This curriculum vitae outlines the education and career of Dr. Lucia Kris Dinarti. She completed her internist training at Universitas Gadjah Mada in 1999, her cardiologist training at Universitas Indonesia in 2003, and her cardiologist consultant training also at Universitas Indonesia in 2006. Her current positions are as a staff member of the Cardiology and Vascular Medicine Department at Universitas Gadjah Mada/RSUP dr. Sardjito Yogyakarta and as the Head of the Cardiac Ward at RSUP dr. Sardjito Yogyakarta.
This curriculum vitae outlines the education and career of Dr. Lucia Kris Dinarti. She completed her internist training at Universitas Gadjah Mada in 1999, her cardiologist training at Universitas Indonesia in 2003, and her cardiologist consultant training also at Universitas Indonesia in 2006. Her current positions are as a staff member of the Cardiology and Vascular Medicine Department at Universitas Gadjah Mada/RSUP dr. Sardjito Yogyakarta and as the Head of the Cardiac Ward at RSUP dr. Sardjito Yogyakarta.
Original Title
simposium iii. 2. guch. dr. l. krisdinarti sppd spjpk.pdf
This curriculum vitae outlines the education and career of Dr. Lucia Kris Dinarti. She completed her internist training at Universitas Gadjah Mada in 1999, her cardiologist training at Universitas Indonesia in 2003, and her cardiologist consultant training also at Universitas Indonesia in 2006. Her current positions are as a staff member of the Cardiology and Vascular Medicine Department at Universitas Gadjah Mada/RSUP dr. Sardjito Yogyakarta and as the Head of the Cardiac Ward at RSUP dr. Sardjito Yogyakarta.
This curriculum vitae outlines the education and career of Dr. Lucia Kris Dinarti. She completed her internist training at Universitas Gadjah Mada in 1999, her cardiologist training at Universitas Indonesia in 2003, and her cardiologist consultant training also at Universitas Indonesia in 2006. Her current positions are as a staff member of the Cardiology and Vascular Medicine Department at Universitas Gadjah Mada/RSUP dr. Sardjito Yogyakarta and as the Head of the Cardiac Ward at RSUP dr. Sardjito Yogyakarta.
Cardiologist Consultant : Universitas Indonesia (2006)
Current Position:
Staf Bagian Kardiologi dan Kedokteran Vaskular Universitas Gadjah Mada/RSUP
dr. Sardjito Yogyakarta
Kepala Instalasi Rawat Jantung RSUP dr. Sardjito Yogyakarta
Clinical Approach to Grown Up Congenital Heart Disease (GUCH) Lucia Krisdinarti Cardiology Department and Vascular Medicine Medical Faculty UGM/Sarjito Hospital YOGYAKARTA Introduction GUCH can be divided into 2 groups : those who have not previously had an intervention and those who have. Commonly divided into non cyanotic (L R) and cyanotic (R L) categories based on direction of shunting In USA, incidence of GUCH increase 5% /year. Data of incidence in Indonesia not available Incidence of CHD in RSUP dr. Sardjito 2014
Age Gender
(Hidayati et.al, 2015)
Incidence of CHD in Children and Adult in Sarjito Hospital 2014
Children Adult
(Hidayati et.al, 2015)
Acyanotic Heart Disease Atrial septal defects (ASD) Ventricular septal defects (VSD) Patent ductus arteriosus (PDA) Obstruction to blood flow Pulmonic stenosis (PS) Aortic stenosis (AS) Aortic coarctation (ESC, 2010) Cyanotic Heart Disease Tetralogy of Fallot Tricuspid atresia (TA) Total anomalous pulmonary venous return (TAPVR) Truncus arteriosus Transposition of the great vessels Hypoplastic left heart syndrome (HLH) Pulmonary atresia (PA) / critical PS Double outlet right ventricle (DORV) (ESC guidelines , 2010) Basic Patient Assessments Thorough patient evaluation is crucial for management of GUCH! Patient History - assess present and past symptoms - look for intercurrent event and changes in medication - question lifestyle to detect progressive changes in daily acativities
Clinical Examination Plays a major role and includes, during follow up, careful evaluation with regard to any changes in auscultation findings, blood pressure, and development of sign of heart failure
ECG and pulse oxymetri
Routinely carried out along alongside clinical examination
Chest X-ray Performed on indication but helpful during follow up ( ESC guidelines , 2010) Further Examination Echocardiography - First line investigation, providing morphology of cardiac anatomy, shunting and the surrogate for hemodynamic measurement. Cardiac MRI - Alternative to echo when both provide similar information but echo cannot be obtained with sufficient quality - second method when echo result are borderline or ambigous Computed Tomography Cardiopulmonary Exercise Testing Cardiac catheterization - assesment of PAP, PVR, shunt quantification particularly in shunt lesion - testing of vasoreactivity - coronary angiography before surgery in men>40 y.o, post menopausal women, and patients with risk factors for CAD (ESC guidelines, 2010) Most common in adult
Commonly asymptomatic Essentials of diagnosis: Right ventricular heave S2 widely split and usually fixed Grade I-III/VI systolic murmur at the pulmonary area RBBB in ECG; RAD for secundum type and LAD for primum type Cardiac enlargement on CXR (Rao, 2005) Three major types Ostium secundum most common In the middle of the septum in the region of the foramen ovale Ostium primum Low position Form of AV septal defect Sinus venosus Least common Positioned high in the atrial septum Frequently associated with PAPVR (Rao, 2005) Atrial Septal Defect Closures I IIa IIb III Closure of an ASD either percutaneously or surgically is indicated for right atrial and RV enlargement with or without symptoms. I IIa IIb III A sinus venosus, coronary sinus, or primum ASD should be repaired surgically rather than by percutaneous closure. I IIa IIb III Surgeons with training and expertise in CHD should perform operations for various ASD closures. (ACC/AHA guidelines , 2008)
12 Closure contraindicated in severe PAH Previously surgical; now often closed percutaneously using device Clinical findings Grade II-IV/VI, medium- to high-pitched, harsh pansystolic murmur heard best at the left sternal border with radiation over the entire precordium
Chest X-ray : LV enlargement
ECG : LVH, later biventricular hypertrophy (Brickner et al, 2000)
(Brickner et al, 2000)
Surgical Ventricular Septal Defect Closure VSD Closure Operations I IIa IIb III Surgeons with training and expertise in CHD should perform VSD closure operations.
I IIa IIb III
Closure of a VSD is indicated when there is a Qp/Qs (pulmonary-to-systemic blood flow ratio) of 2.0 or more and clinical evidence of LV volume overload.
I IIa IIb III
Closure of a VSD is indicated when the patient has a history of IE. ACC/AHA guidelines, 2008) 15 Persistence of normal fetal vessel joining the pulmonary artery to the aorta
Closes spontaneously in normal term
infants at 3-5 days of age
Epidemiology facts Accounts for about 10% of all cases of CHD Higher incidence of PDA in infants born at high altitudes (> 10,000 feet) More common in females
Pulses are bounding and pulse pressure is widened
Characteristically has a rough machinery murmur which peaks at S2 and
becomes a decrescendo murmur and fades before the S1
(Brickner et al, 2000)
Most common cyanotic lesion (7 to 10% of all CHD) Typical features Cyanosis after the neonatal period Hypoxemic spells during infancy Right-sided aortic arch in 25% of all patients Systolic ejection murmur at the upper LSB
(Brickner et al , 2000; Perloff et al, 2009)
Special Issues of CHD in Adult
Pregnancy Complication of Pulmonary Hypertension/ Eisenmenger Syndrome Mortality Rate Pregnancy in GUCH Maternal Cases of ASD patients in RSUP dr. Sardjito Total 23 pregnant ASD patients from January 2013 Dec 2014; who came in the Delivery/Maternal Unit
PH incidence Mode of delivery Caesarean
Spontaneus PH /ES 5 (22%) non PH 7 (25%)
18 (78%) 16 (75%) Mortality
6 (27%) SeverePH Survive Died 17 (73%)
(Krisdinarti & Anggrahini, 2014)
Euro Heart Survey : Decreased survival in PAH- related CHD
Engelfriet et al., 2007
Eisenmenger Syndrome Eisenmenger syndrome is pulmonary hypertension with a reversed central shunt An uncorrected large left-to-right shunt causes irreversible rise in PVR leading to reversal of or bidirectional shunt flow with resultant hypoxemia Eisenmenger syndrome is not a congenital defect, but a pathophysiologic condition Based on RHC; total number of the patients July 2012 Dec 2014: 124 45 no PH 39 40 mild PH (25-40 mmHg)
High Incidence of Severe PH in young female age groups 21-40 y.o :
Natural History for Eisenmenger?
Genetic background ? Or ASD coincide with IPAH/HPAH ?
(Krisdinarti & Anggrahini, 2014)
Mortality in CHD with PH in RSUP.Dr.Sarjito Yogyakarta
Causes of death
Sudden death (30%)
Congestive heart failure (25%) Hemoptysis (15%) Pregnancy Perioperative mortality of non-cardiac surgery Infectious diseases ( Krisdinarti & Anggrahini, 2014) Mortality Cases of ASD in RSUP dr. Sardjito Number of Mortality patients : 19 of 247 patients
PH severe/ Eissenmenger Right Heart Failure 6% Lung Infection PA dissection Death Sudden Cardiac Death 7% Arrythmia VF Sepsis
No PH 1% All cause mortality
(Krisdinarti & Anggrahini, 2014)
SUMMARY GUCH still become a big problem in Indonesia. Case finding is important Special issue : pregnancy, pulmonary hypertension, high mortality rate. Early screening is needed to decrease the problem Thank You Infective Endocarditis Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable Condition Congenital Specific Condition* Previous infective endocarditis Unrepaired cyanotic CHD, including palliative shunts and conduits Prosthetic cardiac valve or prosthetic Completely repaired congenital heart defect with material used for cardiac valve repair prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure *Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. Repaired CHD with residual defects at the site or Prophylaxis is reasonable because endothelialization of adjacent to the site of a prosthetic patch or prosthetic material occurs within 6 months after the procedure. Modified with permission to include footnotes from Wilson et al. prosthetic device that inhibit endothelialization Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Cardiac transplant recipients who develop Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, cardiac valvulopathy Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116:1736-54. CHD indicates congenital heart disease. Warnes, et al. J Am Coll Cardiol 2008;52. Table 6. Published ahead of print November 7, 2008, at http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.10.001 30 Infective Endocarditis Congenital Cardiac Lesions and Preoperative Risk for Noncardiac Surgery High risk Pulmonary hypertension, primary or secondary Cyanotic congenital heart disease New York Heart Association class III or IV Severe systemic ventricular dysfunction (ejection fraction less than 35%) Severe left-sided heart obstructive lesions Moderate risk Prosthetic valve or conduit Intracardiac shunt Moderate left-sided heart obstruction Moderate systemic ventricular dysfunction Warnes, et al. J Am Coll Cardiol 2008;52. Table 7. Published ahead of print November 7, 2008, at http://content.onlinejacc.org/cgi/content/full/j.jacc.2008.10.001 31 Surgical Ventricular Septal Defect Closure VSD Closure Operations I IIa IIb III Closure of a VSD is reasonable when net left-to-right shunting is present at a Qp/Qs greater than 1.5 with pulmonary artery pressure less than two thirds of systemic pressure and pulse volume recording (PVR) less than two thirds of systemic vascular resistance. I IIa IIb III Closure of a VSD is reasonable when net left-to-right shunting is present at a Qp/Qs greater than 1.5 in the presence of LV systolic or diastolic failure. I IIa IIb III VSD closure is not recommended in patients with severe irreversible PAH.
32 Atrial Septal Defect Closures I IIa IIb III Closure of an ASD, either percutaneously or surgically, may be considered in the presence of net left-to-right shunting, pulmonary artery pressure less than two thirds systemic levels, PVR less than two thirds systemic vascular resistance, or when responsive to either pulmonary vasodilator therapy or test occlusion of the defect (patients should be treated in conjunction with providers who have expertise in the management of pulmonary hypertensive syndromes). I IIa IIb III Concomitant Maze procedure may be considered for intermittent or chronic atrial tachyarrhythmias in adults with ASDs.
Reliability of Echocardiographic Pulmonary Vascular Resistance to Screen for the New Definition of Precapillary Pulmonary Hypertension in Uncorrected Secundum Atrial Septal Defect
Reliability of Echocardiographic Pulmonary Vascular Resistance to Screen for the New Definition of Precapillary Pulmonary Hypertension in Uncorrected Secundum Atrial Septal Defect
