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Objective The objective of this study was to assess the level of Vitamin K antagonist (VKA) therapy knowledge among VKA newly treated patients. Methods Questionnaire-based interviews were administered in a university hospital to VKA newly treated patients covering both cognitive (i.e. indication, route of administration, treatment monitoring and side effects) and know-how (i.e. safety precautions, what affects anticoagulant therapy and the management of overdose signs) aspects of therapy knowledge. Key findings A total of 55 patients were included. The mean overall score of patients’ knowledge was 5.78 (SD = 3.425) out of 20. The mean scores of cognitive and practical knowledge were 3.8 (2.26) and 1.98 (1.78) out of 10, respectively. Factors associated with an insufficient level of VKA therapy knowledge included low level of education, lack of access to therapy information and continuous access to this information. Conclusions Knowledge about VKA therapy among newly treated patients is insufficient. Patient’s medication knowledge should be improved to ensure better adherence.

Clopidogrel (clopi) is a prodrug widely prescribed in the management of coronary artery disease and requires the intervention of hepatic cytochrome P450 2C19 (CYP2C19) for its activation. However, there is interindividual variability in response to clopi despite the use of recommended doses. Thus, the studies have highlighted the effect of the CYP2C19 gene polymorphism or Cyp2C19 gene on the response to clopi and particularly Cyp2C19 * 2 which may be associated with an increased risk of major cardiovascular events or MACE.To evaluate the effect of Cyp2C19 * 2 polymorphism on MACE occurrence and hemorrhagic complications in patients treated with clopi.We carried out a descriptive longitudinal study including 71 patients placed under clopi for a minimum duration of one month. Genotyping of the Cyp2C19 allele was performed by conventional polymerase chain reaction (PCR). After a follow-up period of 495 ± 183 days, we performed a statistical analysis to evaluate the association between the Cyp2C19 * 2 polymorphism and the occurrence of MACE or hemorrhagic complications.Among our patients, 51% had an angioplasty, 42% medical treatment and 7% a coronary artery bypass surgery. In our study population, 52% were heterozygous (HTZ), 28% homozygous (HMZ) healthy * 1 / * 1 and 20% HMZ had the loss of function allele * 2 / * 2. The allelic frequency of Cyp2C19 * 2 was 46%. Follow-up mean duration was of 495 ± 183 days. During this period, the prevalence of MACE was 11% and that of hemorrhagic complications was 13%. In our study, we did not observe a significant association between the occurrence of MACE or hemorrhagic complications with the genotype carrying the Cyp2C19 * 2 allele.Among patients treated with clopi, wearing a Cyp2C19 * 2 function loss allele didn't seem to be associated with a significantly higher risk of MACE, nor a significantly lower risk of hemorragic complications. This suggests the necessity of larger studies.

BACKGROUND Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiologic pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiologic profile and management of atrial fibrillation (AF) patients in Tunisia are limited. OBJECTIVE The aim of this study was to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. METHODS A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective to describe the epidemiologic pattern of AF. Patients will be officially enrolled in the NATURE-AF only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. RESULTS Results w be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. CONCLUSIONS This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. CLINICALTRIAL ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX)

Resume Pre-requis Le syndrome d’apnees obstructives du sommeil est sous-diagnostique en milieu cardiologique en particulier au decours d’un syndrome coronarien aigu. Le score d’Epworth se place comme un moyen simple et rapide pour la selection des malades avant une etude polysomnographique. But Determiner l’interet du score d’Epworth dans le depistage du syndrome d’apnees obstructives du sommeil chez les patients hospitalises pour un infarctus du myocarde avec sus-decalage persistant du segment ST. Patients et methodes Il s’agit d’une etude prospective portant sur 120 patients admis en phase aigue d’infarctus du myocarde, entre avril 2011 et mars 2012. L’evaluation de la somnolence diurne a ete realisee par le score d’Epworth lors du sejour des patients a l’unite de soins intensifs. Tous les patients ont beneficie d’un enregistrement polygraphique realise dans les 15 jours suivant l’infarctus. Le syndrome d’apnees du sommeil a ete defini par un index apnee-hypopnee (IAH) ≥ 5. Resultats Cent deux hommes et 18 femmes avec un âge moyen de 58 ± 12 ans ont ete inclus dans cette etude. Les facteurs de risque cardiovasculaire etaient domines par le tabagisme retrouve dans 72 % des cas, 40 % des patients etaient diabetiques et 44 % etaient hypertendus. Le syndrome d’apnees obstructives du sommeil etait present chez 79 % des patients avec 16 % de formes severes. L’IAH moyen etait de 15,76 ± 14,93. Le score d’Epworth moyen etait de 2,2 ± 1,84 dans la population globale alors qu’il etait de 5,2 ± 1,2 chez les patients presentant un SAOS severe. En regression logistique, un score d’Epworth ≥ 4 etait un facteur predictif independant d’un syndrome d’apnees obstructives du sommeil severe (OR = 28 ; 95 % IC : 8–101 ; p Conclusion La prevalence du SAOS au decours d’un infarctus du myocarde etait tres elevee. Un score d’Epworth ≥ 4 etait un facteur predictif independant de SAOS severe. En depit de son caractere subjectif, ce score semble interessant pour la selection des coronariens pour l’etude polysomnographique.

BACKGROUND: Several studies have reported a circadian variation in the occurrence of sudden cardiac death. AIM: To analyze the circadian, weekly and seasonal variations of sudden cardiac death occurring in northern Tunisia. METHODS: We prospectively collected epidemiological and autopsic data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between October 2010A‚ and September 2012. RESULTS: The study population included 392A‚ men and 108A‚ women with a mean age of 52.3A‚±15.8A‚ years. Physical inactivity and smoking were the most common risk factors, they accounted for 76.4% and 57.9% respectively. Family history of sudden death was identified in 9.8% of victims. The vast majority of deaths occurred in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the most frequent causes of death (269A‚ cases). Sudden cardiac death was homogeneously distributed over the day. A maximum of events occurred on Sundays (17.8%) and a minimum on Mondays (11.4%), we also recorded an excess cardiac mortality in winter with a peak in December and a nadir in September (13% vs. 4.4% P=0.0001). CONCLUSIONS: In northern Tunisia, under Mediterranean climate, a winter excess cardiac mortality was found. Sudden cardiac death was homogeneously distributed over the day, however, an excess of mortality was recorded over the weekend with a nadir on Monday.

Resume Introduction Le risque cardiovasculaire apparait tres tot dans l’histoire du diabete, il est lie a l’hyperglycemie mais surtout aux autres facteurs de risque frequemment associes. Objectif Evaluation de la prevalence des facteurs et des marqueurs de risque cardiovasculaire non conventionnels dans une population de diabetiques tunisiens. Methodes Nous avons inclus dans une etude prospective des patients diabetiques de type 2 recemment diagnostiques et des temoins non diabetiques apparies selon l’âge et le sexe. Parallelement au bilan biologique classique, une analyse des facteurs de risque cardiovasculaires non traditionnels a ete realisee : microalbuminurie des 24 heures, C reactive proteine ultrasensible (CRPus), homocysteine, vitamine B12, folates et insulinemie. Tous les participants ont beneficie de plus d’une echographie abdominale a la recherche d’une steatose hepatique. Resultats L’âge moyen des 120 patients diabetiques (51,4 ± 8,9 ans) etait comparable a celui des 60 temoins (50,1 ± 6,39 ans). Une microalbuminurie etait retrouvee chez 27,5 % des diabetiques et 6,9 % des temoins (OR = 5,1 ; p = 0,001). Les deux tiers des diabetiques avaient un syndrome metabolique contre un quart des temoins (OR = 6,0 ; p Conclusion Les facteurs de risque cardiovasculaire non traditionnels etaient plus frequemment observes chez les sujets ayant un diabete de type 2 de decouverte recente que dans la population temoin. Ces facteurs non conventionnels peuvent etre utiles pour la stratification du niveau du risque et pour guider la strategie de depistage des cardiopathies ischemiques.

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.

Background Conduction disorders in the postoperative period of cardiac surgery impedes prompt clinical recovery and prolongs hospitalization. The aim of this study was to identify the predictive factors of pace maker dependency in patients with high grade atrioventricular block (AVB) after cardiac surgery. Methods 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 AVB requiring definitive pacemaker implantation following cardiac surgery. We 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 screening of conduction disorders in patients undergoing cardiac surgery since immediate postoperative period.

Resume But de l’etude Les objectifs de notre travail etaient de dresser un profil des victimes de mort subite au cours d’une activite sportive et d’etudier les circonstances et les causes de la mort et les caracteristiques autopsiques et anatomopathologiques des victimes. Methodes Il s’agit d’une etude retrospective portant sur les cas de mort subite chez des sportifs dont l’autopsie a ete effectuee au service de medecine legale de l’hopital Charles Nicolle de Tunis, entre le mois de janvier 2005 et le mois de decembre 2009. Resultats Durant la periode d’etude, 32 cas de MSS ont ete enregistres. Il s’agit de sportifs amateurs majoritairement de sexe masculin (84 % des cas). Les victimes sont âgees entre 15 et 79 ans avec une moyenne d’âge de l’ordre de 33,16 ans. Les sujets jeunes dont l’âge est inferieur a 35 ans representant 68,7 % des cas. 9,3 % des victimes avaient des antecedents familiaux de MS et 18,7 % des cas avaient des antecedents cardiaques connus. Les sports les plus en cause sont la course a pied (40,6 % des cas), le football (31,3 % des cas) et la danse (12,5 % des cas). 69 % des victimes sont decedees pendant l’activite sportive. La presence de temoins a ete notee dans tous les cas, cependant aucun de ces temoins n’a entrepris des manœuvres de reanimation. La mort est d’origine cardiaque dans 84,4 % des cas. Chez les jeunes sportifs âges de moins de 35 ans, la cardiomyopathie hypertrophique constitue la premiere cause (neuf cas), suivie de la dysplasie du ventricule droit arythmogene (trois cas). Parmi les autres causes, on trouve le pont myocardique, les anomalies congenitales des arteres coronaires, la dissection aortique et la cardiomyopathie dilatee. Au-dela de 35 ans, la maladie coronaire etait la plus frequente (neuf cas). Le seul cas de deces secondaire a une pathologie non cardiaque est survenu suite a une crise d’asthme severe. Dans quatre cas (12,5 %), l’autopsie etait blanche et l’histologie n’a pas revele d’anomalies microscopiques. La cause de la mort a ete imputee a une pathologie rythmique. Conclusion Il s’agit de la premiere etude necropsique tunisienne traitant de la MSS ayant permis de dresser un profil de victimes specifique a la Tunisie. D’autres etudes portant sur de plus grands echantillons et utilisant des protocoles necropsiques standardises restent necessaires.

Introduction 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. Methods 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. Results 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. Conclusion 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 echocardio-graphic 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.

Background 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 occurrence of FMR in non-ischemic DCM. Methods Prospective study involving 52 patients (mean age = 57 ± 10 years, sex ratio = 1.8) with non ischemic dilated cardiomyopathy. Two groups were compared: the group with FMR (group MR+ = 31 patients) and that without FMR (group MR− = 21 patients). Results Mean QRS duration was 141 ± 29 ms and 63% of patients had complete left bundle branch block (LBBB), with no significant difference between the 2 groups. The echocardiographic parameters representing left ventricular systolic function were similar in the 2 groups except for cardiac output which was lower in the group MR+ (3.3 ± 1 L/min vs 4 ± 1.3 L/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 Conclusion 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.

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 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.

To determine frequency of pulmonary embolism as the cause of sudden death and to study clinical, epidemiological characteristics and risk factors.Prospective study of cases of sudden death secondary to pulmonary embolism, whose autopsy was performed in the forensic department of Tunis, between October 2009 and of September, 2011.During study period, 37 cases of pulmonary embolism were recorded. They represented 6.8 % of all cases of sudden cardiovascular deaths. Victims were male in most cases (65 %). Victims were aged between 21 and 87 years with an average age of about 52 years. Pathological histories were noted in 9 cases: three cases of recent surgery, four cases of pelvic trauma, a case of ovarian tumor and a case of which the PE arose in post-partum. Concerning other risk factors of pulmonary embolism, confinement to bed was noted in 24 cases (64.8 %), obesity in 12 cases (32.4 %), an arterial high blood pressure in 4 cases. Histories of psychiatric pathology were noted in 5 cases (13.5 %). Symptomatology preceding death was dominated by sudden death (35 %) followed by dyspnoea (30 %) and thoracic pains (16 %). In 8 cases , victims consulted emergencies within 48 hours preceding death, for a varied symptomatology without diagnosis of pulmonary embolism is suspected. At autopsy, in 30 cases embolism was massive. In 29 % of the cases, a deep venous thrombosis was revealing in particular at the primitive iliac veins.Pulmonary embolism is an affection that still kills a lot. It can benefit from prevention and from an effective treatment. This testifies the major importance of clinical diagnosis of pulmonary embolism as well as the technical means for the diagnosis.

Objectif Analyser les performances du questionnaire d’Edimbourg (QE) dans le depistage de l’arteriopathie obliterante des membres inferieurs (AOMI) chez les diabetiques de type 2. Patients et methode Il s’agit d’une etude transversale ayant concerne 150 patients diabetiques de type 2 non connus porteurs d’AOMI. Tous ces patients ont repondu au QE et ont beneficie d’un examen des pouls et de mesure de l’index de pression systolique bras-cheville (IPS). L’AOMI etait definie par un IPS Resultats L’âge moyen des patients etait de 57,46 ± 8,04 ans et le sex-ratio (H/F) de 1,3. Selon le QE, une claudication intermittente a ete retrouvee chez 17 patients, ce qui correspondait a une frequence de 11,3 %. A la palpation des pouls pedieux et tibiaux posterieurs, 42 patients (28 %) avaient au moins un pouls faible ou aboli. Selon l’IPS, la prevalence de l’AOMI etait de 16 %. L’aire sous la courbe ROC pour depister une AOMI par le QE etait de 0,58 [intervalle de confiance a 95 % : 0,46–0,69], p = 0,2. La sensibilite, la specificite, la valeur predictive positive et la valeur predictive negative du QE etaient respectivement de 25 % ; 90,3 % : 35,3 % et 85 %. Parmi les faux negatifs (n = 18), 9 patients avaient une neuropathie peripherique (NP). Discussion Chez les diabetiques, le QE avait une tres faible sensibilite pour le depistage de l’AOMI. En effet, le taux important de faux negatifs, pouvant etre explique en partie par la NP, limite l’utilisation de ce questionnaire dans cette population.

Background Whether percutaneous mitral commissurotomy (PMC) should be attempted in patients with severe mitral stenosis and commissural calcifications remains debated, since commissural splitting is the mechanism by which mitral valve stenosis is relieved. Purpose To determine whether the presence of calcium in the mitral valve commissures influence the immediate result of PMC. Methods PMC by the Inoue balloon was attempted in 247 patients (mean age: 35 years) with severe mitral valve stenosis. 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. Results After PMC, the mean MVA increased to 1.79 ± 0.34 cm2 (P Conclusion 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.

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.

Several studies have reported a circadian variation in the occurrence of sudden cardiac death.To analyze the circadian, weekly and seasonal variations of sudden cardiac death occurring in northern Tunisia.We prospectively collected epidemiological and autopsic data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between October 2010 and September 2012.The study population included 392 men and 108 women with a mean age of 52.3±15.8 years. Physical inactivity and smoking were the most common risk factors, they accounted for 76.4% and 57.9% respectively. Family history of sudden death was identified in 9.8% of victims. The vast majority of deaths occurred in a public place (41.4%) or at home (36.6%). Ischemic heart disease was the most frequent causes of death (269 cases). Sudden cardiac death was homogeneously distributed over the day. A maximum of events occurred on Sundays (17.8%) and a minimum on Mondays (11.4%), we also recorded an excess cardiac mortality in winter with a peak in December and a nadir in September (13% vs. 4.4% P=0.0001).In northern Tunisia, under Mediterranean climate, a winter excess cardiac mortality was found. Sudden cardiac death was homogeneously distributed over the day, however, an excess of mortality was recorded over the weekend with a nadir on Monday.

Introduction Ebstein's disease is a rare congenital malformation with many clinical manifestations depending on the age at diagnosis and the severity of the anatomical pattern. In this study we try to describe the clinical manifestations, the echocardiographic patterns and the outcome of this malformation in adulthood. Methods and results Retrospective study about 8 cases of Ebstein's anomaly in adult patients (5 women and 3 men); the mean age is 34 years old. The clinical manifestations were absent in 6% of cases but the majority of patients have exertional dyspnea or palpitations in 56% of cases. Arrhythmias and congestive heart failure were observed respectively in 6% and 13% of cases. Transthoracic echocardiography demonstrated the presence of Ebstein anomaly in all cases, showing apical displacement of the septal leaflet of the tricuspid valve. Five patients had the A grade of the Carpentier's classification and the others had the grade B. After an outcome of 11 years, one patient died by refractory heart failure. Conclusion Clinical manifestations and outcome of Ebstein's anomaly depend on the degree of tricuspid valve malformation and many cases are discovered in adults. The prognosis is worsening by arrhythmia and heart failure. Surgical intervention with tricuspid valve repair should be proposed for patients with severe heart failure and intractable arrhythmia. Conservative surgery and anti arrhythmic therapy had enhanced the prognosis of this congenital malformation.

Introduction Left ventricular aneurysm (LVA) constitutes an important complication of acute transmural myocardial infarction (MI). Angiographically defined, LVA has been reported in 7.6% of patients with coronary artery disease (CAD) referred for coronary angiography. It is well established that patients with LVA are exposed to a higher incidence of complications such as arrhythmias, thromboembolic phenomena, and congestive heart failure. Case report We report the case of a 76-year-old woman, hypertensive, diabetic, with a history of percutaneous coronary angioplasty with stenting of the distal and mid segments of left anterior descending artery (LAD) for myocardial infarction 10 months ago, admitted to our cardiology department for acute coronary syndrome without ST-segment elevation complicated by left ventricular failure. The electrocardiogram showed sinus rhythm at 100 beats per minute with abnormal Q waves (sequelae of necrosis) in the inferior leads. Transthoracic and transesophageal echocardiography revealed an aneurysm of the infero-basal left ventricular wall, having implantation base in the small mitral valve, measuring 44 mm × 44 mm and filled by a thrombus. The LV was dilated and hypertrophied with a reduced ejection fraction (EF) of 40%. There was a severe ischemic mitral regurgitation (MR). MRI confirmed the ultrasound findings. The coronary angiography objective diffuse coronary restenosis in the stent of the LAD and an occlusion of the distal right coronary artery, not supplied by the left coronary arteries. The indication for surgery was taken. The patient underwent a coronary artery bypass grafting of LAD, a mitral valve repair by Carpentier ring and a resection of the ventricular aneurysm. Her postoperative course was uneventful. The postoperative echocardiographic control showed an improvement of LVEF to 50%, a minimal MR. Conclusion The left ventricular aneurysm, late mechanical complication of myocardial infarction, presents a management problem. Surgical treatment is usually effective and followed by a marked improvement in function but is burdened with a heavy postoperative mortality.

Objectives Define echocardiographic predictors of the immediateresults of percutaneous mitral balloon commissurotomy (PMC) Methods 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. Results 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±0,19cm 2 (range 0,5–1,4cm 2 ). Twenty-nine patients (11,7%) had one-commissural calcification. After PMC, the mean MVA increased to 1,79±0,34cm 2 (p 8, this score had a weak predictive value. Commissural morphology was another independent predictor of the immediate result of PMC. Conclusion 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.

Introduction Acute pulmonary embolism (PE) remains a life-threatening disease and one of three major disease entities with chest discomfort seen in the emergency room. Despite progress in imaging techniques and knowledge of this disease, its medical diagnosis is one of the most difficult to achieve. The clinical assessment of PE probability remains central to the diagnosis and evaluation. Presently, accepted diagnostic modalities for the confirmation of PE include V/Q scanning, chest CT, and standard angiography. All approaches have limitations. Because echocardiography is noninvasive, provides rapid bedside results. It is an attractive imaging modality to diagnose PE. Purpose The purpose of this study is to assess the contribution of transthoracic echocardiography (TTE) in the clinical setting of PE. Results Eighteen patients were included. There were 7 men and 11 women. The mean age was 57 years [28; 80]. TTE was performed in all patients within the first 24 to 72 hours of admission. The diagnosis of PE was confirmed by standard angiography in all cases. Tricuspid regurgitation was the most common TTE finding (16 of 18), followed by dilated right ventricle (15 of 18), pulmonary hypertension (11 of 18), paradoxical interventricular septal motion (7 of 18) and right ventricular hypokinesis (2 of 18). TTE revealed thrombi inside the right-sided heart cavities in 3 patients. The thrombus was detected at the apex of the right ventricle in the first case, at the right atria in the second case and many thrombi were objectified even at the right atria and ventricle, at the inferior vena cava and at the left pulmonary artery in the third case. Conclusion Transthoracic echocardiography may reveal findings that strongly support hemodynamically significant PE. In the majority of cases TTE provides only indirect signs of PE. It could, though, far less frequently visualise thromboembolic material inside the right-sided heart cavities. Direct visualisation of the thrombus, although confirming PE, remains an exceptional finding. This may be useful for prompt decision making in patients with haemodynamic compromise considered for thrombolysis or embolectomy.

Introduction Arterial hypertension (AH) is a potent factor of cardiovascular death in chronic dialysis patients (CDP). Development of ambulatory blood pressure monitoring (ABPM) allowed a better analysis of inter dialysis blood pressure (BP) profile. We studied the relationship between ABPM findings and clinical and biological data in CDP, to determinate its clinical application. Methods Retrospective study of 24 hours ABPM (after dialysis) in 28 CDP divided into 3 groups according to pre dialyses BP profile: G1: CDP with controlled AH (n=8) G2: CDP with un-controlled AH (n=12) G3: CDP without AH (n=8) Results ABPM findings are correlated to clinical BP measurements before and after dialysis. Mean systolic ABP is lower than pre dialysis clinical BP. 82% of CDP loose the BP circadian cycle. 64,3% of CDP and 83,3% of patients with AH had echocardiographic left ventricular (LV) hypertrophy. LV mass is correlated to BP load, the anemia's severity, the loss of the BP circadian cycle and the use of acetate in dialysis bath. Conclusion ABPM in CDP has various clinical applications: • diagnosis of AH • Evaluation of AH treatment • Evaluation of cardiovascular death risk

IntroductionIn discrete fixed subaortic stenosis, surgery is indicated when the systolic gradient (Gmax) between the left ventricle (LV) and the aorta exceed 50mmHg or in the presence of significant aortic regurgitation (AR).The aim of this study is to determine the factors that influence the progression of the obstruction and the appearance of AR.Methodsretrospective serial echocardiographic review of 19 patients, mean age 16 years (2 years-38 years), with fixed discrete subaortic stenosis that don’t require surgery (initial Gmax at inclusion 2mmHg/year)Conclusionthe identification of factors determining the evolution of discrete subaortic stenosis (age 40mmHg, distance membrane-cusps >5mm) allows an adequate screening of patients that will require early operation.

To identify prognostic risk factors for in-hospital outcome of right ventricular myocardial infarction (RVI).A retrospective study of 20 patients admitted with acute myocardial infarction with a RVI defined by ST segment elevationor = 1 mm in V3R and V4R leads.The mean age was 62 years. RVI was associated with an inferior myocardial infarction in 18 patients. Half of the patients had hemodynamic complication on admission (cardiogenic shock in 4 cases, right ventricular failure in 6 cases) and third degree atrio-ventricular block was present in 5 patients. Sixteen patients (80%) received thrombolysis and 3 went to an emergency angioplasty. The in-hospital mortality was 25% caused by a cardiogenic shock in 4 patients and a ventricular fibrillation in 1 patient. Statistic analysis showed that cardiogenic shock on admission, the absence of thrombolytic therapy and the low ejection fraction of the left ventricle were associated with a high in-hospital mortality (p = 0.004, p = 0.03, p = 0.03 respectively).In-hospital outcome of RVI is characterized by hemodynamic complications leading to a high incidence of mortality. Thus RVI must be diagnosed quickly and maximal therapeutic efforts must be done to procure the opening of the occluded coronary artery.

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 was to determine the relative importance of the global and regional left ventricular (LV) remodeling in the occurrence of IMR. Methods 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. Results The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity (p 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.

Purpose Despite significant enhancements in resuscitation methodology, survival after sudden cardiac arrest remains low. Improved knowledge of warning signs and symptoms may help to detect victims for sudden death. Aim to study the warning symptoms prior to sudden cardiac death. Methods We prospectively collected epidemiological and autopsy data from victims of sudden cardiac death in northern Tunisia (3.6 million people) between October 2012 and September 2013. We included victims ?20 years old requiring a forensic autopsy. Data (risk factors, symptoms) were collected by assessment of the accounts of family members/relatives, witnesses, as well as medical records during this time period. The heart was weighed and then investigated by macroscopic examination looking for scars of myocardial infarction. The three main coronary arteries were macroscopically examined by transverse slices at 2-3-mm intervals along their lengths. Results Of the 542 sudden deaths within the study period, 372 males and 91 females were medico-legally autopsied. Mean age of victims was 50.9±15 years. Physical inactivity and smoking were the most common risk factors, accounting for 74.7% and 61.5%, respectively. A family history of sudden death was identified in 10.8% of victims. Most deaths occurred in a public place (39.3%) or at home (36.9%). Of the total deaths, 298 (64.4%) occurred while the individuals were relaxing, 52 (11.2%) while sleeping, 92 (19.9%) while dealing with an activity, and 21 (4.5%) under emotional stress. Syncope was the most frequent symptom occurring in 36.1%, chest pain in 18.6%, dyspnea in 8.6% and 10.1% had dizziness or fainting. The autopsic study showed that 231 deaths (49.9%) were due to coronary artery diseases. Eight percent of victims have consulted a doctor within the last 48 hours and 21% up to 1 month. Conclusions Warning symptoms prior to sudden cardiac death may occur longer before the death. Recognizing these precocious signs could have implications for prevention of this public health problem.

IntroductionPercutaneous 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.Methods322 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 >1,5cm2 and gain in MA >25% and mitral regurgitation (MR) ≤ grade 2. Mitral restenosis is defined as a MA 50% of initial gain in MA.ResultsThe rate of primary success of PMC was 86% and mean MA post PMC was 1,82±0,33cm2 compared to MA pre-PMC of 1±0,18cm2 (p 8, MA after PMC

We present the case of a 30-year-old female patient with few coronary risk factors for atherosclerosis but with 3-vessel coronary artery disease possibly secondary to Kawasaki disease. Coronary angiography showed total occlusion of the left anterior descending artery and a right coronary artery aneurysm. Quadruple coronary artery bypass was performed. The postoperative course was uneventful.

IntroductionMitral regurgitation developing in the course of myocardial infarction significantly worsens survival. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of ischemic mitral regurgitation (IMR).Methods81 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.ResultsThe echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity (p

IntroductionFunctional 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.Methods81 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 (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.ResultsThe echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity (p

Objectives The purpose of this study is to assess cardiac remodeling and to determine factors predicting the occurrence of atrial arrhythmia after surgical closure of atrial septal defect (ASD) in adults. Methods 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. Results 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 4 patients and were determined by older operative age (p=0.003) and the absence of cardiac remodeling after surgery. Conclusion 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.

IntroductionCardiac resynchronization therapy (CRT) has emerged as an established therapy for congestive heart failure (CHF). However, up to 30% of patients fail to respond to CRT despite prolonged QRS and some other patients respond to CRT despite thin QRS.The aim of this study was to define the prevalence of mechanical (atrioventricular, interventricular and intraventricular) dissynchrony in heart failure patients with different QRS durations.MethodsA 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.ResultsAccording to QRS duration, 16 patients had QRS ≥150ms (group 1), 15 patients had QRS duration between 120 and 149ms (group 2) and 15 patients had QRS duration < 120ms (group 3). Interventricular dyssynchrony (IVD) was present in 62% of group 1, 13% of group 2 and was absent in group 3 (p

Introduction Heart failure is a common problem in elderly people. In the elderly population, heart failure with preserved ejection fraction (HFPEF) has been increasingly recognized. The aim of this study was to compare clinical features and clinical outcomes between HFPEF and HFREF in patients older than 65 years. Methods We enrolled 30 patients over 65 years old, who were admitted for heart failure between April 2009 and February 2010. We retrospectively analysed the clinical features including laboratory data and echocardiography parameters. Results In 19 patients (63%) left ventricular ejection fraction was preserved. Acute pulmonary edema (74% vs 27%) is the most frequent presentation in patients with HFPEF. Those patients have thicker left ventricular wall (68% vs 27%). The ischemic heart diseases as background disease is more frequent in HFREF (46% vs 5, 2%). There was no difference in short-term outcomes between HFPEF and HFREF. Conclusion Our study has shown that more than the half of the CHF patients over 65 years of age had HFPEF. Left ventricular hypertrophy was one of the risk factors for HFPEF, and the short-term outcomes of HFPEF in this population were not different from that of HFREF.