Cardiologia Croatica. 2025;20(1-2)

Tomislav Biloglav, Vesna Puklin, Hrvoje Lukić, Ivana Barun, Marina Matković

Coronary angiography is an invasive diagnostic used to visualize the coronary arteries. The first selective coronary angiography was accidentally performed by Dr. Mason Sones Jr. on October 30, 1958 at the Cleveland Clinic. In the following years, coronary angiography became an important diagnostic method in clinical practice and the basis of contemporary invasive and interventional cardiology. Nowadays, the most common vascular approach for performing coronary angiography is through the radial or femoral artery. In patients with severe peripheral arterial disease, e.g. occlusion of the subclavian, femoral, or radial arteries, the usual vascular access for coronary angiography cannot be used. Uncommon and very rarely used alternative approach (only a few cases in the world) is through the superficial temporal artery. This is a relatively small artery and is a branch of the external carotid artery. (1, 2) The procedure begins with puncturing the superficial temporal artery and placing an introducer. Then the catheter passes through the internal carotid artery, brachiocephalic artery, aorta to the coronary artery. Such an approach requires knowledge, skill and expertise. Nursing procedures for temporal coronary angiography include a number of activities: preoperative preparation, preparation of the patient, materials and equipment, assisting during the procedure, monitoring of vital signs, and postoperative care. Nursing procedures and care require extensive knowledge and skills, especially for new and rarely performed procedures and therapy. Coronary angiography using the superficial temporal artery access is a very rare and specific technique that requires expertise, and is used when conventional approaches are not possible. Nursing procedures are crucial for the successful outcome of the procedure and patient safety. Nursing procedures and care can significantly reduce the risk of complications and improve patient recovery. Technical knowledge, practical skills, and emotional intelligence are essential for providing high-quality nursing care.

Ivica Benko, Mateja Lovrić, Marina Žanić, Mirela Adamović, Marija Grlić, Nikolina Slamek, Marina Budetić, Ivan Horvat, Mario Tomašević, Matija Vrbanić, Kristijana Radić

Coronary artery visualization plays a crucial role in both epicardial and endocardial procedures, particularly in invasive electrophysiology and structural cardiac interventions. One of the highest-risk procedures is epicardial ventricular tachycardia ablation, where precise imaging of coronary arteries is essential to avoid vascular injury, ischemia, or infarction. Coronary angiography remains the gold standard for preprocedural planning, ensuring safe catheter navigation and targeted ablation. The role of specialized nursing staff in invasive cardiology laboratories is becoming increasingly significant. Nurses trained in electrophysiology and interventional cardiology must possess expertise in coronary angiography, as they play a key role in procedural safety, imaging assistance, and complication management. Several studies have reported rare but serious complications of coronary injury during epicardial ablations. (1-3) In a large cohort of 4655 ablation procedures, the incidence of coronary artery damage was 0.09%, primarily during epicardial procedures. Most injuries involved branches of the right coronary artery (RCA), requiring immediate stenting in cases of acute occlusion. These findings underscore the necessity for real-time coronary imaging to avoid complications. MDCT-derived coronary anatomy integration has been shown to improve safety by identifying high-risk zones before ablation. With the increasing complexity of invasive cardiac procedures, nurses must be proficient in: recognizing coronary anatomy on angiographic images, assisting in real-time fluoroscopic imaging during epicardial access, ensuring safe catheter navigation to minimize coronary injury, and monitoring for ischemic changes and rapid response to complications. Given the growing differentiation of invasive cardiology teams—covering interventional cardiology, electrophysiology, and structural interventions—a fundamental knowledge of coronary angiography is essential for all nurses. Coronary artery visualization remains a key safety measure in epicardial electrophysiology and structural interventions. The integration of preprocedural imaging and real-time coronary angiography significantly reduces the risk of complications. In our center, we emphasize the continuous education of nurses in coronary angiography, recognizing their vital role in ensuring procedural success and patient safety. As invasive cardiology continues to evolve, training in coronary imaging techniques must remain a core competency for all healthcare professionals involved in complex cardiac interventions.

Patricia Jurina

Transcatheter aortic valve implantation (TAVI) is a modern and minimally invasive procedure for treating symptomatic aortic stenosis. This approach is particularly suitable for elderly patients or those at high surgical risk who are not candidates for traditional surgical valve replacement. In addition to extending life expectancy, TAVI has a significant positive impact on patients quality of life. (1) Following the procedure, there is a notable improvement in physical function. Patients often report a reduction in symptoms such as shortness of breath and chest pain, along with an increased ability to perform daily activities, including walking and other physical tasks. The improvement in physical health positively influences mental well-being, reducing levels of anxiety and depression. Enhanced physical autonomy enables patients to return to social activities, further contributing to overall life satisfaction. Despite its numerous benefits, outcomes can vary depending on several factors. The risk of complications, such as paravalvular leakage or the need for permanent pacemaker implantation, can negatively impact postoperative experience. Advanced age and the presence of comorbidities may also affect the speed and quality of recovery. On the other hand, participation in cardiac rehabilitation following the procedure significantly improves functional status and long-term quality of life. TAVI has proven to be an extremely effective method that not only extends the lives of patients with aortic stenosis but also significantly improves their overall quality of life. Careful patient selection and postoperative follow-up are essential for achieving optimal results and maximizing patient benefits.

Tomislav Šipić, Irzal Hadžibegović, Nikola Pavlović, Marin Pavlov, Aleksandar Blivajs, Ivana Jurin, Ante Lisičić, Petra Vitlov, Tomislava Bodrožić Džakić Poljak, Luka Antolković, Šime Manola

Cardiogenic shock is a life-threatening condition in which the heart suddenly cannot pump adequately blood to meet the body’s need, that is mostly driven by the lack of oxygen. This condition is mostly caused by a severe heart attack – up to 10% of AIMs (Acute Myocardial infarction) end up with cardiogenic shock. If the cardiogenic shock is not treated immediately, it is often deadly. Even if treated immediately, it ends up with 50% of survival in one year follow-up. Temporary mechanical circulatory support (MCS) is the tool that can help to overcome such a serious condition. The main MCSs are Impella (CP, 5,5, RP), ECMO (Extracorporeal Membrane Oxygenation) (Vein-Arterial, Vein-Vein), IABP (Intraaortic Balloon Pump) or the combination of two of them, most often ECMO and Impella – called ECpella. Impella CP is the most frequently used MCS in our institution regarding acute and chronic PCI setting. The main indication in acute setting is cardiogenic shock provoked by AMI (1), especially in abrupt occlusion of proximal parts of main vessels (having no collaterals). Impella could be used before urgent PCI procedure (upfront), or after the procedure is done, with better clinical outcomes achieved (survival) using Impella upfront (if possible), respectively. By unloading the left ventricle, Impella stabilizes the patient hemodynamically in that critical situation, and gives needful time to intervene properly. Another very important indication, where the use of Impella is recognized and established, is chronic (or subacute) coronary syndrome (2). These are so called “CHIP” (complex and high-risk procedure) interventions. The main indication is need for revascularization and surgical ineligibility, whatever the reason is. Impella provides the needed comfort and increases the safety for such complex, time-consuming, procedures. Using Impella in a such manner, showed improved outcomes regarding survival, ejection fraction enhancement, amelioration of heart failure and angina status, predominately by achieving a completeness of revascularization (if not always anatomically, then functionally). Impella CP is great mechanical circulatory support device in surmounting cardiogenic shock, especially in ACS, and excellent tool in providing conditions to solve complex and high-risk coronary patients.

Marin Vučković, Kristina Vučković, Sandra Šarić

**Introduction**: Main etiology for left ventricular systolic dysfunction (LVSD) and also heart failure (HF) remains coronary artery disease (CAD). (1) The incidence of HF in patients with CAD has significantly increased, due to the advanced techniques in percutaneous interventions, technical advancement and newer medical treatment that improved survival. Nevertheless, LVSD, the repercussion of CAD is associated with excess of morbidity and mortality. Primary endpoint of cardiovascular death, nonfatal MI, hospitalization or cardiac arrest over 4 years was higher in patients with HF or LVSD (≤35%) in comparison to patients without HF symptoms or LVSD. Moderate documented ischemia on imaging tests, or severe ischemia on exercise tests associated with HF or LVSD in ISCHEMIA trial (The International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) highlighted lower cardiac events in the invasive group when compared to the conservative group. Does viability assessment have important part of the clinical work up prior to revascularization in patients with HF, as the presence of viable myocardium is more likely to lead to prognostic benefits following successful revascularization? The most widely used tests for myocardial viability assessment are single photon emission computed tomography (SPECT), positron emission tomography, cardiac magnetic resonance imaging and dobutamine stress echocardiography. **Case report**: We provided case report in newly detected decompensated ischemic cardiomyopathy patient with severe chronic CAD – stenosis of ostium of left anterior descending artery and right coronary artery. Echo study showed LVSD and HF with left ventricular systolic fraction of 33%, and SPECT examination did not found deficit of viability in left ventricle. After heart team evaluation patient has been referred for percutaneous coronary revascularization. Our team believes that viability scan can have a role in predicting functional recovery. **Conclusion**: The search for viability in HF patients improves the responder screening and can direct us in towards better long-term clinical outcome given the significant reduction in all-cause mortality.

Jelena Mikulan

Interventional cardiology is a specific branch of cardiology that requires thorough mastery of the necessary knowledge and skills. To work in the department, a higher education degree for nurses is required, as well as a background in cardiology and/or intensive medicine. Training for work in interventional cardiology is currently based on the engagement of the head nurse of the department and other team members in transferring knowledge and experience to the new employee. The new employee must know from the beginning what is expected of them. At the start of the training, they must master the fundamental theoretical knowledge of ECG, arrhythmias, coronary diseases, and treatment methods. (1) Currently, there is no formal education for work in interventional cardiology. The employee must be psychophysically prepared to work in an ionizing radiation zone and for daily stressful situations at work. In other countries, there is also no specific education within the education system for work in interventional cardiology. Various continuous education methods are implemented in this field. The length of training for a nurse to work in interventional cardiology depends on the employee’s dexterity and enthusiasm, as well as the entire team’s commitment to the employee’s education.

Ivica Benko

## Dear Colleagues, It is with great pleasure that we announce the 10th Anniversary Meeting of the Working Group on Invasive and Interventional Cardiology of the Croatian Association of Cardiology Nurses, which will be held as part of the 11th Congress of Invasive and Interventional Cardiology with International Participation – CROINTERVENT 2025. This important professional event will take place from March 6 to March 9, 2025, at the Westin Hotel in Zagreb. CROINTERVENT 2025 provides a unique opportunity to acquire the latest insights, exchange experiences, and explore innovations that shape modern invasive and interventional cardiology. Special emphasis is placed on the development of the nursing profession, recognizing the essential role of nurses in the multidisciplinary team. The 10th Anniversary Meeting of the Working Group will focus on specialized knowledge and competencies in interventional cardiology nursing, including training for work in invasive laboratories, optimization of nursing care during and after TAVI procedures, standardization of clinical protocols, and improving patient quality of life after interventional procedures. Through lectures, interactive workshops, and live video transmissions of complex invasive procedures, participants will have the opportunity to learn about the latest techniques and protocols and gain valuable practical skills. The congress content is tailored not only for nurses directly involved in invasive procedures but also for all healthcare professionals providing continuous care to patients before, during, and after interventions. Experts from Croatia and around the world will share their knowledge and experiences, enabling participants to apply newly-acquired insights in daily clinical practice. We invite all nurses, technicians, and other healthcare professionals in the field of cardiology to join us in celebrating this important anniversary. Participating in the congress will provide new perspectives, valuable knowledge, and inspiration to enhance professional practice. We look forward to your presence and our collective contribution to the advancement of cardiology care! Sincerely, predsjednik Radne skupine za invazivnu i intervencijsku kardiologiju Hrvatske udruge kardioloških medicinskih sestara | President of the Working Group on Invasive and Interventional Cardiology of the Croatian Association of Cardiology Nurses Ivica Benko, mag. med. techn., univ. mag. admin. sanit., ECDSAP | Ivica Benko, RN, BScN, MScN, MScHQ., ECDSAP ## ORGANIZATOR | ORGANIZER Hrvatska udruga kardioloških medicinskih sestara | Croatian Association of Cardiology Nurses Radna skupina za invazivnu i intervencijsku kardiologiju | Working Group for Invasive and Interventional Cardiology ## PREDSJEDNICI SIMPOZIJA | SYMPOSIUM CHAIRS Ivica Benko, RN, BScN, MScN, MScHQ, ECDSAP Ana Ljubas, RN, BScN, MScN, FESC ## TAJNIK SIMPOZIJA | SYMPOSIUM SECRETARY Matija Vrbanić, RN, BScN ## ZNANSTVENI ODBOR | SCIENTIFIC COMMITTEE Lucija Barbarić, Ivica Benko, Ante Borovina, Marina Budetić, Miroslav Geček, Zvonimir Katić, Marina Klasan, Ivana Kuserbanj, Krešimir Librenjak, Sara Milanović Litre, Alen Pazman, Željka Roginić, Sabina Škifić, Matija Vrbanić, Samanta Vuković. ## ORGANIZACIJSKI ODBOR | ORGANIZING COMMITTEE Zdenka Čurić, Branka Horvatinec, Marina Jelinić, Ivana Kuserbanj, Krešimir Librenjak, Bruno Mihatović, Jelena Mikulan, Željka Roginić, Marija Romić, Sandra Babić, Sabina Škifić, Renata Valenčak, Ružica Višnjovski, Matija Vrbanić, Alemka Vujičić.

Kristina Marić Bešić, Denis Došen, Vlatka Rešković Lukšić, Sandra Jakšić Jurinjak, Irena Ivanac Vranešić, Antun Zvonimir Kovač, Joško Bulum

**Introduction**: Patent foramen ovale (PFO) closure is a widely performed procedure with a success rate exceeding 98%. However, residual right-to-left interatrial shunting can persist in up to 30% of cases (1, 2). The occurrence and size of residual shunts are influenced by the anatomical characteristics of the PFO and the dimensions of the implanted closure device (3). We aimed to evaluate the incidence of residual shunting, and its correlation with the size of the Amplatzer occluder device at the University Hospital Centre (UHC) Zagreb. **Patients and Methods**: A retrospective analysis was conducted on all patients who underwent PFO closure at the UHC Zagreb to date. The study assessed implantation success rates, device sizing, echocardiographic follow-up methods and frequency, and the detection of residual shunts. Statistical analysis was performed using the Chi-square test and Cramer’s V test. **Results**: Between August 2016 and December 2024, a total of 104 PFO closures were attempted, with 100 (96.2%) successfully implanted. Various sizes of Amplatzer occluder devices were used: 65 patients (66%) received smaller devices: 18/25 mm or 25/25 mm, while 33 patients (34%) received larger ones: 25/30 mm, 25/35 mm or 30/30 mm. Size data was unavailable for 2 cases. During the first year of follow-up, residual shunts were assessed in 41 patients (39.4%) using TTE/transesophageal echocardiography (TEE) with color Doppler and in 59 patients (56.7%) using TTE with a bubble test. Residual shunting was detected in 18 patients (18.3%) exclusively with the TTE bubble test, 78% with larger devices. TTE with bubble test beyond one year was performed in 14 (out of 19) patients. A persistent residual shunt was found in 11 patients (10.6%), again in 73% patients with larger devices. A statistically significant difference was observed in the occurrence of residual shunting among different device sizes (Chi-square, p<0.001), with a higher likelihood of residual shunting as device size increased (Cramer’s V = 0.577, p<0.001). **Conclusion**: PFO closure outcomes at our center align with data from literature. The findings confirm that larger closure devices are associated with a higher likelihood of residual shunting. TTE with bubble test is superior to Doppler-based methods in detecting residual shunting and therefore important for follow-up assessments.

Antun Zvonimir Kovač, Denis Došen, Irena Ivanac Vranešić, Miroslav Muršić, Maja Hrabak Paar, Kristina Marić Bešić

**Introduction**: In patients with congenitally corrected transposition of the great arteries (CCTGA), atrioventricular and ventriculoarterial discordance maintains physiologic circulation. However, early surgical intervention is often required due to associated anomalies such as septal defects, pulmonary valve dysfunction, or subpulmonary outflow tract obstruction (1). Over time, implanted conduits and bioprosthetic valves undergo degeneration, necessitating reintervention. Percutaneous pulmonary valve implantation (PPVI) has emerged as a less invasive alternative to surgical procedures (2). Here, we present a case of PPVI in a degenerated outflow tract conduit. **Case report**: 37-year-old woman with a history of CCTGA presented with progressive exertional dyspnea. She had her first surgery at the age of 9 – patch repair of septal defects and homograft implantation from the left ventricle to the pulmonary artery with the hypoplastic native pulmonary artery left in place. The second operation was at the age of 21 years – replacement of the degenerated homograft with a Conterga conduit. Echocardiography and cardiac magnetic resonance imaging revealed dysfunction of the Contegra conduit with mild stenosis and severe valve regurgitation. Additionally, severe mixed disease of the native pulmonary valve was noted, along with subpulmonary ventricular dilation and elevated filling pressures, while ventricular function remained preserved. Computed tomography angiography confirmed the feasibility of a PPVI. The patient underwent elective PPVI with a Melody 22 bioprosthetic pulmonary valve within the Contegra conduit (**Figure 1**). No intervention was performed on the native pulmonary valve. The procedure was successful, with no residual regurgitation and a normal forward gradient. Postprocedural echocardiography demonstrated significant improvement in subpulmonary ventricular function, and the patient experienced no complications. FIGURE 1. CT image of a percutaneously implanted Melody valve in a Contegra conduit. **Conclusion**: This case highlights the effectiveness of PPVI as a safe and minimally invasive alternative to surgical reinterventions in patients with CCTGA and prior conduit placement. As bioprosthetic valve degeneration remains an ongoing challenge, transcatheter therapies offer a promising approach for long-term management in this complex patient population.

Mira Stipčević, Marin Bištirlić, Jogen Patrk, Zoran Bakotić, Dražen Zekanović

**Introduction**: Percutaneus patent foramen ovale (PFO) closure is the gold standard for treating patients with cryptogenic stroke and PFO. Also, if feasible in adult age, prercutaneus closure of atrial septal defect (ASD) is prefered modality of treatment to reduce morbidity and mortality. (1-3) Our aim was to evaluate short and mid-term risk of recurrent thromboembolic events in patients treated by percutaneous atrial septal defects closure. **Patients and Results**: Between 2019 and 2024, a 51 consecutive patients had atrial septal defect closure in Zadar General Hospital, 55% were male and mean age was 46.2 (20-78). Five patients had ASD and 46 had PFO with a high suspicion of paradoxical embolism or migraine refractory to medical treatment (41 vs 4pts), and one patient was professional scuba diver with repetive decompression illness with evident PFO. All patients were screened for atrial fibrilation (0) and trombophilia (one patient had trombophilia requiering long term anticoagulation therapy). Arterial hypertension was diagnosed in 23.5% of the patients. PFO closure was preformed with Amplatzer PFO closure device in 36 (82%) and Amplatzer Talissman device in 8 patients (12%). All procedures were uneventfull. All patients recived dual antiplatlet therapy for threee months (clopidogrel and aspirin) and monotherapy with aspirin for one year following procedure. After one year 52% of patients are still on aspirin. During a mean follow-up of 26.9 months (max 64mo), 2 patients (4%) had TIA, both patients were older (56 and 58 years) and both had other risk factors for tromboembolic event, including arterial hypertension and hyperlipidaemia. One patient had transient atrial fibrillation ten days after device implantation. No major bleeding was reported. **Conclusion**: Transcatheter atrial septal defects closures are safe procedures with no increased risk of serious adverse events or influence on major bleeding.

Denis Došen, Irena Ivanac Vranešić, Kristina Marić Bešić

**Introduction**: A bicuspid aortic valve (BAV) is a common congenital cardiac anomaly, often associated with coarctation of the aorta (CoA). Current guidelines emphasize that percutaneous treatment of CoA is the preferred approach when anatomically feasible, as it is less invasive and associated with lower morbidity compared to surgical intervention. (1) **Case report**: 46-year-old male initially presented to a local hospital with a diagnosis of a non-ST-elevation myocardial infarction. Percutaneous coronary intervention was performed on the ramus intermedius with successful stent placement. During further evaluation, moderate aortic stenosis secondary to a BAV and CoA with a gradient of approximately 60 mmHg were identified. A multi-stage surgical approach was planned, including coronary artery bypass grafting for the left anterior descending artery lesion, surgical repair of the aortic coarctation, and aortic valve replacement. However, the patient was referred to our center for further management. We opted for a percutaneous approach, successfully implanting a drug-eluting stent in the LAD. In a second procedure, percutaneous intervention for the aortic coarctation was performed, with the placement of a 24x43 mm covered stent. Echocardiography confirmed moderate stenosis of the bicuspid aortic valve, and the patient was scheduled for annual clinical and echocardiographic follow-up. **Conclusion**: Coarctation of the aorta is a relatively common anomaly in patients with a bicuspid aortic valve. Percutaneous treatment of CoA is indicated in all patients where anatomically feasible, offering a less invasive and effective alternative to surgery. When CoA is diagnosed later in life, patients often present with acquired cardiovascular conditions, such as coronary artery disease, necessitating a comprehensive and individualized treatment strategy. This case underscores the importance of timely diagnosis, multidisciplinary collaboration, and the advantages of percutaneous interventions in managing complex cardiovascular conditions.

Petra Radić, Martina Čančarević, Diana Delić-Brkljačić, Vjekoslav Radeljić

**Introduction**: During the last few years, the number of patients with complex coronary artery disease who require circulatory assist devices during percutaneous coronary interventions has increased significantly. Impella CP left ventricular assist device is a continuous-flow axial pump placed across the aortic valve that drives the blood directly from the left ventricle towards the ascending aorta. The most used approach is femoral, however sometimes we need to use an alternative site to place the device. (1, 2) **Case report**: 72-year-old man was hospitalized due to an acute non-ST-elevation myocardial infarction. This patient had a repair of ascending aortic aneurysm with a graft and venous bypass to the marginal branch of circumflex artery in 2021. Prior to the cardiothoracic surgery he had multiple percutaneous interventions on circumflex artery (ACx) and right coronary artery (RCA) as well as both-sided aortofemoral bypasses. An emergency CT aortography was performed in the Emergency Department to rule out acute aortic syndrome. A coronary angiography followed after the admission and it showed subocclusion of the left main, chronic total occlusion of diagonal branch, subocclusion of proximal ACx and 99% stent stenosis in proximal RCA. Due to the lack of femoral access, a team of interventional cardiologists decided on performing a high-risk procedure with transaxillary Impella CP support with the assistance of vascular surgeons. An intervention was performed on the left main with the implantation of one drug-eluting stent and drug-eluting balloon was applied in the proximal ACx. During the procedure, the patient was hemodynamically stable, and at the end of the intervention, the Impella CP was removed. The axillary artery was surgically closed. Due to the high risk of ischemia, the antiplatelet therapy used in this patient was acetylsalicylic acid and prasugrel. **Conclusion**: This is a case of a complex and multi-comorbid patient from everyday clinical practice who can be provided with optimal medical care in specialized centers that, in addition to equipment, also have highly educated specialists. The transaxillary approach with Impella CP performed by experienced teams is safe and enables us to treat such patients.

Aleksandar Blivajs, Irzal Hadžibegović, Ivana Jurin, Šime Manola

**Introduction**: Intravascular imaging helps guide primary coronary intervention (PCI) strategy by providing detaild visualization of plaque morphology, enabeling precise leasion assessment and optimizing stent deployment. (1-3) **Case report**: We present a case of a 59-years-old patient with acute coronary syndrome (ACS) admitted from a referral hospital where he was hospitalized because of typical angina, with no ischemic T wave abnormality and positive high sensitivity troponin levels. Echocardiography revealed mild segmental hypokinesis of the mid and distal septum with preserved ejection fraction and no valvular pathology. He was treated with aspirine and fondaparinux. Invasive angiography performed 48 hours after symptom onset showed no irregularities of the right coronary artery and circumflex artery, however, there was a non-significant plaque of the proximal left anterior descending artery (LAD) causing a 40% narrowing of the artery with no angiographic signs of plaque instability. Intravascular imaging of the LAD was performed using optical coherence tomography (OCT), which showed characteristics of a thin-cap fibroatheroma (TCFA) with no signs of plaque rupture or thrombus. Because of the clinical presentation, we chose to proceed with PCI using a drug-coated balloon strategy. After lesion preparation with a non compliant 1:1 ratio 3.0x20 mm balloon, a paclitaxel-coated balloon was deployed with optimal result. **Conclusion**: In recent years, advances in intravascular imaging have helped better characterize plaque morphology. Thanks to its high spatial resolution, OCT is a superior tool in assessing plaque structure as opposed to IVUS, although it has its own constraints in discerning lipid-rich plaques from fibrous. However, exact measuring of lipid caps is possible using OCT, and in conjunction with new technology, like Intracoronary near-infrared spectroscopy (NIRS), plaque morphology can be highly understood. TCFA plaques have been established as high-risk features for the development of ACS. Treatment of such lesions with PCI and/or optimal medical therapy (OMT) has recently come into focus. The PREVENT trial showed that PCI of non-obstructive lesions with OCT confirmed high-risk features was superior to OMT alone. On the other hand, the EROSION trial showed that conservative treatment with no PCI of plaque erosions that present with ACS can be a safe strategy. This case highlights the importance of intravascular imaging-guided angiography to better understand and treat patients with high-risk plaque features.

Irzal Hadžibegović, Daniel Unić, Ivana Jurin, Tomislav Šipić, Nikola Pavlović, Marin Pavlov, Savica Gjorgjievska, Igor Rudež, Šime Manola

**Introduction**: Percutaneous transfemoral transcatheter aortic valve implantation (TAVI) is the prerequisite for the superiority of TAVI in high-risk population in comparison to surgery. In case of impossible transfemoral approach alternative access to TAVI is required, increasing the periprocedural risks. (1) We present our experience with alternative access to TAVI and compare the outcomes between transfemoral and alternative access. **Patients and Results**: We analyzed the data from a single center TAVI registry with 622 patients treated from Jan 2013 to Dec 2024. There were 463 (74%), 139 (23%), and 20 (3%) patients with full percutaneous transfemoral (standard after Jun 2019), surgical femoral cut-down (standard until Dec 2018), and alternative access respectively. Among 20 patients with alternative access there were 10 (50%), 5 (25%), 3 (17%), and 2 (8%) patients with transapical, percutaneous axillary, transaortic, and surgical subclavian cut-down approaches, respectively. Out of 10 transapical procedures, 8 were performed from Jan 2013 to Jun 2017, and only 2 between Jun 2017 to Dec 2024. A composite outcome of minor or major vascular complication, minor clinically significant or major bleeding, or intrahospital death occurred in 37 (7.9%), 12 (8.6%), and 3 (15%) patients treated with percutaneous transfemoral, surgical femoral cut-down, and alternative access, respectively. Alternative access carried a significantly higher risk of composite outcome in comparison to transfemoral (both percutaneous and surgical) due to higher number of comorbidities - predominantly peripheral artery disease, coronary artery disease, previous cardiovascular interventions, and also in case of transapical alternative approach. **Conclusion**: TAVI procedure by an alternative access carried a higher risk of the in-hospital composite negative outcome because of higher patient risk profile. Negative composite outcome occurred in less than 10% of patients with transfemoral procedure, without significant difference between full percutaneous and surgical cut-down. Full percutaneous femoral approach is safe and effective in reducing risks of unfavorable outcomes during and after TAVI. Percutaneous axillary approach has relatively recently become the first alternative access in our center.

Eduard Margetić

## Dear Colleagues, The 11th Congress of Invasive and Interventional Cardiology with International Participation – CROINTERVENT 2025, will be held from March 6 to March 9, 2025, at the Westin Hotel in Zagreb. Two years have passed since the last congress, during which there has been no shortage of news in the field of invasive and interventional cardiology. We have witnessed progress in all segments of this extremely dynamic branch of modern medicine. By following developments in the profession, the Croatian interventional community has successfully incorporated all newly-acquired knowledge into our clinical practice for the benefit of our patients. It cannot be emphasized enough that direct communication between colleagues is extremely important in this process, which is also the fundamental goal in organizing this congress. We will retain the well-tested concept of providing an overview of current achievements in diagnostic and therapeutic procedures applied in modern interventional cardiology. The congress program will include invited lectures by eminent domestic and foreign experts, as well as oral and moderated poster presentations. In addition to theoretical knowledge, a recognizable and extremely important part of the congress will be direct video transmissions of procedures from interventional laboratories with guidance and comments from confirmed experts. In addition, the practical aspect of the congress will addressed by presentations of previously performed procedures with discussion and conclusions. An important part of the congress will be dedicated to pharmacotherapy as an inseparable part of interventional cardiology, the importance and value of which have been confirmed, both in the primary and secondary prevention of cardiovascular diseases, as well as in optimizing primary outcomes and reducing the frequency of post-interventional adverse cardiovascular events. CROINTERVENT 2025 is not conceived as an exclusively cardiological congress but is also intended for physicians in related specialties and members of other professions who are professionally associated with this important segment of modern cardiology. The goal of the congress is to present the current state, scope, and possibilities of modern interventional cardiology, identify areas that are still insufficiently researched, harmonize positions on controversial topics, consider optimal treatment strategies, and discuss the difficulties we encounter in our clinical work. This Supplement of Cardiologia Croatica – the official journal of the Croatian Cardiac Society – consists of selected original contributions from our participants in the form of abstracts, which will be presented at the meeting in the form of oral presentations and moderated posters. With kind regards, doc. dr. sc. Eduard Margetić | Assist. Prof. Eduard Margetic, MD, PhD predsjednik Radne skupine za invazivnu i intervencijsku kardiologiju | President, Working Group on Invasive and Interventional Cardiology Hrvatskoga kardiološkog društva | Croatian Cardiac Society

Lea Saftić

Acute Coronary Syndrome (ACS) is an emergency cardiovascular condition that requires rapid and precise diagnosis, as well as appropriate treatment. This paper presents the case of a young female patient admitted to our institution with suspected ACS. Upon admission, invasive coronary angiography was immediately performed, which ruled out coronary artery disease as the cause of her symptoms. Further diagnostic workup revealed that the patient was suffering from myopericarditis as a complication of Influenza B. Given the severity of the clinical presentation, treatment was continued in the intensive cardiac care unit with the use of pharmacological and mechanical support, including extracorporeal membrane oxygenation and the Impella CP system, which were employed for hemodynamic support. (1) During the use of the Impella CP system, a device deformation was noted, which posed an additional challenge in treatment. This complication required urgent assessment and intervention by a multidisciplinary team to ensure continuous circulatory support for the patient. The paper will describe the course of the complication, the method of recognizing it, and how the issue was resolved. A special emphasis is placed on the importance of a multidisciplinary approach in treating such complex cases, with cardiologists, intensivists, perfusionists, and nurses playing key roles. The role of nurses in monitoring and caring for patients with advanced heart function support systems is highlighted, with a particular focus on their interventions and tasks in the angiography suite of interventional cardiology and the intensive cardiac care unit.

Maja Španjol

Valvular heart diseases, along with coronary artery disease and heart failure, are among the most common cardiovascular diseases. Aortic stenosis (AS) is the most prevalent among them, and the only effective treatment method is aortic valve replacement. For many years, surgical aortic valve replacement (SAVR) has been the standard treatment method. However, over the past two decades, transcatheter aortic valve replacement (TAVR) has emerged as a less invasive and standardized approach, particularly for elderly, high-risk, and inoperable patients with severe symptomatic AS. This method has brought significant improvements in treatment outcomes and patients’ quality of life. (1-3) An analysis of results from the Department of Interventional Cardiology at the Clinical Hospital Center Rijeka demonstrated that the transcatheter method of aortic valve replacement enables faster patient recovery, shortens hospital stays, and reduces the need for blood transfusions, which is particularly important for patients with high health risks. Furthermore, the TAVR method was associated with a lower mortality rate compared to the surgical approach. In contrast, surgical aortic valve replacement resulted in longer hospital stays, an increased incidence of bleeding, a higher requirement for blood transfusions, and a higher mortality rate. Based on these results, the high efficacy and safety of the transcatheter aortic valve replacement method have been confirmed. The TAVR method represents a significant advancement in the treatment of patients with aortic stenosis, particularly those at high risk for surgical intervention, supporting its broader application as a safer and less invasive alternative in the treatment of valvular heart diseases.

Luka Mitar, Filip Pavlic, Luka Perčin, Joško Bulum, Hrvoje Jurin

**Introduction**: Coronary angiography (CA) remains the gold standard for detecting epicardial stenosis, yet microvascular dysfunction is frequently overlooked despite its significant impact on myocardial ischemia and patient symptoms. An increasing body of evidence (1) suggests that assessing coronary microvascular function, in conjunction with evaluating epicardial lesions, is essential for guiding treatment decisions and optimizing patient outcomes. **Case report**: 64-year-old female patient with a family history of cardiovascular disease was admitted to the cardiology ward due to unstable angina. Urgent CA revealed subocclusive stenosis of the right coronary artery (RCA) with distal TIMI 1 flow and borderline (60%) stenosis of the left anterior descending (LAD) artery. A subsequent percutaneous coronary intervention (PCI) targeting the RCA, identified as the culprit lesion, was successfully performed, involving the implantation of two drug-eluting stents (DES). Regarding the borderline stenosis of the LAD, a decision was made to reassess the lesion during a follow-up procedure three months later. During this follow-up period, the patient reported intermittent episodes of angina. Control CA confirmed an excellent outcome from the previous PCI of the RCA, with TIMI III flow, while the LAD stenosis remained unchanged. The LAD lesion was then functionally evaluated using coronary physiology assessment, which revealed a significantly reduced coronary flow reserve (CFR) and markedly increased microcirculatory resistance (IMR), with the fractional flow reserve (FFR) remaining normal. These findings identified the presence of structural microvascular coronary disease and confirmed that the LAD stenosis was functionally insignificant. Considering these results, PCI of the LAD stenosis was not indicated. Instead, the antianginal therapy was intensified, and the patient was discharged in stable condition. **Conclusion**: This case underscores the importance of functional assessment of both epicardial and microvascular compartments to accurately identify the underlying causes of patient symptoms. As current clinical practice often prioritizes epicardial assessment, this case emphasizes the need for a broader diagnostic approach to ensure appropriate management and avoid unnecessary interventions.

Marija Romić

**Background:** Transcatheter aortic valve implantation (TAVI) has revolutionized the management of severe symptomatic aortic stenosis, offering a less invasive alternative to surgical valve replacement, in selected patients. However, variability in patient selection, procedural workflow, and post-procedural care can impact clinical pathway and outcomes. (1-3) Our goal was to develop a standardized and optimized TAVI clinical pathway to enhance efficiency, safety, and patient outcomes. **Materials and Methods:** A multidisciplinary TAVI team at the University Hospital of Split aimed to prepare a comprehensive list of standardized TAVI protocols, and to monitor its safety and effectiveness through various quality indicators. Key process elements, including patient selection, pre-procedural workup, intraprocedural workflow, and post-procedural care, were reviewed and refined. The protocols aimed to incorporate structured algorithms for different phases of the TAVI clinical pathway. The following quality indicators were used: number of developed protocols; % coverage of each TAVI clinical pathway phase; staff satisfaction; and procedural duration and flow. **Results:** We have developed a total of 9 standardized protocols, encompassing preprocedural, intraprocedural and postprocedural aspects (100.0%). For the purpose of daily utilization and validation, the protocols were solely in Croatian language. The implementation of the protocols was smooth, and all members of the TAVI team have accepted it (100.0%). An overall staff satisfaction was high, resulting in daily utilization of the protocols (100.0%). Procedural duration was significantly shortened after the introduction of the protocols (median procedural time (skin entry to closure): 70 minutes vs. 40 minutes). Finally, based on the abovementioned assessments and quality indicators, the standardization and optimization of the TAVI clinical pathway was achieved. **Conclusion:** Optimization of the TAVI clinical pathway is feasible using the standardized local protocols. The protocols from the University Hospital of Split have met the predefined quality indicators, but its association with the patient clinical outcomes is needed. Further research is needed to validate long-term benefits across diverse populations.

Željka Roginić, Daniela Šmaljcelj, Patricia Kakarigi, Antonio Vuković, Natalija Silović, Robert Seretin

**Introduction:** Aortic stenosis (AS) is the most common valvular disease in adulthood that prevents normal opening of the aortic valve and limits blood flow during systole. The typical symptoms of severe AS are shortness of breath, chest pain, and syncope. Treatment of AS depends on the disease severity and the patient’s risk profile. Severe AS is treated with percutaneous balloon aortic valvuloplasty (BAV), transcatheter aortic valve implantation (TAVI), or surgical valve replacement. The first percutaneous BAV was performed by A. Cribier in September 1985 in a 72-year-old patient with severe symptoms who was denied surgical valve replacement due to her age, and the procedure resulted with excellent result. Nowadays, BAV as a minimally invasive procedure is performed in high-risk patients with severe AS as a bridge to surgical aortic valve replacement or TAVI. (1, 2) The first-choice vascular access in BAV procedure is the femoral artery. However, sometimes the procedure must be performed via an alternative arterial route, that is the case in patients with severe peripheral disease or diseases of the aorta, like coarctation. Aim: To present an alternative vascular access to perform percutaneous BAV via transbrachial access. **Case report:** 79-year-old patient was hospitalized due to severe AS. The patient had many comorbidities, including extensive malignant disease under active treatment, cardiomyopathy, and stenosis of the descending aorta. Because of this a team of cardiologists and oncologists decided for BAV treatment. CT aortography showed tortuous aorta and coarctation, and it was decided to perform BAV via the brachial artery. The brachial artery was punctured, the ProGlide was placed and 8F sheath was inserted. A coronary angiography revealed normal coronary arteries. Using the right coronary catheter the straight wire was inserted into the left ventricle and then replaced with an Amplatz superstiff wire. The right radial artery was punctured to place a protective wire in the right subclavian artery. Aortic valvuloplasty was performed via transbrachial access with a 20 mm balloon dilatation during electrostimulation of the heart at 180/min. Control ventriculography showed no aortic regurgitation and the patient increased her systemic arterial pressure for 20 mmHg. After the procedure, the right brachial artery was successfully closed with the ProGlide device with angiographic confirmation. The patient was discharged on the next day. **Conclusion:** BAV is a minimally invasive procedure performed under local anesthesia and used in palliative care or a bridge to surgical aortic valve replacement or TAVI. Transbrachial access is an alternative vascular approach for BAV procedure that may be needed in patients with severe peripheral arterial or aortic disease.

Matija Vrbanić, Kristijana Radić, Katarina Karimanović, Ljerka Crnković, Ivica Benko, Nikola Krajna, Filip Topolnjak

Transcatheter aortic valve replacement (TAVI) has emerged as a revolutionary procedure for treating aortic valve disease, offering a less invasive alternative to traditional open-heart surgery. In the process of transcatheter aortic valve replacement, nurses play a key role, significantly contributing to patient care and the success of the procedure. They are also crucial members of the multidisciplinary TAVI team, providing comprehensive care before, during, and after the procedure. Their impact spans various aspects of the TAVI process, including patient preparation, intraoperative assistance, valve preparation, and post-procedural monitoring. (1, 2) Acquiring skills in TAVI procedures requires a combination of formal education, practical training, and clinical experience. Nurses interested in TAVI typically undergo specialized training programs covering principles of cardiology care, heart anatomy and physiology, and specific protocols and equipment used in TAVI procedures. Simulation training plays a key role in preparing specialized nurses for valve preparation in TAVI procedures, allowing them to practice skills on demo models in a controlled environment. Simulations replicate various aspects of the procedure, including the preparation of the appropriate sheath, delivery system setup, and, finally, valve preparation. Successful valve implantation requires seamless team coordination, in which nurses have an irreplaceable role. They ensure the preparation of equipment, check all system components, and properly prepare the bioprosthesis, contributing to patient safety and the success of the procedure. Due to technological advancements and the increasing use of the TAVI method, mentoring and peer support are invaluable resources for nurses navigating the complexities of TAVI nursing. Through specialized education, practice, and continuous professional development, nurses acquire the knowledge and experience needed to succeed in the dynamic field of TAVI nursing.

Andrija Matetić, Frane Runjić, Nikola Crnčević, Ivica Kristić, Darija Baković Kramarić

**Introduction**: Transcatheter aortic valve implantation (TAVI) is a life-saving procedure for patients with severe symptomatic aortic stenosis at high surgical risk. The transfemoral approach is preferred, but some patients have unsuitable iliofemoral arteries, necessitating alternative access (1). While no consensus exists on the best alternative, the transcaval approach offers advantages when performed in experienced centers (2, 3). Compared to transaxillary or transcarotid access, transcaval TAVI lowers stroke risk, allows easier valve deployment, accommodates any sheath size, is fully percutaneous, and maintains a transfemoral-like setup (2, 3). This study presents the first transcaval TAVI cases in Croatia and Central-Southeast Europe, successfully performed at the University Hospital of Split. Six cases were completed, with one exemplary case detailed here. **Case report**: 78-year-old male with severe symptomatic aortic stenosis and high surgical risk was referred for TAVI. His history included chronic heart failure, chronic kidney disease with a functional kidney transplant, severe peripheral artery disease, prior carotid surgery, stroke, and cancer treatment. Due to extensive iliofemoral calcification and prior kidney transplant attachment, the transfemoral approach was unfeasible (**Figure 1**). Transaxillary access was also ruled out due to significant stenoses. The Structural Heart Team opted for the transcaval approach after detailed preprocedural planning (**Figure 2**). The fully percutaneous procedure was performed under operator-led sedation. The tract between the inferior vena cava and abdominal aorta was created using an electrified wire and snare, followed by eSheath (16F) placement. An Edwards Sapien S3 Ultra 29 mm valve was deployed successfully, achieving optimal positioning and no regurgitation. The tract was sealed using an Amplatzer Duct Occluder, and vascular access was closed with suture devices (**Figure 3**). The patient recovered uneventfully and was discharged on postoperative day 3. FIGURE 1. Computed tomography reconstructions of iliofemoral arteries: Severe bilateral atherosclerosis and calcifications with a functional kidney donor on the right side. FIGURE 2. Procedural planning using the multiplanar and 3-dimensional reconstructions: Complete planning was done internally by the operators within the University Hospital of Split. FIGURE 3. Procedural execution and steps (A-F): All procedures were done without the proctors, after advanced international education. **Conclusion**: Transcaval TAVI is a viable alternative for patients with unsuitable iliofemoral anatomy. It can be achieved with favourable procedural outcomes, if preceded by meticulous preprocedural planning and performed by experienced operators.

Dario Dilber, Damir Avdagić, Ivan Rosović

**Introduction**: The current gold standard for physiological assessment of intermediate coronary stenosis is fractional flow reserve (FFR) (1). Despite its proven efficacy, FFR is clinically underused, so non-hyperemic instantaneous wave-free ratio (iFR) and non-invasive hyperemic stress cardiac magnetic resonance imaging (Stress CMR) are often used, despite their pitfalls. Angiography-based functional assessment of coronary stenoses is a novel approach to assess coronary physiology and data on quantitative flow ratio (QFR) are validated (1, 2). Vessel fractional flow reserve (vFFR) is computed using different fluid dynamics models (**Figure 1**) and studies on the diagnostic performance of vFFR are still warranted (3). The present study investigated the agreement between vFFR and FFR/iFR, and Stress CMR. FIGURE 1. Illustration of a vessel fractional flow reserve (vFFR) analysis. **Patients and Methods**: All-comers with intermediate coronary stenosis, excluding ST-elevation myocardial infarction patients, were assigned either to invasive coronary wire-based functional assessment (FFR, iFR or both) or to stress CMR. In cases when both FFR and iFR values were obtained in a single vessel, only FFR values were taken and compared to vFFR values accordingly. Coronary lesions involving ostium, left main artery or myocardial bridge were excluded. vFFR analysis was performed retrospectively based on aortic root pressure and two angiographic projections with exclusion of patients with no appropriate two angiographic projections or poor image quality. **Results**: Total of 94 patients with 102 intermediate lesions were included in the study. The mean age of patients was 65.3 ± 10,8 years, 71.4% were male, and 86.2% presented with the chronic coronary syndrome. The majority of physiology assessment was performed in the left anterior descending artery (56.9%). The value of the Pearson correlation coefficient indicates a very good and positive correlation of vFFR vs FFR (r = 0.7055, p < 0.001) (**Figure 2**) and vFFR and iFR (r = 0.7617, p < 0.001) (**Figure 3**), and a moderate and positive correlation of Stress CMR vs vFFR (r =0.5485, p< 0.001). FIGURE 2. Pearson correlation (r) of agreement of vessel fractional flow reserve (vFFR) versus fractional flow reserve (FFR). FIGURE 3. Pearson correlation (r) of agreement of vessel fractional flow reserve (vFFR) versus instantaneous flow reserve (iFR). **Conclusion**: Angiography-based vFFR has a substantial agreement with invasive wire-based hyperemic FFR and non-hyperemic iFR, and only moderate with Stress CMR in assessment of ischemia in patients with intermediate coronary stenosis.

Davor Radić, Eduard Margetić

**Introduction**: Acute occlusion of the left main coronary artery is a rare event but with high mortality (1). As the LMCA (left main coronary artery) is responsible for the blood supply of the whole left ventricular muscle and the anterior two-thirds of the interventricular septum and the whole septum if dominant, its sudden occlusion is a life-threatening condition causing malignant arrhythmias and cardiogenic shock (2). **Case report**: We present a 59-year-old patient who was admitted to the Coronary Care Unit because of non-ST-elevation myocardial infarction (NSTEMI). The patient had no prior medical history. The patient was initally hemodynamically stable and urgent coronary angiography was performed. RCA (right coronary artery) had moderate stenoses in the proximal and distal part and gave collaterals to the left system (**Figure 1**). Initial angiogram showed acute occlusion of the LMCA (**Figure 2**). After wire passage and extensive predilatations, it was evident that LMCA had a trifurcation-LAD (left anterior descending artery), RIM (ramus intermedius), and LCx (left circumflex artery). Additional protective wires were placed in LCx and RIM (**Figure 3**). During the procedure, the patient became hypotensive, so dobutamine and noradrenalin were administered in continuos infusion which stabilized the patient. We opted for a provisional approach and 3 drug-eluting stents (DES) (2.75/33 mm, 3.0/23 mm, and 3.5/38 mm) were placed from mid-LAD to ostial LMCA. Stents were post-dilated with NC (noncompliant) balloons 3.0/15 mm and 4.0/15 mm with a nice final result and TIMI (Thrombolysis in Myocardial Infarction) 3 flow in all 3 vessels (**Figure 4**). The patient was returned to the Coronary Care Unit in stable condition and the next day weaned of inotropes and vasopressors. During hospitalization, an echo showed mildly reduced ejection fraction (45%) of the left ventricle, without valvular disease or pulmonary hypertension. FIGURE 1. Right coronary artery with moderate stenoses in the proximal and distal part. FIGURE 2. Acute occlusion of the left main coronary artery. FIGURE 3. Left main coronary artery trifurcation. FIGURE 4. Final result after placement of 3 drug eluting stents. **Conclusion**: After a total of 7 days, the patient was discharged home from the hospital with dual antiplatelet therapy (aspirin and ticagrelor), statin, betablocker, ACE inhibitor, and mineralocorticoid receptor antagonist. The patient underwent another coronary angiography 19 months after the initial event. Coronary angiography showed patent stents in the LAD and LMCA and patent RIM and LCx (**Figure 5**). He now had significant stenosis of the distal RCA which was treated with an implantation of 1 DES. FIGURE 5. Repeat coronary angiography after 19 months.

Daniel Lovrić

Arterial hypertension is one of the leading causes of cardiovascular (CV) morbidity and mortality worldwide, with a significant proportion of patients failing to achieve target blood pressure (BP) values. The combination of valsartan and indapamide represents a modern therapeutic approach, combining the benefits of renin-angiotensin system inhibition with the antihypertensive effects of a thiazide-like diuretic that has a favorable metabolic profile. Valsartan is distinguished by its efficacy, tolerability, and beneficial effects on renal and CV function, while indapamide surpasses hydrochlorothiazide in BP control, left ventricular remodeling, and CV outcomes. The fixed combination of these drugs, particularly in a slow-release formulation and with the possibility of evening dosing, further enhances patient adherence and optimal hypertension management, thereby reducing overall CV risk. European hypertension treatment guidelines recommend such drug combinations due to their effectiveness and safety profile, enabling a personalized approach to hypertension management.

Irzal Hadžibegović, Ivana Jurin, Tomislav Čikara, Aleksandar Blivajs, Tomislav Šipić, Šime Manola

**Introduction**: Contemporary drug eluting stents (DES) are still mainstay of percutaneous coronary interventions (PCI). However, stentless PCI is evolving, also with coronary bioadaptors - new adaptable implants showing similar short-and mid-term results, and offering potentially even better long-term results compared to contemporary DES. (1) We present initial experience and the follow-up of our first cohort treated in 2024. **Methods and Results**: We analyzed PCI characteristics and outcomes of the first 17 patients treated with the coronary bioadaptor implant from January 2024 to January 2025, and compared it to patients treated with DES in the same period. Among 17 patients treated with bioadaptors, 11 (65%) were male with median age of 52 years. Only 2 (11%) patients had diabetes mellitus, and only 1 (7%) patient had previous PCI. Acute coronary syndrome was the indication for PCI in 8 (47%) patients, with 7 (41%) of patients treated for ST-elevation myocardial infarction (STEMI). All patients except one had left anterior descending artery (LAD) treated. Chronic total occlusion (CTO) was treated in 3 (17%) patients, with 1 (7%) patient having a highly calcified stenosis. Additional imaging (intravascular ultrasound or optical coherence tomography) was used in 3 (17%), whereas functional tests were used to guide PCI in 2 (12%) cases. All 18 bioadaptors were delivered successfully over workhorse wires, or extra-support wires only in case of CTOs. Median bioadaptor diameter was 3.5 mm, and median lesion length 28 mm. Median follow-up was 7 months, with no major adverse events recorded. In comparison to 676 patients who received DES during the same period, patients who received bioadaptors were significantly younger, more likely to be treated for STEMI or CTO in the LAD with larger diameter devices, and less likely to have diabetes mellitus, severe calcifications and previous PCI. They had longer event free survival, but no statistical analysis was performed because of the small sample and marked difference in age and clinical characteristics. **Conclusion:** First experience with coronary bioadaptors showed good short- and mid-term results among a small cohort of younger patients with mostly acute PCI in the LAD or PCI in CTO lesions. These results should be confirmed in a larger cohort of patients with longer follow-up, patients with diabetes mellitus, and patients with more complex and calcified lesions.

Sara Dolički, Zvonimir Ostojić, Hrvoje Laušić, Hrvoje Jurin, Denis Došen, Davor Radić, Luka Perčin, Tomislav Krčmar, Eduard Margetić, Kristina Marić Bešić, Boško Skorić, Joško Bulum

**Introduction**: Interventional cardiology transformed the treatment of coronary artery disease (CAD). The ongoing development of invasive imaging and functional diagnostic enhances the understanding of CAD and improves the outcomes of percutaneous coronary intervention (PCI). Likewise, new therapeutic options enable more patients to be treated. Although guidelines recognize these advancements, their application in practice is often lacking (1, 2). This study aimed to analyze the trends of invasive procedure and implementation of novel technologies over the past decade in a tertiary care centre. **Patients and Methods**: This single centre retrospective study included patients who underwent invasive procedure between 2015 and 2024. Data was collected from Cathlab database and analysed to identify trends in the utilization of invasive diagnostic modalities and types of interventions performed. **Results**: Results are presented in **Figure 1**. A continuous rise in coronarographies and decline in, primarily elective PCI has been observed. At the same time, there was also an observable increase in the use of coronary functional testing ((fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), coronary flow reserve (CFR)) and intracoronary imaging procedures ((optical coherence tomography (OCT), intravascular ultrasound (IVUS)). Likewise, the total number of complex PCIs, such as rotablation, and Impella/IVAC supported PCIs has been observed. Finally, increase in number of coronary flow reducer implantation has been observed. FIGURE 1. Trends in the various types of procedures, diagnostic techniques, and therapeutic methods throughout the study period. A) Total number of preformed coronary angiographies and percutaneous coronary interventions based on urgency; B) Number of complex interventions and coronary flow reducer; C) Number of coronary circulation functional testings preformed; D) Number of intracoronary imaging procedures. CFR - Coronary flow reserve; CTO – chronic total occlusion; FFR – fractional flow reserve; iFR - instantaneous wave-free ratio; IMR – index of microcirculatory resistance; IVUS – intravascular ultrasound; OCT - optical coherence tomography; PCI – percutaneous coronary intervention; RFR – resting full-cycle ratio. **Conclusion**: A steady increase in contemporary diagnostic and therapeutic methods is observed in our centre. These trends indicate a more selective and precise approach in the management of CAD as recommended by current guidlines (1, 2), which could potentially explain observed decline in elective PCI. Conversely, increase in rotablation and supported interventions may suggest that more complex patients are being accepted for PCI. Finally, the rise in coronary sinus flow reducer implantation indicates an unmet need for patients without revascularization options, including those with microvascular disease (1).

Tomislav Čikara, Ivana Jurin, Aleksandar Blivajs, Antonio Bulum, Šime Manola, Irzal Hadžibegović

**Introduction**: Coronary arteriovenous malformation (AVM) is a rare anomaly that consists of abnormal communication between the coronary artery and one of the cardiac chambers or major vessels adjacent to the heart. Approximately half of these patients are asymptomatic while some patients develop myocardial ischemia or infarction resulting from a “steal” phenomenon (1). **Case report**: We present a case of a 59-year-old female with a history of hypertension, diabetes and smoking that was referred for coronary angiography due to symptoms of chest discomfort and shortness of breath. Cardiac scintigraphy showed anterior myocardial ischemia. Her electrocardiogram and echocardiogram were unremarkable. Coronary angiography revealed an AVM ascending from the proximal part of anterior descending artery (LAD) with possible communication with the left atrium and pulmonary artery (**Figure 1**). Additional workup included computed tomography coronary angiography that revealed a tortuous septal branch of LAD passing along the left atrium into the pulmonary artery. During follow-up, despite antianginal therapy exertional angina still persisted, therefore transcatheter AVM closure was indicated. Coronary angiography guided with optical coherence tomography (OCT) was performed to verify the feeding septal branch. After successfully stopping the flow through the AVM using a 5.0x15.0 mm balloon (**Figure 2**), a 4.0x12 mm stent graft was deployed and postdilatated with 5.0x8 mm non-compliant balloon, successfully occluding the branch. Control angiogram revealed a second, smaller fistula distally of stent graft that was not suitable for intervention due to potential closure of a large diagonal branch of the LAD (**Figure 3**). Patient symptoms improved significantly post-procedure. Further myocardial ischemia tests using angiography and computed tomography are planned for follow up. FIGURE 1. Coronary angiography showing a coronary arteriovenous malformation of the left anterior descending artery. FIGURE 2. Occlusion of an arteriovenous malformation using the standard 5.0x15.0 mm balloon catheter. FIGURE 3. Control coronary angiogram after successful occlusion of the arteriovenous malformation “feeding” branch. **Conclusion**: When clinically indicated, transcatheter closure is an effective treatment for selected patients with smaller coronary AVMs. Detailed coronary imaging is necessary to optimally plan the procedure. Follow-up coronary imaging to assess for recanalization is recommended (2).

Krešimir Gabaldo, Domagoj Mišković, Katica Cvitkušić Lukenda, Ivica Dunđer, Ivan Bitunjac, Domagoj Vučić, Josip Silović, Marijana Knežević Praveček

**Introduction**: Patients with a history of coronary artery bypass grafting (CABG) are at high risk for recurrent ischemia due to graft failure or disease progression in native coronary arteries. Graft failure can be classified as early or late. Early graft failure is often asymptomatic, resulting from factors like poor native vessel run-off, competitive flow with the native coronary artery, or anastomotic technical issues. Late graft failure, on the other hand, results from the development of de novo atherosclerosis in the grafts over time. Percutaneous coronary intervention (PCI) has become the preferred treatment for recurrent ischemia in patients post-CABG. PCI of native coronary arteries should generally be prioritized if technically feasible, as it is associated with better long-term outcomes compared to PCI of grafts. However, the choice between treating native vessels versus bypass grafts remains a clinical challenge, given the complexity of the anatomy and the patient’s overall health status. (1-3) **Results**: We analyzed 128 post-CABG patients treated in institution between 2019 and 2024. Of these, 53 PCI procedures were performed on native coronary arteries (41%), while 9 procedures targeted saphenous vein grafts (SVG, 7%). In the group with PCI of native vessels, the failure rate was 17% (9/53), while the failure rate for PCI of SVGs was 11% (1/9). **Conclusion**: PCI remains a cornerstone of treatment for ischemia in post-CABG patients. While PCI of native vessels should generally be the preferred strategy, it carries a higher risk of failure, often due to complex coronary anatomy and patient comorbidities. PCI of SVGs, when performed with modern techniques and appropriate adjunctive therapies, offers a comparable success rate and lower failure rate, making it an important treatment option for patients with recurrent ischemia. The evolving use of newer stents, pharmacotherapy, and embolic protection strategies has further improved the outcomes in these challenging cases.

Josip Stjepanović, Damir Kozmar, Davor Richter, Ena Kurtić, Vedran Radonić, Andro Franković, Niko Grubišić Neidhardt, Tomislav Letilović

**Introduction**: Coronary artery disease (CAD) and aortic stenosis (AS) often require intervention. Coronary artery bypass grafting (CABG) is the standard revascularization method for CAD, whereas surgical aortic valve replacement (SAVR) is recommended for AS. However, percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) may be considered based on patient evaluation (1, 2). A multidisciplinary Heart Team determines the treatment most likely to yield optimal outcomes (3). This study aims to evaluate waiting times for cardiac surgery and assess patient outcomes post-intervention. **Patients and Methods**: We analyzed 324 patients referred to the Heart Team between January 2023 and November 2024, assessed waiting times for cardiac surgery and TAVI at University Hospital Centre Zagreb, documented cardiovascular risk factors pre coronary angiography, and conducted follow-up interviews to evaluate post-treatment outcomes. Data were analyzed using SPSS software. **Results**: Our analysis revealed a significant reduction in cardiac surgery waiting times, from 85 days in 2023 to 41 days in 2024 (51.8%, p=0.008). SAVR wait times decreased from 123 to 60 days (51.2%), and TAVI from 127 to 24 days (81.1%). Patients under 65 had 13.64% shorter waiting time for the procedure (57 vs. 66 days, p=0.037). CAD patients had 37.5% shorter wait times than those with isolated AS (55 vs. 88 days, p<0.001). Patients with reduced ejection fraction showed markedly higher rates of adverse outcomes post-surgery (p=0.001). **Conclusion**: This research highlights a substantial reduction in cardiac surgery waiting times in 2024. Further evaluation is required to accurately assess long-term outcomes and develop survival curves that clarify prognostic trajectories.

Andrija Matetić, Frane Runjić, Ivica Kristić, Darija Baković Kramarić

**Introduction**: Structural heart interventions rely on meticulous planning with multimodal imaging (1). Technological advancements now enable digital 3-dimensional (3D) reconstructions from CT, MRI, and echocardiography (1). The next level of preprocedural planning for complex structural heart interventions includes in silico 3D printed models (2, 3). **Methods and Results**: The utilization of 3-dimensional printing for structural heart interventions at the University Hospital of Split has allowed us to anticipate potential challenges and tailor our approach to each patient’s unique anatomy. Importantly, this methodology is exclusively designed for ex vivo planning purposes to simulate and plan complex structural heart interventions before the actual procedure (2, 3). The protocol includes advanced computation of the 3-dimensional digital reconstructions from different imaging modalities (computed tomography, magnetic resonance imaging, or echocardiography), followed by the model optimization and translation to appropriate digital files, as well as the final 3-dimensional printing. Based on the structural intervention, this protocol may include a priori integration of predefined therapeutic devices into the model (e.g. heart valves; clips; occluders; etc.), or a posteriori integration of these devices as a separate in silico model. Finally, the 3-dimensional models need to undergo post-processing phase to achieve its final form. This approach has facilitated planning for complex transcatheter aortic valve interventions (**Figure 1**), percutaneous paravalvular leak and intracardiac fistula closures (**Figure 2**), mitral valve interventions, and more. Aligned with existing literature, 3D printing optimizes workflow, improves procedural efficiency, and enhances communication within multidisciplinary teams by offering tangible, detailed visualizations of cardiac anatomy (2, 3). FIGURE 1. Exemplary 3-dimensional printed models for various structural heart interventions from the University Hospital of Split. FIGURE 2. A 3-dimensional printed model for the planning of a percutaneous closure of postoperative aorto-left atrial fistula. **Conclusions**: The integration of 3D printing with the planning of structural heart interventions at the University Hospital of Split has multiple favourable effects, overall improving the procedural efficiency. Given its well-documented benefits in experienced centres worldwide, broader adoption of this methodology is warranted.

Jerko Arambašić, Dražen Mlinarević, Iva Jurić, Ivana Lukić, Petra Zebić Mihić, Zorin Makarović, Damir Kirner

With the increasing number of older patients and those with multiple comorbidities, there is a growing need for complex and high risk percutaneous coronary interventions. The use of Impella, a percutaneously placed mechanical circulatory support device, offers temporary hemodynamic stabilization and has the potential to reduce peri-interventional complications and improve early survival in these patients. (1) We present a case of a 77-year-old male patient with coronary artery disease, ischemic cardiomyopathy with reduced ejection fraction, moderate aortic stenosis, diabetes, and a history of hemorrhagic stroke, who presented with acute non-ST-elevation myocardial infarction. Coronary angiography revealed multivessel disease, including significant stenosis of the left main coronary artery, left anterior descending artery (LAD), left circumflex artery, and moderate stenosis of the right coronary artery. Due to the increased surgical risk, high-risk percutaneous coronary intervention (HR-PCI) was performed on the LAD with Impella support, along with the placement of two drug-eluting stents. Postprocedural femoral bleeding and urosepsis were successfully managed. Follow-up echocardiography showed improved ejection fraction and reduced mitral regurgitation. This case highlights the successful use of HR-PCI with Impella support in a patient with severe coronary disease and multiple comorbidities. Despite complications, prompt intervention led to stabilization and recovery.

Kristijana Radić, Matija Vrbanić, Ivica Benko, Ljiljana Švađumović, Vlatka Funduk, Nikola Krajna, Filip Topolnjak, Darko Navoj

Over the past decade, we have witnessed significant advancements in invasive and interventional cardiology. In practice, interventional cardiology aims to overcome the limitations of two-dimensional imaging by incorporating functional diagnostics such as IVUS (intravascular ultrasound), FFR (fractional flow reserve), and OCT (optical coherence tomography). IVUS is a diagnostic test that uses sound waves to provide a clear depiction of the inner lumen of the coronary artery, allowing for the assessment of atherosclerotic plaques. FFR is a minimally invasive procedure that measures the ratio of maximum blood flow through a narrowing compared to normal maximum flow. FFR values between <0.75 and 0.8 are considered functionally significant. This technique is highly valuable for identifying clinically relevant lesions. OCT enables high-resolution imaging of the coronary arteries by utilizing a light beam that scatters, providing interventional cardiologists with ten times better resolution than IVUS technology. Minimally invasive techniques offer a more detailed insight into vascular structure and clearer results within precise mathematical representations. Consequently, they provide more accurate and precise data, enhancing patient management and treatment strategies. This approach ensures that treatment decisions for patients with ischemic heart disease are made based solely on objective parameters, supplementing the limitations of two-dimensional X-ray imaging, image quality (graininess), and the subjective interpretation of the operator (experience or inexperience), thus forming a more comprehensive evaluation. (1-3)

Karlo Gjuras, Kristina Marić Bešić

**Introduction**: Elderly patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are often not revascularized, which may contribute to lower survival rates. (1) **Patients and Methods**: This retrospective study analyzed consecutive NSTE-ACS patients aged ≥80 who were admitted to the University Hospital Centre Zagreb between November 2018 and October 2023. Statistical analysis was performed using data from medical records. The objective was to analyze treatment strategies (revascularization vs. non-revascularization) and clinical outcomes at 6-month follow-up: mortality, recurrent myocardial infarction (MI), and cerebrovascular incident (CVI). (2) **Results**: Of the 274 NSTE-ACS patients with a median age of 84, 42.3% were women, and 238 (86.9%) had a non-ST-elevation MI. Coronary angiography was performed in 199 (72.6%) patients. Revascularization was performed in 136 (49.6%) patients, and the majority underwent percutaneous coronary intervention, except for two patients who underwent surgery. Revascularized patients were younger (83 [81–85] vs. 84 [82–88], p < 0.001) than the non-revascularized, who, on the other hand, had a higher prevalence of aortic stenosis (AS) and a history of CVI, developed more frequent infections, and had a left ventricular ejection fraction of ≤40%. Female sex (OR = 0.52; 95% CI: 0.30–0.90; p = 0.020), moderate or severe AS (OR = 0.43; 95% CI: 0.20–0.90; p = 0.025), and anemia (OR = 0.41; 95% CI: 0.17–0.99; p = 0.048) were predictors negatively influencing the selection of revascularization as a treatment. During the 6-month follow-up, 56 (20.4%) patients died, with significantly lower mortality of revascularized patients (8.1% vs. 32.6%, p < 0.001; **Figure 1**). There were no significant differences between the groups in the incidence of recurrent MI (3.3%) or CVI (1.5%). Multivariable regression analysis identified revascularization (HR = 0.33; 95% CI: 0.16–0.69; p = 0.003) and the use of renin-angiotensin-aldosterone system blockers (HR = 0.34; 95% CI: 0.17–0.67; p = 0.002) to be positively associated with survival. Type 2 diabetes (HR = 2.11; 95% CI: 1.14–3.89; p = 0.017) was negatively associated with survival (**Figure 2**). FIGURE 1. Kaplan-Meier survival curve comparing revascularization and non-revascularization in elderly patients with non-ST-elevation acute coronary syndrome at the University Hospital Centre Zagreb. FIGURE 2. Multivariable Cox regression analysis of 6-month survival in elderly patients with non-ST-elevation acute coronary syndrome at the University Hospital Centre Zagreb. **Conclusion**: Older NSTE-ACS patients who received revascularization treatment had a statistically higher 6-month survival rate than those who were not revascularized.

Jelena Nikolić, Veronika Maksimov Brkljača, Sabina Škifić, Grga Marković

**Introduction**. Iatrogenic aortocoronary dissection (IACD) is a rare but potentially fatal complication of percutaneous coronary intervention (PCI) that requires a multidisciplinary approach for management. It occurs as a result of interventional procedures on coronary arteries, where damage to the artery’s intima layer takes place. In 85% of cases, IACD occurs during PCI of the right coronary artery (RCA). The causes of IACD can be triggered by mechanical trauma (catheter manipulation, guidewire, balloon, or stent), a sudden and excessive injection of contrast agent, and anatomical variations. (1-3) **Case report**. Coronary angiography was performed in a patient with unstable angina pectoris, revealing a significantly calcified stenosis in the middle segment of the RCA at the site of a previously implanted drug-eluting balloon (DEB). During the same procedure, PCI was performed with the implantation of two stents. The procedure was complicated by the inability to remove the guidewire, which became trapped at the distal edge of the implanted stent. After several attempts, the tip of the wire was successfully freed from the distal edge of the stent using a smaller balloon catheter. The next day, due to chest pain, a repeat coronary angiography and intravascular imaging with optical coherence tomography (OCT) of the implanted stents were performed. The guiding catheter used was the Amplatz (AL) 0.75. Significant malposition of the stents was verified, and optimization was carried out. The procedure was further complicated by dissection of the proximal segment of the artery, which extended into the aortic valve cusps. A stent was implanted at the origin of the RCA to close the entry point of the dissection. The stent was optimized with a non-compliant balloon (NC balloon), and optimal control angiography was achieved, showing no further contrast extravasation. Control MSCT aortography was performed day after, which showed no signs of dissection, rupture, or intramural hematoma. **Conclusion**. Iatrogenic aortocoronary dissection is a rare complication of PCI which is especially often during PCI of the right coronary artery. It is obvious from our case that proper manipulation of more „aggressive“ types of guiding catheters such as Amplatz is mandatory and prompt actions should be taken to prevent potentially fatal outcomes.