Cardiologia Croatica. 2018;13(11-12)

Teja Prijatelj, Breda Barbič-Žagar

Although the awareness and control of hypertension have increased, improved achievement rates for target blood pressure (BP) levels remain an unmet need worldwide. Due to a multifactorial etiology of hypertension, BP targets cannot be reached with a single agent in most patients. Low adherence to antihypertensive treatment, which is in direct correlation with the number of medications prescribed, has been recognized as a major contributor to poor BP control. The need to improve BP control is reflected in the 2018 ESC/ESH Guidelines for the management of arterial hypertension, which developed a simple and pragmatic treatment strategy for a more effective and faster lowering of BP to target levels – the most important issue in the management of hypertension.

Ileana Šćepanović, Adrijana Livaja

Mentoring is a complex, interactive process that takes place between individuals of different levels of experience and expertise, in which the mentor gives support to colleagues or a student or mentor. In Croatia, a mentor in health care is usually considered an older, more experienced nurse with professional knowledge, experience, skills and knowledge of health care procedures. It is also necessary for the mentor to have other characteristics and features: high level of communication skills, teaching skills, respectability and support. The main goal of mentoring in nursing is to enable a student to become an independent, qualified healthcare worker with all the necessary competences and skills needed to achieve the highest possible quality of health care. There is no formal mentor training in Croatia but there is awareness of the importance of the mentor role to lead and support future generations of our nurses. (1) In addition to the lack of formal mentor training, there is also a feedback on mentoring work and self-assessment of mentors in order to improve mentoring practice. This is important because the students are mostly shaped by the mentor’s work and behavior. On the other hand, mentoring as a demanding and complex activity is often insufficiently recognized and valued. The most common difficulties in mentoring include academic and professional non-recognition of the role of a mentor, overload of nurses’ work, a large number of mentors mentored by mentors, insufficiently paid work of a mentor and lack of appropriate knowledge and skills that the mentor should have.

Ivica Matić, Ana Ljubas

**Introduction**: Nurse education in Europe differs between countries and usually adapts to the changes in clinical practice and the needs of society. (1) Transformation and adaptation have been especially noticeable in the last decade because development of medical sciences and advances in technology have significantly changed clinical practice. It’s completely clear that these changes lead to the alterations, expanded demands and challenges in nursing practice. (2) Those challenges demand certain changes in the systems of education, continuous improvement and vocational training of nurses. Therefore, development of specific educational program for cardiac nurses is needed to answer the needs of modern society, as well as follow the trend in developed countries where specialized nursing professions have been created. Occupational standard that contains the key information on the defining occupational properties, employer needs and workplace specifics will form the basis for development of quality educational programs. This paper will show the results of the Survey on cardiovascular nursing occupational standard. **Methods**: The data has been collected in the organizations that employ workers in the afore-mentioned occupation, the attributes of the described workplace, needed education, key jobs that workers on those workplaces perform, and the skills and knowledge needed for practice. The survey also collected information on the needed level of development of key competencies for lifelong learning, needs for specific generic skills, psycho-motoric capabilities and working conditions. **Results:** Survey on cardiovascular nursing occupational standard was conducted in Croatia during 2018. Research processed answers of 41 representatives of employers that mostly belong to the group of large employers. The jobs that the participants indicated as key in the occupation cardiac nurse can be summed in 28 job groups. Jobs that were mostly specified were conduction of diagnostic-therapeutic procedures, nursing care, educating patients and families, administering therapy, monitoring of patient status and administration. Knowledge and skills needed to work in the career of a cardiac nurse have been categorized in a total of 72 groups that include generic skills and personality traits. The employers mostly cite that workers should know the process of nursing, communication skills, conducting treatments, monitoring of patient state, education of staff, education of patient, know cardiovascular diseases and possess good communication skills. Most needed key competencies for life-long learning, according to the employer’s assessment, are oral communication in Croatian language, willingness to learn, written communication in Croatian language, having initiative and willingness to act. From the offered generic skills, the employers found responsibility, team work, focusing on patient needs and empathy to be crucial. From the psychophysical skills, the employers found the time of reaction and maintaining focus to be the most important. According to the employer’s assessment for the cardiac nurse occupation the most suitable level of qualification according to the Croatian qualification framework, which would comprise of university graduate studies or specialist graduate technical studies. **Conclusion**: Cardiovascular diseases are the leading cause of mortality in European countries, which has led to a renewed interest in developing specialized nursing education that is needed to bring forward the full potential of nurses that work in cardiovascular treatment centers. Standard of profession that contains the key information on the defining occupational properties, employer needs and workplace specifics will form the basis for development of quality educational programs.

Sanda Franković, Zvonimir Kralj, Vesna Kljajić, Ljerka Pavković

In Croatia, we note no significant efforts in the systematic study of the nursing history. To this day nursing contribution has only been systematically processed for the period between the two World wars. (1) The work of nurses is in historiography relatively poorly treated, despite that it is the key to understanding the social and medical concepts, but also the general public health and social system of the interwar era. (2, 3) The study of the contribution of religious communities was neglected until 1990s, which has its cause in the reluctance of the former political system to study activities within the Church. Croatian Nurses Association, which was according to available data established in 1927 represents the backbone of the nursing professionalization and is reflected in the activities that were directed towards the publishing of professional journals, efforts to develop education at the university level, establishment of nursing unions, chambers and many other activities. The professionalization of nursing in Croatia follows the trends of developed countries with a certain time-delay due to the specific historical, social and economic conditions. Croatian nursing is just on the threshold of the hundred years since the founding of its first nursing school in Zagreb that opened in January of 1921. Since the founding of the school nurses had a distinctive uniform and a corresponding pin which differentiated them from the other personnel. In the wake of the aforementioned needs Croatian Nurses Association has founded in 2013 the Association for the History of Nursing. Accumulated historical data concerning the professionalization of nursing in Croatia will be shown during the exhibit. Two posters depict activities of Croatian Nursing Association since its founding to this day. Other two posters focus on the changes of the nursing uniform and show nursing pins that were awarded after graduation or as awards. The last poster is dedicated to Homeland War (1991-1995) and the role that nurses played in wartime healthcare.

Marina Lacković, Valentina Košćak, Milka Grubišić

During and after the cardiopulmonary surgery and the patient’s stay in the intensive care unit and on the ward, there is a risk of developing a healthcare associated infections (HCAI). The possibility of developing HCAI in cardiosurgical patients is dependent on certain risk factors; elderly patients, chronic obstructive pulmonary disease, diabetes mellitus, duration of extracorporeal circulation, duration of invasive mechanical ventilation, long-term use of mechanical circulation support, type and duration of surgical intervention, postoperative admission of vasoactive drugs and transfusion blood derivatives, presence of colonization or infection. Providing the standard protective measures of care for every patient is necessary, including the use of personal protective equipment, hand hygiene, safe handling of infectious waste, safe handling of the sharp objects, decontamination of the equipment and the patient’s surroundings. In addition to the standard protection measures, it is important to emphasize that there are additional protection measures that depend on the transmission of the causative agent by contact, air or drop and accordingly carry out patient isolation measures, and the most common is a contact isolation. In providing everyday health care, it is important to properly carry out the hand hygiene while complying with the concept of My Five Moments for Hand Hygiene according to the World Health Organization guidelines and the application of the Hand Hygiene Guidelines in health care facilities. (1) In preventing the occurrence of HACI, it is important to recognize and prevent hospital infections through the implementation of adequate measures.

Milka Grubišić, Dragana Jurčić, Petra Lauš

Traditional model of drug supply in hospitals is based on filling compartment stocks, based on their claims, and then preparing prescribed patient therapy. During mid-last-century in USA was developed a new concept of immediate drug supply called Unit Dose Drug Distribution System – UDDDS. (1) In the effort to improve standards of care in Croatian health care system, UDDDS is introduced for each individual patient, not more than 24-hour supply in Department of Cardiac and Transplantation Surgery, University hospital Dubrava. UDDDS team is consisted of physician, pharmacist, nurse, and IT-communication system technician. For each individual patient at Department of cardiac and transplantation surgery prescribed therapy is additionally monitored in terms of adequacy and pharmaceutical drug form, dosing, dosing interval and possibility of clinically important interactions of medications. Medications are daily stored in container with the patient’s name on it, the time precise time of administration. Every drug placed in compartment is adequately single packed and labelled, so that the patient in hospital can be educated on the purpose, mode of application, and the type of medication that he is going to continue using after discharge from hospital. With the use of UDDDS, the distribution of medication is more precise and, there is better monitoring of drug interaction, multiple control of prescribed therapy, education of staff, patients and significant reduction in drug use. The patient becomes more compliant and takes adequate medications in accurate doses at the adequate time, which increases good treatment outcomes. (2) Medical errors are significantly reduced, almost eliminated, and patient safety is better. Also, the storage of medication at ward is reduced to minimum. Implementation of UDDDS has multiple advantages such as: faster and simpler education of newly employed nurses, clear, precise, and flexible system with minimal possibility of error in the daily administration of therapy. All above contribute to cost reduction and additional safety improvement of health care system users.

Marina Deucht, Ksenija Kasap, Ivana Vujeva, Petra Tomljenović

**Introduction**: Heart failure is a chronic, progressive condition in which a heart muscle cannot pump enough blood through the heart to meet the blood and oxygen requirements of the body. (1) It is the result of numerous primary and secondary diseases that lead to impaired heart pump function and reduced heart rate. Recognizing symptoms and establishing diagnosis is an extremely important part of the treatment and therapy of such patients. Through all forms of treatment of such patients, clinically, medically and ultimately surgically, physiotherapeutic processes are present as important factors in the medical team. Methods of monitoring, evaluation and physiotherapeutic intervention itself are performed and recorded in a standardized physiotherapeutic card and qualified questionnaires. The left ventricle assists device (LVAD) is mechanical support that is surgically embedded. It helps maintain the ability of a heart pump that cannot function independently. The LVAD device, sometimes referred to as the “bridge for transplantation”, is now used in long-term therapy. People often have to wait a long time before the appropriate heart becomes available. During this waiting, the already weakened heart of the patient may become even worse. **Case report:** A case study of a patient with diagnosis of dilated cardiomyopathy, received through Emergency services, continuation of treatment in the Coronary Unit, Intensive Care Unit and ultimately at the Institute for Cardiac and Transplant Surgery. Because of the underlying disease, the patient was connected to the extracorporeal membrane oxygenation device, and LVAD was later embedded into the operation. Outstandingly bad respiratory and condition status, physiotherapeutic intervention started in the intensive care unit and continued in the department. After a series of complications, the patient with that has undergone frequent early rehabilitation for 3 months has left our clinic and managed to proceed with daily life activities completely independent. She is currently on the transplant list. **Conclusion:** Given the difficult diagnosis, our patient has been able to overcome all the complications occurring in such a difficult state with the help of the built-in LVAD. A series of respiratory and musculoskeletal complications during surgical treatment required special expertise and knowledge of physiotherapists who, through their physiotherapeutic processes, helped the patients to re-actively engage in everyday lifestyle rhythm.

Barica Stanić, Željka Stojkov, Renata Valenčak

**Introduction**: Atrial fibrillation (AF) is one of the most common types of heart arrhythmia in clinical practice. (1) It is estimated that around 1% of the Croatian population suffer from AF. The majority of the afflicted are older people, though AF is also often found in younger people through ECG tests. It sometimes afflicts younger people without any specific cause, though it is mostly caused by obesity, alcohol consumption, stress and other stimuli. Patient awareness makes it easier to treat the disease, but it also helps the patient accept their condition and the possibility of treatment. (2) Cardiac nurses are trained to give the patient the necessary information about the symptoms of the disease, potential adverse effects of medication, the need to change their lifestyle, and the effect of risk factors on the manifestation of the disease. **Patients and Methods**: The aim of this study is to investigate the awareness of AF, its symptoms and its effects on the quality of life among patients afflicted by the disease. The study also aims to establish a link between the patients’ sex, age, and level of education and their awareness and quality of life. The method of the study is an independently created survey with questions on the patients’ demographic characteristics, awareness of AF, symptoms and the length of treatment. The examinees are patients suffering from AF receiving treatment at the Department of Cardiology at General Hospital “Dr. Josip Benčević” in Slavonski Brod and undergoing regular cardiologic diagnostics tests. 55 people have taken part in the survey. **Results**: The average age of the patients is 67 years. Most patients claim to be well-informed on the potential causes of AF and the treatment of the disease, while they are less aware of potential adverse effects of medication and the symptoms of the disease. Women are more prone to symptoms like nausea, insomnia and excessive sweating. The quality of life of younger patients is not disrupted by the disease. Patients with a higher level of education are more aware of the treatment of the disease. **Conclusion**: The study shows that most patients have a high quality of life. The majority have a high level of awareness of the disease from the medical aspect. However, further education on the symptoms of AF and the recommended changes in lifestyle among patents is necessary.

Tomislav Maričić

Patients admitted to the coronary care unit or arrhythmia department often present with one of numerous heart rhythm disorders. Some of the arrhythmias are not life-threatening (e.g. atrial fibrillation), whereas ventricular tachycardia and ventricular fibrillation are potentially life-threatening conditions, when medical team must react appropriately in the shortest possible time. It is important to note that atrial fibrillation and atrial flutter do not occur solely in coronary patients but may also occur in young individuals without structural heart disease. The aforementioned arrhythmias are mentioned, since they can be converted by electrocardioversion. Ventricular tachycardia occurs only in patients with underlying cardiomyopathy or coronary heart disease. There is an exception to the rule when ventricular tachycardia presents in “the healthy heart” (very rare conditions, e.g. prolonged QT interval syndrome). Defibrillation is a process of electrical energy delivery to the heart muscle with intent to interrupt ventricular fibrillation or tachycardia. Synchronized electroconversion is a modified form of defibrillation applied in atrial fibrillation or atrial flutter with the fast ventricular response, with the intention of restoring the sinus rhythm. Electroconversion can be urgent, or elective. Preparation of patients for elective synchronised electrocardioversion involves psychological and physical preparation. Electrocardioversion is a procedure that requires team work of cardiologists, anesthesiologists and nurses. It is necessary to approach the patient and perform the work professionally, explain the procedure to a patient, give clear answers to the questions posed and provide support during the procedure. In order for nurses to participate as equal members of the team in this, and also in other procedures, continuous nursing education is needed. (1)

Krešimir Librenjak, Darija Grbić, Jogen Patrk, Nikolina Vidaković

Implantation of permanent pacemaker is a routine procedure nowadays for treatment of bradyarrhythmia. Usually, electrodes are inserted to the right atrium, right ventricle and in case of CRT implantation to left ventricle area through coronary sinus, by the puncture of left subclavian vein. To ensure safe and successful puncture, it is desirable to do angiography of subclavian vein with its inflow into vena cava superior. (1) In some institutions it is a standard procedure. In the Cardiac Catheterization Lab of Zadar General Hospital, angiography is not performed in routine manner, but a venous path with an extension is prepared with infusion system and triangular extension for iodine contrast and venous angiography. In case of complex anatomy and difficult puncture of subclavian vein, angiography of subclavian vein is preformed to guide puncture. With this method repeated punctures are avoided and thus the risk of complications is reduced. It is important to emphasize that with the described approach, the possibility of provoking iatrogenic pneumothorax is minimalized, which is complication that extends the length of hospitalization. Also, subclavian venography itself gives us information on possible anatomic malformations or vein variations, and we can be adequately prepared for fast and successful implantation of permanent pacemakers.

Elizabet Horvat, Valentina Horvat, Mirjana Koledić

An electrical conductivity of the heart is provided by the impulse that occurs in the sinus node. Normal heart rate is called a sinus rhythm. (1, 2) A sinus rhythm means that the heart works at a steady pace of 60 to 80 beats per minute. Any change (skipping, accelerating or slowing down the rhythm) that disturbs the same heart rate is called arrhythmia. Ventricular premature beats are the most common cardiac arrhythmia. It is a premature heartbeat or contraction, where the beat occurs earlier than expected. If there is an ectopic beat after each sinus beat, it is called bigeminy, and if a premature ventricular contraction occurs at intervals of two normal beats to one contraction, it is called trigeminy. They can be asymptomatic but those patients with symptoms express fluttering sensation and discomfort, skipping of the heartbeat and palpitations. They are diagnosed with an electrocardiogram (ECG). For a healthy population they are not a hazard but for people with structural heart disease may be a beginning of malignant arrhythmia and that can increase the risk of sudden cardiac death. Causes of these heart rhythm disorders can often not be proven, but the most common causes are stress, increased body activity, alcohol, nicotine, caffeine, high temperature, and some flu drugs. Considering the known data on the high level of risk factors in the Croatian population (a large percentage of smokers and alcohol consumers) and about the data from the Croatian Society of Pharmacists about a very high percentage of people who are taking drugs without prescription, and the fact that 9000 Croats die of sudden cardiac death per year, we think that these seemingly benign arrhythmias also deserve greater medical attention. Nurses as numerous healthcare professionals can make a bigger contribution to health promotion and education of the population of a healthy lifestyle.

Ivica Benko, Nikola Krmek, Šime Manola, Nikola Pavlović, Vjekoslav Radeljić, Ivan Zeljković, Gordana Hursa, Sanja Keleković, Dorotea Vuk, Dario Grgurević, Jadranka Mandić

For most cardiac arrhythmias, antiarrhythmic drug therapy has only modest effectiveness. In addition to that, antiarrhythmic drugs have numerous side effects, proarrhythmic effects and they have very high cost in the long term. In the last two decades invasive electrophysiology (EP) and radiofrequency or cryo catheter ablation have become common and emerged as the first therapeutic option due to high success and low complication rate. (1, 2) Pediatric EP is closely related to the adult EP, but there are some very important differences in preparation and approach as well as characteristics of arrhythmogenic substrates. Children undergoing invasive EP represent a unique population different from adult patients undergoing similar procedure. The pediatric EP programme in University Hospital Centre “Sestre milosrdnice” started officially in March 2018. in collaboration of Pediatrics and Cardiology Clinics. In last 7 months, 23 (14 male, 9 female) pediatric patients underwent EP procedure. After EP study 20 patients successfully underwent radiofrequency catheter ablation and one patient underwent cryoablation. Two patients underwent EP study only – one with benign accessory pathway and one with PVCs that originate from left coronary cusp near the ostium of left coronary artery. 18 patients were diagnosed with supraventricular tachycardia (13 accessory pathways and 5 with atrioventricular nodal reentry tachycardia). 2 patients were diagnosed with PVCs (one from RVOT and one para hisian). All 23 EP studies were performed with 3D mapping system (Ensite Precision) and catheters suitable for children (5F catheters when needed). Youngest child with left lateral accessory pathway and AVRT was three years old. 17 procedures were performed completely without the use of fluoroscopy, while in 6 cases minimal fluoroscopy time was used for the transseptal puncture and in one case coronary angiography had to be performed. No complications occurred. Precisely because of the complexity, standardization of the procedures and the use of custom protocols increases the quality of care and pediatric patient safety and improve ablation outcome.

Ana Marinić, Vjera Pisačić, Valentina Jezl, Danijela Grgurević

Palliative care implies a comprehensive approach to providing the necessary care to patients who are confronted with severe and incurable diseases with fatal outcome. Although it is often associated with patients with oncological diseases, palliative care also includes the whole spectrum of patients with non-oncological diseases, as well as patients with heart failure (HF). The prevalence of HF in developed countries is 1-2%, while this percentage increases to 10% among the population older than 70. (1) Heart failure, with its chronic, progressive development and frequent exacerbations and hospitalizations leads to a series of unpleasant symptoms, such as difficulties or disability in carrying out daily activities, loss of independence, impaired social functioning and reduced quality of life. Symptoms and needs of patients in the terminal stage of HF do not significantly differ from those of patients in terminal stages of oncological diseases. The research conducted by Setoguchi, Glynn, Stedman et al. compared carcinoma patients to patients with chronic HF, and they found that HF patients more often tend to be hospitalized 30 days prior to their death than carcinoma patients (60% vs. 39% emergency aid, 64% vs. 45% acute medical units, 19% vs. 7% intensive care unit), and their mortality rate is also higher in acute units (39% vs. 21%). (2) The palliative approach in the intensive care unit is the only approach which can adequately meet all patients’ needs in the advanced stage of HF, at the stage when all treatment options have already been exhausted. Choosing the right moment to start the palliative care depends on the patient’s needs, and not on the prognosis of the disease. Palliative care should not be understood as “giving up”, but rather as a form of supportive approach, which does not exclude curative medical care and which can also be included in the earlier stage of the disease. Palliative approach in the intensive care unit implies minimizing invasive procedures and it focuses on treating physical, psychosocial and mental symptoms, as well as improving the quality of life, in which a multidisciplinary team is involved. The fundamental goal is to prevent and alleviate suffering. By providing support and encouraging sincere communication between the patient, his family and members of the healthcare team, it is possible to provide the conditions in which questions can be asked, various options can be considered (e.g. quitting excessive diagnostic and therapeutic procedures) and realistic goals can be set, which take into account the patient’s value system and respect his and his family’s wishes. Affirmation of life, accepting the death as a normal process, respecting the patient’s autonomy, holistic approach and helping with decision-making are some of the principles of palliative patient care in the intensive care unit. Palliative care may seem as a paradox in the intensive care unit that primarily advocates life and maintenance of vital functions; however, enabling a death with dignity in such an environment is undoubtedly the best indicator of humanity, which also reflects the most valuable qualities of all healthcare professionals involved in such patient care.

Alisa Bošnjak

**Introduction**: Aim of this study was to investigate views of medical nurses/technician about effects of patient’s dying and death on their beliefs. **Methods**: This research involved 400 participants, nurses and medical technicians of University Hospital Centre Osijek. We used standardized questionnaire Death Attitude Profile-Revised. (1) Questionnaire consists of 32 statements regarding the different attitudes toward death. The second part of research was composed of Interpersonal reactivity index questionnaire (2) which provides multidimensional measure of empathic response, measures of cognitive and affective aspects of empathy. Questionnaire is based on self-assessment and contains 28 statements which are divided in four subgroups. **Results**: Male examinees have less fear of death (p=0.001). Fear of death is higher in examinees with lower level of education in comparison with those with higher degree qualification (p=0.02). There is no difference between surgical and non-surgical wards. Elderly participants have higher grades of acceptance (p=0.178; p<0.001). Stronger interpersonal reactivity was examined in participants who were very religious with median of 63 (IQR=55-71) (p=0.02). 276 (69.1%) participants agree that there is need for education on dying and patient death. **Conclusion**: Statistical higher acceptance of dying and death was examined in nurses and medical technicians who have higher education. There is difference in gender, age and employment. There is a need for education about dying and patient death.

Marin Žilić, Danijela Grgurević

Heart failure (HF) is a clinical syndrome that occurs as a consequence of cardiac function and structure disorders, resulting in insufficient oxygen supply to the tissue and the inability to satisfy the metabolic needs of the body. The main characteristics of this syndrome are repeated hospitalizations, negative impacts on the quality of the patient’s life, an unfavorable outcome and a large economic burden on the health system. According to the values of the left ventricular ejection fraction (LVEF) heart failure can be divided into HF with reduced LVEF (HFrEF, LVEF 50%). Nearly half of all patients suffering from HFpEF and the incidence of HFpEF increases steadily in developed countries, primarily due to the increase of risk factors, specifically life expectancy, female gender, hypertension, diabetes, kidney failure and obesity. (1) First symptoms and signs of HFpEF occur during strain, stress or exercise. Atrial fibrillation (AF), as one of the comorbidities, leads to reduced left atrial (LA) filling, while long term untreated AF results in mechanical and electrical cardiac dyssynchrony. Elevated LA pressure leads to pulmonary hypertension which results in increased pressure values in the right ventricle and consequently affects the negative remodeling of the right ventricle and, eventually, right ventricle failure. HFpEF is diagnosed on the basis of the present symptoms and signs of HF as well as the results of echocardiography EF > 50%, increased LA, pulmonary hypertension, electrocardiogram, xhest X-ray and value of NT-proBNP. The treatment of HFpEF is limited to the symptomatic diuretic therapy, the treatment of comorbidity and possible revascularization. Patients with HFpEF are a very heterogeneous group of patients. Due to the aging of the population in general, the number of patients increases and, accordingly, the role of a nurse in a team that participates in the treatment of patients suffering from HFpEF becomes even more important. With their knowledge and skills, nurses greatly contribute to the early diagnosis of HFpEF and are indispensable members of a team regarding the acute and chronic care for individuals suffering from this syndrome. Educating both patients and their families about the importance of regular exercise, healthy eating habits, regular use of diuretic therapy and adequate individualization of self-care guidelines is the key to improving the quality of life of patients with HFpEF, as well as a part of nursing activities in a multidisciplinary team during the care for patients.

Goranka Oremović, Mara Ćavarušić, Mateja Šolić, Paula Kraljić

Heart failure (HF) becomes an increasingly public health problem. Continued “aging” of the population leads to an increasing prevalence of HF in the population. There are three basic models of treatment for HF. Conservative treatment for patients with a lower HF rate. If the patient does not respond to pharmacological therapy, two methods of treatment remain: heart transplantation and mechanical circulation support. HF, along with other cardiac diseases, greatly affects many physical and psychological changes that can affect nutritional needs and nutritional status. One of common complication of patients with HF is cardiac cachexia. (1) An important part of healthcare is a regular assessment of the nutritional status of a cardiac patient. The role of a nurse is to teach and alert the patients to the importance of proper nutrition. (2) It is also important to plan meals, and dietary supplements; nutritional supplements that fall into the group of enteral nutrition, and nutritional supplements that are not administered by the transitional route, supplements from the parenteral diet group. Enteral nutrition includes a standard diet in consultation with the patient and nutritionist, also with various dietary adjustments to individual clinical requirements. Parenteral nutrition partly or fully satisfies the daily intake of nutritional needs. Nutritional status is an important factor influencing the outcome and recovery from disease. The aim and purpose of this paper is to focus on the importance of enteral and parenteral nutrition in the terminal phase of HF.

Tanja Mikulandra, Mihaela Roguljić

Anderson-Fabry disease is congenital deficiency in α-galactosidase A activity leading to intra-lysosomal accumulation of neutral glycosphingolipids. (1, 2) Patients with this disease are unable to catalyze neutral glycosphingolipids, mainly globotriaosylceramide (Gb3), which re then accumulating in various organ systems, heart, skin, kidney, blood vessels, and central nervous system. The disease is an X-linked LSD inherited recessively. Characteristic symptoms and sings of Fabry disease include angiokeratoma (vascular skin lesions), acroparesthesiae (periodic painful crises in limbs), hypohidrosis (inability to sweat) and characteristic clouding of cornea. Disease occurs at birth, during childhood is usually of no clinical relevance, with organ defects obvious during fourth decade of life in men and fifth decade in women. Cardiac manifestations of the disease are result of s associated with Gb3 accumulation in all cellular components of the heart, including cardiomyocytes, conduction system cells, valvular fibroblasts, endothelial cells and vascular smooth muscle cells, resulting in hypertrophic cardiomyopathy of the left or both ventricles. In advanced stage of the disease, changes in heart muscle can lead to the heart attack, cardiomyopathy and conductive disorders. Echocardiography is an excellent non-invasive diagnostic tool for diagnosis of Fabry disease (left increased left ventricular wall thickness, valvular changes, cardiac chambers quantitation). Cooperation of physicians and nurses is imperative for optimal echocardiographic imaging, detection and monitoring of the disease. In patients with clinical suspicion of Fabry disease, nurse performs venepunction or take blood capillary. After drying, samples are sent for analysis of enzymatic activity and genetic testing. After diagnosis of Fabry disease, patient comes to therapy every two weeks. Enzyme control is performed every three months in order to monitor the effect of therapy. Monitoring of the disease includes ultrasonography, biomarkers (GL3, Lyso GL3) and antibodies during the application of enzyme substitution therapy.

Maja Krajina, Alen Baćar, Sanja Prelec

**Introduction**: Advanced heart failure affects only a small percentage of patients with heart failure (HF), but never the less, is a growing public problem. Heart transplantation was a gold standard of treatment for many years, but in the last 10 years novel advanced treatment methods have become available as a therapy. (1) **Case report:** In this case report we will show a 52 years old patient who was hospitalized in Department of Intensive Cardiac Care due to HF. Patient had biventricular dilative cardiomyopathy and had cachexia on admission. Because he was on inotropic support and his vital signs needed to be continuous monitoring, he needed intensified nursing care. His medical treatment was complicated with hemodynamic instability and eventually he underwent placement of veno-arterial extracorporeal membrane oxygenation, and 3 days after that he had been upgraded to central circulatory support of both ventricles. During that time, diagnostic workup for heart transplant was completed and he was listed for urgent heart transplant via „Eurotransplant“. After 20 days a suitable organ was offered, and he underwent the procedure with a good result during recovery. **Conclusion**: Medical care of patient with mechanical heart support is quite a challenge to nurses. However, her role is a crucial in multidisciplinary approach. Beside physical, educational and psychological help provided by nurse to a patient, she also coordinates work of the health team, navigates patient through the health system and allocates education and support for patient family members. Efficient team work with a focus on quality communication can significantly prevent work errors and can improve patient content with provided service.

Dragana Jurčić, Petra Lauš, Milka Grubišić

Heart failure (HF) becomes an increasingly important public health problem. When optimal therapeutic therapy becomes insufficient for the treatment of patients with HF, only two methods of treatment remain: heart transplantation and mechanical circulatory support. Mechanical circulatory support (MCS) is used as a form of treatment for patients with advanced HF. (1) In the treatment of patients with MCS, experts from different areas, technology engineers, surgeons, cardiologists, perfusionists, anesthesiologists and nurses are involved in health care process. This includes the application of all available knowledge in the area of nursing in accordance with the competences of nurses. Patient health care is based on continuous monitoring of patients and devices and accompanying equipment. Knowledge and handling of the device allows to detect unfavorable changes with the aim of preventing the consequences that may endanger the life of a patient. Nursing care with patients with MCS is very demanding area of nursing care, and requires continuous education, tracking of the latest data, holistic approach, and professional co-operation with team members. Regular assessment, monitoring, monitoring and recording of vital signs, early complication recognition, and aseptic work are the main tasks of nursing care in patients with MCS. The education of health personnel, the teamwork of all health professionals is focused on identifying problems, ways of treating patients and educating patients and their families. The nursing role is to provide support with their care to recognize and relate to the problem, to teach the patient and family all the skills that will help them overcome the difficulties, adapt and accept the new situation.

Tomislav Ivanović, Antonija Grgić, Matea Mandić

Cardiomyopathy (dilated, hypertrophic and restrictive) are diseases with structural and functional changes of hearth muscle, often characterized by progressive course. Although the main cause in unknown, there are numerous factors known to contribute to the development of cardiomyopathy. There are more and more young patients having this disease in recent years (1). Nurse’s /technician’s role in management of patient with cardiomyopathy is crucial not only during the hospital stay but also after the discharge from healthcare institution. Nurse is a patient’s advocate, estimating his needs and helping him to meet them. She/he advocates for the implementation of the plans after the hospital stay. Nurse is helping patients to improve their self-management skills or /and helping family in providing support to patient. We present the case of 34-year-old patient hospitalized in Cardiology ward under diagnosis of chronic breathlessness with minimal exertion, with anasarca, where underlying condition probably was respiratory tract infection (viral pneumonia) consequently resulting in heart failure. Echocardiography showed dilated cardiomyopathy with reduced ejection fraction (EFLV around 15%). All tests are indicative for viral myocarditis as an ethological and pathophysiological mechanism of dilated cardiomyopathy, antibodies (IgM and IgG) against CMV and IgG against EBV were detected in blood. During his stay, with adequate care and optimal therapy for heart failure, significant clinical improvement was reached, patient felt better, and he was released home with plan for receiving immunoglobulins in further course of treatment.

Nikolina Vidaković, Danita Marković, Zdenka Ćurić

The pacemaker is an electrical device that helps stimulate heart stimulation by feeling normal heart pulses and sending impulses if needed to activate cardiac muscle and maintain a normal heart rate. Indications for implanting the pacemaker are made according to the guidelines of the European Cardiac Society. The most common indications are bradyarrhythmia. Depending on the type of arrhythmia and the clinical condition of the patient, there are devices that are different according to the electrical capabilities, the number of electrodes to be carried pulses, and the size of the device itself. The procedure is performed with anesthesia, the device is inserted under the clavicle, and above the chest muscle. As with other invasive procedures and with the implantation of a pacemaker, there is the possibility of some complications. The most common complications are pneumothorax, hematoma, infection and bedsore of the pacemaker bearing. (1) In University Hospital Merkur implantation of pacemakers has begun in December of 1997, in operation theater of General Surgery and after September of 2007 procedures are performed in operation theater in the Department of Cardiology. We will present a patient with pacemaker bearing bedsore.

Kristijana Radić, Matija Vrbanić, Ljiljana Švađumović

Takotsubo syndrome (broken heart syndrome) was first described in Japan. Its characteristics are regional systolic left ventricular dysfunction. Prevalence is currently estimated at 1% to 2% of patients with suspected acute coronary syndrome (ACS), but related with emotional or physical stress. (1, 2) Although the exact pathophysiology isn’t fully elaborated. Despite the fact that this syndrome had high rate of survival and positive reaction to treatment we can link broken heart syndrome with lethal complications that cause death of patients as high as 5%. In University Hospital Dubrava golden standard for differential diagnosis is coronary angiography with ventriculography and it requires exceptional education all involved personnel.

Igor Ferjančić, Marina Maruna

Single use materials represent a standard in interventional cardiology and electrophysiology which should be followed. (1) But the raising need for these costly interventional procedures put in question can this be strictly followed since budget limits institutions are faced with do not allow cardio labs to reach their desired procedure volumes. Reused materials had been shown as a substantial potential to meet these needs. They do allow maintaining high quality service, volume and material quality wise. This practice undoubtedly cuts the hospital costs and spare a substantial money to health care system overall. Numerous studies point out that reusing materials is safe practice and does not jeopardize procedural efficacy. The question left unanswered is how many resterilization processes can certain piece of material undergo? The aim of this lecture is to give an overview of our years long practice of using resterilized materials, the way they are processed and handled to maintain them close to their original quality, thus easy and safe to reuse.

Renata Čosić, Tomislav Pijetlović, Valentina Varmuž, Ivana Benković, Božica Leško, Jadranka Daskijević, Lidija Ban, Ivica Benko, Ivana Tomašić

**Introduction**: This case report presents a patient with arterial hypertension initially examined in the Surgical Emergency Unit because of a head contusion as a consenquence of a mild traffic accident due to a syncope preceded by chest pain. **Case presentation**: After thorough evaluation, patient was diagnosed with an acute ST elevation myocardial infarction of the inferoposterior wall, and since the patient was somnolent and had neurological deficits (anisocoria and left-sided hemiparesis), CT angiography of the cerebral arteries was performed, and acute ischemic cerebrovascular insult was also verified. Immediately afterwards, coronary angiography was performed and triple vessel disease with the occlusion of the right coronary artery was found. During the same procedure, a percutaneous coronary intervention was performed with the implantation of 3 stents in the residual stenosis of the right coronary artery. Subsequently, an endovascular procedure, superselective DSA, was performed and the occlusion of the posterior cerebral artery and superior cerebellar artery was confirmed. Immediately, an intervention with thromboaspiration and mechanical removal of thromboembolic material was performed. The patient was hospitalized at the Intensive Cardiac Care Unit, Department of Cardiovascular Diseases, University Hospital Centar “Sestre milosrdnice” and during the hospitalization there was a complete regression of symptoms and complete neurological recovery. Through an appropriately set up health care plan, identifying nursing problems in the patient, and appropriate healthcare interventions, the set goal during the patient’s hospitalization has been successfully achieved. Experienced skills, combined with knowledge, helped a team of nurses and technicians to prevent a possibility of creating a new nursing problem by implementing interventions through a set health care plan. During further hospitalization, the patient was cardiopulmonally compensated, afebrile, without neurological deficit. **Conclusion**: This paper shows that it is possible to adequately and successfully treat patients with concurrent acute myocardial infarction if there is a possibility for an accurate and prompt use of complicated diagnostic and therapeutic procedures. (1, 2)

Ante Borovina

With the development of technology which enabled a catheter display in the patient’s body without using X-ray radiation, there was an idea that an electrophysiology procedure should be used on high risk patients, such as younger patients, children and pregnant women, without using an X-ray diascope device. (1) The procedure requires the highly experienced operator and a team because manipulation with catheters can cause harm to the patient such as perforation of cardiac structures or blood vessels. Trough the case reports of ablated patients by this zero fluoro method in the period from February 2018 to November 2018 we will present experiences from the Centre for Electrophysiology at the University Hospital Centre Split. Some of the crucial intraprocedural steps will be shown, such as the process of mapping the path to the heart, map processing, recognition of anatomical structures through intracardial electrography, as well as their marking on the map. Our experience is based on 20 patients who underwent the procedure of ablation without using X-ray device. We will especially highlight the case of a patient in the 6th month of pregnancy with atrioventricular nodal reentry tachycardia.

Darko Adžić, Areta Ognjenović, Aleksandar Zrnić, Željka Aćimović, Đorđe Jerković

Acute myocardial infarction (AIM) is a consequence of total interruption of blood flow in coronary arteries. Most often it happens suddenly because of thrombosis which occludes the lumen of coronary artery or some of its side branches. This condition is treated in two ways medications and PCI (percutaneous coronary intervention) (1), that is interventional method in which by passing the wire through occluded coronary arteries and ballooning and respectively placing the stent on the spot of thrombosis and reopening the blood vessel. AMI is successfully managed in Republic of Srpska since 2008 and guided by initiative “Stent for life” since 2014. We are covering the 24-hour time, respectively every acute coronary infarction which arrives in “golden hour” time is immediately hospitalized and taken care of in our Cath lab. Over 600 AIMs per year is hospitalized in University Clinical Centre in Banja Luka from all areas of Republic. The fascinating fact is that over 90% of patients is done by using the radial approach. At the moment, in our Cath lab there are 7 specialists of interventional cardiology, 4 physicians at specialization, 5 medical and 3 x-ray technicians. Our team is educated in world renewed cardiology centers and successfully follows the guidelines of world cardiology association. We are also working on continuity of education and we keep following the latest trends in a world, as for physicians, so for medical and x-ray technicians.

Monika Tuzla, Jasna Čerkez Habek, Mario Ivanuša, Dubravka Kruhek Leontić, Nada Hrstić, Goran Krstačić

**Introduction:** Acute myocardial infarction (AMI) is one of the most severe cardiovascular incidents. The treatment, recovery and change in life style in a patient can result in fear, distress, insecurity, anxiety and depression. In order to improve the quality of recovery and reduce the risk of cardiovascular incidents, a cardiovascular rehabilitation program (CVR) is conducted, which, in addition to some other secondary prevention components, also includes a complete psychological care. (1-3) The aim of this study was to determine the incidence of anxiety and depression in patients involved in the outpatient CVR program. **Patients and Methods:** The retrospective study was conducted in the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The details about patients were collected for the period from 10th September 2015 to 31st December 2017. The patients with AMI basic diagnosis were divided into three groups: those treated by percutaneous coronary intervention (PCI), those treated by coronary artery bypass surgery (CABG) and those treated by optimal medical therapy (OMT). The structured Hospital Anxiety and Depression Scale (HADS) was used for screening of anxiety and depression at the beginning and end of the program of quarterly outpatient CVR. (2, 3) **Results:** 437 patients were involved in this trial of whom 367 were treated by applying PCI, 50 patients were treated by applying CABG and 20 patients were treated by applying OMT. The results (**Table 1**) show that out of the total number of patients at the beginning of the program, 18% of the them have borderline and clinically significant anxiety, and 22% of them have borderline and clinically significant depression. The values of anxiety at the discharge, compared to the anxiety at the beginning of the outpatient CVR program normalized in 10%, while the values of depression normalized in 11% of patients with AMI. ### TABLE 1: Incidence of borderline and clinically significant anxiety and depression in patients with acute myocardial infarction involved in the outpatient cardiovascular rehabilitation program. | **Results on HADS** ≥8 | **On admission** number (%) | **At discharge** number (%) | **Change** number (%) | | --- | --- | --- | --- | | **All patients with AMI (N=437)** | | | | | Anxiety | 80 (18.3%) | 38 (8.7%) | 42 (-9.6) | | Depression | 98 (22.4%) | 48 (11.0%) | 50 (-11.4) | | **Patients with AMI treated by percutaneous coronary intervention (n=367)** | | | | | Anxiety | 69 (18.8%) | 30 (8.2%) | 39 (-10.6) | | Depression | 83 (22.6%) | 39 (10.6%) | 44 (-12.0) | | **Patients with AMI treated by coronary artery bypass surgery (n=50)** | | | | | Anxiety | 6 (12.0%) | 4 (8.0%) | 2 (-4.0) | | Depression | 9 (18.0%) | 6 (12.0%) | 3 (-6.0) | | **Patients with AMI treated by optimal medical therapy (n=20)** | | | | | Anxiety | 5 (25.0%) | 4 (20.0%) | 1 (-5.0) | | Depression | 6 (30.0%) | 3 (15.0%) | 3 (-15.0) | [†] HADS = Hospital Anxiety and Depression Scale; AMI = acute myocardial infarction. **Conclusion:** Participation in the outpatient CVR program results in a decrease in self-assessed anxiety and depression in patients after AMI. The results of screening by using HADS show a better recovery in a group of patients treated by applying PCI.

Paolo Šorić, Ivona Brajković

In Republic of Croatia there is a continuous and statistically significant increase of incidence of death due to cardiovascular disease (CVD). The waiting list for cardiovascular rehabilitation (CR) is increased due to insufficient capacity in Centers providing rehabilitation. Development of new technologies gives us new possibilities in implementation CR. Personalized approach, tracking of physical activity and access to parameters of healthy subjects, as well as ill people, along with the education of patients and their families are all parts of new perspective in personalized approach to rehabilitation of each patient. (1) We are developing a project that consists of a web portal structured with existing multiple-choice menu. Portal will provide all relevant information about his disease for patients, network of CR centers in Croatia, guidelines for patients’ rights to enter rehabilitation and information and contacts with CR centers. The unregistered part of the portal consists of comprehensive and continuous source of primary prevention guidelines through educational programs. Guidelines includes general information about risk factor, cardiovascular diseases, mortality rates and illness in Croatia and world and general guidelines on implementation of CR. The web portal will consolidate joint collaboration of all institutions involved in cardiac rehabilitation, while meeting accreditation standards set for obtaining work license, which includes education of the professional staff. For registered users portal provides patients with additional possibilities in secondary prevention and CR program. Users profiles contains possibility of individualized program of CR taking account patients clinical status. If a patient has undergone rehabilitation program in Thalassotherapy in Opatija, then the profile will include basic parameters and results of CR and plan for programmed training for further rehabilitation. Patients on waiting list will be allowed an early start of rehabilitation if they satisfy initial questionnaire of risk classification. There will be access to various thematic channels and blogs that will, depending of expertise area, contain various educational materials in the form of professional articles and video materials from field of nutrition, clinical psychology, physical and interval training with infallible motivational content. It will be possible to transfer data from smart devices (smartphones, smartwatches) and various applications for tracking of physical activities and to permanently save user profile results, which allows us to monitor continuity of patient physical activity and as part of secondary prevention gives us the possibility to direct and to form recommended dose of physical activity. Access to virtual bicycle training (in the future on treadmill and rowing ergometer) enabled simulated training on outdoor trails. The database will offer each patient trails surrounding his life environment and paths with the same intensity in other parts in Croatia and around the world which builds motive for physical activities. With telemedicine support, the availability of a cardiologist to answer questions related to rehabilitation will be available in all parts of Croatia. Web portal as a large database of statistics will show current status of patient care and thus improve CR. This is a foundation for creating future general and preventive plans in protection from CVD. In the light of increase significance of prevention from CVD, rehabilitation of cardiovascular patients will become more important in overall care and prevention of diseases and mortality from CVD, with decrease of costs and increase in quality of life importance in overall care and prevention.

Mare Silić Kirhmajer

Cardiopulmonary exertion testing (CPET) is a non-invasive diagnostic method for monitoring of cardiopulmonary response to the load. This test enables evaluation of the function and capacity of the cardiovascular, pulmonary and metabolic system. (1) Therefore, ergospirometry has become an important clinical tool for assessing physical ability in patients with heart failure and other cardiorespiratory conditions. Ergospirometry test is considered the gold standard in testing of the functional abilities of cardiorespiratory system and planning individualized physical activity for patients undergoing cardiologic rehabilitation. The nurse has an integral role in the implementation of ergospirometry testing. In addition to helping patients manage their cardiovascular problems, her tasks are also the proper preparation of the room, equipment, and patient for an optimal test performance. During the test, occurrence of symptoms/complications such as fatigue, heart arrhythmia and syncope are possible. Therefore, the nurse working in the ergospirometry laboratory should know very well indications and contraindications for the test and should be skilled in cardiopulmonary resuscitation. Much of the sister’s work in ergospirometry takes place long before the diagnostic test is carried out. Continuous education, development of medical and psychological skills is an integral part of work and progress in the ergometric laboratory.

Žaklina Muminović, Mario Ivanuša

The Outpatient Cardiovascular Rehabilitation Program (AKVR) is a component of secondary prevention of cardiovascular diseases. It is present in large urban areas and is tailored to patients who are indicated such a type of rehabilitation. The AKVR program is conducted in teams by applying interdisciplinary and transdisciplinary approach. Bachelor of Physiotherapy is an important team member and he conducts the physiotherapy treatment (FT) under the supervision of a cardiologist and in agreement with a physiatrist. Following the cardiovascular risk stratification, FT treatment starts by identifying the objectives aimed at the improvement of the patient’s functional capacity, psychological stabilization, preparation for social reintegration and recovery of work capacity. It is continued by conducting the high quality and comprehensive FT assessment (subjective and objective SOAP, ICF) that includes anthropometric measurements and therapeutic education of a patient and his/her family members. In addition, discomforts are identified and recorded, thereby recognizing a need for further diagnosis accompanied by mandatory documenting all stages and aspects of the FT treatment. An individual intervention program by using FT procedures, starting from therapeutic exercises, interval training, riding a modern rehabilitation computer-controlled bicycle to education on the guidelines and laws of the physical activity, the importance of proper breathing, relaxation techniques, posture improvement, etc is determined. Patients are rehabilitated either in groups or individually according to the professional rules and the protocol on teamwork, accompanied by continuous telemetric monitoring of the electrocardiogram that monitors the exertion tolerance and clinical status. A final FT assessment and evaluation is made following the program conducted. All the procedures are documented in the patients’ records and are calculated in accordance with diagnostic and therapeutic procedures in secondary healthcare prescribed by the Croatian Health Insurance Fund. (1-4) Bachelor of Physiotherapy will by applying professional, cognitive, social and communication skills perform various forms of FT program in the Department for Outpatient Rehabilitation of Institute (**Table 1**). He insists on the fact that movement is a medicine, and that continuous physical activity is essential to the health. ### TABLE 1: Forms of physiotherapeutic interventions in the Department for Outpatient Rehabilitation of Institute for the Prevention of Cardiovascular Diseases and Rehabilitation, Zagreb. | | **Group** **AKVR** | **Individualized** **AKVR** | **Individual** **AKVR** | **Physical exercises organized in the afternoon** | **Public Health** **Actions** | | --- | --- | --- | --- | --- | --- | | Warming-up & flexibility | + | +/- | +/- | + | +/- | | Movement coordination | + | + | + | + | +/- | | Interval training | + | + | +/- | + | +/- | | Cooling down | + | + | +/- | + | +/- | | Medical equipment for active rehabilitation | + | + | + | + | + | | Computer-controlled rehabilitation bicycle | + | - | - | + | - | | Electrocardiogram monitoring | + | + | + | - | - | | Monitoring of vital signs and general condition | + | + | + | +/- | - | | Monitoring Borg scale of perceived exertion | + | + | + | +/- | - | | Monitoring of breathing, posture and positioning | + | + | + | +/- | +/- | | Therapeutic education | + | + | + | +/- | +/- | | Duration of the program | 12 weeks | 12 weeks | 12 weeks | At the patient’s choice | During the time of the action | | Number of organized medical gymnastics sessions a week | 3-5 | 2-3 | 1-2 | 2 | - | [†] AKVR = outpatient cardiovascular rehabilitation

Božica Leško, Ivana Tomašić, Ana Plenar, Valentina Sedinić, Tomislav Pijetlović, Danijela Sorić Noršić, Cecilija Leporić, Renata Čosić, Đurđa Vlajković, Saša Matejčić, Ana Meseljević, Mateo Kosier

For the past three years, World Heart Day was held in the University Hospital Centre (UHC) “Sestre milosrdnice”. World Heart Day is held every 29th September and is the largest event of the World Heart Federation (WHF) supported by its members and partners around the world. A series of educational activities, control reviews for public and sports activities are organized, as a goal to raise public awareness of cardiovascular diseases (CVD). CVD (heart disease and stroke) are still the leading cause of death and are responsible for 17.5 million deaths each year. (1) It is expected that by 2030, their number will grow to 23 million. (1) The Clinic for Heart and Cardiovascular Diseases of UHC “Sestre milosrdnice”, along with the Croatian Association of Cardiology Nurses, joined this year to mark the World Heart Day. During public health action for citizens, patients and visitors of UHC “Sestre milosrdnice” measured blood pressure, blood sugar, calculated body mass index, evaluated cardiovascular risk, shared educational leaflets, healthy biscuits and apples with a message: “Love instead of salt it won’t hurt the heart”. Physicians advised event visitors on their regular medication, blood cholesterol control and smoking cessation aswell as allowed alcohol and salt intake. Clinical physiotherapists from the Clinic for Heart and Cardiovascular Diseases stressed out the importance of maintaining physical activity and showed exercises that citizens can perform daily at home. Visitors were also advised on eating healthy foods, prepared with less sugar and salt, as well as their substitutions, by the nutritionists. At the end of this year’s action an educational workshop for nurses about preparing healthy desserts was held. In the past three years, 728 of our citizens have responded to public health action. All visitors participated in a questionnaire and their age and gender, body mass index, physical activity, smoking data and cardiovascular risk factors were analyzed. The data will be presented on the poster. The goal of the WHF is to reduce the premature mortality caused by CVD across the globe through public health actions. Together with their membership they believe in a world where heart health will be the basic human right for everyone, making it a fundamental element of global health justice, because every beat is important. Each year the action has a different motto. This year’s World Heart Day motto is “For my heart, for your heart, for all our hearts. Promise your heart.” In 2017, the motto was “Boost, run, love your Heart - Share energy” and in 2016 “Start up your life”. By marking the World Heart Day, we want to share the message and educate the public about the risks of CVD, the importance of preventing these diseases, and encourage the following thought: “If we enter a few minor changes into our lives, we can live a longer, better and healthier life for our heart.”

Irena Kužet Mioković, Marica Komosar-Cvetković, Ivona Brajković

Cardiovascular disease (CVD) are still the major cause of death and mortality in Republic of Croatia. During 2016 the number of deaths decreased was reduced, and the total mortality rate was 45%. In order to reduce abnormalities, complications and deaths of CVD, a quality preventive program is needed with the aim of long-term changes in lifestyle and habits with acting on psychosocial risk factors. The cardiac rehabilitation benefit arises, not only from its clinical relevance and economic profitability, but also to the undeniably proven reduction of mortality by 50% and reduction of new hospitalization by 25%, compared to those who do not approach the same. Barriers in cardiac rehabilitation are multiple: lack of resources, capacity, reduction sending patients by a doctor, poor economic situation, distance of the patient’s place of residence from the place of cardiac rehabilitation. In Republic of Croatia as well as across Europe the number of centers is missing and only small number of patient’s approach programs of cardiac rehabilitation. The main objective of this project is to increase participation patients of CVD and increase the availability through the programs of opening new centers for outpatient cardiac rehabilitation in Republic of Croatia, education of medical staff, patients and their families. Rehabilitation reduces the likelihood of repeating a cardiovascular event by stabilizing the disease, slowing progression, and even in some cases reducing the disease level. (1, 2) Cardiac rehabilitation is the basic for the preparation for permanent secondary prevention of CVD, leading public health problem of today and as such requires a multidisciplinary approach all with the aim of significant shift towards a positive trend of decreasing mortality from CVD in Republic of Croatia.

Josipa Halapir, Natalija Kovačić

Cardiac rehabilitation as a measure of secondary prevention, and especially education, is an indispensable part of the treatment of cardiac patients. (1) Atherosclerosis as a major pathological alteration has been developing for years, while myocardial infarction and stroke usually occur suddenly causing a temporary loss of work ability and other daily capability of a patients. Performing a cardiac rehabilitation procedure after acute phase of disease requires engagement of the entire team providing the patient with the best possible physical, emotional and social return to life. We present case report of complex, incompletely educated and unmotivated cardiac patient where we comprehensively described all aspects, procedures and ultimately the positive effects of cardiac rehabilitation.

Ruža Čolaković, Kristina Bačić, Ante Krmek

Cardiovascular diseases are the leading cause of mortality and the second leading cause of mortality in the labor-intensive population. (1) Because of the persistent consequences for the health and work ability of an individual, it causes great economic burden due to cost of treatment and reduced productivity, and it is necessary to strengthen preventive measures, early detection and treatment of heart and blood vessels. Primary prevention plays an important role in detecting risky groups, and secondary in improving the quality of life and extending overall survival. (2) The role of nurses in the implementation of preventive measures is permanent education of the population to promote a healthier way of life, removal of habit that affects the development of cardiovascular diseases, early detection of persons with two or more risk factors, early detection of ischemic heart disease, prevention of reinfarction by regular patient monitoring. It is of great importance to teach individuals and groups a health-conscious behavior, identify and care for a high-risk group as well as track the patient’s condition over a longer period of time (education, support, encouragement to regular control). (3) On the occasion of World Heart Day marking the September, General Hospital Dubrovnik in cooperation with the Medical School organizes activities of blood pressure measurement, blood glucose measurements, distribution of promotional materials and counseling with the aim of promoting preventive measures.

Ivona Brajković, Viktor Peršić, Irena Kužet Mioković, Marica Komosar Cvetković, Paolo Šorić

In early 1970s mortality rate from cardiovascular diseases (CVD) was highest in Finland, especially in Finnish province North Karelia. (1) With cooperation and support from World Health Organization (WHO) in 1972. began a North Karelia project with main goals as follows: mortality reductions from CVD and other chronic, non-infectious disease, and promotions of healthy lifestyles. (2) Pilot project lasted for 5 years and it had achieved impressive results and became a demonstration model for promotion of a healthy way of living. Primary end-point was achieved with reductions of mortality rate from CVD in North Karelia province by 85% in 35 years. Main risk factors associated with unhealthy living style in North Karelia were physical inactivity, smoking and unhealthy diet which was rich in saturated fats. Integrated approach to prevention was the main core of the project and it led to achievement of general goal and health improvement. Project success was achieved with appropriate epidemiological and behavioral framework with limited and well-defined goals, flexible interventions, close collaboration with community associated with positive feedback, collaboration with media, international collaboration, WHO support and long-term and dedicated leadership. Universal, determined program that is theory-based can have positive impact on risk factors and life-style changes. These life-style modifications are associated with positive changes in chronic diseases and overall health of population. Big national program can be a strong tool for favorable national development in prevention of chronic diseases and health promotion. If we look at this project, we can produce new perspectives for structural, stratified and relevant approach to health care which relies on personalized medicine, and which incorporate predictive, preventive, personalized and participatory access to each individual.

Mijana Barišić, Marina Raljević Radolović, Jana Špurej Čuljat, Ingrid Buljanović, Tina Škalamera, Veronika Maksimov

**Introduction**: Cardiovascular diseases (CVD) are still leading cause of death, and second cause of death in working population. If we take into consideration riskier behavior of population, such as smoking, inadequate physical inactivity and unhealthy diet which all start in early age, it is necessary to start with preventive measures to decrease risk factors associated with CVD with promotions of healthy life style. Improvement and promotion of health are the first measures in prevention of CVD, and if these measures are implemented correctly, they can decrease CVD for 80%, including active participation of patient in treatment and care for his health. The biggest challenge for all professionals in cardiovascular medicine is to implement many preventive measures. Numerous research shows that inadequate health literacy prevails among cardiovascular patients, and it is estimated that around 18% of them have difficulties in reading of medical documentation, and around of 52% difficulties in understanding and application of written information. (1) Health literacy implies personal, cognitive and social skills which determine individual’s abilities to gain access, understand and use medical information to promote and maintain good health. (2) Furthermore, research has shown that degree of health literacy is associated with quality of communication between healthcare workers and patients which effects compliance of patient, treatment outcome, and frequency of medical use, costs and overall quality of health care system. (3) Thus, more money is spending for patients with lower health literacy in health system, they have longer hospital stays and more frequent clinic appointments, but they rarely use preventive measures. **Subjects and methods:** We have conducted research in Department of cardiology and cardiac rehabilitation in the period of June till September of 2018, and 89 subjects were enrolled. As instrument of research was used New Vital Sign test (NVS) which was translated to Croatian, (4) and general questionnaire about demography data and personal views of participants. Using NVS test we divided participants into three categories: NVS 1 high probability (50%) of low literacy, NVS 2 probability of limited literacy, NVS 3 adequate literacy. **Results:** There were 62% male subjects and 38% female subjects. Average age of subjects was 65,7±10,6 years. 54% subjects had adequate literacy, 28% probably limited literacy and 18% high possibility of low literacy. From overall male subjects, 11% had NVS 1, 24% NVS 2, and 65% NVS 3. From overall female subjects 29% had NVS 1, 35% NVS 2, and 35% NVS 3. Subjects with NVS 3 were smokers in 15%, overweight in 94% and 56% consumed alcohol conveniently. 36% subjects with NSV 2 had grade 1 obesity and 8% of them were smokers, none of the subjects consumed alcohol regularly, while 36% consumed alcohol occasionally. Subjects with NVS 2 has a healthy diet in 84%, 76% were adequately active. None of the subjects in NVS 1 were smokers, and 75% of them don’t consume alcohol, and 81% of them have a healthy diet. 81% of subjects with NVS 1 are physically active enough in their own personal assessment. **Conclusion**: Patients have big role in making decisions regarding their health. In order for patients to make decisions and have a quality participation in healthcare process, it is necessary to understand the instructions given by healthcare professionals. It is important to adjust medical information to patient’s degree of health literacy in order to make the communication between the patient and health professionals as good as possible.

Nevenka Vila, Brankica Juranić

Despite the development of new diagnostic and therapeutic procedures, cardiovascular mortality is still high. According to available data in population register, mortality of patients treated for acute myocardial infarction (AMI) is 30%, out of which in half of the patient, the death occurs before they reach a hospital. (1, 2) Most of the patients do not recognize or misinterpreted symptoms of AMI, and therefor delays asking medical assistance. Other chronic diseases could influence a perception and recognizing patient’s symptoms. Time between the occurrence of first symptoms to the decision on seeking medical assistance is shorter in patient who had AMI before and their family members and friends. Most common symptoms are chest pain, palpitation, shortness of breath, usually after physical activity, sleeping or resting. Most of the patients do not ask for medical assistance, but they apply self-care techniques: they are showering, massaging painful spot, taking medications, or resting while waiting for spontaneous symptoms relief. Patients who decide to seek help are usually referred to emergency hospital admissions, general practitioners or during a pre-scheduled check-up. Some of them are urged to hospital in emergency vehicles, some with their own car, or public transport. The time from the onset of the first symptoms to the doctor’s arrival may take less than one hour up to several days. Time period is an important factor in prognosis and outcome of patients treated for AMI. Since patients are not recognizing most common symptoms of AMI and they are distracted by different pain relief methods, additional education of general population is necessary for prevention of deaths and reduction of mortality from AMI.

Sanda Surina, Ana Traub

Extracorporeal Membrane Oxygenation (ECMO) is an extracorporeal technique of providing prolonged cardiac and respiratory support that is used in patients with life-threatening forms of heart or lung failure. There are two basic forms of ECMO support: venous-venous (V-V) and venous-arterial (V-A) ECMO. (1, 2) This paper presents experience with the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO). Since 2017, peripheral VA ECMO support has been applied in 16 patients (14 men and 2 women). The most common indication for application is cardiogenic shock (62.5%). The average time period spent on the VA ECMO is 64 hours. Of the reported complications, the most common is bleeding (mostly at the canulation site) which is present in 56.2% of cases. Of the total number of patients, 13 (81.3%) were successfully separated from ECMO support, and 9 (56.3%) survived untill the discharge or untill the transfer to another institution. The application of the VA ECMO in the cardiology intensive care unit has greatly improved the chances of survival of the most critical patients.

Ljiljana Kralj, Jasna Cmrečnjak

Non-invasive mechanical ventilation (NIV) is a form of patient ventilation that is carried out without the use of endotracheal intubation. It is performed by use of several types of masks with the use of positive pressure on the respiratory system. Indications for the use of NIV are patients with COPD, pneumonia, bronchial asthma, acute heart failure (pulmonary edema). (1) An important precondition for using NIV is that the patient spontaneously breathes. The main reason for the growing interest in the use of NIV is to avoid complications of invasive mechanical ventilation. Used in intensive care units when starting NIV, it is necessary to make the maximum effort in selecting an adequate interface and its proper adaptation to a particular patient. There are a number of interfaces most commonly used in masks across the face and nose mask. Well-educated and experienced healthcare professionals need to carefully monitor the patient who started this form of mechanical ventilation support. Care should be taken not only on the vital signs and values of PAAK, but also on the comfort and patient tolerance of the interface. Intubation kit should be prepared and in case of inadequate response, invasive ventilation should be initiated without delay. This paper presents the case of a long-term treatment patient who was treated for chronic pulmonary decompensation with NIV application. The basic causative factor in this case was obesity with alveolar hypoventilation. Additional cases are presenting female patients patient treated for pulmonary embolism with use of NIV. These are most common nursing diagnoses in patient care: Fear from feeling facial closure and masking, uncertainty of disease outcomes and Activity intolerance. (2) The efficacy of treating patients with NIV depends largely on a well-trained medical team that plays an extremely important role both in patient preparation and in NIV monitoring because a well-prepared patient cooperates better, and the outcome of non-invasive ventilation is better.

Vesna Grubić, Jelena Hojsak, Marija Renić

**Introduction**: Mechanical circulatory support is becoming a more common therapy for end-stage heart failure in intensive cardiac care unit, and currently there are several types of devices that can be used as bridge therapy to recovery phase or hearth transplantation. Extracorporeal membrane oxygenation (ECMO) replaces heart and lung function using extracorporeal blood flow and it can be used as mechanical support in cardio-circulatory or respiratory failure. (1) In a patient on ECMO support there is a strong activation of inflammatory response in a short period of time, usually due to shock before the initiation of support, but also, due to long, non-physiological blood flow through the piping, rotational pump and the oxygenator, where there is higher possibility of development of infection. In this phase patients are hemodynamically unstable, dependent on vasoactive support and substitution of intravenous fluids with a raise in inflammatory markers seen in laboratory results. Adsorbers for extracorporeal blood purification (CytosorbTM) can absorb molecules ranging from 5 to 55 kDa, which is the size where cytokines and some metabolites such as bilirubin, bile acids and ammonium can be absorbed, and it can be used to control inflammatory response which eventually can damage blood vessel walls and lead to target organs damage. **Case report:** This case report will show a 38-year-old patient who was hospitalized in Department of Cardiac Intensive Care after deterioration of his primary condition (cardiomyopathy) with hemodynamic instability, which lead to placement of both left and right sided mechanical circulatory support with an adsorber. This led to a decrease of inflammatory markers with good clinical and microbiological response. Patients soon underwent heart transplantation without any major complications and fast recovery. **Conclusion**: Use of adsorber via ECMO machine or dialysis machine is a very complex procedure which needs responsible approach to intervention and the only guarantee of success lays in a multidisciplinary approach.

Zdenka Ćurić, Petra Kušter, Mira Rupčić, Ivana Stakor Jakšić

Venous thromboembolism (VTE) is a medical term that includes deep vein thrombosis and pulmonary embolism (PE). Known risk-factors for VTE are pregnancy and puerperium, all trimesters of pregnancy increase the risk of VTE and especially the period of puerperium. (1) The incidence of VTE in pregnancy is around 200 cases in 100.000 deliveries. Physiologic changes that are occurring in pregnancy are the main cause of venous hemostasis of lower limbs, hypercoagulability and damage of venous and arterial endothelium. Although the patients have symptoms of DVT, getting the right diagnosis sometimes is very difficult due to impossibility of performing right diagnostic procedures because some of them are contraindicated in pregnancy. In the treatment of DVT in pregnancy the safety of the fetus should be considered and also the risk of bleeding during the c-section or applying spinal anesthesia. Approach in treatment of patients with DVT should be an individual considering small amount of clinical trials that are conducted during pregnancy. In DVT treatment in pregnancy are included cardiology, hematology, radiological and gynecological teams. In this case report we will present a pregnant woman that was admitted and treated with a diagnosis of DVT.

Vesna Babić, Doris Ivetac, Saša Bura

Syncope means short-term loss of consciousness, which occurs suddenly, with loss of postural tone, resulting in spontaneous recovery and the return of previous neurological functions. (1) The typical presentation of the patient with syncope is a motionless and limp patient, hypotensive, pale, clammy, cold extremities and filiform pulse, and shallow breathing. In most cases syncope is a benign nature, however, with a certain number of syncope patients may indicate a serious, life-threatening condition. Initial evaluation of the syncope is an anamnesis and a physical examination of the patient. The nurse participates in diagnostic and therapeutic methods and provides general and particular health care. Nursing interventions and diagnosis contribute to establishing control over the patient’s condition. It controls whether physical activity is sufficient and provides a peaceful and pleasant environment for the patient. The nurse educates patients about illness and helps create the conditions for a quality life after leaving the hospital.

Ana Ljubas

## Dear, distinguished colleagues, It is my great honor and pleasure to welcome you in Zagreb at the 7th Congress of the Croatian Association of Cardiology Nurses (CACN) with international participation. The motto of the congress is “Changes and challenges of Croatian cardiology practice”. This year we continue the tradition of the biannual congress of the Croatian Cardiac Society and the Croatian Society of Cardiology Nurses. Over four days, professional content will take place in parallel, covering all the topics of today’s cardiology practice. Wishing to design and organize a quality program for invited lecturers, we have invited well-established Croatian and international professionals who will discuss current topics and challenges in today’s cardiology practice. We have accepted all reported topics from Croatian clinical practice that will guide us through expert work of the participants. In this way, the participants have the opportunity to renew the existing knowledge and acquire new knowledge and exchange experiences with Croatian and international colleagues. The implementation of guidelines of nursing cardiac practice and the coordination of nursing practice within the evidence-based practice offers lasting steps to improve patient care and well-being. Therefore, in the thematic symposia on implementation of guidelines in clinical practice, evidence-based practice, and workshops, you can participate in constructive discussions that will surely stimulate critical clinical thinking and contribute to the building of professional excellence. All accepted summaries will be published in the journal Cardiologia Croatica, an official journal of the Croatian Cardiology Society (indexed in EBSCO). We would like to thank the editor-in-chief, Associate Professor Mario Ivanuša, for all his help and support. The congress is the occasion to hold the Assembly of CACN. The special aspect of this year’s Congress and the Assembly is this year’s Election Assembly. Therefore, we invite you to attend the assembly and to jointly elect the members of the Board of Directors and the working groups. I hope that a wide variety of professional content will stimulate creative discussions, that informal and friendly gatherings in our capital will complete the overall experience, and that Zagreb will remain in your heart. Welcome to Zagreb! Sincerely yours,

Mate Zvonimir Parčina, Mijo Meter, Josip Katić, Viktor Blaslov

**Introduction:** Diffuse large B cell lymphoma (DLBCL) is an aggressive and fast-growing type of lymphoma. Cardiac lymphoma is a rare cardiac tumor and an even more rare extranodal site of lymphoma, of which the most common type is DLBCL. (1-3) We report a case of an 85-year-old female patient with pericardial lymphoma presenting with persistent effusions. **Case report:** 85-year-old female patient presented with sudden onset chest pain and dyspnea. A week before she was diagnosed with atrial fibrillation and warfarin and bisoprolol therapy was started. Echocardiography showed a circular pericardial effusion up to 20 mm thickness with no signs of impending tamponade. Thoracic, abdominal and pelvic CT showed no pathology, apart from the effusion. Laboratory tests showed a suspected M-protein and IgM/kappa through serum protein electrophoresis. A 3-week follow-up revealed a progression in effusion volume (29 mm) and symptoms exacerbation with ankle edema, chest pain and night sweats. Cytological analysis of an effusion sample verified DLBCL with plasma cell differentiation. The same was confirmed by bone marrow biopsy. Imaging showed no signs of lymphadenopathy or hepatosplenomegaly. Lymphoma was staged as Ann Arbour IVB and IRI 3. Therapy was initiated according to the R-CEOP protocol. After 4 therapy cycles echocardiography showed no signs of effusion. A total of 8 therapy cycles were administered and a control work-up showed total remission of the disease. **Conclusion:** New therapeutic protocols for this type of aggressive lymphoma have significantly improved patient survival rates. Clinical presentation is usually unspecific with a wide differential diagnosis. Given that extranodal and cardiac involvement is a negative prognostic sign for patient survival, efforts are warranted to improve the time to diagnosis and therapy initiation necessary for a favorable outcome.

Mijo Meter, Zora Sušilović Grabovac, Ivica Vuković, Ivan Gudelj, Nikola Crnčević, Frane Runjić

**Introduction**: Pleuropulmonary synovial sarcomas are rare soft tissue malignancies. (1-3) Additionally, pleuropulmonary synovial sarcoma metastasis with valvular involvement, which was the case with our patient, is even more rare. We present an unusual case of a 42-year-old female patient with metastatic pleuropulmonary synovial sarcoma prolapsing to the left ventricular cavity and causing mitral valve obstruction. **Case report:** 42-year-old female patient with a history of previously resected inguinal synovial sarcoma who underwent radical irradiation and remained stable for 3 years appeared with the following symptoms: cough, dyspnea and hemoptysis. Computed tomography (CT) scan showed a suspected tumor mass within the left inferior pulmonary lobe affecting the mediastinal pleura with infiltration of the left pulmonary vein. CT scan also revealed a 6 cm mass in the left atrium (LA) that prolapsed into the mitral valve. Immediate echocardiography was performed, which showed a left atrial mass measuring 60x27mm prolapsing into the mitral valve and causing valvular obstruction. Mean pressure gradient across the mitral valve was 6 mmHg. Echocardiography revealed normal ventricular systolic function but a dilatated right ventricle with severe pulmonary hypertension. MRI confirmed previous echo findings but showed a more prominent protrusion of the tumor mass to the right atrium through the atrial septal defect. Bronchial biopsy of the tumor mass revealed undifferentiated monomorphic blunt spindle cells with CD 99 positive expression which confirmed the diagnosis of metastatic monophasic synovial sarcoma. Due to a large tumor extension to almost all cardiac chambers, cardiothoracic surgery was not indicated. Patient is considered for further chemotherapy with ifosfamide/doxorubicin. **Conclusion**: The aggressive nature of synovial sarcoma makes its early detection difficult. Because of the small number of reported occurrences, there is no consensus regarding optimal therapy. Therefore, it seems worth investigating both optimal surgical procedures and additional chemo-radiotherapy protocols in order to improve the patient’s survival.

Martina Lovrić Benčić, Lada Bradić, Rea Levicki, Juraj Jug, Marta Begovac, Marina Mihajlović

**Introduction**: Trastuzumab and trastuzumab-emtansine are antibody drugs and antibody-conjugate for human epidermal growth factor receptor 2 (HER2)- positive breast cancer. Their possible side effects can be QT prolongation and reduction of left ventricular ejection fraction (LVEF), as previously documented. (1-3) **Methods and Results**: All patients were previously treated with standard regimen: paclitaxel and cisplatinum. After that they received specific antibody drugs. The aim of this study was to test their effect on QTc interval in our patients. A total of 26 patients with preserved LVEF were treated with trastuzumab and before every application, ECG was obtained and analyzed. Later on, 24 patients (aged 57.33 years; 46-69 years) continued the treatment with trastuzumab-emtansine because of metastatic disease. Due to reduction of LVEF two patients could not continue with therapy. The last ECG was obtained 6 months after the last drug application. Statistical analysis was performed using standard t-test. Significant QTc prolongation was noticed after the third application of both drugs, continued during the fourth, fifth and sixth application of both drugs and normalization was noticed after six months without therapy. Results are shown in **tables 1**, **2** and **3**Table 2Table 3. ### TABLE 1: Average duration of QTc intervals. | | **Average duration of QTc intervals (ms)** — **TRASTUZUMAB** | **Average duration of QTc intervals (ms)** — **TRASTUZUMAB+EMTANSIN** | | --- | --- | --- | | Before th.1 | 447.4750 | 448.6250 | | 4 | 469.8750 | 470.1250 | | 5 | 471.0833 | 474.4583 | | 6 | 469.6667 | 471.8750 | | 6 months after administration of the last dose 7 | 451.4583 | 454.4167 | ### TABLE 2: Statistical significance of QTc prolongation compared to initial values (QTc1). | **QTc interval - comparison** | **p-value** **TRASTUZUMAB** | **CI (95%)** **TRASTUZUMAB** | **p-value TRASTUZUMAB+EMTANSINE** | **CI (95%)** **TRASTUZUMAB+EMTANSINE** | | --- | --- | --- | --- | --- | | **QTc1 vs QTc4** | 0.007907 | 6.192 – 38.807 | 0.002223 | 8.143 – 34.857 | | **QTc1 vs QTc5** | 0.002470 | 8.809 – 38.607 | 0.000605 | 11.714 – 39.953 | | **QTc1 vs QTc6** | 0.005007 | 7.072 – 37.511 | 0.000757 | 10.280 – 36.219 | ### TABLE 3: Statistical significance of QTc prolongation compared to the control value 6 months after the last drug application (QTc7). | **QTc interval - comparison** | **p-value** **TRASTUZUMAB** | **CI (95%)** **TRASTUZUMAB** | **p-value** **TRASTUZUMAB+EMTANSINE** | **CI (95%)** **TRASTUZUMAB+EMTANSINE** | | --- | --- | --- | --- | --- | | QTc7 vs QTc4 | 0.022461 | 2.722 – 34.111 | 0.018883 | 2.717 – 28.699 | | QTc7 vs QTc5 | 0.007911 | 5.399 – 33.851 | 0.005280 | 6.267 – 33.816 | | QTc7 vs QTc6 | 0.015374 | 3.648 – 32.768 | 0.007633 | 4.865 – 30.051 | **Conclusion**: Treatment with trastuzumab and also with trastuzumab-emtansine significantly prolonged QTc interval in patients with breast cancer, but the change was reversible after the cessation of treatment.

Marijana Knežević Praveček, Katica Cvitkušić Lukenda, Antonija Raguž, Ivica Dunđer, Ivan Bitunjac, Krešimir Gabaldo, Damira Pevec, Đeiti Prvulović, Božo Vujeva, Blaženka Miškić

**Introduction**: Cardiooncology is a recently developed (rapidly developing) field in cardiology aimed at significantly reducing cardiovascular morbidity and mortality and improving quality of life in cancer survivors. Cancer survival rates have been constantly increasing, mainly because of the advent of new, more potent and targeted therapies. However, many of the new therapies – along with some of the older chemotherapeutic regimens such as anthracyclines – are potentially cardiotoxic. Cardiotoxicity adversely affects prognosis in cancer patients, thus its prevention and treatment are crucial to improve quality and standards of care. (1) **Case report**: We present a case of a young man cancer survivor who received treatment for osteosarcoma at age 18 years with a regimen that included an anthracycline. Unfortunately, he did not have routine cardiac follow-up in the survivorship period. He presented in his 40s with dyspnea. On further inquiry, he had been experiencing exertional dyspnea and poor exercise tolerance for over a decade. He was diagnosed with heart failure with a reduced left ventricular ejection fraction (LVEF of 35%). His clinical course was complicated by recurrent sustained ventricular tachycardia and defibrillator was implanted. Today he receives optimal medical treatment which includes (carvedilol, furosemid, eplerenon, sacubitril-valsartan). **Conclusion**: Anthracycline cardiotoxicity most frequently presents as either early-onset chronic progressive (within the first year after completion of chemotherapy) or late-onset chronic progressive (greater than 1 year after completion of therapy) left ventricular systolic dysfunction, which is usually irreversible. Clinically, patients present with dilated cardiomyopathy. Those with late-onset chronic progressive cardiotoxicity can present as long as 1–2 decades after completion of cancer therapy. One major limitation to the use of LVEF to monitor for cardiac dysfunction is that changes in LVEF usually occur at a later stage when significant toxicity has already occurred. To minimize the risk of irreversible cardiomyopathy, the goal is to identify signs of toxicity as early as possible so medical therapy can be initiated. Today, global longitudinal strain is used in hospital for early detection of changes in cardiac contractility. In patients with anthracycline toxicity, earlier initiation of medical therapy is associated with an increased likelihood of subsequent improvement in LVEF.

Ivo Darko Gabrić, Ljubica Vazdar, Ozren Vinter, Matias Trbušić, Nikola Bulj, Robert Šeparović, Diana Delić-Brkljačić

**Introduction:** In the past 30 years, malignant disease mortality has been reduced, among other things, owing to advances in chemotherapeutic protocols. However, prolonged survival frequently is achieved at the expense of damage to other organs, including the cardiovascular (CV) system. Both conventional chemotherapy and targeted biological therapy increase the risk of heart injury, left ventricular (LV) dysfunction and symptomatic heart failure. In addition, hypertensive reaction, vasospastic and/or thrombotic myocardial ischemia, rhythm and conductivity disorders may also occur. Some of these adverse effects are irreversible and cause progressive CV disease, whereas others cause only transient dysfunction without long-term sequels. Tumor biological therapy with monoclonal antibodies or tyrosine kinase inhibitors (TKI) target human epidermal growth factor 2 (HER2) receptors, vascular endothelial growth factor (VEGF) and VEGF receptors. However, these actions also interfere with molecular mechanisms that are crucial for cardiovascular health. Anti HER2 therapy generally induces reversible systolic LV dysfunction, whereas VEGF receptor blockade leads to development of arterial hypertension and increased susceptibility to thromboembolic events. (1-3) **Patients and Methods:** In Cardiotoxicity Clinics of University Hospital Centre “Sestre milosrdnice”, in 5 years of existence, more than 200 patients with various malignancies were monitored. Most patients were screened due to systolic LV function, then due to unregulated hypertension, and due to supraventricular and ventricular rhythm disorders. Majority of patients were able to continue and end oncological treatment. The type of treatment was adapted to the stage of malignancy, whether it was metastatic or local or locally spread disease. **Conclusion:** Oncologic patients receiving chemotherapy or targeted biological therapy associated with a high risk of cardiotoxicity require the multidisciplinary approach including cardiologists and oncologists, along with regular cardiologic follow up, for timely recognition and appropriate treatment of CV side effects. Such an approach results in a more favorable clinical outcome and patient quality of life, along with optimal continuation of specific oncologic treatment if possible.

Ivica Kristić, Nikola Crnčević, Velimir Pivac, Mijo Meter, Diana Bajo, Ivica Vuković

**Introduction**: Primary cardiac lymphomas are very rare, representing only 0.5% of all lymphomas and 1-2% of all heart tumors. Cardiac involvement from systemic lymphomas is more common, comprising 10-20% of all lymphomas. Secondary cardiac lymphomas most frequently affect the pericardium, and then the myocardium. The patient’s symptoms are based on the area of cardiac involvement. **Case report:** 79-year-old women was hospitalized due to shortness of breath, fatigue, and lower extremity edema. A transthoracic echocardiogram (TTE) showed a mass infiltrating the myocardium of the right atrium and the right ventricle causing systolic dysfunction of the right ventricle (TAPSE 5 mm, s’0.05 m/s). A thoracic computed tomography (CT) showed a mass in the anterior mediastinum, measuring 5 x 7.5 cm infiltrating the myocardium of the right atrium and ventricle. An endobronchal ultrasound (EBUS) guided biopsy was performed and tissue samples confirmed the diagnosis of diffuse large B cell lymphoma (DLBCL) of the mediastinum, bone marrow infiltration was nonexistent. Immunochemotherapy treatment (R-CEOP) was started and the patient’s symptoms significantly improved during the course of treatment. A follow-up thoracic CT showed that the mass had significantly reduced in size after 4 cycles of therapy, and now measuring 2.1 x 6.2 cm. A control TTE showed only moderate thickening of the right atrium and right ventricle myocardium (14 mm in width), with a normal systolic and diastolic RV function (TV E/A – 1.4). **Conclusion**: In this case, the patient presented with signs and symptoms of right heart failure due to an infiltrating mass. Histology confirmed diagnosis of a DLBCL of the mediastinum. The patient was treated with immunochemotherapy, her symptoms improved, and by the end of treatment she was asymptomatic. The majority of the literature details patients with the rarer primary cardiac lymphoma. (1-3) The involvement of the right atrium and ventricle as a direct extension from an intrathoracic tumor mass in our patient resulted in a heavily impaired right heart systolic function, as a first symptom of the disease, and was completely resolved with treatment.

Elnur Smajić, Nihad Mešanović, Edin Begić

Human beings are social creatures, and in fact need social interactions to maintain a healthy life and mind. The earliest methods of communicating across great distances used written correspondence delivered by hand from one person to another are letters. The earliest form of postal service dates back to 550 B.C. The environmental and genetic factors contribute to social media use. One- to two- thirds of variance in social media use is attributable to additive genetic traits; unique and shared environmental factors account for the remainder of variance. (1-5) After the first super computers were created in the 1940s, scientists and engineers began to develop ways to create networks between those computers. The earliest forms of the Internet, such as CompuServe, were developed in the 1960s. From the first recognizable social media site, Six Degrees, via LinkedIn, YouTube to Facebook and Twitter became available to users throughout the world. LinkedIn represent a professional platform. Twitter is a micro blogging site and is one of the most commonly used forms for this medium. The technology is rapidly evolving and the sharing of medical scientific information is moving from print and on-site presentations to digital online publication (webinars, etc.). Social media is the ideal platform for this development, and cardiology is a leader in this form of communication. The patients are very active on social media, and the numbers of electronic patients continues to grow. The internet use is not limited to the millennial generation, more than two-thirds of all seniors go online every single day and more than half of these seniors go online in order to access health information. Users who Tweeted about cardiovascular disease were more likely to be older than the general population of Twitter users and less likely to be male. A growing percentage of patients use social media for health-related reasons. These effects will contribute to a better understanding of potential benefits and challenges for both patients and healthcare professionals, but also other healthcare actors. Healthcare providers, medical institutions, medical societies, scientific journals and clinicians are recognized great potential for use of social media to improve health outcomes. The use of social media by cardiologists has increased substantially in recent years. While personal use is more common, approximately two-thirds of cardiologists interact with various social media platforms. For example, some cardiologists use social media to promote positive health behaviors, debate health care policy, network with colleagues, and to educate their patients, peers, and students. Specific Twitter cardiovascular journal clubs (#Heart_BMJ, #HeartJC), societies (#escardio, #ESCCongress), and hospitals (#MayoClinicMinute) have become well established. It is important to understand how to use social media in cardiovascular care: engaging directly with patients about a particular disease process, treatment options, and cardiovascular care, it should be provided generally and not specific to a particular patient; provide timely and credible information and disease-specific education to patients as well as colleagues; share medical information and disease-specific knowledge with colleagues around the world, develop a network to engage with colleagues and discuss best practices; market- share your expertise and abilities with the world, establish a national/international reputation and influence policy and practice guidelines. Uses of social media in interventional cardiology, heart failure and cardiac rehabilitation improved patient outcomes and reduced financial burden of CVD on health systems. Social media have positive impact in both the primary and secondary prevention of cardiovascular diseases. Social media opens the opportunity for fast- sharing of information, but no ideal process has been defined. This is leading to an increased number of posts, which unintentionally expose personal data, and once shared it can spread around the globe in seconds. We should protect data from “third parties” (#ProtectMyData). There are some points that we have to keep in mind when using social media: best practice, strive accuracy, never identify a patient, ask permission, assume beneficence, be respectful. The future of cardiovascular care will be transformed by advances in artificial intelligence, digital health technology and mobile devices as a means to prevent and treat heart disease. Cardiologists don’t have to wait until major meetings to discuss new ideas, and now we have entire world. Social media is where we need to be.

Nihad Mešanović, Elnur Smajić

Digital health technologies have flooded the consumer marketplace in the past few years, focusing primarily on mobile health (mHealth) tools, including smartphone applications, wearables, and “smart” devices such as blood pressure devices, smart watches or digital weight scales. (1) Digital health technologies tend to the potential to transform health care delivery, but most technology companies are targeting consumer products rather than developing digital tools for clinicians or to integrate those tools into clinical care. On the other hand, digital health tools provide the opportunity for more personalized care. Those that provide two-way communication between the health care provider and the patient can be individualized for the patient and provide a bit more of a human touch when you’re interacting with both parties. Adoption of digital health technologies in medicine will change health care delivery from traditional hospital- or office-based visits to technology-based interactions that are virtual, on-demand and patient-centered. Integration of digital health tools into clinical practice also has the potential to improve patient outcomes and reduce costs in healthcare. Digital health companies from startups to the largest technology companies are eager to work with the health professionals and engineers because they recognize that the most effective way to develop new health technologies is to partner with the clinical enterprise. The overall goal is to partner with these companies, identify the problems and help design tools to solve those problems. In this paper, the past, present and future in digital health is presented, as well as how social media can change the health care with some real cases.

Goran Krstačić, Antonija Krstačić

mHealth (mobile health) is a general term for the use of mobile phones and other wireless technology in medical care. The most common application of mHealth is the use of mobile phones and wearable devices and software applications (“Apps”) for health purposes, mainly to educate consumers about preventive health care services. However, mHealth is also used for disease surveillance, treatment support, epidemic outbreak tracking and chronic disease management. World population of 7 billion mobile devices could give a nice opportunity for monitoring of physiology, behavior and disease and patient education. (1-3) We present the management of patient with atrial fibrillation using mHealth applications at a distance of 2000 km. This App facilitates earlier and more accurate diagnosis and could create more efficient, convenient and potentially more cost effective delivery of care. Based on the future potential of digital-Health, UK secretary Jeremy Hunt said: NHS app will put patients in control of their healthcare and will be available to everyone in England in December 2018. This is a future for every country. E-Health is also a key area for the European Society of Cardiology because smartphone and apps can also provide education, encourage behavior change, and increase treatment adherence in patients as well as deliver interactive treatment algorithms to aid clinicians. Digital-Health has to be a human imperative.

Mario Ivanuša, Verica Kralj, Mario Olivari

**Introduction:** Ischemic heart disease (IHD) has been the leading cause of mortality in the Republic of Croatia (RoC) for years. (1, 2) During the year 2017, 11,069 persons died of IHD. (3) Analyzing the time series of mortality of acute myocardial infarction (AMI), which is the leading manifestation of IHD, the aim of this paper is to show the trends of mortality and in-patient treatment of this disease in the RoC. **Methods:** The analysis of the data of the Croatian Bureau of Statistics and the Croatian Public Health Institute on mortality of AMI (diagnosis I21 according to ICD-10 classification of the disease) during the period from 2001 to 2016 has been made at the level of the RoC and the counties. Age-standardized death rates (ASDR) were calculated based on population estimates for each year. In order to present the rates as realistic as possible, the standardization was performed on the 2011 Census of the RoC. The data on the frequency of in-patient treatment for the diagnosis I21 has been analyzed for the period from 2009 to 2016, when the hospital system used DTS (diagnostic and therapeutic system) as the only and official way of recording, accounting and invoicing medical services in hospital healthcare system. **Results:** During the observed period, a continuous decline in ASDR of AMI (**Figure 1**) has been observed. In 2001, ASDR of AMI was 114.71 in the City of Zagreb, similar to that in region of ​​the RoC (117.69), while this rate was considerably higher in the County of Zagreb and was 171.28/100,000 inhabitants. In 2016, ASDR of AIM significantly decreased and accounted for 85.97 for the County of Zagreb, while ASDR was 75.79 for the RoC, and ASDR accounted for 50.90/100,000 inhabitants for the City of Zagreb (**Table 1**). In 2016, the lowest ASDR of AMI was recorded in the County of Dubrovnik and Neretva (37.85) and County of Split and Dalmatia (49.32), while ASDR of AMI was highest in Varaždin (119.98) and County of Osijek and Baranja (117.65/100,000 inhabitants). Analyzing the changes to ASDR of AMI for the year 2016 compared to those in 2001 by to the Croatian counties (**Table 2**), the highest decrease in ASDR by 55.62% was recorded in the City of Zagreb and by 49.81% in the County of Zagreb, while ASDR of AMI decreased by 35.60% during the same period in the Republic of Croatia. The frequency of in-patient treatment of AMI in the RoC during the period from 2009 to 2016 significantly increased (41.5%) in all Croatian counties (**Figure 2**). FIGURE 1. The trend of age-standardized death rate for diagnosis I21 for the Republic of Croatia, the City of Zagreb and the County of Zagreb from 2001 to 2016. (data source: Croatian Institute of Public Health) ### TABLE 1: Age-standardized death rates of acute myocardial infarction (diagnosis I21 according to ICD-10) for the Croatian counties and the Republic of Croatia in 2016. | **County** | **Age-standardized death rate** **(ASDR/100,000 inhabitants)** | | --- | --- | | Dubrovnik-Neretva | 37.85 | | Split-Dalmatia | 49.32 | | City of Zagreb | 50.90 | | Primorje-Gorski Kotar | 58.53 | | Karlovac | 59.01 | | Zadar | 64.26 | | Lika-Senj | 64.45 | | Šibenik-Knin | 64.91 | | Virovitica-Podravina | 75.45 | | **Republic of Croatia** | **75.79** | | Zagreb County | 85.97 | | Istra | 86.15 | | Međimurje | 86.69 | | Bjelovar-Bilogora | 90.01 | | Koprivnica-Križevci | 92.93 | | Sisak-Moslavina | 100.48 | | Brod-Posavina | 100.54 | | Požega-Slavonia | 103.67 | | Krapina-Zagorje | 106.04 | | Vukovar-Srijem | 106.57 | | Osijek-Baranja | 117.65 | | Varaždin | 119.98 | [†] (data source: Croatian Institute of Public Health) ### TABLE 2: Changes of the age-standardized death rates of acute myocardial infarction (diagnosis I21 according to ICD-10) for the Croatian counties and the Republic of Croatia in 2016 compared with those in 2001. | County | Changes of the age-standardized death rates 2016 vs 2001 (%) | | --- | --- | | City of Zagreb | -55.62 | | Zagreb County | -49.81 | | **Republic of Croatia** | **-35.60** | | Virovitica-Podravina | -49.54 | | Primorje-Gorski Kotar | -47.39 | | Sisak-Moslavina | -45.65 | | Split-Dalmatia | -43.98 | | Dubrovnik-Neretva | -39.76 | | Karlovac | -37.40 | | Šibenik-Knin | -35.57 | | Međimurje | -33,78 | | Zadar | -31.55 | | Lika-Senj | -31.11 | | Brod-Posavina | -30.09 | | Koprivnica-Križevci | -29.03 | | Krapina-Zagorje | -22.94 | | Istra | -18.08 | | Požega-Slavonia | -16.11 | | Osijek-Baranja | -12.55 | | Bjelovar-Bilogora | -10.19 | | Varaždin | 2.3 | | Vukovar-Srijem | 23.95 | [†] (data source: Croatian Institute of Public Health) FIGURE 2. The trend of hospital discharges from acute myocardial infarction (diagnosis I21 according to ICD-10) in the County of Zagreb, City of Zagreb, the other Croatian counties and in total in the Republic of Croatia from 2009 to 2016. (data source: Croatian Institute of Public Health) **Conclusion:** The combined approach to adhering to prescribing the therapy according to the guidelines is an available and timely intervention in AMI in the Croatian Primary Percutaneous Coronary Intervention Network (4), that when accompanied by numerous scientific and professional activities and preventive and promotional programs has resulted in better AMI outcomes. The decline in mortality by 35% has been recorded in the observed period, while the number of hospitalizations rose.

Edin Begić, Mensur Mandžuka, Elnur Smajić, Enisa Hodžić, Amer Iglica, Aida Mujaković, Azra Durak Nalbantić

**Introduction**: Several bleeding risk scores are developed for estimating bleeding risk in patients with atrial fibrillation (AF) (1-3). These include: HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly (>65 years), drugs/alcohol concomitantly), ORBIT (older age, reduced hemoglobin/ hematocrit/anemia, bleeding history, insufficient kidney function, treatment with anti-platelets), ABC (age, biomarkers, clinical history), ATRIA (anemia, severe renal disease, age ≥ 75 years, previous hemorrhage, and diagnosed hypertension) and HEMORR2HAGES (Hepatic or Renal Disease, Ethanol Abuse, Malignancy, Older Age, Reduced Platelet Count or Function, Re-Bleeding, Hypertension, Anemia, Genetic Factors, Excessive Fall Risk and Stroke) (1-3). The use of oral anticoagulants is still a standard in stroke prevention in AF but should be balanced against associated bleeding risk (2). Aim: Development of software solution that will enable a quick assessment of bleeding risk in patients with AF to the clinician in order to optimize anticoagulation therapy in patients with AF (especially in patients who use vitamin K antagonists in therapy). **Material and Methods**: The software was developed in the form of a web application. Responsive design of the interface was key to optimal user interaction, rendering seamless control of every step of the process regardless of the type of device used, whether it is a laptop or a smartphone. For development, a Python based web framework named Flask was used. It is considered to be a good choice for rapid prototyping and developing and deploying small to medium sized applications. **Results**: The process is separated into three steps. First step displayed prompts the user to select the type of score they wish to be calculated. Following step includes entering anamnestic data, laboratory findings, symptoms and comorbidities. Final screen displays the calculated score which assists to user to determine the course of the treatment. **Conclusion**: The software solution enables a faster and easier assessment of bleeding risk in patients with AF, which leads to a better therapeutic modality. The easy availability of software solutions, as well as the use in offline mode, make it easy to access and distribute it.

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

**Introduction:** Despite intensive treatment mortality in elderly patients presenting with acute cardiac diseases remains high. (1) The aim of this study was to investigate factors associated with intrahospital mortality of patients older than 80 years who were hospitalized in intensive cardiac care unit. **Patients and Methods**: We analyzed data from patients older than 80 years who were hospitalized in the Intensive Cardiac Care Unit of University Hospital Centre Zagreb in the period from 1st January 2015 to 31st December 2017. **Results**: We identified 243 patients older that 80 years (13.39% of total number of hospitalized patients in that period), 146 being women (60.1%). Most common leading diagnosis was acute myocardial infarction (n=107; 44%). All patients’ characteristics are displayed in **Table 1**. Intrahospital mortality was 21.4%. Results indicate that primary diagnosis, the severity of it’s presentation and the use of more invasive treatment are the main predictors of elderly patients’ mortality in intensive cardiac care unit (**Table 2**). ### TABLE 1: Patient characteristics. | **Patients’ characteristics** | | | --- | --- | | N (share in total number of patients hospitalized in CCU, %) Age (years), mean (min-max) Men, n (%) | 243 (13.39) 84.21 (80-98) 97 (39.9) | | **Comorbidities** Arterial hypertension, n (%) Diabetes mellitus, n (%) Atrial fibrillation, n (%) Previous MI or stroke, n (%) BMI (kg/m2), mean (min – max) | 210 (86.4) 68 (28.0) 85 (35.0) 57 (24.1) 26.65 (15.4-47.9) | | **Primary diagnosis** Myocardial infarction, n (%) Pulmonary oedema, n (%) Arrhythmia, n (%) Pulmonary embolism, n (%) TAVI, n (%) Cardiorespiratory arrest, n (%) Other, n (%) | 107 (44.0) 37 (15.2) 28 (11.5) 1 (0.4) 30 (12.3) 15 (6.2) 25 (10.3) | | **Disease presentation** Shock, n (%) Creatinine (mcg/L), mean (min-max) Ejection fraction (%), mean (min-max) | 30 (12.3) 121.99 (36-664) 46.12 (10-74) | | **Treatment course** Nosocomial pneumonia, n (%) Dialysis procedure, n (%) Mechanical ventilation, n (%) Inotropic medication, n (%) CCU hospitalization duration (days), mean (min-max) Reanimation, n (%) In-hospital death, n (%) | 11 (4.5) 16 (6.6) 92 (37.9) 58 (23.9) 2.37 (0. 04-27) 46 (18.9) 52 (21.4) | [†] BMI – body mass index; CCU – coronary care unit; MI – myocardial infarction; TAVI – transcatheter aortic valve implantation ### TABLE 2: Intrahospital mortality predictors. | **Univariabile and multivariable predictors of in-hospital mortality** | **Univariabile and multivariable predictors of in-hospital mortality** | **Univariabile and multivariable predictors of in-hospital mortality** | **Univariabile and multivariable predictors of in-hospital mortality** | | --- | --- | --- | --- | | Predictors | Univariable analysis P | Multivariable analysis | | | OR | P | | | | Gender Primary diagnosis (MI, arrest) Shock Reanimation Inotropic support Mechanical ventilation Nosocomial pneumonia Dialysis procedure Severe valvular disease Arterial hypertension Diabetes mellitus Atrial fibrillation Peripheral artery disease Previous MI or stroke BMI LVEF | 0.427 **0.005** **<0.001** **<0.001** **<0.001** **<0.001** **0.014** **0.002** 0.260 **<0.001** 0.589 0.950 0.214 0.115 0.578 **0.004** | | | | Shock Reanimation Inotropic support Dialysis procedure | | 22.302 15.051 3.003 6.938 | **<0.001** **<0.001** 0.059 **0.016** | [†] BMI – body mass index; LVEF – left ventricular ejection fraction; MI – myocardial infarction **Conclusion:** The share of patients older than 80 years in the total number of hospitalized patients in intensive care units is not negligible. Using intensive treatment in patients of advanced age requires individual assessment of its usefulness and treatment goals. It is necessary to develop adequate, preferably locally applicable models for assessing the condition of this sensitive and significant group of patients to rationalize resources and optimize treatment of severe acute cardiac diseases in individuals of advanced age.

Ivana Jurin, Jasmina Ćatić, Jelena Kursar, Diana Rudan, Irzal Hadžibegović

**Background:** Acute pulmonary embolism (PE) severity index (PESI) well predicts 30-day mortality in PE patients. However, improvements have been advocated because it sometimes overestimates early mortality risk in stable PE patients, especially in shorter simplified forms (sPESI). (1, 2) We aimed to evaluate predictability of PESI in our patients and to explore interaction with other possible prediction tools as a potential improvement in stratifying low risk patients eligible for ambulatory treatment. **Patients and Methods**: Retrospective analysis of demographic, clinical and laboratory variables in consecutive 299 adults with MSCT confirmed acute PE admitted to a single institution over a 3-year period with 30-day mortality as a main outcome. **Results**: There were 19 (6.4%) severely unstable patients who died within 48 hours and were excluded from further analyses. Among remaining stable patients, 30-day mortality was 12.1% (34/280). There were 131 patients with PESI <105 and 185 patients with PESI <125 with 30-day mortality rates of 3.1% and 4.9%, respectively. Among all variables analyzed, only estimated glomerular filtration rate, D-dimer value, platelet-to-lymphocyte ratio, and red blood cell distribution width (RDW) value showed significant effect on PESI predicted mortality in multivariate regression analysis. RDW moderation of PESI effect on mortality was most notable: there were 140/280 (50%) patients identified with both PESI < 125 and RDW < 15% and a 30-day mortality rate of only 0.7% (1/140). In addition, there were no deaths in the first 30 days among 97/280 (35%) patients with both PESI < 105 and RDW < 14.5%. **Conclusions**: In stable acute PE patients RDW strongly moderates 30-day mortality risk associated with PESI. It could be used to improve PESI accuracy and identify a larger proportion of stable patients eligible for safe ambulatory treatment and quick and safe discharge from emergency room with appropriate anticoagulation therapy.

Andrea Crkvenac Gregorek, Dražen Perkov, Ljiljana Banfić, Zoran Miovski, Krešimir Putarek, Majda Vrkić Kirhmajer

**Introduction:** Symptomatic chronic iliac venous compression caused by May-Thurner syndrome (MTS) can occur at advanced age. May-Thurner syndrome results from a frequent anatomic variant in which left common iliac vein (VIC) is compressed by right common iliac artery. MTS usually presents with acute iliofemoral deep venous thrombosis (DVT), but clinical course can also develop gradually. Endovascular intervention with venous stenting can provide resolution of the symptoms. (1-3) **Case report:** 78-year-old woman presented with chronic, painful, sever edema of the left leg. Two years before, she noticed gradual swelling of her left leg and progression of her symptoms with time. In that period several Duplex ultrasound (DUS) excluded DVT, native CT of abdomen and pelvis did not reveal abnormalities and she was treated as lymphedema of unknown origin. At presentation, she complained of venous claudication, her proximal thigh volume was 66 cm on the left side and 54 cm on the right side. Besides antihypertensive drugs, she was taking rivaroxaban due to permanent atrial fibrillation (AF). DUS of the left leg showed clear signs of pelvic veins compression (attenuated respiratory flow variation, dilated deep veins, limitation of full compression), but without DVT. CT venography revealed MTS with filiform lumen of VIC. A venography was performed, followed by angioplasty and stent implantation. Control venography showed unlimited blood flow through stented vein. Significant regression of left leg edema was evident shortly after the procedure. Volume difference between left and right tight changed from 12 cm to 3 cm postprocedural. The patient was discharged from the hospital after 3 days, therapeutic dosage of enoxaparin was continued for the next 2 weeks, and after that switched to rivaroxaban. In control interval (1 and 3 months), the patient was without complaints and DUS showed normal venous flow. Duration of anticoagulant therapy after venous stent is questionable, but since our patient has AF, anticoagulation is, in this case, permanent. **Conclusion:** For patient with chronic iliac vein compression and severe leg problems, endovascular intervention and venous stenting can provide complete resolution of symptoms. Further studies are necessary to identify optimal anticoagulant regimen after venous stenting in MTS.

Dražen Perkov, Mladen Petrunić, Damir Halužan, Ivica Sjekavica, Majda Vrkić-Kirhmajer, Ljiljana Banfić

**Objective:** To evaluate the outcome after endovascular aortic repair (EVAR) of abdominal aortic aneurysms (AAA) in single center. **Patients and Methods:** A total of 34 patients diagnosed with AAA treated by EVAR in University Hospital Centre Zagreb from June 2015 to September 2018 were followed-up and analyzed. There were 31/34 (91%) male and 3/34 (9%) female patients, with a mean age of 73.7±7.4 (range 55-87 years) in this study group. The primary outcome of the study was EVAR technical success (successful implantation) and all-cause mortality. Secondary endpoints were complications, length of stay in the ICU, and patient survival. Descriptive statistics were used to analyze the data. **Results:** Mean diameter of treated AAAs was 62.1±12 mm (range 43-98 mm). Technical success rate were 94% (32/34) for implantation stent-graft system. In one patient we failed to perform implantation because of wide and angulated AAA neck, and one patient had external iliac artery rupture. In the follow-up period we recorded 2/32 (6%) deaths in the group of successfully implanted patients who were not related to AAA and EVAR procedure. Most common complication after successful EVAR procedure were endoleak type II in 11/32 (34%) patients, without the need for reintervention. Average length of stay in ICU was 1.08 day. In patients with EVAR mean survival was 19±11 months (range from 1 to 40 months) after procedure. **Conclusions:** EVAR treatment for AAA is technically feasible and safe, with acceptable complications risks and with very short length stay in ICU after procedure. In order to prevent complications, extreme caution is needed when selecting patients who are anatomically suitable for the EVAR procedure. (1)

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

Registry “Deep vein thrombosis” includes and evaluates all patients with deep vein thrombosis (DVT) treated at the Department of Vascular Diseases, University Hospital Centre Zagreb from 1st January 2016. The results of the registry will be presented as compared to the results presented at the 11th Congress of Croatian Cardiology Society (1), which were related to the pilot project in the period of 1st January until 1st October 2016. The registry includes a total of 305 patients. Parameters covered by the registry relate to the etiology of venous thrombosis, disease localization, complications during treatment, treatment in the acute phase and in the advanced treatment phase. Out of the total data, we highlight an increase of the patients with venous thrombosis related by a surgical procedure (8.8%). In the total population incidence of venous thrombosis after the previous surgical procedure was 23%. The initial treatment of DVT in the acute phase (**Figure 1**) increased significantly in favor of the use of novel oral anticoagulants (NOAC) (15.5%) because in the first 10 months of the pilot project all patients were treated with low molecular weight heparin (LMWH) and warfarin, while in the past 2 years this number was reduced. In the prolonged treatment (**Figure 2**) the use of LMWH increased by 12.2%, the use of NOAC by 27.4%, while the application of the standard treatment method to warfarin recorded a decline of 39.6%. The occurrence of bleeding is reduced by 3%. FIGURE 1. Treatment options during 2016 compared with 2016-2018 in the acute phase of treatment. NOAC = novel oral anticoagulants; LMWH = low molecular weight heparin. FIGURE 2. Treatment options during 2016 compared withj 2016-2018 in the extended treatment. LMWH = low molecular weight heparin; NOAC = novel oral anticoagulants; standard th. = standard therapy. In the period of 2 years, the method of treating venous thrombosis has significantly changed in favor of treatment with new oral anticoagulants, resulting in an increase in the number of outpatient treatment by 15.5%, with a decrease in the occurrence of bleeding by 3%.

Mario Milun, Ana Šutalo, Petar Martinčić

This is a case of a 45-years-old female patient who attended Emergency room (ER) at the Koprivnica General Hospital with a febrile condition, cough, muscular pain, and headache. Laboratory results showed mild anemia, no elevation of leukocytes or CRP. Chest radiogram showed right lobar pneumonia. Medical history showed data of surgical atrial septal defect (ASD) correction in 1980, pulmonary embolism in 2008, and mild right-left shunt diagnosed in 2009. Because there were no signs of leukocytosis or CRP elevation, patient was released home with dual antibiotic therapy. Eight days later patient returned to the ER with almost the same symptoms. Chest radiogram showed stationary findings, again without systemic inflammatory response, so the patient was released home to continue her antibiotics. Day later she was admitted to the Psychiatric ward because of anxiety attack. Lab results and thoracic RTG were stationary, with only worsening of anemia. Broad screening of anemia was done. Tumor markers where normal, so was occult stool hemorrhage test, and gynecology exam. Gynecological ultrasound (UTS) showed enlargement of pelvic veins, and abdominal UTS showed hepatosplenomegaly. Multislice computed tomography (MSCT) was done, and it showed alveolar infiltration with small pleural effusion, azygos vein was 28mm, dilation of inferior vena cava (IVC), hepatic and lineal enlargement, and vena porta was 15mm. So they concluded it was probably chronic right heart failure with right lobar congestion. Transthoracic echocardiography (TTE) was done, and it showed normal systolic left ventricular ejection fraction (LVEF) with mild diastolic dysfunction. In the right atrium (RA) there was a mass on the interatrial septum (IAS) that measured 2.7x1.7 cm. Transoesophageal echocardiography was performed, and its findings confirmed RA “mass” on the IAS, with a left-right shunt near the mass. Differentially there was a possibility of RA myxoma, IVC obstruction, hepatic carcinoma or secondary condition. Patient was sent to University Hospital Centre Zagreb, for further diagnostics. There, MSCT of the abdomen showed no IVC obstruction, or RA mass. Cardiac magnetic resonance imaging (MRI) visualized a 0.3mm thick membranous obstruction of the IVC 2.5cm from the RA. Patient was diagnosed with Budd-Chiari syndrome, more precisely membranous obstruction of IVC (MOVC). (1-3) Percutaneous IVC membrane dilatation was done, with optimal result. Postprocedural TTE showed no RA mass, and RTG showed complete resorption of right basal lung congestion. Patient was released home with antithrombotic therapy and is currently under medical monitoring.

Lana Maričić, Dražen Mlinarević

Venous thromboembolism represents a significant public health issue – it is the third most common cardiovascular disease in Europe. (1-3) In University Hospital Centre Osijek we admitted a total of 193 patients for venous thromboembolism. We diagnosed deep vein thrombosis in 51.3% and pulmonary embolism in 48.7% of those patients. The average age of patients was 65.5 years, 46.6% were male and 53.4% were female. A recurrent venous thromboembolism was present in 8.8% of patients, and 21.2% had a previously diagnosed malignancy. The most common comorbidity was arterial hypertension. During the hospitalization patients were treated with low-molecular weight heparin. We discharged 48.2% of the patients on direct oral anticoagulants, 26.9% on warfarin and 23.3% on low-molecular weight heparin. Since venous thromboembolism is one of the leading causes of cardiovascular mortality, the aim of this study was to compare clinical practice data from our center with data from previously published international registries. After examining the results, we can conclude that there are many similarities and some differences between patients in our cohort and those from other registries. Since there is no objective data (national registry) available in Croatia, we wish to present the current clinical information about patients with venous thromboembolism in our center and explore questions about the situation in other centers and regions.

Tomislav Krčmar, Boris Car

Percutaneous interventions on lesions in aortoiliac localization have been in focus of interest from the very beginning of interventions because of anatomic suitability and very good short and long-term results. New guidelines from European Society of Cardiology on Peripheral Artery Disease (1) published in 2017 made changes in categorization of lesions by abandoning TASC II classification. Endovascular approach has I C recommendation for first choice treatment of occlusive lesions up to 5 cm in length. More complex lesions should be considered for endovascular-first strategy in patients with severe comorbidities. In general, endovascular treatment of peripheral artery disease in aortoiliac localization has a very important role after optimal medicament treatment and supervised exercise training.

Ivana Jurin, Anđela Jurišić, Jasmina Ćatić, Sanda Sokol Tomić, Ana Jordan, Irzal Hadžibegović

**Case report:** We are presenting two clinical cases of patients with patent foramen ovale (PFO). The first case is 46-years-old woman with a negative history of cardiovascular disease. After the fourth pregnancy, a progression of the right-sided saphenofemoral insufficiency was verified and an operative procedure was indicated. On September 14, 2017 the VSM was extirpated. On the first postoperative day a right-sided hemiplegia emerged and the brain MSCT confirmed the occlusion at the level of the left ACM. A thrombectomy of the acute occlusion of the left ACM was performed, which resulted in complete recanalization of the left ACM. The next day, a massive pulmonary embolism was diagnosed. We verified the PFO by echocardiography and concluded that the PFO was trigger of these adverse events. The second case is 46-years-old woman whose family history is positive for cardiovascular disease. For several years, 24-hours ECG has verified paroxysms of supraventricular tachycardia. Because of the pain in the right ankle and in the absence of trauma, Doppler echo showed us occluded right ADP. From the medical history it was known that woman often wears high heels and tight boots, which makes foot positioned in the plantar extension. An extensive treatment was performed, the immunological treatment was neat and the echocardiography verified PFO. Considering that we could have not clearly distinguish Doppler echo from the occluded aneurysms, intramural hematoma or peripheral embolization, additional treatment was done. CT angiography of the foot verified an occluded ADP on the right which was well collateralized and the 70% stenosis of the left ADP. It was a both sided aneurysm of ADP due to plantar extension, precisely “Sandal strap” trauma and atherosclerosis. **Conclusion:** Although the PFO is more common cause of peripheral embolization (1, 2), as we have shown in the first case, here we wanted to emphasize the need of accurate diagnosis of the aneurysms on the peripheral arteries, especially in women who frequently wear high heels and put their feet in the plantar extension, causing repeated long duration of low intensity traumas which can lead to aneurysmal degeneration with secondary atherosclerotic changes.

Damir Halužan, Irena Šnajdar, Andrea Crkvenac Gregorek

**Introduction:** Chronic venous insufficiency represents a major public health problem with a prevalence of 5-30%. (1) Significant number of interventions in vascular surgery are varicose vein operations that are increasingly being performed in one-day surgery due to the development of surgical and anaesthetic procedures. **Methods and results**: We present protocol, essential features of Doppler diagnostic for planning the operations and results of a retrospective analysis of 482 patients operated from April 2014 to October 2018 at the One-Day Surgery Department of University Hospital Centre Zagreb. All patients were operated in local or locally potentiated anaesthesia. In addition to the classic surgical method since April 2018, we also perform endovascular laser ablation. Abiding the protocols of one day surgery, patient selection and detailed postoperative instructions contribute to the safety of operated patients within one-day surgery, this results in a small number of postoperative complications and minimum number of admissions to the hospital. Shorter waiting times, fixed date of operation and going home the same day increases patient’s satisfaction. **Conclusion:** Varicose vein operations within one-day surgery are a reliable and safe method with a small number of complications, thus freeing the space in hospital for patients with arterial diseases.

Mirza Dilić, Dževdet Radončić, Amina Bičo, Alden Begić, Demir Bejtović

The main question in treating patients with symptomatic carotid artery stenosis, or asymptomatic but with high-risk unstable plaques or stenosis >70% is dilemma between surgical or interventional approach. Numerous clinical trials have compared carotid endarterectomy (CEA) with an alternative, less invasive treatment: carotid-artery stenting (CAS). (1, 2) Evidence based medicine (EBM): ECTS (European Carotid Surgery) trial concluded that symptomatic carotid artery stenosis >80% is indication for CEA and that surgery has a significant advantage over medical treatment (MTx) in terms of mortality and morbidity. NASCET (North American Symptomatic Carotid Endarterectomy) trial for symptomatic carotid artery stenosis >70% showed that surgery has a significant advantage over MTx. CAVATAS (Carotid and Vertebral Artery Transluminal Angioplasty) study involved patients to undergo either angioplasty, with or without stenting, or surgery. Rates of stroke and death were similar in the two groups. SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy) trial assigned patients to undergo either stenting or surgery i.e. group who had symptomatic stenosis > 50% or asymptomatic stenosis of > 80% and who were high-risk surgical candidates. The primary end point of stroke, death, or myocardial infarction strongly favored stenting over surgery. On the basis of these studies, the Food and Drug Administration (FDA) granted approval for carotid stenting for both symptomatic and asymptomatic patients. Further on, EVA 3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis) trial was stopped early after an increased hazard was observed with CAS vs. CEA. In meta-analysis of clinical trials (2) authors concluded that CAS and CEA were associated with similar rates of periprocedural death and stroke, but the risk of long-term overall stroke was significantly higher with CAS. EBM data are obviously conflicting in definitively decision making between surgical or endovascular approach and the most important question is - what is really the standard of care in this issue? According to the latest guidelines, optimal medical treatment is an essential part of the treatment but dilemma between CEA and CAS still remains.

Amina Bičo, Alden Begić, Dževdet Radončić, Mirza Dilić

**Introduction**: There are a very few studies analyzing blood flow velocity parameters of internal carotid arteries (ICA), measure with Color Doppler examination, as an independent risk factor for carotid stenosis (CSt). In everyday clinical practice we have are number of patients (pts) with carotid stenosis but with borderline or slightly increased peak-systolic velocity and these findings are not in line with current guidelines. (1-3) In grading of CSt we used University of Washington Duplex criteria and in calculation of cardiovascular risk factor score we used SCORE charts. We performed this study to compare data of blood flow velocity parameters and risk factor score with grading of CSt. **Methods and Results**: We included total of 92 consecutive patients with CSt 50-70% (n=50) and CSt >70% (n=42). Out of them with CSt 50-70%, were 38 males, age of 58.2±10.4 and 8 females, age 59.7±5.8, and with CSt >70%, were 41 males, age of 60.1±6.2 and 9 females, age of 61.3±6.4. Velocity parameters were: peak-systolic velocity (PSV) and end-diastolic velocity (EDV). Measurement was performed on proximal portion of ICA. In the group of CSt 50-70%, ICA hemodynamic parameters were: PSV 106±18.5 cm/s, EDV 37.8±8.7 cm/s, and in the group of CSt > 70% ICA parameters were: PSV of 139±12.4 cm/s. and EDV 41.8±5.7 cm/s. PSV revealed a borderline significant association with group of CSt >70%, p 70%, regression logistic test, with 95% CI, was performed and we got for the CSt >70%, significance for age, hypertension and smoking, p 70%, and risk factors age, hypertension and smoking were significantly connected to CSt > 70%. In the group of CSt 50-70%, PSV of ≥ 106 cm/s was of no significance but age and hypertension were of significant connection. EDV was of no significance in both groups.

Ljiljana Banfić

Deep venous thrombosis (DVT) in high-risk fragile and cancer patient is associated with increased morbidity and mortality. Fragile patient and cancer associated thrombosis patients are estimated to be large number of more than 50% in DVT population treated for deep vein thrombosis. Increased incidence of major bleeding during the course of anticoagulant therapy very often create dilemmas between the safe treatment regime, appropriate pharmacotherapy and adequate drug dosage. The DVT guidelines are the state of knowledge in diagnosis and treatment and gave us the frame and rules for safe DVT treatment. (1-3) The author will give an overview of DVT treatment standard in high- risk patient and present recent literature data that could increase the awareness and possibilities of new treatment modality. Personalized approach for DVT is mandatory but the results of randomized trials that suggested fewer bleeding events in high-risk patients receiving new anticoagulant drugs might open new and safer era in DVT treatment.

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

**Introduction:** Several studies have reported high residual platelet activity (measured using platelet aggregation tests) in patients treated with clopidogrel depending on the grade of drug biotransformation in liver via cytochrome P450 system. (1-3) It is also known that this high on-treatment activity as well as clinical outcomes may be improved by increasing clopidogrel dose. We report the results of a group of patients who have completed 1-year follow-up and who were included in a randomized clinical trial investigating efficacy and safety of individualized P2Y12 receptor antagonists treatment based on aggregometry tests versus fixed dose ticagrelor regimen in patients after acute myocardial infarction with ST-segment elevation (STEMI). **Patients and Methods:** We analyzed the data of 51 consecutive patients (9 female, mean age 58.9 years) treated for STEMI. During the first month after STEMI all the patients were treated using fixed dose ticagrelor with aspirin. Afterwards the patients were randomized into two groups. First group continued with the aforementioned therapy during one-year period. Patients in the second group were switched from ticagrelor to clopidogrel and treated during the one-year period by individualizing clopidogrel dose based on aggregometry tests using Multiplate® analyzer. Primary outcome was the incidence of major cardiovascular events (cardiovascular death, myocardial infarction, stroke and repeat revascularization). Secondary (safety) outcome was the incidence of minor and major bleeding defined using BARC classification. **Results:** During one-year follow-up we haven’t observed primary outcome or major bleeding event. We found statistically significantly lower incidence of minor bleeding in the group of patients treated with individualized P2Y12 antagonists dose tailoring (p=0.027) which transfers to 4.8 times higher chance of having minor bleeding while treated with fixed dose ticagrelor in comparison to patients treated with individualized approach (OR 4.8; 95% CI 1.118 to 20.611; p=0.035). **Conclusion:** These results show that individualized P2Y12 antagonists treatment using aggregometry tests may represent equally effective but safer treatment approach in comparison to fixed dose ticagrelor regimen in patients after STEMI.

Alden Begić, Amina Bičo, Azra Kurčehajić Pošković, Mirza Dilić

Endovascular interventions in patients with peripheral artery disease (PAD) have been significantly developed and improved in the last decade. However, guideline recommendations for the treatment in postprocedural period still vary significantly, ranging from the use of aspirin alone to the use of conventional dual antiplatelet treatment (DAPT) clopidogrel with aspirin for one to three months followed by continued long-term aspirin use. Treatment recommendations focus on platelet aggregation, and do not include the role of coagulation cascade in thrombus formation. (1, 2) Loss of patency after endovascular treatment remains high, ranging from 17 to 40% in patients on dual antiplatelet therapy. Endovascular treatment can also result in catheter-induced damage to the endothelium, exposing tissue factor-rich subendothelium to the blood stream and creating a thrombogenic environment wherein platelets and coagulation factors are activated. That means that with DAPT we do not protect the endothelium or lesion surface i.e. activation of coagulation cascade. At the moment there are several ongoing trials (up to approx. 200 patients) with postprocedural combination of anticoagulant (NOACs) and aspirin treatment for one to three months followed by aspirin. Risk of bleeding according to ISTH (International Society on Thrombosis and Hemostasis) criteria was as follows: non-major bleeding and all bleedings were higher with NOACs and aspirin than with clopidogrel and aspirin, though major bleeding was lower. Further on, in PAD patients, six months composite endpoint event rates showed that NOACs was more favorable treatment than clopidogrel in all cases of restenosis, with or without target lesion revascularization, ischemic complications including amputation and/or major adverse cardiac events. It was also more favorable treatment for all different characteristics of patients such as: gender, lesion length, age and region. Despite significantly increasing number of PAD endovascular procedures still remains dilemma due to postprocedural protection of endothelium and lesion surface. NOACs and aspirin combination is a new promising approach.

Filip Lončarić, Petra Mjehović, Dorja Sabljak, Antonija Mišković, Dominik Oroz, Ines Vinković, Vedrana Vlahović, Grgur Salai, Saša Pavasović, Nina Jakuš, Dora Fabijanović, Maja Čikeš, Davor Miličić

**Background and Aim**: Women with ST-segment elevation myocardial infarction (STEMI) have a higher 30-day risk of all-cause mortality. (1) The aim is to study gender differences in in-hospital mortality and mortality at 1-year follow-up in the Croatian branch of the ISACS-CT registry (NCT01218776). **Patients and Methods**: From January 2012 to October 2017, 1898 patients were enrolled; 46% (n=881) presenting with STEMI, 36% (n=685) with non-ST-segment elevation myocardial infarction (NSTEMI), and 18% (n=332) with unstable angina (UA). Follow-up was performed on 33% (n=630) of the cohort, 44% (n=275) with STEMI, 34% (n=217) NSTEMI, and 22% (n=138) with UA. **Results**: At admission women were older, more burdened with comorbidities, and arrived at the hospital with a longer delay from symptom onset (**Figure 1**). During hospitalization, there were no gender differences in reaching an ejection fraction (EF) below 40%. Nevertheless, women with STEMI had significantly worse outcomes in the acute period (**Table 1****)**. After adjusting for gender, in-hospital mortality was associated with age (OR 1.09, 95% CI 1.06-1.13, p<0.001) and primary percutaneous coronary intervention (PCI) (OR 0.45, 95% CI 0.24-0.86, p=0.015). At hospital discharge there was no gender difference in prescribed ACE-inhibitors or statins, whereas after 1-year there was a significant reduction in ACE-inhibitor (female vs. male: 68.3% vs. 81.1%, p=0.042) and statin therapy in women (**Figure 2**). During follow-up, 15.7% of patients reached <40% EF, 7.6% underwent repeated PCI, 2.7% were readmitted with NSTEMI or UA, 1.3% hospitalized for heart failure, 0.8% had a coronary artery bypass graft (CABG) procedure, 0.6% a stroke or a transitory ischemic attack, and 0.5% were readmitted with STEMI. There was no gender difference in all-cause mortality or in any of the endpoints. After adjustment for the type of acute coronary event at initial presentation and gender - age (HR 1.10, 95% CI 1.06-1.15, p<0.001), EF at discharge (HR 0.95, 95% CI 0.92-0.97, p<0.001) and primary PCI (HR 0.30, 95% CI 0.13-0.65, p=0.002) proved to be significant predictors of survival. **Conclusion**: Our results concur with the current findings of significantly increased in-hospital mortality of female STEMI patients. At 1-year follow-up there was no gender disproportion in mortality or other endpoints. A decrease in statin therapy was noted in women during follow-up, suggesting more through control might be needed to maintain the prescription of statins or compliance. FIGURE 1. Gender differences in comorbidities and admission time in patients admitted due to acute coronary syndrome. ### TABLE 1: Gender differences in mortality at hospital discharge and at 1-year follow-up. | | **STEMI** | **STEMI** | **STEMI** | **NSTEMI** | **NSTEMI** | **NSTEMI** | **Unstable Angina** | **Unstable Angina** | **Unstable Angina** | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Mortality | Male | Female | P value | Male | Female | P value | Male | Female | P value | | In-hospital, n (%) | 25 (4.1) | 32 (12.1) | **<0.001** | 15 (3.3) | 9 (3.8) | 0.827 | 4 (1.7) | 0 (0) | 0.261 | | 1-year follow-up, n (%) | 11 (5.7) | 6 (7.4) | 0.586 | 9 (6.3) | 5 (6.8) | 0.895 | 2 (1.9) | 1 (3) | 0.699 | [†] STEMI = ST-segment elevation myocardial infarction; NSTEMI = non-ST-segment elevation myocardial infarction. FIGURE 2. Statin therapy over time in patients with acute coronary syndrome.

Aleksandar Knežević, Luka Markulin, Marijana Nadinić, Irena Užović Frakin

The study included patients receiving hospitalization in Zadar General Hospital from September 1st 2016 until August 31st 2017 with diagnoses (MKB-10) I63 and K92 and atrial fibrillation (FA) at the time of inoculation. In the observed period of the year, 378 patients with cerebrovascular insult (CV) and 63 patients with gastrointestinal (GI) bleeding were hospitalized. The study included 77 patients with CVI. The first group consisted of 3 (4%) of the patients who had some of the new oral anticoagulants (NOAC) therapy in the FA therapy. The second group consisted of 22 (29%) of the patients who had warfarin therapy, the third group consisted of 15 (19%) of patients receiving acetylsalicylic acid (ASA) while the fourth group consisted of 37 (48%) patients who did not have any of the aforementioned drugs in the therapy. Also, in the observed period of the year, 63 patients with GI bleeding were hospitalized. The study included 10 patients with this diagnosis. Two (20%) patients who did not have FA at the time of admission were FA. 5 (50%) patients had NOAC and 3 (30%) warfarin. No patient from the FA was hospitalized to have ASA therapy. In the group of 22 patients who had warfarin in therapy, well-regulated anticoagulation therapy with INR values ranging from 2 to 3.5 had 4 patients (18%). As it is known that in the Zadar County in the observed period, 2/3 of the patients taking anticoagulant therapy took warfarin and 1/3 of NOAC, and the published data show that the ratio of hospitalized patients with FA and CVI was 1: 8 compared to those who took NOAC against warfarin, and from the literature data it is known that their efficacy in preventing CVI alike, suggests that warfarin-treated patients were not optimally anticoagulated so they could not avoid the occurrence of thromboembolic CVI. At the same time, in hospitalized patients with GI bleeding, there were more those taking NOAC in therapy, which is consistent with the literature data, but also the known data on the nonoptimal INR regulation in patients taking warfarin. It can be concluded that, in conditions of non-optimal regulation of INR, patients with chronic FA do not need to use warfarin, but optimal CVI prevention will have NOAC, with an acceptable risk of gastrointestinal bleeding. (1)

Vanja Hulak-Karlak, Ivana Jurin, Miroslav Raguž, Boris Starčević

**Objective:** To evaluate the presence of certain risk factors of coronary disease, age, gender, psychosocial and educational status among the Roma minority. **Patients and Methods:** Cross-sectional research included 466 patients hospitalized in the University Hospital Dubrava under the working diagnosis of acute coronary syndrome. All patients underwent coronarography, and by ethnicity they were divided into two groups, Roma (97) and non-Roma (369). Within each group the presence of selected risk factors is determined. The data were collected from medical records and processed by statistical parameter tests of independent variables. **Results:** Among the groups, Roma vs. non-Roma there was no statistically significant difference in sex representation (67.01% m, 32.99% f vs. 69.65% m, 30.35% f), but in other categories the differences were significant. The average age of Roma was 54.47 (26-75) vs. 59.51 (32-90), without / primary education had 64.95% vs. 20.1%, high school 31.96% vs. 59.89%, faculty 3.09% vs. 20.01%. Psychotic disorders had 21.65% Roma vs. 13.55% and predominated anxiety-depressive syndrome 95.24% vs. 70%. **Conclusion:** Our research has shown that Roma patients with coronary heart disease are on average younger adults with significant prevalence of psychological disorders, predominantly anxiety-depressive, and low educational status compared to non-Roma population. These findings open up the possibility of new research and implements a plan of ethnically-oriented preventive strategies. (1, 2)

Edin Begic, Suncica Hadzidedic, Ajla Kulaglic, Belma Ramic-Brkic, Zijo Begic, Mirsada Causevic

**Introduction:** Presence of a cardiovascular disorder may contribute to poor cognitive aging and Alzheimer’s disease (AD)-type cognitive decline. AD is the most prevalent age-related neurodegenerative disease which is prominently characterised by progressive loss of cognitive abilities for which specific and sensitive biomarkers and disease-modifying therapies are lacking. (1-3) Brain-type natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) are the most important humoral indicators of cardiac dysfunction and heart failure, and their level in blood is proportional to the degree of myocardial function failure. In an effort to identify key biomarker(s) of AD, from an easily accessible biological fluid, such as blood, that would aid in early diagnosing and/or monitoring of a progression of AD, plasma levels of BNP were examined in subjects with differing cognitive abilities. **Materials and Methods:** Human subjects were recruited for the European Union-funded AddNeuroMed biomarker project through medical centres based in several countries (UK, Finland, Italy, Greece and Poland). BNP levels in the subjects’ plasma samples were measured using Slow Off-rate Aptamer (SOMAmer)-based capture array called SOMAscan (SomaLogic, Inc., CO, USA). BNP measurements from the AddNeuroMed subjects were obtained from the Synapse Data Platform which is hosted by Sage Bionetworks (https://www.synapse.org). **Results:** Plasma BNP levels were compared between two groups of subjects: 1) healthy subjects (N=189), and 2) subjects diagnosed with probable Alzheimer’s-type dementia (N=308). Our analysis shows that subjects diagnosed with probable AD have significantly lower BNP levels (2986.82 ± 238.82) compared to healthy controls (3041.98 ± 236.67) (U = 24935.00, Z = -2.68, p = 0.007). **Conclusions:** Decreased plasma levels of an established cardiovascular biomarker, BNP, as measured by a novel technology termed SOMAscan, appear to associate with declining brain health. Our results warrant further investigations into a role of BNP in AD and they have implications for a wider population as they are related to a research cohort that consisted of subjects who were recruited from a wider geographic area (several European countries).

Ivo Planinc, Patricia Garcia-Canadilla, Hector Dejea, Eduard Guasch, Marco Stampanoni, Davor Miličić, Bart Bijnens, Anne Bonnin, Maja Čikeš

**Background**: Cardiac remodelling is a set of cellular, tissue and organ changes that develop as a consequence of various injuries to the heart, such as myocardial infarction (MI). Global remodelling can be assessed by echocardiography, magnetic resonance or computed tomography imaging, however combining information on both cellular and entire organ level is still not possible by currently available imaging techniques. (1, 2) A prominent technique under research is Synchrotron X-ray Phase Contrast Imaging (X-PCI) that can be used for both 3D analysis of whole hearts, as well as cardiomyocytes (CMCs) without tissue processing or destruction. In basic and translational science rodent animal models are frequently used for myocardial ischemia research. **Methods**: MI was induced by LAD ligation via a left thoracotomy in an established model of adult (8-11 week-old) Wister rats. The animals were sacrificed after 2 weeks when the hearts were extracted and imaged by X-PCI at TOMCAT beamline (Swiss Light Source, Paul Scherer Institute, Switzerland) using an energy of 20 keV with two different voxel sizes in selected regions of interest. 3D datasets obtained by this technique allowed calculation of ventricular volumes, mass and cavity dimensions, fibre orientation analysis, as well as analysis of individual cardiomyocytes (cross sectional area (CSA) calculation). We quantified global left ventricular (LV) remodelling in 4 post-MI rat hearts, and in a control healthy rat heart. In 2 post-MI hearts, the cardiomyocytes were analysed in the area of the MI (preserved cells adjacent to the fibrotic post-MI myocardium - peri-MI zone), and in the contralateral region (the non-affected myocardium). Cardiomyocytes of corresponding areas were analysed in the healthy heart alike. CSA was expressed as the mean value with standard deviation of measurements of 10 CMCs per area. **Results**: **Table 1** shows indices of global myocardial remodelling confirming wall thinning and increase in size and mass of the LV in post-MI rat hearts. The results of CSA calculations (**Table 1**) indicate significant (p2** | | | | | | | | | | **Contralateral region** | **499±141** | **477±116*** | **521±160*** | - | - | **312±62** | | **Peri-MI zone** | **737±127** | **773±118** | **701±126** | - | - | **330±92** | | | **Overall** | **321±75** | **625±194∮** | **611±168∮** | - | - | **-** | | [†] *marks significant difference in cardiomyocyte cross sectional areas between different myocardial areas in the same rat heart, while ∮ marks significant difference in cardiomyocyte cross sectional area between same myocardial areas of affected and non-affected hearts (p≤0.01). MI - myocardial infarction, LV - left ventricle **Conclusion**: X-PCI provides results consistent with previous research in the field but obtained by one single technique that proves it valuable for quantifying both global and cellular myocardial remodelling.

Livija Sušić, Milena Vadoci, Nikolina Milanović, Vedrana Baraban, Marko Burić, Antonio Burić, Tihomir Sušić

**Introduction**: Sudden cardiac death (SCD) is a sudden, unexpected cardiac arrest with a deadly outcome within one hour from the onset of the symptoms. Every year around 275 000 people in Europe experience out-of-hospital cardiac arrest (OHCA). (1) It is estimated that about 60% of those persons die immediately. In recent decades, great public importance has been given to the progress of survival rates of heart attack victims and the reduction of irreversible neurological consequences. For this purpose, there have been organized cardiopulmonary resuscitation (CPR) courses at numerous places, and automatically external defibrillators (AEDs) have been set in the healthcare facilities and in places where a large number of people circulate. (2) In 2010, the American Heart Association recommended continuing education of CPR for healthcare professionals once every two years. (3) In the Republic of Croatia there is no statutory obligation of continuous education of CPR for healthcare professional. **Methods and Results**: The cardiology team at the Health Center Osijek has organized three times in the past three years practical courses on basic life support at reanimation dolls with the use of an AED for the purpose of continuous CPR education and getting acquainted with AED’s work. 213 health professionals from the Health Center Osijek and Valpovo, including physicians, nurses and dentists, attended the courses voluntarily. At the end of the course, the participants filled in an anonymous questionnaire. 122 participants were in the age group 20-40 years, 21 between 40-50 years, 52 in the group 50-60 years and 18 older than 60 years. 51 participants had a working experience 30 years of work experience. 64 participants had previously worked in the hospital, 53 participants actively participated in reanimation during their lifetime, 80 participants had previously passed some of the CPR courses, and only 59 of them were considered to be sufficiently educated prior to the course. The participants evaluated the course extremely useful and at the end of the course 211 said that the CPR courses should be repeated on average every 2 years. **Conclusion**: Health care professionals of primary health care should repeat the CPR course at least every 2 years in order to improve the quality of the procedure.

Hrvoje Pintarić, Marijana Knezović Florijan, Ian Bridges, Robert Steiner, Luka Zaputović, Davor Miličić

**Aim**: An observational study was conducted to evaluate current management of elevated low-density lipoprotein cholesterol (LDL-C) in patients being treated for hyperlipidemia across central/eastern Europe and Israel. Information from this region is somewhat limited at present. Here we present data from the Croatian subpopulation. **Patients and Methods:** We enrolled adult patients who were receiving lipid-lowering therapy (LLT) and attending a specialist (cardiologist/diabetologist/lipidologist) or general practitioner (GP) for a routine visit at a participating academic/specialist/GP centre in Croatia. Data were collected retrospectively from patients’ records for the preceding 12 months. Patients were classified by cardiovascular risk category: Very High Risk (VHR), according to European guidelines, (1, 2) or Extremely High Risk (EHR) according to recent American Association of Clinical Endocrinologists (AACE) criteria. (3) **Results:** 89 patients (all secondary prevention: VHR 41/EHR 48) were enrolled at 4 sites (**Table 1****).** All were receiving statins, as monotherapy (VHR 92.7%/EHR 83.3%) or combined with fibrates (VHR 4.9%/EHR 14.6%) or ezetimibe (VHR 2.4%/EHR 2.1%). Approximately 70% of patients in both subgroups were taking high-intensity statins (atorvastatin 40-80mg or rosuvastatin 20-40mg/day). Median (Q1, Q3) LDL-C levels were 2.5 (2.0, 3.8) mmol/L at the first, and 1.9 (1.6, 2.4) mmol/L at the last, visit of observation for VHR. Corresponding levels were 2.4 (1.7, 3.7) mmol/L and 2.1 (1.5, 3.1) mmol/L for EHR. Only 17 (41.5%; 95% CI 26.3-57.9) VHR patients and 13 (27.1%; 15.3-41.9) EHR patients had LDL-C levels within target (a** | | --- | --- | --- | | Male/female | 35 (85.4%)/6 (14.6%) | 34 (70.8%)/14 (29.2%) | | Age (mean, range), years | 66.1 (56-78) | 64.3 (46-82) | | Weight (mean, range), kg | 88.9 (57-173)[n=32] | 85.0 (49-125)[n=38] | | Current Smoker | 9 (22.0%) | 10 (20.8%) | | Diabetes | 6 (14.6%) | 24 (50.0%) | | STEMI | 12 (29.3%) | 13 (27.1%) | | Statin-intolerantb | 1 (2.4%) | 2 (4.2%) | | Time from diagnosisc | | | | d | 1.1 (1.0, 1.3) | 1.0 (0.8, 1.2) | | Triglycerides (mmol/L)d | 1.3 (1.1, 1.5) | 1.5 (1.0, 2.4) | | Total cholesterol (mmol/L)d | 3.5 (3.2, 3.9) | 3.7 (3.3, 4.8) | [†] a. Progressive ASCVD after achieving LDL-C <1.8 mmol/l; established clinical CV disease in patients with diabetes mellitus, CKD stage 3/4, or heterozygous FH; history of premature ASCVD (aged <55 years male, <65 years female); b. Symptoms of statin intolerance; c. Time from diagnosis of hyperlipidemia to study enrolment; d. Median (Q1, Q3) values at the last visit. **Conclusion:** Our findings indicate that a substantial proportion of VHR and EHR secondary prevention patients being treated across Croatia have LDL-C levels exceeding targets recommended in European and newer AACE guidelines. (1-3) Despite this, not all patients are receiving high intensity statins as recommended. Identification of EHR patients and their lipid patterns may help to optimize usage of high-intensity statin treatment, alone or in combination with newer treatments, for better control of elevated LDL-C.

Viktor Peršić

In Europe, more than 4 million people die each year due to cardiovascular diseases (CVD). In the Republic of Croatia in 2016, CVDs had taken the share of 44.99% (23,190 people) in overall mortality; 50.14% of them were women and 39.67% were men. In the last thirty years, mortality of CVD has been halved. This can be attributed to changes in population risk factors, primarily to reduction of cholesterol, blood pressure and smoking. This favourable trend could have been even better if not being partly compensated by the growth of the other risk factors, mostly diabetes type 2 and obesity. Approach to the total preventive and comprehensive rehabilitation measures in patients with developed CVD with the aim of achieving maximum health, personal, family and social sufficiency as well as preventing a new cardiovascular event, are the main tasks of organized secondary health prevention activities. If implemented successfully, they lead to a significant increase in survival, improvement of quality of life, reduction of the need for interventional, surgical or percutaneous interventions, with a significant reduction in overall social and economic burden. (1-3) Additional efforts are needed in order to bring the number of outpatient and stationary cardiac rehabilitation centers to the level of the current needs in the Republic of Croatia. During the lecture presentation, it will be discussed how and where to open new cardiac rehabilitation centers in the Republic of Croatia.

Marina Njegovan, Viktor Peršić

Every comprehensive cardiac rehabilitation program includes management of psychological factors of cardiac disease. Broadly speaking, the goal of different psychological strategies and techniques in cardiac rehabilitation is to improve subjective wellbeing and quality of life in cardiac patients. Recently, in the field of clinical psychology there is growing number of mindfulness-based interventions. Mindfulness, in its simplest form, is cognitive skill that helps us direct attention to immediate experiences, moment by moment, as they unfold, on purpose and nonjudgmentally. This kind of attention allows us to replace automatic and reactive responses with conscious and engaged ones. Mindfulness is natural attribute of every individual and it can be practiced through different meditative exercises. Studies of regular mindfulness practice show its correlation with different indicators of physical and mental health. From therapeutic point of view, mindfulness-based interventions are being used to address different psychological difficulties: depression, anxiety, stress, chronic pain, as well as eating-related behaviors and smoking cessation. Mindfulness is mechanism utilized to build intrinsic motivation, which is most strongly associated with long-term behavior change. In cardiac patients it is important to work on emotional reactions to disease, along with different health behaviors, so mindfulness as core therapeutic mechanism could find its application in cardiac rehabilitation programs. One of the goals of rehabilitation is to offer patients tools for further independent prevention of disease and mindfulness could be one of those tools. Studies show that mindfulness-based interventions are helpful in reductions in anxiety and improvements in emotional control and coping in cardiac patients, as well as in blood pressure regulation, perceived stress and anger regulation. (1, 2) This paper will present considerations and some of the studies of applications of mindfulness-based interventions in cardiac rehabilitation.

Verica Kralj, Petra Čukelj, Ivana Brkić Biloš, Krunoslav Capak

Tobacco use and alcohol consumption are two leading risk factors for development of chronic noncommunicable diseases, including cardiovascular diseases, cancer, lung diseases and liver cirrhosis. Aside from direct healthcare costs for treating these conditions, they can also cause premature mortality of working-age population and related additional financial costs. World Health Organization has identified an evidence-based list of interventions that are highly cost-effective and feasible to implement, so called „best buys“. (1-3) The most notable ones on population level are tax increase on tobacco products and alcohol. Taxation is an effective, low cost intervention, which can significantly reduce the risk of chronic noncommunicable diseases. Ten percent price increase reduces tobacco consumption for 4 to 5%, and alcohol consumption for 6,5%. Therefore, in their strategic documents WHO proposes measures of fiscal and marketing policies to reduce availability, but also consumption, of tobacco products, alcohol, and food products that are high in saturated fat, trans fat, sugar and salt. Taxation is recognized as an efficient legislative tool to reduce tobacco and alcohol consumption, and therefore not only current, but also future healthcare costs. Meanwhile, although the consumption is reduced, the rate of this reduction is not the same as the rate of price increase, and governments still gain additional tax revenue. Tax increase is especially useful as a tool for reduction of tobacco and alcohol consumption in young people, as the increase in price makes these products less available. Besides the reduction in consumption, this also leads to a decrease in the number of young people that develop tobacco and alcohol habit. Research has also shown that majority of non-smokers, but also a significant number of smokers, supports higher tobacco taxes, especially if additional revenue will be used for prevention programs and improvement of the health system. In order to successfully implement excise taxes, it is necessary to have intersectoral collaboration, especially collaboration of the financial and health sector, but also to deal with lobbying and interfering from the tobacco and alcohol industries.

Nikola Kos, Vjekoslav Radeljić, Diana Delić-Brkljačić

Therapeutic conduct for patients with cryptogenic stroke is somewhat controversial. (1, 2) Patent foramen ovale (PFO) finding in patients with previous cryptogenic stroke emerge several issues unresolved so far. Three randomized controlled trials that have been conducted so far to compare the implant of a transeptal occluding device with a simple medical therapy in patients with PFO and history of cryptogenic stroke did not show a greater protective effect of therapy with transeptal device as regards the recurrences of stroke. Several meta-analyses that have been derived brought results that are strikingly discordant with each other. Some of them come to the conclusion that the transcatheter closure of PFO does not offer significant advantages compared to antithrombotic therapy for the secondary prevention of cryptogenic stroke, while others based on subgroup analyses argue that some could be associated with significantly lower incidence of cerebrovascular events compared with medical therapy alone. Some studies suggest that atrial fibrillation (AF) is a possible cause of cryptogenic stroke. Most of these studies are based on continuous electrocardiographic monitoring. However, there is no consensus on the usefulness of ECG monitoring in this setting and many questions about the association between AF and cryptogenic stroke remain unanswered. A recent consensus document recommends “extended ECG monitoring” in patients with cryptogenic stroke to detect undiagnosed AF. The evidence regarding the monitoring time to be employed in patients with CS for detecting AF is still inconclusive.

Ino Kermc, Danko Relić, Milan Milošević, Zlata Adžić-Ožvačić, Richard J. Schuster, Venija Cerovečki

**Introduction:** Cardiovascular diseases (CVD) are the leading cause of death in developed countries of the world, including Republic of Croatia. The prevention of CVD remains an important factor in reducing total mortality (1). The European Society of Cardiology and related professional societies regularly publish and revise guidelines on CVD prevention. The general objective of this study is to evaluate the appliance of guidelines on CVD prevention in the family physicians’ daily practice. Specific objectives are to examine the availability of guidelines for family physicians, the use of guidelines in their daily work and adherence to guidelines while treating patients with risk factors for CVD. **Methods**: Research was conducted on a convenient sample of 745 family physicians. Data on physician’s characteristics (age, sex, practice status) and availability, usage and adherence to CVD prevention guidelines were collected. Appropriate statistical procedures have been used: description and distribution analysis using absolute numbers and relative frequencies. **Results:** The survey included 484 family physicians (response rate 65.0%) of which 422 (87.1%) women and 62 (12.5%) men. The majority of the respondents were up to 55 years old (N=346, 71.5%), holding a private practice in concession (N=339, 70.1%). Family physicians assessed the availability of guidelines as frequent and very frequent in 60.7% of consultations. Furthermore, 64.7% of the total number of respondents said they used CVD prevention guidelines in more than 60% of patients, but only 15.9% of respondents strictly adhered to the guidelines. **Conclusion:** Relatively large number of family physicians has no CVD prevention guidelines available. It is necessary to find ways to facilitate access to the guidelines and thus encourage their use. Assessment of guideline adherence points out that the guidelines should be implemented in clinical practice in accordance with knowledge, experience, patient preferences, and the social, cultural and economic environment, respecting the model of person-oriented care. (2, 3)

Gordana Kamenečki

Cardiovascular diseases (CVD) are still the leading cause of mortality, despite primary, secondary and tertiary prevention being used to combat morbidity and mortality. Media and public health service projects encourage healthy persons, as well as persons already suffering or having suffered of CVD, to change their lifestyle in order to increase their quality of life and longevity. In the 1950s much research was started trying to detect risky factors for CVD and most famous among them, the Framingham study, added to by Rosenman and Friedman’s research, which definite personality types A and B coronary prone behavior. People with Type A personality tend to exhibit hostility, competitiveness, impatience and are generally “workaholics” and the representation of Type A personality among cardiovascular patients is double that of Type B personality. In the basis of Type A there is a hidden lack of self-confidence and self-respect, which makes Type A feel the need to prove them to others. Such states are connected to increased anxiety as well. (1) The research conducted in the Special Hospital for Medical Rehabilitation Krapinske Toplice has given results that show after three weeks of stationary cardiac rehabilitation, which includes a number of procedures, there is a substantial decrease in anxiety and depression, but this change is not connected to the personality type of the patient. There is a substantial difference between Type A and Type B and the beginning and end of the rehabilitation procedure, but the change is about the same in both groups.

Mario Ivanuša

Secondary prevention of cardiovascular (CV) diseases, according to the guidelines, is conducted by means of treatment that, in addition to changes in lifestyle and the use of medication therapy, also includes the participation of patients in the cardiovascular rehabilitation program (CVR). In addition to the reduction of mortality and morbidity and improvement of life quality, the participation in the CVR program aims at improving the CV function and functional capacity, optimizing the medication therapy, identifying and treating arrhythmias, educating patients and the family about the need to change lifestyle, improving the psychological condition and promoting the patient’s autonomy in treatment. (1-3) The outpatient CVR program at the Srčana Institute in Zagreb has been continuously conducted by the multidisciplinary team led by cardiologists since 1982. It is carried out in the area specifically designed without architectural barriers, where appropriate medical equipment is used along with cardiologists that are constantly present. The outpatient CVR program is carried out in patients that are medically indicated with a low or moderate CV risk and are away from the rehabilitation center up to 50 km or that have to travel by public transport for up to 60 minutes. The cost of conducting the program for a period of three months is covered by the D1 referral issued by the competent family physician. After initial information provided on the outpatient CVR program and patients’ consent to participating in it, all team members (Cardiologist, Physiatrist, Clinical Psychologist, Bachelor of Occupational Therapy, Bachelor of Nursing and Bachelor of Physiotherapy) will conduct an assessment that, in addition to the diagnostic workup performed, will also include the patients’ understanding of the effects of CV disease and information about the current medical status, the use of medication therapy, the presence of signs and symptoms of the diseases and comorbidities, previous and current level of physical activity, nutrition and habits, testing the psychological status and anthropometric measurements. Therapeutic education of patients and families is initiated, which takes place simultaneously with CV diagnostics. Upon doing initial workup, the cardiologist stratifies the risk, classifies the patient into a functional group and prepares a personalized treatment plan. Particular attention is paid to the safety of intervention by means of medical gymnastics and, in addition to indicating the benefits of this procedure, some instructions are given to the patient at the beginning (clothes/ footwear, meals/hydration, non-smoking). Structured intervention by means of physical activity (warming up, conditioning, cooling down) is carried out according to FITT principles (frequency, intensity, time, type) accompanied by monitoring of electrocardiograms, Borg rating of perceived exertion and monitoring of signs of excessive metabolic or circulatory stress. During medical gymnastics, special attention is paid to proper breathing, posture and positioning. In addition to the assessment of the psychological profile, emotional reactions and defense mechanisms, the psychological interventions include education on the significance of risk factors, work on self-efficacy, cognitive interpretation/perception, and, when necessary, they also involve a psychiatrist and a music therapist. All team members continuously monitor the patient’s individual progress. In the event of discomforts or complications, an educated team will respond promptly depending on the clinical manifestations, and may also consult the consillium members from other city Cardiology institutes. The outpatient CVR program ends with the final evaluation of all team members and a letter of discharge containing the results of all tests, recommendations for non-pharmacological and medication therapy and further follow-ups. All patients are advised to follow the instructions for a lifetime while continuing to do physical exercises.

Mario Ivanuša, Gabrijela Ćurić, Dubravka Kruhek Leontić, Ana Katušić, Stipe Drmić

**Introduction:** Since symptoms of anxiety have been recorded in 23% of patients upon admission to the outpatient cardiovascular rehabilitation program (OCVR) and depression symptoms have been recorded in 29% of patients (1), the implementation of the program in the Cardiovascular Disease Prevention and Rehabilitation Institute in Zagreb (Institute) (2) has been recently improved by occupational therapy (3), consulting procedures by psychiatrists (examination and lecture) (4) and music therapist (lecture and receptive music therapy) (5). The aim of this paper is to present initial experience in applying the receptive music therapy in patients involved in the OCVR program. **Patients and Methods:** The implementation of the OCVR program in the Polyclinic has already been described. (2) Hospital Anxiety and Depression Scale (HAD) has been used for assessment of anxiety and depression at the beginning and end of the OCVR program. All of the patients are involved in the psychodiagnostics of a clinical psychologist, and according to the indication of a psychologist and/or a cardiologist, a psychiatric examination has also been performed. The patients with borderline or pathological finding for HAD were involved in the program of receptive music therapy after applying additional diagnostic instruments (5). **Results:** During the period from 30th June 2017 to 25th October 2018, receptive music therapy was applied in a total of 17 patients (10 men and 7 women), in whom the OCVR program was indicated for 14 of them after acute myocardial infarction, for one of them after coronary artery bypass grafting, and for two of them after unstable angina pectoris. Median time that elapsed from the acute cardiovascular event until the start of applying the receptive music therapy was 90 days. The evaluation by a psychologist was done in all 17, and an examination by a psychiatrist was done in 11 patients. Out of 190 music therapy services, there were altogether 170 music therapy sessions. The desired threshold of 8 or more music therapy sessions was achieved in 13 out of 17 patients. The self-assessment result by applying Hospital Anxiety and Depression Scale upon admission to the OCVR program was borderline or pathological in 15 and in 3 patients upon discharge. The mean values ​​when doing the self-assessment on anxiety and depression particles by applying HAD were significantly higher at the beginning compared to those at the end of the OCVR program (anxiety 10 to 6, depression 7 to 4). The results on the Scale of the self-assessment of health condition at the end of music therapy are lower than those at the beginning (11.5 to 10). **Conclusion:** The treatment by receptive music therapy in patients involved in the OCVR program additionally contributes to reducing anxiety and depression. The effect of this procedure should be considered as part of the benefit of the entire OCVR program and in a larger group of patients.

Karlo Golubić

An overview of the risks and benefits of aspirin therapy in primary prevention of cardiovascular diseases (ischemic heart disease, thromboembolic complications of atrial fibrillation, pulmonary embolism...) in the light of old and new evidence. (1-3) For decades it has been considered that aspirin can prevent myocardial infarction and stroke. And until recently, despite the unconvincing evidence, primary prevention trough aspirin was thought to be a sensible treatment strategy. Meta-analyzes on this topic have even indicated that it might be beneficial in terms of reducing overall mortality and reducing the risk of colon cancer. This year, three major prospective studies on the role of aspirin in primary prevention of cardiovascular disease in patients at risk (ASPREE, ASCEND and ARRIVE) have been published, with not only no evidence of benefit compared with placebo but also significant negative consequences (gastrointestinal bleeding) and even a paradoxical increase in mortality. Also, despite convincing evidence, there is still an unusually prevalent use of aspirin in the prevention of thromboembolic complications of atrial fibrillation. Possible reasons for this are multiple.

Kristina Gašparović, Martina Lovrić-Benčić

Obesity is a well-known risk factor in cardiovascular disease development especially in cases with central distribution of fat tissue. Research is mainly focused on visceral fat tissue characteristics, but visceral fat role in cardiovascular disease has yet to be established. In modern era, cardiac imaging methods reveals fat tissue depots, which can influence the work of central organs locally: epicardial fat with influence on the heart, perivascular fat and vascular structures. Mechanisms linking fat distribution and cardiovascular risk are complex and includes: fat and glucose metabolism changes, influence on risk factors (hypertension, inflammation), systemic and local adipokine action. Epicardial fat is a visceral fat tissue depot directly linked to myocardial tissue through conjucted microcirculation and is metabolically active. Recent literature is focused on balancing proatherosclerotic - inflammatory and protective activity of fat tissue. Mazurek et al showed a study on 42 patients referred to coronary artery bypass grafting in which proinflammatory cytokines concentration in epicardial and subcutaneous fat tissue was measured with PCR and ELISA method. They found higher concentrations of proinflammatory adipokines in epicardial fat tissue. Well known Framingham Heart Study on more than 1000 pts revealed liaison of epicardial fat tissue volume and calcium scoring in coronary arteries. Meta-analysis of 9 studies with 3992 pats showed good correlation of high-risk plaques in coronary arteries and fat tissue volume. Quantification of epicardial fat tissue volumes could be implemented in cardiovascular risk stratification. Study published in JACC by Mahabadi et al included 4093 pts and showed good correlation of epicardial fat tissue volume and cardiovascular risk with higher incidence of myocardial infarction in pts with larger epicardial fat volumes. (1) Lot of studies referred to epicardial fat volume and atrial remodeling. Cytokines has been proved to induce atrial wall fibrosis, myocardial inflammation and oxidative stress, factors known to be causative in atrial fibrillation incidence.

Duško Cerovec, Nenad Lakušić, Dora Cerovec

The core components and goals of cardiac rehabilitation (CR) programs are standardized, but the structure, duration and type of programs differ considerably in different countries, depending on national guidelines and standards, legal and financial factors. (1, 2) In Croatia, there are standards of approval of CR and general standards and norms of space requirements, equipment and personnel for performing medical activities, but there are no standards of structure, duration and manner of implementation of CR. The goals of introducing and adhering to standards in CR are to ensure the clinical and cost effectiveness of rehabilitation programs, and the achievement of sustainable and optimal health outcomes for patients. CR facilities standard components are structural (space, equipment, staff) and procedural. We need better regulations of indications and contraindications for CR, standardized rehabilitation timing and services through early acute hospital intervention, post-acute rehabilitation and long-term outpatient programs, with planned larger proportion of rehabilitated patients. It is important that CR is well-structured, performed in a safe, functional and efficient environment, in convenient and well-utilized space, with suitable and maintained equipment, considering the reduction and control of environmental hazards and compliance with safety requirements. Well-educated staff is one of the most important prerequisites for a good implementation of CR services. In addition to the programme director and the multidisciplinary team, it is important to have crisis management staff and protocols as well as available consultant specialists. Patient data and the course of CR should be standardized, with written protocols and clearly set goals, intervention plan and communication methods, final assessment. In this way, the prerequisites for outcomes measuring, reduction of non-compliance, services quality improvement and finally, the improvement of short-term and long-term outcomes are achieved. Other factors such as cost analysis, the role of patient associations, the role of primary health care, local and regional administration and the role of national health policy should be considered in the planning and implementation of the CR. Standards in CR can be over time and revised and changed.

Emir Becirovic, Ammar Brkic, Esad Brkic, Tarik Brkic, Ermina Mujanovic, Amir Becirovic, Semir Hadzic, Amila Jasarevic, Majda Skokic, Esref Becirovic

Rehabilitation of patient suffering from myocardial infarction has a goal to recover physical, psychological and social functions up to optimal level. It begins with the first contact with patient and it is conducted continuously till the end of life. Exercise training presents the basic rehabilitation method for cardiovascular patients. When prescribing the exercise training, must be taken care of: life’s age, gender, muscle-skeletal system integrity, previous physical activity, myocardial infarction (MI) size, ventricular function and functional heart condition, as well as medicaments that patient uses. Exercise training in order to lead to good effects, it must be isotonic or aerobic type. It includes the workout of large muscle groups which demands increased lung ventilation, increased minute-volume of the heart and small increasement of artery blood pressure. A certain number of studies have shown that exercise training can lead to functional capacity increasement even with patients with significant ventricular function disturbances. Increasement of maximal oxygen body consumption under exercise training influence is the first of all the consequence of periphery mechanisms adaptation (increasement of artery-vein oxygen difference, sympathetic nerve system stabilization with lower levels of heart frequency and blood pressure in calm condition and in effort condition) and it can be archived in situations when improvement of disturbed intrinsic heart frequency is hardly expected. (1-3)

Alma Sijamija, Nermir Granov, Omer Perva, Nedžad Hadžić

**Background:** Cardiac secondaries of peripheral tumors can occur by means of hematogenous or lymphogenous spread. (1) With an incidence of up to 1% at necropsy, metastatic deposits to the heart are more than 20 times more common than are primary tumours. (1-3) There are several clinical features, that are seen commonly with cardiac tumors: embolization, obstruction, arrhythmias. Metastases to the heart are, clinically silent in 90% of cases. Echocardiography is the first diagnostic procedure. Owing to the small numbers of cases there is no evidential basis for the optimal treatment regime. **Case report:** 49-year-old patient was admitted to our department due to dyspnea, palpitation, hemodynamic instability. 12-lead ECG: supraventricular tachycardia208 bpm, right bundle branch block. Medical history: hysterectomy with adnexectomy 5 years ago, due to sarcoma of uterus with high degree of malignancy. Completed treatment of chemotherapy and radiotherapy. Laboratory results: elevated tumor marker Ca 125: 366 U/ml and D dimmer 7.46 ug/ml, others found neat. Echocardiography: the enlargement of right heart cavities dimensions, along the entire free wall of the right ventricle (RV) visible tumor mass that starts from the free wall and affects more than 2/3 of the volume of RV, fills the RV outflow tract and is partly seen in the pulmonary artery and the mobile formation 21x23 mm passes through the tricuspid valve and pendulates between right atrium and RV causing an almost severe tricuspid stenosis - with TV PGmax of 4.5mmHg. After introducing into the sinus rhythm, the patient was hemodynamically stable for 30 days, until a new episode of disease progression occurred. X-ray and CT scan of the lung s confirm the enlarged shadow of the heart. The lower right pulmonary lobe consists of the secondary deposit mutually with smaller pleural effusions. Abdominal CT: ascites, enlarged aorto-caval lymph nodes. Ca 125 increasing: 2092 U/ml. Two months after the onset of cardiorespiratory symptoms Superior vena cava syndrome started to dominate. In consultation with a cardiac surgeon, oncologist, gynecologist, because of the aggressiveness of the tumor process, we have decided to conduct palliative medical care. **Conclusion:** The development of cardiorespiratory symptoms in a patient with carcinoma should raise the suspicion of cardiac metastases. Surgical management is generally critical, as the metastases are often neither solitary nor confined to the heart.

Vesna Pehar-Pejčinović, Viktor Peršić, Vedran Buršić, Rajko Miškulin, Iva Uravić Bursać, Marijana Rakić, Dijana Travica Samsa, Damir Raljević, Luka Rotkvić

Left ventricular noncompaction is a rare congenital cardiomyopathy. It can exist in isolated form (INVM) in adults or neonatal form which is caused by mutations gene located on the X chromosome and associated with other congenital cardiac and neuromuscular disease. Isolated noncompaction of the ventricular myocardium (INMV), first described by Chin et al in 1990, is characterized by persistent embryonic myocardial morphology without other cardiac anomalies. In such cases, deep recesses communicate only with the ventricular cavity, not the coronary circulation, whereas in non-compaction associated with other congenital heart disease (non-isolated non-compaction), the intertrabecular recesses communicate both with the left ventricular cavity and the coronary circulation. During embryonic weeks 5 and 8, the ventricular myocardium transforms from a hypertrabeculated morphology to a compacted layer, and this process is concomitant with coronary artery development. Myocardial remodeling proceeding from the epicardium to endocardium and from the base of the heart to the apex. The coronary circulation develops concurrently during this process, and the intertrabecular recesses are reduced to capillaries. Congenital coronary artery fistulas (CAFs) are abnormal communications between a coronary artery and any cardiac cavity or great vessel. Approximately 20% of patients with coronary artery fistulae have other cardiac anomalies, most frequently aortic and pulmonary atresia and patent ductus arteriosus. Coronary artery fistulae between a coronary artery and a cardiac chamber is a rare condition and is found in approximately 0.2% of patients undergoing cardiac catheterization. Non-compaction ventricular myocardium (NVM) in combination with multiple coronary artery to ventricle fistulae are rare cardiovascular malformations. (1-3) We present 53-year-old female patient with INMV, with preserved ejection fraction and functional impairment of left ventricle proved with deformation imaging methods (speckle-tracking echocardiography), and existence of multiple coronary to left ventricle fistulae.

Vesna Pehar-Pejčinović, Viktor Peršić

The most frequent indications for cardiovascular magnetic resonance (CMR) are inflammatory and ischemic heart diseases and cardiomyopathies. (1) It is also very useful in imaging of congenital heart disease. CMR provides detailed information about cardiovascular anatomy and function and particularly in characterization of the myocardial tissue including the detection of edema and fibrosis. MRI is also used in evaluation of coronary disease and myocardial perfusion. Because of mentioned fourteen of the 26 ESC guidelines (53.8%) contain specific recommendations regarding the use of CMR.

Filip Lončarić, Maciej Marciniak, Joao Filipe Fernandes, Loredana Nunno, Laura Sanchis, Bart Bijnens, Marta Sitges

**Background**: A subgroup of patients with chronic hypertension develop basal septal hypertrophy (BSH). Non-invasive left ventricular (LV) pressure estimates and speckle-tracking deformation curves can be used to quantify myocardial work (MW) (1). Incorporation of afterload into deformation analysis demonstrates a potential advantage over isolated global longitudinal strain (GLS). The aim is to assess segmental MW indices of the septum in hypertensive patients. **Patients and Methods**: An echocardiogram and cuff blood pressure measurement were prospectively performed on 115 patients with hypertension. The interventricular septum was measured in parasternal long axis and 4-chamber (4C) views. LV speckle-tracking was performed in 4C, 2C and 3C views. Myocardial work index (MWI), constructive work (CW), wasted work (WW), and work efficiency (WE) were calculated between mitral valve closing and opening. BSH was defined by having both a positive visual assessment of an abrupt change in septal thickness in 4C view and a basal septal-mid septal ratio ≥ 1.4. **Results**: BSH was present in 18% (n=21) of the cohort. Patients with BSH had higher systolic blood pressure at presentation. There was no group difference in cavity dimensions, LV ejection fraction, LV GLS, global MWI, CW or WW. The basal inferoseptum and anteroseptum were significantly thicker in patients with BSH (**Figure 1**). The hypertrophy was related to a decrease of longitudinal strain (LS) in the inferoseptum, but not in the anteroseptum. The segmental MWI and CW were significantly reduced in the inferoseptum of patients with BSH, whereas there was no difference in WW or WE. No differences in MW indices were notable in the basal anteroseptum (**Table 1**). There was a pronounced gradient of LS in both groups, with a decrease from apex to base. The averaged LS of the six basal segments was significantly lower in patients with BSH, with no differences in the mid or apical segments (**Figure 2**). FIGURE 1. Comparison of LV measurements in hypertensive patients with and without basal septal hypertrophy. LV = left ventricle; 4C = 4-chamber view; PLAX = parasternal long axis view. ### TABLE 1: Global and segmental longitudinal strain and myocardial work indices. | | **Patients without BSH (n=94)** | **Patients with BSH (n=21)** | **P value** | | --- | --- | --- | --- | | LV GLS, % | -21.8 ± 2.6 | -20.8 ± 2.5 | 0.108 | | Global MWI, mmHg% | 2631 ± 457 | 2654 ± 426 | 0.833 | | Global CW, mmHg% | 2852 ± 486 | 2906 ± 398 | 0.638 | | Global WW, mmHg% | 64 (42, 88) | 58 (38, 101) | 0.643 | | Basal inferoseptal LS, % | -15.00 ± 2.84 | -12.05 ± 2.65 | **<0.001** | | Basal inferoseptal MWI, mmHg% | 1724 (1516, 2045) | 1441 (1181, 1519) | **<0.001** | | Basal inferoseptal CW, mmHg% | 1881 (1580, 2166) | 1500 (1324, 1747) | **<0.001** | | Basal inferoseptal WW, mmHg% | 40 (14, 92) | 16 (5, 78) | 0.173 | | Basal anteroseptal LS, % | -17.76 ± 3.40 | -17.88 ± 4.37 | 0.892 | | Basal anteroseptal MWI, mmHg% | 2084 ± 500 | 2214 ± 518 | 0.288 | | Basal anteroseptal CW, mmHg% | 2324 ± 501 | 2482 ± 513 | 0.197 | | Basal anteroseptal WW, mmHg% | 41 (11, 74) | 36 (5, 130) | 0.939 | [†] BSH = basal septal hypertrophy; LV = left ventricle; GLS = global longitudinal strain; MWI = myocardial work index; CW = constructive work; WW = wasted work. FIGURE 2. Averaged segmental longitudinal strain of basal, mid and apical levels in hypertensive patients. **Conclusion**: Basal segments are first affected in chronic exposure to increased afterload, resulting in a gradient of LS. BSH in hypertension indicates a more advanced functional impairment of the LV with further decrease in basal segment function. In this setting the basal inferoseptum is most affected, demonstrating a significant decrease in work performed between mitral valve closing and opening.

Vilim Kalamar, Peter Chapman, Julian Elford, Jade Fleet, Alison Wright

**Objective**: Coronary artery disease (CAD) is one of the major public health problems in the world today. The updated 2016 National Institute for Health and Care Excellence guidelines are notable for their new suggested use of computed tomography coronary angiography (CTCA) as the first-line investigation in all patients with stable chest pain. (1, 2) With the increasing emergence of CTCA as a routine outpatient investigation, awareness of patient exposure to ionising radiation has been identified. It is the aim of this first ever CTCA radiation dose exposure audit at Hampshire Hospitals NHS Foundation Trust (HHFT) to set a benchmark for which we can compare all our future CTCAs against and to strive for increased patient safety by implementing methods to systematically reduce radiation doses without compromising diagnostic image quality. **Material and Methods**: A retrospective analysis of all patients attending HHFT between 2013 to 2016 for a clinically indicated CTCA was performed. We had a total of 39 subjects. The total Dose-Length Product (DLP) and heart rate at time of image acquisition of each scan was used for analysis. Their averages were calculated by adding each of their respective totals from each individual scan and dividing them by the total number of scans performed. **Results**: In the scans that we performed, the mean total DLP was 177.26mGy (**Figure 1**). Non-specifically, the Royal College of Radiology (RCR) states the following: the radiation dose should be as low as possible, commensurate with diagnostic image quality. (3) The mean heart rate of our subjects at time of image acquisition was 59bpm (beats per minute) (**Figure 2**). Specifically, the RCR’s guidelines suggest that the patient’s heart rate should be <65bpm during the scan. (3) We successfully achieved this. FIGURE 1. We plotted each of our 39 subject’s radiation dose exposures on this graph. Each separate subject is placed along the x-axis. The level of radiation dose exposure expressed as milligray (mGy) is depicted on the Y-axis. The red line represents the mean total dose length product (DLP) exposure (177.26mGy). FIGURE 2. We plotted each of our 39 subject’s heart rates during their scan. Each separate subject is placed along the x-axis. The heart rate expressed in beats per minute (bpm) is placed along the Y-axis. The red line represents the mean heart rate of all subjects at time of image acquisition (59bpm). **Conclusion**: HHFT have just begun a regular and consistent CTCA service. It is imperative to undertake calculated measures to methodically reduce patient exposure to ionising radiation, thus concomitantly prioritising patient safety, without compromising diagnostic image quality (**Figure 3**). The CTCA has traditionally been labelled as a high radiation dose investigation which has led to concerns and potential reluctance for clinicians to incorporate it in their clinical service. However, achieving optimal image quality at the lowest doses can be challenging. (4) CTCA staff at HHFT have collaborated and discussed internally to identify some strategies and steps towards dose reduction. This first audit loop will serve as our Trust’s benchmark—a specific dose value and heart rate at time of image acquisition to work towards reducing. FIGURE 3. This represents a multi-planar reconstructed image depicting a patent, non-calcified left anterior descending artery in one of our subjects.

Fatmir Ferati, Anida Ferati, Mentor Karemani

**Introduction**: The aim of the paper is the detection of changes in function of the left atrium (LA) and left ventricle (LV) in asymptomatic diabetic patients (1), distinguished by the control group, using two-dimensional (2D) speckle tracking echocardiography. **Methods**: 50 asymptomatic patients with diabetes mellitus were analyzed (28 males and 22 females) with an average age of 56,4 years (56±20 years). In control group without verified disease, 50 individuals have been chosen randomly, 26 males and 24 females, with an average age of 55.3 years (55.3±17). **Results and Conclusions**: **1**. Decrease of 2D strain of left ventricle is registered in patients with diabetes, starting from the global longitudinal strain (GLS) (-21.79 vs. 16.7%), myocardial longitudinal strain (LS) (17.69 vs 13.89%) and global radial strain of LV (GRS) (51 vs 42.9%) (**Figure 1**). **2**. Minimal value from -17% is registered of LS values at control group and from -14.2% at diabetic group where registered **3**. Extension of T2P (time to peak) longitudinal and transversal strain values in patients with diabetes is registered. **4**. Increased value of LV mass at patients with diabetes is registered in our study (133 gr vs 123 gr), **5**. Insignificant increase of LA volume is registered in diabetic group (21,82 vs 20,66 ml/m2). **6**. EF of LA is decreased in diabetic patient (55.69 vs 50.58%) together with decrease fractional area contraction (FAC) of LA (69.56 vs 41.23%) (**Figure 2**). **7**. Decrease in values of end diastolic longitudinal strain (LS) of LA is registered in diabetic patients (48,78 vs 37.33%) **8**. LA strain rate (SR) of E wave is decreased in diabetic patient (1,84 vs 0,91), with smaller decrease of SR of A wave from (2.21 vs 1.97) **9**. E/A SR relation is decreased in the diabetic patients vs control group (0,83 vs 0,43) **10**. Decreased strain parameters of LV also decrease and LV compliance, which decrease the passive E wave SR and increase active A SR phase of LA function. FIGURE 1. Left ventricular function assessment by two-dimensional echocardiography. Figure 2. Left atrial function assessment by two-dimensional echocardiography. ejection fraction (EF); end-diastolic volume (Edv); myocardial global strain of left ventricle (myo GLS); global radial strain of left ventricle (GRS); time to peak of transversal strain (TP-TS); time to peak long strain (TP-LS); left ventricular mass (LV mass); control group (Contr Gr); group of patients with diabetes mellitus (Diab mell) end-diastolic volume of left atrium (edv); ejection fraction of left atrium (ef); endoc gls (End GLS); fractional area contraction of left atrium (FAC); left atrial strain rate of e wave (E SR); left atrial strain rate of a wave (Asr); E/A strain rate (E/A sr); control group (Con gr); group of patients with diabetes mellitus (Diab gr)

Ana Fabris, Mila Jakovljević

Stress echocardiography (SE) is widely used method for assessing coronary artery disease, myocardial viability and valvular heart disease. Among the various stress modalities exercise is safer than pharmacologic stress. (1) Quantitative wall motion analysis during SE may overcome deficiency of visual assessment of systolic thickening and myocardial motion i.e. estimating radial function only. Subendocardial fibers that support the longitudinal function are more sensitive to ischemia and heart failure. (2) There are different methods proposed for quantitative assessment of the left ventricular function feasible in exercise stress echocardiography and each has some drawbacks. Strain imaging techniques can be derived from the color-coded TDI (tissue Doppler imaging) or based on the 2DS (2-dimensional strain). In any Doppler-derived method, the velocities measured are angle-dependent, apical segments cannot be reliably depicted and, because of base-to- apex velocities gradient, there is a need for different segmental cut-off values. Cardiac translation and rotation limit the TDI. The 2DS is more suitable for exercise SE for it is angle-independent and can be used in any projection. 2DS enables display of apical segments and all segments of the specific coronary artery territories. In our work, we first use visual estimation – WMSI (wall-motion score index) and then the single-segment model based on the TDI with offline analysis before exercise and immediately upon peak exercise (within 1 minute) (**Figure 1**). Velocities, strain and strain-rate values are compared with cut-off values and expressed as delta >50% increase. (3) An additional analysis (AFI, automated function imaging) of segmental strain, PSS (post systolic shortening) and TTP (time-to-peak) longitudinal strain based on the 2DS as well as an estimation of the E/E’ ratio are performed before and immediately upon peak exercise (**Figure 2**). This combined approach allows more accurate estimation of ischemia and heart failure. In our experience, feasibility of the 4D exercise SE, both full volume and multiplane mode, is very low because of low spatial and temporal resolutions which become worse at a faster heart rate (FR of 40 fps). The combined approach in quantitative assessment of exercise SE that includes determination of parameters of both systolic (WMSI, TDI, 2DS) and diastolic functions (E/E’) provides a more accurate estimation of ischemia and/or heart failure. FIGURE 1. Tissue Doppler imaging analysis before and immediately after exercise: 20-year male patient with hypertrophic cardiomyopathy. FIGURE 2. Automated function imaging analysis before and immediately after exercise: 70-year female patient who has overcome myocardial infarction.

Ana Fabris

**Introduction**: It is often difficult to diagnose a pulmonary embolism, with or without pulmonary hypertension, without application of a lung perfusion scan or pulmonary arteriography. (1, 2) Namely, without pulmonary infarction, the findings of chest X-ray (CXR) will be normal. **Case report:** 78-year-old patient has had hypertension for several years. In September 2016, he was hospitalized for thrombosis in the popliteal and fibular veins of his right leg. CXR in December 2016: no signs of heart failure, rare linear fibrous opacifications in the lower zone. Color Doppler of the veins (February 2017) was normal, after which the anticoagulant therapy was suspended (due to hematuria). In September 2017, he came because of the resistant hypertension and chest pain. The 12-lead ECG recorded the sinus rhythm 59/min, left posterior hemiblock. The first 2D echocardiography showed: initial eccentric left ventricular hypertrophy with normal ejection fraction; Grade 1 diastolic dysfunction; left atrial enlargement and dilated ascending aorta; moderate mitral and tricuspid regurgitation with systolic pulmonary hypertension (PAPS 60mmHg), and minor pericardial effusion. After therapy correction, the 4D ultrasound (Tomtec 4D RV-function) subsequently found a mildly dilated right ventricle of reduced ejection fraction (19.92%) and prominently reduced longitudinal deformation of the right ventricular free wall (-11.29%), and septum (-6.97%) with normal left ventricular ejection fraction (**Figure 1**). After the applied therapy, there was a regression of pulmonary hypertension and pericardial effusion. Follow-up CXR: phrenicocostal sinus bilaterally discreetly shallower with minimum quantity of effusion and defined small interlobar space. MSCT of the thorax according to the protocol for the detection of pulmonary embolism: partial and full contrast medium filling defects corresponding to blood clots in the lumen of individual segmental or sub-segmental branches of pulmonary arteries for the upper right, medial, lingual, and lower left lung lobe. Treatment with low-molecular-weight heparin and vitamin K antagonists was started immediately. FIGURE 1. 4D right ventricular systolic function and longitudinal deformation image. **Conclusion**: Differential diagnosis of pulmonary embolism (microembolism) is sometimes very demanding, particularly so in patients with unclear clinical manifestations. To start a timely and adequate treatment, it is essential to recognize the disease early, and 4D determination of longitudinal deformation of the septum and the right ventricular free wall and ejection fraction contributes to it.

Mia Dubravčić, Daniel Lovrić, Marijan Pašalić, Vlatka Rešković Lukšić, Kristina Gašparović, Dejan Došen, Jana Ljubas Maček, Zvonimir Ostojić, Marija Brestovac, Davor Miličić, Jadranka Šeparović Hanževački

**Background:** In our previous research (1) we have shown 2D analysis of regional longitudinal peak systolic strain (LPSS) to be superior to visual assessment of regional wall motion abnormalities (RWMA) in detection of ischemia-induced loss of myocardial contractility due to non-ST elevation acute coronary syndrome (NSTE-ACS). (2, 3) The reduction of LPSS in basal segments in patients with arterial hypertension (AH) is well documented. The aim of this study was to assess the impact AH has on the accuracy of regional analysis in predicting the localization of significant stenosis in NSTE-ACS. **Methods:** We performed a retrospective analysis of patients admitted to University Hospital Centre Zagreb from January 2013 till December 2015 due to NSTE-ACS. Exclusion criteria were no coronary angiography, absence of ECHO, and prior coronary artery disease. Total of 123 patients (62±12 years, 68% male) were included. 4 blinded clinicians performed regional LPSS analysis using 18-segment model, while RWMA, interpreted by clinician performing the echo, were categorized according to the wall motion score guidelines. **Results:** Significant correlation between flow limiting stenosis (>70% narrowing on angiography), worse RWMA and a decrease of regional LPSS in basal segments was found for all 3 coronary vessels (**Table 1**). Patients with AH (73%) showed a lower regional LPSS and worse RWMA in all basal segments, with only lateral and posterior ones varying significantly (**Figure 1**). However, regression analysis accounting for AH as a covariant, showed the regional changes in basal segments to be a sole result of coronary disease (**Table 2**). AH was found to have no impact on reliability of LPSS and RWMA in predicting the localization of significant stenosis in NSTE-ACS (average method sensitivities: 59% vs 38%). ### TABLE 1: Regional 2D regional longitudinal peak systolic strain and visual regional wall motion abnormalities assessment according to segments and location of coronary stenosis. | **Segment** | **Lesion location** | **LPSS** **(normal vs pathologic)** | **LPSS Sig.** | **RWMA to CAS** **Correlation** **Coefficient** | **RWMA** **Correlatin** **Sig.** | | --- | --- | --- | --- | --- | --- | | Basal anterior | LAD | -14.1±4.1% vs -12.3±5.4% | 0.044* | 0.232 | 0.032* | | Basal lateral | LCx | -14.7±4.9% vs -10.9±6.5% | 0.001* | 0.262 | 0.015* | | Basal posterior | LCx | -16.2±5.3% vs -12.0±5.7% | <0.001* | 0.354 | 0.001* | | Basal inferior | RCA | -16.3±4.8% vs -11.9±6.3% | <0.001* | 0.163 | 0.133 | | Basal inferoseptum | RCA | -11.5±5.2% vs -10.1±3.8% | 0.139 | 0.186 | 0.087 | | Basal anteroseptum | LAD | -14.4±5.8% vs -12.6±4.9% | 0.076 | 0.179 | 0.098 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 FIGURE 1. Differences in 2D regional longitudinal peak systolic strain in patients with and without arterial hypertension. AH - arterial hypertension; RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain. ### TABLE 2: Multivariable regression analysis models showing interrelation between ratio of longitudinal peak systolic strain and visual regional wall motion abnormalities, and cororonary artery stenosis with arterial hypertension as covariate. | **Segment** | **Lesion location** | **Model 1 (LPSS): Sig. (AH) / Sig. (CAS)** | **Model 2 (RWMA): Sig. (AH) / Sig. (CAS)** | | --- | --- | --- | --- | | Basal anterior | LAD | 0.115 / 0.047* | 0.126 / 0.079 | | Basal lateral | LCx | 0.141 / 0.002* | 0.196 / 0.048* | | Basal posterior | LCx | 0.114 / <0.001* | 0.143 / 0.011* | | Basal inferior | RCA | 0.309 / <0.001* | 0.232 / 0.117 | | Basal inferoseptum | RCA | 0.309 / 0.170 | 0.457 / 0.046* | | Basal anteroseptum | LAD | 0.584 / 0.081 | 0.304 / 0.099 | [†] RWMA – visual assessment of regional wall motion abnormalities; LPSS – longitudinal peak systolic strain; AH – arterial hypertension; CAS – coronary artery stenosis; LAD – left anterior descending coronary artery; LCx – left circumflex coronary artery; RCA – right coronary artery; * P<0.05 **Conclusion:** Changes in regional myocardial contractility, detected by either LPSS or RWMA, in patients with NSTE-ACS should be attributed to coronary disease irrespectively of the presence of AH.

Marko Boban

Cardiomyopathies are diseases of cardiomyocytes or different heart structures which are manifested through changes in morphology or function of the heart. Due to relatively non-negligible prevalence and clinical course, cardiomyopathies are significant public health burden in terms of increased utilization of medical services, impairing quality of life, as well as mortality. In the last decades, cardiac magnetic resonance (CMR) became important clinical tool in management of patients with non-ischemic cardiomyopathy (NICMP). CMR offers virtue of non-invasive 3D imaging of cardiac structures and function, and owing the advances in technology, there is a relatively constant pace of improvements in spatial, temporal resolutions, as well as tissue characterization. For these reasons use of CMR increases in every day clinical practice and growing number of centers is available. CMR brings diagnostic and prognostic advances in managed care of patients with cardiomyopathies, with ability to influence course of treatment and the most important increase survival of patients. Typical complications within the course of NICMP like development of heart failure, malignant arrhythmia and cardiac death could be verified, in part foreseen, and to different degree ameliorated by use of CMR. (1, 2) This lecture will present the most important issues around utilization of CMR in clinical management of patients with non-ischemic cardiomyopathies.

Marko Boban

**Background:** Impairment of systolic function and late gadolinium enhancement (LGE) are well known negative prognostic markers in non-ischemic cardiomyopathies (NICMPs). (1, 2) The aim of our study was to analyze power of connection existing between individual volumetric parameters over left atrial area and systolic dysfunction or existence of LGE in patients with non-ischemic cardiomyopathy and healthy controls. **Patients and Methods**: Consecutive cases of NICMPs and controls were included from computerized data base of cardiac magnetic resonance exams for 2.6-year period. Ratios made from volumetric parameters over left atrial area (LAA) were calculated. **Results:** Study included 210 cases referred to cardiac magnetic resonance (CMR); age was 49.6±16.9 years (range 15.2-79.3), male to female ratio 132 (62.9%) vs 78 (37.1%). LGE significantly correlated with impairment of systolic function (Rho CC=0.338; p<0.001), and linear-LGE as well (Rho CC=0.430; p<0.001). For detection of systolic impairment, a critical value of End-systolic-volume(ESV)/LAA of ≥2.6 had area under curve (AUC) 0.910 (0.862-0.945), p<0.001; stroke-volume(SV)/LAA had AUC=0.814 (0.754-0.864), p<0.001 and end-diastolic-volume (EDV)/LAA had AUC 0.653 (0.584-0.718); p<0.001. ESV/LAA correlated with systolic dysfunction (Rho-correlation-coefficient:0.604; p<0.001) and existence of linear midventricular LGE stripe (Rho-CC=0.286; p<0.001). **Conclusions:** ESV/LAA was the most effective of studied parameters for detection of systolic dysfunction and also connected with existence of LGE. Prospective validation of cardiac remodeling for prognostic significance would be needed in future studies.

Vedrana Baraban, Kristina Kovačević Stranski, Grgur Dulić, Igor Lekšan, Livija Sušić

**Introduction**: According to the literature (1-3), systemic autoimmune diseases are associated with an increased risk of developing malignant diseases. This risk arises from the immune effects of autoimmune combined with drug treatment for autoimmune disease. **Case report**: This case shows a 51-year-old female patient who presented with dyspnea and exercise intolerance in last two weeks, with medical history of long-term treated hypertension and autoimmune diseases: thyreopathy and overlap syndrome. During cardiological assessment transthoracic echocardiography showed large tumor formation that filled left atrium and protruded to the left ventricle in diastole, which was confirmed by transesophageal echocardiography and thoracic CT. After complete cardiological treatment, the patient was successfully operated at the Department of Cardiac Surgery. PHD report confirmed diagnosis of myxoma. It was the most important since the most common intracardiac formations are primary (benign or malignant) tumors, metastatic tumors, thrombus or vegetation. Although there is no clear connection between autoimmune diseases and benign tumors, it is interesting to see significant reduction of immune markers in laboratory labs (especially CCP) following surgery.

Kristina Gašparović, Margarita Brida, Kristina Marić Bešić, Željko Baričević, Maja Hrabak Paar, Darko Anić, Maja Strozzi

**Introduction:** Pulmonary valve (PV) disease is a known predictor of morbidity and mortality in patients with previously surgically corrected Tetralogy of Fallot resulting in right ventricle (RV) dilatation, eccentric hypertrophy, and systolic failure. RV failure can be prevented with opportune PV replacement. PV thrombosis is rare. Long term anticoagulation therapy with warfarin is not indicated with biological valves but positive effect on thrombosis has been described. There is no evidence for positive effect of new anticoagulant drugs (NOAC) on valvular thrombosis. (1, 2) **Case report:** We present a case of a young woman who was born with Tetralogy of Fallot and who underwent a complete surgical correction at the age of four. She was admitted to University Hospital Centre Zagreb with fast atrial fibroundulation requiring immediate cardioversion. Echocardiography (ECHO) revealed a dilated RV with reduced systolic function and volume overload. Cardiac magnetic resonance proved significant pulmonary insufficiency with significant regurgitant fraction and volume (RF 41%, RVEDV 233 ml, RVEDVI 116 ml/m2, RVEF 48%). Surgical implantation of biological prosthesis was done. Postoperative ECHO indicated good function of biological PV and reduction of regurgitant volume. Anticoagulation therapy with warfarin was continued for three months after the surgery. Afterwards, rivaroxaban 20 mg daily was implemented due to paroxysmal atrial fibrillation. Twenty months after bioprosthesis implantation, she presented with signs of right heart failure. ECHO revealed dilated RV but with signs of pressure overload and systolic pressure gradient of 110 mmHg. Transoesophageal ECHO showed organized thrombus formation of 25x10 mm on bioprosthesis. Surgical excision of a thrombosed tissue was done with reimplantation of St. Jude Biocor valve A 25 mm on pulmonary position, anticoagulation with warfarin was indicated. Postoperative ECHO showed reduction of RV volume and improvement of systolic function. PV systolic gradient was 25 mmHg. **Conclusion:** PV thrombosis is a rare event. Warfarin is still recommended in the early postoperative period. Rivaroxaban did not prevent valve thrombosis in our patient who was negative for thrombophilia testing and had no mechanical predisposition for thrombosis.

Petra Vitlov, Ante Lisičić, Aleksandar Blivajs, Hrvoje Falak, Mario Udovičić, Boris Starčević

**Introduction:** Heavily calcified or fibro-calcified stenotic lesions have remained challenging for interventional cardiologists, especially in an acute coronary syndrome setting. Rotational atherectomy (rotablation, RA) of coronary artery is not so often used in high thrombotic state such as acute myocardial infarction (AMI) because of the risk of platelet activation by the rotablator. (1-3) **Case report:** 51-year-old man with arterial hypertension and diabetes mellitus in his previous medical history presented with non-ST-segment elevation myocardial infarction. His GRACE score was 106 and the next day he underwent coronary angiography. Double vessel coronary artery disease was found with calcified significant stenosis of the left anterior descending (LAD) artery. His echocardiogram showed reduced systolic function of left ventricle, hypokinetic anterolateral wall with reduced global longitudinal strain (GLS). He was presented to the Heart team and the decision was made to do percutaneous coronary intervention (PCI) with RA to the LAD, due to calcified LAD in the area of lending zone for possible left internal mammary artery (LIMA) graft. The following day PCI with RA to LAD and PCI to first obtuse marginal branch (OM1) were done. The patient improved remarkably after the procedure, and was discharged after 3 days. **Conclusion**: As known, calcified lesions could be found in 8% of patients with AMI, and one-quarter of them were balloon un-dilatable or un-crossable and the PCI is therefore difficult or impracticable. As seen, RA is safe method in acute coronary syndrome (ACS) when it is done by well-trained team experienced in complex PCI’s.

Matias Trbušić, Ivo Darko Gabrić, Ozren Vinter

The therapy for patients with ischemic cardiomyopathy and advanced heart failure (AHF) is based on the optimal medical therapy, device-based therapies (implantable cardioverter-defibrillators and cardiac resynchronization therapy) and coronary revascularization. The decision to perform coronary artery bypass grafting (CABG) is difficult because of higher operative morbidity and mortality, uncertain benefit (lack of predictive factors including viability testing) and undefined guidelines. Ten-year of the follow-up from the largest randomized trial (STICHES) of CABG compared with medical therapy showed a mortality benefit in CABG patients (1). Percutaneous coronary intervention (PCI) seems to be reasonable alternative to CABG. However, there is a lack of clinical trials testing PCI versus medical therapy and CABG in AHF. The observational study that compared PCI using drug eluting stents with CABG in AHF patients showed no significant difference in death, greater risk of myocardial infarction and need for repeat revascularization but a significantly lower risk of stroke in PCI (2). In PCI patients in whom complete revascularization was achieved, there was no difference in myocardial infarction between PCI and CABG. However, PCI in AHF is considered as a high risk procedure and should be initiated only after full consideration of various factors and after developing a detailed plan. In our experience, there are some measures that need to be performed in order to improve outcome and to avoid complications. Important is to optimize patient’s clinical status and perform pulmonary decongestion. Staged approach to revascularization, especially in complex lesions, is preferred to avoid high total amount of contrast agents (leading to pulmonary oedema and contrast nephropathy) and cardiogenic shock in the case of abrupt artery closure (because of low contractile reserve). Suitable PCI support equipment should be timely considered (3). Because of low rate of complications (compared to the extracorporeal membrane oxygenation), easy to use and low price (compared to Impella), the intra-aortic balloon pump is especially convenient for short term haemodynamic support in patients where short ischemic period is expected during PCI.

Boris Starčević, Aleksandar Blivajs, Irzal Hadžibegović, Petra Vitlov

**Introduction:** Stenosis assessment using angiographic images is standard in everyday clinical practice. However, when combined with intravascular evaluation, patient outcomes dramatically improve, which has been confirmed by numerous large multicentre studies and is incorporated in current guidelines on revascularisation. Intravascular ultrasonography (IVUS) is a procedure using specifically designed probes on guidewire tips that can characterize plaque morphology, lesion length, as well as stenosis significance by calculating minimal lumen area of vessels (MLA) and gives valuable data on stent apposition, instent restenosis and carina shift during bifurcation stenting. Fractional flow reserve (FFR) and instantaneous wave free ratio (IFR) uses pressure tip guidewires to measure pressure drops on lesions and has certain “cut-off” values for stent deferral. (1, 2) **Results:** We present our data using IVUS and FFR/IFR guided PCI in University Hospital Dubrava from the period of January 2016-January 2018. In total 31 patient underwent IVUS assessment, majority of which the indication was evaluation of coronary artery stenosis (61%). Of them, 68% were studies done on LM/ostial LAD stenosis. Four patients were referred to surgical revascularization, 16 patients underwent PCI and 11 patients were deferred. The mean MLA was 3.29 that guided adequate stent sizing and later apposition confirmation. In follow-up there were no registered deaths, there was only one TLF needing PCI, with no other MACE or angina worsening detected. In the same period 20 patients underwent FFR/IFR evaluation. All patients had stable coronary artery disease and a value of 0.80 for FFR and 0.90 for IFR respectively were used for stent deferral. On average 1.9 vessels were evaluated per patient, the LAD being the leading vessel (48%). In the series 55% of patients underwent PCI with a mean IFR value of 0.82, and the mean deferral value was 0.93. On follow up no MACE or angina worsening were detected. **Conclusion:** IVUS and FFR/IFR pose a valuable addition in stenosis assessment and characterization, providing information to help guide the operator in optimal decision making and favor better patient outcomes. The procedures are safe and time-efficient, although still costly making its utilization underscored.

Boris Starčević, Petra Vitlov, Ante Lisičić, Ognjen Čančarević, Irzal Hadžibegović, Aleksandar Blivajs

**Introduction:** Rotational atherectomy, rotablation (RA) facilitates percutaneous coronary intervention (PCI) for complex lesions with severe calcification, in order to facilitate optimal stent delivery and expansion. Advanced age, renal disease and diabetes have all been associated with coronary artery calcification (CAC), with severe CAC affecting between 6 and 20% of patients treated with PCI. (1-3) **Results:** We present data using RA in University Hospital Dubrava from January 2016 to October 2018. The frequency of rotational atherectomy as a function of total PCI was 0.9% in 2016 and 1.2% in 2018 which is the same as in Europe countries (0.8% to 3.1%). During the last three years 27 RA was done, median age 66.7 ± 10.2 years. 92% of patients underwent RA had stabile angina and 8% acute coronary syndrome. In most cases the burr size was 1.25- 1.5 mm considering that plaque modification is easily achieved with a 1.25 or a 1.5 mm burr in most cases with a speed range between 135,000 and 180,000 rpm. RA was done in 75% in right coronary artery, 41% in left anterior descending artery and 4.1% in circumflex artery. In all patients drug-eluting stents were implanted. Due to periprocedural complications there was one contrast induced nephropathy with need for dialysis and one unsuccessful RA due to unsuccessful predilation even with highest burr used to plaque modification, therefore surgical revascularization was done. There were no complications associated to RA only. In our six months and one year follow up period no major adverse cardiac events was detected. **Conclusion:** RA is necessary technique in interventional cardiology canters that do complex PCI’s. With good choice of patients and mastering the technique, RA is safe and successful, as can be seen in our experience.

Zvonimir Ostojić, Marijan Pašalić, Joško Bulum

**Introduction:** Drug eluting stents (DES) proved to be superior to bare metal stents (BMS) with regard to target lesion failure (TLF). (1, 2) However, there are limited studies comparing contemporary DES and BMS that take into count technique of stenting. **Methods:** 1201 consecutive patients with percutaneous coronary interventions (PCI) of left anterior descending (LAD) coronary artery, performed from January 2012 to December 2016, were included. Patients were stratified according to PCI with contemporary DES or BMS (cobalt chrome with thin struts). All procedures were reviewed to determine frequency of direct stenting and non-direct stenting (n-DS) - composed of lesion pre-dilatation and/or stent optimization. Cumulative incidence of clinical TLF (composed of in-stent restenosis (ISR) and stent thrombosis (ST)) was assessed. **Results:** Mean patients age was 64.2 years, with majority being men (74.9%, N=896). BMS was implanted in 61.3% (N=741) of cases. DES implantation was more often performed during elective PCI in patients with known coronary artery disease (36.7 vs. 19.3%) with more often achieved final TIMI 3 flow (94.7 vs. 85.7%). N-DS was performed more often in DES group (78 vs. 55.5%), just as all of its components; lesion pre-dilatation (68.7 vs. 48.6%) and stent optimization (45 vs. 36.7%). Increase in n-DS has been observed during studied years. Patient median follow-up was 2.6 years. TLF was significantly more common in BMS group (9.3 vs. 4.3%, p<0.001). However, this was mainly driven due to significant deference in ISR (7.8 vs. 3.0%, p<0.001). There was no significant differences in ST and its subcategories between groups. Results were unaffected by stenting technique. **Conclusion**: Although, stenting technique does not directly influence TLF, using contemporary stents and implantation technique significant reduction of TLF is achievable compared to historic data. Furthermore, presented real world results suggest incidence of ISR and ST similar to the one observed in modern randomized control trials.

Tomislav Krčmar, Nikola Kos

Complex percutaneous coronary interventions are very common in everyday practice. This type of interventions could not be performed without knowledge of technical aspects of new generation drug eluting stents (DES). There are growing number of publications that new generation DES is more successful in treatment of complex lesions then old generation with better short and long term outcome. (1) Randomized controlled trials on results of percutaneous interventions in complex lesions are crucial in establishing of appropriate treatment for this very challenging group of patients. Results from interventional registries such as Swedish SCAAR registry are very valuable for every day practice.

Irzal Hadžibegović, Mario Sičaja, Ognjen Čančarević, Aleksandar Blivajs, Tomo Svaguša, Boris Starčević

**Introduction:** Percutaneous coronary intervention (PCI) in chronic total occlusions (CTO) is almost the only growing area of ​​coronary interventional cardiology, where the key to success is true indication and knowledge of all available techniques and materials. Recently, the hybrid approach to CTO interventions proved to be an optimal strategy with the best ratio of success and complications. (1) Here, we present experience in University Hospital Dubrava with hybrid PCI approach to CTO. **Patients and Methods:** Procedures before and after the routine adoption of a hybrid approach to CTO interventions were analyzed. Hybrid approach to CTO is based on routine dual catheter contrast injection in each CTO lesion indicated for PCI, and only depending on the angiographic assessment of the proximal cap, collateral circulation visualization, and the appearance of the distal target by collateral circulation, one of the following strategies is selected: anterograde CTO wire escalation (AWE), anterograde dissection and re-entry with dedicated materials (“Crossboss and Stingray”) (ADR), retrograde CTO wire escalation (RWE), or reverse CART (retrograde dissection and re-entry into true lumen). **Results:** After the process of hybrid approach adoption to CTO interventions during 2016, the number of redo procedures in our center decreased considerably, whereas the success rate increased. In the period after the full adoption of the hybrid approach between July 2017 and July 2018, 52 CTO interventions were indicated, of which 34 on the right coronary artery. Proportions of final PCI strategies were: AWE 46/52, ADR 2/52, RWE 2/52, and reverse CART 2/52. Total success rate was 84.6%. Repeated procedure was indicated in 4/52 patients. Periprocedural complications were rare: 1 coronary perforation needing cardiac surgery and 1 coronary perforation treated in Cath lab without need for cardiac surgery. No periprocedural mortality was recorded. **Conclusion:** The hybrid approach to CTO PCI proved to be a safe, efficient, and economical method, and should be adopted as a routine approach to CTO intervention.

Irzal Hadžibegović, Mario Sičaja, Ognjen Čančarević, Miroslav Raguž, Boris Starčević

**Objective:** Anomalous origin of coronary arteries in acute coronary syndrome (ACS) is not only a curiosity, but represent also a challenge for adequate cannulation of the culprit coronary artery and successful percutaneous coronary intervention (PCI) that will lead to the patient’s final stabilization. We present a series of cases within Croatian Primary PCI Network and experience in University Hospital Dubrava with guiding catheter selection in the case of anomalous coronary circulation. **Patients and Methods**: Data on anomalous coronary circulation in patients treated for ACS over a period of 12 months and PCI strategies were analyzed. **Results:** Out of 346 patients with ACS treated with PCI between September 2017 and September 2018, the anomalous origin of culprit coronary artery was found in 6 (1.7%) patients. In 3 patients, the circumflex artery originated from the right coronary artery, 1 patient had anomalous solitary coronary artery from the right coronary sinus, 1 patient had an anomalous origin of the right coronary artery in the superior/posterior position above the left coronary sinus with coronary artery passing between the pulmonary artery and the aorta, and in 1 of the patients there was high atypical origin of the left coronary artery in ​​the anterior aortic wall above the left coronary sinus. The MPA catheter showed optimal support to intervention in all cases of circumflex artery originating from the right coronary artery as well as in the case of the solitary coronary artery. In the other 2 patients, AL2 guiding catheter provided optimal cannulation. In 4/6 cases successful PCI was performed, one patient was sent to cardiac surgery, and one was treated conservatively. **Conclusion:** The anomalous origin of the culprit coronary artery in ACS, albeit very rare, can make PCI difficult or impossible because standard guiding catheters do not usually allow successful cannulation and support (1). MPA and AL2 catheters proved to be appropriate choice for most cases of anomalous coronary artery origin in our patients.

Nikola Bakracheski, Elena Kovacheska, Dejan Mancheski, Deni Razmoski, Jasmina Spaseska

**Background:** Almost all described and well established bifurcational stenting techniques need to be performed with 6F coronary guide catheters at least. (1) **Methods:** 62-years-old female patient was admitted in our hospital for elective coronary angiography due to effort angina and positive coronary stress test. Due to radial artery spasm, 5F diagnostic catheters were used to perform the coronary angiogram and it revealed Medina 0,0,1 bifurcational lesion of left anterior descending artery/diagonal branch 1 (LAD/Dg1). There was no significant stenosis on right coronary artery (RCA). We approached percutaneous coronary intervention (PCI) of the ostium of Dg1 using 5F extra-backup (EBU) 3.5 guide catheter (GC) and Ballance Middle Weight (BMW) guidewire in the Dg1, while LAD wasn’t wired. Predilatation was made with 2.0x20 mm semi-compliant (SC) balloon catheter and 2.25x18 mm Drug-eluting stent (DES) was deployed covering the ostium of the Dg1 and 2 mm proximal to the LAD. Control angiography showed significant residual stenosis of the distal part of the main branch (LAD) due to plaque and carina shift. We successfully exchanged 5F EBU 3.5 with 6F EBU 3.5 guide catheter after the intra-arterial application of nitroglycerin in the radial artery and continued PCI using modified mini-crush bifurcational technique. Main branch was wired and side branch stent was crushed with 2.75x15 mm SC balloon catheter. After side branch wire removal, 3.0x20 DES was deployed in LAD and side branch was rewired. Final kissing balloon inflation with 2.75x15 mm and 2.25x15 mm noncompliant (NC) balloons was performed in the end. **Results:** After compromising the main branch vessel with the side branch stent deployment, we promptly changed our previously intended one-stent strategy to two-stent strategy using modified mini-crush technique, which was facilitated with guiding catheter exchange from 5F to 6F GC and wiring the both vessels. Changing the plan during the procedure resulted in prolonged procedural time (additional 18 min), increased total radiation dose and amount of the contrast media used (70 ml more). The procedure underwent without serious complications with satisfactory final result, utilizing mini-crush technique without residual stenosis of both vessels. **Conclusion:** Mandatory strategy planning and appropriate materials selection before approaching any bifurcational coronary lesion are the essence of every safely-performed and efficient PCI.

Nikola Bakracheski, Dejan Mancheski, Elena Kovacheska, Jasmina Spaseska, Deni Razmoski

**Background:** Transradial access (TRA) is preferred vascular access for the most interventionalists worldwide. Distal radial access (RA) is promising technique for performing percutaneous coronary intervention (PCI), using left radial artery. (1) **Case report:** 62-years-old female patient with effort angina was admitted to our hospital for chronic total occlusion (CTO) recanalization of proximal left anterior descending artery (LAD), after a failed attempt 2 years ago, and mid-right coronary artery stented 3 years ago. Angiogram showed 10 mm long occluded segment of proximal LAD, and no significant lesions of RCA and circumlex artery (Cx). We used antegrade CTO technique via right RA and simultaneous contralateral injection via left distal RA. Using 6F guiding catheter (GC), we advanced Fielder XT guide wire and Finecross microcatheter for the lesion crossing. After the failed first attempt we exchanged Fielder XT with Pilot 200 and successfully crossed the occluded segment. CTO wire was exchanged with normal workhorse wire and lesion preparation with 1.5 mm, 2.0 mm and 2.5 mm semicompliant balloons (SCB) was done. Side-branch (SB) was jailed and 3.0x48 mm drug-eluting stent (DES) deployed. At the end proximal optimization technique (POT) with 3.5x15 mm noncompliant (NC) balloon was done. **Results:** Using bilateral radial access and antegrade CTO technique we restored normal coronary flow with optimal stent deployment and no SB compromising. Total procedural time was 47 min, radiation exposure time was 29 min, and we used 130 ml of contrast dye. Compressive bandages were used for the hemostasis of both radial arteries and the patient was discharged at the same day. **Conclusion:** Bilateral radial access is feasible and safe procedure that can be used for CTO recanalization, providing less puncture site complications and shorter hospitalization.

Nirvana Šabanović Bajramović, Lejla Brigić

**Background:** Already several clinical investigations have suggested that there is an association between hypovitaminosis D and acute myocardial infarction (AMI). Not only has it been linked to incident AMI, but also to high blood pressure, increased morbidity and mortality in this clinical setting. Moreover, vitamin D deficiency seems to predispose to recurrent adverse cardiovascular events, as it seems to be associated with post-infarction complications in patients with AMI. (1-3) The aim of this study was to evaluate correlation of 25(OH)D serum levels to severity of hypertension and diastolic function in patients with acute STEMI successfully treated with primary PCI. **Patients and Methods:** This study included 88 consecutive patients admitted to our ICU with acute ST-segment elevation myocardial infarction (STEMI) treated successfully with primary PCI. Vitamin D serum levels were measured in all patients after admission and prior to treatment. Echocardiography was performed by specialists in our institution 1-3 days after admission. Patients were followed in ICU for 3-4 days. The endpoints were mean systolic and diastolic pressure continuously monitored and mean E/A ratio as a measure of diastolic function. **Results**: Lower 25(OH)D serum levels were significantly associated with higher mean systolic and diastolic blood pressure compared to higher 25(OH)D serum level (p=0.004; p=0.006). Lower 25(OH)D serum levels were significantly associated with lower E/A ratio compared to higher 25(OH)D serum levels (p=0.001). **Conclusion:** Low vitamin D serum level, after adjustment for the main confounding factors, significantly correlates with severity of hypertension and diastolic dysfunction in patients with STEMI.

Martina Matovinović, Kristina Gašparović, Dubravka Memić, Lada Bradić, Rea Levicki, Ivana Vukovac Šokec, Martina Lovrić Benčić

The aim of the study was to determine the correlation between the parameters of obesity (waist circumference, hips, waist/hip ratio) and body mass index (BMI) in 48 patients, 15 male and 33 female, and laboratory findings (lipidogram, glucose, insulin, HOMA (homeostatic model assessment) index) with echocardiographic findings (LViDd, LViDs, left atrium (LA) area, LA volume, E/E’) which values are most correlated with body weight gain. Bayesian Pearson correlation was used in the study to determine the degree of positive correlation (significant coefficient value 0.5 and above). Statistical analysis and correlation of all parameters according to sex, to the subgroup of patients with diabetes and hypertension, or group without comorbidity was performed. Average values: waist circumference 126.6 cm (92.9-180.0), waist circumference 134.3 cm (108-174), waist circumference and hips 0.93 (0.74-1.16), BMI 43.17 kg/m2 (28.91-63.67), insulin 20.35 pmol/L (4.5-88.2), HOMA index 5.02 (0.9- 21.95) for niacytes, of which 15 (35%) patients did not have insulin resistance. Most had a normal left ventricular ejection fraction (on average EF LV 65%). We analyzed correlations of anthropometric and laboratory findings with echocardiographic parameters and showed significantly correlated correlations. Positive significant correlation was found: LViDd and BMI (r = 0.52, BF10 is 121), LViDs and BMI (r = 0.50, BF10 = 65), LViDd and waist circumference (r = 0.56, BF10 = 150) waist circumference (r = 0.55, BF10 = 106), a stronger degree of attachment for men than female gender (R = 0.67, BF10 = 5.23), LViDs and waist circumference (r = 0.61, BF10 = 0.64, BF10 = 4.28). (R = 0.37, BF10 = 1.71), LViDd and waist circumference (r = 0.28, BF10 = 0.59), LViDs and waist circumference (r = 0.37, BF10 = 1.61), LViDs and BMI 0.18, BF10 = 0.36). Findings for diabetic and hypertensive patients: LViDd 5.55 cm (4.54-7.49), LA 3.47cm (2.88-5.96), LA area 18.30 (12.0- 25.6) cm2, LA volume 47.83ml (25.0-76.0), E/E’ 9.83 (6.0 -13), LA volume 48.82 (23.0-99.0), E/E’ averaged 9, 4.2, 41 (6.0-15.0). Adipose men with diabetes and hypertension have significantly more pronounced echocardiographic changes compared to adipose patients without comorbidity. (1-3)

Diana Rudan, Hrvojka Marija Zeljko

**Introduction:** Chest pain is the most frequent symptom of coronary artery disease (CAD). Previous systematic review including 31 countries found average weighted prevalence of angina in males to be 5.7% and 6.7% in women. (1) In primary care the prevalence of patients presenting with chest pain that ultimately have CAD, is even lower, estimated to be around 1-2%. (2) Not every chest pain is associated with CAD, and physicians are using various methods to predict and diagnose CAD in patients with chest pain. Cardiology practice in the UK is guided by the use of National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) Guidelines. Cardiologists in Europe guide their decisions according to ESC guidelines. This review is comparing scientific background for differences between most recent NICE and ESC guidelines in the diagnostic of chest pain and stable CAD that guide physician’s decision making in daily clinical practice. **Comparison of Guidelines:** In 2010 NICE published guidelines for diagnosis, and in 2011 for management of stable CAD. In November 2016, NICE published update of those guidelines. (3) This update consist of two important changes considering the use of pre-test probability assessment, and introduction of wide use of cardiac CT in the diagnosis of CAD. The last ESC guidelines for diagnosis and management of stable CAD were published in 2013. ESC Guidelines combined both CAD diagnostic and management guidelines. Statements are given according to the class of recommendation and level of evidence. This form of guidance is not applied in NICE, where rather simple statements are used. ESC guidelines do not assess cost-effectiveness of the recommendation, as opposed to the NICE Guidelines. **Conclusion:** Differences exist between NICE and ESC guidelines affecting clinical practice in approaching diagnostic of chest pain and stable CAD. The ESC pathway for diagnosis of chest pain is based on the functional/stress imaging, that can be replaced with exercise ECG if stress imaging facilities are not locally available. On the other hand, NICE guidelines moved away from exercise ECG, first towards more accurate functional stress imaging modalities, and later, according to the last update from 2016, towards 64-slice CT coronary angiography as a first line imaging modality.

Diana Delić-Brkljačić

A review of the key points of the new European Society of Cardiology (ESC) guidelines for the treatment of cardiovascular disease during pregnancy. (1) The new ESC guidelines for the treatment of cardiovascular disease during pregnancy recommend the modified World Health Organization classification of maternal risk. In pharmacological therapy, decision making based on Food and Drug Administration (FDA) drugs in pregnancy categories A-X is no longer recommended. There are also changes in antiarrhythmic therapy as well as anticoagulation and thrombolytic therapy during pregnancy. Changes were made regarding timing of intervention in valvular disease and also in diagnostics of deep vein thrombosis in pregnant women. A few changes have been made regarding the management of hypertension and the pregnancy heart team is introduced.

Igor Rudež, Josip Varvodić, Davor Barić, Daniel Unić, Savica Gjorgjievska, Marko Kušurin, Ivana Jurin, Nikola Bulj

**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 experience with the root remodeling, valve sparing technique with the extraaortic expansible ring. **Patients and Methods:** Between November 2014 and September 2018, a total of 65 patients (53.1±13.1 years; 18.5% female, EuroScore II of 0.48% to 11.17%) underwent AVRep; 8 due to isolated cusp malcoaptation and 57 with associated with aortic root dilatation. Reconstruction was done with the Coroneo Extraaortic Ring (27 (25-31)), and the Gelweave graft (28 (25-32)). Concomitant procedures included mitral valve reparation in 4 patients, with tricuspid valve reparation in two of them, coronary artery bypass graft in four patents. In two patients replacement of aortic arch was performed and placement of EVITA stent graft in two patients. Echocardiography was used to determine AR severity grade preoperatively, 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 92.5% (5/65) and there were 2 patients (3%) reoperated due to early postoperative regurgitation. Two patients (3%) were operated two years following surgery, one of them due to severe aortic insufficiency and the other due to aortic root pseudoaneurysm. One patient’s postoperative recovery was complicated by ileus and a laparotomy was performed. A significant decrease in left ventricular end-diastolic diameter (LVEDd) was observed (preoperatively 60.01 mm/postoperatively 54.25 mm) with further decrease at early follow-up. At follow up one patient had major AR (he was reoperated) (AR 0 = 47, AR 1+= 13, AR 2+= 4). **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 left ventricular ejection fraction immediately postoperatively and at early follow up.

Daniel Unić

With the development of transcatheter aortic valve implantation (TAVI) an alternative has emerged to an established surgical treatment of aortic stenosis. After initial success in treating patients with prohibitively high surgical risk, we have witnessed recent expansion of the method on patient groups of intermediate and low risk, a “traditional” surgical cohort, with long experience and excellent results of surgical treatment. The paper involves a short history of the TAVI procedure development, review of pivotal and recent literature on the topic. Moreover, it discusses the future expansion of the method and its impact on surgical AVR, as well as critically appraises certain aspects of the literature (1, 2), comparing them to own and surgical literature results.

Dubravka Šipuš, Vlatka Rešković Lukšić, Jadranka Šeparović Hanževački

**Introduction:** Prosthetic valve endocarditis (PVE) is a severe complication in patients with both mechanical and bioprosthetic valves, occurring in 1-6% of patients with valve prosthesis and 10-30% of all infective endocarditis (IE) cases. Early PVE occurs during the first year after cardiac surgery. PVE has a very high in-hospital mortality rate of 20–40%. (1) We aimed to analyze PVE clinical, microbiological and echocardiographic features and outcomes in University Hospital Centre Zagreb during a two-year period (2016-2018). **Patients and Methods**: A retrospective study was conducted. Patients diagnosed as „definite” or „possible“ IE according to modified Duke criteria were included and data from in-hospital charts and digital echocardiography database were analyzed. Outcomes were in-hospital mortality and reoperation (both urgent and elective). **Results:** There were altogether 27 cases of IE: 19 (70.3%) men, median age 64 (range 28-84). PVE was found in 14 (51.9%) patients, among them there were 5 (35.7%) with aortic mechanical prosthesis, 6 (42.9%) with aortic bioprosthesis, one patient had a mitral mechanical valve and one bioprosthesis, while 2 (14,3%) had mitral valve repair. 6 (42.9%) occurred very early after valve surgery (within 60 days). Large vegetations (11.3±6.4 mm) were revealed by echocardiography in 12 (85.7%) PVE patients. Half of PVE patients (n=7) were referred to reoperation during initial hospitalization, with mortality rate of 14.3% (n=2). Isolated pathogens in blood culture were: coagulase negative Staphylococcus (n=5, 35.7%), Staphylococcus aureus (n=4, 28.6%), Enterococcus spp (n=2, 14.3%), Propionibacterium acnes (n=1) and Stenotrophomonas maltophilia (n=1). Culture-negative PVE was registered in one patient. IE valve involvement is shown in **Figure 1**. FIGURE 1. Vegetation distribution according to native valve or prosthetic valve position, among infective endocarditis on native valves (NIE) and prosthetic valve endocarditis (PVE) patients. PVE = prosthetic valve endocarditis, NIE = native valve endocarditis **Conclusion**: We found an unexpectedly high incidence of PVE among IE patients (1, 2). Contrary, surgery-rate and in-hospital mortality were similar to published data (2). Most of the PVE in our patients occurred early after valve surgery and Staphylococcus spp is predominant isolated pathogen, as it was expected. Interestingly, regardless of prosthesis type, aortic position was predisposed to PVE.

Zrinka Sertić, Tomislav Letilović, Mladen Knotek, Tajana Filipec Kanižaj, Mario Stipinović, Darko Počanić, Helena Jerkić

**Background**: Echocardiography is performed as part of preoperative evaluation of liver (LT) and kidney (RT) transplant recipients. Pathological findings, although associated with survival in the immediate perioperative period, have received less attention as markers of increased incidence of adverse outcomes in the long term. (1, 2) Aim: To establish the association of ≥ mild tricuspid regurgitation, mitral regurgitation (MR) and aortic stenosis with mortality, graft survival and posttransplant cardiovascular adverse events in kidney and liver transplant recipients. **Patients and Methods**: Retrospectively collected data from 219 liver and 115 kidney transplant patients included parameters from one echocardiogram at a single-time point closest to transplantation, patient and graft survival periods, cause of death and CV events in the postoperative period (stroke and MI). Multiple organ transplants, patients lost to follow-up or with incomplete echocardiographic findings were excluded. Patient survival was defined as time from transplantation to death or last follow-up and graft survival as time from transplantation to last follow-up, death or re-transplantation. **Results**: 199 LT and 106 RT patients met the inclusion criteria with median follow up 376±231 and 518±237 days respectively. Overall survival rate was 83.4% for LT and 94.3% for RT. Predominant cause of death was sepsis (43.8%) for LT while different causes of death were equally distributed between RT patients. Significant difference was found only for overall survival in MR (79.1%) and non-MR (94.6%) LT patient groups (log rank, p=0.013). No significant correlation was found between CV event incidence and any of the analyzed parameters. **Conclusion**: In our study, MR was found to be associated with long-term posttransplant mortality in LT patients. The significance of echocardiography in risk-stratification for posttransplant outcomes in RT and LT is yet to be definitively determined in larger sample studies.

Ivana Jurin, Josip Varvodić, Dubravka Šušnjar, Irzal Hadžibegović, Tomo Svaguša, Tomislav Letilović, Stipe Radoš, Nino Tičinović, Jasenka Grgurić, Frane Paić, Igor Rudež

**Objectives:** Aortic stenosis is accompanied by progressive left ventricular hypertrophy and fibrosis. (1) This study sought to investigate the intensity of potential reversal changes in left ventricular (LV) mass and global longitudinal strain at 3 months follow up after aortic valve replacement surgery. **Patients and Methods:** A total of 47 patients (age 70.32 ± 7.59 years; 53,2% female) with severe, symptomatic AS were assessed pre-aortic valve replacement (AVR) by echocardiography. Bioprostheses were implanted in 41 patients (87.23%), and the 6 remaining patients (12.77%) received mechanical prostheses. Assessment was repeated at three months post-AVR. **Results**: At three months post-operatively the mean valve gradient had improved (52.05±13.38 mmHg to 13.05±4.36 mm Hg; p2 to 169.18±38.15 g/m2; p2 to 61.45±17.34 ml/m2) and LV end-systolic volume index (25.42±11.09 ml/m2 to 27.05± 12.25ml/m2; P=0.294). Also, left ventricular ejection fraction (LVEF) did not improve (P=0.66). Nevertheless, septal thickness (P<0.001), posterior (PWT) wall thickness (P=0.001), and relative (RWT) wall thickness (P=0.032) were significantly reduced at follow-up. In addition, average global longitudinal strain (GLS; -15.86±4.25 to -17.16±3.42; P=0.008) and strain measured in two chamber view (2ch; -15.13±5.19 to -16.66±3.87; P=0.013) were also significantly improved while the strain measured in PLAX (-16.83±4.92 to -17.92±4.12; P=0.128) and in four-chamber view (4ch; -15.48±4.64 to -19.06±16.72; P=0.128) showed statistically insignificant improvement at 3 months follow up. There was no statistically significant improvement in diastolic function of LV. **Conclusions:** Three months post-AVR patients showed significant improvement in LV systolic function measured by GLS but not LVEF as well as improvement in reverse remodeling depicted by regression in LV mass. We did not see improvement in LV diastolic function.

Paloma Horjinec, Francisc Ludvig Horjinec

**Introduction**: MASS phenotype is a particular type of fibrillinopathy, the following Ghent criteria being present: Z score of aortic root < 3(child) / 2 (adult); systemic score <5; mitral valve prolapsed (M); borderline aorta dilation(A); skin striae (S) and skeletal features (S). (1) The goal of the study was to reveal correlations between oral abnormalities and cardiac pathology in MASS phenotype, for a better approach and therapy of cardiac involvement. **Patients and Methods**: Our study included 28 patients, with 2 years monitorization, aged between 5 and 48 years, with MASS phenotype. Every 6 months, cardiological and dental examination, laboratory findings, electrocardiogram and transthoracic echocardiogram were done. As concerning patients symptoms, the following were predominant: atypical chest pain, 1st class dyspnea and palpitations. Mild and moderate mitral regurgitation were usually seen on echocardiography, as mild or moderate pulmonary hypertension; 1 patient required mitral valve reconstruction, due to his severe mitral valve regurgitation and severe pulmonary hypertension. The most common oral anomalies were the following: dental implantation abnormalities, periodontal disease, maxillary protrusion and temporomandibular joint dysfunction. **Results**: The study revealed a direct correlation between mitral regurgitation severity and oral modifications. The strongest connection was between temporomandibular joint dysfunction and mitral valve prolapsed (r= 0.728, p=0.03), concordant with previous studies. This observation sustains a previous affirmation: fibrillin deficiency inside mitral valve, in fibrillinopathies, is the same as fibrillin deficiency in temporomandibular joint. **Conclusion**: Oral anomalies, inside MASS phenotype, could be an outcome marker for cardiovascular evolution in this disease.

Lea Skorup, Ivana Grgić Romić, Nikolina Jurjević, Valentina Obadić, Ana Valković, Mihaela Paušić, Alen Ružić, Teodora Zaninović Jurjević, Luka Zaputović

**Aim**: Present heart failure (HF) patients hospitalized during the period of one year in University Hospital Centre Rijeka, describe their characteristics and hospital outcome according to left ventricular ejection fraction (EF) with emphasis placed on heart failure with mid-range ejection fraction (HFmrEF) and compare our results with literature data (1). **Patients and Methods**: Retrospective, observational study was conducted with a total of 375 subjects. All patients hospitalized for heart failure were included, same sample we introduced to European Society of Cardiology HF Register, except those presented with cardiogenic shock or acute coronary syndrome. Patients were classified in three groups according to their left ventricular ejection fraction (EF ≤40%, EF 40-49%, EF ≥50%) measured using echocardiography. **Results**: In comparison with HFpEF (heart failure with preserved ejection fraction) subjects, patients with HFrEF (heart failure with reduced ejection fraction) were younger (73 vs. 78 years, p<0.01), more commonly male (64% vs 34%, p<0.01) with left bundle branch block (32% vs. 7%, p<0.01) and higher prevalence of ischemic HF etiology (52% vs. 22%, p<0.01). HRpEF patients had hypertension (3% vs 14%) more often as a confirmed cause of HF. As expected, atrial fibrillation was significantly more common in HFpEF group (41% vs. 65%, p<0.01). The HFmrEF category resembled the HFpEF population regarding age, gender, body mass index and atrial fibrillation frequency. The average length of hospitalization (8 days) and the intrahospital mortality (6%) did not differ significantly between groups. **Conclusion**: Despite possible differences between HFmrEF and the other two investigated HF categories, our HFmrEF population predominantly resembled HFpEF group. Unlike HFrEF group characteristics and its management, the other two heart failure categories are globally not sufficiently defined. Hence their future research is of special importance for development of evidence-based medical practice.

Mario Udovičić, Sandra Jakšić Jurinjak, Vanja Ivanović Mihajlović, Hrvoje Falak, Boris Starčević

**Introduction:** Heart failure (HF) hospitalization rates are decreasing in Western Europe, but little is known about trends in Central European countries. (1) In this study we analyzed the hospitalizations due to heart failure in University Hospital Dubrava (UHD). **Methods and Results:** The hospital information system of UHD was searched for primary HF hospitalizations of the patients aged ≥20 years from the local hospital catchment area assigned to UHD for the time period between 2007 and 2016. A total of 4428 primary HF hospitalizations in 3376 patients (median age 75 years, 52.0% male) was recorded. The most common co-morbidities were arterial hypertension (52.0%), atrial fibrillation (45.3%), ischemic heart disease (46.9%) and diabetes mellitus (18.9%). HF hospitalization rates increased significantly from 2007 to 2016. In 2007 main hospitalization rate was 130.7 per 100,000, while in 2016 it was 150.5 per 100,000. This is a relative increase of 15% (p=0.023). In the same time, the in-hospital mortality decreased insignificantly (p=0.718) from 11.7% to 10.6%. After a first HF hospitalization, any HF readmission rates within 30, 60, and 90 days and at 1 year were 5.6%, 9.5%, 12.0%, and 21.5%, respectively. **Conclusion:** Despite improvements in management, HF remains a major challenge associated with a significant mortality and readmission rates.

Maja Šipić, Snežana Lazić, Biljana Krdžić, Slavica Pajović, Kristina Bulatović

**Introduction:** Pulmonary arterial hypertension (PAH) is a group 1 pulmonary circulation disease. It is associated with severe arterial remodeling, increase in pulmonary vascular resistance (PVR), precapillary pulmonary hypertension, systemic procoagulant condition, and lastly, with right heart failure. Increased blood viscosity, oxidative stress, Raynaud’s phenomenon (RF) intermittent vasospasms contribute to PAH. The incidence of primary RF and PAH is insufficiently known. (1, 2) **Case report:** 49-year-old male, first hospitalization. Principal complaints: extreme fatigue on the slightest effort and ankle and abdominal edema for the past three months. For the past several years, he noticed paleness of his fingers at exposure to cold, but did not consider this to be significant. Eupneic at rest, acyanotic, emphasized P2, with systolic murmur with point of maximum intensity in the left parasternal area; preserved radial and ulnar pulsations on both sides; discrete ankle edema. BP 110/70 mmHg. ECG – sinus rhythm, HR 100 beats per minute, right axis deviation, negative T in V1-4. Increased levels of bilirubin, Na, LDH, CK and CK-MB. NT-proBNP 3830 pg/mL. Echocardiography - LV shows normal ESD and EDD; EF 40%; without segmental kinetic disturbances. DV:LV>1.06; TAPSE 13 mm; PaccT 61 ms; RVSP 70 mmHg; TR 3 +. Thoracic HRCT shows small zones of ground glass opacity, without lesions of lung interstitium or airways. Right heart catheterization – confirmed precapillary pulmonary hypertension; mPAP 48 mmHg; PVR 7 WU; CI 2.5. Perfusion scintigraphy indicated small perfusion defects. Highly positive ANA in Hep 2 cells. Pulmonary function – FVC 113.20; FEV1 101.30; TTGV% 153.20; pO2 8.59 kPa; pCO2 3.76 kPa; sO2 92.8%; pH 7.43. 6 Min WDT Borg 4. **Conclusion:** The diagnosis of severe PAH in our patient was delayed due to a long oligosymptomatic period. PH evaluation in the presence of Raynaud’s phenomenon is necessary.

Tomo Svaguša, Boris Starčević, Diana Rudan

**Background:** Amyloidosis is a heterogeneous group of diseases characterized by the accumulation of protein deposits. Some of them affect the heart, and the most common are the immunoglobulin light chains and transthyretin. (1-3) **Case report:** A patient at the age of 60 is admitted to emergency care due to chest pain. She has been taking medicines for dyslipidemia. Chest X ray in ER (emergency room) described a heart enlargement. As a result of the echocardiography, a preserved left ventricular fraction was observed and thickened wall of both ventricles. Coronarography excluded atherosclerotic changes in epicardial vessels. Further treatment of the patient verified an elevated NT-proBNP of 4055.4 pg/ml and a 24-hour proteinuria of 1.52 g. Electrophoresis of proteins and immunofixation indicates elevated lambda light chains. Bone marrow puncture is performed and multiplying plasma cells (15%) were observed. Due to kidney involvement, the kidney biopsy was performed with a positive pathohistological finding of amyloidosis with lambda light chains. The second patient at the age of 57 is admitted to emergency care due to signs of heart failure. He has a history of Hashimoto’s disease. Chest X ray in ER has described myopathic heart. 12-lead ECG is characterized by non-specific conduction disorders. As a result of the echocardiography, slightly lowered left ventricular fraction was observed and thickened walls of both ventricles. Further tests verified an increased NT-proBNP > 8000 pg/ml. Electrophoresis of proteins and immunofixation indicates elevated kappa light chains. Bone marrow puncture is performed and multiplied plasma cells (9%) were observed. Due to skin lesions of the face, the biopsy was performed with a positive pathohistological finding of amyloidosis with kappa light chains. **Conclusion:** The timely recognition of cardiac amyloidosis is of extreme importance for the treatment and prognosis of the disease. The timely detection of illness provides patients with adequate treatment and significant life extensions.

Vera Slatinski, Dario Gulin, Zrinka Planinić, Ante Pašalić, Tea Friščić, Marko Perčić, Jasna Čerkez Habek, Jozica Šikić

**Introduction**: Lyme disease is a multisystem disease caused by infection with Borelia burgdoferi and spread by a tick bite. Even though it most commonly affects the skin, joints and nervous system, it can rarely cause Lyme carditis. (1) In Europe, cardiac involvement as a complication of Lyme disease occurs in up to 4%, with 3-fold higher male predominance. The most common clinical feature of Lyme carditis is atrioventricular (AV) conduction block of varying severity but may also include decreased cardiac contractility due to myopericarditis. These cardiac features typically occur one to two months after the onset of infection. We present a case report of a patient with cardiogenic shock and later confirmed Lyme disease. **Case report**: 71-year-old patient, with two-month long history of progressive exertional dyspnea, was hospitalized in coronary intensive care unit due to cardiogenic shock with severely impaired left ventricular function (EF 15%; in 2016 EF was 56%) and developed signs of type 1 cardiorenal syndrome. The patient had no chest pain, no electrocardiographic signs of ischemia nor elevation of cardiac biomarkers. The patient initially required inotropic support that with other standard treatment for acute heart failure gradually led to clinical and echocardiographic improvement (EF 31%). The patient then underwent coronary angiography that showed diseased left anterior descending coronary artery that was treated with two stents. Since acute myocardial infarction was not the cause of acute heart failure, other possible causes were investigated, primarily myocarditis. More detailed clinical history revealed tick bite about two months prior to hospital admission, which rose suspicion of Lyme carditis, even though the patient had no registered AV conduction disturbances. An enzyme-linked immunosorbent assay and Western blot both came seropositive for Borelia burgdoferi antibodies, confirming the diagnosis. **Conclusion**: Lyme carditis is a rare manifestation of boreliosis with possible lethal complications. Therefore, detailed clinical history and physical examination are crucial for making correct diagnosis and giving the right treatment.

Boško Skorić, Dora Fabijanović, Marijan Pašalić, Nina Jakuš, Mia Dubravčić, Maja Čikeš, Jana Ljubas Maček, Jure Samardžić, Hrvoje Jurin, Ivo Planinc, Daniel Lovrić, Renata Žunec, Marija Burek Kamenarić, Ivana Ilić, Višnja Ivančan, Hrvoje Gašparović, Bojan Biočina, Davor Miličić

The diagnosis of antibody-mediated rejection (AMR) is based on immunopathologic features, supported by clinical signs as well as by the presence of donor-specific antibodies (DSA). However, AMR is a continuum with progression from a silent phase of circulating antibodies, followed by subclinical complement deposition without histological alterations, until it becomes symptomatic. Subclinical AMR appears to be associated with poor outcome. DSA are markers of alloimmune activation and are associated with poor graft survival, rejection, and CAV (cardiac allograft vasculopathy). The significance of rising DSA in the early post-transplantation period, as well as their late appearance or increase without pathological changes or clinical manifestations, is unclear, and the treatment may be considered. (1, 2) We retrospectively evaluated 193 transplant (Tx) patients (pts) since 2012, when pathologic analysis for AMR and detection of DSA were gradually introduced. By using different combinations of pathologic, clinical and serologic (i.e. positive DSA) criteria we diagnosed AMR in 12 pts (6.2%). One-quarter of patients with AMR presented with cardiogenic shock. The combination of pathologic and clinical, pathologic and serologic as well as clinical and serologic criteria were present in 17%, 25%, and 25%, respectively. All three criteria were positive in 33%. Median time from Tx to AMR diagnosis was 2.63 yrs (0.7-5.9). The median age was 35 (17-62) and 75% were males. All pts had positive DSA, except 2 pts, in whom testing was unavailable. Seventy percent had class II, and 30% were positive for both class I and class II anti-HLA. The most frequent treatment strategies included: pulse steroid (92%), plasma exchange (75%), intravenous immunoglobulin (58%) and rituximab (58%). Antithymocite globulin, as well as bortezomib, were applied in only one pts. ECMO was implanted in pts with cardiogenic shock. One-year survival is 83%. Among 193 pts, DSA were analyzed in 97 pts. Twenty-four percent were DSA positive (class I in 17%, class II in 65% and both classes in 17%) (**Figure 1**). Although the reported incidence of AMR varies because of different diagnostic criteria and variations in screening schedule, our result is comparable. Both diagnosis and treatment of AMR are not well standardized. We need large prospective multicentric clinical trials to evaluate different strategies. FIGURE 1. The frequency of donor-specific HLA antibodies among tested heart transplant patients. HLA = human leukocyte antigen

Vedran Pašara, Marijan Pašalić, Dora Fabijanović, Nina Jakuš, Ivo Planinc, Maja Čikeš, Jana Ljubas Maček, Jure Samardžić, Hrvoje Jurin, Daniel Lovrić, Renata Žunec, Marija Burek Kamenarić, Ivica Šafradin, Davor Miličić, Boško Skorić

**Case report**: 18-year-old female was hospitalized for acute heart failure three years after a heart transplant. Echocardiography showed thickened walls and reduced systolic function of both ventricles (left ventricular ejection fraction, LVEF 30%). Pulse steroid therapy was started after urgent cardiac biopsy (Bx). Because of the development of cardiogenic shock, a venous-arterial (VA) ECMO (extracorporeal membrane oxygenation) had to be set up. Bx showed a mixed type of acute rejection: antibody-mediated rejection grade pAMR 1(I+) and cell-mediated rejection grade 3R. Luminex® confirmed the existence of numerous anti-HLA donor specific antibodies (DSA) class I (A11, A30, B13, B35) and class II (DR3, DR15, DR51, DQ2, DPA1*02) with maximal MFI 13000 for anti-DQ2. Plasmapheresis, intravenous immunoglobulin (IVIg) and antithymocite globulin (ATG) were immediately initiated. On the fourth day, both ventricles had normal wall thickness and improved systolic function (LVEF 40%). The patient was successfully weaned from ECMO. Rituximab was applied at the end of the second week. Control Bx showed no cell-mediated rejection, while immunohistochemistry remained positive. Coronary angiography was normal. Five additional plasmapheresis cycles were performed and IVIg was administered, whereupon echocardiography showed normal left ventricle size and wall thickness, while right ventricle was normal in size but had slightly reduced function. Bx showed no cell- or antibody-mediated rejection. Seven weeks after treatment initiation DSA class I and class II were all negative, except anti-DQ2 (MFI 6100) (**Figure 1**). 12 months later the patient is stable, without signs of rejection or graft function deterioration. FIGURE 1. Temporal changes of anti-HLA donor-specific antibodies in response to treatment. MFI = mean fluorescence intensity; class I = class I anti-HLA donor-specific antibodies; class II = class II anti-HLA donor-specific antibodies **Conclusion**: This case shows the importance of acute mechanical circulatory support in heart transplant patients with critical heart failure and, therefore, gaining additional time to run tests and wait for therapeutic effects (i.e. bridge-to-decision, bridge-to-recovery). By combining steroids, plasmapheresis, IVIg, ATG and rituximab, we interacted with complex immune mechanisms of mixed cell- and antibody-mediated acute graft rejection, and ultimately provided not only survival, but also the complete recovery of the patient. (1)

Marko Perčić, Vera Slatinski, Ante Pašalić, Tea Friščić, Zrinka Planinić, Jozica Šikić, Edvard Galić

**Introduction:** According to the new European Society of Cardiology Guidelines for Heart Failure may be acute or chronic. According to the left ventricular ejection fraction (LVEF) heart failure (HF) is divided into the preserved (HFpEF, LVEF >50%), mid-range (HFmrEF, LVEF 40-49%) and reduced ejection fraction (HFrEF, LVEF <40%). Sacubitril/valsartan is used in the treatment of HFrEF in patients who, despite of the optimal medical therapy with ACE inhibitors, beta blockers and mineralocorticoid receptor antagonist, have no symptom improvement. In the PARADIGM-HF study, its superiority was demonstrated in relation to enalapril. (1, 2) **Case report:** We present a patient with history of rheumatoid fever, mitral valvuloplasty, implanted heart electrostimulator, and multiple (20 times) hospitalizations due to acutization of chronic, dominant right-sided HF. In May 2018 he was hospitalized again at our Clinic because of acutization of dominantly right-sided HF. There was no sign of pulmonary congestion, but with elevated liver transaminases, ultrasound findings of enlarged liver and distended hepatic veins, ascites and peripheral edema. The left ventricle was borderline size, slightly reduced systolic function (LVEF 43%). The right ventricle was dilated with severe tricuspid insufficiency as a result of anulus dilatation and decreased systolic function (VCI 25 mm, TAPSE 14 mm). Value of NT-proBNP 4356 pg/ml. He was treated according to the recommendations for acute HF and after stabilization of the condition for the first time with sacubitril/valsartan. Control echocardiographic finding showed a lower volume of the right ventricle (VCI 19 mm, TAPSE 15 mm). At regular ambulatory control there was clinical improvement, the value of NT-proBNP 873 pg/ml. **Conclusion**: Although it has been shown that sacubitril/valsartan in treatment of HFrEF reduces overall mortality and number of hospitalization and improve quality of life, its role in HFpEF and HFmrEF has not been investigated. The PARAGON-HF study is underway to investigate its role in comparison to valsartan in HFpEF. Our patient has fewer clinical symptoms and lowered the level of NTproBNP.

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

**Background:** Role of platelets in the pathogenesis of primary pulmonary hypertension is well established. Platelets act as mediators of vasoconstriction, inflammation, coagulation and vascular remodeling, all of which result in changes to the pulmonary circulation. (1-3) Although being a more common entity, data on pathogenesis of pulmonary hypertension (PH) secondary to heart disease remain scarce. The aim of this study was to shed light on the importance platelets have in the pathogenesis of PH secondary to chronic systolic heart failure (CSHF). **Patients and Methods:** Measurement of platelet function was performed on 160 patients (57±10 years; 65% male) with CSHF admitted to University Hospital Centre Zagreb from October 2011 till October 2016. All patients were candidates for advanced treatment modalities and underwent right heart catheterization. Following the invasive measurement of hemodynamic parameters (including pulmonary artery pressure-PAP and vasoreactivity testing using alprostadil), blood samples were obtained from the pulmonary artery. Platelet aggregation induced by acetylsalicylic acid (ASPI), adenosine diphosphate (ADP), collagen (COL) or thrombin receptor activating peptide-6 (TRAP), was measured using Multiplate Analyzer. **Results:** Most common causes of CSHF were ischemic and dilated cardiomyopathy (ICMP 45% vs DCMP 43%). As expected, all patients presented with decreased cardiac index and PH due to elevated left ventricular filling pressure (PCWP) (**Table 1**). Baseline aggregation tests showed reduced platelet activity, with ASPI being lower in patients with ICMP (p 2 | | TPG | 10.8 ± 5.3 mmHg | | PVR | 3.4 ± 2.0 Wood Units | | ASPI | 49.7 ± 33.4 U | | ADP | 51.7 ± 26.6 U | | COL | 42.9 ± 24.5 U | | TRAP | 73.7 ± 37.7 U | [†] CVP – central venous pressure; PAP – pulmonary artery pressure; PCWP – pulmonary capillary wedge pressure; CI – cardiac index; TPG – transpulmonary pressure gradient; PVR – pulmonary vascular resistance; ASPI – acetylsalicylic acid induced aggregation test; ADP – ADP induced aggregation test; COL – collagen induced aggregation test; TRAP – thrombin receptor activating peptide-6 aggregation test FIGURE 1. Regression plots showing linear interrelation between collagen induced aggregation (COL) and mean pulmonary artery pressure (PAP), i.e. left ventricular filling pressure (PCWP). ### TABLE 2: Changes in hemodynamic parameters and aggregation tests following vasoreactivity testing with alprostadil. | | **Mean ± Standard Deviation** | | --- | --- | | ΔMean PAP | -8.8 ± 6.1 mmHg | | ΔPCWP | -6.3 ± 4.9 mm Hg | | ΔCI | +0.6 ± 0.8 L/min/m2 | | ΔTPG | -2.9 ± 3.7 mmHg | | ΔPVR | -1.7 ± 1.5 Wood Units | | ΔASPI | -6.4 ± 17.1 U | | ΔADP | -10.7 ± 22.1 U | | ΔCOL | -6.7 ± 15.7 U | | ΔTRAP | -7.5 ± 19.4 U | | TRAP | 73.7 ± 37.7 U | [†] CVP – central venous pressure; PAP – pulmonary artery pressure; PCWP – pulmonary capillary wedge pressure; CI – cardiac index; TPG – transpulmonary pressure gradient; PVR – pulmonary vascular resistance; ASPI – acetylsalicylic acid induced aggregation test; ADP – ADP induced aggregation test; COL – collagen induced aggregation test; TRAP – thrombin receptor activating peptide-6 aggregation test FIGURE 2. Regression plots showing linear interrelation between changes in acetylsalicylic acid induced aggregation (ASPI) and in mean pulmonary artery pressure (PAP), i.e. changes in ADP induced aggregation (ADP) and in left ventricular filling pressure (PCWP), following vasoreactivity testing with alprostadil. **Conclusion:** Platelets seems to play an important role in pathogenesis of PH secondary to CSHF. Further research on mechanisms and potential clinical significance of this interaction is warranted.

Vjeran Nikolić Heitzler

Digoxin is a positive inotropic agent, the only one suitable for chronic oral administration in patients with systolic heart failure (HFrEF < 45-50%) with or without atrial fibrillation. Significant neurohumoral properties are also significant by suppressing the excessive activity of the sympathetic and renin-aldosterone system. Numerous studies confirm that it gives exceptional hemodynamic effects by increasing the left ventricular ejection fraction (LVEF), the cardiac index by reducing pulmonary capillary pressure. It slows down the heart function and neutralizes blood pressure. Therefore, unlike beta-blockers and ACEs/ARBs, it can safely be used in patients with lower blood pressure values. Digoxin is also associated with the improvement of the renal function, estimated by 20% increase in glomerular filtration. Therefore, unlike the renin-angiotensin-aldosterone system inhibitor, it can be used in patients with limiting renal function without the risk of further renal impairment. Digoxin has been the first choice drug for many years until the 1997 DIG trial proved that the drug does not reduce mortality in patients in III/IV stage according to NYHA with the values of LVEF ≤40% or those in the II stage according to the NYHA classification with LVEF≤ 30% regardless of the presence of atrial fibrillation, although it contributes to the reduction of the symptoms and frequency of inpatient treatment. (1) DIG study may not be criticized for not using beta-blockers and aldosterone antagonists in the heart failure therapy at that time and relatively high digoxin doses were prescribed, which are not common today. Only in the last decade, the use of digoxin in the treatment of HFrEF has decreased by two-thirds. According to the US GWTH-HF register of 250,000 patients with HFrEF, the frequency of use of digoxin recommended at the time of release was reduced from 33.1% in 2005 to 10.7% patients in 2014. (2, 3) Current European (IIb recommendation level) and US guidelines (IIa recommendation level) recommend digoxin in patients with HFrEF who have permanent symptoms despite optimal therapy in order to reduce the incidence of hospitalization. When using digoxin, small doses equivalent to serum concentrations <0.9 ng/ml are recommended. In studies with stable HFrEF, the discontinuation of the digoxin therapy was followed by worsening of symptoms, where the physical stress tolerance was reduced and LVEF fall was recorded. In extremely severe cases of HFrEF, the introduction of digoxin managed to remove the mechanical circulatory support and intravenous inotropic drugs. For the last twenty years, the heart failure treatment has changed considerably. Owing to modern therapy including the mechanical support and the heart transplantation, the industry shows no interest in digoxin and is very likely that some other DIG volume clinical trial will be sponsored. We should also emphasize the fact that digoxin is a very cheap drug. A clinician faces the dilemma of whether he should rely on the data quality resulting from clinical trials conducted more than two decades ago and before modern heart failure therapy was available or on the evidence from mostly observational studies. Digoxin is probably still justified in patients with severely advanced systolic dysfunction who are unable to tolerate high doses of drugs due to limit values ​​of blood pressure, renal function. The drug should also be used to reduce recurrent hospitalization, and the today’s patient with systolic heart failure is on the average 10 years older than the one in the DIG trial and a daily dose of 0.10 may be adequate for a larger number of patients.

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

**Introduction**: Cytomegalovirus (CMV) infection is known as an external trigger for cardiac allograft vasculopathy (CAV), due to the mechanisms that stimulate graft immunogenicity. (1, 2) The aim of the study was to investigate different aspects of CMV infection and their effect on the development of CAV and cellular rejection (CS) after heart transplantation (HTx). **Patients and methods**: 123 patients after HTx performed in the period from 2005 to 2016 were included, with regular CMV monitoring by PCR method. Follow-up was 3 years (IQR 2-6 years). The presence of CAV was evaluated by coronary angiography and analyzed with respect to pretransplant CMV-immunization and the presence and form of CMV infection, time of the infection (early infection, which was permanently cured within 6 months after HTx, or late with persistence of viremia or viral reactivation after the first 6 months). All patients received CMV-prophylaxis for three months. **Results**: CMV infection was detected in 31.7% of patients, of which 64% had asymptomatic viremia, 25% pneumonitis, 10% enterocolitis and 2.5% myocarditis. There was no difference in CMV seropositivity (91% of patients) compared to later CAV development (p = 0.551) and no effect on reduction of CMV infection after HTx (p=0.485). Significantly higher CAV incidence was associated with higher prevalence of CMV infection (p = 0.013), however early CMV infection had a lower prevalence of CAV than late. The number of viral copies by PCR did not correlate with CAV incidence. Patients with CMV infection did not have a shorter survival rate than CMV-negative patients (p = 0.384) or higher frequency of significant cellular rejection. **Conclusion**: Pretransplant CMV-seropositivity did not affect the ultimate number of CMV infections. CMV infection was confirmed as the trigger for later development of CAV, but it was not related to increased mortality. The number of viral copies was not significant in predicting CAV incidence, but late CMV infection showed higher importance in CAV development than early CMV infection. Despite the high prevalence of CMV infection in our patients (32%), no higher incidence of CAV has been demonstrated, possibly due to effective prophylaxis and thus shorter duration of viremia. The CMV infection did not prove to be the cause of the more frequent cellular graft rejection.

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

**Introduction**: Cardiac allograft vasculopathy (CAV) is a chronic heart transplant complication (HTx) that presents a treatment challenge owing to the diffuse pattern of coronary artery involvement. Severe forms of the disease are not suitable for revascularization, which is why retransplantation often remains the only treatment option. (1-3) **Patients and Methods**: Out of a total of 176 patients following HTx, between 2001 and 2015, 129 patients were subjected to at least one coronary artery angiography by which 45 patients were CAV positive (and additionally in two patients based on clinical and autopsy findings). The mean age was 51.6±12.6 years, 78% of patients were male and the average follow-up was 3 years (IQR 2-6 years). The presence of CAV was evaluated by coronary artery angiography and analyzed with respect to the duration of ischemic time (IT), the early concentration of high-sensitive troponin T (hsTnT) and the degree of cellular graft rejection (CR). **Results:** Early hsTnT values (within 3 months after HTx) are significantly higher with prolonged IT (p=0.040) but have no predictive significance for CAV (p=0.529) or more frequent CR. IT does not correlate with the frequency of significant CR. Patients with severe CAV had significantly shorter survival than those without CAV or with mild/moderate forms of disease (p=0.016) (**Figure 1**). CR, expressed as an average patient rejection index, significantly increases the risk of CAV (p<0.001, OR 16.0), including episodes of mild CR during the first year after HTx. CAV was proven in 36% of CAV patients (N=47/131) and was the cause of direct later mortality in 10.2% of patients. Freedom from CAV at the end of the 1st year was 86%, 2nd 75%, 5th 57% and 10th 25%. FIGURE 1. Patient survival curves depending on the degree of vasculopathy: CAV-free patients or those with mild-to-moderate CAV (CAV1/CAV2) had significantly longer survival in comparison to patients with severe CAV (CAV3). **Conclusion**: More pronounced reperfusion-ischemic injury, determined by longer IT, correlated with higher concentrations of hsTnT early after HTx. The prolonged IT does not present predisposition for a stronger CR, later development of CAV or shorter survival. CAV patients have significantly shorter survival only in more severe forms of the disease, while milder and moderate forms are more effectively treated and therefore do not affect survival. Cellular rejection is associated with higher risk of CAV development, which may have important implications in clinical monitoring and treatment.

Nina Jakuš, Jasper J. Brugts, Philippe Timmermans, Anne-Catherine Pouleur, Pawel Rubis, Emeline Van Craenenbroeck, Edvinas Gaizauskas, Sebastian Grundmann, Stephania Paolillo, Eduardo Barge-Caballero, Domenico D’Amario, Aggeliki Gkouziouta, Ivo Planinc, Jesse F. Veenis, Laura Houard, Katarzyna Holcman, Arno Gigase, Bojan Biočina, Hrvoje Gašparović, Lars H. Lund, Andreas Flammer, Frank Ruschitzka, Davor Miličić, Maja Čikeš

**Background:** LVAD (left ventricular assist device) candidates are typically stratified according to three most typical treatment strategies – BTT (bridge to transplantation), BTD (bridge to decision) or DT (destination therapy), reflecting the acute vs. chronic state of disease, age, comorbidities and overall condition of the patient. (1, 2) Approximately half of the European LVAD carriers are concomitantly treated with CIED-D (cardiovascular implantable electronic devices with a defibrillator component), in which we have shown substantial survival benefit from concomitant therapy. We aimed to investigate in more detail whether specific LVAD treatment strategies portended a difference in benefit from CIED-D therapy. **Methods:** 429 patients with continuous flow LVADs have been included in a multicentre registry formed by 12 European centres (median age 56 (IQR 46-62), 82% male), 53% also had CIED-D. Patients were analyzed according to VAD intention (**Table 1**). Median follow-up time was 1.1 years (IQR 0.5-2.0) from the time of LVAD implant. ### TABLE 1: Baseline characteristics of the studied left ventricular assist device population according to implant strategy. | | **BTT (N=305)** | **BTD (N=68)** | **DT (N=56)** | **P value** | | --- | --- | --- | --- | --- | | Female gender, n (%) | 53 (17.4%) | 19 (27.9%) | 4 (7.1%) | 0.01 | | Age | 50.28 ±12.68 | 51.54 ± 13.36 | 64.85 ± 7.30 | <0.001 | | Etiology of disease | | | | 0.18 | | Dilated cardiomyopathy, n (%) | 140 (45.9%) | 23 (33.8%) | 18 (32.1%) | | | Ischemic cardiomyopathy, n (%) | 132 (43.3%) | 35 (51.5%) | 31 (55.4%) | | | Other cause of heart failure, n (%) | 33 (10.8%) | 10 (14.7%) | 7 (12.5%) | | | Arterial hypertension, n (%) | 61 (20.0%) | 15 (22.1%) | 23 (41.1%) | 0.003 | | Diabetes mellitus, n (%) | 49 (16.1%) | 13 (19.1%) | 26 (46.4%) | <0.001 | | Chronic kidney disease, n (%) | 63 (20.7%) | 14 (20.6%) | 24 (42.9%) | 0.001 | | Coronary artery disease, n (%) | 65 (21.3%) | 17 (25.0%) | 22 (39.3%) | 0.015 | | Chronic obstructive pulmonary disease, n (%) | 21 (6.9%) | 6 (8.8%) | 15 (26.8%) | <0.001 | | Atrial fibrillation/flutter, n (%) | 86 (28.2%) | 11 (16.2%) | 29 (51.8%) | <0.001 | | Ventricular arrhythmias, n (%) | 71 (23.3%) | 15 (22.1%) | 16 (28.6%) | 0.65 | | Cerebrovascular accidents, n (%) | 21 (6.9%) | 8 (11.8%) | 4 (7.1%) | 0.39 | | No prior cardiac surgery, n (%) | 265 (86.9%) | 59 (86.8%) | 52 (92.9%) | 0.45 | | INTERMACS class, n (%) | | | | <0.001 | | Class 1 | 49 (16.3%) | 17 (26.2%) | 3 (5.6%) | | | Class 2 | 94 (31.3%) | 18 (27.7%) | 5 (9.3%) | | | Class 3 | 89 (29.7%) | 13 (20.0%) | 28 (51.9%) | | | Class 4-7 | 68 (22.7%) | 17 (26.2%) | 18 (33.3%) | | | Device type, n (%) | | | | <0.001 | | Heart Mate II | 193 (63.3%) | 26 (38.2%) | 15 (26.8%) | | | Heart Ware | 56 (18.4%) | 20 (29.4%) | 16 (28.6%) | | | Heart Mate 3 | 49 (16.1%) | 22 (32.4%) | 14 (25.0%) | | | Other device | 7 (2.3%) | 0 (0.0%) | 11 (19.6%) | | | Prior life support, n (%) | | | | <0.001 | | None | 214 (73.0%) | 42 (61.8%) | 52 (92.9%) | | | Extracorporeal membrane oxygenation | 24 (8.2%) | 8 (11.8%) | 1 (1.8%) | | | Temporary LVAD | 2 (0.7%) | 2 (2.9%) | 0 (0.0%) | | | Temporary BiVAD | 0 (0.0%) | 1 (1.5%) | 0 (0.0%) | | | Intraaortic balloon pump | 42 (14.3%) | 7 (10.3%) | 3 (5.4%) | | | Other life support | 11 (3.8%) | 8 (11.8%) | 0 (0.0%) | | | CIED-D therapy during VAD support, n (%) | 137 (44.9%) | 23 (33.8%) | 42 (75.0%) | 0.001 | [†] BTT = bridge to transplantation; BTD = bridge to decision; DT = destination therapy; INTERMACS = Interagency Registry for Mechanically Assisted Circulatory Support; LVAD = left ventricular assist device; BiVAD = biventricular assist device; CIED-D = cardiovascular implantable electronic devices with a defibrillator component; VAD = ventricular assist device. **Results:****Table 1** presents the baseline characteristics of patients according to LVAD treatment strategy. Crude event rates for the primary outcome (all-cause mortality) were equally distributed among the three groups (event rates per 100 person-years): BTT: 22.4 [18.2-27.5], BTD: 23.5 [15.2-36.4], DT: 21.7 [13.7-34.5]), with similar hazard ratios for all-cause death compared to BTT group in unadjusted analysis: HR (95% CI) for BTD and DT was 1.06 (0.65-1.73), p=0.809 and 1.00 (0.60-1.65), p=0.987, respectively. CIED-D use contiguously with an LVAD significantly altered survival in the BTT and DT groups: for BTT patients, CIED-D use carried a 40% mortality reduction (p=0.017) and 65% for DT group (p=0.032). However, LVAD treatment strategy at implantation did not modify the association between CIED-D therapy and mortality reduction (interaction p=0.055). **Conclusion:** In this analysis, concomitant CIED-D therapy during LVAD support was associated with a reduction in mortality in patients receiving an LVAD as BTT and DT. However, neither BTT or BTD strategy modified the treatment effect of CIED-D on survival. This finding confirms the relevance of continuation of CIED-D therapy throughout the duration of LVAD support.

Irzal Hadžibegović, Ante Lisičić, Petra Vitlov, Boris Starčević

**Background**: Left ventricular non-compaction cardiomyopathy (LVNCC) can be associated with left ventricle (LV) dilation or hypertrophy, systolic or diastolic dysfunction, or both. (1) Heart failure (HF) symptoms and presentations vary, and some patients may be asymptomatic. Affected individuals are at risk of left and/or right ventricular HF, embolization and malignant arrhythmias when device implantation is necessary. One study showed that LVNCC patients showed better response to resynchronization therapy. **Case presentation**: 36-year-old previously healthy male was admitted because of acute left ventricular failure in NYHA III/IV class. ECG showed left bundle branch block with QRS duration of 168 ms. Bedside echocardiography revealed a dilated LV (71 mm in end-diastole) with estimated ejection fraction (EF) of 26%, moderate mitral regurgitation, moderate left atrial enlargement, moderate pulmonary hypertension with indirect signs of preserved right ventricular function. Standard therapy with diuretics, ACE inhibitors, beta-blocker, mineralocorticoid receptor antagonist and prophylactic dose of enoxaparine was introduced. After initial recompenzation he suffered from an acute embolization of the right superficial femoral artery. Successful embolectomy was performed and therapeutic doses of enoxaparine were introduced with warfarin overlap. Control echocardiography revealed no residual thrombi in the LV, that showed trabeculization, but without clear echocardiographic criteria for LVNCC. Warfarin was titrated to optimal INR value, and after optimization of medical therapy he was discharged in NYHA II class and scheduled for MSCT coronary angiography and cardiac MR. Ischemic heart disease was excluded and cardiac MR confirmed LVNCC with EF of 24%. He was scheduled for CRT-D implantation under warfarin in therapeutic range. All three electrodes were implanted with optimal sensing and stimulation values and during resynchronization he had high R wave in V1 and V2 lead, with echocardiographic signs of a super-responder. After 9 months of follow-up he was in NYHA I class without loop-diuretics, and with 100% successful biventricular pacing and no ventricular ectopy detected after introduction of sacubitril/valsartan. **Conclusion**: Patients with LVNCC and appropriate criteria appear to be great responders to resynchronization with chances of optimal reverse remodeling.

Dario Gulin, Jasna Čerkez-Habek, Zrinka Planinić, Leon Adrović, Jozica Šikić

**Introduction**: Angiotensin receptor-neprilysin inhibitors have been introduced in the last few years as a new class of drugs for the treatment of heart failure (HF) patients. Its benefits have been proven in randomized control trials in HF patients, mostly with reduced ejection fraction. Recent studies reveal new indications and information about benefit in patients after myocardial infarction by reducing myocardial fibrosis and remodeling. Treatment of HF in patients after heart transplantation is challenging with limitations in therapeutic possibilities. (1, 2) We present a case report of a heart transplant patient with significant clinical and echocardiographic improvement after sacubitril/valsartan introduction. **Case report**: 56-year-old patient, with a history of heart transplantation in 2014 due to ischemic cardiomyopathy, was hospitalized for HF. Dyspnea and reduced exercise tolerance had been worsening 2 months prior to hospital admission. Echocardiography showed moderately reduced left ventricular systolic function (EF 32%), diffuse hypocontractility (GLPSavg -4%) and pulmonary artery hypertension (RSVP 65 mmHg), which did not differ much from earlier examinations. In order to improve cardiac function, sacubitril/valsartan was added into treatment. 3 months later the patient was feeling much better with significantly improved physical activity tolerance. Echocardiography exam showed improvement of left ventricular systolic function (EF 41%) and longitudinal myocardial deformation (GLPSavg -7.5%) with reduction of pulmonary artery hypertension (RSVP 50 mmHg). **Conclusion**: To our knowledge and available literature, sacubitril/valsartan has not been used in treatment of HF patients after heart transplantation. Significant clinical and echocardiographic improvement in short period of time after introduction of sacubitril/valsartan presents curiosity. Undoubtedly, such information requires further investigation.

Duška Glavaš, Davor Miličić, Katarina Novak, Josip Anđelo Borovac

**Introduction**: The Heart Failure (HF) surveys and registries have been developed with the intention to characterize this patient population and to improve diagnosis, treatment, and prognosis according to established guidelines of the European Society of Cardiology (ESC). We aimed to provide an overview of past, current, and future European HF registries and to integrate clinical information obtained from these registries. **Patients and Methods**: The data of EuroHeart Failure Survey (EHFS), ESC-HF Pilot Survey (ESC-HF Pilot), ESC HF Long-Term Registry (ESC-HF-LT-R) and Croatian Heart Failure Registry (CRO-HF-R) were analyzed. **Results**: The results from EHFS published more than a decade ago suggested that specific clinical investigations for patients with suspected HF such as echocardiography were not performed as frequently as recommended by the ESC. Several years later, the ESC-HF Pilot Survey that encompassed 136 cardiology centers from 12 European countries showed that ischemic etiology of HF was reported in about half of the patients while acute decompensation of HF was the most common clinical profile of acute HF. More recently, results from ESC-HF-LT-R showed that the presence of diabetes markedly increased the risk of 1-year adverse events in HF outpatients and that diabetes treatment was suboptimal. Likewise, the chronic obstructive pulmonary disease frequently coexists in HF and is associated with an increase in all-cause and HF-related hospitalizations during the 1-year follow-up. (1) Data acquired from the CRO-HF-R revealed that disease presentation in HF might differ between women and men. For instance, women had a significantly higher proportion of HF with preserved left ventricular ejection fraction and had higher lipid and uric acid levels compared to men, while men had significantly lower hemoglobin levels and reduced left ventricular ejection fraction compared to women. (2) Finally, latest established version of European HF registry, HF III Registry will continue to gather relevant information about this patient population in modern clinical practice. **Conclusion**: Registries are an important source of information about characteristics, diagnosis, treatment, and prognosis of HF patients and as such will continue to provide a relevant clinical information in the future.

Ivo Darko Gabrić, Ivana Tomašić, Karlo Golubić, Matias Trbušić, Jasna Čerkez Habek, Diana Delić-Brkljačić

**Zaključak:** Anemija u bolesnika s KZS predstavlja značajni faktor loše prognoze te može uzrokovati učestalije hospitalizacije i preglede u hitnoj ambulanti. Kako liječenje čak i visokim dozama peroralnog željeza kod tih bolesnika nije dovelo do kliničkog poboljšanja uveden je novi protokol dokazano korisnog liječenja tih bolesnika visokodoznim intravenskim željezom. **Introduction:** Anemia is frequent in patients with chronic heart failure (CHF) and is connected to a worse prognosis, regardless the severity and type. The correction of anemia contributes to the improvement of health, which also reduces the number of hospitalizations, improves the survival rate and the quality of life. (1-3) **Patients and Methods:** This retrospective analysis includes patients with CHF and a reduced systolic function of the left ventricle who have been treated for the last three years at the Department of Cardiology University Hospital Centre “Sestre milosrdnice“ in Zagreb. The method of parallel sample was used to compare the data of a hundred patients with anemia and a hundred patients without anemia. Using the statistical analysis of multiple factors it was attempted to determine the influence of anemia as an independent risk factor in the number of repeated hospitalizations. **Results:** Although patients with anemia were older than those without anemia (median 77 (66-85): 67.5 (58-75.3); p <0.0001, Mann-Whitney), it was determined that patients with CHF and anemia were hospitalized more frequently than those who have CHF without anemia (median 4 (3-6):2 (1-4); p <0.0001, Mann-Whitney). Patients with anemia were more often examined in the unified urgent reception (median (4 (3-6): 2 (1-4); p <0.0001, Mann-Whitney). **Conclusion**: Anemia in patients with CHF represents a significant factor of a bad prognosis and can cause more frequent hospitalizations and examinations in the emergency department. Even treating these patients with high doses of oral iron hasn’t led to a clinical improvement, so a new protocol was introduced with a proven and beneficial treatment of these patients with high dose intravenous iron.

Jasna Čerkez Habek, Jozica Šikić, Dario Gulin

**Aim**: exploring literature on water immersion, balneotherapy aqua exercise and swimming in patients with left ventricular dysfunction (LVD) and/or stable chronic heart failure (CHF). Aqua exercise is recommended for low-risk cardiac patients, but it is not clear whether it is safe, or what optimal water temperature in patients with CHF is. With water immersion, the water rises pressure on the body surface and blood volume shifts to the central circulation, resulting in marked volume loading of the heart, but only if immersion is up to the neck, with enlargement of all 4 chambers, in 6 seconds up to 30% increase in heart size. (1) **Results**: Until now, based on exploratory studies of central hemodynamics and neurohumoral responses of aquatic therapies it is clear that: 1) In patients with LVD a positive effect of therapeutic warm-water tub bathing is due to afterload reduction caused by peripheral vasodilatation with warm water; 2) In coronary patients with LVD, at low-level water cycling, the heart is working more efficiently than at low-level cycling outside of water; 3) In patients with previous extensive myocardial infarction, immersion to the neck resulted in temporary pathological increases in mean pulmonary artery pressure (mPAP) and mean pulmonary capillary pressures (mPCP); 4) During slow swimming the mPAP and/or PCP were higher than during supine cycling outside water at a 100W load; 5) In CHF patients, neck-deep immersion resulted in a decrease or no change in stroke volume; 6) Even hemodynamically compromised, patients feel well during aquatic therapy: 7) Decompensated heart failure is an absolute contraindication for immersion or swimming; 8) Patient with severe LVD or CHF who can sleep in a flat position can bath in the tube, immersed no deeper up the xiphoid; 9) Therapeutic water exercise in a pool can be allowed, provided that the patient is in an upright position immersed no deeper than up to xiphoid. (2) **Conclusion**: Based on these findings, whether swimming is truly safe, yet needs to be proven for patients with severe LVD.

Ivica Bošnjak, Dražen Bedeković

Over the past few years, we are witnessing a great progress in the treatment of heart failure (HF), as well as in the development of cardiac biomarkers. Intriguing interaction of various mechanisms, involving neurohumoral activation, inflammation, pressure/volume ventricular load, myocardial remodeling and myocardial lesion, lead to heart failure development. Natriuretic peptide testing is commonly used in routine clinical practice. It has a paramount role in the diagnosis and prognosis of HF as well as well-known significance in treatment-guided therapy. Knowing the complexity of HF pathophysiological process, new biomarkers have emerged that can replace the usual ones. (1-3) The aim of this paper is to compare natriuretic peptides, ST2, galectin-3, and highly sensitive troponin. It is reasonable to expect that the future will bring a multibiomarker panel as a necessary tool to improve HF understanding as well as better treatment of HF patients.

Josip Anđelo Borovac, Joško Božić, Daniela Šupe Domić, Zora Sušilović Grabovac, Duška Glavaš

**Introduction**: Heart failure (HF) is a syndrome characterized by the activation of the complex cascade of neurohumoral mechanisms in order to maintain cardiac output. (1) Previous studies have shown that activation of a sympathetic nervous system (SNS) is more pronounced in patients with ischemic cardiomyopathy (IC) compared to those with non-ischemic cardiomyopathy (NIC). (2, 3) On the other hand, catestatin is a pleiotropic endogenous peptide that inhibits nicotinic receptor-mediated catecholamine release into the circulation and, therefore, exhibits inhibitory action on SNS activity. The main goal of the study was to determine and compare circulating catestatin levels among HF patients with IC and NIC. **Patients and Methods**: This study included a total of 38 patients admitted to the University Hospital Centre Split during the March-June of 2018 with an acute decompensation of HF determined by the current diagnostic criteria for HF laid out in the European Society of Cardiology guidelines from 2016. Patients with the acute coronary syndrome and/or infectious disease were excluded. Serum levels of catestatin were determined by the enzyme-linked immunosorbent assay (ELISA). **Results**: Twenty-one (55%) patient had IC while 17 (45%) had NIC. Both groups did not significantly differ in baseline anthropometric, clinical and echocardiographic parameters as well as medication intake (**Table 1**). Almost all patients were in NYHA III or IV class regarding the functional classification of HF (N=36, 95%). Patients with IC had significantly higher mean NYHA degree compared to NIC patients (3.4±0.6 vs. 3.1±0.4, p=0.039). Serum catestatin levels did not significantly differ between women and men (18.9 vs. 15.7 ng/mL, p=0.570). HF patients with IC had more than 2-fold higher catestatin serum levels compared to HF patients with NIC (22.8±20 vs. 10.6±8.5 ng/mL, p=0.025) (**Figure 1**). Catestatin showed positive significant correlation with NT-proBNP in a total sample of patients, independent of sex, age, body mass index and estimated glomerular filtration rate (r=0.516, p2) | 31.1 ± 5.6 | 28.9 ± 3.9 | 0.178 | | BSA (Mosteller, m2) | 2.1 ± 0.19 | 2.1 ± 0.18 | 0.904 | | Systolic BP (mmHg) | 135 ± 24 | 138.1 ± 26 | 0.705 | | Diastolic BP (mmHg) | 83.5 ± 10 | 83.1 ± 12 | 0.909 | | Mean NYHA class | 3.1 ± 0.4 | 3.4 ± 0.6 | 0.039 | | Urea (mmol/L) | 11.6 ± 7.1 | 13.3 ± 7.4 | 0.499 | | eGFR CKD-EPI (mL/min/1.73 m2) | 60.7 ± 26.1 | 48.4 ± 25 | 0.145 | | NT-proBNP (pg/mL) | 8205 ± 6638 | 9858 ± 7783 | 0.746 | | CRP (mg/L) | 23.4 ± 17.6 | 18.6 ± 20.4 | 0.628 | | Glucose, fasting (mmol/L) | 8.4 ± 3.1 | 10.3 ± 4.4 | 0.134 | | LVEF (biplane Simpson, %) | 35 ± 15 | 37 ± 14 | 0.697 | | LVEDd (mm) | 61.4 ± 8.9 | 61.1 ± 8.8 | 0.894 | | LVESd (mm) | 48 ± 11.2 | 47.1 ± 12.8 | 0.843 | | LA diameter (mm) | 50.9 ± 8.8 | 51.3 ± 8.1 | 0.884 | | **Comorbidities (%)** | | | | | Arterial hypertension | 15 (88.2%) | 21 (100%) | 0.106 | | Diabetes mellitus | 4 (23.5%) | 10 (47.6%) | 0.126 | | Atrial fibrillation | 9 (52.9%) | 12 (57.1%) | 0.796 | | Dyslipidemia | 12 (70.6%) | 13 (61.9%) | 0.575 | | History of stroke or TIA | 2 (11.8%) | 3 (14.3%) | 0.819 | | Peripheral artery disease | 5 (29.4%) | 3 (14.3%) | 0.255 | | COPD | 4 (23.5%) | 2 (9.5%) | 0.239 | | **Medication use (%)** | | | | | Aspirin | 5 (41.2%) | 13 (61.9%) | 0.393 | | ACE-I or ARB | 14 (82.4%) | 15 (71.4%) | 0.431 | | Beta-blocker | 15 (88.2%) | 19 (90.5%) | 0.823 | | Diuretics | 17 (100%) | 20 (95.2%) | 0.362 | | Calcium channel blocker | 3 (17.6%) | 3 (14.3%) | 0.778 | | Statins | 6 (35.3%) | 10 (47.6%) | 0.444 | [†] **Abbreviations: ACE-I**-angiotensin-converting-enzyme inhibitor; **ARB**-angiotensin II receptor blocker; **BMI**-body mass index; **BP**-blood pressure; **BSA**-body surface area; **COPD**-chronic obstructive pulmonary disease; **CRP**-C-reactive protein; **LA**-left atrium; **LVEDd**-left ventricular end-diastolic diameter; **LVEF**-left ventricular ejection fraction; **LVESd**-left ventricular end-systolic diameter; **eGFR**-estimated glomerular filtration rate; **NT-proBNP**-N-terminal prohormone of brain natriuretic peptide; **NYHA**-New York Heart Association functional classification of heart failure; **TIA**-transient ischemic attack. FIGURE 1. Difference in mean catestatin serum level (ng/mL) between heart failure patients with ischemic and non-ischemic cardiomyopathy. **Conclusion**: Significantly increased circulating catestatin levels in HF patients with ischemic etiology of the disease might indirectly reflect an increased neurohumoral activation in this population, as well as ventricular pressure overload.

Josip Anđelo Borovac, Joško Božić, Zora Sušilović Grabovac, Anteo Bradarić, Andrija Matetić, Katarina Novak, Duška Glavaš

**Introduction**: Atrial fibrillation (AF) is the most common arrhythmia associated with heart failure (HF). (1) Previous studies have shown correlation of cardiac markers such as NT-proBNP and high-sensitivity Troponin I (hsTnI) with increased risk for thromboembolic and adverse cardiovascular events in patients with AF. (2) Goals of this study were to evaluate the risk for ischemic stroke (IS) and significant bleeding, to examine clinical and laboratory characteristics, and to determine potential associations of NT-proBNP and hsTnI with aforementioned risks in patients with acute decompensated HF (ADHF) and AF. **Patients and Methods**: This study included a total of 47 patients with ADHF and AF, diagnosed according to the current criteria of the European Society of Cardiology (ESC)1, which were hospitalized in University Hospital Centre Split during 2018 (**Table 1**). Patients with an acute coronary syndrome and/or infectious disease were excluded. ### TABLE 1: Baseline characteristics of heart failure patients with atrial fibrillation. | **Variable** | **Mean ± SD or N(%)** **or Median (IQR)** | **Variable** | **Mean ± SD or N(%) or Median (IQR)** | | --- | --- | --- | --- | | Age (years) | 73.3 ± 9.9 | LAVI (mL/m2) | 41.3 ± 15.7 | | BMI (kg/m2) | 30.1 ± 4.1 | Hemoglobin (g/L) | 142 ± 17 | | Male sex | 32 (68.1%) | PT-INR | 3.2 ± 2.4 | | Positive history of a prior ACS event | 18 (38.3%) | APTT (s) | 30.6 ± 13.4 | | Prior stroke, TIA or thromboembolism | 7 (14.9%) | NT-proBNP at index admission (pg/mL) | 6550 ± 3381 | | Prior CABG | 8 (17.0%) | hs-cTnI at index admission (ng/mL) | 56.7 ± 40.6 | | Arterial hypertension | 42 (89.4%) | CRP at index admission (mg/L) | 27.3 ± 29.2 | | Dyslipidemia | 27 (57.4%) | Mean HR at admission (bpm) | 100 ± 27 | | Diabetes mellitus | 16 (34.0%) | Mean QRS duration (msec) | 115 ± 33 | | Smoking (ex or current) | 13 (26.5%) | Mean QTc (msec) | 433 ± 47 | | PAD | 12 (25.5%) | Prolonged QT interval | 17 (36.2%) | | Vascular disease (PAD, AMI, aortic plaque) | 27 (57.4%) | Oral anticoagulants | 40 (85.1%) | | CHA2DS2-VASc score | 5 (4-5) | Warfarin | 21/40 (52.5%) | | 0-4% stroke or thromboembolism risk | 17 (36.2%) | NOAC | 19/40 (47.5%) | | 4-8% stroke or thromboembolism risk | 16 (34.0%) | Antiplatelet agent | 10 (21.3%) | | >8% stroke or thromboembolism risk | 14 (29.8%) | ACE inhibitor or ARB | 38 (80.9%) | | HAS-BLED score | 2 (1-2) | Beta-blocker | 38 (80.9%) | | NYHA functional class | 3 (2-4) | Loop and/or thiazide and/or thiazide-like diuretics | 39 (82.9%) | | SBP (mmHg) | 132 ± 20 | ARNi | 8 (17.0%) | | DBP (mmHg) | 81 ± 11 | Mineralocorticoid antagonist | 14 (29.8%) | | eGFR (mL/min/1.73 m2) | 57.1 ± 22.5 | Calcium channel blocker | 10 (21.3%) | | LVEF (%) | 37 ± 14 | Digoxin | 15 (31.9%) | | LA diameter (mm) | 52 ± 10 | Statin | 18 (38.3%) | | LA volume (mL) | 72 ± 31 | Allopurinol | 7 (14.9%) | [†] **Abbreviations: ACE**-angiotensin-converting enzyme; **ACS**-acute coronary syndrome; **AMI**-acute myocardial infarction; **APTT**-activated partial thromboplastin time; **ARB**-angiotensin II receptor blocker, **ARNi**-angiotensin receptor-neprilysin inhibitor; **BMI**-body mass index, **CABG**-coronary artery bypass grafting; **CRP**-C-reactive protein; **DBP**-diastolic blood pressure; **eGFR**-estimated glomerular filtration rate; **HR**-heart rate; **hs-cTnI**-high-sensitivity cardiac troponin I; **LA**-left atrium; **LAVI**-left atrial volume indexed by body surface; **NT-proBNP**-N-terminal prohormone of brain natriuretic peptide; **NYHA**-New York Heart Association functional classification of heart failure; **PAD**-peripheral artery disease; **PT-INR**-prothrombin time international standardized ratio; **SBP**-systolic blood pressure; **TIA**-transient ischemic attack. **Results**: Mean annual risk for IS without therapy was 8.74% while bleeding risk was 0.60% (p8%). **Conclusion**: The antithrombotic management reduced the risk for IS by nearly threefold, with an acceptable bleeding risk. Levels of hsTnI were increased in a large number of patients suggesting that myocardial injury is common during the hospitalization event of ADHF with AF. Levels of NT-proBNP on admission, in presented population, may aid in annual risk stratification for IS and thromboembolic event.

Ivan Zeljković, Nikola Pavlović, Krešimir Kordić, Nikola Kos, Ivica Benko, Karlo Golubić, Kristijan Đula, Diana Delić-Brkljačić, Vjekoslav Radeljić, Šime Manola, Nikola Bulj

**Introduction**: Pulmonary vein isolation (PVI) by catheter ablation is well established for the treatment of paroxysmal atrial fibrillation (PAF). However, atrial fibrillation recurrence (AFR) is fairly common after the index PVI. Although there are numerous studies reflecting the AFR predictive factors, including different echocardiography parameters, data on appendages’ mechanics and superior vena cava’s area is rather scarce. (1-3) Hence, this study aimed to assess left (LAA) and right atrial appendage (RAA) mechanics by transesophageal echocardiography (TEE) and to explore its value in prediction of PAF after PVI. **Patients and Methods**: We conducted a single-centre, non-randomized, prospective cohort study. Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Transthoracic echocardiogram (TTE) and 3D TEE were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including LAA strain, LAA strain rate, LAA tissue Doppler imaging (TDI) velocity, LAA surface area, SVC surface area, RAA TDI velocity. The primary end point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 seconds. A total of 55 patients with PAF in whom TTE and 3D TEE prior to index PVI was done were included (median age 59 years; IQR 52-63; female 30%; BMI 27.9±4.3 kg/m2, LVEF 60%, LA volume index 34 mL/m2). After a median follow up of 12 (IQR 10-12) months, 15 patients had AFR (R-group) and 40 patients had no recurrence (NR-group). Compared to NR-group, patients in R-group had lower LAA TDI (9.53±1.54 vs. 10.56±1.68 cm/s, p=0.014) and LAA surface area (2.55±0.62 vs. 2.84±0.66 cm2, p=0.045). RAA TDI velocity (p=0.292) and SVC surface area (p=0.361) were not different between the study groups. **Conclusion**: TEE parameters of RAA and SVC did not differ between patients with and without AFR. However, LAA TDI emptying velocity and LAA surface area could be useful in follow-up of PAF patients after index PVI in clinical settings. To our knowledge, this is the first study assessing RAA’ mechanics and SVC surface area in predicting AFR after PVI.

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

Integration of left atrium (LA) images obtained by computer tomography or magnetic resonance reduces atrial fibrillation (AF) ablation procedural time because it enables a more accurate reconstruction of the anatomy (1). Rotational angiography (RA) enables reconstruction of LA immediately before the procedure, but it is the least used method of LA imaging. Data included in our analysis was retrospectively collected from the start of AF ablation program in the University Hospital Centre Zagreb. In the beginning AF ablation program, 3D rotational angiography was utilized to depict LA anatomy and later on, we stopped using preprocedural imaging completely. A28 mm balloon was used via single transeptal puncture and a single 180 seconds freeze strategy was employed. We sought to compare procedural characteristics and outcomes of cryoballon ablation procedures done with the help of rotational angiography (RA arm) versus ablations performed without preprocedural imaging (non-RA). We have analyzed 117 successional second generation cryoballon procedures, 67 in RA group and 50 in non-RA group (74.3% male, 56.9±11.2 years). Paroxysmal AF was present in 78.6% of patients and early persistent in the rest. Mean left ventricle ejection fraction was 60.7±7.1% and mean left atrium diameter was 42.5±5.6 mm. The mean procedure times were significantly shorter for non-RA group (77.5±30.45 min) than RA group (125.3±40.8 min) (p <0.001). The mean fluoroscopy times was also shorter for non-RA group (12.9±7.9 min) than RA group (22.3±10.6 min) (p<0.001). Furthermore X –ray dosage and contrast expenditure were also significantly lower in non-RA group. X ray dosage was 1005.2±850 mGy vs 355.9±421.5 mGy (p <0.001) and contrast expenditure was 190.1±32.5 mL vs 85.2±22.1 mL for RA and nonRA group respectively. There were no significant differences in success rates and complications between groups. In our patient cohort, the use of rotational angiography significantly prolonged procedure times, X ray exposure and contrast expenditure. Superior procedural characteristic could be partly affected by growing operator’s experience. Omitting left atrium imaging did not influence the procedure safety and success rates. Preprocedural imaging is not mandatory for successful PVI but it may be useful to inexperienced operators and or in low volume centers.

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

**Introduction:** Since 2012, we have successfully implemented endocardial ablation procedures in patients with structural heart disease and ventricular arrhythmias (1). These are complex electrophysiology (EP) procedures that are used to treat recurrences of ventricular arrhythmias. However, in some patients endocardial ablation is unsuccessful, since the key substrate of arrhythmia is subepicardial. **Case report**: We report a 20-year-old patient without previous medical history, who has survived out-of-hospital arrest, caused by ventricular fibrillation (VF). The patient was successfully defibrillated, and after the therapeutic hypothermia there was complete neurological recovery. Extensive cardiac work up followed: the 12-lead ECG did not show signs of electrical diseases, and the echocardiographic finding was completely normal. Coronarography showed no coronary artery disease and EP study excluded accessory pathway, Brugada and long QT interval syndrome. Before implanting cardioverter defibrillator (ICD), magnetic resonance was performed and a substrate of arrhythmia was found in the form of subepicardial scar zones in the left ventricle, probably a consequence of myocarditis. Despite multiple antiarrhythmic drugs, the patient had frequent recurrences of VF with multiple ICD shocks. As the substrate of arrhythmia was clearly epicardial, we opted for percutaneous endo/epi procedure. Procedure was performed in the EP room in general anesthesia with invasive hemodynamic monitoring and cardiac surgery on call in case of emergency. The subxiphoid epicardial approach was achieved using Tuohy needle with the help fluoroscopy and small contrast injections. The multipolar catheter was used for substrate mapping of the endocardial and epicardial surfaces. Hence, the target ablation zones were defined. Before epicardial ablation, coronarography was performed to confirm the absence of large arteries in the target zone. The procedure and postprocedural course were without complications, and in the 18 month follow-up the patient was without recurrence of arrhythmia, without specific antiarrhythmic therapy. Due to the high complexity of the procedure, so far these patients have been referred to colleagues overseas. Recently, epicardial ablation of ventricular arrhythmias is also possible in centers in the Republic of Croatia.

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

**Introduction:** The most common cause of atrial fibrillation (AF) recurrence after ablation is pulmonary vein (PV) reconnections. At least 20% of the patients are subjected to repeated procedures after the first intervention. It is assumed that isolation lines made by cryoballoon (single-shot technique are more uniform and durable than those created by the radiofrequent (RF) “point by point” technique (1). **Methods:** We did a retrospective analysis of repeated PV isolation procedures at University Hospital Centre Zagreb. Redo procedures were performed in patients who had symptomatic recurrence of AF after the first ablation despite antiarrhythmics. The interventions were performed in local anesthesia with intracardial ultrasound, CARTO 3 system and contact sensing RF catheters. The intent of the second procedure was the re-isolation of reconnected veins. The aim of this study was to compare the characteristics of repeat procedures and the number of reconnected veins after the initial ablation with the cryoballoon compared to the initial ablation with the RF catheters. **Results:** We have analyzed 16 repeat procedures, 7 of which were after the first cryoballon procedure (CB group) and 9 after ablation with RF energy (RF group). Most patients were men (75%) of average age 62±7.8 years. The most had paroxysmal (75%), and the rest had a persistent FA. The mean left atrial size was 44.6±4.8 mm and mean left ventricle ejection fraction was 61.3±7.4%. There were no significant differences between the basic characteristics of the groups. In the CB group there were 12/26 (46%) PV with reconnections, compared to 26/36 (72%) in the RF group (p=0.396). The procedure duration was 122.8±40.8 min in the CB group, and 190.5±69.8 min in the RF group (p=0.039). The fluoroscopy time in the CB group was 19.7±9.1 min, and in the RF group 22.5±12.0 min (p=0.616). The duration of RF ablation was shorter in the CB group, 558.6±320.2 and in the RF group 1904.5±608.1 (p <0.0001). No complications were observed, and 25% of the patients had recurrent FA. **Conclusion:** After the initial ablation with the second generation cryoballoon (vs. RF energy), we can expect less reconnected PVs in the second intervention, resulting in shorter redo procedures with less need for RF ablation. Due to the small number of patients, not all differences are statistically significant.

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

**Introduction:** In Croatia, endocardial ablation procedures in patients with structural heart disease (HD) and ventricular arrhythmias (VA) have been successfully implemented since 2012. The method of percutaneous epicardial ablation has been introduced since 2017. (1) The ablation of VA in electric storm patients is a lifesaving procedure, and in other patients significantly improves the quality of life and reduces the number cardioverter defibrillator (ICD) shocks. **Patients and Methods:** A retrospective analysis of VA ablations has been made since the beginning of the program in University Hospital Centre Zagreb. All the procedures were performed in electrophysiological (EP) room with local anesthesia, the minority (13.1%) was undergoing general anesthesia. For 3D navigation, the CARTO 3 system was used, and recently multi-polar catheter for high density mapping was used. Substrate and pace mapping was performed, and in some cases activation mapping. Irrigated navigation catheters with maximum 40-50W were used for ablation, and recently contact sensing catheters are available. Ablation success was defined as lack of VA recurrence, and patient follow-up was performed by ICD controls. **Results:** A total of 38 VA ablations were performed in 36 patients (31 male, age 59.1±12.3 years), of which 55.2% in ischemic HD and 44.7% in nonischemic HD. 3 patients suffered from BBRVT (bundle branch reentrant ventricular tachycardia). The average LVED was 36±11.8% with LVIDd of 63.4±10.5 mm. The average duration of the procedure was 297.1±186.6 min with fluoroscopy of 24.6±18.1 min. At the end of the procedure, 64% of patients were not inducible, and in 10.5% of the patients provocation was not performed after the substrate modification of the. In 2 cases endo/epi ablation was performed, and earlier, 2 patients were sent abroad for epicardial ablation. In 5% of patients there were complications (1 AV fistula and one heart failure worsening). 45.7% of ablation patients had recurrent VA, and in 0.8% follow up is not available. In 11.1% of patients, heart transplantation was performed, and 1 was implanted with LVAD. **Conclusion:** More successful treatment of heart failure significantly increases the number of patients referred for VA ablation. As these are the most complex EP procedures, ablation outcomes are far from optimal, but the results of our patient series are consistent with the published series in the world.

Mario Stipinović, Darko Počanić, Matija Marković, Sofiya Andreykanich, Tomislav Letilović, Ivica Premužić Meštrović, Ena Kurtić, Bojana Aćamović Stipinović, Helena Jerkić

**Introduction**: Implantation of implantable cardioverter defibrillator (ICD) as a primary prevention (PP) is indicated in patients with dilated cardiomyopathy (DCM) with a reduced ejection fraction as well as a life expectancy longer than a year. Implantation of ICD as a secondary prevention (SP) is indicated after cardiac arrest and in patients with symptomatic ventricular tachycardia. Results of a Danish register did not show mortality to decrease in patients with non-ischaemic cardiomyopathy (NCM). (1, 2) The goal of our research is to analyze results from University Hospital “Merkur”. **Results and Conclusion**: From 2012 up to 2017 a total of 89 ICDs were implanted due to DCM, 69 for PP and 20 for SP. Data was collected retrospectively and analyzed. The average age of our patients was 62.9 years, 13 out of 89 were women. The average follow up lasted 32 months. 69 patients were treated due to PP, 36 with ischemic cardiomyopathy (ICM) vs 33 with NCM. Death occurred in 9 patients (7 with ICM vs 2 with NCM), 7 died due to heart failure (HF) and 2 due to noncardiovascular cause (in NCM group). Sudden cardiac death (SCD) was prevented in 12 patients (7 ICM vs 5 NCM). There were 30 appropriate ICD therapy deliveries, significantly more in the group of patients with ICM (23 vs 7; p < 0.05). In patients younger then 59 (29 patients) ICD therapy was delivered in 3 patients, and in a group of older patients (40 patients) ICD therapy was delivered in 9 patients. 15 patients with ICM and 5 with NCM were treated due to SP. Death occurred in 5 patients (3 ICM vs 2 NCM), all due to HF. In 4 patients SCD was prevented (3 ICM vs 1 NCM). There were 8 appropriate ICD therapy deliveries (7 ICM vs 1 NCM). 16 patients were older then 59, and all patients in which SCD was prevented, were older then 59. In both groups there were 51 patient with ICM and 38 with NCM. Death occurred in 14 patients (5 ICM and 9 NCM). SCD was prevented in 16 patients (10 ICM vs 6 NCM). In total there were 38 appropriate ICD therapy deliveries (30 ICM and 8 NCM, p<0.05) and all of them occurred in men (p<0.05). There were 33 patients younger then 59 (with 3 appropriate ICD discharge) and 56 older than 59 (with 14 appropriate ICD discharge). We did not detect a significant difference in total mortality between ICM and NCM, neither in the number of SCD. Statistically significant higher numbers of appropriate ICD discharge was detected in the ICM group for PP and in total. Male gender carries a higher risk for SCD. Younger age does not carry a higher risk for SCD.

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

Idiopathic paroxysmal complete atrioventricular (AV) block is a rare form of a complete AV block. It is characterized by the sudden appearance of the complete AV block from - at that moment - normal AV conduction. It occurs in a structurally healthy heart. The appearance is followed by long asystole and syncope, rarely by sudden cardiac death. Although mentioned in previous years, the entity was first defined in detail by Brignole in 1997, and then other authors. Specific features of this block, which clearly distinguish it electrocardiographically and clinically from other types of AV block are: 1) normal baseline electrocardiogram without AV and intraventricular conduction disturbances; 2) appearance of complete AV block from a normal electrocardiogram, without prior variation of the P-P interval, without slowing or accelerating the sinus frequency, and without the extension of the PQ interval. Not triggered by atrial or ventricular premature beat; 3) absence of lower escape rhythm with shorter or longer asystole 4) Instant AV conduction recovery, without lower degrees of AV, 5) normal conduction system on electrophysiological testing; 6) in anamnesis recurring more or less frequent syncope without prodromal symptoms. Although it is a serious disorder, it is rarely diagnosed due to insufficient knowledge of the entity and its unpredictability. Even when considered, it is difficult to “catch” it without long-term monitoring. Recently, as a cause of this block, low basal adenosine serum levels are reported, leading to A2 receptor hyperaffinity of the AV node with the consequent strong reactivity of the conduction system with a sudden rise in adenosine levels. (1-3) Cardiac pacing is the only reliable method of treatment. In the presentation we will present cases of idiopathic paroxysmal AV block from clinical practice.

Davor Radić, Borka Nikolić Pezo, Richard Matasić, Mislav Puljević, Miroslav Krpan, Davor Puljević, Davor Miličić, Vedran Velagić

**Introduction**: Long QT syndrome (LQTS) is characterized by prolongation of the QT interval, with a QTc exceeding 480 ms and an increased risk for syncope and sudden cardiac death secondary to polymorphic ventricular tachycardia (VT). Genetic defects in either cardiac potassium, sodium or calcium channels are responsible for this syndrome. (1) **Case report**: 49-year-old patient without previous medical history was admitted to another hospital because of the syncope. On the day of admission, he felt palpitations and after which he transiently lost consciousness for 1-2 minutes. Initial ECG strip recorded short polymorphic tachycardia (5 QRS complexes, 250 beats per minute). Echocardiography and coronary angiography were both normal. During the hospitalization, he developed ventricular fibrillation and was successfully defibrillated. Amiodarone was introduced in therapy and he was transferred to our hospital for further workup. 12-lead ECG showed normal sinus rhythm with 1 premature ventricular contraction (PVC) originating from right ventricular outflow tract (RVOT). QTc interval was normal (433 ms) with prominent U waves and no signs of J wave syndromes. On 24-hours Holter monitoring, PVC burden was around 5%. Electrophysiologic study was performed, during isoproterenol infusion, QTc prolongation was observed (maximum QTc 555 ms). Therefore long QT syndrome was diagnosed. Combination of intermittently prolonged QTc interval and RVOT PVCs in this patient provoked polymorphic VT and cardiac arrest. After MRI which showed structurally normal heart, implantable cardioverter defibrilator (ICD) was implanted and the patient was discharged with low a dose of beta-blocker. In the follow-up PVC burden is increased to 10% and the patient became symptomatic, so ablation was scheduled. **Conclusion**: Right ventricular outflow tract PVCs in a structurally normal heart is considered a benign condition, but in some patient populations, they can be fatal, as proved in our case. In most cases of malignant right ventricular PVC-s, unrecognized arrhythmogenic right ventricular dysplasia is deemed responsible for mortality but we have to consider other possibilities. In this case, ablation of culprit PVCs can significantly lower the possibility of fatal arrhythmias and ICD discharges, but nevertheless permanent ICD therapy is still mandatory.

Mislav Puljević, Ivica Šafradin, Borka Pezo Nikolić, Richard Matasić, Vedran Velagić, Martina Lovrić Benčić, Miroslav Krpan, Davor Puljević

**Introduction**: Late perforation is a very rare complication following pacemaker. Late perforation occurs more than a month after implantation. This is often an unrecognized complication with high morbidity and mortality. (1) We present a patient who is presented with pain in the left side of the thorax one month after implantation of the electrostimulator. **Case report**: Male, 82 years. Anticoagulated with warfarin for recurrent deep vein thrombosis. 24-hours Holter ECG: AV block I-II degree Mobitz II 3: 1. Since AV block II stage Mobitz II is rare, because of age and comorbidities of the patient, a single lead pacemaker is implanted as a “back up”. The operation was without complications. One month after the implant, the patient presented with sudden pain in the left hemithorax, hemodynamicaly stable, in ECG sinus rhythm 70 beats per minute, PQ prolongation, the laboratory results: hypersaturation with warfarin (PV 0.14). X ray describes a newly described infiltration in the left thoracic region without high inflammatory parameters. Chest MSCT describes active bleeding from the apex of the right ventricle with a hemorrhagic effusion in the left pleural cavity 5.5cm wide with a smaller pericardial effusion. The patient soon became hemodynamically unstable. After resuscitation and blood transfusions, crystalline solutions and correction of coagulation parameters, the patient was stabilized and a cardiac surgery was performed. Intraoperative, ventricular electrode was located in the pleural space with myocardial and pericardial perforation. During operation, 4 liters blood was evacuated, perforation was stitched and an epicardial electrode was placed. Procedure went without complications and patient was hemodynamically stable. **Conclusion**: It is important to bear in mind the late complications of pacemaker implantation and, in case of complications, respond adequately and quickly.

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

**Introduction**: Recently published studies showed that ablation of atrial fibrillation (AF) in patients with heart failure (HF) due to tachyarrhythmia can cause recovery of systolic function and help evade HF complications (1, 2). We are describing series of patients with HF with reduced ejection fraction treated with radiofrequency (RF) ablation, whose HF was thought to be caused by tachyarrhythmia. **Case series:** 42-years-old patient with new onset HF, dilatative cardiomyopathy (LVEF 25%, NYHA III). He had no cardiovascular risk factors. Coronary artery disease (CAD) and myocarditis were excluded. Tachycardic form of AF was identified as probable cause. Patient was treated with three antiarrhythmic drugs of different class with mean heart rate of approximately 115 beats per minute (bpm). Left atrial diameter in long axis was 4.8 cm, LAVI 36mL/m2, therefore we made RF pulmonary vein isolation. On follow up patient was in sinus rhythm, and left ventricle reduced its size with complete systolic function recovery (LVEF 50%). 69-years-old patient with new onset heart failure, dilatative cardiomyopathy (LVEF 20%, NYHA II/III). Past medical history is unremarkable. At admission patient was in atrial flutter (AFL). On electrophysiology study, typical counterclockwise AFL was described and successful cavotricuspid ablation was performed. On follow up patient was in sinus rhythm with complete recovery of systolic function (LVEF 50%). 70-years-old patients with permanent AF. Recently severe reduction of systolic was noted, and AF rate was not under control despite the treatment with three antiarrhythmic drugs of different class (mean rate approximately 120 bpm). CAD was excluded. We implanted a single lead pacemaker, a subsequent AV node ablation was performed. On follow up patient is ventricularly paced 100% of time, and echocardiography showed improvement of systolic function (LVEF 45%). **Conclusion:** Heart rhythm disturbances are related to heart failure, being a cause or a consequence. Identification of arrhythmia as a causative factor of HF, and appropriate usage of ablation therapy can lead to systolic function improvement and can help evade HF complications

Dubravko Petrač

Atrial fibrillation (AF) may interfere with several therapeutic options for heart failure (HF): beta-blockers (BB), cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD). **AF and BB in HF**. Two meta-analyses of randomized trials, that compared BB with placebo in HF patients, found that BB significantly reduced mortality in HF patients with sinus rhythm (SR), but not in HF patients with AF. On the other hand, data from the Swedish HF registry and Danish AF registry showed that BB can reduce mortality both in HF patients with AF and SR. Further randomized trials are needed to clarify BB effect in HF patients with AF and to resolve these contradictory findings. In the meantime, BB remain a standard medical therapy for all HF patients with reduced ejection fraction, irrespective of rhythm disorder. (1) **AF and CRT**. AF is often present in CRT patients and interferes with effective biventricular pacing (BVP). When conducted to the ventricles with R-R interval similar or shorter than the lower pacing rate, AF partially or completely precludes BVP and reduces CRT delivery. The BVP >98% is a cut-point value for the benefit in survival in SR and AF patients. In a study of 54.0190 patients with CRT-defibrillator, the presence of AF and BVP<98% was associated with an increased risk of death. Treatment of AF in CRT patients depends on the type of AF. Catheter ablation of AF is superior to amiodarone in patients with paroxysmal or persistent AF, and AV node ablation is superior to rate control drugs in patients with permanent AF. (2) **AF and ICD**. AF may interfere with ICD therapy in two ways; a) by inducing inappropriate ICD shock when its rapid ventricular rate reaches a device’s programmed detection zone of VT/VF, and b) by triggering episodes of VT/VF and consequent appropriate device therapy. AF is the most common mechanism for inappropriate shocks in ICD patients. Patients who receive appropriate or inappropriate shocks have a substantially higher risk of death than similar patients who did not receive such shocks. The risk associated with inappropriate shocks is limited to those receiving shocks for AF. (3) To minimize this risk, it is necessary to use detection zone appropriately, to consider monitoring zone for slow VT, to ensure adequate rate or rhythm control, and to activate specific discrimination algorhythms.

Vera Slatinski, Ante Pašalić, Petar Pekić, Marko Perčić, Tea Friščić, Zrinka Planinić, Vjekoslav Radeljić, Dijana Delić-Brkljačić, Edvard Galić

**Introduction**: Complete congenital atrioventricular block (CCB) is the most common type of atrioventricular conduction impairment with the incidence of 1 in 15 000 births. It may occur as a result of a structural heart disease or it can be isolated. Estimated mortality rate among adults with isolated CCB is 5%. The exact mechanisms of isolated CCB occurrence is still unknown. The assumption is that the immune response has a major role in its emergence due to transplacental passage of maternal autoantibodies to the nuclear antigens, predominantly SSA/Ro and SSB/La. Consequent inflammation leads to injury and fibrosis of the conduction heart system. Other possible causes include viral infections and long QT syndrome. As patients are predominantly asymptomatic, routine 12-lead ECG is often the first tool in making a diagnosis of CCB. Other diagnostic procedures are 24-hour electrocardiographic recordings (Holter ECG), exercise stress test, and echocardiography. (1, 2) **Case report**: 22-year old female patient was admitted to hospital due to dizziness. Few months earlier, extensive neurological and otorhinolaryngological examination was done, which showed no signs of any central nervous system or vestibular pathology. 24-hour Holter ECG verified atrioventricular dissociation, with average heart rate 47 (interval 32-88) beats per minute (bpm). Exercise stress test was normal, with adequate chronotropic response, maximum to 158 bpm. In the beginning of the test 2:1 atrioventricular block (AVB) was observed, while in the peak load AVB type I was noticed. Tilt-up table test excluded an orthostatic and vasovagal component. Echocardiography showed minimal prolapse of the mitral anterior cusp with mild mitral and tricuspid regurgitation. Repeated Holter ECG showed sinus rhythm, with average heart rate of 54 bpm (interval 32-114 bpm), and intermittent second degree AVB, Mobitz I and total AVB. Additional testing was performed using overlapping Bruce protocol during which significant decrease in heart rate was registered and followed by presyncopal episodes. Therefore permanent pacemaker was implanted which stimulated the His bundle in order to avoid dyssynchrony. **Conclusion**: In patient with CCB, without structural heart disease, using overlapping Bruce protocol we have unmasked presyncopal symptoms, and therefore made an indication for permanent pacemaker implantation.

Mijo Meter, Ante Anić, Toni Brešković, Zrinka Jurišić, Ante Borovina

**Introduction:** Percutaneous catheter, mostly radiofrequency (RF) ablation for supraventricular tachycardias (SVT) is an established way of treating symptomatic patients. Traditionally, essential tool for guiding intracardiac catheter manipulation was X ray fluoroscopy. (1) The risks of exposing patients to ionizing, X ray radiation are well known and are of particular concern in pediatric cases or cases involving pregnant women. Recently, with the help of electroanatomical (3D) mapping systems, a possibility to perform these procedures without the use of X ray fluoroscopy, so called «zero fluoro», emerged. This is a case report with an overview of some intraprocedural aspects of «zero fluoro» RF ablation procedure performed in 26 years old pregnant women at University Hospital Centre Split. **Case report:** The patient was 26 years old primigravida, in sixth month of gestation, with the multiple symptomatic SVT episodes, uncontrolled under atenolol therapy. EP study was performed via right groin venous access and diagnostic catheters inserted in a coronary sinus and right ventricle without the use of X ray. Typical AVNRT was easily inducible and decision was made to proceed with the RF ablation with the intention of maintain «zero fluoro» principle. Couple RF applications (30-40W) were placed in AV nodal slow pathway region under only 3D mapping system guidance. RF application resulted in loss of continuous slow pathway conduction and thus rendered arrhythmia noninducible, even with isoproterenol provocation. Overall procedure time was 47 minutes, including 15 minutes waiting period for eventual tissue recovery. No complications occurred, and the patient had been discharged the day after. She stood arrhythmia free till her labour that had gone uneventful. **Conclusion:** Zero fluoro approach to RF ablation in patients with symptomatic SVT episodes is feasible. It should be preferred approach in vulnerable population such as pediatric cases or cases involving pregnant women.

Richard Matasić, Davor Radić, Davor Puljević, Vedran Velagić

**Introduction:** Traditionally, ventricular pacing leads are placed at right ventricular (RV) apex. This approach has several advantages. First of all, RV apex is easily identified under fluoroscopy and most of the time lead can be easily placed. There is minimal risk of lead dislodgement and reliable parameters are obtained. However, since pacing stimulus starts at the RV apex, iatrogenic left bundle branch block pattern is created. This results in interventricular and intraventricular dyssynchrony (early activation of the right ventricle and interventricular septum and delayed activation of the LV lateral wall). Most of the patients tolerate this very well for some time. In some patients and especially those who require constant ventricular pacing, dilatation, and remodeling of the left ventricle, a decline in left ventricular ejection fraction and even congestive heart failure can occur (1, 2). His bundle pacing activates the ventricles through the native His-Purkinje system, resulting in more physiological pacing. Since activation occurs through the normal conduction system of the heart, there is no intraventricular or interventricular dyssynchrony. Because of that, there are no deleterious effects on ventricular dimensions and functions (3). **Case report:** 15-year-old female patient with congenital total atrioventricular block has been referred for pacemaker therapy to prevent sudden death and insufficient chronotropy. We have successfully implanted dual chamber pacemaker with the ventricular lead placed at the His bundle. This resulted in a narrow QRS complex. **Conclusion:** Technical limitations and higher thresholds at His bundle pacing have restricted use of His pacing in the past but, in recent years development of dedicated tools has made His pacing feasible in most patients.

Ena Kurtić, Matija Marković, Karlo Novačić, Gabrijela Perić Marković, Tomislav Meštrović, Ivica Premužić Meštrović

**Introduction:** Inferior vena cava (IVC) congenital anomalies are relatively rare vascular anomalies that are detected accidentally by imaging during the diagnostic treatment of deep vein thrombosis or more frequently, by treating non-vascular pathology. (1-3) **Case report:** A twenty-seven-year-old patient was hospitalized at the Department of Cardiology of University Hospital “Merkur” for electrophysiological treatment (EPI) due the diagnosis of inappropriate sinus tachycardia (IST) after previously excluded reversible factors of sinus tachycardia and postural orthostatic hypotension. Electrophysiologic study was initiated, but due to unexpected anomalies of the venous system, the same was not done in that act. A MSCT described the duplication of IVC with the continuation of the hemi-azygos veins of the left IVC and the successive right-sided May-Thurner syndrome for which an anticoagulant therapy was initiated, and a thrombophilia test was performed. The patient is homozygous for polymorphism C667T and polymorphism A1298C. In the second act, EPI was performed, confirming the IST and in the same act the sinus node therapeutic modification was done. **Conclusion:** Left-sided IVC cases associated with congenital heart defects are not often described, and IST has never been described as a possible consequence of venous system malformation. The sinus node is a spinal sub-epicardial specialized muscular structure located postero-laterally within the epicardial groove of the right atrial terminal sulcus, at the junction of the trabecular frontal attachment and the smooth-walled muscular venous component posterior. On the epicardial side, it is placed on the attachment of the superior vena cava with a right atrium and continues down and down the sulcus terminalis and ends subendocardially near the IVC. Localization and embryological development are in favour of the same etiologic factor that has led to an anomaly of IVC and sinus node dysfunction.

Josip Kedžo, Zrinka Jurišić, Toni Brešković, Marina Jurić Paić, Ivan Pletikosić

**Introduction:** Literature suggests that cephalic approach is more beneficial than subclavian access in preventing complications when performing cardiac implantable electronic devices (CIED) implantation. In recent survey by European Heart Rhythm Association (EHRA) cephalic vein as venous access for lead implantation was the preferred approach in 60% of the centres (1). In University Hospital Centre Split, we prefer cephalic cut - down as first choice for venous approach in single and dual chamber pacemaker implantation. The aim of study was to analyze the success rate of cephalic cut - down in dual chamber pacemaker implantation. **Methods and Results:** We retrospectively analyzed data regarding dual pacemaker chamber implantation from January 2016 to October 2018. During that period 194 dual chamber pacemakers were implanted. Cephalic vein access was achieved by dissection and direct visualization. When needed, to facilitate entry into cephalic vein we used hydrophilic guidewire and/or introducer sheath. In 118 cases (61%) both leads were inserted using cephalic access exclusively. One lead by cephalic cut down and another by subclavian venipuncture was performed in 34 (18%) cases. In 42 (21%) implantations subclavian venipuncture was required for implantation of both leads. **Conclusion**: Our results are in concordance from data of EHRA survey. Use of refinements of the cut-down cephalic approach might obviate puncture of subclavian/axillary veins in majority of cases.

Josip Katić, Ante Anić, Toni Brešković, Zrinka Jurišić, Ante Borovina, Tanja Kovačević, Davor Petrović

**Introduction:** Percutaneous catheter, mostly radiofrequency (RF), ablation for supraventricular tachycardias is an established way of treating symptomatic patients. Traditionally, essential tool for guiding intracardiac catheter manipulation was X ray fluoroscopy. The risks of exposing patients to ionizing, X ray, radiation are well known, and are of particular concern in pediatric cases or cases involving pregnant women. Recently, with the help of electroanatomical (3D), mapping systems, a possibility to perform these procedures without the use of X ray fluoroscopy, so called «zero fluoro», emerged. (1) **Case report:** This is a case report with an overview of some intraprocedural aspects of «zero fluoro» RF ablation procedure performed at University Hospital Centre Split in 12-year-old with the diagnosis of WPW syndrome (symptomatic SVT episodes with delta wave in native ECG). EP study was performed via right groin venous access and diagnostic catheters inserted in coronary sinus (CS) and right ventricle without the use of X ray. Orthodromic AVRT (atrioventricular reentrant tachycardia) was easily inducible and decision was made to proceed with the RF ablation with the intention of maintain «zero fluoro» principle. Single 40W RF application at proximal CS using contact force catheter and reaching the Lesion Size Index of around 7 abolished permanently accessory pathway conduction. Overall procedure time was 51 minutes, including 20 minutes waiting period for AP recovery. No complications occurred and the ECG the day after the procedure had shown no signs of anterograde AP conduction. **Conclusion**: Zero fluoro approach to RF ablation in patients with WPW syndrome is feasible. It should be preferred approach in vulnerable population such as pediatric cases or cases involving pregnant women.

Zrinka Jurišić, Josip Kedžo, Ivan Pletikosić, Marina Jurić Paić, Toni Brešković

**Introduction:** Marijuana is the most commonly used illegal drug worldwide. Despite the overwhelming public perception of the safety of this substance, an increasing number of serious cardiovascular adverse events have been reported in temporal relation to recreational cannabis usage (1). **Case report**: 38-year-old African with permanent residence in Split was brought to emergency room (ER) after he was witnessed to having cardiac arrest. That same evening, 15 minutes after he had consumed cannabis, the patient complained about a burning pain in the throat and collapsed. His spouse started the cardiopulmonary resuscitation. Four minutes later, when the ER medics arrived, ventricular fibrillation was recorded which cardioverted with 2DC shocks (200 J). Subsequently, atrial fibrillation was recorded with ST elevation in inferolateral leads. Upon arrival at the hospital, his vital signs were stable. The Glasgow Coma Scale was 6/15; hence he was intubated and ventilated the following 24 hours. Further ECG monitoring showed sinus rhythm without signs of ischemia. The results of coronarography were normal except non-significant changes of the right coronary artery. With echocardiography, we excluded structural cardiac disease. The results of other imaging methods (MSCT aortography, MSCT of abdomen and brain) were normal. The urine screening showed to be positive for cannabinoids, negative for cocaine, opium, amphetamine and methadone. After his fifth day of hospitalization, the patient left hospital treatment willingly with no neurological and cardiovascular sequels. **Conclusion**: Cardiac arrest is rare but is one of the possible and potential fatal consequences of cannabis usage. The awareness of this is important taking into account the increasing trend of consumption and possible legalization of this drug.

Ante Anić, Toni Brešković, Zrinka Jurišić, Ante Borovina, Ivica Vuković, Darko Duplančić

**Introduction:** Percutaneous catheter, mostly radiofrequency (RF), ablation for supraventricular reentrant tachycardias is an established way of treating symptomatic patients. Traditionally, an essential tool for guiding intracardiac catheter manipulation was X ray fluoroscopy. This not only exposes patients to the risk that ionizing radiation carries, which is of particular concern in pediatric cases or cases involving pregnant women, yet also exhaust the EP lab personnel with the need for wearing leaded X-ray protection. Recently, with the help of electroanatomical mapping systems, the possibility of performing these procedures without the use of X ray fluoroscopy, so called «zero fluoro», has emerged. (1) **Patients and Methods**: This is a case series presentation with an overview of indications and some intraprocedural aspects of RF ablation procedures performed from February 2018 to November 2018 in 31 patients by using the «zero fluoro» approach at the University Hospital Centre Split. **Results:** The mean patient age was 43 (range 12-71), 21 females (68%). In 3, the diagnosis was WPW (Wolff-Parkinson-White) syndrome with right sided or paraseptal accessory pathways, AVNRT (Atrioventricular Nodal Reentrant Tachycardia) was diagnosed in the rest. The mean procedure time was 54.5 minutes (95% CI 42.1 - 69.4), including a 10 minute waiting period for AVNRT and 20 for WPW cases. No complications occurred during any of these «zero fluoro» cases, while acute success had been achieved in all patients. **Conclusion**: The «zero fluoro» approach to PSVT ablation is a modern standard. Centers which are equipped with 3D systems and capable of supporting this technique should offer it to all comers thus saving the patients from X ray exposure risks and lab personnel from wearing leaded aprons.

Ivo Božić, Zrinka Jurišić, Josip Kedžo, Ante Anić, Toni Brešković, Marina Jurić Paić, Ivan Pletikosić

**Introduction**: Cardiac resynchronization therapy (CRT) is standard for heart failure patients with low left ventricular ejection fraction (LVEF ≤35%) and QRS duration ≥130ms despite optimal medical treatment (1). **Patients and Methods**: This is a retrospective study that involved patients with implanted biventricular heart electrostimulators with (CRT-D) or without (CRT-P) defibrillator functions since 2011 to April 2018. The goal was to assess the CRT efficiency during check-ups after 6 months. **Results**: Including 40 patients, 23 men and 17 women of an average age of 66.3 years. There were 4 (10%) patients with ischemic cardiomyopathy (IDCM), while 36 (90%) of the non-ischemic cardiomyopathy (NIDCM) had equal gender distribution. The average width of the QRS was 160 ms, and 75% of patients presented with typical Strauss left bundle branch block (LBBB). At the time of implantation, 6 (15%) patients had atrial fibrillation. The average LVEF value was 28%, and their NYHA status was III. CRT-D was implanted in all patients with IDCM. CRT-P was implanted in 19 and CRT-D in 17 patients with NIDCM. In 36 (85%) patients, there was an improvement of LVEF of which 11 (all with NIDCM, sinus rhythm and typical LBBB) achieved almost normal heart function (LVEF ≥50%) with regression of LV volume. There was no improvement in NYHA status with 5 (12.5%) patients, and with 6 (15%) there was deterioration or there was no improvement in LVEF. Four (10%) patients were hospitalized for acute heart failure. The average LVEF was 45.4% and the NYHA status was I/II. Sudden deaths or syncope in CRT-P patients were absent, while appropriate and necessary treatment of tachyarrhythmia occurred in 3 patients with CRT-D. Lethal outcomes were with 3 patients (one non-cardiac and two non-sudden cardiac deaths). **Conclusion**: Targeted patient selection with proper left ventricular lead implantation and optimal device programming improves the response rate to resynchronization therapy.

Ivana Jurin, Jasmina Ćatić, Sanda Sokol Tomić, Anđela Jurišić, Ana Jordan, Diana Rudan, Irzal Hadžibegović

**Background**: Atrial fibrillation (AF) is less common in women (0.04%) compared to men (0.06%) (1). Several studies have shown that women with AF are more likely to have atypical symptoms, poorer quality of life, higher risk for stroke and they more frequently have rate compared to rhythm control, and they are less represented in the studies on direct anticoagulants (DOAC). (1-3) The primary objective of this study was to show our experience in the prevention of thromboembolic incidents and follow-up of women with paroxysmal and persistent AF. **Methods**: Our study included 597 patients who were hospitalized in the University Hospital Dubrava from April 2011 to October 2017. Of the total number of patients, 311 of them were men and 287 were women. There was no significant difference in the number of women and men with paroxysmal or persistent AF. Women were older than men (70.8 vs 62.9 years). A total of 217 men and 245 women had arterial hypertension, and 56 males and 54 women had type 2 diabetes. There was no difference in body mass index and in estimated glomerular filtration rate (28.18 vs 28.87 and 70 vs 60), nor in the size of the left atrium (4.29 vs 4.22). Considering the CHA2DS2VAsc-score, as many as 35.5% of men had no indication for anticoagulant treatment. As we expected, women had higher CHA2DS2VAsc-score. There was no statistically significant difference between HATCH and LADS score between the groups. The mean follow-up time was 30 months, and in that time, there was no statistically significant difference in progression to permanent AF (74 males vs 87 women). Overall mortality as well as mortality associated with AF in women was significantly higher even after age adjustment. There was no statistically significant difference in bleeding rates between women and men. Women had warfarin in therapy more often than they had DOAC. **Conclusion**: Our research has shown that we are in line with negative global trends regarding the prevention of thromboembolic incidents in women with AF. Women were rarely prescribed DOAC despite their increased thromboembolic risk. Could we influence the mortality associated with AF in women if we would prescribe them DOAC more, it is to investigate.

Ivana Jurin, Tomislava Bodrožić Džakić Poljak, Ana Jordan, Jasmina Ćatić, Irzal Hadžibegović

**Background**: Stratifying patients with paroxysmal or short-term persistent atrial fibrillation (AF) who are at greater risk of developing permanent AF is challenging. There are studies on predicting persistent AF in patients with paroxysmal AF, but studies evaluating natural course of progression to permanent AF are rare. (1, 2) Aim of our prospective study was to evaluate utility of routine demographic, clinical, laboratory and echocardiography parameters, together with evaluated risk scores in prediction of AF progression to a permanent form. **Methods**: In the period of 30 months we prospectively recruited 409 patients with paroxysmal or short-term persistent AF who were treated at discretion of the referral cardiologist in University Hospital Dubrava and followed them for a median follow-up time of 21 months. Clinical, laboratory, and routine echocardiographic parameters were collected. Endpoint was progression to permanent AF when further attempts to restore sinus rhythm were abandoned. **Results**: Out of 409 patients with non-permanent AF, 109 (26.6%) progressed to permanent AF during follow up. Patients who progressed had significantly lower estimated glomerular filtration rate (eGFR), higher age, body mass index, CHA2DS2-VASc score, HATCH score, LADS score, LA diameter, C-reactive protein, red cell distribution width (RDW) and mean platelet volume (MPV) levels, and also higher proportions of arterial hypertension and previous stroke. In multivariate Cox regression model only increased left atrium (LA) diameter, and increased RDW showed significant independent association with progression. When corrected for LA size at 45 mm and RDW level at 14.5% LADS score dichotomized at 0.60. **Conclusion**: LA size and RDW levels strongly moderate estimated risk of AF progression. Although it is still challenging to predict progression, patients with LA size ≤45 mm and RDW level ≤14.5% and a HATCH score <3 had the least probability of AF progression, and are most probably the best candidates for rhythm control strategies.

Petra Grubić Rotkvić, Petar Pekić, Dario Gulin, Jozica Šikić, Tea Friščić, Gordana Sičaja, Hrvoje Budinčević

**Introduction**: Acquired QT prolongation can be caused by drug therapy and electrolyte abnormalities but can also occur as a result of raised intracranial pressure (ICP). QT prolongation is associated with torsades de pointes (TdP), a life-threatening form of polymorphic ventricular tachycardia. **Case report**: 36-year-old man with a known opioid addiction and receiving methadone maintenance therapy (100 mg/day), came to emergency room after an epileptic seizure. On the admission day he took additional unknown dose of methadone. An expansive intracranial process with cerebral edema was found on CT scan. The ECG showed sinus bradycardia and prolonged QT interval, he had recurrent episodes of TdP, some requiring defibrillation (**Figure 1** and **Figure 2**). Intravenous magnesium was immediately applied. Serum potassium and calcium were mildly decreased and therefore adequately corrected. Antiedematous therapy with glucocorticoids was also initiated. Methadone could not be discontinued because of abstinence syndrome, but the dose was reduced. Acute coronary syndrome was excluded, and no structural heart disease was found. Despite the medicamentous therapy, he continued to have TdP so a transjugular temporary pacemaker was placed and the patient was paced at a rate of 90 bpm with successful resolution of ectopy and TdP. Subsequently the patient was transferred to neurosurgical clinic. FIGURE 1. ECG on admission showing QT prolongation and sinus bradycardia. FIGURE 2. Telemetry strip demonstrating polymorphic ventricular tachycardia consistent with torsades de pointes. **Conclusion**: ECG abnormalities can occur in a variety of central nervous system lesions and are related to ICP fluctuation (1). Methadone is a synthetic opioid and QT prolongation is its side effect. Higher doses of methadone (>100 mg/day) are a strong risk factor of inducing QT prolongation, but the lowest dose at which it occurs, has not been clearly established (2). The above-mentioned causes combined with electrolyte abnormalities could contribute to QT prolongation and TdP in our patient. Even though we couldn’t completely discontinue methadone because the patient was opioid addicted, and we couldn’t control ICP until neurosurgical intervention, pacing was a reasonable and effective approach since it shortens QT interval, prevents TdP recurrence and it is especially useful in cases refractory to magnesium or when TdP is precipitated by bradycardia (3).

Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Krešimir Gabaldo, Ivica Dunđer, Božo Vujeva, Đeiti Prvulović, Antonija Raguž, Ivan Bitunjac, Blaženka Miškić, Anto Lukenda

**Introduction**: Thrombus in left atrial appendage (LAA) is an important cause of cerebral thromboembolism. The prevalence and management of LAA thrombi associated with novel oral anticoagulants (NOAC) remain to be clarified. NOACs are superior to warfarin in preventing stroke or systemic embolism, causes less bleeding and results in lower mortality in patient with atrial fibrillation. In literature, there aren’t too many reports of resolution of LAA thrombus with NOACs. (1, 2) The gold standard for the diagnosis of LAA thrombi remains transesophageal echocardiography (TEE). In patients diagnosed with LAA thrombi, the optimal duration of therapy is uncertain. **Case report**: We present a 59-year-old male patient with persistent atrial fibrillation associated with left atrial thrombus. Initial treatment was with rivaroxaban 20 mg once a day for thirty days. Despite the fact that he was on rivaroxaban thirty days before, we decided to perform TEE, which revealed the formation of a small thrombus (12x10 mm) in the LAA. Thirty days of dabigatran treatment showed complete thrombus resolution. Finally, cardioversion with 120 J was performed successfully without signs of cardiac embolism and the patient was discharged in good medical condition under continued anticoagulant treatment with dabigatran 150 mg twice a day. **Conclusion**: In this case, we selected dabigatran after rivaroxaban. To our knowledge, this is the first documented case of LAA thrombus resolution under dabigatran therapy after unsuccessful rivaroxaban 20 mg once a day therapy. Therefore, dabigatran could be considered to have an important role in rhythm control strategies in similar cases. It requires further investigation in a larger population.

Ammar Brkić, Emir Bećirović, Tarik Brkić, Esad Brkić, Denis Mršić, Amila Jašarević, Majda Skokić

Supraventricular tachycardia (SVT) is defined as an abnormally rapid heart rhythm, with a narrow complex (QRS < 120 milliseconds) having an electropathologic substrate, essential for sustaining the arrhythmia, emerging in atrial or atrioventricular nodal tissue. Most types of SVT are triggered by a reentry mechanism that may be induced by premature atrial or ventricular ectopic beats and are classified according to the location of the reentry circuit. The incidence of SVT is about 35 cases per 100 000 population per year, with a prevalence of 2.29 cases per 1000 population. (1) Excluding the atrial fibrillation and atrial flutter as specific individual arrhythmic entities, supraventricular tachycardia is categorized based on the length of PR interval. First line treatment of patients presenting with sustained SVT is usually to slow conduction through the atrioventricular node, rarely, the arrhythmia is poorly tolerated that immediate electrical cardioversion is needed. Atrioventricular node conduction can be slowed by vagal stimulation with carotid sinus massage or the Valsalva maneuver. If vagal maneuvers are unsuccessful then, recommended first line medication in slowing atrioventricular conduction is intravenous administration of adenosine, unless the patient suffers from chronic obstructive pulmonary disease. The effectiveness of intravenous verapamil seems similar to that of adenosine in terminating SVT, with slightly lower rates of adverse effects such as hypotension associated with adenosine. Major therapeutic goal for SVTs should be improvement of patients quality of life according to symptomatology and patient preferences. Long-term treatment should be offered to patients which suffer from recurrent symptomatic episodes, prolonged medical treatment or catheter ablation. Catheter ablation provides a definitive management option for SVT and after the procedure, most patients can return to their normal activities very quickly.

Lada Bradić, Martina Lovrić Benčić, Marija Peremin

**Introduction:** Frequent premature atrial complexes (PACs) are associated with increased risk of stroke and adverse cardiovascular events. PACs might be a surrogate for occult atrial fibrillation (AF) in patients with stroke, and indicators of underlying atrial cardiomyopathy. Resulting atrial hypocontractility and endothelial dysfunction contribute to stroke occurrence, even in the absence of AF. Timely identification of AF precursors may reduce stroke-related burden. (1-3) **Patients and Methods:** We retrospectively analyzed 307 patients (56% male, 44% female), age 37-95, 72 years on average, admitted to Neurology Department from January to June 2018 for transitory ischemic attack (TIA) or cerebrovascular insult (CVI). Excessive atrial ectopy was arbitrarily defined as >2000 PACs/24-hours and/or ≥10 SVT of any duration and/or ≥1 lasting for ≥10 s and/or AF <30 s in 24-hour Holter monitoring. Control group consisted of age and sex-matched subjects referred to 24-hour Holter monitoring for any reason other than CVI in the same time period. **Results:** On admission, 73% of patients presented with first CVI, 12% with recurrent CVI, 12% with TIA, and 3% with TIA and a history of CVI. Criteria for AF were not met in 79% of patients, 11% had a history of AF (yet 73% were inadequately anticoagulated or not at all) and 11% were newly diagnosed with AF. Excessive PACs were found in 19% of patients. Frequent atrial ectopy in cerebrovascular accidents vs. control was found in 58 vs. 29 patients, respectively (RR:1.44, 95% CI:1.20-1.73, p=0.0001). **Conclusion:** A significant proportion of underdiagnosed patients emerges if we use excessive atrial extrasystolia as a surrogate for undetected AF and underlying atrial cardiomyopathy in patients with TIA or CVI. If we add inadequately and non-anticoagulated patients, the proportion of subjects at risk increases even further. Proper anticoagulation in patients with proven AF is not questionable, but should we consider treating excessive atrial ectopy as a precursor to AF?

Edin Begić, Enisa Hodžić, Zijo Begić

**Introduction:** Brugada syndrome (BS) is a dominantly inherited arrhythmogenic disease caused by a mutation in the SCN5A gene. It accounts for 20% of cases of sudden death, without structural heart abnormalities (1). Diagnosing the BS is achievable by electrocardiography (ECG), ST segment elevation in V1 to V3, with the right bundle branch block pattern as a hallmark of the syndrome (2). BS is divided into three types. However, only type 1 can be verified with an ECG (2, 3). BS manifests as a syncope that is caused by ventricular tachycardia, which, if converted to ventricular fibrillation, leads to a fatal outcome. An implantable cardioverter defibrilator (ICD) implantation is indicated, while pharmacological therapy on its own is not sufficiently effective. Aim: To present a diagnostic and therapeutic approach towards suspected BS in a younger patient. **Case report:** 24-years-old patient was admitted to a hospital, after a cardiac arrest and a prolonged cardiopulmonary resuscitation with intubation. ECG findings verified sinus rhythm, with heart rate of 94 beats per minute, normal heart axis with PQ interval of 0.16 s, and right bundle branch block (RBBB) with an ST elevation from V1 to V3. An ajmalin provocation test was performed, and ECG changes (J-wave elevation of >2 mm with ST elevation from V1 to V3 with RBBB) were recorded, but without induced ventricular arrhythmia. Patent foramen ovale was suspicious as a cause, but after transesophageal echocardiography it was excluded. According to electrocardiographic changes, the BS was diagnosed as the cause of malignant ventricular heart rhythm. Genetic testing for Brugada syndrome was not performed and in consultations with the Centre for Electrophysiology in Sarajevo (Bosnia and Herzegovina) and Zadar (Croatia), the implantation of an ICD was indicated, and subsequently performed. The patient was discharged under pharmacological therapy consisting of metoprolol 25 mg twice per day, amiodarone 100 mg per day, with magnesium, and aspirin once per day. **Conclusion:** In daily clinical work, in all conditions of syncope occurring in younger patients, in order to prevent sudden death, an existence of the BS should be considered. An overall clinical status of a patient, including positive ajmaline test with specific ECG changes, can verify BS, even when information on the presence of the SCN5A gene is not available.

Emir Becirovic, Ammar Brkic, Esad Brkic, Amira Kusljugic, Edita Sijercic, Hazim Tulumovic, Denis Mrsic, Daniela Loncar

**Background:** Atrial fibrillation, as the most common type of arrhythmia, affects 1-2% of general population. Currently more than 6 million Europeans are experiencing this condition, since the average age of population is increasing, and it is expected that this number will rise in next 50 years by 250%. Atrial fibrillation usually leaves lasting consequences on patients overall health. Preventing them is the main therapeutic goal. (1-3) The main objective of this study was to inspect the efficiency of sinus rhythm restoration by means of electrocardioversion. Hemodynamically unstable patients (suffering from angina pectoris or hypertension), unresponsive to resuscitation, are subjected to emergency electrocardioversion. On the other hand, stable patients should undergo electrocardioversion procedure after three week long anticoagulant treatment with warfarin. Patients should continue taking warfarin for four weeks after the procedure in sake of blood clot forming prevention. **Case report:** From January 2017 to September 2018, 58 elective cardioversion cases were done by the Intensive Therapy Unit of the University Clinical Center of Tuzla, 12 of which were atrial flutter patients, while 40 patients had atrial fibrillation. From those 40 cases of atrial fibrillation, 6 patients underwent two cardioversion treatments using 150 J of energy, followed by single 200 J treatment. In 50 cases patients were brought back to sinus rhythm straightaway after the first treatment. **Conclusion:** Although efficiency rate is high (96%), qualified personnel and suitable equipment remain the most important requirements for successful and safe electrocardioversion. In long-term fibrillation, success rate of electrocardioversion and sinus rhythm perseverance decreases over time, especially if it lasts for more than a year. In that case, monitoring of the heart rate and anticoagulative therapy should be minded.

Ante Anić, Toni Brešković, Zrinka Jurišić, Ante Borovina, Mihajlo Lojpur, Dubravka Kocen, Denis Nenadić, Cristian Bulat, Ivica Vuković, Darko Duplančić

**Introduction:** Percutaneous catheter ablation for ventricular tachycardias (VT) is an established way of treating symptomatic. Endocardial approach to ablation is often not sufficient to gain full control of arrhythmia since substrate is contained closer to epicardial myocardium layer. This is especially true for the patients with the non-ischemic cardiomyopathy (NICM). It is for this subset of patients that percutaneous, subxiphoid, epicardial approach for ventricular tachycardia ablation should be utilized (1). **Patients and Methods:** This is a case series presentation with an overview of indications and some intraprocedural aspects of epicardial VT ablation procedures performed from December 2017 to November 2018 in 5 patients in whom we used this approach at University Hospital Centre Split. **Results:** All the patients had diagnosis of NICM (3 dilated cardiomyopathy, 2 post myocarditis). Mean patient age was 57 years (range 27-71), all males. Procedures were done in general anesthesia. The puncture of pericardial space was obtained under an X ray guidance using standardized views and protocol. In 3, epicardial approach was utilized because of the history of previous failed endocardial ablation, while in the rest imaging data pointed toward epicardial substrate (MRI or echocardiography data). All the ablations were done with help of the 3D mapping system, using dedicated, steerable sheath for epicardial approach and contact force sensing catheters. Mean procedure time was 279±33 minutes. No radiofrequency application was applied epicardialy in one patient since the electroanatomical data show no clear arrhythmia substrate. In the rest, combined endo and epi approaches were utilized to gain VT noninducibility at the end of procedures with aggressive stimulation protocol with up to 4 extrastimuli. No complications occurred during any of these epicardial VT cases and all the patients were discharged 2 days after the procedure. **Conclusion:** Epicardial VT ablation is highly invasive procedure with substantial list of serious complications, but when done in institutions with cardiac surgery back-up and high-volume cardiac electrophysiology team holds a promise to gain a control over VT recurrency and prolong patients’ life.

Tomislav Letilović, Luka Perčin, Vedran Radonić, Goran Kurdija, Damir Kozmar, Darko Počanić, Mario Stipinović, Ivana Jurin, Hrvoje Gašparović, Helena Jerkić

**Introduction**: Most of the patients scheduled for cardiac surgery spend certain amount of time on the waiting list. Previous studies have shown that those patients have a risk of new major adverse cardiovascular events (MACE) while awaiting surgery. (1, 2) The first goal of this study was to determine the frequency of occurrence of MACE in patients awaiting cardiac surgery after being invasively assessed at the Department of Cardiology of University Hospital “Merkur”. Furthermore, we tried to find association of various clinical characteristics and higher degree of MACE. **Patients and Methods**: Data were collected from patients presented at out heart team meetings in the period from March 2013 to the end of 2016. Relevant clinical characteristics, of patients regarded as good cardiac surgery candidates, were gathered from central hospital system. Information regarding MACE were collected via telephone contact with a patient or its family and through examining medical documentation if it was available MACE was defined as either death, stroke, myocardial infarction or heart failure. **Results**: We gathered data from 333 patients. Mean follow-up time, defined as a time to surgery or to MACE, was 238.51 days (range 3 do 1269 days). There were 33 (9.9%) adverse events. From various clinical parameters that were tested only previous stroke (p=0.002; HR 1.77-13.23) and diabetes (p=0.036; HR 1.06-5.69) were independently associated with higher rate of MACE. Previous myocardial infarction showed a marginal association with higher rate of MACE (p=0.05; HR 0.99-6.37). None of the other relevant clinical data, including the data on the extent of the coronary disease or/and associated valvular pathology was found to be related to occurrence of MACE. **Conclusion**: In patients awaiting cardiac surgery one can expect adverse cardiovascular events to occur. Previous stroke, diabetes and to some extent previous myocardial infarction were found to be related to higher degree of such events.

Vedran Đambić, Ivica Bošnjak, Aleksandar Kibel

**Introduction**: Syntax score II (SS II) is an angiographic-clinical tool that allows an objective individualization of mortality prediction in patients suffering from multivessel coronary artery disease (CAD) (1). Multivessel CAD indicates the involvement of at least two epicardial coronary arteries and represents a local manifestation of atherosclerosis (2, 3). The aim is to examine whether dyslipidemia, hyperuricemia and the presence of diabetes have a positive correlation to higher SS II values. **Patients and Methods:** 72 participants with multiple CAD hospitalized during the period of October 1, 2015. to October 1, 2017 were included. The necessary data was obtained from the hospital information system (BIS) and the hospital archive. An online calculator was used to calculate the SS I for which an interpretation of the coronary angiogram is required, and then the SS II involving two anatomical (SS I, left main coronary artery involvement) and six clinical variables (age, gender, creatinine clearance, ejection fraction, presence of chronic obstructive pulmonary disease and peripheral vascular disease in anamnesis). **Results:** There is a significant positive correlation of high-density lipoprotein (HDL) concentrations, and the proportion of patients with low-density lipoprotein (HDL) levels above the reference values, with SS II percutaneous coronary intervention (PCI) (median 46.3; P = 0.04). The participants with lower LDL values have significantly elevated SS II coronary artery bypass graft (CABG) values (median 35.5; P = 0.04), but not SS II PCI. There is no significant correlation of total cholesterol and triglycerides with SS II PCI or SS II CABG. The participants with hyperuricemia have a significantly higher value of SS II PCI (median 43.7; P = 0.04), but not SS II CABG. Diabetes as a comorbidity is present in 32 (44%) participants who have a significantly elevated SS II PCI (median 43.4; P = 0.03), but not SS II CABG in comparison with non-diabetic participants. **Conclusion**: SS II is associated with some of the classic risk factors for atherosclerosis (uric acid, diabetes), while in our group of participants there is a surprising correlation of SS II with high HDL levels and low LDL levels.

Helena Jerkić, Zrinka Sertić, Mladen Knotek, Tajana Filipec Kanižaj, Mario Stipinović, Darko Počanić, Damir Kozmar, Tomislav Letilović

**Introduction:** The presence of cardiovascular (CV) risk factors or established CV disease before transplantation is associated with increased adverse events in both renal and liver transplant recipients (1, 2). Studies comparing pretranstplant CV status and CV outcomes of those two population groups are generally lacking. Therefore, we compared those two groups according to pretransplant CV risk status, echocardiographic abnormalities and established CV disease. Differences in short-term and long term adverse cardiac events were further studied. **Patients and Methods:** We consecutively enrolled 99 renal and 220 liver patients transplanted at Merkur University Hospital, Zagreb. Follow up period was up to 27 months. The data were collected from institutional computer system. Major adverse cardiac events (MACE) during follow up were defined as death, myocardial infarction (MI) or stroke. **Results:** Renal transplant recipients were younger (54.7 vs 59.3 years; p=0.014) and showed higher prevalence of hypertension (81.6% vs 52.6%; p<0.001) and hyperlipidemia (67.5% vs 43.8%; p<0.001). Echocardiographic parameters revealed significantly reduced diastolic function (p=0.035) in renal patients. Liver patients had more tricuspid valve regurgitation (76.1% vs 53.6%; p=0.04). Renal recipients had higher prevalence of previous MI (7.9% vs 3.1%; p=0.008), percutaneous coronary intervention (9.6% vs 1.8; p<0.001) and peripheral artery disease (21.9% vs 6.2; p<0.001). No differences in MACE, when renal patients were compared to liver patients, was found up to 30 days (4.2% vs 10.9%; p=0.20) and beyond 30 days (5.4% vs 8.1%; p=0.31) following transplantation. **Conclusion:** Renal and liver transplant recipients differ significantly in pretransplant presence of CV risk factors, echocardiographic parameters and established CV disease. Yet, we could not find any differences in both early and late MACE in those two groups.

Damir Fabijanić

More than 90% of sudden cardiac deaths (SCD) is caused by coronary artery disease (CAD) with arterial stenosis greater than 75%. The pathophysiology bases of SCD - often the first manifestation of CAD – are malignant arrhythmias (ventricular tachycardia and ventricular fibrillation). Until 10 years ago, the investigation of ventricular arrhythmogenesis, in order to predict the arrhythmogenic potential and prevent SCD, was focused to QT and QTc (corrected QT intervals) and QT and QTc (corrected QT) dispersion (QTd, QTcd). (1-3) In this context, the prolonged QT interval was accepted as an indicator of extended repolarization time, and increased QT dispersion was considered a reflection of spatial differences in myocardial repolarization. Recently, research of ventricular arrhythmogenesis has been increasingly focused on two newer electrocardiographic (ECG) indicators: Tp-e (T peak-to-end) interval and Tp-e/QT ratio. According to the latest findings, these ECG indicators are the reflection of transmural heterogenicity of repolarization, i.e. the differences in voltage between the individual layers of the same segment of the ventricle wall. Their changes are accepted as a promising indicator of arrhythmogenic potential in patients with several cardiovascular diseases, such as prolonged (congenital or acquired) QT syndrome, short QT syndrome, Brugada syndrome, hypertrophic cardiomyopathy, acute coronary syndrome and chronic stable CAD. This presentation will provide basic insights into the electrophysiological background of the Tp-e interval and the Tp-e/QT ratio with particular attention to their changes in CAD patients in which restoration of blood supply normalizes exercise-induced repolarization abnormalities, suggesting that revascularization of a previously ischemic myocardium lowers its arrhythmogenic potential.

Davor Barić, Daniel Unić, Robert Blažeković, Željko Sutlić, Bojan Biočina, Igor Rudež

**Background:** Multiple arterial myocardial revascularization seems to offer better long-term graft patency, lower incidence of major adverse cardiac and cerebrovascular events and better long-term survival compared to revascularization with usage of single arterial graft (1-3). Radial artery (RA) has shown to be an excellent choice for second arterial graft, with several benefits over alternative options. Here is presented the 20 years long experience of using radial artery in our Clinic. **Patients and Methods:** In this retrospective study all patients in whom RA was used for surgical myocardial revascularization with multiple arterial grafts were included. Demographic and perioperative data, as well as transit-time flow measurement data were gathered from our Clinic’s database. **Results:** There has been a total of 1421 RA grafts used in 1302 patients since 1998. The mean of distal anastomosis was 2.6±0.6 (2-5). Total arterial revascularization was achieved in 936 (72%) patients. In 66 patients (5%) additional procedure on aortic valve, mitral valve or left ventricle was performed. In 615 patients (half of patients with isolated coronary artery disease) revascularization was done as an off-pump CABG. There were no ischemic complications or postoperative wound infections. 2 patients (0.15%) had radial nerve injury. Radial artery grafts were mostly used in circumflex artery territory (641 grafts, 42%) and right coronary artery territory (599 grafts, 38%). Intraoperative transit-time flow measurements were routinely performed and showed excellent mean flow (46.6 ml/min), diastolic filling (62.9%) and pulsatility index (2.6). **Conclusion:** Although this study does not provide any conclusions about long-term graft patency or patient survival, results for the past two decades show that radial artery can be routinely used in multiple arterial myocardial revascularization with exceedingly rare complications and excellent intraoperative flows.

**Background and aim:** Previous studies found conflicting results on the effects of earlier invasive intervention in a heterogeneous population of acute non-ST elevation myocardial infarction (NSTEMI) (1). Our aim was to explore in-hospital and 1-year follow-up outcomes in NSTEMI patients (pts) treated with PCI in the first 24 h, PCI after 24 h and optimal medical therapy (OMT). **Patients and Methods:** From January 2012 to October 2017, 1898 pts were enrolled in the Croatian arm of the ISACS-CT registry (NCT01218776) 36% (n=685) with NSTEMI, of which 675 had available data on treatment modality. One-year follow-up was available in 217 (32%) of the NSTEMI patients. **Results:** In 57% (n=386) of pts PCI was done within 24 h from symptoms onset, in 14% (n=95) after 24 h, while 29% (n=194) were discharged with OMT. Pts in the OMT group were significantly older, with more comorbidities, with a lower left ventricular ejection fraction (LVEF) value at discharge and greater delay from symptom onset to hospitalization (**Table 1**). Pts with PCI performed within 24 h had the greatest frequency of PCI reintervention during follow-up (PCI ≤ 24 h; PCI > 24 h; OMT: 15%; 3%; 0%; p=0.008). In-hospital mortality did not significantly differ between the groups (PCI ≤ 24 h; PCI > 24 h; OMT: 2.5%; 3.5%; 4.6%; p=0.220), yet in those with data on 1-year mortality (**Figure 1**), this was the highest in the OMT group (PCI ≤ 24 h; PCI > 24 h; OMT: 3.3%; 8.3%; 19.4%; p=0.005). Univariable regression suggested that PCI 25, P75) kg/m2 | 28.7 (26.1, 31.9) | 28.6 (25.6, 32.6) | 27.7 (25.1, 31.1) | 0.183 | | Beta-blockers before initial admission, n (%) | 150 (39) | 37 (40) | 90 (52) | **0.013** | | Diuretics before initial admission, n (%) | 116 (30) | 42 (45) | 94 (49) | **25, P75) µmol/L | 94 (80, 109) | 90 (77, 114) | 103 (85, 128) | **25, P75), days | 5 (4,8) | 5 (4, 9) | 8 (6,11) | **<0.001** | [†] PCI – percutaneous coronary intervention, OMT – optimal medical therapy, BMI – body mass index, EF – left ventricular ejection fraction, SD – standard deviation, P – percentile, h – hours. FIGURE 1. Patient survival. OMT – optimal medical therapy, PCI – percutaneous coronary intervention. **Conclusion:** NSTEMI patients in the three treatment groups had different risk profiles at hospitalization, the OMT group being burdened with most comorbidities. The therapy of choice did not seem to have a significant influence on in-hospital or 1-year survival. Due to their higher risk profile, the pts treated with OMT had significantly lower 1-year survival, with lower LVEF and higher rate of CKD as predictors of primary outcome.

Filip Puškarić, Maja Čikeš, Zvonimir Ostojić, Marijan Pašalić, Ivo Planinc, Joško Bulum, Davor Miličić

**Introduction:** Acute coronary syndrome (ACS), including acute ST-segment elevation myocardial infarction (STEMI), is more prevalent in older patients (pts), leading to fewer studies with young pts. (1) The age limit varies among studies, but a cut-off of 45 years (yr.) is the most common. Traditional differences described in the risk factors for younger compared to older pts. include a higher prevalence of smoking, family history of premature coronary heart disease (FH) and male gender. **Patients and Methods:** We performed a retrospective analysis of medical records of 164 pts. (mean age 43.9±6.5 yr.) hospitalized with STEMI at the University Hospital Centre Zagreb from January 2012 to October 2018, with a cut-off at 45 yr. for men (n=102) and 55 yr. (n=62) for women. Analyzed variables are listed in **Table 1**. Body mass index (BMI, kg/m2) was interpreted as: ≤18.5 (underweight), 18.6–24.9 (normal), 25.0–29.9 (overweight), ≥30 (obese). Positive cardiovascular FH was defined as relatives with ACS, stable coronary artery disease (SCAD) or cerebrovascular disease. ### TABLE 1: Patients’ characteristics. | **Variable** | **N (%)** | **Variable** | **N (%)** | | --- | --- | --- | --- | | **Gender** | | **Thyroid condition** | | | Male | **102** (62.2) | Hypothyroidism | **8** (4.9) | | Female | **62** (37.8) | Hyperthyroidism | **0** (0) | | **BMI** | | **Therapy at discharge** | | | = 30.0 | **58** (37.4) | Ticagrelor | **67** (41.4) | | **Smoking status** | | Beta blocker | **134** (82.7) | | Non-smokers | **26** (16.3) | ACE inhibitor | **127** (78.4) | | Former smokers | **9** (5.6) | ARB | **5** (3.1) | | Current smokers | **125** (78.1) | MRA | **22** (13.6) | | **Arterial hypertension** | **80** (49.4) | Nitrate | **20** (12.3) | | **Diabetes mellitus** | | Statin | **159** (98.1) | | Type 1 | **2** (1.2) | Antiischemic drug | **11** (6.8) | | Type 2 | **10** (6.2) | Factor Xa inhibitor | **40** (24.7) | | **Therapy for diabetes mellitus** | | Antiarrhythmic | **17** (10.5) | | Insulin | **3** (1.9) | Diuretic | **12** (7.4) | | Oral hypoglycemics | **7** (4.4) | Heparin | **4** (2.5) | | **Positive family history** | **87** (53.7) | Vasodilator | **1** (0.6) | | | | Fibrate | **5** (3.1) | | | | Warfarin | **3** (1.9) | [†] BMI = Body Mass Index; ACE = Angiotensin-Converting Enzyme; ARB = Angiotensin II Receptor Blocker; MRA = Mineralocorticoid Receptor Antagonist **Results:** As seen in **Table 1**, the majority of pts. were male (62.2%), had a high BMI (n=119; 76.8%), and were current smokers rather than former or non-smokers (78.1% vs 5.6% and 16.3%). The majority of pts. had positive FH (53.7%), whereas the minority had arterial hypertension (49.4%), diabetes mellitus (DM; 7.4%) and a thyroid condition (4.9%). In-hospital mortality was 0.6% (n=1), while 10.4% of pts. (n=17) required rehospitalization (rehosp.). The vast majority of rehosp. were due to ACS (64.7%), followed by SCAD (11.8%), arrhythmias (11.8%), heart failure (5.9%) and other causes (5.9%). A significant correlation was found between the need for rehosp. and the length of stay during hospitalization for the initial STEMI (OR=1.105, p=0.01), as well as with insulin-treated DM (OR=22.873, p=0.01). **Conclusion:** The most prominent risk factors in the studied population of young STEMI pts. were smoking, increased BMI and male gender. Roughly one out of ten pts. required rehosp., largely due to ACS, which mostly occurred in pts. with longer initial hospitalization lengths or those on insulin therapy. In-hospital mortality was noted in only one patient.

Zrinka Planinić, Ante Pašalić, Tea Friščić, Marko Perčić, Dario Gulin, Leon Adrović, Jozica Šikić

**Introduction**: Hyperlipidemia is a major risk factor for coronary heart disease. Early treatment of hyperlipidemia following acute coronary syndrome (ACS) provides potential benefits. According to ESC Guidelines for the Management of Dyslipidaemias (1), it is recommended to initiate a high-dose statin therapy early after admission in all ACS patients, regardless of initial low-density lipoprotein cholesterol (LDL-C) values, with the aim of reaching the LDL-C goal < 1.8 mmol/L or at least a 50% reduction of LDL-C if the baseline is between 1.8 and 3.5 mmol/L. (1, 2) The latest results of EUROASPIRE V study showed that even though the majority of patients with ACS were receiving lipid-lowering therapy, only about one in three of these patients attained the recommended LDL-C goal values. The aim of this study was to investigate how many patients discharged with the diagnosis of ACS reach the recommended LDL-C goal values at 3-month follow-up. **Patients and Methods**: We retrospectively analyzed 206 patients discharged with a diagnosis of ACS: 90 patients (44%) had ST-segment elevation myocardial infarction, 86 (42%) had no ST-segment elevation myocardial infarction, and 30 (14%) had unstable angina pectoris. Among patients diagnosed with ACS, 66% were men and 34% were women, with a mean age of 66.13 years old. All patients received high-dose statin therapy (atorvastatin 80 mg or rosuvastatin 40 mg), a few of them even in combination with ezetimibe. We analyzed the baseline LDL-C values during hospital admission and after discharge at 3-month follow-up. **Results**: The average LDL-C value during hospital admission was 3.36 mmol/L, considering that 28% of patients already had some type of lipid-lowering therapy. At 3-month follow-up the average LDL-C value was 2.19 mmol/L. The target level of LDL-C < 1.8 mmol/L was attained by 38% of patients (**Figure 1**). FIGURE 1. Therapy effect on LDL-cholesterol reduction. LDL-C = LDL cholesterol. **Conclusion**: Only 38% of patients with ACS reached the LDL-C target at 3-month follow-up despite recommended therapy, which correlates with EUROASPIRE V findings. The poor goal attainment might be due to poor dietary habits and inadequate lifestyle. Therefore, we need to improve lipid management in ACS patients in secondary prevention.

Saša Pavasović, Peter Louis Amaduzzi, Dora Fabijanović, Petra Mjehović, Filip Lončarić, Edina Cenko, Olivia Manfrini, Zorana Vasiljevic, Sasko Kedev, Lina Badimon, Davor Miličić, Raffaele Bugiardini

**Background:** Due to an ageing population in Europe, there will be more and more elderly patients presenting with non-ST-elevation acute coronary syndromes (NSTE-ACS). Despite these findings there is limited data available on outcomes of elderly patients (>75 years) either in observational studies or randomized controlled trials. (1) Objective: To explore whether early percutaneous coronary intervention (PCI) within 24 hours of admission may improve outcomes in elderly patients (>75 years). **Patients and Methods:** We analyzed elderly patients enrolled in 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776) from January 2010 to January 2018. The primary end-point was composed of 30-day mortality and severe LVSD, defined as ejection fraction <30% as measured by echocardiography on discharge. The components of primary end-point were analyzed as secondary end points. For the safety analysis Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding events were analyzed. A landmark analysis was performed with a cut-off point of 24h excluding all patients that died within this time. We also excluded all patients who received PCI after 24h or who had a coronary artery bypass surgery. As an added analysis we also performed an inverse probability of treatment weighting (IPTW) analysis to balance clinical covariates. **Results:** There were 957 subjects with a mean age of 80±4 years in the medical therapy group and 298 subjects with a mean age of 79±4 years in the PCI group. After multivariate adjustment for age, sex, renal function, risk factors, clinical presentation, prior cardiovascular disease and in hospital medical therapy (within 24h), early PCI reduced the occurrence of the primary end-point in the cohort (OR, 0,38; 95% CI 0.22–0.68). The secondary endpoints of severe LVSD and 30-day mortality were reduced in the PCI cohort as well (OR 0,45; 95% CI 0,23-0,88) and (OR 0,33; 95% CI 0,13-0,84) respectively. The effect on the primary end-point persisted after IPTW, even though the effect was less pronounced in comparison with the unweighted model (OR 0,89; 95% CI 0,85–0,92); **Figure 1**). Bleeding events occurred in 4 patients (2.4%) in the PCI group and 0 in the medical therapy group (P=0.671). FIGURE 1. Multivariate regression analysis of primary and secondary outcomes. **Conclusion:** Elderly patients treated with early PCI showed reduced rates of primary and secondary end-points compared to those treated with medical therapy. There was no significant difference in the number of bleeding rates between the groups.

Vera Slatinski, Ante Pašalić, Tea Friščić, Marko Perčić, Zrinka Planinić, Jozica Šikić, Edvard Galić

**Introduction:** Acute myocardial infarction (AMI) is one of the most common causes of death, especially in those who develop cardiogenic shock (CS). The ECG is a main tool in making a diagnosis of the localization of myocardial infarction (MI) and the possible location of the culprit lesion. ST-segment elevation (STE) in lead aVR is of great importance because it is a sign of either left main coronary artery (LM) occlusion or of proximal left anterior descending artery (LAD) or left circumflex artery (ACx) occlusion. STE in aVR > V1 STE suggests of the LM occlusion. The opposite ratio suggests of proximal LAD occlusion. Other ECG features of LM obstruction include diffuse ST-segment depression in precordial and inferior leads. Such patient demands an urgent myocardial reperfusion either via percutaneous coronary intervention (PCI) or, extremely rare, a coronary artery bypass grafting (CABG). CABG accounts STE in V1 and ST depression in other leads. Laboratory tests showed high troponin levels. Echocardiography showed hypokinesis of anteroseptolateral left ventricular wall with mild reduction in LV systolic function (EF 45%). Meanwhile, the patient developed CS, with high lactate levels. After patient stabilization by inotropes, an urgent coronarography was performed. It showed subocclusion of LM, as well as subocclusion of ostial LAD and left circumflex artery (ACx) which is additionally significantly stenosed in proximal segment, and proximal significant stenosis of right coronary artery (RCA). The patient was immediately transferred to cardiac surgery where triple CABG was created, LIMA with LAD and obtuse marginal branch (OM1) and RCA with vein saphena magna. Postoperatively, the patient was hemodynamically stable with normal LVEF. **Conclusion:** Previous studies showed that STE in aVR > STE in V1 suggest LMCA occlusion which we did not find in our patient. New recommendations for universal definition of myocardial infarction suggest that STE in aVR >1 mm is equivalent to myocardial infarction with STE.

Jozica Šikić, Ante Pašalić, Jasna Čerkez Habek, Tea Friščić, Dario Gulin, Edvard Galić

**Introduction**: Hyperhomocysteinemia (Hhcy) is a rare condition, observed in 5% of the general population, more commonly in men. It is mostly caused by a mutation in the MTHFR gene responsible for encoding methylenetetrahydrofolate reductase. Other possible causes include mutations in methionine synthase gene, vitamin B6, B12 or folate deficiency. It may be associated with cardiovascular diseases, renal failure, diabetes mellitus, muscle atrophy, and persistent hypercoagulable state, which can lead to acute coronary syndrome (ACS), acute cerebrovascular events (ACE) and deep venous thrombosis (DVT) (1, 2). **Case report**: We present a case of a young man, 35-years-old, who suffered multiple strokes and transient ischemic attacks, causing right sided hemiparesis and dysphasia. Extensive neurological evaluation showed numerous ischemic lesions. He had dilatated cardiomyopathy (5.8 cm) with mildly decreased left ventricular ejection fraction (50%), frequent episodes of nodal rhythm, bradycardia (3.8 seconds. A permanent VVI pacemaker was implanted. Due to muscular hypotrophy, muscle biopsy was performed, which excluded any known dystrophy. In June 2016 patient was hospitalized with typical stenocardia with normal electrocardiographic (ECG) finding and troponin levels. Coronary angiography has been performed, and coronary artery disease (CAD) has been excluded. In March 2017, due to physical activity patient has had typical stenocardia again. We have found high troponin levels and ST depression in inferoposterior leads on the ECG. Coronary angiography again showed no signs of CAD. Extensive diagnostics were performed in order to see whether the patient suffers from a hereditary hypercoagulable state. Mentioned analysis has showed that patient is homozygous for MTHFR gene and heterozygous 4G/5G PAI-1 gene. Permanent oral anticoagulant therapy as well as vitamin B12 and folate were introduced. **Conclusion**: Hyperhomocysteinemia is a rare condition which can be associated with muscle hypotrophy, as well as hypercoagulable state by which it can lead to ACS and ACE. Therefore, Hhcy should be taken into account in especially in healthy young adults especially because by using therapy, its consequences could be prevented.

Dora Fabijanović, Nina Jakuš, Filip Lončarić, Petra Mjehović, Dorja Sabljak, Antonija Mišković, Dominik Oroz, Ines Vinković, Vedrana Vlahović, Grgur Salai, Saša Pavasović, Maja Čikeš, Davor Miličić

**Background and Aim:** The relevance of statin therapy in acute coronary syndrome (ACS) is well-established, but little is known about the optimal timing of statin administration, particularly within the first 24 hours following ACS. (1, 2) The aim of the study was to gather data on early and late outcomes of ACS patients (pts) through the Croatian branch of the ISACS-CT (International Registry of Acute Coronary Syndromes in Transitional Countries) registry. **Patients and Methods:** The data was gathered retrospectively from January 2012 to October 2017. The study population included 1898 ACS pts: 46.4% (n=881) with ST-segment elevation myocardial infarction (STEMI), 36.1% (n=685) with non-ST-segment elevation myocardial infarction (NSTEMI) and 17.5% (n=332) with unstable angina pectoris (UA). Follow-up was performed on 33% (n=630) of the cohort, 43.7% (n=275) with STEMI, 34.4% (n=217) NSTEMI and 21.9% (n=138) with UA. **Results:** In the first 24 hours following ACS, statins were administered in 1734 (93%) pts (for 24 pts the data is missing), while the pts who received them later or not at all were the control group. The two groups did not differ regarding age, gender, body mass index, left ventricular ejection fraction (LVEF) during initial hospitalization, smoking status, history of diabetes, chronic heart failure or arterial hypertension at initial hospitalization nor at 1-year follow-up (**Table 1**). The overall in-hospital mortality rate was 4%, similar to that in pts treated with statins within the first 24 hours (3%), while in pts without early statin treatment, in-hospital mortality rate was 18% (p<0.001). The risk of in-hospital death was significantly higher in pts without early statin therapy (odds ratio [OR] 7.32, 95% confidence interval [CI] 4.371-12.27, p<0.001), while the risk of primary outcome at 1-year follow-up was not significantly different between groups in univariate regression analysis. Older age (OR 1.1, 95% CI 1.06-1.20, p< 0.001), higher creatinine level (OR 1.0, 95% CI 1.005-1.012, p<0.001), lower LVEF (OR 0.90, 95%CI 0.86-0.94, p<0.001) and lack of early statin treatment (OR 3.6, 95% CI 1.0-13.10, p=0.05) were positively associated with increased odds for early primary outcome in multivariable regression model (**Table 2**). ### TABLE 1: Baseline characteristics and the comparison of patients with acute coronary syndrome with and without early statin therapy. | | **Statin group** **(n=1734)** | **Non-statin group** **(n=140)** | **p value** | **Statin group 1y** **(n=566)** | **Non-statin group** **1y (n=63)** | **p value 1y** | | --- | --- | --- | --- | --- | --- | --- | | Age (IQR) | 65 (57, 75) | 67 (55, 78) | 0.293 | 65 (57, 74) | 65 (52, 74) | 0.402 | | Male sex, n (%) | 1202 (69) | 89 (64) | 0.184 | 397 (70) | 45 (71) | 0.885 | | DM, n (%) | 472 (27 | 37 (27) | 0.921 | 161 (28) | 18 (29) | 0.543 | | HTN, n (%) | 1324 (77) | 103 (76) | 0.912 | 441 (78) | 51 (81) | 0.240 | | Smoking, n (%) | 809 (47) | 70 (50) | 0.527 | 274 (48) | 38 (60) | 0.257 | | CHF, n (%) | 69 (4) | 7 (5) | 0.143 | 16 (3) | 4 (6) | 0.194 | | HR median (IQR) | 77 (67, 90) | 80 (69, 90) | 0.182 | - | - | - | | SBP median (IQR) | 138 (120, 150) | 130 (118, 149) | **0.038** | - | - | - | | STEMI n (%) | 807 (47) | 60 (43) | **0.031** | 252 (45) | 23 (37) | 0.134 | | NSTEMI n (%) | 633(37) | 44 (31) | 196 (35) | 20 (32) | | | | UA n (%) | 294 (17) | 36 (26) | 118 (22) | 20 (32) | | | | Hemoglobin (IQR) | 140 (129, 150) | 138 (123, 150) | 0.144 | - | - | - | | Creatinine (IQR) | 94 (80, 112) | 97 (78, 115) | 0.819 | - | - | - | | hsTnT max median (IQR) | 1600 (240, 5292) | 1145 (242, 4245) | 0.113 | - | - | - | | CRP median (IQR) | 4 (2, 16) | 10 (3, 98) | 0.205 | - | - | - | | LVEF median (IQR) | 52 (45, 60) | 50 (40, 60) | 0.442 | 47 ± 12 | 44 ± 16 | 0.708 | | In-hospital mortality / 1y mortality, n (%) | 50 (3) | 25 (18) | **<0.001** | 28 (5) | 6 (10) | 0.238 | [†] IQR - Interquartile range; y - year; DM – Diabetes mellitus; HTN – Arterial hypertension; CHF – Chronic heart failure; HR – Heart rate; SBP – Systolic blood pressure; STEMI – ST-segment elevation myocardial infarction; NSTEMI - Non-ST-segment elevation myocardial infarction; UA – Unstable angina; hsTnT - High-sensitive troponin T; CRP – C reactive protein; LVEF – Left ventricular ejection fraction. ### TABLE 2: Univariable and multivariable binary regression analysis for early statin therapy with in-hospital and 1-year death as primary outcome. | | **Initial hospitalization (n=1898)** | **Initial hospitalization (n=1898)** | **Initial hospitalization (n=1898)** | **1 year follow-up (n=629)** | **1 year follow-up (n=629)** | **1 year follow-up (n=629)** | | --- | --- | --- | --- | --- | --- | --- | | | **HR** | **95% CI** | **p value** | **HR** | **95% CI** | **p value** | | **Univariable regression** | 7.32 | 4.371-12.27 | <0.001 | 2.02 | 0.80-5.09 | 0.135 | | **Multivariable regression*** | 3.61 | 0.99-13.10 | 0.051 | - | - | - | [†] * Adjusted for age, sex, DM2, BMI, creatinine, LVEF during initial hospitalization, ACS type. DM – Diabetes mellitus; BMI – Body mass index; LVEF – Left ventricular ejection fraction; HR – Hazard ratio; CI - confidence interval. **Conclusion:** Initiation of statin therapy within the first 24 hours following ACS is associated with a significant reduction in in-hospital mortality, although the positive effect of early statin therapy did not reach statistical significance at 1-year follow-up.

Davor Miličić

## Dear colleagues, You are holding the new Congress edition of our journal Cardiologia Croatica, which consists of selected abstracts that are an important part of the 12th Croatian Cardiac Society’s Congress Programme, taking place in Zagreb on November 29 to December 2, 2018. Our Congress represents the biggest national professional and scientific event in Croatian medicine, which is held biannually, as we consider a two years span an appropriate period for achieving and presenting a measurable amount of progress in national cardiology. There is no doubt that we have achieved tremendous progress over the last years, which includes all fields of cardiology. Despite the fact that cardiovascular mortality still holds the leading place in overall mortality, in the last decade it has decreased in Croatia by about ten percent. That can be partially explained by progress in Croatian clinical cardiology, but is surely also due to better and wider cardiovascular prevention, which was always significantly supported by our Cardiac Society and our National Heart Foundation – the Croatian Heart House. There is a plethora of our activities can bear witness that statement. Abstracts selected for our 12th National Cardiology Congress underwent an unbiased evaluation by our Organization Committee. The abstracts were graded by each Committee member from 1 to 10. Abstracts receiving low grades were rejected, while abstracts scoring above 7.5 were considered for potential oral presentations. From these highly graded abstract, we have chosen the most original themes and topics for oral presentation that seemed the most attractive for the Programme. The selected abstracts represent a wide spectrum of cardiac topics, from interesting case presentations to original scientific contributions. Beside abstracts published in this issue of Cardiologia Croatica, the Congress consists of invited state-of-the-art lectures, sponsored satellite symposia and sponsored lectures. Invited lectures will be held by leading Croatian and foreign cardiologists and are aimed at representing a current overview of all the relevant cardiac fields, reflecting the current progress of cardiology subspecialties. Satellite symposia and sponsored lectures will not be commercially oriented, but as much as possible scientifically unbiased with a goal of presenting the newest breakthroughs in cardiovascular therapies with both drugs and devices. Last but not least, we are extremely honored and pleased that the Congress is being held under the patronage of the Croatian Academy of Sciences and Arts, which is our leading institution representing the best of Croatian science, arts, and cultural heritage. The Academy has recognized our Cardiac Society as a promoter of excellence and international recognition of Croatian medicine. Finally, I would also like to express my gratitude to all who enthusiastically contributed to the Congress organization content, including this Book of Abstracts published in our journal Cardiologia Croatica. Beside its scientific and professional aspect, the Congress should also promote our mutual cooperation, networking and support, as well as our critical approach regarding our efforts to become even better and more recognizable on the international map of contemporary cardiology. With my kindest regards and best wishes, Sincerely yours,