Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

Background Percutaneous Transvenous Mitral Commissurotomy (PTMC) has become the treatment of choice for patients with mitral stenosis. PTMC guided by three-dimensional Transesophageal Echocardiography (3D-TEE) promise of greater safety and efficacy. Case Summary We report a 29-year-old woman who came to our outpatient clinic with shortness of breath as a chief complaint for the past three months. ECG depicted sinus rhythm. Transthoracic Echocardiography (TTE) and 3D-TEE showed severe mitral stenosis with MVA planimetry: 0.8 cm2, MV mean PG 12 mmHg, MV PHT 403 ms, Wilkins score was 4 and no thrombus was found. Therefore, we decided to do PTMC. We successfully done the antegrade transseptal puncture by fluoroscopy guided by two-dimensional (2D) TEE . Then, we used Inoue-balloon catheter No. 24 to dilate the mitral valve. Afterthat, we did 3D-TEE evaluation of the mitral valve area and it showed a significant improvement, with MVA 3D planimetry: 2.0 cm2 and MV mean PG: 4 mmHg and we found moderate mitral regurgitation (MR VC 0.4 cm, MR PISA: 0.3 cm), so we decided to end the procedure. Discussion In this case, the PTMC procedure was carried with 2D and 3D-TEE guiding, where process run more easily because interventionist can ensure the targeted site during transeptal puncture, navigation to the mitral valve and post inflation inspection. 3D-TEE guiding can also directly ensure the success of PTMC in real time by evaluating the MVA planimetry (pre and post PTMC) and the mitral regurgitation.

Background Hypertrophic obstructive cardiomyopathy (obstructive HCM) is an autosomal dominant congenital disease characterized by obstruction of the left ventricular outflow tract with asymmetric septal hypertrophy. Obstructive HCM is predispose to the appearance of malignant ventricular arrhythmias, leading to syncope or sudden death. Case Description A 25-years-old male patient came to the hospital with chief complaint intolerance activity and previous syncope, without history of sudden cardiac death in his family member. ECG showed sinus rhytm with left axis deviation and left ventricular hypertrophy. Chest x ray showed cardiomegaly. The echocardiography showed asymmetric septal hypertrophy (septal/posterior wall thickness ratio 1.31), left atrium dilatation (LAVi 94.2 mL/m2), SAM and mild mitral regurgitation, mild aortic regurgitation, hyperdynamic ejection fraction (79%) with lower longitudinal strain values in basal and mid ventricular septal segment, grade I diastolic dysfunction, resting LVOT gradient 19.53 mmHg , provoked LVOT gradient 47.31 mmHg. Discussion Non-invasive treatment was given due to LVOT gradient below 50 mmHg. The patient prescribed diltiazem 100mg once daily and recommended clinical evaluation follow-up every year or any worsening of symptoms. The other family member suggested for familial screening echocardiography.

Background Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction that increases patient’s risk of developing venous or arterial thromboembolism, which maybe life-threatening. The frequency varies from 0.5% to 5%, depending on population studies. This condition will worsen especially in patients with deep vein thrombosis. Case A 52 years old woman was reported swelling and decreased saturation of the lower extremities, with a history of Heparin therapy for 5 days before being referred to Haji Adam Malik Hospital Medan. Platelet count on admission day was 225.000/µl but dropped into 64.000/µl in the 7th post heparin treatment day. Doppler examination showed multiple thrombosis in deep femoral vein and and sign of stenosis peripheral artery. Echocardiography showed intracardiac thrombus without sign of acute pulmonary embolism. Two days after discontinuation of heparin, the platelet still tend to be low but in the next days, its count increases to within normal range. Due to the high risk of embolism, it was decided to place a vena cava filter prior to surgery for thrombus evacuation. Discussion This case demonstrates several interesting aspects of HIT, including thrombotic complication, limitation tools to support diagnosis of HIT, how to prepare this patient into surgical management, and the last is placing a IVCF prior to surgical thrombus evacuation and thrombectomy to reduce the risk of thromboemboli before surgical treatment. This is the first time procedure in Medan for placing a vena cava filter in a DVT patients who have contraindication to heparin administration.

Background Hypertrophic obstructive cardiomyopathy (obstructive HCM) is an autosomal dominant congenital disease characterized by obstruction of the left ventricular outflow tract with asymmetric septal hypertrophy. Obstructive HCM is predispose to the appearance of malignant ventricular arrhythmias, leading to syncope or sudden death. Case Description A 25-years-old male patient came to the hospital with chief complaint intolerance activity and previous syncope, without history of sudden cardiac death in his family member. ECG showed sinus rhytm with left axis deviation and left ventricular hypertrophy. Chest x ray showed cardiomegaly. The echocardiography showed asymmetric septal hypertrophy (septal/posterior wall thickness ratio 1.31), left atrium dilatation (LAVi 94.2 mL/m2), SAM and mild mitral regurgitation, mild aortic regurgitation, hyperdynamic ejection fraction (79%) with lower longitudinal strain values in basal and mid ventricular septal segment, grade I diastolic dysfunction, resting LVOT gradient 19.53 mmHg , provoked LVOT gradient 47.31 mmHg. Discussion Non-invasive treatment was given due to LVOT gradient below 50 mmHg. The patient prescribed diltiazem 100mg once daily and recommended clinical evaluation follow-up every year or any worsening of symptoms. The other family member suggested for familial screening echocardiography.