Cardiologia Croatica. 2025;20(5-6)

Jadranka Šeparović Hanževački, Viktor Peršić

## Dear Colleagues, CroEcho2025 is a scientific and professional congress of the Working Group on Echocardiography and Imaging Modalities in Cardiology of the Croatian Cardiac Society, held under the auspices of the European Association of Cardiovascular Imaging (EACVI) and the European Society of Cardiology (ESC). Once again, it will bring us together in Poreč from May 8 to May 10, 2025, creating a platform for connection and collaboration among cardiologists at all stages of their careers — from beginners to mentors, as well as leading national and international experts from all fields of cardiology. The congress is dedicated to excellence in cardiac diagnostics and clinical decision-making in the management and treatment of conditions where echocardiography and imaging methods play a key role. Our goal is to provide education aligned with European and global standards in the areas of basic echocardiography, advanced echocardiographic techniques, and other imaging modalities. As in previous years, plenary sessions will focus on valvular heart diseases and a multidisciplinary approach to addressing key clinical dilemmas, understanding pathophysiological processes, and disease progression. Special attention will be given to the application of echocardiographic parameters and new advanced methods that enhance the understanding of pathophysiology. Cardio-oncology, cardiomyopathies, and acute conditions are important components of this year’s plenary lectures, which will be delivered by invited speakers and international experts from Europe and around the world. The scope of artificial intelligence and its valuable contributions to clinical echocardiography will also be an unavoidable topic addressed at the congress. By bringing together a community of cardiology specialists to tackle complex clinical cases through expert clinical reasoning and the exchange of diverse perspectives, we reaffirm our commitment to placing the patient at the heart of clinical practice. The quality of the professional and practical content of our echocardiography course has been recognized by the EACVI’s Education and Professional Development Committee, which has endorsed it as an outstanding course. Do come and join us — share your views, knowledge, ideas, and clinical experience, and take part in professional and scientific discussions in the plenary lectures and debates. We look forward to welcoming you and working together in Poreč. Predsjednici kongresa / Congress Directors: Jadranka Šeparović Hanževački and Viktor Peršić

Ivona Mustapić, Andrija Matetić, Frane Runjić, Tea Domjanović Škopinić, Antonia Melada, Tina Bečić, Ante Anić, Darija Baković Kramarić

**Introduction:** Recently, in patients undergoing catheter ablation of atrial fibrillation, the OPTION trial showed that left atrial appendage (LAA) closure was non-inferior to an oral anticoagulant in terms of risk of death from any cause, stroke or systemic embolism (1). The multiple studies showed that tricuspid transcatheter edge-to-edge repair (T-TEER) reduced the severity of tricuspid regurgitation and was associated with an improvement in quality of life (2, 3). **Case report:** In March 2021, a 76-year-old woman with a history of arterial hypertension was hospitalized with clinical signs of heart failure triggered by persistent atrial fibrillation. Echocardiography described preserved left ventricular systolic function, severe tricuspid regurgitation, mild mitral regurgitation and left atrial dilatation. She underwent right-sided catheterization, which did not reveal any criteria for pulmonary hypertension. Coronary angiography ruled out significant coronary artery disease. After discharge from hospital, she had several epistaxis and bleeding gums while taking full-dose rivaroxaban and lower-dose apixaban. In October 2021, she underwent a combined procedure, electrical isolation with pulsed field ablation (PFA) of the LAA with implantation of an Amplatzer Amulet 25 mm occluder (**Figure 1**) and PFA isolation of the pulmonary veins to prevent recurrence of persistent atrial fibrillation. In October 2022, she was hospitalized for symptomatic bradycardia related to sinus node disease and a permanent pacemaker in AAIR mode was implanted. The patient remained symptomatic despite maintenance of sinus rhythm and optimal medical therapy (OMT) for heart failure. She was presented to the Heart Team and accepted as a candidate for T-TEER. Two cobalt-chromium clips [TriClip XTWx2] were placed in the target area of the tricuspid valve in the anteroseptal/posteroseptal coaptation gap (A-S / P1-S). Intraprocedural transesophageal echocardiography confirmed a significant reduction in tricuspid regurgitation (from severe to trivial) with the absence of significant anterograde flow obstruction and immediate improvement in hemodynamic parameters (**Figures 2 and 3**Figure 3). During follow-up, the patient reported an improvement in symptoms. FIGURE 1. Transesophageal echocardiography showing a left atrial appendage (LAA) occluder. FIGURE 2. Transesophageal echocardiography showing massive tricuspid regurgitation before transcatheter edge-to-edge repair. FIGURE 3. Transesophageal echocardiography showing reduction of tricuspid regurgitation to trivial levels after transcatheter edge-to-edge repair using two cobalt-chromium clips [TriClip XTWx2]. **Conclusion:** The use of interventional techniques such as catheter ablation and structural interventions in the elderly leads to a better quality of life and a reduction in symptoms of heart failure that persist despite OMT.

Nora Knez, Tomislav Tokić, Ante Lekić, Hrvoje Gašparović

**Introduction**: Postoperative atrial fibrillation (POAF) is a frequent complication following cardiac surgery, increasing morbidity, length of hospital stay, and healthcare costs. (1) Although multiple clinical factors contribute to POAF risk, echocardiographic parameters reflecting left atrial and ventricular function may improve preoperative risk stratification. Identifying reliable predictors could enhance patient selection, optimize perioperative management, and reduce complications. (2) This systematic review evaluates the role of preoperative echocardiography in predicting POAF in patients undergoing cardiac surgery. **Patients and Methods**: A systematic search, conducted according to PRISMA guidelines, explored PubMed, CrossRef, and Google Scholar for studies evaluating preoperative echocardiographic predictors of POAF in adult cardiac surgery patients. After screening 363 studies, 317 proceeded to title and abstract screening. A full-text review of 112 studies led to the final inclusion of 31 studies. Data extraction included echocardiographic parameters, study design, and POAF incidence. The risk of bias was assessed using the ROBINS-I tool, while the GRADE methodology evaluated the evidence quality. **Results**: 4,512 patients were included, with a POAF incidence of 24.0%. Key echocardiographic predictors of POAF included increased left atrial volume index (LAVI), reduced left atrial strain (PALS, PACS), impaired LV diastolic function (elevated E/e’ ratio), prolonged PA-TDI duration, diminished left atrial function (LAEF, LAFAC), and reduced LV global longitudinal strain (GLS). POAF patients had significantly higher LAVI, E/e’, and PA-TDI duration, while LA strain, LA function, and LV GLS were lower (p<0.05). The ROBINS-I assessment classified 13 studies as low risk of bias, while 18 studies had moderate risk primarily due to selection bias, uncontrolled confounding, and variability in echocardiographic measurements. According to the GRADE assessment, 16 studies were rated as moderate-quality evidence and 15 as low-quality evidence, primarily due to the observational design and inconsistencies in echocardiographic measurement protocols. **Conclusion**: LAVI, LA strain, and LV diastolic dysfunction emerged as the strongest echocardiographic POAF predictors, underscoring their critical role in preoperative risk stratification. Despite moderate-quality evidence, these findings advocate for echocardiographic markers integration into POAF risk models to refine patient selection and optimize outcomes. Future research must focus on standardizing measurements, validating thresholds, and embedding these parameters into clinical decision-making to enable precise, individualized risk assessment.

Viktor Čulić, Ivan Velat, Željko Bušić

**Introduction**: Low triiodothyronine syndrome (LT3), also referred to as sick euthyroid syndrome or non-thyroidal illness syndrome, is commonly defined as a low serum level of free triiodothyronine without a coexisting increase in serum free thyroxine and thyroid-stimulating hormone levels (1). Thyroid dysfunction and alterations in thyroid hormone concentrations can affect the cardiovascular system and lead to cardiovascular disease. Vice versa, cardiovascular diseases such as acute myocarditis, myocardial infarction, heart failure (HF) and acute ischemic stroke, may disturb the levels of thyroid hormones, particularly LT3, which further increases the risk of morbidity and mortality indicating a poor prognosis in such patients (2, 3). In patients with hypertrophic cardiomyopathy, LT3 has been associated with an increased risk of HF worsening or sudden cardiac death (4). **Patients and Methods**: Demographic characteristics, cardiovascular risk factors, previous medical therapy, laboratory findings including serum concentrations of thyroid hormones and echocardiographic parameters were prospectively collected for consecutive patients hospitalized for acute HF. The left ventricular (LV) ejection fraction (LVEF) and LV diastolic dysfunction (LVDD; 3 grades) were assessed in accordance with the current guidelines. **Results**: The study included 303 patients. The mean age of the study population were 72.4±9.4 years, there was 33% women, 14.5% smokers, 62.7% hypertensive patients, 46.5% patients with diabetes, 30.7% with hypercholesterolemia, 22.4% with previous myocardial infarction and 40.5% those with LT3. The mean LVEF was 47.8±13.3%, median LVDD was grade 3 (interquartile range 2–3). Patients with LT3 were older than those without LT3 (73.2±7.1 years vs. 76.1±8.7 years; t=2.28, p=0.022). The frequency of LT3 did not differ according to sex (χ=1.243, p=0.218), smoking (χ=0.001, p=0.996), hypertension (χ=0.584, p=0.442) diabetes mellitus (χ=1.131, p=0.304), hypercholesterolemia (χ=0.762, p=0.412) or previous myocardial infarction (χ=0.875, p=0.267). In the multivariable analysis, which included adjustment for the aforementioned clinical covariates, LT3 showed an independent predictive association for both low LVEF (ß=-0.181, p=0.017) and higher LVDD (ß=0.194, p=0.011). **Conclusions:** The present study suggests that LT3 is an independent predictor of lower LVEF and more progressed LVDD in patients with HF. There is a need for further research of biological mechanisms and therapeutic possibilities of LT3.

Ana Đuzel Čokljat, Petra Grubić Rotkvić, Damir Čokljat, Zdravko Babić

**Aim.** To explore the effect of epicardial adipose tissue (EAT) on myocardial function in stage A and stage B (pre-heart failure) patients with diabetes mellitus type 2 (T2DM). **Materials and Methods**. We have conducted a review of a relevant literature comprising an area of interest as stated. **Results**. Patients with T2DM have a larger amount of EAT compared to non-diabetic individuals. (1) Since all of them, if asymptomatic, are at risk of developing HF (stage A), and if additionally proven structural/functional cardiac abnormalities and/or elevated natriuretic peptides, then diagnosed with pre-HF (stage B), (2) we have searched for a potential mechanism of EAT impact. Firstly, EAT might infiltrate into adjacent myocardium, which disturbs myocardial architecture, stimulates myocardial thickening, and promotes diastolic dysfunction. (3) Secondly, a mechanical effect of thickened EAT resembles that of a constrictive pericarditis: if a pericardial dilatation is non-congruent with EAT expansion (i.e. pericardial restraint), adjacent myocardium is not able to further dilate in case of demanding hemodynamic state because of limited pericardial pliability. (4) Since cardiovascular outcome trials have shown that glucagon-like peptide 1 receptor agonists (GLP1R) agonists reduce the incidence of major cardiovascular events, with effect sizes beyond regulation of glycemia, and EAT expresses GLP1R, it is possible that delta EAT plays an important role in cardiovascular improvement. (5) **Conclusion**: EAT could serve as a novel tool for risk estimation of progression from asymptomatic to clinical (symptomatic) HF in individuals with T2DM. (1-5) In addition, EAT may serve as a target for existing and novel therapies.

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:** Chronic kidney disease negatively impacts valves by increasing the incidence of calcifications on the valves and mortality. (1, 2) The goal of the study was to examine the correlation between severe aortic stenosis (AS), its risk factors and kidney function. **Patients and Methods:** The retrospective study included 548 patients with severe AS, admitted from September 2020 to August 2024 at our Heart Valve Department. More patients were female (54%, N=296). 38 patients were 75 years old (N=385). Mean ejection fraction of the left ventricle (EFLV) was 51.501±11.502 [15-80], and mean eGFR was 59.549±22.322. They were divided into three groups (terciles) according to estimated glomerular filtration rate (eGFR): the 1st group included those with eGFR ≤49 mL/min/1.73m2, the 2nd group consisted of patients with eGFR 50-72 mL/min/1.73m2, while the 3rd group was composed of patients with eGFR >72 mL/min/1.73m2. We compared eGFR and risk factors: arterial hypertension (AH), diabetes mellitus (DM), smoking, dyslipidemia (DIS) and body mass index (BMI). Additionally, we compared eGFR groups and atrial fibrillation (AF), coronary artery disease, and coexisting multivalvular disease (mitral/tricuspid valve regurgitation, mitral valve stenosis). **Results:** Standard cardiovascular risk factors: AH, DM, and DIS were more common in the 1st group (patients with severe AS and eGFR values ≤49 mL/min/1.73m2) compared to the 3rd group (patients with eGFR >72 mL/min/1.73m2) (respectively P2, 1st and 2nd group compared to 3rd group (P=0.013). When comparing coexisting multivalvular disease, the 1st with the 3rd group, mitral valve regurgitation (MR) showed a positive tendency for significance (P=0.05). No statistically significant correlation was observed between BMI and eGFR in patients (P=0.07, Pearson correlation test: r=0.027, P=0.53). When comparing patients by age, those >75 years old, had a lower eGFR compared to younger groups, as expected (P2 are older, and more commonly have AH, DM, DIS, and mitral valve involvement marked as MR. Moreover, even those with eGFR ≤72 mL/min/1.73m2 can have a greater risk for AF.

Viktor Čulić, Željko Bušić, Ivan Velat

**Introduction**: Due to its role in calcium and phosphate metabolism and homeostasis, increased levels of parathyroid hormone (PTH) have been associated with increased cardiovascular morbidity through mechanisms such as enhanced ectopic calcification, systemic and local inflammation, and adverse cardiac remodelling (1). At the same time, patients with heart failure (HF) have increased levels of PTH which may result from activation of the renin-angiotensin-aldosterone system and the use of loop diuretics (2, 3). A positive correlation between PTH and NT-proBNP has also been reported (4). **Patients and Methods**: Baseline characteristics, prehospital cardiovascular medications, cardiovascular risk factors, laboratory findings on admission, serum concentrations of PTH and echocardiographic parameters were prospectively collected on 213 male patients hospitalized for episode of acute HF. The left ventricular (LV) ejection fraction (LVEF) and LV diastolic dysfunction (LVDD) were assessed in accordance with the current guidelines. **Results:** The mean age of the study population was 74.7±8.1 years, creatinine clearance 55.8±19.5 mL/min/1.73 m2, LVEF 46.1±12.9%, median LVDD was grade 3 (interquartile range 2–3) and median PTH was 7.87 pmol/L (interquartile range 5.42–11.26). Compared to their counterparts, patients with hypertension (p=0.011) and previous myocardial infarction (p=0.047) had higher serum PTH levels, whereas there was no difference according to diabetes mellitus (p=0.15) or smoking (p=0.76). Positive linear correlations were observed when assessing the crude relationship between PTH and age (p<0.0001) or LVDD (p=0.002). PTH inversely correlated with creatinine clearance (p<0.0001) or LVEF (**Figure 1**). The multivariable models, which included adjustment for baseline characteristics and cardiovascular covariates, showed an independent predictive association of PTH for both LVEF (ß=-0.336, p<0.0001) and LVDD (ß=0.174, p=0.03). FIGURE 1. Scatterplot of the association between the left ventricular ejection fraction (LVEF) and serum concentration of parathyroid hormone in male patients with heart failure. A significant negative correlation between the variables was observed in the study population. **Conclusions**: There is a possibility that PTH is an independent adverse factor of the complex network of pathophysiological processes impacting the myocardium, LVEF and LVDD. PTH is likely another hormone playing a role in the multiple hormone disbalance syndrome which accompanies HF.

Iva Turić, Andrija Matetić, Vedran Carević, Nikola Crnčević, Darija Baković Kramarić

**Introduction:** Increased use of cardiac imaging leads to earlier identification of coronary artery anomalies (CAA) (1, 2). Multimodality imaging and functional tests could be crucial in CAA diagnosis and management (1, 3). Routine echocardiography plays a key role in their detection, as CAA are often diagnosed incidentally (3). **Case report:** 60-year-old patient with insulin-dependent diabetes presented with non-ST-elevation acute myocardial infarction (non-ST-elevation inferior changes; hsT I 2329.3 ng/L) to the Šibenik General Hospital. On transthoracic echocardiogram, there was a mild basal inferior hypo-contractility, with no other pathological abnormality described. The patient was transferred for urgent coronary angiography at the University Hospital Centre Split, revealing a single coronary artery arising from the right coronary cusp with subtotal stenosis of the right coronary artery as the culprit lesion. Percutaneous coronary intervention with one drug-eluting stent was successfully performed. To further define CAA and its course, computed tomography was done confirming the abovementioned findings (**Figure 1**). The circumflex artery exhibited a retro-aortic course, while the left anterior descending artery followed a pre-pulmonic course. After one year, the patient developed angina recurrence and was referred for invasive angiography. A significant (~80%) in-stent restenosis of the right coronary artery and a subtotal (~95%) stenosis of the circumflex branch were observed and successfully treated with drug-coated balloons (**Figure 2**). The transthoracic echocardiography was again performed, showing clear signs of CAA (**Figure 3**) and emphasizing a distinct long and tortuous course of left coronary artery branches, potentially precipitating this patient for turbulent flow and accelerated atherosclerosis (2). FIGURE 1. Computed tomography reconstruction demonstrating the anomalous flow of the coronary arteries. FIGURE 2. Coronary angiography finding of recurrent ischemic heart disease. FIGURE 3. Echocardiographic images showing the course of coronary arteries (white arrows). A) modified 4-chamber view; B) standard 4-chamber view (no anomalous course seen); C) modified 3-chamber view; D) 4D reconstruction. **Conclusion:** Echocardiography is a useful modality for early detection of the retro-aortic circumflex artery, although such findings could remain undetected in daily clinical settings (1, 2). Despite CAA usually being benign, their timely detection is important as it could be associated with coronary disease (2). To this patient, it would mean closer cardiac supervision and clinical follow-up.

Lucija Klobučar, Sandra Šarić, Kristina Selthofer-Relatić, Marko Stupin

**Introduction**: Differential diagnosis and diagnostic evaluation of patients presenting with chest pain, elevated troponin levels, and no culprit or any other lesion found using invasive coronary angiography (ICA) is sometimes challenging. It includes all causes of type II myocardial infarction (MI) (e.g. anemia, hypotension, tachy/bradyarrhythmia, coronary spasm, coronary microvascular disease) (1), myocardial injury (e.g. myocarditis, Takotsubo syndrome, cardiomyopathies) (1), and the possibility of unrecognized type I MI (e.g. unnoticed smaller branch occlusion, spontaneously recanalized coronary thrombus). Navigating this broad spectrum of diagnoses requires detailed clinical examination and history taking, blood tests, echocardiography, cardiac magnetic resonance imaging (CMRI), coronary computed tomography angiography (CCTA), intravascular imaging. **Case report**: We present the case of 46-year-old male with the history of pericarditis, who was now hospitalized due to suspected inferior wall MI. Besides smoking cigarettes, he had no other known cardiovascular risk factors. Chest pain onset was 4 days prior to hospitalization accompanied by common cold symptoms. Upon admission patient had no chest pain, ECG showed Q waves in inferior leads without ST-segment elevation, minimal ST-segment depression in aVL, and laboratory results showed elevated levels of hsTnI (10545.8 ng/L), NTproBNP (611 pg/ml), LDL-cholesterol (5.07 mmol/L) and CRP (100.4 mg/L). ICA showed no stenosis of LMCA, LAD, Cx. There was a difficulty in locating the ostium of RCA using various techniques, so that raised suspicion of anomalous origin of RCA. Echocardiography revealed hypokinetic inferior left ventricular wall with preserved LVEF. Considering no culprit lesion found on ICA, elevated CRP levels and a common cold preceding the chest pain onset, the working diagnosis of myocarditis was made. Following initial work-up, patient underwent CCTA aiming to find true origin of RCA and its course, as well as CMRI. CCTA revealed typical RCA origin with visible conal branch and occlusion below that level. CMRI indicated ischemic fibrosis pattern of inferior left ventricular wall with no signs of myocarditis. **Conclusion**: This case shows the importance of multimodality imaging in diagnostic evaluation of patients with disputable diagnosis to guide treatment and follow-up. It is important to emphasize that even if RCA ostium had been found on initial ICA, considering the subacute phase of MI and absence of chest pain, current guidelines recommend against PCI of IRA (2).

Karolina Beg, Sandra Jakšić Jurinjak, Nevio Aradski, Katarina Arbanas, Bruno Lekaj, Laura Mikić, Vlatka Rešković Lukšić, Marija Brestovac, Martina Lovrić Benčić, Joško Bulum, Zvonimir Ostojić, Blanka Glavaš Konja, Jadranka Šeparović Hanževački

**Introduction:** A higher body mass index (BMI) is known to be associated with an increased incidence of aortic valve stenosis (AS). (1, 2) We aimed to assess whether obesity is associated with developing severe AS. **Patients and Methods:** The study included 548 patients admitted for severe AS from September 2020 to August 2024 at the Heart Valve Department of the University Hospital Centre Zagreb. The mean age of the patients was 78.491 ± 8.347 [30-95], 54% were female and the mean BMI was 27.711 ± 5.020 [15.6-44.4]. They were divided into three groups based on BMI: Group I consisted of severe AS and BMI ≤ 24.9 kg/m2, Group II included BMI 25-29.9 kg/m2, and Group III comprised BMI ≥ 30 kg/m2. For the groups of patients, we analyzed renal function by estimated glomerular filtration rate (eGFR) and standard cardiovascular risk factors: arterial hypertension (AH), diabetes mellitus (DM), smoking, and dyslipidemia (DIS). The presence of other valve involvement, coronary artery disease (CAD) and the intervention (TAVR or SAVR) were also analyzed. **Results:** Among 548 analyzed patients with severe AS, most of them (68.1%) were overweight or obese. A total of 160 patients (29.2%) had a BMI ≥ 30 kg/m2 (Group III) and they were overall younger (mean age: 76.225 ± 8.098) compared to the other two groups (P<0.001). The majority of patients in Group III had arterial hypertension (92.5%) and dyslipidemia (79.3%). AH showed a tendency for positive significance (92.5% vs. 91.1% vs. 85.1%, P=0.059). There was no difference in renal function between groups (P=0.708). Despite the lower overall presence of mitral valve regurgitation and stenosis, as well as tricuspid valve regurgitation in obese patients with severe AS (Group III), there was no significance compared to the other two groups (P=0.64, P=0.532, P=0.455). Obese patients had more surgical aortic valve repair (SAVR) than patients with lower BMI (30% vs. 19.2% vs. 16%, P=0.005), probably being overall younger. **Conclusion:** This study suggests that among patients with severe aortic valve stenosis, a higher proportion were overweight and obese, indicating that obesity could be a risk factor for the development of severe aortic valve stenosis.

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

**Introduction**: To present three cases of infective endocarditis caused by an enteric pathogen subsequently found to have colorectal disease (1). **Case series**: Patient 1: 60-year-old male presented with prolonged fever and heart failure (HF). Examination revealed a systolic-diastolic murmur and bilateral fine crackles. Transesophageal echocardiography (TEE) identified multiple aortic valve vegetations with severe regurgitation. Streptococcus viridans was isolated from blood culture. Given the patient’s poor oral hygiene, we presumed a dental origin. After six weeks of antibiotic therapy, he underwent successful surgery. Three months later, evaluation of new onset iron deficiency anemia revealed disseminated colorectal adenocarcinoma, causing death one year later. Patient 2: 58-year-old man with a one-month history of fever presented with acute HF and systolic murmur. Computerized tomography (CT) angiography showed pulmonary embolism, but urgent bedside echocardiography explained the clinical-radiological disparity, revealing a 15 mm formation of bicuspid aortic valve, highly suspicious for vegetation, with severe regurgitation and moderate stenosis. Cardiogenic shock soon developed, prompting urgent mechanical ventilation, vasopressor, and inotropic therapy. He underwent emergency surgery at a specialized center. Enterococcus faecalis was isolated from valve and blood cultures. As part of the search for the source, a colonoscopy was performed, detecting a lateral spreading polypoid adenoma. Staging CT confirmed localized tumor and revealed bilateral renal and splenic infarction. Right hemicolectomy followed one month later. Patient 3: 83-year-old man with renal failure on hemodialysis and a history of a transcatheter aortic valve implantation procedure one year earlier was admitted with acute HF and a fever. Physical examination found a continuous precordial murmur, coarse lung crackles, and anasarca. Blood cultures confirmed Enterococcus faecalis, and TEE demonstrated aortic cusp vegetations with moderate regurgitation and a drained periannular abscess (2) (**Figures 1** and **2**Figure 2). Colonoscopy identified multiple polyps, but polypectomy was deferred due to anticoagulation status. The heart team opted for conservative treatment. FIGURE 1. Transesophageal echocardiography: mid-esophageal aortic valve short axis view. Drained paraanular abscess with detectable flow by color doppler (arrows). FIGURE 2. Transesophageal echocardiography mid-esophageal aortic valve short axis view. Fresh vegetations on the left and right coronary cusp (arrows). **Conclusion**: A retrospective analysis of our registry database identified 11 of 45 cases with potentially enteric pathogens (**Figure 3**). As a result, we implemented a systematic gastrointestinal workup in subsequent patients. These cases emphasize the importance of identifying the source of bacteremia in endocarditis. FIGURE 3. Causes of infective endocarditis in General Hospital Zabok and Hospital of Croatian Veterans 2016-2022. BCNIE=blood culture negative infective endocarditis. MRSA= Methicillin-resistant Staphylococcus aureus. MSSA=Methicillin-sensitive S. aureus. CoNS= Coagulase-negative staphylococci.

Anto Stažić, Kristina Selthofer-Relatić, Dijana Dumančić, Ivana Lukić

**Introduction**: Viral myocarditis is an inflammation of the heart muscle often caused by viral infections. Parvovirus B19 is one of the most common viruses associated with myocarditis, especially in adults. It can lead to symptoms such as chest pain, fatigue, arrhythmias, and even heart failure in severe cases. Diagnosis is usually confirmed through blood tests, cardiac imaging, and sometimes biopsy, while treatment focuses on symptom management and heart support. (1) **Case report**: 23-year-old female patient was referred to the Intensive Cardiac Care unit by the Emergency Department due to chest pain and new-onset shortness of breath. Her prior medical history was unremarkable, and she lives an active lifestyle, regularly exercising without experiencing any pain or dyspnea from exertion. Five days prior to hospitalization, she had a fever and complained of a sore throat. At admission initially, vital signs were significant for a high temperature of 39°C. The electrocardiogram showed sinus tachycardia with diffuse ST elevation. The initial highly sensitive troponin I (hsTnI) was severely elevated to 5604ng/l, N-terminal pro-brain natriuretic peptide (NT-proBNP) to 6658ng/l and C-reactive protein (CRP) to 277 mg/l. Echocardiogram showed an asymmetric left ventricular hypertrophy (posterior wall of 15mm), left ventricular ejection fraction (LVEF) of 43% with hypokinesia of posterior and lateral walls and a reduced global longitudinal strain of -12.6%. A coronary angiography was performed and revealed normal coronary arteries. The patient was initiated on a low dose of bisoprolol, ramipril, eplerenone, empagliflozin and parenteral antibiotic therapy (levofloxacin and ceftriaxone). The respiratory pathogen panel test, blood culture tests and urine culture were negative. Computed tomography of the thorax and abdomen without contrast was unremarkable in evaluating the source of infection. Serum Parvo B-19 IgM and IgG antibodies were positive as well as anti-EBV VCA IgG, anti-EBV EBNA IgG, anti-HSV-1 IgG and anti-HSV-2 IgG antibodies. A repeated echocardiogram showed improvement of LVEF to 60%. On day 9, a cardiac MRI was performed and showed acute myocardial edema of the inferior, lateral and posterior walls with late gadolinium enhancement (LGE), which was suggestive of acute inflammatory myocarditis (**Figure 1**). LVEF was 65%. The patient had resolution of symptoms and was stable for hospital discharge after two weeks. hsTnI and CRP were within normal and NTproBNP was 2397ng/l. After being discharged, the patient followed up closely with her cardiologist. She had greatly improved symptoms since she was at the hospital with a reported six-month follow-up cardiac MRI showing LVEF of 66%, normal wall thickness and biventricular volumes with small residual zone of LGE of the basal segment of posterior wall (**Figure 2**). FIGURE 1. Late gadolinium enhancement (red arrows). FIGURE 2. Residual zone of late gadolinium enhancement (red arrows). **Conclusion**: Viral myocarditis, often associated with Parvovirus B19, can lead to serious cardiac complications, including heart failure and arrhythmias. Early diagnosis and proper management are essential to prevent long-term damage and improve patient outcomes.

Antonio Hanžek, Vlatka Rešković Lukšić, Joško Bulum, Zvonimir Ostojić, Sandra Jakšić Jurinjak, Blanka Glavaš Konja, Marija Brestovac, Jadranka Šeparović Hanževački

**Introduction**: Transcatheter aortic valve replacement (TAVR) is a well-established procedure for the treatment of severe aortic stenosis (AS) (1). Durability of those valves is still an issue concerning structural degeneration with obstruction or severe regurgitation (AR). Based on the limited literature, TAVR-in-TAVR seems to be a valid option in such cases (2). **Case report**: 80-year-old female who previously underwent implantation of a bioprosthetic valve (Labcor 23) in 2014 for severe AS presented to our Department in 2021 for evaluation of severe paravalvular and intravalvular AR and secondary valvular cardiomyopathy with reduced left ventricular ejection fraction (LVEF). At first, she was planned for re-do surgery but was declined by the Heart team due to high periprocedural risk. As an alternative, she was treated with valve-in-valve TAVR, followed by a cardiac resynchronization device implantation in November 2021. During follow-up, she had frequent spells of fast atrial fibrillation accompanied by acute heart failure episodes and was eventually treated with atrioventricular node ablation in May 2023. In July 2024, combined transthoracic and transesophageal echocardiography revealed severe intravalvular AR (**Figure 1**), presumably due to damaged struts, with significant paravalvular leak (**Figure 2**), confirmed by a cardiac computed tomography scan. Based on the anatomical features, the Heart Valve Team concluded that the patient was suitable for the implantation of additional prosthesis in the form of the TAVR-in-TAVR technique. The procedure was successfully performed in October of 2024, with the implantation of the Edwards Sapien S3 valve (size 23). The new valve was positioned deeper in the left ventricular outflow tract, without impeding the anterior mitral cusp motion, and without coronary ostia obstruction (**Figure 3**). Postprocedural imaging revealed a significant reduction of AR, now only moderate in severity, with improved LVEF and without significant obstruction of forward flow (mean pressure gradient (PG) of 16 mmHg, and peak PG of 33 mmHg). Based on the last ambulatory visit, the patient is doing well. FIGURE 1. Severe intravalvular aortic regurgitation (transthoracic echocardiography). FIGURE 2. Paravalvular aortic regurgitation (transesophageal echocardiography). FIGURE 3. Position of the new transcatheter aortic valve (diascopy). **Conclusion**: Transcatheter treatment for the failing TAVR seems to be a reasonable option for properly selected patients. Proper preprocedural planning with multimodality imaging is paramount to prevent specific periprocedural complications, such as acute coronary obstruction (3).

Filipa Grljušić, Vlatka Rešković Lukšić, Blanka Glavaš Konja, Jadranka Šeparović Hanževački, Marija Brestovac, Sandra Jakšić Jurinjak

**Introduction:** Pericardial effusion is an abnormal amount of pericardial fluid for various reasons. When it accumulates slowly, there can be a large pericardial effusion without cardiac tamponade. (1) In most cases, atrial arrhythmias require antiarrhythmics, electrocardioversion, and catheter ablation to restore and sustain sinus rhythm, in addition to anticoagulant therapy to prevent thromboembolic incidents. (2) Occasionally, these treatments can contribute to the development of pericardial effusion. (2, 3) **Case report:** 62-year-old female patient presented with shortness of breath following minimal effort a month and a half ago. She had a past medical history of paroxysmal atrial flutter with successful direct-current electrical cardioversion 2 months ago. She was prescribed oral amiodarone 100 mg once daily and dabigatran 150 mg twice daily. She was hemodynamically stable on admission. The ECG showed sinus rhythm with diffuse microvoltage. Laboratory tests revealed mild normocytic anemia, hypoproteinemia, and slightly elevated inflammatory markers. Echocardiography revealed a large pericardial effusion with fibrin deposits measuring up to 50 mm next to the right atrium and ventricle in the subcostal view, while other findings were normal (**Figure 1**). Further investigations showed erosive gastritis, right carotid artery stenosis, significant stenosis of the brachiocephalic trunk and left subclavian artery, as well as an infrarenal abdominal aortic aneurysm. Upon admission, dabigatran and amiodarone were discontinued. The patient was treated with ibuprofen, colchicine and gastroprotection. This was accompanied by a recovery from anemia, normalization of inflammatory markers, and a significant reduction in pericardial effusion, which measured 11 mm on the 14th day of hospitalization (**Figure 2**). Subsequently, immunological results revealed a positive finding of OJ antibodies. Two weeks later, the pericardial effusion had resolved (**Figure 3**), and a PET/CT scan demonstrated increased radiopharmaceutical accumulation in the aortic walls, both subclavian arteries, and both hilus with enlarged lymph nodes and small nodular lung lesions. FIGURE 1. The subcostal view shows a significant pericardial effusion. FIGURE 2. By the 14th day of hospitalization, there was a significant decrease in pericardial effusion observed in both the long parasternal view (left) and the subcostal view (right). FIGURE 3. The subcostal view (left) and 4-chamber view (right) demonstrate the resolution of pericardial effusion following four weeks of conservative treatment. **Conclusion:** This is a case of reactive pericarditis accompanied by pericardial effusion, influenced by several potential precipitating factors: anticoagulant therapy combined with amiodarone, electrocardioversion, and the possibility of an underlying (systemic) disease. It is important to highlight the favorable and rapid response to a conservative treatment approach for extensive pericardial effusion.

Monika Žepić, Vedrana Vlahović, Krešimir Štambuk, Vito Mustapić, Aleksandar Trbović

I**ntroduction**: One-third of ischemic stroke are cryptogenic (1). Transcatheter closure of patent foramen ovale (PFO) reduces the risk of cryptogenic stroke in patients aged 18-60. According to six randomized clinical trials and several meta-analyses, transcatheter closure of PFO has been proved as a safe procedure with many advantages compared to medical therapy. Transcatheter PFO closure is mostly preformed with transesophageal echocardiography (TEE) guidance. Intracardiac echocardiography (ICE) is a promising modality in guiding patent foramen ovale closure. The aim of this lecture will be performance of ICE guided PFO closure, advantages and disadvantages of ICE, comparation to TEE and first results in Clinic Magdalena. **Case report**: This is a case report of a 40-year-old female patient with a history of ischemic stroke and residual right sided hemiparesis. An extensive medical examination proved PFO as the cause of the stroke. PFO closure with ICE guidance was preformed showing high quality images (**Figures 1 and 2**Figure 2) obtained from the ICE probe inserted through the left femoral vein directly in the right atrium. PFO closure with ICE guidance provides a clear visualization of the interatrial septum, a single operator procedure and it can be completed under conscious sedation (2). It also provides a shorter procedure time and shorter hospital stays with a decrease in adverse events comparing to TEE (3). ICE guided PFO closure made the hospital stay much more comfortable for the young patient with less cost for the hospital. FIGURE 1. Catheter passing from right atrium (RA) through the patent foramen ovale to the left atrium (LA). FIGURE 2. High resolution image showing the optimal position of the patent foramen ovale occluder in relation to other heart structures. **Conclusion**: TEE is still a gold standard in guiding PFO closure but studies show that both strategies are useful with some arguments in favor of ICE.

Antun Zvonimir Kovač, Kristina Marić Bešić, Denis Došen, Vlatka Rešković Lukšić, Sandra Jakšić Jurinjak, Irena Ivanac Vranešić, Joško Bulum

**Introduction:** Recent studies report that the incidence of residual shunting after patent foramen ovale (PFO) closure ranges from 10% to 30% (1). Several factors have been proposed as potential predictors, including anatomical characteristics of the PFO tunnel, the presence of atrial septal aneurysms, and occluder device size (2, 3). This study aims to evaluate the incidence of residual shunting and identify its predictors in patients who underwent PFO closure at the University Hospital Centre Zagreb. **Patients and Methods:** We performed a retrospective analysis of patients who underwent PFO closure at UHC Zagreb. Pre-implantation transesophageal echocardiography (TEE) measurements included PFO tunnel size and septal aneurysm presence (**Figure 1**). Implanted device size was recorded from hospital charts. Residual shunting was assessed using transthoracic echocardiography (TTE) bubble test during Valsalva maneuver at 6-month and 1-year follow-ups (**Figure 2**). Statistical analysis included chi-square test, Cramer’s V test, and linear multivariate regression. FIGURE 1. Transesophageal echocardiography showing the patent foramen ovale opening during the Valsalva maneuver. FIGURE 2. Transthoracic echocardiography bubble test showing residual shunting during the Valsalva maneuver. **Results:** Of 104 attempted PFO closures, device implantation was successful in 100 patients (96.2%). Device size data were available for 98 patients who received the Amplatzer occluder: 50 (51.0%) received an 18/25 mm device, 15 (15.3%) a 25/25 mm device, 9 (9.2%) a 25/30 mm device, 14 (14.3%) a 25/35 mm device, and 10 (10.2%) a 30/30 mm device. Residual shunting was detected in 18 patients (18.0%) exclusively via TTE bubble test. Pre-implantation TEE measurements were available for 54 patients (54.0%) for PFO tunnel width (mean 3.9 ± 2.4 mm) and 51 (51.0%) for tunnel length (mean 10.9 ± 3.6 mm). Atrial septal aneurysm was reported in 33 patients (33.0%). Larger device size (p<0.001) and left atrial disk (p<0.001) were independent risk factors for residual shunting. **Conclusion:** The incidence of residual shunting observed in our study (18.0%) aligns with reports from other centers. Notably, all residual shunts were detected exclusively by the TTE bubble test. In our patient population, the only significant predictors of residual shunting were larger device size, particularly the left atrial disk, whereas other studies have identified anatomical PFO features that increase risk.

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

**Introduction**: Aortic valve repair (AVRep) is an excellent method, for treatment of patients with aortic regurgitation, offering good long-term outcomes with low incidence of valve -related complications. Its feasibility has been reported in both tricuspid and bicuspid valves with excellent results. (1, 2) **Case report**: 59-year-old men underwent aortic valve repair with an annuloplasty ring and reimplantation of coronary arteries (Lansac technique) in 2016 due to bicuspid aortic valve with moderate to severe aortic valve regurgitation. Reconstruction was done with the Coroneo Extraaortic Ring (29 mm) and the Gelweave Valsalva graft (30 mm). Eight years later, the patient returned with symptoms of shortness of breath and exertion intolerance. Transthoracic echocardiography showed severe concentric hypertrophy of the left ventricle, moderate diastolic dysfunction, with preserved ejection fraction (LVEF 50%). Aortic valve was severely degenerative altered, hyperechogenic, with reduced cusp separation and severe aortic stenosis with mild to moderate aortic regurgitation. Aortic valve peak velocity of 5.5 m/s, and peak/mean gradients were 121/76 mmHg. Coronary angiography ruled out coronary disease. Preoperative computed tomography shows significantly calcified aortic valve, CACS 6144 (**Figure 1**). Due to the patient comorbidities and risk of resternotomy the transcatheter aortic valve implantation was chosen as the optimal therapeutic option. Bioprosthetic balloon-expandable aortic valve (Meril Octator TVA 30.5 mm) was delivered via a transfemoral approach without complications. Control echocardiography showed correct valve position, with peak velocity of 1.8 m/s, peak/mean gradients were 20/11 mmHg, valve area was 2.2 cm2 and trace of paravalvular leak angio 1+. FIGURE 1. Preoperative computed tomography shows a significantly calcified aortic valve. **Conclusion**: Transcatheter implantation of aortic valve following aortic valve repair with annuloplasty ring may be a reasonable option for patients with high perioperative risk for reoperative AVR. Extraaortic ring provides extra support for transcatheter valves if mechanism of failure is recurrent aortic regurgitation.

Nora Knez, Tomislav Tokić, Ante Lekić, Hrvoje Gašparović

**Introduction**: Minimally invasive aortic valve replacement (miniAVR) is increasingly adopted as an alternative to conventional AVR, offering reduced surgical trauma, improved cosmesis, accelerated recovery, and decreased transfusion requirements. (1) Despite these advantages driving its uptake, concerns regarding longer operative times, technical complexity, and limited operative exposure continue to hinder its wider dissemination. (2) This study aims to evaluate and directly compare perioperative outcomes of miniAVR versus conventional AVR in a contemporary cardiac surgical setting. **Patients and Methods**: This retrospective cohort study was conducted at University Hospital Center Zagreb and included 1,649 patients who underwent full sternotomy AVR (n=1,096) or miniAVR (n=553) between 2010 and 2024. Group comparisons were performed using the chi-square test for categorical variables and the Mann-Whitney U test for continuous variables, with a significance threshold of p<0.05. Multivariable logistic regression was applied to categorical outcomes, while linear regression was used for continuous variables. Statistical analyses were conducted using SPSS. **Results**: The median age was 69 years, with 59.1% male patients (**Table 1**). MiniAVR was associated with longer CPB (101 vs. 95 min, p<0.001) and ACC times (71 vs. 65 min, p<0.001) but shorter ventilation duration (7 vs. 8 hours, p<0.001). Stroke incidence was lower in miniAVR (0.6% vs. 1.2%, p=0.009), while pacemaker implantation was more frequent (2.35% vs. 1.92%, p<0.001). A summary of intraoperative and postoperative outcomes is provided in **Tables 2 and 3**Table 3. Regression analysis confirmed that miniAVR independently predicted longer CPB (B=4.75, p=0.040) and ACC times (B=1.97, p<0.001), lower stroke risk (B=-0.018, p<0.001) and reduced sternal wound infections (B=-0.031, p<0.001). Differences between univariate and multivariate analyses suggest confounding by other perioperative factors, highlighting the importance of adjusted analyses in assessing outcomes in minimally invasive surgery. A full regression analysis is presented in **Table 4**. ### TABLE 1: Demographic and clinical profiles of subjects undergoing isolated aortic valve replacement surgery. | | | **All subjects** **(n=1649)** | **Full Sternotomy AVR (n=1096)** | | **Minimally Invasive AVR (n=553)** | ***p*-value** | | --- | --- | --- | --- | --- | --- | --- | | Age (years), median (IQR) | | 69 (62-75) | 70 (64-75) | | 67 (60-73) | <0.001 | | Female, n (%) | | 675 (40.9) | 447 (40.8) | | 228 (41.2) | 0.862 | | BMI (kg/m2), median (IQR) | | 29 (25-32) | 29 (26-32) | | 29 (26-32) | 0.858 | | EF (%), median (IQR) | | 60 (52-65) | 60 (50-65) | | 60 (55-65) | 0.005 | | BAV, n (%) | | 510 (30.93) | 259 (23.63) | | 251 (45.39) | <0.001 | | Preoperative AF, n (%) | | 290 (17.6) | 217 (17.8) | | 73 (13.2) | <0.001 | | Endocarditis, n (%) | | 45 (2.7) | 37 (3.38) | | 8 (1.45) | 0.023 | | CAD, n (%) | | 430 (26.1) | 323 (29.6) | | 106 (19.2) | <0.001 | | Hypertension, n (%) | | 1200 (72.8) | 792 (72.3) | | 408 (73.8) | 0.537 | | Diabetes mellitus, n (%) | | 491(29.78) | 351 (32.03) | | 140 (25.32) | 0.006 | | Dyslipidemia, n (%) | | 814 (49.36) | 527 (48.08) | | 287 (51.9) | 0.126 | | Smoking, n (%) | | 399 (24.2) | 242 (22.08) | | 137 (24.77) | 0.598 | | COPD, n (%) | | 166 (10.07) | 119 (10.85) | | 47 (8.5) | 0.144 | | Preoperative creatinine (mg/dL), median (IQR) | | 83 (70-100) | 85 (69-105) | | 81 (71-97) | 0.305 | | CKD, n (%) | | 850 (51.55) | 578 (52.74) | | 272 (49.19) | 0.088 | | Previous solid organ transplantation, n (%) | | 20 (1.21) | 12 (1.1) | | 8 (1.45) | 0.461 | | PVD, n (%) | | 117 (7.1) | 89 (7.4) | | 36 (6.5) | 0.570 | | Previous MI, n (%) | | 91 (5.52) | 72 (6.57) | | 19 (3.44) | <0.001 | | Stroke, n (%) | | 189 (11.49) | 138 (12.59) | | 52 (9.4) | 0.009 | | EuroSCORE II (%), median (IQR) | | 2.46 (1.6-3.7) | 2.54 (1.75-3.96) | | 2.20 (1.49-3.15) | <0.001 | [†] AVR: aortic valve replacement; miniAVR: minimally invasive aortic valve replacement; IQR: interquartile range; BMI: body mass index; EF: ejection fraction; BAV: bicuspid aortic valve; AF: atrial fibrillation; CAD: coronary artery disease; COPD: chronic obstructive pulmonary disease; CKD: chronic kindey disease; PVD: peripheral vascular disease; MI: myocardial infarction ### TABLE 2: Intraoperative characteristics of the study subjects. | | **All subjects** **(n=1649)** | **Full Sternotomy AVR (n=1096)** | **Minimally Invasive AVR (n=553)** | ***p*-value** | | --- | --- | --- | --- | --- | | ACC (min), median (IQR) | 67 (55-85) | 65 (56-88) | 71 (53-83) | <0.001 | | CPB (min), median (IQR) | 97 (80-120) | 95 (77-117) | 101 (86-122) | <0.001 | [†] AVR: aortic valve replacement; ACC: aortic cross-clamp; IQR: interquartile range; CPB: cardiopulmonary bypass ### TABLE 3: Comparison of in-hospital outcomes between the study groups. | | **All subjects (n=1649)** | **Full Sternotomy AVR (n=1096)** | **Minimally Invasive AVR (n=553)** | ***p*-value** | | --- | --- | --- | --- | --- | | MCS, n (%) | 36 (2.18) | 27 (2.46) | 9 (1.63) | 0.185 | | Revision due to bleeding, n (%) | 49 (3.0) | 32 (2.92) | 17 (3.07) | 0.366 | | Ventilation (hours), median (IQR) | 7 (5-11) | 8 (6-11) | 7 (5-10) | <0.001 | | ICU stay (days), median (IQR) | 2 (1-2) | 2 (1-2) | 2 (1-2) | 0.771 | | Need for pacemaker, n (%) | 34 (2.1) | 21 (1.92) | 13 (2.35) | <0.001 | | POAF, n (%) | 545 (33.05) | 355 (32.39) | 190 (34.36) | 0.343 | | Sternal wound infection, n (%) | 73 (4.43) | 44 (4.01) | 29 (5.24) | 0.090 | | Stroke, n (%) | 20 (1.21) | 12 (0.8) | 8 (0.6) | 0.221 | [†] AVR: aortic valve replacement; MCS: mechanical circulatory support; IQR: interquartile range; ICU: intensive care unit; POAF: postoperative atrial fibrillation ### TABLE 4: Multivariable regression analysis of factors associated with perioperative outcomes in full sternotomy aortic valve replacement and minimally invasive aortic valve replacement patients. | | **B** **Coefficient** | **95% Confidence Interval** | ***p*-value** | | --- | --- | --- | --- | | Aortic cross clamp | 1.968 | 0.915-3.563 | <0.001 | | Cardiopulmonary bypass | 4.750 | 0.226-9.138 | 0.040 | | Ventilation | -0.770 | -1.660-0.120 | 0.090 | | Intensive care unit | -0.072 | 0.278-0.133 | 0.491 | | Postoperative atrial fibrillation | -0.015 | -0.069-0.038 | 0.577 | | Need for pacemaker | -0.036 | -0.057- -0.016 | <0.001 | | Mechanical circulatory support | 3.671 | | 0.999 | | Sternal wound infection | 0.031 | -0.043--0.019 | <0.001 | | Stroke | 0.018 | 0.027--0.009 | <0.001 | **Conclusion**: The increasing adoption of miniAVR reflects both patient preference and surgical advancements, underscoring its advantages over conventional AVR. By minimizing surgical trauma, accelerating recovery, and reducing stroke risk, miniAVR emerges as an optimal alternative in appropriately selected patients. Its clinical benefits position it as the preferred approach in high-volume centers, supporting enhanced perioperative outcomes and patient satisfaction.

Jure Šeremet, Ivana Smoljan, Davorka Lulić, Petra Baumgartner, Gordana Bačić

**Introduction**: Although primary cardiac tumors are rare, secondary metastatic tumors to the heart structures are much more common, with an incidence of up to 3.5% at autopsy in the general population and up to 9.1% in patients with known malignancies. The clinical manifestations of cardiac metastases are often nonspecific, depending on the heart structures involved. They usually mimic other cardiovascular conditions, which consequently makes them diagnostically challenging (1). We report a case of a patient with the first clinical manifestation of a malignant lung tumor, appearing as of cardiac etiology. **Case report**: 65-year-old male patient was admitted to the Emergency Department because of chest pain, dyspnea, and palpitations. The patient’s medical history included smoking and prior duodenal surgery due to peptic ulcer rupture. Upon arrival, the patient was hemodynamically stable, but tachycardic and tachypneic. The electrocardiography showed atrial fibrillation, with fast ventricular rate and right bundle branch block. Prehospital electrocardiogram showed transitory ST-elevation in inferior leads, with highly elevated troponin levels. The patient underwent urgent coronary angiography, which showed no acute lesions. The left lung was completely opacified on the chest X-ray, with ipsilateral tracheal retraction. Transthoracic echocardiography showed concentric thickening of the left ventricle, with a reduced ejection fraction of 40%. There was an interventricular septal shift in diastole and systole, with indirect signs of elevated pressure in the pulmonary circulation. Two floating masses within the left atrium were identified, measuring 17×11mm and 13x10mm (**Figure 1**), suspected of clots due to atrial fibrillation of unknown time of onset. An urgent pulmonary CT angiography was performed due to a presumed concomitant pulmonary embolism. However, the imaging revealed a large left central pulmonary mass infiltrating the left atrium, pericardium, pulmonary truncus, and left main bronchus, leading to atelectasis (**Figure 2**). No signs of acute pulmonary embolism were observed. The patient was transported to the pulmonology ward for further diagnostic procedures and treatment. FIGURE 1. Echocardiography in the parasternal long-axis view reveals two floating masses within the left atrium. FIGURE 2. Computed tomography showing a pulmonary mass infiltrating the left main bronchus, left atrium, pulmonary truncus, and heart pericardium. **Conclusion:** This case presents an atypical initial presentation of advanced malignant lung disease, and the importance of fast and detailed diagnostics using invasive and noninvasive imaging methods to ensure prompt diagnosis and appropriate treatment.

Ana Veljača, Irena Ivanac Vranešić, Dražen Belina, Željko Đurić, Kristina Marić Bešić, Darko Anić, Hrvoje Gašparović

**Introduction:** Absent Pulmonary Valve Syndrome (APVS) is a rare congenital anomaly characterized by features of tetralogy of Fallot with complete absence of pulmonary valve tissue. (1) After complete surgical correction, many patients require reoperation/reintervention later in life due to significant right ventricular outflow tract (RVOT) dysfunction. The Melody transcatheter pulmonary valve (TPV) is an effective option for addressing RVOT dysfunction in patients with previously implanted conduit between the right ventricle (RV) and the pulmonary artery (PA). (2, 3) **Case report:** 24-year-old male underwent complete surgical repair of the APVS at 18 months of age, which was performed in our institution. His initial surgery included the closure of the ventricular septal defect with the implantation of the RV-PA conduit. At the age of 11, he required reoperation due to stenosis of the conduit, and a larger (22 mm) Contegra conduit was implanted. A decade later, he underwent the implantation of a Melody TPV to address restenosis in the RV-PA conduit. Four years after implantation, the patient presented with cough and febrile illness at the local hospital. An echocardiogram showed signs of pulmonary valve (PV) stenosis, which raised suspicion of infective endocarditis (IE). MSCT pulmonary angiography revealed the presence of septic emboli in the lungs, accompanied by lung infarctions. Initial laboratory tests showed leukocytosis, elevated C-reactive protein levels, and blood cultures confirmed the presence of Staphylococcus epidermidis. Subsequently, antibiotic therapy was initiated, and the patient was transferred to our institution where an echocardiography exam confirmed severe PV/conduit stenosis with suspicion of distal conduit thrombosis. Urgent surgery was indicated with the removal of the Melody valve and conduit, followed by the implantation of an aortic homograft in the pulmonary position. The patient completed antibiotic treatment and was doing well at the 3-month follow-up. **Conclusion:** Although a TPV implantation is nowadays a standard treatment procedure for residual RVOT dysfunction in patients with previously implanted PV conduits, it carries a significantly increased risk for IE. Clinicians should be aware that these patients need prompt evaluation for IE if a new febrile illness with PV stenosis occurs.

Ivana Petrović Juren, Marija Ivić Čikara, Danijela Grizelj, Nikola Pavlović, Sandra Prša, Kristina Milevoj Križić, Vlasta Soukup Podravec, Andreja Čleković-Kovačić, Matea Lukaš, Iva Ladić, Gabriela Lipošćak

**Introduction:** Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is an autosomal dominant inherited disorder, the second-most-common inherited bleeding disorder. Mutations in three genes involved in the TGF-β signaling pathway may occur, leading to disrupted angiogenesis and the formation of fragile and tortuously dilated capillaries and postcapillary venules. The resulting vascular lesions are classified into two groups: arteriovenous malformations (AVM) and telangiectasias. Anticoagulant therapy in patients with permanent atrial fibrillation (AF) and this syndrome presents a challenge in clinical practice and requires a multidisciplinary approach. (1-10) **Case report**: We present the case of a 70-year-old female patient who has had recurrent epistaxis since childhood and, since the age of 50, has been evaluated at the University Hospital Centre Zagreb due to frequent gastrointestinal bleeding-undergoing multiple thermocoagulation of gastrointestinal angiodysplasias. In 2013 AF was diagnosed, but she was not referred for ablation therapy and anticoagulant therapy was not introduced due to frequent bleeding. Family history reveals that the patient’s mother, brother, niece and younger daughter also have telangiectasias. The first hospitalization was in January 2023 with symptoms of heart failure (HF) due to anemia with clearly visible telangiectasias which were noted (**Figures 1** and **2**Figure 2). Echocardiography results were consistent with dilated cardiomyopathy, volume overload of the left ventricle with signs of high-output syndrome, a significantly dilated left atrium, and dilation of the right heart chambers with significant tricuspid and moderate mitral regurgitation as hemodynamic manifestations of hereditary hemorrhagic angiodysplasia. MSCT confirmed multiple arteriovenous malformations in the liver (**Figure 3**), as well in the lower right lung lobe, measuring 25x21x26 mm (**Figure 4**). No such malformations were found in the brain. After optimizing HF therapy and correcting chronic iron deficiency with parenteral iron, given the high ischemic risk and high bleeding risk, the patient was referred to a hematologist at the Dubrava University Hospital, where treatment with bevacizumab was initiated (April to September 2023), achieving a good therapeutic response. A subsequent reevaluation was conducted to assess the possibility of left atrial appendage occlusion, which was performed in December 2023, with the implantation of an Amplatzer Amulet 22 mm device. Post-procedurally, the patient received dual antiplatelet therapy for six weeks. Due to frequent episodes of epistaxis and the need for red blood cell transfusions, a follow-up transesophageal echocardiography was performed in January 2024, which ruled out leakage and thrombosis, so dual antiplatelet therapy was discontinued. The patient has remained clinically stable in terms of HF, with no thromboembolic complications. Continuous follow-up with a hematologist and cardiologist is ongoing, alongside optimized HF therapy. Further therapeutic options for AVM will be reevaluated. FIGURE 1. Face telangiectasias. FIGURE 2. Fingertips angiodysplasias. FIGURE 3. Multiple liver arteriovenous malformations. FIGURE 4. Large lung arteriovenous malformation. **Conclusion:** In a female patient with permanent AF who has developed symptoms of HF - both as part of permanent AF with a clinical presentation of HF with preserved ejection fraction and as part of chronic anemic syndrome, along with multiple arteriovenous malformations and developed high-output syndrome - it is challenging to choose the optimal treatment strategy for stroke prevention while simultaneously managing bleeding. According to two studies conducted on patients with HHT, the use of bevacizumab (a monoclonal IgG antibody that inhibits vascular endothelial growth factor – VEGF) has yielded excellent results in reducing epistaxis. Similar experiences have been reported in Croatia. Despite potential benefits, data regarding the use of left atrial appendage occlusion (LAAO) in HHT patients with non-valvular atrial fibrillation (NVAF) is scarce and need further investigation, but LAAO might represent a promising non-pharmacological alternative to prevent thromboembolic events in patients with HHT and NVAF.

Tea Domjanović Škopinić, Andrija Matetić, Frane Runjić, Antonia Melada, Ivona Mustapić, Tina Bečić, Darija Baković Kramarić

**Introduction:** Aortic pseudoaneurysm is a rare and potentially life-threatening complication that can arise after aortic root surgery (1). Surgical management is the treatment of choice, but substantial proportion of patients have high surgical risk and mortality, particularly in case of reoperations (2), warranting other therapeutic options. **Case report:** We present a 65-year-old woman with a history of aortic dissection (Stanford A; TEM: A-E1-M3) that underwent cardiac surgery with aortic valve resuspension, ascending aorta reconstruction (straight graft), and coronary artery bypass grafting (vein to the right coronary artery) 4 years ago. During the follow-up, she was diagnosed with aortic root pseudoaneurysm, with parietal thrombus and 3 active communications with the sinuses of Valsalva (2 joint apertures in the RCC region and 1 smaller tubular aperture in the NCC region). Other findings revealed an occluded vein graft, and chronic stable dissection of abdominal aorta extending into the right iliac artery. Initial plan included strict clinical follow-up with sequential imaging (‘watchful waiting’), but due to high-risk features (1-year progression; root location; large volume of ~31 mL) there was an indication for active management. Given the high risk of surgical reoperation (EuroScore II = 15.3%), the multidisciplinary Heart team decided for the percutaneous closure. We have conducted individualized planning with detailed multimodality imaging and advanced 3-dimensional reconstructions (**Figure 1**). The procedure was successfully performed by deploying an atrial septal occluder (18 mm) in the RCC apertures (**Figure 2A**), and additional vascular coils within the pseudoaneurysm (**Figure 2B**). There was no interaction with aortic valve nor coronary ostia, as planned. Follow-up imaging confirmed a successful and stable exclusion of pseudoaneurysm from aortic circulation (**Figure 3**), with only a minor residual flow through the occluder (temporary mesh porosity until complete device endothelization). The patient was closely monitored for any complications, and no further issues were observed during the 1-year follow-up. FIGURE 1. A) Transesophageal echocardiography image of aortic pseudoaneurysm (1 – aortic root; 2 – pseudoaneurysm). B) One of the communications of the pseudoaneurysm with the sinus of Valsalva, measuring 7x10 mm. FIGURE 2. Transesophageal echocardiography after the intervention showing the implanted occluder in te RCC aperture (A) and vascular coils that immediately obstructed the flow within the pseudoaneurysm (B). FIGURE 3. CT reconstruction of the aortic root pseudoaneurysm before (upper image) and 6 months after the intervention (bottom image) **Conclusion:** This case highlights the potential of innovative percutaneous transcatheter options in managing surgical complications, such as aortic root pseudoaneurysms, in selected high-risk patients. These cases require multidisciplinary assessment, advanced multimodality planning and accurate performance in experienced centers.

Ana Čala, Ana Bilić-Pavlinović, Vlatka Rešković Lukšić, Dejan Došen, Sandra Jakšić Jurinjak, Marija Brestovac, Jadranka Šeparović Hanževački

**Introduction**: Valvular heart diseases (VHD) are significant contributors to morbidity and mortality worldwide. Early detection and accurate diagnosis are crucial for effective management and improved patient outcomes. (1) The aim of this study was to determine the frequency and distribution of significant (moderate or severe) VHD among patients referred to echocardiography examination at University Hospital Centre (UHC) Zagreb. **Patients and Methods**: A retrospective cross-sectional pilot study was performed, analyzing all echocardiography exams performed in UHC Zagreb during one-month period (November 2024). Patient data were retrospectively analyzed to assess the prevalence and characteristics of different valve disorders. **Results**: Out of 1009 echocardiography studies performed, significant (moderate or severe) VHD was noted in 158 (15.7%) patients. Among these, 92 (58%) were male. The average age of the patients was 68 years (range 20-93, median 73). Among them, 30 (18.99%) patients had aortic stenosis (AS), 23 (14.56%) aortic regurgitation (AR), 8 (5.06%) mitral stenosis (MS), 62 (39.24%) mitral regurgitation (MR), one patient (0.63%) had tricuspid stenosis (TS), 65 (41.14%) had tricuspid regurgitation (TR), and 3 patients (1.90%) had pulmonary regurgitation (PR). None of the patients were diagnosed with pulmonary stenosis. Additionally, 33 patients (20.88%) had significant multiple valve diseases (two or more involved valves with moderate or severe VHD). In **Table 1** and **Table 2**, a summary of patients with multiple VHD and their average age is presented. The most common combination was MR with TR, identified in 22 out of 33 patients (66.67%), with an average age of 69 years. No other combination was present in more than three patients. One patient had a combination of AR-MS-MR (age 66) and another patient had a combination of TR-MR-AS (age 93). ### TABLE 1: Number of patients with multiple valve disease (moderate or severe) showing the most common combinations. | **Values** | **AS** | **AR** | **MS** | **MR** | | --- | --- | --- | --- | --- | | **AR** | 0 | | 0 | 1 | | **MS** | 2 | 1 | | 0 | | **MR** | 3 | 0 | 0 | | | **TR** | 1 | 0 | 1 | 22 | | **%** | AS | AR | MS | MR | | **AR** | 0% | | 0% | 3% | | **MS** | 6% | 3% | | 0% | | **MR** | 9% | 0% | 0% | | | **TR** | 3% | 0% | 3% | 67% | [†] AR – aortic regurgitation; AS – aortic stenosis; MR – mitral regurgitation; MS – mitral stenosis; TR – tricuspid regurgitation ### TABLE 2: Average age of patients with multiple valve disease. | | **AS** | **AR** | **MS** | **MR** | | --- | --- | --- | --- | --- | | **AR** | 0 | | 0 | 79 | | **MS** | 72 | 78 | | 0 | | **MR** | 70 | 0 | 0 | | | **TR** | 88 | 0 | 45 | 69 | [†] AR – aortic regurgitation; AS – aortic stenosis; MR – mitral regurgitation; MS – mitral stenosis; TR – tricuspid regurgitation Values that present age of only one patient are marked in red. **Conclusion**: This retrospective analysis highlights the substantial burden of cardiac valve diseases in a tertiary care setting, with mitral and tricuspid regurgitation being the most frequently diagnosed combined VHD, suggesting advanced stage of the disease. Further large-scale studies are needed to assess disease prevalence in general population, VHD progression, treatment strategies, and long-term prognosis.

Tomo Svaguša, Danijela Grizelj, Mario Udovičić, Šime Manola, Dijana Rudan

**Introduction:** Muscular ventricular septal defect (mVSD) is a rare congenital heart defect seen in adulthood. Most mVSDs close spontaneously, but if they are larger defects, they must be surgically treated at an early age due to hemodynamic instabilty (1). Assessment of the ratio of pulmonary (Qp) to systemic (Qs) flow, which must be greater than 1.6, is essential for timely intervention to close mVSD (2). **Case report:** 45-year-old man presents for a cardiological examination. He knows he has a heart murmur but has not been examined by a cardiologist. The patient has no subjective complaints, tolerates exertion very well. No other significant comorbidities except smoking. The patient had no chronic therapy. Transthoracic echocardiography verifies the mVSD at the middle third of the intraventricular septum. The canal is on the left side with a transverse diameter of about 7mm and narrows towards the right ventricle (**Figure 1**). Flow velocities through the mVSD from left to right were approximately 4.9m/s, with pressures of approximately 95mmHg. Cardiac ultrasound verified borderline enlarged atria, right (right atrium area 19cm2) and left (left atrium volume index 42ml/m2) and right and left ventricles (left ventricle enddiastolic diameter 60mm). Initial analysis of flow through the pulmonary and systemic circulation yielded a Qp:Qs ratio of 1.6. The patient then underwent a cardiac magnetic resonance, which verified a Qp:Qs of 1.1. A follow-up cardiac ultrasound was unremarkable, except for a now measured Qp:Qs ratio of 1.38. The patient then underwent radionuclide ventriculography, which verified a Qp:Qs of 1.41. FIGURE 1. Visualization of muscular ventricular septal defect from apical projection using color doppler. **Conclusion:** Evaluation of shunt fraction by different diagnostics test can obtain different values. An ultrasound hemodynamic assessment is essential in addition to obtaining adequate data from other diagnostic tests for an adequate assessment of timely intervention. In our patient, borderline enlarged cardiac cavity dimensions are observed, but still without hemodynamic parameters of significant left-to-right shunting (Qp:Qs <1.6), so we decided to conduct clinical monitoring and ultrasound reevaluation once a year.

Ivona Mustapić, Tea Domjanović Škopinić, Antonia Melada, Tina Bečić, Darija Baković Kramarić, Vedran Carević

**Introduction:** Primary pericardial mesothelioma (PPM), an extremely rare and highly lethal tumor, accounts for 2-3% of primary cardiac and pericardial tumors with a prevalence rate of less than 0.002% (1). **Case report:** We present the case of a 61-year-old man, a smoker without chronic diseases, who was hospitalized in April 2024 due to prolonged fever, loss of appetite and cough. The MSCT- pulmonary angiography verified subsegmental pulmonary embolism, circumferential pericardial effusion up to 26 mm wide and density 15 HU, mild marginal imbibition of the pericardium suggestive of pericarditis and small bilateral pleural effusions. An extensive investigation for etiological diagnosis was performed (rheumatology and infectiology investigations, esophagogastroduodenoscopy, bronchoscopy, MSCT of the thorax and abdomen, and tumor markers). Echocardiography showed a circumferential pericardial effusion up to 17 mm wide, without hemodynamic effect and with a good response to treatment with ibuprofen and colchicine. In October 2024, the patient was re-admitted to the hospital due to shortness of breath with ascites and peripheral edema. Echocardiography revealed the progression of the circumferential pericardial effusion up to 21 mm, with the impression of deposits on the visceral pericardium up to 10 mm wide, restriction of longitudinal biventricular function and positive “annulus reversus” **(****Figures 1-3**Figure 2Figure 3**)**. A diagnostic pericardiocentesis was performed, during which 2960 ml of a hemorrhagic effusion was removed. The cytologic findings of the exudate showed a proliferation of mesothelial cells with atypia. A PET-CT scan confirmed a primary pericardial mesothelioma with dissemination to the mediastinal and right retroclavicular lymph nodes with suspected spread to the interlobar and costal pleura on the right side. The planned biopsy of the pericardium was not performed because the anesthesiologist considered the surgical risk to be very high. The patient was presented to the oncology team and the first line of systemic chemotherapy (cisplatin and pemetrexed) with immunotherapy (nivolumab and ipilimumab) was started and is still ongoing. FIGURE 1. Annulus reversus: Septal mitral annulus early diastolic (e’) velocity 0.09 m/s (A) larger than lateral mitral annulus early diastolic (e’) velocity 0.03 m/s (B). FIGURE 2. Transthoracic echocardiography: apical four chamber view (upper left image), apical two chamber view (upper right image), three chamber view (lower left image) and “bull’s eye” of longitudinal systolic function of the left ventricle (lower right image). FIGURE 3. Transthoracic echocardiography; three chamber apical view showing thickening of visceral pericardium (10 mm) and pericardial effusion of 21 mm. **Conclusion:** Due to the non-specific clinical presentation, the diagnosis of PPM is usually made late, and in most cases, it is only made at autopsy (2). This case emphasizes the importance of multimodality imaging and diagnostic pericardiocentesis for early diagnosis.

Željko Đurić, Kristina Krželj, Bruno Ban, Sanja Konosić, Irena Ivanac Vranešić, Ante Lekić, Hrvoje Gašparović

**Introduction**: Prosthetic aortic valve endocarditis (PVE) in young adults represents a life-threatening condition and a challenging clinical scenario for the heart team. PVE accounts for 20 - 30% of all cases of infective endocarditis (IE), occurring in 1-6% of patients with valve prosthesis with an incidence of 0.3-1.2% per patient-year. (1) In observational real-world studies, there is an increasing rate of PVE. Currently, there are no clear guidelines on the choice of valve substitute in PVE. In the contemporary era, the Ross procedure performed in specialized centers emerges as an intriguing option for young adults, offering survival benefit compared to prosthetic aortic valve replacement (AVR). (2) However, this procedure is rarely performed in the context of IE, and there is only a paucity of cases reported in the setting of PVE. (3) **Case report**: We present a case of a 26-year-old man with endocarditis of biological aortic valve prosthesis. His past medical history included balloon dilatation of a native bicuspid aortic valve at 15 years of age. A year later, mechanical AVR with an ATS 20 mm valve was performed. However, early in the postoperative course, ECG changes necessitated reoperation with successful Trifecta 19 mm prosthesis implantation. His blood cultures were positive for Granulicatella adiacens, a rarely found Gram-positive variant of Streptococcus species. Transesophageal echocardiography showed severe structural valve deterioration with a peak gradient of 81 mmHg with 10 mm vegetation and raised suspicion of para-prosthetic aortic root abscess in the non-coronary sinus. Computerized tomography coronary angiogram excluded coronary artery disease and revealed an abscess in the area of the non-coronary sinus. Following the explantation of the biological prosthetic valve and meticulous debridement of all infected tissues in the aortic annulus, a full-root Ross procedure was performed. The postoperative course was uneventful. One year follow-up revealed the excellent hemodynamic profile of the autograft with a peak gradient of 7 mmHg and no regurgitation (**Figure 1**). FIGURE 1. Intraoperative transesophageal echocardiography showing excellent hemodynamic profile of the autograft. **Conclusion**: Ross procedure can be performed in experienced centers in the setting of PVE in selected patients. Although it is a complex procedure, Ross offers a living valve substitute and excellent hemodynamic performances. (4)

Lucija Grbić, Dubravka Šipuš, Daniel Lovrić

**Introduction:** Massive pulmonary embolism (PE), which is characterized by severe hemodynamic instability, can lead to cardiac arrest. Patients who progress to cardiac arrest have an associated mortality rate of 65-95% (1). Prognosis is especially poor in patients with reduced left ventricular (LV) function. Although LV dysfunction is observed in up to 10% of patients with massive PE and is typically associated with underfilling of LV, it can also be a consequence of an underlying condition (2). **Case Report:** 49-year-old female with a history of arterial hypertension, menometrorrhagia (on oral contraceptives), and positive family history of cardiomyopathy (CMP) presented to the Emergency Room due to left leg swelling. Color Doppler confirmed deep vein thrombosis, but during observation, the patient became dyspneic, tachycardic (160/min), hypotensive (70/45 mmHg), and somnolent. CT pulmonary angiography confirmed massive pulmonary embolism with a dilated right ventricle (RV), as well as reverse flow in hepatic veins (**Figure 1**). Thrombolysis with alteplase (t-PA) was initiated immediately. However, shortly after starting t-PA, the patient went into cardiac arrest, with an initial rhythm of pulseless electrical activity, and cardiopulmonary resuscitation (CPR) was initiated. After 10 minutes of CPR, signs of spontaneous circulation were observed. Initial echocardiography revealed severe RV dilation, severe tricuspid regurgitation, and elevated pulmonary arterial pressure. Follow-up echocardiograms showed recovery of RV function but impaired systolic function of the dilated LV (ejection fraction [EF] 30-35%), consistent with a diagnosis of CMP. This suspicion was confirmed with magnetic resonance imaging. The patient recovered completely, and three months later, further evaluation of CMP was performed. CT coronarography revealed sub-occlusive stenosis of left anterior descending artery (LAD) (**Figure 2**). Coronary angiography and percutaneous coronary intervention (PCI) of the LAD were performed. After successful PCI of the LAD and the initiation of heart failure therapy, echocardiography showed partial recovery of systolic function (EF 45%). FIGURE 1. A) Multislice spiral computed tomography (MSCT) showing bilateral massive pulmonary embolism (red arrows) and a severely dilatated right ventricle and atrium, with the interventricular septum shifted to the left. B) Ejection fraction calculation after admission. FIGURE 2. A) Multislice spiral computed tomography (MSCT) coronarography of the left anterior descending artery (LAD) showing sub-occlusive stenosis with soft plaque. B) Ejection fraction calculation after initiation of heart failure therapy and successful percutaneous coronary intervention in the LAD. **Conclusion:** Although LV dysfunction after PE is typically associated with RV dysfunction, preexisting cardiac disease may also play a role. This case highlights the importance of multimodal imaging in the acute setting, as well as the need for a detailed evaluation of LV dysfunction using multiple imaging methods after PE.

Marija Tomac Stojmenović, Irena Ivanac Vranešić, Tamara Žigman, Jadranka Šeparović Hanževački, Neven Čače, Vlatka Rešković Lukšić

**Introduction**: FLNA gene codes the protein filamin A that builds the cell cytoskeleton and plays the role in regulating skeletal and brain development, formation of heart tissue and blood vessels, blood clotting, skin elasticity, etc. (1, 2) It is found on the X chromosome and has X linked inheritance. Cardiovascular abnormalities include dilatation and rupture of the thoracic aorta, outflow tract malformations, valvular dysplasia, patent ductus arteriosus (PDA), atrial and ventricular septal defects, etc (3, 4). Individuals diagnosed with FLNA mutation are usually females because this condition is prenatal/neonatal lethal in most males. (3) **Case report**: 19-year-old young man was referred for further follow up due to FLNA mutation (c.4240T>Ap.Tyr1414Asn) and worsening of the left ventricular (LV) function. He was under pediatric cardiologist’s surveillance since birth due to PDA, that was percutaneously closed at the age of 3 years. Regular echocardiography exams revealed myxomatous valves and dilation of the left ventricle. On the CMR dilated LV (EDV 147/ml/m2) with EF of 52% was described, as well as morphological changes of the mitral valve, but no mitral regurgitation (MR). Cardiac CT showed no dilation of the aorta. Genome sequencing was performed and FLNA mutation was found. Afterwards, the same mutation was found in his mother (heterozygotic), whose echocardiogram was normal except mild mitral and tricuspid regurgitation. Our patient was born from mother’s third pregnancy. The first pregnancy ended with a miscarriage, while from the second pregnancy apparently healthy female was born (genetic testing pending). Echocardiography revealed severely dilated left ventricle with reduced ejection fraction (EDV 114ml/m2, LVEF 40%), dilation of the right ventricle (46mm in the apical 4-chamber view) and severe MR (**Figures 1-4**Figure 2Figure 3Figure 4). All heart valves were severely myxomatous with prolapse of the cusps, but with no other significant valvular heart disease. After the new CMR, he will be referred for cardiac surgery. FIGURE 1. Parasternal long axis view in systole (A) and diastole (B) showing prolapse of an extremely myxomatous and thickened anterior mitral leaflet. FIGURE 2. Parasternal biplane short axis views showing an extremely eccentric mitral regurgitation jet. FIGURE 3. Apical 4-chamber view, showing both mitral and tricuspid valve prolapse and pronounced mitral annular disjunction. FIGURE 4. Focused apical 4-chamber view showing the dilated right ventricle and prolapse of the tricuspid valve. **Conclusion**: Spectrum of FLNA mutation phenotype is wide. The most common phenotype in males is valvular dysplasia. Due to complex changes in the structure and morphology of the mitral valve, diagnosis of MR is challenging.

Aleksandar Trbović, Monika Žepić, Vedrana Vlahović, Krešimir Štambuk, Filip Štembal

Acute Stanford type A Aortic dissection is a life-threatening disease in which urgent surgery is primarily life-saving. (1, 2) Safe and expeditious initiation of cardiopulmonary bypass (CPB) is important to stabilize the patient’s hemodynamic status and prevent further end-organ damage imposed by the pathophysiologic dissection process. (1) Central aortic cannulation using the Seldinger technique under transesophageal echocardiography (TEE) guidance is a safe cannulation method with the benefit of establishing quick true lumen perfusion and expediting the surgical procedure. (3, 4) Both, dynamic and static obstruction of aortic branches are well-described mechanisms of end-organ damage (2), and early pressurization of the true lumen might alleviate those effects. We use TEE-guided ascending aortic central cannulation using the Seldinger technique during surgery in a total number of 3 patients during 2024. All patients were operated by the same surgeon. TEE is used to confirm the position of the guide wire in the true lumen of the descending aorta, and after that needle was taken out, and the cannula was advanced over the guide wire TEE confirmed the accurate positioning of the cannulation into the true lumen (**Figures 1-4**Figure 2Figure 3Figure 4). It was achieved in all 3 patients. Aortic arch cannulation with the guidance of TEE during the aortic arch surgery is a simple, fast, safe, and less invasive technique for establishing cardiopulmonary bypass for Stanford type A aortic dissection. (4) FIGURE 1. True lumen identification. FIGURE 2. True lumen cannula. FIGURE 3. True lumen cannula color Doppler flow. FIGURE 4. True lumen flow on cardiopulmonary bypass.

Ivana Peršić, Ena Mršić, Tin Nadarević, Ivana Grgić Romić, Teodora Zaninović Jurjević

**Introduction:** Coronary artery anomalies (CAAs) are rare congenital conditions characterized by an abnormal origin or course of any of the three main epicardial coronary arteries. (1) Most often, CAAs are discovered accidentally during evaluations for ischemic heart disease. Patients are generally asymptomatic, but they may present with chest pain, syncope, or sudden cardiac death, particularly in young athletes. Incidence in the general population ranges from 0.24% to 1.3%. (2) **Case report:** We present the case of a 34-year-old male, referred to a cardiologist following the incidental detection of a heart murmur during a routine check-up. The patient was asymptomatic, with an unremarkable electrocardiogram. Transthoracic echocardiography revealed a bicuspid aortic valve (with peak transvalvular gradient of 16 mmHg), along with a mobile interatrial septum and mild atrial enlargement. Left ventricular systolic function was preserved, with no evidence of segmental wall motion abnormalities. For further evaluation, a CT angiography of the aortic valve and coronary arteries was performed, revealing an aberrant common origin of the right coronary artery (RCA) and the left main coronary artery (LM) arising from ​​the sinotubular junction, just above the left coronary cusp (LCC). Importantly, a malignant interarterial course of the RCA, passing between the ascending aorta and the pulmonary outflow tract, was observed. Given that the patient is a highly active special police unit member exposed to significant occupational stress, further evaluation was needed. A stress cardiac magnetic resonance imaging was done, which revealed possible inducible ischemia in the basal regions. **Conclusion:** Due to the potential for dynamic compression between the aorta and pulmonary artery, the anomalous origin of the RCA arising from ​​the sinotubular junction just above the LCC with a malignant interarterial course is considered a high-risk anomaly. In addition, a bicuspid aortic valve presents an added challenge in long-term follow-up and surveillance. This RCA course can lead to myocardial ischemia, syncope, arrhythmias, or SCD. (3, 4) This case underscores the critical importance of a thorough evaluation of incidental cardiac findings, as congenital coronary anomalies may carry life-threatening risks, even in asymptomatic individuals.

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

**Introduction:** Aortic regurgitation (AR) contributes to left ventricle (LV) eccentric remodeling due to both volume and pressure overload and. Etiological causes are multiple, but the most common cause of AR today is idiopathic degeneration with loss of elastin and collagen fibers. (1, 2) The aim of this study was to evaluate if degenerative etiology of AR contributes to worse outcomes in patients treated for significant AR. **Methods:** Our overall study population (SP) consisted of 123 patients with significant AR due to any cause. All patients were treated in University Hospital Centre Zagreb from 2017-2019 according to guidelines. Further on, a subpopulation of patients with degenerative aortic valve regurgitation (dAR) was analyzed using the same outcome parameters in order to compare mixed etiology (endocarditis, leaflet restriction, rheumatic disease, ascending aorta dilatation) of AR with dAV and highlight the impact of valve degeneration on outcomes. Study population characteristics are shown in **Table 1**. Outcomes included the change in LV end-diastolic volume (ΔEDV, ml), end-systolic volume (ΔESV, ml), ejection fraction (EF, %), myocardial mass (ΔLVMI, g/m2), MACE and mortality in a mean follow up time of 57 months. ### TABLE 1: Characteristics of the overall study population and the degenerative aortic regurgitation subgroup. | | **SP** | **SP** | **dAR** | **dAR** | | --- | --- | --- | --- | --- | | **N** | 123 | | 47 | | | **Age** | 58.7 | | 60.2 | | | **FU (months)** | 75 | | 57.4 | | | **Severe AR** | 80 | 65% | 35 | 74.50% | | **Moderate AR** | 35 | 28.40% | 12 | 25.50% | | **Mortality** | 16 | 13% | 8 | 17% | | **Male** | 99 | 81% | 38 | 80.80% | | **Female** | 24 | 19.50% | 9 | 19.20% | | **No coronary disease** | 89 | 72% | 34 | 72.30% | | **Mechanical AV** | 40 | 32.50% | 12 | 25.50% | | **Biologic AV** | 19 | 15.40% | 6 | 12.70% | | **Reconstructed AV** | 9 | 7.30% | 6 | 12.70% | | **CON** | 55 | 44.70% | 23 | 48.90% | | **AS** | 15 | 12.20% | 12 | 25.50% | [†] N-number of study population, AR-aortic regurgitation, FU-follow up, AV-aortic valve, CON-conservative treatment, AS-aortic stenosis **Results:** Both groups were comparable in age, sex and presence of coronary artery disease. In group dAR patients had more sever AR (65% in SP vs 74.5% in dAR) and more frequently accompanied aortic stenosis (12.2% vs 25.5%), **Table 2**. Patients with dAR had higher EDV at the point of diagnosis and in follow up, but more pronounced reduction in ESV with a tendency for recovery of EF and reduction in LVMI compared to SP. The dAR group showed tendency for less hospitalizations and MACE but higher incidence in mortality. ### TABLE 2: Change in echocardiographic parameters and clinical outcomes between the overall study population and the degenerative aortic regurgitation subgroup. | | **SP** | **SP** | **Δ** | **dAR** | **dAR** | **Δ** | | --- | --- | --- | --- | --- | --- | --- | | **EDV** | 187.4 | 151.9 | 35.5 | 201.0 | 164.6 | 36.4 | | **ESV** | 94.7 | 79.9 | 14.8 | 102.6 | 81.6 | 21.0 | | **EF** | 54.1 | 51.9 | 2.1 | 53.0 | 54.9 | -1.9 | | **LVMI** | 184.9 | 163.6 | 21.3 | 201.4 | 175.6 | 25.8 | | **MACE** | | 30 | 24.4% | | 10 | 21% | | **HOSP** | | 32 | 26% | | 8 | 17% | | **Mortality** | | 16 | 13% | | 8 | 17% | [†] End-diastolic volume-EDV, end-systolic volume-ESV, ejection fraction-EF, left ventricular mass index-LVMI, MACE- major adverse cardiovascular events, HOSP-number of hospitalizations, SP-overall study population, dAR-degenerative aortic- regurgitation, Δ- difference between primary values and in follow up **Conclusion:** Degenerative AR tends to be diagnosed and treated with delay, with more severe AR, accompanied AS and higher mortality rate compared to other etiological factors of AR.

Lana Maričić, Lucija Klobučar, Matija Drinković, Igor Lekšan

**Introduction**: Cardiac tumors are rare but represent a significant part of cardio-oncological practice. These masses include benign and malignant tumors and tumor-like conditions (thrombi, vegetations). Cardiac tumors may be found incidentally during echocardiographic examinations or may present with symptoms. They can manifest with systemic symptoms, followed by local propagation or embolization. (1, 2) **Case series**: The first case involves a young man who, has not any serious illness, until now. He was hospitalized at the Neurology Clinic due to an ischemic cerebral attack. An urgent brain CT revealed thrombosis of the venous sinus. Echocardiographic evaluation showed a tumor mass measuring 22x55 mm in the left atrium, which, based on morphological characteristics, was consistent with a myxoma, confirmed by pathological diagnosis (**Figure 1**). The patient was operated on eight days after hospitalization and discharged after seven days. The further postoperative course was uneventful. The second case involves a 56-year-old female patient who was actively treated by a hematologist for non-Hodgkin lymphoma, with a known history of hypertension, diabetes, and coronary disease. During hospitalization and while receiving immunochemotherapy, she experienced transient bradycardia and became dyspneic. She was transferred to the Cardiology Intensive Care Unit and an urgent FOCUS echocardiogram was performed (**Figure 2**), which confirmed a hyperechoic cardiac tumor in the right atrium without affecting hemodynamics. CT angiography of the pulmonary artery ruled out pulmonary thromboembolism and described a filling defect in the right atrium, suspicious for a thrombotic mass. Considering that the cardiac tumor was located immediately adjacent to the central venous catheter, a mechanical thrombectomy was contemplated, but the procedure was abandoned due to the risk of embolization. Prescribed fibrinolytic therapy, alteplase, but with no regression of the cardiac mass in the right atrium. After that, the patient underwent surgery, the post-procedural course was complicated by the development of sepsis, and the outcome was fatal. Pathohistological diagnosis confirmed that it is non-Hodgkin’s lymphoma, large B-cell type. FIGURE 1. Left atrial myxoma. FIGURE 2. Cardiac tumor in the right atrium, 40x25mm. **Conclusion**: Echocardiography is an effective method for detecting intracardiac masses. Details such as the shape, size, location and ultrasound characteristics, together with the patient’s clinical presentation, are key factors that can significantly help in making diagnosis.

Danijela Grizelj, Tomo Svaguša, Vanja Ivanović-Mihajlović, Hrvoje Falak, Petra Vitlov, Marija Radić, Jana Tarnik, Maja Špoljarić, Mario Udovičić

**Introduction**: The accuracy of transthoracic echocardiography (TTE) in estimating systolic pulmonary artery pressure (sPAP) by determining right ventricular systolic pressure (RVSP) compared to direct measurement with right heart catheterization (RHC) remains a clinical concern (1). This study aimed to assess the correlation, agreement, and diagnostic accuracy of echocardiographic RVSP in detecting pulmonary hypertension (PH) in a cohort of clinically stable patients undergoing both echocardiography and invasive pressure measurement. **Methods and Results**: This retrospective study was conducted at the Cardiology Department of Dubrava University Hospital, including 104 clinically stable patients who underwent TTE and RHC measurements within a 5-day period (**Figure 1**). Pearson’s correlation analysis demonstrated a strong positive correlation between echocardiographic and invasively measured sPAP (r = 0.709, P 20 mmHg), we performed a receiver operating characteristic (ROC) analysis. The optimal cut-off value for sPAP was 38 mmHg, yielding a sensitivity of 77.6% and a specificity of 66.7%. The area under the curve (AUC) was 0.746, indicating moderate discriminatory power. Despite a good correlation, the relatively wide limits of agreement and moderate specificity suggest that TTE alone may not be sufficient for definitive PH diagnosis. FIGURE 1. Relation of right ventricular systolic pressure (RVSP) measured by transthoracic echocardiography to systolic pulmonary artery pressure (sPAP) measured by right heart catheterization. **Conclusions:** Echocardiography-derived sPAP correlates well with invasive measurements but demonstrates considerable variability on an individual level. Although the ROC analysis supports its use as a screening tool, TTE alone lacks the precision required for definitive PH diagnosis. The identified cut-off of 38 mmHg provides a reasonable balance of sensitivity and specificity, but RHC remains necessary for confirmation and clinical decision-making. Future studies with larger cohorts are warranted to refine echocardiographic criteria for PH detection.

Tina Bečić, Andrija Matetić, Antonia Melada, Ivona Mustapić, Tea Domjanović Škopinić, Frane Runjić, Darija Baković Kramarić

**Introduction:** Mitral regurgitation (MR) is a common valvular disorder, occurring in up to 10% of the general population. Although surgery is the established treatment for primary MR (1), transcatheter edge-to-edge mitral valve repair (TEER) has been recommended as a reliable treatment option for selected patients with severe degenerative and functional mitral regurgitation (MR) (2). This report presents the case of a patient with severe primary degenerative mitral regurgitation due to partial papillary muscle rupture resulting with posterior mitral cusp flail. **Case report:** 78-year-old woman with a left-sided hemiparesis due to cerebrovascular insult, who overcame streptococcal endocarditis of the mitral valve treated conservatively five years ago, was admitted to the Cardiology department due to dyspnea. Transesophageal echocardiography showed posterior mitral cusp flail dominantly in P2 segment with complete chordae and partial papillary muscle rupture with consequent severe, eccentric mitral regurgitation directed anteriorly (**Figure 1**). Given the high risk of surgical intervention, the Heart team decided on a transcatheter edge-to-edge mitral valve repair (TEER). The procedure was extremely demanding due to avoidance of the floating part of papillary muscle. It was successfully performed using a single cobalt chromium plate (Mitraclip XTW) placed in the target regurgitant area (A2P2) with significant reduction of regurgitation (severe -> mild). Follow-up echocardiography confirmed correct A2P2 clip position with significant reduction in regurgitation with free floating part of papillary muscle and ruptured chordae between the left cardiac chambers during the cardiac cycle with an acceptable mean gradient (up to 5 mmHg) (**Figure 2**). The patient was closely monitored for any complications, and no further issues were observed. FIGURE 1. 2D and 3D imaging of posterior a mitral cusp flail dominantly in P2 segment, with complete chordae and papillary muscle rupture with consequent severe, eccentric mitral regurgitation directed anteriorly. FIGURE 2. Postinterventional A2P2 clip position with significant reduction in regurgitation and the free floating part of papillary muscle with ruptured chordae between the left cardiac chambers during the cardiac cycle with an acceptable mean gradient. **Conclusion**: This is technically extremely demanding procedure due to floating part of the papillary muscle which makes clipping even more difficult. To our knowledge, only one case has been recorded in Europe which further emphasizes the complexity of the procedure.

Petar Martinčić, Marin Međugorac, Ana Šutalo, Sandra Jakšić Jurinjak, Vlatka Rešković Lukšić, Marko Brinar, Jadranka Šeparović Hanževački

**Introduction:** Hypereosinophilic syndromes (HES) are defined as marked peripheral blood eosinophilia (> 1.5 × 109/L) associated with evidence of eosinophil-induced organ damage when secondary causes of hypereosinophilia are excluded (1). Cardiac involvement occurs in approximately 50% of the patients and has three stages: acute necrosis, thrombosis, and fibrosis. If left untreated, progression of the stages can be expected. **Case report:** 57-year-old female patient, with no known chronic illnesses was admitted to the hospital with abdominal pain and severe eosinophilia. During clinical evaluation, a computed tomography (CT) scan revealed thickening of the distal third of the esophagus, the pyloric part of the stomach, and the duodenum. An incidental finding was a mild pericardial effusion. Electrocardiography (ECG) demonstrated newly diagnosed paroxysmal atrial fibrillation (EHRA class I). This prompted cardiac evaluation and sampling of NT-proBNP and cardiac troponins, both significantly elevated. Mandatory echocardiography and coronary angiography were performed. Echocardiography showed infiltrated, hypoechogenic and hypocontractile lateral and inferoseptal wall (**Figure 1**) with preserved systolic function but reduced global longitudinal strain (**Figure 2****),** and impaired diastolic function with hemodynamically nonsignificant pericardial effusion. Coronary angiography ruled out coronary stenosis while cardiac MRI confirmed the echocardiographic findings. A subsequent hematological assessment was conducted which excluded lymphoproliferative disease. Additionally, multiple endoscopic biopsies showed no eosinophilic infiltration of the digestive tract. After serologic exclusion of parasitic cause for eosinophilia, treatment with systemic corticosteroids, guideline-directed medical therapy, and low-molecular-weight heparin was initiated. Over the following days, normalization of eosinophil blood count and a significant decline of cardiac enzymes was recorded that allowed discharge of the patient with multidisciplinary follow-up. FIGURE 1. Red arrow pointing at the infiltrated, hypoechogenic and hypocontractile lateral wall. FIGURE 2. Speckle tracking of the left ventricle, showing reduced global longitudinal strain -12.5%, with hypocontractile lateral segments. **Conclusion:** Hypereosinophilic syndrome causes acute cardiac involvement within 5 weeks and leads to a severe increase in cardiac enzymes (2). Clinical symptoms may be absent at this stage, but detection is possible with imaging and pathohistological methods. Early recognition is possible, and therapy should aim to reduce the eosinophil count, in our case with systemic corticosteroids, and prevention of thrombotic complications and heart failure.

Goran Međimurec, Irena Ivanac Vranešić, Ana Šutalo, Dražen Belina, Željko Đurić, Mislav Planinc, Kristina Marić Bešić, Hrvoje Gašparović, Darko Anić

**Introduction:** Residual pulmonary regurgitation often occurs after Tetralogy of Fallot (ToF) correction, while homograft degeneration is common in patients with right ventricle outflow reconstruction using a homograft, such as in Rastelli or Ross procedures. Stented bioprostheses have long been used as a robust, off-the-shelf implant for surgical pulmonary valve replacement (PVR) in these situations (1-3). However, optimal type of bioprosthesis in pulmonary position is a subject of debate. The aim of this study is to present our results with PVR using stented bioprostheses and to compare outcomes across prostheses types. **Patients and Methods:** This is a single center retrospective study including all patients that underwent PVR with bioprostheses at University Hospital Center Zagreb from January 2010 to January 2025. Implanted valves were divided by type into pericardial-internally mounted (PIM), pericardial-externally mounted (PEM) and porcine. Three endpoints were defined: prosthesis failure (defined as maximum peak pulmonary valve gradient of 50 mmHg or severe pulmonary regurgitation), reintervention on the pulmonary valve and all-cause mortality. **Results:** During the study period 94 PVRs were performed in 92 patients. Details are outlined in **Table 1**. Mean follow-up time was 146.1 months (95% confidence interval 134.5-157.8 months). The rates of freedom from pulmonary valve reintervention were 100%, 88% and 84% at 1, 2, and 5 years respectively. After dividing the cohort by valve types, Kaplan-Meier survival analysis was performed to compare time to endpoints between groups. Breslow test found statistical significance for prosthetic valve failure between the groups (p=0.036, **Figure 1**), while there was no significant difference for reintervention, or all-cause mortality. When comparing for prosthesis failure, PEM had shorter estimated mean times to prosthesis failure (72.7 months, 95% confidence interval (CI) 42.1-103.3), compared to PIM (111.1, 95% CI 89.1-133.2) and porcine prosthesis (136.5, 95% CI 117-156.1). ### TABLE 1: Cohort characteristics. | **Variables** | **Total cohort (N=94)** | | --- | --- | | Male sex, n (%) | 50 (53.2%) | | Age at surgery, y, median (IQR) | 27.5 (17.0-42.0) | | Age <18, n (%) | 25 (26.6%) | | BSA, m2, median (IQR) | 1.85 (1.57-2.04) | | Original diagnosis, n (%) ToF PS Ross (after AS/AR) other | 54 (57.4%) 15 (16.0%) 9 (9.6%) 16 (17.0%) | | Number of prior surgical procedures, mean ± SD | 1.0 ± 0.74 | | Repeated PVR, n (%) | 5 (5.3%) | | Indication for PVR, n (%) PR PS PR+PS Prosthetic valve thrombosis Endocarditis | 62 (66.0%) 17 (18.1%) 12 (12.8%) 2 (2.1%) 1 (1.0%) | | Type of prosthetic valve, n (%) Porcine Pericardial, internally mounted (PIM) Pericardial, externally mounted (PEM) | 42 (44.7%) 45 (47.9%) 7 (7.4%) | | Concomitant procedure, n (%) | 29 (30.9%) | | Valve size, mean ± SD | 24.99 ± 1.37 | | CPB time, min, median (IQR) | 109.0 (80.0-140.5) | | Prosthesis failure, n (%) | 14 (14.9%) | | Prosthesis replacement, n (%) Interventional, n (%) Surgical, n (%) | 12 (12.8%) 8 (8.5%) 4 (4.3%) | | All-cause mortality, n (%) Early, n (%) Late, n (%) | 8 (8.5%) 1 (1.1%) 7 (7.4%) | [†] IQR, Inter-quartile range; ToF, Tetralogy of Fallot; PS, Pulmonary stenosis; AS, aortic stenosis; AR, aortic regurgitation; SD, Standard deviation; PVR, Pulmonary valve replacement. FIGURE 1. Kaplan-Meier curve showing freedom from prosthesis failure across valve categories. PIM, PERICARDIAL - INTERNALLY MOUNTED; PEM, PERICARDIAL - EXTERNALLY MOUNTED **Conclusion:** We have demonstrated that PVR with stented bioprostheses is a reproducible technique with good mid-term results in the complex population of patients with congenital heart defects. Our findings corroborate the results of other groups (1-3) and raise concern about the use of PEM for this indication.

Bruno Ban, Kristina Krželj, Dorotea Bartoniček, Ivona Vučić, Ante Lekić, Hrvoje Gašparović, Željko Đurić

**Introduction**: Congenital mitral valve stenosis (CMS) is a rare entity of congenital heart disease (CHD). Mitral leaflets in this entity are dysplastic and short, chords are thickened, and papillary muscles are underdeveloped with reduced interpapillary distance. (1) Stenotic mitral valves have non-pliable leaflets, the amount of native tissue is very reduced and significantly less amenable to valve repair. (2) Prosthetic mitral valve replacement (MVR) in the pediatric population carries a great burden of morbidity and mortality. (3) Therefore, complex surgical techniques need to be utilized in attempts of mitral valve repair (MVr). Contrary to the high degree of freedom from reoperation in the adult population after the MVr, due to the somatic growth, congenital patients may undergo series of valve repairs. To illustrate this, we present a case of successful third-time mitral valve repair in a pediatric patient. **Case report**: We present a case of a 12-year-old girl with CMS. In the first year of life, she underwent ring annuloplasty with a flexible band. However, in the early postoperative period, she developed hemolytic anemia and was taken back to the operating room for edge-to-edge repair by the Alfieri stitch. At the age of 2 years, she underwent the second repair with a 24 mm Sorin Memo annuloplasty ring. She presented to our institution with severe mitral valve stenosis with mean PG of 15 mmHg and severe mitral valve regurgitation. A third re-do sternotomy was performed, the patient was placed on the cardiopulmonary bypass and the heart was arrested in the diastolic cardiac arrest. The access to the mitral valve was transseptal. The previous annuloplasty ring was excised, whereas the anterior mitral leaflet was augmented with anterior leaflet tissue from the homograft mitral valve. Finally, the annuloplasty was performed using a 28 mm Carpentier Edwards Physio II ring. Intraoperative transesophageal echocardiography revealed only trivial mitral regurgitation and maximal peak gradient of 4 mmHg. The postoperative course was uneventful. **Conclusion**: This case report highlights the safety and feasibility of the mitral valve re-do repair with anterior mitral valve leaflet augmentation using mitral homograft leaflet tissue in the mitral valve repair center of excellence.

Anita Jukić, Jasmina Ćatić, Ivica Kristić, Frane Runjić, Admira Bilalić, Ivana Gavran

**Introduction**: Prosthetic valve endocarditis is the most severe form of IE and occurs in 1–6% of patients with valve prostheses, which is similar following transcatheter (transcatheter aortic valve implantation, TAVI) or surgical aortic valve replacement. (1) The diagnosis of IE post-TAVI is challenging. Enterococcus species are most common microorganisms involved in IE post-TAVI. (2) **Case report**: We present the case of a 79-year-old male who underwent a TAVI procedure for severe aortic stenosis in September 2021. In March 2022, he was admitted to our institution with persistent fever. Serial blood cultures yielded Enterococcus faecalis, and transesophageal echocardiography (TEE) revealed suspected small vegetations on the bioprosthetic valve. The patient received a six-week course of ampicillin and ceftriaxone. In May 2022, he was readmitted due to fever and right wrist swelling. Blood cultures and joint fluid analysis were positive for Enterococcus faecalis. Transthoracic echocardiography and TEE demonstrated findings consistent with the prior episode. A six-week regimen of ampicillin and gentamicin was administered. Due to recurrent febrile episodes and an embolic event, the patient was evaluated by cardiac surgeons, who recommended continued antibiotic therapy. A positron emission tomography (PET) scan was performed (3) but showed no pathological tracer uptake in the valve or paravalvular region, no peripheral embolic lesions, and no evidence of other metabolically active disease. In July 2022, the patient was again admitted with septic arthritis of the right wrist and febrile episodes, with blood cultures once more positive for Enterococcus faecalis. Despite antibiotic therapy, recurrent bacteremia prompted a comprehensive re-evaluation. Ultimately, colonoscopy revealed rectal adenocarcinoma (CRC). The patient was subsequently managed with oncologic treatment, including radiotherapy, chemotherapy, and surgical resection. Following CRC treatment, he experienced no further episodes of prolonged fever. **Conclusion**: This case highlights the diagnostic complexity of persistent Enterococcus faecalis bacteremia following TAVI. It remains unclear whether the recurrent infections were due to infective endocarditis secondary to TAVI, bacteremia associated with an undiagnosed early-stage CRC, or a combination of both. Given the association between Enterococcus faecalis bacteremia/endocarditis and colorectal malignancy, colonoscopy should be considered in patients with persistent Enterococcus faecalis bacteremia to exclude CRC as an underlying source (4).

Anica Milinković, Ana Marija Slišković, Petra Angebrandt Belošević, Davor Radić, Richard Matasić, Eduard Margetić, Dejan Došen

**Introduction**: Papillary fibroelastomas (PFEs) are benign primary cardiac tumors, typically found downstream of the valves (1). They currently account for 10% of all cardiac tumors, with the incidence rising as the spatial resolution of imaging modalities improves. The pathogenesis is unclear, though it is suggested that they originate as microthrombi at sites of endothelial damage (2). While definitive diagnosis requires pathological identification, echocardiography offers high sensitivity and specificity for their detection (3). **Case series**: The first patient is a 62-year-old woman with a history of atrial fibrillation and hypertrophic cardiomyopathy, previously treated with alcohol septal ablation. During routine follow-up, echocardiography revealed a subvalvular mass connected to the anterior mitral cusp, most likely a PFE (**Figure 1**). Computed tomography (CT) confirmed a similar finding (**Figure 2**). The patient was not compliant with the recommended surgery; therefore anticoagulant therapy was continued along with regular follow-up. Magnetic resonance imaging (MRI) performed one year later showed no change in the tumor’s size (**Figure 3**). FIGURE 1. Transesophageal (left) and transthoracic echocardiogram (right) of the mitral valve papillary fibroelastoma (marked with white arrows). FIGURE 2. A CT image of a mitral valve papillary fibroelastoma (marked with a black arrow). FIGURE 3. A cine-MRI image of a mitral valve papillary fibroelastoma (marked with a white arrow). The second patient is a 70-year-old man who was referred to the cardiology department for further evaluation due to peripheral edema. Echocardiography revealed a mobile tumor on the tricuspid valve, most likely a PFE, along with moderate tricuspid regurgitation (**Figure 4**). The diagnosis was confirmed by CT and MRI (**Figure 5**), which also showed partial anomalous pulmonary venous connection with a significant left to right shunt. Given the significant clinical improvement with medications, conservative treatment was continued. FIGURE 4. Tricuspid valve papillary fibroelastoma (marked with a white arrow) on transthoracic echocardiography (left). Transthoracic Color Doppler showing moderate tricuspid regurgitation (right). FIGURE 5. Tricuspid valve papillary fibroelastoma (marked with white arrows) on CT (left) and cine-MRI images (right). The third patient is a 75-year-old woman who was hospitalized following an ischemic stroke. Electrocardiogram showed atrial fibrillation, whereas echocardiography showed a PFE on the aortic valve (**Figure 6**). Warfarin was initiated, and the patient was referred for elective PFE excision. Unfortunately, a month later, the patient experienced another stroke, which had a fatal outcome. FIGURE 6. Aortic valve papillary fibroelastoma (marked with white arrows) on transthoracic echocardiography. **Conclusion**: While PFEs are often asymptomatic and found incidentally, they can also present with embolic manifestations like stroke, myocardial infarction, or sudden death (2). Surgical excision is recommended for larger left-sided PFEs in eligible patients due to the risk of embolization, or during cardiac surgery for another condition. Otherwise, antiplatelet agents may be considered (3).

Dubravka Šušnjar, Tomislava Bodrožić Džakić Poljak, Tomo Svaguša, Davor Barić, Daniel Unić, Josip Varvodić, Marko Kušurin, Savica Gjeorgjievska, Gloria Šestan, Nikola Slišković, Šime Manola, Igor Rudež

**Introduction**: Left ventricular pseudoaneurysm (PSAN) is a rare condition that occurs because of myocardial free wall rupture, mostly located posterolateral. The most prevalent causes of PSAN are acute myocardial infarction (55%), cardiac surgery (33%), trauma (7%) and infection (5%). It can be asymptomatic, but it may also cause symptoms of heart failure, arrhythmias, thromboembolic events, and sudden cardiac death (1). Treatment is surgical. **Case report**: 50-year-old patient experienced a myocardial infarction without ST elevation. Angiography revealed severe stenosis of the mid-LAD (LAD = left anterior descending artery) and subocclusion of the OM2 (second obtuse marginal) branch. The LAD lesion was treated with stent implantation, and the obtuse marginal arteries lesion were addressed with drug-coated balloons. Echocardiography showed a dilated left ventricle, reduced global ejection fraction (LVEF 38%), and hypokinesia of the inferoposterolateral wall. During a regular cardiology follow-up after 3 months, the patient was asymptomatic, normotensive, and had normal heart rate. The laboratory findings showed only slightly elevated NT-proBNP levels at 1214 pg/ml. Echocardiography revealed a large PSAN of the posterolateral wall. The wall defect measured 34x35mm, and the PSAN itself was almost 7 cm in size, with some thrombotic deposits present (**Figure 1A**). Computed tomography confirmed the presence of a large PSAN in basal posterolateral wall (**Figure 1B**). The patient underwent cardiac surgery, which involved the excision of the LV pseudoaneurysm and patch repair of free wall rupture. The operation was uneventful (Dor procedure) (**Figure 2**). Follow-up echocardiography showed echogenic myocardium of the posterolateral wall (patch), no interruption of myocardial continuity, and continued hypokinesia and dyskinesia of the same region (**Figure 3A**). The global LVEF was reduced to 35%. Postoperative CT confirmed no residual wall microdefects (**Figure 3B**). The patient’s postoperative recovery proceeded well, and he was discharged 7 days postoperatively. FIGURE 1. A) preoperative transthoracic echocardiogram: the four chamber view showing pseudoaneurysm (PSAN) of the posterolateral wall; B) preoperative computed tomography: large PSAN in the basal posterolateral wall. FIGURE 2. Intraoperative photographs show the posterolateral left ventricular pseudoaneurysm. FIGURE 3. A) Postoperative transthoracic echocardiogram: the two chamber view showing the basal lateral wall patch; B) postoperative computed tomography: no residual wall microdefects. **Conclusion**: Asymptomatic patients with PSAN are quite rare and echocardiography is key method for early diagnosis. Surgical treatment is recommended for large pseudoaneurysms, symptomatic patients, and for those discovered within 3 months after myocardial infarction. Due to significantly higher perioperative mortality for patients with PSAN occurring within 2 weeks of myocardial infarction, it should consider deferring surgery for patients with stable acute ventricular pseudoaneurysms to reduce the risks associated with early repair (2).

Fabio Kadum, Ana Petretić, Koraljka Benko, Ivana Smoljan

**Introduction**: Peripartum cardiomyopathy (PPCM) is characterized by symptomatic left ventricular (LV) systolic dysfunction with ejection fraction (EF) usually <45%, with or without LV enlargement, developing during the last month of pregnancy or in the first 5 months after delivery, abortion, or miscarriage in women without previously known heart disease (1). Diagnosis is made after exclusion of other causes of LV dysfunction that are encompassed in a wider term of peripartum-associated cardiomyopathies (PPAC). They vary in etiology, including multiple acquired and inherited disorders (2-4). We present a case series of multiple PPACs. **Case series**: The first case is a 45-year-old woman with a history of multiple pregnancies, hospitalized in 2016 for heart failure (HF), three months postpartum. Echocardiography confirmed significantly reduced LVEF of 20% with LV dilatation. An invasive and noninvasive cardiology workup yielded normal results. Cardiac MRI confirmed reduced LV function with no fibrosis. With regular monitoring and therapy, LV function recovered (EF 60%) within a year. She is now asymptomatic. The second case involves a 37-year-old woman hospitalized in 2024 for HF, two weeks postpartum. She had previously been diagnosed with congenital LV apical aneurysm. Echocardiography showed preserved LV function (EF 55%) and asymmetric hypertrophy of the interventricular septum, primarily at the midventricular level. CT coronary angiography identified an anomalous origin of the right coronary artery. Cardiac MRI confirmed hypertrophic obstructive cardiomyopathy (HCM). Further testing showed no significant pressure gradient across the LV. Genetic testing confirmed a hereditary form of HCM. The patient is now stable and under treatment. Lastly, the most recent case involves a 21-year-old woman hospitalized for cardiogenic shock and preeclampsia, one day postpartum. She required mechanical ventilation and vasopressor support. Echocardiography confirmed significantly reduced LV function (EF 30%). After brief stabilization, she experienced cardiac arrest, was resuscitated and emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation followed. Her condition was further complicated by multiple surgical interventions due to a retroperitoneal hematoma, multi-organ failure, and ultimately, cerebral edema with intracerebral hemorrhage. Despite intensive treatment, she died a month later. **Conclusion**: This case series demonstrates the heterogeneity of PPACs, ranging from reversible PPCM to previously unrecognized HCM and finally, cardiomyopathy associated with preeclampsia. The outcomes varied from full recovery to maternal death. Etiology-specific understanding is essential for optimizing both maternal and fetal outcomes in these high-risk scenarios.

Bruno Ban, Kristina Krželj, Ivona Vučić, Daniel Dilber, Ante Lekić, Hrvoje Gašparović, Željko Đurić

**Introduction**: Congenital tricuspid valve (TV) malformations are very rare entities. The two most common types are Ebstein’s anomaly (EA) and tricuspid valve dysplasia (TVD). Although very similar, there are distinct differences between these conditions. EA is hallmarked by apical displacement of the tricuspid valve, failure of leaflet delamination from the underlying myocardium and a variable degree of myocardial dysfunction. (1) These features are absent in TVD, where tricuspid valve leaflets are thickened, chordal apparatus is foreshortened and may be ruptured. (2) Notwithstanding these well-defined differences, distinguishing between these two conditions is often difficult. Herein, we present a young patient who underwent tricuspid and pulmonary valve repair at our institution. **Case report**: The patient is an 18-year-old female who was misdiagnosed with EA as a neonate. In the neonatal period, she underwent the Rashkind procedure and pulmonary valve balloon dilatation due to the pulmonary stenosis (PS). At the age of 4, atrial septal defect was percutaneously closed with Amplatzer device. At the age of 15, she underwent cardiac magnetic resonance imaging, which revealed severe TV insufficiency with a regurgitation fraction of 50%, severely dilatated right ventricle with end-diastolic volume of 210 ml and a mild pulmonary regurgitation. Surgical correction was performed via median sternotomy, on cardiopulmonary bypass and in diastolic cardiac arrest. An aortic homograft leaflet was used to partially neocuspidise the PV. Tricuspid valve repair comprised of ring annuloplasty with Edwards MC3 30mm ring, anteroseptal commissure closure and the modified Sebening stitch, i.e. approximation of the heads of the anterior and septal papillary muscle. Intraoperative transesophageal echocardiography showed excellent surgical results, without TV regurgitation and only a trace of PV regurgitation. The postoperative course went uneventfully. **Conclusion**: Combined TV and PV regurgitation in young adult patients presents a challenging surgical problem. Valve repair is of immeasurable value to this population as it restores life expectancy comparable to the age- and gender-matched population. In patients with congenital TV insufficiency, multimodal imaging is crucial for precise diagnosis. Furthermore, this case report highlights the safety and feasibility of multiple combined valve repairs in the valve repair centre of excellence.

Dubravka Šipuš, Ana Maria Slišković, Richard Matasić, Davor Radić, Petra Angenbrandt Belošević, Eduard Margetić, Vedran Velagić, Ivo Planinc, Maja Čikeš, Boško Skorić, Dora Fabijanović, Ana Mataić, Davorin Herceg, Hrvoje Gašparović, Davor Miličić, Daniel Lovrić, Dejan Došen

**Introduction:** Primary cardiac tumors are a rare entity, accounting for 0.3-0.7% of all cardiac tumors. Only 25% of primary cardiac tumors are malignant, and of these, 75% are sarcomas. Malignant primary cardiac tumors typically affect young patients and have poor prognosis, with a one-year survival rate of around 10% (1, 2). **Case report:** 35-year-old female, without any known previous comorbidities, was admitted with suspected pericarditis. The patient had experienced flu-like symptoms one month prior to admission, and her symptoms of fever (up to 38.1°C) and chest pain with inspiration began a few days before admission. Initial laboratory work-up revealed anemia (hemoglobin 99 g/L), slightly elevated leukocytes (11.3x10^9/L), and elevated CRP (249 ng/L), with normal troponin levels. Chest X-ray revealed an enlarged heart silhouette, suggestive of pericardial effusion, and small bilateral pleural effusions. Initial echocardiography showed a large circumferential pericardial effusion (maximum of 3 cm) and a large mass infiltrating the right ventricle (67x23 mm), along with a smaller mass infiltrating the left ventricle (**Figure 1**). Given the suspicion of a cardiac tumor, detailed radiological diagnostics were performed. Multislice spiral computed tomography (MSCT) showed a hypovascular tumor infiltrating the right ventricle with characteristics suggestive of sarcoma (**Figure 2**). One of the branches of the right coronary artery was infiltrated by the tumor. Magnetic resonance imaging revealed a large (7.3x5.3x7.5 cm) expansive, inhomogeneous mass between the pericardial layers, infiltrating the right ventricular wall, and showing radiological characteristics of sarcoma. The pericardium was thickened, with dense pericardial effusion (**Figure 3**). Multiple intracardiac echocardiography and MSCT-guided biopsies were performed. The final histopathological diagnosis was myxoid pleomorphic liposarcoma, an extremely rare and aggressive subtype of liposarcoma with a predilection for the mediastinum, particularly affecting young adults (2). Staging with positron emission tomography did not show signs of metastatic dissemination. Given the high surgical risk, the multidisciplinary team recommended chemotherapy with Adriamycin and Ifosfamide as the first-line treatment but later cardiectomy and implantation of two HeartMate3 ventricular assist devices as form of total artificial heart was performed. FIGURE 1. Echocardiography showing a large mass infiltrating the right ventricular wall. FIGURE 2. Multislice spiral computed tomography of the tumor. FIGURE 3. Magnetic resonance imaging of the tumor. **Conclusion:** Although primary cardiac tumors are extremely rare, a comprehensive diagnostic approach using multiple imaging modalities is essential in cases of suspicion.

Ada Đozić, Edin Begić, Zorica Mladenović

**Introduction:** Presentation of the importance of using three-dimensional transesophageal echocardiography (3DTOE) in assessing the morphology and functionality of the shunt. **Case report:****Figure 1** shows a bicuspid aortic valve with a persistent raphe between the non-coronary cusp (NCC) and right coronary cusp (RCC), and the coaptation line positioned between 11 o’clock and 5 o’clock. In the right sinus of Valsalva projection, a residual minimal fistulous communication (4.57x3.62 mm 3D reconstruction) is seen, allowing a connection between the left ventricle (LV) and right atrium (flow direction towards the LV, clearly identified by Color – Gerbode ventricular septal defect (VSD)). (1-3) The patient’s findings additionally include anterior mitral leaflet prolapse at the A2 segment, along with several minor semi-clefts on the posterior mitral leaflet and mild mitral regurgitation (MR) with four jets. No thrombotic mass is observed in the left atrial appendage (LAA). The tricuspid valve is trileaflet, with prolapsing segments, leading to mild functional tricuspid regurgitation (TR). The interatrial septum shows slight aneurysmal dilation, with multiple perforations and detected flow. FIGURE 1. Fistulous connection between the left ventricle and right atrium (flow clearly identified by Collor – Gerbode defect). **Conclusion:** The use of 3DTOE improves the understanding of complex cardiac structures by providing a more realistic and detailed visualization. It is becoming increasingly recommended for the identification, monitoring, and management of grown-up congenital heart (GUCH) patients.

Antonia Melada, Andrija Matetić, Ivona Mustapić, Tea Domjanović Škopinić, Tina Bečić, Frane Runjić, Darija Baković Kramarić

**Introduction:** Paravalvular leaks (PVLs) after surgical valve replacement have a multifactorial etiology. Mitral PVLs are more frequent than aortic PVLs and are more common in patients with mechanical as opposed to those with biological prosthesis. Patients with clinically relevant PVLs most frequently present with symptoms of heart failure, with some degree of hemolysis. (1, 2) **Case report:** 55-years-old male who underwent mitral valve replacement with a mechanical heart valve (St. Jude Medical Masters, M-33) two years earlier due to mitral valve insufficiency was now hospitalized because of suspected heart failure. He was also recently surgically treated for lung cancer with ongoing adjuvant chemotherapy. Laboratory tests were indicative of significant anemia with hemoglobin level of 81 g/L, with elements of hemolysis. Transthoracic echocardiography (TTE) revealed moderate to severe mitral PVL. Further multimodality imaging evaluation was performed (transesophageal echocardiography, cardiac computed tomography, magnetic resonance) and confirmed significant PVL originating from anteromedial region (**Figure 1****)**. The case was discussed with cardiac surgeons and because of high perioperative risk of complications, we decided to perform percutaneous transcatheter TOE guided PVL closure. The procedure was successfully preformed using a 10x5 mm Amplatzer Vascular Plug III (AVP3) (**Figure 2**). Post-procedure echocardiographic controls confirmed the effective PVL closure with only trace of residual regurgitant jet. FIGURE 1. Preprocedural transesophageal echocardiography showing a paravalvular leak originating in the anteromedial region. FIGURE 2. A) Postprocedural transesophageal echocardiography (TEE) showing good results with only a trace of residual paravalvular leak. B) 3D reconstruction of TEE appearance of the Amplatzer Vascular Plug III (indicated with the red dot). **Conclusion:** Even though surgical reoperation is still considered as the first therapeutical option for patients with symptomatic PVLs, percutaneous transcatheter PVL closure is emerging as an alternative treatment for this high-risk group.

Iva Golubić, Antun Zvonimir Kovač, Sandra Jakšić Jurinjak, Marija Brestovac, Vedran Velagić, Ivan Prepolec, Andrija Nekić, Vedran Pašara, Vlatka Rešković Lukšić

**Introduction:** Echocardiographic measurements, such as left atrial (LA) volume, strain, and diastolic dysfunction, have been identified as valuable predictors of atrial fibrillation (AF) recurrence after ablation (1, 2). These factors are associated with structural remodelling, including atrial myocardial fibrosis, which may contribute to an increased likelihood of recurrence (3). In this study, we aimed to evaluate echocardiographic predictors of AF recurrence in our patient population. **Patients and Methods:** We conducted a retrospective analysis of patients who underwent AF ablation between February 2022 and September 2024. AF recurrence during follow-up up was recorded. Data comparison between patients with and without recurrence was performed using t-tests and chi-square. **Results:** A total of 39 patients with preprocedural echocardiography examination available for further analysis were identified and included in the analysis. Baseline characteristics, laboratory findings, and echocardiographic measurements are summarized in **Table 1**. Statistical analysis revealed a significant difference between the recurrence and non-recurrence groups in LA reservoir strain (p=0.002) and E/e’ ratio (p<0.001). ### TABLE 1: Statistical analysis of echocardiographic measurements. | | **No recurrence** | **AF recurrence** | **p value** | | --- | --- | --- | --- | | Age | 63.83±8.43 | 68.27±9.57 | 0.138 | | Female | 10 (41.7%) | 7 (46.7%) | 0.759 | | NTproBNP | 125.75±80.83 | 1222.17±2493.77 | 0.142 | | Diastolic dysfunction | Grade 0 = 4 (16.7%) Grade 1 = 16 (66.7%) Grade 2 = 4 (16.7%) | Grade 0 = 0 (0.0%) Grade 1 = 8 (53.3%) Grade 2 = 7 (46.7%) | 0.057 | | LAVI | 34.38±7.79 | 38.07±9.68 | 0.198 | | LA strain | 26.58±5.30 | 19.33±8.23 | 0.002 | | RAV | 33.08±9.98 | 37.13±9.93 | 0.224 | | RAA | 14.13±2.74 | 14.93±2.52 | 0.362 | | sPAP | 21.71±6.92 | 23.54±8.41 | 0.519 | | Deceleration time | 268.13±83.38 | 236.40±79.46 | 0.247 | | E/A | 1.03±0.40 | 1.61±0.51 | 0.381 | | IVRT | 101.46±24.98 | 105.93±32.77 | 0.632 | | E/e’ | 6.75±1.82 | 9.60±2.32 | <0.001 | | | | | | | Total | 24 (61.5%) | 15 (38.5%) | | [†] LAVI - left atrium indexed volume, LA – left atrium, RAV - right atrium volume, RAA- right atrium area, sPAP - systolic pulmonary artery pressure, E/A - transmitral E wave and A wave ratio, IVRT - isovolumic relaxation time, E/e’ - peak early diastolic velocity of mitral inflow and mitral annular motion ratio **Conclusion:** Although our study is limited by a small sample size, the findings align with previous research, suggesting that LA strain and E/e’ ratio may serve as valuable predictors of atrial fibrillation recurrence. Future studies with larger cohorts are needed to confirm these results and integrate these echocardiographic parameters into clinical management strategies.

Karla Schwarz, Nino Petroci, Luka Perčin, Andrea Studen, Blanka Glavaš-Konja, Sandra Jakšić Jurinjak, Joško Bulum, Boško Skorić, Zvonimir Ostojić, Vlatka Rešković-Lukšić, Jadranka Šeparović-Hanževački

**Introduction:** Transcatheter edge-to-edge repair (TEER) is a minimally invasive procedure aimed at treating patients with mitral or tricuspid regurgitation who are at high surgical risk. This technique allows access to the valves without open-heart surgery. A catheter, inserted through an intravenous line, guides a clip device (e.g. MitraClip or TriClip) to the affected valve, where it grasps the leaflets and pulls them together to reduce the regurgitation orifice (1, 2). **Methods and Results:** We analyzed 34 patients with mitral regurgitation treated with MitraClip. Among them, 14.7% (n=5) required two clips. The average follow-up was 18 ± 16 months, with a mortality rate of 14.7% (n=5), occurring on average 17 months post-procedure. Hospitalization for heart failure was necessary in 8.8% (n=3) of patients after a successful procedure, and re-intervention was required in 5.9% (n=2). We observed a significant reduction in NT-proBNP levels, declining from an average of 7516 pg/mL before the intervention to 1595 pg/mL afterward. The average daily dose of furosemide was significantly reduced from 150 mg to 88 mg. Importantly, NYHA functional status improved, reflecting better symptom management and enhanced functional capacity (**Figure 1**). Concerning tricuspid regurgitation, 12 patients underwent treatment with TriClip, with two clips required in 66.7% (n=8) of cases. The average follow-up period was 6 ± 4 months, with no mortality. Hospitalization for heart failure occurred in 25% (n=3). Post-procedure follow-up indicated notable improvement in NYHA status (**Figure 2**). FIGURE 1. New York Heart Association (NYHA) status before and after MitraClip (MC) procedure. FIGURE 2. New York Heart Association (NYHA) status before and after TriClip (TC) procedure. **Conclusion:** Both MitraClip and TriClip procedures significantly enhance the functional status of patients with mitral and tricuspid regurgitation. MitraClip treatment resulted in reductions in NT-proBNP levels and diuretic requirements. While some patients required re-intervention or hospitalization, overall mortality remained consistent with expectations. These findings demonstrate the effectiveness of TEER in improving quality of life and managing heart failure symptoms.

Željko Đurić, Hrvoje Gašparović

**Introduction**: Improved long-term outcomes and proven survival benefit (1, 2) of the aortic valve-sparing surgery and the Ross procedure increased their utilization in patients with aortic root pathology at comprehensive valve centers. The primary goal of reconstructive surgery is to reestablish normal aortic root anatomy and proper valve motion and function. In cases of aortic root pathology, echocardiography plays a crucial role in defining valve morphology, quantifying aortic regurgitation and its mechanisms, assessing the quality of the valve tissue, and analyzing the performed surgery. The 2D and 3D echocardiography are the keystone in patient selection and predicting the likelihood of a successful reconstruction. (3) However, finding the best alternative for young and middle-aged adults necessitating aortic valve replacement (AVR) is a challenge for the heart team. For young patients with aortic valve disease, the Ross procedure presents a viable substitute compared to prosthetic AVR. (4) **Patients and Methods**: We retrospectively analyzed patients with aortic root dilatation, aortic insufficiency, aortic stenosis, or mixed aortic valve disease who underwent complex aortic root surgery at our institution from September 2022 to March 2025. This surgery included the David procedure, Florida sleeve modification, isolated aortic valve repair, and Ross procedure. **Results**: Among 67 identified patients (16 (23%) were females), 41 (61.2%) underwent David procedure, 4 (6%) the Florida sleeve, 11 (16.4%) isolated aortic valve repair, and 11 (16.4%) the Ross procedure. There were 49 adults (73%), mean age of 44 years (23-77; SD 13.1) and 18 (27%) pediatric patients, mean age of 9 years (0-17; SD 6.0). The median EuroScore II for adults was 5.7% (IQR 4.5-8.0), and there was no in-hospital mortality. **Conclusion**: Despite the complexity of the aortic root functional anatomy, the modern surgical approach in complex aortic root surgery and Ross procedure is associated with better long-term outcomes than AVR (1, 2, 4). The success of aortic valve-sparing surgery and the Ross procedure greatly relies on the dialogue between cardiac surgeons and imaging cardiologists. An accurate, systematic, and detailed echocardiography analysis, particularly 3D techniques, facilitates surgical planning and represents the key to success in this evolving field with the brightest future in heart valve surgery.