enhancing care through applied cardiology asia … · lower limbs, complicated by purulent...

ENHANCING CARE THROUGH APPLIED CARDIOLOGY

11th ASIA PACIFIC CARDIOLOGY UPDATE @USM 201819th -21st October 2018

www.apcu-usm.com

Hotel Perdana Kota Bharu, Kelantan,

Malaysia

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11th ASIA PACIFIC CARDIOLOGY UPDATE@USM 2018

19th - 21st October 2018

Message from the Malaysia Ministry of Health

Message from the Chairperson of 11th Asia Pacific Cardiology Update@USM2018

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Organizing Committee 04

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ECG Masterclass Workshop

Transthoracic Echo Workshop

11th Asia Pacific Cardiology Update@USM 2018 Main Conference

Interventional Cardiology Update

Speakers Curriculum Vitae (In alphabetical order)

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Abstracts

P01. A Rare, Fatal Case of Group B Streptoccocus Related Necrotizing Soft Tissue Infection of the

Lower Limbs, Complicated by Purulent Pericarditis and Cardiac Tamponade.

P02. A Rare, Fatal Case of Burkholdellia Pseudomallei Infection Presenting as Purulent

Pericarditis and Cardiac Tamponade.

P03. A Unique Case of Arrhythromogenic Right Ventricular Dysplasia Diagnosed with Assistance

from Characterization of Cardiac Tissue in a Deceased Sibling.

P04. Electrical Storm in a Patient with Implantable Cardioverter-Defibrillator: A Case Report

P05. Comparative Study of Echocardiographic Doppler Flow Velocities in Left Ventricular Apical,

Mid and Outflow Area in Patients with Heart Failure and Normal Subjects.

P06. A first reported case of successful chronic lead extraction with lead extractor – Evolution

P07. Gastrointestinal Bleeding Risk Assessment Using HAS-BLED In Atrial Fibrillation Patients

Who Are Receiving Warfarin In HUSM

P08.Coronary Artery Calcium Score In Asymptomatic First Degree Relatives With

Family History Of Young Coronary Artery Disease: A Pilot Study

P09. Apical septal rupture: A clinical challenges in rare complication of myocardial infarction case

report.

P10. Aortic Arch Dissection Presenting as Painless Left-sided Pleural Effusion

P11. The Study of Broken Hearts: A Pragmatic Case Report Based on Takotsubo Cardiomyopathy

in Malaysia.

P12. Patient’s Knowledge of Coronary Artery Disease Risk Factors in Cardiac Rehabilitation Ward,

Queen Elizabeth Hospital II, Kota Kinabalu, Sabah

P13. High rate of late stent thrombosis in patients with significant coronary artery stenosis treated

with bioresorbable vascular scaffold (BVS): A Malaysian single center real world experience year

2012 to 2017)

P14. Prevalence of left ventricular systolic and diastolic dysfunction in Type 2 diabetes population

with no signs and symptoms of heart failure.

P15. Yamaguchi Syndrome, a masquerade to acute coronary syndrome

P16. Delayed pericardial tamponade following an early NOAC prescription post pacemaker

implantation.

P17. Apixaban versus warfarin in patients with left ventricular thrombus: A prospective randomized

outcome blinded pilot study on size reduction or resolution of left ventricular thrombus.

P18. Two cases of prolonged ventricular standstill in One Tertiary centre

P19. Relapse infective endocarditis with Nutriently variant streptococci in pregnancy complicated

with systemic embolization

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NHAM ICSM Angio Club

Contents

Local Faculty Members (In alphabetical order)

Overseas Faculty Members

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Message from The Malaysia Ministryof Health



DR DZULKEFLY AHMAD THE HONOURABLE MINISTER OF HEALTH MALAYSIAON THE OCCASION OF:ASIA PACIFIC CARDIOLOGY UPDATE@USM 2018 -‘ENHANCING CARE THROUGH APPLIED CARDIOLOGY’DATE: 19 OCTOBER 2018VENUE: HOTEL PERDANA KOTA BHARU

Assalamualaikum warahmatullahi Wabarakatuh and a very good morning to the guests ofhonour and all participants of Asia Pacific Cardiology Update@USM 2018 (APCU). It is my pleasureto pen few words on this welcoming note. I would like to take this opportunity to congratulate theorganising committee and everyone involved in this event for preparing and organizing anoutstanding event. Thank you for your support, energy and precious time to ensure that this eventbecomes a great success. In these past years, this event has helped to provide one of the bestplatform to enhance patient’s care in cardiology. I am proud to say that after 10 years, the effortfrom the organizer is still strong and continuing smoothly.

This year’s theme of ‘Enhancing Care Through Applied Cardiology’, has been very well-chosen. Enhancing healthcare is always our primary aim since cardiovascular disease is one of theworld’s major killers. According to Department of Statistics Malaysia released on 31 October 2017,ischaemic heart disease was the principal cause of death in Malaysia which was at 13.2%.Malaysians are alarmingly getting cardiovascular disease at a younger age of 58.6 years ascompared to the age of 65 years and above in developed nations.

Applied cardiology is translated as evidenced based latest medications and interventionalstrategies in cardiovascular disease. The application of these new therapy and skills will hopefullyimprove survival in post ACS patients as well as improvement in primary prevention by tackling themodifiable risk factors such as hyperlipidaemia, diabetes and hypertension. The latest NationalCardiovascular Disease (NCVD 2015) has shown greater improvement in survival when patient hadearly access to interventional cardiology services beginning from admission and up to 1 year ofhaving acute coronary syndrome. Data has shown lesser mortality rate of 13.1% compared to21.5% among patients with and without angioplasty respectively at up to 1 year from the firstpresentation.

I am glad to hear that this meeting has gathered 21 cardiologists from all over Malaysia andabroad. Therefore, it is my sincere hope that this gathering will promote the dissemination ofapplied cardiology knowledge among all health practitioners especially those who are serving therural areas. My advice to all participants is to fully utilise the knowledge obtained here to furtherenhance primary prevention care in your practice. I hope that through the meeting this year, APCUwill continue to be a continuous learning platform where all participants will take this thisopportunity to engage with expert reviews and recent advances in cardiovascular disease. TheMinistry of Health is indeed pleased to support this programme. Once again, I am proud to be partof this ongoing effort and hereby wish you all a pleasant learning time in this year’s CardiologyUpdate@USM conference. Thank you.

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Message from The Chairperson of 11th

Asia Pacific Cardiology Update @USM 2018



Assalamualaikum and welcome to our guests of honour, distinguished invited facultymembers and participants of Universiti Sains Malaysia’s 11th Asia Pacific Cardiology Updateconference. On behalf of the Organising Committee I am pleased to welcome you to our annualAsia Pacific Cardiology Update meeting, which is held under the auspice of the National HeartAssociation of Malaysia.

I am proud to say that this year is the 11th year of this conference. “Enhancing Care ThroughApplied Cardiology” is how we improved quality of health care to the patient by using latestcardiac practices, treatments and technological advancements. This theme aims to bring togetherleading cardiologists from all over Asia Pacific to exchange and share their experiences andresearch results about all aspects of Applied Cardiology from recent innovations, trends, andconcerns, practical challenges encountered and the solutions adopted in the field of AppliedCardiology.

Important topics that will be covered by our international and local faculty during this year’score programme will include updates on the heart failure, maternal cardiology with new topics onclinical cardiology and cardiology prevention. Do please make yourselves available to view thesubmitted poster presentations for which prizes will be given out later. You are also most cordiallyinvited to visit the exhibition booths and attend industry-sponsored symposium. I believed that ourimpressive roster of distinguished speakers will be able to effectively achieve this. I am also gladand happy to see a good number of participants and posters submitted for our event this year.Your strong support and active participation have made the APCU@USM 2018 a record breakingevent. As ever, it delights me to see familiar faces in the crowd as well as fresh new ones amongstthe attendees. Thank you for agreeing to spend some of your precious time away from your dailypractice in order to attend our event.

I do sincerely hope that the knowledge obtained from this meeting will ensure a change forthe better when all of us return to our busy practices. To the representatives of the industries, abig thank you goes out to all of you who have supported our event. Enjoy your participation inAPCU@USM 2018 and memorable time visiting the Kota Bharu. Kota Bharu offers not only aunique glimpse of traditional Malay life but also local delicacies and traditional craftwork which arejust a few of Kota Bharu’s distinctive offerings, with many more waiting to be discovered. We hopeyou will return next year with even more colleagues for APCU @USM 2019!

Sincerely,Professor Dato’ Dr Zurkurnai YusofFNHAM, FAsCCOrganising Chairperson11th Asia Pacific Cardiology Update@USM 2018

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Organizing CommitteeADVISORS Tan Sri Dato Seri. Dr Robaayah Zambahari

Dato’ Dr Omar IsmailProfessor Dato’ Dr Wan Azman Wan AhmadDr. Ng Wai Kiat

CHAIRMAN, 11TH APCU @USM 2018 Professor Dato’ Dr. Zurkurnai YusofSECRETARY Dr. W Yus Haniff W Isa

Dr. Muhammad Imran KamarudinTREASURER Sister Zuarini MohamedSCIENTIFIC CHAIRPERSON Dr. Mohd. Sapawi MohamedECHO WORKSHOP MANAGER Sn. Suhaida Azliza Mohd ZainECG MASTERCLASS MANAGER Dr. W Yus Haniff W IsaREGISTRATION Sn. Zuraidah Wan Isa

Ms. Zunulwaniz IbrahimPROTOCOL Dr. Nurul Huda Abdullah

Dr. Mohamad Zikir IsmailDr. Ahmad Zulfathi MokhtarDr. Nur Izat MuhamadSn. Mohd Taufiq Yusop

VENUE Dr. Hany Haqimi Wan HanafiTRANSPORT Dr. Shahrizal MustaffaCO-SPONSOR National Heart Association Malaysia

Local Faculty Members (In alphabetical order)Datuk Dr. Abdul Kahar bin Abdul Ghapar Hospital Serdang, MalaysiaDr Ang Kai Ping Hospital Sultanah Aminah, Johor Bharu, MalaysiaDr Hamat Hamdi Che Hassan University Kebangsaan Malaysia Medical Centre, MalaysiaProfessor Dr Imran Zainal Abidin University Malaya Medical Centre, MalaysiaDr Lee Zen Vin University Malaya Medical Centre, MalaysiaDr Liew Houng Bang Hospital Queen Elizabeth II, Sabah, Malaysia

Dr Lim Bee Chian Sunway Medical Centre, MalaysiaDr Mansor Yahya Hospital Raja Perempuan Zainab II, Kota Bharu, Malaysia

Dr Mohd Rafizi Mohamed Rus Hospital Angkatan Tentera Tuanku Mizan, MalaysiaDr Mohd Sapawi Mohamed Hospital Raja Perempuan Zainab II, Kota Bharu, MalaysiaDr Muhamad Ali SK Abdul Kader Hospital Pulau Pinang, MalaysiaDr Ng Seng Loong Perak Community Specialist Hospital, MalaysiaDr Ng Wai Kiat Pantai Hospital, MalaysiaProfessor Dato' Dr Oteh Maskon University Kebangsaan Malaysia Medical Centre, MalaysiaProfessor Colonel (R) Dr Pauzi Ibrahim Universiti Sultan Zainal Abidin, MalaysiaDr Shaiful Azmi Yahaya Institut Jantung Negara, MalaysiaProfessor Dato' Dr Wan Azman Wan Ahmad University Malaya Medical Centre, MalaysiaAssoc Prof Dr Wan Mohd Izani Wan Mohamed Hospital Universiti Sains Malaysia, Malaysia

Dr W Yus Haniff W Isa Hospital Universiti Sains Malaysia, MalaysiaProfessor Dato' Dr Zurkurnai Yusof Hospital Universiti Sains Malaysia, Malaysia

Overseas Faculty MembersDr Anwar Santoso Harapan Kita Hospital, Indonesia

Dr Martijn Van De Giessen Phillips Health System, Singapore

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ECG Masterclass

Workshop19th October 2018 (Friday)

Venue: Dewan Bunga Emas Hotel Perdana, Kota Bharu

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ECG MASTERCLASS WORKSHOP

Venue: Dewan Bunga Emas Hotel Perdana, Kota Bharu

Friday (19th October 2018)

TIME TOPICS SPEAKER

0730-0800 Registration

0800-0830 Challenges in ECG readingDr W Yus Haniff W Isa, HUSM,

Malaysia

0830-0900A 35 year old woman with narrow complex tachycardia………

What should I do?

Prof Dr Imran Zainal Abidin, UMMC,

Malaysia

0900-0930A 65 year old woman with broad complex tachycardia…........

What should I do?Dr Ang Kai Ping, HSAJB, Malaysia

0930-1000 Unifocal and Multifocal PVCs: Is it an important arrhythmia? Dr Lee Zen Vin, UMMC, Malaysia

1000-1030

Breakfast Symposium-Courtesy of Biotronik Malaysia Sdn. Bhd

New perspective on device therapy for heart failure patient

Speaker: Dr Ang Kai Ping, HSAJB, Malaysia

1030-1100 ECG patterns in acute myocardial infarction you must know Dr Mansor Yahya, HRPZII, Malaysia

1100-1130 Important subtle ECG changes Dr Ang Kai Ping, HSAJB, Malaysia

1130-120075 y.o with chest pain and syncope……

What should I do?

Dr Anwar Santoso, Harapan Kita

Hospital, Indonesia

1200-1300

Lunch symposium- Courtesy of Pfizer Malysia Sdn. Bhd

Are all NOACs the same? Navigating evidences in the real world

Speaker: Prof Dr Imran Zainal Abidin, UMMC, Malaysia

Chairperson: Dr W Yus Haniff W Isa, HUSM, Malaysia

1300-1430 Friday prayers/Break

1430-1500 Recurrent admission for shortness of breath (devicentric)Prof Dr Imran Zainal Abidin, UMMC,

Malaysia

1500-1530 ECG changes in electrolytes abnormalities Dr Ang Kai Ping, HSAJB, Malaysia

1530-1600 Q&A sessions - All Speaker

1600-1630 Afternoon Break

1630-1715 ECGs from experts All speakers

1715-1800 ECGs from audience All speakers

1800-1930

Dinner symposium - Courtesy of Merck Sharp & Dohme

1) Simplifying the Complexity of T2DM

Speaker: Assoc Prof Dr Wan Mohd Izani Wan Mohamed, HUSM, Malaysia

2) Lipid Lowering Therapy In Patients with Peripheral Artery Disease

Speaker: Dr Shaiful Azmi Yahaya, IJN, Malaysia

Chairperson: Dr Mohd Rafizi Mohamed Rus, Hospital Angkatan Tentera Tuanku Mizan, Malaysia

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Transthoracic

ECHO

Workshop19th October 2018 (Friday)

Venue: Kijang 2, Hotel Perdana, Kota Bharu

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TRANSTHORACIC ECHO WORKSHOP


Friday (19th October 2018)

TIME TOPICS SPEAKER


0745-0800 Introduction by Course Director

0800-0825 Basics of Echo ExaminationProf Dato' Dr Oteh Maskon,

UKMMC, Malaysia

0825-0850 Image Optimization in Poor Echo Window Tech. Specialist

0850-0920 Assessment of Systolic and Diastolic Heart Failure

Dr Ng Seng Loong, Perak

Community Specialist Hospital,

Malaysia

0920-0945 Stress and/or Pharmacology EchoDr Mohd Sapawi Mohamed,

HRPZII, Malaysia

0945-1015 Morning Tea Break

1015-1040 LVOT assessment (Cardiac Output) and Basic Right Heart AssessmentProf Dato' Dr Oteh Maskon,

UKMMC, Malaysia

1040-1105 Assessment of Valvular Mass Dr Lim Bee Chian, SMC, Malaysia

1105-1130 Mitral Valve EvaluationDr Mohd Sapawi Mohamed,

HRPZII, Malaysia

1130-1200 Aortic Valve EvaluationDr. Lee Zhen Vin, UMMC,

Malaysia

1200-1245

Lunch symposium - Courtesy of Pfizer Malaysia Sdn. Bhd

Are All NOACs The Same? Navigating Evidence From RWE


Chairperson: Dr W Yus Haniff W Isa, HUSM, Malaysia

1245-1430 Friday prayers/Break

1430-1455 Evaluation of Common Adult Congenital Heart Disease (ASD,VSD,PDA)Prof Colonel (R) Dr Pauzi Ibrahim,

UNISZA, Malaysia

1455-1520 Echo QuizDr Mohd Sapawi Mohamed,

HRPZII, Malaysia

1520-1540 Tea Break

1540-1800 Guided Hands On Practical Sessions with Experts All speakers

1800-1930

Dinner symposium - Courtesy of Merck Sharp & Dohme

1) Simplifying the Complexity of T2DM

Speaker: Assoc Prof Dr Wan Mohd Izani Wan Mohamed, HUSM, Malaysia

2) Lipid Lowering Therapy In Patients with Peripheral Artery Disease

Speaker: Dr Shaiful Azmi Yahaya (IJN), Malaysia

Chairperson: Dr Mohd Rafizi Mohamed Rus, Hospital Angkatan Tentera Tuanku Mizan, Malaysia

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Main Conference20th -21st October 2018

(Saturday & Sunday)

Venue: Dewan Bunga Emas, Hotel Perdana, Kota Bharu

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MAIN CONFERENCE


Saturday (20th October 2018)

TIME TOPICS SPEAKERS


0830-0900 Plenary lecture - Enhancing care through applied cardiology

Prof Dato' Dr Zurkurnai Yusof,

Hospital Universiti Sains Malaysia

(HUSM),Malaysia

0900-0930

Opening ceremony and booth visit by Deputy Director General of Health (Medical)

Dato’ Dr. Hj. Azman bin Hj. Abu Bakar

On behalf of Minister of Health Malaysia

0930-1030 Morning break

1030-1100

Morning Symposium- Courtesy of Astra Zeneca

How to improve NSTEMI patient outcome

Speaker: Dr Hamat Hamdi Che Hassan, UKMMC, Malaysia

1100-1345 HEART FAILURE UPDATE

1100-1130 Shortness of breath - Is it heart failure?Dr Lim Bee Chiam, Sunway

Medical Centre, Malaysia

1130-1200 Management of pregnant mother with unifocal and multifocal PVCsProf Dr Imran Zainal Abidin,

UMMC, Malaysia

1200-1230 Hope in the non-ischaemic heart failure.Assoc. Prof Dato' Dr Oteh

Maskon, UKMMC, Malaysia

1230-1245 Q & A Session/ Quiz Time

1245-1345

Lunch symposium- Courtesy of Phillips Malaysia Sdn. Bhd.

iFR: Current evidence and novel applications

Speaker: Dr Martijn Van De Giessen, Phillips Health System, Singapore

1400-1730 CARDIOLOGY PREVENTION UPDATE

1400-1430 Secondary Prevention following ACS: how to improve in AsiaDr Anwar Santoso, Harapan Kita

Hospital, Indonesia

1430-1500 Impact of new hypertension guidelines on clinical practiseDr Ng Wai Kiat, Pantai Hospital,

Malaysia

1500-1530 Tea Break

1530-1600 Reality of diabetic control in secondary prevention of MACEAssoc. Prof Wan Mohd Izani Wan

Mohamed, HUSM, Malaysia


1630-1730

Evening tea symposium - Courtesy of Bayer Malaysia Sdn. Bhd.

Untangling the Evidence : What matters for the patients with AF and comorbidities?


Chairperson: Dr Ng Wai Kiat, Pantai Hospital, Malaysia

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MAIN CONFERENCE


Sunday (21st October 2018)

TIME TOPICS SPEAKER

0800-1000 MATERNAL CARDIOLOGY UPDATE

0800-0830 How to improve morbidity and mortality in heart failure?Dr Liew Houng Bang, Queen

Elizabeth II Hospital, Malaysia

0830-0900 Management of pregnant with heart failure

Dr Muhamad Ali SK Abdul Kader,

Penang General Hospital,

Malaysia


0915-0930 Short break/booth visit

0930-1000

Morning Symposium- Courtesy of Boston Scientific (M) Sdn Bhd (CRM)

Non pharmacological alternative for stroke prevention in non-valvular atrial fibrillation

Speaker: Prof Dato' Dr Wan Azman Wan Ahmad, UMMC, Malaysia

1000-1245 CLINICAL CARDIOLOGY UPDATE

1000-1030 STEMI network : The impact to society

Datuk Dr. Abdul Kahar Bin Abdul

Ghapar, Hospital Serdang,

Malaysia

1030-1100 Neglected valvular heart disease in the youngDr Liew Houng Bang, Queen

Elizabeth II Hospital, Malaysia

1100-1130 Are there roles for warfarin in the new era?Prof Dato' Dr Wan Azman Wan

Ahmad, UMMC, Malaysia


1145-1230

Lunch symposium- courtesy of Novartis Corporation (M) Sdn. Bhd

Heart Failure Today: Current practices & implications

Speaker: Dr W Yus Haniff W Isa, HUSM, Malaysia

Chairperson: Dr Mohd Sapawi Mohamed, HRPZII, Malaysia

1230-1245 Best Poster Prize & Closing Remarks by Programme Chairperson

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Interventional

Cardiology

Workshop20th – 21st October 2018

(Saturday & Sunday)


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NHAM ICSM Angioclub



INTERVENTIONAL CARDIOLOGY

WORKSHOP20th October 2018 (SATURDAY)

Time: 1430-1830TIME TOPICS SPEAKER


1430-1500 Matching coronary lesions with correct toolsDr Shaiful Azmi Yahaya, IJN,

Malaysia

1500-1530 Approach to calcified, long and bifurcation coronary diseaseProf Dato' Dr Wan Azman Wan

Ahmad, UMMC, Malaysia

1530-1545 Q & A Session

1545-1600 Tea time Courtesy of Boston Scientific (M) Sdn Bhd.

1600-1700 Hands on with experts

1700-1830 NHAM ICSM Angio Club Meeting-1

1830-1930 Dinner Courtesy of Abbot Vascular (M) Sdn Bhd.

21st October 2018 (SUNDAY)

Time: 0900-1300

0900-0930 Tips on managing emergency cases and complicationsDr Shaiful Azmi Yahaya, IJN,

Malaysia

0930-1000 Approach to CTO: Tips for Young CardiologistDr Muhamad Ali SK Abdul kader,

Penang GH, Malaysia

1000-1015 Q & A Session

1015-1030 Tea Time courtesy of (Asahi)Gaia Medical Sdn Bhd.

1030-1130 Hands on with experts

1130-1300 NHAM ICSM Angio Club Meeting-2 and closing remarks by the organizer.

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SPEAKERS CURRICULUM VITAE(In alphabetical order)

DATUK DR. ABDUL KAHAR BIN ABDUL GHAPARDr Abdul Kahar Abdul Ghapar is a senior consultant cardiologist at Hospital Serdang. He is current Head of CardiologyService Ministry of Health Malaysia. He graduated in Universiti Kebangsaan Malaysia in 1990 and obtained Master inInternal Medicine in 1998. He has trained 19 cardiologist since 2006. He has involve in many major landmark studiesin cardiology such as RELY, RECORD_AF, HOPE 3, TRILOGY and many more. He is a fellow of Asia Pacific Society ofInterventional Cardiology (FAPSIC), ASEAN college of Cardiology (FACC), National Heart Association of Malaysia(NHAM). He has given numerous lectures at national conferences and scientific meetings. He is the clinicalinvestigator for international clinical trials and has published in both national and international journals.

DR. ANG KAI PINGDr Ang Kai Ping is a Consultant Cardiologist and Electrophysiologist at Sultanah Aminah Hospital, Johor Bahru. Hegraduated from the Universiti of Malaya in 2005. He obtained membership of Royal College of Physicians - MRCP(UK)& MRCP(London) in 2011 and was gazetted as an Internal Medicine specialist by the Ministry of Health (MOH)Malaysia in 2012. He underwent his cardiology fellowship training with the MOH Malaysia and subsequently pursuedelectrophysiology training at National University Hospital Singapore. He has vast experience in cardiac deviceimplantation and electrophysiological study. He has given numerous lectures at national conferences and scientificmeetings. He is the clinical investigator for international clinical trials and has published in both national andinternational journals.

DR. ANWAR SANTOSO, Sp.JP(K)Dr Anwar Santoso is a Clinical Researcher in the Division of Cardiovascular Research and Consultant Cardiologists ofHarapan Kita Hospital, Jakarta, Indonesia. He is also a Lecturer in the Department of Cardiology in the Faculty ofMedicine, Universitas Indonesia. Dr Santoso did his general and specialist medical training at Airlangga University,Indonesia and received his PhD from Udayana University, Bali, Indonesia. He also completed his advanced cardiologytraining at Epworth Hospital and Victoria Heart Centre in Melbourne, Australia. Dr Santoso is a fellow of the AseanCollege of Cardiology, International College of Angiology, American College of Cardiology and European Society ofCardiology and is the current Chairman of Indonesian College of Cardiology. He is the past President of the IndonesianHeart Association (2014-2016) and the President Elect of Asean Federation of Cardiology. Dr Santoso has publishedextensively in the field of cardiology and remains very involved in academia and training. He served as an EditorialBoard of International Journal of Angiology (2014 – now) and a Journal Reviewer of The Anatolian Journal ofCardiology (2018 – now) and a Journal Reviewer of Indonesian Biomedical Journal (2009 – now). He previously wasthe Principal Investigator of PLATO study and currently is the National Lead Investigator of the ongoing TIPS3 studyand received research grant from PHRI (Population Health Research Institute) of Mc-Master University – Hamilton. Asan expert in cardiovascular diseases, Dr Santoso was the National Coordinating Investigator of the PLATO andCOSIMA-2 studies and one of the Investigators of the ADHERE registry and AVERROES clinical study. Dr Santoso’s workhas been published in several peer-reviewed journals including Atherosclerosis, Heart, Lung and Circulation, AmericanHeart Journal, Journal of Hypertension, Diabetes and Vascular Disease Research, J of ClinExp Cardiology andInternational Journal of Angiology.

PROFESSOR DR. IMRAN BIN ZAINAL ABIDIN Mmed (UM), MBBS (UM)Professor .Dr. Imran Bin Zainal Abidin is a senior consultant cardiologist and senior lecturer at Universiti MalayaMedical Center (UMMC). He is a fellow of the National Heart Association of Malaysia (FNHAM), ASEAN College ofCardiology (FAsCC), Asian Pacific Society of Cardiology (FAPSC), and a member of Society of Pacing and CardiacElectrophysiology (SOPACE), Cardio Rhythm 2015 and European Heart Rhythm Association (EHRA). He has givennumerous lectures at national conferences and scientific meetings. He is the clinical investigator for internationalclinical trials and has published in both national and international journals.

DR. LEE ZHEN-VINDr. Lee Zhen-Vin is an interventional cardiologist fellow and a lecturer at Universiti Malaya Medical Centre (UMMC).He is a clinical investigator and sub-investigator for numerous national and international clinical trials. He haspresented papers in both national and international cardiology conferences.

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DR. LIM BEE CHIANDr. Lim Bee Chian is a consultant cardiologist in Sunway Medical Centre and a fellow of the National Heart Associationof Malaysia (FNHAM) and Academy of Medicine Singapore. He is actively performing both invasive and non-invasivecardiology procedures including mitral clip implants and interventional cardiology procedures. He is actively givennumerous lectures at national and international scientific meetings.

DR. LIEW HOUNG BENGDr Liew Houng Bang is the current Head Of Cardiology Department at Queen Elizabeth II Hospital Kota Kinabalu .Hegraduated from The Queen’s University of Belfast, UK in 1993. Returned to serve in MOH in 1995. He is a member ofthe Royal College of Physician, UK since 1998, and a conferred a Fellowship in the royal college. He further hisprofessional training in Cardiology Fellowship at Sarawak General Hospital in 2002, and Boxhill Melbourne.Later,hesubspecialised in interventional cardiology. He is involved in ISR and IIR over the years as Principal Investigator and Co-investigator. Many of his research projects have been presented at both local and international conferences. Hiscurrent research interests include acute coronary syndromes, valvular heart disease, adjunct pharmacotherapy in PCI,echocardiography, cardiac imaging.

DR MANSOR YAHYADr Mansor bin Yahya is a Consultant Cardiologist at Hospital Raja Perempuan Zainab 2 Kota Bharu.He from MedicalFaculty Universiti Kebangsaan Malaysia 1991 and obtained Master of Medicine from Universiti Sains Malaysia 1999.Heunderwent his cardiology fellowship training at Penang Hospital and Interventional Cardiology at King Fahd MillitaryHospital ,Jeddah,Saudi Arabia.He active in teaching nursing student, medical students and doctors.He has been doinga lot of researches locally and internationally.

DR. MOHD SAPAWI MOHAMEDDr. Mohd Sapawi Mohamed is currently a consultant cardiologist in Hospital Raja Perempuan Zainab II. He was theprevious Head of Cardiology Department at Hospital Sultanah Nur Zahirah, Terengganu. He is a fellow of the NationalHeart Association of Malaysia (FNHAM),European Society of Cardiology (FSEC) and American College of Cardiology(FACC). He has delivered numerous lectures at national conferences. He is the clinical investigator for numerousinternational clinical trials and has published in both national and international journals.

DR. MUHAMAD ALI SK KADIRDr Mohd Ali SK Kadir is a consultant cardiologist at Hospital Pulau Pinang. He is a fellow of the National HeartAssociation of Malaysia (FNHAM), ASEAN College of Cardiology (FAsCC) and American College of Cardiology (FACC). Heis specialises in interventional cardiology procedures. He has given numerous lectures at national conferences andscientific meetings. He is the clinical investigator for international clinical trials and has published in both national andinternational journals

DR. NG SENG LOONGDr. Ng Seng Loong is Interventional Cardiologist & Physician at Perak Community Specialist Hospital. He is a fellow ofthe USM Alumni (PADU-USM). He has delivered lectures during Cardiology conferences and is also clinical sub-investigator for numerous international clinical trials. He has presented papers and published in both national andinternational journals.

DR. NG WAI KIATDr. Ng Wai Kiat is a senior consultant cardiologist at Pantai Hospital Kuala Lumpur and also the past president of theNational Heart Association of Malaysia (NHAM). He is also a fellow from the Royal Australasian College ofPhysician(FRACP). He has delivered numerous lectures at cardiology conferences and workshops. He has givennumerous lectures at national conferences and scientific meetings. He is the clinical investigator for internationalclinical trials and has published in both national and international journals.

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ASSOCIATE PROFESSOR DATO’ DR. OTEH MASKONAssoc. Prof. Dato’ Dr. Oteh Maskon underwent his undergraduate medical training at Royal College of Surgeons inIreland, Dublin. He completed MRCP (Ireland) and joined the Internal Medicine and Cardiology Training in Ireland,completed Masters in Cardiology (MSc Cardiology) from the Trinity College, Dublin in 2005. Now he is a seniorConsultant Cardiologist and Head of Cardiology Unit at UKM Medical Centre a position he held since April 2005. Hewas appointed Head of the Heart and Lung Centre, UKM (2013-2016). Though his main practice as InterventionalCardiologist he has interest in Coronary artery disease and dyslipidaemia, with a particular clinical interest in HeartDisease in Young People. Besides the UKMMC, he also runs private practice clinics and inpatient services at the UKMSpecialist Centre (UKMSC). He was appointed lecturer and Clinical Associate Professor under the Faculty of Medicinein 2007. He had participated in many multicentre clinical trials and numerous fundamental researches includingcollaboration with various institutions in the country. He has over 50 publications in international journals andappointed as faculty members in a number of international meetings, as well as speakers at national and internationallevels. Dr. Oteh was among the first recipients of Fellowship of the National Heart (FNHAM) in 2007, and a councilmember of NHAM for the session 2010-2012. He was also a member of the Clinical Practice Guidelines on StableCoronary Artery Disease, Acute Coronary Syndrome, STEMI and Atrial Fibrillation and had participated as organisingcommittee members for the NHAM and Mylive annual Congress, and the Asian Pacific Cardiology Congress (APCC) inKuala Lumpur (2010).

PROFESSOR DATUK DR WAN AZMAN BIN WAN AHMADProfessor Datuk Dr Wan Azman Bin Wan Ahmad is affiliated to numerous international and national professionalboards in his areas of expertise which includes cardiology and internal medicine. Recent publications include theEffect of Clopidogrel Added to aspirin in Patients with Atrial Fibrillation, The ACTIVE Investigators in the New EnglandJournal of Medicine, and Underutilization of Angiotensin Converting Enzyme Inhibitors Among Heart Failure Patientsin the Medical Journal of Malaysia. Areas of research includes the Detection of Familial Hypercholesterolemia genemutation amongst the Malaysian population and Prognostic markers in Newly diagnosed hypertensive and Diabeticsin collaboration with the Ministry Of Science, Technology, and Innovation. He has also served as a consultant onseveral projects in his areas of expertise as well as developed the Islamic perspective of Medicine.

PROFESSOR COL (B) DR. WAN PAUZI WAN IBRAHIMProfessor Col (B) Dr. Wan Pauzi Wan Ibrahim is a consultant interventional paediatric cardiologist and Head ofPaediatric Departement at Universiti Sultan Zainal Abidin (UniSZA). He has vast experience in paediatric cardiacprocedures including atrial and ventricular septal defect device closures. He is also involved in clinical studies andpublished in journals. He has actively involved in delivering lectures at paediatric cardiology conferences

DR. W YUS HANIFF W ISADr. W Yus Haniff W Isa is an interventional cardiologist and a lecturer at Universiti Sains Malaysia (USM). He is a clinicalinvestigator and sub-investigator for numerous national and international clinical trials. He has presented papers inboth national and international cardiology conferences.

PROFESSOR DATO’ DR. ZURKURNAI YUSOFProfessor Dato’ Dr. Zurkurnai Yusof is the Head of Cardiology Unit and Head of Research cluster group in UniversitiSains Malaysia (USM). He is also currently Head, Department of Medicine, School of Medical Science, Universiti SainsMalaysia. He graduated with an M.D from Universiti Kebangsaan Malaysia and Master in Internal Medicine fromUniversiti Sains Malaysia. He did his training in cardiology at National Heart Institute followed by a fellowshipprogramme in interventional cardiology at Hallstrom Institute, Royal Prince Alfred Hospital, Sydney, Australia. He wasgazetted as a cardiologist whilst working in cardiology Unit at Penang Hospital, Penang. His areas of interest includescoronary interventions, cardiac device implantations, arrthymias, heart failure and echocardiography. He is a fellow ofthe National Heart Association of Malaysia (FNHAM) and ASEAN College of Cardiology (FAsCC) .He is a reviewer fornumerous Malaysian Clinical Practice Guidelines and has delivered lectures at cardiology conferences and scientificmeetings. He is also a reviewer for American Journal of Cardiology. He has also published many clinical papers in bothnational and international journals. He is also involved in numerous international landmark clinical trials includingHEAL, ONTARGET/TRANSCEND, ARISTOTLE, GEMINI-AALA, ROCKET-AF, ATLAS- TIMI, TRILOGY and EXAMINE study.

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ABSTRACTS

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P01. A Rare, Fatal Case of Group B Streptoccocus Related Necrotizing Soft Tissue Infection of the Lower Limbs, Complicated by Purulent Pericarditis and Cardiac Tamponade.Raja Shariff REF1, Khir RN1, Abdul Rahman E1, Ibrahim KS1, Mohd Razi AB1, Ismail JR1, Chua N1, Wen LC1, Alza H1, Kassim SS1

1 UNIVERSITI TEKNOLOGI MARA, SUNGAI BULOH

INTRODUCTION: Necrotizing soft tissue infections (NSTI) are severe and rapidly progressive.Rarely, Group B Streptococcus (GBS) can cause NSTI, majority due to an immunocompromisedstate. Even more uncommon is pericardial involvement following NSTI of a non-adjacent structure.

CASE REPORT: We report a challenging case of NSTI of the lower limbs due to GBS, with acutepericardial dissemination leading to cardiac tamponade. Bedside echocardiography revealed amassive pericardial effusion, measuring largest at 2 cm in depth, with evidence of both right atrialand ventricular collapse, leading to an urgent pericardiocentesis being performed which revealedturbid-looking aspirate. Urgent gram staining revealed moderate amounts of pus cells withoccasional gram positive cocci. Wound debridement was performed on day 3 of admission, andtissue cultures were taken peri-operatively. Cultures from blood, pericardial aspirate and tissueaspirate were positive for Streptococcus Agalactiae. Unfortunately, the patient deteriorated post-operatively due to extensive blood loss and overwhelming septicaemia and succumbed to hisillness 72 hours after.

CONCLUSION: This case highlights the rare possibility of cardiac involvement in cases of NSTI, andthe possibility of cardiac tamponade causing cardiogenic shock masquerading alongside septicshock, and reminds clinicians on the importance of combining clinical acumen and appropriateancillary testing to facilitate early detection of a fatal condition

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P02. A Rare, Fatal Case of Burkholdellia Pseudomallei Infection Presenting as Purulent Pericarditis and Cardiac Tamponade.Raja Shariff REF1, Khir RN1, Abdul Rahman E1, Ibrahim KS1, Mohd Razi AB1, Ismail JR1, Chua N1, Wen LC1, Alza H1, Kassim SS1


INTRODUCTION: Meliodosis is a common cause of disseminated infection in South East Asia.However, pericardial involvement is relatively rare. Even more uncommon is pericardialdissemination leading to cardiac tamponade as an initial presentation.

CASE REPORT: We present a challenging case of severe septicaemia secondary to BurkholdelliaPseudomallei with concurrent cardiac tamponade due to purulent pericarditis from the sameorganism, proven on aspirate cultures. A 71-year old gentleman of Chinese ethnicity presented tothe emergency department after suffering from a sudden onset of shortness of breath andepigastric pain on the day of admission. Due to clinical findings on examination, this prompted afocused, bedside echocardiography scan which revealed a massive pericardial effusion, measuring3.1cm largest, with evidence of right ventricular collapse. An urgent pericardiocentesis andpericardial drain insertion was performed, revealing purulent pericardial fluid, which was sent forcultures and sensitivity. Initial pericardial fluid gram stain revealed non-lactose fermenter, gramnegative rods resembling concurrent blood culture samples sent, which was later confirmed to beBurkholdellia Pseudomallei. Unfortunately, there was little improvement in haemodynamicsdespite inotropic support and intravenous meropenem being initiated and the patient succumbedwithin 48 hours of admission.

CONCLUSION: Albeit rare, this case highlights the importance of keeping Meliodosis in mind aspart of a clinician’s differential diagnosis, especially in endemic areas like Malaysia, in case ofconcurrent septicaemia and pericardial involvement.

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P03. A Unique Case of Arrhythromogenic Right Ventricular Dysplasia Diagnosed with Assistance from Characterization of Cardiac Tissue in a Deceased Sibling.Raja Shariff REF1, Khir RN1, Abdul Rahman E1, Ibrahim KS1, Mohd Razi AB1, Ismail JR1, Chua N1, Wen LC1, Alza H1, Kassim SS1


INTRODUCTION: Arrhythromogenic Right Ventricular Dysplasia (ARVD) is a rare cause ofcardiomyopathy and sudden cardiac death. Often times, diagnosis relies on electrocardiographyfindings and magnetic resonance imaging of cardiac tissue, when available. Rarely, diagnosis isconfirmed via histological evidence from an affected sibling.

CASE REPORT: We present a rare case of ARVD diagnosed via characterization of cardiac tissue ofan affected, deceased sibling. A 21-year old gentleman presented to the emergency departmentfollowing an episode of loss of consciousness. Chest radiography revealed cardiomegaly andelectrocardiogram (ECG) revealed deep T-wave inversions in leads V2 to V4, with ventricularectopic beats. Troponin-I levels were elevated at 480 pg/ml. It was revealed that the patient had asibling who had died from an unknown cause, 5 years prior. His younger brother, 14 years of age atthe time, had collapsed whilst playing basketball in a school compound. Unfortunately, he waspronounced dead on arrival to a medical facility. Autopsy findings revealed epicardial surfacesinfiltrated with excessive fat tissue and with nodular fibrosis with cut sections showing diffusetransmural fibrofatty replacement of the right ventricular free wall extending to the endocardiuminvolving right ventricular septum. This knowledge led to our patient having a cardiac MRperformed, confirming a diagnosis of ARVD.

CONCLUSION: The case highlights how having knowledge and confirmation of the inheritedcondition led to a quicker and more confident decision in managing a patient at high risk of SCD, asour patient was able to obtain an implantable cardiac defibrillator without much hesitation.

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P04. Electrical Storm in a Patient with Implantable Cardioverter-Defibrillator: A Case Report NC Huan, T Aizan Izzati T Mohd YatimDepartment of Medicine, Labuan Hospital, Federal Territory of Labuan, Malaysia

INTRODUCTION: Electrical storm (ES) is a life threatening medical emergency characterized bypresence of three or more episodes of sustained ventricular arrhythmias, or three or moreappropriate shocks in patients with implantable cardiac devices within 24 hours. Its clinicalpresentation can be dramatic.

CASE REPORT: In this case report, we describe a 70 year old lady with congestive cardiac failurewith an implantable cardioverter-defibrillator (ICD) presenting with multiple episodes of suddenloss of consciousness. Prior to this she complained of a 5 day history of cough and fever.Assessment during admission was unremarkable apart from multiple episodes of sustainedventricular tachycardia and torsades des pointes triggering multiple ICD shocks. During stay sherequired intubation and mechanical ventilation for airway protection and sedation. She was givenintravenous amiodarone as her electrolytes were corrected which fortunately accompanied withresolution of ventricular arrhythmias. She was also given intravenous amoxicillin-clavulanate acidfor community acquired pneumonia. A thorough device check confirmed that her ICD wasfunctioning properly. She was discharged well after approximately 10 days of stay.

DISCUSSION: Treatment and management of ES is complex and challenging as it requires anunderstanding of mechanism of arrhythmias, determining and correcting the underlyingischaemia, infection and electrolyte imbalances, device reprogramming, utilizing anti-arrhythmicagents as well as consideration for radiofrequency catheter ablation in selected cases. Aftertreatment of the acute event, subsequent management should be tailored towards optimizingmedical and surgical therapy of heart failure.

CONCLUSION: In conclusion, ES is a life threatening condition with an increasing incidence due towider availability of ICD and improved survival rates among patients with advanced cardiac failure.It is vital for clinicians to be aware of this condition as early recognition and prompt treatment ofES are vital to ensure a better clinical outcome.

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P05. Comparative Study of Echocardiographic Doppler Flow Velocities in LeftVentricular Apical, Mid and Outflow Area in Patients with Heart Failure andNormal Subjects.Nordin M.Hakimi1,WYH W Isa1, Z Yusof 11Cardiology Unit,HUSM,Kubang Kerian.

INTRODUCTION: Heart failure has remain as a one of the major contributory factor forhospitalization and mortality, not only in Malaysia, but the whole world wide as well. Thus,detection during the preclinical phase is crucial for preventive measurement. Ejection fraction (EF)is one of the ECHO parameters that has been widely used, particularly to assess systolic LVfunction. Nevertheless, its value is limited in preclinical phase because of its volume dependent.Another echo modality which is tissue Doppler imaging has been useful to detect regionalmyocardial wall strain. Studies showed myocardial wall strain rate and speckled tracking image hadgiven an accurate measurements of regional LV wall contractility and correlate better with theglobal systolic function. Unfortunately, those parameters were not widely used as it required hightechnical skills and experience. Thus, other modalities to assess regional wall motion abnormalitywhich might be more user friendly are needed. This study primarily design to evaluateintraventricular velocities and pressure gradient that might representing one of the modalities toassess regional LV wall contractility in a simple way yet accurately.

OBJECTIVES: To determine and compare flow velocities in the left ventricle apical, mid and outflowarea among heart failure patients and normal patients.

METHODS: This is a comparative cross-sectional echocardiography pilot study. 42 patients werepresented to HUSM with heart failure symptoms were identified and screening ECHO were done.12 patients were excluded due to inclusion and exclusion criteria were not fulfilled. 30 healthyvolunteers were recruited for the control group after screening ECHO were applied.We evaluate intraventricular velocities and pressure gradient at 3 area in LV cavity (left ventricularoutflow tract (LVOT),mid and apical) which were sampled by pulse wave Doppler.

RESULTS: Mean of intraventricular velocities and pressure gradient(SD) were recorded highest atLVOT area compare to other area among heart failure patients(1.51(2.0) and 3.01(1.28)respectively),also those values were higher if sampled towards (T) the transducer compare toaway (A) the transducer in each area of LV cavity. There was a significant mean differences ofvelocities measurements based on pressure gradient in LVOT A (mean difference: 1.95; 95% CI:1.15, 2.74; p-value<0.001) and also a significant mean differences of Mid T and Mid A betweenheart failure patients and control group (mean difference: 1.45; 95% CI: 0.89, 2.02 and 0.63; 95%CI: 0.23,1.02; p-value<0.001 respectively).Meanwhile, no significant value in comparison betweenthose 2 groups by using intraventricular velocities. There were no significant value in relationshipbetween intraventricular velocities and pressure gradient with other systolic indices and ECHOparameters.

CONCLUSION: This small pilot study has shown only intraventricular pressure gradient as one ofthe possible modality to assess regional wall motion abnormality if sampled at the LVOT and midarea. Hence further studies with bigger sample are highly recommended.

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P06. A first reported case of successful chronic lead extraction with lead extractor –EvolutionP. L. Ingrid Ting1, WYH W Isa1, Mat Saad A.Z2, Z Yusof1

1Department of Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia2Department of Plastic Surgery, School of Medical Sciences, Health Campus, Universiti SainsMalaysia, Kubang Kerian, Kelantan, Malaysia

INTRODUCTION: A pacemaker is becoming more regular in tandem with more access tospecialized cardiology care. Hence with increasing numbers, there is an increase in the rate ofcomplications. One of these is pacemaker lead infection. This is a rare condition, most oftenoccurring following battery changes long after pacemaker implantation. However, when occur it islife threatening as hematogenous dissemination can happen. A complete removal of all the foreignmaterial is suggested, whether it is endocarditis or an obvious pocket infection. Removal ofchronic leads are complex which can be done either by surgical removal; thoracotomy andextracorporeal circulation or percutaneous removal by constant traction or intravascular extractiontechniques. In this case, we describe a first successful removal of chronic dual chamber leads usinga mechanical lead extractor device in Malaysia.

CASE REPORT: 66 years old, female with sick sinus syndrome which was diagnosed in 2001, andhad a dual chamber permanent pacemaker (PPM) inserted in the same year. She underwentbattery changed twice, first in 2010 uneventful and subsequent in 2016 but was complicated withwound infection. She was treated initially with high dose intravenous cloxacillin and cefuroxime,however, the affected area became more swollen and she underwent incision and drainage of puswhich was followed by a wound debridement. Initial tissue culture grew Proteus mirabilis. Thepacemaker box was taken out and a temporary pacemaker was inserted. The old leads were keptand left in situ. After the PPM box was sterilised by ethylene oxide method, the PPM wasreimplanted on the right side. The wound on the old side (left) was debrided again, while the oldleads were capped and implanted at the subpectoral area to avoid contamination and reinfection.This was done after verifying the wound was clean and c&s no more growth. However despiteprolonged antibiotics, the old pockets still have poor wound healing. Repeated swabs from thewound and subsequent cultures showed no organism growth. The decision was made to removethe old leads. The procedure was done in the cardiac operation theatre under general anesthesiawith the Cardiothoracic team on standby for any perforation/complications. Both leads weresuccessfully removed with mechanical lead extractor (Cook Medical). Antibiotics were continuedpost operatively. The patient recovered successfully subsequently. The new leads on the right sidenever showed any signs of infection.

CONCLUSION: The traditional way of removal of an infected pacemaker leads by percutaneousextraction or open chest surgery may be difficult on chronically implanted leads which haddeveloped fibrous adhesions around the surrounding structures. Thus, requiring more advanceextraction tools, such as laser devices and electrosurgical dissection sheaths. The use of therecently introduced evolution system for lead extraction exhibits acceptably high levels ofprocedural and clinical success. This is the first such case in Malaysia.

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P07.Gastrointestinal Bleeding Risk Assessment Using HAS-BLED In AtrialFibrillation Patients Who Are Receiving Warfarin In HUSMSS Idris1, Amry A Rahim1

1School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia.

INTRODUCTION: HAS-BLED is one of the bleeding risk assessment often used before startinganticoagulant among AF patients. Prior to starting treatment, bleeding risk need to be assess inorder to minimize patients’ risk of bleeding. As there has been an increase usage of anticoagulantamong atrial fibrillation patients worldwide, bleeding rate was also thought to be raisedparticularly from the gastrointestinal. HAS-BLED is a simple and user friendly to use. Unfortunately,the utilization of HAS-BLED prior to starting anticoagulant remains unknown. The aim of this studywas to determine the rate of utilization of HAS-BLED and the impact of the usage of this score withrate of GIB among AF patients who were on warfarin.

METHODS: This retrospective study was performed among atrial fibrillation patients who attendedoutpatient clinic in HUSM between January 2011 to December 2017. 88 patients were eligible forthis study and their HAS-BLED was assessed. Patients above 18 years old with atrial fibrillation whoreceived warfarin were included in this study. Exclusion criteria include those who are takingwarfarin for other cause than atrial fibrillation and who were taking warfarin prior to HAS-BLEDestablishment (<2011). Patients were group into those with and without HAS-BLED at the time ofwarfarin commencement. Number of patients with GIB among these 2 group were assessed. Theclinical characteristics and severity of GIB was determined. The association between GIBoccurrences among both groups were evaluated.

RESULTS: Among the selected 88 patients, the incidence rate of GIB is 5.7 cases per 100 patient-years. 44 (50%) had HAS-BLED assessment done prior to starting anticoagulant. The mean age ofthose who received warfarin was 64 years old with gender equally distributed. 83 (94.1%) patientswho were started on warfarin had CHA2DS2 VASc score ≥2. GIB occurred in 11 (12.5%) out of 88patients. 6 (13.6%) patients were with HAS-BLED and 5 (11.4%) were belong to the high risk group.The mean HAS-BLED score for patients with GIB was 2.83 (±0.98). The bleeding rate for score of 1was 0.54 per 100 patient-years and score of 3 was 2.63 per 100 patient-years. There was noassociation between GIB and HAS-BLED (p value= 0.747). There was association between GIB andduration of warfarin intake less than 30 days (p value <0.005).

CONCLUSION: HAS-BLED is valuable in determining patients GIB risk prior to starting warfarin.With increasing HAS-BLED, rate of GIB was also increased among AF patients in HUSM

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P08.Coronary Artery Calcium Score In Asymptomatic First Degree Relatives With Family History Of Young Coronary Artery Disease: A Pilot StudyMaskon O, Mustapa R, Mohamad SF, Che Hassan HH, Abu Bakar N, Govindaraju S, Wei Jyung PT, Azhar Shah S

INTRODUCTION: A family history of coronary artery disease (CAD) at young age is a known riskfactor for premature CAD. Conventional risk assessments that are available underestimate the riskof developing future CAD in some patients. Primary prevention screening with coronary arterycalcium (CAC) score has been advocated as a way to improve risk assessment and to detectsubclinical atherosclerosis independent of other risk factors.

OBJECTIVE: The aim of this study is to compare the value of CAC score, baseline characteristicsand newly diagnosed risk factors in primary prevention screening between young asymptomatic,first degree relatives (FDRs) with family history of young CAD and similar participants withoutfamily history of CAD.

METHOD: This is a comparative cross-sectional study which recruited asymptomatic FDRs of youngCAD patients and asymptomatic participants without family history of CAD (control) who attendedthe Cardiology clinic at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from September2017 to March 2018. Both participants were age and gender matched. Those with target organdamage, malignancy or potentially pregnant were excluded. Their baseline characteristics andbaseline blood screening were obtained prior to CAC scan. Exercise stress test (EST) and CAC scanwere performed as per protocol and assessed accordingly. Statistical analysis were calculated tocompare the differences between the two groups.

RESULTS: We analysed 36 asymptomatic participants (n=18 from each group) (66.7% female; mean(±SD) age 36.9 (±4.9) and 38 (±3.8) in FDRs and control respectively. There were high prevalence ofpre-obese and obesity as well as abdominal obesity in both groups. The control group exhibitedmore comorbid risk factors (namely hypertension, Diabetes and dysplipidaemia) compared to FDR,50% vs 5.6%, p = 0.04. Newly diagnosed dyslipidaemia was higher in FDRs (83.3% vs 44.4%, p <0.01) while other newly diagnosed comorbidties were similar in both groups. The prevalence oflow and moderate risk FRS were 88.9% and 11.1% respectively in FDRs, and similar in control. ESTwere negative in 88.9% of both FDR and control. CAC score > 0 was higher in FDRs compared tocontrol (11.1% versus 0%, p> 0.05). Participants with CAC score > 0 all had normal EST and low riskFRS.

CONCLUSION: Among participants with family history of young CAD with predominance of youngwomen <40, they were found to have low to moderate FRS, mostly negative EST and low CACscore, suggesting their low risk of developing CAD. Similar findings were observed among thosewithout family history of young CAD. However, there were higher prevalence of obesity anddyslipidaemia comparing to national figure, indicating the importance of instituting early primaryprevention in both groups of patients.

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P09. Apical septal rupture: A clinical challenges in rarecomplication of myocardialinfarction case report.Firdaus Hadi1, Sazali Basri1, Nor Ashikin Md Sari1, Norazah Zahari1, Mazeni Alwi2 Wan Azman Wan Ahmad1,1 Cardiology Unit, University of Malaya Medical Centre, Kuala Lumpur, MALAYSIA2 National Heart Institute (IJN), Malaysia

INTRODUCTION: Ventricular septal rupture (VSR) is rare fatal complication of acute myocardialinfarction (AMI) with mortality 40% to 80%. Corrective intervention remains a clinical challenge.We report a successful transcutaneous secondary closure of apical ventricular septal rupturefollowing AMI.

CASE REPORT: A 58 years-old lady,3 days chest discomfort become more severe an hour priorpresentation to ED. Underlying DM and dyslipidaemia with ECG ST elevation leads II, III, AVF, V1 toV6 and streptokinase initiated. Upon review, a pan-systolic murmur at lower left sternal edge whileechocardiogram revealed left ventricular aneurysm and ventricular septal rupture of diameter 13to 14 mm with cardiac shunt (QP/QS) OF 2.7. Coronary angiogram showed significant mid LADlesion, 80% lesion in ostial to proximal LCX and no significant lesion in RCA. Balloon angioplastyand drug eluting balloon (DEB) to LAD was successfully done. CMR showed dilated LV withaneurysmal apical, preserved LVEF of 53%, inferoseptal wall rupture (20mm) and transmuralinfarcts LV apical wall. Although complicated with acute pulmonary oedema and acute kidneyinjury, she stable not required mechanical ventilation. Multidisiplinary, meeting was done anddecided for percutaneous closure under GA. Initial VSR closure with ASD closure device, rightfemoral artery and right internal jugular vein cannulated under GA. Left ventricular angiogram toidentify the VSR and was assisted with transoesophageal echocardiogram (TEE). The VSR wascrossed with 5F right Judkin’s (JR) catheter and 0.035” x 260 cm angled tip and Terumo-wiretrough right femoral artery. Goose neck snare 20 mm x 120 cm advance into RV via internal jugularvein and tip guidewire was retrieved out. Amplatzer delivery device introduced to VSR throughinternal jugular vein. The 16mm Amplatzer septal occluder was placed to VSR and the distal discwas opened and pulled back into LV under fluroscopic and TEE. Once septal alignment confirmed,proximal disc was opened. After ascertained placement by TEE and ventriculogram, device wasreleased. Repeated echocardiogram showed Amplatzer well seated at posterior-inferior wall of LVapex. Small residual with diameter of 3.3mm, left to right shunt and jet gradient 65mmHg. In viewsignificant shunt, secondary VSR closure was successfully done two weeks later with similar stepsand process with 8mm septal occlude. She remained well and was successfully discharged oneweek later. Repeated echocardiogram showed both occlude well seated at posterior-inferior wallregion of left ventricular apex and no residual ventricular septal defect seen. One month follow -upshe remained symptom free and had fair left ventricular function on echocardiogram.

DISCUSSION: VSR rarely complicating an AMI, it remains major concern and associated with highmortality. VSR bring clinical and management challenges in such critical patients. Management ofpatient should be individualized and approached by multidisciplinary decision for better outcome.

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P10. Aortic Arch Dissection Presenting as Painless Left-sided Pleural EffusionAdrian Mark Masnammany1, Woh Wei Mak2, Wu Jing Teng3

1Hospital Kuala Krai, Kelantan, Malaysia2Hospital Bentong, Pahang, Malaysia3Hospital Raja Perempuan Zainab II, Kelantan, Malaysia

INTRODUCTION: Thoracic aneurysm can result in complications of rupture, fistula formation andembolization. Left-sided haemorrhagic effusion is a rare presentation of painless leaking aorticdissection

CASE REPORT: 27 years old gentleman with young hypertension presented with progressiveshortness of breath for 1 week duration. He had no history of chest pain, fever, cough, failuresymptoms or constitutional symptoms. On examination, he was tachypneic, BP 84/43mmHg, HR138bpm, SpO2 96% on room air and afebrile. He remain hypotensive despite aggresive fluidresuscitation and was started on inotrope. Lung examination had reduced breath sounds and stonydullness on percussion over left lung field. Blood investigations: WBC 12x109/L, Haemoglobin15g/dL, platelets 358x109/L, renal and liver profile normal. Chest radiography revealed left pleuraleffusion. He was treated as pneumonia with parapneumonic effusion. However, his haemoglobinlevel reduced to 11.5g/dL within 24hours. A clinical suspicion of leaking aneurysm into lefthemithorax was made as patient was afebrile, and had reducing haemoglobin trend withincreasing inotropic requirement. Urgent CT angiogram showed focal aortic arch dilatationmeasuring 3.9x4.2x6.2cm with dissection extending distal to left subclavian artery and contrastleakage. There was also hematoma extending lateral to the descending aorta until thediaphragmatic level and massive left pleural effusion. Patient rapidly deteriorated and succumbedbefore cardiothoracic intervention could be made.

DISCUSSION: Acute pleural effusions are commonly caused by trauma, malignancy and pulmonaryembolism; however, ruptured thoracic aortic aneurysm is an important differential diagnosis.Radiographic evidence of a pleural effusion has been found in 19% of aortic dissections, and occurmore commonly among women. Early diagnosis of aortic dissection by CT is essential, becausemortality is 40% at presentation and increases by 1-2% per hour thereafter.

CONCLUSION: Leaking thoracic aortic aneurysm is an important and fatal cause for acute pleuraleffusion. High index of clinical suspicion is required to make prompt diagnosis and management.

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P11. The Study of Broken Hearts: A Pragmatic Case Report Based on TakotsuboCardiomyopathy in MalaysiaDr. Syeda Humayra, MD 1Prof Dato’ Dr. Abd. Rahim Bin Mohamad 2 Datuk Dr. Ab. Kahar Bin Ab. Ghapar 3

1Faculty of Medicine, Cyberjaya University College of Medical Sciences, Malaysia2Department of Cardiology, Hospital Serdang Malaysia

INTRODUCTION: Takotsubo cardiomyopathy (TTC), a rare clinical entity that represents as acuteheart failure and manifest symptoms similar to myocardial infarction, without an evident coronaryobstruction. Supposedly, it was first reported by Sato et al. in Japan 1990; and have been referredto octopuses’ trap for showing left ventricular wall abnormality during systole. TTC mostlydominates postmenopausal women and is often preceded by stressful events like physical traumaor emotional breakdown through an act of bereavement. The exact etiology and pathologyremains elusive though hypothesised that an adrenaline surge leads to catecholaminecardiotoxicity and myocardial stunning. Clinical diagnosis is confirmed by angiogram andventriculogram alongside elevation in cardiac biomarkers pro-BNP and NT pro-BNP

CASE REPORT: A 58-year-old, postmenopausal Indian woman was brought into the cardiologyclinic at Hospital Serdang after experiencing severe chest pain on emotional distress. The patienthad a previous medical history of DM, HTN and an event of CVA with no neurological deficit (ADLindependent). She was initially diagnosed at KPJ Kajang with transient apical ballooning syndromeand midbrain infarct causing her diplopia and syncope. A widespread ECG with profound ST-segment depression was found in almost all leads; CK levels:119 U/L, and a normal coronaryangiogram reported on admission. Suggestive scans and ECHO demonstrated 62% EF, stressinduced myocardial ischemia at apical segment of anterior wall (LAD territory) with mild perfusiondefect observed at stress and recovered on rest.

DISCUSSION: Takotsubo cardiomyopathy is characterized by acute myocardial stunning andaccompanied by left ventricular systolic dysfunction with distinctive apical ballooning in theabsence of obstructive coronary arteries. The clinical diagnosis of takotsubo is largely misguidingas the condition tends to mimic acute myocardial infarction. It presents in multiple forms with orwithout the typical stressors suggesting the pathophysiology of circulating catecholamine resultingmyocardial toxicity. In this particular patient the trigger was emotional loss as she witnessed herdaughter-in-law pass away in her arms after getting hit by her husband’s car accidentally.

CONCLUSION: Takotsubo is an acquired cardiomyopathy that recently gained popularity as the‘broken heart syndrome’ and emerged out as a momentous form of cardiac failure over the lastdecade. Recent studies reveal that TTC isn’t rare anymore, but awareness is needed to facilitatebetter cardiac management mostly in emergency department. Dramatically, 6-7% TTC admissionsare predominantly misdiagnosed as heart attack due to inevitable similarity with ACS. Therefore,acknowledging the disease and its overall effect on the sufferer’s heart is precisely fundamental.

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P12. Patient’s Knowledge of Coronary Artery Disease Risk Factors in CardiacRehabilitation Ward, Queen Elizabeth Hospital II, Kota Kinabalu, Sabah.Anibah Duani, Carol Jomin, Dr. Alfieyanto Saripudin, Dona Cyreline ChinCardiovascular Nursing, Queen Elizabeth Hospital II, Kota Kinabalu, Ministry of Health Malaysia

INTRODUCTION: Coronary artery disease (CAD) has continued to be a major cause of deathglobally. Although the modification of CAD risk factors can prevent serious complications such asmyocardial infarction and stroke, the lack of knowledge on CAD risk factors among patients oftenlead to non-adherence to the lifestyle modifications and medications prescribed, which in turnmay lead to an increase in morbidity and mortality rate.

OBJECTIVE: The objective of this study is to determine patients’ level of knowledge on CADmodifiable risk factors and the potential factors affecting that knowledge.

METHODS: A cross-sectional study conducted among patient who admitted at CardiacRehabilitation Ward, HQE II between May 2018 till June 2018. A self-structured questionnaireadapted from previous study used in this study. Total of 64 respondents (60% male;40% female)who eligible according to inclusion criteria were recruited in this study. Beside descriptive analysisto describe the population of this study, we used Pearson Chi-Square test to determine theassociation between gender, levels of education, family history, patient’s belief and experiencesbetween knowledge on modifiable risk factors of CAD. One- way ANOVA test used to determinethe differences of knowledge on modifiable risk factors of coronary artery disease by level ofeducation.

RESULTS: Results shows patients’ level of knowledge on CAD risk factors was adequate with morethan 2/3 of the respondents scoring 70% and above for the overall accumulated marks. The onlylow score was for the risk factors on diet modification which was 66%. The test revealed that therewas a significant relationship between patients’ levels of education and patients’ that concern oftheir heart problem between knowledge on modifiable risk factors of CAD. Where for patients’levels of education (X2 = 10.8, p < .05) and (X2 = 0.10, p < .05) for patients’ that concern of theirheart problem respectively. While for variables gender, family members with heart attack andpatient’s experiences of heart attack shows no significant relationship between knowledge onmodifiable risk factors of CAD.

CONCLUSION: The level of patient’s knowledge on modifiable risk factors of CAD was found to beadequate in general, although inadequate for the aspect of diet modification. Patients’ knowledgeis affected by their level of education and concern with their heart problem. Hence, futurepreventive measures such as developing strategies, approaches and programs that are moreeffective in raising awareness and improving patients’ knowledge on CAD risk factors should beconsidered.

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P13. High rate of late stent thrombosis in patients with significant coronary arterystenosis treated with bioresorbable vascular scaffold (BVS): A Malaysian singlecenter real world experience year 2012 to 2017).Mon Myat Oo1

1 Cardiology unit, Univesity Malaya Medical Center, Malaysia

OBJECTIVES: To investigate the safety and efficacy of bioresorbable vascular scaffold (BVS) in thetreatment of significant coronary artery stenosis.

METHODS: This is a retrospective study conducted in University Malaya Medical Center (UMMC)Malaysia. All patients who had significant coronary artery stenosis on coronary angiogram andreceived coronary revascularizations with bioresorbable vascular scaffolds (BVS) from the year2012 to 2017 were included in this analysis.

RESULTS: A total of 78 patients and total 96 lesions were treated with BVS. 54 (69.2%) were malepatients and the rest 24 (30.8% ) were female with mean age of . Malay ethnic composite 44.9%(35) with the rest were Indian 24.4% (19) and Chinese 21.8% (17). 13 (16.7% ) patients wereactive current smokers. Associated with co morbidities such as dyslipidemia in 58 (74.4%) patients,hypertension in 53 (67.9%) patients and diabetes in 36 (46.2%) patients. Of all, 33 patients(42.3%) presented with acute coronary syndrome (unstable angina, non ST elevation myocardialinfraction, ST elevation myocardial infraction) and the remaining presented with stable angina.72% of all BVS implantations were done under optical coherence tomography (OCT) guiding. Themajority of target lesions ( 64 lesions, 67%) were type B lesions. 16 type C lesions (16.6%) and therest 16 lesions (16.4%) are Type A lesions. Pre-dilation and post-dilation were performed in allcases. Angiographic and OCT based procedural success rate was 100%. In-hospital adverse clinicaloutcome ( pericardial effusion one day after the procedure) was noted in one patient whodischarged well from hospital after few days. No in-hospital MACE or mortality recorded for allpatients. Six months follow up was achieved in all patients while 68 patients (87%) were followedup one year and more. Six month cumulative target vessel failure (composite of all-causemortality, myocardial infraction and target vessel revascularization) rate was 0%. 6 monthcumulative MACE (composite of all-cause mortality, myocardial infraction and target vesselrevascularization) rate was 2.5% (2 patients had myocardial infraction). 12-month cumulativeMACE rate was 5.1% ( 1 patient died from stroke, 3 patients developed myocardial infraction).

CONCLUSIONS: Good procedural and angiographic success rates were achieved with BVSimplantations in our patients with excellent 6-month cumulative target vessel failure outcomewith acceptable cumulative MACE outcome . However, we noted a worryingly high rate of latestent thrombosis which needs serious consideration for future implantation.

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P14. Prevalence of left ventricular systolic and diastolic dysfunction in Type 2diabetes population with no signs and symptoms of heart failure.Mon Myat Oo1, Tan Kok Leng1, Jeyakantha Ratnasingam2, Sharmila2, Alexander Tan2, Imran Zainal Abidin1, Chee Kok Han1

1 Cardiology unit, Univesity Malaya Medical Center, Malaysia2 Endocrinology Unit, University Malaya Medical Center, Malaysia

OBJECTIVES: To identify the prevalence of systolic and diastolic dysfunction in type 2 diabetespatients with no signs and symptoms of heart failure and to clarify the predictors of systolic ordiastolic dysfunction in asymptomatic diabetes patients.

METHODS AND RESULTS: Ongoing prospective cross-sectional study using data from tertiarycenter, hospital medical record database, which contains information of inpatient and outpatientcare, including demographic information, diagnoses, procedures, and prescription records. Venousblood samples will be taken in the morning following an overnight fast. HbA1c and Beta-natriureticpeptide will be measured via standard protocol. Echocardiography was performed as part of thestudy. Cardiac structure and function (systolic and diastolic) will be assessed from M-mode guidedby two-dimensional imaging to obtain the echocardiographic variables. LV mass index (LVMI) wascalculated and . LVEF was determined using biplane modified Simpson’s measurements. The mitralflow was assessed in the apical four-chamber view by pulsed Doppler. The sample was positionedbetween the distal extremities of the mitral valve leaflets, and then the following variables wereobtained: early (E), late diastolic mitral velocities (A), and E/ A ratio. Tissue Doppler was performedin the apical four chamber view to obtain mitral annulus velocities. The sample was placed at thejunction of the LV lateral wall with the mitral annulus and at the junction of the posteriorinterventricular septum with the mitral annulus; then, the early (E0 ) diastolic mitral annulusvelocities and the E/E0 ratio were determined. Follow-up information will be obtained from acomprehensive medical record database. Analyses will be conducted to compare the LV diastolicfunction, LV hypertrophy (LVH), or the symptomatic HFpEF. The AHA/ACC diagnostic criteria of newonset symptomatic HFpEF1 included the following: (a) clinical signs (e.g., elevated jugular venouspressure, pulmonary crackles, and displaced apex beat) or symptoms (e.g., breathlessness, ankleswelling, and fatigue) of HF, (b) evidence of preserved or normal LVEF (50%), and (c) evidence ofabnormal LV diastolic function that can be determined by Doppler echocardiography (E/E0 15).Follow-up and HbA1c measurements will be continued in the event of new-onset symptomaticHFpEF. Targeted study population aimed at 500 participants. Since it is ongoing study, interimanalysis of 150 participants showed prevalence of diastolic dysfunction in totally asymptomaticdiabetic patients found out to be in 61.41% of all participants with the most common type ofdiastolic dysfunction being Grade I diastolic dysfunction. 38.58% was identified as normal diastolicand systolic function.

CONCLUSION: This ongoing single center study proving the significant prevalence of diastolicdysfunction in totally asymptomatic diabetic patients. Wide range of association among diastolicdysfunction and proposed risk factors such as insulin resistance, variability of HBA1C, otherpreexisting risk factors are identified in this study.

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P15. Yamaguchi syndrome, a masquerade to acute coronary syndromeKhairul Shafiq Ibrahim, Cardiology department, Faculty of Medicine, UiTM

INTRODUCTION: Apical hypertrophic cardiomyopathy is a rare variant of hypertrophiccardiomyopathy. It was first described by Sakamoto and Yamaguchi et al in 1970s. This condition ispredominantly seen in oriental population as compared to western population. This case highlightsthe rare incidence of the disease among Malaysians and the associated diagnostic challenge.

CASE REPORT: Mr Z is a 56-year-old gentleman with hypertension, dyslipidaemia, smoking 20 packyears and history of ischaemic heart disease (NSTEMI) with normal coronary angiogram. Hepresented to Hospital Sungai Buloh with recurrent chest pain, central, heavy in nature and lastedfor 30 minutes. The pain was similar to the one he had previously. He experienced shortness ofbreath, palpitation and diaphoresis along with the chest pain. On examination his blood pressurewas 180/100mmHg with heart rate of 88 beat/minute. Cardiovascular and respiratory examinationwas unremarkable. ECG showed giant symmetrical T wave inversion in left precordial leads. Highsensitive Troponin T 12 hours post event was 550 ng/L (cut off point 14ng/L). Repeat coronaryangiography showed similar findings. A left ventriculogram was performed revealing a spadeshaped left ventricle. Repeat echocardiogram and cardiac MRI was arranged which showedfeatures of apical hypertrophic cardiomyopathy.

CONCLUSION: Physicians need to include apical hypertrophic cardiomyopathy, also known asYamaguchi syndrome as one of the differentials in evaluating patient with chest pain. Althoughdiagnosis is challenging, incorporating multimodalities imaging approach as well as recognition ofthe typical changes in ECG has proven to be beneficial.

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P16. Delayed pericardial tamponade following an early NOAC prescription post pacemaker implantation.WNAM Jeffery1, WYH W Isa1, Z Yusof1

1Cardiology unit,HUSM,Kubang Kerian.

INTRODUCTION: Cardiac implantable electronic devices (CIED) are increasing due to the agingpopulation and improvement in diagnostic and clinical practice. Acute complications resultingfrom implantation are well known and include perforation of the right atrium or right ventricle.However acute cardiac tamponade is rare and hence delayed or late presentation is even rarer.We presented one patient with late tamponade following early NOAC prescription.

CASE REPORT: This is a 61 years old lady with underlying hypertension and sick sinus syndromewith paroxysmal atrial fibrillation (AF). Permanent pacemaker dual chamber was successfullyimplanted and she was discharged well with rivoraxaban. She was well for 2 weeks post-implantation before started to have shortness of breath on exertion. Her shortness of breathprogressively worsened and she started to have fever and cough for 3 days. She sought treatmentat HUSM and was diagnosed with cardiac tamponade. Urgent pericardiocentesis was done byemergency physician and 200mls of hemorrhagic fluid drained out during the procedure. Shedeveloped fast AF in ward and her symptoms did not improve. Cardiac CT done showed largepericardial effusion with tip of pericardial drainage catheter seen within the right ventriclemyocardium. The pacemaker lead of the right atrium was traversing the right atrium myocardiumwall with tip seen within pericardial cavity suggestive of perforation. There was no baselinepacemaker data to compare. Removal of pericardial drainage tube was then successfully carriedout in operation theatre. She was able to be discharged after serial echo showed no worsening ofpericardial effusion.

DISCUSSION: Cardiac tamponade is a rare but potentially life threatening complication ofpacemaker implantation. A recent review article proposed several candidates in addition to therisk factors of perforation; the type and the location of the leads, the heart muscle characteristics,anticoagulation therapy, patient age, gender, and body mass[1]. Risk factors for late perforationhave not yet been fully defined, although Polin et al [2] suggested that active fixation leads andanticoagulation therapy (warfarin) may represent predictors for the long-term development of aperforation[3]. Late perforations are often asymptomatic and characterized by a very low rate ofcardiac tamponade or death [2]. As the use of NOACs becomes more common, physician must beaware of delayed cardiac tamponade signs/symptoms after CIED’s implantation not only during theperioperative period but also during clinical follow-up. Experiences of physician conducting theprocedure also must be counted in to reduce the risk of complications.

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P17. Two cases of prolonged ventricular standstill in One Tertiary centerOoi SL, SA Ashari, Dr WYH W Isa, Z YusofCardiology unit,HUSM,Kubang Kerian.

INTRODUCTION: The ventricular standstill is an uncommon but fatal ventricular arrhythmia. It isrequiring urgent recognition and treatment as dangerous of ventricular stand still is similar toventricular fibrillation. The abnormality is identified when absence of QRS complexes and T wavesin electrocardiogram (ECG) in the presence of atrial activity. The patients usually present withpulseless and unresponsive, syncope or sudden cardiac death. We present two such cases from atertiary centre in Malaysia.

CASE REPORT:Case 1 - A 66 years old, woman with underlying IHD with 3 vessels diseases, hypertension, diabeticmellitus, chronic kidney disease presented with typical left-sided chest pain. Physical examinationshowed pan systolic murmur over mitral and left sternal edge, lung auscultation bilateral lowerzone till mid zone fine crepitation, bilateral pedal edema. She developed fast atrial fibrillation andgiven amiodarone infusion. The ECG showed Q wave inferior lateral lead. Echocardiographyshowed EF37% with presented of hypokinetic area basal and lateral cardiac wall. Subsequent ECGshowed showed ST elevation II,III and AVF with reciprocal changes. Patient was thrombolysedsuccessfully. Then within 48 hours she developed 5 episodes of ventricular standstill with thelongest one was 15 seconds. She lost her consciousness during the time. She was not keen forfurther intervention and took at own risk discharged.

Case 2- A 53 years old, man with underlying of hypertension, diabetic mellitus, dyslipidemia. Hewas diagnosed with single vessel coronary artery disease with was stented. He presented withcomplaint of dizziness associated with profuse sweating, dyspnea, palpitation and reduce efforttolerance. Physical examination showed elevated jugular venous pressure with lungs auscultationbibasal fine crepitaion, pan systolic murmur at mitral area. ECG showed third degree heart blockedand ST segment elevation at V1-V4 leads. He was thrombolysed successfully and external pacingdone however was not pacing 100% even after isoprenaline infusion. Emergency transjugulartemporary cardiac pacing was done. Following that, he had 1 episode of ventricular standstilllasting for 15s during non captured temporary pacing. He only had dizziness without loss ofconsciousness. Coronary angiogram showed patented LAD stents and 70% at proximal RPDA. Heunderwent dual chamber pacemaker insertion which was uneventful.

DISCUSSION: Myocardial infarction may cause ventricular standstill. According to ACC guidelinethe for the device-based therapy of cardiac rhythm abnormalities showed that permanentpacemaker implantation is indicate for in sinus with pause more than 3 seconds and atrialfibrillation with pause more than 5seconds. Dual chamber pacing is recommended to maintainphysiological pacing. Our patients demonstrated the ventricular standstill happened aftermyocardial infarction and the patient survived with external pacing and pacemaker insertion.

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P18. Relapse infective endocarditis with nutriently variant streptococci in pregnancy complicated with systemic embolization.V.Rubininair, Dr WYH W Isa, Z YusofCardiology unit,HUSM,Kubang Kerian.

INTRODUCTION: Infective endocarditis in pregnancy is rare and carries a grave prognosis if notidentified and treated adequately. This is the first case of relapse infective endocarditis by anutriently variant streptococci presenting in the first trimester of pregnancy complicated withsystemic embolization. This case is reported to highlight the need of high suspicion to diagnosethis condition early and the dilemma in treating a relapse infective endocarditis in pregnancy.

CASE REPORT: This is a 33 year old Malay lady at 12 weeks of gestation with underlying severemitral regurgitation secondary to chronic rheumatic heart disease who presented with 10 dayshistory of central pricking chest pain .She has refused intervention prior to this. Upon admissionpatient was hemodynamically stable and apyrexial. There were no peripheral signs of infectiveendocarditis. Transthoracic echocardiography revealed a vegetation at mitral valve 0.4-0.6cm2with three blood cultures grew granulicatella adiacens .She completed 6 weeks of intravenousceftriaxone and was discharged well. Her repeated cultures were negative and serialechocardiograph showed reduced size of vegetation. Unfortunately, 6 weeks later she presentedto hospital again with fever. Repeated echocardiogram showed increased size of vegetation to0.4cm2 and repeated blood culture revealed similar organism again. In ward, she complained ofleft loin pain which was suggestive of splenic infarction on ultrasound abdomen. She underwentlower segment caesarean section at 30 weeks gestational age. She managed to complete 6 weeksof ceftriaxone with resolution of vegetation on echocardiogram .She is planned for valvereplacement in the following month.

CONCLUSION: Granulicatella orgnanism is a nutriently variant streptococci.Till date it is auncommon cause which is about 6 % of all infective endocarditis cases.It is reported that thisnutriently variant streptococcus has higher morbidity, relapse and systemic embolization.The mostcommon organism causing infective endocarditis in pregnancy is streptococcus viridans.Thiswould be the first case illustrating a granulicatella adiacens causing infective endocarditis in thefirst trimester of pregnancy and relapse in the third trimester , with systemic embolization.Chronicrheumatic heart disease with moderate mitral regurgitation puts the patient at higher risk todevelop this infection. This requires high index of suspicion and identifying it early to institute theappropriate treatment to safe the mother and fetus .It also potrays the dillema in decidingoptimal duration of medical treatment ,timing of surgical treatment and delivery of the baby.

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P19. Apixaban versus warfarin in patients with left ventricular thrombus: A prospective randomized outcome blinded pilot study on size reduction or resolution of left ventricular thrombus. Niny Hwong1, WYH W Isa1, Z Yusof1

1Cardiology unit,HUSM,Kubang Kerian.

BACKGROUND: Left Ventricular Thrombus (LVT) is a well-recognized complication of acutemyocardial infarction (AMI) and congestive heart failure (CHF) due to severely impaired LV systolicfunction. The rate of LVT incidence is presumably higher in certain place where there was delayedrevascularization due to logistical and financial reasons. Thus, the choice of anticoagulation is vitalfor lower risk of bleeding and complications in patients with multiple co-morbidities.The anticoagulation choice was always VKA – warfarin coupled with IV heparin in the beginningand resulting in longer stay in the hospital in order to achieve the targeted INR. The emergence ofNOACs is an ideal alternative with lesser bleeding rate and no monitoring needed, leading toshorter length of hospital stay.

OBJECTIVES: To compare the novel oral anticoagulant apixaban with the standard therapy ofwarfarin on the size reduction or resolution of left ventricular thrombus over 3 months.

MATERIALS AND METHODS: This is a two arms open label interventional and prospectiverandomized controlled outcome blinded endpoint (PROBE) pilot study.Patients who are diagnosed with LVT by echocardiography will be selected and screened forinclusion and exclusion criteria. Patients then randomized using stratified permuted blockrandomization for treatment arm into two groups, the first group will be given the study drug,apixaban and the second group will receive the standard therapy, warfarin with targeted INR 2-3.Regular outpatient follow ups were carried out and echocardiography was repeated at week 6 and12 of treatment to assess the LVT size in cm2. The echo technician were blinded on patienttreatment arms. The percentage of reduction or total resolution during the first 12 weeks are theprimary endpoints.

RESULTS: At the end of recruitment period, a total of 27 patients were recruited. There were 14 vs13 patients in the apixaban and warfarin arm respectively. 13 patients completed the treatment inapixaban arm with 1 patient was lost to follow up. There was 1 death in the apixaban arm aftercompleted study follow up. While in the warfarin arm, 9 patients completed the study follow upwith 4 died during the follow up. The analysis was done by intention to treat method, whichrevealed bigger mean reduction in percentage [% (SD)] of LV thrombus size in apixaban arm 65.1(31.3) vs warfarin arm 61.5 (43.9) at the 12th week of study follow up. However, the difference wasnot significant with p value of 0.101.

CONCLUSION: This small pilot study suggested that apixaban is similar to warfarin with trendsuggesting better reduction and safety profile. Hence, a bigger randomized study is required toverify these findings.

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1. Case Title: Calcified disease, is this the new approach?Dr Mohd Firdaus Hadi, UMMC

Case summary: A 78 years old gentleman, with background of atrial fibrillation on NOAC, hypertension, dyslipidaemia, chronic kidney disease stage 3, and history ofprolapse intervertebral disk with nerve impingement requiring semi urgent surgery. Patient had recurrent admission for congestive cardiac failure and unstable angina.Echocardiogram: Left ventricle normal in size, mild left ventricular hypertrophy, LVEF 40%. Right Ventricle normal in size. Enlarge left atrium.Catheterization Finding: Coronary angiogram shows a short left main stem. Left anterior descending coronary (LAD) disease shows calcified over the proximal coronaryand 90% stenosis over the mid LAD. Left circumflex coronary (LCX) artery had distal disease. Meanwhile right coronary artery (RCA) shows plaque disease.Procedural Steps: Initial approach via the radial with XB 3.0 6F guide-catheter. Runtrough guide wire used to cross the lesion. Balloon TREK 2.0 x 20 use to dilate the lesionall over the to the Mid LAD which was very tight and TREK 1.5 x15 was used. CHOICE PT Extra support guide wire was used with TREK 1.5 x 15 inflated as scoring techniquefollowed by TREK 2.0 x 20. The dilatation was not optimized and reused TREK balloon cause challenges to cross the mid LAD. Sapphire 1.0 x 15 was then applied, followedby NC Trek 2.25 x 12. After multiple attempt, it was complicated with coronary dissection and TIMI I flow. A vasodilator was applied to improve the TIMI flow andprocedure was abandoned. Patient was stable following that for follow up PCI a week later.Followed up PCI was then carried out via femoral access. Guide catheter XBLAD 3.5 7F was used with a ROTAWIRE FLOPPY. A rotablator burr 1.5 mm was inserted and with162 000 rpm. Rotablator successfully optimized the LAD. Following that NC TREK 2.5 x 15 was applied and a drug coated balloon (DCB) SEQUENT PLEASE NEO 2.5 x 40 and3.0 x 35 over the mid and proximal LAD. Good result obtained, and he underwent the surgery 3 months later.Learning Point: Calcified coronary artery disease is challenging and require multiple approach include scoring balloon and/or rotablator. On many occasions, normalballoon wasn’t adequate to optimize as shown in this case. Applying DCB in calcified lesion has been in shown in few small research studies to be good strategy in patientwith high bleeding risk and an alternative for stent-less revascularization therapy. This case is a good example with patient having high bleeding risk, multiple comorbidityand requiring high risk surgical procedure. This may assist to shorten the triple therapy regime, following PCI.

2. Case Title: The TrifurcationDr Mohd Al-Baqlish Mohd Firdaus, UMMC

Case summary: A 46 years old gentleman with underlying hypertension and dyslipidemia presented with Unstable Angina. Baseline ECHO: good LV function of 71%(thickened interventricular septum) with no RWMA.Diagnostic coronary angiogram: LMS: distal 50%, LAD: proximal 80%, Digonal 1 90%, diagonal 2 80%, LCx: ostial 70%, RCA: distal CTOProcedure: RCA CTO was successful attempted with good result. The trifurcation and left main stem stenting were done under IVUS guided.Outcome: Patient was still under cardio clinic follow upLearning Point: Sharing how we tackle complex trifurcation and left main stenting

3. Title: Long & Winding RoadDr Raja Ezman Raja Shariff, Dr Rizmy Najme Khir, UiTM

Case summary: A 68 years old gentleman, a smoker and hypertension, had chest pain for 2 hours. On examination; BP 100/70mmHg and pulse of 100/min. lung was clear.ECG showed wide spread ST depression, I, II, III, AVL, AVF, V2-V6 and AVR ST elevation > 1mm. This was STEMI equivalent ECG affecting anterior segment. CAG showed 3vessels disease with proximal LAD critical lesion 90%, proximal LCX and distal LCX 90% and 100%(CTO) respectively and distal RCA lesion at 70%. LAD was not typicalappearance.We decided to discuss with the surgeon for CABG however it was deferred due to high risk for emergency procedure. Our first problem was to identify where is the LAD?The vessel chosen although it was small, it ran all the way to the apex, with a large diagonal branch, and large septal vessel that had a large branch acting like the LAD.Second problem was: should we do a full re-vascularisation, or just the infarct related artery? We opted for only the infarct-related artery, as the CTO LCX would addconsiderable time to the procedure. Third problem: should we consider two stent bifurcation strategy or provisional stenting? We opted for provisional stenting, as a two-stent bifurcation stenting may be time consuming during a STEMI as patient was still complaining of severe chest pain.So, proceed with PCI to LAD via radial artery approach and JL 3.5 guiding cathether. Sion blue wired into LAD and Run-through wired into septal branch for protection asthe septal branch is large. LAD predilated with 2.5 x15 semi-compliant balloon and 2.75 x 22 stent deployed from ostial LAD across the septal branch. Post dilate with 4.0 x8 NC, up to 14 atm and good result obtained. Pain receded with BP of 120/80 without inotropic support. For staged PCI to the RCA and LCX.Learning points: We must involve the cardiothoracic team, for consideration of emergency CABG in selected lesions when feasible. We must know on how to identify thecorrect coronary artery and while considering other large branches which may be compromised; so, choice of bifurcation or provisional stenting is correct.

4. Title: First smooth ride does not make the second ride easierDr Mohd Faiz Faizul, Dr Tan NH, Dr Muhammad Ali, Hospital Pulau Pinang

Case summary: Mr LBH, a 71-year-old man with underlying DM, HPT and history of old ischaemic stroke. he was just recently quit smoking. He presented to HPP with chestdiscomfort. ECG showed t wave inversion over chest lead V4 to V6. Echocardiogram showed LVEF of 45% with hypokinetic over anterior wall.CAG showed 70-80% calcified lesion at ostial/proximal LAD, 60-70 mid LAD. He had dominant LCX with 80% stenosis over distal part, 70% OM 1. RCA was non-dominantwith moderate stenosis.We proceed with stage PCI to LAD via radial approach with 6Fr sheath and EBU 3.5 as guider. Asahi sion blue wired down LAD. Calcified lesion LAD was predilated withTazuna 2.5/15 over proximal and 2.0/10 at mid LAD. Stent Ultimaster 2.5/16 at 16atm(2.68mm) was deployed over mid LAD lesion with good post stenting result anduneventful. We attempted to deliver second stent Ultimaster 3.0/33 over the proximal LAD lesion. However, during the process due to the heavily calcified vessel; thestent was accidently dislodged and crumpled. To make matter worse, the coronary wire also completely out. It was complicated with poor reflow and patient becamesymptomatic. LAD was rewired again through stent strut and the position of wire in true stent lumen was confirmed with IVUS. Crumpled stent was dilated with Minitrek(1.2/12), Sapphire II (2.0/12), NC Emerge (2.75/12) and N/C Trek (3.0/12). We tried to deliver new stent inside the crumpled stent up to the distal part of the stent butfailed even by using extra support with the Guideliner. At this point we decided to change approach to femoral access with new guider AL 1. However, this also failedbecause of very diffuse disease of common internal iliac artery.So, we proceed with similar access (RRA). Another Asahi sion blue wired down LCX and anchored with Minitrek balloon (2.0/15) to improve guide stability. The Resolute(3.0/15) stent was used to pass through the lumen but failed. A new stent Siroflex (2.5/13) was successfully deployed to cover till distal to old crumpled stent but unable togo beyond that. Another stent Ultimaster (3.0/24) was successfully delivered till distal dissection and deployed at 14atm (3.16). Finally, the last stent deployed at ostial ladwith Biometrix (3.5/9) at 18atm (3.86). Good result obtained.Learning points: This case illustrated the importance of preparation of the lesion prior to stent delivery especially in severely calcified vessel. It also highlights themanagement of crumpled and dislodged intracoronary stent.

Angio Club: APCU@USM Kota Bharu Kelantan 2018

Large septal

branch

Large diagonal

Small LADPre and Post Stenting



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5. Topic: A strongman PullDr Faizal, Dr Mansor Yahya, HRPZII Kota Bharu

Case summary: A case of PCI to RCA which looks straightforward. After placing 1st stent at Proximal RCA, 2nd stent was placed at mid RCA, after deployment of the 2ndstent the stent balloon took long time to deflate. During the attempt to pull the stent balloon the wire snapped leaving the partially inflated balloon in the RCA. Thiscase is to show how we managed to remove the snapped balloon.

6. Title: Drug coated balloon (DCB) in large and ectatic vessel in ACS.Dr Hamat Hamdi Che Hassan, HUKM

Case summary: A 38 years old army officer admitted with typical chest pain. He had history of inferior posterior STEMI in 2014 and had PCI to RCA with Avantgardestents. He was hypertensive and has history of dyslipidemia and still smoking. He claimed compliance to medication with single antiplatelet and statin. During admissionto ED, his BP was 134/94mmHg, pulse 100/min. His chest was clear. His ECG showed ST elevation at II, III and AVF with ST depression on V1-V3 w good R wave. Therewas RV extension on right sided ECG. He was given metalyse and had good resolution. He then underwent PCI as part of pharmacoinvasive strategy.His CAG showed ectatic and big vessels of LAD and LCX. His RCA showed mild ISR of previous stents. At distal part of vessel, there was severe stenosis of 80-90%surrounded by aneurysmal area and ectatic vessel.JR 3.5 was engaged deeply to give a better support. Sion blue wire was cannulated distally. The lesion was predilated with Sapphire II 2.5x12mm up to 14atm. Thenupgrade to NC 3.0x15mm up to 12atm. The lesion was POBA with DCB Sequent Please of 3.5x20mm up to 6 atm for one minute. Good result at the end. The ECG andsymptoms improved and was discharged well.

7. Topic: Tackling the hostile neck infra-renal abdominal aortic aneurysmConsultant: Dr. Shaiful Azmi bin Yahaya/ Dr. Kumara Gurupparan A/L Ganeson (IJN)Cardiology Specialist: Dr. Mohd Shawal Faizal Mohamad (IJN/ UKM)

Introduction: EVAR has been an accepted form of treatment for Abdominal Aortic Aneurysm since it was pioneered by Parodi et al in the 1990. As interventionalcardiology evolves in skills and device technology EVAR has also been used in the treatment of HOSTILE NECK AAA which is the domain of open surgical repair. A“HOSTILE” neck AAA is defined of as one or all of the following characteristic neck length < 15 mm, diameter > 28 mm, and neck angulation > 60°. Other inclusion of the“HOSTILE” features is proximal neck circumferential thrombus or a calcification (>50%) or a tapered/conical neck, wherein the diameter progressively increasesbetween the renal arteries and the sac with a > 2- to 3-mm change over the first 15 mm of proximal neck. An ENDOANCHOR (Heli-FX by MEDTRONIC) allows betterfixation and sealing between endovascular aortic graft and the native artery. This prevents complications such as graft migration and endo-leaks which is commonlyseen with an EVAR of the “HOSTILE” neck aortic aneurysm.Case Summary: MR ZA is 55-year-old gentlemen was referred to IJN after he was turned down for open surgery to correct an 8cm expanding infra-renal AAA. With apoor LV function due to an underlying 2 Vessel IHD open surgical repair was deemed high risk. On the assessment of the infra-renal AAA morphology Mr ZA iscategorized in the ‘HOSTILE’ territory.Mr ZA had an EVAR done with ENDURANT STENT 25x14x103 with extension of the stent with ENDURANT 16x24x156 and the ENDURANT 16x16 x158 to the right and leftiliac arteries respectively. An ENDOANCHOR X 8 was used to approximate the proximal STENT to the proximal portion of the short neck Aortic aneurysm just below theboth renal arteries. The procedure was successful however, complicated with mild type I endo-leak which is stable upon serial CT surveillance. The use of theENDOANCHOR technology from MEDTRONIC is the 1st in Malaysia by multidisciplinary team (cardiologist, cardiothoracic surgeon, anaesthesiologist) in Institut JantungNegara (IJN)Conclusion: The ENDOVASCULAR ERA, challenges interventional cardiologist to rock the status quo of treatment, grow in skills and knowledge acquisition, and be wellequip in the latest available technologies. With ‘ENDOANCHOR’ HELI-FX, an endovascular repair of a hostile neck AAA can be done much safer with less complication,especially when the patient has a high peri-operative risk of open surgery.

8. Title: Crossing at the right timeDr W Yus Haniff, HUSM

Case summary: Mr Z, a 54 year old Malay man; lorry driver; an ex smoker, dyslipidaemia. Presented with sudden onset left sided chest pain; presented to emergencyafter 12 hours presentation. Had a similar chest pain 1 month prior to admission-did not seek medical treatment. ECG noted Q waves over inferior leads with STelevation on lead II, III and AVF. TTE showed good LVEF 60%, RWMA seen at inferior wall and there was diastolic dysfunction. He was treated for established inferiorMI. First CAG via femoral approach noted large aortic root, JL-5 needed for diagnostic. Finding of 1VD with proximal RCA and mid RCA 99% lesions- and 20% at proximalLAD. JR 3.5 guiding was poor support and changed to AL-2; wire backed out during wiring. Need to use AL-3 (not available at the time) for the next attempt. Second and3rd attempts with AL-3 utilized but was difficult procedure. TORNUS was used since the lesions had worsen and became a CTO with long segment affected. Afterrepeated attempts the procedure was abandoned due to long subintimal wiring and prolonged procedure. Patient remained stable with CCS II to III. The 4th stage PCI –with AL-3 and OCT guided finally crossed the distal RCA with Asahi Sion 0.014” x 180cm wire and predilated with Tazuna (Terumo) semi-compliant balloon 1.25mm x10mm. Stenting done from distal to proximal RCA with 3 DES stents (Boston Scientific). OCT was done before stenting to ascertain true lumen and stent placement.Learning points: Long and complicated CTO lesion require patience and right tools, especially if the patient can wait. Large aortic root is a challenge that need to berecognized in doing complex lesions, so the best support catheter can be chosen. Having OCT/IVUS is reassuring but when they are not available – common senseshould prevail. Know when to stop even though it might hurt our ego.

9. Title: Stuck underneathDr Mon Myat Oo, UMMC

Case summary: A 65 years old gentleman presenting with left sided chest pain associated with sweating and dizziness for 2 days. Dynamic ECG changes with raisedcardiac enzymes despite on optimal medical therapy warranting in patient coronary intervention. Proceed with PCI to RCA uneventfully. Significant ostial LCX lesionwhich was arranged for stage PCI.The initial plan was to cover ostial and proximal LCX stenting. Bailout bifurcation stenting to LAD and left main was done to optimize the final result. IVUS done pre andpost left main stenting and to optimize the stent opposition. During procedure, we failed to re-crossed the wire to LCX and while re attempting to cross the wire thatwas in the LAD, noticed that wire was stuck in the distal end of LAD stent. Minimal force was applied, and stent deformed with accordion effect occurred. With anotherguide wire, managed to cross LAD stent and down to LAD. POBA done with different balloon sizes and TIMI III flow established in LAD. Piece of wire was stuck and left inbetween the stent struts.Patient was monitored in CCU for 3 days. Discharged well with aspirin and ticagrelor. Follow up 3 months’ time with total asymptomatic, free of angina symptoms.



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12th ASIA PACIFIC CARDIOLOGY

UPDATE @USM 2019

“ Fresh Insight in Cardiology”

18th-20th October 2019Kota Bharu, Kelantan.www.apcu-usm.com

SAVE YOUR DATE!!!

http://www.apcu-usm.com/



ACKNOWLEDGEMENTSThe organizing committee would like to extend its deepest appreciation and thank the followingsponsors for their kind support which contributed to the success of this conference.

MAIN SECRETARIATInternal Medicine Society of USM (IMS)Philips (M) Sdn Bhd

ECHOCARDIOGRAPHY WORKSHOP SECRETARIATPhilips (M) Sdn Bhd

ECG MASTERCLASS WORKSHOP SECRETARIATBiotronik (M) Sdn Bhd

COLLABORATIONMinistry of Health Malaysia

AUSPICENational Heart Association of Malaysia (NHAM)

PLATINUM SPONSORPhilips (M) Sdn Bhd

GOLD SPONSORSBayer (M) Sdn BhdPfizer (M) Sdn Bhd

SILVER SPONSORSMSD (M) Sdn BhdNovartis Corporation (M) Sdn Bhd

BRONZE SPONSORSAstraZeneca (M) Sdn BhdBoston Scientific (M) Sdn Bhd – CRM

BOOTH SPONSORSRanbaxy (M) Sdn BhdAspen PharmacareMitsubishi TanabeSanofi-Aventis (Malaysia) Sdn. BhdServier Malaysia Sdn. BhdMerck (M) Sdn Bhd

EDUCATIONAL GRANTMedtronic (M) Sdn BhdAbbott Laboratories (M) Sdn Bhd- SJMBoston Scientific (M) Sdn BhdBiosensors (M) Sdn Bhd

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enhancing care through applied cardiology asia … · lower limbs, complicated by purulent...

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