TY - JOUR
AB -   C.1. Atrial Fibrillation and Complete Atrioventricular Block in Autosomal Dominant Emery-Dreifuss Muscular Dystrophy : A Case Report R A Gumilang R A Gumilang Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada UGM Academic Hospital K Iskandar K Iskandar Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada UGM Academic Hospital F Niken Astari F Niken Astari Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada UGM Academic Hospital A P Nugrahanto A P Nugrahanto Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada N Ilma N Ilma Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada Sunartini Sunartini Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada UGM Academic Hospital Sardjito General Hospital, Yogyakarta, Indonesia Lai Poh San Lai Poh San Yong Loo Lin School of Medicine, National University of Singapore, Singapore Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada UGM Academic Hospital Sardjito General Hospital, Yogyakarta, Indonesia Yong Loo Lin School of Medicine, National University of Singapore, Singapore Background: Emery-Dreifuss muscular dystrophy (EDMD) is a rare genetic muscular disease characterized by involvement of the muscle, joint and myocardium. Compare to other types of muscular dystrophy, cardiac involvement is the most prevalent and severe aspect of EDMD. Case presentation: A-31-year old man, a father of a-2-year old child with suspicion of having muscular dystrophy, has a problem of gait disturbances. He was suffered from paralysis when he was in elementary school, and started toe walking at 8 years old. He has no remarkable symptoms neither disturbance in daily living, only occasional short of breath. Physical examination revealed that there were inability to bend his neck downward and side ward, contracture of the elbow as well as scapulohumeroperoneal muscle wasting. Due to suspicion of hereditary muscular dystrophy, genetic examination by whole exome sequencing was carried out for both father and child. The result of genetic examination demonstrated a C to T transition in exon 7 of the LMNA gene, resulting in an arg453-to-trp (R453W) substitution, suitable for Emery Dreifuss Muscular Dystrophy 2, Autosomal Dominant type. Detection of cardiac involvement was done, electrocardiography revealed there was atrial fibrillation with complete atrioventricular block, echocardiography showed decrease of ejection fraction and hypokinetic in anterior wall of myocardium. Due to the result of those examinations, he is planned for urgent permanent pacemaker placement and further management of cardiomyopathy. Conclusion: Detection of cardiac involvement in muscular dystrophy is a compulsory to do, regardless it is a rare and short life expectancy disease. Proper management of cardic involvement can increase quality of life of the patient and reduce sudden cardiac death Keywords Emery-Dreifuss muscular dystrophy • cardiac involvement muscular dystrophy. C.2. Usefulness of β-angle to Diagnose Brugada Syndrome in Type 2 Brugada Pattern : A Case Series Ratna Andriyati Ratna Andriyati Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Sunu B Raharjo Sunu B Raharjo Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Dony Y Hermanto Dony Y Hermanto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Dicky A Hanafy Dicky A Hanafy Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Yoga Yuniadi Yoga Yuniadi Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia Case Illustration: Case I: a-61 year old-male with history of syncope, ECG pattern showed β-angle 59o and Ajmaline test revealed positive respons. Case II : a-56 year old-male without history of syncope or palpitation, ECG findings revealed β-angle 47o and Ajmaline test showed negative result. Case III : a-60 year old-male without history of syncope and palpitation, ECG pattern showed β-angle 60o and Flecainide test revealed positive result. Case IV : a-41 year old-male with history of palpitation without syncope, Flecainide test showed negative response with baseline ECG showed β-angle 35o. Discussion: Although the type 1 electrocardiographic (ECG) pattern is diagnostic for BrS, the type 2 pattern requires diagnostic distinction between true BrS and different clinical entities. The use of the β-angle (≥58°) in type 2 Brugada ECG pattern may distinct a true Brugada ECG from other conditions with high sensitivity and specificity. All of the patients had neither history of sudden death in family nor documented ventricular arrhythmias. Patients with β-angle >58o yielded positive responses to antiarrhythmic drug challenge (AAD), both using Ajmaline and Flecainide. Otherwise, negative AAD responses were found in patients with β-angle <58o on baseline ECG. Patients with positive response to AAD were planned to undergo electrophysiology study. Conclusion: We reported four cases of type 2 Brugada ECG pattern with different β-angle and response to AAD. β-angle can enable discrimination of type 2 Brugada ECG pattern with consequences of responses to AAD. This simple ECG criteria can be used in clinical practice to guide further risk stratification. Keywords Brugada syndrome • type 2 Brugada pattern • β-angle • antiarrhythmic drug challenge C.3. The Relationship Between the Base diameter of the Triangle r’ Wave and the Results of the Provocation Test in Patients with Non-type 1 Brugada Pattern Fatimah Defina Fatimah Defina Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Sunu Budhi Raharjo Sunu Budhi Raharjo Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Dony Yugo Hermanto Dony Yugo Hermanto Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Dicky Armien Hanafy Dicky Armien Hanafy Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Yoga Yuniadi Yoga Yuniadi Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Indonesia; National Cardiovascular Center Harapan Kita, Jakarta Indonesia Background: Brugada syndrome (BrS) is an arrhythmogenic disorder often inherited in an autosomal-dominant fashion that is suspected when an electrocardiogram (ECG) shows characteristic ST-segment elevation in the right and anterior precordial leads (type 1 Brugada ECG pattern). The diagnosis of BrS is based on the presence of the type 1 Brugada ECG pattern, which may occur either spontaneously or after provocation tests with sodium channel blockers in non type 1 brugada pattern. The duration of the base of the triangle at 4 mm from the high take-off is widely use as the tool to measure in diagnosing of non type 1 brugada pattern. Case illustration: We describe 4 cases of brugada syndrome. All patients was performed provocation test. Case 1 had a positive ajmaline test, with duration of base diameter of r’ wave 5mm. Case 2 had a negative results after ajmaline test with duration of base diameter of r’ wave 2 mm. Case 3 had a positive result with flecainide test with duration of base diameter of r’ wave 4.5 mm, and case 4 had a negative result with flecainide test with duration of base diameter of r’ wave 2 mm. Conclusion: In our study patients with positive result with provocation test either with ajmaline or flecainide have a longer duration of base diameter of r’ wave (> 4 mm). The longer duration of base diameter of r’ wave are useful as a tool for earlier screening in patients with non type 1 brugada pattern and also was the easiest tool to be measured preceding provocation test. Keywords Brugada syndrome • ajmaline test • flecainide test • duration of base of triangle diameter r’ wave C.4. Rupture of Unsuspected Cerebral Mycotic Aneurysm Due to Infective Endocarditis: a Rare Case Series Hans Nuari Hans Nuari Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Vito A Damay Vito A Damay Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Case Illustration: First case: Male 52 year old was referred with intracranial hemorrhage (ICH). Patient presented with sudden decrease of consciousness, right hemiplegia, murmur at mitral area, without any previous history of neurological symptom. Patient has a history of infective endocarditis (IE) one year prior to admission. Surgical evacuation was performed. Further echocardiography revealed severe mitral regurgitation (MR) with mobile vegetation at mitral valve. Digital Substraction Angiography (DSA) was performed afterwards, revealing a cerebral mycotic aneurysm (CMA) at distal middle cerebral artery. However, CMA ruptured before clipping procedure. Second case: Male 44 year old diagnosed with IE, presenting with acute ischemic stroke. CT scan revealed acute infarction at right corona radiate (supplied by middle cerebral artery). Echocardiography revealed moderate MR and vegetation at mitral valve. Blood culture was positive with Streptococcus viridans. Hemodynamics was unstable, and patient passed away due to acute extensive hemorrhagic transformation of ischemic stroke. Intracranial hemorrhages in IE patients are almost always attributed to ruptured CMA, even when no aneurysm is demonstrable. Additionally, ICH is often massive in anticoagulated patients. Discussion: These patients fulfilled criteria of IE and CMA. CMA as a consequence to IE is rare, however, with very high mortality rate (up to 80%) when ruptured. Neurological symptoms as predictors are not always clear. CMA was formed initially by distal emboli that cause infarction and infection. Atrial pulsation towards the thin wall eventually results in CMA enlargement and rupture. Clinical predictors of CMA are ill-defined. However, ruptured CMA was associated with high mortality rate. This phenomenon poses a difficult clinical dilemma regarding the indications for cerebral angiography in infective endocarditis. Conclusion: We describe a case with ruptured CMA due to IE. CMA is a rare complication of IE, but very fatal when it ruptured. Therefore we suggest screening with DSA may be performed in IE patients with any focal deficit or neurologic symptom. C.4. Figure 1 Open in new tabDownload slide Cerebral mycotic aneurysm at distal left middle cerebral artery C.4. Figure 1 Open in new tabDownload slide Cerebral mycotic aneurysm at distal left middle cerebral artery C.4. Figure 2 Open in new tabDownload slide Mitral regurgitation with mitral calcification and vegetation C.4. Figure 2 Open in new tabDownload slide Mitral regurgitation with mitral calcification and vegetation Keywords Infective endocarditis • Mycotic aneurysm • Rheumatic heart disease • Middle cerebral artery • Streptococcus viridans C.6. Late Presentation of Intramyocardial Dissecting Hematoma Following Myocardial Infarction and Coronary Angioplasty: a Case Series Focusing on Cardiac Imaging Eka F Elfi Eka F Elfi Faculty of Medicine, Andalas University, Padang, Indonesia and Installation of Cardiac Centre, Dr. M. Djamil General Hospital, Padang, Indonesia Lee TJ Lee TJ National Heart Institute, Kuala Lumpur, Malaysia Shaiful A Yahaya Shaiful A Yahaya National Heart Institute, Kuala Lumpur, Malaysia Faculty of Medicine, Andalas University, Padang, Indonesia and Installation of Cardiac Centre, Dr. M. Djamil General Hospital, Padang, Indonesia National Heart Institute, Kuala Lumpur, Malaysia Case Illustration: The first case is a 37 years old male with extensive anterior myocardial infarction (MI). Coronary angioplasty shown total occlusion in left anterior descendent artery and left circumflex artery. Angioplasty was performed to both vessel with acceptable result. However, after 6 months patient was readmitted with heart failure. Echocardiogram shown poor cardiac function and mass in apical wall detected differentiated between apical thrombus or IDH (picture 1). CMR confirmed diagnosed of IDH and comprehensive medical therapy for heart failure was given to achieve functional class II. The second case was a 59 years old male with cardiogenic shock following undiagnosed anterior MI. Echocardiogram shown massive mass resembles apical left ventricular clot (picture 2). Further echo analysis concluded that the mass was an IDH, but no CMR performed. Urgent cardiac surgery was planned, but his condition deteriorated, and patient succumbed due to cardiac failure. The third case is a 40 years old male with acute anterior MI post thrombolysis and developed heart failure. Echocardiogram shown apical mass diagnosed as thrombus, but CMR concluded as IDH (picture 3). Angiogram shown severe stenosis in LAD and LCX, but since ischemic study shown infarcted LAD region, patient was treated conservatively. Discussion: Intramyocardial dissecting hematoma (IDH) is a rare mechanical complication of acute myocardial infarction that contribute to high morbidity and mortality rate due to multiple complication associated with this condition. Cardiac imaging is essential to establish diagnosis and further guiding therapy. We present three cases of late presentation of IDH following acute myocardial infarction and coronary angioplasty. Here we emphasize on the role of cardiac imaging, particularly echocardiography and cardiac magnetic resonance imaging (CMR) which provide detailed information leads to diagnosis and therapeutic plans. Conclusion: IDH leads to serious complication and carries high mortality rate. Patient clinical appearance and integrated cardiac imaging is necessary in diagnosing IDH and to determine further management. C.6. Picture 1 Open in new tabDownload slide Echocardiogram and CMR C.6. Picture 1 Open in new tabDownload slide Echocardiogram and CMR C.6. Picture 2 Open in new tabDownload slide Echocardiogram C.6. Picture 2 Open in new tabDownload slide Echocardiogram C.6. Picture 3 Open in new tabDownload slide Echocardiogram and CMR C.6. Picture 3 Open in new tabDownload slide Echocardiogram and CMR Keywords intramyocardial dissecting hematoma • magnetic resonance imaging • echocardiogram • myocardial infarction • coronary angioplasty C.7. Management of Pregnancy Associated Acute Myocardial Infarction (PAMI) in A 27 years old Secundigravida: A Case Report Pramadya V Mustafiza Pramadya V Mustafiza Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Putrika P R Gharini Putrika P R Gharini Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Budi Y Setianto Budi Y Setianto Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Case Illustration: A 27-year-old secundigravida presented to Emergency Room (ER) with acute onset progressive chest pain and diaphoresis within 2 hours. She had coronary risk factors hypertension and obesity. Electrocardiogram revealed an inferior myocardial infarction and laboratory finding showed an elevated high sensitivity cardiac Troponin I (4700ng/L). Ultrasonography study has been done in the ER revealed a gestational sac size 2.4 cm equal to 7-weeks gestation. One year ago, she experienced inferior MI during breastfeeding for her first daughter. Coronary angiography in previous MI showed normal left main, irregular at distal left anterior descending, 30% stenosis at distal left circumflex, and multiple aneurysms with distal total occlusion at right coronary artery. At that time, patient was decided to undergo balloon angioplasty and 5mg intracoronary bolus of Eptifibatide in RCA. Discussion: This patient fulfilled criteria for pregnancy associated acute myocardial infarction (PAMI). Meanwhile, in this episode of MI, with consideration of complex coronary structure that might need more radiation exposure and her pregnancy was in organogenesis phase, therefore a conservative therapy are chosen for the patient. The clinical conference with obstetricians has been done with decision to continue her pregnancy with close monitoring during ambulatory care. The patient was discharged on the fifth day after admission with aspirin, amlodipine, nitroglycerine, and folic acid as routine therapy. Patient was being followed up monthly, there was no symptom of angina and fetal growth is appropriate to gestational age Conclusion: Management of PAMI mainly relies on PCI, but it can be individualized depend on gestational age and condition of the mother. Conservative management with heparinization and antiplatelet therapy might be treatment of choice in PAMI. C.7. Figure 1 Open in new tabDownload slide Electrocardiography in ER revealed an inferior myocardial infarction C.7. Figure 1 Open in new tabDownload slide Electrocardiography in ER revealed an inferior myocardial infarction C.7. Figure 2 Open in new tabDownload slide Coronary angiography in previous MI showed (A) Multiple anuerysm in RCA with total occlusion at distal (B) RCA post POBA showed no residual stenosis and trombus C.7. Figure 2 Open in new tabDownload slide Coronary angiography in previous MI showed (A) Multiple anuerysm in RCA with total occlusion at distal (B) RCA post POBA showed no residual stenosis and trombus Keywords pregnancy • myocardial infarction • secundigravida C.8. Successful Percutaneous Coronary Intervention in Very High Risk Patient with Critical Left Main, Three-vessel Disease, and Chronic Total Occlusion A Wardhani A Wardhani Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia M H Cahyadi M H Cahyadi Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia A S Hutomo A S Hutomo Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia Safir Safir Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia S Rifqi S Rifqi Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr Kariadi Central General Hospital, Semarang, Indonesia Case Illustration: We reported 40 years old male with recurrent hospitalization due to Acute Coronary Syndrome and Heart Failure although on optimal medical therapy. Electrocardiogram showed sinus rhythm with Q wave at anterior lead and non-sustain Ventricular Tachycardia. His coronary angiography showed three-vessel CAD with critical distal LM stenosis and Chronic Total Occlusion at mid-RCA. His SYNTAX-II score was 42 and EuroSCORE II 8.79%. Echocardiography showed severe systolic dysfunction with 17% ejection fraction. Viability study revealed 16.7% ischemic burden. Cardiothoracic surgeon refused to do CABG because of high surgical risk. Finally, patient undergone PCI in LM-LAD with two drug eluting stents. After PCI, there is improvement functional capacity with less dyspnea, angina and rehospitalization. Discussion: Patient with LMD have risk of 3-year mortality nearly 50% when receiving only medical therapy and even worse in HfrEF. Current guidelines position CABG for LMD and high SYNTAX score as the Class I recommendation. However, symptomatic HfrEF doubling risk in CABG. No randomize trials are done which compare the outcome between CABG and PCI in patients with HfrEF. On the other hand, patients with HfrEF with LM and high SYNTAXscore consider poor candidate for PCI because acute closure of lession after ballon dilatation might result in death. Event though in The EXCEL and NOBLE trials showed a 30-days all cause mortality of < 1% with both CABG surgery and PCI. At 3-5 years follow-up, PCI is non inferior for the risk of death, stroke, and myocardial infarction to CABG. Conclusion: Modern PCI is a feasible and save alternative choice of revascularization strategy in very high risk patient than CABG. Keywords Left Main Disease • Chronic Total Occlusion • complex coroner artery disease • CABG • PCI C.9. The Role of Rotational Atherectomy to Prevent Plaque Shifting : Improve Side Branch Patency without Wire Protection Samuel Dwiputra Samuel Dwiputra Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Vireza Pratama Vireza Pratama Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Michael Michael Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Jefry Sianipar Jefry Sianipar Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Ester Mariska Ester Mariska Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Nita Marliyanti Nita Marliyanti Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Fitria Handayani Fitria Handayani Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia M Syarif Hidayatullah M Syarif Hidayatullah Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Wahyu Aditya Wahyu Aditya Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Prihati Pujowaskito Prihati Pujowaskito Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Department of Cardiology, Gatot Soebroto Central Army and Presidential Hospital, Jakarta, Indonesia Case Illustration: A 69 years old male, recently hospitalized with recent NSTEMI and treated with 5 days heparinization. He has history of heart attack, type 2 diabetes, and Hypertensive Heart Disease. Echocardiography was performed and the result EF 30%, Hypokynetic in mid-anterior, mid-anteroseptal, mid-anterolateral segmen. Afterward, he underwent coroangiography procedure and the result showed 60% stenosis in left main coronary artery, subtotal occlusion in osteal left anterior descending artery (LAD), 60% stenosis in proximal left circumflex artery (LCx), and 80-90% stenosis in osteal mid right coronary artery (RCA). He was suggested to had coronary arterial bypass graft (CABG) surgery, but he refused. So PCI was performed and done with 2 stent in LAD and 3 stent in RCA using intravascular ultrasound (IVUS) and rotablation technique. Coroangiography evaluation showed TIMI 3 flow after the procedure. Discussion: Rotational Atherectomy is a technique currently used as a different strategy during PCI and has evolved from plaque debulking technique to plaque modification. The current management of plaque modification followed by stent implantation has remarkedly reduced the incidence of acute complications. Conclusion: Combination between RA technique and PCI was successful in this patient to reduce the incidence of acute complications that can happen because of plaque shifting from main vessel to the side branch vessel without doing wire protection. Also, it improved the stent deployment to reduce the possibility of restenosis and thrombosis. Keywords Rotational Atherectomy • Debulking Technique • Plaque Modification • Calcified lesion C.10. Fragmented QRS in Predicting Presence of Left Ventricular Aneurysm in Post Myocardial Infarction Patients Catherine Jillian Hardi Catherine Jillian Hardi Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Sunanto Ng Sunanto Ng Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Siloam Hospitals, Tangerang, Indonesia Ingrid Maria Pardede Ingrid Maria Pardede Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Siloam Hospitals, Tangerang, Indonesia Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Siloam Hospitals, Tangerang, Indonesia Case Illustration Case Illustration 1: A 44-year-old male presented with CHF NYHA II and Ischemic Cardiomyopathy. ECG revealed pathologic Q waves in leads II, III, aVF and V4-V6, ST-elevation in leads V1-V3 and fragmented QRS in leads II, III, aVF and V2-V3. Cardiac MRI (CMR) revealed an LVA as a thin, dyskinetic apex. Case Illustration 2: A 68-year-old male with history of old anterior MI, previous CVDNH, hypertension, diabetes mellitus presented with no apparent symptoms. ECG showed QS complexes in V1-V2, ST elevation in V1-V2 and fragmented QRS in V3-V6. Echocardiogram revealed an akinetic, scarred, mid-to-apical anterior segment. CMR revealed an LVA as akinetic apical cap to mid-anterior segments. Case Illustration 3: A 60-year-old male presented with CHF NYHA II, old anterior MI, previous CVDNH, diabetes mellitus and hypertension. ECG showed sinus rhythm with ST elevation in V2-V3 with pathological Q waves in V1-V3. Echocardiogram showed akinetic apical anterior and mid-anterior segments. CMR revealed an LVA as a thin, scarred akinetic apex with a small thrombus. Discussion: Left Ventricular Aneurysm (LVA) is a complication of myocardial infarction. LVA is defined as a discrete, thinned ventricular segment, with akinetic or dyskinetic wall motion causing out-pouching of the left ventricle. Systolic expansion of transmural scars in LVAs exert traction on the surrounding myocardium, leading to the appearance of currents of injury at the end of electrical systole, which project positive voltages in overlying leads, which the ECG registers as ST elevation. Fragmented QRS can be caused by zig-zag conduction around the scarred myocardium, resulting in multiple spikes within the QRS complex. Conclusion: We aim to present 3 cases with ECG diagnostic findings of LVA. Persistent ST elevation and fragmented QRS are signs that may be used to detect the presence of LVA. Aneurysm scars can cause conduction changes in the myocardium, manifesting as electrocardiographic findings. C.10. Figure 1 Open in new tabDownload slide Electrocardiogram showing pathologic Q waves in leads II, III, aVF and V4-V6, ST elevation in leads V1-V3 and fragmented QRS complexes in leads II, III and aVF; V2 and V3 C.10. Figure 1 Open in new tabDownload slide Electrocardiogram showing pathologic Q waves in leads II, III, aVF and V4-V6, ST elevation in leads V1-V3 and fragmented QRS complexes in leads II, III and aVF; V2 and V3 C.10. Figure 2 Open in new tabDownload slide Left Ventricular Aneurysm on Cardiac Magnetic Resonance Imaging C.10. Figure 2 Open in new tabDownload slide Left Ventricular Aneurysm on Cardiac Magnetic Resonance Imaging Keywords Left Ventricular Aneurysm • Persistent ST elevation • fragmented QRS C.11. Chronic Thromboembolic Pulmonary Hypertension in a Young Patient with Antiphospholipid Syndrome: A Case Report Claudio Agustino Claudio Agustino Faculty of Medicine, Universitas Indonesia, Indonesia Andrea Maria D’Armini Andrea Maria D’Armini Department of Cardio-Thoracic and Vascular Surgery, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy Faculty of Medicine, Universitas Indonesia, Indonesia Department of Cardio-Thoracic and Vascular Surgery, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy Background: Chronic thromboembolic Pulmonary Hypertension (CTEPH) is classified as group 4 pulmonary hypertension, which can be developed from primary antiphospholipid syndrome, causing hypercoagulable state along with endothelial dysfunction. Patient with CTEPH can develop various unspecific symptoms related with cardiopulmonary system. This condition is potentially curable. Early diagnosis and prompt treatment with surgery and medical therapy could improve the outcomes. Case Illustration: 17 years old man was admitted due to shortness of breath (WHO Fc III-IV). No clinically significant abnormalities were found. The patient was assessed with echocardiographic, CT angiography, V/Q scan and right heart catheterization. The result showed several occluded pulmonary artery branches, severe pulmonary hypertension (PAP 95/57/37 mmHg, PCWP 4 mmHg,) and bilateral ventilation/perfusion miss-match. The studies were suitable for CTEPH. The patient had undergone several genetic testing with positive result in Ab anti nucleus IFI (Hep-2) and MTHFR gene. Pulmonary endarterectomy were performed and showed impressive improvement in symptoms and functional status. Discussion: The diagnosis of CTEPH was made based on symptoms and imaging results. This young patient were not had any certain risk factors for venous thromboembolism. Thus, rare condition like antiphosphoslipid syndrome or other autoimmune diseases should be considered by doing several genetic testing. Specific treatment for this autoimmune condition should be done to prevent reccurence of thomboembolic events. Conclusion: Antiphospholipid syndrome testing should be considered in young age patients with CTEPH without any certain risk factors for thromboembolic event as the therapy should be adjusted. Keywords Chronic • embolism • pulmonary hypertension • antiphospholipid syndrome C.12. A Zugzwang Situation: A Rare Case of Trousseau’s Syndrome Presenting with Stroke and Phlegmasia A L Samson A L Samson Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines A V Dela Cruz A V Dela Cruz Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines L K M Evangelista L K M Evangelista Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines J A Luzano J A Luzano Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines E M Chua E M Chua Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines E B Alajar E B Alajar Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines Department of Medicine, Section of Cardiology, University of the Philippines – Philippine General Hospital, Manila, Philippines Background: Cancer patients are at increased risk for venous thromboembolism (VTE) because of an acquired thrombophilic condition. Patients with cancer can have four to seven-fold higher risk of VTE compared to those without. Phlegmasia cerulea dolens (PCD) is a rare but fulminant clinical presentation of DVT and may occur following thrombosis of the iliofemoral vein may mimic arterial ischemia in the context of massive venous thrombosis Case Summary: A 52-year old, Cervical Cancer Stage IIIB patient was admitted at a tertiary hospital in the Philippines due to a recent right-sided weakness and verbal aphasia from a non-hemorrhagic stroke. Swelling of her right leg was noted which was accompanied by bullous lesions and telangiectasias progressing to cyanosis after 4 days. Pulses were noted to be normal on the left lower extremity and diminished on the right. Venous compression ultrasonography revealed total thrombotic occlusion of the right distal external iliac, common femoral, femoral, popliteal and great saphenous veins. Incidentally, the left external iliac down to the peroneal veins were also occluded. Transthoracic echocardiogram did not reveal any intracardiac thrombus while arterial duplex scan did not show any significant occlusion or stenosis. Intravenous anticoagulation, inferior vena cava filter insertion and thrombectomy were the initial options, however, given her recent stroke, the risk of hemorrhagic conversion is significantly elevated. Discussion of the risks and benefits of the interventions with her family led to non-consent and instead, opted to proceed with medical management. Discussion and Conclusion: The use of anticoagulation should always be weighed against the risks since the incidence of major bleeding in patients with malignancy is higher compared to those without. The dilemma arises when anticoagulation is clinically warranted but concomitant conditions counter it’s use for treatment. Keywords Trousseau Syndrome • phlegmasia • deep vein thrombosis • anticoagulation C.13. Retrograde Approach for Transcatheter Device Closure of Ruptured Sinus of Valsalva in 48-Year-Old Male I Dewa I Dewa Department of Cardiology and Vascular Medicine, Udayana University Sanglah General Hospital, Denpasar G D Sumajaya G D Sumajaya Department of Cardiology and Vascular Medicine, Udayana University Sanglah General Hospital, Denpasar Veny K Yantie Veny K Yantie Department of Child Health Medical School, Udayana University, Sanglah General Hospital, Denpasar Eka Gunawijaya Eka Gunawijaya Department of Child Health Medical School, Udayana University, Sanglah General Hospital, Denpasar Department of Cardiology and Vascular Medicine, Udayana University Sanglah General Hospital, Denpasar Department of Child Health Medical School, Udayana University, Sanglah General Hospital, Denpasar Case Illustration: A-48-year-old man presented with shortness of breath and a history of well controlled arterial hypertension, NYHA class III. Physical examination revealed a grade III/6 continuous murmur at lower left sternal border. Transesophageal echocardiography (TOE) clearly seen typical windsock-like aneurysm from right coronary sinus draining into the right ventricle with turbulent color flow across (Fig.1). Catheterization procedure was done under general anesthesia. Aortic root angiography visualized a ruptured right aortic sinus of Valsalva (SOV) into right ventricle with 3.2 to 4.5 mm in diameter from LAO 40o/ CRA 30o projection (Fig. 2). Flow ratio was 0.78 (1.41 after oxygen test) and pulmonary artery resistance index 8.00 WU.m2 (3.65 WU.m2 after oxygen test). The defect was crossed retrogradely using pigtail and hydrophilic guide wire 0.035inch x 180 cm. A retrograde method of transcatheter closure was done using AMPLATZERTM Duct Occluder II (AGA Medical Corporation, USA) number 6-6 mm under TOE guidance. No major and minor complications was observed during procedure. The patient was discharged one day after procedure with no residual shunt was seen and device well seated on echocardiography follow up without ischemic sign on electrocardiography. Discussion: This patient fulfilled criteria of ruptured sinus of Valsalva aneurysm. This condition is a rare cardiac anomaly. Open surgical repair has been conventionally the mainstay of therapy. However, percutaneous transcatheter closure is in current treatment of choice. This method provided a less invasive, faster recovery and promising early result than surgical approach. Difficulties that will be faced in this procedure such as defects that are too large and too near to coronary ostium, not available dedicated devices, direction of flow from the defect, the structure around the defect, and the presence of other abnormalities that accompany it. Things that must be monitored after the procedure include the position of the device, the presence of residual flow, any ischemic sign from ECG, and infection of the device. In the future it is hoped that more specialized devices can be made for such case. Conclusion: We described a case with ruptured sinus of Valsalva aneurysm into right ventricular chamber. The retrograde approach for percutaneous closure of a ruptured SOV is feasible. Long term follow-up is needed. Keywords Sinus of Valsalva aneurysm • ruptured aortic sinus • transcatheter closure C.14. Massive Purulent Pericardial Effusion caused by MRSA in Young Woman with Eruptive Skin Lesions: a Case Report H Raharja H Raharja Murni Teguh Memorial Hospital, Medan, Indonesia T B Haykal T B Haykal Murni Teguh Memorial Hospital, Medan, Indonesia Murni Teguh Memorial Hospital, Medan, Indonesia Background: Bacterial pericarditis, a rare encounter in the antibiotic era, is associated with a high mortality rate. Bacterial pericarditis itself is usually a result of a hematogenous spread, direct trauma or local extensions from the adjacent organ structures. Case Illustration: A 34-years old woman with unresolved chest pain for more than 24 hours with only remarkable history of illness included scaly skin over all the body for 4 months with a prior hospitalization. Skins in face, trunk, abdomen and extremities were covered by dry, thick and erythematous squama and linear fissures. Echocardiography revealed a massive pericardial effusion. Urgent pericardiocentesis was performed and patient was started with empirical antibiotic. Approximately 450 ml of thick brownish pericardial fluids were drained, followed by regular evacuations of excess fluids. Cytology examination concluded a massive polymorphonuclear infiltration with no malignant cells found. Microbiological culture of the fluid resulted in growth of Methicillin Resistant Staphylococcus aureus (MRSA) which was sensitive to Vancomycin and Tigecycline. No other bacteria or fungus were presented in the specimen. Antibiotic therapy was shifted to intravenous Vancomycin. Clinical conditions and sign of shocks unresolved despite appropriate antibiotic and other supportive treatments. Albeit treatments that have been given, patient expired due to septic shock. Discussion: Bacterial pericarditis is a catastrophic disease with mortality rates as high as 40% of the cases despite appropriate treatments. Most common causative agents were Staphylococcus and Streptococcus. MRSA purulent pericarditis as an aetiology for refractory shock (as in this patient) has a high mortality rate of up to 60%. Obtaining pericardial fluid for culture and microscopic evaluation will help to achieve pathogen-specific goal-directed therapy. Conclusion: MRSA purulent pericarditis, although rare, is a life-threatening condition. Mortality rates of those suffered from the condition remain high despite appropriate and directed therapies. Keywords Massive pericardial effusion • bacterial pericarditis • MRSA C.15. Tuberculosis Patient With Long and Massive Trombus from Right Leg Up to Pulmonary Arteries due to Concomitant Leukemia and Protein C Deficiency– A Case Report Indah Sukmawati Indah Sukmawati Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Cardiology and Vascular Medicine Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Titis D Wahyuni Titis D Wahyuni Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Pulmonology Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Diana Paramita Diana Paramita Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Internal Medicine Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Cardiology and Vascular Medicine Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Pulmonology Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Internal Medicine Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Case Illustration and Discussion: A 26-year-old male treated for tuberculosis came with general weakness and chronic hemoptoe. Severe anemia (Hb 6.1 g/dL) detected and patient was admitted for transfusions. Following day, he developed painful swelling on his right leg. Complete blood count showed pansitopenia with suspicion of acute leukemia supported by blood smear result, LDH 668 U/L and D-Dimer 80 ng/mL. Doppler ultrasound revealed long thrombus from tibial veins and great saphenous veins up to common illiac veins. Otherwise normal echocardiography also showed large thrombus in IVC and right atrium. Chest contrast CT-Scan showed thrombus in IVC to right atrium, left and right inferior pulmonary arteries, pulmonary infarction of left and right lower pulmonary lobes and old tuberculosis with multiple tuberculoma. Further examinations showed protein C deficiency. Patient was given intravenous heparin and was then overlapped with Rivaroxaban 20 mg daily. Overall conditions improved, leg swelling drastically lessened and D-Dimer was 12.03 ng/mL. Day 14, patient was discharged with Cilostazol 100 mg twice daily, Rivaroxaban 20 mg and Clopidogrel 75 mg. On follow-up, D-Dimer down to 1.23 ng/mL, patient was referred to National Cancer Center for further treatment of his leukemia. Conclusion: We have reported a case of young male with tuberculosis who also had leukemia and protein C deficiency which manifested as DVT and PTE. High vigilance, early diagnosis and prompt treatment proven to give great outcome for the patient. Keywords deep vein thrombosis • pulmonary thromboembolism • protein C deficiency • leukemia • tuberculosis C.16. Libman-Sacks Endocarditis: A Case Report N L P D A Putri N L P D A Putri Department of Cardiology and Vascular Medicine, Udayana University, Sanglah General Hospital , Denpasar H Wirawan H Wirawan Department of Cardiology and Vascular Medicine, Udayana University, Sanglah General Hospital , Denpasar Department of Cardiology and Vascular Medicine, Udayana University, Sanglah General Hospital , Denpasar Case illustration: A 26-year-old woman came with a sudden decrease in consciousness accompanied by vomiting 4 hours prior to admission. Patient has a history of fever since 4 months ago and shortness of breath in the last 4 years. From physical examination there was Grade 3/6 rumbling diastolic murmur at apex. From echocardiography, moderate MR was found with vegetation in AML and PML. Lab results showed normal WBC and an increase in ANA IF 1:320. From 4 position blood cultures, the results was steril. An MSCT scan of the head showed ICH. Evaluation echocardiography after 14 days of empiric antibiotic administration did not give favorable result. Discussion: Libman–Sacks valvular lesions are sterile fibrofibrinous vegetations that affect left side heart valves. The pathogenesis is thought to involve formation of fibrin–platelet thrombi, which leads to fibrosis and scarring with subsequent valve dysfunction. The development of Libman–Sacks endocarditis adds in the complexity and diagnostic uncertainty of patient with SLE which in this case report presented with fever and new cardiac murmur. Because the occurrence of bacterial endocarditis in patients with persistent Libman–Sacks endocarditis is not uncommon, it is imperative to differentiate between the 2 medical conditions, as the management and treatments are different. Patient did have positive ANA titers and normal WBC. These laboratory findings combined with patient’s multiple negative blood cultures and lack of response to antibiotics led us to the correct diagnosis of Libman–Sacks endocarditis. Conclusion: These patients will be more likely to develop cardiac manifestations of lupus, such as valvular regurgitation and possible Libman–Sacks endocarditis. Clinicians treating lupus patients with fever and new cardiac murmur should perform careful evaluation and diagnostic testing to establish the correct diagnosis and begin appropriate treatment. Keywords Libman–Sacks endocarditis • systemic lupus erythematosus • infective endocarditis • echocardiography C.17. The Spiked Helmet Sign: The Early Warning ECG Marker of Impending Death in STEMI Patients Lyra Febrianda Lyra Febrianda Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Nurkhalis Nurkhalis Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Muhammad Muqsith Muhammad Muqsith Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Teuku Heriansyah Teuku Heriansyah Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Novita Novita Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Case Illustration: A 66-yo male with a history of hypertension and diabetes mellitus type II presented with sudden shortness of breath and typical angina since 3 days before admission. The ECG demonstrated ST segment elevation in anterior leads with complete RBBB associated with high level of Troponin I. Patient was managed in intensive care unit. On day 1 of hospitalization, the patient developed spiked helmet sign in anterior leads on ECG but was omitted. Later, it disappeared spontaneously. A day later, patient went into ventricular tachycardia and successfully resuscitated. On the following day, coronary angiography was performed. A total occlusion of ostial LAD was found, and managed with a DES stent. Discussion: Twelve-leads electrocardiogram (ECG) is still one of the easiest diagnostic procedure and gives crucial findings. The spiked helmet sign used to be a clue for a possibility of critical illness. The exact cause of the spiked helmet ECG pattern is still debated. This sign on ECG is not yet well-understood and only several cases were reported until now. The most likely mechanism is due to sudden elevation of intra-abdominal and intra-thoracal pressure, excessive sympathetic release and simultaneous contraction of the diaphragm and the heart. Conclusion: The spiked helmet sign is possibly a new ECG marker of mortality in STEMI patients, although the prevalence, mechanism, and clinical applicability remain unclear. Awareness of this sign should prompt immediate reevaluation and activation of the cardiac catheterization laboratory in STEMI patients. C.17. Figure 1 Open in new tabDownload slide Spiked helmet sign in anterior leads C.17. Figure 1 Open in new tabDownload slide Spiked helmet sign in anterior leads Keywords electrocardiogram • spiked helmet sign • STEMI. C.18. Transfusion Associated Circulatory Overload: How to Diagnose and Treat It Jefry Sianipar Jefry Sianipar Department of Cardiology Gatot Soebroto Central Army Hospital Jakarta Ester Mariska Ester Mariska Department of Cardiology Gatot Soebroto Central Army Hospital Jakarta Asmoko Resta Permana Asmoko Resta Permana Department of Cardiology Gatot Soebroto Central Army Hospital Jakarta Department of Cardiology Gatot Soebroto Central Army Hospital Jakarta Background: Blood product transfusion can bring serious non-infectious consequences such as anaphylaxis, transfusion associated circulation overload (TACO), transfusion related acute lung injury (TRALI) and few others. Presence of TACO definitely increase length of stay and mortality rate up to 8%. Many cases of TACO were underdiagnosed or misdiagnosed as TRALI following blood transfusion. Case Presentation: A 71 years old woman complained fatigue, dizziness, palpitations and also dark stool. Patient had a history of non haemorrhagic stroke and atrial fibrillation (AF). Physical examination findings were within normal limits except for an anaemic conjunctivas. Electrocardiography (ECG) reading of AF rapid ventricular response (AFRVR) and laboratory results were within normal limits except for a decreased haemoglobin level (5.5 g/dL). She was immediately given packed red cell (PRC) transfusion of 500 mL, but within 1 hour after transfusion, she developed an acute pulmonary edema and was given nitrate and diuretics but only improved a little. Then she was immediately intubated and transferred to intensive care unit (ICU). She was treated with nitrates, diuretics, angiotensin converting enzyme (ACE) inhibitor and was given betablocker before she was discharged. Discussion: Acute pulmonary edema in TACO is associated with left atrial hypertension or volume overload occured within 6 hours following a blood transfusion. Patients having TACO can be confused with having TRALI but a good clinical judgement can help distinguish them. These TACO patients would typically exert acute respiratory distress, hypertension, hypoxemia, findings of congestive heart failure including elevated jugular venous pressure and S3 gallop. We can also find Kerley B lines and bilateral opacities suggesting pulmonary congestion on chest X-ray. Our patient exerts these features of TACO then correctly diagnosed and treated. Treatment of TACO starts with discontuining any transfusion. Nitrates are used to decrease venous pressure, diuretics are administrated to remove excess fluid and ACE inhibitor are adiminstered to block renin angiotensin aldosterone system (RAAS) activation. Our patient was treated accordingly with these medications. Conclusion: Understanding clinical profile include presenting sign and symptoms, fluid status and cardiac status, TACO can be easily diagnosed and differentiated from TRALI. Keywords Transfusion • circulation overload • diagnose • treatment C.19. Acute Inferior STEMI Presenting a Unique Pattern of “Spike Helmet Sign” in ECG R Abimanyu R Abimanyu Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia A Sitepu A Sitepu Department of Cardiology, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia H. Adam Malik General Hospital, Medan, Indonesia Grand Med General Hospital, Lubuk Pakam, Indonesia Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia Department of Cardiology, Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia H. Adam Malik General Hospital, Medan, Indonesia Grand Med General Hospital, Lubuk Pakam, Indonesia Case Illustration: A male 52-year-old admitted to ER with severe chest pain and dyspnea within 5 hours before admission to hospital. He was alert, respiratory rate was 36 breaths per minute with oxygen saturation 97 %. Heart rate was 110 beats per minute with blood pressure 100/60 mmHg. There were pulmonary rales on the half of both lungs field. ECG showed elevated ST-segment in inferior leads included Spike Helmet sign (SHs). Cardiac markers (CKMB and Troponin T) were extremely high (>40 ng/dL and >2000 ng/dL). Chest x-ray showed pulmonary edema. Coronary angiography showed normal LM, ostial LAD CTO, irreguler LCx, 90% stenosis at proximal and subtotal occlusion at distal RCA with slow flow. The patient underwent primary PCI and was successful to be administered 2 DES in RCA. Discussion: It was rare to find an acute STEMI presenting SHs. The symptoms showed acute heart failure due to acute coronary syndromes. The cardiac serum markers were extremely high that symbolized massive myocardial necrosis. The patient died on the third day due to refractory acute heart failure. Despite the successful primary PCI, the heart failure was still difficult to overcome. Conclusion: We describe a case with a unique pattern of apparent STEMI presenting SHs with critical condition leads to higher mortality. Thus, when finding SHs in STEMI, performing an immediate interventional procedure is very crucial to reduce morbidity and mortality. Keywords Spike Helmet sign • STEMI • ECG C.20. The Multiple Facets of Cryptogenic Stroke Antonia A Lukito Antonia A Lukito Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Yusak M T Siahaan Yusak M T Siahaan Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Hendyono Lim Hendyono Lim Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Marco W Hadi Marco W Hadi Siloam Hospitals Lippo Village Alvin Thengker Alvin Thengker Siloam Hospitals Lippo Village Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Case illustration: Nearly 50% of cryptogenic stroke patients have a patent foramen ovale (PFO). The dilemma of whether to close these PFOs percutaneously or only medical therapy, in an effort to reduce the risk of recurrent paradoxical embolism, has been a matter of ongoing debate. A 45-yo female developed dysarthria and strange sensation on her face a couple days before admission, she is an active person and has no any background risk factor. The workup included laboratory studies to rule out immunologic or hematologic pathologies, a brain MRI, and an echocardiogram with bubble test. Much to our surprise, those tests revealed more than one positive findings. The brain MRI revealed the acute infarctions at right frontal, temporal and parietal lobes, thrombus at right internal carotid artery, and low flow of right middle cerebral artery. The laboratory studies revealed the deficiency of antithrombin III (ATIII) at 73.6% (80-120 %). Furthermore, the echocardiogram revealed a positive bubble contrast with agitated saline consistent with a patent foramen ovale (PFO) without an associate atrial septal aneurysm (ASA). Discussion: Although at that time there was some debate as to the best approach, it was decided by multidisciplinary team to put the patient on oral anticoagulant instead of an PFO closure, in agreement with prior reports and expert opinions as stated in the algorithm below. Conclusion: The cryptogenic stroke has many possible causes, and some may have multiple facets. The detailed and thorough investigation should be carried out to reveal all possible causes and implement the appropriate management accordingly. The PFO closure is recommended for all patients who have stroke from no other likely source. Keywords cryptogenic stroke • female • patent foramen ovale • antithrombin III deficiency C.21. Promising Benefit of Linezolid for Infective Endocarditis Therapy D Laksmi D Laksmi Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia A Yasmin A Yasmin Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia Case illustration: The 61-year-old male patient was diagnosed with acute decompensated heart failure caused by infective Endocarditis related (vegetation in the posterior mitral valve) with severe mitral regurgitation. Intravenous Ampicillin and Gentamicin antibiotic therapy were administered as initial empirical therapy. Patient experienced worsening symptoms and accompanied by worsening renal function during monitoring. After 2 weeks of adjusted dose empirical therapy, the results of blood cultures revealed MRSE (Methicillin Resistant Staphylococcus Epidermidis), only vancomycin and linezolid were sensitive antibiotic. We decided to replace empirical therapy with vancomycin. During 2 days of administration of vancomycin, there was acute worsening of renal function and we replaced vancomycin with linezolid. After 2 weeks of linezolid therapy, blood cultures revealed no more MRSE growth and reduced vegetation size from echocardiography, and improved renal function despite complications of thrombocytopenia. Discussion: Infective endocarditis (IE) is a deadly disease. Despite improvements in its management, IE remains associated with high mortality and severe complications. The success of therapy of endocarditis depends on microbial eradication using antimicrobials. Linezolid is a class of oxazolidinone antibiotics with bacteriostatic mechanism, and the increased frequency of infections caused by Multi Drug Resistant (MDR) microorganisms makes linezolid an option in IE therapy. At present, linezolid is not a standard therapy for IE, although guidelines published recently by the American Heart Association and European Society of Cardiology consider it to reasonable alternative for cases of IE caused by MDR bacteria. Conclusion: We describe a case with Methicillin Resistant Staphylococcus Epidermidis (MRSE) infective endocarditis was treated with Linezolid. Although still limited published reports suggest that linezolid may offer a therapeutic alternative for treatment of IE due to MDR or for those patients who do not tolerate glycopeptides. Keywords Infective Endocarditis • MDR • MRSE • Linezolid C.22. Lupus Cardiomyopathy: A Rare Cardiac Involvement Of Systemic Lupus Erythematosus A Case Report Maria I D Siregar Maria I D Siregar Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia William Soeryaatmadja William Soeryaatmadja Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia Leo D Pradipta Leo D Pradipta Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia Michael Tanaka Michael Tanaka Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia Department of Cardiology and Vascular Medicine, Siloam Hospital Lippo Village, Tangerang, Banten, Indonesia Case Illustration: A 9 year old girl came to the ER presented with 3 days history of shortness of breath, fever, and malar rash. On examination, she had tachycardia with high blood pressure, looked pallor, alopecia, multiple oral ulcer and generalized oedema. Rales were found in both lungs. Investigation showed anemia and deranged renal functions. Antinuclear factor (ANF) was strongly positive and anti-dsDNA titers were high with remarkable results of other ANA profile. Electrocardiogram showed sinus tachycardia with no ST-T segment changes. Echocardiography showed mildly dilated left ventricle and left atrium, global hypokinesia with ejection fraction 45%, and mild mitral regurgitation. She was diagnosed as SLE with cardiomyopathy with congestive heart failure. She was showing improvement after treated with digoxin, captopril, furosemide, and immunosuppressant drugs, methylprednisolone adjunct with supportive treatment. Case Discussion: Myocardial dysfunction in SLE is caused by multifactorial contributors. Endomyocardial biopsy remains the preferred method for the diagnosis of myocarditis, but carries a high risk of mortality. Thorough investigations found on this patient lead towards SLE with its further complications, such as nefritis lupus and global hypokinesia with a low EF on echocardiography as strong pointer to lupus cardiomyopathy. Conclusion: Lupus cardiomyopathy is a rare event in the course of SLE with incidence rate 1.95 per 100.000 person-years and may be secondary to myocardial inflammation or systemic complications such as hypertension. Symptomatic left ventricular dysfunction is the most common clinical presentation and potentially a life threatening event. It may be improved by steroid and immunosuppressive therapy while Identifying the cause leads to definitive treatments. Keywords lupus • cardiomyopathy • SLE C.23. Dyspepsia and Arrhythmogenic Right Ventricular Dysplasia: Related or Just Coincidence? A Case Report Jimmy O Santoso Jimmy O Santoso Badan Pengusahaan Hospital, Batam, Indonesia Priyandini Wulandari Priyandini Wulandari Badan Pengusahaan Hospital, Batam, Indonesia Badan Pengusahaan Hospital, Batam, Indonesia Case Illustration: A 10-years old boy with no significant past or familial medical history came to emergency department with a chief complaint of sudden onset of vomitus and epigastric pain. He often experienced a same complain since 1 year prior but it was never been as heavy as he felt at the time. He also complained a shortness of breath. Patient’s vital sign as follows, blood pressure: unmeasured, heart rate 220 bpm, temperature 36oC, saturation: 99% on room air. Physical examination revealed no murmurs or rales. 12-lead ECG showed a ventricular tachycardia originating from RVOT. We performed a 50 Joule cardioversion and his rhythm converted to sinus rhythm. We then give a maintenance dose (15 mg/kg/min) of amiodarone. Echocardiography was performed and revealed a dilated RV and RA. Discussion: This patient fulfilled criteria for ARVD from QRS duration > 110 ms and sustained VT originated from RV. ARVD can be separated into 4 phases: concealed phase, overt phase, weakening of RV, and weakening of LV. The weakening of RV can cause a symptoms of dypspesia. This is particullary due to right heart failure that lead to systemic venous congestion with one of the symptoms is dypspesia. From here, we can learn that we cannot underestimate epigastric pain in young patients. We should always measure the heart rate, do an ECG examination, and exclude all the possibility of organic cause of dyspepsia. Conclusion: Patients with ARVD may presented an uncommon symptoms such as dypspesia. We must aware of the possibility of ARVD when young patients came with epigastric pain. C.23. Figure 1 Open in new tabDownload slide Initial ECG C.23. Figure 1 Open in new tabDownload slide Initial ECG C.23. Figure 2 Open in new tabDownload slide Post Cardioversion ECG C.23. Figure 2 Open in new tabDownload slide Post Cardioversion ECG Keywords ARVD • dyspepsia • VT RVOT origin C.24. The Link Between Migraine, Infective Endocarditis, Chiari network and Patent Foramen Ovale Antonia A Lukito Antonia A Lukito Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Ingrid M Pardede Ingrid M Pardede Siloam Hospitals Lippo Village Michelle Widysanto Michelle Widysanto Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Marco W Hadi Marco W Hadi Siloam Hospitals Lippo Village Grace M Lukito Grace M Lukito Pelita Harapan University, Tangerang, Indonesia Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Case Illustration: Chiari network (CN), a fine, highly mobile, net-like structure, is found in 2-3% of the population. CN occasionally seen in right atrium near the opening of inferior vena cava and coronary sinus. It may favor thromboembolism and associated with infective endocarditis, arrhythmias, and migraine, however CN may protect from pulmonary embolism by acting as an inferior vena cava filter. A 39-yo female presented with anemia and prolonged febrile for two weeks, she also had been complaining of chronic migraine headache. The appropriate investigations were carried out include the laboratory studies, echocardiogram, and brain MRI. The laboratory results on admission showed hemoglobin of 7.2mg/dL, ESR 80 mm/h, ASTO 800 IU/mL, CRP-Hs 5.61 mg/L and negative blood culture serial. The brain MRI was unremarkable, and the TTE revealed small mitral and aortic valves vegetations with mild regurgitation and good LV function. The diagnosis of Infective Endocarditis was confirmed and she was put on intravenous antibiotics for 6 weeks using ambulatory peripherally inserted central catheter (PICC). After 6 weeks, the bacterial culture test of PICC’s tip upon withdrawal revealed a positive Staphylococcus haemolyticus >100 colonies, therefore, the antibiotics was reinstituted via oral according to bacterial sensitivity test. Since she still complained of migraine, the TEE was then performed and a L to R shunt type-1 stretched patent foramen ovale (PFO) and Chiari’s network (CN) were found. Discussion and Conclusion: The blood culture test of infective endocarditis often shows negative results, by using the central line’s tip for culture specimen could be helpful to identify the bacterial colony and antibiotics sensitivity test. Chiari’s network embryonically favors the persistence of PFO and enhances the reasons for PFO closure to prevent paradoxical embolism. Keywords Chiari’s network • patent foramen ovale • infective endocarditis • migraine C.25. A Rare Case: STEACS Anterior with Malignant Ventricular Arrhythmia Due To Severe Myocardial Bridging in Young Man Hernina Oktaviani Hernina Oktaviani RS Tk. IV Dr. Bratanata Jambi Faculty of Medicine and Health Sciences, University of Jambi Teuku Rahadiyan Teuku Rahadiyan RS Tk. IV Dr. Bratanata Jambi Faculty of Medicine and Health Sciences, University of Jambi RSUD Raden Mattaher Provinsi Jambi RS Tk. IV Dr. Bratanata Jambi Faculty of Medicine and Health Sciences, University of Jambi RSUD Raden Mattaher Provinsi Jambi Case Illustration: A 34-year-old man came to Emergency Department RS Tk. IV Dr. Bratanata Jambi with severe chest pain, weakness, palpitation, nausea, vomiting, and dizziness since two days before admission. Electrocardiogram (ECG) reveals Ventricular Tachycardia (VT) (Fig.1). Cardioversion of 100 joule was administered to resolve VT; after cardioversion ECG revealed Sinus Rhythm, rate of 75bpm with ST segment elevation in V1-V4, and T-inverted in III & aVF (Fig.2), with positive Troponin I. Patient was diagnosed with ST-Elevated Acute Coronary Syndrome (STEACS) Anterior as a trigger of VT and admitted to the ICU. Patient was administered loading dose of double antiplatelet and subcutaneous anticoagulant to resolve infarct. Patient was referred to PCI Center Hospital at RSUD Raden Mattaher to perform coronary angiography examination. Coronary angiogram revealed myocardial bridging (MB) grade III at left anterior descending artery (LAD). bisoprolol Beta Blocker 1x5mg and diltiazem (Calcium Channel Blocker/CCB) 1x100mg were administered Discussion: MB is a congenital coronary anomaly characterized by a major epicardial coronary artery “tunnelled artery”, generally in LAD through the myocardium. When systolic phase, coronary artery is compressed so that coronary blood flow to distal become obstructed. MB is associated with angina, arrhythmia, and myocardial infarction, even sudden cardiac death. MB cause ischemia and infarction by compression of coronary artery. STEACS Anterior develop because myocardial bridging in LAD. Coronary angiography helps to diagnose myocardial bridging and the location. Emergency management should be done to prevent death. Therapeutic approaches for MB include administering beta blocker to reduce tachycardia and increase diastolic coronary filling time with a decrease in myocardial contractility and compression of the coronary arteries. Other options include calcium-channel blockers, stents, and surgical myotomy. Conclusion: We describe a young patient with anterior STEACS due to myocardial bridging in LAD, with initial presentation of malignant ventricular arrhythmia. A rare case in Jambi Province. C.25. Fig. 1 Open in new tabDownload slide ECG reveals Ventricular Tachycardia C.25. Fig. 1 Open in new tabDownload slide ECG reveals Ventricular Tachycardia C.25. Fig. 2 Open in new tabDownload slide ECG after cardioversion reveals ST segment elevation C.25. Fig. 2 Open in new tabDownload slide ECG after cardioversion reveals ST segment elevation C.25. Fig. 3 Open in new tabDownload slide Coronary Angiography. Evidence of myocardial bridging at the LAD is seen as the artery is at normal width at the diastolic phase (a) but shows significant stenosis (black circle) at the systolic phase (b). C.25. Fig. 3 Open in new tabDownload slide Coronary Angiography. Evidence of myocardial bridging at the LAD is seen as the artery is at normal width at the diastolic phase (a) but shows significant stenosis (black circle) at the systolic phase (b). Keywords Myocardial Bridging • Myocardial Infarct • Ventricular Tachycardia. C.26. Supraventricular Tachycardia as First Manifestation of Cardiac Myxoma D Gde D Gde Departemen of Cardiology and Vascular Medicine, School of Medicine, Udayana University, Denpasar, Bali A Diprabawa A Diprabawa Departemen of Cardiology and Vascular Medicine, School of Medicine, Udayana University, Denpasar, Bali I Nyoman Wiryawan I Nyoman Wiryawan Departemen of Cardiology and Vascular Medicine, School of Medicine, Udayana University, Denpasar, Bali Departemen of Cardiology and Vascular Medicine, School of Medicine, Udayana University, Denpasar, Bali Case Illustration: A 19-year old female patient, with unremarkable past medical history, presented with palpitation, heart rate was 170 bpm, Electrocardiography revealed narrow-complex tachycardia, suspected of typical AVNRT, and there was no sign of hemodynamic compromise. Vagal maneuver was ineffective and sinus rhythm restored with intravenous diltiazem. The patient was subsequently questioned in search for symptoms suggestive of underlying cardiac disease, but she denied any history of palpitation, syncope and dyspnea or chest pain. Transthoracic Echocardiography revealed a huge round shaped mass occupying almost the whole left atrium with insignificant left inflow obstruction (MV mean PG 4 mmHg). The mass (5.63x3.46 cm) adhered to the interatrial structure and without enlarged left atrial and no signs of pulmonary veins obstruction. The left atrial mass was surgically removed, and the histopathological diagnosis was consistent with cardiac myxoma Discussion: Primary cardiac tumor is rare entity and atrial myxoma in left atrium is most common primary tumor. Most common symptoms of left atrial myxoma are dyspnea, cough, edema, fatigue and embolization symptoms. There are only few reports of supraventricular tachycardia manifestation in cardiac myxoma. After resection risk of recurrence of myxoma and atrial arrythmias or atrioventricular conduction abnormalities were present 2-5 and 26%, respectively. Conclusion: Cardiac myxoma may be symptomatic or found incidentally during evaluation for seemingly unrelated problem or physical finding. Left atrial myxoma can induce supraventricular tachycardia and can occur post resection. Cardiac imaging plays essential role in the detection and evaluation of cardiac myxoma, providing valuable information thus allowing surgical mass resection Keywords Supraventricular tachycardia • echocardiography • cardiac myxoma • left atrium C.27. Value of Endovascular Intervention in Femoro-popliteal Lesions to Salvage Limbs on Chronic Limb Threatening Ischemia : Short Term Patency is Satisfying Although Redo Procedure May Be Needed Metta Suryani Metta Suryani Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University, Wahidin Sudirohusodo Hospital Makassar Idar Mappangara Idar Mappangara Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University, Wahidin Sudirohusodo Hospital Makassar Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University, Wahidin Sudirohusodo Hospital Makassar Introduction: Chronic limb-threatening ischaemia (CLTI) specifies clinical patterns with a vulnerable limb viability related to several factors. CLTI is a strong risk factor for major amputation, and peripheral revascularization, surgical, or endovascular is the only therapeutic option. Although percutaneous transluminal angioplasty (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in CLTI, wherein anatomic disease is more extensive, remains unclear. We report a 56-year-old male who presented with CLTI of left lower extremity, post amputated of right lower extremity et cause diabetic foot ulcer, diabetes mellitus type 2. Patient had undergone PTA and apparently the short term result is astonishing, which can salvage the left lower limb and avoid the patient from amputation. Case Report: A 56-year-old man was hospitalized in our hospital with chief complaint pain in the left lower limb since 3-month before admission. The pain was felt even in resting. History of amputation in the right leg below the knee at 4-month ago. There was wound with pus in left leg since 4-month, the wound’s size was getting bigger over time. History of DM since 10 years ago, started to use insulin since 1-year ago. The Glasgow Coma Scale was 15, BP120/80 mmHg, HR 80 bpm, temperature 36.7 °C, RR 20 tpm. A significant clinical finding at the left inferior extremity there were severe wound along with pus and blackish around wound area (figure 1). The foot looked pale, cold, pulseless at pedis sinistra. Important findings obtained on Echo Vascular Doppler exams on left lower extremity showed multiple plaque with monophasic and broadening spectrum of duplex imaging from femoralis artery to tibialis artery; diminished flow with low-grade stenosis at the left perineal artery until distal; there was no visible view of thrombus. A CT arteriogram impression mixplaque from internal iliac artery through untill posterior tibialis artery at both extremities; left perineal artery cannot visualized suggestive occlusion; there was visible cut-off at 1/3 half anterior and posterior tibialis dextra (figure 2). A transthoracic echocardiography revealed normal systolic left and right ventricular function. We administered maintenance dose of heparin (18 U/kgBW/h) after initial injection of 80 U/kgBW/h), Pradaxa 110mg, Ciloztazol 100mg and Dissolf. We consulted with Vascular Surgery Subdivision and their suggestion is amputation below the knee of left extremity, but patient refused. Patient was planned to undergone arteriography and PTA if possible. Result of arteriography showed multiple plaque through the length from left femoralis artery to distal artery with visible collateral from femoralis artery; there was constriction of lumen artery from distal superficial femoralis artery to popliteal artery; diminished flow at posterior tibialis artery. We performed ballooning angiography at popliteal artery to posterior tibialis artery (figure 3); smooth blood flow from femoralis artery to distal tibialis artery after PTA (figure 4); diminished blood flow at dorsalis pedis artery. One week after PTA the pain complaint has already diminished, we also seen restoration of tissue started to grown fulfil wound area, no visible pus and necrotic wound (figure 5). After 1-month, all wound area has been replaced with viable tissue, intact sensoric and motoric finding (figure 6). Discussion: CLTI is associated with systemic athero-sclerotic vascular disease involving the coronary and cerebral vascular beds associated with a high morbidity and mortality. The risk is stratified according to the severity of ischaemia, wounds and infection. Without prompt revascularization, CLI may result in loss of a limb and/or life. The goal of endovascular therapy is the re-establishment of pulsatile, straight-line flow to the distal extremity. The BASIL trial demonstrated that PTA and surgery were comparable as first-choice therapy for CLTI, but that PTA was less expensive and did not preclude subsequent treatment with surgery. Therefore, PTA should be chosen first if a patient is a candidate for either procedure, particularly if the patient’s life expectancy is less than 2 years. Femoro-popliteal lesions frequently coexist with stenosis involving the infrapopliteal arteries in patients with limb-threatening ischemia. Successful revascularization is contingent upon restoration of pulsatile flow to the foot that requires revascularization in both territories. Role of PTA in patients with femoro-popliteal disease, is associated with lower patency rates than for iliac arteries. Despite advances in stent technology, patency rates following femoro-popliteal intervention for limb-salvage have remained modest. The latest ESC Guideline recommend endovascular therapy for femoro-popliteal lesion without CFA lesion, primarily those with elevated risk of surgery. A metaanalysis of 19 interventional studies performed between 1999 and 2003 showed that 3-year patency rates were 30–43% following angioplasty. The short term results of PTA in femoro-popliteal lesions is still in the forest and still need to be studied further. C.27. Figure 1 Open in new tabDownload slide View left leg before PTA C.27. Figure 1 Open in new tabDownload slide View left leg before PTA Conclusion: CLTI is a vulnerable limb viability condition and without any prompt revascularization may result in loss of a limb and/or life. Endovascular intervention is recommended in femoro-popliteal lesions, primarily in those with elevated risk of operation. Role of PTA in patients with femoro-popliteal disease in long-term, is associated with lower patency rates than for iliac arteries. The short term results is quite satisfying although it still need to be studied further. C.27. Figure 2 Open in new tabDownload slide A computed tomography arteriogram C.27. Figure 2 Open in new tabDownload slide A computed tomography arteriogram C.27. Figure 3 Open in new tabDownload slide Ballooning angioplasty C.27. Figure 3 Open in new tabDownload slide Ballooning angioplasty C.27. Figure 4 Open in new tabDownload slide Before PTA → After TPA C.27. Figure 4 Open in new tabDownload slide Before PTA → After TPA C.27. Figure 5 Open in new tabDownload slide 1 week after TPA C.27. Figure 5 Open in new tabDownload slide 1 week after TPA C.27. Figure 6 Open in new tabDownload slide 1 month after TPA C.27. Figure 6 Open in new tabDownload slide 1 month after TPA Keywords Chronic limb-threatening ischaemia • atherosclerosis • peripheral arterial disease • percutaneous transluminal angioplasty • salvage limb • amputation C.28. Small but Matters : Coronary Microvascular Disease Agatha Christiani Agatha Christiani Siloam Hospital Lippo Village, Tangerang, Indonesia Antonia A Lukito Antonia A Lukito Siloam Hospital Lippo Village, Tangerang, Indonesia Cardiovascular Dept, Pelita Harapan University Siloam Hospital Lippo Village, Tangerang, Indonesia Cardiovascular Dept, Pelita Harapan University Case Illustration: Coronary microvascular disease (MVD) is a disease that affects the small coronary arteries that leads to spasm and decrease blood flow to the myocardium. It is characterized by the triad of persistent chest pain, no obstructive CAD, and ischemia evidenced by stress testing. The risk factor remain the same as traditional CAD. It is more common in female, diabetic and hypertensive population. Low esterogen levels may raise women’s risk for MVD, whist lower esterogen before menopause raise younger women’s risk. Its potential complications are CV death, non-fatal MI, stroke, and heart failure. MVD is treatable but to diagnose remains a challenge, since the standard tests to diagnose CAD are not designed to detect MVD. A mildly dyslipidemic 45 yo female has been complaining of persistent chest pain during activities for 6 years, which driven her to visit hospital frequently, yet it never been completely relieved. ECG showed no ST-T changes, coronary CT showed normal results, and repeated treadmill stress test showed borderline ischemic response. Laboratory showed LDL 145 mg/dl. Finally cardiac MRI was performed and found inducible subendocardium ischemic in all segments, mild right heart dilatation, right ventricle dysfunction of 21.5% and normal LV function. Discussion: The coronary MVD was finally confirmed as the diagnosis after prolonged and extensive investigations. The cardiac MRI helped to diagnose by showing poor blood supply to the subendocardium whilst the CT angiogram failed to found any major obstruction. Conclusion: MVD is a common yet elusive disease and it increased hospital admissions and health care cost. Diagnosing MVD remains the biggest hurdle and extended investigation is needed to confirm the diagnosis. Cardiac MRI might be a useful modality for detection. More research is needed to find the best diagnostic modalities and proper treatments for the disease. C.28. Figure 1 Open in new tabDownload slide Treadmill stress test showed borderline ischemic response. C.28. Figure 1 Open in new tabDownload slide Treadmill stress test showed borderline ischemic response. C.28. Figure 2 Open in new tabDownload slide Cardiac MRI showed inducible ischemic in subendocardium. C.28. Figure 2 Open in new tabDownload slide Cardiac MRI showed inducible ischemic in subendocardium. Keywords chest pain • cardiac MRI • MVD C.29. ST Elevation ECG Mimicking Acute Myocardial Infarction in Pneumoperitonium Secondary To Gastric Perforation : A Case Report R E Intan R E Intan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia F S Hasibuan F S Hasibuan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Case Illustration: A seventy year old Indonesian man, came to the ER with chief complain of worsening epigastric pain, nausea, abdominal fullness and distention, and difficulty to flatus and defecation since 12 hours before admission, without any chest pain. He has a history of gaster perforation 2 years ago. On physical examination, VS : HR 68 bpm, BP 110/60 mmH, and temperature 37,80C. His abdomen was distended and had defans muscular. ECG recording showed 2 mm ST elevation in precordial lead V1 to V3 mimicking anteroseptal STEMI (Figure1). Cardiac biomarker was normal and TTE showed normal left ventricular function without any regional wall motion abnormalities suggesting a non cardiac cause of ECG changes. Abdominal X-ray showed a distended abdomen with a free air in peritoneum space. He was diagnosed with acute peritonitis and pneumoperitonium secondary to gastric perforation. An urgent laparotomy was performed to solve the problem and following the operation, the electrocardiographic result was reverted back to normal (Figure 2). Discussion: It is important to understand that there are broad differential pathologies for ST elevation seen in ECG beside STEMI, including in gastrointestinal emergency such as gastric perforation like we present in this case report as one of the possibility. The possible mechanism of ST elevation was due to change in the position of the heart in the thoracic cavity secondary to diaphragm distention. Misinterpretation of this sign can lead to unnecessary delay in treatment and increase morbidity and mortality rate. Conclusion: ST elevation myocard infarction (STEMI) is one of the medical emergency in cardiology with a high morbidity and mortality rate, and require an emergency response and treatment, however ST elevation in ECG does not always indicate that the primary pathology is cardiac in origin. We present a case of gastric perforation lead to pneumoperitoneum, with dynamic electrocardiographic changes mimicking anterior STEMI. As our knowledge, our case may be the first published case to be associated with pneumoperitoneum. C.29. Figure 1 Open in new tabDownload slide ECG pre surgery, 12 hours after onset of symptom, showed 2 mm ST elevation in precordial lead V1 to V3 mimicking anteroseptal STEMI C.29. Figure 1 Open in new tabDownload slide ECG pre surgery, 12 hours after onset of symptom, showed 2 mm ST elevation in precordial lead V1 to V3 mimicking anteroseptal STEMI C.29. Figure 2 Open in new tabDownload slide Comparison of ECG serial in precordial lead V1-V3 before and after surgery. ST elevation gradually revert back to normal after surgery. C.29. Figure 2 Open in new tabDownload slide Comparison of ECG serial in precordial lead V1-V3 before and after surgery. ST elevation gradually revert back to normal after surgery. Keywords ECG • ST elevation • STEMI mimicking • gastric perforation • pneumoperitonium C.30. Mitral and Tricuspid Valve Endocarditis Due to an Extremely Rare Pathogen: Streptococcus Constellatus Hans Nuari Hans Nuari Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Natalie Christine Natalie Christine Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Vito A Damay Vito A Damay Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Michael Tanaka Michael Tanaka Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia Case Illustration: A 34 year old male patient was referred to emergency department with fever (38.5 °C) and fatigue since 5 days before. Initial examination found rapid pulse and systolic murmur at mitral area. ECG showed atrioventricular nodal reentrant tachycardia (AVNRT) with 157 b.p.m. Laboratory examination revealed elevated inflammatory markers. Transthoracic echocardiography showed tricuspid regurgitation, severe mitral regurgitation, oscillating mitral valve vegetation, and ‘hockey-stick’ mitral valve typical for rheumatic valve disease. Blood culture was positive for Streptococcus constellatus bacteremia. Amoxicillin 500 mg i.v. was given for 6 weeks, according to sensitivity test. Patient’s condition got worse by time, added by dyspnea on exertion (walking 10 meters). Oral Ramipril 2.5 mg and Furosemide 40 mg was added, and condition gradually got better. Discussion: This patient fulfilled criteria for infective endocarditis (IE). IE although relatively rare, continues to lead as the third to fourth of most common fatal syndromes. IE remains a diagnostic challenge worldwide. Streptococcus constellatus, a pathogen from oral or genital area, has a tendency to form abscess, but not to cause IE. Streptococcus constellatus is the only species capable of producing thrombin-like activity, aggregating platelet, abscess formation, and more serious infection. Documented cases reported nonspecific initial symptoms of Streptococcus constellatus bacteremia. Clinicians should carefully consider the choice of antibiotics in the treatment of Streptococcus constellatus, since penicillin-resistant strains are being found more commonly in hospitals. Conclusion: We describe a case with IE due to Streptococcus constellatus. Streptococcus constellatus is a rare cause of infective endocarditis. Considering its worse infection and poor prognosis, Streptococcus constellatus bacteremia warrants further investigation in healthcare institutions. C.30. Figure 1 Open in new tabDownload slide Mitral vegetation, hockey-stick mitral valve C.30. Figure 1 Open in new tabDownload slide Mitral vegetation, hockey-stick mitral valve C.30. Figure 2 Open in new tabDownload slide Severe mitral regurgitation C.30. Figure 2 Open in new tabDownload slide Severe mitral regurgitation Keywords infective endocarditis • streptococcus constellatus • rheumatic heart disease • mitral valve • tricuspid valve C.31. Drug Induced Torsade de Pointes in Congenital Long QT Syndromes : A Case Report F Caesario F Caesario Dr. Iskak General hospital, Tulungagung, East Java, Indonesia E Ruspiono E Ruspiono Dr. Iskak General hospital, Tulungagung, East Java, Indonesia A Wibisono A Wibisono Dr. Iskak General hospital, Tulungagung, East Java, Indonesia T Astiawati T Astiawati Dr. Iskak General hospital, Tulungagung, East Java, Indonesia F S Laitupa F S Laitupa Dr. Iskak General hospital, Tulungagung, East Java, Indonesia A W Nugraha A W Nugraha Dr. Iskak General hospital, Tulungagung, East Java, Indonesia S Hayon S Hayon Dr. Iskak General hospital, Tulungagung, East Java, Indonesia N A Suyani N A Suyani Dr. Iskak General hospital, Tulungagung, East Java, Indonesia Dr. Iskak General hospital, Tulungagung, East Java, Indonesia Background: Congenital Long QT syndrome is a disease that causes fainting and sudden death due to ventricular arrythmia (Torsade de Pointes/TdP). This allows the occurrence of TdP due to the administration of drugs that actually cause TdP in patients with congenital LQTS. In one research, about 58% patients with long QT syndrome undergoing PPI therapy experienced TdP. Case Illustration: 15-years-old male, came to the Emergency Department with complaints of syncope accompanied with nausea and cold sweating 8 hours before admission. Physical examinations showed GCS 456, blood pressure 100/70 mmHg, pulse 57 times per minute. Abnormalities in general examination were not found. 12 lead ECG examination was performed and the result was sinus bradicardia with prolong QT interval (QTc: 517 ms). Diagnosis was post syncope state and suspection of Congenital Long QT syndromes. The patient then treated with Omeprazole and Ondansentron for the nausea. During the observation, the patient experienced seizures. The ECG monitor showed Torsade de Pointes. CPR was done with defibrilation at 200 joules and 1gram MgSO4 Injection blindly. The patient regained consciousness after 10 minutes of resuscitation. After stabilization, magnesium level obtained and it was normal value (Mg: 2,2 mg/dl). Discussion: In this case, based on the type of risk, Ondansetron is a drug with the known Risk of TdP group (red labeled drug for TdP) and Omeprazole, Drugs to Avoid in Congenital Long QT syndromes (black labeled drug for TdP), so their use must be avoided in patients with congenital LQTS. Conclusion: In Congenital Long-QT syndrome, medical therapy must be chosen carefully in order to avoid the drug induced ventricular arrythmia. Keywords Congenital Long-QT Syndrome • Torsade de Pointes • Ondansetron • Omeprazole C.32. St Elevation in Lead AVR with Widespread St Depression: What are the Chances and Treatment Strategies? A Serial Case Report Jimmy O Santoso Jimmy O Santoso Badan Pengusahaan Hospital, Batam, Indonesia Afdhalun A Hakim Afdhalun A Hakim Badan Pengusahaan Hospital, Batam, Indonesia Priyandini Wulandari Priyandini Wulandari Badan Pengusahaan Hospital, Batam, Indonesia Badan Pengusahaan Hospital, Batam, Indonesia Case Illustration: First case represented STEMI equivalent of 63 years old male and second is 74 years old female. First patient came with chief complaint of typical chest pain with an onset of 2 hours prior to admission. Second case came with shortness of breath with an onset of 3 hours prior to admission. Both cases showed an ECG of showed ST elevation in lead aVR with widespread ST depression. Corangiography was performed in either case with both showed three vessel disease and no left main disease. We planned the CABG for the first patient due to stable condition and complex anatomy (SYNTAX score = 30). However, we performed an early invasive (DES implantation in LAD) in second patient due to unstable condition and CABG cannot performed in our center. Discussion: While ST elevation in aVR with widespread ST depression is often considered as catastrophic condition due to its high mortality, the diagnosis and treatment of this condition often submaximal. The most common pitfall in the management of this condition is treat as if they have NSTEMI. Once we identify this pattern, we have to consider two things: is the patient’s condition stable and can CABG performed in our center? If the patient’s condition is quite stable, we can consider CABG. However, if the condition is unstable and CABG can be performed, withholding P2Y12 inhibitor should be considered to allow early or emergent CABG (to reduce the risk of perioperative bleeding). However, if CABG cannot be performed, PCI should be performed. Conclusion: ST elevation in aVR and widespread ST depression should rise our clinical suspicion of severe coronary stenosis and the need of CABG. Keywords STEMI equivalent • CABG • PCI C.33. Iatrogenic Radial Artery Perforation Treated With Balloon Assisted Tracking Technique and Internal Tamponade: a Case Series L Oddy L Oddy Department of Cardiology and Vascular Medicine, Padjadjaran University, Bandung, Indonesia Achmad F Yahya Achmad F Yahya Department of Cardiology and Vascular Medicine, Padjadjaran University, Bandung, Indonesia Department of Cardiology and Vascular Medicine, Padjadjaran University, Bandung, Indonesia Case illustration: We report two cases, 53 years old woman and 52 years old man, presented with stable angina pectoris who developed arm pain and resistance during advancement of guiding catheter (GC). Diluted contrast injection demonstrated right radial arteries perforation. Following coronary guidewire and balloon assisted tracking technique (BAT), GC was successfully delivered and PCI was successfully performed via the same access. Radial artery evaluation after PCI demonstrated minimal residual perforation in both cases. We managed it with balloon inflation to the perforation site. Doppler ultrasound evaluation one month later demonstrated normal radial artery flow. Discussion: Radial artery perforation is one of the vascular complications from transradial percutaneous coronary intervention (PCI). Continuous haemorrhage and haematoma formation as a result of radial perforation can lead to complications including compartment syndrome in the forearm requiring surgical intervention. In the past, most cases were treated by manual compression on the perforation site and switch to another access site to complete PCI procedure. We report successful management of iatrogenic radial artery perforation and completion of the procedure via the affected artery. Conclusion: BAT technique and internal tamponade successfully seal iatrogenic radial artery perforation and enable successful PCI procedure via the affected artery. Keywords Balloon assisted tracking • internal tamponade • radial artery perforation C.34. Acute Myocardial Infarction in Very Young Male with Protein S Deficiency Rika Pebriana Rika Pebriana Department of Cardiology and Vascular Medicine, Faculty of Medicine, Syiah Kuala University, Banda Aceh, Indonesia T Heriansyah, Novita T Heriansyah, Novita Department of Cardiology and Vascular Medicine, Faculty of Medicine, Syiah Kuala University, Banda Aceh, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Syiah Kuala University, Banda Aceh, Indonesia CaseIllustration: A young male patient, aged 23 years old presented with typical angina and perspiration after playing football. He was an active smoker, no diabetes or hypertension, no history of similar symptoms in the past and no family history of CAD. ECG showed persistance ST segment elevation in I, AVL, V1-V6 with QS pattern in V1-V5. Rales was found in the lower third of the lungs. Troponin I increased significantly. Workup for thrombophilic profile revealed reduced protein S function (43% of normal) and normal protein C function (72% of normal). Patient was treated as acute STEMI KILLIP 2, and transferred to cardiac catheterization laboratory and managed with one DES stent in LAD. The patient was discharged on fifth day. Discussion: Over the past years, Acute Myocardial Infarction (AMI) has been acquainted frequently in the young age. AMI in young patients has been poorly described. Additional examination, such as protein S and protein C sometimes are needed to find the cause of AMI other than smoking which is the most common risk factor. Protein S deficiency is a rare disorder, caused by mutation in chromosome 3 with the incidence is approximately 1:20000. Protein S deficiency causes increased risk of thrombosis with one of clinical manifestations is myocardial infarction. Antiplatelet and anticoagulant should be given for 3 months to 1 year. Conclusion: Examination of protein S or protein C is indicated in patients who has thrombosis at a young age (<50years) even smoking is the most common risk factor. Protein S deficiency in young age may play an important role in AMI. C.34. Figure 1 Open in new tabDownload slide Coronary angiogram showing total occlusion in LAD (arrow) C.34. Figure 1 Open in new tabDownload slide Coronary angiogram showing total occlusion in LAD (arrow) C.34. Figure 2 Open in new tabDownload slide After using one DES in LAD C.34. Figure 2 Open in new tabDownload slide After using one DES in LAD Keywords myocardial infarction • protein s deficiency • young age • smoking C.35. Diverse Clinical Manifestations of Left Atrial Myxoma Patient: Serial Cases F Fathini F Fathini Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia M Hasan M Hasan Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia E Martanto E Martanto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia Case Illustration: We report a serial case of left atrial myxoma, from early 2018 to early 2019, with variety of clinical manifestations. Case 1 illustrates a 52 year old woman with left and right-sided heart failure demonstrate as increasing dyspnea on exertion and intermittent ankle edema. Case 2 illustrates a 53 year old woman with neurological problem, manifest as weakness of right arm and leg, followed by slurred speech. Case 3 illustrates a 40 year old woman with sudden loss of left visual acuity and recurrent episodes of syncope, concluded as embolic manifestation. Case 4 illustrates a 42 year old woman with left-sided heart failure demonstrate as dyspnea on exertion. Transthoracal echocardiography confirmed all patients with large left atrial mass protruding into the left ventricle. Discussion: Myxomas typically present with combination of a triad; intracardiac obstruction, embolization, and/or constitutional symptoms. It may interfere with cardiac function and affect myocardial function, blood flow, or electrical impulse formation and conduction. It also may release tumor fragments or thrombi leading to embolization. Constitutional symptoms such as fever, weight loss, or anemia resulted from cytokine release of the tumor. Conclusion: Myxoma of left atrium is the most common type of benign primary cardiac tumor. Depends on location and morphology, it can cause ranges of clinical manifestations. Further examination with reliable tools such as Echocardiography is essential in diagnosis and further management. Keywords Left Atrial Myxoma • Cardiac Tumors C.36. Major Ischemic Stroke with Hemorrhagic Transformation in Patient with Wide Type A Stanford Acute Aortic Dissection S Belinda S Belinda Faculy of Medicine, Pelita Harapan University, Tangerang K Rani K Rani Faculy of Medicine, Pelita Harapan University, Tangerang L Hendyono L Hendyono Faculy of Medicine, Pelita Harapan University, Tangerang Siloam Hospital Lippo Village, Tangerang Faculy of Medicine, Pelita Harapan University, Tangerang Siloam Hospital Lippo Village, Tangerang Case Illustration: 44-year-old male came to emergency room with history of generalized tonic clonic seizure and loss of consciousness after admitted to another hospital for 5 days with chief complaint uncomfortable feeling at left chest radiates to the back while driving a car. Initial electrocardiogram showed an ST elevation myocardial infarction on the anterior lead with laboratory resulted in significantly high CK-MB and Troponin T. Magnetic resonance (MR) cerebral angiography showed wide acute infarction on the left and right hemisphere with hemorrhagic transformation on the left parietal lobe. Bluish color on both of lower extremities was observed. Right lower extremity was cold and without pulsation. Computed tomography (CT) angiography showed wide aortic dissection start from aorta ascendens and extending into the bilateral common iliac artery. Another laboratory showed elevated in liver enzyme, ureum, creatinine, and decreasead of estimated glomerular filtration rate (eGFR). The patient was admitted to the intensive care unit and died 7 days after admission. Discussion: This patient fulfilled criteria for aortic dissection type A based on Stanford classification. On Computed tomography (CT) angiography showed wide aortic dissection start from aorta ascendens and extending into the bilateral common iliac artery. Complication of this case was Malperfusion syndrome. It was seen by signs of acute limb ischemia, elevated in liver enzyme, ureum, creatinine, and decreasead of estimated glomerular filtration rate (eGFR). Conclusion: We describe a case of major ischemic stoke and wide aortic dissection, which makes it a unique and complicated case. This case highlights the importance of clinical suspicion of this potentially life threatening condition as it may present with atypical symptoms. Physicians should make several considerations in order to manage such unique case. Keywords aortic dissection • ischemic stroke • dissection of the thoracic aorta • dissection of the iliac artery • malperfusion syndrome C.37. Case Series: 3D Transesophageal Echocardiography Guidance for Transcutaneous Atrial Septal Defect Closure Aurea S Soetjipto Aurea S Soetjipto Faculty of Medicine Pelita Harapan University, Tangerang, Indonesia Michael Susanto Michael Susanto Faculty of Medicine Pelita Harapan University, Tangerang, Indonesia Jessica Herlambang Jessica Herlambang Faculty of Medicine Pelita Harapan University, Tangerang, Indonesia Ingrid Pardede Ingrid Pardede Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Sunanto Ng Sunanto Ng Faculty of Medicine Pelita Harapan University, Tangerang, Indonesia Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Faculty of Medicine Pelita Harapan University, Tangerang, Indonesia Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Case Illustration: Case 1: 51 years-old female suffered from progressive shortness of breath for 1 year. Heart sound fixed S2-splitting was found. Right-axis deviation and RBBB was found on electrocardiography. Transthoracic echocardiography (TTE) showed LA, RA, RV dilatation, L-R shunt atrial septal defect (ASD), tricuspid regurgitation. Three-dimensional Transesophageal echocardiography (3D-TEE) showed two secundum ASD close to each other separated by 1mm, total size 16mmx11mm. Surrounding rims were adequate for percutaneous closure. Right heart catheterization (RHC) revealed low resistance pulmonary vessel (PARi 0.34WU/m2), and low pulmonary to systemic vascular resistance ratio (PVR/SVR 0.02). Guided by 3D-TEE, 18mm Amplatzer device closed both defect successfully. Case 2: 64 years-old female suffered from worsening shortness of breath and orthopnea since 2 years ago. Heart sound fixed S2 splitting was found. TTE showed RA, RV dilatation, L-R shunt AS, and moderate tricuspid regurgitation. 3D-TEE evaluation showed round shaped secundum ASD, size 21mmx27mm. Surrounding rims were adequate. RHC revealed high flow L-R shunt (FR 2.99) moderate pulmonary resistance (PARi 0.89 post O2test 0.34WU/m2) and PVR/SVR 0.06. Guided by 3D-TEE, 30mm Amplatzer device closed defect succesfully. Case 3: 33 years-old male come with progressive shortness of breath since 1 year. Heart sound fixed S2 splitting was found. Electrocardiography showed crochetage sign. TTE showed RA, RV dilatation, L-R shunt ASD, and moderate tricuspid regurgitation. 3D-TEE showed oval shaped secundum ASD, size 22mmx26mm. Surrounding rims were adequate for closure. RHC revealed high flow (FR 3.12) low resistance (1.25→0.92WU/m2), and PVR/SVR 0.1. Guided by 3D-TEE, 28mm Amplatzer device closed defect successfully. Discussion: Percutaneous transcatheter ASD closure is widely used. 3D-TEE provides comprehensive information about ASD and surrounding heart structure. 3D-TEE shows clearer and more comprehensive image to measure variable defect shape, position, orientation, size, rim, and spatial relationships to surrounding structures. Conclusion: We described the role of 3D-TEE guiding in three case series of ASD closure. Keywords 3D-Transesophageal Echocardiography • Secundum ASD • Transcutaneous atrial septal Occluder C.38. Iatrogenic Left Anterior Descending Stenosis After Surgery for Penetrating Cardiac Trauma: A Case Report Hiradipta Ardining Hiradipta Ardining Medical Faculty, Universitas Indonesia, Jakarta, Indonesia William Kristanto William Kristanto Department of Cardiology, National University Heart Centre Singapore, Singapore Winn Maung Maung Aye Winn Maung Maung Aye Department of Cardiac, Thoracic & Vascular Surgery, National University Heart Centre Singapore, Singapore Poay Huan Loh Poay Huan Loh Department of Cardiology, National University Heart Centre Singapore, Singapore Medical Faculty, Universitas Indonesia, Jakarta, Indonesia Department of Cardiology, National University Heart Centre Singapore, Singapore Department of Cardiac, Thoracic & Vascular Surgery, National University Heart Centre Singapore, Singapore Case Illustration: We present the case of a 35 year-old man with iatrogenic MI following cardiac stab wound repair. The sutures for the cardiac repair was too tight, causing proximal LAD occlusion. Our patient was thought to have a higher than standard cardiac surgery risk for a repeat sternotomy and revision of the repair to his penetrating cardiac wound. Hence, PCI under IVUS guidance was performed. The patient subsequently made a good recovery and had no cardiac symptom during the ensuing 19 months follow-up. Discussion: Myocardial infarction (MI) can rarely occur due to iatrogenic coronary injury and occlusion following valvular surgery or penetrating cardiac wound repair. There is a paucity of literature to guide revascularization strategy in such rare cases of MI. Hence, the choice of revascularization therapy is should be judged individually based on clinical decision and/or heart team discussion. Surgical revision may be indicated in cases of coronary artery over-sewn by the sutures and local tissue distortion by sutures or implanted prosthesis. However, PCI may be a suitable and less invasive revascularization option in some cases. PCI might be the best revascularization strategy when extensive pericardial adhesion and inflammation is anticipated such as following penetrating cardiac wound and/or the use of pericardial patch. Conclusion: Iatrogenic coronary injury following cardiac surgery is rare. Meticulous surgical technique is required in order to prevent such complication especially during emergency cardiac surgery. Vigilance is required for early detection and intervention peri-operatively. Closer follow-up is necessary as some cases may only become clinically apparent later. The treatment strategy should be individualized with the involvement of the Heart Team. Keywords acute myocardial infarction • percutaenous coronary intervention • coronary bypass grafts • cardiac trauma C.39. Right Atrial Myxoma in Infant Age Group: A Rare and Challenging Diagnosis in Limited-Resources Hospital Steve F Karundeng Steve F Karundeng Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Rafiqa R Akbar Rafiqa R Akbar Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Anggraeni W Astuti Anggraeni W Astuti Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Case Illustration: A 1-month baby girl was reffered to cardiology department with an evidence of PSM gr. II/VI at LLSB and history of preterm, VLBW and gradually progressing respiratory distress. From 2D echocardiography studies, we found pedunculated mass in the right atrium with a short broad base attached to the inter atrial septum, isodense to the myocardium, no venous involvement, having a size of 14 mm x 21.1 mm, moving in rhythm with the opening and closing tricuspid valve, protrude to RV at the opening of tricuspid valve. Laboratory test abnormalities occurred such as anemia and elevated ESR. Discussion: Cardiac tumours represent a rare but important cause of morbidity and mortality in clinical cardiology and are often challenging in diagnostic cardiac imaging. Primary cardiac tumours have a prevalence 0.001 - 0.3%, and myxoma is the commonest. The incidence of cardiac myxoma peaks at 40 to 60 years of age. Approximately, 75% are located in the left atrial cavity, 23% in the right atrial cavity, and about 2% in the ventricular cavity. It is expected to grow antenatally in the late second or third trimester. Clinical presentation of a myxoma is intracardiac obstruction to flow from one chamber to other resulting in congestive cardiac failure, embolization, and constitutional symptoms. With right atrial myxoma, tricuspid valve function abnormalities and thromboembolic phenomena in the pulmonary circulation may be found. Constitutional symptoms (ie. anemia, fever, fatigue) occur because of released tumor yields such as IL-6, TNF, and other neuroendocrine factors from the neoplastic tissue; thus mimic sepsis in infant. Conclusion: Primary cardiac tumours in children are extremely rare and even more infrequent is the right atrial myxoma in infant age group. The patient was reffered for further investigation and planning for surgical removal as the definitive treatment. Keywords myxoma • infant • bintuni C.40. Survivor of Unruptured Giant Left Ventricular Pseudoaneurysm Rini Anastasia Rini Anastasia Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia Muzakkir Amir Muzakkir Amir Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia Department of Cardiology and Vascular Medicine, Hasanuddin University, Makassar, Indonesia Case Illustration: Male 27-year old came to the hospital with a history of atypical chest pain and denial of chest trauma. The electrocardiographic findings was non spesific, but the radiographic findings show an appearance of a cardiac mass. The diagnosis confirm with MSCT thoraks that revealed a giant pseudoaneurysm of left ventricular with the sign of ruptured to mediastinum. Altough the diagnosis confirm and the surgical treatment was discussed, patient refused the treatment despite of the high risk of sudden rupture that can lead to mortality. A short term follow up of a 6 month and 12 month revealed that patient still alive. Discussion: Left ventricular pseudoaneurysm is one of the rare case that cannot easily be found in patient especially in enormous size and without previous of a coronary cause. Congestive heart failure, chest pain and dyspnea were the most frequently reported symptoms, but the most of patients were asymptomatic. The electrocardiographic findings and radiographic were also usually nonspecific. It is a very rare entity, the true incidence and natural history are not clearly known. Echocardiography is usually used for diagnosis, which is confirmed by CT or MRI of chest, while open surgical or percutaneous closure are the available treatment options. Conclusion: We described a case with a left ventricular pseudoaneurysm that has a significant mortality rate in the first year after diagnosis . LV pseudoaneuryms are a “ticking time-bomb” and thus, a surgical approach is often undertaken. While open surgical or percutaneous closure are the available treatment options, mortality rates are very high even with surgical treatment. This case was an example of a rare case giant left ventricular pseudoaneurysm that survive in first year of high mortality rate. Keywords left ventricular pseudoaneurysm • giant pseudoaneurysm • atypical chest pain • high mortality rate C.41. Intravascular Ultrasound Guided Wiring in Chronic Total Occlusion Intervention Nay Thu Win Nay Thu Win Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia Teh Khai Chih Teh Khai Chih Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia Azmee Mohd Ghazi Azmee Mohd Ghazi Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia Azhari Rosman Azhari Rosman Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia Department of Cardiology, National Heart Institute, Kuala Lumpur, Malaysia Case Illustration: A 62 years old gentleman, presented with sudden onset central chest pain and radiated to left shoulder. ECG showed STE at V2-V4. Troponin T was raised (>1000 ng/ml). He was treated as missed myocardial infarction and referred to our center. Discussion: We proceeded for coronary angiogram via right femoral approach, showed normal left main, total occlusion of LAD distal to second diagonal, mild disease of LCX and mild disease of RCA. We proceeded for coronary angioplasty to left anterior descending. We used EBU 3.5 6F guiding catheter and Runthrough floppy wired to LAD with balloon support. We cross the CTO distally. Then we predilated the LAD with semi-compliant 2.5x10mm balloon. After predilatation, there was no flow down to LAD and patient developed chest pain and blood pressure dropped to 70/40 mmHg. We stabilized the patient accordingly. Hence, IVUS showed distal wire was in subintimal space and intimal hematoma. We keep the IVUS catheter at the entry site of wire then advanced second wire, CROSS-IT 200, parallel to IVUS catheter, which successfully cross lesion. The microcatheter - Corsair was then placed at the distal LAD and contrast was injected gently to confirm the position of wire, which later proved to be a true lumen. Subsequently, we predilated LAD with scoring balloon scoreflex 2.5x35 mm serially from distal to proximal lesion. We deployed drug coated balloon Sequent Please Neo 2.25x35mm to distal LAD and Resolute Onyx 3.0x38 to mid LAD. Then postdilation was done with SAPPHIRE NC 3.25x15 mm. Conclusion: Wiring to cross the lesion is the most challenging part of CTO intervention. Despite the risk of larger false lumen while advancing the IVUS catheter into subintimal space, the wire was successfully crossed the lesion under IVUS guidance buddy wire technique. Keywords Intravascular ultrasound • chronic total occlusion • Subintimal wiring • buddy wire. C.42. Determinant Factors of Residual Ischemia of ST Elevation Myocardial Infarction (STEMI) Patients Undergoing Fibrinolysis in Tidar General Hospital Magelang Bintang K Prabowo Bintang K Prabowo Department of Cardiology and Vascular Medicine, Tidar General Hospital Magelang Nurhayadi A Sulistyo Nurhayadi A Sulistyo Department of Cardiology and Vascular Medicine, Tidar General Hospital Magelang Sudiyoko Sudiyoko Department of Cardiology and Vascular Medicine, Tidar General Hospital Magelang Daniel Sukmadja Daniel Sukmadja Department of Cardiology and Vascular Medicine, Tidar General Hospital Magelang Department of Cardiology and Vascular Medicine, Tidar General Hospital Magelang Background: The ability to predict the risk of an adverse outcome is important in clinical decision making and for risk adjustment when assessing quality of care. One of the adverse outcome in myocardial infarction is residual ischemia which can be evaluated using Treadmill Test. Objective: This study aim to determine factors of residual ischemia among patients with STEMI treated with fibrinolysis. Method: In this retrospective study, we obtained the data from medical records of patients diagnosed with STEMI from January 2017 till December 2018 treated with fibrinolysis and undergone Bruce-protocol Treadmill Test. A total of 30 patients were divided into two groups according to the incidence of residual ischemia based on treadmill test result. The univariate relationship analysis between baseline characteristic and residual ischemia event were assessed with Chi-Square. Statistical significance defined by p < 0.05. Result: A total of 30 patients (mean age 52.43±8.27 years, male gender 96.7%) with STEMI following fibrinolysis were included. The mean age of residual ischemia and non-residual ischemia group was 48.92±8.13 and 54.78±7.71 years, respectively. The residual ischemia rate was found to be 40% in this study population. In the univariate analysis we found that history of hypertension (OR: 1.4; 95%CI: 0.3-6.1; p = 0.471), LDL level (OR: 3; 95%CI: 0.4-20.32; p = 0.143), and smoking (OR: 2.2; 95%CI: 0.2-24.08; p = 0.469) shows a positive association but had no statistically significance correlation with residual ischemia incidence. Conclusion: History of hypertension, LDL level, and smoking shows a positive association but had no statistically significant odd ratio in predicting residual ischemia incidence. Keywords Myocardial Infarction • Residual Ischemia • Fibrinolysis C.43. Concomitant Fascicular Ventricular Tachycardia and Total Atrioventricular Block in Mitral Valve Prolapse Syndrome – A Therapeutic Challenge and Dilemma Alexander E Tondas Alexander E Tondas Department of Cardiology and Vascular Medicine, Dr. Mohammad Hoesin Hospital, Palembang, Indonesia Mangiring L Toruan Mangiring L Toruan Department of Cardiology and Vascular Medicine, Dr. Mohammad Hoesin Hospital, Palembang, Indonesia Rolando A Halim Rolando A Halim Department of Cardiology and Vascular Medicine, Dr. Mohammad Hoesin Hospital, Palembang, Indonesia Fredy Tandri Fredy Tandri Department of Cardiology and Vascular Medicine, Dr. Mohammad Hoesin Hospital, Palembang, Indonesia Department of Cardiology and Vascular Medicine, Dr. Mohammad Hoesin Hospital, Palembang, Indonesia Case Illustration: A 25-year-old male came with dyspnea on effort and repeated presyncopal episodes since one month before admission. Moderate to severe mitral regurgitation due to anterior mitral leaflet prolapse and reduced ejection fraction of 43% were detected from echocardiography. Negative cardiac troponin level excluded possibility of ongoing acute coronary syndrome or carditis. ECG recording showed total AV block (TAVB) with junctional escape (Figure 1) as basic rhythm. During palpitations, serial ECGs showed relatively narrow QRS (120-140 ms) tachycardias with right bundle branch block pattern and alternating inferior-superior axis (Figure 1). C.43. Figure 1 Open in new tabDownload slide First ECG demonstrates TAVB with Multifocal PVC (A). Second ECG demonstrates fasicular VT with Inferior Axis (B) and Superior Axis (C) C.43. Figure 1 Open in new tabDownload slide First ECG demonstrates TAVB with Multifocal PVC (A). Second ECG demonstrates fasicular VT with Inferior Axis (B) and Superior Axis (C) AV dissociation during electrophysiology study confirmed both tachycardias as ventricular in origin with at least two reentry circuits. However, mapping of purkinje potential as ablation target was hindered by ventricular asystole that sometimes followed after intermittent fascicular ventricular tachycardias (VT), therefore we decided to end procedure and placed a temporary pacemaker. Later, a dual chamber permanent pacemaker was implanted, and patient was discharged with optimized heart failure medication using ACE inhibitor and diuretics. Fascicular VT episodes seemed to be supressed quite well by verapamil. Catheter ablation maybe reattempted, preferably with 3 dimensional mapping in case of recurrence. Discussion: Apart from refractory VT and associated sudden cardiac death in mitral valve prolapse (MVP), conduction disorders such as sinus node dysfunction, dual AV physiology, and around 12% of second or third degree atrioventricular block had also been demonstrated. Rare association of conduction disorders and MVP is sometimes forgotten in clinical practice. Although still unclear, etiology was thought to be related to a more extensive fibrosis of mitral valve. Meanwhile, fascicular VTs are usually verapamil sensitive and amenable to catheter ablation. Conclusion: To best of our knowledge, this is very first reported case of simultaneous TAVB and fascicular VT in MVP syndrome. Keywords Mitral Valve Prolapse • TAVB • Fascicular VT • Verapamil Sensivity C.44. Insertion Of Preoperative Temporary Pacemaker Through Subclavian Vein Access (Case Report) Taufieq Ridlo Makhmud Taufieq Ridlo Makhmud Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia Sasmojo Widito Sasmojo Widito Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, Indonesia Case Illustration: A woman, 29-years-old, 1 week post cesarean delivery was diagnosed with tubo-ovarial abscess and planned elective laparotomy. At preoperative examination, her heart rate was 40 times/minute, blood pressure was 100/60 mmHg, with ECG image of total AV block. Rhythm abnormalities were suspected due to peripartum cardiomyopathy based on the history of shortness of breath since the last month of pregnancy. Chest X-ray showed cardiomegaly and echocardiography showed impaired left ventricular diastolic function. A 77-year-old male with stable coronary artery disease (CAD) and diabetes mellitus was hospitalized because of gangrenous ulcer at pedis dextra. The patient was planned for surgical debridement and, if necessary, amputation. At preoperative examination, it was found a total AV block rhythm alternates to 1st degree AV block. Blood pressure was 130/80 mmHg, and heart rate 50-60 times/minute. Both patients were put on temporary pacemaker (TPM) before surgery through subclavian vein access. Subclavian veins were chosen to optimize surgery in the abdominal region and lower extremities. To minimize the risk of pneumothorax, contrast injection of the ipsilateral upper extremity vein was carried out before introducer sheath was inserted, and then evaluated using fluoroscopy. After then proceed with insertion of introducer sheath and bipolar lead TPM. There were no complications during insertion and post-insertion of TPM. After surgery, both patients were electively placed on a permanent pacemaker which also used subclavian vein access. Discussion: Total AV block was indication of TPM insertion in both patients. Subclavian vein access rarely being an option because of the risk of pneumothorax. However, in both patients, subclavian vein access was chosen prior to surgery because the femoral vein was potentially complicating the surgery, and the jugular vein were susceptible of changes in lead position and causing greater discomfort to the patient. Total AV block rhythm that persist after surgery was indication of permanent pacemaker insertion in both patients. Conclusion: Subclavian vein as an access of TPM lead insertion is fairly safe and effective option in patients with total AV block who will undergo surgery in the abdominal region or lower extremity. Keywords preoperative temporary pacemaker • subclavian vein • total AV block C.45. Anticoagulant Strategies for Pregnant Patient With Double Mechanical Heart Valve: A Case Report Rahma N Amalisa Rahma N Amalisa General Hospital, Nganjuk, Indonesia Yanuar W Wardana, Nupriyanto Yanuar W Wardana, Nupriyanto General Hospital, Nganjuk, Indonesia General Hospital, Nganjuk, Indonesia Case Illustration: Pregnancy in women with double mechanical heart valves is a rare condition. Pregnancy is a hypercoagulable state that predisposes to thrombosis and optimal use anticoagulants for pregnant women with prosthetic heart valves are still controversial. Anticoagulation management of these patients can be challenging because both oral anticoagulants and heparins may be associated with important maternal and fetal complications. There are no available controlled clinical trials to provide guidelines for effective anticoagulant therapy. Discussion: We reported the case of a 27 years old pregnant woman who had undergone mitral and aortic valve replacement surgery. During the first trimester of pregnancy, Low Molecular Weight Heparin (LMWH) Enoxaparin was given subcutaneously and switched over to Warfarin on the second trimester. Warfarin was re-switched over to LMWH at 36 weeks until the baby born by cesarean section. After delivery, warfarin was started on the usual dose. International Normalized Ratio (INR) was monitored every two weeks with a target range of 2.5-3.5 INR. The results of management anticoagulants that have been done are obtained as a good outcome for the mother and two children who have been born. In the first child, there were no abnormalities in growth and development. The second child who has just been born has no signs of embryopathy. Conclusion: It was found that the use of warfarin was effective enough to prevent the occurrence of either thromboembolism in the mother or embryopathy effect in the fetus if given in doses less than 5 mg per day, and very safe if given above the first trimester and the use of LMWH can be used as an alternative for first trimester and preparation labor. Keywords mechanical heart valve • anticoagulant • warfarin • low molecular weight heparin • pregnancy C.46. Fetal Primary Cardiac Tumor: A Very Rare Case with Dilemmatic Approach V Gerry, Kino V Gerry, Kino Department of Cardiology & Vascular Medicine, Andalas University, RSUP Dr M Djamil Padang H Didik H Didik Department of Cardiology & Vascular Medicine, Andalas University, RSUP Dr M Djamil Padang Masrul Syafri Masrul Syafri Department of Cardiology & Vascular Medicine, Andalas University, RSUP Dr M Djamil Padang Muhammad Syukri Muhammad Syukri Department of Cardiology & Vascular Medicine, Andalas University, RSUP Dr M Djamil Padang Department of Cardiology & Vascular Medicine, Andalas University, RSUP Dr M Djamil Padang Case Illustration: A 27-years old female been admitted to outpatient clinic with a mass had been found in her fetal. It had been diagnosed as intra cardiac mass in 27-28 weeks pregnancy. Ultrasonography revealed a mass in intracardiac chamber since 20 weeks pregnant and gradually getting bigger. There was no family history of cardiac tumor. We found mass in intracardiac chamber from echo fetomaternal, the mass attached to AML, filling until apical LV with diameter 12x22 mm (22mm2), without LVOT obstruction. Serial echo after delivery was found multiple masses attached to RV, LV and RA, ASD, PDA without LVOT obstruction. We diagnosed patient as multiple cardiac primary tumor. Patient discharged after 7 days of hospitalization with stable condition. Discussion: This patient fulfilled the criteria of FCPTs. The mechanism of FCPTs was still unknown, and it can be benign and malignant. The incidence of this case the occurrence in a study of infants and children revealed a prevalence of 0.027 % in 11.000 autopsies. Diagnosis of FPCTs based on echocardiography. It was rarely found because patient barely had symptom in mother or fetus, it may cause intracardiac flow obstruction, heart valve insufficiency, arrhythmia, heart failure, and hydrops fetalis, or even fetal death. Cardiomegaly and pericardial effusions are the most common echocardiographic findings of FPCTs. The treatment still in debatable, and pregnancy should be continued as long as possible if there are no severe complications. In this case, we have to evaluate the size of the mass and symptom that can be occurred in this patient. Conclusion: We described a case with diagnosed Fetal Primary Cardiac Tumor. FPCTs are incidentally very rare and most cases are benign, but may cause a series of cardiovascular events. Echocardiography plays an important role in the prenatal diagnosis of tumors. Options treatment depending on the actual fetal conditions with the intention improvement of cardiac function with prolonged life expectancy. Keywords Fetal primary cardiac tumor • cardiac neoplasm C.47. Cryptogenic Stroke in Young Age Queen S Ariyani Queen S Ariyani Faculty of Medicine Universitas Gadjah Mada, Yogyakarta Michael Susanto Michael Susanto Faculty of Medicine Universitas Pelita Harapan, Tangerang Ingrid M Pardede Ingrid M Pardede Faculty of Medicine Universitas Pelita Harapan, Tangerang Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Sunanto Ng Sunanto Ng Faculty of Medicine Universitas Pelita Harapan, Tangerang Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Faculty of Medicine Universitas Gadjah Mada, Yogyakarta Faculty of Medicine Universitas Pelita Harapan, Tangerang Department of Cardiology Siloam Hospital Lippo Village, Tangerang, Indonesia Case Illustration: A 14-year old male presented to the emergency department with right hemiparesis, facial palsy, and motoric aphasia since 3 hours before hospital admission. ECG was normal. Magnetic resonance imaging (MRI) revealed infarct in the left temporal region and stenosis in the middle cerebral artery. The patient was started on antiplatelets and a cardiologist was consulted for further investigations. Transthoracal echocardiography (TTE) revealed a small shunt in the atrium. Transesophageal echocardiography (TEE) confirmed a type I patent foramen ovale (PFO) with left-to-right shunt. No thrombus was seen in left atrial appendage, left atrium, or interatrial septum. No vegetation was found. Three weeks after, laboratory measure revealed positive result for Protein C and S deficiency with hypo-aggregation of platelet. Discussion: Patent foramen ovale (PFO) refers to a non-closure of potential space between the septum primum and secundum that allows for inter-atrial communication. PFOs are usually asymptomatic. However, additional disorders of coagulation may lead to a hypercoagulable state and contribute to a symptomatic PFO. In this case, a PFO with protein C and S deficiency was responsible for causing a non-hemorrhagic stroke in a young patient. Conclusion: The combined pathology of PFO, and protein C and S deficiency in a single patient may contribute to a greater risk of non-haemorrhagic stroke in a young patient. Keywords Patent Foramen Ovale • Protein C deficiency • Protein S deficiency • Non Hemorrhagic Stroke C.48. Rheumatic Heart Disease and Acute Glomerulonephritis Post Streptococcal Coexistence : Four Case Report P R Indrisia P R Indrisia Tangerang General Hospital A I Nurudinulloh A I Nurudinulloh Tangerang General Hospital D A Putra D A Putra Tangerang General Hospital S E Nauli S E Nauli Department of Cardiology and Vascular Medicine, Tangerang General Hospital H Priatna H Priatna Department of Cardiology and Vascular Medicine, Tangerang General Hospital P Rahasto P Rahasto Department of Cardiology and Vascular Medicine, Tangerang General Hospital Tangerang General Hospital Department of Cardiology and Vascular Medicine, Tangerang General Hospital Case Illustrations Case 1: A 20 moths old boy was admitted to E.D with chief complaint dyspneu and oedema 2 days prior to admission. It was followed by swollen in the eyes, face, feets, and “dark tea” –like urine. Physical examination found hypertention (83/55 mmHg), rales, gallop, hepatomegaly, and pitting oedema. Laboratory findings showed anemia, hematuria, ASTO +200. Echocardiography showed EF 28%, MR Moderate, TR Mild. Case 2: A 13 y.o girl was admitted to E.D with chief complaint swollen in the face and legs. It was followed by PND and DOE. Physical examination showed hypertention (130/95 mmHg), rales, and pansystolic murmur, ascites, and oedema. Laboratory findings showed hematuria, ASTO +200. Echocardiography showed EF 35%, LV Global Hypokinetic, Minimal pericardial effusion, TR Moderate, and apical thrombus. Case 3: A 13 y.o boy was admitted to E.D with chief complaint swollen eyes and face. It was followed by PND and DOE. Physical examination found hypertention (180/120 mmHg), rales, gallop, and pitting oedema. Laboratory findings showed hematuria, ASTO +200. Echocardiopraphy showed EF 66%, minimal pericardial effusion, and normal leaflet. Case 4: A 8 y.o girl was admitted to E.D with chief complaint swollen face. It was followed by “dark tea” –like urine, PND and DOE were denied. Physical examination found hypertension (120/80 mmHg), normal heart sound, ascites, and pitting oedema. Laboratory showed hematuria, ASTO +200. Echocardiography showed EF 25%, global hypokinetic, MR Mild, TR MIlad, and minimal pericardial effusion. Discussion: This patients fulfilled criteria for Rheumatic Heart Disease (RHD) and acute glomerulonephritis post streptococcal infection (AGNPS). They are associated with group A Streptococcal infection from different strain, but rarely found coexistence. It was not sure from different strain or same strain Conclusion: RHD coexistence with AGNPS is a rare condition. Further investigation is needed to analyse if the coexistence from different strain or same strain. Keywords rheumatic heart disease • acute glomerulonephritis post streptococcal infection. C.49. Case Report : Acute Upper and Lower Limb Ischemia as Complication of Hypereosinophilic Syndrome Muhammad A Basith Muhammad A Basith Cardiology and Vascular Medicine Department, Gadjah Mada University / Sardjito General Hospital, Yogyakarta Vita Y Anggraeni Vita Y Anggraeni Cardiology and Vascular Medicine Department, Gadjah Mada University / Sardjito General Hospital, Yogyakarta Cardiology and Vascular Medicine Department, Gadjah Mada University / Sardjito General Hospital, Yogyakarta Case Illustration: A 40-years old male was referred to ER for further management of Acute Limb Ischemia (ALI). 6 days before admission, patient complained pale and limp in both lower extremities. Physical examination showed hypertension (149/101 mmHg), pain, poikilothermia, paraesthesia and pulseless in lower extremities. Percutaneus Intra Arterial Thrombolysis (PIAT) was done in upper and lower extremity but failed. Amputation was done in both lower extremities, 4th finger of right hand, and 2nd finger of left hand. Lab results showed eosinophil 14.1% (2,463 cells/mm3), eosinophilia absolute 185/ul, blood smear show myelodysplastic syndrome leads to the diagnosis of hypereosinophilic syndrome (HES) Discussion: PIAT was performed in upper and lower extremity. The failure of this PIAT can be made possible by poor management of eosinophilia (14.1%). Thrombotic occlusion is the most common cause of acute ischemic limbs. Impaired balance between the mechanism of prothrombosis and antithrombosis can lead to easy thrombus formation. This hemostasis disorder is referred as a hypercoagulation condition. Blood smear examination has been done with the results of Myelodysplastic syndrome leads to the diagnosis of HES. Environmental factors like myelodysplastic disease are one of the trigger factors for atherothrombosis like ischemia. Conclusion: Tracking causes of ALI must be comprehensively including causes such as HES which can cause hypercoagubility Keywords Upper and lower limb ischemia • hypercoagubility • HES C.50. Out-of-Hospital Cardiac Arrest, It Can Be Saved! A Case Report Mirza T Hapsito Mirza T Hapsito Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya – Saiful Anwar General Hospital, Malang East Java Djanggan Sargowo Djanggan Sargowo Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya – Saiful Anwar General Hospital, Malang East Java Case illustration: A 65-year-old man suddenly collapsed in public area. People nearby immediately brought him to the emergency department. Early cardiopulmonary resuscitation (CPR) was performed, electrocardiography (ECG) showed ventricular fibrillation (VF). A defibrillation then delivered. Patient was return of spontaneous circulation (ROSC). ECG after ROSC showed ST-segment depression, therefore patient was sent to catheterization laboratory. Angiography was performed and showed critical stenosis at the left main trunk. After successful percutaneous coronary intervention, patient was stabilized at cardiac intensive care unit. Patient was then discharged after six days with good functional class and without any neurologic deficits. C.50. Fig A Open in new tabDownload slide Electrocardiography at arrival. C.50. Fig A Open in new tabDownload slide Electrocardiography at arrival. C.50. Figure C Open in new tabDownload slide Angiographic view before PCI. C.50. Figure C Open in new tabDownload slide Angiographic view before PCI. C.50. Figure D Open in new tabDownload slide Angiographic after PCI. C.50. Figure D Open in new tabDownload slide Angiographic after PCI. Discussion: Sudden cardiac arrest occurs worldwide each year and has low survival rates. To improve outcomes of patients after cardiac arrest, the American Heart Association promotes the concept of chain of survival and mass media campaign targeting community’s awareness. Early coronary angiography is associated with increased survival to discharge and favourable neurological outcome for the out-of-hospital cardiac arrest survivors. Conclusion: We reported a case of patient who suddenly collapsed at public area. Public awareness and prompt implementation of chain of survival along with angiography resulted in good outcome for the patient. Keywords Out-of-hospital cardiac arrest • chain of survival • public awareness • early angiography C.51. Acute Coronary Syndrome in Young Age, Is It a New Trend? A Case Series Febrina Febrina Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia M Febrianora M Febrianora Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Erwinanto Erwinanto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjajaran University, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Case Illustration Case 1: a 40 years old man came to emergency with typical chest pain. The risk factor was solely a high cholesterol level. The ECG showed dynamic ST-T changes at the anteroseptoapical wall. Patient was diagnosed with Unstable Angina Pectoris and sent to the cathlab. From the angiography we found 2VD and placed 3 DES at LCx. Case 2: a 28 years old woman referred from other hospital with STEMI inferior to get the PCI. She had hypertension for the past one year. In addition, she had history using oral contraception for 9 years. The ECG resulted STEMI inferoposterior and right ventricle wall. The angiography showed 1VD and stented with 1 DES at proximal–mid RCA. Case 3: a 22 years old man diagnosed with nephrotic syndrome for the last 12 years got complaint a typical chest pain. The ECG showed STEMI inferoposterior. He was on medication of prednisone for the last 4 months. The patient underwent primary PCI for 1VD and successfully placed 2 overlap BAS TITAN at distal RCA-proximal RPL branch. Discussion: In the first case, the risk factor was only dyslipidemia. While the second one has additional precipitating factor namely history of using the oral contraceptive. The last case was a patient with hypercoagulable state resulted from nephrotic syndrome. The role of novel risk factors in those patients was unclear but we found that a traditional risk factor was presented among them. Conclusion: Coronary heart disease in young age is a new trend. Thus further investigation towards this phenomenon is needed. Keywords Acute coronary syndrome • young • risk factor C.52. Giant Left and Right Hypertrophy Cardiomyopathy with Compressed Ventricular Cavities in Infant Johan Senihardja Johan Senihardja Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Diyantie Saputri Diyantie Saputri Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Fanny F Abdullah Fanny F Abdullah Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Agrietia Agrietia Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Fonny Wijaya Fonny Wijaya Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Rifky Rifky Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Department of Cardiology and Vascular Medicine, Tasik Medika Citratama Hospital, Tasikmalaya Case Illustration: A 4 months infant was referred to our hospital with chief complaint of shortness of breath. The baby was born with normal delivery at 39 weeks, P5A0. The baby did not cry right after delivery, but gradually to be normal after about 15 minutes later. There was no history of maternal gestational diabetes. Heart rate was 100x/minute. Physical examination showed cleared lung field and a loud systolic murmur at left parasternal border. Oxygen saturation was 91%. A chest x-ray shown cardiomegaly (figure 1). The echocardiography examination revealed giant right and left hypertrophy with compressed ventricular cavities (figure 2). The left ventricular end-diastolic dimension was 12 mm (normal, 20 mm), and the end-systolic dimension was 5 mm (normal, 13 mm). The IVSd was 19 mm (normal, 3.5 mm). There was dynamic gradient along LVOT with pressure 20-34 mmHg. Discussion: Hypertrophy Cardiomyopathy (HCM) in newborn is a very rare case. Study by Steven D. showed that annual incidence of Idiopathic HCM <1 year of age was 21 per 1.000.000 birth cases(1). The therapy for this patient is adequate volume status and beta blockers. While, the surgery has not given the good result. We did follow up 2 months later, but unfortunately the patient had passed away. C.52. Figure. c Open in new tabDownload slide hest x-ray (a) and echocardiography examination at diastole (b) and systole (c) C.52. Figure. c Open in new tabDownload slide hest x-ray (a) and echocardiography examination at diastole (b) and systole (c) Conclusion: Here, we reported one of the rare cases of pediatric cardiology about giant hypertrophy cardiomyopathy in newborn. Even though the mortality rate of severe HCM in newborn is high, early screening by chest x-ray might be helpful to improve survival rate in the future. Keywords hypertrophy cardiomyopathy • pediatric cardiology C.53. Five Years Follow up on 1st Hybrid Coronary Revascularization Patient in Indonesia Todung Silalahi Todung Silalahi Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, and Faculty of Medicine, Universitas Kristen Krida Wacana Ismail Dilawar Ismail Dilawar Department of Cardiothoracic Surgery, Jakarta Heart Center Hospital, Jakarta Andreas M Siborutorop Andreas M Siborutorop Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, and Faculty of Medicine, Universitas Kristen Krida Wacana Simon Salim Simon Salim Division of Cardiology, Department of Internal Medicine, University of Indonesia, Jakarta Division of Cardiovascular, Department of Internal Medicine, Jakarta Heart Center Hospital, Jakarta, and Faculty of Medicine, Universitas Kristen Krida Wacana Department of Cardiothoracic Surgery, Jakarta Heart Center Hospital, Jakarta Division of Cardiology, Department of Internal Medicine, University of Indonesia, Jakarta Background: Hybrid Coronary Revascularitzation (HCR) procedures introduced in 2011 by the American Heart Association/ American College of Cardiology Foundation updated guidelines for coronary artery bypass grafting (CABG) surgery1, combine the superiority of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) revascularization2,3 with percutaneous coronary intervention (PCI) by means of drug-eluting stents (DES) for non-LAD vessels.4 Various minimally invasive surgical approaches are used to perform LIMA to LAD graft.5 The advantages of this procedures is no need for open heart surgery, off pump surgery, less pain, easier and faster recovery, shorter hospital stay, lower risk of infection, minimal scarring and decrease blood clots6. In Indonesia, the 1st case was done in Jakarta Heart Center (JHC) in 2013. We report the follow up of this 1st patient 5 years after the procedure. Case: A 63 years old man with Diabetes Mellitus, Hypertension, come with chest pain. His coronary lesion was 3 Vessel Disease + Left Main Disease (SYNTAX Score <22). After discussion with the patient, we perform hybrid revascularization grafting with LIMA to LAD then PCI DES into the LM to LCX, and PCI DES into the Proximal and Distal RCA and within the same day. The procedure took 15 minutes flouro time for PCI and 150 minutes for grafting. Patient was safely discharged after 5 days. Recent follow up of after 5 years, the patients showed good grafting LIMA-LAD and below 30% ISR by Quantitative cumulative angiography. Discussion: Hybrid coronary revascularization procedure has been accepted as the one of the intervention modality for coronary artery disease (CAD), that combining the most effective therapeutic methods of cardiovascular surgery and interventional cardiology in order to perform a functionally complete revascularization, with one of the main benefit is the procedure does not need heart paralyzsation (off pump surgery)7. The decision of doing hybrid coronary revascularization is based on several consideration, such as no need for open hearth surgery, off pump surgery, less pain, easier and faster recovery, shorter hospital stay, lower risk of infection, minimal scarring and decrease blood clots. Our patient is diabetic with 3 Vessel Disease + Left Main Disease, which will benefit from faster recovery and lower risk of infection. Several reports showed a good patency and patients remain symptoms free for 5 years8. Our patient also remains symptoms free and good patency for 5 years follow up after the procedure. Conclusions: Hybrid coronary revascularization is safe and reduce hospitalization. The 1st patient did not have any complication and have good 5 years outcome. Keywords Hybrid Coronary Intervention • PCI • MID-CAB C.54. Pseudo Obstruction and Acute ST Segment Elevation in Inflammatory Bowel Disease, What Is The Possibility ? F S Hasibuan F S Hasibuan Department of Cardiovascular, Dr. R. Koesma General Hospital, Tuban, East Java H R T Wilujeng H R T Wilujeng Department of Radiology, Dr. R. Koesma General Hospital, Tuban, East Java T N Octora T N Octora Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia R E Intan R E Intan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Department of Cardiovascular, Dr. R. Koesma General Hospital, Tuban, East Java Department of Radiology, Dr. R. Koesma General Hospital, Tuban, East Java Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Case Illustration: A 50 years old man came to ER with frequent mucous diarrhea, abdominal cramp for few days, which evolve to abdominal distention and billous vomit. Vital sign was normal, while abdomen distended. BOF, USG abdomen indicate high partial obstruction. Laparotomy was planned, however just before started, his ecg showed ST elevation at anterior and inferior lead, along with chest pain with raised CKMb, He was diagnosed as STEMI. Trombolytic was given while the surgery withhold. Surprisingly, post trombolytic the ECG showed even more diffused ST elevation with >10 mm with “shark fin” like appearance in precordial (Figure1). TTE showed modearate pericardial effusion with normal LV function, supporting acute pericarditis. Colcichin ,MP, and antibiotic was started for conservative therapy, and the ECG showed rapid resolution and progressive change back to normal baseline. Interestingly, his abdomen symptoms also resolved after the therapy. CT scan later result support the diagnosis of pericarditis and enteritis(Figure2a,b), as IBD is one of the differential diagnosis. Discussion: ST-elevation in IBD can have multiple causes. Pericarditis has been uncommonly reported as an extraintestinal disease manifestation. The etiology is unknown, with some hypothesis include autoinflammatory mediated and C.Jejuni associated pericarditis. Other possibly mechanism is giant J waves and ST-segment elevation associated with acute gastric distension. Conclusion: Eventhou rare, pericarditis should always be considered as differential diagnosis in acute chest pain and ST segment ECG changes in IBD patient. CT scan and TTE is simple diagnostic tool that important to differ the diagnosis. In case of pericarditis, first line therapy in IBD patients are corticosteroids combine with colchicines. C.54. Figure 1 Open in new tabDownload slide ECG post trombolytic showed diffused ST elevation. C.54. Figure 1 Open in new tabDownload slide ECG post trombolytic showed diffused ST elevation. C.54. Figure 2 Open in new tabDownload slide A. CT scan of the heart showed enhance pericardium. B. Mucosal thickening of enteritis C.54. Figure 2 Open in new tabDownload slide A. CT scan of the heart showed enhance pericardium. B. Mucosal thickening of enteritis Keywords ST elevation • pericarditis • pseudo-obstruction • IBD • C.Jejuni C.55. Histamine-2 Receptor Antagonist Induced Malignant Arrhythmia in Long QT Syndrome Patient A Akbar A Akbar Hasna Medika Cardiovascular Hospital, East Palimanan, Cirebon, West Java, Indonesia D Friadi D Friadi Hasna Medika Cardiovascular Hospital, East Palimanan, Cirebon, West Java, Indonesia G I Hadiyat G I Hadiyat Hasna Medika Cardiovascular Hospital, East Palimanan, Cirebon, West Java, Indonesia Hasna Medika Cardiovascular Hospital, East Palimanan, Cirebon, West Java, Indonesia Case Illustration: A 30 year old woman was referred to our emergency department after having two short-lasting episodes of unconsciousness and apnea which were witnessed by family member. Local clinic electrocardiogram (ECG) recording showed a non-sustained polymorphic ventricular tachycardia (VT). She claimed to have experienced these complaints after ingesting ranitidine syrup the previous day. On arrival, she was awake but pale and had several episodes of non-sustained polymorphic VT. Intravenous magnesium sulfate was administrated and non-sustained polymorphic VT was stopped. ECG showed prolonged corrected QT interval with 653 msec after conversion to sinus (suggestive of Long QT Syndrome). Laboratory investigation showed normal electrolyte levels except for a slight hypocalcemia which was corrected. She had a prior family history of sudden cardiac death. Propranolol 20 mg three times daily was given at the time of her discharge from the hospital. After a 2 month outpatient clinic follow up, her ECG showed shortening of corrected QT interval. Since then, she has been well with no subsequent recurrence of the problem. Discussion: Long QT Syndrome (LQTS) is a cardiac disorder caused by abnormally prolonged ventricular repolarization due to defects in cardiac sodium and potassium channels. It is characterized by prolongation of the QT interval in an ECG, and has the propensity to develop torsades de pointes or VT which frequently leads to syncope or cardiac arrest. Conclusion: Analyzing the ECG and calculating corrected QT interval still remain relevant as one of the mainstay diagnostic tool. Acute treatment with intravenous magnesium sulfate in patient with recurrent non-sustained polymorphic VT successfully converted the rhythm into sinus. Several histamie-2 receptor antagonist has been linked to cause arrhythmia, however to our knowledge, there has been no previous report about ranitidine inducing arrhythmia in LQTS. Beta blocker (propranolol) is effective in shortening QT interval for this patient. Keywords long QT syndrome • magnesium sulfate • beta blocker • histamine-2 receptor antagonist C.56. Effusive-Constrictive Pericarditis due to Tuberculosis Pericarditis Diza K Mukhlisah Diza K Mukhlisah Department of Cardiology and Vascular Medicine, Hasanuddin University, South Sulawesi, Indonesia Levina T Ratana Levina T Ratana Department of Cardiology and Vascular Medicine, Hasanuddin University, South Sulawesi, Indonesia Aussie F Ghaznawie Aussie F Ghaznawie Department of Cardiology and Vascular Medicine, Hasanuddin University, South Sulawesi, Indonesia Akhtar F Muzakkir Akhtar F Muzakkir Department of Cardiology and Vascular Medicine, Hasanuddin University, South Sulawesi, Indonesia Department of Cardiology and Vascular Medicine, Hasanuddin University, South Sulawesi, Indonesia Case Illustration: A 39-year-old male came with chief complaint of dyspnea on effort and mild cough for 3 weeks. Transthoracic echocardiography showed a massive pericardial effusion without signs of impending tamponade. The patient’s sputum revealed negative for culture and acid-fast bacilli (AFB) smear. Pericardiocentesis and tapping was performed with a total of 2200 mL. Analysis of pericardial fluid showed exudative with negative culture, AFB smear, and PCR for MTB. A control echocardiography result was: EF 35.9%, normal chamber dimensions, global hypokinesia (global circumferential strain:13.0%, global longitudinal strain:-13.6%), severe diastolic dysfunction, lateral e’ 13.2, medial e’ 17.3, with a conclusion of constrictive physiology. Chest CT scan showed pericardial thickening. Viral markers and autoantibodies were negative. There were no history of chest trauma, radiation exposure, malignancy or surgery and no signs of connective tissue disorders. A follow up of a month later, echocardiography control revealed a massive pericardial effusion without evidence of tamponade. Pericardiocentesis and tapping was performed with a total of 1100 mL of serous fluid. Other laboratory tests were normal. Pericardial fluid was examined using GenExpert assay. Discussion: This patient fulfilled criteria for Constrictive Pericarditis due to extrapulmonary TB which was proofed by GeneXpert MTB/RIF assay of pericardial fluid detected MTB and sensitive to RIF. The patient was treated with oral anti tuberculosis fixed drug combination. Conclusion: We describe a rare case of effusive-constrictive pericarditis due to MTB which was diagnosed by GeneXpert assay. The assay is helpful for diagnosing when there is no proof of TB elsewhere with unexplained pericardial effusion. Keywords constrictive pericarditis • tuberculosis • pericardial effusion • GeneXpert C.57. Neurocardiogenic Stunning: A Clinical Dilemma A Case Report on Patient with Subarachnoid Haemorrhage Indah Puspita Indah Puspita Department of Cardiology and Vascular Medicine, Mohammad Hoesin General Hospital, Palembang, Indonesia Department of Cardiology and Vascular Medicine, Mohammad Hoesin General Hospital, Palembang, Indonesia Case Illustration: This case was observed in March 2019. A sixty-two-year-old woman was loss of consciousness since 3 days before admission to emergency unit. The symptom was initiated by first episode of severe headache, followed by vomit and defect on lips position. She was known to have hypertension for 15 years and not well treated. Discussion: Neurocardiogenic stunning (NCS) remain clinical chalange to be diagnosed and treated. NCS occurs in 20% to 30% cases of patients with subarachnoid hemorrhage (SAH). Clinical signs of CNS was mimic acute coronary syndrome, such as electrocardiographic changes on ST-T segment and signs of left ventricular (LV) dysfunction. Patient’s examination revealed signs of spastic quadripharese and right vagal nerve pharese, cardiomegaly and stage I hypertension. Cranial CT-scan showed subarachnoid haemorrhage with vasogenic edema. Electrocardiography showed ST elevation in anterior segment with suspicion of LV aneurysm that confirmed by echocardiography examination that showed an apical ballooning of left ventricle. The patient was passed away in third day of hospitalization, due to cardiac pump failure. Conclusion: Clinical dilemma was made when patient need a permissive hypertensive state to reduce intracranial swelling, which will worse LV dysfunction. Intracranial aneurysmal identification for SAH etiology seems to be an important step, followed by aneurysm clipping, resulted on cessation of bleeding that will increase LV function. Keywords neurocardiogenic stunning • subarachnoid haemorrhage. C.58. Usefulness of IVUS for in-stent Re-stenosis After Previous Complex PCI – a Case Report Indah Sukmawati Indah Sukmawati Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Siloam Hospitals Lippo Village, Tangerang, Indonesia Sunanto Ng Sunanto Ng Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Siloam Hospitals Lippo Village, Tangerang, Indonesia Faculty of Medicine, University Pelita Harapan, Tangerang, Indonesia Siloam Hospitals Lippo Village, Tangerang, Indonesia Case Illustration and Discussion: A 50-year-old overweight, hypertensive and poorly controlled diabetic male with atypical chest pain. He had myocardial infarction in 2015 and primary PCI in RCA was done. Complete revascularization in 2016 with PCI LM-LAD (cross-over technique). Less than 2 years, patient felt chest pain, angiography showed new lesion in ostial LCX, stent was placed with Culotte technique. One year later, another chest pain, angiography showed subtotal ISR LCX and 70% ISR LAD, significant stenosis ostial D1 and patent stent RCA. Lesion prepped with balloon dilatation. IVUS showed ISR LAD minimum stent area (MSA) 4.1 mm2 and ISR LCX MSA 4.2 mm2, both underexpansion. Drug-eluting stent deployed in LAD and high-pressured post-stenting dilatation with non-compliance balloon was done. Bigger balloon was used to treat ISR in LCX. Kissing balloon dilatation done at bifurcation. IVUS and angiography displayed shifting plaque to LAD then dilated with high-pressured non-compliance balloon. Re-evaluation revealed plaque shifted to LCX and were dilated. IVUS showed LCX MSA 6.5 mm2 and LAD MSA 8.1 mm2. Final result, no residual stenosis, TIMI 2 flow managed with intracoronary nitroglycerin 100 mcg, MBG 3. In this case, IVUS proven to be an invaluable tool to help explain lesion etiology and to guide its management. Underexpansion can be well managed by using bigger balloon and high pressure inflation. Conclusion: We have reported a case of in-stent restenosis due to underexpansion which proven by IVUS and managed by expanding with bigger balloon. Keywords IVUS • in-stent restenosis • complex PCI • snow-plow effect C.59. Acute Heart Failure with Pericardial Effusion in Suspected Lupus Myocarditis Patient : A Case Report Alief Leisyah Alief Leisyah Public Bandung Hospital, West Java, Indonesia Dini Rostiati Dini Rostiati Public Bandung Hospital, West Java, Indonesia Public Bandung Hospital, West Java, Indonesia Case Illustration: A 28 years old woman admitted due to shortness of breath for 1 month and worsening for 1 week ago. Patient also complaint joint pain, fever and weight loss. Clinical examination revealed blood pressure was 90/60mmHg, heart rate was 146 bpm, respiratory rate was 36 per minute, body temperature 38 C, alopecia, pallor, malar rash, bilateral pulmonary rales, purpura in abdominal and extremities region and pretibial pitting edema. Chest radiography showed cardiomegaly, interstitial pulmonary edema, and pleural effusion (Fig. 1). Echocardiogram showed dilated left ventricular, left ventricular end-diastolic dimension/ end-systolic dimension (LVEDD/LVESD; 58/49 mm), global hypokinesia of LV with decreased ejection fraction (LVEF; 34%), and pericardial effusion (LV anterior wall; 1.0 cm (Fig. 2). Laboratories results were Hb 7.8 g/dl, leukocytes 5300/mm Ht 25%, Platelet count 123,000/mm. She was given methylprednisolone 250mg 2 times daily, furosemide 40mg, and digoxin 0,25mg intravenously once daily. The patient became hemodynamic unstable in 2 days after admitted, dobutamin 20mcg was given and had been referred to another hospital for further treatment. Discussion: In clinical studies, myocarditis has been identified in about 9% of patients with SLE. In our case, we could make a diagnosis as SLE based on the 1997 revised American College of Rheumatology (ACR) criteria for classification of SLE such as malar rash, lupus cutaneous, joint involvement, hemolytic anemia, lymphopenia, thrombocytopenia. Most myocarditis in SLE is asymptomatic but may be manifest with fever, dyspnea, palpitation. Therefore, the diagnosis of myocarditis in SLE depends largely on the clinical suspicion and echocardiographic findings. Echocardiographic findings in lupus myocarditis include decreased ejection fraction, increased chamber size, prolonged isovolumic relaxation time, decreased diastolic descent rate of the anterior mitral leaflet, decreased ratio of mean systolic velocity to mean diastolic velocity in the left ventricular posterior wall, decreased deceleration of early diastolic flow velocity and reduced E/A ratio, and atrial ejection force. Our patient met those criteria. Echocardiography revealed dilated LV, global hypokinesia of LV with decreased EF (34%), and pericardial effusion. Conclusions: Cardiac complication in SLE such as myocarditis accompanying with acute heart failure and pericardial effusion was a rare case and we must treated it carefully. C.59. Figure 1 Open in new tabDownload slide Chest X ray showed cardiomegaly C.59. Figure 1 Open in new tabDownload slide Chest X ray showed cardiomegaly C.59. Figure 2 Open in new tabDownload slide Echocardiography showed pericardial effusion, dilated LV and reduce EF C.59. Figure 2 Open in new tabDownload slide Echocardiography showed pericardial effusion, dilated LV and reduce EF Keywords Lupus • Myocarditis • Heart Failure C.60. Balloon Angioplasty As Adjunctive of Catheter-Directed Thrombolysis in Acute Limb Ischemia: When Should We Do? Ganda Wibowo Ganda Wibowo Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta M Taufik Ismail M Taufik Ismail Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Hariadi Hariawan Hariadi Hariawan Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Department of Cardiology and Vascular Medicine, School of Medicine, Gadjah Mada University, Yogyakarta Case Illustration: Female 54 year old admitted to emergency room with pain and cyanosis of right upper limb. She was diagnosed with acute right upper limb ischemia rutherford I and urgent angiogram was performed for achieving percutaneous revascularization. The angiogram showed total occlusion in right axillar artery. Guiding catheter JR 3.5/6 F was inserted via femoral artery and the tip of catheter advanced maximally to subclavian artery due to tortuosity of the subclavian artery. Intrathrombotic CDT therefore cannot be done in this situation, then we decided to cross the lesion and performed balloon angioplasty combined with administration of alteplase infusion for the next 24 hours. One day later, the angiogram evaluation showed no thrombus found in the axillary artery. The fingers was warm and have a good saturation with no bleeding was reported. Discussion: This patient fulfilled criteria for acute right upper limb ischemia rutherford I . Acute limb ischemia is mostly caused by thrombotic occlusion. The management of acute limb ischemia requires a thorough understanding of the anatomy of the arterial occlusion, and the management is catheter-directed thrombolysis (CDT) or surgical embolectomy. We report a case of 54 year old female who developed acute right upper limb ischemia and underwent endovascular revascularization CDT. Endovascular revascularization provides more rapid restoration of the blood flow compare with surgical embolectomy. However the technique remains challenging due to high rate of failed revascularization. Drug combined with mechanical revascularization is believed have higher successful revascularization. Conclusions: We describe a case with acute right upper limb ischemia rutherford I and urgent angiogram was performed for achieving percutaneous revascularization. Balloon angioplasty during Catheter-Directed Thrombolysis showed a good result as an adjunctive treatment of CDT especially if we cannot advance the catheter distally to the thrombus. Keywords balloon angioplasty • catheter-directed thrombolysis • acute limb ischemia • adjunctive treatment C.61. Late Development of Total Atrioventricular Block due to Exacerbation of Systemic Lupus Erythematosus at 32 Weeks Pregnancy: A Case Report Rio Alexsandro Rio Alexsandro Department of Biochemistry and Molecular Biology, School of Medicine, Tarumanagara University, Jakarta Maria P Inggriani Maria P Inggriani School of Medicine, Gadjah Mada University, Yogyakarta Rachelle Betsy Rachelle Betsy Department of Biochemistry and Molecular Biology, School of Medicine, Tarumanagara University, Jakarta P A D Kuntadi P A D Kuntadi Department of Cardiology and Vascular Medicine, Kariadi Hospital Grace Juniaty Grace Juniaty Department of Biochemistry and Molecular Biology, School of Medicine, Tarumanagara University, Jakarta Mustika Mahbubi Mustika Mahbubi Department of Cardiology and Vascular Medicine, Soewondo Hospital, Pati Department of Biochemistry and Molecular Biology, School of Medicine, Tarumanagara University, Jakarta School of Medicine, Gadjah Mada University, Yogyakarta Department of Cardiology and Vascular Medicine, Kariadi Hospital Department of Cardiology and Vascular Medicine, Soewondo Hospital, Pati Case illustration: We found a 39-year-old gravida 3, para 2 at 32 weeks of gestation coming to our hospital with none of common features of SLE. She came due to imminent preterm labor with history of stillbirths in prior pregnancies. At the first presentation, she had normal vital signs and otherwise unremarkable physical examination. During admission, patient suddenly had asymptomatic bradycardia with heart rate of 42 beats per minute. Electrocardiogram showed TAVB with narrow QRS complex. She became symptomatic 2 days later. We aim to describe the possibility of late development TAVB during pregnancy due to unspecified SLE status. Discussion: Total atrioventricular block (TAVB) due to systemic lupus erythematosus (SLE) during pregnancy was extremely rare and observed only in two cases. This case may represent the first report in patient with asymptomatic initial presentation. Diagnosing late development form of TAVB caused by SLE is almost impossible regarding the unspecified symptoms. Some journal reports that pregnancy may lead to different level of SLE-associated antibody, but only few cases are associated with TAVB. Following multi-specialist cooperation, we finally established relations between oligohydramnion, thrombocytopenia, stillbirths, and atopic disease. Further investigation resulted positive for antinuclear antibody test. Previous data reported that SLE-associated antibody is often detected between 18 and 30 weeks of gestation, which might cause fibrosis of AV nodes, leading to TAVB in adult. Low level antibody production before pregnancy may cause absence of common features of SLE. Some form of TAVB with SLE may be reversible into normal rhythm. We considered the use of temporary pacemaker until termination of pregnancy. According to ESC Guideline, permanent pacemaker should be implanted either if the patient is symptomatic or the rhythm remains TAVB. Conclusion: Pregnancy may cause exacerbation of SLE leading to TAVB. Permanent pacemaker implantation can be delayed until SLE remission. Keywords total atrioventricular block • systemic lupus erythematosus • pregnancy • bradycardia C.62. Huge Floating Thrombus in Acute Myocardial Infarction: The Wait and See Approach Muhammadnur R Enoch Muhammadnur R Enoch Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Achmad F Yahya Achmad F Yahya Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Robin H Wibowo Robin H Wibowo Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Januar W Martha Januar W Martha Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Mohammad R Akbar Mohammad R Akbar Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia Case Illustration: There is no clear recommendation for mechanical intervention in acute myocardial patient with high thrombus burden and normal flow. A few cases of large intracoronary thrombus have been reported successful with aggressive medical treatment. We reported an unusual case of huge floating thrombus in right coronary artery with our approach. A 50-year-old male presented to our emergency department with chest pain on 5 days. His ECG showed normal sinus rhythm with persistent ST segment elevation in leads II, III, aVF, V7-V9. Traditional risk factors for coronary artery disease (CAD) were hypertension and smoker. The patient had no remarkable physical findings. Serum troponin-I >10 ng/mL (normal range (NR) 0–0.2 ng/mL) and others measurement were on normal range. Transthoracic echocardiography (TTE) revealed preserved LVEF 53% with hypokinetic inferoseptal,inferior,inferolateral wall. The angiography showed right dominance and huge floating thrombus on mid RCA into distal with TIMI flow 3. The patient was stable and PTCA was not performed. Prolonged antiplatelet (acetylsalicylic acid and ticagrelor) and anticoagulation (enoxaparin) was administered for 5 days. Repeat angiography after 5 days showed low thrombus burden in mid RCA, non-significant stenosis and TIMI flow 3. Repeat TTE showed there is no difference with the first one. The patient was discharged after 2 days angiography without complaint. Discussion: There is still uncertainty of the best treatment for acute myocardial infarction with high thrombus burden and normal flow. Current management with thrombus aspiration was associated with fewer cardiovascular deaths but increased the risk of stroke. Some case reports used prolonged antiplatelet and anticoagulation for thrombus treatment. Conclusion: Prolonged standard pharmacological therapy can be alternative choice for high thrombus burden in acute myocardial infarction. Further studies would be useful to explore these findings in more detail. Keywords Acute myocardial infarction • PTCA • thrombus C.63. Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) in a 12 Years Old Female: A Case Report Zaki H Islami Zaki H Islami Department of Cardiology and Vascular Medicine, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Indah K Murni Indah K Murni Department of Pediatric, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Sasmito Nugroho Sasmito Nugroho Department of Pediatric, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Noormanto Noormanto Department of Pediatric, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Putrika P R Gharini Putrika P R Gharini Department of Cardiology and Vascular Medicine, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Department of Cardiology and Vascular Medicine, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Department of Pediatric, Dr. Sardjito Hospital/Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia Case Illustration: A case of 12 years old female with a complaint of dyspnea on exertion. Her physical examination showed cardiomegaly and systolic murmur heard best at apex. Echocardiography result showed the suspicion of an origin from the coronary artery at the pulmonary artery, enlarged left atrium and left ventricle, and moderate mitral regurgitation due to anterior mitral leaflet prolapse. After the patient undergoing angiography, it’s revealed she had anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) malformation, with collaterals between right and left coronary arteries which explains the patient survives to teenager. Discussion: ALCAPA was first reported in 1866, but wasn’t made popular until in 1933 with incidence of 1 in 300,000 children or 0%-5% cases of all congenital heart defect. Patient with ALCAPA starts to have symptoms at 2-3 months old ranging from irritable, pallor, cold sweat while nursing to congestive heart failure symptoms. Most of the patients die in infancy if it is not surgically corrected due to myocardial ischemia, although 15% survived into adulthood due to collateral development. This malformation rarely manifest in teenager and adult but it may be one of the causes of sudden cardiac arrest due to ischemia. Echocardiography can evaluate the ostia and initial segments of the coronary vessels thus aims the suspicion for anomaly of the coronary. Angiography are still the method of choice to diagnose this anomaly. Surgical correction should be done to reduce the risk of sudden cardiac death. Conclusion: ALCAPA is a rare congenital anomaly in teenagers. This patient developed collaterals between right and left coronary arteries that explain her survival. Early diagnosis and subsequent correction should be done to decrease the chance of sudden cardiac death. Keywords: ALCAPA, congenital coronary malformation C.63. Figure 1 Open in new tabDownload slide Echocardiography shows the opening of the left coronary artery toward pulmonary artery rather than aorta C.63. Figure 1 Open in new tabDownload slide Echocardiography shows the opening of the left coronary artery toward pulmonary artery rather than aorta C.63. Figure 2 Open in new tabDownload slide Angiography shows the normal origin of the right coronary artery from aorta and the anomalous origin of the left coronary artery arising from pulmonary artery C.63. Figure 2 Open in new tabDownload slide Angiography shows the normal origin of the right coronary artery from aorta and the anomalous origin of the left coronary artery arising from pulmonary artery C.64. Dengue Myocarditis : A Complication that Need to Be Watched Out Reza Y Sari Reza Y Sari Panti Rahayu Yakkum Hospital Purwodadi, Panti Waluyo Hospital Surakarta Martha O D Savitri Martha O D Savitri Panti Rahayu Yakkum Hospital Purwodadi, Panti Waluyo Hospital Surakarta Robert S Sudirga Robert S Sudirga Panti Rahayu Yakkum Hospital Purwodadi, Panti Waluyo Hospital Surakarta Panti Rahayu Yakkum Hospital Purwodadi, Panti Waluyo Hospital Surakarta Case Illustration: An 18 years old male came to ER with fever, nausea, cephalgia, and epigastric pain since 3 days before admission. Normal vital signs and epigastric tenderness was found on physical examination. Laboratory study showed decreased platelet counts (111.000/µL) and positive dengue IgM. The patient was diagnosed with dengue fever and admitted to ward. Soon after admission, he complained palpitation with BP 90/70, HR 160bpm, RR 24bpm, and temperature 38,5oC. ECG revealed supraventricular tachycardia (SVT) 160bpm. Chest xray showed minimal perihiler haze. Carotid massage was performed, but it was unsuccessful. He was transferred to ICU, and amiodarone on syringe pump was programmed (150 mg in 30 minutes, continued with 375 mg in 6 hours, and continued with 525 mg in 18 hours). Treatment also included RL infusion 1500cc/24 hours, paracetamol 4x500mg peroral, ranitidin 3x500mg, cefuroxime 2x1g, and metoclopramide 3x5mg. The SVT was converted to sinus rhythm 86 bpm after 6 hours. On second day follow up, there was no complaint. ECG revealed sinus rhythm 88bpm with inverted T wave on lead II, II, aVF, V4, V5, and V6. Additional laboratory study including thyroid function and blood electrolyte revealed no marked abnormality. Consecutive platelet counts for 3 days follow up showed this following: 95000/µL,130000/µL, 140000/µL. He was discharged after 4 days treatment and got himself controlled on 5 days after with no significant complaint. He was then transferred to another center to undergo echocardiography. Discussion: Dengue rarely affects the heart, however, patients with dengue fever are at high risk of developing myocarditis, with prevalence of 9-15%. Symptoms of myocarditis include palpitations, chest pain, acute onset of or sudden worsening of heart failure, and cardiac arrhythmias. Cardiac enzyme are usually elevated. ECG abnormalities range from unspecific abnormal Q waves or ST inversions to diffuse concave ST segment elevations without reciprocal changes. In this case, the patient’s complaint and examination results supported to suspect dengue myocarditis as the diagnosis, unfortunately there was no data for the cardiac enzyme. The treatment was focused on reducing symptoms and converting the arrhythmia. Amiodarone was used to treat the SVT due to its easy availability in our center and its efficacy and safety for control of SVT. Conclusion: A high index of suspicion for myocarditis is needed in patients with dengue infection, and early treatment of the cardiac manifestation can result in a good outcome. C.64. Figure 1 Open in new tabDownload slide Patient’s ECG revealed SVT C.64. Figure 1 Open in new tabDownload slide Patient’s ECG revealed SVT Keywords SVT • dengue • myocarditis • dengue myocarditis C.65. Non-Significant Coronary Angiography with Positive Nuclear Stress Test : Failure to Identify a Blockage ? Meidianaser Putra Meidianaser Putra Department of Cardiology and Vascular Medicine, Faculty of Medicine, Andalas University Anna Fuji Rahimah Anna Fuji Rahimah Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University Elen Elen Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia National Cardiovascular Center Harapan Kita, Jakarta Celly Atmadikoesoemah Celly Atmadikoesoemah Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia National Cardiovascular Center Harapan Kita, Jakarta Manoefris Kasim Manoefris Kasim Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia National Cardiovascular Center Harapan Kita, Jakarta Department of Cardiology and Vascular Medicine, Faculty of Medicine, Andalas University Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia National Cardiovascular Center Harapan Kita, Jakarta Case Illustration: A 59-year old male with risk factor of dyslipidemia had chest discomfort during moderate to severe activity since 1 year ago. Patient underwent double valve repair due to degenerative on March 2018. Echocardiography showed good LV systolic function (EF 60%), global normokinetic, mitral valve post repair with mild-moderate residual MR, aortic valve post repair with mild residual AR, mild TR, and good RV systolic function. Catheterization showed 50-60% stenosis at proximal LAD. Further evaluation of this patient was done by SPECT to evaluate the cardiac viability. It revealed that the patient has 11,25% ischemic burden at LAD territory. Discussion: Noninvasive testing in patients with suspected CAD is commonly performed to determine the presence or absence of angiographic CAD. In this paradigm, angiography is the gold stan¬dard to define the presence or absence of CAD, and performance of the noninvasive test is measured by its sensitivity (percentage of true-positive test results among those with CAD as defined by angiography) as well as by its specificity (percentage of true-negative test results among those without CAD). Ischemic burden has repeatedly been identified as a powerful prognostic factor among patients referred for stress testing using nuclear imaging, echocardiography and more recently, cardiac MRI (CMR). It is notable that both COURAGE and BARI-2D entry criteria required evidence of ischemia, but the evidence could be as limited as exercise electrocardiographic changes, a limited perfusion defect or a stenosis of ≥ 70–80% plus classic angina. Among the 60% of patients enrolled in COURAGE after nuclear stress imaging, most had less than moderate ischemia. Observational data from the Cedars-Sinai nuclear registry published that selection for revascularization based on ischemia burden may be a reasonable approach. The approximately more than 10% risk level of left ventricular ischemic burden from SPECT that need revascularization. Based on Ischemia trial, the cut off burden ischemic point is ≥ 10% that was associated with n approximately 5% per year mortality. In case of non significant ICA with positive ischemic burden, we have to make sure there are no misinterpretation the angiogram, and revascularization should be a choice if the patient with symptoms. In this case, after we evaluate SPECT stress test, we found 11,25% of ischemic burden at LAD territory with inducible ischemic (viable) semiquantitative result despite of non significant ICA, it should be suggest to revascularization to reduce risk of MI or death. According to ESC guidelines on management of stable coronary disease, patient with symptoms of chest pain and positive non-invasive testing, the invasive strategy will provide a definitive answer, even the normal finding can reassure the patient and therefore significantly improve the quality of life. C.65. Figure 1 Open in new tabDownload slide Coronary angiogram C.65. Figure 1 Open in new tabDownload slide Coronary angiogram Conclusion: We describe a case with non significant coronary angiography with positive nuclear stress test. Coronary angiography is an invasive method to identifies coronary artery disease, but non-significant lesion doesn’t means have no ischemic burden, because coronary angiography only identify blockage at epicardial region. SPECT is a generally safe and effective noninvasive method of assessing ischemic burden and whether such blockages are responsible for symptoms such as chest pain, or have already produced permanent heart muscle damage. C.65. Figure 3 Open in new tabDownload slide 4DM image showing reversible defect at LAD territory with TID 0,91 C.65. Figure 3 Open in new tabDownload slide 4DM image showing reversible defect at LAD territory with TID 0,91 Keywords coronary artery disease • Single-Photon Emission Computed Tomography • coronary angiography. C.66. The Difficulties in Identifying Early Electrocardiogram Features of Right Ventricular Infarction Karina Alferinda Karina Alferinda Faculty of Medicine, Pelita Harapan University, Tangerang Ellen Fernanda Ellen Fernanda Faculty of Medicine, Pelita Harapan University, Tangerang Anasclara Anasclara Anasclara Anasclara Faculty of Medicine, Pelita Harapan University, Tangerang Jason W Haryanto Jason W Haryanto Faculty of Medicine, Pelita Harapan University, Tangerang Denny Intan Denny Intan Faculty of Medicine, Pelita Harapan University, Tangerang Grace M Lukito Grace M Lukito Siloam Hospital Lippo Village Antonia A Lukito Antonia A Lukito Faculty of Medicine, Pelita Harapan University, Tangerang Siloam Hospital Lippo Village Faculty of Medicine, Pelita Harapan University, Tangerang Siloam Hospital Lippo Village Case Illustration: A 61-yo hypertensive male was referred from other hospital with prolonged chest pain of more than 14 hours, total AV block, and severe hypotension after being given sublingual nitrate. The patient arrived with intravenous inotropics. The chest pain was sustained with BP 71/47 mmHg and anuric. The diagnosis of RV infarct along with inferoposterior wall was confirmed by the ECG and clinical features. The volume loading to increase the LV preload was carried out with the noradrenalin infusion, and the BP was improving to 103/70 mmHg. Since the chest pain still continues, despite the anuric due to acute kidney injury (AKI) as a consequence of several hours of hypotension in the referring hospital, the primary PCI was performed and the angiogram revealed a total occluded thrombotic lesion at the proximal RCA, LCX was a diffuse vessel, and LAD was total occluded chronically. One DES was implanted at the proximal-mid RCA, and the flow improved to TIMI 3. Temporary pacemaker was inserted before the procedure at the RV apex on TAVB indication. After procedure, the ST elevation resolved completely, the patient was stable and transferred to ICCU with BP 113/75 mmHg and HR 80 bpm. The sustained low efficiency dialysis (SLED) was performed later. Discussion: Classic features of RV infarction were not shown on early ECG findings at the referring hospital, the sublingual nitrate was given due to unawareness of the possibility of RV infarction. The nitrate therapy in RV infarction may reduce preload and induce pronounced hypotension that may worsen the clinical condition of the patient and increase the inhospital mortality. Therefore, the possibility of RV infarct should be considered in the management of alleviating chest pain in the ED settings as the prudent approach in the inferoposterior MI patients. And the clue of RV infarct in the inferoposterior MI should be mastered. The first step to spotting RV infarction is to suspect it, in all patients with inferior STEMI, RV infarction is suggested by the presence of ST elevation in V1, the only standard ECG lead that looks directly at the right ventricle, so the right-sided precordial leads are critical to the evaluation of suspected RV infarction in inferoposterior MI. RV infarction should be suspected by the presence of ST elevation in lead III greater than lead II, and isoelectric ST segment in V1 with marked ST depression in V2. Conclusion: The ECG changes of RV infarction are subtle and easily missed. The acute management of ACS in the ED settings should be mastered by ED staffs to deliver the appropriate treatment strategies and to reduce the inhospital mortality of ACS C.66. Fig. 1 Open in new tabDownload slide The serial standard 12-lead ECG findings at the referring hospital C.66. Fig. 1 Open in new tabDownload slide The serial standard 12-lead ECG findings at the referring hospital C.66. Fig. 2 Open in new tabDownload slide The standard 12-lead ECG findings (left) and right-sided precordial leads (right) at the ED C.66. Fig. 2 Open in new tabDownload slide The standard 12-lead ECG findings (left) and right-sided precordial leads (right) at the ED Keywords RV infarction • inferoposterior • STEMI • ECG • V1 C.67. Acute Myocardial Infarction in a 22-years-old Male : a Very Rare Case A P Mangkoesoebroto A P Mangkoesoebroto Faculty of Medicine, Diponegoro University, Semarang, Indonesia R A Raharjo R A Raharjo Faculty of Medicine, Diponegoro University, Semarang, Indonesia A Wardhani A Wardhani Faculty of Medicine, Diponegoro University, Semarang, Indonesia S B Utami S B Utami Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University - Dr. Kariadi Central General Hospital Semarang, Indonesia S Rifqi S Rifqi Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University - Dr. Kariadi Central General Hospital Semarang, Indonesia Faculty of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University - Dr. Kariadi Central General Hospital Semarang, Indonesia Case Illustration: A 22-years-old male presented with chest pain of 9 hours duration. The pain was dull, heavy, retrosternal in location, and accompanied by diaphoresis and nausea. Previously he consumed three bottles of alcohol and three ecstasy pills (amphetamine). The cardiac risk factors were active cigarette smoking (1 pack per month), alcohol and drug abuse. The physical examination was in normal limit. The ECG showed sinus rhythm with ST elevation on leads I, aVL, V1-V6 (Figure 1). The chest X-ray was unremarkable. Laboratory report showed elevated troponin I 4.2 ug/L and CKMB 116 U/L. Coronary angiography demonstrated total occlusion of mid left coronary anterior descending, which was managed with primary percutaneous coronary intervention and repeated thrombosuction (Figure 2). Post procedure ECG demonstrated >50% ST-segment resolution. A treatment of aspirin, clopidogrel, atorvastatin, bisoprolol and ramipril were initiated. The patient remained symptom-free and was discharged on day five of hospitalization. Discussion: Acute myocardial infarction (AMI) represents the leading cause of mortality and morbidity worldwide AMI in young adult is a rare event, which only represents 0.7-4.0% of all AMIs. The disease carries a significant morbidity, psychological effects, and financial constraints for the person and the family when it occurs at young age. The causes of AMI among young patients can be divided into four groups: atheromatous coronary disease, non-atheromatous coronary disease, hypercoagulable states, and substance misuse. This case was exceptional considering the very young age of patient. The patient presented with tobacco smoking and substance misuse as the potential triggers and risk factors of the AMI. Conclusion: AMI in very young patient is an uncommon but significant entity, given the risk of morbidity and mortality. Aggressive therapy and guideline implementation must be applied to minimize death and negative outcome after AMI. C.67. Figure 1 Open in new tabDownload slide Electrocardiogram C.67. Figure 1 Open in new tabDownload slide Electrocardiogram C.67. Figure 2 Open in new tabDownload slide Coronary Angiography (left) pre-PPCI, (right) post-PPCI C.67. Figure 2 Open in new tabDownload slide Coronary Angiography (left) pre-PPCI, (right) post-PPCI Keywords acute myocardial infarction • ST-elevation myocardial infarction • young age • primary percutaneous coronary intervention • drug abuse C.68. ST-segment Elevation in Lead aVR: STEMI or NSTEMI? Anita D Riyanti Anita D Riyanti Jakarta Heart Center Hospital, Jakarta, Indonesia Meita M Siborutorop Meita M Siborutorop Jakarta Heart Center Hospital, Jakarta, Indonesia Wishnu A Widodo Wishnu A Widodo Jakarta Heart Center Hospital, Jakarta, Indonesia Jakarta Heart Center Hospital, Jakarta, Indonesia Background: The utility of lead augmented vector right (aVR) in the evaluation of acute coronary syndrome has been historically underestimated in clinical practice.1,2 Case Illustration: A 64-year-old male was brought to the ER with sudden onset chest pain 5 hours prior. BP 90/50 mmHg HR 123 bpm. Rales (+/+). ECG showed STE-aVR and diffuse ST-segment depression in other leads. Laboratory examination showed increased Troponin. Emergency corangiography showed subtotal occlusion of LM. LAD was totally occluded with good collateralization from RCA. PCI was performed with 1 Coronary DES implanted in distal LM to proximal LCx. After the procedure, patient was hemodynamically stable, ST elevation and depression in ECG resolved, and chest pain relieved. Discussion: STE-aVR is often associated with severe CAD, especially LM stenosis.3,4 The mechanism of this condition is not fully understood.5 Whenever it happens in ACS condition, decision to classify this as STEMI or not and require primary PCI is debatable. In our case, patient underwent urgent corangiography and PCI because of hemodynamic instability, apart from the diagnosis was STEMI or NSTEMI. Based on ESC Guidelines, STEMI is determined when there is ST-segment elevation in at least 2 contiguous leads. However, there are few atypical ECG images that require primary PCI procedure, one of which is ST-segment elevation in lead aVR and / or V1 combined with ST-segment depression > 1 mm in > 8 lead.6 Those ECG finding shows the possibility of LM disease or three-vessel-disease7,8; similar to the condition we found in our case. Conclusion: When ACS appeared with avR elevation, making a definite diagnosis is challenging. Whenever there’s doubt or hemodynamic disturbance, primary PCI or at least emergency corangiography should be done. C.68. Figure 1 Open in new tabDownload slide ECG showed ST-segment elevation in aVR lead and ST-segment depression in inferior, lateral, and pre cordial leads C.68. Figure 1 Open in new tabDownload slide ECG showed ST-segment elevation in aVR lead and ST-segment depression in inferior, lateral, and pre cordial leads C.68. Figure 2 Open in new tabDownload slide ECG 6 hours after primary PCI was performed C.68. Figure 2 Open in new tabDownload slide ECG 6 hours after primary PCI was performed C.68. Figure 3 Open in new tabDownload slide Corangiography showed subtotal occlusion of LM artery. LAD was totally occluded with good collateralization from RCA. C.68. Figure 3 Open in new tabDownload slide Corangiography showed subtotal occlusion of LM artery. LAD was totally occluded with good collateralization from RCA. Keywords Acute Coronary Syndrome (ACS) • augmented vector right (aVR) • ST elevation myocardial infarction (STEMI) • STEMI variation • Primary Percutaneous Coronary Intervention (PPCI) C.69. A Challenging Case of Acute Pulmonary Embolism with Cardiogenic Shock: The Role of Trans Thoracic Echocardiography in Diagnostic and Treatment Decision R E Intan R E Intan Dr. R. Koesma General Hospital, Tuban, East Java F S Hasibuan F S Hasibuan Dr. R. Koesma General Hospital, Tuban, East Java Dr. R. Koesma General Hospital, Tuban, East Java Case Illustration: A 53 years old woman came to ER with main complain of sudden dyspnea and atypical right sided chest pain penetrating to the back since 1 hour . She also felt pain and swelling at her right thigh since 3 days. She had neglected right collum femur fracture history 1 year ago. Physical examination, VS: BP100/70, HR123x/min, RR28x/min, Sp02: 89%. Right thigh non pitting edema (+). ECG showed sinus tachycardia with unspecific S1Q3T3 pattern and T inversion in V1-V4 (Figure1). Laboratory results were normal. She was treated as CAD at first. 1 hour later, she fell to shock sign with BP 90/60. We suspected pulmonary embolism (PE), with calculation of geneva score of 12 with PESI class IV (high risk), and supported by TTE and duplex ultrasound which showed RV thrombus with dyskinetic RV, positive Mac Connel sign, normokinetic LV, and thrombus at right common femoral vein(figure2). CTPA and thrombolytic was planned but the patient refused. Rivaroxaban 15 mg bid was added, while DAPT was discontinued. After 5 days, her condition improve well, she was discharged with rivaroxaban continued with dose of 20 mg od after 3 weeks. Evaluation a month later showed normokinetic RV and LV without thrombus, while DVT reduced, with dyspnea (-) and thigh swelling reduced. Discussion: Pulmonary embolism should be considered in the differential diagnosis of every chest pain event. Careful history and physical examination and TTE finding of TES (typical echocardiographic signs of acute PE) and RV dysfunction, might benefit for early diagnosis, while anticoagulant remain preference therapy for patients with hight risk PE when definitive treatment is unavailable. Conclusion: Pulmonary embolism carries high mortality if not suspected and treated early, however its diagnosis continues to be difficult, primarily because of the vagaries of the presentation, which can mimick other disease. C.69. Figure 1 Open in new tabDownload slide ECG on admission showed sinus tachycardia with unspecific S1Q3T3 pattern and T inversion in V1-V4 suggesting RV strain. C.69. Figure 1 Open in new tabDownload slide ECG on admission showed sinus tachycardia with unspecific S1Q3T3 pattern and T inversion in V1-V4 suggesting RV strain. C.69. Figure 2 Open in new tabDownload slide a. TTE showed thrombus (0.9 x 0.8cm) with diskinetic RV, positive Mac Connel sign, normokinetic LV, with normal systolic LV (EF 88%) and abnormal diastolic LV function. b Duplex ultrasound at thigh showed thrombus at the right common femoral vein, with (+) compression ultrasound. C.69. Figure 2 Open in new tabDownload slide a. TTE showed thrombus (0.9 x 0.8cm) with diskinetic RV, positive Mac Connel sign, normokinetic LV, with normal systolic LV (EF 88%) and abnormal diastolic LV function. b Duplex ultrasound at thigh showed thrombus at the right common femoral vein, with (+) compression ultrasound. Keywords Pulmonal embolism • TTE • RV dysfunction • TES • anticoagulant C.70. Paroxysmal Supraventricular Tachycardia and Wolf-Parkinson-White Syndrome in Ebstein’s Anomaly Patient: A Case Study R Rohmatussadeli R Rohmatussadeli Division of Cardiology and Vascular Medicine, RSUD Brebes, Central Java, Indonesia M Athoilah M Athoilah Division of Cardiology and Vascular Medicine, RSUD Brebes, Central Java, Indonesia Division of Cardiology and Vascular Medicine, RSUD Brebes, Central Java, Indonesia Case Illustration: A 36 years old women came to an emergency room with palpitation and unstable condition such as loss of consciousness, hypotension, rapid heartbeat, and hypoxia. Electrocardiography (ECG) showed supraventricular tachycardia. We did 90 joules of synchronized cardioversion and successful to stabilize the patient’s condition. Sinus rhythm, RBBB, and pre-excitation with probability of right-posteroseptal accessory pathway (APs) are showed by ECG after synchronized cardioversion. Chest radiograph revealed right atrial enlargement. Echocardiography showed dilatation of right atrium and right ventricle, atrialization and apical displacement of the tricuspid valve, and mild tricuspid regurgitation. Patient received bisoprolol 1x5mg oral. Discussion: Diagnosis of paroxysmal supraventricular tachycardia (PSVT) is established by sudden onset and termination, narrow QRS complexes, and the rates between 140-250bpm. Anterograde-retrograde conduction in Wolf-Parkinson-White syndrome (WPWS) can cause PSVT, and 85-95% of that is narrow atrioventricular reentrant tachycardia (AVRT). Apical displacement of the tricuspid valve in Ebstein’s Anomaly (EA) is related to the presence of APs on the right side chambers, and it triggers the occurrence of PSVT and WPWS. AHA guideline recommends vagal maneuver or anti-arrhythmia drugs to treat stable PSVT, and synchronized cardioversion 50-100j for unstable PSVT. Catheter or perioperative ablation is used for definitive therapy. Conclusion: PSVT patient can be treated by anti-arrhythmia drugs or synchronized cardioversion depend on the hemodynamic states. However, the condition found in WPWS and EA, the further treatments are necessarily needed. Keywords Paroxysmal Supraventricular Tachycardia (PSVT) • Wolf-Parkinson-White Syndrome (WPWS) • Ebstein’s Anomaly (EA) C.71. Evaluation of Cardiac Embolism in Cryptogenic Stroke : A Case Series Dessytha N Hudaja Dessytha N Hudaja Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Ingrid M Pardede Ingrid M Pardede Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Vonny F Goenawan Vonny F Goenawan Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Michael Susanto Michael Susanto Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Aurea S Soetjipto Aurea S Soetjipto Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Catherine J Hardi Catherine J Hardi Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Sunanto Ng Sunanto Ng Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Department of Cardiology and Vascular Medicine and Department of Neurology Medicine, School of Medicine, Pelita Harapan University, Tangerang, Indonesia Case Illustration: We presented five cases of cryptogenic stroke that have a clinical presentation of ischemic stroke confirmed with brain magnetic resonance imaging. Patient’s age ranged between 14-55 years and four of them were male. All the patients underwent a transesophageal echocardiogram (TEE) with bubble test. Four patients were found to have patent foramen ovale (PFO). The youngest patient (14 years old) had PFO and protein C and S deficiency. Paroxysmal occult atrial fibrillation (less than 1 minute) was found in two patients from 7-day Holter monitoring. Four patients treated with medical therapy, one patient underwent PFO closure. Discussion: Cryptogenic stroke is defined as a ischemic stroke without apparent etiology even after adequate diagnostic evaluation. However, some conditions are found to be the possible causes of cardiac embolism in cryptogenic stroke including PFO, aortic arch disease, sub-stenotic atherosclerosis, paroxysmal occult atrial fibrillation, or atrial cardiopathy and left atrial appendage dysfunction. Although cryptogenic is defined as an unclear etiology, there are still underlying causes that should be elaborated. Conclusion: Patent foramen ovale and paroxysmal occult atrial fibrillation are found to be the causes of cryptogenic stroke. TEE and Holter monitoring are an important diagnostic work-up to identify cardiac embolism. Appropriate management and future prevention of recurrence can be applied after the identification of etiology. Keywords Cryptogenic stroke • Patent foramen ovale • Paroxysmal occult atrial fibrillation C.72. Coronary Artery Fistula to Pulmonary Artery, Will Be Closed or Not?: A Case Report G Swandita G Swandita Gadjah Mada University Sardjito General Hospital H Hariawan H Hariawan Gadjah Mada University Sardjito General Hospital A B Hartopo A B Hartopo Gadjah Mada University Sardjito General Hospital Gadjah Mada University Sardjito General Hospital Background: Coronary artery fistula is the rare case. It often found incidentally when the coronary angiography was performed. The mechanism of anginal pain in coronary artery fistula is due to “stealing effect” of the distal coronary flow, that flow through the fistula and reduce the blood supply to cardiac muscle. The coronary artery fistula also increased the left ventricular end diastolic pressure (LVEDP) and cause atrial fibrilation. The closure management strategy of the fistula is to minimize the symtoms and prevent pulmonary hypertension. Case Illustration and Discussion: A 51 years old man had a chief complain of chest pain (heaviness of the chest) since 8 month ago, the pain is induced by heavy activity (more than his ordinary activities) and release at rest. He also complaint of dyspneu on effort and palpitation. Electrocardiogram was performed and there was atrial fibrilation with normal ventricular respond, and normal axis. Echocardiography gave informations that there were dilatation of left atrium (LA), right atrium (RA), and right ventricle (LA) (LA 40, RA 40, and RV 36). The left ventricular ejection fraction was decrease (34%) with suspicious of hypokinetic at apical, apicolateral, mid inferoseptal, and mid inferior segment of the left ventricle. Another finding were TAPSE 14 mm, TR Mild (TRV 2.19 m/s, TVG 19 mmHg) and MR Mild. The Dobutamin Stress Echocardiography (DSE) was performed and there was positive viability respond of the hypokinetic segment. The patient proceed to coronary angiography procedure and surprisingly the result was normal coronary artery with right coronary artery fistula to distal right pulmonary artery. Continued with right heart catheterization and there were big coronary artery fistula from RCA to distal RPA, inter atrial and inter ventricular septums were intact, with mild pulmonary hypertension (mPAP 27 mmHg), high flow low resistance (FR 1.65, PARI 2.38). Clinical conference has been done with decision to performed MRI first to asses the myocard scar and the size of the fistula, and after that this case will be conferred again to make a decision. Conclusion: Coronary artery fistula closure is indicated in the case of there was stealing effect of the coronary blood flow (induce angina), the rise of LVEDP (induce atrial fibrilation), and the potential of pulmonary hypertenstion. Keywords Coronary Fistula • Fistula Closure C.73. Peri-Procedural Myocardial Infarction After Coronary Artery Bypass Graft Aldila N Sulma Aldila N Sulma Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Safir Sungkar Safir Sungkar Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Case Illustration: Male 62 yo had a three-vessel coronary artery disease with heavy calcified in the mid left anterior descending (LAD) artery underwent elective CABG. The surgery was done in four and a half hours with aortic cross clamp time 86 minutes and cardiopulmonary bypass time 104 minutes. Four saphenous vein grafts was connected right coronary artery (RCA), left circumflex artery (LCx), first diagonal and LAD artery with aorta, and also endarterectomy procedure in the RCA and LAD. On the third day after CABG, patient complained typical chest pain, electrocardiogram showed new pathologic Q waves on lead V3-V6 and cardiac troponin I was elevated >40 ug/L. Discussion: This patient fulfilled criteria for CABG-related myocardial infarction (MI) and medically managed with anticoagulant, more potent P2Y12 inhibitor, high intensity statin, beta-blocker and angiotensin-converting enzyme inhibitor. Transthoracic echocardiography evaluation showed new regional wall motion abnormality in the anterior wall of the left ventricle. Coronary angiography wasn’t done due to untransportable patient. Conclusion: We describe a case with CABG-related myocardial infarction which sometimes overlooked as a complication after surgery. Cardiac biomarker, electrocardiogram, echocardiography and coronary angiography was modality for diagnose and made therapeutic decision of periprocedural MI. Keywords CABG • myocardial infarction C.74. CTO PCI Procedure, be Prepared to Deal with Complications Reza M Munandar Reza M Munandar Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Lita H D P Efendi Lita H D P Efendi Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Arman Christiawan Arman Christiawan Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Anindia Wardhani Anindia Wardhani Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Agus Probo Agus Probo Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Sodiqur Rifqi Sodiqur Rifqi Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, School of Medicine, Diponegoro University, Semarang, Indonesia Case Illustration: A 71-year-old gentleman was admitted to our hospital for an elective procedure of Percutaneus Coronary Intervention (PCI). The procedure was targeted to the tandem CTO lesion in mid and distal RCA. The lesion was pierced-through using Fielder XT (Asahi, Japan) guidewire until the distal PL branch. But after predilatation with a small balloon in mid to distal part of RCA, there was extravasation of contrast agent, suspected of Ellis type III perforation. The attempt for rewiring using floppy wire and escalating through to stiff wire was to no avail as it always went to false lumen. The patient went to hypotension and there was contrast trap silhouette in pericardial space. Emergency pericardiocentesis was done successfully, the patient was stabilized, and the procedure was then stopped. Discussion: Chronic Total Occlusion (CTO) are pretty common and is observed in up to 25% of patients undergoing angiography. Revascularization of CTO’s are challenging due to the marked lesion variability, the variety of techniques and devices required, and the complications that may often arise than non CTO procedure. Coronary perforation is known complication when performing CTO procedure with various incidence rate. Our patient got an Ellis type III perforation and went to cardiac tamponade, but it was handled safely by the experienced team and readily available equipment for pericardiocentesis. Conclusion: The challenges in performing CTO PCI comes in many ways, and sometimes lead to life-threatening events – such as tamponade. And it is important to be aware of potential complications and recognise them in a timely fashion, so it can be dealt with in a safe and efficient manner. Thus understanding and experience is needed not only in performing with advance techniques and devices, but also how to safely and effectively managing the complications. Keywords CTO PCI • perforation • cardiac tamponade • complications C.75. Arteriovenous Fistula Stenosis : A Case Report Seprian Widasmara Seprian Widasmara Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, East Java, Indonesia Novi Kurnianingsih Novi Kurnianingsih Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, East Java, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Brawijaya University, Malang, East Java, Indonesia Case Illustration: A 64 years old man with stage V CKD on routine HD was admitted to hospital with difficulty in cannulation during his last hemodialysis. He already had arteriovenous fistula for hemodialysis access in his left arm since 2 years ago. In the last month before admission, he went to surgery to make hemodialysis access via arteriovenous fistula in his right arm, but failed to mature. Vascular ultrasound on dialysis vascular access was ordered. The examination revealed there was stenosis in the juxta-anastomosis site and stenosis vena cephalic in his left arm. He undergone percutaneous angioplasty with POBA in anastomose arteriovenous fistula and implantation stent in left cephalic vein. Discussion: Dysfunction of hemodialysis access is a major problem for patient undergoing hemodialysis. It is generally due to venous stenosis, which diminishes flow in the hemodialysis access arteriovenous thereby leading to poor dialysis. Fistulas tend to develop stenosis most commonly either at the juxta-anastomosis site and the outflow vein. Peripheral venous stenosis is the most common cause of arteriovenous fistula dysfunction and may lead to access thrombosis. First line treatment of stenosis should be balloon angioplasty. Stent placement in the peripheral vein is generally not recommended except in special circumstances. Conclusion: Hemodialysis vascular access is the “lifeline”for patients on hemodialysis. Vascular access-related complications can lead to patient morbidity and reduced quality of life. Surgery often cannot be provided as rapidly as a percutaneous approach Keywords arteriovenous fistula • stenosis • percutaneous angioplasty C.76. A Rare Case of Infective Endocarditis Accompanied by Acute Pericarditis with Massive Pericardial Effusion in End-Stage Renal Disease Patient on Hemodialysis Sofina Kusnadi Sofina Kusnadi Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University Niniek Purwaningtyas Niniek Purwaningtyas Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University- Dr.Moewardi General Hospital Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University- Dr.Moewardi General Hospital Case Illustration: A 23-year-old man with end-stage renal disease (ESRD) was on routine hemodialysis. Patient complained of shortness of breath, history of fever, and joint pain. Echocardiography revealed vegetation in the anterior mitral leaflet (AML) of 1.68 x 0.93 cm and posterior mitral leaflet (PML) of 1.49 x 1.07 cm, accompanied by mild mitral regurgitation. In addition, massive pericardial effusion was also obtained. Concentric Left Ventricular Hypertrophy (LVH) was also found. Electrocardiography (ECG) showed depression in the PR segment and widespread ST segment elevation. Laboratory examination showed anemia, leukocytosis, increased Hs-CRP, azotemia, and hypoalbuminemia. Patient was diagnosed with infective endocarditis (IE) accompanied by pericarditis with massive pericardial effusion. Patient received treatment according to the guidelines adjusted for renal failure. Pericardiocentesis was performed with exudative pericardial fluid collected. Patient was also given Ampicillin Sulbactam injection 3 grams / 24 hours iv, Ibuprofen 600 mg / 8 hours, Carvedilol 3.125 mg / 12 hours and Ramipril 5 mg / 24 hours po. Hemodialysis was also performed for two times a week. Echocardiographic evaluation after 7 days of therapy showed a decrease in vegetation size, in AML 1.28 x 0.77 cm and in PML 0.83 x 0.95 cm. Pericardial fluid was minimal. Discussion: Infective endocarditis is an infection of the endocardium. Patients with ESRD are treated with hemodialysis (HD). Vascular access to HD can cause exposure to various pathogens causing IE. Renal insufficiency can also cause pericardial disorders. IE accompanied by pericarditis with pericardial effusion are rarely found but can occur. Conclusion: Patients with repeated medical instrumentation such as hemodialysis has risk of infective endocarditis so it is important for clinicians to detect this clinical possibility. Pericarditis and pericaldial effusion is also an inflammatory complication to watch out for in patients with renal insufficiency. Keywords Infective endocarditis • pericarditis • pericardial effusion • ESRD C.77. Case Report of Acute Myocardial Infarction Presenting as Renal Calculi Fauziah Fauziah Department Cardiology, Awal Bros Bekasi Hospital, West Java Robert E Saragih Robert E Saragih Department Cardiology, Awal Bros Bekasi Hospital, West Java Department Cardiology, Awal Bros Bekasi Hospital, West Java Case Illustration: We reported a 49 years old man presented to Emergency Department (ED) with complained of flank pain on right side since one day before admission. On examination, right costovertebral angle tenderness and murphy punch sign were positive. Other examination was not significant. ECG taken in ED showed ACS STEMI anterior with elevation of troponin I. Renal ultrasound was performed showing a 10 mm stone in the calyx of right kidney. Initially analgetic NSAID is given to relieve his colic pain, then after diagnosis ACS STEMI was made, the patient managed for ACS STEMI according to guidelines. Discussion: Atypical chest pain in Acute Coronary Syndrome (ACS) should not be miss because some patients frequently undertreated and delayed management can occur which can worsen prognostic. Common presentation of ACS is chest pain which described as pressure, tightness or heaviness. It may radiate to the neck, jaw, shoulders, back or arms. The pain may also be described as indigestion or heartburn with associated nausea or vomiting. Additional symptoms in the absence of chest pain may include weakness, dizziness, lightheadedness or loss of consciousness. Shortness of breath alone can be the presenting symptom of ACS and was found to be present in 26% of patients. Sex differences, age and certain diseases like diabetes may relate to different incidence of neuropathy, which tends to affect vagal nerves before it affects symphatetic nerves, diabetic patient represented 50% of atypical chest pain. Relation of renal stones with Myocardial Infarction is in the nature of the stones. Conclusion: Atypical presentation of chest pain has a negative impact on the diagnosis of patients with ACS, which could delayed or missed diagnosis and led to worse outcome. Keywords atypical • acs • stone C.78. Should Not Miss The Diagnosis : A Case of Young Male with Wellens’ Syndrome in Pain Free Episode Jimmy O Santoso Jimmy O Santoso Badan Pengusahaan Hospital, Batam, Indonesia Afdhalun A Hakim Afdhalun A Hakim Badan Pengusahaan Hospital, Batam, Indonesia Priyandini Wulandari Priyandini Wulandari Badan Pengusahaan Hospital, Batam, Indonesia Badan Pengusahaan Hospital, Batam, Indonesia Case Illustration: A-36 years old male with a history of hypertension came to emergency department with a history of typical chest pain 1 day prior to admission. No symptoms was complained during the admission (no chest pain, no shortness of breath, no palpitation). Patient’s vital sign was normal. ECG showed biphasic T waves in V2-V3 (Wellenoid pattern). Cardiac enzyme was elevated (troponin T = 428 ng/L). Corangiography showed 90% stenosis in ostial LAD with no stenosis in other vessel. Drug eluting stent then implanted in the lesion with good result (TIMI flow 3 with no residual stenosis). Discussion: In the case of Wellen’s syndrome in young male with pain free episode, we may be easily decide to discharge the patient to be evaluated in another day (by stress testing or another risk stratification test). However, stress testing or delayed treatment of this disease may lead to sudden cardiac death. Once we recognized this pattern, we have to immediately consult a cardiologist and not to discharge the patient. Until PCI performed, we should treat this syndrome similarly to acute coronary syndrome. Conclusion: We should recognized the Wellens’ syndrome pattern and not to underestimate the ‘pain free episode’ since it can cause a catastrophic event. Keywords Wellens’ syndrome • pain free • critical LAD stenosis C.79. Right Coronary Artery Anomaly in Asymtomatic Patient using Coronary Computed Tomography Angiography K Budiman K Budiman Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia E Sahara E Sahara Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia C A Atmadikoesoemah C A Atmadikoesoemah Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia M Kasim M Kasim Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Udayana, Bali, Indonesia Case Illustration: Female 60 yo diagnosed with Paroxysmal AF, hypertension, pro ablation. On MSCT SCAN 128 examination, the result is from CACS (Coronary Artery Calcium Score) RCA: 00.00, and high take-off osteal RCA (10 mm) with an intra-arterial course. It concluded there was a minimal calcium plaque and High take-off osteal RCA with intra-arterial course. Discussion: Coronary artery anomaly (CAA) is an abnormality pattern or coronary manifestation, can be seen with CT angiography and Cardiac Magnetic Resonance (CMR). CAA occurs in approximately 1% of the general population, ranging from 0.3-5.6% in studies in patients undergoing coronary angiography and approximately 1% on autopsies. The most common CAA is origin separate from LAD and LCX, followed by LCX arising from the right coronary artery (RCA). Conclusion: A case of CAA has been reported in patients with minimal calcium plaque and High take-off osteal RCA with suspected intra-arterial course. High Take-off RCA is rare and causing decrease in coronary perfusion. The symptoms often hidden and appear as incidental findings. High take-off intra-arterial RCA means there is connection between aorta and pulmonary artery, has more severe prognosis and increases risk of sudden death. The pathophysiological mechanism is unknown. Anomalies can be corrected surgically using saphenous vein or reimplantation of RCA to the correct sinus in adults. The American Heart Association guidelines recommend surgical coronary revascularization when there is evidence of ischemia in RCA anomalies Keywords Coronary artery anomaly • RCA • myocardial ischemia C.80. Lemierre’s Syndrome with Acute Pericarditis, An All-But-Forgotten Disease : Case Report Metta Suryani Metta Suryani Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University Peter Kabo Peter Kabo Wahidin Sudirohusodo Hospital Makassar, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University Wahidin Sudirohusodo Hospital Makassar, Indonesia Introduction: Lemierre’s syndrome is condition which should be suspected in young healthy patients with prolonged symptoms of pharyngitis followed by septicemia or atypical lateral neck pain. We present a case report of a young female with dental infection with submandibullar abcess followed by rare complication of acute pericarditis and left pleural effusion suspect lemierre’s syndrome, which illustrates that subsequent reemergence of this often forgotten disease may become more common in clinical setting. Objective: Rare disease Background: Lemierre’s syndrome is a rare disease, often called “the forgotten disease”, characterized by primary oropharyngeal infection with evidence of septic thrombophlebitis, exhibited by positive blood cultures, clinical or radiographic evidence of internal jugular vein thrombosis, and at least one metastatic focus. Clinical manifestations include fever, respiratory distress, and swollen cervical lymph nodes. A rare complication of these disease is pericarditis. Case Report: We present a 21-year-old female who presented 4-day history of dental pain with flu-like symptoms and fever. He had visited an urgent care centre 2 days prior and was discharged with ciprofloxacin and prednison. Her symptoms progressively worsened and reported new onset left-sided chest pain. Chest pain was pressure-like sensation, intensified with laying down and inspiration. She was toxic-appearing, tachycardic, tachypneic on arrival. Physical examination findings were significant for submandibular abcess with exudate and diffuse crackles on auscultation. Laboratory values revealed elevated WBC, CRP and AKI. Chest radiograph showed left-side pleural effusion (Fig 1). Electrocardiography finding showed widespread ST-elevation and PR depression (Fig 2). Pericardial effusion revealed in echocardiography. The diagnosis of Lemierre syndrome was suspected and given broad-spectrum antibiotics pending culture results. Contrast-enhanced CT of neck revealing right IJV thrombosis (Fig. 3). Thoracentesis confirmed the left exudative effusions. Discussion: Lemierre’s syndrome also known as necrobacillosis or postanginal sepsis, is a rare life-threatening complication of oropharyngeal infections caused by the anaerobic bacterium. Classically, the focus of infection is oropharynx, followed by thrombophlebitis of the local veins that ultimately ends by thrombosis of the IJ veins. This may lead to high-load bacteremia and sepsis, with multiple end-organ failure, lungs being the most commonly involved organ in metastasis. Rare metastatic infection is pericarditis. CT scan with contrast, Doppler of the neck vessels, and MRI are the usual imaging modalities. Timely recognition and prompt start of antibiotics cannot be over emphasized. Like most endovascular infections, the treatment is challenging and often prolonged due to fibrin clot formation that makes it difficult for the antibiotic to penetrate. C.80. Figure 1 Open in new tabDownload slide Chest radiography showed bilateral pleural effusion particularly left-side C.80. Figure 1 Open in new tabDownload slide Chest radiography showed bilateral pleural effusion particularly left-side C.80. Figure 2 Open in new tabDownload slide ECG impression showed sinus tachycardia, diffuse ST-elevation, diffuse PR depression C.80. Figure 2 Open in new tabDownload slide ECG impression showed sinus tachycardia, diffuse ST-elevation, diffuse PR depression Conclusion: Lemierre’s syndrome is a rare disease but nonetheless with severe clinical implications and hence should be noticed regarding the possibility of such differential diagnosis during the approach of patients with such clinical presentation. It is usually seen as an oropharyngeal infection and subsequently complicated with thrombosis of the IJ vein. This case presented patient with recent dental infection with submandibular abcess followed by new onset chest pain and left pleural effusion. Physical findings were submandibular abcess with exudate and diffuse crackles on auscultation. The ECG and echocardiography findings consistent with acute pericarditis. Diagnosis was confirmed by the identification of IJ vein thrombophlebitis by imaging study and anaerobic bacteria on blood culture. C.80. Figure 3 Open in new tabDownload slide Axial contrast-enhanced CT scan of neck shows thrombus occluding right internal jugular vein (arrow) C.80. Figure 3 Open in new tabDownload slide Axial contrast-enhanced CT scan of neck shows thrombus occluding right internal jugular vein (arrow) Keywords Lemierre • Lemierre’s syndrome • Oropharyngeal infection • Septic thrombophlebitis C.81. Presentation and Treatment of Infective Endocarditis Michael Susanto Michael Susanto Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia Queen S Ariyani Queen S Ariyani Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia Ingrid Pardede Ingrid Pardede Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia Siloam Hospital Lippo Karawaci Sunanto Ng Sunanto Ng Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia Siloam Hospital Lippo Karawaci Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia Siloam Hospital Lippo Karawaci Case Illustration Case 1: A 55-year-old male with prolonged fever and shortness of breath presented with grade III systolic murmur at the apex. Transesophageal echocardiography (TEE) showed mitral regurgitation due to flail PML-P1 due to chordae rupture, and 2 large mobile vegetations sizes 5-7 x 7-8 mm. Blood cultures were positive for Streptococcus viridians. The patient was treated with ceftriaxone for 2 weeks and gentamycin for 4 weeks. The patient successfully underwent mitral valve replacement surgery. Pathological anatomy showed cells with signs of acute and chronic inflammation. Case 2: A 39-year-old male with prolonged fever, significant weight loss, and chest discomfort presented with a continuous crescendo-decrescendo grade II murmur located in the second and third intercostal area. Transthoracal echocardiography (TTE) only showed a patent ductus arteriosus (PDA). Further TEE confirmed it along with an attached mobile vegetation size 4-5 x 5-9 mm. Blood cultures were negative. The patient was treated with ceftriaxone and gentamycin for 2 weeks and is scheduled for surgical PDA closure. Discussion: Both patients showed a similar presentations of infective endocarditis (IE) confirmed by vegetations seen with TEE. Both patients also had an existing cardiac abnormality that allowed for the infection to occur. Treatment by antimicrobial therapy was successful in controlling the infection. Furthermore, surgical intervention is required to repair the existing anatomical abnormality and removal of the vegetation(s). Conclusion: We present 2 cases of IE and their treatment. IE is an infection of the endocardial surface of the heart and most commonly occurs in the presence of anatomical abnormalities. Blood cultures and echocardiography are essential for diagnosis. Treatment firstly consists of antimicrobial therapy and surgery where required. C.81. Figure 1 Open in new tabDownload slide Mitral valve of Case 1 showing a vegetation located at the PML (circled). The valves also appear thickened and calcified C.81. Figure 1 Open in new tabDownload slide Mitral valve of Case 1 showing a vegetation located at the PML (circled). The valves also appear thickened and calcified Keywords Infective endocarditis • transesophageal echocardiography • surgical treatment • mitral regurgitation • patent ductus arteriosus C.82. A Rare Case : Stanford type A Chronic Aortic Dissection in Marfan Syndrome Maria F Delong Maria F Delong Prof Dr. W. Z Yohanes Hospital, Kupang Magma P Putra Magma P Putra Prof Dr. W. Z Yohanes Hospital, Kupang Prof Dr. W. Z Yohanes Hospital, Kupang Case Illustration: A 38-year-old man was referred to Prof Dr. W.Z. Yohanes Hospital Kupang from Rote Hospital (109.7 kilometers away, different island) with chief complaint progressive shortness of breath and indistinct history of tearing chest pain since 1 month before admission. Family history of similar disease was denied. In physical examination we found grade 3/4 early diastolic murmur on left sternal border and rales in both lungs. Systemic features showed wrist and thumb sign, reduced upper segment/lower segment and increased arm span/height, plain flat foot, reduced elbow extension and striae on his mid back. We gave him low dosage of bisoprolol, candesartan, furosemide and spironolactone. During hospitalization, several times the patient’s condition was priorly worsened due to cardiogenic shock. Discussion: Based on revised Ghent criteria, echocardiography and CT scan result, the patient was diagnosed with Stanford type A Chronic Aortic Dissection in MFS (Marfan syndrome), severe AR (Aortic Regurgitation) and CHF (Congestive Heart Failure). MFS prevalence is 2–3 per 10.000.2 MFS is an autosomal dominant disorder caused by mutations in FBN1 gene. Aortic dissection is a life-threatening disease which often found in MFS and commonly involves the ascending thoracic aorta (65%), while chronic dissections presenting symptoms of more than 2 weeks duration.1 For this case, approriate therapy was an aortic operation with operative mortality 1.5% for elective and 11.7% for emergency operations but the patient must be reffered to another hospital in different province.2 Conclusion: We describe a case with 38-year-old man diagnosed as Stanford type A Chronic Aortic Dissection in MFS, severe AR and CHF. The patient must be reffered to another hospital in different province (2000 kilometers away reachable by plane or ship in several days), but could not be done because patient’s unstable hemodynamic. Keywords Marfan syndrome • aortic dissection • surgical therapy • medical therapy. C.83. Endovascular Intervention for Severe Below the Knee Artery Disease Yudistira Panji Santosa Yudistira Panji Santosa Cardiovascular Division, Department of internal Medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia Cardiovascular Division, Department of internal Medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia Case Illustration: A 62-year old, Men, presents with complaint of three month claudication in both leg especially left leg. Pain was associated with numbness. Patient risk factors are hypertension and dyslipidemia. Duplex ultrasound of the leg revealed biphasic wave in bilateral Anterior Tibialis Artery and Posterior Tibialis Artery. CT scan lower limb showed that significant occlusion in left Anterior Tibialis Artery dan Peroneal Artery. We proceed to make arteriography and we found total occlusion from left proximal Anterior Tibialis Artery dan Peroneal Artery. So we decided treat endovascular treatment. Contralateral puncture, with Judkins Right guiding catheter and V14 guide wire could pass stenosis and inserted in distal artery. We dilated with balloon Coyote 2.5 and 3.0 diameter from distal to proximal at anterior Tibialis and Peroneal Artery. Flow was very good and no dissection. After several hour, patient felt no pain and after few weeks numbness also diminished. Discussion: Endovascular intervention for lesions involving the below knee Popliteal Artery is a safe and effective therapy for claudication and prevents amputation. After intervention antiplatelet and statin use is protective against restenosis and mortality in patients peripheral endovascular interventions.Conclusion: Endovascular intervention can be considered for standard treatment in symptomatic below knee lesion in peripheral arterial disease. Keywords endovascular intervention • below knee • peripheral arterial disease • chronic limb ischemia C.84. Endovascular Intervention for Acute Limb Ischemia Yudistira Panji Santosa Yudistira Panji Santosa Cardiovascular Division, Department of internal medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia Cardiovascular Division, Department of internal medicine, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Jakarta, Indonesia Case Illustration: A 68-year old, Men, presents with complaint rest pain in left leg in one week. Pain was associated with numbness. Patient risk factors are Diabetes mellitus, hypertension and dyslipidemia. Patient already has history of cardiac coronary intervention, atrial fibrillation and low ejection fraction heart failure. In physical exam, we found irregular pulse; cold left leg and we cannot found pulse in popliteal and Dorsalis Pedis Artery. In hour, we make arteriography and we found total occlusion from proximal Popliteal Artery. Contralateral puncture, with Judkins Right guiding catheter, V14 guide wire were used for thrombectomy. After that we dilated with balloon 3.0, 4.0 and 5.0 diameters from distal to proximal at popliteal artery. Flow arteries still slow and no dissection. After intervention we give unfractionated heparin for several days and after that double antiplatelet and anticoagulant treatment for one month. After one month, patient felt no pain and no neurological problem. Arteriogram was done with good result in flow to the distal plantar pedis. Discussion: Endovascular therapy is often preferred, especially in patients with severe comorbidities. Catheter-directed thrombolytic therapy is more appropriate in less severe cases without neurological deficit. Conclusion: Endovascular intervention is preferred for acute limb ischemia patient without neurological deficit Keywords endovascular intervention • peripheral arterial disease • acute limb ischemia C.85. Scorpion Envenomation-induced Acute Inferior ST-Elevation Myocardial Infarction: a Case Report Atiya Nurrahmah Atiya Nurrahmah Department of Cardiology and Vascular Medicine Muhammadiyah Lamongan Hospital, Lamongan, East Java, Indonesia Lakhsmi Pramushinta Lakhsmi Pramushinta Department of Cardiology and Vascular Medicine Muhammadiyah Lamongan Hospital, Lamongan, East Java, Indonesia Department of Cardiology and Vascular Medicine Muhammadiyah Lamongan Hospital, Lamongan, East Java, Indonesia Case Illustration: A 40-year-old man presented with pain on right hand after scorpion stung his index finger ten minutes before admitted to emergency units. The patient received analgesic. Immediately after thirty minutes, patient presented with severe substernal anginal chest pain. There was no previous cardiac disease, and the cardiac risk factor was smoking. The patient’s heart rate was 60 bpm, blood pressure was 110/80 mmHg, respiratory rate was 22 breaths/min with mild respiratory distress and oxygen saturation 98% on room air. Initial electrocardiogram (ECG) demonstrated sinus rhythm with ST segment elevations in lead II, III, aVF, V6, and ST segment depression in Lead I, aVL, V1, V2, V4. Right ECG demonstrated ST segment elevation in lead V3, V4, V5, V6, concerning for acute ST Elevation myocardial infarction in the right ventricle and the posteroinferior territory. Echocardiography demonstrated hypokinetic inferior, inferolateral and inferoseptal wall, with ejection fraction was 55%, Tricuspid Annular Plane Systolic Excursion (TAPSE) 1,4 cm and Estimating Right Atrial Pressure (RAP) = 5 mmHg. Result of initial laboratory tests was an increase in serum cardiac biomarker levels (troponin I = 0.13 ug/L). The patient was treated with dual antiplatelet therapy, statin, anticoagulant and thrombolytic. On the sixth day, the patient was totally symptom free and discharged from the hospital. The patient refused to be referred to PCI center. Discussion: This patient fulfilled criteria for scorpion envenomation induced acute myocardial infarction. Because the patient got anginal chest pain right after he was stung by a scorpion. In cases of myocardial infarction after scorpion stings, vasoactive, inflammatory, and thrombogenic substance -such as histamine, serotonin, bradykinin, leukotriens, and thromboxane- are released, may induce coronary artery vasospasm and platelet aggregation, as well as facilitate thrombus formation. Myocardial infarction is an uncommon complication of scorpion stings, however, it has increased risk of heart failure and a high mortality rate within 24 hours. Electocardiography (ECG) is initial management to recognized acute myocardial infarction. Conclusion: We describe a case with scorpion envenomation induced acute myocardial infarction that ECG should be taken immediately for patient who has anginal chest pain after a scorpion sting. Keywords scorpion stings • envenomation • myocardial infarction • electrocardiography C.86. Importance of Wellens Syndrome Villia Damayantie Villia Damayantie Department of Cardiovascular School of Medicine, Padjadjaran University, Indonesia Kurniawan Prakoso Kurniawan Prakoso Department of Cardiovascular School of Medicine, Padjadjaran University, Indonesia Sulis Rahmawati Sulis Rahmawati Department of Cardiovascular School of Medicine, Padjadjaran University, Indonesia Cut Arsy Rahmi Cut Arsy Rahmi Department of Cardiovascular School of Medicine, Padjadjaran University, Indonesia Department of Cardiovascular School of Medicine, Padjadjaran University, Indonesia Case Illustration: A 53-year-old male came to ED with complaint of chest burn. He had been feeling this burning sensation for a week. Complaint was associated with dyspneu and diaphoresis. There was no radiating pain, blackout, nausea and vomitus. He had history of uncontrolled hypertension and smoking 1 pack cigarette per day. Blood Pressure was 180/100 mmHg otherwise within normal limits. The ECG showing T-wave inversion in lead V1-V6, I, and aVL consistent with Type A Wellens Syndrome. Laboratory finding revealed Troponin T 59 ng/dL. Echocardiography showing hypokinetic basal anteroseptal. The patient wad diagnosed with NSTEMI Anterolateral Killip Class I with Stage II Hypertension. He received Heparin IV, Aspilet, Clopidogrel, sublingual ISDN, Bisoprolol, and Ramipril. The CAG revealed severe 3 VD and LM with 95% proximal stenosis of LAD. The patient was scheduled for CABG. Discussion:The diagnostic criteria for Wellens syndrome include the presence of pattern A or pattern B in ECG with history of angina, pain-free period, little of no elevation of ST segment, no Q wave in chest leads, and normal or minimal elevation of cardiac enzyme. Unlike the algorithm of possible ACS with no ST elevation, cardiac stress test is contraindicated in Wellens syndrome patients. When identified, coronary angiography should be performed immediately. If there is significant proximal LAD occlusion, percutaneous coronary intervention (PCI) or CABG should be performed to prevent extensive anterior myocardial infarction. Conclusion: It is important for clinicians to identify the pattern of Wellens syndrome in ECG. Thus, clinicans can provide necessary tests and appropriate management. In patients with suspected ACS with Wellens sign, prompt coronary angiography should be performed to determine treatment options in attempt to prevent extensive anterior myocardial infarction. C.86. Figure 1 Open in new tabDownload slide Initial 12-lead ECG showing sinus rhythm, left axis deviation, left atrial enlargement, left ventricular hypertrophy, T-wave inversion in lead V1-V6, I, and aVL consistent with Type A Wellens Syndrome. C.86. Figure 1 Open in new tabDownload slide Initial 12-lead ECG showing sinus rhythm, left axis deviation, left atrial enlargement, left ventricular hypertrophy, T-wave inversion in lead V1-V6, I, and aVL consistent with Type A Wellens Syndrome. C.86. Figure 2 Open in new tabDownload slide Coronary angiogram showing lesion (arrow) in LAD, LCx, RCA and LM with 95% proximal stenosis of LAD. C.86. Figure 2 Open in new tabDownload slide Coronary angiogram showing lesion (arrow) in LAD, LCx, RCA and LM with 95% proximal stenosis of LAD. Keywords Wellens syndrome • T-wave Syndrome • CAD C.87. Premature Ventricular Contractions That Develops into Malignant Arrhythmia and Cardiac Arrest: a Case Report Sri Yanty Pardede Sri Yanty Pardede Omni Hospital Alam Sutera, Tangerang, Indonesia Berlian Idris Berlian Idris Omni Hospital Alam Sutera, Tangerang, Indonesia Marselinus Surya Marselinus Surya MRCCC Siloam Hospital, Jakarta, Indonesia Omni Hospital Alam Sutera, Tangerang, Indonesia MRCCC Siloam Hospital, Jakarta, Indonesia Case Ilustration: A 64-year-old, otherwise healthy, female came for routine pre-operative evaluation before an arthroscopic procedure. She had no other complaints besides knee pain. History of past or chronic illnesses were denied and no routine medications. Vital signs and physical examinations were unremarkable. ECG strips show PVCs and signs of CAD, but echocardiography was normal. Laboratory results and chest X-ray were also within normal limits. However, 2 hours before procedure she suddenly had a cardiac arrest and monitor show a Torsades de Pointes pattern. CPR and defibrillation was performed with successful ROSC. Discussion: Premature Ventricular Contractions (PVCs) are extra heartbeats that initiated by Purkinje fibers in the ventricles rather than by the sinoatrial node, the normal heartbeat initiator. PVCs may cause no symptoms at all, but they may also be perceived as a "skipped beat" or felt as palpitations in the chest. A single beat PVC do not usually pose a danger. However, very frequent PVCs can be symptomatic of an underlying heart disease and lead to more serious events such as heart failure and lethal arrhythmias. Conclusion: Although most oftenly benign, PVCs still warrants special consideration regarding its safety profile. Further investigation such as EP study is sometimes worth the time, especially in the peri-operative setting. Keywords PVCs • cardiac arrest • malignant arrhythmia C.88. No-reflow Phenomenon in Early PCI of STEMI Patient Rendi Asmara Rendi Asmara Department of Cardiology and Vascular Medicine, Prof. Dr. Margono Soekarjo Hospital Purwokerto, Central Java Rio Probo Kaneko Rio Probo Kaneko Department of Cardiology and Vascular Medicine, Prof. Dr. Margono Soekarjo Hospital Purwokerto, Central Java Department of Cardiology and Vascular Medicine, Prof. Dr. Margono Soekarjo Hospital Purwokerto, Central Java Case Illustration: A 56 yo male patient with chief complaint chest pain typical of angina since 3 days before admission, the heaviest chest pain occurred in 15 hours before admitted to hospital. Patient’s risk factor was heavy smoker. Blood pressure was 85/40 mmHg, HR 45 x/mnt. Physical examination was still normal. The ECG showed 3rd degree AV block, ST segment elevation of inferior leads with Q waves. Hb 11.8, Haematocryte 36.2, Ureum 63.08, Creatinine 1.31, Troponin positive. Patient was diagnosed with Inferior ST-elevated myocardial infarction STEMI onset 15 hours Killip IV with TAVB. Patient received anticoagulant therapy with UFH due to increasing of creatinine level. Until second day of hospitalization patient was still in shock condition with TAVB so we decided to do early PCI. In the cathlab, we placed transvenous temporary pacemaker and performed coronoangiography with the result of total occlusion at mid RCA and 70% stenosis at proximal LAD. Then we decided to do intervention of the IRA, predilatation with compliance balloon several times then we could see the flow was getting better and some thrombus images was identified. Then we delivered drug-eluting stent placed at proximal to mid RCA. After we deployed the stent and did postdilatation, we found that no-reflow phenomenon was occurred. We decided to performed postdilatation using the previous compliance balloon several times from proximal until distal of RCA. The flow was better with TIMI 2 flow so we ended the procedure. Then, patient went back to ICCU and hospitalized for total 10 days and discharged from the hospital with good condition. Discussion: Percutaneous coronary intervention (PCI) has been the treatment of choice in most acute myocardial infarction cases. Although the results of percutaneous coronary interventions have ben good, the no-reflow phenomenon and distal embolization of intracoronary thrombus are still major problems even after successful interventions. Thrombus encountered in the setting of acute coronary syndromes has been correlated with acute complications during percutaneous coronary interventions such as no-reflow, acute coronary occlusion and long term complications such as stent thrombus. The incidence of acute stent thrombosis, occurring within 0-24hours after PCI, is relatively low, but underlying causes and treatment strategy are not well defined. Multi-vessel disease, STEMI, and large thrombotic burden are known risk factors of acute stent thrombosis. Thrombus aspiration, balloon angioplasty and glycoprotein IIb/IIIa receptor blocker could be therapeutic options. Conclusion: The main target of emergency PCI for patient with high risk ACS is to make a flow. If we found thrombus images, it will be much beneficial if we performed thrombus suction because thrombus that still there can make another problem in the coronary flow like no-reflow phenomenon. Keywords no-reflow phenomenon • STEMI • early PCI. C.89. A Very Rare Case Of An Adult With Pulmonary Atresia With Ventricular Septal Defect E Mariska E Mariska Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia S Dwiputra S Dwiputra Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia Michael Michael Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia N Marliyanti N Marliyanti Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia J Sianipar J Sianipar Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia F Handayani F Handayani Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia M S Hidayatullah M S Hidayatullah Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia V Pratama V Pratama Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia A R Permana A R Permana Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia P Pujowaskito P Pujowaskito Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia Cardiology Department Gatot Soebroto Army Hospital, Jakarta, Indonesia Case Illustration: A 28 years old man was initially diagnosed as TOF from other hospital. He was advised to underwent surgery in infancy but his parents refused. The physical examination revealed central cyanotic appearance (SaO2 75%), clubbed fingers, normal heart sound and single S2 with continuous murmur 3/6 in left infraclavicle. Echocardiography showed no pulmonary outflow tract and valves, VSD subaortic 1.7 cm right to left shunt, overriding aorta ± 30%, patent ductus arteriosus (PDA) 1.7 cm, decreased RV function (TAPSE 1.1 cm), normal ejection fraction and other heart valves were within normal limit. Discussion: This patient fulfilled criteria for pulmonary atresia with ventricular septal defect (PA-VSD). PA-VSD is considered as an extreme form of Tetralogy of Fallot (TOF). PA-VSD has poorer outcome due to the complexity of its pulmonary blood supply, compared to classic TOF. The incident of PA-VSD is about 1.4% of all forms of congenital heart disease (CHD) and 0.07 of 100 live births. The survival rate without surgery is about 50% at 1 year old and 8% at 10 years old. Adult survivors of PA-VSD without surgery are rare. The mean life expectancy without operation did not exceed 3 decades. This case presents about a 28 year old man with PA-VSD. Some studies said only small percentage of patients survived into adulthood because an adequate but not excessive pulmonary circulation. The adequancy of pulmonary circulation derived from PDA with or without major aortopulmonary collaterals (MAPCAs). Some factors causing excessive pulmonary circulation are aortic valve dysfunction and elevated ventricular end-diastolic volume. Conclusion: We describe a case with a living adult with PA-VSD which is a very rare case. Futher examination and study are needed to investigate the anatomical malformation and how had he survived. Although PA-VSD is a complex malformation, collateral vessels and PDA may increase life expectancy. Keywords pulmonary atresia • ventricular septal defect • patent ductus arteriosus • tetralogy of fallot C.90. Dilemmatic management of Pre-Excited Atrial Fibrillation: Is Amiodarone Always Harmful? A Case Report Dzikrul H Karimullah Dzikrul H Karimullah Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Ardian Rizal Ardian Rizal Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Evit Ruspiono Evit Ruspiono Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Arif Wibisono Arif Wibisono Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Tri Astiawati Tri Astiawati Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Fitranti S Laitupa Fitranti S Laitupa Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Adriyawan W Nugraha Adriyawan W Nugraha Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Department of Cardiology and Vascular Medicine, Dr. Iskak General Hospital, Tulungagung, East Java, Indonesia; Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya-Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia Case Illustration: A-39-years-old smoker, non-hypertensive, and non diabetic male presented with palpitation at rest. Past history revealed a similar episode of palpitation a year ago which subsided spontaneously. The electrocardiogram (ECG) revealed narrow QRS complex of AF Rapid ventricular Response (AF RVR). Amiodarone intravenous 150mg, followed by 1mg/min for 6 hours and 0.5mg/min for 18 hours were administrated. ECG revealed pre-excited AF RVR 180 bpm with Shortest Pre-Excited RR interval (SPERRI) <230ms with unstable hemodynamic. Unconverted AF with normal ventricular response still occurred despite synchronized electrical cardioversion 150J was performed. We decided to continue Amiodarone with closed observation. Intravenous Amiodarone promptly used to convert to sinus rhythm. ECG revealed AVRT which converted to sinus rhythm 54 bpm with WPW anterosuperior bypass tract. We referred to Saiful Anwar General Hospital for Undergoing Accessory Pathway Ablation. Discussion: Arial Fibrillation (AF) has a different dimension in the context of Wolff-Parkinson-White (WPW) syndrome. Indeed, AF may be a nightmare in young adult who has an accessory pathway (AP) with fast anterograde conduction. The safety of amiodarone use in WPW syndrome is controversial. Hereby we present a case of AF in WPW syndrome converted by amiodarone. Amiodarone use in AF with WPW remains controversial due to its ability to induce ventricular fibrillation. Its major therapeutic effect is to prolong action potential duration and refractoriness of all myocyte fibres. The proposed mechanism of action to terminate AF is that Amiodarone delays AV node conduction with slightly direct effect on atrial or ventricular properties and on bypass tracts as well. Conclusion: Amiodarone may not the be the first line drug in this case, but the effect of prolonged refractory period of the accessory pathway makes this drug especially useful in patients with WPW syndrome and AF over antiarrhythmic agent class I such as flecainide or propafenone. Keywords Amiodarone • Atrial Fibrillation • WPW Syndrome C.91. Left Atrial Myxoma Mimicking Acute Coronary Syndrome Symptom Jefri Jefri Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Hindun Zakiyah Hindun Zakiyah Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Vickry H Wahidji Vickry H Wahidji Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Case Illustration: This case describes a 64 years old male with chief complain of heavy pressure on middle of chest and palpitation. Symptoms not relieve with 5 mg sublingual ISDN. There was no history of tumor in other organs or weight loss. BP: 150/90 with history of uncontrolled hypertension, HR: 86x/minute irregular. Early diastolic low pitched sound or tumor plop sound heard in heart apex. No sign of heart failure. Electrocardiogram show atrial premature complexes and incomplete RBBB. All laboratorium results in normal range. Transthoracic echocardiography revealed a mass that was attached to the interatrial septum, with partial prolapse into the left ventricle, no regional wall motion abnormality. Discussion: A cardiac myxoma is the most common tumor originating from the heart with the most common location is the left atrium. The two main concerns in the setting of a left atrial myxoma are the development of congestive heart failure symptoms from mitral inflow obstruction and embolization of the tumor in circulation. The presence of atypical symptom of left atrial myxoma are rare. In this case symptom of heavy pressure on chest with rbbb pattern lead to diagnosis of acute coronary syndrome, but still further examination such as troponin and imaging should be taken as recommended by the ESC guideline about chest pain. Conclusion: Further examinations such as laboratories and echocardiography can help make a diagnosis despite typical complaints of acute coronary syndrome, such as left atrial myxoma in this case. Keywords Left Atrial Myxoma • Mimicking • Acute Coronary Syndrome C.92. A Missing Guide Wire After Placement of Peripherally Inserted Peripheral Central Catheter, How to Treat and How to Prevent? Hendrawati Hendrawati Faculty of Medicine, Universitas Brawijaya-dr.Saiful Anwar General Hospital, Malang East Java, Indonesia B Satrijo B Satrijo Faculty of Medicine, Universitas Brawijaya-dr.Saiful Anwar General Hospital, Malang East Java, Indonesia T Astiawati T Astiawati Department of Cardiology and Vascular Medicine, dr. Iskak General Hospital, Tulungagung East Java, Indonesia Faculty of Medicine, Universitas Brawijaya-dr.Saiful Anwar General Hospital, Malang East Java, Indonesia Department of Cardiology and Vascular Medicine, dr. Iskak General Hospital, Tulungagung East Java, Indonesia Case Illustration: A 69-year-old, male with multiple comorbidities, including incarcerated inguinal hernia and heart failure because of hypertensive heart disease was admitted to the inward care unit for post operative monitoring. He need to performed a peripherally inserted central line because of difficult peripheral access in his right upper extremity. A nursing staff who was certified for placement of central lines placed the midline independently, without supervision by an experienced physician. During the procedure, the guidewire was pushed into the venous system accidently and was not initially recognized. A checklist was not utilized during the procedure. The x ray of chest and arm were performed to evaluate upper extremity revealed a foreign body in the right arm. At this point, interventional cardiology was notified for possible foreign body retrieval. The interventionalist on duty was able to utilize the existing basilic vein access, and successfully performed a snare retrieval of the guidewire without difficulty. Fortunately, there was no adverse complication to the patient. Discussion: Although complications are relatively lower with the placement of peripherally inserted central catheter (PICC) usage, some may arise which could be serious. Missed guidewire can be associated with the complications such as migration of catheter into the circulation, embolism from fragment of catheter or guide wire,and cardiac tamponade. Guidewire should be removed as quickly and completely as possible. Missed guidewire during the insertion of central venous catheter is a rare and potentially avoidable complication of central venous catheterization. It is frequently underreported due to its iatrogenic nature and medicolegal issues. Conclusion: We want to emphasize and raise awareness of potential complications of the catheter. Close supervision by a senior person, use of ultrasound before and after placement of catheter, and use of a checklist may help to identify and prevent similar complications. The loss of a guide wire is a completely preventable complication, provided that one always holds onto the tip of the wire. Keywords Catheterization • Central Venous • Foreign Bodies C.93. Case Series of Acute Pericarditis Unusual Presentation : Fallacious At First, Content At Last R E Intan R E Intan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia T N Octora T N Octora Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia D R Balti D R Balti Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Case Ilustration: First patient, a 48 y.o woman, came to the ER with typical chest pain since 1 day, and worsen dyspnea. Other symptoms and past illness (-). VS : BP: 100/60 mmHg, HR: 146x/min, RR: 28x/min, T : 37.20C. Physical examination : bilateral rales at the basis of the lung. ECG showed sinus tachycardia with Brugada pattern type 1. She was admitted and treated with diagnosis of ADHF and UAP. A few hours later, her ECG showed widespread deep T inversion in anterior and inferior lead without clinical improvement. (Figure 1a) Second patient, a 46 y.o man, came to ER with progressive chest tightness and epigastrial pain, nausea and vomiting since 2 days. History of uncontrolled hypertension and DOE (+). VS : BP: 230/130 mmHg, HR: 96x/min, RR: 24x/min, T : 36.60C. ECG showed normal sinus rhythm with LVH. He was treated for UAP and HT emergency. The next morning, he had fever with palpitation. ECG showed sinus tachycardia, 145x/min. (Figure 2a). Paracetamol and bisoprolol 10 mg given without improvement. Blood routine test, CKMB, ESR, and CRP are within normal limits in both patients. On careful examination at ICCU, pericardial friction was heard. TTE was performed and showed pericardial effusion, while other parameters were normal (Figure 1c,2c) They were assessed with acute pericarditis. Anti inflammatory cholcisin 0.5 mg and ibuprofen 200 mg was started. The patients responding well and ECG return to normal gradually. (Figure 1b,2b). Evaluation on third week showed normal result. Discussion: Chest pain, along with ECG and cardiac enzym level, usually became the basis of diagnosing ACS. However, other cause of chest pain, such as pericarditis can be missed without careful examination. Pericarditis usually marked by typical ECG features, but that’s not always the case. Conclusion: Acute pericarditis can mimick other symptom such as ACS. TTE is a simple important diagnostic tool to evaluate possible pericardial effusion as the cause. NSAID is a treatment of choice which have good response in most cases. C.93. Figure 1 Open in new tabDownload slide First patient. a. ECG on second day showed diffused T inversion in anterior and inferior lead. b. ECG on last day at hospital, showed normal sinus rhythm with T wave return to normal. c. TTE on second day showed minimal pericardial effusion on posterior, anterior, and inferior with normokinetic and systolic function of LV C.93. Figure 1 Open in new tabDownload slide First patient. a. ECG on second day showed diffused T inversion in anterior and inferior lead. b. ECG on last day at hospital, showed normal sinus rhythm with T wave return to normal. c. TTE on second day showed minimal pericardial effusion on posterior, anterior, and inferior with normokinetic and systolic function of LV C.93. Figure 2 Open in new tabDownload slide Second patient. a. ECG on second day showed sinus tachycardia with HR 145x/min. b. ECG after given coclchisin 0.5 mg and ibuprofen 200 mg, showed normal sinus rhythm. c. TTE on second day showed massive pericardial effusion at basal (2.9 cm) and minimal pericardial effusion at lateral, with normokinetic and systolic function of LV C.93. Figure 2 Open in new tabDownload slide Second patient. a. ECG on second day showed sinus tachycardia with HR 145x/min. b. ECG after given coclchisin 0.5 mg and ibuprofen 200 mg, showed normal sinus rhythm. c. TTE on second day showed massive pericardial effusion at basal (2.9 cm) and minimal pericardial effusion at lateral, with normokinetic and systolic function of LV Keywords acute pericarditis • TTE • pericardial effusion • NSAID C.94. Role of Direct Oral Anticoagulant in Simultaneous Therapy of Cancer-related Venous Thromboembolism Lyra Febrianda Lyra Febrianda Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Adi Purnawarman Adi Purnawarman Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Teuku Heriansyah, Novita Teuku Heriansyah, Novita Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Syiah Kuala, Banda Aceh, Indonesia Case Illustration: Female patient, aged 52 yo, presented with sudden shortness of breath and intense chest pain before admission. The patient is suffering from lung cancer and had removal inferior lobe of left lung six months before admission. We performed Contrast CT of thorax and accidentally found a large thrombus in vena cava superior and inferior. The patient treated by LMWH (enoxaparin), DOAC (rivaroxaban) and P2Y12 Inhibitor (clopidogrel). After 5 days of treatment, Contrast CT of thorax was repeated. No thrombus was detected and no major bleeding complication during treatment. The patient was discharged on seventh day and continued DOAC. Discussion: Cancer-related venous thromboembolism (VTE) is a leading cause of death in cancer patients. The management is still challenging. The majority of current clinical guidelines recommend low molecular weight heparin (LMWH) followed warfarin for the acute or extended treatment. Cancer-related VTE is high risk of recurrence and bleeding during treatment. We treat the patient with combination of LMWH and direct oral anticoagulants (DOAC) simultaneously. In recent studies, DOACs have shown a good efficacy and a better safety profile. Their fixed-dose regimens with predictable effect and less intensive monitoring make DOACs a fascinated choice for thromboprophylaxis and treatment of cancer-related VTE. P2Y12 Inhibitor also prevents the further aggregation of platelets. Conclusion: Under such circumstances it is needful to give DOACs simultaneously with LMWH. These drugs reach the therapeutic effect briefly and at least prevent the further progression of the disease, low risk for Post Thrombotic Syndrome (PTS) and can be continued with less complication. Patients are glad taking drug which neither obligate regular blood testing nor follow up. A larger randomized trial would be needed for stronger evidence. C.94. Figure 1 Open in new tabDownload slide Contrast CT of thorax before treatment C.94. Figure 1 Open in new tabDownload slide Contrast CT of thorax before treatment C.94. Figure 2 Open in new tabDownload slide Contrast CT of thorax after treatment C.94. Figure 2 Open in new tabDownload slide Contrast CT of thorax after treatment Keywords direct oral anticoagulant • venous thromboembolism • cancer. C.95. Development of Extensive Anterior ST Elevation Due to Electrical Injury Jefri Jefri Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Nico Kusuma Nico Kusuma Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia M Rijal Alaydrus M Rijal Alaydrus Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Regional Hospital Prof. Dr. H. Aloei Saboe, Kota Utara, Gorontalo, Indonesia Case Illustration: This case describes a 38 years old male with history of electrical injury one hour before. There was history of unconsciousness right after the accident. No history of other trauma or comorbidity factors of heart diseases. BP: 110/80, HR: 78x/minute regular, no cardiac and lungs abnormality in physical examination. There are grade II burn injury around 18 percent of body area involving both arms. Electrocardiogram show sinus tachycardia with marked st elevation in lead V2-V6, I, and aVL. Laboratorium: leukocytosis (12200/μl). Patient got antibiotic, tetanus prophylaxis and oral isdn, then close monitored in ICCU. One week later patient discharge from hospital. Discussion: ST segment elevation with high probability of myocardial infarction is a potential, though rare, consequence of electrical injury. Based on literature, inferior myocardial infarction is the most common injury due to electrical injury, estimated by the close proximity of right coronary to the chest surface, although the location of injury in this case suspected in left coronary. Coronary arteries were detected to be normal in most of the patients who had MI following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm though be the primary cause although still a hypothesis. Conclusion:ST segment elevation especially in anterior is a rare condition due to electrical injury. Since coronary artery spasm was considered as a possible reason, no fibrinolytic therapy was given to the patient. Keywords Electrical Injury • ST Elevation • Extensive Anterior • Coronary Vasospasm C.96. Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) After Scuba Diving : a Case Report Intan Toekan, MD Intan Toekan, MD Binawaluya Cardiac Center, Jakarta, Indonesia Haikal A Balweel, MD Haikal A Balweel, MD Binawaluya Cardiac Center, Jakarta, Indonesia Beny Hartono, MD Beny Hartono, MD Binawaluya Cardiac Center, Jakarta, Indonesia Binawaluya Cardiac Center, Jakarta, Indonesia Background: Scuba diving is one of the safest water sports. But, recent study showed that the prevalence of myocardial infarction was 11% in divers with >150 professional dives/year. Objective: We report an uncommon case of myocardial infarction after scuba diving Case Illustration: A 57 year old man was referred to our hospital 5 days after suffering from anteroseptal ST elevation myocardial infarction during scuba diving in Labuan Bajo. The symptoms were chest pain, when he went down and worsened when he ascended, followed by shortness of breath and were only medicated with nitroglycerin. His risk factor only hypertension. The first ECG showed Q wave in V1-V2 and ST elevation in V2-V3. The symptoms still remarkable until he came to our hospital with change of ECG that reveals Q wave in V1-V3 and T inversion in V1-V6. His cardiac marker were elevated. The echocardiography showed EF 59%, hypokinetic of anteroseptal wall and LVH. Phyisical examination showed normal result. He was then treated with clopidogrel,aspirin, and statin. We decided to do coronary angiography and the result were normal coronary arteries. The patient were discharged 2 days after admission with no symptoms. Discussion: Due to the patient rapidly ascended, expansion of intraalveolar gas resulted in local pulmonary overpressure and alveolar rupture. Thus, a small amount of air passed into the pulmonary venous component of the bronchovascular bundle, returned to the left side of the heart, and embolized to the left coronary circulation. In this case, a myocardial infarction was confirmed by the electrocardiographic changes, elevated cardiac marker and anteroseptal wall motion abnormality. The possible cause in this case were air embolism. Conclussion: Myocardial infarction can occur as a complication of arterial gas embolism during scuba diving, but does not always reveal a significant obstructive coronary artery disease. A coronary angiogram must be performed in this situation, but must not delay hyperbaric therapy. Keywords Myocardial infarct • scuba • diving • normal coronary artery C.97. Electrocardiographic Change in Acute Stroke: A Case Report Siska Siska Prince Nayef Bin Abdul Aziz Hospital, Banda Aceh Suherman Suherman Department of Neurology of Iskandar Muda Hospital, Banda Aceh Prince Nayef Bin Abdul Aziz Hospital, Banda Aceh Department of Neurology of Iskandar Muda Hospital, Banda Aceh Case Illustration: We present the case of a 79-year-old man who came to the emergency department with decreased consciousness occurred suddenly when the patient was resting. The patient has a history of hypertension and do not take the medication regularly. The GCS score was E3M5V3. Hemodynamic was stable and the blood pressure was 140/80 mmHg. From the physical examination, we found that seventh cranial nerve was paralyzed. Furthermore, there was a weakness of the right side of the extremities. ECG showed an inverted U wave in lead V4 and V5. The patient was referred to another hospital to get specialty care. Discussion: The damage of the central nervous system can affect ventricular repolarization. From the previous research it is known that the most common wave abnormalities are: elevated or depressed ST-segment, inverted T-waves, presence of U-waves, and the most common is prolonged QT interval. Frequently, the changes are found in the anterolateral or inferolateral leads. However, the pathophysiology of this entity is still unclear. Some possible cause has been suggested, including elevated intracranial pressure, vagal tonicity, and excessive stimulation of the sympathetic nervous system with catecholamine production. The leading theory involves the neurohormonal system. Damage to the CNS can result in increased catecholamine levels and sympathetic outflow, which would not only cause electrical problem, but also lead to the damage of physical myocardial. Conclusion: Abnormalities in ECG are commonly seen in cerebrovascular accident (CVA) patients. ECG changes in acute stroke mimic the myocardial ischemia or rhythm disorders. For this reason, it becomes necessity to not misdiagnose the CVA patients with an abnormal ECG. Keywords electrocardiography • inverted U wave • stroke C.98. Paroxysmal Supraventricular Tachycardia in Patient with Hyperthyroidism : A Case Report in Rural Setting Martha O D Savitri Martha O D Savitri Panti Waluyo Hospital Surakarta Reza Y Sari Reza Y Sari Panti Rahayu Hospital Grobogan Robert S Sudirga Robert S Sudirga Panti Rahayu Hospital Grobogan Panti Waluyo Hospital Surakarta Panti Rahayu Hospital Grobogan Case Illustration: A 40-year-old female presented to ED with sudden onset of heart palpitation and dyspnea with a previous history of hyperthyroidism with medication noncompliance and dyslipidemia. She appeared out of breath with BP 130/90 HR 160bpm RR 28bpm SaO2 90%. Exophthalmos, diffuse goiter with thyroid bruit, carotid bruit, systolic mitral murmur were found during physical examination. ECG revealed paroxysmal supraventricular tachycardia (pSVT) 160bpm and depressed ST segment in V2-V6. Thorax Xray showed cardiomegaly. Laboratory findings showed total cholesterol 246 mg/dl, trygliceride 238 mg/dl, FT4 1.46 ng/dl, and TSH 0.16 uIU/ml. There is no echocardiography in our setting. The patient was transferred to ICU and treated with O2 3lpm (nasal cannula), RL 12 dpm, digoxin injection 500mcg single dose at the first day, dexamethasone injection 4x2mg, propranolol 4x20mg, PTU 4x200mcg, aspilet 1x80mg. The ECG converted to sinus rhythm 72 bpm after 6 hours. Patient was discharged home after 4 days with clinical improvement. At outpatient setting, patient was referred to higher center for advance management. Discussion: In this case, patient was in subclinical hyperthyroidism state. This state decreased myocardial contractile reserve and increased cardiac output on exertion. The main manifestations of this state were left ventricular hypertrophy, atrial fibrillation, and heart failure. Actually, pSVT was uncommon in patient with hyperthyroidism. Management of the thyroid dysfunction was crucial. Tacchyarhythmia usually reverts to sinus rhythm by achievement of euthyroid state. Due to limited drug availability, digoxin as atrioventricular nodal blocking agent was used as an acute management of the pSVT. Propranolol, as β-adrenergic-blocker, to reduce heart rate and prompt control of symptoms should be first line therapy. PTU was used to supress thyroid hormones. Dexamethasone was given to prevent peripheral conversion of T4 to T3. However, these patient’s conditions were indications for referral to higher center. Conclusion: Early and effective treatment of hyperthyroidism is a key to terminate pSVT and prevent worsening of the disease C.98. Figure 1 Open in new tabDownload slide Patient’s ECG at the ED C.98. Figure 1 Open in new tabDownload slide Patient’s ECG at the ED Keywords pSVT • hyperthyroidism C.99. Aortic Dissection and Acute Ischemic Cerebral Infarction: A Case Report N L P D A Putri N L P D A Putri Department of Cardiology and Vascular Medicine, Udayana University – Sanglah General Hospital, Denpasar I B R Wibhuti I B R Wibhuti Department of Cardiology and Vascular Medicine, Udayana University – Sanglah General Hospital, Denpasar Department of Cardiology and Vascular Medicine, Udayana University – Sanglah General Hospital, Denpasar Case Illustration: A 53-year-old woman presented at the emergency department with right chest pain and paralysis on her right side body since 2 days before admission. There is a history of uncontrolled hypertension since 10 years ago. Neurological examinations showed right side hemiparesis. ECG result was normal sinus rhythm. Chest X-ray showed cardiomegaly and dilatation of the aorta. Head MSCT scan was performed with results suggesting infarction stroke in right external and internal capsule. Suspicion of aortic dissection was confirmed by echocardiography which showed severe concentric LV and false lumen in aortic arch and descending aorta. Aortic CT angiography showed aortic dissection in ascending aorta up to the aortic arch with intraluminal thrombus down to descending aorta. Eight days later, patient suffered worsening paralysis, and new head CT showed new cerebral infarction. Discussion: Cerebral ischemic complications occur in 18-30% cases of aortic dissections. They result from occlusion at the origin of common carotid artery by dissection flap or due to artery-to-artery embolism from thrombus developed on intimal surface of the dissected artery. By evaluating the symptoms and infarction area in this case report, the stroke was most likely caused by thromboemboli. Dissection ensues after a tear in the intimal layer of blood-vessel creating a space within the plane of medial layer which is known as false lumen. Patient’s management includes surgery, pain control, blood pressure management and heart rate control. In this patient, total arch replacement was planned but the procedure was not performed due to financial problem. Conclusion: Aortic dissection is a life-threatening condition in emergency department. Stroke occurs in 18-20% cases of aortic dissection. Pain, blood pressure, and heart rate control are very important for these patients, as well as immediate surgery. Keywords aortic dissection • stroke • hypertension C.100. Recurrent Rheumatic Fever in the Presence of Rheumatic Heart Disease How to Deal With It? D A Permitasari D A Permitasari Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi Central General Hospital Semarang, Indonesia R W Kusuma R W Kusuma Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi Central General Hospital Semarang, Indonesia F Ahnaf F Ahnaf Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi Central General Hospital Semarang, Indonesia S B Utami S B Utami Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi Central General Hospital Semarang, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine Diponegoro University, Dr. Kariadi Central General Hospital Semarang, Indonesia Case Illustration: A-18-year-old girl was admitted with fever, dyspnea and polyarthralgia. She was previously diagnosed with rheumatic heart disease and already got Erythromycin for secondary prevention of reccurent rheumatic fever. The early diastolic murmur in Erb’s area and pansystolic murmur in the mitral area were evident. The laboratory test revealed positive ASTO titer with elevated leucocyte, Erythrocyte Sedimentation Rate and C-Reactive Protein. The throat swab culture revealed Streptococcus pyogenes and Cefotaxime as culture-based sensitive antibiotic. Chest x-ray showed pancardiomegaly and pulmonary edema. Echocardiography revealed severe mitral and aortic regurgitation without vegetation. These findings indicated that the patient’s suffering from recurrent rheumatic fever. Cefotaxime, ibuprofen, and standard therapy of heart failure were administered. The patient was planned to continue secondary prevention with Erythromycin and scheduled for double valve replacement. Discussion: We describe a rare case of recurrent rheumatic fever in patient with rheumatic heart disease. It sometimes shows that secondary prevention with antibiotic prophylaxis wasn’t fully able to prevent recurrent rheumatic fever, since it largely depends on health education, socioeconomic, and environment. It is still not clear whether antibiotic resistance may interfere efficacy in antibiotic prophylaxis in recurrent rheumatic fever. Conclusion: Recurrent rheumatic fever may cause further cardiac valve damage. Secondary prevention with antibiotic prophylaxis and health education is important to reduce mortality and morbidity from rheumatic heart disease. Keywords rheumatic heart disease • rheumatic fever C.101. Right Atrial and RIGHT VENTRICLE THROMBUS WITH SUSPECT NON HODGKIN’S LHYMPHOMA : A CASE REPORT Grace Nikensari Grace Nikensari Abdoer Rahem Hospital, Situbondo Ariadi Nugroho Ariadi Nugroho Abdoer Rahem Hospital, Situbondo Abdoer Rahem Hospital, Situbondo Case Illustration: Male 74 y.o admitted to emergency room with severe breathless for 1 week and dry cough since 3 weeks before. He was normotensive, tachycardic and tachypneic. Physical examination : solid multiple tumor in colli and antebrachia dextra. Initial ECG showed IRBBB in leads I,II,AVF, V1-V2. Laboratory result are leukositosis, thrombocytosis, increase of PT, aPTT and INR. Echocardiography showed RA and RV dilated with floating thrombus (1,8cm x 0,5cm in RA and 4,57cm x 3,1cm in RV). Discussion: Biopsy could not be done because the patient discharged against medical advice. 10% of patients with lymphoma develop venous thromboembolism related to hypercoagulability due to tumor activating of clotting, vessel wall injury, or venous stasis caused by mechanical compression. Treatment should be individualized according to the thrombus (number and sizes of clots and their mobility and morphology). Anticoagulation and thrombolysis are considered to be the treatment of choice. In this case, the patient received warfarin, aspilet, spironolactone, and Car Q. Conclusion: RA and RV thrombus usually underdiagnosed and uncommon. In this case, right atrial and right ventricle diagnosed by using echocardiography with suspected NHL treated with warfarin, aspilet, spironolactone, and car Q. Keywords Right heart thrombus • Non Hodgkin’s Lymphoma • echocardiography • Pulmonary embolism. C.102. Diffuse Large B-Cell Cardiac Lymphoma: A Rare Case Report of 70 Year-Old Male Presenting as Progressive Dyspnea E D N Rahmawati E D N Rahmawati Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia H Hariadi H Hariadi Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia Budi Y Setianto Budi Y Setianto Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada - Dr. Sardjito Hospital, Yogyakarta, Indonesia Case Illustration: Male 70 years old with large and extensive cardiac lymphoma presented with progressive dyspnea and electrocardiography showed paroxysmal atrial fibrillation. Transthoracal echocardiography revealed large mass in right atrium and left atrium and also extended to pericardial space with moderate pericardial effusion (as shown in figure 1) which considered to be cardiac myxoma at initial. Mass evacuation had been planned for this patient. But surprisingly, mass was extended and the superior vena cava and right atrium difficult to be exposed during procedure open heart surgery (figure 2). So the surgeon decided to took tumor piece for biopsy. Tissue biopsy showed a high-grade diffuse large B-cell lymphoma. Unfortunately biopsy result confirmed 10 days after patient died due to uncontrolled pulmonary infection. Discussion: Cardiac lymphoma is lymphoma located in the heart and/or pericardium. It can be primary or cardiac involvement from other site of lymphoma. It is very rare case contributes 0.5% extranodal lymphoma and mostly affected elderly male. Most common manifestations are pericardial effusion and heart failure. Imaging plays important role in the diagnosis of cardiac masses. Echocardiography provides images of myocardium and cardiac chambers as well. This patient had cardiac masses located in right and left atrium, extending to intrapericardium based on transthoracal echocardiography. Surgical approach with histopathological examination was performed and the histopathological examination revealed diffuse large B-cell lymphoma. Due to poor prognosis, treatment of this malignant tumor is palliative including chemotherapy since this type of malignant tumor is chemosensitive. Conclusion: We describe a case with Non-Hodgkin cardiac lymphoma. It highlights the challenging to establish diagnosis cardiac lymphoma because it is very rare disease and has non-specific clinical manifestation. Delay to establish diagnosis could carry poor prognosis, besides this kind of tumor is very aggressive and rapidly progressive. Transthoracal echocardiography is simple, non-invasive and practical tool to use for defining the detail of tumor. Histopathological examination is the gold standard. Since cardiac lymphoma is chemosensitive, chemotherapy is recommended treatment. C.102. Figure 1 Open in new tabDownload slide Apical 4-chambers view shown large mass in right and left atrium, extending in pericardial space with moderate pericardial effusion C.102. Figure 1 Open in new tabDownload slide Apical 4-chambers view shown large mass in right and left atrium, extending in pericardial space with moderate pericardial effusion C.102. Figure 2 Open in new tabDownload slide Extracardiac mass during procedure open heart surgery C.102. Figure 2 Open in new tabDownload slide Extracardiac mass during procedure open heart surgery Keywords cardiac lymphoma • Non-Hodgkin lymphoma • diffuse large B-cell lymphoma • dyspnea • paroxysmal atrial fibrillation C.103. Transient ST Elevation: immediate or Delayed Invasive Strategy? S P I Nasruddin S P I Nasruddin Cardiology and Vascular Medicine, Sebelas Maret University, Dr Moewardi General Hospital, Surakarta, Indonesia M T Nugraha M T Nugraha Cardiology and Vascular Medicine, Sebelas Maret University, Dr Moewardi General Hospital, Surakarta, Indonesia Cardiology and Vascular Medicine, Sebelas Maret University, Dr Moewardi General Hospital, Surakarta, Indonesia Case Illustration: A 54-year-old man was referred to Dr. Moewardi Hospital with diagnosis of inferior myocardial infarction without initial treatment. He complained about chest pain since 6 hours ago, but symptoms fully resolve upon admission. Prehospital ECG (5 hours of onset) revealed inferior ST elevation with reciprocal changes in high lateral leads. In hospital ECG (6 hours of onset), showed complete normalization of ST elevation. Cardiac enzyme was elevated. Delayed invasive strategy is performed (72 hours of onset), revealed critical stenosis (95%) at mid right coronary artery (RCA) and normal coronary angiography at left coronary artery (LCA). Insertion of one drug eluting stent (DES) at mid RCA was perform without any complications. Discussion: Current guidelines on STEMI or NSTEMI provide no specific recommendations for the treatment of transient STEMI (TSTEMI). Prolonged coronary spasm can trigger coronary thrombosis, while a thrombus forming over a plaque rupture plaque itself can cause coronary spasm due to the release of vasoactive agents by platelets. Also, plaque erosion and temporary thrombotic occlusion could be the underlying aetiology of TSTEMI1. The rationale assumption of delaying angiography and PCI in patients with TSTEMI is will reduce infarct size by reducing the chance of procedural-related complications such as slow or no-reflow, distal embolization, and microvascular plugging. The delay makes it possible to reduce thrombus burden2. Conclusion: We have described a TSTEMI patient with delaying PCI procedure by more than 24 hours is safe, effective, and results in fewer angiographic complications. C.103. Figure 1 Open in new tabDownload slide Pre hospital ECG: Inferior ST elevation with reciprocal changes in high lateral leads. C.103. Figure 1 Open in new tabDownload slide Pre hospital ECG: Inferior ST elevation with reciprocal changes in high lateral leads. C.103. Figure 2 Open in new tabDownload slide In hospital ECG: Complete normalization of ST elevation. C.103. Figure 2 Open in new tabDownload slide In hospital ECG: Complete normalization of ST elevation. C.103. Figure 3 Open in new tabDownload slide Delayed invasive strategy A) Critical stenosis (95%) at mid right coronary artery (RCA). B) PCI was performed with one drug eluting stent (DES) at mid RCA without any complications. C.103. Figure 3 Open in new tabDownload slide Delayed invasive strategy A) Critical stenosis (95%) at mid right coronary artery (RCA). B) PCI was performed with one drug eluting stent (DES) at mid RCA without any complications. Keywords Transient ST elevation • Invasive strategy. C.104. Purulent Pericardial Effusion Treated with Intrapericardial Streptokinase Andre Pasha Ketaren Andre Pasha Ketaren Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia Columbia Asia Hospital, Medan, Indonesia Sabar Petrus Sembiring Sabar Petrus Sembiring Columbia Asia Hospital, Medan, Indonesia Muhammad Khadafi Muhammad Khadafi Columbia Asia Hospital, Medan, Indonesia Department of Surgery, Dr Pirngadi General Hospital, Medan, Indonesia Faculty of Medicine, University of Sumatera Utara, Medan, Indonesia Columbia Asia Hospital, Medan, Indonesia Department of Surgery, Dr Pirngadi General Hospital, Medan, Indonesia Background: Purulent pericardial effusion is a life-threatening condition that may later cause constrictive pericarditis. Treatment for pericardial effusion caused by purulent pericarditis includes drainage and pericardiectomy, but drainage alone may not prevent constrictive pericarditis, while many physicians feel reluctant to perform pericardiectomy to prevent constrictive pericarditis. Intrapericardial fibrinolysis has been proposed as a method to prevent constrictive pericarditis. Case Illustration and Discussion: A 16 years-old male presented with abscess in his left gluteus and shortness of breath. Abscess drainage was planned. Preoperative chest x-ray showed a globular heart, and echocardiography showed massive pericardial effusion. Pericardiocentesis was performed and 500 cc of milky-yellow fluid was aspirated. Antibiotics were also given. For the next seven days, the fluid was still purulent, so streptokinase was injected twice daily into the pericardial space through the pericardial catheter. The fluid become serous after two days of intermittent intrapericardial streptokinase. Follow up echo studies performed two weeks and one month later showed no pericardial effusion nor signs of constrictive pericarditis. Conclusion: A patient with purulent pericardial effusion was treated with pericardiocentesis, antibiotics, and intrapericardial streptokinase and showed good result without signs of constrictive pericarditis on one month follow up. Keywords Purulent pericardial effusion • intrapericardial fibrinolysis C.105. Mitral Valve Endocarditis due to Methicillin-Resistant Staphylococcus Haemolyticus (MRSH) : A Case Finding in Rural Area Ero A Angga Ero A Angga Selong Regional General Hospital, East Lombok, Indonesia Hesti Wulandari Hesti Wulandari Selong Regional General Hospital, East Lombok, Indonesia Selong Regional General Hospital, East Lombok, Indonesia Case Ilustration: A 57 years old man was referred to emergency room with history of fever for 2 months. No symptoms of shortness of breath, chest pain, and exercise intolerance. No history of IV drugs uses and no prostetic valve. Previously tested for thypoid fever, dengue fever, and tuberculosis were negative. Physical examination showed fever (39.3 ̊C), tachycardia and systolic murmur grade 3/6 in MV. Electrocardiogram showed sinus tachycardia and Left Ventricular Hypertrophy. Echocardiographic findings were vegetation in anterior mitral leaflet (1.4x0.6 cm) in size. Left Ventricle (LV) dilatation, moderate mitral regurgitation, and normal LV systolic function (70%). Laboratory test showed leukocytosis and neutrophillia. Three sets of blood culture from 3 different extremities were obtained. Blood culture from right hand resulted methicillin-resistant S. haemolyticus. Vancomycin was sensitive but not available. He was given intravenous gentamicin injection for 2 weeks. Azythromycin were added orally. Discussion: Infective Endocarditis is an infection involving endocardial surface of the heart. The most site of infection in native valvular endocarditis is mitral valve (MV). Staphylococcus aureus and group B streptococci are typically the causative agent of this type of endocarditis. Coagulase negative, staphylococci, Staphylococus haemolyticus, account for less than 5 % of all case native valve endocarditis and has been limited to aortic valve. This patient showed improvement in clinically manifestation and reduction in size of vegetation from 1,4 x 0,6 cm to 1.42 x 0.42 cm during first month therapy. Conclusion: The MRSH endocarditis affecting native mitral valve is a rare disease. Echocardiography and blood cultures are the cornerstone of diagnosis. The sensitive antiobiotic therapy was needed for optimal treatment. Keywords Infective endocarditis • MRSH • blood culture C.106. Myocardial Scar with Right Bundle Branch Block (RBBB) as Assessed by Electrocardiography (ECG) with Symptom Dyspepsia Syndrome is an Predictor of Sudden Cardiac Death of Ventricular Tachycardias (VTs) Monica Dwi Jalma Monica Dwi Jalma Dumai Kota Hospital, Dumai – Riau Province Dumai Kota Hospital, Dumai – Riau Province Background: The presence of myocardial scar, as assessed by Electrocardiography (ECG) is an predictor of sudden cardiac death and all-cause mortality in patients with Ventricular Tachycardias (VTs). Sustained monomorphic ventricular tachycardias (VTs) often due to scar-related fixed re-entry. Slow-conducting parts of these re-entry circuits are found in regions with myocardial scar. Objectives: To present a case of myocardial scar as assessed by electrocardiography (ECG) with symptom dyspepsia syndrome is an predictor of sudden cardiac death with symptoms and change of electrocardiographic (ECG) to ventricular tachycardias (VTs). Case Illustration: A male patient, 46 years old, came to Emergency Unit with complaints of discomfort of cest, but not typical cest pain, and patien also complain to breathlessness, nause and vomitus since the day before. The history of habitual smoker active. Before that, 10 January 2019 patient comes in primery health care and diagnosis is dispepsia syndrome and patient planing for home care with Sucralfat syr 3 dd 10 cc, Vitamin B Complexes 2 dd 1 tablet, and Ranitidin 2 dd 1 tablet. The next day, patient go to emergency unit, 15 January 2019 patient had complain the same symptom, but now it show by jaundice, ECG was sinus tachycardia, left axis deviation, RBBB, and scar in lead inferior, laboratorium was abnormal (bilirubin was elevated), radiology was cardiomegaly. During follow-up in the emergency unit, patient had a seizure with VT in monitor and then patient had cardiac arrest. After 5 cycles cardiopulmonary resuscitation (CPR), patient return of spontaneous circulation (ROSC), but it not long lasting and patient had sudden cardiac death. Conclusion: A case of myocardial scar with RBBB as assessed by ECG with symptom dyspepsia syndrome is an predictor of sudden cardiac death. More important to know ECG changes in patient with symptom of dyspepsia syndrome and we should do a routine holter ECG examination for this condition. Keywords Myocardial scar • Right Bundle Branch Block • Dyspepsia Syndrome C.107. Chronic Tromboembolic Pulmonary Hypertension due to Deep Vein Thrombosis : Case Report D J Simatupang D J Simatupang Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara A A Siregar A A Siregar Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara H Hasan H Hasan Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara Department of Cardiology and Vascular Medicine, School of Medicine, Universitas Sumatera Utara, Medan, Sumatera Utara Case Illustration: We report a case of a 43-year-old woman presenting with shortness of breath. She was referred to Haji Adam Malik General Hospital emergency room after 2 days of hospitalization with clinical suspiscion of Congenital Heart Disease. Physical examination showed systolic murmur in ICS 4 parasternal sinistra. The initial ECG showed S1Q3T3 sign,. Then, the patient underwent a echocardiography with the result RA,RV dilatation with PASP 84 mmHg. The patient went to USG Duplex and thrombus was found at the popliteal vein, the lung perfusion scan was performed with the result obstruction was found at the right lower part of the lung. Discussion: Thromboembolic disease is a rare case that formed of occlusive pulmonary vascular disease and serious condition. The clinical diagnosis based on the history and physical examination is nonspecific. Clinical approach, laboratory and imaging examination, and accurate diagnosis and treatment are essential for outcome. Conclusion: This case report focused on the importance of high suspicion of Chronic Thromboemboly Pulmonary Hypertension due to deep vein thrombosis with presence of sudden shortness of breath with non significant clinical sign. Therefore, clinicians must always be aware of chronic thromboemboly pulmonary hypertension and more concern about management of deep vein thrombosis. Keywords chronic thromboemboly pulmonary hypertension • deep vein thrombosis • lung perfusion scan C.108. Acute Rheumatic Fever with Severe Carditis and Heart Failure ACCF/AHA Stage C, Ross/NYHA Class IV: a Case Report S F Karundeng S F Karundeng Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia R R Akbar R R Akbar Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia A W Astuti A W Astuti Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Teluk Bintuni Hospital, Teluk Bintuni Regency, West Papua 98364, Indonesia Case Illustration: A 9-year-old boy was admitted to the hospital with progressive exertional dyspnea and palpitations for the past 2 months. From the examination, we found evidence of preceeding GAS infection, clinical carditis, elevated ESR, prolonged PR interval, and monoarthralgia. Chest X-Ray revealed bilateral pleural effusion and cardiomegaly with dilatation of all chambers. Abdominopelvic sonography confirmed hepatomegaly with dilatation of central hepatic vein, inferior vena cava and massive ascites. Transthoracal echocardiogram (TEE) revealed dilated all chambers, severe mitral regurgitation, thickening AML and subvalvular, moderate aortic regurgitation with thickening and sclerotic valve, high probability pulmonary hypertension, pulmonary regurgitation, moderate to severe tricuspid regurgitation, and a reduced contracted right ventricle with well contracted left ventricle. Discussion: WHO has decided for the first time that Rheumatic Fever and Rheumatic Heart Disease (RHD) as global health priorities at the World Health Assembly in Geneva on May 2018. Indonesia has a high Rheumatic Fever incidence and prevalence of Rheumatic Fever Disease (RHD). We present a case of Acute Rheumatic Fever with severe carditis and heart failure ACCF/AHA Stage C, Ross/NYHA Class IV patient. The treatment consist of secondary prophylaxis Rheumatic Fever (administration of Benzathine Penicillin G), therapy of severe carditis (initial steroids then aspirin administration), and treatment of heart failure (salt and fluid restriction, diuretics, afterload reduction). The patient was admitted to ICU for 12 days until the failure’s problem subsided. The rest of patient care was done in ward for 1 months with restricted activity. Routine review & management plan (BPG administration, cardiologist/pediatrician/physician review, echocardiography, and dental review) have been working on this patient. Conclusion: Primary prophylaxis (treatment of GAS pharyngitis) is effective in preventing RF, but many cases go untreated (very mild symptoms or subclinical pharyngitis, or inadequate resources). The manifestation of Rheumatic Fever associated with long-term morbidity and mortality is carditis. Keywords Acute Rheumatic Fever • Heart Failure • Bintuni C.109. Challenging Diagnose of Acute Rheumatic Fever with Carditis Manifestation in Children at Rural Area (Type C of General Hospital dr. R. Soedjono Selong, East Lombok) Z Saidi Z Saidi dr. R. Soedjono Selong General Hospital, East Lombok H Wulandari H Wulandari dr. R. Soedjono Selong General Hospital, East Lombok dr. R. Soedjono Selong General Hospital, East Lombok Case Illustration: A 10-year-old girl presented with shortness of breath, paroxysmal nocturnal dyspnea and orthopnea. She complained of arthralgia for 4 weeks. Patient often had a fever that subsided with medicines from the clinic. Physical examination showed tachycardia, other vital signs was normal. We found pale conjunctiva and normal jugular venous pressure. There were left ventricular hypertrophy and holosystolic murmur at the apex spreading to the axilla with ventricular gallop sound. No Bibasilar crackles were found on auscultation. The patient suffered hepatomegaly concomitant with 1+ pitting type of pretibial edema. Discussion: ARF diagnosed based on presences of carditis, fever, arthralgia and increasing titer of streptococcal antibody. Diagnosis of Rheumatic heart disease (RHD) is based on signs of heart failure, pericardial effusion and holosystolic murmur at the apex of the heart which extends to the axilla. Cardiomegaly was identified on the chest x-ray. Transthoracic Echocardiography with adult probe showed normal left ventricular systolic function, impaired relaxation diastolic function, all chamber dilatation with eccentric left ventricular hypertrophy and moderate to severe mitral and tricuspid regurgitation. Conclusion: Carditis is important sign of ARF. Despite endocardium, myocardium and pericardium involvement were various in degree, RHD was associated with murmurs heard in valvulitis. Echocardiography play role for confirming abnormalities found in the heart due to ARF. Keywords echocardiography • carditis • acute rheumatic fever • diagnosis • rural area C.110. A Chronic Case of Migraine and Patent Foramen Ovale Antonia A Lukito Antonia A Lukito Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Rocksy F Vidiaty Rocksy F Vidiaty Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Ingrid M Pardede Ingrid M Pardede Siloam Hospitals Lippo Village Alvin Thengker Alvin Thengker Siloam Hospitals Lippo Village Michelle Widysanto Michelle Widysanto Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Agatha Christiani Agatha Christiani Siloam Hospitals Lippo Village Siloam Hospitals Lippo Village Pelita Harapan University, Tangerang, Indonesia Case Illustration: Migraines remain one of the most debilitating chronic diseases, ruining quality of life of otherwise healthy men and especially women during their productive years. The medications for migraine mostly are effective, yet have disabling side effects and limited efficacy leave a treatment gap. It was postulated a cause and effect relationship between migraine and patent foramen ovale (PFO). However, it’s appeared that not infrequently PFO closure fail to improve the migraine symptoms. A 47-yo female was referred from a neurologist with long standing migraine aggravated by frequent hospitalization episodes since 4 years ago. She has well controlled hypertension by candesartan and subclinical hyperthyroidism. The neurologist colleague had conducted thorough investigations, include laboratory studies, chest X ray and brain MRA, but the results were unremarkable. The TEE was then carried out with bubble contrast using agitated saline revealed the bubbles across the septum from right atrium to left atrium. The PFO was confirmed. Discussion: In this case, the migraine was highly symptomatic and decrease the patient’s quality of life with many episodes of hospitalization, which was not controlled by medications. Although the PREMIUM trial was failed to show the benefit of PFO closure in improving migraine symptoms, yet according to the expert opinions, PFO closure might have beneficial effect for filling the treatment gap of chronic migraine sufferers. Conclusion: TEE with bubble contrast should be carry out in the case of chronic migraine to rule out PFO. The PFO closure may be considered when the medications do not help to alleviate the symptoms of chronic devastating migraine. Keywords chronic migraine • patent foramen ovale • bubble test • PFO closure C.111. A Case of Supraventricular Tachycardia Associated with Wolff-Parkinson-White Syndrome in Child R A Musyaddad R A Musyaddad RS. Jantung Hasna Medika Cirebon S F Nadya S F Nadya RS. Jantung Hasna Medika Cirebon Y P Rachmawan Y P Rachmawan RS. Jantung Hasna Medika Cirebon G I Hidayat G I Hidayat RS. Jantung Hasna Medika Cirebon RS. Jantung Hasna Medika Cirebon Case Illustration: A 9-year-old female patient presented to ED with palpitation, chest discomfort and dyspnea worsening in 2 days before admission. She was stable, afebrile, BP:99/60 mmHg, HR 223 BPM, and physical examination was within normal limit. Laboratory blood examination showed leukocytosis of 18 10^3/ul, electrolyte level and thyroid hormone level was normal. ECG examination revealed narrow complex tachycardia at 223 BPM thus conforming SVT, and there was abnormal p wave following the QRS complex. The patient remained alert, a trial of vagal maneuvers are unsuccessful, and initiate intravenous bolus of digoxin 0.25 mg was given followed by a push of 10 ml normal saline. After 5 hour, the rhythm didn’t revert. Initiate intravenous bolus amiodarone 150 mg for 30 minutes which the rate slowly reduced to 106 BPM and reverted to sinus rhythm after an hour of amiodarone treatment and followed by maintenance dose amiodarone 0.135 mg/minute for 24 Hour. ECG findings post treatment revealed sinus rhythm as evidence by the present short PR interval, QRS complex widened and delta wave (QRS has slurred rather than a sharp upstroke). Discussion: The most age at presentation SVT in childhood is within the first 2 months of life, and after the newborn period, the peak age for first occurrence of childhood SVT is about 8 years. SVT is common in children associated with WPW. WPW syndrome is an electrical abnormal conduction due to the presence of AP. When the AP is present, it can serve as a pathway for reentry which result in paroxysmal tachycardia. This case is a typical presentation of SVT, successfully managed with IV amiodarone after failed treated with vagal maneuvers and IV digoxin, all treatments that aim to block the AV node to terminate the circuit. Following the management of arrhythmia, delta wave is detected in ECG suggestive of pre-excitation in WPW syndrome. The pathophysiology WPW syndrome lies an aberrant re-entrant electrical pathway in conducting system of the heart, which responsible for all the rhythm changes. Conclusion: We report a case of SVT with WPW Syndrome in a child. To assess WPW syndrome on ECG during tachyarrhythmia it’s very difficult and it can be evaluated after converted. This case highlights the importance of follow-up of arrhythmias patients and interpreting ECG after acute management of arrhythmia. C.111. Fig. 1 Open in new tabDownload slide ECG at admission C.111. Fig. 1 Open in new tabDownload slide ECG at admission C.111. Fig. 2 Open in new tabDownload slide ECG after Amiodarone treatment C.111. Fig. 2 Open in new tabDownload slide ECG after Amiodarone treatment Keywords Supraventricular Tachycardia • WPW Syndrome C.112. The Link between Anomaly of Conus Branch Artery and Arrhythmias Jennifer M Widysanto Jennifer M Widysanto Cardiovascular Department, Pelita Harapan University Antonia A Lukito Antonia A Lukito Cardiovascular Department, Pelita Harapan University Siloam Hospital Lippo Village, Tangerang, Indonesia Cardiovascular Department, Pelita Harapan University Siloam Hospital Lippo Village, Tangerang, Indonesia Case Illustration: The incidence of coronary artery anomaly is 0.2-1.2%. Coronary anomalies may cause ischemic myocardial and sudden cardiac death. Conus artery normally arise from RCA and it supplies the Right Ventricular Outflow Tract (RVOT) and a large portion of anterior free wall of the right ventricle. A dyslipidemic 59-yo female presented with palpitation and near syncope episodes for 2 months. A detailed-studies was performed and sinus tachycardia with incomplete RBBB was found on ECG, a moderate TR with dilated RA and RV on echocardiogram, and a negative ischemic response with Paroxysmal Atrial Fibrillation (PAF) and PVC’s on treadmill stress test. Eventually, these results lead to coronary CT and revealed an anomaly of conus artery originated from the right cuspid of aorta and terminating into RV. Discussion: This finding may explain the cause of arrhythmias. Because of the conus artery supplies the RVOT, it may cause arrhythmia from benign like this case until lethal types. This is may be due to a blockage or narrowing by incidental emboly of the conus branch from aorta. Anatomic variation of this branch can be an important limiting factor leading to different conclusions about the frequency and type of arrhythmias. Conclussion: Conus anomaly sometimes has a deadly-consequences, yet the incidence is rare and usually found incidentally. Coronary artery anomalies should be considered in patients with unexplained arrhythmias and have no background risk factor. C.113. Torsade de Pointes in Young Adult Women with Hypokalemia without Structural Heart Disease Yusa A Nurhuda Yusa A Nurhuda Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia Niniek Purwaningtyas Niniek Purwaningtyas Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University, Surakarta, Indonesia Case Illustration: Female 25 yo admitted to the emergency department because she experienced syncope about 5 minutes. She did not take any medication before. Her electrocardiogram (ECG) shown sinus bradycardia with bigeminy premature ventricular contractions (PVCs) and prolongation of corrected QT interval (560 ms). Twelve hours after patient admitted to the hospital, her ECG shown Torsades de pointes (TdP). Her laboratory test shown severe hypokalemia (2.0 mmol/L), and then she was given intravenous potassium and intravenous lidocaine. Her echocardiogram suggested normal wall motion, normal heart valves, and normal ventricular function. When her potassium was normal, her ECG did not show PVCs and TdP. Discussion: Torsades de pointes is one of the life threatening arrhythmias. TdP can manifest as syncope or sudden cardiac death. As many as 10% to 20% of individuals dying suddenly have no evidence of structural heart disease. Hypokalemia-induced TdP is attributed to prolongation of QT interval. Hypokalemia is one of the common causes of QT prolongation. It got corrected with potassium replacement. Mild to moderate hypokalemia well tolerated in normal healthy people. However, severe hypokalemia in healthy people could lead to the arrhythmias. Increasing serum potassium by administration of potassium has been shown to shorten the QT interval. Intravenous potassium should be given for patients with severe hypokalemia. Serum potassium should be maintained at upper limit of the normal range (4.5-5 mmol/L). Conclusion: The reason for reporting this case is to highlight that TdP can be developed in healthy people with severe hypokalemia without evidence of structural heart disease. Intravenous potassium should be given to increase serum potassium in this case. It has been shown to shorten the QT interval. Keywords Torsades de pointes • hypokalemia • prolonged QT interval • healthy people • potassium replacement. C.114. Bifurcation Stenting in Patient with Coronary Anomaly : RCA Arising from LAD - A Case Report Gunarsa Gunarsa Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University/Sanglah Hospital, Denpasar, Indonesia Junior Rina Artha Junior Rina Artha Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University/Sanglah Hospital, Denpasar, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University/Sanglah Hospital, Denpasar, Indonesia Case Ilustration: We report a case of male, 71 years old with history of chest discomfort, came to Sanglah Hospital for coronary angiography evaluation and elective PCI. Patient had been hospitalized with ACS at one private hospital at Gianyar 6 month before admitted to Sanglah Hospital. Patient had been done elective PCI twice at Siloam Hospital on January 2nd 2018 and March 12th 2018 on LAD. No shortness of breath nor palpitation before. He had history of hypertension since 2 years ago with poor medical compliance, diabetes mellitus without medication and history of stroke on 1990. Physical examination was within normal limit except for blood pressure 140/80 mmHg. Electrocardiogram revealed normal sinus rhythm 60 bpm. Transthoracic echocardiogram (TTE) found normal cardiac chamber dimension, no LVH, normal left and right ventricular systolic function (LVEF biplane 70% & TAPSE 23mm), global normokinetic and normal valves. From coronary angiography found with non significant lesion at LM, calcified at LAD with patent stent at proximal to mid LAD, RCA arising from proximal LAD with stenosis 80% at proximal and mid RCA. The patient assesed with CAD/2VD, anomaly RCA arising from proximal LAD and DM type 2. We use BL 3.5/7F for cannulation into LCA. Patient had been done successful elective PCI with DES at osteal to proximal RCA and DES at proximal LAD with Final Kissing Balloon Technique. Optimal medical therapy and risk factor management also important. Discussion: The anomalous origin of RCA arising from LAD, a subgroup of single coronary artery, is extremely rare and was found in 1 of 70.850 patients (0.0014%) undergoing coronary angiography in Turkey. The anomalous coronary artery may run in front of the main pulmonary artery, posterior to the aortic trunk or between the aorta and main pulmonary artery. Anomalous vessel does not appear to be predisposed to develop atherosclerosis. In this case, risk of atherosclerosis increase by diabetes and hypertension with poor medical compliant. Management of anomalous coronary artery lesion is still no concensus and controversial. Medical treatment is generally proposed in asymptomatic patients, with no malignant subtype and in the absence of associated severe coronary artery disease and/or overt ischemia. Surgical treatment is generally proposed in the other cases. Percutaneous coronary intervention may be an alternative treatment choice to surgery, especially in patients with high surgical risk and complex coronary anatomy. In older patient with anomalies coronary artery lesion, PCI with medical treatment prefer than surgery. Choosing appropriate guiding catheter is equally important in doing angioplasty in the anomalous coronary artery. The decision should balance between good catheter support and risk of perforation. We choose 2 stent technique with final kissing balloon inflation in this case. Conclusion: We report a case of anomalous RCA arising from proximal LAD with 2 stent technique PCI with final kissing ballon technique. PCI in patient with single coronary anomalies is still debated but prefer in older patient. Keywords coronary anomaly • RCA arising from LAD • PCI C.115. Ortner Syndrome as a Complication Patient with Severe Mitral Regurgitation A Basworo A Basworo Department of Cardiology and Vascular Medicine, Dr. Soetomo Hospital, School of Medicine, Airlangga University, Surabaya, Indonesia A Subagjo A Subagjo Department of Cardiology and Vascular Medicine, Dr. Soetomo Hospital, School of Medicine, Airlangga University, Surabaya, Indonesia Department of Cardiology and Vascular Medicine, Dr. Soetomo Hospital, School of Medicine, Airlangga University, Surabaya, Indonesia Case Illustration: Male 47 yo presented to our outpatient department with history of shortness of breath, palpitations and insidious onset hoarseness of voice since a year ago. Physical examination revealed late systolic murmur in apex. Echocardiography confirmed severe mitral regurgitation due to prolapse anterior mitral valve leaflet with hugely dilated left atrium (9.0 cm). Laryngoscopy showed left vocal cord paralysis. He underwent successful mitral valve replacement. After 3 months there was partial improvement in hoarseness of voice and the patient is under follow up. Discussion: This patient fulfilled criteria for ortner syndrome. Mitral valve disease to be responsible in 0.6–5% cases of recurrent laryngeal nerve paralysis. The recurrent laryngeal nerves which branch from vagus nerve provide ipsilateral motor innervations to the intrinsic laryngeal muscles for vocalization. In unilateral vocal cord palsy due to thoracic diseases, left-sided vocal cord paralysis was 1.75 times more frequent than right-sided paralysis. Neck and chest CT/MRI should be done in patients with no laryngeal cause of hoarseness is identified and if echo is normal. As we have ruled out laryngeal causes of hoarseness and echocardiography showed hugely dilated left atrium, we have not done CT/MRI. Conclusion: We describe a case with ortner syndrome due to severe mitral regurgitation. Ortner syndrome is an important differential diagnosis of loss of voice. Comprehensive evaluation and intervention allow reversal of the damage to left recurrent laryngeal nerve, whereas delay in diagnosis may lead to permanent nerve injury. Keywords ortner syndrome • mitral regurgitation • cardiovocal syndrome C.116. The Necessity of Anticoagulant on Wolff-Parkinson-White Syndrome Hendyono Lim Hendyono Lim Cardiovascular Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Petra O P Wahjoepramono Petra O P Wahjoepramono Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Neurosurgery Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Antonia A Lukito Antonia A Lukito Cardiovascular Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Cardiovascular Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia Neurosurgery Department, Siloam Hospitals Lippo Village, Tangerang, Indonesia Case Illustration: A 23 years old female, presented with sudden weakness of right side body and numbness of left side body. Brain MRI confirmed infarct site at lateral of spinal cord caused by thrombus. The 12 lead ECG (figure 1) showed short PR interval with delta wave, typical characteristic of pre-excitation. This patient recalled history of recurrent palpitation episodes during childhood. Both transthoracic and transesophageal echocardiogram show normal cardiac chambers and function with no significant intracardiac shunt (PFO or septal defects). Anticoagulation protein C and S also antithrombin III were within normal limit. She was put on anticoagulant and planned for AP catheter ablation. Discussion: We reported a case of cryptogenic stroke in young patients with ECG findings fulfilled Wolff-Parkinson-White (WPW) syndrome criteria. WPW syndrome applied to patients with both pre-excitation on the ECG and paroxysmal tachycardia, with incidence of atrial fibrillation (AF) reported around 20-25%. About quarter of ischemic strokes are cryptogenic with cardiac source of embolism as the possible culprit. There are several possible mechanisms trigger development of AF in WPW syndrome, included spontaneous degeneration of atrioventricular reciprocating tachycardia in AF, the effects of AP on atrial structure, and intrinsic atrial muscle vulnerability. Conclusion: To date, treatment of WPW syndrome still focusing on prevention of tachyarrhythmia and ablation of accessory pathway (AP). Development AF in WPW syndrome may be life-threatening in setting of fast anterograde AP conduction, because of rapid ventricular response may develop into ventricular fibrillation. Besides that, AF also increase incidence of thrombus formation which is accounted as a culprit of cryptogenic stroke. Several studies reported decrease incidence of AF after successful catheter ablation of AP, but sustained episodes of AF still occur in certain patients. This should be a consideration for anticoagulation treatment on WPW syndrome besides prevention of tachyarrhythmia. Keywords wolff-parkinson-white syndrome • atrial fibrillation • tachyarrhythmia • cryptogenic stroke • anticoagulant. C.117. Acute Left Main Coronary Artery Occlusion Manifesting as ST-Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention and Insertion of Intra-Aortic Balloon Pump: A Case Report Robert A Raharjo Robert A Raharjo Faculty of Medicine, Diponegoro University, Semarang, Indonesia Safir Sungkar Safir Sungkar Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Mohamad F A Murtazam Mohamad F A Murtazam Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Pipin Ardhianto Pipin Ardhianto Faculty of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Sulistiyati B Utami Sulistiyati B Utami Faculty of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Mochamad A Sobirin Mochamad A Sobirin Faculty of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Rahageng W Kusuma Rahageng W Kusuma Faculty of Medicine, Diponegoro University, Semarang, Indonesia Aldila N Sulma Aldila N Sulma Faculty of Medicine, Diponegoro University, Semarang, Indonesia Sodiqur Rifqi Sodiqur Rifqi Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Faculty of Medicine, Diponegoro University, Semarang, Indonesia Department of Cardiology and Vascular Medicine, Kariadi General Hospital, Semarang, Indonesia Case Illustration: A 56-year-old man without previous medical history presented with typical chest pain of 3-hours onset. The patient was hypotensive (90/60 mmHg) and tachypneic (30 times/min) with pulmonary edema on presentation. The electrocardiogram showed ST-elevation in leads aVR, aVL, and V1-V2, with ST-depression in all other leads (Fig. 1). The patient was arranged for PPCI and was given the loading dose of aspirin and ticagrelor, maintained thereafter. Intra-aortic balloon pump (IABP) was inserted through left femoral artery and PPCI was performed through right femoral artery. The coronary angiography of the LMCA revealed a thrombus-type total occlusion at the distal left main coronary artery (LMCA) (Fig. 2) with Rentrop 2 collateral to left circumflex artery. Pulseless ventricular tachycardia complicated the procedure and the patient was successfully resuscitated. Three drug-eluting-stents were placed in proximal LMCA to mid LAD with a resultant TIMI 3 flow and improved hemodynamic. At the second day in CCU, the patient deteriorated and was intubated. Invasive hemodynamic assessment wasn’t routinely performed in our hospital, as in this patient. Hemodynamic assessment was only supplemented by ultrasonography device. The patient developed hematemesis, azotemia, pneumonia, and decreased consciousness. A multidisciplinary team optimized the therapy. Unfortunately, the patient died on the fourth day of hospitalization. Discussion: Albeit essential, the management of LMCA STEMI do not stop at prompt diagnosis, timely PPCI, and IABP. Post-PPCI care in CCU is also crucial in ensuring favorable outcome. Earlier mechanical ventilation, invasive hemodynamic monitoring, proper echocardiography examination, and gastrointestinal bleeding prevention might improve the outcome in this complex patient. Conclusion: We describe a case of LMCA STEMI and highlight that all aspects of management are important to ensure the best outcome for this population. C.117. Figure 1 Open in new tabDownload slide C.117. Figure 1 Open in new tabDownload slide C.117. Figure 2 Open in new tabDownload slide Left coronary arteriography before (A) and after (B) primary percutaneous coronary intervention. C.117. Figure 2 Open in new tabDownload slide Left coronary arteriography before (A) and after (B) primary percutaneous coronary intervention. Keywords STEMI • left main coronary artery • primary percutaneous coronary intervention • intra-aortic balloon pump • mortality C.118. Acute Coronary Occlusion and In-Stent Thrombosis in a Patient With Essential Thrombocythemia Eka S Wulandari Eka S Wulandari Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia Bagus A Pradnyana Bagus A Pradnyana Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine, Udayana University, Bali, Indonesia Case Illustration: Male 86-year-old with history of essential thrombocytemia (ET) admitted to ER with acute anterior MI just few hours after discharged from hospitalization for an elective PCI procedure that he had one day earlier. He firstly diagnosed with ET 3 months ago, treated with aspilet 80 mg OD. The platelet count was 1.102.000/mm3 prior the procedure. He had 3 vessels disease and CTO on RCA with deployment of DES in LAD artery. Primary PCI that has performed showed total occlusion with thrombus in the proximal part of the previous LAD stent. After dilatation of the totally occluded artery at proximal LAD, patient developed cardiac arrest during procedure and successfully resuscitated. Procedure was terminated with coronary flow showed TIMI 3 flow of the LAD artery, eptifibatide was administered with addition of aspirin, ticagrelor, hydroxyurea (HU) and low-molecular-weight heparin. Patient was stable for the first 2 days, but at the third day he developed refractory VF unresponsive to resuscitation and was pronounced dead. Discussion: Essential thrombocythemia (ET), a chronic myeloproliferative disease, is characterized by an increased number of platelets and increased risk of vascular thrombosis. Coronary artery involvement leading to acute coronary syndromes is a rare complication of ET. The reoccurence of coronary thrombosis in this patient could be explained by several factors, including the presence of a prothrombic state (ET), the use of intracoronary stent (potentially thrombogenic source), underlying atherosclerotic plaques that potentially become unstable after prior stenting, and the discontinuation of eptifibatide treatment. Conclusion: We describe a case of acute coronary occlusion and in-stent thrombosis in a patient with ET. ET patient with high risk for trombotic event undergoing stent placement need optimal antiplatelet treatment and normalization of platelet count using myelosuppresive drug prior and after the procedure. Keywords essential thrombocythemia • acute coronary syndrome • in-stent thrombosis • percutaneous coronary intervention C.119. A Young Female with Refractory Wide Complex Tachyarrhythmia : When There’s No Bullet Left Giovanno R Maulana Giovanno R Maulana Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Deri Arara Deri Arara Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Muhammad Fadil Muhammad Fadil Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Masrul Syafri Masrul Syafri Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Muhammad Syukri Muhammad Syukri Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Andalas University/ DR. M. Djamil General Hospital, Padang, West Sumatera, Indonesia Case Illustration: A 36-year-old female presented with persistent palpitation that’s been going for 4 days. There was no history of tachyarrhytmia. The vital signs are blood pressure 129/99 mmHg, heart rate 190 bpm regular, respiration rate 18 times per minute and saturation 98% on 4L/m bi-nasal canule. An ECG showed SVT with aberrancy. Laboratory findings showed hypokalemia and hypomagnesemia, other findings were normal. The patient had been treated with intravenous amiodarone 150 mg bolus and continuous drip. The ECG didn’t convert for more than 12 hours and then we decided to perform electrical cardioversion but until 3 times with the dose of 50 J, 100 J, and 150 J but still did not convert, then after giving verapamil with dose of 80 mg bid orally the ECG converted to sinus rhythm and was discharged with oral verapamil. Discussion: Refractory tachyarrhythmia is a rare and very challenging case. We have to correctly differentiate the ECG using the wide complex QRS tachycardia algorithm and in this case we diagnosed the patient as SVT with aberrancy. Adenosine is the first line therapy, then followed by intravenous beta blockers and CCBs but due to limited resources we gave amiodarone instead. Unfortunately the SVT lasts even we performed electrical cardioversion. Eventually we gave oral verapamil. Conclusion: Wide complex tachycardia could lead to misdiagnose, therefore physicians should be cautioned. Even after using the appropriate therapeutic algorithm, it does not guarantee that the therapy will convert the arrhythmia. Then we refered the patient for undergo electrophysiology study for further examination. Figure 1 Presenting electrocardiogram of the patient Keywords SVT • abberancy • tachyarrhythmia • cardioversion. C.120. Wolff-Parkinson-White (WPW) Syndrome as An Underlying Culprit of Supraventricular Tachycardia in Pregnancy : A Case Report A S Rahayu A S Rahayu Urip Sumoharjo Hospital, Bandar Lampung, Indonesia K Wijayanti K Wijayanti Soewondo Regional Public Hospital, Kendal, Indonesia J Budiman J Budiman Pharmacology Department, Faculty of Medicine, Soegijapranata Catholic University, Semarang, Indonesia R Handayani R Handayani Urip Sumoharjo Hospital, Bandar Lampung, Indonesia Urip Sumoharjo Hospital, Bandar Lampung, Indonesia Soewondo Regional Public Hospital, Kendal, Indonesia Pharmacology Department, Faculty of Medicine, Soegijapranata Catholic University, Semarang, Indonesia Case Illustration: A 29 year-old primigravida at 29 weeks of gestation was referred to our hospital with palpitation, shortness of breath, and substernal chest dyscomfort. She has never suffered from similar symptoms previously. In previous hospital, her electrocardiography (ECG) showed supraventricular tachycardia (SVT). She was given isosorbide dinitrate and digoxin orally as adenosine was not available in the hospital. Suddenly, her symptoms worsen so she was referred to our hospital. In our hospital, she was compos mentis with hemodinamically stable condition and her ECG was consistent with WPW syndrome. She was given verapamil orally. Her symptoms improved and she was discharged 4 days later. Discussion: This report indicates increased propensity for SVT in pregnancy with underlying preexcitation. Several hypothetical mechanisms have been invoked to explain this phenomenon which include hemodynamic, autonomic, hormonal, and emotional changes. The physiologic volume overload during pregnancy resulting in increased left ventricular end diastolic volume and myocardial irritability. Elevated heart rate in WPW syndrome may induce unidirectional block in the reentrant circuit and start atrioventricular reciprocating tachycardias. The occurence of tachycardia makes WPW syndrome clinically significant. Acute management of SVT in pregnancy is challenging because the available data are limited. In acute setting, carotid massage should be started. If failed, it is recommended to give adenosin as first line treatment followed by low dose beta blocker. Verapamil can be given as second choice only for patients in second and third trimester. If drugs are failed or patient presenting with life threatening symptoms, it is recommended to start cardioversion. Conclusion: WPW syndrome could trigger SVT in pregnant patient. However, further studies with more patients shoud be conducted to clarify the cause of this association. Keywords Wolff-Parkinson-White (WPW) syndrome • supraventricular tachycardia • pregnancy C.121. Myocarditis Mimicking Acute Inferolateralposterior ST Elevation Myocard Infarction Evi F Lubis Evi F Lubis Bumi Waras Hospital, Bandar Lampung, Lampung, Indonesia Kuswandi Kuswandi Bumi Waras Hospital, Bandar Lampung, Lampung, Indonesia Bumi Waras Hospital, Bandar Lampung, Lampung, Indonesia Case Illustration: A 31-year-old male experienced severe chest pain suddenly while being hospitalized because of fever. Previously, this complaint of chest pain has not ever been experienced by him. He had no family history with cardiac disease. ECG image showed inferolateralposterior ST elevation. Elevated cardiac biomarker was found. When onset of chest pain undergo to 2 hours, we treated as ST elevation myocard infarction and performed trombolytics with alteplase accordingly. Immediately coronary angiography was performed and showed non obstructive lesion of coronary arteries. Echocardiogram showed concentric left ventricular hypertrophy (LVH), regional wall motion abnormalities (RWMA), efusi pericard minimal and diastolic dysfunction. After 1 month of clinical onset, transthoracic echocardiography (TTE) and cardiovascular magnetic resonance imaging (CMR) were performed. TTE confirmed hypokinetic inferior, apicoinferior and apicointerior. CMR confirmed hypokinetic at apico-basal inferior and mid-basal inferolateral, myocardial edema at basal lateral and non-ischemic scar at apico-basal infero lateral and apico-basal inferior. Discussion: We suspected this patient to have myocarditis because he has clinical manifestation of severe chest pain and fever, ECG image ST segment elevation with elevated cardiac biomarker and normal coronary arteries. To confirm our suspicion to myocarditis was needed CMR to find specific sign about myocarditis. Conclusion: Clinical manifestation including normal coronary angiography and late gadolinium enhancement (LGE) in CMR can help to determine the diagnosis of myocarditis and different from acute myocard infarction. Keywords Myocarditis • acute myocard infarction • CMR • LGE C.122. Case Report: Heavy Physical Activity Induced Myocardial Infarction in Young Adult with Strong Family History D P Widiaputro D P Widiaputro Faculty of Medicine, Mataram University, Mataram, Indonesia D Z P Andiyani D Z P Andiyani Faculty of Medicine, Brawijaya University, Malang, Indonesia Faculty of Medicine, Mataram University, Mataram, Indonesia Faculty of Medicine, Brawijaya University, Malang, Indonesia Case Illustration: A 25 years old man presented to emergency department with 2 hours history of new onset retrosternal chest pain after pushed motorcycle for about 1 km. The pain was dull, heavy but not radiating and it was accompanied with diaphoresis. It was not relieved with analgesic medication consumption. His cardiovascular risk profile was only premature of coronary artery disease in family history (his father and his brother suffered from myocardial infarction in young age). The patient never smoked, denied any use of drugs or alcohol, and no history of hypertension. The physical examination of arrival showed that the patient was awake with blood pressure was 180/100 mmHg, pulse 110x/minute, respiration rate 24x/minute and SpO2 99%. Nutritional status is normal with BMI 24,96. Lung and cardiac examinations were normal. Initial 12-lead ECG demonstrated sinus tachycardia with pulse rate 110 bpm and showed ST-segment elevation involving anteroseptal lead as shown at figure 1. Laboratory test (lipid profile, physiological hemostasis, random blood glucose showed normal result) and thorax x ray showed normal result. Echocardiography showed severe hypokinetic at anteroseptal mid apex segment with 39% of ejection fraction. The patient was administered with streptokinase and unfractionated heparin in addition to double antiplatelet, beta blocker and statin medication. On the 3rd day, he was referred to the hospital that can do percutaneous coronary intervention. It showed small coronary size and 8 occlusions (>70% occlusion in left anterior descending artery, 1st and 2nd diagonal branch of left anterior descending artery and 2nd obtuse marginal of circumflex artery, <70% occlusion in right coronary arteries). Two stents were positioned in left anterior descending and 2nd obtuse marginal of circumflex arteries. Patient was admitted for about 6 days without any signs of ischemia after adequate mobilization and cardiac rehabilitation. The patient was managed with aspirin, ticagrelor, atorvastatin, bisoprolol, candesartan, and nitroglycerine. He was symptom free at 1 year follow up. ECG showed old myocardial infarction at anteroseptal segment as shown in figure 2. Echocardiography was improved as the ejection fraction was 49.4%. Treadmill studies showed normal stress test with no evidence of chest pain. Discussion: This patient fulfilled criteria for anteroseptal STEMI in young age. The interesting point in this case was that MI occurred in young male. Myocardial infarction (MI) mainly occurs in patients older than 45 and was not common in young age. The problem of MI in such young age group became substantial since they are in the productive age. The disease carries a significant morbidity, psychological effects, and financial constraints for the person when it occurs at a young age. The suspicion for MI in younger age should be increased especially for those who has strong risk factors. It has not been clear yet whether myocardial infarction in young age is associated with acceleration process of atherosclerosis as in older population. Family history holds important role which may contribute in owing tiny vessels and coagulopathies process. The causes of MI among patients aged less than 45 years old can be divided into four group: (1) atheromatous coronary artery disease. It was linked to the conventional risk factor as in adults, such as cigarette smoking, lipid abnormalities especially hypertriglyceridemia and low HDL and psychosocial stress can add a significant morbidity and were associated with MI in young adult; (2) non atheromatous coronary artery disease such as congenital coronary artery anomalies, coronary dissection, and coronary artery aneurysm can occur spontaneously in young adults.; (3) hypercoagulable states such as antiphospholipid syndrome that is associated with recurrent arterial and venous thrombosis. It can be primary or secondary associated with other autoimmune disease; (4) MI related to substance misuse like cocaine used. Family history of premature CHD, risk factor profile such as smoking, obesity, diabetes, and dyslipidemia would give better clues as to the likelihood of atheromatous coronary artery disease. Initial clinical examination should concentrate on hemodynamic stability, evidence of sympathetic hyperactivity such as tachycardia, hypertension, and sweating. Upon investigation, ST segment elevation in the ECG is often noted if the patient present to the emergency department soon after the onset of chest pain. Abnormal q waves are usually seen in patients who present later than 12 hours after the onset of chest pain. Non specific T wave changes, ST depression and T wave inversion are seen in patients with partially occluded coronary arteries. Cardiac enzymes are invariably raised in all the people with MI. Cardiac specific troponin T increase is considered to be the most sensitive marker of myocardial damage. Initial administration of oxygen, morphine, nitrates and aspirin should be considered in all young patients as to adult. Younger patients seem to tolerate the thrombolytic agents better with a good ST segment resolution in the ECG. In patients with non-ST segment elevation MI, the initial management should be followed by risk stratification based on persistent or dynamic ECG changes, higher degree of cardiac enzyme rises, and presence of other risk factors like diabetes mellitus. Higher risk patients should be referred to the specialist to assess the need for early coronary angiography and intervention. Coronary angiography is not routinely offered in all the younger patients as a significant number tend to have normal coronary arteries. In patient with risk factors such as diabetes mellitus, dyslipidemia, and family history of premature CHD, the probability of finding abnormal coronary artery is higher. Coronary angiography should be offered to people with significant left ventricular dysfunction as this group of patients has better outcome with early revascularization. Exercise stress testing could well be a useful tool for risk stratification. Most of the younger patients who managed stage 3 of the Bruce protocol (nine minutes or more) were found to have normal coronary arteries. Echocardiographic assessment of left ventricular function should be done in all patients. Young patients have better prognosis and lower mortality rates when suffering from an acute coronary than elderly patients, because they have fewer associated diseases. Early complete revascularization improves survival, as myocardial infarction in young patients indicates an aggressive atherosclerotic process. MI in younger patients does carry a better prognosis if appropriately treated. On the other hand, poor control of risk factors carries a significant morbidity and mortality. Antiplatelet agents like aspirin and clopidogrel should be used as per the guidelines for adults. Statins are invariably prescribed in all patients with MI and their clinical effects extend beyond lipid lowering. Statins are said to stabilize plaques in patients with atheromatous CHD, thereby improving their outcome, and reducing recurrent events. ACE-I and ARB should be offered to all patients with all patients with left ventricular dysfunction as substantial benefits were shown in using them. Lifestyle changes play an important part in the managements of these patients. Stopping smoking, good control of diabetes and correction of lipid abnormalities were shown to improve prognosis in patients less than 45 years. Conclusion: We describe a case of a 25 years old male with anteroseptal STEMI due to atherosclerotic plaque rupture. Although he has no significantly modifiable risk factor, the strong family history combined with heavy activity should explained pathogenesis of MI in this patient. The careful examination and aggressive therapy must be adjusted to decrease mortality and negative outcome after MI in young age. C.122. Figure 1 Open in new tabDownload slide Electrocardiography on arrival showed ST elevation in anteroseptal lead C.122. Figure 1 Open in new tabDownload slide Electrocardiography on arrival showed ST elevation in anteroseptal lead C.122. Figure 2 Open in new tabDownload slide Electrocardiography after 1 year follow up showing old myocardial infarction in anteroseptal lead C.122. Figure 2 Open in new tabDownload slide Electrocardiography after 1 year follow up showing old myocardial infarction in anteroseptal lead Keywords Myocardial infarction • young age • family history • physical activity C.123. A Challenging Management ADHF in Patient with HOCM : Case Report Dian Herlusiatri Rahayu Dian Herlusiatri Rahayu Air Force Central Hospital Dr. S. Hardjolukito, Yogyakarta Margono Gatot Suwandi Margono Gatot Suwandi Air Force Central Hospital Dr. S. Hardjolukito, Yogyakarta Air Force Central Hospital Dr. S. Hardjolukito, Yogyakarta Introduction: Hypertrophic obstruction cardiomyopathy/HOCM is defined by the presence of increased left ventricular (LV) wall thickness with abnormal loading conditions and outflow obstruction of the left ventricle. Furthermore, HOCM can lead to clinical heart failure, life-threatening arrhythmias, mitral regurgitation and sudden cardiac death. Case Illustration: A 31 years old male patient was admitted to Emergency Department with agitation and difficult breathing. Vital sign showed blood pressure 196/116 mmHg, HR 120 bpm, RR 40bpm, SpO2 86%. Elevated jugular vein, cardiomegaly, rales in auscultation were found in physical examination. Sinus tachycardia with HR 120 bpm and LVH were shown in the electrocardiography. Normal ejection fraction, diastolic dysfunction, systolic anterior motion positive, gradient of LVOT 11 mmHg were shown in the echocardiography. MRI result were: LV hypertrophy with asymmetrical septal hypertophy, systolic anterior motion of AML, and segmental transmural fibrosis. We diagnosed patient with ADHF forrester II and hypertensive (HT) emergencies in HOCM patient and treated him with furosemide 120mg bolus intravenously but congestion still persists. Then, furosemide was given continuously and additional ISDN drip given. Gradually, patient’s complaint was improved and patient admitted to the ward. Discussion: This patient came with agitation and dyspnea, moreover the examination showed ADHF and HT emergencies in HOCM patient. There is no specific sign and symptoms of HOCM patients so that it is difficult to diagnose and eventually manage this patient. In patient with ADHF and HOCM, the essential initial management is to reduce overload volume. However, it should be done cautiously due to the potential worsening volume that pumped to systemic and than lead to shock even death. Conclusion: In ADHF and HOCM patients, the initial management in regards of giving diuretic but to maintain the status volume. Furthermore, maintenance therapy and education to patient are important things to improve quality of life the patient. C.123. Figure 1 Open in new tabDownload slide Chest X-Ray C.123. Figure 1 Open in new tabDownload slide Chest X-Ray C.123. Figure 2 Open in new tabDownload slide MRI Cardiac C.123. Figure 2 Open in new tabDownload slide MRI Cardiac Keywords HOCM • ADHF • Hypertensive Emergencies C.124. A Rare Case of Ruptured Aneurysm of Sinus Valsava and Ventricular Septal Defect In A Young Man : What Can We Do At Rural Area Hospital ? R E Intan R E Intan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia F S Hasibuan F S Hasibuan Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Dr. R. Koesma General Hospital, Tuban, East Java, Indonesia Case Illustration: A 20 years old man came into the ER with a chief complaint of sudden chest pain followed with rapid progressive dyspneu since 3 hours before admission. The chest pain felt like stabbed sensation in left parasternal location with no spreading, with DOE and orthopnoe. He has history of treatment for congenital heart disease until 3 years old. Physical examination, VS : BP 100/60 HR 77x/min RR 30x/min. There was grade 5/6 systolic and 4/4 diastolic murmur with palpable thrill, best heard at left sternal border, and bilateral basal rales. ECG showed RV strain. Chest X-ray revealed cardiomegaly. He was admitted with acute heart failure and suspicion of VSD, and treated with diuretic and betablocker. TTE showed small VSD (0.4 cm) with left-to-right shunt, and aneurysm of sinus valsava with significant left-to-right shunt from right coronary cusp to the right ventricle (Figure 1,2). Diagnosis of ruptured aneurysm of sinus valsava was made, then ace inhibitor was added to the therapy. On third day, his condition getting better, with stable hemodynamic, he was discharge with oral therapy continued, and referred to get TEE for further diagnosis and management decision. Discussion: Rupture of valsava sinus should be considered in every continuous murmur and sudden progressive dyspnea. TTE have important role for early suspicion and diagnosis which need to be confirmed by TEE. Early referral to surgical intervention will lead to increase of survival rate, while medical treatment intended to stabilize the patient. Conclusion: Aneurysm of sinus valsava is rare congenital anomaly. Rupture of the aneurysm is one of the complication and can lead to progressive heart failure and high mortality unless early surgical repair is performed. However, diagnosis decision is often difficult. We present a unique case of a ruptured aneurysm of sinus valsava in limited resource hospital. Early referral to get TEE and surgical intervention are vital in management of aneurysm of sinus valsava. C.124. Figure 1 Open in new tabDownload slide TTE parasternal long axis view showed aneurysm of sinus valsava along with perimembranous VSD (diameter of 0.6 cm) with left-to-right shunt C.124. Figure 1 Open in new tabDownload slide TTE parasternal long axis view showed aneurysm of sinus valsava along with perimembranous VSD (diameter of 0.6 cm) with left-to-right shunt C.124. Figure 2 Open in new tabDownload slide TTE parasternal short axis view at aortic valve level, showed ruptured of sinus valsava aneurysm with significant left-to-right shunt from right coronary cusp sinus to the right ventricle C.124. Figure 2 Open in new tabDownload slide TTE parasternal short axis view at aortic valve level, showed ruptured of sinus valsava aneurysm with significant left-to-right shunt from right coronary cusp sinus to the right ventricle Keywords Aneurysm sinus valsava • VSD • TTE C.125. Wellens’ Syndrome : A High Risk Electrocardiographic Pattern That Possess Diagnostic and Prognostic Value Jaya Suganti Jaya Suganti Putri Bidadari General Hospital, Langkat, North Sumatera, Indonesia Hasinah Hasinah Putri Bidadari General Hospital, Langkat, North Sumatera, Indonesia Bidadari General Hospital, Binjai, North Sumatera, Indonesia Zulfikri Mukhtar Zulfikri Mukhtar Murni Teguh Memorial Hospital, Medan, North Sumatera, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, North Sumatera, Indonesia Zainal Safri Zainal Safri Bidadari General Hospital, Binjai, North Sumatera, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, North Sumatera, Indonesia Harris Hasan Harris Hasan Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, North Sumatera, Indonesia Putri Bidadari General Hospital, Langkat, North Sumatera, Indonesia Bidadari General Hospital, Binjai, North Sumatera, Indonesia Murni Teguh Memorial Hospital, Medan, North Sumatera, Indonesia Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Sumatera Utara, Haji Adam Malik General Hospital, North Sumatera, Indonesia Case Illustration A 55-year-old male with history of uncontrolled diabetes mellitus admitted to emergency department due to numbness and tingling sensation around left shoulder that radiated to left arm. He was referred to neurologist and internist, diagnosed with diabetic neuropathy and type 2 diabetes. He was also consulted to cardiologist and a 12-lead ECG was recorded that showed sinus rhythm with biphasic T-waves in the precordial leads (V2-V5), a characteristic pattern of Wellens’ syndrome (WS). Cardiac enzym level and echocardiography results were within normal range. He was transferred to another hospital for coronary intervention. A critical stenosis (99%) at the proximal of left anterior descending (LAD) artery was found and a stent was succesfully deployed. Second case presentation was almost similar, but during hospitalization the patient complained of severe chest pain and his ECG showed an anterior wall myocardial infarction. He was transferred to another hospital for primary percutaneous coronary intervention. A total occlusion (100%) at the proximal of LAD was found and the lesion was successfully opened and stented. Discussion: In daily clinical practice, physicians are mainly focus on ST elevation myocardial infarction (STEMI) ECG pattern because the need for minimizing time to reperfusion therapy, but unaware of other high risk ECG findings that signify impending acute myocardial infarction (AMI), such as Wellens’ syndrome (WS) which required urgent coronary intervention. We reported two cases of WS, first case underwent coronary intervention before marked AMI develop and second case was a WS that progress to anterior wall AMI over the course of days. Wellens’ syndrome (WS) is a clinical syndrome consist of angina and ECG pattern of biphasic or inverted T-waves in the precordial leads (V2-V3) associated with critical stenosis of proximal LAD artery. Our cases showed that WS does represent critical stenosis of proximal LAD and patients with WS are at high risk of developing an anterior wall AMI if a timely revascularization is not performed. Therefore, medical therapy without revascularization is insufficient as it may still lead to AMI and potentially death. Conclusion: Early recognition of WS followed by urgent coronary revascularization is imperative as adverse outcomes can be prevented. C.125. Figure 1 Open in new tabDownload slide Wellens’ syndrome ECG : Sinus rhythm with biphasic T-waves in the precordial leads (V2-V5). C.125. Figure 1 Open in new tabDownload slide Wellens’ syndrome ECG : Sinus rhythm with biphasic T-waves in the precordial leads (V2-V5). C.125. Figure 2 Open in new tabDownload slide Subtotal stenosis (99%) at the proximal segment of LAD coronary artery (red arrow). C.125. Figure 2 Open in new tabDownload slide Subtotal stenosis (99%) at the proximal segment of LAD coronary artery (red arrow). Keywords wellen’s syndrome • proximal LAD stenosis • anterior wall myocardial infarction C.126. Transcatheter Closure of Large Secundum Atrial Septal Defects Using Amplatzer Septal Occlude in Adult I G A Wijayanty Permatasari I G A Wijayanty Permatasari Department of Cardiology and Vascular Medicine, Wangaya District General Hospital, Denpasar, Bali I Pt Parwata Jaya I Pt Parwata Jaya Department of Cardiology and Vascular Medicine, Wangaya District General Hospital, Denpasar, Bali Department of Cardiology and Vascular Medicine, Wangaya District General Hospital, Denpasar, Bali
TI - Case Report Abstract
JF - European Heart Journal Supplements
DO - 10.1093/eurheartj/suz185
DA - 2019-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/case-report-abstract-O0Wm7y6Suh
SP - F115
VL - 21
IS - Supplement_F
DP - DeepDyve
ER -