[Evaluation of the quality of long-term anticoagulation therapy with antivitamin-K in atrial fibrillation]. / Évaluation de la qualité de l'anticoagulation au long cours par antivitamine-K dans la fibrillation auriculaire.

AIM: To assess the quality of long-term anticoagulation therapy with antivitamin-K in patients with atrial fibrillation by measuring the TTR and to determine the factors associated with a good TTR. PATIENTS AND METHODS: This is an observational study conducted over a period of three years (from January 2013 until December 2015) in the outpatient clinic of cardiology of Farhat Hached hospital of Sousse, Tunisia. Pre-established individual plugs were used for data collection. The data analysis was performed using the SPSS Software, version 20. RESULTS: Overall, 200 patients were eligible. Half of the patients did not know the risks of AVK and 29.1% were unaware of their interest. The average TTR was 57.3±18.2%. Good control of anticoagulation was obtained in 24.5% of patients. Those with a≥70% were more autonomous, observant, of urban origin, living in Sousse and Kairouan, with good knowledge about AVK and having a small left atrium. The factors associated negatively with TTR were hypertension, diabetes, old AF, hematological diseases, high number of medications taken daily and the presence of mitral insufficiency, mitral valve replacement, a tricuspid insufficiency or a tricuspid plasty. CONCLUSION: The quality of AVK anticoagulation in AF patients is insufficient. Improving this indicator would reduce the morbidity and mortality associated with AVK treatment.

Incidence and risk factors of peripheral venous catheter-related adverse events in cardiology department of a Tunisian university hospital: A prospective observational study.

AIM: The purpose of our study was to determine the incidence and risk factors of Peripheral Venous Catheter-Related Adverse Events (PVCAEs) in a cardiology department of a university hospital. PATIENTS AND METHODS: We carried out a prospective observational study from Mars 2017 to May 2017 in the cardiology department of the University Hospital of Farhat Hached in Sousse, Tunisia. During this period, we actively followed-up all inserted PVCs (every 12hours) from insertion up to 48hours after removal. Regression analyses were applied and significance limits were set at P<0.05. RESULTS: Data were analysed for 210 PVCs (794 PVC-days) in 148 patients. The incidence of PVCAEs was 33.33% with density of incidence of 8.81/1000 PVC-days. PVCAEs were mainly pain (50%) and mechanical events (31.42%). Infections accounted for 11.42%. The most frequent mechanical PVCAEs, was haematoma (15.71%). Multivariate analysis revealed as independent factors for the occurrence of PVCAEs: the hydro electrolytic nature of the injected product (OR=13.42, P<10-3), the medicinal nature of the injected product (OR=5.08, P=0.003), bad cutaneous state (OR=8.08, P=0.003), admission during nightshift (OR=3.76; P=0.014) and advanced age (OR=1.04, P=0.042). CONCLUSION: Multicenter studies would be very useful to better analyze risk factors associated with PVCAEs.

[Cardiac involvement in polymyositis]. / Manifestations cardiaques au cours de la polymyosite.

Cardiovascular involvement in polymyositis constitutes a major cause of death. However, the cardiac location is rarely symptomatic and does not usually represent the principle clinical feature at the time of the initial presentation. We present here an unusual case of polymyositis with severe and polymorph cardiac disturbances that predominant the muscular signs.

[Study of the intronic polymorphism of the angiotensin 1 converting enzyme among coronary Tunisians]. / Étude du polymorphisme intronique de l'enzyme de conversion de l'angiotensine I chez des coronariens tunisiens.

BACKGROUND: The acute coronary syndromes (ACS) are classified among the major causes of mortality in the industrialized countries. The increased angiotensin I converting enzyme (ACEI) activity related to a genetic polymorphism constitutes a hereditary predisposition to these syndromes. AIM: Evaluate the ACEI activity in Tunisian patients with coronary heart disease, and investigate the association between this activity and an intronic deletion of 287 pb on the intron 16 of the ACEI gene. PATIENTS AND METHODS: Seventy-two coronary patients and 34 control subjects are recruited for our study. ACEI activity was measured by kinetic method. The intronic deletion was identified by PCR technique. RESULTS: An increased activity of ACEI was observed in patients compared with control subjects (84.38 ± 33.83 UI/L vs 59.06 ± 18.2 UI/L, P=10(-5)). The molecular study showed a raised relative frequency of D/D genotype (51.4%) among patients, whereas among the witnesses, I/I genotype prevailed (62%). D/D genotype is always associated with highest ACEI activity for the patients and the control subjects. CONCLUSION: The molecular studies and the biochemical investigations of the various parameters of cardiovascular risk (including the ACEI) direct towards a better treatment.

Systemic embolism and septic shock complicated left atrial myxoma: case report.

Myxoma is the most common primary tumor of the heart. The rarity of infected cardiac myxomas leads to numerous diagnostic and therapeutic difficulties. We present a case of infected left atrial myxoma caused by methicillin-sensible Staphylococcus aureus in a 48-year-old woman complicated by systemic embolism and septic shock.

[Oral anticoagulants and atrial fibrillation]. / Anticoagulation orale et fibrillation auriculaire.

INTRODUCTION: Oral anticoagulants (OA) are effective in the prevention of cerebrovascular events among patients with atrial fibrillation (AF). However, several studies showed OA to be widely underused in these patients. The purpose of this study was to assess the use of OA and associated factors with non-use of this treatment. METHODS: We conducted a retrospective study of 233patients affected by non valvular AF hospitalized in our institution between 2005 and 2007. Patients were stratified in three groups for stroke's risk (high, moderate and low) according to the international antithrombotic therapy recommendations. RESULTS: The average age of our patients was 64+/-14 years, with 35% of subjects being older than 75years. Hypertension was the more frequently reported risk factor for stroke (61%), followed by diabetes mellitus (19%) and congestive heart failure (12%). Five percent of the patients reported a stroke or a systemic embolic event history. Of the 233patients studied, 48% were stratified to the high risk group, among them 75% were being treated with OA, 20% with Aspirin and 5% were taking no medications. To explore possible reasons for not prescribing anticoagulation, we analysed 27patients at high risk who did not receive OA. We found a low benefit/risk ratio (37%), neuropsychological impairment in 5%, a past bleeding episode in 6% but almost 50% of those patients reported no risk factors for haemorrhage. CONCLUSION: In our retrospective study, among 25% high-risk patients with non valvular AF were not treated with OA and one half of the patients report none of the factors associated with perceived or actual risk factors for bleeding. These data confirmed OA underuse, despite guidelines that delineate higher-risk patient populations for whom anticoagulation is recommended.

[Hydatid cyst of the right atrium]. / Le cas clinique du mois. Kyste hydatique de l'oreillette droite.

Cardiac hydatid cysts are rare; the right atrial location is even rarer and carries serious complications. We report three cases of cardiac hydatid cyst of the right atrium. The first patient died in the postoperative period due to right heart failure and massive tracheal bleeding. The course of the disease of the two other patients was uneventful. Echocardiography is the most informative technique for identifying and localising the cyst before surgery. Right atrium hydatid cyst should be treated by early surgical excision with a view to prevent the risk of pulmonary embolism.

[Impact of diabetes on mortality after myocardial infarction]. / Impact du diabète sur le pronostic de l'infarctus du myocarde.

UNLABELLED: Myocardial infarction is a common cause of mortality in people with diabetes. The aim of this study was to determine early and mid-term mortality in diabetic patients with myocardial infarction and to determine if hyperglycemia was predictor of mortality. We conducted a retrospective study of 100 diabetic patients compared with 100 non diabetic patients who were hospitalised in our institution between 1999 and 2003 for myocardial infarction. RESULTS: Hospital and one year mortality were highest among diabetic patients compared with non diabetic patients. Multivariate analysis showed that admission plasma glucose was a consistent predictor factor of in hospital mortality RR 1.2 (IC 1.02-1.47). Admission plasma glucose was significantly higher in nonsurvivors diabetic patients than in survivors (22.7 vs 16 mmol/l P = 0.04). The predictor factors of one year mortality was age, female sex and no beta blocker at discharge RR5.3 (1.9-14.3). CONCLUSION: Diabetic patients with myocardial infarction have poor prognosis and hyperglycemia was associated with in hospital mortality.

[Prognosis of periprosthetic regurgitation after mitral valve replacement using the Saint Jude prosthesis]. / Valeur pronostique des fuites paraprothétiques aseptiques après remplacement valvulaire mitral par une prothèse Saint Jude Médical (SJM).

UNLABELLED: Periprosthetic regurgitation (PPR) is a common complication of mitral valve replacement (MVR). The management of moderate and minor PPR remains controversial. The goal of this prospective study was to determine the incidence, predictors and outcome of PPR discovered using omniplan transoesophageal echocardiography (TEE) performed at the early postoperative period (14.7 days) of MVR with SJM prosthesis. Our study enrolled 56 patients, the mean age was 44.5 +/- 11.9 years. The incidence of PPR was 59% (33 patients). TEE showed one jet in nine patients (27%), two jets in 23 patients (70%) and three jets in one patient (3%). PPR is minor in 24 patients (63%) and moderate in nine patients (27%). No patient developed hemolytic anemia or congestive heart failure. In univariate analysis, diameter of prostheses > 27 mm, number of suture knots < 17 and diameter of prostheses/number of knot ratio > 1.7 independently predicted the presence of PPR. In multivariate analysis only a rapport diameter of protheses/number of suture knots > 1.7 mm is predictif of PPR (odd ratio = 9, P = 0.036). Ninety percent of PPR remained present at six weeks and only 29% were present after 12.5 months. CONCLUSION: Mild and minor PPR were frequent during the early postoperative period after MVR. The clinical significance and natural history is benign and they do not require any specific treatment.

[Evaluation of the hemodynamic profile of mitral Saint Jude Medical prostheses in the early and late postoperative period]. / Evaluation du profil hémodynamique des prothèses Saint-Jude Médical en position mitrale en postopératoire précoce et tardive.

This study was to estimate the Doppler haemodynamic profiles of 56 prosthetic mitral valves (St Jude prosthesis) in the premature post-operating period, to study the correlation of the prosthetic area calculated by Doppler method (continuity equation (CE) and pressure half times (PHT)) and the area of the effective orifice in the post-operating premature period, in 6 weeks and after 6 months. The values of peak gradient and mean gradient at six week and at 12.5 months were not significantly different from those obtained in the premature exam. The prosthetic area calculated by continuity equation (ACE) in the premature postoperative period was significantly different between the various size (p = 0.0001). The (ACE) measured at 6 weeks and late (12.5 months), was not significantly different from that calculated in the premature exam (respectively p = 0.79 and p = 0.8). The (PHT) was very variable even within the different size of the prosthesis, however values measured at six weeks and in the late exam was not different from that calculated in the premature exam. In absence of complications, it seems to us that we can satisfy with using as reference exam data obtained in the premature exam.

Hydatid cyst of the right atrium and rheumatic mitral disease: a fortuitous association.

Ecchinococcal infestation of the heart accounts for only 0.5-2% of ecchinococcosis cases. A case is reported of right atrial hydatid cyst associated with rheumatic mitral valve disease in a 43-year-old woman. Physical examination and chest X-radiography revealed mitral disease. Transthoracic and transesophageal echocardiography demonstrated a single, large cystic mass of 4 x 4 cm located in the right atrium, and heavily calcified mitral rheumatic disease with commissural fusion. Confirmatory computed tomography and magnetic resonance imaging excluded other extracardiac locations. Radioisotopic lung perfusion scanning and angiographic scanning excluded pulmonary embolism. The patient underwent mitral valve replacement and the hydatid cyst was excised. An intraoperative examination and subsequent pathology confirmed a diagnosis of hydatid cyst.

[Familial hypertrophic cardiomyopathy associated with Wolff-Parkinson-White syndrome]. / Cardiomyopathie hypertrophique familiale associée à un syndrome de Wolff-Parkinson-White.

Familial hypertrophic cardiomyopathy (HCM) with Wolff-Parkinson-White (WPW) syndrome is extremely rare and associated with a high risk of ventricular tachyarrhythmia and sudden death. We report a familial form of hypertrophic cardiomyopathy associated with Wolff-Parkinson-White syndrome in two siblings 7 and 12-year-old. These patients showed progression to left ventricular dilatation. Early recognition and treatment of such forms can improve such evolution and the risk of sudden death.

[Delays in the management of AMI: Results of an investigation conducted in Sousse (Tunisia)]. / Délais de prise en charge de l'IDM en phase aiguë: résultats d'une enquête dans la région de Sousse (Tunisie).

UNLABELLED: The goal of our work was to assess the delays of admission for Acute Myocardial Infarction (AMI) in Sousse (Tunisia) and to identify predictors of these delays. Our prospective survey was led from January 1999 to December 2001; 232 patients with AMI were included. The onset of symptoms usually occurred in the patient's home (80.6%). The chest pain was atypical in 19.4% of cases; 91% of patients directly consulted the emergency departments, whereas the ambulatory emergency services were used in only in 2.2% of cases. Delays of hospitalization in coronary care units were on average too long (14 h 21 min +/- 19 h 16 min). This prolongation was essentially caused by a too long period between onset of symptoms and first patient call. In bivariate analysis, dyslipidemia, diabetes, absence of smoking and an atypical symptoms were associated with prolonged hospitalization delays. However in multivariate analysis, only diabetes and atypical symptoms were independent factors associated with a hospitalization delay of more than 12 h. In 23% of the patients, a prolonged pre-hospital time period prevented the use of thrombolysis. CONCLUSION: Pre-hospital delays should be shortened by a multidisciplinary action that especially focuses on a better sanitary education of patients to risk.

[Myocardial infarction and abnormal origin of the circumflex coronary artery]. / Infarctus du myocarde et anomalie de naissance de la circonflexe.

Abnormal origin of the circumflex coronary artery without any stenosis is generally considered benign and without any particular ischemic risk. We report a case of a 21 year old man who suffered a posterior lateral myocardial infarction with objective criteria: electrocardiographic, echocardiographic and isotopic. The patient received thrombolytic therapy at H2. Angiography showed an abnormal origin of the circumflex coronary artery which was free of any stenosis. Certain cases of the circumflex artery anomaly can, therefore, be complicated by myocardial infarction, and the benign nature of the anomaly needs to be re-examined.

[Effort phlebitis of the upper limb. Report of 5 cases]. / Phlébite d'effort du membre supérieur. A propos de cinq observations.

Deep venous thrombosis (DVT) of upper limbs is extremely rare. DVT related to physical stress is a less known form. The purpose of this study was to outline the clinical pattern and laboratory features as well as the clinical course and outcome of this disease. The authors report 5 documented cases of upper limb DVT related to physical stress: 4 patients were hand workers and 1 was a young athletic man. None of the patients developed pulmonary embolism. Two patients had late sequelae. Treatment is based on prompt and early anticoagulation. Prevention can be achieved by contention, active physiotherapy and professional rehabilitation.

[The role of Doppler echocardiography in chronic constrictive pericarditis]. / L'apport de l'echocardiographie Doppler dans la pericardite chronique constrictive.

Constrictive péricarditis (CCP) is a rare but serious disease. It still poses diagnostic difficulties. The purpose of our work is to study the contribution of the echocardiographic Doppler in the diagnosis of the CCP. The authors report six cases of CCP proven after surgery. Study by ultrasound Doppler of intracardiac blood flow and their respiratory variations showed the existence of abnormalities. The decrease of 25% of the mitral E wave in inspiration compared to the value observed in expiration, the increase of 100% of the ebb in sus hépatic vein in expiration and the modifications of the flux in pulmonary insufficiency are the most reliable signs for the diagnosis of the CCP. This method seems so interesting for the diagnosis and to estimate the degree of constriction of the CCP.

[Cardiovascular risk in schoolchildren in rural Sousse, Tunisia]. / Risque cardiovasculaire chez l'enfant en milieu scolaire rural à Sousse, Tunisie.

There is no data available on the cardiovascular risk of children under 18 years of age in Tunisia, although it is well known that these risk factors present themselves in childhood. The authors performed an epidemiological study based on a representative sample of 793 schoolchildren in the rural region of Sousse, in Tunisia, to determine the incidence of the following risk factors: hypertension, hypercholesterolaemia and other lipid disorders, obesity and smoking. The main results show that the prevalence of hypertension is 11.2% with no statistically significant difference between the sexes. The prevalence of hypercholesterolaemia (2.9%), of hyper-LDL cholesterolaemia (0.6%) and hypertriglyceridaemia (1%) were comparable in boys and girls. Obesity (BMI > 30) was observed in 1.8% of the study population and was as common in girls (1.7%) as in boys (1.9%). Smoking was recorded in 4% of the study population and was commoner in boys (7.3%) than in girls (1.2%). This cardiovascular risk profile is encouraging and efforts should be made to maintain these levels until adulthood. This data will form the basis of a regional programme for the promotion of cardiovascular health in schools.