[Monocentric retrospective study on the prevalence and significance of incomplete right bundle branch block in young competitive athletes in Tunisia]. / Étude rétrospective monocentrique sur la prévalence et la signification du bloc de branche droit incomplet chez les jeunes sportifs de compétition en Tunisie.

AIMS: Few studies have assessed the prevalence and significance of right bundle branch block in athletes. Aims of this study were to evaluate the prevalence of incomplete right bundle branch block and its correlation with the nature of sports practice and to compare the athlete with right bundle branch block and the one with a normal electrocardiogram. METHODS: It was a retrospective study of the electrocardiogram and echocardiography of competitive athletes recruited in the medical-sports center of Sousse RESULTS: A total of 554 athletes were included. Mean age was 16.1 ± 2.9 years and 69 % were male. The mean training duration was 5.8 hours per week. The prevalence of incomplete right bundle branch block was 13.9 % (77 cases). Endurance sports were practiced in 71.4 % of cases among subjects with right bundle branch block versus 55.4 % in the rest of the population (p < 0.001). The basal diameter of the right ventricle was larger in athletes with right bundle branch block compared to athletes without right bundle branch block: 28 ± 3.6 mm versus 24 ± 2.4 mm (p < 0.001). CONCLUSIONS: The results of this study suggest that right bundle branch block is a marker of incomplete right ventricular remodeling. This remodeling represents a form of adaptation to sustained elevation of volumetric load observed mainly in endurance sports.

A retrospective study from a single center to compare outcomes in 79 patients with in-stent restenosis treated with paclitaxel-coated balloon angioplasty or drug-eluting stent implantation.

BACKGROUND: Despite the recent progress made in drug-eluting stents (DESs), in-stent restenosis (ISR) is still a common complication of percutaneous coronary interventions. This retrospective study from a single center aimed to compare outcomes in 79 patients with ISR treated with paclitaxel-coated balloon (PCB) angioplasty or DES implantation. RESULTS: From January 2017 to December 2021, 83 ISR lesions from 79 patients were included. Thirty-two were treated with PCB and 51 treated with available DES in the catheterization laboratory. Baseline characteristics were similar in both groups. Mean time between index angioplasty and restenosis was 27 months with a minimum of 4 months and a maximum of 70 months. Concerning Mehran ISR angiographic classification, classes II and III were more likely treated with DES. Stenosis diameter and minimal lumen diameter (MLD) were similar in both groups. PCB used was significantly shorter than DES: Mean length was 19.75 ± 5.7 versus 22.1 ± 16.5 (p < 0.001), respectively. Angiographic results immediately after intervention were similar in both groups: In-segment MLD after the procedure was 2.5 ± 0.4 in the DES group and 2.26 ± 0.55 in the PCB group. A median follow-up of 20 months was achieved for 68 patients, and 11 were lost to follow-up. There was also no difference in both groups regarding free from events survival. CONCLUSIONS: The findings from this study support recent international studies that have shown no significant differences between DES and PCB and in-stent restenosis. This suggests that PCB use is an option to consider in our local daily practice.

Combination Therapy With Nicardipine and Isosorbide Dinitrate to Prevent Spasm in Transradial Percutaneous Coronary Intervention (from the NISTRA Multicenter Double-Blind Randomized Controlled Trial).

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS.

[Clinical impact of SARS-CoV2 infection in professional footballers of the Tunisian Premier League]. / Impact clinique de l'infection par le SARS-CoV2 chez les footballeurs professionnels de la première ligue Tunisienne.

AIM OF THE STUDY: The aim of our work, developed within the Tunisian Football Federation (TFF), was to study the clinical manifestations and the possible cardiac complications in professional footballers of the first league having contracted an infection by SARS-CoV2. PATIENTS AND METHODS: This is a retrospective, descriptive, and analytical study. Professional Premier League football players who contracted COVID-19 from the onset of the pandemic through June 2021 were included. RESULTS: Among the 1388 players of the Tunisian first professional league, 102 players (7.35%) had COVID-19. Three were excluded for lack of clinical data. The average age of the subjects included was 26 ± 4 years with extremes ranging from 19 to 37 years. The most frequent clinical manifestations were anosmia, agueusia and muscle fatigue. The clinical examination was normal in all the subjects included except for the presence of fever among 37 (37.9%) subjects. All subjects' electrocardiogram did not show any unusual abnormality. As for the imaging data, two players presented a pericardial effusion without signs of severity. In the other players, echocardiography was normal. Cardiac magnetic resonance imaging did not reveal any abnormality. CONCLUSION: The results of our study showed that there was no severe form of COVID-19 among professional soccer players. Larger scale studies integrating other leagues and different sport categories may provide more information on the clinical impact of this disease in high level athletes.

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.

Prognostic impact of diabetes mellitus on patients managed by urgent percutaneous coronary intervention.

INTRODUCTION: Diabetes Mellitus (DM) is known to be associated with worse outcomes following percutaneous coronary intervention (PCI). AIM: To assess prognostic impact of DM on patients managed by urgent PCI following ST-segment elevation myocardial infarction (STEMI). METHODS: In a retrospective study, STEMI patients admitted to our department from January 2016 to December 2019 and treated with urgent PCI (primary or rescue PCI) were included. They were divided in two groups: Diabetic and non-diabetic patients. They were followed-up for a period of 12 months. Major cardiac adverse event (MACE) was a composite outcome of the following events: myocardial infarction, target vessel revascularization, target lesion revascularization or cardiovascular death. MACEs were collected during follow-up. RESULTS: Our population consisted of 225 patients. DM was observed in 104 STEMI patients (46.2%). Diabetic patients had higher frequency of hypertension (p 1.4mmol/l (p 75 years, hyperglycemia at admission (>10mmol/l), extensive anterior infarction and procedure failure were associated with in-hospital mortality in the non-diabetic group. Factors associated with 12-months mortality and MACEs among diabetic patients were age > 75 years, anemia, CKD and left ventricular systolic dysfunction. CONCLUSIONS: Despite modern era of STEMI treatment, diabetic patients still have a poor prognosis. These results highlight the need for coronary risk factors treatment among these patients.

Outcomes and prognostic factors of patients treated for in-stent restenosis: a retrospective single-center experience.

BACKGROUND: The incidence of in-stent restenosis (ISR) remains relatively common despite the use of drug-eluting stents. Outcomes and prognostic factors following ISR revascularization are still being investigated. We aimed to describe the outcomes following different ISR treatment strategies in order to identify prognostic factors associated with worse outcomes. RESULTS: In a retrospective cohort study, we included patients who were admitted to our department and treated for ISR, from January 2017 to December 2018. All patients were followed up for a median period of 24 months. Major cardiac adverse event (MACE) was a composite outcome of the following events: myocardial infarction, target vessel revascularization, target lesion revascularization or cardiovascular death. MACEs were collected during follow-up. Our population consisted of 116 patients. Mean age was 60 years old with a sex ratio of 2.8. During follow-up, 44 patients (37.9%) had at least one MACE. Independent factors identified by multivariate logistic regression were ISR of the proximal left anterior descending artery [Odds ratio (OR) = 1.29; 95% confidence interval (95% CI) 1.16-1.81; p = 0.05], diffuse ISR [OR = 2.16; 95% CI 1.1-3.47; p = 0.022], double or triple vessel disease [OR = 2.97; 95% CI 1.2-6.8; p = 0.008], two or more stents per lesion [OR = 1.82; 95% CI 1.14-2.21, p = 0.031] and absence of post-dilatation in the initial angioplasty [OR = 1.32; 95% CI 1-1.35; p = 0.04]. CONCLUSIONS: Our study suggested that ISR is related to poor outcomes. Identifying prognostic factors would play a key role in the refinement of interventional techniques.

Distal radial approach versus conventional radial approach: a comparative study of feasibility and safety.

The distal radial approach (DRA) is suggested to have benefits over the conventional radial approach (CRA) in terms of local complications and comfort of both patient and operator. Therefore, we aimed to compare the feasibility and safety of DRA and CRA in a real life population. We conducted a prospective, observational multicentric trial, including all patients undergoing coronary procedures in September 2019. Patients with impalpable proximal or distal radial pulse were excluded. Thus, the choice of the approach is left to the operator discretion. The primary endpoints were cannulation failure and procedure failure. The secondary endpoints were time of puncture, local complications and radial occlusion assessed by Doppler performed one day after the procedure. We enrolled 177 patients divided into two groups: CRA (n = 95) and DRA (n = 82). Percutaneous intervention was achieved in 37% in CRA group and 34% in DRA group (p = 0.7). Cannulation time was not significantly different between the two sets (p = 0.16). Cannulation failure was significantly higher in DRA group (4.8% vs 2%, p < 0.0008). Successful catheterization was achieved in 98% for the CRA group and in 88% for the DRA group (p = 0.008). Radial artery occlusion, detected by ultrasonography, was found in 3 patients in the CRA group (3.1%) and nobody in the DRA group (p = 0.25). The median diameter of the radial artery diameter was higher in the DRA than the CRA group (2.2 mm vs 2.1 mm; p = 0.007). The distal radial approach is feasible and safe for coronary angiography and interventions, but needs a learning curve.