Cardiologia Croatica. 2024;19(11-12)

Lucija Dizdarević, Nevenka Vila, Saša Dizdarević

**Introduction:** Deep vein thrombosis is a multifactorial disease, and obesity as a global public health problem is associated with many pathological conditions of the organism, including deep vein thrombosis. (1) There are also numerous diseases that increase the risk of deep vein thrombosis, such as diabetes mellitus type 2, coronary artery disease, hypertension, obstructive sleep apnea syndrome, malignant diseases, stroke. (2) Deep vein thrombosis is the third most common cardiovascular disease resulting from the interaction of acquired and genetic risk factors. One of the acquired risk factors is obesity, which is associated with inactivity, and the risk of developing deep vein thrombosis is even greater when obesity interacts with other risk factors. **Case report:** 33-year-old patient was hospitalized at the Department of Cardiovascular Diseases with a diagnosis of deep vein thrombosis. The patient came to the emergency because of pain and edema of the left leg. The patient had symptoms for the past 7 days and had previously consulted a family medicine physician. Otherwise, the patient suffers from diabetes mellitus type 2 and arterial hypertension. The patient has degree 3 obesity (BMI 56.7 kg/m2, body weight 162 kg, height 169 cm). After admission to the department, the patient underwent basic laboratory findings, as well as laboratory findings related to blood clotting disorder and lipid profile. In addition to the cardiologist, the patient’s treatment includes a transfusion specialist, a diabetologist and an endocrinologist. The patient was started on low molecular weight heparin treatment. During hospitalization, the patient was educated about lifestyle changes, introduction of physical activity, weight loss, all with the aim of controlling deep vein thrombosis, obesity and associated diseases. **Conclusion:** Obesity is on the rise all over the world, and studies have shown that obese people have twice the risk of developing deep vein thrombosis, while obese patients under the age of 40 have almost five times the risk of those who are not obese. Obesity is a global health problem that has reached the level of a pandemic, and this case highlights the role and importance of early treatment of obesity and its complications, given that there is strong evidence of an association between obesity and deep vein thrombosis.

Emilija Katarina Lozo, Mirna Alebić, Jasmina Matijašević Škerlj, Nives Kerner

**Introduction:** Drug therapy problem (DTP) is an undesirable event experienced by a patient that involves drug therapy, interferes with achieving goals of therapy and requires professional judgement to resolve. Providing a medication management service, a pharmacist can ensure that all medications are the most appropriate and effective, the safest possible and taken as intended (1).The aim of this research was to determine the prevalence of DTPs, interventions of clinical pharmacist and follow-up which includes clinical outcomes. **Patients and Methods:** We included 150 patients in the research, of which 57 patients were in HTx (heart transplant) group, 19 in LVAD (left ventricular assist device) group, 64 in CMP (cardiomyopathy) group and 10 were classified as Others. At the initial assessment patients, DTPs were grouped into 4 categories: indication, effectiveness, safety and adherence. Follow-up was conducted on next following visit. Clinical parameters and number of hospital admission were assessed at the baseline and following visits for all patients, while parameters such as international normalized ratio or tacrolimus concentration were appointed to specific group of patients. **Results:** On average, patients were 57 years old, majority were men (80.00%). The number of prescribed medications was 1734 with an average of 11.5 per patient. Analysis revealed 484 DTP and their distribution overall and among 4 patient groups is shown in **Table 1**. In HTx group most frequent intervention included immunosuppressants; 85.96% had immunosuppressant values within the therapeutic levels range, compared to 61.40% prior intervention. In the CMP group 82.70% patients had 4 pillars of heart failure therapy at baseline, compared to 89.13% after follow-up. Details about target doses are shown in **Table 2**. High percentage of four pillars is not surprising considering that prescribers are adopting a guideline-directed medical therapy for heart failure with reduced ejection fraction. Achieving target doses of medications was limited by symptomatic hypotension and bradycardia, renal impairment and hyperkalemia. Long-term anticoagulation with warfarin is required after LVAD implantation; 68.42% patients in LVAD group were in the INR range comparable to 89.00% after follow-up. According to the percentage of drug interactions, the narrow therapeutic width of warfarin is predisposing factor for clinically significant interactions. ### TABLE 1: Distribution and percentage of drug therapy problem between the groups. | **The most common DTP overall** | **The most common DTP in HTx** | **The most common DTP in CMP** | **The most common DTP in LVAD** | **The most common DTP in Others** | | --- | --- | --- | --- | --- | | **Effectiveness:** ineffective dose (15.70%) | **Effectiveness:** ineffective dose (15.27%) | **Indication:** untreated condition (17.46%) | **Indication:** untreated condition (19.67%) | **Indication:** untreated condition (19.35%) | | **Effectiveness:** needs additional monitoring (14.88%) | **Effectiveness:** needs additional monitoring (14.29%) | **Effectiveness:** ineffective dose (15.34%); needs additional monitoring (15.34%) | **Effectiveness:** ineffective dose (18.03%); needs additional monitoring (16.39%) | **Effectiveness:** ineffective dose (16.13%) | | **Indication:** untreated condition (13.84%) | **Safety:** dose too high (12.32%) | **Effectiveness:** more effective drug available (12.70%) | **Safety:** drug interaction (16.39%) | **Effectiveness:** needs additional monitoring (12.90%) | | **Percentage of DTP** **in categories:** | 41.94% | 39.04% | 12.61% | 6.41% | [†] DTP *=* drug therapy problem; HTx = heart transplant group; CMP = cardiomyopathy group; LVAD = left ventricular assist device group; ### TABLE 2: Percentage of patients with target doses of guideline-directed medical therapy for heart failure with reduced ejection fraction. | | **ARNI** | **BB** | **MRA** | **SGLT2i** | **4 PILLARS** | | --- | --- | --- | --- | --- | --- | | **After intervention** | 26.92% | 11.53% | 80.77% | 90.38% | 82.70% | | **After follow-up** | 47.83% | 15.22% | 82.61% | 95.65% | 89.13% | [†] ARNI: angiotensin receptor/neprilysin inhibitor; BB: beta blocker, MRA: mineralocorticoid receptor antagonists; SGLT2i: sodium-glucose cotransporter-2 inhibitors **Conclusion:** As a part of multidisciplinary team, clinical pharmacists have essential role in identifying and resolving DTPs, simplifying complex regimens and providing individualized education thus ensuring patient safety and having positive impact on clinical outcomes.

Mila Jakovljević, Ana Fabris

**Introduction**: The aim of the study was to assess the impact of the integrative metabolic support (IMS) on the cardiac function and quality of life (QoL). We accepted the concept that O2 consumption and ATP regeneration are two processes mutually dependant and inseparable and that the flux through energy-providing pathways determines the functional state of the tissue. (1, 2) **Patients and Methods**: IMS, i.e. supplemental support cardiac therapy (SSCT) consists of a 15-day session and includes the use of coenzymes/substrates, O2, antioxidants, a low-frequency pulsed magnetic field and exercise training (ET). SSCT was applied in 106 sessions – 30 sessions in patients with preserved ejection fraction (EF) and 76 sessions in patients with reduced EF. M-mode, 2D echocardiography and vascular ultrasound were performed in all patients. Cardiopulmonary echocardiographic test with was performed at the start and the end of 30 sessions and EF and left ventricular volumes were determined using 4D biplane volume measurement. Patients with reduced EF were asked to evaluate the QoL the Minnesota Living with Heart Failure Questionnaire. In addition to optimal medical therapy patients received Mg, niacin, Q-10, thiamine diphosphate, riboflavin, pantothenic acid, pyridoxal, biotin, glutathione and vit. E. After ET the patients inhaled 95% O2, 4 l/min through O2 concentrator with ionisation while lying in a low frequency pulsed magnetic field (up to 30 microT). After the inhalation of O2, the patients received carnitine, arginine, NADH, lipoic acid, selenium, and vitamin C. For patients with reduced EF,the SSCT did not include ET. Statistical analyses were performed using SPSS Statistics version 17.0 and version 25. **Results**: The values before SSCT compared to values after SSCT are in strong correlation with the VAS, NYHA and LVIDd indicators and in a very strong correlation with physical dimensions, emotional dimensions and EF indicator. Arithmetic means of most Ergospiro echocardiographic parameters are lower before and higher after SSCT. 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 SSCT range from 0.568 to 0.952. P-values are less than 0.05 for all 20 pairs of cardiopulmonary echocardiographic variables. **Conclusion**: SSCT, supporting normal mechanisms for energy production, supports the cardiac function and QoL.

Dijana Travica Samsa, Kristina Skroče, Viktor Ivaniš, Ana Brajdić Šćulac, Ivana Peršić, Iva Uravić Bursać, Marijana Rakić, Silvija Miletić Gršković, Viktor Peršić

**Introduction**: Cardiopulmonary exercise testing (CPET) is the gold standard for evaluating cardiovascular functional capacity. It provides assessment of the integrative exercise responses involving pulmonary, cardiovascular and skeletal muscle systems. CPET integrates different variables that support the understanding of physiological and pathophysiological mechanisms. Moreover, it provides a remarkable tool for monitoring the cardiac rehabilitation program (CR) and the effect of therapy. Clinical decision-making and recommendations for its application are continuously evolving every year. In patients with chronic heart failure (HF), physical activity is one of the main components of CR (1), although the training structure is not clearly defined. Many parameters are used to classify the intensity of physical activity (RPE, MET, %HRpeak, %Wpeak) (2). Still, “threshold-based” classification, determined regarding the first and second ventilatory thresholds (VT), VT1 and VT2, is considered as the optimal for improving individual’s functional capacity (3). **Patients and Methods**: A pilot project of 8 patients with HF (HFrEF, HFimpEF) with underlying coronary artery disease (CAD) (age 65 ± 6 yrs; VO2peak 15.4 ± 2.7 ml min-1 kg-1, EF 42±9%) underwent CR for 3 weeks. Functional capacity (VO2peak) and all corresponding cardiopulmonary parameters were assessed using CPET at the program’s beginning and end. The training zones were prescribed and adjusted according to the parameters obtained in the CPET. Aerobic continuous training (ACT) of moderate-intensity was carried out for all patients. **Results**: Peak VO2 significantly increased by 9% (15.4 ± 2.7 vs. 16.9 ± 2.6 ml min-1 kg-1, p=.001, d=1.93) after 3 weeks of training. At the same time point, VT1 and VT2 significantly improved by 12% (9.6 ± 2.6 vs. 10.8 ± 3.0 ml min-1 kg-1, p=.005, d=1.43) and 12% (13.5 ± 3.3 vs. 15.0 ± 2.4 ml min-1 kg-1, p=.011, d=1.21). **Conclusion**: A 3-week ACT program is sufficient to induce significant functional adaptations visible in VO2 peak and VO2 improvements at VT1 and VT2 in patients with HF, provided that patients are trained at the same volume but at an individually defined intensity. Further research is needed to define if volume or intensity (ACT vs HIIT, High-Intensity Interval Training) is the key parameter that induces significant functional improvements in CAD patients with HFrEF in 3-week CR.

Diana Rudan, Tomo Svaguša, Marta Puškadija, Stipe Radoš, Šime Manola

**Introduction**: The primary goal of this retrospective study was to assess the use of Multi-Slice Computed Tomography (MSCT) coronary angiography in comparison with conventional invasive coronary angiography for the detection of significant coronary artery disease (CAD) at Dubrava University Hospital over a one-year period. **Patients and Methods**: From February 2022 to February 2023, 283 patients with symptoms of coronary artery disease were scheduled to undergo MSCT coronary angiography; however, 12 were found to have contraindications for the procedure due to arrhythmia and chronic kidney disease. **Results**: In total, CT coronary angiography was performed on 271 patients, of whom 86 tested positive for coronary artery disease and required conventional coronary angiography. Notably, only 36% (31 patients) had significant coronary disease that necessitated intervention or functional assessment of coronary stenosis. **Conclusion**: Although MSCT coronary angiography is a non-invasive and cost-effective method for evaluating coronary artery disease—with the added advantage of imaging plaque compositions—it demonstrated a tendency to overestimate the degree of stenosis, leading to false-positive results. (1) Consequently such overestimations can result in unnecessary follow-up procedures, increased healthcare costs, and potential patient anxiety.

Aida Mujaković, Edin Begić, Belma Paralija, Besim Prnjavorac, Ada Đozić, Nejra Mlačo-Vražalić

**Introduction:** In individuals with chronic obstructive pulmonary disease (COPD), evaluating the severity of hypercapnia and/or acidosis following the start of non-invasive ventilation (NIV) is a key predictor of NIV failure. (1) This study sought to investigate how arterial hypertension affects the treatment outcomes of patients admitted for COPD exacerbation. **Patients and Methods:** This prospective study involved 80 patients who were divided into two groups of 40, based on the mode of non-invasive ventilation (NIV): CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure). A 1:1 randomization approach was employed to determine the NIV mode for each patient. The research took place at the General Hospital “Prim. Dr Abdulah Nakaš” in Sarajevo and included patients admitted to the Non-surgical Intensive Care Unit with a history of chronic hypercapnic respiratory failure (HRF) related to one of the three COPD phenotypes. **Results:** The average age of patients on BiPAP was 66.6 ± 8.6, while for CPAP it was also 66.6 ± 8.6. There were no significant differences in the use of ACE inhibitors, beta-blockers, diuretics, or vasodilators between the two patient groups. In the BiPAP group, the impact of arterial hypertension on the reduction of pCO2 compared to admission was not observed. The chi-square test demonstrated that in the CPAP group, arterial hypertension did influence the reduction of pCO2 compared to admission (p=0.019). **Conclusion:** Arterial hypertension significantly affects the efficacy of both NIV modalities concerning a single outcome – the reduction of pCO2. The absence of hypertension enhances the positive effect of BiPAP on lowering pCO2. In the BiPAP group, the influence of arterial hypertension on the reduction of pCO2 compared to admission was not evident. In the CPAP group, arterial hypertension significantly correlated with a more frequent reduction of pCO2 compared to patients without arterial hypertension.

Nikola Verunica, Ivana Smoljan, Gordana Bačić, Josip Aničić, Davorka Lulić, Nikola Pavlović, Vjekoslav Tomulić

**Introduction**: In patients with severe tricuspid insufficiency who are not candidates for surgery due to age or comorbidities, caval valve implantation (CAVI) has been available recently as a therapeutic option (1). Two valves are implanted in the upper and lower vena cava to reduce the symptoms of right-sided heart failure. Patients with liver cirrhosis are prone to bleeding complications, especially abdominal, due to portal hypertension and coagulopathy (2). **Case report**: 81-year-old woman with chronic heart failure, secondary pulmonary hypertension, permanent atrial fibrillation and severe tricuspid insufficiency was admitted to the Clinic for planned CAVI. In addition, the patient has cardiac cirrhosis and ischemic heart disease. The necessary image processing was done pre-procedurally, and the patient had no contraindications (EFLV >45%, Child-Pugh Score B, NYHA III, RSVP 55mmHg, TAPSE >13mm). The patient was anticoagulated with intravenous heparin during the procedure, and target ACT values were >250. A control venogram did not reveal a significant paravalvular leak. At the puncture site of the right femoral vein, hemostasis was achieved using a combination of a closure device and a “Z” suture. On the left side, hemostasis was achieved by manual compression. The early post-procedural course was complicated by left paraumbilical swelling of the abdominal wall, severe pain, hypotension and a significant drop in the red blood count. Urgent MSCT of the abdomen and pelvis verified an extensive extraperitoneal hematoma in the pelvic area and large intramuscular hematomas of both rectus abdominis muscles. Immediate exploratory laparotomy was performed, which showed no active bleeding from puncture sites. Hematomas were evacuated, and both femoral veins were sutured. The patient was sedated and mechanically ventilated and underwent standard treatment for hemorrhagic shock. A “second look” surgery was carried out three days later, and no active bleeding was found. Unfortunately, further hemodynamic instability ensued, and the patient died five days after the procedure. **Conclusion**: In patients with severe tricuspid insufficiency and cirrhosis-related coagulopathy, standard intraprocedural anticoagulation for CAVI and postprocedural venous blood pressure rise can lead to severe spontaneous intra-abdominal bleeding (3).

Alen Ružić

**Introduction:** There is very limited literature on the impact of bicuspid aortic valve (BAV) on pregnancy outcome despite the potential critical importance of this disorder. The importance of the topic becomes even more emphasized if we take into account a number of possibilities: cases of known or newly diagnosed BAV in pregnancy, differences in the functional status of the aortic valve during pregnancy, and the presence and degree of progression of aortopathy. (1-3) **Material and Methods:** Relevant international scientific databases search were conducted to find original scientific papers, registries, meta-analyses and review papers on BAV in pregnancy that were published in the last 20 years. **Results:** BAV in pregnancy can cause life-threatening cardiovascular events, among which aortic dissection stands out, although the development of valvular dysfunction or acute endocarditis should not be neglected. All acute complications of BAV in pregnancy potentially threaten maternal outcome or fetal demise. In the review of data from the literature, we provide key data on recommendations for diagnostic follow-up, recommendations for possible interventions in case of strict indications such as severe aortic stenosis, aortic regurgitation or aortic dissection, as well as elaboration of approaches in birth of a child planning. **Conclusion:** According to currently available scientific data, it is crucial to individualize the approach to pregnant women with BAV in all phases, from diagnosis, individual counseling, detailed diagnostic monitoring, to planning the necessary cardiovascular interventions to optimal preparation and management of child delivery.

Petra Bistrović, Tomislav Čikara, Dijana Bešić, Marin Viđak, Marija Radić, Fran Rode, Martina God, Marko Galić, Klara Pospiš, Sara Varga, Merljinda Ljušaj, Dominik Buljan, Fran Šaler, Šime Manola, Ivana Jurin

**Introduction**: Elevated lipoprotein a [Lp(a)] levels are strongly associated with adverse cardiovascular events. (1) It is commonly believed that Lp(a) does not change throughout a person’s lifetime and is not affected by oral hypolipidemic therapies. With novel therapies targeting elevated Lp(a), such as inclisiran and pelacarsen, research has been expanding, including observations of intrapersonal variability, impact of comorbidities and regional Lp(a) differences on cardiovascular health, thus putting into question prior beliefs. Our goal is to establish frequency of elevated Lp(a), Lp(a) levels in subgroups of patients undergoing coronary angiography and its relationship to sociodemographic and clinical characteristics. **Patients and Methods**: Our study included 119 patients who underwent coronary angiography at Dubrava University Hospital from July to October 2024. **Results**: Median age was 62 years, the majority were male (76.5%) and had acute coronary syndrome (70.3%). Lp(a) was drawn at admission, median level was 29,85 nmol/L (IQR 10.5-142.6). Elevated Lp(a) was detected in 37 (31.1%) patients (cut off value 105). We compared Lp(a) levels according to patients’ sociodemographic and clinical characteristics. There was no significant difference in Lp(a) levels in any of the subgroups, however we noticed some trends. Median Lpa was higher in patients under 65 years (40 vs 27), women (41 vs 27), nonsmokers (36 vs 30 for smokers and 13 for ex-smokers), family history of cardiovascular events (46 vs 27), chronic obstructive pulmonary disease (114 vs 30) and left main affection (42 vs 27). Interestingly, Lp(a) was lower in acute coronary syndrome versus chronic (33 vs 106) and chronic total occlusion (33 vs 22). Lp(a) was also lower in patients with prior comorbidities typically associated with elevated cardiovascular risk – arterial hypertension (24 vs 62), stroke (20 vs 36), diabetes mellitus (22 vs 42) and peripheral artery disease (21 vs 37). Lower Lp(a) levels were also measured in patients with prior statin therapy (20 vs 40). **Conclusion**: Although there was no significant difference in Lp(a) levels between the subgroups, some interesting trends were observed that might put prior knowledge of Lp(a) to test. As we include more patients, we plan to further expand our research on Lp(a) and its effects on long term outcomes in follow up.

Nikolina Slamek, Ivica Benko, Mateja Lovrić, Ivan Zeljković, Mirela Adamović, Marija Grlić, Marina Žanić, Mario Tomašević, Ivan Horvat

**Introduction:** Crucial aspect of invasive electrophysiology procedures is the safe and effective closure of venipuncture sites. (1, 2) The Z-stitch is a relatively novel method designed to achieve faster and more effective haemostasias compared to manual compression, which is now rarely used. It allows patients to ambulate six hours post-procedurally and, in the absence of contraindications, be discharged the following day. The Z-stitch is employed in electrophysiology procedures during which the unfractionated heparin was used. However, it has potential drawbacks, including localized skin trauma, patient discomfort, and hematoma formation. A possible complication is the damage of the venous introducer sheath during the Z-stitch placement. **Case report:** This case presents a 36-year-old patient hospitalized due to recurrent wide-QRS complex tachycardia. During hospitalization, an electrophysiology study and radiofrequency ablation were performed successfully. However, during the placement of the Z-stitch, to be exact during the removal of the 5Fr venous introducer, the introducer sheath was damaged, likely caused by needle trauma during the Z-stitch placement. X-ray imaging confirmed that the introducer’s segment was located subcutaneously, but not intravascularly. After localizing the segment, a 5 mm skin incision was made, and the segment was surgically removed. A skin suture was placed at the incision site, and the venipuncture site was closed using a Z-stitch. The complication was exacerbated by the simultaneous removal of all venous introducers, which should ideally be removed individually, starting with the larger ones. This method minimizes complications and allows for easier detection of introducer damage by the operator and the assistant. **Conclusion:** The collaboration of the medical team plays a critical role in preventing complications. If complications arise, prompt and appropriate intervention can resolve them without lasting harm to the patient. Continuous education of medical staff is essential to ensure procedural safety. This case underscores that the risk of complications extends beyond the procedure itself and can occur at any stage, from the initial intervention to the patient’s discharge.

Livija Sušić, Matea Lukić, Ana Matijević, Ksenija Lukić

**Introduction**: According to data from the European Resuscitation Council (ERC) from 2021, the incidence of out-of-hospital cardiac arrest (OHCA) in European countries was between 67 and 170 per 100,000 inhabitants with an average survival rate of 8%. The European country with the highest OHCA survival rate of 25% is Norway, where the cardiopulmonary resuscitation (CPR) course has been an integral part of the national school curriculum since 1961. (1-3) Aim: To examine general knowledge about recognizing emergency situations and the correct procedure for performing CPR among high school students and teachers in the General Gymnasium in Valpovo, Croatia. **Patients and Methods**: A cross-sectional study was conducted with 47 teachers and 47 students in the second grade. An anonymous survey containing 10 questions with 4 proposed answers was used, and the number of correct answers was unknown. **Results**: Knowledge of the etiology of cardiac arrest and the purpose of CPR is unsatisfactory among both teachers and students (2% of teachers vs 0% of students answered correctly). Teachers achieved better results in questions about the EpiPen mechanism of action (51% compared to 17% of students), accurate localization of pulse palpation in unconscious persons (68% compared to 60% of students) and recognition of situations in which emergency medical help should be called (38% compared to 26% of students), while the students achieved better results regarding the correct ratio of heart massage and ventilation during the CPR procedure (38% compared to 15% of teachers). Knowledge of proper handling of an unconscious person was satisfactory in both observed groups. **Conclusion**: First aid and CPR courses should be understood as lifelong learning programs that should be implemented at a young age and repeated regularly. As a result, the survival rate of OHCA would increase.

Matko Spicijarić, Tomislav Jakljević, Vjekoslav Tomulić

**Introduction**: Coronary artery anomalies (CAA) are congenital conditions that include an unusual origin, flow, or termination of the coronary artery (1). They are usually incidental findings on cardiac imaging or autopsy. According to earlier research, CAA appears in less than 1% of the general population (2) but is, therefore, present in about 17% of sudden cardiac deaths (SCD) in younger athletes (3). **Case report**: 71-year-old patient came to the Emergency Department of University Hospital Centre Rijeka due to chest pain that had been present for the past three hours. The pain was spreading to the left arm, accompanied by nausea and sweating. Arterial hypertension, chronic obstructive pulmonary disease, and smoking were present in the earlier medical history. The 12-lead electrocardiogram (ECG) was performed immediately, and posterior and lateral ST-segment elevation with atrial fibrillation of unknown duration was detected (**Figure 1**). Point of care echocardiography showed hypokinesia of the base and inferolateral wall. An emergency coronary angiography was performed, which initially showed atherosclerotic changes in the left anterior descending (LAD) and right coronary artery (RCA). Non-selective angiographic contrast injection near RCA origin revealed a trace that suggested the existence of an anomalous left circumflex artery (LCx) and acute occlusion of its origin. The culprit lesion was crossed with a guide wire, and pre-dilatation was performed with a Traveler balloon catheter (2.5 x 20 mm). Furthermore, two drug-eluting stents (2.5 x 19 mm and 2.5 x 13 mm) were implanted. The optimal effect was achieved with TIMI 3 flow (**Figure 2**). In the further course, the patient was without complaints, triple therapy was initiated due to atrial fibrillation, and ultrasound described a mildly reduced ejection fraction of the left ventricle, with hypokinesia as stated earlier and no significant valvular pathology. The follow-up examination was in six months and one year; recovery went well, and the patient had no complaints. FIGURE 1. Posterior and lateral ST-segment elevation with atrial fibrillation. FIGURE 2. Before and after successful percutaneous coronary intervention in the anomalous circumflex artery. **Conclusion**: In acute coronary syndrome, early detection and localization of CAA are crucial for successful treatment. Present coronary arteries and ECG findings can indicate which irrigation area is in ischemia. Also, non-selective contrast injection can be beneficial in distinguishing what is missing.

Viktor Peršić, Kristina Skroče, Dijana Travica-Samsa, Ana Brajdić Šćulac, Viktor Ivaniš, Ivana Peršić, Marina Njegovan, Koraljka Knežević

**Goal:** This presentation aims to explore the evolving landscape of cardiac rehabilitation (CR) through innovative technologies and personalized treatment approaches for patients with cardiovascular diseases. Moreover, we aim to compare outcomes in myocardial infarction survivors participating in outpatient and inpatient CR programmes. **Patients:** The focus is on individuals diagnosed with various cardiovascular conditions who require rehabilitation to enhance their health outcomes and quality of life. Results related to cardiopulmonary testing, blood analysis and quality of life obtained from a multidisciplinary team of experts will be presented. **Methods:** Key innovations such as telemedicine, health tracking applications, and the formation of multidisciplinary teams are analyzed. The presentation emphasizes the importance of individualized exercise and nutrition programs, alongside the integration of psychosocial support, to create a comprehensive rehabilitation experience. **Conclusion:** The adoption of modern technologies and personalized approaches in cardiac rehabilitation is transforming patient care, leading to improved outcomes and enhanced well-being. By embracing a holistic methodology, healthcare providers can better address the unique needs of each patient. (1, 2) If organized properly, outpatient and inpatient CR programmes might lead to similar outcomes.

Hrvoje Falak, Mario Udovičić, Danijela Grizelj, Mate Car, Mariam Samara, Ana Jordan, Vanja Ivanović Mihajlović, Petra Vitlov, Diana Rudan, Šime Manola

**Introduction:** Atrial fibrillation (AF) is the most common arrhythmia in the general population and represents a significant public health problem worldwide leading to an increased risk of stroke, heart failure, dementia, and mortality (1, 2). **Patients and Methods**: Using the hospital information system, we exported data as spreadsheets from the inpatient lists, protocol books, and a list of e-diagnoses based on ICD-10 classification for the 10-year period from 2007 to 2016 using information reporting options. We then integrated all these datasets into a single database, filtering only patients who were alive in January 2017 and residing in the service area of our hospital. AF patients were identified and regional age-and gender-specific prevalence was established using regional census data from the 2011. For long-term projections, we calculated expected numbers and prevalence rates of AF for Croatia in 2061, assuming a constant prevalence in specific age and gender groups. Population projections were based on estimations from the Croatian Bureau of Statistics, using assumptions of low fertility and low immigration levels (3). **Results:** According to our data, regional AF prevalence on January 1, 2017 was 2.0%. Based on population estimate and regional age-and gender-specific prevalence rates, AF prevalence for Croatia in 2061 is projected to be 4.72% (5.69% for men and 3.79 for women) (**Figure 1**). FIGURE 1. Estimated prevalence of atrial fibrillation in Croatia in 2061. **Conclusion:** This epidemiological study demonstrates increasing trends in AF prevalence. The data should highlight the importance of risk mitigation, healthcare planning, and cost management.

Maja Štrajtenberger, Hrvoje Ružić, Vanja Nedeljković, Lara Nađ Bungić

**Introduction**: Dyspnea and chest pain are common symptoms affecting 25% patients in ambulatory setting and can be caused by many underlying conditions which can sometimes present a clinical challenge. Symptoms associated with cardiac myxomas are typically because of the tumor mass obstructing a normal blood flow within the chambers of the heart. More than 75% of myxomas originate in the left atrium either at the mitral annulus or the fossa ovalis border of the interatrial septum; 20% arise from the right atrium while 5% stem from both atria and the ventricle. Atrial myxomas are usually associated with a triad of complications, including obstruction, emboli, and constitutional symptoms. (1-3) **Case report**: 44-year-old woman was referred for a cardiology examination due to persistent shortness of breath and progressive intolerance on physical exertion over the past 3 years with everyday chest discomfort for the past few months. Her past medical and family history are unremarkable, reporting only the tendency to anxiety and panic attacks. Occasionally she felt palpitations, but earlier electrocardiographic findings corresponded to sinus tachycardia. Physical examination revealed normal vital signs and a systolic murmur in her left axillary line. Laboratory findings showed an elevated heart failure marker (NT-proBNP 359 ng/L). Echocardiography revealed a dilated left atrium (LAVI 59 ml/m2) almost filled with a tumor mass (58 x 53 mm) attached by a stalk to the interatrial septum (**Figure 1**). During diastole the tumor was pushed into the left ventricle through the mitral valve creating high transmitral flows causing a functional stenosis. Other cavities were of regular dimensions and function with no described indirect signs of pulmonary hypertension. MSCT coronary angiography finding was normal as well as color doppler of the carotid and vertebral basin. A median sternotomy was performed, and the tumor was completely removed. The pathohistological finding of the extirpated mass corresponded to myxoma and immunohistochemically the tumor cells were positive for calretinin. Postoperative care was eventless. In further outpatient follow-ups, she was subjectively symptom-free with an excellent recovery of functional status and echocardiography showed no signs of disease relapse (**Figure 2**). FIGURE 1. Myxoma filling the left atrium (preoperatively). FIGURE 2. Postoperatively image without visible myxoma. **Conclusion**: Primary cardiac tumors are extremely rare and usually benign. Most common are myxomas and they usually appear between the fourth and seventh decades of life. Approximately 20% are asymptomatic but can cause all kind of symptoms such as shortness of breath, chest pain, arrhythmias, syncope, fever, malaise, weight loss or can be the cause of a sudden death. Upon diagnosis, surgical resection is typically indicated and the gold standard method for confirming the diagnosis of myxoma is pathology. The best method for detection is echocardiography which is widely available, noninvasive and it allows a quick and sufficiently accurate evaluation of the morphology, involvement of valve leaflets, and functional obstruction of the LV outflow tract. Myxomas have been reported to grow at a rate of 0.15 - 2 cm each month so surgical excision should be performed as soon as the diagnosis is confirmed.

Marija Brestovac, Blanka Glavaš, Sandra Jakšić Jurinjak, Vlatka Rešković Lukšić, Martina Lovrić Benčić, Marijan Pašalić, Jadranka Šeparović Hanževački

**Introduction:** Significant aortic regurgitation (sAR) results in left ventricle (LV) remodeling and LV dysfunction due to chronic pressure and a volume overload. Timing of surgical intervention is defined by left ventricle ejection fraction (LVEF) 50 mm. (1, 2) The aim of this study was to investigate if there is difference in LV positive remodeling after AV surgery, according to LVEF above cut of value (EF>50%) at the timing of surgery. **Patients and Methods:** We retrospectively analyzed echocardiographic (ECHO) database for 52 patients (pt) who underwent aortic valve surgery (AVR) from January 2017 to April 2021 due to sAR, in UHC Zagreb. Preoperative ECHO data as well as during follow-up (FU) were analyzed. The study population was divided in three groups according to initial LVEF values: group (I) included 17 pt with EF>60% (mean age 54+/-9.4), group (II) 16 pt with EF 50-60% (mean age 52+/-15.7) and group (III) 19 pt with EF2) and left ventricular internal dimension at end-systole (LVIDs, mm) were compared prior surgery and in the mean FU time of 38 months. **Results:** The change in absolute values of ECHO parameters and their calculated mean change are shown in **(****Figure 1****)** and **(****Table 1****)**. Preoperatively, group III revealed the highest EDV/ESV/LVIDs values 259.18/148.6/51 compared to group I and II (186.11/76.83/39.6 vs. 182.21/86.8/40.2). During FU after AVR, no difference in reduction in EDV and MM (EDV p=0.115, MM p=0.774) was noticed between the 3 groups, while absolute values almost reached normal ranges only in group I and II (EDV 138.7 in I and 138.8 in II). Importantly, normalization of ESV and LVIDs during FU was shown only in group I and II, while rate of change was highest in group III (ΔESV 40.3, ΔLVIDs 13.5), LVIDs decreased more in more dilated LV (p=0.006) and even though ESV reduced in all three groups, in group III it remained enlarged (p=0.006), as expected. FIGURE 1. Change in absolute values of end-diastolic volume, end-systolic volume, myocardial mass, and left ventricular internal dimension at end-systole after aortic valve surgery in patients surgically treated due to significant aortic regurgitation. ### TABLE 1: Absolute values and calculated change in end-diastolic volume, end-systolic volume, myocardial mass, and left ventricular internal dimension at end-systole in 3 patient groups divided according to ejection fraction prior to aortic valve surgery due to aortic regurgitation. | | **Group** — **EF>60%** — **Mean** | **Group** — **EF>60%** — **Standard Deviation** | **Group** — **50%2); LVIDs = left ventricle end-systolic diameter (mm); p = statistical significance. **Conclusion:** Our results confirmed LV positive remodeling after AVR due to chronic AR, indicating that initial LVEF prior AVR could predict residual LV dilatation despite the reduction in EDV after AVR. In patients with LVEF>60% preoperatively, reversible positive remodeling after AVR may occur with complete normalization of ESV/EDV and LVIDs values during FU.

Lucija Lisica Kordić, Ivan Sikirić, Zrinka Jurišić, Ante Anić, Toni Brešković

**Introduction**: Endocardial vagal denervation, known as cardioneuroablation (CNA), is an emerging treatment option for treating conditions associated with symptomatic periods of increased vagal tone such as refractory vasovagal syncope (VVS), functional atrioventricular block, and sinus node dysfunction (SND) (1). The cornerstone of CNA is targeting groups of autonomic ganglia known as ganglionated plexi (GP) (1). Pulsed field ablation (PFA) is a non-thermal form of energy during which a strong electric field delivered to the underlying tissue leads to the opening of pores on the cell membrane, resulting in the destruction of the cell (2). **Patients and Methods**: Cardioneuroablation was performed in symptomatic patients with proven cardioinhibitory reflex. The procedure was performed in deep sedation with propofol, fentanyl and midazolam. Standard transseptal approach was obtained and 3D electroanatomical mapping of the left atrium was preformed prior to the ablation. The presumed anatomical location of the right superior vagal GP was verified by the delivery of focal PFA lesion in anterosuperior aspect of right superior pulmonary vein ostium. The proximity to the ganglion was verified by the induction of transitory sinus bradycardia after PFA delivery. Once the anatomical position was verified, further ablation was performed using radiofrequency energy. Additional consolidation lesions were applied from the right side of interatrial septum. The ablation was considered successful by the lack of vagal response after repeated PFA delivery at the initial position (**Figure 1**) (3). FIGURE 1. An example of the use of pulse field ablation (PFA)-guided cardioneuroablation (CNA) in one patient. *Panel A*: application of PFA (yellow dot) to the anterior superior ostium of the right superior pulmonary vein causes transient sinus bradycardia, indicating proximity to the right superior vagal ganglion. *Panel B*: set of radiofrequency ablation lesions surrounding the initial PFA application site. *Panel C*: after ablation, application of PFA does not induce sinus bradycardia. **Results**: The PFA-guided CNA was performed in 4 patients. In 2 the indication was SND and in other 2 VVS. Acute endpoint was obtained in all patients. During the median follow up period of 12 months all patients remained symptom free (**Table 1**). ### TABLE 1: Cohort of patients treated with cardioneuroablation guided by pulsed field ablation at University Hospital Centre Split. | **Pt.** | **Sex** | **Age** | **Indication** | **Follow up period (months)** | **Recurrence** | | --- | --- | --- | --- | --- | --- | | 001 | F | 35 | Sinus arrest | 14 | NO | | 002 | F | 40 | Vasovagal syncope | 12 | NO | | 003 | M | 42 | Vasovagal syncope | 12 | NO | | 004 | M | 44 | Sinus arrest | 1 | NO | **Conclusion**: A PFA-guided CNA is a safe procedure with promising acute success rate and could be the treatment option for patients with pronounced drug-refractory cardioinhibitory reflex. Larger randomized studies are warranted to assess the procedural success rate and further optimize ablation strategy.

Rina Dalmatin Kršćanski, Manuela Balaban Kumpare, Ivana Šmit, Danijela Raušl Malagić, Krešmir Milas

**Introduction**: S. salivarius is a gram-positive bacterium which primarily and predominantly colonizes oral cavity and intestines but is also proven to have infectious capacity. It is a member of viridans bacteria species which cause 40% of endocarditis but it is important to note that S. salivarius alone causes bacterial endocarditis in only 2% of cases (1, 2). **Case report**: 28-year-old patient is hospitalized in General Hospital (GH) Pula because of the 3-week long febrility. In 2015 the patient was diagnosed with the posterior mitral cusps prolapse with moderate to severe mitral regurgitation and atrial septal defect with left-to-right shunt. An operation was suggested but the patient was not prone to it. Echocardiography verified the diagnosis of endocarditis of both mitral cusps with severe mitral regurgitation. An MSCT of the abdomen showed splenic and renal infarct. The next day the patient was transferred to University Hospital (UH) “Dubrava” Zagreb where he underwent a mechanical mitral valve replacement surgery on July 15, 2024. The operation went well and the patient was transferred back to GH Pula. During the hospitalization the patient indicated the pain in the lower abdomen and constipation. The MSCT of the abdomen revealed newly grown porta hepatis mass. On July 31, 2024 the patient was transferred to UH “Merkur” Zagreb. Due to the decline in liver function and the occurrence of encephalopathy a request was sent to Eurotransplant asking to categorize this patient as high-urgency for liver transplant. The liver transplant was done on August 3, 2024. **Conclusion**: A patient with mitral cusps prolapse, prolonged febrility, and confirmed bacterial infection is at risk of endocarditis. The patient in question had 1 major and 3 minor Duke Criteria that clearly indicated infective endocarditis. Although S. salivarius rarely causes endocarditis, we must not forget it is potentially very infectious for cerebrovascular, cardiovascular, musculoskeletal, and gastrointestinal system (3).

Petra Bistrović, Miroslav Raguž, Ante Lisičić, Tomislav Šipić, Petra Vitlov, Tomislava Bodrožić-Džakić Poljak, Katarina Bistrović, Ivan Zeljković, Šime Manola, Irzal Hadžibegović, Ivana Jurin

**Introduction**: Chronic inflammation has been associated with adverse long-term outcomes in transcatheter aortic valve implantation (TAVI) patients, however no specific markers have yet been validated. (1) Previous research has shown a potential impact of RDW/albumin (RAR) and CRP/albumin (CAR) on mortality and complications in diseases such as myocardial infarction and COVID-19. Research on these parameters is scarce in chronic diseases, and so far RAR and CAR have not been studied in TAVI patients. The aim of our research is to determine if RAR and CAR have effects on survival and complications post-TAVI. **Patients and Methods**: Our study included 547 patients who underwent TAVI at Dubrava University Hospital from 2012 do 2024, followed to present date. RDW, CRP and albumin were collected through routine blood samples drawn at admission. Using ROC analysis, we determined cut-off values for RDW/albumin (0.35) and CRP/albumin (0.08). Primary outcome of the study was all-cause death in follow up and secondary outcome was major adverse cardiac event (MACE) in follow up. Data was collected through in-person visits and telephone check-ups. **Results**: Sociodemographic and clinical characteristics of the patients are shown in **Table 1**. Median RAR was 0.35 (IQR 0.32-0.40), while median CAR was 0.08 (IQR 0.03-0.17). Our analysis showed a significant difference in survival post-TAVI in patients with elevated RAR (14 vs 45 months, P 0.001; HR 2.61, 95% CI 1.79-3.82) and CAR (15 vs 23 months, P 0.017; HR 1.55, 95% CI 1.08-2.24). There was no difference in MACE during follow-up in either group. ### TABLE 1: Patient characteristics. | **Variable** | **All patients** | **CRP/albumin =0.08** | **P value** | **RDW/albumin=0.35** | **P value** | | --- | --- | --- | --- | --- | --- | --- | --- | | Age (years) | 80 (76-83) | 80 (77-84) | 80 (75-83) | 0.016* | 80 (76-83) | 80 (76-84) | 0.308 | | Male | 289 (51.6%) | 161 (53.3%) | 119 (49.4%) | 0.363 | 147 (56,5%) | 133 (47.2%) | 0.029* | | Diabetes mellitus | 207 (37%) | 106 (35.1%) | 97 (40.4%) | 0.204 | 88 (33.8%) | 115 (40.9%) | 0.090 | | Arterial hypertension | 489 (87,3%) | 261 (86.4%) | 211 (87.6%) | 0.699 | 230 (88.5%) | 242 (85.8%) | 0.359 | | Cerebrovascular insult | 55 (9.8%) | 26 (8.6%) | 27 (11.3%) | 0.304 | 25 (9.6%) | 28 (10%) | 0.891 | | COPD | 68 (12.1%) | 29 (9.6%) | 39 (16.2%) | 0.021* | 27 (10.4%) | 41 (14.5%) | 0.145 | | eGFR (ml/min/1.73m2) | 56.8 (41.2-73.0) | 60.3 (44.8-73.5) | 52.6 (36.2-71.9) | 0.001* | 59.7 (44.9-72.8) | 53 (36.7-72.7) | 0.015* | | Atrial fibrillation | 228 (40.7%) | 111 (36.8%) | 112 (46.5%) | 0.022* | 88 (33.8%) | 135 (47.9%) | 0.001* | | Hemoglobin (mg/dl) | 128 (116-138) | 130 (119-139) | 125 (112-136) | 0.003* | 133 (124-143) | 121 (109-133) | 0.001* | | Hematocrit (%) | 39 (35-42) | 39 (36-42) | 38 (34-41) | 0.011* | 40 (37-43) | 37 (34-41) | 0.001* | | Platelets (10^6) | 206.5 (166.5-252.0) | 193 (164-230) | 224 (172-279) | 0.001* | 207 (168-248) | 206 (166-258) | 0.770 | | CRP (mg/L) | 2.9 (1.3-7.0) | 1.5 (0.9-2.4) | 8.00 (4.88-16.00) | 0.001* | 2.1 (1.0-4.5) | 4.0 (1.9-11.2) | 0.001* | | RDW (%) | 14.4 (13.7-15.7) | 14.2 (13.6-15.3) | 14.9 (14.1-16.2) | 0.001* | 13.8 (13.4-14.3) | 15.7 (14.6-16.9) | 0.001* | | Serum albumin (g/L) | 41 (39-44) | 42 (40-44) | 39 (37-43) | 0.001* | 43 (42-45) | 39 (37-41) | 0.001* | | NTproBNP (pg/nl) | 2280 (761-5508) | 1452 (561-3873) | 3919 (1169-8854) | 0.001* | 1372 (546-3569) | 3164 (1015-8036) | 0.001* | | PAD | 197 (35.2%) | 103 (34.2%) | 91 (37.8%) | 0.393 | 99 (38.2%) | 95 (33.7%) | 0.272 | | Coronary artery disease | 106 (20.3%) | 60 (21.4%) | 43 (19%) | 0.505 | 53 (21.7%) | 50 (19.2%) | 0.475 | | LVEF (%) | 55 (45-60) | 58 (50-63%) | 55 (40-60) | 0.001* | 59 (50-65) | 54 (40-60) | 0.001* | | meanPG (mmHg) | 47 (38-59) | 47 (40-59) | 46 (36-59) | 0.2844 | 48 (40-59) | 46 (37-58) | 0.106 | | RDW/albumin | 0.35 (0.32-0.40) | 0.34 (0.32-0.37) | 0.38 (0.34-0.44) | 0.001* | 0.32 (0.31-0.34) | 0.40 (0.37-0.82) | 0.001* | | CRP/albumin | 0.07 (0.03-0.17) | 0.04 (0.02-0.06) | 0.19 (0.12-0.41) | 0.001* | 0.05 (0.02-0.11) | 0.10 (0.05-0.28) | 0.001* | [†] Numerical values are displayed as median and interquartile range. Categorical values are displayed as numbers and percentages. *Denotes statistical significance, P<0.05; COPD-Chronic obstructive pulmonary disease; eGFR-estimated glomerular filtration rate; CRP-C reactive protein; Red cell distribution width; PAD-Peripheral atherosclerotic disease; LVEF-Left ventricular ejection fraction; meanPG-Mean pressure gradient. **Conclusion**: CAR and RAR are derived from parameters used in routine practice that can be easily utilized and have the potential to be used as predictive markers of survival post-TAVI. Further research is neccessary to establish exact cut-off values for TAVI patients, allowing for use in clicinal practice, which in turn could impact how we treat patients at risk.

Marija Radić, Irzal Hadžibegović, Daniel Unić, Savica Gjorgjievska, Ivan Skorić, Aleksandar Blivajs, Nikola Pavlović, Ana Jordan, Vanja Ivanović Mihajlović, Šime Manola, Ivana Jurin

**Introduction:** Decreased cardiac output (CO) because of aortic stenosis (AS), as well as ageing, atherosclerosis, diabetes, and hypertension, are risk factors involved in cognitive impairment (CI). (1) CI is one of the major components of quality of life (QoL) and therefore both should be assesed during the decision process regarding the best treatment option. This study investigates the QoL outcomes following Transcatheter aortic valve implantation (TAVI), hypothesizing that while survival is enhanced, QoL outcomes may vary, influenced by factors such as post-TAVI hospitalizations and the prevalence of cognitive impairment or decline. **Patients and Methods**: This prospective observational study included 395 patients who were followed over a 1-year period post-TAVI. QoL was assessed using KCCQ overall score, categorizing patients into three groups: improved, unchanged or worsened. The prevalence of cognitive impairment using the Mini-Mental Status Examination (MMSE) was also evaluated to explore its impact on patient recovery and post-procedural QoL. Data were collected through medical record reviews and follow-up telephone interviews. **Results**: Among 395 patients analyzed, 65% reported an improvement in their quality of life, 27% experienced no change and 8% experienced a decline after one year. Cognitive impairment was present in 38% patients before TAVI. Mortality rates were significantly higher among patients with worsened QoL (65.5%) compared to those with unchanged (35.4%) and improved (15.2%) QoL. Hospitalization rates were elevated among patients with unchanged (67.8%) or worsened QoL (42.8%). Furthermore, 12.35% of patients were diagnosed with deterioration of cognitive impairment, which was associated with poorer QoL outcomes and higher hospitalization rates. **Conclusion**: These findings suggest that 35% patients report no change or even experience worsening of QoL after TAVI. Although recent advancements have substantially increased survival rates after TAVI, patients may not fully benefit from TAVI despite a technically successful procedure. This highlights the need for careful evaluation of patients before the procedure and to determine those who are more suitable candidates for palliative care.

Petra Vitlov, Petra Bistrović, Hrvoje Falak, Vanja Ivanović Mihajlović, Mario Udovičić, Danijela Grizelj, Šime Manola

**Introduction**: Low flow-low gradient aortic stenosis (LFLG AS) with preserved left ventricular ejection fraction (LVEF), also called “paradoxical” LFLG (PLFLG) is defined as AS with a mean gradient (mean PG) 2 with preserved LVEF (>50%) but stroke volume index (SVi) 2. (1, 2) Even after exclusion of measurement errors and other potential causes of the echocardiographic findings, diagnosing true severe AS in these patients still remains a challenge. Given that prior studies have shown worse prognosis in PLFLG severe AS patients compared to those with moderate AS and true severe AS, it is crucial to establish the correct diagnosis. (3) **Case report**: 76-year-old female patient was referred to our institution due to symptoms of stable angina and echocardiographic parameters of severe LFLG AS with preserved LVEF. Coronary angiography revealed a subtotal proximal LAD stenosis. Initially, surgical aortic valve replacement and a LAD-LIMA bypass were planned. However, after revaluation, due to borderline calculated AVA of 1 cm2, peak aortic valve velocity 3 m/s, mean PG 21 mmHg, and SVi 32 ml/m2, further tests were necessary before potential surgery. After confirming low flow state, AVA of 1.4 cm2 was measured using transesophageal planimetry. Also, the aortic valve calcium score of 250 was calculated through computed tomography, thus excluding severe AS. Patient underwent percutaneous coronary intervention with successful LAD stenting using provisional technique and will be followed up regularly for AS progression. **Conclusion**: PLFLG AS remains a challenging diagnosis. Even with additional testing, such as dobutamine echocardiography, it is unclear how to optimally distinguish pseudosevere and true severe AS. Transesophageal valve planimetry and quantification of valve calcification may add important information in this context. In any case, severe AS must be carefully confirmed before deciding on intervention.

Luka Antolković, Marin Pavlov, Aleksandar Blivajs, Anđela Jurišić, Nikola Pavlović, Tomislav Šipić, Irzal Hadžibegović, Nikša Bušić, Petra Vitlov, Mario Udovičić, Danijela Grizelj, Domagoj Kobetić, Fran Rode, Tomo Svaguša, Šime Manola, Ivana Jurin

**Introduction:** Statins play a crucial role in the secondary prevention of cardiovascular events; however, patient adherence remains suboptimal. This study aimed to evaluate adherence to statin therapy and its impact on LDL cholesterol levels at 12 and 24 months post-myocardial infarction. (1) **Patients and Methods:** This retrospective cohort study included 1,521 patients treated for acute myocardial infarction at our institution from January 1, 2017, to August 1, 2023. Adherence scores were assigned during outpatient visits or telephone follow-ups. Additional data on cholesterol levels, medications, and comorbidities were obtained from electronic health records. Patients were categorized into three groups: highly adherent, moderately adherent, and non-adherent. Statistical analyses were performed using the Mann-Whitney U test for continuous variables and the Chi-square test for categorical variables. **Results:** The adherent cohort was significantly younger (mean age: 66 vs. 62 years, p < 0.0001) and had a lower prevalence of diabetes (39.6% vs. 25.7%, p < 0.0001). Baseline LDL cholesterol levels were similar across groups (3.2 mmol/L in non-adherent vs. 3.4 mmol/L in moderately adherent and 3.5 mmol/L in highly adherent). After 12 months, all groups showed a significant reduction in LDL levels (p < 0.0001), with values of 2.6 mmol/L in non-adherent, 2.3 mmol/L in moderately adherent, and 1.8 mmol/L in highly adherent patients. The adherent group had a greater decrease in LDL after 12 months and continued to show reductions at 24 months (2.2 mmol/L vs. 2.0 mmol/L vs. 1.7 mmol/L). Notably, 59.5% of adherent patients reached target LDL levels after 12 months. **Conclusion:** These results highlight the importance of adherence to lipid-lowering therapy in achieving target LDL cholesterol levels. Prioritizing patient adherence is essential before introducing new hypolipidemic agents. Further research is needed to explore the relationship between adherence and patient survival outcomes.

Nikola Slišković, Gloria Šestan, Davor Barić, Daniel Unić, Josip Varvodić, Marko Kušurin, Savica Gjorgjievska, Ivana Jurin, Danijela Grizelj, Dubravka Šušnjar, Zrinka Šafarić Oremuš, Nikola Bulj, Igor Rudež

**Introduction**: The aortic root is a complex structure connecting the heart to systemic circulation that ensures intermittent, unidirectional channeling of large volumes of fluid while maintaining minimal resistance, and the least possible tissue stress during varying hemodynamic demands. When any component of the aortic root fails, the intricacy of this structure highlights the importance of reparative surgical techniques that preserve its functionality and anatomy (1). Continuing research in this field is leading to improved surgical techniques with the goal of aortic valve repair becoming the new standard for patients suffering from AI and/or aortic root dilatation (2). We report our 10-year experience with adult aortic valve repair. **Patients and Methods**: Between 2014 and 2024, a total of 180 patients with AI with/without aortic root dilatation underwent aortic valve repair performed by a single surgeon. All the patients were included in the AVIATOR database and the transthoracic echocardiography examinations were reported during follow-up period. **Results**: In baseline characteristics, mean age was 50.8±13.5 years and 82.7% of patients were males. Regarding the number of leaflets, majority of patients were in TAV group (52%), with 3% quadricuspid and 1% unicuspid. BAV patients were significantly younger, with narrower roots at the level of SV and STJ. No other major differences were observed. There were no deaths during the hospital stay and 7 patients died in the follow-up period with none of the deaths cardiac- related. Intraoperative conversion to valve replacement due to insufficient repair was necessary in 7 patients. Overall, 10 patients required reoperation – 3 in the early postoperative period and 7 in the later phases, resulting in a freedom from reoperation rate of 94.2% at 10 years. **Conclusion**: Valve-sparing aortic root surgery is both challenging and demanding, yet it offers remarkable rewards, yielding excellent outcomes when approached with systematic methodology. External annuloplasty is recognized as the most physiological technique and has become a vital component of aortic valve repair (3). With continuous advancements in surgical techniques and personalized strategies for each patient, we can achieve excellent repair durability and a high rate of freedom from valve-related complications.

Željko Đurić, Hrvoje Gašparović

The ideal substitute in young and middle-aged adults requiring aortic valve replacement (AVR) remains a matter of debate and poses a challenge for the heart team. In patients with good-quality cusps and aortic root dilatation, valve-sparing root replacement (VSRR)- David procedure / Florida sleeve modification, has become a standard for preserving native aortic valve when aortic root replacement is needed. In young patients with aortic valve disease the Ross procedure offers a potential alternative to the prosthetic AVR. We retrospectively identified all patients with aortic root dilatation, aortic insufficiency, aortic stenosis or mixed aortic valve disease who underwent David procedure, Florida sleeve modification, isolated aortic valve repair and the Ross procedure at our department between September 2022 and October 2024. From 59 consecutive patients, 34 patients (57%) underwent David procedure, 4 patients (6%) Florida sleeve modification, 11 patients (18%) isolated aortic valve repair and 10 patients (16%) underwent the Ross procedure. There were no in hospital mortality. In young patients with aortic valve disease, complications from prosthetic valves necessitate a better approach. In addition to alleviating the need for anticoagulation, the VSRR procedure and the Ross procedure offer a hemodynamic profile similar to the native aortic valve and carry a low risk of endocarditis. Contemporary advancements and experience acquired in complex aortic root surgery highlighted the importance of reinforcing the annulus and sinotubular junction of the pulmonary autograft. Thus, the Ross procedure was revived as an intriguing alternative to prosthetic AVR. Furthermore, recent data shows that the Ross procedure is the only AVR procedure that restores the life expectancy of the general population. (1)

Vedran Radonić, Mario Šekerija, Marijan Erceg, Ivana Jurin, Irzal Hadžibegović, Miran Martinac, Tomislav Letilović

**Introduction**: While the benefits of moderate physical activity on overall and cardiovascular health are well known, impacts of competitive sport are not clear. Objective of this research is to perform the general and cardiovascular mortality comparison of Croatian athletes who represented Yugoslavia or Croatia in the Olympic Games from 1948 to 2016 and the general Croatian population standardized by age, gender, and time period. (1) **Methods**: Total of 652 male athletes were included for general mortality analysis. Among them, 642 athletes were eligible for cardiovascular mortality analysis. General mortality analysis included 158 female athletes. Due to small sample size, cardiovascular mortality analysis could not be performed for female gender. If available, data on athletes’ causes of death were obtained from the official registers of countries where deaths occurred. Alternative method to obtain athletes’ causes of death was interview with family members or acquaintances of the deceased. The interviews were conducted on World Health Organisation (WHO) verbal autopsy principles. Data on general population mortality were obtained from Croatian Bureau of Statistics’ and WHO databases. General and cardiovascular standardized mortality ratios (SMR) with 95% confidence intervals (CI) were used for the Olympians’ and general population mortality rates comparison. **Results**: During the follow-up, 142 male and 2 female Olympic athletes died. Expected numbers of deaths in the Croatian general population were 255.37 for male and 8.96 for female gender. Olympians’ general mortality was lower for both males (SMR 0.56; CI 0.47–0.66; p < 0.001) and females (SMR 0.23; CI 0.03–0.81; p = 0.013) compared to the Croatian general population. Among 142 deceased male athletes, 132 had known cause of death. Total of 52 male athletes died from cardiovascular causes of death, while the expected number of cardiovascular deaths in the Croatian general male population was 102.93. Hence, athletes’ cardiovascular mortality was significantly reduced (SMR 0.51; CI 0.38–0.66; p < 0.001). **Conclusion**: Croatian male and female Olympic athletes have lower general mortality in comparison to the Croatian general population. Croatian male Olympic athletes have lower cardiovascular mortality in comparison to the Croatian general population.

Martina Roginić, Siniša Roginić, Andrija Škopljanac Mačina, Sandra Ljubičić, Iva Zec, Tereza Knaflec, Nikolina Mijač Mikačić

**Introduction:** High suspicion for infective endocarditis is driven by fever and positive blood cultures in the absence of an alternative focus of infection. (1, 2) This case underlines the importance of exploring other more obvious sources of bacteremia to avoid unnecessary tests and delays in diagnosis. In cases of inconclusive echocardiography results, imaging should be repeated. **Case report**: 59-year-old patient with diabetes and hypertension was admitted for sepsis, unilateral leg pain and plantar rash. Medical history includes aortobifemoral reparation of infrarenal aortic aneurysm 19 years ago and recurrent leg abscesses with prolonged periods of antimicrobial and probiotic therapy. Blood cultures found Lactobacillus rhamnosus and Candida glabrata. Positive blood cultures and clear Janeway lesions (**Figure 1**) indicated transesophageal echocardiography (TEE) which showed competent aortic valve with small hyperechogenic lesion (7mm X 6 mm) on base of left coronary cusp (**Figure 2**). TEE was repeated after 2 weeks of effective antimicrobial therapy, showing no change of suspected valvular lesion. Patient clinically improved and repeated blood cultures were negative. Further workup (including FDG-PET/CT) found intensive tracer uptake in the region of implanted aortic prosthesis. The surgeon opted for prolonged course of antimicrobial therapy. Unfortunately, only 4 days after completion of therapy the patient was septic with positive blood cultures. The operation was inevitable and aortointestinal fistula, graft infection and thrombosis were found. Partial graft replacement and bowel reconstruction were conducted. FIGURE 1. Unilateral Janeway lesions on the left leg. FIGURE 2. Transesophageal echocardiography image (midesophageal view, short axis) showing a nodular lesion on the noncoronay cusp of the aortic valve. **Conclusion**: Even in patients with highly specific findings for endocarditis like skin lesions and positive blood cultures, workup and therapy should be clinically guided. Bizarre blood culture isolates in our patient are easily explained when we know complete course of disease.

Lana Maričić

The development of myocardial dysfunction in sepsis is associated with an increased mortality rate, and the prevalence of the development of septic cardiomyopathy in patients with sepsis ranges from 10-70%, depending on the research. Previous research has established that it is a global and reversible dysfunction of the myocardium. Almost half of these patients develop diastolic and systolic myocardial dysfunction. The presence of diastolic dysfunction is an early biomarker of the development of septic cardiomyopathy and has prognostic significance. Current research shows that myocardial damage occurs because of weakened myocardial perfusion, the direct adverse effect of inflammatory mediators, and bacteria and their toxins, as well as mitochondrial dysfunction. It is the consequences of the development of mitochondrial dysfunction that represent a key problem in the development of sepsis-induced cardiomyopathy. The pathophysiological mechanisms of the development of sepsis-induced myocardial dysfunction are the subject of many studies, and certainly the results of these studies have an impact on the therapeutic approach itself. The use of advanced echocardiographic methods, such as global longitudinal strain and magnetic resonance imaging, is a sufficiently sensitive method in the detection of sepsis-induced cardiomyopathy, but there are limitations to its application in the Intensive Care Unit. Current therapeutic possibilities in treatment of sepsis-induced cardiomyopathy include achieving hemodynamic stability of the patient and the use of antibiotic therapy. The discovery of new treatment methods is based on animal models, and the goal of immunomodulatory action at the cellular level, to reduce myocardial injury. (1-3) The aim of this paper is to present the current knowledge about the development of myocardial dysfunction associated with sepsis, and to review biomarkers, diagnostic methods in its recognition, as well as possible therapeutic methods in development.

Karolina Beg, Sandra Jakšić Jurinjak, Andro Koren, Luciana Koren, Vice Zubak, Vlatka Rešković Lukšić, Marija Brestovac, Martina Lovrić Benčić, Joško Bulum, Zvonimir Ostojić, Blanka Glavaš Konja, Jadranka Šeparović Hanževački

**Introduction**: Severe aortic stenosis (AS) is associated with an increased risk of developing ischemic stroke, but there is a lack of data on the impact of atrial fibrillation (AF). (1-3) Therefore, our aim was to identify variables related to cerebrovascular insult (CVI) in calcified severe AS, apart from AF. **Patients and Methods**: We retrospectively analyzed a database of 353 patients with severe aortic stenosis who were admitted from September 2020 to July 2023 at the Heart Valve Department of the University Hospital Centre Zagreb. Patients had an average age of 78.7 years ± 8.6 (range: 42-95), with 53.3% being female, and an average BMI of 27.7 ± 5.08 (range: 15.6-44.4). They were divided into four groups: (Group I) those with AF and CVI, (Group II) those in sinus rhythm (SR) and CVI, (Group III) those with AF and no-CVI, (Group IV) those in sinus rhythm SR and no-CVI. For the group of patients with AF, we calculated the CHA2DS2-VASc score. **Results**: Of the 353 analyzed patients with severe aortic stenosis, 138 (39.1%) had AF with an average CHA2DS2-VASc score of 4.841 (±1.395). Marked at the time of inclusion patients with AF had anticoagulation therapy. Additionally, the average CHA2DS2-VASc score in the group of patients with AF and no-CVI was 4.549 (±1.165) and in the group of patients with AF and CVI was 7.063 (±0.929), as expected. When analyzed the group of patients with AF and history of CVI and severe AS (11.6%), there was a significant difference (p 0.008), as in the SR group and CVI, there were 9.3% of patients with a history of CVI (p 0.006). No difference was found comparing a pair of patient groups (SR and AF) with CVI (p 0.490), suggesting an increased risk of stroke in the presence of calcified aortic valve stenosis could be an independent risk factor. Considering other risk factors, in the group with AF and CVI, 93.8% had hypertension, 56.3% had diabetes mellitus (DM), and 25% of patients were smokers. Only DM, as a risk factor, showed a tendency for positive significance between the groups AF and SR (respectively p 0.065, p 0.074). **Conclusion**: In our group of patients with severe calcified aortic stenosis, there is a significant risk of ischemic stroke, apart from atrial fibrillation at the time of diagnosis, suggesting an increased risk of stroke in the presence of calcified aortic valve stenosis that could be an independent risk factor.

Marin Bištirlić, Mira Stipčević, Zoran Bakotić

**Introduction**: Coronary artery perforation is extremelly rare but potentialy fatal complication of percutaneous coronary intervention which in certain circumstances can lead to cardiac tamponade, myocardial infarction, cardiogenic shock and finally death (1) The incidence is 0.43% but rises up to 2.9% in chronic total occlusion (CTO) interventions. (2) If cardiac tamponade occurs, the in-hospital mortality increases to more than 5%, even if pericardiocentesis is performed. Risk factors include older age, female gender, previous bypass graft, heavily calcified lesions, CTO, severe tortuosity etc. (1) **Case report**: 85-year-old male patient was admitted to Coronary Care Unit due to non ST-elevation myocardial infarction (NSTEMI). Previously he had intervention on left anterior descending artery (LAD) and right coronary artery (RCA). Upon admission coronary angiography was performed which showed patent LAD and RCA (with no in stent restenosis) but with severely calcified and stenosed circumflex artery in proximal and distal segment. After predilatation with „semi-compliant“ balloon (SC), in distal part of the vessel was implanted „drug eluting stent“ (DES) 2.5x22 mm. Control coronary angiography showed extravasation of contrast into the pericardium (Elis type III perforation) at the distal part of the stent. Patient was hemodinamically stable. At the site of perforation „covered stent“ (CS) was implanted which stopped extravasation of contrast and TIMI3 flow distally. The ultrasound (US) showed minimal pericardial effusion (5 mm). In the continuation of the procedure another DES 2.75x26mm was implanted in the proximal part of the vessel. The patient was transferred to CCU for monitoring. Control US showed minimal pericardial effusion and the patient was stable. He was discharged after four days. At the ambulatory control, the patient was well, without chest pain. **Conclusion**: Although coronary artery perforation is a severe and potentially fatal complication of percutaneous coronary intervention, quick diagnosis and treatment with proper materials is crucial in treatment of this condition.

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

**Introduction:** Bicuspid aortic valve stenosis (AS) differs from degenerative tricuspid AS. Patients with bicuspid AS are younger, with more unfavorable anatomical characteristics (calcium distribution, ascending aorta dilatation, annular diameter, and aorta horizontality) and thus less favorable for transcatheter aortic valve implantation (TAVI). (1) We present single center experiences with TAVI in bicuspid AS. **Patients and Methods:** Patients who underwent TAVI procedures in our center between September 2019 and June 2024 were included in the analysis. **Results:** Out of 467 patients there were 26 (5.5%) patients with true bicuspid AS verified by specific multi-slice computed tomography (MSCT) analysis. In comparison to other patients in the TAVI registry, patients with bicuspid AS who received TAVI were younger (77 vs 80 years), received more frequently balloon expandable systems (93% vs 67%) with larger device diameters (27.5 vs 26 mm). They also had horizontal aorta more frequently in comparison to other patients. In regard to intervention strategy, all patients with bicuspid AS had balloon predilatation before implantation. There were no differences in cardiovascular mortality within 30 days. Proportion of moderate or severe paravalvular leak (PVL) and permanent pacemaker implantation (PPM) after TAVI was higher in patients with bicuspid AS in comparison to other patients (11.5% vs 10% for PPM, and 15% vs 12% for PVL) but those differences were not significant. **Conclusion:** Patients with bicuspid AS in our TAVI cohort were less represented than in other comparable registries where they represent 10-15% of all TAVI patients, most probably because of the use of only true bicuspid definition regarding MSCT analysis and lower proportion of low-risk patients who more frequently present with bicuspid AS in our registry. They have more unfavorable anatomical characteristics, but with careful device selection and sizing, and proper implantation protocols they can achieve comparable results to patients with tricuspid aortic valves.

Tomo Svaguša, Danijel Cvetko, Danijela Grizelj, Miroslav Raguž, Šime Manola, Diana Rudan

**Introduction**: Cardiac tumors are extremely rare tumors. The most common cardiac tumors are myxomas located in the atria, they usually have a stalk and are attached to the interatrial septum. Tumors located in the appendage of the left atrium are extremely rare and they are most often myxomas. (1, 2) **Case report**: 85-year-old patient was admitted to the cardiac intensive care unit due to pulmonary edema caused by acute coronary syndrome. Coronary angiography revealed multivessel coronary disease with left main affection and significant coronary disease of all three coronary arteries. The initial cardiac ultrasound verifies degenerative valves disease with a reduced left ventricle ejection fraction. Considering the findings of the coronary angiography and cardiac ultrasound, it was decided to present the patient to the heart team. A control ultrasound shows at the beginning of the left atrial appendage an isoechoic oval formation measuring 1.3 cm x 1.2 cm, which seems to be fixed to the myocardium and without visible flotation (**Figure 1**). An MSCT of the heart verifies a 45x15x13mm oval tumor formation, which is attached to the lateral part of the atrium wall by its base, and protrudes into the lumen of the left atrium. The radiological characteristics of the solid mass corresponded to a myxoma (**Figure 2**). The patient refused any interventional treatment. Hospitalization was complicated by the development of a stroke and the patient died. The autopsy was not performed due to the clear cause of death and at the request of the patient’s family so the PHD finding of this tumor mass is missing. FIGURE 1. Transthoracic echo projections in the apical view. The red arrow indicates a mass in the region of the beginning of the left atrial appendage. FIGURE 2. Cardiac multislice computed tomography imaging. The red arrow points to a mass in the left atrial appendage. **Conclusion**: Serial performance of cardiac ultrasound is extremely important when monitoring patients in the cardiac intensive care unit. Atypical projections in standard cardiac ultrasounds can be of significant importance and can provide us with additional diagnostic value. A detailed approach to performing an ultrasound of the heart enables a correct diagnosis and the overall treatment of the patient.

Fran Šaler, Tomislava Bodrožić Džakić Poljak, Šime Manola, Ivana Jurin

**Introduction**: Despite the importance of timely revascularization in acute myocardial infarction (AMI), the necessity for additional medical treatment for the prevention of ischemic heart disease and heart failure (HF) is still high (1). Recent trials (EMMY, DAPA-MI) demonstrated the benefit of early initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with AMI (2, 3). SGLT2 inhibitors exhibit effects that could modify the progression of coronary disease to chronic HF. We aimed to assess the efficacy and safety of early initiation of SGLT2i in patients following AMI. **Patients and Methods**: This was a prospective, single-center, observational study conducted at University Hospital Dubrava from September 2021 to February 2024. We included patients with type 1 AMI who developed signs of HF. Exclusion criteria were: prior HF, treatment with SGLT2 inhibitors, or death during initial hospitalization. Before discharge, echocardiography was performed on all patients. Ejection fraction (EF), NYHA class, renal functions, levels of NT-proBNP, contrast-induced acute kidney injury, and body weight were assessed at six and twelve months. The patient registry is registered at ClinicalTrials.gov (NCT06090591). Categorical variables were presented as frequencies, and continuous variables as median and interquartile range. Statistical analysis was performed using JASP software (v. 0.19.1). **Results**: We included 188 patients, and 31% were women. There were 110 patients (58.5%) with ST-elevation myocardial infarction and 78 (41.5%) with non-ST-elevation myocardial infarction. In total, 98.5% (N=185) underwent coronary angiography. Most patients had hypertension (83.5%), hyperlipidemia (80.3%), and 34% had diabetes. Most patients had HF with reduced EF (N=110, 58.5%), followed by HF with preserved EF (N=46, 24.5%). Death occurred in 15 patients (8%). Empagliflozin was prescribed to 117 patients (62.2%), and dapagliflozin to 70 (37.8%). There was a statistically significant reduction of NT-proBNP levels (p<0.001), NYHA class (p<0.001), and body weight (p<0.001), while median EF improvement was 4.5% (p<0.001). There was no significant effect on estimated glomerular filtration rate (p=0.6). No patient developed contrast-induced acute kidney injury. **Conclusion**: SGLT2 inhibitors have multiple positive effects and no safety concerns and therefore should be initiated early following AMI owing to their cardiovascular and metabolic potential benefits once the patient is hemodynamically stable.

Mijo Bergovec

Artificial intelligence (AI) using machine learning (ML) intends to mimic the works of the neural networks of the human brain. AI is the ability to make computers or machines learn to solve problems that would otherwise require human effort. Advances in computing power have made it possible to analyze large amounts of data quickly with consistency, accuracy and enable more precision on various fields of medicine, especially in cardiology. In the last 100 years rules-based interpretation of the electrocardiogram (ECG) is widely used by physicians, or, in the last 50 years, in existing devices. Still, both have known limitations that may adversely affect medical decision-making. The application of AI/ML to the ECG has already dramatically affected electrocardiography to assist in diagnosis, stratification and management. AI/ML of the ECG can identify existing or occult structural or other heart disease, including hypertrophic cardiomyopathy, amyloid heart disease, heart failure, aortic stenosis, pulmonary hypertension, arrhythmias, ST-segment changes, QT prolongation, and other ECG abnormalities. AI/ML can improve quality of ECG signals by removing noise and artefacts, and extract features not visible to human eye (heart rate variability, beat to beat intervals, etc). Conclusions based on AI offer guide strategies to improve outcomes. The use of AI in ECG analysis has several benefits, including the quick and precise detection causes of symptomatic cardiac problems or silent cardiac diseases. It has the potential to help physicians with interpretation, diagnosis, risk assessment, and disease management. (1, 2) In the future, despite some concerns about the risks of AI technology, AI is expected to play important role in ECG diagnosis and management of various fields in medicine and cardiology as more data become available and more sophisticated algorithms are developed.

Mateja Ćosić, Marina Vidosavljević, Livija Sušić, Dragica Pavlović, Goran Galić

**Introduction:** Peripheral arterial disease (PAD) is characterized by the atherosclerotic narrowing of the peripheral arteries, most commonly affecting the blood vessels of the lower extremities. (1) The Ankle-Brachial Index (ABI) is the first non-invasive test and screening method in diagnosing PAD. ABI ratios between 0.90-1.40 are considered normal for adults, while ratios less than 0.90 and higher than 1.40 indicate the presence of PAD. **Case report**: 67-year-old patient was referred by a cardiologist for ergometric testing due to chest discomfort during greater exertion. He has type 2 diabetes mellitus, occasionally measures an elevated blood pressure but has not been on medication and has been a smoker for 36 years. His laboratory results showed LDL levels of 3.5 mmol/L. He takes oral antidiabetic medications. During the ergometric test at the second level of exertion, he complained of severe pain in both calves, and soon afterward experienced pressure in his chest, with visible changes on the ECG, which brought the test to a halt. Given these symptoms, the physician recommended myocardial scintigraphy and ABI testing. The ABI index was 0.4 on the left and 0.6 on the right. The patient was referred for a Doppler ultrasound of the leg arteries, which confirmed moderate atherosclerotic changes in the femoral arteries and occlusion of the tibial arteries in the lower legs. The myocardial scintigraphy detected ischemia, and the patient was referred for an invasive coronary angiography, which confirmed significant narrowing of the LAD and placement of a stent. In addition to his previous diabetic therapy, the patient was started on antihypertensive, hypolipidemic, and dual antiplatelet therapy. Nursing education was provided regarding lifestyle changes, including dietary modifications, introducing daily walks of at least 30 minutes, and mandatory cessation of smoking. **Conclusion:** The ABI confirmed peripheral arterial disease and directly categorized the patient into a high cardiovascular risk category. We can conclude that measuring the ankle-brachial index is a useful and reliable method for detecting PAD. The nurse plays a significant role in performing the ABI diagnostic method and educating patients about healthy lifestyle habits.

Anita Jukić, Monika Lorena Čotić, Frane Runjić, Ivica Kristić

**Introduction:** The aim of this study is to determine whether there are differences in the clinical, laboratory and procedural characteristics (1-3) of patients treated with transcatheter aortic valve implantation (TAVI) at University Hospital Centre Split in 2019-2020 and 2023. **Patients and Methods**: The study included 187 patients diagnosed with severe aortic stenosis who underwent TAVI during 2019, 2020 and 2023. Basic clinical and procedural data were collected from the hospital’s information system and archives. To compare the outcomes, patients were divided into two groups: the 2019-2020 group and the 2023 group. **Results**: The 2019-2020 group had 39 patients, while the 2023 group had 148 patients. The median age for the entire cohort was 82 years (IQR=6.5), with no significant change over time (P=0.366). The proportion of patients aged ≤75 years remained the same (15.38% in 2019-2020 and 16.22% in 2023). The 2023 group had a significantly shorter median hospital stay, 3 days compared to 6 days in the 2019-2020 group (P<0.001). The estimated EuroSCORE II decreased from 4.4% to 3.71% in 2023 (P=0.649). In the 2023 group there were more patients classified as New York Heart Association (NYHA) class 4 for heart failure (12.84% compared to 0% in 2019-2020; P=0.054). In the entire cohort, 81.82% of patients had arterial hypertension, 39.57% had atrial fibrillation, and 33.16% had diabetes. No significant differences were found in most comorbidities between the two groups. The 2019-2020 group had significantly more patients who had previously undergone percutaneous coronary intervention (33.33% vs. 14.19%, in 2023; P=0.012). The use of balloon pre-dilation and post-dilation did not change significantly over time. The transfemoral access was most commonly used, although a small number of procedures in 2023 were performed using the transaxillary access. In the entire cohort, the most commonly implanted valve was the Medtronic Evolut PRO + (31.5%, N=57) and Edwards Sapien 3 (25.4%, N=46). **Conclusion:** Over the four-year period, there has been a significant increase in TAVI procedures, with the use of various types of valves and vascular access routes, and more complex procedures. The length of hospital stay has been significantly reduced. The comorbidities burden and patient age did not change significantly during the observed period.

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

**Introduction:** Recently, a randomized head-to-head LANDMARK trial demonstrated that the balloon-expandable transcathether valve (BEV) Myval was non-inferior to the BEV Sapien S3 in terms of the primary composite endpoint at 30 days. (1) Aim: To explore if there is difference in mean pressure gradient (MPG), paravalvular regurgitation (PVR), major bleeding and vascular complications, permanent pacemaker implantation (PPI) and long-term survival between Myval and Sapien S3 BEV. **Patients and Methods**: In this single center, observational cohort study we included 347 patients who underwent transcatheter aortic valve implantation (TAVI) and were implanted with either Myval BEV (n=199) or Edwards Sapien S3 BEV(n=148). Mean follow-up (FU) was 12 months. We compared MPG after TAVI between two groups as well as the rate of conduction disturbances that require permanent pace-maker implantation (PPI), and the incidence of moderate to severe paravalvular regurgitation (PVR), major bleeding and vascular complications and survival rate in the FU. **Results**: There was no significant difference in demographic and clinical parameters between two groups. Patients implanted with Myval BEV were statistically significant more likely to experience early adverse effects (68 vs 34 early adverse effect, p 0.02) driven mostly by higher incidence of moderate PVR (21 vs 7, p 0.049) and non-fatal stroke (11 vs 1, p 0.04) but there was no statistically significant difference in PPI (12.6% vs 9.46, p 0.49) and major bleeding and vascular complications .There was no statistically significant difference in survival during index hospitalization or during follow up. Mean pressure gradient (MPG) did not differ significantly between groups (11. 49 (9.28 – 15) vs 12 (9.35 – 15.9), p 0.51). **Conclusion**: Our all-comer observational real-world registry showed similar survival rates as well as early MPG after TAVI with both platforms.

Filip Grulović, Tomislav Letilović

**Introduction**: Percutaneous coronary intervention (PCI) is a procedure aimed at restoring adequate coronary flow in ischemic myocardial tissue. Conventional PCI techniques must sometimes be upgraded to so called debulking techniques (i.e. rotational atherectomy or intravascular lithotripsy) to achieve optimal results in heavily calcified lesions. (1-3) The aim of this study was to identify clinical factors associated with a need for these debulking techniques. **Material and methods**: This retrospective study included 1537 patients who were treated with PCI between 2020 and 2023. We identified 50 patients who underwent debulking methods (rotational atherectomy or intravascular lithotripsy) while 1487 patients underwent conventional PCI. Clinical data from patients were collected using institutional computer system. **Results:** Patients in the debulking group were older (a difference of 4.57 years, p=0.0006) and were more likely to be diagnosed with hyperuricemia (difference in prevalence 8.08%, p=0.02). In contrast, the use of acetylsalicylic acid (difference in prevalence 15.59%, p=0.0038) was less prevalent in the group of patients treated with debulking methods. **Conclusion**: Our results show differences in clinical characteristics of patients treated with debulking methods when compared to patients that underwent conventional PCI. Retrospective nature of our study as well as unbalanced group numbers warrant further studies. Nevertheless, this study can potentially serve as a cornerstone for future trials.

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

**Introduction:** The Croatian Transthyretin Cardiac Amyloidosis (CroATTR) Registry was founded in September 2022 to acquire demographic characteristics and follow clinical outcomes including echocardiographic, electrocardiographic and laboratory data of patients with wild type (wtATTR) or hereditary (hATTR) transthyretin cardiac amyloidosis as well as their family members with confirmed mutation of the TTR gene. (1) **Patients and Methods**: We analyzed data collected retrospectively and prospectively of 48 patients included in CroATTR. Descriptive statistics methods were used to analyze the data. **Results:** Of 48 patients included in CroATTR, 8 have hATTR, 34 wtATTR and 6 were phenotype negative with confirmed mutation of TTR gene. Eight hATTR patients were male, with median age 50 years (range 43-66 years). Seven have Asp18Glu mutation, while one has Val30Met mutation. Three have received heart and liver transplantation (Tx), of them two concomitant heart and liver Tx. One patient has died 5 years after heart Tx. Remaining 5 patients are treated with tafamidis. Of 34 wtATTR patients 58% are male, with median age 75.5 years (range 45-86 years). Most of the patients have several comorbidities: 79% have arterial hypertension, 38% have chronic kidney disease, 74% have atrial fibrillation, 23% have implanted pacemaker and 18% have aortic stenosis. Twenty-eight patients are on tafamidis treatment, of which 16 are on tafamidis for longer than 6 months. There is tendency to lower NTproBNP (prior to tafamidis treatment median NTproBNP 2263 ng/L, range 495-12531 ng/L, after 6 months median NTproBNP 2251 ng/L, range 349-9574 ng/L) and better 6-minute walk test results (prior to tafamidis median length 335 m, range 160-480 m, after 6 months median length 420 m, range 250-495 m) with tafamidis treatment. Three patients died of heart failure, and one has had heart failure admission. All six phenotype negative patients with confirmed mutation of TTR gene have Asp18Glu mutation. In 2 years of follow-up one patient has developed early signs of cardiomyopathy. Complete patients’ data are shown in **Table 1**. ### TABLE 1: Patient characteristics. | | **Wild type ATTR** | **Hereditary ATTR** | **Phenotype negative, genotype positive** | | --- | --- | --- | --- | | Number of patients (n) | 34 | 8 | 6 | | Male (%) | 58 | 100 | 50 | | Age (years) | 75.5 (45-86) | 50 (43-66) | 44.5 (25-53) | | Comorbidities (n,%) Arterial hypertension Chronic kidney disease Atrial fibrillation Pacemaker Aortic stenosis | 27 (79%) 13 (38%) 25 (74%) 8 (23%) 6 (18%) | 2 (25%) 1 (12.5%) 2 (25%) 0 0 | 1 (17%) 0 0 0 0 | | Echocardiography EF (%) IVSd (mm) GLS (%) | 46 (20-65) 17 (12-33) -10.5 ((-3.5) – (-17)) | 45 (25-60) 19 (17-30) -7 ((-6) – (-13)) | 65 (60-75) 11 (8-14) -18 ((-16) – (-21)) | | ECG Hypertrophy Microvoltage Pseudo Q | 4 (11.7%) 9 (26%) 4 (11.7%) | 1 (12.5%) 5 (62.5%) 3 (37.5%) | 0 0 1 (17%) | | Tafamidis (n) | 28 | 5 | 0 | | Laboratory and functional parameters before tafamidis NTproBNP (ng/L) Troponin I (ng/L) Creatinine (umol/L) 6MWT (m) | 2263 (495- 12531) 55.5 (0-200) 117.5 (56-154) 335 (160-480) | 3058 (887-5119) 67.5 (10-120) 93 (71-115) 465 (450-490) | 41.5 (33-84) / 57 (50-101) / | | Laboratory and functional parameters 6 months after tafamidis NTproBNP (ng/L) Troponin I (ng/L) Creatinine (umol/L) 6MWT (m) | 2251 (349- 9574) 35.5 (0-179) 111.5 (71-170) 420 (250 -495) | 4037.5 (498-7279) 50 (19.4-67) 98 (69-133) 495 (450-520) | / / / / | | Outcomes Heart Transplantation Death | 0 3 | 3 1 | 0 0 | [†] All values are shown as median (min-max). 6MWT = 6-minute walk test; ECG = electrocardiogram; EF = ejection fraction; GLS =global longitudinal strain; IVSd = interventricular septum diameter; NTproBNP = N-terminal prohormone of brain natriuretic peptide **Conclusion:** CroATTR is designed to increase knowledge about ATTR-CM and to follow treatment with specific therapy. According to the current data, there are signs of lower natriuretic peptides and better 6-minute walk test results in patients treated with tafamidis. (2)

Iva Turić, Viktor Čulić

**Introduction**: Approximately 50 per cent of pericardial effusions are idiopathic, while the epidemiological data and pathophysiology are poorly known. Thyrotoxicosis-related pericarditis is not a common finding with toxic multinodular goitre (TMNG). (1-3) **Case report**: 63-year-old female patient with a history of TMNG presented with chest pain, general weakness, fever, and palpitations. Laboratory findings showed increased inflammatory parameters. Despite taking antibiotics for several weeks, her condition did not improve. The performed MSCT of the thorax described a circular pericardial effusion (**Figure 1**) and an enlarged thyroid gland. The echocardiography exam showed a hyperkinetic left ventricle and a large pericardial effusion with no signs of tamponade. There were signs of pulmonary hypertension. The thyroid-stimulating hormone was 0.006 mIU/L (normal 0.54-4.07), free thyroxine was 35.7 pmol/L (normal 11.8-19.8), and free triiodothyronine was normal. The immunology tests were normal except for the higher IgE and eosinophil cationic protein levels. The patient was given thiamazole 10 mg t.i.d., propranolol 20 mg t.i.d., ibuprofen 600 mg t.i.d., and colchicine 0.5 mg b.i.d. with subsequent clinical improvement. Although there were no signs of right ventricular (RV) dysfunction, the RV function parameters were further restored two months later, with normalised pulmonary pressure indicators and a complete reduction of the pericardial effusion. In the follow-up, the patient had no symptoms or signs of recurrent pericarditis. FIGURE 1. Multislice computed tomography of the thorax showing circular pericardial effusion. **Conclusion**: Our case suggests that hyperdynamics with pulmonary hypertension and subclinical RV dysfunction may present an important pathological mechanism in the genesis of pericardial effusion in thyrotoxicosis. Microvasculature inflammation along with enhanced vascular reactivity may be among the significant mechanisms as well. Further investigation is needed to better understand this condition and to enable better patient management.

Dubravka Šipuš, Dora Fabijanović, Nina Jakuš, Marijan Pašalić, Hrvoje Jurin, Jure Samardžić, Boško Skorić, Daniel Lovrić, Anna Mrzljak, Igor Petrović, Ognjan Deban, Hrvoje Silovski, Željko Čolak, Hrvoje Gašparović, Davor Miličić, Maja Čikeš Vodušek, Ivo Planinc

**Introduction:** Transthyretin amyloid cardiomyopathy (ATTR-CM) is characterized by deposition of amyloid fibrils in the myocardium which can lead to advanced heart failure (HF). Heart transplantation (HTx) is curative treatment option in patients who reach advanced HF stage, and it is recommended to combine HTx and liver transplantation (LTx) in cases of hereditary ATTR-CM to prevent further progression of the disease (1). We retrospectively analysed data of 6 ATTR-CM patients who received HTx or HTx and LTx in UHC Zagreb. **Case Series:** Historically, the first patient was a female, aged 53 at the time of HTx. She had HF symptoms for 2 years prior HTx, and even though ATTR suspicion was made after first echocardiography, multiple tissue biopsies were negative for amyloid deposits. In 2011 she underwent HTx and histopathological analysis of explanted heart diagnosed ATTR-CM. One year following HTx there were signs of progression of the disease, predominantly polyneuropathy (PNP) but also signs of ATTR-CM of cardiac graft. She died 6 years after HTx due to infective complications. The second patient was a female, aged 58 at the time of HTx. Five years following the first HF symptoms, the tissue biopsy was positive for amyloid deposits, and genetic testing proved Asp18Glu mutation. She underwent HTx in 2016, and from 2018 to 2019 was treated with tafamidis. LTx was never performed due to progression of PNP with infective complications, of which she died 4 years following HTx. The third patient was male, aged 53 at time of HTx. He received HTx in 2019, a few months after positive genetic testing (Asp18Glu) and 4 years after the first HF symptoms. He received LTx in 2022 and died in 2024 due to infective complications. The fourth patient, male, aged 64 at the time of HTx was the only patient transplanted in our centre with the wild type of ATTR-CM, also proven by tissue biopsy. He underwent HTx in 2019 and is still in regular follow-up. The fifth and the sixth patient were both males, aged 47 and 52 at the time of HTx respectively. They both had positive family history and proven Asp18Glu mutation. They were both on tafamidis for more than 2 years before HTx. The first of the two received combined HTx and LTx in January 2023 and had one episode of early acute liver rejection that resolved completely. The second underwent combined HTx and LTx in August 2024, so far without complications. Complete patients’ data are shown in **Table 1**, and typical echocardiogram before Htx is shown in **Figure 1**. ### TABLE 1: Patient characteristics. | | **1** | **2** | **3** | **4** | **5** | **6** | | --- | --- | --- | --- | --- | --- | --- | | Gender | Female | Female | Male | Male | Male | Male | | Age at HTx | 53 | 58 | 53 | 64 | 47 | 52 | | Comorbidities | HA, Afib | Afib, Emphysema | CKD | HA, CKD, DM | Gastritis | Afib | | HF symptom onset | 2009 | 2011 | 2015 | 2018 | 2019 | 2021 | | ECHO signs of ATTR-CM | 2010 | 2012 | 2017 | 2014 | 2009 | 2021 | | Polyneuropathy | Sensorimotor and autonomic | Sensorimotor and autonomic | Sensory, autonomic (CASS 2) | Autonomic (CASS 2) | Mild sensory | Sensorimotor and autonomic (CASS 3) | | Genetics | / | Asp18Glu | Asp18Glu | negative | Asp18Glu | Asp18Glu | | Tissue biopsy | negative | Fat pad + | Fat pad + | Fat pad + | Fat pad + | / | | ECHO - EF (%) - GLS (%) - IVSd (mm) | 25 / 20 | 25 / 15 | 30 / 28 | 45 -5.1 25 | 45 -8 18 | 45 -9 22 | | HTx | 18.04.2011 | 27.04.2016 | 30.05.2019 | 5.10.2019 | 04.01.2023 | 24.08.2024 | | LTx | / | / | 03.06.2022 | / | 04.01.2023 | 24.08.2024 | | Histopathology of explanted heart | amyloidosis | amyloidosis | amyloidosis | amyloidosis | amyloidosis | amyloidosis | | Specific therapy | / | 2018-2019 | / | / | Feb. 2021- Jan. 2023 | Dec. 2022- Aug. 2024 | | Complications | Infections, vision loss | Infections, vision and hearing loss | Infections, vision and hearing loss | CMV infection, osteoporosis | Liver rejection | / | | Outcome | Died in Jul. 2017 | Died in Nov. 2020 | Died in Aug. 2024 | Follow-up | Follow-up | Follow-up | [†] Afib = atrial fibrillation; ATTR-CM = transthyretin amyloid cardiomyopathy; CASS = Composite Autonomic Severity Score; CI = cardiac index; CKD = chronic kidney disease; DM = diabetes mellitus; ECHO = echocardiography; EF = ejection fraction; GLS = global longitudinal strain; HA = arterial hypertension; HF = heart failure; HTx = heart transplantation; IVSd = interventricular septum diameter; PCWP = pulmonary capillary wedge pressure; PVR = pulmonary vascular resistance. FIGURE 1. Echocardiography of patient 6. a) Apical 4 chamber view showing thickened left ventricular walls, b) Global longitudinal strain with typical apical sparing, c) Lateral annulus tissue doppler showing low velocities, d) Transmitral inflow doppler showing diastolic dysfunction **Conclusion:** In patients with advanced heart failure due to hereditary ATTR-CM combined HTx and LTx is preferred therapy while outcomes following isolated HTx are hindered by continuous progression of the disease.

Ivo Darko Gabrić

Vascular endothelial growth factor (VEGF) is an endothelial cell-specific mitogen that plays an essential role in developmental angiogenesis but is also a mediator of pathological angiogenesis. Therefore, blockade of the VEGF pathway by humanized monoclonal antibodies that bind to circulating VEGF (bevacizumab and ramucirumab) and by small molecules that block tyrosine kinase (sunitinib, pazopanib, axitinib, neratinib, sorafenib, and dasatinib) is used to treat several types of tumors. Cardiovascular (CV) adverse events are quite common with this therapy and include high-grade arterial hypertension, thromboembolic events, and heart failure. The main mechanism of hypertension is a decrease in nitric oxide production in endothelial cells, leading to vasoconstriction and an increase in peripheral vascular resistance. Bevacizumab therapy can worsen arterial hypertension to the 3rd and 4th degree in about 17% of patients. Bevacizumab is also associated with an increased risk of thromboembolic events, such as acute myocardial infarction and cerebrovascular insult, with an incidence of thromboembolic events of 3.8%. Heart failure develops in about 2-4% of patients, usually due to uncontrolled hypertension. Sunitinib, a tyrosine kinase inhibitor that blocks VEGF, can also cause arterial hypertension, similar to that induced by bevacizumab. The incidence of arterial hypertension associated with sunitinib is 17-43%. In addition to arterial hypertension, another common complication is symptomatic heart failure, which develops in 2.7-15% of cases. Anti-VEGF therapy leads to improved survival in many tumors, but it is also associated with various CV side effects that present challenges in treatment. Patients treated with VEGF inhibitors should be assessed for CV risk and adequately monitored to detect and treat CV toxicity in time. (1-3) In this way, the risk of CV side effects is reduced, allowing effective oncological treatment to continue.

Paula Gašpar, Valentina Pandža

**Introduction**: Takotsubo (stress) cardiomyopathy (CMP), or “broken heart syndrome,” is a condition where the heart muscle suddenly becomes weakened or stunned. It usually occurs after intense emotional or physical stress. The heart chamber appears like the Tako-Tsubo pot, which is a Japanese fishing pot used to catch octopuses and was first described in 1990. (1) Takotsubo CMP can occur at any age, in both men and women, but it most commonly affects older women. More than 90% of reported cases are in women aged 58 to 75 years. Research shows that up to 5% of women suspected of having a heart attack have this condition. **Case report:** 59-year-old female patient with a positive personal history of cardiovascular diseases was hospitalized on August 30, diagnosed with Takotsubo CMP. The patient experienced chest pain at work, rated 7-8/10 on the pain scale, following a stressful situation. As the symptoms worsened, the patient presented to the Emergency Department. After undergoing tests, the patient was prepared for the procedure and taken to the operating room. Upon completion of the examination, the diagnosis confirmed Takotsubo CMP, and with medical personnel, the patient was transferred to the Intensive Care Unit, visibly distressed by the events leading to her hospitalization but cooperative regarding further treatment. She was seen by a psychiatrist, prescribed therapy, and received psychological support. Nurses and medical staff, through 24-hour monitoring, care, and frequent psychological support conversations, did everything to improve the patient’s condition. Over the following hours, the patient reported a reduction and cessation of chest pain. The day after hospitalization, the patient was in a low mood, feeling tired and fearful of a recurrence of the event. After two days of monitoring and examination, with her condition improving, the patient was transferred to a ward for further observation. Upon further improvement, the patient was discharged home on September 4, after five days of hospitalization, with recommendations and education regarding therapy and lifestyle adjustments. **Conclusion**: Takotsubo CMP is a temporary but significant condition triggered by severe stress. The case presented illustrates the importance of prompt diagnosis, comprehensive medical care, and psychological support in managing this condition. Education on lifestyle adjustments and stress management remains crucial to prevent recurrence and support long-term well-being.

Nikolina Jurković Dubravčić, Renee Mixich, Andrea Pleša, Senka Pejković

**Introduction**: Anderson-Fabry disease is a rare, inherited X-linked lysosomal storage disorder. It is the second most common lysosomal storage disorder after Gaucher disease. Diagnosis is typically done through dried blood spot testing, and early detection is crucial for effective treatment. Recognizing Fabry disease in its early stages is challenging, as the initial symptoms in childhood are often subtle and nonspecific, leading to potential misdiagnosis. The hallmark of Fabry cardiomyopathy is left ventricular hypertrophy. Often, diagnosis is made after unexplained strokes in younger patients, cardiac complications, or kidney failure, meaning specialists such as neurologists, cardiologists, and nephrologists are often responsible for diagnosis. (1, 2) **Case report**: The case describes a 65-year-old female patient hospitalized in April 2023 with suspected hypertrophic/infiltrative cardiomyopathy. Her family history was negative for sudden cardiac death (SCD) or heart failure. Extensive diagnostics were performed, including echocardiography, serum protein electrophoresis with immunofixation, renal and abdominal ultrasound, coronary angiography, cardiac scintigraphy, fundoscopy, and cardiac MRI. The MRI results suggested cardiac amyloidosis, leading to further investigation. Enzyme activity testing for Fabry disease showed normal alpha-galactosidase levels but positive lyso-GL3, which prompted genetic testing. This confirmed a pathogenic mutation in a heterozygous state, indicating the classical form of Fabry disease. The patient began receiving Fabrazyme therapy at a collaborating healthcare facility, with a dose of 70 mg (Fabrazyme 35 mg) during a two-hour infusion. After successful nurse training at the facility, she transitioned to receiving treatment at Dubrava University Hospital (DUH), where she is regularly monitored. Her first treatment at DUH was administered successfully in September 2024, without any side effects or allergic reactions, highlighting both the effectiveness of the treatment and the team’s preparation. **Conclusion**: Accurate and timely diagnosis is critical to initiate enzyme replacement therapy, which significantly improves patient outcomes.

Matija Vrbanić, Ljiljana Švađumović, Biljana Šego, Zoran Marić, Darko Navoj, Kristijana Radić, Vlatka Funduk, Ivica Benko, Nikola Krajna, Mario Salajec

Invasive and interventional cardiology has significantly advanced with the emergence of innovative technologies aimed at improving patient outcomes. One such advancement is the use of drug-coated balloons (DCBs), which integrate balloon angioplasty with localized pharmacological therapy. These balloons play a crucial role in the treatment of coronary artery disease, particularly in complex lesions and in patients at high risk of restenosis. Preparation of lesions prior to intervention is fundamental for optimizing results. The characteristics of lesions, including morphology and the degree and type of calcification in the coronary artery, significantly influence the choice of treatment strategy. The specificity of treatment with this method is localized drug delivery, which minimizes systemic side effects and maximizes drug concentration at the target area, contributing to better outcomes. The efficacy of DCBs is not solely based on immediate procedural success but also on long-term results. Studies show that patients treated with DCBs have improved clinical outcomes, including reduced rates of restenosis. Furthermore, the incorporation of drug delivery technology via balloons into clinical practice requires a comprehensive understanding of the optimal pharmacological agents used in conjunction with DCBs. Immunomodulatory agents, including sirolimus and paclitaxel, have been utilized with demonstrated effectiveness in reducing restenosis rates. The selection of appropriate pharmacological agents is crucial for achieving the desired therapeutic outcomes and should be tailored to individual patient needs. (1) The use of drug-coated balloons represents a significant advancement in the field of interventional cardiology. As clinical experience with DCBs continues to grow, they are likely to become an integral part of strategies aimed at improving long-term outcomes in patients with coronary artery disease.

Filip Lončarić, Tomislav Bubalo, Pave Markoš, Boško Skorić, Nadira Duraković, Ana Ostojić

**Introduction**: Demonstrate an approach to managing a patient with elevated bleeding risk requiring major non-cardiac surgery (NCS) early after coronary stenting. **Case overview**: The timeline is show in **Figure 1**. A 70-year-old male patient was admitted due to generalized weakness and jaundice. An CT scan revealed a mass in the head of the pancreas with no visible dissemination or vascular invasion. Two months earlier the patient underwent elective percutaneous coronary intervention (PCI) of the left anterior descending artery, whereas, eight days earlier PCI of the left circumflex artery. Acetylsalicylic acid and ticagrelor were introduced as chronic therapy. The case was discussed at the multidisciplinary meeting and urgent pancreaticoduodenectomy was recommended. The patient was ruled as a high-bleeding risk due to active malignancy and NCS required on dual antiplatelet therapy, and high-thrombotic risk due to PCI interventions performed within the past 2 months on multiple vessels, with 4 implanted stents related to a large myocardial territory. The consortium weighted the thrombotic risk as clinically relevant, and bridging with intravenous eptifibatide was recommended (1). Ticagrelor was discontinued five days before the NCS. On the same night the patient experienced rectal bleeding - polypectomy was performed in the 48-hour window after ticagrelor discontinuation and before eptifibatide initiation, removing three polyps. Eptifibatide was initiated 4h after polypectomy. Surgery was performed without problems achieving hemostasis and periprocedural thrombotic events, revealing no local metastatic disease. A loading dose of clopidogrel was given six hours following the end of the procedure. A switch to ticagrelor was performed, and the patient discharged eight days after admission. An adjuvant chemotherapy protocol with gemcitabine was administered through 4 months, with no signs of disease at 8 months follow-up. FIGURE 1. A timeline of clinical events and periprocedural antiplatelet therapy. PCI = PERCUTANEOUS CORONARY INTERVENTION; LAD = LEFT ANTERIOR DESCENDING ARTERY; DES = DRUG-ELUTING STENT; LCx = LEFT CIRCUMFLEX ARTERY; GI = GASTROINTESTINAL; ASA = ACETYLSALICYLIC ACID **Conclusion**: The decision to perform NCS early after PCI should be guided by a multidisciplinary team and patient preference to achieve the most favorable outcome. Decision on cessation of antiplatelet therapy in bleeding events should be based on clinical recommendations and tailored to the overall thrombosis and bleeding risk. Perioperative bridging with intravenous antiplatelet agents may be considered in specific clinical scenarios.

Nikolina Mijač Mikačić, Siniša Roginić, Alan Hodalin, Tereza Knaflec, Iva Zec, Martina Roginić

**Introduction**: Mechanical complications of myocardial infarction are very rare due to reperfusion therapy (1). Postischemic ventricular septal defect (VSD) is the most common mechanical complication occurring in less than 1% of patients, primarily in those with ST-elevation myocardial infarction (STEMI) (2). This is an emergency condition with high mortality, which requires urgent cardiac surgery (3). **Case report**: We present 63-year-old female patient, smoker with obesity who at the Emergency Department with non-specific symptoms such as vomiting, diarrhea and upper abdominal pain which radiates to the back. Later it was revealed that she had chest pain and dyspnea during physical activities for the past 15 days. Clinical examination showed systolic precordial murmur (III/VI) with symptoms of heart failure with tachypnea (26/min). Electrocardiographic findings were subacute myocardial infarction with ST elevation in the anteroseptal region. Laboratory tests confirmed elevated cardiac-specific enzymes with a downward trend after one hour. Also liver lesion was found. Chest X-ray showed acute congestion changes and right pleural effusion. Urgent echocardiography showed normal sized of concentric hypertrophic left ventricle with hypokinesis of middle segment of anteroseptal wall and akinesia of apex. In distal segment of interventricular septum was found VSD (9 mm in diameter) with left to right shunt. Ejection fraction was estimated 40-45% without significant valvular disease with high probability of pulmonary hypertension. Patient was immediately transported to clinical institution whit cardiac surgery capacity. VSD was repaired using pericardial patch. Patient recovered. **Conclusion**: This case shows the importance of clinical examination and electrocardiographic with patients with non-specific symptoms. Mechanical complications of myocardial infarction are rare and unexpected particularly in patients who presents with non-specific symptoms. However, echocardiography, essential method for diagnosing mechanical complications, showed life threatening state of the patient.

Nirvana Šabanović Bajramović, Amer Iglica, Alen Džubur, Edin Begić, Marina Vučijak Grgurević, Senad Bajramović

**Introduction**: Left atrial (LA) mechanical dysfunction due to LA fibrosis, which is common in atrial fibrillation (AF) regardless of LA enlargement, can be assessed by LA strain. Important factor in determining which patients are more likely to experience an AF recurrence following cardioversion is among others the early detection of LA dysfunction. Predicting the likelihood of an AF recurrence prior to electrical cardioversion enables more effective patient selection and avoiding unnecessary risk and treatment costs. In addition, better selection of patients with high probability to FA recurrence enables us to manage more safely further drug treatment. (1-3) The main objective of this study was to assess whether LA function estimated by strain echocardiography carries any additional predictive significance for the early AF recurrence after electrical cardioversion. **Patients and Methods**: In total 36 symptomatic patients (EHRA symptom score ≥3) with permanent atrial fibrillation and preserved systolic function who underwent successful electrical cardioversion were prospectively monitored. Following previous saturation with antiarrhythmic medications, successful electrical cardioversion was performed utilizing synchronized 200J energy to max three times. Mean age of patients was 49.8 ± 5.3 years, 81% of them were male and 19% were female. Prior to cardioversion, a comprehensive echocardiography evaluation was carried out, including measuring the LA volume index and strain. As well TEE evaluation of the LAA was performed in each patient regardless of anticoagulant therapy status. The assessment of rhythm was carried out within the first month following cardioversion (33±3 days). Confirmation of the recurrence of persistent AF at the ambulatory control examination was the main outcome. **Results**: Regardless of the duration of AF, 12 patients (33,3%) of the total study population experienced an AF recurrence. The greatest incremental predictive value for an AF recurrence was found in patients with peak atrial longitudinal strain (PALS) ≤17% (HR =7.37, 95% CI: 3.12–19.25, p < 0.001). PALS≤17% continued to be an independent predictor of AF recurrence in patients with non-dilated LA (HR = 5.23, 95% CI: 2.32–15.71, p = 0.005). **Conclusion**: This study showed that LA function assessment using PALS can serve as an additional predictive marker for early recurrence of AF after electrical cardioversion independent of left atrial volume and AF duration. A better prediction of the early AF recurrence after electrical rhythm conversion allows a better selection of patients who undergo invasive treatment and can facilitate the decision of the clinician in tailoring the treatment strategy in terms of rate or rhythm control.

Andrej Novak, Ivan Zeljković, Ante Lisičić, Ana Jordan, Nikola Pavlović, Šime Manola

**Introduction**: Ventricular late potentials (VLPs) are small, high-frequency signals found at the end of the QRS complex, often associated with areas of fibrosis in the heart. Detecting VLPs is crucial for identifying patients at risk of ventricular arrhythmias and sudden cardiac death. Traditional methods, such as signal-averaged electrocardiograms (SAECGs), rely on the aggregation of multiple beats, but these techniques have limitations in sensitivity and specificity. (1-3) Aim: To develop and evaluate statistical learning models capable of detecting VLPs from a single cardiac beat, potentially reducing the need for time-consuming signal-averaging methods and improving the accuracy of real-time VLP identification. **Methods:** We employed a range of statistical learning models—Decision Tree, Random Forest, TimeSeries Forest, and MiniRocket—to classify ECG beats as containing VLPs or not. The dataset consisted of 4500 beats across three leads (II, V2, V6), with equal representation of beats containing synthetic VLPs. Feature extraction included both time-domain and frequency-domain features, with special emphasis on the Fast Fourier Transform (FFT) and feature engineering to enhance model performance. The interpretability of the models was assessed using SHapley Additive exPlanations (SHAP) to analyze feature importance across all models. **Results:** The Random Forest model achieved the highest accuracy, outperforming other models across all leads, with particularly strong performance in lead V2, where it reached an accuracy of 97.9%. The Decision Tree and TimeSeries Forest models also demonstrated reasonable performance, with the Decision Tree achieving an accuracy of 84.7% on lead V2 and the TimeSeries Forest showing a lower but consistent performance, with an accuracy around 50% across all leads. MiniRocket, while fast, showed the least consistent results, especially in capturing the subtle features associated with VLPs. Feature importance analysis revealed that frequency-domain features, particularly those derived from the FFT and its first derivative, were the most influential in detecting VLPs across models. SHAP further confirmed that these features had the greatest impact on model predictions, particularly in distinguishing beats containing VLPs from those without. Models trained on individual leads consistently outperformed those trained on all leads combined, with lead-specific characteristics playing a significant role in improving classification accuracy. **Conclusion:** Machine learning models, particularly Random Forest, show strong potential in detecting VLPs from single cardiac beats. Training models on individual leads yields better classification performance than using combined leads, confirming that lead-specific characteristics are critical for accurate VLP detection. The findings suggest that incorporating frequency-domain features, especially those derived from FFT, is essential for enhancing model performance. This study demonstrates the feasibility of moving from traditional signal averaging to real-time, single-beat VLP detection using advanced statistical learning approaches, offering a more efficient and accurate method for risk stratification in patients prone to ventricular arrhythmias.

Vedran Pašara, Ivan Prepolec, Andrija Nekić, Hrvoje Šobat, Dragan Schwarz, Davor Miličić, Vedran Velagić

**Introduction**: Cardiac stereotactic body radiotherapy (SBRT) is a treatment option for patients with refractory ventricular tachycardia (VT) despite optimal medical therapy and one or more failed catheter ablation procedures. (1) Several studies have reported that SBRT is associated with reduced VT burden and implantable cardioverter defibrillator (ICD) therapies. (2) This study aimed to assess the clinical outcomes of cardiac SBRT for VT in our institution. **Patients and Methods**: The target substrate for radioablation was determined by combining a preprocedural cardiac computed tomography (CT) scan and 3D cardiac modeling software merged with a real-time CT scan for simulation. All patients were treated with a single 25 Gy fraction using respiratory motion mitigation strategies. We analyzed the outcome of death, the incidence of recurrent VT, and possible side effects of irradiation. **Results**: Three men aged 34, 61, and 66 years with advanced heart failure as a consequence of ischemic heart disease were referred for cardiac SBRT due to VT and ICD therapy recurrence despite antiarrhythmic drugs (AADs) and previously failed catheter ablations for VT. Cardiac SBRT was successfully performed in all patients. During the follow-up, all patients had VT recurrence. In two patients, it happened during a 6-week blanking period, while the third patient had VT recurrence after six months. Two patients eventually received a heart transplant, one and ten months after cardiac SBRT, respectively. The third patient underwent endocardial-epicardial catheter ablation for VT a month after receiving cardiac SBRT, but eventually died nine months post-SBRT due to advanced heart failure worsening. There were no radiotherapy-related adverse events observed during follow-up. **Conclusion**: We demonstrated the feasibility and safety of cardiac SBRT in advanced heart failure patients. However, cardiac SBRT did not achieve successful mid-term arrhythmia control in our selected high-risk patients, and, therefore, efficacy aspects remain unclear. Further studies are needed to clarify this issue.

Natalia Pappo, Josip Aničić, Petra Baumgartner, Zoran Miovski, Ivana Smoljan, Tomislav Jakljević

**Introduction**: Coronary artery spasm can cause transient ischemia that can lead to acute myocardial infarction, arrhythmias and sudden cardiac death (1). Due to ischemia and stressful stimuli in patients with myocardial infarction, lactate and glucose levels can be elevated and possibly dependent on each other (2). **Case report**: 63-year-old woman presented to the Emergency Department with dull chest pain at rest, palpitations and vomiting, preceded by a headache. Her past medical history was significant for myocardial infarction with non-obstructive coronary arteries (MINOCA) accompanied by transient hyperlactatemia and stress hyperglycemia after a stressful event 3 years prior. At that time, coronary angiogram showed normal coronary arteries without significant stenosis and echocardiography showed no significant pathology. Stress cardiac magnetic resonance imaging was also performed and the results were negative for inducible ischemia. During the current admission, the patient was in a fair general state, pale and tachypnoic upon examination, with the same symptoms as in the previous hospitalization. 12-lead electrocardiography (ECG) showed inferolateral ST-segment depression and premature ventricular contractions. Troponin T level measured 210 ng/L. Acid-base status revealed hyperglycemia, lactic acidosis, hypokalemia and hypocalcemia. Standard treatment led to correction in acid-base status. Echocardiography again showed preserved ejection fraction with no wall motion abnormalities and no significant valvular disease. The patient was referred to nephrologist and other causes of lactic acidosis were ruled out. Invasive assessment of coronary microcirculation showed normal findings and a provocative test with acetylcholine was then performed. It revealed diffuse coronary artery vasospasm accompanied by chest pain, inferior and anteroseptal ST depression on ECG with resolution after nitrate application. A diagnosis of vasospastic angina (VSA) was made and diltiazem 60 mg two times a day was recommended. **Conclusion**: VSA is a known cause of MINOCA (3). This case discusses the possibility of VSA being triggered by systematic metabolic disorders, like in our case, lactic acidosis, in opposition to the possibility of VSA being the underlying cause of lactic acidosis and stress hyperglycemia.

Josip Varvodić, Gloria Šestan, Davor Barić, Daniel Unić, Marko Kušurin, Nikola Slišković, Igor Rudež

**Introduction**: Atrial fibrillation (AF) is a common heart arrhythmia with a high prevalence and a growing number of cases globally. The global prevalence of AF is estimated to be around 60 million cases. The lifetime risk of developing AF is about 1 in 3–5 people after age 45. AF contributes to more than 8 million disability-adjusted life years. By 2050, the number of cases is expected to increase by 60%. (1) **Patients and Methods**: In our hospital we have performed 78 procedures since 2003. Formerly only radiofrequency ablation was performed. Program was reinitiated in October 2022. We have performed ablation in 31 patients until April 2024. These results will be presented in this abstract. 20 patients had chronic AF, and 11 patients paroxysmal AF. 65% of patients were male, with average age of 68 years. Average size of left atrium was 5 cm, and average duration of AF was 1.8 years. **Results**: We used AtriCure Cryoice cryoablation probe, and RF Isolator Long Synergy Clamp. 19 patients had contaminant mitral valve surgery, and cryo ablation was done in all of those patients with biatrial full lesion set. 12 patients had non mitral valve surgery (3 CABG, 3 AVR, 3 AVR+CABG, 1 AVR+aorta, 1 TVR) and radio frequent ablation was performed. All patients had LAA excluded. Every patient was administered amiodarone on day of surgery (1200 mg), followed by 200 mg orally daily. NOAC/Warfarin was continued until rhytmologist control visit after three months. 80% of patients were in synus rhythm at three months follow up. Patients remaining in AF were predominantly males with long lasting AF (more than 2.3 years). **Conclusion**: Atrial fibrillation presents a growing health issues and with new guidelines recommendations, having a surgical ablation program is mandatory. We have shown that the program in our institution is in line with results of all other world expert centres.

Matija Vrbanić, Zoran Marić, Ljiljana Švađumović, Biljana Šego, Kristijana Radić, Vlatka Funduk, Darko Navoj, Ivica Benko, Nikola Krajna

Left ventricular assist device (LVAD) is revolutionary in the treatment of advanced heart failure, representing a challenging and complex procedure in the management of patients with severe heart failure, providing significant improvements in quality of life and survival. For patients with end-stage heart failure, LVAD serves as a bridge-to heart transplantation. (1) While LVAD implantation is well-established, the process of its removal, especially through percutaneous techniques, is a new area of interest. After myocardial remission is confirmed, accompanied by satisfactory hemodynamic and echocardiographic findings, the LVAD is typically removed via median sternotomy, followed by complete removal of the pump housing, inflow cannula, and outflow graft, along with closure of the ventriculotomy site and aortic anastomosis. However, this approach requires repeat sternotomy, which poses additional risks, perioperative complications, and increases operative risk if another sternotomy is needed. The removal (decommissioning) of LVAD may be necessary for several reasons, such as heart transplantation, recovery of cardiac function, chronic LVAD-related infections that do not respond to conservative therapy, mechanical failure of the LVAD interfering with its proper function, and some thromboembolic complications. Alongside surgical explantation of the device, percutaneous removal techniques are becoming increasingly common, with transcatheter extraction and minimally invasive surgical techniques being the most frequent methods. The percutaneous removal technique has the advantage of avoiding repeated sternotomy, thereby simplifying any future cardiac surgical interventions. (2) Percutaneous transcatheter removal of LVAD is a complex procedure that involves a process of transcatheter extraction where nurses play a crucial role, significantly contributing to patient care and the success of the procedure. They are also key members of the multidisciplinary team, providing comprehensive care before, during, and after the procedure. Their influence extends across various aspects of the procedural process, including patient preparation, intraoperative assistance, and post-procedural monitoring.

Paula Keblar, Ivica Benko, Verica Šeb, Ružica Lovrić, Patricia Bručić Ričko, Anita Botić, Mateja Šolić, Nikolina Glogovšek

**Introduction**: Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is a rare hereditary condition characterized by structural abnormalities of the right ventricle, often linked to ventricular arrhythmias. Family history analysis, diagnostic procedures, and appropriate treatment are critical to prevent sudden death, with heart transplantation as the only definitive cure. (1, 2) **Case report**: This case presents late-onset ARVD/C in a 38-year-old woman. Diagnosis was confirmed through ECG, MSCT, cardiac MRI, genetic mutation analysis, and frequent ventricular tachycardia from the right ventricle, leading to implantable cardioverter defibrillator implantation as secondary prevention. Despite amiodarone treatment in August 2023, her condition worsened, with increasing heart failure symptoms and NT-proBNP levels, necessitating heart transplantation. The patient underwent heart transplantation in September 2024, followed by a complicated postoperative course. She initially developed metabolic acidosis and rising lactate levels, requiring inotropic and vasopressor support, along with broad-spectrum antibiotics (vancomycin and meropenem). By the third postoperative day, continuous veno-venous hemodiafiltration was needed due to oliguria. Inflammatory markers decreased, and her condition gradually stabilized. Microbiological testing showed urinary colonization with Klebsiella oxytoca and Morganella, both sensitive to ceftriaxone, which was administered. After gradual improvement, including weaning from mechanical ventilation and vasopressor support, she was transferred to the cardiac surgery unit. A myocardial biopsy confirmed good graft function. She was discharged hemodynamically stable, continuing immunosuppressive therapy with regular follow-up. **Conclusion**: This case highlights the complexity of managing patients with advanced ARVD/C, demonstrating the need for continuous nursing education to ensure comprehensive post-transplant care and optimal patient outcomes.

Nikola Škreb, Filip Lončarić, Ivo Planinc, Ivana Ilić, Boško Skorić, Hrvoje Gašparović, Igor Rudež, Mario Udovičić, Anne Bonnin, Hector Dejea, Davor Miličić, Bart Bijnens, Maja Čikeš

**Introduction:** Acute cellular rejection (ACR) of the cardiac allograft is the clinically most relevant complication after heart transplantation (HTx). Light microscopy-based histopathology diagnosis (PHD) of endomyocardial biopsy tissue (EMB) is the golden standard in post-HTx follow-up. Recent studies have demonstrated the application of X-ray phase-contrast imaging (X-PCI) in cardiac tissue imaging, enabling 2D and 3D virtual histopathology (1, 2). **Methods:** 152 EMB samples were collected prospectively at multiple timepoints from 75 Htx recipients in two clinical centres (University Hospital centre Zagreb and Dubrava University Hospital), imaged by X-PCI at the Paul Scherrer Institute TOMCAT beamline (Villigen, Switzerland) with an established imaging protocol3 (average of 6678 images per sample at 0.65 µm pixel size), and then prepared for PHD analysis with light microscopy. Three image datasets of digitalized standard PHD 2D slides, X-PCI 2D images, and X-PCI 3D whole sample scans were prepared for the ACR grade analysis by a pathologist in a blinded fashion based on the ISHLT 2004. criteria. Agreement between methods was assessed using Cohen’s weighted kappa, with clinically relevant grades (2R and 3R) carrying increased magnitude of weight in the calculations. **Results:** A comparison of digitalized PHD slides and X-PCI images of samples with different ACR grades is shown in **Figure 1**. Majority of samples (83.56%) did not show a clinically relevant grade of rejection in all 3 datasets (0R in 76.32% and 1R in 7.24% of samples), 15.79% of samples had 0R and 1R grade variation between datasets, and one sample had a significant 2R grade. Conventional PHD grading showed substantial agreement with both 2D X-PCI (κ = 0.63, 95% CI: 0.41-0.84) and 3D X-PCI histopathology (κ = 0.61, 95% CI: 0.40-0.82), with the highest level of agreement (κ = 0.78, 95% CI: 0.64-0.92) achieved comparing 2D and 3D X-PCI analyses. FIGURE 1. Comparison between digitalised histopathology slides and X-PCI images with selected similar regions of interest of the same sample (0R, 1R and 2R rejection grade). **Conclusion:** A high level of agreement was achieved when comparing 2D and 3D X-PCI virtual histopathology with conventional PHD analysis in ACR grading. X-PCI is a non-destructive method that enables whole EMB sample scanning to assess ACR grading, showing potential for future application in HTx follow-up. ## Acknowledgments Supported by the Croatian Science Foundation (research grant GRAFT-XPCI HRZZ-IP-2020-02-5572).

Katarina Grandavec, Biljana Hržić, Martina Vidak, Petra Kušenić, Magdalena Kunić, Ivica Benko

**Introduction:** Heart transplantation is a complex procedure with a high risk of postoperative complications, including infections that are common due to immunosuppressive therapy. In addition to immediate complications such as bleeding and organ rejection, patients are also prone to long-term risks such as infections, hypertension, kidney failure, and even lymphoma. Infections can persist for up to 18 months after transplantation, requiring close nursing care. (1) **Case report:** This case report presents a 40-year-old patient who underwent a heart transplant due to dilated cardiomyopathy caused by myocarditis and subsequently developed an infection in the form of an abscess in the right axilla, associated with the bacterium Bartonella henselae, the causative agent of cat scratch disease. The bacterium is transmitted through the scratch of an infected cat, causing lymph node inflammation. In immunocompromised patients, such as those with heart transplants, the infection can be serious, prolonging recovery and increasing the risk of complications such as bacillary angiomatosis or endocarditis, which could endanger the transplanted heart. Infection with Bartonella henselae is extremely rare in heart transplant patients. Research shows only one documented case, making this instance unique. Nursing care during the postoperative period of heart transplantation plays a crucial role in monitoring the patient’s condition, preventing complications, and ensuring recovery. The healthcare team must be diligent in managing immunosuppressive therapy to minimize the risk of heart rejection while adequately treating infections. With the cooperation of plastic surgeons, an incision of the abscess was performed, and antibiotics adjusted to the immunosuppressive therapy were administered. The patient was successfully discharged home without further complications. **Conclusion:** This case underscores the importance of vigilant monitoring and infection management in heart transplant patients on immunosuppressive therapy. The rare Bartonella henselae infection highlights the unique risks faced by transplant recipients and the role of attentive nursing care in early detection and intervention. Collaborative, multidisciplinary care was essential in managing the infection and ensuring a successful recovery, emphasizing the need for tailored care approaches in transplant patient management.

Petra Sertić, Ivo Darko Gabrić, Krešimir Crljenko, Krešimir Kordić, Luka Linarić, Ljubica Vazdar, Zdravko Babić, Diana Delić-Brkljačić

**The goal:** To analyze patients who underwent pericardiocentesis at the Intensive Cardiac Care Department, University Hospital Center Sestre milosrdnice, over the past five years, focusing on those with cancer-associated pericardial effusion and their clinical characteristics. **Patients and Methods:** Medical records of all patients who underwent pericardiocentesis between 2019 and 2024 were reviewed. We analyzed patient demographics (median age, tumor type, disease stage), treatment status (active vs. non-active), treatment modality, effusion size, presence of cancer cells in the pericardial fluid, and hospitalization outcomes. **Results:** A total of 60 patients were analyzed, 46% of whom had cancer-related pericardial effusion. The median age of these patients was 71 years (range: 42-87). The most common cancers were lung (n=13) and breast cancer (n=5). Of the 28 cancer patients, 11 had known metastatic disease (63% were in active treatment), and one was in surveillance for early-stage cancer. Additionally, in two patients, pericardial effusion indicated the progression of early-stage melanoma and breast cancer, while three others were newly diagnosed with malignancies. The most frequent treatment was chemoimmunotherapy (n=3), all in lung cancer patients treated with pembrolizumab. Other treatments included chemotherapy, antibody-drug conjugates, and dual anti-HER2 therapy. Cancer cells were detected in the pericardial effusion of 19 patients (67%), with a median effusion size of 27.5 mm (range: 10-50 mm). Four of the 28 cancer patients died during their hospital stay. **Conclusion:** This pilot study highlights the need for improved education on the potential cardiotoxicity of immunotherapies, such as pericardial effusion requiring pericardiocentesis. Early detection and timely intervention for pericardial effusion is essential to ensure continuous anticancer therapy and improve the quality of life for cancer patients. (1-3)

Fabio Kadum, Ana Petretić, Koraljka Benko

**Introduction**: Hedinger syndrome or carcinoid heart disease is a term that represents all cardiac manifestations of carcinoid syndrome. It is a rare disease that requires a high level of clinical suspicion. The presence of cardiac symptoms in the context of carcinoid syndrome means an advanced stage of the disease. (1, 2) **Case report**: We present the case of a 65-year-old male with clinical manifestation of progressive dyspnea, leg edema and profuse diarrhea. Before cardiology referral, the patient underwent multiple diagnostic tests for diarrhea including an infectious disease and gastroenterology workup. Upon presentation, after taking the patient’s history and performing the physical examination, which showed signs of cardiac decompensation, an electrocardiogram was performed showing sinus rhythm with tachycardia and right bundle branch block. Laboratory tests showed polycythemia with slightly elevated cardiac troponin T and N terminal pro brain natriuretic peptide levels. Due to his symptoms combined with 12-lead ECG abnormalities, CT pulmonary angiography was performed, and pulmonary embolism was excluded. Upon admission transthoracic echocardiography was performed and showed preserved ejection fraction, however the tricuspid valve insertion was higher than the mitral valve with signs of severe tricuspid regurgitation. Transesophageal echocardiography excluded the presence of shunts and confirmed severe tricuspid regurgitation with a failure of tricuspid leaflets coaptation. Tumor markers showed an elevated neuron-specific enolase and chromogranin A levels. Hedinger syndrome was suspected. Further tests showed an increase in 5-hydroxyindoleacetic acid. Thoracic and abdominal CT showed liver metastases of unknown origin. A biopsy of the liver lesions was suggestive of a neuroendocrine tumor. Later, a somatostatin receptor scintigraphy showed multiple positive liver lesions, and a magnetic resonance cholangiopancreatography confirmed a neuroendocrine tumor of the tail of the pancreas. Despite all treatment modalities, the patient’s condition got progressively worse, until he eventually passed away. **Conclusion**: Due to bad outcomes, it is important to rise clinical suspicion of Hedinger syndrome in patients with right-sided heart failure and vasomotor changes, mainly by imaging methods and specific laboratory tests. (2, 3)

Paola Bušljeta, Kristina Brumen, Sanda Surina Židan

Nursing documentation has become a crucial aspect of the nursing duties in Croatia following the adoption of the Nursing Act in 2003 and the establishment of the Croatian Chamber of Nurses. According to this legal framework, nurses are required to document all procedures performed for each patient, 24 hours a day, 365 days a year. This documentation provides a clear overview of all procedures carried out, ensuring the delivery of high-quality and safe healthcare. Precise record-keeping minimizes the risk of errors, such as double medication administration, missed procedures, or improper monitoring of vital signs, thereby protecting both the patient and the healthcare staff. At the Department of Intensive Cardiac Care, University Hospital Centre Rijeka, nursing documentation has specific requirements tailored to the needs of patients in critical conditions. This documentation includes: 1. monitoring of vital signs: pulse, blood pressure, heart rhythm, fluid intake and output (intravenous and oral), urine output, vomiting, as well as recording sweating and bowel movements; 2. detailed documentation of interventions such as coronary angiography, monitoring radial wristbands, and recording the administration of therapy (oral, intravenous, and intramuscular); 3. patient categorization, evaluation through scales, and continuous monitoring, which not only ensures medical protection for patients but also provides legal security for nurses and staff. This type of documentation is a fundamental tool for maintaining continuity of care, and accurate record-keeping is essential for preventing errors and ensuring legal protection within complex cardiac procedures. (1)

Valentina Jezl, Romana Ivelić

**Introduction**: Fulminant myocarditis is defined as myocarditis with new-onset severe heart failure that requires the use of inotropes or mechanical circulatory support (1), which arises quickly and has a high mortality rate. The purpose of this study is to describe a case of fulminant myocarditis induced by a COVID-19 infection. **Case report**: On September 25, 2023, a 41-year-old patient with minor symptoms and a fever tested positive for SARS-CoV-2. Prior to hospitalization, the patient was being treated for scleroderma, which was in remission and had been ruled out as a probable cause of the new disease. The patient is admitted to cardiology the next day due to deteriorating conditions, and methylprednisolone and azithromycin medication are initiated. Due to the disease’s progression, hypotension, and an increase in lactate, she was transferred to the critical care unit on the same day with the use of inotropes. Due to her continued poor general state and the requirement for mechanical circulatory support, the patient was transported to University Hospital Center Zagreb’s Institute for Intensive Cardiac Treatment, Arrhythmias, and Transplant Cardiology in the evening. Upon admission, she is aware, slightly fatigued, with a nasal catheter providing 6L/min of oxygen, cold sweating, tachycardia, on a continuous infusion of dobutamine and milrinone, and receiving parenteral corticosteroids and immunoglobulins as directed by the immunologist. Furthermore, the worsening of heart function (EF 15-20%) is monitored, and on the fifth day of hospitalization, Impella CP, mechanical circulatory assistance for the left ventricle, is implanted via a transfemoral route. The third cycle of immunoglobulin and remdesivir is provided for 10 days, and the results demonstrate a decrease in NT-proBNP and troponin levels, as well as a recovery of the left ventricular ejection fraction to 63%. On the seventh day following implantation, Impella CP was successfully removed. On the 18th day of hospitalization, the patient was discharged home in good general health, and at the one-month follow-up examination, she reported full regression of the signs and symptoms of fulminant myocarditis. **Conclusion**: The role of the Impella CP device is to ensure the hemodynamic stability of the patient and sustain it until permanent mechanical circulation support, heart transplantation or recovery. To achieve positive outcomes of treatment, it is necessary to monitor the latest insights and guidelines based on evidence and the multidisciplinary approach in which every member of the team (cardiologists, surgeons, nurses, perfusionists, physiotherapists) plays a responsible role.

Nikolina Slamek, Ivica Benko, Mateja Lovrić, Ivan Zeljković, Mirela Adamović, Marija Grlić, Marina Žanić, Mario Tomašević, Ivan Horvat

**Introduction**: Pulmonary vein isolation (PVI) using freezing method, known as cryoballoon ablation (CBA), involves reaching temperatures as low as -70°C. As a novel method for cardiac ablation, it has proven to be equally effective compared to radiofrequency ablation. CBA is primarily used in treating atrial fibrillation (AF) in individuals who continue to have symptoms despite therapy or have developed resistance or intolerance to antiarrhythmic drugs. While generally considered safe, complications can still occur. This paper discusses gastroparesis, a rare but potential complication following CBA. Gastroparesis results in delayed gastric emptying. (1) **Case report**: We present a 59-year-old female patient, who was treated with CBA for paroxysmal AF. Her medical history included breast cancer surgery, chemotherapy, radiotherapy, and ongoing hormone therapy. After chemotherapy, episodes of AF began, initially brief and infrequent but becoming more frequent and intense over time, for which she was examined in Emergency Department (ED) multiple times. During her hospital stay CBA was performed. She remained hemodynamically stable throughout the procedure, with the lowest temperature reaching -56°C. The patient had no immediate complaints and was discharged the next day in a stable condition. However, two days after the procedure, the patient returned to the ED with severe abdominal distension caused by food retention. Fluoroscopy revealed a highly distended stomach extending to the pelvic inlet, with weakened peristalsis but no pyloric damage. Gastroscopy showed solid food remnants in the esophagus and stomach. Oral intake was suspended, and gastrointestinal decompressions were performed multiple times. After seven days of hospitalization, the patient’s condition improved, and she was discharged with dietary recommendations. **Conclusion**: It is crucial to emphasize that complications from CBA may not always manifest during or immediately after the procedure. In rare cases, symptoms can develop several days later. Patients may not associate these symptoms with the procedure, highlighting the importance of thorough patient education. Medical staff should also be aware of potential complications and trained to manage them efficiently, ensuring timely and effective care. (2, 3)

Matija Vrbanić, Darko Navoj, Ljiljana Švađumović, Biljana Šego, Kristijana Radić, Vlatka Funduk, Zoran Marić, Nikola Krajna, Ivica Benko, Mario Salajec

Pulmonary embolism (PE) is a clinical condition characterized by the obstruction of pulmonary arteries, typically caused by thrombi originating from the venous system. It poses a significant risk of morbidity and mortality, particularly in patients with hemodynamic instability. Percutaneous thrombectomy has become a key intervention in the management of PE, especially for patients who are not candidates for conventional anticoagulation therapy or those who exhibit severe forms of the disease. The management of pulmonary embolism involves a multidimensional approach that encompasses diagnosis, risk assessment, and intervention. Percutaneous thrombectomy can be performed using various techniques, including catheter-directed thrombolysis and mechanical thrombectomy. Mechanical thrombectomy techniques, such as the use of aspiration devices or stent retrievers, allow for the physical removal of thrombus from the pulmonary arteries. (1) Each method has its own indications, risks, and benefits, necessitating a tailored approach based on individual patient factors. The role of nursing professionals in managing patients undergoing percutaneous thrombectomy is crucial. Nurses are vital members of the multidisciplinary team, involved in preoperative assessment, intervention, patient education, and postoperative care. Their responsibilities include monitoring vital signs, assessing potential complications, and ensuring adherence to safety protocols throughout the procedure. During the procedure, nurses play a key role in monitoring the patient’s hemodynamic status and responding promptly to any changes. Their ability to recognize early signs of complications, such as bleeding or respiratory distress, is essential for optimizing patient outcomes. In conclusion, percutaneous thrombectomy for pulmonary embolism represents a significant advancement in the management of this serious condition. The collaboration of a multidisciplinary team is crucial for optimizing patient outcomes. As the field continues to evolve, the contributions of nursing professionals will remain essential in shaping best practices and improving the long-term management of pulmonary embolism.

Renata Čosić, Ivana Tomašić, Martina Kralj

**Introduction**: The implantation of a left ventricular assist device (LVAD) represents a crucial solution for patients with advanced heart failure, either as a bridge to transplantation or as long-term therapy. However, gastrointestinal bleeding is one of the most common and serious complications in these patients, particularly during the preparation for LVAD implantation, due to several specific factors related to the underlying condition and the therapy these patients receive. (1, 2) **Case report**: The patient, a 71-year-old male diagnosed with advanced heart failure, was a candidate for the implantation of a left ventricular assist device (LVAD). Several weeks before the planned surgery, an implantable cardioverter-defibrillator (ICD) was placed due to the high risk of sudden cardiac death. His hospital stay was complicated by rectal bleeding accompanied by a drop in hemoglobin levels, which was corrected with a blood transfusion. To assess the cause of the anemia and rectal bleeding, further diagnostic evaluation of the gastrointestinal tract was conducted. Colonoscopy revealed a large polyp measuring 4-5 cm in the sigmoid colon. After the removal of the polyp, the patient was closely monitored for potential complications, such as bleeding, but no signs of complications were observed. After successful stabilization of hemoglobin levels, the patient underwent LVAD implantation without perioperative complications. Anticoagulant therapy was carefully titrated to avoid postoperative gastrointestinal bleeding, given the recent endoscopic intervention. **Conclusion**: Gastrointestinal bleeding in patients prior to LVAD implantation presents a significant challenge due to the complexity of pathophysiological and therapeutic factors. Successful strategies include early risk identification, optimization of the patient’s condition, careful management of anticoagulant therapy, and a multidisciplinary approach. This case highlights the complexity and intricacies of nursing care for a patient with advanced heart failure requiring LVAD implantation. Early identification of the cause of anemia and successful endoscopic removal of the polyp enabled the safe execution of the LVAD implantation.

Mislav Puljević, Mia Dubravčić Došen, Vedran Pašara, Ivan Prepolec, Pero Hrabač, Ana-Marija Brekalo, Martina Lovrić-Benčić, Miroslav Krpan, Richard Matasić, Borka Pezo Nikolić, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: While implantable cardioverter-defibrillators (ICD) effectively reduce sudden cardiac death, their impact on overall survival differs between ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM). (1-3) This study investigates survival outcomes and the significance of age in a cohort of ICD recipients. **Patients and Methods**: A retrospective cohort of 786 patients who underwent ICD implantation between 2009 and 2018 was analyzed. Survival outcomes were assessed with a focus on differences between ICM and NICM, and the influence of age on device efficacy. **Results**: Patients with NICM showed a lower rate of appropriate device activation compared to ICM (23% vs. 28%). Despite this, ICD implantation significantly improved survival in both groups, with younger patients (<70 years) benefiting the most. Age, non-sustained ventricular tachycardia (NSVT), and cardiac decompensation history were strong predictors of (non)survival. **Conclusions**: ICD implantation offers clear survival benefits in both ICM and NICM, though younger patients and those with ischemic cardiomyopathy experience better outcomes. Age and cardiomyopathy type are crucial factors in determining the effectiveness of ICD therapy.

Viktoria Lišnić, Fran Šaler, Marin Viđak, Ana Marušić

**Introduction**: Atrial fibrillation (AF) is a major global health issue that requires a careful assessment of both conservative and invasive treatments (1). Decisions must consider patient preferences, success rates, and potential adverse events (AEs), which are any undesirable occurrences during trials. Inconsistent AE reporting can mislead conclusions about treatment safety and efficacy. To improve patient safety, clinical trials should be preregistered in public databases like ClinicalTrials.gov, with accurate and consistent reporting. However, discrepancies between registry data and corresponding publications are common (2). This study aims to evaluate the completeness and consistency of AE reporting in registered AF trials and related publications. **Methods**: This cross-sectional study analyzed AF trials registered on ClinicalTrials.gov with matching publications. A search for completed AF treatment trials using “atrial fibrillation” was conducted on November 5, 2023. Two authors (VL, MV) independently screened trials, extracted AE data, and checked for inconsistencies. Discrepancies were classified as inconsistent, with a third author (FŠ) resolving disagreements. **Results**: Of 340 identified trials, 75 with publications were analyzed. All trials in the registry reported serious adverse events (SAEs) and other AEs (OAEs). However, only 48 publications (65%) reported SAEs, and 47 (63%) did not report OAEs. In 12 publications (16%), only total AE numbers were mentioned. SAEs were more frequently reported in the registry than in publications (p=0.0468), with OAE reporting in only 26 publications (p=0.0011). Discrepancies were higher in invasive procedure trials. Industry-sponsored trials (n=52) showed more SAE reporting inconsistencies (p=0.0304). **Conclusions**: AE reporting for AF trials is thorough on ClinicalTrials.gov but inconsistent in publications. Improving publication reporting is critical for enhancing patient safety and translating trial evidence into practice.

Matea Mamić, Petra Baumgartner, Zoran Miovski, Tomislav Jakljević

**Introduction**: Vasospastic angina is a clinical condition that occurs as a result of an abnormal spasm of the coronary arteries. It includes chest pains during rest, transitory ST-T segment changes, and adequate response to nitrates. (1) **Case report**: We report the case of a 44-year-old male who presented to the Emergency Department by ambulance due to chest pain that woke him during the night. The pain was localized in the middle of the chest, without any propagation. He complained of nausea and sweating. During the transport, he suffered cardiopulmonary arrest with the initial rhythm being ventricular fibrillation. He was defibrillated successfully. Upon arrival to the emergency room, his symptoms subsided. Electrocardiogram showed ST-elevations in leads V1-V6. Laboratory results revealed elevated troponin T levels of 108 ng/L. He was admitted to the Intensive Care Unit. Coronarography established atherosclerotic disease of the left coronary artery without significant stenosis, so an acetylcholine test was indicated. During the test, upon administration of acetylcholine, the patient developed chest pain followed by vasospasm of coronary arteries. The vasospasm subsided after the application of nitroglycerin and the diagnosis of vasospastic angina was confirmed. He was prescribed diltiazem and discharged home. **Conclusion**: Although vasospastic angina is a rare form of angina, it should always be considered as a potential diagnosis because in a small percentage of cases, it can lead to sudden cardiac death.

Vedran Velagić, Vedran Pašara, Ivan Prepolec, Andrija Nekić, Zvonimir Katić, Davor Miličić

**Introduction**: We aimed to investigate the feasibility and safety of zero-fluoro approach for the repeat atrial fibrillation (AF) procedures after initial cryoballoon (CB) ablation. **Patients and Methods**: We have performed a retrospective study on patients that have undergone repeat pulmonary vein isolation (PVI) procedures in our institution since zero-fluoro program was initiated in 2020. All patients received CB ablation for the initial procedure. Repeat procedures were performed under conscious sedation and with intracardiac echo (ICE) and 3D mapping system - without the use of fluoroscopy and lead aprons. **Results**: We have analysed in total 50 patients (76% male, 57.9±10.2 years old), 50% of which suffered from paroxysmal AF. All procedures were successfully performed without the use of fluoroscopy. The mean procedure time was 93.9 ± 27.1 min and the mean RF time was 825 ± 468 sec. The mean of 0.98 ± 0.91 veins was reconnected per patient and 36% of patients did not have PV reconnections. In all patients successful PV isolation was performed, confirmed by entry and exit block. No major periprocedural complications were observed. After the mean follow up of 12.5 ± 3.4 months: 68% of mixed AF population patients were free from AF after one year. **Conclusion**: In our cohort of patients, zero-fluoro, apron-less approach for repeat PVI procedures after index cryoballoon ablation proved to be feasible and safe. Index CB ablation resulted with low rates of PV reconnections and mid-term results after repeat procedures are favourable. (1)

Merljinda Ljušaj, Ivan Zeljković, Ana Jordan, Jasmina Ćatić, Petra Vitlov, Fran Šaler, Dominik Buljan, Šime Manola, Marin Pavlov, Ivana Jurin

**Introduction**: Acute myocardial infarction (AMI) can result in long-term left ventricular remodeling that alters its dimensions and function. These changes are critical prognostic factors for mortality following AMI. Since not all patients experience left ventricular dysfunction after AMI, the aim of our study was to identify the predictors that contribute to the non-recovery of left ventricular ejection fraction (LVEF). (1, 2) **Patients and Methods**: A single-centre analysis included 925 patients who were followed from their hospitalization for acute coronary syndrome (ACS) up to one year after, during the period from December 2016 to June 2023. **Results**: The median age was 63 years (interquartile range IQR: 55-70) and 71% were men. The median LVEF was 55% (IQR: 50-60), at discharge and after one year. The median left ventricle end-diastolic diameter (LVEDD) at time of ACS was 52mm (IQR: 47-55). After one year of follow up, patients were categorized into two groups: patient with non-recovery of LVEF (69%) and those with recovery of systolic function by >= 5% (31%). Among patients with ST-elevation myocardial infarction (STEMI), 65% did not recover LVEF, while 72% of patients with non-ST-elevation myocardial infarction (NSTEMI) failed to recover systolic function. Additionally, 72% of patients with NSTEMI, those with recurrent acute coronary event, left anterior descending artery (LAD) involvement and increased LVEDD showed no recovery of systolic function after one year (all P<0.05). With a multivariate logistic regression model analysis, LVEDD (OR 1.01, CI 1.002-1.027, P = 0.02) and LAD involvement (OR 1.44, CI 1.044-1.986, P = 0.02) were identified as significant individual predictors of poor LVEF recovery. Although ACS type, troponin levels, and previous AMI did not individually predict outcomes, when combined with LVEDD, these factors provided important prognostic information for predicting weaker systolic function recovery (P = 0.003). **Conclusion**: This study shows that LVEDD and LAD involvement have a small, but statistically significant impact of predicting poorer LVEF recovery as individual factors. When combined with other risk factors, specifically LVEDD, they become strong predictors, highlighting the importance of comprehensive approach.

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

**Introduction**: Implantable cardioverter-defibrillators (ICDs) are the gold standard for preventing sudden cardiac death (SCD). Subcutaneous ICDs (S-ICDs) offer an alternative to traditional transvenous devices (TV-ICDs), reducing the risk of lead complications and systemic infections and offering safe and effective therapy in case of anatomic constraints. (1, 2) The new extravascular ICD (EV-ICD) is being developed as an option that addresses some limitations of both TV-ICDs and S-ICDs. However, adopting these technologies involves increased costs and a learning curve for new implantation centres. **Patients and Methods**: We analysed data on all non-TV-ICDs implanted at University Hospital Centre Zagreb since their introduction in December 2021. **Results**: A total of 19 patients (68% male) were included, with a median age of 49 years (range 10-73). Eighteen patients received S-ICDs for primary SCD prevention, while one 10-year-old patient received an EV-ICD for secondary prevention after a failed TV-ICD implantation due to ischemic cardiomyopathy (ICM). The indications for S-ICD use included ICM (6 cases), hypertrophic cardiomyopathy (5 cases), and non-ischemic cardiomyopathy (7 cases). Various reasons for choosing S-ICD over TV-ICD were noted: 8 patients had severe kidney failure (3 with chronic dialysis catheters), 5 were young and preferred S-ICD, 4 had anatomical constraints preventing TV-ICD placement, and one had a prior TV-ICD infection. The first 6 implants were conducted with the assistance of an experienced proctor. In one S-ICD case, the defibrillation test was unsuccessful requiring lead repositioning during revision procedure. One patient experienced inappropriate S-ICD activation one day post-implantation, but no other periprocedural complications occurred. During follow-up, 5 patients had appropriate device activations; 2 patients died of congestive heart failure and chronic renal insufficiency, and 2 received heart transplants (one being a combined heart-kidney transplant). **Conclusion**: Non-TV-ICDs have been successfully integrated into our practice over the past three years. Increasing expertise with these newer technologies is crucial to meet the rising demand for SCD prevention in specialised patient populations. However, broader adoption remains challenged by reimbursement issues.

Nives Bognar, Valentina Sedinić, Vesna Erceg, Tomislav Glavak

**Introduction**: Cancer and heart failure represent serious health issues that are interconnected, as certain types of cancer and their treatments can significantly impact cardiovascular health. Heart failure may occur because of the toxic effects of chemotherapy, radiation therapy, or the tumor itself, leading to decreased cardiac function and an increased risk of severe cardiac arrhythmias. In such cases, the implantation of an implantable cardioverter-defibrillator (ICD) can be a crucial preventive measure against sudden cardiac death. (1) **Case report**: This case involves a 44-year-old female patient with an implanted subcutaneous ICD due to toxic cardiomyopathy and reduced ejection fraction, a consequence of a primary breast cancer diagnosis. The patient presented at the electrophysiology clinic feeling anxious, frightened, and distracted, reporting a possible ICD activation while dancing. This case emphasizes the importance of a multidisciplinary approach and holistic care for patients with complex health issues. To rule out potential complications, we first tested the ICD device. The memory of the intracardiac ECG showed no shock activation, confirming that there was no actual cardiac arrhythmia when the patient experienced her symptoms. Additional examinations were conducted, including cardiac MRI, chest X-ray, laboratory tests, and ECG. (2) Through conversation with the patient, we assessed her anxiety level, which was primarily related to the fear of unexpected ICD activation in everyday situations. Education played a crucial role in our approach: we explained in detail how the device works and under what conditions it might activate. We also reiterated proper behavior and emphasized that she could continue her activities, including dancing, without fear. Additionally, we recommended further psychological support to help her cope with her fears. **Conclusion**: This case highlights the importance of a holistic approach to patients with ICDs. Along with technical device checks, it is equally important to understand the patient’s emotional needs. Education, clear communication, and providing support are crucial for reducing anxiety and enabling a safe return to daily activities. A multidisciplinary team, including nurses, cardiologists, oncologists, and psychologists, can significantly contribute to optimizing care and long-term outcomes for patients with subcutaneous ICDs.

Karla Štivičić, Ingrid Bingula

A heart biopsy is a diagnostic method often used to monitor patients after heart transplantation. The goal of the biopsy is to detect signs of transplant rejection and assess any other potential complications, such as infections or heart muscle diseases. A heart biopsy involves taking small samples of heart muscle tissue for microscopic analysis. This method allows doctors to identify early signs of transplant rejection, which is crucial for timely treatment and preserving the function of the transplanted heart. The procedure can be performed in several ways, with the most common method involving the insertion of a catheter through a vein in the neck (jugular vein), which is then guided to the right atrium of the heart. Through the catheter, a bioptome - a small device used to take tissue samples - is inserted into the heart. The procedure is minimally invasive, and patients typically experience mild discomfort but not pain. There is also the option of a femoral approach, where the catheter is inserted through the groin vein. Although biopsies are more frequently performed during the first few months after transplantation, when the risk of rejection is highest, they are conducted less often later on but remain an important tool for long-term patient monitoring. Histological analysis of the samples taken during the biopsy allows for the classification of rejection levels according to internationally recognized criteria, such as the International Society for Heart and Lung Transplantation guidelines. (1) Based on biopsy findings, doctors can adjust therapy to reduce the risk of rejection and damage to the transplanted heart. Although heart biopsy is a relatively safe procedure, complications such as bleeding, perforation of the heart wall and arrhythmias can occur. However, these complications are rare when the procedure is performed by experienced physicians. Heart biopsy is a crucial tool in post-transplant monitoring, enabling the early detection of transplant rejection and therapy adjustment. The procedure is minimally invasive, and its significance in preventing complications makes it a standard practice in transplant medicine.

Lucija Grbić, Dubravka Šipuš, Luka Perčin, Dora Fabijanović, Marijan Pašalić, Hrvoje Jurin, Ivo Planinc, Jure Samardžić, Maja Čikeš Vodušek, Boško Skorić, Davor Miličić, Daniel Lovrić

**Introduction:** Fulminant myocarditis (FM) is a severe and rapidly progressive cardiac inflammatory disease which has historically high mortality rates of >50%. However, recent improvements in treatment options, especially in mechanical circulatory support (MCS), have significantly enhanced survival rates (1, 2). **Patients and Methods:** We retrospectively analyzed data from patients who required MCS for FM from the beginning of 2023 to the present. We used descriptive statistical methods to analyze demographic and epidemiological data, treatment options, laboratory data and outcomes. **Results:** Since the beginning of 2023, eight patients admitted for FM required MCS. 50% were male, median age 40 years (range 18 – 55 years). The cause of FM was Influenza in 4 cases, SARS-CoV-2 in 1 case, S. pyogenes in 1 case, while the etiology remains unknown in 2 cases. Before the initiation of MCS, median lactates were 10.55 mmol/L (range 2 – 13.6 mmol/L) and median mean arterial pressure was 68.5 mmHg (range 45 – 85 mmHg). All patients were on inotropic support with dobutamine (median dose 9.72 mcg/kg/min, range 4.48 – 16.6mcg/kg/min) and two received additional milrinone at a dose of 0.5 mcg/kg/min. Four patients required support with norepinephrine (median dose 0.26 mcg/kg/min, range 0.11 – 0.4 mcg/kg/min) and two required additional support with argipressin and angiotensin II. Upon admission, laboratory findings showed a median NT-proBNP of 18,069 ng/L (range 3,373–25,252 ng/L), median troponin I of 3,929.5 ng/L (range 8.5–>50,000 ng/L), and median CRP of 69.3 mg/L (range 2.60–268.7 mg/L). Three patients were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for transport to University Hospital Center Zagreb. In total, 6 patients required VA-ECMO support, of whom 4 needed left ventricular unloading (2 with Impella and 2 with ProtekSolo), and 2 required reconfiguration of the ECMO circuit to VAV ECMO due to poor oxygenation. One patient was solely on Impella CP support, and one patient was solely on VV ECMO support. Median MCS support time was 216 hours (range 98 – 480 hours). All patients were successfully weaned from MCS, although one patient died due to MCS complications. In one case, heart function did not recover, leading to the implantation of long-term MCS. Full patients’ data are shown in **Table 1** and **Figure 1**. ### TABLE 1: Patient characteristics. | | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Gender | Male | Male | Male | Male | Female | Female | Female | Female | | Age (years) | 52 | 52 | 21 | 29 | 18 | 41 | 55 | 38 | | BMI (kg/m2) | 24.3 | 22.5 | 26.5 | 28.8 | 18.4 | 20.3 | 29.4 | 16.6 | | Comorbidities | Asthma Gastritis | Emphysema Gastritis Smoking | / | Smoking | / | Scleroderma Smoking | Hypertension Hypothyroidism | Asthma Smoking | | Etiology | Influenza B | Influenza A | ? | Influenza B | ? | SARS-CoV-2 | Influenza A | S. pyogenes | | ECHO, admission: EF (%) TAPSE (mm) | 20 / | 10 5 | 15 11 | 35 10 | 35 / | 15 26 | 35 18 | 40 12 | | MAP (mmHg) | 80 | 49 | 81 | 85 | 45 | 70 | 67 | 48 | | Lactate (mmol/L) | / | 13.5 | / | 4.6 | 12 | 9.1 | 13.2 | 2 | | Inotropes/ vasopressors | **Dobutamine** 7.84 mcg/kg/min **Levosimendan** | **Dobutamine** 10.26 mcg/kg/min **Norepinephrine** 0.31 mcg/kg/min | **Dobutamine** (unknown dose) | **Dobutamine** 4.48 mcg/kg/min **Milrinone** 0.5 mcg/kg/min | **Dobutamine** 16.6 mcg/kg/min, **Norepinephrine** 0.33 mcg/kg/min | **Dobutamine** 9.72 mcg/kg/min **Milrinone** 0.5 mcg/kg/min | **Dobutamine** 11.1 mcg/kg/min **Norepinephrine** 0.4 mcg/kg/min **Argipressin** **Angiotensin II** 20 ng/kg/min | **Dobutamine** 9 mcg/kg/min, **Norepinephrine** 0.11 mcg/kg/min **Argipressin** **Angiotensin II** 40 ng/kg/min | | MCS | VA ECMO Impella | VAV ECMO | VAV ECMO Impella | VA ECMO ProtekSolo | VA ECMO ProtekSolo Impella | Impella | VAV ECMO Impella | VV ECMO | | MCS duration (h) | 98 | 480 | 135 | 240 | 321 | 192 | 480 | 100 | | Hemodialysis/ filters | / | CVVHDF + Oxiris | Cytosorb | / | CVVHDF Cytosorb+Seraph | / | CVVHDF + Cytosorb | CVVHDF + Oxiris | | Corticosteroids | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone Hydrocortisone | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone Hydrocortisone | | Immunoglobulins | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | | Complications | Death | Sepsis GI Bleeding Limb ischemia | Harlequin syndrome | Sepsis | Sepsis | / | Impella thrombosis | Limb ischemia | | ECHO, discharge: EF (%) TAPSE (mm) | 50 | 50 13 | 40 18 | 58 20 | 15 5 | 63 26 | 45 18 | 50 12 | | Outcome | Death | Discharged | Discharged | Discharged | LVAD implantation | Discharged | Discharged | Discharged | [†] BMI = body mass index; CVVHDF = continuous venovenous hemodiafiltration; ECHO = echocardiography; EF = ejection fraction; LVAD = left ventricular assist device, MAP = mean arterial pressure; MCS = mechanical circulatory support; TAPSE = tricuspid annular plane systolic excursion; VA/VAV/VV ECMO = veno-arterial/veno-arterial-venous/veno-venous extracorporeal membrane oxygenation FIGURE 1. **Laboratory parameters.** NT-PROBNP = N-terminal prohormone of brain natriuretic peptide; CRP = C-reactive protein **Conclusion:** Our data support the finding that MCS should be considered in FM and that MCS can be associated with promising results.

Andrea Pleša, Nikolina Jurković Dubravčić, Renee Mixich, Senka Pejković

The implantation of implantable loop recorders (ILR) in the context of a cardiac day hospital offers numerous benefits, particularly in terms of more efficient resource utilization. Traditionally performed in invasive labs, transitioning this minimally invasive procedure to day hospitals alleviates the burden on invasive labs and reduces the need for patient hospitalization. This leads to faster recovery and a lower risk of hospital-acquired infections. Nurses play a critical role in this process, with responsibilities ranging from organizing the procedure and educating patients to preparing for the intervention and providing postoperative care. Nurses need to possess specific skills, including knowledge of implantation techniques, managing postoperative complications such as hematomas or device dislocations, and communication skills to effectively inform patients about their recovery and device usage. According to available research, the inclusion of nurses in the ILR implantation process has shown excellent results. Programs led by nurses have demonstrated success rates comparable to those in invasive labs, with fewer complications and quicker patient recovery. In conclusion, ILR implantation through day hospitals require a high level of organization and expertise, particularly among nurses. They must be equipped with specific knowledge and skills to ensure safe and effective care for patients. (1-3)

Biljana Hržić, Nikolina Slamek, Katarina Grandavec, Martina Vidak, Petra Kušenić, Magdalena Kunić, Ivica Benko

**Introduction**: Carney Complex (CNC) is a rare, autosomal dominant genetic syndrome characterized by the development of benign connective tissue tumors (myxomas), skin pigmentation changes, endocrine abnormalities, and tumors in other tissues. This syndrome is associated with mutations in the PRKAR1A gene, which plays a crucial role in the regulation of cellular growth. Cardiac myxomas are rare in the general population, with an incidence of 0.5–1 per million people per year, but they are frequently observed in patients with Carney Complex, appearing in 20–40% of cases. These myxomas are a leading cause of death among CNC patients, often being multiple and sometimes present at birth. Recurrence of myxomas in these patients is linked to the excessive secretion of growth hormone. Surgical treatment is the primary therapeutic approach for atrial myxomas, and regular follow-up is essential for preventing complications and managing the risk of recurrence. (1, 2) **Case report**: This case involves a 46-year-old female patient who was hospitalized due to a tumor in the left atrium. She had a history of Hashimoto’s thyroiditis, iron deficiency anemia, and mild allergic asthma. The tumor, measuring 37x47 mm, was attached by a stalk to the interatrial septum, and was diagnosed at another healthcare facility. Clinical signs and symptoms raised suspicion of Carney Complex, leading to a thorough endocrinological evaluation. After a cardiology and cardiothoracic surgery consultation, surgical intervention was deemed the optimal treatment approach. The surgery was successfully performed, and the patient was discharged in good condition with recommendations for ongoing follow-up. **Conclusion**: Nursing care for patients with atrial myxomas and Carney Complex requires a specialized, individualized approach due to the complexity of the condition. It is crucial to recognize symptoms early, provide necessary support, and ensure a safe recovery. The focus is on continuous assessment, multidisciplinary collaboration, and patient support to minimize the risk of complications and achieve optimal treatment outcomes.

Vesna Grubić, Lucija Šegović, Iva Bušić

Septal ablation (PTSMA) is a minimally invasive procedure used to treat hypertrophic obstructive cardiomyopathy (HOCM), a condition characterized by thickening of the heart muscle and obstruction of the left heart outflow tract. PTSMA reduces the thickness of the septum, improving blood flow and alleviating symptoms such as dyspnea, angina, and syncope. It is an invasive procedure during which a localized acute myocardial infarction (AMI) is intentionally induced in the septal area. (1-3) Patient preparation for septal ablation involves several important nursing interventions. Psychological preparation consists of explaining the entire procedure, potential complications during and after the intervention, and physical preparation (intravenous access, electrocardiogram - ECG, shaving of the groin area). Alcohol septal ablation is performed under local anesthesia. The procedure is preceded by the implantation of a temporary endovenous electrical stimulator due to the risk of conduction disturbances during and after the ablation procedure. The right femoral artery and right femoral vein are punctured for the introduction of the temporary pacemaker. The procedure involves the injection of a small amount of ethanol into the septal artery, resulting in a subsequent myocardial infarction in the targeted area of hypertrophic myocardium associated with obstruction. Immediately after the administration of ethanol, there is an instant akinesia of the targeted part of the septum, which facilitates blood flow and reduces the dynamic component of obstruction related to myocardial contractility. Post-septal ablation nursing care involves several aspects: monitoring (ECG, respiratory status, blood pressure, pulse), inspection of the arterial puncture site, and the site of the temporary pacemaker. The temporary pacemaker remains in place for up to 72 hours to ensure proper heart rhythm. Creatine kinase (CK) is measured daily for three days to monitor potential myocardial damage and assess heart function after the procedure. (1-3) Septal ablation is an important procedure for patients with HOCM, and nursing care plays a crucial role in ensuring optimal preparation, implementation, and post-interventional care, thereby reducing complications, facilitating hospital stay, and improving the patients’ quality of life.

Patricia Bručić Ričko, Verica Šeb, Ružica Lovrić, Ivica Benko, Paula Keblar

In modern society, health is shaped by complex interactions between biological, social, and economic factors. Key aspect influencing health outcomes, particularly in cardiology, is the socioeconomic status (SES) of patients. Research shows that low SES significantly impacts hospital readmission rates, with wide-reaching consequences for patients, healthcare systems, and society. SES includes factors such as education, employment, income and living conditions, all of which affect access to healthcare services health behaviors and the ability of patients to follow medical advice. (1) Patients with lower SES often face delays in diagnosing and treating cardiovascular diseases due to limited access to quality healthcare. This delay in care leads to the progression of diseases resulting in more frequent and severe hospitalizations. Low SES is also associated with higher rates of hospital readmission due to several factors, including financial limitations that hinder adherence to treatment guidelines. The inability to afford medications or follow medical recommendations increases the risk of complications, requiring frequent hospitalizations. Additionally, psychosocial factors such as stress, anxiety, and depression play a significant role. These challenges, combined with difficulties in accessing healthcare can prevent regular check-ups and early detection of problems, further exacerbating the situation. Patients with low SES are more likely to suffer from severe forms of disease that lead to increased hospital readmissions which affect their quality of life and place financial strains on the healthcare system. Nurses play a crucial role in addressing these challenges. Their role goes beyond care provision; they are responsible for educating patients, providing support and ensuring coordination between various healthcare professionals. Nurses can recognize early signs of health deterioration, which allows them to intervene before hospitalization becomes necessary. Through patient education, close monitoring and care coordination, nurses can significantly reduce the risk of hospital readmission. Investing in nursing interventions enhances patient outcomes, improves quality of life and strengthens the overall healthcare system by reducing the burden of frequent hospitalizations.

Stella Kamenjašević, Lana Šabić

**Introduction**: Pulmonary embolism is obstruction of one or more branches of the pulmonary artery caused by a clot that most often forms in the veins of the legs or pelvis and reaches the lungs through the bloodstream. It is a condition that requires immediate diagnostic workup and therapy. CT angiography of the pulmonary arteries is a gold standard when diagnosing pulmonary embolism. Symptoms and signs are dyspnea accompanied by chest pain and cough, tachycardia and headache. One of the possible and at the same time the most serious complications is sudden cardiac arrest. Fainting and convulsions occur due to the reduced ability of the heart to deliver a sufficient amount of oxygenated blood to the brain and other organs. Standard treatment is anticoagulant therapy and/or fibrinolytics, the use of oxygen and supportive therapy such as analgesics and sedatives. It is important to inform the patient about possible complications in a timely manner. (1-3) In this paper, we will present the case of the patient with a massive pulmonary embolism. **Case report**: A 40-year-old female patient was admitted to Intensive Cardiac Care unit after surviving out of hospital cardiac arrest. Patient recently had laparoscopic gynecological surgery due to menometrorrhagia and was on oral contraceptive therapy. Upon arrival at the emergency department the patient was unconscious and had no pulse, cardiopulmonary resuscitation was performed until spontaneous circulation was established. The patient was intubated and mechanically ventilated. MSCT pulmonary angiography showed bilateral massive pulmonary embolism. During the patient’s stay in Intensive cardiac care unit, trained nurses monitored daily vital functions and recorded changes in them. Due to hemodynamic instability, vasopressors and inotropes were initiated. Due to a recent surgical procedure, a mechanical thrombectomy was performed through the right femoral vein, during which a significant amount of clots were removed. Due to recurrent and persistent hemodynamic instability after thrombectomy, alteplase fibrinolytic therapy was administered, which led to only temporary stabilization. Unfortunately, ones again patient condition was getting worse and she was in cardiogenic shock that did not respond to medical therapy. ECMO circulatory support was instituted. After hemodynamic stabilization ECMO decannulation was performed three days later and patient was extubated the day after. This was followed spontaneous breathing with preserved consciousness and adequate contact with the environment. Given the complexity of the patient’s condition, the nurses created an adequate health care plan and selected interventions to achieve the set goal as best as possible. The patient was stable and discharged home awaiting further rehabilitation. **Conclusion**: In addition to patient care, nurses participate in education and psychological support. It is a serious and potentially fatal condition that requires quick and coordinated teamwork of healthcare professionals, which is crucial for quick diagnosis, adequate treatment and recovery of the patient.

Andrija Matijević, Ivo Darko Gabrić, Marin Boban, Ozren Vinter, Marko Boban, Krešimir Kordić, Ljubica Vazdar, Matias Trbušić

**Introduction:** Neoadjuvant protocols are vital for improving outcomes for patients in HER2-positive breast cancer by reducing tumor mass and micrometastases before surgery. Dual HER2 receptor blockade, using trastuzumab and pertuzumab, is the gold standard in this context and is generally considered safe. (1-3) However, cardiotoxicity remains a serious complication impacting subsequent treatment, delaying surgery and necessitating adjustments to oncologic therapy. **Case series:** We present a series of six patients with HER2-positive breast cancer who developed cardiotoxicity during neoadjuvant therapy. The average age was 62.43 years, and all were treated with standard chemotherapy consisting of trastuzumab and pertuzumab. The mean time from chemotherapy initiation to cardiotoxicity onset was 176 days, while the average time to surgery was 503 days, significantly extending the time required for surgery. The average decrease in left ventricular ejection fraction (LVEF) was 27%, with one patient showing no decrease. All patients developed symptomatic heart failure, necessitating hospitalization in 66.7% of cases. Despite initial severe cardiotoxicity, all patients showed significant clinical improvement following the implementation of optimal heart failure therapy. Although LVEF improved in all cases, complete recovery of systolic function was not achieved. Additionally, three more cases of significant cardiotoxicity were noted in patients who received double anti-HER neoadjuvant therapy followed by adjuvant treatment after surgery **Conclusion:** While dual anti-HER blockade shows efficacy and safety in neoadjuvant protocols, our case series highlights the risk of severe cardiotoxicity, which can delay surgical treatment. This delay may negatively impact oncologic outcomes and prognosis. Careful cardiac monitoring during neoadjuvant therapy is essential for early detection and management of complications, ultimately improving overall survival.

Ivana Lukić, Lana Maričić, Kristina Selthofer-Relatić, Željka Breškić Ćurić

**Introduction:** Sepsis is defined as life-threatening organ dysfunction caused by an unregulated host response to infection. (1) Myocardial dysfunction is common in patients with sepsis and septic shock. Establishing the diagnosis of septic cardiomyopathy is a great challenge, and echocardiography as a key diagnostic tool provides several possibilities for the diagnosis of septic cardiomyopathy. Systolic and diastolic dysfunction of the left ventricle is present in 50-60% of patients with sepsis. Right ventricular dysfunction is present in 50-55% of cases, while isolated right ventricular dysfunction is present in 47% of cases. (2, 3) Diastolic dysfunction of the left ventricle is very common in septic shock, and this represents an early biomarker and has prognostic significance. (4) Aim: To examine the influence of sepsis on systolic and diastolic myocardial function in patients with sepsis and septic shock using echocardiographic parameters. **Patients and Methods:** The research included 20 adult patients with a diagnosis of sepsis and septic shock, the sequential organ failure assessment (SOFA) score ≥ 2, hospitalized at the University Hospital Centre Osijek. Each patient underwent two echocardiographic evaluations: the first one on the second day of hospitalization, and the second between the seventh and tenth day of hospitalization for comparison. Key echocardiographic parameters were monitored, which included mitral annular plane systolic excursion (MAPSE), left ventricular ejection fraction according to Simpson biplane, tricuspid annular plane systolic excursion (TAPSE), systolic wave prime (S’) for assessment of left and right ventricular systolic function, and for assessment of left ventricular diastolic function the early diastolic transmitral flow by Doppler (E wave), late diastolic transmitral flow by Doppler (A wave) E/A ratio, mitral annular velocity obtained by tissue Doppler (E`), E/E´ ratio, and isovolumic relaxation time (IVRT). **Results**: In the follow-up examination, compared to the first examination, the values ​​of E` were significantly higher (median 1.0 vs. 0.06) (Wilcoxon test, P = 0.01), and IVRT values were significantly lower (median 81 vs. 99), while there were no other significant differences between measured values in two examinations (**Table 1**). ### TABLE 1: Differences in echocardiography findings at the first and follow-up examination. | | **Median** **(interquartile range)** — **First examination** | **Median** **(interquartile range)** — **Follow-up examination** | **Difference** | **95% CI** | **P*** | | --- | --- | --- | --- | --- | --- | | MAPSE | 12.75 (10 – 15) | 13.0 (10.5 – 14.5) | 0 | -1 do 1 | 0.82 | | TAPSE | 22.5 (20 – 26) | 24.5 (21.5 – 26.5) | 1 | -1 do 3.5 | 0.42 | | E wave | 0.84 (0.7 – 1.05) | 0.76 (0.60 – 0.90) | -0.08 | -0.16 do 0.04 | 0.16 | | A wave | 0.79 (0.6 – 0.89) | 0.75 (0.67 – 0.89) | 0.05 | -0.09 do 0.17 | 0.51 | | E/A | 1.31 (0.83 – 1.50) | 0.9 (0.82 – 1.26) | -0.17 | -0.37 do 0 | 0.06 | | E’ | 0.06 (0.043 – 0.085) | 1.0 (0.06 – 108.0) | 53.9 | 0.03 do 104.9 | 0.01 | | E/E’ | 11.55 (7.8 – 13.9) | 11.0 (0.09 – 14.4) | -2.7 | -5.65 do 1.31 | 0.17 | | IVRT | 99 (90 – 112) | 81 (9.9 – 96.8) | -44.05 | -62.2 do -4.5 | 0.01 | | S’ | 15.0 (13 – 16.75) | 16.0 (14.3 – 16) | 0.75 | -0.5 do 2.0 | 0.09 | | EF Simpson BP | 58.7 (54 – 61.8) | 58.0 (53.0 – 62.3) | -0.55 | -3 do 2.2 | 0.60 | [†] *Wilcoxon test (Hodges-Lehmann`s difference of medians); MAPSE =mitral annular plane systolic excursion; TAPSE = tricuspid annular plane systolic excursion; E wave = early diastolic transmitral flow by Dopple; A wave- late transmitral flow by Doppler; E/A ratio, E` mitral annular velocity by tissue Doppler; E/E` ratio; IVRT = isovolumic relaxation time; S` = sistolic wave prime; EF Simpson BP = left ventricular ejection fraction according to Simpson Biplane **Conclusion:** The results of this study suggest a reversible form of diastolic dysfunction caused by sepsis. It is a common phenomenon in septic cardiomyopathy, where cardiac function can be significantly compromised in the acute phase, but with appropriate treatment, function is restored within a few days.

Hrvoje Lukić

**Introduction:** Peripheral artery disease is narrowing or occlusion of the arteries in the lower extremities. Typical symptom is pain in the lower extremity muscles during walking and relieved with rest. Some patients have pain at rest or even ulcerations on the legs. Therapy includes surgical revascularization, percutaneous transluminal balloon angioplasty (PTA) or stenting, and atherectomy. Atherectomy is a procedure that uses various endovascular devices for physical removal of calcified plaque by cutting or scraping. Directional atherectomy is a procedure that uses a catheter with a rotating blade to remove plaque from arteries. (1) Aim: To present the procedure of directional atherectomy for treatment of peripheral vascular disease. **Case report:** 74-year-old patient with polyvascular disease complained of pain in the right calf after 100 meters of walking. He had no angina or dyspnea. He was admitted for PTA of right common and superficial femoral artery. An arteriography was performed following a puncture of the left femoral artery, and showed severely calcified lesions. We decided first to perform a directional atherectomy for plaque preparation, before balloon PTA. Using the crossover technique, an introducer was placed in the right external iliac artery. A Spider FX protective mesh was placed in the popliteal artery, and a HawkOne directional atherectomy of the right common and superficial femoral artery was performed. In addition, PTA with scoring and drug eluting balloon was performed. The result was excellent and the procedure went without complications. **Conclusion:** Directional atherectomy is an interventional procedure used for the treatment of highly calcified atherosclerotic lesions as a preparation for percutaneous transluminal angioplasty by cutting out the calcified plaque in the artery wall.

Paula Kontek, Dijana Tutić, Andreja Virt

**Introduction**: Acute heart failure is defined as rapid appearance of symptoms and signs caused by abnormal heart function. Steps in heart failure treatment includes medicament therapy, electrostimulator implantation and heart transplantation as the most advanced form of treatment. The aim of this paper is to present the journey from the diagnosis to heart transplantation and successful recovery, with the importance of accurate evaluations and support provided by the healthcare team. (1) **Case report**: The case is presented using the patient’s medical documentation available in the Hospital Information System. The patient is a 40-year-old male who, in March 2024, suffered from ST-elevation myocardial infarction, which caused ischemic cardiomyopathy. On June 27, 2024, he was hospitalized in Dubrava University Hospital for advanced treatment methods of heart failure. Initially, he was admitted to the intensive care unit for inotropic support and invasive monitoring. To prevent sudden cardiac death, an implantable cardioverter defibrillator was implanted on July 11. Given the patient’s condition, on August 2, 2024, he was presented to the Cardiology-Cardiac Surgery Council, where he was approved for a heart transplant. He was placed on the emergency national list, and within just 8 hours of being listed, he received the opportunity for a new heart. The heart transplant was performed on August 3. A complication occurred in the form of cholecystitis, and an emergency cholecystectomy was performed. He later experienced abdominal pain, and an ultrasound confirmed fluid collections. A surgical revision was carried out, and a large hematoma was evacuated. Throughout his further stay, the patient was hemodynamically stable and felt well subjectively. The collections of fluid were regressing or no longer visible. The patient was discharged in good general condition, hemodynamically stable, with normal systolic and diastolic function. For patients with advanced heart failure, where other treatments are no longer effective, heart transplantation offers a chance to return to a normal life. **Conclusion**: Potential complications following such complex procedures must be identified early, with nurses playing a crucial role as part of the multidisciplinary team. Support and education from nurses during the hospital stay are necessary to help the patient successfully adapt to new circumstances and improve their quality of life. (1, 2)

Glorija Gočin Vuković, Danijela Krnjić

**Introduction**: Brugada syndrome is a genetic disorder characterized by abnormal electrocardiogram (ECG) findings and an increased risk of sudden cardiac death, particularly in young adults. The condition is most often linked to mutations in the SCN5A gene, which affect sodium channels in the heart. Clinical manifestations can range from asymptomatic cases to life-threatening arrhythmias. Approximately 20-30% of cases are linked to genetic mutations, and it predominantly affects males. (1) **Case report**: This case describes a 45-year-old male patient diagnosed with Brugada syndrome, confirmed via ECG after episodes of ventricular tachycardia (VT) in 2017. Despite normal echocardiograms and coronary angiography, the patient exhibited a characteristic ST-segment elevation in leads V1-V2. Given the high risk of sudden cardiac death, he underwent the implantation of an implantable cardioverter-defibrillator (ICD) in March 2018. The procedure was successful, with no complications, and proper positioning of the ICD lead was confirmed with chest X-ray. Following the ICD implantation, the patient was scheduled for follow-up in three months and was given instructions on wound care and activity restrictions. He was advised to avoid specific medications and situations known to trigger arrhythmias, in line with current management guidelines for Brugada syndrome. In terms of family screening, ajmaline testing was arranged for his two children, his brother, and his brother’s two sons. All tested negative except for his son, who showed borderline results, indicating the need for continuous monitoring. Genetic testing may have also been performed to further assess the risk of Brugada syndrome within the family. **Conclusion**: This case underscores the importance of ICD implantation in patients at high risk of sudden cardiac death and highlights the value of genetic testing and family screening to identify and manage potentially affected relatives.

Andrija Nekić, Vedran Pašara, Ivan Prepolec, Domagoj Kardum, Zvonimir Katić, Borka Pezo-Nikolić, Mislav Puljević, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: Cardiac ablation has been established as the first-line treatment for atrial fibrillation. Pulse field ablation is a novel nonthermal cardiac ablation modality, with recent studies showing it to have a comparable acute efficacy with fewer complications compared to traditional thermal ablation procedures. (1) The goal was to showcase a single-center experience with this new technology. **Patient and Methods**: This was a retrospective, single-center analysis. All patients with paroxysmal or persistent AF that underwent pulse field ablation from April 2023 to August 2024 at University Hospital Centre Zagreb were included in the study. Primary success was defined as the complete pulmonary vein isolation during the procedure. Safety outcomes included acute major adverse events. **Results**: A total of 89 patients were included in the study (67.4% male, mean age 61 ± 11 years with LVEF 56% and LAVI 37.5ml/m2) of which 57.4% had paroxysmal AF. Complete pulmonary vein isolation was achieved in 87 patients (97.8%) with an average procedure duration of 47.6 ± 13.6 min with an average fluoroscopy time of 11.6 ± 3.9 min and total radiation dose of 11.6 ± 3.9 mGy. Posterior wall ablation was performed in a total of 39 patients (43.8%) of which 26 were the ones with PersAF (p<0.001). In 24 (27.0%) patients this was a redo procedure after a previous cryoballoon or radiofreqency ablation. There was only one registered catheter malfunction. Acute major events occurred in 2 (2.2%) of patients, one being a cardiac tamponade and other a femoral pseudoaneurysm. **Conclusion**: This retrospective study suggests a high acute success rate for pulse field ablation for AF (97.8%) with a low acute major adverse event rate (2.2%). Incomplete pulmonary vein isolation only occurred in the two cases that developed cardiac tamponade and catheter dysfunction.

Davor Miličić

## Dear Colleagues, It is with pleasure and honour that I wish you a warm welcome to the 15th Congress of the Croatian Cardiac Society with international participation, held under the patronage of the Croatian Academy of Sciences and Arts. Our national cardiology congresses are organized biannually, as the most important gathering of Croatian cardiologists and other related specialists. I hope we have prepared an attractive and interactive Programme, which covers the most important advances and current knowledge in contemporary cardiology. The Congress Programme comprises many of your original communications, together with invited lectures from renowned domestic and top international speakers. Round table discussions and Satellite symposia from our sponsors will also be an important and up-to-date part of the Programme. The Croatian Cardiac Society, in addition to hosting professional and scientific events, has been actively involved for decades in the promotion of cardiovascular health and development of cardiology in Croatia, which includes our leadership in numerous initiatives, public health activities, and permanent interaction with our stakeholders: the Ministry of Health and the Croatian Health Insurance Fund. Thus, the Croatian Cardiac Society has, is, and will have an active and direct impact on Croatian cardiology in a real-life setting. As part of this Congress, we will celebrate the 20th anniversary of the Croatian Primary PCI Network for patients with myocardial infarction, a bright example of how a national professional medical society can influence decision-making policies and facilitate the implementation of the newest guidelines in daily practice. Last but not least, as cardiovascular mortality in Croatia has been constantly decreasing, we would like to believe that Croatian Cardiac Society had a significant part in those trends. Today, Croatian cardiology is advanced, internationally active and networked, and implements the achievements of modern science and practice in our daily routine. However, we should not relax, as there is much to be done in the exiting future that is rapidly approaching. Many thanks to all of you who supported this event, in any way. Let us enjoy a pleasant, eventful, and successful Congress! Sincerely yours, akademik Davor Miličić / Prof. Davor Miličić, MD, PhD, FESC, FHFA, FACC predsjednik Hrvatskoga kardiološkog društva / President, Croatian Cardiac Society, predsjednik 15. kongresa Hrvatskoga kardiološkog društva / President, 15th Congress of the Croatian Cardiac Society

Karlo Gjuras, Kristina Marić Bešić

**Introduction**: With increasing age, the proportion of men and women affected by acute coronary syndrome (ACS) becomes more equal. Women with ACS tend to have more comorbidities compared to men, are less likely to undergo revascularization therapy, and experience a higher incidence of adverse cardiovascular events. (1) **Patients and Methods**: This retrospective study included consecutive patients aged 80 or older with ACS, treated at University Hospital Centre Zagreb from November 2018 to October 2023. Medical records were used to conduct the statistical analysis. (2) This study aimed to assess sex-related differences in clinical characteristics, treatment strategies, and outcomes in elderly patients with ACS. **Results**: Among the 488 patients with ACS, 245 (50.2%) were women. No significant difference in age was observed between male and female patients (84 [81–86] vs. 84 [82–87], p = 0.137). Men had more often a history of previous ACS and revascularization, smoking, chronic kidney disease, and chronic obstructive pulmonary disease. ST-elevation myocardial infarction (STEMI) was more commonly diagnosed in women (60.3% vs. 39.7%), while men were more frequently diagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS; 57.7% vs. 42.3%, p < 0.001). In the STEMI group, no significant sex-based differences were observed in the choice of therapeutic strategy or survival outcomes. However, women with NSTE-ACS were less likely to receive invasive treatment compared to men (41.4% vs. 55.7%, p = 0.019). Logistic regression analysis identified female sex as an independent predictor associated with a lower likelihood of receiving invasive treatment in the NSTE-ACS group (OR = 0.52; 95% CI: 0.30–0.90; p = 0.020). Six-month mortality was significantly higher among conservatively treated women with NSTE-ACS compared to those who received invasive treatment (32.4% vs. 14.6%, p = 0.029), as well as in the male population (32.9% vs. 4.5%, p < 0.001). **Conclusion**: In our cohort of patients over 80 with ACS, women had fewer comorbidities but were less frequently treated with an invasive strategy. Female patients with ACS exhibited lower survival rates during follow-up compared to male patients, regardless of the treatment strategy, though this difference was not statistically significant.

Tomislav Čikara, Davor Barić, Daniel Unić, Igor Rudež, Šime Manola, Mario Sičaja, Vanja Ivanović Mihajlović, Danijela Grizelj, Petra Vitlov, Hrvoje Falak, Mario Udovičić

**Introduction:** Left ventricular assist device (LVAD) is life-saving therapy in patients with end-stage heart failure both as bridge-to-transplantation or destination therapy. (1) Most common complications after LVAD implantation are bleeding, thromboembolic events and infections, but some other complications like driveline damage can occur. (2) **Case report:** We present a case of a patient who in 2011, at the age of 64, underwent an LVAD implantation due to ischemic heart disease (HeartMate II, Abbott Laboratories, Abbott Park, IL). In 2017 he was admitted to cardiac care unit because of intermittent device alarm activation, cause by driveline avulsion and continuity disruption caused by a sudden start of an engine rotor during an attempt at domestic amateur repair. Urgent cardiac surgery was performed, and the device was explanted and replaced by a new device (HeartMate III, Abbott Laboratories, Abbott Park, IL). The postoperative course was uneventful, and the patient was discharged home. Two years later, he was again hospitalized due to sudden onset of repetitive low-flow alarms. The LVAD parameters were flow of 2.3 L/min, 6400 rotations/min, and power of 5.0 W, with increase of flow in supine body position. Computed tomography scan showed LVAD outflow tract kinking and thrombotic mass in the left ventricle at the junction of the outflow tract with LVAD. Partial resection of the outflow graft and band-relief with reconstruction with 14 mm Gore-Tex® Vascular Graft was performed. In the follow-up there were no new alarms detected, and the patient was discharged from the hospital. He died of pneumonia and diabetes complications in 2021, at the age of 74, after ten years of LVAD support. **Conclusion**: Driveline damage is rare but often lethal complication of LVAD. Damage that cannot be promptly repaired requires immediate pump exchange or listing for heart transplantation (3).

Petra Grubić Rotkvić, Tomislav Krčmar, Nermin Lojo, Kristina Marić Bešić, Andrea Crkvenac Gregorek, Anica Milinković, Majda Vrkić Kirhmajer

**Introduction**: A ruptured aortic arch aneurysm is a life-threatening condition associated with extremely high rates of mortality. If diagnosed before rupture, it can be prevented by elective repair, but in an acute setting, the fatal outcome is often unavoidable. (1) **Case report**: We present the case of a 73-year-old male patient with a history of chronic obstructive pulmonary disease (COPD), nicotinism, arterial hypertension, and atrial fibrillation on anticoagulant therapy. He was referred to our center for operative assessment after being diagnosed with contained polytopic aortic arch rupture extending between the innominate to the left subclavian artery (LSA) (**Figure 1**). Additionally, there was a dissection of the proximal LSA and a moderate hemorrhagic pericardial effusion without signs of tamponade. Upon arrival, the patient was hemodynamically stable complaining of chest pain and hoarseness. Due to the technically challenging lesion location, prolonged cardiac surgery operative duration, extended circulatory time arrest, and the unavailability of custom-made prosthesis in acute setting, the multidisciplinary team determined that the patient was a candidate for a hybrid approach using both open surgical extra anatomic aortic arch debranching and Thoracic Endovascular Aortic Repair (TEVAR). (2, 3) Since TEVAR needed to be extended into zone 1 of the aortic arch, revascularization of the left carotid artery was necessary to prevent neurovascular compromise. A carotid-carotid crossover bypass with revascularization of LSA along with TEVAR placement extending from zone 1 to the descending aorta were successfully performed. The patient recovered in the intensive care unit and was extubated the following day. A subsequent CT angiogram showed a good position of the endograft without endoleak and with patent bypasses (**Figure 2**). He was transferred to the cardiology ward where he exhibited an exacerbation of COPD that was successfully treated with standard pharmacological and breathing therapy. Two months after discharge, he attended an outpatient visit in a very good functional status (**Figure 3**). FIGURE 1. Contrast enhanced CT angiography showing aortic arch rupture (A), hemorrhagic pericardial effusion (B), 3D reconstruction of the aorta (C). FIGURE 2. CT angiography showing patent carotid-carotid bypass and carotid-subclavian bypass (A), and 3D reconstruction showing bypasses with TEVAR (B). FIGURE 3. Healed postoperative wounds after aortic arch debranching. **Conclusion**: This case demonstrates a successful hybrid, less invasive approach in an acute life-threatening setting for a condition that is conventionally treated with complex elephant trunk procedure.

Lucija Grbić, Dubravka Šipuš, Luka Perčin, Dora Fabijanović, Marijan Pašalić, Hrvoje Jurin, Ivo Planinc, Jure Samardžić, Maja Čikeš Vodušek, Boško Skorić, Davor Miličić, Daniel Lovrić

**Introduction:** Fulminant myocarditis (FM) is a severe and rapidly progressive cardiac inflammatory disease with high mortality rates. Mechanical circulatory support (MCS) has significantly improved survival outcomes, but there are only a few cases of successful recovery with Impella CP support (1). Here, we report a case of SARS-CoV-2-related FM managed with Impella CP. **Case report:** 41-year-old female with a history of scleroderma tested positive for SARS-CoV-2 four days before admission. Immunosuppression with mycophenolate mofetil was discontinued immediately, and treatment with nirmatrelvir/ritonavir was initiated but stopped two days later due to side effects. On the fourth day of symptoms, she was admitted due to elevated troponin I (TnI) and a reduced ejection fraction (EF of 45%) on echocardiography (echo). She received pulse corticosteroids and intravenous immunoglobulins along with heart failure therapy. On the fifth day, she was transferred to University Hospital Center Zagreb due to cardiogenic shock. Initial laboratory findings showed severely elevated NT-proBNP (30,662 ng/L) and TnI (3,508.3 ng/L), while CRP was normal (2.6 mg/L). Her lactate levels were elevated at 9 mmol/L. The echo showed EF of 20% and mildly reduced right ventricular (RV) function. Initially, she was stabilized with inotropes—dobutamine (10 mcg/kg/min) and milrinone (0.5 mcg/kg/min)—but two days later, Impella CP was implanted due to the progression of shock. The position of Impella CP on echo is shown in **Figure 1**. With Impella CP support, her condition improved, and subsequent echo showed signs of recovery in systolic function. Eight days later, she was successfully weaned off Impella CP support. Control echo before discharge showed an EF of 63% and normal RV function. Magnetic resonance imaging also revealed a recovered EF of 60%, with diffuse myocardial edema consistent with the diagnosis of FM. Complete laboratory findings on admission and discharge are shown in **Table 1**. The patient was discharged home after 18 days. She remained on heart failure treatment, including valsartan, bisoprolol, and eplerenone, for six months following FM. FIGURE 1. Echocardiography, parasternal long axis, showing Impella CP position and small pericardial effusion. ### TABLE 1: Laboratory findings on admission and discharge. | | **Admission** | **Discharge** | **Reference interval** | | --- | --- | --- | --- | | Hemoglobin (g/L) | 142 | 85 | 119 – 157 | | Leukocytes (x109/L) | 7.6 | 8.3 | 3.4 - 9.7 | | Neutrophils (x109/L) | 6.70 | 7.5 | 2.06 - 6.49 | | Lymphocytes (x109/L) | 0.73 | 0.49 | 1.19 - 3.35 | | Platelets (x109/L) | 158 | 228 | 158 – 424 | | BUN (mmol/L) | 5.8 | 7.1 | 2.8 - 8.3 | | Creatinine (µmol/L) | 58 | 56 | 49 – 90 | | ALT (U/L) | 99 | 88 | 10 – 36 | | GGT (U/L) | 145 | 151 | 9 – 35 | | CRP (mg/) | 2.6 | <1 | < 5 | | Troponin I (ng/L) | 3508.3 | 58 | 0 – 15.6 | | NT-proBNP (ng/L) | 30662 | 2714 | <125.0 | [†] BUN = blood urea nitrogen; ALT = alanine transaminase; GGT = gamma-glutamyl transferase; CRP = c-reactive protein; NT-proBNP = N-terminal pro–B-type natriuretic peptide. **Conclusion:** Although FM has historically high mortality rates, MCS can be associated with promising results. We described a case of SARS-CoV-2-related FM with full recovery managed solely with Impella CP support, which provides significantly less support than the more commonly used venoarterial extracorporeal membrane oxygenationor (VA ECMO) or Impella 5.5.

Martina God, Ivan Zeljković, Šime Manola, Nikola Pavlović, Marin Pavlov, Irzal Hadžibegović, Tomislav Šipić, Aleksandar Blivajs, Mario Udovičić, Ana Jordan, Andrej Novak, Ivana Jurin

**Introduction**: Studies have shown that age, serum creatinine levels, and left ventricular ejection fraction (LVEF) combined in ACEF score have predictive value for clinical outcomes in patients undergoing elective coronary artery bypass surgery and promising value for those undergoing percutaneous coronary interventions (PCI) (1-3). The aim of this study was to investigate the prediction value of ACEF score for a novel major adverse cardiovascular events (MACE) and cardiovascular (CV) death in patients with acute coronary syndrome (ACS). **Patients and Methods**: We included patients hospitalized at Dubrava University Hospital with ACS from January 2017 to January 2024. Data involving baseline demographic characteristics, laboratory results on admission, comorbidities, ACS type and MACE were collected. The ACEF score was calculated using the formula: age (years)/LVEF (%) +1(if baseline serum creatinine was>176 µmol/L). MACE was defined as a composite of novel ACS and need for elective or urgent percutaneous or surgical revascularization. Follow-up data were collected by clinical visits or telephone interviews. **Results**: This registry-based study included 1414 ACS patients with median age of 64 years (IQR 56-72), 70% male. Total of 817 (58%) patients had ST elevation myocardial infarction (STEMI). Median follow up was 16 months (IQR 4-36). Median serum creatinine levels were 81 µmol/L (IQR 69-96) and LVEF 55% (IQR 45-60). ACEF score ranged from 0.436 to 5.533 with median of 1.181 (IQR 1.00-1.454). Patients were devided into tertiles based on ACEF score (low ≤1,000 (n376); 1,000> mid ≤1,454 (n686), high ≥1,454(n352)). ACEF score correlated significantly both with CV death (HR 31.17, 95%CI 15.58 -74.12, p<0.05) and with MACE (HR 21.28, 11.24-98.04, p<0.001), with AICcWt severity 0. **Conclusion**: Our data suggest that ACEF score has significant correlation with MACE and CV death in ACS patients, but more patients with diverse ACEF score must be included to confirm its real prediction value.

Viktor Čulić, Željko Bušić, Ivan Velat

**Introduction**: The association of circulating testosterone levels with various parameters of cardiac function and wider pathophysiological framework of processes involved in the development and progression of heart failure (HF) syndrome have been well-described (1). However, the links between circulating sex hormone-binding globulin (SHBG) and HF have been less extensively investigated; previous studies have suggested no association (2) or a low risk of HF with low circulation SHBG levels (3). **Patients and Methods**: Data on baseline characteristics, cardiovascular risk factors and medications were collected for 196 male patients who were consecutively hospitalized for an acute episode of HF. In addition to baseline laboratory findings, serum concentrations of both SHBG and total testosterone were prospectively recorded. The left ventricular ejection fraction (LVEF) was assessed by the biplane Simpson’s method and in accordance with the current guidelines. **Results**: The study population consists of 12.8% smokers, 57.1% those with hypertension, 40.3% with diabetes mellitus, 26.5% with hypercholesterolemia and 20.4% of those with previous myocardial infarction. The mean age was 74.2±7.9 years, body mass index 27.5±5.1 kg/m2, creatinine clearance 53.5±18.8 mL/min/1.73 m2, LVEF 46.4±13.7%, whereas median SHBG was 46.8 nmol/L (interquartile range 32.3 – 62.7) and total testosterone was 10.2 nmol/L (interquartile range 6 – 14.1) In the univariate analysis, plotting the LVEF according to SHBG suggested a non-linear association well described by a cubic polynomial function (**Figure 1**). In the multivariate analysis, the association of LVEF with testosterone and SHBG was adjusted for all of the above clinical variables. In addition to younger age (p=0.004) and high creatinine clearance (p=0.02), both high circulating serum levels of total testosterone (p<0.0001) and low levels of SHBG (p=0.005) were identified as the independent predictors of LVEF. FIGURE 1. Scatterplots depicting the association between sex hormone-binding globulin (SHBG) and left ventricular ejection fraction (LVEF) in male patients with heart failure. A significant association (cubic regression equation: Y = 93.683 - 2.573x + 0.04x2 - 0.0002x3) was observed in the study population. (Regression equation, R2 and p values were obtained from the cubic regression analysis.) **Conclusions**: The present study concurred evidence suggesting that SHBG is not just a glycoprotein that binds and carries the circulating testosterone, but that it may also be independently involved in biological processes affecting cardiac function in HF. Possible mechanisms Possible pathophysiological and subcellular mechanisms of SHBG in HF should be further explored.

Andrija Nekić, Vedran Pašara, Ivan Prepolec, Domagoj Kardum, Zvonimir Katić, Borka Pezo-Nikolić, Mislav Puljević, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: The ablation of ventricular tachycardia (VT) is increasingly performed in patients with sustained VT. The development of inHEART Models software as a three dimensional (3D) cardiac model allows preoperative planning for VT ablations and therefore targeted elimination of VT isthmi. (1) The goal was to showcase a single-center experience since the introduction of this new visualisation modality. **Patients and Methods**: This was a retrospective, single-center analysis. All patients that underwent VT ablation aided by the inHEART system were included in the study, accumulating to a total of 20 patients. The ablations were executed using Carto3 EAM system with mapping generated via multipolar mapping catheter and subsequently merged with the inHEART model. **Results**: Majority of patients were the ones with ischemic cardiomiopathy (n=17, 85.0%) and the rest were non-ischemic (n=3, 15.0%). The mean age during ablation was 64.1 ± 9.5 years with 18 patients being male (90.0%). Average left ventricular ejection fraction was 29.8 ± 6.9% and 4 patients had previous VT ablations (20.0%). Average period from first registered VT to ablation was 28.6 ± 26.3 months. Mean procedure duration was 220.5 ± 61.5 min with fluoroscopy time of 15.5 ± 7.6 min, average radioation dose of 36.5 ± 34.6 mGy and ablation time of 2363.2 ± 889.8 sec. In 14 patients there was an episode of VT during the procedure, either provoked or during mapping or ablation and in 9 patients DC was performed. In 6 patients (28.5%), any VT was still inducible after the ablation, none of which were clinical. During follow-up a total of 10 patients had registered ICD activation with ATP and in 4 cases DC was necessary. **Conclusion**: The use of CT inHEART 3D cardiac model enables more detailed preoperative planning of VT ablations which can yield better results. The data from our center show an encouraging effect of this new technology.

Luka Antolković, Marin Pavlov, Aleksandar Blivajs, Anđela Jurišić, Nikola Pavlović, Tomislav Šipić, Irzal Hadžibegović, Nikša Bušić, Petra Vitlov, Mario Udovičić, Danijela Grizelj, Domagoj Kobetić, Fran Rode, Tomo Svaguša, Šime Manola, Ivana Jurin

**Introduction**: A subset of patients experiencing acute coronary syndrome (ACS) and undergoing successful percutaneous coronary intervention (PCI) subsequently require another revascularisation (1).This study aimed to identify factors associated with recurrent myocardial infarction in patients who experienced acute coronary syndrome (ACS) and underwent successful percutaneous coronary intervention (PCI). **Patients and Methods**: We conducted a retrospective cohort study of patients treated for ACS at our institution from January 1, 2017, to February 1, 2024. Participants were divided into two groups: those without further ACS events and those requiring additional revascularization (either PCI or surgical) during follow-up. Data were extracted from electronic health records and analyzed for comorbidities, baseline characteristics, medication regimens, and procedural details. Statistical significance was assessed using the Mann-Whitney U test and Chi-square test, with odds ratios calculated for significant differences. **Results**: The study included 2,574 patients (1,789 men). Among those requiring multiple revascularizations, there were significantly more men (74.69% vs. 67.76%, p = 0.0005) and higher incidences of peripheral artery disease (18.8% vs. 13.4%, p = 0.001), smoking (28.1% vs. 19.8%, p < 0.0001) and heart failure (33.9% vs. 23.3%, p < 0.0001). This group had a greater prevalence of dual antiplatelet therapy with clopidogrel (27% vs. 21.7%, p = 0.0005), lower therapy adherence, worse renal function, and lower rates of complete revascularization (64.9% vs. 73.4%, p = 0.001), higher LDL cholesterol level and SYNTAX scores. Multivessel disease (OR 2.69 (2.18 - 3.32), p = 0.001) increased the likelihood of revascularization during follow-up. **Conclusion**: These findings should be interpreted with caution due to the study’s retrospective, single-centre design also, correlation does not imply correlation. Identified risk factors for recurrent revascularization include male gender, smoking, poor medication adherence, inadequate lipid management, extensive coronary disease, incomplete revascularization, and cardiogenic shock. Further research should investigate whether improved adherence and risk factor management can reduce the incidence of recurrent revascularization

Milka Grubišić, Dragana Jurčić, Katarina Karimanović, Ružica Mrkonjić

**Introduction**: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice, classified into three types: paroxysmal, persistent, and permanent. Paroxysmal AF occurs intermittently and typically resolves spontaneously, while persistent AF requires intervention for the restoration of sinus rhythm. Permanent AF is characterized by a sustained rhythm that is resistant to conversion. (1) Effective management often involves surgical interventions such as ablation techniques and left atrial appendage (LAA) occlusion, aimed at reducing symptoms and the risk of stroke. **Patients and Methods**: Between September 2022 and April 2024, 31 patients with concomitant AF underwent surgical intervention. Each patient underwent LAA excision, followed by either cryoablation or radiofrequency ablation, depending on the specific surgical approach needed for the primary surgery type. **Results**: The mean age was 68.1±7.1 years, with 64.5% being male. The mean duration of AF prior to surgery was 1.8 years. Of the patients, 35% presented with paroxysmal AF and 65% with persistent or permanent AF. Notably, 55% of patients received cryoablation, while the remaining 45% underwent radiofrequency ablation. At the 6-month follow-up, more than 80% of patients-maintained sinus rhythm. This significant outcome highlights the effectiveness of the combined surgical approach in restoring normal heart rhythm. **Conclusion**: The management of atrial fibrillation requires a multidisciplinary approach, with the nursing role being crucial in administering antiarrhythmic and anticoagulation therapies postoperatively. Additionally, a thorough understanding of ECG interpretation is essential for monitoring patients and ensuring optimal outcomes after surgical intervention. (2)

Ljiljana Kralj

**Introduction**: Cardiac arrhythmias, irregularities in the rhythm of the heart, are a serious health problem that can directly affect heart function and lead to heart failure. Timely detection and treatment of arrhythmias is important to reduce the risk of developing more serious conditions such as heart failure. The incidence of arrhythmias in the world is increasing, while atrial fibrillation is the most common. The long-term duration of this arrhythmia leads to a weakening of cardiac function, damage to the heart muscle, and eventually heart failure. Heart failure can be described as a clinical syndrome characterized by well-known symptoms and physical signs, but sometimes the patient has no symptoms present and the disease is accidentally detected during systematic examinations. (1, 2) **Case report**: This paper presents a case of a 52-year-old patient who was admitted to hospitalization due to newly observed atrial fibrillation in the ECG detected during a systematic examination. Upon admission to the Department of Cardiology, further processing begins. An ultrasound of the heart is performed, where dilated cardiomyopathy with severely reduced systolic function of the left ventricle is determined, and coronary angiography is performed, which excludes coronary heart disease. During the stay in the hospital, paroxysms of non-permanent ventricular tachycardia during sleep were recorded on the telemetry record. From laboratory findings, it is important to single out a mild liver lesion and an elevated value of markers of heart failure. The patient was indicated for implantable cardioverter defibrillator implantation as the primary prevention of sudden cardiac death since there were more cases in the family. After a few days, the patient is discharged home with the recommendation of regular check-ups in the heart failure clinic. **Conclusion**: Early detection of arrhythmias allows the application of appropriate therapies that can significantly reduce the risk of heart failure and other complications. Without timely intervention, arrhythmias can progressively damage the heart, increasing the chances of permanent damage, so education and awareness of recognizing symptoms, maintaining healthy lifestyle habits, regular therapy and regular check-ups with cardiologists is crucial, which can greatly improve the quality of life of patients.

Marina Matković

**Introduction:** The AngioVac system is a catheter-based device used for percutaneous thrombus removal. It provides a method for extracting thrombotic material using a vacuum system while minimizing the risk of embolization. The aim of this case study is to report the successful use of the AngioVac system in conjunction with veno-venous extracorporeal membrane oxygenation (VV-ECMO) for the removal of a large thrombus located at the junction of the superior vena cava (SVC) and the right atrium in a critically ill patient. **Case report**: 80-year-old patient underwent a lung computerized tomography (CT) due to suspected pulmonary embolism, which revealed a thrombotic mass in the SVC extending into the right atrium. SVC thrombosis can lead to significant hemodynamic instability and severe complications, such as pulmonary embolism or right heart failure. The patient had previously been treated for colorectal adenocarcinoma, sepsis, and acute abdomen. Given the complexity and location of the thrombus, conventional surgical intervention posed a high risk. The AngioVac system, designed for minimally invasive thrombus removal, was chosen as an alternative to surgery. (1) **Conclusion:** This case demonstrates the effective use of the AngioVac system in combination with VV-ECMO for the safe and successful removal of a large thrombus located in the SVC extending into the right atrium. The use of AngioVac minimized the need for surgery and reduced the risk of embolization, while maintaining hemodynamic stability with ECMO support.

Magdalena Kunić, Biljana Hržić, Petra Kušenić, Martina Vidak, Katarina Grandavec, Ivica Benko

**Introduction**: A ventricular septal defect (VSD) is one of the most severe mechanical complications of myocardial infarction, which can lead to acute heart failure and cardiogenic shock, resulting in a high mortality rate. According to a recent study, due to the development of successful reperfusion therapy, the incidence of VSD has decreased from 1%-2% to 0.17%-0.13%, but the risk of fatal outcome remains high (up to 80%). (1) The management of patients with VSD following myocardial infarction, according to current guidelines, depends on the severity of the clinical presentation and patient stability, with several treatment strategies exist: medical therapy with inotropes, vasopressors, mechanical circulatory support (MCS), surgical septal repair, and percutaneous intervention may also be considered. **Case report**: This paper presents a 60-year-old man hospitalized in the Department of Intensive Cardiac Care at the Dubrava University Hospital with a clinical presentation of cardiogenic shock caused by a subacute inferior wall myocardial infarction. Echocardiography confirmed a rupture of the interventricular septum, and due to an inadequate response to vasopressor and inotropic drugs, veno-arterial extracorporeal membrane oxygenation was established via femoral approach. Given the patients conditional stability with MCS, other treatment options were considered, and urgent heart transplantation was indicated. The patient was processes and placed on an urgent international and national transplant list. On the thirteenth day of being listed, the patient was prepared and transferred for an emergency heart transplant. **Conclusion**: Nursing preparation of patients prior to emergency heart transplantation involves frequent assessment and monitoring of the patients condition, hemodynamic monitoring, infection control and prevention, management of bleeding, and other potential complications, as well as providing psychological support to the patient and their family. Essential skills and competencies include understanding the transplantation process, preparation and coordination of necessary procedures and tests, as well as critical nursing monitoring of the patient for emergency heart transplantation.

Lucija Schneider, Dražen Zekanović, Marin Bištirlić, Mihovil Santini

**Introduction**: Kounis syndrome is defined as cardiovascular symptoms or acute coronary events that occur secondary to an allergic or anaphylactoid reaction caused by inflammatory mediators released mostly from activated mast cells (1). There are 3 types of Kounis syndrome: spasm of coronary artery (type 1), atheromatous plaque rupture/erosion (type 2), and stent thrombosis (type 3). (2) **Case report**: 59-year-old female patient was admitted to the Emergency department (ED) due to chest pain that started 3 hours before arriving at the ED. The day before, the patient was stung by a bee in the lip with localized angioedema reaction. Upon arrival at the ED, the patient’s vital parameters were normal, and her clinical status was unremarkable, with no signs of angioedema or allergic reactions. Acid-base balance and X-ray were normal, while laboratory findings showed elevated high-sensitivity cardiac troponin (699 ng/L) with neat inflammatory parameters and D-dimers. 12-lead electrocardiogram showed sinus rhythm with a discrete elevation in inferior leads and ventricular bigeminy (**Figure 1**). Aspirin was prescribed, and the patient was admitted to the Coronary Care Unit (CCU) with a diagnosis of acute coronary syndrome. Immediately after admission to the CCU, an emergency coronary angiography was performed, which showed intact epicardial blood vessels. Echocardiography findings were normal except for asynchronous movement of the left ventricle apex due to ventricular bigeminy. The patient was treated with corticosteroids, antihistamines, nitrates, low-molecular-weight heparin, beta-blockers, and aspirin. During hospitalization, the patient was hemodynamically and rhythmically stable. At the time of discharge, the patient was in sinus rhythm without ischemic changes and without ventricular extrasystoles with normal echocardiography findings. FIGURE 1. 12-lead electrocardiogram showing sinus rhythm, 70 beats per minute, with a discrete elevation in inferior leads and ventricular bigeminy. **Conclusion**: Considering the findings of coronary angiography, echocardiography, laboratory findings, and the clinical presentation, our patient was diagnosed with Kounis syndrome type I. We would like to emphasize that educating nurses about the connection between an allergic reaction and acute coronary syndrome in CCU is extremely important, considering that nurses in CCU actively monitor patients and provide 24-hour care.

Matea Mamić, Ivana Peršić, Fabio Kadum, Kristina Uglešić, Teodora Zaninović Jurjević

**Introduction:** Malignant pericardial effusion is a critical and often life-threatening condition that can lead to development of cardiac tamponade, hemodynamic instability, and if untreated, death (1). **Case report:** We report the case of a 32-year-old female who presented to the Emergency Department with a two-week history of dry cough, dyspnea on exertion, loss of appetite, and food aversion. Physical examination revealed multiple palpable lymph nodes and absent breath sounds over the lower half of the left lung. Laboratory tests showed mild microcytic anemia. The patient was hospitalized in the Department of Pulmonology, where tumor markers, including CA 19-9, CA 72-4, PIVKA-II, and CA 125, were positive. An axillary lymph node excision was performed, and CT of the thorax, abdomen, and pelvis revealed bilateral pleural effusions, pericardial effusion, and free abdominal fluid. Echocardiography confirmed minimal pericardial effusion. The patient underwent multiple left-sided thoracocenteses, both during hospitalization and outpatient follow-up. Pathohistology of the excised lymph node revealed signet ring cells, leading to an esophagogastroduodenoscopy, which confirmed gastric adenocarcinoma through a gastric ulcer biopsy. She was later hospitalized in the Department of Oncology, where staging confirmed disseminated disease, and she began chemotherapy and radiotherapy. After initial relief, the patient was readmitted two days post-discharge with dyspnea. A thoracic CT showed extensive pericardial effusion (**Figure 1**), and echocardiography revealed signs of impending cardiac tamponade. Emergent pericardiocentesis removed 900 ml of hemorrhagic fluid. Chemotherapy and supportive measures were continued, but within a month, another pericardiocentesis removed 700 ml of fluid. Despite interventions, the patient died months later due to disease progression. FIGURE 1. Thoracic CT showing extensive pericardial effusion. **Conclusion:** Any cancer can metastasize to the pericardium, causing effusion through increased vascular permeability or lymphatic obstruction, with breast, lung, and Hodgkin lymphoma being the most common culprits (2). Malignant pericardial effusion in advanced gastric adenocarcinoma has a poor prognosis despite timely interventions, with survival remaining limited in widespread disease.

Dragana Jurčić, Milka Grubišić, Ružica Mrkonjić, Katarina Karimanović

Heart tumors are not a common pathology. However, due to their occurrence in a vital organ, they have important clinical significance. They can develop from the endocardium, myocardium, or pericardial tissue of the heart. According to biological behavior, they are divided into two groups, primary (benign and malignant) and secondary (metastatic). The most common form of primary heart tumors are cardiac myxomas (50 - 85%). (1) Cardiac myxomas are benign and slow-proliferating tumors. They occur sporadically or as part of the syndrome between 30 and 60 years of age and are more common in women. They can develop in any ventricle of the heart, but approximately 60-80% of myxomas are diagnosed in the left atrium. Symptoms of cardiac myxoma depend on the localization, size, histological structure and mobility of the tumor. About 20% of patients with cardiac myxoma are asymptomatic and are often detected through routine examinations. The diagnosis of myxoma is made through non-invasive diagnostic methods, where echocardiography is the gold standard. Magnetic resonance imaging and computed tomography are used as additional methods for detailed assessment of tumor size and localization. Treatment of cardiac myxoma is exclusively surgical and includes complete resection of the tumor. (2) Surgery should be performed as soon as possible after diagnosis due to the risk of embolization, valvular insufficiency and sudden death of the patient. Surgical treatment shows good results, and recurrences are rare, especially if the tumor has been completely removed. Cardiac myxoma, although a rare and most often benign tumor, is a serious medical condition. Early diagnosis, surgical treatment and postoperative care are important to reduce the risk of complications and ensure a good prognosis of the patient in the long term. Long-term monitoring is necessary in patients with hereditary forms of the disease due to an increased risk of recurrence.

Tomislav Čikara, Tomislava Bodrožić Džakić Poljak, Aleksandar Blivajs, Marin Pavlov

**Introduction:** Profound investigation of clinical, laboratory and imaging findings is crucial for optimal management of shock. (1) We here present a post-resuscitation patient in hypertensive pulmonary edema that presented as shock. **Case report:** 66-year-old male was successfully resuscitated for cardiac arrest with pulseless electrical activity in the Emergency department. A posteriori heteroanamnestic data suggested dyspnea on exertion and several episodes of syncope in preceding months. History of heavy smoking and hypertension was also known. As consistent hypotension was measured (60/30 mmHg) noradrenalin was started at escalating rate until 1.0 mcg/kg/min. Initial work-up revealed diffuse pulmonary infiltrates resembling cardiac or non-cardiac edema. Upon admission to cardiac intensive care unit, adequate pulsations of right femoral artery were detected. Invasive blood pressure monitoring at this site provided normotensive pressures, and lactate levels measured 1.6 mmol/L. However, mechanical ventilation required high positive end expiratory pressures and weaning trials failed. Echocardiography revealed marked left ventricle hypertrophy and imaging of aorta suggested Leriche syndrome with stenoses/occlusions of all 3 supra-aortic branches. Thus, within catheterization laboratory, a 60 cm sheath was placed into abdominal aorta where blood pressures measured 220/90 mmHg. It was eventually after endovascular procedures assuring adequate limb blood flows that normotension was reached and patient successfully extubated. Clinical course was otherwise unremarkable. **Conclusion**: A thorough work-up is needed in all cardiac arrest patients, but particularly meticulous inspection is needed in patients with seemingly persistent shock.

Marina Petrinić, Vesna Strelar

Heart transplantation is a treatment method reserved for patients in the final stage of heart failure for whom all other treatment options have been exhausted. The aim of the paper is to describe the cases of two patients who underwent a heart transplant with a satisfactory result, and to highlight the role of the nurse in preoperative and postoperative care. The patients were 11-year-old twins admitted with symptoms of heart failure. They were diagnosed with dilated cardiomyopathy, with an ejection fraction (EF) of less than 30%. An extensive clinical, laboratory, targeted genetic, imaging and microbiological examination for cardiotropic viruses were performed, but did not reveal the etiology of the disease. Both patients had severe dilated cardiomyopathy, primarily affecting the left ventricle, with markedly weakened systolic function. Cardiac MRI and invasive cardiology procedures, including left and right heart catheterization, were also conducted. Laboratory findings indicated an extremely high level of NT-proBNP, a marker of heart failure, and both twins presented with deep hypomagnesemia resistant to compensation methods. Until the transplant, patients were dependent on magnesium supplementation. Despite ongoing medical treatment, their general condition severely deteriorated, prompting referral to the heart transplant team within Eurotransplant five months after diagnosis. Heart transplantation was successfully performed in both patients within six weeks of each other, six months after the diagnosis of cardiomyopathy. Transplantation enables optimal medical, personal and social rehabilitation of the patient. The nurse’s role includes educating the patient about the procedures involved in treatment, which encompasses laboratory and diagnostic methods for all organ systems, notifying the physican of any deviations, maintaining a protocol for tests administration and ensuring that the patient consents to the possibility of transplantation. Only patients with meticulously managed medical documentation can remain on the Eurotransplant list, as any deviations lead to automatic removal. (1-3)

Pavica Stanišić, Maja Španjol, Iva Capan

Valvular heart diseases represent one of the leading causes of cardiovascular morbidity and mortality, especially in developed countries, where the condition is associated with increased life expectancy and access to healthcare. Among the most common valvular diseases are aortic stenosis and mitral regurgitation, while the prevalence of aortic and tricuspid regurgitation has been rising, reaching epidemic proportions. Although surgical intervention has been the gold standard for treating these conditions for many years, a large proportion of elderly patients are not suitable candidates for invasive surgery. In the past two decades, new transcatheter treatment methods have been developed as a less invasive and effective alternative. (1, 2) The aim of this presentation is to showcase the new transcatheter methods for treating valvular heart diseases used at the Interventional Cardiology Department of the University Hospital Center Rijeka, with a focus on their application and benefits for high-risk patients.

Luka Košak, Josip Aničić, Gordana Bačić, Ivana Smoljan, Tomislav Jakljević

I**ntroduction**: Prolongation of QT interval increases the incidence of cardiac events and fatal arrhythmias. Long QT can be congenital or acquired. The prevalence of congenital long QT syndrome is 1:2,500 live births (1, 2). Annual risk of syncope, aborted cardiac arrest or sudden cardiac death is 1% to 5%, and in previously asymptomatic patients as low as 0,3% (3). **Case report**: 36-year-old previously asymptomatic patient was admitted to our Clinic in July 2024 after a cardiorespiratory arrest with successful return of spontaneous circulation. He lost consciousness after a sudden awakening caused by a loud child’s cry. The first rhythm was ventricular fibrillation, followed by asystole. The cardiopulmonary resuscitation lasted 6 minutes with total of two defibrillations. Upon admission he was hemodynamically stable with myotic and light-responsive pupils and was urgently analgosedated and intubated. CT scans revealed no signs of acute brain lesion or pulmonary thromboembolism. Echocardiography showed preserved left ventricular ejection fraction without regional wall motion abnormalities. Urgent coronary angiography was performed and no signs of acute coronary lesion was found. The postresuscitation electrocardiogram revealed sinus rhythm with normal QTc interval, while the following showed prolonged QTc interval (609ms). Intravenous propranolol has been started and the QTc shortening has been observed. The patient’s level of consciousness was unchanged despite the cessation of analgosedation. From the 12th day, the gradual recovery of consciousness was observed and on the 20th day he was extubated. Repeat CT scan showed no sign of brain injury. Implantation of cardioverter defibrillator for secondary prevention of sudden cardiac death was performed. Genetic test results for channelopathies are still pending. The patient had been released from our Clinic 29 days after admission, fully conscious, dysarthric with mild left hand monoparesis, requiring assistance in daily activities. **Conclusion**: The long QT syndrome is a relatively common cause of sudden cardiac death. Long QT syndrome with normal resting QTc can be unmasked by exercise or stress. In our patient, cardiac arrest was the first clinical presentation of the disease. Complete workup of other family members is essential.

Jan Čavar, Andrija Matijević, Ivo Darko Gabrić, Matias Trbušić, Ozren Vinter, Krešimir Kordić, Anita Atelj, Marija Perić Bešlić, Diana Delić-Brkljačić

**Introduction**: This case series investigates the incidence, types, and outcomes of opportunistic infections in the first year following heart transplantation. Heart transplantation is a critical intervention for patients with end-stage heart failure. However, the necessity for immunosuppression significantly increases the risk of such infections. (1) **Case series**: This study reports on five out of eleven patients who underwent heart transplantation in 2023. Those five patients, with a mean age of 56.96 years, presented with fever and elevated C-reactive protein levels during routine check-ups. Within an average of 10.5 months after their transplantations, four out of those five febrile patients were diagnosed with opportunistic fungal infections, while one patient remained without a confirmed infectious agent. All five febrile patients received prophylactic miconazole and ganciclovir treatments immediately after transplantation. The detection of nodular formations on chest CT scans prompted further evaluation, which confirmed infections through bronchoalveolar lavage and the identification of β-D-glucan and galactomannan in blood samples in four of five febrile patients. The infections were exclusively fungal, with Candida albicans, Aspergillus fumigatus, and Cryptococcus neoformans identified as the primary pathogens. One patient infected with A. fumigatus also exhibited a co-infection with Mycobacteroides spp. and Cytomegalovirus. During the infection, it was necessary to carefully adjust the immunosuppressive therapy to achieve better control of the infectious process and simultaneously avoid transplant rejection. All four diagnosed patients responded positively to their specific antifungal treatments and were subsequently discharged. **Conclusion**: This case series highlights the substantial risk of opportunistic infections following heart transplantation. The observed high incidence of infections underscores the need for continuous monitoring and vigilance in this patient group. Successful management and favorable outcomes emphasize the critical role of timely diagnosis and intervention in improving patient care post-transplantation.

Irzal Hadžibegović, Ivana Jurin, Ivan Skorić, Anđela Jurišić, Ante Lisičić, Aleksandar Blivajs, Luka Antolković, Šime Manola

**Introduction**: Patients with bystander chronic total occlusion (CTO) in acute coronary syndromes (ACS) are not rare and have worse prognosis. (1) We analyzed their long-term clinical outcomes in regard to revascularization strategies and adherence to medical therapy. **Patients and Methods**: ACS registry from Jan 2017 to May 2023 was used to identify 1950 patients with PCI in ACS who survived to discharge with documented clinical characteristics, treatment strategies, and medical therapy adherence during a median follow-up time of 49 months. **Results**: There were 171 (9%) patients with bystander CTO found during initial PCI in ACS. They were significantly older with more unfavorable clinical characteristics, and with significantly higher Syntax score (27.5 vs 11.5). Patients with bystander CTO had lower proportion of patients with high adherence to medical therapy (32% vs 46%). Patients with bystander CTO had significantly higher cardiovascular mortality during follow-up (18% vs 8%, RR 1.87, 95% CI 1.27-2.75). After adjusting for relevant CTO status, and clinical and treatment characteristics only lower LVEF, worse renal function, presence of DM and lower adherence to medical therapy remained significantly and independently associated with higher cardiovascular mortality during follow-up, with low adherence to medical therapy as the strongest predictor (RR 3.18, 95% CI 1.76-5.75). Time-to cardiovascular death was significantly lower in 120 patients who did not receive bystander CTO revascularization and was similar between 51 patients with CTO who were revascularized and 1779 patients without bystander CTO, although significant independent association was not established in a multivariate analysis of CTO revascularization. **Conclusions**: ACS patients with bystander CTO had significantly higher cardiovascular mortality after discharge. Because of more unfavorable clinical characteristics and worse adherence to medical therapy, these patients need a more scrutinized approach during follow-up to increase adherence and to receive revascularization of bystander CTO despite the severity of symptoms if it is clinically indicated and reasonably achievable without excess risks. Larger trials with more ACS patients receiving total revascularization are needed.

Dominik Buljan, Anđela Jurišić, Marin Viđak, Tomo Svaguša, Diana Rudan, Ante Lisičić, Tomislav Šipić, Aleksandar Blivajs, Vanja Ivanović Mihajlović, Ivan Zeljković, Šime Manola, Ivana Jurin

**Introduction**: The role of inflammation is known in genesis of atherosclerosis and consequently atherosclerotic cardiovascular disease (ASCVD) events. Data from previous research exposed significant relation between elevated plasma level of C-reactive protein (CRP) and prevalence of underlying atherosclerosis as well as risk of recurent adverse cardiovascular events among patients with established ASCVD. Furthermore, some studies showed connection between increased plasma concentration of other inflammatory markers like fibrinogen, IL-1β, SDF-1α and cardiovascular ischemic events. (1, 2) The primary aim of this study is to examine relation of early CRP values and all-cause mortality among patients with acute coronary sindrome (ACS). **Patients and Methods**: This single-center registry-based prospective research included 2536 patients with acute coronary sindrome who were hospitalized between January 2017 and December 2023 and had long-term follow up. Early CRP values were evaluated at admission to the hospital. The primary composite end point was all-cause mortality, contained of cardiovascular and non-cardiovascular mortality. Secondary analyzed outcome was reinfarction. All the participants were exposed to percutaneous coronary intervention. Patients with proven infection were excluded. **Results:** A total of 462 patients (18.2%) died during the long-term follow up. Early CRP values were mesured among 409 of them (88.5%); 289 (70.7%) of whom died due to cardiovascular death and 134 (29.3%) of whom died due to non-cardiovascular death. This study showed no significant difference in observed values of CRP between mortality groups (7.2 vs 7.0, p=0.825). **Conclusion**: While some previous studies showed significant difference for risk-prediction following ACS due to early mesured CRP values, this observational study showed no significant difference in observed CRP values between mortality groups. Furthermore, there are other inflammatory markers which should be messured at the admission to the hospital and compared among tested groups.

Mateja Lovrić, Ivica Benko, Mirela Adamović, Marina Žanić, Marija Grlić, Mario Tomašević, Ivan Horvat, Ivan Zeljković, Nikola Pavlović

**Introduction**: The epicardial approach for ventricular tachycardia (VT) ablation is sometimes necessary but high-risk procedure. While most VTs can be successfully treated with endocardial ablation, certain cases, especially those associated with arrhythmogenic and particularly non-ischemic cardiomyopathies, require epicardial mapping and ablation for effective treatment. The use of epicardial approach, however, poses procedural risks, such as injury to coronary arteries, phrenic nerves, subdiaphragmatic vessels, and accidental puncture of the right ventricle. To enhance the safety and efficacy of this approach, intentional puncture of coronary venous branches with epicardial carbon dioxide (EPI CO2) insufflation has emerged as a valuable technique to facilitate pericardial space visualization and access. In this technique, a coronary sinus branch is cannulated using a diagnostic JR4 coronary catheter, followed by intentional perforation of the branch using an angioplasty wire (Conquest PRO). A microcatheter (Corsair PRO, Asahi Intecc, Japan) is then positioned over the wire into the pericardial space, allowing CO2 insufflation. This enables direct visualization of the anterior pericardial space, facilitating safer subxiphoid puncture. (1-3) **Case report**: 36-year-old female with arrhythmogenic cardiomyopathy and ventricular tachycardia, previously unresponsive to medical therapy, underwent combined endocardial and epicardial ablation. She had a history of ventricular fibrillation during childbirth in 2020. The procedure, performed under deep sedation with midazolam, propofol, and fentanyl, involved epicardial ablation using an 3D mapping/ablation catheter (Navistar SmartTouch ST/SF, Biosense Webster), with phrenic nerve stimulation monitoring and coronary angiography. After the ablation, VT could no longer be induced. At the end of the procedure, intrapericardial corticosteroids were administered to prevent pericarditis and minimize its symptoms. **Conclusion**: Proper pre-procedural planning and understanding of potential complications are essential for reducing the risks associated with the epicardial approach. Techniques such as EPI CO2 insufflation represent significant advancements in improving the safety and precision of percutaneous epicardial access, especially for complex VT cases.

Domagoj Marković, Jelena Stipanović, Ingrid Prkačin, Antonela Karačić, Duška Glavaš

**Introduction:** The treatment approach for heart failure patients, according to recent European Society of Cardiology (ESC) guidelines and scientific papers, is well defined (1). The aim of this study was to investigate whether the prescribed therapy for the treatment of heart failure in patients from Split region, follows the latest ESC guidelines. **Patients and Methods:** The study analyzed patients with heart failure included in CRO-HF registry, Split region, who were hospitalized in the period between 2022 and 2023. There were 37 patients (32%) in the heart failure group with preserved ejection fraction (HFpEF), 18 (16%) had mildly reduced ejection fraction (HFmrEF) and 60 (52%) had reduced ejection fraction (HFrEF). Fisher’s test was used to compare variables, and statistical significance was set at p <0.05. **Results:** Overall, 106 (92%) patients with heart failure were prescribed diuretics and 102 (89%) beta blocker therapy. Less often patients had mineralocorticoid receptor antagonist (MRA) medication 77 (67%), sodium glucose cotransporter 2 (SGLT2) inhibitors 74 (64%) and angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blockers (ARB)/angiotensin receptor/neprilysin inhibitor (ARNI) 72 (63%). There was no difference in diuretic therapy between groups (p=0.067). According to ESC guidelines, beta blockers were prescribed in 95% patients with HFrEF and HFmrEF, and in 76% patients with HFpEF (p=0.018). MRA and ACEi/ARB/ARNI were prescribed in 12 (67%) patients with HFmrEF; MRA in 48 (80%) and ACEi/ARB/ARNI in 47 (78%) patients with HFrEF (p=0.003 and p<0.001; respectively). SGLT2 inhibitors were prescribed in only 10 (27%) patients with HFpEF and in 47 (78%) patients with HFrEF (p<0.001). **Conclusion:** In Split region, diuretic and beta blocker therapy was prescribed in all heart failure groups according to ESC guidelines. MRA and ACEi/ARB/ARNI were prescribed less often compared to the recommendations from the guidelines in HFrEF and HFmrEF patients, while SGLT2 inhibitors were underprescribed in all heart failure groups. The study discusses current heart failure therapy in patients from Split region and we need future complex initiatives and trials to give new information and explanation of these results.

Tomislava Bodrožić Džakić Poljak, Fran Šaler, Marin Pavlov, Aleksandar Blivajs, Šime Manola, Ivana Jurin

**Introduction**: The predictive model for 30-day mortality of patients with acute pulmonary embolism (PE), called pulmonary embolism severity index (PESI) was designed and validated in 2005. It classifies patients into five groups based on clinical indicators, predicting 30-day mortality. It is used in daily clinical practice as a prognostic indicator and as a factor in determining the treatment approach. PESI includes only vital parameters and the most frequent comorbidities. (1) We assumed that the PESI score is not specific for pulmonary embolism and that it could reflect the severity of other conditions, such as acute coronary syndrome (ACS). We aimed to evaluate the role of the PESI score in patients with ACS and to examine its effectiveness in predicting 30-day mortality. **Patients and Methods**: This was a retrospective, single-center, observational study conducted at Dubrava University Hospital from January 2017 to December 2023. We included all patients hospitalized for ACS within this timeframe. PESI score and follow-up data were calculated and collected using available electronic health records. The patient registry is registered at ClinicalTrials.gov (NCT06090591). Categorical variables were presented as frequencies and percentages, and continuous variables as median and interquartile range. Survival was analyzed using Kaplan-Meier estimations. Statistical analysis was performed using JASP software (v. 0.19.1). **Results**: We included 2312 patients with ACS; (STEMI n=1291, 55.8%; NSTEMI n=995, 43%; uAP n=26, 1.12%). Patients were divided into three risk groups according to PESI score – high risk (N=387); intermediate risk (N=454); and low risk (N=1471). Median age of participants was 64 years (IQR 56-73), and 69% were male. 30-day mortality for the low-risk group was 1.56%, for the intermediate-risk group was 4.19%, and for the high-risk group was 18.6%; overall mortality was 4.93% (**Figure 1**). Patients with higher PESI scores had higher mortality (p<0.001). FIGURE 1. **30-day mortality in patients with acute coronary syndrome according to pulmonary embolism severity index score.** HR = HIGH RISK; IR = INTERMEDIATE HIGH RISK; LR = LOW RISK **Conclusion**: PESI score is well validated in predicting mortality in patients with pulmonary embolism. In our study, it was equally good in predicting the mortality of patients with ACS. A higher PESI score accurately reflects the severity of acute conditions such as ACS, in addition to pulmonary embolism.

Luka Antolković, Marin Pavlov, Aleksandar Blivajs, Anđela Jurišić, Nikola Pavlović, Tomislav Šipić, Irzal Hadžibegović, Nikša Bušić, Petra Vitlov, Ivana Jurin, Danijela Grizelj, Tomo Svaguša, Domagoj Kobetić, Fran Rode, Šime Manola, Mario Udovičić

**Case report:** We present a patient with advanced heart failure who underwent implantation of a left ventricular assist device (LVAD) as destination therapy due to severe pulmonary hypertension and pulmonary vascular resistance, precluding heart transplantation. Shortly after implantation, the patient developed chronic LVAD driveline infection with MRSA colonization. Despite multiple rounds of antibiotic therapy, the patient underwent surgical debridement and driveline replacement. However, despite these interventions, the patient experienced an exacerbation of the chronic driveline infection, leading to the spread of infection to deep tissues, LVAD pocket infection, left pleural empyema, and sepsis. Through prolonged antibiotic therapy, surgical drainage of the pleural empyema, and finally, pleural debridement and atypical lingular resection, clinical stabilization was achieved with successful infection control. The subsequent clinical course in patients with LVAD pocket infection represents a significant challenge. We decided to repeat right heart catheterization to assess the patient’s transplant eligibility. The patient responded favorably to LVAD decongestive therapy, evinced by decreased pulmonary vascular resistance rendering him a viable heart transplantation candidate. Following the catheterization, decision was made to enlist the patient on the heart transplantation waiting list as a definitive treatment for both the chronic LVAD pocket infection and terminal phase of heart failure. During follow-up, the patient remained on continuous suppressive antibiotic therapy, maintained good general health, and was included on the regular heart transplant list. **Conclusion:** LVAD pocket infections are relatively uncommon occurrences associated with high mortality rates. (1) Heart transplantation is preferred treatment option, if possible, as literature suggests that patients on suppressive, targeted antibiotic therapy do not exhibit higher post-transplantation relapse risk, albeit with elevated mortality compared to those free of LVAD infection history. Therefore, this case report emphasizes approach to prolonged antibiotic therapy and decision-making processes in managing systemic infection and treating this complex medical condition.

Martina God, Šime Manola, Andrej Novak, Irzal Hadžibegović, Nikola Pavlović, Tomislav Šipić, Marin Pavlov, Aleksandar Blivajs, Mario Udovičić, Ante Lisičić, Ama Šerman, Ivan Zeljković, Ivana Jurin

**Introduction**: Dyslipidaemia is an important correctable risk factor for coronary artery disease (CAD). Studies have shown that low levels of low-density lipoprotein cholesterol (LDL-C) correlate with lower CAD morbidity and mortality rates (1). Many patients who achieved low levels of LDL-C still encounter a major adverse cardiovascular event (MACE) due to other risk factors. Better stratification of patients at higher risk for novel MACE after first acute coronary syndrome (ACS) is needed. Evidence indicate that LDL-C/HDL-C ratio could be a better predictor of cardiovascular disease, as it includes levels of both LDL-C and HDL-C (2, 3). The aim of this study was to investigate the prediction value of LDL-C/HDL-C ratio for long term prognosis after ACS and correlation with CAD severity. **Patients and Methods**: We included patients hospitalized at our centre with ACS from January 2017 to 2024. Demographic data, data on LDL-C and HDL-C levels on admission and calculated Syntax score were used. Syntax score is an angiographic scoring system which determines complexity by using coronary anatomy and lesion characteristic (3). Follow-up data were collected by clinical visits or telephone interviews. MACE was defined as the composite of cardiovascular death, ACS and need for surgical or percutaneous revascularization. **Results**: This registry-based study included 2471 patients with ACS, median age of 64 (IQR 56-73) years, 69% male. Median follow up was 17 (3-27) months. 44% had non-ST elevation (NSTE) ACS and 54% had ST elevation myocardial infarction (STEMI). Median Syntax score was 13 (IQR 7-20.5), with 61% patients having low (≤16), 21% patients medium (16-22), and 18% high Syntax score (>22), respectively. LDL-C/HDL-C ratio correlated significantly with cardiovascular death, with weak coefficient (2.94 vs. 2.54 p<0.001; rho=0.102, p<.0001), but did not correlate with MACE (2.88 vs. 2.92, p=0.188, rho=0.06, p=0.77) or CAD severity as assessed by Syntax score (low 2.92 vs. medium 2.83 vs. high 2.86, p=0.597; rho=0.4, p=0.09). This remained the same in both STEMI and NSTE ACS patients. **Conclusion**: Our data suggest that LDL-C/HDL-C ratio can not be used as a relevant predictor of long-term MACE after ACS, cardiovascular death or CAD severity. Additional studies are needed to establish the real value of LDL-C/HDL-C ratio.

Marija Romić

Whereas surgical aortic valve replacement (SAVR) has been the traditional treatment option for decades for patients with severe aortic stenosis (AS), more recently transcatheter aortic valve replacement (TAVR) has become a widely used alternative to surgery based on clinical trials suggesting comparable efficacy and safety profiles among patients at intermediate or high surgical risk. During the first decade of TAVR innovation, there has been development of improved devices, multimodality assessment, case selection and procedural approaches by the researchers and clinicians. (1) That resulted in TAVR rapidly becoming established as a safe and effective treatment option for people with symptomatic severe AS with surgical profiles ranging from prohibitive to low and has surpassed SAVR as the preferred treatment for AS in multiple international jurisdictions. (2, 3) This accelerated success has enabled us to refocus our attention from „ how we do TAVR“ task to „ how we care for TAVR patients“ task. New focus is driven by early clinical experience, and the pressing need to standardize processes of care to consistently achieve excellent outcomes, patient experiences, and program efficiencies. A successful TAVI program aims to resolve AS safely and efficiently, enabling the patient to be discharged home rapidly without sustaining in-hospital complications and thus improving outcomes. In order to achieve these goals, it is necessary to implement a standardized clinical pathway. Implementing a streamlined TAVI patient pathway requires engagement of TAVI heart team, other hospital staff (cardiac program administration, care coordinators), patients and their families. The dedicated TAVR nurses play a pivotal role in optimizing patients’ pathway, communication, and program efficiencies. The goal of TAVR care is to enable patient’s easy transitions from their preprocedural assessment pathway and procedure planning to their periprocedural experience and finally to their postprocedural care. As such, the adoption of best practices must encompass a single clinical pathway inclusive of all time points to improve transitions of care and multidisciplinary collaboration.

Ružica Lovrić, Ivica Benko, Verica Šeb, Patricia Bručić Ričko, Paula Keblar, Anita Botić

**Introduction**: Cardiovascular diseases, including heart failure (HF), remain a significant public health challenge, contributing to high morbidity, mortality, and medical-economic burdens. Initially designed as a bridge to heart transplantation or recovery, Left Ventricular Assist Devices (LVADs) are now increasingly used as destination therapy, significantly improving long-term patient outcomes. LVAD explantation is considered in clinical cases such as myocardial recovery, heart transplant candidacy, or managing complications like infections. Successful explantation requires a multidisciplinary team, including cardiac surgeons, anesthesiologists, cardiologists, perfusionists, nurses, physiotherapists, and psychologists. The process involves thorough hospital evaluations based on hemodynamic and echocardiographic parameters. (1) **Case report**: We present the case of a 57-year-old female patient who received a HeartMate 2 LVAD in 2015 due to dilated cardiomyopathy and left-sided HF. Her medical history includes cholecystectomy, long-term hypertension management, and progressive HF. The patient underwent pre-transplant evaluation and had multiple hospitalizations for microcytic anemia. In March 2020, she was hospitalized for a local infection and bleeding around the LVAD exit site. Monthly clinical and echocardiographic monitoring followed. By July 2023, LVAD flow and speed were gradually reduced as part of re-evaluation. A favorable myocardial response led to the decision for potential LVAD explantation. Cardiac function was assessed in three stages: normal pump support, minimal support, and finally, percutaneous LVAD decommissioning. After deactivating the LVAD, her hemodynamic and echocardiographic parameters remained stable. The procedure and recovery were uneventful, with the patient remaining hemodynamically stable. She was discharged in good condition with long-term heart failure therapy. Follow-up confirmed full recovery. **Conclusion**: This case demonstrates that a multidisciplinary approach and ongoing education significantly improve patient outcomes. The involvement of primary healthcare and family support is vital. This rare LVAD decommissioning case highlights the need for staff education in managing complex scenarios, benefiting both patients and healthcare teams.

Merljinda Ljušaj, Marin Pavlov, Ana Jordan, Jasmina Ćatić, Petra Vitlov, Fran Šaler, Dominik Buljan, Šime Manola, Ivan Skorić, Ivan Zeljković, Ivana Jurin

**Introduction:** The Pulmonary Embolism Severity Index (PESI) is a well-validated tool for prediction of 30-day mortality in acute pulmonary embolism (PE) patients, but it still requires additional improvement in early mortality risk estimation. Simple, cost-effective and widely accessible markers are needed as reliable supplementary tools to PESI score in any clinical or organizational setting. (1, 2) The aim of this study was to compare the predictive value of well-known and validated PESI score and the ratio of red blood cell distribution width (RDW) to albumin concentration (RAR) for 30-day mortality in patients diagnosed with PE, along with evaluating RDW and albumin as individual biomarkers. **Patients and Methods:** A double-center analysis included 712 patients hospitalized for pulmonary embolism from January 2013 to September 2023. **Results:** Of the hospitalized patients, 56,5% were women. The median age was 73 years (interquartile range IQR:61-80). The median PESI score was 102 points (IQR:70-135). A total of 20,1% of patients had malignant disease in their medical history. The median RDW was 14.2% (IQR 13.3-15.6), albumin level was 37 g/L (IQR: 32-40), while for RAR was 3.98 dl/g (IQR: 3.42-4.89). The 30-day mortality was 12.2%. Patients were categorized into two groups: a low RAR group and high RAR group with median RAR of 3.988 g/dL. Those with higher RAR were significantly older, more often female and had a lower BMI (P14.6%, albumin 4.41 dl/g and PESI >121, RDW >14.6 (OR 2.71, 95% CI (1.34-5.47), P=0.005), albumin 121 points (OR 6.9, 95% CI (3.72-12.79), <0.001) were recognized as mutually independent predictors of 30-day mortality, while RAR did not statistically significantly contribute to prognosis in the context of other analyzed parameters. **Conclusion:** In patients with pulmonary embolism, RDW and albumin can provide additional prognostic information compared to the PESI score. However, their ratio (RAR) does not contribute additionally to the prognosis of 30-day mortality when RDW and albumin are taken into account as individual parameters.

Valentina Jezl, Matej Tadejević, Ana Marinić, Vlatka Rado, Vjera Pisačić, Aleksandra Kraljević, Dino Glavočević, Danijela Grgurević

**Introduction**: Primary cardiac tumors are very rare, with just 25% being malignant and 65% being sarcomas. (1) The clinical expression of the disease is mostly determined by the tumor’s location; therefore, the range of symptoms is wide. The diagnosis is often established between the ages of 40 and 50 (2), with a median survival time of 6 to 12 months (3). **Case report**: The purpose is to present the case of a healthy 35-year-old woman who was diagnosed with cardiac sarcoma in April of this year. The patient was admitted to the hospital for treatment of suspected pericarditis, and an echocardiogram was performed to identify the suspicious tumor in the right ventricle. In the context of the observations, a radiological examination was undertaken, which verified the tumor mass in the right ventricle, which is pushed into the lumen of the right atrium and shows no distant indications of the disease. A biopsy of the tumor reveals changes consistent with sarcoma. Considering the size of the formation, chemotherapy is initiated, with surgical treatment excluded as a possibility. Following three cycles of chemotherapy and repeated discussion of surgical treatment, the patient underwent a cardioectomy in June, with two HeartMate3 devices implanted in the configuration of a total artificial heart. After a complex surgery, the patient required prolonged mechanical ventilation due to respiratory complications and failed extubation attempts on the 5th and 7th postoperative days (POD). To facilitate long-term ventilation, a percutaneous tracheotomy was performed on the 13th POD, and bilateral pleural drains were placed to manage substantial pleural effusions. In the early stages, the patient was heavily dependent on ventilatory support, experiencing severe chest pain (VAS 10), cachexia, and left peroneal nerve paresis. Her physical condition was notably limited, with the ability to perform only active-assisted movements and sitting at the bed’s edge with support. Early mobilization and intensive respiratory physiotherapy were initiated to counteract muscle atrophy and improve respiratory function. Throughout July and August, the patient underwent a slow weaning process from mechanical ventilation, supported by CPAP and high-flow oxygen therapy, which provided crucial respiratory support and reduced the work of breathing. By the end of August, she was fully weaned from mechanical ventilation, marking a significant milestone in her recovery. By the 62nd POD, the patient was independently active within bed, could stand with walker support, and had achieved a 150-meter walking distance. With no evidence of residual or relapsing malignant disease, the patient was scheduled for ongoing oncological monitoring. Discharge occurred in early September, with partial dependence on assistance for daily activities and a continued need for home-based care. **Conclusion**: This case emphasizes the importance of a comprehensive, multidisciplinary approach in managing rare malignancies with complex postoperative needs. Early mobilization and targeted rehabilitation were pivotal in the patient’s recovery, and nursing care played a vital role in supporting device maintenance, wound care, and psychological well-being. Long-term outcomes remain uncertain due to the unique nature of the diagnosis, reinforcing the need for individualized care and lifetime follow-up.

Luka Linarić, Petra Sertić, Ivo Darko Gabrić, Krešimir Kordić, Ozren Vinter, Ljubica Vazdar, Matias Trbušić, Nikola Bulj

**Introduction:** Colorectal cancer typically spreads via the hematogenous route but rarely metastasizes to the pericardium. In unstable patients, the standard of care for pericardial effusion is pericardiocentesis, which helps relieve symptoms and aids in diagnostic evaluation. **Case report:** 72-year-old patient with metastatic rectal cancer undergoing second-line therapy presented with chest pain and bronchospasm during oxaliplatin infusion. The infusion was immediately stopped, and the patient was stabilized. Coronary angiography showed no abnormalities. CT scans identified pericardial effusion, which was later confirmed by echocardiography, without hemodynamic compromise. Due to the life-threatening reaction, oxaliplatin was contraindicated, and third-line treatment with trifluridine-tipiracil was initiated. Soon after, the patient was admitted to a local hospital with signs of cardiac tamponade. An urgent pericardiocentesis was performed, draining 800 ml of pericardial fluid containing malignant adenocarcinoma cells. Post-discharge, during a routine oncology check-up, a recurrence of pericardial effusion was suspected, along with signs of cardiac tamponade. The patient was urgently readmitted to the Intensive Cardiac Care Unit. Bilateral pleural effusions were also noted, and a pleuropericardial drainage procedure was performed, removing a total of 4500 ml of hemorrhagic fluid, which contained malignant cells. Following discharge, anticancer treatment was resumed. However, the patient soon returned to the Emergency Department with worsening dyspnea and new-onset hemiplegia. Recurrent pleuropericardial effusion was identified, and a brain CT scan revealed newly diagnosed brain metastases. Due to the patient’s overall health condition, further active anticancer treatment was contraindicated. **Conclusion:** Timely detection and intervention for pericardial effusion are essential to ensure uninterrupted anticancer therapy and improve the quality of life for cancer patients. (1)

Valentina Jezl, Vlatka Rado, Doris Remar, Aleksandra Kraljević, Ana Marinić, Matej Tadejević, Vjera Pisačić, Dino Glavočević, Danijela Grgurević

**Introduction**: Streptococcal toxic shock syndrome (TSS) is an acute, toxin-mediated condition characterized by rapid deterioration and multiorgan involvement, associated with a high mortality rate. (1) We report a case of Streptococcus pyogenes-induced TSS in a healthy 39-year-old woman who developed a multiorgan dysfunction syndrome, including myocarditis. **Case report**: On April 12, 2024, the patient presented to the emergency department with fever, sore throat, and upper back pain. Following treatment, she was discharged with a prescription for oral antibiotic therapy. The next day, she presented with a fever and stomach pain, with poor overall health and hypotension. Radiological analysis reveals a suspicious formation in the lower right abdomen quadrant that is not seen during laparoscopic investigation. Following surgery, hemodynamic collapse develops, and severe streptococcal toxic shock syndrome is suspected. The patient is hemodynamically stable on high levels of vasopressor and inotropic support, has livid extremities, and undergoes hemodialysis with hemopurification and intravenous immunoglobulin injection. Due to the development of acute respiratory distress syndrome, veno-venous extracorporeal membrane oxygenation is initiated, with support gradually deescalating over the next few days. The patient, requiring extended mechanical ventilation due to respiratory failure, underwent a percutaneous tracheotomy on April 26. Early mobilization and respiratory physiotherapy began on the second day of admission to counteract the risks of deconditioning from prolonged bed rest. During early hospitalization, the patient developed ischemia in both feet and fingers, which led to progressive necrosis in affected areas. In early May, signs of neurological improvement emerged, with the patient beginning to communicate nonverbally and verbally. High-flow oxygen therapy was applied, and by the end of May, she achieved respiratory independence. The patient developed a total AV block, necessitating the placement of a temporary electrode until a permanent pacemaker was implanted on July 15. Meanwhile, ischemia worsened in her extremities, resulting in significant tissue necrosis and requiring surgical intervention, which was performed on 60th hospitalization day and included a right below-knee amputation, transmetatarsal amputation of the left foot, and finger amputations at the DIP joints. Despite these amputations, the patient continued with active physical therapy, mobilizing on her remaining limb. Due to complications in the left leg, on the 94th day a multidisciplinary team opted for a left below-knee amputation to ensure proper wound healing. After 110 days in the hospital, the patient achieved hemodynamic stability, respiratory independence, and sufficient recovery to be discharged in good condition, despite the significant loss of limbs. **Conclusion**: TSS is a life-threatening illness that can rapidly spread and affect all organ systems. The patient’s successful recovery, despite severe complications and prolonged hospitalization, highlights the adaptability of multidisciplinary teams and coordinated interventions such as hemodynamic support, immunotherapy, advanced respiratory management, psychological support, and ongoing rehabilitation. Nursing care for those patients demanded an individualized approach that addressed the patient’s psychological and emotional needs as well as to the physical aspects of care. Effective communication, continuous monitoring, and collaboration with the healthcare team are essential for improving patient outcomes and promoting recovery and rehabilitation.

Aleksandra Kraljević, Matej Tadejević, Vlatka Rado, Dino Glavočević

Organ transplantation remains the most optimal therapeutic method for treating end-stage solid organ failure. In 2023, around 100 solid organ transplants were performed in the Republic of Croatia, including 48 heart transplants, with the first simultaneous heart and liver transplant at University Hospital Centre Zagreb. Early mobilization is a physiotherapy intervention in the rehabilitation process, initiated immediately after injury, illness, or surgery. The goal of early mobilization is to help patients recover as quickly and fully as possible while preventing or minimizing complications associated with prolonged immobilization. Heart transplant patients have reduced exercise capacity due to cardiovascular and musculoskeletal changes. Impaired vascular function and diastolic dysfunction cause reduced cardiac output, leading to decreased peak oxygen uptake in heart transplant recipients. Early mobilization improves cardiac and vascular endothelial function in heart transplant recipients. All patients post-heart transplant should begin early mobilization with therapeutic exercises of the upper and lower limbs and respiratory physiotherapy to facilitate early verticalization. (1) New findings confirm that early mobilization of patients is inversely related to metabolic syndrome following liver transplantation. (2) Therefore, it is recommended to perform early mobilization interventions to reduce the complications of metabolic syndrome and potential post-transplant immunosuppression disorders in liver transplant recipients. Therapeutic exercises should be performed more frequently throughout the day, gradually increasing the intensity and duration of the exercise sessions to improve aerobic capacity after liver transplantation. Data on long-term follow-up of patients with simultaneous transplants are not available, indicating the need for further high-quality and well-founded studies to demonstrate the long-term benefits of exercise in this population.

Marin Viđak, Petra Vitlov, Jasmina Ćatić, Ana Jordan, Andrej Novak, Vanja Ivanović Mihajlović, Marin Pavlov, Marta Puškadija, Nikola Pavlović, Ivan Zeljković, Šime Manola, Ivana Jurin

**Introduction**: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have become the cornerstone of heart failure (HF) therapy across the ejection fraction (EF) spectrum, with plethora of metabolic effects (1, 2). Knowledge on effects of SGLT2i on electrolyte levels and kidney function in patients with preserved (HFpEF) and reduced HF (HFrEF) is still limited. **Patients and Methods**: This was a registry-based study recruiting patients diagnosed with HF from May 2021 to February 2024 in Dubrava University Hospital, Zagreb, Croatia. We extracted data on age, gender, NTproBNP and electrolytes levels, and estimated glomerular filtration rate (eGFR). Patients with mildly reduced EF were grouped with patients with HFrEF. **Results**: We have collected data from 1018 patients diagnosed with HF (median age 70 (95%CI 69-70.76) years, 33% female). HFpEF was diagnosed in 125 (12.3%), while HFrEF was diagnosed in 893 (87.7%) patients. There were 69 women (55.2%) in the HFpEF group and 267 women (29.9%) in the HFrEF group. Patients were younger in the HFrEF group (69 vs 73 years, p=.0004). HFpEF group had higher BMI when compared to HFrEF group (30.44 vs 28.67, p=.0074). Initial NTproBNP was higher in the HFrEF group (1615.5 vs 2667pg/L, p2, p=.1453). ### TABLE 1: Participants’ characteristics (N=1018). | | **HFpEF group (N=125)** | **HFrEF group (N=893)** | **P-value*** | | --- | --- | --- | --- | | Age | 73 (72.0-74.94) | 69 (68-70) | **0.0004** | | Sex | | | | | Male | 56 (52.5%) | 626 (70.01%) | | | Female | 69 (47.5%) | 267 (29.9%**)#** | | | Body mass index (kg/m2) | 30.44 (28.92-31-37) | 28.67 (27.96-29.16) | **0.0074** | | NT-proBNP at admission (pg/L) | 1615.5 (1098.43-2020-84) | 2667 (2413.96-3083.03) | **2) | 65.09 (60.31-69.7) | 66 (63.89-67.85) | 0.4071 | | eGFR at 6 months (45mL/min/1.73m2) | 66.2 (49.96-73.85) | 65.4 (63-67.42) | 0.1707 | | eGFR at 12 months (45mL/min/1.73m2) | 63.1 (48.22-77.01) | 65.7 (61.23-68.8) | 0.2103 | | Potassium at admission (mmol/L) | 4.3 (4.2-4.4) | 4.3 (4.3-4.4) | 0.8729 | | Potassium at 6 months (mmol/L) | 4.3 (3.96-4.73) | 4.3 (4.3-4.4) | 0.6646 | | Potassium at 12 months (mmol/L) | 4.5 (4.2-4.61) | 4.4 (4.4-4.6) | 0.4323 | | Chloride at admission (mmol/L) | 103 (102-103) | 103 (102-103) | 0.8178 | | Chloride at 6 months (mmol/L) | 102 (101-103) | 103 (102-103) | 0.400 | | Chloride at 12 months (mmol/L) | 104 (103-104) | 103 (103-103) | 0.4078 | | Hematocrit at admission | 0.3975 (0.3907-0.4056) | 0.411 (0.407-0.415) | 0.1042 | | Hematocrit at 6 months | 0.4050 (0.3905-0.4239) | 0.426 (0.421-0.0431) | **0.0171** | | Hematocrit at 12 months | 0.4265 (0.4010-0.4430) | 0.4310 (0.4260-0.4377) | 0.3972 | [†] * Mann-Whitney test, # Chi square test, p2) | 67.06 (56.6-74.32) vs 66.2 (49.96-73.85) | **0.0375** | | eGFR at 6 months vs 12 months (45mL/min/1.73m2) | 62.8 (44.83-75) vs 59.2 (57.8-77.01) | 0.4595 | | Hct at admission vs 6 months | 0.3925 (0.3832-0.4066) vs 0.4045 (0.3901-4230) | 0.2007 | | Hct at 6 months vs 12 months | 0.419 (0.383-0.4354) vs 0.4265 (0.4010-0.4467) | **0.0431** | | Potassium level at admission vs 6 months (mmol/L) | 4.15 (4.0-4.372) vs 4.3 (3.964-4.7361) | 0.2293 | | Potassium level at 6 months vs 12 months (mmol/L) | 4.1 (3.95-4.45) vs 4.15 (3.95-4.6) | 0.375 | | Chloride level at admission vs 6 months (mmol/L) | 103 (100-104) vs 102 (101-103) | 0.4320 | | Chloride level at 6 months vs 12 months (mmol/L) | 103 (101.02-104.97) vs 103 (102-104) | 0.1055 | | **HFrEF group** | | | | | **C (95% Confidence interval)** | **P-value*** | | NT-proBNP at admission vs 6 months (pg/L) | 2416 (2032.58-2687.03) vs 938 (863.33-1001-42) | **0.0001** | | NT-proBNP at 6 months vs 12 months (pg/L) | 865 (765.9-966) vs 685 (637.53-755.56) | **2) | 66.34 (64.59-68.66) vs 65.4 (63-67.42) | 0.3025 | | eGFR at 6 months vs 12 months (45mL/min/1.73m2) | 66.1 (64.23-69.1) vs 65.6 (61.16-68.8) | **0.095** | | Hct at admission vs 6 months | 0.4110 (0.4070-0.4160) vs 4.260 (0.4210-0.4310) | **<0.0001** | | Hct at 6 months vs 12 months | 0.430 (0.422-0.433) vs 0.4310 (0.4259-0.4371) | **0.0005** | | Potassium level at admission vs 6 months (mmol/L) | 4.3 (4.2-4.3) vs 4.3 (4.3-4.4) | **0.0197** | | Potassium level at 6 months vs 12 months (mmol/L) | 4.3 (4.23-4.4) vs 4.4 (4.227-4.5) | 0.5033 | | Chloride level at admission vs 6 months (mmol/L) | 102 (99-104) vs 103 (100-104) | **0.0052** | | Chloride level at 6 months vs 12 months (mmol/L) | 103 (101-105) vs 103 (101-105) | 0.8231 | [†] * Wilcoxon paired sample test HFrEF = heart failure with reduced ejection fraction, HFpEF = heart failure with preserved ejection fraction, NT-proBNP = N-terminal prohormone of brain natriuretic peptide, eGFR = estimated glomerular filtration rate, Hct = hematocrit **Conclusions**: There were no differences in electrolyte levels and kidney function between HFpEF and HFrEF groups, confirming that SLGT2 inhibitors provide similar efficacy across the spectrum of HF patients.

Ana Marinić, Vjera Pisačić, Valentina Jezl, Danijela Grgurević

Introduction Intensive Care Units (ICU) offer a chance of recovery to critically ill individuals. Families of the patient place the life of their loved one into the hands of strangers – doctors, nurses and other medical staff while they themselves often remain on the other side of the ICU doors. Often, the perception of what the patient and their family are experiencing is lost, and in the fight to save a life, the focus on the HUMAN and their dignity is diminished. Elaboration One of the most important prerequisites for reducing the dehumanization of patients is the introduction of more liberal visiting hours. Visits in the ICU can be divided into: 1. Restricted visits – limited visiting times, duration and number of visitors; 2. Flexible visiting hours – visits are allowed but with certain restrictions and 3. Open visiting hours – a fully liberal approach to visitors with minimal restrictions. (1) The research results, especially after the SARS-CoV-2 pandemic, demonstrate that strict visiting restrictions negatively affect patients and families. Many families have reported that they were deprived of their last moments with their loved ones and did not have the opportunity to say goodbye. On the other hand, a liberal approach brings numerous benefits – it reduces stress levels in both patients and families and shortens the number of days spent in the ICU. (2) Conclusion A hospital stay, especially in the ICU, induces high levels of stress and anxiety. The presence of families with their loved ones in the ICU has a mutually positive effect and can be a decisive factor in a positive treatment outcome. Sometimes, neither all technological advancements nor all medical knowledge will be sufficient to save a human life. Sometimes, even the presence of family by the patient’s bedside will not be enough, but it will make a significant difference in those final moments – moments when the physical presence of loved ones, their touch, words, and that last goodbye are the only medicine needed.

Fabio Kadum, Gordana Bačić, Kristina Uglešić, Tomislav Jakljević, David Gobić

**Introduction:** Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a life-saving treatment option for patients with hemodynamic instability or in cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE) (1, 2). **Case report:** We report the case of a 56-year-old female who presented with sudden onset of chest pain and dyspnea one month after left ankle surgery. Immediately upon arrival in the Emergency Department, the patient suffered cardiopulmonary arrest. Focused transthoracic echocardiography during CPR revealed an enlarged right ventricle, which, in conjunction with the patient’s history, led to the diagnosis of high-risk PE. A systemic thrombolytic therapy was administered, and upon return of spontaneous circulation, VA-ECMO was initiated due to persistent hemodynamic instability. This was followed by mechanical thrombectomy with extraction of multiple thrombi from both pulmonary arteries. VA-ECMO support was gradually decreased and successfully discontinued on the third day of treatment, with stable hemodynamic parameters onwards. However, the next day, the patient developed discoloration of the right foot, accompanied by an absent peripheral pulse. Urgent CT peripheral angiography suggested compartment syndrome, prompting multiple fasciotomies and necrotomy of ischemic right lower leg muscles. Simultaneously, the patient became oliguric, with worsening renal function and myoglobinuria, suggestive of rhabdomyolysis-associated acute kidney injury, leading to hemodialysis. The patient’s renal function later recovered and after discontinuation of analgosedation the patient regained consciousness without neurological deficits and was successfully weaned from mechanical ventilation. The patient was then transferred to the Department of Plastic and Reconstructive Surgery for further management of right lower leg defects. Anticoagulation therapy was switched from low-molecular-weight heparin to an oral anticoagulant. A thrombophilia work-up was negative and the patient was discharged in stable condition. **Conclusion:** This case highlights the complexity of managing high-risk PE and its associated complications, emphasizing the importance of a multidisciplinary approach in critical care.

Marina Klasan, Ivana Hodanić, Katarina Matković, Ivan Šragalj, Saša Bura

Atrial fibrillation (AF) is the most common persistent arrhythmia, affecting millions of patients worldwide and carrying a significant risk of serious complications such as stroke, thromboembolism, heart failure, and reduced quality of life. The goal of AF treatment is to control heart rhythm and rate, reduce symptoms, and prevent complications, particularly stroke. AF treatment includes various therapeutic options, chosen based on the severity of symptoms, patient age, comorbidities, and the risk of complications. Modern approaches to AF treatment include pharmacological methods (anticoagulants, antiarrhythmics, and drugs for rhythm and rate control) and interventional therapies such as electrical and pharmacological cardioversion, catheter ablation, and pacemaker implantation. Today, physicians take a holistic approach, combining these methods to achieve optimal results. Special attention is given to interventional therapy, especially catheter ablation, which has proven highly effective in patients with symptomatic atrial fibrillation who do not respond to medications. This minimally invasive procedure allows for the precise location and destruction of heart tissue causing the arrhythmia, restoring normal heart rhythm. (1) Nurses and technicians play a key role in the treatment process, whether by monitoring patients’ heart rhythms, administering therapy, educating patients on symptom self-management, or providing support after invasive procedures.

Glorija Gočin Vuković, Danijela Krnjić, Marija Peremin

Ajmaline testing is a diagnostic tool used primarily for the identification of Brugada syndrome, a genetic condition associated with a risk of sudden cardiac death due to arrhythmias. The test involves the intravenous administration of ajmaline, a class Ia antiarrhythmic agent, which can unmask the characteristic electrocardiographic (ECG) changes seen in Brugada syndrome, particularly the type 1 Brugada pattern. This pattern is often transient and may not be visible under normal conditions, making pharmacological provocation critical in diagnosing at-risk individuals. The procedure is generally safe but requires careful monitoring due to the potential life-threatening arrhythmias during the test. The role of the nurse in ajmaline testing is crucial, spanning from pre-procedural preparations to post-test monitoring. Nurses are responsible for ensuring that the patient is fully informed about the procedure and potential risks. During the test, they play a key role in monitoring the patient’s vital signs and ECG in real time, being vigilant for any arrhythmic events that may necessitate immediate intervention. Nurses also assist in the administration of ajmaline under the supervision of a physician, ensuring the correct dosage and timing are followed. Post-test, nurses continue to monitor the patient for delayed arrhythmic events and help manage any adverse reactions. In addition to their procedural role, nurses contribute significantly to the screening and identification of candidates for ajmaline testing. This includes reviewing patient history for signs of unexplained syncope, family history of sudden cardiac death, or abnormal ECG findings. Nurses are also involved in educating patients about Brugada syndrome, its genetic implications, and the importance of screening family members. Their role extends beyond the test itself, providing psychological support to patients who may be anxious about the potential outcomes. This multidisciplinary approach, with the nurse playing an integral role, ensures patient safety and enhances the effectiveness of ajmaline testing as a screening tool for Brugada syndrome. (1-3)

Manuela Balaban Kumpare, Rina Dalmatin Kršćanski, Ivana Šmit, Danijela Raušl Malagić, Krešimir Milas

**Introduction**. Biatrial thrombus is a rare condition. It causes both systematic and pulmonary embolization. Right atrial (RA) thrombi are occasionally found with pulmonary embolism (PE), or under the setting of atrial fibrillation (AF). Left atrial (LA) thrombi are most commonly found in the setting of AF, and sometimes with severe mitral valve disease, and like RA thrombi are almost never found in a patient in SR (1). The presentation of biatrial thrombi are reported in patients with a patent foramen ovale (PFO), known as “thrombus in transit”, and in patients with coagulopathies. The absence of RAA enlargement may explain the lower incidence of RA thrombi (2). Transesophageal echocardiography (TEE) has emerged as the most sensitive modality for the detection of intracardiac thrombi. Multidetector computed tomography (CT) and cardiac magnetic resonance (CMR) may be powerful tools to differential diagnosis between a thrombus and other intracardiac masses, most frequently atrial myxomas. Treatment options may include anticoagulation, thrombolysis, interventional and surgical procedures. There is no evidence supporting the superiority of one above the others (3). **Case report**: We present the case of a 76-year-old man with dyspnea and persistent AF. TTE showed masses in LA and RA with preserved left ventricular systolic fraction (**Figure 1**). A TEE with bubble study showed no evidence of PFO with a mass in RA (54x36 mm), LA (35x15 mm) and left atrial auricle (41x25 mm) (**Figures 2-4**Figure 3Figure 4). D dimer was high but CT angiography showed no pulmonary emboli. Venous ultrasound duplex for deep vein thrombosis of the lower extremity was also negative. CT of the chest, abdomen and pelvis showed no signs of tumor, only bilateral pleural effusions with elevation of brain natriuretic peptide in the laboratory (**Figures 5, 6**Figure 6). The patient was hemodynamically stable and anticoagulation with low molecular weight heparin was started. The next treatment plan was CMR and then decision for surgery procedure in another hospital but the patient died before transfer of sudden cardiac death. The autopsy report showed that it was a thrombotic masses. FIGURE 1. Transthoracic echocardiography image showing right and left atrial masses with different structures. FIGURE 2. 60-degree view transesophageal echocardiography image showing right (54x36 mm) and left (35x15 mm) atrial masses. FIGURE 3. 138-degree view transesophageal echocardiography image showing an oval homogeneous left atrial mass. FIGURE 4. 30-degree view transesophageal echocardiography image showing a homogeneous mass in the left atrial auricle (41x25 mm). FIGURE 5. Computed tomography image showing hypodense avascular left atrial masses suspected of thrombi and hyperdense possible vascular right atrial mass. FIGURE 6. Computed tomography image showing right atrial mass with inhomogeneous structure, suggestive for a myxoma or thrombus. **Conclusion**: Biatrial thrombus is a rare condition that presents the danger of progressing to embolism, syncope, congestive heart failure and sudden cardiac death. Treatment options should be decided case-by-case.

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

**Introduction**: Persistent atrial fibrillation is associated with more significant atrial structural remodeling and more severe atrial cardiomyopathy compared to paroxysmal AF, making catheter ablation for persistent AF more challenging. Over time, various strategies have been explored to address this complexity. Recently, ethanol ablation of the vein of Marshall (VOM) and a comprehensive ablation approach—Marshall bundle elimination, pulmonary vein isolation, and line completion for anatomical ablation of persistent AF (Marshall-PLAN)—have shown promising results. (1) Since January 2022, we adopted this strategy as the first-line treatment for HFpEF patients with long-standing persistent AF. Our goal was to compare AF recurrence in patients undergoing Marshall-PLAN ablation, both with and without a complete lesion set (in cases where the Marshall vein was either not found or deemed unsuitable for ablation). **Patients and Methods**: The case series included 57 consecutive patients with long-standing persistent AF (age 65 ± 2 years; 12 women; AF duration 9 ± 11 months; mean LA index volume was 44 ± 2 ml/m2, mean NT-pro BNP was 1202±169). VOM ethanol infusion (median dose 5-9ml ethanol) was completed in 41patients. 16 patients underwent ablation without a complete lesion set. All patients are enrolled in an institutional registry (CaRD registry-Arrhyhmias). **Results:** The primary outcome measured was AF recurrence during a one-year follow-up. In the complete lesion set group, AF recurrence occurred in 14 patients (34.1%). In the group without a complete lesion set, AF recurrence was observed in 3 patients (18.8%). **Conclusion**: The findings from this study suggest that the use of a complete lesion set (CLS) does not necessarily reduce AF recurrence. This challenges the assumption that achieving a CLS guarantees better clinical outcomes. The complexity and extent of lesions in the CLS group could result in more extensive myocardial damage, potentially leading to a higher incidence of postoperative AF episodes. Additionally, the prolonged procedural duration and associated inflammation may contribute to early recurrence. Individual patient characteristics—such as left atrial size, underlying structural heart disease, or the presence of fibrosis—are also important factors that could influence outcomes. Future studies should focus on identifying patient-specific factors that predict the success of complete lesion sets in AF ablation.

Klara Pospiš, Ivan Zeljković, Fran Šaler, Marin Pavlov, Jasmina Ćatić, Šime Manola, Ivana Jurin

**Introduction**: In patients with acute myocardial infarction (AMI), the triglyceride-glucose (TyG) index may be a good predictor of adverse cardiac events. Higher TyG index has been linked to greater incidence of in-stent restenosis during percutaneous coronary intervention and severity of coronary artery disease, according to recent research. (1) Aim: To investigate the prognostic value of TyG index in patients with AMI. **Patients and Methods**: This was a registry-based study conducted at Dubrava University Hospital. We recruited patients with an AMI diagnosis from December 2016 to August 2023. The TyG index was calculated as ln[fasting triglyceride level (mg/dL)xfasting plasma glucose level (mg/dL)/2]. We collected data on gender, age, type of AMI: ST-elevation (STEMI) or non-ST-elevation (NSTE), occurrence of death from all causes, which was divided into several groups (death from: unknown or external causes, AMI, stroke, bleeding and pulmonary embolism). The primary outcomes were all-causes mortality and mortality from AMI during follow-up period. We looked into the relationships between the TyG index and the primary endpoints using the chi-square test. P value of 0.05 was defined as statistically significant. **Results**: We included 2273 patients diagnosed with AMI. Their median age was 64 years (IQR 56-73). Median follow-up was 18.6 months (IQR 2.4-42.5). The patients were split apart using the median of TyG index (4.126 mg/L) IQR (3.929-4.359). Statistically significant difference (chi-square 6.52, p=0.01) was observed in the deaths of 367 patients (16.1%) who were in the group with a higher TyG index. Patients with a TyG index above the median showed a statistically significant difference when evaluating mortality from AMI (chi-square 4.6781, p= 0.031). **Conclusion**: Among patients who experienced AMI, the TyG index was substantially correlated with both long-term all-cause death and death from AMI. TyG index may therefore be useful in daily clinical practice.

Mia Dubravčić Došen, Hrvoje Jurin, Marijan Pašalić, Branka Golubić Ćepulić, Ines Bojanić, Sanja Mazić, Dora Fabijanović, Nina Jakuš, Ivo Planinc, Jure Samardžić, Maja Čikeš, Daniel Lovrić, Kristina Marić Bešić, Joško Bulum, Hrvoje Gašparović, Davor Miličić, Boško Skorić

**Introduction:** Cardiac allograft vasculopathy (CAV) remains a major cause of long-term morbidity and mortality after heart transplantation (HTx). Coronary intimal thickening that occurs during the first post-HTx year is an early sign of CAV. (1) To the best of our knowledge, only one study has reported of decreased intimal thickening in HTx recipients who received prophylactic extracorporeal photopheresis (ECP) in addition to maintenance immunosuppressive therapy (IST) consisting of cyclosporine, azathioprine, and steroid. (2) The ECP-OCT2019 trial is designed to evaluate the effect of prophylactic ECP on intimal thickening during the first post-HTx year, as assessed by optical coherence tomography (OCT), in light of modern IST which includes mycophenolate mofetil, proven to have advantages over azathioprine in CAV prevention. **Study design:** ECP-OCT2019 is a pilot, interventional, prospective, randomized, open-label study. A total of 38 patients were randomized into two arms to receive either 10 cycles of ECP treatment in addition to standard IST or standard IST alone. In all patients, coronary angiography with OCT imaging was performed within the first three months after HTx and repeated one year after HTx to detect progression of intimal thickening. The primary endpoint was defined as the change in intimal volume from baseline to one-year follow-up. Secondary endpoints included changes in maximal and mean intimal thickness, maximal and mean intimal layer area, as well as minimal and mean lumen area. **Conclusion:** ECP-OCT2019 is the first prospective study to evaluate the effect of prophylactic ECP on intimal thickening in HTx recipients in the context of modern IST. Our results may influence current clinical practice in CAV prevention and diagnostics.

Marin Pavlov, Marin Viđak, Šime Manola, Ivana Jurin

**Introduction:** To investigate the impact of chronic obstructive pulmonary disease (COPD) diagnosis on one-year outcome in heart failure (HF) patients in whom sodium-glucose transport protein 2 inhibitors (SGLT2i) were initiated de novo. **Patients and Methods**: Patients were recruited from a local HF registry. All patients with established HF diagnosis according to contemporary guidelines (1) in whom SGLT2i were initiated were eligible for the study. Only patients with at least 6-month follow-up were analyzed. Follow-up included either day-hospital visit or telephone interview with electronic transfer of laboratory data. Primary endpoint was composite of death and hospitalization due to acute decompensated heart failure. **Results:** Out of 1191 patients included in the registry, 996 completed at least 6-month follow-up. Population was predominantly male (67.3%), aged 70 (62-76) years. In 122 (12.2%) patients a diagnosis of COPD was previously established. COPD patients had more often history of peripheral artery disease (PAD) (p=0.001), diabetes (p=0.042), New York Heart Association class III or IV ((p=0.002), presented with higher red cell distribution width (RDW) (p<0.001), and lower estimated glomerular filtration rate (p=0.024) and albumin levels (p=0.005). Death (p=0.002), HF hospitalization (p<0.001), and primary outcome (p<0.001) occurred more often in COPD patients. In Cox regression (forward conditional approach with 16 variables), COPD (Exp(B)= 2.03, 95% confidence intervals 1.33-3.12, p=0.001), along with age, log (NT-proBNP), RDW, history of stroke, and PAD predicted the occurrence of primary endpoint. At 6-month follow-up, COPD patients had higher NT-proBNP (p<0.001) and C-reactive protein (p<0.001). **Conclusion:** HF diagnosis represents a high-risk feature for HF patients, not merely as a marker of more severe risk profile, but also independently being associated with worse outcome.

Nejra Mlačo-Vražalić, Ada Đozić, Nejra Prohić, Mirza Skalonja, Šejla Biščević, Jasmin Idrizović, Edin Begić

**Goal:** To present protocol for diagnosis and differentiation of cardiac amyloidosis, and to review treatment options for patients with transthyretin amyloid cardiomyopathy (ATTR-CM) in daily clinical practice. **Case presentation:** 70-year-old man was hospitalized with symptoms consistent with peripheral neuropathy, polyarthralgia, Raynaud syndrome and dyspnea on exertion. His past medical history included hypertension and hypothyroidism. Electrocardiogram (ECG) revealed left axis deviation, low voltage and intermittent atrial fibrillation. Echocardiography showed concentric left ventricular hypertrophy with granular speckling, normal ejection fraction and grade 1 diastolic dysfunction. Moderate aortic stenosis with mild aortic regurgitation was present, as well as moderate mitral regurgitation and mild tricuspid regurgitation. Subsequent analysis of global longitudinal strain (GLS) showed GLS reduction with nonspecific apical sparing pattern (**Figure 1**). Infiltrative cardiomyopathy was suspected, and we obtained serum and urine protein electrophoresis with immunofixation and the kappa/lambda ratio, which were negative for clonal plasma cell dyscrasia. Bone scintigraphy showed Technetium 99m-methyl diphosphonate uptake in the myocardium which was less/similar to ribs uptake (Perugini grade 1-2). Cardiac magnetic resonance (CMR) was obtained since scintigraphy results were inconclusive, and it confirmed cardiac amyloidosis pattern. Patient had significantly high levels of rheumatoid factor, without specific diagnostic criteria for rheumatological diseases. Electromyoneurography of arms and legs confirmed severe polyneuropathy. Since the patient presented with both cardiomyopathy and neuropathy, disease-specific therapies to consider would be tafamidis and patisiran. Genetic testing should be performed to detect specific mutations and to guide the treatment. FIGURE 1. Analysis of global longitudinal strain (GLS) showed GLS reduction (-7.1%) without typical pattern. Perugini grade 2 with a region of interest (ROI) ratio of 1.51. **Conclusion:** Extracardiac manifestations which represent ‘red flags’ for ATTR-CM, should guide clinicians to perform echocardiography. After establishing the diagnosis, patient should be treated with specific treatment based on the dominant disease phenotype. (1-3)

Mia Dubravčić Došen, Marija Doronjga, Hrvoje Jurin, Marijan Pašalić, Dora Fabijanović, Nina Jakuš, Ivo Planinc, Jure Samardžić, Maja Čikeš, Daniel Lovrić, Joško Bulum, Hrvoje Gašparović, Davor Miličić, Boško Skorić

**Introduction:** Rapidly progressive, or fulminant cardiac allograft vasculopathy (CAV) is associated with a high risk of graft failure and mortality in heart transplant (HTx) patients. (1) Since clinical presentation is often dramatic, patients do not typically undergo intravascular imaging, especially not serial assessments of progressively evolving coronary changes. **Case report:** We present a case of a 59-year-old HTx recipient who presented in April 2021 with severe dyspnea, three years following HTx. Echocardiography revealed left ventricular (LV) wall thickening (IVSd 13 mm) with a severely reduced ejection fraction (LVEF) of 30%, restrictive filling pattern, and high values of NT-proBNP (>35000 ng/L). Urgent endomyocardial biopsy and coronary angiography were performed. Angiography showed severe CAV, and optical coherence tomography (OCT) of the left anterior descending artery (LAD) showed multiple coronary lesions, including wall edema with side-branch compromise, intimal hyperplasia, erosions, fissure, and spasm (**Figure 1**). Immunohistopathological analysis showed no signs of cellular or antibody-mediated rejection (AMR), however Luminex® revealed a very high mean fluorescence intensity for class II donor-specific anti-HLA antibodies, supporting the clinical suspicion of AMR and related accelerated CAV. Anti-rejection treatment was immediately initiated, along with dual antiplatelet therapy, low-molecular weight heparin, and substitution of cyclosporine with tacrolimus. Anti-rejection therapy, consisting of intravenous immunoglobulins, pulse corticosteroids, and plasmapheresis resulted in significant clinical improvement, improvement in LV function (LVEF 45%), and decrease in NT-proBNP values (16249 ng/L at discharge). Follow-up coronary angiography with OCT showed evolution of coronary lesions including bright spots, necrotic intimal lesions with spasm, and layered fibrotic plaques **(****Figure 1****)**. FIGURE 1. Coronary artery lesions detected by serial optical coherence tomography (OCT) imaging. *Row 1* – the initial OCT imaging: A, intimal erosion; B, wall edema with side-branch compromise; C, intimal fissure (longitudinal view). *Row 2* – the follow-up OCT imaging 6 months later: D, bright spots; E, vessel spasm with necrotic lesion; F, layered fibrotic plaque. **Conclusion:** Serial intravascular imaging using OCT in patients with rapidly progressive CAV can provide in vivo insight into the evolution of coronary changes, which may help us better understand the pathogenesis of this form of CAV.

Ivan Aranza, Ivan Pletikosić, Leida Tandara, Zrinka Jurišić

**Introduction:** This study aimed to evaluate the presence of iron deficiency as a possible factor contributing to poorer outcomes in cardiac resynchronization therapy (CRT). It also sought to explore the relationship between sideropenia (iron deficiency) and the clinical characteristics of the patients. **Patients and Methods:** In this cross-sectional study, 121 heart failure patients undergoing CRT were included after providing informed consent (1). Each participant underwent a thorough clinical evaluation, including blood tests and collection of detailed demographic and medical history information. **Results:** Sideropenia was observed in 55% of patients, while anemia of any cause was identified in 20.4%. The most frequent condition was prelatent sideropenia, affecting 27% of the cohort, with sideropenic anemia present in 4.5%. When comparing patients with and without sideropenia, no significant differences were noted in demographic factors (such as age, BMI, gender) or general clinical characteristics (e.g., duration of CRT therapy, type of implanted device, baseline heart rhythm, hospitalization history, and blood pressure). However, those with sideropenia exhibited higher rates of arterial hypertension (P=0.001), type II diabetes (P=0.011), and ischemic cardiomyopathy (P=0.011), and were more likely to be on statin therapy (P=0.030). Optimal medical therapy was reached in 69.4% of participants. Additionally, patients with sideropenia were more commonly classified in the higher functional classes of the New York Heart Association (NYHA) (P=0.024, **Figure 1**) and exhibited elevated NT-proBNP levels (P=0.034). Poorer clinical status correlated with reduced hemoglobin, hematocrit, and serum iron levels, along with increased RDW and the proportion of hypochromic red blood cells. Marginal significance was noted in the reduced transferrin saturation levels in patients belonging to the higher NYHA classes. Moreover, anemia and sideropenia were more prevalent in higher NYHA classes, while patients in lower classes predominantly had neither condition (P=0.011, **Figure 2**) (1). FIGURE 1. Differences in the distribution of patients in NYHA classes depending on iron deficiency status. *Fisher’s test; NYHA – New York heart association functional class. FIGURE 2. Prevalence of anemia and/or iron deficiency in patients of different NYHA classes. *Χ2 test; NYHA – New York heart association functional class. **Conclusion:** The findings highlight a considerable prevalence of sideropenia, which may be a modifiable cause of suboptimal CRT response (2). Its strong association with worsened cardiopulmonary function underscores the need for prompt diagnosis and treatment of sideropenia to improve CRT outcomes in heart failure patients (3, 4).

Klara Pospiš, Fran Šaler, Ivan Zeljković, Marin Pavlov, Jasmina Ćatić, Šime Manola, Ivana Jurin

**Introduction:** Current guidelines for management of acute coronary syndromes (ACS) point out that in patients after acute myocardial infarction (AMI), dual antiplatelet therapy (DAPT) is recommended for 12 months, regardless of the method of revascularization. (1) It is evident from routine clinical practice that there are variations in the prescription of DAPT and that the guidelines are not being sufficiently adhered to. The aim of this study was to investigate the frequency and variations in DAPT prescribing patterns among patients who underwent coronary artery bypass grafting (CABG) following an AMI. **Patients and Methods**: This was a registry-based study, conducted at Dubrava University Hospital. We recruited patients diagnosed with AMI who underwent CABG from December 2016 to January 2024. We collected data on gender, age, body-mas index (BMI), type of AMI: ST-elevation (STEMI) or non-ST-elevation (NSTE-ACS), prescribed medications after discharge (single antiplatelet therapy (SAPT) with acetylsalicylic acid (ASA), DAPT with ASA plus clopidogrel, ticagrelor and prasugrel) and data on major adverse cardiovascular events (MACE) which were divided into three groups: non-MACE, adverse coronary events and others: stroke, pulmonary embolism, atrial fibrillation and bleeding. **Results**: We included total of 126 patients. The median follow-up was 21.8 months (IQR:32.1:2.7). Median age was 67 years (IQR:59-73), 76.2% were male and 87.3% had NSTE-ACS. Total of 73.8% patients received DAPT after CABG of which majority (88.8%) were discharged with clopidogrel plus ASA. Of the remaining patients, 28.6% received SAPT with ASA and 7.9% were discharged with DAPT including ASA and ticagrelor. No patient received prasugrel. A chi-square test showed a statistically significant difference (p<.001) in prescribing DAPT depending on STEMI vs. NSTE-ACS but no statistically significant differences were found comparing prescribed DAPT and MACEs (p<0.197). There was also no difference in DAPT prescribing patterns in relation to gender, age and BMI. **Conclusion**: The most common prescribed pattern remains DAPT with clopidogrel even though the guidelines of the European Society of Cardiology give priority to the DAPT with ticagrelor.

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

**Introduction**: Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to cryoballoon ablation (CBA) in patients with atrial fibrillation (AF)). Each modality induces distinct biological responses, resulting in varying degrees of tissue injury and inflammation but. (1, 2) This study aimed to determine the extent of myocardial injury and systemic inflammation following PFA and cryoballon ablation using established biomarker: lactate dehydrogenase (LDH), C-reactive protein (CRP), and high-sensitivity troponin T (hs-cTnT). **Patients and Methods**: The study included two groups of patients: one group undergoing cryoablation (N=57) and the other undergoing PFA (N=57). All patients are enrolled in an institutional registry (CaRD registry-Arrhyhmias). Biomarker levels of LDH, CRP, and troponin were measured at baseline AND 18-24 hours after the ablation. **Results:** In the cryoablation group, LDH levels increased significantly by 16.7% and in the PFA group, the increase in LDH was even more pronounced, with a rise of 59.1% (P < 0.001). For the cryoablation group, CRP levels increased by 113.5% and in the PFA group, the increase in CRP was far more substantial, with a rise of 1015.5 (P < 0.001). In the cryoablation group, troponin levels exhibited an increase of 53505.2% and similarly, in the PFA group, troponin levels increased by 44114.5 (P < 0.001). **Conclusion**: The data demonstrate that both cryoablation and PFA result in significant increases in LDH, CRP, and troponin levels, indicating tissue damage and inflammation. However, PFA leads to a larger increase in LDH and CRP, suggesting a stronger inflammatory and cellular damage response compared to cryoablation. Conversely, both procedures cause profound elevations in troponin, indicative of cardiac injury, but the relative increase is higher in the cryoablation group which can be explained by gradual cell death in cryo group and wider affected area during ablation. Despite signs of higher tissue damage and inflammation in PFA group, the NT-proBNP showed a significant reduction after three months. Further studies are needed to fully understand the clinical implications of these biomarker changes and their impact on patient outcomes.

Tomislav Glavak, Valentina Sedinić, Nives Bognar

**Introduction**: Holter ECG is a method of detecting bradycardia and tachycardia heart rhythm disorders. (1) This paper will present the case of a patient with intermittent AV block who is a professional driver. **Case report**: N.N., male, aged 60, who hid his ailments until he was persuaded to submit to diagnostic treatment, which established the seriousness of the case itself and indicated the urgent implantation of an electrostimulator. Through the conversation after the first diagnostic test, we found out that the patient had been suffering for a long time, but he attributed his problems in the form of dizziness, general weakness, and on a couple of occasions loss of consciousness to having a “bad day”, lack of fluid intake, and simply took it as a passing phase he has to keep to himself since he is a professional driver. The ailments he had did not cause him as much of a concern, as he was more concerned about keeping his driver’s license. Upon persuasion, a holter ECG was performed, which determined AV block Mobitz II (2:1) in the awake state with a low frequency. The patient was referred to the Emergency Department, and admission to the department was arranged due to the indication for the implantation of an electrostimulator. **Conclusion**: Cardiogenic syncope can lead to serious consequences, especially if it happens in specific, professional job, as in this case. Professional driving requires complete concentration on oneself and one’s surroundings. It is important to emphasize that educating and informing the patient himself is crucial when establishing a diagnosis so that similar things are not covered up and thus endanger their own health and that of others.

Marina Vidosavljević, Dijana Dumančić, Boris Dumenčić, Livija Sušić, Goran Galić, Domagoj Vidosavljević

**Introduction:** Myxomas are the most common benign mesenchymal heart tumors. Right atrium myxomas occur in 10-20% of all cases. (1, 2) **Case report:** 61-year-old male has been diagnosed with rectal adenocarcinoma and treated by neoadjuvant chemotherapy and surgery in 2022. In 2023, he was reoperated due to local metastasis. During this March, cancer progressed in pelvis and asymptomatic pulmonary embolism of the branches for the right lung middle lobe was registered on CT scan. Embolism was presumed instead of metastasis, so anticoagulant therapy was introduced, and heart echo was recommended. A transthoracic echocardiogram (TTE) showed heart cavities of normal size and preserved biventricular contractility, and formation attached to right atrial wall was shown, not limiting the blood flow in the right atrium and through the tricuspid valve, without signs of pulmonary hypertension (**Figure 1**). Contrast-enhanced CT scan described a homogeneous, hypodense semilunar defect, measuring 4x2x4.5 cm with signs of moderate post-contrast imbibition, located along the posterior contour of the right atrium and morphologically inseparable from the vena cava inferior (**Figure 2**). Surgical removal of the tumor was performed and pathohistological diagnosis showed myxoma (**Figure 3**). FIGURE 1. A transthoracic echocardiogram with formation attached to right atrial wall. FIGURE 2. MSCT showing heart mass. FIGURE 3. Pathohistological diagnosis – Myxoma, HP x 10. **Conclusion:** CT angiography has a high degree of specificity in the PE diagnosis, but TTE remains an important method of diagnosing suspected PE and a method of excluding other CVD. TTE has a high sensitivity (95-100%) but TEE is a better choice for tumors 1-3 mm in size and located on posterior wall of the left and right atrium and atrial septum. Myxomas of the right atrium usually are not the source of fatal PE and surgical removal of right atrial myxoma with PE is the first line of treatment. The recurrence rate of right atrial myxoma is 1-3%, and the risk of recurrent PE is 0.4-5%. The interval from surgery to recurrence of myxoma is several months to eight years, therefore annual TTE and CT angiography or ventilation perfusion lung scintigraphy are recommended during the same period. In this case, right atrial myxoma was the probable source of the PE.

Marina Klasan

Pulmonary vein isolation is an ablative method used to treat symptomatic atrial fibrillation (AF) that does not respond to medication. However, the outcome of ablation often depends on a variety of risk factors, including age, obesity, hypertension, diabetes, sleep apnea, smoking, and other comorbidities. Studies have shown that patients with well-managed risk factors, such as normal body weight and stable hypertension, tend to have better long-term outcomes and lower rates of recurrence. On the other hand, comorbidities can significantly reduce the success of the ablation procedure and increase the likelihood of arrhythmia recurrence. The treatment of AF requires an integrated approach that encompasses not only pharmacological and interventional therapies but also active management of risk factors. (1-3) An individualized treatment plan that includes both pharmacological and non-pharmacological measures for managing comorbidities can improve long-term outcomes and reduce the risk of recurrence following ablation.

Ana Petretić, Marija Tomac Stojmenović

**Introduction**: Malignant neuroleptic syndrome (MNS) is life-threatening condition caused by psychotropic medications (1, 2). Pulmonary embolism is known complication of antipsychotics, but incidence of pulmonary embolism in MNS is not known. Raised levels of creatine kinase can be helpful in diagnose but are not specific for MNS and there are cases with normal levels. (3) **Case report**: We present the case of a 59-year-old female with severe bipolar disorder who presented with high fever, altered mental status and acute respiratory insufficiency. Upon presentation she was hospitalized in local institution for worsening of mental status receiving typical and atypical neuroleptics. On fourteenth day of hospitalization on psychiatric ward she was transferred to our Clinic because of acute respiratory insufficiency. High fever and altered mental status preceded, together with tachycardia and tachypnea but without hemodynamic instability. In laboratory tests special attention was on creatine kinase level which was not elevated. Before transport analgosedation and orotracheal intubation was preformed and she was mechanically ventilated. Upon admission CT pulmonary angiography showed bilateral pulmonary thromboembolism. Patient developed hemodynamic instability requiring vasopressors so systemic fibrinolytic therapy was applied. Hospitalization was complicated with severe thrombocytopenia, acute kidney failure, prolonged and difficult weaning from ventilator (with need of tracheostomy), partial epileptic seizures, bacteriemia (Staphylococcus species), and tetraparesis following prolonged immobility. Slowly, on tailored medical therapy together with intensive physiotherapy patient started to recover physically but then her mental status started to deteriorate again. **Conclusion**: According to patient history, drug therapy, clinical presentation and excluded other possible causes we conclude that patient had MNS. Prompt reaction and therapy is necessary to reduce mortality in such lethal condition.

Marin Viđak, Fran Šaler, Jasmina Ćatić, Jelena Kursar, Petra Vitlov, Ana Šerman, Miroslav Raguž, Diana Rudan, Andrej Novak, Ivan Zeljković, Šime Manola, Ivana Jurin

**Introduction**: Chronic inflammation plays a role in heart failure (HF) progression across its subtypes (reduced, mildly reduced, and preserved ejection fraction (EF) (1). While C-reactive protein (CRP) and albumin are known prognostic markers (2), the potential of the CRP-to-albumin ratio (CAR) and red blood cell distribution width-to-albumin ratio (RAR) as prognostic indicators in HF remains underexplored. **Patients and Methods**: This prospective observational study was conducted at Dubrava University Hospital (CaRD registry, NCT06090591), enrolling HF patients between May 2021 and March 2024. Data on demographics, comorbidities, serum biomarkers, EF, and adverse events (death, HF-related emergencies, or hospitalizations) were collected. Patients with complete CRP and albumin measurements at baseline and 6-month follow-up were included. **Results**: Among 1170 hospitalized HF patients, 368 were included. The median age was 67 years (IQR 60-74), 30% females (**Table 1**). Over the 6-month follow-up, CAR significantly decreased from 0.12 (95% CI 0.106-0.147) to 0.063 (95% CI 0.056-0.071), p<0.0001, with no significant difference between empagliflozin and dapagliflozin groups (p=0.922). There were 40 HF composite events. CAR and RAR were both correlated with HF composite events (CAR: r= 0.163, p= 0.0017; RAR: r= 0.157, p= 0.0025), particularly in the HFpEF group (CAR: r= 0.32, p= 0.0032; RAR: r= 0.307, p= 0.0047). ### TABLE 1: Baseline characteristics of participants (n=386). | **Category** | **Number** | **%** | | --- | --- | --- | | *Sex* | | | | Male | 258 | 66.8 | | Female | 110 | 28.5 | | Dapagliflozin | 195 | 50.5 | | Empagliflozin | 173 | 49.5 | | *NYHA status* | | | | NYHA I | 15 | 3.9 | | NYHA II | 174 | 45.1 | | NYHA III | 156 | 40.4 | | NYHA IV | 23 | 5.9 | | BMI (C, IQR) | 28.5 (25.6-32.6) | | | Smoking | 128 | 33.1 | | *Comorbidities* | | | | Atrial fibrillation | 171 | 44.3 | | Hypertension | 302 | 78.2 | | Diabetes mellitus | 158 | 40.9 | | Coronary artery disease | 177 | 45.9 | | Peripheral artery disease | 62 | 16.1 | | Dyslipidemia | 256 | 66.3 | | Stroke / TIA | 32 | 8.3 | | COPD / asthma | 38 | 9.8 | | HFrEF | 240 | 62.1 | | HFmrEF | 45 | 11.7 | | HFpEF | 83 | 21.5 | | *Ejection fraction* | | | | EF in HFrEF (C, IQR) | 30 (25-35) | | | EF in HFmrEF (C, IQR) | 45 (43-46) | | | EF in HFpEF (C, IQR) | 55 (50-60) | | | *Serum values* | | | | Hemoglobin (C, IQR) | 138 (127-148.5) | | | eGFR (C, IQR) | 66.8 (49.9-84.6) | | | NT-proBNP C, IQR) | 2612 (1143-6806) | | | Albumin (C, IQR) | 41 (38-43) | | | CRP (C, IQR) | 5 (2.1-11.35) | | | RDW (C, IQR) | 14.1 (13.4-15.2) | | | CAR (C, IQR) | 0.12 (0.05-0.28) | | | RAR (C, IQR) | 0.35 (0.32-0.4) | | [†] NYHA = New York Heart Association functional classification, BMI = body mass index, C = median, IQR = interquartile range, TIA = transient ischemic attack, COPD = chronic obstructive pulmonary disease, EF = ejection fraction, HFrEF = heart failure with reduced ejection fraction, HFmrEF = heart failure with mildly reduced ejection fraction, HFpEF = heart failure with preserved ejection fraction, eGFR = estimated glomerular filtration rate, NT-proBNP = N-terminal prohormone of brain natriuretic peptide, CRP = C-reactive protein, RDW = red blood cell distribution width, CAR = C-reactive protein to albumin ratio, RAR = red blood cell distribution width to albumin ratio **Conclusion**: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) significantly reduced CAR over the 6-month follow-up period, irrespective of the specific SGLT2i agent. Both CAR and RAR were independently associated with adverse HF outcomes, particularly in the HFpEF cohort, highlighting the significance of inflammatory processes in HF and the potential role of SGLT2i in modulating these markers in clinical practice.

Krešimir Crljenko, Karlo Golubić, Helena Jerkić, Iva Klobučar, Mislav Vrsalović, Zdravko Babić, Diana Delić-Brkljačić

**Introduction**: Pulmonary embolism is a common diagnosis encountered in everyday practice. We present a case of a high-risk pulmonary embolism patient in which we were forced to use both thrombolysis and mechanical thrombectomy together with ECMO for stabilization (1). **Case report**: 40-year-old female patient presented as an out-of-hospital cardiac arrest and was brought by ambulance to our Emergency Department (ED) with ongoing resuscitation. The initial rhythm was pulseless electrical activity (PEA). Upon arrival at the ED, resuscitation was continued and ROSC was achieved, the patient was intubated and mechanical ventilation was started. Due to hemodynamic instability, noradrenaline and dobutamine were administered. An urgent CT pulmonary angiography was performed and filling defects in terms of massive pulmonary embolism were described in both pulmonary arteries. Considering the critical condition of the patient and recent surgical treatment, it was decided to perform mechanical thrombectomy. The procedure was performed bilaterally with 20 and 24 F catheters, and a larger amount of thrombotic masses were removed, mainly from the right pulmonary artery. The procedure was performed without periprocedural complications. After the patient was transferred to the CICU, an echocardiogram was performed, which revealed a dilated right ventricle with signs of pressure overload. About an hour after the thrombectomy, hemodynamic deterioration occurred, which resulted in further escalation of the dose of vasopressors and inotropes. Due to significant clinical deterioration of the patient, systemic thrombolysis was applied. Despite this, there was no improvement, and the patient was in refractory cardiogenic shock which led to decision to place a veno-arterial extracorporeal membrane oxygenation (ECMO). Shortly after the ECMO circuit establishment, native cardiac function deteriorated with minimal opening of the aortic valve visualized on bedside echo. Inotropic therapy with levosimendan was initiated and after a few hours cardiac function started to improve. The next day the pulse pressure was over 20 mmHg and lactate levels dropped significantly. On the third day, the patient was hemodynamically stable with minimal vasopressor and inotropic support, VA ECMO was removed. Over the next few days, the patient was hemodynamically stable with recovered respiratory function. A follow-up echocardiogram showed a normal size of the right ventricle with normal longitudinal function and the patient was transferred to the cardiology department where she fully recovered. **Conclusion**: There are patients for whom pulmonary embolism can be a lethal diagnosis. In an acute setting, with hemodynamically unstable patient, temporary use of mechanical cardiopulmonary support (2) has shown to be very helpful in stabilizing the patient.

Petra Kušenić, Biljana Hržić, Katarina Grandavec, Martina Vidak, Magdalena Kunić, Ivica Benko

**Introduction**: Bilateral subclavian artery stenosis, which involves the narrowing of both subclavian arteries, can lead to significant clinical complications such as pseudohypotension, upper extremity ischemia, and subclavian steal syndrome. This condition is relatively rare, with a prevalence of 2-4% in the general population, and is typically characterized by a difference in blood pressure between the upper and lower extremities. If left untreated, complications can include ischemic stroke and respiratory issues. (1) **Case report**: 65-year-old male patient was admitted following successful resuscitation after a cardiopulmonary arrest. Initially, he was mechanically ventilated and hypotensive, with ultrasound revealing an abdominal aortic aneurysm. Further diagnostic work uncovered an iliac artery occlusion, which was successfully treated, but the patient remained hypotensive. A significant difference in blood pressure between the upper and lower extremities prompted further investigation, revealing stenosis in both subclavian arteries. Due to these stenoses, standard blood pressure measurements from the arms were unreliable, necessitating the use of femoral artery monitoring. This approach provided accurate hemodynamic data, as arm measurements would have produced falsely low values due to the subclavian artery stenosis. **Conclusion**: In cases of subclavian artery stenosis, reduced blood flow to the upper extremities can cause falsely low blood pressure readings in the arms, potentially leading to incorrect conclusions about systemic hypotension or shock. Continuous monitoring of blood pressure through appropriate methods is critical to accurately assess the patient’s condition. In terms of nursing care, it is essential to continuously monitor and record blood pressure values, adjusting therapy accordingly based on these readings. Special attention should be paid to the patient’s hemodynamic stability. This situation also highlights the need for additional training for nursing staff to properly interpret blood pressure readings and respond promptly to any changes in the patient’s condition.

Irena Kužet Mioković, Marica Komosar Cvetković, Samanta Vuković, Kristina Marić

**Introduction**: Today, health literacy has exceptional importance in health communication. It becomes the strongest predictor of the health status of each individual, and is even ahead of education, age or religious affiliation. Various studies show that the degree of health literacy is directly related to the success of communication, which ultimately affects better patient cooperation, medication adherence, frequency of use of health services, reduction of repeated hospitalizations and the outcome of treatment itself. (1) **Subjects and methods:** The research group consisted of 100 patients of Thalassotherapia Opatija between the ages of 39 and 86, who participated in an inpatient cardiac rehabilitation program. By using a standardized protocol, we determined general data (age, gender, education) and the existence of risk factors for all respondents. We observed and determined risk factors by anthropometric measurements, laboratory diagnostics, measurement of arterial pressure values and insight into the correct intake of prescribed therapy during admission. Furthermore, we used the CARRF-KL questionnaire translated into Croatian (measuring the level of knowledge about risk factors for cardiovascular diseases). **Results:** 21% of women and 79% of men participated in the research. Their average age was 64.47 years. The average body mass index was 28.78 kg/m2. 22.44% of them had normal waist circumference, while 23.21% had excessive values, and 54.35% of patients had high-risk values. 35% of them were smokers. 39.42% had elevated arterial pressure values, and 79.53% had hyperlipoproteinemia. Furthermore, it was determined that 40% of patients took the prescribed therapy in the correct dose and at the correct time. By analyzing the data on the level of knowledge for cardiovascular disease risk factors (CARRF-KL), a significant statistical difference was observed between age groups and the level of education, and the average knowledge score was read, which is - good. **Conclusion:** It is necessary to develop skills and improve health literacy so that patients can find information, understand the meaning and usefulness of certain information and understand the possibility of choice, all with the aim of changing lifestyle and habits, quality of life, and ultimately reducing the rate of morbidity and mortality.

Mihaela Roguljić

**Introduction**: Acute pulmonary embolism is a common and life-threatening condition that requires urgent diagnosis and treatment. It affects approximately 117 people per 100,000 inhabitants annually, and its incidence increases with age. (1, 2) Echocardiography is the most used imaging method for diagnosing and managing acute pulmonary embolism. In patients with acute PE, it is used to assess right ventricular function. **Case report**: Patient N.N., 66 years old, was admitted to the Intensive Care Unit (ICU) due to massive pulmonary thromboembolism. Upon admission, the patient was hypotensive, had low oxygen saturation, and an emergency echocardiography showed reduced right ventricular function with elevated levels of cardio-selective troponin. Mechanical thrombectomy of the pulmonary arteries was immediately performed. The patient’s condition stabilized, and partial recovery of right ventricular function was observed. On the fourth day in the ICU, after getting up and going to the restroom on his own request, the patient experienced a recurrence of dyspnea, along with a drop in blood pressure and oxygen saturation. Fibrinolytic therapy with alteplase was administered. After the fibrinolysis, the patient’s condition fully stabilized, with continued recovery of right ventricular function. Following treatment, the patient was discharged home with a recommendation to continue prescribed therapy and follow-up with a cardiologist. **Conclusion**: The degree of right ventricular dysfunction, along with hemodynamic stability, is an important parameter in assessing the risk and mortality of patients with acute pulmonary embolism. Trained nurses follow protocols and standards in echocardiography, and by advancing their knowledge and expertise, they contribute to improving the quality of patient care.

Renata Jažić

Coronary heart disease (CHD) is a significant cause of morbidity and mortality worldwide. It occurs due to the accumulation of plaque in the walls of the coronary arteries, leading to reduced blood flow to the myocardium. The prevention of CHD is an important public health priority, with measures divided into primary, secondary, and tertiary prevention. Primary prevention focuses on the susceptibility to disease development when risk factors are present without symptoms of the disease. General measures relate to the daily organization of life and work, as well as the creation of good environmental conditions, while specific measures aim to eliminate risk factors and identify new etiological agents. Preventive programs promote the management of known cardiovascular risk factors such as hypertension, hyperlipoproteinemia, diabetes, obesity, inadequate nutrition, physical inactivity, smoking, depression, and numerous other health conditions. (1) Nurses educate and provide support to individuals at risk of CHD, promoting healthy behaviors such as regular physical activity, healthy eating, and smoking cessation. Through the implementation of secondary prevention and early diagnosis of critical and permanent damage, interventions are aimed at lifestyle changes, management of risk factors, and the application of pharmacological treatment. Tertiary prevention involves patients with existing CHD, with the goal of improving patients’ quality of life through treatment and rehabilitation, reducing the occurrence of disability and the development of complications by improving cardiac function. Nurses, with their professional knowledge and patient-centered care, contribute to promoting heart health and reducing risk factors associated with the development and onset of CHD.

Vjera Pisačić, Ana Marinić, Valentina Jezl, Danijela Grgurević

Post-intensive care syndrome (PICS) is a relatively new clinical entity that is recognized in patients after critical illness who are discharged from the intensive care unit. It is characterized by new or worsening changes in the individual’s physical, cognitive and/or mental functioning. A wide range of symptoms and signs that can be manifested (from generalized muscle weakness and poor mobility, sleep disturbance, malnutrition, disturbances in attention, concentration and memory, all the way to anxiety, depression or symptoms of post-traumatic stress disorder - PTSD) constitute this syndrome often unrecognized. (1) With the increase in the number of survivors in contemporary cardiac intensive care units (CICU), due to evolution in cardiac and other critical care-based technologies (temporary mechanical circulatory support, therapeutic hypothermia, advanced respiratory support, renal replacement therapy etc.) it is assumed that the number of people with certain symptoms of PICS will also increase. The best way to prevent the occurrence of PICS is to prevent the occurrence of a critical illness, but since this is not possible in most cases, the need to implement PICS prevention measures in CICU is indicated. A review of the existing literature recommends the ABCDEF bundle of prevention measures, which will be explained in more detail, includes the following: Awakening and Breathing Coordination with daily sedative interruption and ventilator liberation practices, Delirium monitoring and management, Early ambulation and Family empowerment and engagement. (1) Considering the prevalence, duration and burden of PICS symptoms, its impact on the poorer quality of life of the individual and the family, and the associated mortality, the introduction of the preventive measures as part of daily practice in CICU certainly seems to be a reasonable and useful option.

Tomo Svaguša, Danijela Grizelj, Dominik Buljan, Marta Puškadija, Šime Manola, Diana Rudan

**Introduction**: Unicuspid aortic valve (UAV) is a very rare congenital anatomical variation of the aortic valve. Instead of the aortic valve having three separate leaflets, in the UAV all three leaflets are interconnected. Because of the above, hemodynamics over the valve itself are disturbed, which leads to accelerated degeneration of the valve. (1) **Case report:** 32-year-old patient was examined by a cardiologist due to unregulated arterial hypertension and a positive family history of cardiovascular disease (a brother suffered a myocardial infarction at the age of 33 years). Unregulated arterial hypertension of 190/98mmHg was verified by the examination. A systolic murmur was heard over the precordium. The patient had a echocardiography done 2 years earlier in a peripheral hospital where suspected mild aortic stenosis was described without a description of the morphology of the aortic valve. Since then, he has not been referred for regular follow-up with a cardiologist. Now during the examination, transthoracic echocardiography verified moderate aortic stenosis and mild to moderate extremely eccentric aortic regurgitation. Apart from a slightly thicker myocardium of the left ventricle, the rest of the findings were normal. Although the parasternal echo projections were extremely poor, a UAV was suspected (**Figure 1**) and the patient was referred for a transesophageal echocardiography (TEE). Unicommissural unicuspid aortic valve is verified by TEE (**Figure 2**). FIGURE 1. Echo projections in the short parasternal axis. Due to the poorer echo windows, the morphology of the valve is not adequately visible. An extremely eccentric aortic regurgitation jet is seen. FIGURE 2. Transesophageal ultrasound shows a unicommissural unicuspid aortic valve. **Conclusion**: Although UAV is an extremely rare malformation of the aortic valve, it presents a significant risk of accelerated valve degeneration. Timely detection of UAV in order to control risk factors which can contribute to accelerated degeneration such as unregulated arterial hypertension enables the prolongation of operative treatment of the valve.

Daniela Lončar

Propafenone is a drug that is most commonly used in medicine for the prevention of supraventricular tachycardias, such as atrial fibrillation. It belongs to the Class IC class antiarrhythmics. Propafenone is well resorbed from the gastrointestinal tract (about 95%), but the bioavailability is low, only 12%. Almost all drug metabolism takes place in the liver, and in the bloodstream 95% of the drug is bound to plasma proteins, which is why hemodiafiltration has no effect in the treatment of possible overdose. The initial dose that clinicians prescribe to patients is generally 150 mg of the drug, two to three times a day, while the maximum dose would be twice as high. The drug is switched off if the QRS complex on the ECG expands by more than 20% compared to the original state. In literature we found, about 60 cases of propafenone poisoning were described. (1) One retrospective study found that propafenone overdose mortality was 23%. Due to the strong binding to plasma proteins (> 95%) and the large volume of distribution, hemodialysis is not effective. In addition, to general emergency measures, it is necessary to monitor the vital indicators of patients in the intensive care unit. Defibrillation, as well as dopamine and isoproterenol infusion, are effective for controlling heart rhythm and blood pressure. **Case report**: 19-year-old female patient was treated at the Clinic for Internal Diseases due to intentional poisoning with propafenone tablets. The patient was hospitalized due to suicidal poisoning with propafenone tablets, and she drank 32 tablets. Upon admission to the Department of Intensive Care, cardiopulmonary resuscitation was immediately started due to pulseless cardiac activity and dyspnea, as well as bizarre QRS complexes on the ECG monitor, which is interpreted as a proarrhythmogenic effect. During resuscitation, the patient received several ampoules of adrenalin and atropine, and electroconversion was performed about 30 times due to ventricular fibrillation. Over the next two days, the clinical condition gradually stabilizes, after which the patient becomes agitated and states that she will attempt suicide again, and a psychiatrist is consulted and a transfer to the Psychiatric Clinic is indicated.

Verica Šeb, Anita Botić, Nikolina Glogovšek, Ružica Lovrić, Paula Keblar, Mateja Šolić, Patricija Bručić Ričko

Cardiomyopathies are diseases of the heart muscle that cause structural and functional changes in the heart. They can affect the heart muscle by weakening it, enlarging it, or altering its structure, which can lead to a reduced ability of the heart to function. There are several main types of cardiomyopathies, and the causes can vary. Cardiomyopathies often do not manifest symptoms in the early stages until serious complications arise, such as heart failure or arrhythmias. Early detection and treatment are crucial for reducing the risk of severe outcomes. We distinguish several types of cardiomyopathies: dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), and Takotsubo cardiomyopathy (stress-induced cardiomyopathy). A common feature of most cardiomyopathies is their genetic cause. Genetically caused cardiomyopathies represent a group of hereditary heart diseases that are transmitted autosomal dominantly or recessively, depending on the type of mutation, from parents to children. These diseases result from mutations in genes that control the structure and function of the heart muscle and can manifest in different forms and var yin disease severity. Genetic factors play a key role in several major types of cardiomyopathies, most commonly in HCM, ARVC, and sometimes in DCM. Genetic testing plays a crucial role in early diagnosis, allowing for the identification of mutation carriers, as well as monitoring and prevention of these diseases in family members predisposed to these diseases. (1) This paper presents the basic facts about genetic cardiomyopathies, along with an overview of the key types of these hereditary heart diseases, with a special focus on their mechanisms of development, clinical manifestations, and diagnostic methods. Additionally, several cases from practice are presented, illustrating the different forms and progression of genetic cardiomyopathies, with the aim of better understanding their impact on patient health and the options for their treatment and management.

Matko Filipović, Jurica Kotarac, Lucija Mičik, Matija Vrbanić, Andreja Virt, Biljana Hržić, Marina Budetić, Kristijana Radić, Ivica Benko

The role of a Transcatheter Aortic Valve Implantation (TAVI) coordinator is essential in managing the growing complexity of TAVI procedures. Acting as the central link between patients, families, and the multidisciplinary medical team, the TAVI coordinator ensures the seamless coordination of care from pre-procedural assessment to post-operative management. Effective communication is key to optimizing patient outcomes and minimizing risks. Nurse coordinators in particular play a critical role in educating patients, scheduling tests, and facilitating decision-making between cardiologists, surgeons, and other healthcare professionals. Studies have shown that dedicated TAVI coordinators significantly enhance patient outcomes by improving procedural efficiency, reducing hospital stays, and minimizing post-procedure complications. In addition, the presence of a coordinator promotes continuity of care, ensuring that all stakeholders are well-informed at each stage of the patient’s journey. Challenges faced by TAVI coordinators include managing the high volume of elderly patients with complex comorbidities, organizing multidisciplinary team meetings, and addressing logistical hurdles in pre- and post-procedural care. TAVI coordinators also play a key role in post-discharge follow-up, monitoring recovery and ensuring adherence to prescribed therapies. Their role extends to addressing patient concerns, managing complications, and reducing the readmission rate by providing ongoing education and support. (1, 2) In conclusion, the TAVI coordinator serves as a crucial element in modern TAVI programs, enhancing patient care through multidisciplinary collaboration, ensuring smooth procedural workflows, and addressing the unique challenges posed by an aging patient population.

Mario Ivanuša

Nowadays, a rehabilitation centre stands as a better place for cardiovascular health as it combines diagnostics, treatment, education and evaluation of patients delivered by an interdisciplinary team. Cardiovascular rehabilitation (CVR) program is traditionally carried out in a hospital or outpatient environment. Following the COVID pandemic, more focus has been on virtual CVR which can be either synchronous (direct interaction of staff and patient across different locations) or asynchronous (using technology to remotely transfer data and educational content). Considering the availability, life tempo and desire to return to work activities as soon as possible, hybrid CVR is becoming more dominant as it combines onsite and virtual approach of the program. (1) Cardiovascular rehabilitation is an evidence-based and medically supervised intervention and part of secondary prevention of cardiovascular (CV) disease. It is executed according to the guidelines of professional societies and has different goals depending on the stage of the disease. (2) During the initial hospital treatment (Phase I CVR), the goal is informing and motivating needed for the necessary change of CV risk factors, alongside support and guidelines for discharge / early mobilization. Phase II CVR goals depend on the achieved level of patient motivation for rehabilitation after CV event or procedure. They can be recovery of functional capacity, cardiovascular optimization, psychological wellbeing, therapeutic education (**Table 1**), improving the quality of life as well as documentation and monitoring of adherence. In the maintaining phase (Phase III CVR) activities learned in previous stages are continuously executed with a goal of lowering the risk of CV morbidity and mortality. ### TABLE 1: Therapeutic education workshops for outpatient cardiovascular rehabilitation patients ( Phase II ) during the pandemic period at the Institute for Cardiovascular Disease Prevention and Rehabilitation Zagreb. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | Education is continuously provided over a period of 3 months. All cardiovascular rehabilitation team members provide education individually or in small groups. | | --- | --- | --- | --- | --- | --- | | **Nurse workshops** | **Psychologist workshops** | **Physiotherapist workshops** | **Nutritionist workshops** | **Music therapist workshops** | **Kinesiologist** **workshops** | | Passport for life | What to do with anger? | Let’s breathe for the hearth | Heart and sugar | | | | Risk factors: • arterial hypertension | Communication - Me | Neck and shoulder exercises | Heart and salt | | | | Risk factors: • smoking | Communication - You | Heart relaxation | How and why to lower the body mass | | | | Risk factors: • stress | How to stand up for yourself - assertiveness | | | | | | Risk factors: • adequate nutrition and health meal preparation | Our daily stress | | | | | [†] Risk factors: • without sugar please [†] Educational materials are available both offline and on the website of the Institute. [†] Depending on the risk stratification and the patient’s progress, we also carry out additional interventions aimed at metabolic, psychosocial and other risk factors or changes in exercise capacity Despite the negative impact on health and life quality, CV event should motivate patients to take care of their health, acquire new knowledge and change their unhealthy behavior, while accepting CV therapy to ensure increased functionality and lower the risk of future complications. (3)

Zvonimir Katić, Ante Lisičić, Ana Jordan, Sandra Sokol Tomić, Ivan Zeljković, Šime Manola, Nikola Pavlović, Ivan Prepolec, Andrija Nekić, Vedran Pašara, Borka Pezo-Nikolić, Vedran Velagić

**Introduction:** Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia; significantly affecting healthcare services. (1) Pulmonary vein isolation (PVI) has emerged as the standard treatment for AF, with radiofrequency energy historically being the primary method employed. The second most common ablation technique has been cryoenergy, particularly using cryoballoon (CB) technology, which has demonstrated superiority over drug therapy in patients with paroxysmal atrial fibrillation (PAF) (2). Recently, an expandable CB capable of adjusting its size from 28 to 31 mm has been developed. Our study aimed to compare two different CB technologies: the legacy 28 mm fixed-size balloon and the new expandable CB. **Patients and Methods:** This multicenter randomized controlled trial has so far enrolled 136 of the planned 200 patients with PAF indicated for PVI. Participants were randomly assigned in a 1:1 ratio to either the Medtronic 4th generation CB (Arctic Front Advance Pro) (MDT group) or the Boston Scientific resizable CB (PolarXFit) (Polar group). Follow-up visits and 24-hour ECG recordings were scheduled at 3, 6, and 12 months, with subsequent visits every six months. **Results:** Among the 136 patients, 57 (41.9%) were female, with an average age of 60.78±12,29 years. Both groups were similar regarding sex and age. Procedure durations were similar: 65.5 ± 19.9 minutes for the Polar group vs. 61.8 ± 21.1 minutes for the MDT group (p=0.375). Fluoroscopy times were comparable as well, with 10.6 ± 7.5 minutes in the Polar group and 9.4 ± 7.7 minutes in the MDT group (p=0.414). Complete pulmonary vein isolation was achieved in 98.5% of Polar cases and 95.6% of MDT cases (p=0.303). Only minor complications were reported, including 4 large hematomas (3 in the Polar and 1 in the MDT group), along with 2 transient phrenic nerve palsies (1 in each group). **Conclusion:** The new resizable PolarXFit CB is comparable to the MDT CB regarding procedure duration, fluoroscopy time, radiation dose, and acute PVI rate. Complications were minimal and primarily related to venous access. Follow-up data will be needed to confirm non-inferiority in terms of long-term success.

Ante Lisičić, Ana Jordan, Ivan Zeljković, Ivica Benko, Šime Manola, Nikola Pavlović

**Introduction**: Ventricular tachycardia (VT) poses a significant challenge in patients with both ischemic and non-ischemic cardiomyopathy, requiring precise localization of VT exit sites for effective ablation. (1). The use of preprocedural image-based substrate reconstruction with inHEART software has become integral in identifying scar and fibrosis patterns that correlate with VT exit sites. This study examines the correlation between inHEART-based imaging and the actual ablation zones in patients with ischemic versus non-ischemic cardiomyopathy. **Patients and Methods**: This retrospective analysis included 40 patients (mean age 50 ±25, female: 5 (N)) undergoing VT ablation. Out of the 40 patients, 31 had ischemic cardiomyopathy and 9 had non-ischemic cardiomyopathy. Preprocedural imaging (computed tomography (CT)), was processed using inHEART software to reconstruct myocardial substrates and identify potential VT exit sites. These predicted exit sites were then compared with the actual ablation zones to assess the accuracy of the inHEART-based substrate reconstructions. **Results**: The ablations were executed utilizing a 3D mapping system CARTO after merging with the inHEART model. In 6 patients, all from the non-ischemic cardiomyopathy group, the predicted VT exit zones based on inHEART imaging did not correlate with the areas targeted during ablation. **Conclusion**: The study underscores the effectiveness of inHEART software for preprocedural planning in ischemic cardiomyopathy, where scar patterns are typically well-defined and align closely with VT exit sites. However, the lack of correlation in non-ischemic cardiomyopathy patients highlights the complexity of diffuse fibrosis and other substrate characteristics that may not be fully captured by imaging alone. These findings suggest the need for further refinement in imaging protocols and possibly integrating functional mapping to enhance ablation strategies for non-ischemic cardiomyopathy.

Tomislav Čikara, Irzal Hadžibegović, Miroslav Raguž, Marin Pavlov, Nikola Pavlović, Petra Vitlov, Petar Lišnjić, Šime Manola, Ivana Jurin

**Introduction**: There are many trials who have demonstrated that lower low-density lipoprotein-cholesterol (LDL-C) levels after acute coronary syndrome (ACS) are associated with lower cardiovascular event rates (1). The current guidelines for secondary prevention recommend lowering LDL-C to 2) | 28.9±4.9 | 29.1±4.4 | 29.0±4.6 | | Medical history Hypertension, n (%) Diabetes, n (%) Coronary artery disease, n (%) Peripheral artery disease, n (%) | 512 (75.6%) 167 (25.7%) 111 (16.4%) 60 (8.9%) | 991 (74.2%) 310 (23.2%) 196 (14.7%) 185 (13.9%) | 1503 (74.7%) 477 (23.7%) 307 (15.3%) 245 (12.2%) | | ACS type STEMI NSTEMI UAP | 384 (56.7%) 288 (42.5%) 5 (0.7%) | 724 (54.2%) 596 (44.6%) 15 (1.1%) | 1108 (55.1%) 884 (43.9%) 20 (1.5%) | [†] ACS = acute coronary syndrome; STEMI = acute ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction; UAP = unstable angina pectoris **Conclusion**: Our analysis shows that lipid-lowering treatment is suboptimal and needs significant improvement. Earlier control visits with therapeutic interventions should be performed. Also, earlier high intensity statin combination therapy should be encouraged.

Filip Lončarić, Emilija Katarina Lozo, Davor Miličić, Ivo Planinc, Maja Čikeš

**Goal**: To report our centre’s experience with screening and introduction of mavacamten in symptomatic patients with obstructive hypertrophic cardiomyopathy (HOCM). **Patients and Methods**: Mavacamten has demonstrated improvements in left ventricular outflow (LVOT) obstruction, symptoms, and NT-proBNP levels in patients with symptomatic HOCM. (1, 2) We report the characteristics of the first patients initiated on mavacamten therapy at the University Hospital Centre Zagreb. Patients with HOCM, previously hospitalized at our heart failure unit or outpatient clinics, were evaluated for reduced functional status to assess for mavacamten candidacy. Before drug introduction, pharmacogenetic testing was performed for CYP2C19 to determine the starting drug dose. Clinical reevaluation and echocardiographic follow-up were performed after 4 weeks of treatment. **Results**: Five patients with signs of functional impairment, all presenting with NYHA III functional status, were determined as first candidates for treatment. Patient characteristics are shown in **Table 1**. Mean patient age was 53 ± 12 years with three female and two male patients. Three patients had a negative genetic cardiomyopathy panel, whereas in two the results are pending. All patients had a normal CYP2C19 metabolizer phenotype. At the time of this report, two patients reached the 4-week follow-up checkpoint, both reporting a significant improvement in functional capacity (now assessed as NYHA II), and an improvement in well-being (e.g., decreased chest pain, reduced fatigue). The LVOT gradient decreased from 110 and 70 mmHg to 26 and 48 mmHg, respectively, resulting in an average -53 mmHg decrease in LVOT gradient in the first 4 weeks. NT-proBNP decreased from 486 and 3321 ng/L to 166 and 597 ng/L, respectively. Treatment was well tolerated in both patients. ### TABLE 1: Patients initiated on mavacamten treatment (n=5). | **General characteristics** | **General characteristics** | | --- | --- | | Age, years, mean (standard deviation) | 53 (13) | | Female gender, n (%) | 3 (60) | | Body mass index, kg/m2, mean (standard deviation) | 34 (4) | | Positive genotype for HCM, n (%) | 0 (0) | | Ventricular tachycardia or syncope in patient history, n (%) | 0 (0) | | Implantable cardiac defibrillator, n (%) | 3 (60) | | Atrial fibrillation, n (%) | 4 (80) | | Beta blocker use, n (%) | 5 (100) | | Alcohol septal ablation performed, n (%) | 1 (20) | | **Echo and laboratory parameters at introductory visit** | | | LV ejection fraction (%), mean (standard deviation) | 67 (2) | | Global longitudinal strain (%), mean (standard deviation) | -11 (3) | | Maximal myocardial thickness (mm), mean (standard deviation) | 28 (5) | | Maximal LVOT gradient (mmHg), mean (standard deviation) | 76 (18) | | Systolic anterior mitral leaflet motion, n (%) | 3 (60) | | LA indexed volume (ml/m2), mean (standard deviation) | 53 (6) | | NT-proBNP (ng/L), mean (standard deviation) | 1854 (2533) | [†] HCM = hypertrophic cardiomyopathy; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow **Conclusions**: Our centre’s initial experience with mavacamten reflects the results of clinical trials showing improvement in LVOT obstruction, NYHA functional class and overall patient health status. Further patient and family screening will be crucial for adequate disease recognition and appropriate and timely treatment introduction.

Marija Radić, Tomislav Letilović, Vanja Ivanović Mihajlović, Ivan Skorić, Irzal Hadžibegović, Aleksandar Blivajs, Ana Jordan, Ivana Jurin

**Introduction**: Current evidence supports the early initiation of guideline-directed medical therapy (GDMT) for heart failure as each component independently contributes to improved outcomes (1). However, there is limited evidence on how sodium glucose co-transporter 2 inhibitors (SGLT2i) specifically affect patients with heart failure with reduced ejection fraction (HFrEF) based on the etiology whether ischemic or non-ischemic. Understanding these differences is crucial as the underlying cause can significantly influence disease progression treatment response and overall prognosis. This study aims to investigate the early introduction of SGLT2i in patients with newly diagnosed HFrEF comparing outcomes between ischemic and non-ischemic etiologies. **Patients and Methods**: This prospective observational study included 253 patients newly diagnosed with HFrEF divided into ischemic (78 patients) and non-ischemic (179 patients) groups based on the underlying cause of heart failure. Data were collected through detailed medical record reviews and follow-up telephone interviews. We assessed short-term (6 months) and long-term (12 months) outcomes including mortality, left ventricular ejection fraction (EFLV), NT-proBNP levels, NYHA functional class, and heart failure-related hospitalizations. **Results**: In the short-term both groups showed similar symptomatic improvement evidenced by comparable reductions in NYHA functional class. However long-term follow-up revealed significant differences: NT-proBNP levels remained significantly higher in the ischemic group (m 1602.61 pg/mL) compared to the non-ischemic group (m 793.73 pg/mL). LVEF recovery was similar between the groups, with mean values of 43.34% in the ischemic group and 42.91% in the non-ischemic group. Mortality rates were higher in the ischemic group as were emergency visits while heart failure-related hospitalizations were slightly more frequent in the non-ischemic group. **Conclusion**: Early initiation of SGLT2i appears to provide substantial benefits in managing newly diagnosed HFrEF across both ischemic and nonischemic etiologies. Nevertheless, patients with ischemic heart disease may experience greater clinical challenges as reflected by persistently elevated NTproBNP levels and slightly lower EFLV improvement. These findings underscore the need for tailored treatment strategies for ischemic heart failure patients to optimize outcome.

Fran Rode, Ana Jordan, Ivan Zeljković, Nikola Pavlović, Ante Lisičić, Aleksandar Blivajs, Vanja Ivanović, Jelena Kursar, Danijela Grizelj, Luka Antolković, Domagoj Kobetić, Ivan Skorić, Šime Manola, Ivana Jurin

**Introduction:** Guideline-directed medical therapy (GDMT) with beta-blockers, mineralocorticoid receptor antagonists (MRA), angiotensin convertase inhibitors (ACEi) or angiotensin receptor–neprilysin inhibitors (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2I) represents a cornerstone for heart failure with reduced ejection fraction (HFrEF) treatment. Patients should receive therapy in evidence-based target doses or maximally tolerated doses before cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) implantation. Therapy prescription practice before and after the device implantation in the era of quadruple GDMT is to be fully examined (1). The aim of this study is to evaluate the use of disease-modifying drugs in their corresponding target doses in patients with HFrEF before and after the ICD or CRT implantation procedure. **Methods:** This single-centre retrospective cross-sectional study included all patients with HFrEF hospitalized for ICD or CRT implantation from January 2021 to January 2023. Data was collected through documented patients’ medical history and phone calls. **Results:** We collected data on a total of 107 patients with HFrEF and ICD or CRT implantation. Most patients received beta-blockers (91.6%), MRA (86,0%), ACEi (31.8%) or ARNI (59.8%) and SGLT2I (59,8%) before device implantation. Evidence-based target doses were reached for 10.2% beta blockers, 52.2% MRA, 11.8% ACEi, 32.8% ARNI and 100% SGLT2i. After device implantation, implementation of beta-blockers (99.1%), MRA (97.2%), and SGLT2I (87.9%) increased. More ACEi (19.6%) were replaced with ARNI (75.7%). Target doses were reached for 19.8% beta-blockers, 72.1% MRA, 28.6% ACEi, 37.0% ARNI and 100% SGLT2I. **Conclusion:** Most of the patients received all GDMT drugs before and after the procedure. Therapy titration was non-compliant with guidelines. A slight improvement in up-titration after the procedure can be explained by more common medication adjustments during device controls and better drug tolerability after cardiac resynchronization. Despite objective obstacles to adequate therapy titration, including intolerance or patients’ non-adherence, further effort in up-titrating guideline-oriented medications should be applied.

Karlo Gjuras, Kristina Marić Bešić

**Introduction**: Due to their advanced age and comorbidities, elderly patients with acute ST-elevation myocardial infarction (STEMI) receive less frequent treatment with percutaneous or surgical revascularization. This can negatively impact their quality of life and survival. (1) We performed a retrospective study to analyze treatment strategies in STEMI patients aged 80 or older and to evaluate clinical outcomes according to the treatment modalities. **Patients and Methods**: A retrospective study included consecutive acute STEMI patients in their eighties and nineties who presented at the University Hospital Centre Zagreb from November 2018 to October 2023. The statistical analysis was conducted based on data collected from medical records. The primary aim was to analyze the treatment strategy (invasive vs. conservative). Demographic characteristics, risk factors, and outcomes were also compared based on the type of therapeutic approach (death during 6-month follow-up, recurrent myocardial infarction, and cerebrovascular stroke). (2) **Results**: Among the 214 STEMI patients, with a median age of 83.5 [81–87] years, 129 (60.3%) were women. Thirty patients (14%) had a prior myocardial infarction, and 27 patients (12.6%) had received some revascularization treatment. The majority of patients had arterial hypertension (83.6%), and one-third of patients had hyperlipidemia (34.6%) and diabetes mellitus (29.9%). An invasive strategy was used in 152 patients (71%). All patients treated with an invasive strategy received percutaneous coronary intervention (PCI), and in 143 patients (94.1%) a drug-eluting stent was implanted. These patients were younger (83 [81–86] vs. 85.5 [82–88], p = 0.009) and had an insignificantly higher frequency of prior myocardial infarctions (15.1% vs. 11.3%) and coronary revascularizations (13.2% vs. 11.3%). During the 6-month follow-up, a total of 67 (31.3%) patients died. Significantly fewer deaths occurred in the invasive group compared to the conservative group during the 6-month follow-up (25.7% vs. 45.2%, p = 0.005). The incidence of recurrent myocardial infarction and cerebrovascular stroke did not differ between the invasive and conservative treatment groups. Multivariable regression analysis revealed that active or prior oncologic disease (HR = 2.55; 95% CI: 1.12–5.82; p = 0.026), moderate or severe aortic stenosis (HR = 4.71; 95% CI: 1.78–12.42; p = 0.002), or infection during hospitalization (HR = 2.53; 95% CI: 1.17–5.45; p = 0.018) were negative predictors of 6-month survival, whereas the invasive approach did not show a significant association (HR = 0.59; 95% CI: 0.27–1.30; p = 0.192). **Conclusion**: This study showed that STEMI patients aged 80 and above treated with PCI had a statistically significant better 6-month survival than patients treated conservatively.

Ana Jordan, Ivan Zeljković, Ante Lisičić, Ivica Benko, Andrej Novak, Šime Manola, Nikola Pavlović

**Introduction**: The Vein of Marshall (VOM) alcohol ablation technique has been introduced as a complementary procedure during catheter ablation to reduce AF recurrence, particularly in patients with persistent AF. Ethanol is directly injected into the vein to induce localized necrosis of the surrounding myocardial tissue. (1) The goal of this study is to assess the serum ethanol concentrations following the VOM alcohol ablation procedure and explore the relationship between ethanol levels and clinical factors like left atrium size and body mass index (BMI). **Patients and Methods**: This prospective study included 5 patients undergoing VOM alcohol ablation as part of their treatment for atrial fibrillation. Blood samples were collected at baseline and at 30 minutes and 1 hour after ethanol administration. Serum ethanol concentrations were measured using standard laboratory methods and clinical parameters and liver function tests were monitored to assess the systemic effects of ethanol. **Results**: All patients had an ethanol concentration of 0.10 mg/dl before procedure. The average ethanol concentration increased to 0.134 mg/dl after 30 minutes with levels raning from 0,10 to 0,19 mg/dl. At 60 minutes ethanol concentration returned to 0,10 mg/dl for all patients. The correlation between administred ethanol and serum levels suggests thate ethanol absorption is midest and transient. Larger left atrium nd higher BMI with lower ethanol concetntrations at 30 minutes. No patient experienced ethanol concentrations high enough to cause systemic toxicity or noticeable clinical effects such as altered consciousness, hypotension, or hepatic dysfunction. **Conclusion**: The results indicate that VOM alcohol ablation does lead to measurable increases in serum ethanol concentrations, though these levels remain well below the toxic threshold. The transient nature of the increase suggests that systemic absorption is limited and the body efficiently metabolizes the ethanol within hours of the procedure. The metabolic response to the ethanol injection appears to vary minimally between individuals, with most patients exhibiting a rapid clearance of ethanol from their system. The procedure remains a safe and effective option for reducing atrial fibrillation recurrence, with minimal systemic ethanol exposure.

Zvonimir Katić, Ivan Prepolec, Vedran Pašara, Andrija Nekić, Matija Mlinar, Domagoj Kardum, Vedran Velagić

**Introduction**: Supraventricular tachycardia (SVT) comprises a heterogeneous group of arrhythmias with an atrial and/or ventricular rate of more than 100 beats per minute at rest, which involve cardiac tissue at the level of the His bundle or above. (1) Radiofrequency (RF) catheter ablation of SVT is considered the gold standard, delivering excellent outcomes. (2) The traditional fluoroscopic approach is increasingly being replaced by electroanatomical mapping (EAM) systems and intracardiac echocardiography (ICE), which eliminate radiation exposure for both patients and medical staff. **Patients and Methods**: Data on patients with supraventricular tachycardia (SVT), including AV node reentry tachycardia, atrioventricular reentry tachycardia, atrial flutter, and atrial tachycardia, were retrospectively collected from hospital records. The fluoroless (FL) group contains 203 patients who underwent ablation using EAM systems, while the control group included the last 140 patients who received conventional SVT ablation using fluoroscopy. Two EAM systems were utilized, with all procedures performed by three experienced operators. **Results**: FL group had 50.7% of female patients with age of 51.1±16.5 while control group had 38.5% of female patients with age of 52.8±16.6 years. The duration of the procedure was comparable between the two groups, with times of 57.4 ± 26.5 minutes for the FL group and 66.5 ± 29.0 minutes for the control group. Acute success, defined as the non-inducibility of arrhythmia or, in the case of atrial flutter (AFL), the presence of cavotricuspid isthmus conduction block, was achieved in 97.5% of the FL group and 96.5% of the control group. **Conclusion**: We have successfully implemented fluoroless technologies for SVT ablation, achieving excellent acute outcomes and a safety profile that matches one of conventional methods. By removing the risks associated with fluoroscopy, these technologies could be advantageous for both patients and physicians.

Matko Filipović, Jurica Kotarac, Lucija Mičik, Matija Vrbanić, Andreja Virt, Biljana Hržić, Marina Budetić, Kristijana Radić, Ivica Benko

Transcatheter Aortic Valve Replacement (TAVI) is a minimally invasive procedure increasingly used to treat severe aortic stenosis, particularly in high-risk patients. However, a notable complication following TAVI is the occurrence of arrhythmias, including new-onset atrial fibrillation (AF) and conduction disturbances requiring permanent pacemaker implantation. The incidence of new-onset AF following TAVI is clinically significant. According to Jilaihawi et al. (2019) (1), AF occurs in approximately 10-15% of patients post-TAVI, with a considerable impact on outcomes. (1) New-onset AF increases the risk of ischemic stroke, heart failure, and prolonged hospital stay. The predictors for AF after TAVI include older age, pre-existing heart conditions, and procedural factors like valve size and positioning. Management strategies focus on anticoagulation therapy to mitigate stroke risk and optimize rate or rhythm control to enhance patient outcomes. Chakravarty et al. (2017) highlight that one of the most frequent conduction disturbances after TAVI is atrioventricular block, leading to the need for permanent pacemaker implantation. (2) Pacemaker implantation rates vary depending on the type of valve used, with some studies showing rates as high as 20-30%. The need for a pacemaker is associated with increased morbidity, including longer hospital stays and a higher risk of heart failure. Risk factors for pacemaker implantation include pre-existing right bundle branch block, extensive calcification of the aortic valve, and deeper valve implantation during the procedure. In summary, the management of rhythm disturbances post-TAVI, including new-onset AF and conduction blocks requiring pacemakers, is essential for improving patient outcomes. Early identification of high-risk patients and adopting tailored therapeutic approaches are crucial for minimizing complications.

Petra Taboršak, Ana Marinić

**Introduction**: Fulminant myocarditis is a rapidly progressive inflammatory disease of the myocardium, which consists of cardiac muscle cells responsible for cardiac contractions and is among the leading causes of sudden cardiac death in young people. Patients are in poor general condition, hemodynamically unstable and require urgent care. Fulminant myocarditis can quickly progress to multiorgan failure. (1, 2) This paper presents a case of fulminant myocarditis of most likely viral origin, followed by a picture of cardiogenic collapse. **Case report**: 19-year-old female patient reported to the Emergency Department due to nausea, vomiting, lack of appetite and fever up to 39°C. The laboratory findings showed moderately elevated inflammatory parameters with significantly elevated cardioselective enzymes and signs of heart failure. Cardiac ultrasound revealed impaired heart function (left ventricular ejection fraction 35%). The condition rapidly deteriorated in the manner of fulminant myocarditis, and despite intensive pharmacological support, there was a cardiac arrest. During cardiopulmonary resuscitation, a veno-arterial extracorporeal membrane oxygenation (ECMO) was established as a bridge to further treatment strategies. The course of treatment was complicated by the development of ‘ECMO lung,’ and an Impella CP device. Along with Impella and inotropic support, the patient’s hemodynamic stability was monitored and V-A ECMO was soon removed using a surgical technique, but only minimal recovery of cardiac function was monitored. Finally, the left ventricular assist device (LVAD) pump is left placed, with which the patient is hemodynamically stable. The course of hospitalization was complicated by multiple infectious events in the form of sepsis and multiple pleural effusions. Throughout the entire hospitalization, a holistic approach was used with the daily psychological and pharmacological support and nutrition counseling, which was one of the leading obstacles which needed to be overcome. After 6 months of hospitalization, the patient is discharged home in good general condition. **Conclusion**: Fulminant myocarditis is one of the leading causes of acute heart failure in young people. The complexity of care for patients with fulminant myocarditis cannot be overstated. Nurses must coordinate multidisciplinary teams, administer intricate treatment regimens, and provide emotional support to patients and their families. Their expertise in managing mechanical circulatory support devices, such as ECMO and LVADs, is vital to improving patient outcomes.

Helena Jerkić, Antun Lončarić, Krešimir Crljenko, Iva Klobučar, Zdravko Babić, Vjekoslav Radeljić, Diana Delić-Brkljačić

**Introduction**: Mitral annular disjunction is a rare and poorly recognized condition which involves the separation between the ventricular myocardium and the mitral annulus during systole (1, 2). Mitral annular disjunction is a risk marker for ventricular arrhythmias and sudden cardiac death and is often associated with mitral valve prolapse. **Case report**: 32-year-old female presented to the hospital after successful resuscitation of out-of-hospital cardiac arrest. She has been followed up by a cardiologist, due to mitral valve prolapse and palpitations since age of 15. Echocardiography at admission showed dilated, globally hypokinetic left ventricle, with severely reduced systolic function, thickened mitral valve cusps, bileaflet mitral valve prolapse, with mild mitral regurgitation and without pericardial effusion. Coronary angiography excluded coronary artery disease. Targeted temperature management was maintained. Heart failure therapy have been administrated, as well as antiarrhythmic therapy with amiodarone. Blood samples were sent for genetic analysis were negative for arrhythmias and cardiomyopathies. Cardiac magnetic resonance imaging revealed normal left ventricular dimensions, basal inferoseptal wall hypertrophy, with mildly reduced systolic function of left ventricle. Additionally, mild mitral regurgitation, bileaflet mitral valve prolapse and insertion point of posterolateral annulus 6 mm out of left ventricular myocardium, suggestive for mitral annular disjunction were shown (**Figures 1 and 2**Figure 2). There was no late postcontrast imbibition. Furthermore, patient received implantable cardioverter defibrillator for secondary prevention of sudden cardiac death and was discharged with bisoprolol and amiodarone. No neurological deficits remained after the neurorehabilitation. FIGURE 1. Cardiac magnetic resonance (4 chamber view) - separation between the ventricular myocardium and the mitral annulus. FIGURE 2. Cardiac magnetic resonance (2 chamber view) - separation between the ventricular myocardium and the mitral annulus. **Conclusion**: This case report emphasizes the importance of awareness and diagnosis of mitral annular disjunction, particularly in patients presenting with ventricular arrhythmias, syncope or cardiac arrest. Recognition and diagnosis of mitral annular disjunction, with or without mitral valve prolapse, should be routinely done in practice.

Mateja Pilatuš, Željka Božić, Gordana Prugovečki, Božica Parać

Left Atrial Appendage Closure (LAAC) is a minimally invasive procedure designed to occlude the left atrial appendage, reducing the risk of stroke in patients with atrial fibrillation (AF). (1) This technique serves as an alternative to oral anticoagulation therapy, particularly for patients contraindicated for such treatment. (2) The implantation procedure is conducted via the femoral vein, where a catheter delivers a device to the entrance of the left atrial appendage, effectively obstructing blood flow. (3) Contraindications for LAAC include cardiac thrombi, pericarditis, infections and anatomical issues with surrounding structures. Verification of the device’s position is typically performed using transesophageal echocardiography. (2) Potential complications may arise, such as allergic reactions, arrhythmias, bleeding, cardiac tamponade, device malfunction, and, in severe cases, multi-organ failure. (1) Following implantation, some patients are placed on anticoagulant therapy until follow-up, while others receive dual antiplatelet therapy, with long-term management involving aspirin and clopidogrel. (3) Our clinic commenced LAA occluder implantations on October 23, 2018, successfully completing 12 procedures (4 women and 8 men), each lasting between one and 1.5 hours. Preoperative and postoperative preparation is essential; patients are admitted the day prior for routine evaluations, including blood tests and ECG. Hair removal from the groin area is performed, as the procedure is done via the femoral vein. Post-implantation, patients remain on bed rest for six hours with a compressive sandbag at the puncture site, with monitoring for at least 24 hours. Of the 12 patients, two experienced complications: bleeding and inguinal hematoma, while follow-up TEE confirmed normal findings in 10 cases, although the probe could not be inserted in two instances. This method enhances the quality of life for AF patients who are contraindicated for anticoagulant therapy. Studies confirm its effectiveness and low complication rates, underscoring the importance of careful patient selection and ongoing technological advancements. Our experiences have shown positive results, providing encouragement for further treatment of this arrhythmia.

Marina Deucht, Damir Radišić

**Introduction**: Patients with coronary artery disease who also have chronic obstructive pulmonary disease (COPD) represent a special category of patients that require carefully planned preparation for cardiovascular surgeries, where reduced respiratory function is a common complication. Respiratory rehabilitation is a key aspect in the treatment and preparation for surgical procedures in such patients. Functional respiratory tests, such as spirometry, incentive spirometry, thoracic mobility tests, and blood oxygen saturation tests, are essential tools for assessing the respiratory function of these patients. They provide a detailed evaluation of lung function, the degree of airway obstruction, gas exchange, and dyspnea, helping to determine the risks associated with surgical procedures and recovery. The combination of these tests enables a precise assessment of lung dysfunction, which forms the basis for creating individualized rehabilitation programs. (1, 2) **Case report**: 68-year-old patient with coronary artery disease and COPD was admitted to the Department of Cardiac and Transplant Surgery at Dubrava University Hospital for heart surgery. Functional tests, including spirometry, acid-base status, and oximetry, revealed severe obstructive ventilation disorders, leading to the postponement of the surgical procedure. A new pharmacological approach was implemented, and intensive pulmonary rehabilitation was initiated in the department. Respiratory rehabilitation was conducted with a tailored intensity according to a customized pulmonary rehabilitation program guided by the results of the functional tests. After ten days, improved spirometry results and other tests indicated well-prescribed pharmacological therapy, and the results of pulmonary rehabilitation showed an improved respiratory status, allowing the patient to proceed with the surgical procedure. The recovery followed the expected outcomes for a patient with COPD after heart surgery. **Conclusion**: By using functional respiratory tests, rehabilitation programs can be personalized based on the actual needs of patients, leading to better outcomes, faster recovery, and a reduction in the risk of complications.

Jadranka Paun Judaš

Cardiac rehabilitation, or cardiac rehab, is a complex, interprofessional intervention customized to individual patients with various cardiovascular diseases such as ischemic heart disease, heart failure, and myocardial infarctions, or patients who have undergone cardiovascular interventions such as coronary angioplasty or coronary artery bypass grafting. (1) Within the Croatian health system, the “Hospital for Medical Rehabilitation Krapinske Toplice” has been important not only for the medical rehabilitation of hospitalized patients, but also for providing a large number of outpatient services for patients with cardiovascular diseases. Within the hospital, the “Polyclinics for Cardiovascular Diagnostics” provides outpatient services (treatment and prevention of cardiovascular diseases, systematic health examinations) as well as the health care to hospitalized patients. The cardiovascular diagnostics encompasses the following procedures: electrocardiogram (ECG), ergometry, spirometry, continuous 24-hr Holter ECG monitoring, ambulatory blood pressure monitoring (ABPM); Doppler vascular ultrasound; ankle-brachial pressure index (ABPI); transthoracic (TTE) and transoesophageal echocardiography (TEE). The Polyclinics has an important role at the county level, because each year it provides health care for more than 20.000 patients (100 to 150 patients daily). The data for 2023 can be summarized as follows: ECG: 8.080 outpatients and 2.268 hospitalized patients; spirometry: 532 outpatients and 87 hospitalized patients; ergometry: 3.743 outpatients and 2.660 hospitalized patients; Holter ECG: 4.239 outpatients; ABPM: 2.477 outpatients; TTE: 4.104 outpatients and 505 hospitalized patients; TEE: 54 outpatients and 46 hospitalized patients; Doppler vascular ultrasound: 1.177 outpatients; ABPI: 615 outpatients; Individual examinations of 5.632 outpatients (cardiology ward) plus 746 outpatients (diabetology ward). On top of the large number of standard TTE examinations, over the last several years there is a continuous increase in the number of performed TEEs and stress-echocardiograms. The Hospital for Medical Rehabilitation Krapinske Toplice, through its Polyclinics for Cardiovascular Diagnostics, is a cornerstone of cardiovascular health in the region, offering extensive diagnostic and rehabilitative services. Our long-term goal is to continuously improve the daily practice and education of all involved health care providers. With its commitment to improving healthcare practices and expanding service capabilities, the hospital aims to enhance patient outcomes and support the overall health of the community.

Valentina Jezl, Mia Marjanović, Ana Marinić, Vjera Pisačić, Danijela Grgurević

**Introduction**: In cases of advanced heart failure that do not respond to medical therapy, heart transplantation is the sole effective treatment option. (1) Because of the limited supply of organs, these patients frequently require some type of short-term mechanical circulatory support, such as Impella 5.5, as a bridge to transplantation. **Case report**: The purpose of this case report is to describe the care of a 35-year-old patient who had terminal heart failure due to ischemic cardiomyopathy and rhythmic instability, was implanted an Impella 5.5 as a bridge to transplantation. At the age of 28, the patient survived a myocardial infarction, which was worsened by the development of ventricular fibrillation, requiring the implantation of the implantable cardioverter defibrillator (ICD). Between 2016 and 2022, the patient’s good functional status is monitored; till December 2022, when he was hospitalized because of numerous ICD activations. In February 2023, endocardial modification of the scar substrate in left ventricle was performed, followed by stereotaxic radioablation in November. A stable medical condition continues until June 2024, when he presents to the Emergency Department with palpitations and a decrease in functional ability, and pre-transplant treatment is initiated to enroll him on the waiting list. In August, the patient was admitted to because of ICD activation, where he was arrested and briefly resuscitated. During the intensive care unit period, he remained hemodynamically and rhythmically unstable, requiring multiple ICD activations, which requires cardiopulmonary resuscitation with the occurrence of pulmonary edema. Therefore, he was admission to the urgent Eurotransplant list on August 23 and Impella 5.5 was implanted on September 5 to bridge the gap until the heart transplant. It was inserted through the right axillary route, providing assistance to the left ventricle and hemodynamic support to the patient. **Conclusion**: Because of the complexities of the case, a multi- and interdisciplinary team plays a crucial part in the patient’s care. Nursing care included caring for the incision site, controlling the device position, replacing and checking the anticoagulant solution system, checking and resolving device alarms, monitoring the patient’s volume status and diuresis, and detecting and treating complications on time.

Ivana Crnojević, Iva Zec, Ivo Darko Gabrić, Matias Trbušić, Ozren Vinter, Krešimir Kordić, Marko Boban

**Introduction:** We present a case report of severe cardiotoxicity in patient treated with dual anti-HER therapy in a neoadjuvant protocol. **Case report:** 44-year-old patient, with no comorbidities, was diagnosed in June of 2022 with luminal B, HER 2 positive breast cancer. Neoadjuvant chemotherapy (ACdd protocol), followed by HER-2 dual blockade (transtuzumab and pertuzumab) with an addition of paclitaxel was admitted before planned surgical treatment. Echocardiogram, performed regularly during treatment, confirmed a normal ventricular function. One month after finishing neoadjuvant protocol (in February of 2023), patient was diagnosed with congestive heart failure due to severe left ventricular dysfunction and reduction in ejection fraction (EF, 15%). Optimal medical therapy was prescribed, and she was discharged home. In March 2023, she was admitted hospital for planned surgical operation, but since her symptoms did not improve, a worsening of left ventricular dysfunction was detected as well as pulmonary embolism, and she was transferred in Cardiac Intensive Care unit where inotropic and vasopressor therapy (dobutamine and norepinephrine) was initiated. Echocardiogram showed significantly reduced EF (15-20%). Additionally, NMR showed subepicardial and mesocardiac fibrosis suspicious for myocarditis. Myocardial biopsy was not performed, but regression in levels of troponin were accomplished with methylprednisolone admission. Since rhythmic instability, as well as NMR results and reduced systolic function (EF 35%), the patient received a subcutaneous ICD. Right breast segmentectomy and sentinel biopsy were performed after relative cardiac stabilization. The patient continued to be monitored in outpatient clinic and regular echocardiogram registered a slightly better EF, now about 40-45%. **Conclusion:** A significant issue arises in patients undergoing a neoadjuvant protocol when systemic oncological treatment is given prior to surgery. (1-3) In these patients, the emergence of significant cardiotoxicity impacts the timing of surgical intervention and, consequently, the prognosis of the malignant disease.

Ana Radišić, Karlo Tikvicki, Mislav Vrsalović

**Introduction:** The relationship between cardiovascular risk factors (CVRF) and venous thromboembolism (VTE) remains controversial and is not yet fully understood. (1-3) This study aimed to investigate the potential association of CVRF and inflammatory markers with provoked and unprovoked VTE. **Patients and Methods:** A cohort study was conducted on 147 patients (median age 69 years, 55% female) diagnosed with pulmonary embolism (PE), classified as provoked or unprovoked, who were hospitalized at the University Hospital between January 2020 and June 2023. Patients with active cancer or COVID-19 infection were excluded. Variables of interest included age, sex, body mass index, history of cardiovascular disease, arterial hypertension, diabetes mellitus, dyslipidemia, active smoking, renal function, as well as leukocyte and platelet counts, C-reactive protein (CRP), fibrinogen, the Pulmonary Embolism Severity Index (PESI), and the Charlson Comorbidity Index (CCI). **Results:** Patients with unprovoked VTE (68%) were older (67 vs 60 years, P=0.027) and more frequently had hypertension (77% vs 58%, P=0.024), with a trend towards a higher cumulative number of CVRF (2.4 vs 2.0, P=0.09). Patients with provoked PE had higher fibrinogen (5.0 vs 4.4 g/L, P=0.033), CRP (46 vs 35 mg/L, P=0.039), and platelet counts (264 vs 230 x10^9/L, P=0.047). PESI and CCI scores did not significantly differ between the two groups. Logistic regression analysis, adjusted for age and sex, showed that the presence of two or more CVRF was associated with an increased risk of unprovoked VTE (odds ratio 2.27, 95% CI 1.08-4.79, P=0.031). **Conclusion:** This study demonstrates an association between unprovoked VTE and CVRF, and suggests a link between provoked VTE and elevated markers of inflammation. The similar CCI and PESI scores between the provoked and unprovoked PE groups suggest no significant differences in disease severity or comorbid conditions.

Tereza Knaflec, Siniša Roginić, Iva Zec, Martina Roginić, Nikolina Mijač Mikačić

**Introduction**: Ischemic heart disease can be caused by coronary artery stenosis, dysfunction, or both. Most of the coronary vessels are located inside the myocardium and hence unavailable to direct angiographical visualization. Patients with stable microvascular disease are typically female, obese, hypertensive and have positive stress testing results with unremarkable stenoses on coronarography. (1-3) **Case report**: 45-year-old male, with positive family history, was admitted because of typical intermittent chest pain. The laboratory investigations confirmed dyslipidemia. Echocardiography documented normal sized chambers, with preserved left ventricular systolic function (both ejection fraction and global strain) and right ventricular longitudinal function. There were no signs of hypertrophy or valve disease. Treadmill exercise stress test showed significantly positive results: 4 millimeters ST-segment depression in anteroseptolateral ECG leads (**Figures 1** and **2**Figure 2), as well as hypertensive reaction. Due to all findings and risk factors, coronarography was performed which excluded epicardial coronary stenoses. An optimal medical therapy was prescribed, and the patient was discharged. First ambulatory control showed symptoms had significantly receded. Nuclear stress testing showed a small region of basal inferior wall ischemia. Cardiac magnetic resonance imaging did not show myocardia oedema nor postcontrast imbibition. Further work-up to confirm coronary microvascular dysfunction would include invasive functional coronary testing using or noninvasive tests (stress echocardiography, PET, perfusion CCTA, and CMR). FIGURE 1. Exercise electrocardiogram testing. FIGURE 2. Repeated exercise electrocardiogram testing. **Conclusion**: Atypical finding of non-obstructive coronary artery disease in a man with multiple risk factors emphasizes the importance of differential diagnosis, optimal medical therapy and in clinical practice still unmet need for functional coronary testing.

Vesna Babić, Anja Grill

Monitoring patients with arrhythmias requires a high level of expertise and a fast reaction to the possibility of developing serious, even life-threatening situations. The nurse represents a key member of the healthcare team responsible for continuously tracking the heart rhythm of patients, recognizing changes and the right time to react to the deterioration of the condition. Nurses must have the ability to read and analyze ECG and recognize several types of arrhythmias like ventricular tachycardia, atrial fibrillation or different heart blocks. The fast and adequate reaction of nurses in the deterioration of the heart rhythm is crucial for intervening on time and further treatment of the patient. Moreover, their role is not solely technical; the nurse plays a key role in educating patients informing them about symptoms of arrhythmias (palpitations, dizziness, loss of consciousness) and how to properly use home heart rate monitoring devices. Given the rapid technological advancements in the field of cardiology, nurses should also educate patients on the use of modern wearable devices, such as smartwatches with ECG functionality. (1) Continuous professional education for nurses is crucial to ensure they are prepared to address the challenges associated with monitoring and managing arrhythmias.

Matija Mlinar, Zvonimir Katić, Iva Mamić, Iva Petković, Domagoj Kardum, Danijela Krnjić, Dubravka Milača, Glorija Gočin Vuković

**Introduction**: Implantable cardioverter defibrillator (ICD) is vital for treating life-threatening cardiac arrhythmias and preventing sudden cardiac death. Numerous studies highlight the advantages of ICD therapy in adults, as well as some research on its off-label use in children and adolescents. Although ICD therapy accounts for less than 1% of the pediatric population receiving these devices, it remains a crucial treatment option for young patients. (1) Current guidelines give a class I recommendation for ICD implantation in patients with either ischemic or non-ischemic cardiomyopathy with severely depressed systolic function (left ventricular ejection fraction [LVEF] ≤35% for New York Heart Association [NYHA] Class II or III, ≤30% for NYHA Class I symptoms). At five years from implantation, about 37% of primary prevention patients will have an appropriate device intervention (antitachycardia pacing or shock), against 51% of patients implanted for secondary prevention. **Case report**: Goal of this case report is to show that implantation of newly developed extravascular ICD is safe and possible in pediatric patient. As technology advances, there is a lot more possibilities for ICD implantation in sense of access to the heart. At our center last year, we implanted 5 subcutaneous ICDs (3.6% of whole ICD implants) and this year for the first time we implanted extravascular ICD - “Aurora”. Patient was 11 years old female with out of hospital cardiac arrest, ventricular fibrillation and reanimation, without any prior anamnestic problems. First plan was to perform classic endovascular ICD implantation but after doing venogram of both sides’ conclusion was that endovascular classic lead would not be able to go through veins (left v. subclavian was occluded, right v. subclavian was narrow). **Conclusion**: Successful implantation of extravascular ICD was performed and multiple defibrillation threshold test were performed. Patient was discharged from hospital after few days of observation, with all therapy’s features turned on. Follow-up is needed to check if there are any inappropriate shocks.

Marija Antunović, Jelena Miličević, Ivica Benko, Senka Pejković

Over the past 30 years, the treatment of malignant diseases has made significant progress. Modern oncological therapies, including chemotherapy, radiotherapy, targeted therapies, and immunotherapy, have improved patient survival. Unfortunately, the treatment of malignancies has also led to an increase in adverse cardiovascular complications, which can negatively impact quality of life and survival. The cardiotoxic effects of oncological therapy can occur early or late after the initiation or completion of treatment. Their occurrence and intensity depend on the type of drug used, therapy combinations, radiotherapy, and pre-existing cardiovascular conditions. Due to the variability in the onset of negative effects on the heart, even years after treatment, and the increasing number of cancer treatment modalities, a new subspecialty—cardio-oncology—has developed to monitor and manage the impact and intensity of cardiotoxicity. Cardio-oncology plays a key role in addressing issues related to oncological treatments and heart health. According to the guidelines issued in 2022 by the European Society of Cardiology (ESC) for cardio-oncology, the aim is to assist all healthcare professionals providing care to cancer patients before, during, and after cancer treatment in terms of their cardiovascular health and well-being. (1) This highlights the importance of cardiac ultrasound in oncology and its crucial role in diagnosing cardiotoxicity. Three-dimensional (3D) echocardiography offers a more accurate way to measure left ventricular volumes, including left ventricular ejection fraction (LVEF), and has shown less variability in measurements compared to 2D methods. Therefore, 3D echocardiography should be used for serial monitoring of the cardiac effects of chemotherapy whenever possible. To understand the importance of more frequent monitoring of patients with echocardiography, it is essential to be familiar with how various cancer treatments affect the myocardium. (2, 3)

Marko Galić, Ivan Zeljković, Petra Bistrović, Šime Manola, Andrej Novak, Nikola Pavlović, Ivana Jurin, Marin Pavlov, Aleksandar Blivajs, Irzal Hadžibrgović

**Introduction**: Data on the prognostic significance of gender among patients with non-ST elevation acute coronary syndrome (NSTE-ACS) are conflicting. Several studies have identified greater mortality rates in women, attributing this trend to the higher incidence of accompanying comorbidities, higher age and suboptimal treatment among female subjects. Conversely, other research contends that even after adjusting for these factors, the prognosis for women remains poorer. Whether these disparities persist in the era of new guidelines and primary or early PCI treatment is yet to be established. (1) The aim of the study was to assess gender disparities in the severity of coronary artery disease (CAD) and major adverse cardiac events’ (MACE) incidence, among patients with NSTE-ACS. **Patients and Methods**: We conducted a registry-based study including patients with NSTE-ACS hospitalized in our centre from January 2017 to January 2023. Data on CAD severity and Syntax score, which evaluates complexity based on coronary anatomy and lesion characteristics, were collected. Follow-up data were acquired through clinical follow up visits or telephone interviews. The MACE was a composite of reinfarction, need for revascularization, cardiovascular death, or death from any cause. **Results**: This registry-based study included 1102 patients with NSTE-ACS, 32.5% were female. Median Syntax score was 17 (IQR 6-21), with 684 (61%) patients having low (22), respectively. Gender did not correlate with CAD severity as assessed by Syntax score (men: low 59%, medium 18% and high 23% vs. women low 64%, medium 16% and high 20%, p=0.267), nor when assessed as single-vessel or multivessel disease (single-vessel: men 37 vs. women 42%; multi-vessel: men 63% vs. women 58%, p=0.073). After a median follow up of 17 (6-27) months, gender did not impact a MACE incidence during follow up. **Conclusion**: Our real-world data suggests there are no significant gender disparities regarding CAD severity among patients with NSTE-ACS, nor it influences MACE incidence in long-term follow up.

Nikša Bušić, Ana Jordan, Ante Lisičić, Sanda Sokol Tomić, Ivan Zeljković, Šime Manola, Nikola Pavlović

**Introduction**: Sodium-glucose cotransporter-2 inhibitors (SGLT2i), initially developed to treat type 2 diabetes mellitus (T2DM), have shown cardiovascular benefits beyond glucose control, particularly in heart failure patients. (1) However, limited data exist on the effects of SGLT2i on the ventricular arrhythmia (VA) burden in patients with implantable cardioverter defibrillators (ICDs). This study aims to investigate the impact of SGLT2i on VA burden in ICD patients. **Patients and Methods**: This was a prospective, single-center, observational study conducted on patients with ICDs. All patients are enrolled in an institutional registry (CaRD registry-HF). The patients were divided into three groups based on the use of SGLT2 inhibitors: no use (SGLT2 = 0, N=27), and consistent use (SGLT2 = 1, N=50). Variables such as age, sex, body mass index, and primary versus secondary ICD indication were considered. The primary outcome was the recurrence of ventricular tachycardia (VT) events, recorded as the number of VA episodes detected by ICDs. **Results**: The mean age of patients was similar across groups, with a slight variation: 64.5 years (SGLT2 = 0), 61.7 years (SGLT2 = 1). The majority of patients in the SGLT2 = 1 group had primary ICD indications (87.9%), compared to 54.8% in the no-SGLT2 group. Ischemic heart disease was the leading cause in the SGLT2 = 0 group (77.4%) compared to 65.7% in the SGLT2 = 1 group. In patients with no SGLT2i use, 22, 2% patients experienced the recurrence of VT. Patients with SGLT2i use had a lower recurrence rate of VT, with 13,4% of patients experiencing VT (n=21). **Conclusion:** The results of this study indicate that the use of SGLT2 inhibitors is associated with a lower VA burden in patients with ICDs. These findings suggest that SGLT2i may have antiarrhythmic effects, possibly due to their ability to reduce cardiac fibrosis, inflammation, and improve myocardial energy efficiency. Additionally, the reduction in VA could be explained by the favorable effects of SGLT2i on heart failure outcomes, such as improved diastolic function, reduced left ventricular wall stress, and a decrease in overall cardiac workload. Further research is warranted to confirm these findings and establish the role of SGLT2 inhibitors in arrhythmia management.

Domagoj Kobetić, Ante Lisičić, Aleksandar Blivajs, Nikola Pavlović, Tomo Svaguša, Petra Vitlov, Irzal Hadžibegović, Ana Jordan, Danijela Grizelj, Mario Udovičić, Ivan Zeljković, Petar Lišnjić, Tomislav Šipić, Luka Antolković, Fran Rode, Jasmina Ćatić, Marin Pavlov, Šime Manola, Ivana Jurin

**Introduction:** Angiotensin-converting enzyme inhibitors (ACEi) have been a key drug in treating heart failure with reduced (HFrEF) and mildly reduced ejection fraction (HFmrEF), with angiotensin receptor neprilysin inhibitors (ARNI) now proposed as a replacement. Guidelines recommend up-titrating these agents to the maximum tolerable dose for optimal benefit. (1) However, both ACEi and ARNI can increase potassium levels, leading to suboptimal dosing due to hyperkalemia concerns. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to reduce hyperkalemia risk in some patients. This study aimed to assess the prevalence of hyperkalemia in HFrEF and HFmrEF patients and its’ effect on achieving optimal medical treatment. **Patients and Methods:** This registry-based study included HFrEF and HFmrEF patients hospitalized at our center between September 2021 and December 2023. Levels above 4.7 mmol/L were considered as a cut-off for high potassium. **Results**: A total of 764 HFrEF and HFmrEF patients were included, with 19.4% having HFmrEF and 80.6% HFrEF. The mean age was 68 years (range 27-90), and 73.3% were male. Potassium levels increased in 38.9% of patients after therapy implementation. 11.5% received the target doses of ACEi or ARNI. At therapy initiation, 22.8% had potassium levels ≥4.7 mmol/L. No significant association was found between potassium levels and the maximum ACEi/ARNI dose before SGLT2i use. Hyperkalemia prevented 2.4% of patients from receiving the maximum ACEi/ARNI dose. In HFmrEF, more patients were on medium to high ACEi doses at discharge compared to dose at admission. The most common reason for not achieving the maximum dose was low blood pressure or lack of regimen adherence. **Conclusion:** In summary, while hyperkalemia impacted ACEi and ARNI dosing in a small portion of patients, it was not a major factor at inadequate therapy titration. Despite ACEi and ARNI raising potassium levels, factors like diuretic use and SGLT2i contributed to decrease in potassium levels in more patients.

Koraljka Benko, Alen Ružić

**Goal:** To systematically investigate the role of epicardial adipose tissue (EAT) in heart failure (HF) according to key clinical data and to assess the applicability of available data in routine work. **Material and Methods:** conducted search of all relevant scientific databases to identify and analyze relevant information that were published on the highlighted topic during the past 5 years. **Results:** The evaluation of all available data analyzing the impact of echocardiographic EAT on the clinical course and prognosis HF with special emphasis on the type of HF phenotype. The cardiovascular hemodynamics and patient metabolic profile were also taken into consideration if available in the current source. **Conclusion:** According to the available data, in patients with heart failure and preserved left ventricular systolic function (HFpEF), the presence of significant accumulations of EAT is associated with a less favorable circulatory / hemodynamic, but also metabolic status and affects survival. Conversely, lower amounts of EAT are associated with an increased risk of adverse outcomes in patients with heart failure and reduced left ventricular systolic function (HFrEF). Although the causes of these facts are still at the level of pathophysiological hypotheses and require further research, the protective and good prognostic value of EAT in HFrEF, which represents the opposite clinical meaning in patients with HFpEF, are a significant contribution to the knowledge of modern science on HF that have a direct impact on clinical practice (1, 2).

Fran Rode, Ana Jordan, Ivan Zeljković, Nikola Pavlović, Ante Lisičić, Aleksandar Blivajs, Vanja Ivanović, Jelena Kursar, Danijela Grizelj, Luka Antolković, Domagoj Kobetić, Ivan Skorić, Šime Manola, Ivana Jurin

**Introduction:** Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) provides greatest benefit when up-titrated to maximum tolerable doses, therefore an individualized approach to each patient is essential. The differences in GDMT administration between women and men, and its effects on outcomes, have not yet been fully investigated. (1) The aim of this research is to evaluate the difference in HFrEF GDMT up-titration in women and men and its potential effects on the outcomes. **Patients and Methods:** This is a prospective cohort study involving patients with HFrEF processed at a single tertiary centre. We evaluated the proportion of maximally titrated GDMT in each female and male group. We also compared the outcomes of all-cause mortality, cardiovascular mortality and heart failure related hospitalizations. Study endpoints were documented via telephone interviews, regular outpatient follow-up, or by electronic hospital records. Continuous variables were compared using Mann Whitney U test and categorical variables were compared with chi squared test. **Results:** A total of 507 patients were included, out of which 123 were female. The median follow-up period was 730 days. Female group had significantly lower body weight, less smokers, and more kidney disease. In female vs. male population, evidence-based target doses were reached for 25.2% vs. 28.6% (p=0.46) beta-blockers, 52.8% vs. 68.0% mineralocorticoid receptor antagonists (MRA) (p<0.05),10.6% vs. 11.5% angiotensin convertase inhibitors (ACEi)/ Angiotensin receptor blockers(ARB)/ angiotensin receptor–neprilysin inhibitors(ARNI), ACEi/ARB/ARNI (p=0.84) and 100% sodium-glucose cotransporter-2 inhibitors (SGLT2i) in both groups. All-cause mortality was 8.13% vs. 10.93% (p=0.79), and cardiovascular mortality was 4.06% vs 7.03% (p=0.25). Female patients had more heart failure related hospitalizations (65.04% vs. 56.51%, p=0.09). **Conclusion:** The female group had a significantly lower proportion of maximally titrated MRAs. It seems that the female group has more frequent heart failure hospitalizations, but short of statistical significance. Significant differences in the characteristics of these two groups prevent us from concluding that the observed outcomes are exclusively sex-related. Additional research should be performed before elaborating a possible connection of the outcomes. Regardless of sex, an individual approach with the goal of reaching maximal tolerable doses of GDMT should be applied to each patient.

Fabio Kadum, Ana Petretić, Koraljka Benko

**Introduction**: Patients presenting with cardiac symptoms such as chest pain, palpitations, dyspnea, and arrhythmias are often initially evaluated for cardiovascular conditions, leading to admission under cardiology care. However, non-cardiac conditions can sometimes mimic these presentations, posing diagnostic challenges for clinicians (1, 2). **Case series**: The first patient presented with general weakness and fatigue. She did not experience chest pain, palpitations, or loss of consciousness. She had a known history of arterial hypertension but had recorded lower blood pressure values over the past few days. An electrocardiogram (ECG) showed sinus bradycardia with a prolonged PR interval, raising suspicion of sick sinus syndrome. Further investigation revealed reduced thyroid hormones as well as low cortisol levels, leading to the diagnosis of secondary hypothyroidism due to hypopituitarism. The second patient was admitted due to palpitations, exercise intolerance, and leg edema. An ECG revealed atrial flutter with a rate of 150 beats per minute. Echocardiography confirmed mildly reduced systolic function of the left ventricle, leading to a diagnosis of the first manifestation of heart failure. Further testing showed significantly elevated thyroid hormones with low TSH, leading to the diagnosis of thyroid storm. The third patient was admitted due to nausea accompanied by chest and upper abdominal pain on the day of admission. Both the ECG and laboratory results were normal, while a chest X-ray indicated only a hiatal hernia. Due to prolonged chest pain the patient was hospitalized and underwent coronary angiography, which yielded normal results. The patient later experienced an episode of syncope, which led to a CT pulmonary angiography being performed, ruling out pulmonary embolism but confirming a large hiatal hernia. The patient underwent surgery on the same day. **Conclusion**: These cases highlight the importance of considering a broad differential diagnosis in patients with cardiovascular complaints, as well as the need for interdisciplinary collaboration to ensure accurate diagnosis and treatment. By recognizing non-cardiac causes of cardiac-like symptoms, clinicians can avoid diagnostic pitfalls and optimize patient care.

Viktor Čulić, Ivan Velat, Željko Bušić

**Introduction**: Frequent premature ventricular contractions (PVC) (1, 2) as well as PVC-related symptoms (3) have been associated with the development of PVC-induced cardiomyopathy. The role of clinical factors that may modify both the presence of PVC-related symptoms and occurrence of PVC have not been thoroughly explored. **Patients and Methods**: Baseline characteristics, cardiovascular medication, exposure to external triggers, presence of PVC-related symptoms, and PVC occurrence in 3-hour daily intervals were collected for 447 patients who consecutively underwent continuous 24-hour Holter monitoring. The presence of PVC-related symptoms included presence of irregular or skipped heartbeats, palpitations, chest discomfort, pain, pressure or thrill, or shortness of breath. The occurrence of episodes of PVC in 3-hour periods was expressed as a percentage of all episodes recorded during the Holter monitoring. **Results**: In total, 241 (53.9%) patients reported some of the PVC-related symptoms. A significant daily variation in the occurrence of PVC with the peak between 9 and 18 hours were observed in both groups of patients according to the presence of symptoms (p<0.0001 in both groups). There was no significant difference in the overall daily PVC occurrence between the groups (p=0.18). In the multivariate analysis, women (p=0.01), patients over the 65 years age (p=0.004), those with hypercholesterolemia (p=0.045) or without a statin medication (p=0.03) were more likely to report symptoms. In symptomatic patients, hypercholesterolemia (p=0.03) and emotional upset (p=0.002) were the only independent predictors of PVC, whereas in asymptomatic patients the predictors were female sex (p=0.03), previous myocardial infarction (p=0.04), the absence of a ß-blocker (p=0.006) or anxiolytic (p=0.001), physical activity (p=0.02) and emotional upset (p<0.0001). **Conclusions**: Several clinical factors and drug therapies may modify the presence of symptoms in patients with PVC and make the reaching of an accurate diagnosis more difficult. Patients with and without symptoms somewhat differ in their susceptibility to PVC occurrence. Future research should differentiate potential prognostic qualities of PVC-related symptoms to provide risk stratification for PVC-induced cardiomyopathy.

Renata Žabčić, Matea Makar, Mario Josipović

MSCT coronary angiography or CT coronary angiography is a newer radiological diagnostic method that uses computerized tomography (CT) to provide detailed insight into the anatomy of the heart and coronary arteries, i.e. the blood vessels that supply the heart. Narrowing and blockage of coronary arteries belong to the group of diseases of the heart and blood vessels, diseases that are still the first cause of death in the Republic of Croatia. CT coronary angiography is one of the methods by which diseases of the heart and blood vessels can be detected in time and treated. CT coronary angiography is most often compared with classic, invasive coronary angiography. During a classic, invasive coronary angiography the artery leading to the heart is entered through the groin or arm, and the coronary arteries are visualized with the help of a contrast. Unlike classic, invasive coronary angiography, CT coronary angiography is a non-invasive, highly accurate method that does not require a hospital stay, and the contrast medium is applied through a peripheral vein on the arm, as with any other contrast test, providing a detailed view of the coronary arteries. This alone reduces the risk of complications and speeds up the diagnostic process. Therefore, the procedure is quick, i.e. it takes only a few minutes, and after the examination the patient can return to his usual activities. Another great advantage of CT coronary angiography is less exposure of the patient to radiation. (1) This work will compare two methods based on the data collected on our 25 patients.

Ante Komazin, Gordana Hursa, Sanja Keleković, Tomislav Pijetlović, Antonela Barišić

In the last few years, there has been a significant increase in the implantation of permanent electrostimulators of the heart, especially implantable cardioverter defibrillators, whose task is to recognize and interrupt life-threatening cardiac arrhythmia. With the increase in the number of implantations, the possibility of complications related to the electrode and the need for its extraction increases. Electrode extraction is a very demanding and risky procedure in cardiology. It can be done by explanting the electrode with the help of simple traction techniques and by extraction when it is necessary to use specialized equipment and techniques. Indications for electrode extraction can be divided into those in which the risk of leaving the electrode in place is greater than the risk of removal, and those in which the decision to extract requires careful consideration of the risks and benefits for the individual patient. Transvenous electrode extraction is a procedure with a potentially high risk of complications that can be divided into major complications that require rapid intervention and minor complications that are more common but not life-threatening. In this paper, we will present the case of a patient with an implanted cardioverter defibrillator who developed sepsis caused by vegetation on the electrode of the device. (1-3)

Andreja Virt, Arijana Ježek, Pero Martić, Mihaela Štriga, Paula Kontek, Izidor Kranjčec, Dijana Tutić

Heart failure (HF) is a complex clinical syndrome caused by structural and functional disorders, reducing the ability of the heart chambers to fill or empty. It refers to a condition where the heart muscle, as a pump, cannot meet the body’s metabolic demands. Exacerbation of HF is a life-threatening condition requiring immediate care in intensive care units, as it severely impairs heart function. The main objective in treating acute HF is to stabilize vital functions and normalize hemodynamics, which demands prompt recognition of symptoms. Treatment requires the involvement of a multidisciplinary team, consisting of specialized cardiac nurses, cardiologists, cardiac surgeons, radiologists, nephrologists, psychologists, psychiatrists, nutritionists, physiotherapists, and other healthcare professionals. (1) Between March 1 and September 1, 2024, 59 patients were treated in the Intensive Care Unit for acute heart failure. Nearly half (40%) were referred from affiliated hospitals, such as General Hospitals in Koprivnica, Bjelovar, Zadar, Pula, Nova Gradiška, Čakovec, as well as University Hospitals in Zagreb, Rijeka, and Dubrovnik. Upon admission, most patients presented with acute decompensation and reduced ejection fraction. The key objectives were to achieve euvolemia, stabilize heart rhythm and vital signs, and perform diagnostic or invasive procedures. In 13 patients, pacemaker or defibrillator implantation was performed. Coronary angiography, with or without percutaneous coronary intervention (PCI), was performed in 13 others. As part of the pre-transplant workup, right heart catheterization was conducted in 13 patients, while pulmonary vein isolation (for atrial fibrillation) was performed in three cases. Four patients received advanced HF treatments; three underwent heart transplantation, and one had a left ventricular assist device (LVAD) implanted. Sadly, one death occurred in a patient awaiting an emergency heart transplant. This healthcare system, focused on managing acute heart failure, significantly enhances patient outcomes. Continuous professional education, experience-sharing, and a multidisciplinary approach are critical in improving the management of complex cardiac patients and achieving better treatment outcomes.

Elnur Smajić, Nihad Mešanović

Stroke-Heart syndrome is the entire spectrum of functional, morphological and biological cardiac changes as it is acute coronary syndrome, heart failure, arrhythmias and myocardial injury - electrocardiographic and echocardiographic changes and increased troponin levels, which occur in the first 30 days of acute stroke. The incidence of cardiac complications following ischemic stroke usually is 20%. Stroke-Heart syndrome associated with higher 5-year risk of mortality, recurrent stroke and acute myocardial infarction compared with ischemic stroke without cardiac complications. (1) Role of cardiologist in stroke management has three main areas: diagnostics workup of stroke etiology, treatment and prevention of complications and secondary prevention and workup of cardiovascular comorbidity. (1, 2) Artificial intelligence (AI) is used in the early detection and prevention of stroke by analyzing large datasets and predicting the likelihood of stroke occurrence and in determining the appropriate treatment plan and monitoring patient progress. AI can help cardiologist to personalized management of Stroke-Heart syndrome throw prevention and early detection of increased risk of stroke, improve the accuracy and efficiency of diagnosis and patients treatment, and identify any potential complications to save more lives and better quality of life. (3)

Petra Kušter, Paola Turković, Valentina Markušić

**Introduction**: Excessive body weight is defined as a condition in which a person has a body mass that exceeds normal values, which can increase the risk of health problems. As a measure of determining excessive body weight, the body mass index (BMI) is commonly used. BMI is calculated by dividing body weight in kilograms by the square of height in meters. The desired values of the body mass index, according to the World Health Organization, are from 18.5 to 24.9 kg/m2. A BMI of 25 to 29.9 defines overweight. (1) The accumulation of body fat is harmful to health, or rather, excessive body weight in developed countries occurs at epidemic proportions. Atherosclerosis is the basis of all cardiovascular diseases, and its development accelerates the accumulation of fat tissue that promotes inflammatory processes. Cardiovascular disease mortality can be prevented by optimizing body weight. The main goal was to examine the impact of excess body weight on patients with acute coronary syndrome. **Patients and Methods**: Data was collected from the hospital information system, and patients were admitted to Merkur University Hospital with a diagnosis of acute coronary syndrome, during the period from January 1, 2020, to April 30, 2021. **Results:** The study included 99 subjects with excess body weight and 32 subjects with normal body weight. The difference in the number of significant coronary lesions was not proven. Patients with a higher body mass index statistically significantly more often have dyslipidemia. Dyslipidemia and lifestyle are associated with a statistically significantly higher frequency of multiple coronary lesions. **Conclusion:** Of the total number of hospitalized patients due to acute coronary syndrome in the observed period, there was a statistically significant increase in patients with excess body weight, but they did not have a greater number of significant coronary stenoses. However, they statistically significantly more often have dyslipidemia. For the prevention of acute coronary syndrome, it is necessary to prevent excessive body weight.

Senka Pejković, Renee Mixich, Nikolina Jurković Dubravčić, Andrea Pleša, Ivica Benko

**Introduction:** Unexpected adverse events occurring in healthcare settings, especially those affecting patients, are often directly linked to treatment or nursing care. Among such events, patient falls represent approximately 70% of all adverse incidents within hospitals. Patient falls are considered adverse events and must be reported, analyzed, and monitored according to the Regulations of Healthcare Quality Standards and the Accreditation Standards for Hospital Healthcare Institutions. (1) These procedures involve continuous patient monitoring, root cause analysis, and corrective and preventive measures aimed at improving patient safety. Hospitals operate with clear quality management systems that provide guidelines for timely reporting and documentation of adverse events through Standard Operating Procedures and mandatory forms, in accordance with Croatian healthcare laws. Patient falls as adverse events often result in negative outcomes such as injuries, complications requiring further medical interventions, extended hospitalization, surgery, or in severe cases, death. Timely reporting of these adverse events is essential for preventing their recurrence, improving healthcare professionals’ experiences, and ensuring enhanced patient safety through improved nursing practices. Providing high-quality healthcare and maintaining patient safety are core principles of healthcare ethics and serve as a benchmark for nursing care quality. (2) **Case report:** 68-year-old patient with multiple comorbidities, including end-stage heart failure and an implanted left ventricular assist device was undergoing regular cardiology check-ups at the outpatient clinic. During one of these routine evaluations, the patient, while being assisted by medical personnel, fell in a hospital hallway after a dressing change. The patient did not lose consciousness and clearly remembered the event, attributing the fall to improper gait and foot problems. The ground-level fall resulted in a blow to the right side of the forehead, causing a visible hematoma. Given the patient’s use of anticoagulant therapy, a head MSCT was performed, revealing a subarachnoid hemorrhage, leading to hospitalization. Despite emergency surgery and all measures of intensive care, the patient tragically passed away 13 days after the unexpected adverse event. **Conclusion:** Reporting adverse events is essential for preventing and avoiding repeat incidents, improving healthcare professionals’ experience by ensuring patient safety through the provision of safe care and achieving a high level of safety in healthcare institutions. Providing quality healthcare and ensuring patient safety are integral to the professional ethics of healthcare professionals and represent the most reliable measure of quality in nursing.

Josipa Pekez, Ivana Šmuc, Zrinka Paić, Ivica Benko, Nikolina Valjak, Ivana Alković, Dora Aldžić, Valentina Brcković, Kristina Kardum Antunović, Petra Ozimec, Julija Buljan, Anita Pleško, Anamarija Mikša, Ljiljana Bažant

**Introduction**: Infective endocarditis is a serious medical condition associated with high mortality and morbidity, despite advancements in diagnosis and treatment. With the aging population, the increasing use of cardiac implantable electronical devices and heart valves, the risk of infective endocarditis, has grown significantly over the years with its incidence on the rise. (1) This paper presents the case of a 54-year-old patient with enterococcal endocarditis linked to cardioverter, defibrillator leads and surgically treated tricuspid and mitral valves. **Case report**: The patient presented with symptoms such as high fever and back pain and was treated with antibiotics a long side surgical removal of the device. His symptoms included a fever reaching up to 40°C persisting for three weeks. He was evaluated at an infectious disease clinic where Enterococcus faecalis was isolated in three sets of blood cultures. Initially treated for enterococcal sepsis with suspected endocarditis at the infectious clinic. The patient was later transferred to Dubrava University Hospital for further treatment. Transesophageal echocardiography revealed vegetation on the lead of the implantable cardioverter-defibrillator (ICD), and treatment proceeded with three intravenous antibiotics. The patient’s medical history includes the implantation of a mechanical mitral valve and tricuspid valve annuloplasty with a ring in 2022. He also had a ICD implanted in 2015, which was replaced in 2022. The patient underwent a six-week course of antibiotic therapy, during which complete extraction of the ICD and leads was performed. How ever, due to secondary prevention after two weeks of stable inflammatory markers and an echocardiogram showing no visible vegetations, a subcutaneous ICD was implanted to mitigate the risk of sudden cardiac death. The S-ICD was developed as an alternative for patients without venous access to the heart, aiming to reduce complications such as endocarditis associated with transvenous leads. (2) The patient was discharged after 42 days of treatment in improved general condition, with regular follow-ups by a cardiologist and device check-ups. **Conclusion**: In patients with cardiac implantable electronic devices and prosthetic valves, a multidisciplinary approach involving surgical intervention, targeted antibiotic therapy, and alternative device strategies, such as the use of an S-ICD, can be critical in managing infection risks and improving outcomes in cases of infective endocarditis.

Tomislav Biloglav

Severe tricuspid regurgitation is manifested by exercise intolerance, peripheral edema, jugular venous distention and hepatomegaly, often accompanied by atrial fibrillation or flutter. The diagnosis is established with echocardiography, and patient is evaluated with right-side heart catheterization as well. (1) TriClip is a transcatheter edge-to-edge repair system for reparation of severe tricuspid regurgitation that was approved in 2020. The procedure is performed using the TriClip G4 TEER system through femoral venous access under fluoroscopy and transesophageal echocardiography. (2) For the procedure, the patient is under general anesthesia. This method offers a minimally invasive treatment option in comparison to open-heart surgery. The patient’s recovery is very short, the patient can walk the next day and very quickly returns to normal life. The procedure results with a significant reduction of symptoms in a short time and his quality of life improves drastically. The TriClip procedure was performed in Croatia for the first time in 2023 at University Hospital Centre Zagreb. The goal of this method is to improve the patient’s quality of life with minimally invasive treatment of symptomatic, severe tricuspid regurgitation. There are possible complications such as bleeding, including local hematoma at the puncture site, allergic reaction to contrast or material, pulmonary embolism, etc. However, the benefits of this method greatly outweigh the possible risks.

Livija Sušić, Lana Maričić, Kristina Kralik, Ines Šahinović, Tihomir Sušić, Marina Vidosavljević, Mateja Ćosić

**Introduction:** Although lower extremity arterial disease (LEAD) is the third leading cause of atherosclerotic morbidity, it is still underdiagnosed and undertreated. In most cases, it is discovered in advanced stages. Ankle-brachial index (ABI) is the first-line noninvasive diagnostic method for LEAD. (1-3) The primary goals of our research were: to determine the prevalence of LEAD in the general population and to compare it with the prevalence of two early predictors of endothelial dysfunction - left ventricular diastolic dysfunction (LVDD) and plasma concentrations of asymmetric dimethylarginine (ADMA). Secondary goal was to evaluate the effect of drugs on ADMA concentration. **Patients and Methods:** We conducted a cross-sectional study which included 165 subjects from general population aged 40 to 65 years. We used transthoracic echocardiography to assess left ventricular diastolic function (LVDF). For assessment of LEAD we used ABI, and additionaly duplex ultrasound if ABI was ≤ 1.0 or ≥ 1.4. ADMA was determined from venous blood sample using ELISA method. Subjects were divided into 3 groups: the 1st group - with normal left ventricular diastolic function (LVDF), the 2nd group – with LVDD only and the 3rd group – with coexisting LVDD and LEAD. **Results:** LEAD was confirmed in 21 (13%) participants, the majority were smokers, had diabetes mellitus, heart failure, coronary artery disease, atrial fibrillation and chronic kidney disease. Even 14 of them (67%) were asymptomatic. Participants with normal LVDF had the highest and those with coexisting LEAD and LVDD the lowest plasma ADMA values. Most antihypertensives, as well as acetylsalicylic acid, MRA, insulin and SGLT2 inhibitors reduced ADMA values, but the most powerful were statins. **Conclusion:** We should look for LEAD more often, considering that the vast majority of patients are asymptomatic. Many drugs that we use today to treat dyslipidemia, hypertension, HF and DM improve endothelial function, but statins are the most effective.

Luka Perčin, Marijan Pašalić, Joško Bulum

**Introduction**: The management of severe aortic stenosis (AS) complicated by acute myocardial infarction (AMI) presents significant challenges and is associated with a high mortality rate (1). The Impella device is emerging as an effective hemodynamic support in “high-risk” percutaneous coronary interventions (PCI) and in AMI complicated by cardiogenic shock (2, 3). However, evidence regarding the effectiveness of Impella in patients with concomitant severe AS is limited. **Case report**: 83-year-old man with a history of arterial hypertension and atrial fibrillation was admitted to the Coronary Care Unit due to the posterior AMI. Initial bedside echocardiography revealed mildly reduced left ventricle global systolic function and severe AS. Urgent coronary angiography confirmed an occlusion of the proximal left circumflex artery (LCX), alongside severe calcified stenosis (90%) of the proximal to mid left anterior descending artery (LAD) (**Figures 1 and 2**Figure 2), and a diffusely diseased right coronary artery (RCA). The decision of the “ad-hoc” Heart Team was to perform a primary PCI on the “culprit lesion.” However, during the procedure the patient suffered a cardiac arrest, prompting the immediate initiation of cardiopulmonary resuscitation (CPR). Return of spontaneous circulation was achieved after 10 minutes of CPR, although the patient remained hemodynamically and rhythmologically unstable. Consequently, urgent balloon aortic valvuloplasty (BAV) was performed, followed by the percutaneous implantation of the Impella CP which resulted in clinical improvement. A complex PCI of the LCX and LAD was then successfully performed, yielding optimal angiographic results (**Figures 3 and 4**Figure 4). The next day, Impella was percutaneously removed in the catheterization laboratory, and the puncture site was closed using a vascular closure device. Upon discharge, the patient underwent computed tomography aortography and was scheduled for elective transcatheter aortic valve implantation. FIGURE 1. Coronary angiography, right anterior oblique caudal view. The arrow highlights the occlusion in the proximal left circumflex artery. FIGURE 2. Coronary angiography, anteroposterior cranial view. The arrow highlights the severe calcified stenosis in the mid left anterior descending artery. FIGURE 3. Coronary angiography following percutaneous coronary intervention of the left circumflex artery, left anterior oblique caudal view. The black arrow indicates the revascularized left circumflex artery, while the red arrow highlights the Impella device. FIGURE 4. Coronary angiography following percutaneous coronary intervention of the left anterior descending artery, anteroposterior cranial view. The arrow indicates the revascularized left anterior descending artery. **Conclusion**: In patients with concomitant severe AS and AMI complicated by cardiac arrest, performing emergent BAV followed by PCI with Impella support is a viable therapeutic option. Furthermore, if feasible, we recommend using bedside echocardiography before primary PCI, as it can impact the treatment strategy and clinical outcomes.

Azra Durak-Nalbantić, Marina Vučijak-Grgurević, Samir Mehmedagić, Indira Melezović, Amer Iglica, Alden Begić, Alen Džubur, Enisa Hodžić, Zina Lazović, Bedrudin Banjanović, Kenana Aganović, Lejla Divović-Mustafić

**The goal:** among possible etiology of constrictive pericarditis, IgG4-related pericardial disease is an unusual cause of pericardial constriction. **Case report:** 43-year-old male was admitted due to persistent right pleural effusion. Since 2021 he has been complaining of shortness of breath, fatigue, stomach and leg swelling and it was suspected heart failure. A year ago, he was examined for inguinal and retroperitoneal lymphadenopathy and due to ascites and liver enlargement liver cirrhosis was suspected. NP levels were mildly elevated (NT-proBNP 613 pg/mL), and on 12-lead electrocardiogram there were microvoltages. On echocardiography left heart size and LVEF were normal, right heart size and TAPSE were normal, VCI was dilated, incompressible, hepatic veins dilated, we found characteristic respiratory related shift of the septum (septal bounce), the lateral e’ velocity was lower than medial e’ velocity (annulus reversus). It was suspected constrictive pericarditis and on a CT scan there were heavy calcium deposits in the medioapical part of the pericardium of both ventricles. A rheumatologist performed an extensive immunological search for systemic disease due to elevated sedimentation rate (SE=56) and elevated IgE values, along with normal eosinophils. It was found elevated IgG- 4 (4.98 g/l, ref value 0.03-2.01) and diagnosis of IgG 4-related disease was established. The patient was put on intravenous corticosteroid therapy, but due to the current infectious disease (empyema pleurae), immunosuppressive therapy is at the moment contraindicated. Cardiac surgent has still been waiting for the resolution of pleural empyema and response to corticosteroids to make decision about possible pericardiectomy. **Conclusion:** Constrictive pericarditis is not so common, and the evaluation of etiology should include immunological tests. (1)

Renee Mixich, Nikolina Jurković Dubravčić, Andrea Pleša, Senka Pejković

**Introduction**: Left bundle branch block (LBBB) is a conduction abnormality of electrical impulses in the heart, clearly visible on an electrocardiogram (ECG). In this condition, the activation of the left ventricle is delayed, causing the left ventricle to contract later than the right ventricle. (1) Slow or absent conduction through the left bundle branch means that the left ventricle takes longer than normal to fully depolarize. This may be due to a damaged bundle branch that cannot conduct impulses, or it may represent intact conduction that is slower than normal. LBBB can be constant, present at all times, or intermittent, occurring, for example, only during an increased heart rate. (2) Painful LBBB syndrome is a condition where angina pectoris appears simultaneously with transient LBBB, without evidence of myocardial ischemia. The syndrome was first described in 1976 by Vieweg et al. A few years later, the authors reported a series of 7 patients with painful LBBB. In 2016, Shvilkin et al. described 4 new cases, along with 46 previously reported in the literature, establishing this clinical entity. Additionally, in 2013, two more cases were reported, one involving atypical chest pain and another in a young female. The leading theory for the origin of the pain is dyssynchronous ventricular contraction during LBBB. The asynchronous contraction of the right and left ventricles is thought to cause the pain, likely combined with small-vessel dysfunction or vasospasm. **Case report**: In this case report, we discuss a 32-year-old female patient with no prior history of cardiac disease who presented to a cardiologist with chest pain during minimal activity. Based on her medical history, she was referred for an exercise stress test. During the test, LBBB appeared after 90 seconds, accompanied by chest pain. The test was subsequently stopped, and the patient entered the recovery stage, during which she was monitored until the symptoms and ECG abnormalities resolved. LBBB disappeared by the 4th minute of recovery, and her chest pain also completely subsided. The patient was advised to engage in aerobic physical activity to improve conditioning, and a beta-blocker was introduced to her treatment plan. At the follow-up visit, the patient reported similar symptoms on only two occasions, both during intense exertion. A Holter ECG did not record any LBBB episodes. **Conclusion**: LBBB is a significant conduction abnormality that can lead to various clinical manifestations, including the painful LBBB syndrome. The case of the 32-year-old female patient illustrates the complex relationship between cardiac electrophysiology and chest pain. Effective management, including the use of beta-blockers and encouragement of aerobic activity, proved beneficial in her case. This highlights the need for increased awareness among healthcare providers regarding painful LBBB syndrome to ensure appropriate care and prevent potential complications.

Ivica Benko, Mateja Lovrić, Marina Budetić, Mirela Adamović, Nikolina Slamek, Marina Žanić, Marija Grlić, Ivan Horvat, Mario Tomašević

Pericardial tamponade is the most common major complication during invasive electrophysiology (EP) procedures, particularly in atrial flutter and atrial fibrillation ablations. According to a multicenter analysis, the incidence of tamponade in atrial fibrillation ablation is 0.67%, while in atrial flutter ablation it is 0.27%, and the highest incidence is during ventricular tachycardia ablations, with an incidence of 2.2%. Tamponade requires urgent care, including pericardiocentesis, and can be fatal if not promptly recognized and treated. Mortality associated with ablations is 0.17%, with tamponade contributing to 9.7% of all deaths following these procedures. (1) The most common procedure in most centers for treating tamponade begins with fluoroscopy-guided pericardiocentesis, typically through an anterior subxiphoid approach. After puncture, a pigtail catheter is inserted for continuous drainage of pericardial fluid. Protamine is routinely administered in most centers either immediately after diagnosis or after complete aspiration of blood from the pericardium. Auto-transfusion of aspirated blood is also standard in more than 70% of centers, while the decision for surgical intervention is made if bleeding is not controlled within 60 to 80 minutes. (1) Nurses play a key role in recognizing early symptoms of tamponade, quickly activating emergency protocols, and assisting during pericardiocentesis. Their responsibilities include monitoring vital signs, administering protamine to neutralize heparin, and performing auto-transfusion of aspirated blood, thereby contributing to the stabilization of the patient. (2) Establishing an effective, agreed-upon emergency protocol for cases such as tamponade is crucial for reducing risk and improving treatment outcomes, especially in hospitals with limited resources or without constant availability of cardiac surgery. (1)

Diana Delić Brkljačić, Karlo Golubić

Cardiovascular disease (CVD) are a major global health challenge, ranking as one of the leading causes of mortality worldwide. They encompass a broad spectrum of disorders affecting the heart and blood vessels, including coronary artery disease, stroke, heart failure, and peripheral artery disease. While both men and women are at risk of developing CVD, notable sex-related differences exist in terms of prevalence, symptom presentation, outcomes, and responses to treatment. Although women tend to have a lower incidence of acute cardiovascular events compared to men, their prognosis following such events is often worse, with a higher fatality rate and increased likelihood of long-term complications. These sex-related differences are evident across a range of cardiovascular diseases, including aortic diseases, heart failure, stroke, and coronary heart disease. For example, women are more likely to experience non-traditional symptoms of heart attacks, such as nausea, shortness of breath, and fatigue, which can lead to delays in diagnosis and treatment. Additionally, women are more prone to developing certain types of heart failure and may experience worse outcomes after a stroke compared to men. Hormonal factors, genetic predispositions, and differences in risk factor profiles, such as cholesterol levels, blood pressure, and body composition, contribute to these disparities. The recognition of these sex differences is essential for the effective management, diagnosis, therapy, and prevention of CVD. Tailoring cardiovascular care to account for these variations can improve outcomes for both men and women. For instance, preventive strategies such as lifestyle modifications, medication, and early interventions may need to be adjusted based on sex-specific risk profiles. Likewise, diagnostic tools and treatment protocols should be refined to better capture the unique manifestations of CVD in women, thereby reducing the risk of misdiagnosis and undertreatment. (1) This paper aims to provide a comprehensive overview of sex-related variations in several prevalent cardiovascular diseases and to explore the potential mechanisms underlying these disparities. By understanding the biological, hormonal, and social factors that contribute to the differences in cardiovascular outcomes between men and women, we can improve risk assessment and develop more personalized approaches to care. Moreover, future research should focus on identifying and integrating sex-specific markers, such as hormonal levels or genetic factors, into current cardiovascular risk assessment models. This will ensure that both sexes receive the most accurate and effective care, ultimately reducing the burden of cardiovascular disease on a global scale.

Fran Rode, Ana Jordan, Ivan Zeljković, Nikola Pavlović, Ante Lisičić, Aleksandar Blivajs, Vanja Ivanović, Jelena Kursar, Danijela Grizelj, Luka Antolković, Domagoj Kobetić, Ivan Skorić, Šime Manola, Ivana Jurin

**Introduction:** Implantation of cardioverter-defibrillator devices prevents sudden cardiac death in eligible patients with heart failure with reduced fraction (HFrEF). Optimal titration of guideline-directed medical therapy (GDMT) to evidence-based target doses before the implantation is mandatory to reduce unnecessary implantations. Ventricular tachycardia (VT) burden has been related to worse outcomes in patients with HFrEF. (1) The aim of this study is to evaluate the up-titration of GDMT in patients receiving implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT-D) devices with HFrEF, and to evaluate the eventual effects of maximally titrated drug classes of GDMT for HFrEF on the incidence of VT and appropriate device therapy. **Patients and Methods:** This single-center retrospective observational study included all patients with HFrEF hospitalized for ICD or CRT-D implantation from January 2021 to November 2023 with at least one device check-up session after the initial implantation. Data was collected through patients’ medical history and phone calls. The Fisher exact test was used to test the statistical significance of differences between groups for nominal variables. **Results:** Data on 132 patients with HFrEF and ICD or CRT-D implanted were collected. Median follow-up time from device implantation to the last device session was 201 days. VT was reported in 43 (32,6%) patients. Appropriate device therapy was administered in 9.3% vs 15.4% patients with CRT-D vs ICD. In patients with CRT-D vs ICD, evidence-based target doses were reached for 31.5% vs 19.2%; 44.4% vs 33.3%; 79.6% vs 69.2%; and 98.1% vs 83.3% receiving beta-blockers, angiotensin receptor–neprilysin inhibitors (ARNI), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter-2 inhibitors (SGLT2i), respectively. The occurrence of VT and appropriate device therapy did not differ significantly between patients receiving beta-blockers, ARNI, and/or MRA in their maximal target doses and patients with incompletely titrated doses. Incidence of VT was significantly lower in recipients of CRT-D compared to ICD (18.5% vs 42.3%, p<0.005). **Conclusions:** Our study presented that maximal up-titration of either of the classes of GDMT individually or all of them did not result in a significant decrease in VT or appropriate device therapy incidence. Cardiac resynchronization therapy, in addition to providing room for better GDMT up-titration, might have an additional benefit in VT burden reduction.

Marko Galić, Jelena Kursar, Mario Špoljarić, Ana Jordan, Aleksandar Blivajs, Irzal Hadžibegović, Petra Vitlov, Ante Lisičić, Dominik Buljan, Danijela Grizelj, Šime Manola, Ivana Jurin

**Introduction:** Previous studies have shown that real-life patients with heart failure with reduced ejection fraction (HFrEF) often fail to reach the target doses of disease-modifying treatments that demonstrate benefits in randomized controlled trials, which form the basis of guideline recommendations. The reasons behind this appear to be multifactorial, leading to a gap between guideline recommendations and everyday clinical practice. (1-3) This study aimed to investigate the main reasons why are the patients with HFrEF not receiving the target doses of guideline-directed medical therapy (GDMT). **Patients and Methods:** We conducted a registry-based study including patients with HFrEF hospitalized at our center between September 2021 and September 2023. Information was collected on therapy adherence, doses, and reasons for not achieving target doses. Follow-up data were obtained through clinical visits or phone interviews. **Results:** This study analyzed 266 patients with newly diagnosed HFrEF, and GDMT was initiated according to the European Society of Cardiology guidelines. The mean age was 64 years (IQR 16), and 27.4% were female. Only 7.7% of the patients were on the maximal doses of all four pillars of GDMT. Most patients regularly took their prescribed medication, and adherence did not vary significantly between different groups of medications. The primary reasons for not achieving maximum doses included lack of dosage increase attempts, issues with kidney function and potassium levels, and low blood pressure. **Conclusion:** The greatest challenges in achieving GDMT for HFrEF include clinical inertia, side effects, and patients perceptions of the necessity of medication. Physicians may overestimate the quality of care they provide, contributing to clinical inertia. Other factors include time constraints during office visits, patient nonadherence, and reluctance to adjust therapy. Additionally, gaps in education, training, and organizational support are well-recognized causes of clinical inertia.

Mihovil Santini, Lucija Schneider, Marin Bištirlić, Jakov Santini, Nikola Verunica, Martina Lovrić-Benčić, Dražen Zekanović

**Introduction**: Plasma calcium concentration is maintained within a narrow range between 2.2 and 2.6 mmol/L. Severe hypocalcemia is defined by a concentration below 1.9 mmol/L (1). Decrease of extracellular calcium concentration slows down spontaneous sinus node beating (pacemaking) significantly by attenuation of ICaL (L-type Ca2+) and INaCa (sodium/calcium exchanger) current during late diastolic depolarization. It is usually compensated by a higher sympathetic tone, but in hypocalcemic circumstances, an abrupt decrease in sympathetic tone could reveal a low basal sinus node beating rate and result in severe bradycardia. (2) **Case report**: 80-year-old female patient was admitted to the Emergency Department due to chest pain, nausea, frequent dizziness, and lightheadedness, but without loss of consciousness. The symptoms lasted for about 10 days. She has arterial hypertension and hyperlipidemia, and in 2018, a total thyroidectomy was performed due to thyroid cancer. She was regularly checked by an endocrinologist due to iatrogenic hypoparathyroidism. Upon arrival, basic laboratory workup and X-ray were done. During continuous 12-lead electrocardiogram monitoring, a sinus rhythm with a frequency of around 50/min was recorded, with episodes of sinus node arrest and consequent acquisition of the atrioventricular node resulting in symptomatic bradycardia. With regard to the symptomatic bradycardia, she was admitted to the Department of Cardiology. A detailed medical history revealed that the patient had recently stopped taking calcitriol that was prescribed earlier by an endocrinologist. In the further work-up, the electrolytes were checked, and severe hypocalcemia (1.65 mmol/L) was verified. Echocardiography was normal. During hospitalization, hypocalcemia was corrected, after which automaticity of the sinus atrial node was restored without episodes of sinus arrest. The patient no longer had bradycardia nor complaints of dizziness and lightheadedness. Calcitriol was reintroduced into the therapy. It was recommended to regularly check electrolytes and to take chronic therapy in addition to an outpatient 24-hour ECG. **Conclusion**: To the author’s best knowledge, this is one of the few cases in which severe hypocalcemia led to sinus arrest and subsequent symptomatic bradycardia.

Sanda Sokol Tomić, Ana Jordan, Nikola Pavlović, Nikša Bušić, Ante Lisičić, Ivan Zeljković, Šime Manola, Ivana Jurin

**Introduction**: Atrial fibrillation (AF) is a common arrhythmia in patients with heart failure (HF), and its recurrence after catheter ablation (CA) remains a significant clinical challenge. The use of SGLT2 inhibitors (SGLTi), has shown cardiovascular benefits in HF patients, including potential impacts on arrhythmias. (1) This study aims to evaluate the effect of SGLT2 inhibitors on recurrence of persistent AF in HF patients following CA, focusing on different heart failure subtypes: HFpEF (preserved ejection fraction), HFmrEF (mid-range ejection fraction), and HFrEF (reduced ejection fraction). **Patients and Methods**: This study included 74 patients with heart failure, divided into two groups of 37. Group 1 (mean age 65 ±7, female 27%, mean NT-proBNP 2458 ±3299 pg/ml) consisted of patients who did not receive SGLT2 inhibitors, while group 2 included patients who were on SGLT2 inhibitors (mean age 66 ±8, female 18,9%, mean NT-proBNP 242 ± 1371 pg/ml). Each group was further categorized based on heart failure subtypes: HFpEF, HFmrEF, and HFrEF. AF recurrence after CA was recorded for all patients. In Group 1, there were 28 patients with HFpEF, 4 with HFmrEF, and 5 with HFrEF. In Group 2, 13 patients had HFpEF, 4 had HFmrEF, and 21 had HFrEF. The primary outcome was the recurrence of AF within a specified follow-up period. **Results**: In Group 1 (without SGLT2 inhibitors), the recurrence of AF was observed in 6 patients with HFpEF (21,4%), 1 patient with HFmrEF (25%), and 2 patients with HFrEF (40%). In Group 2 (with SGLT2 inhibitors), AF recurred in 3 patients with HFpEF (23%), 0 with HFmrEF, and 6 with HFrEF (28%). Conclusion The results suggest that the use of SGLT2 inhibitors may reduce AF recurrence in HFpEF and HFmrEF subtypes but may have limited or no effect on HFrEF patients. The lower recurrence rates in these subgroups suggest potential benefits of SGLT2 inhibitors in modulating arrhythmic risk, likely through mechanisms related to improved cardiovascular function and reduced inflammation. **Conclusion**: In patients with HFrEF, the effect of SGLT2 inhibitors on AF recurrence appears to be less pronounced, which could be due to the more advanced structural heart changes seen in this population. Further studies with larger sample sizes and longer follow-up periods are needed to confirm these findings.

Vanja Ivanović Mihajlović, Ivana Jurin, Zrinka Šakić, Marin Pavlov, Tomislav Šipić, Petra Vitlov, Hrvoje Falak, Danijela Grizelj, Šime Manola, Mario Udovičić

**Introduction**: Hypochloremia is a common finding in patients with heart failure (HF) and is often associated with drug therapy, primarily the use of diuretics. In the last few years, several studies have established that serum chloride levels are a very powerful prognosis predictors in both acute and chronic HF. Considering that sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the only medications proven to be effective in the treatment of HF in the complete spectrum of left-ventricular ejection fraction (LVEF), we conducted a research to evaluate the impact of SGLT2i on serum chloride levels during follow-up in patients with HF. **Patients and Methods**: This was a prospective observational study, conducted at Dubrava University Hospital and involving patients with HF, recruited from the local HF registry. We included 241 participants between May 2021 and April 2023. All data were obtained before the introduction of SGLT2i and at 6 and 12 months follow-up. The primary outcome was changes in chloride concentration during the follow-up time. The secondary outcome was the correlation between chloride concentrations and N-terminal Pro-Brain Natriuretic Peptide (NT-proBNP) values, the functional status of the patient and interdependence of NT-proBNP levels and other measured patient-specific parameters. **Results:** Results show that SGLT2i significantly increase the chloride concentration at 6 and 12 months of follow-up. Higher chloride concentration is an independent predictor of lower NT-proBNP levels and correlates with better functional status of the patient according to the New York Heart Association (NYHA) classification. Furthermore, higher body mass index at the baseline is an independent predictor of lower NT-proBNP levels at both 6 and 12 months. Age influenced NT-proBNP levels positively at both time points, and smoking only at 12 months. Gender did not affect NT-proBNP levels. **Conclusion**: There is increasing evidence that serum chloride is a very important prognostic marker in patients with HF. (1, 2) Given that SGLT2i have become a mandatory part of the treatment of patients with HF and the fact that in this study we have shown the influence of SGLT2i on chloride values, the determination of serum chloride values should certainly become part of the routine follow-up in patients with HF.

Fran Rode, Ana Jordan, Ivan Zeljković, Nikola Pavlović, Ante Lisičić, Aleksandar Blivajs, Vanja Ivanović, Jelena Kursar, Danijela Grizelj, Luka Antolković, Domagoj Kobetić, Ivan Skorić, Šime Manola, Ivana Jurin

**Introduction:** Beta-blockers are one of the four major pillars of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). The therapy has presented the best effects when up-titrated to evidence-based target doses. Despite their proven benefits, physicians have traditionally shown reluctance to up-titrate beta-blockers because of their negative inotropic and chronotropic effects. The effects of newly introduced sodium-glucose transporter 2 inhibitors (SGLT2I) in treating HFrEF might open more room for adequate beta-blockers up-titration (1). The goal of this study was to evaluate the up-titration practice, and impact of target doses of beta-blockers in patients with HFrEF receiving SGLT2I. **Patients and Methods:** This is a prospective cohort study involving patients with HFrEF receiving SGLT2I therapy. Up-titration to the evidence-based targets was examined. We compared the groups of patients receiving maximally titrated beta-blockers versus incompletely titrated. Primary outcome was composite of: 1) rehospitalization or revisit to emergency unit due to the heart failure; 2) all-cause death and major adverse cardiac events (MACE). Secondary outcomes were heart rate at rest, left ventricular ejection fraction, NT-proBNP and New York Heart Association (NYHA) status at 6 and 12 months of follow-up. Study endpoints were documented via telephone interviews, regular outpatient follow-up, or by electronic hospital records. **Results:** The study included 458 patients with median follow-up time of 365 (186-502) days. A total of 122 (26.6%) patients had maximally up-titrated beta-blockers. The results show adherence to maximal target doses of beta-blocker therapy significantly reduces hazard of death or MACE compared to not using maximal doses of beta-blocker (factor 0.43). Hazard reduction was not statistically significant for composite of rehospitalization or revisit to emergency unit due to HF. Maximal doses of beta-blockers did not result in a significant decrease in resting heart rate. **Conclusion:** Our real-world data have highlighted the prevalence of incomplete titration of beta-blockers. Although it has been shown that evidence-based target dosing of beta-blockers reduce death and MACE, there is still room for improvement with up-titrating beta-blockers in in eligible patients.

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

**Introduction**: Total arterial myocardial revascularization offers better long-term graft patency, lower incidence of major adverse cardiac and cerebrovascular events and better long-term survival compared to revascularization using single arterial graft (1, 2). Specifically, the radial artery has shown distinct advantages over other grafting options. This retrospective study presents 26 years of experience using the radial artery in coronary artery bypass grafting (CABG) at our institution, emphasizing its role as an excellent second or third arterial graft. **Patients and Methods**: Data were collected from all patients who underwent CABG using the radial artery. Demographic information, perioperative outcomes, and intraoperative transit-time flow measurement (TTFM) were extracted from our clinical database. **Results**: From February 1998, a total of 1765 radial artery grafts were used in 1423 patients with an average age of 59.1±8.6 years. Left main coronary artery disease was present in 352 patients (25%). Total arterial revascularization, without venous grafts, was achieved in 90% of patients. The left radial artery was the most frequently used graft (90%), followed by the right radial artery (2%), and both radial arteries (8%). The mean number of distal anastomoses was 2.6±0.6. Off-pump CABG was performed in 42% of patients with isolated coronary artery disease, with no reported ischemic complications or wound infections. Radial nerve injury occurred in only two patients (0.12%). The radial artery grafts were primarily used in the circumflex (45%) and right coronary (39%) territories. TTFM results showed excellent mean flow (50.6 ml/min), diastolic filling (63.9%), and a pulsatility index of 2.5. **Conclusion**: While long-term graft patency and patient survival were not assessed, the study demonstrates that the radial artery can be routinely used in multi-arterial myocardial revascularization, showing excellent intraoperative blood flow and a very low rate of complications.

Ivica Benko, Mateja Lovrić, Marina Budetić, Mirela Adamović, Nikolina Slamek, Marina Žanić, Marija Grlić, Ivan Horvat, Mario Tomašević, Nikolina Gracić, Tomislav Delić, Ante Lisičić, Ivan Zeljković, Nikola Pavlović, Ana Jordan, Šime Manola

Conventional electrophysiology (EP) interventions are typically performed in specialized EP labs, where fluoroscopy is the main imaging method for catheter placement. Due to the risks of ionizing radiation, staff must wear protective equipment. In contrast, magnetic resonance imaging (MRI) -guided EP procedures present a novel, radiation-free alternative with superior anatomical visualization. Preparing patients for MRI-guided EP procedures requires a coordinated multidisciplinary team, including physicians, engineers, radiology technologists, and nurses. This team is responsible for conducting safety assessments, monitoring vital signs, and managing MRI-compatible medical equipment. Nurses and radiology technologists face specific challenges in the MRI environment, which demands expertise not typically required in conventional settings. Patient preparation begins with detailed education about the procedure and MRI safety protocols. The nurse ensures that there are no contraindications, such as metal implants, and carries out standard preparations, including intravenous line placement and setting up MRI-safe monitoring devices. During the procedure, continuous monitoring requires specialized MRI-compatible equipment. The nurse also manages emergency equipment, such as defibrillators and infusion pumps, positioned outside the magnetic zone. In case of emergencies, such as intubation or defibrillation, interventions must be performed outside the MRI suite. Given the invasive nature of these procedures, maintaining strict hygiene and aseptic conditions are crucial. Throughout the procedure, nurses collaborate closely with radiology technologists to ensure seamless communication with physicians inside the MRI room, using specialized optoacoustic headsets for synchronized execution of all steps. MRI-guided EP procedures, such as atrial flutter ablation, achieve comparable outcomes to conventional methods, with the added benefits of reduced radiation exposure and enhanced anatomical precision. However, performing these procedures outside the traditional fluoroscopy lab presents technical, practical, and safety challenges, which require the expertise of a dedicated and experienced multidisciplinary team. (1, 2)

Tomislav Pijetlović, Ante Komazin, Gordana Hursa, Sanja Keleković

In patients with recurrent ventricular tachycardia, catheter ablation is an essential therapeutic strategy to prevent arrhythmia recurrence. Using inHEART’s AI-driven platform increases the efficiency of this procedure by creating a 3D digital replica of the patient’s heart from preoperative CT and MRI scans. (1) This technology allows detailed visualization of cardiac anatomy, including scar tissue (as well as its thickness) and arrhythmogenic areas, which helps in precise targeting of the ablation site. The use of inHEART greatly helps the identification of the arrhythmia substrate and simplifies the procedure. Preoperative images are processed to create a highly detailed patient-specific model of the heart, which is imported into the CARTO system. After merging the anatomical map from CARTO and the inHEART map, the mapping of the area of ​​interest begins. The detailed map allows the electrophysiologist to accurately identify arrhythmogenic zones in the scar tissue and guide the catheter to optimal ablation sites, minimizing procedure time and reducing the risk of recurrence. The inHEART-guided procedure improves overall outcome by reducing procedural complexity and the risk of ventricular tachycardia recurrence. We will present the case of a 59-year-old patient with recurrent episodes of ventricular tachycardia, which has an underlying ischemic cardiomyopathy. On two occasions, VT was recorded on the patient’s ICD. The device recognized the ventricular tachycardia and delivered a DC shock both times without successfully stopping the tachycardia using “overdrive” stimulation.

Ana Ljubas

## Dear Colleagues, It is both a joy and an honor to greet and welcome you to the 11th Congress of the Croatian Association of Cardiology Nurses (CACN) with international participation and the 15th Congress of the Croatian Cardiology Society (CCS) with international participation, which will be held from November 28 to December 1, 2024, at the Westin Hotel, Zagreb. We are proud that our congresses are held under the auspices of the Croatian Academy of Sciences and Arts and the European Society of Cardiology. The professional and scientific programs of both congresses will run simultaneously, and the content is intended for all healthcare professionals involved in the promotion, prevention, and treatment of cardiovascular diseases in any capacity. As in our previous congresses, we have aimed to cover all current topics in cardiological practice, which will be addressed by recognized experts from both national and international fields. The lectures of our invited speakers and oral presentations of selected topics from cardiological practice will present contemporary insights into the prevention, diagnosis, and treatment of cardiovascular diseases. In order to ensure that technological advancements and modern trends do not distance us from the core values of healthcare, the theme of our 11th congress is “Person-centered care: mission, vision, and values.” This theme is both the mission and vision of the CACN. A testament to our credibility is the fact that CACN was a co-organizer of the First International Congress on Person-centered Medicine in 2013, and the president of CACN has been invited to present the work, mission, and vision of our association at the XII International Congress of Person Centered Medicine. Our congresses are an opportunity for multiple generations of healthcare professionals to meet, for those who have built the professional growth of our specialist societies to share their knowledge and experiences with those who represent the future of Croatian cardiological practice. The fact that our young members will uphold the core values of healthcare has been affirmed by the words of one among them: “Person-centered care is the flagship of our association.” We extend our thanks to the president of the CCS, Academician Davor Miličić, for his support and contribution to the professional development of CACN, and to Prof Mario Ivanuša for his extensive assistance in the preparation and publication of abstracts in the supplement of the Cardiologia Croatica journal. We believe that, enriched by both professional and friendly gatherings, you will enter the Advent season with joy and carry the spirit of Advent from Zagreb to your homes. Predsjednica kongresa / Congress president: Ana Ljubas, mag. med. techn., FESC

Nihad Mešanović, Elnur Smajić

The goal of this abstract is to present available artificial intelligence (AI) software and tools for the development, assessment, and implementation of artificial intelligence/machine learning in cardiovascular research and clinical care, ensuring they are safe, reliable, and cost-effective. (1) AI has the potential to enhance patient outcomes by offering faster and more accurate diagnoses, personalized treatment plans, and reduced healthcare costs. Scientists, industry leaders, and global governmental agencies are focused on developing and applying AI and other advanced analytical tools to transform healthcare delivery. This abstract also addresses how digital tools and AI provide clinical insights, as well as how education and implementation strategies can improve cardiovascular outcomes for both healthcare workers and patients. Additionally, a key objective is to identify the best practices, strategies, and challenges for stakeholders within the healthcare system. Both academics and software developers support the creation of tools and services that advance the science and practice of precision medicine by enabling more precise approaches to stroke and cardiovascular care and prevention. Currently, several challenges remain, although many AI software and tools have been shown to sufficiently improve cardiovascular care to warrant broader adoption. This abstract outlines the current state of the art in the use of AI algorithms and data science for the diagnosis, classification, and treatment of cardiovascular disease.

Marija Pleško Avšar

Our facility has been providing outpatient cardiovascular rehabilitation for several years, aiming to improve both primary and secondary prevention of cardiovascular diseases among the island`s population. At the facility, we focus solely on personalized cardiovascular rehabilitation, enabling both physicians and nursing staff to devote their full attention to each patient. This program caters to individuals with heightened risk of cardiovascular and heart muscle disorders, those in recovery from myocardial infarction, and patients who have undergone invasive cardiac interventions. Recently, the program has also been expanded to include individuals recuperating from COVID-19. A nurse is required not only to provide education to patients regarding cardiovascular prevention but also to provide them with a Quality-of-life questionnaire both prior to and following the 15-day rehabilitation program. Furthermore, the nurse is responsible for preparing the rehabilitation setting, managing and activating the resuscitation equipment, and overseeing the temperature of the rooms. Prior to and following rehabilitation, the nurse is required to engage in the administration of a cardiopulmonary echocardiographic test with physical exertion. Their responsibilities include preparing the patient for the echocardiographic assessment by inputting data and positioning electrodes, conducting dual calibration of the ergospirometry, configuring a nasal O2 mask, and affixing a cuff for blood pressure measurement, which is to be continuously monitored during the test. (1, 2) Prior to and following physical training on the ergometer bike, the nurse is required to provide the prescribed supportive therapy and verify the appropriate administration of the optimal medical treatment. After each physical training session, their task is to oversee the delivery of O2 therapy within a low-frequency magnetic field while simultaneously monitoring the patient`s arterial pressure and pulse rate. Based on the assessment of the attending physician, the nurse must take blood samples for analysis and participate in additional tests during rehabilitation (Holter ECG, 24-hour BP measurement, etc.). In summary, it can be asserted that the nurse`s role in facilitating personalized outpatient rehabilitation is both extensive and indispensable.

Ružica Mrkonjić, Milka Grubišić

Extracorporeal membrane oxygenation (ECMO) is an important component of cardiogenic shock management, temporarily performs the functions of the heart and lungs - allowing them to “rest” and recover. As circulatory support, ECMO has been successfully used in clinical practice, prevents metabolic disorders. However, ECMO is only supportive therapy, not a disease-modifying treatment. (1) It does not treat heart failure. In order to be counted as cardiac support, ECMO should have an effect on reducing the loading and unloading conditions of the heart. Contrary to that, in certain situations, ECMO has a harmful effect on the function of the heart, leads to distension and decrease its recovery potential. Distension occurs in 10-30% of patients with implanted femoral ECMO support. (2) The large variability in incidence is probably related to the condition of the left ventricle when connecting the patient to ECMO. If the ejection fraction of the left ventricle is somewhat preserved, there will be no distension of the ventricle, ECMO will improve the flow through the coronary arteries and thereby further improve the contractile function of the left ventricle, proportionally to the circuit flow rate. (2) If patient has a very poor contractile function venous return to the heart exceeds the ECMO drainage. Venous return cannot be counterbalanced by the impaired LV contractility, and on the other hand, there is retrograde flow generated by the ECMO system, the ventricle becomes distended, backflow into the pulmonary circulation results in pulmonary edema. Permanent damage can occur to the heart if it remains overdistended. Management of distended heart consists modification of ECMO flow, medical management and mechanical decompression technics. Decompression strategies usually begin with modification of ECMO flow, adequate for end-organ perfusion, but determined by cardiac contractile function and retrograde ECMO flow. Medical management consists of pharmacological interventions to reduce mean arterial pressure, inotropic therapy to improve pulsatility, and measures to reduce circulation volume. Where medical management is insufficient consideration should be given to provision of mechanical decompression. The intra-aortic balloon pump is first line mechanical decompression. Another possibility is to use an Impella, blood pump, which can generate continuous blood flow contributing to LV unloading. An alternative approach is to vent blood from the pulmonary artery, left atrium or left ventricle with cannulas connected to the ECMO system.

Daniela Lončar, Maida Taletović Dugonjić

**Introduction**: Cardiovascular disease is the leading cause of death in kidney transplant patients. Patients on hemodialysis have a 10-20 times greater risk of developing cardiovascular disease compared to the general population. The risk of cardiovascular disease may differ in hemodialysis patients and kidney transplant patients. (1) Aims: To determine the frequency of risk factors for occurrence of cardiovascular disease and frequency of cardiovascular diseases in kidney transplant patients and patients on chronic hemodialysis. **Patients and Methods**: We compared the frequency of risk factors for cardiovascular disease and the incidence of cardiovascular disease in kidney transplant patients and hemodialysis patients. Patients were divided into two groups: kidney transplant patients (60 patients) and patients treated with hemodialysis (30 patients). **Results**: The incidence of non-traditional risk factors for cardiovascular disease in kidney transplant patients was as following: hypertension 30%, diabetes mellitus 23.3%, 26.67% active smoking, dyslipidemia 41.67%.Congestive heart failure had 3.33% kidney transplant patients and 16,67% patients treated with hemodialysis. Hypertension had 30% kidney transplant patients and 66.67% patients treated with hemodialysis. Left ventricular hypertrophy had 50% kidney transplant patients and 76.67% patients treated with hemodialysis. Coronary heart disease had 13.33% kidney transplant patients and 36.67% patients treated with hemodialysis. Atrial fibrillation had 10% kidney transplant patients and 26.67% patients treated with hemodialysis. Mitral regurgitation had 33.33% kidney transplant patients and 56.67% patients treated with hemodialysis. Aortic regurgitation had 15% kidney transplant patients and 33.33% patients treated with hemodialysis. **Conclusion**: We find statistically significant differences in the frequency of cardiovascular disease between kidney transplant patients and patients treated with hemodialysis.

Nives Kerner, Jure Samardžić, Nada Božina

**Introduction:** Tacrolimus is a cornerstone of modern immunosuppressive regimen after heart transplantation. Optimizing it’s use is crucial to increase effectiveness and reduce potential harm. (1-3) This paper aimed to present key insights into the pharmacogenetic profile of crucial cytochrome P450 (CYP) enzymes and ABC transporters involved in tacrolimus metabolism. **Materials and Methods:** This study involved search and review of relevant literature in PubMed and PharmGKB database using keywords: heart transplantation, immunosuppressive therapy, tacrolimus, pharmacogenetics, pharmacogenomics, CYP3A4, CYP3A5, polymorphism and pharmacoeconomics. **Results:** A systematic review of the literature established links between gene polymorphisms and tacrolimus metabolism. Whether therapeutic drug monitoring could be replaced by routine pharmacogenetic testing to adjust tacrolimus dosing more efficiently is still debated. Currently, the metabolizer phenotype CYP3A5 *1/*1 or *1/*3 is the only one with official guidelines, indicating these patients may need a 1.5 to 2-fold dose increase to achieve therapeutic levels. These guidelines are published by Clinical Pharmacogenetics Implementation Consortium (CPIC). Other referent scientific societies have similar guidelines. Among Caucasians, 3-15% are CYP3A5 expressors (*1 carriers). **Conclusion:** Further research is required to assess the cost-effectiveness of routine pharmacogenetic testing in clinical practice, considering its potential to prevent side effects and drug inefficacy. While pharmacogenetic testing provides valuable dosing insights, it should complement other clinical and laboratory tools in a multidisciplinary approach that includes the clinical pharmacist as part of the team.

Damjan Dušević, Marica Komosar-Cvetković, Irena Kužet-Mioković

**Introduction:** Professional burnout is described as a psychological syndrome that develops as a prolonged response to chronic interpersonal stress in the workplace. (1) Studies show that nurses and technicians are particularly affected, with burnout negatively impacting the productivity of healthcare institutions. (2, 3) Therefore, the aim of this study was to examine the relationship between shift work and certain employee characteristics, such as years of service and level of education, with the level of professional burnout, the presence of psychological difficulties, and general life satisfaction, as well as the interrelationships between these variables. **Methods:** Forty nurses (92.5% women and 7.5% men) employed at Thalassotherapia Opatija, Special hospital for medical rehabilitation of heart, lung and rheumatic diseases, participated in the study. The participants completed the Burnout Assessment Tool, which assesses the core symptoms of professional burnout, the Clinical Outcomes in Routine Evaluation - Outcome Measure, which measures the intensity of current psychological distress, and the Satisfaction with Life Scale, which evaluates an individual’s overall satisfaction with life. **Results**: This study found that employees engaged in shift work reported significantly higher life satisfaction compared to those working only in one shift (t=-2.67, df=38, p<0.05). Furthermore, employees working exclusively in a single shift exhibited significantly better perceived functioning in everyday life (t=2.06, df=38, p<0.05). Significant negative correlations were also found between all subscales assessing the primary symptomatology of professional burnout and life satisfaction, with correlation ranges from -.38 to -.45. Similarly, a negative association was found between general psychopathological difficulties and life satisfaction. Additionally, the results indicated a significant negative correlation between work experience and professional burnout. **Conclusion:** In conclusion, fundamental work determinants, such as working conditions, professional burnout, emotional state, and life satisfaction, can play a crucial role in daily functioning and overall quality of life.

Alenka Tuličić-Mihelčić, Ivan Bitunjac, Blaženka Miškić, Katica Cvitkušić-Lukenda, Željka Stojkov, Barica Stanić, Domagoj Vučić

**Introduction**: Ischemic cardiomyopathy is characterized by significantly impaired left ventricular function (ejection fraction [EF] ≤ 40%) due to coronary artery disease (CAD) and is the most common cause of heart failure. Non-pharmacologic treatments for heart failure, such as cardiac resynchronization therapy (CRT) via biventricular pacing (BVP), have played an important role in improving heart failure prognosis (1). In patients with electrical dyssynchrony, especially those with a widened QRS complex, CRT combined with a defibrillator (CRT-d) is a proven therapy. However, up to 30% of patients show no clinical benefit, often presenting with a broad QRS complex and a suboptimal response (2). Certain studies suggest that left bundle branch area pacing (LBBAP) is effective in improving cardiac function, mechanical synchronization, and efficiency (3). Both strategies can be combined with left bundle branch-optimized cardiac resynchronization therapy (LOT-CRT) to provide greater electrical resynchronization (4). This case illustrates the successful use of LOT-CRT-d in a patient with heart failure with reduced ejection fraction (HFrEF) and progressive clinical deterioration. **Case report**: 74-year-old male with long-standing ischemic cardiomyopathy and a baseline ejection fraction (EF) of 30% had been stable for many years on optimal medical therapy—New York Heart Association classification of heart failure (NYHA) class I. Over the past six months, he experienced worsening symptoms, including exercise intolerance and nocturnal orthopnea, with elevated N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) (780 pg/ml) and QRS widening to 170 ms, leading to a clinical decline to NYHA class II. Due to this deterioration, the patient was selected for LOT-CRT-d implantation. The procedure was uneventful, with left bundle branch area pacing achieved via a transseptal lead. A quadripolar left ventricular lead was positioned in the posterolateral region. A defibrillation lead was placed in the right ventricle, and a pacing electrode in the right atrium. Biventricular pacing successfully reduced the QRS duration from 170 to 100 ms, and the patient was discharged the following day without complications. At the one-month follow-up, the patient reported significant symptomatic improvement, returning to NYHA class I, walking 10 km daily without limitations, and no longer requiring diuretics. Echocardiography showed an improved EF of 40%, and NT-proBNP levels dropped to 150 pg/ml. **Conclusion**: This case demonstrates the effectiveness of LOT-CRT-d in improving both clinical and echocardiographic outcomes in a patient with worsening ischemic cardiomyopathy and HFrEF. LOT-CRT offers several advantages over traditional CRT, including more physiological pacing by targeting the left bundle branch area, which enhances interventricular synchronization. The patient’s significant improvement in QRS duration, EF, and NT-proBNP levels supports the growing evidence of the benefits of LOT-CRT over conventional biventricular pacing, especially in patients with severe interventricular dyssynchrony.

Antun Zvonimir Kovač, Marin Boban, Hrvoje Jurin, Denis Došen, Kristina Marić Bešić, Mladen Jukić, Ladislav Pavić, Joško Bulum, Davor Miličić

**Introduction:** Patients with chest pain, non-ST elevation ECGs, and normal troponin levels present challenges in identifying acute myocardial injury and are often classified as having unstable angina, necessitating further evaluation. Current guidelines recommend non-invasive imaging, such as coronary computed tomography angiography (CCTA), to exclude coronary artery disease (CAD) or guide management. (1-3) However, in Croatian hospitals, this approach is underutilized, with a primary focus on invasive coronary angiography (ICA). This study evaluates diagnostic and treatment strategies for unstable angina at the University Hospital Centre (UHC) Zagreb and examines CCTA’s potential role in the Emergency Department. **Patients and Methods:** We conducted a retrospective analysis of patients admitted for unstable angina at UHC Zagreb from January to March 2024. We focused on patients without ST-segment elevation on ECG and normal troponin levels. Data collected included diagnostic procedures, treatments, length of stay, and overall costs. **Results:** We identified 65 patients with a diagnosis of unstable angina. Of these, 53 (81.5%) underwent ICA, while 12 (18.5%) had non-invasive testing. Percutaneous coronary intervention (PCI) was performed in 8 patients (12.3%), with no referrals for coronary artery bypass grafting (CABG). In the non-invasive group, 5 patients (7.7%) had CCTA, identifying one case of CAD, managed medically. The remaining 7 (10.8%) underwent exercise stress tests, requiring no further evaluations. The average hospital cost for ICA without PCI was €2876, rising to €4259 with PCI. Invasive patients had an average stay of 4.0 days, compared to 3.1 days for non-invasive patients, who incurred an average cost of €657. **Conclusion:** Real-world data from a tertiary institution show that excluding CCTA from unstable angina diagnostic algorithms results in suboptimal care. Over 80% of patients are sent to the catheterization lab, but only one-sixth require revascularization, leading to higher costs and longer hospital stays without significant benefits. Non-invasive testing is underused, with reliance on less effective exercise stress tests rather than CCTA. These findings highlight the need to improve practices, especially in integrating CCTA into emergency and cardiology departments.

Juraj Županić, Karlo Gjuras, Marko Žarak

**Introduction**: Heart failure (HF) affects 38 million people globally, contributing to increasing hospitalization rates and placing a significant burden on healthcare systems worldwide. Routinely used biomarkers for diagnosis, therapy monitoring, and evaluation of HF are B-type natriuretic peptide (BNP) and its N-terminal prohormone’s fragment of B-type natriuretic peptide (NT-proBNP); however, both have limitations. (1-3) Therefore, it is important to discover new biomarkers for early diagnosis. MicroRNAs (miRNA, miR) are small, non-coding ribonucleic acids with around 22 nucleotides. They are involved in the posttranscriptional regulation of numerous genes. (2) Their stability, non-invasive availability, high sensitivity, and specificity for disease make them promising biomarkers for various pathological states, including HF. (3) **Method**s: The PubMed database was searched using the keywords “microRNA” and “heart failure”. The analysis included systematic reviews and meta-analyses published from 2019 to 2024. **Results**: According to the research, several miRNAs (miR-21, miR-30c, miR-210-3p, let-7i-5p, miR-129, let-7e-5p, and miR-622) were identified as potential biomarkers for HF diagnosis. (3) Studies also indicate that the expression of specific miRNAs is positively or negatively correlated with the New York Heart Association functional class and left ventricular ejection fraction (LVEF), which may be valuable for evaluating the severity and prognosis of HF. (1, 2) Panels of various miRNAs have demonstrated high sensitivity and specificity in distinguishing between HF with reduced and preserved LVEF. (2) **Conclusion**: MicroRNAs have big potential as novel biomarkers of HF. (3) They remain unusable in routine diagnostics due to issues including unstandardized methods for measuring their expression and long turnaround times. However, when combined with well-known biomarkers and diagnostic tools like BNP, NT-proBNP, and echocardiography, they could enable earlier and more precise diagnoses and better monitoring of patients with HF. (2)

Petra Bistrović, Ana Jordan, Danijel Unić, Andrej Novak, Sanda Sokol Tomić, Nikola Pavlović, Irzal Hadžibegović, Marin Pavlov, Tomislav Šipić, Šime Manola, Ivana Jurin, Ivan Zeljković

**Introduction**: Permanent pacemaker implantation (PPI) is a frequent complication of transcatheter aortic valve implantation (TAVI), however no specific combination of predictive parameters (radiologic or electrocardiographic) has been established yet. (1, 2) Various prediction scores are used in stratifying patients according to periprocedural risk of TAVR, however there is no data whether patients these scores are associated with an increased incidence of PPI. The aim of this study was to investigate the association between TAVI risk scores and PPI after TAVR. **Patients and Methods:** We conducted a registry-based study on patients who underwent TAVI at Dubrava University Hospital from 2011 to 2024. We analyzed risk scores routinely calculated for TAVI candidates - Charlson comorbidity index (CCI), H2PEF, HARMS-AF, ACEF, France score, Euroscore II, Society of thoracic surgeons score (STS), Katz score. Patients who had a prior pacemaker were excluded. **Results**: A total of 397 patients (mean age 80 years, 51% female) were included, 45 (11%) requiring PPI. There was no significant difference regarding basic demographic and cardiovascular risk factors between non-PPI and PPI group. PPI group had a significantly higher Charlson comorbidity score (7 vs 6 points, p=0.011), H2PEF score (6 vs 5 points, p=0.037) and STS (5.9 vs. 4.7%, p=0.031) compared to the non-PPI group. There was no significant difference for the other scores. Cut-off points were defined for the scores with best predictive properties (CCI>7 points; H2PEF >4 points; STS >5.1%; AUC 0.6 for all). After logistic regression and evaluating CCI, H2PEF and STS synchronously as predictors for PPI, none of the scores remained significant. **Conclusion**: Our data suggests that CCI, H2PEF and STS might aid in finding a prognostic tool. Further research is necessary to establish a score, most probably combining clinical and diagnostic findings, for adequate identification of patients at higher risk of PPI.

Mihovil Santini, Lucija Schneider, Marin Bištirlić, Jakov Santini, Martina Lovrić Benčić, Dražen Zekanović

**Introduction**: Coronary artery aneurysm (CAA) is a rare condition that occurs in 0.3%–4.9% (mean incidence of 1.65%) of patients undergoing coronary angiography and is characterized as dilatation of the coronary artery exceeding 50% of the reference vessel diameter (1, 2). The left anterior descending artery is affected in 32.3% of all CAAs. (2) **Case report**: 46-year-old patient was admitted to the cardiology department due to chest pain. Previously, the patient had no comorbidities; he was non-smoker but with a positive family history of cardiovascular diseases. Upon arrival at the emergency department, the blood pressure was elevated (190/110 mmHg). The clinical status was unremarkable. The 12-channel electrocardiogram (ECG) showed a sinus rhythm of 70 beats per minute with the ST segment depression up to 2 mm in the anterolateral leads. Immediately upon arrival, acetylsalicylic acid was prescribed. A serial control of high-sensitive troponin (HsT) showed a rise of HsT from 5.98 ng/l to 75 ng/l, with a maximum of 2265 ng/l. After a significant increase in troponin and with regard to ongoing chest pain and ischemic changes in ECG, the patient was admitted to the coronary care unit (CCU) under the diagnosis of acute coronary syndrome - non-ST elevation myocardial infarction. Upon arrival in the CCU, an urgent coronary angiography was performed, which showed intact left main coronary artery, left circumflex artery, and right coronary artery. The left anterior descending artery was strongly aneurysmatic changed in the entire middle segment (beginning at a strong diagonal branch) with TIMI I-II flow (**Figures 1 and 2**Figure 2). Echocardiography showed mild hypokinesia of the apical part of the anterolateral wall, with the left ventricle ejection fraction of 50%. Due to the findings, percutaneous coronary intervention was ceased, and conservative treatment of acute coronary syndrome was initiated. The patient was urgently referred to a tertiary center for cardiosurgical revascularization of the myocardium. FIGURE 1. The figure shows aneurysm of the left anterior descending artery in early contrast phase. FIGURE 2. The figure shows aneurysm of the left anterior descending artery in late contrast phase. **Conclusion**: In order to provide the best possible outcome for the patient, our aim was to highlight the importance of a multidisciplinary approach with the cardiac surgeons and the criticality of determining when to cease percutaneous coronary intervention.

Ana Fabris, Mila Jakovljević, Marija Pleško Avšar

**Introduction**: Quantitative stress echocardiography provides sensitive markers for diagnosing subendocardial dysfunction but its specifity is low. (1, 2) We combine exercise gas exchange measurements with quantitative stress echocardiography in order to better distinguish between ischemic and non-ischemic causes of myocardial dysfunction. **Patients and Methods:** We describe the method of the cardiopulmonary echocardiographic exercise test (CPEET) and provide examples that differentiate between ischemic and non-ischemic substrates. In 35 patients, we correlated peak strain rate, peak systolic myocardial velocity, and peak left ventricular filling pattern with gas exchange parameters: pVO2, dVO2/dWR, pO2 pulse, AtPETCO2, and VE/VCO2 slope during exercise test. Statistical analysis was performed using SPSS Statistics for Windows version 25. The values of p 2, AtVO2, dVO2/dWR, pO2 pulse, AtPETCO2 and negatively with VE/VCO2 slope. pVs correlates positively with pVO2, AtVO2, O2 pulse, dVO2/dWR, AtPETCO2, and negatively with VE/VCO2 slope. Correlation of pSR with pV02 and dV02/dWR is stronger than correlation of Vs, respectively. pE/e ratio correlates negatively with pVO2, AtVO2, PETCO2 and positively with VE/VCO2 slope. **Conclusion**: Combining pSR/pVs with peak VO2, dVO2/dWR, and peak oxygen pulse may better distinguish ischemic from non-ischemic substrate. Additionally, other exercise gas exchange parameters combined with stress echo-derived metrics could enhance the diagnosis of pathophysiological conditions, such as reduced exercise peak VO2 and reduced SR/Vs.

Nikolina Jurković Dubravčić, Renee Mixich, Senka Pejković

**Introduction:** Despite the progress of echocardiography (ultrasound diagnostics), myxoma was discovered accidentally in a patient due to asymptomatic reasons. (1) **Case report:** We present the case of a 60-year-old man in whom orthopedic surgery for hallux rigidus on the left foot was indicated. As part of the preoperative work-up, atrial undulation was determined, and a TEE with the question of a thrombus in the auricle and electrocardioversion was referred. The finding of a tumor, a mass of 10.3x4.9 cm, located by the stalk against the lateral wall of the right atrium (RA), which during diastole is completely pressed through the tricuspid annulus, and in systole prolapses towards the superior vena cava. It is diagnosed as right atrial myxoma and urgent cardiac surgery is indicated. The patient underwent extirpation of the right atrial myxoma and reparation of the tricuspid valve with the implantation of a tricuspid ring with the support of a machine for extracorporeal blood flow. After the operation, the patient made a complete clinical recovery and was discharged. Currently, he is in a good clinical condition, tolerates effort properly (control ergometry), in sinus rhythm. Correction of the bunion of the left foot has been made, and he regularly goes to the cardiologist for follow-up examinations. **Conclusion:** Echocardiography as a standard method of cardiology treatment of patients with atrial fibrillation and undulation should be transesophageal, regardless of whether the patient is on anticoagulant therapy. Surgical extirpation of myxoma is a method of treating myxoma, and the prognosis is positive.

Andrijana Erak

**Introduction:** Echocardiography is a diagnostic examination that provides into the comprehensive anatomy and physiology of the heart. The most commonly used method is transthoracic echocardiography. There is also invasive diagnostics, transesophageal echocardiography, and intracardiac echocardiography, which is performed under anesthesia (1). Importance of informing patients has been emphasized, which facilitates cooperation during diagnostic procedures and treatment. It is necessary to clearly and concisely explain the type of examination and describe how the examination is performed. Psychological preparation sometimes is more challenging and more important than the physical preparation of the patient. (2) The aim was to examine the preparation and information of patients for echocardiography regarding age, gender, education level, and the type of examination. **Patients and Methods:** A cross-sectional study included 106 patients who came for echocardiography. A survey questionnaire developed for this research was used as the research instrument on patients’ awareness and preparedness for echocardiography. The study included 106 participants, of which 52 (49%) were males and 54 (51%) were females. **Results:** There was no significant difference in the awareness and preparation of participants for echocardiography regarding gender and age. Participants with higher education levels agreed that they knew how the examination was conducted before coming, unlike participants with lower levels of education. The results of the conducted research indicate that participants are well informed and prepared for echocardiographic examinations, with no significant differences based on gender and age. **Conclusion:** Participants who underwent transesophageal ultrasound of the heart considered themselves better informed and prepared compared to those who underwent transthoracic echocardiography.

Anica Milinković, Petra Grubić Rotkvić, Mia Maria Jurinjak, Ana Šutalo, Ivana Jurca, Majda Vrkić Kirhmajer

**Introduction**: Inferior vena cava (IVC) thrombosis is associated with high morbidity. Common causes include the presence of an IVC filter, malignancy, congenital abnormalities, thrombophilia, or trauma. Delayed treatment may lead to post-thrombotic syndrome or pulmonary embolism with potentially fatal outcome (1, 2). **Case report**: 44-year-old male with no significant medical history presented to the emergency department with acute pain in the left groin and swelling of the left leg. Duplex ultrasound showed slow flow in the dilated left common femoral vein, with absent respiratory flow modulation, suggesting a proximal obstruction. Computed tomography (CT) venography revealed narrowing in the suprarenal segment of the IVC with intraluminal calcification and stenosis of the right renal vein, accompanied by formed venous collaterals, suggesting unrecognized prior thrombosis. Partial thrombosis of the infrarenal IVC and complete thrombosis of left iliac veins was also noted, along with bilateral lobar pulmonary embolism with no signs of right heart strain (**Figure 1**). Upon admission, the patient was immediately started on low molecular weight heparin. Further workups for thrombophilia, malignancy and urological pathology returned negative. Detailed history revealed that he was an ultra-distance trail runner, a factor that may have contributed to thrombosis via dehydration and endothelial injury. Given the favorable clinical course he was discharged with a recommendation for long-term anticoagulation with rivaroxaban. Follow-up at 2 months showed normalization of D-dimers and sonographic improvement. After 5 months, CT venography revealed significant recanalization of affected vessels, and the patient was in excellent clinical condition, without venous claudication or leg swelling (**Figure 2**). FIGURE 1. Computed tomography venography showing acute left iliocaval thrombosis (black thin arrows). Amorphous calcification in the lumen of the pararenal inferior vena cava and ostium of the right renal vein (black thick arrow) accompanied by venous collaterals around the left kidney (white arrow) suggesting prior thrombosis (A). Acute emboli in the right lobar (thick arrow) and segmental (thin arrow) pulmonary arteries (B). FIGURE 2. Computed tomography venography in a 5-month follow-up revealing resolution of prior thrombosis in the inferior vena cava and left iliac veins (white arrows). **Conclusion**: IVC thrombosis is an under-recognized condition, commonly associated with malignancy or thrombophilia. Abdominal trauma, microtrauma, and dehydration related to intense physical exertion, particularly in athletes, can also contribute to its development. Current guidelines for IVC thrombosis management are limited, but anticoagulation remains essential, while interventional treatment may be considered depending on the disease severity (2, 3).

Matko Spicijarić, David Gobić, Sandro Brusich, Vjekoslav Tomulić

**Introduction**: Transcatheter aortic valve implantation (TAVI) is the optimal solution for many patients but requires procedure planning and prediction of possible complications. Sometimes, a permanent pacemaker must be implanted during or after the procedure. Therefore, preoperative implantation is indicated in high-risk patients, especially if other indications are also present (1). **Case report**: 80-year-old patient came to the Emergency Department of University Hospital Centre Rijeka due to difficulty breathing and exercise intolerance. Acute heart failure was diagnosed with the bifascicular block and intermittent second-degree atrioventricular block Mobitz type I (**Figure 1**). Earlier documentation and a two-week discharge letter from another institution have shown numerous percutaneous interventions of all coronary arteries, as well as peripheral arterial disease and severe aortic stenosis with the low flow-low gradient phenomenon. Left ventricular ejection fraction (LVEF) was 37%. The last coronarography two weeks ago showed significant stenosis of the ostium of the left anterior descending artery (LAD - 70%) with tubular stenosis of the left main trunk (LM - 50%) and stenosis of the circumflex artery ostium (LCx - 50 - 60%). Instantaneous wave-free ratio (iFR) suggested hemodynamically insignificant stenosis of LCx ostium (0.93). In the same act, percutaneous coronary intervention (PCI) of the middle LCx was performed due to subocclusive stenosis. The patient’s case should have been presented to the Heart team, but he was urgently hospitalized. A device for cardiac resynchronization therapy (CRT-P) was implanted, and subsequent hospitalization was arranged in six days for coronarography and TAVI procedures. At the beginning of the procedure, a calcified 90% stenosis was shown in the previously placed stent of the left external iliac artery, and dilation was performed (**Figure 2**). Then, significant stenoses of the ostium and proximal LCx and the distal LM and proximal LAD were observed. Successful PCI LM/LAD/LCx was performed (**Figure 3**), and afterward, the TAVI procedure was continued. The Evolut R prosthesis was implanted in the proper position and function (**Figure 4**). The patient was discharged in good general condition. At the follow-up ultrasound three months after the procedure, LVEF recovery was observed at 55%, and the patient felt much better. The next check-up was in half a year, the patient had no symptoms. FIGURE 1. Bifascicular block and intermittent second-degree atrioventricular block Mobitz type I. FIGURE 2. Calcified 90% stenosis in the previously placed stent of the left external iliac artery. FIGURE 3. Before and after successful percutaneous coronary intervention of the left main trunk, the left anterior descending and the circumflex artery FIGURE 4. Proper position and function of the Evolut R prosthesis. **Conclusion:** Complex cardiac interventions require detailed preparation, especially in fragile elderly patients. In some patients, expedited interventional treatment is needed to prevent the irreversible progression of symptoms.

Marin Pavlov, Andrej Novak, Šime Manola, Ivana Jurin

**Goal:** To determine the outcome predictor rank list in a population of pulmonary embolism (PE) patients with follow-up longer than one year using contemporary machine learning models. **Patients and Methods:** Machine learning models (LightGBM variant of XGBoost) were used to analyse the outcome data of a PE cohort. Patients were recruited from November 2013 until November 2018 in two academic hospitals in metropolitan area and followed by a telephone interview or hospital visit. Primary outcome was all cause mortality. In all patients PE diagnosis was established by computed tomography. Two models were generated in both XGBoost and frequentistic analysis: 1) a model with 19 variables 2) a model with 8 variables. Both models were recreated from previously published results (1, 2). **Results:** The study population comprised of 761 patients (predominantly female (57.4%), aged 73 (61-81)) has been described previously (1, 2). Median follow-up was 675 days (114-1331). Death within follow-up occurred in 335 cases (44.0%). In XGBoost algorhitm, Pulmonary Embolism Severity Index (PESI) score and body mass index (BMI) were the two strongest predictors of primary outcome. Overall, the models were accurate with area under curve of 0.840 and 0.864. For BMI, this is contrary to the results of frequentistic statistic inference, in which BMI failed to enter the Cox proportional hazards model. **Conclusion:** In the XGBoost analysis, a machine learning framework more suitable to handle non-linear data, outcome analysis yielded different results as compared to frequentist statistical inference. Since such non-normally distributed data prevail in health care data bases, machine learning models may provide deeper insight in analysis of variables impact on outcome.

Dijana Bešić, Petra Bistrović, Tomislav Čikara, Klara Pospiš, Sara Varga, Dominik Buljan, Fran Rode, Fran Šaler, Marko Galić, Merljinda Ljušaj, Marija Radić, Marin Viđak, Martina God, Šime Manola, Ivana Jurin

**Background:** Independent of low-density lipoprotein cholesterol (LDL-C) levels, lipoprotein (a), or Lp(a), is a widely acknowledged biomarker for atherosclerosis and coronary artery disease. Studies have demonstrated the role of Lp(a) in the development of acute coronary syndrome (ACS), however it is unclear if Lp(a) could have a significant role in identifying those individuals who are at risk of developing chronic coronary syndrome (CCS). (1, 2) This study sought to investigate the association of Lp(a) and LDL-C levels with occurrence of acute and chronic coronary syndrome. **Patients and Methods**: We analyzed patients included in CaRD registry (NCT06090591) who underwent coronary angiography in Dubrava University Hospital between June 2024 and September 2024. Logistic regression analysis was conducted to investigate the association of higher Lp(a) and LDL-C levels with occurrence of ACS and CCS. A p value of 0.05 was regarded as statistically significant. **Results:** This registry-based study included 141 patients with a median age of 63 years (IQR 54-71). Male patients were more prevalent than female patients (77% vs 23%, respectively). Notably, women were more likely to display higher Lp(a) levels (p=.004). No statistically significant correlation of Lp(a) with age was observed, though older patients tend to have higher LDL-C value (p=.011). Patients with higher LDL-C levels were more likely to experience acute coronary syndrome (p=.005), while patients with higher Lp(a) levels more frequently presented with chronic coronary syndrome (p=.024). **Conclusion:** Based on results of our study, joined Lp(a) and LDL-C analysis might be invaluable tool in primary prevention setting, with the objective of distinguishing high-risk individuals who are more likely to present with CCS from those who are more likely to present with ACS. Additional research and larger sample sizes with longer follow-up are required to investigate the role of Lp(a) and LDL-C as markers of chronic and acute coronary syndrome, respectively.

Ivan Zeljković, Anais Gauthey, Martin Manninger, Katarzyna Malaczynska-Rajpold, Federico Migliore, Šime Manola, Nikola Pavlović, Julian Chun, Giulio Conte

**Introduction:** Genetic testing in the cardiovascular field has advanced significantly in the past years, with expanding indications. (1, 2) The aim of this physician based European Heart Rhythm Association (EHRA) survey was to provide a snapshot on current clinical practice regarding the genetic testing for cardiac diseases across ESC countries. Croatia provided most responses, thus we compared Croatia to all other ESC countries included in the survey. **Methods:** An online 28-item questionnaire was promoted by the Scientific Initiative Committee of EHRA, the European Cardiac Arrhythmia Genetics Focus Group (ECGen) and the Young Electrophysiologists Committee and disseminated through EHRA Research Network and dedicated social media channels. **Results:** There were 357 respondents from 69 countries (48 ESC), out of which 60 from Croatia. The majority were cardiac electrophysiologists working in a University Hospitals. Most respondents, including in Croatia, indicated to have performed < 10 genetic tests in the last year. Half of the respondents sent their samples to the regional or national genetic laboratory; however, Croatia has no genetic laboratory in the country and all samples are sent to the laboratory abroad. The main reason for not providing genetic testing were no availability of the genetic lab/facility (35%) or reimbursement issues (25%), similar to Croatian responses. The most frequent indication for genetic testing was diagnostic purposes (55%). Clinical usage of genetic testing in the diagnostic, prognostic, and therapeutic assessment showed heterogeneity depending on the examined inherited disease, but high adherence to current guidelines. **Conclusion:** The survey highlights a significant heterogeneity of the of genetic testing clinical usage in Croatia compared to different ESC countries, mostly due to the differences in availability of genetic lab/facility and reimbursement issues but shows high adherence to current recommendations regarding the indications.

Ivana Jurin, Irzal Hadžibegović, Šime Manola, Vladimir Trkulja

**Introduction**: The current guidelines of the European Society of Cardiology for the management of patients with heart failure denote two sodium-glucose co-transporter 2 inhibitors (SGLT2i) – dapagliflozin and empagliflozin - as the only pharmacological options with a disease-modifying effect in chronic heart failure (CHF) across the entire range of left ventricular ejection fraction (LVEF) values. (1) The aim of our study was to assess relative efficacy of dapagliflozin and empagliflozin in routinely treated CHF patients. **Patients and Methods**: In this single-center registry analysis, prevalent and incident CHF patients with a wide range of left ventricular ejection fraction values started on dapagliflozin or empagliflozin in addition to other guideline-directed therapy were mutually balanced on a range of characteristics, and were assessed for incidence of a composite of all-cause death/major adverse cardiac events (primary outcome) over the initial 6 months of treatment, and for New Your Heart Association (NYHA) functional class at 6 months (secondary outcome). Frequentist and Bayes (with a moderately informed skeptical prior) estimates were generated for dapagliflozin vs. empagliflozin comparison. **Results**: In both prevalent (dapagliflozin n=393, empagliflozin n=328) and incident (dapagliflozin n=124, empagliflozin n=116) patients, those prescribed dapagliflozin had somewhat higher incidence of the primary outcome and were more likely to present with a worse NYHA class at 6 months, but the estimates were imprecise. In the pooled data, primary events (102 in total) were more common in dapagliflozin-prescribed patients (frequentist estimate RR=1.519, 95%CI 1.239-1.861; Bayes RR=1.380, 95%CrI 0.981-1.944). Dapagliflozin-prescribed patients were also were more likely to have a worse NYHA class at 6 months (OR=1.540, 95%CI 1.208-1.962; Bayes OR=1.425, 95%CrI 1.098-1.781). **Conclusion**: CHF patients prescribed with dapagliflozin apparently had poorer outcomes than those prescribed with empagliflozin over the initial 6 months of treatment. Data emphasize a need for a direct randomized comparison of the two treatments in this setting.

Josipa Logožar, Ivana Babić, Ivana Tunić, Martina Gazec

**Introduction**: Congenital heart diseases are among the most common congenital anomalies, varying from the simplest to the most complex forms. (1, 2) Infective endocarditis (IE) is an inflammation of the inner lining of the heart, known as the endocardium, as well as the heart valves. Although rare, IE has a high mortality rate. Patients with congenital heart diseases are at particular risk for developing infective endocarditis. **Case report:** This paper presents the case of a 46-year-old patient who was admitted to the hospital due to fever. After an initial workup at the local hospital, IE was suspected, and the patient was transferred to the University Hospital Centre Zagreb, to the Clinic for Cardiovascular Diseases, Department for Adult Congenital Heart Disease (ACHD). Further diagnostic testing confirmed the diagnosis of IE involving the bicuspid aortic and mitral valves, accompanied by severe aortic regurgitation (AR) and septic embolic encephalitis. The cardiac surgery team decided on emergency surgery, during which both the aortic and mitral valves were replaced. Postoperative recovery was smooth, and the patient was transferred to the Department for ACHD from where he was discharged back to the local hospital. However, his treatment was complicated by deteriorating kidney function, anemia, and the development of pleural effusions, prompting another transfer to clinic. Due to a paravalvular leak at the aortic and mitral valves, and a pseudoaneurysm of the left superficial femoral artery, the patient underwent a reoperation. After being transferred to the Department for ACHD, the patient developed rhythm instability, chills, shivering, fever, and elevated inflammatory markers. Candida parapsilosis was isolated from blood cultures, leading to the addition of antifungal therapy. After successful antibiotic treatment, the patient was discharged home with an emphasis on regular follow-up appointments and education on the importance of taking IE antibiotic prophylaxis. **Conclusion:** Infective endocarditis is a condition that requires continuous monitoring for complications, psychological support, and education for both the patient and their family. Caring for such patients presents a significant challenge, requiring ongoing education and continuous professional development for nursing staff.

Marica Komosar-Cvetković, Irena Kužet-Mioković, Samanta Vuković, Kristina Marić

The lack of health personnel in Europe, worldwide, and our country is a negative trend that requires solutions to prevent long-term consequences. Considering the demographic and epidemiological trends from the future perspective, a multidimensional problem will likely await us. Elaboration Due to the ageing population, the proportion of diseases increases, and the proportion of technological development increases as well. This will result in a changed approach in clinical practice and, thus, increased demands regarding the work of all health professionals. There is a shortage of health personnel in all EU member states. Some countries (Norway, Switzerland, Denmark, Finland, Iceland...) have implemented the so-called ‘task shifting’, increasing the availability of health services and providing solutions regarding the deficit of health professionals. (1) In these countries, non-medical health workers with higher education are significantly represented. Examples of today’s nursing practice in developed countries of Europe and the world support this. An efficient healthcare system needs the stability of available personnel with adequate skills in the right place at the right time. For example, some specific tasks are transferred from doctors to workers with bachelor’s or master’s degrees in health fields, having the specific knowledge and skills. Today, the education of nurses is experiencing the most significant changes. In many countries, education and development of specific clinical competencies in nursing lead to the transfer of certain competencies from doctors to nurses. (2) In this way, nursing is critical in specific care segments because nurses can significantly reduce the disease burden as they are the most numerous professionals.

Antun Zvonimir Kovač, Hrvoje Jurin, Denis Došen, Irena Ivanac Vranešić, Kristina Marić Bešić, Maja Hrabak Paar, Miroslav Muršić, Maja Čikeš, Davor Miličić

**Introduction:** Cardiac magnetic resonance (CMR) imaging has a reported accuracy of 97% in distinguishing between ischemic and non-ischemic heart diseases. However, ischemic patterns are still observed in 6–13% of patients with non-obstructive coronary artery disease. One randomized controlled trial showed that CMR alone identifies the specific cause of non-ischemic heart failure in 36% of cases, a figure that increases to 50% when combined with other clinical information. (1-3) This study aims to evaluate the accuracy of CMR in diagnosing specific non-ischemic cardiomyopathies at the University Hospital Center (UHC) Zagreb. **Methods:** We conducted a retrospective analysis of cardiac MRI scans performed at UHC Zagreb between January and June 2024. The analysis focused on the clinical indications for each scan, the diagnostic findings, and any changes to preliminary diagnoses based on CMR results. **Results:** A total of 92 cardiac MRI scans were successfully performed during the study period. Of these, 50 (54.3%) were performed to investigate the etiology of heart failure or acute myocardial injury in patients with non-obstructive coronary artery disease. The remaining scans assessed ischemia, viability, fibrosis, valvular disease severity, and other conditions. Among the 50 etiology-related scans, 27 (54%) provided a specific diagnosis of non-ischemic cardiomyopathy, 6 (12%) showed ischemic findings despite the absence of significant coronary artery disease, and 17 (34%) did not clarify the etiology. **Conclusion:** Findings suggest that at our tertiary center, the accuracy of CMR in diagnosing the etiology of cardiomyopathies is comparable to that of other institutions. Further improvements in diagnostic outcomes could be realized through enhanced interdisciplinary collaboration between cardiology and radiology teams.

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

**Introduction**: Percutaneous hemostasis after transcatheter aortic valve implantation (TAVI) involves perclose devices, vascular seal devices, hemostatic bands, or combinations of any of them. (1) We present our experiences with full percutaneous hemostasis after transfemoral TAVI achieved by two different strategies involving perclose devices. **Patients and Methods**: Patients who underwent full percutaneous transfemoral TAVI between October 2019 and September 2024 were included in the analysis. In total, 465 patients were divided in two groups: 176 patients who systematically received two perclose devices as a primary closure strategy from October 2019 to November 2022 were assigned to group 2PC, whereas the group 1PC+1VS consisted of 289 patients who systematically received one perclose device with one 8 French vascular seal from December 2022 to September 2024. Primary endpoint was a composite of 30-day major and minor vascular complications defined by VARC-3 consortium. **Results:** There were no significant differences in demographic and clinical characteristics between the groups. Primary endpoint occurred in 12 (6.8%) patients in the group2PC and in 22 (7.6%) patients in the group 1PC+1VS (RR 1.12 95% CI 0.57-2.20 for VARC-3 major or minor vascular complication). Proportion of major vascular complications was higher in the 2PC group (1.7% vs 1%), but that difference was not significant. Logistic regression showed independent association of age (RR 1.08 95% CI 1.01-1.16) and peripheral artery disease (RR 2.66 95% CI 1.26-5.61) with the primary endpoint. There were no significant differences in primary endpoint regarding closure technique in the whole cohort, and also among different TAVI devices or sizes within both groups. **Conclusions**: Hybrid vascular closure with one perclose and one 8 French vascular seal showed similar safety with relatively lower proportion of major vascular complications compared to a standard technique using two perclose devices, irrespective of TAVI platform or size. Age and peripheral artery disease were the only variables independently associated with vascular complications.

Sara Varga, Ivana Jurin, Ante Lisičić, Andrej Novak, Fran Šaler, Dijana Bešić, Mario Udovičić, Nikola Pavlović, Marin Pavlov, Marta Puškadija, Šime Manola, Ivan Zeljković

**Introduction**: Low-grade inflammation has been associated with pathogenesis and progression of all specters of heart failure (HF). (1) Sodium glucose cotransporter type 2 inhibitors (SGLT-2i) have been shown to reduce inflammation and improve cardiac function (2). Aim: to assess the change in C-reactive protein (CRP) levels in patients with HF treated with SGLT-2 inhibitors in follow up of 12 months. **Patients and Methods**: We included patients diagnosed with all specters of HF – reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF) according to the guidelines, at Dubrava University Hospital from May 2021 to September 2023 and prescribed with SGLT-2i among other guideline directed medical therapy (GDMT). We assessed the initial values of CRP and after 12 months of follow up. **Results**: This CaRD registry-based study included 268 HF patients with a median age of 66 (IQR 58-72) years, 71% male. 55% of patients were diagnosed with HFrEF, 27.6% with HFmrEF and 17.5% with HFpEF. 7.8% of patients stopped using SGLT-2i or were lost to follow up. 8.95% patients had other three pillars of GDMT prescribed at the initiation of SGLT-2i treatment. Median initial value of CRP was 5 mg/L (IQR 2.2-11.35mg/L). After 12 months of follow up, we observed a reduction of CRP by 1.3 mg/L (IQR -6.8-0.13mg/L, p2, IQR –2.9-68.6, p<0.001) during follow up. **Conclusion**: SGLT-2i reduced CRP in all specters of HF during follow up of 12 months.

Antun Zvonimir Kovač, Ivo Planinc, Boško Skorić, Nina Jakuš, Dora Fabijanović, Anna Mrzljak, Nikolina Bašić-Jukić, Hrvoje Gašparović, Ante Lekić, Željko Čolak, Hrvoje Silovski, Igor Petrović, Ognjan Deban, Željko Kaštelan, Maja Čikeš, Davor Miličić

**Introduction:** Dual organ transplantation, such as heart-liver or heart-kidney, is a rare but essential option for patients with multi-organ failure. While outcomes for single-organ transplants are well-documented, reports of dual transplants are limited. (1-3) This case series presents two heart-liver and one heart-kidney transplant cases to provide insights into clinical outcomes and management. Aim: To analyze the clinical characteristics, clinical course, perioperative management, and post-transplant outcomes of patients undergoing simultaneous heart-liver and heart-kidney transplantation at the University Hospital Centre (UHC) Zagreb, Croatia. **Case series:** Three patients underwent dual organ transplantation between January 2023 and September 2024. Two patients received heart-liver transplants for heart failure due to hereditary transthyretin amyloidosis, while one patient underwent heart-kidney transplantation for end-stage heart failure secondary to ischemic heart disease and renal failure associated with polycystic kidney disease. Surgical techniques and postoperative care were tailored to each patient’s clinical profile. The first patient, a 49-year-old male who underwent heart-liver transplantation, has a 20-month follow-up. His course included early liver graft rejection, successfully treated with pulse corticosteroids. Heart function remains preserved, and he initially had transient, low-intensity donor-specific antibodies (DSAs). The second patient, a 52-year-old male with heart-liver transplantation, has a one -month follow-up with preserved organ function, no rejection, and no DSAs. The third patient, a 54-year-old male who underwent heart-kidney transplantation, has a one-month follow-up complicated by prolonged postoperative peritoneal drainage, but both grafts are functioning well, with no rejection or DSAs (**Table 1**). ### TABLE 1: Patient characteristics in dual-organ transplantation. | **Patient characteristics** | **Patient characteristics** | **CASE 1** | **CASE 2** | **CASE 3** | | --- | --- | --- | --- | --- | | Age, sex | | 49, male | 52, male | 54, male | | Follow up | | 20 months | 1 month | 1 month | | Transplanted organs | | Heart and liver | Heart and liver | Heart and kidney | | Etiology of primary organ failure | | Hereditary TTR amyloidosis | Hereditary TTR amyloidosis | Ischemic heart disease Polycystic kidney disease | | Pretransplant laboratory values | Erythrocytes Hemoglobin | 4.38 x 1012/L 142 g/L | 4.02 x 1012/L 128 g/L | 3.83 x 1012/L 109 g/L | | Leukocytes | 4.2 x 109/L | 6.1 x 109/L | 7.6 x 109/L | | | Platelets | 170 x 109/L | 196 x 109/L | 129 x 109/L | | | Total bilirubin PV-INR AST ALT GGT ALP | 27 µmol/L 1.55 43 U/L 18 U/L 97 U/L 148 U/L | 15 µmol/L 1.06 46 U/L 93 U/L 33 U/L 73 U/L | 28 µmol/L 1.04 68 U/L 21 U/L 14 U/L 48 U/L | | | BUN Creatinine eGFR | 10.5 mmol/L 114 µmol/L 66 mL/min/1,73 m2 | 8.5 mmol/L 113 µmol/L 64 mL/min/1,73 m2 | 16.9 mmol/L 243 µmol/L 25 mL/min/1,73 m2 | | | NT-proBNP Troponin I | 6759 ng/L 172.7 ng/L | 5407 ng/L 105.5 ng/L | 4101 ng/L 37.0 ng/L | | | Posttransplant events | Surgical | Pericardial effusion | Pericardial effusion | Prolonged peritoneal drainage Pericardial effusion | | Infective | None | None | None | | | Neoplastic | None | None | None | | | Organ rejection | | Early cellular liver graft rejection | None | None | | Graft organ function | | Both preserved | Both preserved | Both preserved | | Donor-specific antibodies | | Transient low intensity | None | None | **Conclusion:** Dual organ transplantation is a viable option in selected patients with favorable outcomes when managed appropriately. This case series from the UHC Zagreb highlights the importance of individualized care and follow-up to optimize survival and graft function. Further studies are needed to standardize protocols for these complex procedures.

Iva Zec, Tereza Knaflec, Nikolina Mijač Mikačić, Martina Roginić, Siniša Roginić

**Introduction**: Atrial septal defects (ASDs) represent the most common congenital heart defect diagnosed in adulthood. There are several types of ASD and the most common one is ostium secundum defect type (80%). The heterogeneity in anatomy and the progression of complications over time, including arrhythmias, thromboembolism, right heart failure, and pulmonary arterial hypertension, pose significant challenges to finding optimal diagnostic and treatment solutions. (1) **Case report**: 70-year-old woman was hospitalized due to acute heart failure presumably precipitated with new-onset atrial fibrillation (AF). Transthoracic echocardiography found right ventricular volume overload (right ventricular dilatation resulting in tricuspid annular dilatation and moderate tricuspid regurgitation) with also dilatated both atrium (more right than left) and abnormal motion of the interventricular septum (towards the left atrium). There was also a high probability of pulmonary hypertension. All of these features initially raised suspicion of pulmonary embolism, later ruled out by CT angiography. Afterwards, transesophageal echocardiography (TEE) was performed to exclude left atrium thrombus. In the end, a successful cardioversion was performed and she was then discharged home with a prescription for optimal medical therapy. On hospital readmission in three months, control TTE was made, but now we detected an ASD (16-20mm) with L-D shunt (Qp/Qs 2,5:1) later confirmed with TEE. She was then scheduled to undergo coronarography and right heart catheterization. **Conclusion**: This case illustrates the importance of a systematic protocol for transthoracic and transesophageal echocardiography rather than a targeted approach. Another important message is not to jump to conclusion that heart failure is caused by an obvious pathology (in this case atrial fibrillation), but to think about congenital heart defect, even in older patients.

Petra Vitlov, Mario Udovičić, Hrvoje Falak, Vanja Ivanović Mihajlović, Danijela Grizelj, Antonio Bulum, Diana Rudan, Ivan Pećin, Šime Manola

**Introduction:** Anderson-Fabry disease (AFD) is a rare X-linked lysosomal storage disorder caused by mutations in galactosidase A gene encoding for the enzyme alpha-galactosidase A, resulting in the progressive accumulation of glycosphingolipids in various tissues. The heterogeneous nature of symptoms, along with its rarity, poses several challenges in diagnosing and managing AFD. Cardiac involvement frequently occurs in AFD patients, manifesting as left ventricular hypertrophy, conduction system impairment, and valvular abnormalities. (1-3) Aim: To raise awareness and increase the role of cardiologists in the early detection of Anderson-Fabry disease, to initiate early treatment and prevent the progression of this, still underdiagnosed, disease. **Patients and Methods:** Two patients from the same family have been diagnosed with AFD, while the rest of the family is still undergoing evaluation. After extensive evaluation, AFD was confirmed in multiple organ systems in both patients, with predominant involvement of the heart. The diagnostic workup of AFD should be based on a stepwise approach, including extracardiac and cardiac “red flags”, to recognize AFD as early as possible. AFD-associated cardiomyopathy can be potentially reversible or stabilized after a specific treatment. Therefore, early and timely detection of cardiac “red flags” is important. Furthermore, it is important to highlight the collaboration with leading centres that have more experience in creating a team that deals with the treatment and monitoring of such patients. Through our single-centre experience, we have implemented a structured approach to improving the diagnosis and follow-up of AFD patients, an approach that includes medical staff education, systematic screening, multidisciplinary team approach with personalized treatment and follow-up plans. **Conclusion:** Raising awareness of this rare disease is important because, due to its non- specific symptoms, it continues to go underdiagnosed. Early detection can lead to earlier treatment, improvement of patients’ quality of life and prevention of fatal complications.

Mario Udovičić, Ana Livun, Tomo Svaguša, Željko Sutlić, Danijela Grizelj, Vanja Ivanović Mihajlović, Hrvoje Falak, Petra Vitlov, Marko Lucijanić, Šime Manola

**Introduction:** Cardiomyopathies represent an important cause of heart failure and genetic testing for cardiomyopathies has become an established care pathway in contemporary cardiology practice (1), as it is valuable for risk stratification, treatment decisions, and family screening. Since 2020 we have established in Dubrava University Hospital a genetic testing program for cardiomyopathies using next-generation sequencing. **Patients and Methods:** We are reporting on the results of genetic testing performed on patients with cardiomyopathies as well challenges and the future direction of the program. From June 2020 to June 2024 selected patients were subjected to genetic testing. We used standard Illumina TruSight Cardio Sequincing Kit, a panel covering 174 genes most associated with inherited cardiac conditions. Results were uploaded and analyzed using Variant Interpreter Illumina, cloud-based interpretation and reporting platform for genomic data. **Results:** 77 patients underwent genetic testing in UHD (58 males, 40.4±14.4 years). Of those patients, 8 had previously undergone heart transplantation, and one analysis was postmortem. According to the phenotype, 39 patients were classified as having dilated cardiomyopathy, 31 had hypertrophic cardiomyopathy, 6 arrhythmogenic cardiomyopathy and 1 restrictive. Pathogenic or likely pathogenic mutation was identified in 40 patients. **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). For a successful genetic testing program, a multidisciplinary team and close collaboration of different specialties are necessary, as well as a good patient selection. All this accompanied by a close follow up, genetic counseling and family screening enables a complete program of genetic monitoring.

Irzal Hadžibegović, Ivana Jurin, Tomislav Šipić, Marin Pavlov, Aleksandar Blivajs, Nikola Pavlović, Ante Lisičić, Mario Udovičić, Tomislav Čikara, Miroslav Raguž, Šime Manola

**Introduction**: Treatment of epicardial coronary artery stenosis in chronic and acute coronary syndromes has been constantly changing and developing. Currently, the concepts of „leaving nothing behind“ and doing lumen enlargement without permanent scaffolding irrespective of vessel diameter seem feasible, but the contemporary data are conflicting. (1) We present single center experience in percutaneous coronary intervention (PCI) techniques in acute and chronic coronary syndromes in regard to lumen enlargement and scaffolding. **Patients and Methods**: We analyzed PCI techniques regarding techniques of lumen enlargement and scaffolding in 1577 patients treated between September 2022 and September 2024 and followed-up in a single center PCI registry. **Results:** There were 843 (53%) patients who received PCI in acute coronary syndromes (ACS), and 734 (47%) patients with PCI in chronic coronary syndromes (CCS). Among ACS patients, 731 (87%) patients received drug eluting stents (DES), 104 (12%) patients were treated with drug coated balloon (DCB) dilatation only, whereas 8 patients (1%) received coronary bioadaptors. There were no differences in cardiovascular mortality or reinfarction within 30 days among different PCI strategies. There were more bleeding events during follow-up (5.6% vs 1.8%) among patients treated with DES in comparison to DCB. Among CCS patients, 468 (64%) patients received DES, 263 (35.5%) patients were treated with DCB dilatation only, whereas 3 (0.5%) patients received coronary bioadaptors, and only 1 patient received bioresorbable vascular scaffolds (BRS). There were no differences in cardiovascular mortality or target lesion failure within 30 days among PCI strategies. Posterolateral part of coronary circulation, bifurcations, late stent failures and distal segment involvement were predictors of DCB only use in both ACS and CCS. **Conclusion**: DCB only PCI is significantly more represented among patients with CCS in comparison to ACS. In CCS, every third patient received a DCB only intervention. DCB only PCI had comparable short-term results and similar predictors of use in both ACS and CCS. Further studies on routine use of modern stentless PCI principles in both ACS and CCS are needed to evaluate its value as standard PCI techniques.

Nenad Lakušić, Ivana Sopek Merkaš, Tina Grgasović

**Introduction**: ST-T segment changes are frequently observed in clinical practice and reflect alterations in ventricular repolarization, ranging from physiological and benign to nonspecific or specific indicators of serious cardiac conditions. The most clinically relevant ST-T segment changes are those linked to acute and chronic coronary syndromes, pericarditis, hypertrophic cardiomyopathy, among others (1). It is crucial to correlate ECG changes with clinical symptoms and laboratory findings (such as high-sensitivity troponin, C-reactive protein, electrolytes), and use all available data to formulate conclusions, establish a diagnosis, and develop a treatment plan. **Case report**: We present the case of an asymptomatic middle-aged male with an unremarkable medical history and no significant comorbidities, in whom extensive “pathological” ST-T segment abnormalities were identified during a routine examination (**Figure 1**). A comprehensive stepwise diagnostic evaluation, including laboratory tests, echocardiography, exercise stress testing, multislice computed tomography (MSCT) coronary angiography, and cardiac magnetic resonance imaging (MRI), revealed no underlying pathological correlates for the observed ECG ST-T changes (2). During a nearly two-year follow-up, the patient remained asymptomatic, with preserved exercise tolerance, including moderate-intensity recreational sports, and persistent “fixed” ECG abnormalities. FIGURE 1. Electrocardiographic ST segment and T wave changes. **Conclusion:** A review of the available literature1 did not reveal any condition or disease that could account for the observed ST-T segment changes in the patient described. Given this finding, we conclude the summary with the intriguing question: “What is the correct diagnosis?”

Martina God, Mario Udovičić, Petra Vitlov, Vanja Ivanović Mihajlović, Danijela Grizelj, Ivana Jurin, Igor Rudež, Antonio Bulum, Irzal Hadžibegović, Šime Manola, Hrvoje Falak

**Introduction**: Bicuspid aortic valve (BAV) is the most common congenital heart defect (CHD) with a prevalence of 1–2%. The prevalence of aortic coarctation (CoA) in BAV patients is between 22-36%. CoA localizes beyond the origin of left subclavian artery or distal to the insertion of ligamentum arteriosum. The presence of CoA increases afterload and wall stress on left ventricle (LV) causing hypertrophy and dysfunction. Survival of patients with CoA greater than 65 years is rare. BAV and CoA are associated with aortic stenosis (AS) and mitral stenosis (MS) and coronary artery anomaly (CAA) like abnormal origin, course or calibre. Diagnosis is made by echocardiography, magnetic resonance imaging or computed tomography (CT) aortography. Current treatment of CoA includes endovascular or surgical repair and replacement of BAV. (1, 2) **Case report**: 60-year-old women presented with chest pain and dyspnea on exertion. Examination showed arterial hypertension known since pregnancy, systolic murmur over precordium and interscapular region. Echocardiography showed preserved ejection fraction of LV with concentric hypertrophy, BAV with parameters of severe AS (Vmax of 4,41 m/s, AVA 0,6 cm2) without dilatation of ascending aorta and mild MS. Coronary angiography showed no stenosis of left anterior descending artery but nonvisible origin of right coronary artery (RCA) and circumflex artery (LCX). CT coronary angiogram revealed origin of RCA arising LCX from anterior wall of ascending aorta without stenosis and bilateral hypertrophy of intercostal and internal mammary arteries. CT aortography was performed and showed focal CoA one centimeter distal to left subclavian artery with peak gradient of 33 mmHg seen by echocardiography suprasternal view. The treatment plan included surgical left subclavian-aortic bypass grafting and bioprosthetic aortic valve replacement in separate operations. **Conclusion**: Diagnosis of CHD may be overlooked even until adult age and may be isolated or in conjunction with other anomalies. Some defects are diagnosed after the onset of complications or as casual findings during medical evaluation for other reasons. Presence of additional anomalies should be carefully investigated with multimodality imaging as it may have potential implications during corrective interventions.

Petra Jambrović Posavec, Lana Požgaj, Tina Novak, Rebeka Kerovec, Martina Juras, Nataša Matoš

Effective communication in healthcare can improve the patient experience, encourage collaboration, and contribute to better health outcomes. (1) Nurses play a leading role in this, as they have direct interaction with patients. The connection between communication and quality healthcare is evident in-patient satisfaction with the care provided, both physical and emotional. (2) The development of communication skills - both verbal and non-verbal- as well as the holistic adaption of the individual, is essential for providing quality nursing care. Communication is one of the key elements in nursing, encompassing all areas of activity such as therapy, education, rehabilitation, prevention and health promotion. Nurses must create positive relationship with patients to effectively educate them about their health conditions and the course of treatment. This ensures that patients follow the given instructions, fully understand their care plans, and can identify potential issues early. They also need to communicate with the patient’s family members, and everyone involved in the patients care while navigating stressful situations, explaining complex medical concepts in simple terms, and offering emotional support while maintaining professional boundaries. Effective communication with patients and their families engages them in their own healthcare, helping patients recover in the shortest possible time. Nurses need to master verbal, non-verbal, and written communication to provide compassionate care, which reduces the chances of errors and ensures patients safety. It’s all about empathy, clarity and consistency.

Matijana Jurišić, Miro Jakovljević

Psychocardiology is a multidisciplinary field that connects psychology and cardiology with the goal of providing comprehensive care to patients with cardiovascular diseases. Psychological factors, such as stress, anxiety, and depression, often have a significant impact on the development and outcome of cardiovascular conditions. (1) Patients with chronic heart diseases frequently suffer from depression, while prolonged stress is linked to high blood pressure and an increased risk of heart attacks. (1) These connections emphasize the importance of psychological health in cardiac treatment. Empathy and resilience are key factors in the care of patients with cardiovascular diseases, especially within the field of psychocardiology, which examines the interaction between psychological and cardiac conditions. These concepts contribute to the understanding and approach to patients not only from a physical but also from an emotional aspect, enabling comprehensive health care. Empathy refers to the ability to understand and share the emotions of others, and in the context of caring for heart patients, it helps create a connection between medical staff and patients. (2) Through an empathetic approach, patients feel understood, accepted, and emotionally supported, reducing their psychological stress and contributing to recovery. In medical practice, when healthcare workers show empathy toward patients, communication improves, which not only reduces patients’ fear and anxiety but also positively influences their motivation to follow therapeutic plans. (3) Empathy also plays an important role in the decision-making process, as better communication enables patients to become more actively involved in their own treatment and recovery. Resilience, as the ability to adapt to stress, trauma, and challenges, is crucial in the context of chronic diseases such as heart conditions. Patients with heart diseases often face long-term and serious health challenges, and resilience allows them to better cope with the physical and emotional difficulties that accompany their illness. Empowered patients, who develop the ability to cope with challenges, have a better prognosis in terms of long-term mental and physical health.

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

**Introduction:** Previous studies have shown that glucagon-like peptide-1 receptor agonists (GLP-1 Ras) and sodium glucose cotransporter-2 inhibitors (SGLT2i) improved survival in patient with type 2 diabetes mellitus (TD2) after acute myocardial infarction (AMI). GLP-1 RAs and SGLT2i act with different mechanisms, GLP-1 RA have been shown to reduce atherosclerosis-related events, while SGLT2i were demonstrated to reduce the risk of heart failure (HF) after AMI. (1) Aim: To evaluate the effect of GLP1 RAs and SGLT 2i combination therapy on major adverse cardiac events (MACE) after AMI. **Patients and Methods:** This prospective observational study was conducted in Dubrava University Hospital and included T2D patients hospitalized for AMI, followed for 12 months. Data on demographics, comorbidities, medications, and MACE, including death, recurrent AMI, stroke, target vessel revascularization, new-onset HF and atrial fibrillation (AF) were collected. Statistical analyses were performed using MedCalc software. **Results:** Of 2757 AIM patients, 663 T2D patients were included (68.5% male), with a median age of 67 years (IQR 59-75). A total of 157 patients (23.7%) were prescribed the combination of GLP-1 RAs and SGLT2i at discharge. All patients in our study used semaglutide as their GLP-1 RAs agent. The SGLT2i/GLP-1 RAs group had a higher baseline BMI (32.3 kg/m2 vs. 28.6 kg/m2, p2 vs. 28.5 kg/m2, p<0.0001). However, SGLT2i/GLP-1 RAs group achieved higher weight loss (median BMI decrease of 1.75 vs. 0.075, p<0.0001) and had lower incidence of MACE (20.5% vs. 23.7%, p=0.0004) and AF (24.2% vs 24.4%, p=0.012). Number needed to treat for prevention of MACE was 6. **Conclusion:** In this prospective observational study, SGLT2i/GLP-1 RAs combination therapy was associated with a lower incidence of MACE. What we consider a novel finding is that this combination reduced the incidence of new-onset AF after myocardial infarction probably due to better weight reduction as well as GLP-1 RAs positive effect on reducing atrial fibrosis.

Marko Šustić, Berislav Lisnić, Eleni Dapergola, DiyaaElDin Ashour, Lisa Popiolkowski, Ilija Brizic, Georg Gasteiger, Gustavo Ramos Campos, Stipan Jonjić

**Introduction**: In recent decades, physiological and pathological processes in the heart have been increasingly looked upon through the lens of the immune system, giving birth to the new field of cardioimmunology (1). Several lines of research have indicated that latent cytomegalovirus infection (CMV) can have major impact on the functioning of the immune system of mammals. Human data have shown that cytomegalovirus serostatus was a single largest non-genetic determinant of an immune phenotype of an individual (2). Importantly, strong epidemiological signal exists associating CMV seropositivity with increased incidence of cardiovascular mortality (3), yet the causal relationship has hitherto not been established. **Methods**: To investigate the long-term effects of latent CMV infection on cardiac tissue, we used murine cytomegalovirus (MCMV) as a model. C57BL/6J mice were infected intravenously with MCMV or left uninfected. Immune cell composition within the heart was determined by flow cytometry and bulk RNA sequencing of cardiac tissue was performed during acute and latent viral infection. Myocardial infarction was induced using the standard surgical LAD ligation procedure. Left ventricular function was assessed with echocardiography. **Results**: During acute infection there was a large increase in the number of T cells in the hearts of infected mice which remained substantially elevated during the latent infection. Majority of them were MCMV specific and, importantly, some of them expressed the markers of tissue residency. Bulk RNA sequencing of cardiac tissue from infected animals revealed 500 deferentially expressed genes with considerable increase in transcripts associated with interferon signaling and T cell activation. Furthermore, transcripts associated with oxidative phosphorylation and ATP synthesis were extensively down regulated in latently infected mice. Crucially, mice latently infected with CMV showed poorer left ventricular function after experimental myocardial infarction. **Conclusion**: Latent viral infection with murine cytomegalovirus causes long term alterations in the composition and phenotype of the immune cells within the heart, which is associated with worst cardiac function after experimental myocardial infarction.

Dijana Bešić, Mario Špoljarić, Ivan Zeljković, Ante Lisičić, Jelena Kursar, Mario Udovičić, Diana Rudan, Ana Šerman, Nikola Pavlović, Andrej Novak, Šime Manola, Ivana Jurin

**Introduction**: Beta-blockers (BBs) have proven their efficacy in reducing mortality in patients with heart failure with reduced ejection fraction (HFrEF). However, the effects in patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection faction (HFmrEF) are less clear and consistent data are lacking. (1, 2) The aim of this study was to examine the association of BB therapy with all-cause mortality in different groups of HF patients. **Patients and Methods**: We investigated BB use in real-life cohort of patients with heart failure (HF) diagnosis included in the registry in the period between June 2021 and February 2024. We compared all-cause mortality between patients who did not receive any BB therapy and patients receiving BB therapy at three different doses, defined as maximal, medium (≥50% of maximal dose) and low (≥25% of maximal dose). For statistical analysis we used chi-square and Fisher’s exact test and the p value of 0.05 was defined as statistically significant. **Results**: This registry-based study included 1009 patients with median age of 70 years (IQR 62-76), and median follow-up period of 365 days (IQR 184-367). Total of 247 patients had HFpEF (24.5%), 146 patients had HFmrEF (14.5%) and 616 patients had HFrEF (61.1%). In HFrEF group patients with BB therapy in any dose had significantly lower all-cause mortality compared to the patients without BB therapy (mortality rate 11 vs. 32%, p=.02). All-cause mortality rate between patients receiving BB therapy at any dose and patients without BB therapy in both HFmrEF and HFpEF group did not differ. There was no statistically significant difference in dose-related outcomes for three different BB doses in overall HF cohort, nor in each HF group separately. BB use in HFrEF patients with history of AF was associated with significantly lower all-cause mortality (7 vs. 47%, p<.00001), but these results did not translate to HFpEF nor HFmrEF patients with history of AF. **Conclusion**: Our findings indicate that BB do not improve survival in patients with HFmrEF and HFpEF, independently of history of AF. Real-life studies and well-designed registries with larger cohorts of patients and longer follow-up period are needed to investigate the impact of BB use and dosing on survival in different groups of HF patients.

Lucija Klobučar, Ivica Bošnjak, Kristina Selthofer-Relatić

**Introduction:** Lipoprotein (a) [Lp(a)] is a particle consisting of lipids and proteins, structured similarly to low-density lipoprotein (LDL), with the addition of apolipoprotein (a). Lp(a) promotes atherogenesis – it increases release of proinflammatory cytokines and infiltration of monocytes to the arterial wall, and decreases stability of atherosclerotic plaques. Its levels are genetically determined and relatively stable during lifetime. Levels >125 nmol/L are considered to be elevated. It is recommended to measure Lp(a) levels in individuals with premature cardiovascular disease (CVD), reccurent CVD despite optimal therapy, SCORE risk ≥5% or aortic valve stenosis. (1-3) Aim: To analyze Lp(a) serum levels in patients with acute coronary syndrome (ACS) under the age of 60. **Patients and Methods**: Patients hospitalized due to ACS at the University Hospital Center Osijek, under the age of 60, were enrolled into the study. **Results:** Lp(a) levels were measured in 21 patients (14 male, 7 female). Median Lp(a) levels for all patients were 36 nmol/L (3–560 nmol/L) with no significant difference between male and female (p=0.551). Lp(a) levels did not correlate with widely known risk or protective factors for CVD: age (p=0.172); body weight (p=0.437); body mass index (p=0.204); serum levels of total cholesterol (p=0.312), LDL cholesterol (p=0.541), HDL cholesterol (p=0.942), triglycerides (p=0.074); and did not differ depending on prior statin treatment. Nineteen patients were treated with percutaneous coronary intervention, 1 was appointed to surgical revascularization, and 1 did not require invasive treatment. The number of surgically treated patients was low and did not enable statistical analysis, but it should be emphasized that Lp(a) levels of the patient treated surgically were 206 nmol/L, compared to the median Lp(a) levels of 36 nmol/L for all enrolled patients. **Conclusion:** Lp(a) represents additional risk factor for CVD and its levels do not correlate with traditionally known risk and protective factors for CVD. Although specific Lp(a)-lowering therapies are not yet available in everyday clinical practice, lipoprotein apheresis may be considered in patients with very high Lp(a) levels and progressive atherosclerotic disease despite optimal control of all other modifiable risk factors.

Monika Tuzla, Ivica Benko, Marija Peremin, Tomislav Glavak

Over the past decade, the role of nurses in Holter ECG analysis has been under-explored in the scientific literature. While the nursing profession’s responsibilities in Holter ECG monitoring, particularly in terms of patient care, electrode placement, and data collection, are well documented, there is limited research on their involvement in the technical analysis of Holter ECG data. Studies in this area mainly focus on the logistical and patient-care aspects of Holter monitoring. Nurses are instrumental in setting up the Holter device, ensuring accurate electrode placement, educating patients on maintaining diaries, and managing potential complications like skin irritation or electrode displacement during monitoring. (1, 2) Additionally, they play a significant role in identifying arrhythmias by correlating patients’ symptoms with recorded cardiac events. (2) However, despite their vital role in managing and conducting these tests, little literature delves into their involvement in interpreting the data itself. Despite the vast amount of research—over 16000 papers published on Holter ECG between 2012 and 2021—very few address the specific role of nurses in analyzing the data itself. Most of the focus has been on technical aspects, and less than 1% of the papers deal with topics like the nurse’s involvement in the interpretation of Holter ECG readings. (3) This highlights a gap in the available research concerning the more analytical and diagnostic responsibilities nurses could potentially take on with proper training. Recent advancements in Holter ECG technology present opportunities for more comprehensive patient assessments. These developments could potentially expand the role of nurses beyond patient care to data analysis, given the growing complexity of Holter ECG outputs. (3) In conclusion, while the nursing role in Holter ECG setup and patient management is well defined, there is a notable gap in literature addressing their involvement in data interpretation. Despite the abundance of general Holter ECG research, less than 1% of these publications focus on nursing analysis. Future research could explore training opportunities for nurses to engage in the analytical side of Holter monitoring, enhancing interdisciplinary collaboration in cardiovascular diagnostics.

Kristina Marić, Marica Komosar-Cvetković, Irena Kužet-Mioković, Samanta Vuković

**Introduction**: Heart failure is a severe and chronic condition that requires active management and cooperation of the patient, family and healthcare professionals. (1, 2) **Case report:** We describe an 81-year-old patient who was admitted to Department of Cardiology in February 2023, September 2023, February 2024, March 2024, May 2024 and July 2024 with a diagnosis of acute heart failure. Other diagnoses include permanent atrial fibrillation, severe mitral and tricuspid insufficiency, and type II diabetes. Considering the history of frequent hospitalizations, caused by non-compliance with prescribed therapy, improper diet and physical inactivity, we conclude that she needs additional education and support from the family that will accompany her. Her low level of interest in her health condition further aggravated the situation. Family support until then was minimal, because family members did not fully understand the seriousness of the condition and their role in helping the patient. During hospitalization in July 2024. all risk factors for frequent exacerbations of heart failure and poorly regulated diabetes were identified. We conducted daily education of the patient and her daughter. In addition to the nurses, a nutritionist, physiotherapist, and cardiologist participated. The workshops and lectures explained in detail, adjusted to their level of health literacy, the symptoms of the disease, signs of deterioration, the importance of adherence and proper taking of the prescribed therapy, ways of monitoring symptoms and self-management, then changing the way of life and proper nutrition. We taught her light daily exercises adapted to her age and the condition of her locomotor system, which she can do herself at home. Psychologists have emphasized the importance of providing emotional and psychological support. The role of the family was crucial for improving her health and quality of life. The last hospitalization was in July 2024. After that period, every 15 days, a nurse consults with the patient over the phone to check the health status and support, as a standard measure of permanent independent secondary prevention of cardiovascular patients. **Conclusion**: This case report highlights how the education of the patient with heart failure and the involvement of the family, where it has become a more active participant in the patient’s care, play a key role in improving the quality of their life, reducing the number of hospitalizations and optimizing treatment outcomes and long-term health maintenance of the patient with heart failure. The paper emphasizes the importance of continuous education and support for patients with heart failure to optimize treatment, reduce the number of hospitalizations and improve self-management of the disease.

Ivan Rosović

Myocardial bridging (MB) is one of the most common congenital coronary anomaly. (1) In this lecture, four angiographic findings of my patients are presented. Each with LAD bridging and anginal complaints. Previous studies show that this phenomenon could be responsible for the development of myocardial ischemia. The part of the vessel proximal to the bridging is subject to atherosclerotic changes, while the tunneled part is usually spared. Hemodynamic forces could be the reason for such an atherosclerotic distribution of plaques. This is supported by studies on a cellular level. It was proven by histological analysis that foam cells and modified smooth muscle cells are missing in the tunneled part, while they are normally found in the remaining parts of the vessel. And the structure of the endothelium itself speaks in favor of different pressure loads inside the vessel. In the proximal part the endothelium is flat and polymorph, indicating low shear stress, whereas in the tunneled segment, the endothelium has a helical, spindle-shaped orientation which indicates the existence of laminar flow and presence of high shear stress. Low shear stress may trigger the release of endothelial vasoactive agents such as endothelin-1 (ET-1) which is known to participate in the pathogenesis of atherosclerosis at all stages. Although it doesn’t seem like it, myocardial bridging is not just a systolic phenomenon but a systolic-diastolic one. Intravascular ultrasonographic and doppler measurements showed that during diastole in these vessel segments there is a form of delayed relaxation with slowed flows especially during episodes of tachycardia. Today fractional flow reserve is the “gold standard” in assessing the hemodynamic significance of fixed lesions but it can fail to assess the importance of “dynamic” stenoses. For the non-invasive functional diagnostics (CMRI, SPECT, PET) there are not enough studies or clear criteria. Pharmacotherapy is the strategy of first choice, beta blockers in the first place and non-dihydropyridine calcium channel blockers in the second place. In case of unsuccessful drug therapy revascularization is the options. However PCI carries a high degree of complications, CABG is the procedure of choice in case of complex anatomy, while myotomy is the procedure of choice in the pediatric population.

Mario Špoljarić, Aleksandar Blivajs, Sanda Sokol Tomić, Hrvoje Falak, Šime Manola, Ivan Skorić, Ivana Jurin

**Introduction**: The triglyceride-glucose index (TyG) has been proposed as a surrogate marker of insulin resistance (IR) in heart failure (HF). Recent studies have shown that higher TyG index was directly related to impaired left ventricular structure and function and to an increased risk of HF. (1) The aim of this study was to investigate the prognostic value of TyG index in patients with heart failure. **Patients and Methods**: We examined the real-live cohort of patients with heart failure diagnosis from the registry of Dubrava University Hospital in the period between June 2021 and August 2023. The TyG index was calculated as ln [fasting triglyceride level (mg/dL) × fasting plasma glucose level (mg/dL)/2]. The primary outcomes were all-cause mortality and hospitalization during follow-up period. We used chi-square test and logistic regression to investigate the associations of the TyG index with primary endpoints and the p value of 0.05 was defined as statistically significant. **Results**: This registry-based study included 916 patients with a median age of 69 years (IQR 62-76), and a median follow-up period was 365 days (IQR 281-386). The patients were divided into two groups using the median of the patients’ TyG index values (10.39). A total of 97 (9.7%) all cause deaths occurred. Although the mortality rate was 32% higher in the group with TyG index above 10.39, the difference in mortality between the two groups was not statistically significant (chi-square 3.19, p=0.07), even with after the adjustment for confounding factors and performed logistical regression analysis (p=0.09). Similarly, the hospitalization rate (19% and 17%) between two groups was not statistically significant (p=0.39). **Conclusion**: TyG index is readily available marker that has been associated with atherosclerotic cardiovascular diseases and incidence of HF in general population. While the difference in mortality between the two groups was not statistically significant at the conventional threshold, there is a trend toward increased mortality in a group of patients with the higher TyG index. These results require further investigation of the prognostic value of TyG index in heart failure with larger cohort of patients and longer follow-up period.

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

Calcifying aortic stenosis is the most common heart valve disease and important cause of cardiovascular morbidity and mortality. The gold standard for treatment of aortic stenosis is surgical replacement of the aortic valve through sternotomy. A minimally invasive approach through an upper ministernotomy, results in a reduction of perioperative complications, especially in obese patients, including less postoperative drainage, a lower frequency of postoperative atrial fibrillation, reduces the number of days patient stays in the intensive care unit, faster recovery, easier verticalization, and ultimately faster discharge from the hospital. Upper ministernotomy can be performed through the 3rd or 4th intercostal space, and the skin incision, in our institution, measures 6-10 cm on average. (**Figure 1**). In the early postoperative course, with the application of intercostal block due to minor pain, it was possible to quickly separate the patient from the machine for mechanical ventilation (extubation) and place the patient in a semi-sitting position. On the first postoperative day, if the drainage is below 200 mL, the patients are transferred to the Department of Cardiac Surgery and verticalized on the same day. Due to the smaller wound, the possibility of developing infection is reduced, especially in the lower part (xiphoid) where infections occur most often. In our institution, aortic valve replacement through ministernotomy is amounted to 14% of the total number of classical surgical aortic valve replacement over the last 5 years (**Figure 2**). The goal of minimally invasive surgery is to preserve the integrity of the sternum, whitch leads to a reduction of postoperative complications. But we must also mention the shortcomings. Reduced visualization of the surgical field and the valve, may result in the implantation of a suboptimal prosthesis size and increased rate of paravalvular regurgitation. (1, 2) FIGURE 1. Upper ministernotomy. FIGURE 2. Comparison of aortic valve replacements and minimally invasive aortic valve replacement with patient percentage by year. AVR = aortic valve replacements; MINI AVR = minimally invasive aortic valve replacement The minimally invasive approach represents a significant benefit for the postoperative recovery of the patient and therefore it should become the standard for aortic valve operations.

Sara Varga, Ivana Jurin, Fran Šaler, Vanja Ivanović Mihajlović, Ana Jordan, Anđela Jurišić, Hrvoje Falak, Petra Vitlov, Danijela Grizelj, Nikša Bušić, Šime Manola, Ivan Zeljković

**Introduction**: Transcatheter aortic valve intervention (TAVI) has been accepted as an alternative strategy for treating severe aortic valve stenosis (AS) (1). Congestion can worsen outcomes after TAVI and covert congestion can be indirectly assessed by estimated plasma volume status (ePVS) (2). Aim: to assess is high ePVS associated with higher all-cause mortality and major adverse cardiac events (MACE) in short-term (30 days) and long-term (12 months) follow up. **Patients and Methods**: We included patients treated in Dubrava University Hospital from December 2010 to September 2023, who underwent TAVI due to severe AS. We used Strauss-derived Duarte formula (EPVs= (100-hematocrit (%)) ÷ hemoglobin (g/L)) to estimate PVS values at the baseline (iePVS) and two days after TAVI procedure (pePVS). MACE included stroke, bleeding, worsening heart failure (HF) and acute coronary syndrome (ACS). **Results**: This study included 366 patients, median age 80 years, 48% female. Median iePVS was 5.598 (IQR 5.173-6.251) and median pePVS was 6.654 (IQR 6.227-7.375). Values of ePVS higher than median were considered as high. Patients with high iePVS had no significant difference in all-cause mortality or MACE during the short or long term follow up compared to those with low iePVS (p=0.960 for short-term and p=0.357 for long-term all-cause mortality, p=0.414 for short-term and p=0.414 for long-term MACE). However, patients with high pePVS had statistically significant higher all-cause mortality rate compared to patients with low pePVS (p=0.030) in long term follow up. Short term survival was similar in both groups (p=0.373). There was no significant difference in MACE in short (p=0.981) or long-term (p=0.296) follow up between the groups. **Conclusion:** Our results suggest that initial ePVS did not prove to be prognostic for the adverse short- or long-term outcomes of TAVI patients. Postprocedural ePVS predicted higher all-cause mortality in long-term follow up.

Petra Radić, Ivo Darko Gabrić, Krešimir Kordić, Maja Hrabak-Paar, Diana Delić-Brkljačić, Matias Trbušić

**Introduction:** Isolated cardiac sarcoidosis (iCS) is an infiltrative cardiomyopathy that is the result of granulomatous inflammation that manifests predominantly in the myocardium. The annual incidence of sarcoidosis varies between 1 and 15 per 100,000 depending on the region (1). The prevalence of iCS among patients with systemic sarcoidosis varies widely (23–54%) because of differences in the definitions used (2). Establishing a diagnosis of iCS is extremely difficult, since there is no unique echocardiographic, radiological or laboratory test to confirm the diagnosis. iCS may present with symptoms of heart failure, sudden cardiac death, ventricular arrhythmia, myocardial infarction or atrioventricular block (3). **Case report:** 60-year-old female patient was recently hospitalized in our institution who presented with symptoms of heart failure without a history of previous cardiac diseases. Echocardiography showed a dilated left ventricle with hypokinesia of the basal segments of the septum, posterior, inferior and lateral walls with a reduced ejection fraction (EF) of 30%. Obstructive coronary artery disease was ruled out with coronary angiography. Cardiac magnetic resonance imaging (CMRI) was performed, which suspected the diagnosis of iCS. Positron emission tomography (PET) computed tomography (CT) showed increased metabolism of glucose analogues in the greater part of the left ventricle, which is consistent with iCS. Corticosteroid therapy was also introduced into the therapy in addition to the optimal medical therapy of heart failure. As part of the primary prevention of sudden cardiac death, a two-chamber ICD device was implanted. **Conclusion:** Patients with iCS have poor prognosis. If left untreated, iCS leads to progressive failure of the left ventricle with frequent ventricular arrhythmias and sudden cardiac death. iCS is a frequently misdiagnosed due its rarity and high index of suspicion needed to make the diagnosis. It should be noted that this is the only diagnosed case of iCS in the last 5 years in our institution, which, considering the incidence, leads us to the question of an adequate diagnosis confirmation. It is of utmost importance to increase the use of non-invasive diagnostic methods such as PET CT scan and CMRI to detect all patients with iCS.

Marin Pavlov, Tomislava Bodrožić Džakić Poljak, Aleksandar Blivajs, Šime Manola

**Goal**: To evaluate data on patients treated with aspiration embolectomy (AE) for acute pulmonary embolism (PE) in Dubrava University Hospital from March 2022 until September 2024. **Patients and Methods**: All patients listed in a prospective AE registry were eligible for the analysis. Patients with biomarker positive acute PE and signs of right ventricle strain (intermediate-high risk PE (1)) were admitted in Intensive Care Unit and observed for 24-48 h. Patients with high-risk PE and contraindication for lytic therapy were also considered. Unfractionated heparin was the treatment of choice. Clinical and echocardiographic controls ensued. Patients that remained symptomatic (hypoxia, tachycardia, dyspnea or with deterioration and no other contributing condition) were discussed among Pulmonary Embolism Response Team (PERT) for interventional treatment. Intervention was performed in catheterization laboratory by experienced interventional cardiologists. **Results:** Total of 37 patients in 38 procedures were treated with aspiration embolectomy (35.1% females, aged 68 (57-76)). In one case, in addition to PE, a thrombus in transit was an indication for the procedure. A total of 4 patients were treated due to high-risk PE. On one occasion Indigo Penumbra system was used, in other instances Inari Flowtriever was used. Malignancy was present in 8.3% of the patients, history of thromboembolism in 25.0%, concomitants deep vein thrombosis in 80.0%. Initial N-terminal pro B-type natriuretic peptide levels were 5011 (1560-7863) pg/mL and high sensitivity troponin I 545 (146-569) ng/L. Sheathless approach was used in 36.8% with two instances of access site thrombus strangulation requiring access site change. One patient (a thrombus in transit case) experienced cardiovascular collapse requiring resuscitation and mechanical circulatory support. All patients survived the procedure and initial periprocedural period. None of the intermediate-high risk patients died during follow-up. All of the high-risk PE patients died during follow-up, none due to PE. **Conclusion**: In highly selected PE patients, AE provides effective treatment for symptom relief, hemodynamic and oxygenation improvement. Learning curve for the procedure is acceptable, particularly within the teams accustomed to large bore interventions.

Valentina Sedinić, Ivana Tomašić

PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors represent a significant advance in the treatment of hyperlipidemia, especially in patients at high risk of cardiovascular events who do not achieve target lipid values with standard statin therapy. (1) Educating patients about the importance and correct application of this therapy is essential for achieving optimal results and improving their cooperation. (2) Our experience with educating patients about the use of PCSK9 inhibitors shows that thorough information is a key factor in increasing cooperation and success of therapy. For the therapy to be effective, patient cooperation is of crucial importance. Patients included in our education program underwent a detailed consultation, in which the role of PCSK9 inhibitors in reducing the risk of cardiovascular events was explained to them. A clear understanding of how the drug works significantly increases patients’ confidence in the therapy. The education included demonstrations of the correct administration of injections. After the education, most patients stated that they felt more confident and competent in self-administration of injections. This increased their adherence to therapy, which is in line with the findings of other studies that indicate that proper education reduces the possibility of application errors. Regular follow-up of patients through follow-up examinations and telephone consultations further improved cooperation. At first, some patients showed resistance to therapy due to fear of injections, side effects, and the great distance between their place of residence and the University Hospital Centre. Through talking and providing information about available options, such as the possibility of receiving the same therapy from a family medicine doctor, we were able to increase the acceptance of the therapy. Patients who received adequate education about PCSK9 inhibitors had significantly better compliance. Clear communication, individual approach and continuous support are key elements in maintaining successful therapy. To achieve the best results, education must be continuous and adapted to the needs of each patient.

Martina Žderić, Mirela Šarić, Petra Bukovski, Glorija Udiljak

Pulsed field ablation or irreversible electroporation is a newer method in the ablation treatment of cardiac arrhythmias. The first atrial fibrillation ablation procedure using pulsed electric fields at the Department of Arrhythmias, University Hospital Centre “Sestre milosrdnice”, was successfully performed in September 2023. By July 2024, a total of 74 patients successfully underwent pulsed electric field ablation. Of these, 59.46% had paroxysmal atrial fibrillation, while 40.54% had persistent atrial fibrillation. In 100% of patients, the desired acute outcome was achieved by isolating the entrances of all pulmonary veins. Follow-up showed atrial fibrillation recurrence in 13.5% of patients, comparable to data from the literature. (1) Patients from various age groups underwent the procedure, the average age of women is 59 years and of men 68 years. Regarding gender distribution, men predominate (74%), consistent with global trends, which can be explained by the fact that women are referred for ablation treatment later in life. (2) The procedure lasted an average of 48 minutes and 22 seconds. The overall complication rate was 10%, with most being vascular - hematoma or prolonged bleeding at the puncture site, which required only conservative treatment, such as prolonged compression (up to 12 hours). An A-V fistula requiring surgical treatment occurred in 1.3% patient. For the successful treatment of atrial fibrillation patients, timely detection is crucial, as early-stage treatment offers the highest success rate (up to 80%). Pulsed electric field ablation, as a new method, represents a significant step forward in the treatment of atrial fibrillation, which will improve the quality of patient care. In this paper, we presented the experiences at the University Hospital Center “Sestre milosrdnice” in applying this new treatment method, showing that our results are comparable to those from other electrophysiology centers. It is important to emphasize that role of nurse is essential. Together with doctor, she provides healthcare during hospitalization. (3) Our experiences with pulsed electric field ablation in the treatment of atrial fibrillation have been extremely positive. Due to the fact that this is a highly effective procedure with a low rate of procedural complications.

Refet Gojak, Edin Begić, Buena Aziri, Amer Iglica, Nejra Mlačo-Vražalić

**Introduction:** Cardiovascular disease (CVD) frequency is high in individuals with human immunodeficiency virus (HIV) infection receiving antiretroviral therapy, mainly because of lipodystrophy and endothelial dysfunction leading to immune activation and chronic low inflammation degree, which in turn promote atherosclerosis. The question arises whether the CD4/CD8 ratio can have an influence on the increase in cardiovascular risk in patients with HIV infection (1-3) Aim: To examine whether the CD4/CD8 ratio, as well as C-reactive protein (CRP), can be predictors in monitoring cardiovascular risk changes in HIV-positive patients during two years of combination antiretroviral therapy (cART). **Patiens and Methods:** The study was designed as a retrospective-prospective, cohort longitudinal and clinical study. The sample size was determined based on the following conditions: 1) alpha value=0.05, 2) study power (1-B)=0.8, and 3) effect size=0.3351 (average therapeutic effect of increasing CD4/CD8 ratio one year after cART administration). With the receiver operating characteristic (ROC curve), we showed whether CRP and the CD4/CD8 quotient (ratio) can be markers for CVD risk that was monitored in different periods, at baseline, and after 3, 6, 12, 18, 24 months. We checked the statistical significance of the regression model with the analysis of variance (ANOVA) test, and the value model (r2) presented as % variance. In HIV-infected patients, the values of CD4 and CD8, and CRP are preferred for cardiovascular risk assessment given the data-collection on adverse effects of anti-HIV drugs (D:A:D score). **Results:** A total of 76 HIV patients were included in the research, 67 (88.2%) men and 9 (11.8%) women. The average age of the subjects was 35.2+8.7 years. Before the start of cART, CD4/CD8 ratio, CRP, and risk for CVD were not significantly correlated (p>0.05). However, after 24 months of treatment, CRP was positively and strongly correlated with the risk for CVD (rho =0.747; p=0.0001) and was considered a marker of intermediate risk for CVD (p=0.0001; area under a curve (AUC) 0.882). The CD4/CD8 ratio was positively correlated with the risk for CVD (rho -0.409; p=0.0001) after 12 months of therapy and was considered a marker of low CVD risk after 24 months from the start of therapy (p=0.001; AUC -0.762). Finally, after 18 months of cART therapy, the CD4/CD8 ratio was negatively and moderately strongly correlated with both CRP and CVD risk (rho=-0.483 to rho=0.483; p<0.01), which was maintained even after 24 months. **Conclusion:** CD4/CD8 ratio and CRP have been shown to be significant predictors of CVD risk. CD4/CD8 ratio and CRP were negatively and moderately strongly correlated. The higher the CD4/CD8 ratio, the lower the CRP values and the lower the risk for CVD during 24 months of cART therapy.

Dijana Bešić, Ante Lisičić, Jelena Kursar, Aleksandar Blivajs, Hrvoje Falak, Petar Lišnjić, Diana Rudan, Šime Manola, Ivana Jurin

**Introduction**: Following cessation of anticoagulant medication, individuals with spontaneous index events reportedly have a greater incidence of recurrent venous tromboembolism (VTE). Numerous factors have been suggested to increase the risk of recurrence; identifying and targeting these traits could be helpful to prevent recurrence of VTE incidents. (1-3) The purpose of this study was to investigate the relationship between recurrence of VTE and particular risk factors, such as body mass index, hormone medication, and history of thrombophilia. **Patients and Methods**: Between May 2013 and September 2023, a real-world cohort of patients diagnosed with pulmonary embolisms (PE) were the subject of our analysis. The patients who had a history of a single VTE occurrence were compared to the patients who had recurrent VTEs, which were defined as two or more PE and/or deep vein thrombosis (DVT) incidents. For statistical analysis we employed chi-square test, and a p-value of 0.05 was considered statistically significant. **Results**: This registry-based study included 852 patients with a median age of 73 years (IQR 61-80) and a median follow-up period of 1732 days (IQR 460,25-2604,75). A total of 172 patients had recurrent VTE events (20%). All-cause mortality rates between the two groups of patients did not differ. History of thrombophilia was associated with a higher rate of recurrent VTE events (p =.000068). Patients who were overweight or obese (BMI greater than 25 kg/m2) were more likely to experience recurring VTE, though this outcome was only marginally significant (p =.04). Recurrence of VTE did not appear to be linked to hormonal therapy. **Conclusion**: Our research indicates that a higher body mass index and inherited thrombophilia are linked to recurrent episodes of venous thromboembolic events. In individuals without any other known predisponing factors, efforts to diagnose thrombophilia following an index VTE event and to encourage weight loss in overweight and obese patients may be crucial in preventing recurrent VTE episodes.

Tonći Batinić, Karlo Golubić, Nikola Kos, Mislav Vrsalović

**Introduction:** Approximately 10% of all cases of deep vein thrombosis occur in the upper extremities (UEDVT). There are two types of UEDVT, primary exertional thrombosis, caused by excessive and repetitive arm movements that are often triggered by great exertion (Paget-Schrötter disease), and secondary, usually associated with central venous catheters and malignancies. Compression ultrasound is the most used imaging initial test for the diagnosis of UEDVT. The initial treatment is anticoagulation. Although traditionally LMWH in a therapeutic dose is provided, followed by a vitamin K antagonist, studies have been conducted that have proven that direct oral anticoagulants (DOACs) are as safe and effective as LMWH and/or warfarin. (1, 2) The aim of the study was to identify patients with UEDVT in our population, find potential causes, monitor treatment and follow up of patients. **Patients and Methods:** During the period 2021-2024, a total of 261 people with deep vein thrombosis were hospitalized at the Department of Vascular Diseases, Clinic for Cardiovascular diseases, University Hospital Centre “Sestre milosrdnice”. **Results:** Out of the total number of hospitalized patients with DVT, there were 13 hospitalized patients with UEDVT (5%). Mean age was 43 (37-49) years and five (38%) patients were female. Two patients had provoked UEDVT of brachial veins because of intravenous cannula insertion and one patient had provoked UEDVT of brachial and axillary vein following humerus fracture surgery. The remaining 10 patients had a history of marked exertion of the affected arm (sport and professional activity, Paget-Schrötter disease). All patients were treated initially with LMWH, followed by DOACs for up to six months. **Conclusions:** In our study sample most patients with effort thrombosis were young male adults. All patients were treated with DOACs and had no recurrence of UEDVT nor bleeding in follow up period.

Duška Glavaš

**Introduction:** Heart failure (HF) is disease with high morbidity and mortality, despite advanced treatment. European Society of Cardiology (ESC), Heart Failure Association (HFA) and Croatian Heart Failure Society try to improve prognosis for HF patients and create projects. (1, 2) Aim of this paper is review of some recent projects to show directions of ESC, HFA and Croatian HF society plans to cure better HF patients. **Methods:** With the help of ESC institution, from expert groups to medical centers with logistics support and IT statistics teams, Croatian HF society develops quality projects. **Results:** We have a lot of initiatives that include Registries in which we have been participating since 2005. The Peptide for life study find out that utilization of natriuretic peptide increased in emergency department, leading to improved diagnosis and treatment. (3) The results of HFA ATLAS study has shown heterogeneity in HF disease burden, the resources available for its management and data quality across ESC members. The findings emphasize the need for a systematic approach to this problem. An ongoing initiative is Central-Eastern Europe Quality of Care Centers study. The objective of the research is to assess risk factors, clinical characteristics and quality of care for hospitalized HF patients and to assess adherence to the Guidelines. Recent, ICARe-HF project has been created by HFA and National Heart Failure Societies (NHFS). Accreditation process for ICARe-HF is developed to improve HF outcomes across Europe. ICARe-HF support excellence by recognizing quality care centers (QCC) who apply best practices, research and education, and enables raising standards in HF care facilities. ICARe-HF centers could be general, specialized and advanced. There are two phases in accreditation. Phase 1 is pre-accreditation part with identification of the centre’s category; phase 2 implies validation of performance and application of HFA Guidelines through data collected in the GRASP-HF Register. The aim of this Register is analysis of the application of ESC guidelines for diagnosis and treatment of HF patients through data collection via Register („the new global registries and surveys program-GRASP“). **Conclusion:** ESC and HFA continuously creates and implements projects, guidelines and registries with a goal of treatment patients with HF better. Our mission is to actively participate in it.

Lovorka Maras Jurišić, Valentina Levak, Marsel Baukovac, Ivana Babić

Congenital heart defects are among the most common congenital anomalies and involve structural defects in the heart and large blood vessels, as well as issues with the heart valves. (1) The exact causes of these defects are not fully understood, but they are associated with the use of certain medications during pregnancy, maternal health conditions, alcohol and drug use, physical trauma like exposure to radiation, and genetic abnormalities. According to the latest data from the Croatian Institute of Public Health, in 2023, out of 32,674 live births, 462 children were born with congenital heart defects, four of whom were diagnosed with Tetralogy of Fallot. Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart defect, involving a combination of several heart abnormalities such as pulmonary stenosis (PS), ventricular septal defect (VSD), an overriding aorta, and right ventricular hypertrophy. The symptoms include dizziness, chest pain, shortness of breath, frequent lung infections, slowed growth, cyanosis, and fatigue. This heart defect is linked to maternal phenylketonuria and is common in children with Down syndrome. Diagnosis is based on physical examination, echocardiography, and chest X-ray. Treatment typically involves early surgical intervention, along with medication. A potential complication includes arrhythmias, such as atrial or ventricular tachycardia, making regular check-ups crucial. The role of the nurse in caring for patients with congenital heart defects, including ToF, involves monitoring vital signs, educating patients on lifestyle, pregnancy, and motherhood, preventing infections, properly administering prescribed medications, assessing pain, and administering oxygen therapy, among other responsibilities. Since these patients often undergo multiple surgeries and frequent hospitalizations throughout their lives, psychological support is essential, and nurses play a key role in providing that support. Continuous education for nurses and medical staff can improve the quality of care, safety, and overall satisfaction of patients.

Ivana Šmuc, Josipa Pekez, Ivica Benko, Zrinka Paić, Dora Aldžić, Ivana Alković, Ljiljana Bažant, Valentina Brcković, Kristina Kardum Antunović, Anamarija Mikša, Petra Ozimec, Anita Pleško, Nikolina Valjak, Julija Buljan

**Introduction**: Cardiac implantable electronic devices (CIEDs), including pacemakers, implantable cardioverter defibrillators and cardiac resynchronization therapy devices, are essential for regulating heart rhythm, improving hemodynamics, and preventing sudden cardiac death. With the aging population and expanding indications, the number of CIED implantations is rising globally, with complications occurring in about 10% of patients within six months post-implantation. As cardiovascular disease prevalence and healthcare technology advance, further growth in CIED demand is expected. CIED implantation is an invasive procedure, and understanding potential complications, such as infections, lead dislocation, pneumothorax, hematomas, cardiac tamponade, and device malfunction, is crucial for minimizing adverse outcomes. (1) **Patients and Methods**: From January 1, 2023, to August 30, 2024, a retrospective study was conducted on 685 patients undergoing CIED implantation at Dubrava University Hospital. **Results**: The average patient age was 71.8 years (IQR: 65-82), with 69.8% being male. There were 538 primary implantations (78.5%) and 147 generator replacements (21.5%). Among the devices, 32.7% were high-voltage, and 67.3% were pacemakers of varying configurations. Additionally, 11.7% of patients received conduction system pacing (CSP) devices. Periprocedural complications were rare, occurring in only three cases (0.44%), which included two coronary sinus dissections (0.29%) and one acute lead dislocation (0.15%). Post-procedural complications were noted in 76 patients (11.1%), with the most frequent being wound site pain (3.6%) and operative field hematomas (2.6%). Other complications included lead dislocation (1.9%), arrhythmias (1.2%), fever (0.58%), vagal reactions (1.6%), bleeding (0.44%), and one case each of chest pain with elevated enzymes (0.15%) and pneumothorax (0.15%). **Conclusion**: The most complications occur post-procedurally, emphasizing the need for a multidisciplinary approach in CIED patient care. This should involve cardiologists, well-trained cardiac nurses, and effective patient communication to minimize complications and improve outcomes.

Nejra Mlačo-Vražalić, Denis Mačkić, Jasmin Idrizović, Bilal Oglečevac, Ada Đozić, Buena Aziri, Amer Iglica, Zijo Begić, Nirvana Šabanović-Bajramović, Edin Begić

**Introduction:** Left atrial (LA) remodeling is a complex anatomical and functional process in response to electrical, mechanical and metabolic disturbances. LA remodeling is usually a consequence of LA volume overload, left ventricular systolic dysfunction and physiological aging process. LA remodeling directly correlates with atrial fibrillation occurrence. (1-3) Aim: To analyze left atrial strain parameters for the purpose of prediction of atrial fibrillation (AF) after the electrical cardioversion. **Patients and Methods:** Analysis included 31 patients, who underwent electrical cardioversion due to AF at the Department of Cardiology, General Hospital “Prim. Dr. Abdulah Nakaš” in the period from May 2023 until May 2024. Transthoracic and transesophageal echocardiogram was performed in all patients, regardless of the previous anticoagulation therapy. **Results:** There was a statistically significant correlation between the recurrence of AF three months and six months after the electrical cardioversion and the following echocardiographic parameters: LA reservoir strain (p<0.001; p=0.001), LA conduit strain (p<0.001, p=0.001), LA contractile strain (p<0.001; p<0.001), E/e’ ratio (p<0.001, p=0.001), and left atrial stiffness index (p<0.001; p=0.004). Left atrial volume index did not significantly correlate with AF recurrence within three and six months after the cardioversion. **Conclusion:** Patient risk stratification for AF recurrence could be made based on LA strain parameters.

Ivana Jurin, Anđela Jurišić, Diana Bešić, Ivan Skorić, Šime Manola, Tomislav Čikara, Igor Rudež, Irzal Hadžibegović

**Introduction**: In our recent study (1), we examined the characteristics and clinical outcomes of the proportion of statin-naïve patients in our practice who had normal low-density lipoprotein cholesterol (LDL-C) upon admission for acute coronary syndrome (ACS). A total of 15% of patients had normal LDL-C (< 2.6 mmol/L) upon admission, and these patients had significantly higher mortality throughout long-term follow-up as well as in-hospital mortality. **Patients and Methods**: After the analysis of our CaRD registry (NCT06090591), we postulated that lipoprotein(a), or Lp(a), might be the final missing piece in ACS conundrum. Since this biomarker has recently become readily available in our institution, we conducted a small pilot study which included 90 patients who presented with ACS in the period between June 2024 and September 2024. **Results**: According to previous study1, patients with normal LDL-C values at admission were considerably older (median 67 vs. 62 years), with worse renal function, had considerably higher rates of peripheral artery disease (PAD) (14% vs. 9%) and diabetes mellitus (DM) (26% vs. 17%). In our pilot study, patients with those comorbidities also had lower levels of Lp(a). Additionally, we discovered that patients with higher LDL-C values at admission were likely to have higher Lp(a) levels as well. **Conclusions**: Although examining Lp(a) values in a different patient cohort is a drawback of our study, the propensity score analysis leads us to the conclusion that Lp(a) is probably not the missing piece of the puzzle, and that further research is needed to understand why patients with normal LDL-C values who were admitted for ACS had worse outcomes.

Mario Udovičić, Nikola Pavlović, Davor Barić, Danijela Grizelj, Irzal Hadžibegović, Vanja Ivanović Mihajlović, Hrvoje Falak, Petra Vitlov, Igor Rudež, Šime Manola

**Introduction:** Left Ventricular Assist Devices (LVADs) have become essential instruments in the treatment of advanced heart failure. Some patients on LVAD may experience myocardial recovery, which is uncommon, but opens up the possibility of discontinuing LVAD support. Minimally invasive percutaneous decommissioning has emerged as a potential approach for this process, and here we describe the course and the process of a first such case at our Institution. **Case report:** In 2015, a 48-year-old female patient was referred to our center due to advanced heart failure caused by dilated cardiomyopathy, necessitating the implantation of a HeartWare Ventricular Assist Device (HVAD) device as a bridge to candidacy. Following the implantation, the patient’s clinical condition significantly improved, with no complications related to the device or any infections in the follow up. Over time, her left ventricular function also gradually recovered, left ventricular ejection fraction (LVEF) reaching 50% and a left ventricular internal diastolic diameter of 5.0 cm. After thorough review, it was concluded that the patient had achieved responder status and decided that LVAD decommissioning was the most appropriate course of action, as previously described (1, 2). The procedure was performed under sedation with continuous transesophageal echocardiographic and fluoroscopic guidance. Following heparinization, the LVAD speed was reduced to the point of zero net device flow. Over a stiff wire a 10 × 40 mm balloon was inflated and held occluding the outflow graft. The patient was so observed for the next 20 minutes, without any deterioration. Then, a 14-mm vascular plug was placed, the LVAD was turned off, and the outflow graft thrombosed over the following 15 minutes, with all hemodynamic parameters remaining stable, ending the procedure. Echocardiography before discharge showed a stable LVEF of 45-50%. Six months later, the patient remains clinically stable. **Conclusion:** The bridge-to-recovery strategy in LVAD patients is a rare but highly desirable outcome. The minimally invasive percutaneous LVAD decommissioning in those patients is a safe and viable alternative to the conventional surgical explantation. Careful patient follow-up, selection, preparation and coordinated multidisciplinary approach are essential to the success.

Ivana Peršić, Matea Mamić, Fabio Kadum, Ana Petretić, Salem Osman, Teodora Zaninović Jurjević

**Introduction**: Cardiac myxomas are rare benign neoplasms of the heart, typically arising in the left atrium, especially on the septum. Although they can be incidentally discovered through imaging, about 70% of patients present with symptoms, often involving a triad of intracardiac obstruction, embolic events, and constitutional symptoms. The prevalence of cardiac myxomas is approximately 0.03% in the general population (1). **Case report**: We present the case of a 56-year-old male with an incidental finding of a right atrial mass during a routine check-up. He was initially referred to a cardiologist because of a previous medical history of arterial hypertension. He was asymptomatic, with a normal 12-lead electrocardiogram. Transthoracic echocardiography revealed an enlarged left atrium, mild mitral and tricuspid regurgitation, and normal overall cardiac function. However, a large intracardiac mass in the right atrium was also discovered (**Figure 1**). This was further confirmed by transesophageal echocardiography (**Figure 2**). Cardiac magnetic resonance imaging was contraindicated due to the presence of metal shrapnel in the patient’s body. He was referred for further preoperative examination and was scheduled for cardiac surgery. Coronary angiography was performed and was without pathological findings. Cardiac surgery was performed via a median sternotomy incision. Total cardiopulmonary bypass was used and cardioplegic medications were administered. A tumor mass approximately 5x5 cm in size was found in the right atrium attached by a narrow base to the interatrial septum. Atriotomy of the right atrium and a complete tumor excision were done (**Figure 3**). The specimen was sent for histopathological examination which confirmed a diagnosis of a cardiac myxoma. FIGURE 1. Intracardiac mass in the right atrium (transthoracic echocardiographic examination). FIGURE 2. Intracardiac mass in the right atrium (transesophageal echocardiographic examination). FIGURE 3. Intraoperative finding. **Conclusion**: Right atrial myxomas are rare, occurring in only 20% of cases. If untreated, they may lead to serious complications such as systemic embolization or intracardiac obstruction. Surgical excision is the only effective treatment and is crucial for recovery and preventing further complications. This case is notable because of the atypical location and the silent presentation of the cardiac myxoma (2).

Karla Savić, Ozren Vinter, Ivo Darko Gabrić, Marko Boban, Krešimir Kordić, Matias Trbušić

**Introduction**: Advanced heart failure (HF) patients, particularly those ineligibles for heart transplantation (HT) or left ventricular assist devices (LVADs), remain at high risk for recurrent hospitalizations and mortality despite optimal medical therapy (OMT). Vericiguat, a soluble guanylate cyclase (sGC) stimulator, enhances myocardial and vascular function by increasing cyclic guanosine monophosphate (cGMP) production, while intermittent levosimendan, a calcium sensitizer with inotropic and vasodilatory properties, provides hemodynamic support. When added to OMT, both agents offer potential therapeutic benefits in stabilizing advanced HF through complementary mechanisms. (1-3) **Patients and Methods**: This retrospective study examined three patients with advanced heart failure with reduced ejection fraction (HFrEF) who received vericiguat and intermittent levosimendan in addition to OMT. The primary endpoint was a reduction in NT-proBNP levels over one year, reflecting HF severity. Secondary endpoints included improvements in left ventricular ejection fraction (LVEF), right ventricular function (TAPSE), and tricuspid regurgitation (TR) severity. **Results**: After one year of combination therapy, all patients demonstrated significant reductions in NT-proBNP levels, indicating improvement in HF severity. Additionally, LVEF improved across patients, from a baseline of 25-30% to 35-40%. Improvements in TAPSE and TR severity reflected enhanced right ventricular function and reduced pressure load on the right side of the heart. These changes were associated with fewer hospitalizations, enhanced exercise tolerance, and an improved quality of life. **Conclusion**: When added to OMT, vericiguat and intermittent levosimendan effectively improved multiple cardiac function parameters and reduced NT-proBNP levels in patients with advanced HFrEF. These findings suggest that this combination therapy could be a viable long-term option for patients ineligible for HT or MCS, with further research warranted to confirm these results in larger populations.

Dražen Mlinarević, Marko Stupin, Ivica Bošnjak, Zorin Makarović, Jerko Arambašić, Petra Zebić Mihić, Marin Vučković, Iva Jurić, Kristina Selthofer-Relatić, Damir Kirner

**Introduction**: Intravascular ultrasound (IVUS) complements coronary angiography in treating complex coronary lesions. Several studies have demonstrated improved outcomes after IVUS-guided percutaneous coronary intervention (PCI). (1-3) Since there is a paucity of published data about IVUS-guided PCI in our country, we sought to investigate clinical outcomes in our center since 2022. **Methods**: We conducted an observational cohort study of IVUS-guided PCI. All patients were >18 years of age. We included patients with both acute and chronic coronary syndromes. PCI was performed using proximal radial, distal radial, ulnar or femoral access. Coronary lesions were treated as per operator preference and IVUS was used in all procedures. Dual antiplatelet therapy was provided according to ESC guidelines. Complex coronary artery disease was defined as left main stem PCI, bifurcation lesions, long lesions requiring stents of >33 mm, multivessel PCI, heavily calcified lesions, in-stent restenosis (ISR) or aorto-ostial lesions. Statistical analysis was performed using IBM SPSS Statistics v.23. **Results:** A total of 79 patients were included, with an average age of 66.8 years, 83% male and 17% female, with a median follow-up of 12.4 months. The prevalence of hypertension was 90%, diabetes 37%, chronic kidney disease 13% and atrial fibrillation 22%. Patients with chronic coronary syndromes comprised 66% of the cohort, 27% were smokers and 8% had previous coronary artery bypass grafting. The average left ventricular ejection fraction measured by Simpson’s BP was 47.7%. Proximal radial access was used in 72% of cases, distal radial in 11%, femoral in 14% and ulnar in 2%. The left main coronary artery was treated in 48% of patients, 56% had bifurcation lesions and 53% had lesions longer than 33 millimeters. Drug-coated balloons were used in 8% of cases, 30% had PCI with 2 or more stents. Aorto-ostial lesions were treated in 18% and 71% of patients had calcified lesions. Clopidogrel was administered in 19% of cases, ticagrelor in 65% and prasugrel in 14%. Two periprocedural complications occurred (3%). The 30-day mortality was 4% (3 patients), while mortality during follow-up was 5% (4 patients). One patient had a myocardial infarction (1%) and there were no documented target lesion failures of strokes in the cohort. **Conclusion**: Intravascular ultrasound is essential in ensuring optimal PCI results and reduction in cardiovascular outcomes in complex coronary artery disease.

Nejra Mlačo-Vražalić, Dino Alić, Lana Mrdović, Džana Badžak, Amela Sofić, Aida Mujaković, Tijana Muhić-Skalonja, Akif Mlačo, Denis Mačkić, Nejra Prohić, Ada Đozić, Adnan Mušanović, Jasmin Idrizović, Edin Begić

**Introduction**: Obstruction of the pulmonary artery and its branches increases the pulmonary vascular resistance, resulting in pulmonary hypertension and right ventricular (RV) dysfunction. (1, 2) Aim: To analyze the correlation between the pulmonary artery obstruction index (PAOI) score obtained from quantifying obstruction in pulmonary embolism (PE), inflammatory markers, coagulation parameters, and echocardiographic findings. **Patients and Methods**: This retrospective study included 59 patients hospitalized with PE at the Department of Internal Medicine, General Hospital “Prim.dr. Abdulah Nakaš” in the period from 2022 until 2024. PE was confirmed on CT angiography and the PAOI score was calculated using the Qanadli index. Echocardiography was performed during hospitalization. Inflammatory and coagulation parameters were obtained. **Results**: The PAOI score significantly correlated with the right ventricular systolic pressure (RVSP) (p=0.03) and with the presence and degree of the tricuspid regurgitation (p=0.03). No correlation was found between the PAOI score and other echocardiographic parameters. Strong correlation was found between the PAOI score and D-dimer values (p<0.001). No significant correlation was found between the PAOI score and C-reactive protein, hemogram and hemogram-derived ratios. **Conclusion**: The PAOI score on admission in patients with PE is in correlation with RV function and coagulation parameters.

Nikolina Slamek, Ivica Benko, Mateja Lovrić, Ivan Zeljković, Mirela Adamović, Marija Grlić, Marina Žanić, Mario Tomašević, Ivan Horvat

**Introduction**: Cardiac arrhythmia refers to an abnormal heart rhythm. Approximately 5% of the general population will experience some form of it during their lifetime. Arrhythmias can be completely asymptomatic or cause significant symptoms, impairing daily life and even leading to sudden cardiac death. While often seen in a negative context, this paper highlights that in certain situations, arrhythmia can have beneficial effects, potentially lifesaving one. Atrial arrhythmias occasionally co-occur with sinus node disease (SND). Although the sinus node function can sometimes recover spontaneously, in some cases, the implantation of a permanent pacemaker becomes necessary. **Case report**: This case study examines a 58-year-old patient who was hospitalized for electrophysiology study (EPS) due to recurrent atrial flutter (AFL) following a previous cavotricuspid isthmus ablation. During the EPS, right atrial mapping was performed via the right femoral venous approach. Upon catheter entry for heart mapping, the arrhythmia was unexpectedly terminated, revealing complete atrial standstill with no compensatory rhythm from the AV node or ventricles, leading to both atrial and ventricular asystole. This abrupt cessation of the arrhythmia unmasked the underlying SND, which had been masked by the presence of the AFL. Prolonged atrial arrhythmias are known to be a common cause of SND. The patient was briefly paced using a catheter positioned in the coronary sinus, and sinus rhythm was restored with isoproterenol, followed by 1 mg of atropine, calcium gluconate, and aminophylline. A temporary pacemaker electrode was placed in the right ventricle, and the puncture site in the right femoral region was closed with a Z-suture and elastic bandage. The patient maintained stable sinus rhythm post-procedurally, and the temporary pacemaker was removed the next day. SND predominantly affects older adults with comorbid cardiac conditions or diabetes mellitus. In this case, the patient had undiagnosed diabetes mellitus, contributing to the development of the sinus node disease. (1, 2) **Conclusion**: Although prolonged AFL negatively impacted the atrial myocardium, it inadvertently saved the patient’s life by sustaining cardiac output. This case demonstrates that while arrhythmias are typically considered harmful, there are instances where they can have a lifesaving effect.

Martina Kralj, Ivana Tomašić, Valentina Gal

In the healthcare system, nurses represent a key component of patient care. Today’s challenges related to motivation and retention of nurses are becoming increasingly significant due to the global workforce shortage, increased workplace stress, and high turnover rates. Nurses often work under extremely difficult conditions, with high workloads and staff shortages. This contributes to physical and emotional burnout, negatively affecting their motivation and desire to remain in the profession. The COVID-19 pandemic has further worsened these conditions, increasing the number of patients and pressure on healthcare workers. (1) Increasing the number of nursing staff to reduce the workload, improving work organization, shorter shifts, and more flexible work schedules can significantly improve job satisfaction. Introducing programs for burnout prevention and providing psychological support can help reduce stress and emotional exhaustion. (2) Raising salaries and offering financial incentives (bonuses, rewards for outstanding work) have been recognized as important steps in retaining qualified nurses. Education and opportunities for advancement are key to long-term motivation. Organizing continuous professional education, specialization, and providing opportunities for career advancement increases engagement and a sense of achievement. Mentorship programs for younger nurses’ help transfer knowledge and boost confidence, leading to greater job satisfaction. A culture of recognition within healthcare institutions, where the employer actively acknowledges and praises the work of nurses, can improve the work atmosphere and increase the sense of belonging. Retaining nurses in the workplace is one of the greatest challenges facing today’s healthcare system. Only through adopting a holistic approach can the healthcare system ensure long-term motivation and satisfaction among nurses, thereby improving the quality of care provided and reducing workforce turnover.

Ana Šutalo, Petra Grubić Rotkvić, Mislav Puljević, Marija Brestovac, Ivana Jurca, Majda Vrkić Kirhmajer

**Introduction**: A free-floating thrombus is a mobile aortic thrombus that appears to float freely, while being attached at one end to the aortic wall. Although rare, it has 73% risk of embolic events (1). Etiologies include atherosclerosis, acute aortic syndrome, and hypercoagulability. Surgical thrombectomy and thrombolysis are the primary treatments in the acute setting (2), but clear management recommendations are lacking. Treatment depends on the clinical picture, patient condition and thrombus size and location. **Case series**: We present three cases of free-floating aortic thrombi from 2021 to 2023. A 68-year-old male was hospitalized due to COVID19 pneumonia. Computed tomography angiography (CTA) of pulmonary artery revealed a floating thrombus in the distal ascendent aorta, extending throughout the aortic arch. Spleen and renal infarction coexisted. A 65-yeard-old male presented with upper left abdominal pain. Computed tomography (CT) confirmed spleen infarction. Further imaging revealed floating thrombi in ascendent aorta. Laboratory findings were positive for ANA, anti dsDNA, and anti U1RNP raising suspicion for collagenosis or vasculitis. A 70-year-old female was admitted with critical limb threatening ischemia. Laboratory testing revealed leukocytosis and thrombocytosis. CTA showed a floating thrombus in the infrarenal aorta extending into both common iliac arteries (**Figures 1** and **2**Figure 2). A JAK2 positive myeloproliferative neoplasm was diagnosed. All patients were initially treated with low molecular weight heparin. The first patient was discharged on warfarin and two others on rivaroxaban. The third patient was additionally prescribed acetylsalicylic acid. Follow-up CTA showed complete resolution of thrombi in first two patients and complete resorption of the thrombi in iliac arteries and partial resorption in the infrarenal aorta for the third one (**Figures 3** and **4**Figure 4). All three patients underwent a full clinical recovery. FIGURE 1. Computed tomography angiography showing floating thrombi in the infrarenal aorta of a 70-year-old female. FIGURE 2. Floating thrombi extending into both common iliac arteries in the same patient. FIGURE 3. Follow-up scan showing resolution of thrombi in common iliac arteries. FIGURE 4. Only partial resorption of thrombi in the infrarenal aorta of the same patient. **Conclusion**: A conservative approach involving anticoagulation and management of cardiovascular risk factors can be effective regardless of underlying etiology.

Mia Dubravčić Došen, Ines Prskalo, Anica Milinković, Ana Šutalo, Petra Grubić Rotkvić, Mislav Puljević, Tomislav Krčmar, Majda Vrkić Kirhmajer

**Introduction:** Chronic limb-threatening ischemia (CLTI) is a serious global health issue characterized by high mortality rates and an increased risk of amputation. (1) Patients with multiple comorbidities have poor clinical outcomes, particularly regarding major adverse limb events (MALE) and amputation-free survival (AFS). (2, 3) The aim of our study was to investigate clinical characteristics and outcomes in patients admitted due to CLTI at University Hospital Centre (UHC) Zagreb. **Patients and Methods:** We conducted a retrospective analysis of patients admitted for CLTI at UHC Zagreb between May 2021 and June 2022. The main objective of the study was to examine AFS, MALE and overall one-year mortality among patients with CLTI during 12-month follow-up. **Results:** A total of 149 patients (66.4% male, average age 68.3 years) were included in the study. Most patients had some cardiovascular comorbidity, including arterial hypertension, diabetes mellitus and coronary artery disease (CAD) (78.5%, 47%, and 24.2%, respectively). Chronic renal insufficiency (CRI) was documented in 21.5% patients, while 8.1% had end-stage renal disease (ESRD). At admission, 79 patients (53%) were anemic (hemoglobine (Hb) levels were not available in seven patients). Presence of arterial hypertension or diabetes mellitus did not show a statistically significant difference in main outcomes. Significantly higher one-year mortality rates were observed in patients with CAD, anemia, CRI and ESRD (p<0.001, p<0.05, p<0.001, p<0.001, respectively), compared to patients without these comorbidities. Similar results were observed for AFS rates (p<0.05, p<0.001, p<0.001, p<0.001, respectively). Patients with anemia also had significantly higher rates of MALE and re-admission for CLTI (p<0.05, p<0.05, respectively), compared to those with normal Hb levels. **Conclusion:** Multiple comorbidities in CLTI patients are associated with poor clinical outcomes in terms of mortality and limb preservation. This is particularly pronounced in patients with anemia. Future research is needed to determine the importance and thresholds for optimizing anemic CLTI patients.

Dijana Bešić, Ante Lisičić, Jelena Kursar, Aleksandar Blivajs, Hrvoje Falak, Petar Lišnjić, Diana Rudan, Šime Manola, Ivana Jurin

**Introduction:** SGLT2 inhibitors are by now well-recognized pharmacotherapeutic agents that have demonstrated efficacy in lowering mortality and morbidity in a variety of cardiovascular and metabolic conditions. Current evidence from randomized trials found no association between SGLT2 inhibitors and risk of venous thromboembolic events (VTEs) among patients with type 2 diabetes. However, as far as the authors of this abstract are aware, no studies have investigated the relationship between SGLT2 inhibitors and recurrence of VTE events. (1, 2) The aim of this study was to explore association between SGLT2 and the recurrence of VTE episodes. **Patients and Methods:** A real-world cohort of patients with pulmonary embolisms (PE) diagnosed between May 2013 and September 2023 was included in our study. We evaluated the incidence of VTE recurrence in a cohort of patients treated with SGLT2i either before or subsequent to the original VTE episode, and in a cohort not treated with SGLT2i. VTE recurrence was defined as two or more PE and/or deep vein thrombosis (DVT) incidents. We used the chi-squared test for statistical analysis, and a p-value of 0.05 was regarded as statistically significant. **Results:** This registry-based study included 852 patients with a median age of 73 years (IQR 61-80) and a median follow-up period of 56.8 months (IQR 15.1-85.6). Recurrent VTE episodes occurred in 172 individuals (20%) and were less common in patients prescribed with SGLT2i medication before or after index VTE events, although this difference was not statistically significant (p =.887). **Conclusion:** There was a trend towards lower recurrence rate of VTE episodes in the group of patients treated with SGLT2 inhibitors. However, this sample included only few patients, considering that SGLT2 inhibitors are relatively new medications in the pharmacovigilance field. Additional research and larger sample sizes are required to investigate the potential beneficial effects of SGLT2 inhibitors on the recurrence of VTE.