Cardiologia Croatica. 2021;16(5-6)

Aleša Primožič, Alenka Glavač Povhe, Mateja Grošelj, Breda Barbič-Žagar

In spite of optimization and simplification of arterial hypertension (AH) treatment, achieving blood pressure (BP) control is still challenging, with most patients requiring combination treatment to achieve target BP. Due to the multifactorial effect of AH, additional prevention of hypertension-mediated end-organ damage and the maintenance of vascular integrity achieved by antihypertensive medications in addition to the BP-lowering effect are beneficial for the optimal reduction of cardiovascular (CV) risk. The aim of VICTORY II, a multicenter, open, prospective clinical study with 100 patients included in the active phase was to assess the safety and the efficacy of single-pill combinations (SPC) of amlodipine/valsartan (Wamlox®) and amlodipine/valsartan/hydrochlorothiazide (Valtricom®) in naïve or previously treated but uncontrolled patients with grade 2 or 3 AH. All patients with grade 2 AH started the treatment with the SPC of amlodipine/valsartan 5 mg/80 mg, which if necessary could be up-titrated step by step to the final option – the SPC of amlodipine/valsartan/hydrochlorothiazide 10/160/12.5 mg to achieve the target levels of BP. Patients with grade 3 AH started the treatment with the SPC of amlodipine/valsartan 5 mg/160 mg, which could be up-titrated step-by-step to the SPC of amlodipine/valsartan/hydrochlorothiazide 10/160/25 mg if necessary to achieve the target levels of BP. In addition to achieving the target office BP in 90% of the patients after 16 weeks of therapy, the amlodipine/valsartan-based treatments also decreased the prevalence of albuminuria and the central aortic pressure, improved vessel elasticity, and exerted a positive effect on the vascular endothelial function through its effect on the markers involved in the endothelial function.

Ksenija Burić

The rapid development of technology and hectic lifestyles have led to an increase in stress, anxiety, and dissatisfaction. Processes related to psychological stress contribute to the multifactorial risk for the occurrence and development of various diseases. The high incidence of acute heart disease imposes the need to create efficient and cost-effective prevention and rehabilitation strategies. As a young discipline, music therapy can be considered interdisciplinary and transdisciplinary because it contains elements from several professional fields and disciplines connected in new ways and represents the professional use of music and musical elements to achieve therapeutic goals. As a complementary therapy, receptive music therapy serves to relax and manage stress and has no side-effects. A meta-analysis on the effects of music on stress and anxiety shows that listening to music can most effectively reduce the degree of anxiety in people if they are offered to make a choice of music content according to their preferences. Further studies should examine the way music is perceived with regard to patient musical preferences within a cardiovascular rehabilitation program. To establish this, it is necessary to design instruments for assessing and collecting data on music preference and perception of music, as well as to include a certified music therapist in the cardiovascular rehabilitation team.

Mihajlo Kovačić, Dario Dilber

Achieving radiation dose reduction without compromising efficacy and safety is a permanent goal in cardiac catheterization procedures, as they pose a health hazard to both the patients and physicians and support staff. An important component of radiation energy delivered during invasive procedures is the pulse rate at which fluoroscopic and cine-acquisition (CINE) images are generated. (1) Previous research has shown that ultralow-dose protocols are feasible in a cardiac catheterization setting and result in a significant decrease in radiation exposure. Modern fluoroscopy devices deliver X-ray energy in a pulse range from 1 to 30 frames per second (FPS); the default setting is mostly in the range from 7.5-10.0 FPS. The evolution of catheterization-related radiation delivery has one of decreasing energy values: in the early years X-ray energy was delivered continuously; the first pulsed fluoroscopy regimes were performed at 30 FPS and later reduced to 15 FPS. In the recent decade, the agreed-upon standard has been 7.5 FPS, a value shown to significantly reduce adjusted total X-ray energy and radiation exposure in the staff and patients. (2, 3) Since late 2019, we have introduced and routinely use an “ultralow dose radiation protocol” at the Cardiac Catheterization Laboratory at Čakovec County Hospital, with a fluoroscopy pulse rate of 3.75 FPS and cine-acquisition at 7.5 FPS. All percutaneous coronary interventions (PCI) for acute coronary syndrome, including complex PCI like bifurcations and chronic total occlusion (CTO), are performed under fluoroscopy at 3.75 FPS. We did not notice a reduction in image quality, and the whole team quickly adopted to the lower frame rate without deleterious effects on efficacy/safety: i.e. procedure time, contrast usage, or less-than-optimal visualization. In comparison with the previously used 7.5 FPS protocol, the radiation exposure on part of the patient has been significantly reduced using the novel 3.75 FPS protocol. To scrutinize the proposed protocol scientifically, we have joined an outside center in conducting a randomized study aimed at investigating the radiation exposure reduction from the 3.75 FPS vs. the 7.5 FPS protocol. While awaiting the results of said trial, we urge the community of interventional cardiologists to consider the new protocol even in the most complex cases, such as CTO procedures, to minimize radiation exposure for the patients and staff, since our experience shows that the new protocol does not compromise the procedure in any way.

Petar Medaković, Zrinka Biloglav

The European Society of Cardiology (ESC) published guidelines for the diagnosis and management of chronic coronary syndromes in 2019 that included new recommendations for coronary computed tomography angiography (CCTA). The new ESC guidelines promoted CCTA as a Class I examination, which means that CCTA or non-invasive functional imaging is recommended or indicated for myocardial ischemia as the initial test for diagnosing CAD in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone. Patients who are difficult to scan, such as those with extensive coronary calcifications (>400 Agatston Units), increased (>65 bpm) or irregular heart rate, or those who are obese (body mass index >30) and unable to hold their breath, have been already identified by the National Institute for Health and Care Excellence (NICE) in earlier scanner generations. For these patients, NICE recommends the new generation of scanners or even particular scanner models, as opposed to the ESC guidelines which do not recommend CCTA. In spite of differences between ESC and NICE recommendations, an experienced clinical team consisting of a radiographer, radiologist, and cardiologist can obtain good image quality from new-generation CT scanners, even from patients who are difficult to scan. Considering the burden of risk factors and the 2019 ESC guidelines, referrals to CCTA are expected to rise at the national level, as they have in other countries with a similar cardiovascular burden, although clinical practice may vary. Numerous public hospitals have purchased scanners that fulfil SCCT technical guidelines, but these are neither cardiac-dedicated nor recommended for patients who are difficult to scan. CT scanners for these patients should feature dual-source technology with two powerful current generators in order to provide good temporal resolution; they should also have a long z-detector array in order to ensure high spatial resolution and volume coverage. Good image quality requires appropriate patient preparation and the adjustment of scan protocols to individual patient characteristics. This is the only way patients can benefit from this high-tech radiological procedure, according to recent clinical guidelines.

Lana Maričić, Ivana Tolj, Anto Stažić

**Introduction:** Cardiotoxicity is an important complication of several cancer therapeutic agents. The spectrum of cardiovascular complications of cancer therapy is wide and includes left ventricular (LV) dysfunction, congestive heart failure (CHF), coronary vasospasm, angina, myocardial infarction, arrhythmias, systemic hypertension, pericardial effusion, pulmonary fibrosis and pulmonary hypertension. (1, 2) Several anticancer agents, such as anthracyclines, trastuzumab/pertuzumab (monoclonal antibodies), cyclophosphamide, 5-fluorouracil, angiogenesis inhibitors and tyrosine kinase inhibitors (TKIs) are associated with an increase in the risk of cardiovascular morbidity and mortality. **Case report**: 47-year-old woman with diagnosed breast cancer (pathohistological diagnosis: invasive carcinoma), started with neoadjuvant chemotherapy (doxorubicin and cyclophosphamide). From earlier in the patient known chronic kidney disease with stable renal function. Prior to treatment, echocardiography was performed and determine the preserved systolic function of LVEF 62%, GLPS Avg -13,8%. After two cycles of chemotherapy, the deterioration of renal function was monitored, and treatment with taxane (paclitaxel) was started, cyclophosphamide was excluded. Concomitantly with the taxane the patient was treated with double anti-HER therapy (trastuzumab + pertuzumab). After 6 months, the patient has an intolerance to physical exertion, bilateral pleural effusions present on lung X-ray, and laboratory analysis shows NT-proBNP >30000 ng/L with further exacerbation of chronic renal injury (terminal stage). Control echocardiography showed significantly reduced systolic function LVEF 25% globally reduced contractility, with dilatation of the left heart cavities, GLPS Avg -5,6%. **Conclusion**: The development of newer, more potent and targeted chemotherapeutic agents has improved the outcome of patients with cancers, but a cardiotoxic effect should be considered, especially if more than one cardiotoxic drug is administered. (3, 4) It’s also important to individually assess the possible cardiac consequences in each patient with regular echocardiographic monitoring. Timely determination of the cardiotoxic effect certainly changes the course of the disease and affects the final outcome.

Petra Bulić, Koraljka Benko, Tamara Hlača Caput, Davorka Lulić, Sanja Matijević Rončević, Saša Matulić, Lea Skorup Ćutić, Ivana Grgić Romić, Alen Ružić, Luka Zaputović, Teodora Zaninović Jurjević

**Introduction**: Myxomas are the most common benign cardiac tumors. (1) In 75% of cases, myxomas are located in the left atrium, usually connected to the interatrial septum by a stalk. (1, 2) The frequency of myxomas in the right atrium varies from 10-20%. (1, 2) They are often clinically silent or cause unspecific symptoms like dyspnea, weight loss, leg swelling, fatigue, palpitations or paraneoplastic syndrome, which is why they are often diagnosed after they’ve grown large in size. (1, 3) Right atrial myxomas may have serious repercussions such as embolization of tumor fragments to pulmonary circulation or functional tricuspid stenosis by obstructing tricuspid valve, causing syncope, symptoms of right ventricular failure and even sudden cardiac death. (1, 2) **Case report**: 70-years-old woman presented to the Emergency department with lower abdominal pain persisting for the last 10 days. An abdominal ultrasound was performed and verified hepatomegaly with dilated hepatic veins, ascites and a formation of the right ovary with retroperitoneal lymphadenopathy. It also found large right atrial mass which is why the patient was referred to the Cardiology Department. Echocardiogram showed giant tumorous mass in the right atrium, measuring 10x6 cm in diameter, attached to interatrial septum and protruding into the right ventricle through the tricuspid valve in diastole. Due to the formation of the right ovary, gynecological diagnostic work up was performed. The patient’s case was presented in Gynecological/Heart Team expertise meeting and the patient was referred to surgery and underwent simultaneous bilateral adnexectomy and right atrial tumor excision. Pathohistological results confirmed diagnosis of myxoma, while analysis of ovarian formation is still in progress. Our patient recovered well and was discharged from the hospital 10 days after surgery. **Conclusion**: Due to its atypical symptoms and low incidence rate, right sided myxomas can go unnoticed for a long period of time. Giant myxoma is a rare finding, it should be treated surgically and the time to surgery should be as short as possible, since prolongation may have serious consequences on the outcome.

Ante Matana, Teodora Zaninović Jurjević

Cardiovascular diseases continue to be the leading cause of death in the world. A quarter of them occur by the mechanism of sudden cardiac death. Current criteria for identifying high-risk patients are unreliable and misclassify most at-risk patients as a low-risk group. Several studies in the last ten years confirmed the usefulness of mechanical dispersion in differentiating patients with high versus low risk for sudden cardiac death. Mechanical dispersion is a consequence of slow and inhomogeneous conduction of electrical impulse in the scar border zone, resulting in inhomogeneous myocardial activation and heterogeneity of myocardial contraction. This is why mechanical dispersion is in fact an expression of electrical dispersion, but unlike electrical dispersion it can be measured more easily and more reliably. It is obtained by speckle tracking echocardiography and is expressed as the standard deviation of all time intervals to the maximum myocardial shortening. Several studies have shown this method is significantly more reliable than the left ventricular ejection fraction and the left ventricular global longitudinal strain in differentiating high-risk from low-risk patients. Best results have been obtained in conditions characterized by fibrosis and/or scarring of the myocardium, such as in patients with myocardial infarction, hypertrophic, dilated and arrhythmogenic cardiomyopathy, some valvular heart diseases and heart failure. Mechanical dispersion could be useful as a risk stratification tool in identifying patients that can optimally benefit from the prophylactic treatment. (1-3) Although promising, for now this method is not listed in the current guidelines for the prevention of sudden cardiac death. It remains to be seen whether the new ones will bring changes in this field.

Marija Brestovac, Jadranka Šeparović Hanževački, Martina Lovrić Benčić, Richard Matasić

**Introduction**: His bundle pacing (HBP) is an alternative method for achieving resynchronization in patients with LBBB and heart failure (HF). HBP retains activation of the intrinsic electrical conduction system in non LBBB conduction and may improve LBBB conduction.(1-3) The aim of this pilot study was to compare the sucess of cardiac resynchronization therapy (CRT) between HBP (HBP-CRT) and standard biventricular CRT pacing as global longitudinal strain changes of the left ventricle (GLS) in HF patients with LBBB. **Patients and Methods**: In this study 31 patients were included with HBP-CRT (group I) and 39 patients with standard CRT pacing using biventricular pacing (group II). The two groups were matched according to type of cardiomyopathy (CMP), NYHA status, left ventricular enddiastolic volume and gender (35% ischemic CMP, 65% dilated CMP, 25% female). Each patient underwent an echocardiographic study (ECHO) including the assessment of LV myocardial deformation using two-dimensional speckle tracking before and within 3 months after implantation. The change in GLS within 3 months of CRT was compared between the two groups. **Results**: Both groups, HBP-CRT (p=0.048) and standard CRT (p=0.001) are associated with significant improvement in GLS within 3 months of CRT (**Table 1**). There were no significant differences between both groups in improvement in GLS (p=0.395). ### TABLE 1: Change in left ventricular global longitudinal strain within 3 months of cardiac resynchronization therapy between the analyzed groups. | **Group** | **N** | **GLS before CRT** | **GLS after CRT** | **Δ** | **SD** | | | --- | --- | --- | --- | --- | --- | --- | | I (HBP-CRT) | 31 | -10.06 | -12.30 | 2.24 | 3.85 | **p=0.048** | | II (standard CRT) | 39 | -7.24 | -9.73 | 2.48 | 3.90 | **p=0.001** | [†] HBP-CRT – His bundle pacing – cardiac resynchronization therapy, GLS – Left ventricle global longitudinal strain, Δ – mean GLS change between prior and after CRT, SD – standard deviation. **Conclusion**: Improvement of GLS was present in HBP-CRT as well as standard CRT. No significant difference was found between the two methods of myocardial resynchronization in GLS change within 3 months of follow up. According to these results we could suggest that both resynchronization methods could be equally used as cardiac resynchronization therapy according to GLS measurement.

Marija Brestovac, Blanka Glavaš Konja, Martina Lovrić Benčić, Vlatka Rešković Lukšić, Kristina Gašparović, Jadranka Šeparović Hanževački

**Introduction**: Cardiac resynchronization therapy (CRT) is a widely used method in the treatment of symptomatic patients with advanced heart failure and LBBB. Its beneficial impact on the reduction of left ventricular (LV) volumes has already been shown. (1, 2) The aim of this study was to determine if echocardiographic optimization of CRT pacing intervals (ECHO) after CRT device implantation has a favorable impact on LV volume change compared to electrocardiographic optimization (ECG). **Patients and Methods**: An overall of 147 patients with implanted CRT according to guidelines were included in this study and divided into two groups according to the CRT optimization method (N=70 in ECG arm an N=77 in ECHO arm). ECG optimization was performed using 12-lead electrocardiogram, fusion-optimized intervals, intracardiac electrogram-based algorithms and electrocardiographic imaging. ECHO optimization implied correction of atrioventricular, inter- and intraventricular dyssynchrony using echocardiographic imaging. The change in LV end-diastolic (EDV), end-systolic (ESV) and stroke volume (SV) as well as LV ejection fraction (EF) was compared between groups, before and 6 months after CRT implantation. **Results**: EDV and ESV significantly decreased and EF increased in both groups. In the ECHO a statistically significant reduction in EDV compared to ECG was present (p=0.028). According to greater EDV reduction, SV significantly decreased in ECHO (p=0.026). No significance was observed in ESV change between groups (p=0.063) (**Table 1**). ### TABLE 1: Left ventricle volumes and ejection fraction change before and 6 months after cardiac resynchronization therapy between the analyzed groups. | | **ECG (N=70)** | **ECG (N=70)** | **ECG (N=70)** | **ECHO (N=77)** | **ECHO (N=77)** | **ECHO (N=77)** | | | --- | --- | --- | --- | --- | --- | --- | --- | | | Before CRT | 6 months after CRT | Mean change, SD | Before CRT | 6 months after CRT | Δ | | | EDV (ml) | 218.81 | 167.48 | 51.32 (±64.25) | 231.81 | 157.53 | 74.28 (±80.25) | **p= 0.028** | | ESV (ml) | 162.27 | 112.25 | 50.01 (±59.38) | 169.67 | 102.57 | 67.1 (±75.02) | p= 0.063 | | SV (ml) | 56.54 | 55.23 | 1.31 (±16.46) | 62.14 | 54.96 | 7.18 (±19.66) | **p= 0.026** | | EF (%) | 26.67 | 36.79 | 10.11 (±8.39) | 26.97 | 39.13 | 12.16 (±10.80) | p= 0.1 | [†] EDV - left ventricular end-diastolic volume, ESV - left ventricular end-systolic volume, SV - left ventricular stroke volume, EF - left ventricular ejection fraction, SD - standard deviation. **Conclusion**: ECHO optimization of CRT leads to a more significant reduction of EDV compared to ECG optimization after 6 months of follow up.

Marija Brestovac, Blanka Glavaš Konja, Martina Lovrić Benčić, Vlatka Rešković Lukšić, Kristina Gašparović, Sandra Jakšić Jurinjak, Jadranka Šeparović Hanževački

**Introduction**: Cardiac resynchronization therapy (CRT) is used in the treatment of severe symptomatic heart failure with LBBB. Such patients often have at least one echocardiographic sign of either one type of dyssynchrony, interventricular (VV), intraventricular or atrioventricular (AV), present. It is known that about 30% of patients are nonresponders to this type of treatment. One of the causes is residual dyssynchrony after CRT device implantation. (1, 2) The aim of this study was to determine whether there is a difference in the presence of any of the echocardiographic signs of dyssynchrony after 6 months of follow up using two different CRT optimization methods. **Patients and Methods**: We included 147 CRT patients in this study. Each patient underwent full echocardiographic study with assessing signs of dyssynchrony before and 6 months after CRT device implantation. Patients were divided into two groups according to the method of CRT optimization, echocardiographically (ECHO) or electrocardiographically (ECG) guided CRT optimization. In Both groups initially AV and VV delay optimization were set up according to QRS width. On top of this ECHO group was additionally echocardiographically optimized accordingly to echocardiographic signs of dyssynchrony, septal flash (SF) disappearance, A wave truncation and merged E and A waves (AVd) and interventricular mechanical delay (IVMD). After 6 months of follow up residual dyssynchrony was defined as presence of SF, AVd and/or IVMD >40 ms. **Results**: In both groups, a significant reduction of echocardiographic signs of dyssynchrony was observed during the follow-up period. Comparison between the groups showed that residual SF and AVd were less frequent present in the ECHO group and reached statistically significance (p<0.01 for SF and AVd) while IVMD reduction did not differ between groups (p=0.84) (**Table 1**). ### TABLE 1: Comparison of echocardiographic signs of dyssynchrony before and 6 months after cardiac resynchronization therapy between the analyzed groups. | | **ECG (N=70)** | **ECG (N=70)** | **ECHO (N=77)** | **ECHO (N=77)** | | | --- | --- | --- | --- | --- | --- | | | Before CRT | 6 months after CRT | Before CRT | 6 months after CRT | | | SF | 65 (92.8%) | 26 (37.1%) | 73 (94.8%) | 14 (18.1%) | **p<0.01** | | AVd | 49 (70%) | 26 (37.1%) | 52 (67.5%) | 11 (14.2%) | **p<0.01** | | IVMD | 53 (75.7%) | 11 (15.7%) | 55(71.4%) | 8 (10.3%) | p=0.84 | [†] SF - septal flash, AVd- atrioventricular dyssynchrony, IVMD- interventricular mechanical delay. **Conclusion**: Echocardiographic optimization of CRT is associated with a greater reduction of residual SF and AV dyssynchrony compared to ECG optimization while no difference in the reduction of IVMD was observed between analyzed groups 6 months after CRT.

Vlatka Rešković Lukšić, Joško Bulum, Zvonimir Ostojić, Blanka Glavaš Konja, Marija Brestovac, Martina Lovrić Benčić, Sandra Jakšić Jurinjak, Jadranka Šeparović Hanževački

**Introduction**: Left atrial appendage (LAA) is the most common site for cardiac thrombus. This issue is especially addressed prior cardioversion of atrial fibrillation (Afib). In clinical practice, transesophageal echocardiography (TEE) is the most important diagnostic tool for analysis of LAA morphology, flow patterns and presence of thrombus. However, better echo machines allow more frequent visualization of spontaneous echo contrast (SEC), which by itself is not contraindication for cardioversion (1). Distinguishing LAA thrombus from pectinate muscles and SEC is today improved by multimodality imaging, especially computed tomography (CT). Even though, the use of contrast echocardiography in this setting is still of most importance since it is safe, quick and easily available. **Case report**: 51-year-old male with history of arterial hypertension and diabetes mellitus was admitted because of NSTEMI, first episode of heart failure and first episode of paroxysmal Afib. Echocardiography reveled reduced LVEF of 30% with largely dilated left atrium. Coronary angiography showed subocclusive LCx - PCI was performed and 1 DES was implanted. The patient was at the time (2016) discharged with dual therapy with ticagrelor and dabigatran. Four months later, he was hospitalized again because of paroxysmal Afib, TEE was performed to exclude LAA thrombus and successful electrocardioversion was performed. In 12/2018 he presented himself again with symptoms of heart failure and persistent normofrequent Afib. TOE was performed and dense SEC was found in LAA (**Figure 1**). The patient was switched to warfarin. We have repeated TOE, but significant SEC was still present in the LAA, and TTR was poor. So, we have decided to switch the patient again to dabigatran and to perform CT in order to exclude LAA thrombus. However, MSCT was inconclusive so we performed contrast enhanced TEE which revealed good opacification of the whole LAA with no thrombus (**Figure 2**). Electrocardioversion was successfully performed. In 07/2020 the patient presented again with symptoms of HF and persistent Afib. TEE with contrast was performed (2D echo looked the same as previously) - after the use of contrast agent, a small thrombus in the LAA was found (**Figure 3**), so the treatment strategy was switched to rate control. FIGURE 1. X-plane transesophageal echocardiography showing spontaneous echo contrast in the left atrial appendage (LAA); blue arrows pointing at the LAA, red arrows pointing at pectinate muscles. FIGURE 2. Contrast X-plane transesophageal echocardiography; arrows pointing at the left atrial appendage (LAA), stars are placed towards the bottom of LAA. The whole LAA is opacificated with contrast – presence of thrombus is excluded. FIGURE 3. Contrast X-plane transesophageal echocardiography; arrows are pointing to the area that was not opacificated with the contrast agent – the black round zone is the left atrial appendage thrombus. **Conclusion**: In this case, the importance of multimodality approach in LAA imaging is and its impact on treating options is emphasized. The use of contrast agent with TEE is highlighted as highly valuable diagnostic tool. Ultrasound contrast agents enhance visualization, with greater sensitivity (92-100%)/specificity (98-99%) for LAA thrombus detection than MR (67/44%) or CT (96%/02%) (2). Using all the possibilities in TEE, echocardiography is found to be superior imaging modality for LAA if thrombus has to be excluded.

Teodora Zaninović Jurjević, Ervin Avdović, Danijel Premuš, Ana Lanča Bastiančić, Ana Antonić, Lea Skorup Ćutić, Ivana Grgić Romić, Davorka Lulić, Željka Rubeša Miculinić, Ivana Smoljan, Gordana Bačić, Anamarija Flego Bojić, Alen Ružić, Luka Zaputović

**Introduction**: Atrial mechanical standstill is a rare phenomenon. Electrical function is preserved but atrial contraction is absent. Standard 2D transthoracic echocardiography evaluates isolated left atrial standstill by analyzing pulsed-wave Doppler imaging of mitral valve (MV) inflows and tissue Doppler imaging (TDI) at MV annulus. **Case report**: In a 65-year old patient with arterial hypertension and hyperlipidemia electrical conversion of persistent atrial flutter to sinus rhythm was achieved. The patient has had atrial flutter for about a year. He also suffered from COVID-19 pneumonia infection 2 months before being admitted to the hospital. In spite of sinus rhythm after the electrical conversion that was seen on twelve-lead electrocardiography, 48 hours after conversion no mechanical left atrial activity was restored. MV inflow demonstrated normal E wave (passive filling in early diastole) but absent A wave (atrial contraction during late diastole). TDI at the MV annulus also confirmed isolated mechanical LA standstill. There was absence of a’ at the MV annulus. **Conclusion**: Atrial standstill is condition that may involve impairment of electrical function (electrical silence or an inability to pace or capture), or mechanical function (based on imaging). (1, 2) The pathophysiologic mechanism can be the underlying presence of atrial fibrosis, myopathy or it may include interatrial block. (3) The absence of mechanical LA contraction has potential hemodynamic consequences, also there could be the possibility for the thrombus formation within the atria leading to thromboembolism. That is why anticoagulation should be continued. (4)

Krešimir Šutalo, Ana Šutalo, Renato Filjar

**Introduction:** The function descriptors and size of the left atrium are commonly found in inversely proportional terms. Enlarged left atrium is the most common predictor of adverse cardiovascular event. (1) Professional athletes are exposed to great physical exertion that leads to cardiac remodeling as a consequence of hemodynamic adaptation. Large meta-analyses confirmed that the linear dimensions and volume of the LA are significantly higher in athletes while the assessment of function is significantly more complex (2). **Patients and Methods:** The aim of the study was to compare the difference between let atrium size and function in professional athletes and healthy people. The sample included 20 healthy individuals (17 female and 3 male), divided into two groups: athletes (N=12) and control. The size of the left atrium was measured linearly using M mode and 2D, and by using biplane method from an apical position. All patients also underwent pulse and tissue Doppler and 2D speckle tracking analysis of left atrium. The following parameters were included: body surface area, left atrium diameter in M mode, left atrium endsystolic volume index, left ventricular mass index, mitral valve E wave velocity/mitral A wave velocity ratio, deceleration time, mitral valve E wave velocity/e’ wave velocity lateral ratio, pulmonary vein systolic wave velocity/diastolic wave velocity ratio, pulmonary vein reversal A wave duration/mitral valve A wave duration ratio, left atrium strain average reservoir, left atrium strain average conduit, left atrium strain average conduit contraction, and left ventricular global longitudinal strain. All exams were done on Philips Epiq 7G, and quantified off-line by Philips QLAB Autostrain. **Results:** Statistically significant difference between two groups was identified for variables: mitral valve E wave velocity/mitral A wave velocity ratio, left atrium strain average reservoir, left atrium strain average conduit. For all three variables the values were higher in the athletes group. **Conclusion:** Our study did not show difference in size of the left atrium between two groups. Significantly higher values of global deformation of the left atrium, represented by the average value of the reservoir function, the average conduit strain and the mitral valve E wave velocity/mitral A wave velocity ratio, were noticed in the athletes group. We infer the cause lies in the better compliance of LA, associated with increased left atrium passive emptying volumes (3).

Sandra Jakšić Jurinjak, Vlatka Rešković Lukšić, Diana Kovač, Blanka Glavaš Konja, Marija Brestovac, Marina Prpić, Zvonimir Ostojić, Joško Bulum, Martina Lovrić Benčić, Jadranka Šeparović Hanževački

**Introduction**: Recurrent pericarditis can occur in up to 30% of patients after acute episode of pericarditis and is associated with significantly impaired quality of life and morbidity (1). High rate of recurrence remains despite treatment as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, steroids or other immunosuppressants (1). If medical therapy fails, in case of symptomatic constrictive hemodynamics, surgical approach-pericardiectomy is indicated. Therefore, imaging modalities have to distinguish between hemodynamic assessment, where echocardiography is first line imaging modality, and inflammation where other cardiac imaging modalities complement echocardiographic findings (2). **Case report**: We present series of two cases, first of recurrent pericarditis in patient with postpericardiotomy syndrome and second recurrent pericarditis which lead to constrictive pericarditis resolved by pericardiectomy. First case is 60-year female who had aortic valve replacement due to severe aortic stenosis three weeks prior development of first symptoms, comprised of severe chest pain, fever with elevated markers of infection, and pleural effusion. Echocardiography revealed normal function of artificial aortic valve, normal ejection fraction of left and right ventricle and pericardial effusion, mainly inferoposterolateral and in front of right ventricle with septal bounce and hemodynamic signs of elastic constriction. PET CT confirmed inflammation only in pericardium and pleura (**Figure 1**). Regression followed due to NSAIDs, colchicine, steroids treatment. She had signs of recurrence within next six month, but less severe inflammation. Second case is 45-year male who was admitted to our institution due to right heart failure and atrial undulation. Echocardiography revealed septal bounce with respiratory dependent septal shift to the right as result of interventricular interdependence due to severe calcification of pericardium mainly in front of right ventricle and pericardial effusion inferolaterally. CT revealed massive calcification of the pericardium and no active inflammation in patient with right heart failure leading us to indicate surgical treatment pericardiectomy (**Figure 2**). Patient is recovering after surgery and was discharged in good condition. FIGURE 1. A) Chest CT showing pericardial and pleural effusion. B) echocardiography showing pericardial effusion. C) PET CT identifying inflammation of the pericardium. FIGURE 2. A) Hepatic flow reversal with IVC plethora. B) Hemodynamic information bet seen by echo C) Diastolic septal bounce best seen on M mode as septal notch in early diastole. D, E, F) CT showing pericardial calcification. **Conclusion**: Multidisciplinary approach to pericardial disease and multimodality imaging of pericardial pathology is paramount, as diagnosis and treatment often include multiple subspecialties. Echocardiography is still superior imaging modality when hemodynamic is the question but is best complemented with imaging modalities indicating inflammation.

Ana Šutalo, Krešimir Šutalo, Eugen Fucak, Siniša Štubelj, Mario Milun, Daniel Unić, Savica Gjorgjievska

**Introduction**: A perivalvular extension of infection is the complication of bacterial endocarditis. Because prosthetic valve endocarditis (PVE) usually begins as periannulitis, it is not surprising that infected prosthetic valves had these complications with a higher frequency than did infected native valves. (1) In case of an aortic prosthetic valve infective endocarditis (IE), the infection has tendency to extend towards the membranous septum and into the conducting tissue. We present a case of culture-negative IE resulting in a dehiscence of a bioprosthetic aortic valve complicated by aortic root abscess and complete heart block. **Case report**: 67-year-old man, who underwent aortic valve replacement (Medtronic Mosaic A25) for severe aortic valve insufficiency 15 months before, presented to the emergency department with dyspnea and syncopal episodes. Electrocardiogram demonstrated left bundle branch block with intermittent complete heart block causing ventricular pauses up to 15 seconds. An urgent pacemaker implantation was performed. During the consecutive hospital staying he developed fever accompanied by worsening of congestive heart failure. The chest radiography showed suspected pneumonia. The transesophageal echocardiography revealed perivalvular aortic root abscess with partial valve dehiscence and moderate aortic regurgitation (**Figure 1**, **Figure 2**). Inflammatory markers were elevated, while blood cultures remained sterile. The empirical antimicrobial treatment for infective endocarditis and pneumonia was initiated. Despite pharmacological measures, the patient’s condition was gradually deteriorating so he underwent early cardiac surgery. The prosthetic valve replacement together with pericardial patch reconstruction of annulus was successfully performed. FIGURE 1. Transesophageal view of the aortic valve in long axis showing dehiscence of the valve ring and hypoechogenic cavity in the artic root. FIGURE 2. Transesophageal view of the aortic valve in the short axis also showing perivalvular abscess. **Conclusion**: Culture-negative endocarditis constitutes up to 16% to 18% of PVE, (2, 3) and can rarely be complicated by prosthetic aortic valve dehiscence. (4) The appearance of an AV conduction block can be a sign of underlying aortic root abscess as perivalvular complication of prosthetic aortic valve IE.

Petar Martinčić, Davor Barić, Krešimir Šutalo

**Aim:** To report a case of a patient with undiagnosed endocarditis that presented as COVID-19 pneumonia. **Case report:** 62-year-old woman with a history of arterial hypertension, presented to the Emergency Department of General Hospital Koprivnica with fever and cough lasting for 7 days and general fatigue lasting for 3 weeks. Her vital signs were in physiologic range, while auscultatory she had a systolic murmur over the whole precordium with diffuse pulmonary crackles. Chest radiograph showed bilateral interstitial pneumonia whilst laboratory results displayed elevated inflammatory markers, cardiac troponin and D-dimers combined with mild partial respiratory insufficiency. She was admitted to an isolated COVID-19 ward where empiric antibiotic therapy with ceftriaxone began in parallel with dexamethasone, dalteparin and oxygen therapy via nasal cannula. During the night of admission, she became hemodynamically unstable and fluid resuscitation in conjunction with inotropes was initiated. Emergency pulmonary CT angiography ruled out pulmonary embolism and showed bilateral ground-glass changes with pleural effusion as well as signs of venous congestion. Subsequently, COVID-19 was confirmed with the RT-PCR test. After a 10-day isolation period, she was transferred to the Cardiology Department where transthoracic echocardiography was performed. Massive vegetation on the anterior mitral leaflet that caused obstruction of the left ventricular outflow tract and moderate mitral regurgitation with filiform vegetation on the aortic valve were shown. Initial antibiotic therapy was swapped to amikacin and gentamicin. Further hospital stay was complicated with paroxysmal atrial fibrillation, worsening of heart failure and psychological disturbance. Indication for emergency valve replacement and transfer to the University Hospital Dubrava was indicated. Intraoperatively, massive vegetation on A1/A2 section of mitral leaflet and a smaller vegetation on ventricular side of left and noncoronary cusps of the aortic valve were visible. Both valves were replaced with mechanical valves with satisfying results and the patient was returned to the parent hospital. Coagulase-negative S. aureus susceptible to vancomycin was later verified on the mitral leaflet specimen. **Conclusion:** Despite our focus on SARS-CoV-2 pandemic, it is important not to neglect other diagnosis and usefulness of echocardiography as a powerful diagnostic tool in everyday clinical practice. (1-3)

Ana Marija Slišković, Vlatka Rešković Lukšić, Sandra Jakšic Jurinjak, Blanka Glavaš Konja, Marina Prpić, Zvonimir Ostojić, Marija Brestovac, Martina Lovrić Benčić, Maja Hrabak-Paar, Joško Bulum, Jadranka Šeparović Hanževački

**Introduction**: Infective endocarditis is related to a wide range of complications including septic embolizations such as spondylodiscitis. Risk factors associated with systemic include left-sided vegetation, large vegetation size, microbiology, age, diabetes, etc (1). Endocarditis masked by such complications might be difficult to diagnose and lead to invalid and late treatment which in turn results in increased morbidity and mortality (2). **Case report:** During one year period we observed three cases of endocarditis complicated with severe form of spondylodiscitis leading to immobilization and prolonged rehabilitation. Two out of three patients underwent surgical procedure. First patient, a 66-year-old female was admitted to our department due to E. faecalis aortic valve endocarditis and consequently moderate aortic regurgitation (**Figure 1 A**). Few years preceding the initial presentation, patient was hospitalized in our institution because of non-ischemic cardiomyopathy and implantable cardioverter defibrillator (ICD) was implanted for primary prevention of sudden cardiac death. During routine follow-up patient complained about general weakness, weight loss, fever and chills and limited walking ability caused by lumbar back pain. On echocardiogram, ICD lead-associated thrombus was described, although patient was already receiving oral anticoagulant therapy for atrial fibrillation. Three months after that, patient was hospitalized once again and endocarditis was confirmed. Clinical presentation was complicated not only with spondylodiscitis and paraparesis but also with septic emboli to the right kidney which was initially believed to be tumor. Following PET CT and MR scan, infection of ICD electrodes together with L3/L4 spondylodiscitis were revealed (**Figure 1 B, C**). Second patient, a 48-year-old male was evaluated because of recurrent fever, hypergammaglobulinemia and sacral pain. Multiple myeloma was suspected and investigated to be the cause of patient’s disability, when blood cultures, along with echocardiography, confirmed diagnosis of Aggregatibacter aphrophilus mitral valve endocarditis resulting in severe mitral regurgitation (**Figure 2 A**). MR scan was performed due to long standing lumbar pain - L5-S1 spondylodiscitis was described and treated with prolonged antibiotic therapy (**Figure 2 B**). Third patient, a 52-year-old man is still hospitalized in our institution due to Gemella morbillorum sepsis, aortic valve endocarditis and thoracic spondylodiscitis (**Figure 3 A**). He was initially treated for 6-weeks with antibiotics, however, clinical course was complicated by vancomycin-induced DRESS syndrome along with acute kidney injury which required renal replacement therapy. PET CT scan reported resolution of aortic valve inflammation, but active metabolism was detected in thoracic spine in Th6 (**Figure 3 B**). Even though tremendous effort is exerted to improve patient’s condition, his full recovery is very uncertain. FIGURE 1. Aortic vegetation on transthoracic echocardiography (A), infection of electrodes and L3-4 spondylodiscitis on PET CT (B) and on MR scan (C). FIGURE 2. Mitral valve endocarditis described on 3D TEE (A) with L5-S1 spondylodiscitis (B) on MR scan caused by *Aggregatibacter*. FIGURE 3. Th 5-7 spondylodiscitis in a patient with *Gemella morbillorum* aortic valve endocarditis shown on a MR scan (A) and on PET CT (B). **Conclusion:** Septic embolism due to infective endocarditis warrants multidisciplinary team approach, prolonged antimicrobial therapy and surgery as a definitive treatment in most of the cases. Early diagnosis and treatment are highly important because any delay may lead to life-threatening, long-term sequelae and prolonged rehabilitation.

Ivana Petrović Juren, Iva Ladić, Sandra Prša, Kristina Milevoj Križić, Andreja Čleković-Kovačić, Renata Janković Ivanac, Gabriela Bašković, Vlasta Soukup Podravec, Marina Šimunović, Tihana Gržinčić

**Introduction**: Prevalence of patent foramen ovale (PFO) is somewhere between 20 to 30% in general adult population. It is mostly asymptomatic, but specific circumstances like acute or transient right heart pressure elevation can cause interatrial shunting and consequent paradoxical embolism. It is defined by occurrence of systemic embolism in the context of deep vein thrombosis or pulmonary embolism. Cardiogenic source of embolism accounts for approximately 20% of ischemic strokes, of which at least some portion is considered to be associated with PFO, atrial septal defect or atrial septal aneurysm. Still, PFO in the context of ischemic stroke does not necessary prove causal relationship between two (can be “innocent bystander”). (1-4) **Case report**: 54-years-old male patient presented to the Emergency Care Unit with acute development of right-sided hemiparesis, aphasia and worsening of dyspnea lasting for couple of days. Urgently, computed tomography (CT) of brain was performed, which initially showed no signs of cerebral ischemia or hemorrhage. Transthoracic echocardiography was performed and acute right heart dilatation with flattening of interventricular septum was visualized, with systolic pulmonary pressure measuring 90 mmHg suggesting acute pulmonary embolism. Also, large thrombotic masses floating in the right atrium, passing into the right ventricle through tricuspid valve were visualized, with large thrombus trapped in PFO, showing pending paradoxical embolism (**Figure 1**, **Figure 2**). CT pulmonary angiogram confirmed massive pulmonary embolism. Systemic fibrinolytic therapy was administered with complete resolution of thromboembolic masses in the heart but with persisting neurological deficit. CT angiography of brain was performed, and acute medial cerebral artery occlusion was visualized. Urgent thrombectomy was performed. Subsequently deep vein thrombosis of lower limb was found. During first 4 weeks anticoagulant therapy imposed significant risk and inferior vena cava (VCI) filter was implanted. After device explantation, long term anticoagulant therapy was continued. Patient is regarded to be a candidate for PFO occlusion device implantation in the future. FIGURE 1. Large thrombus floating in the right atrium and right heart dilatation. FIGURE 2. Large thrombotic masses passing through patent foramen ovale as a sign of paradoxical embolism. **Conclusion**: For secondary prevention of systemic embolism and stroke in patients with PFO antiplatelet or anticoagulant therapy or PFO occlusion device implantation seem to be reasonable options. Decision about treatment option is made depending on patient age, risk factors, other possible sources of embolism and atrial septal anomaly characteristics.

Ana Antonić, Lea Skorup Ćutić, Ivana Smoljan, Tamara Hlača Caput, Sanja Matijević Rončević, Petra Bulić, Ivana Grgić Romić, Koraljka Benko, Tomislav Jakljević, Alen Ružić, Luka Zaputović, Teodora Zaninović Jurjević

**Introduction**: Paradoxical embolism referring to venous thromboembolism traversing through intracardiac shunt into systemic circulation is an important clinical entity. (1) Depending on the site of embolism it can result in ischemic stroke, myocardial infarction, embolization of abdominal or limb arteries. It represents around 2% of all cases of arterial embolizations. (2) Patent foramen ovale is the most common intracardiac shunt that can be found in up to 30% of population and its presence is strongly related to paradoxical embolism. (1, 2) **Case report**: 44-year-old male with no significant medical history was admitted to Emergency Department because of left arm pain and coldness with absent radial pulse. In addition, patient reported exertional dyspnea over the past three days. Examination and imaging revealed thromboembolism of distal part of left subclavian artery, axillar and brachial artery with saddle pulmonary embolism (PE) and embolism in distal parts of left and right pulmonary arteries, lobar, segmental and subsegmental arteries with deep popliteal vein thrombosis. Initial echocardiographic examination showed right ventricular dysfunction with interatrial septal aneurism and suspected defect. Although PE was of intermediate low risk it was decided to apply systemic thrombolysis (using recombinant tissue-type plasminogen activator). Therapy went without complications with complete resorption of saddle thrombus in main pulmonary artery with only partial resorption of arm thrombus, so Fogarty arterial embolectomy was indicated. Transesophageal echocardiography with agitated saline injection and Valsalva maneuver revealed patent foramen ovale. After initial treatment with therapeutic dose of enoxaparin rivaroxaban was initiated. **Conclusion**: In a case of concomitant venous and arterial embolization it is important to search for intracardiac shunts. Transesophageal echocardiography is reference method in shunt detection. Treatment of paradoxical embolism includes antithrombotic and anticoagulant treatment, percutaneous closure devices or surgical treatment.

Marija Tomac Stojmenović, Vlatka Rešković Lukšić, Irena Ivanac Vranešić, Velena Radošević, Tamara Žigman, Maja Hrabak Paar, Jadranka Šeparović Hanževački

**Introduction**: The FLNA gene provides instructions for producing protein filamin A. It is found on the X chromosome and has X linked inheritance. The dysfunction of this gene is associated with congenital malformation of the cerebral cortex, cardiac abnormalities, thoracic aneurism and joint hypermobility. (1-4) **Case report**: We present a family with heterozygous pathogenic variant of FLNA. Disease was discovered during workup of older daughter’s miscarriages. She had a double miscarriage in the first trimester. She knew for mild mitral and aortic regurgitation from youth. From family history: mother had two miscarriages and two successful deliveries, pulmonary hypertension, coronary artery disease and percutaneous coronary intervention at the age of 56, grandmother from mother side had one successful delivery and three miscarriages, died at the age of 64 from diabetic coma. Sister has moderate aortic regurgitation, dilatation of ascending aorta (42mm), one miscarriage. Father has dilatation of ascending aorta. In 2020. echocardiography revealed dilatation of the ascending aorta (43mm) with mild central aortic regurgitation, and a trace of mitral regurgitation. The cardiologist recommended CT aortography and genetic testing. On CT aortography aorta was measured at a maximum of 46mm (**Figure 1**). Genetic testing identified one pathogenic variant in FLNA. After this discovery, genetic testing was performed on all family members (**Figure 2**), and mutation was identified in the mother and sister. During this workup, the younger sister found out that she was pregnant. Soon, the mother suddenly died at the age of 60. Autopsy revealed a dissection of the thoracic aorta. With this finding, the younger sister went from category three to category four in classification of maternal cardiovascular risk score and was advised to abort. At the time of writing this paper she is 10 weeks pregnant and, knowing all the risks, does not want an abortion. FIGURE 1. CT scan, dilatation of the ascending aorta. FIGURE 2. Genetic tree. **Conclusion**: In young women with dilatation of ascending aorta, connective tissue disease should be considered. Today we have possibility for family screening, so we can discover pathogenic mutation in families. In FLNA mutation, safe size of ascending aorta dilatation is smaller than in healthy population, which should be considered during pregnancy planning. In case of pregnancy multidisciplinary approach is mandatory.

Ivona Mustapić, Zora Sušilović Grabovac, Darija Baković Kramarić

**Introduction**: Atrial septal defect (ASD) is the second most common adult congenital heart disease, usually asymptomatic until the third decade. Superior sinus venosus defect (SVASD) account for 5% of ASD and it is usually associated with the partial or complete connection of right pulmonary veins to vena cava superior (SVC) or right atrium (RA) (1, 2). **Case report**: We report a case of a 45-year-old woman with previously known thyroiditis and hyperprolactinemia. She was referred for echocardiographic examination after an accidental finding of mid-systolic murmur during preoperative preparation for ovarian cyst surgery. She worked as a waiter and reported exertional dyspnea. An electrocardiogram revealed sinus rhythm with the right bundle branch block. Transthoracic echocardiography (TTE) demonstrated a normal-sized left heart with preserved systolic function (LVEF 70%), a dilated RA and right ventricle (RV) without signs of pulmonary hypertension. Cardiac magnetic resonance (CMR) showed a dilated RV (end-diastolic diameter 46 mm), dilated RA and dilated pulmonary artery (diameter 33 mm). During the CMR scan there was constantly a high concentration of contrast in the RV which raised suspicion of shunt presence. Transesophageal echocardiography using contrast revealed SVASD (**Figure 1**, **Figure 2**). The patient was referred for computer tomography angiography which demonstrated superior SVASD, 16 mm in width. The right superior pulmonary vein had abnormal inflow into SVC, while the right inferior and both left pulmonary veins had typical anatomical inflow into the left atrium. Cardiac scintigraphy with technetium-99 confirmed the existence of a left-right shunt, Qp: Qs ratio of 1.7: 1. Surgical repair was performed by forming an intraatrial patch using autologous pericardium and dilating plastic of the SVC and RA with a xenopericardial patch. Postoperative recovery went well and control TTE showed less dilated RV with good patch position and no signs of shut over intraatrial septum. FIGURE 1. Transesophageal echocardiography. Arrow pointing at a superior sinus venosus atrial septal defect. LA - left atrium; RA - right atrium; SVC - superior vena cava. FIGURE 2. Transesophageal echocardiography with contrast study. LA - left atrium; RA - right atrium; SVC - superior vena cava. **Conclusion**: We represented a rare case of congenital heart disease, diagnosed in a middle-aged patient. Having a patient with a dilated right heart and normal-sized left heart without signs of pulmonary hypertension needs to raise suspicion of L-R shunt existence and further investigation should be done.

Anto Stažić, Grgur Dulić, Sandra Makarović, Ivica Bošnjak, Nora Pušeljić, Luka Švitek, Mihaela Roguljić, Tanja Mikulandra, Kristina Selthofer-Relatić

**Introduction**: Native valve infective endocarditis (IE) is a result of bacteremia with high mortality rate of about 30%. Optimal outcome of valve IE depends on timely diagnosis, etiology, antibiotic treatment, involved valve, patient age, comorbid diseases, extent and location of metastatic complications, and the duration of the infection. Besides invasive procedures and mechanical damage breaking these boundaries, it has also been shown that routine daily activities such as tooth brushing, and chewing could lead to bacterial penetration of the bloodstream. Bicuspid aortic valve (BAV) is the most common form of congenital heart disease with 30-fold higher risk of IE than in the general population. Common complications are congestive heart failure (HF), peri annular abscesses and systemic embolization. Ventricular septal defect (VSD) is often a predisposing factor for the development of IE, but only rarely occurs as a complication of the condition. (1-4) This case report presents the outcome of a patient with BAV that was complicated with a chronic form of BAV IE caused by inadequate tooth hygiene and resulted in the rare IE complication of VSD. **Case report**: In a 43-year-old obese male patient mid-range stenosis and mild regurgitation of aortic valve (AV), probably BAV, was detected by transthoracic echocardiography (TTE). Tooth caries were detected, and antibiotic prophylaxis was recommended. Eight months later, the patient was hospitalized because of intermittent fever. TTE imaging due to the patient’s obesity were poor quality, while patient cooperation for transesophageal echocardiography was limited. He felt better after antibiotic therapy and went home. One month later, he was readmitted because of HF caused by chronic BAV IE showing severe aortic regurgitation, aortic valve abscess and, consequently, a membranous VSD (**Figure 1**). Cardiac surgery with mechanical prosthesis valve replacement and septal defect patching was performed (**Figure 2**). FIGURE 1. Infective endocarditis of the bicuspid, aortic valve by transesophageal echocardiography (a); ventricular septal defect (did not exist before) (b); bicuspid, aortic valve abscesses (c); ventricular septal defect by color Doppler (d). FIGURE 2. Infective mass on the aortic, bicuspid valve (a); ventricular septal defect due to infective endocarditis (b); patch plastic of ventricular septal defect (c). **Conclusion**: This case highlights the need for early suspicion of IE, precise cardiac imaging and early investigation for comorbid diseases. Patient cooperation and understanding of the risk are crucial parts of prevention or treatment, or the spread of IE could become complicated with rarer and more complex forms of disease.

Dubravka Šipuš, Blanka Glavaš Konja, Sandra Jakšić Jurinjak, Marija Brestovac, Jadranka Šeparović Hanževački, Vlatka Rešković Lukšić

**Background:** Unicuspid aortic valve (UAV) is a rare congenital malformation observed in 0.02% of population (1). It shares several characteristics with bicuspid aortic valve (BAV), such as premature valvular calcification and aortic root dilatation which occur more rapidly in UAV. UAV most often presents with aortic stenosis (AS), either isolated or concomitant with aortic regurgitation (2). **Case report:** 47-year-old female was diagnosed with BAV and AS at the age of four. She underwent regular echocardiographic follow-ups and was asymptomatic, which was regularly confirmed with stress tests. She had two uncomplicated pregnancies and one miscarriage. In 2019, stress echocardiography showed good functional capacity and preserved left ventricular (LV) function, with good improvement in LV ejection fraction (LVEF) and global longitudinal strain (GLS) during exercise, normal NT-proBNP, but increase in mean pressure gradient (PG) during work-up for >20 mmHg (**Figure 1**). Closely follow-up was indicated. In January 2021 she had anaphylactic reaction after food intake. After that event she started to complain of frequent light-headedness and palpitations on effort, without syncope. She underwent thorough neurological and ear, nose and throat evaluation including brain magnetic resonance imaging, and no pathology was found. Laboratory findings showed elevated NT-proBNP of 400 ng/L. She was admitted to resolve if the symptoms were truly due to AS. Transthoracic and transesophageal echocardiography (**Figure 2**) demonstrated a LVEF of 60%, GLS -22% and UAV with severe AS (max PG 80 mmHg, mean PG 51 mmHg, AVA VTI 0.58 cm2). MSCT aortography showed slightly dilated ascending aorta, diameter 4,2 cm. On 24-hour ECG recording, nonsustained ventricular tachycardias originating from LV were recorded and correlated with symptoms. Due to arrythmias caused by pressure overloaded LV, elevation in NT-proBNP and clinical correlation, aortic valve replacement was indicated. FIGURE 1. Stress echocardiography at baseline (A) and at 130 W (B) showing normal response in improvement in left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). The aortic valve area (AVA) remained unchanged, with increase in the mean pressure gradient (PG) of 24mmHg. The patient was asymptomatic during the test. FIGURE 2. 3D transesophageal echocardiography reconstruction for measurement of the 3D aortic valve area (AVA) by planimetry (A). Unicuspid aortic valve shown in TOE X-plane, arrow pointing at single commissural zone of attachment and eccentric valvular orifice during systole (B). Transthoracic measurement of peak velocity across the aortic valve (C). **Discussion:** UAV with AS is rare congenital malformation usually diagnosed in childhood but may advance into adulthood before becoming symptomatic. Echocardiography is a key tool in confirming presence and assessment of severity of AS. Additional value of stress echocardiography is in revealing symptoms or proving truly asymptomatic AS, which is of most importance for timing of surgery. We presented a case of UAV with long asymptomatic phase of the disease. Asymptomatic patients should be re-evaluated every six months for the occurrence of symptoms and change in echocardiographic parameters (3). **Conclusion:** In every case of severe AS, no matter of valve morphology, close clinical and echo follow up, including stress test is crucial in deciding on right timing for intervention.

Hrvoje Falak, Mario Udovičić, Diana Rudan, Aleksandar Blivajs, Matea Martinić, Danijela Grizelj, Ivana Jurin, Petra Vitlov

COVID-19 pandemic has resulted in a multidimensional strain on the health care system and to critically evaluate clinical workflows and how care is delivered, which is especially true for dedicated COVID-19 centers (1). University Hospital Dubrava has been in its entirety repurposed as the dedicated COVID-19 center for all of Central Croatia, thus closing it for all other patients over extended periods during 2020 and 2021. In this retrospective study we wanted to estimate the amount of unperformed transthoracic echocardiography (TTE) studies due to the COVID-19 pandemic at our center. We conducted a single center study using hospital electronic record system by collecting data of TTE studies for the period from 2011 to 2020. We established that the compound annual rate of growth (CARG) in that period was 12.1%, notwithstanding the expected drop in numbers during the pandemic. Taking into account the following CARG, anticipated normal numbers of TTE studies at our center for 2020 and 2021 would be 5471 and 6135 studies respectively. Therefrom we have established that there is in total a predicted burden of about 5500 unperformed TTE studies due to the COVID-19 pandemic as of March 2021 at our center. All these affected patients have either been put on waiting lists, delaying their work-up, or diverted to other echocardiography centers, increasing the local burden of work. The results of this study urge that it is of utmost importance to reinstate the TTE diagnostic facilities of our center as soon as possible, in order to work off the accumulated recess TTE studies on waiting lists. Also, every week of idling cycle due to the extended hospital lockdown generates a further anticipated deficit of 118 unperformed TTE studies in 2021 at our center alone.

Dubravka Šušnjar, Josip Varvodić, Verica Mikecin, Irzal Hadžibegović, Savica Gjorgjievska, Daniel Unić, Davor Barić, Igor Rudež

**Introduction**: Infective endocarditis (IE) is a life-threatening condition, especially when diagnosis is prolonged, as the symptoms of IE overlap with COVID-19 infection (Coronaviruses disease 2019). (1-4) We present the case series of two patients with a diagnosis of IE concomitant with COVID-19 infection. **Case report**: 36-year-old patient admitted to the hospital, due to pneumonia and meningitis caused by Streptococcus pneumoniae. Transthoracic echocardiography (TTE) showed paravalvular aortic abscess with mild aortic insufficiency without vegetations. Month after, patient had a positive COVID-19 swab, developed bilateral COVID-19 pneumonia, requiring oxygen therapy and respiratory support, and transferred in University Hospital Dubrava. Transesophageal echocardiography showed aortic root abscess with pseudoaneurysm in the projection of non-coronary cusp (NCC), destroyed NCC and left coronary cusp with mobile vegetations measuring 17x11 mm. The abscess cavity communicates with left ventricular outflow tract (LVOT), with massive aortic insufficiency and the regurgitation jet filling >75% of LVOT diameter (**Figure 1**). Ejection fraction was reduced to 45%, with signs of right ventricle deterioration. Emergent surgery was indicated, patient was successfully operated. Biologic aortic valve was implanted (Edwards Inspiris Resilia A 23) with pericardial patch of the aortic root. Control TTE showed closure of pseudoaneurysm cavity and normal function of bioprosthetic valve. Patient recovered successfully and discharged home twelve days after surgery. FIGURE 1. Intraoperative transoesophageal echocardiography showing: A, B) pseudoaneurysm cavity communicates with left ventricular outflow tract; C) massive aortic regurgitation; D) turbulent flow within the whole pseudoaneurysm cavity. 63-year-old female patient, with multiple comorbidities, bilateral COVID-19 pneumonia and symptoms of acute heart failure. TTE showed massive vegetation on the anterior mitral leaflet measuring 15x15 mm, with peak pressure gradient on LVOT >120 mmHg, and highly susceptible aortic valve vegetation (**Figure 2**). She had to undergo urgent surgical operation. The mechanical mitral valve (On-X M 31) and mechanical aortic valve (On-X A 21) were successfully implanted. Postoperative recovery went well, and control TTE showed a good function of both mechanical valves. FIGURE 2. Intraoperative transesophageal echocardiography showing: A, B) vegetation on the anterior mitral leaflet, susceptible aortic valve vegetation; C) massive mitral regurgitation. **Conclusion**: Despite applied therapy, COVID-19 infection caused the hyperinflammation and suppresses our immune system to defend against pathogens, accelerating the symptoms which leads to cardiac collapse. Such clinical condition requiring urgent cardiac surgery, which could be performed only with the implementation of all epidemiological measures in the therefore planned COVID-19 hospitals.

Vedran Pašara, Marko Kutleša, Maja Hrabak Paar, Irena Ivanac Vranešić, Nina Jakuš, Davor Miličić, Daniel Lovrić

**Introduction**: A life-threatening hyperinflammatory condition occurring several weeks after primary infection with SARS-CoV-2 that can include severe acute heart failure has been reported in children in early 2020. Later on, a condition with similar characteristics has also been reported in adults. (1, 2) **Case report**: 26-year-old male patient with obesity and arterial hypertension presented to the emergency department with 3 days history of fever, chills, dyspnea, exercise intolerance, headache, dry cough, nasal discharge and diarrhea approximately six weeks after he has been diagnosed with mild COVID-19. Initial blood tests showed markedly elevated laboratory inflammatory markers. CT scan showed enlarged lymph nodes in the neck and small areas of residual ground-glass opacities in the lungs. Pulmonary thromboembolism was ruled out. He was admitted to the infectious disease clinic and was started on cloxacillin, ceftriaxone, antipyretics and appropriate rehydration. On the third day of hospital treatment, the patient complained of chest and neck pain and severe dyspnea. His general condition deteriorated rapidly, and he was transferred to the intensive care unit due to the development of cardiogenic shock. Inotropic and vasopressor support was initiated. Echocardiography showed mildly dilated left ventricle with severe impairment of global systolic function (LVEF 20%). High-sensitivity troponin I and NT-proBNP were markedly elevated with a peak concentration of 792 and 18200 ng/l, respectively. Therefore, the patient was transferred to the tertiary center coronary care unit (CCU). Pulse steroid therapy and intravenous immunoglobulin were immediately initiated, while heart failure therapy was gradually introduced in the following days. Seven days after admission to CCU, multiparametric cardiac magnetic resonance imaging (MRI) revealed preserved LVEF with diffusely prolonged myocardial T1 relaxation time and T2 relaxation time, confirming myocardial injury and edema, respectively. There was no late gadolinium enhancement (**Figure 1**). Updated Lake-Louise criteria for myocarditis have been fulfilled. (3) The following criteria for multisystem inflammatory syndrome in adults (MIS-A) were met: age over 21 years, a positive test result for previous SARS-CoV-2 infection, documented fever >38.0°C for ≥24 hours, laboratory evidence of inflammation, involvement of cardiovascular and gastrointestinal system, and severe illness requiring hospitalization. FIGURE 1. Cardiac magnetic resonance imaging (MRI) findings; Multiparametric cardiac MRI revealed preserved left ventricular ejection fraction with diffusely prolonged myocardial T1 relaxation time (1058 ms, normal values 954-1042 ms, A) and T2 relaxation time (49,0 ms, normal values <47,5 ms, B), confirming myocardial injury and edema, respectively. There was no late gadolinium enhancement (C). There was left ventricular concentric symmetric myocardial hypertrophy with myocardial thickness of 15 mm. LV- left ventricle, RV- right ventricle. **Conclusion**: This case indicates that there is a vast diversity of clinical presentation and underlying mechanisms of COVID-19 and post-COVID-19 syndromes with myocardial injury. Recently described MIS-A is a rare but potentially life-threatening complication of previous SARS-CoV-2 infection. Clinicians should be aware of this syndrome in order to recognize it on time and start with appropriate treatment.

Irena Mitevska

**Introduction**: COVID-19 infection significantly increases the risk for thromboembolic complications which can cause multi organ dysfunctions and worsen patients clinical course and prognosis. (1-3) **Case report**: We are presenting a 73-years-old patient admitted to ICU unit due to first episode of sudden dyspnea, syncope and chest pain. He has no history of previous cardiovascular or respiratory disease, no history of thromboembolism (PTE) or deep vein thrombosis (DVT). ECG showed atrial fibrillation with HR 120 bpm and incomplete RBBB. Blood pressure was 85/45mmHg with cold periphery. Patient denied any provocable PE risk factors. Bed site POCUS (Point-of-Care Ultrasound) echocardiography was performed immediately in order to evaluate the cause of patient symptoms and hemodynamic instability. Examination showed increased right ventricle (RV) size, reduced RV function (TAPSE 13, TDI S’ 9), presence of McConnell’s sign, severe tricuspid regurgitation with dilated v. cava and signs of pulmonary hypertension. Due to hemodynamic instability and indirect signs of the presence pf pulmonary embolism fibrinolysis with alteplase infusion was applied. Patient hemodynamically stabilized after first hour. Nasopharyngeal smear for SARV CoV-2 was taken due to ongoing pandemic and result come out positive for virus RNK (real-time fluorescence polymerase chain reaction-PCR). CT angiography was performed which showed large intraluminal thrombi in the right pulmonary artery, extending to left pulmonary artery up to subsegmental level. His D-dimer values were 7813 ng/ml, CRP 123 mg/L. Evaluated sPESI score was 2, which indicated elevated 30-day death risk. Patient remained clinically stable. He was transferred to the infectious disease clinic for further treatment. After two weeks was discharged with recommendations for three months anticoagulation treatment with Rivaroxaban. Patient performed control visit at our clinic after four months. He was stable, asymptomatic with normal right ventricular function. **Conclusion**: This is case of successful treatment of pulmonary embolism complicated with cardiogenic shock as a first manifestation of COVID-19 infection at our clinic since the start of pandemic. POCUS echocardiography is fast noninvasive method that help us urgently assess the cause of patient instability and guide diagnostic approach and patient management.

Mia Dubravčić, Kristina Gašparović, Tihana Balaško Josipović, Mia Rora, Rajka Gabelica, Maja Hrabak Paar, Daniel Lovrić

**Introduction**: Coronavirus disease 2019 (COVID-19) was first described in China, in patients with flu-like symptoms in December 2019 (1). This family of viruses is known for its cardiotropism (2). Arrhythmia is possible clinical manifestation in COVID-19 patients and several cases of COVID-19 myocarditis have been reported, some as a cause of death (3). **Case report**: We present a case of a 37-years old, previously healthy, female patient who was admitted to COVID-19 Intensive care unit (ICU) at University Hospital Centre Zagreb after out of hospital cardiac arrest and successful resuscitation. She manifested episodes of chest pain and palpitations during two months prior to cardiac arrest. Initial laboratory findings showed elevated levels of high-sensitive troponin I and NT-proBNP, significant hypokalemia and normal values of C-reactive protein. Additional urgent work-up (pulmonary CT angiography and brain CT scan) showed no significant pathology and Sars-Cov-2 PCR RNA test came positive, without respiratory involvement. Due to ECG changes and ultrasound finding of reduced left ventricular ejection fraction (LVEF 25-30%) with anteroseptal and apical akinesia and inferior hypokinesia, urgent coronary angiography was performed, there were no signs of coronary artery disease, and the suspected diagnosis was Takotsubo cardiomyopathy or myocarditis. Soon after admission heart failure therapy was introduced, and follow-up echocardiography showed improvement in LVEF (40-45%). Patient was given no specific antiviral treatment nor corticosteroid therapy. Additional work-up regarding serology for cardiotropic viruses came negative, and IgG antibodies for Covid-19 showed borderline result. Cardiac magnetic resonance imaging (MRI) performed 18 days after initial event described recovered left ventricular ejection fraction (LVEF 53%), with mild hypokinesia, oedema and mid-wall late gadolinium enhancement in apical 2/3 of anterior, anteroseptal and anterolateral wall, with pattern characteristic for myocarditis (**Figure 1**) (4). At follow-up, one month after discharge, patient is completely recovered, without signs of heart failure or arrhythmias, with preserved LVEF and normal NT-proNBP levels. FIGURE 1. Cardiac magnetic resonance imaging (MRI) findings consistent with typical characteristics of myocarditis; A) MRI (2-chamber view) shows a high intensity area of the left ventricular wall on T2-weighted short-tau inversion recovery STIR, consistent with myocardial oedema in apical 2/3 of the anterior, anteroseptal and anterolateral wall (arrow); B) MRI native T1 mapping (SAX; short axis view) shows significantly increased native myocardial T1 values - mean value 1267 ms in comparison with normal myocardium mean value of 1025 ms in the same area (arrow), where native myocardial T2 values were also increased - mean value 70 ms in comparison with normal myocardium mean value of 53 ms (image not shown); C) MRI (SAX view) shows post-contrast enhancement on LGE of mid-wall distribution in the same area (arrow). LV- left ventricle, RV- right ventricle. **Conclusion**: This case once again highlights cardiac complications of SARS-CoV-2 infection, without respiratory involvement. Also, it shows good prognosis without specific antiviral treatment, emphasizing importance of early introduction of heart failure therapy.

Jadranka Šeparović Hanževački, Viktor Peršić

CroEcho2021, our traditional biannual echocardiographic conference, will provide a completely different experience this year. New limiting circumstanced due to the COVID-19 pandemic have compelled us to hold the conference remotely for the first time. However, the application of digital technology and the CroEcho2021 conference network platform also provides some new advantages to our participants, including free and unfettered participation in discussions, addressing questions and comments to lecturers through direct and freer communication, pre-conference viewing of conference speeches and exhibits, and free communication between participants during the conference. The conference program has been adjusted to the new circumstances and is reduced in scope, with no events taking place in parallel and addressing only selected topics from the echocardiography course, and echocardiography workshops being staged remotely. The conference focuses on carefully selected cardiologic topics addressed in plenary lectures in which echocardiography plays a central role, along with clinical scenarios that require goal-oriented choices and clinical interpretation based on multiple imaging methods in planning interventions and treatment. The conference is organized by the Working Group on Echocardiography and Cardiac Imaging Modalities of the Croatian Cardiac Society, with the support of the European Association of Cardiovascular Imaging (EACVI). We look forward to meeting each other once again, albeit this time via a computer interface. Predsjednici kongresa: / Congress Directors: Jadranka Šeparović Hanževački and Viktor Peršić