A Case of Malignant Course of Right Coronary Artery: Frequent Angina in Young Person

Introduction:Congenital anomalous coronary artery is a rare condition, but it might be the biggest pitfall for cardiologist. It might be silent until the patient reach young adult and has high intensity activity. Symptomatic anomalous course of coronary artery has wide spectrum from asymptomatic until the lethal one.Case Ilustration: We present a case of young adult with activity-triggered atypical chest pain and diagnose with anomalous origin of right coronary artery (RCA) from the left coronary sinus with inter-arterial course between the aorta and the main pulmonary artery that was detected by CT coronary angiography. This anomaly has been called malignant course RCA.Discussion:Coronary artery anomaly is a congenital condition. Most of the cases are remain asymptomatic. This condition also one of the most cause for sudden cardiac death because the coronary artery examination is not regularly done. Nevertheless, during high intense activity, it will be symptomatic and might be lethal.Conclusion:Diagnose coronary artery anomalies might be tricky and cardiologist must be aware with this. More devastating, no firm guideline in treatment of right anomalous coronary artery from opposite sinus.

Case Presentation - Biventricular Hypertrophy and Valvular Pulmonary Stenosis in Adult Patient with Noonan Syndrome: A Rare Case

Introduction: Noonan syndrome (NS) is a genetic disorder often accompanied by multiple congenital abnormalities. The prevalence of NS at live birth has been reported as one in 1000-2500 individuals. About 80% of patients with Noonan syndrome have abnormalities in the cardiovascular system.Case presentation:41-year-old Javanese male presented with chief complaint shortness of breath. His Body Mass Index (BMI) was 18,3. He had an oval-shaped face with a short neck, thin hair, and prominent nasolabial fold. Echocardiography showed biventricular hypertrophy alongside pulmonary valve stenosis, pulmonary regurgitation and minimal pericardial effusion. Discussion: In 1962, Jacqueline Noonan, a pediatric cardiologist, identified 9 patients whose faces were very similar, had short stature, significant chest deformities, and with pulmonary stenosis. Noonan syndrome is a relatively common non-chromosomal syndrome that is similar to the phenotype of Turner's syndrome and presents with cardiovascular malformations. Adult with NS has distinctive facial features such as ptosis, wide eyes, low posterior rotation of ears and helical thickening, and a wide neck.Pulmonary stenosis is the most common heartdefect found in NS, besides HCM isalsoquitecommon inabout20% of patients. We reported a case of a patient with typical characteristics of NS such as pulmonary valve stenosis accompanied by biventricular ventricular hypertrophyand its typical face who survived through adulthood.Conclusion: Syndrome Noonan in the adult is quite rare and difficult to diagnose. We reported a case of an adult man with facial appearance and echocardiographic findings identical with Noonan Syndrome.

Infective Endocarditis: A Case with Prolonged Fever

Infective endocarditis (IE) is associated with a high rate of mortality and morbidity in patients with anomalies of heart valves. We present a case of a 23-year-old male known to have severe mitral regurgitation (MR) with a history of prolonged fever for 5 months. According to The Modified Duke Criteria, clinical sign and symptoms fulfilled one major criterion (echocardiography finding of vegetation on mitral valve) and three minor (fever of at least 380 Celsius, valvular heart disease as a predisposing heart condition, and positive blood culture for Lactococcus sp. and Pediococcus sp.) considered as definite IE. Fever is one of the most common symptoms of IE (>90% of cases). Patient with prolonged fever and structural abnormality of heart valve should be considered for acute or subacute of IE. Establishing an diagnosis of IE and appropriate antibiotic therapy will improve the patient's clinical condition, and reduce morbidity and mortality.

Clinical Manifestation and Outcomes of Thrombolytic and Consevative Therapy in Covid-19 Patients with ST-Segment Elevation Pattern: A Case Series

COVID-19 pandemic has become a global issues, especially involving cardiovascular diseases. The management of COVID-19 patients with ST-Segment elevation in early pandemic era faces new challenges. Challenges can occur in term of patient’s delay and healthcare safety. This case series discussed clinical manifestations, examination findings, alternative strategies including thrombolytic and conservative therapy, and patients’ outcomes.

Potential Biomarkers as Early Detection of Diabetic Cardiomyopathy

Diabetes mellitus (DM) is one of the most prevalent and burdensome among chronic disease worldwide. Its complications accelerate mortality rate within population. Diabetic cardiomyopathy (DCM) is one of diabetes macrovascular complications, which symptoms are frequently unforeseen. Advances in pathogenesis understanding DCM underlying mechanisms remain not fully perceived. Current diagnostic approach of DCM can hardly determine diabetic patients with asymptomatic cardiomyopathy. Previous studies suggested biomarkers might detect early stage DCM. There are numerous selective biomarkers representing several pathophysiological pathways, such as myocardial fibrosis, inflammatory response, cardiomyocyte apoptosis, and metabolic dysregulation in the development of diabetic heart anomaly It was also reported those biomarkers are useful for the prognostic assessment of the disease. However, not all biomarkers are cardiac specific and can be an auspicious diagnostic tool candidate. Recent studies show that there are certain biomarkers, such as microRNA, H-FABP, IGFBP7, and some other novel cardiac biomarkers were more specifically associated with the pathological mechanism of DCM. In this review, we aimed to discuss the role of several potential cardiac biomarkers as early detection in DCM that may predict future incident of DCM, and contribute to improving mortality prediction in patients with subclinical DCM.Keywords: Biomarker; Diabetic Cardiomyopathy

Profile of Major Risk Factors in Acute Coronary Syndrome (ACS) at Pusat Pelayanan Jantung Terpadu (PPJT) Dr. Soetomo Public Hospital Surabaya Between the Period of January-December 2019

Background: Coronary heart disease (CHD) is a leading cause of death worldwide. One type of CHD that most often causes clinical manifestations and death is Acute Coronary Syndrome (ACS). In 2013 the prevalence of SKA in Indonesia reached 1.5% and it is estimated that it will continue to increase every year. Objective: This study aims to determine the profile of major risk factors for ACS sufferers in the Pusat Pelayanan Jantung Terpadu (PPJT) Dr. Soetomo Public Hospital Surabaya in the period January-December 2019. Methods: This study used a retrospective descriptive method to analyze the patient's electronic medical record (e-MR). Results: Out of 623 patients diagnosed with ACS, 429 were excluded from the research. 194 patients who met the inclusion criteria were studied with the following details: 19 APTS patients, 43 N-STEMI patients, and 132 STEMI patients. It was found that 73% of ACS patients were male, with the 55-64 years’ age group dominating by 46%. Based on blood pressure and serum cholesterol examination data, it was found that 51% of patients had hypertension and 77% of patients had dyslipidemia (40% hypercholesterolemia, 42% hypertriglyceridemia, 40% low HDL-C levels, and 34% high LDL-C levels). 60% patients had type-2 diabetes mellitus and 52% of patients had a history of smoking. Conclusion: 73% of ACS patients in this study were men. Most common age groups were 55-64 years old (46%), had hypertension by 51%, had dyslipidemia by 77% (40% hypercholesterolemia, 42% hypertriglyceridemia, 40% low HDL-C levels, 34% high LDL-C), had type-2 diabetes mellitus by 60%, and had a smoking history by 52%.

Correlation Between Bioelectrical Impedance Analysis-Measured Body Fat, Body Mass Index and Waist Circumference with Cardiovascular Risk Factors in Acute Coronary Syndrome Patients

Estimation of fat using bioelectrical impedance analysis (BIA) is thought to be a more predictive measure of cardiovascular (CV) risk assessment than body mass index (BMI) or waist circumference (WC). Percent body fat as measured using BIA (BIA-BF%) is independently associated with future cardiovascular events namely acute myocardial infarction, ischemic heart disease. This study is conducted to determine the correlation between body fat which consists of BIA-BF%, percentage of subcutaneous adipose tissue (SAT) and visceral fat level (Visceral Adipose Tissue/VAT) measured using BIA device, BMI and WC with CV risk factors (blood pressure, blood glucose level, LDL, HDL, TG, total cholesterol, HbA1c and serum fibrinogen) in patients with acute coronary syndrome (ACS). Material and Methods : This study used a cross-sectional correlation analysis. Sample was 70 ACS patients that match with inclusion criteria. Results : We found significant correlations between BIA-BF% with diastolic blood pressure, TG, and total cholesterol (r = 0.246, r = 0.250, r = 0.348 respectively; p <0.05). There was a significant correlation between VAT with diastolic blood pressure, LDL, TG, total cholesterol, HbA1c, and fibrinogen (r = 0.299, r = 0.306, r = 0.278, r = 0.265, r = 0.292, r = 0.330 respectively, p <0.05). There was a significant correlation between the percentage SAT and HDL levels (r = 0.318; p <0.05). We found no correlation between BMI and WC with blood pressure, LDL, HDL, TG, blood glucose, HbA1c and fibrinogen levels in ACS patients. Conclusion: VAT and BIA-BF% correlate with several cardiovascular risk factors better than BMI and WC. Body fat examination using BIA may be done to manage risk factors in ACS patients.

A Suspected COVID-19-associated Myocarditis Case Mimicking Life-threatening STEMI: a Shark Fin Appearance

Some cases of myocarditis have been reported associated to Covid-19. The presence of proinflammatory response from immune cells suggested occurs by binding to membrane protein ACE-2 leading to myocardial damage. Our hospital got a refferal from a non-PCI-capable hospital with a 51-years-old woman chest pain and progressive heavy breath with history of fever two days ago. She was diagnosed with anterior STEMI and cardiogenic shock on vassopressors. Her electrocardiogram showed shark fin appearance suggesting life-threatening STEMI. Her rapid test for covid-19 are non-reactive for both IgM and IgG. Her NCCT-thorax showed ground glass opacity in both lungs. Her laboratories finding showed elevated inflammatory markers and elevated cardiac biomarker. We took her naso-oro-pharingeal swab in the same day and process her with emergency PCI. Surprisingly, her angiography showed normal coronary artery without any significant stenosis. From There was no SARS-CoV-2 detected. In myocarditis, patient can mimick the same symptoms as STEMI such as chest pain and heavy breath with elevated cardiac biomarker, but the electrocardiogram usually shows widespread concave ST-elevation with PR-segment depression. Shark fin appearance is usually seen in life-threatening STEMI. In our patient, the NCCT-thorax showed GGO suggested Covid-19 involvement. But, the first swab was negative for SARS-CoV-2. Unfortunately, the patient was discharged without doctor’s consent, so we can not process the second swab and echocardiography to evaluate the function of myocardium. We still can not confirmed this case if it is true myocarditis-associated covid-19 and how was the involvement of the myocardium creating a shark fin mimicking life-threatening STEMI.

Inferior Myocardial Infarction and Total AV Block in a Patient with Single Ostium in the Right Sinus of Valsava (A Rare Congenital Coronary Anomaly)

A 51-year-old male suffered from a STEMI inferior and a total AV block. Echocardiography shows hypokinetic wall motion at the inferior and inferoseptal that result in decreased EF. Coronary angiography revealed a single ostium of coronary artery without any stenosis. Cardiac CT revealed a single coronary artery arises from a single ostium from RCC and divided into RCA and LCA. There was an inter-arterial course of proximal RCA and proximal LCA between aorta and pulmonal artery. There was an acute angle take off of RCA from aorta. Inter-arterial course and acute angle take off of coronary artery from aorta result in kinking and narrowing of coronary artery that contributes to myocardial infarction. There is a mismatch between myocardial demand which is increased during exertion and myocardial oxygen delivery that decreased during exertion. A surgical anterior pulmonal transposition is the suggested choice of therapy.

Aorto Femoral Bypass Graft in Chronic Limb Ischemia Patient

A 44-year-old man was admitted to hospital to be performed re-thrombectomy after previously performed thrombectomy at the referring hospital but did not show clinical improvement. CT angiography results before re-thrombectomy showed a central thrombus measuring 1.1 cm in diameter, and an impression of 2.6 cm long at the branching of the right external Iliaca artery which caused total obstruction of the right illiaca external artery to the distal. Aortofemoral bypass graft surgery is a procedure utilized commonly for the treatment of aortoiliac occlusive disease. The treatment given to manage symptoms if medical management or minimally invasive therapy, such as balloon angioplasty and stenting, was unsuccessful or unsuitable for the patient. Aortofemoral bypass graft surgical procedure was performed on the patient. However, post procedure angiography showed no visible flow through the newly placed graft. A repair graft procedure was planned for the patient, but the patient refused to undergo further surgical procedures.