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Aims Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between the risk of bleeding and thromboembolism. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) and there are no guidelines which specify an initial unfractionated heparin (UFH) dose. We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. Methods We conducted international, multi-centre, registry-based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analysed. Before the transseptal puncture, UFH bolus of 100 U/kg was administered regardless of the anticoagulation drug. Results A total of 873 AF patients were included (median age 61 years, IQR 53-66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257±50 sec, overall procedural ACT 295±45 sec and total UFH dose 158±60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262±57 and 270±48 vs. 248±42 and 241±44 sec, p

Background: Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between bleeding and thromboembolic risk. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) with target value >300 s, and there are no guidelines specifying an initial unfractionated heparin (UFH) dose. Methods: We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. We conducted an international, multi-center, registry-based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analyzed. Before transseptal puncture, UFH bolus of 100 IU/kg was administered regardless of the anticoagulation drug. Results: Total of 873 patients were included (median age 61 years, IQR 53-66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257 ± 50 s, mean overall ACT 295 ± 45 s and total UFH dose 158 ± 60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262 ± 57 and 270 ± 48 vs. 248 ± 42 and 241 ± 44 s, p < .001), (ii) significantly higher ACT throughout PVI (309 ± 46 and 306 ± 44 vs. 282 ± 37 and 272 ± 42 s, p < .001), and (iii) needed lower UFH dose during PVI (140 ± 39 and 157 ± 71 vs. 171 ± 52 and 172 ± 70 IU/kg). Conclusion: There are significant differences in ACT values and UFH dose during PVI in patients receiving different anticoagulants. Patients on warfarin and dabigatran had higher initial and overall ACT values and needed lower UFH dose to achieve adequate anticoagulation during PVI than patients on rivaroxaban and apixaban.

Background: Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI. Methods: Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage’s TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s. Results: This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ± 4.1 kg/m2, LA volume index 32 ± 11 mL/m2). After a median follow-up of 14 (IQR 10–22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28–1.62, p

Introduction: Although radiologic technologists have many responsibilities in the cardiac catheterization laboratory, the most important responsibility is to perform invasive cardiac surgery using radiological equipment in a safe manner, both for staff and for the patient. Very often, in addition to working with radiological equipment, radiologic technologists must have specific knowledge of specific interventional procedures in invasive. In order to monitor the complexity of today’s procedures and actively participate in an invasive team, ongoing and specific education is essential. The job of a radiologic technologist in the cardiology intervention room consists of a series of tasks such as: knowledge of the complexity of radiation protection, knowledge of heart anatomy, physiology, hemodynamics and all the technical capabilities of devices used in invasive cardiac methods. At the catheterization laboratory, radiologic technologists participate in preparing the patient for the procedure, which includes checking patient data, taking anamnestic data related to the procedure, placing the patient on the table, monitoring vital functions, etc.1 The paper presents the experience of University Hospital Center „Sestre milosrdnice“, whereby after the establishment of the Clinic for Cardiovascular Diseases, the team settings at the Department of Invasive and Interventional Cardiology were changed. In earlier periods, practically from the moment the laboratory started with work, the radiological device was operated traditionally and habitually, but also due to a lack of staff, by invasive cardiologists and/ or perioperative nurses. Goal: To compare radiation exposure before and after changes in team settings, and to determine the immediate impact of the work of radiologic technologists in the invasive cardiology laboratory. Conclusion: Radiologic technologists who directly control radiological equipment and accurately follow the instructions of the operator (interventional cardiologist), by standardizing procedures, can significantly affect the safety of the patient and team in the invasive laboratory.

Heart transplantation is a therapy of choice for patients with advanced terminal heart failure. A particular problem in these patients represents the titration of immunosuppressive therapy during infection, which is especially true in COVID-19. We present a case of a heart transplant recipient, who was successfully treated for a severe COVID-19 pneumonia. The patient underwent the orthotopic heart transplantation in 2018 at the age of 52 due to ischemic cardiomyopathy. Early posttransplantation phase was uneventful, and his immunosuppressive regimen consisted of tacrolimus and mycophenolate mofetil. Following the recommendations he was fully vaccinated for COVID-19. Despite this, one month after the last vaccine, he presented to our emergency department with dyspnea, prostration, fatigue and respiratory insufficiency. A bilateral pneumonia caused by SARS-CoV-2 was verified, and he was hospitalized in the COVID-19 primary intensive respiratory center where high flow oxygen therapy was immediately initiated. The treatment was further complicated by secondary pneumonias, extending the duration of his hospital stay. Finally, after two months of hospital treatment the patient was discharged home. The treatment of immunosuppressed heart transplant recipients for COVID-19 is an extraordinary clinical challenge, requiring an uneasy act of balance between a deadly infection and a potentially equally fatal heart transplant rejection. [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.)

BACKGROUND: A small proportion of patients undergoing primary prophylactic implantation of implantable cardioverter defibrillators (ICDs) experiences malignant arrhythmias. We postulated that periodic repolarisation dynamics, a novel marker of sympathetic-activity-associated repolarisation instability, could be used to identify electrically vulnerable patients who would benefit from prophylactic implantation of ICDs by way of a reduction in mortality. METHODS: We did a prespecified substudy of EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD), a prospective, investigator-initiated, non-randomised, controlled cohort study done at 44 centres in 15 EU countries. Patients aged 18 years or older with ischaemic or non-ischaemic cardiomyopathy and reduced left ventricular ejection fraction (≤35%) were eligible for inclusion if they met guideline-based criteria for primary prophylactic implantation of ICDs. Periodic repolarisation dynamics from 24-h Holter recordings were assessed blindly in patients the day before ICD implantation or on the day of study enrolment in patients who were conservatively managed. The primary endpoint was all-cause mortality. Propensity scoring and multivariable models were used to assess the interaction between periodic repolarisation dynamics and the treatment effect of ICDs on mortality. FINDINGS: Between May 12, 2014, and Sept 7, 2018, 1371 patients were enrolled in our study. 968 of these patients underwent ICD implantation, and 403 were treated conservatively. During follow-up (median 2·7 years [IQR 2·0-3·3] in the ICD group and 1·2 years [0·8-2·7] in the control group), 138 (14%) patients died in the ICD group and 64 (16%) patients died in the control group. We noted a 43% reduction in mortality in the ICD group compared with the control group (adjusted hazard ratio [HR] 0·57 [95% CI 0·41-0·79]; p=0·0008). Periodic repolarisation dynamics significantly predicted the treatment effect of ICDs on mortality (adjusted p=0·0307). The mortality benefits associated with ICD implantation were greater in patients with periodic repolarisation dynamics of 7·5 deg or higher (n=199; adjusted HR 0·25 [95% CI 0·13-0·47] for the ICD group vs the control group; p

Percutaneous coronary interventions (PCI) have been the fastest growing major invasive procedure in the past decade. Although PCI has many advantages, there are certain risks, including cardiac arrhythmias. It is known that myocardial ischemia and infarction leads to severe metabolic and electrophysiological changes that induce silent or symptomatic life-threatening arrhythmias. Both atrial and ventricular arrhythmias may occur during PCI procedure.1-3 Arrhythmias and conduction disturbances are common during the early hours after myocardial infarction (MI) and a major cause of death in the pre-hospital phase. In STEMI patients undergoing primary PCI, ventricular arrhythmias, including non-sustained ventricular tachycardia (VT) in 26% of cases and sustained VT in 2-5% cases, have been reported. As the most lethal arrhythmia, ventricular fibrillation (VF) has been reported in 2-5% of cases. But on the other side, sustained VT occurs in 17-21% and VF even in 24-29% in patients with MI and cardiogenic shock undergoing pPCI. The occurrence of atrial fibrillation (AF) is frequently associated with severe left ventricular damage and heart failure. Episodes may last from minutes to hours and are often repetitive. In the case of cardiogenic shock, AF can quickly lead to a worsening of symptoms. High-grade AV block and asystole develop in about 23-35% of acute MI patients with cardiogenic shock, especially in the case of right coronary artery occlusion. Either ventricular or atrial arrhythmias or conduction disturbances occur as a complication of the PCI procedure, but many of them are related to reperfusion injury. The majority of the arrhythmias tend to revert spontaneously, but when necessary, special treatment must be given promptly. For nurses to be able to react properly, effective and early recognition of cardiac arrhythmias during PCI is crucial and beneficial. Also, it is important to identify changes in cardiac status and to early recognize high-risk patients for cardiac arrest, before the patient becomes symptomatic. Accuracy of cardiac rhythm interpretation improves with intermittent educational interventions. Moreover, cardiac rhythm recognition is crucial during Advance Life Support (ALS) training and it is recommended for all cardiac catheterization staff to undergo this type of training.

Four thousand cardiac implantable electronic devices (CIED) are implanted yearly in Croatia with constant increase. General anesthesia and surgery carry some specific risk for the patients with implanted CIEDs. Since most of the surgical procedures are performed in institutions without reprogramming devices available, or in the periods when they are unavailable, these guidelines aim to standardize the protocol for perioperative management of these patients. With this protocol, most of the procedures can be performed easily and, more importantly, safely in the majority of surgical patients., U Republici Hrvatskoj na godinu se implantira oko 4000 kardiovaskularnih implantabilnih uređaja i taj broj je u stalnom porastu. Anestezija i kirurški zahvati kod bolesnika s ugrađenim implantabilnim uređajima nose određene rizike. Ove smjernice su nastale zato što se većina zahvata izvodi u ustanovama bez mogućnosti testiranja i reprogramiranja navedenih uređaja ili u vrijeme kada to nije dostupno. Cilj je standardizirati perioperacijsku skrb ovih bolesnika te učiniti kirurške zahvate dostupnima i sigurnima za veliku većinu ovih kirurških bolesnika u svim ustanovama u Hrvatskoj.

We report the case of a 46-year old patient in whom an electrophysiology study (EP) was performed due to paroxysmal supraventricular tachycardia documented in 12-lead ECG. During the EP study, supraventricular tachycardia was induced easily and it corresponded to orthodromic AV reentry tachycardia (AVRT) using a concealed left free wall accessory pathway. However, during the study AVRT spontaneously and repeatedly converted to the typical slow-fast AV node reentry tachycardia (AVNRT). Both accessory and AV nodal slow pathways were ablated, due to the finding that both AVRT and AVNRT were independently inducible during the EP study.

Nurses have great influence on health care system. As they face many different states of affairs nowadays, it is necessary to find a way to promote and enable their profession. The significant interaction between nurses and patients and other medical professions makes them a powerful marketing tool of a medical institution. Therefore, the promotion of their image is necessary because of authorizing their professional status. There are numerous ways of creating and improving their image. Some of them include implementation of marketing principles and the Internet as well. This paper presents the web page promotion of nursing, i.e. the Nursing and Related Professions of the Sestre milosrdnice University Hospital Center homepage, as a tool of nursing promotion.

Transseptalna punkcija (TSP) je postupak koji omogućuje perkutani transvenski pristup strukturama lijevog srca. TSP je razvijena primarno radi hemodinamske procjene valvularnih grešaka i mitralne valvuloplastike, dok je danas, u eri izolacije plućnih vena (PVI), postala rutinska procedura većine elektrofiziologa. Obzirom na porast broja PVI u Hrvatskoj, tehnika TSP postaje svakodnevica elektrofiziologa. Stoga liječnici i osoblje moraju biti upoznati s TSP i potencijalnim komplikacijama. Svrha ovog preglednog članka je prikazati kratku povijest i razvoj TSP, samu tehniku, indikacije te potencijalne komplikacije., Transseptal puncture (TSP) is a procedure that allows transvenous access to the structures of the left heart. TSP has been primarily developed for the evaluation of valvular disease and mitral valvuloplasty, while today, in the era of pulmonary vein isolation (PVI), it has become a routine procedure performed by a great number of electrophysiologists. Since there is a constant increase in a number of PVIs in Croatia, TSP is becoming a standard procedure for electrophysiologists. Physicians and staff must therefore be trained in TSP and its potential complication. This review focuses on the historical development of TSP, its technical aspect, indications and complications.

Transradial approach became frequent procedure in treatment of percutaneous coronary interven- tions while the same approach is still used rarely with the patients who need invasive angiology diag- nostics. The main advantages of the transradial approach concerning the potential complications are generally very well known as well as the advantages in the means of comfort for the patient.1-3 In University Clinical Centre “Sestre milosrdnice” from 2011 transradial approach was used in total of 101 cases of invasive diagnostics or interventional treatment. In 32 situations it was used as one of the additional approaches within the main intervention on iliac arteries, whilst in 11 cases the transradial approach was the main the intervention on iliac arteries. For now, the transradial approach is mainly reserved for the interventions on renal and iliac arteries. Transradial approach is safe and reliable method for invasive diagnostics of peripheral arteries whilst the application of the interventions on arteries of the lower limb just recently started to be applied more often.

We report the case of a 47-year old female patient in whom an electrophysiology study (EP) with 3D mapping system (CARTO) was performed due to paroxysmal idiopathic sustained ventricular tachycardia (VT). Anterograde as well as retrograde approach was used during the procedure and fascicular VT using left posterior fascicle was diagnosed, however it was rather non-sustained. After 90 minutes of mapping, patient complained of chest pain and sustained VT was recorded in 12-lead electrocardiogram. After short conversion to sinus rhythm an ST-segment elevation in anterior leads was noticed. The EP procedure was aborted and coronary angiography was performed. Coronary angiography showed dissection of ostial left anterior descending artery and percutaneous coronary intervention with implantation of 2 drug-eluting stents was performed. After 3 months follow up, echocardiography showed normal left ventricular systolic function (EF 60%) with mild hypokinesia of the anteroseptal region. With verapamil as antiarrhythmic therapy the patient was free of VT during 6 months and without heart failure symptoms.

Unatoč činjenici da je koronarna bolest srca (KBS) prvi uzrok smrtnosti, u Hrvatskoj ne postoji sveobuhvatni registar osoba koje boluju od KBS, a registre za perkutanu koronarnu intervenciju (PCI) imaju samo pojedini laboratoriji za kateterizaciju srca, koji se značajno razlikuju i nisu međusobno kompatibilni. Laboratorij za invazivnu i intervencijsku kardiologiju Kliničkog bolničkog centra Sestre milosrdnice 1. siječnja 2011. godine je oformio vlastiti registar za PCI. Ovaj registar dostupan je u elektroničkom obliku, s visokim stupnjem zaštite pristupa. U registar se upisuje 45 različitih podataka koji su podijeljeni u pet skupina: opći podaci, čimbenici rizika, simptomi i znakovi akutne bolesti, zahvat i utrošeni materijal te dijagnostički i terapijski nalaz. Osnovne razlike ovog registra, u odnosu na postojeće, jest model prema kojem je upis podataka za svakog bolesnika podijeljen između medicinskog tehničara, inžinjera medicinske radiologije i intervencijskog kardiologa, izrazita jednostavnost, kratko vrijeme potrebno za upis te istovremeno ispisivanje nalaza kateterizacije. Tek nakon što su ispunjeni svi traženi podaci intervencijski kardiolog upisuje dijagnozu i nalaz te se podaci zaključavaju. Na taj smo način osigurali da se u bazu podataka upisuju sve varijable vezane uz svaku pojedinačnu učinjenu intervenciju, mogu ispisati u Excel ekstenziji te implementirati u bilo koji registar. Nakon prve godine uporabe zaključili smo da je Registar značajno olakšao svakodnevni rad te da predstavlja nadopunu novih tehnologija uvedenih u liječenje KBS. Formiranje ovog Registra samo je korak prema zajedničkom cilju, formiranju nacionalnog registara PCI te sudjelovanju Republike Hrvatske u europskom registru bolesnika s akutnim koronarnim sindromom., Despite the fact that coronary heart disease (CHD) is the first cause of mortality, in Croatia there is no comprehensive registry of patiens with CHD, while the registries for percutaneous coronary intervention (PCI) are maintained only by specific cardiac catheterization laboratories, which greatly differ from each other and are not mutually compatible. Laboratory of Invasive and Interventional Cardiology of the University Hospital Centre Sestre milosrdnice established its own PCI registry from 1st January 2011. This registry is available in electronic format, with a high access protection level. The registry includes 45 different data which are divided into 5 groups: general data, risk factors, symptoms and signs of acute disease, procedure and materials used, and diagnostic and therapeutic results. The main differences of this registry compared to the existing registries is a model according to which the entry of data for each patient are divided between the medical technician, medical radiology engineer and interventional cardiologist, its utmost simplicity, short time required for the registration and writing the findings of catheterization at the same time. Only after all the required data have been filled in, the interventional cardiologist will enter a diagnosis and findings and the data are locked. In this way we have ensured that all the variables relating to each individual intervention performed are entered in the database, they can be written in Excel extension and implemented in any registry. After the first year of use, we have reached a conclusion that the Registry has greatly facilitated the daily work and that is complements the new technologies introduced in the treatment of CHD. The establishment of this Registry is only a step towards a common goal, establishment of the national PCI registry and participation of the Republic of Croatia in the European registry of patients with acute coronary syndrome.

2. Trbusic M, Gabric ID, Planinc D, Krcmar T, Pintaric H. What happens when transradialists use transbrachial approach. J Invasive Cardiol. 2013;25 (Suppl E):30E. UvOD: Od 2011. primarni postav naseg laboratorija za invazivnu kardiologiju promijenjen je s femoralnog u lijevi radijalni i danas se oko 95% svih postupaka ucini lijevim ili desnim „nefemoralnim“ pristupom. Primarna perkutana koronarna intervencija (PCI) u bolesnika s infarktom miokarda s elevacijom ST-segmenta (STEMI) je najzahtjevniji oblik koronarne intervencije i stoga operateri moraju biti dobro obuceni u radijalnom pristupu. Cilj istraživanja bio je utvrditi je li u bolesnika sa STEMI, kojima je primarna PCI ucinjena lijevim radijalnim pristupom, iskustvo operatera, kao i doba dana kada je intervencija ucinjena, utjecalo na uspjeh postupka, bolesnikovu i operaterevu sigurnost.