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

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

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

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.

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.

This article describes the development of the p-PCI network in Bulgaria. Even though interventional treatment of STEMI in the country was introduced around 1990, it was not performed on a regular basis which made it largely inefficient. The paper tracks the network evolution with all the problems encountered and the solutions undertaken until the present moment. Historically, all the important factors concerning the implementation, such as spreading of PCI centres, networks and infrastructure, training and certification, emergency medical service, public awareness campaigns, 24/7 work, reimbursement, etc., are reviewed. Finally, the current increase of the percentage of STEMI patients treated by p-PCI and the decrease of overall STEMI mortality rates are shown, clearly demonstrating the huge value of the SFL know-how and contribution.

Aims: Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, a 2007 study reported that only 40-45% of European STEMI patients were treated with PPCI, with large variations in treatment availability between countries. In 2008, the Stent for Life (SFL) initiative was launched by the European Association of Percutaneous Cardiovascular Interventions and EuroPCR in partnership with the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care and country-specific national cardiac societies. The aim is to promote the prioritisation of percutaneous coronary intervention treatment towards those who will benefit most, namely STEMI patients. The following countries are currently participating: Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey., Methods and Results: Since SFL was launched, several activities have been initiated in the participating countries. Preliminary reports suggest that major increases have been seen in the numbers of PPCI performed, with some countries reporting very significant increases in PPCI use from 2008-2010. Improvements in STEMI mortality rates have also been observed., Conclusions: This report summarises the progress of the SFL initiative in the 10 target countries.

Background: We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients with acute ST-segment elevation myocardial infarction, as compared with abciximab administered immediately before the procedure (primary PCI)., Methods: In this international, double-blind, placebo-controlled study, we randomly assigned patients with ST-segment elevation myocardial infarction who presented 6 hours or less after the onset of symptoms to receive combination-facilitated PCI, abciximab-facilitated PCI, or primary PCI. All patients received unfractionated heparin or enoxaparin before PCI and a 12-hour infusion of abciximab after PCI. The primary end point was the composite of death from all causes, ventricular fibrillation occurring more than 48 hours after randomization, cardiogenic shock, and congestive heart failure during the first 90 days after randomization., Results: A total of 2452 patients were randomly assigned to a treatment group. Significantly more patients had early ST-segment resolution with combination-facilitated PCI (43.9%) than with abciximab-facilitated PCI (33.1%) or primary PCI (31.0%; P=0.01 and P=0.003, respectively). The primary end point occurred in 9.8%, 10.5%, and 10.7% of the patients in the combination-facilitated PCI group, abciximab-facilitated PCI group, and primary-PCI group, respectively (P=0.55); 90-day mortality rates were 5.2%, 5.5%, and 4.5%, respectively (P=0.49)., Conclusions: Neither facilitation of PCI with reteplase plus abciximab nor facilitation with abciximab alone significantly improved the clinical outcomes, as compared with abciximab given at the time of PCI, in patients with ST-segment elevation myocardial infarction. (ClinicalTrials.gov number, NCT00046228 [ClinicalTrials.gov].), (Copyright 2008 Massachusetts Medical Society.)

Rotational atherectomy was introduced with a view to approaching percutaneously, cases that were suboptimal or unsuitable for conventional percutaneous transluminal coronary angioplasty (PTCA). In this article we present our findings for a period of two years starting in April 2001, when 60 procedures were performed on 54 patients. We found the procedure to be successful in B2 and C type lesions. It is our opinion that the lower burr-to-artery ratio used in our cases was significantly beneficial in decreasing immediate complications related to the procedure. Complimentary PTCA and stenting improved the angiographic end result. Using this strategy, we have achieved very acceptable clinical results.

In a double-blind randomized trial, the hemodynamic and electrophysiologic effects of the low-osmolar nonionic contrast medium iohexol (Omnipaque) and the standard high-osmolar ionic monomer sodium-meglumine-ioxithalamate (Telebrix) at left ventricular angiography and selective coronary arteriography were evaluated. Sixty patients were divided into two groups of 30 patients; one group received Omnipaque in a dosage of 350 mgI/ml and the other group received Telebrix in a dosage of 350 mgI/ml. The Omnipaque showed significantly less effects on heart rate and myocardial contractility, and induced less electrophysiological changes than did Telebrix. However, there was a significant increase of 10% in the diameter of the left coronary artery following selective coronary injection with Telebrix, while Omnipaque induced practically no change in vessel diameter. All hemodynamic and electrophysiologic effects proved to be short-lasting. We conclude that ionic and nonionic agents are similarly efficacious in providing adequate images with minimal risk to the patient. However, the nonionic agents exert slightly more alterations in cardiac hemodynamics and in electrocardiographic intervals. The vasodilatory effect on coronary artery diameter by Telebrix may entail a more rapid clearance of contrast medium from the coronary circulation, which might be of some advantage over nonionic contrast media.