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Abstrak :
Questo volume di ecocardiografia si propone di trattare il tema della valvola mitrale nei suoi aspetti normali e patologici, aggiornandone la trattazione in base ai più recenti sviluppi della tecnologia. L’approccio interdisciplinare nella diagnosi e nella scelta dei trattamenti ha caratterizzato il taglio medico-divulgativo dell’opera e il linguaggio chiaro e conciso del testo, rivolto anche ai cardiologi clinici e non ai soli ecocardiografisti. Ampio spazio è dedicato quindi all’eziologia e alla fisiopatologia della valvulopatia mitralica.

Abstrak :
Background. Spontaneous Echo Contrast (SEC) appears as a curling motion of echo in real lime and this indicates Wood stasis, ft is therefore predictive for thrombus formation and higher risk for thrombocmbolic phenomenon. Accumulating evidence showed higher incidence of (hrombus formation in mitral stenosis (MS) patients if they presented with positive SEC. Detection of left atrial thrombus is even more important before mitral valvuloplasty procedure to prevent .systemic and especially cerebral embolism. The aim of this study was to compare the utility of transthoracal eehocardiography (TIE) to transesophageal cchocardiography (TEE) in detecting SEC and thrombus in patients with MS. Method. Forty-eight patients with MS were studied with TEE and TTE. The diagnosis of MS was established by TTE. Result. With TTE, 15 patients (31,3%) had positive SEC, 33 patients (68, 7%) had negative SEC and 6 patients (12,5%) of the SEC positive patienls had thrombus in LA. On the other hand with TEE, SEC were positive in 36 (75%) patients, negative in 12 (25%) patients and 17 (35,4%) of the SEC positive patients showed LA thrombus. This study confirmed the strong association between SEC and thrombus formation, as thrombus was only observed in SEC positive patients. Conclusion. TEE is superior to TTB in detecting SEC and LA thrombus in patients with MS, because of the belter acoustic window of TEE. TEE should be considered in every patients with MS where thrombus formation has to be ruled out, particularly before baloon mitral valvuloplasly procedure.

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ABSTRACT
Infective endocarditis (IE) is associated with high mortality and morbidity and requires surgical intervention in about half of all patients. Mitral valve repair (MVrep) is reported to achieve better results than mitral valve replacement because the insertion of a prosthesis during active infection is avoided. However, MVrep in active IE is complicated and no definitive guidelines have been compiled. The current study reviews the literature from 2000 to 2016 and summarizes the surgical details of MVrep for IE.

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Latar Belakang: Pasien yang menjalani bedah katup mitral cenderung mengalami penurunan fungsi ventrikel kanan Vka pasca pembedahan katup. Disfungsi Vka pasca pembedahan katup dapat menetap ataupun mengalami perbaikan di kemudian hari. Banyak faktor yang dapat mempengaruhi perbaikan fungsi Vka pasca operasi. Namun, belum ada studi yang menilai faktor-faktor yang dapat menjadi prediktor perbaikan fungsi Vka pasca operasi katup mitral dalam suatu studi multivariat. Tujuan: Mengidentifikasi faktor-faktor apa saja yang dapat menjadi prediktor perbaikan fungsi Vka pada pasien dengan penyakit katup mitral yang mengalami disfungsi Vka segera setelah pembedahan katup mitral. Metode: Penelitian ini merupakan studi kohort retrospektif yang dilakukan di Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita RSJPDHK . Subjek penelitian adalah pasien yang menjalani operasi katup mitral di RSJPDHK sejak Januari 2016 sampai dengan Februari 2017. Data yang diambil yakni karakteristik dasar, data operasi, data obat-obatan pasca operasi, pemeriksaan ekokardiografi sebelum, segera sebelum lepas rawat, dan enam bulan pasca operasi. Hasil penelitian: Sebanyak 100 subjek yang dinilai pada penelitian ini. Terdapat 68 68 subjek yang mengalami kenaikan fungsi Vka, dan 32 subjek 32 yang tidak. Median TAPSE sebelum lepas rawat meningkat secara signifikan enam bulan pasca operasi dari 1,1 0,6-1,5 menjadi 1,4 0,7-2,8 dengan nilai p ......Background In patients undergoing mitral valve surgery, right ventricular function may decline immediately after the surgical procedure. This condition may sometimes remain, but may also improve later on. Many factors have been proposed to account for this phenomenon. As of yet, there are no studies using multivariate analysis to investigate factors that may be predictors of right ventricular function improvement after mitral surgery. Objective This study aims to identify factors that may be predictors of right ventricular function improvement in patients with right ventricular dysfunction following mitral valve surgery. Methods This is a retrospective cohort study, taking place at National Cardiovascular Center Harapan Kita NCCHK , Jakarta, Indonesia. Subjects are patients who underwent mitral valve surgery between January 2016 until February 2017. Data taken include basic characteristics, surgical data, drugs prescribed after surgery, and echocardiography data before surgery, predischarge, and six months after surgery. Results There are 100 subjects who fulfilled the criteria to participate in this study. There are 68 68 cases of right ventricular function improvement and 32 32 cases without improvement. The median of predischarge TAPSE increases significantly six months after surgery, from 1,1 0,6 1,5 to 1,4 0,7 2,8 with p value.

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Pendahuluan: Obat penyekat beta telah teruji efikasi dan keamanannya pada berbagai penyakit jantung, terutama yang melibatkan ventrikel kiri. Berlawanan dengan hal tersebut, efikasi obat penyekat beta pada ventrikel kanan belum diketahui secara pasti. Beberapa penelitian sebelumnya menunjukkan hasil yang inkonsisten. Penelitian ini bertujuan untuk mengetahui apakah terdapat efektivitas obat penyekat beta pada disfungsi ventrikel kanan yang terjadi pascaoperasi penggantian katup mitral. Metode: Disain penelitian adalah kohort retrospektif. Jumlah sampel sebanyak 232 orang, terbagi dalam dua kelompok yaitu menggunakan penyekat beta (n=129) dan tidak menggunakan (n=103). Pengukuran data TAPSE kontrol dilakukan dalam waktu 1-12 bulan dari data pascaoperasi. Kejadian rehospitalisasi dan kematian dinilai 6 bulan pascaoperasi. Hasil: Penggunaan obat penyekat beta tidak menunjukkan efektivitas dalam memperbaiki nilai TAPSE [median delta TAPSE adalah 4 (7-29) mm pada kelompok penyekat beta vs 4 (-8-20) mm pada kelompok non penyekat beta; p = 0,71]. Angka rehospitalisasi adalah 14,7% (kelompok penyekat beta) vs 8,7% (kelompok non penyekat beta) dengan p = 0,16. Sedangkan angka kematian adalah 0,8% (kelompok penyekat beta) vs 1,9% (kelompok non penyekat beta), p = 0,60. Kesimpulan: obat penyekat beta tidak memperbaiki disfungsi ventrikel kanan, serta tidak menurunkan angka rehospitalisasi dan kematian pada pasien pascaoperasi penggantian katup mitral. ......Introduction: Beta blockers have proven its efficacy and safety in various heart diseases, especially those involving the left ventricle. Contrary to this, the efficacy of beta blocking drugs in the right ventricle is not well known. Some previous studies have shown inconsistent results. This study aims to determine whether there is an effectiveness of beta blocking drugs on right ventricular dysfunction that occurs after mitral valve replacement surgery. Methods: Design of the study is retrospective cohort. The number of samples is 232 people, divided into two groups, those using beta blocking drugs (n=129) and not using them (n=103). Measurement of control TAPSE data was carried out within 1-12 months of postoperative data. Rehospitalization and mortality incidence were assessed at six months postoperatively. Result: The use of beta blockers did not show any effectiveness in improving TAPSE value [median delta TAPSE value are 4 (7-29) mm in the beta-blocker group vs 4 (-8-20) in the non beta-blocker group]. The rehospitalization rate is 14,7% (beta-blocker group) vs 8,7% (non beta-blocker group), p = 0,16. While the death rate is 0,8% (beta-blocker group) vs 1,9% (non beta-blocker group), p = 0,60. Conclusion: beta-blocking drugs do not improve right ventricular dysfunction, and do not reduce rehospitalization and mortality rates in postoperative mitral valve replacement patients.

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ABSTRAK
Latar belakang: Prosedur Cox-Maze IV merupakan standar baku emas dalam terapi fibrilasi atrium (FA) secara ablasi bedah dengan keberhasilan yang tinggi. Konversi dari FA menjadi irama sinus diharapkan mengurangi komplikasi akibat dari FA, yaitu risiko terjadinya tromboemboli termasuk gagal jantung. Prosedur yang kompleks dan lama, yang menambah beban operasi, menjadi pertimbangan dokter bedah untuk melakukan tindakan ini terutama pada pasien risiko tinggi. Penelitian ini untuk menilai peran irama jantung pascaoperasi Concomitant Cox-Maze IV, serta faktor-faktor lain yang berhubungan terhadap perubahan fungsi jantung kiri. Metode: Desain penelitian adalah cross sectional. Pasien dengan penyakit katup mitral dan fibrilasi atrium diperiode Januari 2012 sampai Desember 2017 dilakukan operasi katup mitral dan Cox-maze IV menggunakan single clamp radio frekuensi. Kemudian dievaluasi peran irama jantung pascaoperasi serta faktor-faktor yang dapat berhubungan dengan perubahan fungsi jantung kiri. Hasil: Total subjek adalah 73 subjek. Keberhasilan Concomitant Cox-Maze IV dengan menggunakan single clamp radio frekuensi di RS Jantung Harapan Kita mencapai 86,3%. Irama jantung pascaoperasi, baik irama sinus maupun tetap FA, juga tidak mempunyai hubungan terhadap perubahan EF (nilai p 0,792). Kelainan fungsi katup mitral (stenosis dan regurgitasi) sebelum operasi merupakan faktor yang berperan dalam perubahan EF pascaoperasi (nilai p 0,01). Berdasarkan derajat disfungsi ventrikel sebelum operasi terdapat perubahan EF bermakna (nilai p <0,0001). Pada kelompok disfungsi ventrikel kiri yang sedang (EF 36% - 45%), terdapat perbaikan EF menjadi normal, yaitu dari 43,17% ke 61,5%. Perbaikan EF lebih baik pada stenosis mitral dengan disfungsi ventrikel kiri sedang yang kembali menjadi irama sinus pascaoperasi yaitu dari 43,3 ± 2,9% ke 64 ± 10,9% dibandingkan yang tetap irama FA 42% ke 49%. Simpulan: Irama jantung pascaoperasi concomitant Cox-Maze IV dengan metode single clamp radio frekuensi tidak mempunyai hubungan terhadap fraksi ejeksi ventrikel kiri secara statistik. Prosedur ini lebih memberi manfaat yang lebih berarti dalam perbaikan fungsi ventrikel pada fraksi ejeksi yang rendah terutama pada stenosis mitral.

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ABSTRACT
Background: The Cox-Maze IV procedure is the gold standard in the treatment for atrial fibrillation (AF) by surgical ablation with high of success rate. Conversion of AF into sinus rhythm is expected to reduce complications resulting from FA, such as the risk of thromboembolism and heart failure. Complex and lengthy procedures especially in high-risk patients, which add to the burden of surgery, are considered by surgeons to perform this procedure. This study was to assess the role of postoperative heart rhythm Concomitant Cox-Maze IV, as well as other factors related to changes in left heart function. Methods: The study design was cross sectional. Patients with mitral valve disease and atrial fibrillation in the period January 2012 to December 2017 performed mitral valve and Cox-maze IV surgery using a single radio frequency clamp. The role of postoperative heart rhythm and the factors that can be related to changes in left heart function were then evaluated. Results: Total number of subjects were 73 subjects. The success of the concomitant Cox-Maze IV by using a single frequency radio clamp at Harapan Kita Heart Hospital reached 86.3%. Postoperative heart rhythms, both sinus rhythm and AF, showed no relationship with EF changes (p value 0.792). Mitral valve dysfunction (stenosis and regurgitation) before surgery is a factor that plays a role in changes in postoperative EF (p value 0.01). Based on the degree of ventricular dysfunction before surgery, there was a significant change in EF (p value <0.0001). There was an improvement in EF to normal in the group of moderate left ventricular dysfunction (EF 36% - 45%), ie from 43.17% to 61.5%. Improved EF was better in mitral stenosis with moderate left ventricular dysfunction returning to postoperative sinus rhythm, from 43.3 ± 2.9% to 64 ± 10.9% compared to those that remained in AF 42% to 49%. Conclusion: Postoperative heart rhythm after concomitant Cox-Maze IV with single frequency radio clamp method has no statistically significant relationship to the left ventricular ejection fraction. This procedure has more significant benefits in improving ventricular function in low ejection fractions, especially in mitral stenosis.

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ABSTRAK
Latar Belakang: Studi menunjukkan pasien dengan gangguan fungsi ventrikel kanan VKa perioperasi, memiliki luaran mortalitas dan morbiditas yang kurang baik. Akan tetapi, studi yang menilai prediktor disfungsi VKa masih sedikit dan belum pernah dilakukan di Indonesia. Tujuan: Mengidentifikasi faktor-faktor yang apa saja yang dapat menjadi prediktor disfungsi sistolik VKa pada pasien yang menjalani pembedahan katup mitral. Metode: Studi kasus kontrol dilakukan di Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita RSJPDHK . Subyek penelitian adalah pasien yang menjalani operasi katup mitral sejak Januari 2016 sampai Februari 2017. Karakteristik dasar, data operasi, pemeriksaan ekokardiografi sebelum dan pasca operasi pre- discharge , serta catatan ruang intensif yang diperoleh dari rekam medis dicatat. Data kemudian diolah dengan analisis bivariat dan multivariat. Hasil Penelitian: Subyek sebanyak 282 pasien dengan 75 mengalami disfungsi Vka dengan TAPSE pascapembedahan

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ABSTRACT
Background Studies have shown that patients with right ventricle RV dysfunction perioperatively have worse mortality and morbidity outcomes. Yet studies evaluating predictors of RV dysfunction are still scarce and have never been carried out in Indonesia. Objectives To identify which factors may predict the occurence of postoperative RV systolic dysfunction in patients undergoing mitral surgery. Method Case control study taking place in National Cardiovascular Center Harapan Kita NCCHK . Subjects are patients who underwent mitral surgery in NCCHK from January 2016 until February 2017. Data consisting of basic characteristics, surgical data, echocardiography parameters before and after surgery predischarge , and intensive care unit integrated records acquired from medical records are gathered. Bivariate and multivariate analyses are carried out. Results 282 patients were included in the study, 75 having RV dysfunction with postoperative TAPSE of...

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ABSTRAK
Tujuan Penelitian mengenai penggunaan analisis faktor risiko dan mortalitas pada operasi jantung masih menjadi perdebatan dan merupakan area yang sedang berkembang. Analisis faktor risiko dalam penilaian suatu hasil pembedahan jantung merupakan hal yang tidak dapat dihindari. Ahli bedah dan rumah sakit memerlukan suatu hasil penilaian faktor risiko terhadap risiko kejadian mortalitas perioperasi agar dapat menentukan keputusan klinis. Tujuan penelitian ini adalah untuk membandingkan Parsonnet dan European System for Cardiac Operative Risk Evaluation (EuroSCORE) pada pasien yang menjalani perbaikan katup mitral dan memperkirakan faktor-faktor risiko apa saja yang dapat mempengaruhi mortalitas perioperatif. Pasien dan Metode Dari bulan Januari 2010 sampai dengan bulan Desember 2012, 96 pasien terpilih yang telah menjalani operasi perbaikan katup mitral menggunakan mesin jantung paru dan telah dilakukan analisis faktor risiko berdasarkan Parsonnet score and EuroSCORE . seluruh faktor risiko dianalisis dengan analisis deskriptif, tabulasi silang, Pearson Chi Square, dan uji Anova, keduanya juga dianalisis dengan kurva ROC Hasil Angka mortalitas riil sebesar 5,2 %. Berdasarkan Parsonnet score, nilai prediksi mortalitas sebesar 18,26 % sementara pada EuroSCORE nilai prediksi mortalitas sebesar 3,68 %. Hasil keduanya signifikan secara statistik. Nilai prediksi EuroSCORE lebih mendekati angka kematian riil bila dibandingkan Parsonnet score . Kesimpulan EuroSCORE lebih unggul dibandingkan dengan Parsonnet score .Nilai prediksi EuroSCORE lebih mendekati angka kematian riil . EuroSCORE merupakan alat ukur yang baik dalam analisis faktor risiko dan mortalitas pada operasi perbaikan katup mitral

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ABSTRACT
Objective The use of risk stratified mortality studies for analyzing surgical outcome in cardiac surgery is obviously a developing area. Unfortunately, outcomes research in valve repair surgery has been relatively limited. The risk stratification in the assessment of cardiac surgical results is inevitable. Surgeons and hospitals need availability of risk assessment result which may influence decision-making. Without risk stratification, surgeons and hospitals treating high-risk patients will appear to have worse results than others. Our purpose was to compare the performance of risk stratification models, Parsonnet and European System for Cardiac Operative Risk Evaluation (EuroSCORE) in our patients undergoing mitral valve repair (MVr) and predict the risk factors that influence inhospital mortality . Patient and methods From January 2010 to December 2012, 96 consecutive patients have undergone MVr using cardiopulmonary bypass and scored according to Parsonnet score and EuroSCORE algorithm. All risk factors were analyzed by descriptive analytic, cross tabulation, Pearson Chi Square, and Anova test, both scores analyzed by ROC curve. Results Overall hospital mortality was 5,2 %. In Parsonnet model, predicted mortality was 18,26 % while in the EuroSCORE model, predicted mortality was 3,68 %. and it was statistically significant for the Parsonnet score and EURO score . Parsonnet Score has a higher sensitivity compared to the EuroSCORE. From the ROC curve, AUC for Parsonnet score (0,905) higher than AUC for EuroSCORE (0,892). Problems with the Parsonnet score of subjectivity, inclusion of many items not associated with mortality, and the overprediction of mortality have been highlighted. Pre operative NYHA class, age, ejection fraction , complication, etiology, EuroSCORE, and Parsonnet score during mitral valve repair were statistically significant for affecting inhospital mortality risk. Conclusions The EuroSCORE is more reasonable overall predictor of hospital mortality in our patients undergoing MVr compared to Parsonnet score.

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Angka re-operasi setelah reparasi katup mitral dapat mencapai 10% dan pada penyakit katup degeneratif sebagian besar (70%) re-operasi disebabkan prosedur yang dilakukan. Island flap rotation technique merupakan teknik reparasi katup mitral baru yang pertama kali dilakukan untuk mengakomodasi ketidaktersediaan artifisial korda dan menghindari tegangan jaringan. Tujuan penelitian ini adalah untuk mendapatkan metode baru operasi jantung reparasi regurgitasi katup mitral yang fungsional dan aman tanpa membuang sebagian jaringan katup. Penelitian dilakukan terhadap 29 pasien regurgitasi mitral berat dengan lesi P2 yang memenuhi kriteria inklusi di RS Jantung dan Pembuluh Darah Harapan Kita, Jakarta, pada tahun 2022 hingga 2023. Desain penelitian adalah double blind randomized controlled trial. Subjek dirandomisasi menjadi 2 grup. Grup perlakuan menjalani prosedur island flap rotation dan grup kontrol menjalani prosedur selain island flap rotation. Semua subjek menjalani pemeriksaan transesophageal echocardiography (TEE) pasca–tindakan sebelum pasien dipulangkan dari rumah sakit. Pengukuran meliputi coaptation length index (CLI), trans mitral mean gradient, dan vena contracta area (VCA3D). Mortalitas dan kejadian trombo-emboli dievaluasi pada bulan ke-3 pasca-operasi. Karakteristik dasar kedua kelompok berimbang kecuali pada kelompok perlakuan yang mempunyai rerata usia lebih muda, dimensi LA sebelum operasi lebih kecil, durasi CPB lebih singkat dan LVESD yang lebih kecil secara bermakna dibandingkan dengan kelompok kontrol. Pada evaluasi TEE pasca-tindakan didapatkan tidak ada perbedaan bermakna secara statistik antara nilai CLI pada kedua kelompok (p = 0,727) dengan nilai median kedua kelompok sama (37,7% vs. 35,6%). Tidak ada perbedaan bermakna antara nilai VCA3D pada kedua kelompok (p = 0,413), namun nilai median kelompok perlakuan lebih kecil dibanding dengan kelompok kontrol (0,03 cm2 vs. 0,06 cm2). Terdapat perbedaan bermakna antara nilai trans mitral mean gradient pada kedua kelompok (p = 0,017) dengan nilai median yang lebih rendah pada kelompok perlakuan dibandingkan kelompok kontrol (2,00 mmHg vs. 3,00 mmHg). Selain itu, tidak ditemukan adanya kejadian trombo-emboli dan mortalitas pada kedua kelompok. Simpulan: Penggunaan metode baru island flap rotation technique pada kasus regurgitasi mitral berat lesi P2 terbukti memiliki efektivitas yang tidak berbeda dengan tehnik perbaikan katup mitral yang selama ini diterapkan dengan nilai trans mitral mean gradient yang secara bermakna lebih kecil dibanding kelompok kontrol dan nilai VCA3D yang lebih kecil separuh dibandingkan kelompok kontrol. ......The re-operation rate after mitral valve repair reach up to 10% and 70% of degenerative valve disease because of procedure related. Island flap rotation technique is a novel mitral valve repair technique first performed by myself to accommodate the challenges of the unavailability of artificial chordae and to avoid tension in the tissue. A total of 29 patients with severe mitral valve regurgitation (P2 lesions) who met the inclusion criteria in National Cardiovascular Center Harapan Kita, Jakarta, Indonesia were randomly assigned into 2 groups. Intervention group underwent island flap rotation technique procedure while the control group underwent procedures other than island flap rotation technique. Subjects were evaluated using transesophageal echocardiography (TEE) before discharged. Measurements taken include Coaptation Length Index (CLI), Trans Mitral Mean Gradient, and Vena Contracta Area 3D (VCA3D). Thromboembolic adverse event and mortality were evaluated up until three months postoperatively. Baseline characteristics in both groups were similar except significantly lower subjects’ age, smaller pre-operative LA dimension, shorter CPB time and smaller LVESD in the intervention group compared to the control group. Postoperative TEE showed no significant difference in CLI between both groups (p = 0,727) with similar median values in both groups (37,7% vs. 35,6%), no significant difference in VCA3D between both groups (p = 0,413) with lower median value in the intervention group compared to the control group (0,03 cm2 vs. 0,06 cm2), and a significant lower trans mitral mean gradient in the intervention group (p = 0,017). There were no thromboembolic adverse event and mortality observed in both groups. Conclusion: The use of island flap rotation technique as a novel method for severe mitral regurgitation with P2 lesions has been proven to be as effective as the current available mitral valve regurgitation repair technique with statistically significant lower trans mitral mean gradient value in the intervention group compared to the control group and VCA3D value being two-fold lower in the intervention group.