Reversal of Tachycardia Induced Cardiomyopathy

Indonesian Journal of
Cardiology
Indonesian J Cardiol 2018:39:suppl_A
pISSN: 0126-3773 / eISSN: 2620-4762
doi: 10.30701/ijc.v38isuppl_A.830
Abstracts of the 6th
Annual Scientific Meeting of the Indonesian Heart Rhythm Society 2018
45
Annual Scientific Meeting of the Indonesian Heart
Rhythm Society
Jakarta, 21-22 September 2018
Case Reports
Radiofrequency Catheter Ablation With 3D Mapping of Recurrent Orthodromic Atrioventricular
Reentrant Tachycardia in A Young Lady with Congenitally Corrected Transposition of The Great Arteries
and Small Atrial Septal Defect.
M.H. Hazleena1
, I.Perkasa1
, P.Ardhianto1
, D.Y.Hermanto1,2
, SB Raharjo1,2
, D.A.Hanafy1,2
, Y Yuniadi1,2
1
National Cardiovascular Centre, Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita, Jakarta,
Indonesia. 2
Faculty of Medicine, University of Indonesia, Jakarta, Indonesia.
Introduction: CCTGA is a rare cardiac malformation. Most CCTGA patients have at least 1 associated
cardiac anomaly, mainly VSD. 2%–5% of them have AP-related tachycardia. A combination of orthodromic
AVRT, CCTGA and ASD is rarely reported.
Materials and Methods: A 23-year old lady with CCTGA and ASD was presented with recurrent episode
of palpitation. Long RP tachycardia with VA interval of 140ms was easily induced during PES. The
tachycardia was resetting during HSVPB and the PPI – TCL < 115ms with VAV response. Therefore, the
diagnosis was AVRT. The 3D Ensite Precision electroanatomic mapping was used to facilitate the RFA . One
6F quadripolar catheter and one 6F duo-decapolar were placed at LV and HRA, respectively. The irrigated
7F CoolFlex, 4 mm tip ablation catheter was placed at the tricuspid annulus from the right to the left
atrium via the ASD secundum. The area with fused V and A signal was mapped by using the ablation
catheter during pacing from LV.
Results: The area with earliest activation was at the right posteroseptal. RFA was delivered at 45 degree
Celsius, 30 Watts in pulses of 60-120 seconds during LV pacing till VA dissociation occurred. After RFA,
pacing from LV showed retrograde block.
Conclusion: We illustrated that right posteroseptal AP in patient with CCTGA can be successfully ablated
by a trans-septal approach across the ASD secundum. Hence, the retrograde approach was not needed.
The 3D electroanatomical mapping was useful in case of AVRT with complex structural heart disease.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
46
Atrial Incisional Tachycardia Following Three Decades of Cardiac Surgery
Rizki Pandelaki, Gunawan Yoga, Beny Hartono, Muhammad Munawar
Binawaluya Cardiac Center, East Jakarta, Indonesia
Introduction: Incisional reentry tachycardia is rare type of atrial tachycardia. It is commonly related to
congenital heart surgery. Its mechanism is generally from macro reentry around a scar.
Pharmacologgical treatment is sometimes chalengingg. We reported a case of such type of tachycardia
which successfully ablated.
Methods: N/A
Results: A 66-year-old female, admitted to our hospital because of recurrent palpitation, which had
history of atrial septal defect closure surgery 30 years prior admission. She still had recurrent symptoms
despite treated medically for 6 months. ECG during tachycardia showed supraventricular origin at rate of
233 bpm, with RP>PR interval and RP interval 140-160ms. Chest radiography and echocardiography
showed no remarkable parameters nor structural problems. Electrophysiology study set up and activation
mapping using CARTO 3D® visualized earliest activation signal at inferolateral of right atrium with small
re-entry circuit related to those area of probable surgical scars. A pair of linier ablations then applied on
the inferolateral wall toward the IVC, and successfully rendered it non-inducible, which can be easily
induced prior to ablation. The total procedural time was 70 minutes. No complication occurred following
ablation and patient was discharged on the next day. No reccurent palpitation within 3 months follow-up.
Conclusions: This case showed radiofrequency ablation procedure is a effective treatment of incisional
tachycardia. Three-dimensional mapping system provides an excellent electroanatomic and activation
map and also reliable monitoring of the ablation catheter, hence may increases procedural success rate.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
47
Reversal of Tachycardia Induced Cardiomyopathy Caused by Atrial Flutter Is Not A Myth
Gunawan Yoga, Vika Fransiska, Rizki Pandelaki, Beny Hartono, Muhammad Munawar
Binawaluya Cardiac Center, Jakarta, Indonesia
Introduction: Long-sustain tachycardias are well-recognised cause of left ventricular (LV) dysfunction and
heart failure, well-known as tachycardia-induced cardiomyopathy (TIC). This kind of cardiomyopathy is
generally a reversible if the causative tachycardia can be treated effectively, either with medications,
surgery or catheter ablation. The diagnosis can be made after recovery of LV function with heart rate
normalisation and the absence of other identifiable aetiologies.
Methods: n/a
Results: First case is a 50-year-old female presented with typical atrial flutter 2:1 ventricular response and
severe heart failure. The baseline echocardiography was LVEDD 59mm, LVESD 52mm, EF 25%, LAD 42mm.
Coronary angiogram showed no significant stenosis. No history of fever, alcohol or any systemic disease.
In addition to optimal medical therapy, the ablation to the cavo-tricuspid istmus (CTI) was performed to
terminate flutter. There was an improvement of symptoms on 26 months of follow up. Echocardiogram
showed dynamic progression especially during 12-24months and latest study showed significant
improvement of EF to 59% with LVEDD 51mm and LVESD 35mm. On exercise test, the maximum capacity
was 7.4 Mets. Second case is a 47-year-old male with fatique and reccurent palpitation for few years. A
typical atrial flutter with 3:1 ventricular response was recorded. Baseline echocardiography study showed
EF 26%, LVEDD 55mm, LVESD 48mm, LAD 42mm. No coronary artery disease or other remarkable disease.
Ablation of CTI was also performed in addition to optimal medical therapy. There was early progressive
reversal of cardiac dysfunction and improvement of symptom with EF 46%, although there is still no
significant difference of LV systolic and diastolic dimensions, but there was reduction in LAD (39mm). The
maximum capacity was 10.7 Mets on exercise test within first 3 months follow-up.
Conclusions: We presents two cases of reversible heart failure following atrial flutter induced TIC.
Elimination of any symptoms and able to achieve average maximal capacity are signs of good prognostic
on these patient. In addition to symptoms improvement, remodelling reversal will be the goal in the
management of these patients

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
48
Successful Ablation of PVC Originated from Left Ventricular Summit with Conventional Ablation: A Case
Report
V. Kurniawati1,2
, S. B. Raharjo1
, D.A. Hanafy1
, D.Y. Hermanto1
, D.H. Karimullah1,2
, Y. Yuniadi1
1
Division of Arrhythmia – Department of Cardiology and Vascular Medicine, Faculty of Medicine
Universitas Indonesia
2
Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya – National
Cardiac Center Harapan Kita
Introduction: Catheter ablation of Premature Ventricular Complex (PVC) is highly successful, with overall
success rates 90%, and is accepted as a first-line therapy by current guidelines. There is a percentage of
patients in whom successful ablation cannot be achieved because of anatomic limitations. The summit of
the left ventricle (LV) is the most superior portion of the epicardial LV bounded by an arc from the left
anterior descending coronary artery, superior to the first septal perforating branch to the left circumflex
coronary artery. Ablation of PVC from LV summit is still challenging with only 50% success rate, even with
3D ablation.
Objective: To present a case of successful ablation of PVC originated from Left Ventricular Summit using
conventional method.
Case Illustration: A 45 years old man presented with palpitation. The ECG shows sinus rhythm with PVC.
The PVC had LBBB morphology, inferior axis, R/S transition at V2-V3, positive in lead I and negative in aVL.
Suggesting PVC came from LV summit. Before the ablation was started, the Betensky score was 0.33 and
MDI Score was 0.58. Mapping with ablation catheter in posteroseptal RVOT showed earliest activation
(EA) of 27 ms. Pace mapping could not be done, due to subvalvar region. Multiple ablation was done with
power set to 15 watt and temperature to 500
C. Ablation catheter was inserted to Great Cardiac Vein
showed EA of 32 ms and multiple ablation was done with 15 watt and temperature of 500
C at the anterior
region of LV summit. Mapping at the Left Coronary Cuspis subvalvar showed EA of 15 ms. Multiple RFAs
was done at 60-120 second with temperature of 600
C and power set to 30 watt. The PVC was completely
abolished. During 30 minutes follow-up, the patient showed no further PVC.
Conclusion: We reported successful conventional catheter ablation of PVC originated from LV summit
using multiple approaches, i.e. posteroseptal RVOT, GCV and subvalvar LCC.
Keyword: Ablation of PVC, Left Ventricular summit

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
49
Prolonged Ventricular Dyssynchrony Due to Atrial Fibrilation and Pre-Excitation Syndrome Induced
Cardiomyopathy: A Case Report
O. Litanto1
, M Iqbal1
, M Pramudyo1
Department of Cardiology and Vascular Medicine, Padjadjaran University, Bandung, Indonesia1
Introduction: In patients with Wolff-Parkinson-White syndrome (WPW), ventricles are electrically pre-
excited through an accessory pathway (AP) which may cause dyssynchrony. Approximately, 80% patients
with WPW experienced tachyarrhythmia. Atrial fibrillation (AF) is not uncommon in patient with WPW
syndrome. We presented a case of a patient with AF WPW and severe LV dysfunction who was successfully
ablated and showed significant improvement of LV function.
Objective: To report the effect of ablation and maintain sinus rhythm in patient with AF WPW and severe
LV dysfunction.
Methods: A 76 years old male, already diagnosed had WPW syndrome since 2016, was referred to our
hospital with a chief complaint palpitation and shortness of breath. The patient had cardiomegaly, with
no sign of congestion. There is no history of angina or MI. The patient complained more frequent
palpitation, and symptoms of heart failure in the last 1 year. Two years before admission, ECG showed
normal sinus rhythm and typical characteristics of WPW. The polarity of delta wave is consistent with the
features of left lateral AP. ECG in our hospital showed pre-excited AF (HR 132 x/min). Previous TTE on
2016 showed normal all chambers with EF >50% and normokinetic at rest. Present TTE showed dilated all
chambers, reduced LV systolic function (LVEF 29%) with global hypokinetic.
Result: The rhythm was successfully return to sinus after electrical cardioversion and AP was successfully
ablated. We maintained sinus rhythm with amiodarone oral 200mg daily. Three months after ablation,
symptoms of heart failure disappeared, rhythm remained sinus and follow up TTE showed significant
improvement of LV systolic function (EF 65%) with normokinetic at rest.
Conclusion: Prolonged ventricular dyssynchrony and frequent episode of tachyarythmia due to AF WPW,
may cause cardiomyopathy. Maintaining sinus rhythm in patient with AF WPW syndrome after ablation,
lead to LV reversed remodelling. Duration of amiodarone oral to maintain sinus rhythm in patient with AF
WPW post ablation, need further investigation.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
50
Case Report: Is AV Dissociation Determine Wide Complex Tachycardia Differential Diagnosis?
Hendyono L, Indah S, Ignatius Y, Antonia AL
Siloam Hospital Lippo Village, Karawaci
Faculty of Medicine, Pelita Harapan University, Karawaci
Background: Wide Complex Tachycardia (WCT) remains problematic where the correct diagnosis is
uncertain. Defined as tachycardia with QRS width >120ms which ventricular tachycardia (VT) accounts up
to 80% cases of WCT, while supraventricular tachycardia (SVT) with aberrancy is up to 15 to 20%. AV
dissociation has 100% specificity to distinguish VT from SVT with aberrancy. We present a case of
recurrent WCT with initial electrophysiology study (EPS) showed no AV dissociation.
Case Presentation: A 31-year-old male patient presented to our emergency department with palpitation
last for 4 hours accompanied with epigastrium discomfort, shortness of breath and dizziness. Symptoms
began after exertion and did not abate. Patient heart rate was 178 beats/min with blood pressure 90/60
mmHg. ECG showed WCT with RBBB pattern and left superior axis deviation, with no visible P waves.
Intravenous calcium channel blocker was given, and tachycardia terminated with resultant of sinus
rhythm. EPS initial evaluation showed A and V signals fused during induced tachycardia with 1:1
conduction. Further EPS evaluation easily induce WCT with RBBB pattern and left axis deviation with right
ventricular programmed stimulation and AV dissociation was identified. EPS mapping done in posterior
fascicle near left ventricular septal with earliest activation 25ms and mid-diastolic signal was seen.
Discussion: Idiopathic Left Ventricular Tachycardia (ILVT) mostly affects young males aged 15-40 years,
presents typical symptoms include dizziness, palpitations, chest discomfort and syncope. Characteristics
of surface ECG with tachycardia, RBBB pattern and left superior axis deviation indicated ILVT (axis
deviation depends on the anatomical site of reentry circuit), but often mistaken for SVT with aberrancy.
EPS important to distinguish ILVT from SVT, with clear identification of AV dissociation during induced
tachycardia exhibits RBBB pattern and left axis deviation. In our case, initial intracardiac electrogram
during induced tachycardia showed A-V signals fused with 1:1 conduction mislead to SVT diagnose.
Further entrainment mapping succeeded inducing AV dissociation during tachycardia similar to surface
ECG pattern. These findings indicate that even though AV dissociation confirms VT, it is not always present
during VT episodes.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
51
Keywords: arrhythmia, ventricular tachycardia, idiopathic left ventricular tachycardia, supraventricular
tachycardia, electrophysiology study.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
52
2:1 Atrioventricular Block: What Can We Learn from Atropine Effect?
A. Tridamayanti 1
, Irnizarifka1,2
1
Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Sebelas Maret,
Surakarta, Indonesia. 2
Departement of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas
Sebelas Maret, Sebelas Maret University Hospital, Surakarta, Indonesia.
Background: 2:1 atrioventricular block can occur in either AV node (AVN) or HIS-Purkinje System (HPS)
and cannot be classified into type I or type II second-degree AV block because there is only one PR segment
to be examined before the dropped-beat. On the other hand, it is essential to have two consecutive
conducted P waves to differentiate between type I or type II second-degree AV block. Determining those
types of atrioventricular or HPS block is very important as treatments are also unlike.
Case Illustration: 56 year old diabetic woman was admitted with chief complaint of chest pain since 15
hours beforehand, accompanied with diaphoresis and near syncope. Her resting ECG revealed 2:1 AV
block, with PR interval was not prolonged (0.2 sec), and ST segments were not elevated. Cardiac enzyme
proved diagnosis of NSTE-ACS and 2:1 AV block. In order to define the site of block, we performed atropine
challenge test. After administration of 0.5 mg atropine, ECG revealed improvement of AV conduction ratio
with 3:2 Wenckebach-like manners. It indicated the location of the block was at AV node.
Discussion: Fixed 2:1 AV block poses a diagnostic dilemma because it can be difficult to determine the
site of block by the surface ECG alone. The AVN is richly innervated and highly responsive to both
sympathetic and vagal stimuli, whereas HPS is influenced minimally by the autonomic nervous system.
Atropine or exercise can improve AVN conduction because of sympathetic stimulation and/or
parasympatholysis. Therefore, atropine administration can improve AVN conduction but worsen
infranodal block due to sympathetic stimulation of the sinus node and AVN without changing the HPS
refractoriness.
Conclusion: This case illustrates the importance of noninvasive atropine challenge test to confirm site
of 2:1 atrioventricular block, thus will guide the definite therapy.
Keyword: 2:1 atrioventricular block, atropine challenge test, wenkebach, HIS-purkinje block

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
53
Low Hasbled Score: Is It Safe from Bleeding?
Alvin Thengker 2
, Antonia Anna Lukito1,2
1
Cardiovascular Dept. Pelita Harapan University
2
Siloam Hospital Lippo Village, Tangerang, Indonesia
Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia with an increasing
incidence with advanced age and remains one of the major causes of stroke, heart failure, sudden death,
and cardiovascular morbidity in the world.1,2
The risk of ischemic stroke is 5-fold higher among patients
with AF. Contemporary studies show that 20–30% of patients with an ischaemic stroke have AF diagnosed
before, during, or after the initial event. White matter lesions in the brain, cognitive
impairment, decreased quality of life, and depressed mood are common in AF patients, and between 10–
40% of AF patients are hospitalized each year.2
Anticoagulant medications are commonly used for the
prevention and treatment of thromboembolism. Although highly effective, they are also associated with
significant bleeding risks.3
Optimal warfarin dosing varies greatly among patients, as there are multiple
factors that influence its anticoagulant effect. One major factor is the individual's genetic makeup.4
Case Illustration: A 49 years old female with cor pulmonale, paroxysmal atrial fibrillation with zero
HASBLED score had been on warfarin for two months and the INR was 2.3 with warfarin 2 mg OD and then
decreased to 2 mg and 1 mg alternating day. Three days prior to admission she was diagnosed with lung
TB and given anti TB drugs. She was admitted with abdominal pain, vaginal bleeding, anemic and
hypotension. Hemoglobin showed 8.3 mg/dl and high value INR 12.34. Vitamin K intravenous was given
three times a day for 1 day. Due to the difficulty to decide which factor influencing the INR, the genetic
(warfarin Indiv®) test was done and showed showed AA genotype on VKORC1 and *1/*1 on CYP2C9.
Discussion: The gene encoding vitamin K epoxide reductase, VKORC1, has an associated A1639-G
polymorphism leading to the possible genotypes GG (wild-type normal), GA (heterozygous), and AA
(homozygous), with respective estimated frequencies of 49%, 40%, and 11%. These polymorphisms lead
to decreased expression of the enzyme and increased warfarin sensitivity. The majority of patients have
*2/*2, *3/*3, or AA allele are deemed “hyper-responders”, while wild-type G/G *1/*1 patients are
considered “normal responders”. Collectively, it is estimated that these two genes account for as high as
40% of the variance in warfarin-dosing requirements.2
The result of this patient showed high sensitivity
for VKORC1, that means the patient hyper-responder to warfarin therapy. On the other hand, oral
antituberculosis drug, espesially isoniazid, also increase INR by inhibiting warfarin’s metabolism.
Conclusion: Individual response to warfarin has been known fluctuating due to multiple factors both
external and genetic factors, therefore using warfarin on warfarin hyper-responder’s patient and on lung
tuberculosis therapy may double the risk of bleeding even he/she has low HASBLED score.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
54
Multiple Accessory Pathways (Combination of Wolff Parkinson White Syndrome with Mahaim FIBER)
Andy Sukmadja1
, Gadih Ranti Endamatriza1
, Mohammad Iqbal1
1
Department of Cardiology, Padjadjaran University
Introduction: Multiple accessory pathways (AP) is not uncommon in coronary sinus abnormalities. It is
associated with ablation failure. Combination of Wolff Parkinson White (WPW) AP and Mahaim Fiber is
rare to be found.
Objectives: Reporting a rare case of multiple AP associated with coronary sinus abnormalities
Methods: N/A
Result: A 46 years old man with history of recurrent palpitation mainly during exercise was referred to
our hospital. Baseline ECG showed positive delta wave in V1, V2 and inferior lead. There were three
different ECG during tachycardia. The first one showed atrial tachycardia (AT) with RBBB, the second one
showed AT with various degree of preexcitation, and the third one showed regular narrow QRS
tachycardia without clear P waves. First mapping showed AV fusion electrogram on CS 7-8 catheter. V
pacing showed earliest retrograde A in CS 5-6. First ablation guided by AV fusion (CS 7-8) succeed to
terminate WPW in this area. V pacing after first attempt showed VA dissociate. After first attempt, another
AV fusion was found on CS 11-12, despite RV pacing showed VA dissociate. HRA pacing showed
decremental and AH jump. Ablation from the left septal could terminate AP in this area easily, but it is
always recur. We tried to ablate this AP from right side, near septal-CS ostium. Ablation from this site
succeed to terminate AP. VA dissociate remain persist until the end of procedure. No inducible tachycardia
with extreme HRA and RV pacing after ablation. Echocardiography in the next day showed large coronary
sinus.
Conclusion: Multiple AP is frequently seen in coronary sinus abnormalities. Combination of WPW
syndrome and mahaim fiber in coronary sinus abnormalities is rare.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
55
Post Permanent Pacemaker (PPM) Implantation Cardiac Tamponade of 3-Hour Onset: A Diagnostic
Dilemma
Levina Tri Ratana1
, Muzakkir Amir1
1
Department of Cardiology and Vascular Medicine University of Hasanuddin
Introduction: Cardiac tamponade following PPM implantation subtly occurs with a prevalence of 0.35%.
Classically, ones with rapid onset is caused by cardiac perforation and their slower counterparts is caused
by Post Cardiac Injury syndrome (PCIS). To author’s knowledge, PCIS causing cardiac tamponade with
onset as rapid as 3 hours has never been reported before.
Objectives: To present a diagnostic dilemma between cardiac perforation and PCIS manifested as rapid
onset cardiac tamponade after PPM implantation.
Methods: N/A
Result: A 40-year-old male had suffered from multiple episodes of near-syncope for 1 year. He was then
underwent Holter monitoring with result of sick sinus syndrome. Consequently, the patient underwent
placement of dual chamber pacemaker with ventricular lead implanted to the apex and active atrial lead
implanted to right atrial appendage with normal postoperative device interrogation. Three hours after
the procedure, the patient suddenly experienced severe breathlessness and an emergency
echocardiography was done showing massive pericardial effusion with signs of cardiac tamponade.
Pericardiocentesis was emergently performed and the operator evacuated 150 cc pericardial fluid to
patient’s relief. Subsequent echocardiography was done and mild pericardial effusion was found with no
signs of tamponade. The operator performed repeated fluoroscopy in an attempt to locate lead
perforation and fix lead position, yet, no perforation was found and leads were located at expected site.
No lead reposition was done. A control chest X-ray was performed and showed pericardial effusion and
thickening of minor fissure. Control complete blood count showed Hb of 12.8 g/dL and WBC count of
16500/mm3
. Pericardial fluid analysis showed red-brown exudative fluid and cytology showed dense
neutrophilic inflammation, necrotic masses with abundant erythrocytes and was concluded as
suppurative inflammation. AFB stain and culture were negative. The patient was treated with colchicine
and NSAID. Subsequent pericardial fluid aspiration of 60 and 15 cc was done on the 2nd
and 3rd
day. The
patient was discharged on the 4th
day with no further symptoms and no pericardial effusion in
echocardiography.
Conclusion: Post pacemaker pericarditis is a rare form of PCIS with favorable prognosis at early
recognition. Still, lead perforation is an important differential diagnosis to rule out.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
56
New Onset Atrial Fibrillation in Type II Severe Psoriatic Patient: Is It Only A Coincidence?
Achmad Fitrah Khalid1
, Margono Gatot Suwandi2
1
General Practitioner in Air Force Central Hospital Dr. S. Hardjolukito, Yogyakarta. 2
Cardiologist in Air
Force Central Hospital Dr. S. Hardjolukito, Yogyakarta
Introduction: Psoriasis is a chronic immune mediated disorder characterized by hyperproliferation of
keratinocytes. Patient with psoriasis might also be at increased risk of developing atrial fibrillation.1
Although the specific explanation has not been found yet, chronic inflammatory mechanism plays an
important role in both development of the disease.1,2
Kidney disease is also reported as a complication of
psoriasis due to inflammation of microvascular.3,4
Case Illustration: a 50-year-old male patient admitted to hospital with thick reddish plaque and scale in
most of his joints and his scalp since 4 days ago. Patient was also complained with palpitation since the
lesion worsened. Patient had history of hypertension that was well-controlled with valsartan 80 mg.
Hemodynamic was stable, however, irregular 90 bpm was found. Physical examination showed thick
reddish plaque in scalp, elbow, and knee joint covering >30% of BSA. ECG showed normal ventricular
response atrial fibrillation (Figure 1). 2 weeks prior to admission, ECG showed normal sinus rhythm (Figure
2). Laboratory examination showed normal electrolyte level and significantly elevated level of ureum (327
mg/dL) and creatinine (12,7 mg/dL). Amiodarone drip 150 mg and maintenance dose of it was given along
with hemodialysis and immunosuppressive agent. The patient passed away 2 days later because uremic
encephalopathy caused by inadequate response of dialysis.
Discussion: Cardiovascular disease is well recognized as one of the major comorbidities of psoriasis.
However, the association of atrial fibrillation and psoriasis has not been comprehensively studied. A study
showed that patients with psoriasis have 21% excess risk of atrial fibrillation compared to patient without
psoriasis.1
The most possible explanation of this phenomenon is that atrial fibrillation was caused by
structural and electrical remodeling caused by cytokines as inflammatory response.1,2
Another study
showed that atrial electromechanical delay (EMD), which has been used as an early indicator of AF
development, was prolonged and well associated with severity of psoriasis.5
Conclusion: Cardiovascular disease has been well recognized as one of the major comorbidities of
psoriasis. Correlation of AF and psoriasis have been showing inadequate result. It has been hypothesized
that chronic inflammation plays an important role in development of AF in patient with psoriasis.
Keywords: Psoriasis, Atrial Fibrillation
References:
1 Ungprasert P, Srivali N, Kittanamongkolchai W. Psoriasis and risk of incident atrial fibrillation: A
systematic review and meta-analysis. Indian J Dermatol Venereol Leprol 2016;82:489-97
2 Ole Ahlehoff, Gunnar H. Gislason, Casper H. Jørgensen, Jesper Lindhardsen, Mette Charlot, Jonas
B. Olesen, Steen Z. Abildstrøm, Lone Skov, Christian Torp-Pedersen, Peter Riis Hansen; Psoriasis
and risk of atrial fibrillation and ischaemic stroke: a Danish Nationwide Cohort Study, European
Heart Journal, Volume 33, Issue 16, 1 August 2012, Pages 2054–2064

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
57
3 Wan J, Wang S, Haynes K, Denburg MR, Shin DB, Gelfand JM. Risk of moderate to advanced kidney
disease in patients with psoriasis: population based cohort study. The BMJ. 2013;347:f5961.
doi:10.1136/bmj.f5961.
4 Naif O. Al-Harbi, Ahmed Nadeem, Mushtaq A. Ansari, Mohammed M. Al-Harbi, Moureq R.
Alotaibi, Abdulaziz M.S. AlSaad and Sheikh F. Ahmad, Psoriasis-like inflammation leads to renal
dysfunction via upregulation of NADPH oxidases and inducible nitric oxide synthase, International
Immunopharmacology, 10.1016/j.intimp.2017.02.018, 46, (1-8), (2017).
5 Calapkorur B, Kelesoglu S, Sarli B, Turasan A, Arinc H, Kaya M, G, Atrial Electromechanical Delay Is
Impaired in Patients with Psoriasis. Med Princ Pract 2015;24:30-35
Figure 1. ECG Showed Atrial Fibrillation
Figure 2. ECG 2 Month Prior to Admission

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
58
Sick Sinus Syndrome in Young Air Force Academy Candidate: A Case Report
Achmad Fitrah Khalid1
, Margono Gatot Suwandi2
1
General Practitioner in Air Force Central Hospital Dr. S. Hardjolukito, Yogyakarta. 2
Cardiologist in Air
Force Central Hospital Dr. S. Hardjolukito, Yogyakarta
Introduction: Sick Sinus Syndrome (SSS) is a term applied to a syndrome encompassing a number of sinus
node abnormalities. This anomaly can be categorized as having intrinsic sinus node disease unrelated to
abnormal automaticity or combination of both.1
Many clinical symptoms could be made from this
anomaly, from asymptomatic, syncope, to sudden cardiac death.1,2
Case Illustration: a 17-year-old man came to cardiology polyclinic to do medical check-up to enter military
academy. The patient said that he was rejected once in police academy selection because heart problems.
He said that he was preparing himself for the test by joining semi-military high school and do military
physical training in the past few years. He never complained any symptoms such as light-headedness,
dispneu, or syncope. Family history with cardiac problem was denied. Hemodynamic was stable, however,
47 irregular bpm was found. All physical examination is within normal range. 24-hour Holter ECG was
performed in this patient. A 24-hour Holter ECG revealed Mobitz II AV block (Figure 1), frequent APC (>30%
of total beat) with episodes of burst APC. Episodes of asymptomatic junctional rhythm (Figure 2) and atrial
tachycardia (Figure 3) were also found. There was sinus bradycardia during rest and sleep with minimum
rate of 38 bpm. Patient’s health problem cannot be waived. No medication was given to this patient.
Patient was advised to performed de-training period for 1 month and re-evaluate his condition.
Discussion: The course of SSS is often intermittent and unpredictable because it is influenced by severity
of underlying heart disease. It could be destruction of sinus node, inflammation, or fibrosis of the sinus
node. However, SSS could occur in the absence of cardiac abnormalities.1
Excessive physical training can
heighten vagal tone and produce symptoms related to sinus bradycardia or AV conduction abnormality in
normal individual. Sinus bradycardia and AV block is often found phenomenon in active endurance
athletes. Atrial fibrillation or flutter has also been significantly found in those with high physical
activity.1,3,4
Pacemaker is not needed in this patient (Class recommendation III).2
Based on military pilot
guidelines, those with second degree Mobitz II type AV block cannot be waived due to risk of progression
to complete heart block.5
Period of de-training was performed to determine appropriate therapy.
Conclusion: SSS can be caused by structural disease. However, SSS can also be found in athlete or highly
physical trained people. This condition could happen because heighten of vagal tone. Evaluation after de-
training period should be measured to determine further therapy.
Keywords: Sinus Node Dysfunction, Atrioventricular Node Dysfunction, Sick Sinus Syndrome, Arrhythmia
References:
1. Mann D, Zipes D, Libby P, and Bonow R. Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine 10th
Edition. Elseiver. 2015. P626-628
2. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM,
Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ,

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
59
Stevenson LW, Sweeney MO 2012 ACCF/AHA/HRS focused update incorporated into the
ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a
report of the American College of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2013;61:e6–75.
3. Baldesberger S, Bauersfeld U, Candinas R, Seifert B, Zuber M et al. Sinus Node Disease and
Arrhytmias in The Long-Term Follow Up of Former Professional Cyclists. European Heart Journal.
Vol 29(1);2008;p71-78
4. Davidson C, Obel O. Arrhythmias in an Athlete: The Effect of De-Training. Postgraduate Medical
Journal. 2005;81;p62-64
5. Lt Col Hui Ling Li and Dan Van Syoc. Air Force Waiver Guide: Coronary artery disease. United States
Air Force School of Medicine. 2015.
Figure 1. 24-Hour Holter ECG showed Mobitz 2 Second Degree AV Block
Figure 2. 24-Hour Holter ECG Showed Junctional Rhythm

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
60
Figure 3. 24-Hour Holter Showed Atrial Tachycardia.
Management of Electrical Storm in ICD Patient: Where is The Role of Non-Selective Beta Blockers?
Aditya Fahmi Prianda1
, Mohammad Iqbal1
1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Padjadjaran, Dr.
Hasan Sadikin Hospital, Bandung, Indonesia.
Introduction
Electrical storm (ES) is a medical emergency characterized by repetitive episodes of ventricular
arrhythmias (VAs) in a limited amount of time (at least 3 within a 24-h period) leading to repeated
appropriate implantable cardioverter defibrillator (ICD) therapies. Effective management of electrical
storm requires knowledge of arrhythmia mechanisms, therapeutic options, ICD programming,
radiofrequency catheter ablation, and emerging techniques for the treatment of refractory cases. Non-
selective beta blockers has been demonstrated to be effective in suppressing VAs refractory to both
selective beta blockers and amiodarone. Herein we present a case of ES in ICD implanted patient.
Objective
To report the effect of propranolol in management of ES.
Methods
A 66-year-old man presented with recurrent palpitations since 2 months, which resolved with shocks from
ICD. Patient had ICD implantation in 2017 due to total atrioventricular block with recurrent episodes of
ventricular tachycardia (VT). Patient underwent angiography and stent implantation at left circumflex
artery due to acute coronary syndrome in 2016. Patient also had history of hyperthyroidism. Electrolytes
were normal, thyroid hormones were normal, echocardiography showed reduced ejection fraction (41%)
with abnormal regional wall motion. ICD interrogation showed history of repetitive monomorphic VT with
appropriate shocks and anti-tachycardia pacing. Angiography showed tight stenosis at mid LAD, stent

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
61
patent insitu at LCx, and CTO at mid RCA. Stent was implanted at mid LAD. During hospitalization, the
patient experienced ES with stable hemodynamic, despite of medical therapy with lidocaine, amiodarone
and carvedilol, ICD programming, and stent implantation. ES was controlled after switching carvedilol to
propranolol.
Result
Propranolol was effective in management of ES.
Conclusions
ES is a life-threatening condition which requires multimodality approach. Initial management involves
identifying and correcting the underlying ischemia, electrolyte imbalances, or other inciting factors. Non-
selective beta blockers, especially propranolol, is one of the alternative and effective antiarrhythmic drugs
to prevent the recurrences of ES.
Keywords: electrical storm, implantable cardioverter defibrillator, propranolol

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
62
Total Atrioventricular Block Complicating Acute Myocarditis in Adult with Acute Rheumatic Fever: A
Rare Case Report
Afif Anshari1
, I N. Sukamiartadana1,2
1
Surya Husadha Nusa Dua General Hospital, Bali, Indonesia. 2
Surya Husadha Hospital, Bali, Indonesia
Introduction. Acquired complete heart block can be secondary to multiple etiologies, including infections
and inflammatory conditions such as myocarditis. However, complete heart block is not usual features of
acute rheumatic fever (ARF), which accounts for only 0.6% cases based on previous case reports.
Case Report. A 27-year-old man presented into the emergency department with shortness of breath,
generalized seizures, and fever. Previous history of chest pain and seizure was denied. On physical
examination, he had slightly elevated blood pressure and markedly low heart rate (HR) of 33 beats per
minute (bpm). His electrocardiographic (ECG) was showing total atrioventricular block (TAVB) with tall-T
and anteroseptal ST-segment elevation. He was then given intramuscular benzathine penicillin,
dopamine, aspirin, and was admitted to the intensive cardiovascular care unit (ICCU). He was also
prescribed with intravenous diazepam in case seizure recurs and planned for computed-tomography (CT)
scan of the head. Laboratory study showed slight neutrophilia with normal white blood cell count,
markedly elevated high-sensitivity C-reactive protein, hyperkalemia, and positive antistreptolysin O titer.
Thus, he was given oral calcium polystyrene sulfonate and intravenous 6α-methylprednisolone. Thorax X-
ray and CT scan results were normal. On the 3rd
day in the ICCU, he developed steroid-induced
hyperglycemia and was given subcutaneous insulin lispro. Afterwards, he was transferred to the ward
with TAVB (HR 56 bpm), acute myocarditis, ARF, and drug-induced hyperglycemia. On the 6th
day of
hospitalization, his ECG converted to first-degree AV block (HR 84 bpm). His echocardiography showed
normal valves and normal ejection fraction with no signs of left ventricular hypertrophy. On the 8th
day
his ECG converted to sinus rhythm, thus he was discharged with nebivolol, candesartan, and
methylprednisolone as take-home medication. He is now on routine follow-up with sinus rhythm on ECG
and no longer experience chest pain nor shortness of breath.
Conclusion. We present a case of complete heart block associated with acute myocarditis and ARF.
Although rare, this diagnosis should be considered in patients with TAVB particularly when it is associated
with features of ARF. Prompt evaluation and appropriate management can resolve conduction disorders
associated with ARF without the need for permanent pacemaker placement.
Keywords: Atrioventricular block, rheumatic fever, myocarditis, heart block

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
63
Case Report: Difficult Radiofrequency Ablation in Patients with Thyrotoxicosis and Paroxysmal Atrial
Fibrillation Mixed Wolff-Parkinson White Syndrome.
Sudharsono. A1
, Wahyu, A, Muzakkir. A
1
Department of Cardiology and Vascular Medicine University of Hasanuddin
Introduction
Wolff-Parkinson-White (WPW) syndrome is one of the most common form of preexcitation. In certain
cases, it could be co-existence with hyperthyroid. Thyroid hormone concentration is an independent risk
factor for atrial fibrillation (AF), which altering the electrophysiological characteristics of atrial myocytes,
enhancing automaticity and activity in the pulmonary veins. The combination of atrial fibrillation and
WPW syndrome could result in sudden cardiac death.
Case Presentation
A 52-year-old man admitted to the emergency department with 10 hours history of palpitations
accompanied with diaphoresis and shortness of breath. It was his second episode of palpitation. The first
episode was felt on September 2016, he refused to seek any medical advise. He reported a 20-kilos
unintentional weight loss, increased appetite, night sweats and palpitations for one month. Physical
examination during admission revealed an irregular heart rate (HR) of 136-214 bpm and blood pressure
of 146/102 mm Hg. His ECG revealed an AF with WPW syndrome. Intravenous Amiodarone was
administered with resolution of the arrhythmia and symptoms. His subsequent ECG revealed sinus rhythm
with δ waves, which was consistent with Wolff-Parkinson-White (WPW) syndrome. Thyrotoxicosis was
confirmed based on the presence of serum thyroid-stimulating hormone (TSH) receptor antibody <0.05
and FT4 5.05, We decided to start with propylthiouracil 200 mg t.i.d. The patient underwent WPW
accessory pathway (AP) ablation twice, one week after initial presentation. We planned several different
approaches to ablate the accesory pathway (AP), however we found difficulities in ablating the AP since
there are multiple AP. During the first ablation the AP was located in CS 9-10, but in second ablation the
earliest activation was noticed in in CS 4-5 and CS 7-8. Due to prolong time and difficulities in approaching
the anatomical pathway, we called off the procedure and decided to continue medication.
Conclusion
Radiofrequency ablation in WPW successfull rate is above 90% but in certain cases, it is quite challenging.
The multiple AP in WPW and difficulities in anatomical pathway location approaches should be
considered. Further investigation is needed, regarding to the different characteristics between WPW and
WPW in thyrotoxicosis.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
64

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
65
Pregnancy with Complete Heart Block: A Case Report
Ferly, A. Manurung, Y.
Introduction
Complete heart block is one of the rare clinical signs that is usually detected in late pregnancy. Patient
with complete heart block usually has risk factors which is history of congenital heart diseases as a children
or other structural heart diseases. The most common presenting symptoms for patients with complete
heart block are syncope during pregnancy. Other common signs/symptoms include dyspnea. Good
antenatal service are important in early detection and management of complete heart block as the risk
for problem in delivery can be mitigated with good antenatal care services.
Objective
To understand the importance of good antenatal care in detecting complete heart block early Case 42
years old, G24P1 38 wga singleton live head presentation, underwent Caesarean section Patient had
previous CS with history of bradycardia due to total AV block and post insertion of temporary pacemaker.
Patient had been referred from community health center due to Bradycardia.
Material and Methods
Follow up were done in the maternity wards
Results
Temporary pacemaker was inserted to the patient and the heart rate increase to normal range. C-section
were done afterwards on the patient.
Conclusion
This case should remind us the importance of good antenatal care in the management of
pregnancy/delivery with complete heart block in early detection and management. If the patient has
persistent relative bradycardia, insertion of temporary pacemaker was a management of choice. Multi-
department management with internal medicine department may be needed if the patient has indication
of pacemaker insertion

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
66
Epilepsy? Think Twice
Ang Jian Gang1
, Lim Yuen Han2
, Kantha Rao3
, Saravanan Krishnan4
Cardiology Department Hospital Sultanah Bahiyah, Kedah, Malaysia.
Introduction:
Syncope is a common presentation that poses diagnostic challenge to most clinicians as it is difficult to
differentiate seizure from cardiac syncope. Epilepsy in clinical practise is an overdiagnosed condition.
We are presenting a case of recurrent syncope that was misdiagnosed as epilepsy.
Case report:
A 25-year-old lady was referred to cardiology clinic for further investigation of recurrent syncope. She
had 4 episodes of syncope from 2016 till 2018. All her syncope episodes were preceded with aura,
palpitation and dyspnoea. Each syncope lasted for 1 minute and was associated with jerky movements
of limbs. She was aware of her surroundings during the attacks with no urinary or fecal incontinence.
After she regained her consciousness, she would experience generalised body aches. She was initially
diagnosed as epilepsy and was started on anti-epileptic. Her electroencephalogram (EEG) results were
within normal limits. However, her syncope had not improved despite compliance to medication and
she experienced frequent episodes of palpitation and reduced effort tolerance. There was no family
history of epilepsy, heart condition, arrhythmia and sudden death. Cardiovascular examination noted
fixed splitting of second heart sound and electrocardiogram (ECG) showed right bundle branch block
(RBBB). Echocardiogram examination showed partial anomalous pulmonary vein (PAPV).
Echocardiogram finding was further confirmed by right heart study and CT pulmonary angiogram. Holter
examination detected 5% premature ventrical beat (PVC). The cause of her syncope was later revised to
PAPV with concomitant PVC. Subsequently, her anti-epileptic was stopped and she was started with
beta-blocker that resulting in improvement of her symptoms with no further syncope reported. She was
referred to cardiothoracic surgeon for correction of her underlying congenital heart defect.
Conclusion:
High index of suspicion and meticulous assessments are required to investigate for the cause of
recurrent syncope. Screening for underlying heart pathology takes precedence over other causes of
syncope in order to prevent sinister cardiac complication. Partial anomalous pulmonary vein is a rare
congenital heart condition but it can still occur.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
67
Flecainide Challenge Test for Diagnosis Brugada Syndrome
Arya Yuliana Nasution1
, Mohammad Iqbal1
1
Hasan Sadikin Hospital, Bandung, Indonesia.
INTRODUCTION
Brugada syndrome (BrS) can be identified by clinical presentation such as syncope or sudden cardiac death
history with electrocardiogram (ECG) images of right bundle branch block (RBBB) with ST segment
elevation on anterior lead (V1-V3). In some patients with suspect of BrS with a normal ECG or without a
typical electrocardiogram for the diagnosis of BS, provocative test with medication may show typical
electrocardiogram features of BrS. The proper diagnosis and management of BrS should be well-known in
an attempt to prevent sudden cardiac death.
OBJECTIVE
Beneficial of flecainide (class IC antiarrhythmic) challenge test for umasking non-typical brugada pattern
in ECG
CASE REPORT
A 41-year-old man presented having syncope with no evidence of neurological deficit. He did not have
any palpitations. His initial ECG showed <2 mm ST elevation in V2 only with incomplete RBBB pattern
(Brugada pattern type II). There was no evidence of an acute coronary syndrome. We then performed
flecainide challenge test with dose 400 mg orally and we did ECG examination every 15 minutes in the
first hour and every 30 in five hours later. His baseline ECG changes to Brugada type I with a maximum of
6 mm ST elevation in V1 and V2 associated with T wave inversion, 30 minutes after flecainide. No
arrhythmia was provoked.
CONCLUSION
Flecainide challenge test with oral administration can be useful to provoke BrS type I in ECG. The
mechanisms responsible for the ECG actions of class IC antiarrhythmic agents in BrS are thought to be due
to their strong ability to block sodium channels.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
68
Cardiac Dysryhtmia in Severe Head Injury and Management in Rural Setting: A Case Report
Bagus Putra D.K1
,Nadya Anisah2
1,
General Practitioner in Penajam Paser Utara Regional Public Hospital, Penajam,Indonesia. 2
General
Practitioner in Sidoarjo Regional Public Hospital, Sidoarjo, Indonesia
Background: Electrocardiographic changes, dysrhythmias, and increased cardiac enzymes have been
reported in patients with head injury, even without any traumatic cardiac injury and associated with
increased morbidity and mortality.
Cases: A 67 years old woman was admitted to the emergency room with loss of consciousness after a
head trauma due to a motorcycle accident with Glasgow Coma Score at admission was 3. She had no
evidence of thoracic contusion. She had history of hypertension. BP was 200/110 mmHg, HR 120 bpm, RR
20 tpm, temperature 37.90
C. Laboratory follows, Leucocyte 16.810/µL, other complete blood count
parameter, renal function test and Skull X-ray were normal. On the examination of 12 leads ECG showed
non-sustained ventricular tachycardia. After airway, breathing and circulation management were done.
Patient was intubated. Intravenous fluid, neuroprotective agent and analgesic were given. The patient
was then treated by amiodarone 150mg bolus, few minutes after, the dysrhythmia was converted into
normal sinus rhythm, we gave maintenance dose of amiodarone and prepared for referral procedure.
Unfortunately, family refused to refer.
Discussion: Head injury induce a systemic catecholamine ‘storm’ driven by the central neuroendocrine
axis which massively increases sympathetic outflow and activates the adrenal glands. A 12-lead ECG
should be recorded on admission and repeated at 24 h intervals until any abnormalities have resolved.
Management of the underlying intracranial pathology is the most effective way to prevent and treat the
arrhythmia but significant ECG abnormalities, particularly those associated with ventricular dysfunction,
may require specific intervention because of the risk of progression to a malignant rhythm pattern.
Conclusion:Cardiac dysfunction and rhythm disturbances occur after head injury and are significant cause
of morbidity and mortality. Management of the underlying head injury and general supportive critical care
are important. Some significant ECG abnormalities require specific intervention.
Keyword: Dysrhythmia, Head injury, Cardiovascular complication

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
69
Successful Radiofrequency Catheter Ablation in Male with Wolff-Parkinson-White Syndrome
Bobby Saunders1
, Muzakkir Amir
1.
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Hasanuddin University,
Makassar, Indonesia
Background
Wolff-Parkinson-White (WPW) syndrome is a congenital involving abnormal conductive cardiac tissue
between atria and ventricles, that provides a pathway for a re-entrant tachycardia circuit or rapid
repetitive ventricular response during atrial fibrillation.1
WPW syndrome can be associated with a
malignant arrhythmia resulting in sudden death. Symptomatic patients have an estimated risk reported
0.25% per year, or 3% to 4 over a lifetime.2
This paper reports a case of 39-year-old mongoloid male
with WPW syndrome and clinically symptomatic. WPW syndrome can be detected by electrocardiogram
by the presence of delta waves in various leads. Electrophysiological (EP) study with radiofrequency
catheter ablation confirms the accessory pathway responsible for conduction disturbance.
Case Report
A 39-year-old mongoloid male presenting with palpitations and chestpain/discomfort. There was no
history of vomiting, dizziness, dyspnoea and syncope. he was non smoker, non alcoholic and non drug
abuser. Examination of cardiovascular, central nervous, abdominal and respiratory system was
unremarkable. ECG revealed a WPW pattern suggestive of a right-sided accessory pathway. An
echocardiogram demonstrated a structurally normal heart with good ejection fraction. Laboratory
investigations including serum electrolytes and cardiac biomarkers did not reveal any abnormality.
After informed consent was given, an electrophysiologic (EP) study was performed when the patient
was not receiving any antiarrhythmic agents. Radiofrequency catheter ablation of the accessory
pathway was successfully performed. After one month of follow-up, there was no palpitation or
chestpain recurrence or findings of pre-excitation on the electrocardiogram.
Discussion
A 12-lead surface ECG showed pre-excitation, a predominantly negative delta wave in V1 and left axis
deviation, negative delta wave in lead III, positive in lead II, and positive in V2, which was consistent with
the presence of a right-posteroseptal accessory pathway. Electrophysiology was performed and the
programmed atrial stimulation and ventricular stimulation was performed. EGM revealed earliest
activation and fusion beat showed at CS 9-10 then radiofrequency ablation were performed. We
performed the ablation several times until no delta wave showed on ECG.
Conclusion
Electrophysiology study is the best means to define the prognosis of a patient with the WPW syndrome.
The indications should be large to avoid misdiagnosis of a form at risk of rapid arrhythmias. The
radiofrequency catheter ablation is a promised therapeutic modality for WPW. The ablation technique
entails little invasion or risk and is economical.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
70
Keywords: Wolff-Parkinson-White Syndrome; Radiofrequency catheter ablation; Accessory pathway;
Electrophysiology

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
71
Risperidone-Induced Premature Ventricular Complexes (PVC) in Paranoid Schizophrenia Patient in
Psychiatry Ward Dr Soetomo General Hospital Surabaya: An Evidence Based Case Report
Boby Pratama Putra1
, Agus Subagjo2
1
School of Medicine, Universitas Airlangga, Surabaya, Indonesia. 2
Department of Cardiology and Vascular
Medicine, Faculty of Medicine Universitas Airlangga - Dr Soetomo General Hospital, Surabaya, Indonesia
Background. Schizophrenia is one of mental health problems with its prevalence is 1.7 per 1000 in
Indonesia. Antipsychotic drugs, such as Risperidone, were used to treat Schizophrenia. However, the use
of antipsychotic drugs may cause heart rhythm disturbances kind of Premature Ventricular Complexes
(PVC) even Ventricular Tachycardia (VT).
Case Illustration. A 45-year-old woman was brought to emergency department after behavioral changes
of getting anger and suspicious feeling. The patient was diagnosed paranoid schizophrenia then
hospitalized in psychiatry ward. The patient was treated with Risperidone 4 mg daily. After 7 days
treatment, the patient was discharged and given the same outpatient drug. About 2 weeks later, the
patient was hospitalized again because of having more paranoid symptoms. The patient also had
palpitation and sometimes felt losing heart beat. At first, the patient was given psychotherapy. However,
the symptoms did not relieve then the patient was consulted to cardiology department. The patient
previously did not have any cardiac problems. The physical examination revealed irregular heart rhythm
without additional heart sound. The electrocardiogram showed normal sinus rhythm with multiple PVCs.
The electrolytes (Na,K,Cl,Ca,Mg) were normal. Bisoprolol 2.5 mg daily was administrated and two days
later the patient did not complain palpitation anymore.
Methods. A literature review was conducted literature searching in Pubmed, Cochrane, and Science
Direct. The keywords used were ‘antipsychotic’ and ‘arrhythmia’ then selected the articles specifically
about PVC.
Discussion. Most antipsychotic drugs include Risperidone block Potassium channel thus inhibit
repolarization, prolong the QT interval and might cause ventricular arrhythmia. Besides, Risperidone also
blocks the alpha-2c receptor that stimulates cardiac effect which may induce PVC. PVC has also been
reported in Schizophrenia patient who received other antipsychotic drugs such as Thioridazine and
Quetiapine. The first choice of PVC therapy is selective beta-blocker such as bisoprolol, because the

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
72
problem is in the heart only. Selective beta-blocker blocks beta-1 adrenergic receptor then causes
automaticity decrease, prolong atrioventricular nodal refractory period, low ventricular responses rate,
and reduce ventricular ectopic beat, thus decreases PVC.
Conclusion. The use of antipsychotic drugs can induce PVC and selective beta-blocker is the first choice of
treatments.
Keywords: Schizophrenia, Risperidone, Arrhythmia, Premature Ventricular Contraction, Beta-blocker.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
73
A Case of Sinus Node Dysfunction and Atrial Fibrillation: Associated yet Reversible Matter
Cindy Monika Agatha1
, Wendy Wiharja1
, Raymond Pranata1
, Vito A. Damay2
1
Faculty of Medicine, University of Pelita Harapan, Karawaci, Tangerang, Indonesia. 2
Department of
Cardiology, Siloam Hospital Lippo Village, Karawaci, Tangerang, Indonesia
INTRODUCTION
Sinus Node Dysfunction (SND) irregular pulse in the SA node diagnosed with electrocardiography (EGC)
proceeds sinus bradycardia[1]
. AF a common yet unclear case associated with SND. Therefore complicates
the management both conditions.
CASE REPORT
A 67 y.o. female with syncope since 6 hours before hospitalized. History of chest pain characterized as
being crushed by heavy object, accompanied by cold dryness 6 months ago without treatment. Physical
examination: BP (70/40 mmHg) Pulse(30x/minute), RR(50x/minute), Temperature(36.80
C), cardiovascular
and respiratory system were unremarkable. Complete Blood Count(CBC) revealed Haemoglobin(10,9
g/dL), hematocryte(35%), Leukocyte(17.600/mm3
), platelets(218.000/mm3
). ECG showed AF Slow
Ventricular Response and Old Myocard Infarct Inferior with unstable hemodynamic. She was consulted
with bradycardia, cardiogenic shock and was given SA 3mg.
DISCUSSION
A study suggested that damage to the SA node was an important factor. SND causes AF is explained
through the presence of SND depressed the sinus impulse formation, as the atrial extrasystole occurs
during the slow atrial cycle[1]
. Compensatory pause usually occurs in most atrial extrasystoles. In SND the
pause may be prolonged, if a dominant pacemaker ceases its activity, or slows its rate below that of a
lower pacemaker, the latter will escape and control the cardiac rhythm[3]
. AF shut downs SN by long term
overdrive suppression of its activity. Prolonged sinus pauses (>3sec) improved SN function after ablation.
Sinus pauses might be due to long-term suppression of SN activity[2]
. Syncope is a rare case in AF, it occurs
in bradycardia syndrome which terminates protracted sinus pauses in SND. The patient’s case illustrates
syncope associated with AF suggest the presence of underlying SND. Failure of the sinus node to overcome
overdrive suppression is due atrial fibrillation causes sinus arrest[3]
.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
74
CONCLUSION
SF and AF might be a reversible phenomenon, the important role of the atrial substrate near the sinus
node area in the maintenance of sinus nodal function in AF. AF rarely cause syncope, the incidence might
be caused by bradycardia influenced by sinus pauses. Therapy suggestion for risk of atrial fibrillation is
greatly reduced when a physiologic pacemaker rather than a ventricular pacemaker is used.
Keywords: Atrial Fibrillation, Sinus Node Dysfunction

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
75
Delayed Diagnosis of Congenital Long Qt Syndrome by Possible Masking Effect of Phenytoin
D. A. Kurniawan1
, D. H. Karimullah1
, M. Abusari2
, 1
, A. Rizal3
1
Resident of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya, Malang
Indonesia. 2
Cardiologist of dr. Soedono General Hospital, Madiun Indonesia. 3
Supervision of Arrhythmia
Division– Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Brawijaya,
Malang Indonesia.
Background: Long QT syndrome (LQTS) is an inherited arrhythmogenic ion channel disorder characterized
by severely abnormal ventricular repolarization which results in QT interval prolongation. Its prevalence
in the population is 1:5000. This genetic channelopathy have variable penetrance that is associated with
increased propensity to syncope, polymorphous ventricular tachycardia (torsades de pointes), seizure
disorder and sudden arrhythmic death. LQTS clinical presentation sometimes attributed to epileptic
experience a particularly diagnostic delay.
Case report: A 34-years-old, female, had history of palpitation and recurrent seizures. Patient was
diagnosed epilepsy and kept on phenytoin for 10 years. When she pregnant, she stops consuming
phenytoin. She had syncope accompanied by seizure 3 months after delivery. Electrocardiography
showed prolonged QT interval and Torsades de Pointes (TdP). Physical examination and laboratory result
within normal limit. Echocardiography also normal. She was given bisoprolol 5 mg once per day and
lidocaine drip 1mg/minute. The risk stratification was high risk. She undergo successful implantation of
implantable cardioverter defibrillator (ICD).
Discussion: Phenytoin had somewhat paradoxically rendered the patient asymptomatic for over decade
prior to being reassessed for current seizure in the context of which a congenital Long QT Syndrome was
discovered. Phenytoin acting through sodium channel blockade that reduce the refractory period or
action potential. The mainstay of treatment on LQTS is β blockers. ICD was installed because of the patient
was refracter on medical treatment and deemed at high risk. The role of pacing is to prevent, or at least
shorten, the postextrasystolic pauses that facilitate the onset of TdP. Faster pacing will shorten
postextrasystolic pauses, potentially reducing the risk of pause-induced TdP.
Conclusion: Delayed diagnosis of long QT syndrome is frequent. Symptoms are often attributed to
alternative diagnoses, most commonly seizure disorder. Phenytoin has certain mechanism as
antiarrhythmic drug that can delay LQTS diagnosis. Given the potentially preventable mortality of long QT
syndrome, emergency physicians investigating syncope and seizure should maintain a high index of
suspicion.
Keywords: Long QT syndrome, Diagnosis, ICD implantation

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
76
Total Atrioventricular Block as a Rare Complication of Bicuspid Aortic Valve Disease: A Case Report
Dedy Lizal1
, Mohammad Iqbal1
1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Padjadjaran University, Dr.
Hasan Sadikin General Hospital, Bandung, Indonesia
Introduction
Bicuspid aortic valve (BAV) is one of the most common congenital heart disease. Typical complications
presented are calcific aortic stenosis, aortic regurgitation, aortic dissection, and infective endocarditis.
Objectives
The aim of this study was to describe a rare case of BAV causing total atrioventricular block (TAVB).
Methods
N/A
Results
A 43 year-old male patient came with chief complaint of syncope 1 day before admission. Patient had
history of syncopal episode 1 year ago and was diagnosed with valvular heart disease. Since then, patient
never experience syncope until now. Patient was generally asymptomatic. Patient was fully alert at
presentation, hemodynamically stable, but was found to have profound bradycardia with a rate of 40
times per minute. On auscultation, there was a systolic murmur grade 3/6, maximal in the aortic area,
was radiated into the neck and the mitral area. ECG examination revealed TAVB with right bundle branch
block pattern Temporary pacemaker was implanted as initial management. Transthoracic
echocardiography revealed bicuspid aortic valve with heavy calcification of right coronary cusp which
extend to aortic-tricuspid continuity, mild-moderate aortic stenosis AV pressure 16, AVA 1.1 cm2
, AVA
index 0.7 cm2
/m2
, and mild dilatation of ascending aorta. Patient underwent implantation of dual chamber
pacemaker. rate modulated pacemaker in the next day and was discharged after his condition was
stabilized. Surgical aortic valve replacement was planned for him.
Conclusion
Total atrioventricular block is a rare complication of bicuspid aortic valve. The mechanism of TAVB in BAV
is not known for sure. Few case reports mentioned infective endocarditis as the cause of TAVB, which
occurred due to extension of the infective process to AV node or his bundle. TAVB in this patient was
thought to be resulted from calcification spreading into the cardiac conduction tissuebe. Although TAVB
is not typically considered a main cause of syncope in aortic stenosis patients, it should nevertheless be
considered in the differential diagnosis.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
77
Complete Heart Block in Pregnancy: A Report of Caesarean Section in Parturient without Pacemaker
Denso Darta Antonius1
, I Putu Parwata Jaya2
1.
Dokter Umum Rumah Sakit Umum Daerah Wangaya, Denpasar, Bali, 2.
Departemen Kardiovaskular,
Rumah Sakit Umum Daerah Wangaya, Denpasar, Bali
Introduction
The incidence of complete heart block (CHB) is estimated to be 15.000 to 20.000 live birth. Whenever
encounterd in a pregnant woman, CHB presents a challenge for a multidisciplinary approach involving the
obstetrician, cardiologist and anesthesiologist.
Objective
This case want to emphasize that caesarean delivery might be safely contemplated without temporary
pacing in asymptomatic women with CHB. Nevertheless, close monitoring, multidisciplinary approach
with facilities for temporary pacing, and follow-up symptom and cardiac function is warranted in these
pregnant women during labour and preoperative period.
Case Illustration
A 29-year-old, G2P1A0, presented to the labour ward at 39 weeks of pregnancy with complete heart block
and have a planned elective caesarean delivery. Two years back, she had a caesarean delivery for the first
pregnancy and history of bradycardia during labour that improved with atropine injection.
Haemodynamic, cardiorespiratory system, obstetric examination was unremarkable. An
electrocardiogram (ECG) demonstrated sinus with third degree AV block, no prior ECG for baseline
comparison. Echocardiography and routine blood investigation were within normal limit. Labour was went
on as planned caesarean section without temporary pacemaker. However, injection atropine and
temporary pacemaker was kept on standby. She was preloaded with 500 mililitres of Ringer’s lactate
solution prior to spinal anaesthesia. During labour of the baby, heart rate dipped to 50 beats/minute and
one episede of non-sustained VT with stable hermodinamic. Postoperative was uneventful.
Discussion
CHB is relatively benign with narrow QRS complexes on ECG, and heart rate may increase with atropine
or sympathomimetics.2 Fetomaternal outcome is favourable in asymptomatic cases and uncomplicated
bradyarrythmia without significant underlying heart disease. Vaginal delivery is not contraindicated,
however cesarean section is reserved for obstetric reasons. A pacemaker is indicated in the presence of
symptoms (chest pain, dyspnea, syncope, palpitation), Q-T interval prolongation, wide QRS complex,
ventricular dysfunction or heart failure.
Conclusion
Women with asymptomatic CHB can present at the time of labour and pose a challenge to
multidisciplinary approach. Guidelines should be established to prevent unnecessary morbidity and
expense of the procedure.
Keyword: Complete Heart Block, Temporary Pacing, Pregnancy

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
78
ST-T Changes in Hyperkalemia Patient with Diabetes Mellitus: A Case Report
Pertiwi DY1
., Rostiati D2
.
1
General Practitioner, Bandung Regional Public Hospital. 2
Cardiologist, Bandung Regional Public Hospital
Introduction:
Hyperkalemia in adult patients is defined as serum potassium concentration grater than approximately
5.0-5.5 mEq/L. This condition can cause several abnormal EKG and it often proggresively. ST depresion in
hyperkalemia patient with Diabetes Melitus (DM) is rarely to find. This situation often confused with
myocardial injury. We were seen situation after hyperkalemia correction shown ST-T changes.
Objective:
To present a case report of ST-T Changes in hyperkalemia patient with DM.
Case Illustration:
A 50 years old, female presented with nausea and fatigue. She had been diagnosed to suffer from diabetes
mellitus type 2 eight month ago with routine consumed biguanin oral antidiabetic drug. She denied to has
heart disease. Also, she declared to be a non-smoker and non-alcoholic.
Her BP was palpation and pulse 115 x/min, rapid and deep. After complete rehydration BP was 100/60
mmHg and pulse 100 x/min. Systolic murmur, rhonchi and wheezing were not revealed. ECG showed ST
depression in II, III and AVF leads. Glucose serum was 122 mg%. Serum chemistries were notable
potassium concentration of 7.30 mEq/L. Troponin T level was 30.89 ng/ml. Ureum and creatinine were
0.53 and 7 mg%. Echocardiography showed normokinetik with EF: 60%. She was diagnosed to suffer from
hyperkalemia with diabetes mellitus.
Electrocardiograph:
Pre-hyperkalemia Correction

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
79
Post-hyperkalemia Correction
Discussion:
The risk factors for hyperkalemia in this situation was diabetes melitus. History of sedentary life is known.
Patient with DM had dimished kidney capacity to excreate potassium in urin. The combination of
potassium shift out of cells and diminished urine potassium excretion causes hyperkalemia. In this case,
hyperkalemia was shown as ST depresion in inferior leads. This situation can confused with myocardial
injury, but serum potassium concentration is higher than normal. After 3 cycle of correction, EKG was
reported normal sinus rythm.
Conclusion:
Not all ST-T changes are myocardial injury, sometimes it can occur in patients with hyperkalemia. We can
compare it with electrolyte and cardiac marker laboratories test.
Keywords: Hyperkalemia, ST-T Changes, Diabetes Melitus

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
80

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
81
Successful Pulmonary Veins Isolation in Symptomatic Persistent Atrial Fibrillation and Reduced Ejection
Fraction
Dwisetyo Gusti Arilaksono, Sunu Budi Rahardjo, Yoga Yuniadi, Dicky Armein Hanafy, Dony Yugo Hermanto
Background: Atrial fibrillation (AF) is a major public health burden worldwide, and its prevalence is set to
increase especially in rapidly developing country like Indonesia. Frequently, AF coexist with heart failure
with reduced ejection fraction (HFrEF) and complicates the course and treatment of each other. Catheter
ablation, by complete pulmonary vein isolation (PVI), is effective in restoring and maintaining sinus rhythm
in patients with all spectrum of AF, after failure of or intolerance to antiarrhythmic drug therapy.
Case: A 58-year-old male came to our outpatient clinic complaining frequent palpitation episode and
dyspneu on effort since 2 years before admission. Electrocardiogram record showed AF with QRS rate
79x/minute. Symptoms are still occur frequently despite optimal pharmacologic treatment.
Echocardiography study showed reduced LV ejection fraction (LVEF 23%) with left heart chambers
dilatation. The results of the coronary CT-scan showed normal coronary arteries. We then proceed to
perform ablation and successfully isolated all pulmonary veins. Both direct after procedure and outpatient
ECG evaluation showed sinus rhythm. By echocardiography, the LVEF also showed improvement to 42%.
Most importantly, the patient denied any palpitation episode and a significant improvement in daily
activity.
Discussion: PVI has developed into a common treatment for recurrent and persistent AF. This procedure
is more effective in maintaining sinus rhythm, and the complication rate is similar to antiarrhythmic drugs.
Studies examining outcomes of PVI in AF with HFrEF, both observational and RCT, mostly showed that this
procedure is relatively safe and associated with improved LVEF, quality of life and functional capacity.
Conclusion: A significant improvement in symptoms, quality of life and LV ejection fraction was found in
our patient as well as maintained sinus rhythm after PVI. Therefore, this procedure should be considered
as an available and effective options in symptomatic patients with AF despite optimal pharmacologic
therapy.
Keywords: Atrial Fibrillation, Catheter Ablation, Pulmonary Veins Isolation, Reduced Ejection Fraction
References
1. Rahman F, Kwan GF, Benjamin EJ. Global Epidemiology of Atrial Fibrillation. Nat Rev Cardiol. 2014;
11 (11); 639-54
2. Liang JJ, Callans DJ. Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction.
Cardiac Failure Review. 2018; 4(1); 33-7
3. Kirchhof P, Benussi S, et al. 2016 Guidelines for the management of atrial fibrillation developed in
collaboration with EACTS. Eur Heart Jour. 2016; 37; 2893-962

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
82
Post- TD Vaccination Myocarditis Presenting with Long QT Syndrome: Serial Cases
Edwin Chandra 1
, Tania Sabrawi 1
, Cut Arsyi 1
, M. Arsyi 1
, Miftah Pramudya 1
, M. Iqbal 1
1
Hasan Sadikin General Hospital, Bandung, Indonesia
Introduction:
In recent years, diphtheria classified as extra ordinary outbreak in our country. Myocarditis after TD
vaccination is also very rare to be found. Acute myocarditis can be lethal, especially if it developed into
fulminant state. Based on previous studies, prolongation of QTc interval is predictive factor for mortality
in myocarditis. This is in accordance with findings in our cases that QTc recovery related with the
outcomes.
Methods:
Results:
Female, 40 years old, presented with syncope 2 days after vaccinated. ECG showed diffuse ST depression
with prolonged QTc (500 ms). Coronary angiogram showed normal coroner. Echocardiography showed
LVEF 46% with global hypokinetic, restrictive diastolic function. Patient was treated 4 days in intensive
care unit with circulatory support, no recovery of QTc interval in serial ecg, and had 4 times cardiac arrest
before death. Male, 43 years old, presented with palpitation 2 weeks after vaccinated. ECG showed
tachycardia with prolonged QTc (491 ms). Echocardiography showed LVEF 50% with abnormal regional
wall motion, impaired diastolic function. Cardiac Magnetic Resonance showed late enhancement of
gadolinium in pericardium and septal wall that representing subacute myocarditis, and he got high dose
intravenous immunoglobulin (IVIG). After 11th
days, he discharged alive with improvement of
echocardiography and QTc interval.
Conclusions:
Reduced left ventricular systolic function and prolonged QTc interval can predict the prognostic fulminant
myocarditis. Improvement of QTc interval during hospitalization related to the good prognostic.

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
83
Giant Biphasic T Wave Electrocardiogram Pattern (Z Syndrome) in Patient with Plasmodium Vivax
Malaria Infection
Perdana Rezha Kusuma1
, Ervan Zuhri2,3
1
Department of Emergency and Critical Care, PT. Freeport Hospital, Papua, Indonesia. 2
Department of
Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia. 3
Resident in National
Cardiovascular Center Hospital of Harapan Kita, Jakarta, Indonesia
Background: Malaria was a unique disease where many organ might be affected simultaneously or
sequentially. Several studies showed that malaria infection could affect cardiovascular system, especially
in electrocardiogram pattern. Here, we presented a case report of patient with giant biphasic T wave
electrocardiogram pattern (Z syndrome) in plasmodium vivax infection.
Case Report: Mr. R, 41 years old, non-obese man came to emergency room (ER) department with chief
complaint fever with chill since 3 days ago, patient’s fever was felt during a day and night, patient also
complaint headache with nauseas but no vomiting, felt pain in all of his joint, no chest pain or shortness
of breathing. Patient was smoker 12 stick per day, no dyslipidemia, no hypertension or diabetes mellitus,
no cardiac disease before, and no history of cardiac disease in his family. At the time in a on arrival at ER,
the hemodynamic was stable, with the body’s temperature was 38.10
C. The other physical examination
were in normal limit. The ECG examination revealed giant biphasic U wave at lead II, III, AVF and V2-6
(figure 1). The blood smear examination revealed plasmodium vivax infection. The peripheral blood
examination was in normal limit, except thrombocyte was 51.000 /uL. Blood electrolyte, blood glucose,
lipid profile, cardiac enzyme, renal function, hepatic function, chest x-ray, and previous echocardiogram
was in normal limit. Patient was treated with dihydroartemisinin-piperaquine, primaquine, paracetamol,
esomeprazole, and ringer lactate infusion.
Discussion: The exact mechanism of electrocardiogram pattern changes was unknown. A biphasic T wave
might represent cardiac ischemia and might be related with microvascular obstruction because of parasite
sequestration.
Keywords: Giant biphasic T wave, Plasmodium Vivax, Malaria Infection, Z syndrome

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
84
A Case Report: Succesful Primary PCI in Attempts to Manage Cardiac Arrest in Catheterization
Laboratory
Fauziah. Haakim AA
Cardiac arrest is one of a leading cause of death in patient with ACS. Presentation of early ventricular
fibrillation during hospital admission is associated with better prognosis as compared to late ventricular
fibrillation.2 We report a case of 66 years old man referred to our hospital for primary PCI. He was
admitted to ED of previous hospital with chest pain. ECG upon admission showed ST elevation in lead II,
III, aVF and aVR. Investigation of Troponin-T was 60 ng/L, random blood sugar level was 236 mg/dl.
Loading dose of aspilet and ticagrelor were given and patient transferred to catheterization laboratory as
soon as he arrived to our hospital. While performing angiography, patient developed cardiac arrest.
Defibrillator was performed and and after each defibrillation, patient’s rhythm convert to sinus then
shortly after that ventricular fibrillation was appear for more than ten times. During cardiac arrest,
primary pci was successfully performed. Management of cardiac arrest were done according to ACLS1. In
this case, higher survival rates of cardiac arrest were associated with daytime cardiac arrest, primary
cardiac disease as the cause, cardiac monitoring, favorable initial rhythm.3 Observational investigators
associated with in- hospital cardiac arrest determined success rates of 39% to 72% for any ROSC, 25% to
42% for survival at 24 hours.3
Keyword: Acute coronary syndrome, cardiac arrest, defibrillation, success.
References:
1. 2017 American Heart Association Focused Update on Adult Basic Life Support and Cardiopulmonary
Resuscitation Quality.
2. B. Libungan, et al. Successful percutaneous coronary intervention during cardiac arrest with use of an
automated chest compression device: a case report. 2014. Department of Cardiology, Sahlgrenska
University Hospital, Göteborg, Sweden.
3. Nusbaum. DM, et al. A Case of Survival after Cardiac Arrest

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
85
Prolonged QTc Interval in Severe Hypokalemic Patient Complicated by Fatal Ventricular Arrhythmia,
What are the Possible Causes?
Filipus Michael Yofrido 1,2
, Ika Christine 1
, Dian Kartika 2
, Tiar Oktavian 2
, Rhesa Prasetya 2
, Nur Aini M. T. 2
,
Devina Nataliany2
1
Faculty of Medicine, Widya Mandala Catholic University, Surabaya, Indonesia. 2
Emergency Department,
Darmo Hospital, Surabaya, Indonesia
INTRODUCTION: QT prolongation (QTc > 440 ms) is risk factor for ventricular arrhythmias, especially
Torsade de Pointes. Immediate treatment for the underlying can make better outcome.
OBJECTIVE: To describe the possibilities that make QT prolongation.
CASE DESCRIPTION: A 66-years-old man came to emergency department with nausea, postural
imbalance, and constipation for last three days. He had history of periodic hypokalemia and often did
self-medication with oral metoclopramide, potassium chloride, and diet modification. In the first hour,
he was alert and normal findings in other general physical examination. Initial therapy were omeprazole,
ondansetron, and sodium phosphate enema. 12-lead ECG revealed sinus rhythm with QT prolongation
(QTc 650 ms). Laboratory showed hypokalemia (1.5 mEq/L), hyponatremia (118 mEq/L), hypocalcaemia
(7.1 mg/dL),hypomagnesaemia (1.4 mg/dL), and hyperglycemia (264 mg/dL). Three hours later, he was
suddenly collapse and ECG showed polymorphic Ventricular Tachycardia (VT) Torsade de Pointes.
Magnesium sulfate and CPR were given. Fourthy-five minutes resuscitation didn’t return of spontaneous
circulation and he was dead.
DISCUSSION: QT Prolongation (especially >500 ms) is very high risk cases. It can be caused by congenital
(long QT syndrome/LQTS), hypokalemia, hypocalcaemia, hypomagnesaemia, and drugs. Drugs that can
lead to QT prolongation are antipsychotics, anti-depressants, Metoclopramide, Macrolides, Cisapride,
Terfenadine, and Quinolons. Combination of above could potentiate the worsening of QT prolongation.
CONCLUSIONS: Prolonged QT interval is risk factor for lethal ventricular arrhythmia. Meticulous
monitoring and immediate treatment are useful to prevent lethal event. Immediate treatment of
underlying and avoiding drug-induce-QT prolongation could be lead better outcome.
Figure 1. 12-lead ECG report

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
86
Management of Atrial Fibrillation with Heart Failure to Improve Qualify of Life
Fransiscus Nikodemus Hosea1
, Priyandini Wulandari1
, Afdhalun Hakim1
Atrial Fibrillation (AF) is a common electrical disturbance in Heart Failure (HF) patients. AF may exacerbate
HF, while HF may predispose AF. Moreover, AF has the potential to worsen the progression of left
ventricular systolic dysfunction and impact hemodynamics profile of HF patients. Hence, special attention
is needed to treat those with AF and HF as a comorbidity. Rate control strategy and rhythm control
strategy along with prevention of stroke have been the hallmarks in management of AF.
We describe a case of 60 years old male admitted to Emergency Room (ER) with shortness of breath
worsening in the last 2 hours before admission. The patient was diagnosed with Heart Failure Reduced
Ejection Fraction (HFrEF) and AF in the last 2 years. The patient came with low blood pressure, tachycardia,
and cold extremities. Other physical examination was found to be irrelevant. ECG was performed and
showed atrial fibrillation with aberrancy. Echocardiography showed 35% ejection fraction (EF), dilatation
of left atrium and left ventricle, and decreased left ventricular systolic function. Fluid replacement along
with diuretics, digitalis, warfarin, and fondaparinux were administered. The symptoms were slightly
improved and the patient was discharged on 10th
day of admission. The patient had been admitted to the
hospital, consistently with AF and HFrEF, six times in the last two years.
Despite optimal pharmacological therapy in the last 2 years, readmission occurred six times. Several
studies showed that rate control strategy has the same impact as rhythm control strategy on clinical
outcome. While the others showed that rhythm control strategy is reasonable to ameliorate symptoms.
Considering the benefit and harm, catheter ablation, surgical ablation, and cardiac resynchronization
therapy need to be considered in order to achieve the improvement of symptoms.
Atrial Fibrillation along with HF may compromise quality of life. When optimal pharmacological treatment
is not able to meet the patient’s need, non-pharmacological treatment can be considered to improve
quality of life.
Keywords: Atrial Fibrillation, Heart Failure, Management, Quality of Life
Reference:
1. The Task Force for the management of atrial fibrillation of the European Society of Cardiology
(ESC). 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration
with EACTS. Eur Heart J.2016;37:2893-962

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
87
2. Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, et al. Rhythm control versus rate control for atrial
fibrillation and heart failure. NEJM.2008;358(25):2667-77
3. Olsson LG, Swedberg K, Ducharme A, Granger CB, Michelson EL, et al. Atrial fibrillation and risk of
clinical events in chronic heart failure with and without left ventricular systolic dysfunction.
JACC.2006;47(10):1997-2004
4. McAlister FA, Ezekowitz J, Hooton N, et al. Cardiac resynchronization therapy for patients with
left ventricular systolic dysfunction. A systematic review. JAMA.2007;297:2502-14

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
88
The Role of Cardiac Magnetic Resonance Imaging in Supporting Diagnosis of Brugada Syndrome
G. Angga Permana A.W.2
, Stephanie Salim1
, Celly A. Atmadikoesoemah1
, Elen1
, Manoefris Kasim1
1
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia,National
Cardiovascular Center Harapan Kita, Jakarta. 2
Department of Cardiology and Vascular Medicine, Faculty
of Medicine, Universitas Udayana
Background: Brugada syndrome (BrS) is a relatively frequent inherited arrhythmogenic syndrome
associated with ventricular tachyarrhythmias and sudden cardiac death. BrS has been considered a purely
electrical disease characterized by a typical electrocardiographic pattern for many years and despite the
description of BrS excluded structural abnormalities, anecdotal observations on small cohorts suggested
the presence of right ventricle (RV) abnormalities. Cardiac magnetic resonance imaging (CMRI) allows a
high-quality assessment of cardiac morphology and function, therefore it is an accurate and reproducible
tool for evaluating the RV in BrS.
Case Illustration: A 51-year-old male patient with palpitation and history of multiple cardioversion in
previous hospital due to recurrent ventricular tachycardia (VT). Physical examination was normal. Resting
12-lead electrocardiogram showed normal sinus rhythm. Treadmill test showed negative ischemic
response with bigeminy premature ventricular contraction (PVC). Holter examination showed infrequent
benign monomorphic PVC with bigeminy episode and suspected BrS type III saddleback pattern in lead
V1. Echocardiography showed concentric left ventricular hypertrophy (LVH) with ejection fraction of 57%,
normal right ventricle (RV) anatomy and function with mild mitral regurgitation Electrophysiology study
revealed non-sustainable episode of PVC bigeminy. CMRI showed increased RV volume with reduced
systolic function, severe hypokinetic mid-basal anterior RV, dilatation of RV outflow and inflow tract.
Patient was planned for implanted cardioverter defibrillator (ICD) implantation.
Summary: CMRI in our case detected RV structural changes (enlargement, dilatation of inflow and outflow
tract and mild wall motion abnormalities that is highly suggestive for RV abnormalities in BrS. Prospective
studies to assess the long-term evolution of such abnormalities are warranted to support CMRI as a tool
for BrS diagnosis.
Keyword: arrhythmia, brugada, cardiac magnetic resonance, dilatation, imaging, right ventricle

Cardiology
pISSN: 0126-3773 / eISSN: 2620-4762
89
Diffuse T Wave Inversion After Episode of Ventricular Tachycardia: Cardiac T-Wave Memory or
Ischemia?
Gemi Nastiti Indi Putri1
; Mohammad Iqbal1
1
Department of Cardiology and Vascular Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General
Hospital, Bandung, Indonesia.
Introduction
T wave inversion after episode of ventricular tachycardia (VT) also known as cardiac T wave memory is a
persistent but reversible T wave abnormalities after return of normal ventricular activation. Eventhough
cardiac memory usually did not need therapy, but consideration of ischemia should be given priority.
Awareness of cardiac T wave memory may guide physician from unnecessary work-up.
Objective
To provide awareness of physician towards cardiac T wave memory.
Methods
A case of 30-years old female with history of recurrent palpitation since 2010, already known had
Idiopathic Left Ventricular Tachycardia (ILVT), was reffered to our hospital for ablation. She brought the
electrocardiogram (ECG) showed left posterior fascicular ventricular tachycardia. After episode of
ventricular tachycardia, ECG showed diffuse T wave inversion at infero-anterolateral leads. Patients are
known to have no risk factors for any structural heart disease and also have no symptoms of ischemia.
Patient underwent electrophysiology study and ablation. The ablation was done from posterior fascicle
and success to terminate tachycardia, no inducible tachycardia after ablation. The ECG after ablation
revealed normal sinus rhytm. Resting echocardiography revealed normal heart.
Results
Diffuse T wave inversion after VT is not always sign of ischemia, especially in patient with low likehood of
coronary artery disease (CAD).
Conclusions
Cardiac T wave memory is considered as an adaptive reaction to abnormal ventricular conduction. It is
often confused with ischemic condition. Awareness about the situations in which T-wave memory mimics
ischemia on ECG may occur is important for the clinician to avoid the misdiagnosis of serious underlying
heart disease, particularly ischemia. The transient T-wave memory changes seem to be benign and
requires no treatment.
Keywords
Idiopathic Left Ventricular Tachycardia (ILVT), Cardiac T wave memory, Ischemia, ECG

Reversal of Tachycardia Induced Cardiomyopathy

Reversal of Tachycardia Induced Cardiomyopathy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Reversal of Tachycardia Induced Cardiomyopathy

Similar to Reversal of Tachycardia Induced Cardiomyopathy (20)

Recently uploaded

Recently uploaded (20)

Reversal of Tachycardia Induced Cardiomyopathy