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Introduction/Objective. The optimal percutaneous coronary intervention (PCI) in patients with non-STelevated myocardial infarction (NSTEMI) and multivessel coronary artery disease (CAD) is still not clear. The aim of our study was to examine intrahospital and long-term major adverse cardiovascular and cerebrovascular events (MACCE) in this group of patients. Methods. This retrospective study included 225 patients with NSTEMI and multivessel CAD treated with PCI at the Institute of Cardiovascular Diseases of Vojvodina. Three groups were formed: complete one-stage PCI; complete multi-stage PCI, and culprit-only PCI. We analyzed intrahospital and one-year follow-up MACCE and mortality after three years in all three groups. Results. Complete one-stage PCI was performed in 112 (49.8%), complete multi-stage PCI in 70 (31.3%), and culprit-only PCI in 43 (19.1%) patients. Patients with multi-stage complete PCI had the lowest mortality in comparison with one-stage and culprit-only PCI, both intrahospital (0% vs. 0.9% and 20.9%, respectively, p < 0.0005) and after one year (0% vs. 2.7% and 30.2%, respectively, p < 0.0005) and three years (4.3% vs. 5.4% and 32.6%, respectively, p < 0.0005). There was no significant difference in other MACCE between the groups, both intrahospital and after one year. Conclusion. In our study, multi-stage PCI significantly reduces intrahospital, one-year and three-year follow-up mortality in patients with NSTEMI and multivessel CAD.

Gestational hypertension (GH) and preeclampsia (PE) are associated with the onset of hypertension. This study aimed to investigate whether the blood pressure (BP) pattern in GH is associated with the prevalence of hypertension later in life. In this prospective cohort study pregnant women screened for GH underwent medical history, laboratory analysis, ambulatory blood pressure monitoring (AMBP), and transthoracic echocardiography (with left ventricular global longitudinal strain (LVGLS)) assessment. Overall, 138 GH (67 non-dippers and 71 dippers), 55 preeclamptic, and 72 normotensive pregnant controls were included. Women were followed in the postpartum period, first after 6 weeks and later on, for the occurrence of hypertension. The median follow-up was 8.97 years (8.23; 9.03). Non-dippers and PE compared with normotensives and dippers had a higher prevalence of hypertension onset (p < 0.01), as well as significantly reduced absolute values of LVGLS during pregnancy, after delivery, and at the time of onset of hypertension during follow-up (p < 0.01). Night-time diastolic BP, LVGLS, age, and left ventricular ejection fraction were the strongest predictors of postpartum onset of hypertension. The non-dipping BP pattern in GH was significantly associated with the onset of hypertension later in life, as well as with decreased systolic function. [ABSTRACT FROM AUTHOR]

Introduction. Congenital coronary anomalies are detected in about 5% of all performed coronarographies. Coronary artery (CA) anomalies (CAA), considered to be of great risk, are the ones where the CA arises from the opposite sinus (anomalous origination of CA from opposite sinus, ACA-OS) of Valsalva. These anomalies are detected in about 1% of cases. This report shows a unique case of a patient with anterior wall ST-elevation myocardial infarction (STEMI) caused by left main CA (LMCA) occlusion, which arose from the right coronary cusp and had an interarterial course, successfully treated with primary percutaneous coronary intervention (PCI). Case report. A 46-year-old male patient was admitted to the hospital due to STEMI of the anterior region. On admission, the patient was hypertensive (150/100 mmHg) in sinus rhythm (heart rate 70/min), Killip I. After the initial examination and admitting dual antiplatelet therapy, the patient underwent urgent coronarography. Coronarography was performed using the transradial approach. The right CA had no significant stenosis and was easily cannulated, whereas the left CA could not be cannulated at the usual position. Attempts to cannulate the left CA with multiple catheters of various curves were unsuccessful. The conclusion was that there was a CA anomaly, and the cannulation of the anomalous left CA, which arose from the opposite (right) coronary cusp (anomalous aortic origin of the left CA, AAOLCA), was successfully performed with a Multipurpose catheter. Moreover, the LMCA was occluded in the distal segment. Two drug-eluting stents (DES) were implanted, but the patient developed the no-reflow phenomenon and cardiogenic shock. After the patient was stabilized, computed tomography (CT) coronarography was performed, and AAOLCA with an interarterial course was registered. During the follow-up period, single photon emission computed tomography (SPECT) was per-formed, and in the staged procedure, a stent was implanted into the proximal circumflex artery using the T and protrusion (TAP) technique. Conclusion. Patients with STEMI and the anomalies of CAs are very rare. As such, these patients represent a great challenge for revascularization. Possessing the knowledge of anatomic varieties is paramount when it comes to these patients to treat them adequately with primary PCI.

Introduction/Objective Left breast cancer patients undergoing radiotherapy are at higher risk of cardiovascular diseases (CVD), as a partial volume of the heart is anatomically close to target volume. This may cause CVD in the years following cancer treatment. The aim of this work was to develop a scoring system which identifies patients with increased risk of development of CVD, as a consequence of the left breast irradiation. Methods The patients followed up in this study were treated during 2009. Eight years later, they were invited to participate in a study where they underwent a cardiology evaluation. Their current condition was statistically correlated to the doses received by their heart and left anterior descendant artery (LAD). Results Out of 114 patients, 31 women were evaluable for cardiology assessment. Out of these 31 subjects, six women were with a history of CVD before cancer treatment. Four women never developed any kind of heart associated disease, while in the other 27, newly onset CVD were diagnosed ranging from hypertension to myocardial infarction, strongly positively correlated to doses to heart and LAD (p = 0.003). Severity of developed cardiovascular toxicity was formulated through the correlation of mean heart and mean LAD doses with CVD developed in the form of a scoring system. Conclusion The doses to critical organs depend on patient anatomy and technique of irradiation. The cardiovascular complications are proven as consequence of radiotherapy. Scoring system based on doses received by heart and LAD is a reliable tool in predicting CVD.

Introduction/Objective: Survival and neurologic recovery after out-of-hospital cardiac arrest remain poor despite significant advances in the therapeutic approach. The study aimed to evaluate predictors of intrahospital survival and neurologic outcome among patients after outof-hospital cardiac arrest as well as to evaluate the influence of mild therapeutic hypothermia introduction on intrahospital survival and neurologic outcome among comatose patients after out-of-hospital cardiac arrest. Methods The research was conducted as a retrospective observational study among patients hospitalized at the Cardiac Intensive Care Unit of the Institute for Cardiovascular Diseases of Vojvodina from January 2007 until November 2019 as a result of an out-of-hospital cardiac arrest. Results. The research included 506 survivors of OHCA. Multivariate regression analysis showed that initial shockable rhythm, cardiopulmonary resuscitation efforts lasting no longer than 20 minutes and a Glasgow Coma Score above 8 at admission, were predictors of intrahospital survival and good neurological outcome. Introduction of mild therapeutic hypothermia improved intrahospital survival (54.1% vs. 24.4%; p < 0.0005) and neurological outcome (42.9% vs. 18.3%; p < 0.0005) in comatose patients with initial shockable rhythm. Conclusion. In our study group of out-of-hospital cardiac arrest patients, initial shockable rhythm, cardiopulmonary resuscitation efforts lasting no longer than 20min and a Glasgow Coma Score above 8 at admission were predictors of intrahospital survival and favourable neurological outcome. The introduction of mild therapeutic hypothermia significantly improved survival and neurological outcomes in comatose patients with initial shockable rhythms.

Introduction. Implantation of left ventricular assist device (LVAD) improves survival and quality of life in patients with end-stage heart failure. We reported a case of a severe gastrointestinal bleeding as a life threatening complication in early recovering postoperative period of continuous blood flow LVAD implantation. Case report. The patient had a history of heart failure due to ischemic cardiomyopathy with low systolic function, as an indication for LVAD implantation. The operation and the postoperative course were uneventful. On the 17th postoperative day, the patient developed severe anemia, which was followed by melena with blood clots. Endoscopic examinations revealed diffuse colonic bleeding. Oral anticoagulation therapy was discontinued, and fresh frozen plasma, K vitamin substitution, and human prothrombin complex were administered. The LVAD speed was reduced and subcutaneous administration of somatostatin analog octreotide was initiated. These measures successfully stopped the bleeding and the patient was stabilized. Due to a multidisciplinary team approach, the bleeding was successfully managed and the patient re-covered. Conclusion. Acute gastrointestinal bleeding represents a serious, life-threatening condition that can develop after LVAD implantation, but with timely and appropriate measurements, it can be successfully treated.

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

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

Introduction. Bifurcation lesions on venous Y grafts are rare. We present a case of a woman who developed non-ST segment elevation myocardial infarction complicated by cardiogenic shock due to a bifurcation lesion on the venous Y graft for left anterior descending artery (LAD) and ramus circumflex artery (RCX). Case outline. A 72-year-old woman was admitted to the coronary care unit as an emergency in September 2017 due to acute heart failure followed by the development of cardiogenic shock. Urgent coronarography revealed severe atherosclerotic disease of native coronary arteries with significant bifurcation lesion on venous Y graft for LAD and RCX (medina classification of 1,1,1) with thrombolysis in myocardial infarction (TIMI) grade 2 flow. According to the general condition of patient, a life-saving ad hoc percutaneous coronary intervention (PCI) was performed. Two stents were implanted in the Y graft with T and protrusion (TAP) technique achieving optimal result followed with patient stabilization. On one-year follow-up, the patient was without symptoms of angina, and computed tomography coronarography revealed patent both stents in the Y graft. To the best of our knowledge, this is the first described TAP technique used on the Y graft. Conclusion. The PCI on a vein graft is not uncommon either in elective cases or in cases with acute coronary syndrome due to the poorer persistence and more frequent progression of atherosclerotic disease in the venous grafts. The use of bifurcation techniques for the treatment of lesions on a vein graft and especially on the Y graft is rare, but it can be used the same way it is used in native vessels.

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

Background: as a relatively high number of ST-segment elevation myocardial infarction (STEMI) patients develop major adverse cardiovascular events (MACE) following percutaneous coronary intervention (PCI), our aim was to determine the significance, and possible predictive value of QRS complex width and ST-segment elevation. Methods: our patient sample included 200 PCI-treated STEMI patients, which were divided into two groups based on the following duration of symptoms: (I) less than 6 h, and (II) 6 to 12 h. For every patient, an ECG was performed at six different time points, patients were followed for up to six years for the occurrence of MACE. Results: the mean age was 60.6 ± 11.39 years, and 142 (71%) were male. The 6–12 h group had significantly wider QRS complex, higher ST-segment elevation, lower prevalence of ST-segment resolution as well as MACE prevalence (p < 0.05). ECG parameters, QRS width, and magnitude of ST-segment elevation were proved to be independent significant predictors of MACE in all measured time points (p < 0.05). Even after controlling for biomarkers of myocardial injury, these ECG parameters remained statistically significant predictors of MACE (p < 0.05). Conclusion: our study highlights that wider QRS complex and a more pronounced ST-segment elevation are associated with longer total ischemic time and higher risk of long-term MACE. [ABSTRACT FROM AUTHOR]

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

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

Introduction. Management of cardiogenic shock caused by severe drug intoxication is always challenging. In case of multidrug intoxication, a result, despite aggressive medical therapy, is often unpredictable. Utilization of extracorporeal life support devices in these cases has been suggested and reported results are promising. Case report. We presented a case of profound cardiogenic and distributive shock caused by suicidal intoxication with diltiazem and anionic surfactant ingestion in a 36-year-old woman. The patient ingested more than 90 tablets of diltiazem of 90 mg (ingested dose of 8.1 g), and 4 pieces of household toilet refresh agent containing anionic surfactant. During the admission, systemic blood pressure was 65/40 mmHg, heart rate 45 beats per minute, with signs of metabolic acidosis. The patient underwent several repeated gastric lavages. Emergent fluid resuscitation, calcium gluconate, insulin and vasopressive agents (dopamine and noradrenaline) infusions were administered with negligible effect. Due to progressive and refractory cardiogenic shock with signs of multiorgan failure, a decision was made to put the patient on venoarterial extracorporeal membrane oxygenator. Immediately after starting the extracorporeal membrane oxygenation, diuresis was established. During the next 36 h, an adequate end-organ perfusion was achieved with complete reversal of multiorgan failure. After the successful restoration of all major organ functions, the patient was successfully decannulated and discharged from the hospital after 10 days in a good condition. Conclusion. In severe cases of refractory cardiogenic and distributive shock due to diltiazem and other poison intoxication, venoarterial extracorporeal membrane oxygenation could allow additional circulatory support providing the bonus time for endogenous clearance of toxins. Venoarterial extracorporeal membrane oxygenation could be used in conjunction with the optimal medical therapy aiming to the restoration of end-organ perfusion and allowing for intrinsic drug and toxin metabolism and natural elimination.

Background/Aim. Despite considerable progress in terms of early myocardial revascularization and the use of mechanical circulatory support, cardiogenic shock continues to be the leading cause of death in acute myocardial infarction. The current recommendations of the European Society of Cardiology advocate early revascularization of all critical stenosis or highly unstable lesions in the state of cardiogenic shock, while recently published studies favour the early revascularization of the infarct related artery only, in patients with acute myocardial infarction with the ST segment elevation (STEMI) presenting with cardiogenic shock. The aim of the study was to assess the impact of the complete early percutaneous myocardial revascularization in an acute myocardial infarction complicated by cardiogenic shock on intra- hospital mortality. Methods. The research was conducted as a retrospective observational analysis of data obtained from the hospital registry for cardiogenic shock. The study group consisted of 235 patients treated in the period from August 2007 until October 2016 for STEMI complicated by cardiogenic shock. Three groups were formed. The first group consisted of patients with one vessel disease who underwent revascularization of infarct related artery; the second group of patients had multi-vessel disease and only culprit lesions were revascularized and the third one consisted of patients with multi-vessel disease and the complete myocardial revascularization performed. Additional subgroups were formed in reference to the intra-aortic balloon pump (IABP) implantation. Intra-hospital mortality was analyzed in all groups and subgroups. Results. Revascularization of the culprit lesion alone among patients with multivessel disease was performed in 142 (60.4%) patients while the complete revascularization (revascularization of “culprit” and other significant lesions) was performed in 28 (11.9%) patients with multi-vessel disease. There were 65 (27.7%) patients with single-vessel disease who underwent revascularization of infarct related artery. The lowest mortality was found in the group of patients with multi-vessel coronary disease who underwent complete myocardial revascularization and had IABP implanted (mortality was 35.7%). The difference in the mean value of the left ventricular ejection fraction (EF) between the surviving and deceased patients was statistically significant (p < 0.005). The average EF of survivors was 44% (35%–50%) while 30% (25%–39.5%) deceased of patients. Based on the obtained data, the mathematically predictive model was tested. The receiver operating characteristic (ROC) curve showed that our model is a good predictor of fatal outcome (p < 0.0005; AUROC = 0.766) with the sensitivity of 80.3%, and the specificity of 67%. Conclusion. STEMI complicated by cardiogenic shock is still associated with a high mortality rate. Complete myocardial revascularization independently as well as in combination with an IABP, significantly reduces mortality in patients with acute STEMI complicated by cardiogenic shock.

Introduction. Chronic total occlusion (CTO) is defined as a 100% obstruction of the blood vessel lumen with Thrombolysis in Myocardial Infarction grade 0 flow in the occluded segment at least three months old. Advancement of technological devices and techniques used during the percutaneous coronary interventions (PCI) in the past years brought more success in blood vessel recanalization. According to the latest guidelines for myocardial revascularization, the CTO treatment should be considered when there are symptoms or objective proof of viability or ischemia in the occluded area. The aim of this work is to present two cases with a recanalization of the coronary artery CTO by the retrograde approach. Outline of cases. The first patient had a single vessel coronary disease which led to a decision to first attempt PCI. During the attempt of antegrade recanalization, the guidewire penetrated subintimally, risking blood vessel dissection below the occluded area as well as serious complications. Retrograde approach enabled easier and safer passing of guidewire through the occlusion and then successful establishment of the antegrade flow. In the second case, the antegrade approach was also first attempted. Since it could not pass through the occluded area despite changing several guidewires, the strategy was changed during the intervention. It was continued with the retrograde approach, which led to the successful revascularization. Conclusion. These two cases demonstrate that retrograde approach and new technological improvements in dedicated guidewires can be implemented in everyday angiography practice for successful recanalization of CTO lesions.

Introduction. The aim of each diagnostic method is to serve as a guide in deciding about the right patient treatment. During myocardial revascularization the decision to perform revascularization is usually not easy to make, especially in case of borderline stenosis. It has been proven that it is not enough to base morphological evaluation of coronary artery vessel stenosis solely on angiography. It is necessary to include additional modern diagnostic methods for functional analysis and detailed morphological analysis using fractional flow reserve (FFR) and optical coherence tomography (OCT), respectively. Case reports. In the first case report we showed the significance of morphological analysis using OCT and proved that it was not lumen stenosis. The second and the third case reports showed the complementarity between functional analysis (FFR) and morphological analysis (OCT) of stenosis in solving a complex coronary disease. The fourth case report showed the significance of OCT in dealing with the recurrent stent restenosis. Conclusion. By these short case reports we confirmed that percutaneous coronary intervention (PCI) guided by angiography is definitely not enough in deciding about myocardial revascularization especially in patients with a complex coronary disease. In certain cases FFR and OCT procedures can be complementary methods and improve quality of revascularization, particularly in the case of recurrent in-stent restenosis.

Introduction. Streptococcus bovis is labeled in the literature as a cause of bacteremia and endocarditis, which are often associated with gastrointestinal malignancy. Case Outline. In our paper we present a patient with endocarditis induced by Streptococcus bovis who was also, after completed cardiologic examination and treatment, diagnosed colon cancer in situ by targeted endoscopy. Owing to the timely diagnosis, and after successful cardiologic surgery with implantation of an artificial aortic valve, patient underwent surgery of the colon, and is now asymptomatic and in good health. Conclusion. Complete and detailed endoscopic examination of the colon must be done in patients with endocarditis caused by Streptococcus bovis, even if the patient is asymptomatic. By following these recommendations, it is possible to detect precancerosis or cancer at an early stage and save the patient’s life.

Introduction. Syncope represents a relatively atypical symptom of acute coronary syndrome. Syncope itself does not provide enough information to indicate an acute coronary event, especially a lesion of the left main coronary artery, without malignant rhythm and conduction disorders. Case report. A male patient, aged 63, was admitted to the intensive cardiac care unit because of a short loss of consciousness, in sinus tachycardia, with signs of acute heart failure and being hypotensive. Electrocardiogram showed a possible acute anterior myocardial infarction, followed by cardiogenic shock and emergency coronary angiography (subocclusive ostial lesion of the left main coronary artery) and primary percutaneous coronary intervention with intraaortic balloon pump therapy was performed. A direct drug eluting stent was implanted with the optimal primary result. Conclusion. The prompt diagnosis, especially in such relatively atypical clinical presentation, reperfusion therapy with primary percutaneous coronary intervention in acute myocardial infarction complicated by cardiogenic shock, contribute to the improvement in the survival rate and patient's quality of life. This case report is clinically educative due to relatively atypical presentation and performed interventions.

Introduction. Double heart rupture is a rare complication of acute myocardial infarction with high mortality. Case report. We presented a 67-year-old female patient with symptoms and signs of myocardial infarction, diagnosed with echocardiography, rupture of the septum, the presence of a thrombus and a small pericardial effusion. Soon after admission the patient died. Autopsy revealed tamponade and double myocardial rupture, free wall rupture and ventricular septal rupture, as a cause of death. Conclusion. This case highlights the need to evaluate patients with myocardial infarction, recurrent chest pain, echocardiographic signs of effusion and the presence of thrombus in the pericardium in terms of double rupture of the heart.

Introduction. Rhabdomyosarcoma (RMS) is the most common sarcoma of the soft tissue, mostly affecting the region of head and neck (orbit, paranasal sinus). Histological types include embryonal (66­70%) with better prognosis, and alveolar type (20%) with poorer prognosis. There are also diffuse anaplastic and undifferentiated sarcomas (10%). Due to multimodal therapy approach (surgery, chemotherapy and radiotherapy), RMS survival rate is considerably improving. Nevertheless, early diagnosis of RMS is of crucial importance for the outcome of treatment. Standard conformal radiation therapy is very complex due to closeness of many critical structures of head and neck, thus limiting optimal tumor dose coverage. Case Outline. Patient aged 59 years, surgically treated for RMS of nasal cavity several times before radiation therapy treatment. Due to relapse, patient was re­operated, when subtotal re­resection of the maxilla with exenteration of the right orbit was done. The patient received IV cycles of polychemotherapy postoperatively. Standard procedure and planning for conformal radiation therapy did not lead to acceptable irradiation plan, and hence modification in the patient’s preparation was done, resulting in optimal therapeutic plan according to internationally recognized recommendations. Conclusion. The reported case shows a rare pediatric tumor, which often occurs in children but extremely rare in adults. The problem of inadequate isodose distribution obtained by standard conformal plan was solved by placing bolus material into the orbital cavity. The outcome of the treatment plan showed much better isodose distribution and tumor bed coverage.

Background/Aim. In our Intensive Coronary Care Unit (CCU) a specific scoring system named the AMIS_NS was developed both for prediction of mortality in patients with acute myocardial infarction and for evaluation of the quality of work. One of the most important variables of the AMIS_NS system is the variable Jung which stands for the interrelationship unified mortality predictors. The variable includes all the values of systolic blood pressure, heart rate and age, without limiting values for any of these. The cutoff value is 2.08. The patients with the lower variable value account for a significantly higher mortality. Data on the actual infarction are not necessitated now for this variable. The aim of this study was to assess the significance of the variable Jung in non-infarction patients with acute pulmonary edema. Methods. In a 24-month period out of 2,223 patients there were 1,087 and 1,136 patients with and without acute myocardial infarction, respectively. There was the subgroup without myocardial infarction of 312 (84.1%) patients admitted with the diagnosis of pulmonary edema. The subgroup with myocardial infarction consisted of 59 (15.9%) patients who were admitted for acute myocardial infarction and pulmonary edema which developed immediately after admission or during hospitalization in the CCU. For all the patients a uniform questionnaire was fulfilled on admission. Data were put into the personal computer. The variable “Jung” was used: (systolic bloog pressure/heart rate × age) × 100. Results. Regarding sex, there was no difference in mortality, so that males and females were regarded as a whole. Previous myocardial infarction was equally registered in both groups. The investigated persons had less percent of mortality and a significantly higher systemic pressure as well as higher value of the variable Jung. There was no statistically significant difference in the heart rate between the two groups. In both groups of deceased patients the variable Jung (1.5 vs 1.6) was significantly lower in respect to the survived patients (2.3 vs 2.1). Conclusion. The variable Jung is simple, highly reliable and can absolutely be used as a significant indicator of clinical status also in noninfarction patients with the acute pulmonary edema, no matter if it is caused by acute myocardial infarction or not.

Copyright of Acta Medica Croatica is the property of Croatian Academy of Medical Sciences 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.)

Introduction/Aim. The most important clinically relevant cause of global cerebral ischemia is cardiac arrest. Clinical studies showed a marked neuroprotective effect of mild hypothermia in resuscitation. The aim of this study was to evaluate the impact of mild hypothermia on neurological outcome and survival of the patients in coma, after cardiac arrest and return of spontaneous circulation. Methods. The prospective study was conducted on consecutive comatose patients admitted to our clinic after cardiac arrest and return of spontaneous circulation, between February 2005 and May 2009. The patients were divided into two groups: the patients treated with mild hypothermia and the patients treated conservatively. The intravascular in combination with external method of cooling or only external cooling was used during the first 24 hours, after which spontaneous rewarming started. The endpoints were survival rate and neurological outcome. The neurological outcome was observed with Cerebral Performance Category Scale (CPC). Follow-up was 30 days. Results. The study was conducted on 82 patients: 45 patients (age 57.93 ± 14.08 years, 77.8% male) were treated with hypothermia, and 37 patients (age 62.00 ± 9.60 years, 67.6% male) were treated conservatively. In the group treated with therapeutic hypothermia protocol, 21 (46.7%) patients had full neurological restitution (CPC 1), 3 (6.7%) patients had good neurologic outcome (CPC 2), 1 (2.2%) patient remained in coma and 20 (44.4%) patients finally died (CPC 5). In the normothermic group 7 (18.9%) patients had full neurological restitution (CPC 1), and 30 (81.1%) patients remained in coma and finally died (CPC 5). Between the two therapeutic groups there was statistically significant difference in frequencies of different neurologic outcome (p = 0.006), specially between the patients with CPC 1 and CPC 5 outcome (p = 0.003). In the group treated with mild hypothermia 23 (51.1%) patients survived, and in the normothermic group 30 (81.1%) patients died, while in the group of survived patients 23 (76.7%) were treated with mild hypothermia (p = 0.003). Conclusion. Mild therapeutic hypothermia applied after cardiac arrest improved neurological outcome and reduced mortality in the studied group of comatose survivors.

Copyright of Acta Medica Croatica is the property of Croatian Academy of Medical Sciences 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.)