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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.

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

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

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.

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

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

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

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.

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

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

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

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

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

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

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

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

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.

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.

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

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

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

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

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

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

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

Editorial

Anthracycline-induced cardiotoxicity (AIC) has been known since the 1970s but remains relevant, mainly due to the widespread use of anthracyclines in oncological practice. Currently, AIC is viewed as a prolonged and continuous process that starts with the initial dose at molecular and cellular levels and advances, ultimately resulting in cardiomyopathy and heart failure. Many contemporary studies aim to discover methods for early detection of anthracycline-related myocardial injury. Additionally, ongoing research focuses on agents for primary prevention of AIC, examining their effectiveness, place, and timing of administration. This review aims to present the available preventive options, interconnecting them with their mechanisms of action and the mechanisms of AIC. According to current recommendations, primary prevention is indicated for high- and very high-risk patients and includes general measures to lower cardiovascular risk, neurohormonal therapy, and statins. Regular cardiology assessments are a crucial component of heart damage prevention. Evidence of mild myocardial injury (deteriorated Global Longitudinal Strain and troponin release) justifi es cardioprotective measures. Some aspects remain unanswered, including whether early cardioprotection is required, as well as the role and effi cacy of sacubitril/valsartan and sodium-glucose cotransporter 2 inhibitors (SGLT2 inhibitors) for AIC prevention. Physical activity is a promising method to reduce the cardiac damaging effects of anthracyclines.

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.

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

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.

This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) cardiac ablations in 2023. Material and methods. This is a retrospective study of a full one-year sample of the BG-EPHY registry. Sex and age distribution of the patients, number of ablations, use of electroanatomic mapping (EAM), irrigated and cryoablations, distribution of different types of arrhythmias, acute procedural success, and complications are presented. Results. In 2023 nine EP centers performed 2021 ablations in 1309 men (61.8%) and 807 women, incl. 20 ablations in pediatric patients (1%). EAM was used in 941 procedures (46.6%), irrigated-tip catheter – in 1121 (55.5%), cryocatheter – in 420 (20.8%), and intracardiac echocardiography – in 43 (2.1%). The most frequently performed ablation was pulmonary vein isolation (46.4%), followed by ablation for AV nodal reentrant tachycardia (16.3%) and typical atrial flutter (15.2%). The acute success was over 98%, while intraprocedural complications were less than 2%. Conclusion. The national registry of electrophysiology collects systematically and continuously basic data on all ablations of cardiac arrhythmias performed in the country. In 2023, after the end of the COVID-19 pandemic, the number of ablations increased compared to 2022, but at a slightly slower rate. Distribution of EP procedure types was similar to previous years. Acute success was very high, while intraprocedural complications were rare.

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.

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

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

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.

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.

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

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.

Introduction: Catheter ablation (CA) is an established therapy for most arrhythmias. Non-fl uoroscopic three-dimensional (3D) electroanatomic mapping systems allow ablation of supraventricular tachycardia (SVT) and atrial fl utter (AFL) with zero or near-zero fl uoroscopy (ZF/NZF). The current study aims to report our initial experience with ZF/NZF in SVT or AFL CA. Material and methods: We conducted a single-center prospective registry enrolling consecutive patients referred for CA of SVT or AFL. ZF/NZF CA was attempted in all patients using a commercially available 3D mapping system. Fluoroscopy use was allowed at any point of the procedure. Procedural characteristics and long-term outcome were analyzed. The learning curve effect was also studied. Results: Sixty-three patients (age 53.5 ± 14.1, 57% males) with SVT or AFL were enrolled. According to arrhythmia type typical AVNRT was diagnosed in 36 (57.1%) cases, right atrial fl utter in 25 (39.7%) cases, left-sided accessory pathway in 1 (1.6%) and focal right atrial tachycardia in 1 (1.6%) case. Three patients (4.8%) had two arrhythmia substrates. The procedure was performed with ZF in 49/63 cases (77.8%), while NZF was necessary in 14 (22.2%) patients with a fl uoroscopy time of 220 ± 169 sec and a dose-area product of 7556 ± 5886 mGy*cm2. Median procedural time was 88 (IQR 25-75 percentile 71.5-116) min with 22 (IQR 25-75 percentile 16-31) min of mapping time. Acute procedural success was accomplished in all patients with no periprocedural complications. Over a follow-up of 12 ± 3 months, all patients remained arrhythmia-free. There was a learning curve effect with a signifi cant reduction of procedural time (P = 0.025) and a signifi cant difference (P = 0.019) in the rate of fl uoroscopy use among different periods of the study duration. Conclusion: ZF/NZF CA of SVT and AFL is associated with high effi cacy and safety. Entirely fl uoroless CA can be performed in the vast majority of patients. It is a feasible approach associated with a detectable learning curve effect.

A bacterial infection of the heart’s endocardial surface causes infectious endocarditis (IE). The heart valves or an intracardiac devices are most affected. In most cases of right-sided endocarditis, the tricuspid valve is involved. Using drugs like cocaine, heroin, or any number of others can cause this disorder. Infective endocarditis can develop if methadone is not administered in accordance with the Methadone program, despite the cessation of drug use. In drug users, Staphylococcus aureus is the most common cause of right-sided infective endocarditis with pulmonary embolism and persistent bacteraemia. Cutaneous vasculitis, particularly leukocytoclastic vasculitis, is a rare manifestation of IE.

A case is presented of a patient with a rare narrow QRS tachycardia with alternating R-R intervals in the presence of dual AV nodal physiology. The tachycardia was successfully treated by catheter ablation. The mechanism of the arrhythmia and the intracardiac and ECG recordings are discussed.

The current study analyses the activity on cardiac pacing in Bulgaria in 2022 based on data derived from a national registry of patients with cardiac implantable electronic devices (CIEDs). Materials and methods. Data from the national registry BG-Pace for 2022 was studied retrospectively. Demographic data, procedure and device type, pacing mode, etiology, symptoms, preimplantation ECG, number of implantations, and centre and operator volumes were analyzed. Results: Four thousand seven hundred seventy devices were implanted by 45 operators in 30 centers. Median age was 76 (IQR 69-82, 14-98) years, and male patients were 2843 (59,6%). The most significant number of implantations were carried out in the age group 70-79 years. The most commonly implanted CIEDs were antibradycardia devices - 578,8/million. Of them, conduction system pacing was used in 111 (2.3%). Implanted cardioverter-defibrillators demonstrated a growth compared to previous periods and reached 31.9/million. Cardiac resynchronization defibrillators implantations also shown a growth to 15.9/million. A considerable increase was found with implantable loop-recorders, which reached 8.8/million. Number of implantations per center was 115.5 (IQR 53-261.,3, 3-546), and 76,5 (IQR 36,8-154,8, 3-364) devices per operator. Dual chamber devices were most commonly implanted with a share of 83.1% in AVB I and II degrees, 72.5% in complete AVB, 82.6% in intraventricular conduction disturbances, and in 66.8% in patients with sick sinus syndrome. Pacing modes allowing for atrial sensing were most frequently implanted – 62.4% of all implantations for conduction disturbances. There was a significant increase in the use of VVI mode with increasing age (P

Introduction: Over the last decades the rate and rhythm control options available for patients with atrial fi brillation (AF) have been aimed at improving arrhythmia symptoms and quality of life (QoL). In terms of rhythm control catheter ablation has become a valid treatment option. Since it is an invasive and relatively costly procedure generally performed with the aim of symptom control, obtaining information on the degree to which QoL is affected by the intervention is of great importance. The aim of the present study was to assess the effect of pulmonary vein isolation (PVI) on the QoL of patients with AF and to determine the factors of greatest infl uence on the change in QoL. Material and methods: This was a multicenter prospective cohort study involving patients with atrial fi brillation who underwent radiofrequency PVI. Standardized questionnaires and scores were used to assess QoL before the procedure and at the end of the follow-up period. Results: The study included 131 patients at mean age of 59 ± 9.27 years, 75.6% (n=99) were men. The patients were followed for a mean of 39.7 ± 13.3 months. At the end of the follow-up period, we observed a signifi cant improvement (p < 0.001) in all domains of quality of life compared to baseline. Through multivariate regression analysis, left ventricular ejection fraction (p = 0.047), mitral regurgitation (p < 0.0001), body mass index (p = 0.002) and recurrences within the fi rst 3 months following PVI (p = 0.009) were found to be independent predictors of the change in QoL before and after ablation. Conclusion: Catheter ablation of atrial fi brillation results in improvement of QoL in patients with AF. Left ventricular ejection fraction, functional mitral regurgitation, body mass index and recurrences within the fi rst 3 months following PVI are important predictors of change in QoL after radiofrequency ablation. They are to be considered when choosing therapeutic strategy and defi ning the individual approach to each AF patient.

Takotsubo cardiomyopathy or broken heart syndrome is a stress-induced cardiomyopathy with clinical, laboratory and ECG resemblance to acute coronary syndrome. Major differences stem from transient segmental wall motion abnormalities beyond the territory of a single coronary artery and the lack of obstructive coronary disease during angiography. Overall the condition is considered as a benign one with a favourable outcome, however there are reports of complicated clinical course by cardiogenic shock, apical thrombus, death and arrhythmias. The latter are reported to occur in 13% of the cases with ventricular arrhythmias (ventricular tachycardia, ventricular fi brillation, torsades de pointes) as a leading fi nding and in minor percentage – high-grade AV block. Despite advances in our knowledge and experience there are still no strict guidelines for the management of conduction disorders. We present the case of a 78-year old lady with an apical variant of Takotsubo, complicated by syncope, complete AV block, new left bundle branch block, paroxysmal atrial fi brillation, ventricular tachycardia and implantation of a permanent pacemaker. During the hospitalization she developed acute cardiac failure with echocardiographic evidence of left ventricular systolic dysfunction and an apical thrombus. The presented case demonstrates the complexity of the condition and the necessity of strict follow-up and timely therapy.

We present a case of a 78-year-old patient with persistent atrial fl utter, history of atrial fi brillation and atrioventricular conduction disturbances, including fi rst-degree atrioventricular block (AVB) and paroxysmal complete AVB. Echocardiography revealed mildly reduced left ventricular ejection fraction (LVEF, 44%). The patient had high thromboembolic risk, had previous ischemic stroke, suffered from chronic coronary artery disease treated with hybrid coronary revascularization (minimally invasive direct coronary artery bypass grafting and subsequent percutaneous coronary intervention) as well as left atrial appendage closure. Because of high bleeding risk, double antiplatelet therapy (acetylsalicylic acid and clopidogrel) combined with low dose of low-molecular-weight heparin after cardiac surgery were introduced. Due to persistent atrial fl utter, complete AVB, lack of intraventricular conduction abnormalities, mildly reduced LVEF and expected high right ventricle pacing burden, the patient was referred for dual-chamber pacemaker implantation using conduction system pacing (CSP), preferentially His bundle pacing (HBP). The procedure was performed with good outcome and CSP was utilized via HBP. After reassessment of thromboembolic and bleeding risk, the patient was discharged home on reduced dose of dabigatran. Short-term follow-up showed stable HBP parameters along with no additional symptoms. Despite good short-term outcomes and no complications in studied patient, large randomized controlled trials are needed to verify long-term safety and effi cacy of HBP to optimize clinical care of patients with atrioventricular conduction abnormalities using a personalized approach.

Prosthetic valve thrombosis is one of the life-threatening complications in patients with prosthetic heart valves. It is more common in mechanical prosthetic valves in the setting of inadequate or missing anticoagulation. Besides optimization of anticoagulation urgent surgery or thrombolytic therapy should be considered but both are associated with an increased risk for complications and mortality. We report a case of a patient with imaging data for mechanical prosthetic mitral valve thrombosis. Considering the individual patient’s characteristics and the published guidelines we decided to perform systemic thrombolysis with ultra-slow low-dose infusion of tissue-type plasminogen activator. The therapy was successful without any bleeding or thromboembolic complications.

Conduction system pacing (CSP) is a pacing technique involving the implantation of permanent pacing leads at different sites along the cardiac conduction system and includes His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Intracardiac echocardiography (ICE) might facilitate the implantation of the permanent pacing lead in the left bundle branch (LBB) area of the interventricular septum. We report a case of an 83-year-old patient presenting with right bundle branch block (RBBB), left anterior fascicular block (LAFB), and dizzy spells during episodes of 2:1 atrioventricular (AV) block who underwent CSP with ICE guidance at our center. Apart from standard fl uoroscopic guidance and monitoring of intracardiac signals, ICE was also used to monitor lead advancement in the septum during the implantation. The landing zone and penetration depth of the pacing lead through the RV septum, mid-septum, and LBB area septum were easily visualized with ICE. Selective LBBAP demonstrated by the accepted ECG and electrogram criteria was achieved. Automated strain rate protocol with speckle tracking was used to demonstrate preserved left ventricular (LV) synchrony following the implantation. The use of ICE to guide LBBAP implantation can be used to monitor lead penetration in the septum, potentially improving the safety and effi cacy of this promising pacing modality.

Patients with recurrent vasovagal syncope with cardioinhibitory or mixed mechanism, or with symptomatic functional sinus bradycardia or AV block can be treated with cardioneuroablation. Material and methods: A case series of 5 patients is presented – four with recurrent syncope and/or symptomatic sinus bradycardia, and one with paroxysmal atrial fi brillation and recurrent syncope. After a confi rmation of the syncope mechanism with tilt table test, and after positive atropine test, radiofrequency catheter cardioneuroablation was performed (this was adjunctive procedure for the patient with atrial fi brillation who received pulmonary vein isolation). During short-term follow-up none of the patients had syncopal recurrence. Conclusion: Catheter neuromodulation provided very good short-term results and lack of serious complications in this fi rst case series in Bulgaria.