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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DOI: 10.3897/bgcardio.30.e129676

Authors: S. Barakova, B. Grigorova, E. Pashkuleva-Dermenjieva, N. Ivanov, P. Moraliyska, P. Lazarov, A. Gamisheva

Abstract: We present a clinical case of a 19-year-old young woman who was admitted to the Emergency Department of the Medical Military Academy in September 2023 with complaints of palpitations, nausea, vomiting, a shortness of breath and a previous syncope. After the conducted clinical, laboratory and instrumental tests, an acute myocardial infarction (AMI) with ST-elevation (STEMI) was established in the presence of increased levels of total (TC) and low-density cholesterol (LDL) and triglycerides (TG). There was no indication of hypercholesterolemia up to this point from the anamnesis. The case is interesting because of the young age of the patient, which suggests familial hypercholesterolemia (FH) as a risk factor (RF) for atherogenesis in the absence of other RF, such as diabetes mellitus (DM) and arterial hypertension (AH).

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DOI: 10.3897/bgcardio.30.e135426

Authors: V. Dimitrova, I. Gruev

Abstract: Hodgkin's lymphoma is a systemic disease of the lymphatic tissue that most commonly affects adolescents and young adults. Modern treatment of the disease aims at long-term remission in patients. During this process, some patients develop complications that require timely diagnosis and treatment. It is fundamental to ensure continuity between pediatric oncologists, pulmonologists, and cardiologists, pediatricians on the one hand, and specialists in the relevant field treating adult patients. Keeping and maintaining accurate patient medical data serves as a springboard for screening adolescents and young adults in remission after treatment for Hodgkin's lymphoma. The treatment methods (radiation, chemotherapy, etc.) have different mechanisms of action on the disease and, accordingly, different potential early and late complications. The role of functional breathing studies and cardiopulmonary stress tests with exercise in this group of patients can explain the etiology of clinical complaints, assess the functional status and effect of treatment, as well as timely diagnosis of complications during the treatment process with the aim of early cardio rehabilitation and achieving durable clinical remission.

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DOI: 10.3897/bgcardio.30.e118884

Authors: G. Slavchev, A. Dacheva, T. Velikov, Y. Seytaridou, E. Mekov, S. Dzhambazov, D. Vasilev

Abstract: Introduction: Intravascular ultrasound (IVUS) is an imaging modality used primarily in interventional cardiology to characterize lesion morphology, quantify plaque significance, guide stent sizing, assess stent implantation, and identify procedural complications. Aim: This analysis aims to present a cost-effectiveness analysis and budget impact analysis of intravascular ultrasound for imaging in patients undergoing cardiac catheterization and percutaneous coronary interventions. Material and methods: A model evaluating the cost-effectiveness of IVUS-guided PCI versus PCI with the classic angiography-guided strategy was created. The analyses used a healthcare perspective of the payer - the National Health Insurance Fund (NHIF). The economic method chosen to evaluate IVUS is of the cost-utility analysis type. In addition, a cost-effectiveness analysis was conducted. Health benefits for patients in the applied model were measured as quality-adjusted life years (QALYs) and life-years added (LYs). Results: Performing IVUS-guided PCI generated an additional total cost of BGN 2,329.40 at 0.2660 additional QALYs and 0.4932 LYs gained, compared with PCI guided by conventional coronary angiography in patients with STEMI. Similarly, performing IVUS-guided PCI gener-ated an additional total cost of BGN 2,213.11 at 0.1363 additional QALYs and 0.2457 LYs gained, compared with PCI guided by conventional coronary angiography in patients with UA/NSTEMI. Conclusion: The IVUS-guided PCI strategy is a cost-effective option for intravascular imaging.

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DOI: 10.3897/bgcardio.30.e138709

Authors: E. Levunlieva, R. Lekova, K. Nenova, L. Dimitrov, D. Pechilkov, A. Kaneva

Abstract: Pulmonary embolism (PE) is a disease representing partial or complete obstruction by various types of emboli of one or more of the pulmonary bed vessels. It is relatively rare in childhood, but in recent years it is found more often in children. The aim of the study was to perform a retrospective analysis of age distribution, predisposing factors, clinical presentation, and manage-ment in children with proven PE not directly related to cardiac surgery over a 10-year period. Data of 14 children with a total of 15 episodes of pulmonary thromboembolism (PTE), hospitalized in the Clinic of Pediatric Cardiology, National Heart Hospital, Sofia, Bulgaria with evidence of pulmonary embolism for a period of 10 years were analysed. The children with PTE are 7 girls and 7 boys, aged 3 months to 17.5 years. In two of the cases (13%), PTE occurred under the age of 3 years, in 5 cases (33%) between the ages of 6 and 13 years, and in 8 (53%) between the ages of 13 and 18 years. The clinical manifestations included: tachypnea and dyspnea – 73% (n = 11), chest pain – 73% (n = 11), tachycardia – 67% (n = 10), asthenia/fatigue – 60% (n = 9), hypoxemia (SatO2 < 95%) – 53% (n = 8), hemoptysis – 13% (n = 2), acute hemodynamic collapse – 7% (n = 1). In the acute phase of the disease, the patients were treated using unfractionated heparin, low molecular weight heparin, interventional treatment with thromboaspiration and local fibrinolysis, as well as systemic fibrinolysis. The increasing incidence and the severity of the disease require a good knowledge of risk factors and symptoms, as well as the development of age-specific recommendations for diagnosis, management, and follow-up of the disease.

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DOI: 10.3897/bgcardio.30.e135697

Authors: V. Dimitrova, B. Vodenicharova, D. Dimitrov, P. Krastev

Abstract: Introduction: In recent years with the increase in the incidence of pulmonary embolism (PE) worldwide and the rapid development of new devices in interventional cardiology, there has been a tendency to expand the indications for the endovascular treatment of acute PE. Systemic thrombolysis significantly reduces mortality in patients without contraindications for the procedure but at the cost of an increased risk of bleeding. High mortality with a conservative approach in patients with high-risk PE and contraindications for fibrinolysis, as well as moderate-risk patients with a lack of clinical response to optimal anticoagulant therapy, requires a more selective treatment approach to ensure an inevitable positive hemodynamic response. Catheter-based therapy (CBT), including mechanical thrombus fragmentation and selective thrombolysis, is a combined approach with potentially increased efficacy and safety over systemic thrombolysis. In the published literature there is a lack of sufficient data on the application of this therapeutic strategy as a first-line treatment for PE. Large, randomized trials are needed to confirm the value of CBT in these patient groups and to establish precise criteria and recommendations for the initial and follow-up monitoring during treatment. Aim: To evaluate the safety and efficacy of CBT in high- and moderate-risk patients with acute PE as an initial treatment strategy at one-year follow-up. Material and methods: For the period of May 2021- 2024, a total of 35 patients with acute PE were treated in our clinic. In this retrospective study, 23 patients were included, in which a decision was made to conduct CBT as a primary strategy, (in one case there is not a long enough follow-up at this stage). The remaining 8 patients were treated conservatively with low-molecular-weight heprain (LMWH), and the systemic thrombolysis in three of patients was administered. Demographic indicators, history of deep venous thrombosis (DVT), hemodynamic status on admission, non-invasive and invasive parameters of right ventricular burden, contraindications for fibrinolysis, fatal and non-fatal post-procedural complications were recorded. The clinical follow-up is in-hospital conditions, at 6 and 12 months in terms of mortality, manifestations of heart failure, bleeding and hospitalization for PE relapse. All patients in the study group underwent right heart catheterization according to a standardized protocol. CBT includes defragmentation of the thrombi using a Pigtail catheter and selective fibrinolysis with recombinant tissue plasminogen activator /r-TPA, alteplase/ with a dosage of 0.3 mg/kg. Results: The PESI score, which evaluates 30-day mortality in patients with acute pulmonary thromboembolism based on 11 clinical criteria, was used for risk assessment The studied cohort included patients with very high and moderately high risk and an estimated PESI score in the III-V range. CBT was technically successful in 100% (n = 23) of patients. The overall clinical success of the procedure, defined as haemodynamic stability, reversal of hypoxia, reduction of respiratory rate and improvement of peripheral perfusion was achieved in 90.4% of patients. During the hospital stay, 2 deaths were registered (8.69%), the fatal outcome being due to treatment-refractory cardiogenic shock in the first case (the patient died 24 hours after admission) (4.35%) and haemorrhagic stroke in the second (4.35%). In the remaining patients, not a single haemorrhagic incident as well as serious periprocedural complications, were detected. The comparative analysis between echocardiography and invasively assessed pulmonary artery pressure (PAP) before and after the CBT shows that the decrease in the mean PAP (m-PAP) after the treatment is statistically significant - on average 10 mm Hg, which suggests a positive effect of the treatment. During the 6-month follow-up, two more deceased patients were registered – an 81-year-old woman with previous melena before treatment for PE, and with a new episode and a large drop in haemoglobin, sent for treatment to a gastroenterology department, and a second patient with an unclear cause of death - probable sudden cardiac death (SCD). (Mortality at 6 months is 8.6%). Up to 12 months, no other adverse cardiovascular events were observed in the remaining patients. Conclusion: Our experience in endovascular therapy of acute PE showed that the methodology is both therapeutically and prognostically effective, but also low-risk for the patient. A large, randomized trial is needed before the technique can be recommended as a first-line treatment.

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DOI: 10.3897/bgcardio.30.e139492

Authors: M. Peneva, G. Vladimirov, H. Mateev

Abstract: Aims: Patients with residual perfusion defects and echocardiographic signs of pulmonary hypertension (PH) are referred for chronic thromboembolic pulmonary hypertension (CTEPH) evaluation. The first aim of this study was to test an echocardiographic index as a screening marker for pre-capillary PH. The secondary aim was to assess its potential for PH type discrimination. Methods and results: The single-center’s retrospective cohort included 79 patients divided by gender, age, presence of chronic perfusion defects diagnosed by computer tomography (CT) or angiography, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (TAPSE/sPAP), right ventricle (RV) basal diameter, the ratio (TAPSE/sPAP)/RV x 100, PH groups – CTEPH/pre-capillary, combined pre- and post-capillary (CpcPH) and isolated post-capillary (IpcPH) and no PH. From a total of 79 patients – 43(54%) men and 36(46%) women at a mean age of 65, residual clots were detected in 42(53%). Analysis of invasive haemodynamic and echocardiographic data diagnosed no PH in 22 (28%), IpcPH – 25 (32%), CpcPH – 16 (20%) and CTEPH - 16(20%). There was a statistically significant difference in the mean index values between all PH subtypes groups (p < 0.001). Further analysis proved (TAPSE/sPAP)/RV x 100 to be statistically significant discriminator of PH subtypes and defined patients with a value above 1.79 as likely having no PH, leading post-capillary PH in the range of 0.83-1.79, pre-capillary PH < 0.52 (p < 0.001). Conclusion: The index might serve as a screening method for CTEPH and possible PH type discrimination.

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DOI: 10.3897/bgcardio.30.e137573

Authors: T. Shalganov, I. Baltov, R. Ralchovski, I. Dostov, M. Stoyanov

Abstract: Inadvertent vagal denervation has been reported as an adjunctive effect during pulmonary vein isolation (PVI) for atrial fibrillation (AF). However, it is not known how frequent and durable this effect is during thermal ablation. Material and methods: This is a retrospective study of consecutive patients with AF and first PVI in sinus rhythm using radiofrequency or cryogenic energy. We studied the incidence of non-targeted and non-transient heart rate (HR) acceleration, induction and abolition of vagal reflex (VR), as well as the durability of the HR increase at the end of the first month. Results: PVI was carried out in 102 patients (cryo, n = 46). Overall, 60 patients (58.8%) had inadvertent neuromodulation, presented by VR induction and abolition (n = 18, 17.6%) and predominantly by HR increase (n = 50, 49%). In patients with vs those without HR acceleration the mean HR increase at the end of the procedure was 14.2 ± 5.64 bpm vs. -2.63 ± 5.43 bpm, and at the next day – 10.6 ± 7.53 bpm vs. 3.68 ± 7.75 bpm (p < 0.001 for all). The mean HR at 1 month was 74.2 ± 9.91 bpm vs. 68.9 ± 12 bpm (p = 0.048). Patients with a durable HR increase were younger (median age 61 vs. 65.5 years, p = 0.016) and less frequently had heart failure with reduced ejection fraction (1% vs. 6.9%, p = 0.031). Conclusion: Inadvertent neu-romodulation occurs in more than half of the patients with radiofrequency or cryo PVI for AF. It is mostly represented by a HR increase and persists for up to at least one month post-procedurally.

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DOI: 10.3897/bgcardio.30.e134809

Authors: D. Hristov

Abstract: Atherosclerosis is a generalised process with a long latent period. Its manifestations in the context of ischemic heart disease are acute coronary syndrome and chronic coronary syndrome. Vascular inflammation is an integral part of the development and complications of atherosclerosis. Although primary and secondary prevention of ischemic heart disease has received much attention in clinical practice, the role of vascular inflammation remains incompletely understood and studied. Pentraxin 3 is an inflammatory biomarker that has the potential to be used for diagnostic and prognostic purposes in cardiology due to its local secretion from the vascular endothelium with peak values in the setting of acute coronary syndrome within 6-8 hours from symptom onset. The aim of this review is to examine the available evidence in the literature for its use in patients with ischemic heart disease.

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DOI: 10.3897/bgcardio.30.e129108

Authors: G. Voynova, P. Kalaydzhiev, R. Ilieva, G. Nikolova, D. Markov, S. Yakov, Ts. Kotsev, N. Georgieva, A. Hristova, L. Shopov, E. Kinova, A. Goudev

Abstract: The individual approach in the treatment of heart failure (HF) and personalized medicine have been the main topic in recent years in all scientific forums. The combination of chronic obstructive pulmonary disease (COPD) and sleep apnea (SA) further complicates the clinical presentation in patients with HF. The overlap of all three diseases requires a team of specialists and additional therapeutic approach for better control and to improve the prognosis. A large number of the pathophysiological mechanisms of the three diseases also overlap. The novel therapies for HF have shown good results, both in COPD and CA subgroups. Noninvasive ventilation during hospitalization and at home is an established method in the individual groups. In a combination of the three diseases, definitive data from randomized trials are still lacking.

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DOI: 10.3897/bgcardio.30.e136583

Authors: I. Bayraktarova

Abstract: Pulmonary thromboembolism (PE) related mortality worldwide is decreasing due to current therapeutic advances. However, PE remains the third leading cause of death in developed countries and its incidence is increasing. Timely diagnosis and appropriate therapeutic measures are extremely important in clinical practice. Echocardiography (EchoCG) remains a preferred imaging technique at the bedside for both primary diagnosis and individual patient risk determination, and provides invaluable information regarding general hemodynamics in emergency situations. The development of the methodology in recent years adds new parameters to the classic image of the patient with PE. In this review, modern approaches for risk stratification of patients with PE by means of echocardiography and the role of echocardiography in the diagnosis of the disease are considered.

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DOI: 10.3897/bgcardio.30.e143668

Authors: Aleksandar Aleksandrov

Abstract: Editorial

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DOI: 10.3897/bgcardio.30.e123529

Authors: A. Venkatesh, A.R. Raghuram, A.M. Kumar

Abstract: Introduction: Heyde syndrome is a multisystem disorder characterized by the triad of aortic stenosis, acquired coagulopathy (von Willebrand syndrome type 2A) and gastrointestinal angiodysplasia. The diagnosis of Heyde syndrome in adults is challenging because of high frequency of aortic stenosis and gastrointestinal angiodysplasia. Clinical suspicion is therefore essential for diagnosis. Case Presentation: We present the case of a male with recurrent hospital admissions and transfusions for anemia post bleeding per rectum who was diagnosed to have Heyde’s syndrome. The patient was managed with aortic valve replacement and coronary artery bypass surgery involving left anterior descending artery. He remained symptom free 1 year after appropriate therapy. Conclusions: The management of aortic stenosis in patients with Heyde syndrome results in resolution of anemia. Hence, treatment decisions are based on correct identification.

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DOI: 10.3897/bgcardio.30.e125148

Authors: M.R. Logesh, A. Speedie, O.K. George, A.G. Alex, R. Karuppusamy

Abstract: Background: Data on balloon-assisted techniques (BAT) for transcatheter closure (TCC) of ostium secundum atrial septal defect (ASD-II) is scarce. The objective was to study the outcomes of the balloon-assisted technique (BAT) for transcatheter closure (TCC) of ostium secundum atrial septal defect. A single-centre retrospective study of patients with ostium secundum ASD who underwent balloon-assisted TCC. Results: This study included 36 patients. Thirty-three out of 36 patients with ASD-II and complex morphological features underwent successful BAT TCC. Our cohort of patients had a high prevalence of inadequate/floppy Aortic (90%), Posterior (40%) and Superior/Right upper pulmonary vein (25%) rims. Procedural success was defined as stable device position on post-procedure echocardiogram at 24-48 hours with no residual shunt. BAT was successful in 33 out of 36 patients (91.6%). The mean ASD size with BAT success was 27 mm. BAT was unsuccessful in 3 out of 36 patients. The combined deficiency and floppy nature of the Aortic, Superior, and Posterior rims was the reason for the failure of the Balloon-assisted technique along with the large size of ASD-II. BAT-failed patients were referred for emergent surgical device retrieval and closure of the atrial septal defect. No procedure-related mortality was encountered. Conclusions: Balloon-assisted device closure of ASD had a 90% success rate. BAT is a safe and effective technique in patients with large ASD-II. This technique enables controlled device delivery and alignment when conventional techniques fail.

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DOI: 10.3897/bgcardio.30.e127924

Authors: L. Bardarska, K. Genova, Z. Shomanova, T. Chamova, I. Tournev, M. Gospodinova, A. Kaneva

Abstract: Mitochondrial diseases are rare and heterogeneous conditions frequently affecting the heart. They are caused by mutations in nuclear or mitochondrial DNA with maternal inheritance or de novo occurrence. We present a case of 13-year-old girl with malignant mitochondrial cardiomyopathy. First presentation of the disease is with tamponade and atrial fibrillation. Cardiac imaging shows non-specific changes of the left ventricle that cannot be explained by any cardiomyopathy: hypertrophy, dilation, hypertrabeculation. These findings raised the suspicion for mitochondrial cardiomyopathy. The patient is examined by neurologist due to multisystem character of the disease. Electromyography reveals myopathy. Serum lactate and creatine phosphokinase are elevated. Acute inflammation is excluded with endomyocardial biopsy which also discovers complex III deficiency. Genetic testing identified likely pathogenic mutation in mitochondrial DNA with maternal inheritance. Two years after initial presentation patient was referred for cardiac transplantation due to fast progression of the disease. Mitochondrial cardiomyopathies have variable clinical manifestation which impedes the diagnosis and makes impossible the creation of unified criteria. The disease often affects various organs with high oxygen demand. Multiparametric approach and multidisciplinary team are recommended to increase diagnostic accuracy.

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DOI: 10.3897/bgcardio.30.e130390

Authors: E. Nuellari, E. Kapedani, S. Kuci, A. Kenga

Abstract: The aim of this study was to demonstrate a case of aorto-carotid bypass in a patient with carotid artery stenosis as a reasonable and necessary method for preventing ischemic stroke. The study was conducted at the University Hospital Center “Mother Teresa” (QSUT), Tirana. A 63-year-old patient with atherosclerotic arteriopathy and hypertension presented with episodes of dizziness and syncope. Doppler echocardiography revealed an increase in blood flow velocity in the right and left carotid arteries by more than 2.5 times. Computed tomography angiography visualised stenosis of the right and left common carotid arteries, stenosis of the brachiocephalic trunk at the beginning, and occlusion of the left subclavian artery. Performed revascularization of the common carotid arteries using a bifurcated 14×7 mm Dacron graft. The proximal end of the graft was anastomosed to the ascending aorta, and the distal ends were connected to both common carotid arteries. Follow-up Doppler echocardiography showed normalization of blood flow velocity in the carotid arteries. The patient’s neurological symptoms completely disappeared. The patient was discharged without complications after 10 days. The method of resolving complex multisegmental stenosis by aorto-carotid bypass ensures optimal perfusion of the brain and is proposed for use in appropriate conditions for the prevention of ischemic stroke.

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DOI: 10.3897/bgcardio.30.e126760

Authors: Z. Shomanova, H. Welp, R. Schmitz, J.R. Sindermann

Abstract: The follow-up of pregnant patients with cardiomyopathies is a challenge that every cardiologist will be facing sooner or later. We present the first case of a patient with restrictive cardiomyopathy and Alpha-B-crystallinopathy (distal myopathy type), who was followed up during two pregnancies. Cardiac follow-ups were carried out by short-term clinical status monitoring, echocardiography, ECG monitoring and NT-proBNP. At the same time, foetal ultrasound scans should be performed. Follow-up requires constant communication between the cardiologist and the gynaecologist. Any decision concerning the mother or the foetus should be made by consensus between both teams. Despite good follow-up, pregnancy in such complex patients remains a high risk due to heart. Heart failure and neuromuscular symptoms can worsen during or after pregnancy.

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DOI: 10.3897/bgcardio.30.e127156

Authors: P. Angelova, N. Stoyanov, V. Velchev, S. Atemin, M. Sleptsova, T. Todorov, D. Gencheva, M. Gospodinova, D. Pechilkov, A Dasheva, T. Tchamova, A. Taneva, I. Tournev, V. Mitev, A. Todorova

Abstract: Introduction: Cardiomyopathies are a clinically and genetically heterogeneous group of diseases, that are associated with significant morbidity and mortality. The aim of the present study is to clarify the molecular-genetic characteristics of cardiomyopathies in patients in Bulgaria. Material and methods: In the present study, targeted analysis of an expanded panel of 242 genes, associated with cardiomyopathy, and an additional panel of 20 genes, associated with hereditary amyloidosis, was performed in a total of 20 Bulgarian patients, diagnosed with cardiomyopathy, as follows: 12 patients with hypertrophic cardiomyopathy (HCM), including 1 pediatric patient, 6 patients with dilated cardiomyopathy (DCM), of whom 2 pediatric patients, and 2 patients with restrictive cardiomyopathy (RCM). Family segregation analyses were performed by direct Sanger sequencing. Results: Genetic findings were present in 90% of the patients. Pathogenic/likely pathogenic variants were found in 12 of the patients (60%), while genetic findings related to the clinical symptoms were not detected in the RCM patients (10%). Approximately 1/3 of the patients had a family history of sudden cardiac death or cardiomyopathy. Pathogenic/likely pathogenic variants were found in 55% of HCM patients with no family history, in ~67% of HCM patients with family history or with sporadic DCM, and in 100% of DCM patients with a positive family history. A respectively 2,5 and 4-fold higher frequency of truncating variants was found in the study group compared to the reports of around 10% in the literature, both in patients with HCM, and in patients with DCM. Pathogenic/likely pathogenic variants in the MYBPC3 gene (71%) were found with the highest frequency in HCM, while DCM is characterized by a diverse genetic profile, and genetic findings in the NDUFB11 and TAZ genes were associated with severe clinical presentation in pediatric patients in the first postnatal days. Results of segregation analyses were reported in 6 of the affected families. Conclusion: The data from the present study supports the importance of conducted genetic testing and medical-genetic counseling in patients and affected families with cardiomyopathy in Bulgaria

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DOI: 10.3897/bgcardio.30.e122119

Authors: Z. Vassileva, R. Lekova, A. Kaneva

Abstract: Infective endocarditis (IE) is a rare entity in children and predominantly affects patients with congenital heart defects (CHD). Our study assesses the association between the time to diagnosis of IE and the time to surgery and outcome. The mean period from initial symptom presentation to diagnosis confirmation was 38 days (3-180 days). 12 patients (60%) had an early diagnosis (< 30 days), while in 8 cases (40%) the diagnosis was delayed (>30 days). 75% of the patients with a delayed diagnosis had received prior antibiotic therapy vs. 58% of the children with an early diagnosis. All 3 children with lethal outcomes had received prior antibiotic therapy, in two of the cases the diagnosis of IE was early, and in one case it was delayed. In conclusion, empiric antibiotic therapy is associated with a delayed diagnosis of infective endocarditis, and the longer the time to surgery the greater the risk for unfavorable patient outcome.

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DOI: 10.3897/bgcardio.30.e125503

Authors: P. Moraliyska, P. P. Lazarov, E. Pashkuleva-Dermendzieva, S. Barakova, E. Georgieva

Abstract: We present a clinical case of a 20-year-old woman with acute myocardial infarction with persistent ST-segment elevation (STEMI). The coronary angiography performed on the patient showed coronary vasospasm with no evidence of atherosclerotic plaque. The aim of this case report is to draw attention to the different types of myocardial infarction, other possible differential diagnoses (DD), and to the investigations necessary for determining a definitive diagnosis.

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DOI: 10.3897/bgcardio.30.e127340

Authors: S. Stefanov, N. Stoyanov, N. Koleva, D. Mikova, A. Yordanov, Z. Pavlova, E. Kinova, I. Petrova, L. Demirevska, T. Todorov, T. Chamova, M. Garcheva, A. Kundurdjiev, A. Todorova, I. Tournev, Y. Palashev, I. Daskalov, M. Dimova, I. Gruev, Y. Yotov, A. Goudev, V. Velchev, Mariana Gospodinova

Abstract: Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) is a severe progressive disease, more common than previously expected. The main objectives were to evaluate hereditary and wild type ATTR-CM frequency and clinical manifestations. Material and methods: One hundred seventy-eight patients at mean age 68 ± 13 years (129 males), referred by cardiologists with suspected cardiac amyloidosis (left ventricular wall thickness ≥ 12 mm and red flags) were evaluated. Pyrophosphate scintigraphy (99mTc-PYP) grade 2-3 myocardial uptake in the absence of monoclonal protein confirmed the diagnosis. Genetic test differentiated variant from wild type ATTR-CM. Endomyocardial biopsy with amyloid typing was performed in two patients. Results: Cardiac amyloidosis was diagnosed in 69 patients: light chain in 24 (13%) and ATTR-CM in 45 patients (25%). Wild type (ATTRwt) was found in 21 (12%) male patients at mean age 81 ± 6 years and variant type (ATTRv) in 24 patients (13%) at mean age 58 ± 7 years (15 males). In all ATTRv-CM patients some degree of peripheral polyneuropathy was found. The most common clinical red flags at diagnosis in both ATTRv and ATTRwt were heart failure in all patients, atrial fibrillation (16; 36%), pacemaker (5; 11%), and carpal tunnel syndrome (8; 18%). Severe aortic stenosis (4; 19%), spinal stenosis (2;10%), biceps tendon rupture (1; 5%) were characteristic for the wild type. At follow up, four patients needed a pacemaker for high degree AV block, six patients developed new onset atrial fibrillation, seventeen patients needed either initiation or an increase of the dose of loop diuretic, another 7 patients were hospitalized for heart failure exacerbation. Eight patients (18%) died, 7 (33%) with ATTRwt-CM and 1 (4%) with ATTRv-CM, all with advanced heart failure, 4 with concomitant severe aortic stenosis. Conclusions: This study provides the first nationwide estimates of the frequency and the clinical manifestations of ATTR-CM. Confirming the severity of the disease and poor prognosis, a low threshold for screening is needed for early diagnosis and timely treatment.

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DOI: 10.3897/bgcardio.30.e128344

Authors: A. Partenova, D. Kostova-Lefterova, E. Tasheva-Terzieva, V. Grudeva, K. Genova

Abstract: Introduction: Parametric mapping is a non-invasive method to quantify tissue changes in the myocardium by measuring T1, T2 and T2* relaxation times and extracellular volume, requiring a pre-established range of normal values. Purpose: To establish reference values for native T1 and T2 myocardial relaxation times in healthy subjects on 1.5 T magnetic resonance imaging and to assess changes in their values according to left ventricular segments, age, sex, heart rate, and myocardial thickness. Material and Methods: A prospective 1.5 T magnetic resonance imaging study was performed with the voluntary participation of 50 healthy individuals in different age groups. Image analysis was performed by a radiologist with 5 years of experience in the field of CMRT and further coordinated with a radiologist with more than 20 years of expe-rience in the field. Siemens ARGUS integrated software was used to calculate the volumes and function of both cameras. Global and segmental T1 and T2 values were measured in the shortaxis midlevel section by manually delineating the region of interest. Myocardial thickness of the mid septum was measured for each patient. Results: The distribution of volunteers was 25 men and 25 women. Significantly higher global T1 values were observed in women (1027.7 ± 25.4 ms) compared to men (992.9 ± 24.4 ms), at p < 0.001. The same correlation was observed in individual segments, with a significant difference between genders. Examination of the correlation between T1 and other parameters demonstrated a negative linear relationship only with myocardial thickness. Global T2 in women (48.6 ± 2.49 ms) was also significantly higher than in men (44.6 ± 2.06 ms), with an observed difference of 3.95, p < 0.001. Global T2 showed a very strong negative correlation with myocardial thickness (r = -0.769; p < 0.001). There was no sig-nificant correlation between T2 times and heart rate and age of patients. Conclusion: A statistically significant difference in native T1 and T2 values by sex was demonstrated. The use of sex-specific reference values to distinguish healthy from pathologically affected myocardium is recommended.

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DOI: 10.3897/bgcardio.30.e125882

Authors: S. Yambolov, R. Grigorov

Abstract: Colchicine, one of the oldest medications still in use, is a relatively inexpensive and well-tolerated agent with a documented role in a range of inflammatory diseases, such as gout, Behchet’s disease and pericarditis. In recent years, different clinical trials also tested colchicine in the management of cardiovascular conditions and demonstrated favorable results. The aim of this literature review is to evaluate the prospective use of colchicine instead of aspirin as double-antiplatelet therapy (DAPT) after percutaneous coronary interventions in patients with acute coronary syndrome.

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DOI: 10.3897/bgcardio.30.e128810

Authors: T. Boneva, V. Groudeva, K. Karamfiloff

Abstract: Myocardial interstitial fibrosis (MIF) occurs in several ischemic and non-ischemic cardiomyopathies and is associated with left ventricular dysfunction and progression to heart failure (HF). MIF exists in two types – reparative and reactive with different origin and molecular mechanisms. Although MIF arises mainly because of alterations in collagen turnover leading to collagen fiber accumulation, there are also qualitative changes in collagen fibers in cardiac diseases. There are several studies for cellular and molecular mechanisms and his role in cardiac function, biomarkers and potential target therapies.

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DOI: 10.3897/bgcardio.30.e128352

Authors: V. Groudeva, А. Partenova

Abstract: Hypertrophic cardiomyopathy (HCM) is one of the most common form of cardiomyopathies. It is characterized by primary hypertrophy, disorganization, and fibrosis of the myocardium. These morphological characteristics determine the applicability and significance of magnetic resonance imaging in the evaluation of these patients. Cardiac magnetic resonance helps the diagnostic process by identifying hypertrophic segments, which are less accessible by echocardiography ensures more precise measurements of wall thickness and differentiates HCM from other causes of left ventricular hypertrophy. The method allows for not only qualitative but also quantitive evaluation of focal and diffuse fibrosis which plays an important role in evaluation of patients’ prognosis and follow up. The aim of this article is to review the role of cardiac magnetic resonance in the diagnosis of HCM, demonstrating different forms and their typical morphological features, as well as to demonstrate the role of the method in the differential diagnosis of myocardial hypertrophy.

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DOI: 10.3897/bgcardio.30.e127290

Authors: N. Koleva, Y. Yotov, K. Dzhinsov, I. Gruev, M. Gospodinova

Abstract: The 2023 European Society of Cardiology guidelines for the management of cardiomyopathies (CM) provide practical recommendations for diagnosis and treatment. They emphasize on the need for a systematic clinical evaluation beginning with clinical suspicion of CM and using a multiparametric approach that leads to classification of CM into one of five distinct phenotypes. А cardiomyopathy mindset, together with a multidisciplinary approach are crucial. Further investigations, including advanced imaging and genetic testing, are needed to make a phenotype-based etiological diagnosis. Detection of pathogenic genetic variants allows risk stratification of sudden cardiac death, where new recommendations are available regarding primary prevention. Therapeutic options are expanded with the approval of a new class of drugs for the treatment of symptomatic hypertrophic cardiomyopathy with left ventricular outflow tract obstruction. Specific exercise recommendations are given and reproductive issues in patients with CM are addressed. The lack of reimbursement by the National Health Insurance Fund (NHIF) of genetic testing and the severely limited reimbursement of some imaging methods are a significant problem in Bulgaria, which leads to difficulties in implementing the new guidelines.

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DOI: 10.3897/bgcardio.30.e134498

Authors: Mariana Gospodinova, Kameliya Genova

Abstract:

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DOI: 10.3897/bgcardio.30.e118587

Authors: Zh. Kolev, D. Topalov, A. Angelov, Zh. Ilieva

Abstract: Drug induced bradycardia is a frequent reason for hospitalization in cardiology clinic. Knowing the causes of this type of bradycardia is important for the proper management of these patients. Pyridostigmine bromide is an indirect parasympathomimetic drug, inhibitor of the cholinesterase enzyme. Pyridostigmine decrease the breakdown of acetylcholine, which is the natural neurotransmitter of the electrical impulses send by the somatic and parasympathetic nervous systems. Despite its relative safety and effectiveness, in rare cases there have been reports of conduction disturbances of the heart. In this clinical case report, we present a patient with atonic bladder treated with pyridostigmine. The patient developed a rare adverse reaction of the drug with an induced second-degree аtrioventricular block 2:1 type. The bradycardia caused pronounced symptoms which forced hospitalization in intensive cardiology clinic.

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DOI: 10.3897/bgcardio.30.e114526

Authors: P. Iliev, D. Hazarbasanov, Em. Azis, D. Farandzha, P. Pavlov

Abstract: Large bore access vascular closure devices (VCDs) are used to achieve immediate haemostasis after large device percutaneous procedures through the common femoral artery. Such a device or a combination of devices provide early patient ambulation and recovery and avoid surgical complications, however they carry the risk of typical access-related complications seen with percutaneous interventions. In the case of transcatheter aortic valve replacement (TAVR) vascular access complications remain the some of the most common. The MANTA vascular closure device is widely used for access management after TAVR, providing closure for up to 20F or 25F OD devices in the 18F variant. We present a case of loss and restoration of percutaneous femoral arterial access during a TAVR procedure. The necessary guidewire for MANTA deployment was removed mistakenly but was subsequently recovered which enabled successful MANTA deployment afterwards. Postprocedural angiography and ultrasound all revealed successful vessel closure with no access-related complications.

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DOI: 10.3897/bgcardio.30.e117188

Authors: N. Dragnev, V. Valkov, N. Kalvachev

Abstract: We are presenting a clinical case of a 53-year-old woman with a sudden decline of the general condition during a stressful moment, respiratory arrest requiring intubation and intensive care unit transfer. Due to the clinical evidence of acute left-sided heart failure, ECG and echocardiographic evidence of acute coronary syndrome, invasive coronary angiography with left ventriculography was performed, demonstrating a non-occlusive coronary artery disease with signifi cant LAD stenosis and left ventricular kinetics indicative of a stress-induced cardiomyopathy. In the course of the treatment, the patient regained consciousness with favourable dynamics in the ECG, echocardiographic and laboratory fi ndings. A follow-up coronary angiography and intervention of the signifi cant LAD stenosis at a later stage were discussed with the patient.

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DOI: 10.3897/bgcardio.30.e120143

Authors: P. Nikolov, G. Goranov, G. Tonev, M. Aleksiev

Abstract: Left anterior descending artery (LAD) bypass via left internal mammary artery (LIMA) as an arterial graft in the cardiac surgical treatment of multivessel ischemic heart disease is the gold standard due to its long-term patency and durability compared to all other grafts. Acute LIMA thrombosis causing acute coronary syndrome is rare. Several cases of acute LIMA occlusion in the late postoperative period are described in the literature, as one of the patients died during the procedure and the others undergoing successful percutaneous coronary intervention (PCI). Here we report a case of probable thromboembolic event in the LIMA graft area 8 years after CABG causing an anterior acute anterior myocardial infarction with ST elevation and managed with aggressive pharmacotherapy.

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DOI: 10.3897/bgcardio.30.e120323

Authors: E. Dimitrova, D. Kyuchukov, M. Peneva, B. Kunev

Abstract: Chronic thromboembolic pulmonary hypertension is a rare condition that is usually a consequence of prior acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by organized thrombi resulting in redistribution of blood flow and secondary pulmonary microvascular remodelling. Thus, pulmonary vascular resistance and pulmonary artery pressure are increased leading to right ventricle pressure overload, development of right heart failure and death. In eligible patients pulmonary endarterectomy is the standard of care and it can result in complete normalization of haemodynamics and right ventricular morphology and function. We present the case of a patient with chronic thromboembolic pulmonary hypertension with severe right ventricular dilation and dysfunction and refractory heart failure. After successful pulmonary endarterectomy we observed almost complete normalization of hemodynamics and restoration of right ventricular dimensions and function, as well as significant clinical improvement.

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DOI: 10.3897/bgcardio.30.e116069

Authors: V. Netiazhenko, S. Mostovyi, O. Safonova

Abstract: The research relevance is predefined by the need to establish the relationship and identify new markers and potential contributions to clinical practice and scientific progress. This opens up new opportunities for further development in the field of cardiology and infectious diseases, which is of great importance for improving diagnosis and treatment. The research aims to establish the relationship between indicators and the role of endothelial dysfunction in the pathogenesis of various conditions. The clinical observation method was used, and data such as symptoms, medical history, and laboratory and instrumental studies were collected. The conclusions of the study are based on the analysis of the collected data and indicate the existence of a relationship between the indicators. The study revealed an increased activity of von Willebrand factor in the majority of patients. When comparing groups of patients depending on the presence of concomitant coronavirus disease, it was found that the highest level of von Willebrand factor was observed in patients with coronary heart disease in combination with coronavirus disease, a lower level in patients with coronavirus disease alone, and the lowest level in patients with chronic coronary heart disease. This indicates a correlation between the level of von Willebrand factor and the presence of concomitant coronavirus disease, which emphasises the importance of vascular endothelial dysfunction in the pathogenesis of coronary heart disease. It was found that the value of the von Willebrand factor correlates with the left ventricular end-diastolic size in both patients with coronary heart disease and patients with coronary heart disease in combination with coronavirus disease. This demonstrates that there is a strong association between von Willebrand factor and the clinical manifestation of coronary heart disease in combination with coronavirus disease, which may indicate a dysfunction of the vascular endothelium in these patients.

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DOI: 10.3897/bgcardio.30.e118905

Authors: Т. Velikov, А. Dacheva, G. Slavchev, Y. Seitaridou, E. Mekov, S. Dzhambazov, D. Vasilev

Abstract: Introduction: OCT is a noninvasive, contactless, optical method that uses infrared light to produce images of blood vessel anatomy, tissue microstructure, and stents during cardiac catheterization. Aim: This review aims to present a cost-effectiveness analysis and budget impact analysis of optical coherence tomography for imaging in patients undergoing cardiac catheterization and percutaneous coronary interventions. Methods: An incomplete economic analysis was chosen to evaluate the cost-effectiveness of OCT, in which only direct medical costs were assessed. The time horizon for estimating the costs and health benefi ts of OCT was one year. In addition, a budget impact analysis was conducted. Results: As a result of the incomplete economic analysis of the costs of OCT-guided PCI, it could be seen that the total cost per patient amounted to BGN 4,954.89. These costs include the unit cost of the device (OCT catheters) – BGN 2,000.00 including VAT, and the weighted average cost of the OCT-guided PCI procedure – BGN 2,954.89. Conclusion: The OCT-guided PCI strategy is associated with higher procedural costs but with more favorable clinical benefi ts, making it a cost-effective option for intravascular imaging in the long term.

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DOI: 10.3897/bgcardio.30.e117990

Authors: E. Levunlieva, K. Nenova-Karakasheva, A. Kaneva-Nencheva

Abstract: The fenestration in Fontan operation consists in creation of a communication between venous circulation and the pulmonary venous atrium, allowing direct passage of blood from the venous to the systemic circulation (right-to-left shunt). There is no general agreement concerning the mean pulmonary artery pressure (mPAP) level above which fenestration is indicated. There are no strict guidelines for the indications for fenestration closure as well. Here we present our data about invasive hemodynamic assessment before and after temporary closure of the fenestration in patients after Fontan operation. Our recommendations regarding comprehensive evaluation of patients with fenestrations after Fontan surgery are also presented.

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