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An electrical storm (ES) is defined as the presence of at least three episodes of sustained ventricular tachycardia or ventricular fibrillation within 24 h. This patient had a previously known arterial hypertension, type II diabetes mellitus, and chronic kidney disease and has presented to the Emergency Department (ED) with symptoms of retrosternal chest pain lasting for several hours prior. The initial 12-lead electrocardiogram revealed ST segment elevation in the anterior leads (V1–V6). Emergent coronary angiography revealed an acute occlusion of the proximal left anterior descending artery (pLAD) and percutaneous coronary intervention was performed with successful implantation of one drug-eluting stent in the pLAD. On day 8 of hospitalization, the patient developed a refractory ES for which he received 50 DC shocks and did not respond to multiple lines of antiarrhythmic medications. Due to a failure of medical therapy, we decided to implant a temporary pacemaker and initiate ventricular overdrive pacing (VOP) that was successful in terminating ES. Following electrical stabilization, the patient underwent a successful ICD implantation. This case demonstrates that VOP can contribute to hemodynamic and electrical stabilization of a patient that suffers from refractory ES and this treatment modality might serve as a temporary bridge to ICD implantation. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 39-year-old woman with a recurrent cardiac myxoma discovered decades after initial surgery, prompting evaluation due to symptoms and elevated biomarkers. Topics discussed include the rarity and diagnostic complexities of late recurrence, the typical and atypical locations of cardiac myxomas, and considerations for long-term monitoring and treatment strategies in such cases.

Background: The need for computed tomography pulmonary angiography (CTPA) to rule out pulmonary embolism (PE) is based on clinical scores in association with D-dimer measurements. PE is a recognized complication in patients with SARS-CoV-2 infection due to a pro-thrombotic state which may reduce the usefulness of preexisting pre-test probability scores. Aim: The purpose was to analyze new clinical and laboratory parameters while comparing existing and newly proposed scoring system for PE detection in hospitalized COVID-19 patients (HCP). Methods: We conducted a retrospective study of 270 consecutive HCPs who underwent CTPA due to suspected PE. The Modified Wells, Revised Geneva, Simplified Geneva, YEARS, 4-Level Pulmonary Embolism Clinical Probability Score (4PEPS), and PE rule-out criteria (PERC) scores were calculated and the area under the receiver operating characteristic curve (AuROC) was measured. Results: Overall incidence of PE among our study group of HCPs was 28.1%. The group of patients with PE had a significantly longer COVID-19 duration upon admission, at 10 vs 8 days, p = 0.006; higher D-dimer levels of 10.2 vs 5.3 µg/L, p < 0.001; and a larger proportion of underlying chronic kidney disease, at 16% vs 7%, p = 0.041. From already established scores, only 4PEPS and the modified Wells score reached statistical significance in detecting the difference between the HCP groups with or without PE. We proposed a new chronic kidney disease, D-dimers, 10 days of illness before admission (CDD-10) score consisting of the three aforementioned variables: C as chronic kidney disease (0.5 points if present), D as D-dimers (negative 1.5 points if normal, 2 points if over 10.0 µg/L), and D-10 as day-10 of illness carrying 2 points if lasting more than 10 days before admission or 1 point if longer than 8 days. The CDD-10 score ranged from -1.5 to 4.5 and had an AuROC of 0.672, p < 0.001 at cutoff value at 0.5 while 4PEPS score had an AuROC of 0.638 and Modified Wells score 0.611. The clinical probability of PE was low (0%) when the CDD-10 value was negative, moderate (24%) for CDD-10 ranging 0-2.5 and high (43%) when over 2.5. Conclusions: Better risk stratification is needed for HCPs who require CTPA for suspected PE. Our newly proposed CDD-10 score demonstrates the best accuracy in predicting PE in patients hospitalized for SARS-CoV-2 infection. [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]

Amiodarone-induced pulmonary toxicity (AIPT) has a variety of presentations. Amiodarone use has been rarely associated with the development of acute respiratory failure. We present a patient with a history of paroxysmal atrial fibrillation who developed acute respiratory distress syndrome despite taking a low dose of amiodarone and having no risk or precipitating factors. The diagnosis of AIPT was made after drug discontinuation and exclusion of other potential causes. The development of acute respiratory failure due to AIPT is often underdiagnosed and undertreated. Better identification of risk factors and developing appropriate diagnostic tools for risk stratification of patients receiving amiodarone is mandatory. • Amiodarone use is rarely associated with the development of acute respiratory failure. • The most clinical presentation of AIPT is a subacute illness presented by the nonproductive cough, progressive dyspnoea, and low-grade fever • The diagnosis of AIPT is often made after drug discontinuation and exclusion of other potential causes. • Identification of risk factors and developing appropriate diagnostic tools for risk stratification of patients receiving amiodarone is mandatory [ABSTRACT FROM AUTHOR]

Introduction: Electric shock is the set of pathophysiological events resulting from the action of an electric current on the human body. Electrical injuries involve both direct (caused by contact with electricity arc) and indirect mechanisms (mechanical trauma due to falls). The most common sequels after electrical injury in the heart are arrhythmias and myocardial contusion. Large arteries like aorta are rarely affected because their rapid flow allows them to dissipate the heat produced by the electric current. However, they are susceptible to medial necrosis, with aneurysm formation and rupture at a later point of time. There is one case in the literature which described aortic valve rupture due to high-voltage electrical injury. Case report: 47-year-old male patient was admitted to our echo lab for ultrasound examination of the heart. In the last two months he had been complaining about exertional dyspnea. His medical history was quite poor: he had never been admitted to the hospital until two months ago when he had been observed for 24 hours after he had suffered a high-voltage electric injury. The transthoracic echocardiography was performed, and we discovered moderately enlarged left ventricle (LVED volume 180 ml) due to severe aortic regurgitation on bicuspid aortic valve with holo-diastolic retrograde flow. The regurgitation jet that filled the two thirds of left ventricular outflow tract with laceration and flail of bicuspid cusps confirmed on transesophageal ultrasound. The patient underwent surgery. The aortic valve was removed and replaced with a mechanical prosthesis. Conclusion: Cardiac symptoms and echocardiographic findings that initiated two months after a high-voltage electric injury led us to conclusion that bicuspid valve was probably injured by electrical shock. To the authors' knowledge, this is the first reported case of valvular rupture due to electrical injury in Croatian population. [ABSTRACT FROM AUTHOR]

Introduction: Sinus of Valsalva aneurysm (SVA) is an abnormal dilatation of the aortic root located between the aortic valve annulus and the sinotubular junction. The estimated rate of SVA is approximately 0.09% of the general population and involve up to 3.5% of all congenital heart defects. Aneurysm predominantly originates from the right coronary sinus and may rupture up to 35% of the time commonly to the right cardiac chambers. We present an unusual case of a patient with SVA originating from the non-coronary sinus. Case report: 63-old-year male with no history of prior cardiovascular disease was presented to department with shortness of breath and chest pain. Physical examination showed blood pressure of 140/80mmHg, respiratory rate of 18/min and heart rate of 84 beats/min. Electrocardiogram revealed complete right bundle-branch block. A routine transthoracic echocardiography showed the enlargement of the left ventricle with large aneurysm originating from non-coronary sinus measuring 3.6x4cm. Echocardiography also revealed a trileaflet aortic valve with moderate aortic regurgitation and normal systolic function of the left ventricle. TEE demonstrated a non-coronary SAV protruding into the left atrium cavity with no signs of rupture. Selective angiography showed normal epicardial coronary arteries, and SAV with dilatation of ascending aorta measuring up to 40 mm. Moderate aortic insufficiency was also detected. The patient was referred to the cardiothoracic surgery ward for further operative treatment. Conclusion: Although rare, SAV can be a cause of sudden death. Therefore, a combination of transthoracic echocardiography with other imaging techniques, such as TEE, 3D echocardiography, CT angiography and aortic angiography is recommended to obtain comprehensive information and to improve diagnostic accuracy. [ABSTRACT FROM AUTHOR]

Introduction: The left atrial appendage (LAA) is the most common place of thrombosis in patients with atrial fibrillation (AF). Numerous studies have shown that oral anticoagulation (OAC) significantly reduces the risk of thromboembolism. However, there are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated. Case report: 68-years-old male with permanent non-valvular AF, currently taking apixaban, was hospitalized for the second time due to recurrent ischemic cerebrovascular stroke. At the time of his first presentation six months ago, he was well anticoagulated with warfarin (international normalized ratio was 3.56) and have had a CHA2DS2VASc score 2. He had no significant carotid disease or mobile aortic arch atheroma. Transesophageal echocardiography (TEE) revealed a significantly dilated left atrium (LA) with dense spontaneous echo contrast (SEC). There was no organized thrombus in the LA nor in the LAA. The contractile function of the LAA was severely decreased, with peak systolic velocity of 33 cm/s on Doppler evaluation. Despite taking effective anticoagulant medications for both times our patient experienced recurrent ischemic stroke and yet again had dense SEC in the LA and LAA. In order to prevent upcoming cardioembolic event, we decided to preform percutaneous LAA closure with Amplatzer Amulet device under TEE guidance. Successful LAA closure was confirmed by color Doppler imaging and a single postocclusion angiography. The patient was discharged with OAC (warfarin) in addition of 100 mg/day of acetylsalicylic acid to prevent thrombus formation on device. Follow up TEE was performed one month after the procedure. Good position of LAA occluding device was confirmed with no evidence of thrombus formation on the left atrial face of the device. Conclusion: In general, after implantation of LAA occluding device, OAC is not indicated. However, combination therapy with indefinite OAC plus LAA closure in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous catheter, mostly radiofrequency (RF) ablation for supraventricular tachycardias (SVT) is an established way of treating symptomatic patients. Traditionally, essential tool for guiding intracardiac catheter manipulation was X ray fluoroscopy.1 The risks of exposing patients to ionizing, X ray radiation are well known and are of particular concern in pediatric cases or cases involving pregnant women. Recently, with the help of electroanatomical (3D) mapping systems, a possibility to perform these procedures without the use of X ray fluoroscopy, so called «zero fluoro», emerged. This is a case report with an overview of some intraprocedural aspects of «zero fluoro» RF ablation procedure performed in 26 years old pregnant women at University Hospital Centre Split. Case report: The patient was 26 years old primigravida, in sixth month of gestation, with the multiple symptomatic SVT episodes, uncontrolled under atenolol therapy. EP study was performed via right groin venous access and diagnostic catheters inserted in a coronary sinus and right ventricle without the use of X ray. Typical AVNRT was easily inducible and decision was made to proceed with the RF ablation with the intention of maintain «zero fluoro» principle. Couple RF applications (30-40W) were placed in AV nodal slow pathway region under only 3D mapping system guidance. RF application resulted in loss of continuous slow pathway conduction and thus rendered arrhythmia noninducible, even with isoproterenol provocation. Overall procedure time was 47 minutes, including 15 minutes waiting period for eventual tissue recovery. No complications occurred, and the patient had been discharged the day after. She stood arrhythmia free till her labour that had gone uneventful. Conclusion: Zero fluoro approach to RF ablation in patients with symptomatic SVT episodes is feasible. It should be preferred approach in vulnerable population such as pediatric cases or cases involving pregnant women. [ABSTRACT FROM AUTHOR]

Introduction: Pleuropulmonary synovial sarcomas are rare soft tissue malignancies.1-3 Additionally, pleuropulmonary synovial sarcoma metastasis with valvular involvement, which was the case with our patient, is even more rare. We present an unusual case of a 42-year-old female patient with metastatic pleuropulmonary synovial sarcoma prolapsing to the left ventricular cavity and causing mitral valve obstruction. Case report: 42-year-old female patient with a history of previously resected inguinal synovial sarcoma who underwent radical irradiation and remained stable for 3 years appeared with the following symptoms: cough, dyspnea and hemoptysis. Computed tomography (CT) scan showed a suspected tumor mass within the left inferior pulmonary lobe affecting the mediastinal pleura with infiltration of the left pulmonary vein. CT scan also revealed a 6 cm mass in the left atrium (LA) that prolapsed into the mitral valve. Immediate echocardiography was performed, which showed a left atrial mass measuring 60x27mm prolapsing into the mitral valve and causing valvular obstruction. Mean pressure gradient across the mitral valve was 6 mmHg. Echocardiography revealed normal ventricular systolic function but a dilatated right ventricle with severe pulmonary hypertension. MRI confirmed previous echo findings but showed a more prominent protrusion of the tumor mass to the right atrium through the atrial septal defect. Bronchial biopsy of the tumor mass revealed undifferentiated monomorphic blunt spindle cells with CD 99 positive expression which confirmed the diagnosis of metastatic monophasic synovial sarcoma. Due to a large tumor extension to almost all cardiac chambers, cardiothoracic surgery was not indicated. Patient is considered for further chemotherapy with ifosfamide/doxorubicin. Conclusion: The aggressive nature of synovial sarcoma makes its early detection difficult. Because of the small number of reported occurrences, there is no consensus regarding optimal therapy. Therefore, it seems worth investigating both optimal surgical procedures and additional chemo-radiotherapy protocols in order to improve the patient's survival. [ABSTRACT FROM AUTHOR]

Introduction: Diffuse large B cell lymphoma (DLBCL) is an aggressive and fast-growing type of lymphoma. Cardiac lymphoma is a rare cardiac tumor and an even more rare extranodal site of lymphoma, of which the most common type is DLBCL.1-3 We report a case of an 85-year-old female patient with pericardial lymphoma presenting with persistent effusions. Case report: 85-year-old female patient presented with sudden onset chest pain and dyspnea. A week before she was diagnosed with atrial fibrillation and warfarin and bisoprolol therapy was started. Echocardiography showed a circular pericardial effusion up to 20 mm thickness with no signs of impending tamponade. Thoracic, abdominal and pelvic CT showed no pathology, apart from the effusion. Laboratory tests showed a suspected M-protein and IgM/kappa through serum protein electrophoresis. A 3-week follow-up revealed a progression in effusion volume (29 mm) and symptoms exacerbation with ankle edema, chest pain and night sweats. Cytological analysis of an effusion sample verified DLBCL with plasma cell differentiation. The same was confirmed by bone marrow biopsy. Imaging showed no signs of lymphadenopathy or hepatosplenomegaly. Lymphoma was staged as Ann Arbour IVB and IRI 3. Therapy was initiated according to the R-CEOP protocol. After 4 therapy cycles echocardiography showed no signs of effusion. A total of 8 therapy cycles were administered and a control work-up showed total remission of the disease. Conclusion: New therapeutic protocols for this type of aggressive lymphoma have significantly improved patient survival rates. Clinical presentation is usually unspecific with a wide differential diagnosis. Given that extranodal and cardiac involvement is a negative prognostic sign for patient survival, efforts are warranted to improve the time to diagnosis and therapy initiation necessary for a favorable outcome. [ABSTRACT FROM AUTHOR]