Cardiologia Croatica. 2015;10(3-4)

Vlatka Reskovic Luksic, Sanja Cekovic, Sandra Veceric, Jadranka Separovic Hanzevacki

## Aim In patients with arterial hypertension, due to chronic pressure overload, structural concentric remodeling occurs. Hypertrophy pattern is determined by fiber orientation, interaction with local wall stress and is the most prominent in the region of basal interventricular septum. Every single segment deforms during systole in three dimensions — longitudinal, radial and circumferential, depending on fibers orientation. By analyzing standard echocardiographic parameters, no reduction in global ventricular function is to be found in this early phase of geometric changes, but longitudinal fibers are known to be affected and longitudinal function could already be reduced. (1-3) In this study, we wanted to investigate whether in hypertensive patients with septal bulge, there is a difference in regional longitudinal function. ## Patients and Methods 30 patients with essential arterial hypertension, no other comorbidities (valvular heart disease, coronary artery disease, diabetes mellitus, atrial fibrillation, stroke or TIA) and preserved LV ejection fraction were enrolled. Complete standard echocardiographic examination was done, along with 2D speckle tracking analysis of longitudinal strain. Patients were divided into two groups depending on presence of the basal interventricular (iv) septal bulge. Three patients were excluded from the study because of poor acoustic echo window. In 16 patients, iv septal bulge was present, and in 11 of them was not. Regional values of longitudinal strain were measured for each LV segment and data was compared between groups. ## Results In no bulge group (Figure 1), there was equal number of males (5 pts) and females (6 pts), but in septal bulge group, majority of patients were male (10 out of 16). There was no significant difference in patient’s age between groups (45.7±12.9 years in no bulge and 48.4±9.9 years in bulge group). Mean duration of hypertension was 8.1±8.9 years in no bulge and 6.2±8 years in bulge group. We found no statistically significant difference in regional longitudinal strain values, except in the region of medial interventricular septum (-21.4±3.1% vrs -18.3±3.02%, P=0.26), which was significantly reduced in patients with basal iv septal bulge. This is the area closest to the region most prominent to pressure overload and hypertrophy and significance of this finding should be investigated further on. Figure 1. Comparation of regional longitudinal strain values between hypertensive patients with and without septal bulge. ## Concluson In patients with hypertension and preserved ejection fraction, even in early stages of hypertensive heart disease, subtle changes in LV longitudinal function can be found. Interventricular septal hypertrophy could be a macroscopic marker for this changes and could help us in identifying patients in greater risk for developing heart failure. This data should be confirmed on larger number of patients and with particular focus on septal segments and correlation between regional longitudinal and radial function.

Jure Samardzic, Marijan Pasalic, Zeljko Baricevic, Hrvoje Jurin, Maja Cikes, Davor Milicic

## Introduction Tako-Tsubo cardiomyopathy (TTC) is a clinical condition characterized by acute and generally reversible myocardial dysfunction. It is usually triggered by significant emotional or physical stress. Catecholamine activation of adrenoceptors has been recognized as a primary trigger of pathophysiological changes in TTC (1). Previous data showed no evidence that cardioprotective drugs such as beta-blockers (BB) decrease reoccurrence of TTC (2). We sought to evaluate whether chronic BB therapy attenuates myocardial dysfunction and type of wall motion abnormalities (WMA) in patients presenting with TTC. ## Methods We retrospectively analyzed medical record data of patients admitted with TTC from January 2011 to March 2015. Left ventricular ejection fraction (LVEF), location and extent of MWA were compared between patients previously treated with BB and patients without a BB in therapy at admission. ## Results Twenty-one patient with TTC was identified. Nine patients were BB users and eleven patients were BB non-users. Information on previous BB therapy was not available for one patient who was excluded from the analysis. There was no significant differences in demographic and clinical data between study groups. No statistically significant difference in LVEF and forms of WMA was found between study groups (0.425 and 1.000, respectively) (Table 1). ### Table 1: Patients’ data. | | BB users (N=9) | BB non-users (N=11) | p | | --- | --- | --- | --- | | Age, mean (min-max) | 63.56 (33-79) | 60.09 (45-76) | 0.617 | | Women, n | 8 | 7 | 0.319 | | Type of WMA, n apical apical and midventricular midventricular basal | 5 4 0 0 | 6 5 0 0 | 1.000 | | LVEF, mean (SD) | 47.22 (14.1) | 42.27 (12.9) | 0.425 | [†] BB — beta-blocker; LVEF — left ventricular ejection fraction; SD — standard deviation; WMA — wall motion abnormality ## Conclusion Results indicate that previous use of BB does not attenuate the severity of myocardial dysfunction nor the type of WMA in patients presenting with TTC. These results warrant further investigation and confirmation on a larger number of patients. Time of patient presentation and echocardiographic examination should also be considered in the analysis.

Vlatka Reskovic Luksic, Dejan Dosen, Sanja Cekovic, Sandra Veceric, Jadranka Separovic Hanzevacki

## Aim Global and regional left ventricular (LV) longitudinal strain (LS) is often reduced, despite normal LV ejection fraction (LVEF) in patients with severe aortic stenosis (AS). (1-4) We wanted to analyze subtle regional longitudinal LV deformation changes after aortic valve replacement (AVR). ## Patients and Methods 45 patients with severe symptomatic AS (AVA/BSA 0.33±0.09cm2/m2) and preserved LVEF (57.3%±8), without concomitant coronary artery disease were enrolled. Complete transthoracic echocardiography with longitudinal strain analysis by speckle tracking was performed before, in early postoperative period (7.5±6.2 postoperative days) and late follow up (mean 17.14 months). ## Results GLS was reduced in patients prior AVR (-12.64±6.7%) (Figure 1). We found no statistically significant difference in GLS (p=0.888) in early postoperative period and neither in late follow up (p=0.109), although trend was towards improvement in global LS and absolute values came close to normal (-19.6%). Regional longitudinal strain analysis of the LV basal segments in early postoperative period showed significant improvement of longitudinal LV function in the basal interventricular (IV) septum (p=0.011). Those differences were even more expressed in late follow up — there was also significant improvement of LS in the basal lateral LV wall (p=0.015). Figure 1. Left ventricular longitudinal strain curves show segmental loss of longitudinal LV function. ## Conclusion After AVR, even in early postoperative period, we found significant improvement of longitudinal deformation in basal IV septum. Those changes attribute to pressure unload, while in late follow up, because of LV positive remodeling, basal lateral LV segment also recovers in longitudinal function. We conclude that IV septum has not permanently lost his longitudinal function in spite of low longitudinal LS prior surgery. This is the area most prone to pressure overload state and it recovers immediately after operation due to pressure unload. Later on, positive remodeling takes place, so that other LV segments can also improve their function.

Jasmina Catic, Sandra Jaksic Jurinjak, Robert Blazekovic

Ebstein’s anomaly as a rare congenital disorder serves as a model of right ventricle dysfunction and altered atrial and ventricular coupling. It is characterized by failure of delamination of tricuspid valve leaflets and downward-apical displacement of the tricuspid valve attachments, apical displacement of the tricuspid valve due to adherence of the septal and posterior leaflets to the interventricular septum, redundancy, fenestration and tethering of the anterior tricuspid valve leaflet, dilatation of the anatomic (true) valve annulus, resulting in valve insufficiency and partial atrialization of the right ventricle. (1-4) We report 36-year-old female. She presented with exertional dyspnoa. Enlarged right atrium and ventricle, a hump-shaped infundibulum was evident on chest radiograph (Figure 1). ECG showed atrial intraventicular conduction delay (Figure 2). The 2D echocardiogram (Figure 3) revealed the presence of poor right ventricular function and atrialization of the right ventricle, malformation of the tricuspid valve (TV) and the right ventricle (RV). The most prominent morphological feature of EA was degree of apical displacement of the TV into the RV, dividing the RV into a proximal chamber of atrialized RV (aRV) and distal portion of functional RV. Massive tricuspid regurgitation (TR), extensive dilatation, and dysfunction of the right atrium (RA) and RV were found. Figure 1. Chest radiograph showing enlarged right atrium and right ventricle. Figure 2. Fragmented QRS complexes observed in adult patients with Ebstein anomaly. Figure 3. Measurement of the severity of Ebstein anomaly. Planimetry was performed in the apical 4-chamber view at end diastole. Poor right ventricular function was shown by the 2D echocardiogram including atrialization of the right ventricle, malformation of the tricuspid valve (TV) and the right ventricle (RV). The most prominent morphological feature of EA was degree of apical displacement of the TV into the RV, dividing the RV into a proximal chamber of atrialized RV (aRV) and distal portion of functional RV.

Viktor Culic, Zeljko Busic, Marija Busic, Marina Juric-Paic, Adrijana Livaja

## Background Previous studies found no correlation between serum testosterone levels (TL) and left ventricular (LV) ejection fraction, but the role of testosterone in diastolic dysfunction (DD) is less understood. ## Methods Male patients hospitalized because of acute HF at the Department of Cardiology, University Hospital Center Split-Krizine between December 2011, and March 2014 were enrolled. The diagnosis was established according to clinical presentation and echocardiographic findings of either systolic (LV ejection fraction <45% assessed by the Simpson method) or DD. Color M-mode, pulsed-wave Doppler from the apical four-chamber view and tissue-Doppler imaging parameters of diastolic LV function were measured to assess the severity of DD according to four basic grades. ## Results Of the 121 patient, 31 (25.6%) had previous MI. They significantly more often used aspirin, loop diuretic, spironolactone or beta-blocker and have a significantly lower serum total TL and higher GFR (p<0.05 in all cases) compared to patients without a previous MI. There were no differences in average age, LV ejection fraction, cardiovascular risk factors or prehospital use of digoxin, angiotensin converting enzyme-inhibitor, angiotensin II receptor I blocker, calcium channel antagonist or statin. DD showed a significant inverse correlation with total TL (r=—0.222, p=0.001) in all patients, and the same trend was present separately in both men with (r=—0.334, p=0.07) and without (r=—0.198, p=0.06) previous MI. Multivariate analysis revealed that in all patients, both low total TL (ß=—0.244, p=0.006) and smoking (ß=—0.255, p=0.004) were significant predictors of DD severity. Among post-infarction patients only smoking (ß=0.604, p=0.0002) remained a strong independent predictor whereas in their counterpart group it was only low total TL (ß=—0.213, p=0.047). ## Conclusions The results of the present report suggest that lower TL could be an important factor in the development of DD in men with HF without previous MI. In HF patients who have had a MI, smoking seems to be the chief factor in the progression of DD.

Andreja Cerne Cercek, Pavel Berden

## Background Left ventricle (LV) contractile function depends on a complex longitudinal, circumferential and radial deformation. LV ejection fraction (LVEF) is not an ideal measure of subtle decrease in regional LV function in acute myocarditis due to selective damage of the subepicardial layers. Speckle tracking echocardiography is a more accurate technique for quantifying myocardial deformation and might denotes subtle longitudinal dysfunction in these patients. ## Aim The aim of our study was to assess longitudinal and circumferential strain of the LV in patients with acute myocarditis and to correlate these findings with the cardiac magnetic resonance imaging (CMR) results. ## Methods Thirty consecutive patients (age 30±8, 90% male) with acute myocarditis mimicking acute coronary syndrome and preserved LVEF were compared to 30 age and sex-matched healthy participants. All the patients had elevated troponin I (11.5±8.3 ng/L), normal coronary angiogram and CMR evidence of late gadolinium enhancement (LGE). Global longitudinal (GLS) and circumferential (GCS) strain was assessed by 2-dimensional speckle tracking echocardiography in all participants. ## Results Multiple areas of subendocardial LGE were detected in all patients, additional intramural LGE lesions were found in three (10%) patients. GLS was significantly decreased in the myocarditis group as compared to controls (-15±2% vs. -20±4%, p<0.01), while no significant difference in GCS was observed between the two groups. However, a reduced GCS was detected in patients with intramural LGE (patient No.8, No.13 and No.17: -16%, -14% and -10%). In the myocarditis group, segments with LGE showed significantly lower GLS in comparison to segments without LGE (-15±6% vs. -18±6%, p<0.01). A GLS cut-off point of <-16% was able to identify 92% of the lesions with LGE. ## Conclusions In patients with acute myocarditis and preserved LVEF, longitudinal deformation is diffusely impaired and being lowest in the areas with CMR detected subepicardial damage.

Zeljko Baricevic, Dejan Dosen, Sandra Veceric, Ivica Safradin, Darko Anic, Jadranka Separovic Hanzevacki

## Introduction We present two cases of the extremely rare and life-threatening cardiac surgery complications in patients presenting with dyspnea as the leading complaint, with echocardiographic imaging leading to a prompt and precise diagnosis. ## Case 1 A 41-year-old man was admitted to our department with the history of progressive dyspnea on exertion. Two years earlier a composite mechanical-valved conduit aortic root replacement (Bentall operation) had been performed due to severe regurgitation of the bicuspid aortic valve coupled with the aneurysm of the ascending aorta. Transthoracic echocardiogram demonstrated a 10 cm large aortic pseudo-aneurysm with the total dehiscence of the valved conduit at the site of the proximal anastomosis (Figure 1). The conduit was floating in the pseudo-aneurysmal cavity and was kept loosely in place by the tension of the coronary arteries, with preserved flow through the mechanical valve. Emergency surgery was performed. Intraoperatively, no signs of endocarditis were found, leaving suture line tension and connective tissue quality issue (due to underlying disease, namely BAV) as possible risk factors associated with the occurence of the complication. Figure 1. Parasternal long-axis view demonstrating the total separation of the mechanical-valved conduit (large arrow) within large pseudoaneurysm of the ascending aorta (delineated by the small arrrows) from the left ventricular outflow tract. ## Case 2 A 63-year-old man was referred to our department due to marked progressive dyspnea. A complex surgical procedure, namely aortic valve replacement with stentless bioprosthesis, ascending aorta and aortic arch reconstruction with dacron graft, triple aortocoronary bypass and mitral valve annuloplasty had been performed two months earlier in an out-of-country surgical center. Transthoracic and 3D transesophageal ecocardiography revealed total dehiscence and migration of the mitral annuloplasty ring to the left ventricular outflow tract through the perforation of the anterior mitral leaflet, approximately 1 cm from the aorticomitral junction, causing severe mitral regurgitation (Figure 2). The patient recovered uneventfully after successful mitral valve replacement (with mechanical prosthesis). Figure 2. 3D transesophageal echocardiogram demonstrating perforation of the anterior mitral leaflet by migrating mitral annuloplasty ring (arrows), from the left atrial view. ## Conclusion Due to its ready availability and high accuracy, echocardiography plays pivotal role in early diagnosis and appropriate management of the various complications following cardiac surgery.

Slavica Mitrovska

## Background Continuous variations of volume and pressure in dialysis patients have an impact on left ventricular (LV) function. Pulsed-waved Doppler analysis records transmitral flow velocities and the volume changes affect its accuracy in the evaluation of cardiac function. Tissue Doppler imaging (TDI) quantifies mitral annular velocities and as a relatively load-independent method, more precisely reflects structural myocardial changes. ## Aim To assess the role of TDI in the early detection of subclinical dysfunction of the left ventricle in dialysis patients. ## Methods Cross-sectional, single-center study that included 36 patients (24 men and 12 women, mean age 59+/-12 years), on regular hemodialysis (HD) program (mean HD vintage 48+/-71 months). All patients underwent transthoracic echocardiography (pulsed-wave Doppler and TDI) to assess diastolic function. To minimize the effect of fluid overload, analyses were performed 24 hours after HD session. We analyzed the diastolic parameters from both echo-techniques and their relations with traditional and uremia-related factors. ## Results TDI identified significantly higher rate of diastolic dysfunction (DD) vs PW Doppler analyses (Z=-4.26, p <0.00). TDI-derived diastolic velocities suggest a positive relationship with plasma levels of calcium (r=0.65, p=0.03), calcium phosphate product (r=0.63, p=0.03), LVMI (r=0.53, p=0.03), and systolic blood pressure (r=0.49, p=0.03), but negative correlation with hemoglobin (r= -0.79, p=0.03) and hematocrit (r= -0.74, p=0.03). ## Conclusion TVI is more sensitive method than PW Doppler for early identification of diastolic dysfunction and better identify dialysis patients at risk of development of heart failure.

Fatmir Ferati, Mentor Karemani, Anida Ferati, Ardian Preshova, Nexhbedin Karemani

The aim of this paper is the analysis of 2D strain values and other values of LV such as: dV/dT among non-symptomatic diabetic patients (without documented heart disease) and the control group. (1*—*4) One hundred patients with non-symptomatic diabetes mellitus were analyzed (55 males and 45 females) with an average age of 56 years (56 ± 20 years). In the group of people without a verified disease, 50 individuals have been chosen (26 males and 24 females), with an average age of 55.3 years old (55.3 ± 17). ## Results 1. At parasternal views, there is a decrease of 2D strain in patients with diabetes, more emphasized in the MV level while at the PM level, these changes are less emphasized. 2. Decrease of longitudinal strain values (LS) at the 4C and 3C, bellow the normal values for the LC are registered. A decrease of RS values is registered in our study but they are within normal values for RS.Considering these two facts, it can be concluded that LS is the main damage which occurs and characterizes non-symptomatic diabetic people. 3. On the basis of these data, it may be stated that the value of under 18% of LS can be taken as the dominant value which is recorded in this study in patients with diabetes. 4. In relation to the duration of diabetes, a significant difference is recorded in 2D strain between patients with diabetes in relation to the duration of the disease. 5. The changes in LC are the first recorded changes in patients with diabetes. 6. In patients with diabetes and complications, decrease in values of 2D strain appear, which are more emphasized in LS. 7. A decrease in values of strain is registered in patients who were on therapy with insulin, unlike those without. 8. There is decrease of dV/dT in patients with diabetes 9. Extension of T2P values in patients with diabetes is registred. 10. A post systolic shortening phenomenon (PSS) is recorded at patients with diabetes compared to those without diabetes, 11. Increase of the left ventricular mass in patients with diabetes is recorded.

Karlo Golubic, Vlatka Reskovic Luksic, Irena Ivanac Vranesic, Vojtjeh Brida

Implantable device leads can cause tricuspid regurgitation (TR) when they interfere with leaflet motion. Patients may present with clinical symptoms of right-sided congestive heart failure (jugular venous distention, pulsatile liver, peripheral edema), although many are asymptomatic. The detection of severe tricuspid regurgitation by echocardiography may be missed because of acoustic shadowing from the pacemaker wires and suboptimal visualization of the regurgitant jet. (1-3) The aim of this study was to present the various mechanisms through which ventricular leads may cause TR in real-life cases detected by echocardiography. We describe five patients with new or worsening preexisting TR after the implantation of one or more right ventricular leads, their clinical presentation, diagnosis and treatment (Figure 1, Figure 2). The mechanisms of TR include lead adherence to the leaflets due to fibrosis and scar formation causing incomplete valve closure, valve obstruction caused by a lead placed in between leaflets, lead entrapment in the tricuspid valve apparatus, valve perforation or laceration by the pacemaker lead and annular dilatation of the valve. Figure 1. 3D view of the malcoaptation of the tricuspid valve leaflets caused by a pacemaker lead. Figure 2. Apical four chamber view of the malcoaptation of the tricuspid valve leaflets caused by a pacemaker lead. ## Conclusion TR should be suspected in patients with implantable device leads who develop new onset right heart failure. Echocardiography plays an important role in the diagnosis of device-related TR although it has limitations.

Karlo Golubic, Vlatka Reskovic Luksic, Irena Ivanac Vranesic, Vojtjeh Brida

We present the case of a 61-year old female patient who was clinically asymptomatic and in good general condition. The patient was referred for echocardiography during the course of the diagnostic evaluation of her moderate arterial hypertension. During the echocardiographycal examination, a large mass arising from the posterior part of the mitral annulus was found with echo-dense smooth borders suggestive of calcification (Figure 1, Figure 2). After the first examination, the patient remained for years in follow-up in our echocardiographic laboratory. We observed different changes in the aforementioned mass in yearly echocardiographic examinations. The changes included echo „dilution“ of the center of the mass followed by the formation of a communicating duct between the center of the mass and the left atrium. Also irregular protuberations were formed at the sides facing the left atrium and the left ventricle. Considering the potential for a systemic thromboembolic event arising from the protuberances of the mass, additional 3D tranoesophageal analysis was performed which is described in this case-report. It appears that the mass is most probably a fibrocalcification of the mitral annulus with a central amorphous content that eventually drained into the left atrium of left ventricle, but without apparent thromboembolism. The patient has been treated conservatively because there was no impairment of the mitral valve function. Due to a high risk of thromboembolism, she was started on anticoagulation therapy with warfarin. Although the mass was not excised and we do not have a histological analysis, judging by the echocardiographic appearance, clinical presentation and data from literature, the findings primarily indicate degenerative disease of the mitral annulus with possible calcification. This condition has a benign prognosis, but can mimic cardiac tumor, vegetation or calcified thrombus. (1, 2) Figure 1. 3D view of the calcification of the mitral annulus. Figure 2. 2D view of the calcification of the mitral annulus.

Irena Ivanac Vranesic, Karlo Golubic, Eduard Margetic, Petra Angebrandt, Vojtjeh Brida, Anton Smalcelj

## Introduction Alcohol septal ablation (ASA) is established treatment method for symptomatic patients with hypertrophic cardiomyopathy (HCM) and left ventricle outflow tract (LVOT) obstruction who do not respond to medical treatment. LV diastolic dysfunction is one of the causes of the symptoms in these patients and also of the left atrial (LA) enlargement. (1*—*3) Since LA size provides important prognostic implications, we wanted to evaluate impact of SAA on diastolic function and LA size and function. ## Methods and Results We analyzed retrospectively echocardiography exams of 18 HCM patients with LVOT obstruction who were treated with SAA in period from 2010 to 2014. Only data from 10 patients (age 57 (50-58) years, 7 men) who were in sinus rhythm and had complete echocardiography exams before and 355 (69-459) days after successful SAA were included in our study. LVOT gradient significantly decreased from 76 (70-87) mmHg to 15 (11-30) mmHg, p=0.0007. Several parameters of diastolic function (E and A wave velocity, E/A, deceleration time, isovolumic relaxation time, A wave duration, E/E') as well as left atrial end-systolic area, volumes and ejection fraction were studied. We found no significant changes in these parameters after successful ASA. ## Conclusion We found no significant changes in echocardiographic diastolic function or LA size and function parameters in our small group of patients with HCM and LVOT obstruction after successful ASA. Larger studies are needed to evaluate these parameters in this patient population.

Daniela Loncar, Zumreta Kusljugic, Zinka Donlagic, Irma Bijedic, Amira Bijedic, Esad Brkic, Denis Mrsic, Lejla Jasarevic

## Introduction Cardiovascular diseases are the greatest cause of morbidity and mortality in patients after kidney transplantation. Valvular heart disease is a common occurrence in patients on chronic dialysis. Abnormalities include valvular and annular thickening and calcification of any of the heart valves, causing regurgitation and/or stenosis. Valvular thickening or sclerosis in patients on chronic dialysis treatment most commonly affecting the aortic and mitral valve. Current knowledge of valvular heart disease in patients after kidney transplantation are scarce. ## Aim To determine the prevalence of valvular heart disease in kidney transplant patients and patients treated with hemodialysis. To determine whether there is a difference in the prevalence of valvular heart disease among kidney transplant patients and patients treated with hemodialysis. ## Patients and Methods We conducted a prospective study that included 90 patients. All patients had their history data taken, electrocardiogram, complete physical examination and echocardiography. The diffeence in frequency of the observed parameters was tested by chi-sqyare test. ## Results Patients were divided into two groups: kidney transplant patients (60 patients) and patients treated with hemodialysis (30 patients). In the group with kidney transplant patients was 42 (70%) men and 18 (30%) women. In the group with patients treated with hemodialysis was 15 (50%) men and 15 (50%) women. The average age in kidney transplant patients was 42.22 ± 1.71 years, in the group with patients treated with hemodialysis was 52.97 ± 2.98 years. The mean duration of dialisys before kidney transplant in the group with kidney transplant patients was 43.00 ± 9.19 months. The average kidney graft survival was 9,1±9,68 years. The mean duration of dialisys in the group with patients treated with hemodialysis was 87.00 ± 15.6 months. Tricuspidal regurgitation had 20 (33.33%) kidney transplant patients and 12 (40%) patients treated with hemodialysis; p value 0.1988. Mitral regurgation had 20 (33.33%) kidney transplant patients and 17 (56.67%) patients treated with hemodialysis; p value 0.0294. Aortic regurgitation had 9 (15%) kidney transplant patients and 10 (33.33%) patients treated with hemodialysis; p value 0.0435. Pulmonary valve regurgitation had 0 (0%) kidney transplant patients and 3 (10%) patients treated with hemodialysis; p value 0.0346. Mitral stenosis had 1 (1.67%) kidney transplant patients and 4 (13.33%) patients treated with hemodialysis; p value 0.0407. Aortic stenosis had 1 (1.67%) kidney transplant patients and 2 (6.67%) patients treated with hemodialysis; p value 0.2567. ## Conclusion We find statistically significant differences in the frequency of valvular heart disease between kidney transplant patients and patients treated with hemodialysis.

Viktor Persic

Coronary artery disease remains the leading cause of death in Europe and the leading cause of heart failure. In the management of therapeutic procedures in patients with heart failure caused by coronary heart disease is crucial assessment of myocardial viability, an important procedure that needs to be addressed when patients with dysfunctional myocardium are considered to be revascularised. The benefit of revascularization is greater if the supply area of the affected coronary blood vessels has enough viable myocardium whose revascularization achieve a functional benefit and significant impact on the prognosis and survival of patients. Assessment of myocardial viability can be detected by nuclear techniques (PET, SPECT), stress echocardiography and magnetic resonance imaging (MRI). In the latter helps a combination of several MRI protocols: Cine MRI, perfusion MRI, delayed contrast enhancement. MRI of the heart is not just a tool, it makes a number of integrated tools in a unified search.The presentation will show the potential of MRI in the managing diagnostic and therapeutic approach in patients with known coronary heart disease.

Viktor Persic

Echocardiography has evolved to be an important tool in the assessment of patients with hypertrophic and restrictive cardiomyopathy. Hypertrophic cardiomyopathy (HCM) is a common inherited cardiovascular disease and the most frequent cause of sudden death in young athletes. HCM causes functional disability from heart failure and stroke. Therefore, the identification of patients with HCM is a challenge. Two-dimensional echocardiography is the usual initial method of diagnosis. Echocardiography can be used to confirm the heart dimension, the pattern of ventricular hypertrophy, systolic and diastolic function and the severity of the outflow gradient. Echocardiographic criteria for diagnosis of HCM have been proposed (1, 2). The World Health Organization defines restrictive cardiomyopathy (RCM) as a myocardial disease characterized by restrictive filling and reduced diastolic volume of either or both ventricles with normal or almost normal systolic function and wall thickness. Clinically, RCM is difficult to distinguish from constrictive pericarditis, which is treatable. Echocardiography and cardiac magnetic resonance imaging (MRI) have been reported to be comparable in their ability to differentiate RCM from constrictive paricarditis. Compared with MRI, echocardiography may be restricted by by inadequate echo window, and pericardial thickness can be overlooked. (3) The presentation will be shown current and emerging methodology approach and echocardiographic tools used in contemporary echocardiography in the diagnosis of HCM and RCM and differentiation from mimicking diseases, assessment of prognosis, and managing therapeutic approach.

Arbnore Batalli-Këpuska, Ramush Bejiqi, Arlind Batalli

## Introduction Congenital heart abnormalities are fairly common anomaly, that are numbered in second place after urinary tract anomalies. Large problem presents complex heart abnormalities due to lack of cardiological center in our country. The aim was to present the congenital heart abnormalities in the period January-June 2013 at children aged 1-12 months. ## Patients and Methods All outstanding children with congenital anomalies have been hospitalized at the Pediatric Clinic at the Cardiology and Rheumatology Department. At children are taken routine laboratory tests (erythrocyte sedimentation rate, blood, urea, creatinine, glycaemia, urine) at all children has become conducted chest X-ray. Golden method in diagnosing the correct congenital heart abnormalities has been echocardiography. ## Results Out of 22 children with congenital heart anomalies 4 children have been with tricuspid valve atresia, 3 children with Tetralogy of Fallot, 3 children with pulmonary artery atresia, 2 children with truncus arteriosus communis, 3 children with hyperplastic left heart syndrome, 6 children with transposition of large blood vessels and 1 child with total spill anomaly of pulmonary veins. ## Conclusion Although our country conducts accurate diagnosis of congenital heart anomalies, still due to lack of cardiological center mortality is high.

Blanka Glavas Konja, Vlatka Reskovic Luksic, Josko Bulum, Martina Lovric Bencic, Zvonimir Ostojic, Aleksander Ernst, Jadranka Separovic Hanzevacki

## Background Constrictive pericarditis is a rare disease but can cause diagnostic problems. The diagnosis can be even more difficult if combined by pulmonary emobolism (1, 2). We present the case of constrictive pericarditis complicated with several thromboembolic incidents. ## Case Presentation A 58-year-old was admitted to Clinical Hospital with symptoms of dyspnoea, ortopnoe, fatigue and signs of dominantly right heart congestion. As a 6-year old child he had left sided pleuritis. Later, he was working at shipyard in the region close to asbestos factory. Four years before admission he was accidentally diagnosed atrial fibrillation. Anticoagulant therapy with dabigatran was started. Electrocardioversion was done successfully for three times and finally radiofrequency ablation had been planned when patient felt breathless suddenly. He was admitted to local hospital where thoracic MSCT showed bilateral incapsulated pleural effusion, bronchial deformities and a small pericardial effusion that measured 0.7 cm. Right sided pneumonia was suspected so patient was treated with antibiotics but with no benefit. MSCT pulmonary angiography did not show pulmonary embolism, but verified worsening of pericardial effusion, hepatic congestion and ascites. PET CT showed no pathology. Fiber optic bronchoscopy found only nonspecific mucopurulent substrate. Quantiferon test was negative. Dyspnoea was worsening, as well as pericardial effusion. Anticoagulant therapy had been stopped for a while. Echocardiography examination found dilatation of both atria with an indirect signs of high right atrial pressure and constrictive hemodynamic and thrombus in right atrium (Figure 1). Control CT showed multiple thrombotic masses in right atrium, segmental pulmonary arteries, left atrial auricular. Doppler did not show peripheral vein thrombosis. Anticoagulant therapy was started again. Searching for thrombophilia found normal FV, FII, MTHFR (CC gene type), polymorphism (4G/5G) for PAI-I, and insertion ACE genotype. Polyserositis was suspected so corticosteroid wad added to therapy. Heart MR confirmed constrictive pericarditis and made suspicious of thrombotic masses in both atria. Meanwhile patient had another thromboembolic episode; inferior and superior caval vein thrombosis, hepatic and renal veins thrombosis, and right iliac artery embolism. Iliac artery trombendarterektomia was successfully done. Patient was transferred to the tertiary hospital for the diagnostic confirmation of constrictive pericarditis. Figure 1. Echocardiography shows thrombus in right atrium at the entrance of superior vena cava. At the admission, patient was afebrile, cachectic, tachypneic, orthopnoic and hypotensive with signs of hepatomegaly, ascites, peripheral oedema and jugular distension. Decubital ulcer stared to form at sacrum. Fatigue end exhaustion was in progression. As PET CT showed intensively metabolic active pericardial region, antituberculotic therapy was started despite of negative Quantiferone test with partial benefit (Figure 2). Heart catheterization was performed, but typically four chamber equalization of pressure was not confirmed (Figure 3). Pulmonary artery pressure was normal, and right atrial pressure was high. Patient was re-evaluated and transferred to cardiac surgery department for pericardiectomy. Procedure risk was classified as very high. Figure 2. PET CT. Figure 3. Ventricular pressures with left ventricular dip-and-plateau pattern. Pericardiectomy has been done partially because of heavily adherent thick pericardium. Rehabilitation procedure was started, and clinically status of the patient was improving gradually. Samples of pericardium were sent to pathology department, but the histological examination did not show specific inflammation. Antituberculotic therapy was stopped. Patient was discharged in improved condition, without dyspnoea or oedema. ## Conclusion The diagnosis of constrictive pericarditis is difficult. The cardiac catheterization with intracavitary pressure curves analysis is considered as a gold standard. Typically equalization within 5 mmHg range difference of end-diastolic pressure in all chambers has low sensitivity and specificity. The diastolic curve profile in both ventricles that represents dip-and-plateau pattern is not present always (3, 4). Right atrial thrombus associated with pericarditis is very rare. (5) Thrombosis of other vascular structures associated with pericarditis is even more rare. Cases of chronic inflammatory diseases as Behcet's disease or hematogic malignant diseases have been described. (6) We have presented the case of idiopathic constrictive pericarditis combined with thrombophilia and atrial fibrillation. Every of this conditions predispose to thrombi formation. Pericardiectomy followed by anticoagulant therapy is optimal treatment option. (7)

Urban Brumen, Mateja Groselj, Breda Barbic-Zagar

Statins have been proven to reduce cardiovascular morbidity and mortality in primary and secondary prevention of cardiovascular disease. However, statin treatment is still not optimal, with the majority of patients not achieving the maximum benefits of this preventive strategy. Krka offers a wide range of statins that have been extensively studied. The studies have provided clear and conclusive evidence about the benefits of atorvastatin (Atoris®) and rosuvastatin (Roswera®) in primary and secondary prevention patients, including effective management of the total lipid profile, achievement of target lipid levels, prevention of severe ischemic outcomes in patients with acute coronary syndrome, protective pleiotropic effects and a good safety profile. Clinical studies with Krka’s statins represent an important contribution to a better management of hyperlipidemia in different groups of patients.

Sandra Jaksic Jurinjak, Mira Stipcevic, Boris Starcevic, Josip Vincelj, Jasmina Catic, Diana Rudan, Mario Udovicic

Strain echocardiography is a validated and accurate measure of regional systolic left ventricular function, superior to visual assessment of wall motion in detection and quantification of regional systolic function and is sensitive tool for detection of ischaemia (1). The ischaemic risk area can only be assessed clinically by perfusion imaging with single photon emission computed tomography or contrast echocardiography, and these modalities are not available in the emergency setting at most hospitals (1). We demonstrate the use of a non-invasive bedside imaging modality, global and regional assessment of left ventricle (LV) longitudinal strain, to identify acute coronary lesion in the Non—ST-segment elevation (NSTE) acute coronary syndromes (ACS) patient. This has important clinical implications, since acute coronary occlusion is a potentially reversible cause of myocardial ischemia and necrosis, if reperfusion therapy is initiated promptly. We present an example of a 45-years-old female patient with acute myocardial infarction without ST-segment deviations. The ECG obtained at admission to our hospital showed no evidence of ischemia, and prehospital nonsustained ventricular tachycardia was reported. Troponin I was measured to 10.23 µg/L. The patient was stable during 4 hours observation, and had no chest pain after admission. Biplane left ventricular ejection fraction (EF) calculation utilising the Simpson method was performed showing preserved LVEF (52-57%). However, this method is dependent on visual delineation of the endocardial border, which can be a challenge in patients with poor acoustic conditions. This limitation could contribute to the superiority of global longitudinal strain (GLS) over LVEF, but the same challenges are present when performing two-dimensional speckle tracking (2). A bull's eye plot of strain values demonstrated a functional risk area of eight adjacent segments with strain greater than or equal to −12% (Figure 1, Figure 2). Coronary angiography revealed significant stenosis in the proximal left circumflex artery, the left anterior descending artery, and the right coronary artery with no significant stenosis and no occlusion was found. Figure 1. Severely impaired global longitudinal strain in a 54 years old female patient with preserved left ventricular ejection fraction and non-ST segment elevation myocardial infarction. Figure 2. Left panel demonstrates apical four-chamber view with the region of interest drawn, corresponding strain curves are shown in the right panel. Reduced systolic shortening in the basal and mid lateral wall (blue, red) is demonstrated by peak systolic strain values of −4 to −7%. End-systole is defined by aortic valve closure (AVC), and is marked with a vertical green line. Several mechanisms may explain large areas with dysfunction, most important, transient occlusion with subsequent spontaneous lysis may render the myocardium stunned or necrotic, even if the epicardial vessel is patent when coronary angiography is performed. The prevalence of total occlusion is previously reported to fall during the first 24 h after infarction (1, 2) indicating that spontaneous lysis is frequent in patients with myocardial infarction. Percutaneous coronary intervention (PCI) was performed at the discretion of the operator, performed by a experienced invasive cardiologist, placing a drug-eluting stent in proximal left circumflex artery. These patients are also important to identify, as they may profit from intensified antithrombotic therapy and PCI to stabilise the ruptured plaque. The eight-fold increase in mean Tn observed in patients with large risk areas is likely to reflect significantly larger infarctions (1-3). This may be due to transient occlusion or distal embolisation, and may explain some of the patients presentation. We present 2D strain echocardiography as a diagnostic tool to identify patients with NSTE-ACS patients who may benefit from urgent reperfusion therapy, and can be used in acute setting based on information that can be obtained in the emergency room or invasive centre, to minimise delay. Strain echocardiography is valuable tool for better risk stratification and therapy in patients with NSTE-ACS in acute settings.

Livija Susic, Vedrana Baraban, Josip Vincelj, Jasmina Catic, Robert Blazekovic

## Case report 61-year-old woman with long history of hypertension presented with progressive dyspnea and chest pain that she has been experiencing at minor physical exertion for several months. Current medical records confirmed T-wave inversion in right precordial leads, attacks of supraventricular and ventricular arrhythmia, including attacks of non-sustained ventricular tachycardia and reccurent syncopal episodes from the age of 23. Dilated right heart chamber are detected by transthoracic echocardiogram year 2006, presence of the shunt was excluded by scintigraphy. ## Imaging studies 2-dimensional transthoracic echocardiogram revealed one large (Figure 1) and two smaller hyperechogenic masses (Figure 2) inside extremely dilated (Figure 3) and globally hypokinetic right ventricle with moderate tricuspid regurgitation. 3-dimensional transesophageal echocardiogram confirmed mobile pedunculated mass by free wall of right ventricle (Figure 4). Magnetic resonance imaging describe dilated right heart chambers, hypertrophic septomarginal trabeculae of the mid-apical part of right ventricular and mass within the same chamber appears to be a tumour. CT pulmonary angiogram, PET CT and coronarography ruled out specific pathomorphological substrate. Figure 1. 2-dimensional transthoracic echocardiogram - PLAX: large hyperechogenic mass (4.2 x 2 cm) inside right ventricle. Figure 2. 2-dimensional transthoracic echocardiogram - PLAX: one large and two smaller hyperechogenic masses inside right ventricle. Figure 3. 2-dimensional transthoracic echoardiogram - PLAX: diameter of right ventricle (47.6 mm). Figure 4. 3-dimensional transesophageal echocardiogram: mobile pedunculated mass by free wall of right ventricle. ## Treatment Three large individual masses were surgically removed from the chamber of right ventricle (Figure 5). Annuloplasty of the tricuspid valve was performed. Figure 5. Three large individual masses that were surgically removed from the chamber of right ventricle. Pathohistological diagnosis: focal-organizing thrombi. ## Conclusion Although final diagnosis has not been made, it is possible that the patient suffers from arrhythmogenic right ventricular dysplasia. This conclusion is based on the presence of three big McKenna’s criteria (1) (T-wave inversion in right precordial leads, ECHO-PLAX RVOT >32 mm and non-sustained ventricular tachycardia detected during Holter monitoring) and the fact that literary sources describe several cases of thrombotic masses in right heart chambers in patients with the same diagnosis. (2, 3)

Diana Rudan, Josip Vincelj, Mira Stipcevic, Sandra Jaksic Jurinjak, Jasmina Catic, Boris Starcevic

Surgical aortic valve replacement (AVR) is the conventional treatment for severe aortic stenosis (AS). Conservative management of patients with severe AS is known to have a poor prognosis and without surgery, the outcome of thiese patients is also extremely poor. However, with the aging of the population, the number of elderly patients with severe symptomatic aortic stenosis has grown, and a significant proportion of high-risk patients are not candidates for surgical aortic valve replacement because of age and comorbidities. Transcatheter aortic valve implantation (TAVI) was developed to address this unmet need. After the demonstration of feasibility of TAVI in 2002, it is now widely practiced, and the technique has been recommended as an alternative strategy for patients in high-risk surgical groups. (1-4) An integrated approach with the use of multiple modalities for annular assessment is recommended because there are cases in which significant discrepancies in the measurements made using any 1 of the standard imaging techniques may exist. However, echocardiography plays importante role in anatomical case selection, in procedural guidance, and in the management of complications. 2D and 3D transoesophageal echocardiography (TEE) enable detailed imaging of aortic valve (AV) and aortic root anatomy, measurement of AV annulus dimensions, and review of other cardiac and aortic structures. Measurement of the size of the aortic annulus requires precise assessment to allow appropriate valve selection and to minimize the risks of paravalvular leak and device migration. Standard 2D TEE techniques, with complementary 3D TEE imaging, are used in addition to fluoroscopy for intra-procedural guidance. Continuous real-time 2D and 3D TEE imaging enables the prompt detection, assessment, and management of complications, Comprehensive postprocedure TEE evaluation is performed following the initial confirmation of satisfactory transcatheter heart valve position and function. In conclusion, echocardiography plays an essential role in the planning and provision of TAVI for high-risk patients with severe AV stenosis, and in combination with other imaging modalities, it allows appropriate case selection, correct choice of prosthetic size and type, guides successful implantation, and facilitates the treatment of complications.

Krunoslav Koscak, Tomislav Vuger, Josip Vincelj

In this poster we are presenting a case of 62-years-old female patient with „broken heart syndrome“ also known as Takotsubo cardiomyopathy (1), with left ventricular thrombus. 62-years-old female patient with history of hypertension was hospitalized on Cardiology Department with acute hearth failure and chest pain, that started half an hour after very stressful verbal conflict with close relative. 12-lead ECG shown inversion of T wave in lateral leads. Laboratory results of troponin I 0,12ng/ml at arrival rise to 2,45 ng/ml. Echocardiography show typical hypokinesia of apical and mid-left ventricular myocardium with basal hypercontractility. Our conclusion was an acute coronary syndrome. Fourth day there was also forming of a left ventricular thrombus that we monitored. After treating patient with furosemid, ramipril, acetilsalicylic acid and low molecular weight heparin for few days, she was sent to coronary angiography. There was no obstructive coronary artery disease found. Our patient was treated for few more days back in our hospital and fully recovered. Three month after releasing from hospital on check-up, she had normal 12-lead ECG and echocardiography. From all the data we conclude that she had Takotsubo cardiomyopathy.

Niksa Drinkovic, Niksa Drinkovic

Handheld ultrasound (HHU) machine is a pocked-sized, battery operated device limited to 2-dimensional and color Doppler imaging. HHU examination is becoming part od bedside diagnostic methods and in near future it will probably became an important part of medical education. Incorporation of HHU as an adjunct to the pxysical examination rouse speculation that auscultation will become less important. So report by Mehta et al confirmed the value of HHU in accuracy improvement of bedside cardiac diagnosis (1). They assume however that increase experience with HHU will decrease the use of stethoscope. In their response article Steinhubl and Topol, among others, advocate stethoscope retirement in favor of HHU (2). From practitioner view heart auscultation before any echo examination, either HHU or standard, further improves diagnostic accuracy. It provides better clinical perception, directs examination, and help us not to miss certain pathology. Good example is characteristic ASD auscultatory finding (pulmonic midsystolic ejection murmur and fixed splitting of the second heart sound) which warns on defect presence and in case of normal echo finding obligate us to proceed with transesophageal echocardiography (TEE). Another example is artificial valve malfunction where changes in the normal sounds produced by prosthetic valve help us to recognize the problem and regardless of HHO finding standard and TEE examination are indicated in each patient.

Elnur Smajic, Nihad Mesanovic, Daniela Loncar, Azur Latifagic

Acute aortic dissection is the most frequent and most dangerous manifestation of the so-called acute aortic syndrome. In its natural evolution, without treatment, acute aortic dissection type A has a mortality rate of about 1% per hour initially, with dead outcome expectancy of more than 50% of the patients by the 3rd day after initial diagnosis, and almost 80% by the end of the 2nd week. Death rates are lower but still significant in acute type B aortic dissection: 10% death rate for patients at 30 days, and 70% death rate or more in the highest-risk groups. The reliable identification of the true and false lumen is crucial for treatment planning. Three dimensional vascular reconstruction with vascular segmentation and centerline reconstructions are often helpful in aortic measurements for stent graft planning. The elasticity and mobility of the dissected septum tend to decrease over time and gradually increasing stiffness. Computational analysis can predict hemodynamic status of the true lumen, false lumen, entry, reentry tear and wall shear stress. However, this task is a difficult and time-consuming even for trained cardiologists and engineers. A Computer Aided Detection (CAD) system needs to be capable to display the different lumina, and hemodynamic status of them in an easily comprehensible way to help the physicians in setting the right diagnosis. Using multislice computer tomography data, aortic dissection can be detected by checking for an abnormal shape of the aorta using edge detection methods. Integration of knowledge between diverse scientific fields is essential (i.e., engineering, informatics and medicine). CAD established its role in medical imaging and steps forward to fill the new, more demanding positions in medical practice. On the one hand, aortic dissection represent a diagnostic and therapeutic challenge for cardiologists, but on the other hand the progress of CAD is particularly important in the diagnosis and treatment of aortic dissection. (1-4)

Ena Kurtic, Stjepan Kranjcevic, Darko Pocanic, Darko Vujanic, Tomislav Letilovic, Mario Stipinovic, Helena Jerkic

A 65-year-old woman was hospitalized because of the sudden onset of angina-like chest pain and dyspnea. Deep negative T waves were seen on ECG in the anterolateral leads. The cardiac enzyme levels were mildly elevated. The patient was admitted with a diagnosis of acute non-ST-segment-elevation myocardial infarction. Laboratory findings also revealed leucocytosis with eosinophyllia (6.71 g/L). An echocardiogram showed mildly reduced ejection fraction (45-50%) due to anteroapical balloning in systole. Cardiac catheterization disclosed no obstructive coronary artery disease. Four weeks later, the ECG showed complete resolution of the T waves inversion and no Q-wave formation. Echocardiography revealed improvement of the wall motion abnormality and normalization of the ejection fraction. It was concluded that acute emotional stress after the death of her brother had precipitated the initial symptoms. Patient's medical history revealed similar event 3 years ago, also precipitated with emotional stress. The number of eosinophils in peripheral blood also recovered without specific hematologic therapy. Takotsubo cardiomyopathy is a syndrome that mimics acute coronary incident, while the angiographic examination shows no coronary lesions. Intense stress and high adrenergic stimulation are the triggers of Takotsubo cardiomyopathy. (1) In most cases (95%) there is a complete recovery of cardiac function, but in the acute phase ventricular arrhythmias, heart failure with pulmonary edema and cardiogenic shock, and very rarely rupture of the heart muscle, are possible. Mortality ranges from 1 to 3.2%. (1) Hypereosinophilic syndrome, a disorder of excessive eosinophillic production, may cause cardiovascular complications that are commonly manifested as a heart failure. (2) Myocardial infarction is a rare complication in hypereosinophillic syndrome, and it is result of embolic events. In the literature, there is no associated case of Takotsubo cardiomyopathy and hypereosinophilic syndome. Although the prognosis of Takotsubo cardiomyopathy is very good, continuous cardiac care is necessary because the pathophysiological mechanism, treatment, long-term prognosis and natural course of the disease are not clearly defined. The therapy recommendation is long-term treatment with beta—blocker and stress control.

Vesna Pehar-Pejcinovic

Hemodynamics is an important part of cardiovascular physiology dealing with the forces the heart has to develop to circulate blood through the cardiovascular system. A significant majority of cardiovascular disorders and diseases is related to systemic hemodynamics. In order to properly understand and assess developments in the heart, healthy or sick, we need to understand hemodynamic events. Echocardiography helps us a lot in that assessment, particularly Doppler methods, as well as newer strain imaging methods. (1*—*2) Echocardiography has a important role in evaluation of morphology of the heart's structure, valve function and systolic and dyastolic cardiac function. There is standard 2 D (two dimensional) echocardiography which help us in evaluation of structure (dimension of heart's chamber, thickness of the myocard and pericard, morfology of the valves) and partially in function of the heart (especially systolic function). Without using Doppler methods and tissue Doppler it is impossible to get a glimpse of diastolic left ventricular function, because that is known the mitral inflow pattern represents the cornerstone in the assessment of diastolic function. Without using Doppler echocardiography we could not assess valvular defects, and additional use of tissue Doppler allows us to shed light on events in complex situations where there is valvular disease associated with heart failure or pericardial diseases (such as differentiation restrictive cardiomyopathy from constrictive pericarditis), as well as differentiation hypertrophic cardiomyopathy of left ventricular hypertrophy. Moreover, the use of tissue Doppler and strain imaging methods helps us in quantification of regional and global left ventricular function in ischemic diseases and other cardiomyopathies. In addition, tissue Doppler and strain imaging methods today are unavoidable in the assessment of cardiac dyssynchrony and the results of cardiac resynchronization therapy.

Elizabeta Srbinovska Kostovska

Echocardiography plays a key role in each of the steps of assessment of infective endocarditis (IE): the diagnosis, risk stratification, time for operation and follow up. The major echocardiographic criteria for IE are discovering vegetations, abscess, new valvular regurgitation and prosthesis dehiscence. According to the recent ESC recommendation for diagnosis and assessment of patients with IE, in all patients with clinical suspicion of IE, transthoracic echocardiography (TTE) is the first step of assessment. In all patients with prosthetic endocarditis, poor quality of TTE image and in majority of patients with positive TTE for IE, transesophageal echocardiography (TEE) is recommended. If the TTE examination is negative, with low suspicion of IE, the further follow up have to be stop. And, if TTE is negative, but there is a high suspicion of IE, TTE and TEE have to be repeated in 7-10 days. (1-3) Anatomical features of IE which can be discovered with echocardiography examination have specific characteristics: 1. Presence of vegetation, which can be oscillating or non-oscillating intracardiac mass typically attached on the low pressure side of the valve, but may be located anywhere in the valvular and subvalvular apparatus and endocardium; 2. Destructive valve lesion like perforation or prolapse of the valve; 3. Abscess formation (more frequent located in Ao valve and in prosthetic valve endocarditis), which can be complicated with perivalvular pseudo-aneurysm and fistulization. Color Doppler echocardiography and continuous wave Doppler are useful modalities for assessment severity of valvular lesion. Three dimensional echocardiography allows better assessment of cardiac morphology and structure, and is particularly useful in assessment complication (Figure 1). Other cardiac imaging modalities (multislice computed tomography (CT, magnetic resonance, 18F-fluorodesoxyglucose PET-CT, and single photon emission computed tomography (SPECT) /CT sometimes can be used in discovering complications in IE. Figure 1. A. Two-dimensional image on parasternal long axis in patients with Ao prosthesis. There is a paravalvular abscess under the prosthesis, which is better seen in three-dimensional echocardiography (B). C. Two-dimensional echocardiography in short axis of the Ao plane. There is a color flow in the abscess, and on D. Two-dimensional three chamber view we can see communication of the perivalvular abscess with left ventricle. Conclusion: Echocardiography is powerful tool for the diagnosis of endocarditis, the assessment of the severity of the disease, the prediction of short-term and long-term prognosis, the prediction of embolic risk, discovering complications of the disease, for decision to operate or not and for the choice of optimal time for operation and the follow-up patients with Infective endocarditis.

Niksa Drinkovic

We have noticed characteristic regional wall motion pattern in dilated cardiomyopathy — inferoposterior akinesia with preserved contractility in proximal third of the posterior wall together with various degree of hypocontractility in the remaining left ventricle. (1) In retrospective analysis of 30 consecutive echocardiographic examinations this pattern was present in 28 adult patients with dilated cardiomyopathy. In the remaining two, regional wall motion abnormality started with inferoposterior hypokinesis and during 3 to 4 years follow up evolved in akinesia but contractility in proximal third of the posterior wall remained preserved. We are currently investigating if this wall motion pattern can help in avoiding unnecessary coronary angiography procedures. Also it is of great interest to answer when this pattern occurs in the course of chemotherapy and is it a useful sign of early cardiotoxicity. In ongoing study we hope to answer this questions and find out what is the recovery potential if chemotherapy is stopped an cardioprotective medications instituted immediately after recognition of these simple and quickly acquirable parameters.

Sandra Makarovic, Zorin Makarovic, Ranko Ugljen, Kristina Selthofer-Relatic, Grgur Dulic, Igor Leksan, Jasmina Rajc

There are three basic types of cardiac masses: tumor, thrombus and vegetation. A differential diagnosis for the echocardiographic finding is based on the location, appearance, size, mobility and physiologic effects of the mass. Other echocardiographic findings such as valvular heart diseases and cardiomyopathies may suggest the mass is a thrombus. Concerning cardiac tumors, nonprimary cardiac tumors are approximately 20 times more common then primary cardiac tumors. The goal of echocardiography in patients with cardiac tumor are: to define the location and extent of tumor involvement; to evaluate obstruction or regurgitation caused by the tumor; to evaluate any associated pericardial effusion and signs of tamponade. (1, 2) We present a 53-years-old women presented at Emergency Department in January 2015 with the simptoms of shorteness of breath. Her medical history revealed anamnesis of malignant melanoma on the left femoral region. The patient underwent wide local excision in 1995. Distant metastasis-searching procedures were negative. In September and October 2014 she was treated from recurrent deep vein thrombosis of left femoral vein. In November 2014 CT angiography was performed, and showed an embolus of left pulmonary artery and a thrombus in the right ventricule. She was treated with therapeutic dose of low molecular heparin. When she was administrated to Cardiology from the Emergency Department the transthoracic echocardiography were performed and showed large mass in the right ventricle as well in the main pulmonary brunch, obstructing flow in right ventricular outflow tract, compromising cardiac and pulmonary flow. She was transferred to the Department of Cardiac Surgery immediately, and an operation of the mass in right ventricle was performed. After surgery, all cardiac chambers appeared normal in size and function with associated moderate tricuspid regurgitatin. She was transmitted to oncological treatment. A PHD analysis of the mass showed a malignant melanoma.

Josip Vincelj, Sandra Jaksic Jurinjak, Mario Udovicic, Diana Rudan, Mira Stipcevic, Mario Sicaja, Ilko Vuksanovic

Echocardiography is a fundamentally important procedure for the evaluation of intracardiac masses, and can reliably identify mass location, shape size, attachment and mobility. Intracardiac masses can easily be detected by transesophageal echocardiography (TEE). Detection of intracardiac masses often represents a difficulty for transthoracic echocardiography (TTE) due to its smaller dimension or location in the left atrial appendage or the right atrium that cannot be adequately analysed by this technique. Diagnostic problems also occur in same patients with a poor „echo window“ and in patients on mechanical ventilatory support. Echocardiography can usually distinguish between the three principal intracardiac masses: thrombus, tumor and vegetation. Three-dimensional (3D) echocardiography provides better understanding and assessment of intracardial masses than 2D echocardiography, improves the diagnostic capabilities of cardiac echocardiography in the assessment of the location, composition, size, and relationship to adjacent structures of intracardiac masses. (1-4) Imaging plays a pivotal role in the diagnosis and surgical planning of cardiac masses treatment. Clinical features, such as patient age, location, and imaging characteristics of the mass will determine the likely differential diagnosis. Thrombi are formed within heart chambers due to trauma, endocarditis, myocardial infarction, dilated cardiomyopathy, mitral stenosis and atrial fibrillation, polycythaemia, thrombocytosis and systemic lupus erythematosus. Thrombi are more commonly found in left-sided heart chambers than in the right (Figure 1 and Figure 2). Cardiac tumors are found in 0.001% to 0.28% of cases in pathoanatomic studies. Primary tumors are far less common than metastatic tumors in the heart, and benign primary cardiac tumors occur more frequently. Approximately 75% of cardiac tumors are benign, and the most common cardiac tumor is the myxoma. Myxomas are found in the atria in 90% of cases, three times more commonly in LA than in RA. Vegetations can be found on native or artificial valves and on the pacemaker or implantable cardioverter defibrillator leads (Figure 3). 3D echocardiography has been more commonly used in diagnosis of intracardial masses with much higher specificity than 2D echocardiography. The evaluation of cardiac masses is often a challenge for cardiac imaging techniques. The traditional standby has been 2D echocardiography. Real time 3D echocardiography offers incremental value for the evaluation of intracardiac masses by providing more accurate assessment of the size and shape, their attachment and their mobility in some cases. Figure 1. Three-dimensional TTE showing a large left ventricle thrombus. Figure 2. Three-dimensional TTE showing a rihgt ventricle thrombus. Figure 3. Three-dimensional TEE showing a vegetation on the prosthetic mitral valve. We report our experience with 3D TTE and 3D TEE for the assessment of intracardial masses. Three-dimensional echocardiography assessment od intracardial masses is feasible and could provide more valuable information than that obtained with 2D echocardiography. We presented LV and RV thrombus, LAA thrombus, LA myxoma and vegetation on native and prosthetic mitral valve diagnosed by 3D echocardiography.

Jana Ambrozic, Mojca Bervar, Matjaz Bunc

## Background Surgical mitral valve repair is considered the gold standard treatment for severe symptomatic valvular mitral regurgitation (MR) (1). However, almost half of the patients are not referred for surgery due to increased operative risk related to advanced age and co-morbidities (2). On the other hand in patients with severe functional MR due to ischemic or non-ischemic dilated cardiomyopathy the results of surgery are not favorable and procedural risk is much higher1. The percutaneous mitral valve repair with the Mitraclip system has emerged as an alternative option for high-risk inoperable patients and as an adjunctive heart failure therapy for patients with advanced cardiomyopathy (3). Transesophageal echocardiography plays a pivotal role in the assessment of specific and restrictive anatomical criteria that need to be fulfilled for the Mitraclip procedure. In addition it is used as the primary imaging modality to guide the procedure. We report the first Slovenian Mitraclip cases and their 3-month outcome. ## Case reports Three symptomatic patients with ischemic dilated cardiomyopathy and severe ischemic functional MR were selected for the Mitraclip therapy. Two of them had previous cardiac bypass surgery and percutaneous coronary interventions and one patient had suffered extensive anterior myocardial infarction. They were symptomatic (functional class NYHA III or IV) despite optimal medical therapy with no option for revascularization. One patient was also non-responder to cardiac resynchronization therapy. Echocardiography before the procedure confirmed suitable anatomical conditions. Mitraclip therapy was feasible in all patients. During follow-up of 3 months functional class improved, mild residual MR remained stable and reduced left ventricle volumes were detected. ## Conclusions First Slovenian experience with the Mitraclip therapy confirmed feasibility of the procedure and demonstrated improved functional class and reverse left ventricular remodeling in our patients. Careful assessment of the mitral valve anatomy with comprehensive echocardiography is crucial in this procedure.

Aleksandra Sustar, Davorka Zagar, Ingrid Buljanovic, Viktor Persic

Atrial septal defect (ASD) is the most common congenital heart disease in adults and adolescents. Transthoracic echocardiography (TTE) is the primary imaging modality in diagnosing of ASD. Two dimensional transesophageal echocardiography (2D TEE) is superior to two dimensional transthoracic echocardiography (2D TTE) or three dimensional transthoracic echocardiography (3D TTE). However, 3D TEE is further superior to 2D TEE. Cardiac magnetic resonance imaging (CMR) may be useful for unusual septal defects and can provide information including shunt quantification and measurement of ventricular size and function. (1-3) This case report describes a 47-years-old man with newly diagnosed premature ventricular contractions and enlarged right heart chambers who was reffered to CMR imaging to rule out structural right ventricular disease. CMR revealed enlarged right atrium and right ventricle with mildly reduced right ventricular ejection fraction and non ishemic left ventricular hyperenhancement pattern pathognomic for myocarditis, right ventricular pressure overload (i.e. congenital heart disease) and infiltrative myocardial disease. Furthermore, cine MR imaging also revealed suspected atrial septal defect. The patient was reffered to 2D and 3D TTE and TEE. The 3D TEE confirmed sinus venosus atrial septal defect with small left to right shunt. The calculated Qp/Qs was 1.5. The patient was dissmised with antiarrhythmic and antiplatelet therapy. Volume overloaded right ventricle might be a characteristic of both arrythmogenic right ventricular dysplasia and atrial septal defects. Considering that, patients with unexplained right ventricular volume overload should be always evaluated for possible atrial septal defect. In this case the cardiac magnetic resonance was crucial for establishing the diagnosis which was confirmed by TTE and TEE. CMR imaging is particulary useful if echocardiographic findings are technically suboptimal. However, echocardiography (TTE and TEE) is the imaging modality of choice for the diagnosis of ASD. 3D TEE enable precise measurements of ASD and may be very important for treatment.

Mislav Vrsalovic, Scott L. Hummel, Hamid Ghanbari, Craig Alpert, Hakan Oral, Theodore J. Kolias

## Background Atrial fibrillation (AF) frequently recurs after radiofrequency catheter ablation (CA). (1-4) This study investigated novel echocardiographic strain parameters as predictors of outcome in AF treated with CA. ## Methods 110 patients (pts, mean age 59, mean CHA2DS2-VASc = 1.37) with paroxysmal and 92 pts (mean age 62, mean CHA2DS2-VASc = 1.5) with persistent AF and preserved ejection fraction (EF) underwent CA and echocardiography ≤ 30 days prior to CA. Left atrial (LA-GS) and left ventricular (LV-GS) global longitudinal strains were measured with 2D speckle tracking. Patients were followed for AF recurrence after CA. ## Results During follow-up period (16±6 months for paroxysmal and 13±3 months for persistent AF), 44 (40%) and 47 (51%) pts had AF recurrence in each group. In both paroxysmal and persistent AF subgroup pts with AF recurrence had lower LA-GS (22% vs 31%; p38 mL/m2) (HR=2.28, 95% CI=1.26-4.13; p=0.006) both entered as binary variables were independent predictors of AF recurrence. When echocardiographic parameters were analyzed as continuous variables LA-GS (HR=0.82, 95% CI=0.75-0.88; p<0.001) was the only independent predictor of AF recurrence. ## Conclusion LA-GS using speckle tracking echocardiography is a strong and independent predictor of AF recurrence after first CA therapy in patients with paroxysmal and persistent AF and preserved EF.

Jadranka Separovic Hanzevacki, Viktor Persic

It is our pleasure to welcome you on behalf of the organizational and scientific board at the 8th CroEcho, the professional, educational and scientific echocardiographic meeting organized by the Working Group on Echocardiography and Cardiac Imaging Modalities of the Croatian Cardiac Society. Apart for being the biggest echocardiographic gathering in the region, our meetings are aimed at boosting the level of professional excellence of clinical cardiologist, echocardiographers and imaging cardiologists in accurate and fast making of cardiology diagnoses and efficient medical treatment. Our goal is to provide an education according to the principles of the European and world standards in the field of basic echocardiography and advanced echocardiographic methods. The proof of the quality of the course and of the entire meeting is the endorsement by the European Association of Cardiovascular Imaging (EACVI) Educational Board, which took the meeting under its auspices. Two years have passed from the previous CroEcho 2013 congress in Dubrovnik and, in the meantime, our integral approach to all imaging modalities in cardiology has been verified in practice. Also, some new insights into echocardiography and cardiac imaging have become available, which serves as a perfect opportunity for us to meet again this year. An important part of our program is again dedicated to the basic echocardiography course intended for cardiologists, future cardiologists and to all those who would like to master the basics of echocardiography as well as for experts who would like to improve their knowledge. The course is divided into several streams with lectures in basic echocardiography, imaging workshops and case studies from the clinical practice. The colleagues who would like to acquire some new knowledge can participate in the advanced workshops for learning and mastering the latest technologies, such as 3 D and 4 D echocardiography, myocardial deformation in the clinical practice and the workshop for selecting and monitoring CRT patients with a special emphasis being put on the optimization of devices. The plenary part of the congress is comprised of expert gatherings on various topics and panel discussions on important and always relevant topics of clinical issues and disputes relating to the diseases of heart valves, heart muscle and pericardium, hemodynamics and many other topics. We have again set aside a part of our program for the elaboration of some interesting cases from the everyday clinical practice. The scientific part of the program enables you to get an insight into the scientific achievements of echocardiographic and other imaging laboratories of Croatia and other countries represented at the congress. The abstracts from the CroEcho 2015 congress have been published in this edition of the Cardiologia Croatica journal, giving us a glimpse into the scientific and professional work of the CroEcho 2015 participants in their echocardiographic laboratories. CroEcho 2015 is also an opportunity for the annual meeting of the Working Group on Echocardiography and Cardiac Imaging Modalities of the Croatian Cardiac Society. The national accreditation in echocardiography, the new prices for diagnostic procedures in cardiology, the recognition of the new echocardiographic methods as well as the need to take a prudential approach in forwarding patients to these procedures are the topics of interest for all members of the Working Group. We look forward to your visit to Opatija!

Davorka Zagar

Mitral regurgitation (MR) is the second most common valvular lesion seen in adult Caucasians. It may be caused by primary valvular pathologies such as congental heart disease, rheumatic heart disease or mixomatous degeneration and this form of MR is known as organic or primary. Secondary or functional MR is a consequence of ishemic heart disease, dilated cardiomiopathy or severe left atrial dilatation. Echocardiography as the most widely available cardiac imaging modality is routinely used to assess patients with suspected or known MR. Two-dimensional (2D) transthoracic echocardiography (TTE) is recommended as a first-line imaging modality in valvular regurgitation. On the other hand three-dimensional echocardiography (3D) can provide additional information in patient with complex valve lesions. 2D TEE is indicated when TTE is insuficient or when further diagnostic refinement is required. Furthermore, it has a role in preoperative and intraoperative evaluation when mitral valve surgery is being considered, and is not indicated for routine follow-up. The mechanism of MR is a very important component of the echocardiographic examination especially when MV repair is required. In theese circumstances the Carpentier 's functional classification which describes leaflet motion in relation to the mitral annular plane is used. Type 1 describes normal leaflet motion, type 2 excessive leaflet motion above the annular plane into the left atrium and type 3 describes leaflet restriction. (1, 2) Severity of mitral regurgitation is based on qualitative, semiqantitative and quantitative assessment. Qualitative assessment includes color flow imaging and continuous wave Doppler signal intensity of MR. Anterograde velocity of mitral inflow (mitral to aortic TVI ratio), systolic flow reversal in pulmonary veins and vena contracta are used in MR semiquantitative assessment. Quantitative assessment which is the most important for grading the severity of MR includes Doppler volumetric method and PISA method. Transthoracic echocardiography as a useful modality for assessment of mitral valve morphology and severty of MR plays an important role in treatment of patients with mitral valve disease. Newer echocardiographic modalities such as 3D imaging may be valuable diagnostic tool in management of mitral valve disease.

Alma Sijamija, Zumreta Kusljugic, Nermir Granov, Omer Perva, Alma Agacevic

## Introduction Cardiac tumors can be primary (benign or malignant), with incidence from 0.002 to 0.3% according to autopsy reports, and secondary which are more common, found in about 5-10%. The most common primary tumor of the heart is the myxoma. About 75% of all myxomas are located in the left atrium. They occur in all age groups, usually from the third to the sixth decade. They are more common in women, usually solitary, round tumors with a diameter of 10 cm, uneven surfaces. Thrombi in the left atrium are related to conditions associated with the blood stasis, such as atrial fibrillation, mitral valve disease, artificial mitral valve and dilated cardiomyopathy. ## Goal To present the role of echocardiography in the diagnosis intracavitary cardiac mass. ## Case report 69-years-old female patient was brought to the hospital with symptoms of stroke, and history of moderate aortic stenosis with preserved EF 58%. At the physical examination: precordial systolic murmur, blood pressure 220/120 mmHg. 12-lead ECG: atrial fibrillation, frequency 80/min, RBBB. Cranial CT confirmed hemorrhagic stroke and patient had permanent sequelae, motor aphasia. A year later, diabetes mellitus was verified. Three years after hospitalization, routine transthoracic echocardiogram was performed and it was observed tumor mass in the left atrium, inhomogeneous echo structure, size 29x62 mm, with narrow base attached to the bottom of the left atrium and with no repercussion on the function of the mitral valve; aortic valve: sclerotic with gradients of moderate stenosis; tricuspid valve: functional TR 2+ with PHT 60 mmHg; EF 53%. The patient is presented to cardiosurgical team, who considering previous comorbidity, suggests conservative treatment. Due to the high risk of bleeding, oral anticoagulants were not included in therapy. Two years later (January 2015) patient was admitted to hospital, mixed ischemic-hemorrhagic stroke was confirmed with cranial CT, with the lethal outcome. ## Conclusion Transthoracic echocardiogram is the method of choice in the diagnosis intracavitary cardiac mass. (1-4) 2D echocardiography facilitates differentiation of thrombus and left atrial myxoma, including characterization of cardiac masses, in the case when additional diagnostics and therapy is not available.

Zeljko Baricevic, Maja Cikes, Jana Ljubas Macek, Bosko Skoric, Ivan Skorak, Hrvoje Jurin, Hrvoje Gasparovic, Bojan Biocina, Davor Milicic, Jadranka Separovic Hanzevacki

## Introduction Speckle tracking echocardiography (STE) permits early recognition of myocardial dysfunction. In heart transplant recipients, the reduction in strain has been shown to denote both rejection and vasculopathy (1, 2). However, when compared with control subjects, deformation indices are also reduced in "healthy" HTx recipients (3), which implies normal LV ejection fraction with no valvular disease, normal ECG, lack of cellular rejection and the absence of vasculopathy. Whether the reduction in strain is a chronic progressive process or the immediate result of transplantation has not been established. Hence, the lack of ST reference values in HTx population is one of the reasons that strain has not been used in Htx follow-up. ## Patients and Methods 10 adult Htx patients with 2D STE performed within 14 days post-transplantation were enrolled. Standard first post-transplant check-up included clinical examination, ECG, laboratory tests, endomyocardial biopsy and coronary angiography. The study included "healthy" HTx patients only, with normal LV ejection fraction (EF ≥ 55%), normal ECG with sinus rhythm and QRS <120 ms, lack of cellular rejection (ISHLT grade ≤ 1B) and the absence of coronary disease (<50% epicardial artery stenosis). Patients with significant valvular disease, major cardiovascular events or poor quality echocardiographic records were excluded. Echocardiographic images were obtained with acquisition of apical views using high frame rates (50-90 frames/s) for adequate speckle tracking. Global and segmental strain values were determined (Figure 1) and compared to normal subjects' reference values, using data from the literature (4). Figure 1. Bull’s-eye map showing segmental and global longitudinal peak systolic strain. ## Results Average global longitudinal peak systolic strain (GLPSS) shortly after HTx was significantly reduced when compared with normal subjects' values (-15.48±2,08% vs -19.7%±0,28, p<0,0001) (Figure 2). Figure 2. GLPSS in heart transplant recipients vs. normal controls. ## Discussion The reduced GLPSS values exhibit soon after HTx, which may possibly be caused by prolonged ischemic time, denervation, cardioplegia etc. Whether strain values remain stable over a longer time period has yet to be established. If that case, an early assessment of "normal" strain values in all transplant recipients could serve as a reference, which could allow non-invasive identification of usual post-transplant complications.