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IPAVA su krvne žile velikog promjera 15-500 μm (čak i do 1000 μm), prisutne u >95% zdravih osoba, dok je PFO prisutan u ~ 1/3 opće populacije i oboje predstavljaju mogući izvor desno-lijevog šanta. U Studiji I smo istražili učinak nitroglicerina, noradrenalina i aminofilina na otvaranje i novačenje intrapulmonalnih arteriovenskih anastomoza u zdravih ispitanika u mirovanju. Ovi lijekovi primijenjeni u ranije navednim dozama nisu imali učinka na filtrirajuću sposobnost pluća u zdravih ljudi u mirovanju. Čini se da ovi lijekovi nemaju utjecaja na otvaranje i novačenje IPAVA, krvnih žila velikog promjera, kako direktnim (putem receptora) tako niti indirektnim (putem povećanja tlaka ili protoka) učinkom. Unatoč njihovim različitim vazoaktivnim i hemodinamskim učincima, nijedan od lijekova nije uzrokovao značajan porast srčanog minutnog volumena i/ili sistoličkog tlaka u plućnoj arteriji stimulusa ranije dokazanih da pasivno otvaraju i novače IPAVA. Naposljetku valja naglasiti da primjena ovih lijekova, u navedenim dozama, ne otvara mogući put za sistemsku embolizaciju vitalnih organa. U Studiji II smo istražili mogući doprinos protoka krvi kroz IPAVA-e i PFO na arterijsku hipoksemiju u CHF bolesnika sa i bez plućne hipertenzije. Otkrili smo da je arterijska hipoksemija u mirovanju bila prisutna samo kod CHF PH+ bolesnika s PFO-om. S obzirom da protok krvi kroz IPAVA-e nije bio prisutan ili je bio beznačajan, čak i kod onih s plućnom hipertenzijom, zaključujemo da protok krvi kroz IPAVA-e nije pod utjecajem povećanog tlaka u plućnoj arteriji te da isti ne pridonosi arterijskoj hipoksemiji kod ovih bolesnika. Pridonosi li PFO vježbanjem induciranoj arterijskoj hipoksemiji u CHF bolesnika ostaje nepoznato. Podatci dobiveni u ovoj studiji, kao i prethodno publicirani, dokazuju da starenje negativno utječe na IPAVA-e, što podrazumijeva da se sa povećanjem životne dobi protok krvi kroz IPAVA-e značajno smanjuje. Potrebno je istražiti kakve su posljedice, ako ih ima, povezane s tim smanjenjem. Također, u ovoj studiji smo dokazali izvrsnu podudarnost detekcije i kvantificiranja desno-lijevog šanta (protok krvi kroz IPAVA-e i/ili PFO) transtorakalnom kontrastnom ehokardiografijom i transkranijskim doplerom. Dakle, obje metode mogu poslužiti za istu svrhu, što je osobito značajno kada izvođenje jedne od njih nije podobno ili nije moguće. Kirurško/intervencijsko zatvaranje PFO-a može se uraditi zbog različitih indikacija, kao što su, npr. preboljeni ishemijski moždani udar ili tranzitorna ishemijska ataka. Međutim, s obzirom da PFO pridonosi arterijskoj hipoksemiji u CHF bolesnika s plućnom hipertenzijom, ova grupa bolesnika mogla bi profitirati od zatvaranja PFO-a s ciljem da se poboljša i oksigenacija, osobito u onih s težim stupnjem hipoksemije. Postojanje IPAVA je poznato najmanje posljednjih 50 godina, međutim, njihova fiziološka i klinička značajnost nije do kraja istražena. Iako, trenutno predložene uloge uključuju mogućnost alternativnog puta embolima iz venskog sustava da dosegnu sistemsku cirkulaciju, zatim da služe kao paralelna vaskularna mreža, koja se u određenim uvjetima otvara za preusmjeravanje potencijalno štetne hidrodinamske energije od krhkih plućnih kapilara čime čine desno-lijevi šant, zbog čega mogu negativno utjecati na plućnu izmjenu plinova. Proučavanje protoka krvi kroz IPAVA-e i PFO predstavlja značajno istraživačko područje s ciljem da se predložene uloge bolje odrede, zbog čega detektiranje i kvantificiranje protoka kroz IPAVA-e i PFO može postati mnogo važnije i u kliničkoj praksi., IPAVA are large diameter 15-500 μm (up to 1000 μm) vascular conduits, present in >95% of healthy humans, while PFO is present in ~ 1/3 of general population and both represent possible source of right to left shunt. In Study I we investigated the effects of nitroglicerine, norepinephrine and aminophylline on opening and recruitment of intrapulmonary arteriovenous anastomoses in healty humans at rest. We found that these drugs applied in above named doses did not seem to modify the filtering capability of the lung in healthy humans at rest which speakes in fovour that drugs are not affecting the large-diameter inducible intrapulmonary arteriovenous anastomoses by direct effect on opening and recruitment of the IPAVA (via receptors) nor indirect (via increase in pressure and flow). Despite their various vasoactive and hemodynamic effects, none of the drugs caused a substantial increase in QT and/or PASP, stimuli previously shown to passively open IPAVA. Finally, application of these drugs, in named doses, does not open the pathway for systemic micro/embolization of vital organs. However, further research is needed to examine their effect on IPAVA during physical activity intensities required for ordinary daily activities or in moderate and strenuous exercise as well as in others than healthy subjects. In Study II we examined the potential contributions of blood flow through IPAVA and PFO to arterial hypoxaemia in subjects with CHF with and without pulmonary hypertension. We found that arterial hypoxaemia at rest was present in CHF PH+ subjects with PFO. Given that blood flow through IPAVA was absent or insignificant, even in those subjects with pulmonary hypertension, we conclude that blood flow through IPAVA is not influenced by increased pulmonary pressures and does not contribute to arterial hypoxaemia in these subjects. Whether or not PFO contributes to exercise-induced arterial hypoxaemia in subjects with CHF remains unknown. Data from our study and previous data indicate that aging process may negatively affect IPAVA, assuming that blood flow through IPAVA is reduced with increasing age. We still need to investigate what consequences, if any, are associated with this decline. Also, in this study we have shown excellent correlation between detection and quantification of right to left shunt (blood flow through IPAVA and /or PFO) using transthoracic contrast echocardiography and transcranial Doppler. Thus, both methods can be used for the same purpose which is especially important when performing one of them is not suitable or possible. Surgical closure of the PFO may be undertaken for various reasons, such as history of stroke or transient ischaemic attack, yet PFO closure for this purpose remains controversial. However, because PFO contributes to arterial hypoxaemia in subjects with CHF and pulmonary hypertension, these specific subjects may also benefit from PFO closure as an intervention to improve oxygenation, particularly in those subjects with more severe levels of hypoxaemia. IPAVA have been known to exist for over 50 years, but their physiological and clinical significance are still being established; although, currently suggested roles for IPAVA include allowing emboli to reach the systemic circulation, also serve as a parallel vascular network that under certain conditions open to divert potentially damaging hydrodynamic energy from fragile pulmonary capillaries thus creating the right to left shunt which could adversely affect the pulmonary gas exchange. Studying blood flow through IPAVA, as well as through PFO, is an important area of research and as the suggested roles become better established, detecting and quantifying flow throug IPAVA and PFO may become significantly more important in the clinic.

Some of the clinical concerns associated with upstream platelet inhibition in NSTE-ACS are based on the notion that such a strategy might be harmful in patients with other conditions mimicking NSTE- ACS, such as aortic dissection or may be at risk for major or fatal bleeding events such as intracranial bleeding. Likewise, NSTE-ACS patients who would need to undergo coronary artery bypass graft (CABG) surgery after their coronary anatomy is visualized by diagnostic coronary angiography might be at increased risk of bleeding complications and procedural delays due to receipt of P2Y12 inhibitor pretreatment since 3 to 7 days are required to allow for recovery of platelet function prior to CABG. Furthermore, there are complex discretion factors in real-life, such as surgical hesitancy or decline to operate on a patient on a current dual antiplatelet treatment (DAPT). It should also be noted that non-CABG-related bleeding is a relevant concern for clinicians, such as gastrointestinal bleeding or catheterization access bleeding, and these complications are likely to be more frequent with pretreatment use. Since the latest ESC guidelines state that “pretreatment strategy might be harmful to a relevant proportion “of such patients, we sought to determine what exactly is the proportion of patients with NSTE-ACS that were referred to CABG surgery following angiography and we report on the prevalence of high-risk features that might predispose them to a potential receipt of surgical revascularization.

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.

Rapid recognition of ST-segment elevation myocardial infarction and electrocardiogram interpretation in patients with dextrocardia could be a challenging situation. This case report discusses presentation in a patient with dextrocardia and situs inversus who was found to have acute inferior myocardial infarction. Percutaneous coronary intervention in cases of dextrocardia can be technically challenging considering coronary origin and orientation, and difficulty in appropriate catheter selection., Pravodobno prepoznavanje infarkta miokarda s elevacijom ST segmenta i interpretacija elektrokardiograma u bolesnika s dekstrokardijom predstavlja klinički izazov. Ovim prikazom slučaja opisujemo bolesnika s dekstrokardijom i situs inversusom za kojeg je utvrđeno da ima akutni infarkt miokarda s podizanjem ST segmenta. Perkutana koronarna intervencija u slučajevima dekstrokardije može biti tehnički izazovna s obzirom na poziciju ušća koronarnih arterija te poteškoće u odgovarajućem odabiru i manipulaciji intervencijskim kateterima.

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.

Numerous disorders of coagulation and fibrinolysis have been reported in patients with thyroid diseases, especially with hyperthyroidism. Most articles are focused on deep vein thrombosis risk, however, few of them describe association between hyperthyroidism and pulmonary embolism. We report a case of a 43-year-old woman with long-term uncontrolled hyperthyroidism complicated by venous thromboembolism. The potential mechanisms could be endothelial dysfunction, decreased fibrinolytic activity, and increased levels of coagulation factors. Thyroid evaluation should be recommended in patients with unprovoked venous thromboembolic events., Različiti poremećaji koagulacije ponekad se povezuju s bolestima štitnjače, najčešće hipertireozom. Većina dosadašnjih radova je usredotočena na rizik duboke venske tromboze kod takvih bolesnika, dok je u vrlo malom broju radova opisana povezanost hipertireoze i plućne embolije. Prikazuje se slučaj 43-godišnje bolesnice s dugogodišnjom nekontroliranom hipertireozom i posljedičnim akutnim venskim tromboembolizmom. Vjerojatni patofiziološki mehanizam uključuje oštećenje endotela, smanjenje fibrinolitičke aktivnosti i povećanu razinu faktora koagulacije. Klinička i laboratorijska evaluacija štitnjače preporučljiva je u bolesnika s neprovociranim tromboembolijskim događajem.

Therolesof intrapulmonary andintracardiac shunt in contributing toarterialhypoxaemia at rest in subjects with chronic heart failure (CHF) have not been well investigated. We hypothesized that blood flow through intrapulmonary arteriovenous anastomoses ( ˙Q IPAVA) and/or patent foramen ovale ( ˙Q PFO) could potentially contribute to arterial hypoxaemia and, with pulmonary hypertension (PH) secondary to CHF, this contribution may be exacerbated. Fifty-six subjects with CHF (New York Heart Association Classes I– III), with (+) or without (−) PH [defined as peak tricuspid regurgitation velocity 2.9 m s−1 (CHF PH+, n = 32) and peak tricuspid regurgitation velocity 2.8 m s−1 (CHF PH−, n = 24)], underwent arterial blood gas analysis and transthoracic saline contrast echocardiography concomitant with transcranial Doppler to detect ˙Q IPAVA and ˙Q PFO. Seventeen of 56 subjects with CHF (30%) had ˙Q PFO, but only four of 56 subjects with CHF had ˙Q IPAVA (7%), both similar to age- and sex-matched control subjects. Mean arterial oxygen saturation (SaO2 ) was lower in subjects with ˙Q PFO. Only CHF PH+ subjects with ˙Q PFO had arterial hypoxaemia (mean SaO2