National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study.

BACKGROUND: In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics. OBJECTIVE: The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention. METHODS: The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite). RESULTS: The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation. CONCLUSIONS: This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/47525.

Thrombosed left ventricular pseudoaneurysm following myocardial infarction: a case report.

BACKGROUND: Pseudoaneurysm of inferior wall of the left ventricle is an uncommon complication of myocardial infarction with high mortality. CASE PRESENTATION: We report the case of a 63-year-old Tunisian man, diagnosed with a thrombosed left ventricular pseudoaneurysm and a pericardial effusion after 1 week of angina. CONCLUSIONS: Left ventricular pseudoaneurysm is a serious complication of myocardial infarction that has atypical presentations. Diagnosis is generally established by transthoracic echocardiography but confirmed by magnetic resonance imaging. Urgent surgery is the treatment choice given the risk of embolization and rupture.

Atrio-ventricular block on Wolff Parkinson White's syndrome: a rare association.

Complete atrioventricular block (AV block) associated with an accessory pathway is a rare phenomenon. We report the case of a third degree AV block paired with a Wolff Parkinson White (WPW) syndrome in a 91-year-old patient. The electrocardiogram (ECG) on admission showed a Mobitz type II AV block alternating with a third degree block on a wide-QRS ventricular rhythm beating at 35 cycles per minute. The patient urgently underwent the implantation of a single-lead pacemaker. The post-implantation ECG revealed a Kent accessory pathway on the left posteroseptal site. The existence of a complete AV block in the presence of an accessory pathway implies a more or less permanent blockage of atrial depolarization, both through the normal conduction tissue and the accessory pathway.

Adverse cardiovascular effects of doping in athletes.

The use of doping substances and methods is prevalent not only among elite athletes, but also among amateur athletes and other athletes. However, the abuse of substances and methods of doping has been associated with the occurrence of numerous adverse health effects. Cardiovascular effects are the most deleterious. The objective of this manuscript is to study through a review the literature, adverse cardiovascular effects after the abuse of substances and doping methods in athletes. Three major classes of products have more cardiovascular side effects; they are anabolic, stimulants and narcotics. It is possible to predict their use according to the desired objectives. Anabolic doping is used by sportsmen who practice strength sports, stimulants are used by those who practice speed sports, while endurance sportsmen prefer products that improve the transport of oxygen. Cases of myocardial infarction, hyperlipidemia, hypertension, venous thrombosis, arrhythmogenesis, heart failure and sudden cardiac death have been observed. The doping substances of varied nature seem to have adverse cardiovascular effects whose physiopathology remains a research and investigation track. Further randomized trials are needed to better understand the interaction of these doping substances taken in a combined way in athletes.

Predictors of the effectiveness of acupuncture in smoking cessation in coronary patients: a prospective study of 25 patients.

BACKGROUND: Smoking cessation should be a priority for smokers, especially coronary patients. AIM: To study the place and effectiveness of acupuncture in smoking cessation in coronary patients. METHODS: We conducted a prospective open-label study of 25 coronary smokers treated by acupuncture over a 10-month period, from June 2017 to March 2018. A 2-session protocol acupuncture weekly for three to five weeks, with a positive response. In order to evaluate the effectiveness of acupuncture, a questionnaire was completed by the doctor during the treatment, at three and six months after the end of the sessions. Positive response was defined by total cessation of smoking. RESULTS: The average age of our patients was 55.5 years (33 to 77 years). The sex ratio of our population was 1.5 with a male predominance. All our patients had a coronary history. The average cigarette consumption was 22.7 pack-years on average. The results of our study showed that acupuncture allows the withdrawal of 5 smokers (20%) from the first session. After the fifth session, 60% of our patients stopped smoking. At the end of the treatment, 17 smokers (70%) stopped smoking completely. At 3 and 6 months of treatment, we observed a stabilization of smoking cessation and decrease rates. CONCLUSION: Smoking cessation is difficult to obtain whatever the therapeutic method used, which encourages us to strengthen preventive measures.

Echocardiographic parameters of the right ventricle in chronic hemodialysis.

INTRODUCTION: Right ventricular (RV) dysfunction is one of the leading predictors of mortality and heart failure in chronic hemodialysis (HD) patients. AIM: To describe the different echocardiographic abnormalities of the RV in subjects with HD. METHODS: We performed a descriptive cross-sectional study covering the period from July to October 2018; involving 42 patients treated with chronic HD. Patients underwent a conventional transthoracic echocardiographic (TTE) study supplemented with tissue Doppler between two hemodialysis sessions. RESULTS: We included 42 patients. The sex ratio of our population was 1.6 with a male predominance, the average age of patients was 62.7 ± 12.4 years. The most important cardiovascular risk factor was arterial hypertension (78.6%). The most important causative nephropathy was nephroangisclerosis (31% of cases). The average age of dialysis was 34.5±30 months. Forty-two percent of our patients had RV dilation, 38% had right atrium dilatation, 7% had Right ventricular outflow tract dilatation, and 59.5% had RV hypertrophy. We noted RV systolic dysfunction in 66.7% of cases, a predominant normalized tricuspid profile with an average E / A ratio of 1.11 ± 0.5. CONCLUSION: Our study is consistent with the various echocardiographic data already raised in the literature, showing a high prevalence of RV dilatation and systolic dysfunction. It is one of the leading predictors of mortality and heart failure in chronic hemodialysis patients.

Attempted suicide by Flécainide overdose: A case report.

Class Ic antiarrythmic overdose is associated with a relatively high mortality. We presenta case report regarding a suicidal intoxication of an 18-year old female with a medical history of Wolff-Parkinson-White syndrome. The preliminary examination highlighted a profound cardiovascular collapse. The electrocardiogram showed a PR interval extended to 360 ms. The QRS complexes were enlarged to 360 ms with a right bundle brunch block appearance associated with left posterior hemibloc. There were repolarization abnormalities such as elevation of the J-point, convex ST segment and biphasic T wave in the right precordial leads ("Brugada-Like ECG pattern"). Sodium bicarbonate was administered. A rapid decrease in the duration of the QRS complexes was noted as well as a slowing of the heart rate. The electrocardiogram aspect on the 4th day showed the reappearance of the ventricular pre-excitation. The severity and lethal potential of Flecainide poisoning are linked to the cardiotoxic effects of these molecules. The prognosis remains poor despite progress in intensive care procedures.

Atrial fibrillation and hypertension: State of the art.

Atrial fibrillation and hypertension are often coexistent. Their incidence increases with advancing age and they are responsible for considerable morbidity and mortality. The relation between theses 2 diseases has long been discussed and determined by clinical studies. Left ventricular hypertrophy and left atrial remodeling during hypertension favor the development of atrial fibrillation. AF during hypertension increases the risk of thromboembolic complications and heart failure. In patients with hypertension, pharmacological treatment may control the cardiac structural changes and retard or prevent the occurrence of atrial fibrillation. In case of atrial fibrillation, treatment should be focused on the control of heart rate and rhythm and the prevention of thromboembolic accidents. A strict control of blood pressure is highly required in this situation.

Hisian extrasystole mimicking second degree atrioventricular block. a case report.

Hisian extrasystoles originate from the His bundle. They are rare and usually misdiagnosed. In fact, they manifest on the EKG, with a p' wave located before, in or after the QRS complex. More rarely, the extrasystole blocks the propagation of the influx to the ventricles simulating a Mobitz II atrioventricular (AV) block. We report the case of a 36-Year-old woman with no medical History, suffering from presyncope and palpitations at rest. Her physical examination and EKG were normal. The 24-hour Holter monitoring showed some long periods with unexpected blocked p waves but with no significant pause. Considering her young age and the absence of causes of AV block, we performed an intracardiac electrophysiological study which showed hisian extrasystoles with normal conduction tissue properties at baseline and under flecainide. The diagnosis of hisian extrasystoles simulating Mobitz II AV block was made. A simple monitoring with beta-blockers therapy was recommended. Hisian extrasystoles may simulate first or second degree AV block with different therapeutic and prognostic implications. Nevertheless, these hisian extrasystoles may be the marker of a vulnerable AV conduction, long-term follow up should be considered.

[Limits of quantitative coronary angiography (QCA) in intermediate stenosis measuring: a correlation and concordance study with intravascular ultrasound (IVUS)]. / Les limites de l'angiographie semi quantitative (QCA) dans l'évaluation des sténoses coronaires intermédiaires: étude de correlation et de concordance avec l'échographie endocoronaire (IVUS).

BACKGROUND: Although coronarography is still the gold standard to evaluate coronary lesions, it remains a bidimensional representation of a tridimensional complex structure, which can represent a source of error in measurements. AIMS: to perform a correlation and concordance study between quantitative coronary angiography (QCA) and intravascular ultrasound measurements for intermediate and ambiguous lesions. METHODS: We analysed 40 patients' coronary arteries from March 2009 to November 2011 by both QCA and intravascular ultrasound to perform then a correlation and concordance study. RESULTS: the correlation study confirmed the limits of the angiogram in providing accurate measurements. The correlation coefficient was yet high in reference diameters (r=0,78, p<0,001) and minimal lumen diameters (r=0,58, p<0,001), but was middling for stenosis percentages (r=0,23, p=0,03). This coefficient was also high for lesions lengths (r=0,51, p=0,01). Bland &Altaman diagrams showed however wide limits of agreement, reflecting possibility of large measurements error and confirming the absence of concordance between the two techniques. CONCLUSION: Coronarography though being the most widespread mean of evaluating coronary lesions lacks to provide accurate measurements, which can influence patient's management, especially in case of intermediate lesions.

[Benefits of coronary revascularization in septuagenarian patients with acute coronary syndrome]. / Bénéfice de revascularisation coronaire chez les patients septuagénaires au décours d' un syndrome coronarien aigu.

BACKGROUND: Prognosis of acute coronary syndrome (ACS) in elderly patients is bleak. Also older people tend to receive less invasive treatment than younger patients. AIM: To analyze the impact of coronary revascularization on the mid-term outcome of septuagenarian patients admitted with ACS. METHODS: We retrospectively studied 250 patients 70 years or older hospitalised for ACS between january 2006 to september 2010. RESULTS: This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% NSTEMI, 40% STEMI). Coronary angiograms showed complex coronary lesions with a high incidence of multivessel disease, bifurcation lesions, and calcified stenosis. Seventy-six patients were treated medically and 174 underwent percutaneous or surgical revascularization. At six-month clinical follow-up, major adverse cardiac events (MACE) were significantly higher in medically treated than revascularized patients (62% Vs 31.7%, P <0.001). Patients with invasive strategy have significantly higher event free survival rate comparing to those assigned to medical management (64% Vs 49.7%, p: 0.01). CONCLUSION: Our study confirmed the superiority of invasive strategy compared to medical treatment in septuagenarian patients with acute coronary syndromes. Advanced age should not exclude patients from invasive strategy with complete revascularization.

[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.

[Results of cardiac pacing: report of 188 patients]. / Résultats de la stimulation cardiaque définitive: a propos de 188 malades.

BACKGROUND: Indications for permanent pacing are currently well codified. This treatment may, however, present complications AIM: To report the results of cardiac pacing and to identify predictive factors of pacing's complication. METHODS: We conducted a retrospective study of 188 consecutive patients admitted to the cardiology department of Mongi Slim university hospital in La Marsa between January 2005 and June 2011 and implanted with a single or dual chamber pacemaker. RESULTS: In our study, we had 92 men and 96 women (sexratio= 0.95). The mean age was 70.21 ± 13 years. The indication for cardiac pacing was a high degree heart block in 74.46% of cases and a sick sinus syndrome in 15.95% of cases. The degeneration conduction tissue was the main etiology (72.34% of patients). Success implantation was obtained in 98.4%of cases. The main operative complication was the pneumothorax in 3 patients (1.59% of cases). At Long term, cumulative survival rate was 78.95%. Only operating time affects significantly the rate of early complications (p<0.001). Late complications were related to the valvular heart disease (p = 0.007), the ischemic etiology (p = 0.05), the oral antivitamine K treatment (p = 0.04) and the occurrence of early complication (p = 0.002). CONCLUSION: Our hospital, which is considered as a small Center of cardiac pacing (less than 80 procedures/year) had a low complication rate as well as big centers.

[Coronary angiographic characteristics in septuagenarian patients with acute coronary syndrome]. / Caractéristiques angiographiques des septuagénaires hospitalisés pour syndromes coronariens aigus.

BACKGROUND: Although the prognosis of acute coronary syndrome (ACS) in elderly patients is bleak , elderly population is less well treated both in medical and interventional terms. aims: to analyse angiographic findings in septuagenarian patients admitted with ACS and its impact on the therapeutic strategy. METHODS: We retrospectively analysed 250 patients 70 years or older hospitalised for ACS who underwent a coronary angiography between january 2006 to September 2010. RESULTS: This population was more likely to be male with mean age 74 years and 93 % of ACS were inaugural events (60% N STEM, 40% STEMI).Coronary angiograms showed complex, diffuse coronary lesions with a high incidence of multivessel coronary artery disease , bifurcation lesions , and calcified stenosis. CONCLUSION: Angiographic findings after ACS in elderly were characterised by multivessel disease and complex lesions .Surgical or percutaneous coronary revascularizaion was possible in the majority of these patients.

Comparison of coronary calcifications detection by angiogram versus intravascular ultrasound.

BACKGROUND: The presence, extent and location of calcium in coronary artery lesions are important determinants of the success of per cutaneous coronary intervention (PCI). Although coronarography remains the gold standard for coronary disease detection, Intravascular ultrasound ( IVUS) is proposed as a superior technique for identifying patients with coronary artery calcification . AIM: To define sensibility and specificity of coronary angiography in detecting calcifications considering the IVUS as gold standard. METHODS: Target lesion calcification was assessed in 40 patients (35 men; mean age 57.4 ± 10 years) by angiography and intravascular ultrasound. RESULTS: Ultrasound detected calcium in 51 of 85 target lesion (60%),whereas angiography showed calcifications in only 16 lesion (19% p<0.001 compared with IVUS). Coronary angiography detected 8% of 0-45° arc calcium category, 7% of 45-90° calcium category, 58% of 90-180° calcium category, and 80% of more than 180° calcium category. The overall sensitivity of angiography in identifying calcium was 31% and increased with an increasing arc of lesionassociated calcium. The overall specificity of the angiographic detection of target lesion calcium was 100%. CONCLUSION: Intra coronary ultrasound analysis shows that target lesion calcification is much more widespread in coronary artery disease than what angiography reveals. The sensitivity of angiography was poor, with although a very high specificity.

[Atrial fibrillation following coronary artery bypass grafting: predictors and mid- term outcome]. / La fibrillation atriale aprés chirurgie de pontage aortocoronaire: facteurs prédictifs et pronostic àà moyen terme.

BACKGROUND: Atrial fibrillation (AF) is a frequent complication after coronary artery bypass grafting (CABG) which increase morbidity and hospitalization length. AIM: To identify the predictors of atrial fibrillation and its repercussion on hospital and mid-term outcomes in patients undergoing (CABG). METHODS: We undertook a retrospective review of the data of 224 patients undergoing CABG. The mean age of the patients was 60.8 years. Atrial fibrillation was diagnosed from serial postoperative electrocardiogram. RESULTS: Twenty two patients developed postoperative atrial fibrillation. Multivariate analysis showed that only: age, left circumflex stenosis, sternal wound infection and low cardiac output were predictors of AF following CABG. Hospital mortality was similar in the two groups (5% Vs 9.6 % P=0.7). CONCLUSION: In our study, the incidence of post-CABG atrial fibrillation was 9.8%. Multivariate predictors were age, left circumflex lesion, sternal wound infection and low cardiac output. Hospital mortality and mid-term outcome were similar in the two groups.

[Coronary artery bypass grafting in diabetic patients: early and mid-term outcomes]. / La chirurgie du pontage aorto coronaire chez les diabétiques : Résultats immédiats et à moyen terme.

BACKGROUND: The outcome of coronary artery bypass grafting (CABG) in diabetic patients has traditionally been worse than in nondiabetic patients. Recent studies have suggested an improvement in outcome in diabetic patients undergoing CABG. However, the direct impact of diabetes on mortality and morbidities following CABG remains unclear. AIM: To evaluate the early and mid term outcomes of diabetic patients compared to non-diabetics following CABG. METHODS: We retrospectively analyzed the data of 228 CABG patients from January 2005 to December 2010: one hundred and twenty-six diabetics and 102 non-diabetic.Diabetic patients were more likely to be female(27% Vs 12.7% P=0.009) were less smoker (55.6% Vs 80.4% P<0.0001) with higher rate of three vessel disease(67.5% Vs 42.2% P=0.005) compared to non-diabetics. RESULTS: Hospital mortality was significantly higher among diabetic patients (16% Vs 4.1% P=0.005).Length of care unit stay was more important (2.3 days Vs 2.1 days P=0.048) , but with a similar rate of sternal wound infection even after bilateral internal thoracic artery grafting. After 28 months mean follow- up, mid-term survival of diabetics was significantly decreased compared to no-diabetics (91% Vs 99% p<0.001) .However, Event-free survival was similar in the two groups (76% Vs 80% p=0.82). CONCLUSION: These results suggest that diabetes is associated with poorer early and mid-term outcomes following (CABG).

[Single versus bilateral internal thoracic artery grafts for multi vessel coronary artery bypass grafting: mid-term results]. / Mono-pontage versus pontage bilatéral mammaire interne : Résultats immédiats et à moyen terme.

BACKGROUND: The issue of superiority of single internal thoracic artery grafting versus bilateral internal thoracic artery grafting remains unresolved. AIM: The aim of this study was to compare the early results and midterm outcome of single and bilateral internal thoracic artery grafting for multivessel coronary artery bypass grafting. METHODS: Between January 2005 and March 2010, 196 patients underwent primary coronary artery bypass grafting with at least one internal thoracic artery grafts. Early results and Outcomes of patients undergoing single internal thoracic artery (SIMA) plus saphenous vein grafting (n=145) and bilateral internal thoracic artery (BIMA) plus saphenous vein grafting (n=51) were obtained at a mean followup of 29 months. RESULTS: Patients with bilateral internal thoracic artery grafting were younger, had less hypertension, higher left main disease and better Euroscore than patients undergoing single internal thoracic artery grafting. In-hospital mortality was similar for the two groups: 6.9 % for patients undergoing SIMA versus 5.9 % for those undergoing BIMA (p=0.8). Sternal wound infection was also similar (2.8% versus 3.9% p=0.68). Mid-term mortality was (4% VS 4.8% p=0.71) and event free survival probability at 28 months was 75% for the single-graft group compared with 85.7% for the bilateral-graft group (P =0.46). CONCLUSION: Our study found similar early and mid-term clinical outcomes for patients undergoing SIMA plus saphenous vein grafting and those undergoing BIMA plus saphenous vein grafting for multivessel coronary artery bypass grafting.