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"Sinkap vasovagal merupakan masalah kesehatan yang sering didapatkan pada populasi dewasa muda. Tilt table teat (ITT) merupakan satu-satunya metoda diagnosis sinkop vasovagal. Isoprenalin yang merupakan obal baku yang digunakan pada ITT saat ini sulit sekali didapatkan di Indonesia, oleh karena itu kami melakukan studi hemodinamik dari isosorbide dinitrate (ISDN) yang merupakan alternative bagi isoprenaline karena memiliki cara kerja yang serupa melalui penimbunan darah di vena. Sebanyak 17 orang dewasa muda yang sehat (rerata umur 28,6 ±4.7 tahun, dan pria 14 orang) menjalani TIT dengan memakai ISDN 400 ug disemprotkan sublingual sebagai obat provokatif. Perubahan hemodinamik. yang ferjadi selama fase dasar dan provokatif diuknr. Tidak satupun dari 17 subyek yang mengalami sinkop. Sekalipun terdapat penuriman bermakna pada tekanan darah sistolik, diastolik dan lekanan rerata arteri serta peningkatan bermakana laju jantung, akan tetapi perubahan-perubahan itu tidak cukup bermakna nntitk menyebabkan sinkop. Kesimpulannya pemberian ISDN semprot sublingual pada populasi dewasa muda sehat yang menjalani TTT menyebabkan perubahan hemodinamik yang bermakna tetapi tidak menimbulkan sinkop. Hasil penelitian ini dapat menjadi dasar bagi penggunaan ISDN sebagai obat provokatif pada TIT. (Med J Indones 2006; 15:24-9).

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Vasovagal syncope is a common health problem in young adult population. Tilt table test (TTT) is the only method to diagnose vasovagal syncope. Since isoprenaline as a standard provocative drug of TTT is hard to be found in Indonesia, we xtndv the haemodynamic effect of isosorbide dinitrate (ISDN) which has similar venous pooling effect with isoprenaline. Seventeen young healthy adult subjects (age of 28.6 ±4.7 year old. and 14 males) underwent ITT using 400 fig ISDN spray sublingually as a provocative drug. The haemodynamic changes were observed during baseline and provocative phase. None of 17 subjects experienced of syncope. Although, the systolic, diastolic, and mean arterial blood pressure were significantly decreased and the heart rate significantly increased after ISDN administration, but the changes were not sufficient to cause sync-opal event. In conclusion sublingual ISDN spray during TTT of young healthy adult subject changes haemodynamic measures but did not cause syncope. These results give a reasonable basic for ISDN usage as provocative drug of TTT. (Med J Indones 2006; 15:24-9)"

"Ablasi A V junction terbukti efektif pada pasien atrial flbrilasi (AF) yang refrakter dengan isolasi vena pulmonalis inaupun antiaritmia. Akan tetapi pada hampir 15% kasus ablasi AV junction dengan teknik konvensional (sisi-kanan) gagal. Penelitian ini berinjuan mempelajari karakterislik potensial berkas His pada ablasi AV junction secara konvensional inaupun dengan teknik sisi-kiri. Dua puluh pasien AF yang simtomatik dan refrakter terhadap antiarimia (rerata umur 60,539,28 tahun, 11 wanita) dilakukan ablasi AV junction dengan teknik konvensional. Bila 10 kali aplikasi energi frekuensi-radio tidak dapat menyebabkan blok A V total, maka ablasi dilakukan melalui sisi-kiri. Amplitud berkas His yang terekam pada tempat ablasi dianalisa. Seluruh pasien berhasil diablasi, 17 dengan cam konvensional dan 3 pasien degan teknik sisi-kiri setelah teknik konvensional gagal. Amplitud berkas His pada sisi-kiri lebih besar daripada sisi-kanan yang berkesesuaian (16,0 ±4,99 mm vs. 6,9 ±4,02 mm, p = 0,001, 95% IK -14,0 to -4,3). Dengan nilai titikpotong amplitude berkas His sisi-kanan > 4,87 mm didapatkan sensitifitas 8!.3% dan spesiftsitas 53,8% untuk keberhasilan ablasi pada sisi yang bersangkutan. Teknik sisi-kiri pada ablasi AV junction efektif bila teknik konvensional gagal. Pada pasien dengan amplitud berkas His sisi-kanan yang rendah (< 4, 87 mm) dianjurkan untuk ablasi dengan teknik sisi-kiri untuk menghindari pemberian energi frekuensi-radio yang tidak perlu. (MedJ Indones 2006; 15:109-14)

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AV junction ablation has been proven effective to treat symptomatic atrial fibrillation refractory to antiarrhythmias or fail of pulmonary vein isolation. However, about 15% of conventional right-sided approach AV junction ablation failed to produce complete heart block. This study aimed to characterize His bundle potential at ablation site during conventional or left-sided approach of AV junction ablation. Twenty symptomatic AF patient (age of 60.5 ±9.28 and 11 are females) underwent conventional AV junction ablation. If 10 applications of radiofrequency energy are failed, then the ablation was performed by left-sided approach. Seventeen patients are successfully ablated by conventional approach. In 3 patients, conventional was failed but successfully ablated bv left-sided approach. The His bundle amplitude at ablation site was significantly larger in left-sided than correspondence right-sided (16.0 ±4.99 mm vs. 6.9 ±4.02 mm respectively, p = 0.001, 95% Cl -14.0 to -4.3). ROC analysis of His bundle potential amplitude recorded from right-sided revealed that cut off point of > 4.87 mm given the sensitivity of 81.3% and specificity of 53.8% for successful right-sided approach of AV junction ablation. In case of failed conventional approach, the left-sided approach is effective for AV junction ablation. An early switch to the left-sided approach may avoid multiple RF applications in patients with a low amplitude His-bundle potential (< 4.87 mm). (MedJIndones 2006; 15:109-14)"

"Tujuan penelitian ini untuk melihat karakteristik elektrofisiologi dan hasil ablasi frekuensi radio (AFR) pada flutter atrium (FLA) yang belum tersedia hingga saat ini di Indonesia. Tiga buah kateter elektroda multipolar dimasukkan perkutan ke dalam jantung lalu ditempatkan di sinus koronarius (SK), berkas His dan mengitari anulus trikuspid. Kateter ablasi 8 mm digunakan untuk AFR linier cavotrikuspid isthmus (CTI) pada FLA tipikal dan kebalikan tipikal. Blok bidireksional ditentukan atas dasar pemanjangan waktu konduksi dinding lateral bawah ke ostium SK dan sebaliknya lebih dari 90 mdet, dan/atau dengan cara pemacuan diferensial. Terdapat 27 subyek dengan 30 FLA terdokumentasi yang terdiri dari 19 tipikal, 5 tipikal terbalik dan 6 atipikal. Hanya 9 pasien yang tidak mempunyai penyakit jantung struktural. Rerata panjang siklus takikardia (PST) adalah 261,79 ± 42,84, 226,5 ± 41,23, dan 195,4 ± 9,19 mdet masing-masing untuk FLA tipikal, kebalikan tipikal dan atipikal (p = 0,016). Konduksi CTI menempati 60% dari PST atau rerata 153,0 ± 67,37 mdet. Aktivasi SK terbagi menjadi 3 jenis yaitu proksimal ke distal, distal ke proksimal dan fusi. AFR pada FLA tipikal dan tipikal terbalik sukses sebanyak 96 % dengan tingkat kekambuhan 4,5 % pada rerata masa pengamatan 13 ± 8 bulan. Pada populasi penelitian ini jenis FLA terbanyak adalah FLA tipikal. Kebanyakan subyek menderita penyakit jantung struktural. AFR sangat efektif menyembuhkan FLA tipikal dan kebalikan tipikal. (Med J Indones 2007; 16:151-8)

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This study aimed to elaborate the electrophysiology characteristics and radiofrequency ablation (RFA) results of atrial flutter (AFL) which has not been established in Indonesia. Three multipolar catheters were inserted percutaneously and positioned into coronary sinus (CS), His bundle area and around tricuspid annulus. Eight mm ablation catheter was used to make linear ablation at CTI of typical and reverse typical AFL. Bidirectional block was confirmed by conduction time prolongation of more than 90 msec from low lateral to CS ostium and vice versa, and/or by means of differential pacing. Thirty AFL from 27 patients comprised of 19 typical AFL, 5 reverse typical AFL and 6 atypical AFL enrolled the study. Mean tachycardia cycle length (TCL) were 261.8 ± 42.84, 226.5 ± 41.23, and 195.4 ± 9.19 msec, respectively (p = 0.016). CTI conduction time occupied up to 60% of TCL with mean conduction time of 153.0 ± 67.37 msec. CS activation distributed to three categories which comprised of proximal to distal, distal to proximal and fusion activation. Only nine of 27 patients had no structural heart disease. RFA of symptomatic typical and reverse typical AFL demonstrated 96% success and 4.5 % recurrence rate during 13 ± 8 months follow up. Typical AFL is the predominant type of AFL in our population. The majority of AFL cases suffered from structural heart disease. RFA was highly effective to cure typical and reverse typical AFL. (Med J Indones 2007; 16:151-8)"

"Latarbelakang: Kondisi atrium kanan yang terdiri dari berbagai struktur yang kompleksmenyebabkan timbulnya variasi sifat elektroiisiologis yang memberikan kemudahantimbulnya aritmia. Aritmia atrium kanan merupakan jenis aritmia yang panting karenaprevalensi yang tinggi dan konsekunsi klinis yang berbahaya. Akan tetapi epidemiologiaritmia atrium kanan beserta karakteristik eleklrofisiologinya di Indonesia belum pemahdilaporkan. Krista terminalis yang merupakan garis hambatan konduksi posterior padakepak atrium (KA), dan sumber trbanyak takikardia atrium (TA), nierupakan strukturunik dengan karakteristik elektrofisiologis yang belum diungkap secara luas. Di lainpihak, berkembangnya pemahaman mekanisme KA, menimbulkan masalah diagnosiskarena adanya kemiripan morfologi gelombang kepak antar berbagai jenis KA yangmekanismenya berlainan, dan adanya variasi morfologi gelombang kepak pada KA yangsejenis. Oleh karena itu akan dilakukan rangkaian penelitian untuk menjawab beberapamasalah mekanisme dan diagnosis aritmia atrium kanan.Metode: Dilakukan studi elektrofisiologi baik secara konvensional maupun denganpanduan sistem pemetaan non-kontak Ensite pada subyek dengan KA dan TA. Pada KAyang melibatkan ismus kavotrikuspid (KA-IKT) dilakukan entrainment untuk konfirmasidiagnosis. Pada ULR, lokasi dan lebar taut konduksi ditentukan atas dasar perubahankonvergensi propagasi impuls setelah melalui krista temiinalis. Pola aktivasi sumber TAdianalisis meinalcai propagasi impuls dan elektrogram unipolar virtual. Nilai 30% darivoltase negatif puncak dipakai sebagai pembeda daerah parut dari jadngan sehat. Analisisrnorfologi gelombang kepak pada EKG 12-sadapan dilakukan oleh dua orang ahli elektrofisiologi yang bebas. Suatu algoritme diagnosis KA yang sederhana akan dibuatatas dasar EKG permukaan. Ablasi frekuensi radio (AFR) dilakukan pada sumber atausirkuit reentry aritmia atrium kanan dengan memakai teknik yang sudah baku.Hasil: KA tipikal merupakan kasus KA terbanyak di Pusat Jantung Nasional HarapanKita, dan Iebih dari 60% subyek KA mempunyai penyakit jantung struktural. Rcratapanjang siklus takikardia (PST) ialah 261,8 ± 42,84, 226,5 ± 41,23, dan 195,4 ± 9,19mdet masing-masing untuk KA tipikal, tipikal terbalik dan atipikal (p = 0,016).Morfologi EKG pada KA tipikal terdiri dari 3 tipe gelombang kepak yaitu F-/f+ disadapan inferior dan P+ atau F+/f- di V, (tipe 1); F- di sadapan inferior dan P+ di V1 (tipe2); dan f-/F+ di sadapan inferior dan F+ di V1 (tipe 3). Pada KA tipikal terbalikdidapatkan 2 tipe rnorfologi yaitu P+ di sadapan inferior dan F- di V1 (tipe 1); dan P+ disadapan inferior dan isoeiektrik di V; (tipe 2). Akan tetapi tidak didapatkan perbedaanbermakna aktivasi atrium kanan pada variasi morfoiogi KA-IKT. Tidak didapatkankonduksi transversal Krista terminalis pada 90% KA-IKT, sebaliknya didapatkankonduksi transversal pada seluruh ULR. Pada saat ULR, KKL lebih cepat dari pada KK-r(1,228 ± 0,43 vs. 0,73 ± 0,30 m/det, p < 0,001). Rasio KK;/KKT ialah 1,95 ± 0,77 yangberbanding terbalik dengan lebar taut krista terminalis (1,57 ± 6,8 mm) (p < 0,00l).Algoritme diagnosis baru atas dasar morfologi dan amplimdo gelombang kepak disadapan I mempunyai akurasi 90 hingga 97%, sensitivitas S2 hingga 100% danspesifisitas 95% dalam membedakan KA tipikal terbalik dari ULR. TA fokal mayoritasberasal dari krista terminalis dan memperlihatkan adanya jalur konduksi istimewa.Dengan teknik konvensional, keberhasilan AFR pada IKT, taut krista terminalis padaULR dan TA fokal berturut-turut mencapai 96 % , 90% dan 91,7%.Kesimpulan: KA tipikal merupakan KA terbanyak pada populasi penelitian ini, denganmayoritas menderita penyakit janlung struktural. Tidak terdapat perbedaan aktivasiatrium kanan pada variasi morfologi gelombang kepak pada KA-IKT. Mayoritas tautkonduksi krista terminalis bersifat fungsional dan selalu didapatkan pada saat ULR. Suatualgoritme diagnosis baru, akurat untuk membedakan KA tipikal terbalik dari ULR.Impuls TA fokal menyebar ke seluruh atrium setelah melalui jalur konduksi istimewa.AFR efektif menyembuhkan KA-IKT, KA non-IKT dan TA.;Background: Complex structures with variable electrophysiological properties in rightatrium facilitate arrhythmias occurrence. The right atrial arrhythmia is one of clinicallyimportant anrhythmias as it has high prevalence and significant clinical consequences.However, clinical and electrophysiological characteristics of iight atrial arrhythrnias havenot been elaborated in Indonesia. The crista terrninalis has been shown as a posteriorobstacle line during atrial flutter (AFL), and as a major source of focal atrial tachycardia(AT). However, as a unique structure of right atrium, little has been known about Cristaterrninalis electrophysiological properties as a substrate of right atrial arrhythmias. Abetter understanding of AFL mechanisms yielded a diagnostic problem, since the flutterwave of different AFL has similar rnorphologies and the variable morphologies of thesame AFL. Therefore, we conduct several interconnected study to overcome thosediagnostic and mechanisms issues in right atrial arrhythmias.Methods: Atrial flutter and AT subjects underwent electrophysiology study usingconventional and/or noncontact mapping Ensite system. Entrainment pacing wasperformed to confirm the diagnosis of cavotricuspid isthmus (CTI) dependent AFL. InULR subjects, location and width of gap conduction was determined by the change ofconvergent wavefront as it is passed the crista terminalis. Careful wavefront and virtualunipolar electrogram analysis was performed during focal AT. A value of 30% of peaknegative voltage was used to differentiate low voltage zone and normal tissue. Twoindependent electrophysiologist analyzed the morphology and polarity of flutter wave in standard 12-lead ECG. Radiofrequency ablation was peformed at the origin and/orreentry circuit of right atrial arrhythmias using a standard technique.Results: Typical APL is predominant AFL cases in National Cardiovascular CenterHarapan Kita. More than 60% of all AFL cases suffered from structural heart disease.Mean tachycardia cycle length of typical, reverse typical and atypical AFLS were 261.8 ±42.84, 226.5 ± 41.23, and 195.4 ± 9.19 msec, respectively (p = 0.0l6). Typical AFLshowed 3 types flutter wave morphologies comprised of F-/f+ at inferior and P+ or F+/f-at V1 (type 1); F- at inferior and F+ at V, (type 2); and f-/F+ at inferior and P+ at V1 (type3). Reverse typical AFL showed 2 types flutter wave morphologies comprised of F+ atinferior and F- at V, (type 1); and P+ at inferior and isoelectric at V1 (type 2). However,there were no significant different of right atrial wavefront activations between thoseAFL morphologies types. Ninety percent of CTI dependent AFL demonstrated notransversal conduction at crista terminalis, on the contrary all ULR demonstratedtransversal conduction. During ULR, CVL was faster than CVT (1.23 ± 0.43 vs. 0.73 ±0.30 m/sec, p < 0.00l). The ratio of CVL/CVt (1.95 :t 0.77) had inverse correlation withthe gap width (1.57 ± 6.8 mm) (p < 0.001). A new diagnostic algorithm based onmorphology and amplitude of flutter wave at lead I had accuracy of 90 to 97%, sensitivityof 82 to 100% and specificity of 95% to differentiate reverse typical AFL from ULR. Themajority of focal AT originated hom crista terminalis and showed a preferentialwavefront conduction before spreading to the whole atrium. The success rate ofradiofrequency ablation of CTI dependent AFL, crista terminalis gap of ULR and focalAT were 96%, 90% and 91.7% respectively.Conclusion: Typical AFL is the predominant AFL cases and majority of AFL hadstructural heart disease. There was no right atrial activation different among flutter wavemorphology types of CTI dependent AFL. The majority of crista tenninalis gap wasfunctional and always exists during ULR. A new diagnostic ECG algorithm has beendemonstrated to have excellent accuracy to differentiate typical AFL from ULR. Thewavefront of focal AT spreads out to the whole atrium after traveled in preferentialconduction. RPA was effective to eliminate CTI and non-CTI dependent AFL, and focalAT.

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Background: Complex structures with variable electrophysiological properties in rightatrium facilitate arrhythmias occurrence. The right atrial arrhythmia is one of clinicallyimportant anrhythmias as it has high prevalence and significant clinical consequences.However, clinical and electrophysiological characteristics of iight atrial arrhythrnias havenot been elaborated in Indonesia. The crista terrninalis has been shown as a posteriorobstacle line during atrial flutter (AFL), and as a major source of focal atrial tachycardia(AT). However, as a unique structure of right atrium, little has been known about Cristaterrninalis electrophysiological properties as a substrate of right atrial arrhythmias. Abetter understanding of AFL mechanisms yielded a diagnostic problem, since the flutterwave of different AFL has similar rnorphologies and the variable morphologies of thesame AFL. Therefore, we conduct several interconnected study to overcome thosediagnostic and mechanisms issues in right atrial arrhythmias.Methods: Atrial flutter and AT subjects underwent electrophysiology study usingconventional and/or noncontact mapping Ensite system. Entrainment pacing wasperformed to confirm the diagnosis of cavotricuspid isthmus (CTI) dependent AFL. InULR subjects, location and width of gap conduction was determined by the change ofconvergent wavefront as it is passed the crista terminalis. Careful wavefront and virtualunipolar electrogram analysis was performed during focal AT. A value of 30% of peaknegative voltage was used to differentiate low voltage zone and normal tissue. Twoindependent electrophysiologist analyzed the morphology and polarity of flutter wave in standard 12-lead ECG. Radiofrequency ablation was peformed at the origin and/orreentry circuit of right atrial arrhythmias using a standard technique.Results: Typical APL is predominant AFL cases in National Cardiovascular CenterHarapan Kita. More than 60% of all AFL cases suffered from structural heart disease.Mean tachycardia cycle length of typical, reverse typical and atypical AFLS were 261.8 ±42.84, 226.5 ± 41.23, and 195.4 ± 9.19 msec, respectively (p = 0.0l6). Typical AFLshowed 3 types flutter wave morphologies comprised of F-/f+ at inferior and P+ or F+/f-at V1 (type 1); F- at inferior and F+ at V, (type 2); and f-/F+ at inferior and P+ at V1 (type3). Reverse typical AFL showed 2 types flutter wave morphologies comprised of F+ atinferior and F- at V, (type 1); and P+ at inferior and isoelectric at V1 (type 2). However,there were no significant different of right atrial wavefront activations between thoseAFL morphologies types. Ninety percent of CTI dependent AFL demonstrated notransversal conduction at crista terminalis, on the contrary all ULR demonstratedtransversal conduction. During ULR, CVL was faster than CVT (1.23 ± 0.43 vs. 0.73 ±0.30 m/sec, p < 0.00l). The ratio of CVL/CVt (1.95 :t 0.77) had inverse correlation withthe gap width (1.57 ± 6.8 mm) (p < 0.001). A new diagnostic algorithm based onmorphology and amplitude of flutter wave at lead I had accuracy of 90 to 97%, sensitivityof 82 to 100% and specificity of 95% to differentiate reverse typical AFL from ULR. Themajority of focal AT originated hom crista terminalis and showed a preferentialwavefront conduction before spreading to the whole atrium. The success rate ofradiofrequency ablation of CTI dependent AFL, crista terminalis gap of ULR and focalAT were 96%, 90% and 91.7% respectively.Conclusion: Typical AFL is the predominant AFL cases and majority of AFL hadstructural heart disease. There was no right atrial activation different among flutter wavemorphology types of CTI dependent AFL. The majority of crista tenninalis gap wasfunctional and always exists during ULR. A new diagnostic ECG algorithm has beendemonstrated to have excellent accuracy to differentiate typical AFL from ULR. Thewavefront of focal AT spreads out to the whole atrium after traveled in preferentialconduction. RPA was effective to eliminate CTI and non-CTI dependent AFL, and focalAT."