Cardiologia Croatica. 2022;17(9-10)

Nikolina Matić, Alma Matić, Branka Lujić

Mentoring and different mentoring approaches in nursing teaching is a current topic of discussion in nursing pedagogy. Nurse as a clinical mentor/educator is a special field in nursing that is talked about in a context of improving the teaching system. The roles of mentoring the nurses are different, however it often refers to mentoring during the clinical practice as well as mentoring in the process of introducing a new employee to the system of work. Mentoring is a complex process that significantly depends on the mentor’s characteristics. It is recommended that mentors develop skills of active listening, showing enthusiasm, include reflexion towards the mentored topics, as well as personal professional growth. A high level of professional competences along with developed methodical and pedagogical and psychological skills. There is frequently a gap between these requirements in the nursing practice in Croatia. Individuals who work at highly sophisticated positions and carry out a progressive nursing care, do not have competencies of pedagogical methodology acquired. At the same time, the number of vocational teachers without professional competences acquired through long-term clinical work is increasing. Therefore, the aim of this paper is to emphasize the importance of the role that is demanded by mentoring in a clinical environment with the constant need to expand professional and pedagogical competencies, as well as different mentoring approaches in a clinical nursing teaching. Some of these approaches could be eased style, counselor style or prescriptive style while simultaneously describing different mentor’s characteristics, such as researcher, visionary, investor, career advisor etc (1).

Ivica Matić

Knowledge of scientific methodology and professional competences are basic prerequisites of successful writing and publishing of a scientific paper. Since the unbiased research of the experiential phenomena is more frequently used in nursing, it is important for the researchers to continuously adopt new and renew the existing knowledge of scientific methodology that includes a system of rules based on which research procedures are conducted, theories are proposed and tested. Every paper in science, as well as in nursing, is as valuable as the methodologically determined and scientifically accepted procedures included in it. Therefore, the aim of this workshop is to empower the participants in the competences of basic scientific methodology of planning the research and creating the manuscript that usually follows the determined way and generally accepted structure. The intention of every researcher is the publication of the scientific paper. The most common way of presenting the results is in the form of a scientific article in any of the scientific journals (1). In the workshop part all the article parts will be analyzed: summary, introduction, methods, results, discussion, and conclusion. The participants will be given theoretical and practical guidelines in successful forming of these parts. Since the goal of the researcher is to publish the paper in scientific journals, which are numerous in the field of biomedicine, the workshop will help the participants to acknowledge the skill of researching the journals and finding the best choice for their paper using information and communication technology (2).

Ivica Matić

Creating the research question is an important part of every research and represents a key step for its successful implementation. Generally, the research should give us an answer to the asked research question, and therefore the skill of its’ good wording is of great importance not only in the planning of the scientific research (1, 2), but also in the brief review of the available information in the bibliographic database. Good research question contributes to narrowing down the topic to fields. It also explains the research variables more clearly and has an impact on other research elements. With analyzing fields of the research question, keywords that are inevitable for a good literature search are found. This is crucial to determine the knowledge gap in a particular field. There are numerous criteria which determine a well thought out research question. These criteria demand the question to be feasible, interesting, novel, ethical and relevant. Also, to design research question, it is advised to use the PICO framework that includes some important elements, such as population or problem, intervention, comparison group or treatment and outcome of interest. Therefore, the aim of this workshop is for the participants to develop fundamental competences of creating the research question, whereby in the work part they will be working experientially on creating their own examples. After successfully designing research questions, they will be able to search the most used bibliographic databases in search of published scientific articles and answers to asked questions.

Renata Habeković

Most literature does not deal with behaviors and communication skills in the nurse/technician-patient relationship or the role of both. There is a large amount of documentation on self-care strategies, adherence to prescribed therapy, psychological interventions, and patient and nurse/technician satisfaction (1). Studies on the implications of this relationship in the perceived improvement of patient care are also common. Many studies have focused on researching the nurse/technician-patient relationship based on empirical studies, and most of the literature refers to the experiences of nurses/technicians that are told based on personal experiences. The most common topics in the reviewed literature on the nurse/technician-patient relationship are: a) the role of the patient; b) the role of the nurse/technician; c) type of nurse/technician-patient relationship. A good nurse/technician-patient relationship shortens hospital stays and improves quality and satisfaction. But, in contrast, a good relationship is conditioned by the submissive role of the patient. The equal distribution of “power” enables patients to make decisions about procedures related to their own health and/or illness independently, with the advice of doctors and nurses/technicians.

Iva Starešinić

In developed countries, one of the most common causes of death is sudden cardiac arrest. After an out-of-hospital cardiac arrest, the survival rate is very low, and the biggest problem is the time that passes from the arrest to the start of resuscitation (1). In most European countries, the time it takes the emergency services to reach the scene of the accident is more than 10 minutes. In a most cases, the cause of the arrest is ventricular fibrillation or ventricular tachycardia. The chances of patients’ survival increase with timely recognition and the treatment of rhythms with defibrillation. Projects that have been started in Denmark and Sweden introduce a mobile application trough which volunteers who are near a person who has experienced an arrest are called to help. Volunteers are people who have completed a resuscitation course and are called by the dispatcher if they are 500 meters from a patient who has experienced an arrest. Several volunteers are called, one of whom immediately runs to the scene, and the other volunteers run to get the AED. Research conducted in these countries shows that the survival rate has tripled. Through this project, citizens were encouraged to complete a cardiopulmonary resuscitation course and learn how to use an automatic external defibrillator. The goal of this research is not only to increase survival in Denmark and Sweden, but also to encourage other countries in the development of new techniques. By training and developing such techniques, we can greatly help save human lives.

Nikolina Slamek, Biljana Hržić, Dijana Tutić, Katarina Grandavec

**Introduction**: Kounis syndrome is described as an acute coronary syndrome related to allergic reaction (1, 2). The syndrome is caused by inflammatory mediators released in the event of hypersensitivity and allergic reaction to food, drugs, or insect sting. The syndrome is poorly described and often underdiagnosed, while its etiology is hard to determine due to numerous possible causes. **Case report**: We describe 51-year-old male patient with arterial hypertension and diabetes, who reported flushing, malaise, and lightheadedness immediately after hornet sting. Upon Emergency Ambulance arrival, the patient was pale, diaphoretic, and hypotensive. Treatment for severe anaphylactic reaction was initiated. However, during the Emergency Department workup, patients reported anginal chest pain and sinus tachycardia was recorded. A 12-lead electrocardiogram showed ST segment elevation. The diagnosis of acute coronary syndrome was established and admission to the Cardiac Intensive Care unit was arranged. Urgent coronary angiography and successful percutaneous coronary intervention LAD using right trans radial approach was performed with one stent implantation in the responsible thrombotic occlusion of the proximal segment. After 6 days the patient was discharged. Moderate physical activity and a 12-month course of dual antiplatelet therapy were recommended. **Conclusion**: Beside the case report, we here emphasize the importance of nurse practitioner care, as well as the importance of early recognition of acute coronary syndrome. One of the most important tasks of a nurse is observing the general condition of the patient and identifying pathological changes. Providing a high level of health care requires continuous education on new knowledge and skills.

Patricija Sigal, Biljana Hržić, Andreja Virt, Ankica Josipović

**Introduction**: Pulmonary embolism (PE) is a life-threatening condition caused by the occlusion of a pulmonary artery by a blood clot. Reduced blood flow through lungs, lowers oxygenation and increases pulmonary blood pressure. Pulmonary embolism is one of the leading causes of hospital mortality. Symptoms of pulmonary embolism can vary, depending on the severity and degree of the obstruction of pulmonary arteries (1, 2). Percutaneous aspiration thrombectomy is a treatment option for patients with high-risk PE with contraindications for fibrinolytic therapy and for patients with intermediate risk PE with severe tachycardia, hypoxia, and dyspnea at rest. **Case report**: We present a 71-year-old female who was diagnosed with deep vein thrombosis and intermediate-high risk PE. Patient presented to the Emergency Department with shortness of breath, cough, and pale skin; she recently recovered from COVID-19 infection that puts her at high risk for PE. Multi-slice CT pulmonary angiography and arterial and venous Doppler examination was performed which revealed thrombotic masses in pulmonary arteries. The patient was admitted to the Cardiac Intensive Unit for monitoring and treatment, oxygen supplementation was administered while she was prepared for percutaneous thrombus aspiration. The procedure was performed via the right femoral vein using an aspiration catheter. The catheter was placed near affected pulmonary arteries and thrombi were removed with negative pressure aspiration. The procedure was successfully performed, and the patient was no longer hypoxic. After three days of monitoring, she was discharged from the hospital with oral anticoagulant therapy (rivaroxaban). **Conclusion**: Percutaneous aspiration thrombectomy is high risk intervention that is being used in an increasing number of patients. Studies show better mortality and morbidity outcomes in patients treated with percutaneous aspiration thrombectomy. We emphasize the importance of continuous professional importance and the determination to apply new and modern techniques to ensure the highest level of healthcare.

Nina Krpan, Nikolina Šoštarić, Katarina Vađić, Renata Čosić, Mihaela Ipša, Marija Kesedžić

Since the early 1960s of the last century, dynamic challenges and changes have accompanied modern nursing in cardiology with the opening of independent units for the intensive treatment of cardiac patients. Department of Intensive Cardiac Care Unit at Sestre Milosrdnice University Hospital Centre was founded in September 1971, as the oldest intensive care unit for cardiology patients in Southeast Europe. In 2016, it grew into an Institute for Intensive Cardiac Care with ten intensive care beds and associated monitoring. A team of nurses and doctors annually cares for around 1,600 hemodynamically unstable and vitally endangered patients with an average of 2.2 days in bed, putting us next to the European average. The introduction of new technologies and sophisticated equipment challenges nurses to master the skills needed to participate in complex procedures. Medical care for cardiovascular patients is highly specialized and specific, and as such, it requires lifelong learning, flexibility, and critical thinking from nurses to acquire a higher level of professional knowledge and skills (1). With a holistic approach and 24-hour presence at the patient’s bedside, nurses give patients security, removing the fear and uncertainty that occurs during hospitalization. All the patient’s observations about his condition and procedures have always been recorded in writing on the patient’s daily sheet, and today we use the hospital’s information system. Continuous training of nurses is carried out through various courses, symposia, and congresses. Well-educated nurses base their work on evidence-based knowledge with the goal of improving the quality of health care outcomes for this specific group of patients.

Romana Ivelić, Ana Radan

Intensive care represents the highest level of health care and is a multi-professional and multidisciplinary field of medicine. Aggressive treatment in intensive care units with an emphasis on sedation and mechanical ventilation of the patient is a predisposing factor for the occurrence of delirium. In clinical settings, delirium is used to describe a patient with altered mental status as a reduced ability to focus, direct, maintain, and redirect attention (1). Delirium is a sign of a poor outcome of the patient’s treatment, and its frequency is estimated at 80% of patients on a respirator. An increased level of pain, most often in the postoperative period as a response to stress, leads to an increased risk. Prolonged duration and accumulation of drugs such as sedatives and analgesics lead to delirium (2). The interventions of the nurse are aimed at spotting the first symptoms, adequate reaction, and assistance in the occurrence of first problems. Emphasis is placed on the use of scoring scales, of which the most used is the CAM-ICU scale, which is standardized, but from a nursing perspective, the Nu-DESC scale is adapted to assess the occurrence of delirium by nurses in the ICU. Early recognition of this condition is associated with the prevention of bad outcomes and allows the provision of non-pharmacological measures that reduce the suffering of the patient. The strategies for preventing delirium are evaluating, preventing, and managing pain, choosing analgesia and sedation, spontaneous waking and breathing, early mobilization and exercises, and the involvement of the family in the process (3). Nurses play a significant role in working with patients, given that they are most in contact with the patient, provide support, inform, and educate the patient and his family, and allow a visit during the hospitalization. In their work, the nurse should provide a holistic and individual approach and adapt to the patient’s difficulties and needs.

Valentina Gal, Tomislav Kučina, Ivana Pecak, Ana Vlašiček, Josipa Faletar, Valentina Pandža

Therapeutic hypothermia is a method of treating patients with post-resuscitation syndrome (1). Invasive and non-invasive methods are used to lower the central temperature and reduce destructive processes in the central nervous system caused by circulatory arrest. Our Intensive Cardiac Care Unit routinely implements therapeutic hypothermia as a treatment method for post-resuscitation syndrome. The three most important elements for carrying out therapeutic hypothermia are: preparation of the patient, induction and maintenance of hypothermia, and rewarming. The active participation of the nurse in the implementation of the procedure requires continuous education on specific knowledge and skills. In the process of therapeutic hypothermia, the nurse participates equally in diagnostic and therapeutic procedures, and as such, acts as an important member of the medical team that continuously cares for patients during the process. The specific interventions of the nurse refer to the preparation of the equipment, the space where the procedure will take place, taking care of vital functions with an emphasis on temperature, the patient’s state of consciousness, laboratory findings, and pathological signs that may occur during hypothermia. Successful implementation of therapeutic hypothermia requires high-quality communication between nurses and doctors. Care for a patient during therapeutic hypothermia is complex and requires specific knowledge, skills, good organization, and proper recognition of the patient’s needs to be able to make appropriate nursing diagnoses, carry out interventions accordingly and fulfill the set goals. An individual and holistic approach as well as teamwork are the keys to the successful therapeutic hypothermia.

Damir Strapajević, Katarina Smoljo, Kata Butković

Atherosclerosis is the most common cause leading to the development of a blood theft syndrome of the subkey artery in which the stenosis or occlusion of the subkey artery occurs (1). A special form of subclavian artery blood theft syndrome coronary blood theft syndrome of the subclavian steal syndrome. The syndrome is characterized by “theft” of the coronary circulation, which bypass a part of the myocardium and affects the upper part of the circulation of the ipsilateral limb, and most often occurs with severe stenosis (≥75%) or left subroutine occlusion, and the use of the left adrenal mammary artery for the heart bypass. The aim of this study is to provide data on coronary blood theft syndrome of the subkey artery and to link some of the characteristic symptoms with the confirmation of the disease as well as the treatment. By physical examination we found differences in brachial systolic pressures of both arms (> 15 mmHg), chest pain, decrease in pulse amplitude, vertebral and subkey artery forests, change in skin of arms and nails in the form of discoloration. Noninvasive methods were used for the final confirmation of the diagnosis: Doppler, duplex ultrasonography, CT angiography. In patients we have chosen endovascular treatment with stent setting. Selection of endovascular treatment with stent setting resulted in lower hospitalization and faster recovery of patients. Since I have not found standardized guidelines for post treatment monitoring, we use once agreed guidelines in which we control the patient for 3 to 6 months in the first year, and then year thereafter. At each angiological control visit, blood pressure should be checked in both arms and hand plethysmography should be performed. The drop in pressure on the operated side as well as the reduction of the results of the tiltismmographic curves on the hands may be a sign that recurring stenosis is starting to develop. Annual neurological controls are recommended. The patient with an endovascular approach should be treated with aspirin for life and clopidogrel for 6-12 months.

Ana Novak, Ana-Marija Brekalo

Kawasaki is a relatively rare mucocutaneous acute childhood lymph node infection of unknown cause (1). Immunological disorders can occur, which create antibodies that attack endothelial cells and smooth muscle cells of blood vessels. Due to inflammatory changes, the wall of blood vessels is damaged, and there is a risk of a blood vessel aneurysm or thrombosis. It starts with febrility, conjunctivitis, skin rash, enlarged lymph nodes on the neck, and less frequently described complications on the heart in the sense of coronary artery aneurysms. Peripheral arterial and aortic aneurysms occur rarely but can lead to severe complications such as aneurysm rupture or acute ischemia (1). Although most aneurysms due to Kawasaki disease are diagnosed within a few weeks of diagnosis, it can develop later in life. In this case, the first symptoms appear in a 10-year-old boy who is hospitalized due to a high temperature that only decreases with the use of antipyretics, despite the use of antibiotics. Other symptoms include conjunctivitis and pleural effusion. Ten years after the diagnosis, the patient was hospitalized due to a thoracoabdominal aneurysm. The operation was successfully performed in Budapest, and the resection of the thoracoabdominal aneurysm was performed with reimplantation of the intercostal visceral and renal arteries along with a left nephrectomy and reconstruction up to the bifurcation. Seventeen years later, he was hospitalized in the vascular cardiology department due to ischemia of the left hand due to thrombosis from a previously known aneurysm of the subclavian and axillary artery, manifested as pain and tingling in the fingers of the left hand. ABI plethysmography, MSCT coronary angiography, ergometry and scintigraphy were performed, according to which it was decided to discharge the patient with regular controls and rivoxaban. Two weeks later, he was re-hospitalized due to progressive pain and tingling in his arm, and it was decided to perform an emergency subclavian bypass with a VSM graft. After the operation, the patient was discharged in good general condition. The aim of the paper is to describe the case of a 38-year-old patient with the development of multiple coronary artery aneurysms and limb artery aneurysms, as well as a thoracoabdominal aneurysm because of Kawasaki disease.

Tanja Mikulandra, Nevenka Vila

**Introduction**: Deep vein thrombosis (DVT) is a medical condition that occurs when a blood clot forms in a deep vein and obstructs the normal blood flow. (1, 2) These clots usually develop in the lower leg, thigh, or pelvis, but they can also occur in the arm. It is important to know about DVT because it can happen to anybody and can cause serious illnesses, disability, and in some cases, death. Assessment of the venous thrombosis in the Republic of Croatia is about 160/100,000, which assumes about 6,500 new cases per year in the total population. The incidence grows exponentially with age and at the age of 80 it occurs in 5/1000 people. According to guidelines, warfarin and new oral anticoagulants (NOAC) are used to treat DVT. This paper will present the course of DVT treatment with alteplase, which is not the standard procedure in DVT treatment, and the importance and role of a nurse in the care of the patient. **Case report**: 48-year-old person was hospitalized at the Department of Cardiovascular Diseases with a case of iliofemoral DVT. The patient checked in the emergency ward due to swelling, pain, and paresthesia in her left leg. At the time of arrival, the patient was contactable, oriented, eupneic, afebrile, normotensive and normohydrated. Despite administered therapy, leg pain was getting stronger, the leg was extremely swollen, and pulsation was getting weaker. The patient was visibly upset and thought she would lose her leg. A nurse talked with the patient and managed to get her to relax. The patient was transferred to the Coronary Care Unit so she can be administered with Alteplase. After the therapy administration the patient stopped feeling strong pain and started to feel better. Two days after therapy the redness and swelling of the leg disappeared. The patient was verticalized with an elastic bandage and was able to walk with the help of a nurse. **Conclusion**: Treating DVT with alteplase is a much quicker and more efficient way to treat this disease and the adequate patient preparation significantly lowers the fear of the outcome of the disease. No matter how well-acquainted the patients are with their disease and its possible outcomes, they always look for support and understanding. Nursing care and education of the patient with DVT is of key importance in understanding their condition and accepting treatment and possible outcomes.

Mirela Šarić, Martina Kralj

Cardiovascular diseases are one of the leading causes of morbidity and mortality in modern society. Thrombotic and thromboembolic diseases are common and may have serious consequences, such as myocardial infarction, cerebrovascular insult, deep vein thrombosis, and pulmonary embolism. For the treatment and prevention of thrombosis and thromboembolic events, we use antithrombotic drugs (1). The most common thrombotic event in the venous system is venous thrombosis, which most commonly occurs in the deep veins of the legs. If not recognized and treated on time, deep vein thrombosis may have serious consequences and, in some cases, even lead to death. The most important and life-threatening complication of deep vein thrombosis is pulmonary embolism. Namely, when a blood clot develops in a deep vein, a part of the thrombus can break off, which then travels through the circulatory system through the heart to the lungs. If this “traveling” thrombus, which we call an embolus, is large enough, it can block one of the large blood vessels in the lungs and thus cut off the blood supply to the lungs, which can end fatally. A thromboembolic event can also occur in the arterial system. The most common cardiac arrhythmia, atrial fibrillation, increases the risk of a blood clot that can then travel to the blood vessels of the brain and cause a stroke. Stroke is the most frequent and dramatic consequence of atrial fibrillation, and the risk of its occurrence in these patients is increased fivefold. Antithrombotic therapy includes anticoagulant and antiplatelet therapy with drugs used in the prophylaxis and treatment of various clinical conditions. The main role of an antithrombotic is to prevent the formation of a clot and the expansion of an already existing thrombus. Antithrombotic drugs are among the most used drugs in medical practice, with the highest frequency of prescription for cardiac and neurological patients. The side effects caused by antithrombotic drugs are more serious compared to the side effects of other drugs and often require hospitalization. Therefore, increased caution is needed when using them, and education of health workers and patients is important (2).

Monika Tuzla

**Introduction**: Telemedicine represents the use of information and communication technology to exchange medical information from one place to another in order to improve the clinical health of patients (1). Since the prevalence and mortality of cardiovascular disease is high worldwide, the use of telemedicine in cardiology helps in the early diagnosis and treatment of cardiovascular diseases. It also has great potential in reducing health care costs and increasing quality of life and patients’ satisfaction (2, 3). The aim of this paper is to show the importance of remote Holter electrocardiogram analysis with regard to the frequency of patients for whom the need for further cardiac monitoring is indicated. **Patients and Methods**: A retrospective study was conducted at the Institute for Cardiovascular Prevention and Rehabilitation, Zagreb from 1 March until 26 May 2022. Patients from rural areas of Croatia from 9 telemedicine centers (Petrinja, Topusko, Glina, Slatina, Orahovica, Voćin, Novalja, Korenica, Otočac, Senj, Pitomača) participated in the research by using Holter electrocardiogram in the local health center, while the remote analysis was carried in Zagreb. Demographic data and the proportion of patients who need further treatment based on the classification burden of ventricular premature contractions (VES) were analyzed according to gender and age. **Results**: 130 patients participated in the study, 72 of which were women (55%) and 58 men. (45%) between the ages of 21 and 89. The largest group were patients between 50-70 years of age (51%). Analysis of the VES classification revealed that 77% of patients belong to the group of low VES load, while 23% of them belong to the medium VES load group, 53% of which are men and 47% women older than 70 (40%). **Conclusion**: The use of remote Holter electrocardiogram analysis in rural areas allows patients prompt provision of medical care and financial savings. Since more than half of the patients belong to elderly population, the use of such diagnostics contributes to more accessible and faster medical care, but also facilitates a multidisciplinary approach among healthcare professionals, as well as more efficient and faster treatment.

Hrvoje Topalović, Ana Marinić

Heart transplantation is the choice of treatment for patients with chronic heart failure who, with the use of maximum medical and mechanical therapy, do not show improvement in the function of heart according to the 3rd and 4th degree by the NYHA (New York Heart Association) qualification (1). The patient is surgically transplanted with a healthy heart from a suitable donor. Patient mortality after heart transplantation has been greatly reduced by improving postoperative care which consists of the use of immunosuppressive therapy. The main goal of immunosuppressive therapy is to prevent rejection of the donor organ with minimal toxicity of the organism by monitoring the concentration of the drug in the blood and setting the dose appropriately, especially in the early postoperative period. In addition to immunosuppressive therapy, it is also important to prevent infections as a side effect of the body’s immunosuppression by introducing antibacterial and antiviral medications (2). An important role in maintaining the favorable health status of the organism is also played by regular pathohistological findings obtained by regular heart biopsy in order to detect acute rejection as soon as possible, which is most common in the first year after surgery. In addition to post-operative patient care, nutritional adaptation to metabolic disorders caused by medicinal post-operative therapy and physical activity are required to maintain optimal body weight, which should not deviate significantly from pre-operative. The education of the patient about the way of life after transplantation is carried out by a multidisciplinary team (nurses, physicians, physiotherapists…) that plays an important role in achieving, monitoring and maintaining a favorable health condition in order to extend life expectancy and improve the quality of life.

Jadranka Paun Judaš

**Introduction**: In heart surgery patients, the rehabilitation serves to improve their psychophysical status and successful return to daily activities (1). Respiratory training is important already during the first phase of rehabilitation (in the intensive care unit, to prevent complications) and it continues in the second phase (physiotherapy facility), when patient condition is sufficiently improved. During the respiratory training, patient learns specific breathing techniques (diaphragmatic breathing, Three-ball respiratory training). The goal of this study was to assess effects of respiratory training in heart surgery patients during the rehabilitation process. **Patients and Methods**: To assess the effects of respiratory training, we analyzed two groups of patients: 1) The experimental group patients (N = 100) combined cardiac training (physical exercises + bicycle ergometry) with respiratory training (Three-ball device); 2) The control group patients (N = 100) performed cardiac training only. The following variables were statistically analyzed in both groups at the beginning and at the end of rehabilitation: respiratory index, spirometry results (forced vital capacity - FVC, forced expiratory volume during the 1 second - FEV 1, forced inspiratory vital capacity - FVC IN), six-minute walking test (6MWT), and Borg scale (subjective assessment of fatigue). **Results**: Spirometry testing show that both physiotherapeutically interventions (cardiac training, respiratory training) improved pulmonary function in both groups of patients. However, experimental group patients achieved significantly better results (p <0.001) in all measures of pulmonary function (FVC, FEV 1, FEV IN). **Conclusion**: Our results show that respiratory training (Three-ball device) has an additional beneficial effect on the improvement of pulmonary function in heart surgery patients. These respiratory exercises improve the strength of inspiratory muscles, increase pulmonary capacity, increase the mobility of thorax, and decrease the consumption of energy. Therefore, we propose that this type of respiratory training should become an integral part of cardiac rehabilitation, especially in heart surgery patients.

Žaklina Muminović, Mario Ivanuša

**Introduction:** The cardiovascular rehabilitation (CVR) is one of the measures of secondary preventions that is proven to have a positive effect on survival and life quality of cardiovascular patients (1, 2). The goal of this research was to determine whether there are differences in recovery of patients after their first acute myocardial infarction (AIM) depending on their demographic variables as well as engagement of cardiovascular rehabilitation. **Patients and Methods:** The data of consecutive patients, who were included in CVR programme at the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb after their first AIM during the period between September 10, 2015 and September 10, 2019 were analyzed. The analysis included demographic data, onset of programme considering the time of AIM, exercise stress test (EST) results, and dose of medical gymnastics. **Results:** 474 AIM patients, 356 being male (75.1%) and 118 being female (24.9%) were included in the programme. The average age of men was lower than that of women (62 ± 9.8 vs 65 ± 8.6 years). The patients in age group 30 to 50 started their CVR programme sooner than the patients older than 70 years (69.5 ± 41.9 vs 106.7 ± 75.4 days). Significantly better recovery and EST results, measured with ≥2 MET change at discharge, were shown by 59.3% of patients, mostly men (66.0 vs 38.3%). The average engagement of medical gymnastics was 24.3 ± 8.3 hours, and patients in the age group 30 to 50 years old, as well as those at the age of 51 to 60 were more regular at their medical gymnastics than 61 to 70 or older patients (26.3 vs 25.9 vs 23.6 vs 21.9 attendances). The regression analysis stated that the male gender and medical gymnastics dose were closely tied, while the age stays negatively to the possibility of EST results improvement during discharge. **Conclusion:** The prompt inclusion in CVR programme and regular participation in its components, especially medical gymnastics (3), leads to better EST results during patient discharge.

Irena Kužet Mioković, Marica Komosar-Cvetković, Ivona Brajković, Romina Mrakovčić, Anamarija Velčić Tasić, Kristina Skroče

**Introduction**: Acute myocardial infarctions (AMI) are one of the leading causes of death in the developed world and patients experience numerous physical symptoms including fatigue, dyspnea, or chest pain which affect their physical, emotional, and social well-being with significant impairment in Quality of Life (QoL). The aim was to access the improvement of QoL, if any, throughout the 12 weeks of individually-prescribed high intensity interval training (HIIT) training. **Patients and Methods**:16 ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) patients (age 58 ± 10 years; height 177 ± 9 cm; weight 86.8 ± 15.4 kg; VO2max 19 ± 5.3 ml min-1kg-1) underwent 12 weeks of supervised cycling HIIT (4x4 min at 85-95% of HRmax) 3 times per week. A questionnaire including Short Form-36 Health Survey (SF-36) was assessed prior to, at 4th, 8th and post 12 weeks of HIIT training. The Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) Scale was used prior to the training intervention to assess patient’s knowledge on CVD. **Results**: Patients demonstrated statistically significant improvements (P2 increased significantly by 8% (19.2 ± 5.1 vs 20.8 ± 5.0 mil min-1 kg-1,P=.002) across the group already after 4 weeks of training. The absolute improvement in VO2 peak at the end of the 12-week training was 32% (19.2 ± 5.1 vs 25.5 ± 4.9 mil min-1 kg-1, P<.001). **Conclusion**: Patients showed a low level of initial CVD-knowledge on the CARRF-KL scale. Regardless of that, significant improvements in patient-reported health status are in line with changes in functional capacity. We recommend that the rehabilitation intervention for the STEMI and NSTEMI patients include an exercise program aimed at improving functional capacity (1).

Aleksandra Kraljević, Matej Tadejević, Vlatka Rado, Dino Glavočević

Cardiac cachexia and dyspnea are one of the leading symptoms in heart failure patients. (1) In 2017, 46-year-old man was diagnosed with severe ischemic biventricular cardiomyopathy together with other comorbidities. As a “bridge” to transplantation, in February 2018 left ventricular assist device (LVAD) was implanted, and due to the right heart failure right ventricular assist device (RVAD) was implanted in March 2018. On the twenty-first postoperative day, the patient was partially respiratory insufficient (SpO2 91%), almost bedridden. Early mobilization and respiratory rehabilitation were delayed due to the volume overload, profuse and frequent epistasis due to the anticoagulant therapy, infections and the occurrence of left leg intramuscular hematoma. The patient was gradually verticalized, separated from the oxygen (SpO2 96%) and discharged home in April 2018 hemodynamically stable, fully mobilized, properly anticoagulated and with stable pump parameters. During next 48 months, patient was independent in his everyday activities (6 minute walking test = 69%, 500m), without biventricular assist device (BiVAD) related complications. In March 2022 patient was hospitalized due to the right-sided hemiparesis and motor dysphasia caused by development of intracerebral hemorrhage and subarachnoid hemorrhage. After initial stabilization of the intracerebral bleeding, intensive physical therapy was carried out with gradual improvement of neurological deficits. Patient’s condition was also complicated by pneumonia and frequent RVAD alarms. In July 2022 patient was listed as an elective Eurotransplant candidate and was discharged home in good overall condition and fully mobile. In late August 2022, he was again admitted due to the worsening of dyspnea. At the admission, worsening of anemia and intermittent BiVADa low flow alarms were detected. His functional capacity was significantly reduced by the severe shortness of breath (SpO2 95%), and his walking distance was only 40m. During the course of that hospitalization (September 2022), heart transplantation was performed. After the heart transplantation, patient was hemodynamically stable and soon being able to move independently. This is a valuable example of multidisciplinary team work focused on the preservation of patient’s hemodynamic stability and mobility.

Verica Kralj, Ivana Grahovac

Cardiovascular diseases are a leading public health problem both in the world and in Croatia (1-4). In recent decades, starting from the second half of the 20th century, there has been an increase in chronic non-communicable diseases (NCD) in almost all countries of the world. The increase was first observed in the developed countries of the world, followed by the low-income countries. Cardiovascular diseases (CVDs) contribute the most to the burden of NCDs, and among them, ischemic heart disease and stroke are the most common causes of mortality and morbidity. They are responsible for 18.6 million deaths annually, and 80% of these deaths occur in middle- and low-income countries. It is estimated that by 2030, this number of deaths will increase to 23 million per year if the current trends are not stopped. In Croatia, CVDs have been the leading cause of death for decades. In 2021, 23 184 people died from CVDs, which accounts for 37% of all deaths. Analysis by gender shows that it is the cause of death in 41.8% of women and in 32% of men. The leading diagnostic subgroups are ischemic heart disease with 7 773 deaths and cerebrovascular diseases with 5 011 deaths. It is a well-known fact that most CVDs can be prevented by avoiding risk factors and that is possible to prevent up to 80% of premature deaths. By eliminating risk factors such as smoking, alcohol, unhealthy diet and insufficient physical activity, as well as timely early detection and treatment of hypertension, dyslipidemia and diabetes, cardiovascular health can be significantly improved, and cardiovascular morbidity and mortality can be reduced. In the last fifteen years, there has been a trend of decreasing mortality from cardiovascular diseases in Croatia, as was previously recorded in developed countries, but CVDs continue to represent the leading cause of mortality and morbidity. Compared to EU countries, Croatia with a standardized mortality rate of 572.8/100.000 is among the countries with higher mortality rates than the EU average of 367.6/100.000. There are huge inequalities within and between EU countries in CVD prevalence, mortality and adequate cardiovascular care, often due to social and economic reasons. CVD mortality rates are higher in Central and Eastern Europe than in other parts of Europe. For example, the age-standardized death rate from heart disease is 13 times higher in women in Lithuania than in France, and 9 times higher in men. Although mortality rates from CVDs are decreasing in developed countries, the number of people living with these diseases is increasing, which is related to longer life expectancy and better survival of people with cardiovascular diseases, as well as more effective preventive and therapeutic procedures. All this results in a higher prevalence of CVDs. The COVID-19 pandemic will further contribute to the increase in morbidity and mortality from CVDs and other chronic diseases. Due to demographic changes in terms of population aging, high prevalence of risk factors, better prevention and improvement of treatment, a higher prevalence of stroke and a growing burden can be expected, if comprehensive prevention measures are not taken through a systematic comprehensive program.

Marija Heinrich, Renata Stošić, Kristina Galez Janevski

Rehabilitation of cardiovascular patients after invasive cardiovascular procedures is part of medical treatment which we included in national guidelines. The specificity of outpatient rehabilitation is its duration. Rehabilitation of cardiovascular rehabilitation lasts up to three months, individual approach to each patient is mandatory, interventions and goals of rehabilitations are planned individually and findings at final evaluation are different. The nurse is a member of multidisciplinary cardiovascular rehabilitation team. She is involved in diagnostic procedures, recognizes pathological findings and informs cardiologist about them, detects and records absence of patients and makes appointments. In case of patients discomfort during rehabilitation the nurse conducts certain therapeutic procedures, detects occurrence of new nursing diagnoses, reevaluates the goals of rehabilitation and if necessary, changes interventions according to individual patients needs (1). Adherence is mandatory in determining type of interventions and goals of rehabilitation. Goals and interventions differ in each individual patient. At present time nursing documentation is not obligatory. Completing patients’ medical documentation with nursing documentation and creating nursing lists for patients will make nursing diagnoses available, planned and completed interventions visible as well as necessary additional interventions to help patients to take their place in family and society which they had prior to their disease. This can help to prevent progression end repetition of their disease (2, 3).

Marina Deucht

**Introduction:** Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary support system. It has advanced significantly in recent years and has become a therapeutic option for patients with cardiorespiratory failure. ECMO support is established by cannulation of the patient’s circulatory system. There are two basic types of ECMO systems, veno-arterial and veno-venous modality. The VA-ECMO modality is most often used in cardiothoracic surgery, because unlike VV-ECMO support, it also provides respiratory support to the cardiovascular system. Neurological complications after ECMO occur frequently, and the prevalence and types of neurological complications vary depending on the patient population (1). A patient with a brachial plexus injury associated with VA-ECMO immediately after heart transplantation is presented. Weakness of the right arm was noted after cannulation of the axillary artery to place the ECMO device. Application of the ECMO procedure is associated with multiple risks (e.g. bleeding, formation of blood clots). He was diagnosed with a peripheral nerve injury through a neurological and electrodiagnostic examination (multi slice computer tomography of the brain and electromyoneurography of the right hand), which revealed a lesion of the right brachial plexus. Doppler sonography was performed to determine the compressive risk of a blood clot. Early physiotherapy procedures for such neurological complications aim to restore the function of the injured nerves and muscles to their previous level and prevent potential disability. **Methods and Results:** The patient was selected from the register of the Institute for Cardiac and Transplantation Medicine from patients treated with ECMO from January 2013 to September 2022. One patient had unilateral arm weakness after starting ECMO therapy. The data from the neurological examination and electrophysiological examination for this patient proved the diagnosis of brachial plexus injury, dominantly the upper part of the plexus. **Conclusion:** Axillary artery cannulation resulting in hematoma formation was identified as a probable risk factor for brachial plexus injury in our patient. Physiotherapists are crucial in the early rehabilitation phase after such neurological injuries in re-establishing functions through strength, coordination, flexibility and preventing disability.

Ivona Brajković, Irena Kužet Mioković, Marica Komosar-Cvetković

**Background**: Scientific data confirm the effectiveness of cardiac rehabilitation (CR) elements in the form of individually tailored physical activity (PA) protocols. CR based on PA is a safe and well-established intervention for improving cardiorespiratory fitness (CRF) and quality of life of patients. For decades, the preference of the guidelines was medium intensity continuous training (MICT), however, in the past ten years, high-intensity interval training (HIIT) has been introduced into CR and showed excellent clinical improvements in patients with coronary heart disease (CHD) and chronic heart failure (CHF). This systematic review analyzed data on the significance and safety of HIIT profiles within CR. In addition, the importance of the most appropriate protocol, performance and intensity at the individual level when performing PA within CR was pointed out. **Methods and Results**: A systematic literature search was conducted using online bibliographic databases. The review included studies comparing MICT vs. HIIT and the patients with a diagnosis of CHD or CHF within the CR. All interventions were carried out under supervised conditions at specialized institutions for CR. HIIT is a term for a time-efficient training modality that involves alternating periods of high-intensity aerobic exercise (85-95% HRmax; RPE 15-18) with a low-intensity active recovery interval (70% HRmax; RPE 11-13). The optimal time dose of HIIT to maximize health outcomes is the HIIT model 4x4min. A psychological approach and a safe environment provide the patient with confidence and motivation to achieve the outcome. Systematic reviews based on such an approach indicate the superiority of HIIT over MICT in terms of VO2peak (1). **Conclusion**: The HIIT protocol provides a greater physiological stimulus and adaptation compared to MICT, therefore creating a greater benefit for improving CRF and other metabolic processes important for primary and secondary prevention of cardiovascular disease. Due to the lack of guidelines, various models of interval training are on the market, therefore it is necessary to incorporate current objective and subjective concepts of intensity to determine and follow a personalized approach based on patient preferences and abilities, especially in the context of long-term adherence (2, 3).

Marina Jelinić, Tatjana Pereša

**Introduction:** A new healthcare era is now beginning in Istria. In the new hospital, our service has begun performing new diagnostic and therapeutic procedures. One of these procedures is the transesophageal echocardiography (TEE) (1). Until now, we have performed five procedures. We will present a rare case of a cardiac tumor located in the right atrium. **Case report:** Patient V.N., born in 1962, was admitted to the Cardiology Unit after a thoracic CT scan, performed under the National Lung Cancer Early Detection Programme. The patient’s general condition was good, his only complaints relating to quickly becoming fatigued, sweating. No chest pains and no losses of consciousness. ECG sinus rhythm 72/min. Smoker. Upon treating the patient, we ruled out pulmonary embolism. Taking the appearance of the growth into account, it appears to be a large tumor mass in the right atrium and ventricle, 8.9x5.2 cm. Myxomas are the most common cardiac tumors and 75% of all detected cases are in the left atrium. Our case is interesting due to its size, its appearance in the right atrium and the very few complaints in the patient’s medical history. **Conclusion:** We have presented our first cardiac tumor diagnosis since we began performing the TEE diagnostic method earlier this year. Owing to our institution’s modern diagnostic facilities, the patient was treated very quickly and by agreement transferred to the Sestre milosrdnice University Hospital Centre in a good general condition.

Nikolina Vidaković, Kristina Pavlović

Distal embolization, during coronary intervention, of thrombotic material resulting in compromised coronary flow is a common complication usually described in the context of invasive treatment of acute ST-segment elevation myocardial infarction (STEMI) (1). In our case, we report distal embolization, presumably with a calcified atherosclerotic plaque fragment. It occurred during an elective percutaneous coronary intervention on the subostial part of the right coronary artery. Fortunately, this embolization did not compromise distal flow, but it did result in a significant „de novo” lesion of the right coronary artery crux. This lesion was uncrossable with dilatation balloons using a variety of different basic and advanced tools and techniques. Therefore, we decided to perform a rotational atherectomy that enabled a successful percutaneous coronary intervention with stent implantation.

Veronika Maksimov, Tihana Kolar, Samanta Vuković, Tomislav Brkljača, Melisa Mehmedović

Cardiovascular diseases are one of the leading causes of disease both in Croatia and the rest of the world (1). In Croatia, cardiovascular diseases cause as much as 45% of mortality compared to other diseases (2). Invasive procedures in cardiology are becoming more common, even though they themselves represent certain risks. Proper preparation of the patient is one of the key procedures before performing the procedure itself in order to reduce the occurrence of risks to a minimum probability. Patient preparation consists of different components, such as physical preparation, psychological preparation, and preparation of medical documentation. Special attention should be paid to the psychological preparation of the patient. Depressive and anxiety disorders are three times more common in people with cardiac diseases than in the rest of the population. One of the reasons for this is the insufficient information collected by the patient about the disease itself, the deterioration of their general physical condition, and knowledge about the change in their quality of life. When informing the patient about the cardiac disease he is dealing with, there are often various signs of stress that affect the patient’s general condition. Different perceptions of the disease affect the individual’s behavior and, more precisely, the willingness to cooperate between the health care staff and the patient. In addition to the fear of the disease itself, there is also a great fear of performing invasive procedures. Physical preparation differs depending on the planned invasive procedure (implantation or replacement of a permanent or temporary pacemaker, invasive percutaneous coronary angiography). When handing over the patient to the medical team in the laboratory for heart catheterization or cardiac electrostimulation, the data that was verbally transmitted must be corrected with the data filled in on the transferred patient list.

Hrvoje Lukić, Vesna Puklin, Ivana Barun

**Introduction:** Angina pectoris is deemed refractory when it cannot be controlled with optimal pharmacotherapy and revascularization of the coronary arteries, and lasts for three or more months (1). The percutaneous implantation of a blood flow reducer through the coronary sinus represents a potential alternative treatment option. The implantation of a flow reducer leads to a decrease in the effective diameter of the coronary sinus, thus slowing down blood flow (2). This results in an increase in pressure in the sinus, and consequently in the coronary circulation, which leads to a redistribution of blood from well-perfused to poorly perfused areas of the myocardium. Aim: To present an alternate therapy for patients with refractory angina by implantation of a blood flow reducer in the coronary sinus. **Case report:** 76-year-old patient with known coronary disease, hypertension, and hyperlipidemia, reports angina during a minimal walk (8/10) despite the previous revascularization of the coronary arteries (PCI and CABG), and optimal pharmacotherapy is referred for the implantation of Flow reducer. Under ultrasound control, a sheath was placed in the right jugular vein. An MP catheter was introduced in the coronary sinus, and its anatomy was visualized with contrast. A flow reducer (steel mesh – hourglass appearance) was implanted over a stiff wire. The venogram confirmed the proper position of the device. The optimal effect is expected around six weeks after installation. **Conclusion:** Percutaneous implantation of a flow reducer has been used worldwide for many years and has proven to be an effective method in the treatment of refractory angina. Studies have shown that this method leads to a subjective improvement of the symptoms of angina pectoris as well as a reduction of myocardial ischemia on MRI.

Ružica Lovrić, Goranka Oremović, Mario Udovičić, Ivica Benko

A pulmonary embolism (PE) is an acute obstruction of pulmonary blood flow and differs between thrombotic and non-thrombotic PE (1). The main cause is an embolus originating from deep veins. The clinical appearance of PE is preceded by hemodynamic instability with mild to severe symptoms. The gold standard for the diagnosis of PE is MSCT pulmonary angiography and laboratory blood tests. Anticoagulant therapy with embolectomy is the cornerstone of pulmonary thromboembolism treatment. In this case, we present a 29-year-old female patient who was hospitalized at the Dubrava University Hospital due to a left-sided segmental pulmonary embolism after pregnancy. A pulmonary embolism was confirmed by MSCT pulmonary angiography. Based on the clinical assessment, an aspirational thrombectomy was performed with the Inari Flowwtriever catheter. The post-procedural course proceeds with clinical improvement and without any complications. A multidisciplinary approach is of great importance in the treatment of patients with PE. Regular and adequate assessment of the patient is necessary for safe and successful post-procedural treatment. Special clinical knowledge and skills in the invasive treatment of PE are necessary for adequate nursing interventions.

Krešimir Librenjak, Mira Stipčević

Hemodynamics as part of cardiac catheterization is a somewhat forgotten art of recording blood pressures at different levels of the heart cavities (1). That is why the idea of our work is to refresh knowledge and remove any dust from that “artwork”. Before the advent of modern ultrasounds and other diagnostic devices, the diagnosis itself relied to an extremely large extent on the finding of “microcatheterization of the heart”. Today’s new methods that we introduce in catheterization laboratories, such as PFO occluders, TAVI implantation, and PVI intervention, in addition to the standard number of daily coronary angiographies, their basic support and confirmation for the performance are in an inadequate hemodynamics of the heart (2). When recording and performing this examination with the help of the most modern digital hemodynamic devices, we need to stick to the basic principles of aseptic work, the basis of heart catheterization with all its legalities and compliance performing cardiac invasive procedures. Knowledge of typical amplitudes of the pressure curve, basal pressure values of the right atrium (RA), right ventricle (RV), pulmonary artery (PA), pulmonary capillary wedge (PCW), left atrium (LA), left ventricle (LV), aortic systemic pressure (AO), and abnormalities in certain diseases and arrhythmogenic conditions are extremely important to us. As an emphasis on precise hemodynamic measurements, we emphasize absolute knowledge and safe handling of the hemodynamic station, the importance of correct and accurate “zeroing” of the sensor for converting mechanical force of blood pressure into a digital record, and an adequate and completely secured from any obstacles (thrombus, air emboli, or inadequate construction) lumen of the catheter with which we reach all levels of the heart and output structures in the very near future. Adherence to all these step-by-step procedures is the basis for the hemodynamic measurements we perform safely, accurately, and precisely.

Ivana Kuserbanj, Sandra Benković, Mateja Kovačević

The purpose of this case report is to highlight the importance of hemodynamic support for the high-risk percutaneous coronary intervention (PCI) procedure in order to maintain vital parameters and optimum conditions for complex PCI. The 70-year-old patient with a history of high blood pressure and smoking was hospitalized due to myocardial infarction without ST segment elevation. The echocardiography shows the reduced ejection fraction of the left ventricle (LV), ejection fraction (EF) LV 20–25%. Coronary angiography has revealed multivessel disease with significant stenosis of the left main and proximal LAD, two significant stenoses of the LAD in the distal segment, two significant stenoses of OM1, and chronic total occlusion of one significant branch of the RCA with retrograde collateral flow. Surgical myocardial revascularization was scheduled, and preoperative examinations were performed. Next, the patient developed clinical worsening with angina pectoris, and continued cardiac decompensation and coronary percutaneous intervention with hemodynamic support with the Impella CP device were done (1). A coronary intervention of the left main was performed, and the Impella device was removed immediately following the procedure. The patient was discharged cardiopulmonary compensated, hemodynamically stable, without chest pain, and with optimal vital parameters.

Lucia Gašpar

Rotational coronary angiography is a new imaging technique involving three-dimensional rotation of the gantry around the patient with simultaneous left to right and craniocaudal movements (1). This allows complete imaging of the left or right coronary tree with a single acquisition run. After preparing the patient for procedure and radial artery puncture, the operator cannulates the left main coronary artery (LMCA) with a customized catheter, and places the X-ray device in the isocenter for performing the continuous rotational imaging procedure. With its dynamic recording range, it enables us to find the most adequate projection/position from which, if necessary, intervention on the lesion of a certain coronary artery will be performed. In 9 seconds, which is the time period of rotation for imaging the left and right coronary tree, 36 ml of contrast medium is applied to the patient, which greatly reduces the load on the kidneys, unlike conventional imaging of the coronary arteries. This way of performing the procedure is very important for patients with kidney failure and high creatinine values.

Tomislav Biloglav, Daniela Šmalcelj, Natalija Silović

**Introduction**: Coronary microcirculation dysfunction can present as either a chronic coronary syndrome with angina or an acute coronary syndrome with normal coronary angiography (1). Invasive tests for microvascular disease include coronary flow reserve (CFR) and index myocardial resistance (IMR). CFR and IMR measurements are taken during routine coronary angiography using the Coroventis CoroFlow console and the PressureWire X coronary wire. A continuous adenosine infusion is used to induce stable hyperemia during the test, which causes vasodilation of the microcirculation and simulates the state of physical activity. CFR functions as a standard thermodilution method, measuring the time it takes for the saline flush to reach the thermistor. In contrast, while measuring CFR and IMR, a measurement of fractional flow reserve (FFR) is obtained, which rules out epicardial stenosis. IMR, on the other hand, is a ratio of pressure to flow velocity during maximal hyperemia. Aim: To demonstrate new diagnostic tools for determining myocardial resistance and coronary flow reserve. **Results**: The first CFR and IMR tests were performed in May 2022 at the University Hospital Center Zagreb’s interventional cardiology department. The tests successfully detected microvascular disease, allowing this group of patients to receive appropriate medical treatment. **Conclusion:** The clinical significance of CFR and IMR is to enable better treatment selection for our patients. Although these tests are minimally invasive, they can cause complications, so careful patient selection is essential.

Ivica Benko, Marina Budetić, Mateja Lovrić, Mirela Adamović, Marina Žanić, Mario Tomašević, Ivan Horvat

Invasive cardiology procedures are nowadays performed in cardiac catheterization laboratories (CAT LAB) and electrophysiology laboratories (EP LAB) or their hybrid versions. Invasive cardiac LABs are a complex environment in which highly trained subspecialists and nurses interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities (1). Nonetheless, the highly skilled and dedicated personnel in LABs are human and adverse events are possible. The hazards associated with invasive cardiovascular procedures include vascular injury, systemic embolization, contrast agent-induced nephropathy, and radiation-induced injury (2). Although substantial progress has been made, severe life-threatening and fatal complications still occur, and the goal of making such procedures hazard-free remains elusive. In the most developed countries, despite the use of the most modern technologies, 10 to 12% of patients are exposed to incident situations, of which even half could have been prevented. In Croatia, for now, there is no systematic data on incidents that threaten the safety of treatment at the level of institutions and at the national level. Preventable errors are often not related to the failure of technical skill, training, or knowledge but represent the cognitive, system, or teamwork failures. Many studies highlight lack of communication as a factor in adverse events in more than 80% of cases. The risk can be best minimized by careful patient preparation and attention to details in the execution of the procedure itself. Many studies have shown how the usage of checklists can improve team dynamics and minimize errors. The concept of a preprocedural “time-out” or checklist has become an established safety practice throughout health care. A checklist forces the team to take a systematic approach to reviewing the issues specific to an individual patient. Checklists are most valuable where most of the procedures performed are routine, where staff may become complacent with the risks of a procedure and overlook preventable safety risks.

Sandra Babić, Renata Jažić

The greatest challenge of today’s medicine and health care is the need to reduce health care costs without reducing the quality of treatment (1). This type of challenge requires an innovative approach to reducing health care costs, and one of these approaches is performing invasive cardiologic diagnostic procedures, such as coronarography, in the daily hospital. Although invasive procedures, such as coronarography, are traditionally done during hospitalization, they are nowadays performed more often in the daily hospital. Since the 1980s, coronarography has been performed in the daily hospital worldwide. During the 1980s and 1990s, much research was done about the safety and cost-effectiveness of this approach. By comparing multiple studies about the safety of this kind of approach in more than 105000 patients, the rate of complications obtained between 1 and 2%. The rate of patient hospitalization was between 0.5 and 2.3%. The study from 1988 showed cost savings of 885 dollars per patient, which would in today’s time be the equivalent of 2138 dollars or 16550 Croatian Kuna (inflation adjusted). Newer studies are rare because the safety and efficiency of performing coronarography in daily hospitals have been proven since the 1980s. Performing coronarography in the daily hospital is a sustainable concept of providing health care that gives modern, high-quality health care at a lower cost without jeopardizing patient safety.

Saša Dizdarević, Lucija Dizdarević

Cardiovascular diseases are at the top of the leading causes of death in the 21st century. Overweight and obesity are risk factors for the development of arterial hypertension, which is associated with an increase in disability and cardiovascular mortality. Reducing excess and maintaining a stable body weight allows for a reduction in cardiovascular risk. Although reduced body weight does not necessarily mean protection of the cardiovascular system, maintaining an ideal body weight is the main goal in reducing cardiovascular risk. This is achieved by continuous education of patients about proper nutrition and increased physical activity as key aspects in reducing excess body weight (1). Objective is to emphasize the importance of education of cardiac patients with hypertension and obesity with reference to the competencies of nurses and an emphasis on their indispensable involvement in providing holistic care in hospital and home conditions where the patient is. Changing life habits prevents obesity and the development of hypertension with consequent organ damage and impaired functioning of organ systems. For the purpose of their treatment, preference over pharmacological methods of treatment is given to non-pharmacological therapeutic procedures aimed at weight loss by applying a proper diet and regular physical activity. The optimal effect in lowering blood pressure and blood fats is achieved by proper nutrition with regulation of salt intake, moderate reduction of diet in terms of reduced energy intake in obese patients and continuous physical activity. The nurse/technician participates in a number of activities to improve and promote health in order to prevent cardiovascular disease, conducts education of patients with hypertension and obesity on changing lifestyle habits and provides support during treatment (2, 3). Obesity and hypertension in comorbidity are a major public health problem. The nurse/technician, as an educator and motivator, provides support to the patient and encourages prevention and treatment through lifestyle changes as part of weight reduction by adhering to a regulated plan of proper nutrition and conducting moderate, continuous physical activity.

Mia Čarapina, Milka Grubišić, Dragana Jurčić, Katarina Karimanović

Wound infection in cardiac surgery most affect the sternum and cause a prolongation of the patient’s recovery, an increase in costs and the risk of morbidity. Despite numerous risk factors such as diabetes, obesity and duration of the operation, the nurse has a major role in preventing infection. An aseptic procedure of wound care can remove, reduce and prevent infection. By daily assessment of the wound the nurse monitors the degree of healing and notices the first signs of infection. Early identification can prevent further spread of the infection. In cardiac surgery wound on the sternum or extremities can most often have minimal or no secretion and require dry wound care using sterile gauze. However, modern waterproof dressings resistant to bacteria which are placed on the dry wounds, with their honeycomb-like appearance, allow constant monitoring on the wound and reduce the risk of incorrectly healing. In early postoperative days the nurse checks the wound every day and when she reached a satisfactory stage of healing, she can remove the gauze and leave the wound on oxygen which helps in quality of healing. Preparation of sterile equipment, area and nurse (hair, short nails, gown, mask, clean hands, and gloves) are the role of the nurse before treating the wound. A medical documentation and high-quality nursing anamnesis make it easier to identify patients which are in risk for infection. Studies are suggesting the importance of the role of a multidisciplinary team, but only with proper education of the nurse we can give to our patients the highest level of quality of wound care. Regular and proper dressings, ensuring favorable microclimatic conditions encouraging the patient to practice personal hygiene, proper handling of the place where the drains are placed and proper preoperative preparation of the patients skin can contribute to the prevention of the infection in cardiac surgery (1, 2).

Anđela Marušić, Katarina Vrdoljak

**Introduction:** Aortic stenosis (AS) is the most common among valvular diseases and it mainly affects people over 65 years old. AS is a progressive disorder that can be divided into two phases; the stage of aortic sclerosis and the stage of aortic stenosis. Transcatheter aortic valve implantation (TAVI) is performed through a retrograde transfemoral approach, using a catheter on a beating heart, an artificial biological valve is implanted in place of the degenerated valve (1, 2). After the TAVI procedure, patients are admitted to the Cardiac Intensive Care Unit for continuous monitoring. The goal is to disclose the important role of nurses/nursing technicians in post-procedural care and the course of treatment after a successful TAVI procedure trough a case report. Medical literature and patient records from the archives of University Hospital of Split were used as sources and guidelines for this report. **Case report:** A patient with history of arterial hypertension, diabetes mellitus type 2, permanent atrial fibrillation with severe aortic stenosis is hospitalized at University Hospital of Split, undergoing periprocedural screening and TAVI preparation protocols. After a successful procedure, the patient is admitted to the Cardiac Intensive Care Unit. During the 24-hour monitoring and prevention of possible complication, the course of treatment becomes complex after periprocedural bifascicular block develops into 3rd degree atrioventricular block. Afterwards, the patient is being prepared for a permanent pacemaker placement. **Conclusion:** TAVI is the gold standard in treatment for patients with severe aortic stenosis that have a high surgical risk or have contraindication for a classical surgery. 2019 was the year that UHC Split began effectively practicing TAVI procedures. As an equal member of the healthcare team, nurses/nursing technicians have a big role and responsibility in patient care. Here, we reflected on the irreplaceable role of a nurse in the process of quality nursing care. Furthermore, nurses now face a new scope of work with greater responsibility, thus indicating the need for further education, competencies, and expertise. To provide the best care, nurses/nursing technicians should continuously improve and renew their knowledge, keeping up to date with new technological and scientific achievements.

Dragana Jurčić, Milka Grubišić, Katarina Karimanović, Mia Čarapina

The choice of aortic valve depends on many factors, including the characteristics of the valve itself. A mechanical valve lasts longer than a biological one but requires lifelong anticoagulant therapy. After implantation of a mechanical aortic valve there is a high risk of clot formation, and the drug of choice is warfarin. Warfarin therapy requires strict discipline and control of therapy, which is why patients require a comprehensive approach and education. Education about the use of anticoagulant therapy should be an important part of care for the patient. The nurse plays a major role in the application of anticoagulant therapy after the implantation of a mechanical aortic valve, in terms of patient and family education. Teaching should be adapted to each patient individually, accompanied by written sources and using different teaching methods (1). Effective education about anticoagulant therapy includes understanding the very purpose and effect of the drug, dosage, international normalized ratio target range, self-monitoring strategies, the importance of regular monitoring with laboratory tests and the possibility of complications (2). Also, patients should be educated about reducing the risk of bleeding and injury, as well as procedures if bruises, nose/gum bleeding, blood in the urine and/or stool, vomiting of blood, heavy or prolonged menstruation occur. It is recommended that patients point out that they are using blood thinner therapy, furthermore, they should possess an anticoagulation card and always carry it with them. Given that patients require chronic use of anticoagulant therapy after the implantation of a mechanical valve, the approach should be systematic and coordinated not only by nurses, but by all healthcare workers. It is important that patients are educated in the hospital so they can properly carry out their therapy at home and achieve better clinical outcomes for themselves. Education should be continued on an outpatient basis and/or through day hospitals.

Alenka Tuličić Mihelčić, Željka Stojkov, Barica Stanić, Blaženka Miškić, Vesna Ćosić, Karla Miškić

**Introduction**: Heart failure is a complex and progressive disease associated with poor prognosis and significantly reduced quality of life and increased risk of death (1, 2). **Case report**: Patient NN, born in 1959, due to advanced heart failure caused by dilated cardiomyopathy, since 2014 has been a carrier of mechanical circulatory left ventricular assist device (LVAD), and in 2020 undergoes a successful heart transplant procedure. Only some of his hospitalizations are: 2002 myocardial infarction, 2009 cerebrovascular insult with successful recovery, but later that year he was hospitalized again due to an epileptic attack. In 2014 implantation of LVAD (Hart Mate II), 2015 total hip arthroplasty complicated by retroperitoneal and with a subfascial hematoma of the right upper leg and a lesion of the femoral nerve. The same year he was diagnosed with colon cancer, after which he underwent multiple tubular polypectomies adenoma. The patient also has chronic kidney disease, gastritis, hemorrhoids, chronic obstructive pulmonary disease, nephrolithiasis, kidney cyst, cholecystolithiasis, pulmonary hypertension. In 2017, he was fitted with a Cardiac Resynchronisation Therapy (CRT-D). In 2019 suspected LVAD “driveline” infection (Enterobacter cloacae bacteremia, Enterococcus faecalis and others). Consequently, the development of cardiogenic shock, implanted VA ECMO and new HM II pump. In 2020 treatment of anemia followed by heart transplantation in the same year. Nursing diagnoses in patients with these comorbidities are high risk for infection, pain, anxiety, ignorance and the health care process is based on solving the same. **Conclusion**: LVAD has enabled numerous patients with advanced heart failure a better future. In this example, we see a man who despite numerous diagnoses he did not give up his belief in the positive outcome of the treatment and eventually received a heart transplant. All the above would be unimaginable without the continuous efforts of the health care staff, the patient’s wishes for recovery, as well as the successful multi-year support of LVAD.

Magdalena Kunić

Out of the 17million premature deaths (under the age of 70) due to noncommunicable diseases in 2019, 38% were caused by CVDs (cardiovascular disease). (1) In the case report, we describe 29-year-old male who is currently suffering from an advanced stage of left ventricular failure and consequently from ventricular arrhythmia. The first presentation of the disease was syncope in 2009 when he was admitted to local hospital. At that time echocardiography showed only slight of both dilatation of both ventricles, ejection fraction was preserved. Six years later the patient was readmitted to the local hospital, but this time with more advanced heart failure symptoms such as, fatigue, paroxysmal nocturnal dyspnea, and leg edema. His functional status deteriorated to NYHA (New York Heart Association) class III, and he as was referred to our center. Cardiac workup was performed including echocardiography, cardiac magnetic resonance, coronarography and right heart catheterization. Non ischemic, dilated cardiomyopathy was diagnosed probably caused by history of myocarditis. Besides optimal medical therapy, implantable cardioverter defibrillator (ICD) was implanted in primary prevention of sudden cardiac death. He responded well to therapy and there were no sustained arrhythmias detected on ICD follow up. In 2020 his status deteriorated again to NYHA class III/IV. During this heart failure hospitalization patient developed ventricular tachycardia and cardiogenic shock that required veno-arterial extracorporeal membrane oxygenation (VA ECMO) placement. Later, a left ventricular assist device (HEARTMATE III) was implanted. In 2021 patient had a few ICD discharges due to ventricular tachycardia (VT). At that time, whole pre-transplant workup was performed, and patient was placed on elective heart transplant list. In mid-2022 patient developed ventricular tachycardia storm; therefore, amiodarone was introduced. Despite beta blocker and amiodarone therapy VT storm recurred and he was admitted back to Coronary Care Unit. Antiarrhythmic therapy did not have beneficial effect. Therefore, an electrophysiological study was performed and endocardial ablation which was only partly successful. Due to uncontrolled arrhythmia patient was accepted to hi urgent heart transplant list. Nursing care encompasses a wide range of knowledge and skills that are needed to provide the best plan of care for a patients with advanced heart failure and arrhythmias.

Katarina Karimanović, Milka Grubišić, Ivan Markač, Dragana Jurčić, Mia Čarapina

Transplantation is a surgical procedure that is performed when organ failure is in the final stage and when other treatment methods have been exhausted. The diseased organ is replaced by an organ from a suitable donor. The surgical scrub nurse is responsible for securing all necessary organ packaging materials, solutions, transport containers and surgical instruments. During the preparation of the heart transplantation, the operating nurse has a very important role in ensuring the sterile conditions of the operating room and surgical materials, as well as the preparation and availability of surgical instruments. The scrub nurse, as part of a multidisciplinary team, has a specific role due to the extensive field of work in the various stages of the organ donation and transplantation process. To achieve the desired goal, it is very important to constantly improve knowledge, skills, and attitudes, especially in this area, where new challenges and responsibilities are presented every day. Being a member of the transplant team requires a high level of professional education, dedication, and availability in free time, which also results in the adoption of a new lifestyle. (1)

Milka Grubišić, Dragana Jurčić, Katarina Karimanović, Mia Čarapina

Heart transplantation is still the gold standard in the treatment of heart failure. It represents the very top of medicine in organizational, logistical, technical, and medical terms. Also, it is a huge civilizational progress that enables the survival of those patients who have no alternative. It requires careful monitoring for recognition and prevention of complications in the early and late stages after transplantation. Despite high level of development of modern medicine and science, significant probability of complications in the early and late postoperative period still exists. The most common early complications include dysfunction of the donor heart, bleeding, cardiac arrhythmias, acute organ rejection and opportunistic infections, while accelerated atherosclerosis of blood vessels, arterial hypertension, kidney failure, lymphoproliferative diseases and skin cancers occur in the late phase (1). In addition to the complications, infections are one of the most important causes of pain after heart transplantation and are responsible for 30% of deaths during the first year after transplantation (2). There is no successful method of definitive treatment and prevention of complications, therefore, special attention after transplantation should be paid to the modification of risk factors, individualized nursing care, education, regular controls and support from the family and the environment. Heart transplantation is a therapy that improves and saves life; however, it is associated with significant risk of complications. Healthcare professionals must work closely with patients and their families to prevent, identify, and treat those complications. This form of cooperation is crucial in achieving the goal of heart transplantation, which is to prolong survival with a good quality of life for such patients.

Daria Pavliček

**Aim:** The aim is to collect data from the hospital information system and medical documentation, analyze it, and present the obtained results for the implantation of a permanent pacemaker at the General Hospital “Dr. Tomislav Bardek” Koprivnica within two calendar years: 2019 and 2020. **Patients and Methods:** The retrospective study included all patients in the entire hospital who had a permanent pacemaker implanted. The presented results were obtained by collecting data over the period from January 1, 2019 to December 31, 2020. Data is grouped according to differentiation in gender, age of the patients, types of pacemakers (single-chamber pacemaker or dual-chamber pacemaker), whether it is the first installation or replacement of an existing pacemaker, list of diagnoses requiring pacemaker implantation, average duration of hospitalization, and methods or types of discharge. No survey questionnaire was designed for this research. Descriptive statistics using Microsoft Excel were used in data processing. **Results**: 190 permanent pacemakers were implanted as a result of the study. There were 100 men and 90 women among the total. Pacemakers were implanted to the greatest extent in patients over the age of 66 in both years. A total of 125 single-chamber pacemakers were implanted, with 65 patients receiving dual-chamber pacemakers. 87% of patients were hospitalized in the cardiology department. Out of the total number, 16 pulse generator replacements were recorded, whereas the other 174 patients had the first installation of a permanent pacemaker. The most common indication for implantation is complete or total atrioventricular block (grade III). Hospitalization lasts less than 5 days, and patients are discharged for home care. In 2019, no deaths were recorded; in 2020, one death was recorded. **Conclusion:** General Hospital “Dr. Tomislav Bardek” Koprivnica records an increasing number of implanted permanent pacemakers. Hospitalization takes less than 5 days. It is mostly implanted in elderly patients, whereas single-chamber pacemakers are more frequently implanted compared to dual-chamber pacemakers. With the quality and conscientious work of all health professionals, the quality care of patients with implanted pacemakers is guaranteed (1-3).

Matija Mlinar, Zvonimir Katić

Atrial fibrillation (AF) is the most common long-term cardiac arrhythmia found in a wide population of people and is closely associated with an increased risk of death, cerebrovascular insult and other thromboembolic incidents (1). Based on the symptoms and duration of AF, physicians choose a treatment strategy, which can be a frequency control strategy or a rhythm control strategy. In the patient whose case we have described, a rhythm control strategy was chosen, which was carried out with antiarrhythmic therapy and isolation of the pulmonary veins (2). Likewise, in patients with AF, it is necessary to choose the correct anticoagulation therapy. The guidelines emphasize the assessment of risk factors for a thromboembolic event using the Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female or CHA2DS2-VASc score. Also, the risk of bleeding should be considered, and for this purpose the Hypertension, Abnormal liver/renal function, Stroke history, Bleeding history or predisposition, Labile INR, Elderly, Drug/alcohol usage or HAS-BLED scoring system is used. In the patient whose case we have described, in addition to cryoablation of the pulmonary veins, an occluder of the left atrial appendage (LAAO) was placed in the same act.

Mateja Lovrić, Ivica Benko, Mirela Adamović, Marina Žanić, Marina Budetić, Mario Tomašević, Ivan Horvat

**Introduction**: Epicardial ablation is an invasive non-surgical procedure for the treatment of malignant ventricular arrhythmias (1). The procedure is performed under general anesthesia. Epicardial mapping and ablation uses the subxiphoid technique and is most often performed after failed endocardial ablation. Patient selection depends on the etiology of the disease, the location of the substrate, specific electrocardiographic criteria or the previous mapping showing the area of epicardial origin. **Case report**: We present a 30-year-old male patient who was hospitalized in the Coronary care unit at the Dubrava University Hospital due to ventricular tachycardia. Ventricular tachycardia in the patient was diagnosed in 2012, when he was offered ablation or implantable cardioverter-defibrillator (ICD) implantation. In 2022, due to the deterioration of the patient’s condition, ablation was performed using an epicardial approach and 3D mapping system combined with a computerized tomography (CT) image. Before the hospital discharge, an ICD was implanted. Epicardial ablation is performed by experienced electrophysiologists in collaboration with surgeons, anesthesiologists and other medical personnel who make up a multidisciplinary team. The role of the nurse as a member of the team is of great importance. The nurse ensures the physical and mental preparation of patient pre and post-procedure. **Conclusion:** Caring for such patients requires special clinical knowledge as well as broader skills in invasive cardiology and cardiac surgery.

Zvonimir Katić, Matija Mlinar, Domagoj Kardum

**Introduction:** The ventricular assist device (VAD) is used as a “bridge to transplantation” for patients with heart failure. Patients with advanced heart failure have improved survival rates and quality of life when treated with implanted pulsatile - flow left ventricular assist devices as compared with medical therapy (1). Systolic dysfunction associated with chronic tachyarrhythmias, known as tachycardia-induced cardiomyopathy, is a reversible form of heart failure characterized by left ventricular dilatation that is usually reversible once the tachyarrhythmia is controlled. Its development is related to both atrial and ventricular arrhythmias (2). As 3D navigation systems for catheter ablation advance with time, we will be able to reduce fluoroscopy to a minimum, if not remove it from our electrophysiology labs. Studies show that catheter ablation for supraventricular tachycardias can be done with 3D navigation systems without using any fluoroscopy (3). **Case report:** We will present two complex ablations with a 3D navigation system and very low fluoro dosage that we did in the past year. The first patient was a male, 59-years-old, with ischemic cardiomyopathy due to anteroseptal ST-elevated myocardial infarction (March 2018), cardiac resynchronization therapy with defibrillator (CRT-D) implantation (July 2019), ejection fraction (EF) 25% with a left ventricular assist device (LVAD) (February 2021). During the procedure, three clinical ventricular tachycardias (VT) were mapped and ablated. When ablating, the near-inflow tract of pump tachycardia is terminated, and CRT-D takes over with pacing. At the end of the procedure, we did induction of VT using the Michigan protocol, but we didn’t manage to induce clinical VTs. Procedure time was more than 3 hours; fluoroscopy time was 4 minutes. The second patient was a female, 45-years-old, with toxic cardiomyopathy due to breast cancer treatment and biventricular assist device (BiVAD) implantation (November 2021) who came to our center with atrial flutter and 2:1 conduction, and we did an electrophysiology study. We confirmed typical atrial flutter and ablated cavotricuspid isthmus (CTI) with limited X-ray images (anterior-posterior, left and right anterior oblique views were taken and merged with the 3D navigation system). Atrial flutter was terminated, and cavotricuspid isthmus block was confirmed with differential pacing. Patient was released from the hospital in sinus rhythm. Procedure time was 90 minutes, and fluoroscopy time was 50 seconds. **Conclusion:** The main goal of this case report is to show great perspective for a fluorofree future in electrophysiology labs (EP labs). As technology advances, there will be much more opportunity to reduce X-ray imaging in everyday practice. At this moment, there are a few 3D navigation systems, which make our job a lot easier. There are pros and cons for all those systems, but the most important thing to mention is that they give us a big chance for a fluorofree future in EP labs.

Ivana Hodanić, Marina Klasan, Saša Bura, Katarina Matković

Implantation of a pacemaker represents a “prolongation” of life, but at the same time it also requires a change in lifestyle habits (1). That is why it is necessary to approach each patient individually, with the aim for successful prevention of complications. Continuous professional education of nurses and permanent acceptance of new knowledge in the field of cardiology is equally necessary. With the aim of timely detection and suppression of possible complications after implantation of a heart pacemaker. Implantation of pacemakers becomes more essential partly due to the aging of the population and partly due to the expansion of indications. Although the procedure of implantation itself is simple but the risk of complications is still present and sometimes it is underestimated. The development of technology and the develop that occurs in operator’s experience have significantly reduced the frequent occurrence of complications. The most common complications are hematoma, pneumothorax, electrode dislocation and infection. American studies estimate that the frequency of acute complications is from 4% to 5%, and it is related to the experience of the operator, while the occurrence of later complications of pacemaker installation is around 2.7%. Death because of complications is very rare, so the mortality rate is from 0.08% to 1.1%. Retrospective research conducted at the University Hospital Centre Rijeka recorded similar data (2). The research conducted led to the conclusion that with the appearance of new technologies and knowledge about heart pacemaker implantation the incidence of complications is decreasing year by year. Likewise, the experience of the implanter contributes to the reduced occurrence of complications after the installation of the pacemaker. The aim of the exhibited poster is to show possible complications of pacemaker implantation and show the possible prevention and treatment of complications of pacemaker implantation.

Miroslav Geček, Gordana Hursa, Sanja Keleković, Tomislav Pijetlović, Dorotea Tisak

Conduction system pacing is the newest method of cardiac pacing. In comparison to right ventricular apical pacing, conduction system pacing provides a physiological way of the heart stimulation. It also provides a great alternative to biventricular pacing for patients in need of cardiac resynchronization. In this paper, we will explain the anatomy and physiology of the conduction system and its stimulation. We will describe different methods of conduction system pacing (His bundle pacing and left bundle branch pacing) and compare their advantages and shortcomings (1-3). At the very end we will look at the experience in our center.

Ante Borovina, Nela Lemo, Ivan Sikirić

**Introduction:** Pulse ablation by an electric field is a nonthermal ablative modality that uses a short-lived, strong electric field created around the catheter that creates microscopic pores in the cell membrane (electroporation). The left atrial auricula (LAA) has great arrhythmogenic and thrombogenic potential, so its independent isolation without occlusion carries the risk of thromboembolism. Since more than 90% of thrombi occurs in LAA, its occlusion significantly reduces the risk of thromboembolism and has been shown to be not inferior to vitamin K antagonists (1, 2). Here we present an example of the use of pulsed electric field ablation (PFA) for pulmonary vein isolation (PVI), posterior wall insulation (PWI) and electrical insolation of left atrial auricle (LAAI) with simultaneous occlusion with the device. **Case report:** 76-year-old woman with persistent atrial fibrillation was referred to our center for the implantation of a left auricle occlude (LAAO) due to its high thromboembolic risk and contraindications to anticoagulant therapy. As her atrial fibrillation caused signs of heart failure we planned before installing LAAO, to do PFA PVI, PWI and LAAI in the same act. Initially, we used one of the 3D heart mapping systems that we used to display an electro anatomical map of the left atrium, and to determine the quality of electrical activity in the left atrium. After that, we decided to use PFA to isolate all PV, PW and LAA. After the insulation of LAA, we decided to install the Amplatzer Amulet 31 mm device, which was then positioned in LAA under the control of angiography and transesophageal ultrasound (TEE) which confirmed the complete occlusion of LAA. At the end of this part of the procedure, we did an electrical cardioversion and shortly after we reached the sinus rhythm, atrial tachycardia (AT) cycle 320ms was initiated. As we had a stable cycle arrhythmia, we decided to map AT. The best response to Entrainment we had the middle segment of the front of the left atrium. Reproducibly in the same region with a high-resolution catheter (HD grid) we received fragmented, low-amplitude signals. When introducing the PFA catheter (Farapulse) into the desired position, we mechanically interrupted the tachycardia, which restarts after about 10sec. It was decided before the new application to check the safety risks so that with a large output we stimulated one of the poles of the catheter to prove that we are not close to the conductive system, according to our map the conductive system is approximately 2.5 cm away from the focus of the arrhythmia. When we were convinced of the security aspects, we started with the PFA. After the delivery of the first impulse (2.0 kV) AT was interrupted. With repeated provocations of isoproterenol and aggressive stimulation protocols, we could no longer initiate atrial arrhythmias and the procedure was successfully completed. **Conclusion:** The presented case represents our view of complete care for patients with persistent atrial fibrillation. Due to its excellent safety profile and efficiency, it is likely that the PFA will become the dominant modality of ablation in the left atrium in the foreseeable future. Concomitant PFA PVI, PWI, LAAI and LAAO implantation is safe and fast and procedure, which is an important aspect for patients with atrial fibrillation and high thromboembolic risk who are the most fragile patients in clinical practice.

Ivica Benko, Šime Manola, Nikola Pavlović, Ante Lisičić, Ana Jordan, Marina Budetić, Mateja Lovrić, Mirela Adamović, Marina Žanić, Mario Tomašević, Ivan Horvat

Atrial fibrillation (AF) is the most common cardiac arrhythmia encountered in clinical practice with significant morbidity and mortality. The current guidelines and consensus documents on the management of AF state that pulmonary vein isolation (PVI) is a recommended strategy during the treatment of patients with drug-refractory symptomatic paroxysmal AF. The cornerstone of AF catheter ablation is the complete isolation of pulmonary veins by linear lesions around their antrum, either using point-by-point radiofrequency ablation or single-shot ablation devices like cryoballoon ablation (CBA). As the CBA still requires the use of fluoroscopy and iodine contrast, a novel 3D mapping system Kodex-EPD was used with the aim to reduce both fluoroscopy and contrast usage (1, 2). The feasibility and safety of fluoro-free ablation were tested. Differences in nurses’ interventions were also recorded in relation to the classic CBA procedure. During the 2-month period, 15 consecutive patients (9 males and 6 females) undergoing CBA were enrolled (age 60±11). Average time of patient preparation until transseptal puncture was 16±5 minutes while the average mapping time was 12±4 minutes. 7 procedures were performed completely without any use of fluoroscopy, and iodine contrast was used for a single pulmonary vein in only one patient. In all patients, pulmonary vein isolation was achieved without any periprocedural complications. Although on a small number of patients, it can be concluded that CBA with the support of a dielectric mapping system is safe, significantly reduces the need for fluoroscopy and contrast, and in a certain way represents additional engagement in terms of nursing interventions when preparing the patient for the procedure.

Antonela Barišić, Željka Božić

Implantable cardioverter defibrillators (ICD) are currently one of the most efficient methods of treating ventricular arrhythmia and enhancing a healthy lifestyle. (1) The ICDs success rate is very high, reaching up to 98%. Besides its function of defibrillating, it also has the function of a single-chamber electrostimulator, so it can accelerate a slow heartbeat. Due to its efficiency and the lesser effectiveness of medications for heavier forms of ventricular arrhythmias, doctors are more susceptible to implanting ICDs to reduce patients’ mortality. Treatments with ICD are also connected to the negative psychological states of patients, such as anxiety, depression, panic, and a lower quality of life. (2) Current research performed on patients with implanted ICDs has shown that 13-38% of patients have shown some form of anxiety from fear and worry, as well as a lack of education about the device. Patients who have an ICD implanted fear mostly shock delivery, the possibility of a malfunctioning device, embarrassment, and death. ICD shock is a unique form of treatment, and it has its consequences in causing psychological disorder. Because of its uniqueness nurses need to care for patient holistically and cater their abilities of education to every patient individually. It is necessary to collect patients’ anamnestic data and allow patients to express their opinions and fears about the device to allow the nurse to recognize areas of fear, stress, and worry in the patient and to use their unique abilities in education. When educating the patient before and after implantation, we need to explain the risk during and after ICD implantation. We need to warn him about shock delivery, possible complications, procedures with the wound, how to manipulate the arm on the side of the implanted ICD and educate him to pay close attention to devices and areas that could interfere with the device. Patients who have an ICD implanted are in a constant state of fear, and they need help learning how the device works, how complications could occur, how to prevent them, and how to keep living normally. Due to the specificity of shock delivery, it is necessary to educate the patient about the prevention of injury so that when the signs of shock delivery happen, the patient will know what to do.

Renata Jažić

The cardiology day hospital, part of the Clinical Department of Cardiovascular Disease at the University Hospital Centre in Osijek, started working in April 2017. Patients are enabled to conduct diagnostic procedures, treatment, application and monitoring of certain therapeutic procedures, examinations, education of patients and family members, and the dispensing and administration of drugs approved by the Drug and Therapeutics Committee. Last year, 1.074 cardiac catheterizations and twelve electro conversions were performed, as well as 1.232 outpatient physical examinations. Following outpatient physical examinations, 121 patients received venous therapy, twenty-four patients with hypercholesterolemia received subcutaneous therapy, and four patients received a specific therapy for Fabry’s disease. Therapy approved by the Drug and Therapeutic Committee was issued to 509 patients. Residents, cardiologists, and nurses participate in daily work. Nurses need to be trained and educated to react promptly, recognize complications, and alert physicians if an adverse event occurs. They need to have developed communication skills to work in a multidisciplinary team, of which they remain an integral part. The nurse orders, interprets, presents, and monitors diagnostic tests on patients. She collaborates with patients and family members daily, is constantly available via phone or email, and develops and maintains excellent relationships with patients. Initial ˝D2˝ referrals issued by family medicine doctors are valid for one year and provide patients access to health care in the cardiology day hospital. This method of medical practice reduced the need for hospitalizations, improved patient quality of life, and reduced treatment costs significantly (1).

Lea Saftić, Ružica Višnjovski, Dajana Bura-Nekić, Marijan Krpan

Acute myocardial infarction is myocardial necrosis caused by interference of the coronary artery. Acute myocardial infarction complicated by cardiogenic shock is quite rare and occurs in only 5-10% of patients who then experience critically decreased myocardial contractility and low cardiac output. The Impella 2.5 with SmartAssist are temporary ventricular support devices and are used in only high-risk percutaneous coronary interventions (1, 2). This paper presents a case study in which Impella implementation is used as a treatment in an urgent acute myocardial infarction case. The Impella 2.5 in conjunction with an Automated Impella Controller reported a great result in the treatment of myocardial infarction complicated by cardiogenic shock in a 51-year-old patient at the University Hospital Centre Rijeka.

Mihaela Roguljić

**Introduction:** Cardiac patients often suffer from unrecognized symptoms of depression. The provision of spiritual healthcare is regarded as a form of prevention of the symptoms of depression (1). Aim: To examine the correlation between daily spiritual experience and depression among cardiac patients. **Patients and Methods:** A cross-sectional study was carried out at the Institute for Cardiovascular Diseases of the University Hospital Center Osijek. The inclusion criterion was the presence of cardiovascular disease. There were 182 subjects participating in the study. The research instrument was an anonymous survey, that included sociodemographic data, the daily spiritual experience scale, and the Beck Depression and Anxiety Inventory. **Results:** Five subjects (2.7%) suffered from severe depression, while 31 subjects (17%) suffered from severe anxiety. 115 subjects (63.2%) felt very close or as close as possible to God, 41 subjects (22.5%) felt somewhat close to God, and 26 subjects (14.3%) did not feel close to God. There was no significant correlation between daily spiritual experience and the anxiety and depression assessments. The only significant and strong positive correlation is the correlation between anxiety and depression – subjects suffering from more severe anxiety also suffer from more severe depression, and vice versa. **Conclusion:** Based on the data obtained in this research, it has been confirmed that depression and anxiety are present among cardiac patients and that they represent an independent risk factor for the onset of cardiovascular diseases. The need to address psychosocial factors must be recognized by cardiac care nurses to improve the patients’ quality of life. By applying specific knowledge involving the concept of spirituality, nurses help patients achieve spiritual balance and promote health and well-being.

Iva Lazinica

**Introduction**: Acute myocardial infarction is one of the leading causes of death in the developed world, and it is divided into those with or without ST-segment elevation. Myocardial infarction is necrosis caused by a sudden decrease in coronary flow to the affected part of the myocardium. Our aim was to determine the relationship of risk factors to the outcome of percutaneous coronary interventions and to determine the frequency of positive percutaneous coronary interventions in the General Hospital Šibenik-Knin County. **Patients and Methods**: The research was conducted as a cross-sectional study with a convenience sample. Patients hospitalized in the General Hospital Šibenik-Knin County with symptoms of myocardial infarction with or without ST elevation during the 2021 pandemic year were included in the study. Data for this research were extracted from the Hospital Information System after the approval of the Ethics Committee of the General Hospital Šibenik-Knin County. **Results**: We included 118 patients with myocardial infarction, of whom 67 (56%) had non-ST-segment elevation myocardial infarction and 51 (43%) had ST-segment elevation myocardial infarction. In terms of gender, men are more represented (81, or 68%) compared to women. The median age of patients is 71 years. 19 (17%) patients recovered from COVID-19, and 42 (36%) were vaccinated. Percutaneous coronary intervention without stenting was performed in 25 (21%) patients, and in 74 (62%) patients, percutaneous coronary intervention with stenting was performed. Aortocoronary bypass was performed in three (3%) patients. **Conclusion**: By searching professional data bases, papers were found with the results of similar research that confirmed our results (1-3). Namely, the same risk factors were determined, only with a different ratio and gender. The analysis of the results confirmed known risk factors that were present in almost all patients, which indicates the need for active prevention measures and action on modifiable risk factors.

Ana Ljubas, Ivica Benko, Ivica Matić

## Dear colleagues, It is our great honor and pleasure to welcome you all to the 9th Congress of Croatian Association of Cardiology Nurses which will be held in parallel with 14th Congress of Croatian Cardiology Society in Zagreb, Westin Hotel, from 24th to 27th November 2022. Following the postponement of the conference due to the COVID-19 pandemic in 2020, we are continuing the tradition of hosting a major national cardiology conference. We would like to thank the president of Croatian Cardiac Society, academician Davor Miličić, for the invitation and support to organize our congresses together. Our national congresses bring together health professionals involved in cardiovascular care in every aspect of the health system in our homeland and neighboring countries. Throughout the four days of the congress, we attempted to cover all relevant issues and challenges in cardiology practice today. Congress will feature symposiums of CACN working groups and thematic sessions with chosen subjects proposed by attendees. Thematic workshops run by our experts are also included in professional content. The welcome speech and honorary lecture will be delivered by the president of ACNAP, prof. Izabella Uchmanowicz PhD. A special lecture on compassion and empathy will be given by prof. Tonči Matulić, PhD, as 33 months have passed since we began to live and work under challenging circumstances and saw how crucial it is to preserve and strengthen fundamental human values. We thank Assoc. Prof. Mario Ivanuša, MD, PhD for his overall help in the preparation and publication of articles in the journal Cardiologia Croatica. We believe the scientific contents, which we have prepared, will contribute to your professional development, as well as that your active participation in constructive discussions will contribute to the success of our congress. Predsjednici kongresa / *Congress Directors* **Ana Ljubas**, mag. med. techn., FESC **Ivica Benko**, dipl. med. techn., ECDSAP Dr. sc. **Ivica Matić**, mag. med. techn.

Fran Šaler, Tomislava Bodrožić-Džakić Poljak, Robert Blažeković, Jasmina Ćatić, Šime Manola

**Case report**: We present a case of an asymptomatic patient with atrial flutter and giant right atrial myxoma. 60-year-old male was referred to a cardiologist after a preoperative assessment where atrial flutter was verified for the first time. The patient was asymptomatic, and his history was unremarkable, without cardiovascular risk factors or burdening family history. During the examination, right atrial (RA) flutter with fast ventricular response was verified. During the echocardiography (ECHO), a large (9x10cm), isoechogenic, hypermobile, lobulated, and partially calcified mass was verified on the free anterior/lateral wall of the RA. During diastole, the mass completely protruded through the tricuspid valve in the right ventricle cavity but did not reach the right ventricular outflow tract; during systole, it protruded into the superior vena cava. Coronary angiography was performed, and coronary artery disease was excluded. Blood analysis was unremarkable, except for elevated brain natriuretic peptide (NT-proBNP 1877pg/mL). The patient was referred to a cardiac surgeon, and the tumor was removed. Due to severe tricuspid annular dilatation and tricuspid regurgitation (TR), tricuspid valvuloplasty with tricuspid ring implantation was performed. Postoperative recovery was unremarkable. Pathological analysis revealed a large tumor consisting of mesenchymal cells and a prominent stroma with areas of bleeding, coinciding with myxoma. Seven days after surgery, ECHO was performed which confirmed dilated RA with mild TR, and no residual tumor masses. A second check-up was performed after three months, revealing regression in the size of the RA, minimal TR, and the patient reported no symptoms. **Conclusion:** We present this case because of the unusual localization of the tumor, its size, and the complete absence of symptoms (1). Atrial flutter acted as a compensatory mechanism, as it enabled right ventricle filling during early diastole, resulting in absence of symptoms. Effective atrial contraction would occlude the tricuspid valve and drastically reduce the filling of the right ventricle.

Marijana Knežević Praveček, Krešimir Gabaldo, Domagoj Mišković, Ivan Bitunjac, Ivana Grgić, Jelena Jakab, Domagoj Vučić, Ivica Dunđer, Blaženka Miškić, Katica Cvitkušić Lukenda

Cardiovascular disease is the most common cause of late morbidity and mortality among cancer survivors. The incidence of cancer and acute coronary syndrome in the same patient requiring percutaneous coronary intervention (PCI) is increasing significantly. The reported prevalence of cancer among patients with acute coronary syndrome ranges between 3% and 17% (1). In our institution in the past ten months, the prevalence of cancer among patients with acute coronary syndrome (ACS) who underwent PCI was about 10% (3% in active cancer treatment). It was found that lung, prostate, stomach, pancreas, and breast cancer are the most common types associated with ACS, which corresponds to our observations. A proinflammatory and hypercoagulable state with increased platelet activation and aggregation commonly occurs in cancer, increasing the prevalence of ACS. New cancer treatments have significantly improved cancer survival, on the other hand, this has at the same time led to an increase in the incidence of cardiovascular disease. Direct endothelial injury can be induced by radiotherapy. In the general population, a non-ST elevation myocardial infarction (NSTEMI) is the most common clinical presentation of ACS in cancer patients. Myocardial infarction with non-obstructive coronary arteries and Takotsubo syndrome can also occur in cancer patients, more often in women. Treatment of ACS in cancer patients should be based on an assessment of the risk of thrombosis and bleeding. Treatment should be tailored to each patient, not only according to the ACS subtype (unstable angina, NSTEMI and ST elevation myocardial infarction), but also considering the stage and type of cancer, anemia and thrombocytopenia, risk of bleeding, hemodynamic stability, life expectancy, previous or current cancer therapy, future treatment plans, planned operations and prognoses. Despite the recognized clinically relevant impact of cancer, cancer is not included in ischemia and bleeding scores such as The Global Registry of Acute Coronary Events (GRACE) and Can Rapid stratification of Unstable angina patients Suppress Adverse outcomes with early implementation of the ACC/AHA guidelines (CRUSADE). Patients with concomitant cancer and coronary artery disease are underrepresented in most ACS trials. One of the most relevant issues strongly limiting the invasive strategy in cancer patients is the prospect of dual antiplatelet therapy required after PCI. The presence of cancer should not limit the effective and safe treatment of ACS but requires a strict assessment of the risk of bleeding and thrombosis, in both cases with pharmacological and interventional treatment.

Elnur Tahirović

**Introduction:** Atrial fibrillation (AF) is the most common cardiac arrhythmia leading to a five-fold increased risk of stroke. Timely detection of AF is important for the initiation of appropriate therapy and the prevention of adverse outcomes such as AF-related stroke. The aim of this pilot study was to assess the use of a photoplethysmography (PPG)-deriving smartphone application (app) for early detection of AF and initiation of appropriate treatment to avoid AF-related complications such as stroke (1, 2). **Patients and Methods:** Participants were instructed to perform heart rhythm measurements twice daily and when experiencing symptoms for 7 days using a PPG-deriving smartphone application. All participants with possible AF based on the results of the PPG-deriving app were invited for a confirmatory 24h Holter electrocardiogram (ECG). **Results**: A total of 201 patients participated in the study with a mean age of 54 years, ranging from 40 to 84 years. In total, 55% of the population was male, and the AF prevalence was 5.47% (male n= 6; age 61.7±5.3). All patients with possible AF based on the PPG measurements were confirmed on 24h Holter ECG. There were 3 patients without previously diagnosed AF. Nine patients (82%) were known with hypertension, five (45%) suffered from heart failure, and 7 (64%) were on anticoagulation therapy. One patient with AF had already a stroke. The thromboembolic risk evaluated with the CHA2DS2-VASc score was high in participants with AF (score ≥2). In this pilot study, the prevalence of AF was higher among participants with lower levels of education. **Conclusion:** The use of smartphone-based technologies for the detection of AF has proven to be an effective way of screening the population for this heart rhythm, as all patients with a positive result based on the 7-day screening were confirmed via the 24-hour Holter ECG. Although this is a small pilot study, the results indicate that the number of patients with AF is higher in relation to available statistical data and date from everyday medical practice. PPG-deriving technologies enable remote AF detection and may contribute to timely initiation of appropriate treatments to avoid complications such as AF-related strokes. One of the major advantages of this approach is the fact that physicians can remotely screen and follow-up patients at risk without the need for face-to-face contacts.

Nihad Mešanović, Elnur Smajić, Samir Kamenjaković

Artificial intelligence (AI) is an integral part of clinical decision support systems (CDSS) - in this context, AI refers to a collection of computational concepts that can be summarized as a computer ability to generalize learning in order to autonomously and efficiently achieve complex tasks. Machine learning (ML) techniques, such as Artificial Neural Networks (ANNs) and support vector machines (SVMs), are based on models with parameters that can be optimally corrected using different algorithms, and it achieves this by using algorithms to improve task performance without needing to be explicitly programmed and can be broadly divided into supervised and unsupervised approaches. With this objective, the term deep learning has been introduced to characterize ML based on deep ANN architectures with multiple layers of artificial neurons. It has turned out to be very good at discovering intricate structures in high dimensional data and is, therefore, applicable to many domains in science, business and government (1). Furthermore, deep learning models can learn from input data, including numbers, text or even combinations of input types (2). Cardiologists make decisions for patient care from data, and they tend to have access to richer quantitative data on patients compared with many specialties. AI requires close collaboration among computer scientists, engineers, clinicians, other healthcare professionals, and regulatory authorities to identify the most relevant problems to be solved. AI is currently being investigated in several cardiology domains, from CDSS to imaging interpretation, nuclear cardiac imaging as well as voice technology in cardiac practice. As a result, researchers have proposed new innovative ideas and practices related to the diagnostic and therapeutic management of cardiovascular diseases, promising ground-breaking developments for both cardiovascular sciences and care (3). Integrating AI into cardiology practice is a change that the profession should embrace. AI has the potential to provide physicians access to actionable data in even greater depth than ever before. Yet, despite the apparent potential, the impact of AI in current clinical practice is still limited.

Karlo Golubić, Nikola Kos, Tonći Batinić, Mislav Vrsalović

Pulmonary embolism remains the one of the commonest cardiovascular disease, the severity of which is variable and can be lethal. The incidence is expected to increase due to the aging population. Intermediate-high risk pulmonary embolism is characterized by hemodynamical stability, but elevated mortality risk and both radiographic and laboratory signs of right heart strain. Thrombolysis remains a possible life saving treatment option but bears an increased risk of potentially life-threatening hemorrhage. Optimal treatment is still not established. (1-3) We present a series of intermediate-high risk patients treated in our hospital with thrombolytic therapy (n=4, 2 male, median age 58.5) and compare relevant direct and indirect values of right ventricular load before and after treatment (**Table 1**). We also provide a summary of our clinical approach in light of current guidelines and two meta-analyses. ### TABLE 1: Comparison of relevant direct and indirect values of right ventricular load before and after treatment. | **Before treatment** | **Before treatment** | **Before treatment** | **After treatment** | **After treatment** | **After treatment** | | --- | --- | --- | --- | --- | --- | | **SO2 (%)** | **TnI (ng/L)** | **NTproBNP (ng/L)** | **SO2 (%)** | **TnI (ng/L)** | **NTproBNP (ng/L)** | | 80 | 657 | 6103 | 98 | 35 | 83 | | 82 | 61 | 3522 | 92 | <10 | 145 | | 84 | 190 | 9122 | 97 | 262 | 2976 | | 94 | 125 | 2597 | 96 | <10 | 139 |

Nikola Kos, Karlo Golubić, Tonći Batinić, Mislav Vrsalović

Pericardial effusion with tamponade and pulmonary embolism as concomitant diseases are found almost exclusively in patients with cancer and pose a diagnostic and therapeutic dilemma (1, 2). We present a case of a 73-years-old female patient with concomitant cardiac tamponade and pulmonary embolism. At initial presentation patient complained about progressive dyspnea and showed clinical signs of imminent cardiac tamponade with reduced blood pressure and tachycardia and the “electrical alternans” pattern in the electrocardiogram (**Figure 1**). After initial pericardiocentesis, hemodynamic stability was obtained. Due to concomitant pulmonary embolism, therapeutic dose of heparin was initiated, without any hemorrhagic complication during hospitalization. Pericardial fluid analysis showed metastatic cells and ovarian cancer as a primary site was found on the CT scan. After discharge, treatment with direct oral anticoagulant (apixaban) was continued and chemotherapy with capacitabine was started. The patient is doing well on routine three-month follow up. FIGURE 1. ECG with “electrical alternans”.

Dubravka Šušnjar, Josip Varvodić, Savica Gjeorgjievska, Nikola Slišković, Igor Rudež

**Introduction:** Aortic dissection is a high mortality rate disease with incidence of 2,5-3,5/100000 people per year (1, 2). Primary manifestation of aortic dissection is sudden and persistent chest and back pain. 1/3-1/2 aortic dissection with neurological symptoms have no chest pain. Without surgical intervention, dissection mortality at 3 days after onset of symptoms is greater than 50% (3). **Case report**: 58-year-old female previously healthy, initially presented with cerebrovascular insult and right sided hemiparesis. On admission, patient was unconscious, without verbal contact, anisocoria was presented. Head Computed tomography (CT) scan did not show signs of ischemia, hemorrhage, or tumor. CT angiography showed dissection of left internal carotid artery and verified diagnosis of acute aortic dissection Stanford type A with retrograde intramural hematoma and large pericardial effusion **(****Figure 1****)**. Due to threatening tamponade, pericardiocentesis was performed, and guide wire was place in the true lumen through femoral artery. Patient was immediately transferred to the operating room. The replacement of the root and ascending aorta graph with reconstruction of coronary arteries was performed (sec Bentall). Aortic arch was replaced with reimplantation of supra-aortic branches and implantation of stent graft in thoracic aorta (Evita Open Neo) **(****Figure 2****)**. Circulatory arrest lasted 36 minutes, operation was finished without complications. She was extubated on first postoperative day, with significant neurological improvement fourth day. Control CT aortography showed proper flow through graft, coronary arteries, supra-aortal branches, with no signs of paravalvular endoleak or pseudoaneurysm. Head CT scan showed hypodense areas in right hemisphere in terms of acute embolic ischemia. Echocardiography showed good function of mechanical aortic valve (mean pressure gradient 10 mmHg, aortic valve area velocity time integral 2,2 cm2), without regurgitation and normal ejection fraction of the left ventricle. Intensified physical therapy led to a complete neurological recovery. Patient was discharged nineteenth postoperative day in good condition. FIGURE 1. CT angiography image shows dissection of the ascending aorta and intramural hematoma. FIGURE 2. Intraoperative image of replaced aortic arch with reimplantation of supra-aortic branches and implantation of a stent graft in the thoracic aortae (Evita Open Neo 26/24). **Conclusion:** Considering the atypical manifestation of aortic dissection in forms of neurological symptoms, such patients represent a demanding challenge in establishing the diagnosis as well as in its prompt treatment.

Zdravko Babić, Marin Pavlov, Petra Radić, Jozica Šikić, Edvard Galić, Tomislav Letilović, Diana Balenović, Davor Horvat, Luka Perčin, Dubravka Šipuš, Valentina Obadić, Davor Miličić

**Introduction:** In 2020 Croatia was stuck with two major earthquakes: on March 22nd with epicenter 7 km north of Zagreb city centre and on 29th December with epicenter 5 km south of city of Petrinja (5.5 and 6.2 degrees on the Richter scale respectively). The authors sought to investigate whether these events had an influence on characteristics and number of patients with cardiac chief complaints examined in the Emergency Departments (ED) (1, 2). **Patients and Methods:** Data on all emergency visits of patients with cardiac chief complaint examined in two University Hospital Centres (UHC) (Sestre Milosrdnice UHC, Zagreb and Zagreb UHC, Zagreb), two University Hospitals (UH) (“Sveti Duh UH, Zagreb and “Merkur” UH, Zagreb) and two regional hospitals (Sisak General Hospital, Sisak and Karlovac General Hospital, Karlovac) examined 7 days prior to earthquake, on the day of each earthquake, and during subsequent 6 days were collected. **Results:** In the examined period, there were 5575 ED visits (average age 66 years, female gender 45%), out of which in 1251 (22.4%) cases the chief complaint was cardiac. While in all patients seen after the earthquake only more often primary cardiac diagnosis found was non-anginal chest discomfort (28.8% vs 18.0%; p<0.001), when narrowed down the patients group to only the ones who were located within the 20 kilometers from the epicenter we found that there was significantly more patients with acute myocardial infarction (14.5% vs 22.8%; p= 0.028), acute elevation of blood pressure (10% vs 21.8%, p= 0.001), as well as more paroxysmal arrhythmias treated with electrocardioversion (0.9% vs 4.5%, p=0.022) (Table 1). ### TABLE 1: Comparison of patients examined at the emergency department prior to the earthquake and on the day or on days following the earthquake. | | **Total population** | **Total population** | **Total population** | **Within 20 km of epicentre** | **Within 20 km of epicentre** | **Within 20 km of epicentre** | | --- | --- | --- | --- | --- | --- | --- | | | **prior to EQ** | **on the day or after the EQ** | **P** | **prior to EQ** | **on the day or after the EQ** | **P** | | | **Count (%)** | **Count (%)** | | **Count (%)** | **Count (%)** | | | Age | 72 (65-80) | 68 (59-79) | <0.001 | 71 (59-80) | 66 (57-76) | 0.004 | | Female gender | 283 (46.9%) | 277 (42.9%) | 0.158 | 108 (48.9%) | 76 (37.6%) | 0.020 | | Medical history: | | | | | | | | - Hypertension | 475 (78.9%) | 407 (63.4%) | <0.001 | 182 (82.4%) | 147 (72.8%) | 0.018 | | - Dyslipiedmia | 247 (41.2%) | 210 (32.9%) | 0.002 | 97 (43.9%) | 87 (43.1%) | 0.865 | | - Diabetes | 120 (20.0%) | 109 (17.1%) | 0.182 | 48 (21.8%) | 44 (21.9%) | 0.986 | | - Active smoking | 125 (23.4%) | 148 (25.9%) | 0.333 | 46 (23.0%) | 58 (32.6%) | 0.037 | | - Previous CAD | 258 (42.8%) | 210 (32.9%) | <0.001 | 110 (49.8%) | 78 (38.6%) | 0.021 | | Admission | 251 (41.7%) | 223 (34.6%) | 0.010 | 89 (40.5%) | 83 (41.1%) | 0.895 | | Time in ED | 4 (2-7.25) | 4 (1.5-8) | 0.066 | 4 (2-6) | 4 (2.15-8) | 0.099 | | Hospital stay | 5 (3-9) | 5 (3-7) | 0.195 | 4 (2-6) | 4 (2-7) | 0.448 | | Non-anginal chest discomfort | 109 (18.0%) | 186 (28.8%) | <0.001 | 27 (12.2%) | 19. (9.4%) | 0.354 | | Main diagnosis | | | | | | | | - Myocardial infarction | 100 (16.6%) | 89 (13.8%) | 0.170 | 32 (14.5%) | 46 (22.8%) | 0.028 | | - Unstable angina | 32 (5.3%) | 12 (1.9%) | 0.001 | 14 (6.3%) | 5 (2.5%) | 0.056 | | - Decompensated HF | 117 (19.4%) | 60 (9.3%) | <0.001 | 53 (24.0%) | 22 (10.9%) | <0.001 | | - Arrhythmia | 114 (18.9%) | 95 (14.7%) | 0.048 | 47 (21.3%) | 34 (16.8%) | 0.247 | | - Hypertension | 117 (19.4%) | 90 (13.9%) | 0.010 | 22 (10.0%) | 44 (21.8%) | 0.001 | | Coronary angiography only | 5 (0.8%) | 9 (1.4%) | 0.341 | 1 (0.5%) | 2 (1.0%) | 0.510 | | PCI | 80 (13.2%) | 74 (11.5%) | 0.341 | 28 (12.7%) | 35 (17.3%) | 0.179 | | Electrical cardioversion | 10 (1.7%) | 13 (2.0%) | 0.636 | 2 (0.9%) | 9 (4.5%) | 0.022 | | Mechanical ventilation | 12 (2.0%) | 9 (1.4%) | 0.417 | 5 (2.3%) | 2 (1.0%) | 0.306 | | CPR | 11 (1.8%) | 9 (1.4%) | 0.549 | 4 (1.8%) | 3 (1.5%) | 0.794 | | Inhospital mortality | 19 (3.2%) | 13 (2.0%) | 0.201 | 6 (2.7%) | 5 (2.5%) | 0.877 | [†] EQ = earthquake; CAD = coronary artery disease; ED = emergency department; HF = heart failure; PCI = percutaneous coronary intervention; CPR = cardiopulmonary resuscitation **Conclusion:** In this study, increment in the frequency of cardiac emergencies was detected after a moderate earthquake in patients who were within 20 kilometers of the epicenter. They had significantly more often acute myocardial infarction, acute elevation of blood pressure, as well as paroxysmal arrhythmias treated with electrocardioversion. The health system should be prepared to treat a larger number of cardiac patients in difficult conditions after the earthquake.

Vedran Pašara, Lucija Lučev, Vlatko Šulentić, Andreja Bujan Kovač, Romana Perković, Daniel Lovrić

**Introduction:** Contrast-induced encephalopathy (CIE) is a rare neurological complication of the intravascular administration of iodinated contrast agent in angiographic procedures. Patients with CIE can experience various neurological deficits that usually occur shortly after the administration of iodinated contrast agent and resolve spontaneously within 48 hours (1, 2). **Case report:** 75-year-old male patient who received a heart transplant 13 years before the event and had undergone a total of eleven coronary angiographies and five percutaneous coronary interventions (PCI) due to cardiac allograft vasculopathy (CAV), was admitted for a regular follow-up. Coronary angiography followed by right coronary artery PCI with two drug-eluting stents implantation was performed during this hospital stay. An iodinated contrast agent was used. The patient received unfractionated heparin during the procedure. Two hours later the patient was found sitting on the bed, head and eye deviated on the left, unresponsive with oroalimentary and gestural automatisms. Both pupils were equal. There was no facial asymmetry or lateralization. A head computed tomography (CT) scan was performed immediately and showed no signs of acute ischemia, hemorrhage, or focal intracranial process. Levetiracetam was introduced due to a suspected seizure. The cranial CT follow-up on the next day showed no abnormalities. Electroencephalography (EEG) revealed diffuse dysrhythmic changes with the focal slowing on the right frontotemporal and left frontocentrotemporal region, and paroxysmal discharges of high voltage low-frequency delta activity (encephalopathic pattern). Therefore, levetiracetam was continued. The patient was discharged on the fifth day oriented, responsive, and without speech impairment. Three months later, EEG showed a mild slowing in the right frontocentrotemporal and left frontotemporal regions. **Conclusion:** CIE is a rare complication of cardiac catheterization, probably underrecognized and underdiagnosed. However, it should not be overlooked, and invasive cardiologists should be aware of this condition.

Duška Glavaš, Admira Bilalić, Antonela Karačić, Mislav Lozo, Mijo Meter, Mate Zvonimir Parčina

**Introduction:** Acute myocardial ischemia is a well-known cause of ventricular arrhythmias, often fatal. Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are mostly seen during ongoing myocardial ischemia and within first 72 hours of a myocardial infarction which often results in hemodynamic instability with significant risk of mortality (1, 2). This is a case report of a 42-year-old male presenting with a hemodynamically unstable electrical storm following an acute in-stent thrombosis. **Case report:** 43-year-old man presented to the Emergency Department (ED) with retrosternal chest pain. His initial electrocardiogram (ECG) showed an ST elevation in anteroseptolateral leads. In the ED he suffered a cardiac arrest due to VF. On successful cardiopulmonary resuscitation with defibrillation, urgent coronarography was performed with the placement of one drug-eluting (DE) stent in the proximal left anterior descending artery. Postprocedural, in the Coronary Care Unit an electrical storm with incessant and recurring PVT and VF refractory to medical treatment and requiring multiple direct-current shocks (in total over 60 times). An indication was made for re-evaluation by coronary angiography. Prior to the procedure in the Catheterization Laboratory a peripheral veno-arterial (VA) femoro-femoral extracorporeal membrane oxygenation (ECMO) was placed. Repeated angiography showed an acute in-stent thrombosis and reperfusion was successfully performed with placement of a second DE stent. After the intervention the patient was rhythmically stable with no recurrence of ventricular arrhythmias. He was successfully weaned off VA-ECMO 8 days later and discharged 55 days later with optimized medical therapy, no clinical signs of heart failure and with no neurological deficits. On follow-up, echocardiography showed hypokinesia of anterolateral wall with left ventricular ejection function 45% and he had no signs of heart failure and no anginal symptoms. **Conclusion:** In the setting of an acute myocardial infarction, an electrical storm following a percutaneous revascularization, especially one refractory to medication and with no evident metabolic cause, should raise suspicion of acute in-stent thrombosis. A low threshold for reintervention should be set in such situations. Temporary mechanical circulatory support, if available, provides a good hemodynamic stabilization for the procedure and for later rhythm and circulatory management.

Marija Grebenar, Petra Radić, Ivo Darko Grabić, Zdravko Babić

**Introduction:** Working in emergency and intensive care is one of the most common occupations that face high levels of occupational stress, which has been shown to have a major impact on the development of early cardiovascular disease. Prolonged exposure to stressors at work increases cardiovascular risk (CVR) (1, 2). The aim of this research is to determine, by measuring vital parameters, whether there is a certain influence of professional stressors on the increase in arterial pressure and pulse and on pathological variations in the electrocardiogram record of health personnel working in intensive cardiac care unit. **Participants and Methods:** Observational case control study conducted on adult health professionals aged 18-65 years, both sexes, working in the Intensive Cardiac Care Unit of the Sestre Milosrdnice University Hospital Centre. Duration of the research was 4 months. **Results:** In the total sample of 17 respondents, the female gender predominated with a share of 70.6%. The average systolic pressure was 128.47 mmHg (standard deviation, SD 8.70), while the average diastolic pressure was 82.65 mmHg (SD 7.31). There was a trend of increasing pressure during the working night (2.57%, SD 6.01), and a decreasing trend during non-working nights (-12.42%, SD 4.55). By comparing diastolic pressure during working and non-working 24 hours, a statistically significant difference was observed with an average value of 8.18 mmHg (p<0.001) increasing during work. By comparing systolic pressure during working and non-working 24 hours, a statistically significant difference was observed with an average value of 7.18 mmHg (p<0.001) increasing during work. In addition, statistical significance was observed in the average difference in the number of QRS, minimum frequency and pressure changes during the night by comparing working and non-working hours all increasing during work (**Table 1**). ### TABLE 1: Comparison of investigated parameters by t test for paired samples. | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | **Paired Samples Test** | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | **Mean** | | **Paired Differences** | | | | | **t** | **df** | **P** | | **Std. Deviation** | **Std. Error Mean** | **95% CI of the Difference** | | | | | | | | | **Lower** | **Upper** | | | | | | | | | | Pair 1 | Mean SBP- work day (mmHg) - Mean SBP-free day (mmHg) | 4.11 | 8.14 | 1.97 | -0.07 | 8.29 | 2.08 | 16 | 0.054 | | Pair 2 | Mean DBP- work day (mmHg) - Mean DBP-free day (mmHg) | 5.31 | 6.71 | 1.63 | 1.86 | 8.77 | 3.26 | 16 | 0.005 | | Pair 3 | Mean SBP- work night (mmHg) - Mean SBP-free night (mmHg) | 10.22 | 7.79 | 1.89 | 6.21 | 14.22 | 5.41 | 16 | 0.000 | | Pair 4 | Mean DBP- work night (mmHg) - Mean DBP-free night (mmHg) | 10.78 | 5.72 | 1.39 | 7.84 | 13.72 | 7.78 | 16 | 0.000 | | Pair 5 | Mean DBP- working 24h (mmHg) - Mean DBP-free 24h (mmHg) | 8.18 | 4.18 | 1.01 | 6.03 | 10.33 | 8.07 | 16 | 0.000 | | Pair 6 | Mean SBP- working 24h(mmHg) - Mean SBP-free 24h (mmHg) | 7.18 | 5.26 | 1.28 | 4.48 | 9.88 | 5.63 | 16 | 0.000 | | Pair 7 | QRS number work day - QRS number free day | 5785.57 | 8926.99 | 2385.84 | 631.28 | 10939.86 | 2.42 | 13 | 0.031 | | Pair 8 | QRS number work night - QRS number free night | 5305.07 | 7800.63 | 2084.81 | 801.12 | 9809.02 | 2.54 | 13 | 0.024 | | Pair 9 | QRS number 24h work - QRS number 24h free | 9499.79 | 13398.92 | 3581.01 | 1763.48 | 17236.09 | 2.65 | 13 | 0.020 | | Pair 10 | Minimum frequency work day - Minimum frequency free day | 6.07 | 20.53 | 5.49 | -5.78 | 17.93 | 1.11 | 13 | 0.289 | | Pair 11 | Maximum frequency work day - Maximum frequency free day | 6.86 | 18.76 | 5.01 | -3.98 | 17.69 | 1.37 | 13 | 0.195 | | Pair 12 | Minimum frequency work night - Minimum frequency free night | 7.14 | 8.65 | 2.31 | 2.15 | 12.13 | 3.09 | 13 | 0.009 | | Pair 13 | Maximum frequency work night - Maximum frequency free night | 6.50 | 17.73 | 4.74 | -3.74 | 16.74 | 1.372 | 13 | 0.193 | | Pair 14 | Minimum frequency 24h work - Minimum frequency 24h free | 7.07 | 7.25 | 1.94 | 2.89 | 11.26 | 3.651 | 13 | 0.003 | | Pair 15 | Maximum frequency 24h work – Maximum frequency 24h free | -0.29 | 14.35 | 3.84 | -8.57 | 8.00 | -0.074 | 13 | 0.942 | | Pair 16 | VES number work day - VES number work night | 2.00 | 7.04 | 1.88 | -2.06 | 6.06 | 1.063 | 13 | 0.307 | | Pair 17 | VES number free day - VES number free night | -0.29 | 0.99 | 0.27 | -0.86 | 0.29 | -1.075 | 13 | 0.302 | | Pair 18 | VES number 24 h work day - VES number 24h free day | 2.79 | 7.59 | 2.03 | -1.60 | 7.17 | 1.374 | 13 | 0.193 | | Pair 19 | SVES number work day - SVES number free day | -0.29 | 2.23 | 0.60 | -1.58 | 1.00 | -0.479 | 13 | 0.640 | | Pair 20 | SVES number work night - SVES number free night | -0.50 | 1.83 | 0.49 | -1.56 | 0.56 | -1.023 | 13 | 0.325 | | Pair 21 | SVES number 24h work - SVES number 24h free | -0.71 | 3.77 | 1.01 | -2.89 | 1.46 | -0.709 | 13 | 0.491 | | Pair 22 | Blood pressure fluctuations during work night (%) - Blood pressure fluctuations during free night (%) | 14.99 | 8.82 | 2.14 | 10.45 | 19.53 | 7.003 | 16 | 0.000 | [†] SBP = systolic blood pressure; DBP = diastolic blood pressure; VES = ventricular premature beats; SVES= supraventricular premature beats **Conclusion:** The research proved the adverse impact of professional stressors on the cardiovascular system of intensive cardiac care unit employees, which increases their cardiovascular risk profile in the long term. It would be desirable to conduct a larger multicenter study with a larger number of respondents, including a larger number of doctors, and a longer follow-up time that would confirm the results of this study.

Tomislava Bodrožić Džakić Poljak, Marin Pavlov, Aleksandar Blivajs, Ilko Vuksanović, Miroslav Raguž, Irzal Hadžibegović, Šime Manola

**Case report:** 64-years-old female was admitted because of subacute myocardial infarction (MI) of inferoposterior wall. Upon admission she was pale, hypotensive, prostrated with loud systolic heart murmur. Due to characteristics of heart murmur, mechanical complication was suspected and echocardiogram showed large (28mm) mid inferoseptal ventricular rupture (VSR). Because of cardiogenic shock with elevated lactates, intraaortic balloon pump (IABP) was inserted, coronary angiography was performed and occluded mid part of right coronary artery was found. With mechanical circulatory support (MCS) by IABP patient was stable with little dose of vasopressors. Cardiac surgeons were consulted and they suggested to postpone the operation. Third day after admission patient deteriorated so we decide to upgrade MCS and switched IABP to Impella CP3.5 with great circulatory improvement. Patient needed no inotropes or vasopressors to maintain mean arterial blood pressure, serum lactate was within normal range and she had no clinical and radiographic signs of pulmonary congestion. Tenth day by admission, surgery was performed. VSR was fixed by huge patch. After surgery, she was getting better but unfortunately died of septic, gram negative, shock. **Discussion:** Current guidelines recommends MCS, dominantly IABP in mechanical complications of acute MI. There are no recommendations for Impella CP usage. Ventricular septal defect is considered as relative contraindication for Impella insertion due to possibility of left-right shunt reversal (1, 2). With careful and precise placement of Impella in left ventricle (LV) and watchful hemodynamic monitoring it can be avoided. We suggest Impella implantation in VSR if the right ventricular function is normal as Impella reduces afterload, pulmonary capillary pressure, unloads LV and reduces wall stress of both ventricles while maintain cardiac output. Possible, but real, negative side of it, would be reversal of shunt to right/left and suction of necrotic myocardial tissue with peripheral embolization.

Josip Stjepanović, Mislav Puljević, Ana Šutalo, Mia Dubravčić Došen, Majda Vrkić Kirhmajer

We analyzed the register in which the etiology of deep vein thrombosis, recurrence, localization of thrombus, complications, primary and secondary treatment and finally treatment complications were listed. The register includes 730 patients treated at the Department of Cardiovascular Diseases in University Hospital Centre (UHC) Zagreb, from 2016 to 2022. Men (49.86%) and women (50.14%) are equally represented in the register. The average age of men is 65, while the average age of women is 72. The age range of patients registered is the same for both sexes, ranged from 21 to 100 years old. Data show that COVID-19, with 20% of the total etiology, is the leading known risk factor for deep vein thrombosis. Compared to previous results, 14% more patients initially had deep vein thrombosis (DVT). No major differences were observed in the localization of the thrombus, with the femoral vein (38%) in first place compared to the previously most common localization, the popliteal vein (27%). Of all hospitalized patients with DVT, 72% did not develop any complications, while pulmonary embolism (PE) was manifested in 28% of those hospitalized. 25% patients presented immediately with PE. The initial treatment of patients with DVT and PE was predominantly (89%) with low molecular weight heparin. In secondary prevention 65% of patients were treated with novel oral anticoagulants (NOAC), which represents an increase in treatment with modern therapy compared to previous data in registry (9%). There was no complication in 98% of patients treated with NOAC, while the remaining patients experienced bleeding (1%), thrombosis and heparin-induced thrombocytopenia (<1%). When comparing the older registry data (2017) and the current one, it is observed that the average age of patients has increased. The average age for men increased by 6 years, while for women it increased by 4 years. There is also a significant increase in the frequency of prescribing NOAC (1).

Nikolina Jupek, Ana Šutalo, Ivana Jurca, Mislav Puljević, Dražen Perkov, Karlo Novačić, Majda Vrkić Kirhmajer

**Background:** Acute limb ischemia (ALI) is defined as a sudden decrease in limb perfusion that requires urgent treatment (1). Treatment methods include surgical, endovascular and hybrid revascularization. The aim of this study is to investigate the results of intra-arterial catheter-directed thrombolysis (CDT) in adult patients with acute limb ischemia, treated at University Hospital Centre Zagreb. **Patients and Methods**: Between 2012 and 2022, 48 patients with ALI, symptoms no longer than 14 days, and viable extremity were treated with CDT. Clinical success was defined by an increase in the ankle-brachial index (ABI)- by at least 0.15 and the absence of rest pain, while technical success is defined as complete thrombolysis of more than 95% of the thrombus or almost complete thrombolysis of more than 70% of the thrombus with continuous flow in at least one crural vessel, without distal thromboembolism. **Results:** The median duration of symptoms was 3 days, during CDT a median dose of 33.0 mg of alteplase was administrated, and the median duration of application was 22 hours. Out of 48 patients, clinical success was achieved in 81.3% of patients and technical in 77.3%. During CDT, 5 patients had a total of 6 major complications (5 major bleeding and 1 major amputation). A statistically significant association was found between clinical success and intervention on native blood vessels vs “in-stent” occlusion, venous bypass, and synthetic bypass graft (p20 cm (p=0.005), major complications (p=0.023), and pre-interventional statin use (p=0.015). Also, patients with clinical success had a significantly higher ABI after a procedure (p<0.001). **Conclusion:** CDT is an effective method of treating ALI, especially in native vessels with occlusion length less than 20 cm. Careful patient selection is needed for high clinical and technical success and an acceptable number of major complications.

Krešimir Gabaldo, Domagoj Mišković, Katica Cvitkušić Lukenda, Ivica Dunđer, Marijana Knežević Praveček

Critical limb ischemia is a clinical syndrome of ischemic pain at rest or tissue loss, such as a nonhealing ulcer or gangrene, associated with peripheral artery disease. Smoking and diabetes are “strong” risk factors for the development of peripheral atherosclerotic disease, and more than 50% of patients with critical ischemia have diabetes. Treatment and diagnostics include a multidisciplinary approach of several specialties including vascular surgeons, radiologists, diabetologists, infectious disease specialists, dermatologists, and cardiologists. (1) For the proper functioning of the team, it is necessary to have a precise diagnostic and therapeutic algorithm. Patients with critical limb ischemia have a one-year risk of amputation and cardiovascular death greater than 25%. The assessment of the risk of amputations is done by calculating the “WI-FI” score. Endovascular treatment is preferred as the first option of revascularization treatment. The main goal of the treatment is to establish flow through at least one vessel to the foot, which often involves addressing the “inflow” and “outflow” regions. Small amputations are often necessary and are an integral part of treatment. Patients with critical ischemia of the extremities have associated significant heart disease. More than 70% of patients have associated coronary artery disease, over 30% of patients have chronic congestive heart failure, and 15% have permanent atrial fibrillation. That all cause a high one-year risk of adverse cardiovascular events and death (>25%) which gives a special importance to the participation of cardiologists in the multidisciplinary team, both in diagnosis and in the actual implementation of endovascular treatment.

Dominik Strikić, Ana Marija Slišković, Andro Vujević, Ivana Sopek-Merkaš, Iveta Merćep

**Introduction**: Dyslipidaemia is one of the leading cardiovascular risk factors. For a long time, successful treatment options were used, with statin therapy being the cornerstone. Nowadays, more and more new agents are being discovered and approved for the treatment of dyslipidaemia. This summary provides a brief overview of newly approved drugs and those still in development. Methods: For this review, online databases were searched using the keywords “dyslipidaemia”, “statins”, “PCSK9 inhibitors”, “inclisiran” and “new agents”. **Discussion**: Statins have been used to treat dyslipidaemia for over 30 years. Studies have shown excellent results in lowering LDL cholesterol levels and reducing cardiovascular risk (1). Therefore, statins have become the most important preventive therapeutics for high-risk patients. However, changes in people’s lifestyles and the fast pace of life have presented us with new challenges and shown us that statins are not enough in some cases. The first monoclonal antibodies approved for the treatment of dyslipidaemia were the PCSK9 inhibitors evolocumab and alirocumab (1, 2). Studies have shown very good results in lowering blood LDL cholesterol levels, so PCSK9 inhibitors, given once weekly, have gradually become a second-line treatment option (2). Recently, the EMA approved a new siRNA molecule called inclisiran that interferes with PCSK9 mRNA translation, thereby lowering LDL cholesterol levels. The main advantage of inclisiran is its dosing scheme of once every three months**3**. Volanesorsen is the first drug to target chylomicrons and lower triglyceride levels. The latest agent in the pipeline is evinacumab, an ANGPLT-3 inhibitor that has shown excellent potential in clinical trials (3). **Conclusion**: The reduction in cardiovascular risk with PCSK9 inhibition and inclisiran therapy is not yet known, but its effect on lowering LDL cholesterol is evident. Conventional statin treatment requires everyday oral administration and highly motivated patients, whereas novel agents administered weekly or even monthly are putting patient compliance first.

Ana Marija Slišković, Livija Šimičević, Majda Vrkić Kirhmajer, Lana Ganoci, Hrvoje Holik, Jure Samardžić, Tamara Božina

**Introduction**: Rivaroxaban has large interindividual trough concentration variability affecting its efficacy and safety. This variability could be associated with age, liver and kidney function, concomitant illness and therapy (1). Rivaroxaban is a substrate of ABCB1 and ABCG2 drug transporters (2), and CYP2J2, CYP3A4/5 metabolic enzymes. The polymorphisms of these genes may affect the pharmacokinetics and consequently safety profile of rivaroxaban. Aim: To evaluate possible risk factors for rivaroxaban-associated bleeding in patients treated for cardiovascular diseases. **Patients and Methods**: Presented data are part of the larger ongoing prospective case-control study “Pharmacogenomics in Prediction of Cardiovascular Drugs Adverse Reaction” (funded by the Croatian Science Foundation) with 402 patients recruited by now. Clinical and laboratory data were collected. Pharmacogenetic analyses were performed using specific TaqMan® DME and SNP Assays on 7500 Real-Time PCR System for genotyping of CYP3A4*1B, *22, CYP3A5*3, CYP2J2*7, ABCB1 (c.1236C>T, c.3435C>T), and ABCG2 (c.421C>A) gene variants. For drug-drug interactions (DDI), The Lexicomp® Clinical Decision Support System was applied. **Results**: Sixteen patients (median age 73 years; rivaroxaban median dose 17.5 mg) with rivaroxaban-associated bleeding: gastrointestinal (N=9), epistaxis (N=5), haematuria (N=1) and gynaecological (N=1) were analysed. In 9/16 DDI with increased bleeding risk were found. Two patients were CYP3A4*22 carriers (*1/*22 and *22/*22), three were CYP3A5*3 heterozygous, four were CYP2J2*7 heterozygous, two patients had ABCB1 T/T+T/T genotype, four ABCG2 C/A and one A/A genotype. Three patients who experienced bleeding did not have any of investigated risk factors. **Conclusion**: Our data suggest a possible role of clinical and pharmacogenetic factors and their interactions in predicting rivaroxaban-associated bleeding, but further comprehensive research is warranted.

Marin Viđak, Ivan Skorić, Danijela Grizelj, Irzal Hadžibegović, Šime Manola, Ivana Jurin

**Introduction:** Coronavirus disease (COVID-19) pandemic is a public health emergency caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Vaccines are the most effective measure for both preventing COVID-19 infections and its complications. Even before the COVID-19, vaccine hesitancy was becoming prevalent in European Union (EU) and Croatia. Vaccine hesitancy is correlated to lack of trust in science, lower levels of education and lower health literacy (1). Lower medication adherence is a problem in treating chronic disease, especially cardiovascular disease. Identifying patients prone to lower drug adherence could help target interventions for better adherence (2). Seeing as data on SARS-CoV-2 vaccination is readily available, vaccination status could help identify these patients. In this study, we wanted to see if vaccination status correlated with drug adherence in patients with cardiovascular disease. **Patients and Methods:** This was a retrospective observational study conducted at Dubrava University Hospital, Zagreb. We recruited patients hospitalized for acute coronary syndrome (ACS) from January 2017 to January 2020. We collected data on sociodemographic data, type of ACS, prescribed drugs, body mass index (BMI) and vaccination status. Adherence score was calculated using Morisky Medication Adherence score. Data was collected either during regular visits or by telephone contact. **Results:** We collected data for 1,441 participants in total. Median age of the participants was 64y (interquartile range, IQR 56-72), with 409 females (29.6%) and 974 (70.4%) males. Majority of participants had at least high school level of education and were retired. Median BMI of the participants was 28.87 (IQR 25.73-31.20). We grouped the participants according to their SARS-CoV-2 vaccination status. The groups did not differ by age, sex, marital status, BMI, or smoking status. The vaccinated group had a higher number of participants with higher level of education and active employment. Medication adherence score was higher in the vaccinated group (odds ratio, OR=1.64 (1.55-1.74), p<0.001). **Conclusion:** Vaccinated participants had a higher medication adherence score. Vaccination status could be used to identify ACS patients that might benefit from an early intervention to improve drug adherence.

Diana Rudan, Marin Viđak, Ivan Skorić, Šime Manola, Tomo Svaguša, Ivana Jurin

**Objective**: Limited data exists about health-related risk behavior among myocardial infarction (MI) survivors. Healthy lifestyle through physical activity, balanced diet and stress management remains the key recommendation in secondary prevention of cardiovascular events. However, this is challenging process that requires many lifestyle changes supported by organized professional help in the community, to encourage participants in the attempt to improve their health. In this study the relationship between COVID-19 vaccination status and dietary habits, among patients after myocardial infarction, has been evaluated. Positive correlation between vaccine hesitancy and poor diet could be explained by the lack of trust in science, lower level of education and lower health literacy (1). **Patients and Methods:** From January 2017 to January 2020, data from 1441 patients hospitalized for acute coronary syndrome in Dubrava University Hospital were reviewed. The median age of participants was 64 years, among them there were 409 females, and 974 males. The participants were divided into groups according to their COVID-19 vaccination status and dietary habits, based on diet questionnaire survey. **Results**: Patients who were not vaccinated less frequently reported daily consumption of fruit, fish, salad, and vegetables, with predominant consumption of pasta, lard, dried meats, white bread and alcohol (p<0.001). **Conclusion**: In our research, COVID-19 vaccination status in patients after myocardial infarction was associated with better dietary habits. This might imply that vaccinated patients show higher level of health literacy. Future research is necessary to establish which healthcare interventions are required in order to manage and maintain the full potential of health lifestyle improvement in those patients.

Fran Rode, Ivan Skorić, Irzal Hadžibegović, Nikola Pavlović, Mario Udovičić, Šime Manola, Ivana Jurin

**Introduction:** Obesity is considered one of the main reversible risk factors for coronary artery disease development. On the contrary, earlier research demonstrated that higher body mass index (BMI) might have a beneficial effect in some patients after acute myocardial infarction - a phenomenon called the “obesity paradox” (1, 2). The aim of this study is to determine a relation between the change in BMI and the long-term outcomes of patients treated for acute myocardial infarction. **Patients and Methods:** The patient registry for myocardial infarction in Dubrava University Hospital collects data on patients with ST-elevation (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) admitted to Department for Cardiovascular Medicine from January 2017. Patients without noted BMI value after 1-year of follow-up were excluded from this trial. A total of 1400 patients were divided into three groups with maintained, increased, and reduced BMI, the latter of which was further divided into groups with intentional and unintentional BMI reduction. The median follow-up time of all patients was 1298 days. We observed and compared the occurrence of major adverse cardiac events (MACE) among the examined groups of patients. **Results:** The group with reduced BMI had a significantly higher incidence of MACE (39.9%) in comparison to the groups with maintained (24.5%, p<0.001) and increased BMI (27.4%, p<0.001). There was no significant difference in the incidence of MACE between the groups with maintained and increased BMI (p=0.353). The patients who died during the follow-up had a significantly greater reduction of BMI than the survivors (1.50 vs 1.14, p<0.001), however, this is not applicable to other MACE. Patients with unintentional reduction of BMI had a much higher incidence of MACE than those with the intention to reduce BMI (69.1% vs 18.9%, p<0.001). **Conclusion:** The results of our study imply that reduction of BMI after undergoing treatment for STEMI or NSTEMI might represent a risk factor for the future development of MACE. Greater BMI reduction is connected to higher mortality, but not the occurrence of other MACE. In previously conducted research, we have not found the outcomes being evaluated based on patient’s intention to lose weight. We demonstrated that unintentional BMI reduction goes in pair with the highest incidence of MACE.

Ivo Planinc, Dubravka Šipuš, Filip Lončarić, Nina Jakuš, Dora Fabijanović, Marijan Pašalić, Hrvoje Jurin, Jure Samardžić, Boško Skorić, Fran Borovečki, Davor Miličić, Maja Čikeš

**Introduction:** Transthyretin amyloidosis (ATTR) is a rare disease with heterogeneous symptoms and unfavorable outcomes unless diagnosed and treated in the early stage. Phenotypes and clinical presentations relate to underlying genetic variants (where genotype heterogeneity is well-known and related to endemic geographic regions) or the acquired form (wild type) (1, 2). The Croatian Transthyretin Cardiac Amyloidosis (CroATTR) Registry is designed as a national, longitudinal, non-interventional, and both retrospective and prospective ATTR registry. **Methods:** We aim to include patients with clinically proven hATTR-CM or wtATTR-CM according to the current guidelines, or family members with confirmed mutation of the TTR gene (regardless of the presence of cardiomyopathy). The registry will acquire basic demographic characteristics and results of genetic testing (for hATTR), followed by clinical work-up capturing patient demographics, quality of life questionnaires, medical and family history, data from 12-lead electrocardiogram (ECG), echocardiography, cardiac magnetic resonance imaging (cMRI) (with an emphasis on typical ATTR red flags), 99mTc- pyrophosphate scintigraphy, electromyoneurography, and myocardial biopsy, as available. The registry will follow disease-specific outcomes: 1. overall survival, 2. cardiovascular mortality, 3. heart failure hospitalizations/unscheduled physician visits, 4. patient reported outcomes in the area of quality-of-life changes. The registry will also collect data on disease- specific treatments in our population: the proportion of patients treated with of guideline directed medical therapies (GDMT) for amyloidosis and heart and/or liver transplantation. The data will be captured at the time of inclusion of the patient in the registry (including retrospective data focusing on the time the diagnosis was first made) and will include prospective recurring visits. Data will be collected and managed using REDCap electronic data capture tools (the design of the database is shown on **Figure 1**). FIGURE 1. Croatian Transthyretin Cardiac Amyloidosis Registry Electronic Case Report Form. **Conclusion:** The CroATTR Registry will aggregate ATTR patients and allow further insights into the occurrence and natural course of disease. A particular emphasis will be made on the rare genetic mutation prevalent in our population, the utilization of guideline directed medical therapies and transplantation procedures.

Anđela Jurišić, Ivan Skorić, Nikola Šerman, Šime Manola, Hrvoje Falak, Irzal Hadžibegović, Ivana Jurin

**Introduction**: Statin use in secondary prevention after acute coronary syndrome (ACS) is one of the most researched areas in cardiology (1). The aim of this study was to determine the association between adherence to statin therapy and major adverse cardiovascular events in patients after a myocardial infarction. **Patients and Methods:** The examined group consisted of 421 patients who were treated for ACS- percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) from 2019 to 2020 at the Dubrava University Hospital, Zagreb. We have collected basic demographic, clinical and laboratory data available in digital medical documentation. Adherence to the drug therapy was measured by Morisky Medical Adherence scale during telephone monitoring. It was primarily analyzed association between adherence to recommended statin therapy and occurrence of major adverse cardiovascular events (MACE), and secondarily the association of other demographic and clinical features with MACE. **Results:** Adherence to therapy after discharge was measured successfully in 371 (88%) patients. Most of them had moderately high adherence. Of the recommended drugs at discharge, the drug that respondents indicated as the one they most often forget to take, do not take regularly as prescribed was statin. Even 11% of patients did not take any dose of statin and 189 patients (51%) took the statin as recommended. A total of 93 (22%) patients experienced a composite MACE. Patients with low adherence to statin therapy had the highest proportion of MACE (26%) compared to the other two groups. Relative risk for experiencing MACE in patients who did not reach value of low-density lipoprotein cholesterol (LDL) <1,8 mmol/L at 12 months follow-up was 1.25 (25% higher relative risk, p=0.248) and was not statistically significant. On the other hand, the relative risk for experiencing MACE in patients who did not reach the target LDL-cholesterol value of less than 2.6 mmol/L after 12 months was 1.68 (68% higher relative risk, p=0.008) and was statistically significant. **Conclusion:** Our study aimed to show that regular statin therapy intake is as much important as achieving target LDL values ​​in reducing MACE.

Tomislav Šipić, Irzal Hadžibegović, Jelena Kursar, Ivan Skorić, Jasmina Ćatić, Šime Manola, Ivana Jurin

**Background:** Obesity has become a great healthcare problem and its incidence has been expanding over past several decades. Taking that fact into account, it is reasonable to expect an increasing number of obese patients with severe aortic stenosis being referred for transcatheter aortic valve implantation (TAVI). Obesity is considered an important and modifiable risk factor for cardiovascular morbidity and mortality and has been associated with greater mortality in the general population and patients with cardiovascular disease, but several studies have showed better outcomes for overweight and obese patients after surgical aortic valve replacement and a few even after TAVI (1). We analyzed the effect of body mass index (BMI) on outcomes of elderly high-risk patients with severe aortic valve stenosis undergoing TAVI. **Methods and Results:** We analyzed 252 consecutive patients who underwent TAVI procedure in our institution from 2012 to October 2020. We observed that BMI did not significantly differ among patients who had better outcome. Patient with better survival had mean BMI of 28.86 kg/m2, and patients who died during follow up had mean BMI 28.25 kg/m2. We could say that those with slightly higher BMI had better survival, but that difference was not significant. **Conclusion:** Unlike in other studies, we found no “obesity paradox” after TAVI. This might be due to the limitations of our analysis since the data presented in this cohort included patients from the early TAVI era, where the learning curve could have influenced these results. Earlier, our patient selection was somehow homogenous- they were all older and high risk which might have affected our results. Better patient selection using now available risk scores, the procedure itself, and post-operative management might provide a more reliable data in the future.

Ivana Jurin, Anđela Jurišić, Šime Manola, Irzal Hadžibegović

**Introduction:** Findings from clinical trials cannot be generalized to population at large due to the stringent eligibility criteria. Real-world data (RWD) are data relating to patient health status and/or the delivery of health care routinely collected from a variety of sources. RWD complement clinical trials by generalizing the findings from clinical trial to general population. Furthermore, RWD can provide information on other areas, such as natural history and course of disease, effectiveness studies, outcome studies, and safety surveillance (1). **Methods:** In Dubrava University Hospital, RWD are a part of our every -day practice. Currently there are real world data concerning acute myocardial infarction, transcatheter aortic valve implantation, oral anticoagulation therapy in atrial fibrillation and pulmonary embolism, efficacy, and safety of sodium-glucose co-transporter-2 inhibitors (SLGT2i) in patients with heart failure. We collect RWD from Electronic health records (EHRs). After the enrolment, patients are followed up by accessing data from hospital information system and by telephone visits. Telephone visits are performed for all patients every 6 months to collect information on endpoints. **Conclusion:** Real-world data encompass a wide range of research methodologies and data sources and can be broadly categorized as non-interventional studies, patient registries, claims database studies, patient surveys and electronic health record studies. Studies that use RWD include a patient population that is far more representative of unselected patient populations than those of randomized clinical trials (RCT) but they do not provide a robust basis for comparing treatment strategies RWD cannot substitute RCT, they can complement the findings from RCTs by providing valuable information on treatment practices and patient characteristics among unselected patients. RWD from our center have been recognized in Croatian and global scientific community. It takes much effort to conduct such real-world data bases, it can be time consuming in everyday practice, but the results are what motivate us and drive us forward.

Tomislav Šipić, Jasmina Ćatić, Jelena Kursar, Ivan Skorić, Marin Viđak, Nikola Šerman, Šime Manola, Ivana Jurin

**Background:** Dual antiplatelet therapy (DAPT) is a cornerstone of the treatment of acute coronary syndromes. In Rapid Early Action for Coronary Treatment 5 (ISAR-REACT 5) trial, prasugrel was superior to ticagrelor regarding the primary outcome, a composite of all-cause death, myocardial infarction (MI), or stroke, at 12 months. This superiority was primarily driven by a reduction in the number of MIs in the prasugrel group. Limited data are available concerning differences in clinical outcomes for real-life patients treated with ticagrelor versus prasugrel after percutaneous coronary intervention (PCI). One observational study indicated that prasugrel was safer and more effective than ticagrelor in patients with non-ST-elevation myocardial infarction (NSTEMI), with a reduction of reinfarction and major bleeding events at 12-month follow-up (1). Our objective was to determine and compare the efficacy and safety of ticagrelor and prasugrel in a real-world population in our center. **Patients and Methods:** This was an observational study conducted in Dubrava University Hospital. In total, 1380 patients (1176 ticagrelor, 204 prasugrel) who were hospitalized for acute MI from January 2017 to January 2020. There were 837 patients with acute myocardial infarction with ST elevation (STEMI) in ticagrelor group and 62 patients in prasugrel group. There were 329 patients with NSTEMI in ticagreolor group and 140 patients in prasugrel group. SYNTAX score was significantly higher in prasugrel group (13 vs 11). Median age of patients in prasugrel group was 64, and 62 in the ticagrelor group. **Results:** After 12 months of follow up, 5.8% patients in the ticagrelor experienced major adverse cardiac event (MACE) (reinfarction, death, stroke or bleeding) vs 1.5% of patients in the prasugrel group irrespective of MI type (STEMI or NSTEMI) (p=0.003). **Conclusions:** Comparison of these drugs suggested that prasugrel is safer and more efficacious than ticagrelor in combination with aspirin after both STEMI and NSTEMI. The nonrandomized design of the present research means further studies are required to support these findings.

Jelena Kursar, Dijana Bešić, Irzal Hadžibegović, Ivan Skorić, Nikola Šerman, Jasmina Ćatić, Tomislav Šipić, Šime Manola, Ivana Jurin

**Background:** Only a few studies have demonstrated a relationship between socioeconomic and marital status and pulmonary embolism (PE) (1, 2). Therefore, in the present study we aimed to investigate age, gender, marital as well as socioeconomic status at the time of PE onset as well its impact on therapy choice. **Patients and Methods:** The prospective study enrolled 370 consecutive patients presenting with objectively confirmed acute PE who were discharged from the hospital and who continued to take the recommended therapy 30 days after diagnosis of which 193 (52%) were taking warfarin, and 177 (48%) were taking direct oral anticoagulants (DOAC). **Results:** Analysis of the results of the social variables questionnaire showed that patients on warfarin were statistically significantly more represented in the group with incomes below 332 euros per month, among patients who had incomplete or only completed elementary school and among patients who were widowed. DOACs were statistically significantly more represented among patients with incomes above 831 euros, highly educated patients and patients from single households who are not widowed. Additional analysis of demographic and social variables showed that among women, who took warfarin statistically significantly more often, there were statistically significantly more people with low incomes below 332 euros per month and statistically significantly more widows. **Conclusion:** Our main observation, that older female patients receive warfarin more frequently because of socio-economic reasons is supported by objectively evaluated patients’ socioeconomic status which is the first such real life study. To treat our patients as well as possible, it is necessary not only to increase health literacy even more, but also to emphasize the need for full financing of DOAC by the Croatian Institute of Health insurance, which would ultimately lead to the relief of the health system by reducing adverse events.

Petra Čukelj, Verica Kralj, Karmen Korda Orlović, Ivana Grahovac

**Introduction:** We know from the literature that socioeconomic variables, such as education and income level, are related to cardiovascular risks and outcomes (1). Our goal was to explore possible differences in prevalence of risk factors for cardiovascular disease (CVD), stroke, myocardial infarction (MI), coronary heart disease (CHD) and raised lipid levels in older people (65+ years of age) population in Croatia, depending on their education and income level. **Methods**: We used the data from the European Health Interview Survey (EHIS) conducted in 2019. Prevalence of MI, CHD, hypertension, raised blood lipids, overweight and obesity and smoking were calculated, stratified by income groups and education level. EHIS differentiates 5 quintiles/income groups; for the purpose of this research, we combined quintile 1 and 2 into “lower income” group, and quintiles 4 and 5 into “higher income” group. Education was stratified according to ISCED 2011 classification into lower levels (primary school or less), middle level (secondary school) and high level (tertiary education). **Results**: Older people with lower income have higher prevalence of stroke, MI and CHD, while prevalence of high lipid levels is higher in people with higher income. Overweight is more prevalent in higher income group, while opposite is found for obesity and smoking. Stroke and raised lipid levels are more prevalent in the low education group, MI in high education group, while no difference is seen in CHD. Smoking and obesity are also higher in people with lower education levels. Results are presented in **Table 1****.** ### TABLE 1: Percentages of cardiovascular disease, smoking, overweight and obesity by income and education levels in people aged 65+, results of the European Health Interview Survey 2019 survey in Croatia. | | **Income** | **Income** | **Education level** | **Education level** | **Education level** | | --- | --- | --- | --- | --- | --- | | % | **Low income** **(Q1-2)** | **High income** **(Q4-5)** | **Low** | **Middle** | **High** | | Stroke | 6.9 | 5.1 | 8.0 | 7.9 | 4.5 | | Myocardial infraction | 6.7 | 6.3 | 6.8 | 9.2 | 10.0 | | Coronary heart disease | 20.6 | 18.3 | 21.2 | 18.2 | 21.5 | | Raised lipid levels | 27.2 | 34.6 | 34.5 | 32.4 | 31.4 | | Daily smokers | 13.1 | 10.2 | 6.2 | 13.7 | 16.2 | | BMI >25 | 72.6 | 78.8 | 74.5 | 75.0 | 71.7 | | BMI >30 | 31.0 | 29.0 | 33.1 | 27.7 | 17.4 | [†] BMI = body mass index; Q = quintile **Conclusion**: From a simple descriptive analysis, we can see a higher prevalence of some CVD risk factors (obesity and smoking) in people with lower income and lower levels of education in Croatia. Similarly, people with lower levels of education and income have higher self-reported prevalence of stroke and raised lipid levels. More complex analysis and research is needed to establish the relationship and interaction between these variables and targeting these higher risk groups in prevention activities and screening for CVD risk factors could reduce the inequalities.

Luka Antolković, Marin Pavlov, Šime Manola, Sanda Sokol Tomić, Nikola Šerman, Ivana Jurin

**Background:** There have been scarce data comparing cardiovascular outcomes between individual sodium-glucose cotransporter 2 (SGLT2) inhibitors (1-3). We aimed to compare the subsequent cardiovascular risk between individual SGLT2 inhibitors. **Patients and Methods:** All patients diagnosed with or treated for heart failure (HF) at our hospital who were prescribed either dapagliflozin or empagliflozin were analyzed for the primary composite outcome of death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke, hospitalization, or emergency room visit for worsening HF or atrial fibrillation (AF). The key secondary outcomes are individual primary events plus worsening peripheral artery disease and urinary tract infections. **Results:** A total of 467 patients with median age of 69 years, 67.75% of which are men are included in Registry. During a mean follow up time of 191 days, the primary outcome occurred in 65 patients. 48 patients in whom primary outcome occurred were taking dapagliflozin while 17 patients in whom primary outcome occurred were taking empagliflozin. Currently we did not record enough of primary events to conclude if either dapagliflozin or empagliflozin is superior in reducing primary outcome. The risk for death from cardiovascular causes, death from any cause, developing non-fatal myocardial infarction, non-fatal stroke, AF, worsening renal function, new or worsening peripheral artery disease were not significantly different between the two when accounted for baseline characteristics. We confirmed the robustness of these results through multitude of sensitivity analyses. **Conclusion:** When taking in account baseline characteristics currently we did not manage to demonstrate difference between empagliflozin and dapagliflozin in reducing risk for primary and secondary outcomes, but we hope to incorporate much more patients in the future. To our knowledge this is the first study comparing wide range cardiovascular outcomes in patients with HF treated with individual SGLT2 inhibitors using large-scale real-world data.

Davor Miličić

## Dear colleagues, After COVID-19 pandemic and consecutive lockdowns, after our virtual National Congress held in December 2020 and January 2021, and after our Spring 2022 Dubrovnik meeting named Collegium Cardiologicum, time came for our in vivo gathering together on the XIV Congress of the Croatian Cardiac Society, in Zagreb, Hotel Westin, November 24-27, 2022. Despite that our Society lives very intensively through numerous activities of its working groups, advisory boards, international engagements and numerous public health promotion activities, nothing can replace a comprehensive national Congress. As a small but a very active member of the European Society of Cardiology, and many other international cardiology associations, we would be honored once again to host some prestigious European and world-renowned cardiologists. We are honored that the Congress is going to be held under the auspices of the Croatian Academy of Sciences and Arts – the leading Croatian institution of excellence, which recognized our Society to be worth supporting. We, members of the Croatian Cardiac Society, may also be proud that we, for many years, represent probably the most active and homogenous professional association in Croatian medicine. In this Congress edition of our journal Cardiologia Croatica, you can find a respectful number of interesting original communications, that cover wide range of cardiology themes – from epidemiology and prevention, imaging, pharmacotherapy, interventional cardiology, angiology, adult congenital heart diseases, to heart failure, mechanical circulatory support, and transplantation. Despite the Congress brings to the audience many attractive invited lectures and supported satellite symposia, original contributions published in this journal issue in the form of abstracts, bring specific value to the Congress and allow many members of our Society, in particular young cardiologists, to present their work, either as oral presentations or as interactive posters in front of a curious audience. My gratitude goes to all who contributed to the Congress, but on the occasion of the Congress issue of Cardologia Croatica, my special thanks goes to the Congress secretaries and to the editor of the Journal, for their great enthusiasm and effort in preparation of this Book of abstract and the Congress as a whole. With my kind regards, Prof. Davor Miličić, FESC, FHFA, FACC Fellow of the Croatian Academy of Sciences and Arts President, Croatian Cardiac Society

Marija Brestovac, Martina Lovrić Benčić, Blanka Glavaš Konja, Vlatka Rešković Lukšić, Sandra Jakšić Jurinjak, Kristina Gašparović, Zvonimir Ostojić, Joško Bulum, Jadranka Šeparović Hanževački

**Introduction**: Resynchronization therapy is an effective method for treating advanced heart failure that contributes to echocardiographic, clinical and laboratory favorable outcomes. (1-4) This study was aimed to compare the dynamics in the reduction of heart failure biomarker (NTproBNP) between two groups of patients whose resynchronization device (CRT) was optimized by a) echocardiographic and b) electrocardiographic method. **Patients and Methods**: A total of 146 patients with implanted CRT according to the guidelines for resynchronization therapy were included in this randomized study. The examined population was divided into two groups depending on the method used for CRT optimization. In the first group (US) the echocardiographic method was used, correcting the parameters of cardiac mechanical dyssynchrony, and in the second group (ECG) an electrocardiographic method that corrects the parameters of CRT according to QRS width. NTproBNP values were determined before and 6 months after the implantation of CRT and compared with each other. **Results**: The results are shown in **Figure 1**. In both groups there was a significant reduction in NTproBNP (p<0.001) over a period of 6 months, but in the US group this decrease was even more significant (p=0.037). FIGURE 1. **Difference in NT-proBNP reduction between the echocardiographic and electrocardiographic optimization groups.** NTproBNP - N-terminal pro B-type natriuretic peptide; CRT = cardiac resynchronization therapy; US = echocardiography group; ECG = electrocardiography group **Conclusion**: Echocardiographic optimization of CRT leads to a significant decrease in NTproBNP compared to electrocardiographic optimization over a period of six months.

Petar Martinčić, Sandra Jakšić-Jurinjak, Vlatka Rešković-Lukšić, Marija Brestovac, Blanka Glavaš Konja, Zvonimir Ostojić, Joško Bulum, Martina Lovrić-Benčić, Jadranka Šeparović-Hanževački

**Introduction**: Atrial fibrillation (AF) and other cardiac arrhythmias can be provoked by diverse pathologies including pericarditis (1). Pericarditis can be caused by various causes and clinical presentation varies depending on the underlying etiology and time of presentation (1-3). Pharmacological treatment usually leads to symptom resolution, but still the possibility of constrictive hemodynamic remains. **Case series**: 52-year-old male presented with right heart failure and AF. Three years earlier he had stroke due to left internal carotid artery dissection and AF was diagnosed as well as calcification of pericardium of unknown etiology. As the patient had no signs of heart failure, the heart team opted for pharmacological treatment at that time. On a follow up, regression of calcification did not occur even after treatment with non-steroidal anti-inflammatory drugs, colchicine, steroids and rhythm control of AF failed. Additionally, echocardiography revealed constrictive hemodynamic with septal bounce with a respiratory dependent septal shift to the right as a result of interventricular interdependence and severe calcification of the pericardium in front of both ventricles. Right heart catheterization confirmed the diagnosis. Computed tomography (CT) exposed massive calcification of the pericardium that led to pericardiectomy as the only treatment available (**Figure 1**). The second case is 45-year-old male who was admitted with symptoms of right heart failure and AF. After prior AF ablation treatment, sinus rhythm was maintained shortly. Echocardiography once again revealed signs of constrictive hemodynamic. CT unveiled severe calcification of pericardium in front of the right ventricle with pericardial effusion. Surgical pericardiectomy was indicated for right heart failure relief (**Figure 2**). FIGURE 1. A. Pericardial calcification and shadowing due to calcium. B. Electrocardiogram showing atrial fibrillation and microvoltage. C. Cardiac computed tomography showing massive calcification. FIGURE 2. A. Hepatic flow reversal with inferior vena cava plethora. B. Diastolic septal bounce best seen on M mode as septal notch in early diastole. C. Computed tomography showing pericardial calcification dominantly in front of the right ventricle. **Conclusion**: Advanced constrictive pericarditis at the time of diagnosis was the reason pharmacotherapy and ablation treatment failed for AF. Possibly, constrictive hemodynamic was the initial trigger for AF that further accelerated heart failure. Multidisciplinary approach to pericardial disease and multimodality imaging is still the cornerstone of treatment, but echocardiography remains superior imaging modality in monitoring hemodynamic, best complemented with cardiac CT and right heart catheterization.

Damir Raljević, Rajko Miškulin, Sandra Kraljević Pavelić, Viktor Peršić

**Background**: Cardiovascular diseases are recognized as the leading cause of death in the developed world. Also, the serum level of vitamin D is recognized as one of the risk factors for cardiovascular diseases. Since all active and inactive forms of vitamin D are transported by the vitamin D binding protein (VDBP), it can be assumed that polymorphisms of the VDBP gene that affect its functionality and serum level also affect the serum level of vitamin D and thus may participate in the development of cardiovascular diseases. (1) The aim of this research is to investigate the association of VDBP gene polymorphisms rs4588 and rs7041 with acute myocardial infarction and to investigate the association of these polymorphisms with the serum level of 25-hydroxyvitamin D. **Patients and Methods**: This cross-sectional study included 155 subjects with acute myocardial infarction and 105 healthy subjects in the control group. Serum vitamin D level was determined using liquid chromatography tandem mass spectrometry (LC-MS/MS). Allele frequencies at polymorphic sites rs4588 and rs7041 of the VDBP gene were determined using real time polymerase chain reaction (RT-PCR). **Results**: A marginally significant association was observed between the VDBP (rs4588) T/T genotype and acute myocardial infarction. Furthermore, we found a significant association between VDBP (rs4588) T/T genotype and the acute anteroseptal myocardial infarction. No association was found between rs7041 VDBP polymorphism and acute myocardial infarction. Although no association of vitamin D serum level with acute myocardial infarction was found, the VDBP (rs4588) G/G genotype was associated with a higher vitamin D serum. Multivariate logistic regression analysis found an association between low vitamin D serum level, VDBP (rs4588) T/T genotype and anteroseptal myocardial infarction. **Conclusions**: The results of this study suggest that the VDBP (rs4588) T/T genotype may be associated with acute myocardial infarction of anteroseptal localization. (2) Additional research is needed to further investigate the association of VDBP gene polymorphisms with acute myocardial infarction.

Mario Udovičić, Ana Livun, Željko Sutlić, Rajko Kušec, Danijela Grizelj, Tamara Žigman, Katica Cvitkušić Lukenda, Diana Rudan, Šime Manola

**Background:** Cardiomyopathies represent an important cause of heart failure and genetic testing for cardiomyopathies has become an established care pathway in contemporary cardiology practice (1, 2). **Patients and Methods:** In this pilot study we have conducted genetic testing for cardiomyopathies in selected patients with clear non-ischemic cardiomyopathy phenotypes. Genetic testing was performed in Dubrava University Hospital genetic laboratory using standard next-generation sequencing (NGS) Illumina cardiomyopathy gene panel covering 174 genes most associated with cardiomyopathies, arrhythmias and aortopathies. The results were uploaded and analyzed using Variant Interpreter Illumina, a cloud-based interpretation and reporting platform for genomic data. **Results:** From June 2020 to March 2021 16 patients underwent genetic testing (10 males, 33.6±18.7 years), as a part of a pilot testing. Of these patients, 7 had previously undergone heart transplantation (HTx), while one was on the waiting list for HTx, 7 were in a regular follow up and one analysis was postmortem. Clinically, 12 patients were classified as having dilated cardiomyopathy (DCM), two had hypertrophic cardiomyopathy (HCM) and two arrhythmogenic cardiomyopathy (ACM). Diagnostic yield of the performed genetic testing was relatively high, in only two patients out of 16 we did not identify any mutations **(****Table 1****).** This testing led to the detection of Danon’s disease in one family, and to change of clinical treatment in one patient. The results were discussed with the clinical geneticist; in seven cases the patients were referred to genetic counseling, while further family screening was initiated in five cases. ### TABLE 1: Short summary of the detected variants, classified according to the clinically observed phenotypes. | | Number (males) — Average age — Previous HTx | **DCM** — 12 (8) — 27.8±16.9 — 6 | **HCM** — 2 (1) — 56.5±10.6 — 0 | **ACM** — 2 (1) — 45.5±14.8 — 1 | | --- | --- | --- | --- | --- | | Variant classification | Pathogenic | 5 | 0 | 1 | | Likely pathogenic | 2 | 1 | 0 | | | VUS | 4 | 0 | 1 | | | negative | 1 | 1 | 0 | | [†] HTx = heart transplantation; VUS = variant of unknown significance; DCM = dilated cardiomyopathy; HCM = hypertrophic cardiomyopathy; ACM = arrhythmogenic cardiomyopathy. **Conclusion:** Genetic testing provides insight into diagnosis, treatment, and prognosis of patients with non-ischemic cardiomyopathies, and directs screening which allows the identification of relatives at risk and initiation of appropriate medical and device therapies (1).

Domagoj Vučić, Nikola Bijelić, Edi Rođak, Jasmina Rajc, Boris Dumenčić, Tatjana Belovari, Kristina Selthofer-Relatić

**Introduction:** Excess cardiac visceral adipose tissue, which includes epicardial adipose tissue, is a risk factor for the development of coronary heart disease, arterial hypertension, diabetes and metabolic syndrome. Obesity is one of the known predictors of visceral obesity, but its influence on the morphology and function of cardiac adipose tissue is still incompletely elucidated (1). **Materials and Methods:** The research included post-mortem analysis of 8 samples (4 male and 4 female) of the right atrium with associated epicardial adipose tissue. The exclusion criterion was cardiac pathology affecting the right heart. All 8 samples were fixed in formalin and embedded into paraffin blocks and processed for staining with hematoxylin and eosin. The epicardial adipose tissue was measured using FIJI, a distribution of ImageJ software with Adiposoft plugin (v1.16) (**Figure 1****)**. Samples were compared on the gender and waist circumference basis. The criteria for visceral obesity were waist circumference with a cut-off value of >80 cm for females and >94 cm for males. FIGURE 1. Processing of histological samples (sample from a male patient on the left, sample from a female patient on the right). Images A and B represent the “native” histological sample of the right atrium with associated epicardial adipose tissue (stained with hematoxylin and eosin), images C and D were processed by Paint.net software with the aim of isolating only adipose tissue and images E and F are the results of morphological quantification of adipocytes using FIJI, a distribution of ImageJ software with the Adiposoft plugin (v1.16). **Results:** There were 4 samples (2 male and 2 female) of patients with increased waist circumference and the same number and gender distribution with normal waist circumference. No statistically significant difference was found in the morphometric parameters according to the waist circumference (p > 0.05). However, women had a higher median value of adipocyte area, which was compared to men (p < 0.05). **Conclusion:** The obtained preliminary data indicate a different cellular morphology of atrial visceral adipose tissue according to gender, but to obtain more convincing results, research on a larger sample is needed (2).

Mia Dubravčić Došen, Petra Mjehović, Dubravka Šipuš, Maja Čikeš, Dora Fabijanović, Nina Jakuš, Hrvoje Jurin, Daniel Lovrić, Marijan Pašalić, Ivo Planinc, Jure Samardžić, Marija Burek Kamenarić, Renata Žunec, Ines Bojanić, Sanja Mazić, Branka Golubić Ćepulić, Željko Čolak, Hrvoje Gašparović, Davor Miličić, Boško Skorić

**Introduction:** Human leukocyte antigen (HLA) sensitization is a barrier for successful heart transplantation (HTx), reduces the chance for compatible donors, prolongs waiting time to HTx, and increases the risk of acute rejection and cardiac allograft vasculopathy. Increasing prevalence of HLA sensitization and limitations of current desensitization strategies represent a great challenge in transplantation cardiology (1, 2). Rather than using pretransplant desensitization, in the last several years we have started peritransplant prophylactic therapy after careful selection of acceptable HLA antigen incompatibility. Therapy includes mechanical removal of antibodies, intravenous immunoglobulins (IVIg), and immunosuppressive drugs targeting antibody production (3). We present a series of four HLA sensitized patients who underwent successful HTx at University Hospital Center Zagreb. **Case 1:** 58-year-old male patient with history of two cardiac surgeries (mitral valve replacement in 1993 and coronary artery bypass graft and mitral valve repair in 2009) underwent HTx in September 2018. Due to positive complement-dependent cytotoxicity (CDC) crossmatch and donor-specific antibodies (DSA, anti-HLA antibodies class I), seven procedures of plasmapheresis followed by intravenous immunoglobulins were conducted, starting on the first postoperative day. Initial endomyocardial biopsy (performed on twenty fourth postoperative day) showed no cellular (CMR) or antibody-mediated (AMR) graft rejection, and DSA showed decline in reaction sensitivity during first 6 post-transplant months. In March 2019 endomyocardial biopsy revealed signs of AMR (without clinical correlate) and three plasmapheresis procedures with intravenous immunoglobulins application were performed. Procedures were suspended due to leukopenia, influenza infection and Cytomegalovirus (CMV) viremia. Follow-up biopsy two months later showed no signs of AMR, with further decline in DSA reaction intensity. Treatment was continued with monthly extracorporeal photopheresis (ECP) procedures (25 cycles over the course of 2,5 years). One year after HTx a coronary angiography with optical coherence tomography imaging was performed and it showed signs of intimal hyperplasia. Due to that finding and continuously positive anti-HLA antibodies, everolimus was introduced as fourth immunosuppressant drug (together with tacrolimus, mycophenolate mofetil and prednisone). Latest patients’ check-up was in September 2022, there were no signs of heart failure, CMR or AMR, and DSA are still positive, but with low Luminex median fluorescence intensity (MFI) reactions. **Case 2:** 44-year-old female patient with end-stage heart failure due to left ventricular noncompaction cardiomyopathy (LVNC) underwent urgent HTx in December 2019. Due to positive anti-HLA DSA (with negative CDC crossmatch), desensitization protocol was performed (five plasmapheresis procedures, intravenous immunoglobulins and rituximab application). Since initial biopsy, performed one month after HTx, showed CMR (class 1R/2) and AMR, and DSA values showed MFI increase, pulse corticosteroid therapy followed by additional five cycles of plasmapheresis and intravenous immunoglobulins was applied. Control biopsy showed resolution of CMR and AMR. Patient attends regular check-ups (latest in September 2022) in which no signs of CMR or AMR were detected, and DSA are positive, but with low MFI reaction. **Case 3:** 60-year-old male patient with ischemic cardiomyopathy underwent HTx in February 2020. Due to positive anti-HLA DSA (with negative CDC crossmatch), desensitization protocol was performed (seven plasmapheresis procedures and intravenous immunoglobulins, followed by anti-CMV immunoglobulin application). Early post-transplantation period was marked with prolonged leukopenia, with no other adverse events. Patient attends regular check-ups (latest in September 2022) in which no signs of CMR or AMR were detected, and DSA remain continuously negative. **Case 4:** 54-year-old female patient underwent HTx in August 2022 due to end-stage heart failure caused by ischemic cardiomyopathy. Due to positive virtual crossmatch (but prospective CDC crossmatch negative) and anti-HLA DSA, desensitization protocol was started immediately, with first procedure of immunoadsorption prior to the transplantation. Another eight cycles of immunoadsorption were performed in initial postoperative days, followed by application of intravenous immunoglobulins, without adverse events. First endomyocardial biopsy, one month after transplantation, showed no signs of CMR or AMR, with no anti-HLA DSA in follow-up. **Conclusion:** Anti-HLA sensitization among heart transplant candidates is a growing problem with significant risk for posttransplant graft dysfunction and death. Strategy that includes virtual crossmatch and peritransplant desensitization therapies allow us to perform transplantation with good clinical outcome.

Karmen Korda Orlović, Verica Kralj, Petra Čukelj

**Introduction**: Social media are used by more than half of the global population, and for most users they are the primary source of information about various events, news, phenomena, etc. This has been recognized by numerous stakeholders, including the public health sector. (1) One of the main advantages of using social media in public health campaigns is their relatively low cost for reaching a large part of the population. In addition, numerous tools are available (primarily on Meta platforms) so that specific groups can be targeted very precisely, which enables greater effectiveness of ads, especially paid ones. **Methods**: This year, for the third year in a row, the Croatian Institute of Public Health has created a public health campaign on social media on the occasion of World Heart Day. The three most essential items for creating a campaign are identified before creating the campaign – target population (people over 45 years old), communication channel (primarily Facebook), and the format (simple graphics and videos). The objective of this campaign was to raise awareness of the importance of preserving the health of one’s own heart and knowledge about the most common risk factors and heart diseases. The campaign took place from 19th Sep to 5th Oct 2022, and consisted of a total of 8 posts. Three posts were informative (that World Heart Day is being held), three were educational, and two were thematic videos. Five paid ads were created. **Results**: All posts, except the one on which the largest ad amount was invested, achieved an above-average engagement rate. As expected, posts that were advertised achieved the highest reach and the highest absolute engagement. The results can be improved by creating interaction with users in comments. **Conclusion**: Public health campaigns on social media represent a simple tool for communicating important messages with the target population. Meta platforms provide good advertising opportunities and analytical data. Although achieving good results without paid ads is difficult, they are still more affordable than traditional media. However, a lot of research is still needed in this area, especially in the context of transferring engagement into actual behavior change. (2)

Damir Raljević, Rajko Miškulin, Sandra Kraljević Pavelić, Viktor Peršić

**Background:** The vitamin D receptor (VDR) is a nuclear receptor responsible for the transcription of many vitamin D-dependent genes. Recently vitamin D low serum level have been recognized as a risk factor for cardiovascular disease. Since vitamin D achieves its biological function through the vitamin D receptor, it can be assumed that polymorphisms of the VDR gene that affect its functionality may be associated with an increased risk for cardiovascular diseases. (1) The aim of this research is to investigate the possible association of three known VDR polymorphisms - FokI (rs2228570), BsmI (rs1544410) and Taq1 (rs731236) with acute myocardial infarction. Also, to determine the vitamin D serum level and its association with acute myocardial infarction in the population of the northern Adriatic. **Methods:** This cross-sectional study included 155 subjects with acute myocardial infarction and 105 healthy subjects in the control group. Serum vitamin D level was determined using liquid chromatography tandem mass spectrometry (LC-MS/MS). Allele frequencies at polymorphic sites rs2228570, rs1544410 and rs731236 of the VDR gene were determined using real time polymerase chain reaction (RT-PCR). **Results:** No significant difference was found in the serum level of vitamin D between the studied groups. There was no association between the Fok1 (rs2228570) VDR polymorphism and acute myocardial infarction. A significant association between the T/T genotype of the BsmI (rs1544410) and the G/G genotype of the Taq1 (rs731236) VDR polymorphism and acute myocardial infarction was found. **Conclusion:** The results of this study suggest a potential association of BsmI (rs1544410) and Taq1 (rs731236) VDR polymorphisms with acute myocardial infarction. (2) Since no difference was found in the vitamin D serum level between the studied groups, it could be concluded that the investigated VDR polymorphisms are associated with acute myocardial infarction independently of the vitamin D serum level.

Mila Jakovljević, Ana Fabris

**Introduction**: Physical training increases cardiac exercise capacity, but generally does not affect cardiac function. Since energy metabolism is closely linked to cardiac function, we assessed the impact of the integrative metabolic approach on the cardiac function during cardiovascular rehabilitation (1, 2). **Patients and Methods**: 3 weeks exercise training was undertaken on an upright bicycle ergometer in 25 complementary supportive cardiac rehabilitation (CSCR) sessions. Before each exercise, the patients received magnesium, niacin, coenzyme Q10, thiamine diphosphate, riboflavin, pantothenic acid, pyridoxal, biotin, glutathione, and vitamin E. Following the exercise, the patients inhaled 95% oxygen 4 L/min provided by oxygen concentrator with ionization lying inside a low frequency pulsed electromagnetic field with intensity of up to 30 microtesla. After oxygen inhalation, the patients received carnitine, arginine, NADH, lipoic acid, selenium, and vitamin C. A cardiopulmonary echocardiography exercise test was performed at the start and the end of the three-week session, and the patients were asked to evaluate the visual analogue scale. **Results**: Arithmetic means of most Ergospiro echocardiographic parameters are lower before and higher after rehabilitation. Exceptions are the values VE/VCO2, VD/VT and E/e’, where the ratio of arithmetic means is reversed. The correlation coefficients for all 20 pairs of cardiopulmonary echocardiographic variables before and after rehabilitation range from 0.567 to 0.949. Most of them are closer to the number 1, that is, most of them show a strong positive association. p values are less than 0.05 for all 20 pairs of cardiopulmonary echocardiographic variables. **Conclusion**: Supporting normal mechanisms /pathways/ for energy production might be the way of improving cardiac function during CSCR.

Muhamed Zuko, Mirela Arnautović Tahirović, Amir Tahirović, Nejra Siručić

**Introduction**: Myocardial infarction in patients with psychiatric diseases is to a large extent more prevalent and is accompanied by a worse prognosis after a cardiac incident. Despite the higher mortality, these patients are less frequently subjected to coronary angiography and coronary intervention. With this research, we want to show the frequency of myocardial infarction in patients with schizophrenia, bipolar affective disorder, and depression, depending on age, gender, socioeconomic characteristics, professional qualifications, and dietary habits. (1, 2) **Patients and Methods**: Patients diagnosed with schizophrenia, bipolar affective disorder and depression hospitalized in Psychiatric Hospital of Sarajevo Canton. A total of 405 patients were treated over a period of five years. **Results**: Myocardial infarction in patients with schizophrenia was represented in 11.9% of cases. Depending on socioeconomic characteristics, myocardial infarction was most often experienced by patients who were married, employed, or retired, and who lived in urban areas. The youngest patient in whom we verified a myocardial infarction was a 37-year-old man. Examining the risk factors for the occurrence of myocardial infarction, through our research, we found that smoking, elevated blood pressure values, elevated BMI, although they are more frequent, do not have a significant impact on the occurrence of myocardial infarction in all three study groups. Patients with elevated values of glucose, total cholesterol and LDL cholesterol had a higher incidence of myocardial infarction. Eating habits had no influence on the onset of myocardial infarction in patients with schizophrenia and depression. By analyzing the presence of metabolic syndrome, we did not prove a statistically significant difference in the occurrence of myocardial infarction compared to patients without metabolic syndrome. **Conclusion**: To prevent cardiac events, it is necessary to work on raising the awareness of people suffering from psychiatric diseases regarding lifestyle and eating habits, and to conduct periodic health examinations. The most important preventive measure after a myocardial infarction is to stop smoking. Smokers live an average of ten years less than non-smokers.

Maja Štrajtenberger, Vanja Nedeljković, Marina Božan

**Background**: Coronary artery disease is s significant cause of mortality and morbidity worldwide. It occurs due to reduced blood flow through coronary arteries, most commonly due to atherosclerotic plaque. Clinically, it presents as angina pectoris, acute coronary syndrome, or sudden cardiac death. Diagnosis is made upon patient’s history, ECG, ergometry and coronarography. It is essential to recognize and treat risk factors such as hypercholesterolemia, obesity, physical inactivity, smoking, or underlying diseases as diabetes. **Case report**: 34-year-old obese man came to our infirmary due to exercise induced chest discomfort and pain which would resolve upon rest after 3-4 minutes. His family history is significant for familial hypercholesterolemia and his father’s sudden death at the age of 44. Five months prior to our exam he did 24-hour holter ECG and thyroid ultrasound which showed no abnormalities. Carotid ultrasound revealed minor atherosclerotic plaques along ACC and on bifurcations. MSCT coronarography described insignificant to borderline stenosis of LMCA and insignificant stenosis of LAD, Cx, RCA. Due to elevated values in lipid panel, he was administrated with combination therapy rosuvastatin and ezetimibe. For further evaluation we did an echocardiography which showed all measures within reference values, 24-hour blood pressure monitor which revealed underlying hypertension, and exercise stress test which was interrupted due to chest pain and inferolateral ST-segment depression. Invasive coronarography was done (6 months after the first one) which depicted LMCA subocclusion, so the patient was accepted for urgent cardiovascular procedure – a double bypass was done (LIMA-LAD, LRA-OM1). He is treated due to recently published guidelines for ischemic heart disease and high lipid management. (1) **Follow up**: Patient underwent rehabilitation process, has no precordial discomfort upon physical effort with ergometry proven significant physical tolerance improvement. Due to unsatisfying lipid regulation, the therapy was escalated with proprotein convertase subtilisin/kexin type 9 inhibitor. Patient failed to reduce his body weight, as well as his lifestyle changes and eating habits, so many risk factors still represent a challenge for further management and prevention.

Mira Stipcevic, Jogen Patrk, Igor Rudez, Vedrana Terkes, Zoran Bakotic, Marin Bistirlic, Drazen Zekanovic, Zorislav Susak, Branimir Buksa, Stipe Kosor, Karla Savic, Dino Mikulic, Nikola Verunica

**Introduction:** Staphylococcus lugdunensis is a species of coagulase-negative staphylococci (CNS) that causes a variety of infectious diseases, including infective endocarditis (IE), usually in an aggressive form with valve destruction and abscess formation, requiring surgery with a high mortality rate (1). **Case report:** 23-year-old female, with no risk factors, presented in December 2020, with fever up to 40ºC, vomiting and weakness lasting for ten days. Initial laboratory showed leukopenia with elevated C-reactive protein and procalcytonine. The patient was admitted to hospital and without obvious source of infection, treatment with broad spectrum antibiotics (co-amoxiclav and azithromycin) was started. Seven days later there was no clinical improvement. Transthoracic echocardiography (TTE) showed normal morphology of heart valves. As blood cultures were positive on S. lugdunensis, vancomycin was introduced in therapy and more frequent TTE examinations were taken. Three weeks after symptom onset and two weeks after blood cultures were positive, a TTE revealed vegetation, in the atrial aspect of the P3 segment of posterior mitral cusp with eccentric mitral regurgitation and transesophageal echocardiography (TEE) confirmed mitral valve endocarditis. Linezolid was introduced to therapy and patient was referred to cardiac surgery due to persistent septicemia. Intraoperatively, vegetations found on P3 segment of mitral valve with perforation, were excised and A3-P3 segment was reconstructed with pericardial patch, followed by a 30 mm annuloplasty ring. Postoperative course was uncomplicated and antibiotic treatment with cotrimoxazole and rimactan was continued three weeks postoperatively. After one year the patient was stable and TTE showed no mitral valve regurgitation. **Conclusion:** In contrast to other central nervous system (CNS) infections, S. lugdunensis mainly affects native heart valves and is more likely to be acquired through the community without an identifiable source of infection (2). In S. lugdunensis septicemia careful monitoring and more frequent TTE should be obtained. In native valve endocarditis valve repair has been shown as a valuable alternative to valve replacement with decreased morbidity and mortality and no need for anticoagulation (3).

Tereza Knaflec, Siniša Roginić, Martina Roginić, Marija Čajko, Nikolina Mijač Mikačić, Domagoj Futivić

**Case report**: 61-year-old woman presented to the Emergency Department with sudden onset of fever, shortness of breath, headache, arthralgia, upper-abdominal pain and generalised maculoerythematous rash. Laboratory testing showed pancytopenia, slightly elevated C-reactive protein, normal procalcitonin value and altered hepatogram with unconjugated hyperbilirubinemia. An abdominal ultrasound confirmed hepatosplenomegaly. Electrocardiographic findings were unspecific. Fever, heart murmur, elevated values of cardiac troponin and N-terminal pro b-type natriuretic peptide (NT-proBNP) raised clinical suspicion of endocarditis. Transthoracic echocardiography found thickening and potential vegetation on the aortic valve. Besides that, there were signs of hypertensive heart disease with preserved left ventricle ejection fraction, no wall motion abnormalities, normal right ventricular size and function and insignificant valve dysfunction. Transesophageal echocardiography showed round, well-circumscribed, wide-based, hyperechogenic structure on noncoronary cusp. Multiple blood cultures were negative. Since Duke criteria were not met, more plausible diagnoses of Arantius nodule or fibroelastoma were considered. High sensitive troponin I (Hs-TnI) values were persistently elevated without dynamic changes or clinical correlation. In the setting of acute (especially viral) infection, heterophile antibodies can cause interference and positive or negative results. Different immunoassay in another laboratory showed normal Hs-TnI, thus confirming false-positive results. Extensive workup did not confirm infective pathogen but nevertheless patient has recovered completely (Figure 1). FIGURE 1. Transesophageal echocardiogram images: thickening on the aortic valve (A); round, well-circumscribed, wide-based, hyperechogenic structure on noncoronary cusp (B); trace aortic regurgitation (C). **Conclusion**: Clinical history and physical examination are crucial since laboratory and imaging results can be misleading. Guideline based approach for the diagnosis of myocardial infarction and endocarditis helps to avoid false positive diagnosis (1-3).

Katarina Kovačević, Elnur Smajić, Mirsad Selimović

**Introduction**: ASD is one of the most common congenital heart diseases in adults. It is characterised by the presence of communication between the two atria (1). Most ASDs are asymptomatic until the fourth decade of life (2). Some present with fatigue, dyspnoea on exertion, exercise intolerance or, occasionally, syncopal attack (3). Others may go on to develop complications such as atrial arrhythmias, paradoxical embolism, and pulmonary hypertension. In untreated patients with ASD, some may go on to develop complications such as atrial arrythmias, pulmonary hypertension and Eisenmenger syndrome. Here, we would like to illustrate a case of ASD presenting with atrial flutter and secondary pulmonary hypertension in elderly man. **Case report:** 65-year-old patient hospitalized due to symptoms and signs of heart failure. On admission, he complained of heart palpitations and intolerance of exertion. At admission, atrial flutter is verified, ventricular rate 120 per minute with a 2:1 block **(****Figure 1****).** The presence of a primum type ASD with a diameter of 2.12 cm **(****Figure 2****)** with a left-right shunt is confirmed **(****Figure 3****)** and moderate tricuspid regurgitation with a gradient of 36 mm Hg along with the inferior vena cava, 2 cm in diameter on admission. Present moderate mitral regurgitation with criteria for prolapse of both mitral cusps. The values of the performed laboratory parameters were referential. During hospitalization, the patient was treated with beta blockers, anticoagulants, antihypertensives and diuretics, which achieved clinical stabilization and heart rhythm control, with a satisfactory heart rate at discharge. FIGURE 1. Electrocardiogram on admission with atrial flutter, with block 2:1. FIGURE 2. A. Apical view of atrial septal defect, type primum (A); size of atrial septal defect, type primum (B). FIGURE 3. Left to right shunt of atrial septal defect, apical view. **Conclusion:** Although ASDs are common, they remain very much underdiagnosed, as most are asymptomatic. This case highlighted the importance of early diagnosis of ASD, as early interventions can help in preventing the development of complications.

Petra Mjehović, Mia Dubravčić Došen, Marijan Pašalić, Maja Čikeš, Dora Fabijanović, Nina Jakuš, Hrvoje Jurin, Daniel Lovrić, Ivo Planinc, Jure Samardžić, Branka Golubić Ćepulić, Ines Bojanić, Sanja Mazić, Željko Čolak, Hrvoje Gašparović, Davor Miličić, Boško Skorić

**Background:** Oral anticoagulation therapy for the prevention of thromboembolic complications of atrial fibrillation in patients awaiting heart transplantation (HTx) traditionally includes warfarin, and in the last few years it increasingly includes dabigatran. Anticoagulation must be reversed before the surgery. The possibility of rapid reversal of the anticoagulant effect of dabigatran with idarucizumab seems to represent an advantage (1). A comparison of bleeding complications between these two strategies has not been completely investigated. **Patients and Methods:** We did a retrospective analysis of bleeding complications during and immediately after HTx performed in University Hospital Center Zagreb in 15 patients divided into 3 groups: patients who were on warfarin prior to HTx, patients who were on dabigatran prior to HTx, and control patients without indication for anticoagulation therapy. Patients were mutually paired to eliminate the influence of other risk factors including age, gender, etiology of heart failure, renal function, as well as whether surgery was primary or after previous sternotomy. For the comparison of bleeding complications we measured the utilization of blood products (red blood cells, platelets, fibrinogen, fresh frozen plasma (FFP), prothrombin complex (PC) and the amount of thoracic drainage within the first 24 hours after the HTx. **Results:** There was no significant difference in the utilization of blood products as well as the amount of 24h thoracic drainage between these three groups **(****Table 1****)**. Only 2/5 patients in the warfarin group were within the therapeutic INR range (2 pts below and 1 pts above the range). 24h thoracic drainage, FFP and PC consumption correlated with pretransplant INR **(****Table 2****).** ### TABLE 1: Comparison of different demographic and clinical characteristics, and crucial pretransplant/posttransplant laboratory findings between patient groups stratified according to anticoagulant use. | **Therapy groups:** | **No anticoagulation** **(n=5)** | **Warfarin** **(n=5)** | **Dabigatran** **(n=5)** | **p-value** | | --- | --- | --- | --- | --- | | Male gender, N (%) | 4 (80) | 4 (80) | 4 (80) | 1.000 | | Age at the time of HTx [y] (IQR) | 53 (53-57) | 59 (46-60) | 62 (46-63) | 0.756 | | Ischemic CMP, N (%) | 1 (20) | 1 (20) | 1 (20) | 1.000 | | Resternotomy, N (%) | 1 (20) | 1 (20) | 1 (20) | 1.000 | | eGFR [mL/min/1,73m2] (IQR) | 71 (66-84) | 65 (53-71) | 65 (50-76) | 0.423 | | Erythrocyte concentrate [mL] (IQR) | 260 (0-1510) | 250 (250-1020) | 550 (470-730) | 0.755 | | FFP [mL] (IQR) | 1020 (910-1060) | 1310 (1240-1380) | 1060 (1030-1150) | 0.385 | | Platelet concentrate [doses] (IQR) | 8 (6-8) | 8 (8-8) | 5 (0-10) | 0.919 | | Fibrinogen [g] (IQR) | 2 (2-3) | 2 (2-2) | 2 (2-4) | 0.698 | | Prothrombin complex [IU] (IQR) | 0 (0-0) | 0 (0-2500) | 0 (0-0) | 0.117 | | Thymoglobulin (IQR) | 24 (22-24) | 26 (24-29) | 28 (24-30) | 0.363 | | Thoracic drainage within the first 24h [mL] (IQR) | 400 (300-700) | 450 (400-550) | 600 (450-650) | 0.643 | | Hemoglobin before HTx [g/L] (IQR) | 139 (137-146) | 125 (121-160) | 142 (138-149) | 0.756 | | Platelets before HTx [10E9/L] (IQR) | 205 (200-260) | 282 (270-292) | 188 (174-202) | 0.102 | | PT-INR before HTx (IQR) | 0.96 (0.92-1.15) | 2.40 (1.18-2.41) | 1.09 (1.06-1.13) | 0.230 | | APTT before HTx [s] (IQR) | 24.60 (23.25-26.40) | 36.9 (27.7-37.5) | 31.3 (28.9-47.3) | 0.079 | | Fibrinogen before HTx [g/L] (IQR) | 3.75 (3.35-4.15) | 4.20 (3.40-5.70) | 3.85 (3.70-4.95) | 0.693 | | Hemoglobin 1st day after HTx [g/L] (IQR) | 101 (93-111) | 107 (95-112) | 96 (95-100) | 0.485 | | Platelets 1st day after HTx [10E9/L] (IQR) | 113 (94-163) | 135 (129-171) | 98 (92-131) | 0.330 | | PT-INR 1st day after HTx (IQR) | 1.02 (0.99-1.09) | 1.22 (1.03-1.43) | 1.18 (1.10-1.23) | 0.259 | | APTT 1st day after HTx [s] (IQR) | 25.7 (24.6-27.4) | 27.7 (23.9-28.4) | 25.4 (24.6-25.9) | 0.635 | | Fibrinogen 1st day after HTx [g/L] (IQR) | 4.50 (3.80-6.70) | 3.50 (3.40-3.70) | 3.4 (3.0-3.4) | 0.068 | | Hemoglobin 7th day after HTx [g/L] (IQR) | 102 (96-111) | 100 (92-101) | 88 (88-92) | 0.150 | | Platelets 7th day after HTx [10E9/L] (IQR) | 117 (97-193) | 112 (104-154) | 93 (73-108) | 0.228 | | PT-INR 7th day after HTx (IQR) | 1.00 (0.98-1.02) | 1.01 (0.95-1.12) | 1.08 (1.06-1.11) | 0.203 | | APTT 7th day after HTx [s] (IQR) | 20.5 (19.1-21.0) | 22.8 (21.3-23.3) | 21.7 (21.1-22.2) | 0.172 | | Fibrinogen 7th day after HTx [g/L] (IQR) | 2.3 (2.2-3.3) | 3.4 (2.9-5.2) | 3.5 (2.3-3.5) | 0.438 | [†] HTx – Heart Transplant; CMP – cardiomyopathy; eGFR – estimated Glomerular filtration rate; FFP– Fresh Frozen Plazma; PT-INR – Prothrombin Time – International Normalized Ratio; APTT – Activated Partial Thromboplastin Time. ### TABLE 2: Potential predictors of periprocedural bleeding in the observed heart transplant patient population. | **Correlation Pair** | **Spearman ρ** | **Correlation Significance** | | --- | --- | --- | | Total Chest Output in 24h & *Pretransplant PT-INR* | 0.645 | 0.009* | | Packed Red Blood Cell Transfusion Volume & *Ischemic Etiology of Heart Failure* | 0.543 | 0.036* | | Fresh Frozen Plasma Transfusion Volume & *Pretransplant PT-INR* | 0.661 | 0.007* | | Platelet Transfusion Volume & *Ischemic Etiology of Heart Failure* | 0.583 | 0.022* | | Prothrombin Complex Concentrate Transfusion & *Pretransplant PT-INR* | 0.592 | 0.020* | [†] PT-INR – Prothrombin Time – International Normalized Ratio * P < 0.05 **Conclusion:** Although there was no difference in the consumption of blood products and 24h thoracic drainage between patients who were on warfarin or dabigatran anticoagulation before HTx, it should be noted that the majority of patients on warfarin were not within the therapeutic INR range, and it was precisely the elevated INR that significantly correlated with the consumption of blood products and 24h thoracic drainage. It is necessary to conduct a study on a larger number of patients in order to find out whether the pre-HTx use of warfarin is equally safe and effective as the use of dabigatran, in terms of the perioperative bleeding.

Anita Jukić, Ana Maria Ćupić, Frane Runjić, Ivica Kristić, Damir Fabijanić, Andrea Gelemanović

**Objective:** To present basic clinical characteristics and comorbidities of patients with severe aortic valve stenosis and to determine the differences between those treated with surgical valve replacement (SAVR) and transcatheter valve implantation (TAVI) during 2021 at University Hospital of Split. **Patients and Methods:** A total of 144 patients were included in this observational retrospective study. Age, gender, European System for Cardiac Operative Risk Evaluation (EuroSCORE II), the New York Heart Association (NYHA) stage, comorbidities, cardiac bypass, percutaneous coronary intervention, laboratory parameters, days of hospitalization and ultrasound parameters were analyzed. **Results:** Out of a total of 144 patients hospitalized with a diagnosis of severe aortic stenosis, 93 (65%) underwent TAVI, and 51 (35%) underwent SAVR. In both groups, men predominated, in the TAVI group 56%, and in the SAVR group 69% of patients. Basic demographic, anamnestic, laboratory and ultrasound parameters in relation to the performed procedure show that TAVI patients are older, have decreased renal function and more comorbidities. A statistically significant difference was found in hospitalization days after the procedure (P<0.001; median TAVI 4 days, SAVR 19 days). Among TAVI patients, a higher number of previous coronary artery bypass graft (CABG) was found in the younger age group ≤75 years (P=0.033). Patients undergoing SAVR aged ≥65 years had a significantly higher operative risk (P=0.006), higher NYHA status (P=0.040) and lower glomerular filtration (P=0.003) compared to the age group <65 years. Patients undergoing SAVR and CABG in the same act have a much higher operative risk (P=0.003) and a longer hospitalization (P<0.001). **Conclusion:** The age distribution of patients treated with TAVI and SAVR is in accordance with treatment recommendations. No significant difference in patient characteristics was demonstrated depending on the choice of method. Very fast recovery and improvement of hemodynamic parameters after TAVI procedure has been proven. A third of the patients were between the ages of 65 and 75, there was no significant difference in the choice of method or the characteristics of patients of that age, which confirms the spread of TAVI in younger and low-risk patients (1, 2).

Siniša Roginić, Martina Roginić, Tereza Knaflec, Nikolina Mijač Mikačić, Marija Čajko, Domagoj Futivić

Infective endocarditis is a rare but clinically underappreciated condition associated with high morbidity and mortality. We present data from 30 cases of endocarditis diagnosed and treated in our hospital during 7 years period, including COVID-19 pandemic lockdown. Demographic and clinical data were collected, including microbiological isolates, number of affected valves, perivalvular, embolic, and immunological complications, surgical outcome and mortality. Most patients were male, average age was 62 years and Enterococcus was the most frequently isolated pathogen. 17/30 patients were operated, most of them urgently due to valvular dysfunction, uncontrolled infection and/or systemic embolization. In-hospital mortality of 30% was directly associated with severity of infection and necessity for emergency and urgent surgery. Unexpected rise of incidence occurred in 2021 with 11 identified cases. We assume possible rebound effect of postponed diagnosis after COVID-19 pandemic lockdown due to restricted access to all levels of health care. Our data generally reflect literary data on incidence and prognosis of endocarditis with additional peak in incidence during 2021 and more severe clinical presentation (1-3).

Dominik Buljan, Aleksandar Blivajs, Irzal Hadžibegović, Ivana Jurin, Ilko Vuksanović, Šime Manola

**Introduction**: Kounis syndrome (KS) represents acute coronary syndrome (ACS) caused by mast cell activation and release of inflamatory cytokines due to allergic or even anaphylactic reaction. KS is classified in three types depending on mechanism of onset of the acute coronary syndrome: vasospastic allergic angina (type I), allergic myocardial infarction (type II) and stent thrombosis (type III). (1) There are numerous examples of KS caused by iodine contrast during radiographic procedures, while it can also be caused by insect stings such as hornet. **Case report**: We report the case of 51-year-old male patient with common cardiovascular risk triade (diabetes melitus type II, arterial hypertension and hyperlipidemia) who presented with acute anteroseptolateral ST elevation myocardial infarction (STEMI) in clinical setting of anaphylactic reaction caused by hornet’s sting followed by intramuscular aplication of epinephrine in emergency department. Acute thrombotic occlusion of proximal left anterior descent (LAD) artery was confirmed by urgent coronarography therefore thromboaspiration and consequently implantation of drug-eluting stent in culprit lesion was committed. Before stent implantation, tirofiban was applied intracoronary due to TIMI II flow at control coronarogram following the thromboaspiration. We also used Intravascular Ultrasound (IVUS) to evaluate vessel size due to ectasis and underlying atheromatous plaque. **Conclusion**: The presence of underlying atheromatous coronary artery disease during coronarography suggests type II variant of the KS. Allergic symptoms and concomitant ACS following hornet sting is highly sugestive for KS which should be recognised and promptly treated.

Jogen Patrk, Marin Bistirlic, Zoran Bakotic, Mira Stipcevic, Drazen Zekanovic, Zorislav Susak, Branimir Buksa, Stipe Kosor, Dino Mikulic, Karla Savic, Nikola Verunica

**Introduction:** Data from multiple studies show a rare risk for myocarditis following receipt of messenger ribonucleic acid (mRNA) COVID-19 vaccines. It occurs most frequently in adolescent and young adult males, within two weeks after receiving the second dose of an mRNA COVID-19 vaccine with incidence 0.48 per 100,000 in the general population and 1.2 per 100,000 in recipients aged 18–29 (1). For most cases, patients who presented for medical care have responded well to medications and rest and had prompt improvement of symptoms. It is important to distinguish myocarditis from other conditions presenting with chest pain and heart failure due to treatment decision and prognosis. **Case report:** 46-year-old male with no risk factors received second dose of mRNA vaccine in August 2021. Ten days later he was admitted to hospital due to chest pain lasting for six hours. At presentation ST-segment elevation was detected on electrocardiography (ECG), which was most prominent in the anterolateral leads **(****Figure 1****)**. Both, troponin I and N-terminal pro b-type natriuretic peptide (NT-proBNP) were elevated suggesting myocardial infarction. Coronary angiography was preformed upon admission and revealed intact coronary arteries. A transthoracic echocardiogram showed global left ventricular systolic dysfunction with ejection fraction (EF) 35-40% and normal left ventricular dimensions. Global longitudinal strain (GLS) showed severe reduction in all analyzed segments (GLS avg -11%), **Figure 2**. As the patient was hemodynamically stable, he received only analgetic (paracetamol) for pain relief. Ten days after presentation, left ventricular EF was 50% with completely normal ECG, significant regressive dynamics of troponin I and NT-proBNP serum levels and he was discharged home. GLS remained altered with normalization after four months **(****Figure 3****).** FIGURE 1. Electrocardiogram at presentation. FIGURE 2. Initial longitudinal strain diffusely reduced. FIGURE 3. Complete recovery of longitudinal strain after four months. **Conclusion:** Myocarditis after mRNA COVID 19 vaccine is rare complication and, in most cases, self-limited disease. The benefits (prevention of COVID-19 disease and associated complications) outweigh the risks (expected myocarditis cases after vaccination) in all populations for which vaccination has been recommended (2). Supportive therapy is a mainstay of treatment, with targeted cardiac medications or interventions as needed.

Jelena Jakab, Domagoj Mišković, Katica Cvitkušić Lukenda, Krešimir Gabaldo, Marijana Knežević Praveček, Blaženka Miškić, Irzal Hadžibegović

**Background**: In-stent restenosis (IRS) and postpericardiotomy syndrome (PPS) are considered complications that can occur after percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). IRS is a gradual re-narrowing of the stented segment because of neointimal tissue proliferation. PPS is triggered by damage to the mesothelial cells of the pericardium, leading to the stimulation of the immune response. (1, 2) **Case report**: 67-year-old male patient was repeatedly admitted to our department since 2016. The first PCI with drug-eluting stent (DES) implantation in the proximal segment of the left circumflex artery (LCX) was performed in another hospital due to non-ST-elevation myocardial infarction. Over a 4-year period, the patient underwent eight repeat PCIs with noncompliant balloons and drug-coated balloons, including three times with DES implantation and once with IVUS guidance. During this time, the patient was treated with corticosteroids and once with sirolimus which resulted in acute hemorrhagic enterocolitis and posthemorrhagic anemia. In 2019, transthoracic echocardiography (TTE) revealed ischemic mitral regurgitation of moderate severity. Due to numerous PCIs of the LCX and limited vascular access, the patient underwent CABG surgery (VSM-OM2) in April 2021. In July 2021, the patient was diagnosed with PPS and has been admitted to our department for recurrences four times since then. TTE revealed a moderate pericardial effusion (1.7 cm) that resolved after administration of corticosteroid and colchicine. Azathioprine and ibuprofen were initiated, as was the oral hypoglycemic agent due to iatrogenic diabetes mellitus. A comprehensive immunologic workup revealed no immunologic abnormalities. The patient is now asymptomatic and has had no recurrent episodes of PPS since January 2022. **Conclusion**: Most patients with IRS require repeat PCI and the role of surgery is uncertain. The use of DCB angioplasty instead of DES is reasonable when possible. First-line therapy for PPS includes NSAIDs and colchicine, while corticosteroids are effective in refractory cases. As fourth-line agents studies support the use of IL-1 inhibitors, intravenous immunoglobulin, and azathioprine or methotrexate and mycophenolate mofetil, although limited evidence is available.

Vlasta Soukup Podravec, Ivana Petrović-Juren, Renata Ivanac Janković, Andreja Čleković-Kovačić, Sandra Prša, Kristina Milevoj Križić

**Introduction**: Cardiac death is the most common cause of death among hemodialysis patients, predominantly acute myocardial infarction. High-sensitivity troponins (hs-cTnT, hs-cTnI) have become the gold standard for the diagnosis of the acute coronary syndrome (ACS) in the general population. The aim of this presentation is to show the limitation of these biomarkers in patients with end-stage renal disease (ESRD) because the serum troponin levels are very often elevated in those patients (1-3). **Case report**: 68-year-old woman has been on a chronic hemodialysis program for the past 4 years. She also had a history of arterial hypertension, dyslipidemia, and diabetes. During the regular hemodialysis program, she mentioned intensive chest pain that she had two days ago. She had a high blood pressure (240/120 mmHg) then, but now she felt good. In the laboratory elevated values of hs-cTnI were found (1995 ng/L). 12-lead electrocardiogram showed the signs of septal ischemia with a discretely elevated ST segment in inferior leads (**Figure 1**). An emergency echocardiography was done. Concentric hypertrophy of the left ventricle with normal ejection fraction was found but with regional wall motion abnormality - hipocontractility of the basal part of anteroseptum and basal part of inferoseptum. The patient was referred to the University Hospital for coronary angiography. The stenosis of the proximal right coronary artery around 40% was found. Obstructive coronary disease has been ruled out as well as the diagnosis of ACS. It was concluded that echocardiographic and ECG changes are related to hypertensive heart disease. FIGURE 1. 12-lead electrocardiogram in the hemodialysis patient with a history of chest pain. **Conclusion**: When patients with ESRD present themselves with chest pain and the ECG findings are suggestive of myocardial ischemia, it is necessary to make a coronary angiography to confirm or to exclude the diagnosis of ACS. In any case, we must keep in mind that elevated troponin in patients undergoing dialysis, is directly correlated with cardiovascular and total mortality.

Petra Bistrović, Marko Lucijanić, Šime Manola

**Introduction**: Antiviral drug remdesivir used in treatment of COVID-19 has been observed to have cardiovascular side effects, most commonly sinus bradycardia (1). Previously published research suggests bradycardia caused by remdesivir might be a positive effect (2). Our research aims to investigate impacts of remdesivir use in patients with atrial fibrillation (AF). **Patients and Methods**: Our study included 5959 consecutively hospitalized severe and critical COVID-19 patients among which 876 received remdesivir with 876 matched controls. We compared the primary outcome, in-hospital death, in remdesivir treated AF patients compared to AF patients without treatment. **Results**: 188 (10.4%) of analyzed 1752 patients had AF, with prevalence comparable between groups (10% in remdesivir group vs 11,4% in control group). Overall, while patients with atrial fibrillation experienced significantly worse mortality compared to those without (50.5% vs 29.2%, p<0.001), when treated with remdesivir, the increased mortality was significantly smaller (43.2 vs 27.7%, OR 1.98, P<0.001) compared to the AF patients in the untreated group (57 vs 30.8%, OR 2.97, p<0.001), however these benefits were not evident in those requiring high flow oxygen therapy or mechanical ventilation at beginning of treatment. **Conclusion**: Atrial fibrillation is associated with increased mortality in severe and critical COVID-19, however early application of remdesivir might improve survival in this patient subgroup. Additional research is required to improve treatment.

Alden Begić, Edin Begić, Nirvana Šabanović-Bajramović, Amer Iglica, Nermir Granov, Mirza Dilić, Zijo Begić

**Goal:** To indicate the influence of risk factors for the development of coronary artery disease (CAD) on coronary flow reserve (CFR) values assessed by transthoracic echocardiography (TTE) ​​in patients without verified CAD. **Methods:** The paper presents an analysis of the available literature from reference databases covering the mentioned topic. **Results:** TTE-CFR presents a ratio of hyperaemic coronary blood flow during maximum vasodilation in relation to resting coronary blood flow. The most commonly used vasodilators are dipyridamole and adenosine (adenosine 140 mcg⁄kg⁄min (1-2 min), dipyridamole 0.84 mg⁄kg⁄6 min). Age and female gender have a lesser effect on the values of hyperemic CFR. Ethnic differences (vascularization, left ventricle structure) can influence the CFR values. Also, obesity, smoking, hyperlipidemia, elevated values ​​of low-density lipoproteins (LDL), arterial hypertension, diabetes mellitus, and obstructive sleep apnea in a healthy population can have a negative effect on CFR values. **Conclusion:** There is evidence of the effect of risk factors for CAD on CFR values ​​in a population without established pathology. (1-3) It is a marker of the early stages of coronary atherosclerosis (a tool in the stratification of patients regarding cardiovascular risk, and it could be a guide in the primary prevention of cardiovascular disease). Also, TTE-CFR<2 has good sensitivity and specificity to predict the significance of stenosis. Clinical presentation of the patient should be a part of the mosaic of interpretation of test results. CFR is an additional test, and stress echocardiography presents the first choice in the evaluation of ischemic heart disease.

Nermir Granov, Hened Kelle-Karavdić, Zina Lazović, Alden Begić, Edin Begić, Fuad Zukić

**Aim:** To present a therapeutic modality of a 70-year-old patient with double-vessel coronary disease, along with associated severe aortic stenosis and vascular ring. **Case report:** Patient admitted for elective coronary angiography because of preoperative preparation due to surgical treatment of accidentally detected severe aortic stenosis (peak aortic valve velocity of 4.4 m/sec, peak gradient of 80 mmHg, mean gradient of 47 mmHg, aortic valve area of 0.8 cm2 (continuity equation using velocity time integral (VTI)), with preserved left ventricular ejection fraction. Double-vessel coronary disease was verified by coronary angiography and percutaneous coronary intervention (PCI) of left anterior descending with drug eluting stent (DES) implantation and right coronary artery with DES implantation was done. Echocardiography verified the orderly dimensions of the visible part of the aorta, while computed tomography demonstrated the presence of anatomical variation in the right-sided aortic arch, with slight compression of the esophagus by the left subclavian (**Figure 1**). Surgical revascularization treatment was indicated, with aortic valve replacement through V-type mini sternotomy. During the operation and in the postoperative course, there was no need for blood and blood products. Throughout the procedure, the patient was hemodynamically stable, without catecholamine support. On the second postoperative day, the patient was transferred to post-intensive care, while on the fifth postoperative day, the patient was discharged home. FIGURE 1. Right-sided aortic arch with aberrant left subclavian artery. **Conclusion:** Mini sternotomy represents an optimal therapeutic modality for severe valvular heart disease (1, 2), even when it is accompanied with an anomalous vascular structure.

Petra Radić, Matias Trbušić, Ozren Vinter, Krešimir Kordić, Marko Boban, Ivica Šafradin

**Introduction:** In developed countries, infectious endocarditis (IE) is one of the most common causes of mitral valve failure. It is estimated that the annual prevalence of IE is 3 to 9 cases per 100,000 people, and almost 40% are mitral valve infections (1, 2). Despite the promotion of a surgical approach in the treatment of patients with endocarditis, there are conflicting conclusions on the benefit of surgery for IE and its timing (3). **Case report:** 79-year-old patient was hospitalized with clinical and laboratory findings of sepsis. The patient had autoimmune hemolytic anemia and splenomegaly and was recently hospitalized due to a recurrence of autoimmune hemolytic anemia which was treated with methylprednisolone. Blood cultures came positive on Methicillin-resistant Staphylococcus aureus. Transthoracic echocardiography (TTE) revealed large vegetation (18x12 mm) on the posterior leaflet of the mitral valve without signs of valve destruction and severe mitral regurgitation (Figure 1, Figure 2). Since two major and two minor Duke Criteria for definite IE were met, the patient was started on standard antibiotic treatment according to European Society of Cardiology (ESC) Guidelines. Due to newly developed right-sided hemiparesis, an MRI was performed which verified septic emboli and subarachnoid hemorrhage in reabsorption. In such cases, ESC Guidelines propose urgent surgical treatment with I class of recommendation which we decided against due to patient’s frailty and reluctance. The dose of methylprednisolone is gradually reduced. Control blood cultures came sterile after the initiation of antibiotics. Control TTE and TEE showed significant almost complete reduction of vegetation size. The patient became afebrile after 6-week administration of intravenous antibiotics with no laboratory or clinical signs of infection. In consultation with the cardiac surgeon, a strategy of watchful waiting was taken. The patient was transferred to a hospital for prolonged treatment for further rehabilitation. FIGURE 1. Transthoracic echocardiography image of vegetation on the mitral valve. FIGURE 2. Transesophageal echocardiography image of mitral valve endocarditis. **Conclusion:** When deciding on the therapeutic approach of infective endocarditis, the fatal consequences and complications of medical treatment should be taken into account in relation to the risks of surgical intervention. Considering recent literature has drawn conflicting conclusions on the benefit of surgery, every patient should be estimated individually.

Denis Mačkić, Edin Begić, Faruk Čustović, Salko Isaković

**Aim**: To present accidental detection of quadricuspid aortic valve (QAV), a rare congenital heart anomaly with an incidence of 0.01–0.04%. **Case presentation**: 49-years-old patient came for an examination due to tachycardia and palpitations during physical exertion. Transthoracic echocardiography verified the regular dimensions of the left and right heart cavities, with preserved systolic function of the left ventricle, and mild mitral and tricuspid regurgitation. The existence of QAV was suspected, while moderate aortic regurgitation was verified (pressure half-time 390 ms, vena contracta 5 mm, jet covered 40% left ventricular outflow tract, regurgitant volume 35 mL, regurgitant fraction 36%, effective regurgitant orifice area 0.16 cm2). Transesophageal echocardiography confirmed the diagnosis of QAV (**Figure 1**). FIGURE 1. **A quadricuspid aortic valve with moderate aortic regurgitation.** **Conclusion**: In QAV, diagnosis, as well as monitoring of aortic regurgitation, are of essential importance because of timely surgical treatment (1, 2).

Denis Mačkić, Faruk Čustović, Edin Begić

**Aim:** The aim of article was to present a patient with heart failure symptoms caused by prosthetic mechanical valve endocarditis. **Case presentation**: 44-years-old male patient was admitted because of dyspnea and swelling of lower extremities. The patient is a long-standing heroin addict who had an aortic valve replacement done 8 years ago due to endocarditis. The implanted valve was a mechanical aortic valve – Edwards MIRA bi-leaflet valve No 32 (Edwards Lifesciences; Irvine, California). He also was already diagnosed with hepatitis C years before. At admission the patient had heart failure signs with sinus tachycardia on the electrocardiogram. During physical examination a metallic click of the mechanical aortic valve was heard on stethoscope along with a diastolic murmur on the precordium with a punctum maximum above the aortic valve. Large pretibial edemas on both legs were present also. In laboratory findings nonspecific inflammatory parameters were increased. On transthoracic echocardiography dilatation of all heart chambers was found. The left ventricular systolic function was moderately reduced (left ventricular ejection fraction of 42% by Simpson method), along with restrictive filling pattern. Hypoechoic mass along the right side of the mechanical aortic valve was noted measuring 3.57x1.03cm. On the artificial aortic valve a high degree, severe aortic regurgitation, was verified with pressure half time 133ms. Blood cultures were examined and showed no significant bacterial growth. At admission dual parenteral antibiotic therapy was ordered. On the 7th day of hospitalization the patient becomes hypotensive with signs of acute renal failure. Despite of the therapeutically measures that were taken patients clinical worsening progressed and lethal outcome was declared. **Conclusion**: In this case even though aggressive parenteral antibiotic therapy was started, lethal outcome came due to several concomitant reasons. Paravalvular abscess of mechanical heart valves is a very serious complication with a high mortality rate. It is essential to recognize this type of pathology as early as possible, so aggressive parenteral antibiotic therapy could be started, while in many cases surgical reoperation is needed (1).

Marija Radić, Ivan Skorić, Ivana Jurin, Jelena Kursar, Šime Manola, Irzal Hadžibegović

**Background:** The prevalence of atrial fibrillation (AF) in patients undergoing transcatheter aortic valve implantation (TAVI) is about 30%-50%. Because of their multiple comorbidities, TAVI patients are likely to be at a high thromboembolic as well as bleeding risk, making appropriate management of AF in those patients challenging. Current guidelines support the use of oral anticoagulation monotherapy with vitamin K antagonists (AVK) in patients with AF after TAVI and direct oral anticoagulants (DOACs) are being currently investigated as monotherapy in patients with AF with conflicting results among different agents. Several prior studies have shown that pre-existing AF in TAVI patients is associated with worse outcomes including mortality compared with patients in sinus rhythm (1). We aim to investigate the impact of pre-existing AF on survival in our cohort of TAVI patients. **Patients and Methods:** We analyzed 252 consecutive patients who underwent TAVI procedure in our institution from 2013 to October 2020. **Results:** There were 48% patients with AF (either paroxysmal, persistent, or permanent) that underwent TAVI procedure. Their median age was 80 years, their median CHA2DS2Vasc score was 5 and median HASBLED was 4. Early post-procedural anticoagulation therapy was AVK in 24%, DOACs in 74%, and 2% of patients received no anticoagulant therapy due to very high bleeding risk. Two patients with AF had post-procedural stroke, with no cases of post-procedural stroke among non-AF group. Their in-hospital mortality was 3.4%, in comparison to 2.7% in patients without AF. In the case of a new introduction of oral anticoagulants (OAC), mainly DOAC is introduced depending on the assessment of the risk for major bleeding and the possibility of choosing the optimal dose, except in special cases (kidney disease) when preference is given to AVK. **Conclusion:** Almost half of high-risk patients scheduled for TAVI have indication for OAC due to AF. AF is associated with poor outcome and increased mortality after TAVI. These risks might be reduced by carefully choosing the optimal OAC strategy but strong conclusions with respect to optimal anticoagulation strategies cannot yet be made, and further research is required to transcend the current equipoise regarding the optimal OAC especially regarding which DOAC to choose after TAVI.

Irzal Hadžibegović, Daniel Unić, Ivana Jurin, Ivan Skorić, Savica Gjorgjievska, Nikola Pavlović, Tomislav Šipić, Marin Pavlov, Igor Rudež, Šime Manola

**Introduction:** Transcatheter aortic valve implantation (TAVI) is currently recommended as a first line treatment for patients with severe aortic stenosis and high surgical risk. Trials in 2019 showed safety and long-term efficacy also in low risk patients (1, 2). We aimed to investigate possible changes in patient selection for TAVI in our center after 2019’s steep and marked increase in numbers of procedures performed annually. **Patients and Methods:** We analyzed data from our prospective single center registry of TAVI procedures from 2011 to 2022. In all, 257 patients were included in the registry, out of which 87 (34%) patients were operated in the first period (low annual volume; 2011-2018), whereas 170 (66%) patients underwent TAVI in the second period (high annual volume; 2019-2022). Differences in patients’ characteristics and 1-year, 2-year, and 3-year survival were analyzed between the two periods. **Results:** There were no significant differences in patients’ main clinical characteristics, comorbidities and periprocedural outcomes, except those patients treated in the second period had significantly higher Society of Thoracic surgeons (STS-MM) scores compared to the first period (23.6 vs 18, p<0.001) and significantly lower proportion of patients with history of coronary artery bypass graft (CABG). Overall, 1-year and 2-year survival was 83% and 75%, respectively, with no differences between periods. 3-year survival after TAVI was 63%, with significantly more patients surviving 3 years after TAVI in the first (low volume) period (70% vs 55%, p=0.017). **Conclusion:** The steep increase in annual TAVI volume (from initial 1.5/month to 8/month in the second period) did not lead to more non-high-risk patients in the registry. Conversely, STS-MM scores were significantly higher during the second (high volume) period, meaning that with higher volume we started treating more complex patients. There were no differences in in-hospital, 1-year and 2-year survival. However, we observed lower long-term survival in the second period that was probably due to more complex patients entering the TAVI program. To achieve maximal long-term benefit of TAVI in near future, patients should be included in the TAVI program earlier, mainly by expanding the indication for TAVI to medium risk patients or elderly low risk patients with favorable anatomic characteristics warranting uncomplicated and successful TAVI procedure.

Livija Sušić, Matea Lukić, Marko Burić, Antonio Burić, Lana Maričić, Kristina Kralik, Tihomir Sušić

**Goal**: The aim of this study was to determine the impact of unhealthy lifestyle habits on the occurrence of cardiometabolic disease (CMD) depending on age and gender. **Patients and Methods**: A cross-sectional population study that included 163 participants (86 women, 77 men) aged 20 to 65, without known cardiovascular disease and diabetes mellitus. Based on the laboratory findings and the obtained anthropometric measurements, the cardiometabolic profile of the subjects was evaluated. Lifestyle habits were examined through a questionnaire. The impact of 11 unhealthy lifestyle habits (**Table 1**) on the incidence of arterial hypertension, dyslipidemia, overweight, obesity, impaired fasting glycaemia and metabolic syndrome was observed. Chi-square test and logistic regression were used to identify the risk factors for CMD. Significance level p set at Alpha = 0.05. Odd’s ratio and 95% confidence interval were used to report the findings. ### TABLE 1: 11 unhealthy lifestyle habits. | | **Unhealthy lifestyle habits** | **Weekly frequency** | | --- | --- | --- | | 1. | Smoking | | | 2. | Adequate physical activity | 3 | | 4. | Sweets | > 2 | | 5. | Fish | < 2 | | 6. | Fruits | < 7 | | 7. | Vegetables | < 7 | | 8. | Dairy products | < 7 | | 9. | Nuts | < 4 | | 10. | Bread/pasta/cereals | < 7 | | 11. | Extra salting | | **Results**: The average number of unhealthy lifestyle habits was 7 (min 2 - max 11). There was no significant difference in the number of unhealthy lifestyle habits in relation to gender and age. Of all, 84% of respondents already had one or more CMD. Men, compared to women, were significantly more obese, overweight and had dyslipidemia **(****Table 2****).** CMD was also significantly more common in those subjects who drink coffee in an amount of up to 2 dcl daily. Using bivariate logistic regression, we assessed which lifestyle habits would be more significant in predicting the occurrence of CMD and obtained the data that respondents with more meat meals per week have a 1.29 times greater chance of CMD occurrence. In the age group up to 50 years subjects with ≥ 6 unhealthy lifestyle habits were 5.7 times more likely to develop CMD (OR = 2.7; 95% CI 1.13 to 29.3). ### TABLE 2: 11 Gender differences in the incidence of cardiometabolic diseases | **Cardiometabolic disease** | **M** **n (%)** | **W** **n (%)** | **P*** | | --- | --- | --- | --- | | Dyslipidemia | 69 (90) | 52 (60) | 0,01 | | Metabolic syndrome | 42 (55) | 33 (38) | 0,07 | | Overweight | 44 (57) | 25 (29) | 0,002 | | Arterial hypertension | 30 (39) | 30 (34) | 0,55 | | Obesity | 24 (31) | 8 (9) | < 0,001 | | Impared fasting glucose | 23 (29) | 15 (17) | 0,08 | [†] M = men; W= female; * χ2 test **Conclusion**: Unhealthy lifestyle habits are rooted in our society regardless of gender and age (1-3), and as a result, a significant proportion of our population has already developed CMD.

Ivica Bošnjak, Dražen Bedeković, Kristina Selthofer-Relatić, Hrvoje Roguljić, Ines Bilić-Ćurčić

**Background**: The aim of this study is to examine possible association between serum galectin-3 values and the presence of significant atherosclerotic epicardial artery disease in patients with chronic coronary syndrome. **Patients and Methods**: Subjects with suspected coronary artery disease and indication for coronary angiography were included in study. Subject were divided in three groups: a) subject with indication for PCI, b) subject with indication for CABG and control group (without coronary artery disease). Galectin-3 value was measured by enzyme immunoassay (EIA) test. **Results**: T-test and ANOVA variance analysis was performed for statistically analysis (SPSS program, version 17.0). The mean value of galectin-3 in the study group was statistically higher than in control group (19.98 ng/ml vs. 9.51 ng/ml, p<0.001). In subgroup analysis there was no statistically significant difference in the values ​​of galectin-3 between the PCI and CABG groups (18.84 ng/ml vs. 21.27 ng/ml (t=7.417, p<0.001). **Conclusion**: Galectin-3 has shown potential to be reliable marker for assessment of significant coronary disease existence as well as a predictor of adverse cardiovascular events (1-3).

Katica Cvitkušić Lukenda, Ivan Bitunjac, Jelena Jakab, Blaženka Miškić, Vedran Velagić

**Introduction**: Atrial fibrillation (AF) is the most common cardiac arrhythmia associated with increased risk of stroke, heart failure, and death. The accepted method for invasive treatment of arrhythmia is pulmonary vein isolation (PVI), either by a point-by-point radiofrequency method or cryoisolation with a cryoballoon. (1, 2) We performed a retrospective analysis of patients who underwent pulmonary vein cryoisolation at the General Hospital “Dr. Josip Benčević” in Slavonski Brod. The primary objective of the study was to determine the efficacy and safety of the procedure 12-month after cryoisolation. **Patients and Methods**: We used data from the registry of patients who underwent cryoballoon PVI at the General Hospital “Dr. Josip Benčević”, data from medical documentation, and data from the hospital information system. Subjects were followed up at three time points: 1, 3, and 12 months after the procedure. An ECG was recorded each time, and a 24-hour Holter ECG was recorded at the third follow-up. Echocardiographic parameters were measured before the procedure. **Results**: Data were collected from 89 patients. The mean age was 62 years, and 54 (60.7%) of the patients were men. According to the type of AF, the persistent form was present in 38 (42.7%) patients, of which 24 (63.2%) were in male patients. The most common comorbidities were arterial hypertension in 75 (84.2%) patients and dyslipidemia in 52 (58.4%) patients. Heart failure associated with tachyarrhythmia was present in 25 (28.1%) patients. Diabetes was present in 11 (12.4%) patients. The mean CHA2DS2-VASc score was 2. The mean left atrial diameter was 52 mm. 53 (82.8%) patients were free of AF 12 months after the procedure. Of the 12 (17.2%) patients who experienced a recurrence of AF, 2 (16.7%) were hospitalized for heart failure associated with tachyarrhythmia. The median time to recurrence of AF was 7 months, IQR 8 (5-13). No bleeding, TIA/CVI, or death from any cause was recorded. **Conclusion**: In this single-center retrospective analysis, pulmonary vein cryoisolation is an effective and safe method for maintaining sinus rhythm 12 months after the procedure in patients with symptomatic paroxysmal and persistent AF.

Andrijana Kološa, Katarina Gorup, Matija Marković, Ena Kurtić, Maro Dragičević, Tomislav Letilović, Tomislav Meštrović, Ivica Premužić Meštrović

**Introduction**: Atrial fibrillation (AF) today, as an arrhythmia with the highest prevalence of about 1-2% in the general population, is associated with a high risk of developing stroke, heart failure, dementia (cognitive impairment) etc. Also, numerous studies have irrefutably linked AF and various depressive/anxiety disorders, as well as the presence of depressive symptoms with an increased perception of the severity of cardiac symptoms and more frequent recurrence of arrhythmias. (1, 2) The aim of this study was to examine the frequency of prescribed psychopharmacotherapy in patients hospitalized for electrophysiological (EP) treatment at “Merkur” University Hospital. **Patients and Methods**: A retrospective analysis of the medical data base of patients treated in the Electrophysiology Department of “Merkur” University Hospital in the period from June 15, 2020 to December 31, 2021 was performed. **Results**: The sum of 205 patients was included (132 men - 64%, 73 women - 36%). The median age was 62 years (ranging from 17 to 79). Of the included patients, on psychopharmaceutical therapy there were 46 patients (22%) and of which only 4 (1.9%) had a psychiatric diagnosis. The proportion of patients with left arrhythmias (paroxysmal and persistent AF and atypical atrial flutter) among patients on psychopharmacotherapy was 50%, but no statistically significant difference was found between left arrhythmias and other types of arrhythmias (all within the common group) (p = 0.463). There was found no association with cardiovascular risk factors (arterial hypertension, hyperlipidemia) nor with sleep apnea syndrome. In contrast, female gender was statistically significantly associated with the use of psychotropic drugs (p = 0.0239). In the statistical analysis, the Fisher’s test was used. **Conclusion**: Our results showed a significant presence of psychopharmacotherapy in group of patients with arrhythmias for which they underwent EP treatment. Considering that and evidently psychiatric diagnosis being underdiagnosed, we believe that, in a holistic approach to the treatment, an early multidisciplinary approach with the inclusion of different specialties (family medicine doctors, psychiatrists) is desirable with main aim to improve the wholesome clinical outcome.

Fran Rode, Jure Samardžić

**Introduction**: Right ventricular (RV) myocardial infarction (MI) is most commonly concomitant to inferior region MI and is a known cause of complications such as arrhythmia, bradycardia, hypotension, and cardiogenic shock. Previous research mostly investigated RV involvement with in-hospital mortality. However, effects on long-term follow-up after discharge are unfully investigated. (1, 2) The aim of our study was to determine the incidence of RV involvement in patients with inferior MI with ST-segment elevation (STEMI) and its significance in mid and long-term follow-up. **Patents and Methods**: We retrospectively analyzed hospital records from 1st January to 31st December 2015 to identify patients who were hospitalized in Department of Cardiovascular Diseases of University Hospital Centre Zagreb with inferior STEMI. Identified patients were divided into two groups – with and without concomitant RV involvement. The criteria for RV involvement were ST-segment elevation in leads V3R and/or V4R and a new RV hypokinesis on the echocardiogram. We observed the impact of RV MI on one and five-year survival rates and the incidence of reinfarction in patients with previous inferior STEMI. Follow-up data were collected from hospital records or phone calls. **Results**: In total, 111 patients had inferior STEMI. Out of 103 discharged patients, 15 (14.6%) had RV infarction. There was no significant difference between groups with and without RV involvement in one (92.9% vs 98.9%) and five-year survival rates (85.7% vs 93.1%). The group with RV infarction had a higher incidence of reinfarction, however without statistical significance (21.4% vs 5.7%, p=0.147). Our results did not show a statistically significant effect of RV involvement on reinfarction rate and one and five-year survival. We hypothesize that this might be explained by RV’s very good ability to recover in the period after revascularization for MI. **Conclusion**: It seems that RV involvement should raise an alert in acute settings and close treatment, but less so during period after recovery from MI. Further studies with larger sample sizes are needed to confirm the results of this study.

Kata Ćorić, Petar Medaković, Lidija Pleš, Antun Zvonimir Kovač, Nino Rudman, Zoran Miovski, Mladen Jukić

**Introduction**: To present a case of pulmonary embolism (PE) assessed with echocardiography (ECH) and confirmed by computed tomography (CT) pulmonary angiogram. PE is common and potentially lethal medical condition. Early systolic notching (ESN) on ECH is highly sensitive and specific for the diagnosis of submassive or massive PE (1). Patients with PE and ESN are more likely to have other evidence of right heart strain (such as right ventricular (RV) dilatation, McConnell’s sign, 60/60 sign, RV dysfunction). **Case report**: 68-year-old male was admitted to our hospital with a main complaint of worsening dyspnea over the past 10 days and chest pain that started on the day of admission. He also had pain in his right lower leg that started two weeks prior to admission. We immediately performed electrocardiogram, ECH and cardiac markers. ECH revealed signs of right heart strain: ESN of the right ventricular outflow tract; McConnell’s sign or right ventricular free wall akinesia with sparing of the apex, RV dilatation with flattened interventricular septum and D shaped left ventricle because of right ventricular overload. Cardiac markers (TnT, NT pro-BNP, D-dimer) were elevated. Based on the performed ECH, a massive pulmonary embolism was suspected, even though the patient was still hemodynamically stable. We referred the patient to the “Sveti Duh” University Hospital, where pulmonary CT angiogram was performed, and massive bilateral pulmonary embolism confirmed. The patient was admitted to the Intensive Care Unit for further treatment. A Doppler ultrasound revealed deep vein thrombosis of the right leg. **Conclusion**: PE is a common disease with a wide spectrum of illness severity. Point of care ECH has been used to find evidence of right heart strain (2). This, in combination with their hemodynamic parameters can help with stratification of these patients into a submassive or massive PE category, which has diagnostic and prognostic value.

Mario Udovičić, Sanda Jakšić Jurinjak, Mira Stipčević, Boris Starčević, Anđela Jurišić, Igor Rudež, Daniel Unić, Šime Manola

**Introduction:** Congenitally corrected transposition of the great arteries (ccTGA) is a rare anomaly comprising a minimal portion of congenital heart disease cases. Some patients are not identified until adulthood (1). **Case report:** We report the case of 57-year-old female patient with congenitally corrected trans-position of large blood vessels and associated dextrocardia. Except for the previously mentioned, she had also significant dilatation and insufficiency of the systemic ventricle with severe insufficiency of the systemic atrioventricular valve. She was repeatedly hospitalized due to heart failure. In 2017 a complete pre-transplantation management was performed, and due to congestive heart failure refractory to medications and high pulmonary vascular resistance, the multidisciplinary team decided for long-term unloading with ventricular assist device as a bridge to decision. In September 2020, due to clinical deterioration, she was accepted on the urgent international list for heart transplantation, and on September 7, 2020, the patient was transferred to the operating room of cardiac surgery for heart transplantation. Postoperatively, she was treated in the cardiosurgical intensive care unit, and the course of her stay was complicated by a severe cardiac tamponade and bleeding which required surgical drainage, and by a massive ischemic cerebral insult and renal insufficiency. Also, resistant hospital strains were isolated from blood cultures and catheters for which the patient was continuously on antibiotic therapy. Finally, the patient died of septic shock 32 days after the heart transplantation. **Conclusion:** Because the existing literature consists mainly of case reports, the management of a case like this one should include the stepwise introduction of the treatment modalities and close monitoring of the clinical response as well as the decision making by the heart multidisciplinary team (2).

Daniel Unić, Irzal Hadžibegović, Nikola Pavlović, Tomislav Šipić, Marin Pavlov, Marko Kušurin, Ivana Jurin, Davor Barić, Robert Blažeković, Josip Varvodić, Šime Manola, Igor Rudež

**Goal**: To present surgical complications in a cohort of patients treated with transcatheter aortic valve implantation (TAVI) in a single institution. Complications were reported according to Valve Academic Research Consortium-2 (VARC-2) criteria. **Patients and Methods:** Since 11/2011 a total of 257 patients (139 male, 118 female) were treated with TAVI procedure. Average age was 78.6±7.3 years (30-91). Average Society of Thoracic Surgeons (STS) score was 5.4±3.8% (0.9-23.8). Self-expanding prosthesis was used in 98 and baloon expandable in 159 patients. Transfemoral approach was used in 243 (95%) of patients. Alternative access sites included transapical - 10, transaortic - 2 and subclavian - 2. **Results:** Overall mortality was 2.3% (6/257). Most frequent complications requiring surgical intervention included peripheral access site complications 17/243 (7%). Bleeding was observed in 9/257 (3.5%) with cardiac tamponade in 6/257 patients – 1 requiring subxiphoid drainage. Valvular embolization was observed in 4/257 patients (2%) with 1 requiring surgical intervention. Conversion to open sternotomy was required in 3/257 (1%) – 2 annular rupture, 1 apical rupture with 2/3 patients expiring. **Conclusion:** Complications of TAVI procedure that require surgical intervention are mostly related to vascular access site. Conversion to sternotomy is rare but yields a high mortality (1).

Savica Gjorgjievska, Nikola Pavlović, Ivana Jurin, Irzal Hadžibegović, Tomislav Šipić, Marko Kušurin, Davor Barić, Igor Rudež, Šime Manola, Daniel Unić

**Introduction**: Reoperation after mitral valve surgery comes at a high risk to the patient, especially when there are significant comorbidities involved. Current practice is a standard median resternotomy approach. Transcatheter approach to mitral and tricuspid valves is being investigated as an optional treatment modality. **Case description:** 69-year-old male underwent mitral valve replacement and tricuspid valve annuloplasty 13 years ago. He presented with symptoms of global cardiac decompensation. Current comorbidities include: atrial fibrillation, diabetes, chronic renal insufficiency and hepatic cirrhosis with esophageal varices of ethylic/cardiac etiology. Echocardiography revealed structural valve deterioration of previously implanted mitral prosthesis resulting in stenosis due to pannus overgrowth. Severe tricuspid regurgitation was also present with dilated and impaired right ventricle. Severe pulmonary hypertension was measured on cardiac catheterization. High risk of reoperative surgical treatment, made us consider transcatheter approach. In a first step, a balloon expandable aortic valve was placed in a degenerated mitral bioprosthesis (valve-in-valve) transseptally. Since we observed no change in severity of tricuspid regurgitation, nor in the function of the right ventricle despite medical therapy over the next 2 months, a balloon expandable transcatheter valve was placed inside the tricuspid annuloplasty ring as a second step of the procedure. Moderate to severe eccentric tricuspid regurgitation was present on first postprocedural echo. On follow up, with optimized medical therapy, mitral bioprosthesis is performing well, tricuspid regurgitation is moderate, with an improvement in right ventricular function and decrease in pulmonary hypertension with patient in New York Heart Association (NYHA) status I-II. **Conclusion**: Transcatheter valve-in-valve and valve-in-ring implantation maybe a viable option for treating patients with multiple comorbidities yielding high risk for surgical reoperation. Long term benefits of this approach need to be evaluated (1).

Tomislav Čikara, Tomislava Bodrožić Džakić Poljak, Miroslav Raguž, Aleksandar Blivajs, Maria Nicole Sičaja, Šime Manola, Mario Udovičić

**Introduction:** Anatomically interrelated aneurysms and aneurysmal-like structures arising in and around the left ventricular outflow tract (LVOT) are a rare condition, and although most often clinically silent, they can cause a plethora of complications such as left main coronary artery compression, systemic emboli, or even new left-to-right shunts secondary to rupture (1). **Case report**: We present a case of a 69-year-old male with an asymptomatic aneurysm of LVOT containing a large mural thrombus. In 2017. the patient was referred for cardiology examination after a contrast-enhanced computed tomography done as part of the preoperative examination revealed a round calcified lesion (56x54x43 mm) above left ventricle. Further imaging processing confirmed a saccular aneurysm of LVOT located between the left and right coronary leaflets. His previous medical history was unremarkable except for a blunt chest trauma sustained in a traffic accident 35 years prior, which at the time did not require any surgery. We decided on a conservative approach and follow-up. Two years after the diagnosis, the patient was admitted to the hospital due to recurrent chest pains. There was no change in aneurysm size or structure. Coronary angiography showed dilated proximal branches of the left coronary artery with a subtotal stenosis of the marginal branch. A successful percutaneous coronary intervention with a drug eluting stent implantation was performed. Two years later, a contrast-enhanced multi-slice computed tomography showed the lesion stationary in size and the patient remains asymptomatic. **Conclusion**: In this case the LVOT aneurysm has remained stable over years and has well responded to a conservative approach.

Mira Stipcevic, Drazen Zekanovic, Jogen Patrk, Igor Rudez, Zoran Bakotic, Marin Bistirlic, Zorislav Susak, Branimir Buksa, Stipe Kosor, Karla Savic, Kresimir Librenjak

**Introduction:** Inhibitors of tumor necrosis factor-α are frequently encountered in modern clinical practice for treatment of psoriatic arthritis and opportunistic infections are in that context a common concern. Infective pericarditis has been described as a complication of these treatments (1). In most cases patients present with acute pericarditis, caused by wide spectrum bacteria, and can lead to cardiac tamponade and acute heart failure. Some patients present with symptoms of pericardial constriction (2). **Case report:** We present a case of sixty-year-old patient who was treated for psoriatic arthritis for fifteen years, and due to recurrent polychondritis adalimumab was introduced in therapy two years ago. The patient had good response to treatment, without side effects. In January 2021 he presented with symptoms of fatigue, swollen abdomen, difficulty breathing, swelling of legs and weakness. Symptoms started two months earlier. There were no signs of acute infectious illness. Echocardiography revealed thickened pericardium and moderate circumferential pericardial effusion, with respirophasic interventricular septal motion. Computed tomography showed thickened and calcified pericardium (**Figure 1**). Finally, heart catheterization confirmed the reciprocal respiratory pressure changes in the right and left ventricle (**Figure 2**). The patient’s symptoms of constrictive heart failure persisted and led to surgical treatment consisting of radical pericardiectomy and decortication (**Figure 3**). No pathogen was identified in pericardial fluid and pathohistological examination of pericardium showed chronic inflammation. The patient recovered completely and was without symptoms ten months later. FIGURE 1. Computed tomography showing thickened and calcified pericardium. FIGURE 2. Heart catheterization confirming the reciprocal respiratory pressure changes in the right and left ventricle. **Conclusion:** Prolonged treatment with adalimumab can pave the way to opportunistic infections which can cause acute pericarditis. In some cases, it can lead to chronic inflammation with late onset of chronic pericarditis. In case of constrictive pericarditis with severe and persistent hemodynamic impairment which cannot be controlled by medical therapy surgical pericardiectomy should be considered (3). FIGURE 3. Thickened and calcified pericardium (A). Excised pericardium (B).

Kristina Gašparović

The prevalence of heart failure (HF) is constantly increasing due to the aging population and progress in treatment of cardiovascular disorders (arterial hypertension, valvular heart disease, ischemic heart disease, congenital heart disease). At the same time, there is a rise in prevalence of risk factors including obesity, type 2 diabetes, smoking, physical inactivity. It is estimated that there are currently 64.000.000 people worldwide affected by heart failure, 2.400.000 new cases of HF per year in the European Society of Cardiology (ESC) member countries and over 2.000.000 hospital admissions in Europe every year. The prevalence of heart failure with preserved ejection fraction (HFpEF) in patients with HF is around 40% or even more. Risk factors and clinical characteristics of HFpEF include advanced age, female sex, arterial hypertension, obesity, prediabetes and diabetes. The most prevalent phenotype of patient with HFpEF is old, female patient with longstanding hypertension, left ventricular hypertrophy and left atrial dilation. Patient with HFpEF are burdened with comorbidities (hyperlipidemia, type 2 diabetes, chronic lung disease, chronic kidney disease). Aging, comorbidities and proinflammatory state lead to increased left ventricular stiffness and limited functional capacity. Diagnosis of HFpEF is made based on the presence of symptoms and signs of heart failure, echocardiographic evaluation (EF ≥ 50%, diastolic dysfunction confirmed with E/A ratio, e’ velocity, left atrial volume index) and laboratory assessment of increased natriuretic peptides. Heart Failure Association (HFA) provided an algorithm for the diagnosis of HFpEF (1). Treatment of HFpEF has been challenging because there was no specific treatment for the patients with HFpEF. Sodium-glucose Cotransporter-2 (SGLT2) inhibitors has been proven beneficial for cardiovascular outcomes in patients with HFpEF. The EMPEROR Preserved trial (Empagliflozin outcome trial in patients with chronic heart failure with preserved ejection fraction) confirmed that empagliflozin treatment resulted in a statistically significant 21% relative risk reduction for HF hospitalization and cardiovascular mortality compared with placebo in patients with HFpEF (2). The DELIVER trial (Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction) showed significant 18% reduction in the primary composite endpoint of cardiovascular death or worsening HF. These trials suggest that treatment with SGLT2 inhibitors in patients with HFpEF can be safe and effective in reducing the risk of future cardiovascular events (3).

Nikolina Šego, Lana Maričić

**Introduction**: Obstructive sleep apnea (OSA) independently increase the risk of coronary events. (1-3) The study aimed to assess the risk of OSA in patients with coronary heart disease and examine the correlation of risk for OSA with age, sex, associated comorbidities, body mass index (BMI), biochemical and echocardiographic characteristics. **Patients and Methods**: Cross-sectional study included 131 patients hospitalized at the Department of Cardiology, University Hospital Centre Osijek, due to acute coronary syndrome. The study included patients of both sexes, median age of 67 years. Three standardized questionnaires were used in the evaluation of the risk for OSA: the STOP questionnaire, the Berlin questionnaire, and the Epworth sleepiness scale (ESS). The respondent’s neck circumference was measured. Data on comorbidities, echocardiographic and biochemical parameters were collected from medical records. **Results**: According to the STOP questionnaire, 83 (63.4%) respondents had an increased risk for OSA, 45 (34.4%) patients according to the Berlin questionnaire, and 28 (21.4%) according to the ESS questionnaire. According to the STOP questionnaire, patients with hypertension (P < 0.001), gastroesophageal reflux disease (GERD) (P = 0.02), and patients using sedatives (P = 0.02) had an increased risk of OSA. Also, respondents with positive STOP questionnaire had higher BMI (P < 0.001) and greater neck circumference (P = 0.02). According to the Berlin questionnaire, patients at increased risk for OSA had significantly higher BMI (P = 0.001), neck circumference (P = 0.01) and lower troponin values (P = 0.01). Patients with a positive ESS had significantly higher urea (P = 0.01) and creatinine values (P = 0.003). The sum of ESS questionnaire was significantly and positively related to BMI (Rho = 0.194), neck circumference (Rho = 0.180) and urate values (Rho = 0.179). **Conclusion**: Increased risk for OSA, in patients with coronary disease is associated with comorbidities such as hypertension and GERD, increased BMI and neck circumference, sedative use, renal injury and urate values. Early recognition of OSA, with simple and available tests, in patients with coronary disease will have a favorable effect on the overall therapeutic response to treatment and will influence the prevention of further complications.

Ana Jordan, Ante Lisičić, Sanda Sokol Tomić, Nikša Bušić, Ivica Benko, Fran Rode, Šime Manola, Nikola Pavlović

**Introduction**: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Radiofrequency point-by-point ablation (RFA) in conjunction with 3D mapping systems uses minimal or no fluoroscopy, while cryoballon ablation (CBA) still requires longer use of fluoroscopy. (1) KODEX-EPD (3D mapping system) is a cardiac imaging system that can be used to guide CBA. With its ability to assess the dielectric properties of structures around an inserted catheter, 3D maps can be made, and the system can assess the occlusion of PVs without the use of fluoroscopy or iodine contrast (2). The aim of our study was to test the feasibility and safety of this relatively new dielectric imaging system in reducing fluoroscopy and contrast use during CBA. **Patients and Methods**: Consecutive patients undergoing CBA were enrolled with the intention to perform flouroless procedures. The KODEX-EPD navigation system was used to image the anatomy of the right atrium (RA). A single transseptal puncture was performed guided by intracardiac echocardiography. Mapping of the pulmonary veins and LA was performed by navigation with an inner lumen circular mapping catheter. The degree of PV occlusion with the inflated CB was verified using the “occlusion tool” software module and additionally with the use of saline injection. **Results**: During the two months, 15 consecutive patients undergoing CBA were enrolled (age 60±11; 6 women; mean left atrial diameter 39±4 mm). The average procedural and fluoroscopy times were 105±32 minutes and 3.5 ±3 1.8 minutes, respectively. In 7 patients (46,6%) procedure was performed with no use of fluoroscopy, while in 8 (53,4%) fluoroscopy was used due to the difficult crossing of the interatrial septum. No fluoroscopy was used after achieving LA access in all patients. In all patients, PVI was achieved with a mean total freezing time of 18.5± 4 minutes. PV occlusion was verified using the system’s occlusion tool successfully in all but one patient in whom 16 ml of iodine contrast was used to verify the PV occlusion. No complications have occurred. **Conclusion**: Although still a small number of patients were included, the results show promising effects of this novel electroanatomic system in performing CBA with no or minimal use of fluoroscopy and a significant reduction in the use of iodine contrast.

Petra Čerina, Tomislav Kopjar, Hrvoje Gašparović, Marjan Urlić

**Introduction**: Atrial fibrillation (AF) is the most common adult arrhythmia. Previous reports have suggested that surgical ablation concomitant with cardiac surgery significantly increases freedom from AF. (1) The goal of this study was to present our experience with AF surgery concomitant to conventional heart surgery at the University Hospital Centre Zagreb. **Patients and Methods**: We performed a retrospective analysis of our cardiac surgery database to include all patients with concomitant AF surgery from January 2020 to September 2022. During hospital stay patients were monitored with ECG telemetry. Patient follow-up consisted of checkup at 6-weeks and 6-months with a 12-lead ECG and a 24-hour Holter ECG. Continuous variables are summarized in terms of median and interquartile range (IQR); with the IQR being the range between the first and third quartile. Dichotomous variables are summarized in terms of frequencies and proportions. **Results**: This study included 15 patients. Median age was 64 (17) years. All patients, but one, were on anticoagulation therapy and had at least one rate control drug. All patients had paroxysmal AF. Indication for surgery was mitral, aortic and aortomitral disease. Early postoperatively 13/15 (87%), while upon hospital discharge, 12/15 (80%) patients were in sinus rhythm (SR). There were no surgical complications. One patient developed a high degree AV-block requiring permanent pacemaker implantation. At 6-week follow-up the incidence of SR remained the same. A 24-hour Holter ECG was available for 9/15 (60%) patients at 6-month follow-up and 8/9 (89%) were in SR. All patients were recommended anticoagulation and there were no thromboembolic events during the follow-up period. **Conclusion**: Concomitant AF surgery is an efficient method to maintain sinus rhythm during 6-months follow-up. Previous reports have suggested that surgical ablation concomitant with cardiac surgery significantly increases freedom from AF. Long term anticoagulation therapy after surgical ablation of AF is recommended based on the patient’s thromboembolic risk. Whether the patients following concomitant AF surgery should remain anticoagulated in the long-term, remains a matter of debate. Large, prospective, properly designed trials are needed to answer the question of anticoagulation following AF surgery.

Tomislav Čikara, Ivan Skorić, Miroslav Raguž, Irzal Hadžibegović, Šime Manola, Ivana Jurin

**Introduction:** Diabetes mellitus (DM) is an important risk factor for acute myocardial infarction (AMI) and a frequent comorbidity in patients hospitalized with AMI (1). After the first AMI, a considerable proportion of patients are newly diagnosed with diabetes mellitus (DM) (2). We observed the number of patients with newly diagnosed DM (new-DM) among patients hospitalized with AIM and their characteristics and clinical course in comparison to patients with established diabetes (known-DM) and patients who did not have DM (non-DM). **Patients and Methods:** The study included 1743 patients with AMI admitted in Dubrava University Hospital between January 2017 and December 2021. We defined new-DM as (1) unknown history of DM at presentation (2) DM listed as a discharge diagnosis. We compared characteristics (age, sex, past medical history) and clinical course of patients with new-DM and those with know-DM and non-DM over 3 years period post-AMI (M(Q1-Q3) 1244 days (934-1565)). **Results:** Among 1743 patients there was 74 (4.24%) patients with new-DM, 420 (24.09%) patients with established diabetes (known-DM) and 1239 (71.08%) patients who didn’t had DM (non-DM). We also noticed a group of 10 patients (0.57%) who had criteria for DM (HbA1c ≥ 6.5%, FPG ≥ 7.0 mmol/L, RPG≥ 11.1 mmol/L) but did not had DM listed as discharge diagnosis. Compared to know-DM patients with new-DM where younger (M(Q1-Q3) 61(55-70) vs 69(61-77)) and had less comorbidities (hypertension, dyslipidemia, atrial fibrillation, prior stroke, peripheral artery disease). The incidence of all-cause death and major adverse cardiovascular events (MACE) was significantly higher in the known-DM group than in the non-DM and new-DM groups (HR (95% CI) = 1.95 (1.36-2.81), p < 0.001; HR (95% CI) = 1.66 (1.28-2.16), p < 0.001). However, in follow-up period new-DM group did not have significantly higher incidence of all-cause death and MACE as know-DM group. **Conclusion:** Newly diagnosed diabetes mellitus is frequent in patients hospitalized with for AMI and it is recommended that all patients with AMI be screened for DM. Unlike known-DM, new-DM was not associated with higher risks of major adverse cardiac events in follow-up period (2, 3).

Mario Udovičić, Nika Barbara Pravica, Mihovil Santini, Danijela Grizelj, Vanja Ivanović Mihajlović, Hrvoje Falak, Igor Rudež, Davor Barić, Daniel Unić, Robert Blažeković, Josip Varvodić, Dubravka Šušnjar, Šime Manola

**Introduction:** Heart transplantation (HTx) remains the gold standard and treatment of choice for advanced heart failure refractory to other methods (1). In this study we investigated the outcomes of patients after HTx undergoing follow up at the Department of Cardiology, Dubrava University Hospital and their dependence upon the recipient characteristics at the time of HTx. **Patients and Methods:** We retrospectively examined the outcomes from 120 HTx between 1995 and November 2022, the recipient characteristics, and the impact of their comorbidities on survival. **Results:** The mean recipient age was 53.6 years at the time of HTx, and 80.8% were male. Dilated cardiomyopathy was present in 51%, ischemic in 41% and 8% were other causes. Survival was studied using Kaplan-Meier curves. Early in-hospital mortality was 10.0%. The survival rates at 1, 5, and 10 years were 83.9%, 74.5% and 56.3% respectively, and the mean survival was 132.9 months (95% CI, 110.5-155.3). Among the characteristics of the donors, none was found to separately have an impact on survival. However, the Charlson Comorbidity Index (CCI) ≥ 5 at the time of HTx was associated with a reduced survival, with a mean survival time of 91.0 months (95% CI, 67.0-115.0) compared to the group with CCI <5, whose mean survival of 157.4 months (95% CI, 129.6-185.2) was significantly better (p=0.004). **Conclusion:** Heart transplantation remains an excellent treatment option for selected patients with advanced heart failure, but our data implies that the high overall recipient comorbidity burden negatively impacts the posttransplant survival.

Davor Barić, Gloria Šestan, Daniel Unić, Robert Blažeković, Josip Varvodić, Marko Kušurin, Dubravka Šušnjar, Savica Gjorgjievska, Nikola Slišković, Igor Rudež

**Background**: Timing of surgery continues to be one of the most challenging point of interest in management of patients with acute infective endocarditis (IE). Recent guidelines recommend early surgery in most patients as soon as indication is met. (1, 2) We present our 26-year experience of surgical treatment for IE with additional analysis of optimal timing of surgery. **Methods and Results**: An analysis of prospectively collected data of 325 adult patients who underwent surgery due to acute IE between 1996 and 2022 at our institution was performed. Isolated aortic valve IE was observed in 48%, isolated mitral valve IE in 32%, multiple valves were affected in 12% and right-sided valves involved in 7% of cases. There were 12% of patients with previous cardiac operations and 10% of patients with prosthetic valve endocarditis. Perioperative mortality was 10.7% (35/325). An additional analysis was performed on subgroup of 155 consecutive patients with supplementary data available. They were divided in 2 groups: patients operated early (up to 14 days of diagnosis) or late (after 14 days). Patients in early-surgery group were significantly younger, had better renal function, lower incidence of neurologic impairment and higher incidence of perivalvular abscess. There was an observed tendency of higher valve repair rate in late-surgery group. Difference in perioperative mortality was observed (5.3% early-surgery group; 10.0% late-surgery group) but was not significant (p=0.277). **Conclusion**: The current evidence and our experience suggests survival benefits in early operated patients with IE, if an urgent indication for early surgery is present. To delay surgery for prolongation of preoperative antibiotic therapy is likely not going to lead to any additional patient benefit.

Jasmina Ćatić, Tomislav Šipić, Jelena Kursar, Marin Viđak, Nikola Šerman, Šime Manola, Ivana Jurin

**Introduction:** Patients with diabetes have long been known to be at high risk for morbidity and mortality after an acute myocardial infarction (MI) in part, because of more extensive coronary artery disease, additional cardiovascular (CV) risk factors, and higher burden of comorbidities. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are novel glucose-lowering treatments for type 2 diabetes with low risk for hypoglycemia that have been available in Croatia since March 2021. Trial evidence indicates that GLP-1 RAs may reduce the risk of CV events in patients with diabetes MI, but real-world data are limited. Therefore, we aimed to expand this observation to routine care settings (1). **Methods and Results:** Since March 2021, 74 diabetic patients that survived MI received GLP-1 RAs as a part of their diabetic care, and 22 of them had a follow-up period of 12 months. All the patients in our study used semaglutide as their GLP-1 RAs agent which represents the market penetration of this drug in Croatia. Median age of participants was 64 years in the group who received GLP-1 RAs, and 55 in the group who received other standard diabetic care. Median body mass index (BMI) in the group who received GLP-1 RAs was 32.98 kg/m2, and in the other group 29.18 kg/m2. After follow-up, BMI reduction was significantly higher in the GLP-1-RAs group (32.02 vs 28.8, p <0.01). In the GLP-1-RAs group, no patients experienced acute MI, stroke, new onset of atrial fibrillation. One patient died in GLP-1-RAs group from non-cardiac death. In non GLP-1 RAs group, 3.9% patients experienced acute MI, 0.9% experienced stroke, 0.3% experienced pulmonary embolism and 1.5% experienced new onset of atrial fibrillation and 3.2% patients died of which 0.2% was non-cardiac death. **Conclusion:** We conclude that compared with the standard of diabetes care, the use of GLP-1 RAs by routinely cared survivors of an acute MI was associated with a lower risk of subsequent major CV adverse events as well as significantly reduction in BMI. The cardio-protective effects of GLP-1-RAs seem to go beyond glucose control, possibly involving weight loss, although the real mechanism is not clear. Further real-world studies are needed to confirm these statements.

Kristijan Đula, Ivan Zeljković, Vjekoslav Radeljić, Siniša Car, Mislav Nedić, Nikola Bulj, Diana Delić-Brkljačić

Until recently, right ventricular apical electrode placement was predominantly used during bradycardia pacing management. Decades of clinical practice have taught us that a high burden of pacing in right apical position can deteriorate left ventricle function leading to increased mortality and morbidity. In the last few years, our daily clinical practice has fundamentally changed after the introduction of so-called conduction system pacing (His-bundle pacing and left bundle branch pacing area). The idea that the natural pacing of the heart prevents the aforementioned undesirable effects of ‘’classical’’ way of pacing, while maintaining the effectiveness, has led to a revolution in the treatment of such patients. The growing evidence indicate that conduction system pacing has the potential to become preferred pacing mode in various clinical indications, including the treatment of dyssynchrony in setting of heart failure. (1) We will present the results of our single center experience regarding conduction system pacing.

Nenad Lakušić, Ivana Sopek Merkaš, Anita Klasić, Tina Grgasović

In daily clinical practice, criteria for diagnosing acute coronary syndrome (ACS) are clinical presentation and patients’ symptoms, changes in the electrocardiogram and elevated troponin level. Troponin I and T are the most specific and the most sensitive biomarkers of myocyte damage which have in the last two decades taken precedence over isoenzyme CK-MB. Although elevated troponin level is mostly associated with myocardial ischemia caused by coronary atherothrombosis, it can also be elevated in different conditions such as long-term tachyarrhythmia, reversible prolonged vasospasm, myocarditis, electrocardioversion, cardiac surgery, sepsis, chronic renal failure, stroke, pulmonary embolism, etc. Also, in some cases significantly elevated troponin level is found in patients without ACS as a result of analytical interference which includes heterophile and human anti-animal clot antibodies or microparticles in the analysed blood sample, hemolysis, lipemia, etc. Cross-reacting heterophile antibodies are produced against incompletely defined antigens. Those antibodies can occur as a result of vaccinations, blood transfusions, exposure to different animal antigens (pets, veterinary profession), etc. According to literature data, their prevalence is very wide; from less than 1% to as much as 80%. When there is a suspicion of a false positive troponin level, a close collaboration between clinicians and biochemical laboratory staff is needed. It is important to highlight that in the cases of false positive troponin level because of circulating cross-reacting heterophile antibodies, the obvious dynamics of troponin as in ACS is not present, but the level is fixed at a plateau showing only small oscillations. Through the presentation of two cases from our clinical practice (1), we want to make clinicians aware of the possibility of false-elevate troponin level due to analytical interference (2) caused by cross-reacting heterophile antibodies in order to avoid unnecessary procedures and overtreatment of these patients and „patients“.

Rea Levicki, Tamara Božina, Nada Božina, Maja Sirovica, Dubravka Memić, Martina Matovinović, Martina Lović Benčić

**Introduction**: MTHFR C677T and MTHFR A1298C polymorphisms are associated with hyperhomocysteinemia that results in prothrombogenic and atherogenic effect and could influence atrial fibrillation (AF) onset. (1, 2) The goal of our study is to investigate relationship between MTHFR gene polymorphisms and AF. **Patients and Methods**: We included 55 patients (31M, 23W) with AF. To all patients MTHFR C677T and MTHFR A1298C polymorphisms were determined, routine laboratory tests were done, transthoracic echocardiography was performed, body mass index was determined. **Results**: In analysis of MTHFR C677T polymorphisms (**Figure 1**), there were 20 patients (36,4%) with healthy genotype (without present mutation) CC (cytosine–cytosine), 29 patients (52,7%) heterozygous CT (cytosine-thymine), and 6 patients (10,9%) with homozygous mutation TT (thymine-thymine). In analysis of MTHFR A1298C (**Figure 2**) there were 24 patients (43,6%) with healthy genotype AA (adenine-adenine), 23 patients (41,8%) heterozygous AC (adenine-cytosine), and 8 patients (14,5%) with homozygous mutation CC. Average weight of patients was 91.1±15.47kg, height 174.8±9.15 cm, and determined body mass index 29.54±3.68kg/m2. There were no differences in left atrium diameter in different genotype groups of patients. FIGURE 1. MTHFR C677T polymorphisms distribution. CC = cytosine–cytosine, CT = cytosine-thymine, TT = thymine-thymine FIGURE 2. MTHFR A1298C polymorphisms distibution. AA = adenine-adenine, AC = adenine-cytosine, CC = cytosine-cytosine **Conclusion**: While incidence of MTHFR C677T homozygous mutation TT was similar in our group of patients with AF as in general population in our geographic region, the incidence of MTHFR C677T heterozygous mutation (52.7%) was significantly higher than the incidence of general population; approximately 20-40% of Caucasian. (3) MTHFR A1298C homozygous mutation CC incidence in our group of patients with AF (14.5%) was higher than in European population (7-12%). Pathological MTHFR C677T and MTHFR A1298C polymorphisms distribution in our group of patients with AF, that includes high incidence of heterozygous mutation and higher incidence of homozygous mutation than in general population, could indicate association of pathological MTHFR polymorphisms with AF onset.

Petra Mjehović, Mia Dubravčić Došen, Dubravka Šipuš, Marijan Pašalić, Maja Čikeš, Dora Fabijanović, Nina Jakuš, Hrvoje Jurin, Daniel Lovrić, Ivo Planinc, Jure Samardžić, Ivana Ilić, Željko Čolak, Hrvoje Gašparović, Davor Miličić, Boško Skorić

**Background:** Late graft disfunction in patients after heart transplantation (HTx) is most often due to allograft rejection or allograft coronary artery disease but may also be due to infectious myocarditis or occasionally may occur without any documentable cause. Nonspecific allograft dysfunction may be caused by unrecognized myocarditis or even rejection because of unremarkable endomyocardial biopsy (EMB) specimens due to sampling error (1). Management of these patients is very challenging. **Case report**: We present 3 patients who developed nonspecific allograft dysfunction within 2 years after HTx. 38-year-old male presented with severe acute heart failure with left ventricle ejection fraction (LVEF) 30% two weeks after acute respiratory infection. 68-year-old male presented with a gradual reduction of functional capacity and LVEF 40% one month after COVID-19 infection. 55-year-old female was asymptomatic with LVEF 50%. She received COVID-19 messenger ribonucleic acid (mRNA) vaccine 5 months before. All patients had elevated biomarkers of cardiac injury (high sensitive Troponin-I and N-terminal pro b-type natriuretic peptide (NT-proBNP). Endomyocardial biopsy was negative for both cellular and antibody-mediated rejection but was also negative for histological signs of myocarditis. All patients were negative for donor-specific antibodies. Coronary angiography was normal. Cardiac magnetic resonance suggested a diagnosis of myocarditis. We have not diagnosed infectious cause in any of these patients. The findings were suggestive for clinically suspected myocarditis, and we decided to treat the patients with pulse steroid and intravenous immune globulins (IVIG). Patients showed significant improvement in graft function and so far have uneventful follow-up. **Conclusion:** It is difficult to recognize the cause of allograft dysfunction in some patients after HTx. It is crucial to exclude allograft rejection and vasculopathy. Post-transplant myocarditis is very unusual cause of graft failure, and EMB may be negative due to a lack of sufficient sensitivity considering the limited possibility of myocardial sampling. Although there are no controlled randomized data on steroid and IVIG treatment in these patients it seems that such therapy is safe and effective.

Nikola Škreb, Filip Lončarić, Anne Bonnin, Hector Dejea, Ivana Ilić, Antonio Hanžek, Hrvoje Gašparović, Davor Miličić, Ivo Planinc, Maja Čikeš

**Background:** Cardiac imaging is essential in identifying structural changes in advanced heart failure (HF) enabling understanding of the underlying pathophysiology. Synchrotron radiation-based X-ray phase contrast imaging (X-PCI) is a novel non-destructive imaging modality that can provide high resolution three-dimensional (3D) visualization of cardiac tissue on the macro- and microstructural level, enabling analysis from the epi- to the endocardium, as well as collagen matrix reconstruction (1, 2). We aimed to explore the feasibility of utilising X-PCI for the imaging of full thickness myocardial samples and to explore microstructural features of cardiac tissue in different advanced HF aetiologies. **Patients and Methods:** Eight patients were included - two receiving a left ventricular assist device (LVAD) (LVAD group), and six undergoing heart transplantation (HTx) (HTx group). Aetiology of advanced HF in the LVAD group was ischaemic heart disease (IHD) and dilated cardiomyopathy (DCM). In the HTx group, 2 patients had IHD, while one patient had each of the following: DCM, restrictive cardiomyopathy, toxic cardiomyopathy, and adult congenital heart disease. Transmural tissue samples were obtained by left ventricular apical coring (LVAD group) and from the explanted hearts (HTx group). The tissue specimens were imaged by X-PCI at the Paul Scherrer Institute (Villigen, Switzerland) using a multi-scale setup resulting in low (LR) and high resolution (HR) imaging, at 5.8 and 0.65 µm effective pixel size, respectively. Imaging datasets were used to visualize morphological features and an open-source software (Ilastik) was used for semi-automatic collagen segmentation. **Results:** The images resulting from the apical coring samples are shown in **Figure 1****.** X-PCI enabled multiscale exploration of transmural myocardial tissue samples providing 3D virtual histopathology. Additionally, reconstruction of the collagen matrix highlighting microstructural features and potential differences amongst different aetiologies of advanced HF was shown to be feasible without further sample preparation. FIGURE 1. Examples of X-ray phase contrast imaging images of different aetiologies of advanced heart failure in the left ventricular assist device group (dilated cardiomyopathy – panels A, B, C; ischaemic cardiomyopathy – panels D, E, F). Panels A and D show low resolution images, B and E high resolution images, and C and F show collagen segmentation. **Conclusion:** X-PCI is a non-destructive, 3D imaging method that can extend the amount of information available from ex-vivo tissue analysis and potentially improve disease phenotyping.

Željka Dragila, Lana Maričić, Romana Marušić, Lea Gvozdanović

**The goal:** To investigate treatment options for patients with heart failure and their impact on rehospitalization. **Patients and Methods:** This cross-sectional study included 200 patients hospitalized for heart failure at the Department of Cardiovascular Diseases, University Hospital Center Osijek, during 2020 and 2021. Patients were assigned to two groups based on whether it was their first hospitalization for heart failure or rehospitalization. There were 119 (59.5%) patients with reduced ejection fraction (EF), 44 (22%) patients with mid-range EF and 35 (17.5%) with preserved EF. Data on therapy at discharge were available for 177 patients (23 patients died during hospitalization). **Results:** There were 111 (55.5%) patients for whom it was their first hospitalization for heart failure, while 89 (44.5%) patients were rehospitalized. At admission, 140 (70%) patients had a beta blocker, 119 (59.5%) angiotensin-converting enzyme (ACE) inhibitor, 62 (31%) mineralocorticoid receptor antagonist (MRA), 24 (12%) angiotensin receptor–neprilysin inhibitor (ARNI) and 4 (2%) sodium-glucose cotransporter-2 inhibitor (SGLT2i). Majority of patients who were rehospitalized at admission had beta blocker (78, 87.6%) and ACE inhibitor (59, 66.3%) compared to those for whom it was their first hospitalization (P <0.001 and P =0.08, respectively), while MRA (46, 51.7%), ARNI (19, 21.3%) and SGLT2i (2, 2.2%) were used to a lesser degree. During hospitalization beta blocker was initiated in 37 patients, ACE inhibitor in 9 patients, MRA in 71 patients, ARNI in 24 patients and SGLT2i in 3 patients. **Conclusion:** Drug therapy for heart failure including a beta blocker, ACE inhibitor/ARNI, MRA and SGLT2i has been proven to prevent rehospitalization and decrease mortality in heart failure patients. However, in other studies it has been shown that a considerably large number of patients do not have guideline-directed medical therapy (1). Our study has shown that, in relation to other research, more patients are adequately treated, but there is still room for improvement. Even if rehospitalization for heart failure occurs it presents a great opportunity for treatment optimization which has a main goal of stabilizing the patient and preventing future hospitalizations for heart failure.

Ante Lisičić, Ana Jordan, Nikša Bušić, Sanda Sokol Tomić, Ivica Benko, Marin Viđak, Šime Manola, Nikola Pavlović

**Introduction**: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation, however with still a significant recurrence rates in patients with persistent AF. (1) Recently, ethanol ablation of the vein of Marshall (VOM) and a comprehensive ablation strategy (Marshall bundle elimination, Pulmonary vein isolation, and Line completion for anatomical ablation of persistent atrial fibrillation [Marshall-PLAN]) have been developed for ablation of persistent AF with promising results. (2) We adopted this strategy for the first time ablation in patients with persistent AF since January 2022. **Patients and Methods**: Left atrial (LA) sites were sequentially targeted for ablation as follows: (1) coronary sinus and vein of Marshall (CS-VOM) musculature; (2) PVI; and (3) anatomical isthmuses (mitral, roof, and cavotricuspid isthmus [CTI]). The primary endpoint was 6-month freedom from AF/atrial tachycardia (AT). **Results**: The case series included 20 consecutive patients with persistent AF. The median age was 66.5 years (IQR 63.25 – 69.25). The mean AF duration was 9 ± 11 months and mean LA index volume was 47 ±7 ml/m2). VOM ethanol infusion was completed in 14 patients (median dose 5 ml). One patient had a coronary sinus dissection, and in five patients the VOM was not found or considered too small for infusion (<1mm). The full Marshall-PLAN lesion set (VOM, PVI, mitral, roof) was completed in 13 patients. One patient had only VOM ablation due to an unsuccessful transeptal puncture. The mean procedural time and fluoroscopy time were 160±74 minutes, and 17±6,8 minutes respectively. At a follow-up (2.25-8 months), all patients were free from AF/AT after a single procedure. Compared to 15 historical patients with persistent AF in whom PVI only was performed, procedures were significantly longer with longer use of fluoroscopy (160±74 vs 90±20, p=0.001; 17±6.8 vs 5± 3 minutes, p<0.001). **Conclusion**: Based on initial experience, ablation according to the Marshall-PLAN protocol is a feasible and safe procedure for increasing the success rates of sinus rhythm maintenance in patients with persistent AF. Although our numbers are still small, initial results are comparable to larger trials.

Zdravko Babić, Marko Mornar Jelavić, Dorijan Babić, Diana Balenović, Ronald Lipovščak, Hrvoje Pintarić

**Goal**: to investigate the long-term prognosis of acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). **Patients and Methods**: This prospective study included 229 patients who survived acute STEMI. They were followed (2011-2021) and classified into two groups (with/without major adverse cardiovascular events (MACE)), and compared by their baseline (age, gender, cardiovascular risk factors), laboratory (maximal CK/TnT, acute inflammatory (white blood cells (WBC), hs-CRP) and liver biomarkers (AST/LDH), glomerular filtration rate (eGFR)), angiographic (stenosed coronary arteries and their segments, Gensini score) and clinical severity parameters (hospitalization duration, total in-hospital complications, echocardiography (LVEF)). **Results**: Cardiac rehospitalization, stroke, mortality and total MACE was present at 35.4%, 3.4%, 4.8% and 38.9% of patients, respectively. Logistic regression analysis revealed that several baseline (age, hypertension, metabolic syndrome, previous PCI/CABG), laboratory (LDH, max CK), angiographic (significant stenosis of LAD and ACx, multivessel CAD, proximal coronary stenosis, Gensini score), and clinical severity parameters (total in-hospital complications) increase, while the others (higher eGFR and LVEF) reduce the risk of the total MACE (for all P<0.05). In the multivariate analysis, the number of significantly stenosed coronary arteries, as well as lower LVEF and eGFR are the main predictors of the total MACE (for all P<0.05). **Conclusion**: Long-term prognosis after acute STEMI is influenced by the severity of the CAD, systolic and kidney function. (1-3) Primary prevention must be directed to the treatment of arterial hypertension and metabolic syndrome generally, two modifable risk factors that increase the risk of MACE.

Vanja Ivanović Mihajlović, Mario Udovičić, Stjepan Galić, Danijela Grizelj, Hrvoje Falak, Anđela Jurišić, Šime Manola

**Background:** Takotsubo cardiomyopathy (TCM) is an acute, stress-induced cardiomyopathy with an increased prevalence in post-menopausal women (1). There is yet no consensus on the diagnostic criteria for TCM. Mayo Clinic Criteria include transient wall motion abnormality, absence of obstructive coronary disease or angiographic evidence of acute plaque rupture, new electrocardiographic abnormalities or modest elevation in cardiac troponin and the absence of pheochromocytoma and myocarditis (2). Aim: To report the clinical characteristics from a single center of patients with TCM. **Patients and Methods:** We retrospectively analyzed data of 49 consecutive patients from 2012 to 2022 discharged as TCM. Baseline demographics, ECG, coronary angiography, and echocardiography were reviewed. **Results:** 42 (86%) patients presented with chest pain, while 21 (43%) had dyspnea. Almost all patients (48/49, 98%) were female. The mean age was 62±12years, of which 47% (n=23) were aged ≤55 years. Arterial hypertension was present in 63% (31/49), hyperlipidemia in 80% (39/49) and diabetes in only 14 patients. Various stressors were noted. 45% of patients had a new onset of ST elevation. Mean ejection fraction (EF) at presentation was 51%. In 11 patients we did a subsequent echocardiography and mean EF was 60% at follow-up. **Conclusion:** TCM is an important safety issue occurring predominantly in post-menopausal women undergoing specific stressing condition. Timely diagnosis and treatment can prevent the development of later complications associated with heart failure (3).

Mario Udovičić, Danijela Grizelj, Vanja Ivanović, Hrvoje Falak, Ana Jordan, Ante Lisičić, Anđela Jurišić, Diana Rudan, Šime Manola

**Introduction**: Current guidelines in atrial fibrillation (AF) recommend using CHA2DS2-VASc score when deciding whether anticoagulant (AC) therapy should be given for stroke prevention in patients with AF (1). In anticoagulated patients, the risk of stroke/systemic embolism is similar across AF patterns (2). Aim: To examine relationship between AF temporal pattern and the practice of prescribing AC by cardiologists and internal medicine specialists to patients with CHA2DS2-VASc score ≥2 for men and ≥3 for women in Dubrava University Hospital (DUH) in 2016. **Patients and Methods**: We reviewed hospital records contained in the hospital electronic system for all patients with AF diagnosis and permanent residence within DUH area, who were treated or examined at the Department of Internal Medicine, Division of Cardiology and Emergency Department. Only those patients were included who: 1) had previously at least one explicit AF in-patient diagnosis, or two AF out-patient diagnoses, 2) finding signed by a cardiology or internal medicine specialist and 3) had a hospital record from 2016 with therapy data and explicit AF pattern classification. The last AC therapy entry and last AF pattern classification in 2016 were taken as relevant. We compared the practice of AC therapy in the paroxysmal AF group to the combined persistent/permanent AF group. **Results**: Of 2124 AF patients with therapy data and explicit AF pattern classification, 1947 were CHA2DS2-VASc score ≥2 for men and ≥3 for women. Out of 641 patients classified as paroxysmal, only 323 (50.4%) patients received AC therapy, while 86 (13.4%) were prescribed antiplatelet therapy (APT) or in 232 (36.2%) patients nothing. Out of 1306 patients with persistent/permanent AF, 986 (75.5%) were prescribed AC, 93 (7.1%) were given APT, while 227 (17.4%) were given none. The difference in AC prescription practice was significant. **Conclusion**: There is a significant hesitation by physicians in practice to prescribe AC therapy to patients with paroxysmal AF despite high CHA2DS2-VASc score.

Petra Radić, Vjekoslav Radeljić, Matias Trbušić, Zdravko Babić, Ivo Darko Gabrić, Ivan Zeljković, Diana Delić-Brkljačić

**Introduction**: Impella CP is a percutaneously inserted left ventricular assist device indicated for temporary mechanical cardiac support during high-risk percutaneous coronary interventions and for cardiogenic shock (1). Our single center’s experience with Impella CP is a representation of the clinical advantages this device provides, which may result in the expansion of indications for its application. **Patients and Methods**: This study is a single-center retrospective cohort analysis of hospitalized adult patients in whom Impella CP was applied for mechanical circulatory support. **Results**: A total of 4 implanted Impella devices were utilized in 4 patients at Sestre Milosrdnice University Hospital Centre from January 2022 to November 2022. The overall survival rate was 100%. In three cases, Impella was used due to the extent of coronary disease and very high-risk percutaneous interventions, while in the last case, it was used due to cardiogenic shock and hemodynamic instability of the patient. All the Impella devices were extracted immediately after completion of the procedures. The puncture sites were closed in two cases with the Manta system, and in the other two cases with the Proglide closure device. There were no complications in our cohort. **Conclusion**: Our hospital’s experience with Impella has been excellent and we strive to establish this device as one of the main options for mechanical circulatory support.

Ana Fabris

**Aim**: As coronary flow reserve is diminished in both coronary micro and macrovascular disease (1, 2), we investigated whether there is a difference in exercise gas exchange between those two derangements. **Case report**: 62-year-old man with the history of the arterial hypertension and type 2 diabetes quantitative exercise stress echocardiography was done due to significant number of premature ventricular contractions and nonsustained ventricular tachycardia in the 24-hour ECG monitoring and chest pain. Significant immediate postpeak color Doppler derived strain rate decrease is registered in midanteroseptal, basal inferolateral and midinferior segment without significant hemodynamic derangements and without ST-segment depression. Coronary angiogram has revealed no organic stenosis of the main epicardial coronary arteries, but diffuse tightening of the lowest segments of the coronary macrocirculation, which might be related to the diffuse microvascular disease. After one year, the exercise gas exchange measurement during quantitative stress echocardiography showed normal parameters of oxygen consumption: peakVO2 28.6ml/kg/min, ATVO2 20.9ml/kg/min, dVO2/dWR 16.64 ml/min/W, peak O2 pulse 19,8ml/beat with normal linear curve. There was significant segmental decrease in delta SR, slight WMSI and electrocardiographic derangements, without hemodynamic changes. **Conclusion**: As opposed to macrovascular derangements, oxygen consumption might still be normal in patients with coronary microvascular disease. Changes in dSR without metabolic and hemodynamic derangements /alternative ischemic cascade/ in cardiopulmonary echocardiography exercise test might signify microvascular disease.

Antun Car

This case report focuses on cardiac dysfunction and death during 24-Hour Holter monitoring in the setting of ischemic stroke of the 73-old-male hypertensive patient. Multi-sliced computed tomography of the brain showed hyperdensity of the middle cerebral artery (MCA) of the right side and hypodensity of the irrigation of the right MCA of the right hemisphere of the brain. The patient has been checked by cardiologist two days before the death. He was in sinus rhythm, without signs of myocardial ischemia, treated with antiedematous therapy by neurologist. Because of the ischemic brain changes in the right MCA, thrombolytic therapy could not be used. Low molecular weight heparin and parenteral antihypertensive therapy has been used and rehydration of the patient. During the continuous 24-Hour Holter monitoring during 21.54 h (until the moment of death) registered 89 364 cardiac cycles. It was sinus rhythm since 8 o’clock until 8.47 pm when one short period of atrial fibrillation appeared. After reaching the sinus rhythm again, appeared salves of ventricular extrasystoles (VES) (up to 4 VES). Finally, there was appearance of the new right bundle branch block (RBBB), which was followed by slow ventricular tachycardia which ended in bradyarrhythmia, asystole and death. Death came during the 24-Hour Holter monitoring due to the grave ischemic acute insult of the right cerebral hemisphere. This case report proves that patients with the right stroke have different arrhythmic disturbances due to the cerebral ischemia. The risk of cardiac complications increases proportionally to the severity of ischemic stroke and neurologic deficit. Approximately 67% of acute ischemic stroke patients have ECG abnormalities of ischemic, and arrhythmic in the first 24 hour after stroke. Cardiac arrhythmias are common reasons for death after acute ischemic stroke. Sympathetic hyperactivity and decrease in parasympathetic activity caused by stroke may be the reason of arrhythmia and sudden death. At the patients with the terminal no cardiac disease final cause of the death was confirmed to be bradyarrhythmia in 87% of the patients and ventricular tachyarrhythmia in 17%. Agonal ST-segment elevation was observed like in our case. Death was due to the bradyarrhythmia. Incidence of sudden death during acute stroke ranging from 2% to 6% (1-3).

Matea Bilić-Pavlinović, Tony Rumora, Drago Baković, Denis Došen, Irena Ivanac Vranešić, Darko Anić, Kristina Marić-Bešić

**Introduction**: Coronary sinus (CS) atrial septal defect (ASD) is a congenital abnormality of both the atrial septum and the CS that falls within a wide spectrum of unroofed coronary sinus syndrome (URCS) (1). The rarest type of ASD called ‘isolated CS ASD’ can be found in less than 1% of all ASDs. This case report aims to highlight the symptoms and diagnostic approach in an elderly patient with CS ASD. **Case report:** We present a 60-year-old man who complained of moderate effort dyspnea lasting more than 12 months. He was treated for arterial hypertension, atrial fibrillation and had a history of pulmonary hypertension of unknown etiology. Physical examination showed an accentuated second heart sound over the pulmonary ostium with a systolic murmur. Transthoracic echocardiography showed pulmonary hypertension, right ventricular hypertrophy and dilatation, enlargement of both atria, a dilated coronary sinus and no visible atrial septal defects. Right heart catheterization revealed postcapillary pulmonary hypertension, with mean pulmonary artery pressure (mPA = 48 mmHg), pulmonary capillary wedge pressure (PCWP) of 25 mmHg, a significant left-to-right shunt (Qp/Qs = 2.5:1) and pulmonary vascular resistance (PVR) of 2 Wood units. Cardiac CT (**Figure 1**) showed a large communication around 3.3 cm in diameter between both atria as well as a dilated CS of 1.1 cm diameter. Transesophageal echocardiography (**Figure 2**, **Figure 3**) with bubble test disclosed a communication between the left atrium and the CS consistent with diagnosis of CS ASD without a persistent left superior vena cava (PLSVC). After intensification of diuretic therapy, follow-up catheterization 2 months later showed a reduction of PCWP (10mmHg) and mPA (25 mmHg) leading to successful surgical repair. FIGURE 1. Heart computed tomography. FIGURE 2. Transesophageal echocardiography. FIGURE 3. Transesophageal echocardiograph – color Doppler. **Conclusion**: Patients with left-to-right shunts due to CS ASD are usually asymptomatic throughout adulthood. However, once symptoms occur, this congenital heart malformation remains often misdiagnosed. Therefore, we emphasize the importance of multimodal imaging in these patients (2).

Tonći Batinić, Karlo Golubić, Nikola Kos, Mislav Vrsalović

**Introduction:** Subjects with multiple renal arteries have been shown to suffer more frequently from hypertension (1, 2). The aim of the study was to determine the prevalence of multiple renal arteries in patients in whom other causes of secondary hypertension have been excluded. **Patients and Methods:** Out of 361 patients with hypertension screened through our outpatient department, we studied 13 patients that were subsequently hospitalized during the last 12 months. All of them had blood samples taken for exclusion of endocrine disorders and all had undergone abdominal CT angiography in order to exclude renal parenchymal disease or renal artery stenosis (**Figure 1**). FIGURE 1. A CT angiogram showing a double left renal artery. **Results:** 8 od 13 (62%) patients with no other secondary cause of hypertension have had multiple renal arteries (Chi-Square „Goodness of Fit“ Test, p=0.036). Mean age was 36.2 years and all patients were male. Four patients had double right renal artery and four patients had double left renal artery. The median value of antihypertensive drugs taken was 2.5. **Conclusions:** The prevalence of MRA was greater in our study group than in the general population. We conclude that patients with multiple renal arteries and no other secondary causes of hypertension constitute a group who may be prone to develop arterial hypertension.

Ana Fabris, Mila Jakovljević

**Introduction**: Doppler myocardial imaging provides sensitive indicators for diagnosing subendocardial dysfunction, but their specificity is low (1). We wanted to establish whether exercise gas exchange measurement might improve differing myocardial ischemia from fibrosis. **Case report**: In the case of 79-year-old woman with the history of the myocardial infarction and the left anterior descending artery stenting 7 years ago, quantitative exercise stress echocardiography was done due to emerging atypical chest pain. In mid anteroseptal segment, there was significant decrease in myocardial systolic velocity /delta Vs -73,83/, in deformation velocity /delta SR-88,96/ and deformation /delta S-62,21/. Deformation velocity was decreased in mid inferior segment as well /delta SR-20,23/. Measurement of exercise gas exchange showed slight decrease of oxygen consumption parameters /pVO2 76%, ATVO2 30%, O2 pulse 67% of the predicted values and dVO2/dWR 8.80 ml/min/W/ but without “ischemic threshold”. **Conclusion**: Measurement of exercise gas exchange during quantitative stress echocardiography might help differentiating myocardial ischemia from fibrosis.

Marin Pavlov, Aleksandar Blivajs, Tomislava Bodrožić Džakić Poljak, Miroslav Raguž, Ilko Vuksanović, Irzal Hadžibegović, Nikola Pavlović, Šime Manola

Use of percutaneous catheter-directed treatment of pulmonary embolism (PE) has increased. Current guidelines recommend such treatment for patients with high-risk PE and contraindication for fibrinolysis (class IIa, level C), as well as an alternative to thrombolytic therapy for patients with intermediate risk PE and hemodynamic deterioration (class IIa, level C) (1). Several options are available for catheter-directed treatment of PE. Methods which avoid the use of fibrinolytic therapy are gaining more attention. Inari Flowtriever offers an option for a large bore (20F/24F) catheter aspiration of centrally positioned thrombi. Catheter is positioned in front of the thrombus over the stiff wire. Vacuum aspiration is performed by a 60 ml syringe. Repositioning of the catheter should always be performed over the stiff wire. Advancing of the catheter is obligatory performed with introducer inserted into the catheter. This makes catheter navigation more complex. In addition, if the thrombus is not engaged, 60 ml of blood is wasted. A system for filtering and reinfusing clot-free blood is available, however it has not yet been introduced in Europe. Despite the shortcomings, the possibility of complete thrombus aspiration, even in the setting of extreme thrombus size, is exceptionally practical. Thus far we performed 12 procedures in 11 patients, including a procedure in failed fibrinolysis and thrombus-in-transit setup. All the procedures were successful. Lightning Intelligent Aspiration System (Penumbra) offers an alternative for aspirational embolectomy. An active aspiration system is delivering suction over highly steerable 12F catheter. Aspiration is active when thrombus is engaged, performing fragmentation and extraction of thrombotic masses. When thrombus is not engaged, suction is suspended, thus limiting blood loss. Such features make negotiating of multiple pulmonary artery branches less demanding. For now, we have no experience with the device. Comparison with Inari system in efficacy and completeness of thrombus extraction should be verified in everyday work. Both systems have been widely used in patients with intermediate-high risk PE. Lack of randomized control studies and a particular guideline make aspirational embolectomy debatable, despite promising initial experiences.

Vedran Velagić, Ivan Prepolec, Vedran Pašara, Borka Pezo-Nikolić, Mislav Puljević, Davor Puljević, Davor Miličić

**Introduction**: The so called „zero fluoro” or „apron less” approach is getting more popular in the electrophysiology labs (1). The main concern of this strategy is its safety. We aimed to demonstrate the feasibility of zero-fluoro approach for the repeat atrial fibrillation (AF) procedures after initial cryoballoon ablation (CB). **Patients and Methods**: We have performed a retrospective study on patients that have undergone repeat pulmonary vein isolation (PVI) procedures in our institution since we started the zero-fluoro program in 2020. All patients received CB ablation for the initial procedure. Procedures were performed under conscious sedation with the help of intracardiac echo (ICE) and 3D mapping system, without the use of fluoroscopy. Right-sided femoral vein was used for the two introducers. A single transseptal puncture was performed guided by ICE. Steerable sheath was used and high-density voltage map of left atrium (LA) was created to evaluate the pulmonary vein (PV) reconnections. Contact-sensing radiofrequency ablation (RF) ablation catheters were used to reisolate the reconnected veins and in the case of no reconnections, posterior wall isolation was performed. **Results**: We have analyzed in total 38 patients (74% male, 59.3±0.3 years old), 53% of which suffered from paroxysmal AF. The mean left ventricular ejection fraction was 61.6±7.0% and mean LA diameter was 42.0±5.2 mm. In two (5.2%) patients RF energy was required to cross the intraatrial septum. In one patient (2.7%) conversion to fluoroscopy was required because of demanding transseptal puncture. The mean procedure time was 98.1.3±26.4 min and the mean RF time was 821 sec±420 sec. The mean of 1.25±0.893 veins were reconnected per patient and 10 patients (26.3%) did not have PV reconnections. In all patients successful PV/PW isolation was performed confirmed by entry and exit block. No periprocedural complications were observed. **Conclusion**: In our cohort of patients, zero-fluoro approach for repeat PVI procedures ablation proved to be feasible and safe. Conversion to fluoroscopy was needed infrequently for more difficult transseptal procedures.

Dražen Bedeković, Ivica Bošnjak, Jerko Arambašić

**Introduction**: Brugada syndrome is congenital disorder that can lead to sudden cardiac death (SCD). It is characterized by spontaneous or provoked typical ECG features and the occurrence of malignant ventricular arrhythmias, most commonly manifested by syncope or SCD. The use of an implantable cardioverter-defibrillator (ICD) is the only effective therapy for arrhythmic death prevention. The coexistence of Brugada syndrome and coronary heart disease (CHD) is rarely described in the literature. (1-3) We present a case report of patient with coexistence of two different heart conditions: symptomatic Brugada syndrome and CHD. **Case report**: 60-year-old male was admitted to the Coronary Care Unit due to recurrent syncope. A few hours before admission the patient suddenly lost consciousness and spontaneously recovered. He had a similar event a few years earlier but did not report to the physician. He asserted to have occasional mild chest discomfort during physical activity. He had well controlled hypertension. The patient was generally in good health, afebrile, eupneic, normal neurological status, with audible murmur over the heart apex, intensity II/VI. The recorded 12-channel ECG showed a typical pattern for type I Brugada syndrome: right branch block and concave ST-segment elevation in V1 and V2 leads higher than 2mm (**Figure 1**), without criteria for acute ischemia. Coronary angiography revealed the existence of hemodynamically significant stenosis (IFR 0.86) of middle segment left anterior descending artery (LAD) at bifurcation with first diagonal artery (D1), including D1 ostium with 75% lumen stenosis. Percutaneous coronary intervention was performed with dilatation of LAD and D1 and implantation of by drug-coated balloon (**Figure 2**). We implanted a single-chamber ICD for the purpose of SCD prevention due to possible ventricular arrhythmias associated to Brugada’s syndrome. FIGURE 1. Electrocardiogram: Brugada typ I pattern. FIGURE 2. Percutaneous coronary intervention on left descendent coronary artery and its first diagonal branch. **Conclusion**: Brugada’s syndrome estimated incidence is five cases per 10,000 people; and only a few published studies and case reports describe its coexistence with CHD. Type 1 ECG pattern like in our patient does not require an arrhythmia provocation test with sodium channel blockers and it was not done. We consider CHD in this patient to be a concomitant accidental finding, which was not the cause of syncope or Brugada related ECG pattern. Due to increased risk of sudden arrhythmic death: syncope, type I ECG pattern and male gender, patient received ICD which is the only effective therapy to prevent sudden arrhythmic death for Brugada syndrome and even with only strong suspicion of ventricular arrhythmia existence we consider ICD implanting justified. In conclusion, we believe that there were two different diseases in this case, mildly symptomatic/asymptomatic CHD and symptomatic Brugada syndrome, both recognized and successfully treated.

Aleksandar Blivajs, Miroslav Raguž, Marin Pavlov, Ilko Vuksanović, Tomislava Bodrožić-Džakić Poljak, Šime Manola

**Introduction:** Extracorporeal membrane oxygenation (ECMO) combined with cardiopulmonary resuscitation (CPR) is known as extracorporeal cardiopulmonary resuscitation (ECPR) and permits hemodynamic and respiratory stabilization of patients with cardiac arrest (CA) refractory to conventional CPR. Current evidence does not support the routine use of ECPR in all patients with refractory CA, and should be applied only in high-volume facilities. (1-3) **Case report**: 33-year-old patient was brought to the Emergency Department because of CA. Having lost consciousness 10 minutes prior to admission, he was complaining of chest pain and nausea. Advanced life support with intubation and mechanical ventilation was immediately begun, along with cardiopulmonary resuscitation (CPR) measures. Initial rhythm on ECG was ventricular fibrillation, and he was electrocardioverted on multiple occasions with temporary return of spontaneous circulation (ROSC). The patient was transferred to the Cardiac Intensive Care Unit under measures of CPR, and after 30 minutes of no ROSC, an on-site ECMO was primed with right arterial and left venous femoral cannulation. After implementation of temporary mechanical circulatory support he was rushed to the Cath-lab where angiography revealed occlusion of the proximal left anterior descending and percutaneous coronary intervention with one DES implantation was performed. The patient was sedated, on intermediate dose vasopressors (noradrenaline 0.2 mcg/kg/min), with ECMO support ranging around 3200 rpm. De-escalation from vasopressors and weaning from ECMO was initiated. Echo revealed a non-dilated left ventricle with mildly reduced ejection fraction due to hypokinesis of the septum and apex. After 24 hours, ECMO was successfully decannulated using percutaneous closure devices AngioSeal and ProGlide. Upon inspection 6 hours after decannulation, the right leg was pale with no palpable peripheral pulsations. Multi-slice computed tomography (MSCT) angiography revealed occlusion of the right AFC on closure site. Emergency thromboendarterectomy and „patch“ angioplasty of the common femoral artery (AFC) were performed. Follow-up MSCT angiography three hours later showed significant residual stenosis in the region of AFC and external iliac artery and subsequent percutaneous intervention was performed with implantation of one peripheral stent. The patient was later extubated with complete neurologic recovery and hemodynamic and rhythmic stability. He was discharged on his feet 11 days after hospitalization. **Conclusion**: Despite high mortality rates in OHCA, we present a successful case where an experienced and trained team can perform effective and timely treatment of critically ill patients.

Ivan Prepolec, Miroslav Krpan, Vedran Pašara, Borka Pezo Nikolić, Richard Matasić, Martina Lovrić-Benčić, Mislav Puljević, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: Implantable cardioverter-defibrillators (ICD) are a gold-standard therapy for prevention of sudden cardiac death (SCD). (1) Subcutaneous ICDs (S-ICD) provide a valuable alternative to conventional transvenous devices (TV-ICD) and can eliminate the risk of lead-related complications and lower risk of systemic infection in selected patients. Introduction of this technology involves higher economic burden and period of learning in emerging implantation centers. **Patients and Methods**: We analyzed data regarding all S-ICDs implanted since the introduction of the procedure in our institution in December 2021. **Results**: There were in total 7 patients (4 male and 3 female) with the median age 49 (28-64 years). All patients received S-ICD for primary prevention of SCD. Indications were as follows: ischemic cardiomyopathy (3 cases), hypertrophic cardiomyopathy (2 cases), non-ischemic cardiomyopathy (1 case) and catecholaminergic polymorphic ventricular tachycardia with concomitant cardiomyopathy (1 case). There were several different reasons for implantation of S-ICD rather than TV-ICD. Three patients suffered from severe kidney failure and two of them already had chronic dialysis catheters in situ. One patient had a previous infection of TV-ICD. Another patient with ischemic cardiomyopathy and repaired tetralogy of Fallot was not suitable for TV-ICD due to occlusion of left subclavian vein and probable need for future percutaneous implantation of pulmonary valve. In one patient S-ICD was a preferred option due to young age. First 6 cases were implanted with support of an experienced proctor. In one case the defibrillation test was repeatedly unsuccessful, and the patient required multiple external defibrillations. Reposition of the device was scheduled with optimal final result. No other complications were observed periprocedural or during follow-up. **Conclusion**: Subcutaneous ICDs have been safely and successfully implemented in our cardiology department without special surgical support. This experience will help to better address the need for prevention of SCD in special populations of patients. Although the total number of patients is still rather low, this could be improved by overcoming reimbursement issues.

Lana Maričić, Damir Mihić

**Introduction**: Infective endocarditis (IE) is a disease that is continually changing, with new high risk patients, new diagnostic procedures, the involvement of new microorganisms, and new therapeutic methods. Patients with IE are at high risk of developing an excessive systemic hyperinflammatory state, resulting in systemic inflammatory response syndrome and septic shock. Hemoadsorption by cytokine adsorbers has been successfully applied to remove inflammatory mediators and may represent a potential approach to control the hyperinflammatory systemic reaction associated with the surgical procedure itself and subsequent clinical conditions by reducing a wide range of immunoregulatory mediators. (1, 2) **Case report**: 60-year-old male with history of asymptomatic, moderately severe aortic stenosis of the bicuspid aortic valve, was hospitalized for respiratory insufficiency and fever. Two months ago, he was treated on an outpatient basis for occasional febrility in the evening and urinary tract infections. Echocardiographic analysis showed endocarditis of the aortic valve, with the development of a paravalvular abscess, and severe aortic regurgitation (**Figure 1**). Considering the severe general condition of the development of multi organ failure as part of sepsis, the patient was started with continuous renal replacement therapy using a modified membrane (oXiris) capable of adsorption that can reduce the level of endotoxin and cytokine with regional citrate anticoagulation, after which patient underwent emergency cardiac surgery, aortic valve was replaced, due to involvement of the anterior mitral cusps, the mitral valve was also replaced. FIGURE 1. Transthoracic echocardiography showing extensive vegetation of the aortic valve. **Conclusion**: Modalities in the approach to the treatment of IE continue to represent a challenge due to the high mortality of patients, which is why the application of the hemadsorption opens the possibility of preoperative stabilization of patients. Appropriate selection criteria are needed for a more targeted application of hemoadsorption therapy.

Antun Zvonimir Kovač, Lidija Pleš, Kata Ćorić, Petar Medaković, Ladislav Pavić, Mladen Jukić

**Introduction**: Congenitally corrected transposition of great arteries (CCTGA) is a rare structural heart disease constituting less than 1% of all congenital heart diseases. It is characterized by a unique anatomy of morphologically swapped ventricles and malposition of aortic root and pulmonary trunk (1-3). Despite the transposition, physiological blood pools are preserved. Patients may not be diagnosed until adulthood, when left-located right ventricle begins to fail due to dealing with systemic blood flow. They may also present with heart rhythm or conduction disorders. The aim is to present a case of CCTGA detected by coronary computed tomography angiography (CCTA). **Case report**: 58-year-old woman with suspected coronary artery disease (CAD) was referred to our clinic for a CCTA. Presenting symptoms were occasional unprovoked tachycardia accompanied by atypical chest discomfort and decreased ability to endure physical exertion. Patient mentioned (without in-hand report) that recent echocardiogram was unremarkable. Physical examination and blood tests were done. Among risk factors, arterial hypertension and dyslipidemia were recorded. CCTA was performed and revealed anomalous coronary arteries originating from anteriorly placed aorta where pulmonary trunk was behind aorta and both great arteries running parallel to each other that was consistent with CCTGA. No CAD was found. **Conclusion**: CTA is nowadays recommended as the initial test for diagnosing or excluding CAD after clinical assessment. It is also used as a complementary modality to echocardiography in evaluation of congenital heart diseases. In our case, CCTA revealed CCTGA. It is a complex condition that can be overlooked or underestimated due to its initial clinical insignificance. Even though the condition was probably assessed in earlier life, CCTGA should have been followed up regularly because of chance of reduction of cardiac function or disorder of cardiac rhythm.

Iva Mišljenčević, Luka Rotkvić, Krešimir Štambuk, Alan Jelić

**Introduction**: Patients with severe aortic stenosis and reduced left ventricular ejection fraction have worse prognosis and higher risk of adverse events. Transcatheter aortic valve replacement has become an alternative method, especially in high-risk patients (1). **Methods and Results**: In Magdalena Clinic, over a period of 10 years, 152 transcatheter aortic valve replacement interventions were performed, of which 44 patients (29.1%) had reduced left ventricular ejection fraction (LVEF < 50%). Mean age was 75 years (52-89), most were men (77.3%), with average ejection fraction of the left ventricle 33%. The aim of this retrospective analysis was to examine changes in ejection fraction during 1 year follow-up and 1-year mortality after TAVR procedure in patients with reduced ejection fraction. Patients were stratified according to baseline value of LVEF (40-49% vs <40%). Clinical end point was improvement in LVEF during follow-up and primary outcome was all-cause mortality at 1 year. Patients in both group showed significant increase in LVEF during 1 year follow-up (64.7% in LVEF 40-49%, 51.9% in LVEF <40%). 1 year mortality was 5.9% (1 patient) in the group with 40-49% baseline LVEF, and 18.5% (5 patients) in the group with <40% baseline LVEF. 1 patient died (3.7%) in the group with <40% baseline LVEF during the procedure. **Conclusion**: Mortality post-TAVR was higher in patients with more severely reduced ejection fraction, but TAVR was associated with significant increase in LVEF in both groups.

Vedran Pašara, Ivan Prepolec, Borka Pezo-Nikolić, Vlatka Rešković Lukšić, Sandra Jakšić Jurinjak, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: Transcatheter left atrial appendage occlusion (LAAO) is a stroke prevention method for patients with atrial fibrillation (AF) and increased thromboembolic risk with a contraindication for oral anticoagulation (OAC) or with an elevated bleeding risk under chronic OAC. (1) This study aimed to assess patient characteristics, acute success rate, and periprocedural complication rate of transcatheter LAAO procedures in our institution. **Patients and Methods**: This single-center retrospective observational study included all patients who underwent transcatheter LAAO in our center from June 2021 until October 2022. Data were collected from hospital electronic medical records. **Results**: We evaluated all 18 consecutive patients (55.6% male, 72.2 ± 6.3 years) who underwent transcatheter LAAO. Patient characteristics and risk factors are shown in **Table 1**. The acute success rate was 88.9%, two proctored procedures were unsuccessful due to unfavorable anatomy. There were no procedure-related stroke, device embolization, or device-related thrombus. Procedure characteristics are shown in **Table 2**. Three patients (16.7%) developed postprocedural groin hematoma. One patient developed a femoral arteriovenous fistula and required surgical repair, while another patient developed hemodynamically irrelevant pericardial effusion. During follow-up, there were no thromboembolic complications, and one patient had a bleeding complication with dual antiplatelet therapy. ### TABLE 1: Patient characteristics and risk factors. | Male, N (%) | 10 (55.6) | | --- | --- | | Age, years | 72.2 ± 6.3 | | BMI, kg/m2 | 27.5 ± 4.1 | | LVEF, % | 53.9 ± 9.1 | | Persistent/permanent AF, N (%) | 9 (50) | | Prior TIA/stroke, N (%) | 4 (22.2) | | Prior major bleeding, N (%) | 14 (77.8) | | CHADSVASc | 3.5 ± 1.5 | | HASBLED | 3.0 ± 0,.5 | ### TABLE 2: Procedure characteristics. | Procedure time, min | 75.8 ± 27.6 | | --- | --- | | Fluoroscopy time, min | 9.3 ± 4.5 | | Radiation dose, mGy | 529.4 ± 472.3 | | Dose area product, mcGy/m2 | 4542.4 ± 4132.1 | | Contrast agent, ml | 61.4 ± 29.5 | **Conclusion**: Our data suggest that, since the introduction of this technology, transcatheter LAAO can be performed in our center with a good rate of acute success and low risk of periprocedural adverse events.

Dragan Novosel, Matej Majetić

**Introduction**: The purpose of this study was to determine whether the geographical distance and/or the time required to arrive from the place of residence of a patient with heart failure (HF) to the place of secondary health care, along with other variables including age, gender, body mass index (BMI) affects mortality. **Patients and Methods**: The trial was designed as a prospective study in which 275 selected subjects with HF were monitored within 5 years from 2013 to 2018 with the determination of mortality at the end of the follow-up. All subjects’ residence and contact phone numbers were recorded during hospitalization. The geographical distance of the residence and the time needed to arrive at University Hospital Centre Osijek (KBCO) were determined using the Google Maps application with the criterion of selecting the fastest arrival route. **Results**: Distance from KBCO was observed as a possible predictor of mortality. Lower BMI, older age and shorter time to arrival in KBCO proved to be significant predictors of five-year mortality. **Conclusion**: We can conclude that the basic hypothesis, in which it is assumed that respondents who have a greater geographical distance have a higher five-year mortality, after applying additional statistical analyzes (Cox’s proportional hazard regression with the Enter method) seems to be correct. Additional research is needed, as arrival time is probably more important than distance itself. Although the two are strongly positively correlated (longer journey, longer time). The assumption is that with a better organization of health care mortality can be reduced in this way. (1-3) Proposed modalities include translocation of patients with heart failure to places that are closer to the source of secondary health care such as retirement homes and inpatients with the aim of reducing mortality.

Antonio Hanžek, Zvonimir Ostojić, Luka Perčin, Filip Lončarić, Davor Radić, Marijan Pašalić, Denis Došen, Hrvoje Jurin, Tomislav Krčmar, Kristina Marić-Bešić, Eduard Margetić, Boško Skorić, Davor Miličić, Joško Bulum

**Background**: Diabetes mellitus (DM) is related to higher rates of complications after coronary revascularization. (1) The efficiency of drug-coated balloon (DCB) percutaneous coronary intervention (PCI) has been shown for in-stent restenosis (ISR) and native small-vessel disease, however data on outcomes in DM is scarce. (2) The aim is to compare the incidence of target lesion restenosis at follow-up (FUP) coronary angiography in patients with and without DM receiving DCB PCI. **Patients and Methods**: The registry included patients undergoing a DCB PCI at the University Hospital Centre Zagreb from February 2011 to January 2022 (n=645). Patient demographics, comorbidities, pharmacotherapy, as well as data on the initial and FUP coronary angiography/PCI was collected. An FUP angiography was performed in 47% of patients (n=295), with a median FUP of 29 (interquartile range 8-41) months. **Results**: Data is shown in **Table 1**. The cohort was 75% male, mean age 65 ± 10 years. DM was present in 35% (n=223) of patients, equally in both sexes, and was associated with a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke, as well as arterial hypertension, and renal insufficiency. No age difference was noted between groups. At initial PCI, more DM patients had multivessel coronary disease and ISR as the indication for DCB (DM vs non-DM: 41% vs 31%, p=0.023). After DCB, no group difference was noted in regard to the need for a bail-out PCI. FUP was performed in an equal percentage of patients in both groups (50% vs 45%, p=0.256), with no differences seen in the incidence of restenosis (18% vs. 17%, p=0.965), the need for target lesion PCI (15% vs. 12%, p=0.491), or the use of anti-anginal drugs. ### TABLE 1: Comparison between diabetic and non-diabetic patients. | | | **Patients with diabetes mellitus (n=223)** | **Patients without diabetes mellitus (n=422)** | **P -value** | | --- | --- | --- | --- | --- | | **Initial PCI hospitalization** | | | | | | Age, years (IQR) | | | | | | Male sex, n (%) | | 163 (73) | 322 (76) | 0.369 | | History of myocardial infarction, n (%) | | 110 (49) | 169 (40) | 0.024* | | History of PCI, n (%) | | 148 (66) | 240 (57) | 0.019* | | History of CABG, n (%) | | 14 (6) | 12 (3) | 0.035* | | History of stroke or TIA, n (%) | | 21 (9) | 21 (5) | 0.030* | | Arterial hypertension, n (%) | | 211 (95) | 349 (83) | 2), (%) | | 32 (14) | 24 (6) | <0.001* | | ACS as indication for DCB PCI, n (%) | | 102 (46) | 198 (47) | 0.844 | | Multivessel coronary disease, n (%) | | 130 (59) | 200 (48) | 0.022* | | In-stent restenosis, n (%) | | 89 (41) | 131 (31) | 0.023* | | Bail-out PCI, n (%) | | 15 (7) | 25 (6) | 0.668 | | **Repeat coronary angiography** | | | | | | Elective procedure, n (%) | | 92 (84) | 154 (83) | 0.795 | | Restenosis of target DCB PCI lesion, n (%) | Rep. coro cohort (n= 295) | 19 (18) | 32 (17) | 0.965 | | Whole cohort (n=645) | 19 (9) | 32 (8) | 0.675 | | [†] IQR – interquartile range, PCI – percutaneous coronary intervention, CABG – coronary artery bypass graft, TIA – transient ischemic attack, eGFR – estimated glomerular filtration rate, ACS – acute coronary syndrome, DCB – drug-coated balloon * p<0.05 **Conclusion**: The findings of our single-centre analysis show that although DM is related to more advanced comorbidities it does not increase the risk of target lesion restenosis after DCB PCI. DCB PCI should be considered as a therapeutic option in candidate patients regardless of DM status.

Davor Horvat, Andrea Grman Fanfani, Morana Kasunić Jelić, Kamal Al Rajabi, Andrej Došen, Ronald Lipovšćak, Dario Jelić, Lorena Kalčina Uravić

**Case report**: 79-year-old patient comes to the Emergency Department of Karlovac General Hospital, where he presented with chest pains immediately before arriving at the hospital. 12-lead electrocardiogram (ECG) shows inferior and anterolateral acute ST-elevation myocardial infarction (STEMI) (**Figure 1**). He was referred to the Percutaneous Coronary Intervention Network (Sestre Milosrdnice University Hospital Center, Zagreb) where, after emergency coronary angiography, all three epicardial coronary arteries were shown without hemodynamically significant stenoses, with screening at the LAD/D1 bifurcation, which would correspond to the site of a spontaneously reperfused thrombus. The following day, he was returned to the home institution. On ECG: sinus rhythm with ventricular rate 63/min, amputated R inferiorly, q from V1-6 (**Figure 2**). Echocardiography: akinesia of the distal 2/3 septum, anterior wall and apex with consequent left ventricular ejection fraction 40%. During the stay, he is treated with low molecular weight heparin, antiplatelet, antihypertensive, and other symptomatic therapy. In the Holter ECG: transient ST elevation is verified in all three leads, which corresponds to the inferior and anterolateral region in the 12-channel ECG (**Figure 3**). This event was not accompanied by significant angina pains or an increase in troponin. ECG at discharge: sinus rhythm 52/min., anterior ischemia, and minor residual anterior ST elevation (**Figure 4**). Discharge diagnoses: Inferoposterior and anteroseptolateral STEMI, Spontaneous reperfusion, Unstable angina pectoris (vasospastic). Therapy at discharge: aspirin, clopidogrel, atorvastatin, trimetazidine, diltiazem, perindopril. FIGURE 1. Electrocardiogram on arrival at the Emergency Department shows significant elevation of the ST-segment in the inferior and anterolateral leads. FIGURE 2. Electrocardiogram on the second day of hospital stay after coronary angiography and spontaneous reperfusion shows amputated R wave inferiorly and q wave in all precordial leads. FIGURE 3. Electrocardiogram from a three-channel holter recording with significant elevation of the ST-segment in all three leads. FIGURE 4. Electrocardiogram at discharge from the hospital shows a negative T wave and minor residual ST segment elevation in all precordial leads. **Conclusion**: The occurrence of ST-segment elevation in ECG as part of an acute myocardial infarction is a common finding in STEMI and indicates the need for urgent access to the patient. The appearance of spontaneous reperfusion in the infarct is a welcome natural revascularization when the performance of the PCI procedure is mostly no longer necessary. (1-3) Although spontaneous reperfusion still indicates a thrombotic cause of infarction, transient ST-segment elevation in the ECG caused by vasospasm can rarely be seen at these moments. In order to ultimately reduce additional complications and mortality, a proper and timely approach to diagnosis and therapy in these patients is extremely important.

Marijana Mikačić, Duška Glavaš, Josip Anđelo Borovac

**Introduction**: Recent studies showed that patients without standard modifiable cardiovascular risk factors (CVRFs) suffering an acute myocardial infarction (AMI) might have worse outcomes and prognoses than patients with established CVRFs (1). The goal of the present study was to determine the proportion and relevant characteristics of patients with no apparent CVRFs who present with AMI at a tertiary-level clinical center. **Patients and Methods**: We grouped and analyzed a cohort of consecutive patients admitted for AMI to our center during the 2019-2020 period. We examined the presence or absence of apparent CVRFs including smoking, arterial hypertension, diabetes mellitus, history of myocardial infarction or revascularization, and atrial fibrillation. **Results**: The proportion of patients with AMI and without apparent CVRFs in our sample was 14.4% (29/202 patients). The rate of composite outcome consisting of in-hospital death and emergent referral to coronary artery bypass graft surgery was lower in patients without than with CVRFs (3.4% vs. 8.7%). Both groups had a similar prevalence of multivessel coronary disease (17.2% vs. 23.1%). Furthermore, they were less likely to present with dyspnea or nausea and vomiting, compared to patients with CVRFs (13.8 vs. 27.7% and 17.2 vs. 33.5%, respectively). Notably, both groups did not significantly differ in terms of age (median 67 vs. 65 years), male sex (62.1 vs. 68.8%), AMI type (ST-elevation myocardial infarction in 66 vs. 58% of cases), hemoglobin (median 139 vs. 141 g/L), renal function (median creatinine of 74 vs. 79 μmol/L), and C-reactive protein (median 6.1 vs. 5.0 mg/L). However, patients without apparent CVRFs exhibited a significantly greater degree of myocardial injury as evidenced by higher median high-sensitivity cardiac troponin I levels, compared to patients with at least one CVRF [1073 (IQR 156-7000) vs. 300 (IQR 65-3551) ng/L, p<0.05] as shown in **Figure 1**. FIGURE 1. Median circulating high-sensitivity cardiac troponin I levels in patients admitted for acute myocardial infarction with and without apparent cardiovascular risk factors. CVRF = CARDIOVASCULAR RISK FACTORS **Conclusion**: About 14 in 100 patients with AMI in our cohort did not have apparent CVRFs. These patients seem to be less likely to present with dyspnea or nausea and vomiting and do not differ significantly in most of the clinical and laboratory variables to patients with CVRFs. However, these patients had more than a 3-fold greater myocardial injury as measured by circulating troponin levels. Therefore, clinical scrutiny should be applied to patients without overt symptoms and a history of CVRFs that present to emergency department with chest pain.

Petra Bistrović, Ivan Skorić, Irzal Hadžibegović, Tomislav Šipić, Šime Manola, Ivana Jurin

**Introduction**: Atrial fibrillation (AF) and acute myocardial infarction (MI) often coexist together, whether it is MI in patients with earlier AF or AF as a complication of MI. Previously published work has shown results indicating worse quality of life in patients with both AF and MI, with some potential differences in long-term outcomes depending on time of fibrillation onset. (1, 2) We aimed to compare clinical outcomes of IM patients with prior and new onset AF at two tertiary centers. **Patients and Methods**: We evaluated 1662 patients discharged after acute MI at Dubrava University Hospital and „Merkur“ University Hospital from January 2017 to December 2021, followed up to present date. Among them, 28 patients who were discharged had AF prior to MI, whereas 42 patients had newly diagnosed AF. We compared the differences in baseline characteristics, all cause death as the primary outcome and all-combined MACE events as secondary outcome in follow up between patients without AF, prior AF and new onset AF. **Results**: Our results show that patients with AF diagnosed after MI were significantly older and were discharged with lower eGFR and left ventricular ejection fraction compared to the other groups (p<0.05). After comparing the groups in follow up, the new onset AF group had significantly lower survival time (HR 3.24 compared to no AF, HR 4.71 compared to prior AF, p<0.001). However, in multivariate analysis after adjustment for clinically relevant parameters, there was no significant difference in survival probability between the groups. There was no statistically significant difference in free-from MACE time between the three groups. **Conclusion**: Our data suggests potentially increased long-term mortality in those who develop AF in the acute setting of MI. Further research is necessary to evaluate the potential risks of new onset AF and to develop strategies for its prevention.

Alma Sijamija-Haskić, Aida Hadžigrahić, Mirsad Selimović

**Introduction**: Lyme disease is a tick-borne spirochetal infection caused by Borrelia burgdorferi. Although the disease is often manifested with clinical signs of erythema migrans, it can present a multisystem disorder. In about 2-10% of patients infected with the Borrelia burgdorferi cardiac symptoms, transient character will usually occur. Cardioborelliosis may manifest primarily as AV conduction disturbances, and very rare as myocarditis and pancarditis, which represents the second stage of Lyme borreliosis. Complete AV block occurs in 15% of patients, associated with syncope, usually transitory in character. (1-3) For diagnosis beside clinical presentation and data about tick bites serological confirmation is needed. Cardioborreliosis treatment with antibiotics is useful for all stages of the disease but is most successful in the first stage if it is recognized. **Case report**: We present two cases of cardioboreliosis hospitalized with clinical manifestations of acute carditis and arrhythmias, AV block II and grade III. Case 1: Patient male, 30-years-old, was hospitalized to epigastric pain, feeling short of breath. ECG on admission: AV block type Wenckebach, ventricular rate 43/BPM (**Figure 1**). ECHO signs of marked dilatation of the left ventricle and both atria. Case 2: 30-years-old female patient admitted to the intensive care unit because of the crisis of consciousness, vertigo, headache, fever, ECG verified third degree AV block, and ECHO verified small pericardial effusion. Data on skin changes, erythema migrans were obtained subsequently. Diagnosis was based on clinical manifestation, and on positive serologic tests to Borrelia. They were treated with antibiotic therapy. The recovery was very good, and cardiac disturbances were resolved. FIGURE 1. 12-lead electrocardiogram on admission: second-degree AV block type Wenckebach. Control electrocardiogram on the next day: second-degree AV block type Mobitz. **Conclusion**: It is necessary to think of cardioborreliosis in all patients with cardiac symptoms unexplained etiology. Early treatment with antibiotics according to recommended protocols leads to complete to the of Lyme myocarditis healing.

Nikola Škreb, Filip Lončarić, Bart Bijnens, Anne Bonnin, Hector Dejea, Marta Farrero Torres, Patricia Garcia Canadilla, Sven Lončarić, Angela López-Sainz, Hrvoje Gašparović, Ivana Ilić, Davor Miličić, Igor Rudež, Boško Skorić, Ivo Planinc, Maja Čikeš

**Background:** Graft rejection remains the most important complication after heart transplantation (HTx). Endomyocardial biopsy (EMB) is the gold standard in HTx follow-up, however, conventional histopathological (HP) analysis is limited by tissue damage during preparation, 2-dimensional (2D) analysis, and low inter-observer agreement in rejection grading. X-ray phase contrast imaging (X-PCI) has shown potential for non-destructive imaging of the myocardium, enabling high-resolution 3-dimensional (3D) analysis with fibrosis and fibre orientation quantification. (1) **Methods and Design:** GRAFT-XPCI is a multi-centric, prospective observational study aiming to prove non-inferiority of X-PCI in graft rejection diagnosis, vs. conventional HP **(****Figure 1****)**. It will include approximately 400 patients in standard post-HTx follow-up at 3 clinical centres: University Hospital Centre Zagreb, Dubrava University Hospital and Hospital Clinic Barcelona. Collected data will include EMB samples, patient history, laboratory, electrocardiogram (ECG), coronarography and echocardiographic data. EMB specimens will be initially imaged by X-PCI at the Paul Scherrer Institute (Villigen, Switzerland), producing digital 3D imaging datasets (at 0.65 um pixel resolution) for computational analysis, and then prepared for HP microscopy at the University of Zagreb School of Medicine. Three datasets will be generated for analysis - 2D X-PCI dataset, 3D X-PCI dataset, and 2D HP images. Acquired X-PCI images and HP slides will be diagnostically graded (ISHLT 2004. grading system) (2), comparatively assessed by at least two observers in a blinded fashion, further analysed in conjunction with gathered clinical data. Computer methods for the automatic and semi-automatic analysis of digital image datasets will be developed as an additional output. FIGURE 1. GRAFT- X-ray phase contrast imaging study. **Conclusion:** GRAFT-XPCI will: 1) compare X-PCI and conventional HP in graft rejection analysis, 2) enable insight into structural and pathophysiological processes in graft rejection after HTx, 3) extend the amount of information gained by EMB analysis. The development of new research tools and imaging protocols should widen future research of EMB analysis in various cardiac conditions. This study has been fully supported by the Croatian Science Foundation under the trial registration no. UIP-2020-02-5572.

Zina Lazović, Kenana Aganović, Behija Hukeljić-Berberović, Ilirijana Haxhibeqiri-Karabdić, Nermir Granov, Alden Begić

**Goal**: Aim of the article is to present our experience in minimally invasive thoracotomy in relation to the current state of literature. Minimally invasive thoracotomy has been progressively used in heart surgery, becoming a viable alternative to standard full sternotomy. Potential advantages are associated with decreased surgical trauma, shorter intensive care unit and hospital stays, enhanced patient satisfaction and sense of recovery. The operative challenges include restricted view and access to the operative field, longer aortic cross-clamp time, and cardiopulmonary bypass time (1). **Patients and Methods:** During the period between 2020 and 2022, we performed 209 minimally invasive thoracotomy at the Clinic for Cardiovascular Surgery, Clinical Center University of Sarajevo. **Results**: Minimally invasive thoracotomy is procedure that is now being routinely performed. A detailed preoperative assessment is required for selecting patients, and echocardiography is an essential imaging method for heart evaluation. Preoperative transthoracic (TTE) or transesophageal echocardiography (TEE) is used to precisely characterize cardiac morphology and function. Intraoperative TEE is employed to confirm previously found pathological changes, to guide the operative procedure in phase of cannulation, myocardial protection, to assess the effectiveness of dearing maneuvers, to identify complications during the operation. Furthermore, postoperative TTE and/or TEE is performed to elucidate various etiologies of perioperative hemodynamic instability, allowing identifying and managing complications accurately and efficiently. **Conclusion**: Improving minimally invasive cardiac surgery is still an on-going process and sharing the experience is essential for further development. Evolving use of non-invasive cardiac imaging is crucial for patient care within this field and holds great potential for the future of echocardiography (2).

Irzal Hadžibegović, Nikola Pavlović, Ante Lisičić, Marin Pavlov, Miroslav Raguž, Mario Udovičić, Tomislav Šipić, Aleksandar Blivajs, Ivana Jurin, Tomislava Bodrožić-Džakić Poljak, Šime Manola

**Introduction:** Recent guidelines proposed routine functional assessment of all 20-90% coronary artery stenoses without objective signs of myocardial ischemia within the chronic coronary syndromes (1, 2). We present the results of functional assessment of coronary stenoses found in patients with stable angina pectoris and no evident myocardial ischemia during a one year period and analyze its impact on treatment strategy. **Patients and Methods:** We evaluated clinical data, 2D quantitative coronary angiography, and functional assessment results in all patients undergoing coronary angiography for stable angina pectoris from October 2021 to October 2022. **Results:** Out of 1088 patients who underwent coronary angiography because of stable angina pectoris, invasive functional testing was performed in 98 (9%) of patients. Median percentage of luminal stenosis assessed was 60%, with 25 (26%) patients having two or more different segments involved. In 98 patients a total of 127 stenoses were analyzed, with 66 (52%) stenoses in the left anterior descending artery (LAD), 22 (17%) in the circumflex artery (CxA) /marginal/diagonal, and 39 (31%) stenoses in the right coronary artery (RCA). All patients had non-hyperemic indices (instantaneous wave free ratio (iFR) or cRR) analyzed, with 10 (10%) patients with borderline results requiring additional fractional flow reserve (FFR). Positive iFR or cRR was found in 32 (48%) LAD stenoses, and only 4 (19%) and 9 (24%) stenoses in the CxA/marginal/diagonal and RCA, respectively. Positive mismatch of the iFR/cRR with the FFR was found in 3/10 stenoses with borderline results. All patients with positive functional tests received percutaneous coronary intervention (PCI). There were no complications related to the pressure wire (Verrata) or the pressure microcatheter (TruePhysio) during functional assessment. There was one case of a trapped pressure wire during post-PCI assessment that required additional non-compliant balloon optimization of the proximal segment of the stent after successful removal of the pressure wire. In comparison to the same period in 2019, functional assessment increased significantly from 1.3% to 9%, whereas the proportion of elective PCI for stable angina pectoris among all PCI performed decreased from 55% to 45%. **Conclusion:** Most non-LAD lesions were non-significant according to functional assessment. Functional testing is increasing according to guidelines, and it clearly affects the rates of PCI in chronic coronary syndromes.

Marin Bistirlić, Zoran Bakotić, Mira Stipčević, Jogen Patrk, Dražen Zekanović

**Introduction:** Stent loss is challenging and potentially lethal complication of percutaneous coronary intervention. Although the lost stents were successfully retrieved in most cases, stent loss was associated with high rates of complications, such as coronary artery bypass graft surgery, myocardial infarction, and death (1). **Case report:** 56-years-old man who was admitted to Coronary Care Unit due to ongoing chest pain and rise of troponin as a sign of cardiac injury. An electrocardiogram showed a biphasic T wave in leads V2-V5. After standard treatment patient became asymptomatic and the coronary angiography was scheduled for the next morning. Bedside echocardiography was normal. Coronary angiography showed two-vessel disease with a long, significant stenosis of proximal and mid part of left descending artery (LAD) and significant, short stenosis of mid right coronary artery. Percutaneous coronary intervention (PCI) of LAD was planned. A guide catheter „EBU 3.5, 6Fr“ in left main (LM), a guidewire „Hi-Torque BMW“ was set in distal part of LAD. Predilatation of LAD was performed after which first DE stent „Orsiro, Biotornik“ 2.75x30 mm was placed in mid part of LAD. Rest of the mid and the distal part of proximal segment we planned to place another drug-eluting (DE) stent „Ultimaster“ 3.5x30mm. After impossibility to place the stent on desired position we planned to do additional redilatations. During withdrawing the stent, it stucked at the tip of the guiding catheter and we noticed stent loss in LM. We decided to put 8Fr introducer in right femoral artery, setting a new guiding catheter „EBU 3.75, 7Fr“ in LM. With a new guidewire „Hi-Torque Whisper“ we managed to pass through a middle part of the stent and put the guidewire in a distal LAD. A non-compliant balloon 2.5x8 mm was inflated distally to the stent after which we managed to pull/retrieve the stent in guiding catheter. In continuation of procedure the additional predilatation with „scoring balloon“ NSE Alpha 2.75x13 mm was preformed after which two stent were placed in the mid and proximal part of LAD (3.0x22 mm, 3.5x18 mm). Final angiography showed good result in LAD and LM. The patient was discharged after 3 days. **Conclusion:** Stent loss is uncommon but serious complication of PCI. Several techniques can be applied to resolve the problem (snare, stent crush) but we managed to pull it back in guiding catheter by passing with a new wire through the stent.

Janko Szavits Nossan, Vito Mustapić, Igor Šesto, Lucija Barbarić, Nikola Jutriša, Iva Kopčić

**Aim**: To determine in-hospital and long-term results of atrial macro-reentry and focal tachycardia ablation using high-density mapping. **Patients and Methods**: In 2021 and 2022, a total of 47 consecutive patients with atypical macro-reentry and focal atrial tachycardia were ablated using the 3D mapping system. Ablations were performed using Carto 3 (Biosense Webster) mapping system in all patients, but high-density mapping catheter with new Carto Prime module was used only in patients ablated in 2022 (total 29). **Results**: Ablation procedure was successful in 96% of all patients with no inducible tachycardia at the end. Mean follow-up period was 11 months (3-19 months) for all patients. Patients ablated in 2022 had shorter mean follow-up period of 7 months (3-11 months) compared to patients ablated in 2021, but majority of relapses occurred within first 6 months after ablation. Daily trans-telephonic ECG was used for follow up in 85% of patients (similar in both groups) and clinical follow up with Holter ECG after 6 months in 99% and 90% of patients, respectively (similar in both groups). 96% of patients ablated in 2022 were free from any tachycardia in the follow up period in comparison to 78% of patients ablated in 2021. Proportion of macro-reentry tachycardias was significantly higher in 2022 when high-density mapping was used, suggesting better understanding of the tachycardia mechanism. **Conclusion**: High-density mapping system increases acute and short-term results of atrial macro-reentry and focal tachycardias (1).

Drago Baković, Matea Bilić Pavlinović, Tony Rumora, Denis Došen, Miroslav Krpan, Kristina Marić Bešić

**Introduction**: Fibromuscular dysplasia (FMD) of coronary arteries is a rare disorder that can present as an acute coronary syndrome, left ventricular failure or even sudden cardiac death. The most common manifestation of FMD is spontaneous coronary dissection (SCAD) with intramural hematoma. Percutaneous coronary intervention (PCI) for SCAD carries a significant risk of adverse outcomes due to dissection propagation. (1-3) **Case report**: We present a 58-year-old woman, who was hospitalized in the Department of Cardiovascular diseases due to chest pain and high troponin values. The ECG was normal and after taking a fast-acting nitrate, the symptoms subsided. Coronary angiography showed normal epicardial arteries and the diagnosis of MINOCA (myocardial infarction with non-obstructive coronary arteries) was established. Echocardiography revealed a normal systolic function with mild hypocontractility of the inferior and inferolateral wall. The patient was discharged without antiplatelet therapy due to aspirin allergy. She was re-hospitalized for the same symptoms seven months later. A repeated coronary angiography revealed a severe stenosis of the distal first obtuse marginal artery (**Figure 1**) and SCAD was suspected. Therefore, coronary angiography of the initial hospitalization was revised and a significant stenosis of first diagonal artery (D1), which was overlooked during the initial coronary angiography, was found (**Figure 2**). Since the D1 was now completely normal, the diagnosis of possible fibromuscular dysplasia was made. She was treated conservatively and was discharged with clopidogrel and statin therapy. FIGURE 1. Comparison of coronary angiography findings showing stenosis of the distal first obtuse marginal artery (left) and normal findings (right). FIGURE 2. Comparison of coronary angiography findings showing stenosis of the first diagonal artery (left) and normal findings (right). **Conclusion**: 58-year-old female was hospitalized twice due to an acute coronary syndrome because of suspected FMD. Although the etiology is poorly known, attempts are still being made to clarify FMD’s genetic and molecular underpinnings. Since PCI has worse outcomes, a conservative therapy is typically preferred because lesions heal on their own.

Ivan Pletikosić, Ivona Mustapić, Zrinka Jurišić, Vedran Carević, Ana Barić Žižić

**Introduction:** Hereditary transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative cardiomyopathy caused by mutation of the transthyretin (TTR) gene (1). We present our center’s first experience in diagnosing this rare disease, which is associated with a high mortality. **Case report:** 59-year-old male was admitted to the Coronary Care Unit due to hemodynamically unstable monomorphic ventricular tachycardia with left bundle branch block morphology **(****Figure 1****).** Urgent electrocardioversion was performed with successful hemodynamic stabilization. He denied dyspnea, chest pain and previous heart disease. His sister died suddenly at age 53. Serial electrocardiograms and laboratory parameters did not show any definite signs of acute coronary syndrome. Urgent coronary angiography was performed to rule out underlying ischemic injury, which revealed subtotal stenosis of the mid left anterior descending artery (LAD), with normal findings of the remaining epicardial arteries. Successful percutaneous coronary intervention of LAD was performed. An echocardiogram revealed left ventricular hypertrophy with diffuse myocardial fibrosis and apico-posterior-lateral hypertrabeculation with decreased systolic and restrictive diastolic function **(****Figure 2****).** Due to the discrepancies between the ultrasound, electrocardiographic and angiography findings, further work-up of hypertrophic cardiomyopathy was performed. Cardiac magnetic resonance imaging showed morphologic features of “non-compaction” cardiomyopathy (NCC). Also, nuclear imaging using technetium pyrophosphate (Tc-99 PYP) was performed, which showed diffusely increased uptake by the myocardium, highly suggestive of TTR amyloidosis. A cardioverter-defibrillator was implanted, and genetic testing for hereditary TTR amyloidosis was carried out. The patient was then discharged. Genetic testing confirmed our suspicion, with a mutation of pathogenic clinical significance. Genetic counseling was provided to the patient and his family members, and the patient was informed about available specific treatment options. The patient was then referred to a heart failure center of excellence for further treatment. FIGURE 1. Ventricular tachycardia with left bundle branch block morphology. FIGURE 2. Left ventricular hypertrabeculation with apical sparing pattern. **Conclusion:** The aim of this case presentation was to increase clinical awareness of ATTR-CA as a cause of hypertrophic cardiomyopathy. Furthermore, only a few cases of ATTR-CA with morphologic characteristics of NCC have been reported in the literature.

Viktor Peršić, Kristina Skroče, Dijana Travica Samsa, Koraljka Knežević, Irena Kužet Mioković, Marina Njegovan, Danijel Premuš, Viktor Ivaniš

**Introduction:** High intensity interval training (HIIT) is now recognized in international clinical-based exercise guidelines as an appropriate and beneficial adjunct to moderate intensity continuous training. (1) Moreover, prescribing precise HIIT intensity based on individual capacities and needs is mandatory to optimize results. However, intensity prescription might encounter some obstacles when it comes to implementing pre-training testing. This study showcases individual exercise prescription in a group of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) patients to achieve progressive increase of functional capacity and therefore – better health and quality of life as primary outcomes. **Patients and Methods:** 16 STEMI and NSTEMI patients (age 58 ± 10 years; height 177 ± 9 cm; weight 86.8 ± 15.4 kg; VO2max 19 ± 5.3 ml min-1 kg-1) underwent 12 weeks of supervised cycling HIIT (4x4 min at 85-95% of HRmax) 3 times per week. Functional capacity (VO2max) and all cardiopulmonary parameters as well as HRmax ware assessed by means of the incremental cardiopulmonary test to exhaustion (CPET) every 4 throughout the training program. Individual training zones were prescribed and adjusted according to the parameters obtained in CPET. **Results:** There was a good correlation (r= 0.67) between the predicted HRmax and measured HRmax at the beginning of the training period but a weak correlation (r=0.43) at the end of a 12-week training program. The absolute improvement in VO2peak at the end of the 12-week training was 32% (19.2 ± 5.1 vs 25.5 ± 4.9 mil min-1 kg-1, P<.001). **Conclusion:** The “dose” of the exercise can be operationalized and monitored using a specific indicator (or set of specific indicators) of internal load as proxy. In this regard, to maximize safety in clinical populations, it is mandatory to precisely adjust pre-exercise screening and regular monitoring. Modifying the exercise prescription by carefully adjusting the external load in relation to internal parameters, can define an optimal dose for this group of patients.

Điđi Delalić, Nora Knez, Ingrid Prkačin

**Introduction**: The burden of cardiovascular disease on both the healthcare system and patients’ quality of life is a topic that has been discussed and researched a lot through the years, in part owing to the transition from a strictly mechanistic approach to disease to a biopsychosocial one that incorporates many different factors besides the pathophysiologic mechanism and objective parameters of disease activity. (1-3) However, it often feels that some aspects are still not talked about often enough, one of which is the effect that cardiovascular disease has on sexual behavior and function of humans. **Materials and Methods**: A search of the literature has been performed in the MEDLINE, Google Scholar and Web of Science databases using combinations of keywords “cardiovascular disease”, “sexual behavior”, “sexual function”, “sexual dysfunction”. **Results**: Narrative reviews, original research papers and professional society guidelines were examined to extrapolate data and recommendations regarding sexual activity and behavior in patients suffering from cardiovascular disease. The resulting paper describes ways in which physiologic changes that occur in cardiovascular disease impact sexual function, the influence of cardiovascular medications on sexual function and behavior and several recommendations for sexual behavior and habit modifications that improve patient health and protect them from risk of unwanted cardiovascular events. **Conclusion**: The combination of altered physiology and medications used to treat cardiovascular disease significantly impacts normal sexual function. Seeing as sexuality is recognized as a basic human right and fundamental need with a significant impact on quality of life, some attention should be diverted to educating patients how to maintain normal and healthy sexual function despite suffering from cardiovascular disease.

Katica Cvitkušić-Lukenda, Jelena Jakab, Domagoj Vučić, Krešimir Gabaldo, Vesna Ćosić, Marijana Knežević-Praveček

**Introduction:** Shift work is associated with cardiovascular risks and metabolic diseases. (1) The natural circadian rhythm plays a role in maintaining normal metabolic and hormonal status. (2, 3) The aim of this cross-sectional study was to determine the relationship between circadian rhythm disorders, blood pressure, metabolic and hormonal parameters in women. **Methods**: The respondents were nurses divided into two groups: 12-hour shift work (day/night) and regular 8-hour work (day). The questionnaire included primary health status, medical history, premenopausal or postmenopausal status, habits, chronic therapies, duration of shift work or regular work in years. Blood pressure was measured three times during the examination. Anthropometric measures were obtained, and body mass index (BMI) was calculated. Postmenopause was defined by absence of menstruation for 12 or more months. Fasting blood samples included a hematological, biochemical, and hormonal panel. The level of statistical significance was set at p < 0.05. **Results:** Of all respondents, 43 (64%) worked shift work, 45 (67.2%) had a BMI ≥25, antihypertensive therapy was taken by 19 (37.3%), diabetes therapy by 3 (4.5%), and 42 (62.7%) subjects were postmenopausal. We found a significant and positive correlation between ferritin and high-sensitivity C-reactive protein (hsCRP) in shift working nurses (Rho = 0.468; P = 0.002). A positive correlation was found between the duration of shift work and systolic blood pressure (Rho = 0.424, P = 0.03). Subjects working in shifts had significantly lower triglyceride levels (Mann Whitney U test, P = 0.03) and higher testosterone levels (Mann Whitney U test, P < 0.001). Prediabetic nurses had significantly higher LDL-C and fasting blood sugar levels. **Conclusion**: In this study, we found a significant and persistent link between shift work and systolic blood pressure. There is a significantly positive correlation between hsCRP and ferritin in all subjects, especially in subjects working in shifts. Further studies are needed to determine the relationship between shift work and cardio-metabolic diseases and thus the necessary preventive measures.

Verica Kralj, Petra Čukelj

Cardiovascular diseases (CVDs) are the leading public health problem both globally and in Croatia, responsible for 18.6 million deaths every year. More than a third of deaths in the EU, 1.8 million, are due to CVDs, and 60 million of EU citizens live with some form of the disease. Subsequently, due to very high financial costs (in the EU, 210 billion Euros yearly) CVDs present an enormous burden to society and the economy. Research has shown that CVDs are largely preventable, and the biggest reductions in mortality rates are recorded in western European countries that invested resources in both prevention measures and treatment; but CVDs remain the leading cause of mortality, with rates reaching a plateau in some countries. Although more common in older people, CVDs are also common in younger age groups: 20% of all preventable deaths (deaths in people under 65 years of age) in the EU are due to CVDs. Every year in Croatia more than 20 000 people die from CVDs. Mortality rates are decreasing, but with a standardized rate of 572.8 (per 100 000 population) for CVD mortality we are still above the EU average of 367.6. Compared to neighboring countries, Croatia has a higher mortality rate than Slovenia (393.6), Austria (362.9), Italy (270.7), and lower than Hungary (714.8). Although geographically a Mediterranean country, high CVD mortality rates in Croatia are more similar to those in Eastern and Central Europe. In 2021 a total of 23 184 (13 199 women, 9 985 men) persons died from CVDs in Croatia (37% of all deaths). Leading diagnostic groups were ischemic heart disease and cerebrovascular diseases, with 12.5% and 8.0% share in total mortality, respectively. (1-3) COVID-19 pandemic brought on some changes in CVDs epidemiology; in 2020 and 2021 we saw a slight increase in mortality, with concurrent drop in hospital discharges - similar results are seen in other European countries. Patients with CVDs and CVD risk factors are identified as being under increased risk for COVID-19 morbidity and mortality. Due to reallocation of health care resources during the pandemic, access to emergency treatment was more difficult. Fear of getting infected with COVID-19 also delayed help seeking, and these factors combined led to delays in diagnostics and treatment. We still do not know the effect that the long-term effects of both COVID-19 infection and delays in CVDs treatment will have on CVDs morbidity and mortality, and this requires a coordinated systemic response from both policy makers and health care professionals. With that in mind, European Alliance for Cardiovascular Health presented the Cardiovascular Health Plan on May 16, 2022. The European Commission recognized the magnitude of the problem and supported the initiative. The goal of the Plan is to reduce the number of premature deaths from CVDs by a third, improve access to cardiovascular risk assessment for all, establish multidisciplinary care and improve the quality of life. The focus should be on primary and secondary prevention with early diagnosis and equal access to diagnostics, treatment and rehabilitation services. At the same time, Member States are called to establish national plans for cardiovascular health. (4) CVDs are a global epidemic that endangers lives, health and quality of life. Despite the recent trends of decreasing age standardized mortality rates, we can expect further increase in CVDs burden due to increased prevalence, better treatment, and survival. This public health problem was further aggravated during the pandemic, highlighting the need for comprehensive, structured and mandatory prevention, early diagnosis, treatment and rehabilitation programs.

Ivana Grahovac, Verica Kralj

**Goal**: The aim of this study is to present mortality indicators for ischemic heart disease (IHD) in Croatia and compare them with indicators of other countries in Europe and the European Union. **Materials and Methods**: This study was based on mortality data from the Eurostat and the Croatian Bureau of Statistics. The data were processed as part of routine mortality statistics of the Croatian Institute of Public Health. **Results**: Ischemic heart disease (I20-I25, ICD 10) was the second leading cause of death in Croatia in 2021, after the disease COVID-19. (1) A total of 7839 people died from IHD, which accounts for 12.50% of all deaths. Ischemic heart disease in 2021 was the most common cause of death in women with 3976 deaths and a share of 12.59% of all deaths in women, while it was the second leading cause of death in men with 3863 deaths and a share of 12.41% of all deaths in men. In total, the most frequent cause of death from this group is chronic IHD (I25) with 4782 deaths, followed by acute myocardial infarction (I21) with 3006 deaths. Observing the period from 2002 to 2019, there is a trend of decreasing mortality from IHD by 32.36% in Croatia. According to the Eurostat, the age-standardized mortality rate from IHD has fallen from 305.6/100.000 in 2002 to 206.7/100.000 in 2019, which currently ranks Croatia 7th out of 34 European countries (including all EU countries) in terms of mortality from IHD. (2) According to national data, the age-standardized mortality rate from IHD is higher in the continental and lower in the coastal area of Croatia. (3) In addition, age-specific mortality rates for IHD, both in men and women, increase with age and are higher in men than in women. A more intensive increase starts from the age group of 45-49 years in men and 55-59 in women. From the age of 80, mortality rates for women approach or exceed the rates for men. **Conclusion**: Ischemic heart disease, as a significant cause of death in Croatia, is a major public health problem, therefore it is necessary to invest additional efforts at all levels in prevention, early diagnosis and adequate treatment of this condition.

Damir Raljević, Lovro Bebić, Sanja Matijević Rončević, Vesna Pehar Pejčinović, Dijana Travica Samsa, Viktor Peršić

**Introduction:** There is a large body of evidence that supports the positive effect of exercise based cardiac rehabilitation on reducing mortality, hospitalization rate and increasing the quality of life and exercise capacity in patients with heart failure. Also, there is more evidence about the positive effect of cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD) in patients with heart failure with reduced ejection fraction and interventricular conduction abnormalities in reducing mortality, increasing quality of life and exercise capacity. (1, 2) The aim of this review is to determine the existence of an additive effect of the exercise cardiac rehabilitation program in CRT patients on the increase in functional capacity. Also, the aim of this review is to establish the safety of the exercise based cardiac rehabilitation program in ICD patients regarding to anti-tachycardia pacing, appropriate and inappropriate ICD shocks. **Methods**: Systematic review of available scientific literature and discussion of collected data. **Results**: CRT therapy, in addition to optimal drug therapy, is a well-established treatment method in patients with heart failure with reduced left ventricular ejection fraction and intraventricular conduction abnormalities. Several randomized controlled studies and meta-analyses have established the association of exercise based cardiac rehabilitation with an additional increase in aerobic exercise capacity measured by VO2 max and improvement in quality of life in CRT patients. (1) Furthermore, several RCTs and meta-analyses have confirmed an increase in aerobic exercise capacity and quality of life in ICD patients without affecting mortality, serious adverse events, the number of anti-tachycardia pacing, appropriate and inappropriate ICD shocks. (2) **Conclusion**: Well-managed exercise based cardiac rehabilitation programs show an additive effect on CRT therapy in increasing aerobic functional capacity and increasing quality of life with a good safety profile without affecting mortality, episodes of anti-tachycardia pacing, appropriate and inappropriate ICD shocks.

Mihovil Santini, Juraj Jug, Maja Sirovica, Martina Matovinović, Martina Lovrić Benčić

**Goal**: To check the differences between A Body Shape Index (ABSI), recently proposed as a better mortality risk stratification tool, and alternative indices Systematic COronary Risk Evaluation2 algorithm (SCORE2) and Atherosclerotic Cardiovascular Disease Risk Score (ASCVD). (1-3) **Patients and Methods:** In this cross-sectional study, 132 obese patients (24 male, 109 female, average age 46 years; body mass index 40.65kg/m2) treated at the Division of Endocrinology at University Hospital Center Zagreb were included. ABSI was calculated with the proposed formula created by Bertoli et al. [waist circumference/(BMI2/3 *height1/2)]. ABSI z score was calculated from ABSI, gender, and age of each patient. Atherosclerotic cardiovascular risk was calculated using the ASCVD score and SCORE2. General laboratory and anthropometric parameters were checked in all patients. Spearman’s correlation, one-way ANOVA, and descriptive statistics were used in Statistica v.12. **Results**: There were no differences between genders. Although a significant correlation between SCORE2 and ASCVD risk was found (r=0.873; p<0.001), there was no correlation between them and ABSI or ABSI z score (r=0.152; p=NS). SCORE2 and ASCVD risk were higher in patients with higher BMI (r=0.761; p<0.001), higher blood pressure (r=0.446; p<0.01), lower HDL (r=-0.346; p<0.05), lower glomerular filtration rate [CKD-EPI] (r=-0.268; p<0.05), but no significant correlation was found between ABSI, or ABSI z, between any observed parameter except BMI (r=-0.367; p<0.01). One-way ANOVA on five risk groups created according to the ABSI z score did not show any connection between higher-risk groups and observed parameters. **Conclusion:** In this study ABSI and ABSI z scores did not show any connection with alternative indices (SCORE2 and ASCVD risk) and observed laboratory and anthropometric parameters. Accordingly, risk stratification significantly differs between ABSI and alternative indices. More extensive multicentric studies are needed to check these findings.

Viktor Ivaniš, Kristina Skroče, Dijana Travica Samsa, Koraljka Knežević, Irena Kužet Mioković, Marina Njegovan, Danijel Premuš, Viktor Peršić

**Introduction**: High-intensity interval training (HIIT) is increasingly popular exercise training intervention and meta-analyses have suggested HIIT to be more effective at improving cardiorespiratory fitness (CRF) and reducing adiposity compared to moderate-intensity continuous training (MICT) in patients after myocardial infarction. (1) However, the impact of HIIT training on cardiac biomarkers is still controversial. Therefore, the aim was to longitudinally follow up on the main blood markers during 12 weeks of HIIT training in ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) patients. **Patients and Methods**: 16 STEMI and NSTEMI (age 58 ± 10 years; height 177 ± 9 cm; weight 86.8 ± 15.4 kg; VO2max 19 ± 5.3 ml min-1kg-1) underwent 12 weeks of supervised cycling HIIT (4x4 min at 85-95% of HRmax) 3 times per week. Lipid profile as well as cardiac biomarkers (C-reactive protein, hs-Troponin, NT-proBNP) were assessed prior, at week 4 and 8 and post 12-week of proposed training programme. **Results**: Blood triglycerides decreased significantly by 22% across the group (1.77 ± 0.97 vs 1.38 ± 0.75 mmol/L, P=.003) after 12 weeks of training. HDL increased by 3.6% whole LDL cholesterol decreased by -2.36% across the group although not in a significant way. CRP decreased by 43.4% (1.99 ± 1.51 mg/dL vs 1.11 ± 1.04 md/dL) and NT-proBNP did not change significantly although a drop of 3.15% was measured. **Conclusion**: HIIT did not have a negative effect on the NT-proBNP levels while it improved the lipid profile and C-reactive protein levels. Prescribing safe and progressive exercise programs after CR is critical to improve these parameters that represent prognostic indicators for CVD patients. HIIT has shown to be a type of safe exercise intervention in this group of patients that positively improves blood biomarkers already after 4 weeks of HIIT.

Tomo Svaguša, Šime Manola, Marko Žarak, Filip Vujević, Luka Pfeifer, Luka Prgomet, Ivo Vučko, Senka Pejković, Nikolina Jurković Dubravčić, Renee Mixich

**Introduction**: Cardiac troponin I (cTnI) has been shown to have predictive value for cardiovascular incidents in the general population. With the newest 5th generation cTn tests it is possible to measure its concentration in most of population (1, 2). The aim of this study is to investigate the correlation between plasma levels of cTnI measured by Beckman Coulter high sensitivity test and presence of cardiac pathology (mostly coronary artery disease and heart failure). **Patients and Methods**: All 100 patients who underwent computed tomography coronary angiography in Dubrava University Hospital from 14th February until 28th June 2022 were included in study. 75 patients had no cardiac pathology (median age 58 y [IQR 48-85], 49% were male) and 25 patients had heart failure or known/new verified coronary artery disease (median age 63 y [IQR 57-72], 60% were male). cTnI was measured using chemiluminescent high sensitivity Beckman Coulter cTnI test. **Results:** For statistical analysis, we used the non-parametric Mann Whitney U test. The median value of cTnI concentration in the population of patients without verified cardiac pathology is 3.9 ng/L [IQR 2.9-5.15], while the median value of cTnI in patients with heart disease is 7.4 ng/L [IQR 4.2-11.5] P=0.2113. **Conclusion**: Although cTnI values are slightly higher in patients with cardiac pathology compared to the control group, the difference is not statistically significant. The above can be explained by the good control of cardiovascular risk factors, which is why the most of concentration of cTnI in heart disease group overlaps with the values in the control group. cTnI could be a good screening marker for patients with increased cardiovascular risk.

Dijana Travica Samsa, Kristina Skroče, Viktor Ivaniš, Koraljka Knežević, Danijel Premuš, Irena Kužet Mioković, Marina Njegovan, Viktor Peršić

**Introduction**: Functional capacity, also termed maximal oxygen consumption (VO2max), or aerobic fitness, has been shown to be an independent risk factor for all-cause and cardiovascular disease mortality. The cardiopulmonary exercise test (CPET) is the golden standard for assessing the functional capacity of the patient and it is becoming the integral part of the growing number of recommendations and guidelines. (1, 2) While high-intensity interval training (HIIT) would seem to be more effective than other types of training in improving cardiac performance and function (3), the time course of functional adaptations to this training in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction patients is still unknown. Therefore, the aim was to assess the progressive cardiopulmonary improvements throughout the process of 12 weeks of individually-prescribed HIIT training. **Patients and Methods:** 16 STEMI and NSTEMI patients (age 58 ± 10 years; VO2max 19 ± 5.3 ml min-1 kg-1) underwent 12 weeks of supervised cycling HIIT (4x4 min at 85-95% of HRmax) 3 times per week. Functional capacity (VO2max) and all cardiopulmonary parameters ware assessed by means of the incremental cardiopulmonary test to exhaustion (CPET) every 4 throughout the training program. Individual training zones were prescribed and adjusted according to the parameters obtained in CPET. **Results:** Peak VO2 increased significantly by 8% (19.2 ± 5.1 vs 20.8 ± 5.0 mil min-1 kg-1, P=.002) across the group already after 4 weeks of training. In the same timepoint, anaerobic threshold (AT) and respiratory compensation point (RCP) significantly improved by 15% (12.4 ± 3.1 vs 14.3 ± 3.0 mil min-1 kg-1, P<.001) and 19% (15.5 ± 4.2 vs 18.6 ± 4.3 mil min-1 kg-1, P<.001), respectively. The absolute improvement in VO2peak at the end of the 12-week training was 32% (19.2 ± 5.1 vs 25.5 ± 4.9 mil min-1 kg-1, P<.001) **Conclusion:** 4 weeks of HIIT are enough to induce significant functional adaptations like VO2max, VO2 at AT and RCP in STEMI and NSTEMI patients provided that patients are trained at the same in terms of volume, but at individually tailored intensity. Moreover, across 12 weeks of training, HIIT has proven to be effective training method in increasing functional capacity as well as exercise tolerance in STEMI and NSTEMI patients.

Livija Sušić, Lana Maričić, Lucija Klobučar, Ines Šahinović, Kristina Kralik, Tihomir Sušić, Josip Vincelj

**Goal**: The goal of this study was to determine the relationship between the occurrence of left ventricular diastolic dysfunction (LVDD), the value of asymmetric dimethylarginine (ADMA) as a biomarker of endothelial dysfunction and estimated Systematic COronary Risk Evaluation2 algorithm (SCORE2). (1-3) **Patients and Methods:** A cross-sectional population study that included 178 adult people (79 women, 99 men) aged 40 to 65, was conducted in the period from November 15, 2019 to May 25, 2022. Sociodemographic, anthropometric characteristics and cardiovascular risk factors were recorded. Laboratory evaluation was performed. ADMA was determined by the ELISA method. Transthoracic echocardiography was used to assess left ventricular diastolic function. Chi-square test and Kruskal-Wallis test were used to evaluate the correlation between LVDD severity, SCORE2 value and plasma concentration of ADMA. Significance level p set at Alpha = 0.05. **Results**: Subjects with any degree of LVDD had a significantly higher SCORE2 compared to those with normal left ventricular diastolic function (p10 developed LVDD grade 2 and 3 (p< 0.001) and took medication significantly more often (p< 0.001). They also had significantly lower plasma ADMA values (p<0.001). Using Fisher’s exact test, we determined that angiotensin-converting enzyme inhibitors, beta-blockers, statins (p<0.001), mineralocorticoid receptor antagonists, aspirin (p=0.001), angiotensin receptor-neprilysin inhibitor (p=0.004), proton pump inhibitors (p=0.007), sodium-glucose transport protein 2 inhibitors, insulin and diuretics (p=0.01) had a favorable effect on lowering the concentration of ADMA in plasma. **Conclusion**: In our study we confirmed a positive correlation between LVDD and SCORE2 severity. Surprisingly, we obtained a negative correlation between biomarkers of endothelial dysfunction and severity of LVDD and SCORE2. We believe that the reason for this is the effect of drugs on endothelial dysfunction.

Lidija Pleš, Antun Zvonimir Kovač, Kata Ćorić, Petar Medaković, Ladislav Pavić, Mladen Jukić

**Introduction:** Coronary computed tomography angiography (CCTA) is an accurate noninvasive diagnostic test for diagnosing coronary artery disease (CAD), evaluation of intracoronary stent patency and percutaneous coronary intervention (PCI) related complications. (1, 2) Coronary artery aneurysm formation is one of the possible post PCI complications. (3) The aim is to present a case of coronary artery aneurysm assessed by serial (CCTA after intracoronary stent placement. **Case report:** 54-year-old man with previously known CAD and low adherence to prescribed therapy that was treated with multiple PCI and intracoronary stents was referred to our hospital for a follow-up CCTA to evaluate the possibility of CAD progression and stent patency. Baseline post-PCI CCTA in 2019 revealed normal stents patency and moderate CAD with no sign of aneurysm. Among risk factors, arterial hypertension, dyslipidemia and heavy smoking was revealed with no chest symptoms. Two follow up CCTA were performed. First follow up CCTA revealed progression of CAD in proximal circumflex artery (Cx) with mild in-stent restenosis and newly outpouching of the mid Cx between two stents consistent with the formation of partially thrombosed coronary artery aneurysm (CA). CA considerably increased in diameter (9 vs 17 mm) and amount of thrombosis at the second post PCI follow up CCTA with subocclusion of distal stent. **Conclusion**: CCTA serves as a guidance tool to plan interventional procedures as it allows three dimensional assessment of coronary atherosclerotic plaque features and also procedure and disease related complications.

Denis Mačkić, Edin Begić, Faruk Čustović, Deana Avdalović, Benjamin Palić, Salko Isaković

**Aim**: To present a rupture of sinus of Valsalva aneurysm (SOVA) of the non-coronary cusp (NCC) in a 30-year-old female patient who was admitted for hospital treatment because of symptoms related to congestive heart failure. **Case presentation**: After transthoracic echocardiography (TTE), where the existence of a ventricular septal defect (VSD) was suspected, transesophageal echocardiography (TEE) was indicated for a patient with a diagnosis of Down syndrome. The left and right heart cavities were of regular dimensions, with preserved systolic function of the left ventricle, along with mild mitral and pulmonary regurgitation. TEE detected a SOVA of NCC, with visible communication with the right atrium, along with trileaflet aortic valve (**Figure 1**). FIGURE 1. Rupture of the noncoronary sinus of Valsalva aneurysm. **Conclusion**: SOVA is a rare congenital heart defect, which is most often detected accidentally, and due to rupture, surgical treatment is indicated (1, 2).

Petar Medaković, Kata Ćorić, Mladen Jukić, Zrinka Biloglav

**Aim:** To analyse the impact of coronary atherosclerotic burden quantified with coronary computed tomography angiography (CCTA) based scores on non-fatal cardiovascular (CV) events in coronary patients during ten-years follow up and compare them with previously published event rates of cardiac death. **Material and Methods:** We used standard clinical and demographic data of patients with suspected coronary heart disease referred to CCTA from January to June 2008. Agatston calcium score (CACS), Computed tomography **(**CT) -Leaman score (CT-LeSc), segment involvement score (SIS) and segment stenosis score (SSS) were calculated. CT-LeSc≥5.52 was defined by upper tertile as high burden, and SIS and SSS ≥5. Survival analysis and regression models with aforementioned CT scores for outcomes of cardiovascular death and composite outcome of non-fatal cardiovascular (CV) events (myocardial infarction + stent +coronary artery bypass graft) were compared ending with June 2018. **Results**: The median CT-LeSc, SIS, SSS and CACS were 3.2, 2.0, 3.0 and 16.7, respectively. Of 261 patients (mean follow-up of 120.6±16.1 months), 10 (3.8%) experienced cardiac death (mean follow-up 77 months) and 31 (11.9%) composite of non-fatal CV events (mean follow-up of 115 months). Event-free survival of patients with high atherosclerotic burden evaluated with all four CT scores was shorter than in patients with low burden. Cox regression models indicate that beside hypertension and hyperlipidaemia CT scores above cut-off value were significantly associated with cardiac death (HR of 8.21 for SIS, 7.93 for SSS, 38.03 for CT-LeSc and 9.84 for CACS) and composite of non-fatal CV events (HR of 7.41 for SIS, 11.25 for SSS, 14.66 for CT-LeSc and 4.01 for CACS). **Conclusion:** CT specific scores that quantify total coronary atherosclerosis on CCTA were significantly associated with non-fatal cardiovascular events and cardiovascular death during ten-year follow up (1-3).