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Background: Cardiovascular (CV) risk factors, causing endothelial dysfunction (ED) and left ventricular diastolic dysfunction (LVDD), contribute to an increased risk of heart failure (HF). The aim of this study was to determine the relationship between the occurrence of LVDD and ED with CV risk assessed by the Systematic Coronary Risk Evaluation2 (SCORE2) algorithm and HF. Methods: In the period from November 2019 to May 2022, a cross-sectional study that included 178 middle-aged adults was conducted. Transthoracic echocardiography (TTE) was used to assess left ventricular (LV) diastolic and systolic function. ED was assessed using the plasma values of asymmetric dimethylarginine (ADMA) and was determined using the ELISA method. Results: The majority of subjects with LVDD grades 2 and 3 had high/very high SCORE2, developed HF and all were taking medication (p < 0.001). They also had significantly lowest plasma ADMA values (p < 0.001). We found that the reduction of ADMA concentration is influenced by certain groups of drugs, or more significantly, by their combinations (p < 0.001). Conclusions: In our study, we confirmed a positive correlation between LVDD, HF and SCORE2 severity. The results showed a negative correlation between the biomarkers of ED, LVDD severity, HF, and SCORE2, which we believe is due to medication effects.

International audience; BackgroundFor infective endocarditis (IE) with extensive perivalvular lesions or end-stage cardiac failure, heart transplantation (HT) may be the last resort.MethodsWe retrospectively collected all cases of HT for IE within the International Collaboration on Endocarditis (ICE) network.ResultsBetween 1991 and 2021, 20 patients (5 women, 15 men), median age 50 years [interquartile range, 29-61], underwent HT for IE in Spain (n = 9), France (n = 6), Switzerland (n = 2), Colombia, Croatia, and USA (n = 1). IE affected prosthetic (n = 10), and native valves (n = 10), primarily aortic (n = 11) and mitral (n = 6). The main pathogens were oral streptococci (n = 8), Staphylococcus aureus (n = 5), and Enterococcus faecalis (n = 2). The major complications included heart failure (n = 18), peri-annular abscess (n = 10), and prosthetic valve dehiscence (n = 4). Eighteen patients had previous cardiac surgery for this episode of IE, and four were on circulatory support before HT (left ventricular assist-device and extra-corporeal membrane oxygenation, 2 patients each). The median time interval between first symptoms of IE and HT was 44.5 days [22-91.5]. The main post-HT complication was acute rejection (n = 6). Seven patients died (35%), four during the first month post-HT. Thirteen (81%) of the 16 patients discharged from the hospital survived with a median follow-up of 35.5 months [4-96.5] after HT, and no relapse of IE.ConclusionsIE is not an absolute contraindication for HT: Our case series and the literature review support that HT may be considered as a salvage treatment in highly-selected patients with intractable IE.

International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

Background: Microvascular dysfunction and glucometabolic dysregulation are associated with poor prognosis after acute myocardial infarction. It has been reported that adiponectin modulates vascular homeostasis and protects against cardiometabolic disorders. This study aimed to investigate the association of adiponectin and HbA1C with major adverse cardiac events in non- diabetic patients who survived STEMI. Methods: The study prospectively enrolled 73 non-diabetic white patients who experienced STEMI infarction. The subjects were divided into two groups: 37 patients with elevated glycated hemoglobin (group 1) and 36 patients with normal levels of glycated hemoglobin (group 2). In a one- year follow-up, the study subject were observed for major adverse cardiac events (MACE). Results: Adiponectin correlated inversely with HbA1C and BMI in all study subjects (P6% were at particularly high risk for MACE and should be considered for prevention interventions.

Aim:To assess the epidemiological and clinical differences between men and women with acute myocardial infarction (AMI).Patients and methods:This retrospective study included 579 patients (352 men and 227 women) who were hospitalized at the Coronary and postcoronary unit at the General hospital Karlovac, Croatia, from 2013 to 2016.We determined the frequency, patient's age, type of symptoms, cardiovascular risk factors, localization AMI, the time from the onset of symptoms to arrival to the hospital, treatment and complications during hospitalization. Results:AMI is more frequent in man than in women (p

Background and aim: The aim of the study was to establish the effect of valsartan and combination of valsartan and hydrochlorothiazide (HCTZ) on pulse wave velocity (PWV) and central blood pressure (CBP) in a large population of patients with mild to moderate arterial hypertension. Methods: This was an international, multicentre, open-label, prospective trial. After one week of washout in previously treated patients, 74 subjects were treated with valsartan or valsartan combined with HCTZ for 16 weeks according to the protocol. Naive patients received the treatment immediately. During the active treatment, four visits were planned for each patient to obtain data for the primary and secondary efficacy. At the beginning and at the end of the study PWV and CBP were determined with central arterial pressure waveform analysis (SphygmoCor ® , Atcor Medical). This study is registered with clinicaltrialsregister.eu, EudraCT number 2012-005129-57. Results: The results of the present VICTORY trial showed that valsartan and combination of valsartan and HCTZ effectively reduced the brachial blood pressure in patients with mild to moderate arterial hypertension as well as PWV, central systolic blood pressure and central diastolic blood pressure. The effects on the augmentation index were not statistically significant. Conclusions: Valsartan and valsartan/HCTZ improve arterial stiffness in patients with mild to moderate hypertension.

Background During acute myocardial infarction, phosphorylated TnI levels, Ca2+ sensitivity and ATPase activity are decreased in the myocardium, and the subsequent elevation in Ca2+ levels activates protease I (caplain I), leading to the proteolytic degradation of troponins. Concurrently, the levels of apelin and APJ expression are increased by limiting myocardial injury. Methods In this prospective observational study, 100 consecutive patients with ST-elevation acute myocardial infarction were included. Patients meeting the following criteria were included in our study: (1) continuous chest pain lasting for >30 min, (2) observation of ST-segment elevation of more than 2 mm in two adjacent leads by electrocardiography (ECG), (3) increased cardiac troponin I levels, and (4) patients who underwent reperfusion therapy. We evaluated the levels of apelin-12 and troponin I on the first and seventh days after reperfusion therapy in all patients. Results Apelin-12 was inversely correlated with troponin I levels (Spearman’s correlation = −0.40) with a p value 2.2 for the association of apelin with MACE was determined, and the AUC was 0.71 (95% CI, 0.58–0.84). Survival analysis using the Kaplan-Meier method showed a lower rate of MACE among patients with apelin levels >2.2 (p = 0.002), and the ROC curve analysis showed a statistically significant difference in the area under the curve (p = 0.004). Conclusion The influence of apelin levels on troponin levels in the acute phase of STEMI is inversely correlated, whereas in the non-acute phase, low apelin values were associated with a high rate of MACE.

Background and aim: The aim of the trial was to establish the efficacy and safety of Valsacor ® (valsartan) and Valsacombi ® (combination of valsartan and hydrochlorothiazide) in a wide variety of patient populations with mild to moderate arterial hypertension. Methods: We performed an international, multicentre, open-label, prospective trial. After one week of washout in previously treated patients, the patients were treated for 16 weeks according to the protocol. Naive patients entered the treatment period immediately. During the active treatment, four visits were planned for each patient to obtain the data for the primary and secondary efficacy endpoints analysis. The principal methods were blood pressure (BP) measurement, additionally in a subgroup of patients, assessment of erectile function. The initial dosage of valsartan 80 mg/day was titrated up to 320 mg/day to achieve the BP goal, with the addition of hydrochlorothiazide (HCTZ) in a fixed-dose combination (FDC), if needed. Results: Mean ± standard deviation changes from baseline at week 16 were –26.6 ± 10.4 mm Hg (systolic BP) and –14.8 ± 7.6 mm Hg (diastolic BP). A total of 91% of the patients treated with either valsartan or valsartan FDC achieved the BP goal. Adverse reactions were experienced by 7.1% of the patients, with the most common being headache (1.9%), palpitation (1.6%), dizziness (1.6%), and fatigue (1.6%), during the whole trial. Conclusions: The results of the VICTORY trial show that valsartan and valsartan FDC effectively reduce the BP in patients with mild to moderate arterial hypertension and have a good tolerability profile.

Primary cardiac neoplasms are extremely rare and often overlooked as differential diagnosis. Angiosarcomas are the most common primary malignant neoplasms of the heart often with nonspecific symptoms. We present a 43-year-old woman admitted to our hospital with chest pain and inferoposterolateral myocardial infarction. Coronary angiography indicated the distal occlusion of the left circumflex artery. Transthoracic and transoesophagic echocardiography revealed a mass in the left atrium with probable myocardial infiltration and vascularisation. The mass in the left atrium was removed by surgical resection, and histopathology confirmed angiosarcoma. We emphasize the pivotal role of transthoracic and transoesophageal echocardiography in evaluating even rare differential diagnosis of acute coronary syndrome as cardiac neoplasms.

Case report: 56-year-old male patient was admitted due to fever of unknown origin. Upon admission, the patient was in bad general condition with high values of inflammatory markers in laboratory results and signs of right side heart failure. 12-lead ECG showed nonspecific conduction disorders. No signs of systemic disease have been found with extensive internal and diagnostic treatment. Scintigraphy with labeled leukocytes, as attempt to find origin of infection did not show any pathological accumulation. Coronarography excludes atherosclerotic changes in epicardial vessels. Transthoracic (TTE) and transesophageal (TEE) echocardiography described a visible hyperechogenic formation in a right ventricular outflow tract (RVOT), oriented towards pulmonic valve, 1.6 cm long and 0.3 cm wide (Figure 1). Right ventricle (RV) showed milder reduced systolic function, with signs of right-side congestion. There was moderate pulmonary valve regurgitation (PR 2+), and mild tricuspid regurgitation with estimation of right ventricular systolic pressure of 27 mmHg. Preserved left ventricular fraction of 58% was observed. MSCT of thorax identified a strange metal body, resembling to sewing needle in the RV area. The patient initially refused the surgical procedure of foreign body extraction, until the clinical condition deteriorated. He was hospitalized again with fever, hem culture positive on Escherichia coli. Transthoracic echocardiography now showed a formation of 8 mm, possibly vegetation, on the ventricular surface of the pulmonary valve with severe pulmonary insufficiency, severe tricuspid regurgitation and moderate right-side heart failure. Diagnosis of pulmonary valve endocarditis has been established. The patient was successfully operated, the bioprosthetic pulmonary valve was implanted combined with tricuspid valve repair and the foreign body was removed from the right ventricle. Postoperative recovery went well, and control echocardiography showed a good function of the bioprosthetic pulmonary valve and tricuspid valve repair. Foreign body was a sewing needle, but the patient could not remember how did it get there. Conclusion: Isolated right ventricular heart failure can be caused by pulmonary valve insufficiency1,2, as in our case by foreign body in RVOT finally complicated by endocarditis of pulmonary valve.

Detection of an intracardiac mass always represents a clinical challenge. We present a 61-year-old female patient with symptoms of New York Heart Association class III. Two-dimensional transthoracic echocardiography revealed a hypoechogenic mass in the cavity of the dilated right ventricle (RV). Cardiac MRI described a pathologic structure of the RV free wall with pedunculated tumor in its cavity. Three months later, on a repeated echocardiography, there were three individual masses. The patient underwent surgery and the pathohistologic report demonstrated thrombotic masses. During the postoperative period, after reviewing all medical records, the conclusion was arrhythmogenic RV cardiomyopathy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:362-369, 2017.

Introduction: Cor triatriatum sinister (CTS) is a very rare congenital cardiac malformation in which the left atrium (LA) is divided into two chambers by a fold of tissue, a membrane, or a fibromuscular band. The anomaly is usually diagnosed in childhood, but in adult age is less common. Clinical symptoms can mimic mitral stenosis.1-5 Case report: We report a case of 54-year-old woman referred to our hospital for transesophageal echocardiography (TEE). She had in history of dyspnea, headache, dizziness and effort intolerance for five years. Physical examination and laboratory values were unremarkable. Two-dimensional and threedimensional transesophageal echocardiography revealed fibromembranous structure in the dilated LA (Figure 1 and Figure 2). The membrane attached laterally to the junction of the left upper pulmo-nic vein and left atrial appendage, and medially to the interatrial septum. The membrane divided LA into two chambers (proximal chamber and distal chamber). Proximal chamber was receiving the pulmonary veins, and distal chamber contained left atrial appendage and mitral valve orifice. We found few fenestrations connecting the two chambers (Figure 3). Multislice computed tomography (MSCT) confirmed diagnosis of CTS (Figure 4). Coronary angiography revealed normal coronary arteries. The patient was referred to surgery following a TEE and MSCT diagnosis of CTS. The atrial membrane was excised around its periphery. Recovery from the surgery was uneventful and she was asymptomatic on further hospital stay and follow-up. Conclusion: The diagnosis of cor triatriatum sinister is paramount because of possibility of surgical repair with excellent long-term prognosis. 3D TEE is noninvasive method for comprehensive imaging and correct diagnosis of this rare congenital cardiac malformation. Surgical repair is an easy and definitive treatment choice of CTS should be considered in patients with left heart chamber obstruction symptoms.

Assessment of left ventricular(LV)geometry and function reprsents the most frequent indication for an echocardiographic study in patient evaluation, management and indication for cardiac surgery.Three-dimensional transthoracic echocardiography(3DTTE)has been shown to be more accurate for quantification of LV volumes, compared to conventional 2D echocardiography and real time 3DTTE is only imaging technique based on volumetric scanning able to show moving structures in the beating heart.We present a patient with ischemic cardiomyopathy and LV aneurysm who underwent Dor procedure, and was preoperatively assessed by real time 3DTTE combined with contrast echocardiography to assess LV, mitral valve function and presence of LV thrombus.In conclusion, 3DTTE povides a comprehensive assessment in the management of heart failure patients with LV aneurysm which is crucial for their clinical management.

Contrast echocardiography is a noninvasive technique for the assessment of myocardial function and perfusion which improves estimation of endocardial border delineation through ventricular cavity opacification. The first report of contrast echocardiography date from 1968, when Gramiak and Shah reported their observation of "clouds of bubbles" in the aortic root following injections of saline through an intra-aortic catheter.The first contrast agents used were indocyanine green, agitated saline solution, sonicated solutions of dextrose and patient's blood, while today we are using second generation contrast agents:perflutren, perfluoropentane, perfluoropropane, perfluorooctylbromide and sulphur hexafluoride.Using the contrast agent with perflutren (Optison)the endocardial border is visible in mote than 93% of the patients, opacification of the whole left ventricle is achieved in 87% of the patients. Many noninvasive diagnostic laboratories are using contrast echocardiography in diagnosing 10%-15% of patients.

Introduction: Right ventricular (RV) function and cardiac involvement in systemic sclerosis (SSc) is important factor for the prognosis of SSc but often remains undetectable despite echocardiographic screening. 1,3 Speckle derived strain (2D-STE) of the right ventricle (RV GLS) was utilized to detect subclinical abnormalities in regional and global contractility in SSc patients with no echocardiographic signs of pulmonary arterial hypertension. Aim of pilot study was to study the advantages of 2D speckle-tracking echocardiographic derived parameters in identifying RV dysfunction in SSc patients for quantifying myocardial deformation and conventional RV indexes in patients with SSc and to investigate whether these could be indicative of right heart failure or can be used as non-invasive methods of screening in SSc. Methods and Results: 27 SSc patients (mean age, 54.3 years; 96% female) with technically adequate echocardiograms were studied. Standard morphological measurements of RV chamber function, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), tricuspid tissue Doppler annular velocities (TDIs,), right ventricular myocardial performance index (RIMP) and global longitudinal right ventricular free wall strain (RV FW GLS) were obtained. Twenty-two patients without pulmonary arterial hypertension (PAH) due to systemic sclerosis were studied. When we used the cutoff value recommended by the American Society of Echocardiography Guidelines to identify abnormal RV function4, patients were determined to have normal RV function, TAPSE 21.9 (±2.21), RV FAC 49.4 (±3.45), RIMP 0.44 (±0.08) respectively. Global longitudinal strain (LS) of the RV was calculated by averaging the LS value of 3 segments of the RV free wall in RV focused apical 4-chamber view (Figure 1). 40.9% of those patients had abnormal RV FW GLS (-14.8%) more pronounced in the basal regional longitudinal strain. Conclusion: Right ventricular strain reveals a diverse pattern of regional strain in SSc that is not detected by conventional measures of function, suggestive of subclinical RV myocardial disease and could be used as non-invasive method in screening for PAH in SSc to select patients eligible for right heart catheterization or to monitor the effects of PAH therapy.1-3

Apical hypertrophic cardiomyopathy (AHC) is a rare variant of hypertrophic cardiomyopathy characterized by thickening of the most distal part of the left ventricular (LV) wall. It was first described by Sakamoto in 1976 in Japanese patients. AHC was reported as a stri- king electrocardiographic pattern of giant negative T-waves and angiographic feature of end diastolic LV cavity configuration resembling an ace of spade by Yamaguchi et al. Although AHC is more common in Asia and it accounts for about 13% to 25% of all cases of hypertrophic cardiomyopathy, it is much less prevalent in the western population. Diagnostic modalities include ECG, echocardiography, ventriculography, nuclear myocardial perfusion studies and cardiac magnetic resonance imaging. We present a 58-year-old man with AHC that was unre- cognized for the previous 10 years. In conclusion, this rare disease could be found in the Croatian population too, whereas the appropriate interpretation of the ECG and echocardiography is crucial in recognizing this rare, but important form of hypertrophic cardiomyopathy.

Background Host factors and complications have been associated with higher mortality in infective endocarditis ( IE ). We sought to develop and validate a model of clinical characteristics to predict 6‐month mortality in IE . Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ ICE ]–Prospective Cohort Study [ PCS ], 2000–2006, n=4049), a model to predict 6‐month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry ( ICE ‐ PLUS , 2008–2012, n=1197). The 6‐month mortality was 971 of 4049 (24.0%) in the ICE ‐ PCS cohort and 342 of 1197 (28.6%) in the ICE ‐ PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE , causative organism, left‐sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6‐month mortality, and surgery was associated with a lower risk of mortality (Harrell's C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell's C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62–0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six‐month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE .

capabilities of echocardiography and its broad use in routine every day clinical practice. In the evaluation of infective endocarditis echocardiography can detect vegetations on heart valves, cuspis rupture or perforation and perivalvular inflammatory process spreading. According to the Duke criteria echocardiographic finding is one of the main criteria for diagnosis of endocarditis. The positive echocardiographic findings include: vegetations, abscess, new onset of artificial valve dehiscence and new onset of valvular regurgitation [2]. We use echocardiography to detect changes of cardiac valves and to evaluate systolic and diastolic heart function. Vegetations can be found on native or artificial valves and on the pacemaker or implantable cardioverterdefibrillator (ICD) leads. Vegetations are detected in 42-86% of patients with IE by applying echocardiography. The comparison of the results between transoesophageal echocardiography (TOE) and transthoracic echocardiography (TTE) in the detection of vegetations shows better sensitivity of TOE (85-90%) than the sensitivity of TTE (60%). Specificity of TTE is 67%, and specificity of TOE is around 91-98%. 3D and 4D TOE have been used more commonly in the diagnostics in the last ten years. The sensitivity of this new methods in diagnosis of infective endocarditis is similar to 2D TOE, while its specificity is much higher (100%). However, sensitivity of TTE is much lower in detecting vegetations in patients with artificial valves, implanted pacemaker or implantable cardioverter-defibrillator. We can use the echocardiography to determine size, echogenity and mobility of vegetation. Based on this indicators it is possible to make a decision about surgical treatment, estimate the risk of embolic event and predict the clinical outcome [3]. The patients with vegetations that larger than 1,0 cm in diameter have significantly higher risk of embolic event (36%) than the patients with vegetations smaller than 1,0 cm (6%). According to the new Guidelines of European Society of Cardiology (ESC) for the management of infective endocarditis, it is important to perform TTE in each patient with suspicion of infective endocarditis. In all patients with artificial heart valve, pacemaker or cardioverter- defibrillator, it is indicated to perform TOE [5-7]. Further more, in cases of negative TTE in patients with high clinical suspicion of endocarditis, it is advisible to perform TOE as well [4]. About 15 % of patients with endocarditis have normal echocardiographic finding. Echocardiography may not detect vegetations in too early stage of disease or in case when vegetation caused an embolic event [8]. In some cases we may not detect vegetations due to significant preexistent lesions on valves, such as mitral valve prolapse, degenerative process or due to acustic shadows and reverberations caused by artificial valves. In case echocardiography assesment was made in very early stages of disease with negative examination but with high clinical suspicion of infective endocarditis, it is indicated to repeat the TTE and/or TOE within 5-7 days. Conclusion Early diagnosis, prompt and efficient therapy and detecting and dealing with the complications are the most important factors in achieving good outcome in endocarditis treatment. Echocardiography has important role in diagnosis of endocarditis, detection of complications, decision making regarding the surgical treatment and patients follow-up with great prognostic significance remarkably contributing to better outcome.

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect with only approximately 3% of uncorrected patients surviving past age 40. In this case report, we present a 48-year-old mentally retarded man suffering from congenital spastic quadriplegia who was diagnosed with a unique combination of symptomatic TOF and cor triatriatum dexter (CTD). Reduced preload because of CTD with spastic quadriplegia that prevented physical exertion is believed to have facilitated this patient's unusually long survival.

Background Infective endocarditis (IE) remains a severe disease with contemporary in-hospital mortality rates of 20%. Although valvular replacement is performed in 50% of patients during the acute phase, heart transplantation remains the last resort in selected patients with extensive perivalvular lesions or end-stage cardiac failure. Methods Cases were identified through the International Collaboration on Endocarditis (ICE) network. All patients who underwent heart transplantation during the acute phase of IE, with at least three months follow-up, were enrolled. Data were extracted from medical charts on a standardized questionnaire. Only patients who fulfilled Duke criteria for definite IE were enrolled. Results Between 1991 and 2017, 19 patients (6 women, 13 men), with a median age of 52 years (interquartile range, 41–61) underwent heart transplantation for IE refractory to optimized medical treatment and/or other cardiac surgery in Spain (n = 9), France (n = 6), and Colombia, Croatia, Switzerland, and the United States (one patient each). IE affected prosthetic (n = 10), native valves (n = 9), primarily aortic (56%), and mitral (28%). Pathogens were oral streptococci (n = 7), Staphylococcus aureus (n = 5, including two methicillin-resistant), Enterococcus faecalis (n = 2), and Mycoplasma hominis, Haemophilus para-influenzae, Candida albicans (one patient each). Two cases were not documented. Main cardiac lesions were vegetations (n = 17), severe regurgitation (n = 15), peri-annular abscesses (n = 9), prosthetic valve desinsertion (n = 4), and intra-cardiac fistula (n = 1). Seventeen patients underwent cardiac surgery at least once before transplantation, and four patients were on circulatory assistance (left ventricular assist-device, or extra-corporeal membrane oxygenation, two patients each). Median delay between first cardiac surgery and transplantation was 28 days (IQR, 18–71). Six patients died (32%), including four during the first month post-transplant. Thirteen patients survived, with a median follow-up of 44 months post-transplantation (IQR, 13–88). Conclusion Heart transplantation may be considered as salvage treatment in highly selected patients with intractable infective endocarditis. Disclosures All authors: No reported disclosures.

Septična kardiomiopatija reverzibilna je disfunkcija miokarda u septičnih bolesnika. Smanjenje kontraktilnosti miokarda prisutno je u više od 40 % bolesnika s teškom sepsom ili sa septičnim šokom. Sepsom inducirana disfunkcija miokarda (SIDM) jedan je od glavnih prediktora lošeg ishoda septičnih bolesnika. Smrtnost septičnih bolesnika sa SIDM je od 70-% do 90 %, a bez SIDM je oko 20 %. SIDM karakterizira dilatacija klijetki, sniženje istisne frakcije klijetki, slabiji odgovor na nadomjestak tekućine i na vazoaktivnu terapiju te reverzibilnost promjena unutar 7-10 dana. Za nastanak SIDM odgovorni su brojni izvanstanični i stanični mehanizmi uz interakciju brojnih čimbenika koji sudjeluju u regulaciji radne muskulature srca i u sustavu međustaničnog prijenosa signala. Rezultat interakcije je poremećaj u povezanosti između unutarstaničnog citoskeleta i izvanstaničnog matriksa i slabljenje prijenosa snage kontrakcije miokarda. Za dijagnosticiranje SIDM koriste se hemodinamski monitoring, EKG, transtorakalna i transezofagusna ehokardiografi ja i laboratorijski testovi. U liječenje SIDM spada kontrola infekcije, optimizacija hemodinamskih parametara, nadomjestak tekućine, vazopresori, inotropna terapija, primjena krvnih pripravaka i statini. Adekvatnu i učinkovitu terapiju septične kardiomiopatije za sada još nemamo. Koristimo kardioprotektivnu terapiju, uzročno liječenje sepse ili septičnog šoka uz suportivne mjere., Septic cardiomyopathy is a reversible myocardial dysfunction in patients with sepsis. Depression in myocardial contractility is detected in more than 40% of patients with severe sepsis or septic shock. Sepsis-induced myocardial dysfunction (SIMD) is one of the main predictors of poor outcome in patients with sepsis. Mortality rate in patients with sepsis and SIMD is 70%-90%, while it is only 20% in patients without SIMD. SIMD is characterized by ventricular dilatation, decreased ejection fraction, less response to fl uid replacement and catecholamines. It is reversible within 7-10 days. Many extracellular and intracellular mechanisms and mediators included in the regulation of the heart muscle cell contraction may contribute to septic cardiomyopathy. The underlying cause is disorder in communication between the intracellular contractile apparatus and extracellular matrix, resulting in attenuation of the myocardial contraction. Hemodynamic monitoring, ECG, transthoracic and transesophageal echocardiography, and various laboratory tests are used in the diagnostic work-up. There are several therapeutic interventions such as infection control, optimization of hemodynamic parameters, adequate volume resuscitation, inotropic drugs, transfusion of blood derivatives, and statins. However, for now, there is no effi cient therapy for septic cardiomyopathy. The management of SIMD includes cardioprotective therapy, etiologic treatment of sepsis and septic shock, and supportive measures.

Candida infective endocarditis is a rare disease with a high mortality rate. Our understanding of this infection is derived from case series, case reports, and small prospective cohorts. The purpose of this study was to evaluate the clinical features and use of different antifungal treatment regimens for Candida infective endocarditis. This prospective cohort study was based on 70 cases of Candida infective endocarditis from the International Collaboration on Endocarditis (ICE)-Prospective Cohort Study and ICE-Plus databases collected between 2000 and 2010. The majority of infections were acquired nosocomially (67%). Congestive heart failure (24%), prosthetic heart valve (46%), and previous infective endocarditis (26%) were common comorbidities. Overall mortality was high, with 36% mortality in the hospital and 59% at 1 year. On univariate analysis, older age, heart failure at baseline, persistent candidemia, nosocomial acquisition, heart failure as a complication, and intracardiac abscess were associated with higher mortality. Mortality was not affected by use of surgical therapy or choice of antifungal agent. A subgroup analysis was performed on 33 patients for whom specific antifungal therapy information was available. In this subgroup, 11 patients received amphotericin B-based therapy and 14 received echinocandin-based therapy. Despite a higher percentage of older patients and nosocomial infection in the echinocandin group, mortality rates were similar between the two groups. In conclusion, Candida infective endocarditis is associated with a high mortality rate that was not impacted by choice of antifungal therapy or by adjunctive surgical intervention. Additionally, echinocandin therapy was as effective as amphotericin B-based therapy in the small subgroup analysis.

Aim To determine the impact of infarct localization and types of reperfusion therapy on the frequency of ventricular premature beats (VPBs) in patients with acute myocardial infarction (AMI) and reduced left ventricular ejection fraction (LVEF). Methods A total of 705 patients with acute ST elevation myocardial infarction (STEMI) were divided according to the infarct localization (anteroseptal, anterolateral, inferior and posterior) and reperfusion therapy (fibrinolysis or percutaneous coronary intervention with stenting) into two groups: LVEF45% was a control group. The occurrence of VPBs10 per hour defined as a significant. Results In patients with fibrinolysis therapy and LVEF

Surgical aortic valve replacement (AVR) is the conventional treatment for severe aortic stenosis (AS). Conservative management of patients with severe AS is known to have a poor prognosis and without surgery, the outcome of these patients is also extremely poor. However, with the aging of the population, the number of elderly patients with severe symptomatic AS has grown, and a significant proportion of high-risk patients are not candidate for surgical AVR because of age and comorbidities. Transcatheter aortic valve implantation (TAVI) was developed to address this unmet need. After the demonstration of feasibility of TAVI in 2002, it is now widely practiced, and the technique has been recommended as an alternative strategy for patients in high-risk surgical group. Echocardiography plays important role in anatomical case selection, in procedural guidance, and in the management of complications. 2D and 3D transoesophageal echocardiography (TEE) enable detailed imaging of aortic valve(AV) and aortic root anatomy, measurement of AV annulus dimension, and review of other cardiac and aortic structures. Measurement of the size of the aortic annulus require precise assessment to allow appropriate valve selection and to minimize the risk of paravalvular leak and device migration. Comprehensive postprocedure TEE evaluation is performed following the initial confirmation of satisfactory transcatheter heart valve position and function. Echocardiography plays an essential role in the planning and provision of TAVI for high-risk patients with severe AS, and in combination with other imaging modalities, it allows appropriate case selection, correct choice of prosthetic size and type, guides successful implantation, and facilitates the treatment of complications.

In this poster we are presenting a case of 62-years-old female patient with „broken heart syndrome“ also known as Takotsubo cardiomyopathy1, with left ventricular thrombus. 62-years-old female patient with history of hypertension was hospitalized on Cardiology Department with acute hearth failure and chest pain, that started half an hour after very stressful verbal conflict with close relative. 12- lead ECG shown inversion of T wave in lateral leads. Laboratory results of troponin I 0, 12ng/ml at arrival rise to 2, 45 ng/ml. Echocardiography show typical hypokinesia of apical and mid-left ventricular myocardium with basal hypercontractility. Our conclusion was an acute coronary syndrome. Fourth day there was also forming of a left ventricular thrombus that we monitored. After treating patient with furosemid, ramipril, acetilsalicylic acid and low molecular weight heparin for few days, she was sent to coronary angiography. There was no obstructive coronary artery disease found. Our patient was treated for few more days back in our hospital and fully recovered. Three month after releasing from hospital on check-up, she had normal 12-lead ECG and echocardiography. From all the data we conclude that she had Takotsubo cardiomyopathy.

International audience; Background - The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods - Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results - EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions - In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

Primary light-chain (AL) amyloidosis is a plasma cell dyscrasia associated with the deposition of immunoglobulin-derived amyloid in multiple organs. In the heart, this results in an infiltrative cardiomyopathy, with increased left ventricular wall thickness, normal or decreased left ventricular (LV) cavity size and congestive heart failure. Cardiac involvement is a major determinant of prognosis of AL amyloidosis. We report a patient with cardiac amyloidosis proven by cardiac biopsy, and aim to point out at transthoracic echocardiography as the hallmark of diagnostics. Echocardiography revealed increased LV thickness at 20mm, impaired LV ejection fraction (EF) at 35%, enlarged atria, transmitral deceleration time at 156 ms and increased E/A ratio at 4.25. Early diagnosis and intervention can have a significant impact on the patient's response to treatment, especially when the underlying condition involves a malignancy or infiltrative disorder. Standard transthoracic echocardiography as a noninvasive diagnostic tool is valuable and has a significant role in diagnosis and prognosis.

Objectives: The aim of this study was to assess the recovery of regional myocardial function of the left-ventricular septal wall and the septal site of the mitral valve (MV) annulus by tissue Doppler imaging (TDI). Methods: In 63 (32 diabetic and 31 control) patients having off-pump coronary artery bypass grafting (OPCABG), including the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD), TDI measurements were performed before operation (baseline), 5 min after LIMA-LAD revascularization (early reperfusion) and after completion of all anastomoses (after revascularization). Results: Compared to the patients with diabetes, the controls had higher peak systolic velocities of the mid septal segments in the early reperfusion measurement (p = 0.002). After revascularization, values of peak systolic strain at the basal (-10.13 vs. -13.36%, p = 0.044) and mid septal segments (-8.25 vs. -12.69%, p = 0.009) were decreased in the diabetic patients compared to the controls. There was no difference between the groups with respect to the velocities acquired at the septal site of the MV annulus. Conclusions: This study demonstrates an insufficient recovery of regional myocardial function in patients with type II diabetes undergoing OPCABG.

Coronary artery bypass graft surgery (CABG) is performed to reduce cardiac mortality and to relieve patient's symptoms of CAD and prolong lives. Health related quality of live (HRQL) is a sensitive tool to asses the outcome of CABG surgery in terms of patient's postoperative functionality.The aim of our study was to detremine HRQL of our patients and to determine variables that have an impact on impaired or unimpaired HRQL, based on the completion of the short form health questionnaire (SF-36). The study population included 140 patients who underwent CABG surgery during 2007, age range 43-83 years. Demographic data, clinical characteristics and co- morbidity were collected. Good or exellent health was reported 62% of patients. Limited performance during vigorous activities was reported 62, 9% of patients, while only 20% of them reported limited performance during moderate activities. Physical health or emotional problems didn't interfere with their normal social activities in 73%. Based on SF-36 answers we identified two groups of patients, first with unimpaired, and second with impaired HRQL after CABG surgery. Overall HRQL is unimpaired for most of the patients. There were no significant predictors for impaired or unimpaired HRQL. We identified variables that are associated with specific HRQL outcoms, which could be used as preoperative assessment and to improve patient's outcomes.

IntroductionVarious risk factors for development of acute coronary syndrome (ACS) have been discovered. ACS has numerous consequences, including physical and mental health disturbances.AimTo distinguish mental health consequences and risk factors for ACS.ObjectivesTo explore the interdependence between poor life-style choices (physical inactivity, cigarette smoking, unhealthy diet, alcohol consumption) and development of anxiety or depressive disorders 1 month and 6 months after ACS.MethodsFollow-up study on 120 subjects with ACS, retested after 1 and 6 months. Existence of previous or actual mental disorders were excluded in the first phase.InstrumentsMini International Neuropsychiatric Interview, questionnaire of general sociodemographic data and life-style factors, Acute Stress Disorder Interview and Clinician-administered PTSD Scale. Lipid levels and BMI were tracked.ResultsAfter 1 month 27.5% of the subjects had acute stress disorder (ASD) and 13,8% had major depressive disorder (MDD). After 6 months, 37.5% subjects had PTSD and 27.3% had MDD. Alcohol consumption showed to be predictive for development of MDD in the second phase (P = 0.002; OR = 2.48), and physical inactivity showed to be predictive for development of comorbidity of MDD and ASD in the second phase (P = 0.036; OR = 100.00).ConclusionCardiovascular disorders can cause anxious & depressive disorders in frequent alcohol consumers and physically inactive subjects. Since depression, anxiety, physical inactivity, and alcohol consumption cannot only be considered as risk factors for cardiovascular disorders, but also be seen as a consequence of cardiovascular disorders, strategies for primary and secondary prevention of coronary events should include a greater concern for mental health as well.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Echocardiography is the main imaging technique in diagnosing and follow-up of carcinoid heart disease, but in the last decade magnetic resonance imaging (MRI) has evolved into new diagnostic modality. Most of reported MRI features are similar to those observed by echocardiography - tricuspid and/or pulmonary valve thickening and immobility with consequent valvular dysfunction and right heart enlargement. According to our knowledge this is the first report describing endocardial enhancement of right cardiac chambers, tricuspid valve and subvalvular apparatus that corresponds to fibrous carcinoid plaques which can be seen histologically.

Patent foramen ovale (PFO) is a defect of the interatrial septum usually with no clinical repercussions, incidence of about 25%, but can also be associated with various clinical conditions such as cryptogenic stroke, migraine, platypnea- orthodeoxia syndrome and decompression illness.Some studies showed that the success of the procedure-transcatheter closure, with the goal being complete occclusion without any residual shunt, is more dependent on the anatomy of the atrial septum than the type of the device used for the procedure.Therefore, also in our opinion 2D and 3D echocardiographic assessment, initially in patient selection and afterwards during the intervention, is crucial for the successful treatment.

Cor triatriatum is one of the rarest congenital cardiac anomalies accounting for 0.1-0.4% of all congenital heart disease. It is frequently associated with other congenital heart defects and is normally diagnosed in childhood mostly because it is symptomatic with symptoms of left heart obstruction or arrhythmia. We present three cases of cor triatriatum sinister diagnosed in adult age with successful conservative treatment and follow up. Cor triatriatum is a rare congenital heart disease with varying presentations. The golden standard in three dimensional TTE and TEE.

Noninvasive assessment of regional myocardial function is important for diagnosis of myocardial disease, assessing therapeutic interventions, and predicting clinical outcomes. Although there are other noninvasive techniques for assessment of myocardial function, such as magnetic resonance imaging and computed tomography, echocardiography remains the tool of choice in widespread clinical use because of the ease of its usage. Echocardiographic strain imaging, also known as deformation imaging, is a technological advancement that has been developed to objectively quantify regional myocardial function. In this paper, we will show the role that speckle tracking plays in our daily clinical routine.

Cor triatriatum sinister rijetka je prirođena srčana greška, koja obično biva otkrivena u djetinjstvu. Donosimo prikaz slučaja mlade bolesnice kojoj je cor triatriatum sinister otkriven u odrasloj dobi te njegovo praćenje tijekom trudnoće i uspješno konzervativno liječenje sve do poroda. Obzirom na sličnu patofiziologiju odlučili smo se bolesnicu pratiti kao umjereno tešku asimptomatsku mitralnu stenozu. Kliničko praćenje i redoviti ehokardiografski pregledi zauzimaju pri tome centralno mjesto. Prema našem saznanju, ovaj slučaj pacijentice predstavlja prvi slučaj majčinskoga cor triatriatum sinister u trudnoći u Hrvatskoj., Cor triatriatum sinister is a rare congenital cardiac malformation, usually diagnosed in childhood. We describe a case of maternal cor triatriatum diagnosed in adult age and its successful conservative management throughout pregnancy until postpartum. Due to hemodynamic similarities, we decided to treat the cor triatriatum sinister like a moderate asymptomatic functional mitral stenosis in this case. Clinical controls, regular echocardigraphic controls have a central place in the follow up of gravida with congenital cardiac anomalies. To the best of our knowledge, this case is the first case of maternal cor triatriatum sinister in Croatia.

Anomalous origin of the left coronary artery from the right sinus of Valsalva is a rare congenital coronary anomaly. We report a case of a 62-year-old woman with a history of hypertension, diabetes type 2 and hypercholesterolemia who was admitted to the local hospital because of unstable angina pectoris. Coronary angiography was performed revealing the anomalous left main coronary artery arising from a single ostium in the right sinus of Valsalva together with the right coronary artery which showed a 90% proximal stenosis. The patient was referred to our hospital for further management. Multislice computed tomography (MSCT) coronary angiography confirmed these findings and determined coursing of the anomalous left coronary artery anterior to the pulmonary trunk. The proximal RCA lesion was successfully treated with direct stenting. She is asymptomatic on clinical follow-up at 18 months.

Infective endocarditis during pregnancy is uncommon but very serious. A 31-year-old woman in the 36th week of second pregnancy was admitted to a hospital because of fever, weakness, chest pain, painful skin over her right leg and dyspnea. Transthoracic echocardiography showed aortic valve vegetation and severe aortic regurgitation. Transesophageal echocardiography revealed a 18 mm × 6 mm mobile vegetation, attached to the right coronary cusp. Emergency cesarean section followed with a delivery of a healthy baby. Cardiopulmonary bypass with subsequent aortic replacement with bioprosthesis was initiated immediately after cesarean section. Early echocardiographic examination and 6 months after surgery revealed normal function of aortic valve bioprosthesis and normal LV function. Clinical recognition and early echocardiographic diagnosis followed urgent simultaneous cesarean section and aortic valve replacement was lifesaving for both mother and fetus.

A case is reported of a right sinus of Valsalva aneurysm rupture into the right ventricle during vaginal delivery in a 34-year-old healthy woman in her third pregnancy. Pregnancy was carried to term and a healthy baby was delivered vaginally. On day 7 following vaginal delivery she was admitted to hospital for dyspnea and cough, with clinical signs of severe heart failure. The diagnosis of the right sinus of Valsalva aneurysm rupture into the right ventricle was established by transthoracic and transesophageal echocardiography. Clinical recognition and early echocardiographic diagnosis followed by immediate surgical repair proved lifesaving in our patient.

Lutembacherov sindrom je kombinacija kongenitalnog atrijskog septalnog defekta (ASD) i stečene mitralne stenoze (MS). Prvi put ga je opisao francuski liječnik Lutembacher 1916. godine. Ovaj sindrom je vrlo rijedak i smatra se da mu je incidencija 0.001/10,00000. Hemodinamski efekti ovog sindroma posljedica su relativnog utjecaja težine MS i veličine ASD. Prikazujemo 54-godišnju pacijenticu kojoj je bio indiciran transtorakalni ehokardiografski pregled (TTE) zbog evaluacije prijašnjeg nalaza srednje teške MS u sklopu progresije zaduhe unatrag mjesec dana. Prije dvije godine prilikom hospitalizacije uslijed srčanog popuštanja, primjenom TTE registrirana je srednje teška MS uz urednu sistoličku funkciju lijeve klijetke. Sada se primjenom TTE i transezofagijske ehokardiografije registrira srednje teška MS te ASD koji nije bio opisan u prijašnjim ultazvučnim nalazima pa je postavljena dijagnoza Lutembacherova sindroma. Ovaj prikaz slučaja pokazuje kako je ehokardiografija nezaobilazna dijagnostička metoda u otkrivanju mnogih kardioloških entiteta uključujući i ovaj rijetko prisutan sindrom., Lutembacher’s syndrome refers to a con- genital atrial septal defect (ASD) complicated by aquired mitral stenosis (MS). It was first described by Lutembacher, a French physician, in 1916. This syndrome is a very rare disease, it is found that the incidence of Lutembacher’s syndrome is 0.001/10,00000. The hemodynamic effects of this syndrome are a result of the inter- play between the relative effects of the ASD and MS. We present a 54-year-old female referred to hospital for echocardiographic evaluation of previously diagnosed mild MS. She reported progression of dyspnea over the last month. Two years ago, she was admitted to another hospital because of heart failure and transthoracic echo- cardiography (TTE) revealed moderate MS with perserved left ventricular systolic function. We performed TTE and transesophageal echocardiogram and found severe MS with ASD that was previously unrecognised. The diagnosis of Lutembacher’s syndrome was established. This case demonstrates the presence of this rare disease in our population, but we would also like to stress the importance of the role of echocardiography in identifying many clinical syndromes including this one.