Cardiologia Croatica. 2025;20(7-8)

Jana Brguljan-Hitij, Zbigniew Gaciong, Dragan Simić, Peter Vajer, Parounak Zelveian, Irina E. Chazova, Bojan Jelaković

Blood pressure (BP) control is a primary clinical objective in managing patients with hypertension. In Croatia, only 20% of patients with hypertension achieve BP control, with a disparity between men (15%) and women (25%). To address this issue, recent discussions and investigations have focused on sex-related differences in BP control. The PRECIOUS trial was designed to evaluate the treatment response to dual and triple single-pill combinations (SPCs) of perindopril/amlodipine and perindopril/amlodipine/indapamide in men and women with hypertension. The results indicate that initiating antihypertensive treatment in newly-diagnosed patients or intensifying treatment in uncontrolled patients with perindopril-based SPCs (dual and triple) leads to effective BP reduction in both men and women, with higher absolute reduction in women. After 16 weeks, 75% of men and 87% of women achieved office BP control. The trial also demonstrated significant reductions in 24-hour BP and central systolic BP (cSBP). A total of 68% of men and 76% of women achieved the target 24-hour systolic BP, while 68% of men and 73% of women attained cSBP control. Regardless of the examined parameter, women achieved better BP control than men. The findings highlight the efficacy and safety of perindopril-based SPCs in both sexes, with notable sex differences in BP response.

Nora Knez, Tomislav Tokić, Hrvoje Gašparović

**Background**: Postoperative atrial fibrillation (POAF) remains a frequent complication following valve surgery, contributing to increased morbidity and prolonged hospitalization. (1, 2) Existing risk stratification models demonstrate limited predictive value. Peak atrial longitudinal strain (PALS), a marker of left atrial functional remodeling, may improve preoperative risk assessment. (3) **Methods**: A PRISMA-compliant systematic review was conducted. From a validated base of 31 observational studies on echocardiographic predictors of POAF, we identified 3 studies exclusively involving isolated valve surgery patients. These studies underwent ROBINS-I risk of bias assessment and GRADE evidence quality evaluation. Standardized mean differences (Hedges’ g), 95% confidence intervals (CI), and standard errors (SE) were calculated. A random-effects meta-analysis was performed; heterogeneity was assessed using the I2 statistic. **Results**: All three studies demonstrated significantly lower preoperative PALS values in patients who developed POAF Pooled effect sizes were large and consistent (**Figure 1**): Motoki et al. (g=1.63, 95% CI 1.14–2.12), Kim et al. (g=1.45, 95% CI 0.99–1.90), Ancona et al. (g=1.50, 95% CI 0.98–2.02). No heterogeneity was observed (I2=0%). Reported PALS cut-off values across the studies ranged from 23% to 26%, with corresponding AUC values between 0.90 and 0.93, indicating excellent discriminative performance. FIGURE 1. Forest plot showing peak atrial longitudinal strain and postoperative atrial fibrillation in valve surgery. **Conclusion**: Preoperative reduction in PALS is strongly associated with POAF in valve surgery. This focused meta-analysis is the first to evaluate PALS exclusively in isolated valve surgery patients. It demonstrates that the predictive power of PALS remains robust in this clinically distinct subgroup, with large effect sizes and no heterogeneity across studies. These findings support the integration of PALS into preoperative risk assessment protocols for valve surgery patients, where atrial structural and functional remodeling is particularly relevant. This work adds novel evidence that may inform tailored prophylactic strategies and future guideline development.

Krešimir Kordić, Ozren Vinter, Ivica Šafradin, Nikola Bulj, Matias Trbušić

**Introduction:** Severe primary mitral regurgitation predisposes patients to serious complications, including infective endocarditis, which remains a life-threatening disease with high morbidity and mortality, particularly when affecting previously damaged valves (1, 2). The mitral valve is among the most involved sites (3). We present a case of mitral valve endocarditis in a patient previously followed for severe primary mitral regurgitation, highlighting diagnostic and therapeutic challenges. **Case report:** 50-years-old male patient with known severe asymptomatic primary mitral regurgitation (P2/P3 prolapse) was admitted due to persistent fever. There were no signs or symptoms of heart failure. Blood cultures came positive with coagulase-negative Staphylococcus and suspicion of endocarditis was raised. Transesophageal echocardiography revealed large vegetations on both mitral leaflets, with larger one on the posterior mitral leaflet (15x16 mm), suspected chordal rupture and severe regurgitation (**Figure 1**). The patient was started on standard antibiotic treatment according to ESC guidelines. No signs of septic embolization were found. Given the size and mobility of the vegetation, early surgery was considered. Nine days later, the patient was transferred to Cardiac Surgery Department where he underwent mitral valve replacement (Epic Mitral 33 mm). Pseudomonas spp. was isolated from the vegetation and targeted antibiotic treatment with meropenem was administered for a total duration of four weeks with repeated negative blood cultures. Afterwards, the patient was discharged and remained asymptomatic on follow-up. FIGURE 1. Large vegetation on the posterior mitral leaflet and smaller vegetation on the anterior mitral leaflet. **Conclusion:** This case highlights severe primary mitral regurgitation as a predisposing factor for infective endocarditis of the mitral valve. However, the pre-existing regurgitation may have played a protective role by preventing acute cardiac decompensation during infection.

Jozica Šikić, Zrinka Planinić, Jelena Faletar Barišić

**Introduction**: Transthyretin cardiac amyloidosis (ATTR-CM) frequently coexists with aortic stenosis (AS), particularly in patients over 65 years, with a reported prevalence of 4–16%, especially among those undergoing transcatheter aortic valve implantation (TAVI). Identifying concomitant ATTR-CM in AS is challenging due to overlapping features, yet it is crucial for accurate diagnosis and optimal management (1). **Case report**: 83-year-old male patient with a history of arterial hypertension, hyperlipidemia, and a previous cerebrovascular stroke was hospitalized due to progressive dyspnea and chest discomfort. Physical examination revealed a midsystolic precordial murmur and the presence of peripheral edema. Laboratory analysis demonstrated elevated levels of N-terminal pro–B-type natriuretic peptide. Transthoracic echocardiography showed a normal-sized left ventricle with concentrically thickened and hyperechoic walls (17 mm), preserved ejection fraction, but reduced global longitudinal strain with an apical sparing pattern and miminal pericardial effusion. Furthermore, there was an estimation of low-flow, low-gradient severe AS (AVA VTI 0.9 cm2) with CT calculated calcium score of 1475. Coronary angiography showed no signs of coronary artery disease. Due to echocardiographic suspicion of cardiac amyloidosis, the patient underwent targeted diagnostic evaluation. Hematological workup excluded systemic light-chain (AL) amyloidosis. Tc-99m-pyrophosphate bone scintigraphy combined with SPECT/CT revealed intense radiotracer uptake in the myocardium, corresponding to a Perugini grade 3. This confirmed ATTR-CM diagnosis in our patient, which also explains relatively lower aortic valve calcium score than expected. After Heart Team discussion, the patient was accepted for TAVI procedure, which was later performed successfully. The patient remained stable during six months follow-up. **Conclusion**: Patients with concomitant AS and ATTR-CM exhibit significantly poorer clinical outcomes compared to those with isolated AS (2), underscoring the importance of early recognition and tailored management of this high-risk subgroup. Echocardiography has a crucial role in identifying early signs of ATTR-CM, which should prompt further diagnostic evaluation.

Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Krešimir Gabaldo, Blaženka Miškić

Aortic stenosis (AS) is the most common valvular heart disease in the elderly, associated with high morbidity and mortality. Its pathophysiology involves inflammation, fibrosis, and calcification of the aortic valve. At the same time, the global prevalence of obesity continues to rise at an alarming rate, becoming one of the most significant public health concerns. Recently, obesity has emerged as an important risk factor influencing AS development. Obesity affects hemodynamics, promotes systemic inflammation, and alters metabolism, potentially accelerating the progression of valvular degeneration. Epidemiological studies, including the Cohort of Swedish Men and the Swedish Mammography Cohort, have shown a significant association between body mass index (BMI), waist circumference (WC), and the risk of clinically significant AS (1). According to a study by Kontogeorgos et al, (2) women with overweight or obesity have an increased likelihood of being diagnosed with aortic stenosis, with elevated risk observed even in those with high-normal BMI values. Recently published data from the Copenhagen General Population Study indicated an association between genetically determined obesity and the risk of developing symptomatic aortic stenosis and the need for intervention, independent of traditional cardiovascular risk factors (3). However, obesity remains a long-term risk factor for cardiovascular and metabolic complications. glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP) receptor agonists, used for type 2 diabetes and obesity, may provide cardiovascular benefits, but their role in AS remains uncertain (4). More research is needed to determine their impact on AS progression and outcomes. Given the link between obesity and AS, prevention and treatment of obesity are key. Identifying obesity as a modifiable risk factor may support earlier detection and more effective management of AS risk.

Zrinka Planinić, Ines Zadro Kordić, Ante Petrović, Jozica Šikić

**Introduction**: Complete heart block is an uncommon but serious complication of infective endocarditis occurring due to paravalvular extension of infection, including the cardiac conduction system (1, 2). Cardiac implantable electronic device (CIED) infections represent one of the most serious complications of device-therapy (3). Therefore, management of patients with infective endocarditis and complete heart block poses serious challenge for clinicians. **Case report**: 74-years-old male patient with a history of coronary artery disease who had previously undergone coronary artery bypass surgery and mechanical aortic valve replacement, was admitted due to symptomatic intermittent complete heart block and pneumonia. Transthoracic echocardiography showed normal systolic heart function, preserved function of the aortic mechanical valve, but also revealed a floating formation on the atrial side of anterior mitral leaflet suspected of vegetation, without functional impairment of the mitral valve. The latter was confirmed by transesophageal echocardiography with maximal length of vegetation measuring 16 mm. Since the clinical suspicion of infective endocarditis (IE) was high, regardless of repeated negative blood cultures, antibiotic treatment with ampicillin and gentamycin was administered, resulting in adequate reduction of inflammatory markers. Multiple suspected embolic infarctions of the kidneys and spleen were revealed on a multi-slice CT scan. FDG-PET/CT supported the diagnosis of IE by detecting pathological FDG accumulation on the anterior mitral leaflet, but also in the aortic root. After normalization of inflammatory markers, there was no significant bradyarrhythmia registered. Due to high risk of embolization, the patient was referred for urgent extensive cardiac surgery. Epicardial pacing was considered as a potential option if heart block persisted despite infection resolution. **Conclusion**: Infective endocarditis can cause complete heart block, and despite its potential reversibility, may present a therapeutical challenge if pacing is eventually indicated. In such cases, epicardial pacing should be preferred over usual transvenous pacing to minimize the risk of CIED infections (2, 3).

Andrija Matetić, Frane Runjić, Ivica Kristić, Nikola Crnčević, Darija Baković Kramarić

**Introduction**: Transcatheter aortic valve implantation (TAVI) is contraindicated in patients with a high risk of coronary obstruction. The Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) technique enables TAVI in these high-risk patients by creating intentional and controlled leaflet laceration prior to valve deployment (1). The procedure requires meticulous preprocedural planning and experienced operators to minimize the risks and ensure coronary flow preservation (2, 3). This study presents the first BASILICA procedure in Croatia, successfully performed at the University Hospital of Split for a patient with intermediate-to-high risk of coronary obstruction. **Case report**: 80-year-old female with critical symptomatic aortic stenosis [Vmax 4.7 m/s; MPG 60 mmHg] and high surgical risk was referred for TAVI. Preprocedural assessment revealed an intermediate-to-high risk of left coronary obstruction and sinus sequestration. Calculations revealed a low height of left coronary [9 mm] and sinotubular junction (13 mm), shallow sinuses of Valsalva [SOV-LCC 26.4 mm] and other unfavourable relevant parameters [valve-to-coronary 3.6 mm; valve-to-STJ 1.6 mm; leaflet-STJ mismatch -1.5 mm] (**Figure 1**). The right coronary artery had a higher origin and negligible risk of obstruction. The Structural Heart Team opted for a modified solo LCC-BASILICA technique after detailed preprocedural planning, including 3-dimensional printing simulation. The procedure was performed under echocardiographic and fluoroscopic guidance with operator-led analgosedation. Using an electrified coronary wire, successful and controlled leaflet splay was achieved, followed by TAVI [Edwards Sapien S3 Ultra Resilia 23 mm] with preserved coronary flow and optimal positioning (**Figures 2** and **3**Figure 3). The patient was discharged on postoperative day 4 with uneventful follow-up at 6 months. FIGURE 1. Preprocedural planning and reconstructions from cardiac computed tomography: A. Plain multiplanar reconstructions; B. Valve simulation and calculations; C. 3-dimensional simulation and printing. LCA - left coronary artery; 3D - 3-dimensional. FIGURE 2. Fluoroscopic phases of the procedure: A. Equipment positioning in the left coronary cusp; B. Preparation for electrosurgical crossing; C. Electrosurgical crossing; D. Preparation for controlled leaflet laceration using the ‘flying V’; E. Final successful result. TAVI - transcatheter aortic valve implantation. FIGURE 3. Echocardiographic images: A. Confirmation of catheter position before BASILICA; B. Confirmation of successful left coronary leaflet laceration and splay. BASILICA - Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction. **Conclusion**: The BASILICA technique represents a viable solution for TAVI patients with high risk of coronary obstruction. It can be achieved with favourable outcomes when preceded by detailed preprocedural planning and performed by experienced operators.

Sandra Šarić, Marko Stupin, Iva Jurić, Damir Kirner, Kristina Selthofer-Relatić

Remodeling of the left ventricle (LV) occurs due to conditions like ischemic heart disease (IHD) or dilated cardiomyopathy (DCM). These changes disrupt the normal geometric relationships between the LV and the mitral valve. Secondary mitral regurgitation (MR) arises not from inherent issues with the mitral valve itself but from the altered geometry of the LV. This results in a change in how the valve apparatus functions. The remodeling leads to a mismatch between the forces that close the valve and those that tether it to the LV walls. This imbalance can result in regurgitation, where blood flows backward into the LV during contraction (1). Understanding these mechanisms is crucial for managing patients with heart failure and can influence treatment decisions, including surgical interventions or the use of device therapies. Echocardiography is vital for diagnosing the cause and severity of MR, as well as for characterizing LV remodeling. This information is crucial for selecting the right therapeutic approach. It’s important for echocardiographic studies to differentiate between functional MR due to global ventricular dilation and MR caused by localized abnormalities. Understanding how altered LV geometry affects MR is key to effective management. In cases of IHD, an inferolateral myocardial scar leads to localized remodeling, which distorts the LV’s normal geometry. This distortion displaces the posteromedial papillary muscle, causing an imbalance between the forces that close the mitral valve and those that tether the valve leaflets (2). The asymmetrical displacement of the papillary muscles results in improper alignment of the mitral valve leaflets. This misalignment leads to an eccentric and posteriorly directed jet of MR, which can significantly impact patient outcomes. In DCM, both papillary muscles are symmetrically displaced posteriorly and apically. This symmetrical movement results in an apical displacement of the coaptation line of the mitral valve leaflets, leading to a central regurgitant jet. Reverse remodeling refers to the regression of the left ventricle’s hypertrophy, size, shape, and function. This process is associated with improved morbidity and mortality in patients (3). Both types of LV remodeling—those caused by chronic volume overload due to primary valve lesions and the initial remodeling leading to secondary MR—can be reversed following various therapeutic interventions. This highlights the potential for recovery and improvement in cardiac function. Echocardiography remains the preferred imaging modality for monitoring patients with MR post-intervention. It is crucial for evaluating the success of treatments and assessing their effects on the LV’s geometry and function. Optimal medical treatment is considered the first line for managing MR, by the European Society of Cardiology (ESC) guidelines (4). This approach is particularly important in secondary MR cases. For patients with secondary MR, the initial treatment often focuses on addressing the underlying cardiomyopathy, whether it’s DCM or IHD. The current ESC guidelines for the management of valvular heart disease recommend a surgical strategy for symptomatic patients and asymptomatic patients presenting with chronic primary MR and LVESD ≥45 mm, placing emphasis on the worse postoperative outcome of patients with LVESD of 40-44 mm compared to those with LVESD less than 40 mm (4). After surgical intervention (both mitral valve repair and valve replacement), symptom and cardiac function improvement occur rapidly. Echocardiography is the most important imaging tool for assessing LV reverse remodeling by documenting the decrease in LV volumes that usually occurs between four and six months after the surgery. After a successful percutaneous edge-to-edge mitral valve repair, MR severity and loading conditions decrease. The LV unload can explain the rapid decrease in LVEDV already seen 24 hours after the intervention (5). After 12 months, further favorable changes are seen in the echocardiography follow-up consistent with a greater reduction in LVEDV and decreases in LVESV and LV mass (6). Left ventricular remodeling may be the consequence of chronic volume overload in the case of primary MR or the cause of valvular insufficiency in the case of an LV with a distorted geometry resulting from IHD or DCM. Echocardiography is an invaluable tool able to differentiate between both etiologies of MR (primary or secondary) and characterize the remodeling of the LV as well as reverse remodeling secondary to therapeutic interventions.

Jasna Čerkez Habek, Ines Zadro Kordić, Ante Petrović, Jozica Šikić

**Introduction**: The congenital Gerbode defect is a rare cardiac anomaly characterized by an abnormal left ventricle–to–right atrium communication, resulting in a left-to-right shunt. This may lead to right heart volume overload, pulmonary hypertension, and eventual right heart failure if unrecognized. Due to its nonspecific clinical presentation, it is often misdiagnosed as tricuspid regurgitation (1, 2). **Case report**: 43-year-old male with no significant prior medical history other than long-term tobacco use was admitted with signs of right-sided heart failure. A computed tomography pulmonary angiography demonstrated a segmental pulmonary embolism and radiological features of pulmonary emphysema. Transthoracic echocardiography showed dilated right heart chambers with reduced systolic function, moderately impaired left ventricular systolic function due to abnormal septal motion, severe tricuspid regurgitation, and a high-velocity systolic jet from the left ventricle to right atrium at the membranous septum. Transesophageal echocardiography supported the suspicion of a shunt and cardiac MRI confirmed a Gerbode defect (direct, type 1). Coronary angiography excluded atherosclerosis of the epicardial coronary arteries. Right heart catheterization showed pulmonary hypertension with a pulmonary vascular resistance of 8.9 Wood units. The Qp/Qs ratio was 1.1:1 measured invasively and with MRI. Pulmonary function tests revealed severe obstructive ventilatory defect and reduced diffusing capacity, indicative of advanced chronic obstructive pulmonary disease. Because of markedly elevated pulmonary vascular resistance and pulmonary hypertension, he was treated with optimized therapy for heart failure, pulmonary hypertension, pulmonary embolism, and lung disease. Depending on the effect of the therapy, either surgical closure of the defect or heart and lung transplantation will be considered. **Conclusion**: Determining the etiology of right-sided heart failure with pulmonary hypertension and severe tricuspid regurgitation is often challenging. Accurate diagnosis relies on multimodal imaging, echocardiography, cardiac MRI, and invasive diagnostic procedures. Despite comprehensive diagnostic workup and established diagnoses, the case continues to pose a therapeutic challenge.

Jozica Šikić, Jasna Čerkez Habek, Zrinka Planinić, Jelena Faletar Barišić

**Introduction**: The coexistence of aortic and mitral regurgitation represents a relatively common but insufficiently explored form of multivalvular heart disease. Combined severe aortic and mitral regurgitation is the most poorly tolerated combination and, in its severe form, is rare in clinical practice (1). These patients are more prone to early left ventricular dysfunction due to increased preload from both lesions, with higher risk of postoperative left ventricular dysfunction compared to isolated regurgitation (2). **Case report**: 70-year-old male patient with a history of arterial hypertension and hyperlipidemia was hospitalized for further diagnostic evaluation of an abnormal outpatient echocardiographic finding. Transthoracic echocardiogram (TTE) demonstrated dilated aortic bulbus and ascending aorta, significant dilation of the left atrium and left ventricle with spheric remodeling pattern, reduced global systolic function (EF of 35%), and severe aortic and mitral regurgitation. Transesophageal echocardiography confirmed tricuspid aortic valve with type I severe aortic regurgitation and severe mitral regurgitation based on significant annular dilatation and coaptation defect. MSCT aortography demonstrated maximal aortic diameter of 5.5 cm at the Valsalva sinuses and fusiform ascending aorta dilation up to 4.7 cm. Coronary angiography revealed short significant proximal left anterior descending (LAD) artery stenosis. Considering the aforementioned pathology the patient was discussed by the Heart Team and accepted for surgical treatment. The patient underwent successful replacement of the ascending aorta, aortic and mitral valve replacement with bioprosthesis and LAD bypass surgery. The patient is expected for follow-up to assess eventual echocardiographic improvement of left ventricular systolic function with standard heart failure therapy after surgical treatment. **Conclusion**: Combined aortic and mitral regurgitation often causes left ventricular dysfunction, so early surgery is advised when symptoms or dysfunction appear. Since the potential for recovery of left ventricular function is questionable in a patient with two preexisting severe valvular lesions (2), the postoperative outcome for our patient might not be satisfactory.

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

**Introduction**: Since performing our first transcatheter aortic valve implantation (TAVI) in 2011, we have made substantial progress in integrating this procedure into routine clinical practice. Nevertheless, identifying the most appropriate candidates for TAVI remains a complex clinical challenge. The use of validated risk scores, as recommended by the European Society of Cardiology (ESC), may aid in refining the selection process. (1) This study aimed to explore the relationship between pre-procedural risk scores and the incidence of mortality and major adverse cardiac events (MACE) following TAVI, with the goal of informing future patient selection strategies. **Patients ans Methods**: We conducted a retrospective analysis of patients who underwent TAVI at our institution between September 2011 and July 2025. The following risk scores were evaluated: Charlson Comorbidity Index (CCI), EuroSCORE II, FRANCE-2, Katz Index, and Society of Thoracic Surgeons (STS) score. The Mann-Whitney U test was used to compare demographic variables and risk scores between survivors and non-survivors. Correlations between risk scores and outcomes (in-hospital and follow-up mortality, MACE) were assessed using MedCalc Statistical Software version 14.8.1. **Results**: A total of 732 patients were included (median age: 80 years [IQR: 76–83]). Eighteen patients (2.47%) died during hospitalization, while 177 (24.2%) died during follow-up, most commonly due to heart failure (n = 39, 22.0%). After excluding cases with incomplete data, we found that follow-up mortality was significantly associated with CCI (p < 0.0001), EuroSCORE II (p < 0.0001), FRANCE-2 (p < 0.0001), Katz Index (p < 0.0001), and STS score (p = 0.01). The occurrence of MACE during follow-up was significantly associated with the STS score (p = 0.01). **Conclusion**: Over more than a decade of performing TAVI procedures and following patients longitudinally, our center has gained valuable insights into patient selection and risk stratification. This study highlights the prognostic value of commonly used risk scores and underscores their potential to support clinical decision-making. As we continue to refine our approach, integrating objective risk assessments remains essential for improving long-term outcomes in patients undergoing TAVI.

Zrinka Planinić, Haris Ahmić, Mirko Tomić, Jozica Šikić

**Introduction**: Functional tricuspid regurgitation (FTR) in the setting of atrial fibrillation (AF) is increasingly recognized as a distinct pathophysiological entity, in which longstanding AF leads to progressive right atrial remodeling, promoting tricuspid annular dilation, incomplete leaflet closure, and ultimately the development of severe regurgitation (1, 2). **Case report**: 72-year-old female patient with unremarkable previous medical history was admitted because of symptomatic persistent AF despite maximal dose bisoprolol therapy. The patient experienced exertional dyspnea and palpitations for at least six months prior to hospitalization. At the time of admission, the patient was hemodynamically stable with no clinical signs of congestion, but with elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Transthoracic echocardiography (TTE) showed significant enlargement of both atria and right ventricle that had reduced systolic function and consequently severe FTR (estimated regurgitant volume of 60 ml), while left ventricle was normal in size and function. After excluding the presence of thrombus in the left atrial appendage on transesophageal echocardiography (TOE), synchronized electrical cardioversion with previous amiodarone facilitation was performed, successfully restoring sinus rhythm. At one month follow-up the patient was symptom free, remained in sinus rhythm, without detected new episodes of AF, and with normal NT-proBNP levels. Repeated TTE showed notable reduction of both right atrial and ventricular dimensions, recovery of right ventricular systolic function and regression of tricuspid regurgitation to mild to moderate. Following positive right heart remodeling and heart failure symptoms improvement with rhythm control strategy, the patient was referred to electrophysiologist. **Conclusion**: Despite the risk of AF recurrence this case illustrates that FTR secondary to AF can be partially reversed with timely rhythm control that can further prevent heart failure development. The observed improvement following sinus rhythm restoration is consistent with recently published evidence highlighting the potential for reverse remodeling of the tricuspid valve and right heart in selected patients (3).

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

**Introduction**: Patient and device selection, appropriate expansion and apposition, and implantation depth optimization are all essential aspects of a successful percutaneous transcatheter aortic valve implantation (TAVI). (1, 2) However, guidelines clearly state that advantages of TAVI over surgery are warranted only in case of safe and uncomplicated transfemoral procedure. We present our experiences with hemostasis after transfemoral TAVI with different strategies, alternative vascular access in patients without the possibility of transfemoral access, and vascular and bleeding complications analysis. **Patients and Methods**: We analyzed 736 patients who underwent TAVI in our center between 2012 and 2025. Median age was 80 years, 51% were female, with median aortic MPG 46 mmHg and LVEF of 55%. There were 41% of patients on oral anticoagulants, whereas 14% of patients had peripheral artery disease. **Results:** There were 76.2% patients with full percutaneous transfemoral approach, 18.8% patients with surgical cut down of femoral artery (performed routinely between 2012 and 2018), and 5% of patients with alternative access. Composite clinical endpoint of major bleeding, major or minor vascular complication, stroke or 30-day cardiovascular mortality occurred in 8.3%, 10.8%, and 28% of patients undergoing TAVI with full percutaneous transfemoral, surgical transfemoral, and alternative vascular access, respectfully. Full percutaneous transfemoral access with one perclose device combined with a vascular plug was the safest technique in comparison to other percutaneous closure techniques (RR 1.12 95% CI 0.57-2.20 for composite endpoint that occurred in 7.6% of patients, with proportion of major vascular complications or major bleeding of only 1%). Age, peripheral artery disease and alternative vascular access were the only variables independently associated with the composite endpoint. **Conclusions**: Uncomplicated percutaneous femoral access remains the most important secondary factor in TAVI. Hybrid vascular closure with one perclose and one vascular seal showed optimal safety with the lowest proportion of major vascular complications compared to other closure techniques. Alternative access should be carefully weighed against surgery since it carried the greatest risk of major complications and bleeding.

Jasmina Ćatić

Transcatheter edge-to-edge repair (TEER), most performed using the MitraClip device, has become a cornerstone intervention for patients with symptomatic secondary mitral regurgitation (SMR) who are considered high or prohibitive surgical risk. The COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) was a pivotal study that demonstrated significant reductions in heart failure hospitalizations and all-cause mortality in patients with TEER, compared to guideline-directed medical therapy alone, in a carefully selected population with moderate-to-severe or severe SMR, left ventricular ejection fraction (LVEF) between 20–50%, and left ventricular end-systolic diameter (LVESD) <70 mm, who remained symptomatic despite optimal medical therapy . However, as TEER has entered broader clinical use, real-world practice has increasingly included patients who fall outside the strict COAPT inclusion criteria. Patients with more advanced left ventricular dysfunction, severely dilated ventricles, atrial functional mitral regurgitation, or incomplete GDMT have been treated, often with acceptable safety and symptomatic benefit. Data from large registries such as suggest that outcomes in these broader populations may not mirror those of COAPT, particularly regarding survival, but still provide meaningful improvements in symptoms and quality of life. This change in clinical practice reflects a shift from rigid trial-based criteria toward individualized, heart team–guided decision-making. While the COAPT criteria remain essential for prognostication and trial-based benchmarking, clinical equipoise now allows for selective use of TEER in patients previously considered marginal candidates. The role of the multidisciplinary heart team, comprising interventional cardiologists, heart failure specialists, cardiac imaging experts, and cardiac surgeons is crucial in carefully evaluating anatomical suitability, balancing risks and benefits, and ensuring that TEER is appropriately tailored to each patient’s clinical profile and goals of care. (1-3)

Tea-Terezija Cvetko, Jasmina Ćatić, Ivana Jurin, Danijela Grizelj, Irzal Hadžibegović, Tomislav Šipić, Jelena Kursar

Isolated aortic regurgitation (AR) presents distinct challenges in interventional cardiology. Unlike aortic stenosis (AS), AR typically lacks annular calcification, complicating the anchoring of transcatheter valves. While surgical aortic valve replacement (SAVR) remains the gold standard, many patients are deemed high-risk or inoperable due to comorbidities or frailty. In this population, transcatheter aortic valve implantation (TAVI), although off-label for AR, is emerging as a viable alternative. New-generation TAVI devices offer features designed to improve sealing and anchoring in non-calcified anatomy. Among these, only the JenaValve has been specifically developed and tested for use in pure AR. Although currently limited in availability across Europe, it has received CEmark approval for severe, symptomatic AR in highsurgicalrisk patients and has seen early commercial use in select centers. The other valves are used off-label in this setting. These include self-expanding systems like Evolut PRO+, CoreValve Evolut R and ACURATE neo2. Self-expanding valves rely on radial forces for anchoring, but their use in pure AR is limited due to the risk of valve migration. Balloon-expandable valves, such as the SAPIEN 3, typically require some degree of annular calcification for optimal fixation. Careful patient selection through multimodal imaging—echocardiography, CT, and MRI—is critical. Ideal candidates include those with severe symptomatic AR, high surgical risk, and anatomical suitability for TAVI. Clinical data from registries (TOPAS, GARY, FRANCE-TAVI) show encouraging results with newer devices, including symptom relief, left ventricular remodeling, and improved quality of life, albeit with higher rates of complications like device migration and paravalvular leak. (1) Ethical considerations are paramount, necessitating thorough patient counseling and shared decision-making. As dedicated devices and ongoing trials evolve, off-label TAVI may redefine treatment paradigms for high-risk AR patients. However, further randomized data are needed to establish its safety, efficacy, and long-term outcomes.

Jozica Šikić, Zrinka Planinić

## Dear Colleagues, The 7th Congress of the Working Group on Valvular Diseases of the Croatian Cardiac Society with international participation, CROVALV 2025, will be held on September 11th to September 13th, 2025, at the Sheraton Hotel in Zagreb. CROVALV is a biennial congress designed for cardiologists, cardiac surgeons, anesthesiologists, neurologists, residents, general practitioners, and for all those professionally involved in the treatment of valvular diseases. Much has been learned and significant progress has been made since the last CROVALV congress, especially in the field of percutaneous interventional treatment as well as in cardiac surgery, treatment of coronary artery diseases, heart failure, and obesity, all of which indirectly affects improvement of cardiac valve function. The goal of the CROVALV congress is to present and discuss challenges in the approach, diagnosis, and selection of the optimal way of treating patients with valvular diseases and to help implement the latest research findings into clinical practice. In addition to invited lectures by reputable speakers from abroad, leading national experts will present the best entries among the submitted abstracts. We hope that you will once again recognize the importance of this congress, and we cordially invite you to come and actively participate in jointly contributing to its quality and success. Predsjednica kongresa / Congress Director: izv. prof. dr. sc. Jozica Šikić, dr. med. / Assoc Prof Jozica Šikić, MD, PhD predsjednica Radne skupine za bolesti srčanih zalistaka Hrvatskoga kardiološkog društva / President of the Working Group on Valvular Diseases of the Croatian Cardiac Society Tajnica kongresa: / Congress Secretary Zrinka Planinić, dr.med / Zrinka Planinić, MD

Dijana Bešić, Mario Špoljarić, Marin Viđak, Irzal Hadžibegović, Marija Križanović, Šime Manola, Ivana Jurin

**Introduction**: Paravalvular leak (PVL) has historically been recognized as the most frequent complication following transcatheter aortic valve implantation (TAVI), with significant impact on patient outcomes. However, recent studies suggest that moderate/severe PVL may not be independently associated with increased risk of major adverse cardiac and cerebrovascular events (MACCE), challenging earlier evidence that even mild PVL contributes to worse prognosis. (1, 2) Aim: To evaluate the impact of immediate post-procedural PVL on long-term clinical outcomes in a real-world cohort of patients undergoing TAVI. **Patients and Methods**: This retrospective, registry-based study included patients who underwent TAVI between September 2011 and July 2025 at a single tertiary center. Patients were stratified based on PVL severity: moderate/severe PVL versus no/trace-to-mild PVL. Clinical endpoints included all-cause mortality and the composite MACCE (stroke, myocardial infarction, new-onset atrial fibrillation or complete AV block, venous thromboembolism, major bleeding, and aortic root rupture). Logistic regression was used to evaluate associations, with a significance threshold of p < 0.05. **Results**: A total of 692 patients were included, with a median age of 80 years [IQR 76–83] and median follow-up duration of 381 days [IQR 178–812]. Moderate/severe PVL was present in 65 patients (9.4%). Its presence was marginally associated with increased all-cause mortality (p = 0.046), but not with the incidence of MACCE. **Conclusions**: In this real-world cohort, moderate/severe PVL following TAVI was associated with a slight increase in all-cause mortality, but not with composite adverse cardiovascular events. Despite these findings, minimizing PVL should remain a key technical objective during the TAVI procedure to optimize long-term outcomes.

Antun Car

The case of a 78-year-old man is described, in which the fibroelastoma was addressed first due to its high thromboembolic risk, followed by the treatment of Zenker’s large esophageal diverticulum within two months. The patient was found to have a fibroelastoma of the aortic valve during a routine echocardiogram. A papillary fibroelastoma is a benign primary heart tumor. Approximately 95% of these tumors are located on the left side of the heart. Papillary fibroelastomas are associated with an increased risk of embolic strokes. They are the third most common type of cardiac tumor. Surgical excision is the typical treatment, involving removal of the entire tumor. The patient had no complaints related to the cardiac tumor but experienced rapidly worsening dysphagia. Zenker’s diverticulum is a posterior protrusion of mucosa and submucosa through the cricopharyngeal muscle. It can fill with food, which may be regurgitated when the patient bends over or lies down. Night-time regurgitation can lead to aspiration pneumonitis. Rarely, the diverticulum becomes large enough to cause dysphagia or a palpable neck mass. Due to the size of the diverticulum, surgery was indicated. It was decided to remove the tumor via excision and subsequently operate on the diverticulum. Both procedures were completed without complications. The patient needs to fully recover from the aortic valve surgery, which includes achieving medical stability and resolution of any active issues related to the heart or other organs. The decision to proceed with surgery for Zenker’s diverticulum was based on the patient’s specific medical history, overall health, and the recommendations of the surgical team. Surgical outcomes are known to be influenced by various factors, including the surgical approach, the surgical speciality, and patient age. (1, 2)

Dario Dilber, Vesna Pehar Pejčinović, Iva Uravić Bursać

Cardiovascular magnetic resonance (CMR) imaging offers a comprehensive approach to evaluating valvular heart disease which is emphasized in assessing mitral valve prolapse (MVP). The prevalence of mitral annular disjunction (MAD) with MVP is 20-58%. MAD is characterized by a systolic separation between the ventricular myocardium and the mitral annulus supporting the posterior mitral leaflet. MAD may not be associated with mitral regurgitation and patients with MAD may develop symptoms related to ventricular arrhythmias, configuring the MAD arrhythmic syndrome, which may progress to sudden death. (1-5) First line to the diagnosis is transthoracic echocardiography, complemented with CMR (**Figure 1** and **2**Figure 2). The arrhythmic mitral valve complex is defined by presence of MVP (with or without MAD), combined with frequent and/or complex VA in the absence of any other well-defined arrhythmic substrate. CMR improved the assessment of this pathology as myocardial fibrosis determined according to late gadolinium enhancement is associated with adverse outcome in patients with MVP without moderate-to-severe mitral regurgitation or left ventricular dysfunction. CMR can distinguish adjacent structures and characterize myocardial tissue, detecting a minimal disjunction of up to 1 mm and can accurately identify the presence of myocardial fibrosis in the posterior region of the papillary muscle and in the inferior basal segment of the LV (**Figure 3**). Even small disjunctions (< 4mm) can cause malignant ventricular events, thus, CMR is a desirable test that can better identify the presence of MAD and MVP with high arrhythmogenic risk. FIGURE 1. Ultrasound image of mitral valve prolapse and mitral annular disjunction (white arrow) (left image); lower values of longitudinal strain in the posterolateral segment of the left ventricle (right image). FIGURE 2. Cardiac magnetic resonance imaging: 56-year-old man with prolapse of the mitral valve and mitral annular disjunction (arrows). FIGURE 3. A 56-year-old man presenting with frequent premature ventricular contractions (blue arrows), with right bundle branch block morphology and a rS pattern in V5-V6, which corresponds to origin in the posterolateral wall of the left ventricle and evidence on cardiovascular magnetic resonance of a patchy area of midventricular late gadolinium enhancement, involving the basal inferolateral left ventricular segment (yellow arrow). CMR should be done in patients with unexplained syncope or nonsustained ventricular arrhythmia, for assessment of left ventricle size and function, severity of mitral regurgitation, leaflet thickness, but also should be done in patients with arrhythmic mitral valve prolapse and at least one phenotypical risk feature —palpitations, T-wave inversion in the inferior leads, repetitive documented polymorphic PVCs, MAD phenotype, redundant MV leaflets, enlarged left atrium or ejection fraction ≤50%.