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Left ventricular pseudoaneurysm (LVP) is a rare and life-threatening complication that is most often reported after myocardial infarction or cardiac surgery but can also occur after bacterial endocarditis, chest trauma, or myocardial tumor invasion. The LVP develops when a zone of free wall cardiac rupture is contained by the pericardium or scar tissue without myocardial tissue involvement while fatal rupture can be prevented by urgent surgical aneurysmectomy. Patients with LVP treated with surgery have a mortality rate of 23% while those treated medically die in 48% of cases. To the best of our knowledge, LVP as a late complication of Takotsubo syndrome (TS) has not been described in literature while Jaguszewski et al. reported on ventricular rupture as an early complication of TS thus confirming that this entity might not always have a benign course

INTRODUCTION: Proximal venous approaches (femoral or jugular) for catheter-directed thrombolysis (CDT) of acute pulmonary embolism (PE) dominate in clinical practice. AIM: We investigated the feasibility and safety of CDT in acute PE by using the superficial cubital venous approach. MATERIALS AND METHODS: All patients with acute PE received intravenous unfractionated heparin plus CDT. CDT included mechanical thrombus fragmentation and the local application of adjuvant thrombolytic therapy through the pigtail catheter – alteplase administered as 2.5 mg bolus in each main branch of the pulmonary artery plus adjuvant 25 mg for 12 h in the more severely affected branch of the pulmonary artery. Results: Twenty-seven consecutive patients presenting with acute massive (high risk) PE (n = 10) or submassive (intermediate risk) PE (n = 17) were enrolled in the study. The mean age of the enrolled cohort was 60.6 (14.1) years and most patients were female (n = 14, 52%). The procedural success of CDT application through the cubital vein was achieved in all patients. After the procedure, the systolic pulmonary artery pressure decreased from 61.4 (18.3) to 35.8 (12.3) mm Hg (p < 0.001) while the mean pulmonary artery pressure decreased from 35.7 (10.8) to 21.1 (6.5) mm Hg (p < 0.001). Similarly, the mean arterial pressure increased from 81.9 (12.8) to 89.0 (10.3) mm Hg (p = 0.031). Miller angiographic obstruction score and Miller index decreased significantly after the CDT intervention (p < 0.001). There were no deaths, major bleeding events, or hemorrhagic strokes. CONCLUSIONS: CDT by using the cubital approach is a simple, safe, and feasible treatment option for PE. This approach was associated with significant improvement in hemodynamic parameters without fatal outcomes or major periprocedural complications.

Coronary artery perforation (CAP) is a potentially severe complication of percutaneous coronary intervention (PCI) with an incidence of 0.71% and is managed conservatively in 73.3% of the cases, followed by the use of covered stents (24%), deployment of coils (0.7%), and fat embolization in 2% of cases [1]. Most large vessel perforations occur due to balloon or stent overinflation while distal vessel perforations are usually caused by the guidewire exit [2]. Furthermore, large vessel perforations are dominantly treated with covered stent implantation while distal and collateral perforations are typically amenable with coils or fat embolization with both methods having inherent advantages and disadvantages [3–5]. CAP is associated with substantial mortality and morbidity as nearly 50% of patients require pericardiocentesis for tamponade and up to 13% require emergency cardiac surgery for tamponade treatment [1]. Prompt recognition of CAP and immediate intervention during coronary angiography can significantly minimize the adverse consequences.

The aim of the study was to evaluate the influence of door-to-balloon time and symptom onset-to- balloon time on the prognosis of patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in the Croatian Primary PCI Network. A total of 1190 acute STEMI patients treated with primary PCI were prospectively investigated in eight centers across Croatia (677 non-transferred, 513 transferred). All patients were divided according to door-to-balloon time in three subgroups (< 90, 90-180, and > 180 minutes) and according to symptom onset-to-balloon time in three subgroups ( 360 minutes). The postprocedural Thrombolysis in Myocardial Infarction flow, in-hospital mortality, and major adverse cardiovascular events (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in six-month follow-up were compared between the subgroups. The Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable with randomized studies and registries abroad. None of the result differences among the door-to-balloon time subgroups was statistically significant. Considering the symptom onset-to-balloon time subgroups, a statistically significant difference at multivariate level was highest for in-hospital mortality in the subgroup of patients with longest onset-to-balloon time (4.5 vs. 2.6 vs. 5.7% ; p = 0.04). Door-to-balloon time is one of the metrics of organization quality of primary PCI network and targets for quality improvement, but without an impact on early and six-month follow-up results of treatment for acute STEMI. Symptom onset-to- balloon time is more accurate for this purpose ; unfortunately, reduction of the symptom onset-to- balloon time is more complex than reduction of the former.

Cilj je istraživanja istražiti izvedivost programa PCI u bolnici bez kardiokirurške potpore, i usporediti naše rezultate sa smjernicama i skupinom konzervativno liječenih bolesnika u razdoblju prije uvođenja primarne perkutane koronarne intervencije (pPCI). Podatci o svim bolesnicima s akutnim infarktom miokarda sa ST elevacijom (STEMI) liječenim pPCI prospektivno su bilježeni. Od početka programa pPCI od siječnja 2005. do listopada 2007. godine kada je u našoj ustanovi započeo s radom Odjel kardiokirurgije liječeno je 366 bolesnika. Unutarbolnička smrtnost iznosila je 6, 3%, u usporedbi s 15% (87/583) u skupini konzervativno liječenih bolesnika u trogodišnjem razdoblju prije uvođenja pPCI. Prosječno vrijeme od početka boli do postavljanja balona iznosilo je 315 minuta, vrijeme od boli do prvoga medicinskog kontakta 102 minute, vrijeme od prvoga medicinskog kontakta do vrata bolnice 94 minute, vrijeme od vrata bolnice do laboratorija 84 minute, vrijeme od laboratorija do otvaranja krvne žile 45 minuta, a vrijeme od vrata do postavljanja balona 129 minuta.Analiza rezultata pokazuje da je uvođenje programa primarne PCI u bolnici bez kardiokirurške potpore u regiji sigurno i da pruža značajnu redukciju mortaliteta u bolesnika sa STEMI. U organizaciji službe za zbrinjavanje akutnog infarkta miokarda treba naglasiti agresivno rješavanje vremenskog zastoja u primjeni pPCI unutar bolnice.

Authors evaluate the importance of door-to- balloon time, and symptom onset-to-balloon time (total ischemic time) for prognosis of patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). 1190 acute STEMI patients treated with primary PCI in eight centers across Croatia (Croatian Primary PCI Network) were prospectively investigated. 677 non-transferred and 513 transferred patients were divided according to door-to-balloon time in three subgroups (180 minutes) and according to symptom onset-to- balloon time in three subgroups (360 minutes). Among door-to-balloon subgroups none of results differences (for postprocedural TIMI flow, in- hospital mortality, and major adverse cardiovascular events (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in six- month follow-up) was statistically significant. Between onset-to-balloon time subgroups a statistically significant difference on multivariate level was the highest in-hospital mortality in the subgroup of patients with longest onset-to-balloon time (4.5 vs.2.6 vs. 5.7%, p=0.04). According to these results, authors concluded that door-to-balloon time has no impact on early and six-month prognosis of acute STEMI patients. Symptom onset-to-balloon time is more accurate for this purpose.

Hrvatska mreža primarne perkutane intervencije, organizirana 2005. godine, međunarodno je prepoznati sustav dobre organizacije urgentnog liječenja kardioloških bolesnika. Osnutkom „mreže“ polazilo se od principa postupne implementacije u sustav zdravstvene zaštite, a sve u cilju osiguranja jednake razine liječenja akutnoga srčanog infarkta u svim dijelovima Hrvatske. Rezultati mreže usporedivi su s onima bogatijih zemalja i dokazuju da pošten i stručan rad može nadoknaditi manjak financijskih sredstava. Organiziranjem simpozija 15. svibnja 2010. želja vodstva Radne skupine za akutni koronarni sindrom bila je okupljanje svih sudionika urgentnog liječenja bolesnika s akutnim infarktom miokarda. Ujedno, bila je to i prigoda za obilježavanje 40. godišnjice osnivanja koronarne jedinice KB Sestara milosrdnica.

The main goal of this investigation is to evaluate primary percutaneous coronary intervention (PCI) network in economically less developed country and to compare them with economically more developed countries. The Republic of Croatia, with gross domestic product per capita of 11, 554 US $ in the year 2008, is economically less developed western country. The authors prospectively investigated 677 non-transferred, 513 transferred acute STEMI patients treated with primary PCI in eight centers across Croatia (Croatian Primary PCI Network). Postprocedural TIMI flow, in-hospital mortality, and major adverse cardiovascular events (MACE) (mortality, pectoral angina, restenosis, reinfarction, coronary artery by-pass graft and cerebrovascular accident rate) in the six-month follow-up were investigated. In all investigated patients the average door-to balloon time was 108 minutes and total ischemic time 265 minutes, postprocedural TIMI 3 flow was established in 87.1% of them, while in-hospital mortality was 4.4%. No statistically significant difference in the results of treatment was found between transferred and non-transferred patients in general, as well as in subgroups of older than 75 years, female gender and those with cardiogenic shock. Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable to those of randomised studies and registries of economically more developed countries in all parts of Croatia and even in STEMI patients with higher risk profile

There are different literature data about results of primary PCI in STEMI patients treated during nights or off-hours generally. Mostly, those results are worse or similar in comparision with results of primary PCI performed during working hours. Authors prospectively investigated 1161 patients with acute STEMI who were treated with primary PCI in eight Croatian high-volume PCI centers between Sep 1st 2005 and Aug 31st 2007 and compared those treated during working hours with those treated during off-hours, as well as those treated during day with those treated during night. Intrahospital mortality and incidence of MACE during 6-month follow up (angina pectoris, myocardial reinfarction, cerebrovascular insult, target lesion revascularization, late death) were compared. STEMI patients treated with primary PCI during working hours and during daily hours had worse prognosis, especially non-transported patients. One of the reasons for such results in this investigation could be higher proportion of hazardous patients (cardiogenic shock) in that part of day and this group of patients. Last disconcordance should be avoided in the future work.

Primary PCI performed in high-volume centers is superoir treatment of acute STEMI. Transport for primary PCI up to 150 km to such centers is safe and, mostly, with better results than the fibrinolysis. Principles of the Croatian Primary PCI Network introduced in 2005 are: 1. Step-by- step implementation principle: 2.Proportional allocation of PCI centers in all parts of Croatia, 3. Continious mutual comunication of all participants. Authors evaluated in prospective multicentric study in time period between Sep 1st 2005 and Aug 31st 2007, 1161 acute STEMI patients treated with primary PCI (490 transported, 671 non- transported) in eight PCI centres in all parts of Croatia. Croatian Primary PCI Network ensures results of treatment of acute STEMI comparable to those of randomised studies and registries of economically more developed countries. These results are ensured in all parts of Croatia and even in STEMI patients with higher risk profile

There are conflicting reports in the literature regarding the role of sex on the in-hospital mortality of patients with acute myocardial infarction. The objective of this study is to determine whether there are gender differences in in-hospital mortality and angiographic findings of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). We conducted a prospective study of all patients admitted to University Hospital Center Split, Croatia with STEMI from 2004 to 2008 who underwent PCI. From March 2004 throughout September 2008, 488 patients with STEMI underwent PCI (364 men, 74.6%; 124 women, 25.4%). Compared with men, women were significantly older (mean age, 67.3 vs. 60.3 years; p0.001). Men had a significantly higher proportion of circumflex artery occlusion (19.5% vs. 10.5%, p = 0.022). A higher proportion of men had a multivessel disease than women (56.8% vs. 41.9%; p = 0.004). In-hospital mortality was significantly higher among women (11.3% vs. 4.6%; p = 0.002) but after adjustment for the baseline difference in age, the female sex was not an independent predictor of in-hospital mortality (adjusted OR 1.15; 95% CI 0.82-1.84). In men, occlusions of left anterior descending artery showed higher mortality rate than occlusions of other coronary arteries (LM 0%, LAD 7.3%, Cx 2.8%, RCA 0.7%, p = 0.03). According to our results female gender is not an independent predictor of in-hospital mortality after percutaneous coronary intervention. In men, occlusions of left anterior descending arteries are associated with higher mortality rate comparing to occlusions of other coronary arteries.

Report of first phase results of treatment of acute STEMI in Croatian Primary PCI Network.

Gender differences in in-hospital mortality and angiographic outcomes of patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI)

Croatian Primary PCI Network was introduced in the middle of 2005 organizing eight high-volume PCI centers and all county hospitals across Croatia. Between Sep 1st 2005 and Aug 31st 2007 authors prospectively investigated 1190 patients with acute STEMI who were treated with primary PCI in quoted eight high-volume PCI centers. Investigated patients were either citizens of major Croatian cities (non-transported, 677 pts) or they were urgently transported from outside regions (transported, 513 pts). Among all investigated patients 75% were male, average age was 60 years. The main goal of Croatian Primary PCI Network was to achieve equal quality treatment of acute STEMI in all parts of our country. First results show that such network can ensure equal prognosis for acute STEMI patients in all parts of country. In post-analysis authors compared percentages and results of short- and long-term prognosis of different age, gender and clinical severity groups among transported and non-transported patients. In conclusion, non-adequate selection of STEMI patients transported for primary PCI on county hospital level results in avoidance of optimal treatment for some of them.

Croatian primary PCI network-analysis of working hours and off hours results.

INTRODUCTION: Transporting the patients suffering from acute STEMI up to 150 km distance to high volume PCI centers proved to be safe and feasible and superior to standard medical treatment. The total population of Republic of Croatia is 4.437.460 inhabitants (year 2001), with total area of 87.609 sq. km, and gross domestic product per capita of 8.980 US $ (year 2006). Despite the new freeway network, there is still a problem with geographically isolated regions, especially mountains and islands, which may affect the availability of providing health care to the citizens especially in urgent situations. Since the middle of 2005, the Croatian Primary PCI Network (CPPN) was introduced into the system of the Health Institution of the Republic of Croatia using step-by-step and mutual communication principles. The main goal is to achieve equal quality treatment of acute STEMI in all parts of Croatia. MATERIALS AND METHODS: Since the middle of 2005 four high volume PCI centers (in the cities of Zagreb and Rijeka) included in CPPN more than half Croatian citizens. Authors investigated 505 patients with acute STEMI who were treated with primary PCI in those centers, 212 of them were transported from outside regions, while other 293 were from cities of Zagreb and Rijeka. RESULTS: Among all investigated patients 75% were male, average age was 60 years. Among patients citizents of Zagreb and Rijeka average pain-to-door and door-to-balloon times were 117 minutes and 82 minutes respectively, while among transported patients 188 minutes and 155 minutes respectively (p< 0.001 for door-to-balloon time, door means first ER). Differences among values of TIMI flow after primary PCI in both groups were non-significant. Incidence of cardiogenic shock in first group and in transported group was 7% and 5% respectively (p=NS). Higher incidence of malignant ventricular arrhytmias (VT/VF) was found in transported patients (10% vs. 19%, p

Cilj rada je bio utvrditi učestalost hospitalizacija bolesnika zbog infarkta miokarda, te bolnički mortalitet u tih bolesnika tijekom razdoblja od 1. siječnja 1981. g. do 31. prosinca 2005. godine u KB Split. Podaci su prikupljeni iz povijesti bolesti, a promatrani su u odnosu na spol i dob. Analizom podataka utvrdili smo da godišnji broj hospitaliziranih bolesnika u navedenom razdoblju neprestano raste, od 196 u 1981. godini, do 522 u 2005. godini. Prosječan godišnji bolnički mortalitet od infarkta miokarda neprestano pada od 20% u 1981. godini do 10% u 2005. godini. Pri tome je mortalitet žena u odnosu na muškarce stalno dvostruko veći od 30% prema 15% u 1981. godini do 16% prema 8% u 2005. godini. Prosječna životna dob hospitaliziranih žena se smanjila sa 69 u 1981. godini na 66 u 2005. godini, dok se prosječna životna dob muškaraca povećala od 59 u 1981. godini na 62 godine u 2005. godini. Prosječna dob svih zajedno ostala je ista, 61 godina. Iz dobivenih rezultata može se zaključiti da broj hospitaliziranih bolesnika kroz 25 godina neprestano raste, a hospitalni mortalitet se smanjuje zahvaljujući sve kvalitetnijem liječenju. Broj hospitaliziranih žena u odnosu na muškarce se povećava što se barem dijelom može objasniti sve većim brojem pušača među ženama.

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Obilježja akutnog infarkta miokarda kod muškaraca na splitskom području od 1996.-2002.g

Rad obuhvaća dinamičku promjenu difuzijskog kapaciteta pluća kod bolesnika sa sustavnim lupusom.

The aim of this study was to determine the pattern of myocardial infarction (MI) incidence regarding the age, gender, infarction site and the most important risk factors. Between 1989 and 1997 there were 3454 patients hospitalized in coronary care units of Clinical Hospital Split. In the three-year period preceding the war, from 1989- 1991, 1024 patients were hospitalized because of MI. During the three years of full was activities, from 1992-1994, there were 1257 patients (significantly more, p < 0.05), and in the three- year period after the was, from 1995-1997, there were 1173 patients. In the war period there were 12% (151) patients under the 45 years of age (p < 0.05) ; of that number, 95% (143) were men (significantly more than in other two periods, p < 0.05), and 5% (8) were women. In the period preceding the was there were 6.5% (66) patients under the 45 years ; 91% (60) men and 9% (6) women, whereas in the period after the war there were 7.5% (88), 92% (81) and 8% (7), respectively. The patients under 45 (305) more often had MI of inferior than anterior site (49 vs. 28%, p < 0.001), whereas there was no difference in patients over 45 (36 vs. 37%, p > 0.05). The patients over 45 had significantly higher hospital mortality (21 vs. 4%, p < 0.001), and were more likely to have hypertension (51 vs. 15%, p < 0.001) as well as hypercholesterolemia (54 vs. 14%, p < 0.001). Smokers were more prevalent among those under the 45 (75 vs. 51%, p < 0.001). The number of hospitalized patients with MI was the greatest during the war period. It included significant increase in incidence in men under 45 (12 vs. 7%, p < 0.05), with smoking as the most important risk factor, especially for infarctions of inferior site.

Rad obrađuje uporedbu ultrazvuka srca i testova plućne funkcije.

Antifosfolipidni sindrom (APS) karakteriziraju tromboembolijska zbivanja, ponavljani gubitak čeda, moguća trombocitopenija, te antifosfolipidna protutijela i/ili lupus antikoagulans. Izvorno je opisan u bolesnika sa sistemskim eritemskim lupusom, no kasnija su istraživanja ukazala na prisutnost APS-a i u osoba bez sistemske autoimune bolesti. Trombotska zbivanja mogu nastati u bilo kojem dijelu krvožilnog sustava iskazujući se kroz kliničke manifestacije koje po težini variraju od blagih - tek zamijetnih, do teških - koje izravno ugrožavaju život bolesnika. U članku su naznačeni mogući mehanizmi nastanka i djelovanja antifosfolipidnih protutijela, najčešće kliničke prezentacije APS-a, te dane osnovne terapijske smjernice.

Aim of the study was to assess whether acute myocardial infarction (AIM) in younger patients (45 years) differs from that in the older individuals (>45 years). The records of all patients admitted to the University Hospital Split from January 1, 1987 to December 31, 1998 because of AMI were evaluated. The study group consisted of 3282 patents, 276 (8, 4%) below, and 3006 (91.6%) above the age of 45. In the "young" subgroup there were only 17 (6.2%) females, significantly less than in the "old" one (941 out of 3006 or 31.396, p < 0.001). There were much more smokers among the younger (224 out of 276 or 81.3%) than among the older patients (1 l 18 out of 3006 or 37.2% ; p < 0.001). In the "young" subgroup there were about 73% heavy smokers with >35 cigarettes per day. Arterial hypertension was more prevalent in the "old" (1347 out of 3006 or 44.8%) than in the "young" subgroup (100 out of 276 or 36.1% ; p

Cilj istraživanja bio je utvrditi povezanost lokalizacije infarkta miokarda (IM) s najznačajnijim čimbenicima rizika. Lokalizacija IM određivana je na temelju karakterističnih promjena u EKG-u. Analizirana je zastupljenost hiperkolesterolemije, hipertenzije, dijabetesa, prekomjerne tjelesne težine i pušenja u 3802 bolesnika liječenih zbog IM u Klinici za unutarnje bolesti KB Split u razdoblju od 1989. do 1998. godine. Od ukupnog broja, muškarci (2699) su činili 71%, a žene (1103) 29% bolesnika. Prosječna dob bolesnika bila je 60+/-9 godina (57+/-9 muškarci i 67+/-11 žene). Ukupna smrtnost iznosila je 18% ; smrtnost u muškarac bila je 13%, a u žena 28%. Tri četvrtine od ukupnog broja infarkta činili su infarkti anteriorne (38%) i inferiorne (37%) lokalizacije. Povećane vrijednosti kolesterola imalo je 52%, hipertenziju 49%, dijabetes 21%, prekomjernu tjelesnu težinu 61%, a pušilo je 57% bolesnika. Hiperkolesterolemija (55% prema 49%, p

Cilj istraživanja je bio utvrditi razliku u vremenu nastanka, ishodu liječenja i zastupljenosti čimbenika rizika za ishemičnu bolest srca u odnosu na spol bolesnika liječenih zbog akutnog zatajivanja lijeve klijetke (LK). Dijagnoza akutnog zatajivanja LK postavljena je temeljem kliničkih, radioloških i ehokardiografskih pokazatelja. U istraživanje nisu uključeni bolesnici u kojih je uzrok akutnog zatajivanja LK akutni infarkt miokarda, valvularna greška, kao ni bolesnici s kroničnom obstruktivnom bolešću pluća. U šestogodišnjem periodu liječeno je 560 bolesnika: 293 (53%) muškaraca prosječne dobi 73+/-18 godina i 267 (47%) žena prosječne dobi 72+/-22 godine. Praćenjem incidencije akutnog zatajivanja LK tijekom trosatnih dnevnih intervala, u žena smo utvrdili značajno veću incidenciju u vremenu od 21 do 24 sata (30% od ukupnog broja akutnog zatajivanja LK nastalog u žena). Razlika incidencije u jednakim trosatnim intervalima u muškaraca nije statistički značajna. Usporedbom čimbenika rizika za ishemičku bolest srca u žena je utvrđena veća učestalost dijabetesa (17, 5% prema 8, 5%, p

Razlika u učestalosti vanjskih okidača akutnog infarkta miokarda u odnosu na spo.