Cardiologia Croatica. 2016;11(10-11)

Vera Slatinski, Ante Pašalić, Krešimir Kordić, Edvard Galić

**Introduction:** Coronary artery anomalies (CAA) are congenital anomalies that affect the coronary vessel origin, their anatomy and histologic structure with the prevalence in the general population between 0.5-2%. The most common subgroup of CAA are the anomalies of the vessel origin and direction. Most patients are asymptomatic for a large portion of their lives, although the first clinical symptom may be sudden death. There are 3 treatment options: medical treatment/observation, coronary angioplasty with stent deployment, and surgical repair. (1-3) We report a patient with anomalous origin of the left coronary artery (LCA) who presented with chest pain and was treated conservatively. **Case report:** 71-years-old female arrived at the Emergency Department complaining of an intermittent retrosternal chest pain and dyspnea during the last 7 days. Her blood pressure was also higher for the last 7 days, up to 200 mmHg in systole. She performed an unremarkable exercise testing and a nuclear stress testing which showed inferolateral, posterolateral, apicoseptal and inferoposterior hypoperfusion. The physical examination was unremarkable. ECG showed sinus bradycardia with ventricular premature beats. She was prescribed a bisoprolol, trimetazidine, nitrate, amlodipine, statin and aspirin. Six months later, she performed coronary angiography which showed an anomalous origin of LCA from the right Valsalva sinus. She was referred to a MSCT coronarography which confirmed the finding. RCA was free of pathomorphologic changes. ACx was a dominant artery, while LAD was gracile, without stenotic lesions. On follow-up visit after three months, the patient was free of chest pain. The last follow-up visit was three years later, and the patient is still asymptomatic. **Conclusion:** The main finding of this case report consisted of a LCA emerging from the right Valsalva sinus without anomalous features of other coronary arteries. The elderly patient presented with atypical chest pain and was treated conservatively, with a combination of beta-blocker and anti-ischemic agents, trimetazidine and nitrate, in order to provide the decompression of the vessel between aorta and pulmonary artery.

Domagoj Mišković, Đeiti Prvulović, Božo Vujeva, Irzal Hadžibegović, Krešimir Gabaldo, Martina Menegoni

**Background**: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by venous or arterial thrombosis. Myocardial infarction occurs in about 7% of APS patients, and data on optimal anticoagulation therapy after percutaneous coronary intervention (PCI) in these patients is insufficient. (1, 2) **Case report**: 35-years-old male with APS was admitted with ST-segment elevation myocardial infarction. He was on warfarin due to secondary prevention of DVT with an average INR of 2.1. Urgent angiography showed severe thrombotic stenosis of the proximal LAD (**Figure 1**). Successful PCI with implantation of everolimus eluting stent was performed without complications (**Figure 2**). Dual antiplatelet therapy (DAPT) consisted of aspirin 300 mg and ticagrelor 180 mg that were continued as per protocol, whereas unfractionated heparin 100 U/kg IV was used before and during PCI. After PCI and during hospitalization, enoxaparine 1 mg/kg subcutaneously BID was added to DAPT. On hospital discharge ticagrelor was switched to clopidogrel (300 mg on the first day, 75 mg in continuation), whereas enoxaparine was switched to rivaroxaban 20 mg, and aspirin 100 mg was continued. Figure 1. Severe thrombotic stenosis of the proximal left anterior descending artery. Figure 2. Final angiogram after implantation of drug-eluting stent. **Conclusion**: Guidelines for the treatment of patients with APS who have had arterial thrombosis suggest a target INR of 3 or more. Although being off label, we believed novel oral anticoagulants (NOAC) would achieve better anticoagulant effect and lower the risk of bleeding compared to warfarin with high target INR together with DAPT. In addition, rivaroxaban is currently the only novel anticoagulant being tested to treat venous thrombosis in APS (RAPS study). Studies on triple therapy after stenting in APS, or similar syndromes, are needed.

Zvonimir Ostojić, Vlatka Rešković Lukšić, Blanka Glavaš Konja, Joško Bulum, Richard Matasić, Martina Lovrić Benčić, Jadranka Šeparović Hanževački

Transcatheter aortic valve implantation (TAVI) is acknowledge method of treatment for patients with severe aortic stenosis whose surgical risk is too high. Nevertheless, in some cases unconventional methods have to be applied prior to definitive decisions considering treatment. (1) 70 year-old-male without any medical history, was admitted because of cardiogenic shock and pulmonary edema. Parenteral diuretics and high dose inotropic therapy with dobutamine and dopamine were administered, along with antibiotics for pneumonia. Echocardiographic examination described biventricular cardiomyopathy (EF 15%), severe low flow-low gradient aortic stenosis (max PG 35mmHg, AVA 0.6cm2), intraventicular (iv) dyssynchrony due to left bundle branch block (LBBB) (QRS 178ms) and sever pulmonary hypertension. Treatment was complicated with frequent ventricular tachycardia, which required continuous treatment with amiodarone and magnesium. On given medication partial volume unloading was achieved, despite which patient remained hemodynamically unstable, dependent on inotropic support, NYHA 4 functional status. As palliative method, aortic valve balloon valvuloplasty (BAV) was preformed, followed with increase in AVA (1.0cm2) and decline of gradient (maxPG15mmHg), with rise in systemic pressure. After procedure inotropic therapy was discontinued, but with persistent ventricular ectopic activity (nsVT). In spite of partial volume and pressure unloading, echocardiographic signs of iv dyssynchrony are still evident, with consequently marked reduction in systolic function, because of which permanent CRT-D device was implanted. Considering residual mechanical dyssynchrony, echocardiographic optimization was preformed (after pre-excitation of left electrode - EF 25%) and patient was discharged. After discharge appropriate defibrillations were observed in ER. In 6 weeks follow-up patient had no symptoms (NYHA 2). Positive remodeling of myocardium has been observed (EF 35%, AVA 0.8cm2). TAVI, as final treatment method was recommended to patient, but he refused it. In conclusion, hemodynamically and rhythmological unstable patient with terminal valvular cardiomyopathy and mechanical dyssynchrony due to LBBB, was stabilized using BAV and cardiac resynchronization therapy. Using unconventional treatment methods, we provided rehabilitation period and predispositions for surgical or percutaneous treatment of aortic stenosis.

Igor Šesto

In accordance with the current guidelines for the treatment of acute coronary syndrome without ST elevation (NSTEMI ACS) surgical revascularization is indicated in approximately 12% of patients who were admitted to hospital with the diagnosis. (1) The aim of study was to re-evaluate the role of surgical revascularization in patients hospitalized in University Clinic for Cardiovascular Diseases Magdalena with a diagnosis of ACS NSTEMI for a period of three years from 1st January 2012 to 1st January 2015 (we included patients who were admitted to our clinic within 24 hours of onset of symptoms for further treatment). During this time period there were a total of 174 hospitalized patients with the diagnosis of ACS-NSTEMI. Of these 174 patients in all was coronary angiography performed. In view of the findings of coronary angiography in 127 patients (73%) underwent PCI, in 27 patients (15%) further conservative therapy was indicated, and in 20 patients (11%) underwent coronary artery bypass graft surgery (CABG). Hospital mortality in patients who underwent CABG was 1.7% (3 patients). In the treatment strategy for ACS-NSTEMI there is key role of heart-team - which sets indication for adequate revascularization strategy (PCI vs. conservative therapy vs. CABG). The obtained results have shown significant and irreplaceable role of cardiac surgery in revascularization in patients with ACS NSTEMI.

Irzal Hadžibegović, Đeiti Prvulović, Krešimir Gabaldo, Marijana Knežević Praveček, Katica Cvitkušić Lukenda, Ivica Dunđer, Martina Menegoni, Domagoj Mišković, Božo Vujeva

**Introduction**: National networks of treatment of acute myocardial infarction with ST elevation (STEMI) are a key segment in the standardization of the quality of care of patients with acute coronary syndrome (ACS), with strictly defined protocols, which should be tailored to each region depending on the organizational capabilities. (1) Patients with acute coronary syndromes without ST segment elevation (NSTE-ACS) are not usually treated as part of the network, and require additional efforts in treatment standardization. **Patients and Methods**: We analyzed data on patients with percutaneous coronary intervention (PCI) performed in ACS in the catheterization laboratory in Slavonski Brod in the period between 2014 and 2015, and compared it with data obtained from the beginning of 2016 after the adoption of standardized Protocols for the entire region of Western Slavonija (2). **Results**: In the period after the adoption of the protocol, the number of primary PCIs in STEMI increased by 36%. Proportion of transported patients undergoing primary PCI in STEMI also increased, and amounted to 48% by September 2016. First medical contact in 36% of patients with STEMI occurred by means of patient’s own transportation. All transported patients passed through the Emergency Department of hospitals without PCI capabilities. By the end of September 2016, 96% of patients with STEMI were pretreated with aspirin, ticagrelor and unfractionated heparin. The share of primary PCI in cardiogenic shock increased from 2.5% to 7.8%. Total in-hospital mortality after primary PCI in STEMI increased insignificantly from 5.2% to 6.9% in 2016. Number of PCI in NSTE-ACS increased by 14%. PCI in NSTE-ACS was organized within 72 hours in 81% of cases. Proportion of PCI in transported patients with NSTE-ACS within 24 hours increased by 13%. Total in-hospital mortality after PCI in NSTE-ACS was very low and did not change notably. **Conclusion**: The data collected using the standardized ACS treatment protocol helped in maintaining the quality of treatment and identifying new problems which require new solutions. Standardized protocols for treatment of all patients with ACS should be a part of the strategy for formation of regional and national networks for emergency PCI implementation within the whole spectrum of ACS.

Ivana Jurin, Jasmina Ćatić, Željko Đurašević, Diana Rudan, Sanda Sokol, Tomić, Ana Zovko

**Introduction:** May-Thurner syndrome is the condition of the left common iliac vein being compressed between the right common iliac artery and the associated vertebral body. This condition has been linked to spontaneous episodes of deep vein thrombosis (DVT) and it is three times more common in women, especially between 20 and 50 years of age. (1) **Case report:** A 82-year-old man with a history of arterial hypertension was hospitalized because of a painless swelling of the left leg which lasted 10 days before admission. In the physical status we measured the circumference of both legs and the difference between the right and left upper leg was 9 cm, and the left and right lower leg was 6 cm. The value of D-dimer was 14.87, while CRP was 7.8 and basal coagulogram as complete blood count was normal. Ultrasound Doppler venous imaging of left leg demonstrated no evidenced signs of deep venous thrombosis but all veins were significantlly dilated with low flow rates which suggested a possible proximal compression or partial thrombosis. MSCT in the arterial and venous phase was done and showed that the left common iliac vein was more horizontal than usual and it was compressed by right common illiac artery. MSCT also showed thrombosis of illiac vein with the propagation of thrombus to the inferior vena cava. The patient was treated with dalteparin, and was discharged with warfarin in therapy. **Conclusion:** We present a case of a patient with May-Thurner syndrome who had left-sided DVT in the absence of risk factors. The monitoring of these patients is important because of possible recurrent deep vein thrombosis with unsatisfactory effect of anticoagulant therapy and then other treatment options such as venous angioplasty and stenting should be considered. At four years of follow up there was no recurrence of deep vein thrombosis with still ongoing warfarin therapy.

Ana Jordan, Mario Sičaja, Boris Starčević

**Introduction:** Fever of unknown origin (FUO) is a challenging clinical syndrome which encompasses wide clinical scenarios and requires bright decision making. (1-3) **Case presentation:** We present a case of a 53-year-old man who was hospitalized because of intermittent fever that lasted for two years. He underwent a huge specter of diagnostic procedures that excluded infectious, immunological, hematological and tumorous causes of a long lasting fever. Due to advanced cardiac imaging a suspected foreign body in the heart was visualized. Computed imaging, transthoracic echocardiography and cardiac catheterization revealed one linear metallic density that corresponds to a sewing needle localized in the right ventricular outflow tract (RVOT). Right ventricle was mildly dilated (3cm) and systolic function was slightly reduced (40%). After all examinations patient was presented to a cardiothoracic surgeon for a surgical removal of the needle. Even after psychiatric consultation it remained unknown whether the strange body in the heart was consequence of self-mutilation or an accidental event. **Conclusion:** A needle in the heart is a comparatively rare event. It has been described in cases of self-mutilation in psychiatric patients, intravenous injection and puncturing with acupuncture needles. Surgical removal of a sewing needle is the treatment of choice, but psychiatric consultation is recommended.

Dario Gulin, Jasna Čerkez Habek, Jozica Šikić

**Introduction**: Acute embolism from artificial aortic valve to the coronary arteries resulting in acute myocardial infarction is an uncommon occurrence. There are cases reported in acute setting after mechanical aortic valve replacement, although embolization in properly anticoagulated patients, years after aortic valve replacement is rare. (1, 2) **Case report**: We report the case of a 64-year-old man who underwent an aortic valve replacement six years earlier and presented to the emergency department with myocardial infarction without ST elevation. He was adequately anticoagulated with warfarin. Transthoracic echocardiography showed normal motion of bileaflet artificial aortic valve, without visualized thrombi or detected abnormally pressure gradient. 12-lead ECG showed ST depression in inferior and lateral leads, while urgent coronary angiography revealed subtotal atherothrombotic lesion of right coronary artery, but without significant coronary artery disease of left coronary artery. Percutaneous coronary intervention of right coronary artery was performed with implantation of one stent. Repeated ECG showed isoelectric level of ST segment. After four days of hospitalization sudden onset of prodromal chest pain occurred. ECG showed deep ST depression in anterolateral precordial leads. Coronary angiography was proposed to the patient, but the patient denied the procedure. One day later, after refractory cardiac arrest, patient died. Autopsy revealed thrombotic occlusion of left anterior descending artery with recent myocardial necrosis of left ventricle anterior wall and few microemboli of the aortic mechanical valve. **Discussion**: Embolic myocardial infarction is underdiagnosed and it is important to diagnose the source of embolism and treat the cause. Despite the patient was adequately anticoagulated, it is considered that even adequate anticoagulation therapy does not eliminate the risk of thromboembolism. Also, favorable in this patient was bileaflet type of valve, which is less thrombogenic. Review of related literature did not show similar cases occurring in relatively short period of time, resulting in recurrent myocardial infarction with emboli of both left and right coronary artery.

Ahmad Shirafkan, Soheil Kazemi Rudsari

**Background**: Hemoglobin A1c (HbA1c) is an excellent marker for diabetes control as it provides a good reflection of plasma glucose concentrations over 8 to 12 weeks with no effect from meals or the circadian cycle. (1) The aim of this study is to evaluate the relationship between HbA1c and severity and complications of acute myocardial infarction in patients with type 2 diabetes mellitus (DM). **Patients and Methods**: This study was based on 700 type 2 diabetic patients hospitalized with first-ever acute myocardial infarction. Patients were divided according to HbA1c that measured from the blood sampled in the first morning after the admission to hospital into group A with 350 patients (HbA1c 7%). All patients were followed up for incident nonfatal myocardial infarction (MI), heart failure, systolic dysfunction, changes in left ventricular ejection fraction (LVEF) and cardiac death for 6 months and these clinical outcomes were compared between the 2 study groups. **Results**: The mean HbA1c of group A was 6.30 ± 0.49% and in group B was 9.34 ± 1.39%. In addition, the mean age of group A was 61.14 ± 10.98 years and in group B was 59.89 ± 9.54 years (p=0.6). In our study, 220 patients (31.4%) were NSTEMI and 480 patients (77.6%) were STEMI that among them, 240 patients (34.3%) were inferior MI, that is not significant difference between two groups (p=0.52). The correlation between HbA1c and LVEF was shown that the mean of LVEF in group A in duration of admission and after 6 months was not significant difference (47.69 ± 10.43% vs 47.31 ± 10.85%; p=0.877) and in group B this difference was significant (42.05 ± 11.81 vs 38.18 ± 10.52; p=0.003). There was no significant difference between the 2 groups in the reinfarction ratio in 6 months (14.28% vs 22.58, p=0.356). However, our study detected different rates of in-hospital and in the 6 month follow up cardiovascular death in these two groups (8.36% vs 20%, p=0.048). **Conclusions**: This study suggests that HbA1c levels are associated with some short-term cardiovascular outcome in patients with type 2 diabetes subsequently admitted with ACS.

Drago Rakić, Ivana Cvitković

**Introduction:** Atrial septal defect (ASD), mostly type II, often remains undetected until adulthood and may contribute to atrial fibrillation (AF) onset. Percutaneous ASD closure is the method of choice if there is enough margin (4-5 mm) for the „umbrella” implantation, particularly in the elderly, otherwise surgical closure is advised. Sinus rhythm frequently reappears within a few months after closing. (1-3) We present four such patients. **Case reports:** Case 1. 67-years-old lady underwent catheter ablation for AF with tachyarrhythmia. At the same time ASD was detected and surgically closed. During the follow-up period her sinus rhythm is maintained with good cardiorespiratory function. Case 2. In 66-years-old lady paroxysmal AF was recurrently drug-converted to sinus rhythm. Eventually ASD type II was diagnosed and percutaneously occluded. The follow-up visits confirm stable sinus rhythm with excellent clinical outcome.Case 3. 59-years-old patient had recurrent paroxysms of AF in 2013. At that time ASD was detected and percutaneously closed. Three weeks later because of atrial undulation he underwent successful electrocardioversion and from that time on she maintains stable sinus rhythm. Case 4. Since 2007 a 59-years-old hypertensive patient is enduring paroxysmal AF attacks; in 2011 he underwent transvenous occlusion of recently diagnosed ASD followed by stable sinus rhythm for 6 months, when an AF relapse was successfully electrocardioverted. Nevertheless, five years later ensued permanent AF. **Conclusion:** ASD discovered in adulthood is often associated with AF. After its closure a stable sinus rhythm may often be achieved.

Alma Sijamija, Nermir Granov, Nedžad Hadžić, Omer Perva, Alma Agačević

**Introduction**: Aortic dissection (AD) is defined as disruption of the medial layer provoked by intramural bleeding, resulting in separation of the aortic wall layers and subsequent formation of a true lumen and a false lumen with or without communication. It occurs at an estimated rate of 3 per 100,000 people every year, among them 40% die immediately and do not reach a hospital in time. Magnetic resonance imaging is currently the gold standard for the detection and assessment of AD, with a sensitivity and a specificity of 98%, however it has limited availability. Transthoracic echocardiography (TTE) is more commonly available diagnostic tool and has sensitivity of up to 98% and a specificity of up to 97%. (1-3) Aim: To highlight the importance of TTE in the diagnosis of type A dissecting aortic aneurysm. **Case 1**: 67-year-old male was admitted to Internal department due to chest pain and dyspnea. Physical examination showed unmeasurable arterial blood pressure on the right arm and 140/100mmHg on the left; diastolic murmur over precordium. ECG: downsloping ST segment depression in V4-6. Troponin T test was positive. TTE revealed dilated ascending aorta (56 mm) with signs of acute dissection: prolapse of intimal flap into the LVOT and severe AR +4 (**Figure 1**). CT angiography confirmed aneurysm of the ascending aorta starting from the root of LCA and was tracked over the entire aorta to the AIC. Bentall procedure was performed. Figure 1. A transthoracic echocardiogram revealed dilated ascending aorta (56 mm) with signs of acute dissection: prolapse of intimal flap into the left ventricular outflow tract. **Case 2**: 50-year-old male was presented to the internist due to occasional chest pain and shortness of breath, appeared 3 months earlier. Physical examination revealed hypertension, diastolic murmur over precordium. TTE: dilated ascending aorta (48 mm), structure above projection of non-coronary aortic cusp, at the level of sinotubular junction, reminiscent of the intimal flap; severe MR +4 and AR +3/4 (**Figure 2**). CT angiography visualized the hypodensic linear area that separates lumen of thoracic aorta into two parts and extends to the bases of brachiocephalic trunk. Patient received surgical treatment. Figure 2. A transthoracic echocardiogram: dilated ascending aorta (48 mm), structure above projection of non-coronary aortic cusp, at the level of sinotubular junction, reminiscent of the intimal flap. On regular follow-up, 5 years after the procedures both patients feel great. **Conclusion**: Echocardiography has become the preferred imaging modality for suspected aortic dissection. Prompt diagnosis and access to surgical therapy increases survival.

Maja Hrabak Paar

Cardiac magnetic resonance imaging (MRI) is frequently used for evaluation of cardiac diseases. It enables depiction of cardiac morphology and function, with precise measurement of biventricular volumes, ejection fraction, myocardial mass, as well as quantitation of valvular disease. The main indications for cardiac MRI are myocardial diseases, ischemic heart disease, congenital heart diseases, cardiac masses and pericardial diseases. (1-3) The MRI scan is safe for patients with prosthetic valves, sternal wires and coronary stents. Cardiac MRI examination is also possible in patients with an MR-compatible pacemaker or defibrillator designed and tested for full-body MRI scan, but detailed analysis of the heart is often precluded by artifacts. During MRI scan gadolinium-based contrast agent is usually administered intravenously, but should be avoided in patients with estimated glomerular filtration rate < 30 ml/min and in dialysis patients because of increased risk for nephrogenic systemic fibrosis. Late gadolinium enhancement (LGE) is present in scar regions. Based on LGE pattern etiology of cardiomyopathy can be determined, ischemic dilated cardiomyopathy differentiated from non-ischemic, and myocardial affection with systemic diseases (amiloidosis, sarcoidosis...) can be detected. The most common emergent indication for cardiac MRI is myocarditis that is morphologically characterized by myocardial edema, and subepicardial early or late enhancement. On the contrary, infarct scar presents with subendocardial to transmural LGE, whereas reversible ischemic changes can be depicted using stress perfusion imaging with administration of vasodilator, usually adenosine. In follow-up of patients with congenital heart diseases using MRI it is possible to determine right and left ventricular volumes and function, myocardial mass, grade of valvular disease and significance of shunt by measurement of flow through the pulmonary and systemic circulation.

Monika Tuzla, Mario Ivanuša, Žaklina Muminović, Dubravka Kruhek, Leontić

**Introduction:** Cardiovascular (CV) diseases and psychiatric disorders are common problems, not only in the general population, but also in patients enrolled in the CV rehabilitation program. The interaction of anxiety and/or depression on CV disease is not only a barrier to conducting the program, but also significantly affects the outcomes of the program. (1, 2) Therefore, timely diagnosis of cardiac and psychiatric symptoms in patients undergoing CV rehabilitation allows adequate treatment which results in the improvement of the quality of life and outcome of the CV disease. This paper aims to show that early screening by using structured HAD scale (Hospital Anxiety and Depression Scale) (3) that evaluates anxiety and depression can help us determine the recovery after the outpatient CV rehabilitation program is completed. **Patients and Methods:** The Institute for Cardiovascular Prevention and Rehabilitation in Zagreb has conducted the retrospective study. All patients undergoing the outpatient CV rehabilitation program were rehabilitated during the period from 10th September 2015 that completed the program prior to 29th September 2016. Demographic data was analyzed. The leading indicators for the enrollment in the program were acute coronary syndrome (group 1), heart surgery treatment (group 2) or cardiac implantable electronic devices (group 3). By using the HAD scale, the patients were tested at the beginning and end of the program. The results were presented by groups by using the descriptive statistics methods. **Results:** The analysis was conducted in a total of 215 patients who completed the program. Most of them were enrolled in group 1 (74.9%), followed by the group 2 (20.0%) and group 3 (5.1%). Demographic characteristics are shown in **Table 1****.** The test results by using the HAD scale at the beginning and end of the CV rehabilitation by groups of patients are shown in **Table 2****.** ### Table 1: Demographic characteristics of patients included in the study. | | **Group 1** | **Group 2** | **Group 3** | **All** | | --- | --- | --- | --- | --- | | *Men* | 126 (78.3%) | 29 (67.4%) | 7 (63.6%) | 162 (75.3%) | | *Women* | 35 (21.7%) | 14 (32.6%) | 4 (36.4%) | 53 (24.7%) | | **All** | 161 | 43 | 11 | 215 | | **Age in years** | | | | | | *(minimum-maximum)* | 35-81 | 41-83 | 50-81 | 35-83 | ### Table 2: Level of anxiety and depression at the beginning and at the end of cardiovascular rehabilitation according to the group of patients. | **All (N = 215)** | **All (N = 215)** | **All (N = 215)** | **All (N = 215)** | **All (N = 215)** | **All (N = 215)** | **All (N = 215)** | | --- | --- | --- | --- | --- | --- | --- | | **Hospital Anxiety and Depression Scale** | **Level of anxiety at the beginning (%)** | **Level of anxiety at the end (%)** | **Change in level of anxiety (%) at the end** | **Level of depression at the beginning (%)** | **Level of depression at the end (%)** | **Change in level of depression (%) at the end** | | **Normal** | 166 (77.2) | 189 (87.9) | +14 | 153 (71.2) | 184 (85.6) | +20 | | **Borderline** **abnormal** | 32 (14.9) | 15 (7.0) | -47 | 36 (16.7) | 18 (8.4) | -50 | | **Abnormal** | 17 (7.9) | 11 (5.1) | -65 | 26 (12.1) | 13 (6.0) | -50 | | **Group 1 (n = 161)** | | | | | | | | **Normal** | 126 (78.3) | 143 (88.9) | +13 | 116 (72.1) | 141 (87.6) | +22 | | **Borderline** **abnormal** | 23 (14.3) | 12 (7.5) | -52 | 27 (16.8) | 11 (6.9) | -41 | | **Abnormal** | 12 (7.5) | 6 (3.8) | -50 | 18 (11.2) | 9 (5.6) | -50 | | **Group 2 (n = 43)** | | | | | | | | **Normal** | 34 (79.1) | 39 (90.7) | +15 | 31 (72.1) | 36 (83.7) | +16 | | **Borderline** **abnormal** | 6 (14.0) | 2 (4.7) | -33 | 7 (16.3) | 5 (11.6) | -71 | | **Abnormal** | 3 (7) | 2 (4.7) | -67 | 5 (11.7) | 2 (4.7) | -40 | | **Group 3 (n = 11)** | | | | | | | | **Normal** | 6 (54.6) | 7 (63.7) | +17 | 6 (54.6) | 7 (63.7) | +17 | | **Borderline** **abnormal** | 3 (27.3) | 1 (9.1) | -33 | 2 (18.2) | 2 (18.2) | 0 | | **Abnormal** | 2 (18.2) | 3 (27.3) | +50 | 3 (27.3) | 2 (18.2) | -67 | **Conclusion:** Most patients enrolled in the CV rehabilitation has a history of some form of acute coronary syndrome (ACS). In addition 3 out of 4 patients enrolled in the program are men. On completion of the rehabilitation program, a large number of patients have normal values of anxiety and depression test results, by using the HAD scale, compared to the test results at beginning of rehabilitation, whereas the number of those with borderline and pathological values has reduced. This trend is present in the groups of those with ACS or those that underwent heart surgeries, but is not recorded in those with implanted electronic devices.

Boško Skorić, Jana Ljubas Maček, Maja Čikeš, Hrvoje Jurin, Jure Samardžić, Daniel Lovrić, Ivo Planinc, Dora Fabijanović, Marijan Pašalić, Nina Jakuš, Renata Žunec, Davor Miličić

**Case report:** On the second year after heart transplantation (HTx), a 25-years-old man was hospitalized for effort intolerance and epigastric pain. Echocardiography showed anterolateral akinesia. Severe cardiac allograft vasculopathy (CAV) with diffuse left anterior descending (LAD) stenoses, occlusion of diagonal branch, diffuse stenoses of obtuse marginal and slow flow in the dominant right coronary artery (RCA) was diagnosed. No signs of cell-mediated rejection (CMR) were present, but swollen endothelial cells as well as positive C3d and C4d capillary staining with immunofluorescence detected antibody-mediated rejection (AMR). The patient was treated with steroids, plasmapheresis and intravenous immunoglobulins. Control biopsies (Bx) were free of AMR and echocardiography showed recovery of systolic function. On the third year he developed inferior ST segment elevation myocardial infarction and primary percutaneous coronary intervention (PCI) of RCA was done. This time left coronary artery was not diffusely ill, and a focal LAD stenosis was electively stented. Neither CMR nor AMR were detected on Bx. On the fourth year, routine angio control revealed CAV progression and we performed PCI of distal left main coronary artery, LAD and intermediate branch (RIM) with double-kissing crush technique. On the fifth year, PCI of RCA restenosis was performed. This time we could measure donor specific antibodies (DSA). Though Bx failed to show AMR, both anti-HLA class I and II were highly elevated and photopheresis was started. On the sixth posttransplant year, despite significant drop in anti-HLA class I, anti-HLA class II antibodies remained high and the patient developed congestive heart failure. An angioplasty with drug-eluting balloon of RIM stenosis was performed. No signs of rejection on Bx were noted. Because of graft failure and advanced CAV, we decided to prepare the patient for re-transplantation. As the calculated panel reactive antibodies (cPRA) were high, we opted for desensitization therapy (plasmapheresis, IVIg, rituximab, bortezomib) to increase the number of potential donors (**Figure 1**). Since cPRA remained >50%, we listed the patient for re-transplantation after the definition of unacceptable HLA antigens. Figure 1. The dynamics of donor specific antibodies (DSA) in serum. **Conclusion:** This case presents difficulties in the management of antibody-mediated rejection. (1) Only a combination of clinical with both pathologic and serologic data, that were not readily available in the past, may prove early effective therapy and prevent progressive graft deterioration.

Paloma Manea

**Goal**: The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) is very high, if the patient associates an antiphospholipid syndrome (APS). The traditional oral anticoagulants do not provide, for all the patients, a cessation of the thrombotic process relapse, so new strategies are necessary. (1-3) **Patients and Methods**: The study included 39 patients with previous PE and recurrent DVT; they had also APS and systemic lupus erythematous. The patients were monitored 24 months, after the diagnosis of recurrent DVT. The following were performed, every 3 months: the clinical examination, electrocardiogram, echocardiogram, vascular sonography and laboratory findings. Echocardiogram was performed every 6 months and antiphospholipid antibodies were determined at the beginning of the study. Computed tomography pulmonary angiogram was done for the firm diagnosis of PE, before our study beginning. The patients were included in the study after the emergency treatment for PE and after the relapse of DVT. Long-term treatment, after the relapse, consisted in acenocumarol and sulodexide. **Results**: Addition of sulodexide to acenocumarol reduced the incidence of recurrent DVT, after first relapse. Only 8% from our patients, p < 0.001, had another episode of DVT, after associated treatment (acenocumarol and sulodexide). These last percentage received higher doses of acenocumarol (for a target index normalized ratio INR ≥ 3). **Conclusion**: High risk of life – treating events in this fragile category required new strategies. According to deontological reasons, control group could not be composed (only acenocumarol treated), because all the patients had a high probability of a new PE. Only 3 minor hemorrhages occurred at this association. Future studies are necessary with novel oral anticoagulants, in order to sustain their superior efficiency in antiphospholipid syndrome, complicated with venous thromboembolism.

Fatma Nihan Turhan Caglarą, Nilgun Isiksacan, Ismail Biyik, Ismail Ungan, Selcuk Opaną, Hulya Cebeą, Ibrahim Faruk Akturką, Murat Koser, Nursel Kocamaz

**Background:** Acute myocardial infarction (AMI) could be considered to be a state of inflammation. Many inflammatory markers have been evaluated during AMI setting so far. Presepsin (PSP) is a novel biomarker for diagnosis and prognosis of systemic inflammation that have not been studied in AMI setting up to date. In this study, we aimed to examine serum PSP levels in patients with acute ST elevation myocardial infarction (STEMI). **Patients and Methods:** 48 patients with STEMI and fifty healthy controls without coronary artery disease, verified by coronary angiography, were included in the study. Together with routine laboratory tests needed for STEMI, plasma concentrations of PSP were measured in peripheral venous blood samples of the participants. **Results:** Plasma PSP and troponin levels were significantly higher in patients with STEMI than controls (1988.89±3101.55 vs 914.22±911.35 pg/mL, p=0.001 and 3.46±3.39 vs 0.08±0.43 ng/mL, p=0.001, respectively). Cut-off value for PSP was found 447 pg/ml to detect STEMI with 87.5%, sensitivity, 44% specificity, 60% positive predictive value and 78.5% negative predictive value. **Conclusions:** In this study, PSP levels were found significantly elevated in patients with STEMI together with high sensitive troponins. PSP may be a new marker for AMI detection. Large scale studies are needed to reveal the importance of PSP in the diagnosis of AMI.

Fatma Nihan Turhan Caglar, Nilgün Isiksacan, Ismail Biyik, Hakan Sahin, Dilay Karakozak, Fahrettin Katkat, Faruk Akturk, Nursel Kocamaz

**Background:** Acute decompensated heart failure (HF) represents a major public health burden, and it is understood that HF is not simply a mechanical failure of the heart pump but inflammatory mediators play a crucial role in the development of HF. Possible targets involve pro- and anti-inflammatory cytokines and their receptors, endotoxins, adhesion molecules, nitric oxide and nitric oxide synthase, reactive oxygen species, and different types of leucocytes. Recently, the soluble CD14 subtype; presepsin (PSP) has been suggested as a reliable marker for systemic inflammation which have not been studied in DHF setting. Our aim of this study was to evaluate serum PSP levels in patients who were admitted to coronary care unit with DHF. **Patients and Methods:** 50 patients with confirmed acute decompensated HF (27 male – 54%; 23 female – 46%) and 51 controls without (20 DHF – 39.2% male; 31 female – 60.8%) were included in our study. Besides routine clinical and laboratory data, brain natriuretic peptide (BNP) and PSP levels were measured in peripheral venous blood samples of all the participants. **Results:** PSP levels were significantly higher in patients with HF than controls (1107.98±1001.15 vs 540.47±526.9 pg/ml, p=0.001). Cut-off value for PSP was 442 pg/ml to detect HF with 76%, sensitivity, 62.7% specificity, 66.7% positive predictive value and 72.7% negative predictive value (CI: 0,975-1,000). The HF diagnostic accuracy of PSP was not superior to that of BNP (AUC: 0.99 vs 0.74). **Conclusions:** PSP levels are significantly elevated in patients with HF compared to controls. PSP may be a new marker for HF.

Karolina Kalanj, Ljiljana Banfić, Majda Vrkić, Kirhmajer, Miroslav Krpan, Krešimir Putarek, Mislav Puljević, Zoran Miovski

**Introduction:** Left ventricular noncompaction is a rare cardiomiopathy morphologically characterized by left ventricular (LV) trabeculae, deep intertrabecular recesses and a thin layer of compacted epicardium. The etiology of the disorder is still not clear, and the disease can develop during the embrionic phase of heart development, between 5-8 weeks of pregnancy, or sporadically in adults mostly in athletes, patient with sickle cell anemia and during pregnancy. Clinical manifestations of the disease are: heart failure, heart arrhythmias (atrial and ventricular) and thromboembolic events (21-24%). Celiac disease is an autoimmune disorder that affects the intestinal mucosa causing inflammation, crypt hyperplasia and villous atrophy, which leads to the malnutrition of different nutrients. In addition to hematological and gastroenterological symptoms, celiac disease can affect the cardiovascular system causing dilated cardiomiopathy, ischemic heart disease, atrial fibrillation and thromboembolic events. Due to the significant incidence of disease of 1% in Europe and North America and the increasing incidence of cardiovascular disease, the effect of celiac disease on the cardiovascular system is the subject of much current research. (1-3) **Case report:** We present a patient (recreational athlete), 34 years old, admitted to University Hospital Center Zagreb, Croatia whom we diagnosed as having noncompaction LV and celiac disease. Due to the critical chronic ischemia of the left leg caused by a thromboembolic event (occlusion of femoral and popliteal artery) limb saving procedures were performed twice, but because of infection and eventual gangrene in the left foot, lower limb amputation was indicated. During the episode of care patient was diagnosed with noncompaction LV (MR imaging: NC/C 2.7 LV apical part) and celiac disease (EMA positive; tTG >200 H RU/ml, DNA analyses homozygous C677T and heterozygous A1298C). As both diseases, acting in concert can, by different pathogenesis, cause further deterioration of the heart function, condition management protocols must include a gluten free diet, regular cardiac function staging and adequate rehabilitation (use of prostheses depending on heart function).

Dora Fabijanović, Nina Jakuš, Ivo Planinc, Gloria Bagadur, Filip Lončarić, Hrvoje Jurin, Jure Samardžić, Boško Skorić, Maja Čikeš, Davor Miličić

**Introduction**: Pharmacological treatment options for acute coronary syndrome (ACS) are well established, but little is known about the optimal timing of administration of each individual drug, particularly within the first 24 hours. (1-4) The aim of the study was to gather data on early outcomes of ACS through the local ACS registry (part of the International Registry of Acute Coronary Syndromes in Transitional Countries (ISACS-TC). **Patients and Methods**: We conducted a retrospective observational single center study in the period from January 2013 to January 2015. Study population included 1197 ACS patients (pts) (563 pts with acute ST segment elevation myocardial infarction, 630 pts with non-ST segment elevation myocardial infarction + pts with unstable angina, 4 pts missing; 372 females, 825 males, 66±11 years). Overall, median hospital length of stay was 5 days (3-8). Multiple binary logistic regression with in-hospital death as primary outcome was used for statistical analysis. For group comparison Pearson chi square, Student’s t-test and Mann Whitney tests were used. **Results**: In the first 24 hours following ACS, statins were administered in 94%, beta-blockers (BB) in 87%, and ACE inhibitors (ACEI) in 89% of pts. Among the early treatment positive and negative groups, pts did not differ according to age, gender, presence of diabetes, left ventricular ejection fraction (LVEF), body mass index, smoking status, creatine kinase levels and the history of heart failure for each of the studied groups. The odds ratio [OR] for in-hospital death was significantly lower in the early statin group (1104 pts, OR 0.019, 95% confidence interval [CI] 0.002-0.224, p = 0.002). Older age, higher creatinine level and lower LVEF were positively associated with increased odds for primary outcome in regression model. As opposed to early statin treatment, early administration of BB and ACEI did not reduce in-hospital mortality (p=0.06, p=0.27) at a significance level of 0.05. The crude overall primary outcome rate was 4%. In pts without statins treatment within the first 24h the mortality rate was 22% (p<0.001), and only 5% in pts without BB or ACEI (**Figure 1**). Figure 1. In-hospital survival among the early statin, beta-blocker (BB) and ACE inhibitor (ACEI) treatment positive and negative groups. **Conclusion**: Initiation of statin therapy within the first 24h following ACS significantly reduces in-hospital mortality.

Blanka Glavaš Konja, Ivan Bitunjac, Zvonimir Ostojić, Vlatka Rešković Lukšić, Joško Bulum, Martina Lovrić Benčić, Jadranka Šeparović Hanževački, Davor Miličić

**Case report**: 65-years-old man has been admitted to hospital because of spontaneous retroperitoneal hematoma. Medical history and concomitant disease: 1996 thyroidectomy for papillary carcinoma, arterial hypertension for more than 10 years and chronic obstructive pulmonary disease. Patient had acute ST segment elevation myocardial infarction (STEMI) when percutaneous coronary intervention on D1 using right transradial approach was done. Because of pulmonary edema during acute phase, he needed mechanical respiratory support and application of bronchodilatatory and corticosteroid therapy. Echocardiography showed reduced systolic function (EF 30%). Patient was discharge from hospital at the 6th day with prescription of ticagrelor 90 mg bid, nebivolol 1,25 mg, aspirin 100 mg, furosemid 125 mg, spironolactone 50 mg, valsartan 160 mg bid, amiodarone 200 mg, atorvastatin 80 mg, pantoprazole 40 mg, methylprednisolone 16 mg, levothyroxine 150 µg and tiotropium bromide 18 µg. 22 days after STEMI he was admitted again because of dizziness and lightheadedness with drop of hemoglobin levels from 136 to 82g/L and high potassium levels. Prothrombin time and APPT was normal. Multiple hematomas on the legs and lumbar region were noticed with no anamnesis of trauma. Multislice computed tomography (MSCT) showed retroperitoneal hematoma on the left side from left kidney to the left inguinal region 7.5 x 10.5 cm, 22 cm in length. Ticagrelor and aspirin were stopped. Platelet function analysis (by Multiplate® analyzer) showed extremely depressed aggregation with aspirin (less than 100 AUmin) and with ticlopidin (234 AUmin). Two dose of concentrated erythrocyte were applied. Hemoglobin levels stayed stabile and control MSCT showed no progression of hematoma 7 days after second admission. **Discussion**: Major bleeding after myocardial infarction portends a poor outcome. In the PLATO trial ticagrelor compared with clopidogrel was associated with similar total major bleeding but increased non-CABG and non-procedure-related major bleeding, primarily after 30 days on study drug treatment. Fatal bleeding was low and did not differ between groups. There remains potential concern about bleeding in a “real world” population compromising more high risk patients; particularly more elderly and female, than those in PLATO. (1) **Conclusion**: A balance is required between potency of platelet inhibition and risk of bleeding.

Mario Ivanuša, Nada Hrstić, Goran Krstačić, Ivana Portolan Pajić

**Introduction:** The results of conducted public health actions we have had so far indicate a high presence of unregulated cardiovascular (CV) risk (1, 2) factors, which explains a continuously high CV mortality in the Republic of Croatia (3). We show the continuation of the initiated research with the purpose of detecting an effective combination of risk factors applicable to screening on increased CV risk beyond primary healthcare. **Patients and Methods:** After being announced in the media, interested persons joined the free, open public health action included in the program of promoting cardiovascular health, “Guardians of the Heart”, which was held on the occasion of the Day of the City of Zagreb in June 2016. After taking the demographic data, data on cigarette smoking and diabetes, they underwent the measurement of the body mass index, waist circumference, glucose and lipid values in the capillary blood and blood pressure. Persons aged 40-65 have been diagnosed CV risk using SCORE (Systematic Coronary Risk Evaluation) risk charts. Participants had the opportunity to choose to undergo an examination of all or certain risk factors, take educational materials and consult health professionals. The data was analyzed in groups, depending on gender. Descriptive statistics of data obtained by counting was performed by using absolute numbers and relative frequencies, whereas testing of the relation was done by using χ2-test. The data obtained by measurements was analyzed by t-test. **Results:** The action was joined by 132 persons (44.7% men and 55.3% women), most of whom was aged over 65 years (63.6%). Dyslipidemia (74.6%), obesity (60.6%), central obesity (56.1%) and hypertension (51.1%) were most common. The analysis of the present factors by gender is shown in **Table 1**. The values ​​of total cholesterol and LDL were higher in men, and HDL values were higher in women. One third of the participants had a glucose value > 6.4mmol/L. Most diabetics did not have a satisfactory regulated glycemia. According to SCORE risk charts (**Table 2**) middle age men were commonly found in high risk category, while women were found in the moderate risk category. ### Table 1: Risk factors in group of patients according to gender. | | **Men (N=59)** | **Women (N=73)** | **P value** | | --- | --- | --- | --- | | **Age (years)** | | | | | mean ± SD | 70.56 ± 11.98 | 66.90 ± 11.09 | 0.0713 | | minimum | 30 | 32 | | | maximum | 95 | 87 | | | 65 | 43 (72.9%) | 41 (56.2%) | | | **Body mass index (kg/m2)** | | | | | mean ± SD | 26.92 ± 3.09 | 26.28 ± 4.78 | 0.3763 | | 102 & women > 88 | 28 (47.5%) | 46 (63.0%) | 0.0807 | | **Lipids (mean value ± SD (mmol/L))** | | | | | total cholesterol | 5.36 ± 0.97 | 6.01 ± 0.93 | **0.0001** | | LDL cholesterol | 2.65 ± 0.91 | 3.02 ± 1.08 | **0.0493** | | HDL cholesterol | 1.70 ± 0.79 | 1.96 ± 0.59 | **0.0318** | | triglycerides | 2.15 ± 1.23 | 2.03 ± 0.95 | 0.5519 | | **Capillary Blood Glucose** | | | | | mean value ± SD (mmol/L) | 7.18 ± 2.78 | 6.39 ± 2.06 | 0.0641 | | > 6.4 mmol/L | 20/59 (33.9%) | 24/73 (32.9%) | 1.0000 | | > 11.1 mmol/L in diabetic patients | 4/8 | 2/3 | | | **Known diabetes** | 8/59 (13.6%) | 3/72 (4.2%) | 0.0642 | | **Arterial hypertension** | 35/59 (59.3%) | 32/72 (44.4%) | 0.1142 | | **Heart rate ≥ 80 beats per minute** | 22/59 (37.3%) | 39/72 (54.2%) | 0.0780 | | **Total cholesterol > 5.0 mmol/L** | 39/58 (67.2%) | 58/72 (80.6%) | 0.1054 | | **Triglycerides > 1.7 mmol/l** | 32/58 (55.2%) | 44/72 (61.1%) | 0.5916 | | **Active smokers** | 8/58 (13.8%) | 8/73 (11.0%) | 0.5906 | ### Table 2: 10-years cardiovascular risk estimation in subjects aged 40 to 65 according to Systematic Coronary Risk Evaluation (SCORE) risk charts. | **SCORE** **risk categories** | **Men** | **Women** | | --- | --- | --- | | **Low-risk** **(< 1%)** | 0 | 3/31 (9.7%) | | **Moderate risk** **(≥ 1% and <5%)** | 5/14 (35.7%) | 25/31 (80.6%) | | **High-risk** **(≥ 5% and <10%)** | 8/14 (57.1%) | 3/31 (9.7%) | | **Very high-risk** **(≥ 10%)** | 1/14 (7.1%) | 0 | **Conclusion:** The measurement of waist circumference, as a quick and simple method, should be considered in future public health activities. Monitoring of glycaemia is useful in diabetics, while others should undergo it only on an empty stomach. People having moderate to high CV risk should consult a general practitioner. Considering a high presence of variable CV factors, a more aggressive approach to screening is required, that in addition to providing information on the priorities of CV prevention (4) should also focus on the cardiometabolic risk.

Božo Vujeva, Katica Cvitkušić, Lukenda, Domagoj Mišković

**Background:** Hypereosinophilic syndrome is a myeloproliferative disorder characterized by eosinophilia that is associated with damage to multiple organs. (1-3) **Case report:** 23-year-old patient, without comorbidity, was admitted to hospital because of weight loss, night’s sweats and cough. Blood test result shows eosinophilia, anemia and thrombocytopenia. **Figure 1** shows 12-lead ECG. Transthoracic echocardiography (**Figure 2**) reveals endomyocardial fibrosis and restrictive diastolic dysfunction with moderate mitral regurgitation. Except the heart, there are no other organs involved. We started the treatment with beta-blockers, ACE inhibitors, aspirin and corticosteroids. Thirteen days after discharge, the patient was rehospitalized because of paroxysmal nocturnal dyspnea and angina. Acute coronary syndrome was ruled out. Right pleural effusion was seen on chest X-ray and further echocardiography showed worsening of mitral regurgitation. For the purpose of further diagnosis and treatment, patient was transferred to the University Hospital Center. Treatment by tyrosine kinase inhibitor imatinib was initiated. MRI exam verified thrombus in the left ventricle. The patient returned to our hospital with a recommendation by concomitant administration of imatinib 400 mg OD and subcutaneously enoxaparine 1 mg/kg BID. Figure 1. Electrocardiographic signs of left atrial dilatation and left ventricular hypertrophy. Figure 2. Echocardiography – thrombus in the left ventricle size 1.57x1.71 cm. **Conclusion:** Concomitant usage of imatinib and warfarin is not recommended since both drugs excreted by the liver-they are substrates of the liver enzyme citokrom P450 3A4 and taking them together could increase the risk of bleeding. As an alternative to enoxaparine, new oral anticoagulants (NOAC) dabigatran could be used. As an advantage compared to enoxaparin, we emphasize oral administration and in comparison to warfarin, dabigatran avoids enzymatic system cytochrome P450 3A4. There are also disadvantages because dabigatran is a substrate of P-glycoprotein, a protein that acts as a pump to transfer the substance from the cells. Imatinib inhibits the activity of P-glycoprotein so that can boost the effect of dabigatran and potentially lead to hemorrhage. There are reported cases of successful treatment of mural thrombi with dabigatran and also the reports of concomitant usage of dabigatran and imatinib without bleeding disorders. However, studies of parallel usage of dabigatran or other NOACs with imatinib in the hypereosinophilic syndrome are needed.

Zorin Makarović, Sandra Makarović, Dražen Mlinarević

In 1967 a first case of angina with angiographically normal coronary vessels was described. That same year, exactly 10 years before the first percutaneous coronary intervention (PCI), the first patient with angina and normal coronary angiography was described. Ever since, for nearly 50 years, this clinical entity remains a subject of numerous discussions and studies. (1-3) There are two basic groups of hypothesis to explain the pathophysiological mechanisms of non-obstructive coronary artery disease (CAD): ischemic and non-ischemic groups of hypothesis. Ischemic theory is based on abnormal microvascular function, and non-ischemic theory is based on the changed perception of pain. Ischemic hypothesis includes the factors that may be endothelium-dependent or independent. Non-ischemic hypothesis is divided according to the involvement of the neural system in the afferent and efferent components. In the background of ischemic, endothelium dependent dysfunction are hypertension, diabetes, glucose intolerance, dyslipidemia, smoking, and in the background of endothelium dysfunction independent hypothesis is inflammation, lack of estrogen in women, hysterectomy, insulin resistance. Non-ischemic group consists hypothesis theory of neural disorders which may be afferent-adrenergic or efferent-nociceptive, and theory of habitual disorders (behavioral approach). There is a connection between factors which are displayed in microvascular dysfunction and nonischemic factors. It is believed that repeated episodes of microischemia by fibrosis and less severe prolonged inflammation lead to the development of neural abnormalities on afferent and efferent level. Thus, there are closed circuit that connects pathophysiological microvascular disfunction and neural disorder in non-obstructive CAD.

Lana Maričić, Sandra Makarović, Vlatka Periša, Vedrana Baraban, Jasmina Rajc, Grgur Dulić

**Introduction**: Primary cardiac tumours are rare with an autopsy frequency of only 0.001-0.03%, they represent an important group of cardiovascular abnormalities. Atrial myxoma is the most common primary cardiac tumor. In about 20% cases, myxomas are asymptomatic and are discovered as an incidental finding. (1-3) Echocardiography is an ideal initial imaging modality since it is simple, non-invasive, widely available, and low cost. Patients with atrial myxoma typically present with, cardiovascular symptoms such as heart failure and mitral valve obstruction. They can also present with neurologic deficits or systemic symptoms. We report case of asymptomatic cardiac myxoma in patient with non-Hodgkin lymphoma, which were diagnosed by means of transthoracic echocardiography (TTE). **Case presentation**: 72-year-old man presented in echocardiography laboratory to assess left ventricular systolic function in preparation for hematological treatment, immunochemotherapy, previously diagnosed lymphoma non-Hodgkin B mantle cell. He was asymptomatic, and specifically denied chest pain, dyspnea, palpitation, and syncope. TTE verified mobile cardiac mass in the left atrium, which protrude into the left ventricle during diastole. Transesophageal echocardiography (TEE) confirmed the existence of the cardiac mass, overall dimensions 2.1x3.9 cm, which pushes the posterior mitral leaflet, and consequently causes a mild mitral regurgitation (**Figure 1**). The patient underwent cardiac surgery, and cardiac masses was removed. Pathologic examination confirmed: large mass 4x4x2 cm, myxsoma. Histological mass of built of myxoid structures without significant atypia, the mass was found some bleeding and fibrin. Control TTE after surgey, showed a non-dilated left atrium, without significant mitral regurgitation. The patient is still under the control of hematologists, plans to initiate further haematological treatment. Figure 1. A transesophageal echocardiogram – polypoid cardiac mass in the left atrium, which protrude into the left ventricle depending on the phase of the cardiac cycle. **Conclusion**: Echocardiography represent the most commonly used and accurate diagnostic tool for the diagnosis of cardiac myxomas. TEE provides very useful information, and is superior to TTE in fully demonstrating the relationship between cardiac mass and the cavity wall, and also for the planning of surgery. Periodic echocardiographic control is necessary to detect possible recurrence myxoma.

Helena Jerkić, Mario Stipinović, Darko Počanić, Stjepan Kranjčević, Damir Kozmar, Tomislav Letilović

**Objectives**: Coronary artery disease (CAD) is the leading cause of mortality in patients with chronic kidney disease (CKD). Patients with CKD who undergo coronary revascularization may have more ischemic events than patients without CKD (1). The aim of this study was to determine the incidence and intensity of periprocedural myocardial injury (PMI) after elective stent implantation among patients with and without CKD. **Patients and Methods**: This study prospectively included 344 consecutive patients with stable angina pectoris who underwent an elective PCI at Merkur University Hospital, Zagreb, Croatia, in a period between March 2012 and June 2015 (**Table 1**). Patients were divided into two groups: control group with estimated glomerular filtration rate (eGFR) > 90 ml/min/1.73m2 and the CKD group with eGFR 2, with further subdivision according to CKD stage. Serum troponin I (cTnI) concentrations were measured at baseline and at 8 and 16 hours after PCI. Periprocedural increase of cTnI above the upper reference limit (URL) was defined as PMI. If cTnI increase ≥ 5x URL, it was considered a PMI of high degree, while an increase to 90 ml/min/1.73 m2** **(n= 128)** | **eGFR** **2** **(n= 216)** | **p value** | | --- | --- | --- | --- | | **Male, n (%)** | 102 (79.6) | 140 (64.8) | 30 kg/m2 (%)** | 38 (29.6) | 73 (33.7) | 0.43 | | **Hypertension, n (%)** | 112 (87.5) | 201 (93.0) | 0.08 | | **Hyperlipidemia (%)** | 107 (83.6) | 186 (86.1) | 0.64 | | **Diabetes mellitus, n (%)** | 38 (29.6) | 83 (38.4) | 0.10 | | **Current smoker, n (%)** | 37 (28.9) | 33 (15.3) | <0.01 | | **Previous PCI, n (%)** | 43 (33.6) | 65 (30.1) | 0.50 | | **Previous CABG, n (%)** | 3 (2.3) | 9 (4.1) | 0.37 | | **Medication:** | | | | | **ACE inhibitors, n (%)** | 107 (83.6) | 188 (87.1) | 0.47 | | **ARB, n (%)** | 11 (8.6) | 22 (10.2) | 0.62 | | **Beta blockers, n (%)** | 110 (85.9) | 177 (81.9) | 0.50 | | **Lipid-lowering drugs, n (%)** | 106 (82.8) | 188 (87.1) | 0.23 | [†] eGFR = estimated glomerular filtration rate; BMI = body mass index; CABG = coronary artery bypass grafting; PCI = percutaneous coronary intervention; ACE = angiotensin-converting enzyme; ARB = angiotensin II receptor blocker **Results**: There were no significant differences in incidence of PMI between control and CKD group after 8 hours (47.6% vs 44.9%, p=0.62) or after 16 hours (64.8% vs. 61.6%, p=0.55). There were also no significant differences in intensity of PMI between control and CKD group after 8 hours (0.13 ± 0.33 vs 0.11 ± 0.21, p= 0,58)) or after 16 hours (0.24 ± 0.46 vs 0.29 ± 0.86, p=0.61). We further assessed incidence and severity of PMI with respect to CKD burden (i.e. CKD stage) and we found no significant differences in the incidence or intensity of PMI 8 and 16 h after PCI in groups according to the eGFR (**Figure 1**, **Figure 2**). Figure 1. Incidence of periprocedural myocardial injury 8 h after percutaneous coronary intervention according to the estimated glomerular filtration rate. eGFR = estimated glomerular filtration rate; PMI = periprocedural myocardial injury Figure 2. Incidence of periprocedural myocardial injury 16 h after percutaneous coronary intervention according to the estimated glomerular filtration rate. eGFR = estimated glomerular filtration rate; PMI = periprocedural myocardial injury **Conclusion**: We found no association between incidence or intensity of PMI and the presence of CKD. Furthermore, CKD burden (i.e. stratification of patients according to the CKD stage) was also not associated with higher incidence or intensity of PMI after elective PCI.

Diana Rudan, Željko Sutlić, Boris Starčević, Mario Udovičić, Sandra Jakšić-Jurinjak, Petra Vitlov

**Introduction:** Primary angiosarcoma of the heart is an extremely rare malignant disease. Angiosarcoma of the heart, the most common primary malignant cardiac tumour, is known to carry a dismal prognosis in adults. Diagnosis is often delayed because of its nonspecific clinical presentation. Symptoms appear depending on the size and location of the tumor. Echocardiography has become the primary diagnostic technique because of its high degree of accuracy, non-invasiveness, and cost-effectiveness. Complete surgical resection is required for improved survival rates. Conventional postoperative chemotherapy or radiotherapy does not appear to modify the clinical course. (1-3) **Case report:** We present a case of 47-year-old male patient with primary cardiac angiosarcoma. He presented with palpitations, shortness of breath and hemoptysis. Transthoracic and transesophageal echocardiograms verified the presence of with a 4.0 × 5.4 cm intracavitary mass arising in the right atrium and passing through the tricuspid valve. Magnetic resonance scanning showed that the cardiac tumor arose from the right atrium and had infiltraded both the epicardium and endocardium. Because of its extended growth, partial resection of the tumor was preformed with patch plastic in the right atrrium. The histology findings indicated primary angiosarcoma. **Summary:** This case highlights the difficulties in both the early diagnosis and the management of patients with cardiac angiosarcoma..

Mislav Puljević, Zoran Miovski, Ljiljana Banfić, Majda Vrkić Kirhmajer, Miroslav Krpan, Krešimir Putarek, Marijan Pašalić

We do not have epidemiologically relevant data about venous thrombosis prevalence in Croatia. The knowledge about the actual prevalence of the disease is only partially possible because it applies only to patients treated in hospital. (1, 2) According to data obtained from the databases Croatian Information System on Health / Croatian Health Insurance Fund in 2015 there was 1925 patients with DVT (deep vein thrombosis) treated in hospitals. Working Group on Angiology and Peripheral Vascular Diseases of the Croatian Cardiac Society has an initiative for formation of a national registry in order to obtain an epidemiological data of population morbidity, mode of treatment and prevention of venous thrombosis. We will present the results of a prospective epidemiological study in the Clinical Hospital Centre Zagreb, which should represent a pilot study that could be a model for the formation of a national Registry “Venous Thrombosis”. Questionnaire (**Figure 1**) includes the relevant data relating to the etiology of DVT, scope and localization of the disease, complications of disease, mode of mandatory and long-term treatment, as well as possible complications during treatment. Figure 1. Croatian Registry of Patients with Deep Vein Thrombosis questionnaire. Results of one center collected in period of 9 months during 2016, included a total of only 71 patients. It is a relatively small number of patients whose results will be processed by electronic database. We will display it according to the etiology, mode of treatment and monitoring as well as appearance and evidence of complications of treatment.

Dražen Perkov, Majda Vrkić Kirhmajer, Ranko Smiljanić, Savko Dobrota, Vedran Premužić, Zoran Miovski, Ljiljana Banfić

**Objective**: To describe the method and technique of paclitaxel drug coated balloon (DCB) angioplasty for atherosclerotic lesions of superficial femoral artery (SFA) (1) and interim results of treatment. **Patients and Methods**: Our study included 20 patients (8 women and 12 men) with symptomatic atherosclerotic lesions of SFA (Rutherford Classification 2-4), treated using paclitaxel DCB (Inpact Admiral, Medtronic, USA), in period from September 2015 to August 2016. Lesions of SFA were categorized according to TASC classification. All patients made a clinical examination, measurement of ankle-brachial index (ABI), digital plethysmography and Color Doppler (CD), before, 24 hours after completion of the endovascular treatment and in regular control follow up (1, 3, 6 and 12 months). Before endovascular revascularization all patients underwent DSA of arteries of the lower extremities. The main objective of the analysis was the primary patency of treated AFS lesions and the value of ABI after the intervention. **Results**: We treated 21 SFA in 20 patients, and technical success of endovascular revascularization was 100% (21/21). Lesions of SFA were categorize according to TASC II classification: TASC A 10, TASC B 6, TASC C 4 and TASC D 1 lesions. Average length of lesions was 71±54 mm and 7/21 (33.3%) were stenotic lesions with average degree of stenosis 83±10%. Occlusion was observed in 14/21 (66.7%) lesions. Mean ABI before intervention was 0.62±0.13. The average follow-up period was 7.9±3.3 months. After the intervention mean ABI was 0.92±0.18. In the control period we recorded two SFA restenoses on CD ultrasound, without clinical significance. Primary patency was 90% (19/21 lesions). There were no major complications or reinterventions in the control interval. **Conclusions**: Interim results show that the use of paclitaxel DCB in the treatment of symptomatic atherosclerotic SFA lesions is feasible and effective with a high degree of primary patency and significant improvement of ABI in a short-term period.

Mateja Sabol, Pušić, Martina Magdalenić, Branko Ostrički, Mihajlo Kovačić

Systemic amyloidosis is a rare disease caused by the extracellular deposition of amyloid fibrils in various organs and tissues, most commonly in the heart and kidneys. Cardiac involvement is associated with an increased mortality and morbidity, especially in primary light chain (AL) amyloidosis. The treatment of cardiac amyloidosis is twofold, oriented both on the underlying disease and heart failure with possible arrhythmic events. (1-3) We present a case of 61-year-old male patient with lambda light chains multiple myeloma, and heart and kidney AL amyloidosis. Our patient achieved hematologic remission after the VAD chemotherapeutic protocol, but because of Mayo III grade heart amyloidosis he was ineligible for autologous transplantation of peripheral blood stem cells (ASCT). We considered the possibility of heart transplantation, followed by ASCT, which has been described in the literature as good solution in selected cases of advanced cardiac amyloidosis, but the patient was not accepted for the procedure because he did not meet the criteria stated in the guidelines. With mostly empirical medicamentous therapy for restrictive cardiomyopathy and chronic cardiorenal syndrome, and treating many infectious complications he achieved survival of more than 2 years, which is a relatively good result, given the stage of the disease. Cardiac AL amyloidosis is a very rare condition, often diagnosed with delay. The treatment mainstay is to control the plasma cell clone which is producing the light chains, and in suitable patients the autologous transplantation of peripheral blood stem cells represents the treatment of choice. Although controversial, a heart transplantation followed by ASCT is the only option for improving prognosis in younger, eligible patients with severe cardiac AL amyloidosis. The therapy targeting amyloid deposits in tissues is for now only in experimental stages and is not yet applied in clinical practice.

Tomislav Krčmar, Hrvoje Pintarić, Matias Trbušić

**Introduction:** Coronary artery anomalies are found in 0.6%-1.5% of patients undergoing diagnostic coronary angiogram or intervention. (1) These arteries present a challenge for diagnosis and intervention particularly in case of acute myocardial infarction presenting with occluded aberrant coronary artery. **Case reports:** We report three cases on acute myocardial infarction with ST elevation presenting with “culprit” lesions in aberrant coronary arteries. First case is thrombosis occlusion of dominant right coronary artery and thrombosis sub occlusion of circumflex artery which originate from right coronary cusp. Second case is thrombotic occlusion of right coronary artery which originate from left coronary cusp. Third case is thrombotic occlusion of dominant left anterior descend artery in situation of absence right coronary artery (“single coronary artery”). All three cases were successfully treated. **Discussion:** Acute myocardial infarction associated with anomalous origin of coronary artery is very unusual. Only few cases have been reported in literature. The technical difficulties associated with interventions include improper visualisation, managing the balance between adequate guiding support and risk of dissection, and casual extreme significant curves that have to be overcome with guide wires and all other interventional material. **Conclusion:** Appropriate anatomical knowledge about the course of aberrant vessels and selecting appropriate hardware leads to safe selective engagement of anomalous coronary artery which is very important for finishing intervention in safe and reasonably quick manner.

Maja Šipić, Snežana Lazić, Bratislav Lazić, Biljana Krdžić, Kristina Bulatović

**Background**: Syncope is one of the most distressing symptoms in cardiologic practice and an uncommon symptom of the coronary disease. Syncope accompanied with chest pain in absence of rhythm and conduction disorders may suggest lesion of the principal trunk of the left coronary artery. (1, 2) **Case Report**: 49-years-old patient came to the cardiology unit because of chest discomfort lasting for the past 2 months. When walking normally, he feels chest discomfort propagating into both arms, occasionally accompanied with syncope lasting for 3-6 minutes. His cardiovascular risk factors are hypertension and smoking. Family history is negative for cardiovascular diseases. Previously, he underwent neurologic evaluation: carotid Doppler sonography and cervical spine X-ray were performed. Electrocardiography at rest was normal. He brought his 24 h Holter ECG showing regular sinus rhythm, rare isolated VESs following T wave (a total of 85 during 24 hours) and rare SVESs. At heart rate of 110/min, there was a 3 mm ST depression in Ch2 and Ch3. No malignant rhythm disturbances or pauses longer than 2 sec were recorded. Heart ultrasound showed normal aortic and left atrial diameter. Left ventricle has normal internal dimensions, wall thickness and no visible segment dysfunctions at the time of the exam. Estimated EF was 75%. After 2 minutes at first level of load, exercise test showed chest pain and 2 mm horizontal ST depression in D1, aVL and V4-V6 with 1 mm elevation in aVR. Emergency coronarography was scheduled and during immediate preparation for it, patient had cardiac arrest. Cardiopulmonary resuscitation measures were administered and the coronarography showed thrombosis of the principal trunk of the left coronary artery. A single stent was implanted ensuring optimal coronary flow. **Conclusion**: The presence of syncope in this patient without any documented arrhythmia or structural heart disease and accompanied with chest pain suggested high grade coronary stenosis and required prompt diagnostics. The case may be informative because syncope was an initial symptom of the coronary disease which drove patient to seek medical assistance.

Viktorija Ana Buljević, Matias Trbušić, Ivan Malčić

Polyarteritis nodosa (PAN) is a systemic vasculitis histologically characterized by necrotic lesions of medium-sized and small arteries, mostly in their bifurcations. PAN is a multi-organ disorder that affects more visceral arteries and the consequences of inflammation and necrosis can lead to ischemia of vital organs. The etiology of the disease is unknown. There are four forms - cutaneous (which is most common), classic, and microscopic system. PAN preferably affects the renal and coronary arteries. The most common finding of affected blood vessels are aneurysm, thrombosis and stenosis. Cardiac complications are rare in children, but 35% of patients in adulthood is developing a complication. The most common complications in adulthood is cardiac decompensation and can be explained as a consequence of long-standing hypertension and changes in coronary blood vessels. The incidence of myocardial infarction is low, particularly in young patients. (1-3) This paper describes the 25-year-old patient with acute myocardial infarction with the changes in the coronary blood vessels and persistent arterial hypertension as a result of PAN diagnosed in childhood.

Ena Kurtić, Matija Marković, Damir Kozmar, Stjepan Kranjčević, Darko Počanić, Ivica Premužić Meštrović, Helena Jerkić, Darko Vujanić, Mario Stipinović, Tomislav Letilović

**Introduction**: Posttransplant lymphoproliferative disease (PTLD) is a complication of organ transplantation and mainly (80%) is associated with EBV (re)infection, usually with early-onset. (1, 2) EBV-negative PTLD is mainly late-onset. The highest risk of developing PTLD is within the first year after transplantation and appears the rarest (1-3%) in kidney and liver transplants. PTLD as heart infiltration for so far was not described and the primary heart lymphoma are extremely rare (0.5-1%) so we represent this case report. **Case report**: We admitted a 31-year-old male for cardiac tamponade. Seven years ago patient underwent OLT due to secondary biliary cirrhosis. Two weeks before admission he developed dull chest pain, fatigues, shortness of breath and generalized lymphadenopathy. After admission, echocardiography showed infiltrative mass of the left atrium and ventricle, the right atrium and both septa with abundant pericardial effusion. Pericardiocentesis and FNA of enlarged lymph node in the neck were done. Cytology described giant B non-Hodgkin’s lymphoma while in an effusion lymphoma cells weren’t find. Patient was empirically treated for 4 days with corticosteroid (dexamethasone 40 mg /day) and the immunosuppressive therapy was modified. Clinical status improved dramatically, with regression of the lymph nodes and the heart chambre mass on echocardiography. Serological analysis of EBV was negative. He received 2 cycles of rituximab and one per CHOP-R protocol, without the complications. Six months later PET CT showed no signs of relapse of lymphoma, and echocardiographically was seen significant regression of all changes. Findings 20 months after completion of treatment verified complete regression of disease in the heart. **Discussion**: PTLD is often aggressive, rapidly progressive and potentially life threatening disease. Diffuse large B-cell lymphoma with associated tamponade in our patient required immediate treatment, therefore we did not do additional image or histopathological analysis. An excellent response to chemotherapy and complete regression testifies the fact that the rapid treatment in this case was crucial. PTLD in heart after liver transplantation has not been described, to our knowledge, and a quick and decisive evidence of disease treatment in our case resulted in a complete recovery.

Tihana Kurjaković, Ivica Bošnjak, Kristina Selthofer-Relatić

**Background:** According to previous studies, dysfunction of coronary microcirculation (CMD) is defined as reduced coronary flow reserve and/or endothelial dysfunction, presented with typical angina in absence of other myocardial/cardiovascular or systemic diseases, with electrocardiographic ischemic changes and normal/minimally changed coronarogram. The main pathophysiologic mechanism of CMD is endothelial dysfunction with impaired vasodilatation, coagulation, inflammation, permeability, cell adhesion, and altered microvascular response. (1, 2) Aim: To determine gender difference and risk factors in patients with slow flow coronary phenomena, without significant epicardial coronary artery stenosis, and typical angina-like chest pain. **Patients and Methods:** The study included 30 patients (14 males, 16 females) hospitalized because of chest pain, with ischemic electrocardiographic changes, normal coronarogram and coronary slow flow. To all patient standard biochemical blood analysis with cardiac enzymes were done, blood pressure and anthropometric measurements, transthoracic echocardiography and coronary angiography. **Results:** Arterial hypertension, diabetes mellitus, dyslipidemia, nicotinismus and family history did not showed significant gender difference, but significance was found in age range (p=0.032), male patients was younger than female. Also, early stage of weight increase, BMI over 25kg/m2, could present risk factor for coronary slow flow in both gender. **Conclusion:** In addition to standard risk factors that underlie coronary microcirculatory disease, obesity and ageing should be considered as a part of clinical presentation and aspect for further treatment.

Majda Vrkić, Kirhmajer, Ljiljana Banfić

The need for better stratification of cardiovascular (CV) risk in primary and secondary prevention has prompted numerous studies of vascular biomarkers. A critical review of peripheral, non-coronary, vascular biomarkers in CV prevention and their potential integration into clinical practice was published by the European Society of Cardiology (ESC) Working Group on peripheral circulation in 2015. Among seven evaluated vascular biomarkers, the best evidence of the potential benefits showed carotid ultrasound (intima-media thickness and carotid plaques), ankle - brachial index (ABI) and carotid - femoral pulse wave velocity. It is important to emphasize that so far, there is no evidence that one vascular biomarker is superior to the other. (1, 2) In this lecture we will show the most important data on the three vascular biomarkers, their limitations and weaknesses, and recommendations on the use of vascular biomarkers according to the ESC guidelines on CV prevention. In conclusion, routine measurement of vascular biomarkers in the assessment of CV risk is not recommended. Rational use of vascular biomarkers primarily in people with moderate CV risk may improve prevention of CV diseases.

Mislav Vrsalović

**Background:** The prognostic role of diabetes, although well established in ischemic heart disease and cerebrovascular disease, was not extensively studied in peripheral artery disease (PAD). Due to the decrease trend in smoking globally, diabetes is fast becoming the major risk factor for PAD. There are accumulating studies showing the association between diabetes and all-cause mortality in peripheral vascular disease. However, the results in these studies were conflicting regarding the impact of diabetes on outcome. (1-3) Therefore, we performed a comprehensive systematic review and meta-analysis to assess the prognostic significance of diabetes to predict all-cause mortality in PAD patients. **Methods:** A meta-analysis was conducted to evaluate the association of diabetes with peripheral artery disease outcomes. Using MEDLINE and SCOPUS, we searched for studies published before January 2016. Additionally, studies were identified by manual search of references of original articles or review studies on this topic. In the final analysis, 21 studies with 15,857 patients were included. **Results:** Diabetes was associated with a statistically significant increased risk of all-cause mortality (odds ratio: 1.89, 95% confidence interval: 1.51-2.35, p <0.001), without detected publication bias (Egger bias = 0.75, p =0.631). The stronger effect on outcome was obtained in patients with critical limb ischemia (odds ratio: 2.38, 95% confidence interval: 1.22-4.63, p<0.001), as the most severe form of peripheral vascular disease. **Conclusion:** Diabetes is associated with an increased risk of mortality in peripheral vascular disease, and the effect is even more pronounced in patients with critical limb ischemia.

Aleksandra Šustar, Luka Bastiančić, David Gobić, Tomislav Jakljević, Ivana Smoljan, Vjekoslav Tomulić

**Background:** Cardiac magnetic resonance perfusion imaging, also called stress CMR, is a noninvasive modality for assessing myocardial perfusion without ionizing radiation. The most common indication for perfusion imaging is the detection of a significant coronary artery lesion. According to the American Heart Association (AHA) recommendations, the left ventricle wall is divided into 17 segments assigned to specific coronary artery territories. (1) In light of the variability in the coronary artery blood supply to myocardial segments, we analysed the correspondence of the 17 left ventricular segments with each coronary artery by comparing the CMR perfusion imaging and coronary angiography results. **Patients and Methods:** 17 patients with suspected coronary artery disease (CAD) underwent CMR perfusion imaging followed by invasive coronary angiography. CMR imaging was performed on a 1.5 T MR system (Siemens Magnetom Avanto, Germany) with a standardised acquisition protocol using an adenosine dose of 140 µg/kg/min for 3 min. The presence of a regional perfusion defect was assessed visually and compared with coronary angiographic images. **Results**: Our results revealed that subjects with angiographically significant coronary artery lesions are six times more likely to have perfusion defects in the CMR study than are those without significant CAD (positive likelihood ratio; LR). **Conclusion:** CMR perfusion imaging is commonly performed in University Hospital Centre Rijeka. Along with stress perfusion imaging, it provides information about the left ventricular function and viability, which may be very helpful to cardiologists and cardiac surgeons in treating patients with coronary heart disease. This study is in line with current trends in noninvasive imaging and highlights the diagnostic utility of CMR perfusion imaging in the detection of significant CAD.

Sandro Brusich, David Židan, Marina Klasan, Koraljka Benko, Daniela Malić Zahirović, Ivana Grgić, Mate Mavrić, Zlatko Čubranić

As the number of implanted pacemaker increases the incidence of complications also increase; this problem leads to a growing need for pacemaker and lead extraction. The most common indication for pacemaker lead extraction is localized or systemic infection. Advances in technology enabled the use of new tools and methods that increase the effectiveness and reduce the risk of serious intra and post-procedural complications. At the Department for Arrhythmia and Electrical Stimulation at the University Hospital Centre Rijeka in early 2013, a pacemaker lead extraction program was started. (1) So far there were a total of 45 procedures, 78 leads were removed, of which five were defibrillator leads. The most common cause of lead extraction was a localized infection of the pacemaker pocket or a decubitus of the skin. The predominant extraction technique was the use of dilatation sheaths, while the use of traction and locking stylet was less common. The most significant complication was the development of symptomatic pericardial effusion. There were no fatal outcomes.

Dubravko Petrač

With regard to clinical profile, atrial fibrillation (AF) is often present in patients with cardiac resynchronization therapy and can have a significant negative impact on the prognosis and clinical response to CRT. Management of AF in patients with CRT is multilevel and includes optimal medical heart failure (HF) therapy, anticoagulant therapy, and rate or rhythm control strategy. (1-3) In patients with HF and AF, rhythm control with antiarrhythmic drugs (AADs) has failed to show any survival benefit compared with a rate control strategy. In this context, a rate control with drugs (beta-blockers or/and digoxin) was preferred as first-line therapy in CRT patients with persistent/permanent AF. However, the most observational CRT studies and meta-analyses indicate that AV junction ablation (AVJA) is superior to rate control drugs in achieving adequate biventricular pacing (BVP) and reducing mortality. Amiodarone and dofetilide are the lone guideline-recommended AADs for rhythm control in HF patients, but they have a moderate efficacy and significant side effects, including proarrhythmia. Because of that the use of AF catheter ablation (AFCA) for a rhythm control is extended to patients with chronic HF. In recent meta-analysis of 16 observational studies with 1253 patients, overall success rate of AFCA in patients with LV dysfunction was 77% with consequent improvement in EF of 13%. Four small randomized studies that compared AFCA with a rate control in HF patients with persistent AF showed a significant improvement in EF, quality of life and functional capacity with AFCA. In randomized study that included 203 pts with persistent AF, HF, EF98%). In this context, rate control strategy remains the first therapeutic option for CRT pts with permanent AF. AFCA should be considered in CRT patients with paroxysmal AF who are non-responders to AADs, and in selected patients with persistent AF prior to accepting a rate control strategy.

Diane L. Carroll

Cardiovascular Disease (CVD) is the leading cause of mortality in Croatia (1) with 80% of these deaths potentially preventable with reductions in CVD risk factors. The performance of healthful behaviors related to CVD risk such as smoking cessation, weight and blood pressure management, have become important facets of disease prevention. Mobile technology (mHealth), the use of smartphones and wearable devices, hold great promise to improve health and reduce CVD. The purpose of this presentation is to review the current literature on mHealth tools available to the consumer for smoking cessation, weight and blood pressure management, as these are the most prominent CVD risks in Croatia. (2) Studies that were reviewed for smoking cessation, weight management, and blood pressure management. The current literature supports the promise that the use of mHealth tools for short-term weight management, smoking cessation and blood pressure management is achievable. mHealth tools have the ability to ‘extend’ current face-to-face consultation and education for CVD risk behavior change. These studies tested a variety of mHealth tools but there is little data on the evaluation of tool effectiveness. Future research is needed to produce the evidence of the great potential of mobile technology.

Sanda Franković, Tomislav Kovačević, Ksenija Brajković, Iva Vinduška, Božica Jurinec, Zvonimir Kralj

Croatian Nurses Association’s (CNA) association for the history of nursing was founded on March 19, 2013 in Zagreb. The goal of the association is to recover materials from the rich history of nursing and to present them to the nursing community and to the whole population. Association primarily focuses on following activities: collection of the materials from the sphere of nursing (pictures, uniforms, brooches, films, books, records, audio files); archiving collected data and materials; analysis of nursing publications; joining with related international organizations; promotion of Croatian nursing history through exhibitions and lectures (schools, broad public); production of nursing calendar; organization of conferences and active participation in other associations conferences. (1) The association so far participated in the central commemoration of the International Nurses Day and in the commemorations in other CNA’s branches; organized displays of historical nurses uniforms on conferences of other CNA’s associations; participated in commemoration of Book Night in the library of the Andrija Štampars School of Public Health and made nursing calendar. “Live pictures from the history of nursing” is a display that has shown uniforms of: Benedictine Sisters, Brothers of Mercy, Daughters of Charity of Saint Vincent de Paul, sisters from Rudolfina Haus, Croatian nursing uniforms in between the World Wars and from the period from 1960. until 1980. The display was accompanied by a description of those communities and the people who worked in the care for the sick and needy. It described the historical moments in which Croatian nursing transformed from a calling to a profession. The uniforms in the show where either originals or replicas made based on the models of original uniforms. Uniforms that we don’t have in original were reconstructed using photographs and available manuscripts. (2-4)

Felicity Astin, J. Probyn, D. Conway, J. Greenhalgh, J. Holt, K. Marshall, J. Wright

**Background:** Percutaneous coronary intervention (PCI) is a common treatment to vascularise myocardial muscle. (1) Serious complication are uncommon, but death is one of them. Doctors must obtain consent before doing PCI; for this to be sound the patient must be mentally able, act of their own free will, and be given enough information to help their decision making. Obtaining valid consent is a legal and ethical requirement. However, published studies tell us that the amount and quality of information given to PCI patients is variable; benefits are often overestimated, risks forgotten and alternative treatments not always considered. Patients may not be informed in the way that they should be. **Patients and Methods:** In this mixed methods study, we aimed to describe the PCI informed consent process and survey the attitudes of patients and cardiologists about informed consent in England. We conducted in-depth interviews with 41 patients, 19 cardiologists, and recorded 37 consent conversations at two hospitals. We also sent questionnaires to 326 patients and 124 cardiologists recruited across England to find out their views on consent. **Results:** Patients were mostly satisfied with the PCI consent process, valued cardiologists as the ‘experts’, and saw PCI as a ‘fix’ for their heart condition. The informed consent process was seen as ‘paperwork’ that was not especially important, but necessary to get access to treatment. Most patients (81%) received written information before PCI and had (94%) signed the consent form on the day of treatment. Patients were not very concerned by this; most (81%) reported being highly satisfied by the explanation they got. The benefits of PCI were overestimated, most (89%) wanted information about all risks, fewer (84%) were interested in knowing about alternative treatments or what would happen if they did not have PCI. **Conclusion:** Patients and cardiologists were generally satisfied with the PCI consent process, but the reality of practice does not fully mirror practice recommendations in England.

Matija Marković, Ena Kurtić, Darko Počanić, Mario Stipinović, Stjepan Kranjčević, Helena Jerkić, Tomislav Letilović, Damir Kozmar, Maro Dragičević, Ivica Premužić Meštrović

**Introduction:** Brugada syndrome (BrS) has low prevalence (14-30:10000), it is more common in men and people from Asia, and it is characterized by typical ECG changes as well as high incidence of sudden cardiac death (SCD). ICD implantation is the only SCD prevention option. HRS/EHRA/APHRS Consensus article (1) states the indications for ICD implantation, but asymptomatic patients, or those with syncope of unclear origin can be hard for risk stratification. (2, 3) **Case reports:** We are presenting two cases from our hospital. A 40-year-old male was seen for atrial fibrillation and type II ECG changes. There were no SCD in family, and he never had syncope. Pulmonary vein isolation (PVI) was done, then ajmaline test (positive) and finally electrophysiology study (EPS) (negative). A 36-year-old male with type II ECG was admitted after syncope which occurred during rest on a hot day at a picnic. Holter as well as neurologic workup were normal. Ajmaline test was positive and EPS negative. Both patients were instructed to avoid specific drugs, to change lifestyle and prevent high fever with antipyretics. Guidelines clearly state ICD should be implanted to SCD survivors or sustained ventricular tachycardia (VT), it can be useful in patients with type I ECG changes and a syncope, and it may be considered in EPS inducible patients. First patient is in follow up because he doesn’t fulfill any criteria. Also he was previously treated with propafenone without any problems, which is also a possible sign of lower risk for SCD, finally he was successfully treated for atrial fibrillation, which is linked ventricular arrhythmias in BrS patients, so this was also a tool to lower his risk. Second patients had a syncope, but other syncope etiologies are possible, he has type II ECG changes and arrhythmia is not inducible therefore he is also in follow up. **Conclusion:** Potentially lethal arrhythmias in asymptomatic patients develop in 1-8% in 3 years (Brugada; Eckardt; Probst). Finally, EPS reccommendations are not clearely defined, therefore we are still conducting EPS as an adjuvant tool for risk stratification.

Borka Pezo-Nikolić, Vedran Velagić, Mislav Puljević, Davor Puljević

**Case report:** 28-year-old man with non-ischaemic dilated cardiomyopathy underwent implantation of an cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death. The implanted device employed a single lead with atrial sensing capabilities (BIOTRONIK Iforia 5 VR-T DX and Linox Smart DX single ICD coil). 6 months after implantation patient received ICD shock. The interrogation reveals a tachycardia with electrogram (EGM) characteristics of very short ventriculoatrial (VA) interval and cycle length (CL) of 280 msec. The tachycardia fell into the ventricular fibrillation (VF) zone, resulting in ICD shock. It was fairly clear that it was initiated by an atrial premature contraction (APC) with a prolonged P-R interval initiating supraventricular tachycardia (SVT). A diagnosis of AV nodal reentrant tachycardia (AVNRT) was strongly suspected on the retrospective review of the tachycardia episode, based on the short V-A time, the unchanged ventricular morphology on intracardiac electrograms. At the electrophysiology (EP) study, dual AV nodal physiology was in fact revealed. A narrow complex tachycardia was reproducibly induced with single atrial extra-stimuli. The tachycardia had a 1:1 VA relationship and concentric atrial activation. Entrainment maneuvers were consistent with typical AVNRT. Slow pathway modification was performed, following which tachycardia was no longer inducible. The ICD normally uses heart rate for a given period of time as the criteria for definition of arrhythmia. Any ventricular rate above the programmed cutoff rate is considered to be an arrhythmia and will be treated according to the programmed protocol. Some supraventricular arrhythmias can attain the programmed cutoff rate and thus be inappropriately treated. Despite increasingly sophisticated discrimination algorithms available in modern ICDs, the ability to differentiate SVT from ventricular tachycardia (VT) can be challenging. Our patient received inappropriate shock for AVNRT. Inappropriate shocks occur in a certain proportion of patients with ICDs and represent one of the most challenging aspects of management for the physician. An EP study may be necessary to determine the appropriate therapeutic course. (1)

Sandro Brusich, Mate Mavrić, Marina Klasan, David Židan, Daniela Malić Zahirović, Koraljka Benko, Ivana Grgić, Zlatko Čubranić

**Background**: In July 2015 the first electrophysiology laboratory in University Hospital Center (UHC) Rijeka became operational. During the 1st year, electrophysiological studies have been performed in 184 patients. In 30 patients electrophysiological studies with ventricular tachycardia provocation have been performed while 154 patients also underwent ablation of the arrhythmia. In 144 patients radiofrequent ablation was used. Since April 2016, cryoablation is being used in patients with atrial fibrillation and by July 2016, 10 patients have been treated with this method. A CARTO system is also being acquired and is expected to become operational in September 2016. The aim of this study is to present the success rate of ablation treatment and the rate of reablation and recurrence of arrhythmias in patients treated with catheter ablation. **Patients and Methods**: 154 patients (92 male and 62 female) who underwent catheter ablation in UHC Rijeka have been included in this study. Indications for ablation included atrioventricular (AV) nodal reentrant tachycardia (52 patients – 33.77%), atrial undulation (32 patients – 20.78%), AV reentrant tachycardia (18 patients – 11.69%), atrial tachycardia (1 patient – 0.65%), cryoablation of atrial fibrillation (AF) (10 patients – 6.49%). In 41 patient (26.62%), the indication for catheter ablation was refractory AF with ventricular tachyarrhythmia, and ablation of the AV node has been performed along with implantation of a cardiac pacemaker if it hasn’t been already implanted (22 three chamber pacemaker were used, and 19 dual or single chamber pacemakers). **Results:** The success rate of catheter ablation in the first try was 96.75% (149 patients). The recurrence of arrhythmia was noted in 5 patients (3.36%), and 5 reablations (4 patients with recurrence and 1 patient whom the arrhythmia was not successfully ablated in the first try) have been performed with a reablation success rate of 100%. Complications have occurred in 2 patients (1.30%) and included AV block and femoral artery pseudoaneurysm. **Conclusion**: Catheter ablation of arrhythmias is proven to be a safe and effective method of treatment. The results of ablation during the first year of the electrophysiology laboratory in UHC Rijeka are similar to the results published by other electrophysiology centers and international guidelines. (1, 2)

Davor Miličić

Dear colleagues, Here is the Abstract Book of the 11th Congress of the Croatian Cardiac Society. Our Congress is the main summit of Croatian cardiology, held biannually. As a short reminder, our Cardiac Society was founded as the first self-standing medical association after recognition of Croatian independence, and since then has become the most active society in Croatian medicine by far. This year we are deeply honored that our Congress is going to be organized under the patronage of the Croatian Academy of Sciences and Arts, our leading national institution in the field of science, art and culture. Despite the fact that Croatian cardiology was much less developed a quarter of a century ago, and based in a small country devastated by the aggressive war that took place on our territory, Croatia was among the founding countries of the European Society of Cardiology. Since then, we have been trying to be actively incorporated in European and global cardiology. During recent years, we have proudly witnessed our international involvement in Cardiology exceed the size of our country and the number of members of our Society. Additionally, what is more important that nowadays there is no need to send our complex patients to international centers of excellence, as we can competently cover practically all our patients’ needs. As an example, we belong to the group of countries with one of the best primary PCI networks for treating patients with acute coronary syndromes. Furthermore, during the last two years we have witnessed a significant breakthrough in arrhythmia ablation rates as well as ICD and CRT implantations, which has brought us to very satisfactory Central European standards. Regarding the advanced heart failure therapies, including use of newest technologies in mechanical circulatory support and heart transplantation rates, we belong to several most successful cardiologic care systems in the world. However, despite very good curative cardiology, Croatia still belongs to the group of high cardiovascular risk countries in Europe, which means that we need better prevention policies and should include more the wider community, media and politicians to help us fight against cardiovascular morbidity and mortality in our county. Abstracts published in this Supplement of our Cardiologia Croatica journal should be representative of our cardiology practice and science during the last two-year period. In addition, we were happy to include some abstracts from international colleagues as well, having in mind importance of the international visibility of our Congress. Other than original contributions printed in this Abstract Book, the Congress consists in a significant part of invited lectures by selected leading international and Croatian cardiologists. Therefore, to get a complete picture of the Congress, one should consult the Congress Programme Book, complementary to this Abstract Supplement. Last but not least, our Cardiac Society was the first in Croatia to start organizing joint congresses with nurses, in our case cardiology nurses from the Croatian Association of Cardiovascular Nursing, which is in concordance with contemporary international practice. Each of our national congresses, including this one, has become a part of the history of Croatian Cardiology. I am sure that this Congress will show the continuous progress of our Cardiology and will be an inspiration for a further development and an even better Congress in 2018. Finally, I would like to express my sincere gratitude to all who actively contributed to this Congress as well as to all our members, supporters and friends of the Croatian Cardiac Society. With my best personal regards, Sincerely yours, In Zagreb, November 2016.

Jure Samardžić, Marijan Pašalić, Ivo Planinc, Hrvoje Gašparović, Dora Fabijanović, Mate Petričević, Maja Čikeš, Boško Skorić, Bojan Biočina, Davor Miličić

**Introduction:** Long term mechanical circulatory support (MCS) is intended for heart failure patients who are not eligible for heart transplantation or who cannot wait for adequate donor due to severity of their condition. It is known that hemostasis in these patients is deranged and that significant number of patients develop bleeding and thromboembolic events. Development of adequate and reliable models which could predict these events might improve treatment and outcomes of patients. MCS, as well as heart failure, affects platelet reactivity (PR) which have an important role in hemostatic balance. (1, 2) We sought to investigate correlation between PR before MCS implantation and long term clinical outcomes. **Patients and Methods:** We analyzed PR before implantation using Multiplate function analyzer (ASPI and ADP tests) in patients who underwent long term MCS implantation in our institution. Measurement was performed in 19 patients (12 HeartMate II, 4 HeartMate III, 2 HeartWare, 1 TAH Syncardia) who underwent the procedure in the period between July 2013 and February 2016. Median follow up was 11 months, mean 13.7 months (range 1-31 months). We analyzed correlation between PR and overall mortality, as well as ischemic and big bleeding events after the surgical treatment has ended. **Results:** In total, 9 patients died (47.3%), 6 patients had significant bleeding (31.5%) while 3 patients had an ischemic event (15.7%). There was no statistically significant correlation between preimplantation PR and overall mortality, ischemic and bleeding events (**Figure 1**). Figure 1. Preimplantation platelet reactivity affects on clinical outcomes. **Conclusion:** Results indicate that preimplantation PR is not connected with mortality, nor bleeding and ischemic events. Further investigations on a larger number of patients are warranted to confirm these results. Future studies should be using comprehensive analysis not only to measure platelet activation pathways but other coagulation parameters as well continuously, to eventually improve prediction and prevention of events in both short term and long term period after MCS implantation.

Mario Stipinović, Sofiya Andreykanich, Helena Jerkić, Bojana Aćamović Stipinović, Darko Počanić, Stjepan Kranjčević, Damir Kozmar, Darko Vujanić, Maro Dragičević, Ivica Premužić Meštrović, Tomislav Letilović

**Introduction:** The incidence of atrial fibrillation is increasing and it is now the most common arrhythmia in clinical practice (1). Primary therapeutic goal in patients with atrial fibrillation is to prevent thromboembolic complications (2). The aim of this study was to determine the incidence as well as risk factors for left atrial appendage (LAA) thrombus formation, detected with transesophageal echocardiography (TEE), in patients with atrial arrhythmias and planned cardioversion. **Patients and Methods:** Patients with atrial arrhythmias, scheduled for synchronized cardioversion at the Department of Cardiology, Clinical Hospital Merkur in years 2014 and 2015 were studied. All patients were treated with different anticoagulation/antiaggregation protocols according to the most recent guidelines. TEE was done before every procedure. We studied various isolated risk factors known or believed to be associated with development of left atrial appendage thrombus, such as: age, sex, type of anticoagulation therapy, duration of therapy, systolic heart function and type of atrial arrhythmia. We also studied influence of coexistence of various risk factors, expressed as CHA2DS2-VASc score≥2, on LAA thrombus formation. **Results:** Data from 65 patients were gathered (mean age 65.5±11.7, mean CHA2DS2-VASc score 2, 40% female, 60% male). In 14 subjects (21.5%), despite adequate anticoagulation/antiaggregation therapy, the thrombus in LAA was discovered. We found no statistically significant correlation between isolated risk factors, that were studied, and LAA thrombus formation. On the other hand statistical analysis showed correlation of LAA thrombus formation with CHA2DS2-VASc score equal or higher than 2 (p=0.017). In fact all 14 patients with thrombus (100%) had a CHA2DS2-VAScof that value. **Conclusion:** There is still a significant risk of LAA thrombus in patients with atrial arrhythmias despite adequate anticoagulation therapy. LAA thrombus formation in those patients correlates with coexistence of several rather than one risk factor.

Milan Milošević, Bojana Knežević

The work, generally, and especially in the health care sector, has a key role in workers’ health due to specific factors in the workplace that can lead to injuries, occupational and work-related diseases or long-term health consequences. (1-3) While workplace dangers are divided into mechanical, thermal or electrical, hazards as biological, chemical and physical, efforts are defined as statodynamic and psychophysiological. The problem of preserving the health of health workers in relation with the dangers and hazards in most cases can be successfully solved by technical and technological solutions at the workplace, while areas psychophysiological and statodynamic efforts required objectification and appropriate intervention. Adequate work ability is compliance of workers biological characteristics with the job demands. The objective of work ability assessment of health care professionals is to preserve workers’ health, prevent of disabilities, occupational diseases and work related diseases and injuries. To preserve health and adequate work ability among health care workers there are measures at the organizational level and the individual level. Under the measures at the organizational level there are changes in the organization of work, involving employees in decision making and problem solving. They should include: the optimum number of employees in order to reduce work overload and time pressure to perform tasks; additional workers education on health and safety at work which is important for the prevention and removal of stress in order to preserve the health of employees as a key prerequisite for maintaining work ability. At the individual level, preventive measures should include appropriate health surveillance, with particular emphasis regarding workplace, working conditions, shift work and risk assessment.

Martina Kralj, Dorotea Vuk, Manuela Šola, Snježana Gašpar

A cardiac electrophysiology study is an invasive procedure that is used for analysis of the heart conduction system and determines the presence of cardiac arrhythmias. Besides determining the existence of an arrhythmia, it also determines the cause, source and the mechanism of occurrence of the arrhythmia. If an arrhythmia is found during the procedure, the procedural approach becomes therapeutic. One of the ways to intervene is the radiofrequency ablation. It represents a controlled local tissue heating that terminates the arrhythmia at its source. (1) The success of the procedure mostly depends on the type of arrhythmia and the structural disease of the heart. Since it’s an invasive procedure, certain complications can happen during or after catheter radiofrequency ablation. The complications that happen during the procedure can be associated with any part of the procedure: during sheath placement, associated with continuous sedation and anesthesia, insertion and manipulation of catheter leads inside blood vessels and cavities of the heart or application of radiofrequent energy. The role of the nurse as a member of a multidisciplinary team is crucial both inside the interventional laboratory where the procedure is performed, as well as on the ward where the care for the patient is continued. Besides physical and mental preparation of the patient before the procedure and providing physical help and psychological support post-procedurally, the role of the nurse in recognizing potential complications is of utmost importance. Those can be a hematoma on the puncture site, bleeding, mechanical traumas to the heart – tamponade, pericardial effusion, thromboembolism, conduction disorders and death. Nurse has to monitor the symptoms and signs that indicate a certain complication is taking place and act in a timely and correct manner. Good organization of ward duties and patient monitoring on a hospital ward is of great importance both for the patient and the nurse.

Dora Bedeničić, Jelena Tereza Čepo

Implantation of pacemaker is a minimally invasive surgical method in patients with heart conditions. Complications during and after implantation are not rare. (1) Department of Cardiology at the Clinical Hospital „Sveti Duh“ implants single chamber, dual chamber, implantable cardioverter defibrillator and cardiac resynchronization therapy devices. Implantation is done following current guidelines and good practice standards. In our institution we have encountered certain complications during procedures, which mostly included pneumothorax and chronic occlusion of the subclavian vein. Rare complications included subacute perforation of the right ventricle and perioperative myocardial infarction. As a complication, pneumothorax usually occurs during procedure, however patient’s condition can worsen as the procedure advances. If possible, the procedure is finalized and if the patient condition is worsening or he develops respiratory difficulties, he is transferred to Coronary Care Unit, chest X-ray is done to prove the complication and the patient is treated until symptoms resolve. Chronic occlusion of subclavian vein makes pacemaker lead placement impossible. It is diagnosed using intravenous contrast and, following that, the opposite side is chosen for the approach. Subacute perforation of the right ventricle is characterized with worsening of the chest pain during procedure, is diagnosed with an echocardiography exam, and the patient is transferred to the Coronary Care Unit. If the patient’s condition worsens, the patient is transferred to the Cardiac Surgery Department. Periprocedural myocardial infarction is usually seen in elderly patients. The most common complication after procedure is displacement of pacemaker leads and, less often, infections. Dislocation of the atrial or ventricular leads demands surgical revision during which displaced leads are repositioned or new leads are placed, while previous, displaced leads are isolated if they cannot be removed. Infections are reduced to the absolute minimum by prophylactic administration of antibiotics, and wound aspirate is taken during procedure and sent to the microbiology lab.

Dora Fabijanović, Vlatka Rešković Lukšić, Željko Baričević, Hrvoje Jurin, Maja Čikeš, Boško Skorić, Ivan Burcar, Sandra Večerić, Jadranka Šeparović Hanževački, Davor Miličić

**Introduction**: In the first few days following acute myocardial infarction mechanical complications such as septal defects, papillary muscle rupture or dysfunction, cardiac free wall rupture or ventricular aneurysms may occur. Incidence of these complications is rather low yet they are all life-threatening and need prompt detection and management. (1, 2) **Case report**: A 64-year-old healthy female was admitted due to acute posterolateral myocardial infarction. During the initial examination, the patient was hemodynamically stable, presenting with a holosystolic murmur heard best at the apex. Initial work up demonstrated newly discovered diabetes with high blood glucose levels (29 mmol/L). Urgent coronary angiography was performed revealing proximal left circumflex artery occlusion and drug eluting stent was put in place at the site. Following the intervention the patient became progressively dyspneic with signs of pulmonary edema, arterial hypotension and sinus tachycardia. Bedside transthoracic echocardiography was performed and despite the poor echo window significant mitral regurgitation (MR) with hyperdynamic left ventricular contraction and left ventricular ejection fraction of 60% was verified. Due to the extremely high values of blood glucose with elements of diabetic ketoacidosis, continuous perfusion of rapid-acting insulin was initiated. Careful titration of intravenous diuretics and nitrates gradually stabilized the hemodynamic status. Although diabetic ketoacidosis is described as a potential cause of noncardiac pulmonary edema, after stabilization was achieved, transesophageal echocardiography was performed. The study showed rupture of the anterolateral papillary muscle resulting in acute, massive and highly eccentric MR due to posterior leaflet "flail" (**Figures 1****,****2** and **3**). Patient underwent urgent mitral mechanical valve replacement surgery and was discharged from the hospital after a total of 14 days. Figure 1. Multiplane transesophageal echocardiogram showing massive, highly eccentric anterior mitral regurgitation jet. Figure 2. 3D transesophageal echocardiogram. Arrows showing flail posterior leaflet in the left atrium and ruptured papillary muscle head in the left ventricle. Figure 3. 2D transesophageal echocardiogram showing flail posterior mitral leaflet, wide mitral valve non-coaptation zone and floating ruptured head of the anterolateral papillary muscle in the left ventricle. **Conclusion**: Differential diagnosis of pulmonary edema during the early postinfarction period is extensive and demanding, particularly in patients with comorbidities that can mask the clinical picture. Although mechanical complications are rare, it is necessary to identify and treat them early on, which is possible only with continuous monitoring and constant search for the causes of new onset hemodynamic instability.

Mateja Podergajs

Cardiovascular diseases, of which the most common one is coronary heart disease (CHD), are still the leading cause of death in the developed world despite the fact that they have already been significantly reduced. (1, 2) Atherosclerosis, the principal cause of CHD, is increased by the risk factors. With their removal we can prevent the development of the disease and to some extent inhibit the progression of the disease which is already present. In order to achieve a better health-related quality of life it is necessary to inform the coronary patients already during hospitalization about the characteristics of the disease and measures of effective self-control. It is important for the patients that they are actively involved in the healing process, which means they must be allowed access to understandable health information, on which they can base their decisions about their treatment and health. However, research has shown that 50% of patients do not fully understand the health information which they receive from medical staff. (3) Educating hospitalized patients is, therefore, a major challenge. Patients sometimes are not physically or mentally ready to learn because of their illness, anxiety, fatigue, or loss of cognitive functions. The outcome of education is significantly affected by the level of health literacy, which the WHO defines as a set of cognitive and social skills, which determine individual’s motivation to access the information, to understand the given information and to use it critically in a way that supports and maintains health. The effectiveness of the health information namely depends on the patient’s ability to understand it and to use it, which is largely affected by the individual’s level of health literacy. (4) The obstacles in health education can be seen in medical staff, whose lack of counselling skills and knowledge about the principles of adult learning and education, especially of those whose health literacy is lower, was noticed. Misunderstandings can arise when medical staff use technical terms to describe the processes and outcomes of the treatment that patients do not understand. However, there can also be obstacles in the health system; for example, short hospital stay of these patients reduces time and opportunities to teach hospitalized patients. Since inadequate health literacy is associated with adverse health outcomes, poor control of chronic disease, premature death and poor quality of life, we, the medical staff, must also strive to improve health literacy, which can be achieved through health education. It is important that medical staff assess the level of patient’s health literacy and on its basis adapt the content of health education. However, due to many factors that affect the level of health literacy it is difficult to assess. For the purpose of facilitating the identification of the patients with low health literacy, a number of instruments have been developed in the world, which are not used in clinical practice often enough. In a survey we conducted, we have discovered that the assessment of the patient’s health literacy is crucial to the development of an effective individual health education of a coronary patient. Structured health education, adapted to the patients’ health literacy level before the discharge from the hospital, empowers the patients and improves their level of health literacy. We have concluded that the concept of health literacy in the medical treatment of patients is important and, therefore, its knowledge is essential for medical staff. It is also one of the chief indicators of the quality of the care. We believe that health literacy is a challenge for modern medical education by adapting communication methods.

Ivica Matić, Asja Jelaković

With Croatian entering into the European Union many possibilities became possible to use financial support of the EU funds. That allowed for new perspectives to finance projects in the field of education. Erasmus+ is a new EU programme that provides funds to finance mobility of the students, especially from vocational schools. It is an important opportunity for schools that educate future nurses that make up the single largest segment of the health care work force (1). It is a profession for which there is interest from most member countries. Projects that are within limits of Erasmus+ offer young, future nurses opportunity to achieve professional competence in an international environment already during education. In that way the youth has the opportunity to experience work abroad and develop additional knowledge and skills and offers them a chance to make a definite decision regarding life and work abroad. Besides that, it provides many new possibilities to improve cultural and language competences. Programme also includes training of professional staff - teachers of nursing care. That way, students and teachers have new, equal opportunities, regardless of financial situation and other limitations. The purpose of this paper is to present experiences from Nursing School „Mlinarska” in project design and utilization of European funds within Erasmus+ programme providing advancement of professional and personal competences of our students and employees.

Aleksandra Kraljević, Nikolino Žura, Martina Ćubić

The modern way of life is burdened by stress combined with unhealthy physical exertion and the decrease in healthy physical activity. This type of lifestyle inevitably leads to high morbidity. Health workers are often at the top of the list when looking at work-related injuries. Back pain due to manual handling of the patients is a common example. Medical assistant personnel take the second, whereas medical nurses the sixth place on the list of most common jobs associated with risk of muscle and joint strain. (1, 2) Work-related injuries occur in the setting where the mechanical burden is greater than the capacity of the musculoskeletal system. Inflammation can occur at the muscle or tendon origin often followed by functional restrictions. Early bone and cartilage degeneration may follow in the long run. Indulging in a recommended amount of healthy physical activity, understanding guidelines to work assignments and taking reasonable time before returning to work after injury can help prevent further injury development. In the setting of an injury a faster recovery and return to the workplace can be achieved through rehabilitation with gradual increase in strain. In order to prevent future work-related injuries, it is necessary to collect and understand data that interprets the potential health hazards at the workplace. Ergonomics is a field that examines the factors that can improve the conditions of the workplace. The conditions of workplace are directly connected to the rate production and the amount of work-related injuries. One of the main goals in this field is the reduction of these injuries, creation of a healthy work environment and proposal of healthy habits for the staff. With this in mind we can surely understand the importance of ergonomics in the medical setting. It is crucial to educate medical nurses about the hazards of the work environment and the guidelines that the ergonomics field suggests regarding the way nurses do their job. Furthermore, education should familiarize the nurses with the devices that can prevent injury development. Ergonomic methods offer solutions to many of the noted problems – in the form of patient cranes or other devices that reduce the strain to the nurses’ musculoskeletal system. Unfortunately, medical staff often does not have these devices in their work settings. By becoming an active figure in the improvement of their own health and workplace, medical nurses will be able to provide better service to the patient. By gradually adjusting the ergonomics of their workplace (by providing necessary devices or implementing healthy posture and increasing physical activity, among others) work-related injuries, the ‘disease of the third millennium’, could be prevented and hopefully overcome in the future.

Vedran Radonić, Hrvoje Jurin, Marijana Grgić, Medić

**Introduction:** Focused cardiac ultrasound (FoCUS) is a simplified application of echocardiography mainly based on visual impression (1). Unlike comprehensive standard echocardiography, FoCUS can be successfully performed after rather short training and in much less examination time. By adding FoCUS to physical examination physician can achieve additional information for better understanding of patient’s pathophysiology. Liver congestion due to weak heart may be the cause of liver failure. Liver congestion and impaired heart function can be detected by FoCUS. **Case reports:** Case 1: 54-year-old male was transferred from Gastroenterology Ward to Intensive Care Unit (ICU) due to general clinical worsening with encephalopathy and oliguria. No liver or heart problems were known from the history. He has been taking duloxetine for depression. Duloxetin is known as an agent with potential risk for liver lesion (2). Laboratory workup revealed lactate 8.4 mmol/L, bilirubin 86 mmol/L, INR > 6.0, AST 9302 U/L, ALT 6549 U/L. FoCUS performed by an intern, who recently attended Ultrasound Life Support Basic Level (USLS-BL1) course, demonstrated dilated inferior vena cava and hepatic veins as well as significant heart enlargement with reduced left ventricular systolic function. Transoesophageal echocardiography showed biventricular non-compaction cardiomyopathy (3). Left ventricle ejection fraction was 20%. By treating congestive heart failure and stopping duloxetine, liver function and mental state improved. The patient was transferred to Cardiology Clinic for follow-up and treatment. Case 2: 44-year-old male was transferred to ICU due to acute liver failure. Lactate was 12.1 mmol/L, bilirubin 69 umol/L, INR 2.79, AST 1648 U/L, ALT 1996 U/L. Three months before, he was hospitalized in another institution due to bilateral lung infiltrates. When the analysis of sputum demonstrated Mycobacterium bacillus, antituberculotic therapy was started. Bicuspid aortic valve and left ventricle EF of 40% were found on echocardiography. Again dilated inferior vena cava and hepatic veins as well as significant heart enlargement with reduced systolic function were found by FoCUS. Hence, echocardiography was performed and showed severe aortic stenosis and left ventricle EF of 20%. After treating congestive heart failure and discontinuing antituberculotics liver function improved. Few weeks later he underwent aortic valve replacement. **Conclusion:** In these two cases liver congestion due to heart failure was recognized by FoCUS performed by an intern, and was as a significant contributing causative factor which influenced on further diagnostic process and treatment. Young physicians, interns and medical students should be encouraged to access the ultrasound training to accept ultrasound as a precious tool in routine patient examination.

Damir Raljević, Vesna Pehar Pejčinović, Viktor Peršić, Karlo Stanić

Sudden cardiac death (SCD) is defined as unexpected death due to circulatory shock, mainly because of cardiac arrhythmias, within one hour of symptom onset. Although coronary heart disease is the most common cause, in young people is mainly due to a congenital structural or arrhythmogenic diseases. Idiopathic ventricular fibrillation (IVF) is a rare cause of SCD. Its incidence is not fully known. Over the past time, with a clearer definition of the diagnosis of primary arrhythmogenic syndromes (Brugada syndrome, long and short QT syndrome, early repolarization, catecholaminergic polymorphic ventricular tachycardia), its incidence decreased, and the definition was changed. The diagnosis of IVF is made by exclusion of known causes of VF. VF without proven structural heart disease or primary arrhythmic syndromes (with its clear phenotypic characteristics) is defined as IVF. It is characterized by rare individual ventricular premature beats (VES) with a narrow interval of binding (R / T phenomenon) and a high propensity for the development of polymorphic ventricular tachycardia (PVT) and VF. The cellular mechanism linked to the Ito potassium current in the His-Purkinje fibers, which causes a strong potential repolarization with surrounding myocardium and leads to VES with short coupling interval bonding with subsequent circular movement in phase II and the emergence of PVT and FK. It is not clear whether it is a monogenic or polygenic entity, and so far has seen the involvement of mutations in genes CALM1, DPP6, RyR and IRX3. Relapse rate is high and ranges (according to the now rare trials) of 11% to 45% annually. (1) In the lecture we will show case of a patient who is at a younger age survived arrhythmic storm and who we follow up for many years.

Rina Dalmatin, Teodora Zaninović Jurjević, Luka Zaputović, Alen Ružić

**Introduction:** Postpartal cardiomyopathy is a rare complication in pregnancy which occurs in healthy mothers to-be in last month of pregnancy and up to 5 months after delivery. It is more common in pregnant women older than 30 years who suffer from hypertension and preeclampsia and in multiple pregnancies. (1, 2) **Case report:** 44-year-old woman presented with new onset of dyspnea and palpitation. The patient gave birth to hers sixth child 3 months ago and who suffered from subacute thyroiditis in 4 years before. Phenotype of dilative cardiomyopathy with low left ventricular function (EF 25%) was verified by echocardiography. After the standard medical treatment and bromocriptin, the symptoms withdrew and the left ventricle systolic function recovered. **Conclusion:** Postpartal cardiomyopathy is a rare but life-threatening complication of pregnancy. Our goal is to emphasize the importance of it’s prevention, early diagnosis, and timely adequate treatment. We also want to highlight the importance of the national and global peripartum cardiomyopathy registries as counseled by the European Society of Cardiology initiative.

Josip Vincelj, Boris Starčević, Danijela Grizelj, Sandra Jakšić Jurinjak, Mario Udovičić, Ivana Jurin, Vanja Ivanović, Petra Vitlov, Željko Sutlić

**Introduction**: Left ventricular (LV) clot is a common occurrence after anterior myocardial infarction in patients with decreased left ventricular ejection fraction (LVEF). (1) We present a case of a patient with a very large LV thrombus in the setting of decreased LVEF and advanced chronic heart failure (CHF) with surgical removal of thrombus and left ventricular assist device (LVAD) implantation as destination therapy. **Case report**: A 66-year old female patient with a medical history of advanced CHF due to ischaemic cardiomyopathy after a subacute myocardial infarction of LV anterior wall, and with surgically treated thrombosed abdominal aortic aneurysm and removed right kidney, was admitted to our hosiptal due to worsening of CHF. 3D transthoracic and transesophageal echocardiographic (TTE and TEE) examination revealed a dilated, globally hypokinetic LV (Simpson BP EF 21%), with thinned wall, akinetic apex and a formed LV aneurysm containing a sesile thrombus with dimensions of 32x47mm. Due to advanced CHF, impaired kidney function, diffuse peripheral vascular disease, elevated pulmonary vascular resistance, preserved function of the right ventricle and minimal tricuspid regurgitation, we decided to refer the patient to LVAD implantation as destination therapy coupled with prior thrombectomy. The ventriculotomy was performed on the apex to achieve the best possible site for good visualization of the LV chamber for clot removal, as well as ideal position for the LVAD inflow cannula implantation. The thrombus was removed and the LVAD (HeartMate II) was then successfully implanted. Treatment of LV thrombus in this setting is particularly challenging because the large clot has to be completely removed in order to prevent potential pump thrombosis and systemic embolism. The patient was subsequently discharged home, and three years afterwards she is doing well on LVAD support as destination therapy, without any thromboembolic events. **Conclusion**: LVAD implantation can be safely performed with previous surgical removal of a large LV clot without systemic embolism. Meticulous preoperative echocardiographic assessment is essential, and novel echocardiographic modalities such as 3D TTE and TEE are of invaluable importance.

Iva Klobučar, Mihaela Trajbar, Ljubica Vazdar, Sandro Brusich, Ivo Darko Gabrić

**Introduction:** Trastuzumab is a humanized anti-HER2 monoclonal antibody, which is used for the immunotherapy of breast cancer. The most frequent manifestation of trastuzumab-induced cardiotoxicity is a reversible decrease in left ventricular contractility, without myocardial necrosis. It is quite often (occurs in 5 to 10% of patients) and in most cases, after the cessation of therapy, recovery of systolic function can be achieved. Rarely, there can be a progression to irreversible dilated cardiomyopathy. (1-3) **Case report:** A 55-year-old female patient with the breast carcinoma (T1N2MO, HER-2 positive) was done a segmentectomy of the left breast. After chemotherapy (ACx6) and radiotherapy (50 Gy), it was planned to start the immunotherapy with trastuzumab during 1 year in 3-week cycles. After the 4th cycle of trastuzumab, the patient started to feel weakness and dyspnea during a light physical activity. An echocardiographic examination showed a decrease of LVEF on 25%, significant mitral and tricuspid valve regurgitation and the high blood pressure in pulmonary artery. The treatment with trastuzumab was stopped. Therapy with ACE-inhibitor, beta-blocker and diuretic was started, what caused a gradual improvement of EF on 40% and reduction of MR and TR. Six years later the patient was admitted to University Hospital Centre Rijeka with symptomatic sustained ventricular tachycardia. Echocardiographic examination showed deterioration of LVEF on 25 to 30%. Coronarography was also done and it showed no pathology of coronary arteries. The patient was implanted a permanent cardioverter defibrillator. The further episodes of VT were not registered. Because of frequent paroxysms of atrial fibrillation, amiodarone and anticoagulant therapy were started. The patient is under regular controls of cardiologist and oncologist and has no signs of recidive of the cancer at the moment. **Conclusion:** In most cases trastuzumab-induced cardiotoxicity is reversible, but there is a small number of patients who develop irreversible dilated cardiomyopathy with all complications of that disease, including malignant ventricular arrhythmias. By timely and adequate treatment, it is possible to prolong the life and to improve the quality of life in that group of patients.

Martina Lovrić Benčić, Lada Bradić, Tea Šimonček, Gregor Eder, Kristina Krželj

**Introduction:** A lot of medications regularly used in everyday practice can prolong repolarization period. Unawareness of this deleterious side effect is especially pronounced with combination of such medications. (1-3) The aim of our study was to analyze mortality in patients with QT ≥ 500ms in correlation with QT prolonging medications used. **Methods:** 28320 ECGs were recorded and analyzed in a 22-month period. Atrial fibrillation and bundle branch blocks were excluded from the analysis. 680 (2.4%) of ECGs with QT≥ 500ms were analyzed manually. Data on patients and medications used was retrieved from the central hospital data registry and submitted for statistical analysis. **Results:** In a period of 301±163 days, all-cause mortality in the cohort of 680 patients was 21% (143/680). QT prolonging medications were grouped as follows: antiarrhythmics 31%, antidepressants 27%, antibiotics 21%, and other. Amiodarone and sotalol were the most common antiarrhythmics used, escitalopram and chlorpromazine the most common antidepressants, while azithromycin and erythromycin were the most frequently used antibiotics. Number of QT prolonging medications was shown to be a predictor of mortality, independent of age and gender (HR 1.23, 95%, CI 1.04, p<0.01). Patients on ≥2 QT prolonging medications had statistically significant increase in mortality (36% vs. 16%). **Conclusion:** Increasing awareness of QT prolonging medications and their effect on patient mortality is warranted, especially if more than two QT prolonging drugs are combined.

Vedran Velagić, Domagoj Kardum, Mislav Puljević, Borka Pezo-Nikolić, Martina Lovrić Benčić, Davor Puljević, Davor Miličić

**Introduction**: Ablation of atrial fibrillation (AF) by cryoenergy preserves intact extracellular matrix and the endothelium of the left atrium and appears to be less thrombogenic than radiofrequency energy (1). Current guidelines recommend anticoagulant therapy (OAC) for a minimum of 8 weeks after ablation of AF (2). There are no published data on the safety of acetylsalicylic acid (ASA) as the only antithrombotic drug after cryoballoon ablation of pulmonary veins. **Patients and Methods:** We performed a retrospective analysis of patients with paroxysmal atrial fibrillation that underwent isolation of pulmonary veins (PVI) by second generation cryoballoon (CB-A) in our institution. All patients had CHADSVASc Score 0 and were followed for a minimum of 3 months after the procedure. None of the patients before ablation were taking OAC. After the procedure, introduction of oral anticoagulants or ASA was left to the discretion of the operator. The cryoballoon procedure itself was carried out under local anesthesia with sedation as described previously (3). **Results:** A total of 16 patients (15 men, average age 51.2±9.8) were analyzed who met the inclusion criteria. Eight patients (50%) after the procedure did not receive OAC (ASA group), while the other half received new oral anticoagulants (5; 31.2%) or a vitamin K antagonist (3; 18.8%) (OAC group). The two groups did not differ considering the relevant clinical and procedural characteristics. In both groups, there were no thromboembolic, nor hemorrhagic events peri- and post- procedurally. Considering the other complications, we noted only one permanent and one transient phrenic nerve paresis in the OAC group (12.5%). In the mean follow-up of 7.7±3.3 months, 2 patients (12.5%) had recurrent atrial arrhythmias after “blanking” period (both in the ASA group). **Conclusion:** Anticoagulant therapy is recommended universally after PVI, but other than protection from thromboembolic events, it increases the risk of bleeding (most often local vascular complications). This small pilot study suggests that the hemorrhagic complications might be avoided without compromising the safety in patients with low basic thromboembolic risk when using second generation cryoballoon. Larger studies are needed to confirm the above findings.

Tomislav Krčmar, Kristijan Đula, Branimir Čulo, Mislav Vrsalović

**Introduction:** Aberrant right subclavian artery (ARSA, a. lusoria) is one of the most common congenital arch anomalies. The prevalence of ARSA ranges from 1 to 2%. ARSA originates from aortic arch as most distal branch and has it’s own aberrant pathway in mediastinum, most commonly retroesophageal. (1) **Case report:** 67-years old male patient with history of arterial hypertension and type II diabetes mellitus was admitted to our hospital for elective coronary angiography. During previous hospital stay coronary angiography using left radial access with implantation of two stents was done due to acute myocardial infarction. Patient was scheduled for another intervention on bifurcation lesion LAD/D1 (Medina 1,1,1). During procedure right radial access with 6Fr guiding catheter was used. The advancement of any cathethers into the ascending aorta was difficult, so we performed angiography of aortic root which revelead ARSA. The procedure was continued with some specific manipulation of guide wires and cathethers. After reaching a bifurcation lesion, stents were implanted using ‘’culotte’’ stenting technique (**Figure 1**). Postprocedural CT angiography was done to confirm ARSA. Exam showed absence of truncus brachiocephalicus, with common carotid ostium, regular position of left subclavian artery and anomalous ostium of right subclavian artery as most distal branch on aortic root which passes behind the oesophagus (**Figure 2**). Figure 1. Coronary angiography – 1. positioning of guiding cathether; 2. bifurcation stenosis LAD/D1; 3. final result after placement of the stents. Figure 2. CT of aortic arch – 3D reconstruction. Abberant right subclavian artery (ARSA) originates form aortic arch as most distal branch. **Discussion:** Congenital arch anomaly are mostly diagnosed sporadically during routine radiological scaning. The reason for that is probably the fact that patients are almost always asymptomatic. If there is some difficulties during coronary angiography and guide wires enter directly to the descending aorta when right radial access is used, ARSA should be considered. Interventions in patients with ARSA is complicated and often requires multiple wires and cathethers changes. Only two cases (1) of interventional treatment through ARSA was described in the literature. **Conclusion:** The existence of ARSA makes coronary angiography more difficult and demanding procedure, but could be done without switching to another vascular acsses.

Dubravka Crnković, Renata Habeković

Postoperative mental disorders are a common complication of cardiovascular surgery (1), with consequences that limit performance of patient’s everyday activities. Nursing role is important in postoperative recovery that refers to falls prevention and improving security environment. Safety improvement for cardiac patients who underwent surgical myocardial revascularization, and who developed cognitive disorders afterwards. Investigation of preoperative risks, intraoperative optimization of oxygenation of the brain, multimodal postoperative approach to the patient are effective methods. In prevention of fall and fall- injury the most important is to minimize risk factors and their number, obligation of training of all health workers in usage of preventive measures, registration of fall-related injuries and deaths in hospital. During patient restriction it is important to asses and plan the procedures that are least aggressive and stressful for the patient, without endangering his physical safety, as the health workers and others also. After the nursing diagnosis is set, the interventions are performed: first verbal calming, then medication restriction, and in the end physical restraint. During patient restriction it is essential to observe the patient and evaluate the possibility for cease the restraint, with mandatory documentation of all the procedures. Cardiac patients who underwent surgical myocardial revascularization, and who developed cognitive disorders afterwards, have an increased mortality and morbidity, longer period of healing, longer stay in hospital, greater need for tertiary care and lower quality of life than patients without cognitive impairment. The risk factors are numerous, improving preventive actions will recognize and optimize risk factors. With adequate prevention of falls and adequate calming, the rights and safety of the patients will be preserved. Cognitive disorders after surgical myocardial revascularization are still relatively common. These disorders lead to difficulties in conducting normal daily activities and significant reduction in quality of life. (2) With improvement of preventive actions, the risk factors will be recognized and optimized, which requires teamwork of the medical staff who cares for the patient. Patient safety will be achieved by using a standardized procedure and operating instructions for the prevention of fall and restraints of patient who is destructive or self-destructive. All health workers are trained to apply preventive measures for the safety of patients and patient restriction, and are required to keep patient safety, implement measures to prevent falls, and to protect their rights in case of application of restriction.

Martina Bunić, Marina Jelinić, Suzana Žmak, Nikolina Cvek

The first pacemaker was implanted in 1958 at the Karolinska Institute in Sweden, the patient was Arne Larsson when he was only 44 years old. His pacemaker was replaced 26 times with a new model, and the patient experienced old age. In Croatia, the first pacemaker was implanted in 1964 at University Hospital Centre Zagreb, and it was implanted by Dr. Miram Pasini. Indications for implantation of a permanent pacemaker in the last 20 years have greatly expanded, which affected the number of implanted pacemaker and contributed to the quality of patient’s life. (1) In the Pula General Hospital most common indications for pacemaker implantation were atrioventricular block and atrial fibrillation with ventricular brady arrhythmia. The implantation of permanent pacemaker started in 2010, and so far 190 are implanted. By 2010, at the Pula General Hospital were implanted only temporary electostimulators. The article presents our results in the mentioned period.

Dubravka Memić, Kristina Gašparović

**Introduction**: Anabolics are responsible for heavy disturbances in male and female organisms. Probability of heart attack is multiplying, anabolics are causing raise of blood cholesterol, development of atherosclerosis, liver damage, prostate hypertrophy, boldness, aggressive behavior, gynecomastia in men and ovulation disturbances in women. (1-3) **Case report**: Forty-eight-year-old male, admitted to Emergency Department for acute anteroseptal ST segment elevation myocardial infarction. He is intensively training in bodybuilding and taking four types of steroids intramuscularly (Testosteron 1 gr. 2 x weekly, Metan 2 x weekly, Trembolan 2 x weekly, Nordipin). On a day he was admitted to hospital, he went cycling for 30 km, he made bodybuilding training in gym for 45 minutes and played two matches of football. Late that night our patient started feeling chest pain, nausea, heavy breathing. He was admitted to hospital sixty minutes after the pain started. 12-lead ECG on arrival: SR 66/min, ST segment elevation for 3 mm in V2 to V5. Laboratory results: cTnT 994 ng/l, AST 247 U/l, ALT 219 u/l, CPK 3366 U/l, LD 346/l. Coronarography was made transradially and subocclusive thrombotic stenosis of proximal LAD with distal embolization was found. Percutaneous coronary intervention was made on LAD and was implanted with optimal result. After the Integrillin bolus LAD was reanalyzed with optimal result. Other coronary arteries were without stenosis. Post interventional period was without complication. Total resolution of ST segment was found on ECG. On echocardiography we found mildly reduced systolic function (LVEF 50%). After discharge from hospital patient went back to his old habits of taking steroids. Two months after hospital discharge he had another episode of chest pain but there were no signs of acute coronary syndrome. Seven days later his exercise stress test was unremarkable. **Conclusion**: Anabolic steroids use is widely spread among bodybuilders-amateurs. Anabolic-androgenic steroids are not available on free market but one can get a whole arsenal of these drugs illegally. Person determined to take steroids will do it one way or another, but we have to let these people know what the possible consequences are. Clinical studies on this matter should be made. It is our opinion that education in primary and secondary schools about steroids usage in our environment is necessity.

Marija Brestovac, Vlatka Rešković Lukšić, Blanka Glavaš Konja, Joško Bulum, Stela Bulimbašić, Mario Laganović, Martina Lovrić Benčić, Jadranka Šeparović Hanževački

**Introduction:** One of the most common causes of mitral chordae rupture is a myxomatous valve disease (1, 2) that causes acute volume overload and progressive heart failure. We present a patient with severe volume overload due to massive mitral regurgitation and acute glomerulonephritis. The key issue was to determine the precipitating event and which condition should be treated first. **Case report:** 60-year-old patient with known mitral valve prolapse (MVP) and mild mitral regurgitation (MR) presented himself in a local hospital as acute heart and renal failure. Two months prior hospitalization he had experienced intolerance to physical exertion, orthopnea, night sweats and fever up to 37.5 °C and has received antibiotics due to tonsillopharyngitis. At the time of admission, he was in functional NYHA IV status with acute nephritic syndrome that required intermittent hemodialysis. One week after, the patient was transferred to University Hospital Centre Zagreb in pulmonary edema, hemodynamically unstable, referred as a suspected endocarditis, although blood cultures were sterile. Three-dimensional transthoracic and transesophageal echocardiography revealed eccentric hypertrophy of the left ventricle with mild reduction of ejection fraction, left atrial enlargement (100ml), severe MR (regurgitant volume 65ml) from a ruptured chordae with complete inversion of the P1 (and prolapse of other segments). Vegetation as sign of endocarditis of the mitral were not found. Acute renal failure contributed to the volume overload of the left ventricle which caused a strain on the myxomatous mitral apparatus that primarily affected the chordae (**Figure 1**). Chordae rupture led to massive mitral regurgitation and acute heart failure. After initial stabilization, we tried to establish the cause of acute nephritic syndrome. Ultrasound examination of the kidneys found diffuse hyperechogenic thickening of the parenchyma. After serologic testing and renal biopsy, a rapidly progressive glomerulonephritis (GN) (pauci – immune cANCA positive) was diagnosed. Treatment included corticosteroid boluses, cyclophosphamide and plasmapheresis along with intermittent hemodialysis which significantly improved renal function so the patient was prepared for cardiac surgery. The patient underwent a mitral valve replacement with a mechanical valve. Postoperative period went uneventful, except paroxysmal atrial fibrillation successfully treated with electrocardioversion. Pathohistological analysis of the resected valve showed myxomatous degeneration without bacterial infiltration. A six months follow up revealed adequate patient recovery. Figure 1. Upper glomerul showing fibrocellular crescent formation, lower glomerul with cellular crescent formation, signs of acute tubular damage and interstitial inflammation. Three-dimensional ultrasound revealed rupture of mitral valve chordae with complete inversion of the P1. **Conclusion:** Acute glomerulonephritis progressed into renal failure, severe volume overload caused chordae rupture of the previously myxomatously altered mitral valve with a consequent development of the “circulus vitiosus”. In order to preserve the renal and cardiac function, glomerulonephritis was treated first and after stabilization, cardiac surgery was performed with an excellent recovery of the patient.

Ljiljana Kralj, Jelena Mikulan, Tina Novak

**Introduction:** Acute myocardial infarction (AMI) is a key component of the burden of cardiovascular disease. Several independent factors for coronary disease such as hypertension, hyperlipidemia smoking, and diabetes, as the most important risk factors. (1) The aim of the research is to obtain data on the incidence of AMI and present risk factors in order to plan further action. **Patients and Methods:** The study used data obtained from the Čakovec County Hospital (ČCH) Information System. The research deals with the number of patients with AMI treated in the Department of Cardiology with Coronary Care Unit of ČCH as well as the age, the sex of patients and the risk factors that influenced the development of the disease. The study used data from 2010 and 2015. **Results:** In 2010, the incidence of patients with AMI was 114 including 58% of men and 42% women, and in 2015, 104 of which 66% of men and 33% women. In the age group of 30-40 the number of patients in 2010 was 1.8%, and in 2015 was 1.9%. In 2010, there were 13%, and in 2015, 6.7% in the age group of 40-50 years. In the group of 50-60 years in 2010 was 16.7%, and in 2015 31.7% of patients. In the group of 60-70 years in 2010, it was 27.2% and in 2015, 22.1% of patients. In 2010 between the age of 70-80 years it was 23.7%, and 11.5% in 2015. In 2010, patients over 80 years it was 17.5%, and 26% in 2015. Hypertension as a risk factor was present in 90% of patients in 2010, and with 86% of patients in 2015. In 2010, hyperlipidemia was present in 85%, diabetes in 43%, smoking in 30%, and adiposity in 44% of patients. In 2015, hyperlipidemia was present in 54%, diabetes in 30%, smoking in 27%, and obesity in 33% of patients. **Conclusion:** It is to be concluded that the incidence is more common in middle age groups, whereby the higher incidence of the disease is to be found with male population. We therefore may conclude that the leading risk factors in investigated periods are the same. The obtained data can be used as a guideline for planning prevention programs for high-risk groups of people, especially middle-aged groups, in which the increasing incidence of AMI is present.

Jadranka Daskijević, Lidija Posavec

Usage of transradial approach for diagnostics and angioplasty of peripheral arteries in recent years is constantly growing. (1) The main limit to more significant application is the distance of the radial artery to the lower limb arteries. Arteries that are available for transradial access are: renal artery, superior mesenteric artery and the arteries of the pelvis while more distal arteries (e.g. a. femoralis superfitialis) according to the available materials are not. Advantages of the transradial approach in interventional cardiology in comparison to femoral are very well known. The usual position of patient in the Cath Lab for transradial peripheral intervention is with head forward. Most common used is left radial approach with if necessary femoral arteries in addition. The procedure starts with introducing diagnostic “pig tail” catheter. Before the angioplasty short introducer has to be replaced to a long one (commercially available introducer is 100 cm). In our Cat Lab from January 2011 to October 2016 for diagnostics and/or angioplasty of peripheral arteries 120 transradial procedures were performed. In 14 cases transradial approach was the only approach needed while in 36 cases femoral access was used as an additional to radial. All interventions were performed at the pelvic arteries. Nowadays the leading approach for catheterization of peripheral arteries is still femoral. According to rapid development of new materials that will enable interventions on more distal arteries the number of transradial dedicated Cath Lab’s for that purpose will rise.

Mijana Barišić, Ingrid Buljanović, Darija Bostijančić, Sabina Škifić

**Introduction**: Quality of life presents the patient’s subjective experience of living in all of it social, physical and mental aspects, and his ability to perform daily activities. Recently, it has been often cited that quality of life is more important than just extending life following a surgical procedure, which is often forgotten in clinical practice. Cardiac rehabilitation is an important set of procedures that not only enhance the physical capabilities of the patient, but also influence it’s mental and social standing. It is well known that the process of cardiac rehabilitation decreases psychological stress and, therefore, increases the quality of life. (1-4) The aim of the study was to determine the quality of life of patients enrolled into the program of stationary cardiac rehabilitation within three months from surgical cardiac revascularization. **Patients and Methods:** We enrolled subjects within three months from surgical revascularization. All subjects filled the health questionnaire SF-36 that is regarded by many authors as the most reliable tool to measure the quality of life in patients with ischemic heart disease. SF-36 questionnaire includes eight dimensions of health; physical function, restriction due to physical health, bodily pains, general health, vitality, social functioning, restrictions due to emotional problems and mental health. SF-36 also represents two general concepts of health, i.e. physical and mental health. **Results:** The study involved 100 subjects out of which 74 were male and 26 were female. Median age was 67 years. Revascularization only was performed in 85 subjects, while 15 subjects had both revascularization and a valve procedure done. The subjects had rated their total physical functioning quality with an average of 37.37±7.6 points, and the overall quality of mental functioning with 50.61±10.67 points. **Conclusion:** Evaluating quality of life garners more and more attention when dealing with the evaluation of disease influence, treatment effect and all the other factors that affect the patient’s life. A number of studies show that cardiac rehabilitation leads to significant improvement in the physical, mental and emotional aspects of patient lives.

Krešimir Kordić, Nikola Kos, Nikola Pavlović, Vjekoslav Radeljić, Nikola Bulj, Ivan Zeljković, Ines Zadro, Karlo Golubić, Diana Delić-Brkljačić, Šime Manola

**Background:** Direct current (DC) cardioversion is an effective method for converting atrial fibrillation (AF) to sinus rhythm. Current ESC Guidelines (1) suggest that transoesophageal echocardiography (TOE) should be performed to rule out atrial thrombi in patients undergoing DC cardioversion, unless adequate anticoagulation has been documented for 3 weeks or AF is 48 hours admitted to the Emergency department or Department of Cardiology at the University Hospital Centre “Sestre milosrdnice” Zagreb from January 2013 to May 2016 who underwent DC cardioversion were included in the study. Patients with AF lasting <48 hours were excluded from the study. All patients underwent preprocedural TOE to exclude LA thrombus regardless on anticoagulation status. The thromboembolic risk status was calculated for each patient using a CHA2DS2-VASc score. DC cardioversion was performed according to local protocols. **Results:** Total of 139 patients were included (106/139; 76% were male) with median age of 66 years (59-72). The overall prevalence of LA thrombi was 30/139 (21.6%). 49 patients were adequately anticoagulated for at least 3 weeks prior to the peri-procedural TOE (35.2%), whereas 90 patients were inadequately anticoagulated (64.8%). 12 patients with a detected thrombus were adequately anticoagulated with warfarin (N=11) or new oral anticoagulants (N=1) out of totally 49 adequately anticoagulated patients (12/49; 24.5%). 18 patients with a detected thrombus were inadequately anticoagulated (20%) (**Table 1**.) There was no statistical significance between prevalence of LA thrombi between adequately vs. inadequately anticoagulated patients (12 out of 49; 24.5% vs 18 out of 90, 20%, p=0.582) ### Table 1: Number of patients with left atrial thrombus in patients with low thromboembolic risk (CHA2DS2VASc score 0-1) and with high risk (CHA2DS2VASc score 2). | **CHA2DS2-VASc** | **TOTAL PATIENTS** | **TOTAL THROMBI (n)** | | --- | --- | --- | | **0-1** | 45 | 6 | | **2-6** | 94 | 24 | **Conclusion:** The prevalence of LA thrombi is high, even in patients who have been adequately anticoagulated. Further research with larger number of patients is needed to determine whether all patients should undergo TEE before elective DC cardioversion.

Vedran Velagić, Davor Puljević, Mislav Puljević, Borka Pezo-Nikolić, Davor Miličić

**Introduction**: Brugada syndrome (BS) is a genetic disease characterized by typical changes in the ECG and an increased risk of sudden cardiac death (SCD). Sodium channel blockers may unmask disease by inducing a typical Brugada type I pattern in the ECG (1, 2). Until recently, ajmaline was not available in the Republic of Croatia and ajmaline testing was not routinely conducted. **Methods:** From December 2015 ajmaline is available at University Hospital Centre Zagreb. Ajmalin test was indicated for individuals with a family history of SCD or unexplained syncope with type 2 Brugada pattern, or the family members of discovered proband. Testing was conducted in electrophysiologic (EP) lab using “EP Medsystems” hardware. Standard ECG settings were applied (25 mm/s, 1 mV/1 cm). In addition to standard precordial leads, V1 and V2 were recorded in the third intercostal space. Ajmaline was applied in a dose of 1 mg/kg within 5 minutes. After recording the basic ECG, traces were recorded at 0.7 mg/kg (3 min), 1 mg/kg (5 min) and washout (2 min after the administration). Test was defined as positive when a typical type I morphology in V1 or V2 leads with ST elevation of ≥2 mm occurred (3). In case of a positive test EP study was performed. **Results:** The study included 14 patients (7 men, mean age 35.9±15.7 years). Five of the 14 tests were positive (35.7%). Four BS probands were discovered, and one family member tested positive. Eight (57.1%) individuals were tested as family screening. In one of the 5 ajmaline positive patients (20%) EP study was positive, while 3 out of 5 (60%) patients positive BS received an implantable cardioverter defibrillator (ICD). Unexplained syncope or positive EP study alongside with positive ajmaline test indicated ICD implantation. One patient (33%) received inadequate ICD shock, due to a previously unrecognized atrial fibrillation with a rapid ventricular response. **Conclusion:** Brugada syndrome is an important cause of sudden cardiac death in patients with structurally normal heart. Ajmalin test allows detection of the disease and prevention of SCD in otherwise young healthy individuals. In addition to avoiding certain drugs, implantation of an ICD is a key part of the treatment of this syndrome.

Alma Agačević, Larisa Ščetić Mešan, Alma Sijamija, Nedžad Hadžić

**Objectives:** To evaluate an association between body mass index (BMI) and the cardiac autonomic activity by measuring heart rate variability (HRV), in obese and non-obese adults. **Patients and Methods:** Cross-sectional data of 116 participants (54.3% females, age: 54.27±15.58 years, BMI: 28.25±5.53 kg/m2) were included in analysis. HRV data were analyzed in time and frequency domains using customized program CARDICODE 300 (type:HT312), obtained from 24 hours, day and night-time segments of Holter monitoring. Analysed HRV indices were: total power (TP), low-frequency power (LF), high-frequency power (HF), square root of the mean squared differences of successive normal to normal intervals (rMSSD), standard deviation of normal to normal RR interval (SDNN) and the proportion derived by dividing number of interval differences of successive NN intervals greater than 50 ms by the total number of NN intervals (pNN50). BMI was obtained according to common calculation using anthropometric measurements (weight, height) (kg/m2). Participants were grouped according to BMI into non obese (BMI2, n= 80) and obese (BMI ≥30 kg/m2, n=36). **Results:** Mean values of all analyzed HRV parameters (SDNN, rMSSD, PNN50, TP, LF and HF) were lower in obese compered to non-obese participants (**Figures 1****,****2****,** and **3**). Statistically significant differences was found for SDNN, TP (p=0.002, p=0.01 respectively, using parametric independent samples t-test), and for pNN50 (p=0.036, using nonparametric Mann-Whitney U test). Figure 1. The values of SDNN (standard deviation of normal to normal RR interval) in obese and non-obese group. The solid horizontal line denotes the median value of SDNN obese and non obese patients, the box represents the 25th and 75th interquartile range. The whisker represents the minimum and maximum value. The median value of SDNN in the non obese group was 163.0163 ms. Range of minimal and maximal values in this group was 60.10-311.60 ms. The median value of SDNN in obese group was 135.6833 ms. Range of minimal and maximal values in this group was 74.50-225.80 ms, which is statistically significant lower (pth and 75th interquartile range. The whisker represents the minimum and maximum value. The median value of PNN50 in the non obese group was 18.7600%. Range of minimal and maximal values in this group was 0.70-72.60%. The median value of PNN50 in obese group was 11.6972%. Range of minimal and maximal values in group was 1.20-32.80%, which is statistically significant lower (pth and 75th interquartile range. The whisker represents the minimum and maximum value. The median value of TP in the non obese group was 13539.3000 ms*ms. Range of minimal and maximal values in this group was 1481.10-41059.90 ms*ms. The median value of TP in obese group was 10083.0500 ms*ms. Range of minimal and maximal values in group was 2566.00-25625.60 ms*ms, which is statistically significant lower (p<0.05). **Conclusion:** These results support previous findings (1, 2) that HRV parameters are decreased in obese adults suggesting reduced both sympathetic and vagal autonomic regulation of heart.

Hrvoje Jurin, Boško Skorić, Maja Čikeš, Daniel Lovrić, Jure Samardžić, Jana Ljubas Maček, Dora Fabijanović, Hrvoje Gašparović, Davor Miličić

**Introduction:** Short-term mechanical circulatory support using extracorporal membrane oxygenation (ECMO) is indicated in the acute and rapidly deteriorating stage of heart failure (HF) or cardiogenic shock. Although the use of ECMO is ubiquitously, there is still no solid medical evidence that it improves survival. (1, 2) Objective: To show the importance of identifying optimal candidates for ECMO implantation and critical thinking when establishing ECMO program. **Patients and Methods:** We conducted a retrospective analysis of patients with HF in whom ECMO was used in the period 2011-2016 (31 men, age 54 ± 14.8 years). The most common indication for ECMO was acute HF within the acute coronary syndrome (ACS) (13 cases), followed by the deterioration of patients status in the context of dilatative (10 cases), ischemic (7) and infiltrative (3) cardiomyopathy (CMP) and other (5). 31 ECMO implants were taken in the stage INTERMACS (ICS) 1, while the remaining units were installed in the ICS 2 stage HF. 19 procedures were conducted in patients in the active stage of cardiopulmonary resuscitation procedure (E-CPR). **Results:** Total number of survived patients is 8 (21%). In 20 patients (53%) ECMO was successfully removed. Statistically, significantly worse survival was in patients who had ECMO within the E-CPR (31%) compared to the others (74%, p = 0.042). With the aim of identifying optimal patient, the above observed period was further divided into two parts - the first (2011-2015) and the second part (2015-2016). At the beginning of 2015, a review of the outcomes (success of ECMO 38%) resulted in a change of paradigm: ECMO was often placed in the ICS 2 stage and in patients with ACS. Such analysis could conclude that the success of ECMO in the second period is even 83%. **Conclusion:** Extracorporal membrane oxygenation represents short-term support and is designed as a bypass method to complete healing or to other modalities of treatment. Because of this, it is important, when making a decision on setting up the ECMO, to be critical to their own abilities, and to the potential recovery of patients – perceive the whole situation and plan further steps of treatment.

Duška Glavaš, Davor Miličiċ, Duje Erceg, Branka Jurčeviċ Zidar, Katarina Novak, Stojan Poliċ

**Introduction:** The prescribtion of life-saving drugs in heart failure (HF) patients could vary in different populations depend on gender and left ventricular ejection fraction (LVEF). Some trials described different treatment of female and male patients. (1, 2) The aim of this study was to analyse the possible differences in prescribtion of life-saving drugs in patients with HF according to LVEF and gender. **Methods:** A group of 705 patients with diagnosis of HF (median age 74, 56.7% males-M, 43.3% females-F) who were hospitalized at University Hospital Centre Split were analysed; the data were part of CRO-HF Registry (3) (established in 2005). **Results:** Heart failure with preserved ejection fraction (LVEF ≥50%) had 40.7% patients (50.8% F, 33% M), and HF with reduced ejection fraction (LVEF <50%) had 59.3% patients. The women and the eldery were frequently in the group with preserved LVEF, and men in the group with reduced LVEF. Beta-blockers were prescribed in 65.1%, aldosterone antagonists in 47.7% and diuretics in 94.6% patients with LVEF ≥50%. Beta-blockers were prescribed in 67.7%, aldosterone antagonists in 59.6% and diuretics in 95.7% patients with LVEF <50%. There is no statistically significant difference in the frequency of prescribing beta-blockers and diuretics in HF patients with preserved and those with reduced LVEF (P=0.826, P=0.795). This difference was found in aldosterone antagonists (X (2)=6.389, df=2, P=0.033), which are more frequently prescribed to HF subjects with reduced LVEF. ACEi or ARB were prescribed in 79.7% HF patients with preserved and in 75.6% HF patients with reduced LVEF. However, there is no statistical significant difference in the prescription of ACEi and ARBs between these two groups (X (2)=1.294, df=2, P=0.524). There were no significant differences in regards to prescribing ACEi and ARBs in HF patients with preserved LVEF (ACEi: X (2)=0, df=2, P=1; ARBs: X (2)=2,223, df=2, P=0.329) and reduced LVEF (ACEi: X (2)=0.355, df=2, P=0.837; X (2)=0.29, df=2, P=0,867) according to gender. **Conclusion:** There is no considerable differences in prescription of life-saving heart HF drugs (ACEi, ARB, beta-blockers) with respect to preserved and reduced LVEF in our patients from Registry. Also, no differences were found regarding to prescription of ACEi and ARBs, in men and women. It will be interesting to analyse the morbidity and mortality of these groups in the period of follow-up.

Mario Udovičić, Mira Stipčević, Hrvoje Falak, Aleksandar Blivajs, Ivana Jurin, Davor Barić, Ognjen Čančarević

**Introduction:** Coronary-cameral fistulae (CCF) are infrequent anomalies which are in general incidentally found during diagnostic coronary angiography. The iatrogenic fistulas are secondary to non-surgical interventions (endomyocardial biopsy (EMB), permanent pacing and ICD leads) or cardiac surgical procedures. (1, 2) Cardiac transplantation is an effective therapy for end-stage heart failure, with allograft rejection as a common problem after transplant. Thus, EMBs still remain the gold standard for its surveillance. **Case report:** We present a case of a 43-years-old-male patient with dilatative cardiomyopathy who underwent an orthotropic, highly urgent heart transplantation in January 2012. The postprocedural recovery was complicated by a massive tricuspid regurgitation that required a tricuspid valve repair. The rest of the first year was uneventful, and the patient underwent 8 regular EMBs, which revealed no signs of cardiac allograft rejection. On a routine follow up angiogram one year after the heart transplantation a CCF between the right coronary artery and right ventricle was detected. Right-sided pressures were normal and there was no significant step-up in blood oxygen saturations from the right atrium to the right ventricle or pulmonary artery, so a conservative approach was chosen. Three years later the patient remains asymptomatic, with normal right sided pressures and cardiac output. **Conclusion:** We hypothesize that the fistula in this patient developed during one of these EMBs. Prevalence of a CCFs is more common in the transplant population compared with the general population (5%–8% vs 0.2%) due to repetitive EMB. Like in this case, CCFs are mostly asymptomatic, with a tendency to spontaneously resolve and have a benign clinical outcome, and only seldom require intervention.

Vedran Velagić, Davor Puljević, Mislav Puljević, Borka Pezo-Nikolić, Boško Skorić, Maja Čikeš, Davor Miličić

**Introduction**: Clinically significant supraventricular tachycardia (SVT) may occur after a heart transplant, and there are reports of successful catheter ablation in these patients. Individual cases of typical flutter, accessory pathways and atrioventricular nodal reentrant tachycardia (AVNRT) ablation are described in patients with transplanted heart (1, 2). **Case report:** Two years ago, 50-years-old patient underwent a heart transplant (biatrial technique) due to terminal dilated cardiomyopathy. The early postoperative course was complicated by persistent supraventricular tachycardia with the heart rate of 150/min, which was interpreted as an atrial flutter. Echocardiography described reduced systolic function of the graft with LVEF of 40%. Cellular and humoral rejection were ruled out and coronarography was normal. After drug-conversion to sinus rhythm left ventricular function gradually normalized. Tachycardiomyopathy due to SVT was set as the possible etiology of reduced graft function. During a recent hospital stay, long bursts of SVT were recognized. Arrhythmia was interrupted by adenosine, and telemetry recordings revealed that tachycardia begin with a long PR interval after which P waves disappeared and pseudoR pattern appeared in lead V1. Despite the antiarrhythmic therapy with propafenone and bisoprolol tachycardia recurred several times a day and lasted for several hours. We performed a standard electrophysiology study with 3 catheters and typical AVNRT was diagnosed. Radiofrequent ablation of the slow pathway was performed at a typical anatomical site. The fact that it was a heart transplant had no greater impact on catheter ablation. Procedure was performed without complications and arrhythmia did not reoccur. **Conclusion:** Supraventricular tachycardia may complicate the postoperative course after a successful heart transplant, and even be the cause of graft dysfunction. Catheter ablation is an effective in this group of patients, and to our knowledge has not yet been described in the Republic of Croatia.

Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Ivica Dunđer, Anto Lukenda, Božo Vujeva

**Background**: Multiple studies have demonstrated that implantable cardioverter-defibrillators (ICD) provide significant mortality and morbidity benefits to eligible patients irrespective of gender. However, female patients are less likely to receive this life-saving therapy and are significantly under-represented in cardiac device trials. (1, 2) We aimed to analyze the data on sex differences in our patients with ICD. **Patients and Methods:** This retrospective study included patients who were implanted with an ICD between 2011 and 2016. Demographic characteristics, clinical information, shock features and complications were analyzed. The study population was divided into two groups: early-era patients implanted before 2013, and late-era patients implanted after 2013. **Results:** Twenty-six patients (mean age 57.61 years, women 30.76%, median follow-up 32.37 months) were implanted with an ICD. Diagnostic categories were ischemic cardiomyopathy (57.69%; women 20%), non-ischemic cardiomyopathy (42.30%; women 45.45%). We performed implantation for primary prevention in 19.23% (0% in early-era and 27.77% in late-era patients; women 33.33%). 38.46% patients received shocks, 70% appropriate shock. Two patients died during the follow-up period. **Conclusions**: A significant increase in ICD therapy use was observed over time in all sex. The previously described sex disparities in ICD use were less significant by the end of the study period.

Mario Udovičić, Mira Stipčević, Sandra Jakšić Jurinjak, Željko Sutlić, Robert Blažeković, Igor Rudež, Davor Barić, Daniel Unić, Josip Varvodić, Boris Starčević

Mechanical circulatory support with a continuous-flow left ventricular assist device (LVAD) is despite heart transplantation (HTx) and pharmacological therapy a valuable treatment option in end-stage heart failure. (1) In this study we report results and outcomes of patients enrolled in the LVAD program established by the Department of Cardiac and Transplant Surgery and the Division of Cardiology of University Hospital Dubrava. We retrospectively examined the outcomes from 18 LVAD recipients between October 2011 and October 2016. The mean recipient age was 56.6±13.0 years, and 61% were male. Dilated cardiomyopathy was present in 56% and ischemic in 44%. Two patients (11%) were INTERMACS 1 and other two INTERMACS 2, 6 (33%) were INTERMACS 3 and 8 patients (44%) were stage 4. Device implanted the most was HeartMate II in 11 patients (61%), followed by HeartWare in 5 cases (27%) and most recently HeartMate III in 3 patients (17%). Of our patients 50% were destination therapy (DT), 17% are considered to be bridge to decision, 11% are bridge to candidacy, while 4 patients were bridge to transplant (BTT). All patients in DT group were ineligible for HTx, except one who declined HTx. Of the BTT patients 2 finally underwent HTx. Overall survival at 30 days, 6 months and 1 year on LVAD was 88%, respectively. Both deaths occurred during postoperative care within one month after implantation due to severe right ventricular failure. During follow-up, NYHA functional class improved from 3.8 ± 0.3 to 2.1 ± 0.5 at 12 months. Continuous-flow LVAD therapy is a viable treatment option for patients with end-stage heart failure ineligible for HTx or as a bridging strategy, with good survival and functional class improvement. An essential prerequisite for a successful LVAD program is careful selection and meticulous preparation of patients, as well as tight controls during follow up, and an excellent cooperation of cardiac surgeons, heart failure cardiologists and perfusionists.

Marina Deucht, Ivana Vujeva

**Introduction:** Chronic obstructive pulmonary disease (COPD) develops and progresses over the years. Disease characterized by productive cough, dyspnea, hypoxemia and hypercapnia presents a high risk of development of postoperative pulmonary complications in patients after cardiac surgery. (1, 2) Repeated endotracheal intubation is neither good nor desirable option therefore physiotherapy respiratory treatment and non-invasive ventilation (NIV) in any form is strongly recommended. (3) Objective: To show effectiveness of high flow oxygen therapy using physiotherapy respiratory treatment and AIRVOTM 2 device with nasal cannula in patient with poorly managed COPD who developed postoperative pulmonary complications after cardiac surgery. **Case report:** This case report presents an example of twenty days treating a patient who had clinically documented acute exacerbation of COPD following cardiac surgery. Respiratory distress, hypoxemia and moderate to severe hypercapnia were developed. In similar patients, along with early respiratory physiotherapy, NIV has become preferred modality of respiratory support because it increases tidal volume, maintains adequate alveolar ventilation, washes out carbon dioxide, reduces the work of breathing and eliminates majority of anatomical dead space. Chosen form of NIV is relatively new method of respiratory support using AIRVOTM 2 device. SPO2 and gasses O2 and CO2 from arterial blood parameter were compared before starting therapy and after few hours. High flows of heated and humidified mixture of air and oxygen delivered through nasal cannula resulted in significantly better and faster recovery of above mentioned patient. **Conclusion:** After several days of treatment with this method, patient was discharged home in stable cardiorespiratory condition with significant improvements in pulmonary and hemodynamic parameters. Implementation of adequately titrated high flow oxygen therapy with early respiratory physiotherapy treatment played an important role in successful recovery.

Tamara Kos, Katarina Arbanas, Petra Radovanić, Antonija Ašperger, Ana Gluhak

Mechanical ventilation can be invasive and non-invasive. Its purpose is to enhance gas exchange and it helps de-stress respiratory muscles. (1, 2) Non-invasive mechanical ventilation is a form of mechanical ventilation in which the respiratory support spans throughout the upper airway without invasive procedures such as intubation or tracheotomy. NIMV can be used in different ways, but CCU establish using full face mask or the oronasal mask. NIMV pros: active participation of the patient in the breathing process without the need for sedation, decreased choices of infection and the development of avoiding trauma, easier implementation of health care and easier communication. (1, 2) There are also contraindications for NIMV use such as: cardiorespiratory arrest, hemodynamic instability, disturbance of consciousness and patient noncompliance, increased secretion of the respiratory system, face traumas, pneumothorax, fresh upper gastrointestinal tract operation. Nurse role is continuous surveillance of the vital functions, respiratory status as well as the general condition of the patient. It`s also important to monitor the lab results and reacting on the time if they change. In this research we will present the complexity of the taking care of a patient on NIMV on an example of a 37-year-old female patient diagnosed with pulmonary edema.

Ana Bognar, Vera Šilić

Atrial fibrillation is the most common arrhythmia which affects 1% of general population. Ischemic stroke, as a thromboembolic complication, is 5-7 times more common in patients with nonvalvular atrial fibrillation in relation to general population and affects 23.5% of patients older than 80 years with more severe consequences then in patients with sinus rhythm. (1) Oral anticoagulants, varfarin and novel generation drugs, despite being the standard in treatment are low tolerable or contraindicated in some patients in which percutaneous left atrial appendage closure can be a method of choice in reducing the incidence of ischemic stroke.

Biljana Šego, Matija Vrbanić, Zoran Marić

Right heart catheterization (RHC) is an invasive diagnostic procedure that allows direct measuring of blood pressures and collection of blood samples from the caval veins, right atrium, right ventricle and pulmonary artery. It plays a central role in identifying pulmonary hypertension or in the evaluation of patients prior to heart transplantation. It also provides direct and essential hemodynamic data that can be used to determine cardiac output, evaluate intracardiac shunts and valve dysfunction. (1) Although RHC is invasive with possible risks of complications and evidence of potential harm associated with pulmonary artery catheterization in patients in critical care units has led to a decline in RHC over recent years, it still remains an important tool and the gold standard in acquiring important right heart hemodynamic data. This presentation covers the history of RHC, nurse role and challenges during right heart study as well as a representative case report from our daily practice. In order for the RHC to be successful, a meticulous previous preparation of the patient and the catheterization laboratory along with the active participation of the cath lab nurse during the procedure are essential. This requires a thorough understanding of the entire procedure as well as human physiology and pathophysiology.

Sanda Surina, Ana Traub

Coronary angiography is an invasive diagnostic method which uses a method of contrast radiography for the visualization of the coronary arteries that supply the heart with blood. (1) Although the technique is known since the 1970s, only in recent years the procedure is increasingly performed through the radial artery of the left or the right hand. (2) The frequency of this access in the University Hospital Rijeka is increasing. The procedure is comfortable for the patients because the sheath is removed from his hand immediately after the procedure. After the removal of the sheath, on the puncture point is positioned a plastic bracelet, which is removed after three to four hours. There is no need for the patient to rest still on his back, and he may be discharged from the hospital a day earlier than after the classical coronary angiography performed thru the femoral artery. Complications due to potential bleeding are also less dangerous. This paper aims to show the role and importance of nurses before and after the procedure of transradial coronary angiography and how this variant of the procedure is better and more comfortable for the patient.

Ivica Benko, Ivan Zeljković, Nikola Pavlović, Šime Manola, Vjekoslav Radeljić, Gordana Hursa, Sanja Keleković

**Case report:** 82-year-old man was referred to our hospital with symptomatic intermittent third-degree AV block with wide QRS complex. A permanent pacemaker implantation was planned. During the formation of the surgical pocket a ventricular asystole with present P waves developed and cardiopulmonary resuscitation (CPR) was immediately started. Axillary vein puncture was attempted during the CPR, but axillary artery was inadvertently punctured, and 7F lead introducer was inserted into the same artery. Dilator and the wire were left in place and additional axillary vein puncture was performed. Permanent pacemaker leads were successfully implanted during the CPR via axillary vein. The patient recovered completely after achievement of stable ventricular pacing. After that, a 7F sheath was replaced for a 7F side-valve sheath so that axillary artery angiogram could be performed. After verifying that there were no stenoses of bifurcations at the place of axillary artery puncture, the 8F AngioSeal vascular closure device was implanted. The puncture site was successfully closed with no residual bleeding and no compromitation of ipsilateral arterial pulses. **Learning objective**: The number of permanent pacemaker implantations being performed is increasing due to population aging. In third-degree AV block (complete AV block, no AV conduction), no atrial impulses reach the ventricles, and ventricular rhythm is maintained by a subsidiary pacemaker. Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (Class I recommendation). (1) The axillary venous approach has been associated with less frequent pneumothorax and subclavian crush syndrome. Fluoroscopic-guided, first rib approach to axillary vein access is the most effective means to access the vessel while minimizing the risk of pneumothorax. However, inadvertent punctures of axillary or subclavian artery happen an are managed by local site compression unless the sheath has been placed. In cases where the artery is cannulated with the sheath the risk of hematothorax is high and there are no guidelines how to proceed. We report on successful hemostasing using (off-label) AngioSeal closure device after inadvertent sheath placement in axillary artery.

Mihaela Ipša, Renata Čosić, Ivana Benković, Karolina Blažeković

Therapeutic hypothermia (TH) is a method of treatment for patients who have survived cardiorespiratory arrest with postresuscitation syndrome. (1) With invasive and non-invasive methods, we lower and control central temperature in order to reduce destruction processes in central nervous system caused by hypoperfusion and consequently ischemia, due to circulatory shock. European Resuscitation Council has introduced the above mentioned method as integral part of advanced life support. Since 2013, University Hospital Centre “Sestre milosrdnice“, Department of Cardiology have routinely used TH as the method treatment for postresuscitation syndrome. We will present the nurses role through TH on a case of a 32 – year old female patient who has admitted in Department due to cardiorespiratory arrest with underlying malignant ventricular arrhythmia. After successful cardiopulmonary resuscitation and regaining hemodynamic stability, the patient is transported to cardiac care unit of our facility where TH was applied.

Milka Grubišić

**Introduction:** Transcatheter aortic valve implantation (TAVI) is a method for replacing stenotic aortic valve with bioprosthesis through transfemoral, transaortic or transapical approach. TAVI is indicated in patients with symptomatic severe aortic stenosis who are not candidates for surgical aortic valve replacement due to high operative risk and comorbidities. (1, 2) With aging of population there are more patients with severe aortic stenosis who can benefit from this innovative method that has been introduced in clinical practice since 2002. The success of TAVI procedure is combined effort and organization of each Heart Team. It is important, that the nurse who is an indispensable member of the Heart Team is well acquainted with the procedure, approaches for implantation (transfemoral, transapical or transaortic), multiple comorbidities of patients as well as most common postoperative complications (total atrioventricular block, atrial fibrillation, bleeding or groin wound infection). Although these patients are not entirely different from most cardiac surgical patients, their age, comorbidities and procedure itself makes their care special. Comorbidities that make care for such patients more complex such as diabetes, chronic renal failure, chronic heart failure, chronic obstructive pulmonary disease are often present. **Results:** First TAVI procedure in University Hospital Dubrava was performed in 2011. Since then with this method we have successfully treated 67 patients (58% males) with mean age of 80 years. 30-day survival was 98%, and three-year survival is 83% **Conclusion:** As the success of TAVI is dependent on preoperative care of patient in sense of better clinical and nutritive status, the important role is on medical care with goal of lowering postoperative complications, less time in ICU and better quality of life of elderly patients. Continuous nurses’ education and exchange of experience in perioperative care of these patients yields better TAVI results, and proves the important role of nurse in modern TAVI Heart Team.

Nina Jakuš, Ivo Planinc, Boško Skorić, Dora Fabijanović, Hrvoje Jurin, Jure Samardžić, Željko Baričević, Hrvoje Gašparović, Bojan Biočina, Davor Miličić, Maja Čikeš

**Background:** Although right ventricular failure (RVF) is a common complication after left ventricular assist device (LVAD) implantation, its occurrence cannot be reliably predicted by an individual echocardiographic parameter or a simple combination of measurements. (1, 2) We aimed to identify easily obtainable measurements that may successfully predict RVF, combining markers of right atrial (RA) and right ventricular (RV) geometry with hemodynamic measurements. **Patients and Methods:** Preoperative echo examinations and right heart catheterization (RHC) data were studied for 48 consecutive patients (pts) (42 male, mean age 59.1±8.7 years), who underwent continuous flow LVAD implantation (80% HeartMate II/III, 20% HeartWare). A standard preoperative echo examination was performed, assessing RV and RA geometry and function (TAPSE (tricuspid annular plane systolic excursion), FAC (fractional area change)), while haemodynamic parameters were measured by RHC (**Table 1**). The Index of RV asymmetry (RVAi) was used as a novel marker of RV geometry, quantified as a ratio of the difference of the medial and lateral portion of RV area in relation to the total RV area at enddiastole (**Figure 1**). ### Table 1: Comparison of the ability of different measures of right heart morphology and function in predicting RVF after LVAD implantation. | | AUC | Sensitivity | Specificity | p-value | | --- | --- | --- | --- | --- | | RAVol/BSA+RVAi | 0.782 | 0.667 | 0.897 | 0.001 | | RAVol/BSA+RVAi+PVR | 0.722 | 0.444 | 1.000 | 0.001 | | RAVol/BSA+RVAi+TPG | 0.708 | 0.444 | 0.971 | 0.004 | | RAVol/BSA+RVAi+sPAP | 0.708 | 0.444 | 0.710 | 0.004 | | RAVol/BSA+RVAi+C.I. | 0.694 | 0.444 | 0.940 | 0.010 | | RAVol/BSA+RVAi+CVP | 0.637 | 0.333 | 0.941 | 0.054 | | TAPSE | 0.721 | 0.889 | 0.553 | 0.025 | | FAC | 0.384 | 0.444 | 0.324 | 0.258 | | TAPSE+FAC | 0.458 | 0.333 | 0.583 | 0.721 | [†] AUC - area under the curve; RAVol - right atrial volume; BSA - body surface area; RVAi - right volume area index; PVR - pulmonary vascular resistance; TPG - transpulmonary gradient; sPAP - systolic pulmonary artery pressure; C.I. - cardiac index; CVP - central venous pressure; TAPSE- tricuspid annular plane systolic excursion; FAC - fractional area change; P value for chi square test. Cut off values: RVAi– 0.33, RAVol/BSA - 50 mL/m2, TPG 12 mmHg, sPAP 70 mmHg, PVR 5 WU, C.I. 1.8 L/min/m2, CVP 12 mmHg, TAPSE 15 mm, FAC 20%. P value for chi square test. Figure 1. The Index of RV asymmetry (RVAi) is quantified as the ratio of the difference of the medial and lateral portion of RV area in relation to the total RV area at end-diastole. A more asymmetric RV will have a greater asymmetry factor, which is typically seen in preserved RV geometry. **Results:** 19% of pts presented with acute or chronic RVF following LVAD implantation. The RVAi was significantly higher (a more assymetric RV) in nonRVF patients: 0.40±0.13 vs 0.25±0.1, p<0.005. The combination of RAvol/BSA (right atrial volume indexed to BSA) and RVAi was confirmed as a superior predictor of RVF, while the addition of PVR maximized the specificity, yet impaired the sensitivity of the testing. The traditional markers of RV function, FAC and TAPSE, failed to successfully distinguish patients that would develop RVF (**Table 1**). **Conclusion:** Our study demonstrates that echocardiographic parameters of RV and RA geometry combined with RHC parameters of RV afterload may be simple yet reliable predictors of post LVAD RVF; however, limited patient numbers suggest further testing of this finding.

Mario Udovičić, Mira Stipčević, Dubravka Jonjić, Vanja Ivanović, Željko Sutlić, Igor Rudež, Davor Barić, Daniel Unić, Mislav Planinc, Boris Starčević

Despite all efforts in conservative medical treatment and the availability of mechanical circulatory support, heart transplantation (HTx) remains the gold standard and treatment of choice for advanced heart failure refractory to other methods. (1, 2) In this study we report single center experience and outcomes of patients referred to HTx by Division of Cardiology, University Hospital Dubrava. All patients underwent HTx at the Department of Cardiac and Transplant Surgery of University Hospital Dubrava, and were subsequently referred for follow up in close collaboration of two departments. We retrospectively examined the outcomes from 70 HTx recipients between 1995 and October 2016. The mean recipient age was 53.9±7.7 years, and 84% were male. Dilated cardiomyopathy was present in 51%, ischemic in 43% and 6% were other causes. Ten recipients (14%) were placed either on high urgent list of Eurotransplant or on national high urgent list. As induction of immunosuppressive therapy antithymocyte globulin was used, while for maintenance we apply the concept of individualized immunosuppression, using combinations of drugs according to patients’ needs and occurrence of side effects. Survival was studied using Kaplan-Meier curves. Early in-hospital mortality was 12%. The global survival rates at 1, 5, and 10 years are 84%, 79% and 73% respectively. The mean survival is 134 months (95% CI, 114.1-153.4). Early main causes of death were sepsis (44%) and primary graft failure (19%) while late causes were cardiac allograft vasculopathy (13%), malignant disease and other causes (25%). In University Hospital Dubrava, post-HTx survival rates at 1, 5, and 10 years are better than those reported by the International Society of Heart and Lung Transplantation, as a result of careful selection of patients and combined effort of all medical personnel involved in pre-, peri- and postoperative management. Our program strives and continues to adopt new strategies to improve the quality of life and life expectancy of our HTx recipients.

Nikola Bulj, Kristijan Đula, Vjekoslav Radeljić, Nikola Pavlović, Šime Manola, Diana Delić-Brkljačić

The results of recent studies indicate that the size of the left atrium (LA) directly correlates with the incidence of atrial fibrillation (AF). Patients who present with dilation of the LA at the time of the pulmonary veins isolation have an increased risk of AF recurrence and therefore an accurate assessment of LA size is of crucial importance in the selection of patients in whom this procedure is planned. Estimating LA volume provides more accurate measure of LA size which can be measured by a standard (two dimensional) and advanced (three-dimensional) echocardiography, computerized tomography and magnetic resonance. Given the widespread use in everyday clinical practice, and taking into account the high incidence of AF in the general population, echocardiography is emerging as the method of choice in the evaluation of the volume of the LA. The development of advanced echocardiographic technologies such as three-dimensional echocardiography has enabled additional insight into the anatomy and function of the LA. Studies indicate that the LA volumes measured by three-dimensional echocardiography correlate well with those measured by magnetic resonance imaging. On the other hand, it seems that conventional, two-dimensional echocardiography underestimates the volume of the LA and thus the risk of recurrence of patients treated with pulmonary veins isolation. (1) In this prospective pilot study we included 20 patients with AF scheduled to pulmonary veins isolation and compared the value of the LA volumes obtained by conventional two dimensional and advanced three-dimensional echocardiography.

Larisa Ščetić Mešan, Alma Agačević, Nedžad Hadžić

**Background:** Lyme disease (LD) is a tick-borne systemic infectious disease caused by the spirochete Borrelia burgdorferi. Clinical manifestations are various. Approximately 2/3 of patients have disseminated form of disease such as Lyme carditis (LC), present in <1% of patients in Europe. The cardinal manifestation of LC is a self-limited conduction system disease, most frequently involving the atrioventricular node and leading to varying degrees of AV nodal block. (1-3) **Case Report:** 48-year-old male without any known past medical or family history of cardiovascular disease presented with postural dizzines, presenting 2 months prior to admission. He was employed in the forest industry and reported allegedlly tick bite. Physical examination on admission did not revealed any skin rash. Initial blood work were within normal limits. EKG on admission showed second degree AV block, and RBBB. Holter EKG revealed AV conduction abnormalites; varying from second (Mobitz II) to third degree AV block. Echocardiography reveale hypokinesis of inferoposterior wall. An exercise stress test showed no signs of coronary insufficiency. Considering patients' risk of exposure to infected ticks and history of a tick bite, serological testings were performed, revealing elevated IgG levels for B.burgdorferi. After antibiotic therapy his heart block resolved. **Discussion**: The diagnosis of LC is challenging: it is usually made in the presence of other manifestations and stages of LD. In differential diagnostic rethinking we considered ischemic etiology which was eventually excluded according to course of the disease and serological findings. Patients suspected of having early disseminated or late disease are diagnosed clinically and serologically. Positive serologic testing is not by itself diagnostic, nor does negative serologic testing exclude the diagnosis.There is an overall consensus in favour of antibiotic treatment but dosage and duration of treatment is still unclear. **Conclusion:** The diagnosis of LC is not always obvious but may be diagnosed if there is a high degree of suspicion. Serological results should always be interpreted in the context of the patient’s clinical condition or course of the disease. This case also demostrated the importance of detailed history taking.

Ivo Darko Gabrić, Ljubica Vazdar, Angela Prgomet

**Purpose:** Cardiotoxicity is the most important side effect of trastuzumab, humanized monoclonal antibody to the HER2 protein, in use for immunotherapy of breast cancer. It is mainly manifested as a reduction in left ventricular contractility and the process is therefore mostly reversible. Temporary cessation of therapy often leads to recovery of cardiac function, and it is possible to continue the oncology treatment. (1-3) **Patients and Methods:** Since the beginning of 2009 until the end of 2015, we have analyzed 496 patients (pts) with non-metastatic breast cancer, treated with trastuzumab for one year with the standard adjuvant therapy protocol. Cardiotoxicity was defined with the reduction of left ventricular ejection fraction (LVEF) by 15% from the baseline or by 10% of normal values. Echocardiography was performed before the beginning and in three months period during therapy. If cardiotoxicity was established, pts were suspended from the trastuzumab therapy, with monthly echocardiography controls. **Results:** Cardiotoxicity was established in 54 pts (10.88%), most commonly in the first 6 months of starting treatment. Complete recovery of the cardiac function was found in 28 pts (51.85%) and they managed to finish trastuzumab protocol. Due to only partial recovery of the cardiac function or cardiotoxicity after readministration, trastuzumab therapy was not finished in 26 pts (48.14%). At the time when diagnosis of the cardiotoxicity were established average LVEF was 44.18% (20-52%). Pts with irreversible cardiotoxicity had significantly greater reduction of LVEF (15:27%, p<0.0001), higher mean serum level of NT-proBNP (134.7:92.3 ng/L, p=0.01) and in those pts trastuzumab was started earlier after prior chemotherapy (27:33.5 days, p=0.037). Only 6 pts had symptomatic moderate or severe heart failure. **Conclusion:** Trastuzumab cardiotoxicity occurs in about 10% of patients mainly in the first 6 months of therapy. It is more likely to be irreversible in pts with a more extensive decrease of the LVEF and a higher serum NT-proBNP level. The time between prior chemotherapy and administration of trastuzumab shorter than 30 days is more often associated with irreversible cardiac impairment.

Maja Vugrinec Mamić, Nuša Matijašić, Višnja Tokic Pivac, Jasminka Stepan Giljević, Gordana Jakovljević, Vesna Herceg-Čavrak

**Introduction:** Cardiotoxicity is a known complication of anthracyclines’ therapy in children treated for malignancies. Regular monitoring of cardiac function enables the identification of heart damage at subclinical level and timely therapeutic intervention. (1, 2) The scope of our study was to show the results of a multiannual echocardiographic follow-up of patients treated with anthracycline chemotherapeutic agents in our institution. **Patients and Methods:** We retrospectively analyzed a data obtained by echocardiographic monitoring of patients treated for malignant diseases in the Department of Oncology and Hematology, Children’s Hospital Zagreb from 2003 to 2016. The systolic function of the left ventricle was observed through shortening fraction (FS), while the diastolic function was studied through early (E) and late (A) ventricular filling velocities, their ratio (E/A) and the dimensions of the left ventricle correlated with age, gender and the anthracycline dose. **Results:** Overall 378 children were included in the study (average age 8.8 years (+7.36), 234 male (62%). From those patients most of them had a diagnosis of sarcoma, while hematologic malignancies were the second most prevalent diagnosis. The total cumulative dose of anthracycline was 2 in 67 (20%) patients, 207 (61%) patients received a dose of 101-300 mg/m2, and 66 (19%) patients received a dose higher than 301 mg/m2. None of the patients had clinical signs of heart failure, however 18% of children had subclinical heart damage, of whom 13.8% during the chemotherapy and within 6 months of its completion, and in 4.2% of patients the damage was still present or observed 6 months after the end of the chemotherapeutic treatment. There was a clear correlation between reduced systolic function and the anthracycline cumulative dose (p <0.01). Diastolic dysfunction was registered in 5% of patients, but no correlation was found with the cumulative anthracycline dose. A total of 55 (14.5%) children received cardiac pharmacotherapy, ACE inhibitors and/or beta-blockers. **Conclusion:** Subclinical damage of the systolic cardiac function in children treated for malignant diseases was present in a significant percentage and correlated with the cumulative dose of anthracyclines, despite the normal cardiac status, which requires regular cardiac monitoring of these patients.

Zdravko Babić, Joško Bulum, Sandro Brusich, Hrvoje Pintarić, Robert Steiner, Ivica Kristić, Ilko Vuksanović, Krešimir Štambuk, Jozica Šikić, Dražen Zekanović, Đeiti Prvulović, Damir Kozmar, Davor Miličić

**Introduction:** PLATO (“Platelet Inhibition and Patient Outcomes”) study demonstrated advantage of ticagrelor in comparison with clopidogrel in acute coronary syndrome in prevention of the cardiovascular death, myocardial infarction and stroke. These results introduced ticagrelor in the European Society of Cardiology and other guidelines for management of acute coronary syndrome. (1-3) **Patients and Methods:** This prospective multicentric observational study compares results of clopidogrel and ticagrelor in the treatment of acute ST-elevation myocardial infarction (STEMI) on national level. Authors investigated acute STEMI patients treated with primary percutaneous coronary intervention (pPCI) in 11 Croatian pPCI centers between June 1st 2015 and May 31st 2016. Patients were divided in three groups: the ticagrelor group, converted group (treatment initiated with clopidogrel and replaced with ticagrelor), and clopidogrel group. **Results:** In 1947 investigated acute STEMI patients treated with pPCI investigators revealed statistically significant better results of treatment (postprocedural TIMI 3 flow, intrahospital mortality) with statistically significant less clinicaly significant bleeding in those treated with ticagrelor in comparision with those treated only with clopidogrel. **Conclusion**: These findings may be considered as real-life confirmation of similar results obtained in randomized studies.

Boris Starčević, Ante Lisičić, Mario Sičaja, Mario Udovičić, Vanja Ivanović, Ana Jordan, Davor Barić, Daniel Unić

Percutaneous mechanical circulatory support (MCS) has been used to stabilize patients in cardiogenic shock and provide hemodynamic support during high-risk percutaneous coronary interventions (PCI) for several decades. (1, 2) We report our recent experience with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use in patients with HR-PCI and cardiogenic shock. Since 2014 thirteen patients (11 males, mean age 66.8 ± 11.5 years) have been referred to coronary angiography with ECMO support in our institution, 10 patients in cardiogenic shock and 3 as elective high risk (HR) PCI. The mean SYNTAX score was 24.1 ± 11.0. Eleven patients underwent a successful PCI, one patient was successfully bridged to emergency CABG and another to a high urgent heart transplant. Median time spent on ECMO was 24 hours. Six patients suffered in-hospital major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of death, acute myocardial infarction (MI), stroke, pulmonary embolism or further need for revascularization, all of them in the cardiogenic shock group. Up to October 2016 eight patients survive, all three from the elective HR-PCI group, who also did not suffer any MACCE, while in the cardiogenic shock group one-year survival rate was 50%. Although strong and convincing evidence is still lacking, VA-ECMO support represents a viable option for delivery of care and support in patients with HR-PCI and cardiogenic shock. In HR-PCI identification of critical patients and careful pre-procedural planning are paramount. In patients in cardiogenic shock, it is essential to initiate the support early enough. Introduction of VA ECMO as MCS in our catheterization laboratory for use in complex clinical situations has dramatically improved the survival of the most critical patients.

Nikola Kos, Krešimir Kordić, Šime Manola, Vjekoslav Radeljić, Nikola Bulj, Ivan Zeljković, Ines Zadro, Karlo Golubić, Diana Delić-Brkljačić, Nikola Pavlović

**Background:** Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation of atrial fibrillation (AF). Current European Heart Rhythm Association Guidelines suggests that all patients undergoing catheter ablation should be anticoagulated for three weeks prior the procedure. (1) All patients with high thromboembolic (TE) risk or in AF should undergo transesophageal echocardiography (TEE) to exclude left atrial thrombus (LAT). Whether patients with low TE risk (estimated with CHA2DS2VASc score) who are in sinus rhythm need TEE routinely remains unclear. The aim of our study was to determine the incidence of LAT in patients undergoing PVI regardless of their risk for TE event. **Patients and Methods:** Patients hospitalized at the Departmet of Arrhythmology, University Hospital Center “Sestre milosrdnice” Zagreb from January 2013 to May 2016 undergoing PVI were included in the study. Following routine protocol all patients underwent a pre-procedural TEE to exclude LAT. The TE risk was calculated for each patient using a CHA2DS2-VASc score. **Results:** A total of 241 consecutive patients (mean age of 59±11 years, 76% male) were included in the study. The overall incidence of left atrial thrombus was 39/241 (16.18%). As shown in **Table 1**, 129 patients had CHA2DS2VASc score 0 or 1 (low TE risk) and 18 of them (18/129; 13.95%) had LAT detected (46.15% of all patients with thrombi). 12 patients with LAT in a low TE risk group were adequately anticoagulated while 8 of them were in sinus rhythm. There were 6 low TE risk patients who were adequately anticoagulated and were in sinus rhythm who had LAT (4.5% of low risk patients, 2.4% of all patients). There was no difference in the LAT incidence between the low and high risk groups (13.95% vs 18.75%, p= 0.29). ### Table 1: Incidence of left atrial thrombus in different thromboembolic risk groups. | **CHA2DS2-VASc** | **Number of patients** | **Number of patients with thrombus** | **%** | | --- | --- | --- | --- | | 0 | 57 | 7 | 12.28 | | 1 | 72 | 11 | 15.28 | | 2 | 52 | 8 | 15.38 | | 3 | 43 | 8 | 18.60 | | 4 | 7 | 1 | 14.2 | | 5 | 5 | 3 | 60 | | 6 | 0 | 0 | 0 | | 7 | 5 | 1 | 20 | | **Total** | **241** | **39** | **16.18** | **Conclusion:** Due to the presence of thrombi in all TE risk groups, even in patients with a low TE risk who were in sinus rhythm and were adequately anticoagulated, TEE (or other imaging modality) could be routinely performed in all patients prior to planned PVI to exclude LAT. The main limitations of the study are relatively small number of patients, lack of standardized follow up of patients with vitamin K antagonists and small proportion of patients on novel anticoagulants. Also, INR data for some patients are lacking which could have influenced the results significantly.

Dorijan Jagačić, Ladislav Pavić, Petar Medaković, Kata Ćorić, Dražen Lovrić, Mladen Jukić

Myocardial bridging (MB) is an anatomical anomaly which is increasingly detected using coronary CT angiography (CCTA). The clinical significance of MB has been still insufficiently explored, moreover there are descriptions of this phenomenon in association with acute coronary syndrome, a variety of rhythm disorders and sudden deaths. After the breakthrough of the invasive coronary angiography (ICA), at which the so-called “milking”-effect may be observed, most commonly in the middle segment of the left anterior descending artery (LAD), in vivo diagnosis could be established. However, the ICA diagnosis showed a great discrepancy compared to post mortem diagnosis in this matter. According to some data, MB-prevalence is up to 50% (CCTA), as well as on autopsy studies, while at ICA this phenomenon has been observed in merely 5-10% of all cases. The presented case refers to a family, with both a father (56) and a son (26) being diagnosed with MB. They both had an unexplained recurrent thoracic pain i.e. palpitations. Thus, the son felt a sharp pain in the right chest whereby the pain spread in the mediastinum, across the right shoulder and the right side of the neck. In addition, he complained of paraesthesia in his extremities during physical activity. As regards his family medical history, on his mother’s side there were some cases of heart diseases. Patient’s general health status was normal. There were no signs of heart failure with a blood pressure of 140/80 mmHg. The standardized ECG in the emergency room was within normal ranges. Lab tests were within normal ranges, as well as chest X-ray. Both neurological and multiple cardiological examinations and findings were normal. The pain in the chest with a normal echocardiography led also to CCTA of the father and subsequently of the son. Shallow MB of the middle and distal LAD has been found in both patients. Additionally, insignificant plaques have been found in the LAD of the father (**Figures 1****,****2****,****3****,****4** and **5**). Both patients are stable under beta-blockers. In summary, we regard these symptoms to be associated with MB. Figure 1. Comparison of the myocardial bridging respectively atherosclerotic lesions of father and son. Figure 2. Calcified plaques in the proximal segment and myocardial bridging of the middle and distal part of the left anterior descending artery (father). Figure 3. Non-calcified plaques in the proximal segment and myocardial bridging of the middle and distal part of the left anterior descending artery (father). Figure 4. Myocardial bridging of the middle and distal part of the left anterior descending artery without atherosclerosis (son). Figure 5. Myocardial bridging of the middle and distal part of the left anterior descending artery without atherosclerosis (son). Owing to the collected data (1-3), we may conclude that MB should also be considered in association with cardiac symptoms that otherwise cannot be explained. The genetic basis of MB in certain families remains a topic of future research.

Nevenka Vila, Tanja Mikulandra

**Introduction:** Heart failure is a clinical syndrome which occurs as a result of disorder between structure and function of the heart. Incidence increases with age so that 10% of population above 70 years old have chronic heart failure. (1) Self-care is important form of nonpharmacological treatment and it includes patients behavior with regard to keeping a stable physiological condition and recognition of signs of disease progression. Aims: Examine the impact of education on self-care of a patient with chronic heart failure. Examine the impact of education in comparison with age, gender, family status, place of living, level of education and number of hospitalizations. Examine in which aspects of self-help education had greatest influence. **Patients and Methods:** Study included 50 patients who were treated at Department of Cardiology in University Hospital Centre Osijek, 14 of whom died in the first phase of the study. The remaining 36 patients, from whom 23 (63%) were males and 13 (36%) were females, age between 51-90, took part in the study. European Heart Failure Self-care Behavior scale (EHFScB-9) questionnaire and a specific questionnaire created for this research were used as instruments of the study. **Results:** Significantly higher average result after education 46.67±6.01, from minimal 34 to maximal 58 points in comparison with average total result before education 33.94±6.85, from minimal 23 to maximal 49 points (p<0.001). Looking separately inside subgroups both males (n=23) 63% and females (n=13) 36%, city inhabitants (n=19) 52% and village inhabitants (n=17) 47%, examinees with elementary (n=18) 50% and highschool education (n=18) 50%; and examinees who live by themselves (n=13) 36% and who live with somebody (n=23) 63%; every subgroup for themselves had statistically higher and better results after education with p<0.001. Respectively, there is no significant difference in progress after education between males and females (p=0.373), nor between those who live in the city or in the village (p=0.485), nor between those who have elementary school versus those with high school education (p=0.639), nor in those who live alone versus those who live with someone (p=0.415). There was no correlation between age and progress in overall number of points (p=0.704) neither between number of hospitalization and progress in overall number of points (p=0.261). **Conclusion:** Education statistically significantly influences the overall results of patients, both if we examine them together or independently as subgroups according to gender, age, place of living, level of education, living alone or with someone, and according to the number of hospitalizations. There were no significant differences between the overall results before and after education with regard to gender, age, number of hospitalizations, place of living, level of education or social status. Patients with chronic heart failure need the education from nurses that is orientated toward self-help and self-control.

Marina Klasan, Doris Ivetac, Vesna Babić

Any sudden, momentary loss of consciousness, due to circulatory disturbances in the brain is called syncope. (1) The management should be started as soon as possible after the event. As more time passes since the episode, the harder it is to determine the diagnosis. (2) If the syncope results in injury or it recurs especially in a short period of time, a more extensive elaboration and management is needed. A medical history provided by witnesses is useful and must be obtained as soon as possible. In patients with suspected arrhythmia, myocarditis or ischemia as a cause of syncope, hospitalization is required. Other patients can be managed ambulatory. The diagnosis of syncope is set on the basis of medical history, physical examination, electrocardiogram, continuous monitoring and additional non-invasive and invasive procedures. The treatment is individual, and depends on the cause of syncope. In our presentation, we will highlight the importance of nurses in the management of the patient during the process of determining the diagnosis and treatment.

Senka Pejković, Biljana Šego, Sanja Piškor, Zoran Marić

**Introduction**: Percutaneous coronary intervention (PCI) is today a standard therapy of patients with coronary heart disease. So far several factors causing the complications of PCI have been identified. (1-4) This study presents types and frequency of complications after PCI (both urgent in the setting of acute coronary syndrome, and elective due to stable coronary disease), as well as potential predictors, that can identify elevated risk situations. **Patients and Methods**: This study enrolled all patients who underwent PCI in University Hospital Dubrava over a period of one year. Data of 727 patients was analyzed (523 men and 204 women). 354 patients underwent a primary PCI, and 377 patients underwent an elective or delayed PCI. **Results**: Most numerous were the patients between 60 and 71 years of age (30.3%), and least numerous those >80 years (6.3% patients); male were 71.9% patients. Acute ST segment elevation myocardial infarction was present in 48.7% patients, and they underwent primary PCI. In general, 18.9% men and 21.1% women have experienced some kind of complication during the hospitalization: 9.9% had bleeding, 2.1% febrility, 5% arrhythmia, 8.7% pain, 6.7% hematoma and 3.35% patients died. 24.2% patients experienced some other form of complication. **Conclusion**: PCI is an effective method for treating patients with coronary heart disease. Results show a real picture of incidence a type of PCI procedure as well as complications and adverse events after procedure, and most results are similar to those previously reported in literature. Risk factors for complications which are identified comprise female gender, age over 60 years and presence of other comorbidities. Nurse is an essential factor for timely detection and prevention of complications in patients undergoing PCI.

Lidija Ban, Ivana Tomašić, Božica Leško, Vesna Slonjšak

Heart failure is a complex clinical syndrome that regardless of the diseases’ etiology is characterized by inability of the heart to receive and pump the blood thus meeting the metabolic needs of the body. Heart failure treatment often requires the introduction of amiodarone into therapy, which can, in some patients, cause the hyper production of thyroid gland hormones. (1, 2) Thyroid gland controls the metabolism through hormones (the way the body uses energy, breathing, heart rhythm, systemic nervous system, body weight, body temperature and many other functions in the body). Therefore, the occurrence of hyperthyroidism in patients with heart failure leads to progression of heart failure and further deterioration of patient health. Nurses’ care for such patients is more complex and involves timely implementation of therapy, daily physical examination, control of vital functions, keeping the balance of fluids, weight control, telemetric monitoring, psychological support. It is of utmost importance to recognize the changes in any of the mentioned segments so therefore enabling timely intervention and in doing so helping the patient to achieve the regression of hyperthyroidism and thus ‘stabilization’ of heart failure.

Đurđa Vlajković, Božica Leško, Cecilija Leporić

The leading causes of limb ischemia are atherosclerosis, inflammatory artery diseases and diabetes. (1) Claudications, a sudden or progressive reduction of walking distance, intense and lasting pain as well as non-healing ulcer formation are the leading symptoms. Maintaining goal values of coagulation and biochemical parameters, prevention of possible contrast allergic reactions, antimicrobial prophylaxis and effective analgesia together with the preparation of intervention fields are essential in preparing patients before the intervention. Post-intervention management of bleeding, pain and renal failure as well as post-intervention monitoring of the affected extremity are the main determinants of nursing interventions. The imaging methods performed at Clinic for Cardiovascular Disease include CT- and MRI- angiography, peripheral angiography via trans-femoral, trans-brachial and trans-radial access. The nurse with all of her knowledge, skills and competence is an active participant in all phases of the above medical intervention, preparation and management.

Jure Samardžić, Hrvoje Jurin, Boško Skorić, Miroslav Krpan, Ivo Planinc, Marijan Pašalić, Nina Jakuš, Maja Čikeš, Davor Miličić

**Introduction**: Early targeted temperature management (TTM) below 36°C in patients who did not recover conscience after out of hospital arrest is crucial to reduce central nervous system damage. Myocardial infarction is often a cause of cardiac arrest and warrants dual antiplatelet therapy. Decrease in body temperature affects platelet reactivity and there are no special guidelines for antiplatelet management in this clinical setting. It is unclear how different TTM methods affects platelet reactivity. (1, 2) Herein, we compared platelet reactivity (PR) in two smaller cohort groups of patients with acute ST segment elevation myocardial infarction who underwent non-invasive and invasive TTM after cardiorespiratory arrest. **Methods**: We analyzed PR changes in patients during first three days using Multiplate function analyzer and arachidonic acid as platelet aggregation agonist. **Results**: Two and three and patients underwent invasive and noninvasive TTM, respectively. All but one had PR measurement on all three days. One patient in the invasive TTM group died on the second day and had no PR measure on day three. Patients in the noninvasive TTM group had higher PR levels (**Figure 1**). Figure 1. Platelet reactivity changes in AU*min - A) ASPItest (arachidonic acid as agonist) B) ADPtest (adenosin diphosphate as agonist). Blue lines - noninvasive temperature control; red lines - invasive temperature control. **Conclusion**: Data shows that there is a difference in PR in patients undergoing different methods of TTM after cardiac arrest and myocardial infarction. We hypothesize that this could be due to direct effect of invasive body temperature lowering on platelets which decrases their sensitivity on aspirin. Further investigations are needed to confirm our results, including measurements of ADP-dependant PR which is inhibited by P2Y12 antagonists.

Martina Osredečki, Igor Ivaniček, Zrinka Paić, Ankica Josipović, Sanja Piškor

The use of extracorporeal membrane oxygenation (ECMO) in interventional cardiology is used in cases of cardiogenic shock and as a support in high-risk percutaneous coronary interventions. Care of patients with ECMO support is a complex process that requires a lot of knowledge and skills of health professionals and a team work in order to provide quality patient care. (1) In this study we will present a case of a 57-year-old patient who was hospitalized at the Department of Cardiology University Hospital Dubrava because of acute myocardial infarction with the presence of comorbidities: cardiac decompensation, liver lesions, diabetes. The patient was hemodynamically and rhythmically unstable which includes the use of specific nursing interventions according to established nursing diagnoses and nursing medical problems. Treatment of patient continues in the direction of emergency percutaneous coronary intervention with ECMO support. In the treatment of this patient highlighted is the teamwork of medical professionals. The patient is discharged after 42 days of hospitalization.

Darko Kranjčec

Bicuspid aortic valve has often familiar clustering, consistent with autosomal dominant inheritance with incomplete penetrance. Bicuspid aortic valve is frequently associated with diseases of aortic root. According to some authors 52% percent of young people with bicuspid aortic valve have aortic dilatation regardless of significant valve dysfunction. (1) **Case**: 46-years old patient with anamnesis of several years of arterial hypertension was referred to transthoracic echocardiography (TTE) as a part of screening for hypertensive heart disease. His blood pressure (at rest) was well regulated with valsartan 80mg. He was on every day heavy-weight lifting trainings for a years. That was his first echo exam in his life. Exam showed bicuspid aortic valve with ectasia of aortic root (40 mm) and marked aneurysm of ascending aorta (till 58 mm as visible by TTE). As a consequence of bicuspid valve, or aortic root dilatation (or both) he had moderate aortic regurgitation as well. Patient was told to stop heavy weight lifting immediately and make CT aortography. CT showed dilatation of aortic root and ascending aorta till 65 mm (**Figures 1** and **2**), while aortic arch and descending aorta were not involved (**Figure 3**). Patient was referred to cardiothoracic surgeon and operated. Figure 1. Chest X-ray. Figure 2. CT aortography – scan at the level of ascending aorta. Figure 3. CT aortography – scan at the level of aortic arch. Patient has three sons, two of them trained in heavy weight lifting as well. To all of them an transthoracic echo was done. Oldest son was 24 and was not involved in training. He had normal TTE result. Other son, 22 years old, involved in heavy weight training had bicuspid aortic valve on TTE (without significant stenosis or regurgitation) with normal diameter of aortic root/ascending aorta. He was counseled to refrain from heavy weight lifting and to make echo controls on annual basis. Third and the youngest son was 20 years old (also active in body building). TTE showed tricuspid aortic valve, although with slight irregularity of aortic valve leaflets and mild aortic regurgitation. Aortic root and ascending aorta were normal. He was told to repeat echo examination in three years.

Marijana Gačić, Marija Renić, Ivana Martinović, Ana Ljubas

Aortal stenosis is quiet often valvular disease, especially in elderly people. The gold standard in medical treatment is surgical aortal valvular replacement. (1) Although, people of advanced age and with multiple comorbidities often have high surgical risk. That is the main reason why TAVI procedure is developed as optimal treatment in that category of patients. TAVI is less invasive and have less perioperative risk than classical cardiosurgical procedure. (2) The role of medical nurse is very important in all aspects of medical care. The nurse has important role in coordination with multidisciplinary team before TAVI procedure and later in education of the patients and family members. Although TAVI procedure is less invasive, the postprocedural treatment is demanding and quiet complicated. It is very important to monitor hemodynamic status and taking into considerations all the comorbidities. Early mobilization and complications are important aspects in medical care. Whereas some patients have diastolic dysfunction and hypertrophic left ventricle it is important to follow adequate volume status and optimize cardiac output and systemic perfusion. Many of this patients have chronical renal impairment and optimal postprocedural hydration is demand as protection of acute renal injury. ECG monitoring and neurological status changes are also required. TAVI procedure is less invasive method in high grade symptomatic aortal stenosis after which patients are very soon mobile, the medical health care is quiet demanding and complicated. Because this is new medical approach in treatment, medical nurses should be adequately familiar with risks, advances and possible complications of this procedure. New researches will make much stronger roll of medical nurses in multidisciplinary team approach and give more quality in medical treatment of this patients.

Vlatka Rešković Lukšić, Jana Ljubas Maček, Zvonimir Ostojić, Sandra Večerić, Sanja Ceković, Blanka Glavaš Konja, Martina Lovrić Benčić, Joško Bulum, Jadranka Šeparović Hanževački

**Background**. In selection patients for transcatheter aortic valve implantation (TAVI), one of the most important measurements is aortic annulus dimension for optimal valve type selection and sizing, being crucial for the procedure success. (1) The aim of the study is to validate different echocardiography tools versus CT for aortic annulus measurement. **Methods and Results**. 24 consecutive patients who underwent successful CoreValve implantation in University Hospital Center Zagreb were enrolled. Selection of valve dimension was based on CT measurements of aortic annulus (mean diameter and perimeter). All patients underwent transthoracic echocardiography (TTE) prior procedure. 2D transesophageal (TOE) echo was performed in all but one patient (due to contraindications), and 3D TOE in 13 pts. Data was analyzed retrospectively, investigator being blinded for the implanted valve size. Annulus diameter was measured from 2D TTE parasternal view, 2D TOE (120°) and 3D multiplane views. 3D TOE perimeter derived annulus diameter was also obtained. 4 CT examinations were incongruent with the implanted valve size. Compared to CT measurements, only 9/24 (37.5%) pts were correctly measured by 2D TTE and 15 pts (62.5%) were undersized. For 2D TOE compared to CT, 11/23 (47.8%) measurements were correct, 10 (43.5%) undersized and 2 (8.7%) oversized. 3D TOE compared to CT was correct in 10/13 (76.9%) pts, 1 (7.7%) being undersized, and 2 (15.4%) oversized. The majority of patients were implanted CoreValve size 26 (13 pts) and 29 (7 pts) – multimodality measurements are shown in **Table 1**. 2D TTE and TOE underestimate annulus size compared to CT for 1-3mm. 3D TOE measurements differ from CT for <0.5mm. ### Table 1: Comparation of the multimodality measurements of aortic annulus dimensions for two most used CoreValve sizes (26 and 29) | | **CT** | **3D TOE** | **2D TOE** | **2D TTE** | | --- | --- | --- | --- | --- | | **CoreValve 26** | | | | | | **Mean annulus diameter** | 22.1 | 21.5 | 20.91 | 20.4 | | **Perimetry derived diameter** | 22.2 | 22.6 | | | | **CoreValve 29** | | | | | | **Mean annulus diameter** | **24.1** | **23.7** | **21.6** | **21.4** | | **Perimetry derived diameter** | 24.6 | 26.6 | | | **Conclusion.** CT, as well as 3D TOE have been shown to provide more accurate aortic annulus geometric measurements. Unlike 2D TTE and TOE they, especially combined, can estimate correct valve size and overstep pitfalls, even when aortic annulus is oval shaped, irregular or severely calcified.

Enes Abdović

**Introduction**: Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with significant morbidity and mortality. An increasing interest exists in identification of noninvasive markers of predisposition to AF. Several ECG and echocardiography-based predictors of AF, such as interatrial block (IAB) and left atrial enlargement (LAE) are well known. (1-3) Aim of this study was to analyze which noninvasive predictors may help identify patients at risk of developing AF. **Patients and Methods**: This was a case-control, observational study which included 9,125 patients evaluated in inpatient or outpatient setting from 2000 to 2016. All subjects underwent 12-lead ECG and transthoracic echocardiogram. AF was defined as an irregularly ECG rhythm without identifiable P wave. IAB was diagnosed if P-wave duration was ≥120 ms. LAE was diagnosed in the apical 4-chamber view with LA area ≥25 cm2. Demographics and medical history were reported. Patients aged <18 years and with long-standing persistent or permanent AF were excluded. Chi-squared test was used to report differences in frequencies. Binary logistic regression was used to analyze odds ratios for the diagnosis of nonpermanent AF. **Results**: There were 798 (8.7%) cases of nonpermanent AF. Patients in sinus rhythm were more often men (51.8%), aged <65 years (50.4%), with frequency of LAE and IAB of 13.3% and 14.4%, respectively. AF cases were women in 52.6%, aged ≥65 in 75.9%, with LAE and IAB diagnosed in 32.6% and 31.1%, respectively. All differences in reported frequencies between patients in sinus rhythm and nonpermanent AF were statistically significant (P<0.001, except for gender comparison with P=0.016). The odds for having nonpermanent AF in women was 1.34 (95% CI 1.13-1.59), in aged ≥65 years was 2.50 (95% CI 2.07-3.02), and in those with LAE or IAB were 2.50 (95% CI 2.07-3.03) and 2.11 (95% CI 1.75-2.56), respectively. Male gender and age <65 years had odds in favor of sinus rhythm, 0.75 (95% CI 0.63-0.89) and 0.40 (95 CI 0.33-0.48), respectively. **Conclusion**: LAE, IAB, aged ≥65 years, and females were independent, noninvasive markers that may help identify patients at risk of developing AF. P-wave duration and LA area measurements, as modifiable predictors, may contribute substantially to AF risk estimation and should be recommended in a routine workup.

Vedran Velagić, Richard Matasić, Mislav Puljević, Borka Pezo-Nikolić, Martina Lovrić Benčić, Davor Puljević, Davor Miličić

**Introduction**: T wave “oversensing” is a relatively common phenomenon that can lead to inappropriate shocks in cardioverter-defibrillator (ICD) carriers. The most common cause of this phenomenon is the low R wave sensing amplitude, but hyperglycemia, hyperkalemia, Brugada syndrome, etc. could also be the culprit (1-3). Here, we present a case where the T wave oversensing occurred exclusively during monomorphic ventricular tachycardia. **Case report:** 53-years-old patient was admitted into the emergency room because of the ICD shock. The underlying condition was ischemic cardiomyopathy due to inferior myocardial infarction. Echocardiography revealed aneurysmal parts of inferior and posterior wall and moderately reduced systolic function of the left ventricle. Later on, during the disease course, the Holter monitoring detected sustained, monomorphic, hemodynamically stable ventricular tachycardia (VT) with the heart rate of 180/min. Therefore, single chamber ICD was implanted. The ICD follow-up revealed the same VT-s that were repeatedly successfully terminated by a single overdrive. All parameters of the ICD function were within normal limits. Patient received optimal medical therapy for heart failure and was in good functional status (NYHA class I-II). Antiarrhythmic therapy consisted of amiodarone and bisoprolol. Interrogation of the device revealed monomorphic VT, cycle length of 330-350 ms, which was adequately diagnosed in VT zone 1. Soon, T wave oversensing occurred, which produced a very short RR intervals of 120-180 ms. These intervals belong to the ventricular fibrillation zone that was too short for the anti-tachycardia pacing delivery which was previously always effective. In awake patient, DC shock delivery occurred, which successfully terminated the arrhythmia. In order to avoid further inappropriate shocks, sensing vector was changed in the ICD programming. In further follow-up there were no more inappropriate shocks. **Conclusion:** Monomorphic ventricular tachycardia can be interpreted as ventricular fibrillation by the ICD due to T wave oversensing which may be the cause of inadequate shock. This can be avoided by programming different sensing vector of the device. To our knowledge, this cause of inadequate ICD therapy has not been previously described.

Vjeran Nikolić Heitzler

The data of diuretics are still controversial. The ability to induce negative fluid balance has made diuretics useful in the treatment of a variety of conditions, particularly edematous states as heart failure (HF). At the beginning of 1940, only three drugs were accepted as effective agents to increase urine flow: caffeine (a mild diuretic), digitalis (a potent agent but useful only in HF), and mercury (despite its improvement as an organomercurial remained potentially a toxic one). In the late 1950s and 1960s, a significant breakthrough was achieved with the discovery of chlorothiazide and furosemide. (1, 2) Since them, diuretics have been the cornerstone for treatment of both acute and chronic HF, with signs and symptoms of congestion (NYHA II-IV), irrespective of ejection fraction (EF). They clearly improve hemodynamics and symptoms, although many studies have not been able to demonstrate a mortality benefit. A recent meta-analysis of a few small trials found that diuretics were associated with a reduction in mortality as well as reduced admission for worsening HF. In Croatia, we routinely used all four groups of diuretics diminishing sodium reabsorption at different sites in the nephron, thereby increasing urinary sodium and water losses. Examples of loop diuretics include: furosemide, torsemide. Examples of thiazide diuretics include: chlorthalidone, hydrochlorothiazide, indapamide. Examples of potassium-sparing diuretics include: spironolactone, eplerenone. Loop diuretics act in the thick ascending limb of the loop of Henle. The bioavailability of furosemide is extremely variable (10-90%). The bioavailability can be improved if it is taken before meals because food can disrupt its absorption. Furosemide is absorbed from the gastrointestinal tract, and its peak diuretic effect occurs between 1 and 1.5 hours after oral administration, and between 10 and 30 minutes after intravenous (iv.) administration. The half-life of the various loop diuretics are not the same: 1-1.5 hours for furosemide and 3-4 hours for torsemide. The half-life of furosemide is prolonged in advanced renal dysfunction, and the half-life of torsemide is doubled in hepatic dysfunction. Because diuretics acutely decrease left ventricular preload (**Figure 1**), they can lead to a reflex neurohormonal stimulation of the sympathetic nervous system and renin-angiotensin-aldosterone axis. Numerous studies have determined that activation of these pathways contributes to the pathophysiology of HF, thus potentially undermining the benefits of diuretic use. That is the reason why furosemide occasionally needs to be administered two or three times a day or in 24-hour infusion. (1) Concurrent treatment with neurohormonal blockade (i.e., vasodilators, beta blockers, renin-angiotensin-aldosterone system antagonists) may improve outcomes. In patients with severe edema, the effect of furosemide may be altered due to inadequate gastrointestinal absorption. Patients unresponsive to oral furosemide should be switched to iv. therapy or oral torsemide. The bioavailability of torsemide is predictable. It is extremely well absorbed (80-90%), regardless of the presence of edema, because it undergoes substantial hepatic elimination. Torsemide can be administered once daily 5-20mg. The dosage of iv. administered furosemide is usually half of the oral dose. Furosemide is started with 20mg and can be incremented up to 40mg according to the diuretic response. Maximum single oral doses of furosemide for patients with normal glomerular filtration range from 40 to 80mg and the maximum daily dose is 600mg. If the maximum dose has already been given, it is recommended to increase the frequency of the dose to 2 or 3 times a day. Figure 1. The curve of pressure pulmonary capillaries (“preload“) patients with dilated cardiomyopathy and congestive heart failure shows high amplitude „v“ wave, which is an indirect indication of mitral regurgitation; before (A) and after furosemid (B). After treatment, not only to reduce mean pulmonary capillary pressure, but also significantly reduce the amplitude „v“ waves, and thus it can be concluded the size of mitral regurgitation. Thiazide diuretics are most commonly used to treat hypertension, although they can be adjuncts in the management of HF. Adjunctive use of thiazides can overcome the resistance to loop diuretics associated with reactive hypertrophy of the distal convoluted tubule of the nephron. They inhibit the Na-Cl symporter in the distal convoluted tubule, leading to decreased sodium and water reabsorption. Spironolactone inhibits the aldosterone receptor in the cortical collecting duct, also limiting sodium and water reabsorption. Its diuretic effect is relatively weak, and its onset of action is slow. To conclude, diuretics are well established as the first-line therapy for HF patients with congestion. Since every patient represents a single entity and may have different responses to the same treatment, the best clinical approach should take into account physical examination, neuro-hormonal overdrive and kidney functional status.

Sandra Jakšić Jurinjak, Mario Udovičić, Mira Stipčević, Boris Starčević, Josip Vincelj, Robert Blažeković, Željko Sutlić

**Introduction:** Left ventricular assist device (LVAD) is used for the management of advanced heart failure patients and associated with a significant risk of gastrointestinal (GI) bleeding. We describe a case of LVAD related recurrent GI bleeding unresponsive to conventional management and successfully treated with a combination of subcutaneous and intramuscular depot formulations of octreotide. **Case report:** Patient is a 61-year-old man with ischemic cardiomyopathy who was implanted with a HeartMate II LVAD as a bridge to transplantation. The initial anticoagulation regimen consisted of a vitamin K antagonist (warfarin) with a goal international normalized ratio (INR) of 2-3, aspirin of 150 mg daily and clopidogrel of 75 mg added after percutaneous coronary intervention of native coronary vessel. Three weeks following discharge, the patient was evaluated for melena, necessitating blood transfusions. Over next four months he had repeated hospital readmissions, each requiring multiple blood transfusions despite stopping the aspirin, clopidogrel and reducing the goal INR to 1.5–2.0. No evidence of Von Willebrand syndrome, hemolysis or pump malfunction was revealed. Repeated esophagogastroduodenoscopy and colonoscopy did not reveal any active source of bleeding. Red blood cell scintigraphy bleeding scan and capsule endoscopy revealed on one occasion bleeding in the proximal small bowel, but no identifiable source. LVAD pump speed was also reduced in an effort to achieve increased pulsatility. He was started on 100 μg SC octreotide twice daily and then switched to 10 mg IM injections monthly. Due to recurrent bleeding warfarin was discontinued for period of 20 days without sign of pump thrombosis, and anticoagulation was continued applying low molecular heparin. He did not require any transfusions for 3 months, and his hemoglobin remains stable. **Discussion:** Gastrointestinal bleeding is the most common cause of readmission in patients supported by continuous flow left ventricular assist devices, mainly continuous flow LVADs. (1, 2) Octreotide exhibit a favorable trend in the frequency of admissions, blood transfusions in patients with recurrent GI bleeding but further prospective studies are needed.

Mario Ivanuša

**Introduction:** Even 1 of 4 patients discharged after acute coronary syndrome will suffer from a heart attack, stroke or cardiovascular (CV) death over the next five years. (1) The risk of these events is highest during the first year from the initial CV event (1) and can be reduced by treatment in accordance with the guidelines and participation in the CV rehabilitation program. (2) The full approach to the CV rehabilitation that encompasses the evaluation of the CV status, therapeutic education, non-pharmacological and pharmacological measures and cardiovascular training successfully reduces the present impact of risk factors. (3) This paper aims to show the incidence of CV risk factors and controls of dyslipidemia in patients enrolled in the outpatient CV rehabilitation program and to compare the results with the available data. **Patients and Methods:** The data on patients enrolled in the outpatient CV rehabilitation program in the Institute for Cardiovascular Disease Prevention and Rehabilitation in Zagreb in 2015 that completed the program by 15th March 2016 were retrospectively analyzed. The frequency of elevated body mass index, dyslipidemia, hypertension, diabetes/glucose intolerance, active smoking, and frequency of administration of individual doses of statins as well as the control of dyslipidemia in patients taking hypolypemic drugs (target values of LDL cholesterol 2 was recorded in 88.4%, dyslipidemia in 78.7%, and hypertension in 75.8% of them. Diabetes/glucose intolerance was recorded in 27.5%, while there was 13.5 active smokers at the time of conducing the outpatient CV rehabilitation programs. The results of the dyslipidemia control are shown in **Table 1**. ### Table 1: Control of dyslipidemia in patients enrolled in outpatient cardiac rehabilitation program. | **Dyslipidemia** | **Number** | **%** | | --- | --- | --- | | *High-intensity statins* | | | | atorvastatin 40 – 80 mg (135/157) | | | | rosuvastatin 20 – 40 mg (22/157) | 157 | 75.8% | | *Standard dose of statins* | 33 | 15.9% | | **Total on statins** | **190** | **91.8%** | | *Dyslipidemia control in patients on lipid-lowering medication, low-density lipoprotein <1.8 mmol/L* | 111 | 58.4% | **Discussion and Conclusion:** In patients undergoing the outpatient CV rehabilitation, there is a high prevalence of CV risk factors, as shown in the data previous published by the Institute. (4) In comparison with the data on patients from the recently published study EUROASPIRE IV (5, 6), the prevalence of risk factors is identical, except for hypertension that is more common in Croatian patients (75.8% versus 45.0%). The frequency of administration of statins, particularly intensive statin therapy is high, while the control of dyslipidemia is much better than in the study EUROASPIRE IV (5, 6) (58.4% versus 25.6%). Despite this, the LDL cholesterol values did not equal the desired therapeutic values in a great number of patients.

Mira Stipčević, Mario Udovičić, Sandra Jakšić Jurinjak, Željko Sutlić, Boris Starčević, Davor Barić, Daniel Unić, Igor Rudež, Vanja Ivanović, Josip Vincelj

**Introduction**: Despite the increasing use of alternative techniques, endomyocardial biopsy (EMB) remains the primary method for diagnosing cardiac allograft rejection, and is considered a safe procedure, with a very low complication rate when performed by experienced operators. Major complications include cardiac perforation, tamponade and endocarditis. (1, 2) **Case report**: We present a case of a 65-year-old male patient who underwent heart transplantation in August 2014 due to dilative cardiomyopathy. The early postoperative course was complicated with pneumonia and ulcers of sacral region. The last scheduled biopsy was performed in December 2015 and the control transthoracic echocardiography (TTE) was unremarkable. By April 2016 a gradual clinical deterioration was observed, with loss of appetite, weight loss, shortness of breath, effort intolerance and swelling of the abdomen and legs. TTE showed a moderate pericardial effusion around the inferior wall and in front of the right ventricle. Mitral inflow velocities suggested ventricular interdependence, but chamber collapse was not evident. Dense collection of 3.4 cm in the pericardium and pericardial thickening of 1.3 cm was noted on. Therefore, a localized parietal and visceral pericardiectomy was preformed via sternotomy with intraoperative transesofageal echocardiogram confirming better kinetics of the inferior wall of the left ventricle and the anterior wall of the right ventricle following procedure. The patient was discharged after 3 weeks and was seen in an out-patient clinic a month later with significant improvement in his symptoms. Repeat TTE showed no pericardial effusion. **Conclusion**: The diagnosis of effusive-constrictive pericarditis as a late complication of EMB is possible and should considered in new onset worsening of heart transplant recipient. Pericardiectomy should be considered in patients with evolution to constrictive pericarditis and clinical features of severe and persistent heart failure.

Marija Čulo, Marija Renić

Heart failure (HF) is a clinical state resulting in impaired cardiac function and structural changes of the heart muscle causing an insufficient oxygen-tissue supply and metabolically impairment. Our aim is to present and evaluate the implantation of left ventricular assist device (LVAD) from a nurse point of view. Congestive heart failure is one of the leading causes of morbidity and mortality in Europe. Left ventricular assist devices have revolutionized the treatment of end-stage heart failure. Its powerful therapeutic approach in acute and chronic heart failure is due to the fact that lowering of left ventricular volume by increasing left ventricular output increases organ perfusion, improves oxygen supply of organs by maintaining adequate minute volume. (1) Every patient who is suffering from heart failure should be examined by a cardiologist to evaluate the stage of heart failure and decide about adequate treatment options. Treatment modalities as well as the prognosis depends on the stage of heart failure and clinical condition. Every patient goes through an extensive diagnostic process. The left ventricular assist device has two optional implant strategies, one considering LVAD as “bridge to transplant” or “bridge to recovery” and the second considering LVAD as long term therapy. When it is determined that the patient is suitable for LVAD implantation he and his family undergo a specific training for managing the implanted device. This training is consisted of education prior and after LVAD implantation. Prior implantation, education consists of informing the patient and his family about benefits and risks of cardiac device implantation as well as explaining what it means living with a heart pump, dependents on mechanical device, everyday issues and concerns, changes in the surface of the body, dealing with cables, portable pump-batteries, possible infections and alarms, changes in quality of life and self-responsibility. After surgery patients are transferred to intensive care unit where it is important to monitor hemodynamic and pump parameters as well as signs of skin infection at the cable surrounding. After implantation of LVAD, recovery seems to depend on patients acceptance of a new body device. For better outcomes, early self-care is being encouraged. The role of the nurse is to prepare the patient for discharge from the hospital by educating the patient about all consistent parts of the pump (control system, battery, battery charger, power supply module, driveline) and managing proper skin hygiene. Another unavoidable issue is the unceasing necessity of anticoagulant therapy (avoiding ischemic events) as well as regular coagulation and volume monitoring. (2) Patients healthcare, after implantation of a cardiac assist device, is nowadays still a challenging venture. The advisory role of the nurse an individual approach and sensibility for noticing and preventing potential risks makes the nurse a link between the entire medical team, the patient and his family.

Valentina Sedinić, Marina Pavlinić, Blaženka Marković, Božica Leško

Today the tilt table test is one of the unavoidable diagnostic tests in patients with syncope. (1) Fainting, transient loss of consciousness, sudden dimming, collapse and dizziness are common indications for performing the test. Syncope, although basically benign, can have fatal consequences for patients if they are engaged in traffic or are injured during the fall. The tilt table test is used primarily to clarify the etiology of syncope in dubious cases. Depending on the result of the test (primarily in cardioinhibitory syncope) it may indicate the implantation of a cardiac pacemaker. In our case report we will show the use of the tilt table test in our daily clinical practice.

Gorana Spitek, Danijela Sorić-Noršić, Vesna Vlahek, Maja Šipek

Cardiac arrest is the leading cause of death in developed countries. (1) Particularly poor prognosis are for patients who experience cardiac arrest outside the hospital, where the hypoxic brain damage is crucial in the development of irreversible neurological complications and may lead to death. In patients who experienced cardiac arrest outside the hospital due to ventricular fibrillation or ventricular tachycardia, and after admission to the hospital were in an unconscious state, ILCOR (International Liaison Committe on Resuscitation) recommends therapeutic use of hypothermia. The role of nurses in the care of patients on whom therapeutic hypothermia is performed is crucial. In addition to the implementation of health care interventions and delegated interventions from other members of the multidisciplinary team, the nurse must monitor the incidence of symptoms and signs of possible side effects that hypothermia can cause. Possible side effects are: tendency for arrhythmias, occurrence of pulmonary edema, hypotension, disorders of hemostasis (increased tendency to bleed). Basic contraindications for therapeutic use of hypothermia are: coma of other etiology, refractory hypotension despite inotropic support and volume compensation, sepsis, hemodynamically unstable arrhythmias, pregnancy and terminal illness, known coagulopathy and active bleeding, a major surgery within 14 days. When therapeutic hypothermia is performed, the application of fibrinolysis and percutaneous coronary intervention are not contraindicated. Body temperature is measured by a rectal thermometer or a special probe in the bladder, and the target temperature is from 32-34° C. The target temperature is achieved by infusion of cold saline solution or Ringer’s lactate cooled to 4° C or coating patients with ice packs (armpits, groin, neck,). Recently, devices for invasive implementation of therapeutic hypothermia are available. The target temperature is achieved during 6-8 hours and maintained for the next 24 hours. The whole time the patient must be sedated and relaxed. After 24 hours, with further maintenance of sedation and relaxation of the patient, passive warming begins to raise body temperature to 36° C which is achieved in 6 hours. This case report will be present the course of recovery of one patient, with an emphasis on the complexity and demands of healthcare for the role of nurses in caring for patients therapeutic hypothermia is performed on.

Ruža Evačić

Today, palliative medicine (palliative care), is not just directed to tumor diseases, but also to others, such as chronic, progressive lung disease, kidney disease, chronic heart failure (1), HIV / AIDS and progressive neurological conditions. The goal of palliative care is to improve quality of patient’s life, as well as the quality of their family life. It is aimed at solving the most sensitive period of human life in which human rights are most at risk. The area in the terminal phase of life is a challenge of nursing ethics on whether the basis of ethics stands in the idea of care or the idea of science? Efforts to avoid unwanted events in the later stage of the disease can be achieved with proper timely identification of patient’s need for palliative care. European GSF-PIG guidelines are recommended as a basic tool with prognostic indicators to identify patients who are approaching the end of life and are in need for palliative care. SPICT is used as an auxiliary tool for quickly grading, CRISTAL as an auxiliary tool for fast recognition in the emergency department while QUICK GUIDE is a tool for keeping a register of patients in palliative care. Guide to identify the person (SPICT) with an increased risk of deterioration and death with two or more indicators of deteriorating health, also defines clinical indicators. For cardiovascular disease clinical indicators are NYHA III/IV category of heart failure, an incurable disease of the coronary arteries, dyspnea, severe inoperable peripheral vascular disease. This approach provides an objective assessment and definition of a dying patient. It allows honest communication with the patient and family, and a management plan for associated signs and symptoms. Medical documentation (E-card) and Nursing letter of discharge enable good coordination with the Team of palliative care in primary health care.

Petra Angebrandt, Karlo Golubić, Irena Ivanac Vranešić, Martina Lovrić Benčić, Anton Šmalcelj

**Introduction**: Anticoagulants appear to be more effective than aspirin in preventing thromboembolism in patients with atrial fibrillation (AF), with no increase in the risk of bleeding. Despite the evidence for the limited efficacy and poor safety of aspirin, as well as for the diminished role of aspirin in recent guidelines, it is still commonly used in AF patients. (1-3) Our aim was to assess the association of aspirin therapy with the prevalence of left atrial thrombosis (LAT) in patients with AF. **Patients and Methods:** We performed an observational study involving 131 patients with AF who underwent transesophageal echocardiography in our institution during the period from January 2011 until January 2015, and who were not on any form of anticoagulation therapy. According to history of aspirin therapy, we divided them into two groups: Group 1 (patients on aspirin) and Group 2 (patients without aspirin). The presence of LAT was evaluated in both groups. We also analyzed thromboembolic risk according to the CHA2DS2-Vasc score system. **Results**: Out of 131 patients, 51 (38.9%) were on aspirin. The prevalence of LAT in the Group 1 as compared to the Group 2 was 6/51 vs. 5/80, respectively, p=0.43. The two groups did not differ in the proportion of intermediate to high thromboembolic risk patients according to the CHA2DS2-Vasc score system 44/51 vs. 67/80, respectively, p=0.59. **Conclusion:** Our study shows that therapy with aspirin is not associated with less prevalence of LAT in patients with AF in comparison to patients who were not on any anticoagulation/antiplatelet therapy. Therefore, we believe that aspirin should not be the drug of choice for prevention of thromboembolic events in patients with AF. Due to the small number of patients, our study was underpowered, but our results correlate with larger studies and recent guidelines recommendations.

Jozica Šikić, Željko Sutlić, Boris Starčević, Mira Stipčević, Mislav Planinc, Sandra Jakšić Jurinjak, Mario Udovičić, Mario Sičaja, Robert Blažeković, Dario Gulin

We present a case of Heart Mate 3 (HM 3) (1) explant after recovery of heart function eight months after implantation. Our patient is 60-year-old man with left side heart failure symptoms since September 2014. At the time he had atrial fibrillation and no other comorbidities. Initial echocardiographic finding was severe left ventricular impairment (left ventricular diastolic diameter - LVEDD 6.4 cm; reduced left ventricular ejection fraction - LVEF 20%). Initial coronarography exposed non-significant left anterior descending (LAD) artery stenosis. Despite optimal medicamentous treatment the patient suffered from repetitive non sustained ventricular tachycardias and had intracardiac defibrillator implanted in June 2015. Persistent left ventricular failure required implantation of the left ventricular assisted device - LVAD. The patient was followed during monthly external consultation, including device inspection, clinical examination and transthoracic echocardiography. Follow-up revealed clinical improvement with recovery of myocardial activity at echocardiography. On postoperative month 7, the echocardiography confirmed ventricular function improvement with an LVEF 50-55%. These led to the decision to remove the assist device. The weaning protocol included in-hospital evaluation consisting of echocardiography and hemodynamic measurements. Testing of cardiac function was performed under regular pump support (step 1), minimal LVAD support (step 2) and pump stop with balloon occlusion of outflow graft (step 3). Step 1 was performed one month prior to explantation (LVEF 50%, LVEDD 5.2 cm, VO2 19 ml/min/kg, PCWP 14 mmHg). Step 2 was preformed 2 days prior to explantation (LVEF 50%, LVEDD 5.4 cm, VO2 18 ml/min/kg, PCWP 15 mmHg). The final 3rd step was performed in the hybrid operating theatre with pump stop and balloon occlusion of outflow graft. After confirming preserved left ventricular function with TEE and hemodynamic measurements (preserved LVEF, CO 4.3-5.0 L/min, PCWP 14 mmHg, SVO2 80%) final decision was made to proceed with explantation immediately thereafter. The patient fully recovered after surgery. His postoperative echocardiography showed normal ejection fraction, with no heart cavities dilatation. Patient has been discharged 20 days after HM 3 explant in a good condition.

Lada Bradić, Martina Lovrić Benčić, Tea Šimonček, Blanka Glavaš Konja, Marija Peremin

**Background:** Partial and generalized epileptic seizures frequently cause central dysautonomia. Sympathomimetic response is seen most frequently – ictal tachycardia occurs in more than 85% of cases, ictal bradycardia in less than 2% of patients, while epileptogenic asystole is very rare, and occasionally related to the underlying cardiac condition. Antiepileptic medications can also modulate autonomic function and arrhythmogenesis. (1, 2) **Case report:** 44-year-old patient with long-lasting focal epilepsy with complex symptomatology and secondary generalization, with no previous history of heart disease, has been referred to ambulatory 24-hour Holter ECG monitoring. Sinus bradycardia with minimal heart rate of 19/min and sinus pauses up to 5.0 seconds was detected in sleep. Period of bradycardia ensued between significant technical interference caused by tonic-clonic seizures. **Conclusion:** Cardiovascular dysfunction can contribute to sudden death in epilepsy, therefore increased awareness and timely detection of concomitant arrhythmias is essential. Simultaneous video-electroencephalography and electrocardiographic monitoring is a diagnostic method of choice.

Gabrijela Ćurić, Marija Heinrich, Mario Ivanuša

The objective of the occupational therapy in patients involved in cardiovascular rehabilitation program is to determine the information on how cardiovascular diseases affect the patient in all aspects of the occupation: self-management, productivity and free time. Bachelor of Occupational Therapy makes occupational and therapeutic evaluation first by individual approach – takes occupational and social medical history and heteroanamnesis, defines occupational profile, analyzes the performance of basic activities of daily living and components of skills within the context in which the daily activity is performed. The evaluation of the activities of daily living requires the use of modern instruments recommended by professional societies, that is, standardized and non-standardized questionnaires for evaluation of the health condition (e.g., structured scale for the evaluation of hospital depression and anxiety – HAD scale, determining the desirable health behavior by examining the locus of control, the Canadian measure of performing the occupation, questionnaire on the level of physical activity, questionnaire on Mediterranean diet, etc.). (1-3) Good evaluation helps an occupational therapist to detect potential presence of certain occupational-therapeutic diagnoses in a cardiovascular patient: reduced effort tolerance, fear of physical activity, lack of criticism towards physical activity, social isolation, lack of education about acceptable health behavior, degree of anxiety and depression, lack of interest in therapy and dates scheduled for examination, fatigue, ignorance of risk factors, architectural and other barriers in the residential and work area. Required occupational-therapeutic interventions are planned in cooperation with a patient and family members, if necessary. Some objectives will be met by team members’ work, while some of them, depending on the evaluation of a cardiologist, physiatrist, psychologist and/or occupational therapist will require an individual approach. The occupational therapist provides therapeutic education by interventions in the field of setting priorities in the activities of daily living, advising on the importance of optimal physical activity and rest ratio, the importance of proper and regular taking of the therapy and following the schedule of examination and workup. A good evaluation helps an occupational therapist to monitor and evaluate which segments of daily living are impaired by the cardiovascular disease and he establishes, renews, modifies and/or maintains the activities of daily living in cooperation with the patient/family members and other team members. Following the completion of additional education and training, we conduct occupational therapy procedures in all patients involved in the outpatient cardiovascular rehabilitation program since September 2015 in the Department of Outpatient Rehabilitation in the Institute for Cardiovascular Prevention and Rehabilitation. The scope of work of Bachelor of Occupational Therapy is documented in the personal accounts of patients by using the diagnostic and therapeutic procedure codes in secondary healthcare as prescribed by the Croatian Health Insurance Fund.

Ivica Matić, Vesna Jureša

**Introduction:** The sense of coherence is the basic construct of salutogenesis and the key in identifying personal advantages when dealing with problems, therefore a protective factor of health. The essential components of the sense of coherence are comprehensibility, manageability and meaningfulness, and they have a common influence in maintaining health considering the dynamics of life cycles. (1) The age of adolescence is marked by numerous changes that have an important influence on heterostasis. (2) The thesis that a high sense of coherence is reflected through a higher capacity for dealing with stressful situations and is a predictor of positive health outcomes is one of the foundations of salutogenesis. Therefore, the main goal is to find the possibilities for improving the level of sense of coherence on a daily basis. The possibilities are endless, in all age groups and in different aspects of human life. The aim of this study is to define in what measure has the international mobility of students, as a newer teaching format in nursing schools, influenced the feeling of coherence in students. **Methods:** For the purpose of research the students were surveyed before and after international mobility. Sense of coherence was measured by Antonovsky’s Orientation to Life Questionnaire, which includes 29 items in a seven-point Likert-type scale that provides a global score where a higher score indicates a stronger sense of coherence. (3) Descriptive and inferential statistical methods were used for data analysis. The IBM SPSS Statistics and Data Mining Server (DMS) (4) software was used for analysis. **Results:** There was no statistically significant difference between the groups in regard to the values of sense of coherence before and after mobility (p=0.44), but DMS analysis did discover specifics in certain domains of the sense of coherence after mobility. **Conclusion:** This research expands knowledge in the field of sense of coherence and contributes to the expansion of new knowledge and it is a step toward promotion of health in adolescents.

Urška Osredkar

Since its establishment in 1999, the Heart Failure Outpatient Clinic (at Department of Vascular Diseases, University Medical Center in Ljubljana, Slovenia) supplemented cardiovascular diagnostic assessment, therapeutic management and follow-up with a structured and comprehensive nurse-led heart failure education program aimed at empowering outpatients with chronic heart failure. In 2012, a pilot program of nurse-led heart failure management (including education, but also follow-up and heart failure medication optimization with uptitration of baseline therapy and adjustment of diuretic dosage) was started. The pilot program of nurse-lead heart failure management consisted of at least 4 visits every 2–3 weeks and included 100 patients (mean age 80±6 years, 39% female); the program accomplished an increase in patients taking optimal heart failure medication (i.e. 38% on maximal ACE inhibitor dose as compared to 18% in the usual care group, p=0.002) and a decrease in patients with congestion/weight gain (12 vs. 42% in the usual care group, p<0.001). From 2015, the nurse-led heart failure management program was implemented as the standard of care at the Heart Failure Outpatient Clinic (3 days/week – once a week for first visits/intake and twice a week for follow-up visits). At first visit/intake, outpatients referred for evaluation of suspected heart failure undergo thorough cardiovascular examination (including cardiologist assessment, echocardiography, blood analysis, 6-minute walk test) and if heart failure is confirmed, appropriate therapy is initiated by the managing cardiologist and education is carried out by a dedicated nurse. A structured and comprehensive education program addresses heart failure natural history, signs/symptoms, precipitating factors and signs of impending worsening, management, diuretic therapy, lifestyle intervention etc. Also, follow-up appointments with managing nurse are arranged and patients are followed at 2–3 weeks interval, with basic check-up (symptoms, adherence to medication, blood pressure, heart rate, body weight) and therapy dosage optimization (uptitration of ACE inhibitors/ARBs, beta blockers, MRAs and sacubitril/valsartan, and dose adjustment of diuretic therapy) under supervision and in consultation with managing cardiologist. Nurse-led heart failure management programs improve outpatients follow-up yielding to better medication adherence and better optimization of both, diuretic therapy and lifesaving heart failure medication (thus possibly decreasing hospitalization rates and even mortality). (1) Also, continuous education through frequent follow-up visits enables better outpatient empowerment and possibly improves quality of life.

Martina Osredečki, Matko Filipović, Daniel Nožarić

Although the implantation of a permanent cardiac pacemaker is already considered a routine procedure it can have many complications on the day of the operation or after a few days or months. (1) Nursing care of the patient immediately after implantation of the pacemaker and education of patients and families can help prevent some complications. In this study we will present the case of a 47-year-old patient who was hospitalized at the Department of Cardiology at University Hospital Dubrava because of syncope and previously known hypertension. The patient was diagnosed with the second degree atrioventricular block in the electrocardiogram. Treatment of the patient is with implementation of a permanent single-chamber cardiac pacemaker and is discharged to home treatment. After a few days, the patient is readmitted in the Department of Cardiology due to dislocation of the electrode of pacemaker. After repositioning the electrode, the patient has a positive postoperative period and seven days later released on home treatment with regular check-in infirmary for pacing.

Vesna Mežnar, Andreja Kvas

**Introduction:** The aging population is increasing, thereby the incidence of symptomatic aortic stenosis due to degenerative aortic valve disease in the elderly with comorbidities is also increasing. Therefore, a less invasive percutaneous method was also developed in parallel with the surgical method of treatment of aortic valve stenosis in order to improve the quality of life of the elderly and extension of survival. Percutaneous balloon dilation of the aortic valve serves as a palliative method or bridging to surgical or percutaneous aortic valve replacement. (1) **Purpose:** The purpose of this paper is to present comprehensive treatment of patients after percutaneous balloon dilatation of the aortic valve, with a focus on nursing care of the patient before and during percutaneous balloon dilatation. **Methods:** The descriptive method of research was used by reviewing domestic and foreign scholarly literature. Resources ware searched using the catalog and bibliographic system COBISS.SI and foreign databases such as CINAHL (Cumulative Index to Nursing and Allied Health Literature), Medline PubMed, Cochrane and Science Direct. **Discussion and Conclusion:** The nurse carries out continuous and individually patient-oriented nursing care maintaining the focus on the individual patient. Their work is directed both to anticipating potential complications of an invasive procedure and to preventing them or warning of them properly and professionally together with other medical team members who are involved in the procedure. The patient must be prepared for surgical procedures and nursing care must be provided throughout the procedures. Access to the patient is integrated and based on the following principles: to take responsibility for their work, not harm and be respectful to life and human dignity. All nurse’s actions, before and during the procedure, must be recorded in the patient’s files.

Ružica Mrkonjić

**Introduction:** Device for mechanical circulatory support are becoming real alternative to heart transplants because of continuous increases in number of patients with heart failure and insufficient heart donors. (1) Many efforts have been made to optimize the technical design, flow characteristics and durability of the devices. Although the technology is now at a high level, there are still problems relating to the nature of the device. Gastrointestinal bleeding is a major problem and 19-40% of patients with implanted support suffer from that problem. Another problem is thromboembolic events that may result in neurological complications, with overall incidence of stroke of about 10%. The overall incidence of pump thrombosis is 2 -5%, and infection of the exit line of percutaneous cable is 10%. (2) **Case report:** Case of the patients in cardiogenic shock placed on extra corporeal membrane oxygenation followed by LVAD implantation and two years there after she is able to sustain her personal and professional activities, says that there is real need for mechanical support, but also the need for further improvement of device. Despite the continuous reduction in the incidence of complications related to device some questions remain unanswered, and better biocompatibility is the biggest question. **Conclusion:** Most patients with implanted mechanical support do not have any problems, and according to most patients quality of life with mechanical support is good, but there is still a certain percentage of patients with serious problems.

Nikolina Matić, Josipa Kern, Ivica Matić

**Introduction:** Compliance is a term that applies to patient’s ability to correctly follow advice and instructions. It is a degree at which the patient follows a prescribed regimen that is harmonized with health care provider. The regimen includes medications, diet and physical activity. A compliant patient takes adequate medications in accurate doses, at the adequate time, during a long period of time. Compliance is a dynamical process, and there are moments in which patient can transcend from compliant to non-compliant. It is very important to realize in time when patient becomes non-compliant. Non-compliance is not seen visible immediately by physical symptoms or by worsening of the disease, so there is a great responsibility on nurses to estimate patient’s compliance. It is important to understand, and for the patient to understand, that a patient who is compliant has three times higher of good outcomes in comparison with a patient who is not compliant. (1) In modern medicine, compliance and communication often begin with the use of informational technologies. The use of information and communications technology (ICT) or services such as electronic mail or text messaging in communication between patients and health care providers is a relatively new trend that is growing in significance. (1) Among other things, this way of communication significantly improves patient compliance. In this investigation we wanted to define the prevalence of non-compliance and whether communication that implies the use of ICT affects compliance. **Methods:** It was a prospective, interventional research including a group of 50 patients at the Department for Internal Medicine of University Hospital Centre Zagreb. After analyzing the initial questionnaire data, an interventional subgroup was formed. Interventional subgroup included patients who confirmed lack of compliance in adherence to follow-up. This subgroup received everyday reminder via e-mail, which represents a modern way of communication, and the subjects were poled again after three months. **Results:** Interventional subgroup with every-day reminders had significantly improved their regularity of coming for regular follow-up. After use of ICT, non-compliance was reduced in terms of both picking the medications from the pharmacist and regularly taking the daily doses. **Conclusion:** Based on this research we can conclude that patient compliance is a phenomenon that consists of many areas that can by additional improved by using ICT.

Anja Zaletel, Polona Knavs Vrhunec, Breda Barbič-Žagar

Arterial hypertension represents the main cause of cardiovascular disorders, such as myocardial infarction, ischemic stroke, heart failure, renal insufficiency, and other clinical events. Therefore, an effective antihypertensive pharmacotherapy is clearly needed, in addition to proper lifestyle changes, in order to provide not only symptomatic relief but also cardiovascular protection. The TANDEM study was undertaken to evaluate the efficacy and safety of telmisartan monotherapy (Tolura®) and the fixed-dose combination of telmisartan/hydrochlorothiazide (Tolucombi®) in adult hypertensive patients. A total of 1,234 patients were enrolled in this non-interventional post-authorization efficacy and safety study. Patients were treated with telmisartan monotherapy or the fixed-dose combination of telmisartan/hydrochlorothiazide once daily for four months. The study demonstrated that Tolura® and Tolucombi® reduce systolic and diastolic blood pressure significantly (p<0.0001) and that they are well tolerated by hypertensive patients.

Luka Bastiančić, Ivana Smoljan, Tomislav Jakljević, Sandro Brusich, Vjekoslav Tomulić, Dimitrij Kuhelj

**Introduction:** Left atrial appendage (LAA) closure is a percutaneous procedure used for prevention of thromboembolic events in patients with non-valvular atrial fibrillation with contraindication for oral anticoagulant therapy. (1, 2) In University Hospital Centre Rijeka we performed a total of 17 percutaneous LAA closure procedures using the Watchman® device (Boston Scientific). In this case report we describe a late complication of the procedure – device embolization. **Case report:** We report a case of a 62-year-old man with a persistent atrial fibrillation and a contraindication for anticoagulant therapy due to non-traumatic intracerebral bleeding. After initial assessment and pre-procedure transesophageal imaging including standard measurements, patient underwent percutaneous implantation of LAA closure device which was done with no early complications. On routine transesophageal echocardiographic follow-up 45 days after implantation no closure device was found in LAA, left atrium or ventricle and the visualized parts of the aorta. Patient was asymptomatic and the time of embolization was unknown. MSCT aortography (**Figure 1**) detected the device in abdominal aorta. Extraction was done via percutaneous right femoral artery approach using an Amplatz Goose Neck® Snare Kit. The device was removed completely with no complications. Figure 1. MSCT scan of the Watchman® (arrow) in abdominal aorta (1) and after extraction (2). **Conclusion:** Late embolization of a LAA closure device is a rare complication of the procedure. Depending on the localization, an embolized device can be successfully removed via percutaneous approach.

Ivan Vuksan, Andrej Belančić, Luka Vranić, Nikolina Jurjević, Tamara Hlača, Caput, Alen Ružić, Luka Zaputović, Teodora Zaninović, Jurjević

Introduction: Takotsubo cardiomyopathy (TTC) has been described, for the past 25 years, as the specific form of left ventricular abnormality without sings of coronary arteries obstruction (1, 2). In 2006, the American Heart Association has recognized TTC as a form of acquired cardiomyophaty (3). Aim: To demonstrate epidemiological and clinical profile of the patients with a discharge diagnosis of TTC, treated in the Department of Cardiovascular Diseases, Clinical Hospital Centre Rijeka. Patients and Methods: Retrospective analysis, with the discharge diagnosis of TTC, in the period 2012-2016 (20 female patients). Data has been collected from the Department’s database. Results: Median age was 62 (range 46 to 92) years. Average length of hospitalization was 4-5 days. On the arrival, blood pressure was 134±21/82±13 mmHg and puls was 90±23 per minute. From the medical history: 60% of the patients had hyperlipoproteinemia, 55% arterial hypertension, 30% diabetes, 25% neoplasms, 10% chronic obstructive pulmonary disease, 10% hypothyroidism, and 5% had chronic cerebrovascular disease. Emotional triggers were: panic attack (30%), personal loss (15%), anger/conflict (10%), and interpersonal conflict (5%). Physical triggers were perioperative anxiety (10%) and malignancy (5%). Troponin T level (TnT) on the arrival was 399.7±393.6 ng/L, whilst on the day of discharge it was 176.8±243.0 ng/L. ECG showed ST-segment elevation in the precordial leads in the 55% of the patients, and in the inferior leads in 15%. Negative T wave was present in the precordial and/or inferior leads in the 80% of the patients. The ejection fraction (EF) value (ultrasound) was 44±13%. 40% of patients had preserved (≥50%) EF, 25% had mid-range (40-49%) EF, and 35% of patients had reduced (<40%) EF. Apical ballooning of the left ventricle was present among 95% of the patients. All patients underwent coronarography, and no signs of obstructive coronary disease were found. 10 patients (50%) underwent ventriculography, and 8 (80%) of them showed apical ballooning. Conclusion: Clinical presentation of TTC is impossible to distinguish from the acute myocardial infarction, but it’s crucial to be taken into observation among certain patient profile. Those are females in the postmenopause with evident emotional/physical trigger, moderately increased TnT, left ventricle disfunction and normal coronarography.

Bojana Radulović, Matias Trbušić, Ines Potočnjak, Sanda Dokoza Terešak, Nada Vrkić, Neven Starčević, Milan Milošević, Saša Frank, Vesna Degoricija

**Introduction:** Numerous studies have shown that during heart failure (HF) exacerbation patients with hyponatraemia have higher mortality, longer hospital stay and higher incidence of rehospitalisation due to HF. To date there has not been effective therapy for hyponatriaemia in AHF. Until now, research related to hyponatriaemia in HF patients did not focus on serum chloride levels, mostly due to traditional view of chloride as a secondary electrolyte whose levels are dependent on sodium levels and acid-base balance. The present study investigated the relationship between serum chloride and follow-up sodium levels in acute heart failure (AHF) patients with normal initial sodium level. (1) **Patients and Methods:** The present study was performed as a prospective, single-centre, observational research with a total of 152 hospitalized AHF patients in University Hospital Centre “Sestre milosrdnice”. Patients have been divided in four groups depending on values of sodium and chloride. Patients were monitored on the second, third and seventh day of hospitalisation and follow up was done after three months. We statistically calculated the likelihood of these groups for developing hyponatriaemia after three months and mortality. **Results:** Compared to patients with initial normochloraemia and normonatriaemia, patients with initial hypochloraemia and normonatriaemia had a statistically significant higher incidence of hyponatraemia after a 3-months follow-up. Binary logistic regression revealed a significantly increased in-hospital mortality in the hypochloraemic/normonatriaemic group. Interestingly, ejection fraction at admission was the highest in hypochloraemic/normonatriaemic patients, although that group of patients had significantly increased in-hospital mortality. The lowest ejection fraction was in a group of patients with hypochloraemic/hyponatraemic patients. The N-terminal precursor Brain Natriuretic Peptide (NT-proBNP) levels at admission were significantly lower in hypochloraemic/normonatriaemic compared to other groups. **Conclusion:** Our study showed that initial low serum chloride concentration is predictive of developing hyponatraemia and associated with increased in-hospital mortality in HF patients. Chloride levels could be used to detect high-risk patients and start appropriate therapy early enough to prevent poor outcome of AHF patients.

Ante Anić, Zorislav Šušak, Branimir Bukša, Iva Pavić, Barbara Petani

**Introduction:** Percutaneous left atrial appendage (LAA) occlusion is a valuable option for stroke and systemic embolism (SSE) prevention in patients with atrial fibrillation (AF) that do not tolerate anticoagulant therapy. (1) Amplatzer Amulet is one of devices available that predominates as a device of choice across European centers **Methods:** This is an overview of indications, some intraprocedural aspects and postprocedural management of 6 patients in whom we implanted LAA occluder (Amplatzer Amulet) from July 2016 till October 2016 in Zadar General Hospital. **Results:** All patients had CHA2DS2 VASC score of ≥3 and had a history of major bleeding under anticoagulant therapy (gastrointestinal in 5 patients, urinary tract bleeding in 1). Preprocedural MSCT left atrial angiography was performed to give insight in LAA anatomy and device landing zone dimensions. Procedures were performed in general anesthesia. Devices size implanted varied from 22-31 mm. No intra or postprocedural complication occurred. All patients were discharged with dual antiplatelet therapy. No device embolization in early follow up had been documented and at 3 months follow up all devices retained their original position and conformation. **Conclusion:** LAA occluder implantation is a rather safe procedure that serves as a good alternative for SSE prevention in patients with AF and at high risk for SSE and who do not tolerate anticoagulant therapy. Amplatzer Amulet device offers biggest size range thus virtually being able to occlude any type of appendage.

Jure Samardžić, Jana Ljubas Maček, Marijan Pašalić, Maja Čikeš, Boško Skorić, Ivo Planinc, Hrvoje Jurin, Davor Miličić

**Introduction:** Cardiac allograft vasculopathy (CAV) is a relatively frequent complication after heart transplantation which limits long-term patient survival. CAV development and progression is related to enhanced platelet reactivity (PR). (1, 2) We sought to investigate the correlation between pretransplant PR level and CAV development 12 months after heart transplantation. **Patients and Methods:** We measured pretransplant PR of 48 patient using point of care platelet function testing device Multiplate. ADP was used as aggregation agonist. We compared PR levels patients who had CAV and patients without sings of CAV on coronary angiography 12 months after heart transplantation. **Results:** Five patients (10.4%) developed CAV after 12 months. Mean PR was 517 AUC (SD ± 178) and 488 AUC (SD ± 230) in patients with and without sings of CAV, respectively. There was no statistically significant difference in PR between the study groups (p=0.79). **Conclusion:** Our results show that baseline PR before transplantation is not linked with CAV development one year after heart transplantation. These results warrant further investigation on larger number of patients using other platelet activation agonists as well. Recipient reaction on donor heart changes with time. It would be reasonable to measure temporal PR changes to evaluate this parameter’s usefulness to predict or indicate CAV development.

Ivan Zeljković, Šime Manola, Vjekoslav Radeljić, Vassil Traykov, Vedran Velagić, Borka Pezo Nikolić, Andrej Pernat, Matevž Jan, Ante Anić, Janko Szavits Nossan, Nikola Pavlović

**Background:** The pulmonary vein isolation (PVI) is a cornerstone of catheter ablation for atrial fibrillation (AF). According to current guidelines, PVI is indicated in selected patients with paroxysmal and persistent AF with the goal to reduce AF burden and symptoms (1). There are several technologies with novel technologies emerging constantly. Also, procedures differ (mainly in the trans-septal puncture, use of fluoroscopy and mapping systems) between centres. There are recommendations for periprocedural anticoagulation but different approaches to anticoagulation have not been evaluated in clinical registries. Aims: to establish a multicenter, multinational PVI registry and evaluate patient periprocedural management with emphasis on anticoagulation therapy and adherence to current guidelines. **Patients and Methods:** We have set up a online based registry of PVI which includes the following southeast and central European countries (number of centers): Croatia (4), Slovenia (2), Serbia (2), Bulgaria (1). Registry constitutes of 130 parameters that are filled up by drop down menu. To complete the online forms it takes 10-12 minutes per patient after the PVI procedure. **Results/Current status:** Since initiation of the registry five months ago, 150 consecutive patients who underwent PVI have been included in 7 centres. However, 3 centres have included less than 10 patients and there are still 2 centres that have not started the enrolment. Among 150 entries, 10 (6%) are incomplete, while other contain all 130 parameters. **Discussion and conclusion:** Registries are becoming increasingly popular, widespread and large in size (2). Our registry was established to provide us ‘’real world’’ data on PVI periprocedural patient management. Also, registry upgrade is being performed to allow follow up data entries and long term PVI success rates evaluation.

Marina Klasan

Removal of pacemaker system is a process that requires expertise of the operator and the team. The most common indication for removal of pacemaker system is local or systemic infection after implantation. Other less frequently indications for removal are electrode breakage, insulation damage as well as bad position of electrodes itself. Until recently methods that physicians used was a pulling force or procedure with weight that usually resulted in rupture of the electrodes or parts of them leading to serious complications endangering the patient s life. Last year’s we have witnessed a significant progress techniques and tools allowing the removal of permanent pacemaker system safer and more successful. (1)

Stana Košćak, Luca Marković, Antonija Pejaković

It is well known that heart failure is the most common discharge diagnosis in patients older than 65 years. (1) Due to the ever-improving medical care average life span is increasing and the incidence of patients with chronic heart failure with it. A cardiology nurse more and more commonly meets patients who were shortly hospitalized and then released home, but their psychophysical capabilities for self-assistance are diminishing. An overall impression points towards a very ill patient. The family, along with the patient himself, is under heavy burden when taking care of such patients and is often exhausted. Active participation of a cardiology nurse, as patient’s advocate, during hospitalization and discharge, can increase the quality of life of patient and his family. An active participation of a nurse in discharge papers is essential, so that the patient can be recognized as a palliative cardiology patient. Our healthcare system recognizes palliative patient with diagnose Z515. During hospital care and discharge of a patient with chronic heart failure in a functional NYHA IV class, it is very useful to consider palliative care for the patient. It is crucial to involve and educate the patient and family in making the decision about accepting palliative care, as well as scope and form of palliative care which can then be planned after hospital discharge. Health care team is obliged to respect a patient’s right to make the decision after receiving adequate information. Using this approach writing a discharge letter will be easier and more useful for the patient and his family. That is the moment where continuous palliative care begins and agreed care continues. It is good to have in mind that a patient who is on a waiting list for mechanical heart support, surgical treatment or heart transplantation, can stop being palliated, but as living in the present we need to provide the assistance that is needed when it’s needed. Palliative care needs to be available with the possibility to choose the place of care. The expert team that takes care about the patient in hospital (physicians, bachelor nurse, psychologist, physiotherapist, social worker, priest) is formed individually after involving the patient and the guardian. On a family meeting, which should be organized the moment patient is admitted, adequate care plan is made, adjusted to expectations and possibilities. Special care is made to provide information to the patient, to provide autonomy, dignity, respect, and a relationship based on truth and confidence. Part of the plan is to involve and educate daily visitors through active participation in patient management. Beside active participation in care, written materials about the hospital and taking care of difficult patient are given, and if needed, materials about urinary catheter care, bedsores, pneumonia prevention, contractures, preventing skin defects, PEG tube, tracheal cannula, suction devices, life with VAD etc. Bedsores presents during admission are photographed. They are integral part of planned intervention in medical care and, with a photo on the discharge day, are enclose into the medical documentation.

Ivana Matoš, Sonja Kalauz

Cardiovascular diseases are the leading public health problem. Available data from the World Health Organization from 2016 for the year of 2012 shows the increase in mortality from cardiovascular diseases. Only in 2012, 17.5 million people worldwide died from cardiovascular diseases. Latest report from the Croatian Institute of Public Health shows that mortality the leading cause of mortality are cardiovascular diseases with 47.43% of the total population died in 2014. (1) Heart failure is a leading cause of morbidity and mortality in the world. Choices of treatment are medication therapy, surgery and heart transplantation. Left ventricular assist device is a mechanical circulatory support for the left ventricle. Right ventricular assist device is mechanical circulatory support for the right ventricle. Biventricular assist device is used in the treatment of double-sided cardiac decompensation. Also, for the mutual treatment both-sided heart failure, there is temporarily totally artificial heart - TAH. Mechanical heart has a role of bypass until heart transplantation, as heart muscle recovery or as ultimate choice of therapy. (2) Nursing care of patients with mechanical heart is a very complex part of nursing. Nurses who care of patients with mechanical heart should have completed additional training and certification program, for example, program SynCardia TAH-t, which confirms that the acquired competencies and level of knowledge for care of this group of patients. Care of patients with mechanical heart requires continuous education of nurses, following the latest data, results of research and application of methods, holistic approach and professional collaboration with team members. Regular assessment, control monitoring and recording the value of vital signs, recognizing early signs of complications are the main tasks of nurses. Very important is the knowledge of the models and the method of operation of devices for mechanical circulatory support, treatment of established protocols for the proceedings. Nursing interventions include constant monitoring of the health status of the patient and the response to the application of appropriate therapy, management of nursing documentation and reporting doctors about the procedures.

Krešimir Librenjak, Karla Zubčić, Ana Martinović, Ante Anić

Implantable cardioverter defibrillator (ICD) has been for a long time the most important device in prevention of sudden cardiac death caused by malignant arrhythmias, be it in primary or secondary prevention. (1) The device uses extreme precision and programmed sensitivity of 0.3 mV to recognize fine amplitudes of ventricular fibrillation (VF) and, following detection and arrhythmia confirmation, delivers programmed therapies. In a small number electromagnetic interference from an external source can conceal the cardiac signal and lead to inappropriate shock delivery. The electromagnetic interference that the device senses instead of a cardiac signal is usually caused by faulty electrical devices, various muscle stimulators, transcutaneous nerve stimulation, alternating current of 50 Hz in defective home installations which is the case in old housing objects, working with electrical appliances in the rain, cleaning of fish tanks while it’s systems are under voltage. Actually, working with any kind of faulty electrical appliance, especially in moist conditions, can lead to leakage of alternating electrical current and detection of that current by the ICD. During regular check-ups of implanted ICDs in our patients we have noticed a certain number of stored episodes when the cardiac electric signal was disguised with electromagnetic interference, ensuing in a detected and inaccurately interpreted arrhythmia. In one case ICD had, due to a longer lasting influence of alternating current of minimal power (voltage), detected VF and delivered an inappropriate shock. The event happened while the patient was taking a shower in a bathtub with inappropriately designed electrical installations in an old apartment building. The first recommendation to the patient was to take the shower with all the appliances turned off inside the bathroom, and the next step would be changing and repairing electrical installations by professional staff.

Nikola Pavlović, Vjekoslav Radeljić, Ivan Zeljković, Ivica Benko, Šime Manola

**Background:** Ablation of ventricular tachycardia (VT) in structural heart disease (SHD) is an effective tool to prevent VT reccurence, improve quality of life and reduce therapy with implantable cardioverter defibrillator (ICD). (1) **Patients and Methods:** Patients treated for sustained VT who underwent radiofrequency ablation from December 2014 until September 2016 in University Hospital Centre ‘’Sestre milosrdnice’’ were included. Electrophysiology studies were performed according to local protocols. Acute success rates, complications and hospital outcomes were evaluated. Also, clinical data and implantable cardioverter defibrilator data were evaluated during the follow up. **Results:** Total of 36 patients were reffered for ablation of sustained VT. Among those, 8 (22%) had no overt SHD while 28 (78%) had SHD. 16 patients (57%) had ishemic heart disease (IHD) while 12 (43%) had non ischemic heart disease (NIHD). 2 patients with IHD (12.5%) had stable VTs that were mapped and ablated while 14 (87.5%) had unstable VTs and substrate modification was performed. In patients with IHD all patients had non inducible clinical VT or any VT at the end of the procedure. There were no procedure related complications. There was one in hospital death (6.2%) due to severe, prolonged cardiogenic shock four days post ablation. After median follow up of 7 months (4-14) there was one re-do procedure. In patients with NIHD 4 (33%) had bundle branch reentry VT, 2 had focal VTs originating from papillary muscle and aortic cusp. 2 patients had VT that was ablated at lateral mitral annulus. 4 (33%) patients had either polymorphic VT or unstable VTs that could not be mapped with no identifiable substrate endocardially. **Conclusion:** Results and experience are comparable to those reported in larger studies. Ablation of sustained VT in patients with SHD is a useful tool to prevent VT reccurence and reduce ICD therapies. However, it should be performed in high-volume centers with standardized protocols for ablation, monitoring and care.

Zoran Bakotić, Marin Bištirlić, Ante Anić

**Introduction**: There are emergency situations in everyday cardiology practice that can been easily solved with basic electrophysiological maneuvers and with greater safety for the patient compared to conventional treatment methods. (1) **Case report**: We report a case of a 76-year-old patient with a history of myocardial infarction 10 years ago, now presenting to Emergency Department with mild chest pain during last 3 hours, caused by sustained ventricular tachycardia with frequency of 140 bpm. Beside mild chest pain the arrhythmia was well tolerated, without signs of hemodynamic instability. From the available medical history there was information about persistent atrial fibrillation for the past 5 years and it was recommended anticoagulant therapy which he did not take (CHA2DS2-Vasc = 4). Last echocardiographic report described hypokinetic basal segment of posterior wall of left ventricle with a relatively preserved LVEF of 45%. Pharmacological conversion with amiodarone was attempted but with no success, and even after 10 hours of ongoing arrhythmia a patient showed no signs of hemodynamic instability. A synchronized electrocardioversion under general anesthesia was planned but with high probability of atrial conversion as well and thus the risk for thromboembolic incident in the case of the presence of thrombus in the left atrial appendage (LAA). Therefore, we decided to try another approach and the patient was transferred to the EP lab. After placing the intracardial ultrasound probe in the right atrium, an LAA with thrombotic masses was showed. A standard diagnostic electrophysiological catheter was placed in right ventricle (RVA) and ventricular tachycardia was terminated with simple overdrive pacing and the patient remained in atrial fibrillation with normal ventricle frequency and without problems. **Conclusion:** There is remaining dilemma regarding further treatment of this patient like permanent anticoagulant therapy, implantation of an implantable cardioverter-defibrillator or just radiofrequency ablation without implantation of device, only medication therapy?!

Ines Potočnjak, Matias Trbušić, Sanda Dokoza Terešak, Bojana Radulović, Gudrun Pregartner, Saša Frank, Vesna Degoricija

**Aim:** To investigate whether patients with acute heart failure and concomitant metabolic syndrome have worse outcome, longer hospitalisation, higher in-hospital and three-month follow-up mortality. **Patients and Methods:** The study was performed as a prospective, single-centre, observational research on 152 patients, defined and categorized according to the ESC and ACCF/AHA Guidelines for HF. **Results:** Mean age was 75.2 years (SD 10.3), 52% were female, mean body mass index (BMI) 28.8 kg/m2 (SD 5.4). Hospital mortality was 14.5%, three-month 27.4%, length of hospitalisation 11.34 (SD 9.26) days. Patients with metabolic syndrome were hospitalized longer comparing to those without metabolic syndrome. Unexpected, patients with acute heart failure and concomitant metabolic syndrome had better survival. Univariate analysis revealed higher odds ratio for in-hospital and three-month mortality in patients without metabolic syndrome. Paradoxically, higher BMI (≥25 kg/m2), total cholesterol and blood pressure were associated with lower odds ratio of in-hospital and three-month mortality. Lower HDL and higher IL-6 were associated with higher three-month mortality. **Conclusion:** Patients with metabolic syndrome were longer hospitalized, patients without metabolic syndrome had higher odds ratio of in-hospital and three-month mortality. Results of this study suggest that “reverse epidemiology” emerged (1-3). Reverse epidemiology is paradoxical association of lowered BMI, total cholesterol concentration, and blood pressure with higher morbidity and mortality in patients with heart failure. To conclude, results emphasize importance of diagnosing metabolic syndrome, lipid control and hypolipemic therapy re-evaluation.

Edhem Kobilić, Elnur Smajić

Atherosclerosis is progressive disease. Changes in arterial blood vessels, with the process of formation of atherosclerotic plaques, are substrates on which consequently arise various forms of vascular changes. The fight against atherosclerosis must be directed to change course of disease, against risk factors responsible for speeding up the process of atherosclerosis. Current models of prevention are not reduce the prevalence of risk factors – epidemic lasts. It is necessary to change the concept that have failed. (1-3) Critical analysis opposes two concepts. The **old** one, unites necessary actions to bring the patient in better physical, psychological and social conditions, to take over the achieved position in society with active life. The **modern** one focuses on quality of life by: - helping and motivating patients: - to change lifestyles - fighting the influence of risk factors - the final effect is an improvement of the prognosis. (4) It starts from the active relationship of the individual to their own health and the adoption of personal responsibility, with economical aspects. It is sports recreation – personal activity on health improvement. Motivation of patient, can stimulate one who does know how to explain all details related to the causes of pathological condition and possible treatment options. This task can be performed by a cardiologist, or a specialist of sports or recreational medicine. The marathon distance is between the need for a change in lifestyle to realization of reeducation and the adoption of positive behavior styles. The best place for it is counselling. The prevention of cardiovascular diseases ideally begins during pregnancy and lasts for life, but is most effective in children and adolescents. It is more effective than pharmacological treatment, and brings enormous economic benefits. The gap between scientific findings and implementation in clinical practice is big. The modern concept is the complex one, changing lifestyles and eliminating risk factors, one can preserve and improve health. It is necessary, that new health profiles and efforts to develop the initial structure to the end. Recreational medicine needs to establish itself in an area that belongs in it.

Lovel Giunio, Anteo Bradarić, Jakša Zanchi, Mislav Lozo, Dino Mirić

**Background:** Current guidelines state that it is reasonable to consider unprotected left main PCI in patients with low to intermediate anatomic complexity who are at increased surgical risk. (1) Coronary bifurcation lesions are considered technically challenging and associated with worse clinical outcomes. (2) We present a complex left main bifurcation lesion treated with a dedicated sirolimus eluting bifurcation stent, BiOSS Lim in combination with plain balloon angioplasty (POBA) of circumflex artery. The dedicated stent protects the carina from being damaged, the large cell at the middle zone gives possibility to enter easily into the side branch with any standard size conventional device. (3) **Case report:** 90-year-old man with a history of hypertension and non ST-segment elevation myocardial infarction (NSTEMI) which he had suffered five months earlier presented with an unstable angina. During hospitalization unstable angina has evolved to NSTEMI leading to acute pulmonary edema. Diagnostic coronary angiography revealed a 90% stenosis in distal left main coronary artery (LM), 80% stenosis in proximal segment of circumflex coronary artery (Cx) and 90% stenosis in mid and distal segment of right coronary artery (RCA). SYNTAX score was 22. For PCI SYNTAX Score II was 41.5 with predicted 4 year mortality of 16.9% and for CABG it was 52.9 with 4 year mortality of 38.3%. EuroSCORE was 29.16% and EuroSCORE II was 9.58%. Considering calculated scores and patient’s wish to be treated by less aggressive medical procedure, PCI was performed. PCI was performed using a right radial artery approach. With 6F JL 4 catheter the left main coronary artery was engaged. A Runthrough Floppy str/180-cm was placed in distal segment of Cx and another wire, Whisper MS str/190 cm was placed in distal segment of LAD. Predilatation in distal LM was done with balloon PTCA catheter Mini Trek 1.20x15 mm and afterwards with balloon Mini Trek 2.5x15 mm. Then a bifurcation drug eluting stent (DES) BiOSS Lim 3.0 distal – 3.75 prox. was implanted, with the larger diameter in distal segment of LM and with smaller diameter in proximal segment of LAD. After BiOSS Lim stent implantation, POBA was performed in mid segment of Cx without predilatation to dilate the stent struts. Final angiography showed adequate flow. This is the first use of BiOSS Lim stent in University Hospital Centre Split.

Ivana Jurin, Boris Starčević, Dražen Šebetić, Mario Udovičić, Ana Jordan, Aleksandar Blivajs

**Introduction:** Pulmonary valve stenosis (PS) is a heart valve disorder in which outflow of blood from the right ventricle (RV) of the heart to the lungs is obstructed at the level of pulmonic valve. It is usually congenital and the prevalence of PS has been reported at 0.6 to 0.8 cases per 1000 live births. It can be due to isolated valvular (90%), subvalvular or supravalvular obstruction, or it may be associated with other congenital heart disorders. 1982 is the year when the technique of percutaneous balloon pulmonary valvuloplasty (BVP) was introduced and replaced surgical methods of treatment. (1, 2) **Case presentation:** We present a case of 67-year-old man with congenital PS. He complained of occasional chest tightness and shortness of breath. There was Grade V/VI middle systolic crescendo-decrescendo murmur over the pulmonary area. Computed tomography, of the chest revealed marked enlargement of the left pulmonary artery (up to 43mm). Transthoracic echocardiography (TTE) revealed valvular PS (Vmax 5.66m/s) with RV wall hyperthropy (11-12mm) and transpulmonary pressure gradient (PG) was 128 mmHg. BPV was performed three days after admission. Initial hemodynamic measurement reported RV pressure of 140/0/12 mmHg and PA pressure 30/16/20 mmHg. After these measurements, balloon valvuloplasty was performed with subsequent decrease of RV pressure to 60/0/10 mmHg. At the follow up visit one year later the patient was asymtopmatic, and on TTE PG measured 51 mmHg with mild pulmonary regurgitation. **Conclusion:** Balloon valvuloplasty is the treatment of choice in the management of moderate to severe PS in adults with good short and long-term results..

Žaklina Muminović, Lidija Brkljačić, Mažuran, Jadranka Dražić-Balov, Srećka Glavaš, Vražić, Mario Ivanuša

The procedures performed by the Bachelor of Physiotherapy are an indispensable part of cardiovascular (CV) rehabilitation following the initial workup performed by a cardiologist, physician, Bachelor of Nursing and Occupational Therapy, and, if necessary, by a psychologist. The goals of physiotherapy interventions in patients undergoing the CV rehabilitation are the improvement of the functional capacity and the stabilization of the condition in order to achieve better control of the disease and present comorbidities, social reintegration and recovery of the working abilities. (1, 2) Physiotherapy (FT) program in CV rehabilitation starts with an evaluation of the patient’s condition performed by analyzing medical records, taking FT medical history, evaluating the condition by SOAP and ICF classification models, thereby using one-dimensional or multidimensional standardized and non-standardized questionnaires for evaluation of the effects of the FT process: stress test, anthropometric measures - body mass index, the waist to hip ratio, respiratory index measures, VAS pain scale, extremity volume, the Borg Scale of Perceived Exertion, voice test, 36-Item Short Form Health Survey (SF-36), FIM – Functional Indepedance Measure and other tests for the evaluation of comorbidities. After the Bachelor of Nursing has completed the therapeutic education on CV risk factors and proper testing of the heart rate and blood pressure, Bachelor of Physiotherapy will continue with conducting the education on the guidelines and legislation pertaining to applying physical exercise, proper breathing, relaxation techniques and posture improvement. Individual needs (type, duration, frequency, intensity) are identified for FT interventions that are performed by applying the cardiorespiratory and vascular therapy methods. (3) This is followed by the interval CV training consisting of the therapeutic exercises mainly of aerobic type, riding a manual bike, riding on a modern computer controlled pedal bike, where treadmill walking is done in case of present peripheral arterial disease, while we also create some other individual programs if indicated by a physiatrist in case of comorbidities. The cardiology societies recommend 36 CV trainings in duration of up to 60 minutes, while the frequency of coming is 3-5 times a week for 3 months. Stress tolerance, clinical status and vital signs are monitored while doing the training, where the electrocardiogram is monitored by telemetric monitoring for several times (at the beginning, in the middle, at the end, and when changing the intensity of the stress). Subject to the assessment of the importance of subjective discomforts, the team makes a decision on the need to change the FT plan and intervention. The effect of the interventions or the CV treatment plan is modified at follow-up examinations and regular meetings of the CV rehabilitation team. At the end of the program, the discharge is being planned when a final FT assessment and evaluation is made. The Bachelor of Physiotherapy documents all elements of FT interventions performed by using the diagnostic and therapeutic procedure codes in specialist-consulting healthcare prescribed by the Croatian Health Insurance Fund. The timely CV rehabilitation in specialized institutions with modern equipment (1, 4), such as Institute Srčana has been conducted by a team of continuously educated health professionals since 1982, providing safety and quality of performed outpatient CV rehabilitation for approximately 400 new patients on an annual basis.

Igor Rudež, Josip Varvodić, Davor Barić, Daniel Unić, Robert Blažeković, Mislav Planinc, Marko Kušurin, Michael Markin, Savica Gjorgjievska, Željko Sutlić

**Introduction**: Extensive aortic pathology with concomitant valvular disease is a challenge for the surgeon. Careful and detailed planning of procedures and thorough preoperative diagnostics are essential for the outcome. (1, 2) **Case report:** We present a case of a 45-year-old male who is under cardiologist control since early childhood and was operated due to aortic coarctation at the age of nine. He presented to the emergency room with chronic heart failure symptoms. MSCT angiography showed aneurysm of descending aorta 88mm x 85mm and stenosis of the arch proximal to the left subclavian artery up to 22 mm. Transthoracic/transoesophageal echocardiography revealed EF 40%, LA 5.1 cm, LVd 6.2 cm, LVs 5 cm, aortic valve bicuspid, sclerotic PPG 41 mmHg, MPG 29 mmHg, area 1.2 cm2 AR 2+, MR 3+ VC 6mm, TR trace. Elective surgery was planned. Under direct visualization a size 24 E-vita open plus stent graft (JOTEC GmbH, Germany, Hechingen) was deployed, aortic arch was replaced with the vascular part of the E-vita open plus, and supraaortic branches were reimplanted using the island technique in circulatory arrest (55 min) with bilateral antegrade cerebral perfusion and moderate hypothermia (28°C). Aortic valve replacement (Carbomedics Mechanical 21), mitral valve repair (Carpentier Edwards Physio II ring 30 mm), tricuspid valve repair (Edwards MC3 Tricuspid Annuloplasty System 30 mm) were done respectively. Left carotido-subclavian bypass was performed to ensure better landing zone for the Evita open plus stent graft (zone II). The patient recovered well from surgery and postoperative ECHO has shown normal function of valves with perfect position of the stent graft with complete exclusion of the aneurysm from circulation. The patient was discharged home seven days after surgery, and was without complications after three months follow up. **Conclusion**: Detailed planning of extensive cardiac surgery procedure can predict successful outcome.

Danilo Gardijan, David Ozretić, Katarina Starčević, Branko Malojčić, Zdravka Poljaković, Marko Radoš

**Introduction:** With careful patient selection and multidisciplinary approach, carotid artery stenting (CAS) showed similar risks and benefits as carotid artery endarterectomy (CEA). Angioplasty of atherosclerotic plaque is the most important step during the CAS because it bears the risk of releasing plaque debris into the intracranial circulation. Distal embolic protection devices were developed to prevent stroke as one of the major complications during the procedure. Due to non-conclusive results of their efficiency in some of major trials and other complications that can theoretically occur during employment of such devices there are large differences in frequency of their use among operators. (1) Objective of this study was to compare incidence of clinical evident stroke in early postprocedural period in patients who had CAS with distal embolic protection with patients who had the same procedure without distal embolic protection. **Patients and Methods:** We retrospectively analyzed data of patients that were endovascularly treated for carotid artery stenosis in our department from 2006 to 2016, and searched for clinical evidence of stroke that could be attributed to the procedure. During that period there was 335 CAS procedures for atherosclerotic stenosis, with 94 procedures with and 241 without distal embolic protection. **Results:** We found no significant difference in periprocedural stroke incidence in two groups of our patients. **Conclusion:** Although our study is retrospective case-control study we displayed safety of our current CAS protocol which does not include distal embolic protection for all patients.

Ivana Jurin, Marko Ajduk, Diana Rudan, Marijan Pašalić

**Introduction:** The increased red blood cells distribution width (RDW) is associated with poor prognosis in patients with cardiovascular (CV) disease and it is a predictive factor for cardiovascular mortality in the general population. Recently, the link between the RDW and the development of diabetes was found. (1) Objective: The increased RDW is associated with CV and overall mortality in patients with heart failure, myocardial infarction, and stroke. Here we present the results of a subanalysis research of the relationship between resistin and other biomarkers of atherosclerosis, in which we have included the RDW with histology of atherosclerotic carotid plaque with emphasis on the influence of anthropometric factors (age, sex, body height, body weight and waist circumference) on the RDW width. **Patients and Methods:** The study included 78 patients (30 women) with significant carotid artery stenosis which were planned for an elective endarterectomy. Blood samples from each patient were taken prior to surgery and RDW was measured (12.4-18.9, mean 13.589%) and anthropometric data were determined as follows: age (45-84; mean age, 66.83 years), body height (148 to 187; mean height 168.78 cm), body weight (47-110, average weight 80.49 kg), and waist circumference (75-122, midrange 101.27cm). **Results:** Subanalysis of data showed statistically significant positive correlation between the RDW and waist circumference (p=0.0034). **Conclusion:** This research showed a positive correlation between RDW and waist circumference for all patients with significant carotid artery stenosis, regardless of age and gender. Positive correlation between RDW and waist circumference which is a risk factor for the development of metabolic syndrome leads to the postulate that the possible inflammatory events might be the cause of increased destruction of red blood cells. Measuring of RDW is applicable and cheap as well as measuring waist circumference which is very useful in determining CV mortality.

Rina Dalmatin, Davorka Lulić, Gordan Gulan, Luka Zaputović, Alen Ružić

**Introduction**: Infective endocarditis (IE) is a life-threatening disease of the heart valves that despite modern therapeutic options has a poor prognosis and high mortality. IE occurs more often in patients with acquired or congenital heart disease, and the etiology is usual bacterial. Echocardiography has the key role in establishing the diagnosis. Given the different, often atypical forms of presentation, this complex infectious disease still represents a diagnostic challenge despite the progress of clinical practice. (1-5) **Case report**: 47-year-old patient with quarterly intermittent fever and pain in the right hip, was hospitalized becomes because of dry cough and breathlessness at minimal effort that occurred few days before admission. Two months earlier, the patient was treated at the Clinic for Orthopaedic Surgery due to synovitis of the right hip. The emergency echocardiography showed endocarditis of the bicuspid aortic valve with severe aortic and mitral regurgitation. Transesophageal ultrasound demonstrated a paravalvular abscess of the aortic valve that was expanding forward the base of the anterior mitral leaflet. With administration of empirical antibiotic therapy, and after hemodynamic stabilization, the patient underwent emergency cardiothoracic surgery. The biological aortic and mitral valve were successfully implanted. From later received blood cultures, Streptococcus sanguis was isolated. **Conclusion**: IE may have a number of different and often atypical clinical presentations. In every prolonged febrile disease course, we should think on IE. Febrile inflammation of the musculoskeletal system of unknown etiology may represent the first manifestation of IE. Patients with congenital heart disease such as bicuspid aortic valve, are at particular risk for the development of IE. Although in this case the bicuspid aortic valve represents a predisposition for the development of IE, the fact that the Streptococcus sanguis endocarditis is more frequently in patients with malignant and inflammatory gastrointestinal diseases bring us to the question on subsequent gastrointestinal treatment in the present case.

Rreze Koshi, Maja Strozzi, Davor Miličić

**Introduction;** The main aim of this study is to determine the correlation of the prothrombin time and accelerated prothrombin time in patients who have stent thrombosis which is implanted drug-eluting stent (DES) and bare-metal stent (BMS). (1) **Patients and Methods:** The study is completed and included in 60 patients and we measured the laboratory test parameters of prothrombin time and accelerated prothrombin time. The study was obtained in the prospectively manner in the period from January 2008 to January 2009 in University Hospital Centre Zagreb. The patients were classified in the groups with the cororanography and the Interventional procedure,also we divided the patients with DES and BMS. **Results:** With T test we did not find an important significant differences in prothrombin time in the patients with stent thrombosis and without stent thrombosis. (T=1736, P=0.087). Also we did not find an important significant statistic differences in accelerated prothrombin time in the patients with and without stent thrombosis (T=0.606, P=0.546). **Conclusion:** Prothrombin time and accelerated prothrombin time did not mach any significance in the patients with and without stent thrombosis. Applying the dual of the antiplatelet therapy decrease the incidence of the stent thrombosis. The metaanlaysis of th new inhibitor P2Y12 reduce the mortality after PCI compared with clopidogrel and are very effective in the STEMI patients treated with PCI. Prasurgel and ticagrelor have the same efficacy but more protective of the stent thrombosis is prasurgel is also with the incidence of bleeding.

Zvonimir Ostojić, Joško Bulum, Maja Strozzi, Ivica Šafradin, Višnja Ivančan, Jadranka Šeparović Hanzevački, Vlatka Resković Lukšić, Bojan Biočina, Davor Miličić

Transcatheter aortic valve implantation (TAVI) has been shown as adequate modality for treatment of high risk or inoperable patients with severe symptomatic aortic stenosis (AS). (1, 2) In this abstract data concerning TAVI from University Hospital Centers Zagreb are presented. In total 44 TAVI were preformed in our institutions. All decisions regarding performing TAVR instead SAVR were made by „heart team“. Most common indication for TAVI was high surgical risk (71%), followed with porcelain aorta (16%), extensive thorax radiation (9%) and previous SAVR – „valve in valve“ procedure (4%). Of all patients, 31 (70.5%) were female and overall average age was 80.3 years. Average NYHA score was 3 and mean STS-mortality score 5.34. Average maximal gradient across valve before TAVR was 88mmHg with average AVA of 0.66cm2. 39% of patient had coronary artery disease and all of those were treated either with CABG or PCI prior to TAVI. Almost all possible approaches were used (trans-apical, -carotid, direct aortic) but majority of procedures were performed using transfemoral approach (86.4%), from which 71% were done using surgical closure of femoral artery, while in rest of the cases Proscar was used. Valve was successfully implanted in 41 (94%) cases. In those, maximal gradient over aortic valve after TAVI was 19 mmHg followed with significant improvement in functional status. From three patients in whom implantation failed, one had to be converted in rescue SAVR, one is candidate for re-implantation, due to embolization of valve in aorta and last one had persisted sever aortic regurgitation. Five patients had some form of vascular complication; three were connected with vascular access and two had cardiac tamponade. After the procedure 6 patient (13.6%) developed some degree of atrioventricular block, from which 3 required permanent pacemaker implantation. None of the patients developed CVI or myocardial infarction. Overall in hospital mortality was 4.6%, and one-year mortality was 5.5%. When compared to data in larger registries our results are almost the same and in some categories even better. In conclusion, TAVI is adequate treatment option for selected patient with sever AS, but reimbursement issues are main barrier for performing optimal number procedures in Croatia (at least 30/million inhabitants).

Dubravka Kruhek, Leontić, Mario Ivanuša

In the last few decades, the awareness of the impact of the psychological functioning on the cardiovascular (CV) system has been rising. Science has first recognized the negative effects of stress followed by other psychological factors. Recently, attention has been focused on the negative impact of depression and anxiety on the development of CV disease and the prognosis of patients after CV incident. Accordingly, many countries and global organizations have recognized the need for a comprehensive CV rehabilitation. Modern rehabilitation of CV patients should therefore involve well-educated interdisciplinary team that will, among other things, provide patients high quality psychosocial care. (1) Various scientific sources suggest that 11-25% of patients with coronary heart disease develop clinically significant depression, and about 30% have a mild depressive disorder. 10-50% CV patients develop clinically significant anxiety. The problem concerning the psychological risk factors is even greater with respect to the results of research on sub-diagnostics and failure to treat mental diseases and disorders in CV patients. Institute for Cardiovascular Prevention and Rehabilitation has in the last two years in its outpatient cardiac rehabilitation program, along with standard psychological care (2), taken steps for early detection of psychological risk factors and the overall management of patients with severe mental disorders. Thus, all patients are at the time of enrollment subject to screening for anxiety and depression by using Hospital Anxiety and Depression scale (3). In addition to a psychologist working for the Institute, the team is also joined by permanent associate - a psychiatrist from the Psychiatric Hospital “Sv. Ivan”. For patients who are assumed to need additional workup and permanent treatment, care is provided in the Referral Centre of the Ministry of Health for Disorders Caused by Stress, in the University Hospital Dubrava. In this way, the care of psychological risk factors has been completed and the element for effective CV rehabilitation has been added.

Željko Baričević, Joško Bulum, Maja Strozzi, Boško Skorić, Jadranka Šeparović, Hanževački, Davor Miličić

Balloon aortic valvuloplasty (BAV) may be used in high-risk patients with severe aortic stenosis and temporary contraindications to immediate intervention (1). It serves as a brief temporizing procedure with a poor long-term outcome (2); however, as a bridge therapy, it is associated with rapid clinical and/or functional improvement allowing eligibility of majority of these patients for definitive invasive treatment, including surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI). TAVI has emerged as an excellent alternative treatment for poor surgical candidates and the number of BAV procedures is expected to increase in the near future. To our knowledge, BAV has been used sporadically in the past years in Croatia. As institutional practices and physician biases can affect patient selection and management approaches to severe aortic stenosis, it is important to have the facility that can offer BAV (especially in the TAVI era) as another management option for patients who would otherwise have been considered unacceptably high risk for aortic valve intervention. We present a short overview of our one-year experience upon systematic BAV reinstitution, following the development of a TAVI programme in University Hospital Centre Zagreb. The classic retrograde technique using 11 F femoral arterial sheath, transvenous temporary cardiac pacing and left transradial approach for ascending aorta pressure monitoring was used. The results of the procedures conducted on 13 patients (7 male, 6 female) between 51 and 90 years of age (78 years on average) and mean left ventricular ejection fraction 30% were very promising. The mean aortic valve area increased from 0.61 ± 0.17 cm2 to 0.83 ± 0.24 cm with an acute drop of the mean transaortic gradient from 37 ±18 mmHg to 26 ±13 mmHg. Among serious adverse events there were no cases of intraprocedural death, stroke, coronary occlusion, severe aortic regurgitation, tamponade or need for permanent pacemaker. Vascular complication occured in 1 patient (non-occlusive femoral artery dissection) and resuscitation/cardioversion was done in 1 patient. 30-day mortality was 15,4%.

Boris Starčević, Mario Sičaja, Ana Jordan, Vanja Ivanović, Hrvoje Falak, Ognjen Čančarević, Ante Lisičić

**Introduction:** Patients with complex or high-risk coronary lesions, such as those with the critical stenosis of left main, multi-vessel coronary disease or last remaining vessel, are increasingly being treated with percutaneous coronary intervention (PCI). Periprocedural hemodynamic compromise and complications may occur rapidly so many of these high-risk procedures are being performed with some kind of mechanical circulatory support. Recently, an extracorporeal membranous oxygenation (ECMO) was suggested as a mechanical support for high risk PCI. (1, 2) **Case presentation:** We present a case of a 76-year-old female who was hospitalized in Coronary Care Unit due to unstable angina. Echocardiography showed mildly reduced systolic function of left ventricle (LV) with akinesia of anterior wall of LV. Coronary angiogram revealed multivessel disease, with significant stenosis of left main, significant stenosis of ostial portion of left anterior descending artery, midportion of left circumflex artery (ACx), ostial, proximal and midportion of right coronary artery and bifurcational highly significant stenosis of ACx with the first obtuse marginal branch (MEDINA 0,1,1). The calculated Syntax score was 41. Cardiac surgeon denied operation due to advanced age of the patient and calcified aorta. Due to high-risk PCI, veno-arterial ECMO support was introduced and total coronary revascularization was done with an optimal final result. Pre-discharge echocardiography showed improved systolic function and two years’ follow-up is without any drawbacks (stable angina pectoris CCS 1). **Conclusion:** ECMO mechanical support is a reasonable option for patients with a high-risk PCI. In our opinion it is of outmost importance to recognize the need for hemodynamic support on time in order to avoid periprocedural complications. Furthermore, it is important to have highly trained team in order to reduce possible ECMO related complications to the bare minimum.

Lovel Giunio, Mislav Lozo, Anteo Bradarić, Jakša Zanchi

**Background:** Untreated massive pulmonary embolism (PE) results in mortality rate of approximately 30%, most frequently within the first few hours of onset and up to 50% 3-month mortality. Catheter-directed therapy (CDT), due to mechanical fragmentation of the clot, removal of obstructing thrombi from the main to distal pulmonary arteries and thrombolytic-enhanced clot lysis, offers rapid reducing of pulmonary artery pressure, right ventricle strain, and pulmonary vascular resistance while simultaneously increase systemic perfusion and facilitate right ventricle recovery. (1) Systemic thrombolytic application carries up to a 20% risk of major bleeding, including a 2% to 5% risk of intracranial hemorrhage and is unwillingly prescribed. (2) CDT offers interesting alternative since, due to local application, dose can be significantly reduced. So far, predominantly the proximal venous access sites, most often transfemoral or transjugular, were used. We report the results of first CDT treatments via the antecubital venous access. **Patients and Methods:** 17 consecutive patients presenting with clinical diagnosis of acute PE confirmed by computed tomographic angiography from January to August 2016 were enrolled in the trial. CDT involved mechanical catheter fragmentation and the application of adjuvant thrombolytic therapy through a pigtail catheter positioned in the pulmonary artery. **Results:** Technical success was achieved in all patients, and in all patients significant improvement in hemodynamics and pulmonary angiography was observed 12 h after procedure (Figure 1). There were no major periprocedural complications. Figure 1. Pulmonary angiogram A) prior procedure shows massive pulmonary embolism B) 12h after catheter-directed pharmacomechanical thrombolysis, almost complete restoration of pulmonary flow. **Conclusion:** Catheter positioned in the pulmonary artery allows continuous assessment of pulmonary hemodynamics, follow-up angiography and additional intervention/s if needed. CDT via cubital vain is feasible in vast majority of patients, offers significant dose reduction with low periprocedural complications and should be considered as a first line treatment for acute PE in experienced centers.

Ana Ljubas

## Dear, distinguished colleagues, It is my great honor and pleasure to welcome you in Zagreb at the 6th Congress of the Croatian Association of Cardiology Nurses (CACN) with international participation. The motto of the congress is “Challenges and new perspectives of a Croatian Cardiac nursing”. In accordance with the well-known tradition of our Congress, it is being held at the same time as the 11th Congress of the Croatian Cardiac Society (CCS). So I take this opportunity to thank the President of CCS academician Davor Miličić on his overall help and support. Cardiac nursing is an active participant in the integration of innovative procedures in cardiological clinical practice. New methods in the diagnosis and treatment of cardiac patients are a challenge for nurses and incentive to constantly search for new knowledge, and to ensure the best possible quality of life of those who need our help. Therefore, our congress aimed to encourage higher standards of professional excellence. This we can see in the Congress program, with numerous lectures and workshops that lead by our invited speakers from local and international cardiology practice and, also, with selected topics and poster presentations that were submitted by nurses and technicians from the Croatian and Slovenian cardiology practice. The Congress is an opportunity to have a regular CACN Assembly. Particularity of this Congress and the Assembly is that this year we celebrate the 10th anniversary of the founding of CACN. Therefore, with wide range professional topics, riche with content, we prepared some surprises too, with the hope that will brighten our friendly gatherings and that Zagreb will stay in your hearts. Welcome to Zagreb! Sincerely yours, Ana Ljubas Congress president

Ljiljana Banfić

The Guidelines on Diagnosis, Treatment and Prevention of Venous Thrombosis (1) created by the Working Group on Angiology and Peripheral Vascular Diseases of the Croatian Cardiac Society is the document synthetized as personal experience but scientifically based on guidelines that were published by ACCP in 2012 and 2016 published in Chest, created by ESC Guidelines on Acute Pulmonary Embolism (2) from 2014 and according to the document of International Union of Angiology 2013. Croatian Cardiac Society as the member of ESC follows all the documents and guidelines published by European Society of Cardiology. Working Group on Angiology and Peripheral Vascular Diseases of the Croatian Cardiac Society faced the needs to offer professional paper on venous thrombosis and thromboembolism that could give the rational strategy and help to overcome diversity in diagnostic and treatment modality of Croatian health professionals for the best of Croatian patients with venous thrombosis. The guidelines will offer the structured pathway in diagnostic, therapeutic and preventive strategies according to specific patient population even before ESC professionals decided to do the same. Concepts in treatment and prevention of venous thrombosis were changed in the past years in most European countries with new drugs; novel anticoagulant drugs that offer greater safety and same efficacy in patients’ management. Those trends were recognized as the challenge to improve and change the therapeutic regime of venous thrombosis and thromboembolism the same as the treatment of acute pulmonary embolism. The guidelines are divided into the chapters starting from epidemiology, diagnostic and therapeutic modalities, the strategy and preventive measures in surgical and medical ill patients, in pregnancy, in cancer patients etc. We expect the professionals would be encouraged with the help of the guidelines, all those who deal with risk and treatment of venous thrombosis such as specialists in cardiology, internal medicine, anesthesiology, geriatric professionals, general practitioners and many other.

Igor Rudež, Josip Varvodić, Davor Barić, Daniel Unić, Robert Blažeković, Mislav Planinc, Marko Kušurin, Michael Markin, Savica Gjorgjievska, Željko Sutlić

**Objective:** Aortic valve replacement (AVR) is still the most commonly used therapeutic option for patients suffering from AR. Aortic valve repair (AVRep) is an attractive alternative method, since it avoids the risks of prosthesis-related complications. (1, 2) We would like to present our experience with the Yacoub root remodeling, valve sparing technique with the extraaortic expansible ring. **Methods:** Between November 2014 and September 2016, a total of 37 patients (52.5±11.5 years; 18.9% female, EuroScore II of 2.8% to 0.46%) underwent AVRep, 6 due to isolated cusp malcoaptation and 31 with associated with aortic root dilatation. Reconstruction was done with the Coroneo Extraaortic Ring (27 (25-29)), and the Gelweave graft (28 (26-32)). Concomitant procedures included MVRep in 3 patients with TVrep in two of them, CABG in two patents and replacement of aortic arch and placement of EVITA stent graft in two patients. Echocardiography was used to determine AR severity grade pre-operatively, during immediate post-operative period (within 7 days from operation) and at early follow-up. **Results:** In postoperative follow-up no patients died. Freedom from reoperation was 92% (3/37) and there were 2 patients reoperated due to early postoperative regurgtation, and one because of early cardiac tamponade. A significant decrease in LV end-diastolic diameter was observed (LVEDD) (60.3/53.3 mm) with further decrease at early follow-up. At follow up none of the patients had major AR (0±0.5, AR0=28, AR1+=7, AR2+=2). **Conclusions:** We have proved that AVRep is a good alternative for patients with aortic insufficiency and leads to LV reverse remodeling with comparable results in terms of LVEDD and LVEF immediately post-operatively and at early follow up.

Verica Kralj, Ivana Brkić, Biloš

Although a trend of reducing mortality from cardiovascular disease (CVD) has been noticed in the developed world in recent decades, CVDs are still the leading cause of death in nearly all countries in the world. According to Global Burden of Disease from 2013, it was estimated that CVDs cause 17.3 million deaths worldwide, i.e. 31.5% of overall mortality. The share of premature deaths from cardiovascular diseases ranges from 4% in high-income countries to 42% in low-income countries, which leads to growing inequality in the incidence and outcomes of CVDs among countries and populations. It is estimated that by 2030, 23.6 million people will die due to CVDs. At European level, this group of diseases is responsible for about 4 million deaths per year, i.e. 45% of all deaths (49% of deaths in women and 40% of all deaths in men). There are great differences or disparities in the burden of CVDs in the European region, as well as in mortality trends. EU member states tend to have lower mortality rates and a significant mortality decrease trend (especially “old” EU member states), compared to other countries in the European region. The range of 10-year reduction of age-standardized mortality rates (from 2003 to 2013) in the “old” EU member states ranges from 25.2% in Austria to 49.7% in Luxembourg for men, while for women mortality reduction ranged from 25.3% in Italy to 49.2% in Portugal. Croatia in this period recorded a decrease in mortality rates of 34.3% for men and 35.2% for women. However, CVDs still remain the leading cause of death in Croatia with 25 694 deaths, i.e. a share of 47.4% in total mortality (52.9% of deaths in women and 41.7% of deaths in men). The leading diagnostic subgroups were ischemic heart disease accounting for 21.2% (11,509) and cerebrovascular diseases, accounting for 13.7% (7433) of total mortality. Comparing the mortality from CVDs in Croatia with other European countries, Croatia with standardized mortality rate of 324/100,000 ranks among the European countries as a country with medium high mortality rates. The average for the countries of the European region is 342/100,000, and for EU countries 208/100,000, which ranges from 107 to 592/100,000 (France-Bulgaria). Analysis of hospital morbidity indicates an increase in hospitalization rates in most European countries, which indicates that the pressure on the health system due to cardiovascular diseases increased, regardless of the reduction in mortality. To conclude, despite the positive trend in the reduction of CV mortality, there are large disparities in Europe in the incidence and outcomes of CVDs, as well as the growing pressure on the health system, which requires comprehensive preventive measures. (1-3)

Ljiljana Banfić, Zoran Miovski, Majda Vrkić Kirhmajer

**Introduction:** The survey on peripheral arterial and venous disease was conducted by the Working Group on Angiology and Peripheral Vascular Diseases, in the course of X Congress of Croatian Cardiac Society. The aim was to get the information about professional opinion in diagnostic and therapeutic status on peripheral arterial and venous diseases in Croatian population. **Materials and Methods:** The survey was completed by 88 participants, 62 cardiologist, 14 specialists in internal medicine and 12 were other medical profession. **Results:** The results of the survey stressed the need for better professional education in primary and secondary prevention in peripheral arterial diseases. The need for further improvement through education and technical support declared 75% participants. The problem with venous thrombosis and embolism was oriented towards anticoagulant therapy, patient compliance and surveillance of therapeutic regime that 68% confirmed as the greatest problem. 70% of participants declared that the majority of the problem with anticoagulant therapy could be overcome with NOAK, as many of the participants (75%) had favorable experience with new drugs. **Conclusion:** It could be concluded according to the survey data that angiology praxis need further rationality and improvement through medical and public initiative in screening, diagnostic and therapy in arterial and venous diseases that could be achieved with better education and availability of technical diagnostic support. (1)

Martina Zeljko, Igor Gošev, Damir Kozmar, Darko Vujanić, Zoran Legčević, Dino Bešić, Frane Paić

**Objective:** Aortic valve stenosis (AS) is the most frequent heart valve disease among adults in the Western societies with ever increasing prevalence due to the rapidly ageing population. Currently there are no effective pharmacological therapies to prevent or slow the progression of AS and the surgical aortic valve replacement (AVR) or less invasive transcatheter aortic valve replacement (TAVR) procedure is still the only clinical therapy at hand for its successful treatment. Numerous research studies have shown association of genetic polimorphism with the prevalence of aortic valve stenosis. (1-3) Aims of this study are to assess the impact of RANK/RANKL/OPG gene polymorphisms on risk and severity of aortic stenosis. Herein we present the data for the rs3102735 osteoprotegrin (OPG/TNRSF11B) gene polymorphism. **Patients and Methods:** The study included 92 AS patients and 131 healthy control subjects. The rs3102735 OPG gene polymorphism was identified using the quantitative real time polymerase chain reaction (qRT-PCR) and the TaqMan® SNP Genotyping Assay (Life Technologies Corporation, Carlsbad, California, USA). **Results:** The OPG rs3102735 (C/T transition, substitution) genotype and allele distribution in AS patients (CC=2.2%, CT=30.4% and TT=67.4%; C=17.4%, T=82. 6%) did not significantly (p>0.05) differ from those in control group (CC=0.8%, CT=22.9% and TT=76.3%; C=12.2%, T=87.8%). Also, no statistically significant difference was found between the AS patient and control subject group stratified by gender. **Conclusion:** This patient-control study shows that rs3102735 osteoprotegrin (OPG/TNRSF11B) gene polymorphism is not genetic risk factors for AS..

Marija Heinrich, Kristina Galez, Janevski, Gabrijela Ćurić, Mario Ivanuša

The nurse is a member of the multidisciplinary cardiovascular (CV) rehabilitation team composed of cardiologists, a physician, a psychologist, a Bachelor of physiotherapy and a bachelor of occupational therapy. The nurse is charged with planning, organizing, monitoring, providing and evaluating health care. Upon the first arrival, the nurse makes the patient familiar with the CV rehabilitation program and opens the necessary medical records. Besides, the nurse plans a required workup, participates in conducting certain diagnostic procedures and therapeutic education, observes and informs cardiologists on the pathological findings. (1) At the beginning of the rehabilitation process, following the examination conducted by a cardiologist, the nurse takes medical history and status, and while changing the standardized and non-standardized forms she makes nursing diagnoses (2) of which, the most common are: - lack of knowledge and skills on CV diseases - symptoms and proper action to be taken in case of discomforts, variable risk factors (hypertension, dyslipidemia, obesity, diabetes, smoking, etc.) and the importance of adherence to and way of action of prescribed therapy - feeling of pains and discomfort in the chest - reduced effort tolerance - reduced capacity for physical and mental work. The patient is often facing social isolation and the loss of support, and some active patients fear the return to the workplace. After making nursing diagnoses, the goal is to be achieved by therapeutic education, thematic workshops and individual counseling for both patients and their family members. The purpose of the lectures and workshops is to provide education about the importance and possibility of influencing variable CV risk factors by non-invasive diagnostic procedures in cardiology. We pay special attention to the education of patients with newly diagnosed diabetes, where patients are educated and advised individually. During the implementation of the CV rehabilitation program, where a patient is to be referred to the hospital, a nurse participates in his management. Then new nursing diagnoses are made, the most common are the fear of recurrent disease and pain. In order to achieve the desired goal, it is important to create a motivating atmosphere, use medical knowledge and social skills and work in a team. The nurse in the CV rehabilitation ward should not only be a professional, but also the patient’s partner and a person that helps the patient. Her availability, expertise and support are an important part in the way to adopt a healthy way of living. The nurse’s job is demanding and responsible. The advancement of medicine requires a lifelong learning and adoption of new knowledge and skills. Although the nurses are always ready to acquire new knowledge, cooperate and adapt, we are sad that our work has remained unrecognized through the codes of the Croatian Health Insurance Fund.

Josip Vincelj, Sandra Jakšić Jurinjak, Mario Udovičić, Kristina Milevoj Križić, Ante Lisičić, Mira Stipčević

**Introduction:** The main goal of the coronary artery bypass graft (CABG) surgery is to reduce the mortality and to reduce or to prevent symptoms of coronary artery disease. Five years after coronary bypass graft surgery 75% of patients didn’t have ischemic events (1, 2). Obesity is the risk factor for morbidity and mortality after coronary artery bypass graft surgery (3). The main goal of the research is to asses relative impact of body mass index (BMI) on major adverse cardiac events (MACE) after CABG in the long term follow up. **Patients and Methods:** In study are involved 100 consecutive patients after CABG surgery at the age of 36-79, average 61.3. Follow up time is about 2 to 29 years, average 8.6 years. BMI is calculated from the formula; body weight (kg) / body height (m2). Based on BMI the patients are divided in two groups; 1. Group with BMI 2; 2. Group with BMI ≥25 kg/m2. MACE include mortality due to cardiac cause, myocardial infarction, unstable angina pectoris, repeated myocardial revascularization, congestive heart failure, stoke, transient ischemic attack (TIA) and death due to all other causes. **Results:** Frequency of arterial hypertension, diabetes, dyslipidemia is higher in a group of patients with excessive weight (82.9%, 34.1%, 87.5%), than in patients with normal weight (75%, 25%, 75%). The majority of smokers are in the group with normal body mass index (51.5%) then in group with excess body mass index (51.5%). During the follow up; 12 patients died (7 of them due to cardiac cause and 5 due to other cause of death), acute myocardial infarction had 11 patients. Of all the 23 patients, only two of them had BMI less than 25kg/m2. Repeated cardiac revascularization had been done in 12 patients, and 7 patients had stroke or TIA. Due to unstable angina pectoris 12 patients were treated, and 8 patients were treated from heart failure. Death due to all other causes during the follow up was in 12% of patients. **Conclusion:** The results of the research show greater frequency of classic risk factors of coronary artery disease in group of patients with higher BMI. Body mass index greater than 25 kg/m2 can be predictor of the MACE after the CABG surgery in the long term follow-up.

Lovel Giunio, Anteo Bradarić, Mislav Lozo, Jakša Zanchi

1. Upon clinical suspicion of pulmonary embolism, bolus dose of heparin is administered, and diagnostic process including urgent echocardiogram, hsTnT, NT-proBNP and MSCT pulmonary angiogram, procoagulant factors begun. The degree of severity of pulmonary embolism (massive, submassive), as well as contraindications to thrombolytic therapy, is assessed, the interventional team prompted, and the patient transported to invasive laboratory (in severe clinical condition, urgently, on the basis of clinical assessment and prior to MSCT angiography), puncture of the cubital vein being done in the Coronary Care Unit. (1, 2) 2. In the intervention lab, 6F sheath is introduced cubitally. Under fluoroscopic guidance, 5F angiographic catheter (Multipurpose or JR 4) is placed in the main pulmonary artery, and exchanged for 5F pigtail catheter. The pulmonary artery pressure is registered, and pulmonary angiography done, followed by mechanical fragmentation of emboli by rotating of the catheter. The goal is to reduce the degree of obstruction caused by thrombi in the trunk and main branches of the pulmonary artery, and resolve the immediate threat to life. Bolus of 2.5 mg/min of alteplase is administered in one of main branches of pulmonary artery. If clinically and angiographically indicated, procedure should be repeated in the other main branch. Intrapulmonary thrombolytic therapy is continued by infusion of 25 mg alteplase over the next 12 hours, followed by standard heparin infusion (starting at 1000 i.e. per hour). Control angiography and of pulmonary pressure measurement is performed as soon as interventional laboratory is available, and catheter and sheath removed. 3. Treatment is continued with subcutaneous low molecular weight heparin (LMWH), at a dose adjusted to body weight. 4. LMWH is replaced with the oral anticoagulation therapy, optimal NOAC (rivaroxaban, dabigatran, apixaban) and continued for 6-12 months. 5. Follow-up is performed at 6 months (ECG, echocardiogram, DLCO).

Vlatka Rešković Lukšić, Zvonimir Ostojić, Branko Kolarić, Sandra Večerić, Ivica Šafradin, Maja Strozzi, Joško Bulum, Jadranka Šeparović Hanževački

**Background.** Thrombocytopenia (TP) after transcatheter aortic valve implantation (TAVI) has been observed, but not well studied. We aimed to investigate incidence and clinical significance of TP associated with TAVI. (1-3) **Patients and Methods:** A total of 42 patients who underwent successful TAVI (37 CoreValve, 5 Edwards Sapien) in University Hospital Center Zagreb were enrolled. Platelet (PT) and hemoglobin (Hgb) count were analyzed before, on day 3-4 after TAVI and before discharge (about 1 week after the procedure). Transfusion units and clinical complications were recorded. **Results:** Before the procedure, Hgb level was 126 (93-161) g/l, and platelet count 197 (101-369) × 109/L. On day 3-4 after the procedure, significant drop of Hgb (104 (86-142) g/l, p 9/L, p 9/L) occurred. In this group of pts, drop in Hgb levels showed no significant difference compared to those pts with no significant TP. None of the pts required PT transfusion. There were 3 major bleedings in non-TP group and none in TP group. 11 units of red blood cells (0.92 per patient) were used in TP group, and 26 units (0.87 per patient) in non-TP group After one week, PT levels showed significant recovery toward normal values (199 (66-333) × 109/L, p=0.014), while Hgb levels showed no significant recovery (105 (88-130) g/l, p=0.286) and remained significantly lower compared to baseline (p=0.001). PT count after one week showed no significant difference compared to preprocedural values (p=0.989); only in 1 patient PT count remained low after 1 week. **Conclusion.** TP after TAVI is common, self-limited process. It occurs 3-4 days after TAVI with complete recovery of PT count during 1 week. In the short term follow up, it has no impact on Hgb level, incidence of major bleeding nor need for transfusion. Etiology of this phenomenon remaines unresloved.

Krešimir Kordić, Marin Pavlov, Ana Đuzel, Zdravko Babić

**Introduction**: Acute cholecystitis is often associated with transient electrocardiographic ST-T segment changes and cardiac biomarker elevation with or without myocardial ischemia. Elevation in troponin in acute cholecystitis are well described, however, few data exist on high sensitivity troponin (hsT). (1) We present a case of a 77-year-old female with simultaneous development of acute cholecystitis and ECG and laboratory changes characteristic for myocardial infarction. **Case report**: 77-year-old female presented with right upper abdominal quadrant pain, nausea and vomiting, denying chest pain. Vital signs were normal. Physical examination revealed right upper quadrant and epigastric tenderness. 12-lead ECG showed atrial fibrillation with ST segment depression and T-waves inversion in the most leads. Laboratory investigations showed normal WCC count, CRP, aminotransferase and amylase levels, bilirubin was 28.8 µmol/L, hsT 66 ng/L, CK 216 U/L. Abdominal ultrasound revealed normal gallbladder wall and two stones in the lumen. Echocardiography revealed mildly reduced systolic function (LVEF 48%) with no regional contractility abnormalities. Repeated laboratory findings showed elevation in hsT to 1076 ng/L and CK to 489 U/L. Patient was admitted to Cardiology Intensive Care Unit with working diagnosis of acute coronary syndrome. Next day patient became febrile (39.0 C), with severe tenderness of upper abdomen, positive Murphy’s sign, findings showed elevation in WCC 13.1×109/L and CRP 214 mg/L. Repeated ultrasound showed gallbladder distention, wall thickening, impaction of one of the stones in cystic duct, so indication for surgical treatment was established. Classified as a ASA IV/V class the patient was transferred to Abdominal Surgery Department. After surgery, patient developed sepsis and two days following surgery a cardiorespiratory arrest resistant to cardiopulmonary resuscitation. According to patients family request, autopsy has not been performed. **Conclusion**: Nonspecific electrocardiographic ST-T segment changes and cardiac biomarker elevation characteristic for severe acute cholecystitis could mask acute abdominal pathology, especially in early stages of the disease, which could lead to delay in establishing the diagnosis. Nevertheless, if signs of myocardial ischemia are present the prognosis is worse.

Ivana Jurin, Marko Ajduk, Lovorka Đerek, Marijan Pašalić, Diana Rudan, Sanda Sokol, Tomić, Stela Bulimbašić

**Introduction:** The most important pathophysiological mechanism of development of carotid atherosclerotic disease is an inflammatory process. With the aim of better understanding of the process, numerous biomarkers were studied including resistin. Resistin peptide intensifies development of atherosclerosis by stimulating monocytes, endothelial cells and smooth muscle cells in the development of inflammation of the vascular endothelium. (1) Aim: Connection between resistin with insulin resistance, obesity and diabetes is well known. Here we present the results of subanalysis research of the relationship between resistin and histology of an atherosclerotic carotid plaque with emphasis on the impact of anthropometric factors (age, sex, body height, body weight and waist circumference) on the serum concentration of resistin. **Patients and Methods:** The study included 78 patients (30 women) with significant carotid artery stenosis which were planned for elective endarterectomy. Before the surgery concentration in serum resistin (1967.15-18619.73, mean 7552.3162 pg/ml) were measured and anthropometric data were determined as follows: age (45-84; mean age, 66.83 years), body height (148 to 187; mean height 168.78 cm), body weight (47-110, average weight 80.49 kg), and waist circumference (75-122, midrange 101.27 cm). **Results:** Subanalysis of data showed statistically significant positive correlation between the concentration of resistin with waist circumference (p = 0.003) and male gender (p = 0.008). **Conclusion:** These results indicate a clear connection between the classic risk factors for atherosclerosis and relatively new inflammatory marker resistin. Further research is needed to confirm the possibility of using resistin as a marker of atherosclerotic disease.

Martina Lovrić Benčić, Jozo Jelčić, Lada Bradić, Tea Šimonček, Marina Mihajlović, Gregor Eder

**Introduction:** Weight loss can result in reduction of multiple cardiovascular risk factors, as well as cardiac structural and functional remodeling. (1-3) **Patients and Methods:** We enrolled 79 obese patients (37 in control group, 42 in intensive weight loss program). All patients were followed in cardiology outpatient department for 12 months, with a 3-month follow-up period. They were all advised to improve life-style and diet habits. All patients underwent initial and final cardiovascular risk assessment, echocardiography, exercise stress testing, ECG Holter monitoring and 24-hour blood pressure monitoring. **Results:** We observed statistically significant improvement in LA and RA volumes, reduced ventricular mass, systolic blood pressure and improved functional capacity on treadmill test. Insulin resistance based on HOMA model also improved, with a significant fall in proinflammatory marker CRP. ECG Holter monitoring revealed significant reduction of AF episodes and SVPBs. Structural changes between groups were independent of the body surface area. **Conclusion:** Structured weight loss program leads to improved cardiometablic risk management, with reduced insulin resistance and modulation of inflammation. Significant reduction in cardiac volumes, blood pressure and added functional benefit was observed. Suppressed supraventricular arrhythmogenicity is hypothesized to reflect structural and electrical remodeling of the heart.

Snezana Lazic, Bratislav Lazic, Maja Sipic

**Introduction**: After surviving a stroke, paralysis of limbs is often encountered followed by deep vein thrombosis and the possible development of pulmonary embolism. However, pulmonary embolism can become complicated by a stroke. (1, 2) Aim: To indicate the complexity and interdependence of thrombogenesis. **Case report**: Female patient, aged 74 was hospitalized due to labored breathing and fatigue that had started 4 days prior. She has been treated for arterial hypertension and permanent atrial fibrillation; is a smoker and overweight. Upon arrival she is conscious, oriented, dyspneic, afebrile, with normal cardiac and pulmonary exam findings, with no edema or organomegaly present. On the second day of hospitalization sudden hypotension (70/mmHg) and hypersaturation (SO2 60%) occurs, ECG shows signs of acute right heart overload (S1Q3T3). Alteplase was administered according to protocol for pulmonary embolism. MSCT pulmonary angiography: complete thrombosis of the right pulmonary artery and its branches and thrombosis of lower branches of the left pulmonary artery. Lung parenchyma accompanied by nonuniformal aeration with wedge-shaped formations and a base towards the costal pleura. Two hours after the administration of fibrinolytics, right-sided hemiplegia develops in patient. Brain CT scan shows acute massive ischemic lesion of the left brain hemisphere (territory of left MCA), along with cerebral edema. Ventricular system and subarachnoid space contain no pathological entities. On the tenth day of admission death occurred. **Conclusion**: Ischemic stroke most likely caused by the cumulative impact of systemic hypotension, embolism due to atrial fibrillation as well as systemic hypoperfusion which is the result of decreased stroke volume due to pulmonary embolism. Hypoxemia contributed to hypoperfusion. Due to the global reduction of blood flow the middle cerebral artery was affected.

Aleksandra Marković, Sandro Brusich, Alen Ružić

**Introduction:** Obesity is a major public health problem, many as 13% of the world population is obese. It is an independent factor for development of cardiovascular disease, diabetes, hypertension and hypercholesterolemia. (1-3) The aim of this study was to analyze certain electrocardiographic parameters in order to realize the difference between obese people and those with normal body weight. **Patients and Methods:** The study included 166 patients, of which 76 obese patients, mostly men aged 43.23 ± 12.43. The main selection criterion was the BMI greater than 30kg/m2. Exclusion criteria were known history of cardiovascular disease, electrocardiographic changes in the form of a block (left or right branch), atrial and/or ventricular extrasystoles, and previously known diabetes mellitus and arterial hypertension. **Results:** A comparative analysis of electrocardiograms found four significant differences. In obese patients electrical axis rotated more to the left than in the control group (21.64 ± 30.31 vs. 53.62 ± 31.21 degrees, p <0.001). Time depolarization of the atrium is also longer in obese based on changes in the size of the atrium ((P wave: 106 ms (62-186 ms) vs. 112 ms (58-162 ms) p = 0.01; PQ interval: 159.23 ± 25.07 ms vs. 148.77 ± 24.18 ms, p = 0.006)). Flattened / negative T waves of precordial drains were found in greater numbers in obese people; T waves on limb drains were found in greater numbers in healthy subjects. QRS, QTc and ST segment elevation were not significantly different between two groups. The study shows obese patients also have a higher blood pressure, over 8 mmHg systolic and 10 mmHg of diastolic blood pressure values (p <0.05). **Conclusion:** Minimum ECG changes such as increasing the atrial depolarization and change of final oscillations could be used in obese patients as a screening method for early detection of cardiac changes and identifying those in need of further processing.

Krešimir Putarek, Ljiljana Banfić, Marijan Pašalić, Anita Špehar Uroić, Nataša Rojnić Putarek

**Introduction:** Early atherosclerosis is asymptomtic, and clinical manifestations are visible relatively late. (1-3) **Patients and Methods:** To determine parameters of arterial stiffness in pediatric patients with preatherosclerosis, in cooperation with Department of Pediatric Endocrinology, we have analyzed 148 patients, 68 obese, 42 with diabetes mellitus type 1 with duration over 5 years, and 38 controls. Patients did not have clinical manifestations of atherosclerosis. The groups were formed due to well-known influence of diabetes and obesity as a risk factors for cardiovascular disease. In our study pediatric patients with diabetes mellitus type 1, obese patients and controls were screened with e-tracking ultrasound method. Novel methods for determination of arterial stiffness by ultrasound e-tracking analysis is easy, safe and reproducible allowing measurement of parameters like Beta stiffness index, pulse wave velocity (PWV), augmentation index (AI), arterial compliance (AC) and elasticity modulus (Ep). Common carotid artery is analyzed 1-2 cm from bifurcation on anterior and posterior wall of vessel. Accurate image of intima-media border is essential for analysis. By positioning the tracking gate on arterial wall we can measure deformation of artery during cardiac cycle. **Results:** We found significant difference in AC (p=0.004) and intima media thickness (p=0.022) between all groups. Also, significant difference between group was found in IMT (diabetic patients vs. control, p=0.015), in IMT (diabetic vs. control, p=0.002) and in AC (diabetic patients vs. obese patients, p=0.004). **Conclusion:** Arterial compliance is most sensitive parameter of early atherosclerosis. Intima-media thickness could be additional marker in detection of preatherosclerosis. Combination of functional arterial stiffness parameters with early morphological markers like IMT is useful in diagnosis and follow-up of these patients. According to our data diabetes mellitus is more significant risk factor than obesity in pediatric patients.

Mario Ivanuša

The difference in understanding the words which have the same or a similar meaning is not only a linguistic problem, but also a problem that we come across in medicine. Colloquial interpretation of certain medical terms in the wrong context can cause confusion not only among patients, but also among specific health professionals, so it is necessary to use the professional terminology appropriately. Here are some examples in the field of cardiovascular rehabilitation, the use of which in the daily clinical practice is not a stylistic feature, but denotes a different meaning. Clinical understanding of cardiovascular (CV) disease requires knowledge, experience, and skills of health professionals to recognize the clinical manifestations of the CV disease. By using the physical diagnosis by summarizing the data obtained by the medical history (which, inter alia, includes the questions about the impact of various physical factors on health) and physical examination by using inspection, auscultation, percussion, palpation and olfactation) (1), a cardiologist cognitively resolves a potential CV problem. A cardiologist makes a diagnosis of the CV disease by interpreting the findings of the available medical records, including the findings by a specialist in physical medicine and rehabilitation (physiatrist) and thereby determines and stratifies the risk and determines the need for treatment, prevention or CV rehabilitation. Cardiovascular rehabilitation constitutes a team process in the secondary prevention of CV diseases that is carried out as a part of the cardiac treatment by interdisciplinary and transdisciplinary approach of different profile of health professionals in specialized centers within one year from the date of development of an acute CV event (usually, acute coronary syndrome or heart surgery procedure). Interval CV training takes place at the same time as the CV rehabilitation under the supervision of a cardiologist accompanied by telemetric monitoring by electrocardiogram, while a complete non-invasive diagnostic CV examination, psychodiagnostics and counseling by a psychologist, occupational therapy interventions, therapeutic education and non-pharmacological measures accompanied by the usual medicamentous treatment constitute inseparable components of the modern CV rehabilitation program. The activity and participation is stimulated in a coordinated process, regardless of whether the program is conducted by hospitalization in a specialized hospital for three weeks or in an outpatient clinic for three months in the polyclinic-consultative healthcare institution. (2, 3) Physical therapy is a methodology of using a physical agent that causes a favorable reaction in the body and is part of a complex rehabilitation treatment program. (4) It represents a target-oriented and time-limited process in a rehabilitation program aimed at compensating for a loss of function or a functional limitation. (5) Physical therapy is prescribed by a specialist in physical medicine and rehabilitation (physiatrist), whereas the physiotherapy interventions are performed by Bachelor of Physiotherapy or physical therapist. The indications, contraindications and fundamental principles must be satisfied in order to be able to perform these interventions. Physical therapy in CV patients is performed: - Within one year from the development of an acute CV event or heart surgery treatment under the supervision of a cardiologist as one of the components of the rehabilitation treatment, participating in organized programs of outpatient or inpatient CV rehabilitation. - After the occurrence of a disease and injuries to the musculoskeletal system or locomotor system under the supervision of a physiatrist regardless of cardiac treatment. - At the request of a patient, and usually after completing the CV rehabilitation program as a part of the programs of organized physical exercise. Participation in this program requires a risk review and stratification for the physical exercise by a cardiologist, whereas the physical exercise process is to be led by the Bachelor of Physiotherapy. - At own discretion in order to improve the musculoskeletal system or locomotor system or the fitness status under the supervision of the Bachelor of Physiotherapy. To conclude, physical therapy in cardiovascular patients and cardiovascular rehabilitation are medical terms that are neither complete nor partial synonyms.

Martina Menegoni, Božo Vujeva, Domagoj Mišković, Irzal Hadžibegović, Katica Cvitkušić, Lukenda, Đeiti Prvulović, Krešimir Gabaldo

**Introduction**: Primary heart tumors are rare, and among them myxoma is the most common. Symptoms of congestive heart failure are the most common manifestation, and embolization of the coronary artery is an extremely rare manifestation. (1) **Case report**: 65-year-old male, with already known arterial hypertension, dyslipidemia, and chronic obstructive pulmonary disease (COPD) was admitted due to the subacute myocardial infarction with an elevation of the ST segment in inferior leads that lasted for approximately 24 hours. Emergency echocardiography showed a mass sized 5.4 x 4.0 cm in the left atrium, with myocardial echogenicity, attached to the interatrial septum with a stalk that floated with its edge through the mitral valve. It also showed a hypokinesis of the inferior left ventricle wall. The patient was highly febrile, but with sterile blood cultures. The possibility of the endocarditis of the mitral valve was excluded, and the febricity explained by an infective exacerbation of COPD. Antimicrobial, bronchodilatational, diuretic and other supportive therapies were implemented, and only after a complete clinic stabilization coronography was executed. An occlusion of the distal segment in the circumflex artery was found, without other significant stenosis. The diagnosis of left atrium myxoma with the embolization into the circumflex coronary artery was made, and the patient was moved into the Department of Cardiac Surgery in the Clinical Hospital Dubrava in Zagreb, where a successful excision was executed. The patient was discharged after a successful recovery. **Conclusion**: This clinical case shows the necessity and value of an early bedside echocardiography with a clinical picture of acute and especially subacute myocardial infarction whenever possible.

Vjekoslav Tomulić, Tomislav Jakljević, David Gobić, Miljenko Kovačević, Davor Primc

Aortic disease includes aortic aneurysm, acute aortic syndrome (AAS): dissection, intramural haematoma, penetrating atherosclerotic ulcer, traumatic aortic injury; pesudoaneurysm, aortic rupture and atherosclerotic or inflammatory aortic disease. Aneurysms of abdominal (AAA) or thoracic (TAA) aorta are most common. They have long-lasting subclinical course and AAS is often first manifestation of the disease, with extremely poor prognosis. (1-3) Endovascular repair of abdominal (EVAR) and thoracic (TEVAR) aorta with graft stents is preferred method of treatment over open surgical procedure. Length of stay in ICU, hospitalisation duration, acute complications, rate of recovery and survival over 5 years are all, according to clinical studies, on EVAR/TEVAR side. Open surgery kept its position in treating disease of ascending aorta and aortic arch. Development of new techniques and devices enables endovascular treatment of high-risk patients (thoracoabdominal aneurysms, „hostile“ neck) who were deemed inoperable until now. In University Hospital Centre Rijeka we performed 49 endovascular procedures (TEVAR 20, EVAR 29) from 2014 to 2016. 14 patients (28,6%) have had an emergency procedure because of AAS. Majority of procedures were performed percutaneously (30 patients, 61%). Periprocedural mortality was 2% (1 patient), 30-days mortality was 8.1% (4 patients). Further development needs stabile financing and additional education and integration of multidisciplinary endovascular team (vascular surgeons, interventional radiologists and cardiologists).

Jasna Čerkez Habek, Jozica Šikić, Dario Gulin

**Introduction:** The European (ESC) Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (STEMI) undoubtedly state reperfusion therapy as the superior therapeutic measure if less than 12 hours have elapsed from the onset of symptoms; in case that 12-24 hours have elapsed from pain onset, patients with signs of onging ischemia in ECG and/or persisting chest pain will benefit from prompt reperfusion. There is no consensus on the procedure in asymptomatic patients presenting beyond 12 hours of pain onset; when to perform percutaneous reperfusion and in which patients; it has not yet been defined what is long-term benefit of late recanalization of occluded artery in the infarction area. (1, 2) Aim: To determine the mode of treatment and outcome in late presenting STEMI patients at Cardiovascular Department University Hospital „Sveti Duh“. **Patients and Methods**: Data on STEMI patients hospitalized at Department from January 1, 2014 to August 31, 2016 were retrospectively analyzed with special reference to the mode of treatment and patient outcome (mortality, heart failure, myocardial reinfarction and repeat percutaneous coronary intervention (PCI)). **Results:** A total of 281 STEMI patients, 204 (72%) male and 77 (28%) female, average age 64 years, were hospitalized during the study period. Chest pain present for less than 12 hours was reported by 207 (73.6%) patients; 195 (94%) of them were successfully treated by PCI, while 12 (5.7%) patients died. Acute stent thrombosis was recorded in 4 (1.9%) patients, 24 (11.5%) patients underwent PCI on major residual stenoses, and stent re-stenosis developed in 6 (2.9%) patients. In the group of 74 (26.3%) patients with late presentation, primary PCI was successfully performed in 37 (50%) patients, while it could not be applied in the rest of 37 (50%) patients due to comorbidities; 7 patients died (9%), all of them was without reperfusion therapy; 7 patients were referred for cardiac surgery revascularization following re-coronarography on their next hospitalization. **Conclusion:** Percutaneous reperfusion was performed less frequently in STEMI patients with late presentation, resulting in higher mortality rate as compared with patients presenting within 12 hours of symptom onset. Results were compared with literature data.

Kristina Gašparović, Vojtjeh Brida, Maja Strozzi, Anton Šmacelj, Jadranka Šeparović Hanževački, Darko Anić, Ivan Malčić, Margarita Brida, Irena Ivanac, Sandra Večerić

**Introduction:** In our country, treatment and follow up of grown-up congenital heart disease patients is limited with relatively low experience and modest diagnostic and therapeutic possibilities. We present a case of a young patient born with complex congenital heart disease corrected with Fontan procedure in childhood, whose medical history was complicated with extracardiac tunnel obstruction. **Case report:** Twenty-year-old patient was hospitalized in University Hospital Centre Zagreb for cardiac decompensation manifested with dyspnea, leg edema and ascites. Patient was born with complex congenital heart disease (dextrocardia, “double inlet” left ventricle, pulmonary atresia and great vessels transposition). On her first month, Blalock-Taussig was performed, two years later Glen correction followed and in her eighth year Fontan operation (1) was done. On her regular check-up visit in September 2014, echocardiographic assessment showed her one ventricle (morphologic left) with normal global systolic function and her extracardiac tunnel had normal flow. Eight months later she presented with cardiac decompensation. Multi slice CT (MSCT) angiography and cavography, performed in UHC Zagreb, found calcifications and partial thrombosis of the conduit which was knicked on its mid portion with complete obstruction of the flow. Two weeks later our patient was transferred to Herzzentrum Munich. Dilatation was performed, followed with implantation of three stents and very satisfactory final flow. Clinical status of our patient improved. MSCT angiography showed no residual stenosis on a stented extracardiac conduit. **Conclusion:** Dextrocardia, in a patient with complex congenital heart disease, complicated stenting of the extracardiac conduit which was placed between vena cava inferior and pulmonary artery sixteen years earlier and which was knicked on the midportion because it was placed in the heart on the right side. Successful percutaneous intervention was made and three stents implanted. Procedure spared our patient from the fourth cardiotomy.

Vedrana Baraban, Lana Maričić, Krunoslav Šego, Grgur Dulić, Livija Sušić

The present case report describes a 31-year-old mother of two children, who was treated for fever and sepsis syndrome in two occasions in 2015, at the Department of Infectious Diseases. During the second hospitalization, transthoracic echocardiography confirmed a cardiac mass attached to the septal leaflet tricuspid valve. The patient was transferred to the Department of Cardiovascular Diseases at the Clinical Hospital Osijek for further treatment. The patient occasionally consumed various drugs at the age of 15-19, later sporadically, and she was a heavy smoker for 15 years. In 2006, during her first pregnancy, the patient was tested for HIV and hepatitis (the results were negative), whereas in 2014, during the second pregnancy, the results were positive for HBV (antiHBs and antiHBc). In addition to fever, the patient complained of weight loss, night sweats and general weakness. The results of laboratory tests revealed elevated inflammatory parameters (CRP 132). During the first hospitalization Staphylococcus aureus was isolated in blood cultures and the patient was treated with cloxacillin and gentamicin whereas during the second hospitalization Pseudomonas aeruginosa was isolated and the therapy included cefepim and ciprofloxacin. The transthoracic echocardiography (**Figure 1****,** **Figure 2**) showed normal dimensions of cardiac chambers, normal global and regional contractility of LV and DV and a cardiac mass on the stalk attached to the tricuspid annulus which during the cardiac cycle protruded into the right ventricle and consequently caused a moderately severe TR 2-3+ with RVSP about 40 mmHg. Figure 1. A transthoracic echocardiogram. Apical four chamber view: cardiac mass 12x19 mm which attached to the septal leaflet tricuspidal valve. Figure 2. A transthoracic echocardiogram. Subcostal view: cardiac mass protrudes in right ventricle and pulmonary artery depending on the phase of cardiac cycle. After six weeks of antibiotic therapy, the patient was transferred to the Department of Cardiac Surgery where she underwent surgery with removal of the cardiac mass and a portion of septal leaflet tricuspid valve. Histopathological assessment described the removed cardiac mass as part of the tricuspid valve with vegetation built of fibrin pervaded by granulocytes and colonies of microorganisms were observed – in conclusion acute endocarditis. (1-3) The postoperative recovery was uneventful, but regarding the tricuspid regurgitation, a reconstruction of tricuspid valve is planned within two years.

Ivo Planinc, Dora Fabijanović, Jana Ljubas Maček, Boško Skorić, Hrvoje Jurin, Jure Samardžić, Nina Jakuš, Hrvoje Gašparović, Maja Čikeš, Davor Miličić

**Introduction:** Recipient age is a well-established risk factor in heart transplantation. Although older recipients have worse survival, incidence of posttransplantational complications is higher in younger recipients, and so far there is no clear evidence of exact pathophysiological mechanism driving the latter. However, it is well known that younger patients have worse therapy compliance. (1, 2) In this study, we investigated if there is difference in achieving target immunosuppressive drugs levels according to age, and if it is associated with worse outcomes. **Patients and Methods:** This is a single center, retrospective study that included 114 adult consecutive patients who underwent heart transplantation from 2010.-2015., and of those 94 with at least 30-day follow up were selected for further analysis (median age 54, 71 male, median follow-up 28 months). Study population was divided into 2 groups according to age. We observed outcomes of overall survival, graft rejection episodes that were treated, and occurrence of vasculopathy. Immunosuppressive drug levels at days 30, 180, and 365 after heart transplantation were collected (**Table 1**). Pearson chi-squared, and Mann-Whitney tests were used for group comparisons, while Kaplan-Meier curves were used for survival analysis. ### Table 1: Patients achieving subtherapeutic immunosuppressive drug levels at 30, 180, and 365 days after heart transplantation according to age groups. Comparison of outcomes (graft rejection requiring treatment and vasculopathy) between study groups. | | **Younger patients (54 years)** | | | --- | --- | --- | --- | | N | 47 | 47 | | | Subtherapeutic immunosuppressive drug levels (calcineurin inhibitors) | | | | | - 30 days after heart transplantation | 25/47 (53%) | 13/47 (28%) | p=0.012 | | - 180 days after heart transplantation | 10/44 (23%) | 12/39 (31%) | P=0.407 | | - 365 days after heart transplantation | 3/38 (8%) | 2/29 (7%) | P=0.878 | | Graft rejection requiring treatment | 13/47 (28%) | 2/47 (4%) | p=0.002 | | Vasculopathy | 13/44 (30%) | 6/46 (13%) | p=0.055 | **Results:** Although significantly higher number of younger patients had subtherapeutic immunosuppressive drug levels at day 30, at other time points there was no difference; as well as there was no difference in outcomes among younger patients according to drug levels. Furthermore, taking into account all the patients, there was no difference in outcomes based solely on subtherapeutic drug levels. Study groups differed significantly only in incidence of graft rejection requiring treatment, that was more frequently observed in younger group of patients. **Conclusions:** In our study population we achieved target immunosuppressive drug levels harder in younger patient at 30-days after heart transplantation, however without influence on survival. Furthermore, younger patients had similar survival and occurrence of vasculopathy as older patients, and higher occurrence of graft rejection requiring treatment.

Majda Gotovac, Ivana Bočina, Branka Medvidović, Ingrid Tripković, Jasna Ninčević

**Aim:** To define mortality and hospital morbidity from ischemic heart diseases (I20-I25, ICD-10) by sex and age in the Split-Dalmatia County, Croatia, in the period 2005.-2014. **Methods:** In this paper we used methods of descriptive epidemiology. In the analysis of mortality from IHD in the population of Split-Dalmatia County (SDC) we used database of Institute of Public Health Split-Dalmatia County formed on the basis of mortality and demographic data of the Croatian Bureau of Statistics. In the analysis of the hospital morbidity we used database formed on the basis of specific health and statistical reports (Patient-statistical form) of the population of SDC hospitalized in the Split University Hospital Center. The indicators of mortality and hospital morbidity were analysed as absolute number, percentage share, rate per 100.000 population. **Results:** During the 10-year study period IHD were first or second major single cause of death of the population of SDC, accounting for 17.3% of total mortality. The analysis of mortality by age and sex shows that age-specific mortality rates for IHD rise with age and are higher in men than in women in all age groups (**Table 1**). At the age over 65 there were recorded 86% of persons who died of IHD (76.9% men and 95.5% woman). IHD were the major cause of hospitalization of the population of SDC hospitalized in the Split University Hospital Center, with average 1.473 hospitalizations annually and the average length of stay for totals to 9.8 days. Crude mortality rates from IHD in the SDC were slightly lower than the Croatian average. ### Table 1: Average annual mortality from ischemic heart diseases by age and sex in the Split-Dalmatia County, 2005 - 2014. | **Age group** | **Total** | **Total** | **Male** | **Male** | **Female** | **Female** | | --- | --- | --- | --- | --- | --- | --- | | | No. | % | No. | % | No. | % | | **20-34** | 1.3 | 0.2 | 1.3 | 0.3 | 0.0 | 0.0 | | **35-64** | 109.9 | 13.8 | 92.1 | 22.8 | 17.8 | 4.5 | | **65+** | 685.1 | 86.0 | 311.2 | 76.9 | 373.9 | 95.5 | | **Total** | 796.3 | 100.0 | 404.6 | 100.0 | 391.7 | 100.0 | [†] Source: Institute of Public Health Split-Dalmatia County. **Conclusion:** Analyzing IHD mortality trends in the SDC, we have observed the rising mortality trend during the 10-year study period. To reduce mortality and morbidity from IHD we need to empower healthier lifestyle promotion programs, to change health-risk behavior and to encourage early detection of the most important risk factors for IHD (hypertension, diabetes, dyslipidemia, obesity). (1-3)

Tomislav Krčmar, Nikola Kos, Boris Car, Mislav Vrsalović

**Objective:** In University Hospital Centre «Sestre milosrdnice» Zagreb transradial approach is traditionally used as a vascular approach for peripheral transluminal interventions. (1) As shown in our previous reports transradial approach is found to be as safe as the transfemoral but with less complications and with shorter postprocedural hospitalization needed. The aim of the study was to determine the safety of the transradial approach and to correlate technical parametars (fluoroscopy time, radiation doses and the volume of contrast) between the group where the transradial approach was used as a single or as an additional approach for peripheral interventions and in transfemoral group. **Methods:** Between January 2011 and September 2016 at the UHC «Sestre milosrdnice», Zagreb at the Department of Cardiovascular Diseases 120 diagnostic and interventional procedures were performed using the transradial approach. There were 74 men (62%), 31 (26%) suffered from diabetes mellitus type II and 85 (71%) were active smokers. **Results:** In 34 procedures (mostly in patients with TASC B or C lesions) the transradial approach was used as one of the additional approaches for the intervention (average volume of used contrast per procedure 156 ml; mean fluoroscopy time 17 min; radiation doses 5286 mcGym2). In 13 cases the transradial approach was the main approach for the intervention, mostly in patients with TASC A or B type of lesiones (average volume of used contrast per procedure 146 mL; mean fluoroscopy time 9 min; radiation doses 5606 mcGym2). In 70 patients the transradial approach was used for diagnostic angiography (average volume of used contrast/procedure 176 mL; mean fluoroscopy time 8,2 min; radiation doses 2332 mcGym2). In 36 procedures (30%) coronary angiography was performed during the same procedure which could have influenced the results. **Conclusion:** This report shows feasibility of transradial approach for peripheral interventions. Concerns about safety due to radiation exposure and fluoroscopy time should not discourage operators from using the transradial approach for peripheral interventions.

Dogan Nasir Binici, Ozge Timur, Ahmet Veli Sanibas

**Introduction**: High blood pressure is a common condition in society. The prevalence of hypertension (HT) in Turkey is 31.8% (36.1% for women and 27.5% for men). Diabetes mellitus (DM) is the sixth leading cause of death in adults. DM prevalence in Turkey is 13.7%. HT is a common problem for Type 1 and Type 2 diabetes. (1, 2) Oral glucose tolerance test (OGTT) is recommended for diabetes screening. OGTT results reveals not only in the diagnosis of diabetes also prediabetic conditions such as impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). The aim of this study is to investigate the prevalence of HT in the prediabetic patients. **Patients and Methods**: In this study the results of 1000 patients attending to Erzurum (the biggest city in the eastern Turkey) Regional Training and Research Hospital Internal Medicine outpatient clinic, scanned with OGTT for diabetes were examined. Prediabetic patients were evaluated for hypertension. **Results**: OGTT results were as follows: 164 (16.4%) patients with IFG (111 women, 53 men), 129 (12.9%) patients with IGT (96 women, 33 men), 161 (16.1%) patients with IFG + IGT (108 women, 53 male), 228 (22.8%) patients with overt diabetes (158 women, 70 men) and 318 (31.8%) had normal (228 females, 90 males). Considered to be prediabetic IFG, IGT and IFG + IGT groups HT frequency was 40% (37% males, 42% females). **Conclusion**: Hypertension is seen more frequently among type 2 DM than normal population. Type 2 DM is seen 2.5 times more than in patients with HT compared with individuals without HT. HT is present about 39% of newly diagnosed type 2 DM patients. In our study, the prevalence of HT in individuals at risk for development of diabetes is 40%. Blood pressure elevation, with micro and macrovascular disease results in increased morbidity and mortality. In our study the incidence of HT in prediabetic individuals were revealed at close to diabetics. Half of the pre diabetic patients develop diabetes in later years. That’s why prediabetes as well as diabetes should be monitored closely. Lifestyle changes and/or medical treatment as metformin, acarbose reduces the risk of diabetes development. Increased awareness of HT in these individuals at risk for development of diabetes, tight blood pressure control is very important in terms of reducing the micro and macro complications.

Irzal Hadžibegović, Đeiti Prvulović, Krešimir Gabaldo, Ognjen Čančarević, Martina Menegoni, Domagoj Mišković, Božo Vujeva

**Introduction:** Local vascular complications, hematomas or bleeding are the most common complications of invasive coronary interventions and are significantly lower if performed transradial than transfemoral. Neurological complications of invasive coronary procedures are very rare, and for now there is no evidence of their increased rate after radial access. (1) **Patients and Methods:** We analyzed the differences in complications of coronary interventions between two 9-month periods in the catheterization laboratory in Slavonski Brod: January to September 2015, when 82% of the procedures were done transfemoral and from January to September 2016, when 87% of procedures were done transradial. The transition period between September 2015 and January 2016 was not included in the analysis. **Results:** In specified period in 2015 there were 584 procedures, of which 18% transradial. There were 11 (1.88%) local vascular complications or bleeding, and 1 case (0.17%) of transient cerebral ischemic attack (TIA) after femoral approach. During the same period in 2016, there were 913 coronary procedures, of which 87% transradial. There were 4 (0.44%) local vascular complications or bleeding, all of which after femoral approach. There were 4 (0.44%), cerebrovascular incidents: two TIA and two ischemic strokes of which one with remaining deficit, and one with a fatal outcome. Common clinical features of patients with neurological complications were: female gender, age greater than 80 years, diabetes, known vascular disease, previous cerebrovascular incident, acute coronary syndrome, and right radial access. **Conclusion:** Radial approach was proven to be safe and effective, with a significant reduction in the number of vascular complications and insignficant increase in the number of neurological complications, whose incidence remained below 0.5%. In the case of patients with associated three or more risk factors mentioned above, access site of choice should be left radial or alternatively femoral.

Ivana Jurin, Dražen Šebetić, Stanko Biočić, Jasmina Ćatić, Aleksandar Blivajs, Ana Jordan, Josip Vincelj

**Introduction:** Congenital malformations of the mitral valve are relatively rare and present with a wide spectrum of morphologic abnormalities. Descriptions of functionally uni-leaflet mitral valves are extremely rare and largely limited to few case reports. (1-3) We present two patients with almost complete absence of posterior mitral valve leaflet (PML) in which three-dimensional transthoracic echocardiography (3D TTE) was used as a valuable diagnostic tool. **Case A:** 38-year-old woman was operated due to constrictive pericarditis. Real-time 3D TTE showed only a single, long, morphologically valid, properly movable leaflet in the place of the anterior mitral leaflet (AML) that leans itself on the PML rudiment. The subvalvular apparatus was anatomically normal, with appropriate chordal attachments and papillary muscles. Color Doppler showed a narrow jet of mitral regurgitation directed towards the lateral wall of the left atrium. **Case B:** 24-year-old patient was admitted due to acute myocardial infarction with ST elevation of inferoposterolateral region and right ventricle. Real time 3D TTE showed a rudiment of the PML with a prolapse of enlarged AML and excentric moderate MR directed towards posterolateral wall of the LA, with no progression within a one year control period. **Conclusion:** Until today there was no need for corrective surgery in these patients, but prognosis remains uncertain. The potential of worsening mitral regurgitation, primarily as a consequence of annular dilatation, has been postulated. Real-time 3D TTE is important in diagnosing heart valve diseases because it enhances the evaluation of morphologic abnormalities and improves understanding of complex relationships through more precise imaging and presentation of interrelations of different parts of the mitral apparatus.