Clinical Presentation and 6-Month Outcomes of Patients with Peripartum Cardiomyopathy in Indonesia

Background

Due to the rarity of peripartum cardiomyopathy (PPCM) globally, baseline characteristic data for PPCM patients are still scarce. Therefore, this study aims to determine the baseline characteristics and 6-month outcomes of PPCM patients in Indonesia.

Methods

From January 2014 to December 2021, all PPCM patients aged ≥18 years who were admitted to Dr. Hasan Sadikin General Hospital in Bandung, Indonesia, participated in this single-center, prospective cohort study. All patients were re-evaluated within 6 months of PPCM diagnosis.

Results

A total of 138 patients with PPCM were admitted to Dr. Hasan Sadikin General Hospital in Bandung. The mean age of all patients was 30.4 ± 6.4 years old. Approximately 60% patients were multipara and had preeclampsia. All guideline-directed medical therapy for heart failure was received by most patients, excluding mineralocorticoid receptor antagonists (25.2%) and bromocriptine (14.1%). The neonatal mortality rate was 5.1%. Among those who survived, 61.2% had normal weight, 31.8% had low birth weight, and 7% had very low birth weight. At the 6-month follow-up, 6.7% of the patients died, 63.3% recovered, and 1.9% were rehospitalized.

Conclusion

The present study found a high incidence of PPCM in Indonesia. Our patients frequently had preeclampsia, which contributed to the higher rate of miscarriage and low birth weight. Our liberal use of beta-blockers and ACEi/ARB may have contributed to the higher 6-month recovery rate than that in other countries.

Ostial Circumflex Dissection Caused by Off-Track OCT Catheter

A 53-year-old man was planned for staged PCI to the left circumflex artery (LCX). He had history of primary PCI at the proximal left anterior descending (LAD) 6 months earlier. Following coronary angiogram, it was decided to perform an initial optical coherence tomography (OCT) evaluation. However, during delivery to the LAD, the OCT catheter was railed-off from the guidewire and knocked to the ostial LCX. After guide-catheter repositioning and double-kissing culotte stenting at the left main bifurcation, the patient was finally stabilized. The purpose of these images is to make the readers aware of the genuine and serious risk of a "railed off" OCT catheter, especially while delivering the catheter at a bifurcation with an eccentric lesion. Meticulous OCT catheter delivery and improvement of the OCT catheter configuration may be considered to avoid this complication.

Iatrogenic Pericarditis and Cardiac Tamponade Following Distal Wire Perforation: A Serial Case Report

Distal wire perforation is an infrequent percutaneous coronary intervention (PCI) complication, which may progress to one of the fearful conditions, cardiac tamponade, and rarely to iatrogenic pericarditis. We described 2 cases of acute pericarditis and cardiac tamponade following distal guidewire coronary artery perforation that was successfully managed with pericardiocentesis, anti-inflammatory agents, and meticulous follow-up. Although uncommon, acute traumatic pericarditis may also be considered as a complication after a complex PCI.

Compressive Coronary Intramural Hematoma: A Case Report

Despite the advancement of various devices and techniques, percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) lesion remains one of the major challenges in interventional cardiology fields. It is also associated with higher complications than non-CTO-PCI due to procedural complexity. We presented a case of iatrogenic compressive coronary intramural hematoma (IMH) as CTO-PCI complications, which was judiciously detected and successfully managed with a cutting balloon.

Eisenmenger syndrome with left main compression syndrome: a case report

Background

Left main coronary artery disease secondary to pulmonary artery compression related to Eisenmenger syndrome is an under-suspected condition that can cause fatal outcomes if left untreated. It presents with typical angina but is frequently mistaken for pulmonary hypertension (PH) symptoms. It is now recognized as one of the few important causes of angina in PH.

Case presentation

A 37-year-old man with a history of unoperated atrial septal defect and Eisenmenger syndrome came to the outpatient department with a chief complaint of angina on exertion. Electrocardiogram showed regular sinus rhythm with right axis deviation, right ventricular hypertrophy, deep T-wave inversion in inferior and anterior leads suggestive of ischemia or strain, and incomplete right bundle branch block. Cardiac CT showed compression of the left main coronary artery due to a dilated main pulmonary artery. Therefore, this patient was diagnosed with Eisenmenger syndrome with left main compression due to dilated pulmonary artery. He was treated successfully with IVUS-guided stent implantation. The patient experienced marked improvement in regular activities, with no recurrence of angina symptoms. Angiography 3 months after the procedure revealed good patency of the stent, without significant stenosis.

Conclusions

Left main coronary artery compression is a complication that should be suspected in patients with Eisenmenger syndrome presenting with angina symptoms. Non-invasive modalities are recommended for diagnostic evaluation, but the gold-standard technique remains coronary angiography. The best treatment is not well-established, with either myocardial revascularization or PH treatment, but a left main coronary artery stenting procedure is considered an ideal emergent treatment to provide a better quality of life for patients in this condition.

Unexpected Infective Endocarditis in Corrected Congenital Heart Disease: A Case Report

Objective: To describe patients with corrected Congenital Heart Disease (CHD) who experienced Infective Endocarditis (IE). Methods: Two cases of IE were observed in 2019. The first case involved a 36-year-old woman with previous percutaneous transcatheter perimembranous ventricular septal defect (VSD) closure four months before admission. Echocardiography showed vegetation at noncoronary cusps of the aortic valve. Patient received antibiotics for six weeks and underwent surgery for evacuation of vegetation and device, along with VSD closure with a cardiovascular patch (Gore-tex). The second case involved a 43-year-old woman with a history of surgical closure in secundum atrial septal defect (ASD) by pericardial patch two months before admission. Echocardiography showed vegetation at the tricuspid valve. Patient received antibiotics for four weeks and planned for surgery to evacuate vegetation. Results: IE is one of the major complications in CHD, whether uncorrected, treated, or corrected. The risk of IE increased with an invasive procedure. Post closure IE is rare. Poor dental hygiene and immunocompromised also increased patient's risk to be exposed to IE as shown in the first patient who had dental caries and the second patient who was on methylprednisolone for post-surgical pericardial effusion treatment. Conclusion: The risk of IE increases with invasive procedures in CHD patients. Although the incidence of IE is quite rare, its possibility should become of a serious concern among physicians.

A Case of Complex Pulmonary Hypertension: the Importance of Diagnostic Investigation

Pulmonary hypertension (PH) encompasses several heterogeneous groups of multiple diseases characterized by abnormal pulmonary arterial blood pressure elevation. Unrepaired atrial septal defect (ASD) may be associated with pulmonary arterial hypertension (PAH), indicating pulmonary vascular remodeling. Furthermore, unrepaired ASD could also be associated with other conditions, such as left heart disease or thromboembolism, contributing to the disease progression. We present a case of a 61-years-old woman with complex PH comprising several etiologies, which are PAH due to unrepaired Secundum ASD, mitral regurgitation caused by mitral valve prolapse as a group 2 PH, pulmonary embolism (PE) which progress to chronic thromboembolism PH (CTEPH) and post-acute sequelae of SARS Cov-2. We highlighted the importance of diagnostic investigation in PH, which is crucial to avoid misdiagnosis and inappropriate treatment that could be detrimental for the patient.

Cardiac manifestations, treatment characteristics, and outcomes of paediatric inflammatory multisystem syndrome temporally associated with severe acute respiratory syndrome coronavirus-2: A systematic review

BACKGROUND

Paediatric inflammatory multisystem syndrome (PIMS) temporally associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) (PIMS-TS) is a rare clinical syndrome associated with a multiorgan system dysfunction, especially acute cardiac injury, and mandates a higher level of care.

AIM OF REVIEW

To investigate cardiac manifestations, treatment characteristics, and outcomes of PIMS-TS.

KEY SCIENTIFIC CONCEPTS OF REVIEW

Twenty-six studies were included with 1228 pooled subjects, with a mean age of 8.6 years, which were dominated by male gender (53%), and African ethnicity (31%). 732 (38%) patients were reactive on a serological test, and 457 patients (45%) were positive on SARS-CoV-2 RT-PCR. ST-segment abnormalities were the most common ECG findings (16%, n/N: 34/212). Various markers of troponin and the pooled mean of BNP and NT-pro-BNP levels were elevated. Cardiomegaly and pericardial effusion (21.8%, n/N: 164/751) were the most common chest X-ray findings. In echocardiography, the majority of patients' left ventricular ejection fraction was reduced (59.0%, n/N: 180/305), with pericardial effusion/ pericarditis seen the most (17.44%, n/N: 221/1267), and Z score ≥ 2 in 28% (n/N: 42/139). Cardiac MRI findings were consistent with acute myocarditis. Intravenous immunoglobulin, corticosteroids, and vasoactive drugs were frequently utilized. The mean length of stay was 6 days, with most patients (71%, n/N: 834/1163) were admitted to the ICU. However, the overall prognosis was favorable, with 98% alive (n/N: 1235/1260), and more than 50% of patients experienced recovery of left ventricular systolic functions at discharge (116 out of 206 patients).

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Background

Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE).

Case Description

We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused.

Discussion

The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Background

Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE).

Case Description

We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused.

Discussion

The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

Superior Vena Cava Syndrome due to pericardial hematoma: A case report and mini-review of literature

Superior vena cava syndrome is a life-threatening condition. Typically, the clinical presentations are gradual; hence, the diagnosis is often delayed until critical compression or obstruction has occurred. Pericardial hematoma is a rare condition that could occur after cardiac surgery. An asymptomatic, 25-year-old female, who underwent surgical atrial septal defect closure 5 days ago, was sent for routine echocardiography examination before discharge. An intrapericardiac hematoma was detected at the right atrium’s free wall without any intracardiac hemodynamic consequences. The patient was discharged and planned for monthly evaluation. During follow-up, the intrapericardiac hematoma was expanding. In the third month’s follow-up, the patient complained of shortness of breath, headaches, and coughs. Echocardiography evaluation revealed enlarged pericardial hematoma, which compressed the right atrium and superior vena cava orifice, without echo’ sign of cardiac tamponade. Computed tomography scan revealed superior vena cava compression by the pericardial hematoma and appearance of the collateral vessel. The patient was diagnosed with superior vena cava syndrome and sent for surgical evacuation. Pericardial hematoma after cardiac surgery should be evaluated meticulously. Chronic expanding hematoma could cause superior vena cava syndrome, which is fatal. Early diagnosis and appropriate treatment are essential in managing this condition.

A case of endocarditis and spondylodiscitis associated with Mycobacterium tuberculosis

Tuberculosis (TB) is a global health problem, in which the majority of cases occur in population-dense developing countries. Despite advances in various diagnostic TB modalities, extrapulmonary TB remains a challenge due to complexities related to its diagnostic approach. Hereby, we present a rare case of endocarditis and spondylodiscitis associated with Mycobacterium tuberculosis (MTB). This case report highlighted the challenges faced in diagnosing blood culture-negative infective endocarditis (BCNIE). We also emphasized the importance of considering MTB as etiology of BCNIE, particularly in endemic TB areas.

Infective Endocarditis with Multiple Valvar Vegetation in Uncorrected Tetralogy f Fallot: A Case Report of Rare Condition

Objective: To describe a case of an adult patient with uncorrected Tetralogy of Fallot (TOF) who suffered from Infective Endocarditis (IE) that involved the tricuspid and aortic valves. Methods: On October 2019, a-twenty-year-old male with uncorrected TOF was admitted to the emergency department of Dr. Hasan Sadikin General Hospital with a chief complaint of fever. The echocardiography showed the presence of vegetation on the tricuspid valve and aortic valve. The patient was given empirical antibiotics therapy for IE treatment. The serial blood cultures did not yield any organism growth and the transthoracic echocardiography evaluation showed healed vegetation after 21 days of antibiotics treatment. Results: A high turbulence in small VSD and valvular stenosis, as found in TOF, can injure the endocardial surface. While bacterial adherence to the injured endocardial surface can cause IE, no specific criteria available for diagnosing IE in congenital heart disease (CHD) patients compared to other population. In CHD patients, it is necessary to consider the diagnosis of IE presenting with signs of infection or fever. Our patient was known to have uncorrected TOF and was admitted to the hospital with a chief complaint of fever. The uncorrected TOF was complicated by an unusual form of aggressive vegetation involving multiple valves. Conclusion: The incidence of IE in uncorrected TOF is around 4%. Patient is advised to receive a corrective surgery for the cardiac anomaly. Surgical repair of CHD with no residual lesion reduces the risk of IE.

Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2: a New Challenge amid the Pandemic

Initially, SARS-CoV-2 infection had been reported as a relatively mild case in children than in adults. Nevertheless, recent evidence found that a subset of children then developed a significant systemic inflammatory response that resembles atypical/typical Kawasaki’s disease (KD) and toxic shock syndrome. This novel clinical syndrome later identified as pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). In contrast with KD, PIMS-TS appears to occur in children at an older age with a predominance of gastrointestinal symptoms, hemodynamic instability, and myocardial dysfunction. However, the exact pathomechanism remains to be understood. Nevertheless, the post-viral immunological reaction is postulated to be the underlying mechanistic underpinnings. The multifaceted nature of the PIMS-TS’ course underlines the need for early recognition and multispecialty care and management.

A rare manifestation of Takotsubo Cardiomyopathy associated with non-tuberculous mycobacterium

Background

Takotsubo Cardiomyopathy or broken heart syndrome is a rare cause of non-ischemic cardiomyopathy that produce left ventricular dysfunction with characteristic left ventricular apical ballooning. It rarely caused by infection. We present an atypical manifestation of non-tuberculous mycobacterial (NTM) infection with myocardial involvement and its diagnostic challenge.

Case illustration

A 57-year-old female presented with prolonged fever, fatigue and weight loss for one and half months. General examination was unremarkable with elevated C-Reactive Protein and normal troponin. Electrocardiogram (ECG) showed diffuse T wave inversion with prolonged QTc. Echocardiography showed hypokinetic apical with normal ejection fraction. Angiography showed patent coronary arteries. Ventriculography showed apical ballooning. Workup with ethambutol scan revealed active mycobacterial infection in both lung and mesentery. Sputum polymerase chain reaction (PCR) was positive for non-tuberculous mycobacterium. Follow up ECG and echocardiography showed improvement in QTc interval and left ventricular wall motion abnormalities.

Results

Takotsubo Cardiomyopathy may manifest as asymptomatic ventricular dysfunction following non-tuberculous mycobacterial infection. A thorough investigation will help identify the systemic disease with cardiac involvement which potentially could be fatal.

Conclusion

Takotsubo cardiomyopathy may be triggered by infection. Identification of causal is crucial as a management strategy to restore cardiac function.