KEL. JANTUNG DIDAPAT (ACQUIRED)KEL. JANTUNG DIDAPAT (ACQUIRED)KELAINAN JANTUNG KARENA INFEKSIKELAINAN JANTUNG KARENA INFEKSI

DI INDONESIA YANG TERBANYAK:DI INDONESIA YANG TERBANYAK:

1.DEMAM REUMATIK(1.DEMAM REUMATIK(DRDR), 2. DIFTERIA DAN ), 2. DIFTERIA DAN

3.ENDOKARDITIS LENTA3.ENDOKARDITIS LENTA

1.DEMAM REUMATIK: OK MENYEBABKAN 1.DEMAM REUMATIK: OK MENYEBABKAN

KEL. JANTUNG KEKEL. JANTUNG KE--2 PADA ANAK SETELAH 2 PADA ANAK SETELAH KEL. JANTUNG KEKEL. JANTUNG KE--2 PADA ANAK SETELAH 2 PADA ANAK SETELAH

KEL.JANTUNG KONGENITAL DI USA. KEL.JANTUNG KONGENITAL DI USA.

DI INDONESIA DR DI INDONESIA DR →→→→→→→→PENYEBAB UTAMA.PENYEBAB UTAMA.

DRDR PERLU DIDIAGNOSA CEPAT, DAN DIOBATI PERLU DIDIAGNOSA CEPAT, DAN DIOBATI

SEGERA SEGERA →→→→→→→→DPT MENCEGAH KEL. KATUP J.DPT MENCEGAH KEL. KATUP J.

[BIAYA BANYAK & ANGKA KEMATIAN TINGGI][BIAYA BANYAK & ANGKA KEMATIAN TINGGI]

INSIDENS INSIDENS ±± 3% PADA MASA EPIDEMIK DAN 3% PADA MASA EPIDEMIK DAN

INSIDENSNYA INSIDENSNYA ±± 0.3% PD MASA ENDEMIK 0.3% PD MASA ENDEMIK

ETIOLOGINYA:STREP. BETA HEMOL.GRUP A, ETIOLOGINYA:STREP. BETA HEMOL.GRUP A,

--DRDR SERING TERJADI BERSAMAAN URISERING TERJADI BERSAMAAN URI

--ASRAMA MILITER, KELOMPOK MASY. YG ASRAMA MILITER, KELOMPOK MASY. YG

TERISOLIR SERING EPIDEMI.TERISOLIR SERING EPIDEMI.

--INSIDENS INSIDENS DRDR PARALEL DGN INSIDENS URI PARALEL DGN INSIDENS URI

OK GABHS.OK GABHS.

Rheumatic feverRheumatic fever--pathogenesispathogenesis

Rheumatic feverRheumatic fever--pathogenesispathogenesis

Ada 4 Lapisan GAS. 1. Capsule (Hyaluronic acid) 2. Cel wall ( M - protein and M – Asosiated protein ) 3. Gtoup Carbohydrate (N-Acethyl Glucisamine Ribosome) 4. Protoplast membrane

1.

2.

3.

4.

Group A Streptococcus = GAS

4. Protoplast membrane (Protein, Lipid and Glucose)

Structur Antigen GAS sama dgn structur dari sel-sel: 1. Sendi (synovial membrane) 2. Sel-sel myocardium 3. Sel-sel Valvula / katup jantung 4. Sarcolema myocardium dan Sarcolema dari Subthalmic brain dan Nucleus caudatus

Dr.Babu UthmanDone by: Samya : RF and RHD 2007.

Rheumatic feverRheumatic fever--diagnosisdiagnosis

Subcutaneous nodules(nodules of rheumatoid arthritis are larger)

Rheumatic feverRheumatic fever--diagnosisdiagnosis

Erythematous patches

with central clearing

Erythema marginatum

Pathology :-Aschoff bodies antigen

presenting cells- Acute phase : inflammation process

in pericard, myocard & pericard- Chronic phase : injury of the valve- Chronic phase : injury of the valve- Difference of clinical and pathologi

cal manifestation in some countries- Host immunological response

take main role in clinical manifesta tion

Diagnosis :Diagnosis :

1944 : Dr.T.Duckett Jones : Jones Criteria 1944 : Dr.T.Duckett Jones : Jones Criteria

1955 : Modification of Jones Criteria1955 : Modification of Jones Criteria

1965 & 1984 : Revised of Jones Criteria1965 & 1984 : Revised of Jones Criteria1965 & 1984 : Revised of Jones Criteria1965 & 1984 : Revised of Jones Criteria

1992 : Update Jones Criteria1992 : Update Jones Criteria

Jones Criteria (focused)Jones Criteria (focused)

Problems : over diagnosis or under diagnosis Problems : over diagnosis or under diagnosis

1965 Jones Criteria (revised)

• Major manifestation• Carditis• Polyarthritis• Chorea• Subcutan nodule

• Minor manifestation• Fever• Arthralgia• Prolonged PR interval ECG

• Increase BSR

Diagnosis

• Subcutan nodule• Erythema marginatum • Increase BSR

• C reactive protein (+)• Leucocytosis• Previous history RF / RHD inactive

Evidence of previous

Strept. Infection

CULTURE / ASTO

1992 Jones Criteria (Updated)

Major manifestationCarditisPolyarthritis ChoreaSubcutan noduleErythema margina tum

Minor manifestationFeverArthralgiaIncrease BSRC reactive protein (+) LeucocytosisProlonged PR interval ECG

Diagnosis

Erythema margina tum LeucocytosisProlonged PR interval ECG

Evidence of previous Strept. Infection Culture / ASTO

Treatment RF & RHD (DR & Peny J.Re)• 1. Primary preventions :

• to eradicate Streptococcal infectcion :

• during acute RF attack

• 2. Secondary prevention :

• to prevent relaps of cute RF• to prevent relaps of cute RF

• 3. Relief the symptoms :

• - carditis / CHF

• - arthritis

• - Chorea

Treatment RF & RHD (DR & Peny. J.Rema)

•1. Primary prevention :

• 1. Benzatine PNC G injection 1 X / i.m.

• (BW > 27 kg 1,2 million unit)

• (BW < 27 kg 600.000 unit)• (BW < 27 kg 600.000 unit)

• 2. Pencilline V : 250 mg/400.000 unit QID

• / oral : 10 days

• Erythromycine : 40 mg /kg BW / day

• TID-QID / oral : 10 days

• Clindamycine, Nafcillin, Amoxycillin,

• Cefalexin

•Duration secondary prevention

•Categori Duration

• RF with carditis & permanent minimal 10 years

• valve abnormalities until 40 yrs or longlife

Treatment RF & RHD

longlife

• RF with carditis without perma 10 years or until

• nent valve abnormalities adult

• RF without carditis 5 years or until 21 years

Relief the symptoms

•A. Carditis :

• Anti inflammatory

• - Carditis : Prednison : 2 mg/kg BW/day tapp.

– 2-6 weeks off

Treatment RF & RHD

– 2-6 weeks off

– - Mild Carditis : Aspirin 90-100 mg/kg BW 4-6

– 4-8 weeks week

•B. Arthritis• - Aspirin : 100 mg/kg BW/ day : 2 weeks

• 2-3 weeks : doses decrease

•C. Heart Failure :

• - Bedrest - Digoxin

• - Diuretics - Vasodilator

• - Fluid & salt restriction

•D. Chorea :

•- Physical stres & emotional must be controlled

Treatment RF & RHD

•- Physical stres & emotional must be controlled

•- Anti inflammation drug : controversial

•- Phenobarbital : 15-30 mg TID-QID

•- Haloperidol : 0,5 mg ---> 2 mg TID

•- Valproic acid / Chlorpromazine / Diazepam

Table. Guidelines for Bed Rest and Ambulation and Recommended

antiinflammatory agents

• Arthritis Carditis Carditis Carditis

• alone minimal moderate severe

•Bed Rest 1-2 wk 2-3 wk 4-6 wk 2-4 mo

•Indoor ambulation 1-2 wk 2-3 wk 4-6 wk 2-3 mo

•Outdor activity 1-2 wk 2-3 wk 4-6 wk 2-3 mo

•(school)

•Full activity 1-2 wk 2-3 wk 4-6 wk 2-3 mo

•Prednisone 0 0 2-4 wk 2-6 wk

•Aspirin 0 0 2-4 wk 2-6 wk

Minimal Carditis Questionable cardiomegaly ; Moderate carditis definite but mild cardiomegaly,

Severe carditis, marked cardiomegaly or CHF

Surgical treatment and invasive intervention

•Surgical treatment :

•1. Valve Replacement :

• - MR

• - MS

• - AR• - AR

•2. Valvuloplasty

•Invasive Intervention :

•- Ballon Mitral Valvuloplasty (BMV) with

• Inoue ballon : MS

DCDC

Decompensatio CordisDecompensatio CordisDecompensatio CordisDecompensatio Cordis

Gagal JantungGagal Jantung

Conto: Mitral insuffisiensi

Setiap ventric.sist, ada darah naik

ke Atrium Ki→→→→lama2

Stagnasi di Atrium Ki

→→→→V.Pulm. →→→→vasc.paru →→→→pe-

numpukan cairan →→→→inf. →→→→Batuk kronik.

↓↓↓↓ darah masuk ke Ao →→→→Jantung kerja keras (HR↑↑↑↑=Tachycardia)

Jantung membesar (Cardiomegali), Bila kerja,perlu O2 banyak napas ↑↑↑↑

(Dyspnoe d’effort, sampai orthopnoe ). Tanda2 DC kiri

PS darah berkurang masuk ke

A.Pulm. Darah banyak ter

kumpul dalam V.Ka →→→→A.Ki →→→→ VCS

(TVC↑↑↑↑) →→→→ VCI (Hepatomegali) →→→→

Edem pretibial, Edema dorsal

pedis, Ascites →→→→ Jantung kerja

keras (Cardiomegali) dan Kalau keras (Cardiomegali) dan Kalau

kerja sesak napas (Tachypnoe).

Freq.Jantung naik (Tachycardi)

Tanda DC Kanan

PENGOBATAN DCPENGOBATAN DC

1. DIGITALIS1. DIGITALIS

2. DIURETIK2. DIURETIK

Dosis dan cara pemberianDosis dan cara pemberian

harus diperlajari baikharus diperlajari baik--baikbaik

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