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Introduction: Mitral valve prolapse (MVP) is a common condition that affects up to 3% of the population. It is usually benign, but a small subset of patient has an increased risk of malignant ventricular arrhythmias and sudden cardiac death.1,2 Case report: We present a previously healthy 56 years old female patient with history of palpitations. In May 2023, she was hospitalized after out-of-hospital cardiac arrest with ventricular fibrillation (VF) as the initial rhythm. After successful resuscitation, she regained full consciousness. Serum electrolytes were within normal range at admission. Electrocardiogram was uneventful. Echocardiography revealed normally sized left ventricle with preserved ejection fraction and severe mitral regurgitation due to posterior leaflet prolapse (P2 scallop) (Figure 1). No mitral annular disjunction (MAD) was visualized. No heart rhythm disturbances were registered during monitoring. Coronary angiography found no stenosis of coronary arteries. Implantable cardioverter defibrillator (ICD) was implanted for secondary prevention of sudden cardiac death. She was discharged with metoprolol and amiodarone. On follow up visit no heart rhythm disturbances were noticed on ICD interrogation. The patient is scheduled for cardiac surgery (mitral valve repair or replacement). Conclusion: Mitral valve prolapse is becoming increasingly recognized as an important phenomenon which can lead to malignant ventricular arrhythmias and sudden cardiac death. We presented a patient who survived sudden cardiac arrest. No predisposing conditions were found other than mitral valve prolapse. The patient is scheduled for cardiac surgery following the implantation of an ICD. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation of atrial fibrillation (AF). Current European Heart Rhythm Association Guidelines suggests that all patients undergoing catheter ablation should be anticoagulated for three weeks prior the procedure.1 All patients with high thromboembolic (TE) risk or in AF should undergo transesophageal echocardiography (TEE) to exclude left atrial thrombus (LAT). Whether patients with low TE risk (estimated with CHA2DS2VASc score) who are in sinus rhythm need TEE routinely remains unclear. The aim of our study was to determine the incidence of LAT in patients undergoing PVI regardless of their risk for TE event. Patients and Methods: Patients hospitalized at the Departmet of Arrhythmology, University Hospital Center “Sestre milosrdnice” Zagreb from January 2013 to May 2016 undergoing PVI were included in the study. Following routine protocol all patients underwent a pre-procedural TEE to exclude LAT. The TE risk was calculated for each patient using a CHA2DS2- VASc score. Results: A total of 241 consecutive patients (mean age of 59±11 years, 76% male) were included in the study. The overall incidence of left atrial thrombus was 39/241 (16.18%). As shown in Table 1, 129 patients had CHA2DS2VASc score 0 or 1 (low TE risk) and 18 of them (18/129; 13.95%) had LAT detected (46.15% of all patients with thrombi). 12 patients with LAT in a low TE risk group were adequately anticoagulated while 8 of them were in sinus rhythm. There were 6 low TE risk patients who were adequately anticoagulated and were in sinus rhythm who had LAT (4.5% of low risk patients, 2.4% of all patients). There was no difference in the LAT incidence between the low and high risk groups (13.95% vs 18.75%, p= 0.29). Conclusion: Due to the presence of thrombi in all TE risk groups, even in patients with a low TE risk who were in sinus rhythm and were adequately anticoagulated, TEE (or other imaging modality) could be routinely performed in all patients prior to planned PVI to exclude LAT. The main limitations of the study are relatively small number of patients, lack of standardized follow up of patients with vitamin K antagonists and small proportion of patients on novel anticoagulants. Also, INR data for some patients are lacking which could have influenced the results significantly. [ABSTRACT FROM AUTHOR]

Background: Direct current (DC) cardioversion is an effective method for converting atrial fibrillation (AF) to sinus rhythm. Current ESC Guidelines1 suggest that transoesophageal echocardiography (TOE) should be performed to rule out atrial thrombi in patients undergoing DC cardioversion, unless adequate anticoagulation has been documented for 3 weeks or AF is <48 hours from a definite onset. The aim of this study was to determine the prevalence of left atrial (LA) thrombus in patients undergoing elective DC cardioversion in our center and to compare LA thrombus prevalence between the patients with different thromboembolic risks. Patients and Methods: All patients with AF lasting >48 hours admitted to the Emergency department or Department of Cardiology at the University Hospital Centre “Sestre milosrdnice” Zagreb from January 2013 to May 2016 who underwent DC cardioversion were included in the study. Patients with AF lasting <48 hours were excluded from the study. All patients underwent preprocedural TOE to exclude LA thrombus regardless on anticoagulation status. The thromboembolic risk status was calculated for each patient using a CHA2DS2- VASc score. DC cardioversion was performed according to local protocols. Results: Total of 139 patients were included (106/139; 76% were male) with median age of 66 years (59-72). The overall prevalence of LA thrombi was 30/139 (21.6%). 49 patients were adequately anticoagulated for at least 3 weeks prior to the peri-procedural TOE (35.2%), whereas 90 patients were inadequately anticoagulated (64.8%). 12 patients with a detected thrombus were adequately anticoagulated with warfarin (N=11) or new oral anticoagulants (N=1) out of totally 49 adequately anticoagulated patients (12/49; 24.5%). 18 patients with a detected thrombus were inadequately anticoagulated (20%) (Table 1.) There was no statistical significance between prevalence of LA thrombi between adequately vs. inadequately anticoagulated patients (12 out of 49; 24.5% vs 18 out of 90, 20%, p=0.582) Conclusion: The prevalence of LA thrombi is high, even in patients who have been adequately anticoagulated. Further research with larger number of patients is needed to determine whether all patients should undergo TEE before elective DC cardioversion. [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.)

Pneumopericardium is a rare condition defined as a collection of air in the pericardial cavity. It is usually caused by blunt or penetrating chest injuries, iatrogenic causes (bone marrow puncture, thoracic surgery, pericardiocentesis, endoscopic procedures), and infectious pericarditis with gas-producing organisms.1'2 We present a case of 82-year-old female patient with spontaneous pneumopericardium caused by malignant ulcer that created fistula between the pericardium and an adjacent air-containing organ (colon). She was admitted in critical condition with chest pain, severe respiratory distress, hypotension, distended neck veins and tachyarrhythmia. High blood leukocyte and C-reactive protein levels and combined respiratory and metabolic acidosis were present. On auscultation, very unusual high frequency metallic sound was heard. 12-lead electrocardiogram showed atrial fibrillation and diffuse microvoltage. Chest X ray and CT showed normal sized heart completely surrounded by air (halo sign) below the aortic arch, and also large left pleural effusion. CT also revealed neoplastic process of the transverse colon infiltrating stomach and diaphragm. An echocardiogram demonstrated intrapericardial spontaneous contrast echoes followed by extreme difficulty to view the heart. Even so, significant respiratory variations in transvalvular blood flow velocities and dilated inferior vena were noticed indicating the tension pneumopericardium caused probably by a valve mechanism, resulting in cardiac tamponade.3 Under fluoroscopy control emergent pericardiocentesis was performed with needle extraction of 160 mL of very unpleasant smelled air. Mechanical ventilation was also started together with antibiotic therapy, volume replacement and pleural drainage. The patient was stabilized and next day transferred to another clinic in satisfied condition were the complex abdominal surgery was performed. In conclusion, spontaneous pneumopericardium is a rare life threatening condition that can be caused by infiltrating malignant process. It can be rapidly recognized by physical examination and standard diagnostic tests. If valve mechanism is present it can result in tamponade requiring immediate pericardiocentesis as a life saving procedure. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Atrial septal defects (ASD) account for 10-15% of cases of congenital heart disease. The most common type is ostium secundum. It is often asymptomatic until adulthood. Isolated valvular pulmonic stenosis (PS) comprises approximately 10% of all congenital heart disease. The majority of patients are asymptomatic. Those with severe PS may experience exertional dyspnea and fatigue. In adult patients, combined occurrence of secundum type ASD and pulmonic stenosis is an uncommon condition. CASE PRESENTATION: 20-years-old male, previously healthy, presented to the hospital emergency department with palpitations and chest pressure. Cardiac examination was notable for a grade 5/6 systolic murmur over Erb's point and over the pulmonary area. Cardiac murmur was first noted at the age of 7. There was no family history of CHD. He is a smoker (20 cigarettes daily). ECG demonstrated sinus rhythm with an incomplete right bundle branch block, vertical axis and possible right ventricular enlargement. Transthoracic echocardiography revealed normal systolic and diastolic left ventricular function with ejection fraction of 65%, moderately enlarged right ventricle, secundum atrial defect with left-to-right shunting and hemodynamically significant pulmonic stenosis. Transesophageal echocardiography revealed a large secundum type defect measuring 23- 25 mm in diameter. Inferior venacaval rim was gracile, aortic rim was even smaller. Right heart catheterisation was performed. The left-to-right shunt ratio of pulmonary blood flow to systemic blood flow was assessed to be 2:1. The peak-to-peak pressure gradient across the pulmonary valve was 70-80 mmHg. Coronary angiography findings were normal. Because of unfavorable anatomy for percutaneous ASD closure (inadequate septal tissue rim), we opted to surgically repair both PS and ASD. Valvulotomy was performed and the ASD was closed with a patch. Follow-up echocardiogram showed no shunt and a small mean gradient on pulmonic valve. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) is the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis. It is a leading cause of death worldwide, causing approximately 7.2 million deaths worldwide each year. Complete occlusion of LCA is an unusual manifestation of CAD. The reported angiographic incidence is very low, it is found in 0.03% to 0.8% of patients in different studies. Occlusion of this vessel compromises flow to at least 75% of the left ventricle, unless it is protected by collateral flow or a patent bypass graft. Left main coronary artery disease rarely occurs as an isolated lesion; over 70% to 80% of patients also have multivessel coronary artery disease. Most patients with this condition complain of recurrent typical chest pain and have a history of myocardial infarction. They may also present with symptoms of heart failure. The diagnosis is usually made by angiography, which reveals a right dominant system. Right coronary artery provides collateral circulation to the left system, but up to two thirds of patients have a marked obstruction of the RCA. Our report describes two patients with ST-elevation myocardial infarction, who developed cardiogenic shock. In both cases, coronary angiography was performed immediately, and showed total occlusion of LCA and a right dominant system. The first patient was referred to primary PCI LMCA, and the second patient was referred to intraaortic balloon pump placement and multiple CABG. Six months later, both patients remain stable. Uncertainty surrounds the optimal revascularization strategy for patients with ST-elevation myocardial infarction LMCA occlusion and treatment guidelines in this setting are vague. PCI of the LMCA should be considered as a viable alternative to CABG for selected patients with myocardial infarction, including those with LCA occlusion and less than TIMI flow grade 3, cardiogenic shock, persistent ventricular arrhythmias, and significant comorbidities. [ABSTRACT FROM AUTHOR]

Peripartum cardiomyopathy (PPCM) is a rare form of dilated cardiomyopathy that occurs in previously healthy women in the last month of pregnancy and up to several months after delivery. The incidence of PPCM is low, but its morbidity and mortality rate are high, with a substantial risk of poor outcome of the pregnancy. Patients who have recovered from PPCM run a high risk of reoccurrence in subsequent pregnancies. In this case report we present a 32-year old female patient who developed acute heart failure (HF) associated with significantly reduced systolic function due to PPCM soon after a delivery of triplets. Treatment was immediately initiated in the intensive coronary unit with oxygen-therapy, loop diuretics, aldosterone blockers, beta blockers, angiotensin-converting enzyme (ACE) inhibitors and bromocriptine. During the follow up period, a year and a half after delivery, a complete recovery of systolic function was observed with no residual symptoms. [ABSTRACT FROM AUTHOR]

Heart failure is the leading cause of morbidity and mortality worldwide, with ischemic heart disease being one of the most important etiologic factors. Heart failure develops due to ventricular remodeling, which leads to increases in left ventricular end-systolic and end-diastolic volumes. In this prospective observational study, we included 101 patients with first episode of ST-segment elevation myocardial infarction in whom percutaneous coronary intervention was conducted within 12 h and Thrombolysis in Myocardial Infarction III flow was achieved. The aim was to determine which clinical and biochemical parameters can help predict pathologic ventricular remodeling 1 year after myocardial infarction. We created a nomogram based on routinely used blood tests and vital parameters which showed highest correlation with pathologic ventricular remodeling. The nomogram included NTproBNP value 12 h after reperfusion, aspartate transaminase value 12 h after reperfusion, systolic blood pressure value on admission, and culprit coronary artery. We performed ROC analysis which yielded great predictive value of the nomogram. The area under curve was 0.907 (95% CI 0.842-0.973). The nomogram value of -3.54 had 91.4% sensitivity and 74.0% specificity. We believe that this nomogram, once validated, could offer a widely available, low-cost option that would help identify patients at risk of developing pathologic left ventricular remodeling and achieve this at a very early stage of myocardial infarction (12 h after reperfusion has been achieved).