bluuebunny/crossref_metadata_2025 huggingface dataset:
C31. Closure of patent ductus arteriosus using intravenous paracetamol : a case series
Authors: Nursalim S , Setyawan D , Limbong M , Ahmad F
Published: March 2023

Background

Although patency of ductal arteriosus is essential for fetal circulation, postnatal ductal closure is critical for postnatal circulation adaptation in order to avoid pulmonary overcirculation with diminished circulation blood flow. Standard medical treatment for patent ductal arteriosus (PDA) consists of pharmacotheraphy and or surgical intervention.

Case Summary

We present 17 cases of PDA confirmed by echocardiography and was observed for ductal closure after 3 days of intravenous paracetamol intervention (10-15 mg/kg) given every 8 hours. The echocardiography evaluation of PDA status was conducted after those pharmacological intervention and divided based on the gestational age group. In the preterm groups (<36 weeks), 3 cases remained open, 3 cases were closed, and 1 case with reduced flow. In the aterm groups (36-42 weeks), 5 out of 8 cases were closed, while the other 3 showed reduced flow. In the postterm groups (>42 weeks), 1 case was closed and 1 case with reduced flow. Successful rate for PDA closure of each groups were 43%, 62,5% and 50%.

Discussion

Indomethacin and ibuprofen are standard treaments for PDA closure. However, they have some side effects such as acute renal failure and gastrointestinal complications. From this case series, paracetamol has a promising effect similar to indomethacin and ibuprofen in conducting PDA closure with less side effects. Paracetamol inhibits prostaglandin synthetase activity eventhough its precise mechanism of action remains controversial.
C34. Concomitant Finding of Hemorrhagic Cardiac Tamponade and Venous Thromboembolism as the First Manifestation of Occult Malignancy – A Case Report
Authors: Sitorus Sondang Jasmine , Alsagaff Mochamad Yusuf , Kusumastuti Etty
Published: March 2023

Background

Venous thromboembolism (VTE) encompasses pulmonary embolism (PE), and deep vein thrombosis (DVT) is a common complication of cancer. Cancer manifestation in cardiac often secondary from the metastatic process, mostly in the pericardium. These concomitant findings of PE, DVT, and hemorrhagic cardiac tamponade as the first signs of cancer in a young patient is rare.

Case Summary

A 39-years-old man was referred to the emergency department from secondary hospital with the main complaint of dyspnea that onset abruptly two days before admission and swollen of the entire right leg since one week before. We report concomitant finding of hemorrhagic cardiac tamponade, deep vein thrombosis, and acute pulmonary embolism as initial presentations of occult malignancy. Starting anticoagulant in the hemorrhagic state and finding the primary cancer were problematic and challenging.

Discussion

The challenge in management, posed by hemorrhagic versus thrombosis state in cancer, prompted us to cautiously deliver the treatment with consideration of benefit over the risk. Primary cancer is not always easy to identify. Comprehensive (re-)evaluation is mandatory.
C36. Deep Vein Thrombosis in A Patient with Thrombocytopenia : Case Report
Authors: Mirza Teuku , Ridwan Muhammad , Heriansyah Teuku
Published: March 2023

Background

Deep vein thrombosis (DVT) is a common but elusive illness that can result in suffering and death if not recognized and treated effectively. Overall, 43% of patients with thrombocytopenia were hospitalized, but just 2% of patients had DVT.

Case Summary

A 48-year-old male patient presented with a complaint left leg pain accompanied by edema leg 8 days before admission. The patient is a smoker, the patient has a history of diabetes since one year ago, In the laboratory results showed platelet count 23,000/mm3, D-dimer above 4000 ng/ml. Anti-dengue IgM and IgG were negative. Doppler examination revealed a thrombus in the common femoral and popliteal veins of the left leg. Patient was treated with low molecular weight heparin (LMWH) Subcutan fondaparinux 5 mg once daily for up to 7 days without bleeding and continued with Rivaroxaban 20 mg once daily, The patient was discharged on day 14.

Discussion

Platelet count below 50 x109/L significantly reduces the risk of DVT. Some known risk factors for DVT still appear to apply in patients with thrombocytopenia, and therefore patients with thrombocytopenia would benefit from DVT risk stratification based on platelet count and comorbidity. Patients having thrombocytopenia with DVT were treated safely with anticoagulants without increased occurrence of bleeding. The majority of cases were given therapeutic doses of LMWH.
C38. Diagnosis and Management of Atrial Septal Defects (ASD) and Pulmonary Hypertension (PH) in Pregnancy
Authors: Sari Anna P , Krevani C K , Karani Y , Kino
Published: March 2023

Background

Atrial Septal Defect (ASD) is a congenital heart disease that is often found in adulthood, including women in pregnancy. Women with ASD are at greater risk for cardiovascular complications during pregnancy especially with Pulmonary Hypertension (PH), so comprehensive management is essential for this case.

Case Summary

A 31-year-old woman with gravida 32-33 weeks complaint of shortness of breath increasing since 3 days before entering the hospital with central cyanosis, clubbing finger, peripheral oxygen saturation 74%, from auscultation showed hardened P2 sound, indistinct wide fixed split, grade 3/6 systolic murmur. Echocardiography showed ASD with High Probability PH (Pulmonary Hypertension). The patient treated with furosemide 2x20 mg, sildenafil 3x12.5 mg, 3x20 mcg berraprost. The pregnancy was electively terminated with cesarean delivery and also got tubectomy. After 18 days of treatment in hospital, patient was discharged with stable and good condition. The patient was planned for right heart catheterization from outpatient clinic.

Discussion

Based on Guidline ESC on the management of Cardiovascular disease during Pregnancy in 2011, patients with ASD-PH are included in class IV WHO classification, where are contraindicated for pregnancy. If the pregnancy continues, recommended for patients to control regularly to the cardiologists and obstetricians during pregnancy, delivery and the puerperium.

From literature, cesarean delivery is recommended for pregnant women with Pulmonary Hypertension (including Eisenmenger's Syndrome). Special attention and comprehensive management are required for pregnant patients with ASD-PH. The choice of intervention method and some medical therapy in this patient must also be considered.
C39. Ductus Arteriosus Stenting: A Promising and Life Saving Procedure for Ductal-Dependent Pulmonary Blood Flow
Authors: Permitasari D A , Priyatno A , Ayukusuma A R , Andini A R , Christina M , Susilawati M
Published: March 2023

Background

Duct-dependant congenital heart disease in newborn presents as a life-threatening emergency and the survival depends on patency of the ductus arteriosus. Stent implantation into ductus arteriosus has been proposed as non-surgical management for critical congenital heart disease with duct-dependent.

Case Summary

We present full-term newborn babies who had critical congenital heart disease with ductal-dependent pulmonary blood blow and successfully managed with ductal stenting. Patient A, a 13-days-old male had Tetralogy of Fallot-Pulmonary Atresia and restrictive Ventricular Septal Defect (VSD). Patient B, a 3-days-old male had Pulmonary Atresia-Intact Ventricular Septum (PA-IVS) with Patent Foramen Ovale (PFO). Patient C, a 5-days-old female had Tricuspid Atresia with restrictive VSD and multiple congenital anomaly. Patient D, a 2-days-old female had PA-IVS with PFO stretch. Prostaglandin-E1 infusion was started at first and stop 6 hours prior to the procedure. Ductus arteriosus stenting using drug-eluting stent and femoral artery approach was successful in all 4 patients. All patient had improvement of oxygen saturation and good post-procedure outcome.

Discussion

Ductal stenting in patient with duct-dependent pulmonary circulation appears to be an alternative to surgery. It provides a bridging palliation in cyanotic congenital heart disease until the time of definitive surgery. Stenting of ductus arteriosus is feasible and safe with good result, thus early recognition and timely management are important to save the life.
C40. Early Repolarization Syndrome: The Dangerous One
Authors: Islami Z H , Hidayati F , Maharani E
Published: March 2023

Background

Early repolarization pattern (ERP) in electrocardiogram (ECG) was thought to be benign in nature. However, for the last 2 decades, several cases reported sudden cardiac deaths (SCD) in patient with ERP.

Case Summary

A 40-year-old male with a history of several syncope episodes. The latest episode in 2019 at 5 am, a brief convulsion happened before the patient went unconscious. In emergency room, he had another convulsion with a witnessed ventricular fibrillation. After resuscitation and defibrillation, the patient awoke, and ECG was recorded showing ST-segment elevation at V2-3 which suspected to be a Brugada syndrome (BrS).

Patient then referred to Sardjito hospital for echocardiography and treadmill test, and the results were within normal limit. Coronary CT Scan showed a non-significant lesion at LAD. Holter examination showed during sleeping, J-wave elevation appeared at the rate of 50 bpm. Meanwhile, during exercise, J-wave disappeared at the rate of 135 bpm. The patient was diagnosed as early repolarization syndrome (ERS) and managed with implantable cardioverter-defibrillator (ICD) implantation.

Discussion

Patient with ERP who suffers syncope/cardiac arrest is classified as an ERS. Particular clinical findings such as history of cardiac arrest, convulsion, apnea, and ECG findings such as short coupled premature ventricular contraction, dynamic J-wave changes, widespread J-wave are associated with a higher chance for ventricular arrhythmia. Due to its similar nature in ECG morphology and its pathophysiology, ERS and BrS are classified into J-wave syndrome.
C41. Echocardiography Assessment of Aortic Native Valve Infective Endocarditis Complicated with Anterior Mitral Leaflet Abscess
Authors: Yudistira K A , Sari N M A W , Saraswati L P O , Wibhuti I B R
Published: March 2023

Background

Infective endocarditis (IE) presents a major therapeutic challenges due to difficulties in diagnosis and a high risk of morbidity. Despite numerous complications of IE, reported cases complicated by abscesses on the heart valve leaflets were extremely rare as illustrated in this case report

Case Summary

A 46-year-old man was admitted with severe shortness of breath since August 14, 2020. The patient also had cough and fever, emerging since 1 month before hospitalized. A history of PND, orthophnea, and DOE was experienced since the 1 month ago. Upon physical examination, abnormal findings include: tachycardia, tachypnea, visible and diastolic murmur at the right second intercostal alongside the parasternal line and systolic murmur at apex, respectively, as well as ronchi at 2/3 of the lung bases. Electrocardiogram revealed both sinus tachycardia and anteroseptal ischemia. An echocardiography was performed; thereby generating a vegetation at RCC and NCC of aortic valve, pocket-shaped echodense structure on anterior mitral leaflet with suspected abscess.

Discussion

Definite infective endocarditis was navigated depicting the suspicion of: a vegetation in the aortic valve of NCC and RCC diagnosis, an abscess of the anterior mitral valve and ADHF of B profile with a potential of VHD and CAD with severe aortic valve regurgitation.
C42. Eisenmenger Syndrome, Could Its Pathophysiological Changes Serve as Protective Factors Against Severe COVID-19 Infection?
Authors: Gunawan R Y , Medishita H
Published: March 2023

Background

Congenital heart disease (CHD) and pulmonary artery hypertension (PAH) are comorbidities to severe COVID-19 infection. We reported a case of adult congenital heart disease (ACHD) with Eisenmenger Syndrome (ES) who survived COVID-19 without progression to severe infection.

Case Description

A 39 years old male with history of uncorrected ACHD complained of low-grade fever and cough for 3 days. Initial oxygen saturation was 85%, no tachypnoea, no tachycardia, and blood pressure was normal. SARS-CoV2 RT-PCR results was positive. Thorax CT showed lung fibrosis, minimal GGO, and prominent pulmonary notch. Notable laboratory result was haemoglobin: 20.4g/dL. Echocardiography showed a large secundum ASD with bidirectional shunt, dilated RA and RV, normal ventricular systolic functions, mild TR with increased tricuspid gradient (TR V max 4.27m/s) which concluded the diagnosis of ES. The patient was treated according to moderate COVID-19 guidelines and ES management. His response to treatment was favourable and was discharged in 3 weeks uneventfully.

Discussion

Studies have documented CHD and PAH as comorbid to severe COVID-19 infection, but our patient had moderate COVID-19 infection and recovered without progression to severe disease. We proposed several pathophysiological characteristics of ES which could serve as protective factors against severe COVID-19, which are: 1) Pre-existing PAH, where pulmonary vasculopathy and remodelling lessened endothelial response to inflammation, and reduced expression of ACE2 receptors,  2) Chronic hypoxia, which prepared cells and tissues against hypoxic environment, and 3) Polycythaemia, might be beneficial in haemoglobinopathy directly caused by SARS-CoV2.
C44. Electrocardiogram might failed identify acute coronary occlusion: When every minute counts
Authors: Habibi F N , Mangkoesoebroto A P , Pradityawati A , Ardhianto P
Published: March 2023

Backgrounds

Prompt diagnosis of acute coronary occlusion based on electrocardiogram (ECG) are essential to decide proper treatment. However, particular ECG such as Wellens syndrome have been higlighted without obvious ST-segmen elevation which is signifies critical stenosis or occlusion of the proximal left anterior descending (LAD) artery but unfortunately is often unrecognized by physicians.

Case Illustration

A 51-year old male patient referred from district hospital diagnosed as five day onset STEMI with recurrent chest pain. The first ECG in there emergency room was a deep inverted T wave in anterior and lateral lead that immediate intervention approach not choosen. The typical infarct evolution in anteroseptal lead appear one day after the onset. Troponin level was significantly increased. Urgent angiography was performed in our hospital, unfortunately it resulted critical stenosis in proximal LAD with triple vessels and left main coronary artery disease. Then we consider send to surgery due to high coronary complexity (Syntax score:62) and optimize antianginal agent.

Discussion

In current practice, ST-segment elevation at the J-point, ≥ 1 mm in ≥ 2 adjacent leads (other than leads V2 and V3, where elevation of ≥ 2 mm in men or ≥ 1.5 mm in women is considered significant) for STEMI diagnosis. However, these general ECG criteria fail to identify the STEMI equivalents. Wellens syndrome is one of them that suggesting severe stenosis of the proximal LAD artery, which will develop into an acute anterior wall MI within a few days to weeks in 75% of untreated patients.
C46. Gastrointestinal-related Symptoms Leading to Acute ST Elevation Myocardial Infarction in a Young Woman without Cardiovascular Risk Factor in Rural Area: A case report
Authors: Kusnadi A , Jambormias E F , Meudi T M K A , Aurora R G
Published: March 2023

Background

Acute Coronary Syndrome (ACS) has been regarded as man’s disease, for many years, women have been underdiagnosed and undertreated. Women commonly present with atypical right-sided chest pain, neck or shoulder pain, and gastrointestinal symptoms.

Case Presentation

A 31-year-old woman presented to the ER with worsening epigastric pain accompanied with nausea, vomiting and diaphoresis since 30 minutes before admission. She had similar complaints before and only took dyspepsia medication repeatedly. She denied any history of smoking, hypertension, T2DM, dyslipidemia, and family history of ACS. Physical examination was within normal limits except for epigastric tenderness. The electrocardiogram showed ST-elevation in leads II, III, AVF, V7-V9, and ST depression in leads V2-V4. Laboratory results were within normal limits. She was diagnosed with acute inferoposterior STEMI and RV infarction. Loading dose of dual-antiplatelets was given, followed by fibrinolysis therapy using Streptokinase. After 60 minutes, the epigastric pain subsided and she had no other complaints, and successful fibrinolysis was achieved, she was transferred to the ICU for further treatment.

Discussion

Although females in reproductive age have cardio-protective effects of endogenous estrogen, ACS is still possible. They can present with non-specific gastrointestinal symptoms, a 12-lead-ECG can confirm the diagnosis of STEMI in young women with non-specific symptoms. Possible etiologies including plaque rupture or erosions, microvascular dysfunction, and spontaneous coronary artery dissection (SCAD) can be determined by coronary angiography. Since catheterization laboratory services are unavailable in our province, this patient is planned to undergo coronary angiography after hospital discharge.
C48. How to handle VT storm in ICD patient : serial case report
Authors: Prismadani M , Julario R
Published: March 2023

Background

Ventricular tachycardia (VT) storm can cause sudden death in patients with trans-venous implantable cardioverter-defibrillator (ICD) and adversely affects prognosis in survivors. Patients with recurrent shocks have a poor quality of life and increased mortality rates. The purpose of this case series was to discuss the available treatment option for VT storm in ICD patients.

Case Summary

We reported two patients with VT storm on ICD. Both patients had palpitation, clinical heart failure, and recurrent shocks from ICD with appropriate rhythms. The first case had hypokalemia with ICD recording showed 45 episodes of VT, 45 antitachycardia pacing (ATP), and 5 shocks therapy. The second case had hypomagnesemia with ICD recording showed 195 episodes of VT, 42 ATP, and 3 shocks therapy. Management approaches to these patients include ICD reprogramming, correcting electrolyte abnormalities, treating heart failure and administering anti-arrhythmic drugs (AADs).

Discussion

VT storm on ICD refers to three or more appropriate therapies for ventricular tachyarrhythmias, including ATP or shocks, within 24 hours. The known triggers must be treated, such as electrolyte disturbance and worsened heart failure. AADs therapy could suppress VT and increased the tachycardia cycle length (TCL) so that the response to ATP is better. ICD reprogramming include higher heart rate treshold, longer detection period, and improving ATP programming. Catheter ablation and cardiac sympathetic denervation (CSD) may be an option if VT storm persists.
C54. Infective Endocarditis with Ventricular Septal Defect and Ruptured Sinus of Valsalva: A Case Report
Authors: Zebua J , Nasution A N , Siregar A A , Hasan H
Published: March 2023

Background

Ventricular Septal Defect (VSD) is the most common congenital heart defect with incidence rate about 50% of all case in children. VSD is often followed by weakness of the wall in the sinus of Valsalva causing aneurysms, where 30-50% of cases of aneurysms in the sinus of Valsalva is associated with VSD. Congenital heart defects also increased risk factors for infective endocarditis (IE) with the risk of infection 15-140 times greater than the general population.

Case Description

A 7-year-old boy was reported with fever and shortness of breath, echocardiography examination showed subaortic VSD, ruptured sinus of Valsalva, multiple vegetation on left ventricular outflow tract, right coronary cusp, and right ventricle, moderate aortic, pulmonal and tricuspid regurgitation with mild pulmonal hypertension. Although there was no growth of bacteria from blood culture but result from kidney ultrasound showed sign of glomerulonephritis, suggesting additional findings in Duke criteria. The patient was treated with broad spectrum antibiotic and heart failure drugs. Then, Heart Team decided to refer the patient to Cardiac Center Harapan Kita for evacuating vegetations and repairing congenital heart defect.

Discussion

Infective endocarditis is one of the most arduous complication that must be treated immediately in patients with VSD. Besides reducing the symptoms that arise from heart defects, the clinicians also have to stop the process of infection. Adequate antibiotics and immediate surgery are the best strategy to evacuate the focus of infection as well as to repair congenital defects.
C55. Intramyocardial dissecting hematoma, a rare complication after myocardial infarction : a case report
Authors: Kaputrin N , Rahimah A F , Rizal A
Published: March 2023

Background

Intramyocardial dissecting hematoma (IDH) is a rare complication of myocardial infarction (MI) that contribute to high morbidity and mortality rate. There is scarce information in literature and hence management uncertainties. Additionally, coronary reperfusion results on the occurrence of IDH is still poorly understood.

Case Summary

A 49-year-old man with a previous anterior wall MI 3 months before without revascularization, presented with a recent onset of New York Heart Association (NYHA) functional class IV heart failure. Echocardiographic diagnosis of IDH was based on the presence of a neocavity with an endomyocardial border extending from the LV mid inferoseptal wall to the apical segments, corroborated with cardiac magnetic resonance (CMR). Coronary angiography showed severe three-vessel disease. The patient underwent staged complete revascularization and kept on optimal medical management. With non-surgical treatment, the patient remained clinically stable and showed a gradual improvement. Repeated echocardiography up to one year after the initial diagnosis demonstrated regression of the haematoma.

Discussion

An unusual form of myocardial rupture that can complicate acute myocardial infarction is IDH. The diagnosis can be missed in some cases. Transthoracic echocardiography may allow diagnosing and evaluating IDH at the bedside. Controversy exists regarding whether surgical repair or conservative treatment is the best option for this condition. The appropriate management should be individualized. Conservative treatment in clinically stable patients suffering from IDH following MI and coronary intervention can be a feasible option.
C56. Isolated Right Ventricular Non-Compaction Cardiomyopathy (IRVNC) in Adolescence: A Case Report
Authors: Fernandes R , Lukito A A , Chandra S , Hutabarat H
Published: March 2023

Background

Non-compaction ventricular myocardium (NCVM) is a rare genetic cause of cardiomyopathy which mostly affects the left ventricle. A limited case of IRVNC was reported which render a limited knowledge for clinician.

Case Summary

A 16-y.o male presented to our emergency unit with recurrent syncope, chest discomfort, palpitation which exaggerated by strenuous exercise. There was no familial history of sudden death. On admission, BP of 102/64 mmHg and bradycardia of 49 bpm were remarkable. Electrocardiography revealed sinus arrhythmia, 49 bpm with early repolarization on precordial leads and LVH. Laboratory tests were in normal limits. Echocardiography revealed hyper-trabeculated RV with no LV-dysfunction. CMR was performed and showed normal LV dimension and function. Right atrium and RV were dilated with RV-dysfunction. RV trabeculae were indicative for IRVNC (NC/C ratio of 4.3). Holter ECG monitoring was done and remarkable for sinus arrhythmia without sinus pause nor ventricular arrhythmia.

Anticoagulant was given for embolic prevention in the non-compacted area. ACEi, β-blockers, and diuretic were not given due to hypotension, bradycardia and no signs of congestion. The patient showed clinical improvement and discharged after 5 days of hospitalization.

Discussions

Recently, there has been no specific criteria and cut off for IRNVC. Earlier studies mentioned that ILVNC criteria could be used for diagnosing IRNVC, as we used in our case. In the future, it’s necessary to determine new cut off points dedicated for IRVNC. Furthermore, close follow-up is needed as complications such as arrhythmia, embolic events and heart failure might occurred.
C57. Left Main Coronary Artery Compression by A Dilatated Pulmonary Artery in Patients with Pulmonary Arterial Hypertension: What Should We Do?
Authors: Jauhari H , Anggrahini D W , Hartopo A B
Published: March 2023

Background

Pulmonary artery hypertension (PAH) is often associated with angina and extrinsic compression of left main coronary artery (LMCA) by a dilatated pulmonary artery is recognized as the cause. The optimal management for pulmonary arterial hypertension with extrinsic LMCA compression has not been clearly established.

Case Summary

We report on 31-year-old female with secundum atrial septal defect and 44 -year-old female with incomplete atrioventricular septal defect complain of progressive typical angina that aggravated with exertion. The electrocardiogram showed right heart strain and chest radiograph showed cardiomegaly involving the right cavities with enlargement of the pulmonary arch. Right heart catheterization showed pulmonary arterial hypertension with the mean pulmonary artery pressure of 61 mmHg and 65 mmHg respectively. Cardiac CT demonstrated compression of proximal LMCA by dilatated pulmonary artery. Although with optimal phosphodiesterase-5 (PDE5) inhibitor and prostacyclin analog therapy, patients still complain of angina.

Discussion

LMCA compression may be associated with additional complications of severe myocardial ischemia, including myocardial infarction, left ventricle dysfunction, arrhythmia, and eventually, sudden death. It may occur in patients with PAH with severely dilated PA and can be identified with either computed tomographic coronary angiography or selective coronary angiography. Furthermore, there are no guidelines recommending optimal management of this disease entity. Optimalization of pharmacologic treatment of PAH may reduce compression-related symptoms. A stent implantation is a promising alternative option for the treatment of LMCA compression and provides an optimal risk-to-benefit ratio, both for symptom relief and for long-term outcomes.
C58. Management of Ellis Type V RV Branch Coronary Perforation Using Handmade Covered-stent: a case report
Authors: Wea Jeffry D D D , Rampengan S H , Pangemanan J A
Published: March 2023

Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI) requiring urgent management including balloon inflation, thrombin, microcoils, fat embolization, autologous blood clots administration, heparin-reversing agent, covered-stent implantation, or surgery. We report a case of Ellis type V RV branch coronary artery perforation during PCI treated with a handmade covered-stent.

A 69-year-old female presented with typical angina in three days. She was hemodynamically stable and no sign of congestion. Laboratory results showed leukocytosis, mild elevation of liver transaminase, elevated CK-MB level, mild hypoalbuminemia. ECG showed sinus rhythm with atrial bigeminy, late-onset inferoposterior and RV MI, and first-degree AV block. TTE revealed reduced LV systolic function (LVEF 45%), impaired LV relaxation, reduced RV function, marked LV hypokinetic in inferior, inferoseptal, apicoseptal, and inferolateral wall, and mild ischemic mitral regurgitation. DCA result showed 90 – 95% tubular stenosis in mid-LAD and total occlusion in proximal-RCA with grade V thrombus. She had an anomaly of RV branch angle that resembles the RCA so that the guidewire perforated the distal part of the RV branch artery. PCI was done using hydrophilic wire to distal RCA. Ellis type V perforation was found following multiple balloon inflation in RV branch. Perforation was managed with a handmade covered-stent using a Sirolimus-eluting stent with Tegaderm film. TIMI flow 3 was reached without thrombi or residual stenosis.

In medical centers that have limited resources, handmade covered-stents can be used as an option after unsuccessful balloon inflation trial.
C59. Management of Subacute Painless Aortic Dissection Stanford A Debakey II in Patient With Undiagnosed Marfan Syndrome During Pregnancy
Authors: Fadlan Muhamad Rizki , Kurnianingsih Novi , Widito Sasmojo , Sargowo Djanggan
Published: March 2023

Background

Pregnant women with Marfan’s syndrome needed multidisciplinary approach to evaluate pregnancy status, fetal and maternal outcome. Marfan’s syndrome was an inherited autosomal dominant with mutation of fibrillin-I (FBN1) gene. Pregnant woman with MFS can lead to aortic dissection. It’s increase 23% of maternal mortality and 35% of fetal death.

Case Summary

a 30 year-old pregnant woman referred from secondary hospital care with valvular heart disease (severe aortic regurgitation due to dilatation of the aortic root and severe mitral regurgitation). Due to her severe myopia, history of aortic dissection in her family, enlarged of aortic root, pulnus excavatum, scoliosis and arachnodactyly, de novo MFS was suspected. She was diagnosed with marfan’s syndrome according her systemic score was 10 (posive >7), and calculated aortic z score was 6.2 (positive >2). Intimal tears and dilatation of the aortic root were considered to terminate the pregnancy. It’s can result bad neonatal outcome. For the management of a potential vascular catastrophe , monitoring of delivery and repairing the aortic root, we needed to multidisciplinary approach.

Discussion

Patient with marfan’s syndrome during pregnancy, may develop painless aortic dissection because massive dilatation of aortic arch prevent compression of pain sensitive structure. Less evidence to manage pregnant woman with MFS with aortic root dilatation more than 45 mm and or progressively dilatation of aortic root ( more than 0.5 mm/year). This patient was categorized as class IV modified WHO classification with high risk maternal mortality and severe morbidity.
C60. Management of Symptomatic Wolff-Parkinson-White (WPW) Syndrome: A Case Report
Authors: Lestari Puspa , Rizal Ardian , A Yudi Putra , Fadlan M R , Ardhi R A Lukitasari Ayu Galuh
Published: March 2023

Background

Atrioventricular reentrant tachycardia (AVRT) could be the reentrant tachyarrhythmia that occurs in Wolff-Parkinson-White (WPW) syndrome. In AVRT, the existence of normal AV node and accessory pathway (AP) along with the atria and ventricles establish the electrical circuit that permits impulse re-entry. The incidence of multiple accessory pathways (MAP) is reported 3-15% and incidence of sudden cardiac death (SCD) in WPW syndrome is about 0.25% per year or 3% to 4% over a lifetime.

Case Description

We presented a case of Wolff-Parkinson-White Syndrome. A 28-year old man was admitted for evaluation of frequent episodes of palpitation. The diagnosis of WPW syndrome was established based on the 12 lead surface electrocardiogram (ECG). Echocardiography showed normal resting echocardiography then we performed electrophysiology study (EPS). We conducted the radiofrequency ablation (RFA) to the accessory pathway (AP). The challenging point of this case was multiple accessory pathways (APs) located at right posteroseptal and left lateral.

Discussion

Ablation of multiple accessory pathways (MAP) had a longer fluoroscopic time and large number of unsuccessful attempts than those with a single accessory pathway. We performed RFA at right posteroseptal and left lateral accessory pathway. The radiofrequency ablation has successfully eliminated both accessory pathways. In summary, we conclude that anatomical consideration, EP study, and the ablation strategy was important to improve the safety and success rate of RFA procedure.
C61. Managing Acute Decompensated Heart Failure with Exacerbation of Chronic Obstructive Pulmonary Disease in Rural Area: A Case Report
Authors: Irfon R , Jusram  , Anggriana E
Published: March 2023

Background

COPD is one of the comorbidities in heart failure patients with a prevalence of around 10-41%. The mortality and morbidity increase in patients with concomitant HF and COPD.

Case Description

A-54-year-old man, smoker, complained dyspnea that worsen for 48 hours, orthopnea, worsening productive cough with thick phlegm for 1 week, diaphoresis, and fatigue. History of untreated COPD since 2014, dyslipidemia, heart attack, and hypertension since 2018. Examination: Obesity, HR 54x/min, RR 30 x/min, BP 140/90 mmHg, SpO2 96% on O2 4 lpm. JVP was increased, gallops, bilateral crackles, wheezing, and pre-tibial edema. WBC count was 15.000, Inferior OMI and LVH on ECG. Signs of pulmonary congestion, cardiomegaly, and increased Broncho-vascular pattern on chest X-ray. Echocardiography and cardiac marker testing were unavailable. The patient was diagnosed with ADHF and AECOPD. The patient was initially given furosemide IV, ramipril, spironolactone but didn’t improve. SABA-anticholinergic nebulization was added then and improved the symptoms. These medications were continued and added corticosteroid IV, antibiotics, aspirin in inward room. After 5 days of treatment, the patient improved, considered as outpatient and advised to control after 3 days.

Discussion

In the limited setting, manages patients with heart disease is challenging. History of untreated COPD, heart attack, hypertension, and dyslipidemia led the patient to this condition. There was no consensus in managing HF in the COPD population. Clinical consideration based on the dominant patient condition was suggested by some studies. This patient had significant improvement after combining diuretic, nebulization, and corticosteroid.
C62. May-Thurner syndrome, a diagnosis and endovascular treatment in adult women with no risk factor: a case report and literature review
Authors: Hidayatullah F N , Pasciolly R M R J
Published: March 2023

May-Thurner syndrome (MTS) is a venous compression syndrome in which the left common iliac vein (LCIV) is compressed between the lower lumbar spine and the right common iliac artery (RCIA). This syndrome is suspected when a patient presents with recurrent or chronic venous insufficiency (CVI) or deep vein thrombosis (DVT) on his/her left lower extremity; although MTS’ clinical presentation varies. A history of recurrent left lower extremity DVT and symptoms associated with chronic venous hypertension, including varicosities, venous ulcers, lower limb swelling, and pain in the inguinal, calf, or upper leg regions suggests MTS diagnosis. We present a case report and conduct a literature review on a patient presenting with painful, numb, and swollen left leg since three months before admission. Intermittent claudication was found. Doppler ultrasonography confirmed no thrombus, yet suggested that the RCIA compressed the LCIV. Doppler’s finding was confirmed using computed tomography (CT) scan, and RCIA compression seemed to cause an obstruction. MTS diagnosis is often missed in patients with lower limb pain because the block is not caused by a thrombus and a clinician often misses to conduct Doppler examination on the iliac artery/vein. This study highlights the importance of considering MTS in a patient with left lower limb pain, and chronic DVT which is unresponsive to pharmacological treatment, hence, endovascular treatment may be warranted.
C67. Patent Ductus Arteriosus Closure with Transthoracic Echocardiography Guidance, Small Changes with a Big Impact: a case report
Authors: Nurawita R , Laode M , Andi A U , Yulius P , Aussie F G
Published: March 2023

Background

Patent Ductus Arteriosus (PDA) is one of the most common congenital heart diseases with a left to right shunt. PDA occurs in 5-10% of all congenital heart disease, excluding premature infants. It is more frequently occurs in women compared to men. Patients could be asymptomatic depending on the size of the PDA, systemic and pulmonary vascular resistance, and the size of the left-to-right shunt.

Case Description

We report a case of an 18-year-old girl presenting with PDA and left-to-right shunt. The patient underwent a PDA closure with a transthoracic echocardiography (TTE) guidance and used an occluder device. The procedure was performed without any complication, the patient was stable, and from the TTE control, we found no residual shunt and device in situ.

Discussion

Several adverse effects of PDA closure using fluoroscopy guidance had been highlighted due to its radiation exposure. The necessity of using a contrast agent is also confirmed to increase the patient risk. To this end, the closure of PDA using TTE guidance was developed to prevent the side effect of fluoroscopy for both doctors and patients. This method required a well-developed collaboration between the pediatric interventional cardiologist and echo-cardiologist. In conclusion, PDA Closure using a device and TTE guidance is as effective as fluoroscopy guidance. Closure of the PDA using TTE guidance may prevent patients and doctors from the adverse effects of radiation and minimize the risk of contrast agents.
C68. Patient with Zero Coronary Calcium Score and Significant Stenosis in Left Anterior Descending Coronary Artery: a case report
Authors: Dylan R , Suratna K S K , Rampengan S H , Pangemanan J A
Published: March 2023

Background

Coronary heart disease is pathological process characterized by the accumulation of atherosclerotic plaque in the epicardial artery, either obstructive or non-obstructive. Coronary calcium score (CCS) detects and calculates coronary artery calcification (CAC) and CT coronary angiography (CTCA) allows evaluation of the coronary arteries anatomy for luminal stenosis due to atherosclerotic plaque with or without calcification.

Case Description

A 70 years-old man, admitted to the emergency department with a chief complain of chest pain. Physical examination was within normal limits. His treadmill stress testing was positive ischemic response one month prior. Then patient undergoing CTCA, the result was zero calcium score with 90-99% stenosis at proximal left anterior descending (LAD) due to soft plaque. Invasive coronary angiography (ICA) confirmed the CT findings and showed total occlusion with grade V thrombus in osteal LAD.

Discussion

A study showed that 1-2% of symptomatic patients with zero CAC potentially had obstructive CAD. It is supported with this report that the patient had typical chest pain with zero calcium score. CCTA has high sensitivity and negative predictive value for the detection of CAD but has a relatively low positive predictive value, especially for moderate severity coronary. In this report CTCA showed 90% -99% stenosis at the proximal LAD and correlate with ICA findings.
C69. Percutaneous Balloon Pulmonary Valvuloplasty for Critical Pulmonary Stenosis Baby as A Challenging Management in Resource-Limited Hospital: A Case Report
Authors: Sitio M , Santoso A S , Iskandar  , Widasmara S , Koentartiwi D , Yogibuana V , Martini H
Published: March 2023

Background

Severe or critical right ventricular outflow tract obstructions are life-threatening conditions. Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis.

Case Summary

A-50-day-old cyanotic baby girl, weighing 4.4 kg, was admitted to hospital with a bluish appearance insidiously progressing over the preceding 2 weeks. Transthoracic echocardiogram (TTE) revealed critical pulmonary valvular stenosis with pulmonary valve annulus diameter 7 mm, severe tricuspid regurgitation (TR), restrictive intraatrial mixing physiology, and an almost spontaneously closed Patent Ductus Arteriosus. The patient underwent percutaneous balloon pulmonary valvuloplasty (BPV). The available balloon, Tyshak mini balloon 9.0 mm x 20 mm, failed to across stenotic lession. It was replaced with coronary balloon 2 mm x 10 mm and inflated several times with a maximum pressure of 10 mmHg within 10 seconds. After the valve was adequately opened, the coronary balloon was replaced by previous Tyshak mini balloon. It was inflated once with pressure of 3 mmHg for 5 seconds. Successful dilatation is indicated by the disappearance of the waist around the balloon under cineangiography. RV-PA gradient decreased from 67 mmHg to 38 mmHg, a 43% reduction. After the procedure, the patient was no longer cyanotic. TTE after BPV demonstrated no pulmonary stenosis, TR TVG decreased from 100 mmHg to 20 mmHg, and no pulmonary regurgitation.

Discussion

Our successful results suggest that percutaneous balloon pulmonary valvuloplasty is a potential and safe intervention for babies with critical Pulmonal Stenosis that was conducted in resource-limited hospital.
C71. Perimyocarditis related Corona Virus Disease: A Case Report
Authors: Budi D S , Anggrahini D W , Hartopo A B
Published: March 2023

Background

One of the ongoing outbreaks is the SARS-COV2 with clinical manifestations are dominated by pulmonary symptoms. However, some patients have reported mild to severe cardiovascular damage1.

Case Summary

We report a 26-year-old male with confirmed Corona Virus Disease (COVID-19), who has manifestation of perimyocarditis. Diagnosis was built through clinical symptoms of fever, dyspnea, with ST elevation and PR depression on ECG, and an increase of hs-Troponin I and NT-Pro-BNP. There appeared to be a pericardial effusion on echocardiography, and an increase number of cardiothoracic ratio (CTR) during the infection. All of the perimyocarditis parameters improved when symptoms are decrease meanwhile laboratory showing improvement of inflammatory parameters (CRP, D-Dimer).

Discussion

Acute perimyocarditis is a reported cardiac complication of COVID-191. COVID-19 perimyocarditis associated with pericardial effusion and cardiac tamponade2. Electrocardiogram (ECG) abnormalities commonly seen with pericarditis, such as ST elevation and PR depression, may be observed in myocarditis3. Many COVID-19 patients were reported to have a detectable level of cardiac-Troponin-I as a result of oxygen supply–demand mismatch, which could precipitate ischemia that results in type 2 myocardial infarction. NT-pro-BNP level also could increase secondary to myocardial stress, a possible knock-on effect from severe respiratory illness4.
C74. Post covid-19 cardiomyopathy in an adolescent patient: a case report
Authors: Pujowaskito P , Tartila T S , Tafriend N A , Jannah F D K
Published: March 2023

Background

Myocardial injury caused by viral myocarditis may occur during COVID-19 infections. This condition may lead to cardiomyopathy as the chronic sequela. We report a case of an adolescent COVID-19 survivor without underlying heart disease presented with dilated cardiomyopathy. 

Case Summary

A 16-year-old male patient was referred to Cardiology Outpatient Clinic, Indonesian Army Central Hospital Gatot Soebroto. The patient presented with a chief complaint of fatigue and just recovered from mild to moderate COVID-19 one month before the visit. There was no prior history of heart disease. Physical examination was within normal limit, but laboratory findings showed highly elevated NT-proBNP (7705 pg/mL) and D-dimer (1850 ng/mL). ECG revealed normal sinus rhythm with poor R wave progression. Echocardiography detected all chamber dilatation, eccentric left ventricular hypertrophy, global hypokinetic, moderate mitral regurgitation, and reduced ejection fraction (22%). The patient was diagnosed with new-onset dilated cardiomyopathy as a COVID-19 sequela and we initiated treatment with ARB (candesartan), beta-blocker (bisoprolol), diuretics (furosemide and spironolactone), rivaroxaban, and trimetazidine. During a follow-up visit three months later, the patient’s recovery was stable.

Discussion

 The occurrence of new-onset cardiomyopathy in our previously healthy young patient highlights the possible mechanism of COVID-19 as a single cause of myocardial injury without underlying heart disease. Comprehensive evaluation and optimal treatment should be taken during hospitalization and post-discharge period to prevent further complications. Additional examinations such as cardiac magnetic resonance and endomyocardial biopsy should be done to provide definitive confirmation.
C79. Pseudonormalisation ECG Pattern in Wellens’ Syndrome : A Pitfall in front of Our Eyes
Authors: Bahri Z , Lubis H A P , Haykal T B , Hasan H
Published: March 2023

Background

Wellens’ syndrome is a syndrome characterized by biphasic (type A) or deeply inverted T-wave (type B) in the anterior lead, without Q-waves and significant ST elevation, no loss of precordial R-wave progression, normal to minimally elevated cardiac enzymes, and a history of angina.

Case Summary

A 37-years-old male patient was admitted to the emergency department with the chief complaint of typical chest pain lasting for about 1 h. He had type 2 diabetes and a history of smoking. First ECG showed non-specific ST-T changes in the lateral lead. On ECG which was taken two hours later in the pain-free period, deeply inverted T waves were seen in the lead V2 and V3. Troponin I was found as 0.25 ng/mL. The patient was admitted to CVCU and brought to the angiography laboratory next day. A 90%-99% critical proximal LAD occlusion was observed. PCI was successfully performed with drug-eluting stent implantation and good restoration of LAD flow. He was discharged from the hospital on the following day without any complication after coronary intervention.

Discussion

Pseudonormalisation of T wave in pain period could be misinterpreted as normal ECG and could delay coronary angiography and revascularization. We should aware if a patient with typical chest pain came with normal or non-specific ECG changes. Evaluation of ECG in the pain-free period is crucial and leads to the best decision in managing the patient with this syndrome.
C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series
Authors: Ibrahim M , Saboe A , Kartamihardja A H A , Cool C J
Published: March 2023

Background

Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE).

Case Description

We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused.

Discussion

The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.