Acute coronary syndrome (ACS) includes a spectrum of clinical conditions, with increasing recognition of myocardial infarction with non-obstructive coronary arteries (MINOCA). Among its potential etiologies, Takotsubo syndrome (TTS) and spontaneous coronary artery dissection (SCAD) present with overlapping clinical features, posing diagnostic challenges. We present a case of a 56-year-old postmenopausal woman with recurrent chest pain and elevated troponin levels, initially diagnosed with TTS based on apical ballooning and a lack of obstructive coronary artery disease. However, persistent symptoms and echocardiographic wall motion abnormalities prompted further evaluation with cardiac magnetic resonance imaging (CMR), which demonstrated subendocardial late gadolinium enhancement (LGE) in the right coronary artery (RCA) and left anterior descending (LAD) artery territories, raising suspicion for an ischemic etiology. A subsequent coronary angiogram with optical coherence tomography (OCT) confirmed SCAD of the LAD, establishing an overlapping diagnosis of TTS and MINOCA due to SCAD. This case underscores the essential role of the multimodal imaging in refining MINOCA diagnoses and highlights the potential interplay between TTS and SCAD. Further research is needed to clarify their shared pathophysiology and improve diagnostic and therapeutic approaches in similar cases..

BACKGROUND: The following case presentation highlights the diagnostic and therapeutic approach to a patient with a rare disease. CASE PRESENTATION: A 47-year-old man was hospitalized with chest pain, shortness of breath, and fatigue. Initial blood test analysis revealed elevated CRP, leukocytosis, and elevated cTn-I. Due to suspected myocarditis, cardiac magnetic resonance (CMR) imaging was performed. CMR ruled out myocarditis. In addition, there were no signs of edema or late gadolinium enhancement (LGE). However, there was evidence of enlarged right ventricular heart chambers. Cine short-axis images and LGE sequences revealed masses in the pulmonary artery, highly suspicious of thrombi. D-dimer was analyzed, showing very high values, and additionally, CTPA confirmed the diagnosis of pulmonary embolism (PE). Venous Doppler ultrasonography demonstrated DVT in the right popliteal vein. Anticoagulation with LMWH was initiated, after which a drug from the NOAC class - Rivaroxaban was given according to a PE protocol. The patient was discharged from the hospital in a hemodynamically stable condition with a recommendation to adhere to the therapy and conduct control after 1 and 3 months of hospitalization. CONCLUSION: Thanks to multimodality imaging, we find it easier to get the specific cause of the problem, by establishing it or by ruling it out. However, the most important thing is to have a high clinical suspicion and common sense for faster diagnosis, treatment, and early recovery of the patient.

BACKGROUND: Prosthetic mechanical valve endocarditis (PVE) can be manifested as early PVE (acquired perioperatively) and late PVE (resulting from infections unrelated to the valve operation). Causes of both are similar but are late PVE are more prone to less virulent microbes. PVE resulting with paravalvular abscess is confirmed through echocardiography (transthoracic or transesophageal), it results with a high mortality rate especially if it is not early recognized. CASE PRESENTATION: We are presenting a patient with heart failure symptoms caused by PVE after Pfizer-BioNTech coronavirus disease-2019 (COVID-19) m-RNA vaccination. CONCLUSION: The exact mechanism of myocarditis in young men who received the second dose of mRNA COVID-19 vaccine is not yet known. However, this is a rare complication and most people generally recover quickly requiring only supportive treatment. In contrast, the risk of developing myocarditis from the viral infection is much higher.

Introduction The left ventricular ejection fraction (LVEF) is commonly used as a marker of aortic stenosis (AS) disease severity and to indicate surgical intervention. However, an LVEF <50% identifies mainly advanced disease. Hence, earlier detection of subclinical LV systolic dysfunction may improve clinical decision-making. The global longitudinal strain (GLS) can identify subclinical systolic dysfunction at earlier stages of AS progression even in the presence of preserved LVEF. To this end, we evaluated the preoperative prognostic significance of the LVGLS to identify patients who will undergo a more extensive postoperative LV reverse remodeling as a surrogate marker for clinical recovery. Methods We performed a prospective observational study based on detailed pre- and postoperative 2D transthoracic echocardiographic examinations, including strain analysis with speckle tracking. We screened 60 consecutive patients with severe AS and a preoperative LVEF ≥50% indicated for surgery; 39 patients met the study entry criteria and consented to their participation. Results The median age was 67 (range 30-79) years; 56.4% were female. At baseline, the GLS was 61.64±7.22%. Surgery led to an improvement in the GLS; the mean difference was 3.23% [95% CI=1.96 to 4.49%] during a median follow up time of 5 (interquartile range 4-6) months. The preoperative GLS correlated with the postoperative LV mass index (LVMI) r=0.526, P=0.001 and the intraventricular septal thickness in diastole (IVSd) r=0.462, P=0.003. Furthermore, patients with a normal GLS (≤-18.9%) at baseline experienced a better recovery of their LV morphology and systolic function during the postoperative course compared to those with an abnormal GLS (>-18.9%). The effect size, hedges g, was at least >0.75 for the LVMI, IVSd, intraventricular septal thickness in systole (IVSs), left ventricular posterior wall thickness in diastole (LVPWd) and LVEF, suggesting a clinically significant difference between subgroups at follow-up. Conclusion A normal preoperative left ventricular global longitudinal strain is associated with an improved left ventricular reverse remodeling and systolic function following surgery to resolve aortic stenosis.

Right coronary artery (RCA) emerged as infarct related artery (IRA) in patients with right ventricular myocardial infarction (RVMI), which is followed by some degree of RV dysfunction. The aim of our study was to identify significant predictors of IRA among angiographic and/or echocardiographic data of RV dimension and/or function in patients with acute RVMI. Out of 122 hospitalized patients with acute inferior myocardial infarction, on the basis of ECG criteria RVMI was diagnosed in 58/47.5% patients. Coronary angiography was applied in 52/89,6% immediately after admission and conventional 2D echocardiography was performed in all referred patients in order to assess right heart dimensions and function according to the professional association recommendations. RCA emerged as IRA in 49/84,5 % of patients with echocardiographicaly diagnosed RVMI. Patients with RCA stenosis/occlusion had 4.9 times higher risk for RVMI presence (OR=4.941; 95%CI: 1.727-14.136; p=0.003) than those without and had significantly worse echocardiographic assessed RV global and/or regional systolic function. Logistic stepwise regression analysis confirmed the significant role of enlarged RV dimension (OR=1.1; 95%CI: 1.023-1.182; p=0.010), RCA stenosis/occlusion presence (OR=4.8; 95%CI: 1.649-14.199; p=0.004) and/or LAD stenosis/occlusion absence (OR=0.18; 95%CI: 0.067-0.476; p=0.001) in prediction of RVMI. The optimal sensitivity of the model was 90% and specificity 75%. RCA and conversely lack of LAD stenosis/occlusion presence along with some of the echocardiographic parameters showing RV dysfunction increased the odds for RVMI. Applying immediate and complete reperfusion of RCA is of a great importance for recovery of RV function. Key words: right myocardial infarction, right coronary artery, right ventricular dysfunction, reperfusion.

It was confirmed that coronary artery plaque [CAP] and its larger burden may influence myocardial perfusion independent of presence of significant coronary artery stenosis.The aim of our study was to examine the role of CAP as predictor of coronary artery disease [CAD] presence using pharmacological stress echocardiography [SE]. We prospectively assessed 61 consecutive patients with symptoms implying CAD who underwent dipyridamole or dobutamine SE and coronary angiography. Conventional 2D echocardiographic wall motion score index [WMSI] as well as global LV longitudinal strain using speckle tracking [GLS%] were measured at rest and peak stress. Out of 61 patients, 25/41.0% had normal coronary arteries, 18/29.5% had obstructive CAD and 18/29.5% had nonobstructive CAD with CAP. In patients with CAP, GLS% at maximal SE showed worsening in comparison to those with and without CAD who showed insignificant lower GLS% or better function after SE [p=0.057]. Presence of CAP [OR=8.358; 95%CI 1.929-36.216;p=0.005] and worsening of WMSI at maximal SE [OR=190.5; 95%CI 2.517-14426.687;p=0.017] appeared as independent predictors of CAD presence, while worse values of GLS% at maximal SE [OR=1.155; 95%CI 0.999-1.334;p=0.051] as well change [increase] of the number of segments with LS< 12% at maximal SE [OR=0.755; 95%CI 0.602-0.946;p=0.015] appeared as independent predictors of CAP presence. Coronary artery plaque presence appeared as independent predictor of CAD as well as worse values of GLS% Key words:coronary artery plaque, coronary artery disease, stress echocardiography, LV systolic longitudinal strai

The aim of the study was to assess the effect of body mass index (BMI) on myocardial function and mechanics among patients with severe aortic stenosis (AS) admitted for surgical aortic valve replacement (SAVR). The dramatic increase in the prevalence of obesity and its strong association with cardiovascular disease have resulted in growing interest in understanding the effects of obesity on the cardiovascular hemodynamics and mechanics especially in circumstances of valvular diseases. A total of 51 consecutive patients (age: 65.8±9.6 y, 58.8% male,41.2% females) who underwent SAVR for severe AS were classified according to World Health Organization criteria such as normal weight, overweight, or obesity according to their BMI (18.5 to 24.9 kg/m2, 25.0 to 29.9 kg/m2, and ≥30.0 kg/m2, respectively). Out of all, 31.4% were obese and 43.1% overweight, with more frequent history of atherosclerotic risk factors. Obese and overweight patients after SAVR showed in comparison to those with normal weight insignificantly smaller indexed aortic valve area (AVAi), higher indexed left atrial volume (LAVI) and left ventricular (LV) end-systolic dimension, lower LV ejection fraction (EF) as well as higher LV filling pressure (E/e`average) as a marker of diastolic dysfunction. In addition, obese patients showed significantly (p=0.008) the highest value of valvuloarterial impedance (Zva) and with borderline significance lowest GLS% (more positive value). Linear regression analysis showed that BMI adjusted to age, gender and history of hypertension appeared as independent significant predictor of higher Zva value (b=0.136; 95%CI 0.65 to 0.207; p=0.0001) and along with male gender of worse (more positive) LV GLS% values (b=0.314; 95%CI 0.098 to 0.531; p=0.005) after SAVR. BMI appears as independent predictor of more extensive impairment of myocardial function and mechanics after SAVR that could contributed to more unfavorable long-term outcome in these patients. Key words: body mass index, obesity, overweight, severe aortic stenosis, surgical aortic valve replacement, echocardiography, subclinical left ventricular function

ABSTRACT Introduction and goal: Degenerative aortic stenosis is the most common valvular disease for which treatment of choice is stil surgery. Without the presence of symptoms, evaluation of systolic function of the left ventricle (LV) is crucial in surgical treatment decision making. Global longitudinal strain (GLS) is a valuable marker for subclinical systolic dysfunction delivering promising conditions for the right timing of the surgical aortic valve replacement (SAVR). Material and methods: We present a case of a 57-year old male with severe aortic stenosis. Detailed echocardiographic examination was performed including GLS of the LV with 2D speckle tracking before and after SAVR. Results: The ejection fraction before and after the surgical treatment was normal. GLS before the surgical treatment was -15, 1%, for 3-chamber GLS the value was -15,3%; for 4-ch it was -14,2% and 2-ch counted -16%. After replacement of the aortic valve with mechanical prosthesis, the echocardiographic assessment done 4 months later showed improvement of the GLS values to -17,1% ( -18,5% for 3-ch, -15,0% for 4-ch and -17,1% for 2-ch). Conclusion: Global longitudinal strain (GLS) of the LV is abnormal in patients with severe aortic stenosis. Surgical treatment of aortic stenosis improves GLS of the LV implicating improvement of the subclinical systolic dysfunction of the LV. Key words: aortic valvular stenosis, longitudinal strain, systolic function, echocardiography

BACKGROUND:Percutaneous transcatheter closure (PTC) of patent foramen ovale (PFO) is implicated in cryptogenic stroke, transitional ischemic attack (TIA) and treatment of a migraine. AIM:Our goal was to present our experience in the interventional treatment of PFO, as well as to evaluate the short and mid-term results in patients with closed PFO. MATERIAL AND METHODS:Transcatheter closure of PFO was performed in 52 patients (67.3% women, mean age 40.7 ± 11.7 years). Patients were interviewed for subjective grading of the intensity of headaches before and after the PFO closure. RESULTS:During 2 years of follow-up, there was no incidence of new stroke, TIA and/or syncope. Follow-up TCD performed in 35 patients showed complete PFO closure in 20 patients (57.1%). Out of 35 patients, 22 (62.9%) reported having a migraine before the procedure with an intensity of headaches at 8.1 ± 1.9 on a scale from 1 to 10. During 2 years of follow-up, symptoms of a migraine disappeared in 4 (18.2%) and the remaining 18 patients reported the significant decrease in intensity 4.8 ± 2.04 (p = 0.0001). In addition, following PFO closure the incidence of the headaches decreased significantly (p = 0.0001). CONCLUSIONS:Percutaneous transcatheter closure of PFO is a safe and effective procedure showing mid-term relief of neurological symptoms in patients as well as significant reduction of migraine symptoms.

Objective: To evaluate additional role of left atrial two-dimensional speckle tracking echocardiography in patients with diabetes mellitus type 2, 218 patients with heart failure with preserved left ventricular ejection fraction divided according to the presence of diabetes mellitus (108 with and 110 without) were enrolled in the study. Methods: Traditional parameters using two-dimensional echocardiography and Doppler imaging were measured as expressions of left ventricular diastolic function as well as peak atrial longitudinal strain and peak atrial contraction strain were measured using two-dimensional speckle tracking echocardiography. Results: Global average peak atrial longitudinal strain and peak atrial contraction strain were significantly lower in patients with diabetes mellitus ( p = 0.002 and p = 0.001, respectively) and its reduced values were significantly associated with higher prevalence of diabetes mellitus ( p = 0.002 and p = 0.001, respectively), its greater severity ( p = 0.002 and p = 0.016, respectively) and longer duration only for global average peak atrial longitudinal strain ( p = 0.030). Multiple linear regression analysis demonstrated that the presence of diabetes mellitus appeared as independent predictor of reduced global peak atrial longitudinal strain [ B = −2.173; 95% confidence interval: −3.870 to (−0.477); p = 0.012] as well of reduced global peak atrial contraction strain [ B = −1.30; 95% confidence interval: −2.234 to (−0.366); p = 0.007]. Conclusion: Two-dimensional speckle tracking echocardiography appeared as a useful additional tool for detection of left atrial dysfunction in patients with heart failure who have preserved left ventricular ejection fraction and diabetes mellitus who are especially prone to develop cardiovascular complications.

BACKGROUND:Percutaneous pulmonary valvuloplasty is well established treatment of choice in pulmonary valve stenosis.AIM:The aim of our study was to present our experience with the interventional technique, its immediate and mid-term effectiveness as well as its complication rate.MATERIAL AND METHODS:The study included 43 patients, where 33 (74%) of them were children between the age of 1 month and 15 years.RESULTS:The procedure was successful in 38 patients or 90%. Mean peak to peak transvalvular gradient was reduced from 91.2 mmHg (55-150 mmHg) to 39.1 mmHg (20-80 mmHg). Follow- up of patients was between 2 and 13 years and included echocardiographic evaluation of pulmonary valve gradient, right heart dimensions and function as well as assessment of pulmonary regurgitation. We experienced one major complication pericardial effusion in a 5 months old child that required pericardiocenthesis. Six patients (13.9%) required a second intervention. During the follow up period there was significant improvement of right heart function and echocardiography parameters. Mild pulmonary regurgitation was noted in 24 (55%) patients, and four (9%) patients developed moderate regurgitation, without affecting the function of the right ventricle.CONCLUSIONS:Percutaneous pulmonary valvuloplasty is an effective procedure in treatment of pulmonary stenosis with good short and mid-term results.

Background: Atrial septal defect (ASD) is a common congenital heart disorder (CHD). While conventional open surgical treatment is the standard procedure in our country, percutaneous device closure with implantation of an atrial septal defect occluder is a promising alternative with very few peri and post procedural complications.Aim: The aim of the study was to present the rate of success and complications in percutaneous ASD closure with the implantation of an atrial septal defect occluder.Material and Methods: We treated 153 patients (ages 2-76; 65% female) with ASD secundum with percutaneous trans catheter closure using a septal occluder. Follow up was on a 3 month interval and assessment included clinical, electrophysiological and echocardiographic status. Results: The mean diameter of ASD obtained via balloon sizing was 16 ± 16 mm. Multiple ASDs were found in 20 (13%) patients and deficitary aortic and anterior rim (< 5 mm) was present in 16 (10%) patients. Due to inadequate placement and/or sizing, the device was removed and replaced in seven patients (5%). During follow up, trivial shunt was present in 4 (2.6%) patients. The diameter of the right ventricle corrected for age was reduced by an average of 20% by the first month and in 130 (86%) of patients it had normalized by one year of follow up. During follow up, 16 (10%) patients reported transient headaches and 3 (1.9%) patients had transient atrial fibrillation (AF).Conclusion: In conclusion, the implantation of a septal occluder was found to be a safe procedure that resulted in improved hemodynamic parameters that result from right ventricular volume overload with favorable short- and mid-term results.

BACKGROUND:Chronic infections in CHD are due to one or both of the organisms Chlamydia pneumoniae and Helicobacter pylori.AIM:To examine the association between serum markers of Chlamydia pneumoniae and Helicobacter pylori infection and markers of myocardial damage. in patients with acute coronary syndrome (ACS), with chronic coronary artery disease (CAD) and in-control group.MATERIAL AND METHODS:Sera were taken from a total of 153 subjects. Subjects were divided in three groups: 64 patients with ACS; 53 patients with CAD and a group of 35 conditionally healthy individuals. Analysis of patients' sera for IgG antibodies to H. pylori and markers for myocardial damage was done on the Immulite system. The presence of specific IgG and IgA antibodies to C. pneumoniae was determined with MIF, Sero FIA (Savyon Diagnostics, Israel). Statistical analysis of data was done using the statistical program SPSS (Statistical Package for Social Sciences), version 13.RESULTS AND DISCUSSION:There was a high significant difference in troponin levels between the three groups of subjects (p=0.0000). Levels of creatine kinase isoenzyme (CK-MB) were highest in the ACS group (500.0 ng/mL). There was a statistically significant difference between CG subjects and ACS patients due to more frequent detection of antichlamydial IgA antibodies in patients with acute coronary syndrome. Positive serum immune response for Helicobacter pylori was 17 (53.1%) and 29 (80.6%), respectively.CONCLUSION:Increased IgA antibody titers for C. Pneumoniae, increased CRP values as well as classic markers of myocardial damage are risk factors for coronary events.

Background: Elevated levels of CRP, myoglobin and creatine kinase are always associated with pathological changes and hence their values give useful information for exact diagnosis and therapy. They are helpful in monitoring the inflammatory processes and associated diseases. Aim: The aim of this study was to determine the usefulness and practical value of application of CRP detection by comparing it with the results obtained for the classical enzymes – markers of myocardial damage, myoglobin and creatine kinase isoenzyme MB (CK-MB) in pts with acute coronary syndrome (ACS), pts with chronic coronary artery disease (CAD) and in healthy individuals. Material and Methods: Sera were taken from a total of 152 individuals (78.9% males, 21.1% females, mean age 61.87 ± 10.32 years). The subjects were divided in three groups: 63 pts with ACS; 52 pts CAD and a group of 36 conditionally healthy individuals. Analysis of patients’ sera for presence of markers for myocardial damage: myoglobin, CK-MB along with determination of CRP level was done on the Immulite system, DPC (Diagnostic Products Corporation), Los Angeles, USA. Results: Comparison of examined biomarker’s values in pts divided according to diagnosis showed statistically significant higher levels in patients with ACS vs. others. As for biomarker’s cut-off values, out of all CK-MB ³ 5.7 ng/mL was found in 34 (53.1%) pts with ACS with significant difference among the groups in favor of its higher values in pts with ACS (p=0.0001). Out of all, myoglobin ³ 25 ng/mL was found in 54 (84.4%) pts with ACS without significant difference among the groups. As for CRP, value of ³ 3 mg/L was found in 39 (60.9%) pts with ACS and there was significant difference among the groups in favor of higher values in pts with ACS (p=0.001). There was significant positive correlation among the levels of examined three biomarkers: CK-MB in correlation to myoglobin (r=0.460; p= 0.0001) and to CRP level (r=0.204; p= 0.009), as well as myoglobin to CRP level (r=0.218; p= 0.005). Conclusion: We could conclude that determination of CRP levels is a valid test for detection of acute coronary artery disease in addition to the classical, standard markers for myocardial damage.