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BackgroundCoronary 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. ObjectiveThe 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. MethodsWe 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. ResultsIn 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. ConclusionsThis 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 RegistrationClinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761 International Registered Report Identifier (IRRID)RR1-10.2196/24595

Introduction. The objective of the study was to explore the role of a genetic variant of angiotensinogen (AGT), M235T, as an independent risk factor for acute myocardial infarction (AMI) and to investigate the possible association with the severity of coronary artery disease (CAD), estimated on the basis of the number of coronary stenoses and critical arterial occlusions.Patients and methods. 123 AMI patients were compared to 144 healthy controls. AGT genotypes were determined by PCR.Results. A significant association was found between AGT M235T polymorphism and AMI (p = .021). By logistic regression, the TT genotype appeared to confer 1.9-fold increased risk for AMI in both the univariate and the multivariate model. The frequencies of the TT genotype and T allele increased with the number of stenoses in coronary vessels. Moreover, the TT genotype and the T allele were more frequent in the subgroup of patients with stenoses in at least four coronary vessels than in other patients, including subjects with one- to three-vessel disease. Furthermore, the TT genotype and the T allele were significantly more frequent in patients with critical arterial occlusions (> 90%) than in subjects without critical stenoses.Conclusions. The AGT M235T polymorphism associates with AMI risk and influences CAD severity. [ABSTRACT FROM PUBLISHER]

Background:   Nurses play a key role in cardiac arrest management, especially those assigned to cardiac intensive care units, where they are often actively involved in cardiopulmonary resuscitation., Aim: To evaluate the effect of simulation training in in continuing professional development of nurses in this setting., Methods: A comparative study using paired samples (where the candidate was his own control with repeated measures before and after intervention), was conducted among nurses working in the cardiology and cardiovascular surgery division of our institution. The primary endpoint was the change in skills judged on the basis of competency score of 20 assessed before and after simulation training., Results: 32 nurses participated in the training session. Despite a median job seniority of 8.5 years [4.0 - 12.5], only 44% of nurses had already participated in a simulation session. Although most of the candidates (84%) had previously performed chest compressions, only 34% had delivered an electrical defibrillation during their exercise. We showed a significant increase in overall scores from 8.0 [5.0 - 9.8] to 17.5 [17.0 - 19.0] after the simulation training session (p<0.0001). All the criteria judged in the evaluation grid (basic life support, manual electrical defibrillation) were significantly improved and the most positive effect was observed in the manual defibrillation where the prior experience of the participants was limited., Conclusions: Simulation learning had a major positive impact on the development of nurses' skills in terms of cardiopulmonary resuscitation.

Introduction: Atrial septal defects (ASD) constitute the most frequent congenital heart disease in adults and ostium secundum (OS) the most common type. Benefit of its closure in adulthood has long been controversial., Aim: To evaluate outcomes of OS-ASD closure in adults., Methods: Retrospective cohort study, over a ten-year period from 2008 to 2018. All adults (≥20 years old) who benefited from OS-ASD closure were included. Study endpoints were closure success rate, functional status evolution and incidence of new arrhythmias at 12 months., Results: Fifty patients were recruited. Dyspnea (≥ NYHA II) was noted in 58% and arrhythmia in 18% of patients. Feasibility of a percutaneous closure was 50%. Closure success rate was 100%. Surgery was associated with high postoperative morbidity with longer hospitalization stay (20 vs. 4 days, p <0.001). At 12 months, an improvement in functional status was observed in 79%. Incidence of new arrhythmias was 5%. A significant decrease in right cavities dilation as well as pulmonary arterial pressure has been reported., Conclusions: Immediate results of OS-ASD closure in adults are satisfactory. Percutaneous closure is associated with reduced hospital morbidity. At 12 months, a significant improvement in functional status was observed however the possible occurrence of new arrhythmias imposes a close follow-up.

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

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

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

Background: Contrast-induced nephropathy (CIN) is associated with an increased cardiovascular morbi-mortality. Little is known about the incidence and risk factors of CIN after cardiac catheterization in Tunisian patients., Aim: To determine the incidence of CIN and its predictors after coronary angiography as well as its prognostic and therapeutic repercussions in a Tunisian patients' cohort., Methods: In this prospective single center study, 180 consecutive patients who underwent cardiac catheterization were enrolled; all patients were followed-up for 3 months., Results: The incidence of CIN defined as an absolute increase in serum creatinine ³ 5 mg/l (44μmol/l) and/or a relative increase in serum creatinine ³ 25%, was 17.2%. In multivariate logistic regression, independent predictors of CIN were: diabetes mellitus (Odds Ratio (OR)=2.26 ; 95% confidence interval (95%CI) : 1.29- 3.98, p=0.005), creatinine clearance < 80ml/mn (OR=2.87 ; 95%CI : 1.59-5.19, p<0.001), left ventricular ejection fraction (LVEF) < 45% (OR=2.03 ; 95%CI : 1.22-3.39, p=0.007) and use of a volume of contrast media > 90ml (1.72 ; 95%CI : 0.99-2.99, p=0.05). Perprocedural hypotension was the strongest independent predictor of CIN in our study (OR=3.99; 95% CI: 1.65-9.66, p=0.002). CIN was totally regressive within one month in 27 patients (86.7%) while 3 patients (10%) had a residual renal dysfunction at the end of the follow-up period (3 months)., Conclusion: More than one angiocoronarography on 6 resulted in CIN in our population. CIN affects cardiovascular prognosis even if renal function normalization is usually obtained within one month after the investigation. Besides identifying risk factors of CIN in order to apply preventive measures in risky patients, we stress the necessity of insuring a good hemodynamic status while achieving the procedure.

Background: Patients undergoing coronary stenting during acute coronary syndrome (ACS) are exposed to a higher risk of stent thrombosis (ST) than those undergoing elective stenting. FEW STUDIES HAVE AIMED TO IDENTIFY ST INCIDENCE AND PREDICTORS IN THIS SPECIFIC POPULATION., Methods and Results: This single-center study enrolled 611 consecutive Tunisian patients with ACS who underwent coronary stenting with bare metal stents (BMS). The incidence of ARC (Academic Research Consortium) definite ST throughout a median 16-month follow-up period was 3.5%; it was 9.2% in patients with ST-elevation myocardial infarction (STEMI) who underwent an emergency percutaneous coronary intervention (PCI). Independent predictors were fever during PCI (hazard ratio (HR) 5.19; 95% confidence interval (95%CI) 1.69-15.95, P=0.004); premature cessation of clopidogrel (HR 2.66; 95%CI 1.02-6.97, P=0.046), resumption of smoking (after PCI) (HR 4.41; 95%CI 1.58-12.27, P=0.005), primary PCI (HR 5.02; 95%CI 1.57-16.01, P=0.006), rescue PCI (HR 6.33; 95%CI 2.08-19.34, P=0.001), reference vessel diameter <2.8mm (HR 6.96; 95%CI 2.06-23.56, P=0.002), TIMI flow grade before PCI <2 (HR 11.51; 95%CI 2.76-48.06, P=0.001) and a visible thrombus (HR 3.57; 95%CI 1.1-11.12, P=0.028)., Conclusions: The incidence of ST in ACS patients was higher than classically described. Clopidogrel discontinuation and resumption of smoking are involved. Efforts should be made to improve patient education and secondary prevention.

The authors report the case of a woman operated at a 50 years of age for a tetralogy of Fallot with a good late result.

The authors report the case of a patient with multiple coronary artery-left ventricular fistulae discovered in coronary angiography for exertional angina.

The purpose of this prospective study is to analyse the immediate effect of Rashkind's atrioseptostomy on systemic saturation in transposition of the great arteries (TGA). Thirteen neonates and infants (10 males and 3 females) with TCiA underwent balloon atrial septostomy (BAS) at a median age of 20 days (range 2 and 60 days). The mean atrial septal defect diameter after BAS was 6.5 +/- 1.1 mm. The right ventricular saturation increased from 37 +/- 17% to 67 +/- 13% (p < 0.001). There was no correlation between the atrial septal defect diameter and the increase of systemic saturation after BAS.

Two girls aged 6 and 15 years with severe congenital valvular aortic stenosis and left ventricular (LV) dysfunction underwent successful balloon aortic valvotomy (BAV). Both patients had severe symptoms at the time of initial evaluation. The electrocardiograms showed LV hypertrophy and cardiac enlargement (cardiothoracic ratio 0.7 and 0.65) was evident in the chest roentgenograms. Immediately after BAV, the aortic valve peak-to-peak gradients decreased from 60 to 8 mmHg and 120 to 30 mmHg respectively, the LV end-diastolic pressures decreased from 47 to 13 mmHg and 40 to 15 mmHg, the LV ejection fractions improved from 40 to 65% in the second girl. On follow-up (30 and 36 ms respectively), both patients were asymptomatic with normalization of LV function and without a change in the residual gradient a cross the aortic valve.

The purpose of this study was to determine the immediate effect of percutaneous mitral commissurotomy (PMC) on left ventricular (LV) performance. We studied 30 patients with severe mitral stenosis undergoing successful PMC by cardiac catheterization and angiography before and 5 minutes after PMC. All patients were in sinus rhythm and no patient had hypertension or clinical coronary artery disease. We conclude that the left ventricular end-diastolic volume and the stroke volume increased significantly immediately after PMC because of and increase in LV filling after relieving the mitral mechanical obstruction.

Six new patients and 33 previously reported with coronary-to-pulmonary artery fistula were reviewed. The mean age at the time of diagnosis was 51 years. A male predominance was found (65%). Angina was the most common symptom. The artery mostly involved was the left anterior descending coronary artery and the fistula drained more often to the main pulmonary artery. The left-to-right shunt is small in the majority of patients and the associated significant coronary artery disease was detected in 18% of cases. Good results of surgical closure of the fistula are usually obtained. An alternative to surgical treatment is percutaneous transcatheter embolization of coronary artery fistulas.

Thirty children (15 males and 15 females) under 2 years of age (mean age 14 +/- 6 months, range 1 to 24 months, mean weight was 8.3 +/- 2.5 kg) underwent diagnostic cardiac percutaneous femoral arterial and venous catheterization for congenital heart disease. The anticoagulation with heparin was not given in any patient. Appropriate arterial sheath varying from 4F to 5F were used for catheterization. The mean duration of the exploration was 38 +/- 16 mn. The mean duration of the left heart exploration was 9.5 +/- 2.5 mn. There were no hemorrhagic or ischemic complications in this series.