European Heart Journal Supplements (2016) 18 (Supplement B), B51– B57
The Heart of the Matter
doi:10.1093/eurheartj/suw024
Case Reports
Abstracts
Clinical effect of ivabradine in patient with congestive heart failure with cardio-
genic shock condition: A case report
A. Widya, Vitriyaturrida, and S. Anjarwani
Department of Cardiology and Vascular medicine, Saiful Anwar General Hospital, Malang,
Indonesia
Background: Inotropic agents are one of the standard treatments in cardiogenic shock.
However, tachycardia is a constraint on the condition that will increase the oxygen
demand, which worsens heart failure condition. A reduction in heart rate with the admin-
istration of b-blockers is contraindicated due to negative inotropic that will be decrease
blood pressure and also congestive heart failure. In this situation, selective heart rate re-
duction via administration of Ivabradine without side effects of hypotension may be ad-
vantageous and better tolerated in patients with cardiogenic shock. Hereby we report a
case of cardiogenic shock with congestive heart failure treated by adding Ivabradine to
the currently used therapy.
Case description: A 58 year-old man came in intensive cardiovascular care unit with
acute decompensated heart failure with ejection fraction 14%. During received care in
hospital, he experienced a decrease in haemodynamic then fell on cardiogenic shock con-
dition. He was treated with heart failure drugs and inotropic agents e.g Dobutamine and
Norepinephrine. Heart rate was 110 bpm. Then the treatment was added with Ivabradine
5 mg two times per day. The ejection fraction was improved and the heart rate was
decreased until 85 bpm. Then he was clinically improved.
Discussion: Heart rate is a well-known sign of clinical prognosis patient with congestive
heart failure with cardiogenic shock. This case supported the fact that Ivabradine, a spe-
cific inhibitor of If channel, which aim to decreasing heart rate and oxygen demand in con-
gestive heart failure condition with cardiogenc shock.
Keywords: ivabradine † cardiogenic shock † heart rate † congestive heart failure
Acute mesenteric ischemia on extensive anterior STEMI with paroxysmal atrial
fibrilation: A rare complication
A. Jalaludinsyah and T. Nugraha
Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of
Sebelas Maret, Dr. Moewardi Hospital, Solo, Indonesia
Background: Acute coronary syndrome (ACS) is one of the major causes of morbidity and
mortality globally. Myocardial infarction and cardiac arrhythmia, particularly atrial fib-
rillation, were predisposition of acute mesenteric ischemia. It was caused by sudden
onset of reduced blood flow in the mesenteric circulation due to thromboembolic
event. Acute mesenteric ischemia was a rare case with high mortality rate.
Objective: To present the rare case report of acute mesenteric ischemia on extensive ante-
rior STEMI with paroxysmal atrial fibrillation and to discuss the diagnosis and management.
Case description: A 54-year old male came to the emergency department of Dr. Moewardi
Hospital with the chief complaint of severe squeezing epigastric pain at rest since 6 hours
before hospital admission, the complaint accompanied by nausea, vomiting, and cold
sweating. On physical examination we found signs of general peritonitis. The electrocar-
diogram showed extensive anterior STEMI with increased of cardiac biomarkers. The
patient was then treated with intravenous fibrinolytic and on the following day the cyto
laparatomy surgery was done with result of necrosis in ileum and jejunum and the
surgeon did resection. Paroxysmal atrial fibrillation was found on the fifth day observation.
Conclusion: Patients with acute abdominal symptoms on the clinical setting of acute cor-
onary syndrome should be suspected to possibility of mesenteric ischemia as a complica-
tion of thromboembolic events secondary to ACS or atrial fibrillation. Accuracy and
minimal time delay in the diagnosis and management of acute coronary syndrome and
acute mesenteric ischemia can improve the patient outcomes.
Keywords: acute coronary syndrome † acute mesenteric ischemia
Acute fulminant myocarditis mimicking ST-elevation myocardial infarction
D.G. Widyawati and K. Rina
Departement of Cardiology and Vascular Medicine, Faculty of Medicine, University of
Udayana, Sanglah General Hospital, Bali, Indonesia
Background: Myocarditis is an inflammatory disease of the heart frequently resulting
from viral infection and/or post viral immune-mediated responses. The clinical manifest-
ation of myocarditis varies with a broad spectrum of symptoms ranging from asympto-
matics courses to presentation with sign of myocardial infarction to devastating
illlness with cardiogenic shock. Although history, physical examination, laboratory
data, and electrocardiogram are helpful in distinguishing myocarditis from myocardial
infarction, differential diagnosis can sometimes be difficult.
Case description: A case of male, 49 years old, referred from local hospital with thypoid
fever. He had symptoms fever since 1 week with nausea and vomiting. On day 3 of
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: journals.permissions@oup.com
hospitalization, he had atypical chest pain and decrease of blood pressure and heart
rate. When referred, his blood pressure was, 60 mmHg over palpation, heart rate 28
times/minute, respiratory rate 24 times/minute, and temperature 38oC. The ECG
showed total AV block with ST segment elevation at V2-V6. Echocardiogram bed side
result was decrease of LV systolic function with EF 23,73%, with hypokinetic at apical,
mid, and basal septal, mid anteroseptal, mid anterior, other segments were normoki-
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netic. Result of initial cardiac enzyme test revealed increase of troponin T (.2000)
and CKMB (.40). The laboratory result were increase of white blood cell 16,2, SGOT
1541, SGPT 1608, Sc 1,84. We did emergent coronary angiography and put temporary
pace maker. Coronary angiogram showed normal coronary arteries. We diagnosed this
patient with acute myocarditis and gave antibiotic meropenem 1 gr three times daily, ino-
tropic, and stop anticoagulant and antiplatelet. Unfortunately, the patient condition
became worsened and unresponsive to treatment.
We reported a case of acute fulminant myocarditis with clinical presentation mimick-
ing ST elevation myocardial infarction.
Keywords: myocarditis † ST elevation myocardial infarction
Fractional flow reserve: Nurturing a functional perspective in angioplasty
(Case Report)
E. Hindoro 1, V. Pratama 2, B.A. Permana 2, I. Purnawan2, R. Pranata 1, and G. Fonda1
1
Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia, 2Departement of
Cardiology and Vascular Medicine, Indonesia Army Central Hospital Gatot Soebroto,
Jakarta, Indonesia
Background: Fractional flow reserve (FFR) is an indirect index determined by measuring
the driving pressure for microcirculatory flow distal to the stenosis relative to the coron-
ary driving pressure available in the absence of a stenosis. The physiologic criterion for
inducible ischemia is FFR, 0.80.
Case description: We present two interesting cases. Case I: 45 years-old female, with
chief complaint of stable angina pectoris CCS II, prior history of hypertension and dysli-
pidemia. ECG Stress test (+), Echocardiography result was unremarkable (LVEF 68%).
CAG showed non-significant stenosis at one-third proximal LAD, FFR showed 0.78.
Patient underwent PCI with DES, post-stenting FFR result of 0.95. At 3rd and 6th months
follow-up there were no chest pain, no nitrate consumption and negative stress test.
Case II: 67 years-old female presented with chief complaint of typical angina. Prior
history of diabetes on OADs and statin. ECG stress test was inconclusive; CAG test demon-
strated non-significant stenosis in proximal LAD. FFR was 0.88. Patient underwent OMT.
At 3rd and 6th months follow-up there were no chest pain, no nitrate consumption and
negative stress test.
Discussion: In Case I: there was insignificant stenosis through CAG with significant FFR.
Patient underwent PCI, follow-up was excellent. Insignificant stenosis through CAG is
misleading and PCI was done and yield excellent post-stent FFR results. In Case 2:
there was non-significant stenosis through CAG with insignificant FFR result, patient
undergoes OMT with remarkable follow-up results. Studies exhibited various benefits
of FFR, significant reduction in major adverse cardiac events at 1st and 5th year. The
number of stents placed/patient was significantly higher in the CAG-guided than FFR-
guided group.
Conclusion: Physiologically FFR-guided PCI was safe, improve cardiac outcomes and
cost-effectiveness with reduced number of stents compared to angiographic criteria.
It’s time for “Functional” era.
Keywords: Fractional Flow Reserve † Functional † Angioplasty † Angiography †
Coronary Artery Disease † Stent
The role of invasive fractional flow reserve (FFR) in multivessel disease
E. Supriadi, I. Nadia, A.A. Alkatiri, and D. Firman
National Cardiovascular Center Harapan Kita (NCCHK), Jakarta, Indonesia
Background: Multivessel disease is often associated with higher burden of comorbidities,
left ventricular dysfunction, and cardiovascular risk. The goals in the treatment of multi-
vessel disease are to reduce angina, heart failure symptoms, and patient’s subsequent
risk of adverse cardiovascular events. Coronary angiography is the standard method
for guiding the placement of the stent in patients with multivessel coronary artery
disease who are undergoing percutaneous coronary intervention. Clinical significance
of coronary artery stenosis with moderate severity can be difficult to determine. The se-
verity of coronary stenosis can be calculated from pressure measurements made during
coronary arteriography by visual estimation, quantitative coronary angiography (QCA)
and index of the functional fractional flow reserve (FFR).
Case description: We report a case of a 35 years old male with history of acute miocardial
infarction (AMI) 4 months earlier and hospitalized for 5 days for heparinisation. Patient
has risk factors of smoker, diabetes mellitus, hypertension, and dyslipidemia. The
B52
angiogram showed that there were multivessel diseases with total occlusion at proximal
part of left anterior decsending (LAD) artery, significant stenosis at mid part of left
circumflex (LCx) artery and also significant stenosis at mid part of obtuse marginal
(OM) artery. The FFR wire was advanced through the lesion at mid part of LCx and mid
part of OM. Measurement was done after intracoronary adenosine administration. The
measurement showed non significant disturbance of coronary blood flow with FFR
result 0,98 at LCx and 0.84 at OM. We decided to do procedure angioplasty only at
proximal to mid part of LAD with a single stent implantation.
Conclusion: The FFR measurement is a simple procedure to guide whether to do angio-
plasty or not to patient with multivessel disease.
Keywords: Fractional Flow Reserve † Multivessel Disease † Angioplasty † Adenosine
Fibrinolytic followed by early angiography in cardiac arrest survivor patients with
ST elevation ACS: A pharmaco-invasive in non-primary PCI capable hospital
G. Adi1 and B. Widyantoro1,2
1 venous insulin administration was initiated with close blood glucose and electrolyte mon-
Intensive Cardiovascular Care Unit, Sentra Medika Cibinong Hospital, Bogor, Indonesia,
2 itoring. After which, the patient had profound recovery, and was discharged at day-5.
National Cardiovascular Center Harapan Kita Hospital, Jakarta, Indonesia
Background: Acute coronary syndrome (ACS) remains a significant cause of cardiovascu-
lar mortality in the modern world despite our best efforts in prevention and risk factor
management. Tremendous progress had been made in the management of ACS in the
last decade, both in ST elevation ACS (STE-ACS) and non STE ACS. Much of improvement
in the mortality rate in STE-ACS is attributed to better emergency network for early
emergency revascularization and the advances in medical treatment with the introduc-
tion of better drugs. Here we report a case of management STE-ACS patient who survived
from cardiac arrest.
Case presentation: A 37 years old male admitted to our ER with typical angina since 5
hours before. Chest pain was accompanied by shortness of breath and also diaphoresis.
He had uncontrolled hypertension and was actively smoking 1-2 packs of cigarettes per
day. His BP was 150/100 mmHg, HR 110 bpm and rales were present over 2/3 of lungs.
The electrocardiogram (ECG) revealed ST elevation in lead V1-V5. He was diagnosed
with acute anterior STEMI onset 5 hours, with Acute Heart Failure. Nasal O2, sublingual
nitrates and dual anti platelet were given immediately, but then the patient had seizures
and pulseless VT. After 20 minutes of optimal CPR, medication, intubation and DC shocks,
patient retain to spontaneous circulation with BP 80/50 and HR 127 bpm Dobutamin and
adrenalin continuous IV was started. Due to unstable condition and long hours traffic,
patient was not able to be transferred to primary PCI capable hospital. Decision for
giving fibrinolytic treatment was taken. After a successful fibrinolytic with streptokin-
ase, he then transferred to ICCU and underwent therapeutic hypothermia for 24 hours.
On the next day he underwent coronary angiography and subsequent PCI in LAD culprit
lesion. On the 3rd day patient got fever and pneumonia, medically managed and success-
fully extubated on the 8th day. He was discharged on 12th day with stable condition.
Early accelerated idioventricular rhythm followed by premature ventricular
complexes as a marker for successful reperfusion in ST-elevation myocardial
infarct patient
G.R.T. Ryanto, H. Afifah, and R. Herdyanto
Aisyiyah General Hospital, Bojonegoro, West Java, Indonesia
Background: Accelerated Idioventricular Rhythm (AIVR) is defined as an ectopic rhythm
with three or more consecutive wide-QRS complex firing at a rate , 120 bpm. Both its
onset and termination are gradual, and it is competitive with normal sinus rhythm.
AIVR occurs in various conditions, such as myocarditis, after administration of anesthesia,
after cardiac resuscitation, or related to reperfusion therapy after acute Myocardial
Infarction (MI), also called reperfusion arrhythmia. Reperfusion arrhythmia is one
of the possible findings in after thrombolytic or primary PCI. It is deemed as a marker
for successful reperfusion, especially when it occurs early after the reperfusion process
(,48 hours). Premature Ventricular Complex (PVC) appearance is another arrhythmia
associated with reperfusion. Even so, evidences for this occurrence as a marker for
success and vessel patency are sometimes inconclusive.
Case report: We report a case of transient AIVR immediately triggered after reperfusion
using fibrinolytic agent (streptokinase 1.5 million units), followed by infrequent PVCs
lasting for one hour and quickly disappearing in a patient diagnosed as inferior ST-Eleva-
tion Myocardial Infarction (STEMI) with concurrent 3rd degree AV block.
Result: Patient was stable throughout the duration of the arrhythmia and no adverse
effect was reported during hospitalization. There is also ST-segment elevation and AV
block resolution found post-reperfusion.
Conclusion: We conclude that early transient AIVR and PVCs appearance after reperfusion
can be attributed to a good short-term results and successful reperfusion, especially in con-
ditions causing limitations on performing primary Percutaneous Coronary Intervention.
Inferior ST-elevation myocardial infarction complicated by unstable total atrio-
ventricular block and diabetic ketoacidosis in end stage renal failure patient
H. Abizar, V. Eveninda, W. Y. Rosa, and D.A. Sinaga
Awal bros Hospital, Pekanbaru, Indonesia.
Case description: This is to report a 70 year-old patient who was referred to our hospital
with inferior myocardial infarction and complete heart block. She had been warded in the
referring hospital for 3 days, however despite heparin infusion and maximum doses of
Abstracts
dual inotropes, was hemodynamically unstable. There was no prior fibrinolysis. Other co-
morbidities comprised uncontrolled DM type II with end-stage renal failure (ESRF), as she
had her inaugural dialysis a week prior.
Upon admission, the patient denied any chest pain, hypotensive with blood pressure 69/
46 mmHg with heart rate 54 bpm. Electrocardiogram showed inferior myocardial infarction
and total atrioventricular block with atrial rate 100 bpm, ventricular rate 30-40 bpm with
persistent STelevation of the inferior lead. An urgent coronary angioplasty was conducted
and 1 drug eluting stent was implanted at the sub-totally occluded middle right coronary
artery. During intervention, her hemodynamic improved with intravenous atropine sul-
phate injections and dopamine being put off; hence temporary pacemaker was not
inserted. Soon following the procedure, she underwent hemodialysis for contrast clearing.
Despite successful intervention, the patient became delirious, then found that she was
dehydrated with laboratory findings supporting diabetic ketoacidosis (uncontrolled
blood glucose, metabolic acidosis, and positive urine ketone). Her heart rate slowed
down again, requiring immediate transvenous pacing insertion. Rapid yet cautious
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fluid therapy, provided depressed left ventricular function (EF 30%), was started. Intra-
Conclusion: Renal patient with late presentation inferior STEMI, complicated by un-
stable complete heart block, was salvaged with coronary angioplasty and subsequent
hemodialysis. Further deterioration was caused by diabetic ketoacidosis which also
required prompt rehydration and glucose control. Transvenous pacing would be
needed should the hemodynamic be not improved with medical therapy.
Keywords: inferior myocardial infarction † diabetic ketoacidosis † diabetes †
Atrioventricular block † end-stage renal failure
Outlflow tract ventricular arrythmia 3D ablation in LV summit Area: A case report
H. Medishita 1 and S.B. Raharjo 2
1
Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Diponegoro
University, Dr. Kariadi Hospital, Semarang, Indonesia, 2Department of Cardiology and
Vascular Medicine, Faculty of Medicine, University of Indonesia National Cardiovascular
Centre Harapan Kita, Jakarta, Indonesia
Background: The outflow tract ventricular premature contractions (VPCs) and ventricle
tachycardias (VTs) are usually idiopathic in origin. Idiopathic ventricular arrhythmias (VA)
consist of various subtypes of VA that occur in the absence of clinically apparent struc-
tural heart disease. Affected patients account for approximately 10% of all patients re-
ferred for evaluation of ventricular VT. Arrhythmias arising from the outflow tract (OT)
are the most common subtype of idiopathic VA and more than 70 –80% of idiopathic VTs
or VPCs originate from the OT. Frequent VPCs stated to cause a higher risk of LV dysfunc-
tion and cardiomyopathy in long term, therefore frequent VPCs which consent to be more
than 10% of total beat within 24 hours Holter monitoring suggested to be ablate.
Case presentation: We present a case of an Indonesian male subjects with a medical history
of hypertension and suffering symptoms of heart failure, prominent dyspnea on effort and
palpitations. Physical examination and laboratory evaluation were unremarkable. Echocar-
diography findings showed a low EF of 28%, global hypokinetic and LA-LV chamber dilatation.
Holter monitoring revealed a frequent, monomorphic, benign PVCs of 26%. The 12 leads ECG
revealed PVC’s with LBBB morphology, predominantly positive in the inferior leads and nega-
tive at I and aVL lead, with early R/S precordial transition at V2. The ratio of QS complexes
in aVL/ aVR was .1. Based on the algorithm, the source most likely located from RVOT -
epicardial - RCC origin which also part of the inaccessible LV summit area.
During the electrophysiology study, the activation mapping from posteroseptal RVOT
showed earliest activation at -62 ms. Pace mapping in this area showed 11/12 similarity
with clinical PVC. Multiple Radio Frequency Ablations (RFAs) with 48 degree and 30 watt
were delivered at posteroseptal area. Post ablation infrequent PVCs was still persists,
then a mapping in the right coronary artery (RCC) was performed and showed earliest ac-
tivation -57 ms, and multiple RFA were also delivered in this area. Infrequent PVCs was
still observed. Therefore, epicardial mapping through coronary sinus to GCV was done.
Activation mapping in the GCV showed earliest activation of -52 ms and fractionated
potentials. Multiple RFAs were also delivered in this area (10-15Watt, 48C). The VPC
was significantly reduced. Programmed atrial and ventricular stimulation showed
normal SA node and AV node functions.
Conclusion: We reported a case of an Idiopathic VPCs which showed early activation from
posteroseptal RVOT, GCVand RCC an intramural arrhythmia focus. Intramural VPCs is one
of the most challenging idiopathic VPCs to be ablated. Our case described a VPCs from the
LV summit origin in which catheter ablation have to deal with several risk, including (1)
the risk of accidental coronary vessels injury dealing with epicardial ablation approach
from the LV summit area, especially the inaccessible site where posterior aspect of the
RVOT is closely located to the left main coronary artery and (2) cardiac perforation result-
ing in tamponade. Those factors cause the idiopathic PVC/VTs ablation is quite complex
to be able to completely be eliminated.
Intravascular hemolysis complication after transcatheter PDA closure with ADO
device: A case report
I.G.B.G. Pranata, E. Gunawijaya, and V.K. Yanthie
Department of Pediatrics, Medical Faculty of Udayana University, Sanglah Hospital,
Denpasar, Bali
Background: Transcatheter PDA closure were the method of choice in benefit of semi in-
vasive strategy and long of inpatient time. The incidence of intravascular hemolysis after
transcatheter PDA closure is rare ranging from 0.3-0.5 % of all procedure of transcatheter
Abstracts
closure. Principally management of patient with clinically significant of intravascular
hemolysis were stabilization of general state, avoiding renal damage and eradication
of residual shunt.
Case description: A patient male 19 years old, come to integrated cardiac services at
Sanglah hospital for transcatheter PDA closure. The patient have history of heart
disease since 12 years old. TTE before transcatheter PDA closure (21st January 2015)
revealed : large PDA (isthmus 5-7 mm/ampulla 13-14 mm) with mild AR/TR/MR. At 7th
March 2015 he undergo transcatheter PDA closure, from PDA graphy and the bedside
TTE revealed smokey central leakage of residual shunt, no LPA and aortic obstruction
caused by ADO. One day after PDA closure (8th March 2015) since 5 o’clock (19 hours
after transcatheter closure) he complaining black reddish discoloration of urine. At 9th
march 2015 (2 days after hematuria) re-echocardiography was done showed relatively
decreased of residual shunt compared from the first time TTE after ADO. Results of 3rd
echocardiography (12th March 2015) showed decreased leakage from 2nd echocardiog-
raphy. Hematuria and icterus were subsided progressively.
Discussion: Intravascular hemolysis is very rare complication but seriously threatening con-
dition. Incidence of secondary hemolysis after transcatheter closure was 0.5 %. Hemolysis is
thought to result from red blood cell mechanical injury when a high-velocity residual jet
comes in contact with the metallic surface of the occluding coil or device. It is more
common after coil closure than with other devices. Hemolysis usually develops in the first
24 hours postprocedure, but may occur weeks later. When severe it may result in anemia,
jaundice, renal failure and coagulopathy. The usual approach to the patient with significant
intravascular hemolysis is stabilization, protection against renal damage, and eradication of
residual flows. This is accomplished by correcting anemia through blood transfusions, iron
and folate supplementation, avoiding dehydration and acidosis by precise fluid manage-
ment, and by inducing alkaline diuresis.
Conclusion: Transcatheter closure were method of choice management of the patient
with PDA, but there are facing with complication of intervention ie intravascular hemoly-
sis. This very rare case of intravascular hemolysis complication caused by transcatheter
PDA closure. Principally management of patient with clinically significant of intravascu-
lar hemolysis were stabilization of general state, avoiding renal damage and eradication
of residual shunt.
Keywords: PDA † transcateheter closure † ADO † intravascular hemolysis
A very rare case: A patient with extreme levocardia without remarkable symptom
I.Y. Suhartono 1 and V. Chairiadi 2
1
Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia, 2General Hospital
Undata, Palu, Indonesia
Extreme levocardia is a rare congenital heart anomaly of having the heart located on the
lateral side of left hemithorax. We describe an adult patient with extreme levocardia
presenting without remarkable symptom. A 48-year-old female was referred to cardi-
ology department for cardiac risk stratification before undergoing noncardiac surgery.
The only symptom she had was uncomfortable for lying on her left side. She had no
history of chest pain, palpitation or syncope. Her exercise capacity was good. Chest CT
scan showed extreme levocardia and hypoplastic left lung. The structures of the cham-
bers and the great vessels are normal. Echocardiographic examination confirmed
normal heart function. We had no specific treatment at that time and classified this
patient into the low-risk group.
Keywords: extreme levocardia † congenital heart anomaly † hypoplastic left lung
Transradial primary percutaneous coronary intervention on a patient with
ST-Elevation myocardial infarction with comorbid peripheral artery disease and
severe partial obstruction in the abdominal aorta
I.S. Prihatiningsih 1,2 and Y.H. Oktaviono1,2
1 Methods: A female 62 years old present to our emergency with retrostrenal chest pain ra-
Department of Cardiology and Vascular Medicine Faculty of Medicine, Airlangga Univer-
sity, Surabaya, Indonesia, 2Dr. Soetomo General Hospital, Surabaya, Indonesia
Background: Primary Percutaneous Coronary Intervention (PPCI) with transradial ap-
proach compared to transfemoral approach provided benefits such as less bleeding,
less vascular access complications and may reduce length of stays in the intensive care
unit. The current guidelines state that radial access should be preferred over femoral
access when it is performed by experienced radial operator. However, this approach is
still underused in this hospital.
Case report: We report a case of a 62 year old male patient diagnosed with inferior ST
Elevation Myocardial Infarction (STEMI) and Peripheral Arterial Disease (PAD) have
B53
been performed PPCI with transradial approach. The decision of transradial approach
was made promptly due to weak pulse of both of the femoral arteries found during pre-
procedure examination.
Result: The intervention of the culprit lesion in the proximal Right Coronary Artery (RCA)
causing the STEMI inferior was a success and there were no complications during or after
the procedure. The remaining lesion in Left Anterior Descending (LAD) artery was
planned for staging PCI. In the follow up examination, the patient was found to have mod-
erate PAD with partial-severe obstruction of the abdominal aorta.
Keywords: transradial primary percutaneous coronary intervention † STelevation myo-
cardial infarction † peripheral artery disease † abdominal aorta obstruction
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Acute coronary syndrome with ventricular storm
K. Elka2, E. Tanoto2, B. Budiono 1, A. L. Panda2, and J. A. Pangemanan 2
1
Cardiology department, Awalbros Hospital Makassar, Indonesia, 2Department of Cardi-
ology and Vascular Medicine, Faculty of Medicine Sam Ratulangi University, BLU RSUP
Prof.Dr.R.D.Kandou, Manado, Indonesia
Case presentation: We report a 43 year old woman, with stabbing retrosternal chest pain
radiating from upper abdominal quadrant, related to physical effort, and palpitation,
begun 1 week previously. No history of hypertension, dyslipidemia, diabetes mellitus
and no family history of cardiac disease and sudden death.
On physical examination, blood pressure 130/110 mmHg, heart rate 160-170 bpm, irregu-
lar, respiration rate 34 bpm. The first and second heart sound were irregular without any
audible murmur, rubs or gallops. Routine blood test is normal, elevated troponin T,
reduced potassium (3,2 mmol/L), normal FT4. The ECG, atrial flutter-fibrillation 175 bpm,
T inverted II, III, aVF, V1-V6. She diagnosed non STelevation myocard infarct with complica-
tion arrhythmia cordis, received antiplatelet and heparin, betablocker. The patient was
transferred tothe intensive care unit where she was started on IVamiodarone and potassium.
During treatment, she became increasingly chest pain and palpitation. An bedside ECG
monitoring revealed brady-tachy arrhythmia; ventricular tachycardia, torsade pointes,
supraventricular tachycardia, atrial fibrillasi-flutter with rapid ventricular response,
asystole. If she had ventricular tachycardia with pulse, we treated with cardioversion.
When she had torsade pointes, we started IV magnesium (magnesium level not deter-
mined). If she had pulseless ventricular tachycardia or asystole, we did resuscitation.
Her vital signs not stable.
Coronary angiography showed non significant lesion. Echocardiography result ejection
fraction 56%, hypokinetic anterior wall, diastolic dysfunction. It returned sinus after 24
hours. Potassium level 3,9 mmol/L (3 days correction). After 4 days, she was discharged
on oral amiodarone and close follow-up with cardiologist.
Conclusion: Arrhythmia is common complication in patients with NSTEMI. But, angiog-
raphy showed non significant lesion. As third definition myocard infarct type 1, patient
may have underlying severe CAD but, on occasion (5 to 20%), non-obstructive or no
CAD may be found at angiography, particularly in women approximately 20% women
has normal angiography.
Cardio-cerebral infaction: A rare case of concomitant acute right ventricular
infarction and ischemic stroke
K. Marwali1,2, H. Pratama 2, Y.M.T. Siahaan 1,2, and S. Ng1,2
1
Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia, 2Siloam General
Hospital, Tangerang, Indonesia
Background: Acute myocardial infarction followed by ischemic strokes in no time are
rare. The relation between ischemic strokes and acute right ventricular infarction
have been rarely discussed. This report aims to highlight the necessity of further research
for the ideal management of such event.
diating to back since one hour ago and suddenly went unresponsive and monitor ECG
showing VT. Resusitation effort was managed sucessfully. However, we found her to be paral-
yzed left sided and hemodynamically unstable with BP 60/40, HR 45x/mnt with the rhythm
of total AV block.12leads ECGshowed STelevation in II, III, aVF. No rales or mumurwas found.
We confirmed she had a right ventricular infarct (STelevation in V3R dan V4R). She was given
normal saline and dopamine awaiting CTscan head which reveal no hemorrhage. We decided
to persue fibrinolysis as revascularization method by using Ateplase.
Results: Rescue PCI planned after failed fibrinolysis. Angiography showed total oclusion
in mid RCA and 80% stenosis from proximal to mid LAD. One BMS was planted without
residual stenosis, TIMI 3 flow. TPM was positioned at RV apex with threshold 0.8 mA,
B54
output 3 mA, pacing rate 60, sensitivity 1 mV. Unfortunately despite successful re-
vascularization patient had acute right heart failure leading to refractory shock on day
two hospitalisation.
Conclusion: The current treatment of right myocardial infarction include optimization of
RVand LV preload with intravenous fluids, maintenance of atrioventricular synchrony, ad-
ministration of inotropic agents, and revascularization. This case was so complicated
that lead to an unfavorable prognosis as it comprised two pathologies. Alteplase could
be beneficial for concomitant acute myocardial infarction and acute ischemic stroke
should be studied further.
Keywords: cardio-cerebral infarction † right ventricular infarction † ischemic stroke
Typical ECG pattern of acute pulmonary embolism in a 45 years old dyspneic and
chest pain male patient: A case report
M.R. Hendiperdana
Emergency Physician at Meilia Hospital Cibubur, Depok, West Java
Introduction: Acute massive pulmonary embolism (PE) that culminate in circulatory col-
lapse have significant diagnostic challenge. None of fast non-invasive assessment which
specific for acute pulmonary embolism. Electrocardiographic (ECG) characteristic can
become important clue for PE. Sinus tachycardias, ST-segment, and T-wave changes in
the right precordial leads (right heart strain), S1 S2 S3 pattern, and right bundle branch
block are the most frequent ECG abnormalities.
Case report: A 45 years old male came to ED with severe dyspnea and chest pain that com-
mence in 7 days before admission and increase in intensity at admission day. Patient was
somnolence, response to pain stimuli, with blood pressure 80/60 mmHg, heart rate
128 bpm regular, and respiratory rate 35. Patient has no ronchi either wheezing on
lung auscultation. Heart auscultation reveal accentuation of P2 heart sound. Clammy
and cold acral. Patient has severe arterial hypoxemia (PO2 ¼ 35.7 mmHg), increase
cardiac troponin-T marker (361 ng/L), and 12-lead ECG show sinus tachycardia, new-
onset right bundle branch block, RV strain pattern with S1,S2,S3 pattern. Patient diag-
nosed as suspect acute massive pulmonary embolism with differential diagnosis was
acute myocardial infarction with left ventricular dysfunction.
Discussion: Diagnostic approach in acute PE patient quite difficult for rapid assessment
and clinical decision because none of the rapid assessment which specific for PE. One of
the non-invasive investigation is 12-lead ECG. Various ECG characteristic that afforo
mentioned can become clues for clinician to diagnose toward acute PE. Patient with clin-
ical condition and ECG characteristic consistent with acute PE accompanied by hemo-
dynamic compromise have strong reason for undergo intravenous thrombolytic therapy
for patient’s life saving.
Conclusion: Although ECG characteristic has no specific value for acute PE diagnosis,
somehow in emergency setting where rapid clinical decision should take place, it can
be some practical and rapid clues for considering clinical decision.
Persistent high degree AV block after early invasive strategy in acute decompen-
sated heart failure caused by NSTEMI: A case report
N.M.A.W. Sari 1 and J.R. Artha 2
1
Faculty of Medicine, Udayana University, Denpasar, Bali, 2Department of Cardiology and
Vascular Medicine, Sanglah Hospital, Denpasar, Bali
Background: Atrioventricular conduction disturbances are well-known complications of
acute coronary syndrome. Although high-degree AV block were infrequent complications
of NSTEMI, they were associated with substantial short-term mortality.
Case description: We report the case of a 68 year old male who presented with Acute De-
compensated Heart Failure caused by NSTEMI. Patient had previous history of a suddenly
shortness of breath 2 hour before admission. Previous medical history with DM type II
more than 10 years. The Electrocardiogram (ECG) showed High Degree AV block with
infero-anterolateral ischaemia. The cardiac enzyme showed elevated. This patient at
high risk, he need early invasive strategy within 24 hours. Temporary Pace Maker was
inserted and Coronary angiography showed 85% stenosis at mid-distal LAD, 90% stenosis
at mid LCx and 70-90% stenosis at proximal RCA, total occlusion at mid RCA. One stent
DES at mid-distal RCA overlapping with 1 stent DES at proximal-mid RCA was inserted
with final angiography showed TIMI grade 3 flow. One week after procedure, ECG still
showed High Degree AV block, patient underwent to insert Dual Chamber Permanent
Pace Maker and continued the medication of acute coronary syndrome.
Conclusion: The AV node has extensive autonomic innervation and abundant blood supply
from the large AV nodal artery, a branch of the RCA in 90% cases, and also 10% from septal
branches of the LAD coronary artery. Culprit lesion usually the first choice in most patient
with multivessel disease. Temporary pacing indicated for symptomatic life-threatening
bradycardia, or, rarely, in acute settings such as acute myocardial infarction not resolving
after successful reperfusion and after medical treatment in the presence of high-degree AV
block and if the indications for permanent pacing are established, every effort should be
made to implant a permanent pacemaker as soon as possible.
Keywords: High degree AV block † NSTEMI † Pace Maker
Adult patent ductus arteriosus complicated by pulmonary artery endarteritis and
pneumonia
P.K Wulandari 1 and K.B Nadha2
1
Department of Cardiology and Vascular, Faculty of Medicine, Udayana University, Bali,
Indonesia, 2Sanglah Hospital, Bali, Indonesia
Abstracts
Background: The incidence of infective arteritis associated with PDA has decreased
dramatically since the early natural history studies before the era of routine surgical
closure and use of antibiotics, when the incidence of infective arteritis was reported
to be 1% per year.
Case description: A 17 years old woman was admitted to the hospital with a febrile sen-
sation, cough and dyspnea. One months ago, she was diagnosed as having a heart problem
and suspicious pneumonia. So, the patient was treated empirically with antibiotics at
another hospital. On physical examination, the blood pressure was 120/70mmHg, the
heart rate was 112 beats/min and regular, and the body temerature was 38,40C. There
were grade 3/6 continuous murmur at left parasternal border and grade 3/6 systolic
murmur at apex with a rhonchi at the base of the right and left lung. Laboratory investi-
gations revealed a normocystic, normochromic anemia (Hemoglobin 10.1 g/dL). The
white cell count and C-reactive protein and erythrocyte sedimentation rate were
9,4x103/mL, 38 mg/dL and 76 mm/h, respectively. Chest x-ray demonstrated cardio-
megaly (CTR 0,58) and a consolidation at the right and left lung. Blood cultures were
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negative. Transthoracic echocardiography (TTE) demonstrated the presence of PDA
with a left to right shunt, a 1,2 x1 cm hypoechogenic movable vegetation attached to
the wall of the main pulmonary artery, mitral regurgitation, LA and LV dilatation. The
patient received antibiotics for 4 weeks then she underwent a new TTE in which the vege-
tation has diminished and subsequently planned for percutaneous clossure of the PDA.
Discussion: The physiological impact and clinical significance of the PDA depend largely
on its size and the underlying cardiovascular status of the patient. The diagnosis of PDA
using TTE now has reached sensitivity 98 % and specificity of 100%. Infective endarteritis
can be diagnosed by clinical features, bacteremia confirmed by blood culture and echo-
cardiography. In patients with infective endarteritis, antibiotics are usually administered
intravenously for two-six weeks.
Conclussion: The patient suffered from complication associated with PDA in which TTE
has demonstrated its presence. Antibiotic therapy was considered succesfull (the vege-
tation has diminished) and the patient subsequently planned for percutaneous clossure of
the PDA.
Routine thrombus aspiration in primary percutaneous coronary intervention:
Is it still necessary? (Case Report)
R. Pranata 1, V. Pratama 2, I. Purnawan 2, E. Hindoro1, and G. Fonda1
1
Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia, 2Departement of
Cardiology and Vascular Medicine, Indonesia Army Central Hospital Gatot Soebroto,
Jakarta, Indonesia
Background: Aspiration thrombectomy has been a modality routinely done during
primary PCI, based on TAPAS trial (n ¼ 1071) which stated one year cardiac mortality
reduced from 6.7% to 3.6%. TASTE Trial (n ¼ 7244) and TOTAL trial (n ¼ 10,732) showed
no differences between 2 treatment groups. Thrombectomy was associated with
increased risk of stroke by twofold.
Case description: We present two interesting cases. 71 years-old male with Anterior
STEMI, onset 6 hours before admission. Coronary angiography showed total occlusion in
proximal LAD, with thrombus (TIMI 0). Significant stenosis in LM, proximal LCx and
RCA. Thrombus aspiration and primary PCI in LAD was done (TIMI 3). Echocardiography
data N/A. Second case is 54 years-old male with Acute inferior STEMI, onset 2 hours
before admission. Coronary angiography showed total occlusion in RCA (TIMI 0). Signifi-
cant stenosis in LAD and LCx. Primary PCI of RCA was done (TIMI 3). PCI in LAD was done
due to hemodynamic instability (TIMI 3), echocardiography: LVEF 66% and RWMA. Both
were clinically and hemodynamically stable after procedure and in 30 days follow up,
there was neither recurrent MI, stent thrombosis nor stroke. Second case was scheduled
for PCI of LCx 6 months later.
Discussion: Both presented with STEMI. Primary PCI and aspiration thrombectomy
was done in first case. Primary PCI without thrombectomy was done in second case.
Both were clinically and hemodynamically stable after procedure and in 30 days follow
up. There is no incident of stroke, which risk is increased. TASTE and TOTAL trial demon-
strated no benefit in performing thrombectomy before primary PCI, with addition of
unnecessary increase in stroke risk. 2015 ACC/AHA/SCAI Focused Update on Primary
PCI stated that routine aspiration thrombectomy before primary PCI is not useful
(Class III, LOE: A).
Conclusion: Interventional cardiology is a rapidly evolving field; there has been a shift in
dogma regarding interventional management of STEMI as new evidence against perform-
ing aspiration thrombectomy surfaced.
Keywords: Thrombectomy † Thrombus † Aspiration † STEM I † PCI
Curable severe tachycardiomyopathy due to typical atrial flutter by
radiofrequency catheter ablation
R.M. Munandar, D. Friadi, B. Hartono, and M. Munawar
Binawaluya Cardiac Center, Jakarta, Indonesia
Background: Tachycardiomyopathy with low pre-ablation LV-EF (20% or less) is a negative
predictor for post ablation resolution. We describe a rare case of patient with low pre-
abalation LV-EF (9%) with very rapid and significant improvement of LV-EF post atrial
flutter ablation and normalization of heart failure symptoms.
Case description: A 50-years old male patient was referred to our hospital for further
management of severe heart failure. ECG showed a typical human type I atrial flutter
with heart rate of 130 bpm. Transthoracic echocardiography (TTE) showed dilated left
atrium, large left ventricular dimension with very low LV-EF. Coronary multi-sliced CT
Abstracts
showed non-significant stenosis of the proximal of LAD and no scar tissue was detected.
The patient was diagnosed as having cardiomyopathy with typical human atrial flutter
and received aggressive medical treatment. His condition worsened with elevated
blood ureum and creatinine level and he underwent continuous veno-venous haemodi-
alysis procedure. After his condition improved, radiofrequency ablation was performed
by conventional method and atrial flutter was converted into sinus rhythm. His heart fail-
ure’s symptoms improved significantly, and in 6-month follow up he has remained ex-
tremely well with no symptoms.
Discussion: Tachycardiomyopathy induced by atrial flutter has been rarely reported.
Most of tachycardiomyopathy case due to atrial flutter caused moderate LV dysfunction
(left ventricular ejection fraction/LV-EF around 30 to 40%). Successful radiofrequency
catheter ablation (RFCA) of atrial flutter with aggressive medical treatment entailed
resolution of heart failure symptoms and normalization of LV function.
Conclusion: RFCA and aggressive medical treatment may be the first line therapy in
patients with tachycardiomyopathy due to typical atrial flutter.
Sinus node dysfunction in right heart failure: A rare case
R. Wiguna1, K. Marwali1, S. Ng1, and D. A. Hanafy2
1
Faculty of Medicine, University Pelita Harapan, 2Department of Cardiology and Vascular
Medicine, University of Indonesia
Background: Right heart failure symptoms accompanying with sick sinus syndrome is
rarely found. Nevertheless, atrial fibrosis can occur in a patient with chronic heart
failure. Aim of this case is to present a rare case with right heart failure accompanied
by sinus node dysfunction suggested due to atrial fibrosis.
Case description: A 55 years old male was admitted to outpatient department presented
with fatigue, feeling full and bloated, swelling of the abdomen, and one episode of
near fainting, for 4 months prior to admission. Patient was hemodynamically stable
with blood pressure 110/70 mmHg, pulse 46 times per minute regular, thorax ex-
amination was unremarkable, with distended jugular vein, ascites, and bilateral legs
edema. ECG showed junctional rhythm at rate 30-40 bpm and intermittently right
bundle branch block at rate 80 bpm. Echocardiography showed dilation of RA and LA
with moderate TR. Pulmonary CTangiography revealed filling defect at right lower ante-
robasal, left lower posterobasal, and left upper subsegmental segment branch. Patient
was diagnosed with CTEPH. Dual chamber pacemaker implantation was scheduled.
During the procedure, pacemaker implantation at apex RV was successful with threshold
output 0.8 mA, R-wave sensing at 5-6 mV. However, no P wave signal was found at RA.
VVIR was implanted instead of dual chamber pacemaker. Patient was discharged after
4 days of hospitalization with improved clinical presentation.
Conclussion: We present a case with right heart failure, which is suspected due to CTEPH.
Interestingly, this condition was accompanied by sinus node dysfunction due toatrial fibrosis.
Keywords: right heart failure † chronic thromboembolic pulmonary hypertension †
atrial fibrosis † sick sinus syndrome
Lipomatous hypertrophy of the interatrial expanding into left atrial appendage
mimicking thrombus: A very rare case report
S. Erriyanti, R. M. Munandar, D. Friadi, and M. Munawar
Binawaluya Cardiac Center, Jakarta, Indonesia
Lipomatous hypertrophy of the interatrial septum (LHIS) is rare, but expanding into the
left atrial appendage (LAA) is even rarer. We therefore, reported the case. To the best of
our knowledge, this is the first report of LHIS in Indonesia. A 77-years old male patient
with atrial fibrillation and CHA2DS2-VASc and HAS-BLED score were 5 and 4. He therefore,
was admitted for stroke prevention using LAA closure procedure. Transesophageal echo-
cardiography (TEE) was done during procedure and revealed a mass mimicking thrombus
in LAA that spreading to around LCx artery. There was a dumbbell-shaped hypertrophy of
7.1 mm thickness in the interatrial septum. For further evaluation, the procedure was
discontinued. On multi-slice computed tomography, confirmed that the lipomatous
area spreading into LAA wall.
Conservative approach for patient in acute heart failure with cor triatriatum
dexter and atrial fibrillation: A rare case report
S.M. Winata and R. Rasmin
Budhi Asih General Hospital, Jakarta, Indonesia
Background: Cor triatriatum dexter (CTD) is an very rare congenital cardiac anomaly in
which right atrium (RA) is divided into 2 chambers by a membrane. This congenital abnor-
mality is commonly associated with other right-sided cardiac abnormalities. In this
report, we describe a patient presenting with acute heart failure precipitated by atrial
fibrillation (AF) which was caused by CTD.
Case report: A 33-year-old man was admitted to emergency room with acute-onset
dyspnea and chest pain. He was presented with jugular vein distension with respiratory
rate 36/minute and 96% percutaneous oxygen saturation in air. Auscultation of the chest
revealed bilateral fine crepitations on lung bases. Other physical examination results
were between normal limit. A 12-lead electrocardiogram (ECG) showed irregular
rhythm consistent with atrial fibrillation with a ventricular rate of 80, no ST segment or
T wave changes. Chest X-ray showed cardiomegaly. An initial transthoracic echocardio-
gram showed a membrane partitioned the right atrium into two chambers consisted
with CTD. The left ventricular function was normal and no abnormalities detected on
B55
the cardiac valve with no turbulent flow detected using the Doppler method. Medical
treatment using intravenous diuretics, anticoagulation treatment and beta-blocker
showed a significant improvement in patient’s condition. The patient was discharged
with beta-blocker and anticoagulation treatment. No complications detected during
outpatient clinic follow up, eventhough the ECG still showed atrial fibrillation. The
patient refused to have further evaluation and management of his heart rhythm.
Discussion: Clinical manifestation in patients with CTD are variable from asymptomatic
and often detected incidentally during echocardiography or surgery to correct other
cardiac abnormalities. This condition can lead to trapped catheters, supraventricular
arrhythmias (such as AF), or embolisms. Symptomatic patient with significant obstruction
should have a surgical resection. In this patient, beta blocker and anticoagulant given with
short course of parenteral diuretic eliminated the symptoms and shared a good results of
the follow-up without any complication detected. Although we found that the AF asso-
ciated with CTD had a tendention to be persistent or permanent, our further evaluation
and treatment could not be done because of patient preferences.
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Conclusion: Although CTD isextremely rare, it can be presented in a young patientwith right-
sided heart failure. It can be easily corrected by surgical excision of the membrane if indi-
cated. Eventhough excision of an abnormal membranous septum could eliminate AF, our
patient outcome for months was still good with beta blocker and anticoagulation treatment.
Acute rheumatic fever in juvenile complicated by complete heart block:
A case report
T.U. Utami and D.A. Sinaga
Awal Bros Hospital, Pekanbaru
Objective: to present a case of acute rheumatic fever in juvenile, complicated by com-
plete heart block, improved with medical therapy alone.
Case description: Reporting a case of a 14 year-old boy (body weight 56 kg) with syncope
and total atrio-ventricular block (TAVB). He had been feverish (temperature 37-39 C) and
breathless for the last 5 days with sore throat and productive phlegm. The patient had
malaise with migrating swollen joints, accompanied with diffuse petechial skin rashes.
He was referred to our center for transvenous pacing; indicated by TAVB with heart rate
of 43 bpm and syncope despite preserved blood pressure (103/68 mmHg).
Physical examination revealed hyperemic pharynx, normal heart sound, without any
obvious skin rash. Electrocardiogram showed complete heart block with atrial rate
72 x/min, ventricular rate of 43 x/min, and left ventricular hypertrophy. By echocardiog-
raphy examination, his left ventricular was slightly enlarged (LVEDD 46 mm) with normal
ejection fraction, without any significant valve abnormality.
Dopamine infusion was commenced in our emergency department, and intravenous at-
ropine sulphate 0.5 mg was administered twice, resulting in improvement of the heart
rate to 80 bpm with blood pressure of 135/88 mmHg. Hence, the transvenous pacing in-
sertion was suspended. Inotrope was dropped in less than 24 hours.
Laboratory test revealed leukocytosis, highly positive anti-streptolysin O titer 1200 IU/mL,
CRP level 46.5 mg/L. As such, the patient was diagnosed with acuterheumatic fever (positive
2 major and 4 minor Jones criteria).
The following management included ceftriaxone injection and oral methylpredniso-
lone 2 mg/kgBW tapered down after 2 weeks. Initial intramuscular penicillin 1.2 million
unit injection was given during hospitalization.
Subsequently he was haemodynamically stable, despite remaining first degree AV
block (PR interval 240 msec), and discharged at day-7 uneventfully.
Conclusion: Involvement of the heart electrical conduction in acute rheumatic fever
could be detrimental, and requires prompt management. Transvenous pacing in unstable
haemodynamic is compulsory, however, initial medical therapy with atropine sulphate
and dopamine should be attempted and proved to be effective in particular patients.
Proper antibiotic and steroid to manage the infection and inflammation were the definite
management, while secondary prevention should be conducted appropriately.
Keywords: Acute rheumatic fever † TAVB
A nineteen years old young woman with idiopathic hypertrophic subaortic
stenosis: A case report
T. F. Atsari, A. Siregar, N.Z. Akbar, and Z. Mukhtar
Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of
Sumatera Utara/Haji Adam Malik Hospital, Medan, Indonesia
Background: IHSS, the most common of the genetic cardiovascular diseases is caused by a
multitude of mutations in genes encoding proteins of the cardiac sarcomere. Prevalence
of the IHSS in the general population of approximately 0.2%, for a frequency of 1 in
500 people, equivalent to approximately 700,000 affected persons in the United States
Initially, several names were promoted to describe this disease entity, idiopathic hyper-
trophic subaortic stenosis in the U.S, muscular subaortic stenosis in Canada. Indeed,
hypertrophic cardiomyopathy predominates as the formal name for this disease.
B56
Case description: We report a case of an Indonesian young woman with symptoms of
breathlessness and chest pain. Physical examination showed the ejection systolic
murmur grade 3/6 on the mid-left sternal border and pansystolic murmur grade 3/6
on the apex. The ECG showed sinus rhytm and ischemic in anterior with right bundle
branch block. The CXR showed cardiomegaly. Transthoracal Echocardiography demon-
strate thickening of ventricular wall septum with thickness 19 mm and Systolic Anterior
Motion (SAM) of the mitral valve. The patient treated with Verapamil, Furosemide, and
Spironolactone. She was suggested to performed echocardiography 6 months later for
evaluation.
Conclusion: In symptomatic IHSS patients with LVOTO (Left Ventricular Tract Outflow Ob-
struction), the aim is to improve symptoms by using drugs, surgery, alcohol ablation or
pacing. Therapy in symptomatic patients without LVOTO focuses on management of ar-
rhythmia, reduction of LV filling pressures, and treatment of angina.
Keywords: IHSS † HCM † Hypertrophic Cardiomyopathy
Recurrent acute coronary syndrome – a manifestation of clopidogrel resistance:
A case report
U. Bahrudin, Y. Budi, F. Ahnaf, M.A. Nugroho, Y. Herry, and S. Rifqi
Department of Cardiology and Vascular Medicine, Diponegoro University Faculty of
Medicine – Dr. Kariadi General Hospital, Semarang, Indonesia
Background: Clopidogrel resistance is a condition in which the occurrence of occlusive
cardiovascular disease events despite regular intake of this agent at recommended
doses. Although evidence of clopidogrel resistance has been reported for a long time,
the diagnosis and management of the patients is not routinely performed in daily
practice.
Case presentation: A-43-year-old woman presented to the emergency department
with 1.5-hours typical chest pain, had cardiovascular risk factors diabetes and dyslipide-
mia, history of recurrent hospitalization 3 times during the last 3 months due to acute cor-
onary simdrom (ACS), and received a drug-eluting stent in 20 days before this admission as
well as taking both clopidogrel and aspirin routinely. Dual antiplatelet and intravenous
anticoagulant were administrated to the patient. The patient experienced recurrent
chest pain on the 4th day of hospitalization. Coronary angiography showed in-stent throm-
bosis and restenosis. Genetic testing for CYP2C19 showed *2/*2 poor metabolizer to
clopidogrel.
Conclusion: We describe a rare recurrent ACS accompanied by a clopidogrel resistance.
It is important to keep in mind that recurrent ACS could be a manifestation of a resistance
to clopidogrel.
Keywords: recurrent acute coronary syndrome † clopidogrel resistance
Subarterial doubly committed ventricular septal defect complicated with
right-sided fungal infective endocarditis
V. Tedjamulia, V. Kartika Yanthie, and E. Gunawijaya
Department of Pediatrics, Medical Faculty of Udayana University, Sanglah Hospital,
Denpasar, Indonesia
Background: The population of children with congenital heart disease (CHD) is expand-
ing, and this is the major substrate for IE in younger patients. The reported incidence of IE
in CHD is 15 – 140 times higher than that in the general population.
Case report: Male 5 years old, referred from Mataram, came to Sanglah hospital, Denpa-
sar for trans-catheter VSD closure. Patient complaint shortness of breath that was accom-
panied with dry cough since 6 months prior to admission. Patient also experienced mild
fever and weight loss since 2 months ago. Two months ago, at Mataram hospital,
patient was diagnosed with ventricular septal defect (VSD) and got blood transfusion.
He underwent TTE and showed large subarterial doubly committed (SADC) VSD and vege-
tation at right ventricular outflow tract (RVOT) and pulmonary valve. Based on echocar-
diography, patient underwent blood culture to find microorganism that caused the
vegetation and the result revealed that Candida guilliermondii as significant causes for
infection. After four weeks of anti-fungal therapy using fluconazole 12mg/kgBW, the
third echocardiography showed no significant changes in vegetation size although
there was significant improvement on the patient’s clinical appearances. Surgery
would be planned afterwards for VSD evaluation, VSD closure, and vegetation excision
at RVOT and pulmonary valve.
Conclusion: This is a rare case of SADC VSD complicated with right-sided fungal endocar-
ditis which usually have poor prognosis with more than 50% mortality rate. Proper man-
agement with both anti-fungal and anti-failure is needed for better outcomes. Surgery
treatment must be individualized each case judging from therapy response and all
other factors associated with increased risk.
Keywords: Ventricular septal defect † infective endocarditis † fungal infection
Abstracts
Case report: The hemodynamic effect of non invasive ventilation in atrial septal
defect with severe pulmonary hypertension and respiratory failure
Vitryaturida1, A. Widya1, and S. Anjarwani2
1
Department of Cardiology and Vascular Medicine – Faculty of Medicine Brawijaya Uni-
versity – Dr Saiful Anwar General Hospital, Malang, Indonesia, 2Department of Cardiology
and Vascular Medicine – Faculty of Medicine Brawijaya University – Dr Saiful Anwar
General Hospital, Malang, Indonesia
Background: The most common acyanotic congential anomaly in adults is Atrial septal
defect (ASD) with high prevalence in females. ASD causes shunting of blood from left
to right causing right ventricular volume overload, hypertrophy and pulmonary hyperten-
sion. Pulmonary hypertension may be encountered in the intensive care unit in patients
with critical illnesses such as respiratory failure. The hemodynamic effects of non-
invasive ventilation with positive pressure in patients with pulmonary arterial hyperten-
sion associated with Atrial Septal Defect are not clearly established.
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Case description: A woman 32 yo come with severe dyspnea, palpitation and leg swel-
ling. Physical examination showed tachypnea, increased of JVP, fixed split of S2, gallop
and parasternal heaves. Blood gas analysis showed Hypoxemia respiratory failure.
Doppler Echocardiography showed Atrial septal defect secundum 5 mm with right to
left dominantly, TR severe (TVG 117 mmHg), PR moderate, PH severe (PASP 127
mmHG), dilatation of RV with decreased of function (TAPSE 0.9 cm), PCWP 22 mmHg
and systolic function still normal (EF 65). Persistent tachypnea and hypoxemia was
noted which prompted iniation of Non-Invasive ventilation with bi-level positive
airway pressure. The resulted is symptomatic improvement and hemodynamic param-
eter (RV systolic function) with Doppler echocardiography.
Discussion: The acute effects of noninvasive ventilation in patients with extreme pulmon-
ary hypertension are not well described. In respiratory failure, minimized positive
end-expiratory pressure can reduce PVR by increasing oxygenation above 60 mm Hg to al-
leviate hypoxic pulmonary vasoconstriction (HPV). With respect to the respiratory system,
its application has as main physiological benefits the decrease in respiratory work and
improve an oxygenation. Therefore another strategy for improving right ventricular systol-
ic function is to reduce pulmonary vascular resistance, thereby decreasing RV afterload.
Keywords: Atrial Septal Defect † Pulmonary Hypertension † Respiratory failure †
Non Invasive Ventilation
Echocardiography-guided percutaneus transvenous mitral commissurotomy in a
pregnant woman with severe mitral stenosis
W. Sakulat1,2 and B. Baktijasa1,2
1
Department of Cardiology and Vascular Medicine Faculty of Medicine, Airlangga
University, Surabaya, Indonesia, 2Dr. Soetomo General Hospital, Surabaya, Indonesia
Background: Mitral stenosis is the most commonly encountered valvular lesion in preg-
nancy and in almost all cases caused by rheumatic heart disease. It can leads significant
maternal and fetal morbidity and mortality, since the hemodynamic adaptations to preg-
nancy are badly tolerated. Percutaneous Transvenous Mitral Commissurotomy (PTMC) is
an alternative to surgery and should consider to treat patients with mitral stenosis who
remain symptomatic despite adequate medical therapy. Although the transseptal punc-
ture during PTMC can be performed primarily by fluoroscopic guidance, echocardiog-
raphy imaging can be useful, improving visualization of the contiguous structures and
mainly avoiding aortic puncture.
Case description: Report a case of a patient 29-year-old female with severe RHD MS +
severe pulmonary hypertension + NYHA III + G2P1001 22 weeks of gestation underwent
Echocardiography-Guided PTMC. The procedure was performed successfully, patient
showed clinical improvement, valve gradient decreased 72.9% from 19.65 mmHg to
5.31 mmHg, mitral valve area had a significant increase from 0.7 to 1.28 cm2, no major
complications and shorter duration of flouroscopy time.
Keywords: mitral stenosis † mitral commissurotomy † pregnancy
The correlation between endothelial function parameter flow mediated vaso-
dilatation with the complexity of coronary artery disease based on Syntax Score
W. Sakulat1,2 and B.S. Pikir1,2
1
Faculty of Medicine, Airlangga University, Surabaya, Indonesia, 2Dr. Soetomo General
Hospital, Surabaya, Indonesia
Background: Coronary artery disease is characterized by atherosclerosis in the epicar-
dial coronary arteries. The key early events in the atherosclerotic process is endothelial
dysfunction that precedes atherosclerotic lesion development and progression. A great
amount of evidences exists about the association between traditional risk factors for car-
diovascular disease and endothelial dysfunction. Noninvasive assessment of endothelial
function is commonly undertaken using the flow mediated dilation (FMD) technique.
Some studies indicate that FMD possesses independent prognostic value to predict
future cardiovascular events that may exceed that associated with traditional risk
factor assessment. The use of FMD as a surrogate indicator for the complexity of coronary
artery disease remains largely unknown The aim of this study is to determine the correl-
ation between flow mediated vasodilatation (FMD) with the complexity of coronary
artery disease based on SYNTAX score.
Abstracts
Methods: Analytical observational, cross-sectional study enrolling 40 patients con-
secutively admitted to cardiology department Dr. Soetomo general hospital over
3 months and undergoing coronary angiography. The SYNTAX score, an angiographic
tool grading the complexity of CAD taking into account the number, position, and ana-
tomical characteristics of coronary lesions was calculated. Endothelial function was
evaluated by flow-mediated dilatation using brachial artery Doppler ultrasonography
(USG). Correlation between brachial FMD and Syntax score was evaluated using
Pearson correlation test.
Result: There was a strong negative correlation and significant correlation between FMD
and SYNTAX score (r ¼ 20.787 and p , 0.0001).
Conclusion: There is a strong negative correlation between endothelial function param-
eter flow mediated vasodilatation (FMD) with the complexity of coronary artery disease
based on Syntax score.
Keywords: endothelial dysfunction † FMD † complexity of CAD † SYNTAX score
Ruptured sinuses of valsalva aneurysms: Report of five cases
Y.B. Hartanto, E. Fredigusta, R. Putra, Ign. F. Yuwono, K. Rizky, U. Bahrudin,
M. A. Nugroho, and Y. Herry
Department of Cardiology and Vascular Medicine, Diponegoro University Faculty of
Medicine - Dr. Kariadi General Hospital Semarang, Indonesia
Background: Aneurysms of sinus of Valsalva are rare cardiac abnormalities with congenital
origin in most of the cases. Sometimes they coexist with other congenital heart diseases
and often rupture into the heart chambers causing clinical syndrome. Here, we present
reports of five cases of ruptured sinuses of Valsava aneurysms treated at our institution.
Methods: We observed retrospectively a series of five cases of ruptured sinuses of
Valsalva aneurysms at the Department of Cardiology and Vascular Medicine, Dr.Kariadi
Hospital, Semarang, Indonesia from January 2013 to December 2015. Data about clinical
presentation, diagnostic procedures, and operation report were obtained from medical
record. Post operative follow-up were made by phone or hospital registries.
Results: The age of the five patients was range from 17-46 years old with three of them
are male. Aneurysms originated from the right coronary sinus in four patients, and non-
coronary sinus in one. Four aneurysms fistulized to the right ventricle and one to the right
atrium. There were subaortic ventricular septal defect in all cases with two aortic regur-
gitation, and one patent foramen ovale concomitant lesions. All cases were treated sur-
gically. One patient died during perioperative period, one patient had rehospitalization
due to haemopericardium, and three patients has been return to work without history of
reoperation or rehospitalization.
B57
Conclusion: From our five cases with various clinical presentation, there are one case of
perioperative death and one case of rehospitalization within one month postoperative
period. Three patients report no rehospitalization with improvement of functional
status beyond 3 month postoperative.
Keywords: Aneurysm of sinus of valsalva † rupture † congenital heart defect
Paracetamol as alternative for patent ductus arteriosus (PDA) management
Yulianto 1, T.W. Hendarto2, S. Lusyati2, and I. Sakidjan 1
1
Department of Cardiology and Vascular, Faculty of Medicine of University of Indonesia,
2
Department of Pediatrics, Faculty of Medicine of University of Indonesia, Women and
Child Harapan Kita Hospital
Background: Prevalence of PDA is about 5-10% of congenital heart disease. PDA usually
occurs in preterm neonates, especially those with lower birth weight. Naturally, PDA
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can close without intervention, but in some cases, it needs intervention with drug,
device, or surgery. Medical treatment is given when there are signs and symptoms
of hemodynamically significant PDA (hs PDA). Indomethacin is a common drug for
PDA with known adverse effects such as necrotizing enterocolitis and intracranial
hemorrhage.
Alternative treatment for closing PDA was considered. Ibuprofen has been used in pre-
mature neonates with PDA. However, it is expensive and not always available, and some
studies have shown that some patients get adverse effects such as NEC and acute kidney
injury. Paracetamol was initially suspected toxic for liver, but further studies have shown
that it is safe. Therefore, paracetamol is considered promising.
Case presentation: We report two serial cases where paracetamol was used in PDA man-
agement. In the first case, preterm newborn boy (32 weeks) with lower birth weight
(1167 gram) was diagnosed with moderate PDA (diameter 3.2 mm). On day three, the
baby showed hs PDA and received paracetamol (dose 15 mg/body weight/8 hour). After
three days of treatment, the PDA was closed. In the second case, preterm newborn girl
(34 weeks) with lower birth weight (1360 gram) was diagnosed with small PDA (diameter
2.3-2.5 mm). On day seven, hs PDA was observed and the baby received paracetamol
(dose 20 mg/body weight/6 hours). After five days, evaluation by echocardiography exhib-
ited closed PDA. It was observed that giving paracetamol for PDA management did not show
adverse effect such as abnormality in liver and renal function and increase of bilirubin level.
Conclusion: Paracetamol is alternative treatment for hemodynamically significant PDA,
beside indomethacin and ibuprofen. However, further research is required for its
application in wider use.
Keywords: PDA † paracetamol † management