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Spontaneous coronary artery dissection (SCAD) is a non-traumatic non-iatrogenic coronary dissection. It's a frequent cause of acute coronary syndrome (ACS) in women without or with few traditional cardiovascular risk factors. We report an unusual case of multivessel SCAD in a middle-aged woman with successful medical management. [ABSTRACT FROM AUTHOR]

La rigidité artérielle représente un facteur prédictif majeur de cardiopathie ischémique. Certaines études ont suggéré une corrélation entre la rigidité artérielle et la diffusion et la sévérité de la maladie coronaire chez les coronariens stables, cependant cette relation est moins bien établie au décours d'un syndrome coronarien aigu (SCA). Étudier la relation entre les paramètres de rigidité artérielle, et la sévérité de la maladie coronaire chez des patients admis pour un SCA de novo. Il s'agit d'une étude analytique portant sur 275 patients hospitalisés pour un SCA de novo. Les paramètres de la rigidité artérielle, ont été mesurés directement par la vitesse de l'onde de pouls carotidofémorale (VOPcf) et indirectement par la pression pulsée centrale (PPc) et l'index d'augmentation (Aix). La sévérité de la maladie coronaire à été évaluée par le nombre du tronc artériel épicardique atteint par une ou plusieurs sténoses dépassant 70 % de réduction du calibre de référence. L'âge moyen des patients était de 56,4 ± 10,6 ans avec une nette prédominance masculine (77,5 %). Cent quinze patients étaient diabétiques et 97 étaient hypertendus. Le motif de la coronarographie était principalement un infarctus du myocarde avec sus-décalage du segment ST (IDM ST (+)) chez 150 patients (54,5 %) et un infarctus du myocarde sans sus-décalage du segment ST (IDM ST (−))chez 103 patients (37,5 %). Le statut monotronculaire était identifié chez 36 % des cas et une atteinte multitronculaire était retrouvée chez 131 patients (47,6 %). L'analyse multivariée à montré une corrélation positive statistiquement significative entre la VOPcf et le nombre de tronc coronaire atteint (B = 0,081 ; IC 95 % [0,019 ; 0,142] ; p = 0,010). Cette relation n'a pas été objectivée avec la PPc (B = −0,001 ; IC 95 % [−0,203 ; 0,020] ; p = 0,891) et avec l'Aix (B = −0,002 ; IC 95 % [−0,025 ; 0,021] ; p = 0,872). Par ailleurs, la VOPcf (OR = 1,272 ; IC95 % [1,090 ; 1,483] ; p = 0,002) et la PPc (OR = 1,071 ; IC95 % [1,024 ; 1,121] ; p = 0,003) étaient les deux facteurs prédictifs indépendants d'une atteinte coronaire multitronculaire. Chez des patients hospitalisés pour un SCA de novo, il existe une corrélation positive entre le nombre de tronc coronaire atteint et la VOPcf. Cette dernière avec la PPc étaient les deux facteurs prédictifs indépendants d'une atteinte coronaire multitronculaire. The association between arterial stiffness (AS) and stable coronary artery disease (CAD) has been previously demonstrated. Whether increased arterial stiffness is associated with severe CAD in patients with acute coronary syndrome (ACS) is less explored. We aim to investigate the relationship between AS parameters and the extent and severity of CAD in patients with ACS. The study population consisted of 275 patients with ACS. We measured various AS parameters including pulse wave velocity (PWV), augmentation index (AIx), and central pulse pressure (cPP). CAD extent and severity was evaluated by the number of vessels with greater than 70% stenosis. The study population was predominantly men (77, 5%) with an average age of 56, 4 ± 10, 6 years. One hundred and fifteen patients were diabetic and 97 were hypertensive. One hundred fifty patients were admitted for ST elevation myocardial infarction (54, 5%) and 37, 5% for non ST elevation myocardial infarction. Thirty six percent of patients had single vessel disease and 47, 6% of the study population had multivessel disease. At the multivariate analysis, a positive correlation was observed between the number of coronary vessels disease and PWV. PWV (OR = 1,272; IC95% [1,090; 1,483]; p = 0,002) and cPP (OR = 1,071; IC95% [1,024; 1,121]; p = 0,003) were also independent predictors of multivessel disease. In patient with ACS, PWV is correlated with the extent of coronary artery disease, as measured by the number of vessels disease. PWV and cPP were also independent predictors of multivessel disease. [ABSTRACT FROM AUTHOR]

La mort subite d'origine cardiaque demeure un problème majeur de santé publique. Certaines études épidémiologiques suggèrent une différence entre les deux sexes en termes de cause et des circonstances du décès. L'objectif de ce travail était d'étudier la différence entre les deux sexes et les spécificités féminines dans la mort subite en termes d'incidence, de cause et de circonstances de survenue. c'est une étude prospective et autopsique, portant sur les victimes de mort subite d'origine cardiaque survenues dans la région du nord de la Tunisie entre janvier 2013 et décembre 2019. Nous avons recueilli les données cliniques, anatomiques, les circonstances du décès, ainsi que la symptomatologie accusée par la victime au cours des 24 dernières heures précédant la mort. Une analyse de la variation circadienne, hebdomadaire et mensuelle des décès à été également effectuée. La population étudiée comprenait 1834 hommes et 468 femmes avec un âge moyen comparable (56,3 ± 13,8 ans chez les hommes et de 57,2 ± 15,8 ans chez les femmes p : 0,26). Les facteurs de risque cardiovasculaire traditionnels et une dyspnée isolée précédant le décès étaient plus fréquemment constatés chez les femmes (15,6 % versus 8,1 %, p < 0,001). Par ailleurs, le décès était survenu plus fréquemment à domicile chez les femmes et dans un lieu publique ou en milieu du travail chez les hommes. Les cardiopathies ischémiques étaient les causes de décès les plus fréquentes chez les hommes et une autopsie blanche avec un cœur structurellement normal à l'examen était plus fréquente chez les femmes (34 % versus 23,6 %, p < 0,001). Un excès de mortalité nocturne chez les femmes a été enregistré entre minuit et 6 heures du matin (43,8 % contre 34,1 % chez les hommes, p < 0,001), en revanche la distribution hebdomadaire et mensuelle des décès était comparable avec en particulier un pic de mortalité hivernale enregistré dans les deux sexes. Il existe une spécificité féminine dans le domaine de la mort subite, avec une mortalité coronarienne moins importante et un taux d'autopsie blanche plus élevé chez cette population. Le décès survenait plus fréquemment à domicile avec une surmortalité nocturne par rapport aux hommes. Sudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death. We prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed. The study population included 1834 men and 468 women with a mean age of 56.5 ± 14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P < 0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P < 0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P < 0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P < 0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P < 0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes. Women had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men. [ABSTRACT FROM AUTHOR]

Functional mitral regurgitation (FMR) is a frequent condition in the setting of dilated cardiomyopathy (DCM) and its physiopathological mechanisms are complex. The aim of this study was to determine the influence of left ventricular remodeling and mechanical dyssynchrony on the occurence of FMR in non ischemic DCM. Prospective study involving 52 patients (mean age = 57 ± 10 years, sex-ratio = 1.8) with non ischemic DCM. Two groups were compared: the group with FMR (group MR+ = 31 patients) and that without FMR (group MR– = 21 patients). Mean QRS duration was 141 ± 29 ms, 63% of patients had complete left bundle branch block (LBBB), with no significant difference between the 2 groups. Echocardiographic parameters representing left ventricular systolic function were similar in 2 groups except for cardiac output which was lower in the group MR+ (3.3 ± 1L/min vs. 4 ± 1,3L/min. P = 0.02). For mitral deformation indices, tenting area (3.6 ± 1 cm2 vs. 2.5 ± 0.8 cm2; P = 0.005) and tenting height (1.5 ± 0.3 cm vs. 1 ± 0.2cm; P < 0.001) were significantly larger in group MR+. For dyssynchrony indices, only temporal longitudinal dyssynchrony was associated to FMR (P = 0.04). In the group MR+, more criteria of intraventricular dyssynchrony were noted (3.4 ± 1.4) than in group MR– (2.4 ± 1.4; P = 0.01). FMR severity was well correlated to tenting area (r = 0.66; P < 0.001) and tenting height (r = 0.67; P < 0.01). However, parameters representing left ventricular systolic and diastolic function were not good determinants of FMR severity and dyssynchrony indices were not at all associated to FMR severity. This study showed that only the mitral deformation indices were well correlated to both the presence and the severity of FMR. Left ventricular remodeling indices were not good determinants of FMT. However, the intra ventricular dyssynchrony indices were associated to the presence of FMR and not to its severity. [ABSTRACT FROM AUTHOR]

The circulating Galectin 3 (Gal-3) emerged as a new biomarker involved in fibrosis and left ventricular remodeling. The aim of our study was to investigate correlations of Gal-3 levels with cardiac function and remodeling parameters evaluated by echocardiography, and with clinical, biological and angiographic parameters in patients hospitalized for ST elevation myocardial infarction (STEMI) We conducted a prospective longitudinal study, including consecutive patients hospitalized for STEMI at the Cardiology Department of the Charles Nicoll Hospital in Tunis. A Gal-3 assay and an echocardiography were performed at four times: admission (T0), one month (T1), three months (T2), and six months (T3). Our study collected 45 patients aged 58 + 12 years. The sex ratio was 10, 2. We found a significant correlation between Gal–3 assayed at T0 with age (r = 0.311; p = 0.037), ALAT (r = 0.4; p = 0.009) and CPK (r = 0.384; p = 0.019); and between Gal-3 assayed at T3 and the infarction localization (p = 0.007). At one month, Gal-3 correlated with the left ventricular ejection fraction (r = 0.308; p = 0.042), left ventricular end-diastolic volume index (LVEDVi) (r = 0.324; p = 0.032), and left ventricular end-systolic volume index (LVESVi) (r = 0.378; p = 0.012). In addition, it had a predictive value on evolution. In fact, Gal-3 assayed at T1 was found to be significantly correlated with LVEDVi measured at T2 (r = 0.O312; p = 0.039) and with left ventricular end-diastolic diameter index (LVEDDi) measured at T2 (r = 0.372; p = 0.014) and at T3 (r = 0. 372; p = 0.032). Gal-3 correlates with remodeling parameters and cardiac function, and predicts structural changes when measured at one month of the acute episode of STEMI. Gal-3 can contribute to tissue repair, but excessive activation of its repair mechanisms may became harmful at a distance from the acute phase, it could then be a prognostic marker and a therapeutic target. [ABSTRACT FROM AUTHOR]

Functional ischemic mitral regurgitation (IMR) is common in patients with ischemic left ventricular dysfunction after myocardial infarction, and significantly worsens prognosis. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of IMR. 81 patients (mean age = 61 ± 11 years) admitted with acute myocardial infarction (AMI) were screened. Patients with atrial fibrillation and organic valvular diseases were excluded from the study. Echocardiography (two-dimensional and Doppler echocardiograms) was performed in the first week after admission. The 81 patients were divided in 2 groups: with IMR (group1 = 39 patients) and without IMR (group2 = 42 patients). LV volumes were calculated by apical biplane Simpson's rule. The LV wall-motion score (WMS) index was obtained in a 17 segment model according to established methods. To identify the influence of regional wall-motion impairment for each individual LV segment, the mean WMS was calculated for each segment and compared between the 2 groups. The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity (p < 0,0001), reduced ejection fraction (p < 0,0001), inferior (p < 0,001) inferolateral (p = 0,01) and anterolateral (p = 0.02) asynergy. The results of this study indicate the importance of abnormalities of both LV geometry and regional wall motion in the pathogenesis of IMR after myocardial infarction. Clinically, these findings imply that myocardial salvage by early coronary revascularisation may improve outcome by preserving LV function and decreasing the incidence of IMR. [ABSTRACT FROM AUTHOR]

Several studies have suggested a circadian and septadian pattern of incidence of sudden cardiac death with a morning peak and a Monday peak. To analyze the circadian and septadian pattern of occurrence of sudden cardiac death in the eight northern Tunisian governorates. We prospectively collected epidemiological and autopsy data of sudden cardiac death victims occurring in the northern region of Tunisia between January 2013 and December 2019. The population included 1834 men (79.6%) and 468 women (20.4%) with a mean age of 56.5 ± 14 years. Smoking (53.9%) was the most prevalent cardiovascular risk factor. One-fifth (20.9%) of victims had known heart disease, and 3% had a family history of sudden death. ischemic heart disease was the leading cause of sudden death (46.8% of cases). One- fourth (25.7%) of autopsies were negative. Analysis of the circadian pattern of occurrence of sudden cardiac death identified a peak (36.1%, p < 0.001) between midnight and 6 am. This nocturnal excess mortality was significant (p < 0.001) and independent of sex (34.1 % in men and 43.8 % in women) and cause of death (39.3 % of cases of sudden ischemic death and 33.3 % of cases of nonischemic death). Moreover, there was a significant septadian variability in the occurrence of sudden death (p : 0.0015), with a peak on Friday (15.8 %, p : 0.042). This study showed a peak of sudden death between midnight and 6 am, and on Fridays, confirming the modification of the classic circadian and septadian pattern of sudden death occurrence. These results may help optimize the deployment of emergency mobile teams and structures during the most vulnerable periods. [ABSTRACT FROM AUTHOR]

Functional mitral regurgitation (FMR) is a frequent condition in the setting of dilated cardiomyopathy (DCM) and its physiopathological mechanisms are complex. The aim of this study was to determine the influence of left ventricular remodeling and mechanical dyssynchrony on the occurence of FMR in non ischemic DCM. Prospective study involving 52 patients (mean age = 57 ± 10 years, sex-ratio = 1.8) with non ischemic DCM. Two groups were compared: A group with FMR (group MR+ = 31 patients) and that without FMR (group MR- = 21 patients). Mean QRS duration was 141 ± 29 ms, 63% of patients had complete left bundle branch block (LBBB), with no significant difference between the 2 groups. Echocardiographic parameters representing left ventricular systolic function were similar in 2 groups except for cardiac output which was lower in the group MR+ (3,3 ± 1l/min vs. 4 ± 1,3l/min. P = 0,02). For mitral deformation indices, tenting area (3,6 ± 1 cm2 vs. 2,5 ± 0,8 cm2; P = 0,005) and tenting height (1,5 ± 0,3 cm vs. 1 ± 0,2 cm; P < 0,001) were significantly larger in group MR+. For dyssynchrony indices, only temporal longitudinal dyssynchrony was associated to FMR (P = 0,04). In the group MR+, more criteria of intraventricular dyssynchrony were noted (3,4 ± 1,4) than in group MR- (2,4 ± 1,4; P = 0,01). FMR severity was well correlated to tenting area (r = 0,66; P < 0,001) and tenting height (r = 0,67; P < 0,01). However, parameters representing left ventricular systolic and diastolic function were not good determinants of FMR severity and dyssynchrony indices were not at all associated to FMR severity. This study showed that only mitral deformation indices were well correlated to both the presence and the severity of FMR. Left ventricular remodeling indices were not good determinants of FMT. However, the intra ventricular dyssynchrony indices were associated to the presence of FMR and not to its severity. [ABSTRACT FROM AUTHOR]

Background Obstructive sleep apnea (OSA) may lead to myocardial preconditioning by increasing coronary collateral vessel recruitment in patients with acute coronary occlusion. Aim To determine the relationship between the severity of obstructive sleep apnea and coronary collaterality during acute myocardial infarction. Methods This study prospectively included 71 patients with an inaugural myocardial infarction who had undergone a coronary angiography within 24 h of onset. All patients underwent an overnight polygraph before discharge and were classified according to the apnea–hypopnea index (AHI). Coronary collaterals were scored by visual analyses and according to the Rentrop grading system. Results Mean age was 59 ± 11 years and 83% of patients were men. All patients had complete or subtotal occlusion of the infarct-related artery. After the sleep study, patients were divided into two groups: 25 were suffering from OSA (AHI > 15/h). Patients with OSA showed better collateral vessel development (Rentrop score ≥ 1) compared to non-OSA patients (68 vs. 41%, P = 0.032). AHI was significantly higher in patients with developed coronary collaterals (Rentrop ≥ 1) compared to those without collaterality (17.74 ± 13.2 vs. 12.24 ± 10.9, P = 0.025). Conclusion Coronary collateral development may be increased in OSA patients who are presenting with a first myocardial infarction. [ABSTRACT FROM AUTHOR]

Résumé: Introduction: Le syndrome d’apnée obstructive du sommeil est incriminé dans l’aggravation et l’entretien de la maladie athéromateuse notamment coronarienne. Il reste cependant sous-diagnostiqué en milieu cardiologique. But: L’objectif de cette étude était de déterminer la prévalence du syndrome d’apnée obstructive du sommeil et les facteurs prédictifs de la forme sévère chez les patients hospitalisés pour un syndrome coronarien aigu avec sus-décalage persistant du segment ST. Patients et méthodes: Il s’agit d’une étude prospective portant sur 120 patients hospitalisés pour un syndrome coronarien aigu avec sus-décalage persistant du segment ST, entre avril 2011 et mars 2012. Tous les patients ont bénéficié d’un enregistrement polygraphique dans les 15 jours suivant l’infarctus. Le diagnostic de syndrome d’apnée du sommeil a été retenu en cas d’indexe apnée-hypopnée≥5 événements par heure ; la forme sévère a été définie par un indexe apnée-hypopnée≥30 événements par heure. Par ailleurs, une évaluation clinique de la qualité du sommeil a été réalisée par le score d’Epworth. Résultats: La population était constituée de 102 hommes et 18 femmes avec un âge moyen de 58±12ans. Les facteurs de risque cardiovasculaire étaient dominés par le tabagisme retrouvé dans 72 % des cas, 40 % des patients étaient diabétiques et 44 % étaient hypertendus. Quatre-vingt-sept pour cent des patients ont été pris en charge dans les 24 premières heures. Une angioplastie primaire a été pratiquée dans 60 % des cas et une fibrinolyse a été réalisée chez 10 % des patients. Un syndrome d’apnée obstructive du sommeil était présent chez 79 % de la population avec un indexe apnée-hypopnée moyen de 15,76±14,9. Une forme sévère de cette affection était identifiée chez 16 % des patients. Après analyse multivariée, les facteurs prédictifs indépendants de la forme sévère au décours d’un syndrome coronarien aigu avec sus-décalage du segment ST étaient un score d’Epworth≥ 4 et une désaturation nocturne≤82 % enregistrée par saturomètre au doigt à l’unité de soins intensifs cardiologiques. Conclusion: La prévalence du syndrome d’apnée obstructive du sommeil au décours d’un infarctus du myocarde était très élevée. Un score d’Epworth≥ 4 et une désaturation nocturne≤82 % étaient prédictifs de la forme sévère. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess cardiac remodeling and to determine factors predicting the occurrence of atrial arrhythmia after surgical closure of atrial septal defect (ASD) in adults. Retrospective study including 33 adult patients (> 20 years old, mean age: 34 ± 11 years, 26 women) who underwent surgical closure of secundum or sinus venosus ASD. Before operation, all patients had dyspnea and 15% were in NYHA III-IV. Sinus rythm was present in 85% of patients. The ratio of pulmonary to systemic blood flow was calculated, yielding a mean of 2,8 ± 1 and pulmonary artery hypertension (PAH) was observed in 80% of patients with a mean value of 41,3 ± 10 mmHg. The ASD were closed by pericardial or Dacron patch in 97% of cases. Operative death was observed in 2 cases. In survival patient, with a follow-up of 97 ± 57 months, regression of right ventricular dilatation and PAH occurred in the first post-operative month and was maintained at late follow-up. Atrial arrhythmia occurred in 5 patients and were determined by older operative age (P = 0.003) and the absence of cardiac remodeling after surgery. Surgical correction of ASD in adults is safe and efficacious. Cardiac remodeling after ASD closure in the adult is a common and an early event and prevents late morbidity which is in most cases due to arrhythmias. The mode of closure does not seem to significantly impact remodeling. [ABSTRACT FROM AUTHOR]

Modifiable risk factors (RFs) play an important role in the development and prognosis of acute myocardial infarction (AMI). This study sought to study the prevalence rates of modifiable RFs during a first AMI, and sex differences in Tunisian young adults. This was a retrospective cohort analysis of a Tunisian tertiary center. From January 2014 to December 2020, we retrospectively studied data of patients with AMI younger than 45 years of age hospitalized for a first AMI. Prevalence rates of hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, and drug abuse were analyzed in these patients. We enrolled 210 patients in the study. The prevalence of AMI in young patients was 8.5%. The mean age was 39.3 ± 4.9 years with a sex ratio of 11. The most frequent cardiovascular risk factors were smoking (88,6%) and dyslipidemia (32%) were the most prevalent risk factors (RF), and 98.6% of patients had at least 1 RF. Hypertension, diabetes, obesity, and drug abuse had a prevalence respectively of 30%, 28%, 8%, and 7.6%. Women had a higher prevalence of diabetes mellitus, hypertension, and obesity, and men had a higher prevalence of dyslipidemia, drug abuse, and smoking. During a first AMI in young adults in whom preventive measures are more likely to be effective, modifiable RFs were highly prevalent and progressively increased over time. Significant sex disparities were observed for individual RFs. [ABSTRACT FROM AUTHOR]

Major adverse cardiac events (MACE) occurring during non-cardiac surgery (NCS) are a common cause of morbidity and mortality. An individual preoperative MACE risk stratification during NCS based on the patient-specific risk factors and the surgical risk is highly recommended by learned societies. The aim of our study was to evaluate the perioperative management of cardiac risk in NCS by anesthesiology residents. We conducted a prospective, longitudinal and descriptive study. One hundred anesthesiology residents practicing their residency training in several Tunisian university hospital centers (UHC) were asked to take a survey inspired by The French RICARDO survey. A quarter of residents reported that they never conducted multidisciplinary team meetings (MDTMs) during the preoperative care and that there were no validated protocols elaborated with cardiologists of their departments. The majority (96,3%) requested an ECG according to the patient's age and 33% a resting Transthoracic Echocardiography (TTE) for coronary artery disease risk assessment. A ß-blocker was initiated by 44,4% of residents. Acetylsalicylic acid and clopidogrel were systematically stopped by respectively 7,4% and 51.9% of residents. Intraoperatively, the anesthetic technique was general anesthesia in 52% of cases versus locoregional anesthesia in 48% of cases. Postoperatively, 14,8% required troponins, ECG, continuous monitoring, and cardiologist follow-up. In the case of troponins elevation, 81,5% requested an ECG, and 59% involved cardiologists. Through our work, we found a discrepancy between the recommendations and the anesthetic practices. Better dissemination of guidelines and the development of local standardized protocols for CV risk assessment would be beneficial. [ABSTRACT FROM AUTHOR]

Hypertension is a common comorbidity of type 2 diabetes mellitus (T2DM). Both conditions are associated with an increased cardiovascular risk, which is reduced by tight blood pressure (BP) and glycemic control. However, non-dipping BP status continues to be an enduring cardiovascular risk factor in T2DM. This study aimed to investigate the association between microvascular complications of diabetes and nocturnal dipping of BP. We compared 13 type 2 diabetic patients with (DM+) and 67 diabetic patients without (DM−) manifest microvascular disease. BP dipping status was assessed from 24-hour ambulatory BP measurements. DM+ patients were older 60.3 ± 8.7 years vs. 58.3 ± 10.4 years (P = 0.47). There was no significant difference between the two groups in diabetes control, clinical systolic BP and clinical diastolic BP. Dyslipidemia was significantly more present in DM+, 84.7% vs. 47.8% (P = 0.015). DM+ patients had significantly higher daytime and 24-hour mean SBP than DM− patients with P = 0.02 and 0.023 respectively. Pulse pressure was significantly (P = 0.03) higher in DM+. The nocturnal blood pressure profile in DM+ was "non-dipper" and "reverse dipper" respectively in 69% and 15% of patients versus 27% and 11% in DM− (P = 0.003; P = 0.026). Our findings once again highlighted the importance of ambulatory BP monitoring and targeted antihypertensive therapy directed toward to restore normal circadian BP in patients with T2DM. [ABSTRACT FROM AUTHOR]

To determine whether the presence of calcium in the mitral valve commissures influences the immediate result of percutaneous mitral commissurotomy (PMC). PMC by the Inoue balloon was attempted in 247 patients (mean age: 35years) with severe MS. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification (CC) and to determine the Wilkins score. According to the absence or presence of CC, patients were divided into 2 groups: 216 patients in group CC- (no commissural calcification) and 31 patients in group CC+ (presence of calcification in 1 or 2 commissures). Baseline mitral valve area (MVA) was 1 ± 0,19 cm2 (range 0,5–1,4 cm2), the mean value of Wilkins score was 7,98 ± 1,61(range 5–13) and 29 patients had unilateral commissural calcification. Post-PMC success was defined as final MVA ≥ 1,5 cm2 and no mitral regurgitation ≥ grade3. After PMC, the mean MVA increased to 1,79 ± 0,34 cm2 (P < 0,001) resulting in a success rate of 83%. Severe mitral regurgitation (MR) occured in 5 patients (2%). Final MVA (1,83 ± 0,32 cm2 versus 1,50 ± 0,36 cm2), success rate (87% versus 55%) and the rate of opening of at least one commissure (97% versus 77%) were significantly different between groups CC− and CC+ (P < 0,001). The rate of post-PMC MR of grade ≥ 3 was not different between the two groups (2% in group CC- and 0% in group CC+; P = 0,6) Our results showed that the presence of commissural calcification was associated with a lower procedural success rate but a good immediate result could be achieved in half of cases. Then, unilateral commissural calcification should not be considered as a contra-indication to PMC. [ABSTRACT FROM AUTHOR]

Functional ischemic mitral regurgitation (IMR) is common in patients with ischemic left ventricular dysfunction after myocardial infarction, and significantly worsens prognosis. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of IMR. Eighty-one patients (mean age = 61 ± 11 years) admitted with acute myocardial infarction (AMI) were screened. Patients with atrial fibrillation and organic valvular diseases were excluded from the study. Echocardiography (two-dimensional and Doppler echocardiograms) was performed in the first week after admission. The 81 patients were divided in 2 groups: with IMR (group1 = 39 patients) and without IMR (group2 = 42 patients). LV volumes were calculated by apical biplane Simpson's rule. The LV wall-motion score (WMS) index was obtained in a 17-segment model according to established methods. To identify the influence of regional wall-motion impairment for each individual LV segment, the mean WMS was calculated for each segment and compared between the 2 groups. The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity (P < 0.0001), reduced ejection fraction (P < 0.0001), inferior (P < 0.001) inferolateral (P = 0.01) and anterolateral (P = 0.02) asynergy. The results of this study indicate the importance of abnormalities of both LV geometry and regional wall motion in the pathogenesis of IMR after myocardial infarction. Clinically, these findings imply that myocardial salvage by early coronary revascularisation may improve outcome by preserving LV function and decreasing the incidence of IMR. [ABSTRACT FROM AUTHOR]

The etiology of valvular heart disease (VHD) has changed dramatically in the last decades. In middle-income countries, the incidence of rheumatic heart disease (RHD) is still high, yet the prevalence of other valve disorders may be on the rise as the population's life expectancy is increasing. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology. A retrospective study involving patients hospitalized in our department and proposed for valvular surgery between January 2012 and May 2021. During the study period, 400 patients were referred for valvular surgery. The mean age was 57 ± 13 years. Two hundred and nine patients were male (52,3%) with a sex ratio of 1,1. Rheumatic etiology was the most important (53,8%). Arterial hypertension and diabetes mellitus are respectively present in 33.3% and 22% of the patients. Before surgery mean LVEF was 58.55 ± 11%. Thirty-nine patients (9.8%) were operated with (left ventricular dysfunction (LVEF ≤ 40%). A preoperative coronary angiography was performed in 69.5% of the patients and coronary artery disease was associated with the valvular heart disease in 127 patients (31.7%). Mitral valve replacement, aortic valve replacement, and double valve replacement were respectively performed in 43.6%, 33.9% and 17,7% of the cases. Bioprothesis were implanted in 5.67% of the cases. Forty-nine patients (12,3%) underwent coronary artery bypass graft in addition to the valvular surgery. In 15.9 of the cases, it was a redosurgery. Contemporary epidemiological data shows a rise of the degenerative etiology and associated coronary artery disease. Yet VHD is still high. Further investment in planning and resources for secondary prophylaxis would be a cost and life-saving strategy for in developing and emerging economy nations. [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially MV disease. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49,3 ± 13,7 years with a sex-ratio of 0,8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20,5 ± 33 months. Patients with significant postoperative TR were more often female (83% vs. 48%, P = 0,03), had more often a previous mitral commissurotomy (58% vs. 23%, P = 0,02) and showed a higher prevalence of significant preoperative TR (69% vs. 42%, P = 0,04). Postoperatively, residual pulmonary hypertension (P = 0,04), dilatation of left atrium (P = 0,02) and dilatation of right cardiac cavities (P = 0,01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardiographic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery. [ABSTRACT FROM AUTHOR]

Define echocardiographic predictors of the immediate results of percutaneous mitral balloon commissurotomy (PMC) PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 ans, 77% female) with severe mitral valve stenosis. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification and to determine the Wilkins score. The mean value of Wilkins score was 7,98 ± 1,61(range 5–13) and the mean mitral valve area (MVA) before PMC was 1 ± 0,19 cm2 (range 0,5–1,4 cm2). Twenty-nine patients (11,7%) had one-commissural calcification. After PMC, the mean MVA increased to 1,79 ± 0,34 cm2 (P < 0,001) resulting in a success rate of 83%. Severe mitral regurgitation (MR) occured in 5 patients (2%). Wilkins score was an independent predictor of the immediate result of PMC, but if > 8, this score had a weak predictive value. Commissural morphology was another independent predictor of the immediate result of PMC. Echocardiography is now the cornerstone in the assessment of mitral anatomy before PMC and should integrate Wilkins score and commissural morphology for the optimal selection of patients to PMC. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) remains the most common and fatal form of endovascular infections despite improvements in its management. To describe epidemiological, microbiological and outcome characteristics of IE. We realised a descriptive retrospective study of 65 patients hospitalized in Charles Nicolle hospital and treated for definite IE from Janury 2011 to April 2021. The mean age of patients was 49.88 ± 16.37 years ranging from the age of 19 and 88 years. The study population consisted of 35 men (53.8%) and 30 women (46.2%). The-underlying heart disease was previously known in 49.2% of our patients and the most common predisposing heart disease was rheumatic valvular disease (26.2%). IE locations were: mitral valve in 40%, aortic in 43.1%, mitral and aortic in 13.8%, tricuspid in 21.5%, prosthesis in 12.3% and in 5 cases on intracardiac material. A portal entry was found in 29 cases (44.6%). Dental procedures was the most frequent cause of bacteremia (16.9%), followed by percutaneous iatrogenic procedures (9.2%) and drug iv (9.2%), then cardiac surgery (3.1%). Eight of patients (12.3%) had chronic renal insufficient stage hemodialysis in whom 3 by catheter of Canaud. Blood cultures were positive in only 43.1%. The most incriminated germs were staphylococci (50%), streptococci (32.14%), enterococci (17.8%), and other pathogens (7.14%). Vegetations visualized by transthoracic echocardiography was greater than 15 mm in 46.2%. Annular abscess was present in 4 cases. The most frequent complication was neurological complications (17%), followed by spleen infarction (15.4%), congestive heart failure (12.3%), and then peripheral embolism (10.8%). Early valve surgery was performed in 55.3%. The in hospital mortality was 12.3%. IE is associated to different clinical and paraclinical aspects. It persists a life-threatening disease associated with a high morbi-mortality that has long-lasting effects. [ABSTRACT FROM AUTHOR]

Percutaneous mitral commissurotomy (PMC) is the alternative treatment of choice for mitral stenosis (MS). Its immediate and medium term results are comparable to those of surgical commissurotomy, however in the long term there is a risk of restenosis. The purpose of this study is to determine the factors predicting restenosis after PMC. Three hundred and twenty-two patients (66% women), average age: 35 ± 13 years (9–75 years) having a tight MS and treated by PMC with Inoué balloon. The anatomic aspect of the mitral apparatus before PMC has been studied according to the criteria of the Wilkins score with a concomitant study of the state of mitral commissures. The primary success of PMC is defined as follows: mitral area (MA) post-PMC >1,5 cm2 and gain in MA > 25% and mitral regurgitation (MR) ≤ grade 2. Mitral restenosis is defined as a MA < 1,5 cm2 and/or loss > 50% of initial gain in MA. The rate of primary success of PMC was 86% and mean MA post PMC was 1,82 ± 0,33 cm2 compared to MA pre-PMC of 1 ± 0,18 cm2 (P < 0.0001). Opening of two commissures has been observed in 74% of patients. After an average period of 62 ± 32 months, only 12% of patients had a dyspnea stage III-IV of NYHA, MA was 1,64 ± 0.3 cm2 (P < 0.001) and mitral restenosis happened in 47 patients (20%) after a period of 60,48 ± 27 months (22–124 months). The independent predictors of mitral restenosis after a successful PMC were: previous surgical commisurotomy, Wilkins score > 8, MA after PMC < 1,8 cm2 and absence of bicommissural opening post PMC. A favorable anatomy of mitral apparatus and the optimisation of immediate result of PMC are the guaranty for the maintain of good result in the long term. [ABSTRACT FROM AUTHOR]

The circulating Galectin 3 (Gal-3) emerged as a new biomarker involved in fibrosis and left ventricular remodeling. The aim of our study was to investigate correlations of Gal-3 levels with cardiac function and remodeling parameters evaluated by echocardiography, and with clinical, biological and angiographic parameters in patients hospitalized for ST elevation myocardial infarction (STEMI) We conducted a prospective longitudinal study, including consecutive patients hospitalized for STEMI at the Cardiology Department of the Charles Nicoll Hospital in Tunis. A Gal-3 assay and an echocardiography were performed at four times: admission (T0), one month (T1), three months (T2), and six months (T3). Our study collected 45 patients aged 58 + 12 years. The sex ratio was 10, 2. We found a significant correlation between Gal–3 assayed at T0 with age (r = 0.311; P = 0.037), ALAT (r = 0.4; P = 0.009) and CPK (r = 0.384; P = 0.019); and between Gal-3 assayed at T3 and the infarction localization (P = 0.007). At one month, Gal-3 correlated with the left ventricular ejection fraction (r = 0.308; P= 0.042), left ventricular end-diastolic volume index (LVEDVi) (r = 0.324; P = 0.032), and left ventricular end-systolic volume index (LVESVi) (r = 0.378; P = 0.012). In addition, it had a predictive value on evolution. In fact, Gal-3 assayed at T1 was found to be significantly correlated with LVEDVi measured at T2 (r = 0.O312; P = 0.039) and with left ventricular end-diastolic diameter index (LVEDDi) measured at T2 (r = 0.372; P = 0.014) and at T3 (r = 0.372; P = 0.032). Gal-3 correlates with remodeling parameters and cardiac function, and predicts structural changes when measured at one month of the acute episode of STEMI. [ABSTRACT FROM AUTHOR]

The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology. A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017. The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery. Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent. [ABSTRACT FROM AUTHOR]

To determine whether the presence of calcium in the mitral valve commissures influences the immediate result of percutaneous mitral commissurotomy (PMC). PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 years) with severe MS. All the patients had undergone echocardiographic examination before PMC to assess mitral anatomy, commissural calcification (CC) and to determine the Wilkins score. According to the absence or presence of CC, patients were divided into 2 groups: 216 patients in group CC- (no commissural calcification) and 31 patients in group CC+ (presence of calcification in 1 or 2 commissures). Baseline mitral valve area (MVA) was 1 ± 0.19 cm2 (range 0,5–1,4 cm2), the mean value of Wilkins score was 7.98 ± 1.61(range 5–13) and 29 patients had unilateral commissural calcification. Post-PMC success was defined as final MVA ≥ 1.5 cm2 and no mitral regurgitation ≥ grade 3. After PMC, the mean MVA increased to 1.79 ± 0.34 cm2 (P < 0.001) resulting in a success rate of 83%. Severe mitral regurgitation (MR) occured in 5 patients (2%). Final MVA (1.83 ± 0.32 cm2 versus 1.50 ± 0.36 cm2), success rate (87% versus 55%) and the rate of opening of at least one commissure (97% versus 77%) were significantly different between groups CC- and CC + (P < 0.001). The rate of post-PMC MR of grade ≥ 3 was not different between the two groups (2% in group CC- and 0% in group CC+; P = 0.6). Our results showed that the presence of commissural calcification was associated with a lower procedural success rate but a good immediate result could be achieved in half of cases. Then, unilateral commissural calcification should not be considered as a contra-indication to PMC. [ABSTRACT FROM AUTHOR]

Abstract: The problem of sizing an electricity storage for a 5000 inhabitants island supplied by both marine renewables (offshore wind and waves) and the mainland grid is addressed by a case study based on a full year resource and consumption data. Generators, transmission lines and battery storage are accounted for through basic simplified models while the focus is put on electricity import/export budget. Self-sufficiency does not seem a reasonable goal to pursue, but partial autonomy provided by renewable sources and a medium size storage would probably be profitable to the island community. [Copyright &y& Elsevier]

The right sided infective endocarditis is a rare disease, it represents 5- 10% of the total number of Infective endocarditis events, mainly occurring in patients with congenital heart disease, patients carrying intravascular catheters or intracardiac devices, and it's frequently seen in injection drug users. The care of these patients is a medical and surgical challenge. We report 13 cases of right sided infective endocarditis. Our patients were seven female, six men with an age ranging between 23 and 68 years. They all had a predisposing factor: pacemaker, venous catheter, recent cardiac surgery and drug abuse. Blood cultures were positive in 10 cases, with the identification of Staphylococcus aureus in 7 patients. Cardiac ultrasound was the key examination to display vegetations and quantify tricuspid regurgitation. Treatment was given according to international recommendations, and was based primarily on a bi-bactericidal antibiotic therapy adapted to the isolated germ; surgical treatment was proposed in three cases with favorable evolution in two patients. There was a two case of death resulting from septic shock. One in the following of cardiac surgery and the other occurred early and did not respond to medical treatment. The outcome was favorable for the other cases. Although rare, tricuspid endocarditis is not exceptional and occurs in a context that favors. The operative indication is rarely hemodynamic, but rather infectious to eradicate an antibiotic resistant focus. Overall prognosis of remains better than the left side. [ABSTRACT FROM AUTHOR]

During the COVID19 pandemic, Tunisia adopted a preventive health policy, consisting of containment, self-quarantine, and social distancing to reduce viral contamination. Many health care workers noticed a decrease in urgent admissions in different medical wards and intensive care units. In this work, we aimed to evaluate the impact of COVID19 preventive measurements on the number of patients' admissions in a Tunisian intensive cardiac care unit. We collected the number of admissions in the ICCU of Charles Nicolle's Hospital of Tunis for acute myocardial infarction and acute heart failure during February, March, and April of the years 2018, 2019, and 2020 and compared the number of admissions between those periods. In Tunisia, containment has already started on March, 22nd. We also compared the mean number of admissions per day between the pre-containment period (40 days before) and the containment period (40 days after), and the mean number of admissions per week during the 6 weeks after March, 22nd. During the three months, the overall number of admissions declined respectively from 103, 100 in 2018, 2019 to 75 in 2020 showing a 25% drop in overall admissions. The mean number of admissions dropped significantly from1 ± 0.93 patient/day (pre-containment period) to 0.6 ± 0.81 patient/day during the containment period (Wilcoxon-Mann-Whitney test; P = 0,024). The mean number of admissions per week during the 6 weeks after March, 22nd dropped respectively from 7.66 ± 1.75 and 7.66 ± 3.2 in 2018 and 2019 to 4.16 ± 3.25 patients per week in 2020. (Kruskal–Wallis test, P = 0.13) (Fig. 1). Many reasons could explain this slight drop in ICU admissions during containment such as the lack of public transport, the business of our emergency hotlines with the COVID 19 calls, and even patient's fear of being infected by the virus in hospitals. This can lead to an increase in sudden cardiac deaths, heart failures due to this lack of medical care. [ABSTRACT FROM AUTHOR]

The circulating Galectin 3 (Gal-3) emerged as a new biomarker involved in fibrosis and left ventricular remodeling. The aim of our study was to investigate correlations of Gal-3 levels with cardiac function and remodeling parameters evaluated by echocardiography, and with clinical, biological and angiographic parameters in patients hospitalized for ST elevation myocardial infarction (STEMI). We conducted a prospective longitudinal study, including consecutive patients hospitalized for STEMI at the Cardiology Department of the Charles Nicolle Hospital in Tunis. A Gal-3 assay and an echocardiography were performed at four times: admission (T0), one month (T1), three months (T2), and six months (T3). Our study collected 45 patients aged 58 + 12 years. The sex ratio was 10, 2. We found a significant correlation between Gal-3 assayed at T0 with age (r = 0.311; P = 0.037), ALAT (r = 0.4; P = 0.009) and CPK (r = 0.384; P = 0.019); and between Gal-3 assayed at T3 and the infarction localization (P = 0.007). At one month, Gal-3 correlated with the left ventricular ejection fraction (r = 0.308; P = 0.042), left ventricular end-diastolic volume index (LVEDVi) (r = 0.324; P = 0.032), and left ventricular end-systolic volume index (LVESVi) (r = 0.378; P = 0.012). In addition, it had a predictive value on evolution. In fact, Gal-3 assayed at T1 was found to be significantly correlated with LVEDVi measured at T2 (r = 0.312; P = 0.039) and with left ventricular end-diastolic diameter index (LVEDDi) measured at T2 (r = 0.372; P = 0.014) and at T3 (r = 0. 372; P = 0.032). Gal-3 correlates with remodeling parameters and cardiac function, and predicts structural changes when measured at one month of the acute episode of STEMI. Gal-3 can contribute to tissue repair, but excessive activation of its repair mechanisms may became harmful at a distance from the acute phase, it could then be a prognostic marker and a therapeutic target. [ABSTRACT FROM AUTHOR]

Despite the decline in rheumatic heart disease worldwide and the use of antibiotic prophylaxis, there is no evidence that the incidence of infective endocarditis (EI) is decreasing. In fact, some data suggestit may be increasing. The classical fever of unknown origin presentation represents a minority of EI cases today; thus, clinicians need to be vigilant about keeping EI in mind with some of these more unusual presentations The aim was to study various presentations of EI, which are organized into three groups of presenting symptoms and signs: nonspecific, cardiac, and embolic This was a descriptive retrospective study of 62 patients hospitalized in Charles Nicolle hospital and treated for definite EI from 2011 to 2019. The mean age of patients was 50.12 ± 16.66 years ranging from the age of 19 and 88 years. The study population consisted of 35 men (57.1%) and 27 women (42.9%). 44 (89.9%) of the patients had been admitted due to fever. Peripheral signs like Janeway lesion and Osler's node were not seen, arthralgia was seen in 9 patients. Heart failure was observed in 30.6% of the cases. Embolic events were common: stroke (18.3%), pulmonary emboli (9%), peripheral vascular emboli (10.2%) and spleen infarction (14.2%). After instauration of the treatment most complication were cerebral (6%), spleenic (7%), cardiac (10%), thirty two of the patients improved and were discharged in good general condition. Seven patients died, and in hospital mortality of 14.3%. EI is a disease in which the presentation are various and acute than previously described and remains a serious and deadly disease despite recent advances in diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Abstract: Controversy persists over the safety of conducted electrical weapons, which are increasingly used by law enforcement agencies around the world. We report a case of 33-year-old man who had an acute inferior myocardial infarction after he was shot in the chest with an electrical weapon. [Copyright &y& Elsevier]

The purpose of this study was to assess cardiac remodeling and to determine factors predicting the occurrence of atrial arrhythmia after surgical closure of atrial septal defect (ASD) in adults. Retrospective study including 33 adult patients (> 20 years old, mean age: 34 ± 11 years, 26 women) who underwent surgical closure of secundum or sinus venosus ASD. Before operation, all patients had dyspnea and 15% were in NYHA III-IV. Sinus rythm was present in 85% of patients. The ratio of pulmonary to systemic blood flow was calculated, yielding a mean of 2.8 + − 1 and pulmonary artery hypertension (PAH) was observed in 80% of patients with a mean value of 41.3 ± 10 mmHg. The ASD were closed by pericardial or Dacron patch in 97% of cases. Operative death was observed in 2 cases. In survival patient, with a follow-up of 97 + 57 months, regression of right ventricular dilatation and PAH occurred in the first post-operative month and was maintained at late follow-up. Atrial arrhythmia occurred in 5 patients and were determined by older operative age (P = 0.003) and the absence of cardiac remodelling after surgery. surgical correction of ASD in adults is safe and efficacious. Cardiac remodelling after ASD closure in the adult is a common and an early event and prevents late morbidity, which is in most cases due to arrhythmias. The mode of closure does not seem to significantly impact remodelling. [ABSTRACT FROM AUTHOR]

In discrete fixed subaortic stenosis, surgery is indicated when the systolic gradient (Gmax) between the left ventricle (LV) and the aorta exceed 50 mmHg or in the presence of significant aortic regurgitation (AR). The aim of this study was to determine the factors that influence the progression of the obstruction and the appearance of AR. Retrospective serial echocardiographic review of 19 patients, mean age 16 years (2 years–38 years), with fixed discrete subaortic stenosis that did not require surgery (initial Gmax at inclusion < 50 mmHg and without any symptom). The mean follow up was 5.42 years. The progression of gradient is defined by the formula (Gmax at follow up–initial Gmax). The mean velocity of increasing of Gmax was 2 mmHg/year. This progression was correlated to the patient's age (cut off = 15 years, r = −0.5 P = 0.02), and the initial value of the Gmax (cut off = 40 mmHg, r = 0.43, P = 0.04). The appearance or the aggravation of aortic regurgitation was determined by: the initial grade of AR (r = 0.64; P = 0.003), initial Gmax (r = 0.65; P = 0.002), progression's velocity of G max (r = 0.47; P = 0.04), and distance between the membrane and the aortic cusps (cut off = 5 mm, r = 0.49; P = 0.03). LV hypertrophy was influenced by the velocity of progression of obstruction (> 2 mmHg/year). The identification of factors determining the evolution of discrete subaortic stenosis (age < 15 years, initial Gmax > 40 mmHg, distance membrane- cusps > 5 mm) allow an adequate screening of patients that will require early operation. [ABSTRACT FROM AUTHOR]

Cardiovascular diseases leading to pacemaker implantations are suspected of being associated with a high rate of undiagnosed sleep apnea syndrome (SAS). The aim of this study was to determine the prevalence of SAS in patients with permanent pacemakers. Cross sectional study in patients presenting to Pacemaker control, between March and October 2018. All underwent Epworth Sleepiness Scale assessment and polysomnography with the pacemaker programmed to right ventricular DDI pacing mode (lower pacing rate, 50 pulses per minute). SAS was defined as an apnea-hypopnea index ≥ 5 h. Fifty-four consecutive patients (mean age, 68 ± 11 years) not known to have sleep apnea were included; 44 patients were paced for high-degree atrioventricular block (83%), and 10 for sinus node disease (37%). Mean Epworth Sleepiness Scale was in the normal range (8 ± 4), although 13 patients (25%) had an abnormal score > 11/h. Thirty-three patients (61%) had SAS; of these, 14 (26%) had a severe SAS (apnea-hypopnea index > 30/h). In paced patients, there is an excessively high prevalence of undiagnosed SAS. Whether treating SAS would have changed the need for pacing is unknown. [ABSTRACT FROM AUTHOR]

Percutaneous mitral commissurotomy (PMC) is the alternative treatment of choice for mitral stenosis (MS). Its immediate and medium term results are comparable to those of surgical commissurotomy, however in the long term there is a risk of restenosis. The purpose of this study is to determine the factors predicting restenosis after PMC. 322 patients (66% women), average age: 35 ± 3 years (9–75 years) having a tight MS and treated by PMC with Inoué balloon. The anatomic aspect of the mitral apparatus before PMC has been studied according to the criteria of the Wilkins score with a concomitant study of the state of mitral commissures. The primary success of PMC is defined as follows: mitral area (MA) post-PMC > 1.5 cm2 and gain in MA > 25% and mitral regurgitation (MR) ≤ grade 2. Mitral restenosis is defined as a MA < 1.5 cm2 and/or loss > 50% of initial gain in MA. The rate of primary success of PMC was 86% and mean MA post PMC was 1.82 ± 0.33 cm2 compared to MA pre-PMC of 1 ± 0.18 cm2 (P < 0.0001). Opening of two commissures has been observed in 74% of patients. After an average period of 62 ± 32 months, only 12% of patients had a dyspnea stage III-IV of NYHA, MA was 1.64 ± 0.3 cm2 (P < 0.001) and mitral restenosis happened in 47 patients (20%) after a period of 60.48 ± 27 months (22–124 months). The independent predictors of mitral restenosis after a successful PMC were: previous surgical commisurotomy, Wilkins score > 8, MA after PMC < 1.8 cm2 and absence of bicommissural opening post PMC. A favorable anatomy of mitral apparatus and the optimisation of immediate result of PMC are the guaranty for the maintenance of good result in the long term. [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation (TR) is probably the most common and anticipated complication of left-sided heart valve pathology, especially MV disease. Whether preoperative functional TR will regress or progress after successful left-sided valve surgery is unknown. The aim of this study was to identify the predictors of significant TR after successful left-sided valve surgery. A retrospective analysis was performed on a total of 56 patients who underwent left-sided valve surgery (mitral or mitro-aortic-valve surgery). We have excluded patients who had organic TR. All patients had complete clinical examination and echocardiographic studies preoperatively and clinical and echocardiographic follow-up postoperatively. Mean operative age of patients was 49.3 ± 13.7 years with a sex-ratio of 0,8. Tricuspid annuloplasty was associated to left-sided valve surgery in 18 (32%) patients. Postoperatively, significant TR was found in 13 patients (23%) with a mean follow-up of 20.5 ± 33 months. Patients with significant postoperative TR were more often female (83% vs. 48%, P = 0.03), had more often a previous mitral commissurotomy (58% vs. 23%, P = 0.02) and showed a higher prevalence of significant preoperative TR (69% vs. 42%, P = 0.04). Postoperatively, residual pulmonary hypertension (P = 0.04), dilatation of left atrium (P = 0.02) and dilatation of right cardiac cavities (P = 0.01) were significant risk factors for development or progression of TR after surgery. Late onset or progression of functional TR after successful left-sided valve surgery is a significant clinical entity as it displays a great impact on patient prognosis. So, the identification of clinical and echocardiographic predictors of late TR allows an adequate screening of patients that will require tricuspid valve repair at the time of initial left-sided valve surgery. [ABSTRACT FROM AUTHOR]

Functional mitral regurgitation (FMR) is a frequent condition in the setting of dilated cardiomyopathy (DCM) and its physiopathological mechanisms are complex. The aim of this study was to determine the influence of left ventricular remodeling and mechanical dyssynchrony on the occurence of FMR in non-ischemic DCM. Prospective study involving 52 patients (mean age = 57 ± 10 years, sex-ratio = 1.8) with non-ischemic DCM. Two groups were compared: the group with FMR (group MR+ = 31 patients) and that without FMR (group MR- = 21 patients). Mean QRS duration was 141 ± 29 ms, 63% of patients had complete left bundle branch block (LBBB), with no significant difference between the 2 groups. Echocardiographic parameters representing left ventricular systolic function were similar in 2 groups except for cardiac output which was lower in the group MR+ (3.3 ± 1l/min vs. 4 ± 1.3l/min. P = 0.02). For mitral deformation indices, tenting area (3.6 ± 1cm2 vs. 2.5 ± 0.8cm2; P = 0.005) and tenting height (1.5 ± 0.3 cm vs. 1 ± 0.2 cm; P < 0.001) were significantly larger in group MR+. For dyssynchrony indices, only temporal longitudinal dyssynchrony was associated to FMR (P = 0.04). In the group MR+, more criteria of intraventricular dyssynchrony were noted (3.4 ± 1.4) than in group MR- (2,4 ± 1.4; P = 0.01). FMR severity was well correlated to tenting area (r = 0.66; P < 0.001) and tenting height (r = 0.67; P < 0.01). However, parameters representing left ventricular systolic and diastolic function were not good determinants of FMR severity and dyssynchrony indices were not at all associated to FMR severity. This study showed that only the mitral deformation indices were well correlated to both the presence and the severity of FMR. Left ventricular remodeling indices were not good determinants of FMT. However, the intra ventricular dyssynchrony indices were associated to the presence of FMR and not to its severity. [ABSTRACT FROM AUTHOR]

The aim of this study was to define the prevalence of mechanical (atrio-ventricular, interventricular and intraventricular) dyssynchrony in heart failure patients with different QRS durations. A total of 46 patients with heart failure (dilated cardiomyopathy with LVEF < 40%, NYHA II-IV) were prospectively evaluated using 12-lead electrocardiogram and complete echocardiographic examination including tissue Doppler imaging. All the patients had sinus rhythm and the dilated cardiomyopathy was primitive in 37% of patients and ischemic in the others. According to QRS duration, 16 patients had QRS ≥ 150 ms (group 1), 15 patients had QRS duration between 120 and 149 ms (group 2) and 15 patients had QRS duration < 120 ms (group 3). Interventricular dyssynchrony (IVD) was present in 62% of group 1, 13% of group 2 and was absent in group 3 (P < 0,001). Intraventricular dyssynchrony (IntraVD) was present respectively in 94%, 40%, 20% of groups 1,2, and 3 (P < 0,001). However, there was no significant difference in the prevalence of atrioventricular dyssynchrony (AVD) between the three groups. A multiparametric approach by focusing on criteria combination found that the association of IVD + IntraVD + AVD was present only in group 1 and the combination of two criteria was seen only in group 1 and 2 with a significantly higher prevalence in group 1 (P < 0,01). The prevalence of mechanical dyssynchrony increases with the increasing QRS duration and the combination of criteria is significantly more prevalent when the QRS width is ≥ 150 ms. Intraventricular dyssynchrony can be observed in heart failure patients with a narrow QRS complex and may be useful in predicting left ventricular reverse remodelling after CRT. The lack of dyssynchrony in some patients with standard CRT indication by QRS duration may sometimes explain the non-responder's rates. [ABSTRACT FROM AUTHOR]

Cannabis is one of the most widely used illicit substances worldwide, and it has the highest prevalence among drugs used in our country in young adults. Yet its potential cardiovascular consequences are not fully understood. Highlighting the demographic, clinical presentation, laboratory results and angiographic characteristics of patients with type 1 myocardial infarction (MI) with a history of cannabis use. Retrospective chart review of patients with MI presenting to our Intensive Coronary Care Unit over a period of 4 years (January 2014–December 2018), and who reported the recent use of cannabis and other substances. No toxicological screen was performed. Of the 14 case subjects studied who presented with chest pain, mean age at presentation was 40.1 ± 9.7 (years) SD. There were 13 males and one female. All patients were tobacco smokers, 4 patients (28%) had a history of diabetes and no history of dyslipidemia and hypertension was noted in all patients. All patients used Cannabis (100%), 14% cocaine and 28% alcohol. At presentation, 11 patients (78%) had an EKG evidences of ST-segment elevation MI (STEMI), two of them were transient. Complete atrioventricular block was found in one case. Troponin I (hs cTnI) peak mean level was 13000 ± 23511 ng/ml. All patients underwent coronary angiography and 9 of them had angiographic evidence of single vessel obstructive coronary artery disease. Left ventricular ejection fraction (EF) as determined by cardiac echocardiogram ranged from 15% to 70%, with a mean of 47% ± 15%. In our study, Cannabis use is associated with MI, occurring at a relatively younger age with half of the cases either low risk or CVD risk free. Additional studies are needed to further characterize this population given the increase in marijuana use. [ABSTRACT FROM AUTHOR]

Acute coronary syndrome (ACS) in young adults seems to be not as low as expected. It presents one of the highly debated issues in cardiology according to the increasing number of those patients. The aim of our study was to describe the clinical and angiographic profile in young patient ≤ 40 years diagnosed with ACS. We performed a retrospective study including 74 patients younger than 40 years of age with clinical and electrocardiographic evidence of ACS, hospitalized in our cardiology department from January 2016 to Mach 2019. All patients underwent a coronary angiography. We analyzed the risk factors, clinical profile, type of ACS and angiographic features of these patients. Mean age was 33 ± 7 years old [26-40] and 94% of them were males (five women versus 70 men). All men were smokers, including four man addicted on cannabis, and only two women were non-smokers. The most common risk factors were diabetes mellitus (14 patients; 19%), systemic hypertension (10 patients; 13.5%), dyslipidemia (7 patients; 9.4%), obesity (7 patients; 9.4%) and a family history of premature coronary artery disease (5 patients; 6.7%). Ten patients (13.5%) were having ST segment elevation myocardial infraction, 13 patients (17.5%) were hospitalized for a non-ST segment elevation and 51 patients (69%) have a history of an unstable angina. The most common abnormal arteriography findings were the involvement of one vessel (23 patients; 31%), followed by double-vessel disease noticed in two cases (2.7%). There was one patient of our population with three-vessel disease (1.3%). The most common vessel to be involved was the left anterior descending (12 cases; 16%). Normal coronary angiography was noticed in 37 patients (50%). ACS in young patients has a huge impact on the patient, the society and the economic burden. It presents a real challenge that the cardiologist must be aware of in order to set on the ideal therapeutic strategy including the perfect clinical management and an early prevention program to control the cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

Background Conduction disorders in the postoperative period of cardiac surgery impede prompt clinical recovery and prolong hospitalization. The severity of this complication and the need of specific management justify a better identification of the predictive factors of its occurrence after cardiac surgery. The aim of this study is to identify the predictive factors of pace maker dependency in these patients. Methods It is a 25 patients’ descriptive retrospective study carried out in the cardiology department of Charles Nicolle's Hospital in Tunis (Tunisia) between 1997 and 2014. We included all patients with a high-grade atrioventricular conduction disorder requiring definitive pacemaker implantation following cardiac surgery. We studied the preoperative clinical and electrocardiographic characteristics of patients, surgical indications, the type of postoperative conduction disorder and the moment of its occurrence. We also investigated the pacemaker dependency of each patient during his last follow-up. Results The mean age was 44 years and 9 months. Our population was made of 14 men (56%) and 11 women. Correction of acquired heart disease was the dominant indication of operation (68%). Preoperatively, 14 patients (56%) were in sinus rhythm. A pacemaker implantation was indicted for a complete AV block in 23 patients (92%). Postoperatively, 10 patients (40%) had an immediate complete AV block. After pacemaker implantation and at the last follow-up, 9 patients were dependent of their pacemaker. The immediate occurrence of AV block is the only factor significantly correlated to the pacemaker dependency ( P = 0.041). Conclusion This study highlights the importance of a regular and pronged follow-up of patients undergoing cardiac surgery since conduction disorders may occur many years later. [ABSTRACT FROM AUTHOR]

The aim of our study was to assess the clinical, electrical, angiographic and therapeutic characteristics of young patients with acute myocardial infarction and to describe the prevalence of in-hospital complications. FromJanuary 2014 to May 2017, we retrospectively studied data of patients with acute myocardial infarction younger than 45 years old in the department of cardiology of Charles Nicolle hospital of Tunis. We enrolled 108 patients in the study. The prevalence of myocardial infarction in young patients was 8.5%. The mean age was 39.5 ± 5.5 years with a sex-ratio of 11. The most frequent cardiovascular risk factors were smoking (88%) and dyslipidaemia (51.9%). We reported 75 cases of ST segment elevation myocardial infarction. Primary angioplasty was performed in 41.3% of cases while lytic therapy was administered for the rest of the patients. It was successful in 75% of cases. Among 33 patients who presented with non-ST segment elevation myocardial infarction, percutaneous coronary angioplasty was performed in 60.6% of patients while 15.2% have undergone coronary artery bypass surgery and 24.2% received medical treatment only. In-hospital complications occurred in 39.8% of cases. In-hospital mortality was 1.9 %. Acute myocardial infarction in the young represents a serious health problem. Primary preventive measures aimed at preventing our youth from adopting tobacco use and developing dyslipidemia should be implemented to delay and even to avoid the onset of coronary artery disease. [ABSTRACT FROM AUTHOR]

Introduction Percutaneous mitral commissurotomy (PMC) is the alternative treatment of choice for mitral stenosis (MS). Its immediate and medium term results are comparable to those of surgical commissurotomy, however in the long-term there is a risk of restenosis. The purpose of this study is to determine the factors predicting restenosis after PMC. Methods 322 patients (66% women), average age: 35 ± 13 years (9–75 years) having a tight MS and treated by PMC with Inoué balloon. The anatomic aspect of the mitral apparatus before PMC has been studied according to the criteria of the Wilkins score with a concomitant study of the state of mitral commissures. The primary success of PMC is defined as follows: mitral area (MA) post-PMC > 1,5 cm 2 and gain in MA > 25% and mitral regurgitation (MR) ≤ grade 2. Mitral restenosis is defined as a MA < 1,5 cm 2 and/or loss > 50% of initial gain in MA. Results The rate of primary success of PMC was 86% and mean MA post PMC was 1,82 ± 0,33 cm 2 compared to MA pre-PMC of 1 ± 0,18 cm 2 ( P < 0.0001). Opening of two commissures has been observed in 74% of patients. After an average period of 62 ± 32 months, only 12% of patients had a dyspnea stage III-IV of NYHA, MA was 1,64 ± 0.3 cm 2 ( P < 0.001) and mitral restenosis happened in 47 patients (20%) after a period of 60,48 ± 27 months (22–124 months). The independent predictors of mitral restenosis after a successful PMC were: previous surgical commisurotomy, Wilkins score > 8, MA after PMC < 1,8 cm 2 and absence of bicommissural opening post-PMC. Conclusion A favorable anatomy of mitral apparatus and the optimization of immediate result of PMC are the guaranty for the maintenance of good result in the long-term. [ABSTRACT FROM AUTHOR]

Introduction Functional ischemic mitral regurgitation (IMR) is common in patients with ischemic left ventricular dysfunction after myocardial infarction, and significantly worsens prognosis. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of IMR. Methods Eighty-one patients (mean age = 61 ± 11 years) admitted with acute myocardial infarction (AMI) were screened. Patients with atrial fibrillation and organic valvular diseases were excluded from the study. Echocardiography (two-dimensional and Doppler echocardiograms) was performed in the first week after admission. The 81 patients were divided in 2 groups: with IMR (group 1 = 39 patients) and without IMR (group 2 = 42 patients). LV volumes were calculated by apical biplane Simpson's rule. The LV wall-motion score (WMS) index was obtained in a 17-segment model according to established methods. To identify the influence of regional wall-motion impairment for each individual LV segment, the mean WMS was calculated for each segment and compared between the 2 groups. Results The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity ( P < 0.0001), reduced ejection fraction ( P < 0.0001), inferior ( P < 0.001) inferolateral ( P = 0.01) and anterolateral ( P = 0.02) asynergy. Conclusion The results of this study indicate the importance of abnormalities of both LV geometry and regional wall motion in the pathogenesis of IMR after myocardial infarction. Clinically, these findings imply that myocardial salvage by early coronary revascularisation may improve outcome by preserving LV function and decreasing the incidence of IMR. [ABSTRACT FROM AUTHOR]

Introduction In discrete fixed subaortic stenosis, surgery is indicated when the systolic gradient (Gmax) between the left ventricle (LV) and the aorta exceed 50 mmHg or in the presence of significant aortic regurgitation (AR). The aim of this study was to determine the factors that influence the progression of the obstruction and the appearance of AR. Methods Retrospective serial echocardiographic review of 19 patients, mean age 16 years (2 years–38 years), with fixed discrete subaortic stenosis that didn’t require surgery (initial Gmax at inclusion < 50 mmHg and without any symptom). The mean follow-up was 5.42 years. The progression of gradient is defined by the formula (Gmax at follow up − initial Gmax). Results The mean velocity of increasing of Gmax was 2 mmHg/year. This progression was correlated to the patient's age (cutoff = 15 years, r = −0.5, P = 0.02), and the initial value of the Gmax (cutoff = 40 mmHg, r = 0.43, P = 0.04). The appearance or the aggravation of aortic regurgitation was determined by: the initial grade of AR ( r = 0.64; P = 0.003), initial Gmax ( r = 0.65; P = 0.002), progression's velocity of Gmax ( r = 0.47; P = 0.04), and distance between the membrane and the aortic cusps (cutoff = 5 mm, r = 0.49; P = 0.03). LV hypertrophy was influenced by the velocity of progression of obstruction (> 2 mmHg/year). Conclusion The identification of factors determining the evolution of discrete subaortic stenosis (age < 15 years, initial Gmax > 40 mmHg, distance membrane cusps > 5 mm) allow an adequate screening of patients that will require early operation. [ABSTRACT FROM AUTHOR]