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.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.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.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.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.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.e173631

Authors: Lubomir Balabanski

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.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.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.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.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.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.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.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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DOI: 10.3897/bgcardio.30.e119179

Authors: S. K. Vasilev, I. S. Petrov, Z. I. Stankov, Zh. D. Stoykova

Abstract: Endoleak represents the most common complication after endovascular aortic aneurysm repair (EVAR) and is defi ned as persistent perfusion of the aneurysmal sac, which subsequently could lead to its expansion and possibly rupture. There are different types of endoleaks, depending on their infl ow source, regardless of the number and type of other vessels involved in the outfl ow (endoleak type I A/B/С, type II, type III, type IV and type V). The current gold standard for the diagnosis of endoleak is the contrast-enhanced helical computed tomography (CT). Since, there is no generally accepted consensus for the best surveillance and treatment methods for this pathology, in this article we will present the most effective endovascular interventions for the successful management of the different types of endoleaks.

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DOI: 10.3897/bgcardio.29.e114208

Authors: S. Vasilev, S. Ivanova, A. Keltchev

Abstract: Cardiac implantable electronic devices (CIEDs) implantation procedure has a complication rate of 5-6% according to most studies. Lead perforation is a possible and serious adverse event which can present with a spectrum of symptoms from asymptomatic to sudden death. Diagnostic tools in case of suspected lead perforation are X-ray, transthoracic echocardiography, pacemaker interrogation and computed tomography with the last one being the gold standard. Lead extraction could be done endovascularly or surgically. Transvenous removal is a possible option for active fi xation leads, while removal of passive fi xation leads is preferably done surgically, because of the bulky tip of the lead, which could damage the heart chambers and the vessels. In this article, we present a case of a massive ventricular perforation from a passive fi xation lead, further complicated by a cardiac tamponade. Surgical removal was the treatment of choice with subsequent implantation of a permanent dual-chamber pacemaker.

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DOI: 10.3897/bgcardio.29.e102027

Authors: A. Alexandrov, H. Mateev, G. Vladimirov, I. Bayraktarova, I. Petrova, E. Kostova-Dimitrova

Abstract: Age is an important non-modifi able risk factor for cardiovascular disease. Both European and American guidelines recommend offering an invasive reperfusion strategy in elderly patients with ACS, taking into account the patients‘ comorbidities and baseline level of functioning. Materials and methods: All patients over 80 years of age with acute coronary syndrome, treated in the Department of Invasive Cardiology of the National Heart Hospital for the period between January 1, 2016. and December 31, 2018, are retrospectively analyzed. The primary endpoint was defi ned as all-cause mortality during the hospital stay and at follow-up. Predictors of mortality were assessed and independent predictors were identifi ed. Results: During the study period, 179 patients aged 80 years or older were identifi ed as being treated for ACS with PCI. In the study population, in hospital mortality for the index event was 11.8%. At a mean follow-up time of 20.19 ± 11.9 months, mortality rose signifi cantly to 64.6%. When evaluating in-hospital mortality on multivariate analysis, the two independent predictors were Cardiogenic shock (HR 0.005, 95% CI 0.01–0.44; p < 0.001) and acute/exacerbated renal failure (0.986 95% CI 0.984-0.997; p = 0.015). Conclusion: The present study provides important information regarding characteristics and outcomes in very elderly patients undergoing PCI for ACS. In the future, this subset of patients is predicted to grow, meaning that their approach must be evidence-based to ensure safe and effective treatment options.

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DOI: 10.3897/bgcardio.29.e100555

Authors: I. Zheleva-Kyuchukova, V. Gelev

Abstract: Background: Acute coronary syndrome with ST elevation (STEMI) with a lesion in the left main coronary artery (LMCA) occurs infrequently; moreover, patients are at very high risk for mortality. However, limited data are available regarding the prevalence, clinical characteristics, and outcomes of patients presenting with LM-STEMI treated with percutaneous coronary intervention (LM-PCI STEMI). Therefore, we aimed to evaluate patient clinical and procedure factors associated with in-hospital outcomes in LM-STEMI patients undergoing PPCI in a real-life registry. Material and methods: From 439 consecutive patients with LM disease treated with PCI in the prospective single-center Acibadem City Clinic UMHAT Tokuda registry enrolled between March 2013 and October 2022, we identifi ed 35 LM-PCI STEMI patients (8%). We analyzed baseline demographic, coronary lesion characteristics, procedural details and success, and in-hospital mortality. Results: Among 35 LM-STEMI patients, the mean age was 66.0 ± 16 years, and 69% were male – forty percent presented with cardiogenic shock (CS). The risk profi le of the overall study population was relatively high (mean Euro Score (ES) was 19.1 ± 22, while 54.3% were high risk with ES > 6). Radial access had a remarkably high proportion (68.6%), regardlessof coronary anatomic complexity being intermediate to high (mean Syntax Score (SS) was 29.5 ± 8,15, 42,9% had SS ≥ 32). The distal LM bifurcation was most commonly involved (82.9%), yet the provisional strategy (85.7%) was most often employed during emergent PCI. The observed overall in-hospital mortality rate was 25.7% (64.3% in pts presenting with CS vs. 23.5% without CS, p = 0.0166). Conclusion: STEMI from culprit LMCA lesion is associated with signifi cant mortality. Emergent LM PCI in unselected patients, including cardiogenic shock, is an appropriate and feasible treatment option for this high-risk group, with acceptable mortality and in-hospital survival rates.

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DOI: 10.3897/bgcardio.29.e100372

Authors: D. Kyuchukov

Abstract: Percutaneous coronary revascularization of the „culprit“ lesion is the most contemporary method of treating patients with acute coronary syndrome (ACS) of all forms. In the management of acute ST-elevation myocardial infarction (STEMI), cardiac surgery remains, in most cases, a third option following PCI and thrombolysis, nevertheless serves an important role in a select subgroups of patients. This review will discuss current indications and potentiality of cardiac surgery in the treatment of patients with STEMI.

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DOI: 10.3897/bgcardio.28.e89444

Authors: V. Dimitrova, I. Petrov, N. Zlatareva

Abstract: A 27-years old female patient presented with a severe general condition of generalized edema and hypotension. Two months earlier computed tomography imaged thrombosis of the inferior vena cava and the three hepatic veins, or Budd-Chiari syndrome (BCS). Additional findings were thrombosis of the right common iliac vein and thrombosis of the renal veins bilaterally. Genetic testing proved congenital thrombophilia. Anticoagulation therapy did not affect thrombotic occlusions. In another cardiovascular center, an unsuccessful attempt for interventional treatment of the inferior vena cava with a jugular approach was made. The patient was admitted to our hospital for further evaluation and decision on treatment strategy. Laboratory and non-invasive imaging at admission rejected hepatic cirrhosis. An abdominal ultrasound scan demonstrated complete occlusion of the three hepatic veins and post hepatic portal hypertension. When thrombosis of all hepatic veins was detected transjugular intrahepatic portosystemic shunt (TIPS) was an option. An endovascular strategy for inferior vena cava was undertaken and complete revascularization was achieved with the right femoral approach as a bridge to TIPS shunt procedure, since the patient didn’t meet the criteria for liver transplantation. In diagnosing disease, the main contributors were the gastroenterologist, diagnostic imaging specialist, and hematologist, while the multidisciplinary team included also cardiologist, interventional cardiologist, and angiologist. In this case the multidisciplinary decisions played a major role in diagnosing and building an appropriate therapeutic strategy for systemic illnesses and conditions for which medical guidance does not yet have clear guidelines.

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DOI: 10.3897/bgcardio.28.e89578

Authors: A. Zagorska, V. Gelev, I. Jeleva, N. Stoyanov, D. Ivanova

Abstract: Introduction: Medical professionals performing fluoroscopy guided interventional procedures in cardiology are exposed to a risk of radiation induced cataract, especially if the eye lens dose exceeds the annual dose limit of 20 mSv. Aim: The aim of the current study is to measure the eye lens exposure in three interventional cardiology departments, to analyze the relationship between patient dose and eye lens dose and to study the effectiveness of lead goggles without side protection. Material and methods: Measurements were performed in three departments with participation of 4 interventional cardiologists and 6 nurses. The exposure of the eye lens was measured with EYE-DTM (Radcard) passive dosimeters. Results: For nurses the annual eye lens dose varied from 1.6 mSv to 4.3 mSv. For the interventional cardiologists the results were between 3.2 mSv and 31.4 mSv. The dose reduction factor of the studied safety goggles without side protection is 1 and 1.1. Conclusions: There is a risk of exceeding the annual exposure limit of 20 mSv among interventional cardiologists The eye lens exposure depends on the workload and the clinical complexity of the procedures, as well as on the use of radiation protection devices. Due to the specifics of the procedures, the use of goggles with side protection is recommended. The eye lens dose for nurses is lower than the annual limit, which can be explained with the larger distance between the patient and the nurses and partial shielding by the main operator. Lead glasses without side shielding are not recommended because the exposure occurs from the side.

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DOI: 10.3897/bgcardio.28.e86417

Authors: I. Tasheva, M. Miletieva

Abstract: Background: The coronavirus disease (COVID-19 disease) leads to multiple organ disease, inflammation of the endothelium, and micro- or macrovasculitis that may result in thrombosis of the small vessels, and thrombosis of vessels in various organs, as well as intracardiac thrombosis. Some of the complications may be long-lasting, as in our case, which makes it particularly interesting to discuss. Case report: We present a 73-year-old male patient with a history of permanent atrial fibrillation and chronic heart failure (II NYHA class), popliteal phlebothrombosis, and surgery of the left hip joint. 53 days after a positive rapid test for Covid 19 performed because of fever and coughing, the patient, who is not vaccinated for Covid 19, was hospitalised at our Department with clinical signs of mild respiratory failure and cardiogenic shock. The laboratory tests revealed elevated markers of inflammation. The ECG showed tachyarrhythmia (170/min) and atrial fibrillation. The EchoCG displayed evidence of right systolic dysfunction, pulmonary hypertension, and a massive thrombus in the right atrium. The Doppler ultrasonography revealed the presence of right femoropopliteal thrombosis, while the CT-pulmoangiography showed evidence of massive bilateral PE. A decision was made to perform systemic fibrinolysis, which the patient tolerated without complications. During the hospitalisation, the examinations revealed no evidence of an oncological disease. Conclusion: The reported clinical case confirms the high risk of thrombosis due to a COVID-19 infection, such as phlebothrombosis, atrial thrombosis, and massive bilateral PE, in the absence of optimal anticoagulant therapy and against the backdrop of the administration of antiplatelet therapy roughly 2 months after the onset of the COVID-19 symptoms.

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DOI: 10.3897/bgcardio.28.e91048

Authors: S. Vasilev, I. Petrov, Z. Stankov, L. Janevska, G. Adam

Abstract: Atherosclerosis is the major cause of cardiovascular diseases (CVD) in the world. It is a multifocal disease that leads to plaque formation and subsequent ischemia in the arteries of the body. Atherosclerotic obstructive peripheral artery disease causes disturbance of blood delivery to the tissues, which can be translated as temperature decrease on the skin surface, making surface temperature an important indicator of vascular health. Even though there are many classical diagnostic tools for assessing patients with peripheral vascular dysfunction, they have many limitations. On the other hand, infrared thermography imaging presents a noninvasive, relatively cheap, quick and reliable method that does not require direct doctor-to-patient contact. It provides a real time screening information of the tissue perfusion, based on the skin surface temperature. In this article, we present a case of a patient with type B aortic dissection, treated with an endovascular approach. A postprocedural closure device complication led to an acute left lower limb ischemia during the night, which was promptly diagnosed with the help of an onsite high-resolution infrared thermography optimized by specialized AI based software performed by the physician on duty followed by remote evaluation by the operator. The obstruction was treated immediately with successful endovascular recanalization and flow restoration and again evaluated with the thermographic camera confirming excellent tissue vascular result. Infrared thermography imaging can be a time-saving method for physicians, while being a very convenient method for the patient and that is why we advocate on the usage of specialized software supported high resolution thermography imaging as a supplementary diagnostic modality for patients with peripheral artery disease.

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DOI: 10.3897/bgcardio.28.e79042

Authors: M. Mihalev

Abstract: Introduction: Conventional access through the radial artery (cTRA) is a standard approach in coronary interventions. Unfortunately, it carries a risk of long-term complications such as radial artery occlusion (RAO) and local complications, usually hematomas. Aim: Sharing initial experience in the application of distal transradial access (dTRA) on 134 patients, from single operator in one center and its applicability on patients with STEMI. Number of procedures required to get experience with this access, assessed by the degree of reduction of failed procedures. Materials and methods: From 08.03.21 to 18.11.21, 134 patients with dTRA (110 successful, 24 unsuccessful) were included in the study. dTRA is comsidered to be an access to the anatomical snuffbox. Completion of the entire procedure, not just a successful puncture or insertion of an introducer, was considered the access successful. Results: It was found that the success of the method was 82% of the criteria preset. Among the successful procedures, 48% were interventions. Of these, 71% had ACS and 43.6% had STEMI. The access was used on 3 patients who had CTO. Two patients underwent rotablation using a 7 in 6 Fr introduser. On 98% of the patients a 6 Fr introducer was used. Right dTRA was used on 93% of patients. From the 134 procedures performed, it was found that 92% of failures were up to the 80th procedures. After the 80’th procedures the frequency of failures decreased significantly. Complications ‒ 3 small hematomas and 2 numbness in the thumb, which did not require additional interventions. Conclusion: The procedure with dTRA was successfully completed by high percentage of patients, including the high-risk patients with ACS and STEMI. After the 80th dTRA procedure was reached level of skills with a low frequency of failed procedures. This suggests that dTRA can be an alternative to standard radial access to prevent radial artery occlusion, which has been confirmed by previous studies, better patient comfort, and lower risk of complications. The results were achieved without the need of reduction of the introducer’s diameter or use of special devices for hemostasis.

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DOI: 10.3897/bgcardio.28.e93484

Authors: I. Petrov, Z. Stankov, J. Stoykova, S. Vasilev

Abstract: Introduction: Arterial hypertension is the most common correctable risk factor for death worldwide. Achievement of therapeutic goal is hampered by multiple factors including non-adherence to drug therapy and individual physiological resistance. Objective: We aimed to determine the efficacy of renal denervation in lowering SBP and DBP at 1st and 6th month, in patients at high cardiovascular risk, in whom lowering BP would possibly also result in risk reduction and lower incidence of future cardiovascular events. Methods: The procedure was performed in 39 patients with resistant hypertension admitted to the University Hospital „Acibadem City Clinic – Cardiovascular Center“ (Sofia) for the period January 2017–June 2020. Access was via brachial artery and the Simplicity Spiral catheters were used, at an average of 19.5 ablation points per artery. The number of complications, as well as the mean systolic and diastolic BP values at 1st and 6th month were recorded. Baseline, risk profile and follow-up medical treatment of the study group was monitored. Results: In the study group, the predominant risk factors were dyslipidemia, age, diabetes mellitus, with 21 patients (53.84%) already having clinically significant atherosclerosis – a realized heart attack, stroke, peripheral or coronary revascularization. At follow-up, a significant reduction in both systolic and diastolic BP (blood pressure) values was observed. At the first month, the fall in SBP (systolic blood pressure) was –17.8 mm Hg, with a persistent reduction in the range of –14.5 mm Hg at 6th month. In terms of DBP (diastolic BP), the mean reduction at the first month was –8.9 mm Hg and at the 6th month it was –7.2 mm Hg. Regarding antihypertensive treatment, there was a mild reduction in the intake of antihypertensive drugs. Conclusion: Substantial proportion of people with hypertension have uncontrolled hypertension (both treatment resistant and due to non-adherence to treatment or due to additional pathophysiological mechanisms). Renal denervation has proven effective and safe in patients with uncontrolled hypertension and high cardiovascular risk profile

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DOI: 10.3897/bgcardio.28.e91105

Authors: I. Petrov, Z. Stankov, J. Stoykova, G. Zlatancheva, S. Vasilev, I. Tasheva, K. Vaseva

Abstract: The most common localizations for upper extremity atherosclerosis are the subclavian artery and the brachiocephalic trunk. Significant stenosis of the subclavian artery occurs in 2% of the population and in 7-11% of patients with manifest cardiovascular disease. Revascularization is indicated in symptomatic or asymptomatic patients with coronary disease with planned surgical revascularization. In addition to atherosclerosis, other causes of the appearance of subclavian artery stenosis include dissection, radiation-induced inflammation of the fibromusculature, and various vasculities, especially Takayasu arteritis. The left subclavian artery is about four times more commonly affected than the right. It usually occurs over the age of 50 years and in 1.5-2 times more common in men than in women. Disease of the subclavian artery is usually focal and the lesion is predominantly in the first 2 cm proximal to the origin of the aorta. Between 2016-2021 in the clinic of cardiology and angiology we treated endovascularly 81 patients (41 men and 40 females, median age 64 ± 11) with either intraluminal balloon dilatation and/or primary stent implantation followed by balloon post dilatation. We achieved a high technical success rate (93.8%) and immediate clinical success, with only a few minor complications.

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DOI: 10.3897/bgcardio.28.e89568

Authors: Z. Stankov, I. Petrov, D. Boychev

Abstract: During the period from March 2014 to May 2018, endovascular treatment of aortic dissection type A and type B was carried out in a total of 70 patients. Patients were divided into two groups, aortic dissection type A (14 patients) and type B (56 patients), a group-by-group descriptive analysis was conducted, and then a comparison was done between the two patient groups. The aim of the study was to establish the effective use of endovascular treatment in type A and type B aorta dissection. As a result of the survey, data on the demographic characteristics and risk profile of these patients are accumulated for the first time in Bulgaria. Endovascular treatment options for the treatment of aortic dissection type A and type B, as well as malperfusion syndrome, are examined, demonstrating their effectiveness and safety. As a result of the study, it is proven that endovascular treatment in aortic dissection type A and type B leads to a significant increase in the size of the true lumen and reduction of the false lumen, which leads to an improvement in perfusion and reduces the risk of developing an aneurysm and rupture. The presence of endoleak and persistent communication between the false and the real lumen are the most common causes of re-intervention, such as endovascular options are most often the first line for their dealing and are proven to be effective and safe. Treatment of dissection of the aorta type A and B is not a one-time act, but requires periodic diagnostic control and, if necessary, surfery and/or endovascular corrections of the complications that have arisen.

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DOI: 10.3897/bgcardio.28.e81705

Authors: P. Gatzov

Abstract: The antithrombotic therapy is an important part of medical treatment in percutaneous coronary interventions (PCI). The so called dual antiplatelet therapy (DAPT), usually including acetyl salicylic acid (aspirin) plus platelet P2Y12 receptor inhibitors is an important part of that therapy. The careful balance between the protective effect regarding thrombotic/ischemic events and the risk of bleeding is an important task of the attending physician. Apart of the standard dosing regiments, in some of the cases a judgment regarding shortened or prolonged DAPT, as its de-escalation is mandatory. To present the causes and the way of application of that individualized approach in patients with PCI is the aim of this review.

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DOI: 10.3897/bgcardio.28.e89800

Authors: G. Dobrev, I. Petrov, Z. Stankov, I. Tasheva, P. Polomski

Abstract: Acute pulmonary embolism is the third most common cause of cardiovascular mortality in the world. The sudden pressure overload of the right ventricle, caused by the thrombotic masses in the pulmonary artery, may quickly progress to profound cardiogenic shock. That results in a mortality rate of more than 50% in patients with a massive form of pulmonary embolism. In such cases, systemic fibrinolysis is warranted, which leads to rapid improvement of the right ventricular function and hemodynamic stabilization. The thrombolytic effect of systemic fibrinolysis is, unfortunately, accompanied by an almost 5 times increased risk of bleeding, especially intracranial one. Therefore, in most cases, for patients with uncompromised hemodynamics, only anticoagulation treatment is offered. Interventional treatment of acute pulmonary embolism consists of the usage of very low-dose fibrinolytic devices or percutaneous thrombus aspiration devices. The goal is to provide rapid removal of the thrombotic masses from the pulmonary artery circulation while keeping the hemorrhagic risk at a minimum. This paper will try to provide a concise review of the most widely used and available devices, together with the latest clinical data, supporting their use. Also, the future perspectives in the field of endovascular treatment of acute pulmonary embolism will be presented.

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DOI: 10.3897/bgcardio.28.e87553

Authors: I. Petrov, Z. Stankov, S. Vasilev

Abstract: The cardiogenic shock is a state of low cardiac output, primarily due to cardiac dysfunction, which leads to severe organ hypoperfusion with tissue hypoxia and increased lactate levels. It presents a severe complication with a prevalence of around 15% of all forms of shock and 2-5% of the cardiogenic shock is a complications of acute heart failure. Despite the diverse etiology of the cardiogenic shock, up to 80% of the cases are due to acute myocardial infarction. The ischemia, leads to dysfunction of the myocardium cells, which causes a decline in the blood pressure and subsequent tissue hypoperfusion. The most important part is to start the treatment regime as soon as possible in the pre-shock stage. The treatment of refractory cardiogenic shock is complex, as it contains an intravenous therapy with inotropes/vasopressors and mechanical circulatory support (MCS). The MCS devices are supposed to reduce the workload of the heart and the oxygen need of the myocardial cells and in the same time to maintain an adequate coronary and systemic perfusion. There are different MCS devices like IABP, Impella, Tandem Heart, V-A ECMO. The aim of this review article is to present the new trends in the treatment approach to cardiogenic shock and to bring clarity in the treatment regimes, based on the latest studies and guidelines.

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DOI: 10.3897/bgcardio.28.e83660

Authors: A. Popova, D. Trendafilova, J. Jorgova, D. Petkov, F. Abedinov, T. Hristova, S. Ivanov

Abstract: We report a case of an 80-years–old patient with a severe, symptomatic aortic valve stenosis and history of ischemic heart disease, previously treated by coronary artery bypass graft surgery. The patient was contraindicated for conventional surgical aortic valve replacement (SAVR) due to advanced age and underlying comorbidity, therefore transcatheter aortic valve implantation (TAVI) has been offered. The access options for the procedure were restricted by the underlying generalized atherosclerosis process causing peripheral vessel disease. We have chosen transaortic access for the patient which in that case was the only possible option. The transaortic valve implantation was successful with satisfactory hemodynamic results, improvement in functional class heart failure of the patient and preserving the function and anatomy of the coronary artery bypass graft. This case report demonstrates that the lack of favorable transfemoral access for TAVI should not be a limitation by itself for the procedure, rather than be stimulus for searching and using new and alternative access for it.

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DOI: 10.3897/bgcardio.28.e82140

Authors: P. Polomski, Z. Stankov, I. Petrov, Zh. Stoykova

Abstract: The frequency of TAVI procedures worldwide is progressively increasing. The age of patients applying for TAVI is also declining, as a result of which life expectancy is increasing. Atherosclerotic disease (including ischemic heart disease) and aortic stenosis share some common risk factors and pathogenesis, which explains the frequent combination of diseases in the same patient. We present a clinical case of successful percutaneous coronary intervention in a patient presenting with acute coronary syndrome with a previously implanted TAVI prosthesis.

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DOI: 10.3897/bgcardio.28.e82423

Authors: R. Pencheva, J. Shabani, D. Trendafilova, J. Jorgova, H. Angelov, P. Simeonov, I. Dimitrova

Abstract: In the modern days and the era of the rapid development of medical technology, the introduction of innovative invasive methods of treatment is gradually displacing traditional conventional surgery. In 2002 was performed the fi rst transcatheter implantation of an aortic valve. Over the next twenty years, with the advancement of technology and the accumulation of experience in clinical centers, transcatheter aortic valve implantation has become the standard in adult and high-risk patients with high-grade Ao stenosis. In a large percentage of cases enrolled under the transcatheter aortic valve protocol a concomitant ischemic heart disease is detected or known. Globally, there is no signifi cant difference in overall mortality on the thirtieth day after TAVI in patients with ischemic heart disease. However, the overall mortality was signifi cantly higher in one – year follow - up of patients after transcatheter aortic valve implantation with underlying coronary pathology. We conducted a study comparing the number of late and early adverse events in patients with concomitant fully revascularized ischemic heart disease and those with insignifi cant coronary atherosclerosis. Based on the data collected, analyzed and summarized in our clinical center, fully revascularized ischemic heart disease does not increase the percentage of major adverse events after transcatheter aortic valve implantation. It can be considered when assessing the risk of transcatheter aortic implantation, as part of the individual approach for each case.

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DOI: 10.3897/bgcardio.28.e82855

Authors: D. Trendafilova, J. Djorgova, H. Varnaliyska, N. Naidenova, R. Stoycheva, R. Valchev, H. Angelov

Abstract: Introduction: Hemodynamically signifi cant mitral regurgitation (MR) occurs in up to 20-30% of patients with high-grade aortic stenosis (AC) indicated for transcatheter aortic valve implantation (TAVI). Despite the establishment of the method as a standard in the treatment of high-risk patients for surgery worldwide and the growing number of patients treated interventionally, behavior in concomitant signifi cant MR continues to be a diagnostic and therapeutic challenge. The decision to intervene on multiple valves must take into account the additional surgical risk of the combined procedures. Signifi cant MR is associated with a worse prognosis in both surgical and interventional treatment. With high operative risk and signifi cant MR, TAVI is a possible solution due to the proven reduction in severity in a signifi cant proportion of patients. The aim of this paper is to evaluate the impact of signifi cant secondary MR on mortality and rate change after TAVI. Material and methods: The article is a retrospective analysis of 50 patients with high-grade symptomatic aortic stenosis who underwent successful TAVI. Patients were followed for a period of 1 year and were divided into two major groups – no signifi cant MR (0.1 degree) and those with signifi cant secondary MR (≥ grade 2). Overall mortality, cardiovascular mortality, functional class of heart failure according to the NYHA classifi cation, ejection fraction and need for rehospitalizations weremonitored. Conclusions: Hemodynamically signifi cant secondary MR, concomitant high-grade AC before TAVI undergoes positive dynamics in a signifi cant proportion of patients postprocedurally and should be considered when deciding on a therapeutic strategy by the Heart team. The worsening of signifi cant secondary MI in the studied patients is associated with 30-day and one-year cardiovascular mortality and the need for rehospitalization, which is consistent with data that the prognosis is important not only the presence of signifi cant secondary MR, but its dynamics after TAVI.

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DOI: 10.3897/bgcardio.28.e83164

Authors: Hr. Angelov, P. Simeonov, P. Krastev, F. Abedinov, J. Jorgova, D. Trendafilova

Abstract: Transcutaneous aortic valve implantation has been established as an effective method for the treatment of highgrade aortic stenosis in non-operative, high-risk for conventional surgery patients. According to the developed implantation technologies, the prostheses are divided into balloon-expandable valve prostheses (balloon-expandable valves, BEV) and self-expanding valve prostheses (self-expanding prostheses SEV). The two types of devices have different models for implantation, stratum architecture, cusps characteristics, leading to different hemodynamics, frequency of use and performance of normal prosthesis function. The research aims to monitor the short-term results, up to 1 month after discharge, in terms of mortality, the manifestation of heart failure, (para) prosthetic regurgitation, implantation of a pacemaker, and vascular complications. Materials and methods: the article presents a retrospective follow-up of a total of 230 high-risk for conventional cardiac surgery patients with high-grade aortic stenosis treated in a cardiology clinic at UMHAT St. Ekaterina Sofia until 2020, divided into two groups depending on the implanted type of prosthesis. Conclusions: The results obtained based on our experience prove the safety of new prostheses. When choosing between BEV and SEV, the best clinical outcome requires a good knowledge of the strengths and weaknesses of using medical devices with a personalized approach consistent with the clinical and anatomical characteristics of the patient.

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DOI: 10.3897/bgcardio.28.e82274

Authors: I. Petrov, Z. Stankov, P. Polomski, J. Stoykova, A. Cherneva, D. Boychev, M. Bonev

Abstract: Since the first procedure in humans in 2002, transcatheter aortic valve implantation (TAVI) has evolved from innovative procedure of the future to treatment of choice in high-risk patients with potential to become a routine procedure in the near future. Thanks to the excellent safety profile, the emerging evidence from clinical trials, TAVI has raised its class of recommendation in the guidelines. The constantly upraising frequency of TAVI and the experience gained have led to the need of procedure improvement and standardization. Between 2013 and 2021 208 patients underwent TAVI in our cardiovascular center. The standard approach was used for 141 of them and the minimalistic and precise approach for the rest 67 patients. The main focus of this manuscript is improvement of the procedure results, quality of life and comfort of the patients, while providing a better pharmacoeconomic profile.The minimalistic and precise protocol of implantation and the vascular device closure are thoroughly described. The safety and the efficiency of the minimalistic and precise approach compared to the standard one, which is considered the ”gold standard” are proven. At the same time the minimalistic approach is described as superior to the standard one in using the radial artery as second vascular approach to reduce vascular complications and bleeding. Other advantage of the minimalistic approach is the implantation of the transcatheter aortic valve in position 0/1 while using rapid pacing, to reduce the frequency of pacemaker implantation, reduction of paravalvular leak and reduction of hospital stay. TAVI has proved to be an alternative to surgical aortic valve replacement in high risk patients and in the past years also in intermediate and low risk patients. In order TAVI to become a PCI-like procedure it must be simplified. That is exactly why the minimalistic and precise approach for TAVI is needed and it is the future of the procedure.

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DOI: 10.3897/bgcardio.28.e82154

Authors: I. Petrov, A. Cherneva, S. Vasilev, Y. Gecov, Z. Stankov

Abstract: Mitral regurgitation or mitral insuffi ciency is the second most common valve pathology requiring a surgical treatment worldwide. It is characterized by an abnormal return of blood from the left ventricle to the left atrium during the systole. The incidence of mitral regurgitation increases in line with the rise in the life expectancy and the overall aging of the world population. According to the pathoanatomy and the mechanism of development, there are two main types of mitral regurgitation: a primary (degenerative) regurgitation and secondary (functional) regurgitation. In the fi rst type, there is organic damage to the valve and/or the valve apparatus, and in the second type, there is a secondary dysfunction of the mitral valve due to damage to the structure and/or the function of the left ventricle. The treatment of choice for the management of the mitral regurgitation is a surgical intervention. In recent years new high-tech transcatheter methods of treatment have been introduced in clinical practice. The most popular and proven method of treatment in patients who could not undergo classic cardiac surgery is the MitraClip edge-to-edge transcatheter approximation system. Other endovascular methods of treatment are percutaneous plasty device Pascal (Edwards Lifesciences) and Cardioband using transseptal approach, and also NeoChord and Harpoon using transapical approach.

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DOI: 10.3897/bgcardio.28.e82414

Authors: P. Simeonov, B. Barzashka, D. Trendafilova, J. Jorgova, D. Petkov, P. Abedinov

Abstract: In recent years the trend towards surgical bioprosthetic valve implantation, especially among young patients, has increased in order to avoid anticoagulant therapy. The patient’s age remains one of the leading risk factors for valve dysfunction. Gold standard for treating such diseases was surgical reintervention until the development of transcatheter heart valves. By 2050 the annual number of patients undergoing surgical bioprosthetic valve implantation is expected to triple from an average of 290,000 in 2003 to over 850,000. This study presents the literature review of Valve in Valve and Valve in Ring procedures, as well as our experience in ViV and ViR transcatheter valve implantation.

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DOI: 10.3897/bgcardio.28.e82418

Authors: I.N. Dimitrova, J. Jorgova, P. Simeonov, H. Angelov, D. Trendafilova

Abstract: Transcatheter aortic valve implantation (TAVI) is an established choice for the treatment of severe aortic stenosis (AS) in patients who are deemed inoperable or at high surgical risk. There are limited data for the safety and effi cacy of the method in patients with bicuspid aortic valve (BAV), the most common congenital valve defect. Patients with BAV were excluded from randomized clinical trials (RCTs), comparing TAVI to surgery due to the heterogeneous anatomy of this nosological unit and concerns about unsatisfactory procedural and clinical outcomes after TAVI. With the improvement of the design of the new generations devices, with the growing technical experience of the teams and the progress in the imaging techniques, better results and fewer complications are observed, which could be a prerequisite for expanding the indications for TAVI in patients with BAV. This review presents TAVI treatment options for patients with BAV, the results of available registers in terms of safety and effi cacy of the procedure, and future perspectives.

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DOI: 10.3897/bgcardio.28.e84919

Authors: Diana Trendafilova-Lazarova

Abstract: Еditorial

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DOI: 10.3897/bgcardio.27.e76435

Authors: Darko Kitanoski, Arman Postadzhiyan, Vasil Velchev, Nikolay Stoyanov, Zhan Zimbakov, Igor Spiroski, Sasko Kedev, Oliver Busljetik

Abstract: In 2015, The European Society of Cardiology for Acute Coronary Syndrome recommended that Class I use radial as the preferred access method for any percutaneous coronary intervention regardless of clinical presentation. However, the use of TRA is associated with some complications: radiation artery occlusion (RAO) (The reported incidence of RAO is highly variable in the range of 2-11%, radial arterial spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, bleeding, nerve damage, and complex regional pain syndrome. Limited data are available regarding the technique of distal radial access, complications, and potential benefits. The purpose of our study is to compare the incidence of radial artery occlusion between distal radial and conventional radial access. The study included 292 patients (who underwent percutaneous coronary intervention)in who is felt pulsations at the site of a puncture of the radial artery. Patients were followed one month after the procedure, with Doppler ultrasonography or access from the same artery. After a month, the occlusion of the radial artery occurred in 8 (5.7%) patients in conventional radial access, there was no occlusion of the radial artery in the distal radial access group. This investigation shows that distal radial access is associated with a lower incidence of occlusion of the radial artery.

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DOI: 10.3897/bgcardio.27.e73251

Authors: Georgi Goranov, Petar Nikolov

Abstract: Aim: To analyze the prognostic factors and create a model for survival in patients after interventional carotid revascularization. Methods: In 329 patients after carotid artery stenting (CAS), the median (MS) and overall survival (OS) were calculated for a follow-up period of 2-101 months. All patients underwent coronary angiography prior to carotid stenting and, if indicated, coronary revascularization. 4 groups of factors were analyzed: carotid disease, coronary artery disease (CAD), underlying cardiac pathology and concomitant diseases. Results: MS in all patients was 86 months, OS at 1, 3, 5, and 9 years was – 94%, 85%, 73%, and 51% respectively. Event free survival was 85 months. Log Rank- Mantel-Cox analysis demonstrated significantly reduced MS in 21 tested factors, most of them related to CAD. Two-step multifactorial Cox regression analysis defined only 7 of them as independent prognostic factors for the survival of patients after CAS: left main stenosis, complete revascularization, late myocardial infarction (MI), stroke, age over 70 years, valvular disease and carotid score. Conclusion: Survival of patients after CAS is limited mainly by CAD and underlying cardiac pathology. Staged revascularization treatment strategy may improve the prognosis and survival of patients with both carotid and coronary disease.

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DOI: 10.3897/bgcardio.27.e79371

Authors: Elena Yordanova, Vasil Velchev, Arman Postadzhiyan, Nikolay Stoyanov, Blagorodna Karatancheva, Bojidar Finkov

Abstract: Besides the standart echcardiografic parameters for mitral stenosis assessment it is necessary to inquire the hemodynamic characteristics as well. The following article describes and illustrates step-by-step the invasive parameters and their significance in the assessment of mitral stenosis in patients who underwent percutaneous balloon mitral valvuloplasty.

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DOI: 10.3897/bgcardio.27.e76463

Authors: Ivo Petrov, Petar Polomski, Zoran Stankov

Abstract: Haemodynamic changes in mitral regurgitation underlie triggering of patient’s symptoms and development of heart failure. A number of endovascular methods for the correction of mitral regurgitation successfully counteract pathological hemodynamics and thus manage to improve both the manifestations of heart failure and the patient's symptoms. This article is a review of the physiology of the mitral valve and the changes that occur in the presence of mitral regurgitation. The peculiarities of the hemodynamics of the left atrium in the conditions of mitral regurgitation and after some types of transcatheter treatment – edge-to-edge correction of the valve with Mitraclip and the implantation of an occluder in paraprosthetic mitral regurgitation are considered. The change in left atrial parameters immediately after correction of the defect is of value both for the assessment of immediate procedural success and for the patient's prognosis.

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DOI: 10.3897/bgcardio.27.e73142

Authors: Svetoslav Iovev, Peyo Zhivkov, Mariana Konteva

Abstract: Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is an established method for the therapy of congestive heart failure (CHF) in the case of asynchronous ventricular contractions. Successful therapy depends on the placement of left ventricular leads usually via the coronary sinus (CS), a technically more challenging procedure than regular pacemaker implantations. Without specifi c precautions CRT implantation can be the gateway to a time-consuming nightmare. Therefore, CS lead implantation methods, with a focus on complications, were reviewed according to the literature and our own experience with approximately 4500 procedures from 2002-2021.

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DOI: 10.3897/bgcardio.27.e67905

Authors: Zhenya Marinova, Svetoslava Slavcheva, Atanas Angelov, Veselin Valkov

Abstract: We present a case of a 75-year-old male who underwent percutaneous coronary intervention in the setting of acute myocardial infarction with ST-segment elevation and who was hospitalized 12 days afterwards with COVID-19 pneumonia. Later the patient presented himself again with acute coronary syndrome with ST-segment elevation in the same region due to in-stent thrombosis. Transient atrioventricular conduction disorders were registered before and after the percutaneous coronary intervention. Possible pathophysiological mechanisms of the in-stent thrombosis following COVID-19 infection are discussed.

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DOI: 10.3897/bgcardio.27.e53896

Authors: Zoran Stankov, Iveta Tasheva, Petar Polomski, Aleksandra Cherneva, Mariya Dotseva, Inna Tsareva, Georgi Dobrev, Ivo Petrov

Abstract: Transcatheter implantation of the aortic valve is an increasingly used method for the treatment of aortic stenosis, with a steady trend worldwide to increase the number of TAVI procedures and reduce the age of patients. In Europe, over 180,000 TAVI procedures are currently implemented annually. This review aims to evaluate the patient’s prognosis for the different approaches, the technical diffi culties during the procedure, and to offer useful tips for overcoming them. We publish our experience in transcatheter treatment of ischemic heart disease after TAVI implantation.

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DOI: 10.3897/bgcardio.26.e53932

Authors: George Dimitrov, Martina Samardzhieva, Zoran Stankov, Y. Getsov, Iana Simova, Naidenka Zlatareva, Gloria Adam, Ivo Petrov

Abstract: We present a case of a 78-year-old female with a history of hypertension, paroxysmal atrial fi brillation and ischemic stroke which was admitted due to an hour-long chest pain with ECG changes indicating sinus rhythm and a newly formed LBBB. Subsequently a ventricular septal defect (VSD) was discovered which we successfully treated percutaneously. At admission, echocardiography revealed septo-apical hypokinesis with an accompanying reduced left ventricular ejection fraction of 38%, in addition to the mid-ventricular septal defect (7/14 mm in size) causing a signifi cant left to right shunt (QP/QS = 1.8/1.0). Coronary angiography demonstrated lack of obstruction of the coronary vessels – MINOCA. Rapid response and Intensive care treatment, including Intra-Aortic Balloon Catheter insertion, lead to LV-functional improvement and hemodynamic stabilization. A dual access approach through the right jugular vein and right radial artery was used and eventual closure of the VSD was achieved with an Occlutech ASD occluder (20.5/16.5 mm), inserted via the venous introducer, while under constant angiographic and transesophageal echo guidance. Immediate VSD shunt elimination was disclosed by EchoCG and angiography. Overall, an uneventful in-hospital stay and six months event-free follow-up period were registered including further EchoCG which confi rmed lack of major cardio-vascular events and the stable position of the occluder, without a visible shunt.

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DOI: 10.3897/bgcardio.26.e58770

Authors: Ivo Petrov, Naydenka Zlatareva-Gronkova, Todor Kundurdjiev, Viktoria Dimitrova

Abstract: Acute coronary syndrome (ACS) represent emergency state in an intensive cardiovascular care unit, which implies immediate and specific treatment. Of peculiar interest for cardiologists are young patients with acute myocardial infarction (AMI). The family history taking for premature coronary artery disease (CAD) and establishment of genetic factors, responsible for coagulation, both are on target for this group of patients. Gold standard for AMI diagnosis is coronary angiography (CA), which usually implies endovascular treatment (EVT). When coronary thrombus formation is found in young patients, different diagnostic opportunities are possible. Thrombophilia (TF) represents blood coagulation abnormality resulting in an increased risk of thrombosis. It could affect different sections of the cardiovascular system, most commonly venous, but also arterial. This clinical condition could be confirmed by performing laboratory genetic tests. We studied a group of forty-one young patients with first appearance of ACS ≤ 55 years old included for a five-year period. All of them were evaluated with CA and received EVT. According to the thrombotic risk, we defined a high-risk group, treated with anticoagulant (AC) on top of dual antiplatelet therapy (DAPT). The patients were followed-up for recurrent ischemic and bleeding events. We performed laboratory tests for the most frequent TF gene mutations in Bulgarian population. There is a conflicting data about this issue in different ethnic origins. The aim of our study is to estimate the possible relationship between the TF and the arterial thrombosis in young ACS patients, to defi ne specific treatment strategies, improving the prognosis of the patients.

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DOI: 10.3897/bgcardio.26.e57740

Authors: Velina Stoyanova

Abstract: Coronary artery disease (CAD) is a chronic progressive disease with social signifi cance, result ofobstructive or non- obstructive atherosclerotic plaque accumulation in the epicardial arteries. CAD is one of the leading causes for deterioration in quality of life and cardiovascular mortality. CAD has dynamic character and its major clinical presentations are: acute coronary syndromes (STEMI, NSTEMI, UA) and chronic coronary syndromes. In this case report we present the treatment algorithm in patient with chronic coronary syndrome: from optimal medical therapy, through objective methods of examination leading to the decision for interventional treatment and the importance of regular follow-up.

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DOI: 10.3897/bgcardio.26.e54126

Authors: Ivayla Zheleva-Kyuchukova, Valeri Gelev

Abstract: Revascularization in patients with severe stenosis of left coronary artery (LCAS) trunk signifi cantly improves their prognosis. Modern clinical studies, registries and meta-analyses have identifi ed percutaneous coronary intervention (PCI) of LCAS as a safe alternative to aorto-coronary bypass (ACB) in patients with low and intermediate lesion complexity. Aims: To confi rm the safety and effectiveness of PCI and implantation of second generation drug eluting stent (DES) in patients with unprotected LCAS and concomitant complex coronary pathology. Material and Methods: For the period March 2013–October 2018 we performed 225 PCIs of patients with LCAS. 170 of patients who received PCI were divided into 2 groups, according to their SS-1 (ST elevation excluded). We analyzed the major adverse cardio-vascular events (MACE – all-cause mortality, cardiac mortality, stroke and ischemia driven TLR) rate and time-to-fi rst MACE during follow up. Results: 103 patients had SS-I < 32 and 67 patients had SS-I ≥ 32 and their mean age was 67,25 ± 11,03. The median follow-up was 26,6 ± 19,1 months. MACE rate was 12,4% and there was no signifi cance between groups (p = 0,118). Conclusions: PCI of unprotected LCAS has high procedural success rate and good mid-term results, even in pts with complex anatomy. High anatomical complexity of coronary lesions defi ned by SS-I ≥ 32 is not predictive for poor clinical outcome after PCI.

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DOI: 10.3897/bgcardio.26.e53596

Authors: Kiparisiya Nenova, Anna Kaneva-Nencheva, Elisaveta Levunlieva, Lyubomir Dimitrov, Margarita Tzonzarova

Abstract: Balloon pulmonary valvuloplasty (BPVP) is the procedure of choice for the treatment of isolated pulmonary valve stenosis. Complications and failure of the procedure are more common in newborns and infants. Aim: To establish the effectiveness and safety of BPVP in newborns and infants. Material and methods: Ninety-one infants (11 newborns) with isolated pulmonary valve stenosis and mean age 171 ± 115 days were catheterized for BPVP between October 1986 and December 2016. BPVP was performed in 86 infants with a balloon catheter size 127±16% from the annulus dimension. The effectiveness (gradient right ventricle (RV) – pulmonary artery (PA) ≤ 35 mm Hg) and safety (lack of life–threatening complications, emergency surgery or death) of the procedure were assessed. Results: Transvalvular pressure gradient decreased from 82 ± 29 mm Hg to 29 ± 24 mm Hg (р = 0,0001) and RV pressure - from 101 ± 28 mm Hg to 52 ± 24 mm Hg (p = 0,0001). BPVP was effective in 61 infants (70,9%), mainly in those with lower initial gradient, RV pressure and less signifi cant infundibular obstruction. There were no children with hemodynamically signifi cant postprocedural pulmonary insuffi ciency. Complications were observed in 16 of the infants catheterized for BPVP (17,6%). In 5 of the children (5,5%), minor (transient) complications arose and were overcome by conservative means. Major complications were observed in 11 infants (12,1%): rhythm and conductive disorders (critical bradycardia, supraventricular/ventricular tachycardia, complete atrioventricular block) in 6 children, hemopericardium or severe right ventricular outfl ow tract rupture – in 5. The evolution was favorable after intensive treatment in 6 children with major complications, two children were sent for emergency surgery (2,2%) and death occurred in 3 of the children associated with the procedure (3,3%). The procedure was interrupted and BPVP was not performed in fi ve of the catheterized children (5,5%), all with severely dysplastic valve. Conclusion: BPVP is effective and comparatively safe procedure under the age of 1 year. Newborns, children with severely dysplastic valve and suprasystemic RV pressure are the most at-risk.

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DOI: 10.3897/bgcardio.26.e51199

Authors: Iskra Bayraktarova, Elina Trendafilova

Abstract: Multivessel coronary artery disease is a frequent fi nding during primary PCI procedures in patients with ST-elevation myocardial infarction (STEMI). Optimal therapy of the infarct-related lesion has been largely elucidated and is stipulated in current guideline documents. Therapeutic options for the additional lesions are a subject of active debate and clinical trial worldwide – both the target degree of revascularization and its timing in relation to the index procedure remain unclear.

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DOI: 10.3897/bgcardio.26.e53002

Authors: Aleksandra Cherneva, Zoran Stankov, Naidenka Zlatareva, Iveta Tasheva, Georgi Dobrev, Galina Georgieva, Ivo Petrov

Abstract: We report a case of a high-risk 73-year–old patient with a combined aortic valve disease with predominant severe, symptomatic aortic regurgitation and a history of an end-stage respiratory failure with prohibitive surgical risk who was successfully treated using a minimalist approach to implant off-label а self-expandable Medtronic Evolut R prosthesis. This case report demonstrates that the self-expandable prosthesis Medtronic Evolut R might be implanted without tissue damage and migration in a moderate-calcified tricuspid aortic valve with predominant regurgitation and mild stenosis with satisfactory hemodynamic results and improvement in functional class heart failure in a patient with concomitant severe respiratory failure.

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DOI: 10.3897/bgcardio.26.e52193

Authors: Anna Zagorska, Desislava Ivanova, Dessislava Kostova-Lefterova, Filip Simeonov, Valeri Gelev, Ivaylo Bogov, Hristo Mateev, Alexandar Alexandrov, Ivayla Jeleva, Nikolay Stoyanov, Katerina Romanova, Ilia Dyakov, Valentin Krastev, Dobrin Vasilev, Vladimir Ivanov

Abstract: Introduction. Interventional cardiac procedures are often associated with high patient exposure and therefore require special care in protecting patients from radiation-induced effects.Materials and methods. A retrospective study of typical patients’doses was performed in nine hospitals, with a total number of fourteen angiography systems. The typical values for kerma-area product (KAP), cumulative dose (CD) and fluoroscopy time (FT) for two of the most commonly performed procedures - percutaneous coronary intervention (PCI) and coronary arteriography (CA), were calculated and compared with the Bulgarian National Diagnostic Reference Levels (NDRL). Data analysis, regarding the risk of radiation-induced skin effects due to interventional cardiac procedures, was performed.Aim. 1) to present and analyze the typical KAP values for PCI and CA procedures in cardiology departments with high workload and to compare them with the NDRL; 2) to compare the patient doses with the follow-up levels published in Ordinance 2, to identify patients at risk for radiation-induced effects.Results. The results show that typical values for PCI and CA procedures for some of the angiography systems are higher than the NDRL. In all investigated departments there are patients with at least one exceeded follow-up level for PCI.Conclusions. The results show a potential for optimization in the departments with both high or very low typical dose or FT values. No radiation-induced effect was observed in the followed-up group of patients. The introduction of procedure with "Instruction to the patient after an interventional cardiac procedure(s) with greater complexity and a long fluoroscopy time" for patient follow-up and its regular implementation into the routine clinical practice will help for timely diagnosis and treatment of radiation-induced skin effects after cardiac procedures under fluoroscopy control.

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DOI: 10.3897/bgcardio.26.e52712

Authors: Aleksandra Cherneva, Ivo Petrov

Abstract: Treatment-resistant hypertension, or resistant hypertension (RH), is defined as arterial hypertension (AH) despite treatment with three properly dosed antihypertensive drugs, at least one of which is a diuretic. Resistant hypertension is associated with an increased incidence of adverse cardiovascular events, renal impairment, and increased mortality. The main treatment of patients with RH is based on maximizing doses of antihypertensive drugs from different groups and adding drugs with complementary mechanisms of action. Despite the combination treatment involving multiple antihypertensive drugs, a small but significant group of patients remains with uncontrolled hypertension, emphasizing the need to find and put into practice new therapies to lower high arterial blood pressure (BP). Among these new methods of treatment, the most promising is the renal sympathetic denervation, showing positive results with the second generation devices.This review summarizes current knowledge about the treatment of RH, with an emphasis on new therapeutic strategies to achieve optimal blood pressure control.

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