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Introduction. Spontaneous coronary artery dissection (SCAD) is defined as a dissection that has not occurred with atherosclerosis, trauma, or has not developed iatrogenically. Case outline. A 53-year-old man was admitted to the hospital due to chest pain and ischemic electrocardiographical changes. Coronarography was performed and 85% of the stenosis of the first diagonal branch (D1) was registered. During percutaneous coronary intervention (PCI), one drug-eluting was directly implanted into the D1. About three hours after the intervention, the patient developed an acute myocardial infarction with ST elevation (STEMI) and recoronarography was performed. The previously implanted stent in D1 was patent without thrombi. The subocclusive stenosis of the left anterior descending artery (LAD) was registered and PCI was performed. After implantation of the stents into the LAD, propagation of dissection towards left circumflex artery (LCx) was creating significant stenosis. Following the registration of the stenosis, PCI was performed on this branch. In order to determine the cause of acute STEMI, intravascular imaging was performed, seven days after last PCI. Optical coherence tomography showed an excellent stent apposition and expansion. In the area under the stents, in the proximal segment of LAD and LCx, showed duplication in the blood vessel wall. This duplication represents an unresorbed intramural hematoma as a consequence of SCAD. Conclusion. When performing coronarography on younger patients, on women in the peripartum and on patients with connective tissue, SCAD disorders should be kept in mind. The use of intravascular imaging could reduce the number of unrecognized SCAD.

Background/Aim. Contrast echocardiography (CE) is an echocardiographic modality where ultrasound contrast echocardiographic agent (CEA) is introduced peripherally for the image enhancement. The aim of this study was to present the initial clinical experience of the use of CEA Optison™ (GE Healthcare, Princeton, NJ) at the Institute for Cardiovascular Diseases of Vojvodina, Serbia and prospectively monitor the occurrence of possible side effects. Methods. A total of 357 patients were referred for resting or stress echocardiographic examinations, with an approved indication for CEA administration. The average age of patients was 63.3 years (range, 21–92 years), 62% of them were men. Most of the patients (77.31%) had some form of ischemic heart diseases. Hypertension was the most frequent risk factor (77.03%), but 57 patients had diabetes mellitus and 33 patients had chronic kidney disease as comorbidity. Most (90.5%) of the patients were on beta blocker therapy, 83.5% of them on angiotensin converting enzyme/angiotensin receptor blockers. Majority (80.3%) of the patients received single or dual (49.5%) antiagregation therapy, 74 (26.3%), of them were on anticoagulation therapy, 55.1% of the patients were taking diuretics. The global ejection fraction (EF) was preserved in 39.85% of them, the majority (136 of them), had left ventricle (LV) impairment, with an EF less than 50%. Patients were followed up for 30 minutes after CEA administration for potential side effects. In 118 patients, vital signs (heart rate, oxygen saturation, body temperature, systolic and diastolic blood pressure) were measured before and 30 minutes after CEA administration. Results. The administration of CEA was not associated with side effects. Diastolic blood pressure drop and heart rate increase were statistically, but not clinically significant (p = 0.027 and p = 0.028, respectively). Conclusion. Changes in analyzed vital signs were clinically non relevant. CE is a safe noninvasive diagnostic modality for patients undergoing rest and stress echocardiography.

Introduction/Objective Patients who have had symptoms for more than 12h before receiving treatment are considered to be myocardial infarction late presenters. The literature contains scarce and often controversial data about treating such patients. The objective of the paper is to present treatment outcome in patients with acute ST-elevation myocardial infarction (STEMI), whose therapy was initiated more than 12h and less than 48 hours after the onset of symptoms. Methods the research included 130 patients who had suffered from acute STEMI in 2017, all of whom presented more than 12h and less than 48h after the onset of symptoms. A primary percutaneous coronary intervention (PPCI) was used to treat 109 patients, while 21 patients were treated conservatively. An analysis was performed correlating treatment results, intrahospital mortality, one-year survival rate depending on the type of treatment, risk factors and comorbidity. Results A statistically significant difference (x 2 =7,119; p=0,017) has been verified when comparing the mortality of STEMI patients treated with PPCI(8.3%) and those treated conservatively (28.6%). A statistically significant difference (t=9,385; p=0,005) has been verified when it came to treating STEMI patients that were also suffering from diabetes. In the group treated with PPCI, 77.8% of the patients that had died had diabetes. No comorbidity showed a statistically significant difference in distribution depending on the type of treatment and treatment results. Conclusion When deciding on the type of treatment these patients shall receive, the following should be taken into consideration: clinical presentation, hemodynamic status and presence of life-threatening arrhythmias. There is still no clear guideline for treating such patients.

Introduction. Several arteries can be used as the approach for coronarography or primary percutaneous coronary intervention (pPCI). In patients with acute ST-elevation myocardial infarction (STEMI), when performing pPCI according to the current recommendations, approach artery should be the radial artery. Complications of the transradial approach, such as spasm, asymptomatic occlusion, perforation, nerve damage, arteriovenous fistula, compartment syndrome, and radial artery pseudoaneurysm are described. However, only a few cases describe rare complications of transradial approach such as the perforation of the axillary artery. Case outline. The patient was admitted due to the STEMI. Urgent coronarography found 90% stenosis of the proximal segment of the left anterior descendent branch of the left coronary artery (LAD). During the pPCI, a metal stent was implanted in the proximal segment of the LAD. One hour after the intervention, a hematoma in the right arm was registered with the hemodynamic collapse. Angiography of the left axillary artery showed an extravasation of the contrast. A graft stent was implanted in the area of extravasation. After the intervention, regression of the hematoma was registered. Ten years after the primary intervention, CT coronarography and angiography were performed. The stent in the LAD, as well as in the axillary artery, was without any stenosis. Conclusion. Advanced life expectancy, hypertension, atherosclerosis, anatomical variations, and blood vessel tortuosity contribute to the perforation of the axillary artery, a very rare complication of the radial approach. It is usually treated conservatively. In the case of hemodynamic instability, a stent implantation can be considered, as it was in our case.

Introduction The ventricular septal defect (VSD) incidence today is less than 1%. It presents with a rapid clinical deterioration and acute heart failure. A loud systolic murmur appears over the precordium. Doppler echocardiography is the golden standard for diagnosis. Case Report A female patient was admitted to the hospital with the diagnosis of an acute myocardial infarction with the involvement of the inferior wall and right ventricle. At admission, a loud systolic murmur above the precordium was noted and an emergency echocardiography was performed. A suspected interruption of the interventricular septum continuity was registered at the inferoseptal level. An emergency coronography was immediately performed to uncover a subocclusion of the medial segment of the right coronary artery. Ventriculography was performed in the same act and passage of contrast was registered from the left ventricle to the right at the septal level. A cardiac surgeon was consulted, but the patient died while being prepared for surgery. Conclusion Keeping in mind the high mortality rate, a prompt diagnosis and aggressive treatment with a timely surgical intervention are necessary to enable a favorable outcome. Poor prognosis parameters are advanced age and a myocardial infarction involving the inferior wall, which were both present in our patient.

Introduction/objective a myocardial infarction without coronary artery obstruction (MINOCA) is defined by universal acute myocardial infarction criteria with no obstructive coronary artery disease and no defined cause of the acute clinical presentation at angiography at that time. We are presenting an interesting case of hyperthyroidism as a potential cause of MINOCA. Case report the patient was admitted to the Clinic of Cardiology, Institute for Cardiovascular Disease Vojvodina under the suspicion of an inferior myocardial infarction with ST elevation. An emergency coronary angiogram was indicated and came back with normal coronary artery lumens. Echocardiography registered akinesia of the medioinferior and mediolateral wall with hypokinesia of the basal inferior wall accompanied by high levels of cardio specific enzymes. A working diagnosis of MINOCA was made and further diagnostic procedures were undertaken. Laboratory findings indicated hyperthyroidism, so the patient was put on suppressive therapy and low doses of beta blockers, nitrates an Ca antagonists. The hyperthyroidism most probably led to a coronary vasospasm, which is considered to have caused the MINOCA in our patient. Conclusion In younger patients, smokers who complain of chest pain early in the morning, hyperthyroidism should be considered to be a potential cause of MINOCA myocardial infarction.

Background: There is evidence that right ventricular (RV) contractile function, especially its coupling with the pulmonary circulation, has an important prognostic value in patients with left ventricular dysfunction. Aims: This study aimed to identify the best echocardiographic parameters of RV function and pulmonary artery systolic pressure (PASP) alone or in the form of the index of right ventricular-pulmonary artery coupling (RV-PA coupling) to determine the best predictor of 1-year major adverse cardiovascular events (MACE), which were defined as cardiovascular death and cardiac decompensation in heart failure patients with reduced ejection fraction (HFrEF). Methods and results: The study enrolled 191 HFrEF patients (mean age 62.28 ± 12.79 years, 74% males, mean left ventricular ejection fraction (LVEF) 25.53 ± 6.87%). All patients underwent clinical, laboratory, and transthoracic echocardiographic (TTE) evaluation, focusing on assessing RV function and non-invasive parameters of RV-PA coupling. RV function was evaluated using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and peak tricuspid annular systolic velocity (TAS'). PASP was estimated by peak tricuspid regurgitation velocity (TRVmax) and corrected by assumed right atrial pressure relative to the dimension and collapsibility of the inferior vena cava. The TAPSE/PASP and TAS'/PASP ratios were taken as an index of RV-PA coupling. During the follow-up (mean period of 340 ± 84 days), 58.1% of patients met the composite endpoint. The independent predictors of one-year outcome were shown to be advanced age, atrial fibrillation, indexed left atrial systolic volume (LAVI), LVEF, TAPSE/PASP, and TAS'/PASP. TAS'/PASP emerged as the strongest independent predictor of prognosis, with a hazard ratio (HR) of 0.67 (0.531–0.840), p < 0.001. Reconstructing the ROC curve 0.8 (0.723–0.859), p < 0.001, we obtained a threshold value of TAS'/PASP ≤ 0.19 (cm/s/mm Hg) (sensitivity 74.0, specificity 75.2). Patients with TAS'/RVSP ≤ 0.19 have a worse prognosis (Log Rank p < 0.001). Conclusions: This study confirmed previously known independent predictors of adverse outcomes in patients with HfrEF—advanced age, atrial fibrillation, LAVI, and LVEF—but non-invasive parameters of RV-PA coupling TAPSE/PASP and TAS'/PASP improved risk stratification in patients with HFrEF. Variable TAS'/PASP has been shown to be the most powerful, independent predictor of one-year outcome. [ABSTRACT FROM AUTHOR]

Introduction. Myxoma is the most common intracardiac tumor accounting for about 50% of all heart tumors. The symptoms depend on the size of the tumor, its location and mobility. Embolic manifestations of coronary arteries are extremely rare, occurring in about 0.06% of cases, and they are caused by tumor fragments. Case Report. A 54-year-old female patient was admitted for an acute myocardial infarction with ST segment elevation in the inferior leads. Urgent coronary angiography was performed showing no coronary vessel stenosis. In the projection of the left atrium, a mobile mass with partial calcification was registered, which was stained to a lesser extent with a contrast agent. These were nutrient vessels with a typical “tumor blush” sign. An echocardiographic examination showed a round, inhomogeneous mass in the left atrium, which was fixed to the interatrial septum. The findings were presented to the cardiology team and urgent surgical extirpation was performed. During the follow-up period of two years, the patient was doing well and echocardiographic examination showed a normal finding, without recurrence of the tumor. Conclusion. Acute myocardial infarction in people without risk factors for ischemic heart disease is very rare. The most common cause of this type of acute coronary syndrome is spontaneous coronary artery dissection. Acute myocardial infarction caused by embolization of the coronary artery by myxoma fragments is a rare phenomenon. Echocardiographic examination is the method of choice in the diagnosis of myxoma. The most effective treatment for these patients is surgical resection of the tumor with low operative mortality. [ABSTRACT FROM AUTHOR]

Introduction. Electrocardiography is an initial non-invasive diagnostic algorithm for ST elevation acute myocardial infarction. Specific electrocardiographic phenomenon is described, when the occlusion of the proximal segment of the right coronary artery or the isolated occlusion of its ventricular branch is presented with ST elevation in the precordial leads. Case Report. A 78-year-old woman was admitted as an emergency due to chest pain and electrocardiographically recorded concave elevation in leads V1 - V3. She was diagnosed with ST elevation myocardial infarction of the anterior region and sent to catheterization laboratory for emergency coronary angiography. It showed an occlusion of the proximal-medial right coronary artery. Behind the occlusion, the right coronary artery, posterior descending artery and posterior lateral artery, a hetero-collateral circulation was seen. Two drug-eluting stents were implanted into the proximal segment of the right coronary artery. Discussion. The phenomenon of acute myocardial infarction caused by occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery, presenting with ST segment elevation in the precordial leads, is a consequence of several anatomical variations: occlusion of nondominant right coronary artery, isolated occlusion of the ventricular branch of the right coronary artery, and the occlusion of the right coronary artery proximal to the ventricular branch with hetero collateral circulation on the periphery of the right coronary artery, like in our case. Electrocardiographic characteristic pointing to the occlusion of the proximal right coronary artery and/or ventricular branches of the right coronary artery is higher ST elevation in the lead V1 than in the other leads, followed by the absence of Q wave development. This ST elevation is concave. Conclusion. It is necessary to emphasize the significance of differential diagnosis of culprit lesion in patients with chest pain and elevation of the ST segment in the precordial leads having in mind further different thera peutic algorithms. Patients with right ventricular myo cardial infarction need to maintain an adequate "preload" and avoid vasodilators in order to maintain the right ventricular stroke volume. [ABSTRACT FROM AUTHOR]