Sindrom Lutembacher Sebuah Penilaian ekhokardiografi

Lutembacher’s syndrome (LS), consisted of Atrial Septal Defect(ASD) and Mitral Stenosis (MS), is a very rare form of cardiac anomaly. Rene Lutembacher’s first described this syndrome in 1916. Currently, any combination of ASD, congenital or iatrogenic and MS, acquired or congenital is referred as LS.By using echocardiography, the hemodynamic of LS could be assesed. Pathophysiologically, the hemodynamic of ASD is related to the magnitude and direction of shunting across the interatrial communication. The determinants of the amount of shunting are the defect size and theventricles relative resistance to inflow. In MS, the restricted in?low leads to increased diastolic pressures in the left ventricle. This resulted in marked accentuation of the left-to-right shunt.We reported a case of a 34 years old female, first came to Harapan Kita National Cardiac Center, in 2010. She was diagnosed with LS, and was planned to have ASD closure and mitral valve repair by surgery. However, she refused to undertake the procedure. In summary, to illustrate the interactions between ASD and MS, the presence of ASD underestimated the severi?y of MS; meanwhile the existence of MS magnified the left to right shunt in patients with ASD.Sindrom Lutembacher (SL), terdiri dari Atrial Septal Defek (ASD) dan Mitral Stenosis (MS), adalah suatu bentuk kelainan jantung yang langka. Rene Lutembacher pertama kali menjabarkan sindrom ini pada tahun 1916. Saat ini, semua kombinasi dari ASD ataupun MS, baik kongenital maupun didapat, diartikan sebagai SL. Dengan menggunakan ekhokardiografi, hemodinamik sindrom ini dapat dinilai. Secara patofisiologis, hemodinamik dari ASD tergantung dari besarnya defek dan aliran darah yang melalui komunikasi interatrial tersebut. Penentu dari jumlah aliran yang melewati defek adalah ukuran dari defek dan resistensi relatif dari aliran yang masuk ke ventrikel kiri. Pada MS, aliran masuk ke ventrikel kiri yang terestriksi menyebabkan peningkatan tekanan diastolik di ventrikel kiri. Hal ini menyebabkan peningkatan aliran dari kiri ke kanan yang berrmakna (left to right shunt). Kami melaporkan sebuah kasus, seorang wanita berusia 34 tahun yang berobat ke Pusat Jantung Nasional Harapan Kita pada 2010. Pasien didiagnosis dengan SL dan ditawarkan untuk dilakukan penutupan defek ASD dan perbaikan katup mitral secara operasi. Namun, pasien menolak prosedur tersebut. Sebagai ringkasan, untuk menggambarkan interaksi antara ASD dan MS, kehadiran dari ASD meringankan gejala yang dit-imbulkan oleh MS; sementara keberadaan MS akan semakin meningkatkan aliran left to right shunt

Echocardiographic Parameters Correlated with Age in Isolated Severe Rheumatic Mitral Stenosis Patients in Indonesia

BACKGROUND: Despite the high prevalence of rheumatic mitral stenosis (MS) in Indonesia, the impact of aging on the anatomical and hemodynamic component of rheumatic MS is not well studied. AIM: To analyze the association of age with various echocardiographic parameters in patients with isolated severe rheumatic MS in Indonesia. METHODS: A cross-sectional study was conducted enrolling 263 subjects with isolated severe rheumatic MS who underwent transthoracic echocardiography (TTE) during January 2015 until December 2017 at National Cardiovascular Center of Harapan Kita, Jakarta, Indonesia. Demographic data were collected, and echocardiographic variables were measured based on standard TTE examination using GE Vivid 7 and S6 Doppler Echocardiography System (GE Medical System, Norway). RESULTS: Of 263 subjects, there are 84 men and 179 women aged 18-80 (mean age 42.9) years old. Most patients had atrial fibrillation (80%), with a higher prevalence of AF in the older group. Age was positively correlated with LA diameter and Wilkin’s score (r = 0.186, P = 0.002; r = 0.142, P = 0.022; respectively); while mean MVG (r = -0.304, P < 0.001), TR Vmax (r = -0.126, P = 0.04), TR maxPG (r = -0.127, P = 0.039) and TAPSE (r = -0.125, P = 0.044) were correlated negatively with age. Mean MVG has the strongest correlation with age in our subjects. CONCLUSION: This is the first study in Indonesia that analyze the association of age and different echocardiographic parameters in isolated severe rheumatic severe MS patients. Age has a significant correlation with mean MVG, LA diameter, Wilkin’s score, TR Vmax, TR maxPG, and TAPSE. We assume that the association of age and these parameters were influenced by the normal aging process and progression of chronic MS

Dobutamine Stress Echo For Myocardial Viability Assessment

The prevalence of left ventricular (LV) dysfunction and resultant heart failure is increasing in developing countries. Two thirds of cases of left ventricular dysfunction are the result of coronary artery disease (CAD). Although there have been significant advances in medical therapy for LV dysfunction and resulting symptoms of heart failure, the prognosis from heart failure remains extremely poor. Many of these patients had previous myocardial infarctions, the extent of remaining viable tissue is of clinical interest, and also related to prognosis. Thus assessing myocardial viability is very important in patient with left verntricuar dysfunction to choose the right management. Dobutamine stress echo is one of the most common tool that used to asses myocardial viability. A 67 years old patient with chronic heart failure because of old anterior and inferior MCI with low ejection fraction. It is very important to assess the viability in patients with advanced heart failure to know the future management because it is related to patients morbidity and mortality. With little viable myocard in this patient, the best management for this patient is conservative therapy with medical therapy. Dobutamine stress echocardiography therefore, may well provide complementary information in the assessment of myocardial viability. Future modalities are now being studied to give more objective measurement of myocardial viability with higher sensitivity and specificity

Atrial Electromehanical Interval Using Tissue Doppler as Predictor of Atrial Fibrillation After Coronary Artery Bypass Grafting

Background. Atrial fibrillation (AF) is the most common arrhythmia complication in patient undergone coronary artery bypass grafting (CABG) with the incidence of 20-50% according to different studies. Although this complication is temporary but can be life threathening, and increased the number of mortality and morbidity. Thus, it is very important to identified factors that can predict the occurance of AF post CABG. This study use atrial electromechanical interval and interval dispertion as predictor of AF post CABG. Methods. One hundred and eight patients were included in this case control study. Samples were taken consecutively from May to September 2012 among patients with coronary artery disease undergoing CABG at the National Cardiovascular Center Harapan Kita Jakarta. The patients underwent a preoperative transthoracic echocardiography with tissue doppler evaluation. We measured the atrial electromechanical interval in the lateral of left atrium, septal and lateral of right atrium also inter and intra atrial interval dispertion. Patients was monitored thorugh out hospitalization for the occurance of AF. Result. In our study, 27 out of 108 (25%) patients developed AF post CABG. There are 3 independent parameters that can predict AF post CABG. These parameters are electromechanical interval in lateral left atrium, left atrial volume index, and post operative beta blocker. There are longer electromechanical interval in lateral left atrium in patients with AF post CABG (81,129,84 ms vs 64,4313,53 ms, P=0.00). Patients with AF had bigger left atrial volume index (37,319,50 ml/m2 vs 30,288,19 ml/m2, P=0.037) and more beta blocker post CABG (20 (74,1%) vs 72(88,9%), P=0.026). There are no difference intra and interatrium dispertion of electromechanical interval. Conclusion. The interval of Electromechanical in the lateral left atrium using tissue dopper echocardiography can predict the occurrence of AF post CABG

Pulmonary Doppler Notch Pattern in Relation with Pulmonary Vascular Resistance Index in Patients with Atrial Septal Defect

Background: Atrial septal defect (ASD) potentially causes pulmonary hypertension (PH) and increased pulmonary vascular resistance (PVR). In previous studies, pulmonary Doppler notch was evident in patients with high PVR. There was a distinct notch pattern in different types of PH. This study aims to examine whether echocardiographic notch pattern could estimate PVR in secundum ASD patients. Methods: Cross sectional study was conducted in secundum ASD patients ≥18 years old who underwent clinically indicated right heart catheterization. Association of notch presence and PVR index (PVRi) and correlation of notch ratio (NR), a parameter of notch location, and PVRi were analyzed. The best cut off of NR value was obtained using the receiver operating characteristics curve. Results: Among 60 patients, the notch was present in 50 patients (83%) and significantly associated with PVRi ≥6 WU.m2 (p<0.0001). Notch ratio and PVRi had a moderate negative correlation (r=-0.410, p=0.003). Receiver operating characteristics curve with area under curve 0.709 showed that cutoff NR value of 1.635 was a good discriminator for PVRi ≥6 WU.m2, with 70% sensitivity, 70% specificity, 56.8% positive predictive value, and 14.9% negative predictive value. Patients were then classified into three groups of notch pattern based on its presence and location, which was significantly associated with PVRi (p<0.0001). Conclusions: Pulmonary Doppler notch pattern is associated with PVRi in secundum ASD patients. This may be used clinically to estimate PVR to aid patient selection for further invasive investigation.   Keywords: atrial septal defect, Doppler echocardiography, notch, notch ratio, pulmonary vascular resistanc

Left Atrial Thrombus Resolution Using Unfractionated Heparin and Warfarin in a Patient with Mitral Stenosis

Abstract Background:  Though the use of Low Molecular Weight Heparin (LMWH) in general is preferred due to its convenient and eliminates the need for activated Partial Thromboplastin Time ( aPTT) monitoring but Unfractionated Heparin (UFH) is still widely used in clinical setting due to its availability and low price. Besides UFH, the use of oral anticoagulant therapy with warfarin, has been the standard therapy for the prevention of thromboembolism in patients with AF. Our aim is to report a case of the resolution of left atrial thrombus in a patient with mitral stenosis. Case Illustration:  A Case report of a female patient aged 54 years who admitted with a sudden neurological deficits and mitral stenosis with atrial fibrillation.  Transthoracal Echocardiography (TTE) showed mobile thrombus which moved and obstructed the mitral valve during diastolic phase. Unfractionated heparin (UFH) was administered 3000 unit bolus intravenously and maintained with 600 unit per hour with the combination of warfarin 2 mg for five days. TTE evaluation showed the resolution of LA thrombus.  Conclusion : The administration of the combination of UFH and warfarin had successfully caused  resolution of  the LA thrombus and prevented the patient from surgical intervention. This case report indicated that Unfractionated Heparin and Warfarin were still the treatments option in LA thrombus patients with mitral stenosis and atrial fibrillation.   Key words :Left atrial thrombus, unfractionated heparin, thrombus resolution   &nbsp

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology

Introduction: Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients. Methods: Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported. Results: A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12–54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%–88.5%), and MVR was 78.3% (95% CI 75.8%–80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%–88.2%) vs. 71.1% (95% CI 56.3%–81.7%) p-value log rank 0.007. Conclusion: Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed

Role of Echocardiography as Supporting Diagnostic Modality in Localized Stanford Type A Aortic Dissection

Ascending Stanford type A aortic dissection carries a high morbidity and mortality. Proper identification of the proximal origin of the dissection and determination of concomitant aortic valve involvement significantly facilitate surgical repair which may improve survival.2Rapid imaging is necessary for the timely diagnosis of a potentially life-threatening condition. Transthoracic Echocardiography is highly accurate for the detection of acute aortic syndromes especially identify ascending aortic pathology such as type A aortic dissection.3 We report the unusual case of 52-years old male who present atypical presentation of aortic dissection with unclear view of dissection by CT Angiography aorta, and diagnosed as Localized Stanford A Aortic dissection with supported data by echocardiography modality