Objective: It is well known that coronary artery bypass grafting (CABG) is often the cause of non-thyroidal illness syndrome (NTIS). Nonthyroidal illness syndrome (NTIS) is a state characterized by low levels of tri-iodo-thyronine (T3) and high levels of reverse T3 (rT3), with normal or low levels of thyroxin (T4) and normal, low-normal, or low levels of thyroid-stimulating hormone (TSH). Today, there are two main techniques of CABG: CABG with the use of cardiopulmonary bypass (on-pump coronary artery bypass - ONCAB) and CABG without the use of cardiopulmonary bypass (off-pump coronary artery bypass OPCAB), or ’beating-heart surgery.’ The OPCAB technique is considered to be less invasive. We prospectively investigated the influence of these surgical techniques on the occurrence of NTIS. Methods: Serum levels of free fractions of thyroid hormones (FT3 and FT4) and TSH were analyzed in 70 consecutive patients subjected to CABG surgery, using the ONCAB technique in 36 patients and OPCAB technique in 34 patients. The measurements of hormone levels were performed prior to surgery and 12 hours and 14 days after surgery. Results: The basic, the early, and the late postoperative serum levels of FT3 (p=0.458, p=0.632, p=0.869, respectively), FT4 (p=0.664, p=0.301, p=0.417, respectively), and TSH (p=0.249, p=0.058, p=0.324, respectively) were similar in both groups. The levels of FT3 and TSH were significantly lower 12 hours after surgery (p<0.0001, p<0.0001, respectively), and the FT4 levels rose at the same time (p<0.0001). The third measurement showed the return of all investigated parameters back to physiological levels, although they were still not precisely within the initial values. Conclusion: NTIS occurs significantly in patients subjected to CABG. Although the OPCAB technique is considered to be less invasive, its impact on the occurrence of NTIS does not differ significantly from the ONCAB technique.

Cardiologia CROATICA Objectives: The aim of this article is to investigate the relationship between the degree of the common carotid artery (CCA) atherosclerosis and the degree of complexity of the coronary artery disease (CAD) expressed with SYNTAX score. It is known that the existence of the CCA disease indicates with high probability the existence of CAD, but few studies have examined the relationship between CCA ultrasound findings and complexity, not just the presence of CAD. Patients and Methods: We included a total of 106 consecutive patients referred to the BH Heart Center for elective coronary angiography. In order to measure and calculate the mean intima-media thickness (IMT) we performed three measurements in predefined segments of CAA for both carotid arteries, the values are converged, and divided by the number of measurements. Plaque score (PS) was measured on the basis of maximum thickness of plaque in four clearly defined segments of both CCA. The final value of PS score is obtained by adding the thickness of plaques found in all segments of CCA. The complexity of coronary artery lesions is evaluated by using the SYNTAX score. The middle and high SYNTAX scores are associated with an increased risk of cardiac death and major cardiac events. Results: Data collection and statistical analysis is in progress and preliminary results indicate that IMT values and PS score significantly correlate with SYNTAX score >18 (r=.0,64, p 27 (r=.0,79, p<0,01). It is expected that final results will show that there is a significant correlation between the degree of CCA atherosclerosis measured by two methods — IMT and PS, and the degree of complexity of coronary artery lesions. Conclusion: Preliminary results show that carotid ultrasound examination has sufficient sensitivity and specificity in the detection of patients with high risk of significant CAD and it is an argument for broader use of CCA ultrasound for the evaluation of patients who are considered for coronary angiography. Besides, we are going to improve algorithm of patients selection for coronary angiography, so, our limited material and human resources and efforts will be directed towards the treatment of patients i.e. net clinical benefit will be improved.

Interventional cardiology today without the use of x-ray technology cannot even be imag‐ ined. This is also true for medicine in general. The radiology era begins with the discovery of the x-rays by Wilhelm Conrad Röntgen, on the November 8th 1895 (following the translit‐ eration conventions for the characters accentuated by 'umlaut', „Röntgen“ is in English spel‐ led „Roentgen“, and with that spelling is most often found in the literature). On that day he produced and detected for the first time the electromagnetic radiation in the wavelengths today known as the x-rays, for which he received the Nobel prize for physics in 1901 [1]. This was the start of radiology, which has developed tremendously over the years. In time, radiology adopted other forms of human body imaging (magnetic resonance, positron emis‐ sion tomography etc.), but even today the most radiologic studies in the world are per‐ formed using the x-rays, whether in the form of classic x-ray imaging, computer tomography, or various forms of fluoroscopy and/or fluorography, which is used in inter‐ ventional cardiology. The term 'fluoroscopy' depicts viewing of structures in real time, while 'fluorography' means that different methods of image aquisition and storage for later review are being used.

Coronary angiography is an invasive diagnostic procedure in which radiocontrast is injected into the coronary arteries under X-ray guidance in order to display the coronary anatomy and possible luminal obstruction. Despite the advances in other diagnostic methods, it remains to be "the golden standard" of coronary disease diagnostics. Although today the complication rate is far lower than previously, the possibility of complication still exists, and an invasive cardiologist must be able to complete the procedure flawlessly, and to competently deal with complications, should they occur. In order to be able to do that, he/she must master the proper techniques in performing the coronary angiography procedure, and be comfortable with all the available access-sites.

MRI in evaluation of perianal fistulae Background. Fistula is considered to be any abnormal passage which connects two epithelial surfaces. Parks' fistulae classification demonstrates the biggest practical significance and divides fistulae into: intersphincteric, transsphincteric, suprasphincteric and extrasphincteric. Etiology of perianal fistulae is most commonly linked with the inflammation of anal glands in Crohn's disease, tuberculosis, pelvic infections, pelvic malignant tumours, and with the radiotherapy. Diagnostic method options are: RTG fistulography, CT fistulography and magnetic resonance imaging (MRI) of pelvic organs. Patients and methods. We have included 24 patients with perirectal fistulae in the prospective study. X-rays fistulography, CT fistulography, and then MRI of the pelvic cavity have been performed on all patients. Accuracy of each procedure in regards to the patients and the etiologic cause have been statistically determined. Results. 29.16% of transphincteric fistulae have been found, followed by 25% of intersphincteric, 25% of recto-vaginal, 12.5% of extrasphincteric, and 8.33% of suprasphincteric. Abscess collections have been found in 16.6% patients. The most frequent etiologic cause of perianal fistulae was Crohn's disease in 37.5%, where the accuracy of classification of MRI was 100%, CT was 11% and X-rays 0%. Ulcerous colitis was the second cause, with 20.9% where the accuracy of MRI was 100%, while CT was 80% and X-rays was 0%. All other etiologic causes of fistulae were found in 41.6% patients. Conclusions. MRI is a reliable diagnostic modality in the classification of perirectal fistulae and can be an excellent diagnostic guide for successful surgical interventions with the aim to reduce the number of recurrences. Its advantage is that fistulae and abscess are visible without the need to apply any contrast medium.

Direct coronary stenting in reducing radiation and radiocontrast consumption Introduction. Coronary stenting is the primary means of coronary revascularization. There are two basic techniques of stent implantation: stenting with balloon predilatation of stenosis and stenting without predilatation (direct stenting). Limiting the time that a fluoroscope is activated and by appropriately managing the intensity of the applied radiation, the operator limits radiation in the environment, and this saves the exposure to the patient and all personnel in the room. Nephrotoxicity is one of the most important properties of radiocontrast. The smaller amount of radiocontrast used also provides multiple positive effects, primarily regarding the periprocedural risk for the patients with the reduced renal function. The goal of the study was to compare fluoroscopy time, the amount of radiocontrast, and expenses of material used in direct stenting and in stenting with predilatation. Patients and methods. In a prospective study, 70 patients with coronary disease were randomized to direct stenting, or stenting with predilatation. Results. Fluoroscopy time and radiocontrast use were significantly reduced in the directly stented patients in comparison to the patients stented with balloon-predilatation. The study showed a significant reduction of expenses when using a direct stenting method in comparison to stenting with predilatation. Conslusions. If the operator predicts that the procedure can be performed using direct stenting, he is encouraged to do so. Direct stenting is recommended for all percutaneous coronary interventions when appropriate conditions have been met. If direct stenting has been unsuccessful, the procedure can be converted to predilatation.

Despite aggressive antiplatelet therapy in the setting of percutaneous coronary intervention, the incidence of stent thrombosis remains approximately 0.5% to 0.8%. We report on a 53-year-old male patient with recurrent coronary stent thrombosis treated by coronary re-interventions and anticoagulation. Initial diagnostic selective coronary angiography revealed 90% proximal circumflex coronary artery stenosis in a patient with 3rd degree of stabile angina by Canadian Cardiology Society classification. After premedication with a loading dose of 600 mg clopidogrel, 300 mg aspirin and intravenous enoxaparine 1 mg/kg, a bare-metal stent was implanted. The initial postprocedural course was normal. On the third day after the intervention, the patient was subjected to reintervention because of the stent thrombosis, and on the fifth day after reintervention – to the third percutaneous coronary angioplasty, also because of the stent thrombosis. Clopidogrel resistence was suspected and treatment with warfarin was initiated, after which there were no new cardiac events. Three months later, anticoagulation was discontinued, and as an antiplatelet agent aspirin 100 mg daily remained in therapy. Up to now (one-year), follow-up of the patient has been uneventful. In the case of suspected clopidogrel resistance, alternative therapeutic options have to be considered, like introducing per os anticoagulation (e.g. warfarin), introducing ticlopidin instead of clopidogrel, or, in the near future, possibly introducing prasugrel, a similar agent currently in transition from investigation into clinical use.

Sinus of Valsalva (SV) aneurysm is rare cardiac lesion with variable clinical presentation. We presented a case of a 41-year-old female who was admitted to our Center because of severe heart failure and a signs of ruptured aneurysm of the SV into the right atrium. Transthoracic echocardiography confirmed communication between noncoronary SV and right atrium measuring 12 mm in diameter, tricuspid insufficiency, biatrial dilatation and preserved left ventricular function. Urgent heart catheterization showed normal coronary arteries. Surgical repair with patch repair of the ruptured aneurysm was performed. Control echocardiography showed no communication with regression in tricuspid insufficiency. Eight days after surgery the patient was discharged home in good condition with no symptoms. Rupture of SV aneurysm may produce serious hemodynamic instability with heart failure or sudden death. Our experience supports the concept that early diagnosis and surgical treatment can save lives for most of the patients.

OBJECTIVES The role of exercise test in risk stratifying of asymptomatic patients with moderate and severe aortic stenosis (AS) in recent literature is still controversial. The aim of this study was to evaluate the role of exercise test in stratifying the risk of patients with moderate to severe aortic stenosis. METHODS At the Internal Medicine Clinic, Department of Cardiology in Tuzla, in the period from January 2008 until January 2010 was followed 33 patients with clinical and echocardiographic parameters of moderate to severe asymptomatic aortic stenosis (mean effective orifice area EOA 0.9 +/- 0.34 cm2). In statistical analysis we used descriptive statistics, t-test, chi-square test and Kaplan-Meier life table for predictive values, sensitivity and specificity. A significance level of 0.05 was used. RESULTS Two patients were excluded due to exclusion criteria, so 31 patient was followed up during 12 months period. Eighteen patients (58%) with EOA pounds sterling 0.8 cm2 had limiting symptoms during the test. During follow-up period, 11 patients developed serious spontaneous symptoms, and out of them 8 patients underwent surgical valve replacement, one patient died (sudden cardiac death), and 2 patients had serious complications (ischemic cerebral stroke). Twenty patients remained asymptomatic. The highest positive predictive accuracy had EOA pounds sterling 0.8 cm2 with limiting symptoms and it was 85%. The highest negative predictive accuracy had ST depression. CONCLUSION only limiting symptoms along with EOA pounds sterling 0.8 cm2 had positive predictive accuracy.