Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study.

BACKGROUND: Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries. OBJECTIVE: The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia. METHODS: We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis. RESULTS: In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022. CONCLUSIONS: This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region. TRIAL REGISTRATION: Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/24595.

Both mediastinal and pericardial hydatidosis revealed by ST elevation acute coronary syndrome.

Hydatidosis remains an endemic disease in some regions of the world, such as Tunisia. The liver and the lungs are the most common sites in adults. Mediastinal and pericardial hydatid cysts are very rare even in endemic areas and true incidence has not been described in the literature. We report the case of a 74-year-old woman with clinical, biological and electrocardiographic features of acute myocardial infraction. Two-dimensional echocardiography and detailed imaging revealed a mediastinal and pericardial hydatid cyst. The particularity of the clinical presentation, the complementary investigations as well as the management and follow-up of the patient are discussed. This case is of great interest since the rarity of concomitant hydatid cyst in two uncommon localizations: mediastinum and pericardium, and the unusual incidental discovery during a myocardial infarction.

A large cardiac hydatid cyst in the interventricular septum: A case report.

Isolated cardiac location is an uncommon presentation of echinococcosis (0.5-2%), and involvement of the interventricular septum is even rarer. It may lead to various complications because of rupture and embolization. We report the case of a 26 - year- old man who was diagnosed to have a large inter-ventricular hydatid cyst complicated by both cerebral and coronary embolism. Presentation, management and follow-up of the patient is discussed. This case is of particular interest because of the rarity of septal localization of a hydatid cyst, and the conflict between the severity of the complications that occurred and the absence of correlated symptoms.

Early outcomes of cardiac surgery in elderly patients.

BACKGROUND: Due to the increase in average life expectancy and the higher incidence of cardiovascular disease, more elderly patients present for cardiac surgery nowadays. At the same time, age has been considered a predictor of morbidity and mortality. AIM: To evaluate the short-term outcomes of cardiac surgery in elderly patients. METHODS: We conducted a descriptive retrospective study including elderly patients who underwent cardiac surgery from January 2012 to 31st of December 2016. All patients were hospitalized before and after cardiac surgery in the cardiology department of Habib Thameur Hospital. RESULTS: Our study included 55 patients. Average age was 72±6 years old and sex-ratio was two. Eighty-five percent presented with angina, 18% with dyspnea and one patient with an aortic prosthetic valve endocarditis. Mean left ventricular function was 54 ±9 %. Mean EuroSCORE II was 1.91±1.18. Twenty-six per-cent had an urgent surgery. Mean extracorporeal circulation time was of 77±26 min and mean extubation time was 8±6 h. Eighty-four per cent had a coronary artery bybass grafting and 16% a valve replacement. Four per cent had a redux and 4% a combined surgery. Stay in surgical department varied between 3 and 10 days with average of 4.6±1.2 days. Early mortality rate was of 2% and 98% had complications. Ninety-eight complications occurred after surgery: 35 reintervention for mediastinal bleeding or tamponade, 28 bleedings requiring transfusions, eight heart rhythm disorders, an atrioventricular conduction block requiring ventricular, five atrial fibrillation, two ventricular tachycardias, a ventricular fibrillation, eight low cardiac outpout, seven prolonged mechanical ventilation and eight pneumonias. In univariate analysis, recent myocardial infarction and chronic kidney disease were predictive of early complications. CONCLUSION: Our data shows cardiac surgery is feasible in elderly patients with acceptable risk in terms of mortality and an increased morbidity due to their frailty. Careful patient selection is needed for the success of cardiac surgery in elderly patients.

Evaluation of patients' knowledge on their vitamin K antagonist treatment.

INTRODUCTION: Vitamin K antagonists (VKA) are currently the most prescribed oral anticoagulant treatment in Tunisia. Despite the standardization of biological monitoring and the better definition of therapeutic objectives, their side effects are a frequent reason for hospitalization. AIM: To evaluate patients' knowledge about their VKA treatment. METHODS: We realized a cross-sectional descriptive study in the Cardiology Department of HabibThameur Hospital from September to October 2016. A questionnaire consisting of 14 items was used in a semi-directed interview in order to assess patients' knowledge on their VKA treatment. RESULTS: Our study included one hundred patients. Mean age was 61 ± 12 years and sex ratio of 1.8. Forty-eight per cent were illiterate. The median duration of AVK intake was 5 years. Atrial fibrillation (AF) was the most frequent indication (57%). Eighty percent of patients had more than five correct answers on the eight items of knowledge: VKA's name (96%), tablet description (93%), dose (99%), time (94%), VKA's effect (70%), INR (56%), treatment's risk (49%) and the target INR (20%). Twenty-two percent had more than four correct answers on the 6 items of know-how: what to do in case of haemorrhage (70%), what to do in case of oblivion (45%), interactions precautions to be observed with food (13%), activities advised against (49%) and medical procedures advised against (27%). In multivariate analysis, only prior VKA information was significantly associated with a better knowledge of VKA (p = 0.027). CONCLUSION: Our patients' knowledge on their VKA treatment was insufficient to ensure the safety and efficacy of treatment. The creation of a therapeutic education program on is therefore necessary to reduce the iatrogenic risk of this treatment.

Effect of ramadan fasting on acenocoumarol-induced antocoagulant effect.

Eating patterns, food intake and type of alimentation vary greatly during the month of ramadan. Furthermore, fasting, which practiced during the month of ramadan, can have an impact on drug's metabolism. These two factors, fasting and eating habits changes during the month of ramadan, may impact acenocoumarol anticoagulant effect, translated by variations of INR values. The aim of our study was to see ramadan fasting effects on INR variations in patients treated by acenocoumarol. A prospective monocentric study was conducted during the ramadan month on fasting outpatients that were treated by acenocoumarol. Baseline INR values (e.i. most recent available value before the month of ramadan) were compared to INR values obtained during the month of ramadan. All patients were monitored for signs of secondary haemorrhagic complications linked to treatment by anti-vitamin K (AVK). Thirty patients were included in the study with a sex ratio 1. Patients mean age was 65 years. Around two thirds of the patients were treated by AVK for atrial fibrillation. The majority of patients (94%) have been treated by AVK for more than a year. Mean INR was significantly higher during the month of ramadan than baseline (3.51 vs 2.52; p< 0.0001). There were also more overdoses during the month of ramadan than baseline (9 vs. 0; p=0.014). The increased INR values highlights the need of a close monitoring of INR values during the month of ramadan, particularly in patients with a high haemorrhagic risk.

Trends in infective endocarditis.

INTRODUCTION: Infectious endocarditis (IE) is a rare disease with a high mortality. In 2009, the European society of cardiology restricted antibiotic prophylaxis to a smaller number of cardiac conditions with very high risk for IE. Did these changes in the guidelines have an impact on the epidemiological and bacteriological profile of IE? AIM: The main aim of our work was to study the evolution of the microbiological profile of IE from 1991 to 2016. METHODS: We realized an analytic retrospective study comparing two groups: group 1 included patients admitted for a certain IE before September 2009 and group 2 those admitted after that date. RESULTS: Patients mean age was 46 ± 13 years and sex ratio was of 1.5. Forty percent of the patients were at high risk of IE. Blood cultures were positive in 19 cases. The most frequently isolated germ was Staphylococcus (10 patients). Serology was performed in six patients and was positive for Chlamydia Trachomatis in two cases. Forty-two patients had surgical treatment, 17 had a valve culture that was positive in 3 cases only. Clinical and paraclinic characteristics were comparable among the two groups. Negative blood cultures rates decreased from 72% to 68% between group 1 and 2 (p = 0.789). Staphylococcus positive blood cultures increased from 13% to 21% (p = 0.49). In contrast, Streptococcal positive blood cultures decreased from 11% to 5% in 2009 (p = 0.69). CONCLUSION: Our data suggest that there has been no change in the bacteriological profile of IE after the reduction in antibiotic prophylaxis.

Right ventricular systolic echocardiographic parameters in dilated cardiomyopathy and prognosis.

BACKGROUND: Right ventricular (RV) dysfunction is associated with poor prognosis in patients with non-ischemic dilated cardiomyopathy. Several RV echocardiographic parameters have been proposed as sensitive markers to detect patients at risk. OBJECTIVE: To compare the predictive value of echographic parameters of RV systolic function for adverse outcomes in patients with non-ischemic dilated cardiomyopathy. METHODS:    Forty patients with non-ischemic dilated cardiomyopathy were included. Right ventricular systolic function assessed by Doppler echocardiography standard (RV fractional area change, Tei index, TAPSE and dp/dt), tissue Doppler (peak systolic velocity (Sa)) and Strain 2D of the RV. The primary endpoint was the occurrence of a major cardiovascular event. The follow-up extended for 6.2 months ± 2,49. RESULTS: Eighteen patients reached the primary endpoint. TAPSE (HR 0.86 [0.74-0.99], p=0.04), Sa (HR 0.77 [0.62-0.95], p=0.01), Tei index (HR 1.06 [1.01-1.12], p=0.02) and strain of the lateral wall of the RV (HR 1.13 [1.04-1.23], p=0.004) were found to be independent predictors of major cardiovascular event. The cut-off thresholds for TAPSE, Sa, Tei index and strain of the lateral wall of th RV, defined using ROC curves were respectively 12,5mm ; 8,5cm/s ; 0,55 et -12. CONCLUSION: TAPSE, Sa, Tei index and strain of the lateral wall of the RV are independent predictors of major cardiovascular event in non ischemic dilated cardiomyopathy.

Ulcer like projection: a case report and follow up.

Here we report the case of a 57-year-old female with an aortic intramural hematoma that was treated with medical approach. Follow confirmed the favorable clinical evolution.

Differences between idiopathic and ischemic dilated cardiomyopathy.

BACKGROUND: Ischemic cardiomyopathy can be reversible after revascularization hence the interest of making systematic coronary angiography that remain an invasive procedure. AIM: To detect epidemiological, clinical and paraclinical differences between idiopathic and ischemic dilated cardiomyopathy to identify predictors of coronary artery disease and to evaluate the interest of making systematic coronary angiography within the etiological check-up of dilated cardiomyopathy. METHODS: We performed a retrospective study in patients with dilated cardiomyopathy in whom coronary angiography allowed to distinguish the ischemic cardiomyopathy group from that of idiopathic cardiomyopathy. We compared the clinical and paraclinical findings between these two groups. RESULTS: We identified 102 patients: 42 had ischemic cardiomyopathy and 60 had idiopathic cardiomyopathy. These two groups were comparable according to age and sex. Diabetes was significantly more common (p = 0.002) in the first group. Dyspnea was more common in the second group (p = 0.03) as well as atrial fibrillation and left bundle branch block (p=0,04 and p=0,05, respectively). Renal failure, fasting hyperglycemia and echocardiographic segmental wall motion abnormalities were significantly more frequent in the group of ischemic cardiomyopathy (p=0.01). In multivariate analysis, diabetes (OR=3,291, IC95% : 1,167-10,969), renal failure (OR=11,001, IC95% : 2,15-39,85) and segmental wall motion abnormalities (OR=2,351, IC95% :0.934-5.915) were independent predictors of ischemic dilated cardiomyopathy. CONCLUSION: Diabetes, kidney failure and disorders of wall motion appears to be predictors for the ischemic origin of dilated cardiomyopathy and thereby help to limit the routine use of this invasive technique in the diagnosis.

A giant right atrial myxoma with pulmonary arterial hypertension.

Here we report a case of a right atrial mass that morphology mimicking myxoma, in a young patient with no past medical history. The mass was pathologically confirmed to be symptomatic and surgical removal was successfully done.

Ischemic cardiomyopathy revealed by central retinal artery occlusion (CRAO).

Here we report a case of central retinal artery occlusion revealing an ischemic cardiomyopathy. A 54-year old smoker man presented at the hospital because of sudden visual loss in his left eye. There was cherry-red spot in the macula in his left eye. We performed a fluorescein angiogram and cervical color Doppler. Later investigations revealed an ischemic cardiomyopathy undiagnosed until then.

[Right ventricular function by the tricupid annular motion in inferior myocordial infarction]. / Evaluation de la fonction ventriculaire droite dans l'infarctus du myocarde inférieur par analyse du mouvement annulaire tricuspide.

AIM: To assess the method of tricuspid annular motion and tricuspid annular velocity in the study of the right ventricular function after inferior myocardial infarction. METHODS: 65 patients with myocardial infarction were studied prospectively. The infarction site was anterior in 30 cases and inferior in 35 cases. 9 patients with inferior infarctus had electrocardiographic signs of right ventricular infarction. 24 healthy individuals served as control patients. The standard echocardiography was completed by the analysis of systolic motion of the tricuspid annulus with the use of M-mode and the recording of tricuspid annular velocity with the use of pulsed-move tissue imaging. RESULTS: The tricuspid annular motion was significantly reduced in inferior myocardial infarction compared with that in healthy individuals (20 and 25 mm, p<0.001). The peak systolic velocity of the tricuspid annulus was significantly reduced in inferior myocardial infarction compared with that in healthy individuals and patients with anterior infarction (11.5; 15; 14 cm/s, p<0.001). In the group of patients with inferior infarction, the tricuspid annular motion was significantly lower in patients with right ventricular infarction than in patients without right ventricular infarction (16 and 13 mm, p<0.001). The patients with right ventricular infarction had also a significantly decreased peak systolic tricuspid annular velocity (11 and 1305cm/s, p<0.001), peak early diastolic velocity (9 and 12.5cm/s, p<0.001) and late diastolic velocity (14 and 18 cm/s, p<0.001). CONCLUSION: The method of recording the motion and velocity of tricuspid annulus is simple and can be used to assess right ventricular function in patients with inferior myocardial infarction.

[Pulse-wave Doppler Tissue Imaging in the assessment of regional left ventricular diastolic function in patients with coronary artery disease]. / Intérêt du doppler tissulaire dans l'évaluation de la fonction diastolique régionale du ventricule gauche chez l'insuffisant coronarien.

AIM: Myocardial ischemia impairs the diastolic left ventricular (LV) function earlier than the systolic function. We evaluated the value of pulse-wave Doppler Tissue Imaging (DTI) in the study of regional myocardial function of LV in patients with coronary artery disease. METHODS: We performed a prospective study in 60 patients with coronary artery disease that we compared to 40 healthy individuals in order to assess the value of pulse-wave DTI to study the diastolic LV function . Both groups had a clinical examination, ECG, echocardiography and pulse-wave DTI. Only the patients had a coronary angiography. Pulse-wave DTI was applied to the 16 myocardial segments of the LV, we measured the isovolumetric relaxation time (IVRT), early (Ea) and late diastolic (Aa) velocities. RESULTS: We have demonstrated that compared with healthy subjects, patients with coronary artery disease has a significant increase of IVRT (100.2 +/- 20 ms vs 62.5 +/- 12.2, p <0.001) and lower Ea (7.6 +/- 1.6 vs. 9.2 +/- 2.6) and report Ea / Aa. These anomalies are more pronounced in akinetic segments compared with hypokinetic segments. Relying on data from the coronary angiography, we found in patients that IVRT had increased, Ea and Ea / Aa lowered in most segments hypoperfused than in normally perfused segments. An IVRT > 70ms and Ea <8.3 cm / s emerge as threshold values to identify myocardial ischemia. More coronary lesions are severe more Ea and Ea/Aa decline and IVRT increase. The culprit coronary artery could be identified by pulse- wave DTI since the DTI parameter anomalies are systemized CONCLUSION: The pulsed DTI technique seems to be attractive as a non-invasive evaluation method of ischemic heart disease.

[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.

[Intracardiac thrombosis: unusual complication of Behcet's disease]. / Le thrombus intra-cardiaque: une complication rare au cours de la maladie de Behcet.

Cardiac involvment is rare, and intracardiac thromboses are exceptional in Behcet's disease. We present a 29 years old male patient seen for right heart-failure, thrombophlebitis and pulmonary embolism. A right atrial thrombosis was showen at the echocardiography and confirmed by computed tomography and magnetic resonance imaging. The diagnosis of Behcet's disease was established on the finding of bipolar aphtous ulcers and skin hypersensitivity. We conclude that Behcet's disease shoud be considered as a possible cause of cardiac thrombosis in the youngs men of the Mediterranean basin.