Prediktor Kegagalan Intervensi Koroner Perkutan pada Oklusi Total Koroner Kronik di Pusat Jantung Nasional, Indonesia

Background. Percutaneous Coronary Intervention (PCI) in patients with Chronic Total Coronary Occlusion (CTO) is associated with higher rate of failure and higher rate of complication compared to non-CTO angioplasty. Improvement in technique, logistic and patient’s selection method lead to a better success rate. Identification of predictor of failure could be an important step in patient selection. The aim of the study is to know the predictors of failure of PCI in patients with CTO.Methods and results. A retrospective analysis of clinical and angiographic data of 78 consecutive eligible CTO patients who underwent PCI selected in series of 1205 total occluded vessel of 3654 angiographic patients in the year of 2005 in our catheterization laboratory. We analysed 25 variables, 12 clinical variables (age, sex, family history, smoking, diabetes mellitus, hypertension, history of myiocardial infarction, history of coronary bypass operation, age of occlusion >1 year, severe angina and poor left ventricle systolic dysfunction)and 13 angiographic variables (true CTO, CTO location, ostial lesion, calcification, tortousity, non-tapered type, side branch type, bridging collateral, diffuse disease, vessel diameter < 3mm, CTO length > 15mm, multi-lesion and multi vessel disease)by univariate and multivariate analysis (logistic regression) in association between 21 cases of procedural failure group and 57 cases of procedural success group. Procedural success was achieved in 57 patients (73%) and complication occured in one patient (1%). Majority of patients are male with mean age 55 year. Presence of calcification is the only predictor identified by univariate analysis (OR 3,28. p 0,04. 95%CI 1.05-10,18). Multivariate analysis identified multivessel disease (OR 7,1. p 0,07 .95%CI 0,85-59,21) and diffuse disease (OR 2,7. p 0,06 .95%CI 0,93-8,08) as predictors of procedural failure.Conclusions. We identified multivessel disease and diffuse disease as two predictors of procedural failure of PCI in our series of CTO patients with 73% success rate and 1% complication rate in the year of 2005.Latar Belakang. Intervensi koroner perkutan (Percutaneous Coronary Intervention = PCI)pada subgrup oklusi total koroner kronik (chronic total coronary occlusion = CTO)sering dihubungkan dengan tingkat kegagalan prosedur dan angka komplikasi yang relatif lebih tinggi dibanding angioplasti koroner secara umum. Penyempurnaan tehnik dan peralatan serta seleksi pasien terus dilakukan, dalam upaya mencapai tingkat keberhasilan yang lebih tinggi. Mengetahui prediktor kegagalan PCI pada CTO merupakan langkah penting dalam proses seleksi pasien. Penelitian ini bertujuan untuk mencari variabel prediktor kegagalan PCI pada CTO.Subyek dan metoda. Dilakukan studi retrospektif cross sectionalpada 78 kasus CTO yang menjalani PCI di Pusat Jantung Nasional - Harapan Kita, Jakarta dalam periode satu tahun (2005). Subyek penelitian diperoleh setelah melewati seleksi pada 1205 pasien CTO dari total 3654 pasien PCI selama periode tersebut. Subyek penelitian dibagi menjadi dua kelompok berdasarkan keberhasilan atau kegagalan tindakan. Ditetapkan 25 variabel yaitu 12 variabel klinis (umur, jenis kelamin, riwayat keluarga, merokok, diabetes melitus, hipertensi, riwayat infark, riwayat bedah pintas koroner, umur oklusi >1 tahun, angina berat dan disfungsi ventrikel kiri) dan 13 variabel angiografik (true CTO, lokasi lesi, lesi ostial, kalsifikasi, tortousity, abrupt type, side branch type, bridging collateral, diffuse disease, diameter < 3mm, panjang > 15 mm, lesi multipel dan multivessel disease),untuk dinilai perannya terhadap kegagalan PCI. Dalam penilaian dipakai uji univariat dan uji multivariat logistic regression. Hasil. Mayoritas kasus adalah pria dengan rerata umur 55 tahun. Keberhasilan prosedur dicapai pada 57 kasus (73%), dengan komplikasi pada 1 kasus (1%). Pada uji univariat, didapat prediktor adanya kalsifikasi yang signifikan berbeda (OR 3,28. p 0,04. 95% CI 1.05-10,18). Melalui uji multivariat terhadap 7 prediktor yang terseleksi lewat uji univariat didapat 2 prediktor kegagalan PCI, yaitu multivessel disease(OR 7,1. p 0,07 .95%CI 0,85-59,21) dan diffuse disease (OR 2,7. p 0,06 .95%CI 0,93-8,08). Kesimpulan. Multivessel diseasedan diffuse diseasemerupakan dua variabel prediktor kegagalan PCI pada seri pasien CTO tahun 2005. Kesuksesan PCI dicapai pada 73% pasien dengan angka komplikasi 1%

The Effect of Hiperbaric Oxygen Therapy on Vascular Endothelial Growth Factor (VEGF) level of Diabetic Ulcer patient

Background. Hyperbaric oxygen therapy (HBOT) increase endothelial oxygenation and stimulates vascular endothelial growth factor(VEGF) as the most specific and potent growth factor for angiogenesis, and increases wound healing process. The aim of the study is to know if five days HBOT can increase the level of VEGF in diabetic ulcer patients. Methods and results. Clinical experimental study was conducted on 12 diabetic ulcer patients who received HBOT 30 minutes, 3 times a day for 5 days (HBOT group) and 10 diabetic ulcer patients as a control group who did not receive HBOT (non-HBOT group). The VEGF level in both groups was measured on days 1 and 5. In HBOT group the mean level of VEGF on day 1 was 1241.325 + 237.6533 pg/ml and became 1244.458 + 264.5641 pg/ml (p = 0.583) on day 5, while in non-HBOT group the mean level of VEGF on day 1 was 1262.350 + 227.9603 pg/ml and became 1112.460 + 220.3795 pg/ml (p = 0.093) on day 5. There were no signifi-cant differentiation of VEGF level between HBOT group and non-HBOT group both on day 1 (p = 1) and day 5 (p = 0.872) Conclusions. Hyperbaric oxygen therapy for 5 days did not increase the VEGF level of diabetic ulcer patients

“Endovascular Stent Graft” pada Diseksi Aorta Tipe B

Pada tahun 1970, Nicholls, seorang dokter kerajaan Inggris, melakukan otopsi terhadap King George II yang mengalami kematian mendadak. Ternyata penyebab kematian sang Raja adalah efusi masif perikardium, rongga perikard dipenuhi bekuan darah, akibat robekan dinding aorta. Hirs dkk (1958) pernah membuat penelusuran terhadap 505 penderita dengan gejala klinis serupa, ia memperlihatkan tingginya angka kematian serta sulitnya menegakkan diagnosis, sehingga pasien umumnya meninggal. Kemajuan modalitas pencitraan berperan sangat penting dalam mendiagnosis diseksi akut aorta secara dini, dan kemajuan teknik terapi akhirnya mampu meningkat-kan harapan hidup pasien dengan kelainan ini

Baroreflex Sensitivity in Patients with Coronary Artery Disease Who Underwent Percuteous Coronary Intervention

Background.Autonomic dysfunction contributes to incidence of ventricular arrhythmias and sudden cardiac death in patients with coronary artery disease (CAD). Revascularization, for example percutaneous coronary intervention (PCI), is intended to improve myocardial perfusion. Besides that, PCI is considered to improve autonomic dysfunction. This study is aimed at assessing baroreflex sensitivity (BRS) in patients with CAD before and after PCI. Methods. Patients with angiographically having coronary stenoses = 50% who underwent coronary angioplasty at the catheterization laboratorium of National Cardiovascular Center Harapan Kita, Jakarta, were included in this study. Baroreflex sensitivity was calculated by administering nitroglycerin 300 g intra aortic before and after PCI. Results.Subjects comprise of 8 (42%) male and 11 (58%) female, aged 57.5 9.3 year old. Most of subjects had dyslipidemia (57%), were smoker (42%), had hypertension (42%) and only 3 (16%) had diabetes mellitus. Nine (47%) of subjects had previous history of myocardial infarction. Medications suspected affecting baroreflex sensitivity, which were used by the time of study included nitrate (63%), beta-blockade (58%), and calcium antagonist (32%). Mean value of baroreflex sensitivity pre-PCI and post-PCI were 2,51+3,23 ms/mmHg and 1,96+1,61 ms/mmHg (p=0,412), subsequently. Multivariate analysis with logistic regression showed that nitrate has significant effect on decreased BRS soon after PCI (p=0,023; CI 95% 1,496-216,62;OR 18,00). Conclusion. In patients with Coronary Artery Disease, immediately after percutaneous coronary intervention, barorefelex sensitivity was decreased. Nitrate has significant effect on alteration of barorefelex sensitivity

Pengaruh Pemberian Pentoksifilin Terhadap Perubahan Kadar Platelets Activating Factor pada Cedera Reperfusi-Iskemik Tungkai Akut

Background. In Acute limb ischemia reperfusion causes further damage to the ischemic tissue through local compartment syndrome, and systemic syndrome: multiorgan dysfunction and failure. Several method and attempt had been studied and performed to prevent and attenuate reperfusion injury such as, ischemic preconditioning, antioxidant, and anti-cytokine therapy, but their clinical benefit were not satisfactory. Pentoxifylline (PTX) a nonspesifik phosphodiesterase derivate of xanthine has emerged as a promising agent that may attenuate inflammation response through several mechanism. However, studies on PTX and its function to prevent and attenuate inflammation response through attenuating Platelet-Activating Factor (PAF) in acute limb ischemic were not consistent. The aim of this study is to investigate the effect of PTX on PAF in rabbits with acute limb ischemic-reperfusion injury.Methods and results.Acute limb Ischemia were performed by direct occlusion of the left femoral artery of 10 New Zealand White male rabbit using non traumatic clamp, and followed by releasing the clamp after 3 hours of occlusion. The rabbits were randomly separated into 2 groups of five (PTX group and control group). The PTX group was given PTX 40 mg/kg bolus half an hour prior to reperfusion, followed by maintenance dose 1 mg/kg/hour until 2 hour post reperfusion, while the control group was given normal saline solution with comparable volume and rate administration. Level of PAF were measured after 2.5 hour of ischemic period and after 2 hours of reperfusion period. After 2.5 hours of ischemic period, the mean PAF levels did not show any significant difference (p=0.754), the mean PAF level of PTX group 13.09±0.41 pg/mL, while the control group 13.38±0.28 pg/mL. After 2 hours period of reperfusion, there were significant differences of mean PAF level between the two groups (p=0.009). The mean PAF level in the control group increase by 12.11±0.79 to became 25.5±0.78 pg/dL, while the mean PAF level of the PTX group decrease by 1.73±1.1 pg/mL and became 11.36±0.78 pg/mL.Conclusions. Pentoxifylline attenuate the production Platelet-Activating Factor level in rabbits with acute limb ischemic-reperfusion injury.Latar Belakang.Pada iskemia tungkai akut, reperfusi menimbulkan cedera reperfusi iskemia yakni reaksi kompleks yang melibatkan inflamasi lokal berakibat sindroma kompartemen, maupun sistemik yang berdampak disfungsi hingga kegagalan multi organ. Platelets activating factors (PAF) sebagai mediator inflamasi pospholipid, mempunyai efek fisiologis yang poten dan beragam, sehingga meningkatkan respon inflamasi pada cedera reperfusi iskemik. Berbagai upaya untuk mencegah dan mengurangi cedera reperfusi iskemik antara lain penggunaan ischemic preconditioning, antioksidan dan terapi anti-sitokin telah di teliti, namun hasil dan manfaat klinisnya belum memuaskan. Pentoksifilin (Pentoxyfillin, PTX) phosphodiesterase nonspesifik derivat xanthine yang memperlihatkan efek penekanan inflamasi dan menghambat interaksi lekosit-endotel, bermanfaat untuk mencegah cedera reperfusi. Namun, hasil penelitian mengenai peran PTX dalam menekan reaksi inflamasi melalui penekanan PAF pada iskemia tungkai akut tidak konsisten. Penelitian ini bertujuan untuk menilai efek PTX dalam mengurangi cedera reperfusi melalui penekanan mediator inflamasi PAF, pada hewan coba kelinci dengan yang mendapat perlakuan reperfusi iskemia akut pada tungkai.Metode dan hasil.Dilakukan tindakan iskemik tungkai kiri selama 3 jam yang kemudian diikuti reperfusi, pada 10 ekor kelinci putih jantan dari New Zealand. Tindakan Iskemik dilakukan dengan oklusi arteri iliaka komunis kiri mengunakan klem selama 3 jam, kemudian dilanjutkan dengan restorasi aliran darah. Kelinci ini dibagi secara acak menjadi 2 kelompok (kelompok PTX dan kelompok kontrol). Pada kelompok PTX diberikan PTX 30 menit sebelum reperfusi dengan dosis awal bolus 40 mg/kgBB diikuti dengan dosis rumatan 1 mg/kg BB/jam hingga 3 jam periode reperfusi. Pada kelompok kontrol diberikan cairan garam fisiologis dengan kecepatan dan volume yang sebanding. Pengambilan sampel untuk pemeriksaan kadar PAF dilakukan pada 2,5 jam iskemik dan pada 2 jam reperfusi Pada periode iskemik 2.5 jam, tidak ada perbedaan bermakna (p=0,754) antara kedua kelompok, kadar rerata PAF pada kelompok PTX 13,09 ± 0,41 pg/mL dan kelompok kontrol 13,38 ± 0,28 pg/mL. Pada jam ke dua tindakan reperfusi, ditemukan perbedaan bermakna (p=0,009); kadar rerata PAF dari kelompok PTX turun menjadi 11,36±0,78 pg/mL sedangkan kelompok kontrol justru meningkat menjadi 25,5±0,78 pg/dL.Kesimpulan.PTX menekan laju peningkatan kadar PAF plasma kelinci yang mengalami cedera reperfusi iskemia tungkai akut

Correlation Between Circulating Leptin Level with Left Ventricle Mass in Normotensive Men

Background.Obesity is one of Cardiovascular risk factor. Obesity caused increase in heart mass due to cellular hypertrophic and metaplastic proses, independently of hemodynamic factors such as blood pressure. There were hyperleptinemia in obesity due to the selective Leptin resistency in central nervous system and peripheral organs. Study with cultured rat cardiomyocyte have shown hypertrophy and hyperplastic effect of Leptin to cardiomyocyte. Some clinical studies have shown correlation between circulating Leptin level with Left Ventricle Mass in hypertensive and insulin resistance men. Objective. This study aimed to elaborate the correlation between circu-lating Leptin level with Left Ventricle Mass in normotensive men. Methods. A cross sectional study was performed with normotensive men, which included 40 obese normotensive and 40 normoweight men. All patients underwent physical and laboratory assessment and examination of Left Ventricle with echocardiography. The circulating Leptin level were determined by ELISA method. The Leptin level were expressed as median (25th percentile; 75th percentile) Results. The circulating Leptin level were significantly different between the obese normotensive and the lean group. The Left Ventricle Mass in Obese increased, although have not fulfilled the criteria for Left Ventricle Hypertrophy. There were significant correlation between Left Ventricle Mass with BMI (r = 0,711; p<0,001) and waist circumference (r = 0,732; p<0,001). Respectively, there were significant correlation between Left Ventricle Mass Index with BMI (r = 0.541; p<0.001) and waist circumfer-ence (r = 0,558; p<0.001. There were significant correlation between circulating Leptin level with Left Ventricle Mass (r = 0,510; <0,001) and Left Ventricle Mass Index (r = 0,414; p<0,001) in obese men. Conclusion.Circulating Leptin level is correlated with Left Ventricle Mass in normotensive men