A Needle in a Haystack: uncovering RV branch compromise after primary PCI of RCA via ECG

Abstract

Background: ECG remains the mainstay of diagnosis of STEMI in clinical practice and proper interpretation helps to identify the culprit artery. We present a rare case in which ST elevation in ECG proved to be quite misleading.

Case Presentation: We present the case of an elderly male patient who presented to emergency department with acute onset of severe chest pain. Ecg done in emergency department which showed inferior wall myocardial infarction (MI) complicated by complete heart block. He underwent angioplasty of right coronary artery. Patient in CCU developed ST elevation in anterior chest leads which was attributed to RV branch occlusion.

Management and Results: Patient was managed medically as he was pain free and hemodynamically stable. Serial ECG’s done. He was strictly monitored in CCU for any hemodynamic or electrical instability. Patient remained pain free throughout his stay in CCU. After 6 to 8 hours ST segment elevation completely settled down with no Q wave formation.

Conclusion: ST segment elevation in anterior leads is hallmark of anterior wall MI. Interestingly, isolated right ventricle MI can also produce similar changes in ECG. Very few case reports found on management of isolated RV branch occlusion and patient can present with a wide spectrum of clinical presentation from being completely asymptomatic to suffering from cardiac arrest. Management of isolated RV branch occlusion is another dilemma and it can vary from case to case.