Muzakkir Amir

Introduction: Pulmonary stenosis is a common form of obstruction in the right ventricular outflow tract, characterized by the narrowing of the pulmonary valve, which results in obstructed blood flow. Case Presentation: A 17-year-old female presented with recurring shortness of breath, chest pain, and palpitations, especially during physical activity. On examination, a grade III/VI continuous murmur was heard at the upper left sternal border. Echocardiography confirmed moderate pulmonary valve stenosis, a left-to-right patent ductus arteriosus (PDA), and mild to moderate pulmonary regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Although cardiovascular care has improved in the last decade in the low- and middle-income countries (LMICs) in South-East Asia Region; these countries, particularly Indonesia, are still encountering a number of challenges in providing standardized healthcare systems. This article aimed to highlight the current state of cardiology practices in primary and secondary care, including the novel cardiovascular risk factors, recommendations for improving the quality of care, and future directions of cardiovascular research in limited settings in South-East Asia. We also provided the most recent evidence by addressing our latest findings on cardiovascular research in Indonesia, a region where infrastructure, human, and financial resources are largely limited. Improving healthcare policies to reduce a nations’ exposure to CVD risk factors, providing affordable and accessible cardiovascular care both at primary and secondary levels, and increasing capacity building for clinical research should be warranted in the LMICs in South-East Asia.