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Aim: To investigate prevalence of arrythmias and thromboembolic events, as well as long term outcomes among patients diagnosed and treated of non-compaction cardiomyopathy (NCC) according to current recommendations in University Hospital Centre (UHC) Zagreb. Patients and Methods: A single center retrospective study was conducted. Patients newly diagnosed with NCC in UHC Zagreb during period 2009-2018 were analyzed. The diagnosis was confirmed by both echocardiography and cardiovascular magnetic resonance. Hospital database and charts were used for clinical data, echocardiography data was obtained from digital database using EchoPac. Patients were followed-up clinically and by the means of echocardiography. Results: 32 patients (pts), 18 men (53.25 %) were included. At the time of diagnosis (baseline), mean age was 47.7±15.4 years, majority of pts (84.38% of pts, N=27) were in functional NYHA class ≥2, with mean NT-proBNP values of 3870±6619 ng/L. Echocardiography revealed reduced left ventricular systolic function; baseline ejection fraction (EF) was 27.52±11.94%. Patients were discharged with heart failure therapy: beta-blockers (30 pts, 93.75%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (29 pts, 90.63%), angiotensin receptor– neprilysin inhibitor (1 pts, 3.13%), mineralocorticoid receptor antagonists (28 pts, 84.38%); and 26 pts (81.25%) required symptomatic diuretic use. Cardiac resynchronization therapy with defibrillator was implanted in 11 pts (34.38%) and implantable cardioverter defibrillator (ICD) in 16 pts (50%). At baseline, 9 pts (28.13%) were already receiving anticoagulation due to previous thromboembolic events (Table 1). At discharge, 17 pts (53.13%) were anticoagulated (warfarin in 14 pts, 82.35%, novel direct oral anticoagulants in 3 pts, 17.65%). Mean follow-up period was 3.42±3.31 years. At the end of follow up period, functional improvement was observed: 21.88% (N=7) pts were in NYHA ≥2 status (p

Background: A new hemodynamic environment is set up after heart transplantation (HTx).1, 2 Our aim was to assess changes in diastolic function of the left (LV) and right (RV) ventricle in HTx patients (Pts) during the 1st year and the influence of donor age, graft ischemic time (GIT) and acute right ventricular failure (ARVF). Patients and Methods: In 55 “healthy” HTx Pts echo was performed 1- and 12 months after HTx. Data on mitral valve (MV) E- (Ew) and A-wave velocity (Aw), MV and tricuspid (TV) E/A ratio, MV and TV E’ and A’ by tissue Doppler, septal E/E’, pulmonary vein diastolic velocity (PVd), systolic pulmonary pressure (sPAP), left atrial indexed volume (LAVI), right atrial pressure (RAP) were collected. Results: Ew significantly decreases during the 1st year (0.80 vs. 0.73 m/s ; p=0.036) as well as E/E’ (11.5 vs. 9.1 ; p=0.009), PVd (0.67 vs. 0.55 m/s ; p mean of 41 years) caused initially lower MV-E’ (r=-0.390, p=0.010) and higher sPAP (r=0.285 ; p=0.045). GIT had no influence on diastolic parameters. ARVF significantly correlated with lower TV-A’ acutely and after 1 year (ARVF 5 vs. no-ARVF 8 cm/s ; r=-0.600, p= 0.011) and higher RAP (r=0.414, p=0.003). Conclusion: During the 1st postransplant year there is improvement in LA diastolic function with better early passive LV filling and reduction in PAH, without change in active filling phase or LA volume. In Pts with significant PAH mean E/E’ ratio within 1st month was 14, but after a year in Pts with persistent PAH it declines to only 10, preserving the higher E/A ratio. Higher donor age could impair the early LV ventricular filling with a trend toward more PAH but MV-E’ improves with time. ARVF reduces active RV filling (TV-A’) throughout the 1st year. GIT does not have influence on diastole.

Case report: 45-year-old woman was hospitalized for severe chest pain. Her medical problem began four months earlier. ECG and echocardiographic findings were normal. Stress test was stopped because of chest pain at 8 METs. At the time of two-minute chest pain, the ECG recorded intermittent left branch block (Figure 1). The 24h Holter ECG showed the frequency dependent left bundle branch block (LBBB) but no chest pain episode. MSCT coronary artery detected normal coronary arteries. Cardiac MR was suggestive to myocarditis. Troponin and inflammatory parameters during the four months of follow-up remained normal. Considering the persistence of symptoms, coronary angiography was performed showing normal epicardial arteries. During angiography, the patient experienced chest pain at the time of right coronary artery (RCA) probing, and coronary artery spasm of the proximal RCA was obvious at the time (Figure 2). After the nitroglycerin bolus application, spasm disappears (Figure 3) and chest pain released. During the coronary angiography there was no ST-segment elevation, nor intermittent LBBB. Vasospastic angina has been diagnosed. The patient was further treated with calcium antagonists and long-acting nitrates resulting in clinical improvement. Discussion: Early diagnosis of variant angina is crucial to avoid major cardiac events1. In the case of large coronary artery spasm, the ECG can show impermanent ST elevation. LBBB was observed temporarily in our patient during stress test concomitant with chest pain but not in the 24h Holter ECG recording. Coronary vasospasm and myocarditis are both recognized mimics of ST-segment elevation myocardial infarction with normal coronary arteries. The occurrence of both pathologies in the same patient has rarely been described2. Our patient had no troponin increase recorded, and no inflammatory parameters. It is important to note that the diagnostic sensitivity and specificity of the CMR for pericarditis is under 100%3. The case confirms the complexity of vasospastic angina diagnosis, and the importance of understanding the diagnostic imaging limitations.

Aim. To investigate early outcomes after balloon aortic valve valvuloplasty (BAV) performed as palliative procedure in patients with decompensated unstable end-stage aortic stenosis (AS). Patients and Methods. A retrospective observational study was conducted in University Hospital Centre Zagreb. It included all patients who underwent lifesaving BAV, and had no options for surgical or transcatheter aortic valve replacement at the time, between 2015 and 2018. Clinical and echocardiographic characteristics before and after BAV procedure were recorded. Results. Study included 29 patients, mean age 80.2 (51-92) years, 65.5% women. Mean logistic Euroscore II was 24.1±21.1% and STS score 16.9±14.5%. Comorbidities included: coronary artery disease (48.28 %), diabetes mellitus (31.4 %), chronic renal insufficiency (58.6 %), peripheral artery disease (17.2 %) and atrial fibrillation (55.2 %). All patients were dependent on parenteral diuretics and 24.14 % on parenteral inotropic support. Echocardiographic parameter before and after BAV are presented in table 1. There was significant increase in indexed aortic valve area and decrease in pulmonary artery systolic pressure in overall population. There was no significant change in severity of aortic insufficiency. Inhospital mortality was 20.1 % (N=6). Periprocedural complications included: 1 (3.4%) myocardial infarction, 1 (3.4%) major bleeding, 1 (3.4%) acute kidney injury and 2 (6.9%) vascular access complications. All other patients have been successfully weaned of parenteral therapy within 4 days and discharged. Conclusion. BAV represents palliative treatment option in critically ill hemodynamically unstable patients with end-stage AS, who are not candidates for valve replacement.1 BAV provides clinical improvement due to increase AVA and decrease in PAPs, with acceptable mortality and complications rate.

Introduction: Patients with symptomatic chronic heart failure (sCHF) and implanted cardiac resynchronization device (CRTD) were included in this retrospective study in order to evaluate possible differences in mitral (MR) and tricuspid (TR) valvular regurgitation severity, NYHA class and left ventricle ejection fraction (LVEF) between male and female CRTD patients during follow up of 6 months after CRTD implantation. Patients and Methods: We included 135 patients (89 men, 46 women) with sCHF due to any cause with implanted CRTD according to guidelines with optimal medical therapy regardless of atrial fibrillation or in sinus rhythm. Clinical (NYHA class) and echocardiographic data (valve pathology, LVEF) were assessed before and 6 months after CRTD implantation. Using color and continuous wave Doppler, PISA, regurgitation volume and vena contracta measurements, mitral regurgitation (MR) and tricuspid regurgitation (TR) were stratified in 3 grades. Echocardiography was recorded always by the same echo-technician to avoid inter-observer variability. Results: Mean age of patients was 60 (±10) years. The results showed improvement in LVEF from 25% up to 36% (p=0.006) in all patients regardless of sex and age, as well as worsening of TR (p

Introduction: Age and gender may influence the incidence of aortic regurgitation (AR) and its severity. Significant aortic regurgitation (sAR) is often treated surgically especially when symptomatic or when systolic function declines.1-3 The aim of this study was to evaluate the outcomes in patients with sAR according to treatment strategy, age and gender differences in our study population. Methods: In this retrospective descriptive single-center study an overall of 107 patients (22 female, 85 male) with significant AR in the last 5 years were analyzed. Patients were treated according to valid recommendations, surgically (SUR) or conservatively (CON), except for 5 patients who refused surgery. Baseline and follow up (FU) data (AR severity, left ventricular ejection fraction (LVEF), ascending aorta diameter (AA), treatment, comorbidities and major adverse cardiac events during FU), from documented medical history and digital imaging data were collected and analyzed. Additional sub-analysis was performed according to sex and age differences (above vs. below the age of 50). For statistical analysis a Chi-Square test was used. Results: In the overall study population, during an average FU of 3.8 years, 16 patients (15%) developed major adverse cardiac events (MACE) with no statistically significant difference between gender (p=0.846). Forty-six (43%) patients were surgically treated (87% male, 13% female) and 61 (54%) conservatively. LVEF did not worsen in FU period (54.1%, vs. 53.8%). In SUR, median age was 54 years, severe AR was present in 93%, incidence of MACE was 21.7%, 80.4% patients were symptomatic and 14.5% had dilatation of AA more than 50 mm. In CON, MACE was present in 9.8% during FU (p=0.87), median age was 64 years. Intermediate AR (48% vs 6.5%) and AA from 40-49 mm (80 vs 35%) was present more frequently as well as arterial hypertension (82 vs 70%) and chronic renal disease (23.2 vs 16.6%). The incidence of MACE was not found to be age-related (p=0.426). Conclusion: In patients with sAR treated by either surgery or medication therapy only, during 3.8 years of FU, LVEF remained unchanged, while incidence of MACE was not found to be related to treatment strategy nor gender. In surgically treated patients, as expected, AR was more severe and AA was more dilated, while neither age nor gender had an impact on the incidence of MACE.

Introduction: More than mild paravalvular regurgitation (PVR) after transcatheter aortic valve implantation (TAVI) represents one of the negative predictive factor for survival and quality of life after TAVI1. However, quantification and definition of more than mild PVR remains to be unified. Most commonly used 3 stage grading scheme is often insufficient2. Aim of this research was to assess differences in incidence of more than mild PVR during and after TAVI comparing 3 and 5 grades staging schemes. Patients and Methods: Study included 40 patients that underwent TAVI between July 2016 and January 2019 in general anesthesia with transesophageal echocardiography (TEE) during procedure. TEE exams had to be sufficiently recorded to quantify PVR with both grading schemes. Parameters used for PVR quantification and differences between models are presented in Table 1. Results: After initial valve implantation 10 (25%) patients had more than mild PVR when quantified using 3 grade model compared to 19 (47.5%) using 5 grade model (p

Introduction: Outside of the immunocompromised patient group, infective endocarditis (IE) of all four valves is a rare finding. It is a potentially deadly disease causing multiple complications, as well as a plethora of associated symptoms and clinical signs which can confound early diagnosis and lead to unnecessary testing.1-4 Case report: We present 71-year-old male patient who was admitted to the hospital for diagnostic workup of microcytic anemia. Medical history revealed permanent atrial fibrillation and arterial hypertension. In the previous two months he was feeling occasionally feverish, with night sweats and orthopnea. His clinical status showed irregular heartbeats with apical systolic heart murmur, bilateral basal crackles in the lungs, hepatosplenomegaly, scrotal edema and swollen legs. He underwent endoscopy without visible signs of hemorrhage and one tubulovillous adenoma with low grade dysplasia was removed. As plasma M protein was present, further hematologic tests were performed including bone marrow biopsy which was normal. Bone scintigraphy and PET CT showed pathologic accumulation in multiple ribs and vertebrae due to compressive fractures, lytic lesions and spondylodiscitis, in bone marrow and spleen without signs of malignancy as well as enlarged mediastinal, tracheal, axillar and inguinal lymph nodes. Patient was treated with diuretics, digoxin, betablockers, proton pump inhibitors, reimbursement of albumin and blood transfusions. During the third day of hospital stay patient became febrile. Transthoracic and transesophageal echocardiographic examination revealed signs of volume overload, normal ejection fraction, vegetations on all four valves with severe mitral regurgitation (MR) due to ruptured chordae and flail of P2 and P3 segments (Figure 1, Figure 2 and Figure 3), severe tricuspid regurgitation (TR) and pulmonary hypertension (Figure 4, and Figure 5). As Streptococcus gallolyticus was isolated in hemocultures, antibiotic therapy was modified according to antibiogram and diagnosis. Coronary artery stenosis was ruled out by MSCT coronary angiography. Patient was admitted to cardiac surgery and a successful mitral valve replacement with a bioprosthetic valve and surgical debulking of vegetations at other valves was performed. Postoperative echocardiography showed good position of mitral bioprosthesis without paravalvular MR, intermediate aortic regurgitation and severe TR without visible vegetations. In a two-year follow up patient is clinically stabile and remains in NYHA II class. Figure 1. Conclusion: Severe anemia may be a sign of infective endocarditis and postpone the diagnosis due to initial gastroenterological and hematologic work-up enabling severe destruction of affected valves.

Introduction: Age and gender may influence the incidence of aortic regurgitation (AR) and its severity. Significant aortic regurgitation (sAR) is often treated surgically especially when symptomatic or when systolic function declines.1 The aim of this study was to evaluate the outcomes in patients with sAR according to treatment strategy, age and gender differences in our study population. Patients and Methods: In this retrospective descriptive single-centre study an overall of 107 patients (22 female, 85 male) with significant AR in the last 5 years were analyzed. Patients were treated according to valid recommendations, surgically (SUR) or conservatively (CON), except for 5 patients who refused surgery. Baseline and follow up (FU) data (AR severity, left ventricle ejection fraction (LVEF), ascending aorta diameter (AA), treatment, comorbidities and major adverse cardiovascular events (MACE) during FU), from documented medical history and digital imaging data were collected and analysed. Additional sub-analysis was performed according to sex and age differences (above vs. below the age of 50). For statistical analysis a Chi-Square test was used. Results: In the overall study population, during an average FU of 3.8 years, 16 patients (15%) developed MACE with no statistically significant difference between gender (p=0.846). Forty-six (43%) patients were surgically treated (87% male, 13% female) and 61 (54%) conservatively. LVEF did not worsen in FU period (54.1%, vs. 53.8%). In SUR, median age was 54 years, severe AR was present in 93%, incidence of MACE was 21.7%, 80.4% patients were symptomatic and 14.5% had dilatation of AA more than 50 mm. In CON, MACE was present in 9.8% during FU (p=0.87), median age was 64 years. Moderate AR (48% vs 6.5%) and AA from 40-49 mm (80 vs 35%) was present more frequently as well as arterial hypertension (82 vs 70%) and chronic renal disease (23.2 vs 16.6%). The incidence of MACE was not found to be agerelated (p=0.426). Conclusion: In patients with sAR treated by either surgery or medication therapy only, during 3.8 years of FU, LVEF remained unchanged, while incidence of MACE was not found to be related to treatment strategy nor gender. In surgically treated patients, as expected, AR was more severe and AA was more dilated, while neither age nor gender had an impact on the incidence of MACE.