Cardiologia Croatica. 2016;11(3-4)

Kristina Marić Bešić, Željko Baričević, Maja Strozzi

**Case report**: A 77-year-old man with stable angina and known left main coronary artery (LMCA) disease was admitted for elective percutaneous coronary intervention (PCI). Dual antiplatelet therapy with aspirin and clopidogrel had been instituted 7 days before the PCI, accompanied by administration of unfractionated heparin (UHF) during the procedure. For the PCI planning purpose, intravascular ultrasound was performed to evaluate the anatomy and the size of the LMCA and the morphology of the left anterior descending artery-first diagonal (LAD-D1) bifurcation lesion that had appeared only moderately stenotic on angiography. Minimal lumen diameter of the middle LAD segment and LMCA was 1.6 mm and 2.6 mm, respectively, indicating the severity of both lesions. After predilatation with the semicompliant balloon, a successful provisional stenting of the LAD-D1 bifurcation lesion using drug-eluting stent (DES) was performed, followed by high-pressure postdilatation to optimize stent deployment. At that time, the thrombus formation on a guide wire within the LMCA was noted, giving rise to distal LAD embolization. Direct stenting of the proximal LMCA with DES 4.0/9 mm was then performed and the intracoronary bolus of eptifibatide was given, leading to complete LMCA thrombus resolution, with residual thrombi seen in the distal LAD segments. Due to chest pain aggravation, a second-look angiography was performed 2 hours after the index procedure, showing non-occlusive dissection at the distal end of the LMCA stent. Additional DES 4.0/9 mm was implanted with optimal result and Thrombolysis In Myocardial Infarction 3 flow. Clopidogrel was replaced with ticagrelor. The 6-month follow-up was uneventful. **Discussion**: Pharmacotherapy during PCI is used to mitigate the sequel of iatrogenic plaque rupture and to reduce the risk of thrombus formation on intravascular PCI equipment. Iatrogenic damage to the endothelium leads to increased expression of tissue factor and activation of the coagulation cascade, ultimately leading to thrombus formation (1). Anticoagulation with UFH alone does not seem to be sufficient for protection from ischemic sequel, such as periprocedural myocardial infarction. One cause of these events is embolization of platelet aggregates that form as a result of platelet activation induced by UFH (2) and the prevention of thrombus formation strongly depends on platelet inhibition by dual antiplatelet therapy. In cases with high-risk plaque features, a care has to be taken to recognize iatrogenic damage in a timely manner. Usefulness of clopidogrel resistance testing before complex PCI has yet to be shown.

Matias Trbušić, Zdravko Babić, Marin Pavlov, Krešimir Kordić

Pneumopericardium is a rare condition defined as a collection of air in the pericardial cavity. It is usually caused by blunt or penetrating chest injuries, iatrogenic causes (bone marrow puncture, thoracic surgery, pericardiocentesis, endoscopic procedures), and infectious pericarditis with gas-producing organisms. (1, 2) We present a case of 82-year-old female patient with spontaneous pneumopericardium caused by malignant ulcer that created fistula between the pericardium and an adjacent air-containing organ (colon). She was admitted in critical condition with chest pain, severe respiratory distress, hypotension, distended neck veins and tachyarrhythmia. High blood leukocyte and C-reactive protein levels and combined respiratory and metabolic acidosis were present. On auscultation, very unusual high frequency metallic sound was heard. 12-lead electrocardiogram showed atrial fibrillation and diffuse microvoltage. Chest X ray and CT showed normal sized heart completely surrounded by air (halo sign) below the aortic arch, and also large left pleural effusion. CT also revealed neoplastic process of the transverse colon infiltrating stomach and diaphragm. An echocardiogram demonstrated intrapericardial spontaneous contrast echoes followed by extreme difficulty to view the heart. Even so, significant respiratory variations in transvalvular blood flow velocities and dilated inferior vena were noticed indicating the tension pneumopericardium caused probably by a valve mechanism, resulting in cardiac tamponade. (3) Under fluoroscopy control emergent pericardiocentesis was performed with needle extraction of 160 mL of very unpleasant smelled air. Mechanical ventilation was also started together with antibiotic therapy, volume replacement and pleural drainage. The patient was stabilized and next day transferred to another clinic in satisfied condition were the complex abdominal surgery was performed. In conclusion, spontaneous pneumopericardium is a rare life threatening condition that can be caused by infiltrating malignant process. It can be rapidly recognized by physical examination and standard diagnostic tests. If valve mechanism is present it can result in tamponade requiring immediate pericardiocentesis as a life saving procedure.

Željko Baričević, Kristina Marić Bešić, Maja Strozzi

**Case presentation**: A 66-year-old man was admitted to our department due to persistent chest pain that awoke him from sleep, accompanied by transient ST elevation in anteroseptal leads (**Figure 1**). Several months earlier a coronary angiography was done due to anginal pain that only revealed nonsignificant atherosclerotic lesion in the ostial segment of the left anterior descending (LAD) artery and mild myocardial bridging of the middle LAD segment, and the patient was discharged on low dose of bisoprolol, amlodipine, aspirin, statin and sublingual nitroglycerin as needed. At this point, the pain was relieved after administration of sublingual nitroglycerin. Echocardiogram showed no regional wall abnormalities and the high-sensitive troponin T test came back normal repeatedly. Coronary angiography was performed the following day, showing nonstenotic coronary lesions at first, but after several contrast dye injections, the ostial LAD showed a total occlusion (**Figure 2**). Intracoronary nitroglycerin was then given that gradually led to a complete relief of the obstruction, revealing the underlying atherosclerotic lesion (**Figure 3**). Figure 1. 12-lead electrocardiogram during pain crisis. Figure 2. Coronary angiography showing a total occlusion of the ostial left anterior descending artery (asterisk). Figure 3. Relief of the obstruction after intracoronary nitroglycerin. **Conclusion**: Based on previous findings, the diagnosis of variant („vasospastic“) angina was made (1). The patient was discharged with diltiazem and long-lasting nitrate. Beta blockade can be useful in case of effort-induced angina caused by atherosclerotic disease and myocardial bridging. However, we decided to withhold it because of possible occurrence of the unopposed alpha-receptor mediated coronary vasoconstriction. We believe that the coronary artery spasm (CAS) prevention was the primary treatment goal in this case, since there were no signs of effort-induced ischemia on the treadmill and myocardial SPECT test. Abstinence from cigarette smoking and optimal dosing and timing of calcium antagonists remain the cornerstone of CAS therapy (2). These patients with acute coronary syndrome (ACS) without culprit lesion have an excellent prognosis for survival and coronary events after 3 years compared with patients with obstructive ACS (3). However, the case of persistent angina represents a challenging problem and leads to an open question whether there is a role of stenting non-severe proximal stenotic lesions which may possibly predispose to local vasospasm.

Josip Lukenda, Boris Starčević, Diana Delić Brkljačić, Zrinka Biloglav

Although there has been progress in interventional cardiology in Croatia over the last two decades, there has been no analysis of interventional cardiologic procedures at the national level. The aim of this article was to analyze of the number of coronary angiographies (CA) and percutaneous coronary interventions (PCI) in the period from 2010 to 2014. Diagnostic and treatment procedures were analyzed based on the CA and PCI hospital claims of Croatian patients in 13 Croatian centers. The average rate of CA in the observed period was 4 390 per million population annually, with a growth of 8.5% over the observed period. The average rate of PCI was 2 208 with an increase of 15%. The PCI/CA ratio grew from 0.48 to 0.52. Of the 47 470 PCI procedures performed in Croatia between 2010 and 2014, 18.6% were performed in the Magdalena Special Hospital for Cardiovascular Surgery and Cardiology, 13.8% in the University Hospital Centre Zagreb, 11.9% in the University Hospital Centre Rijeka, and 11.3% in the University Hospital Dubrava, while other centers had shares below 10%. Based on PCI numbers, 7 Croatian centers (54%) can be classified as high volume centers, and 4 (30.7%) as medium volume centers. The Dubrovnik General Hospital since 2013 had a sufficient annual number of PCIs (>200), while the Karlovac General Hospital only performed CA. Results indicate that Croatian interventional cardiology has achieved a great success over the last two decades: in 2010, Croatia already had an above-average rate of PCIs compared with the Organization for Economic Co-operation and Development and 21 countries of the European Union, as well as a larger annual growth (26.8%) than all analyzed countries except Romania. PCI rates were higher than most European countries except Germany, Belgium, Austria, and Norway. Further analysis of the success of interventional procedures and further development plans require the formation of a unified Croatian Registry of Cardiologic Procedures.

Vjeran Nikolić Heitzler

In my medical practice I meet people every day who seek help because of health problems. As I am a cardiologist, they usually complain about symptoms of what they believe are heart disorders. Should we believe that all of them are ill? Everyday life is not easy, and we are exposed to a chain of stressful situations in our families, at the workplace, in relation to financial problems, in raising our children, and in many other situations. These circumstances may generate problems that are not organic but instead functional disorders. For example, if you are permanently under some kind of pressure or bullying that is a constant source of frustration, you will sooner or later get chest discomfort or some similar symptom. The patients who suffer from oscillating high blood pressure, if we turn off the rare organic causes, are a classical example of neurotic reactions. When examining patients, it is important to create a relaxing atmosphere, make eye contact, avoid negative facial expressions, and listen carefully to their problems. After physical examination and diagnostic procedures we can easily establish the correct diagnosis. The patient will surely be happy if we determine that they do not need medication and instead suggest changing their lifestyle. However, eighty percent of our patients are truly ill and need medication and further medical procedures.

Romana Palić, Daniela Šmalcelj, Irena Ošlaj

A critically ill female newborn with profound hypoxemia and acidosis was transferred from the county hospital with presumptive diagnosis of complex congenital heart disease. A hypoplastic left heart syndrome with double outlet right ventricle, restrictive ventricular septal defect and aortic coarctation was diagnosed in our institution by echocardiography and cardiac catheterization. (1) Repetitive ventricular tachycardias with hemodynamic deterioration complicated catheterization procedure. In a dismal situation, atrial septostomy was performed. Because paroxysmal supraventricural tachycardia during balloon atrioseptostomy, the perforation of right atrium was caused by catheter manipulations. Followed by an abrupt loss of atrial pressure. Cardiac tamponade was recognized immediately and confirmed by echocardiography. Pericardial drainage was instituted right away, together with blood transfusions. An urgent sternotomy with surgical closure of punctured site was performed on the catheterization table. Only a transient hemodynamic stabilization followed, but eventually the baby died because of irretrievable cardiac arrest in spite of resuscitation efforts. It has been known that neonatal mortality in the patients with complex heart defects with intact or highly restrictive atrial septum remains high despite successful urgent septostomy. (1) Moreover, transcatheter creation of an atrial septal defect using conventional balloon atrial septostomy (with or without the combination of blade atrial septostomy) has an abysmal risk with additional complications, including arrhythmias and other cardiac performance leading to death. In such a situation, a highly professional team of competent and skilled nurses trained in highly demanding emergency procedures in cardiac catheterization laboratory is required. We want to stress the necessity of proper education and training of nurses in the team performing demanding cardiac catheterization and surgical procedures in critically ill neonates and infants.

Đeiti Prvulović, Irzal Hadžibegović, Božo Vujeva, Krešimir Gabaldo, Ognjen Čančarević

**Aim**: The aim was to determine soluble vascular adhesion molecule 1 (sVCAM-1) before and 24 hours after the percutaneous coronary intervention (PCI) between the group of patients treated with balloon dilatation with stent implantation, with drug-eluting balloon (DEB) and the control group, to compare the obtained differences and their relationship with clinical and procedural parameters. **Patients and Methods**: The study included 15 patients treated with predilatation and stenting (group A), 15 patients treated with DEB (group B) and 24 patients in the control group. We measured sVCAM-1 before the procedure and 24 hours after the procedure. We compared sVCAM-1 between groups, and their relationship with clinical and procedural parameters. **Results**: Group A had significantly higher sVCAM-1 in the first measurement in relation to both other groups (p < 0.05). There was a significant decrease between two measurements in the group A (p = 0.041), increase in the group B (p = 0.017), and no changes in the control group. There were no significant differences in demographic and clinical characteristics, except for a significantly smaller proportion of patients with previous myocardial infarction (MI) in control group and significantly lower average time elapsed from myocardial infarction in group B. There was positive correlation between the number of balloon inflations and the total duration of inflation and sVCAM-1 24 hours after the procedure, but not statistically significant. In the subanalysis we found no statistically significant difference in the dynamics of sVCAM-1 depending on history of earlier MI, PCI and history of statin therapy, and we noted statistically significant (p = 0.024) increase of sVCAM-1 24 h after the procedure among non-diabetic patients in group B. **Conclusion**: **1**. significant increase in sVCAM-1 24 hours after the procedure in patients of group B could be caused by procedural differences done in groups A and B, but possible reason is in some of the characteristics of the DEB. **2**. significantly higher value sVCAM-1 before the procedure in group A is because we included patients who have had a myocardial infarction less than 3 months before the intervention. **3.** results of this study rejected the hypothesis on the expected lower inflammatory response in patients treated with DEB, but they provide useful information for future studies (1-3) which should clarify the mechanisms of endothelial damage during PCI.

David Gobić, Igor Medved, Vjekoslav Tomulić, Sandro Brusich, Kristian Deša, Luka Zaputović

**Introduction**: Extracorporeal membrane oxygenation (ECMO) is basically a heart-lung machine and an ECMO system consists of a pump and an oxygenator. The oxygenator and pump are integrated into a closed circuit to prevent any contact between the blood and air. All the components of ECMO are mounted on a portable/mobile console positioned near the patient’s bed. These enable ECMO patients to be taken to a cardiac catheter laboratory where ECMO is used to support patients undergoing high-risk percutaneous coronary intervention (PCI). Veno-arterial ECMO (VA ECMO) is indicated for patients with myocardial pump failure and can also support lung failure at the same time. Peripheral cannulation is preferred since cannulation should be as simple as possible and require the least possible surgical intervention. Drainage is carried out via a femoral vein and arterial cannulation is possible on a femoral artery or a subclavian artery. Myocardial pump failure defined as a cardiac index 2 is generally regarded as the criterion for mechanical circulatory support. This is a good indication for the use of VA ECMO in patients who are refractory to treatment with medication. It seems that PCI supported by VA ECMO is indicated for potentially reversible myocardial damage, for example patients in cardiogenic shock in acute myocardial infarction, and for high-risk PCI patients. (1-3) **Patients and Methods**: Clinical characteristics of patients supported by ECMO during the high risk urgent or elective PCI in University Hospital Centre Rijeka are analyzed using available medical records. **Results:** During the 6 months period 8 patients who have undergone an urgent or elective PCI were supported by ECMO. Survival rate was 75%. The shortest ECMO support was performed for 45 minutes and longest for 356 hours and 25 minutes. **Conclusion**: Clearly defined and accepted indications for ECMO are still lacking and they are often derived from local institutional experience. More experience leads to more liberal indication and more successful results.

Tomislav Letilović, Damir Kozmar, Stjepan Kranjčević, Darko Počanić, Helena Jerkić, Maro Dragičević, Mario Stipinović, Ena Kurtić

**Background**: In-stent restenosis (ISR) is an important clinical problem. Underlying cause of ISR can be variable and is believed to be different from the pathophysiology of atherosclerosis in the native vessels. (1) Such different mechanisms could, at least in part, be explained by different demographic characteristics of ISR and non-ISR patients. They could also lead to different approaches to percutaneous coronary interventions (PCI) in those two groups. **Patients and Methods**: We conducted this retrospective analysis, of our interventional data, in order to find such differences. In years 2014 and 2015 there were 657 elective PCI procedures (41 ISR and 616 non ISR interventions) in our institution. **Results**: We found no significant differences in major demographic characteristics in ISR vs. non-ISR patients (**Table 1**). Analysis of procedural characteristics (**Table 2**) showed that we were probably more aggressive with predilatation in ISR (number of balloons used 1.53±0.59 vs. 1.34±0.77; p=0.03). We were less keen to implant a stent in ISR patients (21.9% vs. 82.3%; p<0.001) but when implanted one it was more frequently a drug eluting stent (100% vs. 36.9%; p<0.001). We used more drug eluting balloons for ISR (65.8% vs. 3.7%; p<0.001). No other significant differences in procedural characteristics examined were found. ### Table 1: Demographic characteristics of patients according to the presence of in-stent restenosis. | **Characteristic** | **ISR (n=41)** | **Non ISR (n=616)** | **p-value** | | --- | --- | --- | --- | | **Age (mean±SD)** | 65.9±7.9 | 64.3±9.7 | 0.38 | | **Male sex (n/%)** | 31/77.5 | 434/70.4 | 0.48 | | **Hypertension (n/%)** | 40/97.5 | 587/95.3 | 0.52 | | **Hyperlipidaemia (n/%)** | 41/100 | 566/91.8 | 0.06 | | **Smoking (n/%)** | 9/21.9 | 177/28.7 | 0.56 | | **Diabetes (n/%)** | 11/26.8 | 208/33.7 | 0.92 | | **Previous MI (n/%)** | 22/53.6 | 284/46.1 | 0.89 | | **Previous PCI (n/%)** | 41/100 | 193/31.3 | <0.001* | | **Previous CABG (n/%)** | 1/2.4 | 19/3.0 | 0.25 | [†] ISR = in-stent restenosis; MI = myocardial infarction; PCI = percutaneous coronary intervention; CABG = coronary artery bypass graft; n = number; SD = standard deviation. Mann Whitney test was used for continuous and chi-square for nominal variables. *p<0.05 ### Table 2: Procedural characetristic. | **Characteristic** | **ISR (n=41)** | **Non ISR (n=616)** | **p-value** | | --- | --- | --- | --- | | **LAD//Cx//RCA//Graft//LMCA (n)** | 15//5//19//1//1 | 187/161/258/1/9 | 0.47 | | **Predilatation (n/%)** | 41/100 | 557/90.4 | 0.14 | | **Number of balloons – predilatation (mean±SD)** | 1.53±0.59 | 1.34±0.77 | 0.03* | | **Stent implantation (n/%)** | 9/21.9 | 507/82.3 | <0.001* | | **Number of implanted stents (mean± SD)** | 1.0±0.31 | 1.12±0.51 | 0.31 | | **DES penetration (n/%)** | 9/100 | 219/36.9 | <0,001* | | **DEB application (n/%)** | 27/65.8 | 23/3.7 | <0.001* | | **Postdilatation (n/%)** | 1/2.4 | 62/10.0 | 0.10 | | **Fluoro time in min (mean±SD)** | 8.04±4.51 | 10.09±9.24 | 0.69 | | **Contrast in ml (mean±SD)** | 159.41±67.26 | 165.15±77.49 | 0.76 | [†] ISR = in-stent restenosis; LAD = left anterior descending; Cx = circumflex; RCA = right coronary artery; LMCA = left-main coronary artery; DES = drug-eluting stent; DEB = drug-eluting balloon; n = number; SD = standard deviation. Mann Whitney test was used for continuous and chi-square for nominal variables. *p<0.05 **Conclusion**: There were no significant demographic differences in ISR vs. non-ISR patients treated in our institution. Procedural differences that were found reflect, at least in some part, well known recommendations for ISR interventions. On the other hand, they also probably reflect specific organizational and financial issues of our catheterization laboratory.

Jozica Šikić, Dario Gulin, Edvard Galić, Jasna Čerkez Habek

**Introduction**: Cardiac allograft vasculopathy (CAV) is a challenging long-term complication of cardiac transplantation and remains a leading long-term cause of graft failure, re-transplantation, and death. (1-3) Not only pathological characteristics, but also asymptomatic presentation of CAV is significantly different from typical atherosclerotic coronary artery disease (CAD). Large multicenter studies of heart transplant recipients undergoing percutaneous coronary interventions are lacking. **Case report**: 65-year-old male patient, with prior history of heart transplantation in 2010, was admitted to hospital in October 2014 due to routine annually cardiac testing. Previously performed coronary angiographies showed no significant coronary artery disease. His recent cardiac history was unremarkable. Coronary angiography revealed significant stenosis in middle part of left anterior descending artery (LAD) which was treated with drug-eluting balloon (DEB - paclitaxel). A year and a half later no progression of LAD stenosis was observed. **Discussion**: CAV is a multifactorial process in which the immune system presents the driving force. Cells from the innate and the adaptive system cooperate to reject the foreign heart which results in endothelial dysfunction and migration and proliferation of smooth muscle cells. This process, as opposed to atherosclerosis is very fast, usually lasting few months to complete vascular occlusion. Previous studies about drug-eluting stents (everolimus or sirolimus) and bare-metal stents in treating CAV show no significant difference in target lesion revascularisation rate. Studies with bioresorbable scaffolds are currently being conducted. There are no studies showing concomitant long term use of antiplatelet, especially ticagrelor and prasugrel, and immunosuppressive therapy. Due to our knowledge studies using DEB in CAV have not been performed. As it requires short-term antiplatelet therapy and provides optimised homogenous drug dispersion it could provide optimal treatment of CAV.

Boris Starčević, Ante Lisičić

The spontaneous coronary artery dissection is generally seldom in clinical practice. (1) We present a 41-year-old male who was admitted because of high arterial blood pressure and chest pain. The patient’s risk factors were smoking, dyslipidemia and poorly controlled arterial hypertension. His 12-lead electrocardiogram on admission showed discrete ST-segment elevation and negative T-waves in anterior and lateral leads and Q-waves in inferior leads. Initial laboratory results revealed a slightly elevated troponin I, but other cardiac bio-markers were negative. Echocardiography showed marginally dilated left ventricle and left atrium, preserved global ejection fraction of left ventricle with regional wall motion abnormality involving apex and intraventricular septum. Coronary angiogram revealed a peculiar beaded-like appearance in middle segment of left anterior descending artery and similar finding in proximal segment of right coronary artery, but without angiographically evident stenosis. To further define the nature of the filling defects, an intravascular ultrasound (IVUS) was performed which showed dissection flaps with multiple false lumens involving middle left anterior descending artery (LAD) and proximal right coronary artery (RCA), a finding that indicates recanalized spontaneous coronary artery dissection. A successful percutaneous coronary intervention with drug-eluting stents was done to the LAD and RCA with excellent angiographic result that was confirmed on repeated IVUS. The patient was discharged several days after the intervention with dual antiplatelet therapy, antihypertensive and antihyperlipidemic therapy. He was symptom-free and without any clinical sequelae in the follow-up. Hereby, an IVUS helped us in confirming the filling defects to be recanalized spontaneous coronary artery dissections and also in assessing the length of the lesions and in deciding the correct size of the stents to adequately cover the diseased segments.

Morena Kvaternik, Pavica Stanišić, Marijan Krpan

Transcatheter aortic valve implantation (TAVI) is a method in which biologic aortic prosthesis is implanted in stenotic aortic valve. Procedure is indicated in patients with severe, symptomatic aortic stenosis, with severely impaired quality of life and shortened life expectancy which have high perioperative risk and therefore are not suitable for surgical valve replacement. Typical patient is an older person with one or more concomitant conditions or diseases which significantly elevate surgical risk. Nurses or radiology technicians can be assistants in this procedure. They are important members of TAVI team and their role is very significant and they are irreplaceable during the whole procedure. Alongside experience acquired working in cardiac catheterization laboratory it is necessary to carry out additional education for these kind of interventions. (1-3)

Matias Trbušić, Zdravko Babić, Diana Balenović, Andrea Grman-Fanfani, Ines Zadro, Hrvoje Pintarić

Early performance of primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction is important in minimizing the ischemic insult and infarct size of the myocardium. In addition, the prevalence of slow or no-reflow phenomenon is significantly higher when the duration between chest pain onset and reperfusion (PTB; pain-to-balloon time) was more than 4 hours. Although the latest guidelines recommend less than 90 minutes of door-to-balloon (DTB) time, they strongly emphasize the importance of its shortening. But obviously, the PTB time is more influenced by pain to door (PTD) time than by DTB time. It is shown that the patients with DTB time of <90 minutes and PTD time of <4 hours had the lowest long term mortality (3.51%). (1) The results of Croatian Primary PCI Network are shown to be comparable to result of similar PCI networks of economically more developed countries. (2, 3) Our ongoing study is trying to find the epidemiological, social and organizational factors that are mostly influencing both PTD time and DTB time in North-West Croatia. The study is ongoing in two hospitals without PCI capability and their referral PCI capable hospital, investigating patients from rural and urban areas. The results of this study will help in identification of weak links in chain called PTB time and definition of possible targets for further improvements in Croatian PCI network.

Ivo Darko Gabrić, Tomislav Krčmar, Matias Trbušić, Zdravko Babić, Ozren Vinter, Hrvoje Pintarić, Danijel Planinc

Coronary artery rupture is a rare complication of percutaneous coronary intervention (PCI) that may lead to pericardial effusion frequently accompanied by tamponade. It is one of the most serious complications with a relatively high mortality rate ranging from 7 to 17%. (1-3) We report a case of a 63-year-old patient with acute inferoposterolateral ST-segment elevation myocardial infarction presented 4 hours from the beginning of chest pain. An urgent coronarography with left radial access was done and a 3-vessel coronary artery disease was found with occlusion of strong first marginal branch (OM1). Following stenting of the OM1 with 2nd bare metal stent (BMS), a type III distal guidewire-induced coronary perforation was recognized with extravasation of contrast into the pericardial space. Hemostasis was immediately performed inflating the balloon from the stent and a conversion of heparin with 10.000 I.U. protamine was done. As prolonged balloon inflations were unsuccessful, we decided to do a peripheral embolization with subcutaneous fat. The first guiding catheter, wire and balloon were left in place to maintain hemostasis and we placed another working guiding catheter through the right femoral artery. Prior to placing the introducer, 5 cc of subcutaneous fat was harvested from the patient’s upper right thigh. A mixture of fat and saline was injected through the over-the-wire balloon distally of the balloon for hemostasis resulting in the immediate cessation of leakage at the site of perforation. However, immediately after, most likely due to leakage of the pro coagulant fat tissue from circumflex artery (Cx) to left anterior descending artery (LAD), occlusion of the LAD at the previously diagnosed significant stenosis occurred. The PCI of the LAD was immediately made with BMS implantation and clinical stabilization of the patient. At the end of the procedure Cx was sealed and there was no need for the pericardiocentesis or cardiac surgery. Echocardiography reveled a moderate posterolateral hypokinesia with left ventricular ejection fraction of 45% and a mild mitral regurgitation. After 21 days PCI of the right coronary artery with BMS was done. Subcutaneous fat tissue embolization is a simple technique available to all for the treatment of potentially fatal complications such as rupture of the coronary artery. Even though potential complications must be considered.

Joško Bulum, Vjekoslav Tomulić, Maja Strozzi, David Gobić, Ivica Šafradin, Igor Medved, Jadranka Šeparović Hanževački, Višnja Ivančan, Zvonimir Ostojić

Transcatheter aortic valve implantation (TAVI) has been shown to be adequate modality for treatment of high risk or inoperable patients with severe symptomatic aortic stenosis. In this abstract data concerning TAVI from 2 Croatian University Hospital Centers Zagreb and Rijeka are presented. In total 51 TAVI were preformed in these institutions (29 UHC Zagreb vs. 22 UHC Rijeka). All decisions regarding performing TAVI instead surgical aortic valve replacement (SAVR) were made by “heart team”. Of all patients, 30 (58.8%) were female and overall average age was 79.94 years. Mean European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 9.95 and Society of Thoracic Surgeons (STS) mortality score 5.29. Average maximal gradient across valve before TAVI was 92 mmHg with average aortic valve area 0.65cm2. 40% of patient had coronary artery disease and all of those were treated either with coronary artery bypass graft surgery or percutaneous coronary intervention prior to TAVI. In two patients (3.92%) valve-in-valve procedure was done. Almost all possible approaches were used (transapical, trans -carotid, -subclavian, direct aortic) but majority of procedures were performed using transfemoral approach (88%), from which 51.9% were done using surgical closure of femoral artery, while in rest of the cases Proscar was used. Valve was successfully implanted in 96% of cases. In one patient TAVI had to be converted in rescue SAVR. In 6 cases (11.76%) procedure was complicated with femoral artery bleeding and in one case (1.96%) with retroperitoneal bleeding. After the procedure 6 patients (11.76%) developed atrioventricular block requiring permanent pacemaker implantation. Two patients (3.92%) developed stroke and one (1.96%) developed myocardial infarction. Overall in hospital mortality was 5.88%, and one-year mortality was 4.17%. When compared to data in larger registries (1) our results are almost the same and in some cases even better. In conclusion TAVI is adequate treatment option for selected patient in Croatia and we strongly encourage performing it even more in the future.

Marina Pavletić, Vesna Puklin

Optical coherence tomography (OCT) is a novel invasive imaging technique that produces high resolution intracoronary images. Its general principle of operation is similar to intravascular ultrasound, however OCT uses infrared light, not ultrasound. Using infrared light, optical coherence tomography enables detailed evaluation of coronary atherosclerotic plaques and of the vascular response to coronary interventional devices, such as new generation coronary stents. (1) Optical coherence tomography can also be used as guide for coronary intervention. In the last years, the need for more precise information regarding coronary artery disease to achieve optimal treatment has seen intravascular imaging becoming an area of primary importance in interventional cardiology. OCT in this area has grown and is spreading. It benefits both therapeutic and research purposes and is also proving able to fill gaps in conventional invasive coronary imaging.

Mladen Jukić, Ladislav Pavić, Petar Medaković, Dražen Lovrić, Ivan Bitunjac

In recent years, coronary CT angiography (CCTA) has become a widely adopted technique, not only due to its high diagnostic accuracy, but also to the fact that CCTA provides a comprehensive evaluation of the total (obstructive and non-obstructive) coronary atherosclerotic burden (1). We introduced CCTA in our institution (and country as well) in 2007, and since then have scanned over 7000 patients, mostly for suspected coronary artery disease (CAD), accumulating reasonable experience in this respect. In our own study of 792 patients, conducted during 2009, we tried to systematically evaluate how CCTA influenced the management and treatment of our patients with stable CAD (2). Among other results, we showed that CCTA was able to safely replace diagnostic invasive coronary angiography (ICA) in the majority (77.2%) of patients, no matter the pre-test risk stratification. Further on, findings on CCTA significantly influenced the choice and aggressiveness of medical therapy. Almost all patients had therapy introduced earlier, as based on pre-test risk stratification, but it was still upgraded in 35.6% of patients following CCTA, probably demonstrating the importance of CAD burden visualization in clinical decision making. More recently, a considerable body of evidence has showed what we believe to be the superiority of CCTA in prognostic evaluation of coronary artery atherosclerosis in comparison with other invasive and non-invasive modalities. Further on, due to superb presentation of plaque position, length and composition, CCTA can improve planning of coronary artery interventions. CCTA can also be very valuable in structural heart interventions / surgery, with transcatheter aortic valve implantation being one of its most successful examples. According to current guidelines CCTA is now an established, noninvasive technique that can rapidly exclude obstructive CAD and identify patients who can be safely discharged from the emergency department. Based on our experience (2), and published data, we believe that CCTA can have an important role in a new management model of patients with suspected CAD that is more patient-centered and pro-active. Not only as a gatekeeper ICA, which presents its by now established role, but also in all other above mentioned aspects CCTA can provide valuable additional information.

Ana Bognar, Ivana Raič

Abdominal aortic aneurysm, along with myocardial infarction and stroke is one of the most common diseases of blood vessels, and it is estimated that almost 10% of the male population over age 60 has an aneurysm. The mortality of ruptured abdominal aortic aneurysm in some cases is growing to an alarming 90%. With the former techniques of treating aneurysms, such as conservative (drug therapy) treatment and open surgery, in 1991 the endovascular aortic repair was introduced as a significantly less invasive method than surgery. The main difference between classic open surgery and endovascular stenting is that in the former method the stent is placed into the aortic aneurysm without the need of opening the abdomen and removing aortic tissue. Therefore, the recovery time is faster and the patients are released from the hospital within a week. Because of the mentioned advantages that endovascular repair of aneurysms has over traditional open surgery it can be mentioned advantages that endovascular repair of aneurysms has over traditional open surgery it can be considered as a valid alternative in the treatment of abdominal aortic aneurysms in specific indications. (1)

Jozica Šikić

The introduction of bare-metal stents (BMS) significantly advanced the field of interventional cardiology by reducing the number of reinterventions. In order to reduce restenosis, drug-eluting stents (DES) were developed, and are further differentiated by stent platform, polymer type, and active substance. The first generation of DES, paclitaxel-eluting stents (PES) and sirolimus-eluting stents, are no longer used as the second generation of stents are superior: zotarolimus-eluting stents (ZES) and everolimus-eluting stents (EES). They are biocompatible, cause less inflammatory reactions, and become covered with endothelium more quickly. Resolute zotarolimus-eluting stents (R-ZES) and EES are comparable, and are superior in relation to other DES’s. Meta-analyses of studies have proven DESs with bioresorbable polymer (biolimus and sirolimus) superior to 1st generation DESs (sirolimus) in their reduced revascularisation of target veins and reduced incidence of in-stent thrombosis in a 5-year period. However, if these stents are compared with the new generation of DESs, it becomes clear that the percentage of target vessel reintervention is comparable. DESs with resorbable polymer are comparable to R-ZES in their incidence of in-stent thrombosis and mortality rates, while they are inferior to EES. It is difficult to design a non-polymer DES due to problems in attaining a stable concentration of anti-proliferation drug necessary to prevent neointimal hyperplasia. The first studies are promising, and have shown no significant differences in the later loss of lumens, angiographic restenosis, or revascularization of target veins due to restenosis as compared to a standard DES with paclitaxel. The time necessary to release this drug is one month, and its application would reduce the length of dual antiplatelet therapy, thus completely eliminating rare indications for the application of BMS. (1-3) As opposed to the first generation, the new generation of bioresorbable stents (scaffolds) have been shown to be not inferior to the second generation of DESs (EES) as related to infarction, cardiovascular death, and ischemia-driven target vessel revascularization in a 1-year period. Drug-eluting balloons (DEB, all of which are impregnated with paclitaxel, differing only in the polymer type) are the subject of many studies, and have only been indicated for in-stent restenosis. However, results are expected from numerous studies of small blood vessels and bifurcation lesions.

Rajka Gabelica, Mario Pavlek, Željko Čolak, Mirabel Mažar, Gordana Rajsman, Sandra Uzun, Sanja Konosić, Davor Strapajević, Višnja Ivančan

Anesthesia management for interventional procedures in cardiology becomes increasingly demanding due to growing number and complexity of these procedures. Anesthesiologists are assuming an important role in the multidisciplinary planning of management. A comprehensive understanding of each procedure is essential to ensure a reasonable plan for the anesthesia, monitoring, venous access and additional equipment required. A skilful anesthetic management is critical in maintaining stable hemodynamic and rapidly managing any complications that may occur during the procedure. Cardiac anesthesiologists in University Hospital Center Zagreb provide anesthesia for: percutaneous closure of atrial septal defects and PDA, transcatheter aortic valve replacement, thoracic endovascular aortic/aneurysm repair, implantation of pacemakers, cardiac resynchronization therapy pacemaker and automatic implantable cardioverter defibrillators, electrophysiological studies and the Harmony System for the treatment of heart failure patients. (1, 2) Anesthetic management ranged from sedation to full general anesthesia with invasive monitoring and other modalities such as transesophageal echocardiography. As interventional procedures may be lengthy, and the potential exists for hemodynamic instability and significant blood loss, general anesthesia with endotracheal intubation is commonly performed. In our hospital, in spite of the use of transesophageal echocardiography, device closure of an atrial septal defect in children is accomplished with deep sedation and spontaneous ventilation. Therefore, a vigilant monitoring by anesthetic staff is necessary during the procedure. The importance of skilful anesthetic technician is of huge value for safe management in such as challenging environment. In conclusion, it is clearly evident that the well-prepared and experienced anesthesiologist, responsible for maintaining a high level of anesthetic care, has to be an integral part of the multidisciplinary team to obtain optimal outcome of interventional cardiology procedures.

Frane Runjić, Lovel Giunio, Ivica Vuković, Darko Duplančić, Anita Jukić, Ivica Kristić

We present case of coronary artery perforation during percutaneous coronary intervention (PCI) which was misunderstood as aortic dissection. A 73-year-old woman, diabetic, presented with effort angina of Canadian Cardiological Society (CCS) scale III for the last two months. Coronary angiogram revealed multiple significant stenosis of the left anterior descending artery (LAD) and the right coronary artery (RCA). After she was presented to heart team and refused surgical revascularization we proceeded with PCI. LAD was successfully treated with one drug eluting stent. After that we proceeded with RCA intervention. After first balloon inflation huge contrast extravasation (4x4cm) was noticed in projection of aortic wall. Patient was stable, procedure was temporary interrupted and because of suspicion on aortic dissection urgent echocardiography and CT scan of aorta was performed. Echocardiography did not show fluid accumulation in pericardium while CT scan excluded aortic dissection and showed perforation of ostial RCA with cranial intrapericardial contrast extravasation. After that procedure was continued with implantation of three DE stents in RCA. Final angiogram showed successful sealing of ruptured ostial RCA without any contrast leak. During the following days there was no evidence of fluid in the pericardium, also MSCT coronarography confirmed normal flow in RCA and LAD. After five days patient was safely discharged from hospital. This case shows well known complication of PCI, coronary artery perforation visualized as direct extravasation of contrast from coronary artery defined by the Ellis criteria from grade I to III. (1) Grade I and II in most cases have less dramatically course while grade III often results in cardiac tamponade. Perforations can be successfully treated by covered or noncovered stents, prolonged balloon inflation, microcoil embolization or surgically. This was perforation grade II but because of direction of contrast leak looked like dissection of ascending aorta. Fortunately, this patient was stable enough to perform CT scan to exclude aortic dissection and finally we were able to successfully treat this complication with stent implantation.

Lovel Giunio, Jakša Zanchi, Anteo Bradarić, Mislav Lozo

**Goal**: Despite the guidelines, more than two-thirds of patients with massive/high risk pulmonary embolism (PE) do not receive thrombolytic therapy (1, 2). Submassive/intermediate risk PE, as defined by right ventricular failure and/or NT-proBNP/troponin elevation, which can result in life-threatening deterioration/sequel is treated with thrombolytic therapy even less frequently. The main reason, that thrombolytics are used infrequently despite the potential clinical benefit of rapid clot lysis, is respect for significant bleeding complications, since nonpathologic thrombi are also lysed. The reluctance of majority of treating physicians to actually use thrombolytic therapy in everyday praxis persist and is matched only by zeal to publish successfully treated cases by minority of interventional colleagues. “Radial” – transcubital approach to high risk pulmonary embolism and subsequent catheter directed intervention (CDI) is proposed as a realistic alternative to both routinely used heparin therapy and surgical embolectomy, that can with modifications even be used in the case of contraindications for thrombolytic therapy. The goal of this presentation is to present a real-life center experience of the feasibility and safety of CDI including protocol for transcubital CDI as a first-line therapy in patients with clinically massive/high risk and submassive/intermediate risk PE. **Patients and Methods**: From March 2011 throughout December 2015, 29 patients with massive or submassive PE underwent a CDI at the University Hospital Centre Split, Croatia. CDI involved mechanical catheter fragmentation and the application of adjuvant thrombolytic therapy through a pigtail catheter positioned in the pulmonary artery (PA) or rheolytic thrombectomy (RT). **Results**: A total of 29 patients were enrolled in the study (15 men, 51.7%; 14 women, 48.3%). Clinical success was achieved in 26 of 29 cases (89.6%). There were no major procedural complications (0%). The 90-day survival rate was 89.6%. **Conclusion**: “Radial” – transcubital CDI in patients with clinically massive or submassive PE is feasible and safe. In experienced centers it should be considered as a first line treatment.

Mario Sičaja, Maria Nicole Sičaja, Boris Starčević

Fractional Flow Reserve (FFR) is a wire-based procedure that can accurately measure blood pressure through a specific part of the coronary artery. Instant wave-free ratio (iFR) is a new method that relies on the fact that resistance is naturally constant during the wave-free period for the required measurement. Recently, emphasis is put on increasing usage of FFR/iFR in guiding percutaneous coronary intervention (PCI). FFR is measured after infusion of a hyperemic agent, such as adenosine. The protocol of iFR does not require an infusion of hyperemic agent. In both procedures little is known about intracoronary premedication treatment protocol and it usually varies from hospital to hospital. For the optimal procedure it is of paramount importance to assure the absence of wire induced spasm on functionally insignificant lesions due to the risk of unnecessary PCI treatment. We present a 55-year-old male patient which was referred to our centre for coronary angiography due to suspected acute coronary syndrome. During the procedure an angiographically insignificant lesion was visualized in the proximal part of left anterior descending artery. FFR was preformed, but values on the lesion varied from 0.76 to 0.86. The reason was variable spasm provoked by FFR wire in spite of administration of the hyperemic agent. In conclusion, there is an obvious need for standardized and validated protocol for intracoronary premedication treatment. It is important to eliminate confounding elements in FFR/iFR measurements in order to assure accuracy and the reproducibility of repeated measurements. (1, 2)

Kristina Marić Bešić, Zoran Miovski, Maja Strozzi

The number of octogenarians undergoing percutaneous procedures has increased in the past years as a consequence of demographic changes. According to data 25% of all percutaneous coronary interventions (PCI) are performed in patients over the age of 75 and 12% in those aged over 80 years. There is not only a higher incidence of acute coronary syndrome (ACS), but also an increase of patients with stable angina and transcatheter aortic valve implantation (TAVI) procedures. The elderly have more comorbidities, multivessel disease, complex lesions and therefore a higher incidence of post procedural complications. (1, 2) We present an overview of percutaneous interventions in octogenarians preformed in our catheterization laboratory from 2011 until 2015. The aim was to investigate indications, procedure success, periprocedural complications, intrahospital mortality and 1 year survival rate. There were 762 patients, 417 (55%) male and 345 (45%) female. The majority of patients 448 (58.8%) had an ACS; ST-segment elevation myocardial infarction (149 or 19.5%); non ST-segment elevation myocardial infarction + unstable angina pectoris (275 or 36%) and cardiogenic shock or arrest (24 or 3.1%). Stable angina was the indication in 143 (18.7%) patients and elective PCI in 40 (5.2%) patients. There is an increase for valvular disease evaluation from 5.6% in 2011 to 16.5% in 2015. The majority of patients had 3-vessel disease 255 (33.0%) and 170 (22.3%) had previous PCI or coronary artery bypass grafting. Overall 380 (49.8%) patients were treated (362 PCI, 18 TAVI). The success rate was 87% and the complication rate 5.1%. Intrahospital mortality was 13.7% in the PCI group and 5.2% in the non-PCI group. A total of 495 (65%) patients had a follow-up period of one year, 386 (50.6%) were alive (171 PCI, 251 non-PCI). In conclusion, the number of octogenarians in our catheterization laboratory is increasing. Although data from registries suggest that they appear to benefit in terms of quality of life after PCI, a careful approach to patient selection is essential to get the best outcomes.

Ivan Malčić, Dalibor Šarić, Hrvoje Kniewald, Daniel Dilber, Dorotea Bartoniček, Darko Anić, Višnja Ivančan, Dražen Belina, Alen Hodalin

Development of interventional cardiology in treating heart diseases in children in the Reference Centre for Pediatric Cardiology (1) in the last 20 years (1996 - 2015) is presented. Constant growth in the number of heart catheterizations (from 160 to 241) is followed by a relatively higher growth in the number of interventional catheterizations (from 12.5% to 38.1%). While the number of catheterizations (**Table 1**) has increased by 50% (160 to 241 =1,5), the number of interventional catheterizations has increased by more than 200% (12.5 – 38.1% > 3). In our conditions these data point to an absolute increase of interventional treatment when compared to the diagnostic heart catheterization itself, despite the fact that the latest diagnostic methods are still not applied sufficiently (MSCT, MRI, 3D ECHO and other). Providing we decrease the number if diagnostic catheterizations by applying the mentioned new diagnostic methods, and based on the expected number of interventional catheterizations curve, the 50% level may be expected in about 5 years. All age groups from newborns, including prematures, to the age of 18 are represented. That implies a tremendous body mass span, with the lowest birth mass being 2000 grams at the time of diagnostic catheterization, and 2400 grams at the time of interventional catheterization. In the last twenty years 3695 heart catheterizations have been performed, 937 of which were interventional (averagely 26%). ### Table 1: Development of invasive diagnostics and of interventional heart catheterization in the last 20 years (1996-2015) in the Reference Centre for Pediatric Cardiology University Hospital Centre Zagreb. | Year | Number of heart catheterization | Number of interventions | percentage of interventions in the overall number of catheterizations | estimated number of interventions based on the number of interventions in the previous year | | --- | --- | --- | --- | --- | | 1996 | 160 | 20 | 12,5% | - | | 1997 | 91 | 17 | 18,9% | 11 | | 1998 | 90 | 24 | 26,8% | 17 | | 1999 | 168 | 16 | 9,5% | 45 | | 2000 | 186 | 21 | 11,3% | 18 | | 2001 | 186 | 41 | 22,0% | 21 | | 2002 | 176 | 27 | 15,3% | 39 | | 2003 | 161 | 25 | 15,5% | 25 | | 2004 | 190 | 48 | 25,4% | 30 | | 2005 | 170 | 32 | 18,8% | 43 | | 2006 | 194 | 52 | 26,8% | 37 | | 2007 | 182 | 60 | 33,0% | 49 | | 2008 | 201 | 65 | 32,3% | 66 | | 2009 | 224 | 70 | 31,3% | 72 | | 2010 | 206 | 68 | 33.0% | 66 | | 2011 | 230 | 78 | 33.9% | 76 | | 2012 | 210 | 72 | 34.3% | 71 | | 2013 | 194 | 62 | 31.6% | 67 | | 2014 | 235 | 83 | 35.3% | 75 | | 2015 | 241 | 92 | 38.1% | 85 | | Overall | 3695 | 973 | 26.33% | | In interventional procedures we employed 12 different surgical procedures, thus equaling the developed pediatric cardiology centers in Europe. Cardiac surgeons and anesthesiologists also participate in the work of pediatric cardiologists. Along with statistic data we are also presenting various interventional skills in pediatric cardiology, from balloon atrioseptostomy to stent implantation.

Zoran Miovski, Joško Bulum, Hrvoje Jurin

**Introduction**: Cardiogenic shock is the most common cause of fatal outcomes in catheterization laboratories. It is also the most challenging state. In this report we present an interesting case of cardiogenic shock in younger patient. **Case report**: 49-year-old male was referred from a local hospital to University Hospital Centre Zagreb because of chest pain and ST-segment elevation. At presentation the patient had high blood pressure (RR 220/100 mmHg), was agitated and pail. In the local hospital he received the loading dose of ticagrelor and aspirin. At arrival to the catheterization laboratory, patient was disoriented, with brachial blood pressure of 80/40 mmHg, had dyspnea with low peripheral oxygen saturation of 80%, and pulmonary edema. At auscultation the patient had no precordial murmurs which suggested an acute mitral regurgitation. He was then intubated and mechanical ventilation was started. Due to the lack of radial pulses, we proceeded with right transfemoral approach. Short after sheet insertion, the patient went to cardiopulmonary arrest due to the pulseless electrical activity. Prolonged cardiopulmonary resuscitation was performed, and multiple defibrillations were made due to ventricular fibrillations. After 20 min of resuscitation, spontaneous circulation was obtained. Coronary angiography showed thrombotic occlusion of proximal left anterior descending coronary artery (LAD), without collaterals, marginal stenosis of proximal left circumflex artery (LCX) and normal right coronary artery (RCA). During that time patient was extremely hemodynamically unstable with maximal parenteral inotropic therapy (invasive blood pressure of 60/30 mmHg) and repetitive ventricular fibrillations. Patient was then referred to the extracorporeal membrane oxygenation team. Complex bifurcation percutaneous coronary intervention with 2 drug-eluting stents was performed (T-stenting and small protrusion technique - LAD/LCX), that resulted in partial hemodynamic (RR 90/50 mmHg) and rhythmologic stabilization. The pressure on the femoral sheet showed normal systolic and low diastolic pressure (RR 140/50 mmHg), suggesting severe aortic valve regurgitation, and possible aortic dissection. Aortography confirmed DeBakey type I aortic dissection. The patient was referred to a cardiac surgeon, and an urgent operation was indicated. Shortly after, during CT scan, patient went to cardiopulmonary arrest due to occlusion of the RCA and aortic rupture that resulted with cardiac tamponade and death. **Conclusion**: Acute aortic dissection in frequently misdiagnosed as acute coronary syndrome. Acute coronary syndrome has diagnostic advantages in rapid laboratory tests and ECG. For aortic dissection there are no equivalent rapid diagnostic tests. Unfortunately tests for acute coronary syndrome can be misleading. It is of the most importance to follow small details, that can lead to faster diagnosis and treatment. In patient with Stanford A dissection and cardiogenic shock as a result of occlusion of left main coronary artery, PCI can be bridge to surgery (1).

Krešimir Gabaldo, Đeiti Prvulović, Božo Vujeva, Irzal Hadžibegović, Ognjen Čančarević

Complex lesions interventions are technically demanding and associated with higher rates of adverse events. In left main stenting, ostial lesions and bifurcation procedures, precise stent position, complete lesion coverage and full stent deployment (apposition) are mandatory. These procedures should be guided with other imaging modalities. Intravascular ultrasound (IVUS) is a gold standard for all these indications, but it is expensive, time consuming and carries some added per procedural risk. Clear stent imaging or stent boost is an enhancement of the radiological edge of the stent by digital management of regular X-ray images. It is a simple and fast method especially useful for proper stent positioning, control of stent deployment and apposition. During bifurcation stenting it also allows correct balloon positioning for proximal optimizing technique and correct positioning of side branch stenting in T-stenting and small protrusion technique. Recent studies investigated the accuracy of stent positioning and deployment guided with CLEARstent, compared it and also controlled it with IVUS. The results show sufficient specificity for conventional use in every day practice. (1, 2) We routinely started to use CLEARstent imaging in December 2015. The procedures were carried out on a Siemens Artis zee floor-mounted angiography system integrated with CLEARstent software. We present some clinical cases where we were guided with CLEARstent imaging which definitely improved success of our procedures. The method is simple and quick, and as a center without IVUS, we now routinely use it in every complex lesion intervention.

Siniša Blažon

The rapid development of new medical technologies in interventional cardiology sets new requirements and challenges for physicians as well as for the nurses. Therefore, ability of the nurses must be at high level, so that their resourcefulness, skills, quick reactions, teamwork, knowledge and lifelong learning can contribute to new technologies. Interventional cardiology of today is dynamic and very demanding, if not the most challenging part of cardiology. This case report will present how an invasive procedure in interventional cardiology can result with complications which demand open heart surgery. Those complications can be successfully treated only by a team of professionals and that team make cardiologists, cardiothoracic surgeons, anesthesiologists, perfusionists, X-ray technicians and nurses. Nowadays an urgent sternotomy in heart catheterization lab is not common, but we who work there must always be ready for urgent procedures in order to save lives. Every invasive procedure in modern medicine has specific risks. The same applies to the transcatheter aortic valve implantation as a latest method of aortic valve replacement. (1) This method is the standard of care in adults with severe symptomatic aortic stenosis in which standard surgical aortic valve replacement carries a poor prognosis. The risks associated with surgical aortic valve replacement are increased in elderly patients and those with concomitant severe systolic heart failure or coronary artery disease, as well as in people with comorbidities such as cerebrovascular and peripheral arterial disease, chronic kidney disease, and chronic respiratory dysfunction.

Zorin Makarović, Sandra Makarović, Damir Kirner, Robert Steiner, Ivica Bošnjak, Marin Vučković, Dragan Novosel, Dražen Mlinarević

There are conflicting evidence regarding the use of intra-aortic balon pump (IABP) in acute coronary syndrome and shock patients. (1, 2) Current European Society of Cardiology (ESC) Guidelines does not recommend IABP to be routinely used. It is intended to be used in patients with non ST-segment elevation myocardial infarction (NSTEMI) with acute mechanical complications. ESC Guidelines considered meta-analyses by Sjauw el al and the major randomized clinical trial IABP SHOCK II. This research did not confirm degraded mortality 30 days after ST-segment elevation myocardial infarction (STEMI) with shock. There are several flaws to this study: the absence of long-term survival, not taking into account patients with mechanical complications of myocardial infarction, NSTEMI patients and cardiogenic shock after 12 hours. 50% of patients had blood pressure ≥ 90 mmHg, which rise the question of inclusion criteria. However, meta-analyses showed significant reduction in mortality in cardiogenic shock after STEMI in patients treated with thrombolysis and IABP, but without primary percutaneous coronary intervention. New randomized clinical trials are needed, so that a definite conclusion on long-term survival could be made, as well to establish if there are groups within those patients, which could benefit from the use of IABP. We present our IABP experience, in University Hospital Centre Osijek, in time period from 2014 to 2015, in acute coronary syndrome patients and cardiogenic shock, and their short term outcome and survival. This is ongoing study planned to follow long term outcome as well.

Mario Sičaja, Boris Starčević

In the last few years several technical advancements were introduced in the treatment of coronary bifurcations lesions. Even though several bifurcation stenting techniques are available, majority of them are associated with the high incidence of target lesion revascularization failure, mainly due to the complications of the side-branch. Cross-stenting technique, which represents modified Culotte stent technique and provisional T stenting with the treatment of side branch with drug eluting balloon (DEB) in some aspects reduce several technical limitations which are common for one or two-stent technique. (1-3) Here we present short description of above mentioned techniques with two case examples from our clinical practice. First patient is 48-years-old male hospitalized due to non ST-segment elevation acute myocardial infarction with preserved left ventricular ejection fraction accompanied with mild mitral regurgitation. Culprit lesion was true bifurcation (Medina 1,1,1) on circumflex artery (ACx) and first obtuse marginal branch (OM). Patient was treated successfully with the PCI OM (Medtronic Integrity stent 3,5x19mm) with provisional T stenting of ACx with DEB (SeQuent Please balloon catheter, 3 µg paclitaxel/mm2 balloon surface) with proximal optimization technique (POT). Second patient is 70-years-old male, with long lasting hypertension and history of coronary artery disease, with previous PCI preformed in the region of left anterior descending artery (LAD) due to ST-segment elevation myocardial infarction. He was admitted because of instable angina pectoris, with echocardiography showing preserved ejection fraction with mild mitral regurgitation. Culprit lesion was true bifurcation (Medina 1,1,1), also present on ACx and OM. In this case, the treatment of choice was cross stenting technique with two stents resulting in PCI ACx/OM (DES Resolute Integrity 2,5x16mm and DES Resolute Integrity 2,5x24mm) finalized with POT. In six-month follow-up both patients are doing fine, with angina only during strenuous or prolonged physical activity (Canadian Cardiovascular Society grading - CCS 1). In conclusion, the utilization of above mentioned techniques in everyday clinical practice is easy, timesaving and with acceptable risk in short term follow-up.

Eduard Margetić

## Dear colleagues, The Working Group on Invasive and Interventional Cardiology of the Croatian Cardiac Society is organizing the 7th National Congress of interventional cardiology with international participation – CROINTERVENT 2016, which will be held on March 10-12, 2016 in Zagreb. CROINTERVENT started in 2004. From that point it has grown steadily, not only in size but also in its importance among cardiovascular conferences. All the previous six meetings attracted a prominent International and Domestic Faculty and an interactive audience. CROINTERVENT 2016 is designed not only for cardiologists and cardiology fellows, but also for physicians of other specialties and people who are professionally associated with this dynamic and propulsive segment of modern medicine. The aim of the Congress, besides the display of modern clinical practice in interventional cardiology, is to discuss concerns and problems that we encounter in our daily practice, especially those still without consensus among the interventional cardiologists. The congress program will consist of invited lectures and oral and moderated poster presentations. It is important to note that a significant part of the congress will be dedicated to the practical aspects of interventional cardiology, both through transmitted “live cases” and presentation of already performed interventions with analysis and comments. This special issue of Cardiologia Croatica – the official journal of the Croatian Cardiac Society, consists of selected original contributions from our participants in the form of abstracts, which will be presented at the meeting in the form of oral presentations and moderated posters. Sincerely yours,

Bojana Gardijan, Matija Marković, Darko Počanić, Tomislav Letilović

**Introduction**: Lidocaine is an essential drug used as a local anesthetic and as antiarrhythmic medication of the class Ib type. There are multiple reports in literature that lidocaine can cause coronary artery spasm both in vitro and in vivo (1, 2). Elevation of the ST-segment is described during dental or neurosurgical procedures using locoregional lidocaine anesthesia (2, 3). We present a case in which intra-articular lidocaine instillation caused a vasospastic ST-segment elevation myocardial infarction (STEMI). **Case**: A 49-year-old male patient presented to the emergency clinic with chest pain that had begun an hour ago. The pain occurred at rest, was independent of exertion and radiated to the left arm. Previously that morning, he was at the surgical outpatient clinic due to a chronic knee condition where he underwent punction and intra-articular instillation of 100mg lidocaine. The chest pain started 30 minutes after the procedure. The patient had never experienced chest pain or intolerance of exertion before. Previous medical history was notable for well-controlled arterial hypertension, without any family history of coronary artery disease. He previously received lidocaine anesthesia without complications and had no known allergies. There was 1mm elevation in leads II, III, aVF and inferior STEMI was diagnosed (**Figure 1**). The patient was transferred to the catheterization laboratory for primary percutaneous coronary intervention. The coronary arteriography was without any evidence of stenosis (**Figure 2**). The patient received protocol STEMI care. Echocardiography showed no abnormalities or regional wall motion abnormalities. The initial high-sensitivity cardiac-specific troponin I was beneath the value of detection, with the peak value on the second day of stay, 4678.3 ng/L (reference value <34.2 ng/l). He also developed negative T waves in the inferior leads, as well as Q wave in the inferior leads (**Figure 3**). Throughout the hospital stay he was hemodynamically stable and reported no pain or chest-discomfort. The follow-up echocardiography showed no regional wall motion abnormalities. Figure 1. The 12-lead electrocardiogram recording on admission showing discrete ST-segment elevation in inferior leads. Figure 2. Coronary angiography showing no significant coronary artery disease. Figure 3. The 12-lead electrocardiogram recording on second day showing q wave in inferior leads. We concluded that the intraarticularly instilled lidocaine was absorbed into the blood stream and caused the vasospasm that lead to the STEMI. Although similar events have been described during other procedures, to our knowledge this is a first report of such an association during intra-articular lidocaine instillation.

Zoran Miovski, Miroslav Krpan, Bojan Biočina, Joško Bulum

**Introduction:** Giant aneurysm of the saphenous vein grafts (SVG) is a rare complication of coronary artery bypass surgery, with an overall incidence of <1% (1). SVG aneurysms are often asymptomatic, incidentally identified by imaging modality; there are reports of aneurysm rupture, fistula formation and hemodynamic compromise resulting from compression of adjacent cardiac and vascular structures. **Case report**: We present a case of a 73-year old patient who was admitted to our Clinic with complaint of dizziness and fatigue. He denied having any chest pain or shortness of breath. Nineteen years ago he suffered an inferior myocardial infarction and had surgical myocardial revascularization – aortocoronary bypass surgery with (SVG) on left anterior descending artery (LAD) and right coronary artery (RCA) with no postoperative complications. During actual hospitalization his ECG showed sinus bradycardia. Chest x-ray revealed a nodular infiltrate close to the right side of the heart raising suspicion of intrathoracic tumorous mass. Echocardiography confirmed the presence of paracardial anisoechogenic mass measuring 10x7 cm with partial compression of the right atrium. Color Doppler view of the mass showed pulsatile flow in part of the mass and urgent computerized tomography with intravenous contrast of the thorax and abdomen was performed showing aneurysm of the SVG on right coronary artery with preserved flow mimicking intrathoracic tumor. Coronary angiogram expectedly showed chronic total occlusion of LAD and RCA and patent SVGs with gigantic aneurysmatic dilatation of the RCA SVG and significant stenosis in proximal part of the LAD SVG. Few months later the patient was admitted to surgery, a large aneurysm of venous graft was found with thrombus burden. RCA was bypassed with a new venous graft and reconstruction of venous graft to LAD was done. Fifteen days after operation, patient was discharged to a local hospital. **Conclusion**: Because of its high potential for morbidity and mortality, we should treat this complication adequately. Due to better follow-up and increasing use of diagnostics, more patients with SVG aneurysms will be identified. SVG aneurysms have been generally treated by surgical repair, although percutaneus endovascular methods can be used (2).

Irzal Hadžibegović, Božo Vujeva, Krešimir Gabaldo, Ognjen Čančarević, Đeiti Prvulović

**Background**: Current ESC/EACTS Guidelines on myocardial revascularization emphasized benefit of radial access over femoral access in ST-segment elevation myocardial infarction (STEMI) if performed by an experienced radial operator. There are several definitions of an experienced radial operator. One of them is less than 10% of conversions from radial to femoral approach, and is often used in practice. The other is certainly volume, with 100 procedures as a primary operator needed to be securely on the upslope of the learning curve. (1, 2) We present our experience of long transition from femoral to radial access for primary percutaneous coronary intervention (PCI) in STEMI, mostly due to technical limitations and practical and organizational issues. **Patients and Results**: Data from catheterization laboratory registries in Slavonski Brod from 2004 to 2016 were analyzed. Radial approach was first introduced systematically in mid 2012 after a 3-day radial access workshop in Slavonski Brod. Proportions of patients with radial access in 2012, 2013, 2014, and 2015 were 5%, 22%, 15%, and 18%, respectively. In 2012 70% of radial access was right radial, but in 2013 right radial access was used in only 25% of radial cases. In 2014 and 2015 right radial was used again in most patients (86% and 83% of all radial, respectively). From 2012 to 2015, proportions of radial access in STEMI were small, varying between 3% and 6%, and were mostly driven by impossible femoral access. In first two moths of 2016, after the installation of new coronary angiography suite with adequate room and table options for radial access, and additional education in a high volume radial center in University Hospital Centre Rijeka, Croatia, routine right radial access climbed suddenly to 76%, with 4% of left radial access reserved mainly for left internal mammary artery bypass graft coronary angiography. Conversion to femoral access varied among operators from 6% to 14% during first two months in 2016, that led to routine introduction of radial access in STEMI by the end of January 2016 for 2 out of 5 operators. In first two months of 2016, 40% of STEMI patients had right radial access, with no prolongation of door to balloon time noted. **Conclusion**: Very long transition from femoral to radial access in STEMI, expected to reach a maximum of 90% of STEMI cases by June 2016, was mainly driven by technical limitations of catheterization laboratory suite, and organizational issues with varying approaches and equipment used in the learning curve.

Ervin Avdović, Kristina Uglešić, David Gobić

Pulmonary thromboembolism (PTE) is an acute and rather frequent cardiovascular condition which has considerable short-term mortality and potential of causing severely impairing long-term morbidity such as chronic thromboembolic pulmonary hypertension. After the diagnosis of PTE is confirmed risk stratification for early mortality should be undertaken. According to the latest ESC Guidelines on the diagnosis and management of acute pulmonary embolism therapeutic decision making varies depending on a risk category the affected patient belongs to. Variables taken in account when assessing early mortality risk include shock or hypotension, PESI (Pulmonary Embolism Severity Index), imaging (echocardiography, CT) signs of right ventricular dysfunction and positivity of cardiac laboratory biomarkers. We distinguish low, intermediate (divides in intermediate-low and intermediate-high subgroup) and high risk group. Therapeutic choice for patients in high risk group is primary reperfusion which was mostly confined to administration of systemic thrombolytic treatment, usually with the use of recombinant tissue plasminogen activator. However, a significant number of patients have well-established contraindications for systemic thrombolytic treatment. Catheter-directed thrombectomy is an invasive percutaneous, transvenous procedure which combines direct or ultrasound assisted pulmonary thrombus destruction and aspiration with possibility of local administration of thrombolytic agent. Even though there are various techniques, most of recently published authors gained clinical experience from successful applications of the AngioJettm (Boston Scientific, MA, USA) pharmacomechanical thrombectomy device. It consists out of console and rheolytic thrombectomy catheter. It is a 6 Fr, 120 cm long, over the wire, dual lumen catheter. The console generates power which forces saline solution through the series of high pressure jets located on the tip of the catheter what disrupts the thrombus which is then aspirated into the low-pressure second lumen. There is an option of targeted administering of thrombolytic agent. Commonly encountered complications include bradycardia and hemoglobinuria. Rare, but potentially fatal complications include perforation of pulmonary artery, pericardial tamponade and life-threatening hemoptysis. Method was first described by Koning et al in 1997 and since then only small patient series were reported with the largest one including 50 patients. Despite that, cumulative data on roughly 600 patients suggest safety of the method with survival rates of nearly 90%. (1-3) **Conclusion**: Catheter directed thrombectomy should be considered as a treatment of choice in high risk pulmonary thromboembolism patients with contraindication for systemic thrombolytic treatment. However, optimal use of the described method urges more prospective data.

Zoran Miovski, Kristina Marić Bešić, Maja Strozzi, Joško Bulum

**Introduction**: Among patient with unstable angina and myocardial infarction without ST segment elevation, about 40-60% have multivessel coronary disease. Due the lack of specific recommendations we decided to present a case of young patient with acute coronary syndrome and multivessel disease. **Case report**: 36-year-old male patient was admitted to our hospital from emergency department (ER) because of chest pain in the last 2 months during a low level of activity. He had moderate dyslipidaemia that was not treated. On the day he was hospitalized a treadmill test was done, with clinically positive test, and 3 mm ST-segment depression in inferolateral leads at 6 metabolic equivalents (MET). In the ER, the standard 12-lead electrocardiogram and laboratory tests (troponin T) were normal. Echocardiography showed left ventricular ejection fraction of 55% with hypocontractility of interventricular septum, inferior and distal part of anterolateral wall. The same day coronary angiography was done according to European Society of Cardiology Guidelines (1) and revealed multivessel disease, bifurcational high significant stenosis left anterior descending artery/first diagonal (MEDINA 1,1,1), suboclusive stenosis of strong first obtuse marginal and occlusion of right coronary artery with auto- collaterals and collaterals form left coronary arteries. The patient was referred to the heart team, and complex three vessel percutaneus coronary intervention (PCI) was indicated. Coronary intervention resulted in total coronary revascularization and optimal result. Seven days after admission the patient was discharged from our hospital. **Conclusion**: The present studies suggest that multivessel coronary intervention despite a lack of impact on mortality is associated with a lower repeat revascularization rate, compared to culprit lesion PCI. According to the guidelines decision should be made based on the patient state, lesion characteristics and degree of myocardial damage. Due the lack of studies, the choice between multivessel PCI and culprit PCI rests mostly on operator.

Tomislav Krčmar, Hrvoje Pintarić, Nikola Pavlović, Šime Manola, Krešimir Štambuk, Ivo Darko Gabrić, Mislav Vrsalović

Coronary artery stent fractures are well known and more often described complications of percutaneous revascularisation (1, 2). Coronary artery aneurysms (CAA) after coronary intervention are rare, with a reported incidence of 0.3% to 6.0%, and the most “aneurysms” are in fact pseudoaneurysms. Drug-eluting stents (DES), which locally elute antiproliferative drugs, can dramatically inhibit neointimal growth, thereby suppressing restenosis, but at the same time potentially causing coronary aneurysms. In this presentation our goal is to discuss our already published case of stent fracture and one case of CAA after implantation of DES. First case is a 62-year-old female who was admitted for cardiac catheterization due to positive stress test consistent with anteroseptal ischemia. One year earlier she had undergone percutaneous coronary intervention (PCI) with placement of two sirolimus eluting stents to left anterior descent artery. Coronary angiography showing complete stent fracture in the mid-LAD with lateral dislocation of distal fragment, significant focal in-stent restenosis and saccular coronary aneurysm below the fracture level. We decided to place graft stent covering the site of the stent fracture and in-stent restenosis. After the procedure coronary artery aneurysm was completely excluded. Second case is a 70-year-old female who had gone to PCI due to acute myocardial infarction of anterior wall. Everolimus eluting stent (EES) was implanted in LAD. Another EES was implanted in right coronary artery (RCA) due to suboclusion. Six months after patient was admitted because of reinfarction in anterior wall. Coronary angiography was performed showing two large CAA of LAD (bifurcation LAD/first diagonal) and RCA at the site of previously implanted EES and thrombotic occlusion of LAD at the distal portion of EES. Intervention was performed with implantation of bare metal stent distally to EES in LAD. Patient is scheduled for next intervention with intention to exclude aneurysm of RCA with implantation of graft stent and coil embolization to LAD. In conclusion coronary interventions are valid treatment options, but further investigation is necessary to determine natural history, and best therapies for DES-associated CAA and stent fractures.

Vjekoslav Tomulić, Sandro Brusich, Tomislav Jakljević, Koraljka Benko

Percutaneous left atrial appendage occlusion for stroke prevention in permanent atrial fibrillation is new and dynamic area in interventional cardiology. The procedure involves cardiology team consisting of interventional cardiologist or electrophysiologist and dedicated echo operator. The intervention is simple and straightforward, with low complication rate and high procedural success. (1, 2) To successfully start and maintain the volume of procedures it is necessary to build a multidisciplinary referral network (gastroenterologist, neurologist, urologist, hematologist). Educational seminars and lectures containing up to date registries and studies have to be performed in order to convince the colleagues in procedure’s safety and effectiveness. Pamphlets and simple to use checklists for patient selection have to prepared and distributed to all in referral network. Sharing Your experience on congresses (local or international) is fundamental: it is an opportunity to discuss the cases with other colleagues and reassure them in Your competence and skill. Inviting other interventionalists to see the procedure and organising hands-on courses is the last step in setting such a program. University Hospital Centre Rijeka started the preparations for the procedure in September 2015. All the necessary education of the operators and material preparation was done in a two months’ time. Patients were discussed and selected on the Cardiology Department meetings. First two proctored cases were performed in December 2015, two more in February 2016 and the next procedures are scheduled for April 2016. We had 100% periprocedural success and all four patients are without MACE in follow up period.

Ivica Benko, Šime Manola, Tomislav Krčmar, Nikola Pavlović, Ivan Zeljković, Vjekoslav Radeljić, Gordana Hursa, Sanja Keleković

Nowadays, ablation treatment of ventricular tachycardia is more and more common, whether it is on structural-diseased or normal heart. (1) We report the case of a 47-year old female patient in whom an electrophysiology study (EP) with 3D mapping system (CARTO) was performed due to paroxysmal idiopathic sustained ventricular tachycardia (VT). Anterograde as well as retrograde approach was used during the procedure and fascicular VT using left posterior fascicle was diagnosed, however it was rather non-sustained. After 90 minutes of mapping, patient complained of chest pain and sustained VT was recorded in 12-lead electrocardiogram. After short conversion to sinus rhythm an ST-segment elevation in anterior leads was noticed. The EP procedure was aborted and coronary angiography was performed. Coronary angiography showed dissection of ostial left anterior descending artery and percutaneous coronary intervention with implantation of 2 drug-eluting stents was performed. After 3 months follow up, echocardiography showed normal left ventricular systolic function (EF 60%) with mild hypokinesia of the anteroseptal region. With verapamil as antiarrhythmic therapy the patient was free of VT during 6 months and without heart failure symptoms.

Matias Trbušić, Vesna Degoricija, Krešimir Štambuk, Jelena Dumančić, Ivo Darko Gabrić, Danijel Planinc

The diagnosis of paradoxical thromboembolism (PT) is based on the triad: venous thromboembolism, systemic arterial embolism in the absence of intracardiac thrombus, and intracardiac defect, usually a patent foramen ovale (PFO). (1) We present a case of 54-year-old patient who complained of chest pain and shortness of breath. MDCT angiography showed massive pulmonary embolism (PE) and infarction of left kidney while Doppler showed deep vein thrombosis (DVT) of the right popliteal vein. Due to patients’ high weight (BMI 46.6 kg/m2), therapy with unfractionated heparin was started. Transthoracic echocardiography showed pulmonary hypertension and no intracardiac thrombus or tumors. During the next 24 hours the patient developed thromboembolic occlusion of right axillary artery and the urgent embolectomy was done. After 48 hours, the patient reported severe pain in the right lumbar region and right leg. MDCT angiography revealed right renal artery and the Doppler right femoral artery thromboembolism (second embolectomy was performed). Contrast enhanced transesophageal echocardiography (TEE) revealed tunnel-type PFO and spontaneous right to left flow. Because of repetitive PT despite optimal heparin therapy a temporary vena cava filter (VCF) was placed. The patient was further with no signs of re-embolism (discharged with warfarin). It was proven that the he has positive PAI-1 gene 4G/4G mutation. Two and a half months after the first hospitalization the temporary vena cava filter was removed. Due to the genetic thrombophilia, large PFO and spontaneous right-left flow, a decision was made to perform a percutaneous PFO closure with Amplatzer occluder device. In conclusion: if the arterial thromboembolism occurs in the settings of DVT and PE contrast enhanced TEE must be done as soon as possible owing to high sensitivity and specificity in detection of PFO and other intracardial shunts and masses. (2) This seems to be especially important if the patient has proven thrombophilia. Temporary VCF is an unavoidable option if the patient has repetitive PE or arterial thromboembolism. Percutaneous closure of PFO (together with lifelong anticoagulation therapy) was the definite treatment in our patient despite the unfavorable results in studies for secondary prevention of cryptogenic embolism. (3)

Tomislav Krčmar, Ivica Benko, Jadranka Daskijević

Transradial approach became frequent procedure in treatment of percutaneous coronary interventions while the same approach is still used rarely with the patients who need invasive angiology diagnostics. The main advantages of the transradial approach concerning the potential complications are generally very well known as well as the advantages in the means of comfort for the patient. (1-3) In University Clinical Centre “Sestre milosrdnice” from 2011 transradial approach was used in total of 101 cases of invasive diagnostics or interventional treatment. In 32 situations it was used as one of the additional approaches within the main intervention on iliac arteries, whilst in 11 cases the transradial approach was the main the intervention on iliac arteries. For now, the transradial approach is mainly reserved for the interventions on renal and iliac arteries. Transradial approach is safe and reliable method for invasive diagnostics of peripheral arteries whilst the application of the interventions on arteries of the lower limb just recently started to be applied more often.

Božo Vujeva, Đeiti Prvulović, Krešimir Gabaldo, Ognjen Čančarević, Irzal Hadžibegović

**Background**: Optimal results of primary percutaneous coronary intervention (PCI) in acute ST-segment elevation myocardial infarction (STEMI) are sometimes challenged by large thrombotic burden. TAPAS (Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial Infarction Study) trial in 2008 first showed that thrombus aspiration in STEMI patients with large thrombotic burden improved overall survival after 1 year. (1) Later on in 2013, Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia (TASTE) trial, a prospective national registry showed no benefit of routine thrombectomy in STEMI. (2) 2012 European Society of Cardiology (ESC) Guidelines for the management of STEMI, that are currently available, gave a strong recommendation (IIaB) for manual thrombectomy in STEMI. (3) However, that recommendation was downgraded to IIbA after TASTE trial in 2014 ESC Guidelines on myocardial revascularization. (4) Here, we present the data on thrombus aspiration utilization within the Western Slavonia Primary PCI network, and compare the results between pre-TASTE and post-TASTE era. **Patients and Methods**: Data on primary PCI techniques to achieve Thrombolysis in Myocardial Infarction (TIMI) 3 flow, on utilization of the glycoprotein IIb/IIIa inhibitors, and on clinical outcomes in STEMI were collected in 2012 and 2013, and compared to data from 2014 and 2015. **Results**: In 2012 and 2013, out of 114 patients that underwent primary PCI in STEMI 32% received thrombus aspiration, out of whom 61% had thrombus aspiration in the right coronary artery. Overall TIMI 3 rate was 88%, and overall in-hospital mortality was 6.1%. In 2014 and 2015 there were 253 patients with primary PCI in STEMI, with only 17% of thrombectomy cases (68% of cases were done in the right coronary artery). Overall TIMI 3 rate was 91%, and in-hospital mortality 5.9%. **Conclusion**: Thrombectomy penetration dropped significantly, together with the glycoprotein IIb/IIIa inhibitors use after publication of TASTE trial. Patients that received thrombectomy in 2014 and 2015 had mainly high thrombotic burden in the right coronary artery, or had embolic myocardial infarction. There were no changes in TIMI 3 achievement and in-hospital mortality. Manual thromboaspiration remains a useful tool only in selected population of patients with highly thrombotic lesions, aneurysmal coronary artery disease or embolic myocardial infarction.

Tomislav Letilović, Damir Kozmar

**Background**: In complex coronary interventions stent delivery can be extremely challenging. Stent delivery failure is not only surrogate of procedure failure but it can also result in serious complications. Guide extension devices (Guideliner© and Guidezilla©) are specifically designed to enable stent delivery. (1) The purpose of this report is to present our initial experiences with those devices. **Methods and Results**: Guide extension devices are available in our catheterization laboratory since June 2015. Until January 2016 we used them in 7 percutaneous coronary interventions (2 left anterior descending, 4 right coronary artery and 1 circumflex artery intervention). According to the ACC/AHA classification 5 (71%) of lesions were designated as type C lesion by the operator. In total 6 (85%) interventions resulted in procedural success. Guide extension related interventions were done with 1.50±1.74 balloons and 1.8±1.09 stents on average. Mean fluoroscopy time was 23.90±5.82 minutes and average mean contrast use was 231.40±57.67 milliliters. No device related complications were noted. Interestingly we also used, as a support device, Guideliner© during one CRT implantation. **Conclusion**: Our initial experiences with guide extension devices show that they can enhance procedural success rate in complex coronary interventions. We observed no device related complications in our small group of patients. Those devices could also have a certain role in non-coronary interventions as well.

Jure Samardžić

Despite the presence of novel and more potent P2Y12 receptor blockers on the market for more than five years, clopidogrel is still often used in patients with acute coronary syndrome undergoing percutaneous coronary intervention. (1) It is known that clopidogrel exhibits variable platelet inhibition which affects patient outcome. So called clopidogrel resistance or high on-treatment platelet reactivity on clopidogrel has interested many since it was first described more than ten years ago. How relevant is it today? What do we really need to know about clopidogrel resistance? In this presentation, an overview of relevant studies will be highlighted as well as experts’ position on this phenomenon and future perspectives in antiplatelet management.

Luka Bastiančić, Gordana Bačić, David Gobić, Tomislav Jakljević

**Introduction:** Occlusive thrombus due to ruptured or eroded atherosclerotic plaque is the most frequent substrate for ST-segment elevation myocardial infarction (STEMI). Distal embolization of intracoronary thrombus results in microvascular obstruction and compromised TIMI (Thrombolysis In Myocardial Infarction) flow. Forceful coronary injections, passage of intracoronary devices, initial balloon angioplasty and/or stenting induce distal embolization. Intracoronary thrombus additionally may contribute to vessel and stent undersizing increasing the risk of stent malapposition, in-stent restenosis or stent thrombosis. (1-3) **Case presentation:** We present an 81-year-old Caucasian male with STEMI with rapid progression to cardiogenic shock and cardiorespiratory arrest during diagnostic coronary angiography. Severe stenosis of right coronary artery (RCA) with occlusive thrombus of the left main (LM) was found. The patient received a veno-arterial extracorporeal membrane oxygenation (ECMO) device. We performed a standard percutaneous coronary intervention (PCI) of RCA and rheolytic thrombectomy (AngioJet™) of the LM. The patient was successfully weaned from ECMO 29 hours after the procedure, with no inoconstrictor support. After nine days he was fully mobilized with no neurological deficit and a 40% left ventricular ejection fraction on echocardiography. **Conclusion:** Current evidence does not support the routine use of rheolytic thrombectomy in primary PCI. In specific cases that are involving large occlusive thrombus it may be a therapy of choice.

Irzal Hadžibegović, Đeiti Prvulović, Krešimir Gabaldo, Ognjen Čančarević, Božo Vujeva

**Background**: Current evidence clearly show that patients with ST-segment elevation myocardial infarction (STEMI) should be pretreated with dual antiplatelet therapy (DAPT) and anticoagulation therapy immediately after confirmed diagnosis, and that pretreatment can be even performed safely prehospitally. (1) In non ST-segment elevation myocardial infarction (NSTEMI), recommendations are not so clear, with data showing that pretreatment depends on what combination of DAPT is used and what is the risk profile of the patient. Also, less than 70% of all patients with NSTEMI undergo stenting after coronary angiography whereas the rest continue medical treatment or are scheduled for coronary artery bypass graft surgery. We present our data on anticoagulation and platelet antiaggregation therapy selection and timing in patients with STEMI and NSTEMI scheduled for early invasive approach, that were collected using our acute coronary syndrome flow chart, and compare them to current guidelines. **Patients and Methods**: Standardized prospective flow chart was utilized to collect data on medical and interventional treatment of patients with STEMI and NSTEMI scheduled for early coronary angiography in 2016. Registry data from 2014 and 2015 were used as comparison. **Results**: Data showed that all patients with STEMI received pretreatment with either clopidogrel (in 2014) or ticagrelor (in 2015 and 2016) and unfractionated heparin, but only in-hospital. Only aspirin was administered prehospitally. Patients with NSTEMI received enoxaparine, fondaparinux or unfractionated heparin, mostly before coronary angiography. Clopidogrel was administered before coronary angiography in all patients with NSTEMI in 2014 and 2015, whereas patients with NSTEMI in 2016 received ticagrelor, mostly before angiography. In 2016 there were nearly 10% of patients that were treated with ticagrelor after early coronary angiography, with no thrombotic complications. **Conclusions**: STEMI pretreatment should be done as early as possible, and standardized protocols should encourage early detection and prehospital administration. NSTEMI protocols are however unclear, there are cases with unsupported mixing of anticoagulants before and during invasive treatment. Choice of antiplatelets and their timing of administration is still unclear in NSTEMI and requires further investigation.

Tomislav Krčmar, Ozren Vinter, Nikola Kos, Hrvoje Pintarić

Transradial approach is well established and often used for percutaneous coronary intervention (PCI). The usual opinion is that transfemoral approach is preferable to transradial for complex PCI using a 7 French guiding catheter. (1-3) We report a case of a 60-year-old male with a medical history of peripheral artery disease and stable angina who presented to the Emergency Department with phlegmon of the fourth digit on the left foot. The patient had significant cardiovascular risk factors including insulin-dependent type II diabetes mellitus, arterial hypertension and hyperlipidemia. Due to stable angina and presence of risk factors, coronary angiography was recommended. Coronary angiography revealed 70% stenosis of the distal left main artery that extended to the proximal circumflex and left anterior descending artery with first obtuse marginal artery also significantly narrowed. Coronary intervention was delayed because of the coexisting active phlegmon. Surgical revascularization was recommended but the patient refused surgical intervention (SYNTAX score 23). The patient was scheduled for an elective PCI the following month. The transradial PCI controlled by intravascular ultrasound (IVUS) was performed using a 7 French guiding catheter. Using the “culotte” technique, 2 drug-eluting stents were implanted in the left main coronary artery while additional stenting of the left anterior descending artery and the first obtuse marginal branch was performed with another two drug eluting stents. The total procedural radiation time was 25 minutes and 220 ml of iodine contrast was used. A complex PCI using a 7 French guiding catheter via transradial approach can be performed successfully and safely and it represents a good alternative to transfemoral approach in suitable patients.