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Introduction: Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disorder characterized by the thickening of the myocardial walls of the heart.1 It can lead to structural and functional abnormalities of the heart and is a common cause of sudden cardiac death. Treatment for HCM typically includes medications, lifestyle modifications, and sometimes surgical interventions, including Transcoronary Ablation of Septal Hypertrophy (TASH). This case report presents a patient who underwent a TASH procedure to manage symptoms of the HCM. Case report: A man born in 1983, without previous known heart pathology, working as a chief engineer in a shipyard in South Korea presented himself in November 2019 due to occasional palpitations, discomfort in the chest, and presyncope during exertion. The family history indicated that the patient’s father had undergone heart valve surgery. Patient previously underwent cardiological examination - echocardiogram showed thickening of the proximal interventricular septum with a gradient in the left ventricular outflow tract of 45 mmHg. MSCT coronary angiography ruled out significant atherosclerotic changes in the coronary arteries but revealed deep bridging in the left anterior descending artery. The patient was recommended medication treatment (bisoprolol 2.5 mg) and advised to undergo further testing including echocardiogram. In February 2020, the patient developed severe symptomatic presyncope and syncope, and the diagnosis of hypertrophic cardiomyopathy was made. The patient underwent a TASH procedure in Bad Neustadt. The pre-procedural gradient at rest was 100 mmHg (up to 200 mmHg post-VES/Valsalva). Patient reported significant improvement in symptoms and could now tolerate moderate physical exertion. Follow-up examinations showed no significant changes or abnormalities. The patient is to this day without anginal symptoms, feeling well, and tolerating moderate physical activity. Conclusion: This case report demonstrates the successful use of TASH in managing symptoms of HCM in a patient who presented with palpitations and presyncope. While the procedure can be invasive, it may provide significant symptom relief for patients with HCM who do not respond to other forms of treatment. Regular follow-up examinations are essential for monitoring the patient’s condition and ensuring optimal long-term outcomes. [ABSTRACT FROM AUTHOR]

Clinically significant paravalvular leak (PVL) after prosthetic valve implantation is a rare, but potentially serious complication. Repeat surgery is associated with significant risks and may fail, because the original cause of leak is not always amenable to correction. Percutaneous PVL closure has been introduced as an important alternative with documented good immediate and late results. We present a case of PVL closure in a young patient using the Amplatzer Vascular plug III device, guided by periprocedural transesophageal echocardiography. Immediate success and mid-term result could be documented. In view of the significant number of prosthetic valve implantations in Croatia, an increase in the need for this type of intervention can be expected each year. [ABSTRACT FROM AUTHOR]

The article explores the overall incidence of valvular heart diseases in Croatia, as well as its comorbidity with other heart pathologies. Information on factors that influenced changes in the occurrence of acquired heart valve diseases is provided. The most common valvular pathology in the country is aortic stenosis (AS). Intrahospital complications association with transcatheter aortic valve implantation are liver failure, tamponade and sepsis.

The article discusses the most important parameters that describe the state of rhythmologic procedures in Croatia. An overview of the total number of the most frequent, typical rhythmologic procedures in the country in 2010 is provided. Data showed that the trend of performance in the year of the entire procedure by cardiologists continued. One of the drawbacks shown in the report is the low incidence of implantation of cardioverter-defibrillator.

A trial fibrillation (AF) is the most common arrhythmia in clinical practice. The prevalence significantly increases with age, amounting to up to 1-2% in general population. Catheter ablation of AF implies ablative procedures mostly confined to the left atrium (LA) with the goal of rhythm control. The best results (rhythm control up to 90% after at least one year) can be expected in younger patients (<65 years), with no advanced structural heart disease (including hypertension), no significant LA dilatation, shorter history of repeating paroxysmal symptomatic AF. In good candidates, the procedure typically involves pulmonary vein ostia isolation, acting on the dominant pathophysiologic trigger mechanism, which is usually located in this area. In patients with longer disease history, persistent or permanent AF, large LA, advanced structural heart disease and older age, the dominant pathophysiological role is assigned to the substrate change (LA disease), so the results are less impressive (successful rhythm control in 50-60% of cases). Here, the procedure may be extended to the whole LA (partially imitating the classic surgical procedure of the so-called maze operation, i.e. compartmentalization of the LA). Modern cardiology inevitably uses computerized technology in all segments of diagnostics and therapy. As stated in the introduction, it is clear that we need help of this technology during the process of planning, performing and follow-up after AF catheter ablation. Besides in diagnostics of paroxysmal AF (24-hour ECG Holter, transtelephonic ECG), computerized tomography and/or nuclear magnetic imaging also may help. Both procedures are used for obtaining a three-dimensional image of the LA itself and the adjacent pulmonary veins. It is these structures that are the main target of the ablation procedure, as they are at the same time subject to large anatomical variations, thus making a precise imaging a major help in planning of the procedure. Today, the procedure is typically performed using a computerized 3D-navigation system. This is a highly sophisticated technology which is based on the ability of the computer to recognize the distal part of the ablation catheter (but also other catheters in the area) within an electromagnetic field generated by a part of the device which is placed under the patient's thorax. Moving the catheter then generated a 3D image of the atrium (which, in an ideal case, almost exactly corresponds with the CT or NMR findings). After LA and proximal PV segments reconstruction, we continue with the therapeutic part of the procedure, whereby punctual lesions are created by means of radiofrequency energy in the LA area just before the PV ostia. Connecting the dots finally creates lines, which then electrically isolate the veins from the rest of the LA, thereby achieving the therapeutic goal, i.e. suppressing the AF attacks. During this process, the computer controls the therapy itself, as it optimizes the action of the RF energy, using another trick -- cooling the tip of the catheter with saline. Follow up after AF catheter ablation is not always simple. The clinical picture may often not be enough, as the patient does not necessarily perceive every repeated AF attack. Since the possibility of further AF episodes after the ablation may well be of significance, because of the possible need for anticoagulation therapy in later course, confident ECG information might be of essential importance. Sometimes, a simple 24-hour ECG recording may not be enough, since it may miss the arrhythmia if it occurs on a less frequent basis. Therefore, sometimes additional tools such as continuous loop recorders, periodical transtelephonic monitoring and (if the patient for some other reason already has a pacemaker) modern diagnostic algorhythms and possibilities of the pacemaker are used. [ABSTRACT FROM AUTHOR]

Atrijska fibrilacija (AF) najčešća je aritmija u kliničkoj praksi. Prevalencija se značajno povećava s dobi, a u ukupnoj populaciji kreće se između 1-2%. Kateterska ablacija AF odnosi se na ablacijske postupke uglavnom u lijevom atriju (LA) s ciljem kontrole ritma. Najbolji rezultati (kontrola ritma tijekom najmanje godine dana i do 90%) mogu se očekivati kod mlađih bolesnika (<65 godina), bez uznapredovale strukturne bolesti srca (uključujući arterijsku hipertenziju), ne bitno dilatiranim LA, kraćom anamnezom recidivirajuće paroksizmalne značajno simptomatične AF. Kod dobrih kandidata postupak se odnosi u prvom redu na izolaciju ušća plućnih vena, čime se djeluje na dominirajući patofiziološki mehanizam okidača koji su ovdje anatomski locirani. Kod bolesnika s duljom anamnezom, permanentnom ili perzistentnom AF, velikim LA, uznapredovanom strukturnom bolešću srca i starije životne dobi patofiziološki dominantnu ulogu igra promjena supstrata (bolest LA), pa su rezultati očekivano lošiji (uspješna kontrola ritma u 50-60% slučajeva). Postupak se ovdje mora proširiti na čitav LA (dijelom imitirajući klasični kirurški postupak tzv. maze operacije, tj. stvaranja odjeljaka u LA). Moderna kardiologija neizostavno koristi kompjutorsku tehnologiju u svim segmentima dijagnostike i terapije. Iz uvoda je razvidno da nam pomoć kompjutorizirane tehnologije procesu planiranja, izvedbe i praćenja nakon kateterske ablacije AF treba na više razina. Osim u dijagnostici paroksizmalne AF (24-satni Holter, transtelefonski elektrokardiogram), u planiranju zahvata može pomoći kompjutorizirana tomografija i/ili nuklearna magnetska rezonancija. Obje pretrage u prvom redu služe za konstruiranje trodimenzionalne slike samog LA i plućnih vena. Ove su strukture glavni cilj ablativnog postupka i istovremeno su podložne vrlo značajnim anatomskim varijacijama te je stoga precizan prikaz od velike pomoći u planiranju postupka. Sam se zahvat danas tipično izvodi uz pomoć kompjutoriziranog sustava za tzv. 3D navigaciju. Radi se o vrlo sofisticiranoj tehnologiji koja se temelji na mogućnosti da računalo prepoznaje vrh ablacijskog katetera (ali i ostalih katetera u srcu) u elektromagnetskom polju koje generira dio uređaja koji se postavlja ispod grudnog koša pacijenta. Potom se pokretima katetera "slika" 3D rekonstrukcija atrija (koja se u idealnom slučaju s vrlo velikom točnošću poklapa s nalazima CT ili NMR snimke). Nakon rekonstrukcije LA i početnih segmenata plućnih vena, pristupa se terapijskom dijelu zahvata, pri čemu se radiofrekventnom (RF) energijom stvaraju točkaste lezije u području LA neposredno ispred ušća plućnih vena. Spajanje točkastih lezija u konačnici stvara "linije" koje imaju za cilj električki izolirati plućne vene od ostatka LA, čime se postiže terapijski cilj, tj. suzbijaju napadaji AF. Pri tome računalo nadgleda i samu terapiju u smislu optimalnog djelovanja RF energije u miokardu i okolnog tkiva, koristeći pri tome još jedan trik -- hlađenje vrha katetera fiziološkom otopinom. Praćenje nakon kateterske ablacije AF nije uvijek jednostavno. Naime, klinička slika često može biti nedostatna, tj. bolesnik sam ne mora nužno osjetiti svaki eventualni ponovni napadaj fibrilacije. Budući da eventualna daljnja nazočnost povremenih fibrilacija može biti značajna zbog kliničke odluke o potrebi za antikoagulantnom terapijom u kasnijem tijeku, od velike je važnosti pouzdano bilježenje elektrokardiograma. Ponekad ovdje nije dovoljan kontrolni 24-satni Holter, budući da može propustiti aritmiju, ukoliko se ona javlja rjeđe. Stoga se u nekim slučajevima upotrebljavaju i kontinuirani snimači otkucaja, periodičko transtelefonsko praćenje te (ukoliko bolesnik već od ranije zbog drugog razloga ima elektrostimulator) moderni dijagnostički algoritmi i mogućnosti u samom elektrostimulatoru. [ABSTRACT FROM AUTHOR]

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In demanding modern times with population aging, low natality, delayed start of the work, and extension of working lifetime, the working activity in cardiovascular diseases has become a very important issue. Modern guidelines have shortened period of return to work after acute myocardial infarction (AMI) to 1-3 months (50 days-median in the most countries) while some authors, especially in USA, consider that return to full normal activities, including work, at 2 weeks after AMI appears to be safe in low-risk patients (pts). Inadequate health policy and delayed cardiac rehabilitation after AMI may lead to prolonged hospitalization and sick leave, as well as quality of life lowering, regardless of optimal treatment in acute phase of disease. Hospital readmission in 6 months and mortality in 5 years could be expected in 50% of heart failure (HF) pts. Many studies revealed the positive effect of exercise training on risk of death in those pts. Left ventricular ejection fraction (LVEF) is one of the most important factors that determine the working ability in HF pts: LVEF 40-49% enables moderate workload, 30-39% low workload, 20-29% only sedentary works, and <20% no works. The USA Social Security regulations approve for disability pts after ECG proven arrhythmias caused with irreversible conditions and followed with syncope or presyncope despite the recommended treatment on at least three different occasions in 12 consecutive months. Individual evaluation of permanent vs. transient working inability depending of type of arrhythmia or working place, symptoms and basic disease should be emphasized. Working ability recovery after cardiac surgery is determined with recovery of different organs and organic systems: skeletal (up to 6 weeks), respiratory (1-30 days), visceral (up to 7 days), neurological (1 day-permanent) and heart (depending on a type of work and individual pts. characteristics, on the average 48 weeks). Different activities should be restarted gradually. Suggested non-driving period after cardiovascular events or procedures is different for private and commercial vehicles. After AMI for a private one the non-driving period is 2 and for a commercial vehicle the non-driving period is 4 weeks, after percutaneous coronary interventions 2 days and 4 weeks, and after aorto-coronary by-pass surgery it is 4 weeks and 3 months respectively. After cardiac arrest 6 months of nondriving period is recommended for the both groups of drivers, while ICDs, unlike pace-makers, are not applicable in commercial vehicle drivers. [ABSTRACT FROM AUTHOR]

Partial anomalous pulmonary venous connection (PAPVC) is a rare congenital cardiac anomaly in which a few of the pulmonary veins connect to the right atrium or its tributaries instead of the left atrium. The PAPVC to the superior vena cava (SVC) occurs in about 10% to 15% of all patients with atrial septal defect (ASD). Approximately 10% have a secundum ASD associated with this anomaly. We report a 54-year old female patient with an acute inferior myocardial infarction with ST segment elevation (STEMI). After cardiac catheterization and echocardiography we found significantly elevated pulmonary artery pressure, secundum ASD and high suspicion of Eisenmenger's syndrome. According to multislice computed tomography (MSCT) and magnetic resonance imaging (MRI), it was diagnosed an PAPVC connected through persistent left superior vena cava into the innominate vein and right atrium, associated with secundum ASD. Invasive measurements also confirmed partial anomalous pulmonary venous connection to the PLSVC, that drains to right atrium, and of lower oxygen saturation between the atria at the secundum defect, providing oxygenated blood to the left atrium only from the right atrium. The development of complications depends on how many pulmonary veins return to the right atrium. The special feature of the clinical presentation and hemodynamic characteristics of 54 year old female patient with PAPVC suffered myocardial infarction and reversal of shunt. Due to confirmation that pulmonary hypertension was vasodilator responsive, excluding the Eisenmenger's syndrome patient was referred to cardiac surgery in experienced center to evaluate possibilities for total surgical repair of the TAVC, especially outweighing the risk and benefits. [ABSTRACT FROM AUTHOR]

Background: The aim of this report is to present 7 years results in percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) in Magdalena hospital, and to assess the safety and efficacy of this procedure. Methods: From April 2007 to March 2013, we performed transcatheter ASD and PFO closure in 58 consecutive symptomatic patients (pts). There were 34 percutaneous closures of ASDs and 24 percutaneous closure of PFOs. Indication for ASD closure was significant left-to-right shunt associated with RV overload and mild to moderate pulmonary artery hypertension. Diameter of ASDs were in range from 12 to 28 mm (average diameter 17 mm). For all pts. we used Occlutech Figulla ® Flex ASD and PFO Closure Device (I and II generation) sized from 15 to 30 mm. Closure of PFO was clinically indicated for secondary prevention in pts. with previous cryptogenic cerebrovascular events due to presumed paradoxical embolism. Pre-procedurally thromboembolic events were: 19 ischemic strokes (79%), and 5 transient ischemic attacks (20.8%). All procedures were performed with conscious sedation anesthesia under fluoroscopic and transesophageal echo-cardiography (TEE) guidance. Aspirin and clopidogrel were recommended at least for for 20 weeks after procedure for all patients. Results: Primary success of percutaneous closure was achived in all patients. The in-hospital complications were: self-limited supraventricular arrhythmia in 2 pts (3.4%); paroxismal atrial fibrillation in 1 pts (1.7%); minimal groin hematoma in 1 pts (1.7%). Control TEE pefomed after 20 weeks revealed mild residual shunt due to the lack of complite epitelisation of ocluder in 3 pts (5.1%), and aspirin and clopidogrel were recommended for another 20 weeks. No device malfunction, erosion, valvular regurgitation or thrombus formation were occurred so far. [ABSTRACT FROM AUTHOR]

Introduction: Restenosis in drug-eluting stents (DES) is still a problem, although more recent generations of drug-eluting stents significantly reduce the restenosis rate. The optimal strategy for treating restenosis in DES is still not clear. Objective: Discussion on different treatment strategies for restenosis in DES. Patient: A case report presenting a patient with repeated restenosis after stent implantation. The patient is a 62-year old male with hypertension and dyslipidaemia presenting with stable angina in 2005. He was treated for RCA stenosis with the bare-metal stent (BMS) implantation. In 2006. balloon angioplasty was performed due to focal in-stent restenosis. Few months later sirolimus-eluting stent was implanted for repeated in-stent restenosis. During follow-up the patient was without chest pain or evidence of ischemia until 2011 when restenosis in DES was found and was treated with balloon angioplasty. Few months later the same lesion was treated with paclitaxel-eluting stent implantation. In 2012 the patient presented with unstable angina and was treated with another SES for the same lesion (ISR). Method: Different strategies on treating DES restenosis will be discussed based on the literature review. Implantation of another DES has proven to be more effective than balloon angioplasty. There is no clear evidence that one type of DES is superior to another. Different patophysiology of DES restenosis is possible. Drug-eluting balloons have shown noinferiority to second DES implantation strategy. Conclusion: This case report presents what we know from the clinical practice. DES restenosis is rare but significant problem in percutaneous coronary interventions and the best treatment strategy is yet to be established. [ABSTRACT FROM AUTHOR]

67-year old female patient with previous history of hypertension, hyperlipoproteinemia and coronary artery disease was admitted to our hospital for recoronarography. 6 months ago she had a PCI procedure on the right coronary artery (RCA) and the ACx. PCI on the RCA was performed successfully with two BM stent. During the procedure on the LCA the guiding catheter made a dissection of the LMCA and the ascending aorta producing a crescent-shaped shadow. The dissection was successfully solved percutaneously, with implantation of multiple BM stents in LAD, avoiding the surgical intervention at that moment. The crescent-shaped shadow in ascending aorta disappeared as well. Systolic function was preserved. She is presenting now with dyspnea and stable angina, and the angio is to be done for reevaluation of the disease. On the recoronarography, the finding was the diffuse in-stent restenosis in LAD with good collaterals from the RCA. The stents implanted in the RCA were good, and the ACx was patent, with a stenosis. An ischemic cardiomiopathy has developed, with EF of 30%. Clinical question was whether there was a viable myocardium in LAD perfusion territory demanding secondary revascularization. In order to find viable myocardium, its amount and localization, the stress MRI was performed. Viability study showed that the biggest amount of viable myocardium was in LAD perfusion territory, making reasonable the secondary revascularization. Two possibilities were confronting - bypass grafting or reintervention with DE stents. The decision was made and successful reintervention with DE stents was performed during hospitalization. Before discharge, stress test was negative (96%), and on the control, three months later, echo showed improved EF LV of 45%, and stress test was negative as well (110%). The necessity for secondary revascularization is our every day problem. There are many issues that have to be taken in consideration when deciding of secondary revascularization. This case showed the proposed strategy for solving some dilemmas and finding the best solution. [ABSTRACT FROM AUTHOR]

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare with an overall incidence of 0.02%. We report four cases of aortic dissection during coronary angioplasty with a disparate evolution that was due to the different location of the entry port of the dissection. Three cases of iatrogenic coronary dissection with extensive propagation into the ascending aorta during angioplasty of the right coronary artery are presented. The aortic dissection was successfully treated by stenting at the right coronary artery ostium. Follow-up computed tomography and coronary angiography showed complete resolution of aortic dissection. One case of coronary dissection of LAD/LMCA with propagation into the ascending aorta required surgical intervention. This case also has angiographic and computed tomography follow-up. We conclude that most of localized aortic dissections can be treated by sealing the entry point with a coronary stent. However, more extensive dissections may require a surgical intervention. [ABSTRACT FROM AUTHOR]