Incidence and treatment of congenital coronary artery anomalies.

BACKGROUND: Congenital coronary arteries anomalies are a rare entity. Although their identification started in the 60th, there is a lack of data concerning their frequency and clinical significance in Tunisia. AIM: To characterize clinical and imaging features and mid-term follow up data of congenital coronary artery anomalies in a population of Tunisian adults. METHODS: We reviewed the records of 6358 adult patients who underwent coronary angiography between 2009-2015 years in Mongi Slim hospital La Marsa, Tunisia. Multidetector computed tomography was performed on all patients diagnosed having these anomalies and Angelini classification was used for their arrangement. Patients, having intramural coronary artery, were excluded from this study. RESULTS: Thirteen patients had congenital coronary arteries anomalies (seven females and six males). Ten had anomalies of origination and course while the others had anomalies of coronary termination. The right coronary artery was the vessel involved most frequently. It originated from an anomalous coronary ostium in four patients and a unique right coronary artery was reported in one case. An anomalous left main coronary artery was seen in four cases. One patient had the left anterior descending artery originating from the right Valsalva sinus. Four patients underwent coronary revascularization, one died before the intervention and the remainder received medical management. The mean follow up was 54.1±20 months. CONCLUSION: Congenital coronary arteries anomalies have a low incidence in adults. Coronary revascularization is actually indicated in anomalous aortic origin with inter aorto-pulmonary course.

Management of patients with acute ST-elevation myocardial infarction: Results of the FAST-MI Tunisia Registry.

BACKGROUND: The FAST-MI Tunisia registry was set up by the Tunisian Society of Cardiology and Cardiovascular Surgery to assess the demographic and clinical characteristics, management and hospital outcome of patients with ST-elevation myocardial infarction (STEMI). METHODS: Data for 459 consecutive patients (mean age 60.8 years; 88.5% male) with STEMI, treated in 16 public hospitals (representing 72.2% of public hospitals in Tunisia treating STEMI patients), were collected prospectively.The most common risk factors were smoking (63.6%), hypertension (39.7%), diabetes (32%) and dyslipidaemia (18.2%). RESULTS: Among the 459 patients, 61.8% received reperfusion therapy: 30% with primary percutaneous coronary intervention (PPCI) and 31.8% with intravenous fibrinolysis (IF) (28.6% with pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 min and to PPCI was 358 min. In-hospital mortality was 5.3%. Compared with those managed at regional hospitals, patients managed at interventional university hospitals (n = 357) were more likely to receive reperfusion therapy (52.9% vs. 34.1%; p<0.001), with less IF (28.6% vs. 43.1%; p = 0.002) but more PPCI (37.8% vs. 3.9%; p<0.0001). However, in-hospital mortality in the two types of hospitals was similar (5.3% vs. 5.1%; p = 0.866). CONCLUSIONS: Data from the FAST-MI Tunisia registry show that a pharmaco-invasive strategy of management for STEMI should be promoted in non-interventional regional hospitals.

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.

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.

[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.

[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.

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.

[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.

[Sudden cardiac death of rhythmic origin in athletes: literature review]. / La mort subite d'origine rythmique chez le sportif: revue de la littérature.

The sudden death in athletes is, in the vast majority of cases, related to ventricular fibrillation, often in a subject with unknown cardiovascular abnormality; this dramatic event has a significant impact on society and the medical profession. We conducted through a literature review an analysis of data on sudden cardiac death of rhythmic origin in athletes; sudden death may be cardiovascular in 95.3% of cases and related to ventricular arrhythmia in 88% cases. The main causes are: hypertrophic cardiomyopathy, congenital anomalies of coronary arteries, and arhythmogenic right ventricular dysplasia for athletes under 35 years, and atherosclerosis beyond 35 years. Prevention is based on three main areas: the medical assessment and screening for cardiovascular disease; the chain of survival; the education of the athlete and the public. All these measures should improve significantly the survival prognosis of patients suffering from these accidents.

Echocardiographic marker for bland-white-garland syndrome in adult.

Bland-White-Garland syndrome, also known anomalous origin of the left main coronary artery, is a rare congenital malformation. The authors report the case of a 51-year-old woman with anomalous origin of the left main coronary artery from the pulmonary artery. A prominent large ostium of the right coronary artery and intercoronary "steal" collaterals should raise suspicion for this pathology and subsequently guide a step-by-step echocardiographic approach to identify the left main coronary artery from the pulmonary artery.

[Chronic atrial fibrillation in adults: direct current cardioversion or medical cardioversion]. / La fibrillation auriculaire chronique de l'adulte : cardioversion electrique ou medicamenteuse.

To study cardioversion modalities of atrial fibrillation, we had a look to 100 cases hospitalized in Mongi slim cardiologic department during the period lasting from January 1993 to July 2001. Medical cardioversion (with amiodarone) was performed in 47 patients and electrical cardioversion in 53 patients. Atrial fibrillation was 17 months old. Vavular heart disease was the main etiology (65%). The primary success rate of medical cardioversion (73%) was equivalent to electrical cardioversion (70%). Oldness of atrial fibrillation was the only predictive factor of failure of cardioversion.

[A rare cause of myocardial infarction: carbon monoxide intoxication]. / Une cause rare d'infarctus du myocarde: l'intoxication au monoxyde carbone.

We describe a 34-year-old man who suffered an acute myocardial infarction after carbon monoxide domestic exposure. The coronary angiogram was normal. The necrosis is explained in part by a severe coronary spasm. The purpose of this work was to assess the pathophysiology and the treatment of this rare cause of myocardial infarction.