National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study.

BACKGROUND: In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics. OBJECTIVE: The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention. METHODS: The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite). RESULTS: The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation. CONCLUSIONS: This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/47525.

Epidemiological characteristics, management, and outcomes of atrial fibrillation in TUNISIA: Results from the National Tunisian Registry of Atrial Fibrillation (NATURE-AF).

BACKGROUND: Contemporary registries on atrial fibrillation (AF) are scare in North African countries. HYPOTHESIS: In the context of the epidemiological transition, prevalence of valvular AF in Tunisia has decreased and the quality of management is still suboptimal. METHODS: NATURE-AF is a prospective Tunisian registry, involving consecutive patients with AF from March 1, 2017 to May 31, 2017, with a one-year follow-up period. All the patients with an Electrocardiogram-documented AF, confirmed in the year prior to enrolment were eligible. The epidemiological characteristics and outcomes were described. RESULTS: A total of 915 patients were included in this study, with a mean age of 64.3 ± 22 years and a male/female sex ratio of 0.93. Valvular AF was identified in 22.4% of the patients. The mean CHA2 DS2 VASC score in nonvalvular AF was 2.4 ± 1.6. Monotherapy with antiplatelet agents was prescribed for 13.8% of the patients. However, 21.7% of the subjects did not receive any antithrombotic agent. Oral anticoagulants were prescribed for half of the patients with a low embolic risk score. In 341 patients, the mean time in therapeutic range was 48.87 ± 28.69%. Amiodarone was the most common antiarrhythmic agent used (52.6%). During a 12-month follow-up period, 15 patients (1.64%) had thromboembolism, 53 patients (5.8%) had major hemorrhage, and 52 patients (5.7%) died. CONCLUSIONS: NATURE-AF has provided systematic collection of contemporary data regarding the epidemiological and clinical characteristics as well as the management of AF by cardiologists in Tunisia. Valvular AF is still prevalent and the quality of anticoagulation was suboptimal.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry.

BACKGROUND: The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI). METHODS: Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%). RESULTS: Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866). CONCLUSIONS: Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

Clinical and electrophysiological profile of Brugada syndrome in the Tunisian population.

BACKGROUND: Most clinical studies of the clinical profile of Brugada syndrome (BS) have been conducted in either Asia, Europe, or America and their applicability to North African populations is largely unknown. The aim of the study was to analyze the clinical profile of BS in Tunisian patients. METHODS: The clinical and follow-up data of 24 patients (22 men, mean age: 40.8 ± 13.7 years) were collected since 2002. Baseline characteristics, morbidity, and mortality data were obtained from medical records. RESULTS: One patient (4.16%) survived sudden cardiac death (SCD), four patients (16.3%) had syncope, and 19 patients (79.1%) were asymptomatic. Eleven patients (45.8%) had a family history of SCD. Twenty patients showed a spontaneous coved-type ST-segment elevation on electrocardiogram and after medical challenge on the four remnants. An electrophysiological study was performed in 15 of 24 patients (62.5%), during which ventricular fibrillation was induced in six patients (40%); three of the six patients were previously asymptomatic. An implantable cardioverter defibrillator (ICD) was implanted in 14 patients (58.3%). After a mean follow-up of 26 ± 21 months, one patient died from a noncardiac cause and one patient (with a history of aborted SCD) received an appropriate shock from his ICD. None of the asymptomatic and noninducible patients experienced a cardiac event. CONCLUSIONS: BS is present in the North African population and is probably under-recognized. Tunisian patients with BS share with their western and Asiatic counterparts similar clinical profile.

[Tricuspid dysfunction as a result of rheumatic disease]. / Atteinte tricuspide au cours de la maladie rhumatismale.

BACKGROUND: Rheumatic tricuspid valve dysfunction is the rarest of all valvular disease and is often associated or secondary to left-sided valvular disease. She often realize tricuspid regurgitation. The surgical treatment is generally conservative but also it can be radical generally using bioprotheses. AIM: to assess the epidemiology of the rheumatic tricuspid dysfunction, the average diagnoses and its therapeutic. To evaluate the results of the surgical techniques, the factors of prognosis and to determine the therapeutic regarding an in front of important and symptomatic residual tricuspid regurgitation a long time after a valvular surgery first of the left heart. METHODS: A retrospective, single center of 84 consecutive patients having one significant tricuspid dysfunction regurgitation and/or significant stenosis of rheumatic origin. Hospitalized and followed between January 1992 and March 2008 in cardiology to the hospital Habib Thameur. RESULTS: The prevalence of the rheumatic tricuspid dysfunction was 8.42%. 70% of the patients had a tricuspid regurgitation. The average Age of our patients was 40 years. Our population consisted of 65.5% women. 21% of the patients had benefited at least from a percutaneous mitral dilation. 31% of the patients had antecedents of valvular cardiac surgery. 53% of the patients presented clinical signs of preoperative right cardiac failure and 58% of the patients were in permanent auricular fibrillation. The tricuspid regurgitation was major at 12% of the patients, severe at 88% of the patients, organics at 21% of the patients and functional at 31% of the patients. The average of the systolic pulmonary blood pressure was with 55+-16.8 mm Hg. All the patients had an associated left valvulopathy. The average of the ejection fraction of the left ventricle was 56+12.6%. The dilation of the right cavities was noted at 70% of the patients. The patients of our series were subdivided in two distinct groups. The first group gathers 30 patients who were operated of tricuspid in same operational time as the surgery of the left valves. The surgical gesture on the tricuspid was always conservative. 70% of the patients profited from a tricuspid annuloplasty. Hospital mortality is 10%. 26% of the patients presented a significant residual tricuspid regurgitation after 60 months. 26% of the patients presented late cardiac failure. Late mortality was from 30% to 5 years and 43% to 10 years. The second group is represented by 54 patients not operated on the tricuspid. 30 patients (81%) presented one or more episodes of late cardiac failure. 50% of the patients died during the late follow-up. Among operated patients of the tricuspid, the predictive factors of the residual tricuspid regurgitation post operational are the age<35 years and the mitral disease. The stage NYHA=4 was the only predictive factor of hospital mortality. The predictive factors of late right congestive heart failure postoperative are the clinical signs of preoperative right heart failure and the antecedents of mitral replacement. The predictive factors of late total congestive heart failure postoperative l are the functional tricuspid regurgitation and stage 4 of the NYHA. CONCLUSION: The benefit of a systematic initial correction of a voluminous tricuspid regurgitation and even of average importance realized prematurely in same operation time that the left valvular gesture was largely shown. The late appearance of functional tricuspid regurgitation after mitral valve surgery is a pejorative marker in the evolution of these patients.

[Heart diseases in pregnant women]. / Cardiopathies chez la femme enceinte.

BACKGROUND: diagnosis end treatment of heart diseases, physiopathologic changes in pregnancy. AIM: Pregnancy in woman with heart disease increases the risk of maternal and fetal complications. The aim of the study is to precise the physiopathologic, diagnostic, and therapeutic characteristics of heart diseases in pregnant woman. METHODS: Extensive electronic search of the relevant literature was carried out using Medline. Key words used were:pregnancy, heart disease, maternal outcome, fetal outcome, cardiac complications. RESULTS: Rheumatic heart disease represent the most common cardiopathy found in pregnant woman in our country. Regurgitant valvular diseases are often well tolerated with medical therapy. Severe aortic stenosis is associated with poor prognosis. The use of percutaneous mitral balloon valvuloplasty has transformed treatment of mitral stenosis in symptomatic patients.In developed countries, congenital heart diseases are the most common cause of cardiopathy in pregnant women. Left-to-right shunts are generally well tolerated. Patients with Eisenmenger syndrome should be advised against pregnancy. Obstructive form of hypertrophic cardiomyopathy is associated frequently with hemodynamic deterioration in pregnancy. Dilated cardiomyopathy is usually considered as a contraindication of pregnancy. In the absence of underlying structural heart disease, cardiac arrhythmia are uncommon in pregnancy and usually don't require pharmacological treatment. Drug therapy of arrhythmia in pregnant woman is limited by side effects on the fetus. The prenatal counsel is based on the assessment of maternofetal risk. The management of pregnant woman requires a multidisciplinary team for optimal maternal and fetal outcomes.

[Predictive factors of significant coronary stenosis in women. Review of 230 patients]. / Les facteurs predictifs d'une atteinte coronaire significative chez la femme. Etude de 230 patientes.

To evaluate the predictive factors of significant coronary stenosis in women, we have studied retrospectively data from 230 women explored by coronary angiography. The population has been divided in 2 groups: one (G1) without significant coronary lesions; the second (G2) having at least one significant coronary stenosis (> 50%). The prevalence of the significant disease was 54.3%. Coronary risk factors associated with a significant disease were : age > 55 years, diabetes mellitus, menopause, high lipid levels, and the association of at least 3 risk factors. Typical angina and history of myocardial infarction were significantly more prevalent in the G2 as like as Q necrosis wave, ST segment modifications percritically and premature ventricular beats. A regional abnormal wall motion at rest echocardiography was independently associated with significant coronary artery lesions (OR = 7.35). Using these data we have established a score of prediction of significant disease in women. This score aided to classify our female patients into different levels of risk and to better indicate subsequent explorations. Thus. with a good evaluation of the clinical and at rest data in women, we could obtain a more accurate degree of suspicion of a significant coronary artery disease before the indication of a coronary angiography.

[Introduction to myocardial doppler imaging]. / Introduction au Doppler tissulaire myocardique: principes physiques et applications cliniques.

Introduced in 1989, the myocardial doppler tissue imaging has now many clinical applications. Doppler tissue imaging explores the proper systolic and diastolic regional function of myocardial fibers. We can measure myocardial velocities by recording signals of low velocitiy and high magnitude, the strain and the strain rate are then derived from velocities. Specific software is therefore necessary. There are many ways of recording and representing myocardial doppler tissue parameters. Diagnostic and prognostic value of myocardial doppler tissue imaging is now proved and this method has many applications in ischemic cardiopathy and in cardiomyopathies. The development of powerful software is promising for the applications of the strain in the future.

[Stress echocardiography and mitral stenosis: what interest?]. / Echocardiographie de stress et retrecissement mitral: quel interet?

The stress echocardiography is used extensively as a diagnostic and prognostic tool and the assessment of ischemic cardiopathies. Its use in valvulopathies is more limited, but is increasing with time. The discrepancies between the functional symptoms and hemodynamics at rest is frequently met in patients with mitral stenosis. By assessing changes of pressures, gradients and surface stress echocardiography helps to identify the real hemodynamic conditions permitting to recommend a more aggressive approach in certain situations.

[Myocardial infarction revealed by ischemic stroke]. / Infarctus du myocarde révélé par un accident vasculaire cérébral.

Ischemic cerebral infarction associated with myocardial infarction is yet a real diagnosis challenge. If during the acute myocardial phase the mechanism is mostly embolic, at long-term, the mechanism is not clearant and other causes should be searched. We report a 50 year old man with ischaemic stroke with strong evidence of myocardial infarction in the late phase with wall-motion abnormality and mural clot revealed by echocardiography and Q waves. Atrial fibrillation was suspected and no other abnormalities could be found. The diagnosis of cardio-embolic ischaemic stroke could not be made with certainly.

Acute stent recoil in the left main coronary artery treated with additional stenting.

We report a case of acute stent recoil occurring after the stenting of an ostial left main coronary artery lesion. The marked recoil after high-pressure balloon inflation confirmed that the radial force of the first stent was unable to ensure vessel patency. The addition of a second stent provided the necessary support to achieve a good final result. This case illustrates a possible complication of aorto-ostial angioplasty that could be treated with double stenting.

[Prognostic value of echocardiographic parameters in chronic cardiac insufficiency]. / Valeur pronostique des parameters echographiques chez l'insuffisant cardiaque chronique.

This work was interested in 72 patients (81% males) with chronic heart insufficiency. Ail these patients had a sinusal rythme. The etiology was mainly idiopathic (36%) but also ischemic (64%). 15% of patients were at stage I of NYHA, 37.5% at NYHA II, 40.5% at NYHA III and 7% at NYHA IV. All patients had taken a medical treatment (in 85% of cases, this treatment was based on diuretics and IEC). Transthoracic echocardiography was performed in these patients to determine the telediastolic diameter (TDD = 69 mm), the telesystolic diameter (TSD = 57), the velocity of E wave (0.66 mis) and A wave (0.55 mis) and the E wave deceleration time (DT = 0.196 s), 11 from ali patients were dead after a period of observation 21 months. The factors of pejorative prognostic were: the stages III and IV of NYHA, the cardiothoracic ratio > 0.60 and the echocardiographic parameters: TDD, TSD and DT (p = 0.03, p = 0.02 and p = 0.0001 respectively). But the E and A velocity seems don't influence the prognostic.

[Congenital auriculo-ventricular block in the adult]. / Le bloc auriculo-ventriculaire congenital en milieu adulte.

In this work we report a consecutive series of ten patients having auriculoventricular block "presumed" congenital which is seen in adulthood between 1990 and 2001 to determine their clinical profile and forecast, and to deduct the therapeutic consequences. Our criteria of inclusion requires the existence of patients with a second or third degree heart block, who are less than 40 years old at the time of diagnosis, which is not totally regressive in the effort test and the atropine injection, and whose congenital origin was strongly suspected because of the notion of slow pulse during their youth and the absence of acquired affect which enables us to explain this disease. The population contains ten patients whose average age in hospitalization is 23 years old with the range of 11 to 39, while the average age of the discovery of the disease was 20 years old with the range of 8 to 34. Our patients were referred to us because of cardiac symptoms such as syncope or an equivalent, effort intolerance, asthenia, thoracic pain (like angina), or palpitations. The clinical exam, the electrocardiogram, and additional exams (holter, effort test, echocardiography, electrophysiological investigation) allowed us to retain six indications for the definitive cardiac stimulation, associating to different degrees the existence of worrying symptoms such as a syncope, a congenital heart disorder, a low heart frequency, the association in a sinus dysfunction. Short-term and long-term evolution is favorable for patients of the stimulated group as well as the non-stimulated group.