DOI: 10.3897/bgcardio.32.e191105

Authors: I. Baltov, M. Tarasheva, B. Trifonova, D. Koleva, Ts. Dimitrova, M. Stoyanov, T. Shalganov

Abstract: Introduction: Pulmonary vein isolation (PVI) for atrial fibrillation (AF) induces myocardial necrosis. The extent of myocardial injury and systemic inflammatory or thrombotic response may vary depending on the ablation energy modality. It is not known whether the maximum diameter of ‘single shot” ablation catheters influences the magnitude of biomarker release. We aimed to study the temporal profiles of cardiac (high-sensitivity cardiac troponin I, hs-cTn), inflammatory (C-reactive protein, CRP), and thrombotic (D-dimer) biomarkers, as well as creatinine, within 24 hours of PVI, using cryogenic (CBA) or pulsed field energy (PFA). Materials and methods: We prospectively studied consecutive patients with non-permanent AF undergoing first-time PVI by CBA or PFA. Data were collected on the demographic and clinical characteristics, echocardiographic and procedural parameters, and biomarker levels. Blood samples were collected pre-procedure, 6-8 hours post-procedure, and 20-22 hours post-procedure. Repeated measures ANOVA was used for longitudinal comparisons after log-transformation where required; between-group differences were assessed using the Brunner-Munzel test or the chi-square test. A P-value < 0.05 was considered statistically significant. Results: Each group comprised 35 patients with no significant differences in demographic, clinical, or echocardiographic characteristics. Procedure duration was longer with CBA (90 vs 70 min., p < 0.001). hs-cTn increased in both groups, with a higher peak (10217 ng/L vs 5831 ng/L, p = 0.034) and more rapid decline (6431 ng/L vs 4947 ng/L, p = 0.078) in the PFA group. CRP was higher after CBA (11.7 mg/L vs 4.5 mg/L, p < 0.001). D-dimer and creatinine did not change significantly. Biomarker changes were dependent on the time of sample collection and energy modality used, but not on the diameter of the ablation catheter. Conclusion: Compared to CBA, PFA is associated with a substantially greater early increase of hs-cTn within the first few hours, followed by a steeper decline by the following day. CRP increases more after CBA, while D-dimer and creatinine are not affected by either ablation modality.

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DOI: 10.3897/bgcardio.32.e189464

Authors: A Keltchev, R. Geshev, S. Kazakov

Abstract: Background: Surgical replacement of the ascending aorta remains the gold standard therapy for ascending aortic aneurysm, chronic dissection, and selected aortic root pathologies. Traditionally performed through full median sternotomy, ascending aortic surgery has progressively evolved toward minimally invasive approaches aiming to reduce surgical trauma while preserving procedural safety and durability. Upper partial sternotomy has emerged as the most widely adopted minimally invasive access for ascending aortic surgery. This study presents the institutional experience of Acibadem City Clinic Vitosha Hospital with minimally invasive ascending aortic surgery via upper partial sternotomy and places these results in the context of contemporary literature. Methods: A retrospective analysis was conducted of consecutive elective patients undergoing ascending aortic replacement with or without aortic root intervention through an upper partial sternotomy. Demographic characteristics, operative details, and early postoperative outcomes were analyzed. Institutional results were interpreted considering current evidence comparing partial sternotomy with conventional full sternotomy, as well as alternative minimally invasive approaches including transaxillary and totally endoscopic techniques. Results: Minimally invasive ascending aortic surgery via upper partial sternotomy was associated with excellent early outcomes, including absence of early mortality, low neurological complication rates, limited blood transfusion requirements, and short intensive care and hospital stays. Cardiopulmonary bypass and aortic cross-clamp times were within acceptable ranges and comparable to those reported for conventional sternotomy in the literature. Conclusions: Upper partial sternotomy is a safe, reproducible, and effective minimally invasive approach for ascending aortic surgery in carefully selected patients. When performed in experienced centers, this technique provides outcomes comparable to full sternotomy while offering potential advantages in postoperative recovery. It represents a pragmatic and scalable strategy within the expanding field of minimally invasive aortic surgery.

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DOI: 10.3897/bgcardio.32.e189472

Authors: A. Keltchev, S. Kazakov, M. Garalova

Abstract: Background: Extensive aortic arch and proximal descending aortic pathologies traditionally require multi-stage repair. The Frozen Elephant Trunk (FET) technique allows one-stage ascending aorta and total arch replacement with antegrade stent-graft deployment, enabling complete repair and a platform for future endovascular interventions. The E-vita Open NEO hybrid prosthesis incorporates design improvements that facilitate deployment, shorten ischemic times, and reduce the risk of neurological complications. Objective: The main objective of this case series is to present the initial experience with FET using the E-vita Open NEO graft at Acibadem City Clinic Hospital Vitosha, illustrating feasibility, safety, and early outcomes. Methods: Four elective patients with complex thoracic aortic disease (degenerative aneurysms and chronic post-dissection aneurysms) underwent ascending aorta and total arch replacement with FET using the E-vita Open NEO prosthesis. Procedures were performed via median sternotomy with cardiopulmonary bypass, hypothermic circulatory arrest, and selective antegrade cerebral perfusion. Trifurcated or branched grafts were selected according to arch anatomy. Results: All patients survived with no in-hospital mortality, stroke, or spinal cord injury. Circulatory arrest times ranged 45–60 minutes. Postoperative imaging confirmed correct stent deployment, patent arch branches, and favorable aortic remodeling, including false lumen thrombosis in dissection cases. The device facilitated precise distal deployment and simplified arch reconstruction without graft-related complications. Conclusions: FET with the E-vita Open NEO is feasible and safe in a newly established aortic program. One-stage repair achieved complete anatomical correction, avoided staged procedures, and promoted early aortic remodeling. Early outcomes are consistent with international experience, supporting FET as a standard approach for extensive thoracic aortic disease.

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DOI: 10.3897/bgcardio.32.e189966

Authors: Hansinie Jayasuriya, Kombuge Hiruni Maleesha, Sarvananda Letchuman

Abstract: Cardiovascular diseases (CVDs) are a leading cause of non-communicable disease mortality worldwide, with a disproportionate burden in lower-middle-income countries (LMIC). Hypertension is a significant risk factor for CVDs, and its prevalence is on the rise, posing considerable challenges to public health. This paper provides a narrative overview of the global burden of hypertension, emphasizing its disproportionate impact on LMICs, and then shifts its focus to Sri Lanka, a South Asian lower-middle-income country, where one-third of the adults are hypertensive and discusses awareness, diagnosis, and control rates in the country. The core of this paper explores the evolution of dietary interventions, specifically the Dietary Approaches to Stop Hypertension (DASH) diet, in managing hypertension. From the inception of the DASH study in 1994 to its subsequent impact on blood pressure reduction, the article presents a detailed analysis of the diet’s components and effectiveness. A significant contribution is proposing a culturally and socio-economically adapted DASH diet tailored to the Sri Lankan setting. Addressing challenges related to adherence and compliance, the article emphasizes the importance of community involvement and policy changes to sustain DASH. The conclusion highlights the research gap in Sri Lanka, where very limited studies have explored the exclusive use of the DASH diet. By outlining contextual challenges and key research priorities, this paper aims to inform prospective research in Sri Lanka and comparable LMIC settings, underscoring the importance of tailoring dietary interventions to specific cultural and socio-economic contexts for effective hypertension control.

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DOI: 10.3897/bgcardio.32.e164121

Authors: P.S. Matreja, J. Haria, V.K. Singh, H. Krishna, Sh. Afaq

Abstract: Background: Parkinson’s disease is a progressive neurodegenerative condition not only marked by motor impairment but also by a wide range of non-motor symptoms, such as cardiovascular complications. Cardiac dysfunction, traditionally ascribed to autonomic nervous system damage, is now more and more identified as a major cause of morbidity and mortality in PD patients. The present review intends to integrate current evidence regarding the cardiac manifestations of PD, highlighting their prevalence, mechanisms, and clinical relevance. Methods: A PRISMA-guided systematic review was carried out using the PECOS framework. Seven electronic databases were searched for articles published between January 2010 and January 2025 that explored cardiac involvement as a non-motor symptom in PD. The inclusion criteria included observational studies, clinical trials, and meta-analyses reporting on cardiac outcomes like orthostatic hypotension, arrhythmias, heart rate variability, and cardiovascular mortality. Data extraction and risk of bias evaluation were carried out independently by two reviewers. Results: Starting with a pool of 949 records, 20 studies were found to meet the inclusion criteria. These studies showed a uniform correlation between PD and enhanced cardiovascular risks, including stroke (up to OR 1.66), orthostatic hypotension, and decreased heart rate variability. Though some reports described a decreased risk of myocardial infarction (OR 0.80), autonomic dysfunction was the core mechanism underlying most cardiac events. The results also highlighted the need for individualized cardiovascular monitoring in the management of Parkinson’s disease and indicated underutilization of diagnostic technologies such wearable sensors and HRV analysis. Conclusion: Cardiac failure in Parkinson’s disease (PD), fueled by autonomic dysfunction, is underappreciated in spite of associations with hypotension, arrhythmias, and stroke. Early detection measures such as HRV and wearables are not utilized. Cardiovascular risk reduction, particularly with PD meds, and incorporating cardiac management can better enhance outcomes.

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DOI: 10.3897/bgcardio.32.e184927

Authors: L. Kopaleishvili, T. Chkhaidze, S. Ungiadze, L. Kapanadze, T. Verulava

Abstract: Lipoprotein(a) (Lp(a)) is an independent, genetically determined cardiovascular risk factor that remains underrecognized in clinical practice. Elevated Lp(a) exerts pro-atherogenic, pro-thrombotic, and pro-inflammatory effects, contributing to coronary artery disease, ischemic stroke, and calcific aortic valve stenosis. About 20% of the global population has high Lp(a) (> 50 mg/dL or > 125 nmol/L), associated with a 2-4-fold increased risk of events, independent of low-density lipoprotein cholesterol (LDL-C). Unlike LDL-C, Lp(a) levels are ~90% genetically determined, minimally affected by lifestyle, and stable throughout life. Traditional lipid-lowering therapies (e.g., statins) have little effect on Lp(a). PCSK9 inhibitors provide modest reduction (~ 20-30%), while novel RNA-targeted agents (antisense oligonucleotides, siRNAs) and gene-editing approaches are under active investigation. Recent guidelines, including the 2025 ESC/EAS Focused Update, recognize Lp(a) > 50 mg/dL (~ 105 nmol/L) as a cardiovascular risk-enhancing factor (Class IIa, Level B). They recommend once-in-a-lifetime Lp(a) measurement, particularly in patients at high cardiovascular risk, and emphasize intensive LDL-C lowering in acute coronary syndrome. Bempedoic acid is endorsed for statin-intolerant patients (Class I, Level B), while evinacumab may be considered in homozygous familial hypercholesterolemia (Class IIa, Level B). Emerging evidence also links Lp(a) to atrial fibrillation, broadening its clinical relevance. Large outcome trials of Lp(a)-lowering agents are underway and will determine whether reduction translates into improved cardiovascular outcomes. As one in fi ve adults worldwide has elevated Lp(a), integrating Lp(a) testing into risk assessment and preparing for targeted therapies are critical steps in modern cardiovascular prevention.

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DOI: 10.3897/bgcardio.32.e184449

Authors: YongIl Ho, Zhi-Quan Wang, Jong Hyong Mun, JongDok Kim, CholSok Jang, ChungHyok Kim, SunHui Yun

Abstract: Background: Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of HF cases, predominantly affecting older adults with comorbidities such as hypertension, diabetes, and obesity. Despite the breakthrough provided by angiotensin receptor-neprilysin inhibitors (ARNI), approximately 30% of HFpEF patients do not derive cardiorenal benefits. Soluble ST2 (sST2), a biomarker of fibrosis and ventricular stress, avoids confounders associated with traditional markers (e.g., NT-proBNP) and may serve as a predictor of ARNI response. Objectives: To evaluate whether dynamic changes in sST2 can predict the cardiorenal protective efficacy of ARNI in HFpEF patients, as measured by changes in estimated glomerular filtration rate (eGFR), urinary albumin-to-creatinine ratio (UACR), and left ventricular diastolic function (E/e' ratio). Methods: We searched CENTRAL, The Cochrane Library, Embase, PubMed, Science Citation Index (SCI), and Social Science Citation Index (SSCI) for randomized controlled trials (RCTs) and cohort studies (prospective/retrospective) without language or date restrictions. Eligible studies included HFpEF patients (EF ≥ 50% per 2016 ESC or 2022 AHA/ACC/HFSA guidelines) receiving ARNI for ≥ 1 month with dynamic sST2 monitoring (baseline + post-treatment). Two independent reviewers performed study selection, data extraction, and risk of bias assessment (RoB-2 for RCTs; Newcastle-Ottawa Scale [NOS] for cohort studies). Heterogeneity was evaluated using the I² statistic, with fixed-effect models (I² ≤ 50%) or random-effect models (I² > 50%) for data synthesis. Sensitivity analysis and publication bias assessment (funnel plots, Egger’s test) were conducted using Stata 17.0. Results: A total of 12 studies (4 RCTs, 8 cohort studies) involving 2,863 HFpEF patients were included. Patients with a significant sST2 decrease (≥ 20% from baseline) showed a smaller decline in eGFR (mean difference [MD] = 3.21 mL/min/1.73m², 95% CI: 1.89–4.53, I² = 38%), greater reduction in UACR (standardized mean difference [SMD] = -0.57, 95% CI: -0.79 to -0.35, I² = 45%), and more improved E/e' ratio (MD = -1.83, 95% CI: -2.56 to -1.10, I² = 42%) compared to those with no significant sST2 decrease. Subgroup analysis revealed consistent results across ARNI dosages (200-400 mg/day sacubitril/valsartan) and follow-up durations (3–12 months). Sensitivity analysis confirmed the stability of outcomes, and publication bias was not detected (Egger’s test P > 0.05 for all outcomes). Conclusions: Dynamic changes in sST2 (≥ 20% reduction from baseline) reliably predict the cardiorenal protective efficacy of ARNI in HFpEF patients. Routine monitoring of sST2 may facilitate personalized HFpEF management.

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DOI: 10.3897/bgcardio.32.e192481

Authors: I.G.P.A. Wedharga, M.A. Hendri, M. Sanusi, D. Sarvasti

Abstract: Background: Heart rate (HR) reduction is commonly proposed to improve diastolic filling and reduce left ventricular (LV) filling pressure in heart failure with preserved ejection fraction (HFpEF). Ivabradine selectively lowers HR without direct myocardial effects, providing a mechanistic model to examine whether HR reduction alone translates into improved LV filling pressure. This study aims to evaluate whether selective HR reduction with ivabradine improves LV filling pressure and diastolic function in patients with HFpEF. Methods: MEDLINE and CENTRAL were systematically searched for randomized controlled trials comparing ivabradine with placebo or standard therapy in HFpEF. Outcomes included diastolic echocardiographic parameters (E/e′, e′ velocity, and left atrial volume index [LAVI]), resting HR, natriuretic peptides, and peak oxygen consumption (peak VO2). Pooled mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models. Results: Three RCTs (258 patients) were included. Ivabradine significantly reduced resting HR (MD −12.03 bpm; 95% CI −18.43 to −5.63), yet was associated with a signifi cant increase in E/e′ (MD 1.02; 95% CI 0.22 to 1.82). Septal e′ modestly increased, while no significant differences were observed for lateral or mean e′, LAVI, natriuretic peptides, or peak VO2. Conclusions: These findings suggest a dissociation between HR reduction and LV filling pressure, underscoring the limited role of isolated chronotropic modulation in the pathophysiology of HFpE

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DOI: 10.3897/bgcardio.32.e183465

Authors: A. Shaban, L. Demirevska

Abstract: Frailty is a geriatric syndrome characterized by reduced physiological reserve and resistance to stress factors. With the aging population and increasing life expectancy, the frailty syndrome is gaining significant importance in clinical practice, including in the context of percutaneous coronary interventions (PCI), as it considerably complicates patient management. The presence of frailty is an independent and powerful predictor of adverse outcomes following PCI, such as increased mortality, a higher incidence of major bleeding events, and prolonged hospital stays. This condition necessitates a comprehensive, multidisciplinary approach to optimize and personalize therapeutic strategies, particularly the choice of antithrombotic therapy. Active screening for frailty and adapting clinical management accordingly are crucial for improving clinical outcomes and the quality of life for this vulnerable patient population.

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DOI: 10.3897/bgcardio.32.e207597

Authors: D. Kyuchukov

Abstract: Advanced heart failure (HF) remains a growing clinical challenge, while the limited availability of donor organs has increased the importance of mechanical circulatory support (MCS) as a therapeutic option. Patient selection for MCS implantation, together with decisions regarding the optimal timing and choice of device, has become one of the most critical issues in contemporary heart failure management. Despite robust evidence demonstrating significant improvements in survival and quality of life following implantation of durable mechanical circulatory support (dMCS) devices, only a small proportion of eligible patients receive this therapy in many countries, including Bulgaria. The reasons are multifactorial and include death before referral, advanced irreversible end-organ dysfunction, socioeconomic barriers, and patient refusal. Decision-making is highly complex because every candidate presents unique clinical characteristics requiring comprehensive diagnostic evaluation and preoperative optimization. Final patient selection should be based on structured multidisciplinary discussion within a specialized advanced heart failure team, following clearly defined principles and evidence-based recommendations. The aim of this review is to provide a practical framework for clinicians involved in the management of advanced heart failure, enabling appropriate assessment of individual patient characteristics, definition of the therapeutic intent of durable mechanical circulatory support, and determination of the optimal timing for device implantation.

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DOI: 10.3897/bgcardio.32.e184950

Authors: Zh. Kolev, Sv. Slavcheva, Zh. Marinova

Abstract: Brain injury resulting from a vascular event may trigger a spectrum of cardiovascular disorders, including acute myocardial dysfunction, heart failure, myocardial infarction, life-threatening arrhythmias, and even sudden cardiac death. These events are encompassed by the term ‘Stroke-Heart’ syndrome, which is associated with an increased risk of mortality and incomplete neurological recovery compared with cases of stroke without cardiac complications. We present a clinical case of a 66-year-old female patient from Ukraine in whom aneurysmal subarachnoid hemorrhage was accompanied by a clinical presentation mimicking acute coronary syndrome, with dynamic ischemic-type ST-T changes, prolonged QT interval, and left ventricular systolic dysfunction. Elevated catecholamine levels and impaired autonomic regulation in subarachnoid hemorrhage may cause myocardial stunning and injury in the absence of coronary obstruction. This case highlights the need for thorough knowledge not only of the classical clinical presentation of focal neurological deficits but also of other possible pathophysiological manifestations along the cerebro-cardiac axis in order to support differential diagnostic reasoning and the definitive establishment of the correct diagnosis.

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DOI: 10.3897/bgcardio.32.e184165

Authors: B. V. Ralcheva, L. Demirevska, I. Daskalov

Abstract: Polymethylmethacrylate (PMMA) is a well-known material used in vertebroplasty procedures, characterized by minimal toxic effects, strength, and reliability. As the number of spinal stabilization procedures increases, the incidence of complications also rises, one of which is pulmonary cement embolism. While most cases in clinical practice are asymptomatic or mild, some can be severe, requiring rapid recognition and potentially life-saving intervention. We present a clinical case of a patient after vertebroplasty who exhibited mild clinical symptoms and CT findings indicative of pulmonary cement embolism, in whom a conservative therapeutic approach was successfully applied. The aim of this report is to review current treatment algorithms for PMMA embolism. At present, there is no established evidence-based unified strategy for diagnosis and management.

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DOI: 10.3897/bgcardio.32.e195334

Authors: A. A. Hikmayani, S. L. Widjaja, B. Artiko, D. Hidayah, A. T. Putra, A. A. Nursidiq

Abstract: Background: A peripherally inserted central catheter (PICC) is commonly used in the neonatal intensive care unit (NICU). Although beneficial, PICC can result in deadly silent complications, namely pericardial effusion and cardiac tamponade, requiring urgent pericardiocentesis. In this case, a central venous catheter (CVC) was used in the pericardiocentesis procedure due to the inadequacy of the standard catheter. Case presentation: A female neonate with a birth weight of 920 grams and 29-week gestational age has been admitted to the NICU since she was born. On her 29th day of life, the patient suddenly became tachycardic and has frequent apnea episodes. Babygram showed the tip of the PICC was in the right atrium. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was performed bedside using a 3Fr CVC due to the limited availability of pigtail catheters suitable for neonates. Immediately after the pericardiocentesis, the patients became stable with a normal heart rate and no episodes of apnea. Conclusion: Pericardial effusion is a rare complication of PICC, but it is associated with high mortality. The use of CVC for pericardiocentesis under echocardiography guidance in settings with limited facilities can be an option for this life-saving procedure.

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DOI: 10.3897/bgcardio.32.e200736

Authors: G. Stoitsev, St. Petrov, B. Penev, V. Gegouskov

Abstract: We present the case of a patient with combined valvular heart disease and a history of gout. Following surgical replacement of the aortic and mitral valves, histopathological examination revealed extensive deposition of monosodium urate (MSU) crystals within the aortic valve leaflets. The lesion exhibited a central crystalline core, surrounded by a corona zone and fibrous vascular tissue. The nature of the urate crystals was confirmed using the classical, but rarely applied today - De Galantha’s staining technique. This method allows precise visualization of crystal deposits under light microscopy at various magnifications. No specific pathological findings were identified in the examined specimens from the mitral valve or in the thrombotic mass excised from the left atrium. Based on the histopathological findings, a definitive diagnosis of tophaceous involvement of the aortic valve was established.

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DOI: 10.3897/bgcardio.32.e184793

Authors: Firas R. Al-Obaidi

Abstract: Coronary artery aneurysm (CAA) is defined as abnormal dilatation of the coronary artery more than 1.5 times the diameter of the normal reference segment of that coronary artery. The incidence is about 1.5-5% and more common in the right coronary artery. The coronary artery aneurysm is classified into saccular or fusiform types, and the CAA is identified as giant if the diameter is more than 20 mm. The etiology of CAA is variable and can be due to genetic causes, inflammatory or autoimmune diseases (vasculitis such as Kawasaki disease, Takayasu arteritis, systemic lupus erythematosus and Marfan syndrome), atherosclerotic cause, infectious causes, cocaine use; and post coronary artery stenting. We present a case of coronary artery aneurysm in a patient who is a known case of lupus nephritis.

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DOI: 10.3897/bgcardio.32.e202226

Authors: B. Baev, R. Iliev, D. Trendafilova, S. Georgiev, L. Pampulova, D. Petkov

Abstract: Postinfarction ventricular free-wall rupture is a rare mechanical complication after acute myocardial infarction (AMI). When the rupture is contained by epicardial clots or pericardial adhesions, it commonly leads to the formation of a pseudoaneurysm (PSA). With the development of revascularization therapies the incidence of PSA has decreased dramatically with occurrence about 0.2-0.5% of AMI cases [1]. PSA carry a high risk of rupture, with studies estimating risk between 30% and 45% [2]. We present a case of a 53-year-old woman with a giant pseudoaneurysm secondary to a prior AMI of unknown duration.

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DOI: 10.3897/bgcardio.32.e191723

Authors: I. G. R. Suryawan, M. Ardiana, J. N. E. Putranto, A. Halim, A. N. Fadila, M. F. Fanani

Abstract: Objective: Smoking remains a leading cause of morbidity and mortality globally, with 22.5% of Indonesians identified as smokers. Electronic cigarette (e-cigarette) usage in Indonesia has reached 10.65%, primarily due to the widespread belief that they are a safer alternative to conventional cigarettes. This trend raises concerns due to their nicotine content, which may contribute to atherosclerosis. This study aimed to investigate the effects of exposure to conventional cigarettes and e-cigarettes on early atherosclerotic changes in Wistar rats (Rattus norvegicus), using α-smooth muscle actin (α-SMA) and interleukin-1β (IL-1β) as blood biomarkers. Material and Methods: Thirty-six male Wistar rats were divided at random into three groups: control, conventional cigarette smoke exposure, and e-cigarette vapor exposure. Following a 7-day acclimatization period, both exposure groups received equal nicotine concentrations for 30 minutes per day, five days per week, over a 12-week period. Serum levels of α-SMA and IL-1β were quantified using ELISA to evaluate atherosclerotic changes. Results: Both conventional cigarette smoke and e-cigarette vapor exposure significantly increased α-SMA and IL-1β levels compared with controls (p = 0.004 and p = 0.018, respectively). However, post hoc analyses revealed no statistically significant differences between the two exposure groups (α-SMA: p = 1.000, Bonferroni test; IL-1β: p = 0.374, Mann–Whitney test). Conclusions: Exposure to e-cigarettes produced effects comparable to those of conventional cigarettes exposure in increasing serum α-SMA and IL-1β, suggesting a similar potential risk to cardiovascular health.

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DOI: 10.3897/bgcardio.32.e193494

Authors: I. M. Moreira, L. S. Azevedo, C. R. Carvalho, I. N. Fernandes, M. C. Bernardo, P. R. Carvalho, A. Baptista, P. Mateus, I. Silveira, J. I. Moreira, On Behalf of ProACS Investigators

Abstract: Introduction: Beta-blockers (BB) remain a cornerstone of secondary prevention after acute coronary syndrome (ACS). However, contemporary randomized trials have questioned their routine use in patients with preserved ejection fraction, often excluding those with atrial fibrillation (AF). We aimed to evaluate the prognostic impact of BB therapy after ACS and determine whether the presence of AF modifies its association with in-hospital and one-year mortality. Materials and Methods: We conducted a retrospective analysis of patients included in the Portuguese Registry of Acute Coronary Syndromes (ProACS), between October 2010 and 2021. Patients were stratified ac-cording to AF status and BB prescription. The two co-primary endpoints were in-hospital and one-year all-cause mortality. Results: A total of 14,906 patients were included (mean age 64 ± 13 years, 72.8% male), of whom 9.8% had AF. AF patients were older, had more comorbidities, and higher mortality (in-hospital: 8.6% vs. 1.8%; 1-year: 15.9% vs. 4.5%; p < 0.001 for both). BB therapy was associated with lower in-hospital mortality in both sinus rhythm (OR 0.19, 95% CI 0.14-0.24) and AF (OR 0.21, 95% CI 0.13-0.35), with consistent benefit after adjustment (adjusted OR 0.30, 95% CI 0.23-0.35). At one-year follow-up, BB therapy was associated with reduced mortality (HR 0.57, 95% CI 0.44-0.73), without significant interaction with heart rhythm (p-interaction = 0.335). Conclusions: AF is associated with worse prognosis after ACS. BB therapy is associated with reduced in-hospital and one-year mortality, with consistent benefit irrespective of heart rhythm. These findings suggest that AF does not modify the prognostic association of BB therapy after ACS.

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DOI: 10.3897/bgcardio.32.e191615

Authors: T. Shalganov, M. Stoyanov, K. Dzhinsov

Abstract: This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) studies and catheter ablations performed in 2025. Material and methods: A full one-year dataset from the BG-EPHY registry was retrospectively analyzed. We evaluated patient age and sex distribution, number of ablations, use of electroanatomic mapping (EAM), ablation energy source, distribution of arrhythmia types, acute procedural success, and complications. Results: In 2025, ten EP centers performed 2898 ablations in 1831 men (63.2%) and 1067 women, including 18 procedures in pediatric patients (0.62%). EAM was used in 1607 procedures (55.5%). An irrigated-tip catheter was used in 1526 cases (52.7%), a cryocatheter in 662 (22.8%), and a pulsed field ablation catheter in 114 (3.9%). Intracardiac echocardiography was used in 386 procedures (13.3%). Pulmonary vein isolation was the most frequently performed primary ablation (55.5%), followed by ablation for typical atrial fl utter (13%) and AV nodal reentrant tachycardia (13%). Acute procedural success exceeded 99%, while intraprocedural complications occurred in fewer than 1% of the cases. Conclusion: The national electrophysiology registry systematically and continuously collects data on all catheter ablations performed in Bulgaria. In 2025, the total number of ablations increased compared with 2024, although at a slower pace. The distribution of procedure types remained similar to previous years. Acute success rates were high, and intraprocedural complications were rare.

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DOI: 10.3897/bgcardio.32.e213912

Authors: Dimitar Petkov

Abstract: Editorial

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DOI: 10.3897/bgcardio.32.e185208

Authors: N. Grigorov, E. Pashkuleva-Dermendzhieva, P. Lazarov, E. Grigorov

Abstract: Pulmonary embolism (PE) represents a serious and potentially life-threatening complication in patients with oncologic diseases due to the presence of multiple mechanisms leading to hypercoagulability. The clinical presentation is often nonspecifi c and overlaps with symptoms of infection or tumor progression, which may delay diagnosis. We present the case of a 74-year-old woman with multiple comorbidities and recent chemotherapy, admitted with progressively worsening dyspnea, dry cough, and low-grade fever. The lack of response to empirical antibiotic therapy, together with characteristic laboratory and electrocardiographic fi ndings, prompted further diagnostic evaluation. CT pulmonary angiography revealed bilateral pulmonary embolism with infarct-related changes, while echocardiography indicated an intermediate-risk profi le. Anticoagulant therapy was initiated with a favorable clinical outcome. The presented clinical case highlights the importance of early and targeted differential diagnosis in patients with persistent dyspnea following chemotherapy, as well as the role of a multidisciplinary cardio-oncology approach in ensuring timely diagnosis, risk stratifi cation, and optimization of therapeutic management.

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DOI: 10.3897/bgcardio.32.e190567

Authors: I. Petrov, Z. Stankov, A. Ivanov, E. Dimitrov, G. Hadzhiev, E. Palazova

Abstract: Functional mitral regurgitation in patients with heart failure and reduced ejection fraction is associated with high morbidity and mortality, especially when other serious conditions are present. Here we present a 69-year-old patient with advanced heart failure with reduced ejection fraction (HFrEF), severe secondary mitral regurgitation, stage 5 chronic kidney disease on haemodialysis, complete atrioventricular (AV) block with a permanent pacemaker, and a history of haemorrhagic stroke. Due to the extremely high surgical risk, transcatheter edge-to-edge repair with MitraClip was performed, resulting in a reduction of mitral regurgitation from grade IV to grade I+ without signifi cant mitral stenosis. Five months later, follow-up showed the result was lasting and the device remained stable in place. This case shows that transcatheter edge-to-edge repair (TEER) can be an effective option for high-risk patients with multiple comorbidities.

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DOI: 10.3897/bgcardio.32.e187136

Authors: I. Todorov, A. Doichev, D. Mihaylov, D. Nikolov

Abstract: We present a clinical case of a 77-year-old male with an aortic aneurysm extending from aorta ascendens to the beginning of the descending aorta. Signifi cant patient comorbidities included prostate carcinoma, ischemic heart disease with single-vessel coronary artery disease (status post PCI with DES ×1 of the LCX in 2019), chronic heart failure NYHA class III, peripheral arterial disease stage IIA, anemic syndrome, left-sided nephrolithiasis, hemorrhoidal disease, colonic diverticulosis, and oesophageal haemangiomas. After multidisciplinary discussion, the patient underwent minimally invasive aortic arch debranching and wrapping of the ascending aorta without the need for extracorporeal circulation (ECC), followed by endovascular implantation of an aortic arch stent-graft and PTA of the right common and external iliac arteries with implantation of a 7/150 mm balloon. The postoperative period was uneventful. The patient was discharged in good general condition with recommendations for medical therapy and cardiology follow-up.

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DOI: 10.3897/bgcardio.32.e186598

Authors: V. Byalkova, B. Kunev, M. Ivanov, D. Kyuchukov

Abstract: Floating thrombus of the aortic arch in the absence of aneurysm or atherosclerotic disease is an exceptionally rare condition. We report the case of a 47-year-old woman, an active smoker with iron-defi ciency anemia, who presented with acute retrosternal chest pain, dyspnea, diaphoresis, and vomiting. Initial evaluation showed arterial hypertension, sinus rhythm with poor R-wave progression in the precordial leads on electrocardiography (ECG), and markedly elevated high-sensitivity troponin levels, consistent with acute coronary syndrome. Transthoracic echocardiography (ТТЕ) revealed a large, highly mobile mass in the aortic arch prolapsing into the supra-aortic branches, reduced left ventricular systolic function and apical dyskinesia. Computed tomography angiography (CTA) confi rmed a fl oating thrombus attached to the lesser curvature of the aortic arch, mild non-obstructive coronary artery disease, and an apical left ventricular aneurysm. The patient was initially managed conservatively with unfractionated heparin and aspirin due to high procedural risk. However, despite therapeutic anticoagulation, she developed a transient cerebrovascular event, prompting urgent surgical intervention. Intraoperatively, a loosely attached mixed thrombus was excised from the aortic arch without evidence of atherosclerosis or endothelial injury. The postoperative course was uneventful. This case emphasizes the high embolic potential of fl oating aortic arch thrombi and supports early surgical consideration when embolic complications occur despite optimal anticoagulation.

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DOI: 10.3897/bgcardio.32.e187637

Authors: P. Simeonov, I. Dimitrova, B. Barzashka, V. Grudeva

Abstract: Acute aortic syndromes represent a group of life-threatening conditions characterized by disruption of the integrity of the aortic wall and a high risk of rupture and fatal outcome. These include aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer, which share similar pathophysiological mechanisms. Traumatic aortic injury represents a distinct clinical entity resulting from high-energy blunt chest trauma and is associated with signifi cant early mortality. Blunt traumatic injury of the thoracic aorta most commonly occurs as a result of sudden deceleration forces during road traffi c accidents or falls from height. The most frequently affected segment is the aortic isthmus, due to the anatomical and biomechanical characteristics of the transition between the mobile aortic arch and the fi xed descending thoracic aorta. A substantial proportion of patients die at the scene of the incident, and among those who survive the fi rst hours, the risk of subsequent rupture remains high. Computed tomography angiography is the method of choice for diagnosis and therapeutic planning in traumatic aortic injury, allowing precise assessment of the location and severity of aortic involvement. The Society for Vascular Surgery (SVS) classifi cation provides a standardized approach for determining indications and timing of intervention. In recent years, endovascular treatment with implantation of a thoracic stent-graft (TEVAR) has been established as the preferred therapeutic method in patients with suitable anatomy. Data from clinical registries and meta-analyses demonstrate lower early mortality and a reduced incidence of severe complications compared with open surgical treatment, particularly in polytrauma patients. Objective: The aim of the study is to present the own authors’ experience with endovascular treatment of traumatic aortic injury in patients treated during the period 2014-2021 and to analyze the early clinical outcomes and safety of the method. Materials and Methods: The present article demonstrates 7 patients with traumatic aortic injury treated by TEVAR. The treated group included 6 men and 1 woman, aged between 30 and 71 years. The diagnosis was established by computed tomography angiography. Aortic injuries were classifi ed according to the Society for Vascular Surgery (SVS) classifi cation. Indications for intervention and technical success were analyzed. Results: TEVAR was successfully performed in all patients, with complete technical success and no intraoperative mortality. No cases of paraplegia, spinal cord ischemia, or severe vascular complications were observed. In the early postoperative period, no aortic ruptures were registered. The need for reintervention and balloon post-dilatation due to type I endoleak occurred in one patient. The procedure allowed stabilization of the patients and treatment of associated traumatic injuries.

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DOI: 10.3897/bgcardio.32.e189359

Authors: K. Mavrodieva, A. Keltchev

Abstract: Aneurysmal dilatation of the aortic root and ascending aorta is frequently associated with functional aortic regurgitation due to distortion of aortic root geometry, including dilatation of the annulus and the sinotubular junction, in the presence of morphologically preserved valve cusps. The classic surgical approach – composite aortic root replacement (Bentall-De Bono) – provides radical correction but is limited by the drawbacks of valve substitution, namely lifelong anticoagulation with mechanical prostheses or limited structural durability with the potential need for reintervention in bioprosthetic valves. Over recent decades, valve-sparing operations have become a preferred approach in appropriately selected patients. The David reimplantation technique provides annular stabilisation and control of dilatation of both the aortic root and the sinotubular junction while preserving the native aortic valve. Use of a Valsalva graft facilitates a more physiological root geometry, potentially optimising valvulo-aortic hemodynamics and cusp kinematics. The procedure also allows concomitant cusp repair when necessary to achieve optimal coaptation. The available literature consistently demonstrates low early operative mortality and excellent long-term durability of valve preservation in experienced centers, with high freedom from reoperation and a low incidence of clinically signifi cant aortic regurgitation at follow-up. European recommendations support valve-sparing strategies in younger patients with a dilated aortic root and preserved cusps when performed in specialized centers. Our experience at Acibadem City Clinic Hospital Vitosha since implementation of the technique in 2018 is consistent with published data, with good early hemodynamic results and favourable clinical evolution during follow-up. David valve-sparing aortic root replacement using a Valsalva graft according to the De Paulis method represents an anatomically grounded and highly effective strategy that combines radical correction of root pathology with preservation of the native valve and avoidance of prosthesis-related complications.

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DOI: 10.3897/bgcardio.32.e189379

Authors: G. Manchev, S. Kazakov, A. Keltchev

Abstract: Introduction: The term “monster aorta” is a non-formal colloquial expression of advanced aortic disease. Features of the monster aorta phenotype include large aneurysm (> 6 cm), multisegmented involvement, hostile atheroma, chronic dissection, redo surgery, and emergency conditions. Although the literature commonly refers to these cases as “complex aortic pathology”, we propose the descriptive term “Monster Aorta” to emphasize the extraordinary anatomical complexity and technical challenges associated with such procedures. These operations frequently require multi-segment aortic reconstruction and demand management by a dedicated high-volume surgical team experienced in advanced perfusion techniques and cerebral protection strategies. The phrase “monster aorta” appears only rarely in the literature and generally in an informal descriptive context rather than as a formally defi ned clinical entity, illustrating the use of the term as a descriptive characterization of extreme aortic pathology rather than an established diagnostic designation. Objectives: The aim of the study is to establish the defi nition of monster aorta for clinical purposes and to offer best-practice recommendations. Materials and Methods: This is a single-center retrospective observational study of patients who underwent thoracic aortic surgery with monster aorta phenotype. Eight consecutive cases were described individually with respect to cannulation strategies, cerebral protection, frozen elephant trunk (FET) deployment, spinal cord protection, as well as various safeguards and pitfalls. Primary outcome measures were survival and neurologic complications. Results: No hospital mortality occurred and all patient were neurologically intact on discharge. All patients are alive to date. Discussion and Conclusion: This article demonstrates the strategies applied in the surgical treatment of monster aorta pathology in the Department of Cardiac Surgery, Acibadem City Clinic Vitosha Hospital. Based on the favorable postoperative results these surgical strategies seem to be effective and reproducible. The concept of monster aorta is useful in patient’s referral to high-volume centers specialized in thoracic aortic surgery.

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DOI: 10.3897/bgcardio.32.e126222

Authors: D. Smilkova, A. Krushka

Abstract: Oxidative stress plays a critical role in the development and progression of cardiovascular diseases. This review presents the essence of oxidative stress and its association with cardiovascular issues. It discusses the mechanisms underlying stress formation, its impacts on cellular structures, and potential therapeutic strategies to mitigate its harmful effects. Current research and future perspectives in the fi eld of oxidative stress and cardiovascular diseases are also explored.

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DOI: 10.3897/bgcardio.32.e175390

Authors: D. Junior, G. B. Bramantara, I. G. N. A. S. Diksha, R. C. Suteja, I. N. Wiryawan

Abstract: Background: Anthracyclines have been associated with cancer-therapy related cardiac dysfunction (CTRCD). Sodium-glucose co-transporter 2 (SGLT2) inhibitors are potential cardioprotective agents that could reduce cardiotoxicity in cancer patients receiving anthracyclines. This review aims to report the cardioprotective effects of SGLT2 inhibitors on CTRCD in cancer patients receiving anthracycline chemotherapy. Methods: This study is a systematic review written according to PRISMA guidelines. We searched PubMed, Scopus, and DOAJ on July 24th, 2024, for studies that compared heart failure (HF) hospitalisations and overall mortality between cancer patients with a history of anthracycline therapy who received SGLT2 inhibitor treatment and those without. Results: Three studies included in our review found that subjects in the SGLT2 inhibitor treatment group had fewer hospitalisations due to HF and lower overall mortality than those in the non-SGLT2 inhibitor treatment group. The cardioprotective effects of SGLT2 inhibitors are achievable mainly through their ability to attenuate oxidative stress, mitochondrial dysfunction, apoptosis, and infl ammation induced by anthracycline toxicity. Conclusions: Cohort studies have shown that SGLT2 inhibitors exhibit cardioprotective effects in cancer patients receiving anthracycline chemotherapy through their extensive pharmacodynamics. However, available studies are limited to cancer patients with preexisting type 2 diabetes mellitus (T2DM). Hence, future trials tailored to the general population are highly needed to yield results with greater validity.

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DOI: 10.3897/bgcardio.32.e178064

Authors: L. F. J. Jusni, F. A. Theja, L. Alexander, D. A. Theja

Abstract: Objectives: Myocardial infarction (MI) remains a major cause of morbidity and mortality worldwide, primarily due to irreversible cardiomyocyte injury and minimal regenerative potential. While mesenchymal and bone-marrow-derived stem cells have been widely studied, evidence for cardiac stem cells (CSCs) remains limited. This systematic review and meta-analysis evaluate the effi cacy of cardiac stem cell therapy after MI. Methods: We conducted this meta-analysis in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Eligible studies were identifi ed from electronic searches of PubMed, EBSCO, and ProQuest for randomized controlled trials (RCTs) evaluating the effi cacy of cardiac stem cell therapy after MI. The random effect analysis was performed using R v4.4.1. Results: Four randomized controlled trials comprising 329 participants were included. At six months, cardiac stem cell therapy was associated with a signifi cant reduction in scar mass (MD: -4.25 g, 95% CI: -7.16 to -1.34, p = 0.004) and infarct size (MD: -2.32%, 95% CI: -3.91 to -0.73, p = 0.004) compared with placebo. No signifi cant differences were observed in left ventricular ejection fraction (LVEF), left ventricular end-systolic volume index (LVESVi), left ventricular end-diastolic volume index (LVEDVi) at either six or twelve months, or in the 6-minute walk test at 12 months. Conclusion: Cardiac stem cell therapy after MI is associated with modest reductions in scar mass and infarct size at six months, without signifi cant improvement in global ventricular function or functional capacity up to twelve months. These fi ndings suggest that while CSCs may confer early structural benefi ts, their clinical impact remains uncertain and requires confi rmation in larger trials with longer follow-up.

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DOI: 10.3897/bgcardio.32.e182560

Authors: E. Dimitrova, D. Kyuchukov

Abstract: Drug therapy is a mandatory component of the treatment of patients with acute and chronic aortic syndromes, regardless of the chosen therapeutic approach (surgical, endovascular, or conservative). In the acute phase, it aims to control pain, heart rate, and arterial blood pressure, while in the long-term it seeks to slow disease progression and potentially prevent aortic rupture. This review focuses on the therapeutic goals in aortic diseases, the medications used, and the evidence currently available. Attention is also given to the importance of lifestyle modifi cations, as well as recommendations for follow-up using various imaging modalities.

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DOI: 10.3897/bgcardio.32.e188343

Authors: I. Zheleva-Kyuchukova

Abstract: Thoracic aortic disease has traditionally been assessed using morphological parameters, primarily maximal aortic diameter. However, accumulating experimental and clinical evidence indicates that this approach is insuffi cient for individualised risk prediction. Endothelial dysfunction, chronic infl ammation, and immune activation play central roles in the pathogenesis of aortic disease, driving vascular wall remodelling and functional instability that are not captured by static imaging. Increased aortic stiffness has emerged as a clinically measurable integrator of these processes, refl ecting vascular ageing, infl ammatory burden, and impaired mechanotransduction. By affecting central hemodynamics, aortic stiffness increases left ventricular afterload, compromises diastolic coronary perfusion, and contributes to myocardial ischemia and the development of heart failure with preserved ejection fraction. Incorporating functional and biological markers alongside morphological assessment may improve risk stratifi cation and help explain the occurrence of adverse aortic and cardiovascular events in patients without advanced aortic dilatation.

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DOI: 10.3897/bgcardio.32.e184554

Authors: Dimitar Kyuchukov

Abstract: Acute aortic dissection is a critical surgical condition that in most cases requires immediate intervention. Despite signifi cant advances in surgical and interventional technologies, repair remains increasingly complex. It is associated with considerable mortality (5-65%, average postoperative mortality 20%) and morbidity (8-80%, 20% on average), which signifi cantly depend on the individual clinical and morphological characteristics of each patient. The need for an individualised multidisciplinary approach in establishing the diagnosis, clarifying the anatomical parameters of the involvement – initial intimal tear, characteristics and extension of the false lumen, involved arterial branches, and clinical indicators for the presence of end-organ malperfusion – are key points in choosing a therapeutic strategy (surgical, medical, endovascular, or hybrid). To facilitate these decisions and systematise the diagnostic and therapeutic approach over the past more than 70 years, as data have accumulated, various classifi cation systems have been proposed based on specifi c characteristics of the disease process and associated risks. Alongside these processes, the need for reliable tools for preprocedural risk assessment and prediction of the fi nal therapeutic outcome has increased signifi cantly. This review aims to present the most widely used classifi cation systems and outcome prediction models for acute aortic dissections, and to examine their role in decision-making.

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DOI: 10.3897/bgcardio.32.e184648

Authors: Dimitar Kyuchukov

Abstract: Diseases of the aorta special issue

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DOI: 10.3897/bgcardio.31.e176465

Authors: K. Razlozhka, K. Gospodinov, V. Gitsov, S. Tisheva-Gospodinova

Abstract: Patients with cancer have multiple etiological factors for the development of myocarditis. Classical or conventional chemotherapy, radiotherapy and, more recently, immunotherapy have been described as possible etiological causes of myocarditis. In addition, patients with cancer are immunosuppressed and more susceptible to bacterial and viral infections that can cause myocarditis. This review discusses the many possible causes of myocarditis in patients with cancer. Special emphasis is placed on myocarditis induced by immune checkpoint inhibitors (ICI). ICI myocarditis usually affects male patients over 50 years of age who are being treated for lung cancer, melanoma or renal cell carcinoma and have multiple comorbidities. Clinical manifestations occur early, with elevated troponin and electrocardiogram changes. The mortality rate is high. Treatment consists of discontinuation of the causative ICI and corticosteroid therapy. Myocarditis caused by cyclophosphamide, anthracyclines, 5-fl uorouracil, cisplatin, carboplatin, proteasome inhibitors, immunomodulators, tyrosine kinase inhibitors, and radiotherapy was also reviewed.

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DOI: 10.3897/bgcardio.31.e177070

Authors: G. Goranov, V. Doktorova, V. Goranova-Marinova

Abstract: Factor VII defi ciency is a rare inherited coagulation disorder characterized by decreased activity of factor VII, leading to variable bleeding tendencies that may not correlate with measured FVII levels. While many patients remain asymptomatic, others can experience severe spontaneous hemorrhages. The condition poses signifi cant challenges during surgical or invasive procedures due to the potential for uncontrollable bleeding. Data regarding percutaneous coronary intervention (PCI) in such patients are extremely limited, mostly confi ned to isolated case reports. PCI requires anticoagulation during the procedure and dual antiplatelet therapy afterward, both of which elevate bleeding risk. Conversely, administering FVII concentrate may increase the chance of thromboembolic events. Therefore, individualized planning and a multidisciplinary approach are crucial to balance these opposing risks. We present the case of a 75-year-old Bulgarian woman with congenital FVII defi ciency and severe three-vessel coronary artery disease who underwent successful transradial PCI without FVII replacement. Drug-eluting stents were implanted in the left anterior descending and circumfl ex arteries, enabling short-term dual antiplatelet therapy. No bleeding complications occurred peri-procedurally, and only one minor episode of epistaxis was observed during follow-up. This case illustrates that, with meticulous preparation and procedural care, PCI can be a safe and effective revascularization strategy in patients with congenital FVII defi ciency.

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DOI: 10.3897/bgcardio.31.e177179

Authors: G. Goranov, K. Stanev, V. Goranova-Marinova

Abstract: Transcatheter aortic valve replacement (TAVR) is an effective therapeutic option for patients with severe symptomatic aortic stenosis who are at high surgical risk. Although generally safe, one of its rare but serious complications is clinical valve thrombosis, occurring in approximately 0.5% of cases. This condition can lead to prosthetic valve dysfunction, worsening heart failure, or thromboembolic events. Diagnosis usually begins with transthoracic echocardiography (TTE), while transoesophageal echocardiography (TOE) and multi-slice computed tomography (MSCT) are often required for more precise assessment. Since standardized treatment protocols are not yet established, management must be individualized according to clinical presentation and the degree of valve obstruction. Therapeutic approaches include oral anticoagulation, intravenous heparin, or, in severe cases with hemodynamic compromise, thrombolytic therapy. If conservative management fails, redo-TAVR or surgical valve explantation may be necessary. We present the case of a 78-year-old Bulgarian woman who developed progressive heart failure 12 days after TAVR. Imaging confi rmed bioprosthetic valve thrombosis. Intravenous heparin was ineffective, but thrombolytic therapy followed by oral anticoagulation led to complete thrombus resolution and restoration of valve function without bleeding complications. Clinical valve thrombosis after TAVR, though uncommon, is potentially fatal. MSCT remains the most accurate diagnostic tool, while TOE is valuable for its accessibility. Thrombolysis combined with vitamin K antagonist therapy can be an effective treatment option.

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DOI: 10.3897/bgcardio.31.e174687

Authors: A. Ivanov, E. Levunlieva

Abstract: Left ventricular systolic dysfunction results from complex structural, cellular, and molecular disorders affecting the contractile apparatus of the myocardium and its energy homeostasis. This review discusses the key mechanisms of this process, with emphasis on myocardial contraction and its regulation by calcium dynamics and integrity of the sarcomeres. The main factors leading to the development of systolic dysfunction are presented: volume and tension overload, ischemia, infl ammation, amyloid and other deposits, neurohormonal activation and endocrine disorders, oxidative stress. In addition, cellular and molecular mechanisms are presented, such as defects in SERCA2a, and Na+/Ca2+ exchanger, pathological Ca2+ effl ux through RyR2, alterations in titin phosphorylation, myofi lament damage, proteasome dysfunction, impaired autophagy, epigenetic regulation, endoplasmic reticulum stress, and abnormalities in intercellular connectivity. The complex interaction between these processes leads to progressive myocardial remodeling, fi brosis, energy defi cit, and impaired myocardial contractility. Understanding these mechanisms is important for better understanding the pathogenesis of systolic dysfunction as well as for the development of new therapeutic strategies for its treatment.

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DOI: 10.3897/bgcardio.31.e183802

Authors: Reni Tzveova

Abstract: Editorial

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DOI: 10.3897/bgcardio.31.e175420

Authors: I. Bayraktarova, I. Petrova, T. Doychinova, B. Georgiev

Abstract: Hypertrophic cardiomyopathy is one of the most common hereditary cardiomyopathies in daily practice. The different phenotypic manifestations and hemodynamic features often make diagnosis and therapy a clinical challenge. Diagnosis and imaging follow-up of cardiomyopathies are becoming increasingly multimodal. Despite the new imaging capabilities, echocardiography continues to play a key role in the primary differential diagnostic process, in the follow-up of patients, regardless of the therapeutic approach taken, and in the screening of relatives. Therefore, good knowledge of echocardiographic methods for assessment in these patients, of practical features and possible errors during the examination, is an essential prerequisite for high quality care. Precise systematic measurements and descriptions of the fi nding in each patient are the basis of good follow-up, adequate management planning and reassessment of therapy, and of seamless team care for the patient by various specialists. Confl icting or inconsistent imaging fi ndings, discrepancies in imaging fi ndings and clinical presentation, and the need for specialized therapy are valid reasons for referring the patient for a staged evaluation to an expert center for HCM.

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DOI: 10.3897/bgcardio.31.e177693

Authors: A. Ivanov, E. Levunlieva

Abstract: Diastolic dysfunction is a condition in which ventricular fi lling is impaired, regardless of the presence of symptoms and irrespective of whether the ejection fraction is normal or reduced. Left ventricular diastolic dysfunction results from complex and interconnected biochemical and cellular mechanisms. Among them, impaired myocardial relaxation due to calcium dysregulation, altered titin phosphorylation affecting the passive elasticity of the myocardium, and extracellular matrix remodeling with the development of fi brosis mediated by signalling pathways such as TGF-β/SMAD and MAPK play a leading role. Additional contributing factors include oxidative stress and mitochondrial dysfunction, chronic infl ammation and activation of cytokine cascades, metabolic disturbances such as diabetes and obesity, as well as protein dysfunction related to endoplasmic reticulum stress and impaired proteolysis. All these processes in complex lead to impaired diastolic fi lling of the left ventricle, i.e., diastolic dysfunction. Due to its broad availability and proven clinical value, echocardiography is the primary method for diagnosing diastolic dysfunction. Invasive and other imaging modalities offer complementary information in complex or borderline cases, or when echocardiographic evaluation is diffi cult or impossible.

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DOI: 10.3897/bgcardio.31.e178367

Authors: D. Farandzha

Abstract: Acenocoumarol, a vitamin K antagonist (VKA), has played a pivotal role in anticoagulant therapy for over 60 years. Derived from the coumarin family, acenocoumarol inhibits vitamin K epoxide reductase, disrupting the synthesis of vitamin K-dependent clotting factors (II, VII, IX, X) and effectively preventing thromboembolic events. Compared to warfarin, acenocoumarol offers a rapid onset and shorter half-life, providing clinicians greater therapeutic fl exibility. Despite advances and widespread adoption of direct oral anticoagulants (DOACs), acenocoumarol continues to hold clinical signifi cance, particularly in Europe, Latin America, and Asia, owing to extensive clinical experience, reversibility, and cost-effectiveness. However, its use necessitates regular monitoring of international normalized ratio (INR), with individualized dosage adjustments required due to genetic variability (CYP2C9, VKORC1 polymorphisms), drug-drug interactions, dietary infl uences, and special considerations in the elderly and patients with chronic kidney disease (CKD). Recent clinical trials have expanded our understanding of its effi cacy, safety, and optimal use. Precision dosing strategies, including genotype guidance and advanced INR monitoring based on body-surface area-adjusted estimated glomerular fi ltration rate (BSA-adjusted eGFR) dosing, promise enhanced safety and personalized treatment. Although DOACs are now widely adopted due to their predictable pharmacokinetics and lack of routine monitoring requirements, acenocoumarol remains indispensable in well-defi ned clinical scenarios such as in patients with mechanical heart valves, rheumatic mitral stenosis–associated atrial fi brillation, antiphospholipid syndrome, and other conditions in which individualized dose adjustment offers a therapeutic advantage.

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DOI: 10.3897/bgcardio.31.e178401

Authors: I. Gruev, K. Bletzova, I. Deenichina, G. Goranov, K. Gospodinov, G. Gyuzelev, M. Mihalev, S. Petranov, S. Yovev, V. Velchev

Abstract: Introduction: The EVOLUTION-HF is a prospective, multinational, real-world study designed to describe the demographic and clinical characteristics of patients initiating dapaglifl ozin for heart failure with reduced ejection fraction (HFrEF) in nine countries from the Central and Eastern Europe and Baltic Area. This manuscript presents the results of the Bulgarian cohort of the study. Methods: Enrolment period in Bulgaria was between February 2022 and October 2022, in 10 study sites. Demographic and clinical characteristics were collected at baseline (12 months before dapaglifl ozin initiation), and treatment for heart failure (HF), including guideline-directed treatment (GDMT) was collected prospectively until 12 months after dapaglifl ozin initiation. The HF treatment was administered as per routine clinical practice. Results: One hundred and fi fty patients were included in the full analysis set (mean age: 67 years, males 84%). At the time of initiation of dapaglifl ozin 10 mg/day, 69.3% of patients had treatment with renin-angiotensin-aldosterone system (RAAS) inhibitors and 35.3% all four GDMTs in HF. Almost 98% of patients remained on dapaglifl ozin at 6 months and 12 months. Seven (10.12%) dapaglifl ozin discontinuations were recorded throughout the study. The discontinuation rate of dapaglifl ozin was 4.65 per 100 patient-years and the median time-to-discontinuation was not reached. One patient stopped dapaglifl ozin between baseline and 6 month and between 6 month and 12 month-data collection, respectively. GDMT patterns were relatively stable over one year. Conclusion: A high rate of persistence of dapaglifl ozin was observed at 12-month follow-up after initiation for HFrEF. A substantial gap was noted related to GDMT strategy optimization, with only one third of patients receiving all four GDMT pillars. These results obtained in real-world practice in Bulgaria point to the unmet need for targeted efforts to improve GDMT adoption in patients with HFrEF.

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DOI: 10.3897/bgcardio.31.e176600

Authors: I. Bayraktarova, V. Baycheva, N. Bonev, L. Haralanov

Abstract: Psychogenic pseudosyncope is a state of apparent loss of consciousness, which is indistinguishable from true loss of consciousness by eyewitnesses. However, there are no hemodynamic and electroencephalographic stigmata of true syncope with real loss of consciousness. Sometimes a detailed history can raise doubts about the condition – a relatively long period of unconsciousness, unusual triggers, atypical prodromes and frequent attacks are suspicious signs, but they are far from specifi c in the population of patients presenting for differential diagnosis of syncopal episodes to the cardiologist. The gold standard for making the diagnosis is the provocation with a tilt-table test, in which psychogenic pseudosyncope is registered and simultaneously the absence of hemodynamic (and in the optimal case, electroencephalographic) signs of loss of consciousness is objectifi ed. It should be noted that the presence of psychogenic pseudosyncope does not automatically exclude the presence of true refl ex syncope in the particular patient. Treatment based primarily on a clear explanation of the condition and supportive communication with the patient can lead to a sharp reduction in the frequency of attacks. Pharmacological treatment of associated psychiatric disorders, as well as psychological support, is extremely effective. Cognitive-behavioural therapy is the most preferred approach in this patient population. In this review, we will present the diagnostic process in one patient and discuss the development of the understanding of this condition, the main clinical features and diagnostic approaches, the classifi cation and underlying pathology, as well as therapeutic methods.

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DOI: 10.3897/bgcardio.31.e177007

Authors: M. Samardjieva, I. Simova, V. Petrusheva, M. Sirakov, V. Pavlova-Popova, K. Peeva, N. Chilingirova

Abstract: Marantic endocarditis, also known as nonbacterial thrombotic endocarditis (NBTE), is a rare condition typically encountered in patients with malignancy and hypercoagulable states. It is characterized by the formation of sterile fi brin–platelet vegetations on cardiac valves, which frequently lead to systemic embolic events. We report the case of an 84-year-old woman admitted with progressive exertional dyspnea and intermittent dry cough. Echocardiography revealed mobile vegetations on the mitral and aortic valves, associated with signifi cant valvular regurgitation and pulmonary hypertension. The patient remained afebrile, with persistently negative blood cultures and low infl ammatory markers. Whole-body computed tomography subsequently demonstrated pancreatic tail carcinoma with hepatic and pulmonary metastases. A diagnosis of marantic endocarditis secondary to malignancy was established. Anticoagulation and supportive therapy were initiated. Several days after discharge, the patient developed an ischemic stroke. She died a few weeks later.

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DOI: 10.3897/bgcardio.31.e165716

Authors: G. Goranov, E. Georgieva

Abstract: Transcatheter aortic valve replacement (TAVR) is an established therapy for severe aortic stenosis, particularly in high-risk surgical candidates. While procedural success rates are high, valve migration remains a rare but serious complication, especially when occurring long after implantation. We report a case of late antegrade migration of a TAVR prosthesis presenting as new-onset heart failure nearly one year after successful implantation. A 77-year-old male with a history of hypertension and chronic lung disease underwent TAVR with a 27 mm NAVITOR (Abbott, USA) valve. Post-procedural recovery and early follow-up were uneventful. However, the patient later developed progressive heart failure symptoms. Transthoracic echocardiography revealed elevated transvalvular gradients, prompting further evaluation with computed tomography and fl uoroscopy, which confi rmed migration of the valve into the ascending aorta. Given the anatomic challenges and heavy native valve calcifi cation, the Heart Team opted for surgical explantation and bioprosthetic aortic valve replacement. The patient recovered well postoperatively and remained asymptomatic at three-month follow-up with normal valve function. This case underscores the importance of long-term surveillance after TAVR and highlights the potential for late mechanical complications. Early recognition through advanced imaging and individualized Heart Team decision-making are essential for optimal outcomes in such rare scenarios.

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DOI: 10.3897/bgcardio.31.e167557

Authors: R. Grigorov, S. Yambolov, S. Georgiev, I. Borisov, D. Tsvetkov

Abstract: Introduction: Angina with non-obstructive coronary arteries (ANOCA) is frequently encountered in clinical practice but remains poorly understood and inconsistently managed. Despite the absence of signifi cant coronary stenoses, patients often report persistent symptoms and receive extensive pharmacotherapy. Real-world data on medication use and symptom burden in ANOCA populations remain limited. Material and methods: We conducted a single-center observational study of 102 patients referred to coronary angiography due to angina, who were subsequently found to have non-obstructive coronary artery disease. Baseline medication use and symptom severity were assessed using the Canadian Cardiovascular Society (CCS) classifi cation and Seattle Angina Questionnaire (SAQ). Associations between treatment and symptoms were analyzed using non-parametric tests. Results: The mean age was 61 years; 59% were women. Over 90% of patients were on cardiovascular medications, with 22.6% receiving fi ve or more agents. The most used therapies were β-blockers (59.8%), ACE inhibitors/ARBs (70.6%), and statins (58.8%). Despite this, 54.4% were in CCS class II or higher, and SAQ scores refl ected persistent symptoms. No signifi cant associations were found between drug class or medication count and symptom severity. Trimetazidine use was associated with slightly higher CCS class (p = 0.032). Conclusion: In this ANOCA cohort, pharmacotherapy was intensive but not clearly associated with symptom control. These fi ndings highlight the need for individualized, endotype-guided treatment strategies.

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DOI: 10.3897/bgcardio.31.e164364

Authors: H. Nough, F. Moradi, H. Varasteravan, M. Motamedzade, N. Sartipzade, S. Vaziribozorg, A. Nouah

Abstract: Introduction: Coronary artery ectasia (CAE) is an uncommon angiographic fi nding often associated with atherosclerosis. However, the risk profi le of patients with pure CAE (defi ned as ectasia in the absence of signifi cant obstructive coronary artery disease) remains incompletely understood. This study aimed to evaluate the association between traditional atherosclerotic risk factors and pure CAE in an Iranian population. Material and methods: In this retrospective cross-sectional study, 354 patients with pure CAE were identifi ed among 23,000 consecutive coronary angiography reports from two tertiary hospitals (2015–2022). Pure CAE was defi ned as segmental or diffuse coronary artery dilatation ≥1.5-fold the adjacent normal segment in the absence of ≥50% stenosis in any epicardial vessel. Patients with diffuse but non-obstructive atherosclerosis, history of vasculitis, autoimmune disease, congenital syndromes, or incomplete records were excluded. Demographic data and cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking, family history) were collected. Statistical analysis included both univariate comparisons and multivariable logistic regression to identify independent predictors of CAE. Results: The mean age was 57.5 ± 12.6 years; 64.1% were male. Hypertension (64.7%) and hyperlipidemia (57.9%) were the most prevalent risk factors. Multivariable regression identifi ed male sex (OR 1.8, 95% CI 1.1–2.9, p = 0.01), hypertension (OR 2.1, 95% CI 1.3–3.2, p = 0.002), and hyperlipidemia (OR 1.7, 95% CI 1.1–2.5, p = 0.01) as independent predictors of CAE. Diabetes mellitus and smoking were not signifi cantly associated. Family history showed borderline signifi cance (OR 1.4, p = 0.06). The most common angiographic pattern was three-vessel ectasia (37.9%). Conclusion: Pure CAE is more frequent in men and strongly associated with hypertension and hyperlipidemia, supporting a shared risk profi le with atherosclerosis. The absence of association with diabetes and smoking suggests a distinct underlying pathophysiology.

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DOI: 10.3897/bgcardio.31.e169255

Authors: G. Vassilev

Abstract: Minimally invasive surgical techniques in cardiac surgery are increasingly applied, particularly in elderly and high-risk patients. One of the most universal and promising approaches is the transaxillary access, which allows surgical interventions on all cardiac valves and their combinations. This access does not require bone transection and leaves practically an invisible scar, making it exceptionally sparing. In combination with sutureless valve prostheses (e.g., Perceval S), this approach shortens aortic cross-clamp and cardiopulmonary bypass times, improves hemodynamic outcomes, and facilitates work in a limited surgical fi eld. In the Department of Cardiac Surgery at Tokuda Hospital, 19 operations have been performed using this method over the past year and a half: 8 aortic valves, 10 mitral valves, and 1 tricuspid valve. The present article reviews the advantages and specifi c features of the transaxillary approach in valve replacement.

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DOI: 10.3897/bgcardio.31.e168585

Authors: M. C. R. Bernardo, I. M. Moreira, C. Carvalho, A. Baptista, P. Mateus, S. S. Carvalho, J. I. Moreira, on Behalf of the ProACS Investigators

Abstract: Introduction and objectives: Multivessel disease (MVD) occurs in approximately half of non–ST elevation myocardial infarction (NSTEMI) patients and is associated with an increased risk of cardiovascular events. However, current recommendation for complete revascularization in NSTEMI is based in observational and non-randomized studies suggesting a possible benefi t regarding mortality and major cardiovascular events. This study aimed to retrospectively evaluate the prognostic impact of complete percutaneous revascularization in a population of patients with NSTEMI and MVD. Material and methods: This was a national multicentre retrospective study of patients hospitalized for NSTEMI with MVD, included on the Portuguese Registry for Acute Coronary Syndromes (ProACS). The impact of complete percutaneous revascularization on in-hospital and one-year mortality rates, as well as on the probability of cardiovascular re-hospitalization was evaluated. Results: A total of 3084 patients were included in this analysis. We found no signifi cant differences between groups regarding in-hospital complications and mortality, as well as median hospitalization length. Nevertheless, complete revascularization showed a signifi cant impact on the primary endpoint of all-cause mortality or cardiovascular re-hospitalization (11.9% vs. 20.4%, p < 0.001), mainly driven by a major reduction in unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 16.8%, p < 0.001). Conversely, one-year mortality rate was once again similar between groups (4.2 vs. 5.0%, p = 0.536). Conclusions: In our population, complete revascularization during hospitalization was associated with lower risk of the primary endpoint of all-cause mortality or cardiovascular re-hospitalization, mainly driven by a major reduction in cardiovascular re-hospitalizations, with similar rate of intra-hospital complications.

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DOI: 10.3897/bgcardio.31.e170466

Authors: N. M. Noori, G. M. Aliabad, T. Boryri, A. Teimouri

Abstract: Introduction: Iron defi ciency anemia (IDA) and minor thalassemia (MT) are common hematologic disorders in children that may affect cardiovascular function. Objectives: The goal of the study was to determine whether ECG abnormalities in these populations are clinically signifi cant and potentially reversible. Material and methods: This prospective, randomized clinical trial aimed to evaluate electrocardiographic (ECG) changes in 135 children aged 5-18 years, equally divided into IDA, minor thalassemia, and healthy control groups. ECG parameters such as QT interval, corrected QT interval (QTc), P-wave dispersion (PWd), Tpe interval, and Tpe/QTc ratio were assessed before and after Iron supplementation in the IDA group. Results: Pre-treatment, the IDA group showed signifi cantly lower hemoglobin, ferritin, and serum Iron levels, along with elevated TIBC and marked ECG abnormalities including prolonged QTc, P-wave dispersion, Tpe interval, and increased Tpe/QTc ratio, indicating higher arrhythmogenic risk. Following Iron supplementation, the IDA group demonstrated signifi cant improvements in hematological parameters and normalization of ECG indices. In contrast, the MT and control groups exhibited stable hematologic and ECG profi les throughout the study. Statistical analysis confi rmed signifi cant pre- to post-treatment improvements in IDA patients, while no signifi cant ECG changes were observed in MT or control groups. These fi ndings suggest that ECG abnormalities in IDA are reversible with appropriate treatment, highlighting the importance of early diagnosis and intervention to prevent cardiac complications in pediatric populations. Conclusion: These fi ndings highlight the importance of early detection and treatment of IDA to mitigate cardiac complications in pediatric populations.

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DOI: 10.3897/bgcardio.31.e163761

Authors: H. Nough, A. Amani, A. Andishmand, M. Emami, S. Vaziribozorg, A. Nough

Abstract: Introduction: Pure coronary artery ectasia (CAE) was defi ned as segmental or diffuse coronary artery dilatation ≥ 1.5-fold the adjacent normal segment in the absence of ≥ 50% stenosis in any epicardial vessel. Previous studies on the relationship between ABO blood groups and ischemic heart disease have reported inconsistent fi ndings. This study aimed to investigate the distribution of blood groups in patients with pure CAE. Methods: This descriptive cross-sectional study included 250 patients diagnosed with pure CAE based on angiography fi ndings between 2015 and 2022 at two teaching hospitals. Data on age, gender, ABO blood group, Rh factor, white blood cell (WBC) count, lymphocyte and neutrophil percentages, and number of involved coronary vessels were collected. A control group was selected from patients undergoing coronary angiography in 2019-2020 without CAE and matched with the CAE group. Statistical analyses included Chi-square, Fisher’s Exact test, T-test, ANOVA, and logistic regression. Results: The mean age of patients was 56.2 ± 12.5 years; 160 (64%) were male and 90 (36%) were female. Rh positivity was observed in 222 (88.8%) patients, while 28 (11.2%) were Rh-negative. Blood group distribution among CAE patients was: O, 41.6%; B, 30.4%; A, 21.6%; and AB, 6.4%. Compared with the control group, a signifi cantly higher frequency of blood group O was observed among CAE patients (P < 0.001). In multivariable logistic regression adjusted for age, gender, and number of involved vessels, blood group O remained independently associated with CAE (OR = 1.78, 95% CI: 1.12–2.82, P = 0.015). Conclusion: Blood group O was signifi cantly more frequent among CAE patients compared with controls, even after adjusting for confounders.

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DOI: 10.3897/bgcardio.31.e169297

Authors: G. Chausheva, S. Shefket, K. Tsochev, T. Chalukova, Y. Bocheva, Y. Yotov, V. Iotova

Abstract: Background: Cardiovascular disease (CVD) is a major complication in patients with long-standing type 1 diabetes (T1D). Osteoprotegerin (OPG) has been proposed as a biomarker for cardiovascular risk (CVR), though its utility in this context requires further evaluation. This study aimed to assess the prognostic signifi cance of OPG in CVR estimation among T1D patients using specifi c CVR assessment tools. Patients and Methods: This prospective case–control study includes 183 participants: 124 with T1D (53.2% men, aged 42.7 ± 10.4 years, diabetes duration 25.3 ± 8.2 years) and 59 healthy controls (54.1% men, aged 45.1 ± 9.1 years). Serum OPG levels were determined via ELISA; CRP – immune-turbidimetric method (Advia chemistry 1800); HbA1C (%) – immuno-inhibition assay (ADVIA chemistry 1800); AlbU (mg/l) – immuno-turbidimetric analysis (Olympus AU600). CVR evaluation tools: STENO Type 1 Risk Engine (ST1RE) and ESC – 2019 guidelines. A RiskFactor3 model combined CRP ≥ 3 mg/l, HbA1C ≥ 7%, and AlbU ≥ 30 mg/l. Results: No signifi cant intergroup differences in OPG levels were observed. However, OPG was observably higher in women across both groups (T1D: 5.34 ± 1.2 pmol/l vs. 5.73 ± 1.83 pmol/l; controls: 5.06 ± 1.65 pmol/l vs. 6.16 ± 2.38 pmol/l, p < 0.05). In T1D patients, age (R² = 3%), disease duration (R² = 4.8%), and AlbU (R² = 3.9%) were signifi cant positive determinants of OPG (p < 0.05). According to ESC-2019, 30.6% of T1D patients had high CVR and 69.4% had very high CVR. ST1RE classifi ed 38.7% as low, 28.2% as moderate, and 33.1% as high CVR. ST1RE’s AUC-ROC for males was 0.716 (p = 0.005) with a cut-off of 5.075 pmol/l, and for females, 0.683 (p = 0.039) with a cut-off of 5.355 pmol/l. For ESC-2019, the AUC-ROC for females was 0.644 (p = 0.102) with a cut-off of 5.025 pmol/l. Conclusion: OPG is a promising biomarker for assessing CVR in patients with long-standing T1D. Higher OPG levels in women and its associations with age, disease duration, and AlbU emphasize its potential prognostic role. Using ST1RE and ESC-2019, OPG effectively stratifi ed patients by CVR. Incorporating OPG into clinical practice could improve early detection and personalized management of CVR in T1D patients.

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DOI: 10.3897/bgcardio.31.e173479

Authors: A. Borizanova-Petkova, E. Kinova, R. Савова, D. Markov, B. Krastev, V. Koleva, A. Goudev

Abstract: Acute decompensated heart failure (ADHF) remains a leading cause of hospital admission and is associated with poor clinical outcomes, despite the implementation of guideline-directed medical therapy. This retrospective cohort study aimed to identify laboratory biomarkers predictive of rehospitalization in patients admitted with ADHF to a tertiary cardiac intensive care unit. A total of 100 patients were included and followed for 24 months after discharge in a euvolemic state on optimized heart failure therapy. Laboratory parameters assessed prior to discharge included NT-proBNP, high-sensitivity troponin I (hs-Tn I), hemoglobin, serum sodium, FIB-4 index, and C-reactive protein/albumin ratio. Cox proportional hazards modeling identifi ed several independent predictors of rehospitalization, with NT-proBNP demonstrating the strongest association (HR = 2.000; p = 0.045). Additional signifi cant predictors included elevated hs-TnI, reduced hemoglobin, hyponatremia, and increased FIB-4 index (all p < 0.05). Kaplan-Meier survival analysis revealed the poorest event-free survival among patients with HFrEF. These fi ndings highlight the clinical value of a multiparametric risk assessment approach at discharge, to guide individualized monitoring and therapeutic strategies in patients with ADHF.

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DOI: 10.3897/bgcardio.31.e167112

Authors: I. Hadzhiev, L. Demirevska, I. Daskalov

Abstract: Fluoropyrimidines, including 5-fluorouracil (5-FU) and its oral prodrug capecitabine, are widely used in the treatment of solid tumors. While generally well tolerated, these agents can cause cardiotoxicity, with reported incidence rates ranging from 0 to 35%. Cardiac manifestations include angina, acute coronary syndromes, hypotension, arrhythmias, myocarditis, and heart failure. The primary mechanism of toxicity is thought to involve coronary vasoconstriction and microvascular dysfunction, though direct myocardial and endothelial damage may also contribute. Risk factors remain poorly defined, and cardiotoxicity can occur even in patients without pre-existing heart disease. Diagnostic tools, including biomarkers such as NT-proBNP and troponin, as well as echocardiography and cardiac MRI, play a critical role in early detection. Management typically involves discontinuation of 5-FU and symptomatic treatment with vasodilators and beta-blockers. Prophylactic strategies remain controversial, and guideline-directed therapy is largely based on case reports and observational data. Rechallenge with 5-FU carries a high risk of recurrence and should be approached with caution. Multidisciplinary collaboration, involving cardio-oncology teams, is essential for optimizing patient outcomes and guiding individualized prevention, monitoring, and treatment strategies in patients receiving fluoropyrimidine therapy.

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DOI: 10.3897/bgcardio.31.e167638

Authors: D. Topalov

Abstract: The subclinical atrial fi brillation (SCAF) in patients with cardiac implanted electronic devices (CIED) is a critical area of research in cardiology. It represents episodes of atrial fi brillation (AF) that occur in patients without any noticeable symptoms, registered by electronic devices for prolonged rhythm monitoring. Because of that, early diagnosis has proven to be diffi cult in the absence of advanced monitoring tools, such as smart electronic devices or implantable cardiac hardware. CIED, such as permanent pacemakers (PPM), implantable cardioverter defi brillators (ICD), resynchronization devices (CRT) and Loop Recorders (IRL) are fundamental in the detection of such episodes and provide continuous monitoring of the cardiac electrical activity. The early detections of SCAF provide the ability to initiate early prophylactic or therapeutic measurements that will help reduce not only the burden of disease, but also to reduce morbidity and mortality. The widespread use of CIED`s and wearable devices has led to the detection of subclinical AF in a signifi cant portion of the population. Thus, this detection may often help reduce the incidents of thromboembolism by initiating anticoagulation therapy. However, it is still unknown at what point and in which population long-term anticoagulation is benefi cial, having also in consideration the hemorrhagic risk. This review aims to explore the existing data and to identify the current gaps in knowledge.

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DOI: 10.3897/bgcardio.31.e164002

Authors: V. K. Singh, Shalabh Agarwal, Prithpal Singh Matreja

Abstract: Background: HDL is decisive for reverse cholesterol transport, enabling the removal of cholesterol from macrophages in atherosclerotic plaques. Although HDL-C has long been allied to CVS protection, recent evidence suggests that CEC may more accurately reflect HDL’s functional efficacy. However, studies exploring the relationship between CEC and CAD risk have produced inconsistent results. Objectives: The association between CEC and CAD risk was assessed, along with its potential to predict MACE, including cardiac mortality, all-cause mortality, and non-fatal MI, in this systematic review and meta-analysis. Material and methods: A comprehensive search of PubMed, Scopus, Web of Science, and The Cochrane Library was conducted to identify studies published up to January 2025. Observational studies comparing CEC levels between individuals with and without CAD were included. Results: Twenty-three studies met the inclusion criteria. The pooled SMD of – 0.40 (95% CI: -0.53−-0.26), with a p-value < 0.0001, revealed significantly lower CEC levels in CAD patients compared to non-CAD individuals. Higher CEC was strongly allied with a reduced risk of CAD – OR = 0.57; 95% CI: 0.48−0.67, P < 0.00001, and a pooled risk ratio (RR) of 0.64; 95% CI: 0.48−0.86, p = 0.003. Impaired CEC was associated with an increased risk of cardiac mortality – OR = 3.94; 95% CI: 2.63−5.90, p < 0.00001, and all-cause mortality – OR = 2.84; 95% CI: 2.01−4.00, p < 0.00001. However, insignificant association was found between CEC and non-fatal MI (OR = 3.47; 95% CI: 0.41−29.22, p = 0.25). Conclusion: This meta-analysis underscores the probability of CEC as a biomarker for the assessment of CVS risk. Higher CEC levels are linked to a reduced risk of CAD, cardiac mortality, and all-cause mortality, but no significant relationship was observed with non-fatal MI. Future research should prioritize standardizing CEC measurement methods and investigating its therapeutic potential for preventing atherosclerotic CVS disease.

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DOI: 10.3897/bgcardio.31.e165714

Authors: G. Goranov, V. Goranova-Marinova

Abstract: Somatic mutations in hematopoietic stem cells (HSCs) are an inevitable part of human aging. When these mutations reach a certain variant allele frequency (VAF), they may confer a proliferative advantage to mutated clones, leading to clonal hematopoiesis. Once the HSCs generate over 10¹⁰-10¹² mutated cells, they can initiate various myeloid or lymphoid malignancies. In cases where the VAF exceeds 2% (roughly 10⁴ mutated blood cells) but without clinical evidence of hematologic cancer, the condition is termed clonal hematopoiesis of indeterminate potential (CHIP). Numerous studies have identifi ed that CHIP is frequently driven by mutations in genes implicated in hematologic malignancies, most notably TET2, DNMT3A, and JAK2. CHIP has also been strongly linked to cardiovascular diseases, particularly atherosclerosis. This dual role highlights a shared pathogenesis between cardiovascular and hematologic disorders through mutations in HSCs. CHIP-associated monocytes exhibit a pro-infl ammatory phenotype, activating infl ammasomes and overexpressing cytokines such as interleukin (IL)-1β and IL-6, as well as chemokines like Cxcl1-3 and Pf4. This leads to a chronic infl ammatory loop that contributes to endothelial dysfunction and atherosclerosis. Current data suggest that CHIP poses a cardiovascular risk comparable to traditional risk factors. Ongoing research continues to uncover the complex mechanisms underlying this association.

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DOI: 10.3897/bgcardio.31.e167784

Authors: I. Kostovska, K. Tosheska Trajkovska

Abstract: Introduction: Low-density lipoprotein cholesterol (LDL-C) is a cornerstone biomarker for cardiovascular risk. The Friedewald formula has long been the standard for estimating LDL-C, however, it has limitations, particularly in patients with hypertriglyceridemia or low LDL-C levels. Several alternative equations, including the Martin–Hopkins (M/H) and Sampson formulas, have been developed to improve accuracy. Among them, M/H has gained recognition for its performance in specifi c populations, but it represents only one of several refi ned methods used across professional communities. This study aimed to perform a meta-analysis comparing the accuracy and precision of the Friedewald and M/H formulas in diverse populations, acknowledging that other approaches also exist. Methods: A systematic review of articles published between 2018 and 2024 was conducted using PubMed, Embase, Scopus (Elsevier), and Web of Science-eligible studies directly compared both formulas against direct LDL-C measurement in adult populations. A random-effects model was used to pool mean absolute errors (MAEs), root mean square errors (RMSEs), correlation coeffi cients, and p-values. Heterogeneity was assessed using the I² statistic. Results: Eight novel studies, involving a total of 192,094 participants, were included. The M/H formula showed signifi cantly lower MAE (3.6 mg/dL vs. 8.4 mg/dL, p < 0.001), lower RMSE (5.1 mg/dL vs. 9.8 mg/dL, p < 0.001), and a stronger correlation with direct LDL-C (r = 0.92 vs. r = 0.84) compared to the Friedewald formula. The superiority of the M/H formula was especially evident in patients with triglycerides >200 mg/dL or LDL-C <70 mg/dL. Conclusion: The M/H formula provides more accurate and precise LDL-C estimation than Friedewald, particularly in clinically vulnerable groups. However, it should be considered one of several improved approaches, alongside other equations such as Sampson, which may perform better in certain populations. M/H can be recommended as a strong option, but is not the sole alternative for routine lipid profi ling.

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DOI: 10.3897/bgcardio.31.e180003

Authors: Vesselina Koleva

Abstract:

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DOI: 10.3897/bgcardio.31.e147010

Authors: M. M. Yusuf, M. P. Doss, R. Kannaiyan, R. Valliammai, A. M. Kumar

Abstract: Stent infection is a rare but serious complication that can lead to signifi cant morbidity and mortality. A 75-year-old man with a known history of diabetes underwent percutaneous coronary intervention (PCI) for coronary artery disease involving the right coronary artery (RCA). The patient presented to our hospital with stent infection and a subsequent pseudoaneurysm formation in the RCA. A multidisciplinary team decided on surgical intervention to manage stent-related infection. Infected stents were removed, the pseudoaneurysm was excised, and the RCA was reinforced. Additionally, the aortic valve was inspected and debrided. This case highlights the intricate management of complex coronary stent infections and the importance of a timely and coordinated multidisciplinary approach.

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DOI: 10.3897/bgcardio.31.e150468

Authors: G. Goranov, V. Doktorova, P. Petrov

Abstract: Background: Coronary artery perforation is a highly feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and can lead to pericardial effusion, tamponade, and, rarely, emergent cardiac surgery. Perforation of coronary artery or epicardial collaterals during retrograde CTO-PCI may be particularly challenging to treat, as embolization from both sides of the perforation may be required to control the bleeding. However, only conservative measures in selected cases can be effective. We report a case of distal posterior descending (PD) branch of left circumfl ex (LCX) artery vessel perforation that was managed conservatively with anticoagulation reversal. Case Summary: An 85-year-old Caucasian male patient, with a history of lateral and inferior myocardial infarction and previous PCI, underwent a planned coronary arteriography due to progressive angina. Coronary angiography revealed normal function of implanted drug eluting stents (DES) in the mid-LAD and in the proximal right coronary artery (RCA) and CTO of dominant LCX. A septal branch in the midsegment of LAD was supplying the distal PD of LCX retrogradely. After failed attempt at antegrade PCI for the LCX’s CTO, the retrograde approach was tried. This intervention fi nally succeeded through the septal collateral but after removing the retrograde guidewire with the support of microcatheter, vessel perforation of distal PD of LCX was observed. This complication was successfully managed conservatively with anticoagulation reversal. Post-operatively, the patient had no complications and was stable at 6-month follow-up. Discussion: Coronary artery perforation can be managed conservatively only with anticoagulation reversal in selected cases.

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DOI: 10.3897/bgcardio.31.e171913

Authors: D. Maneva, L. Balabanski, M. Atanasoska, S. Y. Staykova, Е. Filipov, I. Bradinova, I. Tasheva, N. Marinov, R. Vazharova, D. Toncheva

Abstract: Hereditary cardiomyopathies are mostly autosomal dominant disorders that affect cardiac muscle structure and function, often leading to arrhythmias, heart failure, or sudden cardiac death. We report two brothers (aged 41 and 38), who presented with inherited cardiomyopathy and a family history of suspected cardiac disease in their father. The older sibling was referred for genetic evaluation due to clinical symptoms suggestive of cardiomyopathy. Whole genome sequencing (WGS), followed by targeted analysis of cardiomyopathy-associated genes, identifi ed a pathogenic heterozygous variant in the FLNC gene (c.7384+1G>T) located at the canonical donor splice site. The fi nding was consistent with the patient’s phenotype. In conjunction with the current clinical guidelines, an implantable cardioverter-defi brillator (ICD) was implanted as primary prevention of sudden cardiac death (SCD). Cascade genetic screening identifi ed the same FLNC variant in his younger, asymptomatic brother. He was enrolled in a structured surveillance program with personalized lifestyle recommendations. This case illustrates the critical role of WGS in establishing a defi nitive molecular diagnosis, informing clinical decision-making, and enabling timely intervention and clinical management. It also underscores the importance of family-based screening in inherited cardiomyopathies, even when the family history is limited or unconfi rmed. Integration of genomic tools into cardiology practice can enhance early detection, improve outcomes, and facilitate precision medicine strategies in affected families.

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DOI: 10.3897/bgcardio.31.e142199

Authors: F. Farabi, M. N. Afifa, P. Puspawikan, B. B. Tiksnadi

Abstract: Background: Coronary collateral plays a role in maintaining myocardial function, limiting infarct size, and reduced morbidity and mortality. Uric acid to albumin ratio (UAR) has recently been discovered as a novel biomarker associated with cardiovascular disease. However, studies investigating the relationship between UAR and coronary collateral circulation (CCC) formation are limited and have low magnitude. Therefore, this study aims to determine the relationship between UAR and CCC formation in coronary artery disease patients. Methods: The literature was searched in PubMed, Medline, SpringerLink, ScienceDirect, and Scopus for articles published before August 2024. Studies that did not report UAR results as one of the parameters but included uric acid and albumin in their laboratory parameters, had UAR values calculated using the error propagation for ratio formula. Statistical analysis for meta-analysis using Review Manager 5.4 software to evaluate the relationship between UAR and CCC. Results: A systematic search retrieved nine studies that met the eligibility criteria. The total population in these studies was 5290 subjects, including 3744 subjects with good coronary collateral circulation and 1546 subjects with poor coronary circulation. Four of the nine studies assessed albumin parameters using glycated albumin and one study assessed albumin parameters using ischemic modifi ed albumin. The uric acid/albumin ratio is correlated with CCC formation, with the lower the UAR, the more likely CCC formation will occur (SMD -0.31, 95% CI -0.56 to -0.05, p-value 0.02, I2 93%). In the subanalysis of the different parameters, uric acid is also correlated with CCC formation (SMD -0.41, 95% CI -0.74 to -0.08, p-value 0.01, I2 96%), while albumin has no strong correlation. Conclusion: Uric acid to albumin ratio could be a new parameter in predicting the formation of coronary collateral circulation in patients with stable coronary artery disease.

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DOI: 10.3897/bgcardio.31.e152709

Authors: H. Nough, M. Dehghanifirouzaadi, A. Nough, R. Sadeghi, N. Yoshany

Abstract: Background and Objective: Coronary artery ectasia (CAE), a diffuse or focal dilatation of coronary arteries, remains poorly understood. While the neutrophil-to-lymphocyte ratio (NLR) is a well-established infl ammatory marker in cardiovascular diseases, its diagnostic role in CAE is unclear. This study aimed to evaluate the diagnostic utility of NLR in CAE and explore its association with disease severity. Material and Methods: In this case-control study, 115 patients (28 CAE, 87 controls) admitted to Shahid Sadoughi Hospital (2012–2020) were analyzed. Demographic data, medical history, and complete blood count (CBC)-derived NLR were compared using SPSS and appropriate statistical tests. Results: The mean NLR did not differ signifi cantly between CAE (0.79 ± 2.01) and control groups (1.46 ± 2.07) (P = 0.830), nor by age, sex, or ectasia extent. However, NLR was lower in three-vessel involvement (0.49 ± 1.66) versus single-vessel involvement (1.04 ± 2.32) (P = 0.036). Conclusion: NLR lacks diagnostic value for CAE but may correlate with disease burden, as evidenced by reduced NLR in multi-vessel involvement. Further research should investigate NLR’s pathophysiological role and alternative infl ammatory markers in CAE.

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DOI: 10.3897/bgcardio.31.e152971

Authors: R. Talhi, S. Amrit, K. Chenni, D. Larbi, M. Raiah, A. Ghalmi, A. Abdelouahab, N. A. Khelifi Touhami, N. Ouchene, M. Bouziani, M. Farouk Mesli

Abstract: Acute coronary syndrome (ACS) is a heterogeneous and severe acute cardiovascular event, with an early mortality rate estimated at 10.5% in western Algeria. Existing ischemic risk stratifi cation scores for ACS vary in complexity and present certain limitations. The primary objective of this study is to develop and validate a prognostic score for ACS, based on a cohort of patients admitted to the three cardiology departments of Oran ; University Hospital Establishment (UHE), University Hospital Center (UHC) and Regional Military University Hospital (RMUH), with the aim of predicting 30-day mortality. This epidemiological, multicenter, observational study included all patients hospitalized for ACS between 2018 and 2020, with 30-day all-cause mortality as the primary endpoint. The fi nal predictive model was derived using binary logistic regression in a cohort representing 71% of the initial population, while the remaining 29% was used for validation. Model calibration was assessed using the Hosmer-Lemeshow test, and discrimination was evaluated based on the area under the Receiver Operating Characteristic (ROC) curve and C-statistic. A total of 1692 eligible patients were recruited, with a predominance of males (75%) and a mean age of 61 ± 12 years. The developed score consists of seven independent dichotomous variables, yielding a maximum total of ten points. It demonstrated good calibration (p = 0.906) and a discrimination of 0.76 [95% CI: 0.73-0.78] in the derivation cohort, compared to 0.71 [95% CI: 0.66-0.75] in the validation cohort. A new, simple, reproducible, and validated decision-support tool is proposed for practitioners. This prognostic score, designed to be quickly and easily calculated, provides an effective means of predicting 30-day mortality in ACS patients and is well-suited to emergency department practices.

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DOI: 10.3897/bgcardio.31.e145941

Authors: D. P. Amukti, R. I. Pratami

Abstract: Introduction: Amlodipine is a long-acting dihydropyridine calcium channel blocker used in hypertension management. Despite its widespread use, therapeutic response varies signifi cantly among individuals, infl uenced by genetic, environmental, and physiological factors. Pharmacogenomics, which studies genetic variation affecting drug responses, has identifi ed specifi c genetic variants associated with amlodipine metabolism and effi cacy. Genes such as CYP3A4, RYR3, CACNA1C, and CACNA1D are known to play a role in amlodipine’s pharmacokinetics and pharmacodynamics. This review examines these genetic variants and their impact on amlodipine effi cacy, with a focus on population-specifi c responses. Material and methods: This study utilized publicly available pharmacogenomic data from the PharmGKB and GTEx Portal to identify genetic variants associated with amlodipine effi cacy. Genetic variants from CYP3A4, RYR3, CACNA1C, and CACNA1D were selected based on their association with amlodipine response. Population-specifi c variations were also analyzed to assess differences in therapeutic outcomes across diverse biogeographical groups. Results: Seven single nucleotide polymorphisms (SNPs) from four genes were identifi ed: CYP3A4 (rs2246709, rs2740574), RYR3 (rs877087), CACNA1C (rs2239050, rs2239128), and CACNA1D (rs312481). SNPs such as rs2246709 in CYP3A4 and rs877087 in RYR3 were linked to enhanced amlodipine effi cacy in certain populations, while rs2740574 showed greater response in women. Variants like rs2239050 and rs312481 infl uenced amlodipine response in Central/South Asian and European populations. Conclusion: Genetic variants, including CYP3A4 (rs2246709, rs2740574), RYR3 (rs877087), CACNA1C (rs2239050, rs2239128), and CACNA1D (rs312481), signifi cantly infl uence amlodipine effi cacy in hypertensive patients. These fi ndings underscore the importance of genetic factors in personalizing hypertension treatment and optimizing drug effi cacy across diverse populations. However, further clinical validation and mechanistic studies are necessary to confi rm the therapeutic implications of these genetic associations. Understanding the distribution of these variants across populations may aid in tailoring amlodipine therapy based on ethnic and geographical factors, ensuring a more precise and effective treatment approach.

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DOI: 10.3897/bgcardio.31.e146521

Authors: D. P. Amukti, L. M. Irham, M. S. Bachri, D. F. Ismyama, N. B. Sembiring, W. Adikusuma, R. I. Pratami, R. Chong, Sabiah Khairi

Abstract: Introduction: Hyperlipidemia is a medical condition characterized by high levels of lipids, including total cholesterol, low-density lipoprotein (LDL), and triglycerides in the blood. This condition plays a major role in the pathogenesis of cardiovascular diseases, such as atherosclerosis, coronary heart disease, and stroke, which are the leading causes of death and disability globally. The risk factors for hyperlipidemia involve a complex interaction between environmental, lifestyle, and genetic factors. Among these genetic factors, the apolipoprotein E (APOE) gene has long been identifi ed as one of the major determinants of lipid metabolism. This study aims to analyze the impact of APOE gene polymorphisms on hyperlipidemia risk and statin therapy response using a bioinformatics approach, providing insights into personalized lipid-lowering treatments. Material and methods: This study used a bioinformatics approach to analyze genetic and clinical data available in several database sources, including PharmGKB, Ensembl, and GTEx Portal. Results: APOE gene polymorphisms play a signifi cant role in determining the risk of hyperlipidemia and the effectiveness of statin therapy. Genetic variations such as rs7412, rs429358, rs449647, and rs71352238 affect lipid metabolism and patient response to various types of statins, including atorvastatin, pravastatin, simvastatin, and rosuvastatin. The results showed that individuals with certain genotypes, such as CT or TT, tend to have a better response to lowering LDL-C levels compared to other genotypes. Conversely, some alleles, such as the C allele in rs7412 and rs429358, are associated with lower therapy response or increased cardiovascular risk, but these risks can be reduced by selecting appropriate therapy, such as simvastatin. Conclusions: Pharmacogenomic approaches may guide more personalized management of statin therapy to improve clinical outcomes and minimize the risk of side effects. This study highlights the importance of understanding genetic interactions in the management of hyperlipidemia to prevent broader cardiovascular complications.

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DOI: 10.3897/bgcardio.31.e151375

Authors: N. Zlatareva, M. Dotseva, Y. Tomova

Abstract: One of the main methods currently used is the transthoracic echocardiographic evaluation by HyperDopler intracardiac fl ow dynamics. It is based on color Doppler mapping of the blood fl ow by CDMF/Color Doppler fl ow mapping/technology. In addition to conventional transthoracic echocardiography, this technique enables visualization and quantitative assessment of intracardiac blood fl ow. HyperDoppler methodology represents a new paradigm in the analysis of cardiac function with the potential for sensitive risk identifi cation and prediction of impending cardiac damage.It has been shown that a comprehensive assessment of intracardiac structures as well as their intracavitary vortex fl ow can enable the detection of pathologically altered fl ow characteristics. Which in turn identifi es new pathophysiological mechanisms in the development of cardiovascular diseases. Our methods provide additional information on hemodynamics, with the potential for early detection of cardiac dysfunction and assistance in disease treatment and prevention. Convection echocardiographic measurements of cardiac mechanics usually do not reveal signifi cant changes until there is signifi cant dysfunction, making them less effective for early diagnosis and treatment of cardiovascular disease. Blood fl ow dynamics are immediately affected when cardiac hemodynamics change, therefore analyzing it opens new perspectives for the prediction and early diagnosis of diseases. Intracardiac fl ow analysis is a different and modern approach to assess cardiac function, providing important and complementary information to conventional approaches based on cardiac mechanics.

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DOI: 10.3897/bgcardio.31.e150462

Authors: G. Goranov, V. Goranova

Abstract: Absolute and functional iron defi ciency (ID) is a critical factor contributing to various cardiac issues, including mitochondrial dysfunction, myocardial remodeling, and signifi cant systolic and diastolic impairments. These conditions increase the risk of left ventricular hypertrophy, pulmonary congestion, cardiac fi brosis, and decreased exercise tolerance in patients with heart failure (HF). Therefore, timely and accurate diagnosis of ID is essential, as it can be a primary or secondary treatment goal. Current diagnostic criteria often rely on serum ferritin levels, which can be misleading and are derived from previous clinical trial eligibility criteria. This review examines multiple randomized clinical trials, studies, and meta-analyses that advocate for a redefi nition of ID. It proposes new diagnostic criteria based primarily on transferrin saturation (TSAT) levels below 20%, which demonstrate high specifi city and sensitivity for identifying candidates for treatment. These criteria correlate signifi cantly with survival rates and cardiovascular outcomes. Additionally, emerging indicators of ID, such as serum soluble transferrin receptor (sTfR) and the sTfR-ferritin index, are discussed. These indicators provide insights into mitochondrial iron status and help differentiate between absolute iron defi ciency (AID) and functional iron defi ciency (FID).

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DOI: 10.3897/bgcardio.31.e153312

Authors: Zh. Kolev, V. Valkov, A. Angelov

Abstract: Transcatheter aortic valve implantation is gradually becoming the main method of treatment for high-grade aortic valve stenosis. As the indications for the procedure gradually expand and the incidence of severe aortic valve stenosis increases, given the aging population, the number of procedures performed will grow. Despite the minimally invasive nature of the procedure, it remains associated with some inherent complications. One of them is the conduction disturbances after transcatheter aortic valve implantation. Knowledge of the incidence, evolution over time and clinical signifi cance of this type of complications of the procedure is of great importance for the proper management of patients. In recent years, various clinical trials have investigated complications of the conduction system after transcatheter aortic valve implantation. The purpose of this literature review is to discuss established data from the literature related to the incidence, evolution, and clinical signifi cance, primarily of new-onset complete left bundle branch block or permanent pacemaker implantation after transcatheter aortic valve implantation.

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DOI: 10.3897/bgcardio.31.e165330

Authors: V. Gitsov, K. Gospodinov, S. Tisheva, K. Razlozhka

Abstract: Cardio-oncology is a new fi eld in medicine, uniting the two clinical disciplines of cardiology and oncology. With the improvement of anticancer therapies, patient survival has increased, creating conditions for the development of cardiovascular diseases, including rhythm and conduction disorders. Furthermore, the medications used for cancer treatment are themselves associated with cardiovascular system damage. The aim of this publication is to provide a brief overview of rhythm and conduction disorders resulting from treatment with anticancer drugs, to present the medications with the highest cardiotoxicity risk, and the mechanisms and factors that predispose to it.

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DOI: 10.3897/bgcardio.31.e173631

Authors: Lubomir Balabanski

Abstract:

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DOI: 10.3897/bgcardio.31.e149169

Authors: M. Dimova, M. Gospodinova, K, Genova, E. Paskalev, V. Velchev

Abstract: Anderson-Fabry disease is a hereditary, X-linked disorder with multiorgan impairment. The debut of the disease is usually in childhood, the clinical course and the prognosis are determined by the degree of the heart, kidney and brain dysfunction. Cardiac involvement includes the development of hypertrophic cardiomyopathy, conduction disorders and less common - valvular disease. Among patients with hypertrophic cardiomyopathy, about 0.5-1% are due to Anderson-Fabry disease. We present a clinical case of a man diagnosed with Anderson-Fabry disease, the clinical suspicion of which was raised based on rapid progression of renal disease, lead to end-stage kidney failure, cerebrovascular disease, and hypertrophic cardiomyopathy. The patient underwent a successful kidney transplantation, and systemic treatment with enzyme replacement therapy, but despite this, the cardiac involvement progressed, necessitating the placement of an ICD and alcohol septal ablation of the first septal branch due to a severe subvalvular gradient.

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DOI: 10.3897/bgcardio.31.e152746

Authors: T. Shalganov, M. Stoyanov, K. Dzhinsov

Abstract: This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) studies and catheter ablations in 2024. Material and methods: Full one-year sample of the BG-EPHY registry was analysed retrospectively. Sex and age distribution of the patients, number of ablations, use of electroanatomic mapping (EAM), ablation energy source, distribution of different types of arrhythmias, acute procedural success, complications, recurrences and redo procedures are presented. Results: In 2024 ten EP centers performed 2624 ablations in 1714 men (65.3%) and 910 women, incl. 16 ablations in pediatric patients (0.61%). EAM was used in 1506 procedures (57.4%), irrigated-tip catheter – in 1535 (58.5%), cryocatheter – in 507 (19.3%), and intracardiac echocardiography – in 203 (7.7%). The most frequently performed primary ablation was pulmonary vein isolation (51.9%), followed by ablation for typical atrial flutter (15.1%) and AV nodal reentrant tachycardia (13.5%). The acute success was over 99%, while intraprocedural complications were less than 1.5%. Redo procedures for recurrence of the index arrhythmia were done in 190 patients (7.24%), with atrial fibrillation and atrial flutters accounting for the largest numbers (n = 147). Conclusion: The national registry of electrophysiology collects systematically and continuously data on all ablations of cardiac arrhythmias performed in the country. In 2024, the number of ablations increased compared to 2023, but at a slower pace. Distribution of EP procedure types was similar to previous years. Acute success was very high, while intraprocedural complications were rare.

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DOI: 10.3897/bgcardio.31.e146281

Authors: A. Borizanova, I. Gruev, V. Traykov

Abstract: Aim: “It’s Time for Lp(a)” is a survey of Bulgarian Society of Cardiology (BSC) assessing the awareness and use of lipoprotein(a) – Lp(a), and the challenges that limit this lipid assessment. Methods and results: In the period of July-August 2024, the BSC conducted an on-line national survey with questions in three areas: professional information; information on the clinical circumstances in which cardiologists are considering Lp(a) testing and questions about reasons for limited test recommendation. Of the 585 cardiologists who took part in the survey, 189 answered all of the questions, and 396 answered partially. Only 18% of clinicians declare that they routinely measure Lp(a) primarily for cardiovascular risk stratification and in cases of family history. Additionally, 50% of cardiologists never measure Lp(a) at all. The most common reasons for not referring patients for testing Lp(a), according to 55% of cardiologists, are its absence in standard lipid panel and the fact that the test is not reimbursed (54%). 94% of respondents say that they would use Lp(a) if the test was reimbursed. 48% of cardiologists need clear clinical guidance on the use of Lp(a). According to 64%, the availability of therapies targeting this lipoprotein would lead to a greater use of Lp(a) test. Conclusion: These results indicate the need for further efforts by scientific societies to introduce clear and detailed guidelines, inclusion in lipid panels and reimbursement of testing, as well as educational initiatives to address the limited use and recognition of Lp(a) as a risk factor.

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DOI: 10.3897/bgcardio.31.e150300

Authors: I. Paskaleva, E. Doncheva, V. Baycheva, D. Lukanova, E. Naseva

Abstract: Direct oral anticoagulants (DOACs) are used as a more effective and safe alternative to vitamin K antagonists, with a simpler dosing strategy and a stable pharmacokinetic profile. However, existing data on individual variations in DOAC plasma levels suggest that determining on-treatment levels may be beneficial in certain clinical situations. This study assesses the interindividual DOAC variations and determines acceptable therapeutic ranges of plasma levels of apixaban and rivaroxaban in patients with venous thromboembolism (VTE), including a subgroup with inherited thrombophilia (THRPH). Drug levels were measured by anti-Xa chromogenic assays, performed with Innovance heparin tests (Siemens) using rivaroxaban- and apixaban-specific Biophen Hyphen calibrators and controls on CS 2500i coagulometer. The analysis included 198 patients with deep vein thrombosis and/or pulmonary embolism, 106 received apixaban 2 x 5 mg/d and 92 received rivaroxaban 20 mg/OD. The ranges (median, 5th-95th percentile) of rivaroxaban peak levels in VTE group (n = 92) was 234 ng/ml (102-388) and did not differ from plasma levels in VTE with THRPH (n = 27) 220 ng/ml (85-415), p = 0.488. Observed ranges of apixaban trough levels were similar in VTE group 76 ng/ml (32–148) vs 72 ng/ml (44-135) in subgroup VTE with THRPH. A moderate correlation was found between apixaban levels and patient age (r = 0.428, p < 0.001), while the correlation between rivaroxaban levels and age was weaker (r = 0.184, p = 0.045). In the VTE-THRPH subgroup, a moderate inverse relationship was observed between apixaban levels and patient weight (r = -0.530, p = 0.016). The coefficient of variation for rivaroxaban levels in the VTE-THRPH group was significantly higher (48%) compared to other groups. Due to plasma levels falling outside the expected therapeutic range in 12% (23/198) of patients, individualized treatment adjustments were made, including switching to another DOAC or VKA or modifying the dosage. Additionally, plasma levels below the 5th percentile of the defined ranges were observed in 5 of 198 patients receiving concomitant carbamazepine or valproate therapy. In conclusion, anti-Xa measurement of apixaban and rivaroxaban provided an opportunity to individualize anticoagulant therapy.

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DOI: 10.3897/bgcardio.31.e151011

Authors: D. Dineva, Е. Doncheva, I. Paskaleva

Abstract: Dual antiplatelet therapy is the main pharmacological mechanism used to suppress platelet function in order to prevent thrombotic complications following percutaneous coronary angioplasty. Current studies show that the use of tailored antiplatelet therapy leads to significant clinical improvement after stent implantation. The need to individualize therapy is due to the presence of wide interindividual variations in platelet response and the differing pharmacodynamics of various P2Y12 inhibitors – clopidogrel, prasugrel, and ticagrelor. Assessment of ADP-induced platelet aggregation helps prevent both adverse ischemic events and the associated bleeding risk. The primary objective of our studies was initially to establish and overcome resistance to clopidogrel therapy with the aim of reducing adverse ischemic events. With the introduction of prasugrel and ticagrelor – medications that offer a stronger and more predictable antiplatelet effect – our focus shifted to identifying increased response and bleeding in the context of dual antiplatelet therapy, and to individualizing therapy to minimize bleeding. Our long-term experience shows that impedance aggregometry is a fast and reliable method for evaluating platelet function. The tests allow for the differentiation of patients with optimal, high, and low platelet reactivity to P2Y12 inhibitor therapy. The main conclusion from our studies is that individualizing therapy leads to the absence of ischemic events without an increased risk of hemorrhage, thereby achieving a balance between ischemic and hemorrhagic complications during treatment.

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DOI: 10.3897/bgcardio.31.e146656

Authors: R. Grigorov, S. Yambolov

Abstract: A large proportion of patients with angina and evidence of myocardial ischemia do not have obstructive coronary disease. One of the main mechanisms of ischemia/angina with non-obstructive coronary arteries is coronary microvascular dysfunction, which is rarely diagnosed in clinical practice and patients continue to experience symptoms and have a reduced quality of life. The current review discusses the advantages, limitations, and clinical application of the fluoroscopic methods for assessment of microvascular dysfunction.

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DOI: 10.3897/bgcardio.31.e146569

Authors: S. Kitov, L. Kitova

Abstract: The etiopathogenetic mechanisms of metabolic syndrome that affect cardiac electrophysiology and lead to myocardial remodelling are numerous. Cardiomyocyte changes induced by metabolic and proinflammatory factors impair repolarization, exacerbate the heterogeneity of the transmural dispersion of repolarization, and prolong the Tpeak-end interval. Tpeak-Tend interval has been described as a marker of arrhythmogenicity that is more sensitive than the standard QT interval. Multiple pathological conditions and their effect on myocardial repolarisation have been studied – coronary artery disease, sleep apnea, arterial hypertension, Brugada syndrome and other channelopathies, systemic sclerosis, endocrinological diseases such as hypothyroidism, diabetes mellitus, acromegaly, hypertrophic cardiomyopathy, sudden cardiac death, familial hypercholesterolemia, etc. Currently, the most widely accepted theory of the mechanism of formation of Tp-e the interval and its dynamics are transmural myocardial heterogeneity/dispersion repolarisation. For the clinician, this is an additional tool for assessment of arrhythmogenicity through easy and accessible electrocardiographic markers in daily clinical practice. There is very little literature data on the clinical application of electrocardiographic markers (Tp-e interval, Tp-e/QT ratio) for proarrhythmogenicity in patients with metabolic syndrome. Despite progress in the development of new cardiovascular diagnostic methods, electrocardiographic markers can help in daily clinical practice to add important prognostic information about proarrhythmogenicity.

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DOI: 10.3897/bgcardio.31.e150772

Authors: I. Paskaleva, E. Doncheva

Abstract: D-dimer is a terminal product of plasmin-mediated degradation of cross-linked fibrin and is a marker for the activation of both the coagulation and fibrinolytic systems. D-dimer is widely used in routine clinical practice to rule out venous thromboembolism (VTE), assess the risk of recurrent thrombosis, and determine the optimal duration of anticoagulant therapy, as well as for the diagnosis and monitoring of disseminated intravascular coagulation (DIC). The analytical methods for measuring D-dimer are high sensitive but relatively low specific, as D-dimer levels are elevated in several physiological and pathological conditions. The combination of D-dimer measurements with clinical probability scores allows for the safe exclusion of VTE. To improve diagnostic accuracy, several strategies have been proposed to increase the specificity of D-dimer testing. The application of age-adjusted and clinical probability adapted cutoff values for VTE allows VTE exclusion in a greater number of patients without the need for additional imaging studies.

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DOI: 10.3897/bgcardio.31.e154569

Authors: I. Paskaleva

Abstract:

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DOI: 10.3897/bgcardio.30.e141217

Authors: J.Ch. Kurniawan

Abstract: Background: Patients presenting with acute myocardial infarction with ST-segment elevation (STEMI) are recommended to undergo primary percutaneous coronary intervention (PPCI) as a reperfusion therapy to maximize myocardial salvage and maintain myocardial viability. The extent of the myocardial salvage index (MSI) is greatly infl uenced by the onset and severity of myocardial ischemia, which can be assessed using the Anderson-Wilkins score and the Sclarovsky Birnbaum score. Objective: This study aims to determine the effect of the Anderson-Wilkins score and the Sclarovsky Birnbaum score on the electrocardiogram-based myocardial salvage index in patients with STEMI undergoing PPCI. Material and methods: We conducted a hospital-based cross-sectional analytical study from March 1st, 2024, to May 31st, 2024. All STEMI patients who underwent PPCI and met the inclusion criteria had their initial ECG analyzed using the Anderson-Wilkins and Sclarovsky-Birnbaum scores, with an ECG-based myocardial salvage index (MSI) assessment conducted on the last day of hospitalization. Results: Out of a total of 60 study subjects, 70% of the sample patients were men, with an average age of 57.4 years. The median Anderson-Wilkins score was 2.25 (interquartile range (IQR) 1.52 - 3.0), with an AW score ≥ 3 observed in 17 patients (28.3%). Meanwhile, grade III ischemia severity (SB score = 3) was found in 52 patients (86.7%). The median total ischemic time was 850 min (IQR 570-1290), with a total ischemic time of < 720 min found in 23 patients (38.3%). The AW score showed a strong correlation with MSI (p < 0.001, r = 0.588), whereas the SB score did not (p = 0.107, r = 0.163). Conclusion. The Anderson-Wilkins score shows a strong correlation with the myocardial salvage index in patients with acute myocardial infarction with ST-segment elevation (STEMI) undergoing primary percutaneous coronary intervention.

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DOI: 10.3897/bgcardio.30.e139418

Authors: J.W. Martha, A.H.S. Katamihardja, A. Nazir, N. Sylviana, D.K. Turbawaty, B.B. Tiksnadi

Abstract: Introduction: Cardiac rehabilitation may improve health outcomes in coronary artery disease (CAD) patients, but the mechanism is still unknown. Collateralization and improvement of microvascular fl ow is one of the hypotheses underlying this mechanism, however research on this is scant and inconclusive. Collateralization is affected by VEGF expression and has the effect of improving myocardial perfusion. Therefore, this study aimed to assess VEGF levels and myocardial perfusion before and after cardiac rehabilitation. Methods and Results: This study is a comparative study of patients who received cardiovascular rehabilitation treatment at Dr. Hasan Sadikin Hospital. The subjects of this study were consecutively selected from patients who received cardiovascular rehabilitation treatment at Dr. Hasan Sadikin Hospital. The primary outcome of this study is to assess the expression of VEGF A and myocardial perfusion in coronary artery disease patients who have undergone complete revascularization before and after phase II cardiac rehabilitation. Conclusion: This study will assess the benefi cial effects of phase II rehabilitation in more detail as it uses proteomics parameters to determine the underlying mechanism and assesses myocardial perfusion as an outcome.

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DOI: 10.3897/bgcardio.30.e140820

Authors: N. Georgieva, E. Kinova, R, Ilieva, P. Kalaydzhiev, A. Borizanova, A. Goudev

Abstract: Background: Arterial hypertension is the most common factor for structural and functional changes in the heart, but these changes are observed in more advanced stages and in patients with poor control of arterial hypertension. Echocardiography plays a key role in detecting these changes, but a more detailed assessment is needed to identify early changes. The role of left atrium mechanics as an additional indicator of diastolic dysfunction is still being proven, especially for patients in whom standard echocardiographic indicators are borderline and inconclusive. Aim: The aim of our study is to investigate the left atrial mechanics and the structural and functional parameters of the LC in patients with controlled arterial hypertension with a period of 5 years. Material and methods: We studied 45 consecutive middle-aged patients with mild to moderate hypertension and duration up to 5 years and 15 healthy controls. All parameters for arterial stiffness – 24-hour central systolic pressure (cSys24h), central pulse pressure (cPP24h) and 24-hour pulse wave velocity (PWV24h) were measured non – invasively with oscillometric method by Mobil-O-graph PWA. All patients underwent standard two-dimensional echocardiography with spackle tracking analysis for left ventricle (LV) and left atrium (LA) global longitudinal strain (GLS). Results: The patients with hypertension have concentric LV hypertrophy, measured by RWT (p < 0,001), reduced LV GLS (-15,83 ± 3,17 vs. -17,57 ± 2,83, p < 0,001). There is a tendency towards higher fi lling pressures E/e’m ratio (9,84 ± 2,85 vs. 7,62 ± 1,58, p = 0,006), dilated LA (LAVI: 31,86 ± 9,78 vs. 24,96 ± 4,89 ml/m2, p < 0,011) and reduced LA - GLS (29,14 ± 3,90 vs. 41,33 ± 4,37%, p < 0,0001) in comparison to control group. Strongly positive correlation is registered between PWV24h and LV concentric hypertrophy indicated as RWT (r = 0,545, p < 0,0001) There is positive correlation between cSys24h and LV concentric hypertrophy (r = 0,333, p = 0,009) and negative correlation with LA-GLS (r = -0,221, p = 0,09). E/e’ correlated positively with LAVI (r = 0,309, p = 0,016) and negatively with LA-GLS (r = 0,324, p=0,012). Multiple linear regression with multivariate models were used to estimate RWT and LA-GLS. We initially selected clinically relevant variables and known confounders for inclusion in the multivariable regression analysis, using stepwise logistic regression analysis we found that the most powerful predictors for LA-GLS are PWV24h (R = 0,459, B = -4,59, p < 0,0001) and Е/e’m: (R = 0,535, B = -291, p = 0,017). The most powerful predictor for LV hypertrophy, determine by RWT is PWV24h (R = 0,488, B = 238, p< 0,0001) and Е/e’ m (R = 0,561, B = 263, p = 0,022). Conclusion: Left atrial mechanics indicators have additional diagnostic value in assessing diastolic function, where standard indicators of diastolic function are not suffi ciently conclusive. In patients with controlled AH, early changes in the atrio-ventruculo-vascular coupling axis are observed.

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DOI: 10.3897/bgcardio.30.e141268

Authors: H. Varnaliyska, R. Stoycheva, A. Popova, D. Dimitrov, A. Osmanov, V. Groudeva, D. Trendafilova

Abstract: We present a clinical case of a patient with hypertrophic cardiomyopathy (HCM) characterized by an inverted septal curvature phenotype, accompanied by angina and presyncope symptoms. Patients with this type of presentation remain a diagnostic and therapeutic challenge due to their association with midventricular obstruction, apical aneurysm formation, and an increased risk of arrhythmias and sudden cardiac death (SCD). Their treatment and follow-up require a multidisciplinary approach to improve quality of life and prognosis. Various imaging modalities were applied in this case, confirming the presence of severe left ventricular hypertrophy, posterior wall hypertrophy of the right ventricle, and a midventricular gradient. Magnetic resonance imaging (MRI) demonstrated fibrosis involving approximately 25% of the myocardium. The patient was stratified as high-risk patient for SCD. To improve the patient’s quality of life and prognosis, pharmacological therapy was optimized, and an implantable cardioverter-defibrillator (ICD) was placed.

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DOI: 10.3897/bgcardio.30.e141038

Authors: B. Kunev, S. Dineva, A. Aleksandrov, H. Mateev

Abstract: Congenital coronary artery anomalies and acquired coronary artery pathologies are increasingly identifi ed by different imaging modalities. Abnormal aortic origin of a coronary artery from the opposite sinus is estimated at 0.7%. Echocardiography may have an incremental value in these complex patients often requiring multimodality diagnostic approach. We present the case of a female patient with a single coronary artery identifi ed by angiography with left main course between the aorta and right ventricular outfl ow tract. We also briefl y list a number of different clinical scenarios in patients with structurally normal hearts, with congenital heart disease and patients after cardiac surgery or interventions. These are exemplifi ed by different echocardiographic, angiographic and tomographic images.

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DOI: 10.3897/bgcardio.30.e141099

Authors: N. Spasova, E. Kinova, R. Savova, K. Genova, M. Garcheva, A. Goudev

Abstract: Transthyretin amyloidosis (ATTR) is a systemic disease characterized by the deposition of amyloid fi brils in various tissues, leading to progressive neurological manifestations and the development of cardiomyopathy, necessitating timely diagnosis and treatment. This article presents a clinical case of a 74-year-old patient with hereditary transthyretin amyloidosis (ATTRv), diagnosed using non-invasive imaging methods – echocardiography, magnetic resonance imaging, and single-photon emission computed tomography (SPECT-CT) – and confi rmed through molecular genetic analysis revealing a mutation in the TTR gene. The main clinical features of the disease, imaging fi ndings, and therapeutic strategies in the context of the presented case are discussed.

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DOI: 10.3897/bgcardio.30.e140680

Authors: A. Borizanova-Petkova, D. Somleva, E. Kinova, V. Koleva, Y. Zdravkova, A. Goudev

Abstract: Systemic lupus erythematosus is a chronic autoimmune disorder affecting predominantly young women. Cardiac involvement in systemic lupus erythematosus is common and the typical manifestations are pericarditis, myocarditis, valvular disease, coronary artery disease, cardiac arrhythmias, and congestive heart failure. Clinical lupus myocarditis typically occurs early during lupus, in the context of high disease activity. It may present as an acute illness or have a chronic course with the development of cardiomyopathy. We present a clinical case of young patient who developed a severe dilated cardiomyopathy as a fi rst manifestation of systemic lupus erythematosus.

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DOI: 10.3897/bgcardio.30.e145391

Authors: D.P. Amukti, L.M. Irham, S. Surono, W. Adikusuma, R. Chong, R. El Khair, B.D. Purwanto, R.D. Satria, I. Ates, S. Khairi, D. Rungprai

Abstract: Introduction: Atherosclerosis (AS) is a major risk factor for cardiovascular disease (CVD), which is the leading cause of death worldwide. Genetic factors are an integral factor in the cause of AS. This study aims to correlate epidemiological data, prevalence and mortality of AS worldwide with Single Nucleotide Polymorphisms (SNPs) associated with susceptibility and severity in different populations. Hence, utilized the gene variants to discover potential drug targets using bioinformatics. Material and methods: This study used a secondary data-driven bioinformatics approach to analyze the correlation between genetic variants associated with AS and epidemiological data from different regions of the world. Genetic data were obtained from the GWAS Catalog, while epidemiological data were collected from WHO and Our World in Data. The analysis was performed by filtering SNPs based on several criteria, namely the missense variant category, significant p-value < 10-5, and prediction of variant impact using PolyPhen (Possibly Damaging) and SIFT (Deleterious). The correlation between allele frequency and AS prevalence and mortality were analyzed using the Pearson test. The drug target identification process was carried out through the DrugBank database. Results: The results of the study obtained three missense variants – rs11466653 in TLR10, rs2296172 in MACF1 and rs6025 in F5. Variant rs11466653 has a role in the pathogenesis of AS with analysis using SNPnexus which shows the possibility of damaging (PolyPhen) and deleterious (SIFT) properties in addition to the results of the correlation test significant to the global prevalence and mortality of AS (p < 0.05). Due to the challenge of drugging all potential target genes, our study was only able to identify the F5 gene as a viable target. The TLR10 gene is a molecular target for immunomodulators such as hydroxychloroquine, chloroquine, eritoran, and resatorvid (TAK-242) to reduce inflammation and regulate immune responses. In addition, tacrolimus as an immunomodulator shows potential in overcoming chronic inflammation associated with AS through a mechanism involving the MACF1 gene. Conclusion: The findings in this study will encourage efforts to improve AS diagnosis and early treatment, as well as increase public awareness of the importance of genetic factors and lifestyle in preventing this disease. This study can also be a reference for further research focusing on genetic intervention and development of personalized therapy for AS. Therefore, it can provide broader benefits for global public health.

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DOI: 10.3897/bgcardio.30.e140976

Authors: R. Ilieva, E. Kinova, B. Slavchev, P. Kalaydzhiev, N. Georgieva, M. Konstantinova, A. Goudev

Abstract: Introduction: Atrial fi brillation is the main etiological factor leading to the development of atrial cardiomyopathy (ACM). The different types of atrial fi brillation (AF) are characterized by varying severity of atrial dysfunction, symptoms, and prognosis. Objective: The aim of our study is to analyze the echocardiographic parameters of patients with atrial cardiomyopathy with paroxysmal and permanent atrial fi brillation and to investigate the prognosis of these patients. Material and Methods: We studied 180 consecutive patients with advanced atrial cardiomyopathy, defi ned as a severely dilated left atrium with indexed volume (LAVI) ≥ 48 ml/m², preserved left ventricular ejection fraction (LVEF > 50%), without the presence of primary valvular diseases or ventricular dysfunction. We divided patients with ACM into two groups depending on whether they were with paroxysmal AF (n = 88) or with permanent AF (n = 92). All patients underwent detailed echocardiography with volumetric and speckle tracking analysis at inclusion. Results: The mean age of patients with ACM was 74.1 ± 8.7 years, with 58% being women. The ejection fraction and global longitudinal strain of the left ventricle in patients with permanent AF were signifi cantly lower than those in patients with paroxysmal AF. This was also true for the left atrial reservoir strain (LASr: 10.2 ± 4.6% vs. 23.7 ± 7.9%, p < 0.001). Similar fi ndings were observed in the volume of the right atrium, right ventricular function parameters, and right atrial reservoir strain (RASr: 12.1 ± 6.9% vs. 24.4 ± 8.0%, p < 0.001). Patients with permanent AF also showed a signifi cantly higher grade of tricuspid regurgitation. Over a mean follow-up of 19 months, the mortality rate was signifi cantly higher in the permanent AF group at 20%, compared to 8% in the paroxysmal AF group (p = 0.03). Conclusion: Patients with atrial cardiomyopathy and permanent atrial fi brillation exhibit signifi cantly worse echocardiographic parameters, including those of the right heart chambers, and have a poorer prognosis compared to those with paroxysmal atrial fi brillation.

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DOI: 10.3897/bgcardio.30.e140848

Authors: P. Kalaydzhiev, R. Ilieva, N. Georgieva, S. Yakov, D. Somleva, G. Voynova, N. Spasova, E. Kinova, A. Goudev

Abstract: Background: Acute decompensated heart failure (ADHF) is often associated with central sleep apnea (CSA), which exacerbates cardiovascular strain and impacts quality of life. In ADHF patients, CSA contributes to recurrent nocturnal oxygen desaturation, elevated apnea-hypopnea index (AHI), and frequent Cheyne-Stokes respiration episodes, increasing health risks. Echocardiographic monitoring is essential in these patients, providing reliable assessment of heart function over time. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), initially developed for diabetes management, have shown benefi ts for renal function, sleep apnea symptoms, and heart failure outcomes, suggesting potential for multifaceted treatment. Purpose: To evaluate the effects of SGLT2i therapy on echocardiographic parameters and sleep apnea severity in patients with CSA and ADHF with reduced systolic function (HFrEF). Material and methods: We conducted a prospective cohort study with 162 patients, including those with an ejection fraction < 40%, NT-proBNP > 900 pg/ml, and AHIcentral > 5. Exclusions were patients with end-stage renal disease, NYHA class IV heart failure, COPD, or severe respiratory failure. ApneaLink™ and echocardiograms were used for assessments, and patients were followed for three months post-initiation of SGLT2i. Results: Among the 52 eligible patients, 48 completed the study. Echocardiographic improvements were signifi cant, particularly in diastolic function with a reduction in the E/e’ ratio (from 14.74 ± 2.57 to 13.64 ± 2.18, p = 0.002) and right heart function, as shown by decreases in RVOT (from 39.25 ± 4.01 to 38.32 ± 3.59, p = 0.004) and s-PAP (from 41.26 ± 5.74 to 40.07 ± 5.20, p = 0.001). TAPSE also improved (from 18.37 ± 2.17 mm to 18.87 ± 1.96 mm, p < 0.001), and the s-PAP/TAPSE ratio refl ected better right heart effi ciency (from 0.46 ± 0.11 to 0.48 ± 0.10, p < 0.001). Sleep apnea metrics also showed improvement, with reductions in AHI (from 21.35 ± 4.91 to 18.33 ± 4.75, p = 0.015), central AHI (from 13.16 ± 3.70 to 10.04 ± 3.57, p < 0.001), and Cheyne-Stokes respiration episodes (from 33.70 ± 11.20 to 26.58 ± 9.95, p < 0.001). Oxygen desaturation index (ODI) decreased (from 24.29 ± 7.01 to 17.91 ± 5.90, p < 0.001), and NT-proBNP levels, indicating heart failure severity, were reduced (from 1574.89 ± 652.80 pg/ml to 1250.35 ± 484.26 pg/ml, p < 0.001). Conclusion: SGLT2i therapy led to substantial improvements in echocardiographic measures of diastolic and right heart function, along with signifi cant reductions in CSA severity and oxygen desaturation in ADHF patients. These fi ndings support the potential of SGLT2i as an effective treatment option, meriting further study for long-term benefi ts on cardiac and respiratory health.

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DOI: 10.3897/bgcardio.30.e140563

Authors: A. Borizanova-Petkova, E. Kinova, N. Spasova, D. Somleva, A. Goudev

Abstract: Background: The prevalence of obesity and hypertension among healthcare professionals has been previously described. Both diseases are known risk factors for atrial cardiomyopathy (ACM), a new clinical entity with potential to be a determinant of heart failure, atrial fi brillation and thromboembolic complications. In this perspective, early preventive strategy should be initiated in this special population. Aim: To defi ne ACM in middle-aged women healthcare professionals. Material and methods: Hundred and fi ve middle-aged women healthcare professionals, separated in 3 groups: with central obesity (n = 50,47%), obesity and hypertension (n = 24,23%), healthy control (n = 31,30%), underwent echocardiographic examination with volumetric and speckle-tracking analysis. Results: There were signifi cant differences in LA volumes between 3 groups. LA phasic function was signifi cantly reduced, and LA stiffness index was signifi cantly increased in obese groups compared to control. Higher body mass index was associated with increased LA volume index (p < 0.001, r = 0.56) and with reduced Peak atrial longitudinal strain (p < 0.001, r = -0.59) and Peak atrial contractile strain (p < 0.001, r= -0.56). Conclusion: Postmenopausal women, healthcare professionals with obesity and hypertension are at risk for asymptomatic ACM. Further investigations are needed to confi rm this concept.

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DOI: 10.3897/bgcardio.30.e138638

Authors: D. Junior, I G.N.A.S. Diksha, I G.A.M.H. Prawista, R.C. Suteja, I K.H. Adiputra, G.V. Purnama, C.A.W. Purnamasidhi, C.W.D. Sinardja, I G.B.G.P. Putra, S. Harkitasari

Abstract: Myocardial infarction is one of the leading causes of global mortality and is strongly associated with permanent damage and sudden cardiac death. The human heart loses its proliferative ability after birth as cardiomyocytes are compelled to differentiate into mature cells focusing on hypertrophy. Based on the review of existing studies, we hypothesised that the combination of hypoxia and 3, 3', 5-triiodo-L-thyronine (T3) inhibitors could potentially be a more sustainable treatment method. We searched trusted scientific databases, such as PubMed, Directory of Open Access Journals (DOAJ), and Scopus, for relevant studies. T3 is a physiological hormone that was found to promote cardiomyocyte differentiation and inhibit its proliferation. Studies implied that inhibiting T3 during perinatal development could preserve the heart’s proliferative and regenerative capacities for a more extended period. Several animal experiments and human studies have found that inducing a hypoxic environment could revert cardiomyocytes to their endogenous proliferative state. However, long periods of hypoxia were not sustainable due to its deleterious effects on the human body. We suggested that administering T3 inhibitors after the cardiomyocytes have been reverted under hypoxic conditions could enable patients to leave the hypoxic environment while preventing physiological maturation by T3, thus preserving the heart’s regenerative capacity.

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DOI: 10.3897/bgcardio.30.e143367

Authors: D.P. Amukti, L.M. Irham, S. Surono, R. El Khair, W. Adikusuma, R. Satria, B.D. Purwanto, S. Khairi, R. Chong

Abstract: Atherosclerosis (AS) a chronic cardiovascular disease, poses a major threat to human health and remains one of the leading causes of mortality among the elderly. Genetic factors have long been recognized as contributors to the predisposition to heart and vascular diseases, with several studies suggesting that specifi c genetic variants may infl uence AS risk. This study employs a bibliometric analysis to explore scientifi c literature related to AS throughusing genomic approaches, base on Scopus data spanning 1983 to 2024. A total of 1,702 studies related to AS research employing genomic approaches were identifi ed, comprising 1,137 research articles, 445 review articles, and 120 documents in other categories. The fi ndings reveal a marked rise in interest in regarding genomic approaches to AS, particularly since 2017, with the United States, China, and the United Kingdom leading in research output. International collaborations are also prevalent, with the United States contributing the most publications. Although contributions from Indonesian authors remain limited, there is signifi cant potential for future involvement. Notably, the most cited article, authored by Naghavi et al. in 2003, focusing on genomics in AS. Overall, the bibliometric analysis provides valuable insights into research trends and advancements in the study of atherosclerosis through genomic approaches.

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DOI: 10.3897/bgcardio.30.e140717

Authors: G. Tomova-Lyutakova, I. Lyutakov, P. Kalaydzhiev, E. Kinova

Abstract: In a world where metabolic disorders such as non-alcoholic fatty liver disease (NAFLD/NASH) and chronic heart failure (CHF) steadily increase, the limitations of current therapies become even more apparent. Lifestyle changes have been the primary approach to metabolic disorders. However, the new use of glucagon-like peptide-1 receptor agonists (GLP1RA) and sodium-glucose cotransporter-2 (SGLT2) – inhibitors seem to present a breakthrough in improving the outcome of metabolic disorders in diabetic and non-diabetic patients. In the current review, we focused on studies with non-diabetic metabolic disorders. The results underlined the hepatoprotective effect of GLP1RAs on the histological resolution of NASH/NAFLD and improved serum liver enzyme. GLP1RAs, especially Liraglutide, also seem benefi cial in reducing stool frequency in patients suffering from bile acid malabsorption (BAM). SGLT2 inhibitors improve cardiovascular and renal outcomes and decrease the hospitalization rate for heart failure, regardless of the diabetes status. GLP1RA reduce body mass and infl ammation . In conclusion, the most up-to-date studies on the respective topics show that GLP1RAs and SGLT2 inhibitors have promising systemic benefi cial effects on patients with metabolic disorders with or without type 2 diabetes mellitus.

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DOI: 10.3897/bgcardio.30.e142013

Authors: Z. Vassileva

Abstract: Atrioventricular septal defect (AVSD) is a combination of an atrial septal defect type ostium primum, an inlet ventricular septal defect, and a common atrioventricular (AV) valve. In the partial type, there is no ventricular communication, and the common AV valve is divided into two separate orifi ces. Both kinds of AVSD can be corrected surgically through closure of the septal defects and AV valve plasty. The postoperative echocardiographic follow-up includes an assessment of residual septal defects, AV valve function, left ventricular outfl ow tract obstruction, ventricular dimensions and function, and indirect estimation of pulmonary artery pressure.

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DOI: 10.3897/bgcardio.30.e140741

Authors: R. Savova, E. Kinova, A. Goudev

Abstract: Cardiac amyloidosis, once considered a rare disease, is a severe and progressive cardiomyopathy characterized by extracellular deposition of misfolded proteins in the ventricular myocardium. Early diagnosis of cardiac amyloidosis is essential for improving patient prognosis, as it allows for a broader range of therapeutic options that can enhance outcomes and/or prevent potentially irreversible loss of physical function and quality of life. Current data suggest that a majority of patients do not get a timely diagnosis. Patients with early-stage CA do not exhibit reduced global left ventricular systolic function but may develop symptoms of heart failure with preserved ejection fraction (HFpEF), with CA considered as one of the overlooked etiologies of HFpEF in the elderly. Cardiac amyloidosis is a progressive disease with a poor prognosis if left untreated. The average life expectancy of untreated patients with AL cardiac amyloidosis is less than 6 months, while that of patients with ATTR-CA is 2.5-3.5 years. Therefore, early clinical identifi cation is essential.

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DOI: 10.3897/bgcardio.31.e148800

Authors: E. Kinova

Abstract: Редакционен коментар

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DOI: 10.3897/bgcardio.30.e133175

Authors: V. Goranovska, V. Velchev, N. Stoyanov, V. Gegouskov

Abstract: Background: Infective endocarditis (IE) of Automated Implantable Cardioverter Defibrillator (AICD) is a rare and potentially fatal disease with a significant morbidity and mortality. Case Summary: We report on a case of 23-years-old male patient with device - related endocarditis after multiple implantation of (AICD) associated with ventricular tachyarrhythmias. Due to infective endocarditis we performed surgical extraction of AICD and tricuspid valve replacement (TVR). In age of 4 and 10 years the patient had previous cardiac surgeries for perimembranous ventricular septal defect (VSD) and right-vetricular outflow tract obstruction, respectively. Discussion: Device-related endocarditis is a severe complication after AICD implantation. For diagnosis verification we routinely use the echocardiography and 18F-FDG PET/CT scan as nuclear imaging. Tricuspid valve replacement is always recommended if the native valve is completely destructed.

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