Faculty of Medicine

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Persistent foramen ovale as a cause of cerebral strokes in young individuals - case reports
(MIT University Skopje, 2025-03)
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Nikolovski, Robert
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Zhaku, Vegim
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Foramen ovale is a small congenital defect in the level of the interatrial septum of the heart that occurs as a result of the failure of fusion between the septum primum and septum secundum during embryogenesis. It is present in about 25% of the population and is usually clinically insignificant. However, in some cases, it can lead to paradoxical embolism, which may result in an ischemic stroke. Objective: To investigate the association between patients with persistent foramen ovale (PFO) and the occurrence of strokes in young individuals, with a case report. Case Report: A 27-year-old patient presented for a check-up with a history of multiple episodes, especially in the morning, of weakness in the left limbs, particularly the left arm, accompanied by dizziness. These symptoms spontaneously improved, but in the last episode, the symptoms lasted up to 5 hours from the onset. The patient lives in a small area at a higher altitude. The patient was referred for a neurological examination. The neurological examination was unremarkable at the time of the visit, but due to the recurring symptoms, the patient was referred for a magnetic resonance imaging (MRI) scan of the brain, where punctiform hyperintense lesions were detected. The patient was then referred to a cardiologist, where a transthoracic echocardiogram (TTE) revealed a thin septum, leading to a recommendation for transesophageal echocardiography (TEE). TEE showed the presence of a 2mm PFO, after which the decision was made to close it using an Amplatzer PFO Occluder – 25mm in size. Conclusion: Although rare, a transient ischemic attack (TIA) in younger individuals should prompt consideration of the potential existence of PFO. Timely diagnosis and treatment of PFO are crucial for the lives of these patients.
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Prognostic Significance of Echocardiographic Parameters for Right Heart Assessment and Risk of Developing Advanced Gold Classes in Patients with Chronic Obstructive Pulmonary Disease (COPD)
(2023)
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Nikolovski, Robert
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Background: Chronic obstructive pulmonary disease (COPD) аaccording to World Health Organization is the third leading cause for early death and disability in 2022. COPD is characterized by persistent airflow limitation that is typically progressive and associated with an enhanced chronic inflammatory response in the airways and lung tissue. As the disease progresses more cardiovascular complication appear such as right ventricular hypertrophy with preserved systolic function, pulmonary artery pressure (which is slightly to moderately increased), and moderate tricuspid regurgitation. Material and methods: The design of our study was a prospective-clinical cross-sectional study. We analyzed 94 patients with COPD. All patients were divided in groups according to degree of obstruction and classified by GOLD classification system into four groups from GOLD 1-GOLD4. In our study all patients during admission and hospital stay were thoroughly examined with anamnesis, physical examination and electrocardiogram (ECG), as well as with basic and advanced echocardiographic assessment.13teen echo parameters were evaluated applying advanced echocardiographic analysis especially in terms of right heart features. Results: All echocardiographic parameters were analyzed to understand their significance in disease progression in patients with COPD and increasing Gold classes. Twelve of 13-teen echo-parameters evaluated in our study have quantitative values, while collapsibility of vena cava >50% is a qualitative parameter. Quantitative values of the same echo-parameters (DA, S TDV DV, TAPSE, FAC, AT a.pulmonalis, SPAP, v.max, MPI DV, Stain DV, DA area, PVR and collapsibility of vena cava > 50 %) were compared in terms of Gold classes by multivariate linear regression analysis. With multivariate linear regression analysis, there is a statistically significant correlation (with the following three echocardiographic parameters: S’ TDV DV, DV basal and Global strain DV according to GOLD classes. In further analyses, binary categorization of GOLD classes into two binary categories was additionally used: lower GOLD classes (1 and 2), and more advanced GOLD classes (3 and 4) by applying logistic regression model. The parameter basal dimension of the right ventricle (RV basal) has the highest values statistically, the parameters SPAP, AT a.pulm, Gl strain of DV and TAPSE have somewhat lower values. Conclusion: Prevalence of pulmonary hypertension has a linear relationship with severity of COPD and severe pulmonary hypertension is almost every time associated with development of right heart failure. Echocardiography helps in early detection of cardiac complications in COPD cases giving time for early interventions. We suggest screening of all COPD patients for cardiac complications using echocardiography as a non-invasive and repeatable for their follow-up
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Genetically Associated Hypertrophic Cardiomyopathy Combined with Persistent Left Superior Vena Cava
(Valley International, 2023-01-24)
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Grueva, Elena
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Mitevski, Goran
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Nikolovski, Robert
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Janushevski, Filip
Background: Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. An implantable cardioverter defibrillator (ICD) is an efficient way of preventing sudden cardiac death in these patients. Aim: Diagnosis and treatment of genetically associated hypertrophic cardiomyopathy. Case Report: We present a 28-year patient with a history of tachycardia, dizziness, transient chest pains, and anamnestic information on episodes of short-term loss of consciousness and fatigue. She has a positive family history of HCM and her uncle died young from sudden cardiac death (SCD). The electrocardiogram showed hypertrophy, which was confirmed with echocardiography and MRI. Genetic testing confirms PRKAG2 gene mutation. Holter24-hour ECG monitoring showed domination of sinus bradycardia after which it was recommended implantation of ICD. On implantation, persistent left superior vena cava (PLSVC) was discovered and the implantation side was changed. A bipolar Implantable Cardioverter Defibrillator was implanted. Conclusion: When HCM is confirmed at a young age, genetically associated HCM should always be considered. Early recognition of hereditary hypertrophic cardiomyopathy can facilitate better disease management and follow-up even before symptoms appear.
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D DIMERS - A POWERFUL TOOL IN THE DIAGNOSIS OF AORTIC DISSECTION
(Department of Anaesthesia and Reanimation, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, R.N. Macedonia, 2023)
Jovanoski, Marko
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Nikolovski, Robert
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Petkovski, D.
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Introduction: Acute aortic syndrome is one of the most life threatening cardivascular conditions besides acute coronary syndrome and pulmonary embolism. Fifty percent of all the patients with aortic dissection do not survive for surgery or other therapeutic procedure to be performed and they experience a lethal end. D dimers although are a marker with a low specificity and sensitivity they can help us and guide us to make the right diagnosis. Aim: Using d dimers to raise the suspicion for acute aortic dissection and using the triple chest pain CT angiography protocol to confirm the right diagnosis. Case report: This series of case reports are about a few patients that presented in the emergency department with either a chest or back pain which was radiating to different body regions (including the lumbal region and the abdominal area). As these symptoms can sometime overlap and manifest as different acute cardiovascular syndromes, which can lead to increased morbidity and mortality, a CT angiography was performed after the regular noninvasive, low cost echocardiography was done to potentially find a possible diagnosis and show us the right diagnostic path. D dimers were also examined in all of the patients and increased level was found in all of the above mentioned. Aortic dissection (Stanford A or B ) was the final diagnosis in all of them, every single patient requiring a different therapeutic approach. Conclusion: D dimers in combination with a good clinical examination can be a perfect tool to raise the suspicion for acute aortic syndrome and after performing a triple chest pain protocol with CT angiography we can confirm and treat the diagnosis which requested a hospital admission.
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VENTRICULAR ARRHYTHMIAS AS A CAUSE OF A SUDDEN CARDIAC DEATH IN ATHLETES
(Faculty of Physical Education, Sport and Health in Skopje, Republic of Macedonia, 2022)
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Nikolovski, Robert
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Lazovska, Marija
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Janushevski, Filip
We live in a decadewhen the necessity for a healthy life with the prevention of cardiovascular disease is progressively emphasized. Physical activity is one of the basic medical recommendations by the cardiologists in the prevention and improvement of heart health. But what is the edge between the physiological and the possibility of pathological incidents? What are the dangers which are caused by the pro-arrhythmogenic heart in some athletes? Ventricular arrhythmias are a real risk of sudden cardiac death in some athletes. The case with the football player Eriksen at the European Football Championship reopened this question, whether we are doing enough to protect the health of our athletes.
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MISDIAGNOSIS OF CERVICOBRACHIAL SYNDROME WITH SUBOCCLUSION OF THE LEFT SUBCLAVIAN ARTERY
(Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, 2023)
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Nikolovski, Robert
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Introduction: Cervical spondylosis (degenerative osteoarthritis) and subclavian occlusion, mostly caused by atherosclerosis, share similar symptoms. Both are diseases of the advanced age. Thus, there are similarities of overlapping or misdiagnosis of both diseases. The aim of this case report was to present diagnosis and treatment of subclavian subocclusion and possibility of misdiagnosis with cervicobrachial syndrome. Case report: We present the case of a 71-year-old woman with noncontrolled hypertension. For many years she complained of occasional pains and tingling in her neck, left shoulder, and hand, coolness in the fingers of the left hand, headache and occasionally dizziness. An x-ray finding of the cervical spine was in favor of spondyloarthrosis on the neck vertebrae, and after consulting an orthopedic specialist, she was diagnosed and treated as cervicobrachial syndrome for many years without success. Cardiology examination detected different high blood pressure readings in both arms and that induced us to perform a computerized angiography (CT). CT showed subocclusion on the left subclavian artery after which our patient underwent angiography and stent implantation. After the procedure, the blood pressure difference decreased and the symptoms disappeared. Conclusion: Due to similar symptoms, whenever cervicobrachial syndrome is diagnosed, the blood pressures in both arms should be measured. In case of their difference, subclavian stenosis should also be considered and appropriate investigations should be made, especially if the difference in pressures is high.
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SARS-COV-2 INFECTION: CARDIAL AND MULTI-ORGAN INVOLVEMENT
(Department of Anaesthesia and Reanimation, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, R.N. Macedonia, 2022-12)
Furnadziski, Aleksandar
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Mitevski, Goran
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Nikolovski, Robert
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SARS-COV-2 is a single-strain RNA virus that attacks primarily the respiratory system. The second most commonly affected system is the cardiovascular. Often it attacks multiple organ systems causing multi-organ failure. Atrial fibrillation (AF) is the most common sustained supraventricular arrhythmia in acute settings of COVID-19 infection and is associated to more complications and mortality rates. The presence of AF in patients with COVID-19 pneumonia should be managed with increased attention to prevent adverse outcomes. COVID-19 may be a cause of multiple organ damage in some infected patients.
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LEFT MAIN CORONARY ARTRY STENTING IN PATIENTS WITH CHRONIC KIDNEY DISEASE - A LIFESAVING PROCEDURE
(MIT University Skopje, 2022-10)
Mitevski, Goran
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Taravari, Hajber
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Background: Chronic kidney disease (CKD) is one of the most important factors for adverse outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention. These patients have poorer outcomes in comparison with patients without CKD. The strategy for the best revascularization technic in patients with CKD and coronary artery disease is still unknown because these patients are usually excluded from most clinical trials, especially in patients with moderate or severe CKD. Aim: This case report aims to show that percutaneous coronary intervention is a necessary and life-saving procedure in a critically ill patient with CKD despite the risk of complications and worsening renal function. Case Report: We present a 76 years patient with a medical history of CKD stage 4, Diabetes Mellitus type 2 on insulin therapy, and hypertension, one year ago she got a drug-eluted stent on the left anterior descendent (LAD) coronary artery, after which she has developed contrast-induced nephropathy and she underwent on hemodialysis after which kidney function stabilized. She was diagnosed with heart failure with reduced EF (23%). This patient came to the emergency department with pulmonary edema and subacute myocardial infarction. She was medically stabilized and underwent delayed percutaneous coronary intervention (PCI) with stenting to LM/pLAD after which deterioration of kidney function was observed (Creatinin456.8..498..701umol/L, Urea 22.6..23.4..27mmol/L). She underwent hemodialysis after which previously kidney function was obtained and she was dismissed in good health. Conclusion: PCI and Left main stenting is a lifesaving procedure in patients with CKD. A multidisciplinary approach and an experienced invasive cardiologist are of crucial importance for a good outcome in these patients.
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Hypertension in athletes
(MIT University, 2023-03)
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Furnadjiski, Atanas
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Mitevski, Goran
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Nikolovski, Robert
Hypertension is the most common cardiovascular disease in athletes. Prompt diagnosis and management is crucial for ensuring safe sport participation and prevention of long term complications in athletes. Many diagnostic tools are involved in the management algorithm of the hypertension starting from good anamnesis especially the family history, as well as other simple and sophisticated paramedical imaging techniques, as ECG, Echocardiography, 24 Hours ambulatory ECG monitoring, cardiac MRI and many others. Distinguishing an athlete heart from pathological heart muscle hypertrophy is the key step for the differential diagnosis. Conclusion: Proper pharmacological and non pharmacological measures will facilitate satisfying long term prognosis for the athletes.

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