[Management of cardiac arrhythmias during pregnancy]. / La prise en charge thérapeutique des troubles du rythme cardiaque au cours de la grossesse.

INTRODUCTION: Pregnancy can precipitate or exacerbate cardiac arrhythmias. Management of those arrhythmias is not very different from that in non-pregnant women. OBJECTIVE: In this review we tried to specify factors which favour arrhythmias in pregnant women and to show their specific management. METHODS: We carried out a search through PubMed using as keywords: pregnancy, cardiac arrhythmias, antiarrhythmics. RESULTS: Hemodynamic perturbations, direct electrophysiological effects of hormones and underlying heart disease are potential factors that can promote arrhythmias in pregnancy. Usually, no drug therapy is needed for the management of supraventricular or ventricular premature beats but potential promoting factors should be eliminated. In paroxysmal supraventricular tachycardia, vagal maneuvers should be tried firstly. Adenosine could be used if vagal maneuvers are ineffective. In pregnant women with atrial fibrillation, the goal of treatment is the conversion to sinus rhythm or the control of ventricular rate. Ventricular arrhythmias are usually uncommon during pregnancy and often occur in the absence of structural heart disease and are responsive to drug therapy. Symptomatic bradycardia rarely complicates pregnancy and its management does not differ from that in non-pregnant women.

[Thyroid ectopic tumour in the right ventricle of the heart]. / Tumeur thyroïdienne ectopique dans le ventricule droit du cœur.

The intracardiac ectopic thyroid tumour is rare. We report the case of a woman who was admitted for exertional dyspnea. The echocardiography revealed an obstructive tumor in the right ventricular outflow tract. Histological examination of the removed tumour showed the ectopic follicular thyroid tissue.

[Tricuspid dysfunction as a result of rheumatic disease]. / Atteinte tricuspide au cours de la maladie rhumatismale.

BACKGROUND: Rheumatic tricuspid valve dysfunction is the rarest of all valvular disease and is often associated or secondary to left-sided valvular disease. She often realize tricuspid regurgitation. The surgical treatment is generally conservative but also it can be radical generally using bioprotheses. AIM: to assess the epidemiology of the rheumatic tricuspid dysfunction, the average diagnoses and its therapeutic. To evaluate the results of the surgical techniques, the factors of prognosis and to determine the therapeutic regarding an in front of important and symptomatic residual tricuspid regurgitation a long time after a valvular surgery first of the left heart. METHODS: A retrospective, single center of 84 consecutive patients having one significant tricuspid dysfunction regurgitation and/or significant stenosis of rheumatic origin. Hospitalized and followed between January 1992 and March 2008 in cardiology to the hospital Habib Thameur. RESULTS: The prevalence of the rheumatic tricuspid dysfunction was 8.42%. 70% of the patients had a tricuspid regurgitation. The average Age of our patients was 40 years. Our population consisted of 65.5% women. 21% of the patients had benefited at least from a percutaneous mitral dilation. 31% of the patients had antecedents of valvular cardiac surgery. 53% of the patients presented clinical signs of preoperative right cardiac failure and 58% of the patients were in permanent auricular fibrillation. The tricuspid regurgitation was major at 12% of the patients, severe at 88% of the patients, organics at 21% of the patients and functional at 31% of the patients. The average of the systolic pulmonary blood pressure was with 55+-16.8 mm Hg. All the patients had an associated left valvulopathy. The average of the ejection fraction of the left ventricle was 56+12.6%. The dilation of the right cavities was noted at 70% of the patients. The patients of our series were subdivided in two distinct groups. The first group gathers 30 patients who were operated of tricuspid in same operational time as the surgery of the left valves. The surgical gesture on the tricuspid was always conservative. 70% of the patients profited from a tricuspid annuloplasty. Hospital mortality is 10%. 26% of the patients presented a significant residual tricuspid regurgitation after 60 months. 26% of the patients presented late cardiac failure. Late mortality was from 30% to 5 years and 43% to 10 years. The second group is represented by 54 patients not operated on the tricuspid. 30 patients (81%) presented one or more episodes of late cardiac failure. 50% of the patients died during the late follow-up. Among operated patients of the tricuspid, the predictive factors of the residual tricuspid regurgitation post operational are the age<35 years and the mitral disease. The stage NYHA=4 was the only predictive factor of hospital mortality. The predictive factors of late right congestive heart failure postoperative are the clinical signs of preoperative right heart failure and the antecedents of mitral replacement. The predictive factors of late total congestive heart failure postoperative l are the functional tricuspid regurgitation and stage 4 of the NYHA. CONCLUSION: The benefit of a systematic initial correction of a voluminous tricuspid regurgitation and even of average importance realized prematurely in same operation time that the left valvular gesture was largely shown. The late appearance of functional tricuspid regurgitation after mitral valve surgery is a pejorative marker in the evolution of these patients.

[Catecholaminergic polymorphic ventricular tachycardia in adult: a case report]. / La Tachycardie Ventriculaire Polymorphe Catécholergique Chez L'adulte : A Propos D'un Cas.

BACKGROUND: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a primary electrical myocardial disease characterized by exercise- and stress-related ventricular lachycardia manifested as syncope and sudden death usually in child and teenager and was rarely described in adults. The management includes betablockade, with the use of implantable cardioverter defibrillators if medical treatment is insufficient. AIM: Report a new case of CPVT. OBSERVATION: We report a case of a 43 years old patient in whom CPVT diagnosis was made during his exploration for palpitations occurring with the effort. Registration Holter ECG revealed several episodes of supraventricular tachycardia and episodes of nocturnal sino-atrial block. The patient had an ICD and betablockade treatment. CONCLUSION: The TVPC in adult can manifest with attenuated symptoms that can be summarized with palpitations with the exertion. The supraventricular arrhythmias and sinus dysfunction may be at the forefront of Electrocardiographic manifestations. The prognosis of this form seems better than the TVPC of the child. Treatment with betablockade appears to be effective but existing dysfunction sinus facilitates decision to implant the ICD.

[Acute hemorrhage due anti-vitamin K agents. A prognostic and descriptive study]. / Les accidents hemorragiques graves sous anti-vitamines K. Etude descriptive et pronostique.

BACKGROUND: The use of the antivitamines K for more than 50 years, has largely been the proof of its interest: well shown effectiveness, weak cost. However, these drugs are the cause of complications of which most frequent and most serious are the hemorrhagic accidents. AIM: To determine the characteristics of the patients hospitalized for grave bleeding under antivitamins K and identify the predictive factors of these accidents. METHODS: Retrospective study of pilot case type carried out in the service of cardiology of the hospital Habib Thameur of Tunis during the period going from January 2001 to December 2006. It related to a group of 50 patients admitted for "serious haemorrhage under antivitamines K". This group was compared with a reference group including/understanding 100 patients treated by antivitamines K and not having never presented a haemorrhage. The reserved criteria of gravity are the following ones: the location: intracérébrale, rétro péritonéale, articular, intra-ocular with blindness, muscular, subcutaneous if the nasty bruise is voluminous, hematurie, metrorragie, digestive bleeding (high or low), hemoptysie, hemothorax, hemopéricarde; the deglobulisation (fall of the haemoglobin of 2 g/dl or more) requiring or not a transfusion; the necessity of a surgical haemostatic gesture or endoscopique; the transfer in care unit or death. RESULTS: The Middle Age of the patients was of 55 +/- 14 years, the sex ratio was of 0.85. The intermediate duration of the treatment was of 243 +/- 225 weeks. The most frequent indications were the disorder of the supra-ventricular rate/rhythm (72%) and the mechanical valves cardiac (40%). These indications appeared debatable to us at 16% of the patients. One or more supporting factors the hemorrhagic accident were found at half of the patients, the first cause being medicamentous association (20% of the cases). The hématurie was the most frequent complication (28%). The evolution was favorable in all the cases. An internal injury under unclaimed ignored was found at 24% of the patients. The hepatic dysfonction and medicamentous association were in our study of the risk factors of which has occurred of haemorrhage under antivitamines K. In multivariate analysis, medicamentous association was an independent risk factor (Odds ratio adjusted 4.9). CONCLUSION: At least 50% of the hemorrhagic accidents under antivitamines K are avoidable with the help of a rigorous evaluation of the benefit ratio/risk and a vigilance with respect to medicamentous associations. The creation of centers of anticoagulation in our country is essential in order to improve quality of the clinical and biological monitoring.

[Conductive disorders following open-heart valvular surgery. Concerning 230 operated patients]. / Les troubles conductifs après chirurgie cardiaque valvulaire sous circulation extracorporelle. A propos de 230 malades opérés.

AIMS: Conductive disorders following open-heart valvular surgery represent serious complications that may require definitive pacemaker implantation. The natural history of these troubles is not well established thus, controversy persist concerning the timing of pacemaker implantation. In this study we identify the predictive factors of permanent conductive disorders in order to assess the optimal time of pacing. METHODS AND RESULTS: Two hundred thirty valvular replacements were done between 1993 and 2003. The mean age of our patients was 42 +/- 13.4 years. Rheumatic valvulopathies accounted for 76% of cases, with 54% of multiple valvulopathies. Twenty-two patients (9,5%) had an early postoperative conductive disorder, 9 of them (4%) were definitively implanted after a mean delay of 31.8 days. Preoperative bifascicular bloc and early installation of postoperative high-grade conduction disturbances and its persistence for more than 48 hours are significantly associated with permanent postoperative conductive disorders (respectively P = 0.04 and = 0.03). Aortic valve surgery and infective endocarditis were more frequent in the implanted group but the difference was not significant. CONCLUSION: After open-heart valvular surgery; predictive factors of definitive conductive troubles justify an earlier pacemaker implantation. This attitude may accelerate the hospital discharge and decrease the disease cost effectiveness.

[Behcet disease: uncommon cause of myocardial infarction]. / Maladie de Behçet: cause rare d'inarctus du myocarde.

A 25-year-old man who was known to have Behçet's syndrome and who has no coronary risk factors suffered an acute anterior wall myocardial infarction which was complicated by a ventricular fibrillation. The diagnosis of Behçet's syndrome was based on recurrent thrombophlebitis, genital and oral aphtoses, posterior uveitis, positive pathergy test and HLAB51. About 20 cases of myocardial infarction were reported in the literature but the etiopathogeny, the causal relationship and the treatment are yet unknown.

[Prognostic significance of second and third degree atrioventricular block in acute inferior wall myocardial infarction]. / Valeur pronostique du bloc auriculoventriculaire du deuxième et du troisième degré au cours de la phase aiguë de l'infarctus du myocarde inférieur.

High degree atrioventricular block complicates inferior wall acute myocardial infarction in 10 to 15% of cases. Its significance is still controversial. In this study, we have analysed 152 observations of acute inferior wall myocardial infarction during hospitalisation period. The mean age of our patients is 60 years, 48.7% of them have received fibrinolytic treatment. Second or third degree atrioventricular block was detected in 33 cases (21.7%). Mortality is higher in inferior wall myocardial infarctions with atrioventricular block than in those without atrioventricular block (12% versus 2.5%, p < 0.05). Hemodynamic complications like cardiogenic shock due to the extension of the infarction to the right ventricle and left ventricle insufficiency are more frequent (18% versus 3.4%, p < 0.01 and 12% versus 3.5%, p < 0.01 respectively). It appears that the infracted mass of myocardium is larger in case of atrioventricular block, this is assessed by comparing the average value of the peak of creatine Kinase in the two groups with and without atrioventricular block (1534 IU versus 1096 IU, p < 0.02) and by considering the rate of low ejection fraction (EF < 40%) in each group (44.6% versus 16%, p < 0.01). In our study, we note that thrombolysis does not affect the incidence of atrioventricular block (19% and 24% in thrombolyed and not thrombolyzed patients respectively) but it seems that thrombolysis improves the outcome of these patients. The occurrence of atrioventricular block in acute inferior wall myocardial infarction is related to the presence of an important right coronary artery that is occluded, the recanalisation of this vessel leads often to rapid regression of the block that is no longer pejorative.

[Permanent ventricular tachycardia: prognostic and therapeutic problems: three case reports]. / Les tachycardies ventriculaires incessantes: problèmes pronostiques et thérapeutiques: a propos de trois observations.

The permanent ventricular tachycardia (PVT) represent a rare and dangerous arrhythmia that causes prognostic and therapeutic difficulties. Three patients admitted during last year for PVT complicating ischemic cardiomyopathy in two cases and idiopathic cardiomyopathy in the last case. These patients were admitted from emergency department for sustained monomorphic ventricular tachycardia. The ECG showed wide QRS tachycardia of ventricular origin. The direct current shock (DCS) has revealed ECG criteria of old myocardial infarction in two cases. The transthoracic echocardiography displayed dilated left ventricule (LV) with 35% mean ejection fraction. It also showed the presence of LV aneurysm in one case. The cardiac catheterization showed proximal left anterior descending artery obstruction in one patient and left circomflex artery stenosis in other patient. There was no indication of revascularization because of the age of myocardial infarction. The follow-up of these patients demonstrated the persistence of the VT for at least 6 days with recurrence after the DCS and resistant to Lidocaïne-Amiodarone association. The sinus rhythm was established by the propranolol-Amiodarone in one patient, Amiodarone added to treatment of congestive heart failure for the patient with ventricular aneurysm. The third patient died after one week of PVT complicated by cardiogenic shock just before a trial of radiofrequency ablation (RFA). We concluded through these cases that PVT is a troublesome arrhythmia for more than one reason. It appears of tewly in patients with advanced cardiomyopathy worsening the hemodynamic conditions oftenly the pharmacological treatment is mostly always difficult. The treatment of choice is RFA for those resistant to medical treatment.

[Correlation between aortic atherosclerosis at transesophageal echocardiography and coronary atherosclerosis]. / Corrélations entre l'athérosclérose aortique à l'échocardiographie transoesophagienne et l'athérosclérose coronaire.

The aim of this study was to test the relationship between atherosclerotic plaques in the thoracic aorta detected by transesophageal echocardiography and coronary artery disease detected by angiography. A prospective study was carried out in 103 patients who underwent coronary angiography. All patients underwent transesophageal echocardiography with imaging of the thoracic aorta. Aortic intimal changes were classified in 4 grades. The detection of aortic atheroma plaques was the strongest predictor of coronary artery disease. The presence of aortic plaques on transesophageal study had a sensitivity of 97.6% and a specificity of 80% for angiographically proved obstructive coronary artery disease. The positive predictive value of aortic plaque for obstructive coronary artery disease was 95.3% and the negative predictive value was 88.9%. Compared to the other segments, the detection of atherosclerotic plaque in the descending aorta has the highest sensitivity but the specificity was the highest in the ascending aorta. With older age and in women the specificity decreased, while the sensitivity increased.

[Assessment of pure isolated mitral valve insufficiency by Doppler echocardiography]. / Quantification des insuffisances mitrales pures isolees par l'echodoppler cardiaque.

Taking 33 patients having pure MI as a material, the authors find a correlation between regurgitation fraction obtained by calculation of outputs estimated by Touch's method and angiographic values. There is a statistically significant differences (P < 0.001) between regurgitation fraction of grade I to II and grade II to III MI. The ratio mitral integral time velocity (ITV) to Aortic (ITV) is an important semi-quantitative assessment of pure MI. In fact, a ratio > 1.3 identify important degree of MI with 82% sensitivity and 93% specificity. The authors estimate that there is a correlation between the ratio of regurgitant jet surface to left atrial surface found in TEE and their degree of MI in angiography with a significant difference (P < 0.001) between the ratio of grade I to II and grade II to III MI in angiography. A ratio higher than 40% allow to identify grade III MI at minimum.

[Mitral stenosis secondary to Hurler's syndrome]. / Rétrécissement mitral secondaire à un syndrome de Hurler.

Valvular disease in mucopolysaccharidosis type I-Hurler (MPS/1H) is relatively common, but mitral stenosis is very rare in this genetic abnormality. The authors describe the case of a 16-year old girl with Hurler's syndrome diagnosed at 4 years of age. The morphological features were characteristic: bridged nose, thickened lips, macroglassia, short neck (gargoylism, short, thick fingers and limitation of brachial and fore-arm flexion. She presented with stage II dyspnoea and paroxysmal nocturnal dyspnoea. Radiological and echocardiographic studies revealed severe mitral stenosis with haemodynamic complications requiring mitral valve replacement. Anatomopathological analysis of the mitral valve confirmed mucopolysaccharide deposits as the cause of this particular case of mitral stenosis.

[Indications for definitive cardiac stimulation]. / Indications de la stimulation cardiaque definitive.

Within less than a half-century, after the early rising of cardiac pacing, we witness a dramatical in crease of its indications. After the initial aim, which was to prevent transient ischaemic events, and sudden death due to bradycardia, some more physiological objectives have--progressively appeared, such as improvement of patient's quality of life, and optimization of the cardiac performance to fulfill the metabolic needs. The indications of cardiac pacing are nowadays extended to the fields of haemodynamics and rythmology. Numerous studies are advocating the interest of the cardiac pacing in pathologies such as obstructive and dilated cardiomyopathies specially for the improvement of the NYHA functional status, life comfort and effort sustain. On another hand, newly discovered antiarrhythmic virtues of atrial pacing are of a great interest for a certain type of atrial fibrillations such as vagal induced fibrillations, atrial diseases and atypical flutters. For conclusion: after becoming mandatory for bradycardias, cardiac pacing is conquering new indications on the fields of arrhythmias and cardiomyopathies. Within a close future, scientific evidences could definitely validate çardiac pacing using on these new fields.

[Atrial fibrillation]. / Fibrillation auriculaire.

The aim of transesophageal echocardiography (TOE) in atrial fibrillation milieu is to search a cardiac chamber thrombus. In order to establish the indications of TOE and to raise new issues for the echographic prognosis of maintain of sinus rhythm, 40 patients with atrial fibrillation who underwent cardioversion were prospectively screened. All patients had transthoracic and transesophageal echocardiography before procedure to control the absence or disappearing of atrial thrombus (N = 7). All 40 patients underwent a successful cardioversion. Follow-up was done after one, three and six months for both success group (N = 28) and refibrillation group (N = 12). Our study provides evidence that the only predictive echographic factor of maintain of a good result (sinus rhythm) after cardioversion was a systolic velocity peak > 0.25 metir/sec.

[Endocavitary implantation of a permanent pacemaker in the contralateral side of right pneumonectomy: a case report]. / Implantation endocavitaire d'un stimulateur cardiaque définitif du côté controlatéral à une pneumonectomie droite: à propos d'une observation.

The definitive endocardial stimulation is easy to install, allows a stable position of the leads, and a satisfactory stimulation thresholds for a long period. The epicardial approach is reserved for some rare indications including infectious contexts. The endocardial approach has been considered for a 67 years man with a complete AV block and an atrial fibrillation. This patient had undergone a right pneumonectomy 15 years before. A VVIR pacemaker has been implanted successfully by an internal jugular vein approach, and connected to a passively fixed unipolar lead. Because of the right ventricle deformation which made it unrecognizable, even by angiography means, we had to face major difficulties to position the lead. The epicardial approach should be considered even if a direct unique lung controlateral approach is easier than homolateral, because it allows us a quick ventricular access under the view control.

[Place of definitive cardiac stimulation in cardiomyopathies and atrial arrhythmia]. / Place de la stimulation cardiaque definitive au cours des cardiomyopathies et des arythmies atriales.

Definitive cardiac stimulation ralatually used for brady cardia are going to be in the third millennium the specific therapy of arrhythmia and cardiomyopathy. In the last 10 years, may progress occur in the use of cardiac stimulation as hemodynamic therapy of obstructions hypertrophic and dilated cardiomyopathies resistant to conventional medical treatment. Moreover auricular stimulation present antiarrhythmic effects in some atrial arrhythmias as auricular fibrillations auricular diseases and atypical flutters. It confirmed by prospective multicentric randomized trials cardiac stimulation may represent in the future a good physiopathologic and efficient treatment free from the side effects of drugs that remain partially active. These perspectives needs to be modulated by the known and acceptable risks of a definitive cardiac stimulation.

[Infectious enterococcal endocarditis associated with Laubry and Pezzi syndrome]. / Endocardite infectieuse a enterocoque sur syndrome de Laubry et Pezzi.

Laubry and Pezzi syndrome is a rare but serious complication of ventricular septal defect that increase the infectious endocarditis risk. Authors report a case of an 18 years old young girl presenting an enterococcus infectious endocarditis associated to Laubry and Pezzi syndrome. Initial course is not favourable requiring a surgical treatment in the acute stage. Bacterial endocarditis combined with Laubry and Pezzi syndrome have a poor prognosis needing observation and strict preventive precautions when a favoring factor is present.

[Dilated cardiomyopathy secondary to acromegaly]. / Cardiomyopathie dilatée secondaire à une acromégalie.

In acromegaly, dilated cardiomyopathy is rare. Indeed, arterial hypertension, coronary artery disease and hypertrophic cardiomyopathy are more common. The authors report a case of a 42-years-old man with dyspnea (class III NYHA) and palpitations. The cardiac echography showed a dilated cardiomyopathy. The investigations revealed an acromegaly as an etiology. Diagnosis was based on patient morphotype, a high level of growth hormone (GH) and a pituitary adenoma detected by magnetic resonance imagery. This case is characterized by the absence of arterial hypertension and hypertrophic cardiomyopathy. The coronary angiography was normal. Consequently, in this particular case, dilated cardiomyopathy seems specific to acromegaly.

[Right mid-ventricular stenosis with intact interventricular septum]. / Sténose médio-ventriculaire droite avec septum interventriculaire intact.

Pure infundibular stenosis of the right ventricle is a rare congenital anomaly. Right midventricular stenosis with intact interventricular septum is even rarer. It consists of obstruction of the trabecular zone of the right ventricle by a hypertrophied moderator band with or without abnormal muscle bundles. This anomaly can now be diagnosed by transthoracic echocardiography, while haemodynamic and angiographic diagnosis is reserved for doubtful cases. Two cases of midventricular stenosis are reported. In both patients, the diagnosis was suspected bu ultrasonography which showed a right intraventricular gradient of about 80 mmHg without identifying the exact site (infundibular or midventricular). The diagnosis was corrected by the operative findings. A good postoperative course was observed for both patients.