Answer is question is wrong : RAA clot do occur in AF and severe right heart failure.It is less often recognised , since echo views are difficult and clinical events are silent.
Brief account of RAA clot formation
RAA is broad flat ,thin , broad chamber comparable to elephant’s ear.The ostium is not that distinct as the body as it blends with crista terminalis .
Rough pectinate muscles should make it prone for thrombus.Further , RAA has more sluggish flow than LAA increasing the propensity for thrombus.However , the flat nature of the chamber , absence of tortuous tracts , constant SVC flow which is abutting the RAA can counteract this.
RAA clots are less recognised as echo views are difficult .TEE is often required.
Overall RAA clot is 50% less common than LAA.
RAA clot should be specifically looked for in chronic AF and any severe right heart failure. (Unlike MR jet TR jet has less efficiency in flushing the Right atrium )
Finally,clinical events from RAA clot are less conspicuous as the emboli reaches the pulmonary bed silently.Unlike its colleague on the left side it neither triggers TIA nor a stroke !
1. Buğan B, Baysan O, Demirkol S, Güngör M, Yokuşoğlu M. Right atrial appendage thrombus in a heart failure patient with sinus rhythm. Gulhane Med J. 2011; 53(3): 214-215.
2.Subramaniam B, Riley MF, Panzica PJ, Manning WJ. Transesophageal echocardiographic assessment of right atrial appendage anatomy and function: comparison with the left atrial appendage and implications for local thrombus formation. J Am Soc Echocardiogr.; 2006; 19(4):429-33.
3.Sahin T, Ural D, Kilic T, Bildirici U, Kozdag G, Agacdiken A, Ural E. Right atrial appendage function in different etiologies of permanent atrial fibrillation: a transesophageal echocardiography and tissue Doppler imaging study. Echocardiography;2010; 27(4):384-93
4 .Ozer O, Sari I, Davutoglu V. Right atrial appendage: forgotten part of the heart in atrial fibrillation. Clin Appl Thromb Hemost; 2010; 16(2): 218-20
Reperfusion arrhythmia was described originally in the thrombolytic era .
It can be any of the the following .
AIVR(Accelerated Idio Ventricular rhythm)
Sinus bradycardia (In Infero posterior MI )
VF can occur as Re-perfusion arrhythmia.
Does these arrhythmia occur following primary PCI ?
It should isn’t ?
In fact it must be more pronounced as we believe PCI is far superior modality for reperfusion !
Busy Interventional cardiologists of the current era either do not look for it or fail to document it . These arrhythmias occurs only with early Primary PCI (Say less than 2-3 hours) .If re-perfusion arrhythmias are really less common with primary PCI , are we missing some thing ?
Primary VF is the arrhythmia that occurs within minutes to few hours after acute coronary ischemia .This is most common fatal arrhythmia following STEMI accounting for 90% of all pre hospital deaths.
It occurs within 4 hours after onset of symptom and the risk rapidly fade as the hours go by.One variant of primary VF is the re-perfusion arrhythmia after thrombolysis .This can occur up to 12 hours or so.Primary VF responds well to prompt defibrillation.Follow up anti arhythmic drugs are not required in most situations.
What is secondary VF ?
As a rule secondary VF is not related* to index event of ischemia but to the anatomical substrates of Infarcted myocardium or pump failure
It generally occurs after 24 hours .Response to defibrillation is less favorable .Continued anti- arrhythmic drug therapy is required.
Few of them may end up with ICD.
(*However,a role for ongoing ischemia can never be disproved ! What about a small re-infarct trigggering another episode of primary VF ? )
A STEMI patient arrives late after 48 hours with chest pain .There is persistent ST elevation.
What is the likely mechanism of this chest pain ?
Index infarct pain continuing . . .
Post infarct Angina-IRA territory
Re-infarction following intermittent re-perfusion and re-occlusion
Remote ischemia from a branch of IRA
Ischemia from a possible non IRA lesion in a multivessel CAD
If this patient comes to a non PCI eligible centre. Will you lyse him ?
If post infarct angina is unstable angina . Isn’t thrombolysis contraindicated in UA ?
How to differentiate Post Infarct Angina from Re-Infarction ?
A very tricky issue indeed.
Unless fresh ST elevation with fresh enzyme peak is documented these entities cannot be differentiated.
(Even fresh ST elevation can be related to infarct expansion ,stretch or early acute remodeling.Fresh enzyme release or new peak may not represent new infarct always .It can be due to intermittent re-perfusion of IRA .It may simply represent a enzyme flush from the index infarct zone)
What is the practical , realistic , (Unscientific !) solution ?
Why break our head ? Never bother to differentiate PIA from Reinfarction etc . Let it be any thing . Do a emergency CAG .Stent whichever lesion looks good for the same . Of course , make sure he has enough insurance coverage .
This query often evokes confusion among fellows and General physicians .
The answer is simple .Yes , you can.(With few conditions)
Thrombolysis or PCI is done with reference to the presence or absence of ST elevation and chest pain.
If there is ongoing chest pain and significant new onset ST elevation thrombolysis or PCI is indicated whether there is associated q waves or not.
Ischemic q waves: Q wave can occur with transmural ischemia which result in electrical stunning and loss of R waves . (Many of them regenerate this R within few days after STEMI , indicating the q waves can be ischemic in origin)
Reinfarction : Patients with old MI can develop fresh ST elevation in q leads due to tachycardia and dyskinetic infarct segment .This group of patients should be carefully evaluated before labeling them as re-infarction
* q RBBB in early hours of anterior STEMI is fairly common which may revert later. qRBBB is not a contraindication for re-perfusion .
Presence of q waves does not imply one should not entertain thrombolysis or PCI .The decision to reperfuse , rather goes with presence of chest pain , ST elevation and of course within the acceptable time window!