Cardiologia Croatica. 2015;10(5-6)

Bruno R Nascimento, Luisa C C Brant, Diego N Moraes, Antonio L P Ribeiro

The modern definition of Global Health has expanded its scope beyond neglected diseases and low-income and underdeveloped countries. The current initiatives focus on improvement of health, reduction of disparities and protection against global threats, seeking for interaction with health practices, policies and systems. There has been a growing interest on Global Health research, given the epidemiological transition currently underway in low and mid-income countries and the increasing epidemiological importance of cardiovascular and other non-communicable diseases, to the detriment of infectious diseases and nutritional de□ciencies. Various aspects – formerly neglected – of these diseases, such as epidemiology, prevention, diagnosis and therapy, have been addressed in Global Health publications, leading to a better understanding of the importance of health as a public good, beyond borders. Scientific evidence supports broader initiatives in which governments, foundations and the civil society must share responsibilities and funding to achieve health equity, the main goal of Global Health.

Catherine M. Otto

The past few years have seen major advances in the diagnosis of aortic valve disease and in our understanding of the pathophysiology of disease. In addition, transcatheter aortic valve implantation has transformed our clinical management options. This article summarises new aortic valve disease research published in Heart in 2013 and 2014, within the context of other major studies published in general medical journals, including a discussion of the potential impact of these new research findings on the clinical approach to management of adults with aortic valve disease.

Jure Mirat, Igor Alfirević, Stjepan Barišin, Robert Bernat, Bojan Biočina, Vedran Ćorić, Igor Medved, Krunoslav Šego, Daniel Unić, Jakov Vojković

Surgical treatment of aortic valve disease in the Republic of Croatia is a surgical procedure that has a very important place in the overall operating procedures in cardiac surgery centers. According to the reports of all six cardiac surgery centers, aortic valve procedures make up 23% of total procedures performed, which in absolute numbers means 636 aortic valve surgeries in 2014 (Figure 1). In comparison with data from 2012 (1), there has been an increase in the number of aortic valve procedures of about 8% during the last three years. This is in line with the needs based on the incidence of the disease, especially coronary pathology that stands side to side with coronary pathology with which it shares risk factors and similar pathogenesis. We do not have data on the overall prevalence of these diseases in the general population, but if a projection of the incidence of aortic pathology in the Republic of Croatia was made from an European perspective, the need for surgical procedures would be estimated to be much higher. (2) However, observed trends are encouraging and require further monitoring, as well as encouragement to achieve optimum results regarding better prognosis quoad vitam and quoad valetudinem in patients undergoing surgical procedures in comparison to those who do not undergo surgery. (3, 4) Figure 1. The ratio of cardiac surgery procedures on the aortic valve and the total number of cardiac surgery procedures in the Republic of Croatia in 2014. Comorbidity of aortic stenosis and coronary heart disease is high, as our results over the last year indicate. The percentage of combined surgeries with aortic valve replacement (AVR) and aortocoronary bypass implantation (ACBP) was 31%, and the percentage of isolated aortic valve replacement procedures was 69% (Figure 2). The prevalence of combined aortic valve procedures is still somewhat lower in comparison with data from some European registries. Coexistence of aortic disease and coronary heart disease can be up to 37% in severe aortic stenosis cases, and even higher in moderate and mild aortic stenosis. We do not have any data on these relationships in our population. Figure 2. The ratio of isolated and combined aortic valve replacements (AVR) with aortocoronary bypass (ACBP) and other valves in 2014 in the Republic of Croatia. AVR = aortic valve replacement; ACBP = aortocoronary bypass The types of surgical procedures performed in 2014 in Croatia are shown in Figure 3. Aortic valve replacement, using either mechanical or bioprosthetic valves, is the most common. Mechanical valves are slightly more common than bioprosthetic valves. Aortic valve repair is also present in small numbers (3%). Aortic valve repair is still reserved for aortic regurgitation, which has a lower prevalence (Figure 4). The other reason for the small number of aortic valve repair procedures is the complexity of the procedure. With the standardization of two techniques (the David Tirone procedure and Yacoubu procedure, i.e. its modification by Emmanuel Lansac) we can expect an increase in aortic repair instead of replacement. Implantation of composite grafts in the ascending aorta accounted for 10% of all aortic valve surgeries. There were relatively few transcatheter aortic valve implantation (TAVI) procedures in comparison with other procedures. Figure 3. Types of aortic valve surgical procedures in 2014 in the Republic of Croatia. TAVI = Transcatheter Aortic Valve Implantation Figure 4. Reasons for aortic valve surgical procedures in 2014 in the Republic of Croatia. AS = aortic stenosis; AR = aortic regurgitation ## Transcatheter aortic valve implantation It has been three years since the first transcatheter aortic valve implantation in Croatia, and we wrote more extensively about this procedure in a previous editorial in 2012. (1) The number of centers that have tried their hand at this new treatment technique for severe aortic stenosis has since grown to four, but the number of individual implantations in each center is very low, and is sometimes below five. Although the number of TAVI procedures indicates a significant upward trend in comparison with previous years, we are still in the learning phase since only 29 TAVI procedures have been performed in 2014. These data should definitely be taken to indicate that Croatian centers strive to follow the global trend of rapidly increasing preference for these interventions as a replacement for surgical procedures. This trend is best illustrated by results from AQUA Institute GmbH in 2009 and 2012, according to which 10 285 surgical procedures and 2565 TAVI procedures were performed in Germany in 2009, whereas three years later, in 2012, the ratio of TAVI to surgical procedures has become almost one-to-one, with 9929 surgical aortic valve replacements compared with 9341 TAVI procedures. (5, 6) The main limiting factor in caring for inoperable patients with severe aortic stenosis is the economic situation. It will certainly be necessary to come up with modalities that will allow us to reach the treatment standard provided by cutting-edge medical treatment elsewhere in the world. The endovascular, i.e. transfemoral approach is dominant in comparison with the transapical approach (Figure 5), significantly so (83% transfemoral compared with 17% transapical). Individual reports indicate an acceptable likelihood of complications and mortality. Figure 5. Transcatheter aortic valve implantation (TAVI) procedures with regard to the type of the approach in the Republic of Croatia in 2014.

Mario Ivanuša

Cardiovascular diseases have long been the leading cause of death throughout the world and in Croatia as well. The Croatian Cardiac Society (CCS) was founded in 1992 and, as the leading professional association in Croatia, strives to reduce the morbidity and mortality from these groups of diseases, primarily through the interaction of the education of its members and the public and the application of diagnostics and treatment equally throughout Croatia, according to evidence-based medical principles. Of the many initiatives that the CCS undertook during the past twenty years, we will mention only a few relevant to the topic of this editorial. In 1998 the study Treatment and secondary prevention of ischemic coronary events in Croatia (TASPIC-CRO study) (1) was started, and the Prevention of coronary heart disease in clinical practice: recommendations of the Task Force of the European Society of Cardiology (ESC) were translated into Croatian in 1999 (2). In 2004, members of the CCS Working Group on Acute Coronary Syndrome translated the ESC Guidelines on management of acute myocardial infarction in patients presenting with ST-segment elevation (3). In November of the same year, the Croatian Primary Percutaneous Coronary Intervention Network for patients with ST-segment elevation acute myocardial infarction was established in cooperation with the former Ministry of Health and Social Welfare of the Republic of Croatia, the Croatian Health Insurance Fund, and primary, secondary, and tertiary healthcare institutions. This national program for cardiologic interventions is an extremely successful example of arranging treatment for patients with acute myocardial infarction at the national level (4), and one of the most important topics in modern Croatian cardiology. Soon after, the most important media for communication in Croatian cardiology were formed – in May 2006, the monthly bulletin Kardio list published its first issue, and the web portal of the CCS was reestablished (www.kardio.hr). In addition to regular publications in Croatian, this early period was characterized by clear, concise, verified, applicable, and up-to-date cardiologic information as well as being published in the shape of a perforated envelope. (5) From 2007, the bulletin gradually grew into a journal that was first published in the B5 format, with regular monthly or bimonthly issues in the A4 format in both Croatian and English since 2008. The journal was significantly enhanced by an ESC license to organize educational scientific conferences (Dubrovnik Cardiology Highlights: An ESC Update Programme in Cardiology), inclusion into the network of national cardiologic journals under ESC, and international indexing of the journal in 2009 (EMCare) and 2011 (EBSCO/Academic Search Complete). For better international visibility, the title of the journal was changed from Kardio list to Cardiologia Croatica in early 2012. (6) Further incentive came in July of 2014 when the journal acquired a co-publisher – the established publisher Medicinska naklada, which resulted in the modernization of the journal through the introduction of DOI (Digital Object Identifier) identification system, QR (Quick Response) codes, ORCID (Open Researcher and Contributor ID) for authors, and a more advanced graphical design. (7) In the coming months, once all issues since 2013 have been translated to XML, the journal Cardiologia Croatica will upgrade its organization and editorial procedure and then apply to a secondary multidisciplinary bibliographical database.

Ljiljana Banfić

The application of angiotensin receptor blockers (AT1) in cardiovascular prevention is based on the treatment of arterial hypertension. Telmisartan, a medication from the sartan group, has not only an antihypertensive effect but proven pleiotropic, metabolic, biohumoral, antiproliferative, and vascular effects – the basic processes of vascular aging as well as the progression of atherosclerosis, a disease with a high mortality that requires early risk recognition and comprehensive primary and secondary cardiovascular prevention. Based on scientific evidence, telmisartan has been proven to provide a well tolerated antihypertensive effect over 24 hours, and is indicated in the prevention of cardiovascular diseases.

Goran Krstačić

Ivabradine is the first specific heart rate-lowering agent that selectively and specifically inhibiting the pacemaker (lf) current, which regulates spontaneous diastolic depolarization in the sinus node and the heart rate. It directly affects the sinus node, with no effect on the interatrial, atrioventricular, or intraventricular conduction times, myocardial contractility, or ventricular repolarization. Ivabradine is indicated for patients with chronic heart failure, New York Heart Association (NYHA) classification II to IV, with systolic dysfunction and in patients with sinus rhythm with heart rate ≥75/min, in combination with standard therapy that includes beta blockers, or when beta-blockers are contraindicated or poorly tolerated. Ivabradine improves the prognosis in such patients, reducing the risk of mortality from all causes and mortality from cardiovascular events and heart failure. It improves quality of life by increasing tolerance for physical exertion and prevents progression of the disease by reducing the volume of the left ventricle and improving the ejection fraction.

Maja Strozzi

Thoracic EndoVascular Aortic Repair (TEVAR) was initially developed for occlusion procedures in treatment of diseases of the descending aorta, but its use was soon expanded to a whole spectrum of pathologies of this aortic segment, including dissection and traumatic ruptures. Surgical treatment of degenerative aneurysms of the descending aorta has a very high mortality and morbidity, so TEVAR leads to significantly improved outcomes for these patients. This is the reason the University Hospital Centre (UHC) Zagreb introduced the use of this procedure in the Department of Cardiovascular Diseases. Despite difficulties, TEVAR was used to treat the most at-risk patients with aneurysms, type B dissection, and traumatic rupture of the descending aorta. Long-term results of the treatment of 24 patients were acceptable, with a mortality of 8.3% and common complications (type I and II endoleaks in 12.5%; infection in 4.1%; proximal dissection propagation in 4.1%) which were resolved with an additional intervention or surgical procedure. In the future we expect much more rapid development of this method in UHC Zagreb and in Croatia in general once the Croatian Health Insurance Fund has arranged financing for the device.