Very large Atrial Septal Defect Device Closure: Feasibility and safety

Objectives: There is limited data regarding feasibility and safety of very large ASD devices deployment. Percutaneous closure of very large atrial septal defect (ASD) is a valid alternative to surgical approach. But complications like erosion, cardiac perforation, atrioventricular block, pericardial effusion, infective endocarditis, or cardiac arrhythmias may occur following ASD device closure. Methods: Forty four patients with very large ostium secundum ASD were studied in a tertiary medical centre. Adult patients with defect size of 38 mm or more and device size of 40 mm or more were selected for device closure. Patients having suitable anatomy, significant left to right shunt(>1.5:1) ,right ventricular volume overload and without significant pulmonary arterial hypertension were chosen for device closure. Results : There were thirty six female patients and eight male patients in our study. Majority of our patients (twenty four) were in forty to fifty years age group. Device could be deployed successfully in forty two (95.5%). Twelve patients had device size of 46 mm (27%). Eight patients had 44 mm devices(18%). Forty two millimeter devices were used in sixteen patients (36%). Eight patients had device size of 40 mm(18%).Device embolization occurred in two patients. There were two cases of pericardial effusion and pericardiocentesis was needed in one patients. Transient complete heart block was seen in one patient. Four patients had suffered from transient and self terminating atrial arrhythmias. There was no mortality or erosion in our study. Conclusion: Percutaneous closure of very large ASD is feasible and associated with low complication rate

Patent Foramen Ovale Closure Procedure

Patent foramen ovale is strongly associated with cryptogenic stroke. Variousclinical trials has shown the association between cryptogenic stroke andincidence of undelrying patent foramen ovale, these trials also shown thedecrease of cryptogenic stroke incidence with the treatment of patentforamen ovale Lesion. In the absence of absolute contraindications, patientswith patent foramen ovale are advised to undergo closure. Preproceduralexaminations such as trans esophageal echocardiography and pretreatmentwith anticoagulants are required to prevent peri and postprocedural adverseevents. Currently, patent foramen ovale Closure can be done through apercutaneous access with minimal risk. Treatment of patent foramen ovalecan help decrease future incidences of strokes

Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management

A patent foramen ovale (PFO) is a common disorder that affects between 20-34% of the adult population. This condition is a benign finding for most people. However, In some the PFO can open widely and enabling paradoxical embolism to transit from venous to arterial circulation, which is associated with stroke and systemic embolization. There are still unclear to date regarding the effectiveness of pharmacological anticoagulant therapy, defined as antithrombin or antiplatelet therapy, which has proven to be more beneficial for patients with PFO and cryptogenic stroke. In addition, surgical and transcutaneous PFO closure has been proposed for secondary prevention of stroke in patients with cryptogenic stroke with PFO. Both catheter-based and surgical modes of closure have been shown to reduce the incidence of subsequent embolism substantially. This review will discuss the evidence regarding the relationship between PFO and cryptogenic stroke and decision making for management strategies.

Echocardiography Detection of High-Risk Patent Foramen Ovale Morphology

Patent Foramen Ovale occurs in 25% of the general population1. Several studies suggested that paradoxical embolism through a patent foramen ovale (PFO) correlate with cryptogenic strokes (CS). Many epidemiological and clinical observational studies, showed the association between CS and the presence of PFO. There is still a controversy whether PFO should be closed. The information about PFO morphology might be useful for the management of PFO. This article is discussing a technical information about how echocardiography detects PFO and identifies high risk morphologies for the occurrence of PFO related -stroke.

Cryptogenic Stroke: Cardiac Rhythm Monitoring as An Indispensable Screening Modality

The prevalence of stroke in Indonesia increased overtime. CS ranges from 15 to 40% from all ischemic strokes. Finding the etiology of ischemic stroke is important to prevent recurrence. AF is predicted as the etiology behind CS. The current recommendation only supports short period of ECG monitoring. However, studies have shown that a higher detection rate can be achieved with longer duration of monitoring. ICM, a diagnostic tool with the highest detection rate, is still considered cost-effective when the calculation takes into account the QALY gained. Digital health tools such as handheld devices and smartwatch ECG have revolutionized the screening of AF however it is still considered as pre-diagnostic and verification is needed to confirm the rhythm generated.

Cryptogenic Stroke: A Challenge in Diagnosis and Management

Ischemic stroke is responsible for 85% of all stroke globally. However, the etiology of around a quarter of ischemic stroke are undetermined, this is called cryptogenic stroke. This kind of stroke affects younger population. Several mechanism are associated with the incidence of cryptogenic stroke such as paroxysmal atrial fibrillation, patent foramen ovale, atherosclerosis, and atrial cardiopathy. Despite many advanced knowledge on stroke generally, cryptogenic stroke is still a challenge in clinical settings. To understand more about cryptogenic stroke, a new term of embolic strokes of undetermined source (ESUS) is proposed and may need a specific workup. Specific workup aims to detect any silent risk factors and also to evaluate the cardiac structure. The term of ESUS also leads to the understanding that cryptogenic stroke is highly related to embolic mechanism and anticoagulation administration might benefit the patients. However, the result of several recent studies showed that anticoagulant was not superior to antiplatelet, and antiplatelet is still the preferred treatment. Studies on PFO closure also shows different result, but the majority of the trials showed benefit of PFO closure in reducing the risk of stroke recurrence.

Correlation Of Left Ventricular Ejection Fraction And Spatial Qrs-T Angle In Old Myocardial Infarct Patient

Objective: Spatial QRS-T angle (the angle between the QRS and T vectors) is a strong independent predictor of cardiovascular death. Spatial QRS-T angle calculations can be obtained from the ECG 12 lead with Kors visual transform applications closest to Frank lead system. Half of patients with coronary artery disease (CAD) died from sudden cardiac death (SCD) with Left Ventricular Ejection Fraction (LVEF) as a predictor. The aim of this study was to correlate spatial QRS-T with LVEF in patients with old myocardial infarction (OMI). Methods: This is a cross-sectional study in patients with OMI that have not undergone revascularization and have achieved medical therapy. 12-lead electrocardiography (ECG) and echocardiography were done simultaneously. Spatial QRS-T angle was measured by Kors visual transform applications. Statistical analysis was performed using Pearson correlation and multivariate analysis with linear regression. Results: 46 patients meet the inclusion criteria. Baseline characteristics: mean age 58 ± 8 years, 89% male, mean spatial QRS-T was 108.72 ± 43° with mean LVEF 39.39 ± 10%. The spatial QRS-T angle and LVEF was strong negative correlation (r=-0.66, p<0.01) after adjusted with left ventricular mass index (LVMI) correlation between spatial QRS-T angle and LVEF decreasing (r=-0.57, p<0.01). The Spatial QRS-T angle and LVEF of patients with OMI is negative correlation. Conclusion: The spatial QRS-T angle and LVEF of patients with OMI had negative correlation. Spatial QRS-T angle may be an easier index for assessing cardiac dysfunction in patients with OMI.

The de Winter Pattern as Pre-Anterior ST-Elevation-Myocardial-Infarction. “An Evolution Sequence”: A Case Report

Introduction: The de Winter pattern (dWP) was first described by de Winter and colleagues in 2008 as static pattern associated with anterior myocardial infarction. A recent study showed the evolution sequence of this pattern into typical ST-elevation myocardial infarction (STEMI). This case discussed dWP who present as pre-anterior STEMI. Case Illustration: A-56-year old Male arrived in the emergency room complained chest pain about 3 hours. The patient also complained of diaphoresis, nausea, and fatigue. The patient has a previous history of hypertension. The vital signs were stable with an unremarkable physical examination. The initial electrocardiogram (ECG) revealed sinus rhythm with j-point depression followed by prominent T wave in precordial leads, slight ST-segment elevation in aVR, and loss of precordial R-wave progression. The initial-troponin-T was 31 pg/mL. Follow-up 1-hour after initial ECG showed typical ST-segment-elevation in V1-V4. The patient undergoing thrombolytic, followed by angiography that showed subtotal occlusion in the proximal left anterior descending (LAD) artery, occlusion in the proximal circumflex artery and stenosis in proximal right coronary artery, echocardiography revealed regional wall motion abnormality in the septal and anterior segments and preserved ejection fraction 58%, the patient was discharged after 8-days treated in intensive cardiac care unit. Conclusion: dWP has been shown as static and dynamic pattern in some conditions and associated with acute LAD occlusion. In this case, we showed dWP as early anterior STEMI, recognition of this pattern lead to early reperfusion and better myocardial salvage as anterior STEMI has a poor outcome.

Heart Failure with Preserved Ejection Fraction (HFpEF): A Case Report

Background: The prevalence of Heart Failure with Preserved Ejection Fraction (HFpEF) currently reaches 50% of heart failure cases and continues to increase every year. HFpEF is an important clinical condition, but the diagnosis is far more challenging than HFrEF (Heart Failure with Reduced Ejection Fraction), and there has not been any proven effective treatment. In this case presentation, the latest HFpEF diagnosis and therapy will be discussed. Case illustration and discussion: A man and a woman came to the emergency room with signs and symptoms of congestion suggestive of heart failure. Additional examination was performed to support the working diagnosis of HFpEF, namely ECG, NTproBNP and echocardiography. HFA-PEFF scores of the first and second patient was 3 and 4 respectively. During hospitalization, diuretics was given to overcome congestion according to guidelines, as well as ACE-inhibitor and beta-blocker. Both patients were also screened for cardiovascular and non-cardiovascular comorbidities, and were given appropriate therapy. Conclusion: The diagnosis of HFpEF does not have a gold standard yet, meanwhile, the HFA-PEFF scoring can be used. Recommended HFpEF therapy includes diuretics for congestion and management of comorbidities. Several studies of HFpEF treatment are ongoing. Keywords: heart failure with preserved ejection fraction, HFpEF

A Case Series Coexistence of PFO with Other Conditions - Who’s the Culprit?

Background: Patent foramen ovale (PFO) is a major cause of cryptogenic stroke (CS). However, it is still possible that PFO comes with those other conditions during evaluation. This paper presents a series of CS cases highly suspected due to PFO origin with each of its special presentations. Case illustration/summary of a review article: We present three cases of CS with PFO as a possible contributing factor. Case 1 showed a patient with repeated ischemic strokes that was investigated to be cryptogenic in origin. Case 2 showed CS with PFO and occult atrial fibrillation. Case 3 showed CS at a young age caused by a PFO with protein C/S deficiency. Conclusion: The role of PFO as a culprit, risk factor, or a coincidental finding in CS is still debatable and is a controversial issue. Determining PFO as a cause of CS requires a thorough consideration of clinical and PFO anatomical/morphological factors.