Cardiologia Croatica. 2023;18(9-10)

Tea Friščić, Jasna Čerkez Habek, Ognjen Čančarević, Ante Pašalić, Petar Pekić, Jozica Šikić

**Introduction**: Valvular heart disease can lead to chronic heart failure, especially when the treatment adherence is low. (1) **Case report**: 47-year-old-male, obese, smoker, with previous history of diabetes, hypertension, chronic obstructive pulmonary disease and a myocardial infarction without significant stenosis of coronary arteries 6 years prior, was admitted for the first time in 2012 due to heart failure and paroxysmal atrial fibrillation. The echocardiographic exam showed a dilated left ventricle with a reduced ejection fraction (EF) of 38%, a bicuspid aortic valve without significant stenosis or regurgitation and dilated ascending aorta (4.6 cm). During the next four years he was repeatedly hospitalized due to worsening heart failure (WHF) with a gradual decline in EF (35%) and further dilation of the ascending aorta (5.5 cm). Cardio-surgical repair of the ascending aorta and aortic valve replacement was offered to him in 2016 and again in 2019, but the patient never decided to undergo the surgical procedure and he did not show up for his check-ups regularly. During 2021 he was hospitalized several times because of WHF, even with cardiogenic shock when he admitted that he was drinking excessive amounts of alcohol. Repeated coronary angiographies never showed a sign of atherosclerosis. Finally in 2021 an implantable cardioverter defibrillator was implanted in a primary prevention setting. Heart transplantation was also considered but myocardial scintigraphy showed viability of the myocardium and the Heart Team decided he is not a suitable candidate for transplantation. He finally had a cardio-surgical repair of the ascending aorta (plication) and aortic valve replacement in May 2023, then 58 years old, (the aortic stenosis was severe, ascending aorta was 5.5 cm, EF 22% and systolic function of the right ventricle was severely reduced). Shortly after, in June 2023 he was admitted again because of WHF with an EF of 23% admitting he was not taking his medications regularly and seemingly still consuming alcohol every day. **Conclusion**: This is a case report of a patient who would probably have much better outcome if he would have had better treatment adherence.

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

**Background**: Systematic screening for coronary artery disease (CAD) and routine percutaneous coronary intervention (PCI) of significant lesions before for transcatheter aortic valve implantation (TAVI) have been reconsidered recently because of no evidence of benefit. (1, 2) We wanted to investigate important clinical factors that could predict the importance of coronary artery disease in patients scheduled for TAVI. **Patients and Methods**: We retrospectively analyzed all patients with confirmed CAD who underwent TAVI in our center from April 2012 to May 2023. Data on CAD diagnosis and management were compared between patients with different CAD treatment strategies, in regard to complications and composite event rate of death and myocardial infarction during follow-up. **Results**: Among 349 patients (median age 80 years, 52% males, median AVA 0.7 cm2), 124 (36%) had confirmed CAD. Routine invasive coronary angiography during TAVI work-up was performed in 328 (94%) of patients. Patients with CAD had median age of 79, with 88/124 (71%) of males. History of PCI or CABG was noted in 61 (49%) and 46 (37%) of patients, respectively. Significant CAD deserving clinical attention was found in 80 (65%) patients, out of which 48 (60%) patients underwent PCI before TAVI. There were no differences in TAVI complications in regard to CAD management. Composite event rate of death and myocardial infarction during follow-up did not differ significantly between patients treated conservatively (28%) and patients who received PCI (21%) (OR 1.58, 95% CI 0.66-3.64). Significant univariate predictors of composite endpoints were male gender, peripheral artery disease (PAD), history of CABG, and reduced LVEF below 50%. Only PAD remained significant in a multivariate Cox regression analysis (OR 3.02, 95% CI 1.16-7.84). **Conclusion**: Routine PCI before TAVI did not impact clinical outcomes, so CAD could be considered bystander disease in most TAVI candidates. However, our data showed that CAD with history of CABG, reduced EF, and PAD, probably deserves a more scrutinized approach for better long-term outcomes after TAVI, and therefore it should not be considered as bystander in TAVI patients with any of these characteristics.

Siniša Roginić, Martina Roginić, Mladen Predrijevac, Nikolina Mijač Mikačić, Tereza Knaflec, Domagoj Futivić

**Introduction**: Endocarditis is devastating disease with unpredictable clinical course, high morbidity and mortality. (1) We are whithnessing increase in incidence and severity of clinical picture due to comorbidities and rising proportion of invasive and multiresistent pathogens. **Case report**: 62-year-old male with diabetes, hypertension and known kidney stone was admitted due to urosepsis and pionephros. 12-lead ECG upon arrival revealed sinus tachycardia with heart rate dependent right bundle branch block. Besides septic inflammatory parameters, laboratory results showed significant rise in high-sensitive troponin. Patient had no chest pain, but relative left ventricle longitudinal strain reduction and moderate aortic stenosis were found. After initial stabilization and targeted antimicrobial therapy (E. faecium isolated from blood culture) patient was referred to angiography showing significant right coronary artery stenosis and 1 drug-eluting stent was successfully implanted. Afterwards renal abscess was percutaneously drained enabling postponement of nephrectomy for minimum duration of dual antiplatelet therapy. Operation was done but the patient remained subfebrile with elevated inflammatory parameters during urology follow-up despite persistent antimicrobial therapy. Finally, he returned with clinical picture of heart failure, hypotension and elevated hs troponin. Bedside echo raised suspicion of aortic valve vegetation with massive regurgitation and reduced left ventricle global systolic function. Transesophageal echocardiography confirmed aortic valve endocarditis with multiple large hypermobile vegetations and small aortic root abscess (**Figures 1**, **2** and **3**Figure 2Figure 3). Cardiac surgeon initially opted for further antimicrobial therapy, but despite targeted intensive treatment (E. faecium from multiple blood cultures) after 3 days heart failure progressed to cardiogenic shock, and he was urgently operated. Operation confirmed echo findings and after debridement mechanical valve was implanted. Afterwards there were multiple complications including complete heart block (dual-chamber, rate-modulated pacing was also implanted) but eventually after 45 days he was discharged from hospital in a good condition. FIGURE 1. Transesophageal echocardiography (mid-esophageal, long axis, 180°): two large fresh hypermobile vegetations attached to aortic cusps. FIGURE 2. Transesophageal echocardiography (mid-esophageal, long axis, 0°): severe aortic regurgitation jet across the whole left ventricle. FIGURE 3. Transesophageal echocardiography (mid-esophageal, short-axis, 77°): annular abscess between the right and non-coronary aortic cusp. **Conclusion**: This case illustrates clinical doubts in managing patient with complex multiple acute pathologies. Close collaboration between all specialties is condicio sine qua non and echocardiography was key diagnostic tool in all steps of the management.

Zrinka Planinić, Jozica Šikić

**Introduction**: The prevalence of degenerative valvular heart disease is rising because of the ageing population, with aortic stenosis being the most common primary valve lesion requiring intervention (1). The aim of this study was to make a retrospective analysis of patients referred for valvular heart disease (VHD) treatment, whether surgical or transcatheter, and their characteristics. **Patients and Methods**: In the period of 2 years, from June 2021 to June 2023, medical history of patients hospitalized in Department of Cardiovascular Diseases in University Hospital “Sveti Duh” with the diagnosis of severe VHD was examined. **Results**: A total number of 67 patients were identified with the diagnosis of severe VHD that required treatment. Among them, 61% were men and 39% were women, with a mean age of 71.9 years. Similar number of patients were referred for elective (51%) and emergent (49%) treatment. The most common VHD was severe degenerative aortic stenosis (67%), followed by mitral regurgitation (18%), aortic regurgitation (4%) and mitral stenosis (1%). There were no patients with primary or isolated tricuspid valve disease, while concomitant tricuspid valve annuloplasty was performed in 5 patients for secondary tricuspid regurgitation. Multiple valve disease with at least two valves requiring intervention was found in 10% of patients. Among patients with severe aortic stenosis, 71% received biological prosthesis, most commonly C-E Permount Magna Ease in the range of 21-27 mm, 20% received or are awaiting transcatheter aortic valve implantation (TAVI) and 9% of patients younger than 65 years of age received mechanical valve. Primary severe mitral regurgitation was the reason for mitral valve repair or replacement (42% mechanical, 33% biological prosthesis) in 16% of patients. Concomitant coronary artery bypass surgery was performed in 25% of patients. 3% of patients have died, while 18% were lost to follow-up. **Conclusion**: According to our data, the most common VHD requiring treatment was severe aortic stenosis followed by severe mitral regurgitation, which matches the European numbers. TAVI has offered an effective alternative to surgery, but still for older and high surgical risk population.

Jasna Čerkez Habek, Jozica Šikić, Dean Strinić

Aortic regurgitation (AR) is a common valvular disease results from various etiologies, affecting the aortic valve cusps or the aortic root. The clinical presentation depends on the severity of the regurgitation and acutely of progresses. Echocardiography is the primary method to determine the etiology of AR and to define its severity. In same patients is challenging to determine AR severity, because we do not have single parameter that is sufficient. We review the current data regarding the diagnosis of AR. (1, 2) An integrative, multi-parametric approach is required. Echocardiography is key for imaging the aortic valve morphology and flow as well as aortic root and ascending aorta. Mild and moderate AR in individuals with normal left ventricular (LV) dimensions are both generally benign. Determining LV ejection fraction and dimensions is essential for patient management and optimizing timing for intervention. But disease progression occurs at a variable rate, and is often insidious. Hence, symptoms do not correlate with objective evidence of ventricular dysfunction. With severe AR, the central jet width assessed by color flow Doppler exceeds 65% of the LV outflow tract (LVOT), the regurgitant volume is ≥60 mL/beat, effective regurgitant orifice area is >0.30, pressure half time less then 200 ms, vena contracta is > 0.6 cm, and there is diastolic flow reversal in the proximal descending thoracic aorta. Anatomy of the aortic valve cusps and its suitability for valve repair should be provided by preoperative transesophageal and three-dimensional echocardiography. Cardiac magnetic resonance has the potential to add important diagnostic information. The diagnosis and later adequate management of AR requires a comprehensive approach and routine clinical and echocardiographic follow-up. Surgical or percutaneous replacement or surgical preservation of valve is indicated when symptoms develop and in those who have LV dysfunction or LV dilation.

Drazen Zekanovic, Mira Stipcevic, Jogen Patrk, Zoran Bakotic, Marin Bistirlic

Mitral annular disjunction (MAD) is a displacement of the mitral valve leaflet onto the left atrial wall, and it can be found in patients with mitral valve prolapse (MVP). The risk of malignant arrhythmias and sudden cardiac death (SCD) is generally low, and therefore MVP by itself is not routinely considered as a major cause of SCD. For decades, MAD has been associated with a risk of malignant ventricular arrhythmias and SCD, therefore recognition and risk stratification are highly important. Although this entity can be potentially fatal there are no strict guidelines how to treat and follow up these patients. In general, patients who have severe mitral regurgitation can benefit from mitral valve replacement but at the most risk are does who are diagnosed with MVP and MAD, but are oligosymptomatic and, according to current guidelines, have no indication for mitral valve surgery, intracardial defibrillator implantation or even medical treatment. In every day clinical practice, we often encounter young patients, with chest pain and palpitations, mitral valve prolapse, or even without prolapse, and echocardiographic indications of MAD. Detection of MAD by echocardiography is generally evaluated with a single plane image, which can often overlook disjunction. It is important to highlight the usage of multiple imaging techniques to diagnose MAD and complementary value of transesophageal echocardiography and cardiovascular magnetic resonance imaging, given limited clinical knowledge and the lack of a standard imaging technique for MAD diagnosis. But even when we diagnose MAD, there are still no guidelines how to treat these patients. (1-3) We present series of patients with detected MAD and different clinical scenarios, indicating the need for stricter guidelines.

Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Krešimir Gabaldo, Blaženka Miškić, Mario Udovičić, Ana Livun

Aortic stenosis (AS) is the most common structural heart disease. The prevalence of calcific aortic valve disease (CAVD) is increasing due to the aging of the population and the pandemic of obesity, diabetes, arterial hypertension, and renal failure. Men are twice as likely to develop AS, and when they do develop the disease, they have significantly more pronounced calcifications (1). The disease is multifactorial, and we still do not understand the processes leading to the onset and progression of CAVD. It can be asymptomatic for many years, but when symptoms occur and no treatment is given, the mortality rate within 2 years is almost 80% (2). Surgical replacement of the aortic valve (AVR) with a mechanical or bioprosthetic prosthesis is the gold standard for the treatment of patients with severe AS. The introduction of transcatheter aortic valve replacement (TAVR) allowed the treatment of high-risk patients, and now the indication has been extended to patients with lower surgical risk. Understanding the regulatory mechanisms involved in the development and progression of the disease appears to be critical to the discovery of biomarkers that could have diagnostic, prognostic, and therapeutic value. According to published research, microRNA is a future biomarker for numerous chronic diseases, including CAVD. Identifying patients prone to calcification could be important in selecting the type of artificial heart valve to be implanted to avoid repeat surgery. Influencing their expression by up- or down-regulation is a challenge of modern molecular biology. An integrated multiomics approach to uncover the pathophysiology of the disease using systems biology techniques and employing (epi)genomics, transcriptomics, proteomics, and metabolomics is now promising in heart valve disease (**Figure 1**). (3) Combining data from different layers and revealing their communication allows us to understand the molecular mechanisms responsible for CAVD. FIGURE 1. Calcific aortic valve disease: multiomics approach.

David Jacobo Sánchez Amaya, Luis Benjamín Godínez Córdova, David Adrián Ramos Coria, Rodrigo Gopar-Nieto, Jorge Daniel Sierra Lara-Martínez

Spontaneous coronary dissection is an infrequent but well-described cause of acute myocardial infarction. It is associated with women of reproductive age or patients with fibromuscular dysplasia. Treatment consists of controlling cardiovascular risk factors, vasodilators, and beta-blockers. We present a case of 48-year-old patient with myocardial infarction secondary to spontaneous dissection and recurrence due to disease extension at a later stage.

Jozica Šikić

The 6th Congress of the Working Group on Valvular Diseases of the Croatian Cardiac Society with international participation, CROVALV 2023, will be held on September 7th to September 9th, 2023, at the Sheraton Hotel in Zagreb. CROVALV is a bi-annual congress designed for cardiologists, cardiac surgeons, anesthesiologists, neurologists, residents, general practitioners, and for all who are professionally involved in the treatment of valvular diseases. Much has been learned and significant progress has been made since the last CROVALV congress, especially in the field of percutaneous interventional treatment as well as in cardiac surgery, coronary artery diseases, and heart failure, which indirectly affects improvement of cardiac valve function. The goal of the CROVALV congress is to present and discuss challenges in the approach, diagnosis, and selection of the most optimal way of treating patients with valvular diseases and to help implement the latest research findings into clinical practice. In addition to invited lectures by reputable speakers from abroad, leading national experts will present best entries among the submitted abstracts. We hope that you will once again recognize the value of this congress, and we cordially invite you to come and actively participate in jointly contributing to its quality and success. Predsjednica kongresa: / Congress Director izv. prof. dr. sc. Jozica Šikić, dr. med. / Assoc Prof Jozica Šikić, MD, PhD predsjednica Radne skupine za bolesti srčanih zalistaka Hrvatskoga kardiološkog društva / President of the Working Group on Valvular Diseases of the Croatian Cardiac Society

Petar Bešlić, Jasna Čerkez Habek, Zrinka Planinić, Mirko Tomić, Edvard Galić, Jozica Šikić

**Introduction**: As the population ages, there is an increase in mitral apparatus degenerative disease and a decrease in rheumatic disease. Diagnosis and treatment are quite different due to the different distribution of calcifications and the heart diastolic conditions in which the diseases occur. (1-3) **Case report**: 74-year-old male patient with a history of long-term arterial hypertension, diabetes, permanent atrial fibrillation, and mechanical aortic valve implantation in 2006 was admitted to the hospital due to exercise intolerance, NYHA (New York Heart Association) III class, with clinical signs of dominantly right-sided decompensation. Echo revealed preserved systolic function of the non-dilated left ventricle, but diastolic dysfunction in the restriction phase. There was a slightly dilated right ventricle with decreased longitudinal function, TAPSE (tricuspid annular plane systolic excursion) 12mm, bounce and a D-shape of ventricular septum in diastole. The mechanical aortic valve was functioning well. Mitral valve area (MVA) planimetry was not done due to poor window in parasternal short axis (PSAX). A mean gradient of 7mmHg was measured by continuous wave (CW) Doppler. MVA of 2.7cm2 was obtained by pressure half time (PHT). With longer heart cycles diastasis was visible at the end of diastole. The continuity equation was not used because of atrial fibrillation. By PISA (proximal isovelocity surface area) method, which is an only echo method independent from flow conditions in mitral stenosis, calculate area was 1.0 cm2. Pericardial calcification deposits were shown by ultrasound and then by CT scan. Considering the inconsistent findings of mitral stenosis severity with a possible diagnosis of constrictive pericarditis, right heart catheterization (RHC) was performed. It revealed very high left ventricular end diastolic pressure (LVEDP) (40 mmHg), severe pulmonary hypertension (79/34 mmHg, mean 54 mmHg) as a combination of high pulmonary capillary wedge pressure (PCWP) (25 mmHg) and pulmonary vascular resistance (PVR) (6.55 Wood). The diastolic pressures of the left and right side of the heart differed significantly (right ventricular end diastolic pressure (RVEDP) of 15mmHg and LVEDP of 40 mmHg, so constrictive pericarditis was ruled out. **Conclusion**: After all, different results were obtained measuring the severity of mitral valve stenosis, but with certain severe diastolic dysfunction of the left ventricle and severe pulmonary hypertension. The patient was further presented to the heart team and a pulmonary hypertension reactivity test was performed. Since the result was positive, sildenafil therapy was introduced. The RHC will be repeated in three months when the heart team will decide on further treatment modalities.

Vlatka Rešković Lukšić, Sandra Jakšić Jurinjak, Joško Bulum, Ivica Šafradin, Kristina Krželj, Maja Čikeš, Ivo Planinc, Karlo Gjuras, Davor Miličić, Hrvoje Gašparović, Jadranka Šeparović Hanževački

**Background:** Mitral regurgitation (MR) is a common valvular heart disease (1). Without treatment prognosis is poor, especially if left ventricular (LV) function is reduced (2). In high-risk patients who are not eligible candidates for surgery or transcatheter edge-to-edge repair (TEER), transcatheter mitral valve replacement (TMVR) is a viable option (2, 3). All-cause mortality is highest 3-months after valve implantation, while improvement in symptoms and reduction of MR severity are sustained after 2-years of follow-up (2). **Case series:** From April to July 2023, four high-risk patients underwent TMVR with TendyneTM valve (Abbott Vascular, CA, USA) implantation in UHC Zagreb. Case 1 is a 75-year-old female with degenerative MR and preserved LV function – due to fragility and comorbidities the patient was not a candidate for mitral valve (MV) surgery, while due to calcification and MV leaflet morphology TEER was denied. After successful TMVR, mean pressure gradient was 4-5mmHg, no residual MR. Case 2 is a 72-year-old-male with ischemic cardiomyopathy (CMP) who underwent CABG 20 years ago. Due to heart failure, atrial fibrillation with bradycardia and LBBB, CRT was implanted. Because of severe MR due to prolapse P1/P2 and chordal rupture, the patient was a candidate for TMVR – postprocedural mean PG was 5-6mmHg, no residual MR. Case 3 is a 76-year-old female with toxic CMP after chemotherapy for breast cancer and functional MR. Due to deep indentations on the posterior leaflet, TEER was denied, so TMVR was performed – post implantation mean PG was 3mmHg, no residual MR. Case 4 is a 65-year-old male to whom surgical AVR was performed in 2017 due to endocarditis. In 8/2022 due to prosthesis degeneration and HF, he underwent valve-in-valve TAVI. Re-do surgery at that time was denied due to comorbidities (end-stage renal disease- on hemodialysis, COPD, toxic liver lesion), even though severe degenerative MR was also known. Clinical improvement after TAVI was significant, but he was hospitalized due to HF, and MR did not improve, so he was referred for TMVR. After TMVR, mean PG was 6-7mmHg with trace of paravalvular MR (**Figure 1**). FIGURE 1. Case 4: Three-dimensional transesophageal echocardiography recorded during transcatheter mitral valve replacement, showing a good position of Tendyne valve after deployment. **Conclusion:** All patients had undergone the TMVR procedure without complications, with good short-term outcomes. Although there are still not enough studies, the existing evidence indicate that TMVR with TendyneTM valve (Abbott Vascular, CA, USA) is a good option for high-risk patients who are not candidates for surgery nor TEER, with high success implantation rate and good short-term outcomes. Concerns about valve durability and long-term outcomes are yet to be resolved.

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

**Introduction**: Infective endocarditis has an in-hospital mortality rate of 16%. The cardiac conditions predisposing to infective endocarditis have shifted from rheumatic heart disease and congenital heart disease to a preponderance of degenerative valve disease, prosthetic valves and intracardiac devices. Streptococcus species link to bowel lesions is well established including S. sanguinis. It is frequent causative agents of IE, comprising 18 to 30% of cases. S. sanguinis enters the blood via ulcerated bowel lesions and bacteremia can represent a marker of the occult malignancy. ESC Guidelines recommend against routine prophylaxis for infective endocarditis during routine gastrointestinal procedures unless performed at an infected or colonized site. An ulcerating colonic malignancy allows the bacteria to penetrate the bloodstream with subsequent endocarditis. (1-3) We present a case of S. sanguinis bacteremia and subsequent endocarditis of a bio-prosthetic aortic valve in an elderly man who had adenocarcinoma of the sigmoid colon. **Case report**: 74-year-old patient who underwent aortic valve replacement surgery due to severe stenosis six months ago, presented with fever, fatigue and breathlessness. These symptoms occurred a few days ago. He was hospitalized two weeks prior for new-onset microcytic anemia, colonoscopy was performed and PHD results verified adenocarcinoma of the sigmoid colon. Blood cultures were taken upon admission and S. sanguinis was detected. Transesophageal echocardiography (TEE) revealed vegetation on the left coronary cusp of the bioprosthetic aortic valve. The patient was treated for endocarditis with intravenous penicillin G for 6 weeks and gentamycin during the first 2 weeks. The patient was determined as a surgical candidate after receiving sterile blood cultures, decline in inflammatory markers levels, and TEE revealing a regression of the vegetations. **Conclusion**: Viridans group streptococci are considered to be of low virulence but can lead to significant infections including endocarditis in the setting of underlying malignancy. Although guidelines have not been in complete agreement, providing prophylaxis to individuals at high risk of adverse outcomes undergoing high-risk procedures, seems efficient and cost-effective.

Drazen Zekanovic, Dino Mikulic, Mira Stipcevic, Marin Bistirlic, Jogen Patrk, Zoran Bakotic, Karla Savic, Karla Grgic, Stipe Kosor, Nikola Verunica

**Introduction**: Infective endocarditis remains life-threatening disease with in-hospital mortality of 15-30%. This entity represents complex interaction between pathogen, host immune system and coagulation cascade. (1-3) However, routine anticoagulation therapy in this setting is not recommended by the official guidelines. **Case report**: Patient with bioprosthetic aortic valve was admitted for abdominal pain and elevated inflammation markers. Artificial valve vegetations were confirmed by transesophageal echocardiography and CT abdominal scan revealed spleen and right kidney infarctions. Streptococcus viridans was isolated from blood cultures and was sensitive to empirical gentamycin and vancomycin. Repeated transesophageal echocardiogram (TEE) showed no residual vegetations and patient was dismissed on the 26th day with oral amoxicillin. 6 days later patient came again complaining of similar abdominal pain but with normal blood tests and no fever. Repeated CT scan revealed reinfarction of spleen and no residual changes on kidneys. TEE was preformed once again this time showing 6x6 mm floating mobile mass of the same valve highly suspicious of thrombus. Patient was dismissed after 4 days but this time with warfarin. **Conclusion**: This case reminds us of need to individualize therapy for each patient. There is perhaps underrecognized need for more liberal use of anticoagulation therapy especially in high risk patients early in the course of the disease.

Ines Zadro Kordić, Petar Pekić, Ognjen Čančarević, Tea Friščić, Zrinka Planinić, Jasna Čerkez Habek, Krešimir Kordić, Jozica Šikić

**Introduction**: Mitral valve prolapse (MVP) is a common condition that affects up to 3% of the population. It is usually benign, but a small subset of patient has an increased risk of malignant ventricular arrhythmias and sudden cardiac death. (1, 2) **Case report**: We present a previously healthy 56 years old female patient with history of palpitations. In May 2023, she was hospitalized after out-of-hospital cardiac arrest with ventricular fibrillation (VF) as the initial rhythm. After successful resuscitation, she regained full consciousness. Serum electrolytes were within normal range at admission. Electrocardiogram was uneventful. Echocardiography revealed normally sized left ventricle with preserved ejection fraction and severe mitral regurgitation due to posterior leaflet prolapse (P2 scallop) (**Figure 1**). No mitral annular disjunction (MAD) was visualized. No heart rhythm disturbances were registered during monitoring. Coronary angiography found no stenosis of coronary arteries. Implantable cardioverter defibrillator (ICD) was implanted for secondary prevention of sudden cardiac death. She was discharged with metoprolol and amiodarone. On follow up visit no heart rhythm disturbances were noticed on ICD interrogation. The patient is scheduled for cardiac surgery (mitral valve repair or replacement). FIGURE 1. Three-dimensional transthoracic and transesophageal echocardiography showing mitral valve prolapse (P2 scallop). **Conclusion**: Mitral valve prolapse is becoming increasingly recognized as an important phenomenon which can lead to malignant ventricular arrhythmias and sudden cardiac death. We presented a patient who survived sudden cardiac arrest. No predisposing conditions were found other than mitral valve prolapse. The patient is scheduled for cardiac surgery following the implantation of an ICD.

Tea Friščić, Dean Strinić, Jasna Čerkez Habek, Jozica Šikić

Valvular heart disease (VHD) encompasses a spectrum of conditions that demand careful consideration when prescribing exercise. It is crucial to optimize patients’ health through evidence-based recommendations tailored to their specific VHD subtype, severity, and functional status. Valvular stenosis and regurgitation lead to hemodynamic alterations, resulting in pressure and volume overload on the heart. These adaptations necessitate cautious exercise program development to avoid exacerbating symptoms or compromising cardiac function. Before initiating any exercise regimen, a thorough evaluation is essential. Comprehensive clinical assessment, including echocardiography, exercise stress testing, and functional capacity assessment, helps determine the patient’s exercise tolerance and potential risks associated with physical activity. General exercise recommendations should emphasize the importance of adequate warm-up and cool-down routines to reduce the risk of arrhythmias and prevent hemodynamic stress. (1) Periodic reassessment and monitoring are essential to evaluate the patient’s response to exercise and make necessary adjustments to the regimen. Patient education about the signs and symptoms of worsening VHD is also very important, emphasizing the need for prompt medical evaluation. Individual risk stratification based on symptoms, ventricular function, and valve pathology guides the exercise prescription process.

Jozica Šikić, Jasna Čerkez Habek, Dean Strinić

**Aim**: The aim of this study was to make a retrospective analysis of patients admitted to hospital due to endocarditis and their characteristics. **Patients and Methods**: In the period of 2 years, from June 2021 to June 2023, medical history of patients hospitalized in Department of Cardiovascular Diseases in University Hospital “Sveti Duh” with the diagnosis of endocarditis were examined. **Results**: A total number of 9 patients were identified with the diagnosis of endocardits. 6 were women and 3 were men. The average age was 66 years (38-83 y). The average hospitalization days was 35 (1-62 days). 4 patients had endocarditis of the native mitral valve, 4 of the native aortic valve, 1 of the tricuspid valve and only one had it on the artificial valve. 6 patients were discharged home after antibiotic therapy, two underwent surgery and one died. The most common causative agents were Streptococcus (aureus, pneumoniae, alactolyticus) and Staphylococcus (epidermidis, capitis aureus), only one patient had Enterococcus faecalis. **Conclusion**: According to our data, endocarditis of the native mitral valve in middle-aged and elderly women is most often. The Streptococcus and Staphylococcus sp are the most common causative agents. Antibiotics are generally sufficient to treat endocarditis (1, 2).