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BACKGROUND AND OBJECTIVE: Left atrial strain (LAS) has prognostic value in patients with atrial fibrillation (AF). Consequently, therapies that improve LAS may help reduce AF-related adverse cardiac events. We aimed to compare how digoxin and bisoprolol modulate LAS in patients with AF being treated with rate control., Methods: This was a bicentric randomized controlled trial. Patients with AF, naïve to beta-blockers and digoxin, and scheduled for treatment with a rate control strategy were randomized to receive oral bisoprolol 5-10 mg daily or digoxin 0.25 mg daily. The primary aim was to compare the change in peak LAS before and after 30 days of treatment between the two groups., Results: A total of 60 patients, equally distributed between the two groups, completed the trial. By day 30, there was no significant difference in global peak LAS between the groups. However, when analyzed separately, the two-chamber view showed a significantly higher peak LAS in the digoxin group than in the BB group (mean 7.5 ± standard deviation 3.2% vs. 5.9 ± 3.4%; p = 0.004). Similarly, the four-chamber view also showed a higher peak LAS in the digoxin group (7.2 ± 3.6% vs. 6.4 ± 3.8%; p = 0.047). Considering the entire LAS curve rather than solely the peak value, digoxin significantly increased all LAS curves. In the global and four-chamber view, the digoxin maximum effect occurred significantly earlier than the peak of the LAS curve (p < 0.001). This effect remained constant over the cardiac cycle in the two-chamber curve (p < 0.001)., Conclusion: Our findings suggest that, in patients with rate-controlled AF, digoxin positively modulates LAS when compared with bisoprolol., Clinical Trials Registration Number: NCT05540600, https://clinicaltrials.gov ., Competing Interests: Declarations. Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Conflict of interest: The authors have no relevant financial or non-financial interests to disclose. Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Nidhal Bouchahda, Mouna Bader, and Aymen Najjar. The first draft of the manuscript was written by Nidhal Bouchahda, and all authors commented on previous versions of the manuscript. Fathia Mghaieth Zghal, Ghada Sassi, Mohamed Sami Mourali, and Mejdi Ben Messaoud reviewed, improved, and approved the final manuscript. Ethics approval: This work was approved by the regional ethical committee (reference number TN2022-NAT-I NS-86). Consent to participate: Informed consent was obtained from all participants included in the study. Consent for publication: Not applicable. Availability of data and material: Data are available on reasonable request to the corresponding author. Code availability: The R code is available on reasonable request to the corresponding author., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Multi-modality imaging is the recommended approach to assess the severity of valvular heart diseases. Rheumatic mitral stenosis (MS), however, has yet to benefit from this approach. The aim of this study is to assess the added value of cardiac MRI (CMR) and computed tomography (CT) calcium score in assessing severity of MS when compared to 3D echocardiography. Patients with MS in sinus rhythm were included. Both CMR and 3D echo assessments of the mitral valve were performed. Subsequently, three radiologists and three cardiologists independently measured mitral valve area (MVA). In addition, CT of the mitral valve was conducted. Mitral calcium score was calculated according the Agatston method. A total of 41 patients were included. CMR significantly overestimated MVA when compared to 3D echo MVA regardless of the investigator [F (1, 40) = 23.3, p < 0.001, η2 = 0.36]. The more severe the MS, the greater the overestimation by CMR compared to 3D echo. Regarding CT of the mitral valve, 25 (61%) patients had an undetectable calcium. There was no significant difference in CT calcium scores between severe and non-severe MS (74 ± 282 HU vs. 65 ± 210 HU, p = 0.9). MVA measurement by CMR is overestimated when compared to 3D echo. Additionally, mitral valve calcium score is not correlated to MS severity., Competing Interests: Declarations Ethical approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Monastir University Hospital. Consent to participate Informed consent was obtained from all individual participants included in the study. Competing interests The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Purpose: To assess reproducibility of Real time 3D echocardiography (RT3D) and ECG-gated 3D echocardiography (EG3D) when measuring the mitral valve area (MVA) in rheumatic mitral stenosis (MS)., Methods: MVA was assessed by three operators in 68 MS patients using RT3D and EG3D. Reproducibility of each technique was determined by calculating the standard error of measurements (SEM)., Results: SEM was similar between RT3D and EG3D. MVA variability was of 0.4 cm² or 30% of any RT3D or EG3D measured MVA. The minimal change in MVA above which two measurements should be considered to differ significantly for the same operator was of 0.4 cm² for RT3D and 0.5 cm² for EG3D. For two different operators making successive measurements, the minimum significant change was of 0.5 cm² for RT3D and 0.6 cm² for EG3D. The minimum significant difference when switching from RT3D to EG3D or vice versa is of 0.6 cm². Low temporal resolution of 6 Hz has the least variability when using RT3D (0.19 cm² vs. 0.26 cm², p = 0.009) but significantly underestimated MVA (1.3 ± 0.4 cm² vs. 1.4 ± 0.4 cm², p < 10 - 3 ) when compared to EG3D. MVA variability was significantly higher in mild MS when compared to severe MS whether it is RT3D (0.23 cm² vs. 0.18 cm², p = 0.02) or EG3D (0.27 cm² vs. 0.16 cm², p < 0.001)., Conclusion: RT3D and EG3D are equally reproducible in the assessment of MVA in patients with MS. Further measurements standardization is required to have a clinically acceptable estimations of the true 3D MVA and minimal detectable differences., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Electrocardiography (ECG) findings in acute pulmonary embolism (PE) are known to be related to various right ventricular (RV) alterations. These abnormalities are not included in risk stratification algorithms despite emerging evidence of their association with patient outcomes. We aimed to analyze the impact of right bundle branch block (RBBB) and/or SIQIII patterns as indicators for determining the level of risk in patients with PE. Methods: We performed a retrospective cohort study including all patients with confirmed acute PE hospitalized from January 2008 to December 2019 in two tertiary care cardiology departments. The first ECG taken at admission was selected and the analysis focused on the presence of a complete or an incomplete RBBB and SIQIII-type patterns. Results: A total of 255 patients were divided into two groups: Group I (47.8%, n=122) included patients with PE without RBBB nor SIQIII patterns, and Group II (52.2%, n=133) included patients with RBBB and/or SIQIII patterns. Patients in group II presented significantly more frequently with acute right heart symptoms (45.1% vs. 18%, p<0.001) and cardiogenic shock at admission (31.6 vs. 4.1%, p<0.001). Echocardiographic parameters indicating right heart injury also occurred more significantly in group II patients (p<0.001). By univariate analysis, patients in group II were found to be significantly associated with in-hospital mortality (22.6 vs. 6.1%, p=0.002) and major cardiovascular events (MACEs) during hospitalization (43.3 vs. 13.7%, p<0.001). Multivariate logistic regression analysis identified five independent factors predictive of MACEs: SIQIII and/or RBBB, renal failure, positive troponin levels, RV dysfunction and right heart failure symptoms during initial presentation. Kaplan-Meier survival analysis identified the inclusion in Group II and the presence of SIQIII pattern as predictors of overall mortality (p<0.001). Conclusions: Our study suggests an important and independent prognostic value of RBBB and SIQIII patterns and their usefulness in determining the outcome of PE patients., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Hassine M et al.)

Introduction: pulmonary embolism is a real public health problem because of its high morbidity and mortality rate. The purpose of this study is to evaluate the impact of PESI score on the prognosis of pulmonary embolism., Methods: we conducted a retrospective study of 146 cases of formally confirmed embolism. Pulmonary embolism severity index (PESI) score was calculated for the entire study population. The patients were divided into 2 groups: a low-risk group (LR) comprising patients in risk classes I and II: 83 patients; a high-risk group (HR) comprising patients in risk classes III, IV and V: 63 patients; the primary endpoint of the study (MACE) was the occurrence of shock, the need for mechanical ventilation, and the occurrence of in-hospital death., Results: total in-hospital mortality was 15.1%, significantly higher in the HR group (25.4% versus 7.2%, p=0.001). In logistic regression analysis, being in the HR group (OR=5.1; 95% CI: [1,637 - 16,093]; p=0.005)) and having renal impairment (OR=4.5; 95% CI: [1.457 - 14.075]; p=0.009) were the independent factors for the occurrence of MACE. After a mean follow-up of 18 ± 8 months, there were more deaths in the HR group (68.4% versus 33%, p=0.004)., Conclusion: the results of our study show that the PESI score is correlated with the severity of PE. This should encourage the widespread use of this risk score., Competing Interests: Les auteurs ne déclarent aucun conflit d´intérêts., (Copyright: Majed Hassine et al.)

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries., Objective: The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia., Methods: We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis., Results: In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022., Conclusions: This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region., Trial Registration: Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761., International Registered Report Identifier (irrid): RR1-10.2196/24595., (©Rania Hammami, Selim Boudiche, Tlili Rami, Nejeh Ben Halima, Ahmed Jamel, Bassem Rekik, Rym Gribaa, Ben Mrad Imtinene, Salma Charfeddine, Tarek Ellouze, Amine Bahloul, Ben Slima Hédi, Jamel Langar, Habib Ben Ahmed, Zied Ibn Elhadj, Mohamed Hmam, Mohamed Aymen Ben Abdessalem, Sabri Maaoui, Sana Fennira, Laroussi Lobna, Majed Hassine, Sami Ouanes, Drissi Mohamed Faouzi, Souad Mallek, Abdallah Mahdhaoui, Dghim Meriem, Walid Jomaa, Sofien Zayed, Tawfik Kateb, Nidhal Bouchahda, Fares Azaiez, Helmi Ben Salem, Morched Marouen, Aymen Noamen, Salem Abdesselem, Denguir Hichem, Hassen Ibn Hadj Amor, Farhati Abdeljelil, Amine Amara, Karim Bejar, Ben Hamda Khaldoun, Chiheb Hamza, Mohsen Ben Jamaa, Sami Fourati, Faycal Elleuch, Zeineb Grati, Slim Chtourou, Sami Marouene, Mohamed Sahnoun, Morched Hadrich, Maalej Mohamed Abdelkader, Hatem Bouraoui, Kamel Kamoun, Moufid Hadrich, Tarek Ben Chedli, Mohamed Akrem Drissa, Hanene Charfeddine, Nizar Saadaoui, Gargouri Achraf, Siala Ahmed, Mokdad Ayari, Marsit Nabil, Sabeur Mnif, Maher Sahnoun, Helmi Kammoun, Khaled Ben Jemaa, Gharbi Mostari, Nebil Hamrouni, Maazoun Yamen, Yassine Ellouz, Zahreddine Smiri, Amine Hdiji, Jerbi Bassem, Wacef Ayadi, Amir Zouari, Chedly Abbassi, Boujelben Masmoudi Fatma, Kais Battikh, Elyes Kharrat, Imen Gtif, Milouchi Sami, Leila Bezdah, Salem Kachboura, Mohamed Faouzi Maatouk, Sondes Kraiem, Gouider Jeridi, Elyes Neffati, Samir Kammoun, Youssef Ben Ameur, Wafa Fehri, Habib Gamra, Lilia Zakhama, Faouzi Addad, Mourali Mohamed Sami, Leila Abid. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 05.08.2022.)

We investigated the relationship between Left Atrium strain reservoir function and symptoms and its impact on modulating Left Ventricular mechanics, diastolic filling, stroke volume, mean trans-mitral gradient and pulmonary pressure in mitral stenosis (MS) patients. We examined 195 full spectrum MS patients which were divided into two groups: Group 1 (n = 109) included patients with NYHA I & II functional class and group 2 (n = 86) included patients with NYHA III & IV functional class. LA strain reservoir function and classical echocardiographic parameters were calculated. LASr was significantly higher in group 1 versus group 2 in patients with MVA ≤ 1cm 2 [8.8(6.0-12.6) vs 6.8(4.1-8.9), p = 0.03) and when 1cm 2  < MVA ≤ 1.5 cm 2 [10.0 (5.4-13.8) vs 6.7(4.5-9.0), p = 0.02). In patients with Pulmonary Hypertension, group 1 had significantly higher LASr than group 2 [11.1(6.6-14.8) vs 5.9(4.3-9.0), p = 0.002) By multivariate analysis, diabetes (OR = 4.11, 95%CI: 1.6-10.4), stroke (OR = 2.9, 95%CI: 1.1-7.9), LASr (OR = 0.9, 95%CI: 0.80-0.99) and LV ejection fraction (LVEF)(OR = 0.9, 95%CI: 0.91-0.99) were independently associated with NYHA functional class. LASr was significantly and positively correlated to MVA (r = 0.3, p < 10 -3 ), stroke volume (r = 0.25, p = 10 -3 ), mitral inflow (r = 0.4, p < 10 -3 ) and LVEF(r = 0.14, p = 0.05). It was significantly and negatively correlated to left ventricular strain (r = -0.65, p < 10 -3 ), LA indexed volume (r = -0.40, p < 10 -3 ), maximum tricuspid regurgitation velocity (r = -0.25, p = 0.003), MTMG (r = -0.25, p = 10 -3 ), and heart rate (r = -0.4, p < 10 -3 ). We demonstrated a large range of interaction between LASr and mitral valve echocardiographic parameters. This may explain the reasons we identified LASr as an independent factor for MS functional tolerance., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Competing Interests: Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-21-779/coif). The author has no conflicts of interest to declare.

Behcet's disease is a chronic inflammatory syndrome that can affect arteries and veins of all sizes and is an unusual cause of myocardial infarction. We report a case of a 42-year-old male with no cardiovascular risk factors who was referred to our department for a spontaneously resolving anterior ST-elevation myocardial infarction. Clinical and biological investigations revealed a high probability for Behcet's disease. The coronary angiogram showed severe left main artery stenosis with a huge coronary aneurysm of the proximal left anterior descending coronary artery, which was treated by aneurysm resection and coronary artery bypass grafting. Inflammatory arteritis should be considered in young patients with low cardiovascular risk presenting with acute coronary syndrome.

Coronary artery stent infection with mycotic aneurysm is a rare life-threatening complication following coronary angioplasty, usually requiring surgical intervention. Reaching and confirming the diagnosis remains the most challenging aspect of this complication. We describe an unusual case of bare metal stent infection and coronary artery aneurysm in the setting of tricuspid valve infective endocarditis, resulting in ST elevation myocardial infarction, with a favorable outcome after primary angioplasty and antibiotic therapy. In the current era of growth of coronary stent implantation, it's important for clinicians to consider and to prevent such potentially fatal events. The diagnosis process remains difficult and requires the association of multiple clinical, biological and imaging parameters. Although treatment modalities tend to favor surgery, we showed that coronary angioplasty could be a successful alternative solution., Competing Interests: No competing interests were disclosed., (Copyright: © 2019 Ben Messaoud M et al.)

Aims: To assess both epicardiac macrovascular as well as microvascular and tissue reperfusion following different intravenous preadmission antithrombotic strategies prior primary PCI in STEMI patients., Methods and Results: Consecutive STEMI patients (n = 488) undergoing pPCI received prehospitally either bivalirudin (n = 179), bivalirudin and periprocedural GPIIb/IIIa inhibitors (GPI) (n = 109), heparin (n = 99) or heparin and periprocedural GPI (n = 101). Epicardial perfusion and microvascular perfusion were assessed by angiography (TIMI flow rate and corrected TIMI frame count [cTFC]) and by ECG (ST resolution [STR]). TIMI 3 flow was restored at the end of the procedure in 85.2% of the cases; cTFC of ≤23 was obtained in 37.2% of cases and STR >70% in 42.5% of the cases. The rates of STR >70% and cTFC ≤23 were not different between the three groups. Multivariate analysis did not identify a predictive antithrombotic treatment to obtain either post-procedural TIMI 3 flow rate or a STR rate >70%. TIMI 3 flow before procedure and delay first symptoms-balloon <6 h represented a positive predictive value of STR rate >70% and the LAD as infarct related artery a negative predictive value of STR rate of >70%., Conclusion: The process of myocardial reperfusion by pPCI continues to be improved with earlier reperfusion but an optimal tissular reperfusion was present in only half of the cases., (Copyright © 2018. Published by Elsevier Inc.)

Background: Coronary artery embolism (CE) is recognized as an important nonatherosclerotic cause of ST-segment-elevation myocardial infarction. The objective was to describe clinical characteristics and long-term outcomes and to identify risks factors of CE in a large consecutive series of ST-segment-elevation myocardial infarction patients., Methods and Results: We studied 1232 consecutive patients who presented with de novo ST-segment-elevation myocardial infarction. CE was diagnosed based on criteria encompassing clinical, angiographic, and diagnostic imaging findings. A total of 53 patients were identified in the CE group including 12 (22.6%) patients with multisites CE and 9 patients with other extracoronary localization. Compared with the non-CE group, age and coronary risks factors were not significantly different in the CE group except for smoking ( P =0.03) and body mass index ( P <0.001). Interventional coronary procedures were characterized by a higher use of glycoprotein IIb/IIIa inhibitors ( P <0.001) and lower use of angioplasty ( P <0.001) in the CE group. The most frequent underlying cardiac diseases were atrial fibrillation (n=15, 28.3%) followed by dilated cardiomyopathy (n=5), endocarditis (n=4), and intracardiac tumor (n=3), whereas among systemic diseases, malignancy (n=8) and systemic autoimmune disease or antiphospholipid syndrome (n=4) were present. No etiopathological mechanisms could be identified in 14 patients (26.4%). Coronary embolism was associated with a higher risk of death (crude hazard ratio, 4.87; 95% confidence interval, 2.52-9.39; P <0.0001)., Conclusions: Etiopathogenesis of ST-segment-elevation myocardial infarction secondary to CE is diverse ranging from cardiac to systemic disease, and patient long-term survival is worse than expected according to the baseline cardiovascular risk., (© 2018 American Heart Association, Inc.)