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Aim : To investigate changes of anticoagulation therapy in patients with atrial fibrillation (AF) and high thrombotic risk.Methods : We retrospectively analyzed 1061 patients with non- valvular AF and indication for anticoagulation therapy referred in a period from 2013 to 2018 and followed-up for a median time of 38 months.Results : Therapy change occurred in 206 (19.5%) patients (195 switches and 11 permanent discontinuations). Only 37% of patients on warfarin had optimal dosing and their duration of therapy was significantly shorter compared to direct oral anticoagulants (DOACs ; (adjusted HR 1.21, 95% CI 1.09-1.37). Therapy change occurred in only 33% of patients with poorly controlled warfarin, and in only 24% of patients that experienced a thrombotic event while taking warfarin. Optimal dosing was an independent factor for any therapy change during follow-up, irrespective of type of anticoagulant drug at baseline. DOAC swapping occurred in 39% of all DOAC to DOAC switches, with one bleeding event and no thrombotic events documented after a DOAC swap.Conclusion : High risk patients with AF rarely discontinue anticoagulation therapy. The need for therapy change should be emphasized in patients with non-optimal dosing, and in patients that experience thrombotic events while taking warfarin. more...

Purpose To validate red cell distribution width (RDW) as an improvement in 30-day mortality risk stratification based on the Pulmonary Embolism Severity Index (PESI) in acute pulmonary embolism (PE). Patients and Methods Prospective observational analysis of consecutive adult acute PE patients. Results Among 731 patients, 30-day mortality was 11.9%. With adjustment for the PESI score and number of covariates, higher RDW was associated with higher mortality (RDW continuous: OR 1.21, 95% CI 1.06– 1.38 ; Bayesian OR 1.22, 1.07–1.40 ; RDW ‘high’ [>14.5% in men >16.1% in women] vs normal: OR 3.83, 1.98–7.46 ; Bayesian OR 3.98, 2.04–7.68]. Crude mortality was 3.6% if PESI 86–105 (intermediate risk), but 1.2% if RDW normal and 7.1% if RDW high ; 11.8% if PESI 106–125 (high risk), but 3.6% if RDW normal and 18.8% if RDW high. Adjusted probabilities showed higher mortality (ORs between 3.5–5.8) if RDW was high in any PESI risk subgroup. Crude mortality rates in two random-split subsets (n=365 and n=366) again showed the same patterns. Conclusions On-admission RDW above the normal range improves 30-day mortality risk stratification based on PESI score in acute PE. Particularly, it corrects PESI- based intermediate-risk or high-risk allocation by reclassification into very low-risk (11.0%). more...

Background: Pulmonary embolism (PE) severity index (PESI) well predicts 30-day mortality in acute PE patients, yet improvements have been advocated. ----- Objectives: To evaluate predictivity of the red cell distribution width (RDW) through a comparison with PESI and to explore their interaction as a potential improvement in this respect. ----- Methods: Retrospective analysis of consecutive adult PE patients. ----- Results: Of the 299 patients, 19 severely unstable died within 48 h. Among the stabilized patients, 30-day mortality was 12.1% (34/280). With PESI ≤125, mortality was 4.9% (9/185), but it was 0.7% (1/140) if RDW ≤15.0% and 17.8% (8/45) if RDW >15.0%; with PESI >125, mortality was 26.3% (25/95), but it was 15.9% (7/44) if RDW ≤15.0% and 35.3% (18/51) if RDW >15.0%. Adjusted relative risk with PESI >125 vs. ≤125 was 17.5 (95%CI 2.37-129) at RDW ≤15.0% and 1.60 (0.76-3.36) at RDW >15.0%. ----- Conclusions: Thirty-day mortality predictions based on the PESI score may be improved by accounting for RDW. more...

Cardiologists are familiar with valvular heart diseases but often they do not perceive heart valves as source of ventricular arrhythmias (VA). In patients with structural heart disease (SHD) VAs originate from a substrate in diseased myocardium, while in patients without SHD most common origins are outflow tracts (OT)1 . Premature ventricular complexes (PVC) from OT are either from subvalvular, valvular or supravalvular myocardium as there are myocardial extensions above the semilunar valves, these VAs are created predominantly by mechanism of triggered activity or enhanced automaticity1, 2. Papillary muscles, mitral and tricuspid anulus, aortomitral continuity and other sites in a structurally normal heart can also be the origin VAs. There are general and specific ECG characteristics that can localize the origin of VAs: bundle branch block type, axis, QRS polarity in lead V6, QRS duration, precordial transition, maximal deflection index, and so forth, therefore mapping of the PVC starts in the region that is presumed by ECG characteristic3. While different anti-arrhythmic drugs (AAD) aim at different mechanisms ; calcium channel blocker can suppress triggered activity and beta-clocker can suppress automaticity, in general ablation is more effective in clinically meaningful reduction of PVCs compared to AAD (up to 95% vs. up to 25%)4. Ablations are generally safe but complication rates of catheter ablation in aortic root are not negligible and include myocardial rupture and tamponade, stroke, valvular damage, and coronary artery occlusion ; these complications can be lowered by usage of intracardiac ultrasound (ICE)1, 4. When mapping arrhythmias from the valves, we should stop perceiving the heart structures or valves as isolated parts and acknowledge that regional anatomy of these structures is among the most complex of those encountered by cardiac electrophysiologists, e.g., aortic valve is directly related with both atria, the interatrial septum, the right ventricular outflow tract and pulmonary valve, and the aortomitral continuity. Ablation is highly effective in suppression of PVCs, it has low numbers of complications, but ablation in aortic region brings serious complications to the table, therefore shared decision making with the patient and usage of ICE is of upmost importance. more...

Introduction: Transthoracic echocardiography (TTE) is recommended as the standard of care in evaluation of cardiovascular (CV) disease in liver (LT) and kidney (KT) transplant candidates.1,2 Guidelines for preoperative CV assessment are oriented at the immediate perioperative period and non-ischemic CV processes that would predict poor outcomes after LT and KT are defined less clearly. Aim: to establish whether ≥moderate mitral (MR), tricuspid regurgitation (TR) or ≥mild aortic stenosis (AS) on pretransplant TTE are associated with mortality, graft survival or major CV adverse events (MACE) in the late postoperative period (>30 days). Patients and Methods: Patients were stratified into cohorts based on the presence of ≥moderate MR, TR and ≥mild AS. Exclusion criteria was loss to follow up, incomplete TTE findings and death within 30 days of transplantation. MACE were defined as stroke, myocardial infarction (MI) or heart failure. Patient survival was defined as time from transplantation to death or last follow-up and graft survival as time from transplantation to last follow-up, death, graft dysfunction or re-transplantation. Outcomes of interest were compared between cohorts via logistic or Cox regression. Results: 306 LT (median age 59, IQR 53-64) and 196 KT patients were included (median age 52, IQR 40- 61). Median follow up was 36 months for LT (range 14.3 – 55.9), 40,5 months for KT (range 18-64.9). MACE occurred in 4.25% LT and 4.59% KT recipients. Upon univariate analysis AS was associated with MACE in KT recipients but crossed the significance level after adjusting for common confounders (age, sex, hypertension, diabetes, smoking). 11.76% LT and 9.69% KT recipients died. The most common cause of death was sepsis. MR was found to be associated with LT patient survival, but the association was lost after adjusting for age. In an age adjusted model MR was found to be associated with KT patient survival (HR 2.97, 95% CI 1.06-8.26, P=0.037). Graft survival was not associated with any potential predictors. Conclusion: Associating TTE findings with adverse outcomes after LT and KT might help distinguish patients who would benefit from closer management in the late postoperative period. Moderate or more severe MR was found to be associated with late mortality in KT recipients, however the significance of this is yet to be determined in larger sample studies. more...

Introduction: Implantation of implantable cardioverter defibrillator (ICD) as a primary prevention (PP) is indicated in patients with dilated cardiomyopathy (DCM) with a reduced ejection fraction as well as a life expectancy longer than a year. Implantation of ICD as a secondary prevention (SP) is indicated after cardiac arrest and in patients with symptomatic ventricular tachycardia. Results of a Danish register did not show mortality to decrease in patients with non-ischaemic cardiomyopathy (NCM).1, 2 The goal of our research is to analyze results from University Hospital “Merkur”. Results and Conclusion: From 2012 up to 2017 a total of 89 ICDs were implanted due to DCM, 69 for PP and 20 for SP. Data was collected retrospectively and analyzed. The average age of our patients was 62.9 years, 13 out of 89 were women. The average follow up lasted 32 months. 69 patients were treated due to PP, 36 with ischemic cardiomyopathy (ICM) vs 33 with NCM. Death occurred in 9 patients (7 with ICM vs 2 with NCM), 7 died due to heart failure (HF) and 2 due to noncardiovascular cause (in NCM group). Sudden cardiac death (SCD) was prevented in 12 patients (7 ICM vs 5 NCM). There were 30 appropriate ICD therapy deliveries, significantly more in the group of patients with ICM (23 vs 7 ; p < 0.05). In patients younger then 59 (29 patients) ICD therapy was delivered in 3 patients, and in a group of older patients (40 patients) ICD therapy was delivered in 9 patients. 15 patients with ICM and 5 with NCM were treated due to SP. Death occurred in 5 patients (3 ICM vs 2 NCM), all due to HF. In 4 patients SCD was prevented (3 ICM vs 1 NCM). There were 8 appropriate ICD therapy deliveries (7 ICM vs 1 NCM). 16 patients were older then 59, and all patients in which SCD was prevented, were older then 59. In both groups there were 51 patient with ICM and 38 with NCM. Death occurred in 14 patients (5 ICM and 9 NCM). SCD was prevented in 16 patients (10 ICM vs 6 NCM). In total there were 38 appropriate ICD therapy deliveries (30 ICM and 8 NCM, p more...

Introduction: Lidocaine is an essential drug used as a local anesthetic and as antiarrhythmic medication of the class Ib type. There are multiple reports in literature that lidocaine can cause coronary artery spasm both in vitro and in vivo1, 2. Elevation of the ST-segment is described during dental or neurosurgical procedures using locoregional lidocaine anesthesia2, 3. We present a case in which intra-articular lidocaine instillation caused a vasospastic ST-segment elevation myocardial infarction (STEMI). Case: A 49-year-old male patient presented to the emergency clinic with chest pain that had begun an hour ago. The pain occurred at rest, was independent of exertion and radiated to the left arm. Previously that morning, he was at the surgical outpatient clinic due to a chronic knee condition where he underwent punction and intra-articular instillation of 100mg lidocaine. The chest pain started 30 minutes after the procedure. The patient had never experienced chest pain or intolerance of exertion before. Previous medical history was notable for well-controlled arterial hypertension, without any family history of coronary artery disease. He previously received lidocaine anesthesia without complications and had no known allergies. There was 1mm elevation in leads II, III, aVF and inferior STEMI was diagnosed (Figure 1). The patient was transferred to the catheterization laboratory for primary percutaneous coronary intervention. The coronary arteriography was without any evidence of Bojana Gardijan*, Matija Marković, Darko Počanić, Tomislav Letilović University Hospital Merkur, Zagreb, Croatia KEYWORDS: ST-segment elevation myocardial infarction, lidocaine, vasospasm. CITATION: Cardiol Croat. 2016 ; 11(3-4):97-98. | DOI: http://dx.doi.org/10.15836/ccar2016.97 *ADDRESS FOR CORRESPONDENCE: Bojana Gardijan, Klinička bolnica Merkur, Zajčeva 19, HR-10000 Zagreb, Croatia. / Phone: +385-98-1650-393 / E-mail: bojana.gardijan@gmail.com ORCID: Bojana Gardijan, http://orcid.org/0000- 0002-1768-2277 • Matija Marković, http://orcid.org/0000-0002-2852-3730 Darko Počanić, http://orcid.org/0000-0003-3257- 110X • Tomislav Letilović, http://orcid.org/0000- 0003-1229-7983 A case of ST-segment elevation myocardial infarction due to intra-articular lidocaine instillation Extended Abstract ACUTE CORONARY SYNDROME RECEIVED: February 9, 2016 ACCEPTED: February 20, 2016 FIGURE 1. The 12-lead electrocardiogram recording on admission showing discrete ST-segment elevation in inferior leads. Cardiologia Croatica 2016 ; 11(3-4):98. VII. nacionalni sastanak o kardiovaskularnim intervencijama s međunarodnim sudjelovanjem VI. sastanak intervencijskih kardioloških medicinskih sestara i tehničara stenosis (Figure 2). The patient received protocol STEMI care. Echocardiography showed no abnormalities or regional wall motion abnormalities. The initial high-sensitivity cardiac-specific troponin I was beneath the value of detection, with the peak value on the second day of stay, 4678.3 ng/L (reference value more...

1Such different mechanisms could, at least in part, be explained by different demographic characteristics of ISR and non-ISR patients. They could also lead to different approaches to percutaneous coronary interventions (PCI) in those two groups. Patients and Methods: We conducted this retrospective analysis, of our interventional data, in order to find such differences. In years 2014 and 2015 there were 657 elective PCI procedures (41 ISR and 616 non ISR interventions) in our institution. Results: We found no significant differences in major demographic characteristics in ISR vs. non-ISR patients (Table 1). Analysis of procedural characteristics (Table 2) showed that we were probably more aggressive with predilatation in ISR (number of balloons used 1.53±0.59 vs. 1.34±0.77; p=0.03). We were less keen to implant a stent in ISR patients (21.9% vs. 82.3%; p more...

ygomicosis is a fungal disease caused by fungi from the Zygomycota order that are usually airborne spread, with pulmonary and rhinocerebral involvement being the most common. Once in the bloodstream, spores tend to accumulate in vascular tissues leading to thrombosis, infarction, and necrosis of involved tissues. In immunocompromised patients, such as those with hemophagocytic syndrome, zygomicosis is frequently characterized by fulminant disseminated disease, with a 80% mortality rate. We present a 45-year old patient with hemophagocytic syndrome who was treated with steroids, etoposide, and cyclosporine. Two months after the initial treatment, the patient was admitted for a respiratory infection, and was treated with antibiotics and antiviral drugs with a good clinical and laboratory response to the therapy. On the tenth day there was a sudden clinical deterioration with signs of left-sided heart failure, elevated troponin levels, and ECG showing a complete AV block. Right-sided hemiparesis and elevated inflammatory parameters were also present. A temporary pacemaker was placed. A brain MDCT was performed and multiple ischemic and hemorrhagic lesions were found. Emergency echocardiography study showed a semi-mobile, peduncular mass in the left ventricle. It originated from the anterior mitral leaflet, measuring 4x2 cm and protruding to the LV cavity. There were no disorders of myocardial contractility, and ejection fraction was 60% (Figure 1). Echocardiographic features of the mass resembled a myxoma. The patient died three hours later from multiple organ dysfunc- tion syndrome. Autopsy showed disseminated zygomicosis infecting the heart with a mycotic mass in left ventricle. The leptomeninges, brain, and lungs were also infected. Primary heart tumors are rare, accounting for 0.0017-0.19% on unselected biopsies. In immunocompromised patients with a new heart mass, a mycotic mass as a sign of disseminated mycosis should be considered before a primary heart tumor in order to start appropriate treatment. Mortality of patients with disseminated zygomycosis and heart mass is very high and survival is only possible with a combined surgical and antimicrobial approach. The diagnosis of disseminated zygomycosis was considered however due to the patient’s abrupt clinical deterioration, and fulminant course cardiothoracic treatment could not to be arranged. more...

©© ) are specifically designed to enable stent deliv ery. 1 The purpose of this report is to present our initial experiences with those devices. Methods and Results: Guide extension devices are available in our catheterization laboratory since June 2015. Until January 2016 we used them in 7 percutaneous coronary interventions (2 left anterior descending, 4 right coronary artery and 1 circumflex artery intervention). According to the ACC/ AHA classification 5 (71%) of lesions were designated as type C lesion by the operator. In total 6 (85%) interventions resulted in procedural success. Guide extension related interventions were done with 1.50±1.74 balloons and 1.8±1.09 stents on average. Mean fluoroscopy time was 23.90±5.82 minutes and average mean contrast use was 231.40±57.67 milliliters. No device related complications were noted. Interestingly we also used, as a support device, Guideliner © during one CRT implantation. Conclusion: Our initial experiences with guide extension devices show that they can enhance procedural success rate in complex coronary interventions. We observed no device related complications in our small group of patients. Those devices could also have a certain role in non-coronary interventions as well. more...

Cardiologia CROATICA Objectives: Pulmonary embolism after elective coronary angiography is a very rare complication. Herein we report on a case of pulmonary embolism after diagnostic coronary angiography with femoral approach, and we also evaluate various pathophysiologic mechanisms possibly contributing to local vascular complications and also consequently safer and more efficient approaches for percutaneous coronary procedures. Case report: A 66 year-old female patient was admitted to our department for diagnostic coronary angiography due to high clinical suspicion for coronary artery disease. Coronary angiography was performed with the right common femoral artery access, and no coronary artery stenosis was verified on the examination. Although all the standard postangiography procedures were applied and hemostasis completed, subsequently an access site hematoma and a pseudoaneurysm developed. The day after the procedure, during verticalization, the patient complained of malaise, nausea and vertigo, and due to a high level of D-dimers, we performed MSCT angiography which confirmed pulmonary embolism (Figure 1). The doppler ultrasound of the lower extremity veins showed no signs of deep venous thrombosis, and we have not discovered any predisposing factors for pulmonary embolism. Discussion: Pulmonary embolism is rarely reported as a consequence of coronary angiography with femoral approach, probably since it is underdiagnosed considering its frequent asymptomatic course. Predisposing factors for deep venous thrombosis and pulmonary embolism with the femoral approach for coronary angiography are manual compression of the puncture site with unintentional compression of the femoral vein, compression with the sandbag and a gauze, puncture site hematoma or a femoral artery pseudoaneurysm, along with prolonged immobilization and bed rest. Conclusion: We assume that the cause of pulmonary embolism in our patient was transient deep venous thrombosis due to a combination of puncture area compression, hematoma and a femoral pseudoaneurysm with immobilization and postprocedural bed rest. Optimal placement of the arterial sheath, use of smaller sheaths, careful manual compression with shorter period of immobilization and bed rest, can significantly contribute to reducing the incidence of deep venous thrombosis and pulmonary embolism. more...

Cardiologia CROATICA 80-year old female patient, presenting with unstable angina, was transferred to our hospital from the regional hospital. Coronary angiography revealed separate ostia of the left anterior descending artery (LAD) and the circumflex artery (Cx). Borderline stenosis of the ostium of the LAD with tight stenosis of its middle segment as well as distal tortuosity was observed. Cx and right coronary artery (RCA) were without significant lesions. We decided to proceed with an ad hoc percutaneous coronary intervention in the middle segment of the LAD. During advancement of the guidewire (Terumo Runtrough NS Intermediate) dissection, in the region of the lesion, developed with a complete lumen closure. Patient became hypotensive with ST-segment elevation. Subsequent attempts to cross the dissection resulted in multiple disengagements of the guiding catheter (XB LAD, 6Fr) together with its prolapse to the proximal Cx. Eventually this resulted in the dissection with a partial lumen obstruction of the proximal part of the Cx. Because of it, the proximal part of Cx was directly stented and the guiding catheter was exchanged (JL 4,0, 6Fr). After that, we were able to cross the dissection of the LAD with a support of an OTW balloon (Terumo Ryujin Plus) and a hydrophilic guidewire with a tapered tip (Asahi Fielder XT). Appropriate positioning of the OTW balloon in the true lumen was confirmed by the injection of the contrast through its lumen. Through the OTW balloon, whose extraction was found rather difficult using the 6 Fr system, standard guidewire (Terumo Runtrough NS Floppy) was introduced. After multiple balloon dilatations stent was successfully deployed in the middle segment of the LAD. Postprocedurally a rise in cardiac enzymes was observed, without electrocardiographic changes or angina. At follow-up, patient is well without any chest pain during daily activities. more...