Exploring Clinical and Echocardiographic Factors in EHRA Type 2 Atrial Fibrillation for Predicting Ischaemic Stroke: A Search for Unrevealed Insights

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. Valvular heart diseases (VHD), regardless of the arrhythmic problems, increase the risk of thromboembolism, which are even higher in those with associated atrial fibrillation. The EHRA (Evaluated Heartvalves, Rheumatic or Artificial) classification categorised AF patients with significant VHD into type 1 and type 2. Unfortunately, there are currently very limited data on risk prediction in stroke-related valvular AF, particularly in the Asian population. Aims: To investigate the clinical and echocardiographic risk factors for ischaemic stroke prediction in patients with EHRA type 2 VHD. Methods: This retrospective study enrolled 695 AF patients with EHRA type 2 VHD. The data were collected from patients' medical records who met the inclusion and exclusion criteria from 2015 until 2020. The primary outcome was ischaemic strokes within observation period. Results: There were 67 ischaemic stroke events (9,6%) of the total sample. Our analysis found that none of the analysed variables proved to be statistically significant risk factors in predicting the occurrence of ischaemic stroke. The median CHA2DS2-VASc risk prediction in the sample was 3, with an accuracy of AUC 0.502 (CI 95%; 0.429 – 0.576), sensitivity 56.7% and specificity  44.7%. Conclusion: Based on the parameters analysed in this study, no factor was statistically well-predictive to predict the ischaemic stroke incidence in EHRA type 2 VHD AF. In addition, the CHA2DS2-VAS accuracy was low in this population. Further exploration is needed to build an accurate ischaemic stroke risk prediction for EHRA type 2 VHD

Factors Influencing Mortality of Thoracic Aortic Surgery in The Third World Country

Abstract Background: A prominent increase of overall global death rate of aortic disease is seen on developing country, with South-east Asia having the highest increase of 41%. Lack of identification and prompt management of the diseases in conjunction with lack of facilities in third world countries that could perform aortic surgery made the procedure more complex when the patients admitted to tertiary hospitals Methods: The data was obtained through medical record of patients underwent thoracic aortic surgery from 2018 to 2021 in National Cardiovascular Center Harapan Kita (NCCHK). One-year and 3-year survival analysis was obtained through phone calls and digital messages. Statistical analysis was done to investigate the impact of surgical complexity as the main predictor and other variables on primary (in-hospital mortality) and secondary (mid-term survival) outcome. Results: A total of 208 patients were included in the analysis; 157 (75,5%) underwent  complex surgery, and 51 (24,5%) underwent non-complex surgery. In-hospital mortality was similar across 2 groups (23,6% vs 13,7%; p = 0,1240). On multivariable analysis, malperfusion syndrome (OR 3,560; p = 0,002), CPB duration > 180 minutes (OR 4,331; p = 0,001), and surgical priority (urgent OR 4,196; p = 0,003; emergency OR 10,879; p = 0,001) were identified as independent predictor of in-hospital mortality. Cox regression identified diabetes (HR 4,539; p = 0,025) and emergency procedure (HR 9,561; p = 0,015) as independent predictors for 1-year mortality, and diabetes (HR 3,609; p = 0,004), aortic dissection (HR 2,795; p = 0,029), and maximum aortic diameter (HR 1,034; p = 0,003) for 3-year mortality. Surgical complexity was not associated with early and mid-term mortality. Conclusions: In patients undergoing thoracic aortic surgery, surgical complexity was not associated with early and mid-term survival. Early and mid-term survival was largely determined by patient comorbidities and intra-surgery factors

Validasi Skor PEACH sebagai Prediktor Mortalitas Selama Rawatan Paska Operasi Penyakit Jantung Bawaan Pada Dewasa di Rumah Sakit Umum Pusat Haji Adam Malik Medan

Introduction: Congenital heart disease (CHD) is an abnormality in the structure and function of the heart that is acquired while still intrauterine where the incidence of CHD worldwide is estimated at around 8 cases per 1,000 live births. Even though the development of the medical science is currently advanced, there are still CHD patients who are lately diagnosed and found when the patient is an adult so it requires surgical interventions. The PEACH score is a score that can predict postoperative in-hospital mortality in adults CHD patients. This study aims to validate the PEACH score. Methods: This is a retrospective cohort study of 52 adult patients with CHD who underwent surgery at Haji Adam Malik General Hospital from January 2019 to April 2023. Validation was analyzed using a calibration and discrimination test to the PEACH score in predicting postoperative in-hospital mortality. Result: The incidence of in-hospital mortality was 8 (15.4%) patients. There is a relationship between the PEACH score group and the incidence of mortality (p=0.006). The results of the calibration test using the Hosmer and Lameshow analysis and the discrimination test using the Receiver Operating Characteristic analysis showed good validation (p=0.85; AUC=0.83). Conclusion: The PEACH score is valid for predicting postoperative in-hospital mortality in adult congenital heart disease at Haji Adam Malik General Hospital.Latar Belakang: Penyakit jantung bawaan (PJB) merupakan kelainan baik pada struktur maupun fungsi jantung yang didapat sejak masih berada dalam kandungan dimana angka kejadian PJB di seluruh dunia diperkirakan sekitar 8 kasus setiap 1.000 kelahiran hidup. Meskipun perkembangan dunia kedokteran saat ini cukup pesat, masih terdapat pasien PJB yang terlambat didiagnosis dan ditemukan pada saat pasien sudah beranjak dewasa serta membutuhkan penanganan secara operasi. Skor PEACH merupakan skor yang dapat memprediksi mortalitas selama rawatan paska operasi PJB pada dewasa. Penelitian ini bertujuan untuk memvalidasi skor PEACH dalam memprediksi mortalitas selama rawatan paska operasi PJB pada dewasa. Metode: Penelitian ini merupakan penelitian kohort retrospektif terhadap 52 pasien dewasa dengan PJB yang menjalani operasi di RSUP HAM sejak Januari 2019 sampai April 2023. Dilakukan validasi dengan uji kalibrasi dan diskriminasi terhadap skor PEACH dalam memprediksi mortalitas selama rawatan di rumah sakit. Hasil: Jumlah mortalitas selama rawatan adalah 8 (15.4%) pasien. Terdapat hubungan antara kelompok skor PEACH dengan kejadian mortalitas (p=0.006). Hasil uji kalibrasi dengan analisis Hosmer and Lameshow dan uji diskriminasi dengan analisis Receiver Operating Characteristic menunjukkan validasi yang cukup baik (p=0.85; AUC=0.83). Kesimpulan: Skor PEACH valid dalam memprediksi mortalitas selama rawatan paska operasi penyakit jantung bawaan pada dewasa di RSUP Haji Adam Malik Meda

Consensus Statements on the Use of High-Sensitivity Troponin I as the Assessment of Cardiac Risk in Apparently Healthy Population in Indonesia

Cardiovascular disease (CVD) is a growing burden in Indonesia, making primary prevention of utmost importance. High sensitivity cardiac troponin I (hsTnI) has been known as one of the biomarkers of choice for diagnosing acute myocardial infarction. Nonetheless, recent studies indicate that hsTnI assay has potential as a predictor of cardiac risk in asymptomatic individuals. An advisory board consisting of renowned cardiologists from the Indonesian Heart Association was convened in Jakarta in March 2023. The meeting aimed to explore the appropriate use of hsTnI for cardiovascular (CV) risk stratification in apparently healthy adults in Indonesia. The board reviewed relevant literature and developed key consensus statements, including hsTnI cut-off for identifying high-risk asymptomatic patients, the proposed algorithm, and monitoring after aggressive risk factor control. This article presents the resulting consensus statements to provide clinicians with a practical tool for planning primary prevention strategies. Furthermore, it is expected to raise awareness and advocacy among stakeholders in the healthcare infrastructure regarding the use of hsTnI as a guide for assessing CV risk in Indonesia

Transcatheter Closure for Ventricular Septal Defect (VSD): Unveiling Key Predictors in Pediatric Interventions

  Background: Transcatheter closure of specific types of VSD has been widely performed, especially in developing countries, with encouraging follow-up results. Nevertheless, adverse outcomes and failure of closure may occur, which requires sufficient attention. Although transcatheter closure is still the preferable and safest procedure, the risk of failure can lead to the surgical VSD closure procedure. Methods: A retrospective cohort study was done in patients who underwent transcatheter VSD closure in the presence of AVP with or without AR at Integrated Cardiac Service Prof. Dr. I G N G Ngoerah General Hospital between July 2009 to June 2022. Failure to close was defined as a device failing to be implanted. Patient demographic and clinical data were collected. Results: Thirty-eight subjects were enrolled, 10 failed to close, where 8 out of 10 of the failure group were with aortic regurgitation, and 7 of the said group were SADC  type. There were 16 males and 22 females. Among 38 subjects, 23 have  perimembranous outlet VSD, and 15 have subarterial doubly committed VSD. Aortic regurgitation was found in 25 of 38 subjects. Transcatheter closure was done either by a retrograde technique using the Amplatzer Duct Occluder-II or an antegrade technique using the NIT occlude and MFO in 11, 3, and 24 subjects, respectively. The failure happened in 10 patients, 3 of them had minor complications, and 7 had no complications. There are 2 patients out of 10 with membranous septal aneurysms that failed to close. The final analysis identified VSD type SADC (RR 3.578; 95%CI 1.093 to 11.711; p = 0.030) as an independent factor associated with predictors of transcatheter closure failure in pediatric patients with VSD. Conclusion: Failure to close in transcatheter closure is higher in the SADC type compared to the PMO type. Transcatheter closure appears to be feasible but still challenging in our center. Keywords:  transcatheter closure outcome, baseline demographic, ventricular septal defect, sub-arterial doubly committed, perimembranous outle

Hubungan Peak Left Atrial Longitudinal Strain dengan Derajat Keparahan Penyakit Jantung Katup Mitral di RSUP Haji Adam Malik Medan

Introduction: Mitral stenosis and regurgitation, are common throughout the world. Peak Left Atrial Strain (PALS) is a parameter for assessing left atrial deformation in the evaluation of atrial function and a predictor of long-term outcome of various heart diseases. In this study, we assessed the relationship between PALS and the severity of mitral stenosis and mitral regurgitation Methods: This is a cross-sectional study on 119 subjects with mitral stenosis and 103 mitral regurgitation who met the inclusion criteria at Haji Adam Malik General Hospital. PALS measurements were taken. Data were analyzed univariate, bivariate, correlate to assess the relationship between PALS and the severity of mitral valve disease Results: 119 patients with severe mitral stenosis. In mitral stenosis, the mean PALS is 8.2 (4.9-22.8). PALS was significantly higher in patients with sinus rhythm than in the group with AF (10.29 ± 3.89 vs 8.63 ± 7.8%; P = 0.002). PALS had a significant correlation with MVA, pressure gradient, and PHT (r = 0.676, P = <0.001; r=-0.594, P= 0.001 and r=-0.594, P= 0.001). Whereas in mitral regurgitation, it has an average PALS of 15.2 (7.8-19.2). PALS was also significantly higher in patients with sinus rhythm than in the group with AF (16.36 ± 2.43 vs 11.64 ± 2.89%, P = 0.001). PALS has a correlation with VC, PISA, EROA and RVol (r = -0.533, P=0.001; r=-0.618; r=-0.563, P=0.001; r= -0.528, P=0.001). Conclusion: PALS has a significant correlation with the assessment of the severity of mitral stenosis and regurgitation.Latar Belakang: Penyakit jantung katup yaitu stenosis mitral dan regurgitasi mitral sering ditemui di seluruh dunia. Peak Left Atrial Strain (PALS) merupakan parameter penilaian deformasi atrium kiri dalam evaluasi fungsi atrium dan prediktor hasil jangka panjang dari berbagai penyakit jantung. Penelitian ini bertujuan untuk mengetahui hubungan antara PALS dengan keparahan stenosis mitral dan regurgitasi mitral. Metode: Penelitian ini merupakan studi analitik dengan desain cross sectional pada  subyek 119 dengan stenosis mitral dan 103 regurgitasi mitral yang memenuhi kriteria inklusi di RSUP H. Adam Malik. Dilakukan pengukuran PALS. Data dianalisa secara univariat dan bivariat serta uji korelasi untuk menilai hubungan PALS dengan derajat keparahan penyakit jantung katup mitral. Hasil: Sebanyak 119 pasien memiliki stenosis mitral derajat berat. Pada stenosis mitral, rata-rata PALS adalah 8,2 (4,9-22,8)%. PALS secara signifikan lebih tinggi pada pasien dengan irama sinus dibandingkan pada kelompok dengan AF (10,29±3,89 vs 8,63±7,8%; P= 0,002). PALS memiliki korelasi yang signifikan dengan MVA, tekanan gradient, dan PHT (r = 0,676, P = <0,001; r=-0,594, P= 0,001 dan r=-0,594, P= 0,001). Sedangkan pada regurgitasi mitral, memiliki rata-rata PALS yaitu 15.2 (7.8-19.2).  PALS juga secara signifikan lebih tinggi pada pasien dengan irama sinus dibandingkan pada kelompok dengan AF (16,36±2,43 vs 11,64±2,89%, P=0,001). PALS memiliki korelasi dengan VC, PISA, EROA dan RVol (r=-0,533, P=0,001; r=-0,618; r=-0,563, P=0,001; r= -0,528, P=0,001). Kesimpulan: PALS memiliki korelasi yang signifikan terhadap penilaian derajat keparahan stenosis mitral dan regurgitasi mitral

Protokol STEMI yang dimodifikasi untuk PPCI selama Pandemi COVID-19: Apakah itu memperpanjang kinerja Door-To-Balloon

Background COVID-19 became a main health problem and causes heavy impact, especially for healthcare system. Managing ST-Segment Elevation Myocardial Infarction (STEMI) patients before COVID-19 pandemic was already challenging enough for Healthcare Professionals (HCP) to pursue time-sensitive treatment. After COVID-19 pandemic, the time-sensitive treatment of pursuing door-to-balloon (DTB) time put a lot more burden to HCP. In this study, We sought to analyze how a change in protocol of PPCI in STEMI patients before and during the pandemic influence the performance of DTB in the hospital.  Methods This is a single-centered retrospective observational study among STEMI patients which was treated by PPCI. Secondary data from the medical record were collected consecutively from April 2018 to January 2022 (46 months). We compared DTB performances before and during the pandemic. Result During 46 months period, the total population of this research was 880 patients. There were total 358 patients underwent PPCI before the pandemic and 522 patients after the pandemic.   Modified protocol with the addition step to prevent the spread of COVID-19 had been implemented since April 2020. DTB increased significantly during the pandemic (90 (70-124) minutes vs 97 (76-135) minutes, p 0.002). The proportion of the patients who achieved DTB under 90 min was also significantly decreasing (56.4% vs 47.9%, p 0.0013).  Conclusion It is necessary for PPCI center to modify PPCI workflow during the pandemic. A decent workflow should consider practicality and simplicity without compromising HCP and patient safety. Implementing modified PPCI workflow during the pandemic significantly increased DTB time but it is still within the limit of being reasonable and acceptable for the benefit of the patients

Utility of Ischemic Signs from Initial ECG in Detecting Culprit Vessels in NSTE-ACS Patients

ABSTRACT Background: Non-ST-Elevation ACS (NSTE-ACS) is a part of ACS which require some special attentions. Multivessel coronary disease (MVD) is common in patients with NSTE-ACS and associated with difficulties in determining the main target of revascularization. ECG is the first-line diagnostic tool in the assessment of patients with suspected ACS. However, the utility of the ECG in localizing coronary culprit lesions in NSTE-ACS is not well established. This study was conducted to evaluate whether the pattern of the ischemic signs in ECG can be used to identify the coronary culprit vessel in patients with NSTE-ACS. Methods: This is a single-centered cross-sectional study using secondary data. The data of all 101 patients with NSTE-ACS who were planned for revascularization procedure between January 2021 and December 2021 were collected from medical record. ECG with ischemic signs were classified to three locations of suspected coronary vessel with culprit lesions and it will be compared to its corresponding angiographic data. The accuracy data will be presented including both sensitivity and specificity. Results: This study involved 75 men (74.3%) and 26 women (25.7%) with mean age 61.2±9.1 years old. There were 72 patients presented with ischemic signs form ECG with identifiable culprit vessel to be suspected. The sensitivity and specificity of ischemic signs ECG in localizing culprit vessels from angiography were 37.0% and 85.5% in LAD distribution, 38.1% and 81.3% in LCX distribution, and 41.1% and 85.1% in RCA distribution, respectively. Conclusion: Overall ischemic signs in ECG gave impression of modest accuracy with conspicuous key points that ECG distribution have high specificity in detecting culprit vessels but with low sensitivity. Thus, ischemic signs from initial ECG can be used to detect culprit vessels in NSTE-ACS patients. Keyword: Culprit Lesion, ECG, NSTEMI, UAP, PC

Impact of acute kidney injury in patients with acute decompensated heart failure: Cardiorenal syndrome

Cardiorenal syndrome (CRS) is a complex interdependent relationship between the heart and kidneys, prevalent in hospitalized patients with acute decompensated heart failure (ADHF). The main aim of this study is to evaluation of cardiac and renal function, treatment factors, and outcomes in view of mortality and persistent renal dysfunction in acute decompensated heart failure (cardio renal syndrome type 1) patients. We studied 100 patients hospitalised with ADHF and acute kidney injury (AKI). Patients were evaluated clinically, biochemically, ultrasonographically, and echocardiographically to assess demographics, etiologic and risk factors, cardiac and renal function, and outcomes in view of mortality and persistent renal dysfunction. The study monitored the patients until discharge and follow up with three months to one year. Record information about functional improvement, worsening symptoms, and mortality. The majority of the patients were males (72%), with dyspnea being the most common symptom (92%) followed by decreased urinary output (82%). The mean age of the patients was 62.60 years. Low level of Mean arterial pressure (MAP) 18.97 (95% CI 4.59 to 78.37, P 0.0001), estimated glomerular filtration rate (eGFR) 0.92(95% CI 0.87 to 0.99; P 0.02), maximum creatinine 3.08 (95% CI 1.67 to 5.67, P 0.0001), maximum level of urea 1.02(95% CI, P 0.001), lower Left ventricular ejection fraction (LVEF) 1.05 (95% CI 0.15 to 0.84, P 0.04) were independently predictors of in-hospital mortality. CRS-1 is associated with increased risk of mortality (25%), residual renal dysfunction (16%) at one year follow up. Persistent renal dysfunction, renal replacement therapy possibly improves for the treating persistent renal dysfunction, and recurrent HHF (more than 2 admissions) post hospitalisation index within twelve months were predictors of mortality (25%) at one-year

Simplified Selvester QRS Score as an Infarct Size Parameter in STEMI Patients Undergoing Pharmacoinvasive or Primary Percutaneous Coronary Intervention

Background:Cardiovascular disease especially acute myocardial infarct (AMI) is one of the highest cause of mortality worldwide. Majority of AMI comes in the form of ST elevation myocardial infarct (STEMI) that requires timely diagnosis and revascularization management to restore myocardial circulation. The simple method to estimate infarct size is by using simplified Selvester QRS Score to electrocardiogram records, which is a tested  method that have good correlation with gold standard, namely cardiac magnetic resonance imaging.   Objectives :  To investigate difference of infarct size with simplified Selvester QRS score parameter between STEMI patients undergoing pharmacoinvasive compared to primary PCI. Methods: Eighty-two STEMI patients, 41 of pharmacoinvasive and 41 of primary PCI was scored with simplified Selvester QRS score from electrocardiogram recording. Patient data are retroactively taken form Sardjito Cardiovascular Intensive Care (SCIENCE) registry. Scoring of simplified Selvester QRS Score was done by two experienced cardiologist blinded to patient procedure, and results then measured for interobserver agreement with Bland-Altman test. Comparison of QRS Score in pharmacoinvasive and primary PCI group was done with independent sample T test followed with multivariable linear regression test. Results: The means of simplified Selvester QRS score in pharmacoinvasive and primary PCI group is 7.240±3.015 and 8.900±4.188, p=0.043, respectively. Independent sample T test shows significant difference in the simplified Selvester QRS score in pharmacoinvasive and primary PCI group. The multivariable analysis shows that variables other than revascularization method independently influences QRS score are onset, anterior segment ST elevation and ST segment elevation in more > 3 leads in electrocardiogram. Conclusion: There is significant difference in infarct size measured by simplified Selvester QRS score betweem STEMI patient undergoing pharmacoinvasive method compared to primary PCI procedure, which is lower in the pharmacoinvasive grou