A 50 year old man complain from fatigue, short of breath, left chest pain when

SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Etiology of Heart Failure 2. Pathophysiology of Heart Failure 3. Clinical and diagnostic approach of Heart Failure 4. Pharmacologic treatment of Heart Failure 5. Rehabilitation and prognosis of Heart Failure SCENARIO : CASE: A 28-year old female, came to Emergency Room due to shortness of breath since 1 week PTA, and getting worse since 1 day PTA. The shortness of breath was aggravated by supine position and alleviated by sitting position. She had history of taking Benzathine Penicillin intramuscular every month for 2 years due to Rheumatic Heart Disease. The blood pressure at presentation was 10070 mmHg, pulse rate 130 beats per minute, irregular. The physical examination revealed irregular heartbeat, diastolic rumbling murmur at apex, rales on both lung fields. The ECG revealed atrial fibrillation 130 bpm with Right axis deviation and right ventricular hyperthropy. LEARNING TASK : 1. What is the most likely diagnosis of the patient? 2. What is the treatment of choice for this patient? 3. What is the parameters that you should monitor for evaluating the response to therapy in this patient? SELF ASSESSMENT: 1. Please describe the Framingham score of heart failure 2. What are the treatment of chronic heart failure? 3. In heart failure, the heart usually increase doe to hypertrophy and dilatation. Explain about morphology of concentric and eccentric hypertrophy 4. Please describe the classification of primary cardiomyopathy

5. A 50 year old man complain from fatigue, short of breath, left chest pain when

walking. This patient is heavy smoker, obesity, and suffering from DM since 10 years ago. The patient is diagnosed myocard infarct MI Check whether the following statement is true or false: 1. The above patient is high risk for exercise therapy 2. Exercise program is starter is after the chest pain is lost or after 2-3 days 3. Rehabilitation has tha aim to recover self confidence, prevent long immobilitation complication and correct risk factor 4. Exercise can also lost weight and reduce smoking habit 5. After discharge the patient may not do sexual intercourse 6. At thorax surgery case exercise is better to be given after operation MODULE 22 Prof dr. I Gusti Made Aman, SpFK Udayana University Faculty of Medicine, DME 62 Day 22 dr. I G Md Gd Surya Candra Trapika, MSc AIMS: 1. Describe the anti hypertensive drugs 2. Describe the heart failure drugs LEARNING OUTCOME: 1. Can describe the anti hypertensive drugs 2. Can describe the heart failure drugs CURRICULUM CONTENS: 1. Principles and classification of anti hypertensive drugs 2. Important pharmacokinetic properties of anti hypertensive drugs. 3. Mechanism of actions of anti anti hypertensive drugs. 4. Important adverse effects of anti hypertensive drugs 5. Principles and classification of heart failure drugs 6. Important pharmacokinetic properties of heart failure drugs. 7. Mechanism of actions of heart failure drugs. 8. Important adverse effects of heart failure drugs ABSTRACT I : ANTI HYPERTENSIVE DRUGS Hypertension is important because elevated blood pressure BP confers a greater risk of stroke, heart failure, coronary artery disease including angina, myocard infarction, and sudden death, renal disease and peripheral vascular disease. There is a continuous, direct relationship between elevation in blood pressure and increases the risk. JNC 7, 2003 classification of blood pressure in adults is as follows: normal, prehypertension, stage I hypertension and stage 2 hypertension. In general, the higher the blood pressure and the greater the number of risk factors, indicate higher urgency and stringency in treating hypertension. Lowering blood pressure is just one way to prevent complications; attention must also be paid to the presence and reversal of other cardiovascular risk factors such as cigarette smoking, hyperlipidemia and especially in diabetes mellitus. Drugs used in lowering blood pressure will decrease peripheral vascular resistance orand decrease cardiac output. These can be due to either directly decrease arteriolar smooth muscle tone which decrease peripheral resistance, decrease myocardial contractility, heart rate, venous tone, blood volume which decrease cardiac output or indirectly through inhibition of sympathetic nervous system activity or inhibition of renin- angiotensin-aldosteron system. They can be used alone or combination to return the blood pressure to target levels with minimal side effects. ABSTRACT II: Heart failure occurs when the heart is unable to pump blood at a rate sufficient to meet the metabolic requirements of the tissues. Heart failure is frequently, but not always, caused by a defect in myocardial contraction that may result from a primary abnormality in heart muscle, as occurs in the cardiomyopathies or in viral myocarditis. Heart failure also result from coronary atherosclerosis, which interferes with cardiac contraction by causing myocardial infarction. Heart failure may also occur in congenital, valvular and Udayana University Faculty of Medicine, DME 63 hypertensive heart disease in which myocardium is damaged by the long standing hemodynamic overload. Drugs used in heart failure include diuretics, vasodilators, nitrate, angiotensin antagonist, beta blockers and positive inotropes. Positive inotropes increase the myocardial contractility. They improves the symptoms of heart failure but at the cost of increasing mortality. They induce arrhythmias, increase myocardial oxygen consumption and reduced myocardial perfusion reduction blood flow. They are several classes of positive inotropes such as beta1 agonis e.g. dopamine, dobutamine, phosphodiesterase inhibitors eg amrinone, milrinone, and digitalis e.g. digoxin. Beta 1 agonists and phosphodiesterase inhibitors are not used in chronic heart failure. Standard References: 1. Trevor AJ, Katzung BG, Masters SB: Katzung Trevor’s Pharmacology, 7 th ed. New York, McGraw-HillLange., 2005. p 66-93, 95-104 and p. 114-123. SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Principles of anti hypertensive therapy. 2. Classification of anti hypertensive drugs 3. Important pharmacokinetic properties of anti hypertensive drugs. 4. Mechanism of actions of anti anti hypertensive drugs. 5. Important adverse effects of anti hypertensive drugs 6. Principles of heart failure therapy. 7. Classification of heart failure drugs 8. Important pharmacokinetic properties of heart failure drugs. 9. Mechanism of actions of heart failure drugs. 10. Important adverse effects of heart failure drugs. CASE 1: A 60-year-old man was brought to your private practice, and said that he was suffering from headache since 2 days before. He had gone to many doctors. He brought his ECG, urine and blood examination results which were appeared normal. He took with him antihypertensive drugs captopril and hydrochlorthiazide, but they were not taken for the last 6 days because he had no headache. Aside from his BP 17095, results of physical examination appeared normal. LEARNING TASK I: 1. Compare the mechanism of action of antihypertensive drugs. 2. Describe the compensatory responses, if any, to each types of antihypertensive drugs 3. List the major sites of action of sympathoplegic drugs and give examples of drugs that act on each site 4. List the 4 mechanism of action of vasodilator drugs and describe their effects 5. Describe the difference between 2 types of angiotensin antagonists 6. List the major side effects of the prototype antihypertensive drugs 7. Compare the indication and contraindication of antihypertensive drugs 8. Explain the interaction between angiotensin antagonist with potassium sparing diuretics CASE 2 : A 45-year-old woman was admitted to the hospital with shortness of breath when he walked about 2 meters, for about 6 months on and off , but became worst since 2 days Udayana University Faculty of Medicine, DME 64 ago. She also suffered from ankle swelling and fatigue. Her symptoms were improved when she took the prescribed drugs. She had a history of high blood pressure. On admission her blood pressure was 13080, heart rate 100min, regular, raised jugular venous pressure, dilatation of the heart to the right and left, hepatomegaly, ankle edema, basal lung rales on the right and left, no murmur. She was diagnosed chronic heart failure. Digoxin, captopril and furosemide was given to her. LEARNING TASK II : 1. Compare the mechanism of action and clinical uses of positive inotropes.. 2. Describe toxic action of digitalis on the heart 3. Describe the effect of electrolyte imbalance on digitalis effect 4. Describe the interaction between digitalis and diuretic and quinidine Explain either the statement is True or False 1. Severe bradycardia may occur after clonidine overdose 2. Captopril decreases sodium and increases potassium in the urine 3. Hemolytic anemia caused by antihypertensive drug clonidine 4. Postural hypotension is a common adverse effect of alfa blocker 5. Losartan most likely causes cough 6. Nitroprusside must be given by intravenous infusion 7. Minoxidil causes vasodilatation by opening potassium channels MODULE 23 dr. Bagus Ari Pradnyana Dwi Sutanegara, SpJP AIMS: Describe to diagnose and manage Cor Pulmonale Pulmonary Heart Disease. LEARNING OUTCOME: 1. Can describe to diagnose and manage Acute Cor Pulmonale. 2. Can describe to diagnose and manage Chronic Cor Pulmonale. CURRICULUM CONTENS: 1. Etiology of Acute and Chronic Cor Pulmonale. 2. Pathogenesis of Pulmonary Hypertension. 3. Clinical Manifestation of Cor Pulmonale. 4. Physical Findings of Cor Pulmonale. 5. Diagnostic techniques for Cor Pulmonale. 6. Prevention and Treatment of Cor Pulmonale. ABSTRACT: Cor pulmonale is a common complication of pulmonary hypertension. Cor pulmonale refers to altered structure eg, hypertrophy or dilatation andor impaired function of the right ventricle that results from pulmonary hypertension that is associated with diseases of the lung eg, chronic obstructive pulmonary disease, vasculature eg, idiopathic lumonary arterial hypertension, upper airway eg, obstructive sleep apnea, or chest wall eg, kyphoscoliosis. Right sided heart disease due to left sided heart disease is not Udayana University Faculty of Medicine, DME 65 Day 23 considered cor pulmonale. Pulmonary hypertension PH is defined as PA Pressure .20 mmHg and is placed in the heterogeneous group of PH associated with disorders of the respiratory system andor hypoxaemia. The reason for setting such a threshold is that in healthy subjects PA Pressure is always 20 mmHg at rest and, as stated above, a PA Pressure 20 mmHg is associated with increased morbidity and mortality. However, in some recent studies PH was defined by PA Pressure 25 mmHg. Cor pulmonale tends to be chronic and slowly progressive, but it can be acute. Acute cor pulmonale occurs when the right ventricle cannot adapt to an increase in the pulmonary arterial pressure. The increased pulmonary artery pressure may be consequence of a new acute process, such as pulmonary embolism, or progression of the chronic disease. The diagnostic evaluation of cor pulmonale is inseparable from the evaluation for pulmonary hypertension. Cor pulmonale could be diagnosed based on the clinical manifestation and using chest x-ray, electrocardiography, and echocardiography as well as magnetic resonance imaging, pulmonary function testing, and right heart catheterization. Symptoms attributable to cor pulmonale include dyspnea on exertion, fatigue, lethargy, exertional syncope, and exertional angina. Patients with cor pulmonale have physical findings related to both pulmonary hypertension and righ-sided heart disease. All patients with cor pulmonale should have the underlying cause of the cor pulmonale and pulmonary hypertension treated. The treatment of cor pulmonale can be conceptualized as having three major physiological gols: reduction of right ventricular afterload eg, pulmonary artery pressure, decrease of right ventricular pressure, and improvement of right ventricular contractility. In the cor pulmonale condition that leads into heart failure, diuretics and nitrates may be needed to improve the condition of the patient. Oxygen supplementation is often required to resolve the shortness of breath. Treatments of PAH have shown a dramatic change in the past few years. Synthetic prostacyclin epoprostenol, prostacyclin analogues, endothelin-1 receptor antagonists and phosphodiesterase-5 inhibitors were tested in randomised controlled trials, leading to the approval of several drugs in each class. SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Etiology of Acute and Chronic Cor Pulmonale. 2. Pathogenesis of Pulmonary Hypertension. 3. Clinical Manifestation of Cor Pulmonale. 4. Physical Findings of Cor Pulmonale. 5. Diagnostic techniques for Cor Pulmonale. 6. Prevention and Treatment of Cor Pulmonale. SCENARIO: CASE: A 70-year old male, came to Emergency Room due to swelling on abdomen and both legs. The complaints were suffered since 1 month ago and become worsen. He also complains of shortness of breath and cough, that was experienced since years and usually could be resolved by nebulizer. He used to be a heavy smoker for 30 years, with 1-2 packs cigarette per day. The blood pressure was 12080 mmHg; pulse rate was 110 beats per-minute, regular. There were wheezing at both lung field, ascites on abdomen, and pitting edema on both legs, and increased of jugular venous pressure. ECG revealed sinus tachycardia 110 beats per-minute with P pulmonale on lead II, III and aVF. The urinary production is good. Udayana University Faculty of Medicine, DME 66 LEARNING TASK : 1. What is the most likely diagnosis? 2. What the next procedure do you plan? 3. What is your initial treatment? SELF-ASSESSMENT : 1. Please explain the risk factors of cor pulmonale. 2. What are the complications of pulmonary hypertension? 3. What is the treatment of choice in acute and chronic cor pulmonale? MODULE 24 dr. Bajra Nadha, SpJP dr. Luh Kamiati, SpRM AIMS: 1. Able to diagnose and manage Valvular Heart Disease VHD 2. Describe to diagnose and manage Common Peripherial Vascular Disease 3. Describe diagnose and manage Pericardial disease and Endocardial disease 4. Decsribe to rehabilitation patient with Cardiovascular Disease LEARNING OUTCOME: 1. Can describe to diagnose Valvular Heart Disease VHD 2. Can describe the manage Valvular Heart Disease VHD 3. Can describe to diagnose and manage the Common Peripherial Vascular Disease 4. Can describe diagnose and manage Pericardial Disease and Endocardial Disease 5. Can describe to rehabilitation patient with Cardiovascular Disease CURRICULUM CONTENS: 1. Etiology, pathophysiology and clinical spectrum of Valvular Heart Disease 2. Interpret diagnostic tools of Valvular Heart Disease 3. Management and prognosis and rehabilitation of Valvular Heart Disease 4. Etiology and pathophysiology of Common Peripherial Vascular Disease 5. Clinical diagnostic approach, Pharmacologic treatment of Common Peripherial Vascular Disease 6. Etiology and pathophysiology of Pericardial and Endocardial disease 7. Clinical and diagnostic approach of Pericardial and Endocardial diseases 8. Pharmacologic treatment and Prognosis of Pericardial and Endocardial disease 9. Rehabilitation and prognosis patient with Cardiovascular Disease ABSTRACT I: Udayana University Faculty of Medicine, DME 67 Day 24 Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary. The mitral and tricuspid valves control the flow of blood between the atria and the ventricles the upper and lower chambers of the heart. The pulmonary valve controls the flow of blood from the heart to the lungs, and the aortic valve governs blood flow between the heart and the aorta, and thereby the blood vessels to the rest of the body. The mitral and aortic valves are the ones most frequently affected by valvular heart disease. Normally functioning valves ensure that blood flows with proper force in the proper direction at the proper time. In valvular heart disease, the valves become too narrow and hardened stenotic to open fully, or are unable to close completely incompetent. A stenotic valve forces blood to back up in the adjacent heart chamber, while an incompetent valve allows blood to leak back into the chamber it previously exited. To compensate for poor pumping action, the heart muscle enlarges and thickens, thereby losing elasticity and efficiency. In addition, in some cases, blood pooling in the chambers of the heart has a greater tendency to clot, increasing the risk of stroke or pulmonary embolism. The severity of valvular heart disease varies. In mild cases there may be no symptoms, while in advanced cases, valvular heart disease may lead to congestive heart failure and other complications. Valvular heart disease accounts for 10 to 20 of all cardiac surgical procedure. The primary causes of valve disease are age-associated calcific valve changes and inherited or congenital conditions. The prevalence of rheumatic valve disease now is very low in the United States and Europe because of primary prevention of rheumatic fever, although rheumatic valve disease remains prevalent in the developing world. In addition to patients with severe valve disease that eventually requires mechanical intervention, there is a larger group of patients with mild to moderate disease who need accurate diagnosis and appropriate medical management. In developed countries, valvular heart disease is the most common reason for patients to undergo valve replacement. But in developing countries, this procedure is rarely performed due to financial reason. The most prevalent valvular heart disease is the following: 1 mitral valve disease, 2 aortic valve disease, and 3 tricuspid and pulmonary valve disease. Most valvular abnormalities can be managed with medical therapy or percutaneous intervention. One of the management of valvular heart disease is surgical intervention. Valvular surgery is indicated in patients with limiting symptoms despite optimal medical therapy, or in those with objective evidence of progressive cardiovascular deterioration. There are three main surgical approaches to valve disease: a valvotomy, b valve repair, and c valve replacement Standard References: 1. Mann, DL et all. Braunwald’s Heart Disease, 10 th ed. Philadelphia, Elsevier Saunders, 2015. ABSTRACT II: Pericardium is composed of two layers, the visceral pericaradium, a monolayer of mesothelial cells and collagenand elastin fibers that is adherent to the epicardial surface of the heart and the fibrous parietal layer, which is approximately 2mm thick in normal humans and surrounds most of the heart. The pericardial space or sac is contained within these two layers and normally has up to 50ml of serous fluid. Pericardium serves as barrier to infection, as well as lubrication between the visceral and parietal layers. The best characterized mechanical function of the pericardium is its restraining effect on cardiac volume. The spectrum of pericardial diseas comprises congenital defects, pericarditis dry, effusive, effusive-constrictive, constrictive, neoplasm, and cysts. Congenital defect of the pericardium occure 1 in 10.000 autopsies. It comprises partial left 70, right 17 or total bilateral extremely rare pericardial absence. The diagnosis is confirmed by echocardiography and CTMRI. Acute pericarditis is either dry, fibrinous or effusive, independent from its aetiology. A prodrome of fever, malaise, and myalgia is common, but Udayana University Faculty of Medicine, DME 68 elderly patients may not be febrile. Major symptoms are retrosternal or left precordial chest pain radiates to the trapezius ridge, can be pleuritic or stimulate ischemia, and varies with posture, non-productive cough, and shortness of breath. Pericardial friction rub and pleural effusion may be present. Diagnosis can be made by history taking, physical examination, laboratory and imaging. Management include hospitalization, finding the etiology, observe for tamponade and start anti-inflammatory and symptomatic treatment. Endocardium is innermost layer of the heart. Its atrial component is thicker than ventricular, where purkinje fibers are distributed throughout the ventricular subendocardium. Primary endocardial diseases are not common, usually non inflammatory in nature. Endocardial fibroelastosis is familial disease which involve progressive edema of endocardium, fibroblast proliferation and increased amount of collagen withing endocardium lead to restrictive cardiomyopathy and interfere cardiac output. Secondary cause of endocardial disease usually from infection. Infective endocarditis IE incidence range from 3-10 episodes100.000 person-years, male to female ratio is 2:1. Neither the incidence nor the mortality of the disease have decreased in the past 30 years, this disease still carries poor prognosis and high mortality. IE should be suspected in some clinical situations, such as fever, new heart murmur, anemia and embolic events. Up to 90 patient with fever, often associated with systemic symptoms of chills, poor appetite and weight loss. Transthoracic echocardiography must be performed rapidly as soos as IE is suspected. Diagnosis of IE based on modified Duke criteria that composed with mayor and minor criteria. Treatment include supportive therapy based on sign and symptoms and combination with antibiotic which can be start soon despite waiting for blood culture result. Standard References: 1. Mann, DL et all. Braunwald’s Heart Disease, 10 th ed. Philadelphia, Elsevier Saunders, 2015. p. 1391-1550 2. Habib, Gilbert et al. Guidelines on The Prevention, Diagnosis, and Treatment of Infective Endocarditis. European Heart Journal. 2009;30.2369-2413 3. Maisch, Bernhard et al. Guidelines on The Diagnosis and Management of Pericardial Disease. European Heart Journal. 2004; 1-28 Additional reading: 1.Constant, Jules. Essential of Bedside Cardiology, 2 nd ed. New Jersey, Humana Press Inc. 2003 ABSTRACT III: Cardiac rehabilitation is multidisciplinary program of education and exercise established to assist individual with heart disease in achieving optimal physical, psychological and functional status within thw limits of the diseased. The basic goal of cardiac rehabitation are to restore and improve cardiac function, reduce disability, identify and cardiac risk factors, increased cardiac conditioning. Cardiac rehabilitation programs consist primary prevention education, behavior modification, secondary prevention, and exercise program. Cardiac rehabilitation outcomes that can be expected decreased length of hospital stay, more ripid, more complete resumption of ususal activities, self confident, less pshychological distress, and fewer readmissions. Standard References : 1. McPhee SJ, Papadakis MA. Current Medical Diagnosis Treatment. 47 th ed. New York: Lange Mecical Book`sThe McGraw-Hill Companies, 2008.p. 287-299, 351- 358; 398-416, 360-363; 1241-1246 Udayana University Faculty of Medicine, DME 69 2. Garrison SJ: Hand Book of Physical Medicine and Rehabilitation, 2 nd ed, 2003, p. 86 3. Bartels MN: Cardiac Rehabilitation in Grant Cooper: Essential Physical Medicine and Rehabilitation, 2006, p. 119. SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Etiology, pathophysiology and clinical spectrum of Valvular Heart Disease 2. Interpret diagnostic tools of Valvular Heart Disease 3. Management and prognosis and rehabilitation of Valvular Heart Disease 4. Etiology and pathophysiology of Common Peripherial Vascular Disease 5. Clinical diagnostic approach, Pharmacologic treatment of Common Peripherial Vascular Disease 6. Etiology and pathophysiology of Pericardial and Endocardial disease 7. Clinical and diagnostic approach of Pericardial and Endocardial diseases 8. Pharmacologic treatment and Prognosis of Pericardial and Endocardial disease 9. Rehabilitation and prognosis patient with Cardiovascular Disease SCENARIO: CASE I: Using your stethoscope, you would hear single S 1 and single S 2 , and early diastolic murmur of grade 36 at the right 2 nd intercostal-space, radiating to the apical area. Neither S 3 nor S 4 noted. LEARNING TASK: 1. What kind of valvular heart disease is represented by this auscultation findings? 2. Please explain the ECG pattern usually found in this kind of disease 3. Please describe the radiological findings consistent with this disease. 4. Mention definition of cardiovascular rehabilitation 5. Explain the objective of cardiovascular rehabilitation 6. Mention the contraindication exercise therapy 7. Explain the benefit effect of exercise therapy 8. Explain stages of cardiovascular rehabilitation MI 9. Mention effect of exercise to CHF CASE 2: A 23-year old gentleman visited the hospital due to chest pain. The chest pain was sharp in nature. The pain scale was 7 of 10, it was becoming severe when he took a deep breath and radiating to the neck. He suffered from ‘flu-like syndromes’ since the last 1 week. LEARNING TASK: 1. What is the most likely diagnosis of this gentleman? 2. What is the treatment do you plan? 3. What is the common etiology of this situation? SELF-ASSESSMENT 1. Please describe the etiology of mitral regrugitation Udayana University Faculty of Medicine, DME 70 2. Please explain the complication of mitral stenosis 3. Please describe the ECG findings in aortic stenosis 4. What is the Austin-Flint murmur? 5. Please explain the indication of mitral valve replacement procedure? 6. What is the treatment of constrictive pericarditis? 7. What is the management of pericardial effusion? 8. What is the most accurate diagnostic tool of pericardial effusion? 9. Mention definition of cardiovascular rehabilitation 10. Explain the objective of cardiovascular rehabilitation 11. Mention the contraindication exercise therapy 12. Explain the benefit effect of exercise therapy 13. Explain stages of cardiovascular rehabilitation MI 14. Mention effect of exercise to CH MODULE 25 dr. I Nyoman Semadi, SpB, SpBTKV SURGERY IN CARDIAC DISEASES AIMS: Describe the basic principles of surgery in cardiac diseases LEARNING OUTCOME: 1. Can describe the basic principles of cardiac surgery 2. Can describe the basic aspect in cardiac surgery 3. Can describe the cardiac diseases who need surgery CURRICULUM CONTENTS: 1. Surgery of the congenital heart 2. Surgery of the acquired heart diseases ABSTRACT: Atrial septal defects ASD and ventricular septal defect VSD and others are the congenital cardiac anomaly. The intracardiac defects makes the shunt and blood flows through the shunt from right-to-left or reverse of the heart. Atrial septal defects ASD are most common in the vicinity of the fossa ovalis. Septum secundum defects, the typical patent foramen ovale, account for 10-15 of all cardiac anomalies. Normal left atrial pressure is slightly greater than right atrial pressure, a left-to-right shunt occur through an open ASD, oxygenated blood from the left side of the heart is shunted to the right side, thus not associated with cyanosis. An ASD is usually compatible with normal life, except at an extreme exercise, cardiac disease, or pulmonary disease alter chamber pressures, a right-to-left shunt will produce cyanosis. Ventricular septal defect VSD is usually happened at the upper membranous portion that composed of connective tissue continuous with the annulus fibrosus. A small VSD may result in an inconsequential left-to-right shunt. Udayana University Faculty of Medicine, DME 71 Day 25 In the presence of pulmonary stenosis, a VSD produces a right-to-left shunt with cyanosis and the blue-baby syndrome. A large VSD is a principal factor in Tetralogy of Fallot. Patent ductus arteriosus PDA is a persistence of the fetal connection ductus arteriosus between the aorta and pulmonary artery after birth, resulting in a left-to-right shunt. Symptoms may include failure to thrive, poor feeding, tachycardia and tachypneu due to lung infection. Others cardiac diseases are more common as a coronary arterial diseases CAD, Acquierd Valve diaseses of rheumatic heart disease and congenital valve anomaly Standard References: 1. Stuart W. Jamieson and Norman E Shumway: Cardiac Surgery in Rob Smith’s Operative Surgery, 4th edition. Butterworths London, 2004 SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Cardiac surgery in principles TREATMENT FOR AORTA AND ARTERIAL DISEASES AIMS: Describe the basic principles of surgery in aorta and arteries LEARNING OUTCOME: 1. Can describe the basic principles of aorta and arteries 2. Can describe the basic aspect in aorta arteries 3. Can describe the aorta and arteries diseases who need surgery CURRICULUM CONTENTS: 1. Surgery of the aneurysm of aorta 2. Surgery of the peripheral artery diseases ABSTRACT: Atherosclerosis is the usual cause of vascular diseases. The aneurysm of aorta is dilated of aorta lumen over one and half size of normal lumen of aorta. The aorta can enlargement, elongated and tortous with or without thrombus in the lumen of aorta. It can be found on thoracic region or abdominal region or both. The patient got pain of the chest or abdominal pain depend the aneurysm posotion. If you found the abdominal aortic aneurysm triple A, the large pulsatil tumor was found on central topographic of abdomen. The patient become dengerous if aortic aneurysm ruptured and the patient getting haemorhagic shock. Atherosclerosis can cause the peripheral artery diseases. The artery become aneurysm, stenosis and occluded. If the artery got occlusion on midle size of that, the distal part of organ will ischemic and become death of the tissue that call ganggrene. Standard References: 1. Allan D. Callow, Calvin B. Erust. : Vascular surgery, Theory and Practice, Prentice- Hall International Inc.London , 1995 SELF DIRECTING LEARNING Basic knowledge that must be known: Udayana University Faculty of Medicine, DME 72 1. Vascular surgery in principles SCENARIO: CASE 1; This baby aged 4 months has been known to have a cardiac murmur since birth. He was born 8 weeks prematurely and developed respiratory distress requiring high oxygen concentration for the first week. Since then he has feed satisfactorily but height and weight growth have been poor even allowing for prematurity. The diagnosis after examination and investigations: Patent Ductus Arteriosus PDA. LEARNING TASK I 1. How to prepare if the patient have surgery 2. What is cardic surgery category for PDA closure 3. PDA commonly concomittent with congenital anomaly. Is it every PDA have surgery to close the shunt 4. After an operation to close the PDA, why is there a risk of the patient becoming hoarse? CASE 2 : This 13 year old girl was recently found to have a cardiac murmur. She has been generally healthy with good growth, but on questioning her mother admitted she has noticed that girl tends to tire easily with exercise. The diagnosis after examination and investigations: Atrial Septal Defect A.S.D. LEARNING TASK II: 1. What is cardic surgery category for ASD closure 2. What the different between close and open cardiac surgery 3. After ASD was closured, why the patient getting good growing of the body 4. And why is the patient after ASD closure getting arrythmia CASE 3 : A 2 year old boy was admitted to the hospital for evaluation of a heart murmur previously detect at birth. He was less active than other children his age, but although over-exertion was followed frequently by cyanosis of the lips and nails, there was no history of unconsciousness. Initial examination revealed a thin, physically retarded, cyanotic child with no respiratory difficulty. There was moderate clubbing of the fingers. A harsh systolic murmur was maximal over the mid-precardial area. The first heart sound was normal while the second was single, distinct and loud.The lungs were clear. X-ray showed a normal sized heart dominated by a boot-shaped right ventricular outflow tract. Diagnosis of Tetralogy of Fallot. LEARNING TASK III: 1. The cardiac anomaly are PS, VSD, Overriding aorta and RVH. How do repair it 2. Why the patient becoming worse after the surgery repair of the defect SELF-ASSESSMENT : 1. Describe the principle cardiac surgery 2. Describe the principle coronary heart surgery 3. Describe the principle of Valve surgery SCENARIO: Udayana University Faculty of Medicine, DME 73 CASE 1; Old man, he was pain on abdomen and the tumor was found on abdomen palpation. The tumor was pulsatil and 7 cm in diameter and fixed. The blood pressure of the patient got high. The diagnose of the disease is triple A with stable hemodinamically LEARNING TASK I: 1. How to diagnose the patient 2. How to prepare if the patient have surgery 3. How to do to enlargement of aorta 4. Any complication to surgery of aorta CASE 2 : This 43 year old man was recently found to have cold of feet. He has been generally healthy with pain on both leg if he walking for while, he was heavy smoking from teeneger. The diagnosis after phisical examination that conclude: peripheral artery diseases of both popliteal artery LEARNING TASK II: 1. What will you do to investigate the patient for difinitive diagnosis 2. What will you do to improve the blood flow to the distal end of feet 3. How the prognosis and reccurent rate SELF-ASSESSMENT : 1. Describe the principle of vascular surgery 2. Describe the principle arterial repair 3. Describe the principle of care after vascular surgery

8. REFERENCES