We report on a 21-year-old patient with a giant symptomatic hydatid cyst of the interventricular septum, to whom a staged management approach was employed. Induction medical therapy led to a reduction in the size of the cyst, which was then completely removed via surgical excision. A 21-year-old male Caucasian, with main complaints of fatigue and palpitations, was referred to our Centre due to a cystic formation in his left ventricle. The workup consisted of transthoracic echocardiography and cardiac magnetic resonance, which revealed a huge hydatid cyst in an active stage of disease, occupying the basal and mid part of the interventricular septum. Due to the size of the lesion and lack of viable myocardium in the affected area, the patient was declared inoperable and medical therapy was initiated. Serial echocardiography revealed a significant reduction in the size of the lesion and degradation to transitional and inactive stage, after which successful surgical excision of the cyst was performed. In the course of the medical treatment, the patient experienced sustained ventricular tachycardia causing loss of consciousness, which did not reoccur after surgical excision. Medical therapy can result in the degradation of a giant heart hydatid cyst, enabling surgical excision. Heart hydatid cyst can lead to potentially lethal arrhythmia irrespective of its size and stage, which does not reoccur after successful surgical excision.

Despite advances in medical therapy and mechanical circulatory support (MCS), heart transplant (HT) remains the gold standard therapy for end-stage heart failure. Patients in cardiogenic shock require prompt intervention to reverse hypoperfusion and end-organ damage. When medical therapy becomes insufficient, MCS should be considered. Historically, it has been reported that critically ill patients bridged with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) directly to HT have worse outcomes. However, when the heart allocation system gives the highest priority to patients on VA-ECMO support, those patients have a higher incidence of HT and a lower incidence of death or removal from the transplant list. Moreover, patients with a short waiting time on VA-ECMO have a similar hazard of mortality to non-ECMO patients. According to the reported data, bridging with VA-ECMO directly to HT may be a solution in the selection of critically ill patients when the anticipated waiting list time is short. However, when a prolonged waiting time is expected, more durable MCS should be considered. Regardless of the favorable results of the direct bridging to HT with ECMO in selected patients, the superiority of this strategy compared to the bridge-to-bridge strategy (ECMO to durable MCS) has not been established and further studies are mandatory in order to clarify this issue.

Aims: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess aetiology. The European Society of Cardiology guidelines recommend advanced tests to establish an underlying mechanism. We evaluated advanced diagnostic testing utilization and real-world adherence to the current guideline in an international MINOCA registry. Methods and results: DOMINO is a prospective, multicentre, non-commercial registry enrolling 365 patients with MINOCA across 17 centres in 13 countries. Advanced testing was defined as cardiac magnetic resonance (CMR), intracoronary imaging, and/or invasive coronary functional assessment. The association between advanced testing and diagnostic resolution was assessed by multivariable logistic regression, with standard, cluster-robust, and generalized estimating equation (GEE) approaches to account for clustering by centre. Guideline-directed testing was performed in 254/365 (69.6%) and varied markedly by country (0–100%, P < 0.0001). A specific etiologic diagnosis was reached in 337/365 patients (92.3%). Advanced testing was associated with diagnostic resolution in the standard and GEE models, with a directionally consistent but non-significant cluster-robust estimate [standard odds ratio (OR) 3.94, 95% confidence interval (CI) 1.59–10.06; cluster-robust OR 3.75, 95% CI 0.95–14.72, P = 0.058; GEE OR 3.69, 95% CI 1.04–13.11]. Diagnostic resolution increased progressively with the extent of testing performed, from 85.6% with no advanced testing to 97.1% with CMR plus invasive/functional assessment (trend P = 0.02). Discharge pharmacotherapy varied significantly by etiologic diagnosis (P = 0.0001). Conclusion: Advanced diagnostic testing was associated with a higher likelihood of a determined etiologic diagnosis in MINOCA, despite marked international variability in its use; however, this association is partly definitional, as advanced testing directly contributes to diagnostic ascertainment for several etiologic categories. These findings nonetheless support closing the guideline-practice gap in advanced testing, while underscoring the need to distinguish mechanistically confirmed diagnoses from presumptive ones.

Transthoracic echocardiography (TTE) is a basic imaging and functional diagnostic method in cardiology with a wide scope of cardiac diagnoses and monitoring cardiac treatment. In addition to cardiology, the need in the clinical practice of other branches of clinical medicine is growing. Very wide application and nonstandardized referral criteria have led to a high demand for echocardiography. At the same time, there is a growing disproportion in the ratio of unjustified requirements and clear clinical benefits for the patient from timely echocardiographic diagnostics. This is a problem of a global character, and international echocardiographic societies, in cooperation with national health policies, have developed guidelines for triage and indication for echocardiographic examinations (1, 2, 3). In addition to the large number of requests, there is also a noticeable disproportion in the number of requests and available resources for echocardiographic diagnostics in Croatia. In order to provide needed and timely health care, there is a need to standardize echocardiographic availability based on defined criteria for professional screening and indicating examinations as well as determining professionally acceptable time frames of echocardiographic examination. The Working Group for Echocardiography of the Ministry of Health of the Republic of Croatia and the Working Group for Echocardiography and Imaging Modalities of the Croatian Cardiac Society have proposed guidelines for indications and triage of applications for TTE in adults in cooperation with the Croatian Cardiac Society, in accordance with the current guidelines of the European Echocardiographic Society and modern cardiology practice, taking into account national health care database. These guidelines are applicable at all levels of health care and include the most common conditions and diagnoses for which patients are referred for this examination.

Objectives: To investigate early alterations in left ventricular (LV) diastolic function in young patients with uncomplicated arterial hypertension and basal septal hypertrophy (BSH), preserved LV ejection fraction (LVEF), and no overt cardiovascular comorbidities. Methods: Patients were divided into two groups according to the presence or absence of BSH and compared. Conventional diastolic assessment according to current recommendations were performed, along with two-dimensional speckle-tracking echocardiography for LV systolic and diastolic deformation and LA reservoir strain (LARS). Results: A total of 138 patients were included; 53.6% had BSH. For the whole population LV systolic and diastolic function were preserved, and overall LV geometry parameters and LA dimensions and function were within normal limits. However, patients with BSH were found to have more pronounced geometry changes in terms of concentric remodeling beyond BSH (LVMI 109.15 ± 25.33 vs. 89.19 ± 24.59 g/m², p < 0.001; RWT 0.38 ± 0.11 vs. 0.3 ± 0.08, p < 0.001), LA dilation (32.68 ± 9.98 vs. 30.03 ± 11.37, p = 0.05), and impaired LV relaxation according to standard parameters (E wave 0.72 ± 0.18 vs. 0.79 ± 0.2 m/s, p = 0.05; A wave 0.76 ± 0.14 vs. 0.72 ± 0.19 m/s, p = 0.04; E/A 0.96 ± 0.28 vs. 1.16 ± 0.39, p = 0.001; e′ septal 0.08 ± 0.02 vs. 0.1 ± 0.02 m/s, p = 0.001; and e′ lateral 0.12 ± 0.03 vs. 0.15 ± 0.04 m/s, p = 0.001) and diastolic strain rate (SR) (SRe 1.17 ± 0.35 vs. 1.31 ± 0.35%/s, p = 0.02; SRe/SRa 1.39 ± 0.63 vs. 1.69 ± 0.89, p = 0.03). Measurement of the diastolic SR was feasible in 97.1% of the patients with good reproducibility and interobserver difference of 1.28%. Significant correlations were found between basal septal thickness and parameters of LV and LA remodeling and diastolic function. Conclusions: Basal septal hypertrophy appears to represent an early, functionally relevant stage of hypertensive myocardial remodeling rather than an isolated morphological finding. Even in the presence of preserved LVEF, BSH is associated with subtle impairment of LV relaxation. Deformation imaging may improve identification of patients at risk for progression toward overt diastolic dysfunction and heart failure with preserved ejection fraction.