Pulmonary Valve Endocarditis during and beyond Euro ENDO Registry: A Single Center Case Series.

Background: Pulmonary valve infective endocarditis (PVIE) is a rare form of infective endocarditis (IE) and is associated with high mortality and severe complications. Guidelines for treatment of this form of IE are scarce and based on general recommendations. We report a case series of PVE. Detailed Case Description: Case 1-A 36-year-old female with congenital pulmonary artery stenosis, dyspnea and leg edema symptoms for 2 months. Blood cultures yielded Staphylococcus spp. and Corynebacterium sp., and echocardiography revealed multiple floating vegetation at the pulmonic valve and surrounding structures. The clinical course was complicated with sepsis and multi-organ failure. Urgent surgery with pulmonary homograft implantation resulted in successful five-year outcome. Case 2-In a 38-year-old male with previous tetralogy of Fallot correction and symptoms of fatigue, fever, myalgia, and photophobia, echocardiography was suggestive of PVIE. The clinical course was complicated with septic shock, multi-organ failure, ischemic stroke with hemorrhagic transformation and death on the 12th day of hospitalization. Case 3-A 41-year-old male without previous medical history was hospitalized due to prolonged fatigue, fever, dyspnea, and leg edema. He was diagnosed with multi-valve infective endocarditis, affecting the aortic, tricuspid, and pulmonary valve. Acute heart failure and hemodynamic instability indicated urgent surgery with aortic valve replacement and reconstruction of the tricuspid and pulmonary valves. At four-year follow up he was doing well. Conclusion: Symptoms in PVIE may be versatile, and diagnosis is often delayed. High level of suspicion, early recognition, and echocardiography are cornerstones in diagnostics. Despite the standpoint that medical therapy is first-line, the role of surgery needs to be advocated in particular cases.

Impact of the COVID-19 Pandemic on Cardiology Emergency Department Visits.

In 2020, decreased emergency department (ED) visits and hospitalization rates during the COVID-19 outbreak were reported. There is no data about cardiovascular emergencies and mortality for the whole COVID-19 year.This study aimed to compare the rates of cardiology ED visits, hospital admissions, and intrahospital mortality between the pre-COVID-19 and COVID-19 years in a single high-volume center.The retrospective observational cross-sectional study analyzed data on the number of ED visits, hospital admissions by different cardiovascular diagnoses, and outcomes.A total of 11744 patients visited the cardiology ED in the pre-COVID-19 year compared with 9145 in the COVID-19 year, indicating an overall decrease of 22.1% (P = 0.02) (IR 78.76 versus 61.33; incidence rate ratios (IRR) 1.28, P = 0.00), with an observed decrease of 25.5% in the number of hospitalizations (33.1% versus 31.6%, P = 0.02). A marked decrease in hospitalizations for cardiovascular emergencies was observed for hypertensive heart disease (-72.8%, P < 0.0001), acute coronary syndrome (-17.8%, P < 0.0001), myocardial and pericardial diseases and endocarditis (-61.2%, P = 0.00), and valvular heart disease (-70.8%, P < 0.0001). In the COVID-19 year, patients had increased need for mechanical ventilatory support (7% versus 6.3%, P = 0.03) with no overall difference in intrahospital mortality (IR 2.71 versus 2.78, IRR 0.98, 95% CI 0.82-1.16, P = 0.39).Decreased ED visits and hospitalizations not just in outbreaks but through the whole COVID-19 year highlight the risk of continuous delay of needed care for emergency life-threatening cardiovascular diseases. Urgent comprehensive strategies that will address patient- and system-related factors to decrease morbidity and mortality and prevent collateral damage of the pandemic are needed.

Left Atrial Strain as a Predictor of Left Ventricular Diastolic Dysfunction in Patients with Arterial Hypertension.

Background and Objectives: There is emerging evidence of the usefulness of left atrial strain (LAS) in the assessment of diastolic dysfunction (DD). In this study we assess the sensitivity and specificity of LAS, to determine cut-off values and their association to DD with increased left atrial pressure (LAP) in patients with well-treated arterial hypertension. Materials and Methods: We performed a cross-sectional study on 180 subjects with well-treated arterial hypertension. All patients underwent transthoracic echocardiography. Patients were divided into two groups: a group without increased LAP and/or DD and a group with increased LAP DD. Results: In multivariate logistic regression, LAS proved to be the strongest statistically significant predictor of DD with increased LAP (OR 0.834, p < 0.0005), with AUC 0.885 and a set cut-off value of 24.27% with high sensitivity of 78.9% and specificity of 84.6%. The set cut-off for LAS > 24.27% was significantly highly prevalent in the group of DD with increased LAP 78.9% when compared to the group without increased LAP 15.4%, p < 0.0001. Conclusion: The findings of this study suggest that LAS could be a useful and highly sensitive and specific marker in the evaluation of DD. There is the potential for using LAS in everyday practice as a standard parameter in diastolic function assessment.

Gender Related Differences in the Clinical Presentation of Hypertrophic Cardiomyopathy-An Analysis from the SILICOFCM Database.

Background and Objectives: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disease that affects approximately 1 in 500 people. Due to an incomplete disease penetrance associated with numerous factors, HCM is not manifested in all carriers of genetic mutation. Although about two-thirds of patients are male, it seems that female gender is associated with more severe disease phenotype and worse prognosis. The objective of this study was to evaluate the gender related differences in HCM presentation. Materials and Methods: This study was conducted as a part of the international multidisciplinary SILICOFCM project. Clinical information, laboratory analyses, electrocardiography, echocardiography, and genetic testing data were collected for 362 HCM patients from four clinical centers (Florence, Newcastle, Novi Sad, and Regensburg). There were 33% female patients, and 67% male patients. Results: Female patients were older than males (64.5 vs. 53.5 years, p < 0.0005). The male predominance was present across all age groups until the age of 70, when gender distribution became comparable. Females had higher number of symptomatic individuals then males (69% vs. 52%, p = 0.003), most frequently complaining of dyspnea (50% vs. 30%), followed by chest pain (30% vs. 17%), fatigue (26% vs. 13%), palpitations (22% vs. 13%), and syncope (13% vs. 8%). The most common rhythm disorder was atrial fibrillation which was present in a similar number of females and males (19% vs. 13%, p = 0.218). Levels of N-terminal pro-brain natriuretic peptide were comparable between the genders (571 vs. 794 ng/L, p = 0.244). Echocardiography showed similar thickness of interventricular septum (18 vs. 16 mm, p = 0.121) and posterolateral wall (13 vs. 12 mm, p = 0.656), however, females had a lower number of systolic anterior motion (8% vs. 16%, p = 0.020) and other mitral valve abnormalities. Conclusions: Female patients are underrepresented but seem to have a more pronounced clinical presentation of HCM. Therefore, establishing gender specific diagnostic criteria for HCM should be considered.

Identifying subgroups of age and cohort effects in obesity prevalence.

The obesity epidemic represents an important public health issue in the United States. Studying obesity trends across age groups over time helps to identify crucial relationships between the disease and medical treatment allowing for the development of effective prevention policies. We aim to define subgroups of age and cohort effects in obesity prevalence over time by considering an optimization approach applied to the age-period-cohort (APC) model. We consider a heterogeneous regression problem where the regression coefficients are age dependent and belong to subgroups with unknown grouping information. Using the APC model, we apply the alternating direction method of multipliers (ADMM) algorithm to develop a two-step algorithm for (1) subgrouping of cohort effects based on similar characteristics and (2) subgrouping age effects over time. The proposed clustering approach is illustrated for the United States population, aged 18-79, during the period 1990-2017.

Clustering regions with dynamic time warping to model obesity prevalence disparities in the United States.

Current methods for clustering adult obesity prevalence by state focus on creating a single map of obesity prevalence for a given year in the United States. Comparing these maps for different years may limit our understanding of the progression of state and regional obesity prevalence over time for the purpose of developing targeted regional health policies. In this application note, we adopt the non-parametric Dynamic Time Warping method for clustering longitudinal time series of obesity prevalence by state. This method captures the lead and lag relationship between the time series as part of the temporal alignment, allowing us to produce a single map that captures the regional and temporal clusters of obesity prevalence from 1990 to 2019 in the United States. We identify six regions of obesity prevalence in the United States and forecast future estimates of obesity prevalence based on ARIMA models.

Relevance of the TAS'/PASP Ratio as a Predictor of Outcomes in Patients with Heart Failure with a Reduced Ejection Fraction.

BACKGROUND: There is evidence that right ventricular (RV) contractile function, especially its coupling with the pulmonary circulation, has an important prognostic value in patients with left ventricular dysfunction. AIMS: This study aimed to identify the best echocardiographic parameters of RV function and pulmonary artery systolic pressure (PASP) alone or in the form of the index of right ventricular-pulmonary artery coupling (RV-PA coupling) to determine the best predictor of 1-year major adverse cardiovascular events (MACE), which were defined as cardiovascular death and cardiac decompensation in heart failure patients with reduced ejection fraction (HFrEF). METHODS AND RESULTS: The study enrolled 191 HFrEF patients (mean age 62.28 ± 12.79 years, 74% males, mean left ventricular ejection fraction (LVEF) 25.53 ± 6.87%). All patients underwent clinical, laboratory, and transthoracic echocardiographic (TTE) evaluation, focusing on assessing RV function and non-invasive parameters of RV-PA coupling. RV function was evaluated using fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), and peak tricuspid annular systolic velocity (TAS'). PASP was estimated by peak tricuspid regurgitation velocity (TRVmax) and corrected by assumed right atrial pressure relative to the dimension and collapsibility of the inferior vena cava. The TAPSE/PASP and TAS'/PASP ratios were taken as an index of RV-PA coupling. During the follow-up (mean period of 340 ± 84 days), 58.1% of patients met the composite endpoint. The independent predictors of one-year outcome were shown to be advanced age, atrial fibrillation, indexed left atrial systolic volume (LAVI), LVEF, TAPSE/PASP, and TAS'/PASP. TAS'/PASP emerged as the strongest independent predictor of prognosis, with a hazard ratio (HR) of 0.67 (0.531-0.840), p < 0.001. Reconstructing the ROC curve 0.8 (0.723-0.859), p < 0.001, we obtained a threshold value of TAS'/PASP ≤ 0.19 (cm/s/mm Hg) (sensitivity 74.0, specificity 75.2). Patients with TAS'/RVSP ≤ 0.19 have a worse prognosis (Log Rank p < 0.001). CONCLUSIONS: This study confirmed previously known independent predictors of adverse outcomes in patients with HfrEF-advanced age, atrial fibrillation, LAVI, and LVEF-but non-invasive parameters of RV-PA coupling TAPSE/PASP and TAS'/PASP improved risk stratification in patients with HFrEF. Variable TAS'/PASP has been shown to be the most powerful, independent predictor of one-year outcome.

Cardiac biomarkers alterations in rapid weight loss and high-intensity training in judo athletes: a crossover pilot study.

BACKGROUND: Studies evaluating alterations in cardiac biomarkers in rapid sport-associated weight loss (RWL) and high-intensity sport-specific training (HISST) are lacking. This pilot study aimed to examine the effects of RWL and HISST on heart rate, blood pressure, cardiac biomarkers, and left ventricular systolic function. Nine elite male judokas participated in the presented survey. METHODS: The athletes underwent a baseline assessment and two testing protocols, the first phase with RWL where they had to lose 5% of their body weight simultaneously with HISST, and the second phase after 7 days, in which only HISST was performed. Participants underwent electrocardiogram, biomarker, and transthoracic echocardiogram evaluation after each phase. RESULTS: In the first phase (RWL and HISST) athletes, heart rate increased significantly, 58.11 (7.78) versus 79 (9.25), P=0.001; as well as cardiac biomarkers: lactate dehydrogenase isoenzyme 175.33 (31.22) vs. 238.56 (56), P=0.003; aspartate aminotransferase 16.56 (4.61) vs. 29 (9.96), P=0.027; creatine kinase isoenzyme-MB 13 (11.5;24) vs. 29.11 (10.05), P=0.004; and high sensitivity cardiac troponin 10 (0) vs. 14.49 (6.4), P=0.045. In the second phase, only HISST was associated with a significant increase in the alanine aminotransferase isoenzyme, 37.78 (11.22) vs. 26 (8.03), P=0.024, together with creatine kinase 472 (185;654) vs. 166.88 (56.57), P=0.01, compared to the initial measurement. CONCLUSIONS: RWL combined with HISST produced significant alterations in cardiac biomarkers without impairment of left ventricular systolic function.

The Role of QRS Complex and ST-Segment in Major Adverse Cardiovascular Events Prediction in Patients with ST Elevated Myocardial Infarction: A 6-Year Follow-Up Study.

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.

Management and outcomes of spontaneous coronary artery dissection: a systematic review of the literature.

Background: Contemporary management of spontaneous coronary artery dissection (SCAD) is still controversial. This systematic review of the literature aims to explore outcomes in the patients treated with conservative management vs. invasive strategy. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed when we extensively searched three electronic databases: PubMed, ScienceDirect, and Web of Science, for studies that compared conservative vs. invasive revascularization treatment outcomes for patients with SCAD from 2003 to 2023. The outcomes of interest were all-cause death and major adverse cardiovascular events (MACE), including acute coronary syndrome (ACS), heart failure (HF), need for additional revascularization, target vessel revascularization (TVR), SCAD recurrence, and stroke. Results: The systematic review included 13 observational studies evaluating 1,801 patients with SCAD. The overall mean age was 49.12 +/- 3.41, and 88% were females. The overall prevalence of arterial hypertension was 33.2%, hyperlipidemia, 26.9%, smoking, 17.8%, and diabetes, 3.9%. Approximately 48.5% of the patients were diagnosed with non-ST elevated myocardial infarction (NSTEMI), 36.8% with ST elevated myocardial infarction (STEMI), 3.41% with unstable angina, 0.56% with stable angina, and 0.11% were diagnosed with various types of arrhythmias. The left anterior descending artery (LAD) was the most common culprit lesion in 51% of the patients. There were initially 65.2% of conservatively treated patients vs. 33.4% that underwent percutaneous coronary intervention (PCI) or 1.28% that underwent coronary artery bypass graft (CABG). SCAD-PCI revascularization was associated with a variable range of PCI failure. The most common complications were hematoma extension and iatrogenic dissection. SCAD-PCI revascularization frequently required three or more stents and had residual areas of dissection. The overall reported in-hospital and follow-up mortality rates were 1.2% and 1.3%, respectively. The follow-up range across studies was 7.3-75.6 months. The authors reported variable prevalence of MACE, recurrent SCAD up to 31%, ACS up to 27.4%, TVR up to 30%, repeat revascularization up to 14.7%, UA up to 13.3%, HF up to 17.4%, and stroke up to 3%. Conclusion: Our results highlight that conservative treatment should be the preferred method of treatment in patients with SCAD. PCI revascularization is associated with a high prevalence of periprocedural complications. SCAD poses a considerable risk of MACE, mainly associated with TVR, ACS, and recurrent SCAD.

Prediction parameters of left ventricular diastolic dysfunction improvement in patients after acute coronary syndrome.

OBJECTIVES: The aim of this study was to examine the effects of comprehensive cardiac rehabilitation (CCR) in patients after acute coronary syndrome (ACS) resolved by percutaneous coronary intervention (PCI) on left ventricular diastolic dysfunction (LVDD) and to extract the parameters that have the greatest influence on LVDD improvement. METHODS: The study included 85 subjects who were divided into intervention (N = 56) and control (N = 29) groups depending on CCR attendance. Initially and after 12 weeks, patients of both groups were subjected to echocardiography to assess LVDD, as well as CPET to assess improvement in functional capacity. RESULTS: The study showed that 23 patients (27.1%) of both groups demonstrated the improvement of LVDD degree. The improvement of the LVDD degree in the intervention group was significant, whereas in the control group, it did not change (a one-degree improvement in 22 (39.3%) patients of the intervention group (p < 0.001) and only 1 (3.4%) (p > 0.05) in the control group). Multivariate binary logistic regression showed that key parameters in LVDD improvement were participation in the CCR, E/A ratio and haemoglobin value. We created a model, for prediction of LVDF improvement, with a cut-off value of 33 (area = 0.9, p < 0.0005), a sensitivity of 87.0% and a specificity of 85.5%. CONCLUSIONS: CCR can be used as an effective non-pharmacological measure to improve LVDD and functional capacity in patients after ACS. The statistical model may have practical application in prediction of clinical benefit in such a group of patients.

Disrupting arrhythmia in a professional male wrestler athlete after rapid weight loss and high-intensity training-Case report.

Introduction: Physiological heart adaptations may lead to increased susceptibility to arrhythmia in athletes. Furthermore, vigorous training and method like rapid weight loss (RWL) in combat sports could pose additional risks. This case represents how routine cardiovascular screening during high-risk methods like RWL and high-intensity training (HIT) reveal abrupt ventricular arrhythmias in a young athlete. Case report: We report a case of a 20-year-old male wrestler athlete who developed disrupting arrhythmia during RWL and HIT. The study included: a medical exam, 12 lead electrocardiograms (ECG), transthoracic echocardiogram (ECHO), and 24 h of continuous ECG monitoring in baseline, phase one (P1), (in which the athlete had to simulate RWL through vigorous training and dietary intervention and HIT) and phase two (P2), (with the same HIT protocol performed without the RWL procedure). Baseline laboratory analyses were without abnormalities, ECG showed sinus rhythm with one premature atrial contraction (PAC) and ECHO showed signs of concentric remodeling with preserved systolic, diastolic function, and global longitudinal strain. After P1 RWL simulation, he lost 5.15% of body weight in 3 days, which resulted in lower blood glucose levels, higher urea, creatinine, creatine kinase (CK), CK-MB levels, and slightly increased levels of NT pro-BNP, ECG revealed sinus rhythm with one ventricular premature beat (VPB), 24-h continuous electrocardiogram (ECG) revealed frequent ventricular premature beats (PVB) 2,150/ 24 h, with two couplets, and 8 PAC. After an advised 4-week period of de-training continuous 24 h, ECG monitoring was improved with only occasional PVB. The 24 h continuous ECG monitoring was repeated after HIT and revealed even more frequent PVB, 5% of all beats for 24 h, 4,205 in total, and almost all VPB were in bigeminy and trigeminy. The athlete was advised against RWL and extremely vigorous exercise and for regular, frequent checkups with occasional ECG monitoring during and after exercise. Conclusion: The short and long-term implication of abrupt ventricular arrhythmias provoked by intensive training and methods like RWL is unknown. We postulate that cardiovascular screening is necessitated, especially during high-risk methods like RWL and HIT, in helping us prevent adverse outcomes and come to individual-based clinical making decisions for each athlete.

Impact of cardiac rehabilitation on left ventricular diastolic function and exercise capacity in patients treated with percutaneous coronary intervention after acute coronary event.

BACKGROUND: Study examines the influence of cardiac rehabilitation program (CR) on left ventricular diastolic dysfunction (LVDD), functional capacity and major cardiovascular risk factors (CVRF) in patients after with PCI resolved acute coronary syndrome (ACS). METHODS: We performed a non-randomised study included a total of 85 subjects after resolved ACS, with left ventricular ejection fraction (LVEF) ≥ 45% and LVDD, without heart failure. Subjects were divided into control (N = 29) and intervention group (N = 56), depending on CR program attendance consisted of exercise training sessions for 12 weeks, 3 times per/week, 30 min per session. Initially and after 12 weeks, patients were subjected to echocardiography to assess LV filling pressure (E/e') as well as CPET to asses improvement in peak VO2. RESULTS: Initially subjects were similar in CVRF, LVDD and CPET parameters (p > 0.05). Following CR, the intervention group demonstrated a significant improvement in E/e' (8.0 ± 3.0 vs 7.0 ± 2.2; p < 0.05), compared to the control group (8.4 ± 3.0 vs 9.0 ± 3.1; p > 0.05), as well as a significant improvement in peak VO2 (23.2 ± 5.0 ml/kg/min vs 24.8 ± 5.8 ml/kg/min; p < 0.001). Control group also exhibited significant worsening in peak VO2 without CR (23.0 ± 4.0 vs 21.2 ± 4.1 ml/kg/min; p = 0.02). CVRF improved in both groups, except for glycaemia levels and body mass index, which improved only in the intervention group (p < 0.001). CONCLUSIONS: Following ACS treated with PCI, CR had a positive effect on major CVRFs, the degree of LVDD and exercise capacity and should be considered as effective tool to reduce morbidity in such patients.

The elite judo female athlete's heart.

Purpose: There is a paucity of data on physiological heart adaptation in elite-level judo female athletes. This study aimed to assess left ventricular morphology and function in highly trained elite female judokas. Methods: The study prospectively included 18 females aged 23.5 ± 2.25 years, nine elite level judokas, and nine healthy non-athlete volunteers. All participants underwent a medical examination, electrocardiogram, and transthoracic 2D echocardiogram. Left ventricular diastolic and systolic diameters and volumes were determined, and parameters of left heart geometry and function (systolic and diastolic) were measured, calculated, and compared between groups. Results: When groups were compared, judokas had significantly increased left ventricular cavity dimensions p < 0.01, left ventricular wall thickness p < 0.01, and volumes p < 0.01. Elite female judokas exhibited left ventricular dilatation demonstrated as high prevalence increased end-diastolic volume/index, and increased end-systolic volume/index in 88.9% of judokas vs. 0% in controls, p < 0.01. Left ventricle mass/index was significantly increased in judokas, p < 0.01), with a 43.3% difference between groups. The majority (77.7%) of judokas had normal left ventricular geometry, although eccentric hypertrophy was revealed in 2 (22.2%) of judokas. Conclusion: Elite, highly trained female judokas exhibit significant changes in left heart morphology as a result of vigorous training compared to non-athletes. These findings suggest that female judokas athletes' heart follows a pattern toward chamber dilatation rather than left ventricular wall hypertrophy.

Characteristics and Outcomes of Patients with Acute Coronary Syndrome and COVID-19.

Acute coronary syndrome (ACS) in patients with COVID-19 is triggered by various mechanisms and can significantly affect the patient's further treatment and prognosis. The study aimed to investigate the characteristics, major complications, and predictors of mortality in COVID-19 patients with ACS. All consecutive patients hospitalized from 5 July 2020 to 5 May 2021 for ACS with confirmed SARS-Co-2 were prospectively enrolled and tracked for mortality until 5 June 2021. Data from the electronic records for age and diagnosis, matched non-COVID-19 and COVID-19 ACS group, were extracted and compared. Overall, 83 COVID-19 ACS patients, when compared to 166 non-COVID ACS patients, had significantly more prevalent comorbidities, unfavorable clinical characteristics on admission (acute heart failure 21.7% vs. 6.6%, p < 0.01) and higher rates of major complications, 33.7% vs. 16.8%, p < 0.01, and intrahospital 30-day mortality, 6.7% vs. 26.5%, p < 0.01. The strongest predictors of mortality were aortic regurgitation, HR 9.98, 95% CI 1.88; 52.98, p < 0.01, serum creatinine levels, HR 1.03, 95% CI 1.01; 1.04, p < 0.01, and respiratory failure therapy, HR 13.05, 95% CI 3.62; 47.01, p < 0.01. Concomitant ACS and COVID-19 is linked to underlying comorbidities, adverse presenting features, and poor outcomes. Urgent strategies are needed to improve the outcomes of these patients.

Antimicrobial Activity of Selected Essential Oils against Selected Pathogenic Bacteria: In Vitro Study.

The worldwide problem of infectious diseases has appeared in recent years, and antimicrobial agents are crucial in reducing disease emergence. Nevertheless, the development and distribution of multidrug-resistant (MDR) strains in pathogenic bacteria, such as Escherichia coli, Staphylococcus aureus, Salmonella Typhi and Citrobacter koseri, has become a major society health hazard. Essential oils could serve as a promising tool as a natural drug in fighting the problem with these bacteria. The current study aimed to investigate the antimicrobial effectiveness of tea tree (Melaleuca alternifolia (Maiden and Betche) Cheel), rosemary (Rosmarinus officinalis L.), eucalyptus (Eucalyptus obliqua L'Hér.), and lavender (Lavandula angustifolia Mill) essential oils. The antimicrobial properties of essential oils were screened against four pathogenic bacteria, E. coli, S. aureus, S. Tyhpi, and C. koseri, and two reference bacterial strains, while for the testing, the agar well diffusion method was used. Gas chromatography (GC) and gas chromatography-mass spectrometric (GC-MSD) analyses were performed on essential oils. The obtained results showed that M. alternifolia essential oil is the richest in terpinen-4-ol, R. officinalis and E. oblique essential oils in 1,8-cineole, and L. angustifolia essential oil in α-terpinyl acetate. In addition, the main bioactive compounds present in the essential oil of tea tree are rich in α-pinene (18.38%), limonene (7.55%) and γ-terpinene (14.01%). The essential oil of rosemary is rich in α-pinene (8.38%) and limonene (11.86%); eucalyptus essential oil has significant concentrations of α-pinene (12.60%), p-cymene (3.24%), limonene (3.87%), and γ-terpinene (7.37%), while the essential oil of lavender is rich in linalool (10.71%), linalool acetate (9.60%), α-terpinyl acetate (10.93%), and carbitol (13.05%) bioactive compounds, respectively. The obtained results from the in vitro study revealed that most of the essential oils exhibited antimicrobial properties. Among the tested essential oils, tea tree was discovered to demonstrate the strongest antimicrobial activity. The recorded MIC of S. Typhi was 6.2 mg/mL, 3.4 mg/mL of C. koseri, 3.1 mg/mL of E. coli, and 2.7 mg/mL of E. coli ATCC 25922, compared to M. alternifolia. Similarly, only S. aureus ATCC 25923 showed antimicrobial activity towards R. officinalis (1.4 mg/mL), E. oblique (2.9 mg/mL), and L. angustifolia (2.1 mg/mL). Based on the obtained results, it is possible to conclude that tea tree essential oil might be used as an ecological antimicrobial in treating infectious diseases caused by the tested pathogens.

Asymptomatic Giant Aneurysm of the Left Anterior Descending Coronary Artery: A Case Report and Review of the Literature.

The most common cause of coronary artery aneurysms is atherosclerosis, which is associated with over 50% of all aneurysms diagnosed in adults. Although patients can be asymptomatic throughout their lives, giant coronary artery aneurysms can manifest themselves as myocardial infarction, aneurysmal rupture, and sudden cardiac death as well. Herein, we describe an asymptomatic patient with numerous risk factors and a positive cardiopulmonary exercise test who was admitted to the cardiology clinic for coronary angiography. A giant coronary artery aneurysm (3.0×2.0 cm in diameter) in the left anterior descending coronary artery and significant stenosis in both left and right coronary arteries were found. After discussing possible treatment options, the hospital's heart team recommended the surgical resection of the aneurysm and double coronary artery bypass graft. Four years after the cardiac surgery, at the time of writing the current manuscript, the patient is still in good condition and with no symptoms.

Ventriculoatrial synchrony induced heart failure.

OBJECTIVE AND IMPORTANCE: Endless loop tachycardia or pacemaker-mediated tachycardia, and atrioventricular desynchronization arrhythmia or repetitive non-reentrant ventriculoatrial synchrony (RNRVAS) are two forms of reverse impulse conduction - ventriculoatrial (VA) synchrony. Although VA synchrony can theoretically cause aggravation of heart failure, clinical cases describing severe consequential heart failure are lacking. CLINICAL PRESENTATION AND INTERVENTION: We describe a case of a 60-year-old patient who underwent primary percutaneous coronary intervention and mitral valve surgery. Implantation of a two-chamber pacemaker was also performed during the same hospitalization due to development of third-degree atrioventricular block. Ten months later, he presented with a severe form of heart failure with a significant reduction of left ventricular ejection fraction (LVEF). The atrial lead was displaced and VA synchrony was registered (RNRVAS-like condition). The pacemaker was reprogrammed and VA synchrony induced heart failure was successfully resolved. Echocardiographic follow-up showed improvement in LVEF. CONCLUSION: Ventriculoatrial conduction can be present even when the patient has a complete atrioventricular block. Atrial lead displacement and consequently loss of atrial capture with preserved sensing can be a predisposing factor for initiation of ventriculoatrial synchrony. Permanent ventriculoatrial synchrony may provoke aggravation of heart failure.

IMPORTANCE OF INTEGRATED MANAGEMENT SYSTEM APPLIED IN HEALTH ESTABLISHMENTS IN ORDER TO RAISE TREATMENT QUALITY.

INTRODUCTION: The term "management" is best characterized as "managing" economic or social processes to achieve objectives through a rational use of material and immaterial resources by applying the principles, functions, and management methods. This study has been aimed at evaluating the value of an integrated quality management system implemented at the Institute of Cardiovascular Diseases of Vojvodina to improve the quality of treatment. MATERIAL AND METHODS: In the period from 2008 to 2010 about 40 employees from the Institute of Cardiovascular Diseases of Vojvodina attended various courses given by the lecturers of the Faculty of Technical Sciences, where the function and significance of the "International Standards Organization" were explained, after which standards of interest were implemented at the Institute of Cardiovascular Diseases of Vojvodina. RESULTS: The Department of Cardiology has introduced 11 cardiac procedures with 5 special instructions, 14 general procedures, and 7 specific procedures with 2 instructions. The Department of Cardiac Surgery has introduced 7 procedures to be implemented. The "Vojvodina score" model was put into practice for the perioperative evaluation of cardiac surgery risk. During 2014, the Institute of Cardiovascular Diseases ofVojvodina obtained accreditation for the period of 7 years. CONCLUSION: The integrated quality management system must be applied in order to achieve a high level of health care in the shortest possible time and with the least possible consumption of material and human resources. The application of this system in practice gives a realistic insight into the working processes and facilitates their functioning. It demands and requires constant monitoring of the system efficiency along with continuous changes and improvements of all elements of the working processes and functional units.