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Primarily a consequence of sedentary lifestyle, atherosclerosis has already reached pandemic proportions, and with every year the burden of it is only increasing. As low-density lipoprotein cholesterol (LDL-C) represents a crucial factor in atherosclerosis formation and progression, stringent lipid-lowering therapy could conceivably be the key to preventing the unfavorable outcomes that arise as a consequence of atherosclerosis. The use of statins in lipid-lowering is often burdened by adverse events or is insufficient to prevent cardiovascular events as a monotherapy. Therefore, in the present review, the authors aimed to discuss the underlying mechanisms of dyslipidemia and associated atherosclerotic cardiovascular disease (ASCVD) and preclinical and clinical trials of novel therapeutic approaches to its treatment, some of which are still in the early stages of development. Apart from novel therapies, a novel change in perspective is needed. Specifically, the critical objective in the future management of ASCVD is to embrace emerging evidence in the field of atherosclerosis, because clinicians are often burden by common practice and personal experience, both of which have so far been shown to be futile in the setting of atherosclerosis. [ABSTRACT FROM AUTHOR]

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability. [ABSTRACT FROM AUTHOR]

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. Material 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. [ABSTRACT FROM AUTHOR]

Introduction: Acute myocardial ischemia is a well-known cause of ventricular arrhythmias, often fatal. Polymorphic ventricular tachycardia (PVT) and ventricular fibrillation (VF) are mostly seen during ongoing myocardial ischemia and within first 72 hours of a myocardial infarction which often results in hemodynamic instability with significant risk of mortality1,2. This is a case report of a 42-year-old male presenting with a hemodynamically unstable electrical storm following an acute in-stent thrombosis. Case report: 43-year-old man presented to the Emergency Department (ED) with retrosternal chest pain. His initial electrocardiogram (ECG) showed an ST elevation in anteroseptolateral leads. In the ED he suffered a cardiac arrest due to VF. On successful cardiopulmonary resuscitation with defibrillation, urgent coronarography was performed with the placement of one drug-eluting (DE) stent in the proximal left anterior descending artery. Postprocedural, in the Coronary Care Unit an electrical storm with incessant and recurring PVT and VF refractory to medical treatment and requiring multiple direct- current shocks (in total over 60 times). An indication was made for re-evaluation by coronary angiography. Prior to the procedure in the Catheterization Laboratory a peripheral veno-arterial (VA) femoro-femoral extracorporeal membrane oxygenation (ECMO) was placed. Repeated angiography showed an acute in-stent thrombosis and reperfusion was successfully performed with placement of a second DE stent. After the intervention the patient was rhythmically stable with no recurrence of ventricular arrhythmias. He was successfully weaned off VA-ECMO 8 days later and discharged 55 days later with optimized medical therapy, no clinical signs of heart failure and with no neurological deficits. On follow-up, echocardiography showed hypokinesia of anterolateral wall with left ventricular ejection function 45 % and he had no signs of heart failure and no anginal symptoms. Conclusion: In the setting of an acute myocardial infarction, an electrical storm following a percutaneous revascularization, especially one refractory to medication and with no evident metabolic cause, should raise suspicion of acute in-stent thrombosis. A low threshold for reintervention should be set in such situations. Temporary mechanical circulatory support, if available, provides a good hemodynamic stabilization for the procedure and for later rhythm and circulatory management. [ABSTRACT FROM AUTHOR]

Highlights: [•] We examined the effect off nitroglycerin, norepinephrine and aminophylline on IPAVA. [•] All drugs revealed well known hemodynamic effects. [•] None of the drugs were not found to promote intrapulmonary arteriovenous opening. [•] Application of these drugs does not open the pathway for systemic embolization of vital organs. [Copyright &y& Elsevier]

Arterialization of gas bubbles after decompression from scuba diving has traditionally been associated with pulmonary barotraumas or cardiac defects, such as the patent foramen ovale. Recent studies have demonstrated the right-toleft passage of bubbles through intrapulmonary arterial-venous anastamoses (IPAVA) that allow blood to bypass the pulmonary microcirculation. These passages open up during exercise, and the aim of this study is to see if exercise in a postdiving period increases the incidence of arterialization. After completing a dive to 18 m for 47 min, patent foramen ovale-negative subjects were monitored via transthoracic echocardiography, within 10 min after surfacing, for bubble score at rest. Subjects then completed an incremental cycle ergometry test to exhaustion under continuous transthoracic echocardiography observation. Exercise was suspended if arterialization was observed and resumed when the arterialization cleared. If arterialization was observed a second time, exercise was terminated, and oxygen was administered. Out of 23 subjects, 3 arterialized at rest, 12 arterialized with exercise, and 8 did not arterialize at all even during maximal exercise. The time for arterialization to clear with oxygen was significantly shorter than without. Exercise after diving increased the incidence of arterialization from 13% at rest to 52%. This study shows that individuals are capable of arterializing through IPAVA, and that the intensity at which these open varies by individual. Basic activities associated with SCUBA diving, such as surface swimming or walking with heavy equipment, may be enough to allow the passage of venous gas emboli through IPAVA. [ABSTRACT FROM AUTHOR]

The study goal was to evaluate responses in humans following decompression from open-water SCUBA diving with the hypothesis that exertion underwater and use of a breathing mixture containing more oxygen and less nitrogen (enriched air nitrox) would alter annexin V-positive microparticle (MP) production and size changes and neutrophil activation, as well as their relationships to intravascular bubble formation. Twenty-four divers followed a uniform dive profile to 18 m of sea water breathing air or 22.5 m breathing 32% oxygen/68% nitrogen for 47 min, either swimming with moderately heavy exertion underwater or remaining stationary at depth. Blood was obtained pre- and at 15 and 120 min postdive. Intravascular bubbles were quantified by transthoracic echocardiography postdive at 20-min intervals for 2 h. There were no significant differences in maximum bubble scores among the dives. MP number increased 2.7-fold, on average, within 15 min after each dive; only the air-exertion dive resulted in a significant further increase to 5-fold over baseline at 2 h postdive. Neutrophil activation occurred after all dives. For the enriched air nitrox stationary at depth dive, but not for other conditions, the numbers of postdive annexin V-positive particles above 1 μm in diameter were correlated with intravascular bubble scores (correlation coefficients ~0.9, P < 0.05). We conclude that postdecompression relationships among bubbles, MPs, platelet-neutrophil interactions, and neutrophil activation appear to exist, but more study is required to improve confidence in the associations. [ABSTRACT FROM AUTHOR]

Benign thyroid disorders such as goiter, especially retrosternal, can cause tracheostenosis by extrinsic tracheal compression, which is due to the lack of specific symptoms often misdiagnosed. Tracheomalatia develops as a result to long term tracheal compression and refers to weakness of the trachea characterized by softness of the tracheal cartilage arches and by loss of regular tracheal structure. Tracheomalatia is characterized by reduction of the endotracheal lumen and may affect the entire trachea or may be localized to one portion of it. We present the case of a 72-year old patient with distinct tracheostenosis and tracheomalatia, caused by long term pressure by the retrosternal goiter. We have been monitoring the patient for last 20 years after the second endotracheal stent had been placed. The first one was placed 34 years ago, in 1981. On both occasions granulation tissue and colonization of bacteria occurred. In the end the placed stents were rejected and migrated to the main carina. Despite the tracheal diameter narrower than 5 mm the patient has been living normally without the stent for 17 years, with the exception of no hard physical labor. He had a few short term antibiotic therapies and bronchial toilets during symptomatic deteriorations. Diagnosing retrosternal goiter and surgical treatment on time is of crucial importance in cases such as this one. Considering the complications caused by the stent, our opinion is that the majority of patients may require conservative treatment with closely monitoring during respiratory infections. [ABSTRACT FROM AUTHOR]

Localized interlobar effusions in congestive heart failure (phantom or vanishing lung tumor/s) is/are uncommon but well known entities. An 83-year-old man presented with shortness of breath, swollen legs, and dry cough enduring five days. Chest-X-ray (CXR) revealed massive sharply demarked round/oval homogeneous dense shadow 10 x 7 cm in size in the right inferior lobe. The treatment with the loop diuretics and fluid intake reduction resulted in complete resolution of the observed round/oval tumor-like image on the control CXR three days later. Radiologic appearance of such a mass-like configuration in patients with congestive heart failure demands correction of the underlying heart condition before further diagnostic investigation is performed to avoid unnecessary, expensive, and possibly harmful diagnostic and treatment errors. [ABSTRACT FROM AUTHOR]

Background: Untreated massive pulmonary embolism (PE) results in mortality rate of approximately 30%, most frequently within the first few hours of onset and up to 50% 3-month mortality. Catheter-directed therapy (CDT), due to mechanical fragmentation of the clot, removal of obstructing thrombi from the main to distal pulmonary arteries and thrombolytic-enhanced clot lysis, offers rapid reducing of pulmonary artery pressure, right ventricle strain, and pulmonary vascular resistance while simultaneously increase systemic perfusion and facilitate right ventricle recovery.1 Systemic thrombolytic application carries up to a 20% risk of major bleeding, including a 2% to 5% risk of intracranial hemorrhage and is unwillingly prescribed.2 CDT offers interesting alternative since, due to local application, dose can be significantly reduced. So far, predominantly the proximal venous access sites, most often transfemoral or transjugular, were used. We report the results of first CDT treatments via the antecubital venous access. Patients and Methods: 17 consecutive patients presenting with clinical diagnosis of acute PE confirmed by computed tomographic angiography from January to August 2016 were enrolled in the trial. CDT involved mechanical catheter fragmentation and the application of adjuvant thrombolytic therapy through a pigtail catheter positioned in the pulmonary artery. Results: Technical success was achieved in all patients, and in all patients significant improvement in hemodynamics and pulmonary angiography was observed 12 h after procedure. There were no major periprocedural complications. Conclusion: Catheter positioned in the pulmonary artery allows continuous assessment of pulmonary hemodynamics, follow-up angiography and additional intervention/s if needed. CDT via cubital vain is feasible in vast majority of patients, offers significant dose reduction with low peripro- cedural complications and should be considered as a first line treatment for acute PE in experienced centers. [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.)