[Management of patients treated for acute ST-elevation myocardial infarction in Tunisia: Preliminary results of FAST-MI Tunisia Registry from Tunisian Society of Cardiology and Cardiovascular Surgery]. / Prise en charge de l'infarctus du myocarde en Tunisie : résultats préliminaires du registre FAST-MI Tunisie de la Société tunisienne de cardiologie et de chirurgie cardiovasculaire.

UNLABELLED: FAST-MI Tunisian registry was initiated by the Tunisian Society of Cardiology and Cardio-vascular Surgery to assess characteristics, management, and hospital outcomes in patients with ST-elevation myocardial infarction (STEMI). METHODS: We prospectively collected data from 203 consecutive patients (mean age 60.3 years, 79.8 % male) with STEMI who were treated in 15 public hospitals (representing 68.2 % of Tunisian public centres treating STEMI patients) during a 3-month period at the end of 2014. The most common risk factor was tobacco (64.9 %), hypertension (38.6 %), diabetes (36.9 %) and dyslipidemia (24.6 %). RESULTS: Among these patients, 66 % received reperfusion therapy, 35 % with primary percutaneous coronary interventions (PAMI), 31 % with thrombolysis (28.6 % of them by pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 and 358 min for PAMI, respectively. The in-hospital mortality was 7.0 %. Patients enrolled in interventional centers (n=156) were more likely to receive any reperfusion therapy (19.8 % vs 44.6 %; p<0.001) than at the regional system of care with less thrombolysis (26.9 % vs 44.6 %; p=0.008) and more PAMI (52.8 % vs 8.5 %; p<0.0001). Also the in-hospital mortality was lower (6.4 % vs 9.3 %) but not significant. CONCLUSIONS: Preliminary results from FAST-MI in Tunisia show that the pharmaco- invasive strategy should be promoted in non-interventional centers.

[Acute myocarditis complicating Mediterranean spotted fever. A case report]. / Une myocardite aiguë compliquant une fièvre boutonneuse méditerranéenne. À propos d'un cas.

Mediterranean spotted fever (MSF) due to Rickettsia conorii is the most important tick-borne disease occurring in North Africa. The first description of MSF was made by Conor and Brush in 1910 in Tunisia. Clinical diagnosis relies on the association of fever, rash and inoculation's scar during summertime. Prognosis in MSF is usually good, however malignant forms were described. These forms occur in patients with comorbidities. G6PD deficiency is a classic ground for severe forms of MSF. Myocarditis is an uncommon complication in MSF; only few cases were reported in the literature. We report a new case of myocarditis complicating MSF in a 15-year-old patient with G6PD deficiency. The patient presented with fever and rash, evocative of MSF; he reported chest pain and the electrocardiogram showed ST segment elevation in anterior leads. Troponin level was elevated. Echocardiogram showed left ventricular dysfunction with 40% ejection fraction. Serologic tests confirmed R. conorii recent infection. Antibiotic treatment with vibramycine and rifadine was started. Patient also received classic treatment of myocarditis with left ventricular dysfunction associating CEI, ß-bloquers and diuretics. Evolution was favourable with complete recovery of left ventricular function. Myocarditis is an uncommon but severe complication of MSF. Early diagnosis and treatment allow favorable evolution.

[Role of transthoracic echocardiography in the diagnosis of acute pulmonary embolism]. / Apport de L'echocardiographie Transthoracique dans le Diagnostic de L'embolie Pulmonaire.

OBJECTIVES: The objective of our work is to determine the value of transthoracic echocardiography (TTE) in the diagnosis of pulmonary embolism (PE) and its place in the diagnostic strategy in a cardiology department in Tunisia. MATERIAL AND METHODS: It is a retrospective study including 43 patients between 1993 and 2003 in the cardiology department of the "Hôpital Militaire Principal d'Instruction de Tunis" for acute pulmonary embolism. RESULTS: Our population had a feminine ascendancy. The average age was 53.9 +/- 17.6 years. In patients with positive pulmonary perfusion scintigram and by taking pulmonary helical CT as diagnostic gold standard, we found that TTE yielded a sensivity of 74 % and a specificity of 25 % for the diagnosis of pulmonary embolism. The most common echocardiographic signs were the right cavities dilation and the increase of right pressures. CONCLUSION: Transthoracic echocardiography is a good test to screen patients for suspected PE because it has an excellent sensitivity. It must be often completed by transesophageal echocardiography and integrated in all diagnostic approach of pulmonary embolism.

[Management of pulmonary embolism in a cardiology department]. / Prise en charge de l'embolie pulmonaire en milieu cardiologique: expérience d'un hôpital tunisien.

OBJECTIVES: The objective of our work is to study the clinical features and the management of pulmonary embolism in a cardiology department. MATERIAL AND METHODS: It is a retrospective study including 43 patients between 1993 and 2003 in the cardiology department of a Tunisian hospital for acute pulmonary embolism. RESULTS: The most common clinical signs were dyspnea, pleural pain and deep venous thrombosis. The most common physical signs were tachypnea and tachycardia. Electrocardiographic abnormalities were found in 38 patients (88.4%). Chest X-ray was abnormal in 25 patients (60.5%). The arterial blood gas found hypoxia and\or hypocapnia in 95% of cases. D-dimer was high in almost totality of patients (96%). US doppler of deep leg veins was positive in more than 40% of patients. Transthoracic echocardiography was normal in more than 40% of the patients. Lung scan noted a high or very high probability in 87% of cases. Pulmonary helical CT was positive in majority of cases. Unfractionated heparin was administered to about 75% of patients and low-molecular-weight-heparin was prescribed at only 40% of patients. CONCLUSION: Management of pulmonary embolism in our cardiology department is characterized by the frequent use of non invasive techniques on the diagnostic view and appeal to heparine on the therapeutic view.

[Endo arterial investigation: suspicious for the cholesterol crystal embolism disease]. / Explorations endo-arterielles: se mefier de la maladie des embols de cholesterol!!

BACKGROUND: Cholesterol crystal embolism (CCE) is a rare disorder which can complicate cardiac catheterization, angiographic studies and cardiovascular surgery. The CCE exposes to a great risk of renal failure and it can even threaten life by means of a multi visceral failing syndrome. AIM: Report a new case of CCE following cardiac catheterization. CASE: We report the observation of a 63-year-old patient who had a coronary angiography via the right femoral artery after a myocardial infarction. This examination has showed a multi-vessel coronary disease. 15 days later, the patient presented purplish and painful discoloration of his toes. The laboratory findings showed a mild inflammatory syndrome and eosinophilia at 700 / microL. There was not a renal dysfunction nor proteinuria nor hematuria. We performed a skin biopsy and made the diagnosis of CCE. Trans oesophageal echography objectified an irregular atherosclerotic plaque in the isthmic aorta. The CT scan revealed a spindle-shaped aneurysm in the end of the abdominal aorta. This aneurysm contains a marginal surrounding thrombosis with high embolic risk. The patient was put under clopidogrel, enoxaparin, simvastatin, colchicine and atenolol and operated successfully. CONCLUSION: The two particularities of this observation are, on one hand, the absence of a renal involvement, which represents the main prognostic factor of the CCE. On the other hand, the CCE has revealed a very unstable aneurysm of the aorta which could be complicated during the cardiac catheterisation. The CCE is a difficult diagnosis that must be remembered before any cardiac catheterisation, because it often reflects unstable aortic atherosclerotic lesions.

[Distribution of cardiovascular risk factors in a Tunisian cohort of 6901 coronary patients]. / Distribution des facteurs de risque cardiovasculaire chez une cohorte tunisienne de 6901 coronariens.

The Tunisian epidemiological data on cardiovascular disease in the hospital environment are scarce. The aim of this study was to evaluate the frequency of cardiovascular risk factors and their association in patients hospitalised for coronary disease in coronary care units at Rabta, Charles Nicolle, Habib Thameur and Military hospitals, Tunis, over the period 1994-1998. The clinical features of 6901 patients (75.7% men, 3760 myocardial infarction, 3141 unstable angina) on hospital admission were analysed. The prevalence of smoking, dyslipidemia, hypertension, diabetes and obesity was 86; 49.8; 33.9; 40.7 and 15.2% respectively in the men and 12.9; 52.4; 64.6; 53.4 and 29.8% respectively in women. With this risk factor profile Tunisia has to implement a national strategy of primary prevention and heart health promotion in addition to the efforts recently made in secondary prevention of some chronic disease such as hypertension, diabetes and smoking.

[Non-pharmacologic treatment of atrial fibrillation]. / Traitement non pharmacologique de la fibrillation auriculaire.

Curative non pharmacological treatment of AF includes MAZA anti arrhythmic surgery and ist different variants which are reserved to AF associated with mitral valve disease. Radiofrequency (RF) ablation of AF creating lesions mimicking the MAZE procedure is another curative treatment but its numerous complications lead to put it in stand-by. Focal AF radiofrequency ablation is the only curative method that has encouraging results. The development of the internal cardioversion led to the development of the implantable atrial defibrillator. In spite of the low energy used, the internal shocks are often painful and not well tolerated conducting to stop the use of these devices. Prophylactic atrial pacing among patients with interatrial conduction delay is well established by dual site pacing pioneers. After several attempts to restore sinus rhythm and the fail of drug therapy to reduce heart rate, the latest solution to prevent tachycardiomyopathy is the atrio-ventricular (AV) node modulation or ablation using RF energy.

[Predictive factors of normal coronary angiography]. / Les facteurs predictifs d'une coronarographie normale.

The aim of this study is to compare two groups of patients Group A consisted of 120 patients (70 men and 50 women) hospitalised for anginal symptoms, with either clinical or electrical positive exercise test and/or ischemic events on a 24 H electrocardiography and having angiographically normal coronaries Group B consisted of 120 patients (102 men and 18 women) hospitalised for an acute coronary syndrome with pathological coronaries. The analysis of the 2 groups showed that in the group A the average age was lesser (56 years vs 60 years), women's percentage was higher (41% vs 15%) and cardiovascular risk factors were less frequent. Data from non invasive tests was significantly different in the 2 groups: the exercise test showed both clinical and electrical ischemic events in 35% of the patients in group A versus 75% in group B (p < 0.01) and the 24 h electocardiography showed ST depression in 9% of patients in group A versus 25% in group B (p < 0.01%). The coronary angiography is an invasive and an expensive procedure. The results of our study allow us to modulate its indications, especially in young women patients, with few or no cardivascular risk factors and with only electrical positive exercise test.

[Dumesnil's method: is it viable?]. / La méthode de dumesnil: est-elle fiable?

BACKGROUND: Left ventricular (LV) ejection fraction (EF) is an indicator of left ventricular systolic function and is a potent predictor of cardiovascular mortality. LVEF is assessed by a variety of methods, however echocardiography is the most used in clinical practice. Simpson biplane multiple disc method (BMDM) is recommended by the American Society of Echocardiography; Dumesnil's method based on doppler echocardiography seems to be simpler and theoritically less influenced by distortion of LV geometry. OBJECTIVE AND METHODS: To assess the accuracy and reproducibility of Dumesnil's method a group of 100 patients proposed for coronarography with left ventricular angiography, prospectively underwent LVEF measurements by both BMDM and Dumesnil's method. RESULTS: Compared with LV angiography, the correlation coefficient for the Dumesnil's method was r = 0.85 and it was r = 0.9 for BMDM. Correlation in patients with LV regional asynergy were respectively r = 0.69 and r = 0.85. Intraobserver and interobserver variabilities were less then 7% for both echocardiographic methods. CONCLUSION: Although Dumesnil's method is less accurate than BMDM, it is simpler, more rapid with a satisfactory reliability and reproducibility.

[Cardiogenic shock in the acute phase of myocardial infarction]. / Le choc cardiogenique a la phase aigue de l'infarctus du myocarde.

Cardiogenic shock (CC) is the most common cause of death in acute myocardial infarction (MI) and it has been often associated with fatal evolution. The aim of this study is to emphasize the positive impact of myocardial revascularisation especially percutaneous coronary angioplasty (PTCA) on short and mid term survival of 35 patients hospitalised for acute MI with CC. All the 11 patients who were on conventional therapy died, whereas the hospital mortality rate of the 24 patients who underwent primary PTCA was 41%. PTCA in CC complicating MI is highly effective and reduces the mortality rate in the literature from 80% to 40%. For this reason PTCA should be performed in each case of MI with CC seen in the first 6 hours.

[Contracted endocardial fibroelastosis in children: report of a case]. / La fibroelastose endocardique contractée de l'enfant: a propos d'un cas.

Endocardial fibroelastosis is un uncommon disease and it has a very bad prognosis since fatal evolution is usual before 2 years old. We report the case of a 20 years old woman who is affected with the contracted form of this disease associated with atrial septal defect (ASD) and mitral regurgitation. This disease was discovered by endocardial biopsy when she was 4 years old and underwent surgical resection of endocardial fibrosis, a patch on the ASD and mitral valve replacement. She was rehospitalised 15 years later with heart failure although continuous digitoxin therapy.

[Postpartum myocardial infarct (apropos of a case)]. / Infarctus du myocarde du post-partum (a propos d'un cas).

We report the case of a 26 years old woman, who was hospitalized for an acute anterior myocardial infarction, which happened 17 days after delivery. The culprit lesion was a coronary dissection observed on the coronary angiogram which was performed on the 7th day. This dissection cicatrised spontaneously at the control coronarography performed 3 months later. Conventional medical treatment seems to be sufficient, although the use of thrombolysis in our case was safe and successful.

[Sinus node dysfunction after complete correction of tetralogy of Fallot. Report of a case]. / Dysfonction sinusale après réparation complète de tétralogie de Fallot. A propos d'un cas.

Atrioventricular conduction defects after complete correction of tetralogy of Fallot are well known and their prevalence is decreasing with improved operative techniques. On the other hand, sinus node dysfunction has not been described after this type of surgery. The authors report the case of a 24 year old patient operated at the age of 2 for a favourable form of tetralogy of Fallot. In the long-term, this patient had a minimal anatomical sequel (mild pulmonary insufficiency) and first degree AVB with complete right bundle branch block with sinus bradycardia on the surface ECG. A recent aggravation of the patient's functional status led to rhythmological investigation which showed chronotropic atrial incompetence with nodal atrioventricular delay. The patient was implanted with a permanent DDD cardiac pacemaker programmed in the DDDR mode with a good outcome. Atrial chronotropic incompetence is one of the modes of expression of sinus node dysfunction. This has not been previously described in this context. This form of sinus node dysfunction should be systematically excluded after surgical cure of tetralogy of Fallot by exercise stress testing and 24 hour Holter ECG. Symptomatic patients are greatly improved by permanent cardiac pacing with hysteresis.

[Repolarisation anomalies simulating anterior myocardial infarction during ischemic cerebrovascular accident]. / Anomalies de la repolarisation simulant un infarctus du myocarde antérieur au cours d'un accident vasculaire cérébral ischémique.

The authors report the case of a woman admitted to hospital for minor trauma of the left hip and who presented major ST segment elevation on the second day suggesting an acute anterior wall myocardial infarction at the same time as a cerebrovascular accident. Complementary investigations and follow-up excluded the diagnosis of myocardial infarction with normalisation of the ECG on the 5th day. ECG changes during cerebrovascular accidents may be very variable ranging from extrasystoles to ST elevation mimicking myocardial infarction. They carry a poor prognosis with an increased risk of sudden death necessitating continuous ECG monitoring until the ECG reverts to normal. The cardiac involvement is not ischaemic but due to disease of the insular cortex of the brain which induces myocytolysis (centered around the intra-cardiac nerve endings) due to the sudden liberation of catecholamines. These lesions may be treated by propranolol or phentolamine.

[Coxiella burnetti infectious endocarditis. Apropos of a case]. / L'endocardite infectieuse à Coxiella burnetti. A propos d'un cas.

Chronic forms of Q fever (endocarditis) are rare, but are responsible for severe and desperately recurrent infections, resulting in multiple valve replacements with a reserved prognosis. The authors report the case of a 35-year-old patient with a known history of rheumatic fever, who developed blood culture negative infectious endocarditis on a mitral bioprosthesis. The diagnosis of Q fever was based on serological arguments. Despite long-term antibiotic therapy, serology remained strongly positive and was associated with repeated mitral valve disinsertion. The patient died immediately after the fourth operation in a context of haemodynamic failure. This clinical case emphasizes the importance of performing Q fever serology in any case of culture negative endocarditis and the therapeutic difficulties encountered in chronic recurrent endocarditis.

[Pro-arrhythmia effect of pyridostigmine. Apropos of a case]. / Effet proarythmique de la pyridostigmine. A propos d'un cas.

A coronary patient with myasthenia gravis with a previous myocardial infarction presented with severe ventricular arrhythmias after the replacement of neostigmine by pyridostigmine for the treatment of the myasthenia. These arrhythmias were resistant to antiarrhythmic therapy associating betablockers and amiodarone throughout treatment with pyridostigmine but regressed when this drug was withdrawn. A test of reintroduction of pyridostigmine under medical surveillance led to the reappearance of the ventricular hyperexcitability, so confirming the responsibility of this drug. This would seem to be the first reported case of severe ventricular arrhythmias due to a proarrhythmic effect of pyridostigmine. The possible mechanisms of this effect are discussed.