Right Heart Catheterization on Sinus Venosus Type of Atrial Septal Defect with Partial Anomalous Pulmonary Vein Drainage

Atrial septal defect (ASD) is a non-cyanotic congenital heart disease characterized by the presence of defects on atrium septal wall. ASD is 10% of congenital heart disease. This defect is the third most common congenital heart disorder with an estimated incidence of 56 out of 100,000 live births. With the improved echocardiographic technique that can diagnose a defect in asymptomatic abnormalities, the estimated incidence is increased to 100 out of 100,000 live births. The disorder is more common in women than men with a ratio of male: female 1: 2

The Differences of Average Level Serum N Terminal Prob-Type Natriuretic Peptide (NTPROBNP) in Hypertension Patients with and without Left Ventricular Hypertrophy At Cardiology Outpatients Dr. Sardjito General Hospital Yogyakarta

Introduction. Hypertension cause changes in the structure and function of cardial as triggers neurohormonal and vascular changes that concentric cardiac hypertrophy. Myocyte volume expansion or increased pressure will trigger the synthesis of pre-proBrain Natriuretic Peptide (BNP) in the ventricular myocardium. Pre-proBNP will be converted into proBNP and proBNP will be converted into the form of BNP and N-terminal proBNP (NT proBNP).Aim. This study aimed to determine differences in BT pro BNP in hypertensive patients without LVH and hypertensive patients with LVH. The study design was cross-sectional in cardiology polyclinic`s outpatient at Dr. Sardjito General Hospital Yogyakarta from August 2009 until the sample number is fulfi lled.Method. To analyze the difference between the two groups of hypertensive patients using the t-test for normal distribution, while for abnormal distribution were analyzed with the Mann-Whitney U test. To analyze the normality of data conducted by Kolmogorov-Smirnov. The differences of two groups of hypertensive patients considered as signifi cant if p < 0.005 with confi dence interval of 95%.Results. The results showed 73 study subjects grouped subjects into 2 groups: hypertensive subjects without LVH (31 subjects) and with LVH (42 subjects) based on echocardiography parameters (IVSD, LVPWd, LVIDd, LVM, and LVMI) consisting of 24 males and 49 females. The baseline characteristics between the study groups of hypertensive subjects with and without LVH did not differ signifi cantly either in age, BMI, blood pressure, duration of hypertention therapeutic characteristics of the use of drugs such as ACEI, ARB, β-blocker, CCB, spironolactone and furosemide. Mean NT proBNP levels in hypertensive group without LVH (46.60 ± 45.51) and hypertention with LVH group (201.60 ±192.30 ng/ml). From the results of the Kolmogrov-Smirnov test result that the data distribution was not normal then used Mann-Whitney U test, obtained a statistically significant differences.Conclusion. There were significant differences in the mean levels of serum NT proBNP in hypertensive patients without LVH and hypertensive patients with LVH.

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 of Serum Levels of Matrix Metalloproteinase-9 to Acute Heart Failure Event as a Complication af Acute Coronary Syndrome

Background: Acute heart failure (AHF) after acute coronary syndrome (ACS) is the biggest complication with a poor prognosis in a long term. The infl uence of MMP-9 as proteolytic enzyme that degrades extracellular matrix in remodeling left ventricle was recognized. However, according to researcher’s knowledge, evaluation of the MMP-9 as a predictor of AHF after ACS was never reported. Objective: To fi nd out the serum level of MMP-9 in ACS with AHF higher than that without it, as well as to fi nd out the level of MMP-9 with risk of AHF after ACS. Method: The study used a cross-sectional study. Samples were collected by using a consecutive sampling technique among patients with ACS treated in ICCU of Public Hospital Dr Sardjito Yogyakarta, since June 2008 to August 2010. Questionnaires were used to collect sample raw data. The level of MMP-9was examined a time at admission in ICCU before trombolysis was done. The heart failure had Killip II- IV scores. Factors infl uencing the incidence was analyzed by using multivariate analysis technique. A signifi cance level was at p< 0.05. The relative risk of acute heart failure at a certain level of MMP-9 (from cut-off value) was obtained after it was adjusted. Result: Among 122 subjects, 75 was without AHF and 47 with AHF. Median of the level of MMP-9 in the whole sample of ACS was 1248.55 ng/mL with a minimum of 170.50 ng/mL and maximum of 3058.40 ng/mL. Moreover, the level of MMP-9 in ACS with AHF (1700.81±740.43 ng/mL) was signifi cantly higher than ACS without AHF (1189.55±654.60 ng/mL) with p value = 0.000. Independent risk factor after the multivariate analysis was done indicates the level of MMP-9 above 1444 ng/mL (RR= 4.2) and the location of anterior infarction (RR= 2.9). Conclusion: In patients with ACS treated in ICCU of RSUP Dr Sardjito, the level of MMP-9 with AHF was higher than that without it. If the level of MMP-9 above 1444 ng/mL, the possibility of AHF was 4.2 times.Keywords: acute coronary syndrome, MMP-9, acute heart failure after acute coronary syndrom

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

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

Epidemiological Profile of Congenital Heart Disease in a National Referral Hospital

Introduction: Sardjito Hospital is the tertiary referral hospital in Yogyakarta and Central Java, Indonesia. There are no reported data measuring epidemiological profi le of congenital heart disease (CHD) in this region. This study was aimed specifi cally to determine the most major lesion and type of CHD in one of an over-populated area in Indonesia. Methods: The retrospective observational study was conducted during January 2014 to December 2014 in Sardjito Hospital. In and outpatients with CHD taken from medical record were noted their clinical data and only patients with transthoracal echocardiographic proof of CHD were included in this study. CHD with more than single lesion was simplifi ed as one lesion which had most major impact on hemodynamic circulation. The denomerator was the sum of all new patients visiting to the hospital at 2014. Data were entered in MS-excel and analyzed by software SPSS version 22.Results: We had total 650 new patients with CHD registered to Sardjito Hospital in 2014. The incidence of CHD was 134/10.000 person-years consisted of adult 22% and children 78% (female 60% and male 40%). Ventricle septal defect (VSD) was the most common lesion among children (30%) followed by atrial septal defect (ASD) 17%, persistent ductus arteriosus (PDA) 16%, andTetralogy of Fallot (TOF) 7%. Meanwhile in adult, ASD was the most frequent CHD (60%), continued by VSD 23%, TOF 8%, and PDA 4%. Secundum, primum, and sinus venosus type were found in 94%, 3%, and 3% of total ASD in children, and 99%, 1%, and 0% of adult respectively. Perimembran outlet (PMO), doubly committed subarterial (DCSA), and inlet were found in 66%, 12%, and 12% of total VSD in children, and 39%, 54%, and 0% of adult respectively. TOF had the highest incidence of cyanotic heart diseases (33 cases, 7%) in children and also in adult (12 cases, 8%). Conclusion: The incidence of CHD was 134/10.000 person-years. The most common lesion among children was VSD and in adult was an ASD. TOF had the highest incidence of cyanotic heart disease among children and adult. Secundum type was the most common fi nding in all ages of ASD population, whereas PMO and DCSA were the most frequent type of VSD in children and adult respectively.Keywords: incidence, congenital heart disease, hospital, cyanotic, typ

Clinical Characteristics of Adult Uncorrected Secundum Atrial Septal Defect, A Pilot Study

ABSTRACTAtrial septal defect (ASD) is the most frequent congenital heart disease in adulthood. Pulmonary hypertension (PH) complicating ASD compels patients seeking medical assistance because of its disabling symptom. Most adult ASD develop PH which render significant morbidity and mortality. The aim of the study is to characterize the clinical profiles of adult patients with ASD. The study design was cross sectional. The subjects were enrolled consecutively from outpatient clinics and inpatient wards. The demography, medical and imaging data were collected and recorded in case report form. Descriptive statistics was applied to characterize the subjects. Seventy-six subjects were enrolled. The majority were women (77.6 %) in the productive and child-bearing ages (63.2%). The most common symptoms were dyspneu on effort, fatigue, and palpitation. Most subjects had functional capacity of WHO class functional II (70.2 %). The mean oxygen saturation was 96.4 %. Based on the echocardiography examination, 77.6% of subjects had suffered from PH. The mean longest diameter of defects were 2.7 cm. The direction of blood flow was mostly left to right (77.6 %). Left and right ventricle function were within normal limit. Right heart catheterization showed mean left atrial pressure 11.5 mmHg, which confirmed the precapillary or arterial PH. Mean pulmonary artery pressure was 42.0 mmHg. The pulmonary artery resistance index mostly less than 4 Wood Unit/ m2 (63.7 %), indicating the feasibility to close the defect. Whereas 24.6 % of subjects were contraindicated for closing. Pulmonary artery hypertension (PAH) was diagnosed in 77.6 % subjects, meanwhile 13.2 % had borderline PAH. In conclusion, most adult ASD patients had developed PAH, mostly young women in productive ages, mainly visited hospital due to symptom of PH, the direction of flow predominantly left to right side and mostly had reduced functional capacity

THE RELATIONSHIP BETWEEN THE DIAMETER OF ATRIAL SEPTAL DEFECT AND THE SEVERITY OF TRICUSPID VALVE REGURGITATION

Background: Atrial Septal Defect (ASD) is a congenital heart disease which is frequently accompanied by the presence of tricuspid valve regurgitation. Hence, a research is needed to find out the relationship between the diameter of ASD and the severity of the tricuspid valve regurgitation. Objectives: This research is aimed to find out the relationship between the diameter of ASD and the severity of tricuspid valve regurgitation. Method: This was a retrospective study using the data from Atrial Septal Defect Registry. The survey was conducted in Department of Cardiology and Vascular Medicine FK UGM and Dr. Sardjito Hospital, Yogyakarta. The data was analysed using IBM SPSS version 20 in December 2013. Result: The degree of significance is 0.205 (P=0.205) which showed no statistically significant correlation between the diameter of ASD and the severity of tricuspid valve regurgitation. Slightly increase of the mean diameter of ASD was noticed from mild to moderate to severe tricuspid valve regurgitation. Conclusion: There is no statistically significant regarding the relationship between the diameter of ASD and the severity of the tricuspid valve regurgitation. However, there is a slightly increase in mean diameter of ASD from mild-moderate-severe tricuspid vale regurgitation