Capital Health: good practices in “Heart and Brain” in Pleven and Burgas

The high-tech Heart and Brain hospitals in Pleven and Burgas, called palaces of health, are the latest additions to the family of the Bulgarian Cardiac Institute (BCI), consisting of 5 more specialized cardiology hospitals in Varna, Yambol, Pleven, Shumen, Veliko Tarnovo and 15 medical centers across the country. BCI was established in 2007 and is part of the country’s leading healthcare organization with a 30-year tradition – “Commercial League”. The pharmaceutical manufacturer “Tchaikapharma High Quality Medicines”, the insurance company “DallBogg: Life and Health” and the pension insurance company “DallBogg: Life and Health” are part of it.

Stereotactic Radiosurgery (SRS) and Gamma Knife

Dr. Rumen Lazarov, Head of the Radiotherapy Department in Pleven

Since March 2021, more than 100 people have benefited from the capabilities of Bulgaria’s only gamma knife – without having to seek expensive treatment options abroad. The most demonstrative results have been in patients with brain stem metastases that are not amenable to surgical treatment, and in patients with optic nerve meningiomas – for them this is the only treatment that allows preservation of vision. Our clinic also offers opportunities for a second opinion from a qualified specialist both within BCI and from colleagues from other European and international centres with whom we have traditionally worked. We are most often approached by patients with cancer and brain metastases. The maximum number of metastases we have treated at any one time is 10, but when they are less than 1 cm it is possible to treat a larger number. In non-oncological diseases, the most common cases are meningiomas, a benign disease of the meninges, which in many cases is better treated with gamma-knife radiosurgery than with surgery. We use “surgical” radiotherapy to treat functional abnormalities and small brain tumors, so-called stereotactic radiosurgery (SRS). With additional complexity are cases of patients who require re-irradiation. We recently performed such a procedure in a young woman treated twice in Turkey and twice more in Bulgaria. The treatment performed in this extremely complicated case was very successful. Modern radiosurgery is paying more and more attention to the movements of the body and organs during irradiation so that the radiotherapy is as gentle as possible – with the gamma knife this control is automatic and if there is a deviation of more than 0.5 mm the machine stops the radiation. High technology and the skills of our specialists allow us to reach a new level of precision – we use the latest generation of magnetic resonance imaging to plan gamma knife treatments. Accuracy when working with the currently most advanced linear accelerator is achieved by 4D scanner and positioning for tumors that move with the breath. Medicine in general, and radiosurgery in particular, is highly dynamic, so our teams are constantly improving their qualifications – a specialisation in treating severe tremor conditions is coming in the next few months. Constant scientific exchange and the implementation of complex solutions are key in our fight against cancer. For example, we are increasingly using simultaneous radiation and drug treatments, and we are applying all radiation chemotherapy and immunotherapy regimens simultaneously and sequentially.

Endoscopic spine surgery

Prof. Dimitar Haritonov, MD, Head of the Clinic of Neurosurgery in Pleven

Endoscopic spine surgery is the most innovative segment of the whole range of spine surgery. It is a modern and cutting-edge surgical technique that is finding increasing application in the treatment of degenerative disc disease (DDD), which in turn includes disc herniation, spinal canal stenosis, recessural and foraminal stenosis, degenerative spinal arthropathy, and spondyloarthritis. DDD covers an extremely wide age range, from 20 to 85 years (in rare cases affecting older patients), and is one of the main causes of temporary or permanent disability. Timely diagnosis and initiation of treatment is critical to outcome. Annually at the Heart and Brain Hospital – Pleven, we perform between 250 and 300 operations on patients with DDD. The percentage of endoscopic interventions increases significantly every day and now accounts for more than 30% of spinal surgery. The advantages of endoscopic surgery over conventional open surgeries, be it minimally invasive, are key – significantly less pain for the patient, reduced stress for the body, no large incisions, significantly faster recovery, fewer postoperative complications and perioperative blood loss, shorter operating time, the possibility of awake anesthesia during surgery. With the introduction of high technology in medicine, image quality has improved dramatically – we work with HD, 4K image and even 8K imaging technologies. And currently, the only hospital operating with equipment at this level is the Heart and Brain Hospital. So far we have operated on over 100 patients, mostly with disc disease and foraminal stenosis. A Joimax endoscopic lumbar fusion system is in the process of being implemented, which will open up new possibilities in endoscopic surgery. Our experience reports a reduction in operative time from an average of 90 min to 45-50 min, intraoperative blood loss is virtually absent (compared to minimally invasive surgery), the surgical incision is 5-8 mm paravertebral, spinal canal penetration is performed through natural anatomical openings without disturbing the anatomy, stability and biomechanics of the spine, thus eliminating postoperative infections. Patients are back on their feet literally hours after the intervention with restored comfort, quality of life and ability to work. Long-term follow-up of patients is part of the work of our teams, and so far we have no reports of early or late postoperative complications.

Life after COVID campaign and integration of artificial intelligence in the fight against familial hypercholesterolaemia

Prof. Yana Simova, MD, PhD, Executive Director of BCI, Head of the Post-COVID Syndrome Research Group and Head of the Department of Cardiology

Over the past 14 months, BCI has been helping a particularly vulnerable and growing segment of the population – patients with ongoing complaints after COVID-19. More than half have persistent complaints months and even years later – the so-called post-COVID syndrome. We now know that the virus damages and alters small blood vessels, and the complications usually significantly impair quality of life and prevent a full return to work. The BCI research group initiated one of the first campaigns in Europe (“Life after COVID”) to track the effects of the virus on sufferers on a long-term, no-cost basis. We have accumulated a huge amount of experience, which we share with the international scientific community, and so far we have helped nearly 3000 people. Everyone needs to understand the risk not only of the virus, but also of its consequences. It is important that those who have had the disease also get vaccinated, because the immunity after vaccination after a disease is much stronger than after a disease.

BCI is also involved in another innovative project – the creation and integration of a software program (artificial intelligence) to recognize and signal certain features of familial hypercholesterolemia, an inherited disease that leads to aggressive and early cardiovascular pathology. The project is highly relevant – firstly, familial hypercholesterolaemia very often goes unrecognised and timely treatment significantly improves prognosis and prolongs life. Second, the disease usually progresses with severe cardiovascular atherosclerotic disease (heart attacks, strokes, sudden cardiac death) at an early age. Third, adequate, potent and NHIF reimbursed treatment is available when the condition is identified. Last but not least, familial hypercholesterolaemia is a hereditary disease, so making this diagnosis in one patient allows for a cascade screening of their first-degree relatives (including children), early identification and timely initiation of therapy for primary prevention, i.e. to significantly prevent or delay conditions such as heart attack or stroke.

Maximum sparing laparoscopic, minimally invasive and robotic surgery

Dr. Vladimir Kornovsky, Head of the Department of Cardiac Surgery

Two years after it started operating in Burgas, the Heart and Brain Hospital has established itself as the preferred choice for patients in the region – with more than 1,300 heart surgeries performed. As of November 2021, the hospital is housed in its own newly constructed building with 9 above-ground and 2 underground floors – a state-of-the-art structure equipped with top-of-the-line equipment. The Cardiac Surgery Department relies on the most patient-friendly surgical interventions such as minimally invasive aortic valve replacement, endoscopic mitral and tricuspid interventions, minimally invasive bypass (MIDCAB) and beating heart revascularization, which is the standard for the cardiac surgery clinic (OPCAB). Keeping pace with the latest practices in global medicine, from September 2021, interventions for isolated mitral pathology and mitral combined with tricuspid pathology are performed entirely endoscopically at our institution. We work with top-of-the-line instrumentation and equipment, including the Einschtein 3.0 endoscopic 3-D camera. The team consists of highly experienced specialists and postgraduate students. This forms four separate, independent teams that are fully interchangeable and can cover the entire range of cardiac surgery interventions. The da Vinci X 3D – HD, an innovative robotic surgical system with 4 arms unique to the region, will be operational in early 2022. Robot assisted surgery helps in less blood loss, less trauma, faster recovery and return of patient to their daily activities and working capacity. We are about to integrate this “gold standard” in cardiac surgery, but also in the work of other departments such as urology, abdominal and thoracic surgery.

The article was published in the December issue of Capital Health and in the online edition.