Month: February 2024

A conversation with Dr. Valentin Krastev about this urgent and life-threatening condition

Dr Krastev, what is pulmonary thromboembolism and why is it so important?
– In fact, pulmonary thromboembolism and deep vein thrombosis alone or together represent the third most common cardiovascular disease after ischemic heart disease and stroke. The two, united in venous thromboembolism, are often a transition from thrombosis/thrombophlebitis/ of the peripheral veins, most commonly of the legs, in which clots break off from the veins and go to the pulmonary artery. The significance is justified by the fact that it is common, rarely diagnosed and mortality in severe forms is as high as 50%. In survival, an accurate diagnosis is made in only 7% of cases.

Who are the most vulnerable groups to this disease?
– First of all, we should mention that in almost all cases the thrombus comes into the lungs from somewhere. Therefore, all conditions that imply immobility or increased clotting favour the formation of thrombi in the pelvic veins or veins of the lower limbs, and these are immobility, operations, recent hospital stay, pregnancy, malignancy, prolonged travel and genetically determined changes in clotting factors. It is also more commonly seen in women, and the likelihood increases manifold with age.

What are the most common symptoms?
– The severity of symptoms is determined by the size of the thrombus and the condition of the heart and lungs before the embolism occurs. In the most severe, there may be loss of consciousness, a drop in blood pressure or sudden severe shortness of breath. In the milder forms unexplained onset of easy fatigue, breathlessness on ordinary exertion, quickening of the pulse, etc.

How is the treatment you apply different from the standard one?
– For low-risk pulmonary embolisms, treatment is with anticoagulants and there is nothing new to offer at this stage. For high and moderate risk emboli, where the signs of heart burden are also present, we have 2 approaches. In the first, we have recently deployed equipment equipped with a system to suction the thrombi out of the pulmonary arteries via a special catheter connected to a negative pressure line. This makes it possible to remove a large part of the thrombus that is in the pulmonary artery and thus improve the patient’s chances of successfully getting through the critical condition. The second approach is by inserting catheters with side holes through the thrombi and incorporating a medication that melts them called a thrombolytic. This lasts for 24 hours and allows for a much better outcome at a much lower dose of thrombolytic – hence a much lower risk of complications as opposed to the widely used and unscientific method of a single injection of this medication into the pulmonary artery.

Have you already had positive results from the application of this clot suction system?
– In just one week we used it in two patients despite the fact that the cost is very high and not covered by the Health Insurance Fund. One case was particularly interesting as it was a very young man with a pulmonary embolism and a vein thrombus on one leg and with a blockage in the abdomen where the veins from both legs join. We treated the pulmonary embolism with a catheter and a thrombolytic, and unblocked the blocked vein with the new suction and stent system, which allows a full recovery for a man with the very important profession of being an aviator. In addition, I should note that we treat pulmonary embolism as a level of urgency as acute myocardial infarction, i.e. we are on call 24/7.

A high-tech pacemaker has been implanted in a 95-year-old woman who was admitted to the Cardiology Clinic of Heart and Brain Center of Clinical Excellence on an emergency basis with a very slow heart rhythm. The official records show that this is the oldest patient in Bulgaria to have such a device implanted.

On admission to the clinic, the patient was taken over by Dr Nikolay Petrov. After investigations, he and his colleagues found that the woman was suffering from heart failure and had severely reduced heart pump function. Despite her advanced age and high-risk profile for complications, the team did not hesitate and made the decision to place a complex resynchronizing pacemaker.

“There was the option of implanting a standard pacemaker, but due to the risk of worsening heart failure in the future, my colleagues and I undertook the more technically complex procedure. The high-tech pacemaker not only stabilizes the heart rhythm but also treats heart failure. It is one of the few devices that reduces symptoms and prolongs the life of heart failure patients,” said Dr Petrov.

The entire procedure took 90 minutes and went without complications. The very next day, the 95-year-old patient left the clinic in good health. At the first follow-up examination, she said she felt an extraordinary improvement in her general condition.

“Age is no vice, but a privilege and regardless of the age of the patients, they should receive the best and most modern medical care”, the specialists from ‘Heart and Brain’ Pleven are adamant.

Dr. Petya Dinovska, Executive Director of ‘Heart and Brain’

Open days, campaigns for access to specialized medical care in small towns, schools for patients, high-tech medical procedures, long-term follow-up of patients after COVID-19 – this is just a small part of the activities of the hospitals of the Bulgarian Heart Institute. And although we are often copied, no one has yet reached our advanced expertise, work dynamics, way of organization and, most of all, the attitude to the patient. Of course, we are very happy just today, on Trifon Zarezan and Valentine’s Day, to congratulate all colleagues dedicated to the profession with great love and to note that all of us in Bulgarian healthcare together raise its quality to a European level.

17 years ago, with the launch of the first specialized cardiology hospitals in Pleven, Varna, Yambol, Shumen and Veliko Tarnovo and the introduction of the so-called “golden hour” in a total of 16 districts, we significantly reduced the mortality rate from acute myocardial infarction in the country, improved the quality and prolonged the lives of patients with cardiovascular diseases.
Emergency care must be comprehensive, because no country in the world has been able to address 100% of life-threatening conditions alone.

This success was noticed by the leading European and world cardiologists from the United States, Czech Republic, France, Italy, Switzerland and Germany, who accepted to pass on their knowledge and skills to their Bulgarian colleagues. Legendary luminaries such as Professors: Eugene Braunwald, Toby Cosgrove, Frans Van de Werf, Jean-Pierre Bassand, Petr Widimsky, Tomislav Mihaljevic, Steven Nissen, Luigi Martinelli, Ladislav Groch, Francesco Bedogni, Zbyňěk Straka, Bijoy Khandheria, Antonio Pezzano, Robert Hobbs, Christian Matter and many others have supported us and continue to help us in advanced medical science and practice. World renowned cardiac surgeon prof. Thierry Carrel, the renowned vascular surgeon prof. Chang Shu, the renowned orthopaedic endoprosthetist prof. Heinz Roettinger, the star of breast surgery prof. Diego Rivas – all of them chose the high-tech hospital complexes ‘Heart and Brain’ in Pleven and Burgas to present the latest surgical techniques, inspect the work and confirm the expertise of our teams. The long list of legendary luminaries in medicine who have become part of the Bulgarian Heart Institute family continues to grow along with our ongoing advancements in over two dozen important specialty areas.

The long-term investment in new knowledge and skills of physicians from all specialties continues to this day. Heart and Brain physicians continue their training and qualifications in the most prestigious European university clinics and leading hospitals in Europe, the United States, Australia and Israel, learning the most advanced approaches to the treatment of socially important diseases from which Bulgarians suffer – cardiological, metabolic, neurological, etc.

Just seven months ago, the first newly built clinic for maternal and child health ‘Mama and I’ opened its doors in 55 years. A number of metropolitan families travel to Pleven to have genetic testing and receive first-class treatment and care for their children from the best neonatologists, pediatricians, surgeons, orthopedists, medical geneticists in the country. The results have not been long in coming – more than 180 babies have already been born at ‘Mama and I’, and our doctors often treat the most complex cases from all over the country.

In response to numerous inquiries from patients and colleagues, delighted by the modern treatment and individual approach at ‘Heart and Brain’, some of our leading specialists are now examining and consulting patients at the ‘Heart and Brain’ medical centre in Sofia: Lozenets district.

As with any success, only the gloss remains on the surface – hidden are the efforts, coordination, motivation and perseverance of each of us, dedicated to our work with great love and dedication. It is only natural that the way of working, the approach to patients and even the news from ‘Heart and Brain’ should be copied and emulated. This particularly pleases us and fills us with optimism – because we are leading the reform towards achieving European quality in healthcare!

On 12 February we celebrate the International Day of People with Epilepsy. This common neurological disorder affects over 70 thousand Bulgarians and about 60 million people worldwide. Prof. Dr. Plamen Bozhinov is a leading neurologist and head of the Heart and Brain Clinic for Neurological Diseases.

The word epilepsy is of Greek origin and means ‘to grasp, seize, overwhelm’. This term was first used by Aristotle to define conditions accompanied by seizure manifestations. John Hughlings Jackson (1835-1911) contributed to the scientific description of various types of epilepsy. Some of these descriptions were based on his observations of his own wife’s epileptic seizures. These seizures always began in the same way: with involvement of the wrist and subsequent spread to the shoulder, face and finally the leg on the same side of the body. Later, epileptic seizures with similar spread were called Jacksonian, and their spread was defined as Jackson’s march.

Can we briefly tell what epilepsy is?

Epilepsy is a disease affecting the central nervous system (CNS) that is characterized by an individual predisposition to recurrent manifestations called epileptic seizures. They are characterised by intermittent, unprovoked, identical for each patient and in most cases unpredictable disturbances of consciousness, behaviour, emotional state, motor functions, perception or a combination of these. These clinical manifestations are the result of a suddenly occurring, deviating from normal (abnormal) hyperexcitability of brain neurons, called crisis (paroxysmal). In a combination of various genetic and acquired conditions, this hyperexcitability may begin to recur after some time (become chronic) and lead to the development of the disease epilepsy.

The incidence of the disease varies between 4 and 10 per 1000 people. Epilepsy in Bulgaria occurs in about 3% of the population, with an average of 240-3600 new cases diagnosed annually (30-45 cases per 100 000 population). About 50% of epilepsies begin in childhood, before the child reaches the age of 10, and a total of 75% occur by the age of 20. The peak of manifestations in children is around the fourth year, and in adults over 65 years. The mortality rate is between 0.4 and 4 per 100,000 patients, with the most common cause related to the onset of status epilepticus.

When it comes to epilepsy, we should not forget about the stigma associated with this disease.

Yes, it is. Even patients with a mild disease, without accompanying forms of disability, feel stigmatised (marked) and their illness leads to serious social disadvantages. Epilepsy is responsible for significant medical and social impairment and therefore requires medical, neuropsychological, psychiatric and social interventions. In about 60-70% of patients with epilepsy, medication response is good and the active phase of the disease (with the presence of seizures) covers a short period. These patients need short-term rehabilitation, but at the same time a full evaluation and varying degrees of long-term psychological and social support. For the remaining patients with refractory epilepsy, a more prolonged and intensive rehabilitation is needed, especially as 10% of patients with epilepsy have persistent learning problems and the presence of other debilitating conditions.

What are the specifics in diagnosis?

Diagnosing epilepsy and determining the type of epileptic seizures is an important part of the medical art, and specialists are called epileptologists. These are neurologists who have a great deal of practical experience and are familiar with all the steps involved in making or rejecting a diagnosis of epilepsy. Important stages in the diagnostic plan are: recognition and description of epileptic seizures; differential diagnosis (DD) with conditions other than epilepsy but presenting with changes in consciousness, motor, sensory, autonomic or psychic manifestations; proof of the chronic course of the disease in the absence of an obvious seizure provoking factor; proof of the type and aetiology of epilepsy. To make a correct diagnosis, the first step is to take a correct history (accompanying conditions; symptoms during and after the seizure). Secondly, a good assessment of the somatic condition helps to differentiate epilepsy from other diseases that may have similar clinical manifestations. Neurological examination may reveal signs of local or diffuse brain damage, but in most cases there may be no apparent neurological symptomatology.

What else helps specialists?

Epilepsy can arise secondary to various pathological conditions, for example, traumatic or inflammatory changes in the structure of the brain, infectious diseases affecting structures of the nervous system, metabolic disorders, autoimmune diseases in which the immune system reacts against its own structures of the nervous system, and last but not least – to genetic defects. In some cases, even with the use of all the possibilities of modern medicine, the cause of epilepsy can not be established.

After carrying out a wide range of standard tests to exclude the most common causes of secondary epilepsy (imaging, laboratory analyses, immunological tests), genetic analyses can be extremely useful in clarifying the aetiology in some cases. To date, more than 200 genes have been identified that are directly associated with the onset of epilepsy, and dozens of others are known to be associated with the development of diseases in which epilepsy or epileptic seizures are part of the symptoms.

What is the role of genetics here?

Establishing the genetic cause of epilepsy is important because it not only confirms and clarifies a patient’s diagnosis, but can be critical for making therapeutic decisions, allowing assessment of prognosis and prediction of the course of the disease, as well as assessing the risk of affecting other relatives. Making an accurate diagnosis has social, economic and normative implications, allowing those affected to find an adapted place in society, obtain an adequate assessment of their ability to work and to relate to others with the same illness.

Genetic studies to establish the cause of epilepsy are varied, as they offer a search for fundamentally different genetic disorders – there is no universal method of analysis. The choice of the appropriate tests and the order in which they should be carried out is individual and tailored to the disease history of the particular patient. It is done with the help of a medical geneticist who, in the context of a genetic consultation, explains to the patient the advantages and limitations of the different methods and the meaning of genetic analyses so that the patient can make an informed decision about his or her own health.

These and other types of analyses, as well as expert genetic counselling by a team of specialists with high qualifications and clinical experience, are offered for patients with genetically determined epilepsy in the medical genetics laboratory at , Heart and Brain’. The laboratory has state-of-the-art equipment and operates to established European standards. The ability to work collaboratively with specialists from all medical specialties within the hospital allows for a multidisciplinary individualized approach to each patient’s care. In this way, patients with rare genetic syndromes whose clinical picture includes epilepsy can receive an accurate diagnosis and possibly specific treatment without long delays.

The highly specialised hospitals , Heart and Brain’ employ some of the best epileptologists and neurologists in our country. In the high-tech hospital complexes in Pleven and Burgas, specialists can make the most accurate diagnosis of the type of epilepsy and epileptic seizures, conduct genetic testing and drug monitoring, and prepare an individual treatment plan for each patient.

The life-saving approach applied is unique for Bulgaria and the world

Six complex operations, three of which were performed on an emergency basis using the method of a customized and physiologically modeled prosthesis, were performed by vascular surgeons at ‘Heart and Brain’, Pleven. “The technique is extremely complex and specific. Literally on the fingers of the hand are counted the hospital centers in the world that have successfully implemented this type of surgery in a state of emergency,” informed Dr. Todor Samardzhiev, head of the department of vascular surgery at the high-tech hospital. The operated patients were admitted to Pleven from other hospitals in the country. Although transportation carries an additional risk, the survival rate of patients with ruptured aneurysms increases when they are treated in a hospital where the necessary specialists and equipment are available.”

“Five of the interventions we had to do in a very short time were on patients with abdominal aortic aneurysm, three of them with rupture (rupture). The sixth was on a patient with a renal artery aneurysm. These conditions are some of the most life-threatening, and rupture requires immediate measures because it involves the effusion of a large amount of blood into the abdominal cavity. The only treatment is surgical intervention. Any delay could be fatal for the patient, and the risk of a fatal outcome in classic open surgery for a ruptured aneurysm is over 90%.”

Endovascular aortic aneurysm repair (EVAR) is routinely performed at ‘Heart and Brain’, Pleven, both in elective and emergency patients. The challenge in these three cases was that the nature of the aneurysm did not allow standard endovascular surgery. Therefore, in three of the cases we inserted a customized and physiologically modeled prosthesis. An extremely complex method, requiring impeccable precision, team preparation and technique,” explains Dr. Samardzhiev.

The condition of the patients necessitated the placement of a fenestrated endoprosthesis. Fenestrations are openings in endoprostheses through which vital organs are supplied with blood. However, such prostheses are not available in the country and their cost exceeds BGN 70 000. “Making a ready-made custom prosthesis would take a lot of time and money. We have successfully modified an existing graft, which is covered by the NHIF,” says the head of vascular surgery. The multidisciplinary team decided to apply the approach, which is new for our country and was first successfully implemented in ‘Heart and Brain’ half a year ago. Through precise measurements and calculations, the vascular surgeons modify the implant for the patient’s specific needs by 3D imaging in a sterile environment. This is followed by an extremely delicate process of placing stents in the renal and iliac arteries. The surgery is minimally invasive and requires careful advance preparation, a great deal of knowledge and additional skill on the part of the physicians.

“We did all the surgeries as per the global time requirements – from the entry into the room, anaesthesia to the intervention itself. The aneurysms were asymptomatic and the only thing the patient could feel as a kind of warning was pulsations in the abdominal area, but no pain. The appearance of sharp and sharp pain is already a sign of rupture and a state of emergency. Unfortunately, the hospitals in the country where these emergency conditions can be operated are still few,” the experts add.

In just three years, the centre has managed to establish itself as the preferred choice among thousands of patients

Around 3 million Europeans hear the diagnosis of cancer every year. More than half suffer from breast, colon, lung or prostate cancer or malignant haematological diseases. And although cancer is the second most common cause of death in the EU, up to 40% of cases are curable. 4 February is World Cancer Day and it is an occasion to remind people that early detection, prevention and quality care can save thousands of lives.

Oncologists and cancer specialists agree that innovation at all stages, from diagnosis and treatment to patient follow-up, is the cornerstone of successful therapy and improved quality of life. And at the heart of good outcomes is a comprehensive multidisciplinary approach.

Multidisciplinary treatment

Heart and Brain’s multidisciplinary teams include surgeons, pathologists, medical oncologists, clinical haematologists, radiotherapists, neurosurgeons, cardiologists, orthopaedists, pulmonologists, gastroenterologists, neurologists, medical geneticists, obstetricians, endocrinologists, haematologists, clinical psychologists – all in one place. Together they determine the therapeutic strategy for each patient according to their individual characteristics, the biology (type) of the tumour, taking into account comorbidities, family history and other risk factors.

The country’s first cardio-oncology team works in the high-tech hospital complex. Thanks to it, a number of patients with cardiovascular diseases or cardiovascular toxicity from the conducted oncological or oncohematological therapy, who otherwise would not be able to start anti-tumor therapy, actually not only conduct such therapy, but also achieve outstanding results. Guaranteeing this success is the close collaboration between cardiologists and oncologists and clinical haematologists.

Individual approach

The patient is at the centre of modern oncological, or oncohaematological, treatment, so the type of therapy and the sequence of treatment methods are strictly individual.

Target therapy and immunotherapy mark an exceptional advance in the therapeutic algorithms applied at Heart and Brain. Our medical geneticists routinely test biomarkers for predictive, prognostic and diagnostic purposes and determine a patient’s mutational profile so that the optimal individually tailored (personalized) therapeutic approach can be selected. The testing of certain molecular genetic markers provides information on the effectiveness and possible benefit of immunotherapy and the administration of targeted drugs. Timely molecular genetic analysis is part of successful treatment in patients.

Experienced specialists and high technology

The work of the centre is further enhanced by a state-of-the-art radiotherapy complex, equipped with the most technologically advanced linear accelerator in the country, a 4D computed tomography simulator for radiotherapy and radiosurgery planning and the country’s only latest generation gamma knife.

Stereotactic radiosurgery (SRS) is used to treat benign and malignant brain tumors, vascular diseases in the brain (arteriovenous malformations and trigeminal neuralgia), and in recent years, increasingly, brain metastases that some patients develop despite initial cancer therapy. The accumulated experience with the device shows that acute side effects associated with radiotherapy, such as nausea, vomiting, headaches, are in practice extremely rare in patients treated with gamma knife.

Radiosurgery is usually performed as a one-time procedure during a one-day hospital stay. It is much safer and less toxic than both standard neurosurgery, which involves incisions in the scalp, skull, brain membranes and tissue, and other types of radiotherapy, which require multiple exposures. The treatment is paid for by the National Health Insurance Fund.

Robotic oncogynaecology is the trademark of the clinic for maternal and child health “Mom and Me” – part of “Heart and Brain” in Pleven. For a year and a half, the specially trained specialists have performed more than 1,500 surgical interventions, one third of them related to gynaecological oncological diseases.

In addition to standard open and classic laparoscopic surgery, the clinic routinely performs surgery with the da Vinci robotic system. For the robotic gynaecological surgery the hospital has a contract with the NHIF. It brings a number of advantages – minimally invasive, with the lowest levels of trauma and postoperative pain, recovery is fast and patients can return to their normal routine in the shortest possible time. The hospital has a contract with the NHIF for robotic gynaecological surgery.

Breast cancer accounts for a quarter of all cancers and is the most common malignancy in women. In Bulgaria, only Heart and Brain performs sentinel axillary lymph node biopsy – the absolute standard in the treatment of early breast cancer. The method allows during the surgery to detect the lymph nodes that are first in the path of lymphatic drainage and metastasis. If these nodes are metastasis-free, it is assumed that the remaining nodes are also metastasis-free, i.e. that the lymphatic status is negative. There is no need to remove them, which makes the operation much more sparing. The specialists have the most advanced equipment for oncoplastic surgery.

Last year, world-renowned thoracic surgeon Prof. Dr. Diego Rivas and the Heart and Brain teams performed the country’s first uniportal robot-assisted lung resection. This minimally invasive intervention is highly suitable for lung cancer patients, especially those with hard-to-reach lung tumours.

The Heart and Brain Comprehensive Cancer Center’ also treats and diagnoses prostate, kidney, bladder, testicular, penile and ureteral malignancies. Urologists apply conventional and laparoscopic surgery of prostate and kidney, high-tech robotic da Vinci surgery, minimally invasive laser and bipolar surgery for bladder tumors. The teams also use a highly sensitive method to detect areas affected by bladder cancer. This approach allows 24% more tumours to be diagnosed, which is key to a better prognosis.

Starting in 2024, the high-tech Heart and Brain will launch a program to treat primary and metastatic malignancies of the peritoneum (the lining of the abdominal cavity). The hospital now has state-of-the-art equipment for the treatment of this type of disease. The HIPEC (hyperthermic intraperitoneal chemotherapy) and PIPAC (pressurised intraperitoneal aerosol chemotherapy) methods enable the control and, in some cases, complete cure of previously considered incurable primary and metastatic malignancies of the peritoneum. Patient fulfilment of strict criteria is key to inclusion in the programme and obtaining good treatment outcomes.

The doctor-patient relationship

Modern medicine offers hope, but it also poses new challenges for oncologists and their patients. With advances in science, experience, and the application of innovation to daily practice at every stage from diagnosis to treatment, physicians can offer better care and support to those battling cancer. And oncology and cancer treatment is a long-term process – in this challenge, the patient and the doctor are together all the way. Building trust is key to a good prognosis, and often doctors become part of the family.

Why Heart and Brain?

A team of skilled and established specialists, for whom patient trust and appreciation are of the utmost importance, work together in a high-tech environment. It is no coincidence that the Heart and Brain Comprehensive Cancer Centre is the first centre in the country to be certified as a member of the Organisation of European Cancer Institutes (OECI). This enables it to work within the European Cancer Network, sharing valuable experience to offer patients access to advanced personalised treatment based on evidence-based medicine.

Scientific contribution

From 26 to 28 January this year, the second national oncology scientific conference with international participation “The era of innovation in oncology: Innovation is our DNA” was held, organised by the Society of Oncopharmacology and Oncology. Heart and Brain’ specialists presented a number of their own studies that reflect the successes of their real clinical practice in areas such as medical genetics, cardio-oncology, stereotactic radiosurgery, breast cancer, peritoneal cancer and others.