Neurohumoral Pathway in Heart Failure

Heart Failure is now considered as one of the leading cause for mortality and morbidity. It is affecting several organs and cause organ damages due to the myocardial failure to pump inadequate oxygenated blood to the body including metabolites, to end organs and peripheral tissues.  Heart failure results from multifactorial mechanism including neurohumoral activations including increased activity of the sympathetic nervous system, renin-angiotensin aldosteron system, vasopression and the atrial natriuretic peptide. This neurohumoral pathway has significant contribution to the development of myocardial dysfunction that lead to clinical manifestation of heart failure. Some of the markers in these pathways have now been considered as an independent predictors of prognosis in heart failure patient

Clopidogrel Resistance in Patients with Coronary Stent Thrombosis

Antiplatelet drugs plays important role in the therapy of atherothrombosis. Dual antiplatelet therapy is recommended as a strategy for the prevention of stent thrombosis in patients who underwent Percutaneus Coronary Intervention (PCI). In combination with aspirin, tienoperidine is currently the drug of choice to prevent stent thrombosis. The issue of the high inter-individual variability ofresponse is clinically relevant, since poor responders are not adequately protected from major adverse cardiac events (MACE). We reported a 62-years old woman underwent primary PCI with implantation of BAS. She was later known to have in-stent thrombosis in the LAD after repeated angiography. The probable cause for the later cardiac event in this patient were overlapped stent, small vessel diameter, diabetes mellitus, and the patients also shown a persistent platelet reactivity despite clopidogrel therapy. We administered this patient with pasugrel as antiplatelet replacing clopidogrel and the patient was managed without ischemic symptoms afterwards

Surgical and Non Surgical Interventions in Adult Congenital Heart Disease: Our Experience from COHARD registry

Surgical and Non Surgical Interventions in Adult Congenital Heart Disease:Our Experience from COHARD registr

29-Years Old Woman Presenting with ST Elevation Myocardial Infarction

Myocardial infarction in young female is rare condition, but carries significant morbidity and mortality. The recognition management for MI in young female is challenging due to its unspecific clinical presentation and lack of guidance in the current guidelines. We reported a 29-years old woman presenting with infarction type chest pain, showing ST- elevation in the inferior leads with total AVblock as complication. The risk factors in this patient were smoking, family history, cardiomyopathy, and preeclampsia history. The cause for myocardial infarction in this patient was atherosclerotic plaque rupture, but we did not manage to performed coronary intervention due to her low ventricular function and unavailability data for myocardial viability at the time of hospitalization

T Peak–T End Interval Alteration as Parameter of Successful Fibrinolysis in Patients with ST Segment Elevation Acute Myocardial Infarction

Background: In STEMI patients, the duration of action potential dispersion occurs between normal and ischemic tissue due to the lengthening of the refractory period, causing transmural dispersion of repolarization, which could be detected with Tp-Te interval prolongation on the electrocardiogram (ECG). Benefits of fibrinolytic therapy in patients with STEMI has been demonstrated, with reduced mortality significantly and improve coronary patency in order to increase myocardial perfusion. The goal of this study was to determine Tp-Te interval alteration in STEMI patients before and after the fibrinolytic therapy between successful fibrinolysis compared to failed fibrinolysis. Method: Cross-sectional study was conducted to collect ECG from medical records at Dr. Sardjito General Hospital in January–September 2016. STEMI patients with onset less than 12hours whom reperfused with fibrinolytic therapy were registered. Tp-Te interval was measured before, soon after (0 minute), and 30 minutes after fibrinolysis with successful and failed results. The unpaired t-test analysis was used to compare Tp-Te interval alteration after fibrinolysis. Then, ΔTp-Te cut-off value was determined to find sensitivity and specificity based on ROC. Result: Among 84 patients enrolled in this study, 46 patients with successful fibrinolysis and 38patients with failed fibrinolysis. Both of groups had Tp-Te interval prolongation before fibrinolysis, with mean value of 120.30 ± 13.02 ms in successful fibrinolysis group and 118.57 ± 15.24 ms in failed fibrinolysis group. In successful fibrinolysis group, Tp-Te interval reduced significantly with ΔTp-Te value of 17.55 ± 13.35 ms on 0 minute and 20.85 ± 15.62 ms on 30 minutes after fibrinolysis, while in failed fibrinolysis group there was not a decrease of Tp-Te interval with ΔTp-Te value of -0.77 ± 11.00 ms on 0 minute (p <0.001) and -1.53 ± 14.35 ms on 30 minutes after fibrinolysis (p <0.001). Cut-off value ΔTp-Te 20 ms had sensitivity 52.2% and specificity 94.7% based on ROC, with strong discriminator value of AUC (0.888). Conclusion: There was a greater reduction of Tp-Te interval in STEMI patients with successful fibrinolysis compared to failed fibrinolysis, so it may be used as a alternative parameter of successful fibrinolysisKeywords: STEMI; Tp-Te interval; fibrinolysi

Significance of Six Minute Walking Distance in Predicting Functional Capacity Status of Patients with Pulmonary Hypertension Complicating an Atrial Septal Defect

Background: Six minute walk test (6 MWT) is a sub-maximal exercise test that measures an integrated response of all systems responsible during exercise. Pulmonary arterial hypertension (PAH) is a problem encountered by patients with atrial septal defect (ASD). Assessment of functional capacity in patients with PAH based on the WHO functional classifi cation remains a powerfulpredictor of survival in these patients. The World Health Organization functional classifi cation is a subjective tool because it is based on anamnesis of ordinary activity. On the contrary, 6 MWT is an objective tool to measure functional capacity of patients with pulmonary hypertension. Objective: To determine the walking distance obtained using 6 MWT as a measurement of functionalcapacity in ASD patients with PAH. Methods: A cross sectional study was used to determine the walking distance as a measurement of functional capacity in ASD patient with PAH. This study was a sub-study of an Atrial Septal DefectRegistry done in RSUP Dr. Sardijto, Yogyakarta, since 2012. Pulmonary arterial pressure was measured using Pulmonary Arterial Systolic Pressure (PASP) obtained from echocardiography. Pulmonary hypertension was divided into three categories based on PASP, mild with PASP of less than 45 mmHg, moderate with PASP of 45-59 mmHg and severe with PASP of more than 60 mmHg. All patients did 6 MWT to measure their functional capacity. The relationship between 6 MWT distance and severity of PAH was measured using Pearson correlation analysis. Results: Forty-three patients were included in this study with 32 female patients (74%) and 11 male patients (26%) with an age range of 17-70 years old. Forty-four patients (44%) with ASD had severe PAH. The mean of 6 MWT distance was 337 m. There were signifi cant differences between mild, moderate and severe PAH in correlation with the 6 MWT distance (p= 0.001). The patients with severe PAH had only 278 m walking distance compared to those with mild PAH who had 394 m walking distance. There was a significant relationship between the 6 MWT distance and severity of PAH (p=0.01). This study showed that 6 MWT correlates negatively with the severity of PAH. We found that the higher pulmonary arterial pressure, the shorter walking distance (p=0.01, r -0,506). Conclusion: ASD defect patients with severe PAH had shorter walking distance compared to those with mild PAH. The 6 MWT is a reliable and objective measurement of functional capacity for ASD patients with PAH

Correlation Between Right Ventricular Function Using Myocardial Performance Index (Tei Index) with Pulmonary Arterial Hypertension Severity in Patient with Atrial Septal Defect

Background: Right ventricular (RV) volume overload that occurs in patients with atrial septal defect (ASD) could lead to the development of pulmonary arterial hypertension (PAH). RV function has been found depressed in some patients with PAH. Myocardial performance index (MPI) is one of methods to assess RV function. The aim of this study was to assess correlation between RVfunction using RV-MPI with PAH severity in patients with ASD. Methods: We conducted a cross sectional study between July 2012-July 2013. We enrolled 67patients with secundum type ASD. RV-MPI, defi ned as the sum of isovolumic relaxation time and isovolumic contraction time derived by ejection time, was measured from tricuspid infl ow and RV outflow. The normal range is 0.28-0.32. Pulmonary artery systolic pressure (PASP) was measured from echocardiography. Results: There were 67 patients (54 women) with mean age was 38.01±14.29 years (11.9% with no PAH, 11.9% mild PAH, 26.9% moderate PAH and 49.3% severe PAH). The mean PASP was 67.16±32.33 mmHg and mean MPI was 0.44±0.25. We found signifi cant correlation between PASP and MPI (r=0.73; p=0.000). In addition, we classifi ed the PAH severity based on PASP and there was signifi cant differences of MPI between groups (no PAH, MPI 0.25±0.07; mild PAH 0.24±0.05; moderate PAH 0.24±0.12; severe PAH 0.63±0.21; p=0.000). Furthermore, in severe PAH group, the correlation between PASP and MPI remain signifi cant (r=0.42; p<0.05). Conclusion: These result demonstrate a correlation between PAH severity and MPI in patientswith ASD. Specifi cally, RV function found decreased in ASD patients with severe PAH.Keyword: myocardial performance index (Tei index), pulmonary arterial hypertension, right ventricular function, atrial septal defec

Pericardial and Pleural Effusion in Patient with Relapse Stage IV Breast Cancer: Same Pathology, Different Etiology?

Pericardial effusion associated with malignacy has poor prognosis. The prompt identification of etiology is mandatory, such that timely management can be performed and survival can be increased. However, difficulty in etiology determination is commonly encountered. In this case, we report female patient with relapse stage IV breast cancer who develop massive pericardial and bilateral pleural effusion. The similar characteristics were found in both effusion fluids, however the identification of etiology was not similar. Metastatic cells were found in pleural effusion, whereas they were absent in pericardial effusion

The BMPR2, ALK1 and ENG Genes Mutation in Congenital Heart DiseaseAssociated Pulmonary Artery Hypertension

The gene mutation is one of the background underlie the pathogenesis of pulmonary artery hypertension (PAH). Several genes have been recognized to be responsible for the development of PAH. The mutation in transforming growth factor-β (TGF-β) pathway is considered to be major genotype background in heritable PAH. The genetic mutation in bone morphogenetic protein receptor-2 (BMPR2), activin receptor-like kinase 1 (ALK-1) and endoglin (ENG) are known to cause heritable PAH. In congenital heart disease–associated PAH (CHDAPAH), their mutation are also presence

The Incidence of Mitral Valve Prolapse and Mitral Valve Regurgitation in Patient with Secundum Atrial Septal Defect

Background: Association between secundum atrial septal defect (ASD) and mitral valve disease has been recognized for many years. Noninvasive studies indicate a high incidence of mitral valve prolapse (37-70 percent) in these patients. Change of left ventricular geometry in atrial septal defect had been showed were associated with degree of mitral valve prolapse. This study delineates the incidence of mitral valve prolaps and mitral regurgitation in adult patients with secundum atrial septal defect and association with age at onset and size defect. Method: This study was a substudy from ASD registry in Dr. Sardjito General Hospital. The records of 103 adult patients ranged in age from 17 to 76 years old, with an average of 36 years old, and consisted of 16 men and 87 women who had secundum atrial septal defects demonstrated by crosssectional echocardiography between july 2012 until july 2013. Echocardiographic examinations were performed with the patient in the supine position. The echocardiograph was a Vivid 7. The mitral valve apparatus and mitral regurgitation was examined with long axis images, short axis image and apical four chamber view. Result: Mitral valve prolapse was observed in 76% patients with secundum atrial septal defect. Prolaps of anterior mitral leafl et (AML) in age group younger than 35 years and older than 36 years are 38,6% and 61,4% respectively. The incidence of mitral regurgitation was 43%. Severity varianceof mitral regurgitation were 31,7% mild, 7,7% moderate and 2,9% severe. Mitral regurgitation in patient with prolapse AML was 56.4%. None of the patients without mitral valve prolapse had mitral regurgitation.In patient with size defect more than 2 cm, the proportion of prolapse of AML and mitral regurgitation was higher as compared with patient with size defect less than 2 cm. Conclusion: Incidence of mitral valve prolaps and mitral regurgitation are high in patient with atrial septal defect and increase with onset of age. Patients with larger size defect had a greater likelihood of mitral prolapse and mitral regurgitation. Onset of age and size defect might be associated with magnitude of the shunt and abnormal ventricular geometry.Keywords: secundum atrial septal defect, mitral valve prolaps, mitral regurgitatio