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"Latar Belakang. Pada pasien gagal jantung refrakter yang disertai gangguan konduksi intraventrikular, Terapi Resinkronisasi Jantung (Cardiac resynchroni-zation therapy,CRT) diketahui merupakan cara yang efektif dalam memperbaiki kelas fungsional, fraksi ejeksi ventrikel kiri, uji jalan 6 menit, kualitas hidup, dan mengurangi angka hospitalisasi gagal jantung, serta angka mortalitas karena berkurangnya progresivitas penyakit tersebut. Namun demikian persoalan non-responder pasca-CRT masih merupakan masalah yang belum terselesaikan. Tujuan studi ini adalah untuk mengevaluasi ada atau tidaknya reverse remodeling yang ditunjukkan dengan disinkroni mekanis pasca-CRT dihubungkan dengan kapasitas fungsional pasien. Metodologi. Merupakan studi kroseksional dan retrospektif yang dilakukan di Pusat Jantung Nasional Harapan Kita, Jakarta. Semua pasien yang dilakukan pemasangan dari Januari 2008-Oktober 2012 dimasukkan dalam penelitian ini. Data pasien diambil dari data base rumahsakit, termasuk data klinis, EKG, ekokardiografi pra-pemasangan, dan data prosedur pemasangan. Disinkroni intraventrikular, interventrikular, dan atrioventrikular diukur melalui pemeriksaan ekokardiografi dengan Tissue Doppler Imaging (TDI). Kapasitas fungsional diukur melalui kelas fungsional NYHA serta uji jalan 6 menit. Pemeriksaan TDI, penilaian kelas fungsional NYHA dan uji jalan 6 menit dilakukan sedikitnya 6 bulan setelah pemasangan CRT. Hasil. Selama periode penelitian, sebanyak 32 pasien ikut dalam penelitian ini. Tidak ada komplikasi pemasangan. Rerata umur subjek adalah 60,3 + 13,5 tahun. Proporsi disinkroni yang masih terjadi pada subjek adalah 24 orang (75%) untuk disinkroni intraventrikular, 25 orang (78,1%) untuk disinkroni interventrikular, serta 11 orang (34,4%) pada disinkroni atrioventrikular. Rerata nilai Indeks Yu yang menggambarkan disinkroni intraventrikular berdasarkan kapasitas fungsional baik dan buruk secara berurutan adalah 39,04 + 10,69 vs 59,17 + 8,01 (p=0,001). Sedangkan untuk disinkroni interventrikular dan atrioventrikular sebesar 26,07 + 16,17 mdet vs 32,83 + 45,45 mdet (p=0,631) dan 42,76 + 8,65 vs 44,98 + 12,34 (p=0,485). Grafik korelasi linier menunjukkan bahwa adanya peningkatan disinkroni intraventrikular, berkorelasi kuat dengan penurunan kemampuan kapasitas fungsional yang ditunjukkan dalam uji jalan 6 menit (r=0,56;p=0,001). Kesimpulan. Disinkroni intraventrikular yang menetap pasca-pemasangan CRT berhubungan dengan kapasitas fungsional yang lebih buruk.

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Background. Cardiac resynchronization therapy (CRT) is an effective method in management of refractory heart failure with intra-ventricular conduction delay. It will increase functional class, left ventricular ejection fraction (LVEF), six minute walk test, and quality of life, and also decrease hospitalization and mortality rate due to heart failure, and prevent the progression of the disease. However, non-responder after CRT implantation is still a big problem. Aim of this study is to evaluate reverse remodeling after CRT implantation and the correlation with functional capacity of the patients.

Method. This is a cross-sectional and retrospective study which was held in National Cardiovascular Center Harapan Kita, Jakarta. The subject are patients with diagnosis of refractory heart failure who performed CRT implantation between January 2008-October 2012. The data was recorded from medical record, include clinical data, electrocardiography, echocardiography pre-implantation, and implantation procedure. Intra-ventricular, inter-ventricular, and atrio-ventricular dyssynchrony was assessed by tissue Doppler imaging (TDI) echocardiography. Functional capacity was evaluated with New York Heart Association (NYHA) functional class and six minute walk test which performed at least 6 months after implantation.

Results. A total of 32 patients were included in this study, with mean age of 60,3 + 13,5 years. Intra-ventricular dyssynchrony were persisted on 24 subjects (75%), meanwhile interventricular and atrioventricular dyssyncrony was 25 subjects and 11 subjects (78,1% and 34,4%). We found a significant correlation of intraventricular dyssynchrony, which was showed by Indeks Yu, in group with good and poor functional capacity with mean of 39,04 + 10,69 and 59,17 + 8,01, respectively (p=0,001). Meanwhile, mean inter-ventricular dyssynchrony in good functional capacity group and poor functional capacity were 26,07 + 16,17 mdet vs 32,83 + 45,45 mdet (p=0,631), and atrio-ventricular dyssynchrony were 42,76 + 8,65 vs 44,98 + 12,34 (p=0,485). Linear correlation graph showed increasing of intraventricular dyssynchrony will decrease the functional capacity assessed by six minute walk test.

Conclusion. The presence of intraventricular dyssynchrony after CRT implantation correlates with poor functional capacity."

"Latar Belakang. Disfungsi endotel dan aterosklerosis merupakan kondisi yang terjadi secara sistemik. Bila ada aterosklerosis di aorta, maka kemungkinan juga terjadi aterosklerosis di arteri koroner. Kekakuan aorta akibat aterosklerosis tersebut dapat diketahui dari pulse wave velocity (PWV) aorta. Penelitian ini akan menilai hubungan antara PWV aorta dengan keberadaan penyakit arteri koroner (PAK) berdasarkan skor SYNTAX (Synergy between percutaneous coronary intervention with Taxus and cardiac surgery) angiografi koroner. Metode. Penelitian ini merupakan suatu penelitian observasional potong lintang. Evaluasi dilakukan pada 83 pasien yang menjalani angiografi koroner elektif di Pusat Jantung Nasional harapan Kita dan memenuhi kriteria inklusi sejak September hingga November 2013. Hubungan nilai PWV aorta dengan keberadaan PAK berdasarkan skor SYNTAX dinilai dengan analisis regresi logistik. Hasil. Setelah disesuaikan dengan usia, jenis kelamin, indeks massa tubuh, hipertensi, diabetes melitus, dislipidemia, penghambat enzim konverting angiotensin, penyekat reseptor angiotensin, penyekat kanal kalsium, diuretik, dan pasca infark miokard, tidak ditemukan hubungan antara PWV aorta dengan keberadaan PAK (Odds ratio 2,126; IK 95%: 0,744 – 6,072; p= 0,159). Pada kelompok PAK tidak ditemukan korelasi antara nilai PWV aorta dengan skor SYNTAX (r= -0,082; p= 0,539). Uji regresi logistik multinomial antara PWV aorta dengan skor pembuluh juga tidak menunjukkan hubungan yang bermakna. Kesimpulan. PWV aorta tidak memiliki hubungan yang bermakna dengan keberadaan dan beratnya stenosis PAK, tetapi pada kelompok PAK ada kecenderungan terjadi PWV aorta lebih tinggi.

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Background. Endothelial dysfunction and atherosclerosis are conditions that occurs systemically. If atherosclerosis occurred in the aorta, it may also occurred atherosclerosis in coronary artery. Aortic stiffness as a result of atherosclerosis can be known from the pulse wave velocity (PWV) of the aorta. This study will assess the relationship between aortic PWV with the presence of coronary artery disease (CAD) by SYNTAX (Synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) score from coronary angiography.

Method. This study is a cross-sectional observational study. The evaluation was done on 83 patients who undergoing elective coronary angiography at the Harapan Kita National Heart Centre and met the inclusion criteria since September to November 2013. The relationship between aortic PWV values with the presence of CAD by SYNTAX score was assessed by logistic regression analysis.

Results. After adjusting for age, sex, body mass index, hypertension, diabetes mellitus, dyslipidemia, angiotensin converting enzym inhibitor, angiotensin reseptor blocker, calcium channel blocker, diuretic, and post myocardial infarction, analyses revealed there is no associated between aortic PWV with the presence of CAD (Odds ratio 2,126; IK 95%: 0,744 – 6,072; p= 0,159). In CAD group, there was no associated between aortic PWV value with SYNTAX score. After multinomial logistic regression between aortic PWV with vessel score, there is also no significantly associated.

Conclusion. Aortic PWV has no relation with the presence and severity of CAD, but there is a trend toward high aortic PWV in CAD group."

"[ABSTRAKLatar belakang. Pada stenosis mitral sering timbul komplikasi hipertensi pulmoner dan disfungsi ventikel kanan. Belum ada penelitian yang menghubungkan antara resistensi vaskular paru sebelum operasi dengan fungsi jantung kanan saat pasca operasi serta perubahannya pasca operasi stenosis mitral rematik.Metode. Studi ini merupakan studi kohort prospektif pada 31 pasien stenosis mitral rematik yang menjalani operasi katup mitral di Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita sejak April 2014 sampai Maret 2015. Pasien menjalani pemeriksaan ekokardiografi sebelum operasi, sebelum pulang perawatan pasca operasi serta saat follow up mid term di poliklinik. Dilakukan analisa statistik untuk melihat hubungan antara resistensi vaskular paru (RVP) pra operasi dengan strain longitudinal ventrikel kanan saat follow up mid term serta perubahan strain longitudinal ventrikel kanan pasca operasi (delta strain).Hasil. Tidak terdapat korelasi antara RVP pra operasi dengan strain longitudinal speckle tracking ventrikel kanan saat follow up mid term pasca operasi (r 0,199 p 0,264) serta dengan perubahan strain longitudinal ventrikel kanan pasca operasi atau delta strain (r 0,174 p 0,350).Kesimpulan. Resistensi vaskular paru pra operasi tidak berhubungan dengan strain longitudinal speckle tracking ventrikel kanan saat follow up mid term pasca operasi serta dengan perubahan strain longitudinal ventrikel kanan pasca operasi atau delta strain.

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ABSTRACTBackground. In MS right ventikel (RV) dysfunction and pulmonary hypertension often occur as complication. There is no research that connects the pulmonary vascular resistance before surgery with RV function and its changes in the case of rheumatic mitral stenosis who underwent mitral valve surgery.Methods. This study is a prospective cohort study which involves 31 patients with rheumatic mitral stenosis who underwent surgery at National Cardiovaskular Center Harapan Kita Hospital from April 2014 to March 2015. Patients underwent echocardiography before surgery, after surgery pre-hospital discharge and mid-term follow-up at clinic. Statistical analysis was performed to see the relationship between preoperative pulmonary vascular resistance (PVR) with RV function at mid term follow up, which is assessed using echocardiographic parameters right ventricular longitudinal speckle strain, and also with right ventricle longitudinal speckle strain postoperative changes (delta strain).Results. There is no correlation between pre operative PVR with RV longitudinal speckle strain at mid term follow-up (r 0,199 p 0,264), and post operative changes or delta strain (r 0.174 p 0.350).Conclusion. RVP before surgery is not associated with right ventricle longitudinal speckle strain at follow up mid term and post operative changes or delta strain., Background. Acute rheumatic fever and rheumatic heart disease is still regarded as animportant public health problem especially in developing countries. Mitral stenosis (MS) is asequale of rheumatic fever which are most commonly found. In MS right ventikel (RV)dysfunction and pulmonary hypertension often occur as complication. The right ventricle hasa smaller muscle mass so it is more sensitive to changes in pressure loads. There is noresearch that connects the pulmonary vaskular resistance before surgery with RV functionand also changes in the case of rheumatic mitral stenosis who underwent mitral valvesurgery.Methods. This study is a prospective cohort study which involves 31 patients with rheumaticmitral stenosis who underwent surgery at National Cardiovaskular Center Harapan Kita Hospital from April 2014 to March 2015. Patients underwent echocardiography before surgery, after surgery pre-hospital discharge and mid-term follow-up at clinic. Statisticalanalysis was performed to see changes in RV function with longitudinal speckle strain, aftersurgery pre-hospital discharge and mid-term follow-up at clinic. Analysis also performed tosee the relationship between preoperative pulmonary vascular resistance (PVR) with RVfunction at mid term follow up, which is assessed using echocardiographic parameters rightventricular longitudinal speckle strain, and also with right ventricle longitudinal specklestrain postoperative changes (delta strain). Results. Right ventricular function after surgery seen with longitudinal speckle strainimproved from -12.94 ± 3.63 preoperatively into -13.06 ± 3.63 after surgery pre hospitaldischarge, and -15.25 ± 3.75 at follow-up evaluation (p 0.007). There is no correlationbetween pre operative PVR with longitudinal speckle strain at mid term follow-up (r 0,199 p0,264), and RV longitudinal speckle strain post operative changes or delta strain (r 0.174 p0.350). Conclusion. After mitral valve surgery, right ventricle longitudinal speckle strain improves.RVP before surgery is not associated with right ventricle longitudinal speckle strain at follow up mid term and right ventricle longitudinal speckle strain post operative changes or deltastrain. ]"

"Latar Belakang. Diabetes dapat mempengaruhi struktur dan fungsi jantung tanpa adanya hipertensi dan aterosklerosis.Dengan meningkatnya risiko gagal jantung dan kejadian kardiovaskular pada pasien diabetes, maka mengetahui penyebab dan mekanisme utama yang mendasari terjadinya disfungsi diastolik menjadi penting dalam upaya mencari strategi pengobatan yang potensial.Studi pre-klinik menunjukkan bahwa Endothelin-1 (ET-1) berperan penting dalam patofisiologi kardiomiopati diabetes. Namun, hubungan antara kadar ET-1 plasma dengan kejadian disfungsi diastolik serta mekanisme yang mendasari belum diketahui dengan pasti. Tujuan. Mengetahui hubungan antara kadar ET-1 plasma dengan disfungsi diastolik dan mekanisme yang mendasarinya. Metode. Sejumlah empat puluh satu pasien diabetes dan non diabetes yang memenuhi kriteria inklusi dan eksklusi di poliklinik Pusat Jantung Nasional Harapan Kita direkrut secara konsekutif pada bulan Oktober 2012. Fungsi diastolik ventrikel kiri diperiksa dengan echocardiography, sampel darah diambil untuk pemeriksaan ET-1 plasma dengan radioimmunoassay. Pemeriksaan cardiac magnetic resonance imaging (CMRI) dengan kontras gadolinium dilakukan untuk menilai fibrosis diffuse pada miokardium serta MRI spektroskopi untuk menilai kadar trigliserida (steatosismiokardium). Hasil. Kadar ET-1 plasma lebih tinggi pada kelompok diabetes dibandingkan dengan non diabetes (1.48±0.50 vs. 1.08±0.22 pg/ml, p<0.05). Seluruh pasien diabetes mengalami disfungsi diastolik dengan 17 (85%) pasien mengalami disfungsi diastolik derajat 2 dan 3, sementara 13 (61.9%) pasien non diabetes menunjukkan fungsi diastolik normal. Tekanan atrium kiri yang meningkat juga didapatkan pada 16 (80%) pasien diabetes. Pada pasien dengan derajat disfungsi diastolik derajat 3 didapatkan kadar ET-1 yang lebih tinggi dibandingkan dengan pasien dengan fungsi diastolik normal (1.78±0.50 vs. 1.09±0.19 pg/ml, p<0.05). Sejumlah 17 (85%) pasien diabetes mengalami fibrosis, steatosis ataupun keduanya, sementara 16 (76%) pasien non diabetes yang tidak mengalami keduanya. Kadar ET-1 plasma berkorelasi dengan fibrosis miokardium (Speaman koef. R = -0.394, p<0.05), namun tidak berkorelasi dengan steatosis miokardium (Pearson koef R = 0.259, p=NS). Pasien dengan fibrosis dan steatosis mengalami derajat disfungsi diastolik yang lebih berat, dan menunjukkan kadar ET-1 plasma yang lebih tinggi (1.44±0.53 vs. 1.14±0.25, p<0.05). Kesimpulan. Kadar ET-1 plasma yang lebih tinggi pada diabetes berhubungan dengan tekanan atrium kiri yang meningkat dan derajat disfungsi diastolik yang lebih berat, serta berkorelasi dengan terjadinya fibrosis miokardium, namun tidak berkorelasi dengan steatosis miokardium.

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Background. Diabetes may affect cardiac structure and function independent to atherosclerosis and hypertension. Considering the increased risk of heart failure and cardiovascular event in diabetic cardiomyopathy, investigation of etiology and mechanism of this unique entity is important for developing potential therapy. Endothelin-1 (ET-1) has been associated with development of diabetic cardiomyopathy in pre-clinical study.

Objective. This study aims to investigate correlation of plasma ET-1 with development of myocardial fibrosis and diastolic dysfunction diabetes patient.

Methods. Fourty-one diabetes and non diabetes patient with no history of myocardial infarction and left ventricular hyperthrophy were recruited in this cross sectional study. Plasma ET-1 level were measured with radioimmunoassay, diastolic function were evaluated by Doppler echocardiography, and diffuse myocardial fibrosis were evaluated by post-contrast myocardial T1 relaxation time using cardiac MRI.

Results. Plasma ET-1 level is higher in diabetes group as compare to non diabetes (1.48±0.50 vs. 1.08±0.22 pg/ml, p<0.05). All diabetes subjects developed diastolic dysfunction, with 17 (85%) had grade 2 and 3 diastolic dysfunction, compare to 13 (61,9%) non diabetes patient which showed normal diastolic function. We also observed the increased of left atrial pressure (LAp) in 16 (80%) of diabetes patient. Patient with grade 3 (severe) diastolic dysfunction showed higher plasma ET-1 level as compare to patient with normal diastolic function (1.78±0.50 vs. 1.09±0.19 pg/ml, p<0.05). Diabetes subject had shorter post-contrast T1 relaxation time - reflecting diffuse myocardial fibrosis (440.97±16.97 vs. 489.41±6.73 ms, p<.005), and correlates inversely to plasma ET-1 level (Spearman Coeff R = -0.394, p<0.05).

Conclusion. In conclusion, higher plasma endothelin-1 level is associated with diffuse myocardial fibrosis and diastolic dysfunction in diabetes patient. This may provide additional evidence for the potential clinical use of endothelin receptor blockade in preventing diabetic cardiomyopathy."

"Latar belakang : Stenosis mitral (SM) masih merupakan masalah kesehatan yang penting di Indonesia. Pada SM terjadi peningkatan kadar P selectin karena disfungsi endotel dan aktivasi platelet. Komisurotomi mitral transvena perkutan (KMTP) merupakan tatalaksana baku untuk penderita SM yang dapat memperbaiki kemampuan aktivitas fisik yang pada akhirnya akan mempengaruhi kadar P selectin. Belum ada penelitian yang menghubungkan antara tingkat aktifitas fisik dengan kadar P Selectin 3 bulan pasca KMTP pada SM rematik. Metode : Penelitian ini merupakan penelitian potong lintang. Dari 56 subyek penelitian yang menjalani KMTP sejak bulan Mei 2013 sampai Februari 2014 di Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita, didapatkan 35 sampel yang memenuhi kriteria penerimaan . Data klinis dan data ekokardiografi sebelum dan 3 bulan pasca KMTP diambil dari catatan medis. Dilakukan wawancara 3 bulan pasca KMTP. Tingkat aktivitas fisik dibagi menjadi 2 kelompok: kelompok 1 1-4 METs, kelompok 2 > 4 METs. Kadar P selectin diambil 3 bulan pasca KMTP. Selanjutnya dilakukan analisa statistik untuk mengetahui hubungan antara tingkat aktivitas fisik dengan kadar P Selectin 3 bulan pasca KMTP pada SM rematik. Hasil : Pasien yang akan menjalani KMTP memiliki rerata usia 40,00±11,58 tahun dengan proporsi perempuan lebih tinggi daripada laki-laki (74,3%) dan dengan proporsi irama sinus yang lebih tinggi daripada irama atrial (57,1%). Dari uji T didapatkan ada perbedaan bermakna rata-rata kadar P selectin 3 bulan pasca KMTP pada tingkat aktivitas fisik 1-4 METs dan > 4 METs, dimana rerata kadar P selectin 3 bulan pasca KMTP pada tingkat aktivitas fisik > 4 METs lebih rendah secara bermakna dibandingkan 1-4 METs (p=0,003). Setelah dilakukan analisa multivariat terlihat tingkat aktivitas fisik pasca KMTP tetap berpengaruh terhadap kadar P Selectin 3 bulan pasca KMTP (p=0,001). Area Katup Mitral (AKM) pasca KMTP berpengaruh terhadap kadar P selectin 3 bulan pasca KMTP (p=0,018), namun tingkat aktivitas fisik pasca KMTP lebih besar pengaruhnya dibandingkan AKM. Kesimpulan : Terdapat hubungan antara tingkat aktivitas fisik dengan kadar P selectin 3 bulan pasca KMTP dimana pada tingkat aktivitas yang lebih tinggi ( > 4 METs) kadar P selectin lebih rendah 10,489 ug/ml dibandingkan tingkatan aktivitas fisik 1-4 METs.

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Background : Mitral stenosis (MS) is an important health problem in Indonesia. P selectin level in MS increases due to endothelial dysfunction and platelet activation. Percutaneous transvenous mitral commissurotomy (PTMC) is one of the management for MS patients. Thus, the physical activity can improve and in turn affect the level of P selectin. There has been no study link the level of physical activity with the level of P Selectin 3 months after of PTMC.

Method : This is a cross sectional study with 56 subjects who underwent PTMC from May 2013 to February 2014 at the Hospital of National Heart Centre Harapan Kita. Then, 35 samples met the inclusion criteria. Clinical and echocardiography data before and 3 months after PTMC were taken from medical records. Interviews were conducted 3 months after PTMC. Physical activity levels were divided into 2 groups: group 1 (1-4 METs) and group 2 (> 4 METs). Sample for P selectin was taken 3 months after PTMC. Further statistical analysis was done to determine the relationship between physical activity level with level of P Selectin 3 months after PTMC in rheumatic MS.

Result : Patients who will undergo PTMC have the mean age of 40.00 ± 11.58 years with a higher proportion of women than men (74.3%) and the proportion of sinus rhythm is higher than atrial rhythm (57.1%) . T-test analysis result showed significant difference in the average levels of P selectin 3 months after PTMC on the level of physical activity 1-4 METs and > 4 METs. The average P selectin levels on the level of physical activity in group with > 4 METs was significantly lower compared with group 1-4 METs (p = 0.003). After multivariate analysis, the physical activity level still has an effect on the P selectin levels 3 months after PTMC (p = 0.001). The Mitral Valve Area (MVA) after PTMC also has an effect on P selectin levels (p = 0.018). However, the level of physical activity after PTMC has a greater effect than MVA.

Conclusion : There is a relationship between the level of physical activity with P selectin levels 3 months after PTMC.Group with higher activity level (> 4 METs) have lower level of P selectin (with the mean difference levels of P Selectin 10,489 ug/ml)."