Search

Abstract Introduction Post-COVID syndrome (PCS) is characterized by a polymorphism of symptoms with hypothetical pathophysiological mechanisms. Here, we aimed to analyze the profile of inflammatory cytokines in patients with PCS and to study the relationship between this profile, the clinical symptoms as well as the endothelial function in PCS. Methods Our analytical study involved all eligible patients (n = 66) with PCS included from April 2021 to December 2021. The serum concentration of cytokines IFN-γ, IL-1α, IL-1β, IL-6, IL-8, IL-10, IL-12p70, IL-27, IP-10, MCP-1 and TNF-α was quantified by flow cytometry. Endothelial function was explored by assessing microvascular flow and reactivity using thermal probes. A comparative study was carried out according to the presence of each PCS symptom. Results The average age of our patients was 55.9 ± 16.2 years. The sex ratio was 0.69. Forty-one patients (62%) presented with a severe form of acute infection. The most frequently reported symptoms were dyspnea (67%), fatigue (50%), and memory problems (32%). Fifty-seven patients (86%) had endothelial dysfunction. The majority of patients had increased levels of IP-10 (100%), IL-8 (95%), IFN-γ (95%), MCP-1 (80%), and TNF-α (70%). The serum concentration of IL-10 was below the threshold of quantification in 89% of subjects. The severe form of acute infection was associated with elevated IL-10, MCP-1, and IL-27. Increased IL-6 and IL-27 levels were associated with fatigue while IL-8 concentrations were higher in patients who reported dyspnea. Elevation of IL-8 level was more common in patients with profound impairment of endothelial function. Conclusion Our results further support the presence of endothelial dysfunction in PCS and show an elevation of pro-inflammatory cytokines with a downmodulation of the IL-10- anti-inflammatory response. In addition, immuno-clinical phenotypes emerge, such as an inflammatory profile mediated by IL-6 and IL-27 in fatigue and IL-8 in dyspnea. The identification of immuno-clinical phenotypes would allow a better understanding of the pathophysiology of PCS symptoms.

Abstract Background Peripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening condition. Due to the scarcity of epidemiological data in North Africa, we conducted this study to assess the outcomes of PPCM in our region. Materials and methods This monocentric retrospective cohort study involving all patients diagnosed with PPCM was conducted between January 2010 and December 2022. Results Twenty-seven PPCM patients, with a median age of 33 years (Interquartile range (IQR) = 9), were included. 52% of patients were diagnosed during the postpartum period. Dyspnea New York Heart Association III/IV(NYHA III/IV) was the most common functional symptom (85%). The median left ventricle ejection fraction (LVEF) was 30% (IQR = 11%). Atrial fibrillation occurred in 11.1% of patients, thromboembolic complications occurred in 18.5%, Pulmonary edema occurred in 85% of patients and cardiogenic shock occurred in 14.8% of patients, with two patients requiring Extracorporeal Membrane Oxygenation (ECMO) support. The predominant mode of delivery was a cesarean Sect. (82% of patients), and the indication for a cesarean delivery was obstetrical in 59% of patients. Prematurity occurred in 36% of newborns, and intrauterine fetal death occurred in one pregnancy. The median follow-up was 24 months [6–144 months]. LVEF recovery was noted in 67% of patients. Bromocriptine was administered to six patients (22%), and none of these patients died and out of them, five patients recovered their LVEF (83%). The overall mortality rate during the follow-up period was 15%, comprising three in-hospital cardiac deaths and one occurring two years later due to refractory advanced heart failure. No significant differences were observed between LVEF recovery and LVEF non-recovery groups. Factors significantly associated with mortality were multiparity, poor antenatal care (ANC) attendance, thromboembolic events, cardiogenic shock, and Pulmonary edema. Five patients with LV recovery subsequently became pregnant, none experienced a relapse of PPCM. However, one of the descendants of a patient was diagnosed with dilated cardiomyopathy. Conclusion This study revealed that the diagnosis of PPCM in our hospital is often delayed until symptoms become more advanced, resulting in high morbi-mortality.

Hereditary haemorrhagic telangiectasia is a rare disease characterized by cutaneo-mucous and visceral arteriovenous malformations. Cardiac involvement is uncommon and was presented primarily by hyper-output heart failure. Hemorrhagic pericardial effusion, although is extremely rare, can occur during HHT. We report the case of a 48-years-old woman which was hospitalized in 2015 in internal medicine department, Sfax, Tunisia in 2015 for anicteric cholestasis. She noticed a personnel and familial history of recurrent epistaxis. Biologic findings revealed anemia and moderate cholestasis. Viral investigations and immunologic tests were negative. Abdominal tomography showed multiple arterio-venous shunts of the liver. Liver involvement due to Rendu Osler Weber disease was retained. She was treated by ferrous iron, but she was lost to follow up. She was presented in February 2021, with severe anemia (5 g/dL). Physical examination revealed signs of global heart failure. Biological investigations found anemia, inflammatory biological syndrome, cytolysis and cholestasis. Heart ultrasound revealed an abundant pericardial effusion. Only 500cc of hemorrhagic fluid could be aspirated before the needle became blocked. Unfortunately, one week after, re-accumulation of pericardial fluid and worsening occurred. She underwent a partial surgical pericardial excision with pleuropericardial opening. Analysis of the fluid ruled out any infectious cause of this effusion. Histological examination confirmed the vascular dysplasia with signs of hemorrhage and inflammation. The patient was discharged 1 month after surgery with no other bleeding episodes. For her anemia, she received a transfusion of red blood cells. Then, the patient was treated by iron treatment.

Background Over the past decade, major society guidelines have recommended the use of newer P2Y12 inhibitors over clopidogrel for those undergoing percutaneous coronary intervention for acute coronary syndrome. It is unclear what impact these recommendations had on clinical practice. Methods and Results All percutaneous coronary intervention procedures (n=534 210) for acute coronary syndrome in England and Wales (April 1, 2010, to March 31, 2022) were retrospectively analyzed, stratified by choice of preprocedural P2Y12 inhibitor (clopidogrel, ticagrelor, and prasugrel). Multivariable logistic regression models were used to examine odds ratios of receipt of ticagrelor and prasugrel (versus clopidogrel) over time, and predictors of their receipt. Overall, there was a significant increase in receipt of newer P2Y12 inhibitors from 2010 to 2020 (2022 versus 2010: ticagrelor odds ratio, 8.12 [95% CI, 7.67–8.60]; prasugrel odds ratio, 6.14 [95% CI, 5.53–6.81]), more so in ST‐segment–elevation myocardial infarction than non–ST‐segment–elevation acute coronary syndrome indication. The most significant increase in odds of receipt of prasugrel was observed between 2020 and 2022 (P

BackgroundIn Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics. ObjectiveThe study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention. MethodsThe Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite). ResultsThe study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation. ConclusionsThis study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care. Trial RegistrationClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759 International Registered Report Identifier (IRRID)RR1-10.2196/47525

Key Clinical Message Anomalous insertion of chordae is a rare disease that could be associated with hypertrophic obstructive cardiomyopathy (HOCM), but clinical and echocardiographic diagnoses tend to be delayed. Alcohol septal ablation has emerged as an alternative to surgical myomectomy in HOCM. When a patient showed an anomalous insertion of chordae, physicians generally opt for surgery and not alcohol septal ablation. In this report, we present the case of a lady, with symptomatic HOCM associated with a chord inserted on the left ventricular outflow tract. We succeeded to relieve obstruction by alcohol septal ablation without the need for surgery.

Abstract Background Hypertension is the leading cause of morbi-mortality in our country. Thus, we conducted this national survey on hypertension to analyze the profile of the Tunisian hypertensive patient and to assess the level of blood pressure control. Methods Nature HTN is an observational multicentric survey, including hypertensive individuals and consulting their doctors during the period of the study. Blood pressure measurements were conducted during consultation, using a standardized auscultatory or oscillometric sphygmomanometer after at least 15 min of rest. The diagnosis of new hypertension is based on the 2018 ESC/ESH criteria. The primary endpoint of our study was uncontrolled hypertension defined by a systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Results Three hundred twenty-one investigators participated in the study. We enrolled 25,890 patients with a female predominance (Sex ratio, 1.21) and an average age of 64.4 ± 12.2 years. Most individuals were treated in the public sector (74%), 39.4% of patients were diabetic, 25.8% were obese, 44.6% were overweight and 14% were smokers. Hypertension was controlled in 51.7% of cases if we consider 140/90 as a BP target, and only in 18.6% if we consider 130/80 as a target. The independent predictors of uncontrolled blood pressure were male sex (OR = 1.09, 95%CI [1.02–1.16]), age > 65 year-old (OR = 1.07, 95% CI[1.01–1.13], diabetes (OR = 1.18, 95% CI [1.11–1.25], Smoking (OR = 1.15, 95% CI [1.05–1.25]), Obesity (OR = 1.14, 95% CI[1.07–1.21]), management in public sector (OR = 1.25, 95% CI [1.16–1.34]), and Heart rate > 80 bpm (OR = 1.59, 95% CI [1.48–1.71]). Contrarily, high educational level (OR = 0.9, 95% CI [0.84–0.97], absence of history of coronary disease (OR = 0.86, 95% CI [0.8–0.93]), salt restriction (OR = 0.48, 95% CI [0.45–0.51]), drug compliance (OR = 0.57, 95% CI[0.52–0.61]), and regular physical activity (OR = 0.77, 95% CI[0.71–0.84]) are strong predictors of blood pressure control. Conclusion NaTuRe HTN showed that blood pressure control was reached in more than half of the Tunisian people. The control remains low in patients with high cardiovascular profiles and in those treated in the public sector. A national health program based on therapeutic education, regular control and continuous support to the public institutions is needed to decrease the burden of hypertension incidence rate.

BackgroundRadial artery occlusion (RAO) remains the most frequent complication of trans-radial access. Once the radial artery is occluded, its future use as an access site for coronary procedures, or as a conduit for coronary bypass grafting or fistula for hemodialysis, will be precluded. Therefore, we aimed to assess the value of the short-term use of Rivaroxaban to prevent RAO after a trans-radial coronary procedure.MethodsThis was a prospective, open-label, randomized study. The patients were randomly assigned (1:1) to one of two groups: those who received Rivaroxaban 10 mg for 7 days following the trans-radial coronary procedure (the Rivaroxaban Group) and those who received the standard treatment (the Control Group). The primary outcome was an occurrence of RAO evaluated by Doppler ultrasound at 30 days, and the secondary outcomes were hemorrhagic complications according to BARC classification.ResultsWe included 521 patients randomized into two Groups: the Control Group (N = 262) and the Rivaroxaban Group (N = 259). The 1-month RAO was significantly reduced in the Rivaroxaban Group as compared to the Control Group [6.9% vs. 13%; p = 0.011, OR = 0.5, (95% CI, 0.27–0.91)]. We noted no cases of severe bleeding events (BARC3-5). The overall incidence of minor bleeding (BARC1) was 2.3%, with no significant difference between the two groups [Rivaroxaban Group = 2.7%, Control Group = 1.9%, p = 0.54, OR= 1.4, (95%CI 0.44–4.5)].ConclusionsShort-term postoperative anticoagulation with Rivaroxaban 10 mg for seven days reduces the rate of 1-month RAO.

Abstract Background Severe valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease. Methods This is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017. Results We included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12–5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26–31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14–41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01–1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15–23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19–23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002–1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98–38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2–84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4–36.1]). Conclusions Revelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

BackgroundThis trial aimed to assess the efficacy of Atorvastatin reloading on the prevention of Contrast-induced nephropathy (CIN) in patients pre-treated with this statin and undergoing coronary catheterization.MethodsThis was a prospective randomized controlled study including patients on chronic atorvastatin therapy. We randomly assigned the population to the Atorvastatin Reloading group (AR group), by reloading patients with 80 mg of atorvastatin one day before and three days after the coronary procedure, and the Non-Reloading group (NR group), including patients who received their usual dose without a reloading dose. The primary endpoints were the incidence of cystatin (Cys)-based CIN and Creatinine (Scr)-based CIN. The secondary endpoints consisted of the changes in renal biomarkers (Δ biomarkers) defined as the difference between the follow-up level and the baseline level.ResultsOur population was assigned to the AR group (n = 56 patients) and NR group (n = 54 patients). The baseline characteristics of the 2 groups were similar. Serum creatinine (SCr)-based CIN occurred in 11.1% in the NR group, and in 8.9% in the AR group without any significant difference. Cys-based CIN occurred in 37% in the NR group and 26.8% in the AR group without any significant difference. The subgroup analysis showed that high dose reloading had significantly reduced the CYC-based CIN risk in patients with type 2 diabetes (43.5% vs 18.8%, RR = 0.43. CI 95% [0.18-0.99])). The comparison of "Δ Cystatin" and Δ eGFR between the AR and NR groups didn't show any significant difference. However, cystatin C had significantly increased between baseline and at 24 hours in the NR group (0.96 vs 1.05, p = 0.001), but not in the AR group (0.94 vs 1.03, p = 0.206).ConclusionsOur study did not find a benefit of systematic atorvastatin reloading in patients on chronic atorvastatin therapy in preventing CIN. However, it suggested that this strategy could reduce the risk of CyC-based CIN in diabetic type 2 patients.

Abstract We report a case of balloon shaft rupture during percutaneous coronary intervention. Although the entrapped balloon was not yet deflated when the complication occurred, we successfully retrieved it percutaneously using a trapping technique. This case described a cheap and straightforward technique of device retrieval that helped save our patient.

BackgroundCurrent predictive models based on biomarkers reflective of different pathways of heart failure with reduced ejection fraction (HFrEF) pathogenesis constitute a useful tool for predicting death risk among HFrEF patients. The purpose of the study was to develop a new predictive model for post-discharge mortality risk among HFrEF patients, based on a combination of clinical patients’ characteristics, N-terminal pro-B-type Natriuretic peptide (NT-proBNP) and oxidative stress markers as a potentially valuable tool for routine clinical practice.Methods116 patients with stable HFrEF were recruited in a prospective single-center study. Plasma levels of NT-proBNP and oxidative stress markers [superoxide dismutase (SOD), glutathione peroxidase (GPX), uric acid (UA), total bilirubin (TB), gamma-glutamyl transferase (GGT) and total antioxidant capacity (TAC)] were measured in the stable predischarge condition. Generalized linear model (GLM), random forest and extreme gradient boosting models were developed to predict post-discharge mortality risk using clinical and laboratory data. Through comprehensive evaluation, the most performant model was selected.ResultsDuring a median follow-up of 525 days (7–930), 33 (28%) patients died. Among the three created models, the GLM presented the best performance for post-discharge death prediction in HFrEF. The predictors included in the GLM model were age, female sex, beta blockers, NT-proBNP, left ventricular ejection fraction (LVEF), TAC levels, admission systolic blood pressure (SBP), angiotensin-converting enzyme inhibitors/angiotensin receptor II blockers (ACEI/ARBs) and UA levels. Our model had a good discriminatory power for post-discharge mortality [The area under the curve (AUC) = 74.5%]. Based on the retained model, an online calculator was developed to allow the identification of patients with heightened post-discharge death risk.ConclusionIn conclusion, we created a new and simple tool that may allow the identification of patients at heightened post-discharge mortality risk and could assist the treatment decision-making.

BackgroundThis study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions. ObjectiveThis study will provide us an overview of hypertension (HTN) management in Tunisia and the degree of adherence of practitioners to international recommendations. MethodsThis is a national observational cross-sectional multicenter study that will include patients older than 18 years with HTN for a duration of 4 weeks, managed in the public sector from primary and secondary care centers as well as patients managed in the private sector. Every participating patient signed a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated are demographic and anthropometric data, lifestyle habits, blood pressure levels, lipid profiles, treatment, and adherence to treatment. The data are collected via the web interface in the Dacima Clinical Suite. ResultsThe study began on April 15, 2019 and ended on May 15, 2019. During this period, we included 25,890 patients with HTN. Data collection involved 321 investigators from 24 Tunisian districts. The investigators were doctors working in the private and public sectors. ConclusionsObservational studies are extremely useful in improving the management of HTN in developing countries. Trial RegistrationClinicalTrials.gov NCT04013503; https://clinicaltrials.gov/ct2/show/NCT04013503 International Registered Report Identifier (IRRID)DERR1-10.2196/21878

Abstract EP after TEE represents a medico‐surgical emergency. Given the high rate of asymptomatic patients with COVID 19, the risk of contamination and the frailty of esophageal tissues, we should check coronavirus infection in every patient before TEE.

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

Abstract Mixed connective tissue disease (MCTD) is characterized by a mixture of clinical features. The initial presentation is often incomplete, and the features of MCTD usually develop as the disease evolves. We present a 37‐year‐old female patient with overlapping symptoms. The most plausible diagnosis was MCTD.

ObjectiveNon-respiratory long-coronavirus disease 2019 (COVID-19) symptoms are mainly related to a long-lasting endothelial dysfunction and microcirculation impairment. We hypothesized that Sulodexide, a purified glycosaminoglycan mixture with a beneficial endothelial effect in arterial and venous peripheral diseases, may be effective in a subset of patients with long COVID-19.Approach and ResultsWe conducted a multicenter prospective quasi-experimental study. A total of 290 patients from the TUN-EndCOV study with long-COVID-19 symptoms and endothelial dysfunction were included. The endothelial function was clinically assessed using a post-occlusive reactive hyperemia protocol with finger thermal monitoring device. Endothelial quality index (EQI) was assessed at inclusion and at 21 days later. The study population was assigned to a sulodexide group (144 patients) or a no-medical treatment group (146 patients). Clinical characteristics were similar at inclusion in the two groups. Fatigue, shortness of breath, and chest pain were the most common symptoms, respectively, 54.5, 53.8, and 28.3%. At 21 days, the sulodexide group improved significantly better than the no-medical treatment group in chest pain (83.7 vs. 43.6%, p < 10−3), palpitations (85.2 vs. 52.9%, p = 0.009), and endothelial function [median delta-EQI 0.66 (0.6) vs. 0.18 (0.3); p < 10−3]. Endothelial function improvement was significantly correlated with chest pain and palpitations recovery (AUC, i.e., area under the curve = 0.66, CI [0.57– 0.75], p = 0.001 and AUC = 0.60, CI [0.51– 0.69], p = 0.03, respectively).ConclusionSulodexide significantly improves long-lasting post-COVID-19 endothelial dysfunction and alleviates chest pain and palpitations.

Introduction There are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life. Patients and methods This is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients. Results We included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%). Conclusions Our study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

The COVID-19 disease is a multisystem disease due in part to the vascular endothelium injury. Lasting effects and long-term sequelae could persist after the infection and may be due to persistent endothelial dysfunction. Our study focused on the evaluation of endothelial quality index (EQI) by finger thermal monitoring with E4 diagnosis Polymath in a large cohort of long COVID-19 patients to determine whether long-covid 19 symptoms are associated with endothelial dysfunction. This is a cross-sectional multicenter observational study with prospective recruitment of patients. A total of 798 patients were included in this study. A total of 618 patients (77.4%) had long COVID-19 symptoms. The mean EQI was 2.02 ± 0.99 IC95% [1.95–2.08]. A total of 397 (49.7%) patients had impaired EQI. Fatigue, chest pain, and neuro-cognitive difficulties were significantly associated with endothelium dysfunction with an EQI

BackgroundThe frequency of heart failure (HF) in Tunisia is on the rise and has now become a public health concern. This is mainly due to an aging Tunisian population (Tunisia has one of the oldest populations in Africa as well as the highest life expectancy in the continent) and an increase in coronary artery disease and hypertension. However, no extensive data are available on demographic characteristics, prognosis, and quality of care of patients with HF in Tunisia (nor in North Africa). ObjectiveThe aim of this study was to analyze, follow, and evaluate patients with HF in a large nation-wide multicenter trial. MethodsA total of 1700 patients with HF diagnosed by the investigator will be included in the National Tunisian Registry of Heart Failure study (NATURE-HF). Patients must visit the cardiology clinic 1, 3, and 12 months after study inclusion. This follow-up is provided by the investigator. All data are collected via the DACIMA Clinical Suite web interface. ResultsAt the end of the study, we will note the occurrence of cardiovascular death (sudden death, coronary artery disease, refractory HF, stroke), death from any cause (cardiovascular and noncardiovascular), and the occurrence of a rehospitalization episode for an HF relapse during the follow-up period. Based on these data, we will evaluate the demographic characteristics of the study patients, the characteristics of pathological antecedents, and symptomatic and clinical features of HF. In addition, we will report the paraclinical examination findings such as the laboratory standard parameters and brain natriuretic peptides, electrocardiogram or 24-hour Holter monitoring, echocardiography, and coronarography. We will also provide a description of the therapeutic environment and therapeutic changes that occur during the 1-year follow-up of patients, adverse events following medical treatment and intervention during the 3- and 12-month follow-up, the evaluation of left ventricular ejection fraction during the 3- and 12-month follow-up, the overall rate of rehospitalization over the 1-year follow-up for an HF relapse, and the rate of rehospitalization during the first 3 months after inclusion into the study. ConclusionsThe NATURE-HF study will fill a significant gap in the dynamic landscape of HF care and research. It will provide unique and necessary data on the management and outcomes of patients with HF. This study will yield the largest contemporary longitudinal cohort of patients with HF in Tunisia. Trial RegistrationClinicalTrials.gov NCT03262675; https://clinicaltrials.gov/ct2/show/NCT03262675 International Registered Report Identifier (IRRID)DERR1-10.2196/12262

Myocardial infarction is very rare in children. It can have different etiologies such as thromboembolism caused by nephrotic syndrome (NS).We report the case of a 15 year old boy with NS, diagnosed at the age of 7 year, admitted for prolonged chest pain. The final diagnosis was ST-elevation myocardial infarction with thromboembolism in the left anterior descending artery due to hypercoagulability of NS.This association is very uncommon and the management of both conditions presents a challenge. Resumo: O enfarte do miocárdio (EM) é raro nas crianças. Pode ter etiologias diferentes, tais como o tromboembolismo causado por síndrome nefrótico (SN).Apresentamos o caso de um rapaz de 15 anos com SN, diagnosticado desde os sete anos e admitido por dor torácica prolongada. O diagnóstico final foi de enfarte do miocárdio com elevação do segmento ST com tromboembolismo na descendente anterior esquerda (DAE) devido a hipercoagulabilidade do SN.Essa associação é muito incomum e o tratamento de ambas as situações representa um desafio.

INTRODUCTION: Les procédures de cardiologie interventionnelle sont devenues complexes et chronophages avec un sur-risque d´exposition aux rayonnements ionisants. L´objectif de notre étude était d´évaluer le niveau des connaissances et des pratiques en radioprotection des cardiologues Tunisiens exposés au rayon X. METHODES: Notre étude est descriptive analytique réalisée en octobre 2019, organisée sous forme de questionnaire anonyme des connaissances et pratiques en radioprotection et envoyé à tous les Cardiologues Tunisiens exposés aux rayons X. RESULTATS: parmi 126 cardiologues exposés aux rayons X et ayant reçu le questionnaire, 58 médecins ont répondu au questionnaire (48%), avec une prédominance masculine (72%, n=42). Trente-huit médecins (65%) exerçaient dans le secteur public. L´expérience professionnelle était en moyenne de 12,02 ans (ET 6,88 ans). La moitié des médecins avaient un score de connaissances inférieur à 50%. La moyenne du score des pratiques était de 43,83 (ET 13,95%). Le port du tablier en plomb, de la cache thyroïde, du dosimètre, des lunettes en plomb, du calot en plomb était respectivement de 100% (n=58), 86,2% (n=50), 30,7% (n=18), 12,1% (n=7) et 1,7% (n=1). Il n´y avait pas de corrélation entre les scores et l´âge du médecin ainsi que la durée de l´expérience professionnelle. Les scores de connaissances ne différaient pas statistiquement entre les 2 sexes (p=0,06) ni entre le secteur public et le secteur privé (p=0,9). Le score de pratique était significativement plus élevé chez les hommes (0.007) et les cardiologues interventionnels comparés aux rythmologues et cardiopédiatres (p=0.001). CONCLUSION: Le niveau des connaissances et des pratiques des cardiologues Tunisiens en radioprotection est globalement insuffisant. Ce qui interpelle les autorités sanitaires à organiser un plan de formation régulier pour cette population.

INTRODUCTION: L´hypertension (HTA), la fibrillation auriculaire (FA) et l´accident vasculaire cérébral (AVC) sont trois problèmes de santé publique. A travers cette étude nous avons cherché à déterminer la prévalence de la FA et de l´AVC ischémique chez les patients hypertendus et déterminer les facteurs associés à la survenue de la FA non valvulaire chez ces patients. METHODES: nous avons utilisé les données recueillies dans le service de cardiologie de l´hôpital universitaire de Sfax dans le cadre du registre national tunisien d´HTA. Nous avons étudié les associations entre les différentes variables sociodémographiques, cliniques, para cliniques et thérapeutiques et la FA chez les hypertendus en utilisant des modèles de régression logistique. RESULTATS: notre échantillon comprenait 2887 patients avec un sexe ratio à 0,95. L´âge moyen était de 65 ans (±11). La FA était notée chez 230 patients (8%), alors que l´AVC ischémique chez 152 patients (5,3%). Au décours de l´analyse multivariée, les facteurs indépendants associés à une augmentation de la prévalence de la FA étaient: l´âge avancé (p=0,001, Odds Ratio(OR) = 1,647, Intervalle de confiance (IC) à 95%: 1,1227-2,213), la présence d´une hypertrophie ventriculaire gauche (HVG) à l´échographie cardiaque(p = 0,004, OR = 2,140, IC95%: 1,281-3,576), et la fraction d´éjection du ventricule gauche (FEVG) = 50% (p = 0,001, OR=4,677, IC95%: 2,715-8,057). CONCLUSION: nous avons confirmé qu´il existe une relation directe et indépendante entre l´HTA, l´âge avancé, l´HVG et la FA. L´installation d´une FA au cours de l´HTA constitue un tournant évolutif de la maladie par majoration du risque d´AVC ischémique. Un contrôle optimal de la pression artérielle tensionnel être hautement prioritaire chez les hypertendus, en particulier âgés, afin de prévenir le risque de la FA et de l´AVC.

The NATURE-HF registry was aimed to describe clinical epidemiology and 1-year outcomes of outpatients and inpatients with heart failure (HF). This is a prospective, multicenter, observational survey conducted in Tunisian Cardiology centers. A total of 2040 patients were included in the study. Of these, 1632 (80%) were outpatients with chronic HF (CHF). The mean hospital stay was 8.7 ± 8.2 days. The mortality rate during the initial hospitalization event for AHF was 7.4%. The all-cause 1-year mortality rate was 22.8% among AHF patients and 10.6% among CHF patients. Among CHF patients, the older age, diabetes, anemia, reduced EF, ischemic etiology, residual congestion and the absence of ACEI/ ARBs treatment were independent predictors of 1-year cumulative rates of rehospitalization and mortality. The female sex and the functional status were independent predictors of 1-year all-cause mortality and rehospitalization in AHF patients. This study confirmed that acute HF is still associated with a poor prognosis, while the mid-term outcomes in patients with chronic HF seems to be improved. Some differences across countries may be due to different clinical characteristics and differences in healthcare systems.

INTRODUCTION: Our aim was to investigate the value of conventional echocardiography, pulsed Doppler and speckle tracking imaging (STI) analysis in the assessment of the left ventricular (LV) myocardial function in hemodialysis (HD) patients with preserved LV ejection fraction and to evaluate the effect of a single HD session on the LV systolic and diastolic functions. METHODS: the study population consisted of 30 chronic HD patients. Echocardiography and Doppler studies were performed before and after HD. The LV global longitudinal, circumferential and radial strains were measured with two and three-dimensional STI. RESULTS: after HD, LV dimensions, left atrium (LA) area, systolic pulmonary arterial pressure and inferior vena cava diameter decreased significantly. The peak mitral E velocity, the E/A ratio of the mitral inflow and the lateral E/E´ ratio decreased also significantly. The LV and LA volumes index and LV mass index (LVMi) decreased remarkably after HD. The 3D- LV and LA ejection fractions were unchanged after HD. Although, 3D-estimated LVEF seemed to be preserved in the HD patients, the 2D and 3D- strain rates were decreased in all directions. The global strain values improved in all directions after a single HD session. Inverse correlations were found between the LVMi, serum BNP and LV global longitudinal strain. CONCLUSION: in HD patients with preserved LV ejection fraction, the STI analysis may add important information concerning the subclinical LV dysfunction.

The distal radial approach (DRA) is suggested to have benefits over the conventional radial approach (CRA) in terms of local complications and comfort of both patient and operator. Therefore, we aimed to compare the feasibility and safety of DRA and CRA in a real life population. We conducted a prospective, observational multicentric trial, including all patients undergoing coronary procedures in September 2019. Patients with impalpable proximal or distal radial pulse were excluded. Thus, the choice of the approach is left to the operator discretion. The primary endpoints were cannulation failure and procedure failure. The secondary endpoints were time of puncture, local complications and radial occlusion assessed by Doppler performed one day after the procedure. We enrolled 177 patients divided into two groups: CRA (n = 95) and DRA (n = 82). Percutaneous intervention was achieved in 37% in CRA group and 34% in DRA group (p = 0.7). Cannulation time was not significantly different between the two sets (p = 0.16). Cannulation failure was significantly higher in DRA group (4.8% vs 2%, p

INTRODUCTION: Reduced exercise capacity, coronary artery abnormalities and reversible myocardial ischemia have been demonstrated after arterial switch operation (ASO) and coronary reimplantation. Despite this, indices of systolic function, assessed by standard and doppler echocardiography, are within the normal range. The aim of this study was to highlight the long-term changes in myocardial function following coronary reimplantation using Doppler and speckle-tracking imaging (STI) echocardiography. METHODS: this observational case control study included 36 patients and 20 gender and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2015 and May 2016. Systolic and diastolic parameters, left ventricle (LV) and right ventricle (RV) myocardial performance were assessed in each group. RESULTS: the LV global peak strain parameters revealed a significant decrease in the longitudinal and circumferential strain components. The LV global longitudinal strain (GLS) values were lower in both groups of operated patients than controls (-19.9 ± 2.2% (group 1) versus -20.9 ± 1.6% (group 2) versus -22.9 ± 2.3% (group 3), p=0.001). The patients with coronary reimplantation had the lowest values. The LV global circumferential strain was also decreased in the group 1 patients as compared with the 2 other groups (-16.6 ± 4.1% (group 1) versus -19.4 ± 3.9% (group 2) versus -19.8 ± 4.0% (group 3), p=0.001). CONCLUSION: although global LV function, assessed with conventional echocardiographic parameters, was normal, the 2D-STI analysis showed slight but significant decrease in the global and segmental longitudinal and circumferential LV strain during the long-term follow-up after coronary arteries reimplantation.

Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. It is rare to see heart block as the first-and-only presentation of infectious myocarditis. We report the case of a young healthy patient who presented with syncope secondary to a complete heart block. It was caused by acute presumed viral myocarditis. The diagnosis was confirmed with cardiac magnetic resonance imaging. With close monitoring, the EKG abnormalities resolved over the following 5 days. In this case report, we present the importance of several imaging tools to diagnose a rare and reversible cause of conduction disturbances. In at-risk individuals, clinicians should rule out a treatable cause of heart block before proceeding with permanent pacemaker implantation due to enormous clinical and cost implications involved.

Introduction: The GRACE and TIMI scores have been well validated for assessment of prognosis in non-ST-elevation acute coronary syndrome (NSTE-ACS). However, their value in predicting coronary artery disease (CAD) has been little studied. We aimed to assess the relationship between these scores and the extent of coronary disease. Methods: We analyzed 238 consecutive patients admitted for NSTE-ACS and undergoing a coronary angiogram during hospitalization. The severity of CAD was assessed using the SYNTAX score. Obstructive CAD was defined as ≥50% stenosis in the left main or ≥70% stenosis in other vessels. Severe CAD was defined as a SYNTAX score >32. The Pearson test was used to assess the correlation between scores. Results: The SYNTAX score was higher in patients at high risk (GRACE score: p32. O teste Pearson foi usado para avaliar a correlação entre os scores. Resultados: O valor do score Syntax foi superior nos doentes de alto risco (escore GRACE: p

Background: Research in the genetic basis of coronary artery diseases (CAD) has identified some genes and pathways associated with diseases that would not be considered to underlie conventional risk factors. Among these genes there are the EGFR (epidermal growth factor receptor) receptor family genes and the regulation factor genes (such as thyroid hormone receptor α (THRA) and estrogen receptor α (ESR1)). Aim: In this study we investigated the relation between 4 polymorphisms within EGFR, HER2 (human epidermal growth factor receptor 2), ESR1 and THRA genes and CAD. Subjects and methods: The association analysis was performed with 151 healthy individuals and 151 CAD patients documented by angiography. Results: No significant difference was found in the allelic and genotypic frequency distribution of the four variants studied between the control and patient groups. We have also investigated the relationship of these polymorphic sites with clinical and biochemical parameters such as smoking habit, diabetes mellitus, hypertension, dyslipidemia, CAD severity, glucose, triglyceride, total cholesterol and urea levels. The EGFR and THRA variants were associated with glycemia and triglyceride levels, respectively. Also a significant correlation was found between the ESR1 polymorphism and the levels of urea and triglyceride. Conclusion: Our results suggest the absence of any significant association between the four polymorphisms analyzed and CAD risk as well as disease severity.

We reported a rare case of non-penetrating chest trauma-induced fistula from the right sinus of Valsalva to the right heart chambers. The ruptured sinus of Valsalva aneurysm was diagnosed preoperatively and operated on successfully. The rarity of this case highlights the need for a precise preoperative diagnosis, the role of transthoracic echocardiography, and the importance of a prompt surgical management.

Aims: Cystatin C is an endogenous marker of renal function. It is a well established better marker of glomerular filtration rate than serum creatinine. There is also evidence that cystatin C is associated with atherosclerotic disease. The present prospective study evaluated the prognostic value of cystatin C after myocardial infarction in patients without chronic kidney disease. Methods and results: A total of 127 patients who underwent coronary angiography after an acute coronary syndrome (ACS) were included. Cystatin C was associated with the severity of coronary artery disease (CAD). Cystatin C levels were significantly higher in patients with 3-vessels disease and severe CAD according to GENSINI score (p = 0.01 and p

Coronary subclavian steal syndrome is an uncommon cause of ischemia recurrence after coronary artery bypass grafting. Endovascular treatment of subclavian artery stenosis or occlusion is increasingly common and appears to offer a safe and effective alternative to surgical revascularization. We report a case of recurrent angina after coronary artery bypass grafting for critical subclavian artery stenosis. The anomalous origin of the vertebral artery from the aortic arch was an indication for endovascular treatment. We discuss the diagnostic difficulties and the management pitfalls of subclavian artery angioplasty in this syndrome. Resumo: A síndrome de roubo da subclávia é uma causa incomum de recidiva de isquemia após a cirurgia de revascularização do miocárdio (CABG). A terapêutica endovascular da estenose ou oclusão da artéria subclávia é cada vez mais usada e parece oferecer uma opção segura e efetiva à revascularização cirúrgica. Apresentamos o caso de uma angina recorrente após CABG devida a estenose arterial crítica da subclávia. A origem anómala da artéria vertebral a partir da crossa da aorta favoreceu o tratamento endovascular. Discutimos as dificuldades diagnósticas e as dificuldades do tratamento da angioplastia da artéria subclávia durante essa síndrome. Keywords: Angioplasty, Subclavian steal syndrome, Coronary artery graft, Case report, Palavras-chave: Angioplastia, Síndrome do roubo da subclávia, Enxerto da artéria coronária, Caso clínico

Sinus of Valsalva aneurysms are extremely rare, and usually of a congenital nature. There are few documented cases of this condition during pregnancy, which renders unclear the therapeutic options. We here report the case of a26 years old pregnant woman who was referred to our cardiac center for the evaluation of a heart murmur. The two-dimensional transthoracic echocardiography allowed quickly to establishthe diagnosis of a ruptured sinus of Valsalva aneurysm into the right ventricle. A successful surgical correction of the ruptured aneurysm was performed with patch repair.

L'atteinte de la valve tricuspide a été longtemps négligée aussi bien par cardiologue que par le chirurgien, mais depuis quelques années, la fuite tricuspidienne a été démontrée comme un facteur pronostic dans l'évolution des patients opérés d'une valvulopathie du c'ur gauche. Plusieurs techniques de plastie tricuspide ont été développées et les études publiées divergent sur les résultats de ces techniques; Nous avons mené ce travail afin d'évaluer les résultats de plastie tricuspide dans une population caractérisée par une forte prévalence de la maladie rhumatismale et de comparer les techniques d'annuloplastie de carpentier versus la plastie de DeVEGA. Etude rétrospective menée sur une période de 25 ans ayant inclus les patients traités par plastie tricuspide dans le service de cardiologie de SFAX. Nous avons comparé les résultats de groupe 1 (annuloplastie de Carpentier) vs groupe 2 (plastie de DeVEGA) 91 patients étaient inclus dans notre étude, avec 45 patients dans le groupe 1et 46 patients dans le groupe 2. La plupart des patients avaient une IT moyenne ou importante (83%) avant la chirurgie, une dilatation de l'anneau a été observée chez 90% des patients sans qu'il y ait une différence significatives entre le groupe 1 et 2. Les résultats immédiats étaient comparables entre les deux techniques mais au cours de suivi une insuffisance récurrente au moins moyenne a été plus significativement fréquente dans le groupe de plastie de DeVEGA. Les facteurs prédictifs d'IT récurrente significative au long cours étaient en étude multivariée la technique de DeVEGA (OR=3.26 (1.12-9.28)) et la pression artérielle pulmonaire systolique préoperatoire (OR=1.06 (1.01-1.12)). La plastie tricuspide avec anneau de Carpentier semble garantir de meilleurs résultats que la plastie de DeVEGA, par contre une PAPS préopératoire élevée est prédictive de récurrence de la fuite tricuspidienne même après plastie d'où l'intérêt d'opérer les malades à un stade précoce.

Conventional echocardiographic (ECHO) parameters of systolic and diastolic func-tion of the left ventricular (LV) have been shown to be load dependent. However, the impact of pre-load reduction on tissue Doppler (TD) parameters of LV function is incompletely understood. To evaluate the effect of a single hemodialysis (HD) session on LV systolic and diastolic function using pulsed Doppler echocardiography and pulsed tissue Doppler imaging (TDI), we studied 81chronic HD patients (40 males; mean age 52.4 ± 16.4 years) with these tools. ECHO parameters were obtained 30 min before and 30 min after HD. Fluid volume removed by HD was 1640 ± 730 cm [3] . HD led to reduction in LV end-diastolic volume (P

Cirrhotic cardiomyopathy is associated with poor prognosis and risk of acute heart failure after liver transplantation or interventional procedures. We aimed to assess the relationship between the severity of cardiac impairment and hepatic disease. Eighty patients and eighty controls underwent echocardiography, tissue Doppler imaging and speckle tracking measures. We assess the correlation between echocardiographic parameters and Child and MELD scores. Systolic parameters function (s wave, p < 0.001) and global longitudinal strain (p < 0.001) as well as diastolic parameters were significantly more impaired in cirrhotic patients compared to controls. There were no differences among the different groups in ‘Child score’ regarding systolic function as well as diastolic function. Paradoxically, the left atrium size correlated positively to both Child (p = 0.01, r = 0.26) and MELD scores (p = 0.02, r = 0.24). Left ventricular ejection fraction was significantly lower in decompensated patients as compared to compensated patients(p = 0.02).. We did not identify any association between severity of liver disease and cardiac dysfunction. Therefore, a transthoracic echocardiography should be performed in all cirrhotic patients before interventional and surgical procedures regardless of the severity of liver disease.

INTRODUCTION: the objectives were to assess the left ventricular (LV) structure and function in regularly trained young athletes, using 2 D conventional echocardiographic (echo) methods and speckle tracking echocardiography (STE). An observational cross-sectional study. METHODS: thirty-three footballers and 20 healthy untrained subjects were included in the study. The systolic and diastolic LV functions were evaluated by 2D conventional echo parameters, Doppler method and STE. RESULTS: all the found values were within the normal range. The LV End Diastolic Diameter (LVED 37.24,2.08 mm/m2) and the LV Mass index (LVMi 97.93,15.58 g/m2) were significantly higher in young athletes as compared with controls. There was no difference regarding the LV systolic function assessed by conventional echo parameters in the 2 study groups. Regarding the diastolic function, the transmitral inflow velocities ratio was significantly higher in athletes (E/A = 2.10,0.49 versus 1.64,0.26, p= 0.001) but there was no difference in the filling pressure in the 2 groups. The STE demonstrated a different pattern of LV deformation in the different groups. A significant lower LV global longitudinal strain (GLS -20.68,2.05 versus -22.99,2.32 %, p=0.001) and higher radial and circumferential strains have been found in the young athletes as compared with controls. A significant relationship between the GLS values and LVED (r= 0.299, p = 0.03) and LVMi was also reported in athletes. CONCLUSION: while conventional morphological and functional echocardiographic parameters failed to distinguish the adaptations in the athlete's heart, deformation parameters showed a different pattern of LV mechanics in young footballers versus controls.

Objective: To determine the predictive factors, clinical manifestations, and the outcome of patients with post-traumatic pulmonary embolism (PE) admitted in the intensive care unit (ICU). Methods: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each trauma patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study period, all trauma patients admitted to our ICU were classified into two groups. The first group included all patients with confirmed PE; the second group included patients without clinical manifestations of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or its branches. Results: During the study period, 1067 trauma patients were admitted in our ICU. The diagnosis of PE was confirmed in 34 patients (3.2%). The mean delay of development of PE was 11.3 ± 9.3 days. Eight patients (24%) developed this complication within five days of ICU admission. On the day of PE diagnosis, the clinical examination showed that 13 patients (38.2%) were hypotensive, 23 (67.7%) had systemic inflammatory response syndrome (SIRS), three (8.8%) had clinical manifestations of deep venous thrombosis (DVT), and 32 (94%) had respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 32 cases (94%) and low molecular weight heparin was used in two cases (4%). The mean ICU stay was 31.6 ± 35.7 days and the mean hospital stay was 32.7 ± 35.3 days. The mortality rate in the ICU was 38.2% and the in-hospital mortality rate was 41%. The multivariate analysis showed that factors associated with poor prognosis in the ICU were the presence of circulatory failure (Shock) (Odds ratio (OR) = 9.96) and thrombocytopenia (OR = 32.5).Moreover, comparison between patients with and without PE showed that the predictive factors of PE were: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2 /FiO 2 < 200 mmHg, the presence of spine fracture, and the presence of meningeal hemorrhage. Conclusion: Despite the high frequency of DVT in post-traumatic critically ill patients, symptomatic PE remains, although not frequently observed, because systematic screening is not performed. Factors associated with poor prognosis in the ICU are the presence of circulatory failure (shock) and thrombocytopenia. Predictive factors of PE are: Age > 40 years, a SAPS II score > 25, hypoxemia with PaO2 /FiO 2 < 200, the presence of a spine fracture, and the presence of meningeal hemorrhage. Prevention is highly warranted.

Prosthetic joint loosening due to Brucella spp. is a rare event. In this report, we describe a rare case of prosthetic infection caused by brucella. A 71-year-old woman reported a six-month history of progressing pain in the right prosthetic knee, which had been implanted for arthrosis four years prior to admission, associated with fever. No night sweats were noted. On examination, the right knee appeared slightly swollen and painful on mobilization, and the surgical wound was normal. Blood tests showed increased C-Reactive Protein (CRP) (34mg/L) and erythrocyte sedimentation rate (ESR) (34mm/hr). A CT scan of her right knee was performed, showing loosening of the prosthesis, joint effusion, and osteolysis in contact with the internal tibial component measuring 16mm maximum with bone remodeling of the epiphysis and metaphysis regions. Rose Bengal test was positive for brucellosis, a standard brucella tube agglutination test was positive at a titer of 1/80, blood cultures for brucella were negative and a PCR for detection of Mycobacterium tuberculosis was negative. The patient was diagnosed as having Brucella infection of his total knee arthroplasty. Favorable outcome was observed after medical and surgical treatment. We believe this is the first detailed report of Brucella prosthetic infection in the country despite the endemicity of this type of zoonosis.

Authors describe the case of a patient with breast cancer and multiple myeloma as the second metachronous disease responsible for spinal cord compression. Synchronous occurrence of bone marrow breast cancer disease and multiple myeloma has not been described in the literature, as in this case. By presenting this case, we point to possible association between both diseases and the possible factors involved in the development of second malignant disease.

L'endocardite à Bartonalla est une infection ubiquitaire, son diagnostic est difficile vu qu'il s'agit souvent d'endocardite à hémoculture négative. Le but de cette étude est d'analyser les particularités lésionnelles et évolutives de cette entité dans un pays du nord d'Afrique, la Tunisie et de démontrer la gravité de cette infection. Nous avons étudié rétrospectivement les dossiers médicaux de 20 patients atteints d'endocardite à Bartonella, confirmée selon les critères de Dukes modifiés. L'âge moyen de nos patients était 37 ans avec une prédominance masculine (SR=3). Tous nos malades avaient un niveau socio-économique bas. Le motif essentiel de consultation était la dyspnée, 6 patients étaient admis dans un tableau d'insuffisance cardiaque congestive. Une prédilection des lésions au niveau de la valve aortique a été notée (14 cas). Quatorze patients avaient des végétations endocarditiques avec une taille qui dépasse 10 mm chez 8 malades. La majorité des patients (18 patients) présentaient une régurgitation valvulaire massive en rapport principalement avec des mutilations importantes (6 cas de ruptures de cordages mitraux, 2 cas de déchirures des sigmoïdes aortiques, un cas de perforation valvulaire aortique, un cas de désinsertion de prothèse mitrale). Quinze malades (3/4) avaient nécessité une chirurgie à la phase active de la maladie, l'indication majeure était l'insuffisance cardiaque. Une complication neurologique était notée chez 2 malades et une complication rénale chez 3 malades. Treize patients étaient guéris, 5 malades étaient décédés et 2 malades opérés ont présenté une réinfection à staphylococcus aureus et à candida albicans en postopératoire. L'endocardite à Bartonella est une infection grave. Cette Bactérie possède un potentiel destructif important. Le recours à la chirurgie est quasi constant. La morbi-mortalité est élevée. La recherche de cette bactérie devrait être alors systématique chez nos malades suspects d'endocardite d'autant plus que la bartonellose est endémique sur nos terres.

Autosomal recessive congenital ichthyosis (ARCI) is a rare genetic disorder of the skin characterized by abnormal desquamation over the whole body. In this study we report four patients from three consanguineous Tunisian families with skin, eye, heart, and skeletal anomalies, who harbor a homozygous contiguous gene deletion syndrome on chromosome 15q26.3. Genome-wide SNP-genotyping revealed a homozygous region in all affected individuals, including the same microdeletion that partially affects two coding genes (ADAMTS17, CERS3) and abolishes a sequence for a long non-coding RNA (FLJ42289). Whereas mutations in ADAMTS17 have recently been identified in autosomal recessive Weill-Marchesani-like syndrome in humans and dogs presenting with ophthalmologic, cardiac, and skeletal abnormalities, no disease associations have been described for CERS3 (ceramide synthase 3) and FLJ42289 so far. However, analysis of additional patients with non-syndromic ARCI revealed a splice site mutation in CERS3 indicating that a defect in ceramide synthesis is causative for the present skin phenotype of our patients. Functional analysis of patient skin and in vitro differentiated keratinocytes demonstrated that mutations in CERS3 lead to a disturbed sphingolipid profile with reduced levels of epidermis-specific very long-chain ceramides that interferes with epidermal differentiation. Taken together, these data present a novel pathway involved in ARCI development and, moreover, provide the first evidence that CERS3 plays an essential role in human sphingolipid metabolism for the maintenance of epidermal lipid homeostasis.

L'artérite de Takayasu ou maladie de Takayasu (MT) et la polyarthrite rhumatoïde (PR) et sont deux maladies inflammatoires chroniques et leur association a été rapportée dans la littérature à travers quelques observations de cas sporadiques. Nous rapportons une nouvelle observation d'une telle association. Une patiente âgée de 44 ans, diagnostiquée avec une polyarthrite rhumatoïde à facteur rhumatoïde positif, qui a développé des céphalées avec des vertiges de caractère permanent. L'examen révélait un pouls radial et huméral abolis à droite, un souffle carotidien bilatéral et une tension artérielle imprenable à droite. L'artériographie a confirmé la présence d'une atteinte de l'arc aortique type MT. Le diagnostic d'une maladie de Takayasu associée à une polyarthrite rhumatoïde était retenu. La patiente était traitée par une corticothérapie (prednisone à la dose de 0,5 mg/kg par jour) et un traitement de fond par Méthotrexate avec une bonne réponse initiale. A travers notre observation et une revue de la littérature, les caractéristiques épidémiologiques, étiopathogéniques, cliniques, thérapeutiques et évolutives de cette association seront discutées.

Hypertrophic cardiomyopathy (HCM) with midventricular obstruction (MVO) is a rare condition occurring in 1% of HCM patients. It is characterized by asymmetric left ventricular hypertrophy with MVO and elevated intraventricular pressure gradients. Pulmonary embolism has been associated with mid-ventricular obstructive HCM. Briefly, this case presents an unusual clinical scenario where a young pregnant woman suffering from hypertrophic obstructive cardiomyopathy presents with dyspnea hemodynamic compromise related to pulmonary embolism illustrating hemodynamic challenges created by pregnancy and surgery. We concluded that simple measures such as communication between the cardiology and obstetric teams, understanding of the hemodynamic changes, anesthetic planning, and monitoring were paramount for the success in our patient.

Background. The discovery of a large left atrial mass through echocardiography obliges the clinician to perform a differential diagnosis to distinguish tumor from thrombus. The neovascularization of the mass could be helpful to predict the type of the malformation and whether it is in favour of a vacular tumour rather than a thrombus . Observation. A 43-years-old man who had no cardiac antecedent reported that he have had dyspnea and palpitation since 10 months. The cardiac auscultation, revealed an irregular rhythm with diastolic murmur at the apex. The electrocardiogram showed an atrial fibrillation. The transthoracic echocardiography revealed a severe mitral stenosis with a huge left atrial mass, confirmed through transesophageal echocardiography. After 4 weeks of an efficient anticoagulant treatment, the mass was still persistent in the echocardiography. So we decided to resect the mass and to achieve a mitral valve replacement. The preoperative coronarography showed neovascularization among the mass and fistula from the circumflex artery. Considering the characteristic of the mass (neovascularization and resistance to anticoagulant), we strongly suspected a vascular tumor especially myxoma, but the histological exam revealed an organized thrombus. Conclusion. Coronary neovascularization is a specific sign for left atrial thrombus in mitral stenosis, but surgery is the best way to confirm diagnosis.

Les résultats de l’angioplastie (ATL) des coronaires chez la femme ont été pendant de nombreuses années controversés et longtemps considérés comme moins favorable que chez . Le but l'Homme notre travail était d"évaluer les caractéristiques de l’angioplastie coronaire chez la femme, ainsi que les résultats immédiats et à moyen terme et de les comparer à ceux chez l'Homme. Nous avons comparé 200 patients dont 100 femmes, ayant bénéficié d'une angioplastie coronaire, colligés au service de cardiologie de l'Hôpital Hédi Chaker de Sfax entre 2002 et 2007. Les femmes étaient significativement plus âgées que les hommes. La comparaison de la fréquence des facteurs de risque d'athérosclérose chez les deux sexes, a permis de noter une co-morbidité franchement plus importante chez la femme, avec une différence statiquement significative. L"ATL a été plus motivée chez la femme devant un angor stable sévère (p less than 0,05) et un SCA ST- (p=NS). Les femmes avaient plus d’atteintes (p less than 0,05), d’atteintes des segments moyens et distaux (pless than 0,05) et plus des lésions serrées (p=NS), longues et calcifiées (p less than 0,05). 259 stents ont été déployés, un stenting direct était plus fréquent dans la population féminine (pless than 0,05). Le diamètre des artères féminines, assimilé à celui du stent et/ou ballon utilisé, a été significativement moins important que celui des hommes. La longueur des stents et/ou ballon utilisés, ainsi que les pressions de larguage des stents ont été plus importantes chez la population féminine (p less than 0,05). Le succès angiographique global a été obtenu chez 94% de la population générale, sans différence significative entre les deux sexes. Les évènements cardiaques majeurs (MACE) hospitaliers ont été plus fréquents chez la femme (p=0,05). Après un suivi moyen de 31 mois, le taux de MACE global a été significativement plus important chez la femme (39% vs. 28%, p less than 0,05), portant surtout sur la mortalité globale (13% vs. 3%, p less than 0,05). Le taux de resténose a été comparable chez les deux sexes.L"angioplastie coronaire constitue actuellement un moyen thérapeutique efficace et sur chez la femme, au prix de complications plus fréquentes.

Hydatid cysts located in the interatrial septum are especially rare but when they occur, they might cause intracavity rupture. We report on a patient with acute pulmonary embolism caused by an isolated, ruptured hydatid cyst on the right side of the interatrial septum. A 16-year-old-boy with an uneventful history was hospitalized for exercise-induced dyspnea and blood expectorations. Multiple and bilateral opacities were visualized on standard chest x-ray. Signs of right-sided hypertrophy were seen on ECG. Imaging findings led to the diagnosis of pulmonary embolism complicating cardiac hydatid cysts. An operation was performed through median sternotomy to remove the cardiac cyst. The pleural cavity was entered through the fifth intercostal space to withdraw lung hydatid cysts. Operative recovery was uneventful and the patient resumed his normal activities 19 months later. Prompt diagnosis and an appropriate surgical treatment prevented a potentially fatal outcome

Acute myocardial infarction (AMI) is rarely associated with antiphospholipid syndrome. The treatment of these patients is a clinical challenge. We report the observations of 2 young adults (1 woman and 1 man), admitted in our acute care unit for acute myocardial infarction (AMI). A coagulopathy work-up concludes the existence of antiphospholipid syndrome (APS) in the 2 cases. APS syndrome was considered primary in 2 cases. All patients presented an intense inflammatory syndrome (high level of CRP). Anticardiolipine was present in the 2 cases. However, anti B2 glycoprotein I antibodies were detected in only one case. Emergency percutaneous transluminal coronary angioplasty (PTCA) with direct stenting had been performed successfully only in the first case, and the follow-up was uncomplicated. Thereafter, long-term oral anticoagulant appeared to be effective. The last patient was admitted because of peripheral acute ischemia of legs. Standard electrocardiogram showed signs of previous silent anteroseptal wall myocardial infarction confirmed by echocardiography. The latter revealed an apical thrombus and a very low left ventricular ejection fraction. Amputation of the right leg was necessary because of consultation occurred too late. However, he died four weeks later. Primary antiphospholipid syndrome should be considered as a cause of acute myocardial infarction in young adults, and PTCA with anticoagulant treatment is effective for initial treatment of this complication