INTRODUCTION: There is a significant percentage of Bulgarians suffering from ischemic heart disease (IHD) and its complications, such as ischemic mitral regurgitation (IMR). It plays an important role in Bulgarian society. Surgical treatment of this pathological conditions could have positive impact on life expectancy and the medical quality of life of patients. AIM: The purpose of the study is to establish a reproducible algorithm to advise the appropriate surgical treatment of patients with IHD and significant, but not severe IMR based on their condition. MATERIALS AND METHODS: The study is based on the data collected prospectively at the Department of Cardiac Surgery, St. Marina University Hospital in Varna, Bulgaria. IHD and significant IMR (i.e. more than mild 1+, but less than severe 4+ degree) were diagnosed in 186 patients. Applying inclusion and exclusion criteria, 140 patients with pure secondary IMR remained in the study group. The data was analyzed in a retrospective fashion. We discussed two possible treatment strategies: coronary artery bypass grafting + mitral valve repair (CABG+MVRep) and isolated revascularization (CABG only). To obtain comparable data for those treatment strategies, we needed a formal stratification of the patients, allowing comparison between the groups. RESULTS: Creating formal algorithms we are able to divide the patients into comparable Group A (CABG+MVRep) and Group B (CABG only), and surgical strategy is based on characteristics of the individual pathology of every patient. DISCUSSION: Despite data from small randomized and non-randomized trials, to date there is no clear agreement and strategy regarding concomitant mitral valve repair with CABG during the first-time operation. CONCLUSION: Formal stratification with the algorithms created and applied gave us the opportunity for reliable comparison of relatively different patients, and to draw conclusion for the practice. This approach should be applied in such small non-randomized trials to achieve better understanding of the problem of secondary IMR.

Atherosclerosis and its complications, erosion and rupture of the plaque fibrous cap, lead to myocardial infarction and stroke, the main causes of mortality worldwide. In this setting, arterial smooth muscle cells (SMC) of the innermost media undergo phenotypic changes, a switch towards a secretory phenotype engaged in matrix proteins production. In its nature, this is a protective action that forms of a new arterial layer, the fibrous cap covering the plaque thrombogenic lipid core. The risk of plaque rupture is inversely correlated with the presence of secretory state SMC and collagen fibrils within the fibrous cap. Thus, fibrous cap remodeling appears to be the main determinant of plaque vulnerability. Herein, we focus on the potential role of (i) the transcription factors TCF21 and KLF-4 in SMC phenotypic modulation, (ii) the matrix protein secretion of SMC, and (iii) the activity of proteinases (MMP, ADAM, ADAMTS, furin, and the MMP inducer CD147) in this critical process. We argue that focusing on these basic pathways could contribute to the knowledge of fibrous cap stability that might be translated into clinical medicine.

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Up to 30 % of all ischemic heart disease patients present with some degree of ischemic mitral regurgitation. It is proven that any grade adversely affects long-term outcomes. Surgical revascularization and restoration of the valvular function both trigger left atrial and ventricular reverse remodeling and improve the prognosis.

PURPOSE: Pathology of the aortic root and aortic valve is subjected to adult cardiac surgery and includes Stanford A aortic dissection, annuloaortic ectasia or chronic aneurysm of the ascending aorta. In such cases, Bentall-De Bono procedure is usually preferred. Aortic valve reimplantation by using Tirone David's technique presenting with the advantages of valve-sparing surgery can be performed in selected cases. MATERIAL AND METHODS: A retrospective analysis of a three-year experience with the complex surgical treatment of diseases of the aortic valve and root was carried out. During the period from January 1, 2009 to December 31, 2012, fifty-three patients with aortic valve and aortic root pathology were treated in the Division of Cardiac Surgery, St. Marina University Hospital of Varna. Bentall procedure was carried out in 37 patients (Group B). In 19 of them (51%) emergency surgery was done for acute aortic dissection of type Stanford A. The rest 18 patients underwent elective surgery for dilated ascending aorta and aortic valve dysfunction. Aortic valve-sparing surgery by David's technique for aortic aneurysm was accomplished in 16 patients (Group D). This technique was emergently applied in one patient with aortic dissection, too. Baseline data, intraoperative details, early results and complications were compared. RESULTS: Early (30-day) mortality after Bentall-De Bono procedure was 10,5% (0% after elective surgery and 21,1% after dissection repair). All the patients survived after David's procedure that proved the significant advantages of the valve-sparing surgery. CONCLUSION: The aortic valve reimplantation provides long-term results that are comparable to those after the Bentall-De Bono procedure such as high survival rates, low incidence rate of endocarditis, and slightly higher risk of reinterventions. There is no need of lifelong anticoagulation that improves patient's quality of life.