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Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Spontaneous pneumomediastinum (SPM) is an uncommon entity mainly affecting young adult males with a tall, thin body habitus which can be rarely complicated with spontaneus pneumopericardium (SPP)1,2. Case report: 22-year-old female patient was examined in the Emergency Department (ED) due to an acute onset of dyspnoea and severe pain in the left side of the neck, chest and left arm, notably when leaning forward. She denied trauma, physical exertion, coughing, aspiration of foreign body, drug abuse or emesis. On admission, she was afebrile and physical examination revealed symmetric, clear breath sounds and inaudible heart beats without murmur or Hamman’s sign. An arterial blood gas analysis revealed mild hypocapnia: pH 7.443, PaO2 13.09 kPa, PaCO2 4.34 kPa, and SaO2 97%. The complete blood analysis was within normal range apart from lactate dehydrogenase (LDH= 333 U/L). The 12-lead ECG showed sinus tachycardia with normal axis, intervals within the normal range and no sign of low voltage (Figure 1). A chest X-ray showed pneumomediastinum and pneumopericardium (Figure 2), and subsequent chest multi-slice computed tomography confirmed extensive pneumome diastinum with pneumopericardium up to 5 mm in thickness, no signs of pulmonary bullae, or any structural abnormalities in the bronchi or the oesophagus. Echocardiography was done using subxiphoid projection showing no pathology and no hemodynamic repercussions due to pneumopericardium. She was hospitalized and the therapy was absolute bed rest, peroral analgesia and nasal oxygen supply (4 L/min). During hospitalization she was hemodynamically stable and afebrile, therefore no antibiotics were prescribed. The follow-up chest X-ray done 7 days after, showed a complete resolution of SPM and SPP. Thus, she was discharged with a recommendation to avoid physical activity for the next 2 months. At 2-month follow-up visit she was symptom free, with no signs of SMP or SPP (Figure 3). Conclusion: SPM and SPP are benign diseases with low incidences in a young, otherwise healthy adults. When evaluating a young adult in the ED, who presents with chest pain and dyspnoea, it is important to include SPM and SPP in the differential diagnosis if there is reasonable clinical doubt, in order to establish an early diagnosis and avoid potential complications. [ABSTRACT FROM AUTHOR]

Background. Spontaneous recanalization of a chronically occluded artery is rare and reported anecdotally. Case Summary. We report a case of a patient with a chronically occluded right coronary artery, found on a coronary angiography performed due to acute ST elevation myocardial infarction with an occluded circumflex artery as a culprit lesion. Three months later, a follow-up angiography was performed and a recanalization of the occluded right coronary artery was detected. Discussion. There is a possibility that intrinsic fibrinolytic mechanisms with the additional effect of standard antithrombotic drugs administrated after the acute coronary event led to the recanalization. [ABSTRACT FROM AUTHOR]

The most common symptom of ischemic heart disease is angina pectoris. Ischemia with non-obstructive coronary artery disease (INOCA) is defined as presence of signs and symptoms of ischemia and coronary artery stenosis less than 50% on invasive coronary angiography. INOCA endotypes are microvascular angina (MVA), vasospastic angina (VSA) and mixed MVA and VSA. INOCA patients are more likely to be female aged 40 to 70 years. Smoking is a risk factor for vasospastic angina, while diabetes and hypertension are not1. The prognosis of patients with INOCA is not benign. Symptoms are often disabling, and patients have higher incidence of adverse cardiovascular events. Treatment of INOCA patients includes lifestyle modifications, management of common risk factors and antianginal medication. Acetylcholine is parasympathetic nervous system neurotransmitter. The ACh spasm provocation test has become a popular method for induction of coronary spasm. Due to rapid degradation by acetylcholinesterase ACh-provocation coronary spasm is short of duration. ACh is injected into coronary artery within 20 seconds with continuous monitoring of the ECG and patient’s symptoms. ENCORE study protocol proposes incremental doses of 2, 20, 100, and 200 micrograms of ACh manually infused into the left coronary artery (LCA). In patients who remain asymptomatic 80 micrograms of ACh is injected into the right coronary artery. Bradycardia and atrio-ventricular block are often during test, but short of duration and usually resolve spontaneously within few minutes2. Results are based on three criteria. Symptoms such as chest pain or shortness of breath. Second are ECG changes such as ST segment elevation, depression, or T wave changes and third criteria are focal or defuse epicardial diameter reduction of 90% or more. If only first two criteria are met than microvascular angina is diagnosed. Serious complications such as myocardial infarction or ventricular tachycardia/fibrillation are reported in 0.3-1% of cases3. In conclusion, INOCA patients are often under-diagnosed, under-treated and because of that have worse prognosis. ACh spasm provocation should be performed in patient with specific anginal symptoms, evidence of ischemia and non-obstructive coronary artery disease to guide optimal treatment and improve quality of life. [ABSTRACT FROM AUTHOR]

There is increased use of percutaneous mechanical circulatory support in patients with poor left-ventricular (LV) function undergoing elective high-risk percutaneous coronary interventions (HR-PCIs). Complex interventions often require long procedural times as well as special interventional skills and techniques such as rotational atherectomy or intravascular lithotripsy. Such interventions often carry the risk of hemodynamic deterioration especially in patients with reduced left-ventricular ejection fraction (LVEF). The use of percutaneous left-ventricular assist devices (p-LVADs) such as the Impella has the potential to minimize the risk of hemodynamic deterioration. However, the use of Impella may carry risks for the patient and requires experienced interventional cardiologists. Patient selection is an essential key feature to a safe and successful outcome.1-3 Although the use of p-LVAD is well established in HR-PCI, there is no clear guideline recommendation for indication due to limited published data. CHIP score is a useful tool that can be utilized to help risk stratify patients undergoing HR-PCI. Patient factors (age ≥80 years, female sex, previous stroke, previous myocardial infarction, peripheral vascular disease, ejection fraction <30%, and chronic renal disease) and procedural factors (rotational atherectomy, left main PCI, 3-vessel PCI, dual arterial access, left ventricular mechanical support and total lesion length 60 mm) were associated with increased in-hospital major adverse cardiac and cerebrovascular events. These factors should be considered when determining the indication for support. The indication for HR-PCI and protected PCI should be made jointly by the heart team and risk scores should be used to guide discussion. Furthermore, it is suggested that protected PCI/HR-PCI procedures only be performed in specialized centers. Selection of appropriate patients is particularly important given potential p-LVAD-associated complications. In the absence of significant evidence-based knowledge, the multidisciplinary team, patient features, clinical conditions, and the respective experience of all team members play a major role in the decision-making regarding the use of protected PCI. [ABSTRACT FROM AUTHOR]

Access sites for coronary intervention have been changing over the last several decades. Distal radial access, is still not recommended by the guidelines, shows a higher success rate and less complications than other sites. Several complications have been associated with the TRA, such as radial artery occlusion (RAO), radial artery spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, bleeding, nerve damage, and complex regional pain syndrome.1-3 Recently, a new approach was proposed to overcome these limitations and also to give the advantage over the transfemoral approach; this was a “distal transradial approach (dTRA) (snuffbox approach)”. dTRA technique seems to have more advantages. First, the arm position during the intervention is comfortable for the patient. No equipment or investments are necessary to support the patients left arm. The operator can work as usual from the right side of the patient and does not need to bend over the patient to reach for the left radial artery. Second, there is low rate of DRA obstruction since antegrade flow through the superficial palmar arch is still maintained. Other advantages include early hemostasis, low risk for hematoma formation, low level of pain perceived by patients, reduced risk of compartment syndrome, saving the radial artery for possible future coronary artery bypass graft, and the ability of the operator to work at a safe distance from the radiation source. The disadvantages of dTRA are that they are technically more demanding and time-consuming. The radiation time was more. The snuffbox radial artery is smaller in diameter than the radial artery, and there is a higher risk of puncture-mediated vasospasm than TRA. Lastly, the short length of a typical radial catheter is a significant drawback to the snuffbox technique. Distal radial access is a new site for cardiovascular interventions, and it has several advantages over the old access sites. The main advantages are less arterial obstruction and short hemostasis. The main disadvantage is the difficulty in cannulation. However, more studies, especially randomized studies, and meta-analyses, are needed to be a guideline in the future. [ABSTRACT FROM AUTHOR]

Until recently, right ventricular apical electrode placement was predominantly used during bradycardia pacing management. Decades of clinical practice have taught us that a high burden of pacing in right apical position can deteriorate left ventricle function leading to increased mortality and morbidity. In the last few years, our daily clinical practice has fundamentally changed after the introduction of so-called conduction system pacing (His-bundle pacing and left bundle branch pacing area). The idea that the natural pacing of the heart prevents the aforementioned undesirable effects of ‘’classical’’ way of pacing, while maintaining the effectiveness, has led to a revolution in the treatment of such patients. The growing evidence indicate that conduction system pacing has the potential to become preferred pacing mode in various clinical indications, including the treatment of dyssynchrony in setting of heart failure.¹ We will present the results of our single center experience regarding conduction system pacing. [ABSTRACT FROM AUTHOR]

Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Diet rich in lipids and hyperlipidaemia increases incidence of atrial premature beats and all supraventricular arrhythmias. The aim of the study was to investigate the prevalence of hyperlipidaemia in patients with AV re-entry tachycardia (AVRT) and AV nodal re-entry tachycardia (AVNRT). We conducted a retrospective, cross-sectional, case-control study that included all consecutive patients for whom AVRT or AVNRT was confirmed during electrophysiology study. Age and gender-matched patients admitted to hospital or outpatient clinic for various reasons were randomly included and served as a control group. Hyperlipidaemia was defined according to 2016 European Society of Cardiology guidelines. A total of 1448 subjects were included: 725 patients with AVRT/AVNRT and 723 controls. AVRT/AVNRT patients had high hyperlipidaemia prevalence, which was significantly higher when compared to the control group (50.1 vs. 35.8%, p < 0.001). AVRT patients, with median age of 37.5 years, had hyperlipidaemia prevalence of 45.7%. In a multivariate analysis, hyperlipidaemia was independently associated with AVRT/AVNRT (OR 2.128, p < 0.001), both with AVNRT (OR 1.878, p < 0.001) and AVRT (OR 2.786, p < 0.001). Hypercholesterolemia was significantly more prevalent in patients with AVNRT and AVRT, while this was not the case for hypertriglyceridemia. There were no differences between the AVRT and AVNRT patients regarding hyperlipidaemia prevalence (51.9 vs. 45.7%, p = 0.801), even though AVRT patients were significantly younger (37.5 vs. 48.5, p < 0.001). In conclusion, this is the first study that investigated hyperlipidaemia prevalence in patients with AVRT or AVNRT. AVRT/AVNRT patients had higher prevalence of hyperlipidaemia and higher total and LDL cholesterol levels. [ABSTRACT FROM AUTHOR]

Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)