Cardiologia Croatica. 2016;11(12)

Jozica Šikić, Jadranka Šeparović, Hanževački

Dear Colleagues, The Working Group on Valvular Diseases of the Croatian Cardiac Society, in cooperation with The Working Group on Echocardiography and Cardiac Imaging Modalities, is organizing the 3rd Symposium with international participation entitled “Aortic stenosis” which will be held on December 2nd and 3rd 2016, at the Sheraton Hotel in Zagreb. The symposium is designed for physicians in different specialties, cardiologists and cardiology residents, cardiac surgeons, anesthesiologists, general practitioners, and for all who are professionally involved in the treatment of this common valvular disease. The goal of the symposium is to present everyday challenges in the approach, diagnosis, and selecting the most optimal way of treating patients with aortic stenosis, implementing the latest research findings into clinical practice. Beside invited lectures by reputable speakers, more active participation will be enabled by moderated oral and poster presentations, but also echocardiographic workshops on how to avoid pitfalls in assessing the severity of aortic stenosis and simulations of transcatheter aortic valve implantation (TAVI). This symposium is going to create a possibility of expert knowledge exchange from all different parts of Croatia and Europe, as well as it will encourage a new perspective of more effective treatment of aortic stenosis. Selected original contributions from our participants in the form of abstracts, Symposium Directors: Assist Prof Jozica Šikić, MD, PhD, Chairperson, Working Group on Valvular Diseases, Croatian Cardiac Society Prof Jadranka Šeparović Hanževački, MD, PhD, Chairperson, Working Group on Echocardiography and Cardiac Imaging Modalities, Croatian Cardiac Society presented at the meeting, will be part of e-form of Cardiologia Croatica, the official journal of the Croatian Cardiac Society. Thank you for contributing to the quality and success of the symposium.

Blanka Ćuk, Marija Begić, Marija Križić, Vlatka Rešković Lukšić, Dejan Došen, Željko Baričević, Maja Strozzi, Blanka Glavaš, Konja, Joško Bulum, Jadranka Šeparović, Hanževački

A 91-year-old patient was admitted with symptoms and signs of heart failure. Transthoracic echocardiography (**Figure 1**) revaled severe aortic stenosis (max gradient 122 mmHg, mean 62 mmHg, AVA 0.4-0.5 cm2), moderate-severe mitral and tricuspid regurgitation, reduced left ventricular systolic function (LVEF 30%) and high pulmonary hypertension (PAP 90-95 mmHg). Coronary angiography showed no significant coronary artery disease. Due to age and poor functional status (NYHA IIIB / IV), aortic valve surgery was estimated as high risk, and it was decided to perform transcatheter aortic valve implantation (TAVI). Patient was presented to TAVI Heart Team. Meanwhile, the patient underwent successful balloon aortic valvuloplasty (BAV), with a consequent drop in the max gradient between the left ventricle and the aorta from 91 to 52 mmHg, without significant aortic regurgitation. After BAV and intensive diuretic therapy, left ventricle volume unloading and functional recovery was accomplished. Six months later, the patient underwent successful transfemoral TAVI (CoreValve 26). Control echocardiography (**Figure 2**) revealed the recovery of left ventricular systolic function (LVEF 50-55%) with normal function of the CoreValve (max gradient 24 mmHg, mean 10 mmHg), moderate mitral and tricuspid regurgitation and some reduction of pressures in the pulmonary circulation (PAP 45 mmHg). The patient was discharged on the 7th post-interventional day, mobilized, in NYHA II functional status. Figure 1. The apical four chamber view and Doppler aortic valve continuous wave with first presentation, before intervention. Figure 2. The apical four chamber view and Doppler aortic valve continuous wave after transcatheter aortic valve implantation. Balloon dilatation of the aortic valve may successfully bridge the period until the final decision on the definite severe aortic stenosis treatment option. Even in very old patients, symptom relief in terminal stage of heart failure after BAV is raising the quality of life. It also gives an opportunity for patients to undergo more technically demanding, and more durable procedures. Heart team has a central role in this decision-making process. (1)

Maja Hrabak, Paar

Cardiac computed tomography (CT) and magnetic resonance imaging (MRI) are infrequently used for assessment of valvular diseases, mainly because of limited temporal and spatial resolution of these techniques compared to echocardiography. However, in specific clinicaI situations they can of value in assessment of patients with aortic stenosis (AS). Using CT and MRI it is possible to depict valve morphology and motion with measurement of valve opening area. Valve calcifications can be detected using CT only, and on non-enhanced scan the amount of calcium can be quantified, with aortic calcium score ≥2065 Agatston units (AU) for men and ≥1274 AU for women being indicative of severe AS. CT examination is a standard pre-TAVR (transcatheter aortic valve replacement) procedure that enables precise measurement of aortic annulus, and evaluation of aortic bulb and aortoiliac morphology. Using MRI it is possible to detect the level of stenosis, and to evaluate myocardial remodeling response with precise measurement of biventricular volumes, ejection fraction and myocardial mass. Moreover using phase-contrast MRI it is possible to estimate maximum flow velocity through the valve with calculation of the maximum gradient. MRI-measured velocities are underestimated compared to echocardiography, and higher measurement error is present for velocities higher than 3,5 m/s. The main advantage of MRI over echocardiography is that it enables valve depiction in any plane. In AS patients using late gadolinium enhancement it is possible to detect replacement mid-wall fibrosis that is associated with worse prognosis after valve replacement, whereas diffuse myocardial fibrosis can be estimated using newer MRI techniques, such as T1-mapping and extracellular volume measurement. MRI scan is safe for patients with prosthetic valves, sternal wires and coronary stents. Using CT and MRI it is also possible to evaluate concomitant ascending aortic aneurysm, but aortic wall calcification can be detected using CT only. (1-3)

Davorka Žagar, Miroslava Pavić Reić, Rajko Miškulin, Aleksandra Šustar

**Introduction:** Fistulas between the aorta and the left atrium are very rare. They are usually a complication of aortic root abscess formation caused by aortic valve endocarditis, but also of paravalvular abcess, aortic valve replacement, and aortic dissection (1). **Case presentation:** We present a case of a 69-year-old woman who was referred to our Clinic for transesophageal echocardiography evaluation (TEE) of a suspected aorto-left atrial communication. Eight years earlier, she had undergone aortic valve replacement with a 21-mm St. Jude Medical mechanical aortic valve because of aortic stenosis. Three years later, she presented with effort intolerance and dyspnea. These symptoms aggravated over the years. Transthoracic echocardiography performed at the beginning of 2015 demonstrated the normal position and function of a mechanical aortic valve with suspected aorto-left atrial communication. A three-dimensional TEE performed in our Clinic revealed a fistula between the noncoronary sinus of the aorta and left atrium with a shunt through it. The left ventricle function was preserved. **Conclusion:** Although very rare, aorto-left atrial fistulas are very interesting echocardiographic findings which may be presented with heart failure symptoms. Echocardiography, especially TEE, is crucial in confirming the diagnosis. The surgical closure of aorto-left atrial fistulas is the standard treatment in symptomatic patients. The percutaneous closure of aorto-left atrial fistulas with an Amplatzer-type device may be performed in cases when the anatomy is favorable (2).

Jadranka Dražić-Balov, Žaklina Muminović, Gabrijela Ćurić, Kristina Narančić Skorić, Mario Ivanuša

**Introduction:** The aortic valve implantation is immediately followed by the first phase of cardiovascular rehabilitation (CVR). The first follow-up by a cardiac surgeon, which is common in 6-8 weeks after the surgical intervention, is followed by the continued rehabilitation by including the patients in some of the inpatient or outpatient CVR programs, provided there are no contraindications present. (1) The aim of the paper is to present the results of physiotherapy (PT) interventions in patients after aortic valve surgery involved in the outpatient CVR program in the Institute for Cardiovascular Diseases Prevention and Rehabilitation in Zagreb. **Patients and Methods:** We retrospectively analyzed the data from the medical charts of all patients after aortic valve surgery involved in the outpatient CVR program in the Polyclinic during the period from 10th January 2012 who ceased to participate in the program by 6th October 2016. The performance of the CVR in the Institute (2) and the presentation of PT interventions (2, 3) have already been described. The time period from the surgical intervention to involvement in the program, the presence of problems during the training and frequency of participation in the training affect the accomplishment of short-term and long-term PT goals which is shown by descriptive statistics in the groups of subjects by gender. **Results:** During the period of the study, a total of 53 patients, of whom 35 (66%) men and 18 (34%) women underwent the CVR program. The study results of the success of performing PT interventions are shown in **Table 1****.** ### Table 1: Physiotherapy interventions in patients after aortic valve surgery undergoing outpatient cardiovascular rehabilitation. | | **Men (n=35)** | **Women (n=18)** | **Total (N=53)** | | --- | --- | --- | --- | | **Number of days till involvement in the program** | | | | | Average number | 156 | 146 | 153 | | Minimum number | 48 | 51 | 48 | | Maximum number | 763 | 440 | 763 | | **Number of participations in the interval cardiovascular training** | | | | | >35 | 11.4% (4/35) | 16.7% (3/18) | 13.2% (7/53) | | 24-35 | 34.3% (12/35) | 50.0% (9/18) | 39.6% (21/53) | | 13-23 | 20.0% (7/35) | 16.7% (3/18) | 18.9% (10/53) | | <13 | 34.3% (12/35) | 16.7% (3/18) | 28.3% (15/53) | | **Discomforts during the program** | | | | | No discomforts | 34.3% (12/35) | 44.4% (8/18) | 37.7% (20/53) | | Cardiovascular | 25.7% (9/35) | 0% (0/18) | 16.9% (9/53) | | Noncardiovascular | 28.6% (10/35) | 33.3% (6/18) | 30.2% (16/53) | | Cardiovascular and noncardiovascular | 11.4% (4/35) | 22.2% (4/18) | 15.1% (8/53) | | **Rehabilitation conditioning during the program** | | | | | Increase in stress | 28.6% (10/35) | 27.8% (5/18) | 28.3% (15/53) | | Decrease in stress | 0% (0/35) | 0% (0 /18) | 0% (0/53) | | **Accomplishment of physiotherapy goals** | | | | | Short-term goals accomplished | 80.0% (28/35) | 89.0% (16/18) | 83.0% (44/53) | | Long-term goals accomplished | 60.0% (21/35) | 83.3% (15/18) | 67.9% (36/53) | **Conclusion:** The patients with aortic valve operated in Croatia start with the outpatient CVR program late, on the average after 5 months following the surgical intervention. A small number of problems have resulted in a large number of participation in the interval cardiovascular training in patients and therefore more successful accomplishment of short-term and long-term PT goals of the CVR program. Since this is a study in one CVR center, it is necessary to examine the effect in a larger group, as well as in patients with other indications for outpatient CVR.

Iva Jurić, Hrvoje Roguljić, Marko Stupin, Ana Srnović, Grgur Dulić, Kristina Selthofer-Relatić, Sandra Makarović

**BACKGROUND:** Calcific aortic valve stenosis is the most common cause of aortic valve replacement (AVR) in the Western world, and increases in prevalence with ageing, overtaking 2-3% of the population by the age of 65. So far, there is no official register of aortic valve stenosis patients in Croatia. It is very important to recognize the need to have proper follow up of these patients, considering difficulties and challenges that arise in the daily work with these patients and follow up. (1, 2) **PATIENTS AND METHODS:** This study enrolled the patients undergoing aortic valve replacement due to symptomatic severe calcified aortic valve stenosis in University Hospital Centre Osijek, in the period from 2007 to 2016. **RESULTS:** The data showed the overall number of patients underwent aortic valve replacement, distribution by gender, age (**Figure 1**), number of specific type of aortic valve prothesis (mechanical or biological; **Figure 2**), risk factors and atrial fibrillation. Hypertension was shown to be significantly more frequent risk factor in these patients than other risk factors, where significantly higher prevalence of hypertension is in female group in the time of AVR any type (p<0.001). Average age of male patients with mechanical AVR is 57±8 and female 56±9 years old, where number of male patients with mechanical AVR is significantly higher (p<0.005). Average age of male patient with biological AVR is 71±6 and female 71±4 years old, where number of female patients in this group is higher (p<0.005). Figure 1. Distribution and correlation between age and type of implanted aortic valve. Figure 2. Distribution and correlation between sex and type of implanted valve. **CONCLUSION:** This data could present valuable basis for the future register of aortic valve stenosis patients.

Mario Ivanuša

The contents of the new book Oxford Textbook of Medicine: Cardiovascular Disorders consist of selected passages from the fields of diagnosis and treatment of cardiovascular diseases that constitute the Oxford Textbook of Medicine. Although the editors begin with an overview of structure and function, followed by the significance of the most common cardiovascular issues and methods of cardiovascular diagnostics, the subsequent chapters do not in fact follow the conventional progression of the cardiovascular continuum. Despite this, arterial hypertension, coronary heart disease, and heart failure represent the lynchpin of this important cardiologic book. Although they are discussed in different parts of the book, these three diseases are comprehensively described over almost 200 pages. All chapters of the book are written in the classical style of a textbook. The clear and extensive depictions of the topics and the abundant graphical material ensure successful examination of isolated themes even while skipping individual units. The book thus may be very useful to students, physicians, and educators with a professional interest in the fields of internal medicine and cardiology.

Mario Ivanuša

The ESC Handbook of Preventive Cardiology, a new pocket edition from the Oxford University Press, describes the current issues from the field of preventive cardiology, merging theory and practice. Appropriate guidance through the field of prevention of cardiovascular (CV) diseases is ensured by structuring the handbook into three units with a total of 22 chapters with 240 pages. The text of the handbook is accompanied by numerous tables, graphs, and figures that contribute to a better understanding of the described topics. The handbook ends with an index that, along with the simultaneously published digital edition, simplifies searching and improves the utility of the handbook. In the first third of the handbook, the editors present the basic information on CV disease prevention, categorization of CV risk, and the application of biomarkers and imaging methods. The second part of the handbook identifies practical aspects of CV disease prevention and indicates the significance of biological, behavioral, and socio-economical risk factors, as well as the importance of protective CV factors. The final part of the handbook presents recommendations for conducting primary and secondary prevention in health care institutions and in communities, along with instructions for the evaluation of all procedures to ensure quality care for persons with CV diseases. The handbook touches upon all important aspects and issues of preventive cardiology. By ensuring new insights, it facilitates faster identification and more successful resolution of complex organizational problems. Along with the detailed description of the field of CV disease prevention provided by The ESC Textbook of Preventive Cardiology published in 2015 and the new edition of the guidelines (2016 European Guidelines on cardiovascular disease prevention in clinical practice), this handbook represents a useful resource for all professionals working in the field of prevention, ranging from students of biomedicine and health care workers to administrators of the health care system and media representatives.

Martina Zeljko, Igor Gošev, Darko Počanić, Damir Kozmar, Darko Vujanić, Zoran Legčević, Dino Bešić, Frane Paić

**Objective:** Long noncoding RNAs (lncRNAs), a class of noncoding RNA larger than 200 nucleotides, constitute a heterogenic class of regulatory RNAs that includes, for example, intergenic lncRNAs, antisense transcripts, and enhancer RNAs. Due to their ability to modulate miR/mRNA networks and chromatin structure their therapeutic potential is extremely vast thus opening the opportunity for the development of new treatment strategies to be used in cardiovascular medicine. Recent studies indicate that altered expression and function of lncRNAs have also an important role in the development and progression of aortic valve stenosis (AS) and AS-induced cardiac hypertrophy. However, our knowledge of lncRNAs differentially expressed in stenotic aortic valves or during AS-induced cardiac fibrosis and remodelling is still limited on a few examples and as such, requires further investigation. (1) **Methods:** We performed bioinformatic reanalysis of published microarray expressional studies of stenotic and control human aortic valves tissue samples. Data are analyzed using the online Database for Annotation, Visualization and Integrated Discovery (DAVID) v6.8. **Results:** In addition to lncRNA MALAT1 and H19 with known role in the osteogenic transdifferentiation of valvular interstitial cells during the process of aortic valve calcification bioinformatic analysis revealed several previously unrecognized intergenic, intronic and antisense lncRNAs and lncRNA relate miRNA host genes that are differentially expressed in aortic valve tissue of AS patients compared to control valves (**Figure 1**). Figure 1. LncRNA differentially expressed in aortic stenosis tissue compared to normal aortic valve leaflets. **Conclusion:** Bioinformatic data mining of gene expression microarray data combined with upgraded annotation of the human genome landscape provides a useful tool for revealing many previously unrecognized lncRNA transcripts implicated in the pathogenesis of AS.

Dario Gulin, Jozica Šikić, Edvard Galić, Željko Sutlić

**Introduction:** In addition to standard surgical aortic valve replacement (SAVR), transcatheter implantation (TAVI) provides a safe alternative, particularly in patients with an increased risk due to the presence of other comorbidities. Other comorbidities also influence on selection of the TAVI access (1, 2). **Case report:** 73-year-old male patient, with prior history of myocardial infarction and coronary artery bypass grafting (CABG) – (LIMA-LAD – left internal mammary artery to left anterior descending artery; SVG-PD, OM2 – saphenous vein graft to posterior descending artery and second left marginal artery) in 1997, was admitted to University Hospital in February 2013 due to syncope and chest pain. Echocardiography revealed severe aortic stenosis. Coronary artery angiography showed occluded venous bypass grafts and suboccluded circumflex artery (CX) and left internal mammary artery graft (LIMA). Other coronary arteries were completely atherosclerotically changed and inappropriate for percutaneous coronary intervention (PCI). Significant carotid artery disease has been shown. The patient was prepared for synchronous carotid thromboendarterectomy, surgical aortic valve replacement, and re-CABG. In June 2013 carotid procedure was performed, while SAVR and re-CABG could not be done due to porcelain aorta. Due to prolonged chest pain, PCI of CX and LIMA graft was done. After PCI the patient was free of chest pain but left ventricle (LV) function decreased to moderately reduced ejection fraction. Transfemoral approach for transcatheter aortic valve implantation (TAVI) could not be used due to significant peripheral artery disease. In 2014 transapical (first Croatian) TAVI was done. In 2015 due to tachy-brady syndrome permanent pacemaker was implanted. In the follow-up period, LV function significantly improved and the patient was free of chest pain. **Conclusion:** TAVI and PCI are safe alternatives to SAVR and CABG in selected high-risk patients with porcelain aorta. In inoperable patients, who are not candidates for transfemoral TAVI and concomitant significant coronary artery disease with previously performed CABG, careful selection of alternative access options, following PCI can lead to excellent results.

Ante Pašalić, Tea Blažević, Vera Slatinski, Edvard Galić, Jozica Šikić

**Introduction:** Aortic stenosis is the most common valvular heart disease, that occurs more frequent in men. Its prevalence increases with age and while it occurs rather rarely in people in their fifties (0.2%), it is quite an often comorbidity in octogenerians (9.8%). Around 2% people in their seventies suffer from moderate aortic stenosis. Pressure overload in patients with significant aortic stenosis starts a pathogenetic sequence, that causes structural and geometric remodeling of left ventricle and leads to dysfunction of mitral and tricuspid valve apparatus. (1-3) **Patients, Methods, and Results:** Between October 2007 and October 2016, a total of 916 patients with aortic valve stenosis were hospitalized in University Hospital “Sveti Duh”, Zagreb. Patient age range was 44-95 years and 407 of them were men (44.4%). The most significant comorbidity was diabetes, present in over 36.1% of patients, and, interestingly enough, more often in women (53.2%). Hyperuricemia was also found to be a prevalent condition (52.5%). Most of patients had severe aortic stenosis (40.8%), while moderate and mild stenosis were present in 25.7% and 20.8% of patients respectively. Most of our patients had a combined valvular pathology. Aortic valve regurgitation was present in 17.7% patients, most often in those with severe stenosis (53.5%). Nearly half of patients (48.0%) had a significant mitral regurgitation, which correlated with the degree of aortic stenosis, most prominent being in patients with severe stenosis (48.9%). Only 4.8% of patients had mitral stenosis, which is due to a significant decrease in rheumatic fever incidence in our country during the last couple of decades. Combined mitral and aortic valve pathology was more often in women (53.6%). Nearly a quarter of patients (24.8%) had a tricuspid regurgitation, again most often present in patients with severe aortic stenosis (50%). **Conclusions:** Aortic stenosis is not an isolated valvular disorder, but a complex syndrome, characterized by left ventricular remodeling, diastolic and systolic dysfunction, and other valvular disorders. If left untreated, aortic valve stenosis can cause advanced heart failure and a high mortality rate. It is important to notice that aortic stenosis represents a significant medical issue in modern societies, while also being a large financial burden on the society.

Anđela Simić, Dubravka Vrljić Borojević

Nowadays when we think about aortic stenosis, aortic valve area and the gradient over the aortic valve are mainly considered as a precise way of defining the aortic stenosis severity, which is certainly justified, but what about the first-line procedures in diagnosing this pathology? Is it always recognized in a timely manner and who are the physicians who are faced with this highly responsible task? Working in an emergency department is very challenging and difficult and the physician who works there is often being put in a position to raise a suspicion or diagnose serious illnesses and conditions with often limited diagnostic procedures and in conditions that are far from ideal. Regardless of the extent of available diagnostic methods, the most important things that a physician who works under emergency room circumstances can arm himself/herself with, are his/her own knowledge, experience and the maximum dedication to the patient’s medical history and clinical status. Adequate heart auscultation is one of the challenges. Although one could say it is an easy task to hear known crescendo-decrescendo aortic stenosis ejection systolic murmur, in noisy and crowded circumstances of an emergency hospital admission, many times it is far from simple and can be missed. (1, 2) In the paper we have shown a young male patient in whom this murmur was noticed for the first time exactly in an internal medicine emergency room, and that in combination with other typical symptoms that patient’s medical history presented, such as chest pain, progressive effort intolerance, dyspnea and palpitations, and ECG signs of left ventricle strain, gave a whole picture and was the first step toward diagnosing severe symptomatic aortic stenosis, after which the patient was examined by a cardiologist and presented to the cardiac surgeon for the final treatment. Hereby we wanted to point out that today’s modern diagnostic and treatment technology for serious conditions is of little use if the patient does not reach it at all and that a person, that is the physician still has a crucial role with his/her ability to notice, suspect, attend and possibly precisely diagnose numerous diseases and pathology including the aortic valve stenosis.

Marija Begić, Blanka Ćuk, Maja Jelinić, Maja Strozzi, Joško Bulum, Vlatka Rešković Lukšić, Željko Baričević, Dejan Došen, Darko Anić

Patient with hypertension, diabetes, COPD (chronic obstructive pulmonary disease) and chronic kidney disease, was referred to a cardiologist examination because of aortic stenosis progression. In 2002 he underwent triple coronary artery bypass surgery. By transthoracic echocardiography severe aortic stenosis was confirmed with maximum gradient around 95 mmHg, and AVA (aortic valve area) 0.7 cm2. Two passable bypasses were verified by coronography, while bypass on OM1 was ostially subocluded, so a stent had to be implanted. Because of the risk of resternotomy, severe COPD and numerous comorbidities, cardiosurgical operation was not an option, so transcatheter aortic valve implantation (TAVI) became viable option. (1) By transesophageal echocardiography (TEE) we have verified thrombus in the area of descending aorta, specifically microsomatic substance that delayed the procedure. By MSCT aortography we have found aneurysmal widening of the abdominal aorta with diameter of 2.5 cm. During the next hospitalization he was reprocessed by angiography of aortoiliac blood vessels, which by morphology and dimensions were supporting the possibility of percutaneous implantation of aortic valve, also TEE which does not show earlier described intraluminal formation in the aorta. TAVI procedure was done by transcarotid approach because of impossibility of transfemoral approach and because of increased transaortic risk because of severe COPD. Just before the procedure, MSCT angiography of carotid arteries was done which contributed to postintervention complication of contrast-induced nephropathy. The procedure of aortic valve implantation went without complication with minimal paravalvular insufficiency. Soon after the procedure patient developed anuria, which required dialysis after which kidney function was restored to normal. By medical telemetry we spotted ectopic ventricular activity with short term episodes of ventricular tachycardia, so amiodarone was introduced into therapy. Regular echocardiography ultrasound showed normal function of CoreValve, and maximum systolic gradient was 13 mmHg. Patient was discharged home in generally good condition and normalized laboratory values.

Vera Slatinski, Dario Gulin, Ante Pašalić, Jozica Šikić

**Introduction:** Aortic stenosis is the most common valvular heart disease. Its prevalence increases with age and while it occurs rather rarely in people in their fifties (0.2%), it is quite an often comorbidity in octogenerians (9.8%). Symptomatic patients with aortic stenosis exhibit as low survival rates, as 20% within 5 years of symptom onset. Over 67000 aortic valve replacement procedures are performed yearly in the USA, i.e. 112 in 100 thousand people. Prosthetic valve obstruction occurs in 0.4-6.0% of patients after AVR, mostly due to valve thrombosis (75%). However, in 10% of patients with prosthetic valve obstruction, it is a result of pannus formation (mostly on the ventricular side of the valve). (1, 2) **Case report:** A 71-year-old female patient who underwent artificial aortic valve replacement in 2005, was admitted to Clinical Hospital due to signs of congestive heart failure and progressive dyspnea. Transthoracic echocardiography showed severe stenosis of the artificial valve (mean PG 46 mmHg, max PG 73 mmHg, AVA 0.5 cm2, Vmax 4.3 m/s), left ventricular hypertrophy, preserved left ventricular systolic function (EF 65%), and an enlarged left atrium (5.4 cm). Mitral valve was sclerotic and calcified, with reduced mobility of the posterior cusp and signs of moderate mitral stenosis (MVA 1.7 cm2, PHT 117 ms, max PG 15 mmHg, mean PG 7 mmHg) and moderate mitral regurgitation jet (VC 5mm, Vmax 6.2 m/s). Transesophageal echocardiography (TEE) confirmed severe aortic stenosis, moderate mitral regurgitation (VC 6 mm) and moderate mitral stenosis (Vmax 2.5 m/s, max PG 25 mmHg, mean PG 10 mmHg) due to immobile P1, P2 and P3 segments of the posterior cusp. Coronary angiography showed a normal angiogram. Fluoroscopy revealed only one functional artificial aortic valve cusp. Invasive hemodynamic measurements showed a significant pulmonary artery hypertension (49 mmHg), with only slightly elevated both ventricle filling pressures (RAP 10 mmHg, PCWP 18 mmHg). Cardiac index was normal (2.7 L/min/m2), as was the pulmonary vascular resistance (2.3 WU). Patient underwent surgical repair of aortic valve prosthesis – pannus debridement and artificial mitral valve replacement. Postoperative TEE showed normal functioning aortic and mitral valves. **Conclusion:** Pannus induced artificial valve obstruction is a rare postoperative complication, that we have to bear in mind when treating patients after aortic valve replacement.

Kristina Narančić Skorić, Mario Ivanuša, Jadranka Dražić-Balov, Žaklina Muminović

**Introduction:** While the benefits of the cardiovascular rehabilitation (CVR) after the myocardial surgical coronary revascularization are well documented, only a few studies have indicated the benefits of CVR in patients after the aortic valve surgery. (1, 2) The aim of the paper is to show the experience of the only Croatian center of the outpatient CVR in patients after the aortic valve surgery. **Patients and Methods:** We retrospectively analyzed the data from the medical charts of all patients with operated aortic valve involved in the outpatient CVR program in the Institute for Cardiovascular Diseases Prevention and Rehabilitation in Zagreb from 10th January 2012, and who ceased to participate in the program by 6th October 2016. The performance of the CVR program in the Insitute has already been described. (3) In addition to the data on a type of intervention and risk factors, we have also analyzed the frequency of the optimally performed anticoagulant therapy (4) and changes to the functional capacity at the end of the CVR. The results were presented by groups according to gender by using the descriptive statistics methods. **Results:** Out of 53 patients involved, 18 (34%) were women and 35 (66%) men. The average duration of CVR was 2.6 months. The main disease is aortic stenosis, which was present in 80% of men and 89% of women. The analysis of the frequency of the interventions performed, risk factors and the success of anticoagulant therapy is shown in **Table 1**. The mean functional capacity value at the beginning and end of the CVR was 5.9±1.39 and 6.8±1.17 for men and 5.6±0.85 and 6.4±1,12 METs for women. ### Table 1: The frequency of performed cardiac surgeries, risk factors and success of anticoagulant therapy in patients undergoing outpatient cardiovascular rehabilitation following aortic valve surgery. | | | **Men** **n = 35** | **Women** **n = 18** | **All** **N = 53** | | --- | --- | --- | --- | --- | | **Aortic stenosis** | | 80.0% (28/35) | 88.9% (16/18) | 83.0% (44/53) | | **Aortic Valve Replacement Surgery** | | | | | | **Bioprosthetic aortic valve replacement** | | 54.3% (19/35) | 66.7% (12/18) | 58.5% (31/53) | | – bioprosthesis + coronary artery bypass grafting | | 26.3% (5/19) | 25.0% (3/12) | 25.8% (8/31) | | – bioprosthesis + surgery of ascending aorta | | 0% (0/19) | 8.3% (1/12) | 3.2% (1/31) | | **Mechanical aortic valve replacement** | | 45.7% (16/35) | 27.8% (5/18) | 39.6% (21/53) | | – mechanical prostheses + surgery of ascending aorta | | 37.5% (6/16) | 20.0% (1/5) | 33.3% (7/21) | | **Transcatheter aortic valve implantation** | | 0% (0/35) | 5.6% (1/18) | 1.9% (1/53) | | **Risk factors** | | | | | | Average age ± standard deviation (years) | | 64 ± 12.4 | 70 ± 8.9 | 66.1 ± 11.6 | | Age range (minimum-maximum; years) | | 28-81 | 41-80 | 28-81 | | Hypertension | | 85.7% (30/35) | 77.8% (14/18) | 83.0% (44/53) | | Dyslipidemia | | 80.0% (28/35) | 66.7% (12/18) | 75.5% (40/53) | | Diabetes | | 25.7% (9/35) | 11.1% (2/18) | 20.8% (11/53) | | Active smoking | | 17.1% (6/35) | 27.8% (5/18) | 20.8% (11/53) | | Coronary artery disease | | 31.4% (11/35) | 38.9% (7/18) | 34.0% (18/53) | | Mean body mass indeks (kg/m2) | | 28 | 27.9 | 28.2 | | Overweight | | 71.4% (25/35) | 50.0% (9/18) | 64.2% (34/53) | | Obesity | | 17.1% (6/35) | 22.2% (4/18) | 18.9% (10/53) | | Optimaly anticoagulated patients with indications (time in target range of PV/INR) | | 55.0% (15/27) | 55.0% (5/9) | 55.0% (20/36) | **Conclusions:** Men are more often involved in the outpatient CVR program following the aortic valve surgery. Aortic stenosis is a dominant disease, where out of risk factors there is hypertension, dyslipidemia and increased body mass index to be emphasized. Patients with implanted bioprosthetic valve were involved more frequently. Anticoagulant therapy was optimal in a half of the subjects. The CVR program after the aortic valve replacement surgery improves the functional capacity. Further studies on a greater number of patients as well as additional education about the importance of anticoagulant therapy are needed.

Domagoj Mišković, Irzal Hadžibegović, Božo Vujeva, Marijana Knežević Praveček, Đeiti Prvulović, Krešimir Gabaldo, Martina Menegoni

**Background:** Left ventricular wall rupture is a rare complication of myocardial infarction, occurring in approximately 2% of cases. Mortality is extremely high unless early diagnosis is made and urgent surgical intervention is provided. (1, 2) **Case report:** 64-year old female patient with permanent atrial fibrillation and bioprosthetic aortic and mitral valve was admitted to Coronary Care Unit because of subacute myocardial infarction. She was on warfarin therapy due to secondary stroke prevention with an urgent INR of 2.7. Transthoracic echocardiography reveals hypokinesia of posterolateral wall, lobular pericardial effusion behind the posterolateral wall, and severe aortic stenosis and regurgitation of bioprosthetic valve. Urgent angiography showed occlusion of the obtuse marginal branch with spontaneous dissection of the distal segment without extravasation of contrast. Aortography showed severe aortic regurgitation without visible dissection. Because of high INR and pericardial effusion, we did not order a dual antiplatelet therapy. Control echocardiography exam verified pseudoaneurysm of ruptured posterolateral ventricular wall. Computerized tomography of the chest showed extravasation of contrast in the pericardium. For the purpose of surgical repair of left ventricular wall rupture and aortic valve replacement, patient was transferred to the Department of Cardiac surgery. During the hospitalization and transfer, patient was hemodynamically stable, without signs of tamponade. The patient died due to septic shock which occurred postoperatively. **Conclusion*:*** We believe that rupture is result of combination of myocardial ischemia and pressure load caused by severe aortic regurgitation. Left ventricular wall rupture is often fatal complication and mortality is higher in the patients with other structural heart disease such as severe combined aortic disease.

Tea Blažević, Ante Pašalić, Vera Slatinski, Edvard Galić, Jozica Šikić

**Introduction:** Aortic stenosis represents the most common valvular heart disease. It is estimated to affect 2% to 7% of the population more than 65 years of age (1). Development and progression of calcific aortic valve disease results from passive calcium deposition within the aortic valve leaflets but there is increasing evidence that this is an active cellular process. The natural history of aortic stenosis includes a latency period followed by a more or less pronounced progression. Some studies found cardiovascular risk factors to have an impact on the development of degenerative aortic valve stenosis (2) and some authors described an ‘early lesion’ that had much in common with the early lesion in atherosclerotic plaques, proposing the hypothesis of calcific aortic stenosis to be an atherosclerotic disease (3). **Patients and Methods:** We retrospectively analyzed medical documentation of all patients who were hospitalized in University Hospital “Sveti Duh” Zagreb, regardless of the indication, but with a diagnosis of aortic stenosis, during the period from October 2007 to October 2016 with the aim to evaluate the prevalence of cardiovascular risk factors. **Results:** Overall there were 915 hospitalized patients, aged 44-95 years, of which 406 (44%) men, and 330 (36%) with a history of diabetes mellitus. LDL cholesterol levels were elevated (≥3 mmol/L) in 317 (45.1%), with a value above 4.9 mmol/L in 27 (4.8%) patients. HDL levels were ≤1 mmol/L in 258 (36.9%) and triglyceride levels ≥1.7 mmol/L in 187 (26.8%) patients. There were 250 (27.3%) patients with the history of acute coronary syndrome, 119 (13%) undergoing percutaneous coronary intervention and 46 (5%) coronary artery bypass surgery. Total of 176 (19.2%) had a history of cerebrovascular disease (including stroke) and 139 (15.2%) had significant atherosclerotic lesions of carotid arteries verified with color Doppler. 75 (8.2%) had peripheral vascular disease also verified with color Doppler. **Conclusions:** With retrospective analysis of medical data we found that 45% of patients did not have adequately regulated levels of LDL cholesterol which certainly contributes to the progression of coronary, cerebral and peripheral diseases, as well as aortic stenosis.

Krešimir Gabaldo, Irzal Hadžibegović, Domagoj Mišković, Željko Sutlić, Đeiti Prvulović, Božo Vujeva, Marijana Knežević, Praveček, Katica Cvitkušić, Lukenda

Postpericardial injury syndrome (PPIS) is a clinical syndrome that occurs in autoimmune inflammatory reaction within the pericardium and pleura, and manifests with the pericardial and pleural effusion. It occurs in patients who undergo cardiac surgery involving the opening of the pericardium and is among the most common complications of cardiac surgery in the late postoperative time. The incidence of the disease ranges from 2-30%, averaging about 10%. (1-3) Retrospective analysis of the PPIS register at the General Hospital “Dr. J. Benčević” Slavonski Brod in the period from March 1, 2009 to October 1, 2015 shows incidence of the PPIS overall, regardless of the type of procedure of 10.1%, while the incidence of PPIS in patients who underwent aortic valve surgery was 26%. We recommend routine screening of patients 2-4 weeks after the surgery by simple diagnostic criteria. For the diagnosis elevated CRP and fever have strong predictive value and in the presence of pleural/ pericardial effusion sufficient criteria for the diagnosis of disease. The treatment is carried out by using NSAIDs, colchicine or corticosteroids, with the achievement of remission in more than 95% of patients. The prophylactic use of colchicine according to COPPS study reduces the incidence of PPS. While there are no clear recommendations for prophylaxis according to our research, the identification of patients at high risk based on the type of operation, age and other clinical parameters support the hypothesis about the usefulness of prophylaxis.

Maja Jelinić, Nedeljko Ciglenečki, Valentina Slivnjak

Aortic stenosis is the most common valvular disease in Europe and the USA and its prevalence increases with age. It is a disease characterized with a relatively benign course during the asymptomatic period. However, once it becomes symptomatic, survival dramatically decreases. Overall life expectancy during the symptomatic period without age adjustment is about 15 to 50%. Considering available treatment modalities, more and more elderly patients are referred to invasive treatment. (1-3) We would like to present a female patient M.N., aged 89, who is under medical supervision in our hospital for severe aortic stenosis. She was first admitted to Intensive Care Unit in 2013 due to pulmonary edema and atrial fibrillation with ventricular tachyarrhythmia. She was then mechanically ventilated. Her previous medical history was significant for arterial hypertension and hypothyreosis. After initial stabilization a transthoracic echocardiography was performed, which showed a severe aortic stenosis with a PG of 75 mmHg, MPG 51 mmHg and AVA 0.7 cm2, a moderate mitral and tricuspid regurgitation and PAPs 65 mmHg. The patient responded well to treatment and was referred to invasive diagnostics. No significant coronary artery disease was found. She was then presented on a surgical meeting where, considering her age, a very high operative risk and good response to conservative treatment, a decision was made not to operate on her. The patient herself was not prone to surgery. After that she continued medical treatment under supervision of physicians in our hospital. With occasional short hospital stays and titration of diuretic and antiarrhythmic treatment a good quality of life was achieved. The patient is independent in her life activities and has no major symptoms. We find this case an argument for maximal individualization of severe aortic stenosis treatment in the elderly.

Ivana Jovanovska Hristova, Magdalena Otljanska

**Background:** The general population, just like the majority of the patients in the angiography laboratory, have a predictable anatomy and presentation of the coronary arteries. Only 1.3% of the patients in a number of 126.595 have anatomical anomalies of the coronary arteries. Of the three main coronary arteries, the circumflex artery presents with a great variant of length and distribution. There is gender predominance, study reports findings in favor of the male population (73 cases, 57male/16 female). There are three types of anomalies of the left circumflex artery (ALCX), among which the most common are the adjacent ostia in the right coronary sinus. (1-3) **Case report:** We present a clinical case of a 59-year-old female, who presented to a tertiary facility due to a first onset of chest pain who was evaluated for an underlying coronary artery disease. Physical examination showed non-specific signs. She had a previous history of hypertension. The diagnostic workout included: laboratory, electrocardiography, echocardiography and coronary angiography. The electrocardiogram had features of left bundle branch block. The heart ultrasound showed global reduction of the LV systolic function, impaired diastolic function which is a consequence of a long life arterial hypertension. Coronary angiography findings: anomalous left circumflex artery (ALCX) adjacent ostia in the right coronary sinus. We did a one month follow up during that period of time she was treated with: ACE inhibitor, beta-blocker, loop diuretic, aldosterone antagonist and aspirin. **Conclusion:** The coronary artery anomalies are most often an accidental finding in the catheterization laboratory. Most variations are benign with a variable clinical presentation and prognosis. The anatomical variations in the left circumflex artery are relatively common as in our case the adjacent ostia in the right coronary sinus.