Cardiologia Croatica 2024;19(3-4)

Nikolina Bukal Ćaleta

Resistant hypertension is defined as the official values of blood pressure (BP) >140/90 mmHg despite lifestyle changes and treatment with optimal or best tolerated doses of three or more antihypertensives (one of which is thiazide/diuretic like thiazide) and after the exclusion of pseudoresistance, secondary hypertension and hypertension caused by drugs. The inadequate BP control should be confirmed by out-of-office BP measurement showing an uncontrolled 24-hours BP (≥ 130 mmHg systolic or ≥ 80 mmHg diastolic) values. If confirmation of true resistant hypertension by ambulatory blood pressure monitoring is not feasible, home blood pressure monitoring may be used. (1) The prevalence of true resistant hypertension is about 5%. But in patients with comorbidities the prevalence increases to 22.9% with chronic kidney disease, 56.0% with renal transplant and 12.3% with aging. (2) These patients are at higher risk of complications including cardiovascular disease, stroke, kidney failure, and death. Effective treatment should combine lifestyle changes such as reduction of sodium and alcohol intake, implementation of regular physical activity and weight loss in overweight or obese patients, discontinuation of interfering substances, rationalization of current treatment and the sequential addition of antihypertensive drugs to the existing triple therapy. Considering the pathophysiological mechanism, an interplay between multiple neurohumoral factors such as increased levels of aldosterone, endothelin-1, vasopressin and increased sympathetic activity which contribute to volume and sodium overload, increase in peripheral vascular resistance, arterial stiffness the fourth lines of treatment are antagonists of mineralocorticoid receptors. (1) The PATHWAY-2 trial demonstrated that spironolactone was superior in reducing BP compared with bisoprolol (a beta-blocker), doxazosin (an alpha-blocker), or placebo as add-on therapy in patients with resistant hypertension on three blood pressure medications. (3) This drug should be used with caution in chronic kidney disease because of hyperkalemia. The use of newer potassium binders such as patiromer or sodium zirconium cyclosilicate can reduce the risk of hyperkalemia. If gynecomastia becomes intolerable, spironolactone can be switched to eplerenone, a selective aldosterone receptor antagonist that has minimal interaction with sex hormone steroid receptors. The type of diuretic needs to be adapted to renal function. In patients with preserved glomerular filtration rate, the preferred first-line diuretic is either chlorthalidone or indapamide because of their longer half-life and more potent antihypertensive effect compared with hydrochlorothiazide. Chlortalidone (12.5 mg or 25 mg once daily) may be used with or without loop diuretic if eGFR 2. Loop diuretics are preferred in patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m2. Torsemide can be used once a day, but shorter-acting loop diuretics such as furosemide or bumetanide must be dosed at least twice a day. Finally, new more selective nonsteroidal MRAs such as finerenone (approved for the treatment in diabetic kidney disease), esaxerenone (approved for the treatment of hypertension in Japan), and ocedurenone (KBP-5074, in development for resistant hypertension in CKD) might provide future alternatives to spironolactone. Renal denervation, a promising new treatment method, should be considered as an additional therapeutic option if the appropriate criteria are met in patients with eGFR >40 ml/min. (1)

Anamaria Lukačević, Marijana Knežević Praveček, Blaženka Kljaić Bukvić

**Introduiction:** Cardiovascular disease (CVD) remains a major cause of premature mortality and rising health care costs. CVD burden attributable to modifiable risk factors continues to increase globally. (1-3) We aimed to investigate the presence of risk factors for the occurrence of CVD among health workers, their frequency and the association of sociodemographic risk factors for the occurrence of CVD. **Methods and Results:** The research is organized as a cross-sectional study. Participants and methods: 224 respondents, healthcare workers, participated in the research. The research was conducted during January and February 2023. An anonymous questionnaire consisting of 41 questions was used. Five questions related to socio-demographic data and three questions related to place of work, years of experience and working hours. 7 questions related to the question of whether the respondents suffer from CVD. 12 questions are included in the SLIQ questionnaire, a lifestyle assessment questionnaire. The other 14 questions refer to the PREDIMED questionnaire, which contains questions about the Mediterranean diet. Results: The overall result of the evaluation of lifestyle habits was shown as a moderate risk for the development of CVD, and there is no significant difference with regard to the sex of the subjects. There is low adherence to the recommendations for consumption of the Mediterranean diet **(****Figure 1****).** Resident doctors adhere significantly more moderately to the recommendations for the Mediterranean diet compared to all other respondents. FIGURE 1. Distribution of respondents according to adherence to the Mediterranean diet guidelines. **Conclusion**: Risk factors for the occurrence of CVD are present in a higher proportion among healthcare workers. Healthcare workers currently have a low prevalence of CVD; however, they have a moderate or medium risk for the development of CVD. There is no significant difference in the risk for the occurrence of CVD with regard to the gender of the subjects, but with regard to the healthy subjects, the older subjects have worse lifestyle habits and a higher risk for the occurrence of CVD.

Ivica Dunđer, Marijana Knežević Praveček, Ivan Bitunjac, Antonija Raguž, Katica Cvitkušić Lukenda

Thanks to technological advancements, the improvement in the quality of life, and a decline in birth rates, the average age of the world’s population is increasing from decade to decade. It is estimated that by the year 2030, the percentage of people aged 65 and older will rise from 6.9% to 12.0%, and particularly in developing countries (1). Pacemakers are electrical generators designed to mimic a customized pulse in terms of rate (frequency) and output power. While the pulse delivery can be temporary or permanent, the device’s function is assessed and adjusted through interrogation, which includes the stimulation rate, pulse width, and voltage. These devices are typically categorized as external and internal. External pacemakers are commonly used as a temporary measure for cardiac stimulation when a temporary cause of conduction disturbances is suspected (e.g., hyperkalemia), while internal pacemakers are implanted and represent a permanent solution. The primary indications for permanent electrical stimulation are sinus node disease (I), atrioventricular conduction disorders (I), and recurrent syncope (IIa/C) (2). The Implantable Cardioverter Defibrillator (ICD) is a device that, in addition to its pacing function, also has the capability for intracardiac defibrillation. Since its inception in the 1950s, distinguishing ICDs from ‘pure’ pacemakers has become more challenging because every ICD includes a pacing function. Devices for cardiac resynchronization therapy, or biventricular pacing (CRT-P), and those with an integrated defibrillation lead (CRT-D), are used in the treatment of heart failure in a specific patient population where improvement in cardiac function and quality of life is expected through biventricular electrical stimulation (2). In the last two decades (**Figures 1-3**Figure 2Figure 3), approximately 1300 pacemakers (120-140 per year) have been implanted at General Hospital “Dr. Josip Benčević”, Slavonski Brod, with 58% being single-chamber stimulation devices (VVI), 154 ICD devices, 45 CRT (P and D) devices, and a dozen loop recorders. Observing new scientific advancements and their application in everyday clinical practice is of paramount importance for the proper patient care. In line with this, at our institution, starting in the fall of 2023, 5 devices with conduction system stimulation have been implanted. FIGURE 1. The second invasive cardiology room was created by reconstructing a room that was used as a dressing room. Since opening in 2018, it has served as cardiac laboratory for the implantation of cardiac implantable electronic devices, for peripheral angiography and interventions, and also for electrophysiological procedures from 2019. FIGURE 2. Implantation of a cardiac pacemaker. In the picture from left to right, first row: Dr. Marijana Knežević Praveček, Dr. Zrinko Pešut, second row: Alenka Tuličić-Mihelčić, nurse, and Jozo Radičević, medical radiology engineer. FIGURE 3. Preparation of the cephalic vein during cardioverter-defibrillator implantation. In the picture from left to right, the first row: Marina Stanković, nurse, Dr. Domagoj Vučić, and in the second row, mentor Dr. Ivica Dunđer.

Katica Cvitkušić Lukenda, Jelena Jakab, Marijana Knežević Praveček, Krešimir Gabaldo, Anto Lukenda, Vesna Ćosić

**Introduction**: Over the past two decades, the prevalence of myocardial infarction (MI) has trended downward in both sexes in the United States and Europe, although this decline has been smaller in women. (1) According to the available literature, only two models predicting cardiovascular risk (CVD) in women included risk factors specific to women, which were reproductive risk factors. (2) Our previous research showed a significant association between ferritin, hsCRP, and systolic blood pressure in women working shift work. (3) In women, iron stores increase during menopause. We started a prospective study of CVD risk factors and CVD outcomes in women in Brod-Posavina County. Aim: To determine the association between ferritin level and menopause age as female-specific CVD risk factors in women and the influence of body mass index (BMI), non-HDL and hsCRP on cardiovascular risk in women. **Patients and Methods:** Women aged 35 to 75 years, divided into two groups: women without coronary artery disease (CAD) and women with CAD (angiography, medical history of MI). The variables included in the evaluation are: age, BMI, menopause age and status, systolic blood pressure (SBP), non-HDL, ferritin, hsCRP, and smoking habits. Results are mean±SD. For the comparison of continuous variables, we used the Student t-test, whereas for the comparison of categorical variables, we used the Fisher exact test. P # | | Menopause age | 48.73±4.82 | 51.07±4.14 | 0.17* | | non HDL | 4.23±1.25 | 4.6±0.7 | 0.31* | | Ferritin | 96.12±63.75 | 57.77±38.3 | # | [†] BMI = body mass index; SBP = systolic blood pressure *Student t test, #Fisher’s exact test **Conclusion**: The preliminary results of our study show that women without CAD have statistically lower BMI, ferritin and hsCRP levels compared to women with CAD. There were no differences in menopause age and status, non-HDL or smoking habits. Further research is needed to improve women’s health.

Sergej Nadalin, Domagoj Vučić, Maja Vilibić, Vjekoslav Peitl, Luka Maršić, Katica Cvitkušić Lukenda, Dalibor Karlović

Individuals with severe mental disorders (SMDs) consisting of schizophrenia, major depressive disorder and bipolar affective disorder have a life expectancy 15–25 years shorter compared to individuals from the general population (1). Despite the high rate of unnatural deaths (e.g., suicides, injuries), physical conditions represent the main cause of reduced life expectancy among individuals with SMD. Evidence suggests that physical conditions account for ~70% of deaths among individuals with SMD, with cardiovascular diseases contributing 17.4% and 22.0% to the reduction in overall life expectancy in men and women, respectively (2). Lifestyle risk factors for cardiovascular diseases among individuals with SMD (e.g., unhealthy dietary pattern, cigarette smoking, reduced physical activity) are traditional risk factors that are also present, thought usually to a lesser extent, among individuals from the general population. Additional risk factors among individuals with SMD include the use of psychotropic medications (antipsychotic medications, specifically second-generation antipsychotics, antidepressants, and mood stabilizers) and biological risk factors (shared genetic loci for both SMDs and cardiovascular diseases) (3). Importantly, different cardiovascular risk factors among individuals with SMD interact by yet-undefined mechanisms which additionally complicate the relationship between SMDs and cardiovascular diseases (4). In the research literature, there is still a lack of studies on systematic assessment of cardiovascular risk factors among individuals with SMD. Furthermore, in clinical practice, comorbidity of cardiovascular diseases and psychiatric disorders is likely to be underrecognized and undertreated. In this work we discuss the risk factors for cardiovascular diseases among individuals with SMD, highlighting the role of multidisciplinary approach comprising psychiatry and cardiology teams in prevention strategies. We also discuss clinically significant interactions between common cardiovascular and psychotropic medications as well as (neuro)psychiatric effects of common cardiovascular medications. Finally, we provide novel insights related to the genetic relationship between SMDs and cardiovascular diseases, based on genome-wide association studies.

Ana Crnjac, Nataša Đurđević

The World Health Organization estimates that 54% of strokes and 47% of cases of ischemic heart disease are the direct consequence of high blood pressure (BP), which thus takes its place among the main risk factors for cardiovascular morbidity and mortality. (1) Arterial hypertension (AH) is a medical condition in which BP is elevated above 140/90 mmHg. High BP accelerates the process of atherosclerosis in the walls of blood vessels. Clogged arteries provide reduced blood supply to tissues and organs, damaging them and their function over time. Numerous factors have been shown to contribute to development of AH, such as stress, genetic factors, smoking, and alcohol, but being overweight also has a leading role in AH development. (2) Familial clustering implies a genetic predisposition whose interaction with environmental factors, such as the intake of salt and calories and the degree of physical exercise, ultimately determines how severe the rise of blood pressure will be. Elevated BP must be due to elevated cardiac output, elevated peripheral vascular resistance, or a combination of both. Each of these mechanisms is regulated, in turn, by hemodynamic, neural, humoral, and renal processes, all of which vary in their contribution from one individual to another. (3) The first-line drugs for arterial hypertension include long-acting dihydropyridine calcium channel blockers, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and thiazide-like diuretics. Mineralocorticoid-receptor blockers are effective in patients whose blood pressure cannot be brought into acceptable range with first-line drugs. Nurses play a crucial role in the management of AH through both non-pharmacological and pharmacological interventions. Nurses are instrumental in educating patients about the importance of lifestyle modifications. They provide information about dietary changes, weight management, and regular exercise as key components of managing hypertension. Nurses regularly measure and monitor a patient’s BP, helping to identify trends and ensuring that any changes are promptly reported to the healthcare team. Nurses are often responsible for administering antihypertensive medications in various healthcare settings, such as hospitals, clinics, or long-term care facilities. They educate patients on the importance of taking medications as prescribed, potential side effects, and the need for ongoing medication management. In addition to treatment, the nurse has a major role in the prevention of disease. By educating the patient about prevention, in a way they can understand, the nurse can directly reduce the number of patients, which is extremely important.

Ema Didović, Domagoj Mišković, Ivan Bitunjac, Domagoj Vučić, Katica Cvitkušić Lukenda

**Introduction**: Situs viscerum inversus totalis is a rare congenital abnormality characterized by a mirror-image transposition of both the abdominal and the thoracic organs. Frequency of situs inversus is 1:10000. (1) **Case report**: 77-year-old female patient with situs viscerum inversus totalis, type 2 diabetes, coronary artery disease and two coronary artery bypass grafts (VSM-LAD, VSM-OM1) was admitted to Coronary Care Unit because of acute non-ST-segment elevation myocardial infarction (NSTEMI). 12-lead electrocardiogram showed 1mm ST-segment depression in V5 and V6. High sensitivity cardiac troponin I levels were elevated. Echocardiography showed a non-dilated left ventricle with preserved ejection fraction and no regional wall abnormality. Angiography showed subtotal stenosis of the distal segment of VSM-LAD bypass (**Figure 1**), no visible lumen irregularities of VSM-OM bypass and a significant calcified stenosis in the proximal segment of right coronary artery (RCA) and an occlusion of the distal segment. Angiography of left anterior descending artery and circumflex artery with previously known multiple significant stenoses was not repeated. In second act, a successful percutaneous coronary intervention (PCI) of VSM-LAD with implantation of drug eluting stent (DES) was performed (**Figure 2**). There were no periprocedural complications and the patient was soon discharged. Five months after discharge the patient developed NSTEMI again. Angiography showed no bypass stenoses and previously known stenoses of main coronary vessels were confirmed, including a subocclusive calcified stenosis of proximal segment of the RCA (**Figure 3**). The patient then underwent a PCI of proximal RCA, including rotablation and DES implantation with an optimal result (**Figure 4**). Although the main coronary arteries and venous bypasses in this patient are of atypical origin and direction, there were no major problems with the positioning of the guiding catheters. FIGURE 1. Angiography of the saphenous vein graft to the left anterior descending artery showing subtotal stenosis of the distal segment. FIGURE 2. Angiography of the saphenous vein graft to the left anterior descending artery after percutaneous coronary intervention with drug-eluting stent implantation. FIGURE 3. Angiography of the right coronary artery showing subocclusive stenosis of the proximal segment. FIGURE 4. Angiography of the right coronary artery after percutaneous coronary intervention including rotablation and drug-eluting stent implantation. **Conclusion**: Complicated percutaneous coronary interventions on native vessels and coronary artery bypass grafts in patients with situs inversus totalis are possible but pose a technical challenge.

Rea Levicki, Ivan Barišić, Ile Raštegorac, Jurica Petranović, Vladimir Dujmović, Martina Lovrić Benčić

**Introduction:** The most common left ventricular (LV) mass is thrombus. (1) It is important to differentiate LV thrombus from common benign tumors; myxomas, papillary fibroelastoms and lipomas but also some rare tumors; rhabdomyomas and fibromas or malignant cardiac sarcoma. (2, 3) **Case report:** 59-year-old male patient presented with intermittent chest pain and worsening shortness of breath and orthopnea. Four years ago he had myocardial infarction of the anteroseptal region with remaining hypokinesia of the apical anterior wall and apex dilatation. Transthoracic echocardiography showed estimated left ventricular ejection fraction 48%, hypokinesia of the apical anterior wall and apex dilatation with homogeneous mass visualized on apical part of the lateral left ventricular wall and it was difficult to differentiate a thrombus from LV tumor. 4D transesophageal echocardiography was preformed and it showed LV mass measuring 1.5cm×1.9cm attached to the apical part of the lateral left ventricular wall on two sides that resembled a pedunculated tumor (**Figure 1** and **Figure 2****)**. It was homogenous and noncalcified, nonmobile with echodensity similar to the myocardium. On cardiac computed tomography (CT) LV mass showed features of benign tumor (size <5cm, single lesion, pedunculated, with absent enhancement, with smooth, well-defined margines, with no signs of invasion, metastasis, pericardial effusion or calcification), most probably a fibroma (**Figure 3**). Significant coronary artery stenoses were excluded on ct coronarography.With chronic therapy correction and optimal heart failure therapy patient was asymptomatic. On repeted transesophageal echocardiography during 6 months period LV mass remained the same size. Patient was examined by cardiac surgeon and follow up was recommended, considering unchanged size and echocardiographic and CT features of the tumor, surgical treatment was not indicated. Cardiac magnetic resonance imaging (MR) is planned to confirm the diagnosis. FIGURE 1. Left ventricular tumor on transesophageal echocardiography. FIGURE 2. Left ventricular tumor on 4D transesophageal echocardiography. FIGURE 3. Left ventricular tumor on cardiac computed tomography. **Conclusion:** Echocardiography is an important tool in intracardiac mass evaluation and identification of the LV mass size, shape, mobility and attachment is important do differentiate LV thrombus from tumors. An intracardiac mass should be assessed in multiple views, both during systole and diastole. Cardiac MR or CT should be used to confirm the diagnosis.

Krešimir Gabaldo, Tomislav Krčmar, Marijana Knežević Praveček, Domagoj Mišković, Ivan Bitunjac, Ivica Dunđer, Antonija Raguž, Blaženka Miškić, Katica Cvitkušić Lukenda

**Introduction**: Critical limb ischemia (CLI) is a clinical syndrome characterized by chronic ischemic at-rest pain, ulcers, or gangrene in one or both legs attributable to objectively proven arterial occlusive disease (1). Patients with CLI have a one-year risk of amputation greater than 25%. Endovascular treatment is preferred as the first option of revascularization treatment because of lower morbidity and mortality compared to open surgery (2). The main goal of the treatment is to establish flow through at least one vessel to the foot. CLI is often associated with multilevel disease usually requires outflow (tibial) revascularization as well as treating inflow disease. It remains unclear whether revascularization of both inflow and outflow vessels yields better outcomes than treating only inflow vessels in patients with critical limb ischemia (3). **Case report**: We present the case of 75-year-old male patient with CLI presented with non-healing ulcer of right foot. Risk factors for peripheral artery disease were diabetes, hypertension, and previous stroke. WIfI (Wound, Ischemia, foot Infection) index was 2-2-0 which addressed high risk of amputation. MSCT scan showed superficial femoral artery (SFA) occlusion in inflow region, while in outflow region both tibial arteries were occluded, and a peroneal artery was patent. We performed an SFA intervention with a good result in inflow region. In 3 months, follow-up the ulcer healed completely. **Conclusion**: Concomitant inflow and outflow revascularization in CLI did not offer an advantage over just inflow revascularization in reducing the rate of amputation, total death, target lesion revascularization, if there is at least one patent artery in tibial region.

Tihana Smoljo

The number of people suffering from diabetes in the world is constantly growing, and diabetes has become a global pandemic of the modern era. According to data from the CroDiab Registry in 2022, there were 388,213 people with diabetes in Croatia. (1) Some older studies suggest that almost half of those affected do not have a formal diagnosis, which implies an estimate of around 500,000 people with diabetes in Croatia. Lifestyle changes such as unhealthy diet, smoking, obesity, sedentary living, and stress have contributed to this. If not well regulated, diabetes brings with it many complications, including cardiovascular diseases, kidney damage, and vision impairment. On average, diabetes shortens life expectancy by 15 years. People with diabetes have a 2 to 3 times higher risk of heart failure and an increased risk of myocardial infarction. According to the World Health Organization, data based on the cardiovascular mortality rate indicate that Croatia is a high-risk country. (2, 3) A multidisciplinary team plays a key role in the treatment of patient with diabetes. Achieving glycemic control in patients is important, but so is changing their lifestyle habits. The role of a nurse in the treatment of patients with diabetes is significant, whether it involves a hospitalized patient or one in a daily diabetology clinic. (4) The main task is to educate the patient about new knowledge and skills and to check their adoption of these skills. Access should be individual and adapted to each patient’s needs. Sufficient time should be allocated for education, speaking slowly and reassuringly, and encouraging the patient to ask questions and actively participate. Patients need motivation and praise for all acquired knowledge and skills at each visit. The goal of education is to empower the patient for self-monitoring, self-help, and self-treatment. Today’s modern technologies enable simple and painless glycemic control. New devices provide insight into glucose variability, which is a risk factor, enabling better control of diabetes and reducing the risk of complications. Each reduction in HbA1c by 1% reduces the risk of death by 20%, the risk of myocardial infarction by 14%, and the risk of microvascular complications by up to 37%. According to the latest guidelines, devices for continuous glucose monitoring are available to all patients on intensive insulin therapy, including both type 1 and type 2 diabetics. Since type 2 diabetes is the most common form, accounting for up to 90% of all cases, this change is a significant step forward that can lead to improvements in the quality of life of patients with diabetes. Although patients are still more inclined to traditional measurement methods, it is necessary to educate them well, motivate them, and provide support during the adjustment process. Considering the time spent with the patient, a nurse plays a crucial role in training the patient and their family for self-care. Modern technologies have enabled patients with diabetes to receive painless treatment, reducing the number of complications, and consequently, improve their quality of life significantly. It is important to emphasize that modern technologies alone are not enough for success in treatment. A healthy diet, regular physical activity, stress reduction, and proper therapy are fundamental principles that remain key to the successful management of diabetes.

Zvonimir Bosnić, Blaženka Šarić, Stjepan Žagar, Domagoj Vučić, Ljiljana Trtica Majnarić

An alarming increase in the development of cardiovascular (CV) disease and recent knowledge about the common pathophysiological background of cardiometabolic disease, with inflammation being in the center of the pathophysiological networks, has indicated that a more integrated approach is needed for classifying these disorders. (1) Chronic inflammation is considered to be a major force driving the development of cardiometabolic diseases such as myocardial infarction (MI), stroke, diabetes type 2 (T2D). It is known that changes in the body’s shape and structure that occur with aging, followed by muscle loss and an increase in visceral fat, contribute to inflammation and the development of insulin resistance, which taken together increase the risk for metabolic and vascular disorders associated with them. (2) Currently, there is no consensus as to which markers of inflammation best represent which phases of chronic inflammatory response. Interleukin 6 (IL-6) and C-reactive protein (CRP, whose production is stimulated by IL-6) are arguably the two most commonly assayed biomarkers used to stratify risk in patients with CV risk factors. Nowadays, a more prevalent role has been given to the neutrophil-to-lymphocyte ratio (NLR) and new sets of markers of inflammation including interleukins IL-17A and IL-37, that have been explored for their potential use for risk stratification in everyday clinical practice. (3) The evaluation of their circulating levels might provide new insights into the course of disease, and may guide the prognostics and emerging therapeutics in area of cardio- metabolic disease. In contrary to IL-17A, which plays a central role in the process of end-organ damage and is complementary to NLR, alternative anti-inflammatory treatment of IL-37, may turn out to be more effective, depending on genetic predispositions, duration, and manifestation of the disease.

Katica Cvitkušić Lukenda, Ivan Bitunjac, Ivica Premužić Meštrović, Šime Manola, Vedran Velagić

Atrial fibrillation (AF) is the most common arrhythmia in the world with an increasing prevalence in the elderly. It is associated with increased morbidity and mortality in affected individuals, primarily due to heart failure (HF) and stroke. (1) The early rhythm control strategy showed superiority in reducing stroke, total mortality and cardiovascular mortality compared to the rate control strategy and consistent superiority in maintenance sinus rhythm in relation to treatment with antiarrhythmics. (2) In electrophysiology centers, the second most common arrhythmia after AF is atrioventricular nodal re-entrant tachycardia (AVNRT), then atrial flutter and atrioventricular re-entrant tachycardia (AVRT), for which catheter ablation is recommended as initial treatment. (3) The success of catheter ablation with the low risks of the procedure and the availability of technology led to the opening of the first electrophysiological laboratory in Slavonia in the General Hospital “Dr. Josip Benčević” in Slavonski Brod. The first procedure that was performed was the cryoballoon pulmonary vein isolation on February 19, 2019 (**Figures 1-5**Figure 2Figure 3Figure 4Figure 5). Shortly after that, on February 28, 2019, the first electrophysiological study and radiofrequency ablation using a 3D navigation system were performed on a patient with AVNRT (**Figure 6**). To date, we have performed 265 catheter ablations, 124 (46.8%) cryoballoon pulmonary vein isolations, and 141 (53.2%) radiofrequency ablation. Since the beginning, we have established two registers, one for all electrophysiological procedures and the other for pulmonary vein isolation (PVI register) in which we enter demographic data, procedure characteristics, comorbidities, procedural outcomes, and complications. Using data from the PVI register and the Hospital Information System, we conducted a retrospective analysis for the period from February 19, 2019 to February 28, 2023. A total of 105 patients, 61 men (58.1%), median age 64 years (38-79), (IQR 58.5-69). CHA2DS2-VASC score was 2 (IQR 2-3). Paroxysmal fibrillation was present in 61 (58.1%) patients. The most common comorbidities were arterial hypertension in 92 (87.6%) and dyslipidemia in 68 (64.8%) patients. 28 (26.7%) had HF, while coronary heart disease and diabetes were equally represented by 12 patients each (11.4%). FIGURE 1. The first cryoballoon pulmonary vein isolation in Slavonski Brod on February 19, 2019. In the picture from left to right, first row: Assist. Prof. Vedran Velagić, Dr. Ivan Bitunjac, Dr. Katica Cvitkušić Lukenda, second row: Mato Čizmić, medical radiology engineer, Saša Presežnik, nurse. FIGURE 2. The first cryoballoon pulmonary vein isolation in Slavonski Brod on February 19, 2019. In the picture from left to right, first row: Mato Čizmić, medical radiology engineer, Dr. Marijana Knežević Praveček, Dr. Ivan Bitunjac, Dr. Katica Cvitkušić Lukenda, second row: Assist. Prof. Vedran Velagić. FIGURE 3. Preparing the patient for the cryoballoon pulmonary vein isolation. In the picture from left to right, first row: Saša Presežnik, nurse, second row: Mato Čizmić, medical radiology engineer, Barica Stanić i Alenka Tuličić-Mihelčić, nurses. FIGURE 4. February 19, 2019. The first cryoballoon isolation of the left superior pulmonary vein in Slavonski Brod. FIGURE 5. February 19, 2019. The first cryoballon isolation of the left inferior pulmonary vein in Slavonski Brod. FIGURE 6. February 28, 2019. The first electrophysiological study and radiofrequency ablation using a 3D navigation system in Slavonski Brod. Before the procedure, 85 (81%) patients were in sinus rhythm. Electrocardioversion was performed after the procedure in 35 patients (33.3%). Echocardiographic median left ventricular ejection fraction (LVEF) was 63% (IQR 60-68), left ventricular end-diastolic diameter 51 mm (IQR 48-56) and left atrial (LA) diameter 44 mm (40-48). The total duration of the procedure was a median of 60 min (IQR 50-70), and the time of the cryoballoon in the LA was 40 min (IQR 30-45). To evaluate the effectiveness of the procedure, 77 patients were analyzed, who had 12 monthly follow-ups. After 12 months, 64 of them (83.1%) were AF-free. Of the 13 (16.9%) who had AF recurrence, the median time to recurrence was 7.5 months (IQR 4-10). We tried to determine the predictors of AF recurrence in our patient population and found that the persistent form of AF, the diameter of the LA, and the lower LVEF were associated with the occurrence of AF recurrence (**Figure 7**, **Figure 8**). The presence of symptoms and signs of HF was associated with the risk of AF recurrence (p<0.01, Fisher’s exact test). Of all the procedures, one case of AV fistula was recorded, which required surgical treatment, one transient paresis of n. phrenicus and one iatrogenic atrial septal defect that was closed with a percutaneous occluder in our hospital. FIGURE 7. Recurrence of atrial fibrillation based on the type of atrial fibrillation. FIGURE 8. Recurrence of atrial fibrillation based on the echocardiographic parameters. LVEDD = left ventricular end-diastolic diameter; LA = left atrium; LVEF = left ventricular ejection fraction. In this single-center retrospective analysis, cryoballoon pulmonary vein isolation is an effective and safe method for maintaining sinus rhythm 12 months after the procedure in patients with symptomatic paroxysmal and persistent AF. Heart failure, persistent type of AF, LA diametar end lower LVEF were predictors for the recurrence of AF.

Dániel Czuriga, Zsófia Dóra Drobni, Zoltán Pozsonyi

One of the guiding principles of cardio-oncology practice is to minimize the unnecessary interruption of antineoplastic therapy. The overall goal of the specialty is to ensure that cancer patients receive the best possible anticancer therapy safely, while minimizing cancer therapy-related cardiovascular toxicity (CTR-CVT) during oncology care. In this paper, we describe prior and current definitions of CTR-CVT and briefly present the landmark CARDIOTOX registry, as well as corresponding parts of the recently published, first cardio-oncology guideline of the European Society of Cardiology. In our paper, we aim to provide insight into the cardio-oncology-related aspects of precision medicine.

Zvonimir Bosnić, Blaženka Šarić, Stjepan Žagar, Domagoj Vučić, Ljiljana Trtica Majnarić

**Introduction:** The elderly population is increasing because of increasing life expectancy, and the prevalence of frailty increases with age. There are many observational studies which showed strong association between fraility status and cardiometabolic diseases, and chronic inflammation is a major force driving the development of cardiometabolic diseases in those patients. Based on recent developments in understanding of age-related inflammation as a whole-body response, we discuss the negative effect of fraility status on cytokine IL-37, which is emerging as a strong natural suppressor of the chronic innate immune response. (1-3) **Patients and Methods:** The study was performed in primary care settings and included 170 older individuals with T2D and comorbidity. Participants were described by variables that included sociodemographic characteristics, anthropometric measures, comorbidities, medications, frailty, nutritional status, markers of inflammation, and laboratory tests indicating metabolic status and renal function. **Results:** Participants were mostly 50 years old or more, and women participated more than men. They were primarily overweight/obese, most of them also had metabolic syndrome and arterial hypertension. No individuals had severe sarcopenia. Frailty was shown to have a suppressive effect on IL-37 circulating levels and a modifying role in associations of metabolic and inflammatory factors with IL-37, including the effect of treatments. **Conclusion:** Assessment of nutritional status may help stratify the risk of cardiovascular events and encourage improvements in nutritional status of elderly people. In that way, we need better integration and understanding of both cardiometabolic diseases and frailty status, because they share common pathophysiological mechanism of chronic inflammatory status. At the same time, prevention of cardiometabolic diseases should be taken as a factor in reducing the healthcare utilization and expenditures.

Josip Ereiz, Katica Cvitkušić Lukenda, Domagoj Vučić, Ivan Bitunjac, Josip Silović, Blaženka Miškić

**Introduction**: Long QT syndrome (LQTS) has a prevalence of 1:2000, with mutations in the KCNQ1, KCNH2, and SCN5A genes predominating in 90% of cases. The diagnosis should be suspected when the Schwartz score is ≥ 3.5 and can be confirmed by genetic testing. (1-3) **Case report**: 50-year-old Caucasian woman was referred for a first cardiology evaluation (December 2018) after her 18-year-old daughter was diagnosed with a prolonged QT interval during a general medical examination. The patient, a healthy adult with a negative family history of sudden cardiac death (SCD), is a non-smoker with good exercise capacity and no history of syncope. In 12-lead resting electrocardiography (ECG) the QTc interval was 498ms (**Figure 1**). Physical examination and laboratory results were unremarkable, and she was not on QTc-prolonging therapy. Echocardiography showed no structural heart disease. On 24-hour Holter ECG, the predominant rhythm was sinus rhythm, with no premature ventricular contractions and an insignificant number of premature atrial contractions recorded. The average QTc was 482ms and the longest was 534ms. She underwent exercise testing, and in the fourth minute of recovery, the QTc was 511ms. Malignant arrhythmias were not recorded during the test. When we summarize the basic criteria for QTc duration and exercise testing, her Schwartz score was 4, which meets the diagnostic criteria for LQTS. The next step was a genetic test. The results obtained showed a heterozygous missense variant c.251G > A, p. (Arg174His) in KCNQ1, resulting in the final diagnosis of LQT1. Since the chance of inheriting LQTS is 50% (autosomal dominant), the patient’s daughters (18 and 15 years old) also underwent genetic testing. The results were positive in both patients. They were asymptomatic with no recorded arrhythmias, and beta-blockers were introduced at the hospital. FIGURE 1. Maternal electrocardiographic record, QTc 498 ms (Bazett formula). **Conclusion**: Because the patients were asymptomatic and had no family history of malignant arrhythmias or SCD, drug therapy with beta-blockers was recommended. Patients were educated about avoiding strenuous physical activity and about the list of medications that may prolong the QT interval. Acquisition of an automated external defibrillator for home use and regular cardiology follow-up were recommended.

Marijana Knežević Praveček, Hrvoje Pitlović, Domagoj Vučić, Jelena Jakab, Tomislav Kizivat, Blaženka Miškić, Katica Cvitkušić Lukenda

**Introduction**: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a rare but rapidly progressive disease. It is caused by the misfolding of transthyretin protein in the liver, resulting in the formation of amyloid fibrils. These harmful fibers deposit in the tissues of the carpal tunnel and may be one of the causes of carpal tunnel syndrome. While carpal tunnel syndrome can be an early symptom of ATTR amyloidosis and is a valuable indicator for screening for cardiac amyloidosis, it may not be sufficient. To improve the identification of patients at risk for ATTR-CM, we recommend the use of phenotypes obtained by a machine learning-adapted algorithm to identify possible transthyretin amyloid cardiomyopathy. The inclusion of cardiomegaly, osteoarthritis, and cardiovascular symptoms (such as heart failure, atrial fibrillation, and heart block) as part of the phenotypic criteria is a comprehensive approach. (1-3) We will present our first confirmed patient with ATTR-CM who meets all the above criteria. **Case report:** 80-year-old patient was hospitalized for replacement of a pacemaker battery originally implanted in 2017 for bradycardic atrial fibrillation. The patient has several comorbidities, including hypertension, prostatic hyperplasia, and carpal tunnel surgery five years ago that resulted in residual polyneuropathy. In addition, the patient has an elevated NT-proBNP level (>1300pg/l) and the following echocardiographic findings: concentric biventricular hypertrophy, septal wall thickness >14 mm, biatrial enlargement, moderately severe mitral and tricuspid regurgitation, and a mildly reduced ejection fraction (EF 45%), corresponding to heart failure with mildly reduced ejection fraction. ATTR-CM was suspected and eventually confirmed by scintigraphy. The patient is scheduled for treatment with tafamidis. **Conclusion:** Implementation of a screening program for ATTR-CM in patients who have previously undergone carpal tunnel release surgery and present with cardiovascular symptoms such as heart failure, atrial fibrillation, and heart block is a proactive and potentially life-saving approach to early detection and intervention. Collaboration with experts, ethical considerations, and validation of the screening algorithm are essential components of its success.

Kristina Vorkapić, Mario Špoljarić, Ivica Dunđer, Božo Vujeva, Blaženka Miškić, Katica Cvitkušić Lukenda

**Introduction:** The incidence of acute aortic syndromes is estimated at approximately 10.2 and 5.7 cases per 100 000 person-years for males and females, 2-7% of all these cases are penetrating aortic ulcers. (1) Penetrating aortic ulcer (PAU) is more common in males, with increased age (>60 years), with uncontrolled hypertension. The problem is that there are no optimal recommendations for the treatment of an isolated PAU. (2) **Case report:** 72-years-old male was admitted to the Emergency Room with the symptoms of fatigue and nonspecific abdominal pain, hypotensive (blood pressure 80/60 mmHg). In the last two years patient has suffered from cerebrovascular disease and had thromboendarterectomy of right internal carotid artery. Due to history of atherosclerosis and clinical presentation of shock, MSCT aortography was performed and it showed penetrating aortic ulcer of infrarenal abdominal aorta width 12 mm and depth 10 mm. In the lab results there was a rise in inflammatory parameter: leukocytosis (16.89x109 /L) with neutrophilia (15.94x109/L) and high C-reactive protein (381.1 mg/L). Patient was admitted in the Coronary Care Unit in septic shock where he was treated with parenteral antibiotics (K. pneumoniae ESBL was isolated in blood cultures). On the fifth day of hospitalization, patient’s neurological status was worsening so the computerized tomography of brain was done that showed new ischemic lesion. In spite of the antibiotics patient was still febrile and the new MSCT of abdomen was done and revealed hydronephrosis of the left kidney which was treated with the implantation of JJ stent. During the rest of the hospitalization patient had no fever, inflammatory parameters dropped to normal values. A vascular surgeon was consulted multiple times to reevaluate the treatment of aortic ulcer and the conclusion was that surgical treatment was not indicated at the time and it was recommended to continue optimal medicament treatment and regular follow ups. **Conclusion:** This case report on a 72-years-old patient shows that in treating patients with acute aortic syndrome it is crucial to select appropriate combination of medical and procedural therapy and later to provide follow up and imaging surveillance.

Rea Levicki, Ivan Barišić, Matias Trbušić, Ozren Vinter, Jurica Petranović, Ile Raštegorac, Vladimir Dujmović, Martina Lovrić Benčić

**Introduction:** Left ventricular non-compaction cardiomyopathy (LVNC) is defined with excessive trabeculations of the left ventricle and is known to be genetically determined. Several studies suggest that LVNC is associated with adult congenital heart disease (ACHD), especially Ebstein anomaly and infrequently with left ventricular outflow obstruction (bicuspid aortic valve), coarctation of the aorta and tetralogy of Fallot. (1) There are only a few cases in a world of adults with tetralogy of Fallot and combined LVNC described, and the prognosis of this condition is still unclear. (2, 3) **Case report:** 63-years-old patient was admitted to the hospital because of the first clinical manifestation of a heart failure. In his previous medical history, it was known that a patient had tetralogy of Fallot diagnosed in a childhood and he underwent cardiac surgery with total congenital heart disease repair when he was 29 years old. Echocardiography (TTE and TEE) demonstrated dilated left ventricle with asymmetric hypertrophy of the apical wall (25mm) and left ventricular hypertrabeculation (**Figure 1**) with ratio between non-compacted and compacted layer approximately >2, with globally reduced contractility and reduced ejection fraction (LVEF 25%). Coronary angiography and right heart catheterization were preformed, and coronary artery disease was excluded, max systolic pulmonary artery pressure 38mmHg. Cardiac magnetic resonance imaging showed hypertrabeculation of both left and right ventricle in segments 7, 11, 12, 13, 14, 16 with ratio between non-compacted and compacted layer approximately >2,3, globally reduced contractility with fibrosis of basal anteroseptal wall, reduced left and right ventricular ejection fraction, LVEF 25%, RVEF 35%, late gadolinium enhancement demonstrated pathological contrast imbibition of a “mid wall” type in segment 2 (non-ischemic etiology) (**Figure 2** and **Figure 3**). Patient was initially treated with diuretics and optimal heart failure therapy and 3 months later, with satisfied criteria for implantation, cardiac resynchronization therapy defibrillator was implanted. Patient is referred to a heart team for cardiac transplantation evaluation. FIGURE 1. Left ventricular hypertrabeculation on transesophageal echocardiography. FIGURE 2. Cardiac magnetic resonance image of the presented patient. FIGURE 3. Left ventricular hypertrabeculation and pathological contrast imbibition of a “mid wall” type on cardiac magnetic resonance imaging. **Conclusion:** In patients with ACHD, tetralogy of Fallot, LVNC can be combined and can present a higher risk for heart failure onset, severe LVEF reduction, thromboembolic events, and malignant arrhythmia episodes.

Ivana Vučinić Ljubičić, Hrvoje Holik, Božena Coha

**Introduction:** Ibrutinib is an orally bioavailable, irreversible inhibitor of Bruton tyrosine kinase that is standard of care in the treatment of chronic lymphocytic leukemia (CLL), in both front-line and relapse/refractory setting. Side effects include cardiac toxicity, commonly atrial fibrillation (AF) and arterial hypertension and increased bleeding risk. Incidence of ibrutinib related AF varies in different reports (1-4). **Patients and Methods**: Our aim was to determine the incidence of ibrutinib related AF in our group of CLL patients who were treated from December 2017 until December 2022. We included only CLL patients treated with ibrutinib and excluded patients with history or pretreatment ECG of cardiac arrhythmia. The primary endpoint was the incidence of ibrutinib related AF **Results:** We included 14 CLL patients treated with ibrutinib (**Table 1**). Median age of patients was 71 years and they were predominantly male (64%). Median follow-up was 24 months and during that period, one (7%) patient was diagnosed with AF. From known AF risk factors, our patient had only arterial hypertension that was adequately controlled with antihypertensive drug. Echocardiography findings were normal. Atrial fibrillation appeared 12 months into ibrutinib therapy and was grade 1 according to common terminology criteria for adverse events. Treatment strategy was rate control with a beta-blocker and anticoagulation with direct oral anticoagulant for stoke prevention. Ibrutinib therapy was continued and there were no bleeding events. ### TABLE 1: Baseline characteristics of patients. | Baseline characteristics | | | --- | --- | | Total population | 14 | | Male / Female | 9 (64%) / 5 (36%) | | Age (median / range) | 71 y / 56-82 y | | History or pretreatment with cardiac arrhythmia in 12-lead electrocardiogram (yes / no) | 0 (0%) / 14 (100%) | | Pretreatment arterial hypertension (yes / no) | 9 (64%) / 5 (36%) | [†] y = year **Conclusion:** Our experience demonstrated ibrutinib related AF incidence similar to earlier reports. Hematologists and cardiologists should be aware of this cardiotoxicity and be able to diagnose and manage it adequately.

Nataša Moser, Sidbela Zukanović, Maja Jurić Samardžić, Katica Cvitkušić Lukenda

Sodium-glucose cotransporter 2 inhibitors (SGLT2-I) are antihyperglycemic drugs that improve cardiovascular and renal outcomes in patients with or without type 2 diabetes. (1, 2) Under certain circumstances, SGLT2 inhibition could potentially lead to significant renal impairment, like dehydration or renal parenchymal hypoxia and hypoxic kidney injury. The former is caused by osmotic diuresis and natriuresis mostly in patients on diuretics and the latter could be induced by SGLT2-I–mediated medullary hypoxia and might be clinical significant under specific conditions such as the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or radiocontrast agents. (3) Contrast-induced acute kidney injury (CI-AKI) is a possible complication of patients undergoing percutaneous coronary intervention (PCI). (1, 2) Several clinical trials showed the effect of SGLT2-I on the development of contrast-induced nephropathy. Retrospective study (N = 1,510) showed that the incidence of CI-AKI in patients with type 2 diabetes (T2D) with coronary artery disease undergoing percutaneous coronary interventions (PCI) is lower in SGLT2-I users. (1) Another observational study enrolled patients from the SGLT2-I AMI PROTECT Registry (N=646), patients with T2D admitted with acute myocardial infarction (AMI) on chronic SGLT2-I therapy versus non-SGLT2-I users treated with PCI, with or without chronic kidney disease (CKD). The main finding was that in T2D patients with AMI, the use of SGLT2-I was associated with a lower risk of CI-AKI during hospitalization, mostly in patients without CKD. (2) Both studies identified the use of SGLT2-I as an independent predictor of reduced rate of CI-AKI. One smaller study that included patients with T2D on SGLT2-I therapy with non-ST segment elevation myocardial infarction underwent coronary angiography (CAG) and/or PCI also showed a significantly lower risk of CK-AKI in T2D patients on SGLT2-I therapy. (4) In these studies T2D patients had been treated with SGLT2-I for at least 3-6 month before PCI. To examine a possible use of these drugs as a preventive strategy, further studies should focus on the acute use of SGLT2-I in patients undergoing percutaneous coronary interventions, with or without T2D, considering indication of SGLT2-I for the treatment of chronic heart failure and chronic kidney disease.

Ivana Simić, Barica Stanić

**Introduction:** Heart transplantation is a surgical procedure in which a patient’s heart is replaced with a suitable donor heart. Today, it is considered the gold standard in treating patients in the terminal stage of heart failure with an expected life span of less than one year, despite optimal conventional therapy. Given the severity of the disease, the patient’s quality of life is significantly compromised in all aspects. The primary criterion for indicating transplantation is the functional capacity of the patient. According to the well-known NYHA classification (New York Heart Academy), these are patients in functional class III or IV. For a successful transplantation, a careful selection of patients and donors, as well as a well-organized transplant team, are essential. Heart transplantation now enables excellent long-term survival of patients (1-year survival rate is 81%). As the number of transplantations and survival rates continue to rise, emphasis is placed on the quality of life of the transplanted patient. It is important to note that a better subjective perception of health and functional abilities is one of the most critical factors affecting the quality of life after transplantation (1). For most patients, the quality of life improves, and with the help of a good rehabilitation program, they can almost fully return to performing daily physical activities. The patient’s understanding of their own illness, preoperative preparation, postoperative procedures, and complications, as well as a specific post-transplantation lifestyle and monitoring, is crucial for a longer and higher quality life. Family support, the support of the environment, and the entire healthcare team involved in the transplantation program are extremely important in raising awareness about the quality of life of transplanted patients. **Case report:** 57-year-old female experienced an anteroseptal myocardial infarction primarily manifested by cardiorespiratory arrest and underlying ventricular fibrillation. Following successful resuscitation and primary percutaneous intervention, ischemic cardiomyopathy with severely reduced ejection fraction persists. In secondary prevention of sudden cardiac death, the patient underwent implantation of a cardioverter-defibrillator and was placed on the heart transplantation waiting list. The heart transplantation took place in August 2022 at Dubrava University Hospital, Zagreb. Subsequently, myocardial biopsies were performed on multiple occasions, revealing pathological signs of rejection. Throughout 2023, the patient experienced frequent hospitalizations at the Cardiology Department at Slavonski Brod Hospital. The patient presented with poor general condition, nausea, vomiting, lack of appetite, dehydration, and a weight loss of up to 20 kilograms. During this period, secondary diabetes was diagnosed as a consequence of immunosuppressive therapy. The patient’s quality of life was significantly impaired, necessitating a multidisciplinary treatment approach involving cardiologists, diabetologists, infectious disease specialists, physiotherapists, and psychologists. Nursing interventions focused on addressing issues included monitoring food and fluid intake, oral and parenteral rehydration, blood glucose monitoring and correction, education on diabetes and its complications, and monitoring body weight. Throughout this process, the nurse acted as a caregiver, educator, and health promoter, ensuring an improvement in the patient’s quality of life (2). Over a two-week period, the patient experienced gradual recovery and was discharged home in an improved condition with recommended therapy. The patient’s condition is regularly evaluated through follow-up appointments at the cardiology day clinic. **Conclusion:** Heart transplantation represents the gold standard in treating patients with terminal heart failure when all other treatment modalities have been exhausted. An individualized approach to the patient, and collaboration among different specialists within a multidisciplinary team play a crucial role in achieving successful recovery and improving overall health, thereby enhancing the quality of life.

Adrijana Inđić, Dragan Karan, Lejla Bešić, Slađana Marčeta

This lecture will describe the standard methods of imaging coronary arteries, with special reference to the imaging of the right coronary artery (RCA) using the standard and modified methods. (1) In our institution, standard of the RCA display consists of two projections: lateral (LAO 30°) and hemiaxial (LAO 30°; CRA 20°). Our modification implies, in layman’s terms, a moving projection, with an initial position of LAO 30° to CRA 20°, with one angiography and one application of a contrast agent, we get the same result in a shorter time. The goal of our work is to confirm the hypothesis that by applying the modified method, the amount of exposure to radiation and amount of contrast applied is reduced, as well as the duration of the procedure, without reducing the quality of the image. We use this method in diagnostic and preoperative coronary angiography.

Mario Špoljarić, Katica Cvitkušić Lukenda, Domagoj Mišković, Kristina Vorkapić, Domagoj Vučić, Krešimir Gabaldo

**Introduction**: Acute coronary syndrome (ACS) includes unstable angina, non-ST segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI). (1) Acute flaccid paraplegia is a clinical syndrome with symmetrical and dramatic onset of weakness in the lower extremities with many underlying causes and generally poor prognosis. (2) **Case report**: We present a case of a 70-year-old female who was admitted to the Emergency Room with the sudden onset of chest pain, fatigue and nausea. 12-lead electrocardiogram showed horizontal ST-segment denivelation in V3-V6 leads, the baseline cardiac high sensitive troponin I was slightly elevated and there were no regional wall motion abnormalities detected by transthoracic echocardiography. Two hours after being admitted the patient experienced sudden paralysis of the lower extremities and a discrete loss of sensitivity below the Th10 dermatome. A computerized tomography (CT) scan of the brain, of the lumbosacral spine and a CT aortogram showed no abnormalities. A second troponin measurement was performed three hours after the initial measurement, and was significantly elevated. The patient was then admitted to the Coronary Care Unit under the diagnosis of NSTEMI, and the urgent coronary angiography was performed. Coronary angiograms revealed a proximal right coronary artery subocclusion and the patient underwent percutaneous coronary intervention with the implantation of 3 drug-eluting stents in the culprit lesion. On the fourth day of hospitalization, the patient was transferred to the Department of Neurology for the management of persistent paraplegia. Because of deteriorating of patient’s condition, MRI of the thoracic and lumbar spine was not realized. The patient experienced acute respiratory failure due to cardiac insufficiency and sepsis (C-reactive peptide was 375 mg/L, procalcitonin 2.9 ng/mL and Escherichia coli was isolated in the urine culture) and was transferred to the Intensive Care Unit. The patient died on the 17th day of the hospitalization. **Conclusion**: Although there is limited information and no similar cases in available medical literature, we suspect that the cause of paraplegia was concomitant ACS and spinal cord infarction and that the cause of death was acute respiratory insufficiency due to urosepsis and cardiac insufficiency. Autopsy was declined by the patients’ family.

Zrinko Pešut, Katica Cvitkušić Lukenda, Blaženka Miškić, Krešimir Crljenko, Zdravko Babić

**Introduction:** Primary pericardial tumors, benign or malignant, are rare. (1-3) Neoplastic pericarditis may cause various syndromes of cardiac compression or even frank cardiac tamponade. (3, 4) **Case report:** 85-year-old female patient was admitted into the Cardiac Intensive Care Unit due to significant pericardial effusion on transthoracic echocardiography, with clinical signs of cardiac tamponade. Symptoms were described as dyspnea on exertion and in dormant state with lower-extremity oedema, elevated jugular pressure and holosystolic murmur. Patients past medical history of pericardial effusion that has been present since 2020. On hospital admission her blood pressure was 85/55 mmHg, heart rate 121/min, 26 breaths/min. Blood tests showed high levels of NT-pro-BNP at level of 8769 ng/mL. Due to a fact that the blood flow has been severely compromised through the right ventricle, urgent pericardial catheterization has been performed and afterwards in several acts of evacuation through 5 days period, approximately 6700 ml in total has been removed from the pericardial sack, resulting in reduced pressure of pericardial fluid, and thus preventing the heart tamponade (**Figure 1**). The cytological analysis of the pericardial fluid found no presence of malignant cells. Catheterization of coronary arteries has been performed and atypical conglomerate of blood vessels has been registered, the main irrigation of the latter has been supplied by the left anterior descending artery (**Figure 2**). The computer tomography (CT) scan of thorax revealed that there has been a presence of solid mass, 7 cm in diameter, solidly imbibated and localized in the cranial part of pericardial sack adjacent to left ventricle, in vicinity of the pulmonary trunk (**Figure 3**). Pulmonary embolism has been ruled out. Surgical removal was recommended but patient refused the procedure. FIGURE 1. Pericardial effusion on CT scan. FIGURE 2. Circled area represents the irrigation vessels of the tumor supplied by the left anterior descending artery. FIGURE 3. CT scan of the solid pericardial mass adjacent to the left ventricle. **Conclusion:** Echocardiography, CT, MRI, aspiration of pericardial fluid, and cytological examination or open pericardial biopsy are crucial for diagnosing pericardial tumors. However, while echocardiography may provide more definitive information regarding cardiac compression by a neoplasm, CT and MRI can furnish useful information about the extension of the neoplasm into the adjacent structures.

Ivana Čičak, Katica Cvitkušić Lukenda, Domagoj Mišković

**Introduction**: Deep vein thrombosis (DVT) is one of the most common causes of hospitalization and is the third most common cause of death from cardiovascular diseases after myocardial infarction and stroke. (1, 2) Upper extremity DVT (UEDVT) can be primary and secondary. The incidence of secondary UEDVT is increasing due to the frequent use of central venous catheters, pacemakers and defibrillator leads, and tunneled vascular access. Primary UEDVT is known as Paget-Schroetter syndrome, which is the venous form of thoracic outlet syndrome, a clinical syndrome in which nerves, arteries, and veins in the chest or neck are compressed, typically by repetitive movements. It is more common in women than men. Most often occurs between 20 and 50 years. (3, 4) Authors present an unusual case of upper arm vein thrombosis. **Case report**: 41-year-old female patient, who had been healthy until now, was hospitalized due to DVT of the right upper arm. The symptoms of pain and swelling appeared after the medical massage. Vascular ultrasound revealed thrombosis of the basilic and axillary veins. Treatment with low molecular weight heparin (enoxaparin) in a therapeutic dose was started. Screening for malignant disease as well as for thrombophilia was done and the findings were negative. The echocardiogram findings were normal, and breast ultrasound of both breasts showed normal findings of skin and subcutaneous fat tissue on both sides. Magnetic resonance venography was performed, which showed extraluminal compression of the subclavian vein in the abduction position of the left arm with localized filling failure, which primarily corresponded to thoracic outlet syndrome (**Figure 1**). The patient was discharged with a recommendation of taking anticoagulation therapy for 3 to 6 months. Thoracic and vascular surgeons were consulted who also recommended conservative treatment. FIGURE 1. Magnetic resonance venography shows compression of the subclavian vein in the abduction position of the left arm. **Conclusion**: Paget-Schroetter syndrome is usually an effort thrombosis due to mechanical causes. Currently, there are no clear guidelines or consensus for treatment of this condition. Physicians should keep it in mind as a cause of venous thrombosis in patients without risk factors.

Filipa Grljušić, Marijana Knežević Praveček, Krešimir Gabaldo, Ivica Dunđer, Katica Cvitkušić Lukenda, Domagoj Mišković, Ivan Bitunjac, Antonija Raguž

**Introduction:** Prosthetic valve endocarditis (PVE) is a serious condition commonly caused by bacterial microorganisms in patients with a mechanical or biological valve prosthesis that can lead to complications such as abscess, valve dehiscence, paravalvular regurgitation, heart failure, conduction disturbance, as well as embolic events and multiorgan failure. (1, 2) **Case report:** 52-year-old male, who had surgical aortic valve replacement with a mechanical prosthesis two years earlier due to complications of the bicuspid aortic valve, presented to the emergency department with shortness of breath at rest. During the last three weeks, he had fever, chills, cough, fatigue, myalgias, dyspnea, and exertion intolerance, along with weight loss. He was taking two antibiotics at home, but his condition was gradually worsening. Clinically, he was somnolent, pale, ortopnoic, hypotensive, and respiratory insufficient, with an auscultatory precordial diastolic murmur and mechanical valve sound, as well as bilateral lung crepitations and leg edema. The 12-lead electrocardiogram showed PR interval prolongation with a left bundle branch block. Laboratory findings indicated a septic condition with a myocardial injury. The chest radiography showed pulmonary edema with cardiomegaly. Echocardiography revealed severe prosthetic aortic paravalvular regurgitation with dehiscence greater than 50% of the prosthetic valve circumference (in aortic short-axis view). The left ventricle was dilated with an ejection fraction of 35%. The empirical antibiotic treatment for late PVE was administered promptly. All blood cultures were negative for bacterial infection. He was accepted for urgent valve replacement surgery, but his hemodynamic and neurological status rapidly deteriorated. The patient developed status epilepticus. A cranial CT scan revealed multiple acute and subacute ischemic lesions. Additionally, he had postictal respiratory failure, hypotension, bradycardia, and renal shutdown. Despite treatment measures, the patient died within 96 hours of admission in refractory cardiogenic and septic shock with respiratory insufficiency caused by mechanical and systemic complications of prosthetic valve endocarditis. **Conclusion**: PVE represents the most serious form of infective endocarditis. (1, 2) Embolism to the brain is a relatively frequent occurrence in patients with infective endocarditis that is associated with increased in-hospital mortality and morbidity as well as shortened long-term survival. (1, 3)

Josip Silović, Katica Cvitkušić Lukenda, Marin Vučković

**Introduction**: Coronary heart disease is one of the leading causes of death and morbidity in the world. With the advancement of new treatment options, increasing emphasis is being placed on less invasive approach of treating coronary disease, i.e. percutaneous coronary interventions (PCI) (1). A certain population still benefits most from surgical treatment - coronary artery bypass grafting (CABG) (2). Cardiac surgery carries a certain risk of peri- and post-procedural bleeding and the need for blood transfusions. **Case report**: 64-year-old woman patient with long-term arterial hypertension, diabetes, a previous heart attack and PCI of the right coronary artery and ischemic cardiomyopathy with reduced systolic function of the left ventricle, was hospitalized for non-ST-elevation myocardial infarction. Coronary angiography verified three-vessel coronary disease with significant narrowing of the left main coronary artery (LMCA), left anterior descending artery (LAD), chronic occlusion of the circumflex artery, and significant narrowing of the right coronary artery (RCA). Considering the recent guidelines (three-vessel coronary disease and diabetes), the patient was referred to a cardiac surgeon and accepted for CABG. As the patient refused to receive blood transfusions for religious reasons, cardiac surgery was abandoned considering the high risk of periprocedural bleeding. The case was presented to the Heart team, considering the wishes of the patient, and it was recommended to do PCI LMCA/LAD and RCA. It is a complex high-risk procedure with a CHIP (Complex High-Risk Indicated PCI) score of 7. As there was no hemodynamic instability and cardiac output were maintained, we did not decide to use mechanical circulatory support in advance. PCI of the ostial RCA with the placement of a drug eluting stent (DES) and then PCI of the LMCA/LAD with the placement of 2 DES was performed. During the intervention, intravascular ultrasound was used to confirm good apposition of the stented segment. The patient was discharged with the recommendation of medications and further monitoring. **Conclusion**: It is necessary to follow professional recommendations, but always keeping in mind patient’s wishes. Refusal of transfusion treatment presents a difficulty in deciding about the most optimal treatment modality.

Domagoj Mišković, Krešimir Gabaldo, Katica Cvitkušić Lukenda, Ivica Dunđer, Marijana Knežević Praveček, Ivan Bitunjac, Antonija Raguž, Božo Vujeva, Ivan Gudelj, Irzal Hadžibegović

During the research on the influence of plasma protein glycosylation on achieving LDL cholesterol target values (1, 2), we analyzed statin-naive patients with the first presentation of acute coronary syndrome. Between September 2022 and September 2023, a total of 61 statin-naive patients with acute coronary syndrome were hospitalized. Patients transferred from local hospitals and patients older than 75 years were excluded from the study. Out of 61 patients, 36 had STEMI (ST-segment elevation myocardial infarction) and 25 NSTEMI (Non-ST elevation myocardial infarction). More than 50% of patients were men (35), and the average age of all patients was 58.34 years. 40% of patients are smokers. 55% of patients had a BMI greater than 25 kg/m2. The average value of the initial high-sensitivity troponin was 2337 pg/ml. All patients underwent percutaneous coronary intervention (PCI), and the average number of implanted stents was 1.02. In the largest percentage (38%), the infarct related artery or culprit lesion was on right coronary artery. In patients with STEMI, 57% received a loading dose of prasugrel and the rest ticagrelor. In patients with NSTEMI, after coronary angiography, 83% of patients received prasugrel, the rest ticagrelor and clopidogrel. All patients were discharged with a recommendation to take atorvastatin at a dose of 80 mg per day. The average value of LDL (low-density lipoprotein) cholesterol during hospitalization was 3.97 mmol/L. At the first control, 2 months after PCI, the average value of LDL cholesterol was 2.26 mmol/L, and 4 patients (6%) achieved target values of 1.4 mmol/L. Ezetimibe was recommended to all patients who did not reach the target values. At the second control, 3 months after PCI, the average value of LDL cholesterol was 1.95 mmol/L, and the target values were achieved by 6 patients (9.8%). The plan is to recruit statin-naive patients with acute coronary syndrome until September 2024, and clinical and laboratory follow-up for 1 year after PCI.

Antonia Majetić, Gabriela Bertolović, Gloria Špiranović

**Introduction**: Infective endocarditis is an inflammation of the inner layer of the heart. It is mainly a disease caused by bacteria and it presents a broad spectrum of events. Without an early identification and treatment, the disease can cause a lot of intracranial and long-range extracranial complications (1). Treatment of endocarditis can be conservative or surgical. Conservative treatment is conducted with prolonged therapy of antibiotics. Surgical treatment of endocarditis is indicated in case of development of heart failure, atrioventricular block, paravalvular abscess or destructive infiltrative lesions. Surgical treatment is also recommended in case of occurrence of infectious embolism (2). We would like to present a patient treated because of infective endocarditis with multiple embolisms, which are successfully treated with conservative methods. **Case report**: 29-year-old female with history of intravenous drug use has been admitted via Emergency Department with symptoms of sepsis and high fever of unknown origin. By doing medical workup psoas muscle abscess was verified. Transthoracic echocardiography detected vegetations of tricuspid and aortic valve and a septic embolism of left kidney. By doing a blood culture it is excluded Gram-positive bacteria. Transesophageal echo has shown vegetations of an aortic and tricuspid valve. Medical condition achieved additional complication by appearance of neurological symptoms – paresis of left arm. Patient is empirical treated with reserved antibiotics. Considered by multiple embolic abscesses cardiosurgical treatment was indicated. During the surgery vegetation or damage of the valves were not found. Antibiotic therapy was adjusted by infectologist. Further treatment was successful and full recovery was achieved. **Conclusion**: We described a case with patient treated because of infective endocarditis which was created by intravenous drug use. The progress was complicated by appearance of multiple septic embolisms. According to literature, this kind of complications were indication for surgical treatment. In this patients case the treatment was successful by using conservative treatment.

Violeta Čizmić

**Introduction:** The leading causes of mortality and morbidity in developed countries worldwide are malignant and cardiovascular diseases. This paper focuses on cardiovascular complications associated with the therapy of malignant diseases. These adverse effects can develop during or immediately after treatment, as well as several years after the cessation of chemotherapy. Cardiotoxic chemotherapy is a type of cancer treatment that can affect all organs, but the heart is particularly sensitive due to its metabolism. These drugs work by damaging rapidly dividing cancer cells. However, they can also harm healthy cells, leading to side effects such as reduced cardiac function, cardiac arrhythmias, myocardial infarction, and heart failure. There are several ways to reduce the risk of cardiotoxic effects of chemotherapy, including using low doses of cytostatic drugs, using heart-protective medications, and regularly monitoring the heart’s condition. (1-4) **Case report**: An elderly female patient was referred to the Outpatient Clinic following a confirmed diagnosis of breast cancer. She was mobile, afebrile, without neck masses, skin induration, or redness of the areola. She had a history of bilateral adnexectomy and uterine fibroids. After obtaining consent and inserting an IV cannula, the patient began the AC chemotherapy protocol. Throughout the chemotherapy cycle, the patient was closely monitored. A nurse tracked vital signs (blood pressure, respiration) and watched for any undesirable cardiac arrhythmias. The patient received 3 cycles of chemotherapy without any cardiac side effects. One week after hospitalization, the patient visited the Cardiology Department due to chest pain and radiating pain in her left arm and was admitted to the Coronary Care Unit. Based on 12-lead ECG and laboratory findings, it was evident that she had suffered a myocardial infarction. A nurse conducted monitoring, administered prescribed therapy, and on the third day of treatment, the patient was discharged with instructions for further therapy and lifestyle changes. She continued to receive follow-up care through the outpatient oncology clinic. **Conclusion**: The occurrence of cardiovascular disease during cancer treatment affects the disease outcome, as well as the quality of life after the cessation of chemotherapy. To provide the best care for patients undergoing chemotherapy, regular cardiological monitoring before, during, and after treatment is essential.

Jelena Jakab, Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Blaženka Miškić, Aleksandar Včev

**Introduction:** Free wall rupture (FWR) is the most dramatic complication of myocardial infarction with ST elevation (STEMI), with an overall incidence of 0.3%–1% and a mortality rate of up to 90%. (1) The clinical course can range from catastrophic, with acute tamponade and immediate death, to subacute, with hypotension, syncope, and pericardial discomfort. (2) Echocardiography reveals pericardial effusion, tamponade, and pericardial clot. (3) After hemodynamic stabilization and revascularization, definitive treatment requires surgical intervention. The aim of the study was to determine the incidence of FWR in patients admitted with myocardial infarction (MI) to the General Hospital “Dr. Josip Benčević” in Slavonski Brod. **Patients and Methods:** We performed a retrospective analysis of patients admitted with ST-elevation myocardial infarction (STEMI) to the General Hospital “Dr. Josip Benčević” in Slavonski Brod. We used data from the registry of patients treated for acute MI, data from medical records, and data from the hospital information system. **Results:** Between January 2020 and September 2023, five of 820 patients with STEMI developed FWR (0.6%). All patients were initially admitted and treated at Slavonski Brod General Hospital and then transferred to clinic for surgical treatment. Two patients were diagnosed with FWR on admission, a 71-year-old female with posterolateral STEMI and circumflex artery (CX) lesion who died before surgical intervention, and a 68-year-old male with subacute MI and right coronary artery (RCA) lesion who survived initial surgical treatment but died after reoperation because of postoperative cerebrovascular incident, sepsis, and multiorgan failure (**Figure 1**). One patient, a 74-year-old man with anterior STEMI and left anterior descending artery lesion, was treated conservatively for incomplete FWR. One patient, a 71-year-old woman with inferior STEMI and RCA lesion, presented with FWR two days after revascularization and was successfully treated surgically. One patient is still in the hospital awaiting surgical intervention after being treated at our hospital for a subacute inferoposterior MI and CX lesion. FIGURE 1. Contrast-enhanced multi-slice computed tomography angiography (a) and three-dimensional reconstruction (b) showing pseudoaneurysm due to subacute myocardial infarction and a right coronary artery lesion. **Conclusion:** FWR is a rare but potentially life-threatening mechanical complication of acute MI with a high in-hospital mortality rate. Rapid diagnosis by echocardiography is important, and prompt surgical intervention and stabilization are key to survival.

Vito Mustapić, Janko Szavits Nossan, Lucija Barbarić, Karlo Regvar, Iva Kopčić, Šimun Jurišić

**Introduction**: Atypical atrial flutter usually occurs in the setting of prior ablation or cardiac surgery where iatrogenic scares serve as the electrophysiologic substrate for re-entry. Idiopathic atypical atrial flutter is an uncommon variant. Whether the standard anatomical or substrate ablation approach is the best treatment option for this type of arrhythmia remains a debate (1, 2). **Case report**: A middle-aged female patient with a history of ischemic heart disease and percutaneous coronary intervention, ICD implantation for secondary prevention, and no prior history of atrial fibrillation, cardiac surgery, or ablation presented with new onset persistent atrial flutter (**Figure 1**). An electrophysiology study was conducted with entrainment suggesting atypical atrial flutter from the left atrium. 3-dimensional mapping of the left atrium using the Carto 3 system and multipolar catheter (Biosense Webster) was performed, showing a scar with the zone of slow conduction (critical isthmus) on the anterior wall near the roof and the left superior pulmonary vein (**Figure 2**). Ablation of critical isthmus terminated tachycardia (**Figure 3**). A few additional lesions for substrate ablation were applied avoiding linear anatomical lines. After ablation, tachycardia was non-inducible. FIGURE 1. 12-lead electrocardiogram showing atrial flutter on admission. FIGURE 2. Coherent mapping of the left atrium with a zone of slow conduction and critical isthmus (black circle) for atypical flutter. FIGURE 3. Termination of tachycardia during critical isthmus ablation (green arow on the left part and the red circle on the right part of the picture). **Conclusion**: There are still no clear recommendations regarding ablation of atypical atrial flutter and our case highlights the need for an individual approach when considering between anatomical or substrate ablation approaches, thus potentially avoiding excessive ablation lines.

Barica Stanić, Mirela Jerković, Anita Juričić, Matea Hiller

Acute myocardial infarction occurs due to coronary artery blockage and tissue necrosis in the area deprived of blood supply. The most common risk factors include atherosclerosis, hypercholesterolemia, obesity, arterial hypertension, stress, etc. The disease is diagnosed based on clinical presentation, changes in the 12-lead ECG, elevated troponin levels, CK-MB (1). The most frequent symptoms that patients experience are chest pain and tightness, which can occur during physical activity or at rest. Significant complications include decompensation, arrhythmias, cardiogenic shock, cardiac arrest, and rupture of the heart wall. The treatment of myocardial infarction involves the administration of analgesics, fibrinolytics, anticoagulants, antiarrhythmics, sedatives, and oxygen. If it has been less than 6 hours since the onset, percutaneous coronary intervention (PCI) and stent placement can be performed. Opening the blood vessel after stent placement requires the use of antiplatelet therapy for a minimum of 12 months (2, 3). In addition to antiplatelet therapy, patients must take at least six other types of medications, including statins, antihypertensives, and diabetic medications due to the comorbidities that such patients often have. Given the short duration of hospitalization for uncomplicated myocardial infarction, patients often fail to comply with the full treatment regimen and the seriousness of the condition. In the absence of regular antiplatelet therapy, stent thrombosis and recurrent myocardial infarction can occur, necessitating urgent repeat PCI. The role of the nurse in the treatment of these patients includes monitoring the patient upon admission to the Coronary Unit, performing an ECG, and placing an IV cannula. After receiving laboratory results, the patient goes to the Operating Room. Upon return to the Coronary Unit, another ECG is recorded, and the patient is connected to monitoring, and a compression band is loosened according to the protocol used for radial access in PCI. The nurse administers prescribed therapy, monitors the patient’s blood pressure and oxygen saturation, as well as the occurrence of cardiac arrhythmias and bleeding at the puncture site. We believe that in addition to patient care, the nurse has the task of educating the patient about the importance of regular medication intake to prevent further complications. The average hospitalization for such a patient is approximately 5 days, during which patients often recover rapidly.

Hrvoje Holik, Ivana Vučinić Ljubičić, Božena Coha

**Introduction:** Patients with cancer have an increased risk of both venous and arterial thromboembolism (AT) (1). Aggressive lymphomas like the most common type - diffuse large B cell lymphoma (DLBCL) have a higher frequency of AT compared to indolent ones after diagnosis and during treatment (2, 3). However there is little information about the frequency of AT such as myocardial infarction (MI) before the diagnosis of DLBCL. Aim: To determine the prevalence of MI in DLBCL before diagnosis. **Patients and Methods:** We collected data retrospectively from DLBCL patients at the General Hospital Dr. Josip Benčević from the beginning of 2011 by August 2023. **Results:** 59 DLBCL patients were included in this study, 33 (56%) female, median age 67 (range 28 to 82 years). Eight (13.6%) patients had MI before the DLBCL diagnosis, 6 male and 2 female. All eight patients who had a MI achieved a complete remission (CR) of the DLBCL after the planned treatment (4 patients treated with R CHOP and 4 with DA R EPOCH protocol). Seven patients are alive, with no signs of DLBCL, and 1 patient died 8 years after the end of treatment at the age of 84. The rate of CR in the entire study population was 83% after first line of treatment and 47 (63%) patients are still alive in CR. 6 patients died of DLBCL, 8 of infectious complications, while the cause of death for 8 patients is unknown. 2 patients had MI after diagnosis of DLBCL. One 5 years after the completion of chemotherapy and he previously had an MI, while the other patient developed an MI at the time of relapse of DLBCL. **Conclusions:** Our study suggests a higher prevalence of IM in patients with DLBCL (13.6%) than in general population (3.8%) (4). Interestingly in our study is the fact that a previous MI did not negatively affect the outcome of treatment. The group of patients with a previous MI actually had a better survival compared to the entire study population. Further studies with more patients are needed to confirm this observation, and eventually to find a link between DLBCL and MI.

Domagoj Vučić, Sergej Nadalin, Zvonimir Bosnić, Ana Kovačević, Katica Cvitkušić Lukenda

**Introduction**: The pericardium is a double-walled sac (consisting of visceral and fibrous layers) between which lies the pericardial space, enveloping the heart and the roots of blood vessels entering or exiting the heart (1). Although pericardial effusion can arise from various pathological conditions, its etiology is typically presumed based on clinical presentation and comorbidities, and an accurate diagnosis is established through biochemical, microbiological, and cytological analysis of the effusion. However, pericardiocentesis is an invasive procedure indicated when effusion onset is symptomatic or accompanied by tamponade, or when its etiology is unclear (2, 3). **Patients and Methods**: The retrospective analysis included 48 patients with echocardiographically confirmed cardiac tamponade of various etiologies in the period from 2016 to 2021. Descriptive statistical data are presented as a percentage. Due to a small sample size and uneven distribution, the examination of intrahospital mortality between patient groups, based on etiology and effusion treatment, was performed using the Fisher’s exact test and statistical significance was indicated as p-value 0.05). However, patients treated with a combination of cisplatin and pericardiocentesis had a lower mortality rate compared to those treated with pericardiocentesis alone, p < 0.05 (**Figure 1**). ### TABLE 1: The patient characteristics. | | **No. of patients (%)** | | --- | --- | | **Sex** | | | Males | 32 (66.7) | | Females | 16 (33.3) | | **Etiology** | | | Malignant disease | 19 (39.6) | | Inflammation | 8 (16.7) | | Post-procedural | 7 (14.6) | | Other | 14 (29.2) | | **Therapy** | | | No therapy | 1 (2.1) | | Drainage | 36 (75.0) | | Surgery | 8 (16.7) | | Conservative | 3 (6.3) | | **Application of cisplatin** | | | No | 39 (81.3) | | Yes | 9 (18.8) | | **Intrahospital mortality** | | | No | 35 (72.9) | | Yes | 13 (27.1) | | **Total** | 48 (100) | FIGURE 1. Statistically significant difference in intrahospital survival among patients treated with a combination of cisplatin and pericardiocentesis and those undergoing pericardiocentesis alone (p = 0.016 - Fisher’s exact test). **Conclusion**: Malignant diseases are one of the leading causes of death worldwide, and when combined with pericardial effusion and tamponade, the most common ones are lung and breast cancer, melanoma, and lymphoma. The therapy of choice for acutely occurring pericardial effusion is pericardiocentesis, which alleviates symptoms and provides additional diagnostic possibilities. The effectiveness of cisplatin administration in combination with pericardiocentesis is independent of hemodynamic instability parameters and inflammatory markers in patients with recurrent pericardial effusion.

Krešimir Gabaldo, Marijana Knežević Praveček, Domagoj Mišković, Ivan Bitunjac, Ivica Dunđer, Antonija Raguž, Blaženka Miškić, Katica Cvitkušić Lukenda

**Introduction**: Coronary artery ectasia (CAE) is a focal or diffuse dilatation of an epicardial coronary artery, more than 1.5 times the normal adjacent segment. Its prevalence ranges between 0.3 and 5% of patients undergoing coronary angiography (1). These changes are mostly asymptomatic, some patients present as stabile effort angina and minority develop acute coronary syndrome. Percutaneous coronary interventions (PCI) is a treatment of choice in acute coronary syndrome but it presents a major challenge with possible unpredictable complications (2). **Case report**: We present a case of 78-year-old male, presented with inferior ST elevation myocardial infarction. Right coronary artery (RCA) was ectatic and occluded distally. We performed balloon dilatation and thromboaspiration with Export catheter to establish TIMI 3 flow, and a residual stenosis of 70% with high thrombotic burden remain, so we decided to treat the patient with triple anticoagulant therapy initially and postpone stent implantation because of possible no flow phenomenon. After one month we did the angiogram which showed resolution of thrombus and we put the large drug eluting stent 5.0/22mm, postdilated up to 6mm with a good apposition. **Conclusion**: Percutaneous coronary interventions in ectatic / aneurismal vessels carry a high risk of complications, primarily a no-reflow phenomenon. No-reflow is common in patients with acute coronary syndrome. Restoration of TIMI 3 flow can be achieved with thrombectomy or balloon dilatation. In case of large aneurysm consider initial medicament treatment with triple therapy and postpone definite PCI with stent implantation to avoid distal embolization and no reflow phenomenon.

Marina Stanković, Renata Valenčak, Saša Presežnik, Mato Čizmić, Alenka Tulčić-Mihelčić

**Introduction**: Cryoablation is one of the methods used to treat paroxysmal atrial fibrillation, with a complication rate ranging from 0% to 29%, and bleeding being the most common (1). At the General Hospital Slavonski Brod, from 2019 to the present, 118 procedures have been performed. The aim of this research is to determine the frequency of bleeding complications at the puncture site in patients after cryoablation who had an elastic bandage and those who had only gauze pads. **Patients and Methods**: The study included patients who underwent cryoablation from March 2023 to October 2023. Continuous variables (age, height, weight, blood pressure, heparin dosage, and time) are presented as means, and the significance of differences between groups was assessed using the t-student test and expressed as p values. Statistical analysis was conducted using IBM SPSS Statistics (version 26.0). **Results**: The analysis found a statistically significant difference (p < 0.05) between patients in whom an elastic bandage was used and those with just gauze pads (**Table 1**). ### TABLE 1: Patient characteristics. | | **Bandage (N=6)** | **Without bandage (N=7)** | **p*** | | --- | --- | --- | --- | | Age | 66 | 65 | 0.85 | | Women | 3 | 2 | | | Height (cm) | 176 | 172 | 0.78 | | Weight (kg) | 81 | 84 | 0.12 | | Systolic blood pressure (mmHg) | 132 | 144 | 0.03 | | Diastolic blood pressure (mmHg) | 73 | 86 | 0.51 | | Heparin (IU) | 13200 | 13429 | 0.14 | | Time (min) | 89.00 | 96.67 | 0.8 | | Diabetes | 2 | 0 | | | Bleeding (N) | 0 | 1 | | [†] *Student's t test **Conclusion**: During cryoablation, 11 French and FlexCath Advance 12 French sheaths are used for insertion, with the insertion sites being the left and right femoral veins. Patients receive a prescribed dose of heparin during the procedure. The puncture site is manually compressed and sutured, with one group of patients receiving gauze pads and an elastic bandage, while the other group has gauze pads without a bandage. Thus far, there have not been significant differences between the two groups. In one patient without a bandage, bleeding was observed, which could be attributed to the patient’s non-compliance with post-procedure resting instructions.

Katica Cvitkušić Lukenda

## Dear Colleagues, Welcome to the Invasive Cardiology Symposium in Slavonski Brod. We are delighted to commemorate twenty years of exceptional medical care and innovative techniques at our invasive cardiology laboratory. These two decades represent a consistent commitment and dedication to our patients’ well-being, along with a steadfast dedication to enhancing the treatment of heart diseases in our region and neighboring counties. Over these twenty years, we have introduced novel invasive methods for diagnosing and treating heart conditions, as showcased in this edition of the Cardiologia Croatica journal. The symposium program encompasses lectures spanning interventional cardiology, arrhythmology, angiology, heart failure, interdisciplinary approaches, prevention, and basic medical sciences. Beyond technical and medical advancements, we extend our gratitude to all the individuals who played pivotal roles in establishing and advancing our invasive cardiology laboratory. Their dedication, expertise, and commitment form the bedrock of our success. Therefore, we wish to express our profound appreciation to our founders who envisioned this laboratory as a center of excellence in the region, our fellow doctors who supported and guided us along the way, our partners and donors who facilitated the acquisition of cutting-edge equipment and technology, our patients who entrusted us with their health, and our entire team and staff whose expertise, patience, and selfless commitment are integral to our achievements. Today, we take pride in celebrating two decades of continuous progress and dedication to the health of our patients. Thank you all for your contributions and support! Yours sincerely, Katica Cvitkušić Lukenda Symposium Director

Marko Galić, Ana Jordan, Aleksandar Blivajs, Katica Cvitkušić Lukenda

**Introduction**: Myocardial rupture is a well-recognized mechanical complication of ST-elevation myocardial infarction (STEMI). Pseudoaneurysm manifests as a unique entity, in which the rupture is sealed by pericardium, organized thrombus, and fibrosis. Importantly, pseudoaneurysms pose a considerable risk of progressing to a full rupture, mandating urgent surgical intervention. (1, 2) **Case report**: 55-year-old female with a history of arterial hypertension and diabetes presented with subacute STEMI during a COVID-19 infection complicated by bilateral pneumonia. Coronary angiography revealed the mid left anterior descending artery occlusion, and as she was hemodynamically stable and without anginal symptoms, conservative management was continued. Transthoracic echocardiography (TTE) showed reduced left ventricular ejection fraction (EF 40-45%) due to left ventricular anterior wall akinesia. There were no significant valvular heart disease or mechanical complications. The patient was discharged in a stable condition with guideline-directed medical therapy (GDMT) for heart failure and acute coronary syndrome. At the three-week follow-up TTE, a left ventricular aneurysm was identified, measuring 3.8x4.7 cm with a small intracavitary thrombus. Due to persistent NYHA class III symptoms, her medical therapy was optimized by adding ARNI (sacubitril/valsartan) and increasing diuretics. A Vitamin K antagonist was initiated, and a close 10-day follow-up was scheduled. Two weeks later, the aneurysm doubled in size, prompting Intensive Care Unit admission. The patient remained hemodynamically stable. An emergency CT scan revealed a left ventricular aneurysm measuring 5.1x8.3x8.5 cm, with no signs of myocardial rupture or pericardial effusion. The heart team recommended a cardiac MRI to better understand the anatomical relations of the aneurysm, which revealed that it was, in fact, a large pseudoaneurysm that had grown further in size during the five-day interval since the CT scan, now measuring 9.3x8.4x8.2 cm, with an additional pseudoaneurysm formed on top of the first one, measuring 5.5x3.9x5.5 cm. The patient underwent urgent surgery and recovered with no major complications. **Conclusion**: Ventricular pseudoaneurysm is a rare mechanical complication of myocardial infarction. While echocardiography often distinguishes between LV aneurysms and pseudoaneurysms, MRI may be necessary in equivocal cases. Surgical repair is the preferred treatment approach for most patients.

Adriana Levaković, Anamarija Kovač Peić, Ivan Bitunjac, Božena Coha

Colorectal cancer is the second most common cancer in the Croatian population (1). Available treatment options include surgery, radiotherapy, and chemotherapy in combination with the monoclonal antibodies depending on tumor RAS/BRAF status while immunotherapy is the treatment of choice in microsatellite-instability-high colorectal cancer. 5-fluorouracil (5-FU) is the first-line chemotherapeutic drug and presents a foundation of FOLFOX, FOLFOXIRI and FOLFIRI chemotherapy regimens used in the treatment of colorectal cancer. However, 5-FU is the second most common chemotherapeutic drug associated with a cardiotoxicity after anthracyclines, which can manifest as chest pain, acute coronary syndrome, arrhythmia or sudden cardiac death (2). **Case report**: 73-year-old female with a history of arterial hypertension was admitted due to abdominal pain. Computed tomography (CT) showed a wall thickening of the descending and sigmoid colon, left-sided hydronephrosis and hepatic metastases. She underwent sigmoidectomy and omentectomy with ureter reconstruction and pathohistological finding confirmed a diagnosis of the colorectal adenocarcinoma. Postoperative adjuvant systemic chemotherapy with a biweekly FOLFIRI was initiated. After administration of the first cycle, patient developed a chest pain without troponin elevation. Electrocardiogram showed inverted T wave in leads DIII, avR, V1, V3 and V4. Coronarography showed no significant coronary artery stenosis, moreover chest pain was probably caused by coronary vasospasm. Further chemotherapy with FOLFIRI was continued with a dose reduction of 5-FU by 25%. Cetuximab has been included into the therapy since a patient was identified as RAS/BRAF wild-type. During an administration of the fifth cycle patient redeveloped chest pain. Electrocardiogram showed a new-onset atrial fibrillation which was reverted to a sinus rhythm by intravenous administration of amiodarone. After the cardioversion, patient remained asymptomatic. CT reevaluation assessed a regression of the hepatic metastases, but due to cardiotoxicity related to 5-FU, monotherapy with cetuximab was continued as the treatment option for patients who are not considered candidates for further chemotherapy (3). Additionally, hepatic metastases were treated with a stereotactic ablative radiotherapy. **Conclusion**: Cardiotoxicity as an adverse effect of the oncological treatment presents a great challenge in everyday clinical practice. Therefore, it is necessary to conduct further studies to clarify its pathophysiology and thereby improve its prevention and treatment.

Anto Lukenda, Katica Cvitkušić Lukenda, Olivera Gašić Bulajić, Marko Krnić, Josip Samardžić

**Introduction:** Trauma is one of the top five causes of death in Croatia according to the Croatian Institute of Public Health. Blunt thoracic aortic injury (BTAI) is the second leading cause of death in patients with blunt force injury. (1) Motor vehicle accidents remain the most common mechanism of aortic injury (>70%). This potentially fatal condition often has nonspecific signs and is misdiagnosed. The gold standard for diagnosing trauma patients is whole-body computed tomography. The best imaging modality for BTAI is contrast-enhanced CT. (2) Early diagnosis and treatment are critical for patient survival. Endovascular aortic repair techniques are a promising treatment strategy. (3) **Case report**: Two patients were passengers in an accident when the vehicle suddenly left the road. 77-year-old woman had normal vital signs on arrival at the hospital with no clinical or laboratory evidence of bleeding but complained of chest pain. A second patient is a 38-year-old man who presents with polytrauma, conscious, oxygen saturation 94%, normotensive (blood pressure 115/70 mmHg), with bilateral hemothorax and pneumothorax, hemomediastinum, bilateral serial rib fractures, multifragmentary fracture of the left scapula, fracture of the seventh cervical vertebra, renal contusion, and intracerebral hemorrhage. The patient was hemodynamically stabilized and both chest were drained by placing a chest tube. In both cases, whole-body computed tomography with aortography was performed. The first patient was diagnosed with dissection (**Figure 1**) and the second patient with dissection with rupture (**Figure 2**) of the isthmic portion of the aorta, typical of BTAI. Both patients were urgently transported to the clinics for endovascular treatment of BTAI, where an endovascular graft was successfully inserted. FIGURE 1. Whole-body computed tomography with aortography shows the typical location of blunt trauma aortic dissection in the first patient. FIGURE 2. Whole-body computed tomography with aortography shows the typical location of blunt trauma aortic dissection with rupture in the second patient. **Conclusion**: Whole-body computed tomography is an emergency imaging protocol often used to rapidly diagnose life-threatening injuries in polytrauma patients. Once the diagnosis is made, there are two options for aortic repair: open surgery or an endovascular procedure. Early open surgery is often characterized by high mortality and morbidity rates. Since the first reports of endovascular repair of traumatic thoracic aortic injuries, there has been a significant increase in data supporting the use of endovascular stent grafting over traditional open repair.

Ivana Grgić, Katica Cvitkušić Lukenda, Marijana Knežević Praveček, Domagoj Mišković, Ema Didović, Krešimir Gabaldo

**Introduction**: Transradial approach (TRA) is preferred vascular access site for coronary angiography resulting in lower 30-day mortality, major bleeding and access site complications when compared with transfemoral access. Radial artery occlusion (RAO) is the most common complication of TRA with an incidence of 0.8-10% (1). In most cases RAO is asymptomatic, but some patients feel pain at the site of occlusion, have paresthesia, and very rarely signs of acute ischemia of the arm (2). **Methods and Results**: We analyzed 40 subjects who underwent diagnostic coronary angiography using TRA in a period of one month. All patients received 5000 IU of heparin and 200mcg of nitroglycerin after sheath insertion. After intervention hemostasis was performed with Terumo TR Band radial compression device according to standardized protocol. Three patients (8%) reported pain and paresthesia and we confirmed radial artery occlusion using doppler imaging. One patient was hospitalized because of severe pain but without signs of critical ischemia. The patient was treated with aspirin and enoxaparin by subcutaneous injection for 5 days, following with rivaroxaban 20mg for 3 weeks and completely recovered. **Conclusion**: Radial artery occlusion is the most common complication of TRA, but with a low clinical significance. Patency of radial artery is important for future coronary artery procedures, coronary artery bypass grafting, arteriovenous fistula formation or intra-arterial pressure monitoring. Proper medication application together with patent hemostasis reduce the risk of RAO (3).

Dubravko Petrač, Vjekoslav Radeljić, Diana Delić-Brkljačić

Implantable cardioverter defibrillators (ICD) are an important therapeutic option in reducing mortality due to ventricular arrhythmias in patients with heart failure with reduced ejection fraction. Atrial fibrillation (AF) is often present in these patients and may interfere with ICD therapy by inducing inappropriate and appropriate shocks. This issue is important because both types of shock increase mortality in patients with ICD. The strategies to minimize the rate of ICD shocks induced by AF include the optimization of ICD programming, pharmacological therapy for rate or rhythm control, and ablation of AF or atrioventricular junction ablation. In this review, we describe the interference of AF with ICD therapy, examine the impact of this interference on survival, and discuss the strategies for its reduction.

Renata Valenčak, Alenka Tuličić-Mihelčić, Marina Stanković, Saša Presežnik, Mato Čizmić, Katica Cvitkušić Lukenda

It is well known that heart diseases are the leading cause of morbidity and mortality worldwide (1). Good organization and education in diagnosing and treating these conditions are of paramount importance in providing healthcare to cardiac patients. Quality and integrity of healthcare services are crucial for all healthcare institutions. The development of catheterization techniques in invasive cardiology over the past decades has allowed for the widespread use of invasive methods in diagnosing and treating cardiac patients (2). To enhance the care of cardiac patients, the General Hospital “Dr. Josip Benčević” in Slavonski Brod initiated the reconstruction of the Coronary Care Unit in 2003 to repurpose it into an invasive cardiology laboratory, which was officially opened on October 15, 2003 (**Figure 1**). (3) The team, which consisted of two doctors, Dr. Božo Vujeva and Dr. Đeiti Prvulović, two nurses, Ana Bilić and Renata Valenčak, and medical radiology engineer Mato Čizmić, had earlier started education in the field of invasive cardiology, mostly at the University Hospital Dubrava in Zagreb, and in the University Hospital Centre Tuzla, Bosnia and Herzegovina. The first invasive procedure that was performed was the implantation of a single-chamber pacemaker on December 1, 2003 under the mentorship of Dr. Davor Richter from the University Hospital “Merkur” Zagreb. After that, the first coronary angiography was performed on December 6, 2003 under the mentorship of Dr. Boris Starčević from the University Hospital Dubrava (**Figure 2** and **Figure 3**). FIGURE 1. The Minister of Health of the Republic of Croatia, Andro Vlahušić, MD, opens the first invasive cardiology laboratory in Slavonia in the company of the President of the Republic of Croatia, Stjepan Mesić, October 15, 2003, six months after the opening of the new Coronary Care Unit. FIGURE 2. The first coronary angiography was performed at the General Hospital “Dr. Josip Benčević” in Slavonski Brod on December 6, 2003. In the picture, from left to right: Dr. Đeiti Prvulović, Dr. Boris Starčević, Dr. Božo Vujeva, nurses Ana Bilić and Renata Valenčak. FIGURE 3. After the successful first coronary angiography at the General Hospital “Dr. Josip Benčević” in Slavonski Brod, on December 6, 2003. In the picture from left to right: Mato Čizmić, medical radiology engineer, Ana Bilić, nurse, Dr. Đeiti Prvulović, Dr. Božo Vujeva, and Dr. Boris Starčević. Since 2006, we have been performing percutaneous coronary interventions under the mentorship of interventional cardiologists from University Hospital Dubrava. Gradually, our intervention team started providing care to patients from neighboring counties. In January 2014, as part of the Primary PCI Network of the Republic of Croatia, the intervention team was on standby 24/7 for the area of western Slavonia. In the same year, the renovation of the Laboratory for Invasive Cardiology began, and the procedure for a new radiological device for coronary angiography was initiated by the Ministry of Health of the Republic of Croatia. During the renovation of the invasive room, coronary angiography, percutaneous coronary intervention, and electrostimulator implantations were performed in the diascopy room at the Department of Radiology. That hall was located on the ground floor of the building and at the very other end of the building, and it was a small room, so the working conditions were very demanding. After the work was completed and the new radiological device was installed, we started work in the new catheterization laboratory on December 11, 2015 (**Figure 4**). In everyday practice, the following diagnostic and therapeutic procedures are performed: coronary angiography, percutaneous coronary interventions (with or without stent placement), angiography/peripheral interventions, rotational atherectomy, electrophysiological interventions (cryoablation and radiofrequency ablation), implantation procedures (pacemaker, cardioverter-defibrillator, cardiac resynchronization therapy, loop recorder, His bundle pacing), percutaneous closure of patent foramen ovale and atrial septal defect, and balloon aortic valvuloplasty. The introduction of the transradial approach has allowed for the performance of diagnostic coronary angiography through the outpatient clinic, covering the majority of procedures. Since 2019, patient registries have been maintained for those undergoing coronary angiography with or without intervention, peripheral angiography with or without intervention, electrophysiological procedures, and pulmonary vein isolation. To minimize the risks associated with these complex procedures, the invasive cardiology laboratory operates with a specially trained interdisciplinary team composed of invasive cardiologists, radiology engineers, and nurses authorized to work with sophisticated equipment to care for patients with severe heart diseases and significant comorbidities (4). The role of the nurse as part of the interventional cardiology medical team is crucial, involving pre-planning for the admission of critically ill patients. The education of nurses in patient preparation, instrument preparation, patient monitoring before, during, and after procedures, and adherence to established protocols is of utmost importance. Knowledge of the anatomy and physiology of the heart, as well as the pathophysiology and development of cardiac diseases and potential complications, presents a challenge for the nurse in terms of defining interventions for the management and treatment of complications (5). FIGURE 4. The new invasive cardiology laboratory after the reconstruction that was finished on December 11, 2015.

Ivo Darko Gabrić

In the past 20 years or so, the survival of patients with malignant diseases has been prolonged due to the improved chemotherapy protocols, targeted biological treatment, enhanced surgery and radiotherapy and new interventional radiology methods (1). Nonetheless, certain metastatic diseases can be managed in the long term, making them practically chronic. However, improvement in survival is often at the expense of damage to other organs, including the cardiovascular (CV) system (2). CV diseases are the second leading cause of long-term morbidity and mortality in patients treated for cancer (3). Initially, the occurrence of cardiotoxicity was almost exclusively associated with the anthracycline therapy induced irreversible left ventricular (LV) systolic dysfunction leading to symptomatic heart failure. With the development of biological anti-HER based therapy, it has been established that it can cause, for the most part, reversible damage of heart function. A decade and half ago, this triggered a division of cardiotoxicity into two basic types: irreversible (type I) and reversible (type II) (4). However, due to a substantial amount of overlapping in terms of both the clinical picture and the course of the disease, this division has not demonstrated to be indisputable and comprehensive. On the other hand, cardiotoxicity cannot be associated only with LV systolic dysfunction as oncology therapy may cause a number of CV diseases such as new or worsening hypertension, vasospastic and/or thrombotic ischemia in the myocardium, worsening of atherosclerosis, rhythm and conduction disorders, and myocarditis. It is also important to identify patients at high risk for developing cardiotoxicity; the predisposition is multifactorial and determined by an interaction of genetic and environmental factors. Some of the defined risk factors are a positive family history of CV disease, age, gender, arterial hypertension and dyslipidemia. It has also been established that there is an increased risk for the development of cardiotoxicity in patients with reduced LV systolic function and significant arrhythmias. (5) In addition, it was necessary to define the follow-up of patients currently receiving or who had previously received cardiotoxic chemotherapy. Cardiotoxicity can manifest itself symptomatically or completely asymptomatically during or immediately after treatment (in the following few days or weeks), but also long time after the end of antitumor therapy (e.g. after the use of anthracyclines). (6) Due to the complexity of the disease, it was necessary to form cardio-oncology teams. All of the above demonstrates a need to develop guidelines in cardio-oncology. For that reason, after issuing Position Paper (7) in 2016, the European Society of Cardiology (ESC) started to develop comprehensive guidelines that were published in 2022 (8). The guidelines took into account all aspects of cardio-oncology, so instead of the old term cardiotoxicity, a new term **cancer therapy-related cardiovascular toxicity** (CTR-CVT) is used. The guidelines also introduce new standards for defining CV toxicity associated with oncology therapy, and protocols for monitoring patients during and after oncology treatment, diagnosis and treatment of CRT-CVT. In addition to the 6 basic pathophysiological mechanisms for the development of CRT-CVT, the exceptions of CV toxicity that can be caused by certain oncological drugs are listed as well. The emphasis is on prevention, i.e. risk assessment for the development of cardiovascular toxicity before the application of oncology therapy, which minimizes the unnecessary interruption of oncology treatment. It should always be kept in mind that any interruption or change in oncological treatment can significantly change the results of oncological treatment and the prognosis of the disease. The CRT-CVT approach needs to be multidisciplinary, and the development of cardio-oncology subspecialists who have broad knowledge of cardiology, oncology and hematology is recommended. The major weakness of the guidelines is that most of the recommendations are derived from expert opinions or registries (evidence level C). It is simply impossible to do enough randomized clinical trials. In this issue of Cardiologia Croatica, the paper published by Czuriga et al. (9) explains the development of the definition of CV toxicity with special reference to the first ESC guidelines on cardio-oncology. The general goal is to provide patients with the best possible oncology therapy in a safe manner, and to reduce CTR-CVT to a minimum. This would reduce unwanted disturbance of therapy. The authors also briefly presented the key CARDIOTOX registry. An increasing number of patients are treated with chemotherapy and biological drugs, so the incidence of CV toxicity is continuously increasing. (10) The extent of the problem is even greater because some patients have to take a combination of several cardiotoxic drugs (11). Oncology patients with an increased risk of CV toxicity require a multidisciplinary approach and regular cardiological monitoring in order to recognize and adequately treat side effects in a timely manner. In this way, the improvement of clinical outcomes and quality of life is achieved and, possibly, the optimal continuation of specific oncological treatment.

Noémi Németh, Imre Boncz, Diána Elmer, Lilla Horváth, Tímea Csákvári, Dóra Endrei

Ischaemic heart disease is the most common cause of death worldwide according to data of the World Health Organization. Our aim was to analyse national and international data regarding ischaemic heart disease mortality per region in the age group 65 years and above. We performed a retrospective, quantitative analysis on age-specific, ischaemic heart disease mortality between 1990-2016 per 100,000 population on data derived from the World Health Organisation, European Mortality Database on Western European (N=17), Eastern European (N=10) countries, and countries of the former Soviet Union (N=15). Descriptive statistics, time series analysis and Kruskal-Wallis test were performed. Age-related, ischaemic heart disease mortality per 100,000 population was the lowest in Western European countries (males: 1990: 1391.00, 2016: 513.00; females: 1990: 746.91, 2016: 264.93), and the highest in former Soviet Union countries (males: 1990: 3133.51; 2016: 2204.41; females: 1990: 2257.45, 2016: 1566.44). Significant differences were found in age-specific, ischaemic heart disease mortality in both sexes between Eastern and Western European countries and former Soviet Union countries (1990, 2004, 2016: p<0.05). Between 1990-2016, age-specific, standardized ischaemic heart disease mortality showed the biggest decrease in Western European countries (males: -63.12%, females: -64.53%) followed by Eastern European (males: -29.93%, females: -31.50%) and former Soviet Union countries (males: -29.65%, females: -30.61%). Age-specific, ischaemic heart disease mortality decreased in both sexes in all regions analysed. Hungary was found to have seen a decrease lower than the Eastern European average; ischaemic heart disease mortality decreased by 11.57% in males and 10.26% in females aged 65 and over between 1990-2016.

Marijana Knežević Praveček, Krešimir Gabaldo, Antonija Raguž, Domagoj Mišković, Ivan Bitunjac, Marin Pavlov, Ivica Dunđer, Božo Vujeva, Jelena Jakab, Blaženka Miškić, Katica Cvitkušić Lukenda, Daniel Unić

**Introduction:** Saphenous vein graft (SVG) occlusion usually occurs in degenerated vein grafts. (1-4) In this case report, we present the case of a patient who presented with total occlusion of an Aorta-Posterior descending SVG during inferior myocardial infarction (MI), complicated with ventricular septal rupture (VSR) over a fifteen-day period after failed percutaneous coronary intervention (PCI). **Case report:** 63-year-old man with a history of coronary artery bypass graft surgery (CABG) eleven years ago, including hypertension, diabetes mellitus, peripheral artery disease, dyslipidemia, and smoking habits, was admitted to Cardiology Department with atypical chest pain and fatigue. Fifteen days before admission, the patient had been hospitalized for subacute inferior myocardial infarction. Angiogram showed complete thrombotic occlusion of the SVG to tile posterior descending artery (**Figure 1**). Primary PCI to the SVG was unsuccessful. Fifteen days after the initial hospitalization, the control coronary angiogram was unchanged. Transthoracic echocardiography showed VSR of the mid inferoposterior septal segment. Color Doppler evaluation showed a turbulent flow jet at the basal septum between the left and right ventricles. The patient was hemodynamically stable, so surgery was performed after one week. Magnetic resonance imaging was performed before surgery to identify the dissected area and to determine the surgical strategy (**Figure 2**). The VSR was closed by a modified double patch repair. The patient was discharged from the hospital 10 days after surgery without complications. At six-month follow-up, the patient is stable. FIGURE 1. Angiogram showing complete thrombotic occlusion of the saphenous vein graft to tile posterior descending artery. FIGURE 2. Magnetic resonance imaging showing ventricular septal defect and blood shunting. **Conclusion:** Patients with prior CABG represent a high-risk population for future cardiovascular events. Acute MI with SVG involvement is difficult to treat and associated with higher long-term event rates such as procedural complications and no-reflow. This case highlights the role of the interprofessional team in the successful management of patients with VSR after myocardial infarction with prior CABG.

Ana Kovačević, Stjepan Kovačević, Iva Dumančić, Maja Franić, Josipa Meter, Nikolina Bukal, Ninoslav Leko, Blaženka Miškić, Katica Cvitkušić Lukenda

**Introduction**: Chronic obstructive pulmonary disease (COPD) is a global health issue characterized by progressive airflow limitation and respiratory symptoms (1, 2). Recent research have shown that patients with COPD often have a higher prevalence of cardiovascular diseases (CVD), including hypertension, coronary artery disease, and congestive heart failure (3, 4). This retrospective study aims to compare prevalence of CVD based on COPD severity. **Patients and Methods**: Data were collected from patients with COPD attending Pulmonology Clinic between April 2023, and October 2023. We divided patients into Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages I or II (FEV1 >50%) and GOLD stages III or IV (FEV1 0.9 | | | No | 19 (33.9) | 18 (34.0) | 37 (33.9) | | | | | Long-term oxygen therapy | | | | | | | | Yes | 1 (1.8) | 10 (18.9) | 11 (10.1) | | **0.003** | | | No | 55 (98.2) | 43 (81.1) | 98 (89.9) | | | | | Current smoking | | | | | | | | Yes | 27 (48.2) | 17 (32.1) | 44 (40.4) | | 0.1 | | | No | 29 (51.8) | 36 (67.9) | 65 (59.6) | | | | | Exacerbation of COPD over the one year-period | | | | | | | | Yes | 15 (26.8) | 33 (62.3) | 48 (44.0) | | **<0.001** | | | No | 41 (73.2) | 20 (37.7) | 61 (56.0) | | | | [†] COPD = Chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease; * Fisher’s Exact Test FIGURE 1. Comorbidities and cardiovascular diseases among patients depending on the severity of chronic obstructive pulmonary disease. FIGURE 2. The difference in the choice of therapy depending on the GOLD stage (Fisher’s Exact Test). IC = inhaled corticosteroid; LAMA = long-acting muscarinic antagonist; LABA = long-acting β2 agonist; SAMA = short-acting muscarinic antagonist; SABA= short-acting β2 agonist; SS = SAMA+SABA; LL = LAMA+LABA; IL = IC+LABA; ILL = IC+LAMA+LABA. FIGURE 3. The distribution of the use of cardiovascular therapy between Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage I or II and GOLD stage III or IV groups. BP = blood pressure medication; BB = beta-blockers; CLM = cholesterol-lowering medication, AT = anticoagulant therapy; ASA = aspirin; CG = cardiac glycosides; AA = aldosterone antagonists; D = diuretics. **Conclusion**: Despite prior research, we could not confirm the COPD severity-CVD link. Further research is vital to emphasize the need for personalized care, considering the limitation of a small patient sample.

Ognjen Aćimović

Because of its high rate of solubility and rapid diffusion through the lungs, carbon dioxide (CO2) is safe for intravascular use. Due to the absence of allergic reactions and renal toxicity, CO2, as a contrast medium, is an alternative to iodine contrast medium when performing digital subtraction angiography of the lower extremities. The introduction of CO2 into clinical practice made it possible for patients with reduced renal function and a reported allergy to iodine contrast agent to undergo a minimally invasive diagnostic and therapeutic procedure. Through this lecture, I will present the initial experiences of the employees at the Department of Clinical Radiology of the University Hospital of the Republic of Srpska, Banja Luka, and the evaluation of the quality of the images obtained during the procedures and their comparison with the images obtained with iodine contrast medium. In addition to the evaluation of the quality of the obtained image, the paper will pay attention to some other parameters that can affect the performance of the procedure itself. These parameters are the quality of opacification of the blood vessel with the contrast agent, the speed and practicality of the procedure, the biological properties of CO2 and how it affects the patient, compatibility with the device and economic profitability. (1, 2)

Josip Silović, Josip Ereiz, Ana Kovačević, Katica Cvitkušić Lukenda

**Introduction:** Atrial fibrillation (AF) is one of the most common arrhythmia in clinical practice. Apart from pharmaceutical, one of the most successful methods for achieving sinus rhythm is electrocardioversion (ECV). Although we can quickly achieve sinus rhythm with ECV, maintaining it is a challenge. Data from the literature suggest that there are certain predictors associated with the recurrence of AF, such as the duration of AF and long-standing arterial hypertension (1). Recurrence usually does not occur within 24 hours of cardioversion (2). An early catheter ablation strategy may potentially reduce the recurrence of AF (3, 4). We made a retrospective analysis of patients who underwent successful ECV through the emergency hospital admission and the Cardiology Day Hospital at the General Hospital “Dr. Josip Benčević“. Aim: To determine the relationship between gender, left ventricular ejection fraction, use of antiarrhythmic drugs, and comorbidities with recurrence of AF after successful ECV. **Patients and Methods**: We used data from the hospital information system according to the ECV procedure performed from January 1, 2021 to December 31, 2022. Age, gender, use of antiarrhythmic (amiodarone/dronedarone), left ventricular ejection fraction, and recurrence of AF were analyzed. Categorical variables were analyzed with Fisher’s exact test, while numerical variables underwent Student’s t-test with Mann Whitney U test for correlation. P0.9, Fisher’s Exact Test). FIGURE 2. Recurrence based on left ventricular ejection fraction (LVEF). No statistically significant difference was detected (p=0.8, Fisher’s Exact Test). FIGURE 3. Illustration of recurrence based on the use of antiarrhythmics following electrical cardioversion. No statistically significant difference was detected (p=0.5, Fisher’s Exact Test). ### TABLE 1: Display of recurrence depending on comorbidities. | | **Number (%)** | **Number (%)** | **Number (%)** | | | | --- | --- | --- | --- | --- | --- | | | **Yes** | **No** | **Total** | **p*** | | | Comorbidities | | | | | | | Arterial hypertension | 29 (74.4) | 39 (75) | 68 (74.7) | >0.9 | | | Chronic kidney disease | 5 (12.8) | 3 (5.8) | 8 (8.8) | 0.3 | | | Dyslipidemia | 21 (53.8) | 30(57.7) | 51 (56) | 0.8 | | | Coronary artery disease | 7 (17.9) | 8 (15.4) | 15 (16.5) | 0.8 | | | Type 2 diabetes mellitus | 6 (15.4) | 7 (13.5) | 13 (14.3) | >0.9 | | [†] * Fisher’s Exact Test **Conclusion**: Although ECV is a successful method for achieving sinus rhythm, it does not predict or affect its maintenance. Therefore, it is necessary to consider a catheter ablation strategy as early as possible.

Domagoj Mišković, Krešimir Gabaldo, Katica Cvitkušić Lukenda, Blaženka Miškić, Tomislav Krčmar

**Introduction**: In 1950, the American physician Travis Winsor was the first to report connection between peripheral arterial disease of the lower extremities with a systolic pressure in the ankle (1). Today, ABI (ankle brachial index) is the first line of non-invasive diagnostics for the screening and diagnosis of peripheral arterial disease of the lower extremities (2). However, the indication for endovascular treatment is based on the patient’s symptoms and the anatomical characteristics and localization of the lesions. **Case report**: 58-year-old male patient with previously known coronary artery disease, arterial hypertension, and diabetes was in outpatient follow-up with due to symptoms of lumbosacral radiculopathy. On CT scan in 5/2021 L2-S1 disc bulging was described and in in 6/2021, the patient underwent L4-L5 laminectomy. Electromyoneurography of the legs showed L3-S1 radiculopathy and diabetic polyneuropathy. In 3/2022, he underwent an ultrasound scan where 50% calcified stenosis of the right common femoral (CFA) artery and 75% stenosis of the distal segment of the left superficial femoral artery (SFA) was verified. At the vascular surgery outpatient office, he reported a walking distance of 200 meters. He was recommended an ABI, CT angiography of the lower extremities and exercise therapy. In 5/2022, the right ABI was 0.96 and the left 0.75. At the next control, the walking distance was still 200 meters, and the left ABI was 0.66. The decision of the multidisciplinary team was to perform percutaneous transluminal angioplasty of the left SFA. The intervention was done by right femoral approach, after which crossover was performed in the left CFA and DCB (drug-coated balloon) was applied to the lesion in the left SFA. The control ABI after the intervention was 0.93 on the left, with no change in the ABI on the right. At the follow-up after 3 months, the patient had a walking distance of more than 200 m with an ABI index equal to the post-intervention. **Conclusion**: ABI can be a useful tool for appropriateness, especially in atypical and unclear clinical conditions. It is also an important tool for follow up after endovascular interventions (3).