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All Journal Medical Journal of Indonesia The Indonesian Biomedical Journal Sari Pediatri Paediatrica Indonesiana Narra J Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)

Mulyadi M. Djer

Department Of Child Health, Medical School, University Of Indonesia/Cipto Mangunkusumo Hospital, Jakarta

Author-ID : 254970

Biochemistry, Genetics & Molecular Biology Health Professions Immunology & microbiology Medicine & Pharmacology Public Health

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Plasma digoxin levels and ejection fraction in pediatric heart failure Nafrialdi Nafrialdi; Sake Juli Martina; Mulyadi Djer; Melva Louisa
Paediatrica Indonesiana Vol 55 No 6 (2015): November 2015
Publisher : Indonesian Pediatric Society

Background Digoxin has long been prescribed in children with heart failure, but its efficacy has not been evaluated. A previous study at the Department of Child Health, Dr. Cipto Mangunkusumo Hospital revealed that plasma digoxin levels, following a maintenance dose of 15 Î¼g/kg/d, were sub-therapeutic. Regarding its narrow margin of safety, the trend is to use digoxin in even lower dose. Thus, the drugâ€™s impact on cardiac performance need to be evaluated. Objective To evaluate whether a lower maintenance dose of digoxin (10 Î¼g/kg/d) is sufficient to achieve a therapeutic level and to assess for possible correlations between plasma digoxin level and left ventricular ejection fraction (LVEF) as well as fractional shortening (LVFS). Methods A cross-sectional study was conducted on 20 pediatric heart failure patients at the Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Jakarta, from January to May 2012. Plasma digoxin levels were measured by ELISA method after one month or more of treatment; LVEF and LVFS were measured by echocardiography. Correlations between plasma digoxin level and LVEF or LVFS were analyzed by Spearmanâ€™s correlation test. The LVEF before and after digoxin treatment were compared by paired T-test. Results Thirteen out of 20 patients had plasma digoxin levels within therapeutic range (0.5-1.5 ng/mL; 95%CI 0.599 to 0.898) and 7 had sub-therapeutic levels (<0.5 ng/ mL; 95%CI 0.252 to 0.417). No significant correlations were observed between plasma digoxin level and LVEF (r=-0.085; P=0.722) or LVFS (r=-0.105; P=0.659). There was a significant increase in LVEF before [42.18 (SD 14.15)%] and after digoxin treatment [57.52 (SD 11.09)%], (P < 0.0001). Conclusion Most patients in this study have plasma digoxin levels within therapeutic range. There are no significant correlations between plasma digoxin level at the time point of measurement and LVEF or LVFS. However, an increase of LVEF is observed in every individual patients following digoxin treatment.

Prostaglandin E2 and patent ductus arteriosus in premature infants Mochammading Mochammading; Risma Kerina Kaban; Piprim Basarah Yanuarso; Mulyadi Djer
Paediatrica Indonesiana Vol 56 No 1 (2016): January 2016
Publisher : Indonesian Pediatric Society

Background Patent ductus arteriosus (PDA) is a congenital heart disease most commonly occurring in premature infants. Spontaneous ductus arteriosus (DA) closure in premature infants has been suggested to be associated with duct lumen maturity and the DA sensitivity to prostaglandin E2 (PGE2).Objective To assess for a possible correlation between serum PGE2 levels and PDA size in premature infants.Methods This observational study using repeated measurements on premature infants with PDA detected at days 2-3 of life was undertaken in Cipto Mangunkusumo Hospital and Fatmawati Hospital, Jakarta, from April to May 2014. The PDA was diagnosed using 2-D echocardiography and PGE2 levels were measured by immunoassay. Pearsonâ€™s correlation test was used to evaluate a possible correlation between PGE2 level and DA diameter.Results Thirty-three premature infants of median gestational age 31 (range 28-32) weeks and median birth weight 1,360 (range 1,000-1,500) grams were enrolled. Almost two-thirds of the subjects were male. Almost all (30/33) subjects had spontaneous DA closure before the age of 10 days. Subjectsâ€™ mean DA diameter was 2.9 (SD 0.5) mm with maximum flow velocity of 0.2 (SD 0.06) cm/sec, and left atrial-to-aortic root ratio (LA/Ao) of 1.5 (SD 0.2). Their mean PGE2 levels at the ages of 2-3, 5-7, and after 10 days were 5,238.6 (SD 1,225.2), 4,178.2 (SD 1,534.5), and 915.2 (SD 151.6) pg/mL, respectively. The PGE2 level at days 2-3 was significantly correlated with DA diameter (r = 0.667; P < 0.001), but not at days 5-7 (r = 0.292; P = 0.105) or at day 10 (r = 0.041; P = 0.941).Conclusion There is a strong, positive correlation between the PGE2 level and DA diameter in preterm infants at 2-3 days of age. However, there is no significant correlation between PGE2 level and persistence of PDA.

Outcomes of Tetralogy of Fallot repair performed after three years of age Ni Putu Veny Kartika Yantie; Mulyadi M. Djer; Najib Advan; Jusuf Rachmat
Paediatrica Indonesiana Vol 56 No 3 (2016): May 2016
Publisher : Indonesian Pediatric Society

subject of debate, however, in general repair before 3 years of age has resulted in good myocardial performance. Late repair has led to prolonged QRS duration, ventricular dysfunction in terms of myocardial performance index (MPI) and tricuspid annular plane systolic excursion (TAPSE), as well as longer intensive care unit (ICU) stays.Objective To evaluate QRS duration, right ventricular function as measured by TAPSE, and ICU length of stay (LoS) after repair of TOF performed after three years of age.Methods This retrospective cohort study was performed in children and adults who underwent ToF repair, with a minimum follow-up of 6 months. The TAPSE and QRS duration were evaluated during follow-up and compared between children who had the operation before vs. 3 years of age or older using Mann Whitney U and Chi-square tests.Results We enrolled 52 subjects who underwent ToF repair from January 2007 to June 2013 (18 in the â‰¤3 years-old group and 34 in the >3 years-old group). Subjectsâ€™ age at the time of repair ranged from 7 months to 25 years, with follow-up data at 24-30 months after discharge. Abnormalities of the right ventricle and left ventricle MPI were not significantly different between the two groups. However, we observed significant differences between the â‰¤3 years and >3 years groups in median ICU LoS [2 (range 1-9) days vs. 1.5 (range 1-46) days, respectively; (P=0.016)] and median QRS durations [118 (range 78-140) ms vs. 136 (range 80-190) ms, respectively; (P=0.039)]. The age at the time of repair did not increase the risk of having abnormal TAPSE (RR 0.85; 95%CI 0.26 to 2.79; P=0.798).Conclusion Tetralogy of Fallot repair after 3 years of age appears to not increase ICU LoS or is associated with lower TAPSE, but it is associated with longer QRS duration. [Paediatr Indones. 2016;56:176-83.].

Comparison of surgical vs. non-surgical closure procedures for secundum atrial septal defect Mazdar Helmy; Mulyadi M. Djer; Sudung O. Pardede; Darmawan B. Setyanto; Lily Rundjan; Hikari A. Sjakti
Paediatrica Indonesiana Vol 53 No 2 (2013): March 2013
Publisher : Indonesian Pediatric Society

Backgi-ound Surgery has been the standard therapy for secundumatrial septa! defect (ASD) closure, but it has significant associatedmorbidities related to st ernotomy, car diopulmonary bypass,complications, residual scars, and trauma. A less invasive nonsurgicalapproach with transcatheter devices was developed toocclude ASD. AmplatzerÂ® septa! occluder (ASO) is a commondevice in transcatheter closure.Objective To compare two secundum ASD closure procedures,transcatheter closure by ASO and surgical closure, in terms ofefficacy, complications, length of hospital stay, and total costs.Methods A retrospective analysis was performed on childrenwith secundum ASD admitted to the Cardiology Center ofCipto Mangunkusumo Hospital from January 2005 to December2011. Patients received either transcatheter closure with ASOor surgical closure procedures. Data was obtained from patients'medical records.Results A total of 112 secundum ASD cases were included in thisstudy, consisting of 42 subjects who underwent transcatheter closureprocedure by ASO and 70 subjects who underwent surgical closureprocedure. Procedure efficacies of surgery and ASO were not significantlydifferent (98.6% vs 95.2%, respectively, P= 0.555). However,subjects who underwent surgical procedures had significantly morecomplication s than subjects who underwent transcatheter closureprocedure (60% vs 28.6%, respectively, OR 1.61; 95%CI 1.19 to2.18; P= 0.001). Hospital stays were also significantly longer forsurgical patients than for transcatheter closure patients (6 days vs2 days, respectively, P< 0.0001). In addition, all surgical subjectsrequired intensive care. Transcatheter closure had a mean total costof 52.7 (SD 6.7) million Rupiahs while the mean cost of surgery was47 (SD 9.2) million Rupiahs (P< 0.0001) . Since the ASO devicecost represented 58% of the total cost of transcatheter closure, themean cost of transcatheter closure procedure without the deviceitself was less costly than surgery.Conclusion Transcatheter closure using ASO has a similar efficacyto that of surgical closure procedure. However, subjects whounderwent transcatheter closure have lower complication ratesand shorter length ofhosp ital stays than subjects who had surgery,but transcatheter closure costs are higher compared to the surgicalprocedure.

Heart size, heart function, and plasma B-type natriuretic peptide levels after transcatheter closure of patent ductus arteriosus Mulyadi M. Djer; Sudigdo Sastroasmoro; Bambang Madiyono
Paediatrica Indonesiana Vol 53 No 3 (2013): May 2013
Publisher : Indonesian Pediatric Society

Background Patent ductus arteriosus (PDA) is a commoncongenital heart disease causing some blood in the aorta to flowinto the pulmonary artery (PA), resulting in dilatation of the leftatrium (IA) and left ventricle (LY), increased B-type natriureticpeptide (BNP) level, and the development of h eart failure.Objectives To evaluate the clinical course, changes in heart sizeand function, and BNP level after transcatheter closure of PDAusing the AmplatzerÂ® duct occluder (ADO).Methods This quasi-experimental study used a one-group, pretestposttestdesign, and was done on PDA patients who underwenttranscatheter closure using ADO. The outcomes measurementswere performed four times, namely, before the procedure andat one, three, and six months after the procedure. Results werecompared using a serial time analysis. Outcomes measured wereheart failure scores, chest x-ray (CXR) and echocardiographyfindings, and plasma BNP level.Results There were 23 PDA patients enrolled, of which 12 werefemales. Subjects' median bodyweight was 11 (range 6.6 to 55) kg.Prior to PDA closure, 12 subjects had mild heart fa ilure (class II)and 7 had moderate heart failure (class III). On follow-up at onemonth after the procedure, all subjects had improved heart failurescores (P<0.0001), and no heart failure was found on furtherfollow up. Likewise, there was a decreased mean cardiothoracicratio (CTR) from 58 to 55% at 1-month (P = 0.001), and alsofrom 55 to 52% at3-month follow up (P<0.0001), but no furtherdecrease was found afterwards (P = 0.798). The left atrium/aorta(LA/Ao) ratio measured by echocardiography also showed astatistically significant decrease from 1.6 prior to the procedureto 1.3 (P<0.0001) in the first month, but it remained stableafterwards. Diastolic function, represented by peak E and A wavesalso significantly decreased from 127 and 91 cm/sec, before theprocedure, to 90 and 68 cm/sec, respectively, at 1 month follow-up(P <0.0001 and P < 0.0001, respectively) . However, there were nostatistically significant changes in E/ A ratio, ejection fract ion andfractional shortening. Plasma BNP level significantly decreasedfrom 58 pg/mL before the procedure to 28 pg/mL at 1 monthfollow-up (P= 0 .001), but no further significant decrease wasobserved afterwards.Conclusion After PDA closure with ADO, we observe significantimprovements in heart failure scores, heart size, diastolic function,and BNP level of our subjects especially in the first month afterthe procedure.

Transcatheter vs. surgical closure of patent ductus arteriosus: outcomes and cost analysis Mulyadi M Djer; Mochammading Mochammading; Mardjanis Said
Paediatrica Indonesiana Vol 53 No 4 (2013): July 2013
Publisher : Indonesian Pediatric Society

Background Patent ductus arterious (PDA) is a non-cyanoticcongenital heart disease (CHD) caused by the patency of thearterial duct after birth. For the last three decades, managementof PDA with transcatheter closure has been gaining popularity,including in developing countries. However its effectiveness interms of clinical outcomes and cost may vary among center andhas not been thoroughly evaluated yet in Indonesia.Objectives To compare the cost and clinical effectiveness of PDAclosure using transcatheter approach compared to surgical ligation.Methods We performed a retrospective review on patientsunderwent either transcatheter or surgical closure of PDA betweenJanuary 2000 and December 2006 in Cipto MangunkusumoHospital,Jakarta, Indonesia. Clinical outcomes as well as cost werecompared using the student T-test and Chi-square for numericaland categorical variables, respectivelyResults During the study period, 89 patients underwent transcatheterclosure using an AmplatzerÂ® device occluder (ADO) device and67 had surgical ligation. Successful PDA closure on first attemptwas achieved in 87 (96%) and 63 (94%) children who underwenttranscatheter and surgical closure, respectively (P = 1.000). Twochildren with unsuccessful transcatheter closure eventually hadtheir PDA closed by surgery, whereas one child with residual PDAafter surgical closure had his PDA closed by coil. No residual PDAwas found in the transcatheter closure group at one-week follow up.Duration of hospitalization was significantly less for patients havingtranscatheter closure compared to surgery [2.7 (SD 1.5) vs. 6.6 (SD1.5) days, P< 0.0001]. The cost for PDA closure with anAmplatzerÂ®device was more expensive than surgical ligation [Rp. 29,930,000 (SD57,200) vs. Rp. 12,205,000 (SD 89,300), P< 0.0001].Conclusion Transcatheter closure is equally effective as surgicalligation in closing the PDA. Less hospitalization is required withtranscatheter closure although the cost is higher than surgicalligation.

Transcatheter closure of tubular type patent ductus arteriosus using AmplatzerÂ® ductal occluder II: a case report Mulyadi M Djer; Nikmah Salamia Idris; Angelina Angelina
Paediatrica Indonesiana Vol 53 No 5 (2013): September 2013
Publisher : Indonesian Pediatric Society

Patent ductus arteriosus (PDA) is a common congenital heart disease, accounting for 5-10% of all congenital heart diseases. The incidence of PDA is even higher in preterm neonates, ranging from 20-60%.1-4 Closure of PDA is indicated in all cases, except for duct-dependent congenital heart diseases or PDA with Eisenmenger syndrome.1,5,6 In small asymptomatic PDAs, closure is indicated to prevent the risk of complications, such as endarteritis, endocarditis, aneurysm of ductus arteriosus, or congestive heart failure.1,2,7In recent years, interventional cardiology has become a gold standard therapy for the majority of PDA cases beyond neonatal age. Since its introduction in 1967, many devices and methods have been developed to allow transcatheter closure of virtually all PDAs, regardless of size or configuration. Nevertheless, the tubular shape (type C) PDA, which has the highest residual shunt rate, still poses a great challenge for the interventionist.8-10 The second generation of AmplatzerÂ® device occluders (ADO II), released in 2007, has been suggested to be effective in closing tubular PDAs.10 The purpose of this study was to report the initial clinical experience using ADO II to close a tubular type PDA in Indonesia.

Inhaled iloprost as part of combination therapy for persistent pulmonary hypertension of the newborn Heru Samudro; Mulyadi M. Djer
Paediatrica Indonesiana Vol 52 No 1 (2012): January 2012
Publisher : Indonesian Pediatric Society

Persistent pulmonary hypertension of thenewborn (PPHN) is rare, but life-threatening.If not treated, PPHN may cause respiratoryfailure and death in neonates. l,2,3 PPHNoften occurs in term or post-term infants with a historyof difficult labor, infection or asphyxia during birth.These infants do not have adequate oxygen duringlabor.3 Based on etiology, PPHN can be categorizedinto primary PPHN, which occurs by itself withoutapparent cause; or secondary PPHN, which is causedby meconium aspiration, hyaline membrane disease,neonatal sepsis with pneumonia, congenital heartabnormality, or maternal drug use (non-steroidalanti-inflammatories, methamphetamine, or selectiveserotonin re uptake inhibitors) during the thirdtrimester of pregnancy.

Tissue doppler imaging in thalassemia major patients: correlation between systolic and diastolic function with serum ferritin level Syarif Rohimi; Najib Advani; Sudigdo Sastroasmoro; Bambang Mardiyono; Sukman Tulus Putra; Mulyadi M. Djer; Fajar Subroto
Paediatrica Indonesiana Vol 52 No 4 (2012): July 2012
Publisher : Indonesian Pediatric Society

Background Thalassemia is a major public health problem inIndonesia. Cardiac diseases remain as the main cause of death inthese patients due to iron overload. Although the T2* magneticresonance imaging has been considered as the gold standard forassessing cardiac iron overload but it has limited availability.The tissue doppler imaging (TDI) echocardiography, a fairly newand easy method that is suggested, can detect early abnormalmyocardial iron overload.Objective To assess myocardial systolic and diastolic functionof thalassemic patients using TDI and examine their correlationwith serum ferritin level.Methods A crossô€Œsectional study was conducted from January toMarch 2011 at the Harapan Kita Women and Children Hospital.We performed clinical examination, serum ferritin level, as wellas conventional and tissue doppler echocardiography on allsubjects.Results We included 34 regularlyô€Œtranfused patients, of which17 were boys. The mean age of the subjects was 11.6 (SD 4.7years, range 2.6 ô€Œ 20 years). Mean pulse rate and blood pressurewere within normal range. Hemoglobin level at inclusion rangedfrom 5.8 to 6 g/dL. Almost all patients did not receive regularchelation therapy. Median serum ferritin level was 6275 ng/mL(range 2151 - 17,646 ng/mL). Conventional echocardiographyshowed normal systolic function, but some diastolic dysfunctionswere found including E wave abnormalites in 4 patients, A waveabnormalites in 3, and E/A ratio abnormalites found in 3. TheTDI showed decreased systolic function (Sa wave abnormality) in9 patients and diastolic dysfunctions (Ea wave abnormality in 11patients and Aa wave abnormaly in 2). No abnormality was foundin Ea/Aa and ElEa ratios. There was a weak negative correlationbetween ferritin level and Sa wave and Ea wave respectively anda moderately negative correlation between ferritin level and Ea/Aa ratio. There was no correlation between serum ferritin andAa wave or ElEa ratio.Conclusion TDI identifies a greater number of patients Mthsystolic and diastolic myocardial dysfunction than was revealedby conventional echocardiography. There was a weak negativecorrelation between serum ferritin to Sa wave and Ea wave, and amoderately negative correlation between ferritin and Ea/Aa ratio.There was no correlation between serum ferritin and Aa wave orElEa ratio. [paediatr Indones. 2012;52:187,93].

Blood nickel level and its toxic effect after transcatheter closure of persistent duct arteriosus using Amplatzer duct occluder Mulyadi M. Djer; Bambang Madiyono
Paediatrica Indonesiana Vol 49 No 1 (2009): January 2009
Publisher : Indonesian Pediatric Society

BackgroundÂ Transcatheter closure using amplatzerÂ ductÂ occluder(ADO)Â isÂ currently theÂ treatmentÂ ofÂ choice forÂ patentÂ ductusarteriosus (PDA).Â TheÂ ADOÂ deviceÂ isÂ constructed from a Nitinolwire mesh containing 55% nickel. UpÂ toÂ now, thereÂ isÂ still acontroversy about the effectsÂ ofÂ nickel contained in ADO.ObjectivesÂ ToÂ determine blood nickel levelÂ atÂ six months aftertranscatheter closureÂ ofÂ PDAÂ usingÂ ADO,Â toxic effectsÂ ofÂ nickelat six months afterÂ PDAÂ closure usingÂ ADO,Â and the effectsÂ ofnickelÂ onÂ complete bloodÂ countÂ (CBC), blood glucose and renalfunction.MethodsÂ SubjectsÂ wereÂ patientsÂ withÂ PDAÂ atÂ IntegratedCardiovascular Services,Â Dr.Â Cipto Mangunkusumo Hospital,Jakarta. Routine blood test and blood nickel levels were measuredatÂ the timeÂ ofÂ the procedure,Â andÂ atÂ theÂ endÂ ofÂ the first, third,Â andsixth months after intervention.ResultsÂ ThereÂ wereÂ 29Â patients who underwent heart catheteri-zationÂ andÂ PDA closure usingÂ ADO.Â A time series analysis wasconductedÂ onÂ 23Â patients who completed six-month follow-upafter the intervention. Median blood nickel level before procedurewas 58 ng/mL whileÂ atÂ one, threeÂ andÂ six months afterwards were60, 63 and 64 ng/mL respectively.Â TheÂ blood nickel levels didnotÂ differ significantly between pre- andÂ post-ADO. AfterÂ PDAclosure,Â noÂ toxic effectsÂ ofÂ nickel were found,Â bothÂ clinically andlaboratorically.ConclusionsÂ PDAÂ closure usingÂ ADOÂ has no effectsÂ onÂ the nickellevels, CBC, blood glucose and renal function;

Co-Authors Adhi Teguh Perma Iskandar Agus Firmansyah Amin Subandrio Angelina Angelina Anis Karuniawati Antonius H. Pudjiadi Aria Kekalih Arwin A. P. Akib Aryono Hendarto Asri C. Adisasmita Audrey Audrey Badriul Hegar Bambang Madiyono Bambang Madiyono Bambang Madiyono Bambang Mardiyono Bambang Supriyatno Burhanuddin Iskandar Chozie, Novie A. Damayanti R. Sjarif Damayanti R. Syarif Darmawan B. Setyanto Desy Dewi Saraswati Dilawar, Ismail Djajadiman Gatot Emilda Osmardin Erni Erfan, Erni Fajar Subroto Heri Wibowo Herlina Dimiati Heru Samudro Hikari A. Sjakti Idrus Alwi Ika P Wijaya, Ika P Imral Chair Irawan Mangunatmadja Iskandar, Adhi Teguh Perma Ismet N Oesman Joedo Prihartono Johanes Edy Siswanto, Johanes Edy Jusuf Rachmat Jusuf Rachmat Kautsar, Ahmad Laila, Dewi S. Liku Satriani Lily Rundjan Lisnawati Rachmadi Mardjanis Said Maswin Masyhur Mazdar Helmy Mazeni Alwi Melva Louisa Mila Maidarti Mochammading Mochammading Mochammading Mochammading Murni, Indah K. Muzal Kadim Nafrialdi Nafrialdi Najib Advan Najib Advani Najib Advani Najib Advani Najib Advani Nia Kurniati Nikmah S Idris, Nikmah S Nikmah S. Idris Nikmah Salamia Idris NP Veny Kartika Yantie Nurhakiki, Syifa Nusarintowati Ramadhina Perdana, Andri Permatasari, Ruth K. Piprim B Yanuarso Piprim B. Yanuarso, Piprim B. Piprim Basarah Yanuarso Pribadi Wiranda Busro Pustika Amalia Putri, Dyanti Prima Rahmadhany, Anisa Rahmat B Kuswiyanto Rahmat B. Kuswiyanto Renno Hidayat Rinawati Rohsiswatmo Risma Kerina Kaban Risma Kerina Kaban Risma Kerina Kaban, Risma Kerina Rizky Adriansyah Rosary Rosary Rubiana Sukardi Rubiana Sukardi Rubiana Sukardi, Rubiana Safanta, Nurzalia Sake Juli Martina Santoso, Dewi Irawati Soeria Setyanto, Darmawan Budi Shirley L. Anggriawan Sudigdo Sastroasmoro Sudigdo Sastroasmoro Sudigdo Sastroasmoro Sudigdo Sastroasmoro Sudigdo Sastroasmoro Sudung O Pardede, Sudung O Sudung O. Pardede Suhendro Sukman T Putra Sukman T Putra Sukman T. Putra Sukman T. Putra Sukman T. Putra Sukman Tulus Putra Sukman Tulus Putra, Sukman Tulus Supriatna, Novianti Susanti, Dhama S. Sutjipto, Fiolita Indranita Swanty Chunnaedy Syarif Rohimi Talib, Suprohaita Rusdi Taufiqurahman, Khobir Abdul Karim Tetty Yuniati Wardoyo, Suprayitno

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