The Role of Echocardiography as Imaging Modality in Diagnosing Acute Pulmonary

Embolism in Limited Resources Setting: Focus on McConnell’s Sign

Adiwinata S, Posangi I, Reppi GEH
Department of Cardiology and Vascular Medicine, Bethesda Tomohon General Hospital,
Manado, Indonesia

Background: Pulmonary Embolism (PE) is a common disease which remains underdiagnosed.

Nonspecific clinical presentation makes timely diagnosis is more critical and challenging
especially in limited resources hospital.

Case Summary: A 16-year-old female visited Emergency Department due to motorcycle

accident with head injury and closed right femoral shaft fracture. She underwent wound lavage,
external fixation and hospitalization. The next day, she suddenly complaint shortness of breath.
On physical examination, BP 80/60 mmHg, regular HR 140 bpm, RR 40 bpm, peripheral blood
oxygen saturation 80% on room air and diminished breath sounds. Her Revised Geneva Score is
7. Complete Blood Count result was unremarkable. A 12-lead electrocardiography showed sinus
tachycardia with S1Q3T3 pattern. Chest radiography revealed no abnormality. Transthoracic
Echocardiography (TTE) revealed dilated RV with basal RV/LV ratio >1, McConnell sign,
flattened IVS in PSAX view and TAPSE 12 mm. Patient was diagnosed with Acute PE and
Enoxaparin 60 mg twice daily was prescribed. Patient conditions had gradually improved with
normal vital signs and peripheral blood oxygen saturation over a period of hospitalization.

Discussion: Acute PE in young patient is not very common. A young patient with acute onset of
dyspnoea and had strong risk factor such as lower limb fracture should be suspected as acute PE.
By using combination of risk factors data, physical examination, validated scores, ECG and
imaging studies such as TTE can be helpful for early diagnosis and treatment of acute PE in
limited resources setting to increase life expectancy.

Keywords: Acute Pulmonary Embolism, McConnel’s Sign, Transthoracic Echocardiography

 Serial Case Reports of Global Longitudinal Myocardial Strain
Measured by Speckle- Tracking Echocardiography
in Patients Undergoing Extracorporeal Shockwave Myocardial Revascularization

Puspita, I.
Department of Cardiology and Vascular Medicine,
Dr. Mohammad Hoesin General Hospital, Palembang

Abstract

Background. Global longitudinal strain (GLS) has been known to have prognostic value in the
evaluation of myocardial ischaemia in several clinical setting and medical therapy.
Extracorporeal shockwave myocardial revascularization was a novel noninvasive therapy in
treatment of patients with refractory angina. The serial case reports presented GLS measurement
using speckle- tracking echocardiography (STE) in patients undergoing ESMR still limited.

Case Summary. In dr. Mohammad Hoesin hospital, 7 three vessels disease patients undergoing
ESMR from February until April 2021. One patients was 74 years old female, and six patients
was male with age range from 58 years old until 75 years old. Six patient already passed first and
fifth week therapy, one patient completed all week of therapy. GLS was obtained before ESMR
and 1 month after each week of the therapy. Four patients shown increasing score ( -6 to -12, -7
to -11, -9 to -11, -14 to -15), two patient have quite similar score ( -5 to -5, -9 to -8) and one
patient shown close variable score (-17, -15 and -16) before and after ESMR. All patients
addressed improvement of angina, analyzed by Seattle Angina Questionnaire-7 (SAQ-7).

Discussion.We identified GLS and angina score improvement with ESMR therapy, not an
unsatisfied outcome that promote this therapy to be a preferable noninvasive therapy with low
theraupetic risk and comfortable for patients. ESMR improve refractory angina by mechanism of
angiogenesis. Further study, to provide comprehensive data of long period outcome of ESMR,
still needed.

Keywords: GLS, STE, ESMR, SAQ-7

 EBSTEIN’S ANOMALY WITH VENTRICULAR SEPTAL DEFECT:
AN EXTREMELY RARE CASE REPORT AND IT’S MORTALITY SCORE TROUGHT
ECHOCARDIOGRAPHY
1
Hendsun, 2Felicia, 3Helfiani
1. General Practitioner, Tarumanagara University, Jakarta, Indonesia
2. General Practitioner, Depati Hamzah Regional Hospital, Bangka Belitung,
Indonesia
3. Pediatrician, Depati Hamzah Regional Hospital, Pangkalpinang, Bangka Belitung,
Indonesia

BACKGROUND: Ebstein's anomaly is rare, accounting for <1% of all patients with congenital
heart defects, characterized by the downward displacement of septal leaflets and atrialized right
ventricle, usually associated with the atrial septal defect, pulmonary stenosis and pulmonary
atresia. Great Ormond Street Echocardiography (GOSE) is an echocardiography-based grading
score used to assess patients' mortality with Ebstein's anomaly.
CASE SUMMARY: A 1-year-8-month-old boy presented to the emergency department with
bilateral palpebral edema and bilateral pedal pitting edema occurring a week before. He also
became cyanotic on his face, lips, and hands every crying since eight months ago. There was a
left scrotal enlargement, especially when he was crying and waned after he was asleep. Vital
signs were typical. Nutritional status indicates malnutrition. Cardiopulmonary examination
revealed splitting S2, louder pulmonary valve sound, grade 4/6 and 2/6 systolic murmur in
tricuspid and mitral areas. The blood count showed a slight leukocytosis (13,700/uL). The chest
radiograph showed a box-shaped heart and oligemic lungs. Echocardiography demonstrated a
high probability of pulmonary hypertension, perimembranous VSD, severe tricuspid and
pulmonary regurgitation. Bilateral scrotal ultrasound displayed bowels and fluid collection. The
patient was hospitalized, then given intravenous fluid, antibiotics, and a diuretic.
DISCUSSION: The association between Ebstein's anomaly and VSD is unusual. The size and
location of the ventricular defect have a positive correlation with the increase of the pulmonary
flow. The patient's GOSE score was grade-3 with 100% mortality. An early case finding at this
score indicates a lower mortality rate.

KEYWORDS: Ebstein's anomaly; ventricular septal defect; echocardiography.

Table 1. Patients’ GOSE Score Indicate a 100% Mortality.

Grade Ratio Mortality
1 <0.5 8%
2 0.5-1.0 8%
3 (acyanotic) 1.1-1.4 10% (Early); 45% (Late)
3 (cyanotic) 1.1-1.4 100%
4 >1.5 100%
Figure 1. Patients’ Echocardiography.
Right Ventricular Free Wall Strain as Early Detection of Right Ventricular Dysfunction in
Sepsis.

Wardhani A1, Nugroho MA1, Ahnaf MF1, Kristina TN2, Cahyadi MH1
1
Departement of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University/Dr.
Kariadi General Hospital, Semarang, Indonesia
2
Faculty of Medicine, Diponegoro University

Abstract

Aims: The aims of this study is to assest right ventricular function in sepsis patients. Sepsis is an
organ dysfunction due to dysregulation of the body's response to infection which, can be
assessed using Sequential Organ Failure Assessment (SOFA) score. Myocardial dysfunction
occurs in 50-64% of septic patients. Right ventricle (RV) play important hemodynamic
regulation roles. Association between sepsis severity based on SOFA score with RV systolic
function echocardiography has limited study.
Methods and Result: This cross-sectional observational study involved 25 septic patients in Dr.
Kariadi General Hospitals. The SOFA score as a study subject was calculated up to a maximum
of 3 times per patient parallel to the RV function examination using echocardiographic TAPSE
and RVFWS. Correlation tests were carried out between SOFA scores with TAPSE and
RVFWS. There were 56 samples of SOFA scores and echocardiography. There was a significant
correlation between SOFA scores and TAPSE (r = -0.44, p = 0.001), RVFWS (r = -0.52, p =
<0.001). We compare RVFWS and TAPSE to classify RV function, and it showed that RVFWS
decreased in all patients, but there were only 28.6% of patients with RV dysfunction when we
used TAPSE as a parameter.
Conclusion: SOFA score is associated with RV function. RVFWS is a better RV function
parameter compare with TAPSE in sepsis. Echocardiography in septic patients can be considered
to detect early RV dysfunction.

Keywords: SOFA score, RV systolic function, Sepsis, TAPSE, RV FWS.

 Management of Hypertensive Crises in Rural Area : What Can We Do ?

Vicki, N.1, Billy, A.2, Sari, Y.3

1
General Practitioner, Santo Antonius Jopu Hospital, Ende, Indonesia

2
General Practitioner, Santo Antonius Jopu Hospital, Ende, Indonesia

3
Internist, Santo Antonius Jopu Hospital, Ende, Indonesia

BACKGROUND: Physicians in emergency departments frequently triage patients with hypertensive

crises, that is an acute and severe rise in blood pressure presenting with highly heterogeneous profiles
ranging from absence of symptoms to life-threatening target organ damage

CASE SUMMARY: A-54 year old man came to emergency room with decrease of consciousness,
dizziness, nausea and vomitus since 6 hours before. We noticed slurred speech that has the same onset
with other complaints. He reported long history of uncontrolled hypertension and dyslipidemia. He is an
active smoker for the last 34 years. His blood pressure was 240/140 mmHg, heart rate 81 beats/minute,
respiratory rate 20 breaths/min, oxygen saturation in room air 98%. The ECG shows T inverted in lead
V3-V6, I, avL which indicates antero-lateral ischemic heart disease. Total cholesterol on this patient was
326 mg/dl. The patient was diagnosed with Hypertensive Emergency, Dyslipidemia, and Ischemic Heart
Disease. We treated the patient with oral anti-hypertensive drugs (Captopril, Amlodipine), injection of
Citicoline, oral Statin, and some medications for the symptoms (Betahistine, Ranitidine). Blood pressure
decreased to 200/110 mmHg in 1 hour after administrating oral Captopril 25mg and Amlodipine 10mg.

DISCUSSION : Rapid-acting intravenous agent should be given for the treatment of hypertensive
emergencies. Unfortunately in our setting in rural area, these agents are not available and we are pushed
to optimize the treatment with what we have : oral-antihypertensive drug. Preferred two-drug
combinations for the treatment of hypertension are RAS blocker with a CCB or a diuretic.

KEYWORDS : Hypertension, Hypertensive Crises, Rural Area

 Heart Failure and Pulmonary Edema in Rural Area : A Case Report

Vicki, N.1, Billy, A.2, Sari, Y.3

1
General Practitioner, Santo Antonius Jopu Hospital, Ende, Indonesia

2
General Practitioner, Santo Antonius Jopu Hospital, Ende, Indonesia

3
Internist, Santo Antonius Jopu Hospital, Ende, Indonesia

BACKGROUND : Pulmonary edema, especially when associated with acute respiratory failure, often
leads to poor outcomes in hospitalized patients. A subset of this disorder, cardiogenic pulmonary edema,
occurs when the edema is secondary to acute cardiac failure.

CASE SUMMARY : A 62-years old man came to emergency department with dyspnea that got worsened
since one day before. He has been having dyspnea on effort for the last 1 year and worsening since then.
He also feels fatigue, ankle swelling, cough, and chest pain. He is an active smoker for the last 40 years.
He has history of long uncontrolled hypertension. His blood pressure 220/110 mm Hg, heart rate 69
beats/minute, temperature 36°C, respiratory rate 28 breaths/minute, and oxygen saturation in room air
94%. Elevated jugular venous pressure is present. Chest auscultation reveals rales and rhonchi bilaterally.
His chest x-ray shows cardiomegaly and pulmonary vascular cephalization as signs of pulmonary edema.
The patient was diagnosed with Acute Pulmonary Edema, Acute Heart Failure, and Hypertensive
Emergency. We treat the patient with Furosemide injection, oral anti-hypertensive drug, oral isosorbide
dinitrate, oral antibiotics, and oral anti-mineralocorticoid. Patient’s symptoms relieved in 1 hour post
administration of Furosemide injection.

DISCUSSION : In AHF with hypertensive emergency, AHF precipitated by rapid and excessive increase
in arterial blood pressure typically manifests as acute pulmonary edema. A prompt reduction in blood
pressure should be considered as a primary therapeutic target and initiated as soon as possible.

KEYWORDS :

Heart Failure, Pulmonary Edema, Rural Area

The Association Between Clinical Characteristics And Ejection Fraction In Chronic Heart
Failure Patients At Sanglah General Hospital, Bali, Indonesia In 2021 : Cross-Sectional
Study

Upadhana PS1, Sastrawan IGG1, Cahyarini IGAAC1, Sanjiwani MID1, Wibhuti IBR2, Antara
IMPS2

1
Bachelor of Medicine and Medical Profession, Faculty of Medicine, Udayana University,
Denpasar, Bali, Indonesia 2Division of Cardiology, Sanglah General Hospital Denpasar, Faculty
of Medicine, Udayana University, Denpasar, Bali, Indonesia

Aims: This study aims to determine the association between clinical characteristics and ejection
fraction in patients with chronic heart failure.

Method and Results: This study is a cross-sectional analytic study with total population
sampling method. There were 94 chronic heart failure patients included in this study. Most of the
patients were female (54.3%), with a mean age of 52.22. The majority of patients belonged to the
preserved ejection fraction (68.1%) with functional class II (91.4%). Most of the patient had
cardiomegaly (79.8%), with normal left ventricular systolic function (66.0%), and normal right
ventricular function (87.2%). Most of the patients had chief complaints of shortness of breath
(52.1%). Beta-blockers were the most commonly administered drugs to patients (81.9%). The
most type and degree of valve abnormalities were tricuspid regurgitation (32.5%) with mild
degrees (58.4%). The most common medical history of the patient was coronary artery disease
(44.7%). From the chi-square analysis, it was found that male gender (p=0.019;
PR(CI95%),0.712(0.526-0.963), diabetes mellitus type 2 (p=0.001; PR(CI95%),0.485(0.265-
0.885), Coronary artery disease (p=0.001; PR(CI95%),0.605(0.438-0.839), rheumatic heart
disease (p=0.013; PR(CI95%),1.446(1.139-1.835), normal left ventricular systolic function
(p=0.0001; PR(CI95%),7.742(3.092-19.384), and normal right ventricular systolic function
(p=0.036; PR(CI95%),1.727(0.872-3.419) were statistically significant to ejection fraction.

Conclusion: Sociodemographic, medical history, and cardiac function has a significant

association with the ejection fraction of chronic heart failure patient. Thus, early interventions
against these factor can improve the quality of management in chronic heart failure patients.
 RECURRENT ACUTE RHEUMATIC FEVER: A CASE REPORT
Shandy, C.A.1, Sutarmini, S.A.N.Y2
1
Bali Mandara General Hospital
2
Department of Cardiology and Vascular Medicine, Bali Mandara General Hospital

Background
Rheumatic fever is an autoimmune disorder with preceding Group A Streptococcal pharyngitis.
The incidence had been declining significantly in developed countries but remains a mayor
public health issues in developing countries. One of its most important manifestation is carditis
that can lead to rheumatic heart disease, the mayor cause of heart failure in children and young
adult. We present a case of recurrent acute rheumatic fever (ARF) with moderate mitral
regurgitation.
Case Summary
A 14 years old girl came to emergency room with swollen joints, with fever since last week and
chest pain since last 3 days. She had history of ARF 4 years ago, without follow up. Blood
pressure was 100/70 mmHg, heart rate 90 bpm, and temperature was 37 Celcius degree. Physical
examination revealed apical holosystolic murmur, redness and swelling on left knee and toes.
ECG and Chest X-Ray were normal. ASTO titer was 400. Echocardiogram showed moderate
mitral regurgitation with EF 74.7%. She was treated with aspirin, erythromycin, bisoprolol, and
Benzatin Penicillin injection monthly. Echocardiogram after discharge showed persisting mitral
regurgitation.
Discussion
Diagnosis of ARF was based on revised Jones criteria. This patient presented with two major
criteria, carditis and polyarthritis, with positive ASTO and history of ARF. The treatment
consisted of antibiotic, anti-inflammatory, symptomatic treatment, and secondary prophylaxis.
Conclusion
Prevention of ARF recurrence with long term secondary prophylaxis is very crucial to prevent
permanent valve damage. Difficulty for health care access and educational background still
remain big issues in developing countries.

Keywords: ARF, recurrent, carditis

 INFECTIVE ENDOCARDITIS TEAR DOWNED THE SINUS OF VALSAVA
N. Nusantara1, N. Purwaningtyas2
1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Sebelas
Maret, Indonesia;
2
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Sebelas
Maret - Moewardi General Hospital, Surakarta, Indonesia.

BACKGROUND
Sinus of Valsava aneurysm is an anomaly that could be congenital or acquired, rare
etiology of the acquired aneurysms are caused by infective endocarditis. Its complications may
lead to a ruptured of the sinus of Valsava. Echocardiography plays an important role to help the
diagnosis.

CASE SUMMARY
A 37-year-old man was referred to the cardiology department of our hospital with an
initial assessment of ventricular septal defect suspect, He presented dyspnea and febrile
temperature. BP 143/93 mmHg, HR 118, RR 26 x/m, t 38.4°C. We found diastolic murmurs at
the aortic area. TTE found a left to right shunt from the right coronary sinus of Valsava to the
right ventricle, the diameter of the fistula between the right coronary sinus of Valsava and the
right ventricle was 1.1 cm. A 2.9-cm mobilized mass attached to the right coronary sinus of
Valsava that prolapsed to the right ventricle outflow tract were also visualized, indicating the
presence of possible infective endocarditis. Other examinations fulfilled the Duke’s criteria of
definite infective endocarditis, such as: endocardial involvement, fever, roth spots,
glomerulonephritis, and positive blood culture. CT-scan showed the presence of aneurysmal
dilatation of the Valsava sinus with a ruptured to the RV

DISCUSSION
The rupture of sinus of Valsava in this case was caused by infective endocarditis, ie, the
large vegetation adjacent to the sinus of Valsava and tear down its wall and resulted in its
communication to the RV.

KEYWORDS
Rupture, Valsava sinus aneurysm, infective endocarditis
The Association Between Clinical Characteristics And Ejection Fraction In Chronic Heart
Failure Patients At Sanglah General Hospital, Bali, Indonesia In 2021 : A Cross-Sectional
Study

Upadhana PS1, Sastrawan IGG1, Cahyarini IGAAC1, Sanjiwani MID1, Wibhuti IBR2, Antara
IMPS2

1
Bachelor of Medicine and Medical Profession, Faculty of Medicine, Udayana University,
Denpasar, Bali, Indonesia 2Division of Cardiology, Sanglah General Hospital Denpasar, Faculty
of Medicine, Udayana University, Denpasar, Bali, Indonesia

Aims: This study aims to determine the association between clinical characteristics and ejection
fraction in patients with chronic heart failure.

Method and Results: This study is a cross-sectional analytic study with total population
sampling method. There were 94 chronic heart failure patients included in this study. Most of the
patients were female (54.3%), with a mean age of 52.22. The majority of patients belonged to the
preserved ejection fraction (68.1%) with functional class II (91.4%). Most of the patient had
cardiomegaly (79.8%), with normal left ventricular systolic function (66.0%), and normal right
ventricular function (87.2%). Most of the patients had chief complaints of shortness of breath
(52.1%). Beta-blockers were the most commonly administered drugs to patients (81.9%). The
most type and degree of valve abnormalities were tricuspid regurgitation (32.5%) with mild
degrees (58.4%). The most common medical history of the patient was coronary artery disease
(44.7%). From the chi-square analysis, it was found that male gender (p=0.019;
PR(CI95%),0.712(0.526-0.963), diabetes mellitus type 2 (p=0.001; PR(CI95%),0.485(0.265-
0.885), Coronary artery disease (p=0.001; PR(CI95%),0.605(0.438-0.839), rheumatic heart
disease (p=0.013; PR(CI95%),1.446(1.139-1.835), normal left ventricular systolic function
(p=0.0001; PR(CI95%),7.742(3.092-19.384), and normal right ventricular systolic function
(p=0.036; PR(CI95%),1.727(0.872-3.419) were statistically significant to preserved ejection
fraction.

Conclusion: Sociodemographic, medical history, and cardiac function has a significant

association with the ejection fraction of chronic heart failure patient. Thus, early interventions
against these factor can improve the quality of management in chronic heart failure patients.

Keywords : Clinical Characteristics, Chronic Heart Failure, Ejection Fraction, Sanglah Hospital
 Strategy of Implementing Aerobic Exercise as A Cardioprotective In Cancer Patients with A
History of Administration Cardiotoxic Agents

Putu Yogi Pramana1, A.A.G.Kesuma Yudha1, P.Nita Cahyawati3

1
Public Health Center Klungkung I Bali; 2Faculty of Medicine and Health Science, Warmadewa
University, Bali, Indonesia; 3Faculty of Medicine and Health Science, Warmadewa University,
Bali, Indonesia

Background: The development of health science in the world, with the discovery a type of
treatment to reduce mortality due to cancer, namely using chemotherapy agents such as
anthracycline and trastuzumab. From the number of studies that have been done, the types of
drugs such as anthracycline and trastuzumab have a cardiotoxic effect which is often associated
with decreased heart-lung function and the incidence of cardiomyopathy. Exercise is reported to
have a cardioprotective effect.
Objective: Synthesize evidence from the application of cardioprotective exercise in cancer
patients undergoing chemotherapy with cardiotoxic agents.
Methods: The search was performed according to the recommended reporting items for
systematic review and meta-analyses (PRISMA). Obtained an accumulation of 2397 articles
from Pubmed and Google Scholar (2016-2020), which were assisted by the PICO search engine.
The article was reviewed by the author within sorting using inclusion and exclusion criteria and
obtain 28 articles accordingly.
Results: Aerobic exercise has cardioprotective effects by stimulating antioxidants and reducing
ROS levels, reducing species and proapoptosis molecular signaling, stimulating myofilament,
facilitating concentric cardiac hypertrophy remodeling, changing cardiac metabolism via amp
with kinase-mediated. Pretreatment aerobic exercise with minimal supervised 30-min exercise
sessions 3 times/week for ≥12 week effective reduce risk of chemotherapy induced
cardiomyopathy (CRC).
Conclusion: Aerobic exercise has a significant cardioprotective effect in patients undergoing
chemotherapy with cardiotoxic agents by applying it according to the patient's clinical condition.

Keywords: CRC, Aerobic Exercise, Cardioprotective, Cardiotoxic

 Gigantic Thrombus in Left Ventricle and Left Atrium: a Rare Case

Januaresty O1, Novita1, Ridwan M1, Muqsith M1, Heriansyah T1

1. Department Cardiology and Vascular Medicine, Faculty of Medicine, Syiah Kuala
University/Zainoel Abidin Hospital, Banda Aceh, Indonesia
Background:
Left ventricular thrombus is common in clinical conditions with Acute Anterior
Myocardial Infarction and Dilated Cardiomyopathy (DCM). The clinical assessment of left
ventricular thrombus is important because of the potential complication of systemic embolism,
especially stroke.
Case:
A 37 years old male presented fatigue. History of hypertension and DM were absent.
ECG showed sinus Rythme, rate 92 bpm, pathological q wave in V3-V6, II, III, aVF. Laboratory
showed D-dimer > 4000 ng/ml, Fibrinogen 324 mg/dl. Echocardiography showed LVEF 21%
with huge thrombus in LA and 2/3 LV chamber. Anticoagulant and clopidogrel were given. 2
months later, the echocardiographic evaluation was carried out, the thrombus has been reduced
to half in size.
Discussion:
Thrombogenesis is dependent upon Virchow's triad of stasis, hypercoagulable state, and
endothelial injury. If myocardial infarction causes extensive LV akinesis or dyskinesis, blood
flow within that portion of the LV cavity will be slow down, resulting intracavitary stasis.
Prolonged ischaemia leads to subendocardial tissue injury with inflammatory changes. Finally, it
may result in the formation of LV thrombus composed of fibrin, red blood cells, and platelets.
echocardiography provides excellent specificity (85-90%) and sensitivity (95%) in detecting LV
thrombus.
Conclusion:
Early detection, which is heavily reliant on the sensitivity of imaging modality used for
screening, is important to prevent the high rates of thromboembolic complications associated
with established LV thrombus.
Keywords: Gigantic Thrombus, Echocardiography evaluation
 (a) (b)
Figure (a) First echocardiography (b) Echocardiography evaluation
 ABSTRAK
Patent Ductus Arteriosus Closure with Transthoracic Echocardiography Guidance,

Echocardiography Projection Matters

Rahayu, N1, Matahana, L.M. 1, Utama, A.U.1, Patimang, Y.1, Ghaznawie, A.F.1

1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Hasanuddin University, RSUP
Wahidin Sudirohusodo, Makassar, Indonesia.,

Background : Patent Ductus Arteriosus (PDA) is one of the most common congenital heart diseases with
a left to right shunt. Most of the PDA need to be closed. Several negative effects of PDA closure using a
fluoroscopy guidance had been highlighted due to its radiation exposure. The necessity of using a
contrast agent is also confirmed to increase the patient risk. To this end, closure of PDA using TTE
guidance was developed to prevent the side effect of the fluoroscopy for both doctors and patients.

Case Summary : We report a case of 18-year-old girl presenting with PDA and left-to-right shunt. The
patient underwent a PDA closure with a trans-thoracal echocardiography (TTE) guidance and used an
occluder device. The procedure was performed without any complication, patient was stable, and from
the TTE control, we found no residual shunt and device in situ.

Discussion : PDA closure with TTE guidance method required a well-developed collaboration between
the pediatric interventional cardiologist and echo-cardiologist. To perform closure of the PDA with TTE
guidance properly requires a good vascular visualization, so it is necessary to understand the projection
and constellation of the heart and vascular both with the antegrade and retrograde approaches. PDA
Closure using a device and TTE guidance is as effective as a fluoroscopy guidance. Closure of the PDA
using TTE guidance may prevent patients and doctors from the negative effects of radiation, as well as to
minimize the risk of contrast agents.

Keywords : PDA Closure, TTE Guidance, Echocardiography Projection

 ABSTRAK

Enhanced Echocardiographic Assessment of Right Ventricular Outflow Tract

Obstruction with Shunt: A case series with 3D remodeling and printing from Cardiac Computed

Tomography (Beyond Imaging)

M. Laode 1, R. Nurawita1, A.U. Andi 1, P. Julius1, L. Nikmatiah2

1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Hasanuddin University, RSUP

Wahidin Sudirohusodo, Makassar, Indonesia.

2
Department of Radiology, Faculty of Medicine, Hasanuddin University, RSUP Wahidin Sudirohusodo,

Makassar, Indonesia.

Background: Obstruction of the right ventricular outlet may include stenosis of the Right

Ventricular Outflow Tract (RVOT) or the presence of atresia in the valve or pulmonary artery.

Assessment of the RVOTO and accompanying lesions can be performed by echocardiography and

Cardiac Computed Tomography (CCT). These two assessments can complement each other.

Case Summary: In this report, we present five cases with RVOT obstruction with shunts in the

form of Tetralogy of Fallot (ToF), pulmonary atresia with Ventricle Septal Defect (VSD), and pulmonary

stenosis with Double Outlet Right Vetricle (DORV). The first patient with ToF and infective endocarditis.

The second patient with atypical ToF, cardiac dextroposition and susp. Scimitar Syndrome. The third

patient with pulmonary atresia, VSD and post R-BT shunt. The fourth patient with pulmonary stenosis,

DORV, remote VSD, post BT shunt and susp. Criss Cross Heart. The fifth patient with pulmonary stenosis,

DORV, RA isomerism (situs ambigus), malposition of great artery, bilateral SVC and dextrocardia.

Discussion: Patients with RVOT obstruction with shunt have similar hemodynamic status, i.e. ToF

hemodynamic. The Echocardiographic and CCT assessment can be carried out in a segmental sequential

to systematically and comprehensively approach. For complex lesions, CCT provides 3D remodeling and

printing of the heart and may help to easily understand the cardiac morphology. The use of 3D

remodeling and printing can improve practitioners' understanding of RVOT obstruction with shunt,

including the accompanying lesions, and enhancing echocardiographic assessment.

 Keywords: congenital heart disease, RVOT Obstruction with Shunt, Enhanced Echocardiographic

Assessment, CCT assessment, 3D remodelling

ABSTRACT
Epicardial Fat Thickness as a Diagnostic Marker of Coronary Lesions in Stable Angina
Pectoris Patients
Fajar U, Yanni M, Syukri M

Aims: Epicardial adipose tissue is considered as true visceral adiposity of heart that have
important role of proinflamation of coronary vessels. This Study was conducted to knew the cut
off of epicardial fat thickness, and how was it role to predicted the presence of coronary lesions.

Methods: This was an observational analytic study with crossectional comparative design. Data
was retrieved prospectively at the M. Djamil Padang from August 2019 to February 2020 in
stable angina pectoris patients who underwent coronary angiography. The Epicardial Fat
Thickness (EFT) was measured at end-diastole from the Parasternal long axis (PLAX) views of
three cardiac cycles on the free wall of the right ventricle on echocardiography examination.
Bivariate analysis was used to assess epicardial fat thickness and presence of the coronary
lesions using Independent Sample T test. A diagnostic test was performed based on receiver
operating curve (ROC) analysis.

Results: Patients were devided as CAD group group (n =150; 58,11 ± 8,24 years) and non-CAD
group (n = 85; 53,16 ± 9,78 years) after assessing coronary angiograms. We found that epicardial
fat thickness was higher in subjects with coronary lesions (3,62 ± 1,03 mm) compared with
subjects without coronary lesions (1,55 ± 1,10 mm) with p <0.001. Epicardial fat thickness ≥
2.835 mm predict the presence of coronary lesion by 82% sensitivity, 86% specificity and 88.9%
accuracy based on the AUC value.

Conclusions: Epicardial fat thickness can be a good predictor to detect the presence of coronary
lesion.

Keywords: epicardial fat thickness; coronary artery lesions

 Neglected Atrial Septal Defect in Elderly

Hadi,Tjut Farahiya1, Novita1 , Heriansyah,Teuku1

1
Department of Cardiology and Vascular Medicine, Medical Faculty, Universitas Syiah Kuala

Background:

Atrial septal defect (ASD) are commonly occur in one-third of adults with congenital heart disease. It is
difficult to make appropriate diagnosis in adult patients with congenital heart defects, including patients
with ASD.

Case:

A 67-year-old female was consulted by Pulmonology department with suspect mediastinal tumor which
had a history of exertional breathlessness since 5 months, swelling of both lower limbs since 3 months,
cough with expectoration since 1 month. The patient did not have any comorbidities. On examination,
pulse rate was 88 beats per minute, iregular in rhythm. Blood pressure was 128/90 mmHg. Pitting edema
was present and jugular venous pressure was raised. On auscultation, a wide and fixed splitting of S2 was
heard along with a loud P2. A grade 3 systolic murmur was present in the tricuspid areas. Chest X-ray
showed cardiomegaly with a right ventricular type of apex and a prominent pulmonary artery.
Electrocardiography showed atrial fibrillation normoventricular response with HR 94 bpm. CT Scan
Thorax was normal. A transthoracic echocardiography showed an ostium secundum ASD measuring 2.2-
2.4 cm with a left to right shunt. The right atrium, right ventricle and left atrium were dilated. Mild
tricuspid regurgitation and low probability of pulmonary artery hypertension (PASP: 42 mmHg) was
present. Ejection fraction was 73% with smallish LV. TAPSE was 1.6 cm.

Discussion:

The diagnostic process is both complicated and long-lasting. Clinical signs related to ASD may be
uncharacteristic and may suggest the lung and mediastinal disease. Very few cases of ASD presenting for
the first time after 65 years of age have been reported in literature. ASD had complications such as severe
pulmonary hypertension, cardiac failure, and atrial fibrillation.

Conclusion:

In elderly patients presenting with exertional breathlessness, ischemic heart disease is the most frequent
diagnosis made. However, congenital heart disease like ASD can produce symptoms for the first time in
the elderly, albeit rarely and can easily be overlooked. Echocardiography is the simple way to diagnose
ASD.s

Keywords: Atrial Septal Defect, Elderly, Pulmonal Hypertension

 Giant Left Atrial Thrombus in A Patient with Acute Ischemic Stroke
Associated With Patent Foramen Ovale : Case Report

Teuku Mirza1, Novita2

1
Faculty of Medicine, Syiah Kuala University/ Zainoel Abidin Hospital, Banda Aceh, Indonesia;
2
Faculty of Medicine, Syiah Kuala University/ Zainoel Abidin Hospital, Banda Aceh, Indonesia.

Background: Giant Left Atrial Thrombus of patent foramen ovale is a rare occurrence and it is a
risk factor for the occurrence of ischemic stroke, stroke that is cryptogenic after a standard
diagnostic evaluation remains a common clinical challenge, accounting for 20 to 30% of all
ischemic strokes. Patent foramen ovale (PFO) is a potential cause of stroke, and randomized
controlled trials have confirmed the effectiveness of the closure in patients with stroke of
unknown cause and age <60 years, approximately 27% incidence of PFO in all ages.

Case Illustration and Discussion: A male, aged 40 years, with complaints of loss of
consciousness sudden 7 hours before admission to hospital. Patients often complained of
headaches since 7 days before admission to the hospital. The patient had no history of
hypertension, diabetes mellitus, valve disease and venous thromboembolism, patients never
consumed any drugs before, no previous history of similar complaints. The laboratory results
showed 378,000 platelets per microliter, 21.6000 leukocytes per microliter. Echocardiorgraph
examination showed visible thrombus in the left atrium, mobile and with uneven surfaces, size 5
x 2 cm without stalk and patent foramen ovale encountered with a size of 2 mm. Most patients
have no problem with a patent foramen ovale (PFO), even though blood leaks from the right
atrium to the left atrium. Problems can arise when the blood contains a blood clot, the blood clot
will accumulate into a thrombus, causing the risk of acute ischemic stroke. There are numerous
causes of ischemic stroke, Most of these causes can be categorized into 3 groups:
atherosclerotic, cardioembolic, and lacunar (a small vessel occlusion). Echocardiography is a
very useful diagnostic tool for determining patent foramen ovale and thrombus.

Conclusion: Giant left atrial thrombus in patent foramen ovale is a rare case and is a risk factor
for acute ischemic stroke, effective therapy for giant atrial thrombus is anticoagulant.

Keyword: Giant Left Atrial Thrombus, Acute Ichemic Stroke, Patent Foramen Ovale.
 How to Determine Intervention Management of Senile Calcific Aortic Valve Stenosis
N.A.S. Patriya, A. Yasa
Cardiology and Vascular Medicine Department, Faculty of Medicine
Universitas Sebelas Maret, Dr. Moewardi Hospital, Surakarta, Indonesia

Background: Degenerative calcific aortic stenosis involving progressive calcification of the

leaflet, resulted limitation of the cusps opening during systole. It represented consequences of
long standing hemodynamic stress on the valve and was the most frequent cause of aortic
stenosis requiring aortic valve replacement.
Case Summary: A 60 years old man complained chest pain and shortness of breath for 12 hours
before hospitalization. The physical examinations were 110/80 mmHg of blood pressure
measurement, 95 bpm of heart rate, one-third rales of the lung, and 5/6 systolic ejection murmur
in left lower sternal border. The N-terminal pro BNP increased with 25.000 nl/L of the result.
The chest radiograph showed cardiomegaly with lung edema. The echocardiography performed
with the result; severe aortic stenosis (AS) with Aortic Valve Area (AVA) by planimetry 0,4
cm2, AVA by VTI 0,5 cm2, mean pressure gradient 44,55 mmHg, and calcification the three
cusps of the valve. All chamber was dilated, with ejection fraction (EF) 29-32%. Left heart
catheterization was performed with the result significant stenosis in left coronary artery.
Discussion: The patient included to high gradient AS, low EF, and low flow status (Stroke
Volume Index 27,81 ml/m2). The patient had low surgical risk (EuroSCORE II <4%, logistic
EuroSCORE <10%), no other risk factors included, and had severe coronary artery disease
requiring revascularization. Although the patient surgical aortic valve replacement (SAVR) was
suitable, The Heart Team should consider anatomical, technical aspects, and risk-benefit ratio of
intervention modes.
Keywords: Aortic stenosis, Senile Calcific Aortic Valve, Surgical Aortic Valve Replacement
 Echocardiography evaluation in patients with severe aortic valve stenosis concomitant with
moderate aortic valve regurgitation and severe mitral valve regurgitation
Zuhri, E; Soesanto, AM; Kuncoro, AS; Ariani, R; Rudiktyo, E; Almazini, P; Soenarta, AA; Sukmawan, R

Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia

National Cardiovascular Center of Harapan Kita

Background. Echocardiography is the key tool for the evaluation of aortic valve stenosis (AS). Because
clinical decisionmaking is based on the echocardiography assessment of its severity, it is essential to
maintain accuracy. But, AS concomitant with aortic valve regurgitation (AR) and mitral valve
regurgitation (MR) may affect the assessment.

Case Summary. A 59-year-old woman came to polyclinic with chief complain dyspneu on effort. Patient
was compos mentis with her blood pressure was 114/59 mmHg and her heart rate was 68 bpm. Her ECG
was sinus rhythm. Physical examination revealed ejection systolic murmur on upper right sterna border
and pan-systolic murmur on apex. Echocardiography findings were severe AS with heavily calcified due
to degenerative process, moderate AR, and severe MR. Aortic valve area (AVA) was 0.6 cm 2 (VTI),
maximum velocity was 6 m/s, mean pressure gradient was 85 mmHg, maximum pressure gradient was
147 mmHg, AR PHT was 284 ms, and AR vena contracta was 0.6 cm. Mitral valves was prolapse at AML.
MR vena contracta was 0.7 cm. The pulmonary systolic reversal flow was positive. Left atrium was
dilated. Left ventricle size is normal with normal ejection fraction (64%).

Discussion. In mild or moderate AR, measurement of AS severity is not significantly affected. But in
severe AR, because of the high trans-aortic volume flow rate, maximum velocity, and mean gradient will
be higher than expected for a given valve area. Reporting accurate quantitative data for the severity of
both stenosis and regurgitation is helpful for clinical decision-making. MR severity does not affect
evaluation of AS severity except: in severe MR, transaortic flow rate may be low resulting in a low
gradient even when severe AS is present, but valve area calculations remain accurate in this setting as
long as flow is calculated in the LVOT and not by volumetry; and a high-velocity MR jet may be mistaken
for the AS jet. In otherwise, AS can affect measurement of MR severity by increasing regurgitation
volume if ROA is constant, and exaggerating the jet area.

Keywords: Aortic valve stenosis, aortic valve regurgitation, mitral valve regurgitation.