Dicky Armein Hanafy

Background: Electrocardiographic markers, including the r′-wave triangle base duration and beta-angle, have been proposed as adjunctive indicators of Brugada syndrome (BrS). As flecainide challenge testing (FCT) carries potential risks, baseline ECG predictors may refine pre-test risk stratification, although their relationship with oral flecainide challenge positivity remains uncertain. Objective: To evaluate whether baseline r′-wave triangle base duration and beta-angle were associated with FCT positivity. Methods: This retrospective, single-center review included consecutive patients who underwent oral flecainide challenge within a historical institutional diagnostic pathway between September 2023 and September 2025. Baseline right-precordial ECG measurements, including r′-wave triangle base duration and beta-angle, were obtained from archived standard 12-lead tracings. The primary outcome was FCT positivity, defined as the emergence of a diagnostic type 1 Brugada pattern Result: Among 40 included patients, 28 had a positive oral flecainide challenge result and 12 had a negative result. In exploratory analyses, larger baseline β-angle and longer r′-wave triangle base duration were associated with oral flecainide challenge positivity. Mean β-angle was 36.07° ± 15.86° in positive versus 21.83° ± 10.72° in negative challenges (p=0.007); mean r′-wave triangle base duration was 161.6 ± 92.8 ms versus 81.6 ± 38.0 ms, respectively (p<0.001). ROC analysis showed moderate discriminatory performance (AUC 0.756 for β-angle, 0.769 for r′-wave). Sample-derived thresholds of 27.5° and 2.625 mm (105 ms) yielded sensitivity of 71.4% and specificity of 83.3%. A combined model incorporating both parameters showed an AUC of 0.780 (95% CI, 0.635–0.924), with 75.0% sensitivity and 83.3% specificity at the Youden-optimal threshold. Conclusion: Baseline r′-wave triangle base duration and beta-angle were associated with FCT positivity. These findings support further prospective investigation using standardized ECG acquisition and contemporary provocation protocols. Keyword : Brugada Syndrome; Electrocardiography; Flecainide Challenge; Sodium Channel Blocker Test.

Background: Obesity is a major independent risk factor for atrial fibrillation (AF), contributing to adverse outcomes and complicating rhythm control. While lifestyle modification is recommended, catheter ablation remains central to management. Conventional thermal ablation techniques often yield suboptimal results in obese patients due to anatomical and biophysical challenges. Pulsed field ablation (PFA), a novel non-thermal modality, may overcome these limitations. Methods: A systematic search of PubMed, Scopus, and Embase identified observational cohort studies (2017–2026) evaluating PFA outcomes in obese AF patients or across BMI categories. Four cohort studies met the inclusion criteria. Results: Findings on AF recurrence were heterogeneous. Recurrence rates appeared lower with PFA compared to radiofrequency ablation (RFA), though differences were not statistically significant. In a PFA-only study, freedom from arrhythmia recurrence did not vary across BMI categories. Compared with cryoballoon ablation (CBA), one matched-cohort study demonstrated significantly higher one-year freedom from AF with PFA-PVI, whereas another reported no difference. Left atrial epicardial adipose tissue (LA EAT) emerged as the only independent predictor of recurrence in PFA patients, suggesting electrical field perturbation by fat tissue. Radiation exposure was lower with PFA than CBA, while fluoroscopy time and periprocedural complications were comparable across groups. Conclusions: Current observational evidence suggests that PFA may be a feasible and safe option for AF ablation in overweight and obese patients, with outcomes comparable to conventional ablation techniques. However, comparative efficacy and long-term safety remain uncertain. Obesity-related adipose hypertrophy, systemic inflammation, and atrial remodeling may alter electric field distribution, contributing to variable recurrence outcomes. Larger prospective and randomized trials are warranted to define the long-term role of PFA in this high-risk population.

Background: Local anesthesia is considered safe and commonly used in the pacemaker implantation procedure. However, it carries a risk of local anesthetic systemic toxicity (LAST). Although rare, LAST occurrence can be fatal. Case Presentations: We reported a case of a 69-year-old woman with fatigue and dizziness. The patient's ECG indicates atrial fibrillation with total AV block. Pacemaker implantation was performed under local anesthesia. Within minutes of lidocaine injection, the patient developed a seizure followed by cardiac arrest. Immediate administration of intravenous midazolam and cardiopulmonary resuscitation was done, resulting in the patient's stability. A permanent pacemaker was successfully implanted using a modified hand-shaped stylet to accommodate the presence of a persistent left superior vena cava (PLSVC). Brain computed tomography scan showed only mild brain atrophy. No clinical symptoms were documented during the outpatient visit after discharge. Conclusions: Local anesthetic systemic toxicity during pacemaker implantation is a rare but potentially catastrophic. Prompt recognition of its signs and appropriate management are crucial. In this case, a persistent left superior vena cava posed additional challenges to the pacemaker implantation. Keyword : Lidocaine toxicity; Local anesthesia systemic toxicity; Pacemaker implantation; Persistent left superior vena cava; Venous anomaly.

Background The relationship between premature ventricular contractions (PVC) and right ventricular (RV) function is not widely known. Left ventricular (LV) dysfunction due to PVC is known as PVC-induced cardiomyopathy (PIC) and suppressing the PVC substrate would improve LV function. The effect of PVC ablation on changes in RV function in patients with subtle RV subclinical dysfunction remains unknown. Objective Understanding the alterations in RV function parameters after PVC ablation. Method Basic and speckle-tracking echocardiography has been performed on 42 individuals with symptomatic idiopathic outflow tract PVC before and 1 month after a successful ablation. Result At the baseline of the study, there were 26 patients with RV subclinical dysfunction and 16 patients without RV dysfunction. Patients with RV subclinical dysfunction exhibited significantly higher PVC burden and QRS complex duration than those with normal RV function (p < 0.05). A PVC burden ≥ 21% (OR 9.11, 1.54–53.87, p = 0.015) and a QRS complex duration ≥ 138 ms (OR 5.74, 1.07–30.90, p = 0.042) were independently associated with RV subclinical dysfunction. In both groups, measurements of RV subclinical function before and after ablation, specifically by free wall longitudinal strain (FWLS) and global longitudinal strain (GLS), demonstrated significant changes. These improvements were more pronounced in the group with RV dysfunction (FWLS 9.7 ± 4.0, p < 0.001; GLS 7.5 ± 4.2, p < 0.001). Lower initial FWLS and GLS before ablation emerged as significant parameters in the multivariate analysis for the improvement of RV function post-ablation. Conclusion Patients with RV subclinical dysfunction had higher PVC burden and wider QRS duration. Patients with idiopathic outflow tract PVC with RV subclinical dysfunction may experience improvements in RV function after successful PVC ablation. Graphical Abstract

Background: AF substantially increases the risk of stroke. The most widely used risk prediction score for AF is CHA2DS2-VASC. Previous studies have mainly focused on its efficacy among patients with non-valvular AF. The few studies that have considered patients with valvular AF highlight the tool’s poor scoring accuracy. Objective: This study was conducted to evaluate the clinical factors and echocardiographic parameters related to the incidence of ischaemic stroke in anticoagulated evaluated heart valves, rheumatic or artificial (EHRA) type 1 valvular AF patients. Methods: We conducted a retrospective cohort study using data from the Indonesian Registry on Atrial Fibrillation (OneAF). Patients with EHRA type 1 valvular AF recorded in the registry from January 2015 to December 2019 were included in the study. Results: The incidence of ischaemic stroke was 17 (5.2%) out of 329 AF patients with mitral stenosis or mechanical prosthetic valves. A multivariate analysis showed that two clinical factors: hypertension (OR 5.59; 95% CI [1.93–16.15]; p=0.001) and estimated glomerular filtration rate (eGFR) ≤59 ml/min/m2 (OR 3.62; 95% CI [1.30–10.02]; p=0.013), were independently associated with the incidence of ischaemic stroke. No echocardiographic parameters were associated with the incidence of ischaemic stroke in this population. Conclusion: Hypertension and impaired renal function elevated the risk of ischaemic stroke in the patient population. Further research is necessary to determine the proper scoring system for predicting ischaemic stroke in this subgroup.

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.

A 2-year-old girl was referred to the Harapan Kita National Heart Center due to the return of spontaneous circulation after cardiac arrest, bradyarrhythmia and repeated seizures with loss of consciousness. She had been treated with an epilepsy drug for 1 year. Electrocardiography during one epilepsy episode showed complete heart block with junctional escape rhythm and QT interval prolongation, which then progressed to torsades de pointes. Echocardiography revealed left atrium and left ventricle dilatation with reduced ejection fraction. Left bundle branch permanent pacemaker was successfully implanted through left subclavian vein access. During the 3-week follow-up, there were no recurrent seizures and echocardiography revealed improvement of left ventricle ejection fraction.