Cardiac Implantable Electronic Device (CIEDs) had been recommended as an integral part of heart failure management. Despite clear benefits on CIEDs itself, the rate of therapy penetration in Indonesia is still very low. Many contributing factors had been identified, they are lack of physician awareness, lack of referral, and mismatch between national insurance reimbursement and the cost of therapy. We focussed on talking about selective patient selection as one of the most feasible solutions to this problem.

More than two decades after the introduction of cardiac resynchronization therapy (CRT) into clinical practice, respond to highly effective treatments for refractory drug heart failure (HF) approximately one-third of candidates persist to fail. This article will discuss indications for initiating a CRT, the definition of a response to a CRT, steps in response to a CRT, predictors of a CRT response, clinical judgment of patients who do not respond to CRTs, and elimination for possible reversible non-response causes. Here we have reviewed non-response CRTs in many ways. In short, multidisciplinary efforts are needed to overcome them because of the multifactorial causes of non-response (NR). So far, several factors has slowed the progress, such as limitations of NR consensus definitions and technology for therapeutic delivery.

Introduction Congestion is the major problem in Acute Heart Failure (AHF) patients. Despite improving clinical congestion, we should assess and treat the hemodynamic congestion to decrease the progression of the disease and improve outcome of AHF patients. This study assess the ability of congestion index, a simple echocardiography parameter using ePCWP + eRAP to predict short-term clinical outcomes of AHF patients compare with NT-proBNP. Methods This prospective cohort study was conducted at Saiful Anwar General Hospital Malang from January 2108 to July 2019. AHF patients treated according to the 2016 ESC guidelines for AHF. Hemodynamic congestion was defined if congestion index (ePCWP+eRAP) at hospital discharge = 30 mmHg.NT-proBNP level, ePCWP and eRAP were measured at 0-12 hours hospital admisssion and at hospital discharge. Clinical follow-up over a period of 30 days, AHF rehospitalization and mortality due to cardiovascular was registered. Results This was a prospective study of 62 patients hospitalized with AHF. All patients were NYHA functional class IV. AHF mortality and rehospitalization rates in this study were 12.9% and 20.9%, respectively. Patient with congestion index =30 mmHg showed a higher 30 day rehospitalization [10 [66.7%] vs 3 [6.4%]; P =0.000; CI 95% OR 7.53(3.11-18.2)] and cardiovascular mortality [7 [46.7%] vs 1 [2.1%] P=0,000; CI 95% OR 5.90(2.95-11.78)]. NT-proBNP level at hospital discharge (cut off 5853 pg/mL; sensitivity 92%; specificity 91%; AUC 0.945; P = 0.000) was better than congestion index (cut off 30 mmHg; sensitivity 92.9%; specificity 91.7%; AUC 0.914; P = 0.000) in predicting AHF rehospitalization. For predicting mortality, NT-proBNP level at hospital discharge (cut off 8733 pg/mL; sensitivity 87.5%; specificity 88.9%; AUC 0.940; P = 0.000) were better than congestion index (cut off 31 mmHg; sensitivity 87.5%; specificity 81.5%; AUC 0.890; P = 0.000). Conclusion Congestion index could predict AHF rehospitalization and mortality within 30 days in patients with AHF.

Background : Chronotropic incompetence (CI) is defined as the failure of the heart to increase its heart rate along with activity and is an independent predictor of cardiovascular morbidity and mortality. The gold standard for CI is based on a treadmill test. However, up to now, there is no guideline to recommend whether CI could be concluded according to holter monitoring data. Objective : This study aimed to determine CI based on Holter monitoring, specifically using time-domain analysis of heart rate variability (HRV). Methods : This study used descriptive-analytic research with cross-sectional sampling. The population was patients that underwent treadmill and holter monitoring. The treadmill test was used as a gold standard of CI, and compare to holter monitoring using heart rate variability as a parameter. Data analysis used a comparative study (Independent T, Mann-Whitney, Chi-Square) and multivariate analysis logistic regression with a significance of p < 0,05. Results: The subjects of the study were 111 patients with male-dominant (59 men). Standard Deviation N-N interval (SDNN) and Standard Deviation of Average N-N Interval (SDANN) were found lower in the CI group compared to the normal one. Mean SDNN was 113,57 + 51,08 msec in CI group and 117,4 + 39,48 msec in normal group with p = 0.282. Mean SDANN was 94,77 (73,42-118,85) in CI and 104,16 (74,9–139) with p = 0.422. While the Proportion of RR interval with the difference > 50 ms (RR50) and Average of All N-N Intervals (AVNN) found to be higher in CI group, but not statistically significant (p = 0.681; p = 0.061 respectively). Other parameter extracted from holter result, delta HR showed significant correlation with CI (50.5 (43,25-61,5) vs. 56 (50-72) with p = 0.014). Conclusion: Time-domain HRV didn’t had a significant correlation with CI. However, delta HR from holter monitor could be used as a predictor of CI.

Background : Community-based cardiac rehabilitation interventions have been known as an important aspect of secondary prevention. However, no data are available regarding the benefit of this program in Indonesian coronary artery disease (CAD) patients treated with optimal medication. Objectives : To assess the benefit of community-based cardiac rehabilitation on patient adherence to the drugs, quality of life (QoL) and MACE, in stable CAD. Methods : An observational prospective cohort study recruited the Malang community of cardiovascular care (MC3) members as an intervention group and Aisyah Islamic hospital patients in Malang, Indonesia, as a control, for a year follow up. Member of MC3 has regular aerobic exercise, education regarding the disease, the importance of the drugs, and its side effect in addition to standard education given in outpatient clinic setting as the control group members. A validated MMS-8, QOL (SF-36), and SAQ questionnaire were used to assess adherence to the drugs, QoL, and MACE of participants. Results: A total of 73 interventions and 73 control patients were enrolled for the study. Our findings showed that intervention patients were 2.04-fold associated with having a better physical function and 3.85-fold better compliance than control patients. The hospitalization rate also significantly lower in members of the intervention group (MC3). However, no significant difference observed among the two groups. Moreover, in the subgroup analysis, it shows that the intervention group who had participated for 2 years had the highest value of MMS-8 compared to the other groups with p < 0.005. Conclusion: Our study reveals that community based cardiac rehabilitation intervention have better adherence to medication and quality of life than patients control, and also could reduce rehospitalization in stable CAD patients.

Background : Recently, studies have concerned on the use of xanthones for treating patients with cardiovascular diseases. In our country, xanthones were found in Garcinia Mangostana Linn. Objectives : To assess the effect of Garcinia Mangostana Linn Extract (GMLE) to the levels of Circulating Endothelial Cells (CEC) and Endothelial Progenitor Cells (EPC) in patients with high framingham score. Methods : A prospective cohort study was conducted from November 2018 to January 2019. The patients were divided into two groups. The first group was given 2520 mg/day of GMLE for 90 days and the second group was given placebo. In sub group analyses, patients were divided based on previous medication, including statin, statin and angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB), statin and oral antidiabetic drugs (OAD), and statin and ACEI or ARB and OAD. The outcome measures were CEC and EPC levels, measured at baseline and after 90 days of treatment. We used multiple linear regression to analyze the correlation and effect estimates. Results: A total of 72 patients was included in our study. All of the patients baseline characteristics were distributed homogeneously (p>0.05). Our findings confirmed that GMLE administration was associated with decreased CEC level compared to placebo. On other hands, increased EPC level compared to placebo was observed after GMLE administration. In sub-group analyses, our study found that the combination of GMLE with statin and ACEI or ARB and the combination of GMLE with statin and ACEI or ARB and OAD were associated with decreased level of CEC compared to placebo, with the odd ratios were 0.12 and 0.18, respectively. Conversely, increased level of EPC was observed in subjects receiving the combination of GMLE with statin and ACEI or ARB and the combination of GMLE with statin. Conclusion: Administration of GMLE as adjuvant therapy is associated with the improvement of CEC and EPC levels in patients with high framingham scores.

The diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVC) remains challenging. Detailed echocardiography is a sensitive tool for identifying structural and functional when ARVC is suspected. A thorough assessment of cardiac magnetic resonance imaging is required to further establish the diagnosis. This case illustration aimed to broaden the awareness of right ventricular cardiomyopathy among physicians, establishing the appropriate diagnostic approaches, and sensible use of implantable cardioverter-defibrillators may help to prevent unnecessary deaths.

Introduction: Device entrapment during PCI is an uncommon complication with incidence of less than 1%. Percutaneous retrieval should be favored as the treatment of choice for this condition. Case Illustration: A 61-year-old patient came for an elective percutaneous coronary intervention (PCI) procedure. She suffered from chest pain while doing moderate activities for 1 month. Angiography showed a diffuse lesion with maximum stenosis 90% in the proximal LAD, stenosis 75% in the proximal of Left Circumflex Artery (LCx), and diffuse lesions in the proximal and mid of the Right Coronary Artery (RCA). We decided to perform PCI in the LAD. A transfemoral coronary intervention was performed using a Judkins Left 3.5 (7F) guiding catheter to engage the LAD. A Guidewire ( Run-through NS Floppy) was advanced to the distal LAD. Balloon angioplasty was performed with a 2.75 x 15 mm Fluydo balloon in the proximal LAD at 16 bars, but the balloon was entrapped and while withdrawing the balloon, it accidentally ruptured in the LAD artery with the remaining segment inside the guiding catheter. A second Run-through NS Floppy Guidewire was inserted across the ruptured balloon and a 2.5 x 20 mm Fluydo Balloon was passed on the second wire and was inflated at 16 atm pressure, inside the guiding catheter, trapping the ruptured balloon. The ruptured balloon was successfully removed, by withdrawing the whole system, including the guiding catheter and the wire. Finally, we re-engaged the LAD with the same guiding catheter, passed the wire, and post dilated the stent on the LAD to achieve a good result. Conclusion: Percutaneous retrieval using trapping technique could represent a safe and effective technique for ruptured and entrapment of a balloon-catheter in a coronary artery.

Introduction: Device entrapment during PCI is an uncommon complication with incidence of less than 1%. Percutaneous retrieval should be favored as the treatment of choice for this condition. Case Illustration: A 61-year-old patient came for an elective percutaneous coronary intervention (PCI) procedure. She suffered from chest pain while doing moderate activities for 1 month. Angiography showed a diffuse lesion with maximum stenosis 90% in the proximal LAD, stenosis 75% in the proximal of Left Circumflex Artery (LCx), and diffuse lesions in the proximal and mid of the Right Coronary Artery (RCA). We decided to perform PCI in the LAD. A transfemoral coronary intervention was performed using a Judkins Left 3.5 (7F) guiding catheter to engage the LAD. A Guidewire ( Run-through NS Floppy) was advanced to the distal LAD. Balloon angioplasty was performed with a 2.75 x 15 mm Fluydo balloon in the proximal LAD at 16 bars, but the balloon was entrapped and while withdrawing the balloon, it accidentally ruptured in the LAD artery with the remaining segment inside the guiding catheter. A second Run-through NS Floppy Guidewire was inserted across the ruptured balloon and a 2.5 x 20 mm Fluydo Balloon was passed on the second wire and was inflated at 16 atm pressure, inside the guiding catheter, trapping the ruptured balloon. The ruptured balloon was successfully removed, by withdrawing the whole system, including the guiding catheter and the wire. Finally, we re-engaged the LAD with the same guiding catheter, passed the wire, and post dilated the stent on the LAD to achieve a good result. Conclusion: Percutaneous retrieval using trapping technique could represent a safe and effective technique for ruptured and entrapment of a balloon-catheter in a coronary artery.