, circumflex coronary artery.

Results: RVMIs were detected in sixteen patients, and the IRA in 27 patients was the proximal right coronary artery. The right ventricular Sm was observed to be significantly low in patients with RVMIs and those in group I compared to those without RVMIs and those in groups II and III (10.9 ± 1.3 vs 14.3 ± 3.2 cm/s, respectively [p < 0.001]; 11.5 ± 2.5 vs 15.1 ± 3 cm/s, respectively; and 14.9 ± 2.6 cm/s, respectively [p < 0.001]). In the diagnosis of RVMI, the values for sensitivity, specificity, negative predictive value, and positive predictive value of Sm < 12 cm/s were 81%, 82%, 92%, and 62% respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 63%, 88%, 74%, and 81%, respectively. The MPI was high in the same patient groups (0.83 ± 0.12 vs 0.57 ± 0.11 in those patients without RVMI, respectively, [p < 0.001]; 0.74 ± 0.13 vs 0.56 ± 0.15 in group II and 0.54 ± 0.07 in group III, respectively [p < 0.001]). The sensitivity, specificity, negative predictive value, and positive predictive value of an MPI of > 0.70 in the diagnosis of RVMI were calculated as 94%, 80%, 97%, and 63%, respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 78%, 91%, 83%, and 88% respectively.

Conclusions: An Sm <12 cm/s and an MPI > 0.70 obtained by TDI may define RVMI concomitant with acute inferior MI, and the IRA.

Key Words: myocardial performance index • right ventricular myocardial infarction • tissue Doppler imaging


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
In approximately half of patients with inferior myocardial infarction (MI), right ventricular MI (RVMI) develops.1 In patients with RVMI, the risk of death in the hospital is high and major complications are greater.2 3 For early diagnosis, electrocardiography1 and two-dimensional echocardiography4 5 are used, but these methods are occasionally insufficient.6 Tissue Doppler imaging (TDI) has evolved as a new technique that enables myocardial velocities to be detected and makes the quantitative assessment of the systolic and diastolic movements of myocardial walls possible.7 8 9 TDI has been considered to be a technique that leads to the assessment of right ventricular function. RVMI results from the occlusion of the right coronary artery proximal to or at the takeoff point of the marginal branches.10 As determined from the position of the right ventricle tricuspid annulus by TDI, myocardial velocities and the myocardial performance index (MPI), which is a new parameter in assessing left ventricular function,11 can give information about right ventricular function. This study was designed to test the usefulness both of the right ventricular peak myocardial systolic velocity (Sm) and of the MPI obtained by pulsed-wave TDI in the diagnosis of RVMI and in determining the infarct-related artery (IRA) in patients with acute inferior MIs.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Patients Population
Included in this prospective study were 60 consecutive patients (50 men and 10 women; mean [± SD] age, 57 ± 9 years) with inferior MIs who had been admitted to the coronary ICU at the onset of acute chest pain within the previous 24 h. A standard 12-lead ECG and a right chest ECG (V4 through V6R leads) were recorded. Chest pain lasting for > 30 min, characteristic ST-segment elevation of >= 0.1 mV in two or more inferior derivations (ie, leads II, III, and aVF) on ECGs, and a creatine kinase-MB value more than twice that of the highest reference laboratory value were defined as acute MI criteria. The MI localization also was confirmed by the detection of hypokinetic and/or akinetic segments by echocardiography. The presence of an RVMI in association with an inferior MI was defined by an ST-segment elevation of >= BORDER="0"> 0.1 mV in V4 through V6R lead derivations. Accordingly, RVMI was identified in 16 patients. Forty-one patients received thrombolytic therapy. Patients who had experienced MIs in the past, or had valvular disease, left ventricular hypertrophy, left and right bundle-branch block, or atrial fibrillation were excluded from the study.

Echocardiography
Two-dimensional, pulsed Doppler and color-flow Doppler echocardiography examinations were performed within 2 days after the onset of symptoms. A cardiac ultrasonographic unit (model 5000; Advanced Technology Laboratories Inc; Bothell, WA) equipped with a variable (ie, 2 to 4 MHz), phased-array, cross-sectional transducer, harmonic imaging, and TDI systems was used. All the echocardiographic measurements were performed according to the recommendations of the American Echocardiography Association12 without any information about the ECG findings.

Doppler Echocardiography
From the apical four-chamber view, Doppler recordings were obtained with the pulsed sample volume placed at the tip of the mitral leaflets. The early peak filling velocity (E wave), the late peak filling velocity (A wave) peak filling velocity, and the E-wave deceleration time were measured, and the E-wave/A-wave (E/A) ratio was calculated. The pulmonary venous flow was recorded from the apical four-chamber view by inserting the pulsed-wave Doppler sample volume approximately 1 cm into the right upper pulmonary vein. The venous peak systolic velocity (PS), the pulmonary peak diastolic velocity (PD), the PS/PD ratio, and the atrial reverse-flow velocity were recorded. In the presence of tricuspid regurgitation, the pulmonary artery systolic pressure was calculated from the sum of the estimated mean right atrial pressure, and the maximum pressure difference between the right ventricle and right atrium, as determined by continuous-wave Doppler echocardiography.13

Annular Velocities Obtained by TDI
Pulsed-wave TDI images were acquired by activating the TDI function of the cardiac ultrasonographic unit. The best recordings were obtained by optimizing the gains to terminate the signals formed by the transmitral flow and to reduce the noise with the use of low wall filter settings (ie, 50 Hz). A 3.5-mm sample volume was used. From the apical four-chamber view, the TDI cursor was placed to the right of the ventricular free wall and the interventricular septum at the level of the tricuspid annulus in such a way that the annulus moved along the sample volume line. A major positive Sm was recorded with the movement of the annulus toward the cardiac apex during systole. Two major negative velocities were recorded with the movement of the annulus toward the base of the heart during diastole, as follows: one during the early phase of diastolic myocardial velocity (Em) and another during the late phase of diastolic myocardial velocity (Am). In the TDI images, Sm duration was measured as the ejection time (ET), the time between the end of the Sm and the beginning of the Em as isovolumetric relaxation time (IRT), and the time between the end of Am and the beginning of Sm as isovolumetric contraction time (ICT) [Fig 1 ]. The right ventricular MPI was calculated as (IRT + ICT)/ET, by using the values obtained from the right ventricular free wall. In this study, a Doppler velocity range of -20 to 20 cm/s was selected, and the velocities were measured on-line at a sweep of 50 mm/s. A mean of three consecutive cycles was used to calculate all Doppler echocardiography parameters.



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  		Figure 1.. A recording of right ventricular free wall velocities, systolic time intervals, and diastolic time intervals obtained by pulsed-wave tissue Doppler echocardiography at the level of the tricuspid annulus in a patient with an RVMI accompanying left ventricular acute interior MI is shown. Sm, 11.3 cm/s; Em, 5.6 cm/s; Am, 16 cm/s; ET, 280 ms; IRT, 120 ms; ICT, 100 ms; MPI, (120 + 100)/280 = 0.79.

 
Coronary Angiography
Coronary angiography and left ventriculography were performed to detect the IRA within the first month after the MI. Total or subtotal occlusion of the coronary artery supplying the asynergic field, as seen in the features of left ventriculography and arteriographic presenting acute thrombosis or dissected plaque, were accepted as the defining features for the IRA. The patients were divided into two groups according to the level of the right coronary artery lesion when the IRA was the right coronary artery. The patients with the lesion proximal to the marginal branch of the right coronary artery were defined as group I, whereas those with the lesion distal to the marginal branch of right coronary artery were defined as group II. The patients in whom the IRA is the circumflex artery were defined as group III. Those patients in whom the IRA could not be identified were excluded from the study.

Statistical Analysis
The data were given as the mean ± SD. An analysis of variance test was used for the comparison of the results between the groups, and post hoc analysis was performed with Scheffé test. The Student t test was used for the comparison of unpaired groups. A p value of < 0.05 was accepted as being statistically significant. The sensitivity, specificity, negative predictive value, and positive predictive value were calculated with standard formulas. To assess the variability between the observers, another observer in 20 patients repeated the measurements at different times. The variability was defined as the percentage of the difference between two different measurements divided by the mean of the measurements.14


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
The clinical parameters were comparable in the groups based on the IRA. The number of the patients receiving ß-blocker and thrombolytic therapy, and the peak values of creatine kinase and transaminase did not differ between the groups. The number of patients in whom single-vessel disease and multi-vessel disease are detected angiographically, and the percentage of the occlusion of the IRA were comparable (Table 1 ). The conventional Doppler parameters obtained from pulmonary venous flow in all three groups were also the same (Table 2 ). The clinical and echocardiographic data of the patients with and without RVMIs are shown in Table 3 . Systolic BP was lower in patients with RVMIs, whereas the incidence of tricuspid regurgitation higher than in patients without RVMIs. Although pulmonary artery pressure was higher in the group with RVMIs, it was not statistically significant.


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  		Table 1.. Comparison of the Baseline Clinical and Angiographic Parameters Among Patient Groups*

 

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  		Table 2.. Mitral and Pulmonary Venous Doppler Echocardiographic Parameters*

 

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  		Table 3.. Clinical and Echocardiographic Parameters in Patient Groups With and Without RVMI*

 
Annulus Velocities and MPI Obtained by TDI
In the comparison of patient groups with and without RVMI, the values for Sm, Em, and Am obtained from the interventricular septum were lower in those with RVMIs than in those without, but the difference was insignificant (Table 4 ). However, the Sm, Em, and ET values obtained from the right ventricular free wall were significantly lower, and IRT and ICT values were significantly higher in those with RVMIs than in those without. The right ventricular MPI was calculated to be higher in those with RVMI than in those without (Table 4) . In patient groups based on the IRA, the annulus velocities obtained from the interventricular septum also were similar. Nevertheless, the Sm and ET obtained from the right ventricular free wall were lower, whereas the MPI and IRT of the right ventricular free wall were significantly higher in group I than in groups II and III. Also, the Em was lower and the ICT was higher in group I than in group III (Table 5 ).


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  		Table 4.. Comparison of the Tissue Doppler Parameters Obtained from the Interventricular Septum and Right Ventricular Free Wall in Patients With and Without RVMI*

 

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  		Table 5.. Comparison of the Right Ventricular Velocities and the MPI by Patient Group*

 
The Role of Right Ventricular Sm and MPI Obtained by TDI in the Identification of RVMI and the Localization of IRA
The mean variability between the observers was rather low (Sm, 2.5 ± 1.4%; MPI, 3.9 ± 3.3%). In the patient groups, the right ventricular free wall Sm values are shown in Figure 2 . The mean Sm was 10.9 ± 1.3 cm/s (95% confidence interval [CI], 10.2 to 11.6 cm/s) in those patients with RVMIs, and 11.5 ± 2.5 cm/s (95% CI, 10.5 to 12.4 cm/s) in group I. Accordingly, taking 12 cm/s as the cutoff value, the sensitivity, specificity, negative predictive value, and positive predictive value of Sm < 12 cm/s in the identification of RVMI and in showing the proximal right coronary artery lesion as the IRA are demonstrated in Table 6 .



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  		Figure 2.. The mean and 95% CI values of peak Sm obtained from the right ventricular free wall myocardium at the level of the tricuspid annulus by tissue Doppler echocardiography in the patients with (+) or without (-) RVMI (left, A) and in the patients in whom the IRA is the circumflex artery, proximal right coronary artery, and distal right coronary artery (right, B). Left, A: (-), 14.3 cm/s (95% CI, 13.4 to 15.3); (+), 10.9 cm/s (95% CI, 10.2 to 11.6). Right, B: circumflex coronary artery (CX), 14.9 cm/s (95% CI, 13.4 to 16.5); proximal right coronary artery (PRCA), 11.5 cm/s (95% CI, 10.5 to 12.4); distal right coronary artery (DRCA), 15.1 cm/s (95% CI, 13.6 to 16.5).

 

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  		Table 6.. The Sensitivity, Specificity, and Predictive Value of Sm < 12 cm/s and Right Ventricular MPI > 0.70 in Identifying RVMI and in Showing the Proximal Right Coronary Artery Lesion as the IRA*

 
The mean right ventricular MPI was 0.83 ± 0.12 (95% CI, 0.76 to 0.89) in those patients with RVMI, and 0.74 ± 0.13 (95% CI, 0.69 to 0.79) in group I (Fig 3 ). Accordingly, taking 0.70 as the cutoff value, the sensitivity, specificity, negative predictive value, and positive predictive value of a right ventricular MPI of > 0.70 in identifying RVMI and in showing the proximal right coronary artery lesion as the IRA are demonstrated in Table 6 .



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  		Figure 3.. The mean and 95% CI values of the MPI obtained from right ventricular free wall myocardium at the level of the tricuspid annulus by tissue Doppler echocardiography in the cases with (+) or without (-) RVMI (left, A) and in patients in whom the IRA is the circumflex artery, proximal right coronary artery, and distal right coronary artery (right, B). Left, A: (-), 0.57 (95% CI, 0.54 to 0.60); (+), 0.83 (95% CI, 0.76 to 0.89). Right, B: CX, 0.54 (95% CI, 0.50 to 0.58); PRCA, 0.74 (95% CI, 0.69 to 0.79); DRCA, 0.56 (95% CI, 0.49 to 0.63). See the legend of Figure 2 for abbreviations not used in the text.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Right ventricular function is the prognostic predictor of numerous heart diseases,15 16 and it is affected especially by RVMI that accompanies inferior MI resulting from the occlusion of the right coronary artery.17 18 RVMI impairs right ventricular function, although it does not always lead to hemodynamic impairment.19 However, it is difficult to assess both right ventricular anatomy and function with reliable conventional echocardiographic examination because of its complex structure. In most cases, the visual assessment of the right ventricular free wall by echocardiography leads to an underestimation of hypokinesia, due to an asymmetric contraction of the right ventricular walls toward its center.20 It has been suggested that color or pulsed-wave TDI, which is frequently used in assessing left ventricular function,21 22 23 also can be used to assess right ventricular function. However, adequate data concerning its use for this purpose are lacking. The myocardial velocities obtained by pulsed-wave TDI from the right ventricular free wall at the level of the tricuspid annulus in the apical four-chamber view show the longitudinal dynamics of the right ventricle, which is not seen with visual scoring.24 25 In studies26 27 assessing right ventricular function by using techniques other than TDI, the movement of the tricuspid annulus has been shown to represent the global right ventricular function. It has been documented28 that significant right coronary artery disease can be identified with the assessment of systolic velocity obtained by pulsed-wave TDI from the right ventricular free wall close to the tricuspid lateral annulus in the apical four-chamber view during dobutamine stress echocardiography.

Finally, it has been shown that tricuspid annulus systolic velocity decreases in patients with inferior MIs compared to those with anterior MIs, and in those with RVMIs compared to those without RVMIs.29 On the basis of the results of these studies, we studied the diagnostic value of the right ventricular free wall Sm in the identification of RVMI and proximal right coronary artery disease. As demonstrated by Alam et al,29 we found that the right ventricular free wall Sm and Em were significantly low in patients with RVMIs and that the Em/Am ratio was similar. Specifically, the Sm and Em values obtained from the interventricular annulus were lower in the patients with RVMIs than in those without, but no statistically significant difference was detected. So, it was thought that the TDI of the tricuspid annulus at the septal valve could be affected by left ventricular function. Therefore, TDI of the tricuspid annulus may not be a good discriminator of RVMI. Apart from this, we found that the Sm obtained from the right ventricular free wall was significantly lower in the patients in whom the IRA was the proximal right coronary artery than in those in whom the IRA was the distal right or circumflex coronary artery. Although conventional Doppler echocardiographic parameters obtained from the mitral valve and pulmonary vein levels were similar in the compared groups, the decreased Sm of the right ventricular free wall can be accepted as an indicator of right ventricular systolic dysfunction, consequent to RVMIs. Also, a decrease in the Em of the right ventricular free wall shows the development of right ventricular diastolic dysfunction in those with RVMIs and in those who experienced MIs due to a proximal right coronary artery lesion.

In previous studies, including that of Alam et al,29 any predictive Sm value used in the identification of right ventricular dysfunction has not been reported. In this study, the accuracy of the 12 cm/s cutoff value was determined by considering the Sm values, obtained with 95% CI, that were tested in the identification of RVMI and proximal right coronary artery disease. An Sm of < 12 cm/s showed RVMIs with high sensitivity (81%) and specificity (82%). In addition, the negative predictive value was also high (92%). The sensitivity of the same criterion in the identification of proximal right coronary artery disease was low (63%), whereas its specificity was high (88%).

The MPI was defined as a noninvasive Doppler measurement of ventricular function.11 The MPI, also known as the Tei index, is commonly used in the assessment of systolic and diastolic function of the left ventricle.11 30 31 32 It has been reported that the MPI obtained by the combination of systolic and diastolic time intervals can be used in the determination of the degree of dysfunction in patients with left ventricular dysfunction, and it correlates with conventional parameters such as left ventricular ejection fraction32 and invasive measurements.31 It also has been shown that this index is a simple and useful method that is independent of heart rate11 33 and is unaffected by the geometric shape of the ventricle,34 with excellent reproducibility between observers.11 30 31 32 However, studies related to the use of the MPI for the assessment of right ventricular function, in which conventional echocardiography is inadequate, are insufficient. Tei et al35 have shown that the right ventricular MPI is increased (0.93) in patients with primary pulmonary hypertension, and it is the most important indicator in discriminating healthy subjects. Eidem et al36 also have shown that the MPI increases significantly (0.63) in subjects with severe right ventricular insufficiency and Ebstein anomaly. However, any data on the use of this method in the assessment of RVMI, in which right ventricular dysfunction is seen most commonly, have not been noticed. We considered calculating the MPI with TDI. We detected that the MPI that was calculated with this method was significantly higher in patients with RVMIs and in those in whom the IRA was the proximal right coronary artery. Considering the MPI values in the 95% CI, we assessed the role of a right ventricular MPI of > 0.70 in the identification of RVMI and proximal right coronary artery disease. In 15 of 16 patients with RVMIs and in 21 of 27 patients in whom the IRA was the proximal right coronary artery, the MPI was > 0.70, whereas in 35 of 44 patients without RVMIs and in 30 of 33 patients in whom the IRA was the distal right or circumflex coronary artery it was <= 0.70. These findings have demonstrated that an MPI of > 0.70 may diagnose RVMI and proximal right coronary artery disease with high sensitivity and specificity.

The early diagnosis of RVMI still has been suboptimal. Although the clinical triad of hypotension, absence of pulmonary congestion, and elevated jugular venous pressure is quite specific, the sensitivity is only 10 to 25%.1 At the present time, even when using additional chest leads, electrocardiography, which is the most common modality used for the diagnosis of RVMI, remains insufficient when compared with autopsy-proven MI.1 RVMI resulting from the occlusion of the proximal right coronary artery leads to pandiastolic dysfunction as well as to right ventricular systolic dysfunction.37 The results of this study have demonstrated that the TDI method assessing myocardial function impairment is a new diagnostic tool that can be used to detect the IRA localization in patients with acute inferior MIs. The right ventricular free wall Sm and MPI values obtained by this method can give correct and reliable information about the severity of disease and the localization of the lesion, as well as the diagnosis. It may be suggested that the diagnostic value of MPI, which is an indicator of both systolic and diastolic function, is greater.

Limitations of the Study
It has been known that although coordinated right ventricular function depends on the contraction of myocardial fibers along both the long and short axes, myocardial velocities obtained by TDI in the apical four chambers reflect the movements of the myocardium only along the long axis. The contraction of ventricular circumferential fibers does not affect the myocardial velocities in the image in this localization.23 24 25 This can lead to the idea that TDI does not reflect the global right ventricular function exactly. Because imaging of the right ventricle is not easy due to technical difficulties, its assessment is not practical with echocardiography. Besides, it is accepted that mitral and tricuspid annulus changes are affected by the movement of the entire wall of the ventricle.38 That is why the changes in the right ventricular free wall annulus were evaluated. As is known, the improvement in right ventricular function generally occurs early after an MI.39 Although echocardiographic assessment was performed within the first 2 days in this study, the possibility that some patients already had recovered from the damage in the right ventricle may decrease the diagnostic value of the parameters that were used. However, the parameters obtained by TDI provide quantitative data, which can give us an idea about the extent of the RVMI as well diagnosing it. But a correlation of these data with autopsy findings that can be accepted as the only "gold standard" is needed.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
It should be concluded that the right ventricular systolic velocity obtained from the free wall decreases and the right ventricular MPI increases in patients with RVMI and in those in whom the IRA is the proximal right coronary artery when accompanied by acute inferior wall MI. We speculate that RVMI could be diagnosed and a proximal right coronary artery lesion could be predicted correctly by the use of these parameters, which are easily obtained by TDI.


   Footnotes
 
Abbreviations: Am = late phase of diastolic myocardial velocity; CI = confidence interval; E/A = E-wave/A-wave ratio; Em = early phase of diastolic myocardial velocity; ET = ejection time; ICT = isovolumetric contraction time; IRA = infarct-related artery; IRT = isovolumetric relaxation time; MI = myocardial infarction; MPI = myocardial performance index; PD = pulmonary peak diastolic velocity; PS = venous peak systolic velocity; RVMI = right ventricular myocardial infarction; Sm = myocardial systolic velocity; TDI = tissue Doppler imaging

Received for publication April 1, 2002. Accepted for publication November 19, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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G B Bleeker, P Steendijk, E R Holman, C-M Yu, O A Breithardt, T A M Kaandorp, M J Schalij, E E van der Wall, P Nihoyannopoulos, and J J Bax
Assessing right ventricular function: the role of echocardiography and complementary technologies
Heart, April 1, 2006; 92(suppl_1): i19 - i26.
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