bluuebunny/crossref_metadata_2025 huggingface dataset:
C15. Biventricular Heart Failure and Pulmonary Hypertension in Systemic Sclerosis: a rare and unusual case report
Authors: Farissa I P , Trisnawan M H , Ahnaf M F , Hellmi R Y
Published: March 2023

Backgrounds

Systemic sclerosis (SSc), chronic multisystem autoimmune disease, characterized by excessive fibrosis and vascular endothelial dysfunction. Cardiovascular involvement may be induced by various pathways, either primary or secondary to pulmonary hypertension or renal involvement.

Case Summary

A 46 years old woman presented to emergency department with cold, dark purplish ulcers in fingertips with progressive worsening pain in upper extremities, claudication intermitten, and dyspneu since 4 months ago. She had a mask-like facial, shiny skin, microstomia, restricted mouth opening, calcinosis cutis, Raynauds phenomenon, and sclerodactyly. There were pansystolic murmur grade III/6 in tricuspid area, and rales in basal lungs. ECG showed sinus rhythm with fragmented QRS, poor R-wave progression. Chest X-Ray revealed pancardiomegaly with pleural effusion and HRCT thorax revealed interstitial lungs disease. The laboratory revealed leucocytosis, increase D-dimer (870 ug/L), negative ANA and ds-DNA test, positive anti SCl test. Echocardiography showed biventricular dysfunction with decreased LVEF 37% (Teichz) and TAPSE 10 mm, RA RV dilatation, severe TR with high probability for PH. Extremities Doppler showed normal arteries and veins system. These findings indicates that primary and secondary cardiac involvement in SSc. Heart failure, pulmonary hypertension, and cyclophosphamide medication were administered

Discussion

Primary cardiac involvement, a direct consequence of SSc, may manifest as fibrosis of the myocardial, conduction system, pericardial and, valvular disease. Furthermore, a secondary phenomenon due to pulmonary arterial hypertension (PAH), and kidney pathology. Though the burden remains low, it may worsen the outcome, consequently, all patients with SSc should undergo screening.
C16. BRASH (Bradycardia, Renal Failure, AV Nodal Blocker, Shock, and Hyperkalemia) Syndrome: Lost in Plain Sight
Authors: Hazzy Fandy , Rohman M Saifur
Published: March 2023

Background

Bradycardia, Renal failure, AV-Nodal blockers, Shock, Hyperkalemia (BRASH) Syndrome new clinical entities due to a vicious cycle in which hyperkalemia from renal failure synergizes with AV-nodal blockers, consequently between the clinical condition of patients with the degree of hyperkalemia and bradycardia are inappropriate, Furthermore, the symptoms may be refractory to typical positive chronotropic interventions or overdose antidotes.

Case Illustration

A hypertensive 70-years old female with history of heart failure with routinely consume spironolactone, diltiazem, and beta blocker admitted with bradycardia and shock after watery diarrhea and vomit 3 days before. The electrocardiogram showed junctional rhythm 40 beats per minutes. Laboratory findings Hyperkalemia (6.8 mEq/L) and acute kidney injury (urea 58.6 mg/dL, creatinine 3.13 mg/dL, eGFR 16.23) was presented. Refractory hyperkalemia occured, but by using pacemaker, providing adequate fluids, and the return of renal perfusion, hyperkalemia can be overcome.

Discussion

BRASH syndrome usually triggered by hypotension in the elderly due to hypovolemia or an overdose of antihypertensive drugs. The natural compensation response for hypotension is to increase heart rate, but AV-nodal blockers blunt this response, which causes a decrease in renal perfusion. This ultimately results in hyperkalemia and accumulation of AV-nodal blockers which produce a synergistic effect causes bradycardia and decreased renal perfusion. Treatment involves supportive care including hemodynamic support with fluids and management of bradycardia, and also avoid trigger factor.
C17. Can we improve the clinical manifestation of superior vena cava syndrome without treat the underlying disease?
Authors: Mappangara Idar , Syamsuddin Deni , Idul Hafiz
Published: March 2023

Background

Superior vena cava syndrome (SVCS) is a clinical manifestations from obstruction of superior vena cava that has thin wall. The main goals of SVCS management are to relieve the symptom and give therapy for the underlying disease. For now, there some additional therapies that connected to this disease such as steroid, diuretic, and anticoagulant. Flavonoid which a derivate from gamma benzopyrone has pharmacodynamics mechanism that appropriate with SVCS.

Case Summary

We reported a male 35 years old came with SVCS typical manifestations. Then, we done some additional examinations, and we establish the diagnose with SVCS et cause anterior mediastinum mass suspected thymoma. The patient was planned to done histology biopsy, but the patient was refused to done any examination or interventions. We already gave diuretic, Vit-K antagonist anticoagulant, and high dose in short period steroid, but there was no any clinical improvement. Then, we add flavonoid hesperidin-diosmin, and there was clinical improvement after 1 months.

Discussion

Based on the management algorithm of SVCS, we should done histology biopsy to this patient to establish the main cause of SVCS, so we can treat the patient by the cause. In literatures about SVCS, there was no any pharmacotherapies that believed can give clinical improvement, including steroid, diuretics, and anticoagulant. Flavonoid that has pharmacodynamics such as anti-inflammation, improve venous tone, increase lymphatic drainage appropriate with the clinical pathomechanism of SVCS. So it may has rational therapeutic effect to this patient.
C28. Chronic Limb Threatening Ischemia in Patient With Aortoiliac Occlusive Disease (Leriche Syndrome) and Pulmonary Hypertension
Authors: Permana E , Suwirya A P , Sutanegara B A
Published: March 2023

Background

Chronic limb-threatening ischemia (CLTI) is a manifestation of peripheral arterial disease (PAD) which is characterized by stenosis or occlusion of peripheral arteries causing impaired perfusion to the extremities, especially during rest and chronic progresses, which are associated with decreased quality of life and increased morbidity and mortality.

Case Description

A 51-year-old man complained of wound on both legs and pain during light activity. Risk factor is smoking for 30 years. History of primary pulmonary hypertension since 30 years. Physical examination revealed decreased pulsation from femoral artery to dorsalis pedis arteries in both leg. Echocardiography with RA and RV dilatation, D-shaped LV during systolic, mild TR and normal LV systolic function. Dupplex ultrasound and MSCT scan pulmonary-abdominal angiography shows thrombus in the abdominal aorta causing occlusion of blood flow distally. There is a comorbid pulmonary hypertension which causes right heart failure with symptoms of dyspnea. This patient is at high risk of undergoing revascularization surgery, so that in severe comorbid conditions an extraanatomical bypass with axillobifemoral bypass graft is considered.

Discussion

Atherosclerosis that occurs in the abdominal aorta, iliac artery, and femoropopliteal artery is called aortoiliac occlusive disease (AIOD). This condition when symptomatic is known as Leriche syndrome with a triad of symptoms of claudication, impotence, and reduced or no palpable pulsation of the femoral artery. Medical management include antiplatelet, statin, analgetic, and therapy according to risk factors. The main purpose is revascularization by surgery or endovascular which aims to improve blood flow to the distal artery.
C29. Chronic Pericardial effusion associated with Cytomegalovirus
Authors: Hutabarat H , Lukito A A , Chandra S , Fernandes R A P
Published: March 2023

Pericardial effusion is one of the most challenging clinical condition to determine the etiologies. A 60 yo woman presented with atypical sign of pericardial effusion. She visited several physicians and without any clinical improvement. Echocardiography revealed 133.5 ml pericardial effusion and pericardial thickness of 12,14 mm. Cardiac MRI was then performed and indicated, thickening of pericardium (4.8-5.1mm) at lateral right atrium, RV free wall and apical RV. The thickened part of the pericardium at apical RV has rigid, immobile appearance. Moderate amount of pericardial effusion prominently located at basal of heart. Pericardial effusion was at superior and lateral right atrium, apical RV and LV, and lateral, inferior, anterior left ventricle. Serology tests Anti CMV IgG reactive, anti CMV IgM non reactive and TB quantiferon negative. These results confirmed the pericarditis associated with CMV infection. The biggest challenge for the clinician is to find out an etiologic diagnosis. The common causes of pericarditis are infection (viral, bacterial), metabolic (renal failure, hypothyroidsism), cancer, myocardial infarction, and post traumatic. Among infectious causes, the enteroviruses, herpesviruses and mycobacterium tuberculosis are the most common causes. Cytomegalovirus belongs to the herpesviruses group. Clinician should be aware about the possible etiologies, as chronic pericarditis is a condition that requires comprehensive and multidisciplinary approaches.
C33. Complex ebstein anomaly in adult patient: a case report
Authors: Ratnasari A B , Fagi R A
Published: March 2023

Background

Ebstein’s anomaly is a rare form of congenital heart disease. In adult often present with arrhythmias, progressive cyanosis, and right heart failure. Management is complex and individualized.

Case Summary

A 24-year-old woman presented to the emergency room with heart failure presentation, palpitations and fainting. ECG examination shows abberant SVT with pulse, hemodinamically was stable with peripheral saturation 94% without oxygen supplementation. The patient then carried out cardioversion and got anti-arrhythmia amiodarone. Resting ECG obtained sinus rhythm right axis deviation with incomplete LBBB (splintered QRS). Echocardiography examination revealed displacement of the tricuspid valve, a large atrialized component of the right ventricle, the anterior leaflet of the tricuspid valve moves freely with bidirectional shunt ASD and moderate pericardial effusion, confirmed for Ebstein's anomaly type B .

Diuresis therapy was given and anti-arrhythmic therapy was continued. Echocardiographic evaluation showed reduced pericardial effusion to a minimum. Patients were scheduled for electrophysiological studies and angiographic evaluation and total corrections were planned.

Discussion

Ebstein anomaly is a characterized by abnormally formed and apically displaced leaflets of Tricuspid caused by is failure of proper delamination of the tricuspid valve, primarily of the septal and anterior leaflets from ventricular myocardium. The cardinal symptoms in Ebstein’s anomaly are cyanosis, right-sided heart failure, arrhythmias, and sudden cardiac death. Surgery is indicated in adults with symptoms of heart failure. Medical therapy is generally used only for temporary stabilization : diuretic therapy for volume overload, control of heart rhythm abnormalities, and standard medical therapy for left ventricular systolic dysfunction.
C37. Device Closure of Perimembranous Ventricle Septal Defect with Zero Fluoroscopy : The First case in Eastern region of Indonesia
Authors: Yoseph Hendry , Fitriani Aussie , Patimang Yulius , Alief Andi
Published: March 2023

Background

Ventricular septal defects (VSDs) are the most common Congenital Heart Defects (CHD) lesion in children. Transcatheter closure is considered as an alternative to surgery, for past few decades transcatheter closure were performed under fluoroscopy, recently guidance under Transesophageal Echocardiography (TEE) is increased. Transcatheter closure under TEE Guidance remains challenging but an alternative to overcome the radiation effect.

Case Summary

We reported 3-year-old female patient admitted to RSUP Dr. Wahidin Sudirohusodo with chief complaint was easily fatigue, Physical finding revealed regular heart sound with a grade 4/6 pansystolic murmur at the left lower sternal border, Transthoracal Echocardiography (TTE) has shown perimembranous VSD (pm-VSD) 6-7 mm L-R shunt with VSD Gradient 58 mmHg and aortic rim 4,5 mm. The patient was diagnosed with pm-VSD without Pulmonary hypertension and suitable for device closure under TEE Guidance. TEE Procedure was performed under general anesthesia and we found pm-VSD 3-4 mm, we decided to close the defect with Amplatzer Duct Occluder II (AGA) no 4/4 with delivery sheath amplatzer Torqvue LP 4F via retrograde approach with zero fluoroscopy, the device was well fixated with small central residual shunt 1,6 mm with hemodynamically unsignificant, The device was released and the procedure was finished without any significant problem.

Conclusion

We reported first case of VSD closure under TEE guidance in Eastern region of Indonesia, Transcatheter closure of pm-VSD under TEE Guidance are feasible and safe and can be an alternative to surgery and conventional technique under fluoroscopy to prevent radiation effect.
C43. Eisenmenger Syndrome The Challenge of Untreated Large Ventricular Septal Defect in Pregnant Women: A Case report
Authors: Kalista Yuliet , Djoen Herdianto , Rheza Giovanni
Published: March 2023

Background

Eisenmenger syndrome is a constellation of symptoms that arise from an uncorrected large congenital heart disease that have a reversed shunt to right to left. Eisenmenger syndrome in pregnancy is rare because pregnancy in this patient is not recommendeed due to high mortality for mother and baby. The objective of this case report is to highlight the argument of Eisenmenger syndrome in pregnancy.

Case Summary

A 38-years pregnant woman presented to the emergency room with dyspnea since the third trimester. Reported history of the untreated ventricular septal defect. Central cyanosis, systolic murmur and lower extremity oedema were found. ECG showed a right axis deviation with right ventricular hypertrophy. Cardiomegaly was found from a chest x-ray. Left ventricular diastolic dysfunction, large ventricular septal defect with Right-Left shunt, and pulmonary hypertension were found from echocardiography. Based on characteristic appearance, a diagnosis of Eisenmenger syndrome was made. Caesarean delivery was performed and the baby delivered safely, but the mother passed away.

Discussion

Eisenmenger syndrome in pregnancy comes with high mortality to mother and baby. A ventricular septal defect is a common cause of Eisenmenger syndrome. The choice for medical treatment from Eisenmenger syndrome in pregnancy is still controversial. Both caesarean section and vaginal delivery could be harmful to the patient due to vulnerability to hemodynamic change.
C45. Exercise-Induced Ventricular Tachycardia in Normal Coronary Artery Patient with Incidental Finding of COVID-19 : a case report
Authors: Taim A I , Saleh K , Muzakkir
Published: March 2023

Background

Exercised-induced ventricular tachycardia is associated with pre-existing ischemia or structural heart disease. However, exercise-induced ventricular tachycardia in asymptomatic patient without evident of coronary artery disease or structural heart disease needs further investigation.

Case Description

A 53-year-old woman with suspected coronary artery disease underwent an Exercise Stress Test. During recovery phase, the patient developed monomorphic ventricular tachycardia accompanied by drowsiness, which lasted eight minutes before resolving. The patient was tested positive on COVID-19 screening, a mandatory testing before hospital admission. Subsequent evaluation with transthoracic echocardiography and coronary angiography revealed absence of coronary artery stenosis and significant structural heart disease. Twenty-four hours Holter monitoring results were low-grade premature ventricular contractions.

Discussion

Exercise-induced ventricular tachycardia in normal coronary artery patient may be associated with an increased risk of sudden cardiac death, thus required careful examinations and establishment of underlying pathology. COVID-19 was reported to be associated with and might trigger episodes of ventricular tachycardia through sympathetic hyperactivity or re-entry in myocarditis. This case is noteworthy due to the absence of typical cause of exercise-induced ventricular tachycardia and the possible relation with COVID-19 infection. However electrocardiogram monitoring should be taken periodically to observe recurrences and to determine prognosis.
C47. Heparin Induced Thrombocytopenia (HIT) Associated with Multiple Deep Vein Thrombosis (DVT) and Intracardiac Thrombus Who Underwent Vena Cava Filter Prior to Surgical Thrombus Evacuation : a Case Report
Authors: Sihotang I M , Ryanti D , Haykal T B , Habib F , Ardini T W , Ketaren A P , Hasan H
Published: March 2023

Background

Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis.

Case

A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation.

Discussion

This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.
C49. Hybrid Procedure in A Patient with Multiple Aortic Dissections and Marfan Syndrome: A Case Report
Authors: Taofan T , Gill R S D , Wartono D A , Adiarto S
Published: March 2023

Background

Aortic dissection is a tear in the inner layer of the aortic wall, which allows blood to enter into the wall of the aorta, creating a new passage for blood, known as the false lumen. The indications for surgical approach in aortic dissections Stanford A and DeBakey I and II are widely recognised and accepted, but little is known that in certain cases of Stanford A, DeBakey type I or type II aortic dissection patients who meet the eligibility criteria, endovascular repair can be performed.

Case Illustration

A 36-year-old woman came with a chief complaint of acute stabbed pain, she was known to have Concomitant DeBakey type II and IIIb aortic dissection, severe aortic regurgitation, and Marfan Syndrome. Because of her condition, we decided to conduct an open surgical repair with Bentall Procedure that was planned to be followed by an elective thoracic endovascular aortic repair (TEVAR). The Bentall procedure was a success and the patient’s clinical condition improved each day.

Conclusion

In concomitant DeBakey type II and IIIb aortic dissection cases, especially in those who have an underlying condition such as Marfan Syndrome, the Bentall procedure is the treatment of choice. In conditions when surgical procedure cannot be done, a hybrid approach of open surgery and TEVAR may provide a valuable alternative for patients.
C51. Impending Rupture in Acute Type A Aortic Dissection : Case Report
Authors: Santoso Anita Surya , Sargowo Djanggan , Kurnianingsih Novi
Published: March 2023

Background

Acute aortic dissection is a life threatening condition that remains a challenge to diagnose and treat. 67% patients was presented with Acute type A aortic dissection (ATAAD) and often accompanied with some complications.

Case Summary

A 40-year-old male with risk factor hypertension was presented with sudden sharp tearing-like chest pain and radiating to the back 3 hours before admission. He had transient decrease of consciousness and waken up spontaneously. He was compos mentis, with normal JVP, normal heart sound, no pulsus deficit, hypotension, cold acral and oliguria. He got fluid rehydration and the BP was stabilized. Haemoglobin was normal with increase D-Dimer. The ECG was normal and chest radiography revealed cardiomegaly and widening mediastinum. From eyeballing echocardiogram showed moderate pericardial effusion without right atrial and right ventricle collapse. A CT scan angiography was performed and revealed an Aortic Dissection Stanford A Debakey I.

Discussion

The development of an evidence-based strategy to rule out aortic dissection in patients presenting chest pain would be useful to diagnose patients with chest pain. Rapid diagnosis of dissection is most likely when CT is a part of the diagnostic testing. Hypotension and shock occurred in > 25% of patients with type ATAAD and in this patient was associated transient loss of consciousness. This patient was in impending rupture condition. The definitive treatment for this patient was emergency aortic repair surgery. We was succeded to stabilize the patient then referred to a cardiothoracic surgeon in 24 hours later.
C52. Infected Femoral Artery Pseudoaneurysm with Klebsiella pneumoniae Bacteremia in Injected Drug Abuser: A Case Report
Authors: Khairunnisa H , Mardhiyah I , Mahavira A , Pasaribu F Z
Published: March 2023

Background

Injected drug abuse is a significant problem in modern societies today, with increases various vascular complications due to repeated punctures under septic conditions. One of the severe vascular complications is infected pseudoaneurysm. However, no study reported the involvement of Klebsiella pneumonia in infected pseudoaneurysm.

Case Summary

A 40-year-old homeless man, an injected drug abuser, presented to the emergency department with a severe pain lump in the right groin area since three weeks ago. The hemodynamic was unstable and the laboratory examination revealed severe infection. While ultrasonography was suggesting high suspicion of lymphadenitis in the right groin area, the Doppler ultrasonography was showing a pseudoaneurysm in the right common femoral artery. The blood cultures grew Klebsiella pneumonia ESBL. Patient was planned to be referred to vascular surgery center. Unfortunately, before patient got a referral, his condition worsened with a fall of hemoglobin suggesting rupture of pseudoaneurysm that didn’t improve with resuscitation.

Discussion

A tender swollen groin in an injected drug abuser should prompt a high index of suspicion for the presence of pseudoaneurysm. When faced with uncertain diagnosis, further investigation with appropriate imaging is warranted. In this case, diagnosis of infected pseudoaneurysm was confirmed due to the co-incidence of septic condition. Surgical management with controlled infection and resuscitation was required, however, it remained a challenge due to the unstable condition and pseudoaneurysm itself that was prone to rupture. In addition, Klebsiella pneumonia ESBL made bacteria resistant to cephalosporins and monobactams.
C63. Myocardial bridging on coronary angiography: an innocent bystander or a culprit in myocardial infarction?
Authors: Reeiner M , Aryadana W , Sutanegara B A P D , Artha I M J R
Published: March 2023

Myocardial bridging is one of the nonatherosclerotic causes of coronary artery disease and is characterized by muscles overlying the intramyocardial course of a major epicardial coronary artery segment, leading to systolic compression. This condition is usually benign but can be associated with unstable angina, myocardial infarction, and death. We report herein a myocardial infarction associated with a subtotal systolic narrowing of the LAD by a myocardial bridge. A 57-year-old-man with chronic heart failure caused by myocardial bridging post-non-ST elevation myocardial infarction and hypertensive heart disease. The electrocardiography showed sinus rhythm, echocardiography shows normal left and right ventricular function, regional wall motion abnormality, grade I diastolic dysfunction and “milking effect” was observed in the mid-segment of the left anterior descending coronary artery on the coronary angiogram. Schwarz type C is categorized in this case, β-blockers and calcium channel blockers remain the mainstay of treatment and relieve hemodynamic disorders caused by myocardial bridging by decreasing heart rate, increasing the period of diastolic coronary filling, and decreasing coronary artery contractility and compression. Other diagnostic modalities needed if symptoms persist despite optimal medical therapy and myotomy, coronary artery bypass graft, or stent implantation can be considered in these patients. At the six-month follow-up visit, the patient had no acute coronary syndrome event, but chest pain and heart failure were felt occasionally.
C66. Paraaortic abscess complicating an Aerococcus Viridans Endocarditis: A Case Report
Authors: Farissa I P , Goma M S , Permitasari D A , Nugroho M A
Published: March 2023

Background

Infective Endocarditis (IE) associated with high mortality and complication despite improvement in its management. Paravalvular abscess known as feared complication of IE because its association with increased mortality. We describe a case of man with paravalvular abscess complicating IE undergone Aortic Valve Replacement.

Case Summary

A 42 years old man presented with exertional dyspneu since 2 weeks prior to admission, exaggerated with mild activities, accompanied with nausea, vomiting, swollen legs, and subfebrile for weeks. He was conscious and moderately ill with pressure 100/50 mmHg, regular pulse of 70, respiratory rate 25 times/minute, temperature was 37˚C, oxygen saturation was 94% on room air with end diastolic murmur grade II/4 in right upper sternal border. The laboratory result was leucocytosis (12.900/cu mm). The echocardiography revealed calcified in RCC and NCC aortic valve, RCC prolapse, severe aortic insufficiency, hyperechoic in paravalvular area. MSCT Cardiac revealed fistula originating from aortic root to a sac led to left ventricle. Sensitivity cultured revealed Aerococcus viridans. We gave antibiotics for 3 weeks before he undergone Aortic Valve Replacement. 1 month follow up, he had no more symptoms, and the prosthetic valve was normal.

Discussion

The diagnostic of IE remains challenging. It may present as an acute, rapidly progressive infection, but also as a subacute or chronic disease. Its complications need to be monitored vigilantly because it worsens the outcome. Antibiotics use for microbial eradication contributed by removing infected material surgically, might improve successful treatment for IE.
C76. Primary Cardiac Tumors : Benign or Malignant ? The Importance of Clinicopathologic Confirmation : a case series
Authors: Andryan D P , Lestiadi I D , Siswanto B B
Published: March 2023

Background

Cardiac tumor is a rare condition of space-occupying lesion mass in cardiac chamber. The incidence of clinically diagnosed Primary Cardiac Tumors is approximately 1,380/100 million individuals. Majority of cases are benign, with nearly half of them are cardiac myxoma. Although early clinical symptom of benign and malignant cardiac tumor are similar, the management and prognosis are much different.

Objective

To present serial cases of benign and malignant primary cardiac tumor.

Case Description

Mrs. RH, a 60-year-old woman referred to heart failure clinic National Cardiovascular Center Harapan Kita with chief complaint of short of breath on exercise. Echocardiography confirmed a huge mass obstructed her left atrium. She was hospitalized urgently with giant Left Atrial Myxoma with normal coronary artery, then underwent surgery of LA myxoma extirpation, Mitral Valve repair and Tricuspid Valve repair. Histopathological analysis confirmed of LA myxoma.

Mr. RBM, a 42-years-old man came to emergency unit at National Cardiovascular Center Harapan Kita with chief complaint shortness of breath and palpitation in about 1 month. A history of a cardiac tumor extirpation and mitral valve replacement was done in Penang Adventist hospital 10 months before. Transthoracal and transesophageal echocardiography found solid mass obstructing mechanical valve. Histopathology analysis showed undifferentiated cardiac sarcoma and against LA myxoma.

Discussion

Clinical course and management of cardiac tumor depends on early detection and histopathologic analysis. Although surgery is the cornerstone for cardiac tumor management, but confirmation of histopathologic findings is important.
C78. Prosthetic valve thrombosis in uncontrolled internormalized ratio ended up with disaster on prosthetic valve surgary : a barrier of anticoagulant management in rural area
Authors: Hustiar M , Nadia  , Heriansyah T , Purnawarman A
Published: March 2023

Background

Mechanical prosthetic valve thrombosis (PVT) is a life-threatening complication that requires immediate intervention. With current prosthetic devices and aggressive prophylactic anticoagulation, the incidence of PVT remains low. It needs monitoring of international normalized ratio (INR), which is somewhat difficult to do in rural areas such as West Aceh due to geography. This report details the case of a woman with PVT who developed heart failure after a period of suboptimal anticoagulation.

Case Summary

We described a 51-year-old woman who had undergone coronary artery bypass graft and mitral valve replacement procedure in 2017. Her physical examination showed the decrease of the prosthetic click sound and lung congestion. From her blood examination, the INR was subtherapeutic. A thrombus was detected on the prosthetic mitral valve by transoesophageal echocardiography. She had history of uncontrolled INR because the patient do not routinely checked her blood to control the optimal dose of anticoagulant. The patient underwent reoperation for mechanical valve thrombosis but unfortunately in the end the patient died at the procedure.

Discussion

In patients undergoing mechanical heart valve replacement, time in therapeutic range of targeted INR should be ≥ 70 % otherwise it will increase in risk of thromboembolic events. However, in developing countries which have remote areas, repeated examination of the use of warfarin in obtaining the INR target is still a major challenge. Conversely, serious risks can occur if this is not achieved and might be ended up with disaster toward the patient.
C86. Secondary Prophylaxis For Rheumatic Heart Disease During The Pandemic Era: A Case Report
Authors: Ramadhan G F , Supriadi E
Published: March 2023

Background

Rheumatic heart disease (RHD) is heart diseases results from recurrent episodes of acute rheumatic fever (ARF). It often occurs in developing countries and its pathogenesis is not clearly understood. RHD can be controlled with prophylaxis that requires patients to visit healthcare facility regularly. However, the current pandemic condition is a challenge for patients to receive routine treatment and evaluation.

Case Summary

A 17-years-old girl comes to emergency room with complaints of shortness of breath with mark limitation of physical activity 3 days prior to admission. The patient also complaint with joint pain and leg swelling. She was diagnosed Rheumatic Heart Disease and received prophylactic penicillin injections every month. However, since the pandemic, She do vice versa. In physical examination was found pansystolic murmur on aortic valve and bilateral lower extremity edema. Echocardiography showed moderate mitral regurgitation and mild aortic regurgitation. This patient was hospitalized and treated with benzathine penicillin G, prednisone, aspirin, furosemide and captopril.

Discussion

Management of ARF includes eradication cause of infection, treat complications, and secondary prevention. Administration of secondary prophylaxis is useful for reduce new bacterial strains that can cause recurrent acute or chronic attacks. First line of secondary prophylaxis for ARF is intramuscular benzathine penicillin G that given per month. In this current pandemic conditions, patients are expected to continue prophylaxis therapy and follow up the disease with using pandemic health protocols.
C89. Simultaneous Aortic Stenosis (AS) and Pulmonary Stenosis (PS) in A Middle-Aged Man: A Rare Case Report
Authors: Eliza B Suhuyanly , Sumantra I G
Published: March 2023

Background

Combined valvular lesions is very rare. Only 16 cases of combined valvular stenosis of the aortic and pulmonary valves have been reported. Failure to recognize and adequately correct both lesions may be catastrophic for the patient.

Case Illustration

A 38-year-old male came to the outpatient department with shortness of breath, fatigue, and swollen ankles. He had a short posture, broad forehead, bitemporal narrowing, broad nasal tip, long philtrum, wide mouth, and large earlobes. Cardiac examination revealed systolic murmurs over the pulmonary valve and at the aortic valve radiating to the apex (galliverdin phenomenon), rales in both lungs, and bilateral ankle edema. Electrocardiogram revealed sinus rhythm, extreme axis, RA enlargement, RBBB, and bifascicular block. Chest radiograph showed cardiomegaly, pulmonary edema, and left pleural effusion. Echocardiography demonstrated a dilated LA and concentric LVH with good LV function, HF/HG severe AS, a bicuspid aortic valve causing moderate aortic regurgitation, mild mitral regurgitation, mild tricuspid regurgitation, and severe valvular or supravalvular PS with RV hypertrophy. The patient was administered diuretics, a beta blocker, and an anti-platelet.

Discussion

Most patients with combined aortic and pulmonary obstruction at sub-valvular level have hypertrophic cardiomyopathy. Cases with both aortic and pulmonary valve stenoses are exceedingly rare. The age of presentation ranges from neonate to 55 years. It is more common in males. Most patients present with murmur since birth, dyspnea, and fatigue. Our patient is suspected to have Williams syndrome based on the physical appearance and cardiac examination findings.
C90. Successful Procedure of Ductus Arteriosus Stenting: Promising Choice for Pulmonary Atresia Survival
Authors: Andini R , Permitasari D A , Priyatno A
Published: March 2023

Background

Duct-dependant circulation in a baby presents as a life threatening emergency. Maintain the duct patency is crucial for patient survival before they have an cardiac surgery. We describe a case of a baby with pulmonary atresia who underwent succesful procedure of patent ductus arteriosus (PDA) stenting.

Case Summary

a female baby was born in peripheral hospital with birth weight of 3 kg by normal delivery, noticed to have cyanosis sixteen hours after birth. At our centre, the baby look cyanosed. Saturation by pulse oximetry was 84%. In physical examination appears, a continuous murmur was heard below clavicle at linea parasternal. Echocardiography confirmed the diagnosis of pulmonary atresia. Faint flow of PDA observed with duct size less than 1 mm. Prostaglandin E1 Infusion was start immediately at the rate of 1 µg/Kg/min. Within 6 hours of infusion the baby had an episode of apnoea. The baby then taken up for ductal stenting to keep the duct patent for few months before staged cardiac surgery.

Discussion

Pulmonary atresia is an critical case of congenital heart disease. The systemic or pulmonary circulation are mantained through flow in patent ductus arteriosus. Before cardiac surgical repair these patient can survive only if duct patency is reliably maintained. PDA stenting has been shown to be as an acceptable and less invasive approach to maintain ductal patency.
C91. “Successful management of ventricular septal rupture after myocardial infarction in elderly: the role of intra-aortic balloon pump and timing for surgery”: A Case Report
Authors: Pradityawati A , Pradana S Y , Habibi F N , Sidiek A , Safir S
Published: March 2023

Background

Ventricular septal rupture (VSR) after myocardial infarction (MI) is a case with a high mortality rate, early diagnosis and appropriate treatment are essential. Surgical VSR closure though challenging and associated with high mortality, remains one of the main therapy in VSR closure.

Case Presentation

A 70-year-old woman had a complaint about the shortness of breath (SoB). From anamnesis, 17 days before admission, she complained of chest pain. 15 days before admission, she was taken to a local hospital and got hospitalized for 7 days in the intensive care unit. ECG showed anterior MI. During admission, patient developed SoB. From echocardiography, it showed VSR at apical. She was referred to dr. Kariadi hospital for further management.

Coronary angiography showed total occlusion in mid LAD. An intra-aortic balloon pump (IABP) was inserted for stabilized hemodynamic and as bridging. Inotropic support was given and afterload reduction was also administered. Surgical VSR closure and coronary artery bypass grafting (CABG) was successfully performed on the 22nd day after the onset of MI. The patient was discharged 10 days after surgery in a good condition.

Discussion

The mortality of VSR varied significantly depending on the timing of surgery. Patients who underwent surgery within 7 days of presentation had a 54.1% mortality compared with 10 % mortality if the repair was delayed until after 21 days. The cornerstone of preoperative management of VSR is afterload reduction. IABP provides mechanical afterload reduction and augmentation of cardiac output.
C92. Successful Percutaneous Coronary Intervention (PCI) in Rare Case of Anomalous Aortic Origin of the Right Coronary Artery from the Opposite Sinus (AAORCA) Presenting as Inferior ST Elevation Myocardial Infarction (STEMI)
Authors: GK Ahimsa , N Taufiq , BY Setianto
Published: March 2023

Background

AAORCA from opposite sinus is a rare congenital anomaly that can present with symptoms similar to coronary artery disease, even sudden cardiac death. AAORCA with Inferior STEMI is a rare combination situation. Management of acute myocardial infarction with AAORCA is not well established and still debatable.

Case Summary

We presented a case 61 years old aged male with STEMI and AAORCA. He admitted to our hospital with complaint of retrosternal chest pain with ST segment elevation in inferior lead thus we diagnosed as Inferior STEMI. He underwent an emergency coronary angiography (CAG) that showed anomalous of right coronary artery (RCA) and total occlusion of the proximal RCA with atherosclerotic lesion. Stent then implanted at proximal of RCA. Further work-up by Computed Tomography Angiography (CTA) revealed an AAORCA with interarterial course.

Discussion

AAORCA with interarterial course that presents as inferior STEMI is a rare case. Diagnosis requires CAG and coronary CTA to identify anatomy and physiology so revascularization can be carried out appropriately. It is still arguable whether atherosclerosis or the interarterial course of AAORCA that caused acute MI. There is evidence that anomalous coronary arteries doesn’t increase atherosclerosis risk than normal. Total occlusion located at the distal to interarterial course reinforce that atherosclerosis may be the possible cause of acute MI. PCI could be the preferred choice in patients with inferior STEMI accompanied by AAORCA with evidence of atherosclerotic lesion, because may result in complete reperfusion and good clinical outcome.
C93. Temporary Pacemaker Lead Insertion with Echocardiography Guided Technique in Emergency Setting: a Case Report
Authors: Kristanto H , Rizal A
Published: March 2023

Background

The implantation of the temporary pacemaker (TPM) must be done in symptomatic bradycardia to provide adequate heart rate and stabilize hemodynamic. Transvenous TPM is inserted under the fluoroscopy guidance. However, in an extraordinary situation, such as the unavailability of the catheterization laboratory, transvenous TPM insertion can be performed with echocardiography guiding.

Case Summary

A 27 years old male came to our ER with symtomatic bradicardia. Emergency procedure like medical treatment and transcutaneous pacing were done, but failed to increase heart rate. We planned transvenous pacing with fluoroscopy but the catheterization laboratory was not immediately available. Echocardiography guided temporary pacemaker were done in ER successfully and the patient was strabilized.

Discussion

Emergency transvenous pacemaker implantation with echocardiography guiding can be accomplished successfully in our case without complication. There are several techical aspect that we should consider in temporary pacemaker insertion without fluoroscopy. We use femoral access and with echocardiography guided in our case. The confirmation of the lead placement using fluoroscopy was needed to ensure that the tip of the electrode was in the proper position. Future research that focuses on the safety and effectiveness of the technique across the range of operator skill levels is needed.
C94. The characteristics and outcome of pediatric patients with congenital heart disease (CHD) infected by coronavirus disease 2019 (COVID-19) between march 2020 to february 2021 at sanglah hospital: a case series of 12 patients
Authors: Ambara G S , Gunawijaya E , Yantie N P V K
Published: March 2023

Background

Coronavirus disease 2019 (COVID-19) has a complex connection to cardiovascular system. COVID-19 infection has been proven to cause significant dysfunction in lung, heart, and endothelial cells. Therefore, patients with complex congenital heart lesions have a high risk of developing severe complications and worse outcomes. This paper aims to determine the characteristics and outcome of pediatric congenital heart disease (CHD) patients infected by COVID-19 at Sanglah hospital.

Case Summary

Within the period of March 2020 to February 2021, there were 12 cases of pediatric CHD accompanied by COVID-19 infection, which consists of 8 females and 4 males within the age of 6 days to 18 years. Based upon symptomatic CHD classification, there were 4 cyanotic CHD cases and 1 acyanotic case, respiratory problems were reported in all 5 cases. These are pneumonia in 4 cases and respiratory distress caused by hyaline membrane disease (HMD) in 1 case. 2 cases require mechanical ventilation. The outcome of all inpatient cases were favorable.

Discussion

To date, there are only few scientific evidence detailing how COVID-19 affects CHD. We were unable to calculate the correlation analysis since the population sample was too small. The most severe cases that requires mechanical ventilation had comorbidities in the form of malnutrition and down syndrome. From the perspective of pathophysiology, one of the most important factor determining outcome was the severity of CHD itself. Other contributing factors were COVID-19’s destructive effect on heart tissue and co-infection by other microorganism.
C95. The electrocardiographic changes in a hypertensive COVID-19 patient who received beta-blocker and favipiravir: a case report
Authors: Fatimah V A N , Istiqomah N S , Fadjri M
Published: March 2023

Background

Various electrocardiographic manifestations have been reported in COVID-19 which either result from myocarditis or insult-induced re-emerging of pre-existing condition. Some antiviruses used off-labelly for COVID-19, including favipiravir, are considered to be proarrhythmic. Meanwhile, anti-hypertensive drugs such as beta-blocker may induce bradyarrhythmia.

Case Summary

A 69-year-old male with confirmed COVID-19 and a history of uncontrolled hypertension presented with blood pressure of 216/111mmHg at admission. No sign and symptom of acute target organ damage had been reported. His electrocardiography showed normal sinus rhythm (heart rate [HR] 60bpm). The echocardiographic finding revealed normal heart function. He received favipiravir for 5 days, intravenous nicardipine (0.5mcg/kgBW/hour), and peroral amlodipine (1x10mg), candesartan (1x16mg), and bisoprolol (1x2.5mg). During hospitalization, the HR fluctuated between 52-109. On the sixth day, a total atrioventricular (AV) block with junctional escape rhythm (HR 66bpm) was present. Both favipiravir and bisoprolol were ceased simultaneously. The AV block persisted for 4 days then transformed into a junctional rhythm for the next 3 days and sinus bradycardia (HR 48bpm) thereafter. No pacing was performed.

Discussion

The possible differential diagnoses in this case include sick sinus syndrome (SSS), COVID-19-induced myocarditis, and drug-induced. The SSS might explain the wide variability of the HR. There were some reports presenting the sinus node dysfunction as a manifestation of SARS-CoV-2 infection. Further evaluation using Holter and/or electrophysiological study is warranted. Drug-induced cause may be excluded because the bradyarrhythmia remained after the cessation of both beta-blocker and favipiravir.
C97. The Important Role of Manual Aspiration through Guiding Catheter after Percutaneous Mechanical Thrombectomy (Angiojet) in Patient with Subacute Limb Ischemia due to Essential Thrombocytosis
Authors: A Ramadhani , H Hariawan , MT Ismail , VY Anggraeni
Published: March 2023

Background

Essential thrombocytosis (ET) is a myeloproliferative neoplasm characterized by increased platelet counts and excessive large and morphologically mature megakaryocytes in the bone marrow. ET may be complicated by thrombotic events, mostly in small and medium vessel. However there are limited evidence to guide management, particularly in cases with acute tissue ischemia. Understanding the basic pathophysiology concept of thrombosis in patient with ET is vital in choosing the right modality for revascularization.

Case Summary

A 73-year-old female with history of essential thrombocytosis presenting with severe debilitating pain on her right lower extremity. Physical examination showed decreased peripheral oxygen saturation. Dupplex Ultrasound revealed total thrombus at femoral artery dextra and no flow at popliteal artery, anterior and posterior tibial artery. We decided to perform revascularization with percutaneous mechanical thrombectomy (Angiojet). Arteriography evaluation still showing abundant number of thrombus. We continued with manual aspiration using guiding catheter and showing a remarkable result with normal blood flow down to the distal part with minimal residual thrombus.

Discussion

Histopatbological evaluations of arterial thrombi in ET revealed platelet-rich clots with abundant von Willebrand factor (VWF) and very little fibrin. Hence tllrombolysis agent used in CDT will not effective. Large thrombus which can not be lysed by fibrinolytic should be evacuated by a larger hole catheter aspiration