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Introduction. Kounis syndrome is a simultaneous manifestation of acute coronary syndrome and conditions associated with mast cell activation, such as allergies or anaphylactic reactions. We present early stent thrombosis in a female with an atopic constitution without previous atherosclerosis of coronary arteries. Case report. A 50-year-old woman with typical anginal pain was admitted to the Clinic for Cardiology, University Clinical Center Niš. A few hours earlier, she had passed by a linden tree in bloom. She immediately felt chest pain, paresthesia and numbness in her left arm throat tightness, heaviness of the tongue, and swelling of the lips. The symptoms disappeared for 60 min after taking 10mg of loratadine, but then they recurred. On the electrocardiographic (ECG) findings, 30 minutes after admission, ST elevation was seen in leads D2, D3, aVF, and V6. She underwent an emergency percutaneous coronary intervention procedure. Occlusive thrombosis was seen in the ostium of the left anterior descending (LAD) coronary artery. A sirolimus-coated stent was placed and thrombolysis in myocardial infarction (TIMI) 3 flow was obtained. A few hours after the intervention, the patient reported a new onset of chest pain followed by ventricular fibrillation (VF), DC shock, and the occurrence of new ST-segment elevation in aVR and V1–V3 on the ECG. Repeated angiography showed acute instent thrombotic occlusion. Balloon angioplasty was performed, which restored TIMI 3 flow in LAD coronary artery. Anticoagulant and corticosteroid therapy was administered. Three days after the intervention, optical coherence tomography imaging was performed, which showed good stent expansion and apposition, without atherosclerosis and thrombosis. Conclusion. Coronary angiography proved type I Kounis syndrome after exposure to an allergen, and type III Kounis syndrome developed shortly after stent placement when acute instent thrombosis occurred. Newly described causes of acute and sub-acute stent thrombosis in type III Kounis syndrome are stent-associated hypersensitivity reactions.

Introduction. Protocols and guidelines have been improving results of our clinical practice. Sometimes there have been differences between guidelines on the same topic, but they have not been so important usually. As far as the start of vitamin K antagonists (VKA) in a non-high risk pulmonary thromboembolism (PTE) patients is concerned, there is global consensus (reflected in all comprehensive guidelines) that it should be on the admission day or a day later. However, there are situations in which this VKA administering from the first (or second) day of hospitalization may actually complicate the treatment. Case report. As an illustration, our female, 71 years old patient with second unprovoked, intermediate-high risk PTE was given low-molecular-weight heparin (LMWH) + VKA from the second day. Due to lack of improvement in symptoms, oxygen saturation and D dimer after 9 days, computed tomography pulmonary angiography (CTPA) was repeated and it confirmed minimal advancement. The patient already had achieved target international normalized ratio (INR) and it complicated proceeding to fibrinolytic therapy. Conclusion. Correction of the therapeutic approach in the PTE treatment may be needed even if the treatment is completely conducted according to the latest guidelines. We recommend postponing VKA from the first (or second) day of hospitalization (as suggested in all available guidelines for non-high risk PTE patients) until satisfying clinical improvement is reached.

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Bacgraund/Aim. Sudden cardiac death (SCD) is one of the biggest problems of the contemporary medicine. Large studies showed that anti-arrhythmics, including amiodarone, are not effective in prevention of SCD in the patients with cardiac diseases who were on drug treatment. Those patients who received implantable cardioverter defibrillators (ICD) had better survival. The aim of this paper was to determine whether the patients receiving the ICD in the primary and secondary SCD prevention have longer survival than the patients treated exclusively with drug therapy. Methods. We included 1,260 patients with cardiac insufficiency and reduced left ventricular ejection fraction (LVEF < 35%) who were at high risk for malignant ventricular arrhythmias and SCD. Five hundred forty patients received ICD therapy. The cardiac resynchronization therapy – CRT/ICD group (n = 270) comprised the patients with cardiac insufficiency and CRT/ICD pacemaker at an optimal medical therapy. In the control group (n = 450), there were the patients with cardiac insufficiency (NYHA functional class 3–4, LVEF ≤ 35%, QRS duration ≥ 130 ms), at optimum drug therapy. Results. In the ICD group, there was a statistically significant increase in end-systolic volume (ESV) from 92.68 mL to 99.05 mL. In the group of patients with cardiac insufficiency who were on drug therapy, there was a significant decrease in LVEF (33.15% vs. 30.2%; p = 0.017), 6-minute walk distance (6 MWT distance) (216.55 m vs. 203.27 m, p = 0.003). In the same group, there was an increase in the values of ESV (90.19 mL vs. 95.41 mL; p = 0.011). An increase in the mortality rate in the group of patients with drug therapy compared to the CRT/ICD and ICD groups was statistically significant (p < 0.05). Conclusions. An ICD pacemaker implantation significantly reduces mortality compared to medical therapy only. In addition, the patients who have CRT in addition to ICD pacemaker, have a significantly better quality of life and increase in LVEF.

Background/Aim. Coronary artery anomalies are an uncommon but important cause of chest pain, and in some cases of hemodynamically significant abnormalities, sudden cardiac death. The aim of the research was to establish the prevalence of the coronary arteries anomalies in our population. Methods. The study group included 1,562 patients (810 men, 752 women, average age 64.3 ± 12.0 years; range 32–80 years) who were scheduled for 64-slice computed tomography (MSCT), which enables detailed visualization of coronary arteries and heart anatomy. All examinations were made due to suspicion (atypical chest pain, angina equivalent symptoms or multiple risk factors for cardiovascular disease) or assumption of progression of coronary artery disease. Results. From January 2010 till December 2014 a total number of 1,562 patients were sent for evaluation of coronary arteries. The coronary anomalies were found in 45 (2.88%) patients. The most frequent coronary anomaly seen in our population group was absence of left main trunk with the separate origin of the left anterior descending artery (LAD) and left circumflex artery (LCx) originating from a left coronary sinus (LCS). This was found in 12 patients (an incidence of 0.77% or 26.7% of all coronary anomalies). Anomalous location of coronary ostium outside normal aortic sinuses in our study was present as right coronary artery (RCA) that arises from left anterior sinus in 5 (0.32%) patients and left coronary artery from non-coronary sinus in two (0.13%) patients. Conclusion. Knowledge of anomalies of the coronary arteries and their recognition on the multislice computed tomography is of great importance for the further planning of a possible therapeutic treatment. Coronary anomalies that are considered insignificant will require no further therapeutic treatment. But the detection of malignant coronary anomalies will certainly save many lives.

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Background. A prolonged coronary artery spasm with interruption of coronary blood flow can lead to myocardial necrosis and increase of cardiospecific enzymes and can be complicated with cardiac rhythm disturbances, syncopc, or even sudden cardiac death. Case report. A 55-year old male felt a severe retrosternal pain when exposing himself to cold weather. The pain lasted for 20 minutes and was followed by the loss of conscience. Electrocardiogram (ECG) showed a complete antrioventricular (AV) block with nodal rhythm and marked elevation of ST segment in inferior leads. Electrocardiogram was soon normalized, but serum activities of cardiospecific enzymes were increased. Coronarography showed normal findings for the left coronary artery and a narrowing at the middle part of the right coronary artery, which disappeared after intracoronary application of nitroglycerine. The following therapy was prescribed: Diltiazem, Amlodipin, Isosorbid mononitrate, Molisdomin, Atrovastatin, Aspirin and Nitroglycerine spray. After 7 months medicaments were abandoned and the patient experienced again reccurent chest pain episodes at rest. Transitory ST segment elevation was recorded in inferior leads of ECG, but without increase of cardiospecific enzymes serum activities. After restoration of the medicament therapy anginal episodes ceased. Conclusion. Coronary dilators in maximal doses can prevent attacks of vasospastic angina.

Introduction. Entrapment and fracture of diagnostic or therapeutic devices within the coronary circulatory system are a rare, but increasing problem. Case report. A 70-yearold man was admitted in our clinic for coronary angiography before the planned aortic valve replacement. An arterial sheath was inserted in the right common femoral artery. After introducing a J-tip diagnostic coronary guidewire into the aorta and advancing a left Judkins diagnostic catheter over it, suddenly occured peeling off of the wire´s hydrophilic coating at the aortic arch level. Very soon, this outer coating of guidewire carried by the blood stream was entered into the left femoral artery, then into the left popliteal artery. This stripped part of guidewire was successfully caught and extracted out by using a goose-neck snare catheter. Conclusion. A sudden stripping of outer coating of a J-tip diagnostic hydrophilic coronary guidewire during coronary angiography is possible to manage quickly and successfully by the use of a simple cathether.

Background. Ebstein's anomaly is characterized by a displacement of the tricuspid valve toward apex, because of anomalous attachment of the tricuspid leaflets. There are type B of Wolff-Parkinson-White (WPW) syndrome and paroxysmal arrhythmias in more than a half of all patients. Case report. We presented a female, 32-year old, with frequent paroxysms of atrial fibrillation. After conversion of rhythm an ECG showed WPW syndrome. Echocardiographic examination discovered normal size of the left cardiac chambers with paradoxical ventricular septal motion. The right ventricle was very small because of its atrialization. The origin of the tricuspid valve was 20 mm closer to apex of the right ventricle than the origin of the mitral valve. Electrophysiological examination showed a posterolateral right accesorial pathway. Atrial fibrillation was induced very easily in electrophysiological laboratory and a successful ablation of accessorial pathway was made. There were no WPW syndrome and paroxysms of atrial fibrillation after that. Conclusion. Ebstein's anomaly is one of the reasons of paroxysmal atrial fibrillation, especially in young persons with WPW syndrome.

Background. Primary malignant cardiac tumors are rare entities and rhabdomyosarcoma accounts 20% of these lesions. Case report. We presented a female patient with loss of appetite and loss of weight. She also had symptoms of heart failure and bilateral pleural effusions. A mobile tumor in the left heart with the entrance from the left atrium to left ventricle during diastole was seen by transthoracic echocardiography. The tumor was extirpated in total, histologic diagnosis was rhabdomyosarcoma, and the patient died after 6 months. Conclusion. Primary malignant cardiac tumors can simulate heart failure or systemic disorders. Cardiac rhabdomyosarcomas have a poor prognosis with the average survival of 6 months after the occurrence of symptoms and making a diagnosis. In cardiac insufficiency, differential diagnostics should be used to consider cardiac tumors that could be with certainty confirmed or excluded by echocardiography.

Background/Aim. The inhibition of factor Xa (FX) by the use of low-molecular heparin (LMH) is important clinical procedure in patients with moderate and high risk for the developament of venous thromboembolism (VTE) and pulmonary embolism (PE). The aim of this study was to determine the level of inhibition of FXa by the use of prophylactic doses of LMH nadroparin-calcium and reviparine-sodium which were applied in urological patients with moderate risk for VTE and PE. Methods. The examination included 80 urological patients divided into 4 groups after urological, uroradiological and anesthesiological preoperative preparation and categorization of anesthesiological risk according to the ASA III classification. The first two groups, of 20 patients each, received the recommended doses of LMH in accordance with the preoperative risk, and an inhibition of FXa 48 hours after the surgical operation and four hours after the administration of LMH was determined. Heptest and homogenous anti-Xa test were used for monitoring of FXa inhibition. Since the obtained anti-Xa values were not satisfactory, two more groups were formed and given double the recommended doses. In these new groups, inhibition of FXa was in recommended range. Standard descriptive statistical parameters were used for describing the charateristics of the people from the formed groups. Results. All the patients examined were clinically estimated as patients of moderate risk, for VTE and PE. There were no statistically singificant difference in body weight of the patients who received nadroparin-calcium 0.3 ml and reviparine-sodium 0.25 ml and those who received their double doses, respectively. The level of FXa inhibition in the group in which the dose of nadroparin-calcium of 0.6 ml was applied was statistically significantly higher than in the group which received the dose of 0.3 ml (Mann-Whitney U test: Z = 5.416; p < 0.0001). The level of FXa in the group given reviparine-sodium 0.5 ml was significantly higher than in the group which received the half of this dose (Mann-Whitney U test: Z = 5.416; p < 0.0001). This research did not confirm a statistically significant difference in the levels of FXa inhibition in patients who received nadroparincalcium as VTE and PE prophilaxis in the dose of 0.6 ml and those who received reviparin-sodium 0.5 ml (in two doses of 0.25 ml) (Mann-Whitney U test: Z = 0.163; p > 0.05). Conclusion. According to biochemical monitoring, the recommended doses of LMH are insufficient for the prophylactic inhibition of FXa in urological pateints with moderate risk for VTE and PE, so the higher doses which inhibit FXa are recommended. .

Background. Fabry Disease is a rare, X-chromosomal inherited lysosomal storage disease with a consequent intracellular accumulation of neutral glycosphingolipids in various tissues. This can cause skin and ocular lessions, progressive renal, cardiac or cerebrovascular disorders. If a person in a family has Fabry disease, other family members including even extended relatives, may also be at risk. Case report. We presented three cases pointed out various manifestation of Fabry disease, that illustrate a possible cause for otherwise unexplained cardiac hypertrophy and various rhythm and conduction abnormalities. Conclusion. Although most symptoms begin in childhood, various manifestations often lead to misdiagnosis and clinical diagnosis is frequently delayed for many years, even decades. Enzyme replacement therapy has become available, pointing out the importance of early diagnosis so that treatment can be initiated before irreversible organ damage.