Aneurysmal dilatation of the aortic root and ascending aorta is frequently associated with functional aortic regurgitation due to distortion of aortic root geometry, including dilatation of the annulus and the sinotubular junction, in the presence of morphologically preserved valve cusps. The classic surgical approach – composite aortic root replacement (Bentall-De Bono) – provides radical correction but is limited by the drawbacks of valve substitution, namely lifelong anticoagulation with mechanical prostheses or limited structural durability with the potential need for reintervention in bioprosthetic valves. Over recent decades, valve-sparing operations have become a preferred approach in appropriately selected patients. The David reimplantation technique provides annular stabilisation and control of dilatation of both the aortic root and the sinotubular junction while preserving the native aortic valve. Use of a Valsalva graft facilitates a more physiological root geometry, potentially optimising valvulo-aortic hemodynamics and cusp kinematics. The procedure also allows concomitant cusp repair when necessary to achieve optimal coaptation. The available literature consistently demonstrates low early operative mortality and excellent long-term durability of valve preservation in experienced centers, with high freedom from reoperation and a low incidence of clinically signifi cant aortic regurgitation at follow-up. European recommendations support valve-sparing strategies in younger patients with a dilated aortic root and preserved cusps when performed in specialized centers. Our experience at Acibadem City Clinic Hospital Vitosha since implementation of the technique in 2018 is consistent with published data, with good early hemodynamic results and favourable clinical evolution during follow-up. David valve-sparing aortic root replacement using a Valsalva graft according to the De Paulis method represents an anatomically grounded and highly effective strategy that combines radical correction of root pathology with preservation of the native valve and avoidance of prosthesis-related complications.

Floating thrombus of the aortic arch in the absence of aneurysm or atherosclerotic disease is an exceptionally rare condition. We report the case of a 47-year-old woman, an active smoker with iron-defi ciency anemia, who presented with acute retrosternal chest pain, dyspnea, diaphoresis, and vomiting. Initial evaluation showed arterial hypertension, sinus rhythm with poor R-wave progression in the precordial leads on electrocardiography (ECG), and markedly elevated high-sensitivity troponin levels, consistent with acute coronary syndrome. Transthoracic echocardiography (ТТЕ) revealed a large, highly mobile mass in the aortic arch prolapsing into the supra-aortic branches, reduced left ventricular systolic function and apical dyskinesia. Computed tomography angiography (CTA) confi rmed a fl oating thrombus attached to the lesser curvature of the aortic arch, mild non-obstructive coronary artery disease, and an apical left ventricular aneurysm. The patient was initially managed conservatively with unfractionated heparin and aspirin due to high procedural risk. However, despite therapeutic anticoagulation, she developed a transient cerebrovascular event, prompting urgent surgical intervention. Intraoperatively, a loosely attached mixed thrombus was excised from the aortic arch without evidence of atherosclerosis or endothelial injury. The postoperative course was uneventful. This case emphasizes the high embolic potential of fl oating aortic arch thrombi and supports early surgical consideration when embolic complications occur despite optimal anticoagulation.

Transcatheter aortic valve replacement (TAVR) is an established therapy for severe aortic stenosis, particularly in high-risk surgical candidates. While procedural success rates are high, valve migration remains a rare but serious complication, especially when occurring long after implantation. We report a case of late antegrade migration of a TAVR prosthesis presenting as new-onset heart failure nearly one year after successful implantation. A 77-year-old male with a history of hypertension and chronic lung disease underwent TAVR with a 27 mm NAVITOR (Abbott, USA) valve. Post-procedural recovery and early follow-up were uneventful. However, the patient later developed progressive heart failure symptoms. Transthoracic echocardiography revealed elevated transvalvular gradients, prompting further evaluation with computed tomography and fl uoroscopy, which confi rmed migration of the valve into the ascending aorta. Given the anatomic challenges and heavy native valve calcifi cation, the Heart Team opted for surgical explantation and bioprosthetic aortic valve replacement. The patient recovered well postoperatively and remained asymptomatic at three-month follow-up with normal valve function. This case underscores the importance of long-term surveillance after TAVR and highlights the potential for late mechanical complications. Early recognition through advanced imaging and individualized Heart Team decision-making are essential for optimal outcomes in such rare scenarios.

Minimally invasive surgical techniques in cardiac surgery are increasingly applied, particularly in elderly and high-risk patients. One of the most universal and promising approaches is the transaxillary access, which allows surgical interventions on all cardiac valves and their combinations. This access does not require bone transection and leaves practically an invisible scar, making it exceptionally sparing. In combination with sutureless valve prostheses (e.g., Perceval S), this approach shortens aortic cross-clamp and cardiopulmonary bypass times, improves hemodynamic outcomes, and facilitates work in a limited surgical fi eld. In the Department of Cardiac Surgery at Tokuda Hospital, 19 operations have been performed using this method over the past year and a half: 8 aortic valves, 10 mitral valves, and 1 tricuspid valve. The present article reviews the advantages and specifi c features of the transaxillary approach in valve replacement.

Introduction: Low-density lipoprotein cholesterol (LDL-C) is a cornerstone biomarker for cardiovascular risk. The Friedewald formula has long been the standard for estimating LDL-C, however, it has limitations, particularly in patients with hypertriglyceridemia or low LDL-C levels. Several alternative equations, including the Martin–Hopkins (M/H) and Sampson formulas, have been developed to improve accuracy. Among them, M/H has gained recognition for its performance in specifi c populations, but it represents only one of several refi ned methods used across professional communities. This study aimed to perform a meta-analysis comparing the accuracy and precision of the Friedewald and M/H formulas in diverse populations, acknowledging that other approaches also exist. Methods: A systematic review of articles published between 2018 and 2024 was conducted using PubMed, Embase, Scopus (Elsevier), and Web of Science-eligible studies directly compared both formulas against direct LDL-C measurement in adult populations. A random-effects model was used to pool mean absolute errors (MAEs), root mean square errors (RMSEs), correlation coeffi cients, and p-values. Heterogeneity was assessed using the I² statistic. Results: Eight novel studies, involving a total of 192,094 participants, were included. The M/H formula showed signifi cantly lower MAE (3.6 mg/dL vs. 8.4 mg/dL, p < 0.001), lower RMSE (5.1 mg/dL vs. 9.8 mg/dL, p < 0.001), and a stronger correlation with direct LDL-C (r = 0.92 vs. r = 0.84) compared to the Friedewald formula. The superiority of the M/H formula was especially evident in patients with triglycerides >200 mg/dL or LDL-C <70 mg/dL. Conclusion: The M/H formula provides more accurate and precise LDL-C estimation than Friedewald, particularly in clinically vulnerable groups. However, it should be considered one of several improved approaches, alongside other equations such as Sampson, which may perform better in certain populations. M/H can be recommended as a strong option, but is not the sole alternative for routine lipid profi ling.

One of the main methods currently used is the transthoracic echocardiographic evaluation by HyperDopler intracardiac fl ow dynamics. It is based on color Doppler mapping of the blood fl ow by CDMF/Color Doppler fl ow mapping/technology. In addition to conventional transthoracic echocardiography, this technique enables visualization and quantitative assessment of intracardiac blood fl ow. HyperDoppler methodology represents a new paradigm in the analysis of cardiac function with the potential for sensitive risk identifi cation and prediction of impending cardiac damage.It has been shown that a comprehensive assessment of intracardiac structures as well as their intracavitary vortex fl ow can enable the detection of pathologically altered fl ow characteristics. Which in turn identifi es new pathophysiological mechanisms in the development of cardiovascular diseases. Our methods provide additional information on hemodynamics, with the potential for early detection of cardiac dysfunction and assistance in disease treatment and prevention. Convection echocardiographic measurements of cardiac mechanics usually do not reveal signifi cant changes until there is signifi cant dysfunction, making them less effective for early diagnosis and treatment of cardiovascular disease. Blood fl ow dynamics are immediately affected when cardiac hemodynamics change, therefore analyzing it opens new perspectives for the prediction and early diagnosis of diseases. Intracardiac fl ow analysis is a different and modern approach to assess cardiac function, providing important and complementary information to conventional approaches based on cardiac mechanics.

This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) studies and catheter ablations in 2024. Material and methods: Full one-year sample of the BG-EPHY registry was analysed retrospectively. Sex and age distribution of the patients, number of ablations, use of electroanatomic mapping (EAM), ablation energy source, distribution of different types of arrhythmias, acute procedural success, complications, recurrences and redo procedures are presented. Results: In 2024 ten EP centers performed 2624 ablations in 1714 men (65.3%) and 910 women, incl. 16 ablations in pediatric patients (0.61%). EAM was used in 1506 procedures (57.4%), irrigated-tip catheter – in 1535 (58.5%), cryocatheter – in 507 (19.3%), and intracardiac echocardiography – in 203 (7.7%). The most frequently performed primary ablation was pulmonary vein isolation (51.9%), followed by ablation for typical atrial flutter (15.1%) and AV nodal reentrant tachycardia (13.5%). The acute success was over 99%, while intraprocedural complications were less than 1.5%. Redo procedures for recurrence of the index arrhythmia were done in 190 patients (7.24%), with atrial fibrillation and atrial flutters accounting for the largest numbers (n = 147). Conclusion: The national registry of electrophysiology collects systematically and continuously data on all ablations of cardiac arrhythmias performed in the country. In 2024, the number of ablations increased compared to 2023, but at a slower pace. Distribution of EP procedure types was similar to previous years. Acute success was very high, while intraprocedural complications were rare.

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Introduction: Atrial fi brillation is the main etiological factor leading to the development of atrial cardiomyopathy (ACM). The different types of atrial fi brillation (AF) are characterized by varying severity of atrial dysfunction, symptoms, and prognosis. Objective: The aim of our study is to analyze the echocardiographic parameters of patients with atrial cardiomyopathy with paroxysmal and permanent atrial fi brillation and to investigate the prognosis of these patients. Material and Methods: We studied 180 consecutive patients with advanced atrial cardiomyopathy, defi ned as a severely dilated left atrium with indexed volume (LAVI) ≥ 48 ml/m², preserved left ventricular ejection fraction (LVEF > 50%), without the presence of primary valvular diseases or ventricular dysfunction. We divided patients with ACM into two groups depending on whether they were with paroxysmal AF (n = 88) or with permanent AF (n = 92). All patients underwent detailed echocardiography with volumetric and speckle tracking analysis at inclusion. Results: The mean age of patients with ACM was 74.1 ± 8.7 years, with 58% being women. The ejection fraction and global longitudinal strain of the left ventricle in patients with permanent AF were signifi cantly lower than those in patients with paroxysmal AF. This was also true for the left atrial reservoir strain (LASr: 10.2 ± 4.6% vs. 23.7 ± 7.9%, p < 0.001). Similar fi ndings were observed in the volume of the right atrium, right ventricular function parameters, and right atrial reservoir strain (RASr: 12.1 ± 6.9% vs. 24.4 ± 8.0%, p < 0.001). Patients with permanent AF also showed a signifi cantly higher grade of tricuspid regurgitation. Over a mean follow-up of 19 months, the mortality rate was signifi cantly higher in the permanent AF group at 20%, compared to 8% in the paroxysmal AF group (p = 0.03). Conclusion: Patients with atrial cardiomyopathy and permanent atrial fi brillation exhibit signifi cantly worse echocardiographic parameters, including those of the right heart chambers, and have a poorer prognosis compared to those with paroxysmal atrial fi brillation.

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.