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Abstrak :
Latarbelakang: Kondisi atrium kanan yang terdiri dari berbagai struktur yang kompleks menyebabkan timbulnya variasi sifat elektroiisiologis yang memberikan kemudahan timbulnya aritmia. Aritmia atrium kanan merupakan jenis aritmia yang panting karena prevalensi yang tinggi dan konsekunsi klinis yang berbahaya. Akan tetapi epidemiologi aritmia atrium kanan beserta karakteristik eleklrofisiologinya di Indonesia belum pemah dilaporkan. Krista terminalis yang merupakan garis hambatan konduksi posterior pada kepak atrium (KA), dan sumber trbanyak takikardia atrium (TA), nierupakan struktur unik dengan karakteristik elektrofisiologis yang belum diungkap secara luas. Di lain pihak, berkembangnya pemahaman mekanisme KA, menimbulkan masalah diagnosis karena adanya kemiripan morfologi gelombang kepak antar berbagai jenis KA yang mekanismenya berlainan, dan adanya variasi morfologi gelombang kepak pada KA yang sejenis. Oleh karena itu akan dilakukan rangkaian penelitian untuk menjawab beberapa masalah mekanisme dan diagnosis aritmia atrium kanan.

Metode: Dilakukan studi elektrofisiologi baik secara konvensional maupun dengan panduan sistem pemetaan non-kontak Ensite pada subyek dengan KA dan TA. Pada KA yang melibatkan ismus kavotrikuspid (KA-IKT) dilakukan entrainment untuk konfirmasi diagnosis. Pada ULR, lokasi dan lebar taut konduksi ditentukan atas dasar perubahan konvergensi propagasi impuls setelah melalui krista temiinalis. Pola aktivasi sumber TA dianalisis meinalcai propagasi impuls dan elektrogram unipolar virtual. Nilai 30% dari voltase negatif puncak dipakai sebagai pembeda daerah parut dari jadngan sehat. Analisis rnorfologi gelombang kepak pada EKG 12-sadapan dilakukan oleh dua orang ahli elektrofisiologi yang bebas. Suatu algoritme diagnosis KA yang sederhana akan dibuat atas dasar EKG permukaan. Ablasi frekuensi radio (AFR) dilakukan pada sumber atau sirkuit reentry aritmia atrium kanan dengan memakai teknik yang sudah baku.

Hasil: KA tipikal merupakan kasus KA terbanyak di Pusat Jantung Nasional Harapan Kita, dan Iebih dari 60% subyek KA mempunyai penyakit jantung struktural. Rcrata panjang siklus takikardia (PST) ialah 261,8 ± 42,84, 226,5 ± 41,23, dan 195,4 ± 9,19 mdet masing-masing untuk KA tipikal, tipikal terbalik dan atipikal (p = 0,016). Morfologi EKG pada KA tipikal terdiri dari 3 tipe gelombang kepak yaitu F-/f+ di sadapan inferior dan P+ atau F+/f- di V, (tipe 1); F- di sadapan inferior dan P+ di V1 (tipe 2); dan f-/F+ di sadapan inferior dan F+ di V1 (tipe 3). Pada KA tipikal terbalik didapatkan 2 tipe rnorfologi yaitu P+ di sadapan inferior dan F- di V1 (tipe 1); dan P+ di sadapan inferior dan isoeiektrik di V; (tipe 2). Akan tetapi tidak didapatkan perbedaan bermakna aktivasi atrium kanan pada variasi morfoiogi KA-IKT. Tidak didapatkan konduksi transversal Krista terminalis pada 90% KA-IKT, sebaliknya didapatkan konduksi transversal pada seluruh ULR. Pada saat ULR, KKL lebih cepat dari pada KK-r (1,228 ± 0,43 vs. 0,73 ± 0,30 m/det, p < 0,001). Rasio KK;/KKT ialah 1,95 ± 0,77 yang berbanding terbalik dengan lebar taut krista terminalis (1,57 ± 6,8 mm) (p < 0,00l).

Algoritme diagnosis baru atas dasar morfologi dan amplimdo gelombang kepak di sadapan I mempunyai akurasi 90 hingga 97%, sensitivitas S2 hingga 100% dan spesifisitas 95% dalam membedakan KA tipikal terbalik dari ULR. TA fokal mayoritas berasal dari krista terminalis dan memperlihatkan adanya jalur konduksi istimewa. Dengan teknik konvensional, keberhasilan AFR pada IKT, taut krista terminalis pada ULR dan TA fokal berturut-turut mencapai 96 % , 90% dan 91,7%.

Kesimpulan: KA tipikal merupakan KA terbanyak pada populasi penelitian ini, dengan mayoritas menderita penyakit janlung struktural. Tidak terdapat perbedaan aktivasi atrium kanan pada variasi morfologi gelombang kepak pada KA-IKT. Mayoritas taut konduksi krista terminalis bersifat fungsional dan selalu didapatkan pada saat ULR. Suatu algoritme diagnosis baru, akurat untuk membedakan KA tipikal terbalik dari ULR. Impuls TA fokal menyebar ke seluruh atrium setelah melalui jalur konduksi istimewa. AFR efektif menyembuhkan KA-IKT, KA non-IKT dan TA.;Background: Complex structures with variable electrophysiological properties in right atrium facilitate arrhythmias occurrence. The right atrial arrhythmia is one of clinically important anrhythmias as it has high prevalence and significant clinical consequences. However, clinical and electrophysiological characteristics of iight atrial arrhythrnias have not been elaborated in Indonesia. The crista terrninalis has been shown as a posterior obstacle line during atrial flutter (AFL), and as a major source of focal atrial tachycardia (AT). However, as a unique structure of right atrium, little has been known about Crista terrninalis electrophysiological properties as a substrate of right atrial arrhythmias. A better understanding of AFL mechanisms yielded a diagnostic problem, since the flutter wave of different AFL has similar rnorphologies and the variable morphologies of the same AFL. Therefore, we conduct several interconnected study to overcome those diagnostic and mechanisms issues in right atrial arrhythmias.

Methods: Atrial flutter and AT subjects underwent electrophysiology study using conventional and/or noncontact mapping Ensite system. Entrainment pacing was performed to confirm the diagnosis of cavotricuspid isthmus (CTI) dependent AFL. In ULR subjects, location and width of gap conduction was determined by the change of convergent wavefront as it is passed the crista terminalis. Careful wavefront and virtual unipolar electrogram analysis was performed during focal AT. A value of 30% of peak negative voltage was used to differentiate low voltage zone and normal tissue. Two independent electrophysiologist analyzed the morphology and polarity of flutter wave in standard 12-lead ECG. Radiofrequency ablation was peformed at the origin and/or reentry circuit of right atrial arrhythmias using a standard technique.

Results: Typical APL is predominant AFL cases in National Cardiovascular Center

Harapan Kita. More than 60% of all AFL cases suffered from structural heart disease. Mean tachycardia cycle length of typical, reverse typical and atypical AFLS were 261.8 ± 42.84, 226.5 ± 41.23, and 195.4 ± 9.19 msec, respectively (p = 0.0l6). Typical AFL showed 3 types flutter wave morphologies comprised of F-/f+ at inferior and P+ or F+/f- at V1 (type 1); F- at inferior and F+ at V, (type 2); and f-/F+ at inferior and P+ at V1 (type 3). Reverse typical AFL showed 2 types flutter wave morphologies comprised of F+ at inferior and F- at V, (type 1); and P+ at inferior and isoelectric at V1 (type 2). However, there were no significant different of right atrial wavefront activations between those AFL morphologies types. Ninety percent of CTI dependent AFL demonstrated no transversal conduction at crista terminalis, on the contrary all ULR demonstrated transversal conduction. During ULR, CVL was faster than CVT (1.23 ± 0.43 vs. 0.73 ± 0.30 m/sec, p < 0.00l). The ratio of CVL/CVt (1.95 :t 0.77) had inverse correlation with the gap width (1.57 ± 6.8 mm) (p < 0.001). A new diagnostic algorithm based on morphology and amplitude of flutter wave at lead I had accuracy of 90 to 97%, sensitivity of 82 to 100% and specificity of 95% to differentiate reverse typical AFL from ULR. The majority of focal AT originated hom crista terminalis and showed a preferential wavefront conduction before spreading to the whole atrium. The success rate of radiofrequency ablation of CTI dependent AFL, crista terminalis gap of ULR and focal AT were 96%, 90% and 91.7% respectively.

Conclusion: Typical AFL is the predominant AFL cases and majority of AFL had structural heart disease. There was no right atrial activation different among flutter wave morphology types of CTI dependent AFL. The majority of crista tenninalis gap was functional and always exists during ULR. A new diagnostic ECG algorithm has been demonstrated to have excellent accuracy to differentiate typical AFL from ULR. The wavefront of focal AT spreads out to the whole atrium after traveled in preferential conduction. RPA was effective to eliminate CTI and non-CTI dependent AFL, and focal AT.

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Background: Complex structures with variable electrophysiological properties in right atrium facilitate arrhythmias occurrence. The right atrial arrhythmia is one of clinically important anrhythmias as it has high prevalence and significant clinical consequences. However, clinical and electrophysiological characteristics of iight atrial arrhythrnias have not been elaborated in Indonesia. The crista terrninalis has been shown as a posterior obstacle line during atrial flutter (AFL), and as a major source of focal atrial tachycardia (AT). However, as a unique structure of right atrium, little has been known about Crista terrninalis electrophysiological properties as a substrate of right atrial arrhythmias. A better understanding of AFL mechanisms yielded a diagnostic problem, since the flutter wave of different AFL has similar rnorphologies and the variable morphologies of the same AFL. Therefore, we conduct several interconnected study to overcome those diagnostic and mechanisms issues in right atrial arrhythmias.

Methods: Atrial flutter and AT subjects underwent electrophysiology study using conventional and/or noncontact mapping Ensite system. Entrainment pacing was performed to confirm the diagnosis of cavotricuspid isthmus (CTI) dependent AFL. In ULR subjects, location and width of gap conduction was determined by the change of convergent wavefront as it is passed the crista terminalis. Careful wavefront and virtual unipolar electrogram analysis was performed during focal AT. A value of 30% of peak negative voltage was used to differentiate low voltage zone and normal tissue. Two independent electrophysiologist analyzed the morphology and polarity of flutter wave in standard 12-lead ECG. Radiofrequency ablation was peformed at the origin and/or reentry circuit of right atrial arrhythmias using a standard technique.

Results: Typical APL is predominant AFL cases in National Cardiovascular Center

Harapan Kita. More than 60% of all AFL cases suffered from structural heart disease. Mean tachycardia cycle length of typical, reverse typical and atypical AFLS were 261.8 ± 42.84, 226.5 ± 41.23, and 195.4 ± 9.19 msec, respectively (p = 0.0l6). Typical AFL showed 3 types flutter wave morphologies comprised of F-/f+ at inferior and P+ or F+/f- at V1 (type 1); F- at inferior and F+ at V, (type 2); and f-/F+ at inferior and P+ at V1 (type 3). Reverse typical AFL showed 2 types flutter wave morphologies comprised of F+ at inferior and F- at V, (type 1); and P+ at inferior and isoelectric at V1 (type 2). However, there were no significant different of right atrial wavefront activations between those AFL morphologies types. Ninety percent of CTI dependent AFL demonstrated no transversal conduction at crista terminalis, on the contrary all ULR demonstrated transversal conduction. During ULR, CVL was faster than CVT (1.23 ± 0.43 vs. 0.73 ± 0.30 m/sec, p < 0.00l). The ratio of CVL/CVt (1.95 :t 0.77) had inverse correlation with the gap width (1.57 ± 6.8 mm) (p < 0.001). A new diagnostic algorithm based on morphology and amplitude of flutter wave at lead I had accuracy of 90 to 97%, sensitivity of 82 to 100% and specificity of 95% to differentiate reverse typical AFL from ULR. The majority of focal AT originated hom crista terminalis and showed a preferential wavefront conduction before spreading to the whole atrium. The success rate of radiofrequency ablation of CTI dependent AFL, crista terminalis gap of ULR and focal AT were 96%, 90% and 91.7% respectively.

Conclusion: Typical AFL is the predominant AFL cases and majority of AFL had structural heart disease. There was no right atrial activation different among flutter wave morphology types of CTI dependent AFL. The majority of crista tenninalis gap was functional and always exists during ULR. A new diagnostic ECG algorithm has been demonstrated to have excellent accuracy to differentiate typical AFL from ULR. The wavefront of focal AT spreads out to the whole atrium after traveled in preferential conduction. RPA was effective to eliminate CTI and non-CTI dependent AFL, and focal AT.

Abstrak :
Latar belakang. Gagal jantung akut dan aritmia telah menjadi salah satu masalah kesehatan di bidang kardiovaskuler. Hubungan antara aritmia dan gagal jantung dalam mortalitas masih kontroversial. Tujuan. Mengetahui karakteristik pasien gagal jantung akut dan mengidentifikasi hubungan antara aritmia dengan mortalitas pasien gagal jantung akut di rumah sakit. Metode. Penelitian dilakukan dengan desain potong lintang dengan menggunakan metode consecutive sampling. Studi ini menggunakan 976 data sekunder dari studi Acute Decompensated Heart Failure Registry (ADHERE) di lima rumah sakit di Indonesia pada bulan Desember 2005 – 2006. Hasil. Dalam studi ini, pasien dikategorikan menjadi 2 kelompok, kelompok pasien gagal jantung akut dengan aritmia(42,2%) dan tanpa aritmia (67,8%). Pasien laki-laki mendominasi dengan 68%. Angka mortalitas pasien gagal jantung akut dengan aritmia selama perawatan adalah 4,1 %. Sedangkan pada pasien tanpa penyakit jantung koroner adalah 3,7%. Analisis bivariat menunjukkan tidak ada hubungan antara aritmia dengan mortalitas pasien gagal jantung akut (p=0,748 CI 95% 0,468-1,726, OR= 0,899). Kesimpulan. Tidak ada terdapat hubungan antara aritmia dengan angka mortalitas pasien gagal jantung akut selama perawatan. ......Backgrounds. Acute heart failure (AHF) and arrhythmia have become problems in global heath related to cardiovascular. The association between arrhythmia and heart failure with mortality remains controversial. Objective. Define the characteristics of patients with acute heart failure and identify associations between arrhythmia and in-hospital mortality of acute heart failure patients. Methods. The design of this study was cross sectional with consecutive sampling. This study used 976 acute heart failure patients from Acute Decompensated Heart Failure Registry (ADHERE) of 5 hospital in Indonesia from december 2005-2006. Result. Patients in this study were categorized in two groups. The first group was patients with arrhythmia (42,2%) and the second was group wihout arrhythmia (67,8%). Majority of the patients were men with 68%. The mortality rate of the first group was 4,1% and from the second was 3,7%. The bivariat analysis showed that there is no association between arrhytmia and in-hospital mortality of AHF patients (p=0,748 CI 95% 0,468-1,726, OR= 0,899). Conclusions. Arrhythmia is not related to in-hospital mortality of AHF patients.

Abstrak :
Encourages the reader to accept that the ECG is easy to understand and that its use is just a natural extension of taking the patient's history and performing a physical examination. This title directs users of the electrocardiogram to straightforward and accurate identification of normal and abnormal ECG patterns

Abstrak :
This book provides a comprehensive overview of several promising novel drug targets and approaches against arrhythmias, with particular emphasis placed on malignant ventricular arrhythmias. The individual chapters address a single treatment strategy written by a leading expert on the chapter, including arrhythmia mechanisms, kinase inhibitors, calcium and potassium channel targets, and atrial selective drugs.

Abstrak :
As arrhythmias may be transient in nature and not seen during the shorter recording times of the standard ECG, ECG Holter monitoring allows the physician to make better informed decisions for the cardiac patient. The devices are worn by patients on an outpatient basis for days or weeks and can also be implanted subcutaneously. ECG Holter recordings are especially useful since they can be programmed individually for activation and specific tracing analysis. Designed for rapid study, this book contains 100 illustrative cases in ECG Holter monitoring. Each case consists of a tracing followed by a brief explanation of the findings. 100 Cases in ECG Holter is the perfect resource for busy physicians looking to optimize their skills at interpreting ECG Holter readings.