Myocardial Revascularization in COVID-19 Era

Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by the coronavirus 2 that causes severe acute respiratory syndrome (SARS-CoV-2). More discussion is required to achieve the balance between clinical benefit and risk in the treatment of acute coronary syndrome (ACS) patients with COVID-19. The current COVID-19 pandemic prompts the need to evaluate criteria for indication and efficacy of the general safety protocols and particular cardiac catheterization laboratory (CCL) procedures to safeguard the patient and healthcare professional

Analysis of activated clotting time in patients receiving unfractionated heparin with and without continuous infusion during elective percutaneous coronary intervention

  Background: Percutaneous coronary intervention (PCI) involves a risk of thrombotic events. Unfractionated heparin (UFH) remains a preferred antithrombotic agent during PCI, though the optimal administration method is still under debate. Given its narrow therapeutic range, UFH requires careful monitoring through the measurement of activated clotting time (ACT) Objective: The aim is to compare ACT value and the outcomes of administering a bolus of UFH at 70–100 IU/kgBW, with and without a continuous infusion of 2000 IU/hour Methods: An observational retrospective study was conducted on 133 patients who underwent elective PCI by meeting the inclusion and exclusion criteria during the period of July 2022–July 2024. Clinical information, ACT value and the outcome were gathered from medical records. Statistical analyses were performed using SPSS 22, employing univariate, bivariate, and multivariate logistic regression analyses to determine correlations. Result: The range of ACT results of administering an UFH bolus of 70-100 IU/kgBW with continuous infusion 2000 IU/hour was 191 to 426 seconds (mean 281.9 seconds). Among the 44 patients, 66.6% exhibited ACT levels below 300 seconds, 15 patients (22.7%) had ACT levels ranging from 300 to 350 seconds, while 6 patients (8.3%) had ACT levels exceeding this range. The percentage of patients who attained therapeutic success in the unfractionated heparin (UFH) infusion group (22.7%) was significantly higher than the UFH bolus group (5.9%) with statistically significant results (p = 0.000). Complications were observed in both groups, with 1 patient in each group experiencing acute thrombosis (p = 1.000) and no patients experienced bleeding complications. Conclusion: Administering a UFH bolus of 70-100 IU/kgBW with continuous UFH infusion at 2000 IU/hour achieved better optimal ACT values. No significant results were found regarding the risk of acute thrombosis with no bleeding complications.

SGLT2 inhibitor, a new bullet in heart failure management

The global health landscape is confronted with substantial challenges stemming from diabetes mellitus and heart failure (HF). The escalating incidence of diabetes mellitus (DM), in correlation with HF, underscores the imperative necessity for efficacious strategies in the realm of prevention and management. The most recent advancements in therapeutic approaches, specifically Sodium-glucose transporter 2 inhibitors (SGLT2i), present a promising prospect for enhancing outcomes and addressing the existing gaps in HF management. This paper aims to elucidate the significance of SGLT2i in the therapeutic management of both reduced and preserved heart failure, with or without the presence of DM. SGLT2i are new heart failure drugs. In trials, SGLT2i improved diastolic dysfunction, reduced oxidative stress, inflammation, fibrosis, and myofilament rigidity. The first SGLT2 inhibitor studies, EMPA-REG OUTCOME, DECLARE-TIMI 58, and CANVAS, showed that Empagliflozin and Canagliflozin reduced HF mortality and rehospitalization in type 2 diabetes mellitus (T2DM) patients. Dapagliflozin reduces HF hospitalizations without impacting T2DM mortality. Canagliflozin avoided creatinine rises, kidney disease deaths, and cardiovascular deaths in the CREDENCE Study. SGLT2i improve health in heart failure with preserved ejection fraction (HFpEF). SGLT2i improved health status statistically in the PRESERVED-HF and EMPEROR-Preserved investigations. SGLT2i became known as a promising therapeutic choice in the treatment of HF. The substantial evidence from prominent large-scale clinical trials has substantiated the cardiovascular and renal protective effects of SGLT2i. Furthermore, the benefits of these medications are relevant for individuals who have been diagnosed with heart failure with reduced ejection fraction (HFrEF), as well as those who are experiencing heart failure with preserved ejection fraction (HFpEF)

An alternative retrograde access puncture for EVLA: a case report

Background: CVI manifests with a variety of clinical symptoms, spanning from varicose veins to venous ulcers, significantly impacting patients\u27 daily lives. While traditional treatments such as compression therapy and surgery remain options, on endovenous laser treatment (EVLT) has emerged as a viable alternative.  This article delves into the management of CVI, with a particular focus EVLT as a minimally invasive intervention. Through two case illustrations, it sheds light on the difficulties encountered when accessing the great saphenous vein (GSV) using the conventional antegrade approach, particularly in cases involving obesity and vasospasm. Consequently, a retrograde EVLT technique utilizing proximal GSV access, resulting in successful vein ablation with minimal complications. Overall, this approach presents a promising addition to the management of CVI, offering enhanced patient care and improved outcomes. Case Presentation: Two patients with CVI and challenging antegrade GSV access underwent retrograde EVLT using proximal GSV access. Despite initial difficulties, including obesity and vasospasm, successful vein ablation was achieved with minimal complications. Post-procedural evaluations demonstrated significant symptomatic improvement, highlighting the efficacy of the retrograde technique. Conclusion: Retrograde EVLT utilizing proximal GSV access proves to be a safe and effective alternative in cases where antegrade access is challenging. The technique offers simplicity, minimal complications, and high patient satisfaction, with outcomes comparable to traditional approaches. Extended follow-up studies are needed to confirm the long-term effectiveness of retrograde EVLT compared to antegrade methods. Overall, retrograde EVLT presents a valuable option for managing CVI, particularly in patients with anatomical complexities or vasospasm, contributing to improved patient care and outcomes

DETECTION AND MONITORING SYSTEM ON THE PACKAGE RECEIVING BOX

The package delivery system during this pandemic period require concerned health protocols. Receiving packages sometimes needs to be done even though there is no recipient. Here, the box for receiving goods has an important role. The goods receiving box must have security and ensure that the goods are received/placed in the box. In this case, it is necessary to detect the presence of objects in the box using a weight sensor, and a box locking motor is also needed. A push-button is needed when the package items are put into the box. The process of this activity can be monitored directly with the help of the Blynk application from a smartphone. The tests are carried out, and the push button signals to open the box. The weight sensor detects weight changes. The Blynk application will inform the smartphone that the object has been placed in the box from the weight change, and the system will lock the box again. The detection and monitoring system for goods on the box can work well

Reperfusion Arrhythmia in Acute Myocardial Infarction: Clinical Implication and Management

Reperfusion is a critical component of myocardium survival in acute myocardial infarction to minimize infarct size and improve clinical prognosis. Reperfusion, on the other hand, may result in increased and accelerated myocardial injury, a condition known as reperfusion injury. Following reperfusion, several arrhythmias are observed, and it is called reperfusion arrhythmia. Reperfusion arrhythmia is one manifestation of reperfusion injury. Numerous modest studies have evaluated what reperfusion arrhythmias are defined. It is described as an arrhythmia that occurs immediately or within the first minutes after coronary blood flow is restored. Traditionally, Accelerated Idioventricular Rhythm (AIVR) has been seen as a reperfusion arrhythmia. However, reperfusion may reveal any arrhythmia (or none at all); conversely, AIVR may occur in the absence of reperfusion. Calcium excess within the cells is thought to be a significant factor in the development of reperfusion arrhythmias. This may affect the significant delay following depolarization and the regional heterogeneity of regional blood flow restoration inside the ischemic zone, resulting in reperfusion arrhythmia. In some studies, it was mentioned that these arrhythmias may be due to ongoing myocardial cell damage and ischemia. Arrhythmias associated with reperfusion require special attention since hemodynamics can deteriorate quickly. In this review, clinical significance and management of reperfusion arrhythmia, as well as its link with reperfusion injury will be discussed.  

Challenge case of ventricular arrhythmia in young women

Background: Torsade de pointes (TdP) and ventricular fibrillation can cause rapid mortality. The etiological cause the ventricular arrhythmia must be detected and treated early, especially in the ER. Objective: We report a patient with severe hypokalemia and TdP following the administration of Amiodarone in QT-interval prolongation Case Report: A 32-year-old girl with diarrhea and vomiting for two days arrived to the ED with a seizure with her hand flexed and leg straight down. Her family reported she didn\u27t take prescriptions regularly. She was GCS 224, hemodynamically stable, typical ECG showed extended QTc and her head CT was normal. During observation at the ED, she had seizure and the monitor revealed a Torsade de Pointes (TdP) ) with a pulse rate of 160-180 bpm. She was given Amiodarone and peroral Bisoprolol 5 mg. She returned to sinus rhythm with PVC bigeminy and was admitted to the ICU Laboratory data showed hypokalemia (1.9) improved (2.9) after treatment. Eight hours later, she experienced a TdP without pulse palpability for less than 1 minute, then Ventricular Fibrillation, began CPR, and the doctor in charge gave her a defibrillation operation once. She returned with sinus tachycardia 110-130 bpm. The next day, she was having recurring TdP episodes without a pulse. The doctor conducted CPR and defibrillation and returned with 120-130 bpm sinus tachycardia. The patient consulted a cardiologist and was prescribed lidocaine 1 mg/hour and continued Bisoprolol 5 mg for long QT problem. Observation The seizure ended 12 hours later, the patient was alert, GCS 456, and the ECG showed sinus rhythm with extended QTc. Over the days before discharge, electrocardiography demonstrated reduced QT-interval prolongation. Conclusion: Life-threatening ventricular arrhythmia in a young female can be caused by QT-interval prolongation. It must be diagnosed and treated immediately to avoid mortality

Arteriovenous Fistula Stenosis: A Case Report

BackgroundThe arteriovenous fistula (AVF) is the preferred hemodialysis access type because it has better patency rates and fewer complications than other access types. Dialysis vascular access failure is common, is rated as a critical priority by both patients and health professionals, and is associated with excess morbidity, mortality, and healthcare costs.Case IllustrationA 64 years old man with stage V CKD on routine HD was admitted to hospital with difficulty in cannulation during his last hemodialysis. He already had arteriovenous fistula for hemodialysis access in his left arm since 2 years ago. In the last month before admission, he went to surgery to make hemodialysis access via arteriovenous fistula in his right arm, but failed to mature. Vascular ultrasound on dialysis vascular access was ordered. The examination revealed there was stenosis in the juxta-anastomosis site and cephalic venous stenosis in his left arm. He underwent percutaneous angioplasty with POBA in the anastomose arteriovenous fistula and implantation stent in the left cephalic vein.DiscussionDysfunction of hemodialysis access is a major problem for patients undergoing hemodialysis. It is generally due to venous stenosis, which diminishes flow in the hemodialysis access arteriovenous, thereby leading to poor dialysis. Fistulas tend to develop stenosis most commonly either at the juxta-anastomosis site and the outflow vein. Peripheral venous stenosis is the most common cause of arteriovenous fistula dysfunction and may lead to access thrombosis. The first-line treatment of stenosis should be balloon angioplasty. Stent placement in the peripheral vein is generally not recommended except in special circumstances.ConclusionHemodialysis vascular access is the “lifeline” for patients on hemodialysis. Vascular access-related complications can lead to patient morbidity and reduced quality of life. Surgery often cannot be provided as rapidly as a percutaneous approach. Catheter-based interventions are successful in restoring flow in more than 80% of hemodialysis accesses that undergo stenosis and have replaced surgical revision as the treatment of choice for failing or stenosed accesse

Provisional Technique for Bifurcation Left Main In-Stent Restenosis Lesion: A Case Report

BackgroundPercutaneous coronary intervention for bifurcation lesions remains challenging because of its complexity and the lack of trials to guide decision-making. Interventional cardiologists are forced to make decisions based on their own judgment and experience rather than the results of rigorously randomized trials.Case SummaryA 64-year-old male with some coronary risk factors of hypertension, passive smoker, and family history of CAD presented with recurring exertional chest pain for the last 4 months. He was hospitalized to undergo DCA-Adhoc after the ECG stress test revealed a positive result. The coronary angiography revealed a 95% ISR in the osteal LAD and 20% ISR of the proximal LCx. Since the patient refused to undergo coronary bypass surgery, the team decided to perform catheter intervention to the LM bifurcation of LAD-LCx. The procedure begins with the insertion of IABP through the access of the left femoral artery. We performed a provisional approach with the main vessel stenting of LM-LAD. At the end of the procedure, we performed simultaneous kissing balloon inflation of LAD-LCx followed by POT in LM stent as the post-dilation procedure.DiscussionWhen considering intervention on a bifurcation lesion, there are two general strategies i.e the more conservative or provisional technique that intent to only use one stent and the two-stent approach. The provisional technique is considered to offer advantages in terms of reducing procedure complexity, reducing fluoroscopic time, requiring less contrast volume, and reducing resource (stent) use compared by 2 stent strategy

Symptomatic Bradycardia In CAD Patient: Which One First To Treat?

Background: The incidence of sinus node dysfunction (SND) increases with age. Likewise, the incidence of coronary artery disease (CAD) has increased from year to year in Indonesia. When doctors are faced SND patients with CAD, it can be confusing in determining initial treatment options.Objective: This study aimed to describe the diagnosis and management of SND in CAD patient.Case Presentation: We will discuss a 75 years old male who had schedule to management of bradycardia symptomatic related to SND. Five month before admission, he had acute coronary syndrome, and had 2 DES implantation at left main (LM) to proximal left anterior descendent (LAD) artery and mid LAD. Two month after PCI he felt near syncope with bradycardia. Evaluation with ambulatory EKG was performed with result of SND, and correction of reversible cause related to SND already done. Eventually, symptom still exist and PPM insertion was decided to perform.Conclusion: Patients with SND and CAD have a higher risk of complications and death. Correction of reversible factors, one of which is CAD, can be done as an initial step in the treatment of SND. When symptomatic signs still appear after correction of reversible causes, PPM implantation is the modality of choice in management