DOI: 10.3897/bgcardio.32.e190567

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

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

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DOI: 10.3897/bgcardio.32.e187136

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

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

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DOI: 10.3897/bgcardio.32.e187637

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

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

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DOI: 10.3897/bgcardio.32.e189379

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

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

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DOI: 10.3897/bgcardio.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.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.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.30.e127187

Authors: Ivo Petrov

Abstract:

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DOI: 10.3897/bgcardio.29.e105739

Authors: I. Yoncheva, D. Biserov, M. Negreva, S. Gogov, V. Vasilev

Abstract: We present a clinical case of a 49-year-old man admitted in severe general condition and echocardiographic evidence of a thrombotic mass in the left ventricle. Due to a peripheral embolization clinic, catheter-directed thrombolysis (CDT) followed by anticoagulant therapy was performed. This resulted in lysis of the left ventricular thrombus and reperfusion of the emboli in the peripheral arteries. Due to residual occlusion of the left anterior tibial artery, amputation of the front part of the foot of the left lower limb was required. As a result of the treatment, stabilization of the patient’s condition and withdrawal of the amputation line as distal as possible was achieved. The patient had severe left ventricular systolic dysfunction and highgrade mitral regurgitation, necessitating discussion of further management.

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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.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.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.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.e95811

Authors: I. Petrov

Abstract: Еditorial

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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.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.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.e82135

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

Abstract: Balloon valvuloplasty of the aortic valve (BAV) in aortic stenosis has been practiced for over 35 years. The initial enthusiasm caused by the excellent immediate hemodynamic effect of the procedure disappears due to the rapid restenosis of the aortic valve after intervention. The results of modern methods for defi nitive treatment of aortic valve stenosis – AVR and TAVI are excellent, thanks to which they are fi rmly rooted in treatment guidelines. However, BAV has its indications in symptomatic patients who are not suitable for defi nitive interventions. This publication discusses current indications for BAV, the main stages of the procedure, possible complications, and treatment outcomes.

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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.27.e75361

Authors: Georgi Goranov, Petar Nikolov

Abstract: Backgrounds and purpose: To analyse the periprocedural CAS complications in patients with concomitant coronary disease. Material and methods: A prospective study analysed the frequency and characteristics of periprocedural complications after CAS in 329 patients, of whom 62.2% had symptomatic carotid stenosis > 50% and 37.8% had asymptomatic > 70%. The mean age was 70.2 (45-88) years, male/female ratio – 253/76. The degree of carotid stenosis was assessed angiographically according to NASCET criteria and was stratified by a newly proposed carotid score in three risk groups. Distal embolic protection was used in all patients. Results: Periprocedural complications were observed in 25/349 CAS interventions: TIA – 4.9%, major stroke – 0.6%, minor stroke – 1.4%, hyperperfusion syndrome – 0.3%. No MI and death were registered. Out of more than 20 factors analysed, previous MI (χ2 = 7,707; p = 0.021) and stroke (χ2 = 9,835, p = 0.043), “slow flow” (χ2 = 3.752; p = 0.001), residual stenosis> 20% (χ2 = 13.752; p = 0.001), radiation time (F = 13.323; p = 0.000), the amount of contrast used (F = 5.297; p = 0.006), contrast- induced OBN (χ2 = 25.845; p = 0.000), females with CKD (χ2 = 8.681; p = 0.013) or with a high carotid score (χ2 = 7.329; p = 0.026) were found to be predictors of complications. Conclusion: CAS is a safe procedure with low risk of MI and death in patients with concomitant coronary disease.

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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.e72195

Authors: Nikolay Stoyanov, Dinko Kamburov, Nikolay Bonev, Mihail Protich, Vasil Velchev

Abstract: There has been increased rate of cardiac implantable electronic devices (CIED) implanted worldwide. Respectively the numbers of patients with absolute indications for lead extraction (pacemaker and ICD) grow up exponentially. The aim of our study is to present the initial experience and long-term results of pacemaker and ICD lead extraction in patients treated in Cardiology department of University hospital “Sveta Anna” Sofi a. Material and Methods: Retrospective study was performed of patients with CIED implanted greater than 1 year and indications for lead extraction. Clinical and procedural characteristics, success rate, complications rate, and reinfection rate data were collected and analyzed. Results: In the period August 2016 to May 2021, a total of 54 patients were admitted to our department with an absolute indication for lead extraction. A total of 114 pacemakers and ICD electrodes were extracted during 54 procedures. In 47 patients (87%) was shown complete technical success with removal of all hardware and in 53 patients (98.1%) clinical success of the procedure was found. The incidence of major periprocedural complications requiring urgent cardiac surgery in our series was 2 (3.7%). Follow-up revealed a very low recurrence infection rate – only 1 patient (1.9%). Conclusion: Lead extraction is a safe and effective procedure. The establishment of a specialized center with an organized system for lead extraction is key in achieving excellent short- and long-term results.

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DOI: 10.3897/bgcardio.27.e72412

Authors: Mohamed Dardari, Alexandrina Nastasa, Corneliu Iorgulescu, Stefan Bogdan, Vlad Bataila, Radu Vatasescu

Abstract: Objective. Radiofrequency catheter ablation is an effective treatment option for cardiac arrhythmias including complex and ventricular arrhythmias. Remote magnetic catheter navigation (RMN) has been developed as a novel way of approach aiming to improve outcome and reduce complication rate, and reduce radiation exposure for both operator and patient. Our aim was to compare success and complication rate in patients with or without severely reduced left ventricular ejection fraction (LVEF). Methods. We retrospectively analyzed all the patients (n = 98) which have undergone RMN in our center between 2015-2021. No selection criteria for RMN procedure have been applied. All clinical and paraclinical, as well as procedural data were collected. Patients were divided into two groups, with or without severely reduced LVEF ≤ 35%. CARTO system was used for 3D electroanatomic mapping. RMN was done using Niobe ES system and an open-irrigated magnetic ablation catheter. Success rate was defi ned by complete elimination of clinical arrhythmia. Non-inducibility following ablation was assessed in all patients presenting with any type of ventricular arrhythmia other than premature ventricular contractions. Testing for inducibility was done by ventricular programmed pacing with up to four extra-stimuli. The statistical analysis was performed using SPSS software. P-value < 0.05 was considered signifi cant. Results. Successful ablation with complete elimination of the clinical arrhythmia was achieved in 92.3% of the patients with severely reduced LVEF and in 88.1% of patients with LVEF > 35% (p = 0.73). Overall minor complication rate was 2.04% with spontaneous resolution. No major complications were reported. Non-inducibility was achieved in 56.4% of the patients with LVEF ≤ 35% and in 79.2% of the patients with LVEF >35% (p = 0.023). Conclusion. Radiofrequency catheter ablation using RMN is effective and safe regardless of the presence or not of a severely reduced LVEF.

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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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