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New-onset AF atrial fibrillation (NOAF) frequently complicates acute coronary syndromes (ACS) leading to adverse outcomes in the short and long term. The prevalence of NOAF in patients hospitalized for ACS is variably reported and ranges between 2 and 37%. Several predictor factors have been implicated in the literature but remain a subject of controversy.To determine the prevalence of NOAF in a population of patients admitted for ACS and to identify its predictive factors.We carried out a prospective, descriptive and comparative observational study in hospitalized patients with ACS who did not have a previous diagnosis of AF.In our study, we included 404 patients hospitalized for ACS. The prevalence of NOAF was 10%. In the multivariate analytical study, we retained as independent predictors of NOAF: age greater than 62 years (p = 0.04; adjusted OR = 4.83; CI95%: 1.07-21.77), chronic renal failure (p = 0.043; adjusted OR = 6.61; CI95%: 1.06-35.80), history of stroke (p = 0.002; adjusted OR = 44.51; CI95%: 3.97- 498.10) and finally uricemia greater than or equal to 62 mg / l (p = 0.04; adjusted OR = 4.4; CI95%: 1.06-18.15).The prevalence of NOAF in patients with ACS was 10%. Its systematic screening in these patients appears to be a relevant approach because of the strong association between these two pathologies.

Patients with ferromagnetic cardiac devices, particularly cardiac implantable electronic devices (CIED) such as pacemakers or implantable cardioverter defibrillators, are often inappropriately deprived of magnetic resonance imaging (MRI) for safety reasons. This consensus document is written by a multidisciplinary working group involving rhythmologists, interventional cardiologists, echocardiographists and radiologists. Its objective is to establish good practice recommendations to optimize the management of patients with cardiac devices requiring MRI examination, while ensuring their safety and facilitating their access to MRI.

Silent strokes are damagesof brain not accompanied by symptoms suggestive of stroke. Currentepidemiological trends suggesttheirindependent association with atrial fibrillation (AF). However, this association is not yetwelldefined.To assess the prevalence of silent stroke in AF and determine itspredictivefactors.We carried out a cross-sectional study enrolling 37 patients followed for non-valvular AF in the cardiologydepartment. All participants had a clinicalevaluation and brain MRI.The mean age was 66 ± 7 yearswith asex ratio (M / F) of 0.76. The mostcommon class of AF was the persistent form (70%). Oral anticoagulant therapywasprescribedin 32 patients (94.1%). Silent strokewerereported in 9 patients (24.3%). Age ≥72 years and CHA2DS2VASc score ≥ 4 weresignificantlyassociatedwith silent strokes in the univariate study withsensitivities of 77.8% and 62.5% respectively and specificities of 78.6% and 92.3% respectively. In the multivariate study, only CHA2DS2VASc score ≥ 4 wasconsidered to be an independentpredictor of silent stroke in AF (p = 0.004; adjusted OR = 20; CI95%: 2.6-152.6).Our resultsregarding the association between silent strokesand AF confirmedpreviousevidence. Screening for theselesions in AF patients at high thromboembolicriskappears to be a relevant approachgiventheirpoorprognosis.

Obstructive Sleep Apnea Syndrome (OSAS) is a common but often under diagnosed condition that constitutes a real public health problem. The prevalence of OSAS in atrial fibrillation (AF) patients ranges from 32 to 85% according to recent studies.To determine the prevalence and severity of OSAS in a population followed for non-valvular AF (NVAF), and to identify OSAS's predictive factors in this population.A cross-sectional study was conducted, including successive patients followed for NVAF. Patients with a known history of OSAS were not included. All patients had a clinical screening for symptoms suggestive of OSAS and underwent an ambulatory sleep study.We included 100 patients in this study. OSAS was detected in 90% of NVAF patients. The average apnea-hypopnea index (AHI) was 21.6 ± 13.6 e/h. OSAS was mild in 32%, moderate in 27% and severe in 31% of cases. Clinical characteristics were comparable between patients with and without OSAS. The multivariate analytical study concluded that independent predictive factors of OSAS in AF patients were an age greater than 61 years (p=0.029), AF duration more than 2 years (p=0.04) and snoring (p=0.01).OSAS was diagnosed in 90% of NVAF patients. Thus, a systematic screening for OSAS in AF patients may be a relevant approach given its high prevalence in this population and its therapeutic implications. Snoring, age greater than 61 years, and AF duration more than 2 years were independently associated with OSAS in our study.

Cardiac arrest (CA) is a public health problem, with various etiologies and a fatal issue in 90-95% of cases. Toxin-induced cardiac arrests (TICA) are poorly described. Scarcity of national data prompted us to carry-out this study.To determine TICA frequency in a Tunisian reference center in toxicology and its hospital prognosis, and to describe its clinical and therapeutic aspects Methods : Data were collected retrospectively over an 8-years period. We included patients admitted for post-CA care with highly suspected or confirmed TICA. Clinical and toxicological data were recorded.We recorded 21 cases of TICA, which represented 48.8% of CA. A single toxic agent was incriminated in 90% of cases. Main causative agents identified in our series were pesticides and betablockers: chloralosed (n = 6), carbamate inhibitor of cholinesterase (n = 5), acebutolol (n = 4) and organophosphate (n = 2). One case of opiates and cocaine poisoning was reported. Median duration of "no flow" was 0 minutes. Mean duration of "low flow" was 13.74±9.15 minutes. An initial shockable rhythm was noted only in three patients. Mortality rate was 76% (16/21). Four of the five survivors had a Cerebral Performance Category Scale (CPC) 1, only one patient survived with a CPC 3. Factors associated with mortality were : the duration of "low flow" (p=0.02) and APACHE II score (p=0.014). APACHE II≥29 was the only independent factor (OR=2.0, 95%CI [1.07;3.71]).TICA were most frequently provoked by pesticides, mortality was high and was independently predicted by APACHE II score.

We report the case of a 23-year-old woman with a not yet described (to the best of our knowledge) association of left ventricle non-compaction with both atrial and ventricular defects. Family genetic survey concluded to, a probably sporadic, E101K gene mutation.

Nurses play a key role in cardiac arrest management, especially those assigned to cardiac intensive care units, where they are often actively involved in cardiopulmonary resuscitation.To evaluate the effect of simulation training in in continuing professional development of nurses in this setting.A comparative study using paired samples (where the candidate was his own control with repeated measures before and after intervention), was conducted among nurses working in the cardiology and cardiovascular surgery division of our institution. The primary endpoint was the change in skills judged on the basis of competency score of 20 assessed before and after simulation training.32 nurses participated in the training session. Despite a median job seniority of 8.5 years [4.0 - 12.5], only 44% of nurses had already participated in a simulation session. Although most of the candidates (84%) had previously performed chest compressions, only 34% had delivered an electrical defibrillation during their exercise. We showed a significant increase in overall scores from 8.0 [5.0 - 9.8] to 17.5 [17.0 - 19.0] after the simulation training session (p0.0001). All the criteria judged in the evaluation grid (basic life support, manual electrical defibrillation) were significantly improved and the most positive effect was observed in the manual defibrillation where the prior experience of the participants was limited.Simulation learning had a major positive impact on the development of nurses' skills in terms of cardiopulmonary resuscitation.

Strain has shown a promising diagnostic and prognostic value in acute coronary syndromes. With, however, less data in non-ST elevation myocardial infarction (NSEMI).to evaluate in NSTEMI patients, the ability of strain to predict the severity of the disease, by assessing correlations to established prognostic parameters, and to predict culprit and occluded coronary arteries (CA). Secondary, to determine factors associated to strain changes during follow-up.The study was prospective, NSTEMI patients with significant coronary lesion and without significant non-ischaemic disease were included. Angiographic and echocardiographic investigation including global (GLS) and territorial (TLS) longitudinal strain were performed within 24h from admission. Syntax I score was calculated. Severe coronary artery disease (CAD) was defined by left main of three-vessel disease.Seventy NSTEMI patients aged 60.2±10.1 years were enrolled; 61% were smokers, 54% diabetics and 46% hypertensive. 34% had a severe CAD, 7% had an acute coronary occlusion (ACO) and 14% a chronic coronary total occlusion (CTO). GLS-15.3% predicted a left ventricular ejection fraction (LVEF)50% with 80% Sensitivity (Se) and 78% Specificity (Sp). GLS was associated to CAD complexity and severity. GLS-14.1% detected severe CAD with 83% Se and 80%Sp. TLS determined the culprit artery in 74% of cases and TLS-9.2% predicted ACO with 85% Se and 85% Sp. TLS was also associated to CTO. At a 10 months median follow-up [3-12months], GLS significantly improved, baseline LVEF, GLS, wall motion score index and revascularization were the predictors of this improvement.In NSTEMI patients, GLS detected severe CAD and poor myocardial function. TLS predicted the culprit vessel and its occlusion. GLS improvement at midterm was predicted by baseline systolic LV function parameters and myocardial revascularization.

Non-traumatic chest pain is a common cause in pre hospital emergency medicine. The objective of our study was to identify predictive factors of STEMI in patients with acute chest pain, on telephone interview.We conducted a prospective observational study over a period of one year (december 2017 to november 2018) in the Emergency Care System of the North Est (SAMU 01) of Tunisia. We included all adults patients aged more than 18 years old, calling the emergency dispatch center for acute non traumatic chest pain (CP). The demographic and clinical data were collected and studied to identify the predictive factors for STEMI.We included 368 patients. The average age was 56 ± 15 years, the sex ratio was 2.7. Smoking was the most common cardiovascular risk factor (41%) followed by hypertension (31%) and coronary artery disease (20%). Half of calls were made by doctors and 43% of them were made within the first two hours of onset of the CP. Clinical examination showed cardio respiratory arrest in 10 patients, 6 of them were related to STEMI. On the arrival of our emergency mobile teams, an elevation of ST segment was identified in 118 patients (32%) of which 37% were admitted directly into the catheterization room. In multivariate analysis, the independent predictive factors of STEMI were: diabetes (OR = 5.25; CI [1.61 - 17.06]), smoking (OR = 2.78, CI [1.03 - 7.5]), typical CP (OR = 4.68, CI [1.09 - 21.67]), CP persistence of more than 30 min (OR = 63.31, CI [13.51 - 29.49]).History of diabetes, smoking, typical and persistent CP were the main factors associated with STEMI in patients calling the emergency dispatch center for an acute CP. The early identification of these factors by the emergency physician will improve the management of acute CP since the medical regulation.

Atrial septal defects (ASD) constitute the most frequent congenital heart disease in adults and ostium secundum (OS) the most common type. Benefit of its closure in adulthood has long been controversial.To evaluate outcomes of OS-ASD closure in adults.Retrospective cohort study, over a ten-year period from 2008 to 2018. All adults (≥20 years old) who benefited from OS-ASD closure were included. Study endpoints were closure success rate, functional status evolution and incidence of new arrhythmias at 12 months.Fifty patients were recruited. Dyspnea (≥ NYHA II) was noted in 58% and arrhythmia in 18% of patients. Feasibility of a percutaneous closure was 50%. Closure success rate was 100%. Surgery was associated with high postoperative morbidity with longer hospitalization stay (20 vs. 4 days, p0.001). At 12 months, an improvement in functional status was observed in 79%. Incidence of new arrhythmias was 5%. A significant decrease in right cavities dilation as well as pulmonary arterial pressure has been reported.Immediate results of OS-ASD closure in adults are satisfactory. Percutaneous closure is associated with reduced hospital morbidity. At 12 months, a significant improvement in functional status was observed however the possible occurrence of new arrhythmias imposes a close follow-up.

The acute ischemia of the lower limb on the veno-arterial Extracorporeal Membrane Oxygenation (ECMO) is a frequent and dangerous complication that can put the vital and functional prognosis at risk. Several risk factors have been incriminated and the lack of a sufficient distal perfusion is the most common. We report the case of an 11-year-old girl with veno-arterial ECMO for acute myocarditis complicated by severe acute lower limb ischemia.

Multiple arterial coronary artery bypass grafting is a controversial surgical procedure that is still uncommon worldwide. The aim of our study was to determine the outcomes and perioperative complications of the multiple arterial myocardial revascularization and their predictive factors, the mid-term and long term clinical and angiographic prognosis of the studied patients.This was a single center study of the cardiovascular department of The Rabta hospital. Patients included had serial multiple arterial coronary artery bypass grafting between January 2008 and December 2014. A statistical univariate and multivariate analysis had been conducted to identify complications and their predictive factors and a Kaplan-Meier study was done for the clinical and angiographic late outcomes.We included 322 patients mean aged 58 years, sex-ratio was 7.7 with a preserved left ventricle ejection fraction (LVEF) in 68.94% of cases. On-pump 1109 bypasses were made, among them 788 arterial grafts were used. Left internal thoracic artery (LIMA) was used in 100% of patients. Patency of the LIMA was 100%, 94.7%, 91.6% and 73.3% at 1, 3, 5 and 8 years respectively. RIMA (right internal thoracic artery) was used in 87.2% of patients, anastomosed to the left coronary system via the Theile sinus, anastomosed to the LIMA to make a Y shape configuration, or anastomosed in situ to the right coronary artery. Its patency was 98.3%, 86.2%, 68% and 57.9%. There was no significance between configuration patencies except the RIMA anastomosed to the lateral braches of the circumflex artery (p=0.003). Early mortality was 5.9 %, its main predictors were post operative intra aortic balloon pump (OR=22.18), re intervention for bleeding (OR=30.57), post operative myocardial infarction (OR=29.49), aortic clamping= 60 minutes (OR=10.89), post operative high level of catecholamine (OR=9.1) and mediastinitis (OR=7.15). Main early complications were pulmonary infection (20.2%), acute renal failure (5.3%) and mediastinitis (5%). Data of long term following could be collected only in 39.4% of cases. Major Adverse Cardiologic and Cerebral Events (MACCE) occurred in 30.71% controlled patients. Free-MACCE survival was 52.9% at 5. Initially total arterial bypass grafting was superior to other configurations in free-MACCE survival (p=0.036) but we lost significance beyond 5-years following because of selection bias.Multi arterial coronary artery bypass grafting was secure in early morbidity and mortality. Long term prognosis seemed to be better in case of total arterial revascularization.

Unprotected left main (LM) coronary artery disease (CAD) represents a challenging lesion with a major prognostic impact.Evaluate the clinical outcome and major adverse cardiac events (MACE) predictors of unprotected LM percutaneous coronary intervention (PCI) in an "all-comers" population.We performed a prospective observational study of patients with unprotected LM stenosis treated by PCI. MACE were defined as the composite endpoint of all-cause death, myocardial infarction and target lesion revascularization.From January 2012 to December 2017, 150 consecutive patients who underwent unprotected LM PCI were included. The mean age was 64±12 years and 75.3% were males. Diabetes was noted in 50.7%. Emergent revascularization was performed in 20.7% of cases, including 3.3% patients with cardiogenic shock. Distal LM was involved in 76.7% of cases. A majority of patients (94.0%) had low or intermediate SYNTAX Score I (≤32). The median SYNTAX score II was 31.1. Drug-eluting stents were used in 78.7% and bare metal stents in 21.3% of patients, mainly in emergent setting where the former were unavailable. In distal LM PCI, provisional approach was mostly used (81.7%). The median follow-up was 13.4 months. MACE occurred in 23.3% with an estimate of 37.9% at 5 years. Significant predictors of MACE were cardiogenic shock, bare metal stents use, previous PCI, and SYNTAX score II ≥30.Unprotected LM PCI presents encouraging short and long term outcomes. SYNTAX score II might represent a predictor for long-term outcome in this particular lesion subset.

The continuing increase in care, needs and costs in cardiology with the advances in percutaneous coronary intervention (PCI) techniques represent the ideal scenario for considering same-day discharge (SDD) PCI program.The primary endpoints were to examine feasibility and safety of SDD-PCI.We conducted a comparative observational study of a prospective cohort (April 2017 to September 2017) where patients benefited from SDD-PCI with a retrospective cohort (October 2016 to March 2017) where patients were conventionally managed. We established pre-procedural eligibility criteria and per and post-procedural exclusion criteria to estimate feasibility of SDD-PCI. Safety was assessed at 24 hours and 30 days comparatively in both groups.In the one-year study period, 709 PCI were performed. The eligibility for SDD-PCI was 17.2% (122 patients) and feasibility was 14.7% (104 patients). Ultimately, 50 out of 370 patients in the prospective cohort (SDD-group) and 54 out of 339 patients in the retrospective cohort (control-group) had or could have benefited from SDD-PCI. The transradial access was the most used (98.1%). 59.7% of treated lesions were B2 or C type, 53.8% interested the left anterior descending artery and 29.8% were bifurcations. In both groups, no complications were observed at 24 hours. At 30 days, one single non-fatal myocardial infarction related to subacute stent thrombosis occurred in the SDD-group and was attributed to antiplatelet therapy interruption.SDD-PCI is feasible and safe on the condition of strict stratification criteria of patients before judging their discharge the same day after PCI.

Cardiogenic shock complicating ST elevation myocardial infarction is burdened by a high mortality. There is only limited evidence for the management except for early revascularization and the relative ineffectiveness of intra-aortic balloon pump.Our objectives were to evaluate outcome and predictors of early all-cause 30-day mortality in the setting of cardiogenic shock complicating ST elevation myocardial infarction.From January 2009 to August 2018, all patients who presented within the first 48 hours of ST elevation myocardial infarction complicated by cardiogenic shock and receiving invasive management were prospectively included.The study cohort comprised 122 consecutive patients. The mean age was 65±12 years and 74.5% of patients were males. Left ventricular failure was the most common etiology of cardiogenic shock (72.1%) and mechanical complications occurred in 8.2% of cases. Percutaneous coronary interventions were proposed for all patients and performed in a primary setting in 72.1%. A high prevalence of no reflow was noted (15.6%). Multivessel coronary artery disease was noted in 64.8% and multivessel percutaneous coronary interventions at the index procedure were performed in 22.1% of cases. Intra-aortic balloon pump was used in 17.2% of patients. The 30-day mortality was 58.2%. The only predictor of early mortality was the immediate multivessel percutaneous coronary intervention (OR=4.1, 95%CI 1.1-14.5; p=0.031).Despite invasive management strategies, 30-day mortality of cardiogenic shock complicating ST elevation myocardial infarction remained as high as 58.2%. Immediate multivessel percutaneous coronary intervention was the only predictor of early mortality.

The effect of Ramadan fasting on anticoagulation by vitamin K antagonists has been previously investigated in small scale studies with controversial results. From this perspective, this study aimed to compare the fluctuations of anticoagulation in fasting and nonfasting patients taking Acenocoumarol and to identify the factors associated with such fluctuations.The study, conducted between May and August 2018, was a comparative one. Three study periods were defined: before Ramadan (BR), Ramadan and after Ramadan (AR). Enrolment involved ambulatory patients aged over eighteen, without medical contraindications to fasting (for the fasting group) and whom international normalized ratio (INR) was within the therapeutic target range during the last three months BR. Anticoagulation monitoring consisted in five consecutive INR assays; INR0 (during the 14 days BR), INR1 (between the 1st and the 14th day of Ramadan), INR2 (between the 15th and the 28th day of Ramadan), INR3 (28 days after INR2) and INR4 (28 days after INR3). INR stability was assessed by calculating four percentages of time in therapeutic range (TTR); TTR0 (between INR0 and INR1), TTR1 (between INR0 and INR2), TTR2 (between INR2 and INR3) and TTR3 (between INR3 and INR4). The null hypothesis was the occurrence of an anticoagulation imbalance (evaluated by TTR) in fasting patients in comparison with non-fasting ones.One hundred and twenty-two patients (84 fasting patients), aged 60 ± 19 years, were included. In fasting patients, the average differences of INR1, 2, 3 and 4 compared with INR0 were statistically non-significant and accounted for +0.46, +0.34, +0.28 and +0.30 respectively. Among the three TTRs, only TTR2 significantly decreased in comparison with TTR0 in fasting group (50.3 ± 37.4 vs. 63.6 ± 39.3%, p=0.004). TTR1, 2 and 3 were comparable between fasting and non-fasting patients.The fluctuations of anticoagulation balance, assessed by TTR, were comparable between fasting and non-fasting patients taking Acenocoumarol.

The quality of chronic anticoagulation and predictor factors of poor anticoagulant control in patients under acenocoumarol were unknown in North Africa.It is an observational study, carried out between November 2015 and November 30, 2016. The international normalized ratio (INR) values were prospectively obtained, and TTR was calculated using the Rosendaal method.Overall, 215 patients were included in this study, with a mean age of 63±0,8 years. The prevalence of poor anticoagulation control was 78.1%; 95% CI [72.2-83.2] (168 patients with TTR less than 65%). The median TTR with the Rosendaal method was 44.4%. After multivariate adjustment, variables significantly associated with adequate anticoagulation level were: history of ischemic stroke (Adjusted OR equal to 4.3, 95% CI: 1.4-12.9), associated prescription of antiplatelet therapy (Adjusted OR equal to 3.5, 95% CI: 1.1-11.2), daily prescribed dose of coumarins less than 6 mg (Adjusted OR equal to 6.4, 95% CI: 1.1- 36) and lower risk of bleeding assessed as HAS-BLED score (Adjusted OR: 0.5, 95% CI: 0.3-0.8).The quality of anticoagulation management with VKA among outpatients who received acenocoumarol was suboptimal. Strategies should be undertaken by clinicians and patients to improve the quality of anticoagulation, to address challenges to adverse cardiovascular outcomes in individuals treated with chronic anticoagulation.

This report describes a case of isthmus-dependent atrial flutter ablation by the femoral approach in a 54-year-old woman with a previously unknown absence of the inferior vena cava (IVC) and dual chamber pacemaker. Despite looping of the catheters, ablation and termination of atrial flutter were performed successfully without function alteration of the pacemaker leads. This is the first report of an inferior-to-superior approach for ablation of atrial flutter in the absence of the perihepatic IVC with the presence of chronic indwelling leads in the area targeted for radiofrequency.