Coronary Artery Fistula

CORONARY ARTERY FISTULA

Diagnosis and Management

 Irnizarifka, MD.

Resident at Dept. of Cardiology and Vascular Medicine

Faculty of Medicine, Universitas Indonesia

ABSTRACT

Coronary artery fistulae (CAF), also known as coronary arteriovenous malformation, are rare anomalies. Its exact incidence is unknown but estimated for 0.2-0.4% of all congenital cardiac anomalies. Most CAFs are congenital and may be found in patients with structurally normal hearts. A CAF is a connection between one and more of the coronary arteries and a cardiac chamber or great vessel, having bypassed the myocardial capillary bed.

Most children with small CAF are asymptomatic, and continuous murmur may be audible on routine examinations if the fistulae are moderate to large in size. When a large fistula drains into the right side of the heart, there will be volume overload in the right heart as well as pulmonary vascular bed. The patient will develop symptoms of lung overflow and occasionally congestive heart failure. The continuous murmur heard in this anomaly is suggestive of patent ductus arteriosus (PDA) but at the lower site of the left sternal border. The main diagnostic technique is cardiac catheterization and angiography. Transcatheter closure or surgical closure of CAF by epicardial and endocardial ligations are the treatment for CAF and remains safe and effective with good reported success.

We report a case of large CAF originated from the left coronary artery drained into the apex of right ventricle. Recurrent respiratory tract infection (RRTI) was the prominent symptom of the patient. The CAF was confirmed by echocardiography and cardiac catheterization. There was no medication given since heart failure condition was not advanced yet. Transcatheter CAF occlusion was not performed since the fistula was large, hence surgical closure was chosen as definitive treatment. CAF should be considered in children with clinical presentation of left-to-right shunt or lung overflow and continuous murmur at the lower left sternal border.

Keyword : Coronary artery fistula, recurrent respiratory tract infection, continuos murmur.

 

Gagal Jantung Diastolik pada Penyakit Jantung Tiroid

GAGAL JANTUNG DIASTOLIK PADA PENYAKIT JANTUNG TIROID

Diagnosis dan Tatalaksana

Irnizarifka, MD.

Resident at Dept. of Cardiology and Vascular Medicine

Faculty of Medicine, Universitas Indonesia

ABSTRAK

Gagal jantung adalah suatu sindroma klinis dimana pasien mempunyai gejala dan tanda khas gagal jantung yang berasal dari kelainan struktural atau fungsional jantung. Menurut terminologi berdasarkan fraksi ejeksi: fraksi ejeksi yang berkurang dan fraksi ejeksi yang masih baik. Mencari etiologi gagal jantung sangat penting dalam diagnosis dan tatalaksana gagal jantung.

Hormon tiroid mempengaruhi semua sistim organ, terutama jantung yang merespon perubahan minimal pada kadar tiroid di dalam serum seperti pada individu dengan hipertiroid subklinis. Hipertiroidisme menyebabkan perubahan kontraktilitas jantung, konsumsi oksigen otot jantung, curah jantung, tekanan darah, dan resistensi sistemik vaskular. Beban hemodinamik yang diakibatkan hipertiroid menyebabkan peningkatan kontraktilitas miokard, fraksi ejeksi serta curah jantung. Inisiasi fibrilasi atrial (AF) dimulai bila terjadi kombinasi antara faktor pemicu dengan substrat aritmogenik karena penurunan periode refrakter efektif (ERP), peningkatan dispersi spasial refrakter atau konduksi impuls atrial abnormal.

Kasus ini wanita 55 tahun datang ke UGD RSJPDHK dengan keluhan sesak napas yang memberat sejak 7 jam sebelum masuk RS. Didapatkan rasa berdebar, frekuensi nadi cepat dan iregular. Pemeriksaan jantung S1-S2 iregular, murmur pansistolik IV/6 dengan punctum maksimum di apeks, ronki basah halus di ³/₄ lapang paru, gambaran EKG fibrilasi atrium, dan kadar TSH 0,004. Pasien datang dengan penampilan klinis gagal jantung akut, kemudian dilakukan terapi sesuai etiologi dan guideline. Dirawat selama 7 hari, setelah membaik dianjurkan berobat jalan di poliklinik, namun pasien tidak datang.

American Thyroid Association, The Endocrine Society dan The American Association of Clinical Endocrinologist (2005) memberikan pedoman tatalaksana pada individu usia lanjut dan individu dengan faktor risiko (terutama penyakit jantung dan osteoporosis) yang memiliki nilai TSH < 0,1 mU/liter, dibahas pada makalah ini.

Kata kunci : Gagal Jantung Akut, Penyakit Jantung Tiroid.