[In hospital mortality of ST segment elevation myocardial infarction treated with primary angioplasty: monocentric Tunisian study of 250 patients]. / Mortalité intra-hospitalière de l'infarctus du myocarde avec sus-décalage persistant du segment ST traité par angioplastie primaire: étude monocentrique tunisienne de 250 patients.

BACKGROUND: Myocardial reperfusion is the « corner stone ¼ in the treatment of myocardial infarction. Primary percutaneous coronary intervention has proved its superiority upon intravenous thrombolysis. aim: To evaluate in hospital mortality of acute myocardial infarction treated with primary angioplasty and to determine its predictive factors. METHODS: We performed a retrospective study including 250 patients admitted to Mongi Slim university Hospital at la Marsa between January the 1st, 2006 and June the 30th, 2011. All these patients had an ST segment elevation myocardial infarction and underwent primary percutaneous coronary intervention within 24 hours after symptom onset. RESULTS: In our study, males were predominant with a sex-ratio of 4.55. Our patients were aged 59.8± 11.19 years old. Diabetes mellitus was present in 42% of our population. In 60.4% of the cases, myocardial infarction was located in the anterior wall. Cardiogenic shock was present in 13.6% of patients. The culprit coronary artery was the left anterior descending artery in 57.6% of the cases. The coronary flow in the culprit artery was TIMI 0 in 64% of the patients and TIMI 1 in 13.2% of the patients. Angiographic success (TIMI 3 flow and residual stenosis <20%) was achieved in 84% of cases. Our in-hospital mortality rate (cardiogenic shock excluded) was 6.9%. Predictive factors of in-hospital mortality were: female gender, diabetes mellitus, hypertension, renal failure, multi-vessel lesion,TIMI flow before percutaneous coronary intervention, proximal left anterior descending artery lesion, initial cardiogenic shock and acute stent thrombosis. CONCLUSION: In our local context, primary percutaneous coronary intervention is an efficient and safe treatment of myocardial infarction with persistent ST-segment elevation.

[Non alcoholic fatty liver disease: a new risk factor for cardiovascular disease?]. / La stéatose hépatique non alcoolique : Un nouveau facteur de risque cardio-vasculaire?

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is frequently diagnosed in daily practice. This condition is represented by a large spectrum of chronic liver diseases going from pure hepatic steatosis to cirrhosis and its complications, including hepatocellular carcinoma. NAFLD is usually associated to glucose and lipoproteins metabolism increasing the cardiovascular risk. AIM: To review new advances in the knowledge of the pathophysiological links between NAFLD and cardiovascular risk, evaluation of cardiovascular risk in this special situation and the different therapeutics proposed. METHODS: Systematic review of the literature using medical data bases (Medline) with the following key words: non-alcoholic fatty liver disease, hepatic steatosis, cardiovascular risk, metabolic syndrome. RESULTS: We'll report pathophysiological links between NAFLD and cardiovascular risk, propose an evaluation of cardiovascular risk in this special situation and expose a therapeutic strategy. CONCLUSION: The discovery of a non alcoholic fatty liver disease should lead to a cardiovascular risk evaluation.

[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.

[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.

[Peripheral arterial disease: where are we in 2006?]. / Arteriopathie obliterante des membres inferieurs: ou en est-on en 2006?

The prevalence of obstructive arterial disease is between 3.5 and 12.1% in 60 aged populations. It's a current disease which has a pernicious influence in quality of life. Management of patients with peripheral arterial occlusive disease has to be planned in the context of natural history, epidemiology, and apparent risk factors that predict deterioration. The purpose of this review is to take stock of the consensus and the controversies about terminology, epidemiology, diagnosis and management of peripheral arterial occlusive disease.

[Screening and management of coronary artery disease in diabetic patients]. / Dépistage et prise en charge de la maladie coronarienne chez le diabétique.

Diabetes represents as independent risk factor for coronary artery disease (CAD) and the prognosis in term of survival rates is worse for diabetic patients who have CAD with report to those with CAD but no diabetes. The coronary artery disease in diabetes has specificities and, in particular, more extensive atherosclerosis. Diabetic patients are also more frequently asymptomatic. Due to the extreme complexity of ischemic vascular disease in patients with diabetes, an optimal therapeutic strategy is based on the correction of elevated blood glucose and lipid levels, of blood pressure, of platelet and coagulation abnormalities. Diabetic patients benefit from secondary prevention by drug therapy(aspirin, lipid lowering with statines, beta blocker and ACE inhibitors) to the same extent as, or more than, non-diabetic patients. Both percutaneous and surgical myocardial revascularization have been proved equally effective for CAD treatment in diabetes. A recent randomized trial has shown a significantly improved outcome after surgical revascularization. But, the effects of drug-eluting stents, which dramatically decrease the incidence of re-stenosis, seem promising.

[Hypertrophic cardiomyopathy in Freidreich ataxia: about two cases]. / Cardiomyopathie hypertrophique dans le cadre d'une maladie de Freidreich: a propos de deux cas.

Freidreich ataxia is the most frequent ataxia of early onset and of autosomal recessive transmission. It is associated with hypertrophic cardiomyopathy in 34 to 77% of cases. The purpose of this article is to describe the cardiac manifestations of two patients affected by this disease. The first case report is about a 34-years-old, bedridden male patient having muscular hypotony and osteotendinous areflexia of the lower limbs. Chest x-ray findings showed a cardiac silhouette distorted by scoliokyphosis. ECG revealed frequent auricular extrasystoles. Cardiac US examination disclosed a pattern of concentric hypertrophic cardiomyopathy with systolic and diastolic dysfonction.

[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.

[Acute myocardial infarction with normal coronary angiography: a 46-cases descriptive study]. / Infarctus du myocarde sur coronaires angiographiquement saines: etude descriptive de 46 cas.

This a retrospective study on 46 patients conducted over a 9-year period. These patients had an acute myocardial infarctus (AMI) confirmed wilth changes on the electrocardiogram and raised cardiac enzymes. However, the subsequent coronary angiography showed normal in all these patients. The purpose of our study is to assess epidemiologic, clinical, pronostic and therapeutic features of AMI with angiographically normal coronary arteries and compare the results obtained with those of AMI with coronary artery disease. AMI with angiographically normal coronary arteries is a first coronary event in young patients (mean age 47.7 years) having few coronary risk factors (54.3% have only one risk factor) mainly smoking (73.9%). The anterior location is prevalent. The patients with AMI and angiographically normal coronary arteries have a better prognosis than those with coronary artery stenosis. Indeed, their left ventricular function is unaltered (mean ejection fraction 48.7%). Hypokinesis is the most frequent abnormality of wall motion noticed. The patients' post infarction course is bengin when the coronary arteries are angiographically normal. The incidence of hemodynamic complications and ischemic recurrences are lower than in AMI with coronary stenosis. The choice treatment remains fibrinolysis.

[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.

[The type III aortic dissection. Diagnosis, outcome, contribution of the endovascular therapies to their management--a case report]. / La dissection aortique chronique du type III. Aspects diagnostiques, évolutifs et apport des techniques endovasculaires dans le traitement--a propos d'une observation.

The dissection of the descending aorta is a serious affection regarding to its mortality and its complications. It becomes chronic after the 14th day following the first signs of dissection. The authors report the case of a 55 years old patient who has presented a type III dissection diagnosed at the chronic period. The persistance of the pain has indicated the implantation of a stent at the intimal tear. This new endovascular treatement of the aorta diseases is a promising and less invasive alternative to the surgical treatement. It may reduce the morbidity and the mortality of this pathology but it needs an accurate and performant imaging techniques.

[non-Q wave myocardial infarction: study of 31 cases]. / Infarctus sans onde Q: etude descriptive de 31 cas.

The frequency of non-Q wave myocardial infarction is permanently increasing. In this retrospective study, we have tried to establish the clinical features, the prognosis and the therapeutic possibilities in this entity. We have studied the clinical history, the physical examination data, the results of the different explorations and the short and long term general course in 31 patients with a non Q wave myocardial infarction. The main feature of this acute coronary syndrome is the preservation of the myocardial function (normal in 64% of the patients). Concerning the angiographic finding, we note a high prevalence of severe coronary damages particularly of the stenosis of the left main coronary artery (13.5%); but also an important proportion of normal coronary angiographies (20%). In addition to the known factors associated with a poor prognosis in coronary artery disease, we insist on the severity of the initial depression of the ST-segment. The prognosis of the non Q wave myocardial infarction is better at the initial phase than that of the "transmural infarction". However, it becomes similar or worse at the long term general course. The important progress in the prognosis markers and in the anti-thrombotic and interventional therapies may maintain at the long term course the good initial prognosis.

[Aortic stenosis: interest in echocardiography with dobutamine]. / Retrecissement aortique: interet de l'echocardiographie sous dobutamine.

The stress echocardiography with dobutamine confirms her increasing value for the patients with severe aortic stenosis and left ventricular dysfunction in a diagnosis concept by selecting the true severe stenoses and revealing stenoses overestimated by the low fow, and especially prognosis by means of the stratification of the operatory risk and the search for a contractile reserve which represent the guarantee of a survival per and postoperatoire satisfactory. As regards asymptomatic aortic stenosis the times of intervention are in reevaluation, the compliance valvulaire represent reliable means which needs confirmation for a prophylactic indication for surgery.

[Chronic-contained ruptured aortic aneurysm: un unusual cause of back pain]. / Rupture chronique cloisonnée d'un anévrysme de l'aorte abdominale: une cause inhabituelle de dorsalgies.

Chronic contained rupture of abdominal aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as a chronic back pain and the delayed diagnosis and delayed surgical repair may compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repair. We report a case of contained rupture of a small abdominal aortic aneurysm with delayed diagnosis, evaluated by computed tomography showing a beginning erosion of the lumbar vertebral body. The patient was operated on within 24 hours on admission with uneventful surgical outcome.

[Indications for the implantable cardiac defibrillator]. / Les indications du defibrillateur automatique implantable.

The indications of the implantable cardiac defibrillator (ICD) have enlarged over the time. This has been facilitated by the technological progress which permit the device to be more effective and its implantation to be more simple. So, the implantation rate has increased all over the world but especially in the United States. The ICD was initially proposed in case of recurrent cardiac arrests due to ventricular fibrillation. Later, indications have enlarged. They concern at the present time not only the secondary but also the primary prevention of the sudden cardiac death. Indications in secondary prevention are based on the results of randomized studies which have clearly demonstrated the superiority of the device if compared to the antiarrhythmic drugs. The first indication of the ICD in the primary prevention has been defined by the MADIT study. Since, other studies have tried to define high risk population in whom a prophylactic implantation of an ICD should be justified. However, other clinical trials are still necessary to precise the indications of the ICD in some disease states (hypertrophic cardiomyopathy, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, Brugada syndrome) which can be complicated by arrhythmic sudden death. Indeed, indications in these diseases are still based on small studies and in the opinion of experts.

[Coronary disease in hypothyroidism. 10 case reports]. / L'atteinte coronaire au cours de l'hypothyroidie. A propos de 10 cas.

The hypothyroidism and coronary disease are tightly related. Our retrospective study, based upon the data from ten patients with hypothyroidism and coronary disease, aimed to assess the diagnosis, the prognosis and the therapeutic measures in these patients. Our population aged in average 60 years and was almost composed with women. Acute Coronary syndrome was a circumstance to discover hypothyroidism three patients. Bi and tritruncular stenosis were found in seven of the patients. The mean number of coronary lesion by patient is 2, 1. Myocardial reperfusion was proposed in seven of the patients. The three remainders were treated medically. Among the six operated patients, three were insufficiently prepared by the opotherapy. One of these patients died in preoperative period. The only patient who underwent angioplasty presented an uneventful period. At short and long term follow-up the evolution of all survivors patients was satisfactory on the both coronary and thyroidal sides. During the course of hypothyroidism coronary lesions are more extended, complex and severe. The management of such patients is difficult because of destabilisation of affection by the treatment of the other one. Preventive measures seams to warrant the best result.

[Cellular transplantation: a new alternative treatment in ischemic cardiomyopathy]. / Transplantation cellulaire: nouvelle alternative du traitement de la cardiopathie ischémique.

The cellular transplantation in the myocardium or cellular cardiomyoplasty has been tested extensively among the animal. It showed very encouraging results concerning improval of the contractile function in cardiac failure. This work is going to review the set of the experimentations in the animal and the beginnings of the therapeutic tests. It is going to expose the different technical modes that have been proposed, the conditions of their realization, the problems to which they are exposed as well as the perspectives of future.

[Doppler echocardiography and arhythmogenic right ventricular dysplasia]. / Echocardiographie-Doppler et dysplasie arythmogène du ventricule droit.

The aim of this study is to evaluate new echocardiographic modes in diagnosis of arrhythmogenic right ventricular dysplasia (ARVD). Our study is prospective, including ten patients with ARVD and a control group of ten healthy subjects. Transthoracic echocardiography included evaluation of classical criteria's, cross sectional measurements of the right ventricular. M mode and pulsed tissue Doppler techniques were used for quantitative measurement of tricuspid annular motion at the lateral and septal positions. Assessed by M mode, the total amplitude of the tricuspid annular motion was decreased in the lateral and septal positions in the patients compared with the controls. The tissue Doppler velocity pattern showed decreased early diastolic peak annular (Ea) velocity and an accompanying decrease in early (Ea) to late diastolic(Aa) velocity ratio in all positions; the systolic annular velocity was decreased only in the lateral position. Tricuspid annular measurement are valuable, easy to obtain and allow quantitative assessment of right ventricular function. ARVC patients showed an abnormal velocity pattern that may be an early but non specific sign of disease.