Assessment of atrial conduction time by Doppler tissue imaging in hypertensive patients.

BACKGROUND: Hypertension is the first cause of atrial fibrillation. Its onset is explained by intricate mechanisms such as atrial conduction impairment. AIM: To evaluate atrial conduction by tissue Doppler imaging in hypertensive patients compared to a control group. METHODS: This is a comparative prospective study performed in the cardiology department of the FSI hospital   enrolling 55 patients with hypertension and 55 controls. All of them underwent a complete echocardiocardiography exam with Doppler tissue imaging. We measured intraatrial and interatrial electromechanical delay by Pulsed Tissue Doppler. Statical analysis was conducted using SPSS version 22.0. Comparison of means was made with t student test. RESULTS: Left ventricular mass and septal thikness were more important in the hypertensive group. Mitral A wave was greater in hypertensive group compared to controls (7,1cm/s vs 5,6cm/s; p<0,0001; respectively). Left atrial volume was of 32,7±6,8mL/m² in hypertensives vs 29,5±4,3 mL/m² in controls (p=0,006). Doppler Tissue study showed homogeneous statistically significant elongation of atrial conduction times in hypertensive patients compared to controls: interatrial time (16.8±7.8ms vs 12.4±4,2ms, p<0.0003) and left intraatrial (27.6±8.6ms vs 19.0±4.3ms, p<0.0001) and right intraatrial time (10.8±6.0ms vs 6.6±2.9ms, p<0.0001; respectively for hypertensive and control subjects. There was a significant correlation between measured intraatrial and interatrial electromechanical delays and duration of hypertension, indexed left atrial volume ans indexed left ventricular mass (r 0.27-0.41, p<0.001). CONCLUSION: Atrial conduction time is significantly longer in hypertensive patients. Impairment of atrial conduction may be predictive of atrial fibrillation and should prompt closer surveillance to detect this arrhythmia in these patients.

Assessment of left atrial mechanical function by two-dimensional echocardiography in hypertensive patients.

INTRODUCTION: The left atrium (LA) have an important role in the normal functioning of the heart thanks to its three functions: reservoir, conduct and pump. Several pathologies lead directly or indirectly to morphological and functional modifications of the LA. AIM:   Investigate the effect of arterial hypertension on LA size and function. METHODS:   Prospective study including 50 hypertensive patients compared to 50 healthy controls. LA Volumes were measured using transthoracic echocardiography by biplane Simpson  method  at different times of cardiac cycle: at the end of systole (maximum LA volume (Vmax)), at mitral valve  closure (minimum LA volume (Vmin)) and immediately before LA contraction (Vp)). LA reservoir function (total emptying volume and expansion index), conduct function (passive emptying volume and passive emptying fraction) and pumping function (active emptying volume and active emptying fraction) have been calculated. RESULTS:   Hypertension was associated with an increase of all LA volumes: Vmax (p<0.001),  Vmin (p=0.001) and Vp (p<0.001). LA reservoir function evaluated by LA total emptying volume was higher in hypertensives than in control group (p=0.032). LA conduct function was impaired in hypertensive patients with a significantly lower passive emptying fraction in hypertensive group compared to control group (22 ± 12% versus 32 ± 11%, p <0.001, respectively). This decrease was greater in the presence of left ventricular hypertrophy (p = 0.02). LA pumping function was significantly higher in hypertensive patients than in controls with an increase of LA active emptying fraction (35±12% versus 30±12%respectively; p=0.037). The increase of LA pumping function was found to be higher in hypertensive patients with impaired diastolic function (p=0.029). CONCLUSION:   Hypertension was associated with an increase of pumping and reservoir functions and a decrease in left atrial passive emptying function. These changes appear to be related to left ventricular hypertrophy and the degree of left ventricular diastolic dysfunction.

Diagnostic characteristics of acute myocarditis.

BACKGROUND: Acute myocarditis is an inflammation of the heart muscle. Its unpredictable evolution justifies the importance of its early recognition. The clinical polymorphism associated with the lack of sensitivity of conventional diagnostic means make diagnosis a challenge for the clinician. However, the magnetic resonance imaging has been of great interest for the differential diagnosis as well as for the evolutionary follow-up of this pathology. AIM: Determine the clinical profile of acute myocarditis and the contribution of multimodal imaging in its diagnosis. METHODS: This was a descriptive, retrospective study, including 31 patients hospitalized for acute myocarditis at the cardiology department of the Internal Security Forces Hospital-La Marsa between 2011 and 2017. RESULTS: The mean age of our patients was 36.5 ± 13.3 years [17-63] with a clear male predominance (sex ratio = 6.75). Smoking was the most common cardiovascular risk factor (60%). Fifty percent of the population had only two cardiovascular risk factors. The most common clinical picture was acute chest pain (84%) preceded by influenza-like illness (53%). The electrocardiogram was pathological in 97% of cases. Hyperleukocytosis was objectified in 33% of cases. Elevation of C-reactive protein was present in 80% of cases. As for troponins, they were high in 94% of cases. Overall myocardial contractility was conserved in 84% of cases with segmental kinetic disorders in 45%. Cardiac magnetic resonance imaging showed pericardial effusion (10%), spontaneous myocardial hypersignal in triple-reversal-T2 recovery (42%) and which corresponded to the zones of late enhancement. Late contrast enhancement was predominant at the lateral wall (39%), with epicardial involvement occurring in 100% of cases.28 patients had a favorable outcome after a follow-up of 24 months. However, there was only one case of death at 3 months and two cases that progressed to dilated cardiomyopathy. CONCLUSION: Acute myocarditis is mainly a disease of the young male subject. Cardiac magnetic resonance imaging is of crucial interest for positive diagnosis.

Design and Rationale of the National Tunisian Registry of Atrial Fibrillation: Protocol for a Prospective, Multicenter Trial.

BACKGROUND: Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiological pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiological profile and management of AF patients in Tunisia are limited. OBJECTIVE: The aim of this study is to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. METHODS: A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective of describing the epidemiological pattern of AF. Patients will be officially enrolled in the National Tunisian Registry of Atrial Fibrillation (NATURE-AF) only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point, and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. RESULTS: Results will be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. CONCLUSIONS: This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. TRIAL REGISTRATION: ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX). REGISTERED REPORT IDENTIFIER: RR1-10.2196/8523.

Valvular unvolvement in carcinoid disease. a case report.

Carcinoid tumors are rare, mainly located in the gastrointestinal tract particularly in the small intestine. Cardiac involvement, fairly frequent and usually affecting right sided heart valves, had a poor prognosis that is improved by an earlier detection and valve surgery. We report the case of a 50-years old woman with neuroendocrine tumor and liver metastases, in whom carcinoid involvement of the right heart was diagnosed following exertional dyspnea. She had dilated right cavities, severe tricuspid regurgitation, mild tricuspid stenosis and a moderate pulmonary stenosis. She underwent a double valve replacement by bioprosthesis with improvement of symptoms and recovery of normal right cavities size.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Can CS gas induce myocardial infarction?

"2-chlorobenzylidene malononitrile" also named CS gas is the most used riot-control agent in the world. Its reputation as the least toxic tear gas explains its large use by different authorities. Early exposure to CS spray commonly induces visual irritation, skin reactions, with increased mucous secretion in order to temporarily incapacitate targeted people. However, there is a large agreement that safety data of this product is limited and further studies need to be performed since serious problems could occur after heavy exposure such as loss of consciousness, laryngospasm, pulmonary edema and hemorrhage... Herein, we report a case of a young man who had acute myocardial infarction with serious cardiac sequelae after exposure to tear gas. To our knowledge, this is the second case since forty years in the literature that directly links documented acute heart infarction to CS gas exposure.

Impact of obstructive sleep apnea on the right ventricle.

BACKGROUND: Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI). METHODS: Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI<5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h. RESULTS: There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p<0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH. CONCLUSIONS: In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

Can CS gas induce myocardial infarction?

"2-chlorobenzylidene malononitrile" also named CS gas is the most used riot-control agent in the world. Its reputation as the least toxic tear gas explains its large use by different authorities. Early exposure to CS spray commonly induces visual irritation, skin reactions, with increased mucous secretion in order to temporarily incapacitate targeted people. However, there is a large agreement that safety data of this product is limited and further studies need to be performed since serious problems could occur after heavy exposure such as loss of consciousness, laryngospasm, pulmonary edema and hemorrhage... Herein, we report a case of a young man who had acute myocardial infarction with serious cardiac sequelae after exposure to tear gas. To our knowledge, this is the second case since forty years in the literature that directly links documented acute heart infarction to CS gas exposure.

[Evaluation of left ventricular function by systolic time intervals]. / Apport des intervalle de temps systoliques dans l'évaluation de la function ventriculaire gauche: etude bicentrique.

BACKGROUND: Evaluation of left ventricular systolic function, usually based on the assessment of the ejection fraction, is increasingly supplemented by other more sophisticated techniques such as 3D echocardiography and speckle tracking. However these methods require a high technicity and a good echogenicity. As heart failure leads to lengthening of aortic pre-ejectional time (PET) and shortening of left ventricular ejection time (ET), systolic time intervals (STI) were proposed for the evaluation of systolic myocardial performance. AIM: to establish a correlation between left ventricular ejection fraction (LVEF) and STI and determine a cut-off value of PET/ET ratio to diagnose a LVEF inferior to 35%. METHODS: 109 consecutive patients referred to two echocardiographic laboratories had measurements of STI and LVEF estimated by Simpson biplane method. Patients included were in sinus rhythm with a heart rate<100 beats per minute. Patients with atrial fibrillation, pacemaker or prosthetic valves were excluded. RESULTS: Feasibility of STI measurements was 100%. A significant negative correlation between PET and LVEF was found (r=-0.49, p<0.0001). LVEF was also significantly correlated to ET (r=0.44, p<0.0001). PET/ET ratio was significantly correlated to LVEF (r=-0.63, p<0.0001). Receiver operating curve analyses revealed a cut-off value of PET/ET ratio of 0.33 to diagnose a LVEF<35% with a sensitivity of 85% and a specificity of 78%. CONCLUSION: STI, easy to obtain and useful in case of poor quality echographic window, are an interesting alternative to evaluate systolic left ventricular function and may be used to detect alteration of LVEF.

[Cardiac amyloidosis]. / Amylose cardiaque.

UNLABELLED: PREREQUIS: Amyloidosis is a rare infiltrative disease characterized by multiple clinical features. Various organs are involved and the cardiovascular system is a common target of amyloidosis. Cardiac involvement may occur with or without clinical manifestations and is considered as a major prognostic factor. AIM: To analyze the clinical features of cardiac involvement, to review actual knowledgement concerning echocardiographic diagnostic and to evaluate recent advances in treatment of the disease. METHODS: An electronic search of the relevant literature was carried out using Medline and Pubmed. Keys words used for the final search were amyloidosis, cardiopathy and echocardiography. We considered for analysis reviews, studies and articles between 1990 and 2007. RESULTS: Amyloidosis represents 5 to 10% of non ischemic cardiomyoparhies. Cardiac involvement is the first cause of restrictive cardiomyopathy witch must be evoked in front of every inexplained cardiopathy after the age of forty. The amyloid nature of cardiopathy is suggered if some manifestations were associated as a peripheric neuropathy, a carpal tunnel sydrome and proteinuria > 3g/day. Echocardiography shows dilated atria, a granular sparkling appearance of myocardium, diastolic dysfunction and thickened left ventricle contrasting with a low electric voltage. The proof of amyloidosis is brought by an extra-cardiac biopsy, the indications of endomyocardial biopsy are very limited. The identification of the amyloid nature of cardiopathy has an direct therapeutic implication: it indicates the use of digitalis, calcium channel blockers and beta-blockers. Today the treatment of amyloidosis remains very unsatisfactory especially in the cardiac involvement. An early diagnosis before the cardiac damage may facilitate therapy and improve prognosis.