Use of inhaled nitric oxide in the treatment of right ventricular myocardial infarction

In 50% of acute left ventricular inferior-posterior wall myocardial infarction (MI), concomitant right ventricular MI (RVMI) has been reported, with a dramatic increased rate of mortality. We report the case of a woman with RVMI complicated by cardiogenic shock due to dissection of the right coronary artery. She was treated with liquid infusion, epinephrine, milrinone, and an intraaortic balloon pump, but clinical condition decreased. She was then intubated, and prolonged inhalation of nitric oxide (12-15 ppm) was added. Both clinical and hemodynamic parameters slowly improved with decrease of systemic (2513 ± 708 shifted to 1802 ± 369 dynes × s/cm⁵) and pulmonary vascular resistance (365 ± 183 to 309 ± 80 dynes × s/cm⁵) and central venous pressure (fell from 13 ± 4 mm Hg to 6 ± 4 mm Hg) and improvement of cardiac index (from 2.2 ± 0.5 to 3 ±0.3 L/min per square meter). Inhalation of nitric oxide (iNO) withdrawal on day 7 caused a significant rebound pulmonary hypertension with decrease of cardiac output. Inhalation of nitric oxide was then reinstituted until day 8 and was finally gradually withdrawn without major hemodynamic variations. The patient was weaned from the ventilator on day 9 and was stable clinically and hemodynamically.