Cardiologia Croatica. 2015;10(9-10)

Ksenija Tušek Bunc

Background: Patient's perspective of the management of their chronic disease better reflects the quality of care and offers health-care professionals more feedback. (1, 2) Methods and Patients: The study was cross-sectional, included 423 patients with coronary artery disease. A comprehensive questionnaire for patients included the European Task Force for Patient Evaluation of General Practice (EUROPEP) instrument and the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. To identify the number and types of data sets, factorial analysis and descriptive statistics were conducted on the PACIC questionnaire. To determine the correlation between the patient's assessment of the management of their chronic disease and the quality of care, the Pearson correlation coefficient was used. Results: The average age of the participants was 68.0 years (SD = 10.8); 35.2% were female. The average score for the entire PACIC (on a scale of 1-5) was 3.2 (SD = 0.9). The highest scores were for organizational aspects: organization of the practice (3.7), involvement of patients (3.7), and problem solving (3.5); the lowest score was for patient follow-up (2.7) (**Tables 1**, **2** and **3**, **Figure 1**). The Pearson's correlation coefficient (**Table 4**) was 0.11 (p = 0.034). ### Table 1: Descriptive information on the Patient Assessment of Chronic Illness Care (PACIC) items. | Domains | Items | Min (%) | Max (%) | Mean (SD) | | --- | --- | --- | --- | --- | | Patient activity | Asked for my ideas when we made a treatment plan. | 8.5 | 23.0 | 3.5 (1.2) | | Given choices about treatment to think about. | 9.6 | 26.5 | 3.5 (1.3) | | | Asked to talk about any problems with my medicines or their effects. | 4.0 | 47.6 | 4.1 (1.1) | | | Delivery system design/decision support | Given a written list of things I should do to improve my health. | 14.1 | 25.9 | 3.3 (1.4) | | Satisfied that my care was well organized. | 2.0 | 38.9 | 4.1 (0.9) | | | Shown how what I did to take care of myself influenced my condition. | 8.1 | 29.0 | 3.6 (1.2) | | | Goal setting/tailoring | Asked to talk about my goals in caring for my condition. | 11.4 | 20.8 | 3.3 (1.3) | | Helped to set specific goals to improve my eating or exercise. | 7.0 | 30.4 | 3.7 (1.2) | | | Given a copy of my treatment plan. | 21.9 | 19.9 | 2.9 (1.4) | | | Encouraged to go to a specific group or class to help me cope with my chronic condition. | 29.9 | 12.9 | 2.5 (1.4) | | | Asked questions, either directly or in a survey, about my health habits. | 15.8 | 19.5 | 3.1 (1.3) | | | Problem solving/contextual | Sure that my doctor or nurse thought about my values, beliefs, and traditions when they recommended treatments to me. | 4.3 | 39.3 | 4.0 (1.1) | | Helped to make a treatment plan that I could carry out in my daily life. | 11.6 | 28.9 | 3.5 (1.3) | | | Helped to plan ahead so I could take care of my condition even in hard times. | 11.8 | 24.7 | 3.4 (1.3) | | | Follow-up/coordination | Asked how my chronic condition affects my life. | | | | | Contacted after a visit to see how things were going. | 24.7 | 15.9 | 2.7 (1.4) | | | Encouraged to attend programs in the community that could help me. | 29.0 | 7.9 | 2.3 (1.2) | | | Referred to a dietitian, health educator, or counselor. | 37.2 | 9.4 | 2.2 (1.3) | | | Told how my visits with other types of doctors, like an eye doctor or surgeon, helped my treatment. | 19.5 | 19.5 | 3.1 (1.4) | | | Asked how my visits with other doctors were going. | 15.4 | 27.3 | 3.4 (1.4) | | [†] SD = standard deviation; Min = response rate with the lowest score - Floor effect; Max: response rate with the highest score - Ceiling effect ### Table 2: Descriptive analysis on the Patient Assessment of Chronic Illness Care (PACIC) domains (scale 1-5). | PACIC domains | Mean | SD | | --- | --- | --- | | Patient activation | 3.7 | 1.06 | | Delivery system design/decision support | 3.7 | 0.99 | | Goal setting/tailoring | 3.1 | 1.02 | | Problem solving/contextual | 3.5 | 1.07 | | Follow-up/coordination | 2.7 | 1.09 | | Overall PACIC score | 3.2 | 0.91 | [†] PACIC = Patient Assessment of Chronic Illness Care questionnaire ### Table 3: Quality of care of patients with coronary artery disease in the past 15 months. | | n | % | | --- | --- | --- | | Advice/contraindication physical activity | 240 | 56.7 | | Dietary advice offered/recorded | 235 | 55.6 | | Statin offered/recorded | 367 | 86.8 | | Antiplatelet therapy, if not contra-indicated, offered/recorded | 397 | 93.8 | | Influenza vaccination | 144 | 34.1 | Figure 1. Quality of coronary patient care - family doctor advice given and recorded. Items from 0 to 5 is the number of advice given and recorded in the past 15 months. Frequencies represent the number of patients who have received a certain number of tips and measures included in coronary patient care processes. The variable is distributed by the central peak. ### Table 4: Correlations between the Patient Assessment of Chronic Illness Care (PACIC) domains and quality of care and of coronary patients. | | r* | p | | --- | --- | --- | | PACIC Overall PACIC score | 0.11 | 0.034 | | PACIC Patient activation | 0.01 | 0.781 | | PACIC Delivery system design/decision support | 0.08 | 0.132 | | PACIC Goal setting/tailoring | 0.10 | 0.044 | | PACIC Problem solving/contextual | 0.10 | 0.049 | | PACIC S Follow-up/coordination | 0.15 | 0.003 | [†] *r = Pearson's correlation coefficient; PACIC = Patient Assessment of Chronic Illness Care questionnaire Discussion: The PACIC questionnaire is a reliable tool for assessing the management of chronic diseases. The average PACIC score was higher than the average scores of patients with other diseases in other countries. The proportion of those with the highest and lowest scores (floor and ceiling effect) was comparable with a Dutch study. The quality of clinical care was positively correlated with the patient's assessment of that care, which may represent a new indicator of quality of care of chronic diseases. Patient experience and involvement are essential to achieve better quality. In the future, further research is needed to accurately identify individual elements of the evaluation instrument.

Andrea Rzepiel, Eva Kerekes, Kinga Shenker-Horvath, Nora Varga, Akos Koller, Zsolt B. Nagy

The blood clotting system is a very complex, multifactorial system that is controlled by several mechanisms. The role of physiological coagulation – in addition to vasomotor activity - is to avoid the blood loss and prevent prevent the entrance of different pathogens pathogens into the organism. If, for any reason, the system is disturbed, blood clots can be formed in the blood vessels, at inappropriate place and time, which can cause serious problems in the circulation and thus tissue blood supply. From the factors, which can result in pathological blood clotting, the inherited mutations represent significant predisposition for thrombosis. Thus early detection of these factors could be an important first step to design patient-specific prevention of thrombosis and its consequences. Although, predisposition for thromboembolic diseases affects all humans, it is likely that athletes are particularly having higher risk factor for thrombosis, due to the various traumatic exposures during competition. For these reasons, it is utmost important to identify in young ages, the genetic predisposition for thrombosis, especially in young athletes, which can help the development of personal prevention (sport selection, dietary modulation, etc.) of thrombotic diseases, including changing sport types and/or stop competitive sport. (1-3)

Eszter Repasi, Eva Kerekes, Kinga Shenker-Horvath, Akos Koller, Zsolt B. Nagy

The renin-angiotensin-aldosterone system (RAAS) is one of the most significant short and long-term mechanisms of the human body, which - among others - importantly contributes to the regulation of systemic blood pressure and serves as a growth hormone in several tissues. Angiotensin converting enzyme (ACE) is an important part of RAAS, produces the vasoactive angiotensin II acting on AT1 and AT2 receptors. In addition, ACE has two genetic variants: I (insertion mutation) and D (deletion mutation), which can influence the serum level of ACE. D allele carrying individuals have higher ACE level than normal that could cause high blood pressure. Different sport-physiological conditions are also coupled to I and D alleles. The extent of skeletal muscle hypertrophy and mass are greater in a D allele carrying person. Thus the occurrence of the D allele is significantly higher in athletes competing in speed and power-oriented sports, whereas the I allele is more frequent in those involved in endurance sports. Thus common dietary guidelines suggesting 12% protein, 58% carbohydrate, and 30% fat intake may not be applicable for exercising athletes. In general, carbohydrate and protein intake should be greater in speed and power-oriented sports, whereas in endurance sports fat intake should be increased. Also, further modifications of diet could be suggested on the basis of individual genetic variations of ACE assuming that it leads to different body compositions. (1-3)

Igor Šesto, Krešimir Štambuk, Hrvoje Stipic, Tomislav Šipic, Ante-Zvonimir Korda, Igor Alfirevic, Davor Richter, Janko Szavits Nossan, Goran Milašin, Mihajlo Šesto

In our hospital cardio-surgical medical council has over time developed into a genuine heart-team jointly and equally discussing the best possible treatment strategies in patients displayed. What we found interesting to see is what happened to the patients suffering from critical coronary artery disease for whom were on our cardio-surgical council further conservative treatment indicated. The study included all patients with coronary artery disease (no of patients = 85) who were in the last five years presented on our cardio-surgical council, for whom we gave up on any active revascularization strategy (percutaneous coronary intervention or coronary artery bypass graft surgery), and conservative treatment was indicated. Further more included were only patients who were not operable (coronary artery bypass graft surgery) due to anatomical and pathological constellation on their coronary arteries, and percutaneous revascularization was not possible because of extremely high risk of the procedure itself, or intervention was not technically feasible. Inclusion and exclusion criteria were as follows: significant left anterior descending artery disease, the absence of significant valvular disease, the absence of significant comorbidities that could lead to the shortening of life expectancy. Retrospective analysis of collected data, included 85 patients who were shown to our cardio-surgical council in last 5 years, we made a telephone follow-up, which found an mortality of 9.8%, 15.3% of patients were re-hospitalized because of persistent symptoms of coronary artery disease. Only 2 patients subsequently underwent surgical revascularization, none of the patients received further percutaneous revascularization. The results obtained show that in advanced coronary artery disease, which is technically not suitable for any form of revascularization, optimal medical therapy is a feasible treatment strategy. (1, 2)

Marko Mornar Jelavic, Zdravko Babic, Hrvoje Hecimovic, Vesna Erceg, Hrvoje Pintaric

Aim: To investigate the importance and indications of head-up tilt-testing (HUTT) in patients with unexplained syncope. Patients and Methods: We retrospectively analyzed 235 patients who underwent HUTT, between February 2012 and September 2014, at the Department of Cardiology, University Hospital Centre “Sestre milosrdnice” Zagreb. They were divided in three groups according to the HUTT indications as follows: Group A (convulsive syncope, n=30), Group B (suspected vasovagal syncope, n=180) and Group C (paroxysmal vertigo, n=25). The groups were analyzed by their baseline parameters (age, gender, referral specialists (cardiologists, neurologists, others)), HUTT results (positive/negative) and specific responses (cardioinhibitory, vasodepressor, or mixed). Results: Groups A and B were referred most frequently to the HUTT by neurologists and cardiologists (p<0.05) (**Figure 1**). It was positive in 34 (14.5%) patients (5 in Group A and 29 in Group B), i.e. 13 (38.2%) patients had cardioinhibitory, 11 (32.4%) mixed and 10 (29.4%) vasodepressor response (**Figure 2**). In cardioinhibitory subgroup, there were 3 patients (23.1%, 2 males/1 female, mean age 28.5 years) with normal EEG and on antiepileptic drugs. During HUTT, they had typical convulsions with cardioinhibition and bradycardia (heart rate (HR) 30.0±5.0 beats/min) followed by asystole (13.7±11.0 seconds). These three subjects got a permanent DDDR pacemaker (atrial/ventricular stimulation, HR control) and anticonvulsive therapy was slowly withdrawn. They had no syncope recurrences during 24 months of follow-up. Figure 1. Comparison of specialists’ referral to tilt-table testing in patients with convulsive syncope (A), suspected vasovagal syncope (B) and paroxysmal vertigo (C). Figure 2. Electroencephalographic findings in patients with convulsive syncope: 12 patients with antiepileptic drugs (A) and in 18 patients with no medication (B). Conclusion: HUTT has an important role in evaluation of the patients with unexplained syncope. It is indicated in differential diagnosis of vasovagal syncope, especially in patients with syncope accompanied with convulsive elements. (1-3) Finally, pacemaker implantation is effective in preventing syncope relapses in patients with cardioinhibitory convulsive syncope.

Breda Barbic-Zagar, Mateja Grošelj

In the past six decades, Krka has emerged as one of the leading generic pharmaceutical companies in the world. Our innovative generics, i.e. value-added generic medicines, are developed using the company’s own know-how. This ensures that our products hold certain key advantages over competitor products, resulting from the development of new technologies used in the production of active ingredients and dosage forms. Our key therapeutic area in prescription pharmaceuticals is cardiovascular medicines. We offer a wide range of cardiovascular medicines, available in a variety of different dosage forms, fixed-dose combinations and innovative strengths, which enable doctors to optimize the treatment of their patients. The therapeutic equivalence of Krka’s product with the originator’s product is demonstrated by in vivo bioequivalence studies. The results of numerous clinical studies have shown that our medicines are clinically proven, effective, and well tolerated by patients in real clinical practice.

Mislav Puljevic, Vedran Velagic, Borka Pezo-Nikolic, Davor Puljevic

Tachycardia is arrhythmia characterized by heart rate >100 / minute. According to the width of the QRS complex it can be divided into narrow QRS (120 ms). Narrow QRS tachycardia is always supraventricular which means that its source is proximal to the bundle of His, while wide QRS tachycardia can be ventricular (source is in ventricle, distal to the bundle of His) or supraventricular. The strategy of treating this two conditions is different, so correct diagnosis is prerequisite for optimal therapy. (1, 2) We present this case because the differential diagnosis of wide QRS tachycardia and therefore treatment planning was particularly difficult due to simultaneously present atrial fibrillation with hemodynamic instability and an acute threat to life of patient. We present patient who was hospitalized in pulmonary edema caused by wide QRS tachycardia (**Figure 1**) that was resistant to standard drug therapy and demanded mechanical ventilation support. During each episode of VT, DC was done because of hemodynamic instability. Because of multi organ failure we considered the application of ECMO. Before ECMO urgently EPS study was done (**Figure 2**). Study has shown that patient has atrial flutter/fibrillation with occasionally alodromic conduction. The patient underwent successful ablation of the AV node with pacemaker implantation, with following complete recovery of the patient. Figure 1. Tachycardia with wide QRS complexes. Figure 2. An electrophysiology study: His potential before ventricular QRS complex.

Majda Vrkic Kirhmajer, Drazen Perkov, Ljiljana Banfic, Albert Despot, Luka Novosel, Mario Lušic

Introduction: Entrapment of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA) is known as Nutcracker phenomenon. Due to impeded outflow from LRV into the inferior vena cava and consequently LRV hypertension, a variety of symptoms can occur forming a Nutcracker syndrome (NCS). (1, 2) Clinical manifestations include hematuria, proteinuria, flank pain, dyspareunia, pelvic congestion and fatigue. Diagnostic criteria for NCS are not firmly established and treatment is controversial. We present a case of a 38-year old female with Nutcracker anatomy, pelvic varicosities and no clear signs of LRV hypertension. Case report: The patient was referred in our institution because of large pelvic varicosities noticed on transvaginal Colour Doppler Ultrasound (CDUS). She complained on pelvic pain, fatigue and dyspareunia. Besides asthenic constitution her physical examination was unremarkable. Laboratory results were nonspecific, with no hematuria or proteinuria. CT scan showed compression of LRV between the aorta and SMA, enlarged left ovarian vein (LOV) and huge pelvic varicose veins. We did not find signs of elevated renocaval pressure gradient by CDUS. Taking into consideration the possible risks involved with LRV stenting, embolisation of the insufficient LOV by foam and coils was done only. This low risk procedure went well and her pelvic symptoms gradually resolved. On control CDUS and MR scan (after 3 months) the dilated pelvic veins were significantly reduced in size, with unchanged anatomy and flow velocities of LRV. Creatinine clearance and urine analyses were repeatedly normal. Conclusion: In a patient with Nutcracker anatomy and predominantly pelvic congestion symptoms without significant renocaval pressure gradient, ovarian vein embolisation without LRV stenting can provide complete resolution of symptoms. Since gonadal veins may serve as an outflow conduit, in some cases their interruptions may worsen NCS symptoms, so follow up is needed.

Mateja Sabol Pušic, Branko Ostricki, Andrej Pal, Vinko Vidjak

Background: May-Thurner syndrome (MTS) is a rare cause of left iliac deep vein thrombosis (DVT) caused by an anatomical variant in which the left iliac vein is pressed against the lumbar vertebrae by the overlying right common iliac artery. According to some autopsy studies it is present in over 20% of the population, but it accounts for only 2-3% of all lower extremity DVT and is rarely considered in differential diagnosis of DVT. Patients typically present with this syndrome in their second to fourth decade of life with sudden onset of left lower extremity edema and pain. (1-3) Case report: We present a case of a female patient with no evident risk factors for thrombosis who developed extensive left iliofemoral thrombosis. Using pharmacomechanical thrombectomy followed by stent implantation and balloon angioplasty we achieved complete recanalisation of the affected veins. Conclusion: In the treatment of DVT caused by May-Thurner syndrome anticoagulation can reduce thrombus propagation, but does not provide clot lysis and has no effect on post-thrombotic syndrome prevention, so it is ineffective as sole treatment. These patients are suitable for available interventional techniques which improve their outcomes and morbidity. Because of the high restenosis ratio (up to 75%) in patients with MTS treated with thrombolysis without stent placement, it is of clinical importance to choose the appropriate treatment method to reduce short- and long-term sequelae for patients, especially post-thrombotic syndrome which represents an important medical and socioeconomic burden.

Mijana Barišic, Viktor Peršic, Damir Raljevic, Marica Komošar-Cvetkovic, Aleksandar Vcev, Marko Boban

Introduction: Major invasive treatment, like cardiac surgery leads to muscle weakness, unintentional weight loss and increased nutritional risk. (1-3) The aim of our study was to assess these parameters in patients scheduled for cardiac rehabilitation after recent heart surgery, depending on the existence of diabetes mellitus. Patients and Metods: Prospective study that included patients with diabetes scheduled for rehabilitation within one month from surgical procedure, and control number of peers without diabetes. Assessment included anthropometric measurement, hand grip test (HGT), weight lost history (WLH) and standardized NRS-2002 screening tool. Results: There were 59 patients of the mean age 67.0 years, male to female ratio was 48:11 (81%:19%) respectively. Diabetes mellitus was present in 26 (44%). Diabetic vs. non diabetic had 28.7kg vs. 33.5kg for left hand HGT; 29.5kg vs. 38.0kg for right hand HGT; %WLH was 6.7% vs. 6.8%; and NRS-2002 was 3.6 vs. 3.4, respectively. Conclusion: Both groups of patients expressed similarly pronounced nutritional risk after heart surgery, measured by mean %WLH and NRS-2002. However, a significant difference in strength of HGT implies that metabolic perturbations after surgery cause more severe muscle dysfunction in diabetics, in comparison with non-diabetics. This should be taken in to count for individualization of therapeutic approach in cardiovascular rehabilitation process.

Margarita Brida, Darko Anic, Maja Strozzi, Anton Šmalcelj

Case report of a young female patient, 27 years old. The patient was born with congenital heart defect-extreme form of tetralogy of Fallot with pulmonary valve atresia. In the neonatal period she underwent Blalock-Taussig anastomosis and later the Rastelli operation with the implantation of homograft in pulmonary position. During time there was calcification and narrowing of the conduit and at the age of 26 she went in the international center for the mechanical heart valve implantation in pulmonary position. As a young patient she did not understand the importance of follow-up and did not continue treatment in Croatia since she felt good. She stopped taking prescribed medications, including anticoagulant therapy. One year after the operation she gave birth to a healthy child and after she was sent to control cardiac examination. Heart ultrasound was preformed which verified the mechanical pulmonary valve completely stiff in the open position with the presence of mobile clots. Patient, in a relatively short period after implantation of mechanical valve, was re-operated in our clinic with excellent postoperative result. The case of this patient wishes to emphasize the importance of forming Center for congenital heart diseases where the young patients in adulthood could be carefully monitored and treated. (1-3) The patient had the great fortune that the mechanical valve was fixed in hemodynamic relatively favorable position and has been without major problems.

Marija Vavlukis, Kristina Mladenovska, Arlinda Daka, Aleksandar Dimovski, Sasko Kedev

Objective: To compare the effect of rosuvastatin versus atorvastatin alone, and in combination with niacin or fibrates, on elevated lp(a). Method: Patients with lp(a) >50 mg/dl, with cardiovascular disease (CVD), and high/very high SCORE risk, already on statin therapy because of a compelling indications . Analyzed variables: age, gender, risk factors, co-morbidities, SCORE risk, myoglobin, enzymes: CPK, AST, ALT, LP fractions [TG, CHOL, HDL-C, LDL-C, ApoA1, ApoB and Lp(a)]. Patients were divided in four groups depending on the therapy: rosuvastatin 40 mg, atorvastatin 80 mg, atorvastatin 40 mg add-on fenofibrate, and atorvastatin 40 mg add-on 1 g ER (extended-release) niacin. We compared the four treatment regiments in their therapeutic efficiency [especially for lp (a)], and safety profile. Results: 87 pts, at mean age 61±12 years, were analyzed. Obesity (64.7%) and arterial hypertension (64.6%) were main risk factors. Males predominated, had 5.1 OR for smoking, 2.8 OR for CVD, had higher risk profile, but lower total and LDL-C (5.3 vs. 6.2, p=0.002; and 3.5 vs. 4.2, respectively). Mean lp(a) at the starting point was 94.6±39.6 mg/dl, without gender difference. 25 pts. received rosuvastatin, 22 atorvastatin, 20 fibrate+atorvastatin, and 20 niacin+atorvastatin, without inter-group differences in LP fractions at the beginning of the follow up. Significant decrease of all LP fractions was registered after 6 month treatment. Mean lp(a) reduction was 15.9±21.0 mg/dl, with only 16% of patients achieving an lp(a) <50mg/dl. Rosuvastatin was the most efficient on all LP fractions, the mean reduction of lp(a) was 18.2±24.8 mg/dl (p=0.001), similar effect was achieved with atorvastatin in combination with fibrates or niacin (17.3±10.4; p=0.001; and 19.5±10.9, p=0.001 respectively), while high dose atorvastatin alone, was inferior. Rosuvastatin was the only treatment that had beneficial effect on all LP fractions (C p=0.000, LDL-C p=0.001, ApoB p=0.001, TG p=0.000, and increasing of HDL-C p=0.001 and ApoA1 p=0.014). No significant side effects were observed. Conclusion: Rosuvastatin was the most potent agent in reduction of lp(a), and the only one that had beneficial effect on all LP fractions. Rosuvastatin was superior to equipotent dose of atorvastatin. Therapeutic effect of atorvastatin in lp(a) reduction is accentuated when combined with fibrates or nicotinic acid. Given in a recommended doses, all agents are safe. (1-3)

Zrinka Alfirevic, Katija Barac

Coronary heart disease causes more deaths and disability and incurs greater economic costs than any other illness in the developed world. It is logical that this impact reflects on the working capacity of the individual. The frequency of returning to work varies greatly in the world, depending on the type of health insurance, duration of rent, the labor market and sick listing traditions among physicians. The aim of modern therapy is to improve quality of life and the renewal of professional activity. Work ability depends on the hearth conditions and circumstances of the workplace. Presence of chest pain during exercise, risk of arrhythmia and a high level of left ventricular dysfunction are the main symptoms indicating a working disability. The most reliable test for assessing work capacity is the exercise test, but the results of this test should always be carefully analyzed. Functional assessment of the heart muscle is not always based on a strictly scientific basis, varying from examiner to examiner. The authors proposed when assessing coronary reserve that the upper general tolerance limit over on 8 hour work day consisting of mixed physical labor including manual handling operations, should be 40-45% VO2 max. while exposure to short-time work extension may be allowed 70-80% of the end-point level of the exercise test. The assessment should take into account that persons who take up active work after a myocardial infarction have a longer life span, a five times smaller percentage of neurosis and depression in relation to retired reconvalescents, and a significantly lower probability of developing a recurrent cardiac incident. Most often return to work the younger age groups, highly educated, highly educated, employed preoperatively. (1-4) Assessments of working abilities should be made after the completion of treatment and rehabilitation, while taking into account all of the parameters so as not to harm the truly disabled.

Ivo Planinc, Dora Fabijanovic, Boško Skoric, Jana Ljubas Macek, Hrvoje Jurin, Jure Samardzic, Zeljko Baricevic, Hrvoje Gašparovic, Maja Cikeš, Davor Milicic

Purpose: There is a substantial amount of data demonstrating the influence of body mass index (BMI) on outcomes of patients after heart transplantation (HTx) or left ventricular assist device (LVAD) implantation. However, no direct comparisons were made between these two modalities of advanced heart failure treatment in a specific population in terms of pretreatment BMI. (1-3) Patients and Methods: We retrospectively studied 90 consecutive HTx (67 male, mean age 51.9±13, median follow-up 20.8 months) and 32 consecutive LVAD (27 male, mean age 58.3±8, mean follow-up 13.1 months) patients from our centre in the period from January 2010 to December 2014. The patients were categorized in groups according to pretreatment BMI: non-overweight patients (BMI 2 | 38 | 12 | | ≥25 kg/m2 | 52 | 20 | Figure 1. Kaplan-Meier survival curves for body mass index groups in relation to different treatment options. Figure 2. Modified Kaplan-Meier curves representing length of hospital stay for body mass index groups in relation to different treatment options. Conclusion: Non-overweight patients in our cohort demonstrated better survival with HTx than LVAD treatment. No influence of BMI on length of hospital stay was shown between the HTx and LVAD treatment groups.

Mislav Puljevic, Davor Puljevic, Borka Pezo-Nikolic, Vedran Velagic

For ablation of some arrhythmias exact knowledge of anatomy structure which is planned for ablation or relations with the surrounding structures is very important. Two examples of such arrhythmias are atrial fibrillation (AF) and ventricular tachycardia (VT) from the aortic root. For the AF it is important to know the exact anatomy and variations of the position and shape of the pulmonary veins (common trunk left vein, 5 veins, etc.), in order to select the most optimal method of ablation. In VT from the aortic cusps it is necessary to know the exact distance from the focus to the orifice of the coronary arteries (possible lesion of coronary artery). For this purpose in most centers CT angiography or NMR with reconstruction are performed before electrophysiology (EP) procedure. Newer simpler and cheaper method is rotational angiography with 3D reconstruction. (1) During the EP procedure, on the same X-ray device, it is possible to make a 3D reconstruction of specific heart structure. Reconstructed image can be then quickly imported to live fluoroscopic image. On this superponed picture live catheter position is clearly seen, you can easily determine direction of catheter for easier entering of certain vein, whether cryoballoon is on PV ostium or too deep, where exactly atrial appendage is etc. During EP procedure of VT from the aortic cusps, 3D reconstruction shows aortic root and additionally coronary arteries ostias. Superponed 3D image synchronously moves with „live“ fluoroscopic image so it is possible to see exactly position of mapping catheter in regard to coronary artery ostium or aortic valve. On reconstructed image it is possible to tag points, draw lines and measure in exact superposition to „live“ image. Using this method ablation can be easier, faster and more secure. This new method is available in new EP lab at University Hospital Center Zagreb. The first experiences with this new method are very positive, and benefit is clearly depicted in this two examples (AF and VT).

Zvonimir Ostojic, Vlatka Reškovic Lukšic, Zeljko Baricevic, Boško Skoric, Joško Bulum, Blanka Glavaš Konja, Martina Lovric Bencic, Aleksander Ernst, Jadranka Šeparovic Hanzevacki

A 53-year old male farmer with no significant past medical history was hospitalized because of cardiac tamponade. On admission, patient was febrile, dyspneic and orthopneic, with elevated inflammatory parameters. Initial echocardiogram showed circular pericardial effusion up to 26-31mm, with fibrin deposits and elements of constriction. Pericardial drainage was performed (3000 ml of purulent effusion in total over 9 days) along with intrapericardial application of alteplase due to large amounts of fibrin with loculations. Diagnosis of purulent pericarditis was confirmed by biochemical and cytological analysis of the pericardial fluid. Multiple hemocultures and effusion cultures were sterile and Mycobacterium tuberculosis was excluded using PCR. Afterwards, serology on atypical microorganisms was performed. Beside NSAID, empiric antibiotic therapy with vancomycin and meropenem was started, followed by good clinical response and partial normalization of inflammatory markers. On the 13th day of antimicrobial therapy, patient became febrile with inflammatory parameters elevation. Serology results (ELISA and Western Blot) came positive for Borelia burgdorferi. Therapy was changed to iv ceftriaxon for 14 days, followed by 28 days of doxycycline per os, along with NSAID and colchicine. A month after, control echocardiography revealed minimal amount of pericardial effusion and fibrin deposits, some elements of mild constriction and no laboratory signs of active infection. With this case report, we wanted to emphasize the importance of distinguishing the cause of purulent pericarditis taking into account atypical organisms, especially in case of inadequate response to empiric therapy. Borrelia burgdorferi infection, although usually causing conducting abnormalities and myocarditis, should be suspected in patients with purulent pericarditis when some risk factors (profession, endemic areas etc.) are present, even if there is no evidence of tick bite or erythema. (1, 2)

Alma Sijamija, Nermir Granov, Nedzad Hadzic, Omer Perva, Alma Agacevic

Introduction: Cardiac device-related endocarditis (CDE) is a phenomenon for which incidence is on the rise. The prevalence of CDI (cardiac device infection) ranges between 0.13% and 19.9%, and the prevalence of CDE ranges between 0.5% and 7%. The definition of early and late CDE is not uniform, as it is with infective endocarditis of the artificial valve. There is a significant delay in diagnosing CDE – an average of 5.5 months from clinical onset. The diagnosis is confirmed by positive blood cultures and an echocardiogram that demonstrates vegetations on the pacemaker/ICD lead. Transesophageal echocardiography (TEE) has been found to be more sensitive in detecting CDE than transthoracic echocardiography (TTE). TEE has a reported sensitivity of >95% in pacemaker/ICD endocarditis, versus 10, ECHO verified right pleural effusions. About 800 ml of hemorrhagic fluid was evacuated by thoracocentesis. After the recovery, in June 2014, planned surgery was performed (Extractio pace makeris leads DDD, Extractio pacemakeris). Postoperatively ECG Holter monitoring registered the complete AV block with satisfactorily rate, an average 43 per min. Reimplantation of PM was recommended (VVIR). During hospitalizations in our department and after the surgical treatment patient received: Ceftriaxone, Ciprofloxacin, Levofloxacin, Doxicyclin, Vankomycin. On one year follow up patient was doing well, without any clinical symptoms of infection; ECG: sinus rhythm, rate 50 per minute. In July of 2015 patient had two syncope attacks, registered heart rate was 30 per min. He was referred to the Heart Center UKC Sarajevo where was implanted single-chamber PM VVIR with ventricular electrode. The patient today feels great. Conclusion: Management of device-related endocarditis is challenging and requires collaborative efforts between cardiologists, surgeons, and infective disease specialists. The recommended treatment approach is a combination of wire removal (surgically or by traction) along with antibiotic therapy. An MT (medical treatment) approach is not recommended due to the high rate of failure and recurrent exacerbation of the infective endocarditis.

Petra Angebrandt, Marijan Pašalic, Ivo Planinc, Dora Fabijanovic, Maja Cikeš, Hrvoje Jurin, Zeljko Baricevic, Jure Samardzic, Davor Milicic, Boško Skoric

Introduction: Coronary artery disease represents the most common cause of morbidity and mortality in developed countries. With the introduction of percutaneous coronary interventions (PCI) and the primary PCI network, the mortality of acute myocardial infarction (MI) has significantly decreased. However, patients with acute MI complicated with severe acute heart failure still show poor outcomes. Circulatory support with extracorporeal membrane oxygenation (ECMO) in such patients may serve as either bridge-to-recovery or bridge-to-decision treatment modality. This case highlights the importance of early recognition of the need for ECMO support as well as its early implantation in acute MI complicated with severe acute heart failure. (1-3) Case report: A 64-year-old male patient was hospitalized in Coronary Care Unit due to acute anteroseptolateral ST segment elevation myocardial infarction with signs of cardiogenic shock and pulmonary oedema. Echocardiography showed severely reduced systolic function of left ventricle. Inotropic and vasopressor support was initiated. The patient was intubated and mechanically ventilated. Coronary angiogram revealed acute thrombotic occlusion of left main coronary artery (LMCA). Due to the angiography finding and hemodynamic instability, veno-arterial (V-A) ECMO support was introduced, under which a successfull PCI of LMCA was done. Soon after the vessel recanalization, patient became normotensive and both inotropic as well as vasopressor therapy was gradually discontinued. Chronic heart failure therapy was progressively introduced (spironolactone, ACE inhibitor, and finally beta-blocker). Patient was successfully weaned from ECMO support six days after the implantation, without any complications. Three months later the patient is in NYHA I functional status, with a significant improvement in ECHO finding (LVEF 45%). Control coronary angiography revealed significant restenosis in the previously implanted BMS and the re-PCI of LMCA with DES and re-PTCA of proximal LAD with DEB was successfully performed under the IVUS control. Conclusion: V-A ECMO is a life-saving therapy in patients treated with PCI in the setting of acute MI complicated with cardiogenic shock. It may serve as a bridge to myocardial recovery, cardiac transplantation or implantation of long-term left ventricular assist device. It is of outmost importance to recognize the need for ECMO support on time, in order to improve the clinical outcome after successful coronary revascularization.

Mario Sicaja, Boris Starcevic

Extracorporeal membrane oxygenation (ECMO) is a recognised rescue treatment option frequently utilized in the pediatric population or the treatment of severe cardiorespiratory failure. Recent advances in the field have introduced ECMO usage well beyond cardiac surgery operating theatre. There is an increasing evidence of usage in adults, particularly in the setting of interventional cardiology. ECMO exists in two variations: a venovenous (VV-ECMO) variation for respiratory and an arteriovenous form (VA-ECMO) for total cardiopulmonary support. The main advantages of VA-ECMO support are superb hemodynamic support of the body perfusion in patients with severe heart failure, rapid, rapid initiation in the emergency setting, possibility of patient transport and serving as a bridge to the definite treatment modality in critically ill patients. Main drawbacks are high device related morbidity, need for continuous anticoagulation and the need for adequate training of ECMO team members.1,2 We present our initial experience with VA-ECMO use in the setting of high-risk percutaneous coronary interventions.

Helena Jerkic, Mario Stipinovic, Stjepan Kranjcevic, Damir Kozmar, Darko Pocanic, Tomislav Letilovic

Statin treatment, applied before percutaneous coronary intervention (PCI), was shown to reduce periprocedural myocardial damage and overall MACE. (1) Most of the studies showing such relation were done in statin naďve patients. In the only study that was done in statin treated patients, overall population did not reach proposed LDL target i.e. < 1.8 mmol/L. Reaching that target is a measure of adequate statin treatment in everyday practice. We hypothesized that achieving LDL target, i.e. applying adequate statin treatment, could reduce periprocedural myonecrosis in patients with stabile coronary disease scheduled for elective PCI. Data from 372 patients, in a period of 16 months, were collected. Values of troponin I were measured before the procedure as well as 8 and 16 hours after the procedure. Lipid parameters were determined before the procedure. Intensity of periprocedural myonecrosis was measured as a difference between troponin I values before the procedure and the values 8 and 16 hours after the procedure. Statin reload was not applied. In patients reaching LDL target (114 patients) intensity of periprocedural myonecrosis was lower both at 8 hours (p=0,038) as well as at 16 hours (p=0,013) after the procedure when compared to patients that did not reach LDL (258 patients) target. When statin naďve patients were excluded from the analysis the same difference, between patients reaching LDL target (104 patients) and those that did not reach it (204 patients) both at 8 hours (p=0,028) as well as at 16 hours (p=0,003) after the procedure, could be observed. In a multiple regression analysis only LDL levels significantly (p=0,003) correlated with intensity of periprocedural damage. No such correlation was found for other lipid parameters, CRP or creatinine. Our results show that reaching LDL target reduces myocardial damage during PCI. Such a relation could imply a need for a more stringent adherence to LDL target in patients undergoing elective PCI procedures.

Krešimir Gabaldo, Deiti Prvulovic, Bozo Vujeva, Irzal Hadzibegovic

Introduction: Coronary atherosclerotic heart disease is the leading cause of death worldwide. The clinical presentation of the disease is extremely variable – from mild chronic and asymptomatic disease to acute and life threatening. The appropriate use criteria (AUC) for coronary revascularization is a new tool to help cardiologists with clinical decision making. (1) The criteria are based on the clinical presentation, severity of symptoms, extent of ischemia on non-invasive testing, risk assessment, use of anti-ischemic therapy and coronary anatomy. The Technical panel scored the clinical scenarios on a scale 1-9. Scores of 7-9 indicate that revascularization is appropriate, while scores 1-3 indicate inappropriate revascularization. Patients and Methods: We analyzed 20 patients who have undergone coronary angiography and PCI. 10 patients were with stable coronary artery disease and 10 were acute coronary syndrome patients. In decision making we used SCAI Quality Improvement Toolkit. In a group of stabile coronary artery disease we found 7 patients to be appropriate to revascularize. Among them we performed ad hoc PCI on 3 patients, staged PCI on 3 patients, 1 patient was referred for CABG, while 3 patients were uncertain for revascularization and we put them on optimal medical therapy. In a group of ACS patients all 10 patients were appropriate for revascularization, in 7 patients we performed ad hoc PCI, in 2 patients we did staged PCI, while 1 patient was referred to CABG. Conclusion: The appropriate use criteria (AUC) for coronary revascularization is a tool to help cardiologists, not a threat. As a general rule, patients with ACS are usually appropriate for cardiac catheterization and PCI, while asymptomatic patients, particularly those without noninvasive testing are inappropriate. The main issue of AUC is to question your own judgment and improve your current practice.

Hrvoje Gašparovic, Daniel Unic, Lucija Svetina, Jure Samardzic, Maja Cikeš, Zeljko Baricevic, Boško Skoric, Tomislav Kopjar, Darko Anic, Višnja Ivancan, Zeljko Sutlic, Bojan Biocina, Davor Milicic

Goal: Renal insufficiency is a relative contraindication for isolated heart transplantation (HTx). (1-3) We aimed to determine the independent effect of preoperative creatinine clearance (CrCl) on HTx outcomes. Patients and Methods: 220 patients underwent HTx in Croatia from 2008 to 2014. Four patients were excluded due to missing data. Patients were dichotomized according to a CrCl cut-off value of 50 ml/min (Group A: CrCl≤50 ml/min; Group B: CrCl>50 ml/min). Sixty-three patients (29%) had a CrCl≤50 ml/min. Propensity score (PS) adjustment was performed by accounting for recipient age and gender, AF, smoking, ischemic time, CPB time, BMI, mechanical circulatory assistance (MCS) and reoperation. Results: Patients in Group A were older (56±11 vs. 49±12 years, P<0.001) and had longer donor ischemic times (197±65 vs. 162±62 min, P<0.001). No significant differences were noted in recipient gender (48/63 (76%) vs. 125/153 (82%) male, P=0.355), donor age (39±13 vs. 39±12 years, P=0.875), donor gender (46/63 (73%) vs. 100/153 (65%) male, P=0.338), PVR (213±107 vs. 188±96 dyn*s*cm−5, P=0.145), diabetes (18/63 (29%) vs. 34/153 (22%), P=0.382), reoperation (18/63 (29%) vs. 34/153 (22%), P=0.382), CPB duration (175±62 vs. 158±56 min, P=0.06) or preoperative MCS (6/63 (10%) vs. 17/153 (11%), P=0.813). Six-month mortality was higher in patients with a CrCl≤50 ml/min (18/63 (29%) vs. 19/153 (12%); unadjusted OR 2.82 [95% CI 1.36-5.84]; P=0.009). Similarly, group A patients were more likely to require renal replacement therapy (RRT) (16/63 (25%) vs. 17/153 (11%); OR 2.72 (1.28-5.82); P=0.012). After PS adjustment these differences remained significant for both 6-month mortality and RRT (OR 2.44 [95% CI 1.09-5.49]; P=0.030 and OR 3.36 [95% CI 1.43-7.92]; P=0.005, respectively). Conclusions: Patients with a CrCl≤50 ml/min undergoing isolated HTx had inferior 6-month survival and required RRT more commonly. The impact of CrCl remained significant after adjustment for multiple perioperative covariates.

Ksenija Tušek Bunc

Background: Quality management of patients with coronary heart disease significantly contributes to better health-related quality of life (HRQoL). (1, 2) Patients and Methods: The study was cross-sectional and included 423 patients with coronary heart disease from 36 family medicine from all Slovenian regions. The purpose of the study was to identify factors associated with HRQoL at the patient level. A comprehensive questionnaire for patients included, among others, the standardized the EuroQol instrument (EQ-5D) for measuring quality of life. Multivariate regression analysis was performed. Results: The average age of participants was 68.0 (SD=10.8) years, 64.8% were male. Multivariate regression analysis of factors impacting the patient, the presence of vascular co-morbidity, and anxiety-depressive disorders on HRQoL (as measured by the Visual Analogue Scale), showed (**Table 1**) significant association between patient age, frequency of family practice visits, heart failure, anxiety-depressive disorders, and the patient chronic illness care evaluation (p10 years | 1.85 | (-2.46 – 6.16) | 2.19 | 0.04 | 0.84 | 0.399 | | Practice attendance within 12 months | -4.31 | (-6.96 – -1.65) | 1.35 | -0.15 | -3.19 | 0.002 | | Angina pectoris | 1.68 | (-2.05 – 5.41) | 1.90 | 0.04 | 0.89 | 0.376 | | Myocardial infarction | 2.68 | (-1.08 – 6.44) | 1.91 | 0.07 | 1.40 | 0.161 | | Stent/By pass | -3.62 | (-7.53 – 0.28) | 1.98 | -0.09 | -1.83 | 0.069 | | Heart failure | -6.86 | (-10.91 – -2.80) | 2.06 | -0.17 | -3.32 | 0.001 | | Stroke | 2.54 | (-4.89 – 9.97) | 3.78 | 0.03 | 0.67 | 0.502 | | Peripheral artery disease | -1.85 | (-5.95 – 2.25) | 2.08 | -0.04 | -0.89 | 0.376 | | Anxiety / Depression | -10.28 | (-14.17 – -6.39) | 1.98 | -0.25 | -5.20 | 10 years | 0.00 | (-0.04 – 0.04) | 0.02 | 0.00 | -0.03 | 0.973 | | Practice attendance within 12 months | -0.02 | (-0.04 – 0.00) | 0.01 | -0.08 | -1.87 | 0.062 | | Angina pectoris | -0.02 | (-0.05 – 0.01) | 0.02 | -0.05 | -1.24 | 0.216 | | Myocardial infarction | -0.03 | (-0.06 – 0.00) | 0.02 | -0.07 | -1.80 | 0.073 | | Heart failure | -0.05 | (-0.08 – -0.02) | 0.02 | -0.13 | -2.92 | 0.004 | | Stroke | 0.01 | (-0.05 – 0.07) | 0.03 | 0.02 | 0.39 | 0.698 | | PAD | -0.06 | (-0.10 – -0.03) | 0.02 | -0.15 | -3.64 | <0.001 | | Self-percived health | 0.10 | (0.08 – 0.12) | 0.01 | 0.45 | 10.24 | <0.001 | | Medication | 0.03 | (-0.06 – 0.12) | 0.05 | 0.03 | 0.72 | 0.475 | | Patient satisfaction (EUROPEP) | 0.00 | (-0.03 – 0.04) | 0.02 | 0.01 | 0.27 | 0.785 | | Patient assessment of chronic illness care (PACIC) | -0.01 | (-0.03 – 0.01) | 0.01 | -0.03 | -0.61 | 0.543 | [†] R˛=0.450; F = 18.386; p < 0.001 95% CI = 95% confidence interval; SE = standard error Discussion: HRQoL in patients with coronary artery disease is associated with patient characteristics, with vascular co-morbidity and anxiety-depressive disorders. Of the demographic factors related to HRQoL, older age is associated with a worse HRQoL. Another factor predicting a worse HRQoL is frequency of family practice visits. On the other hand, higher education, better self-assessment of health, and better assessment of chronic illness care are associated with a better HRQoL. Heart failure, peripheral artery disease, and anxiety-depressive disorders stand out as diseases predicting of a worse HRQoL.

Marijan Pašalic, Maja Cikeš, Ivo Planinc, Nina Jakuš, Boško Skoric, Tomislav Caleta, Zeljko Baricevic, Hrvoje Jurin, Jure Samardzic, Hrvoje Gašparovic, Bojan Biocina, Davor Milicic

Introduction: Different factors are associated with a poor outcome after left ventricular assist device (LVAD) implantation, the most common being right ventricular (RV) dysfunction, hemorrhage and infections. While many studies evaluate hemodynamic parameters relating to RV function, sparse research focuses on other parameters as potential predictors of worse outcome. We analysed the outcomes of patients that underwent LVAD implantation to determine the main causes of mortality and detect the predictors associated with this outcome. Patients and Methods: We studied 31 patients (27 male, mean age 57.8±14.1 y) with LVADs over a median follow-up period of 11 months. Patient history, INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) score, pre- and postimplantation laboratory results, echocardiography and right heart catheterization data were collected and analysed according to overall survival. Results: Overall, 14 patients (45%) died, mostly due to bleeding complications (5/14), followed by postoperative infections (3/14). All patients had an INTERMACS score 4 or lower, and there was no significant difference between the survival groups according to the analysed hemodynamic parameters. RV function was on average borderline (FAC 26.5±11.8%, TAPSE 1.4±0.4 cm), the cardiac index was low (1.7±0.6 L/min/m2), transpulmonary pressure gradient was slightly (14±8 mmHg) and the pulmonary vascular resistance was moderately elevated (4.1±2.6 WU). The survival groups did not differ in most of the laboratory findings, but the expired patients had a significantly lower preoperative platelet count (Plt) (185±62 vs. 241±70 x10E9/L, p=0.04). The threshold value of Plt set at 170x10E9/L defined an increased hazard ratio for the patients with higher Plts (HR 3.04, C.I. 1.02-9.15; **Figure 1**). Notably, patients with lower Plts had also a significantly lower preoperative hemoglobin levels (109±22 vs 137±26 g/L, p=0.02). Figure 1. Survival after left ventricular assist device implantatation according to platelet count. Conclusion: Rigorous evaluation of hemodynamic parameters is essential in the optimal selection of LVAD candidates, while preoperative platelet count could be a potential predictor of postoperative hemorrhagic diathesis.

Matea Hudolin, Zdenka Curic, Marko Curkovic, Tomislav Letilovic

Coronary angiography is a medical procedure associated with a certain amount of pain and discomfort. (1) We designed our own pain/discomfort questionnaire and conducted this initial study in order to assess its feasibility. Questionnaire consists of three types of questions. Firstly there are the ones addressing the pain and comfort issue in a semi-quantitative manner i.e. scoring of a sensation from 1 to 5 (1 being the lowest intensity of a sensation). Second types of questions are categorical ones and are also related to pain and discomfort. Lastly, there are informative questions mostly covering demographical data. In a period of one month we collected data from 56 patients (36 male) undergoing elective diagnostic coronary angiography. Mean age of our patients was 63.3±9.4 years. Mean score for pain during the procedure was 2.1±0.67 and for discomfort it was 2.16±0.92. The pain after the procedure was scored with 1.71±0.80 and the overall disability from the procedure with 1.78±0.80. Pain during the procedure was graded significantly higher (p=0.036) in women than in men (2.46±0.64 vs. 2.0±0.65). Pain after the procedure was also graded higher (p=0.047) in women (2.07±0.88 vs. 1.51±0.66). There were no differences in the grading of the discomfort or the notion of the disability between the sexes. 55 patients (98%) stated that they would undergo the same procedure again. All (56/56) of the patients declared that they would recommend the procedure either to other persons or their family members. Initial results show that our questionnaire is feasible. Furthermore gathered data show some significant differences in pain sensation, induced by diagnostic coronary angiography, between women and men. We plan to strengthen our findings by including larger number of patients. In the future, using the same questionnaire, we plan to compare pain/comfort sensations in different invasive procedures conducted in our catheterization laboratories.

Alden Begic, Amina Bico, Lana Lekic, Admir Tanovic, Demir Bejtovic, Mehmed Kulic, Mirza Dilic

Introduction: The goal of this study is to evaluate the role of arterial hypertension (HTA) in patients (pts) with atherosclerotic disease (AthD) of coronary arteries (CAD), carotid arteries (CdA) and iliaco-femoro-popliteal (IFP) arteries. (1-3) Patients and Methods: The study included a total of 311 pts with with clear clinical AthD. We evaluated the presence of CAD, CdA, and IFP as well as clinical variables: age, gender, arterial hypertension (HTA), tobacco, hyperlipidemia (HLP), obesity (BMI), fibrinogen and diabetes mellitus. The risk factors score was calculated as x/8. Special focus was given to pts with HTA (n=183) who were divided in two subgroups; isolated systolic HTA and systolic/diastolic HTA. Results: The study included a total of 311 pts, 207 males and 104 females, average age of 64 ±11.2 years. Combination of IFP + CAD was registered in 124 pts, with multiple risk factors (MRF) score 4.35, IFP+CdA was registered in 78 pts, with MRF score 4.51, and IFP+CAD+CdA in 109 pts, with MRF score 4.59. HTA was present in 132 pts (42.4%, p<0.01), 86 males and 48 females, with the average age 67.8±12.9. Isolated systolic HTA was registered in 84 pts (63.6%), and systolic/diastolic HTA in 48 pts (36.4%). There was a significant relation between the IFP+CAD pts and isolated systolic HTA, r=.81, p<0.001 and borderline significant relation between IFP+CAD+CdA pts and systolic/diastolic HTA, r=42, p=0.07. Conclusions: (1) We found a clear link between the PolyAthD and elevated MRF score (r=.64, p<0.01), especially clinical variables HTA (p<0.01) and tobacco (p<0.01). (2) We established a borderline relation rank between dual disease (IFP+CAD and IFP+CdA) and MRF score (r=.46, p<0.05), (3) There was a statistically significant relation between IFP+CAD patients and isolated systolic HTA, r=.81, p<0.001, and a non-significant relation between IFP+CAD and IFP+CAD+CdA disease and systolic/diastolic HTA, r=36, p=0.9.

Marijana Knezevic Pravecek, Irzal Hadzibegovic, Katica Cvitkušic Lukenda, Antonija Raguz, Ivica Dunder, Krešimir Gabaldo, Deiti Prvulovic, Bozo Vujeva

Aim: The goal of this study was to determine, for the first time in an east European country, the relationship of 25-hydroxyvitamin D (25(OH)D) serum concentration with extent of coronary artery disease and prognosis in patients with acute coronary syndrome (ACS) during a three-year follow up period. (1-3) Patients and Methods: The study included 60 ACS patients hospitalized at cardiology department for ACS between March 2012 and September 2012; and 60 matched controls without ACS. Standard laboratory testing and vitamin D determination were performed in all study patients. In addition, ACS patients underwent coronary angiography and were followed-up for 36 months of ACS for major adverse cardiac events (MACE). Results: Patients with ACS had a statistically significant lower mean 25(OH)D level as compared with control group (35.19 nmol/L vs. 58.08 nmol/L, p<0.001). The lowest mean level of 25(OH)D was recorded in diabetic patients with ACS (30.45 nmol/L). After coronary angiography, ACS patients were divided into three subgroups regarding coronary disease severity: single, double and multiple vessel disease with 25(OH)D serum levels of 36.44 nmol/L, 33.65 nmol/L and 31.70 nmol/L, respectively. Event free survival rate at 36 months in the ACS group was 60%. Patients with a MACE had lower 25(OH)D, but that difference was not statistically significant (32.64 nmol/L vs 37.01 nmol/L in event free patients). Conclusion: There is an association between low serum concentration of 25(OH)D and ACS. Vitamin D level is considerably influenced by diabetes comorbidity. There was no significant association between 25(OH)D and MACE at 36 months in ACS patients.

Jure Samardzic, Nada Bozina, Boško Skoric, Marijan Pašalic, Lana Ganoci, Miroslav Krpan, Mate Petricevic, Davor Milicic

Introduction: Multidrug resistance gene 1 (MDR1) encodes clopidogrel’s intestinal efflux transporter P-glycoprotein. Polymorphism in MDR1 exon C3435C>T has been linked to alterations of clopidogrel absorption and the level of platelet inhibiton. (1-3) Patients and Methods: We performed pharmacogenetic analysis from our previously published trial which evaluated the effect of serial clopidogrel dose adjustment based on continuous platelet function testing in acute coronary syndrome patients with initially determined high on-treatment platelet reactivity on clopidogrel. Fourty-two and fourty-three patients were genotyped for MDR1 C3435T from the control group and the interventional group, respectively. PR levels during 12 month follow up were compared between carriers and non-carriers of loss of function allele 3435T. Results: 3435T carriers and non-carriers had similar PR levels in the interventional group (p=0.460). PR of 3435T carriers was higher compared to noncarriers in the control group, however, not statistically significant (p=0.084) during entire follow up period (**Figure 1**). Figure 1. The effect of MDR1 3435T allele on platelet reactivity. Conclusion: Presence of MDR1 3435T allele was not associated with statistically significant changes in PR in both groups of patients. Larger trials with adequate power are warranted to confirm these results.

Mislav Puljevic, Joško Bulum, Aleksander Ernst, Davor Milicic, Davor Puljevic

Background: Microvolt T-wave alternans (MTWA) testing has shown promise as a noninvasive predictor of potentially lethal ventricular arrhythmias. (1-3) No clinical study examined parameters and value of MTWA for detection of ischaemia. We hypothesize: 1) MTWA can be new non-invasive tool for the detection of reversible ischemia in patients with suspected CAD without structural heart disease. 2) MTWA can detect ischemia earlier and with greater sensitivity and specificity compared with exercise ECG testing. 3) Threshold value of MTWA and heart rate at which the alternans is estimated can be different, compared to values in prediction of lethal arrhythmias. Methods: 50 patients with suspected stable coronary disease but without previous structural heart disease were included. All patients have undergone Echo, exercise ECG test, MTWA with classical and modified threshold alternans values and coronary angiography. Results: In group with no significant CAD 37.0% had a false positive result on exercise ECG test, while none of the patients had false-negative findings. Sensitivity of exercise ECG test in the detection of coronary artery disease in our study was 100% and the specificity was 56.5%. In a group of angiographically positive patients, standard MTWA accurately identified 86% of patients, while 15% had a false negative result. All angiographically negative patients were accurately identified with no false positives. Sensitivity of MTWA was 63.6% and specificity 100%. However the best ratio of sensitivity and specificity (92.3% and 95.8%) had modified criteria for positive MTWA (MTWA > 1.5 mcV at heart rate 115-125/min). Conclusions: This study has shown that MTWA can be the new non-invasive tool for the detection of reversible ischemia in patients with suspected CAD without structural heart disease. Also MTWA can detect ischemia earlier and with greater sensitivity and specificity compared to exercise ECG testing. Best ratio of sensitivity and specificity for this indication have modified MTWA criteria.

Marko Boban, Damir Raljevic, Vesna Pehar Pejcinovic, Viktor Peršic

Ischemic heart disease is among most important constituents of cardiovascular disease continuum. The greatest proportion of total mortality burden in developed countries, as well as Croatia happens due to ischemic heart disease. On the other hand, a substantial part of the general population suffers of ischemic heart disease, experiencing among others lower social and professional level of activity, as well as lower quality of life. Cardiac magnetic resonance imaging (CMR) is becoming increasingly valuable as the diagnostic tool for making supplementary objective therapy guided decisions. Accessibility of CMR is in particular helpful for groups of patients with stable coronary disease, complex coronary lesions, earlier revascularizations, and others. Thanks to its favorable pharmacological characteristics, tolerance and safety profile adenosine stress test is the most commonly utilized form of stress-CMR in European Union. Adenosine-CMR stress test allows for quantification and characterization of perfusion defects, which offers important prognostic information, as well as improvement of quality of life, personalized risk assessment, and it can also be used as a screening tool. (1-3)

Dora Fabijanovic, Ivo Planinc, Jana Ljubas Macek, Boško Skoric, Zeljko Baricevic, Hrvoje Jurin, Jure Samardzic, Hrvoje Gašparovic, Maja Cikeš, Davor Milicic

Goal: The clinical value of cardiac biomarkers (such as brain natriuretic peptide (BNP) or troponin T) in heart transplant (HTx) recipients is not completely defined. Despite multiple published studies on the association between cardiac biomarkers and survival or acute allograft rejection, there is insufficient evidence to recommend them in everyday clinical practice. (1, 2) We sought to explore survival of patients after HTx in relation to NTpro-BNP and high sensitive TnT (hs-TnT) values throughout the 1st post-HTx year in our center. Patients and Methods: In this retrospective observational study we included 74 consecutive HTx recipients (53 male, median follow-up 24 months) in whom we obtained NTpro-BNP (pg/mL) and hs-TnT (pg/L) values at 1, 6 and 12 months after HTx. For each time point, we used the median of measurements as a cut-off value for further analysis. Survival rates were analysed by the Kaplan-Meier method (log rank test), followed by the univariate Cox hazard regression analysis. Results: Cut-off median values for respective measurements at specific time points were as follows: NTpro-BNP 1967.5, 418.7 and 366.8 pg/mL; hs-TnT 90, 18.5 and 16 pg/L at 1, 6 and 12 months after HTx, respectively. The patients with lower hs-TnT values at 12-months after HTx had significantly better survival rates (p = 0.048) (**Figure 1**), with a HR of 1.014 (95% CI 1.003-1.024 p = 0.01). Although NTpro-BNP and hs-TnT values at the earlier time points showed a trend towards better survival in patients with lower biomarker values, statistical significance was not observed. Figure 1. Cumulative survival based on hs-TnT levels 12 months post-Htx. Conclusion: The results of our study suggest the importance of biomarker measurements (particularly hs-TnT), even in the later post-transplant period. Larger study groups might enforce its role in detecting individuals at higher risk for worse outcomes.

Jure Samardzic, Nada Bozina, Boško Skoric, Miroslav Krpan, Marijan Pašalic, Lana Ganoci, Mate Petricevic, Davor Milicic

Introduction: Single nucleotide polymorphism of genes involved in clopidogrel metabolism may modulate platelet reactivity (PR) on clopidogrel and clinical outcome. Certain multidrug resistance gene 1 (MDR1) and CYP2C19 gene variants have been shown to impact clopidogrel pharmacodynamic effect by changing its absorption and biotransformation, respectively. Herein, we report PR pattern during 12 months of clopidogrel treatment in a patient with acute coronary syndrome (ACS) and multiple pharmacogenetic variations contributing to reduced clopidogrel effect. (1-3) Patients and Methods: We performed post hoc pharmacogenetic analysis in our previously published randomized controlled trial which evaluated the effect of serial clopidogrel dose adjustment based on continuous platelet function testing (PFT) in ACS patients treated with PCI and with initially determined high on-treatment platelet reactivity on clopidogrel. Eighty-five patients were genotyped for G2677T/A and C3435T variants of MDR1 and CYP2C19. Only one patient was identified as homozygote for all three variants associated with decreased clopidogrel effect (CYP2C19*2, 3435T and 2677T). The patient was assigned to control group and received standard clopidogrel dose. Patient presentation: Fifty-four year old male, ethnic Roma (BMI 34 kg/m2) with a past history of dyslipidemia and previous myocardial infarction was enrolled in the study with ustable angina as index event. Throughout 12 months follow up PR level was above cut-off value for HTPR set at 46U (**Figure 1**). Mean PR was 84.2U (min-max; 69-99U). Figure 1. Platelet reactivity pattern during 12-month follow up. Conclusion: Routine pharmacogenetic testing in patients undergoing PCI is currently not recommended. Higher prevalence of CYP2C19*2 and 3435T alleles has been reported in Roma population compared to European Caucasians. (4) Use of pharmacogenetic testing, PFT and administration of newer P2Y12 blockers such as ticagrelor and prasugrel should be considered to reduce ischemic risk in these patients.

Karlo Golubic, Petra Angebrandt, Irena Ivanac Vranešic, Romana Palic, Anton Šmalcelj

Aims: According to research published so far, severe mitral regurgitation (MR) is associated with reduced prevalence of left atrial thrombosis (LAT) in patients with atrial fibrillation (AF), while moderate MR doesn't seem to affect the rate of thromboembolic complications. (1, 2) Our aim was to assess the relationship between the severity of the MR and the prevalence of LAT in patients with AF. Patients and Results: We conducted a retrospective observational study involving 450 patients with AF who underwent pre-cardioversion transesophageal echocardiography in our department from January 2011 until January 2015. The severity of mitral regurgitation was assessed with Doppler echocardiography and classified as mild, moderate or severe. The existence of spontaneous echo contrast (SEC) or LAT was evaluated. We also analysed the anticoagulation status and thromboembolic risk according to the CHA2DS2-Vasc score system. Out of 450 patients, 176 had no MR, 182 had mild, 84 moderate and 8 severe MR. There was no statistically significant difference among the groups in their anticoagulation status, median INR was 1.79 (1-2.3) vs. 1.86 (1.27-2.38) vs. 1.9 (1.18-2.5) vs. 2 (1.2-2.2) respectively, p=0.22, while more severe forms of MR were associated with higher CHA2DS2-Vasc scores p=0.001. There was no statistically significant difference in SEC 27.3% vs. 25.8% vs. 27.4% vs. 0%, p=0.39 or LAT prevalence 10.2% vs. 14.3% vs. 16.7% vs. 12.5%, p=0.486. Multivariant analysis revealed that MR is not a significant predictor of LAT, OR: 1.36, CI: 0.93-1.98. Conclusion: Our study shows that mild and moderate MR are not independently associated with LAT, but was underpowered for the analysis of the association between severe MR and LAT. Further research is needed to evaluate the association between severe MR and LAT and its repercussions on thromboembolic risk.

Miroslav Krpan, Zoran Miovski

We present a case of a 73-year-old patient who was admitted to our Clinic with complaint of dizziness and fatigue. He denied having any chest pain or shortness of breath. Nineteen years ago he had suffered an inferior myocardial infarction and got surgical myocardial revascularization – aortocoronary bypass surgery with saphenous vein grafts (SVG) on left anterior descending artery (LAD) and right coronary artery (RCA) with no postoperative complications. During actual hospitalization his ECG showed sinus bradycardia. Chest x-ray revealed nodose infiltrate close to the right side of the heart raising suspicion of intrathoracic tumorous mass. Echocardiography confirmed the presence of paracardial anisoechogenic mass measuring 10x7 cm with partial compression of the right atrium. Color Doppler view of the mass showed pulsatile flow in part of the mass and urgent computerized tomography with intravenous contrast of the thorax and abdomen was performed showing an aneurysm of the SVG on right coronary artery with preserved flow mimicking intrathoracic tumor. Coronary angiogram expectedly showed chronic total occlusion of LAD and RCA and patent SVGs with gigantic aneurysmatic dilatation of the RCA SVG and significant stenosis in proximal part of the LAD SVG. Currently, patient is pending for surgical resection of the aneurysmatic SVG and myocardial revascularization.

Jerneja Farkas, Daniel Omersa, Ivan Erzen, Mitja Lainscak

Goal: Hospitalization rate and mortality in patients with heart failure (HF) in Western Europe and USA is decreasing, while little is known about trends in Central and Eastern Europe. (1-3) We aimed to evaluate HF hospitalization and mortality trends in Slovenia. Patients and Methods: Slovenian national hospital discharge registry was used to identify patients with HF hospitalized between 2004 and 2012. In subjects without HF hospitalization during 2004 to 2008, HF related admission in period 2008 to 2012 was considered as first HF hospitalization. Survival status was retrieved from Central population registry. We calculated annual hospitalization rates and mortality rates per 100 000 inhabitants. Results: Overall, 157,695 hospitalizations in 80,180 subjects (76±12 years, 52% women, 5±3 comorbidities) were identified. Arterial hypertension, atrial fibrillation, diabetes mellitus and ischemic heart disease were recorded in 51%, 35%, 25% and 20% patients, respectively. Over time there were 25%, 24% and 4% increase in main, any or first HF hospitalization rate. Non-significant decrease in standardized mortality rate per 100,000 inhabitants at 30 days (152 to 150, p=0.41) and at 1 year (297 to 284, p=0.27) was observed. Proportion of hospitalized patients who died at 30 days and 1 year increased or remained stable. For those first hospitalized with HF, mortality rate reductions at 30 days (80 to 67, p=0.017) and 1 year (128 to 105, p=0.011) were significant. In Cox models of proportional hazard, increased mortality at 1 year or at the end of follow-up was independently predicted by male sex, age, chronic obstructive pulmonary disease, ishaemic heart disease, and cancer (p<0.001 for all). Conclusions: National based study demonstrated constant increase in HF hospitalization rates, mainly due to rehospitalizations. Mortality rate after discharge with HF remains high, with little change in proportion of deceased patients at 30 days and 1 year.

Ksenija Tušek Bunc

Heart failure (HF) is associated with poor quality of life and prognosis. The most common causes of HF are coronary heart disease and arterial hypertension. European HF guidelines are based on the poor sensitivity and specificity of presenting signs and symptoms, and because better diagnostic procedures are now available to identify structural heart disease before it leads to clinical HF. (1) Although the guidelines for diagnosing and treating of patients with HF have been known for years, their implementation is poor due to the lack of availability of certain investigations. In particular, echocardiography is the standard diagnostic tool used to diagnose HF, but its use by family practitioners is low due to lack of accessibility. Therefore, diagnosis of HF is often based on medical history and clinical examination. Unfortunately, the signs and symptoms of HF are relatively common and non specific, especially among the elderly. Their predictive value is low, requiring further diagnostic testing. This, and poor availability of echocardiography, means the diagnosis of HF is often arrived at a later stage of the disease. Family doctors could more quickly diagnose HF with use of brain natriuretic peptide (BNP) and NT-proBNP for screening, and with quick access to echocardiography. Management of HF consists first of nonpharmacological action (advice about healthy lifestyle), then reducing morbidity, improving survival and quality of life, reducing frequency of hospitalizations and, lastly, palliative care for advanced HF. Throughout this process, it is necessary to pay more attention to education, so these patients become equal partners in managing their disease. With appropriate diagnostic tests available, family practice doctors can competently and responsibly manage patients with HF.

Viktor Peršic, Vesna Pehar Pejcinovic, Damir Raljevic, Marko Boban

Sudden cardiac death syndrome is rare in competitive athletes, however, when it occurs, it is a serious event, with broad social implications. Among the most common reasons for sudden cardiac death during or after vigorous physical activities are several conditions like; hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, anomalies of coronary arteries, inherited channelopathy syndromes, and others, which occur less frequently. Several hundred thousands of young individuals are enrolled in competitive sports or repeated vigorous physical activities, so the development of more efficient systems for prevention of unwanted cardiovascular complications is becoming a major health and social objective. Due to of excellent temporal and spatial resolution, structural and functional analysis, tissue characterization, as well as precise structural analyzes of right ventricle, or other anatomic structure that is not easily imaged by echocardiography; cardiac magnetic resonance is a valuable and reproducible diagnostic tool for distinction of athlete’s heart from cardiomyopathy. (1-3)

Azra Durak-Nalbantic, Nafija Serdarevic, Alden Begic, Mirza Dilic, Mehmed Kulic, Berina Hasanefendic, Alen Dzubur, Aida Hamzic-Mehmedbašic

Introduction: Recently, it has been recognised that up to 50% of patients with heart failure have preserved ejection fraction. High sensitive troponin I (hs TnI) and brain natriuretic peptide (BNP) are elevated in acute heart failure (AHF). (1-3) The aim of this study was to investigate possible differences in their release in subpopulation with reduced ejection fraction (HF-REF) in comparison to preserved ejection fraction (HF-PEF) subpopulation. Patients and Methods: we analyzed data from 42 patients hospitalised with AHF in Intensive Care Unit, 2 patients were excluded due to intrahospital death within 72 hours from admission. hs TnI was tested at the admission, while BNP was tested at admission (BNP1) and at discharge (BNP2). We also calculated procentual reduction of BNP at discharge compared to admission values. Results: 25 patients (62.5%) had HF-REF with mean LVEF 31.48 +/- 4.77%. 15 patients (37.5%) had HF-PEF with mean LVEF 52.25+/-2.35%. There was no significant difference in hs TnI release according to different systolic function- in HF-REF group mean values was 151.91 pg/ml vs 60.37 pg/ml in HF-PEF group (p=0.1). BNP1 mean values were higher in HF-REF group compared to HF-PEF group–2183.43 pg/ml versus 853.96 pg/ml, p <0.05. Discharge mean BNP values (BNP2) were also higher in HF-REF group compared to HF-PEF-890.30 pg/ml versus 358.03 pg/ml, p <0.05. There was no significant difference in in-hospital procentual reduction of BNP values (admission vs discharged values) in HF-REF and HF-PEF group- 55.72% versus 55.56% (p=0.77). Conclusion: Even with more impaired systolic function, hs troponin I mean values in HF-REF were not higher compared to HF-PEF group. Admission and discharge BNP levels were higher in patients with reduced EF compared to patients with preserved EF. That means that neurohormonal activation is more pronounced in subpopulation of patients with reduced LVEF. Percentage of intrahospital BNP reduction were similar in were similar in both groups..

Nela Kostova, Magdalena Otljanska, Igor Kostov

Background: Aortic dissection typically presents with severe chest or back pain. Lower limb ischemia occurs in less than 10% of cases of type A aortic dissection. Isolated distal limb ischemia as the first sign of dissection is very rare. (1-3) Case report: A 75-year-old man with history of uncontrolled hypertension and smoking was admitted to our hospital with sudden onset of lower extremities pain. During exertion patient felt transient mild chest pain. He was asymptomatic few hours till onset of sharp pain in his left leg. He was admitted in our hospital with persisting symptoms and sings of critical distal limb ischemia. There was significant systolic blood pressure difference. Troponin T was negative, but other cardiac biomarkers were highly elevated. Transthoracic echocardiography detected aortic root dilatation, mild regurgitation and aortic arch intimal flap. CT angiography was performed and type A aortic dissection, with doubled lumen was detected from ascending aorta to aortic bifurcation. Supra-aortic vessels were not involved and no repercussion on celiac, renal or mesenteric artery flow was detected. Thrombus in left iliac artery with involvement of left external iliac artery could explain signs of distal limb ischemia. Patient was referred to cardiovascular center but unfortunately he died immediately after transfer to surgical institution. Discussion and Conclusions: Aortic dissection is an emergency that, unless it is quickly identified, almost regularly results in death, especially in presence of atypical or rare symptoms. Sudden-onset of lower limb pain or signs of critical ischemia could be the signs of acute aortic disease and should be carefully investigated.

Sanja Markovic, Snezana Lazic, Maja Sipic, Bratislav Lazic

Objectives: One of classifications of atrial fibrillation (AF) includes paroxysmal, persistent and permanent, based on the possibility of conversion into sinus rhythm. Regardless of clinical form of AF, evaluation of thromboembolic risk and decision on thromboprophylaxis has to be individually considered for each patient. (1) Patients and Methods: The study included 90 consecutive patients with atrial fibrillation (AF) divided into three groups: 22 patients (24.4%) with paroxysmal AF in the first group; 3 patients (3.3%) with persistent AF in the second; and 65 patients (72.2%) with permanent AF in the third group. Within the paroxysmal AF group, there was 1 patient with valvular AF and 21 patients with non-valvular AF; in the persistent AF group, there were no patients with valvular AF and 3 patients with non-valvular AF; and in the permanent AF group, there were 11 patients with valvular AF and 54 patients with non-valvular AF. From all patients, aspirin only was used by 20 of them (22.22%), oral anticoagulation therapy (OACT) only by 59 patients (65.6%), while OACT + aspirin were used by 11 patients (12.2%). All patients underwent 12-lead ECG evaluation, transthoracic echocardiogram and laboratory tests. Results: Patients with valvular and non-valvular AF did not significantly differ according to clinical type of AF (p=0.265). In both valvular and non-valvular AF, the most common clinical form was permanent AF. It has been found that patients used OACT significantly more often than aspirin (p<0.001) among total number of patients (n=90). Conclusion: Valvular and non-valvular AF do not determine clinical form of atrial fibrillation. Compliance of our patients regarding OACT use is good, which is important because of the most common permanent clinical form.

Snezana Lazic, Sanja Markovic, Maja Sipic, Bratislav Lazic

Objectives: It is considered that atrial fibrillation (AF) is present among 0.4% of adult population. CHA2DS2-VASc score is used for stratification of thromboembolic risk. Systolic heart failure has significant thrombogenic potential in atrial fibrillation. (1) Data from the literature on causal relationship between enlarged left atrium and thromboembolic risk in patients with AF are controversial. Patients and Methods: The study analyzed 90 patients with atrial fibrillation. Exclusion criterion was AF in sepsis, acute myocarditis and pericarditis, in acute myocardial infarction, and postoperative AF. Methods used were standard 12-lead ECG, transthoracic echocardiogram and laboratory tests. The first group included 12 (13.3%) patients with valvular AF, while the second group included 78 (86.7%) patients with non-valvular AF. Results: Anteroposterior diameter of the left atrium was 55.6±11.5 mm vs. 46.3±6.2 mm in the second group; p<0.001. Ejection fraction (EF, %) was 37.1±10.1% in the first group vs. 43.0±11.6% in the second group; p=0.102. CHA2DS2-VASc score was 4.0 (1.0-6.0) in the first group vs. 3.0 (0.0-7.0) in the second group; p=0.132. The correlation between CHA2DS2-VASc score and anteroposterior diameter of the left atrium among all patients (n=90) was not statistically significant (r=1.0; p=0.346). Significant negative correlation was found between CHA2DS2-VASc score and EF among all patients (r=-0.420; p<0.001). Conclusions: In our study, the anteroposterior diameter of left atrium was not a determining factor of thromboembolic risk. However, with increase of CHA2DS2-VASc score, there was a reduction of EF which favors AF and increase in thromboembolic risk.

Irena Ivanac Vranešic, Majda Vrkic Kirhmajer, Krešimir Putarek, Ljiljana Banfic

Background: Transient ventricular dysfunction (TVD) is rare and potentially fatal complication of pericardiocentesis (PCC). Some authors refer to it as a pericardial decompression syndrome, others call it the stress cardiomyopathy (SCM). The most prevalent pathophysiologic hypothesis states that sudden increase in ventricular preload with concomitantly increased afterload (sympathetic drive) leads to TVD. (1-3) We present a case of asymptomatic TVD with classical features of SCM after PCC for imminent cardiac tamponade. Case report: 49-year-old female presented with 1 month history of chest pain, dyspnea and dry cough. Clinical exam revealed BP of 140/80 mmHg, distended jugular veins, hepatomegaly and muffled heart sounds. ECG showed sinus tachycardia 101/min and microvoltage. Echocardiographycally a large pericardial effusion (PE) with signs of cardiac tamponade was found and PCC was attempted. Only 100 ml of serosanguinous fluid was evacuated and since the patient was clinically stable we postponed the new PCC for the next day. Patient felt significantly better. The follow-up echocardiographic exam showed that the PE had drained into the left pleural cavity and that there was a newly developed apical biventricular akinesis with left ventricular apical thrombus. Cardiac enzymes were slightly elevated and ECG showed inverted T waves in all precordial leads. Treatment with enoxaparin, furosemide and bisoprolol was started. Chest CT scan and PE fluid analysis revealed metastatic pulmonary adenocarcinoma. Ten days after PCC, complete recovery of systolic function as well as complete resolution of the thrombus was found and patient was transferred to the pulmonary clinic for further treatment. Conclusion: TVD is a rare complication of PCC and is more frequently observed in patients with rapid drainage of large PE. Since TVD can be asymptomatic, regular echocardiographic follow up after PCC is important in order to reveal potential complications and to guide optimal treatment.

Professor Davor Milicic

Dear colleagues, The Dubrovnik Cardiology Highlights is the youngest member of the ESC Update Meetings, belonging to the family of three high-level educational and scientific activities of the ESC: Davos Cardiology Update, Rome Cardiology Forum and Dubrovnik Cardiology Highlights. This year it is going to be held from 10-13th October. The Cardiology Highlights started in 2009, as a joint project of the ESC and the Croatian Cardiac Society. All the previous Highlights Meetings attracted a very prestigious International Faculty and an interactive audience from all over the world, with a clear tendency of increasing both – quality of the Programme and the number of Faculty members and participants. The Meeting is primarily clinically designed for cardiologists and cardiology fellows, but also for other professionals and specialists taking part in all relevant fields of cardiovascular medicine. The main aim is to provide a comprehensive state-of-the-art overview of contemporary cardiology, including cutting edges in science and clinical practice, with a special emphasis on the newest ESC guidelines and position papers. Beside invited lectures from the leading representatives of various specialties in Cardiology, the Programme will be enriched with a joint Zagreb and Zurich University young cardiologists’ session on challenging heart failure clinical cases. The second day of the Meeting will be entirely dedicated to Heart Failure and therefore endorsed by the ESC Heart Failure Association. Besides that, a focused session of the ESC Working Group on Coronary Pathology and Microcirculation will also be held, according to our wish to emphasize the importance of the ESC constituent bodies. This special issue of Cardiologia Croatica – the official journal of the Croatian Cardiac Society, consists of selected original contributions from our participants in the form of abstracts, which will be presented in the form of moderated posters. All these abstracts and their presentations are going to be additionally peer reviewed during the Congress and the best of them awarded at the Closing Session of the Meeting. It is worth reminding that Cardiology Highlights is a joint project of the European Society of Cardiology and the Croatian Cardiac Society, giving an important recognition to Croatian Cardiology, being thus directly involved in such an important ESC event. We are particularly proud that this year, for the first time, our Dubrovnik Cardiology Highlights Meeting is organized under the patronage of the Croatian Academy of Sciences and Arts, which represents the most distinguished institution of the scientific and cultural heritage of Croatia. Sincerely yours