Posters

1. dr. Reza Fauzi , General Practitioner Siloam Hospitals Mampang

2. dr. Hariadi Hadibrata, SpBTKV Siloam MRCCC

There are many complications of COVID-19, including acute limb ischemia (ALI). Due to the rapidly changing clinical course, high amputation and mortality rate, accuracy in diagnosis is needed to ensure immediate treatment. This process is challenging as COVID-19 is a novel and complex disease, and ALI has only been recently

We are reporting a 49 year-old woman with COVID-19 and diabetes mellitus type 2 who reported chest pain on her third day of hospitalization. The patient had been given levofloxacin 1x750mg, oseltamivir 2x75mg, heparin drip 15.000IU/24 hour, dexamethasone 3x10mg and novorapid drip 2IU/hour. Lab results included CRP 107.6 mg/L, D-dimer 1.58mg/L, thrombocyte 168.000cells/uL, HbA1c 10.4%. Her ECG showed ventricular extra-systole, thus was given aspirin 1x80mg, clopidogrel 1x75mg, ISDN 1x5mg, and concor 1x2.5mg. On the next day, the patient reported pain on her left arm. Upon USG doppler we found hyperechoic lesion on the left brachial region with diffuse soft tissue swelling on the axillary region, which indicated possible thrombus on the left brachial vein. Therefore, the patient underwent thrombectomy and fasciotomy, continued with open wound care for 10 days until the patient was fit to be discharged.

Our patient showed elevated CRP and D-dimer at the time of admission, which has been reported to be critical biomarkers in assessing the severity of COVID-19 and predicting complications such as ALI. Therefore, we started administering heparin before the patient showed any symptoms of ALI. However, due to having the risk factor of diabetes mellitus type 2, we could not prevent the occurrence of ALI and performed revascularization immediately after the diagnosis was made. Our prompt approach allowed the patient to survive and saved her limbs from amputation.

ALI is a complication that requires immediate diagnosis to improve the patient's prognosis, thus understanding biomarkers that can predict its occurrence in COVID-19 patients, including CRP and D-dimer, can be useful. This case illustrates the diagnostic and therapeutic approach to ALI as a complication of COVID-19.

acute limb ischemia, C-reactive protein (CRP), COVID–19, D-dimer.

1. Prissilia Prasetyo, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
2. Dhama S. Susanti, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
3. Suprayitno Wardoyo, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
4. William Makdinata, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
5. Adityo Budiarso, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
6. Kevin D. Suganda, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
7. Matthew Billy, Subdivision of Pediatric and Congenital Heart Surgery, Division Thoracic, Cardiac, and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia

Extracardiac Fontan operation is currently the preferred method of choice for patients with single ventricle physiology. Avoiding cardiopulmonary bypass during this procedure carries potential benefits. We present a case report of extracardiac off-pump Fontan in a 6-year-old girl with univentricular heart. To the best of our knowledge, this is the

We present a case of 6 years old girl with tricuspid atresia, ventricular septal defect, and pulmonary stenosis who previously underwent central shunt in 2017 and bidirectional cavopulmonary (Glenn) shunt in 2019. We successfully did extracardiac conduit Fontan operation without cardiopulmonary bypass.

The extracardiac off-pump Fontan operation is associated with favorable outcomes. In this patient, the duration of intubation is 16 hours, relatively short. An adverse event in this patient is chylothorax, and prolong duration of chest tube drainage. We believe that the borderline PA pressure and significant discrepancy between diameter of IVC dan conduit are the main factors that contributed to the development of chylothorax

Performing extracardiac off-pump Fontan operation is reported to result in better outcomes. Although the technique may be challenging, however we recommend to attempt the technique whenever possible to eliminate the adverse effects.

extracardiac conduit, fontan procedure, off-pump, single ventricle

1. dr. Putu Wisnu Arya Wardana, Sp.BTKV, Thoracic, Cardiac and Vascular Surgery Program, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
2. Dr. dr. Budi Rahmat, Sp. BTKV, Subsp.JPK (K), Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
3. Dr. dr. Pribadi W. Busro, Sp. BTKV, Subsp.JPK(K), Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
4. Dr. dr. Dicky Fakhri, Sp. B, Sp. BTKV, Subsp.JPK(K), Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia

Characteristics of TGA-VSD patients who will undergo ASO in developing countries are mostly late-presenting cases that result in the development of pulmonary vascular obstructive disease. This study investigated whether the pulmonary vascular resistance index (PVRi) could predict early postoperative mortality and morbidity after ASO in TGA-VSD.

This retrospective cohort study involved TGA-VSD patients who underwent ASO from January 2015 until December 2022 at National Cardiovascular Center Harapan Kita. Preoperative PVRi data and postoperative incidence of early mortality and morbidities such as prolonged ventilator duration, pulmonary hypertension crisis, major adverse cardiovascular event (MACE), and low cardiac output syndrome (LCOS) were collected. A bivariate analysis using independent Student's t-test was done. Diagnostic test using receiver operating characteristic (ROC) curve was also done to obtain the area under the curve (AUC) value. The best cutoff point was determined by Youden's index.

Forty-three subjects were involved in this study. The median age of all subjects was 9.5 (1,47 – 162) months. Subjects who experienced PH crisis (n = 10) and prolonged ventilator duration (n = 19) have significantly higher PVRi compared to subjects who did not have it (p <0.001). There was no significant association between PVRi and early postoperative mortality, MACE, and LCOS in this population. The area under the curve of PVRi for the incidence of PH crisis and prolonged ventilator duration were 93.3% (95%CI: 85.9-100%) and 94.2% (95% CI: 87.5-100%), respectively. The best PVRi cut-off value to predict the occurrence of PH crisis was 7.15 WU.m2, with a sensitivity of 100% and specificity of 87.9%.

The PVRi is associated with the occurrence of PH crisis and prolonged ventilator duration in patients with TGA-VSD who have undergone ASO. The PVRi could be used to predict the occurrence of these postoperative morbidities with a well-defined cut-off.

arterial switch operation, pulmonary hypertension crisis, pulmonary vascular resistance index, transposition of great arteries with ventricular septal defect

1. dr. Abraham Albert Nugraha, Departemen Bedah Toraks, Kardiak, dan Vaskular RSPAD Gatot Soebroto, Jakarta
2. dr. Wijoyo Hadi Mursito, Sp.BTKV, Subspes. JD(K), S.H., M.H., Departemen Bedah Toraks, Kardiak, dan Vaskular RSPAD Gatot Soebroto, Jakart

Based on WHO report on TBC in 2022, Indonesia is one of the country with the highest burden of TBC. About 1-2% of pulmonary tuberculosis patients also have tuberculous pericarditis. There are couple of sequelae to tuberculous pericarditis such as cardiac tamponade, constrictive pericarditis, and death if not treated properly.

In this case we reported a 20 year old man presented with dyspnea and productive cough. The patient had started being treated with the anti-tuberculosis drug 2 weeks prior. The initial diagnosis was pericardial effusion with impending cardiac tamponade based on the echocardiography result. Pericardiocentesis doesn’t relieve the symptoms significantly, instead the symptoms got worse when the man got into activity. Then It was decided to do sternotomy and pericardiectomy. Later found that there are thickening of the pericardium and adhesion of the pericardium to the aorta and the heart. After the adhesion was cleared and the pericardiectomy was done, we could see the heart contraction improved. The patient’s complaints significantly reduced, and he was able to be discharged from the ICU after 1 day of treatment.

Discussion
Despite appropriate and effective management, including pericardiocentesis, there was no significant improvement in the patient's symptoms. The patient continued to experience dyspnea and rapid fatigue upon exertion. Through sternotomy and pericardiectomy procedures, it was observed that there was pericardial thickening and adhesion between the pericardium, the heart wall, and the aorta. Constrictive pericarditis is also a possible sequelae arising from tuberculous pericarditis

Establishing a diagnosis of tuberculous constrictive pericarditis and treating it presents its own challenges. In patients with pulmonary tuberculosis displaying symptoms and signs of cardiac disease, the occurrence of tuberculous pericarditis and its various sequelae, such as pericardial effusion, cardiac tamponade, and even constrictive pericarditis, must be promptly considered.

constrictive pericarditis, pericardiectomy, tuberculous pericarditis

1. dr. Dani Putra Amerta, Dokter Umumu Instalasi Gawat Darurat RSPAD Gatot Soebroto
2. dr. Arief Widya Taufik Sp.BTKV, Kepala Divisi Bedah Toraks, Kardiak dan Vaskular RSPAD Gatot Soebroto

One of the injuries that often occurs common in trauma patients is thoracic trauma. Cardiac injuries are the most lethal in thoracic trauma patients, especially penetrating trauma. Penetrating trauma caused by foreign bodies,a grenade fragmentation, inside the heart are rare cases.

a 36-years old male was admitted in emergency room with chest pain for 1 day prior to hospitalization. The chest pain localizing to the left hemithorax. The man injured by fragmentation of grenade explosion during the training of army. From CT-Scan of thorax, the foreign body was visualized at between the pericardium and the left ventricle. The sternotomy exploration was performed. The pericardium was opened, there is a lesion at lateral of left ventricle with a small hole in the pericardium on the apex of heart. Then evacuation was carried out, but was unsuccesfull. Foreign bodies was evacuated by beating Cardiopulmonary Bypass (CPB), but the hemodynamics became unstable, arrythmia (VT/VF). It was decided to do CPB – cross clamp, the foreign body was succesfully removed. Surgical wound closure was performed. The patient was transfered to ICU, the patient was stable. After a few days, patient was discharged with progressive recovery.

Penetrating cardiac injuries are immediate life-threatening situations with a relatively high mortality rate. In most cases they are caused by war or gun-shot injuries. There can be severe complications for these injuries like infections, sepsis, focus ectopic aritmia and migrating foreign bodies that may cause hemopericardium (cardiac tamponade), emboli, lung contusions, hematoma, hemothorax, pneumothorax. Cardiac foreign bodies are rarely seen because most patients with penetrating cardiac injuries die from hemorrhagic shock or cardiac tamponade. Penetrating cardiac injury, caused by intracardiac foreign bodies, presents a big challenge to surgeons for that it is difficult to exactly locate the intracardiac foreign bodies due to the continuous movement of heart and the evacuation may lead the instability of hemodynamic, arrhytmia (VT/VF) and low cardiac output.

We report a case of a penetrating injury into the thorax with the foreign body being lodged into the intramyocardial left ventricle and then managed surgically. Foreign body is high risk of causing infection, sepsis, embolization and cardiac tamponade. Cause of that urgent surgery must be performed.

Cardiac Injury, CPB, Foreign Body, Intra Myocardial, Left Ventricle, Pericardium

1. dr. Dzulfachri Kurniawan, Dokter Umum RSUD Labuang Baji Makassar
2. dr. Umar Usman, M.Ked.Klin, Sp.BTKV (K), Divisi Bedah Toraks Kardiovaskuler RSUD Labuang Baji Makassar

Needlefish attack can cause critical injuries and fatal complications for patients. Penetrating trauma to the thigh can cause injury to the artery which unnoticed will eventually become a pseudoaneurysm. Injuries by Needlefish causing a superficial femoral artery pseudoaneurysm is a rare case and has never been reported before

A 53 years old male patient with complaint of a throbbing lump on his left thigh since three weeks. Complaints experienced after being impaled by a needlefish while looking for fish in the sea. Complaints of pain when walking. Physical examination found an entrance stab wound in the back of the thigh and a throbbing lump on the left thigh. CT angiography of the lower extremities revealed dilatation focal saccular suggesting a pseudoaneurysm superficial artery femoral sinistra. Furthermore, the patient underwent open repair of the pseudoaneurysm femoral artery sinistra.Identification of the femoral artery then performed Teugel incision. Then open capsule mass and evacuated clot hematom. A fistula was seen in the distal femoral artery with a diameter of 1 cm, then the femoral artery fistula was repaired with a patch of the great saphenous vein. Postoperatively, patient got a good distal arterial pulse and good distal saturation

Needlefish is a fish that lives in the sea. Its nature that jumps to the surface of the sea can injure it causing morbidity and mortality for fishermen when looking for fish. A pseudoaneurysm consists of a blood collection contained by the adventitia or the surrounding soft tissues caused by dissection of all the layers of the arterial wall due to puncture, trauma, or infection. Clinical manifestations of femoral pseudoaneurysms can include a pulsatile mass, femoral bruit, palpable thrill, pain, extremity edema, and/or compressive neuropathy. Pseudoaneurysm should always be treated as an emergency as it can lead to ischemic vascular distal, compression of adjacent vessels and rupture of the lesion. CT angiography is the modality of choice for diagnosis. Open surgical repair was the first treatment option for this case and closure of the A Femoral fistula using a Patch of the Great Saphena vein

Needlefish attacks can be life threatening. Cases of femoral artery pseudoaneurysm by needlefish have never been reported before but these cases should always be treated as an emergency because they can cause morbidity and mortality for patients. Examination and appropriate management can provide great benefits for patients.

Needlefish, Penetrating Injury, Pseudoaneurysm, Superficial Artery Femoral

1. Dr. dr. Budi Rahmat, Sp.BTKV(K)-P, Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita
2. dr. Atha Luthfi, Pediatric and Congenital Heart Surgery Unit, National Cardiovascular Center Harapan Kita

Anomalous origin of Left Coronary Artery from the Pulmonary Artery, ALCAPA, is a rare congenital malformation of the heart coronary system. It affects at about 1 in 300 000 life birth. When left untreated, almost 90% dies within first year of life, leaving only a few thrive into childhood even

We present a case of a 6 year old boy with worsening shortness of breath on daily activities for the past few month. Trans-thoracal echocardiography were able to visualized that the Right Coronary Artery (RCA) rose from the Aorta and the Left Coronary Artery (LCA) from the Pulmonary Artery (PA). There were no decrease in Left Ventricle function with EF of 67%. ECG show no sign of ischaemia or infarct. Diagnostic catheterization find enlarged and tortuous RCA with drainage to LCA and PA. Surgical correction was performed with finding of large RCA and multiple collateral vessels developed. ALCAPA repair surgery including left main extension to Aorta as well Pulmonary Artery repair using pericardium. Patient was discharged at day six post-op with spotless recovery.

In this patient, ALCAPA was left undiagnosed and asymptomatic for more than 6 years. A well developed collateral vessel and pressurized coronary system help prevent myocardial infarction and heart failure as it maintains adequate cardiac perfusion. Surgical correction is paramount to prevent unwanted clinical course such as heart failure and ischaemia.

Physician should be aware that at any age group ALCAPA is still a possibility, thus thorough examination and analysis is important to prevent it being neglected.

ALCAPA, Congenital

1. Mahardika Budjana Sutan Ilham, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
2. Ahmad Muslim Hidayat Thamrin, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
3. Marko Darmawan, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
4. Faris Maulana Irfan, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
5. Vicky Supit, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
6. Tri Wisesa Soetisna, MD, Ph.D, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita

Numerous clinical trials have been conducted to evaluate the efficacy and safety of stem cell therapy. The post-operative improvement in patients with low left ventricular ejection fraction (LVEF <35%) undergoing CABG reported wasn't optimal. Therefore, stem cell therapy could be a new hope as a promising adjuvant approach.

A 69-year-old male has been admitted to our hospital with worsening shortness of breath and persistent chest pain. The patient had a history of hypertension for five years and regular smoking. CT angiography revealed multiple stenoses in left anterior descending (LAD) coronary artery, left circumflex (LCx) coronary artery, obtuse marginal (OM) coronary artery, and proximal-mid right coronary artery (RCA) with significant decrease in global left ventricular function (LVEF 21%). Coronary artery bypass grafting (CABG) was performed by anastomosing left internal mammary artery (LIMA)-LAD ; saphenous vein graft (SVG)-PDA ; SVG-D1-OM2 (Y graft). After the aortic cross‐clamp, the CD133+ stem cells were injected within the transepicardial, transseptal region and along the border area of the hypokinetic segment, which had been previously identified by MRI. The CD133+ were aspirated from bone marrow in posterior iliac crest of the patient. LVEF was significantly increased (LVEF 63%) after two-year stem cell therapies.

The potential therapeutic effects of CD133+ stem cells, as immature endothelial progenitor cells, have been used in various trials. A groundbreaking approach by combined transepicardial and transseptal implantation of autologous CD133+ during bypass grafting is a novel option for regenerative therapy in patients with ischemic heart disease (IHD). The CD133+ improve cardiac function and repair myocardium by stimulating neovascularization, and angiogenesis, suppressing apoptosis, and promoting cardiomyogenesis. A novel implantation site in the transseptal area yields advantages by extending stem cells into the interventricular septum, crucial for sustaining adequate left and right ventricular ejection function and heart contractility. Moreover, the quality of stem cells is essential as we conducted autologous bone marrow stem cells. The burden of diabetic complications is directly related to cells. Therefore, their dysfunctions or decreased cell quantity could impede tissue repair and regeneration. The absence of diabetes in this patient might influence our therapy outcomes.

Combined transseptal and transepicardial implantation of CD133+ stem cells holds promise for enhancing LVEF in CABG patients with low LVEF. The physiological mechanisms involved complete revascularization by CABG itself and stem cells through the secretome process. Furthermore, delivery routes and stem cell quality remained important as diabetes causes stem cell

CABG, CD133+, diabetes mellitus, IHD, LVEF, stem cell

1. dr. Yohannes Septiandi, PPDS BTKV RSUD dr Soetomo Surabaya
2. dr. Dhihintia Jiwangga Suta Winarno Sp.BTKV, SubSp.T(K), Staff BTKV RSUD dr Soetomo Surabaya
3. dr. Mohamad Rizki, Sp.BTKV, MKed Klin, Staff BTKV RSUD dr Soetomo Surabaya

The condition known as TOS is brought on by pressure on the nerve plexuses and blood vessels in the upper thoracic aperture region. The aim of this study is to increase our familiarity with the symptoms of TOS and follow up postoperative outcomes after 6 months.

A 32 years old man was referred to a tertiary hospital in Surabaya from a secondary hospital in Surabaya. Patients complain of right arm pain about 1 month before. The CTA evaluation right subclavian artery stenosis, right radial artery stenosis, right posterior interosseus artery stenosis. The patient underwent elective surgery for costae rib resection and bypass right caroticosubclavian artery.

Evaluation postoperative after surgery, the patient was treated in the low care room with early extubated conditions. Extubation is done immediately in OT.
Three days after extubation the patient went home. 6 days postoperatively patient controls into the outpatient departement of cardiothoracic surgery. Progress was followed up to 6 months and yielded a good results.

Our study shows that patients who complain of weakness, particularly when the right upper limb is elevated, suffer from parasthesia at the same moment. We were followed and evaluated up to 6 months postoperatively showing complaints of parasthesia completely disappearing with no signs of weakness in the right upper extremity.

bypass right caroticosubclavian artery, costae rib resection, thoracic outlet syndrome

1. dr. Merlinda Dwintasari, Resident of Thoracic, Cardiac, and Vascular Surgery Department, Dr Soetomo General Academic Hospital, Faculty of Medicine Airlangga University, Surabaya-Indonesia

2. dr. Setiadi Drajad Kurniawan, Sp.BTKV,SubSp.VE(K), Senior Consultant of Thoracic, Cardiac, and Vascular Surgery Department, Soebandi General Hospital, Jember-Indonesia

3. Dr.dr.Yan Efrata Sembiring,Sp.B,Sp.BTKV,SubSp.VE(K), Senior Consultant of Thoracic, Cardiac, and Vascular Surgery Department, Dr Soetomo General Academic Hospital, Faculty of Medicine Airlangga University, Surabaya-Indonesia

Klippel-Trenaunay syndrome (KTS) is a rare, sporadic congenital disorders characterised by the triad of capillary malformations, unusual varicosities or venous malformations, and bone or soft tissue hypertrophies, typically affecting one extremity.

A 20-year-old male was brought into our hospital with big varicose veins and soft tissue hypertrophy in his left leg. When he had to stand for a prolonged period of time, he complained of leg pain. Based on clinical data and other examinations, we determined the diagnosis of KTS. The saphenofemoral junction and the great saphenous vein (GSV) trunk were not visible during duplex scanning of the veins. A strange sound was found on Doppler examination at the junction between the perforator and the femoral vein. Varicose veins on the posterolateral side of the thigh emptied into the muscular veins through the muscular fascia. Found a dilated femoral vein in the posterior thight accompanied by a perforator vein around it. Total ligation of perforating vein on the lateral and medial side and extirpation of large varicose veins on the thigh, crus and dorsum of the foot were carried out.

Accurate preoperative recording of the venous anatomy and function is necessary for treating chronic venous insufficiency in KTS patients. Duplex scanning is appropriate to make the vascular anatomy clear before surgery. The deep venous system's patency is to be confirmed, and venous incompetence in the deep, superficial, and perforating venous systems in the extremity and pelvis are to be evaluated. The location of the ineffective perforating veins and the locations of the saphenofemoral and sapheno-popliteal junctions can be identified using a duplex scanning examination, which is crucial. In our patient, GSV was absent. Post operative care is also important, which in our case the postoperative course was without complications and patient was discharged on day 2 after the operation.

KTS is a complicated congenital vascular malformation that is uncommon, sporadic, without known cause. Most patients get well without treatment or with elastic compression only. Surgery may be beneficial for patients who have a leg length discrepancy or severe chronic venous insufficiency.

great saphenous vein aplasia, Klippel Tre ́naunay syndrome, rare case

1. dr. Nyoman Saka Ranuartha, Thorax, Cardiac, Vascular and Endovascular Surgery Department, Faculty of Medicine, Airlangga University
2. dr. Erdyanto Akbar, Sp.BTKV, Senior Consultant Thorax, Cardiac, Vascular and Endovascular Surgery Department, Faculty of Medicine, Airlangga University
3. dr. Heroe Soebroto, Sp.B, Sp.BTKV, Senior Consultant Thorax, Cardiac, Vascular and Endovascular Surgery Department, Faculty of Medicine, Airlangga University
4. dr. Arief Rakhman Hakim, Sp.BTKV, Senior Consultant Thorax, Cardiac, Vascular and Endovascular Surgery Department, Faculty of Medicine, Airlangga University

Ventricular septal defect is the most common congenital cardiac anomaly in children and is the second most common congenital abnormality in adults, second only to a bicuspid aortic valve. An abnormal communication between the right and left ventricles and shunt formation is the main mechanism of hemodynamic compromise in VSD

An 3,5-year-old baby, brought by her mother, came to the clinic with a complaint about the symptoms of fever, cough and dyspnea that happened many times in these past 2 months. This baby was then treated in the private hospital and underwent several examination, including the Echocardiograph Examination. Eventually she diagnosed with Perimembranous Ventricular Septal Defect and Moderate Mitral Regurgitation with AML vegetation. The patient is then referred for further treatment at the surgery department to undergo Ventricular Septal Defect Closure.

VSD closure is indicated in medium to large defects with a significant hemodynamic compromise such as those who are symptomatic and have LV dysfunction. Surgical repair of VSDs was the only option; however, recent advances in interventional techniques make percutaneous VSD closure possible.

Young children who remain asymptomatic and have a small VSD have a good outcome. Outcomes in people with a large VSD are poor if the defect is not repaired.

AML Vegetation, Echocardiography, Mitral Regurgitation, Ventricular Septal Defect

1. dr. Georaldhy Yussufy Caecarma, Airlangga University
2. dr. Niko Azhari Hidayat, Sp.BTKV(K)VE, Divisi Bedah Thoraks dan Kardiovascular RS Universitas Airlangga

Hemangiomas are non-malignant vascular neoplasms frequently observed in neonates until infants within a few weeks of birth and constitute around 7% of the total number of benign tumors recorded. Furthermore, the occurrence of intramuscular hemangioma is infrequent, accounting for fewer than 0.9% of reported instances of hemangioma on world.

A 32-year-old male patient came to the hospital with a chief complaint of chronic pain in his left leg that has persisted for 20 years. The patient described the discomfort as a sensation of constriction and tightness. The pain's intensity increased and experienced discomfort radiating from the left buttock to the posterior region of the left thigh and extending to the left knee's posterior region. This pain was exacerbated daily and was described as increasingly uncomfortable. During the physical examination of the medial upper left thigh, a palpable lump measuring 2x3 cm was identified. The mass was seen to be soft, painless, moveable, and non-pulsating. Ultrasound findings revealed the presence of a hypoechoic lesion that stretched intramuscularly from the medial left femur to the popliteal region and observed characteristics suspicion of a soft tissue hemangioma. Patient performed CT scan and this finding raised suspicion of a vascular lesion of hemangioma.

The prevalence of hemangiomas in the adult population is rather low. Typically, the manifestation of hemangiomas occurs before to the age of 40 in around 90% of instances. Moreover, there exists a higher prevalence of hemangiomas in females compared to males, with a ratio of 3 to 1. In contrast, this particular case exhibits uniqueness due to its involvement of an adult guy on the edge of entering his fourth decade of life. In this case, the atypical presentation of hemangiomas requires careful evaluation of additional therapeutic options for the patient. The intramuscular hemangioma is an infrequent vascular neoplasm that is typically ignored based on clinical observations. Specific cases have demonstrated that intramuscular hemangioma occurring in the lower leg muscles shows symptoms that closely resemble those of lumbar disc herniation, posing a diagnostic challenge. When the patient has undergone many therapy modalities without achieving satisfactory outcomes, conducting further examinations.

While intramuscular hemangiomas in the limbs are exceedingly uncommon, particularly in adult patients, it is important to consider hemangiomas as a potential differential diagnosis. The visual characteristics of a hemangioma located on the leg frequently exhibit similarities to the clinical manifestations associated with lumbar nerve herniation.

benign, Case report, femur tumour, intramuscular hemangioma, medial thigh tumour, misdiagnosis, vascular tumour

1. dr. Muhammad Hanafie Heluth, Resident at Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of Medicine, Airlangga University - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
2. dr.Jayarasti Kusumanegara, Sp.BTKV, Subsp.VE (K), Senior Surgeon at Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of Medicine, Hasanuddin University - Dr. Wahidin Sudirohusodo Hospital, Makassar, Indonesia
3. dr. Muhammad Nuralim Mallapasi, Sp.B, Sp.BTKV, Subsp.VE (K), Senior Surgeon at Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of Medicine, Hasanuddin University - Dr. Wahidin Sudirohusodo Hospital, Makassar, Indonesia
4. dr. Dhihintia Jiwangga Suta, Sp.BTKV, Subsp. T (K), Senior Surgeon at Department of Thoracic, Cardiac, and Vascular Surgery, Faculty of Medicine, Airlangga University - Dr. Soetomo General Academic Hospital, Surabaya, Indonesia

Tracheal stenosis due to Penetrating Injury is a relatively rare case. Trauma to the trachea may be penetrating or blunt and acute or subacute. A blow or stab wound to the neck, or crush injuries to the upper chest, may cause acute traumatic disruption of the trachea, but subacute insults

An 11-year-old boys with complaints of shortness of breath since 7 months ago. History of falling from a tree and hitting the neck with a wooden branch On physical examination, stridor and wheezing breath sounds were found in both lung fields. A MSCT Thorax, showed tubular hypodense lesion a size of 7.80 x 0.74 cm at anterior paratracheal region level C5- C7, crossing and constricting the trachea. Patient underwent bronchoscopy followed by surgery for extraction of corpus alienum and repair of trachea with median sternotomy approach and under Cardiopulmonary bypass.

Penetrating tracheal trauma requires urgent surgery for tracheal repair, in this case a median sternotomy approach is performed followed by a two-stage cannulation and tracheal repair is carried out on the bypass to ensure the patient's hemodynamic stability during the operation.

Tracheal stenosis due to penetrating Injury is a stricture of the trachea and is a relatively rare case. Definitive treatment which often involves urgent surgical intervention, has been shown to be beneficial; delays in definitive treatment have been associated with poorer outcomes.

cardiopulmonary bypass, Tracheal Injury, Tracheal Stenosis

1. dr. Adhyasta Nata Prawira S, Resident of Departement of Thoracic, Cardiac and Vascular Surgery, Faculty of Medicine Airlangga University/Dr. Soetomo General Academic Teaching Hospital, Surabaya
2. dr. Dhihintia Jiwangga Suta Winarno, Sp. BTKV, Subsp. T (K), Senior Attending of Thoracic, Cardiac and Vascular Surgery, Departement of Thoracic, Cardiac and Vascular Surgery, Faculty of Medicine Airlangga University/Dr. Soetomo General Academic Teaching Hospital, Surabaya

Germinal cell tumours can present with varying morphologies including benign teratoma and teratodermoid tumour. Teratomas range from benign and well-differentiated cystic lesions to solid and malignant lesions and can contain parts of many tissue types. Cystic teratomas occasionally occur in the mediastinum (7%), retroperitoneum (4%), cervical (3%), and intracranial regions

Here we present a 13-year-old male who presented with shortness of breath, chronic cough, chest pain, incidental weight loss, and history of Tuberculosis treatment who was diagnosed with mature cystic mediastinal teratoma based on thoracic computed tomography (CT) shows a large heterogeneous mass in the anteromedius mediastinum with cystic components, fat, calcification, and necrotic. This mass was approximately 13.6 x 17.7 x10.4 cm in size and histopathological examination of tissue specimens collected using core biopsy. Patient then underwent tumour excision with Clamshell approach. Intraoperative findings showed tumour mass in the right hemithorax with cystic component filled with various tissues. Tumour was found to exert compression towards the mediastinum and causing obstruction of the right lung.

Giant mediastinal tumours in the pediatric population can pose unique threats for resection such as cardiovascular collapse on induction of anaesthesia and injury to surrounding structures. This report highlights the approach of Clamshell thoracotomy which provides the best exposure and enables fastest control of thoracic injuries compared with other incisions. The main challenge in this approach was to control life threatening thoracic bleeding and to prevent bronchovenous air embolism. However, with enough expertise, Clamshell incision is preferred as it allows access to both thoracic cavities and superior mediastinum.

Complete resection of tumour was performed, followed by right lung decortication. Patient was fitted with a thoracic drain on right and left hemithorax with active suction. Clamshell insicion provide a good surgical field and can be safely used in patients with large mediastinal teratomas.

Clamshell incision, Giant teratoma, thoracotomy

1. dr. Devi Agustini Rahayu, Kayuagung Hospital, Palembang, Indonesia
2. dr. Keyshia N Yazid, Department of Cardiothoracic and Vascular Surgery, Dr. Moh. Hoesin Hospital, Faculty Of Medicine Universitas Sriwijaya, Palembang, Indonesia
3. dr. Bermansyah Burhan, Sp.B, Sp.BTKV(K)-VE FCSI, Department of Cardiothoracic and Vascular Surgery, Dr. Moh. Hoesin Hospital, Faculty Of Medicine Universitas Sriwijaya, Palembang, Indonesia

Pulmonary tuberculomas usually present as a solitary pulmonary nodule. Pulmonary tuberculoma is difficult to differentiate from lung cancer. The treatment should follow the multiple disciplinary team. This systematic review is aimed to summarized the effectiveness of pulmonary tuberculoma treatment, including the response to anti-tuberculosis treatment or surgical resection.

PubMed, Wiley, Cochrane, ProQuest, and ScienceDirect were searched for any design study that showed the cure rate of pulmonary tuberculoma treatment, with surgical resection or the used of anti-tuberculosis treatment. Four studies were identified and analyzed from 288 initial articles. Data were then extracted from the studies and summarized descriptively.

Two hundred eighty-eight articles were screened, and four studies were identified and eventually selected. The cure rate of pulmonary tuberculoma increased in patient with surgical procedure compared with medical treatment (only anti-tuberculosis treatment). Pulmonary tuberculoma respond poorly to anti-tuberculosis treatment and often requires long-term treatment. The treatment of tuberculoma with surgical resection works effectively, with better short- and long-term effects for tuberculoma.

Surgical resection was effective to increase the cure rate of pulmonary tuberculoma. Pulmonary resection in combination with post-operative anti-tuberculosis treatment results in excellent cure rate.

anti-tuberculosis treatment, pulmonary tuberculoma, surgical resection

1. dr. Rahmatika Gita Pratiwi, General Practitioner, Tasikmalaya Heart Center, Tasikmalaya, Indonesia
2. dr. Mochamad Rizki Firmansyah, General Practitioner, Tasikmalaya Heart Center, Tasikmalaya, Indonesia
3. dr. Fanny Fauziah Abdulah, M.Kes, Sp.JP, FIHA, Division of Cardiology, Tasikmalaya Heart Center, Tasikmalaya, Indonesia
4. dr. Gusti Reza, Sp.BTKV (K)-JD, FIHA, FICS, Division of Cardiac Surgery, Jakarta Heart Center, Jakarta, Indonesia
5. dr. Ismail Dilawar, Sp.BTKV (K)-JD, MARS, Division of Cardiac Surgery, Jakarta Heart Center, Jakarta, Indonesia

New-onset post-cardiac surgery atrial fibrillation is a frequent complication with incidence approximately 17-40% after coronary artery bypass grafting surgery. It’s associated with higher mortality and morbidity. It carries significant risks for thromboembolism and bleeding (adverse effect of anticoagulant therapy). This case is purposed to report new-onset PCSAF after CABG surgery.

A-62-year-old referred to Tasikmalaya Heart Center with recurrent chest pain. The patient had history of hypertension, old myocardial infarction, ischemic stroke without sequel, but no prior atrial fibrillation detected. Coronary angiography obtained coronary artery disease included 3 vessel disease with complete total occlusion at mid-LCX, mid-RCA, and mid-LAD. Carotid doppler sonography showed severe thickening of the right and left carotid arteries. The patient underwent CABG surgery with 3-grafts. The patient was extubated 7 hours post-operative and stable. Electrocardiography developed atrial fibrillation with rapid ventricular respond on first day post-CABG, reverted sinus rhythm after treatments, and returned back AF RVR on second day post-CABG. The management involved amiodarone, bisoprolol, digoxin, atorvastatin, and double anti-platelet. CHAD2DS2-VASC score was 4 points, eligible as moderate-high risk for thromboembolism. Oral anticoagulant warfarin was administrated after >48 hours of CABG surgery for 4-6 weeks. The patient was stable and step down on fifth-day of hospitalization.

New-onset PCSAF presents major risk for any cardiac surgery. New-onset PCSAF tends to develop within the first 6 days postoperatively, in-line with the patient’s condition. Pre-existing risk factors in this case are male sex, history of hypertension, and myocardial infarction. Current treatments include β-blocker, antiarrhythmics, statins, and oral anticoagulant. Study mentions, combination β-blocker and amiodarone decrease 13,75% new-onset PCSAF. Digoxin can be added to β-blocker and/or amiodarone for better rate control. New-onset PCSAF has been associated with higher-risk thromboembolism. Recent studies have postulated using anticoagulant if new-onset PSCAF persists for >48 hours or >24 hours in patient with high-risk for thromboembolism (CHAD2DS2-VASC ≥2). AHA/ACC/HRS states it’s reasonable to use oral anticoagulant or direct oral anticoagulant. CCS recommends to continue anticoagulant therapy minimum for 6 weeks. In this case, the patient is planned to be given warfarin for 4-6 weeks. During anticoagulant therapy, bleeding and INR are important to be monitored.

New-onset PSCAF after first-time CABG was in this large real-world study associated with a significantly increased risk of ischemic stroke, thromboembolism, heart failure, and recurrence of AF which correlates its negative prognostic impact. Further studies investigating the role of oral anticoagulant in patients with new-onset PSCAF are warranted.

New-onset post-cardiac surgery atrial fibrillation, oral anticoagulant

1. dr. Keyshia N Yazid, Divisi Bedah Thoraks, kardiak, dan Vaskular RSUP Dr. Mohammad Hoesin Palembang

2. dr. Bermansyah, Sp.B, Sp.BTKV, Subsp. VE(K), FCSI, Divisi Bedah Thoraks, kardiak, dan Vaskular RSUP Dr. Mohammad Hoesin Palembang

3. dr. Ahmat Umar, Sp.B, Sp.BTKV, Subsp.T(K), Divisi Bedah Thoraks, kardiak, dan Vaskular RSUP Dr. Mohammad Hoesin Palembang

Thoracic endometriosis syndrome (TES) is defined as the presence of endometrial mucosa implantation inside the thoracic cavity in women of child-bearing age. Patients typically present with recurring spontaneous pneumothorax before being diagnosed. The difficulty in diagnosing TES may significantly delay appropriate treatments.

A 38-year-old woman with neither history of pneumothorax nor endometriosis presented with chief complain of right shoulder blade pain followed by shortness of breath on her first day of menstruation. The woman was infertile for 16 years. Chest X-ray showed a bilateral pneumothorax. A computed tomography (CT) of the thorax later confirmed a predominantly right-sided pneumothorax more than half of the chest cavity. A right-sided chest tube was inserted but no significant lung re-expansion was observed within the following week. Right thoracotomy was performed. Pathological finding established the diagnosis of TES with positive CD10 marker, estrogen receptor (ER), and progesterone receptor (PR). The patient was consulted to gynecologist for further treatment.

Endometriosis is often related to infertility. Patient’s history of infertility and failure to achieve complete lung re-expansion after chest tube insertion, enforced us to think about TES, even if it was the first time the patient had pneumothorax during her menstruation. Thoracic surgeons and gynecologists in the context of TES should jointly evaluate patients who are referred for suggestive TES. Current update of TES treatment including surgical resection and GnRH therapy.

TES is often underdiagnosed even after recurring pneumothorax. TES should be suspected earlier in infertile woman of child-bearing age presenting with pneumothorax. Prompt treatment with well-timed surgical resection and GnRH therapy might give the best outcome for the patient to prevent recurrence of pneumothorax.

endometriosis, infertility, pneumothorax, thoracotomy

1. dr. K. M. Al Kindi, Divisi Bedah RSUD Raden Mattaher Jambi
2. dr. Dian Sulastri, Sp.B, Divisi Bedah RSUD Raden Mattaher Jambi

Impending rupture pseudoaneurysm can be both limb and life-threatening condition if left untreated. Early diagnosis and treatment play a vital role in managing this case. Here, we present a case of impending tupture pseudoaneurysm of brachiocephalic arteriovenous fistula in a center with limited resources

A 45-years-old female referred to surgery clinic prior her hemodyalisis session. She experiencing painfull pulsatile mass in her left elbow since 4 days ago. The mass emerged after her last hemodialysis session and become bigger each day. Duplex ultrasonography revealed a suspicion of pseudoaneurysm of brachiocephalic arteriovenous fistula. Due to the mass looks tension and red-blackish discoloration, an immediate open surgery was performed under general anesthesia. Torniquet was used for proximal control which maintained at 250 mmHg. The pseudoaneurysm was removed and the brachial artery was repaired. There were no sign of distal ischemia nor other complication during the post operative course. The patient was discharged at day 5 post-operative.

The diagnosis of pseudoaneurysm was made only by clinical examination and duplex ultrasonography imaging. In this case, further color doppler ultrasonography was reccomended because it can identify the site lession which might aid the surgeon during the surgery. Due to the tension and size of the mass, open surgical procedure followed by artery repair is a better option in managing this patient. But we only could performing primary suture as the repair technique, which pose a risk of arterial stenosis. Fortunately, there were no sign of distal ischemia during follow-up visit. However, it’s necesarry to perform angiography for further investigation.

Early diagnosis and treatment play a vital role in the management of impending rupture pseudoaneurysm to prevent its fatal complication. Ideally, the diagnosis was made by color doppler ultrasonography and artery repair using vein patch seems a better option in this case to achieve a better outcome

Brachiocephalic AVF, Impending Rupture, Pseudoaneurysm

1. Ahmad Muslim Hidayat Thamrin, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
2. Marko Darmawan, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
3. Mahardika Budjana Sutan Ilham, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
4. Faris Maulana Irfan, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
5. Vicky Supit, MD, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
6. Tri Wisesa Soetisna, MD, Ph.D, Adult Cardiac Surgery Division, National Cardiovascular Center Harapan Kita
7. Anwar Santoso, MD, Ph.D, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita

Benefit of IMSC transplantation during CABG surgery has been widely proven. Our recent meta-analysis shows the superiority of IMSC with CABG compared to CABG alone in improving cardiac function but also shows response variability between patients. We conducted an analysis of our RCT data to evaluate factors determine patient’s response.

Thirty patients with IHD and left ventricular ejection fraction (LVEF) < 35% were randomized to undergo CABG with IMSC transplantation (using CD133+ stem cells) or CABG alone. Cardiac function was evaluated using cardiac magnetic resonance imaging after 6 months. Patients in the IMSC group were then classified as responders if they reached a minimum EF improvement of 5% on evaluation. A thorough characteristic analysis of the difference between responders and non-responders groups was then done.

At 6 months, LVEF changes, wall motion score index improvement, scar size proportion improvement, and 6-minute walking test improvement were significantly higher in IMSC group (p < 0.05). Thirteen patients in IMSC group were then divided into 7 patients in the responders group and 6 patients in the non-responders group. Our analysis shows that, instead of commonly believed higher baseline LVEF, lower baseline left ventricular end-systolic volume (LVESV) and lower baseline left ventricular end-diastolic volume (LVEDV) appears to be the significant determinant of patient’s response to IMSC transplantation (p = 0.462 for LVEF; p = 0.036 for LVESV; p = 0.012 for LVEDV). LV volumes are believed to be determined by the extent of viable myocardial cells, which in turn determines myocardial regenerative capacity. Several factors that determine IMSC response such as body weight, circulating angiogenic factors, kidney function, and bone marrow stem cell levels are currently studied.

Myocardial regenerative capacity can be depicted by left ventricular volumes which in turn determine the patient’s response to IMSC transplantation. Low LVESV and LVEDV suggest higher viable myocardial cells thus increasing the patient's response to IMSC transplantation. Several other individual factors, though still being studied, must also be considered.

coronary artery bypass, intramyocardial, ischemic heart disease, Outcome, response, stem cell

1. dr Martin Susanto, S.ked, Puskesmas Petang II, Badung, Bali
2. dr Citra Aryanti, Sp.B, Department of General Surgery, Universitas Udayana, Denpasar
3. dr Syahroni Ibnu, Sp.BTKV, Department of Thoracic, Cardiac, and Vascular Surgery, Grand Medistra Hospital, North Sumatra
4. dr Gracelia Ruth Elisabeth Damanik, Sp.BTKV, Department of Thoracic, Cardiac, and Vascular Surgery, Dr Saiful Anwar General Hospital, Malang

The increase in the prevalence of antibiotic-resistant strains in wound infections has led to resurgence in larval debridement therapy (LDT) since the 1980s. The Food and Drug Administration approved the method in 2004. This study aimed to determine the efficacy of LDT in treating diabetic, arterial, venous, and chronic ulcers.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were employed in this study. The steps followed the Cochrane Handbook for Systematic Review of Interventions guidelines. The databases of PubMed, Google Scholar, EBSCO, DOAJ, and Cochrane were extensively researched. The date of publication within the last fifteen years was the inclusion criterion. Randomized controlled trials and non-randomized controlled trials were prioritized forms of research publications. Ambiguous remarks, irrelevant correlations to the main issue, or focus on other disorders were the exclusion criteria. Based on the study design, the critical appraisal tool used in this research was the Joanna Briggs Institute (JBI) critical appraisal tool. For dichotomous outcomes, the effects of LDT were expressed as the relative risk (RR) and 95% confidence interval (CI). The pooled effects were estimated using a fixed effect model or random effect model based on the heterogeneity test. All data were analyzed using Review Manager 5.4.

Overall, six studies comparing LDT with standard therapy were included, consisting of 4 randomized controlled trials, 1 prospective case-control study, and 1 retrospective cohort study. A total of 382 participants were included in the six studies, consisting of 203 participants in the LDT group and 179 participants in the standard therapy group. All six studies passed the quality evaluation. The results of this meta-analysis suggested that the LDT group was significantly superior to the control group in the percentage of the healing rate of the ulcers (RR=2.41, 95%CI=1.06; 5.47; p=0.04) and reduced amputation rate after intervention (RR=0.37, 95%CI=0.22; 0.62; p=0.0002). However, pooled differences in the number of reduced infected cases after intervention (RR=5.98, 95%CI=0.08; 447.60; p=0.42) revealed no evidence of a difference between the LDT and control group.

Larval debridement therapy may be a feasible alternative in treating diabetic, venous, arterial, and chronic ulcers. This study revealed that LDT significantly improved the healing rate and amputation rate of ulcers. However, no significant differences were found in the number of reduced infected cases after intervention compared with control group.

arterial, chronic, debridement, diabetic, larva, maggot, management, therapy, treatment, ulcer, venous

1. Rama Azalix Rianda, Dompu General Hospital
2. Heri Satryawan, Dompu General Hospital
3. Jacquels Mozes, Dompu General Hospital

Thromboangiitis obliterans (TAO) or Buerger’s Disease is a chronic inflammatory disease. If not treated early and adequately, TAO can result in limb amputation. The study regarding TAO in women is rare and limited. Also how difficult it is to diagnose and educate patients with TAO, especially in remote areas.

A 38-year-old woman came to the emergency room with the chief complaint of pain and darkening in toes and hands 2 months ago, especially when it is cold. The patient did not come to the public health facility but was treated with traditional medicine according to local beliefs. History of smoking was denied. The localized status was found gangrene in toes and fingers, ulcer in toes, and oedema in legs. Allen's tests were positive. Dorsalis pedis arteries were palpable. ABI wasn’t performed. Laboratory examination showed an increased liver function. Cardiomegaly, Lung oedema, and minimal right pleural effusion were shown in Chest X-ray. History taking, clinical finding, and laboratory finding suggested the patient to amputation but the patient refused it. The Patient was treated by antibiotic, analgetic, anticoagulant, and double. After 3 days of treatment, the patient was discharged and asked to return to the outpatient care for education about amputation.

Most patients are aged 20-45 years. Men are more common than women. The etiology of TAO is unknown, but cigarette exposure is still associated with TAO. The role of hypercoagulability in the pathogenesis of TAO has been proposed. Elevated plasma homocysteine has been reported in patients with TAO. There was a strong link between the plasma Hcy concentration and Liver Fibrosis. We assessed the patient with TAO regarding suspect hypercoagulability affected by increased liver function. Difficult to diagnose due to patient denied smoking history and other imaging and laboratory tests weren’t performed. Patients with TAO who have elevated homocysteine also have a higher rate of amputations. Education is a key role for understanding the concept of health. Countries with higher education levels are more likely to have better national health conditions. We can conclude that lower levels in tertiary education affects a country’s health situation in terms of premature mortality.

It is difficult to diagnose Buerger's disease or thromboangiitis obliterans because of the atypical complaints, minimal risk factors, and limited facilities for imaging and other laboratory tests. The difficulty of educating patients to get the best treatment is also a challenge for general practitioners, especially in remote areas.

amputation, Buerger’s disease, education level, remote area, woman

1. dr. Giadefa Imam Cesyo, Divisi /Program Studi Bedah Toraks, Kardiak, dan Vaskular FK Universitas Udayana / RSUP Prof. dr. I.G.N.G Ngoerah

Pericardial effusion (PCE) is a significant complication after pediatric cardiac surgery and it usually leads to an increased morbidity and re-hospitalization rate. This study investigates PCE development after pediatric cardiac surgery and to investigate the associated factors for its development.

Comprehensive search in PubMed using search terms: pericardial effusion and cardiac surgery. Additional filters included pediatric studies published in the last 10 years. Exclusion criteria were case reports; mixed patient population, or pericardial effusion unrelated to cardiac surgery. Outcomes of interest included incidence and predictive risk factors. Backward citation searching was used.

Total 6 articles were identified using the reported search. There were 4 studies with population of general pediatric cardiac surgery and 3 studies in specific population; ASO, ASD closure, and PA banding surgery. The incidence rate of PCE after cardiac surgery in general varies from 6.4% to 24.3%. Factors that associated with incidence of PCE; fever in first 48 hours (RR 4.5 [95%CI 2.7–7.3], ST-segment elevation (RR 4.7 [95%CI 2.9–7.5), large amount drain production (OR 8.4 [95%CI 2.6–31.5], Fontan procedure (OR 6.9 [95%CI 1.6–12], postoperative warfarin administration (OR 4.1 [95%CI 1.8–10.8], TOF/PA correction (OR 1.9 [95%CI 0.7-3.1], redo-operation (OR 2.7 [95%CI 1.4-5.1], CPB use (OR 2.1 [95%CI 0.9-4.5], CPAP duration 1-12 hours (OR 10.8 [95%CI 3.3-35.2], systemic pulmonary artery shunt procedure (OR 2.23 [95%CI 1.84-2.69], heart transplant (OR 1.82 [95%CI 1.32-2.83], pleural effusion (OR 1.7 [95%CI 1.2-2.4] and mechanical circulatory support (OR 1.81 [95%CI 1.15-2.85].

PCE occurred after 6.4% to 24.3% of pediatric cardiac surgery and was associated with fever in first 48 hours, ST-segment elevation, drain production, Fontan procedure, postoperative warfarin administration, TOF/PA correction, redo-operation, CPB use, CPAP duration 1-12 hours, systemic pulmonary artery shunt procedure, heart transplant, pleural effusion, and mechanical circulatory support.

Pediatric Cardiac Surgery, Pericardial Effusion, Pericardium

1. dr. Jeconia Agrippina Ruth Sinatra
2. dr. Danang H Limanto, SpBTKV, SubSp.VE(K) M.Ked.Klin,
3. dr. Mohamad Rizki, SpBTKV, M.Ked.Klin,
Departmen of Thoracic, Cardiac, and Vascular Surgery, Soetomo Academic General Hospital, Airlangga University, Surabaya

Both acute aortic dissection and ruptured aortic aneurysm are leading causes of death in cardiovascular disease. Management of the disease can affect the rate of mortality and morbidity

We present a case of 53-year-old female came to the hospital with a chief complaint of hemothorax with a chest drain already been placed from the referring hospital. She was complaining of chest and abdominal pain since 17 days before admission. From chest xray, it was shown that there was a hemothorax in the left chest. From chest CT, a thoracic aorta dissection was shown. Patient referred to our hospital for a further management. She underwent a minimal invasive procedure of TEVAR to occlude the rupture aorta and VATS to evacuate clots from hematothorax

Maintaining the hemodynamic condition of patients with free aortic rupture is difficult. The majority of patients with aortic rupture and continuous bleeding cannot survive. Traditionally, patients with this condition have been treated by open repair. Endovascular repair has emerged as an alternative treatment option for such cases with great result.

Acute aortic dissection and ruptured aortic aneurysm is the leading cause of death in cardiovascular disease. However, continuous advances in imaging and treatment technologies are improving short- and long-term outcomes

Minimal invasive, Ruptured aortic, TEVAR, VATS

1. dr. Maria Felinsianita, Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

2. dr. Dhama Shinta Susanti, Sp.BTKV, Subsp. JPK (K), Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

3. dr. Suprayitno Wardoyo, Sp.BTKV, Subsp. JPK (K), Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

4. dr. William Makdinata, Sp.BTKV, Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

5. dr. Bela Dirk, Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

6. Rendy A. Jiwono, Division of Pediatric Cardiac Surgery, Departement of Cardiaothoracic and Vascular Surgery, Dr. Cipto Mangunkusumo National Hospital, Jakarta, Indonesia

Percutaneous closure of atrial septal defect (ASD) and patent ductus arteriosus (PDA) with Amplatzer septal/duct occluder (ASO/ADO) is known as an established, safe, and efficient procedure with high successful rate. However, migration and abandoned device still remains a terrified complication requiring immediate intervention. The aim of this case series study

Within two weeks, we received four referrals to our hospital, Dr. Cipto Mangunkusumo National Hospital, Jakarta Indonesia, from different hospitals, that had device migration requiring immediate surgical intervention. Two female children with secundum ASD had ASO device implanted. One embolized to the right ventricle and the other into the right atrium. Also two female children with PDA had device closure. Device embolization occurred into the descending aorta and left pulmonary artery, respectively.

All four devices were successfully evacuated and the defects was closed surgically without any residual, with a low morbidity and no mortality.

The diagnostic approach and consideration whether the case should be given to surgical or transcatheter closure have to be done more careful and accurate. We recommended that occluder devices should be inserted in facilities where cardiac surgical support is attainable.

amplatzer ductal occluder, amplatzer septal occluder, atrial septal defects, patent ductus arteriosus, surgical evacuation

1. dr. Achmad Dimas Putranto, Residen Bedah Toraks, Kardiak dan Vaskular FKUI
2. dr. Christianto Wisman, Residen Bedah Toraks, Kardiak dan Vaskular FKUI
3. dr. Sutopo Kirlan, Sp.B, Sp.BTKV, MARS, Divisi Bedah Toraks, Kardiak dan Vaskular RSPAD Gatot Soebroto Jakarta

80% of dialysis patients in the USA used catheters for hemodialysis access. The incidence of central venous stenosis occurs 25-40% worldwide. Because high prevalence and challenging treatment of central venous stenosis due to the long-term use of a catheter in dialysis patients, we aim to review the use of venoplasty

The patency of central veins is important to adequate dialysis access. A well-established outflow tract clear of any obstruction is essential for an arteriovenous fistula (AVF) to mature and function efficiently. The long-term use of a catheter is associated with increased central vein stenosis incidents. Subclavian catheter placement is a particularly high risk, with the development of subclavian vein stenosis in approximately 25%-50% of patients in various studies. The asymptomatic patients make the diagnosis difficult to determine the actual prevalence. One of the standard treatments for central venous stenosis is central venoplasty. Venoplasty is defined as the inflation of a balloon in the central vein such as the brachiocephalic vein, subclavian vein, or superior vena cava. Venoplasty for central venous disease has high technical success rates, ranging from 70%-90%. Successful venoplasty defines as the successful inflation of the balloon without residual stenosis.

Adwaney et al found patients with a previous catheter used have a higher incidence than patients without a catheter used (RR 2.2, 95% CI 1.6 – 2.9). Cuthbert et al found that a shorter time to the second venoplasty is needed in patients with ipsilateral tunneled dialysis catheters (p= 0,039). Statistically significant differences were found in primary patency rates in those with a history of ipsilateral tunneled dialysis catheters (p = 0,025). Rehman et al reported primary patency rate was 40%, 24%, and 24% at 6, 12, and 24 months. Cumulative patency was 69%, 66%, and 59% at 6, 12, and 24 months. 74 % of patients had a recurrence of symptoms and 60% of patients undergo repeat angioplasty. Calton et al reported five patients performed the antegrade-retrograde technique of venoplasty. 4 patients success in the antegrade technique while 1 patient only be crossed with the retrograde technique. They also

Venoplasty is a gold-standard treatment for patients with central venous stenosis with a high short-term patency rate. Despite its low procedural risk, some patients require re-intervention because of restenosis occurring over the years. Venoplasty requires further research to obtain better long-term patency rates

Central Venous Catheter, Central Venous Stenosis, hemodialysis, Patency Rates, Venoplasty