Pansystolic Murmur Research Articles

Severe iron deficiency anemia with critically low hemoglobin in a 2-year-old child: a case report

Background: Anemia in young children is a major public health problem worldwide. Around 1.6 million people have been diagnosed with anemia, and 47.4% of them are preschool children. Nutritional Iron Deficiency Anemia (IDA) is the most common type of anemia in pediatrics. Several complications happen due to IDA during the first 2 years of life, such as reducing cognitive development, lowering immunity, and delaying growth. Case Presentation: A 2-year-old girl was brought to the Emergency Room complaining of fever (39°C) associated with skin pallor for 2 months. A complete blood count laboratory test result showed a very critical low hemoglobin (Hb) 3.39 g/dL. She received a blood transfusion, as a life-saving treatment. She was diagnosed with IDA secondary to formula milk dependency. Her Hb reached 10.62 g/dL and she was discharged with iron supplementation for 6 months. Conclusion: This case adds more to the literature by documenting critically low Hb level with positive findings in physical examination, which are pansystolic murmur and palpable bounding pulse, indicating severe IDA.

A RARE CASE OF PROLONGED HASHITOXICOSIS INDUCED CARDIOMYOPATHY

Hashitoxicosis is the initial hyperthyroid phase of the patients with Hashimoto′s thyroiditis and usually this phase lasts for one to two months.We had a rare case of Hashimoto′s thyroiditis with prolonged phase of Hashitoxicosis and Hashitoxicosis induced cardiomyopathy. A 27 year old male presented with 6 months history of heat intolerance, sweating, tremors, weight loss and 3 week history of shortness of breath,palpitations and swelling of lower limbs. On examination, patient had exophthalmos, bilateral pitting pedal edema, goitre, tremors, tachycardia, tachypnea, raised JVP, S3, pansystolic murmurs in mitral and tricuspid areas. Thyroid prole showed elevated T3, T4 and suppressed TSH. Anti-TPO antibodies were elevated. USG neck and FNAC were suggestive of Hashimoto′s thyroiditis. 2D Echo showed dilated cardiomyopathy. Patient was started on anti thyroid drugs, diuretics and advised for follow up.

Pacing Induced Cardiomyopathy: What is The Solution?

ABSTRACT
 Background
 Right ventricular pacing is associated with adverse outcome including increased risks of cardiovascular morbidity and mortality. RV pacing causes abnormal ventricular activation results in an inefficient contraction pattern with ventricular dyssynchrony and loss of myocardial work that may lead to LV dilation, systolic dysfunction, and clinical HF. Pacing induced cardiomyopathy (PICM) is caused by chronic and high burden RV pacing that may occur several months or years after pacemaker implantation.
 
 Objective
 To present a case of pacing induced cardiomyopathy (PICM) managed by CRT-P implantation.
 
 Case Illustration
 A male, 56 years old, was referred from dr. M. Djamil General Hospital with CHF Fc II-III, s/p PPM DDDR due to high degree AV block (2016) and history of failed CRT-P implantation (2018). He complained DOE (+), PND (+) and OP (+) since April 2017. Physical examination revealed pansystolic murmur grade 2/6 at apex, no rales and no oedema at both legs. ECG showed pacing rhythm and intrinsic rhythm was type 2 second degree AV block and RBBB with QRS duration 150 ms. Echocardiography showed global hypokinetic and dilated LV (LV EDD 71 mm, LV ESD 63 mm) with progressively reduced EF 38% à 33% (Simpson), functional moderate MR and mild TR. CAG showed non-significant coronary artery stenosis with 20% stenosis at distal LAD. Patient was diagnosed as pacing induced cardiomyopathy (PICM). At catheter laboratory, there was stenosis of left subclavian vein. His-Bundle pacing (HBP) was planned at first, however CRT-P with biventricular epicardial pacing was then performed in which LV lead was inserted through right axillary vein. During follow up at general ward, ECG showed biventricular pacing rhythm. There was no signs and symptoms of heart failure. Patient was hospitalized for 3 days and then discharged in a good condition.
 
 
 
 Summary
 We reported a case of pacing induced cardiomyopathy in male patient 56 years old. Pacing induced cardiomyopathy is a complication of high burden RV pacing. Options to treat PICM once it has developed, or to prevent it from developing in the first place, may include conduction system pacing (e.g.: HBP) or CRT-P implantation.

454 Sinus of Valsalva Rupture

Abstract Background Sinus of Valsalva (SVA) rupture is a rare cardiac pathology which is important to recognise and diagnose early. Case Summary This case report details a 30-year-old gentleman who presented with a 3-day history of dyspnoea and palpitations on a background of previous congenital heart disease. The patient's examination highlighted a continuous harsh pan-systolic murmur as well as an ECG finding of sinus tachycardia. Transthoracic echocardiography identified a ruptured Sinus of Valsalva. The patient was transferred to a cardiothoracic surgery centre and definitively treated with an aortic root and ventricular septal defect repair. Discussion This case highlights the clinical findings of a patient with an acute left to right shunt and the importance of early diagnosis and urgent surgery. This case emphasises the factors required to decide which surgical approach is appropriate such as the presence of aortic valvular pathology size, size of Sinus of Valsalva aneurysm, any simultaneous cardiac anomaly and the cardiac chamber involved. Learning Points

Coloboma of the Retina, Choroid and Iris Co-Existing with Cardiac & Skeletal Anomalies in a Male Nigerian

A 19-year-old male undergraduate presented to the eye clinic with a history of poor vision in the left eye since childhood. The best-corrected visual acuity was 6/6 in the right eye and hand movement in the left eye respectively. Examination of the anterior segment of the right eye was essentially normal, whereas the anterior segment examination of the left eye revealed a small globe, microcornea, and an iris coloboma inferiorly at the 6 o'clock position. Binocular indirect ophthalmoscopy of the right eye revealed a pink disc, normal vessels and macula, lattice degeneration with retinal holes, and a flat retina. The left eye had a pink disc, normal macula and vessels with an inferior arc-shaped excavation with exposure of the sclera, which involved both the disc and macula and was in keeping with a retinochoroidal coloboma. Systemic examination revealed low-set ears with a left atrophic pinna, mild kyphoscoliosis, pectus excavatum, and an atrophic left lower limb with anomalies of the toes and talipes equinovarus. A pan-systolic murmur was present on cardiovascular examination.

LOOKING DEEPER INTO MITRAL REGURGITATION

A 50 years old male patient previously treated for pulmonary Kochs presented with shortness of breath (functional class II). A non-ejection click and pan-systolic murmur radiating to axilla was heard at apex. Transthoracic echocardiography revealed thickened and markedly prolapsing both leaflets of mitral valve with mild to moderate regurgitation. A clear space was noted between the termination of LV myocardium and atrio-mitral junction (7.7mm) indicating Mitro-annular disjunction (MAD). 24 hours Holter monitoring showed 160 isolated premature ventricular contractions, maximum 20 in one hour. No other arrhythmia was recorded. Beta blocker and an ACE inhibitor were initiated with advice for follow-up as presently no intervention was needed.

Case Report: Coexistence of acute post-streptococcal glomerulonephritis and rheumatic heart disease in a 9 years old girl

Background: Group A-haemolytic streptococcus (GAS), one of the most frequent pathogens in pediatric group causing various diseases, from acute pharyngitis (AP) to severe complication such as acute rheumatic fever (ARF) and acute post-streptococcal glomerulonephritis (APSGN). GAS, round gram positive bacteria typically form pairs or chains, was reported causing 1.78 million cases with 500.000 death due to its severe complication in 2005. Case Illustration: A 9-year-old female patient came to emergency unit (ER) complained swollen face and legs since 5 days ago, accompanied by tea color urine and reduced frequency and volume of micturition. Patient also complained shortness of breath which getting worse since yesterday, easily fatigue and dizziness. Moreover her mother also admitted that her daughter had history of migratory joints pain 3 weeks before admission, with sore throat a month ago. Blood pressure was 110/70 mmHg, Ross score was 8. Physical examination showed puffy face, pretibial edema, heart auscultation we heard pansystolic murmur. Chest radiography showed cardiomegaly and congestive pulmonum while laboratory exam showed ASTO 200, urinalysis showed red color, cloudy clarity, protein 1+, erythrocyte 3+, leukocytes 1+, urinary microscopic examination: 30-40 erythrocytes, 8-12 leukocytes, electrocardiography showed sinus tachycardia, prolonged PR interval, right atrial enlargement, right ventricle hypertrophy with right axis deviation. Patient was diagnosed with APSGN, hypertension grade II and heart failure due to rheumatic heart disease. Summary: APSGN and ARF rarely occur together, the coincidence might be due to streptococci with nephritogenic and rheumatogenic same strains. Early detection and treatment of GAS are crucial to prevent complications.

TRICUSPID VALVE SECONDARY TO OLD BLUNT CHEST TRAUMA

Objective: The patient was a 42-year-old man who presented to the hospital with chest pain caused by movement. The patient had no other symptoms and underwent cardiac examination and examination. Echocardiography is performed. The patient mentions that these pains have been created for 6 months and have increased. Background: After Trauma tricuspid insufficiency is an uncommon presentation generally caused by not traumatic injury to the chest wall and here the tricuspid valve injury is detected after 15 years of Chest injury by motorbike. Design and method: Case presentation A 42-year-old man non-smoker and non-alcoholic presented with complaints of chest pain on movement with no exertional breathlessness for 3 months. Chest pain was increased with movement. He did not have any history of chronic illness. However, 15 years back he had suffered a non-penetrated chest trauma following a bike traffic accident. He was treated medically and since then he had remained well. At admission, the pulse rate was 72/min, blood pressure 110/70 mm Hg, and respiratory rate 20/min. Po2 88 mmHg, So2 97%. Physical examination revealed elevated jugular venous pressure with prominent V wave and Y descent, grade II pan systolic murmur best heard at the fifth intercostal space along the left sternal border, which increases on inspiration and bilateral basal pulmonary crepitations. Results: The patient was a 42-year-old man who had no history of any specific disease. Except for the history of an accident while riding a motorcycle 15 years ago, he did not have any particular complaints. During the operation, we noticed a rupture of the cord (tricuspid valve) which was a sign of rupture due to trauma to the valve. After the surgery, the patient had a complete recovery process and was discharged. Due to the gradual process of severities, which was asymptomatic, we came too the conclusion that after the trauma, the patient suffered a partial tear of the tricuspid cord, which increased with age and time. Conclusions: The patient had chest pain and systolic sonic, which is a rare case of severe TR

COVID19 INFECTION IN CORONARY ARTERY DISEASE WITH DIABETES AND HYPERTENSION IN VALVULAR SURGERY PATIENTS IN TERTIARY HEART CENTRE

Objective: The patient was a 59-year-old man who was referred to the hospital due to shortness of breath due to increased activity, accompanied by cough, weakness, and lethargy. The patient also had a history of diabetes, hypertension, hyperlipidemia, and asthma. The patient also underwent cardiac stenting last year. LCX and LAD stenting Design and method: He had a continuous pan-systolic murmur on cardiac examination diagnosed with valvular dysfunction. Severe aortic regurgitation was reported on echo. The patient underwent a CT scan of the lungs and a PCR test to rule out Covid-19, which was negative. Finally, the patient was diagnosed with severe aortic regurgitation and underwent aortic valve replacement surgery. Echocardiography was performed before the operation, and the diagnosis was confirmed. Results: Echocardiography was performed postoperatively, which showed good valve function and no valve leakage. From the 5th day after the operation, the patient developed fever and increased leukocytosis. Suspected of having Covid19 and accordingly underwent PCR test, the test result was positive; the patient underwent a CT scan of the lungs. After that, he was transferred to the corona ICU. The patient was treated with Remdesivir, and after two weeks, his PCR was negative, and he was almost ready to be discharged. The patient had completed the entire course of treatment and developed pulmonary fibrosis due to Covid disease, but suddenly, after two weeks from the onset of the illness, she developed severe shortness of breath, which led to intubation. We find severe pulmonary fibrosis in the re-CT scan, especially in the left lung, where the entire left lung had fibrosis. Prednisolone was started at a dose of 50 mg three times a day. The patient was intubated for ten days, then gradually removed from the device. Now the patient is extubated and ready for discharge. Conclusions: Risk factors such as Past cardiac surgery and present cardiac intervention with diabetes mellitus increase the risk of developing lung failure in these Covid19 patients. Elective intubation is better than emergency intubation in patients with comorbidities. Corticosteroids can be effective in treating pulmonary insufficiency

Infective endocarditis with Osler’s nodule in a patient with Osler’s disease: a case report and review of the literature

BackgroundHereditary hemorrhagic telangiectasia, also known as Osler–Weber–Rendu disease, induces arteriovenous malformations in visceral organs. Arteriovenous malformations increase the risk of severe infections and are a common complication associated with hemorrhagic telangiectasia. However, cases of endocarditis associated with hemorrhagic telangiectasia are rarely reported. Although hemorrhagic telangiectasia causes erythematous macules on the extremities, these macules are usually painless. We encountered a rare case of infective endocarditis in a patient with Osler–Weber–Rendu disease.Case presentationA 52-year-old Japanese woman who was diagnosed with hemorrhagic telangiectasia 5 years prior presented to our hospital with fever and muscular pain. She had erythematous nodules and tenderness on the finger, heel, and toe, suggestive of Osler’s nodes. A physical examination revealed tachycardia with a 3/6 pansystolic murmur. A transesophageal echocardiogram showed vegetations along the atrial side of the mitral valve and mild mitral regurgitation because of prolapse of the anterior commissure. Methicillin-sensitive Staphylococcus aureus was identified in the blood cultures. Detection of distinctive skin lesions, so-called Osler’s nodes, was the symptomatic key to early diagnosis, and the patient was treated without surgery. She was discharged with negative blood cultures after a 6-week intravenous antibiotic administration.ConclusionsOur report highlights the importance of considering the risk of extracerebral infections including endocarditis in hemorrhagic telangiectasia. This rare case effectively demonstrates the importance of proper diagnosis of skin lesions.

Unexpected Huge Prevalence of Intracardiac Extension of Wilms Tumor-A Single Center Experience from a Ugandan Hospital.

Wilms tumor (WT) is the most common primary renal malignancy in young children. WT vascular extension to the inferior vena cava (IVC) occurs in 4–10% of cases and can reach the right atrium (RA) in 1%. Data on WT clinical presentation and outcome in developing countries are limited. The aim of the present study is to describe the prevalence of intracardiac extension in a consecutive population of WT patients observed in a large non-profit Ugandan hospital. A total of 16 patients with a histological diagnosis of 29 WT were screened in a 6-month period. Patient n°2, a 3 y/o child, presented with a 3-week history of abdominal distension, difficulty in breathing, and swelling of the lower limbs. A cardiovascular system exam showed rhythmic heart sounds, a heart rate of 110 beats per minute, and a pansystolic murmur on the tricuspid area; the abdomen was grossly distended with a palpable mass in the right flank, hepatomegaly, and splenomegaly. An abdomen ultrasound showed an intra-abdominal tumor, involving the right kidney and the liver and extended to the IVC. An ultrasound guided biopsy showed a picture consistent with WT. Cardiac echo showed a huge, mobile, cardiac mass attached to the right side of the interatrial septum, involving the tricuspid valve annulus, causing a “functional” tricuspid stenosis. The patient died of cardiogenic shock 7 days after admission. Patient n°3, a 3 y/o child, presented with analogue symptoms and the same diagnosis. The cardiac echo showed a round mass in the RA. Thirteen more patients were screened with cardiac echo, showing a normal heart picture. In our limited series, we found WT cardiac extension in three patients over 16 (19%). Cardiac echo performed routinely can lead to a better staging, prognostic, and therapeutic assessment. In our setting, the intra-cardiac extension could be more frequent than previously reported and might have prognostic implications.

Anaesthetic implications of right atrial myxoma in a premature infant.

Sir, Cardiac myxoma is a benign tumour and the most common primary cardiac tumour in adults; however, it is unusual in paediatric patients, with only 20% constituting right atrial myxomas (RAMs).[1] A 3-month-old male baby, weighing 1.7 kg, presented to our hospital with tachypnoea while feeding and failure to thrive. The baby was born prematurely after 29 weeks of gestation. On examination, the baby looked emaciated [Figure 1]. A pansystolic murmur was present at the left lower sternal border on auscultation. Transthoracic echocardiography (TTE) revealed a large, homogenous, pedunculated mass (19 mm × 10 mm) attached to the interatrial septum (IAS) and protruding into the tricuspid valve (TV) causing tricuspid regurgitation (TR) [Figure 2]. Blood investigations revealed haemoglobin of 9.8 g/dL and platelet count of 78000/mm3. Surgical removal of the RAM was planned because of the inability to gain weight.Figure 1: Intraoperative image showing an emaciated look of the child. Fr: FrenchFigure 2: Apical four-chamber view on TTE showing RA myxoma. RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricleOn the day of surgery, the baby was shifted to the operating room, and a multiparameter monitor was attached. All preparations were done before induction of anaesthesia to go on emergent cardiopulmonary bypass (CPB) if required. General anaesthesia with endotracheal intubation was induced with intravenous midazolam 0.1 mg/kg, fentanyl 5 μg/kg and vecuronium 0.1 mg/kg through an already placed peripheral cannula. Induction agents were given slowly while constantly monitoring the haemodynamics. Right radial arterial cannulation was done, and central venous catheter (CVC) was inserted carefully in the right internal jugular vein. Anaesthesia was maintained with 1.5% (v/v %) isoflurane and intermittent boluses of fentanyl and vecuronium. After midline sternotomy and full heparinisation, CPB was instituted through aorto-bicaval cannulation. Superior vena cava (SVC) cannulation was done through a higher approach, and other manipulations near the right atrium (RA) were done gently to avoid embolisation of the tumour. Under deep hypothermic circulatory arrest (DHCA), the RA was opened, and the mass was excised completely. The baby was weaned off CPB with inotropic support of intravenous milrinone 0.5 μg/kg/min. After completion of the surgery, the patient was shifted to the paediatric intensive care unit and was extubated after 8 hours. Postoperative TTE showed an intact IAS with no TR or residual mass in RA. RAMs usually present with breathlessness, cyanosis, feeding difficulty, and constitutional symptoms like fever, fatigue, anaemia, thrombocytopenia, malnourishment, and weight loss because of the release of interleukin-6 by RAM.[2] RAM can obstruct the TV causing jugular venous distension, peripheral oedema, hepatic congestion, ascites, and syncope.[3] Our patient looked malnourished, weighed only 1.7 kg along with low haemoglobin and platelet count. Arrhythmias commonly occur due to conduction defects caused by myxoma. Anaesthetic considerations in RAMs include hypoxaemia, low cardiac output, and potential pulmonary emboli due to their mobile nature. Aggravation of the patient’s symptoms and hypotension can occur at certain positions due to intermittent obstruction of TV by a mobile RAM along with a change in the character of the murmur. Evaluation of these positions must be done preoperatively, and induction should be done with careful positioning, with the administration of titrated doses of anaesthetic drugs, which avoid myocardial depression while maintaining the preload and preparation to go on emergent CPB. Placing a CVC and SVC cannulation can be difficult in the presence of a tumour in the RA and may result in its fragmentation and dislodgement. Hence, utmost care should be taken to avoid entering the RA. Intraoperative transoesophageal echocardiography (TOE) monitoring helps in the detection and diagnosis of tumour fragmentation or dislodgement, and in assessing volume status as TR caused by RAM renders CVP measurement unreliable for evaluation of volume status.[4] However, in our case, TOE examination was not done because of non-availability of a neonatal probe. DHCA provides excellent surgical exposure for tumour removal, but the duration of circulatory arrest must be limited to prevent complications.[5] Perioperative care in premature neonates also includes preventing hypoglycaemia, hypoxia and hypothermia.[6] Anaesthetic concerns range from difficult airways, risk reduction for adverse events and adequate pain management.[7] Thus, neonates with RAMs require early diagnosis, meticulous anaesthetic management and multidisciplinary approach to perioperative care. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A CASE STUDY OF A 54-YEAR-OLD MAN WITH NYHA CLASS III, STAGE 2 HYPERTENSION, AND TYPE II DIABETES MELLITUS

Background: Heart failure is when the heart cannot pump enough blood to fulfill the body's needs. This disease is dangerous and can lead to death. The most common risk factors are hypertension, diabetes mellitus, and metabolic syndrome.Case Presentation: A 54-year-old man complained of shortness of breath for the last one month, which worsened during light activities and decreased when he was in a semi-sitting position. The patient had a history of hypertension and type-II diabetes mellitus for the last five years. On physical examination, the patient's blood pressure was 140/100 mmHg, respiratory rate was 25 bpm. There were paroxysmal nocturnal dyspnea, orthopnea, rales on both basal lung fields, dyspnea on exertion, ankle edema, a pansystolic murmur heard in the apex, ascites and ankle edema. Blood laboratory examination showed HbA1c 6%, chest X-ray and ECG showed cardiomegaly.Conclusion: The patient was diagnosed with NYHA Class III Heart Failure with stage 2 hypertension and type-2 diabetes mellitus and was treated with fluids, diuretics, ACE inhibitors, beta-blockers, low salt diet, restriction of fluid intake, and oral antidiabetics.

Pulmonary arterial hypertension after atrial septal defect closure: a case report

Most patients with congenital heart disease (CHD) who underwent successful shunts defect repair can be remained asymptomatic for years. It leads to a high number of losses to follow-up after patients discharge. After closure, pulmonary hypertension (PH) prevalence seems to be high and associated with increased morbidity and mortality. We reported a 55 y.o. female diagnosed with pulmonary arterial hypertension (PAH) and atrial fibrillation (AF) 31 years after atrial septal defect (ASD) closure by surgery, who never had routine follow-up evaluation because she remained asymptomatic for years. Physical examination revealed heart enlargement with irregular rhythm and pan systolic murmur in the fourth left sternal border. Electrocardiogram showed AF normal ventricular response, right axis deviation and suggestive for right ventricular hypertrophy. Laboratory testing found the NT pro-BNP level was 2,476 pg/mL. The chest X-ray showed enlargement of the heart and was representative of PH. From echocardiography study, transthoracic and transoesophageal echocardiography, we found no sign of residual shunt. There were right atrial and right ventricular dilatation, severe tricuspid regurgitation (TR) and a high probability of PH with TR velocity of 4.46 m/s. Right heart catheterization concluded mean pulmonary arterial pressure 46 mmHg, flow ratio 1.1, and pulmonary artery resistance index 15.5 Woods unit.m -2 . We highlight this case because of the high incidence of PH long after defect closure. The high number of lost to follow-up patients can lead to morbidity and mortality.

Pasteurella multocida Endocarditis with Septic Arthritis: Case Report and Review of the Literature

Background: There is a paucity of evidence regarding optimal management of Pasteurella spp. endocarditis. The authors report the first case of Pasteurella spp. endocarditis with septic arthritis and review the literature. Case Description: A 79-year-old patient with significant comorbidities, including prosthetic aortic valve, was admitted with left knee swelling, fever, and confusion, having been scratched by a cat 2-weeks prior. At presentation, there was a metallic click, a Grade 3 pan-systolic murmur and Grade 1 flow murmur audible on auscultation. Blood and synovial fluid cultures both isolated Pasteurella multocida, identified by matrix-assisted laser desorption ionisation–time of flight, which was sensitive to penicillin according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST); minimum inhibitory concentration: 0.094). The patient underwent joint washout and received intravenous piperacillin/tazobactam for 3 days before switching to benzylpenicillin once sensitivities were known. Due to continued pyrexia, a transthoracic echocardiogram was obtained, which revealed a small mobile mass on a thickened mitral valve suspicious for a vegetation. On review by the Infective Endocarditis team, conservative management was deemed best, given the presence of comorbidities. Despite requiring further joint washout due to persistent knee pain, the patient was successfully treated with 8 weeks of antibiotic therapy (24 days of benzylpenicillin monotherapy, 2 weeks of benzylpenicillin and ciprofloxacin, and 15 days ciprofloxacin monotherapy). Discussion: Previous literature reviews report a higher mortality of Pasteurella spp. endocarditis when managed without cardiac surgery, thus recommending surgery in all cases. The authors found these to have confounding factors, including inadequate duration of antimicrobials, aortic root abscess, and rapid progression to death. The authors’ case of Pasteurella spp. endocarditis, complicated by septic arthritis, showed successful therapy without cardiac surgery.

C37. Device Closure of Perimembranous Ventricle Septal Defect with Zero Fluoroscopy : The First case in Eastern region of Indonesia

Abstract Background Ventricular septal defects (VSDs) are the most common Congenital Heart Defects (CHD) lesion in children. Transcatheter closure is considered as an alternative to surgery, for past few decades transcatheter closure were performed under fluoroscopy, recently guidance under Transesophageal Echocardiography (TEE) is increased. Transcatheter closure under TEE Guidance remains challenging but an alternative to overcome the radiation effect. Case Summary We reported 3-year-old female patient admitted to RSUP Dr. Wahidin Sudirohusodo with chief complaint was easily fatigue, Physical finding revealed regular heart sound with a grade 4/6 pansystolic murmur at the left lower sternal border, Transthoracal Echocardiography (TTE) has shown perimembranous VSD (pm-VSD) 6-7 mm L-R shunt with VSD Gradient 58 mmHg and aortic rim 4,5 mm. The patient was diagnosed with pm-VSD without Pulmonary hypertension and suitable for device closure under TEE Guidance. TEE Procedure was performed under general anesthesia and we found pm-VSD 3-4 mm, we decided to close the defect with Amplatzer Duct Occluder II (AGA) no 4/4 with delivery sheath amplatzer Torqvue LP 4F via retrograde approach with zero fluoroscopy, the device was well fixated with small central residual shunt 1,6 mm with hemodynamically unsignificant, The device was released and the procedure was finished without any significant problem. Conclusion We reported first case of VSD closure under TEE guidance in Eastern region of Indonesia, Transcatheter closure of pm-VSD under TEE Guidance are feasible and safe and can be an alternative to surgery and conventional technique under fluoroscopy to prevent radiation effect.

C37. Device Closure of Perimembranous Ventricle Septal Defect with Zero Fluoroscopy : The First case in Eastern region of Indonesia

Abstract Background Ventricular septal defects (VSDs) are the most common Congenital Heart Defects (CHD) lesion in children. Transcatheter closure is considered as an alternative to surgery, for past few decades transcatheter closure were performed under fluoroscopy, recently guidance under Transesophageal Echocardiography (TEE) is increased. Transcatheter closure under TEE Guidance remains challenging but an alternative to overcome the radiation effect. Case Summary We reported 3-year-old female patient admitted to RSUP Dr. Wahidin Sudirohusodo with chief complaint was easily fatigue, Physical finding revealed regular heart sound with a grade 4/6 pansystolic murmur at the left lower sternal border, Transthoracal Echocardiography (TTE) has shown perimembranous VSD (pm-VSD) 6-7 mm L-R shunt with VSD Gradient 58 mmHg and aortic rim 4,5 mm. The patient was diagnosed with pm-VSD without Pulmonary hypertension and suitable for device closure under TEE Guidance. TEE Procedure was performed under general anesthesia and we found pm-VSD 3-4 mm, we decided to close the defect with Amplatzer Duct Occluder II (AGA) no 4/4 with delivery sheath amplatzer Torqvue LP 4F via retrograde approach with zero fluoroscopy, the device was well fixated with small central residual shunt 1,6 mm with hemodynamically unsignificant, The device was released and the procedure was finished without any significant problem. Conclusion We reported first case of VSD closure under TEE guidance in Eastern region of Indonesia, Transcatheter closure of pm-VSD under TEE Guidance are feasible and safe and can be an alternative to surgery and conventional technique under fluoroscopy to prevent radiation effect.

C15. Biventricular Heart Failure and Pulmonary Hypertension in Systemic Sclerosis: a rare and unusual case report

Abstract Backgrounds Systemic sclerosis (SSc), chronic multisystem autoimmune disease, characterized by excessive fibrosis and vascular endothelial dysfunction. Cardiovascular involvement may be induced by various pathways, either primary or secondary to pulmonary hypertension or renal involvement. Case Summary A 46 years old woman presented to emergency department with cold, dark purplish ulcers in fingertips with progressive worsening pain in upper extremities, claudication intermitten, and dyspneu since 4 months ago. She had a mask-like facial, shiny skin, microstomia, restricted mouth opening, calcinosis cutis, Raynauds phenomenon, and sclerodactyly. There were pansystolic murmur grade III/6 in tricuspid area, and rales in basal lungs. ECG showed sinus rhythm with fragmented QRS, poor R-wave progression. Chest X-Ray revealed pancardiomegaly with pleural effusion and HRCT thorax revealed interstitial lungs disease. The laboratory revealed leucocytosis, increase D-dimer (870 ug/L), negative ANA and ds-DNA test, positive anti SCl test. Echocardiography showed biventricular dysfunction with decreased LVEF 37% (Teichz) and TAPSE 10 mm, RA RV dilatation, severe TR with high probability for PH. Extremities Doppler showed normal arteries and veins system. These findings indicates that primary and secondary cardiac involvement in SSc. Heart failure, pulmonary hypertension, and cyclophosphamide medication were administered Discussion Primary cardiac involvement, a direct consequence of SSc, may manifest as fibrosis of the myocardial, conduction system, pericardial and, valvular disease. Furthermore, a secondary phenomenon due to pulmonary arterial hypertension (PAH), and kidney pathology. Though the burden remains low, it may worsen the outcome, consequently, all patients with SSc should undergo screening.

C15. Biventricular Heart Failure and Pulmonary Hypertension in Systemic Sclerosis: a rare and unusual case report

Abstract Backgrounds Systemic sclerosis (SSc), chronic multisystem autoimmune disease, characterized by excessive fibrosis and vascular endothelial dysfunction. Cardiovascular involvement may be induced by various pathways, either primary or secondary to pulmonary hypertension or renal involvement. Case Summary A 46 years old woman presented to emergency department with cold, dark purplish ulcers in fingertips with progressive worsening pain in upper extremities, claudication intermitten, and dyspneu since 4 months ago. She had a mask-like facial, shiny skin, microstomia, restricted mouth opening, calcinosis cutis, Raynauds phenomenon, and sclerodactyly. There were pansystolic murmur grade III/6 in tricuspid area, and rales in basal lungs. ECG showed sinus rhythm with fragmented QRS, poor R-wave progression. Chest X-Ray revealed pancardiomegaly with pleural effusion and HRCT thorax revealed interstitial lungs disease. The laboratory revealed leucocytosis, increase D-dimer (870 ug/L), negative ANA and ds-DNA test, positive anti SCl test. Echocardiography showed biventricular dysfunction with decreased LVEF 37% (Teichz) and TAPSE 10 mm, RA RV dilatation, severe TR with high probability for PH. Extremities Doppler showed normal arteries and veins system. These findings indicates that primary and secondary cardiac involvement in SSc. Heart failure, pulmonary hypertension, and cyclophosphamide medication were administered Discussion Primary cardiac involvement, a direct consequence of SSc, may manifest as fibrosis of the myocardial, conduction system, pericardial and, valvular disease. Furthermore, a secondary phenomenon due to pulmonary arterial hypertension (PAH), and kidney pathology. Though the burden remains low, it may worsen the outcome, consequently, all patients with SSc should undergo screening.

C86. Secondary Prophylaxis For Rheumatic Heart Disease During The Pandemic Era: A Case Report

BackgroundRheumatic heart disease (RHD) is heart diseases results from recurrent episodes of acute rheumatic fever (ARF). It often occurs in developing countries and its pathogenesis is not clearly understood. RHD can be controlled with prophylaxis that requires patients to visit healthcare facility regularly. However, the current pandemic condition is a challenge for patients to receive routine treatment and evaluation.Case SummaryA 17-years-old girl comes to emergency room with complaints of shortness of breath with mark limitation of physical activity 3 days prior to admission. The patient also complaint with joint pain and leg swelling. She was diagnosed Rheumatic Heart Disease and received prophylactic penicillin injections every month. However, since the pandemic, She do vice versa. In physical examination was found pansystolic murmur on aortic valve and bilateral lower extremity edema. Echocardiography showed moderate mitral regurgitation and mild aortic regurgitation. This patient was hospitalized and treated with benzathine penicillin G, prednisone, aspirin, furosemide and captopril.DiscussionManagement of ARF includes eradication cause of infection, treat complications, and secondary prevention. Administration of secondary prophylaxis is useful for reduce new bacterial strains that can cause recurrent acute or chronic attacks. First line of secondary prophylaxis for ARF is intramuscular benzathine penicillin G that given per month. In this current pandemic conditions, patients are expected to continue prophylaxis therapy and follow up the disease with using pandemic health protocols.