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Hypertension is the first cause of atrial fibrillation. Its onset is explained by intricate mechanisms such as atrial conduction impairment.To evaluate atrial conduction by tissue Doppler imaging in hypertensive patients compared to a control group.This is a comparative prospective study performed in the cardiology department of the FSI hospital enrolling 55 patients with hypertension and 55 controls. All of them underwent a complete echocardiocardiography exam with Doppler tissue imaging. We measured intraatrial and interatrial electromechanical delay by Pulsed Tissue Doppler. Statical analysis was conducted using SPSS version 22.0. Comparison of means was made with t student test.Left ventricular mass and septal thikness were more important in the hypertensive group. Mitral A wave was greater in hypertensive group compared to controls (7,1cm/s vs 5,6cm/s; p0,0001; respectively). Left atrial volume was of 32,7±6,8mL/m² in hypertensives vs 29,5±4,3 mL/m² in controls (p=0,006). Doppler Tissue study showed homogeneous statistically significant elongation of atrial conduction times in hypertensive patients compared to controls: interatrial time (16.8±7.8ms vs 12.4±4,2ms, p0.0003) and left intraatrial (27.6±8.6ms vs 19.0±4.3ms, p0.0001) and right intraatrial time (10.8±6.0ms vs 6.6±2.9ms, p0.0001; respectively for hypertensive and control subjects. There was a significant correlation between measured intraatrial and interatrial electromechanical delays and duration of hypertension, indexed left atrial volume ans indexed left ventricular mass (r 0.27-0.41, p0.001).Atrial conduction time is significantly longer in hypertensive patients. Impairment of atrial conduction may be predictive of atrial fibrillation and should prompt closer surveillance to detect this arrhythmia in these patients.

Acute myocarditis is an inflammation of the heart muscle. Its unpredictable evolution justifies the importance of its early recognition. The clinical polymorphism associated with the lack of sensitivity of conventional diagnostic means make diagnosis a challenge for the clinician. However, the magnetic resonance imaging has been of great interest for the differential diagnosis as well as for the evolutionary follow-up of this pathology.Determine the clinical profile of acute myocarditis and the contribution of multimodal imaging in its diagnosis.This was a descriptive, retrospective study, including 31 patients hospitalized for acute myocarditis at the cardiology department of the Internal Security Forces Hospital-La Marsa between 2011 and 2017.The mean age of our patients was 36.5 ± 13.3 years [17-63] with a clear male predominance (sex ratio = 6.75). Smoking was the most common cardiovascular risk factor (60%). Fifty percent of the population had only two cardiovascular risk factors. The most common clinical picture was acute chest pain (84%) preceded by influenza-like illness (53%). The electrocardiogram was pathological in 97% of cases. Hyperleukocytosis was objectified in 33% of cases. Elevation of C-reactive protein was present in 80% of cases. As for troponins, they were high in 94% of cases. Overall myocardial contractility was conserved in 84% of cases with segmental kinetic disorders in 45%. Cardiac magnetic resonance imaging showed pericardial effusion (10%), spontaneous myocardial hypersignal in triple-reversal-T2 recovery (42%) and which corresponded to the zones of late enhancement. Late contrast enhancement was predominant at the lateral wall (39%), with epicardial involvement occurring in 100% of cases.28 patients had a favorable outcome after a follow-up of 24 months. However, there was only one case of death at 3 months and two cases that progressed to dilated cardiomyopathy.Acute myocarditis is mainly a disease of the young male subject. Cardiac magnetic resonance imaging is of crucial interest for positive diagnosis.

The left atrium (LA) have an important role in the normal functioning of the heart thanks to its three functions: reservoir, conduct and pump. Several pathologies lead directly or indirectly to morphological and functional modifications of the LA. Investigate the effect of arterial hypertension on LA size and function. Prospective study including 50 hypertensive patients compared to 50 healthy controls. LA Volumes were measured using transthoracic echocardiography by biplane Simpson method at different times of cardiac cycle: at the end of systole (maximum LA volume (Vmax)), at mitral valve closure (minimum LA volume (Vmin)) and immediately before LA contraction (Vp)). LA reservoir function (total emptying volume and expansion index), conduct function (passive emptying volume and passive emptying fraction) and pumping function (active emptying volume and active emptying fraction) have been calculated. Hypertension was associated with an increase of all LA volumes: Vmax (p0.001), Vmin (p=0.001) and Vp (p0.001). LA reservoir function evaluated by LA total emptying volume was higher in hypertensives than in control group (p=0.032). LA conduct function was impaired in hypertensive patients with a significantly lower passive emptying fraction in hypertensive group compared to control group (22 ± 12% versus 32 ± 11%, p0.001, respectively). This decrease was greater in the presence of left ventricular hypertrophy (p = 0.02). LA pumping function was significantly higher in hypertensive patients than in controls with an increase of LA active emptying fraction (35±12% versus 30±12%respectively; p=0.037). The increase of LA pumping function was found to be higher in hypertensive patients with impaired diastolic function (p=0.029). Hypertension was associated with an increase of pumping and reservoir functions and a decrease in left atrial passive emptying function. These changes appear to be related to left ventricular hypertrophy and the degree of left ventricular diastolic dysfunction.

Background The CHA2DS2-VASc score is validated to evaluate the risk of thromboembolism in non-valvular atrial fibrillation (AF). The relationship between the predictive value of thromboembolic risk by echocardiographic parameters and CHA2DS2-VASc score is still misunderstood. Purpose The aim of this study was to search a relationship between echocardiographic parameters and CHA2DS2-Vasc score in patients with non-valvular AF. Methods One hundred and twenty-two patients were hospitalized for AF. The CHA2DS2-VASc score was evaluated and echocardiography with assessment of the left atrium (surface diameter and volume) was performed. Regular monitoring was provided during 8 ± 12 months. Results The mean age of our patients was 60 ± 15 years, 66% (n = 71) men and 34% (n = 36) women. AF was classified as paroxysmal (59%), as persistent (18%), and as permanent (28%). AF was idiopathic in 34% of cases and associated with hypertensive heart disease in 26%. The percentage of patients who had a CHA2DS2-VASc score 0, 1, and ≥ 2 was 21%, 24% and 55%. Sixty-six percent of patients have been treated with anticoagulant, 30% were put on aspirin and 4% abstaining. During follow-up, nine patients were hospitalized for heart failure, 6 patients (5%) had stroke, 4 patients (4%) had a non-major bleeding and one patient died. No correlation was found between CHA2DS2-VASc score and the left atrium dimensions (P = 0.6, 0.2, 0.8 respectively for the diameter, surface area and volume of left atrium). Conclusion Left atrial dimensions are not correlated to CHA2DS2-VASc score. Other techniques could possibly be more sensitive such as the atrial strain.

Background Hypertension is the first cause of atrial fibrillation. Its onset is explained by intricate mechanisms such as atrial conduction impairment. The aim of our study was to evaluate atrial conduction by tissue Doppler imaging in hypertensive patients compared to a control group. Methods This is a comparative prospective study performed in the cardiology department of the FSI hospital enrolling 55 patients with hypertension and 55 controls. All of them underwent a complete echocardiography exam with Doppler tissue imaging. We measures inter-atrial and intra-atrial electromechanical delay by Pulsed Tissue Doppler. Results Left ventricular mass and septal thickness were more important in the hypertensive group. Mitral A wave was greater in hypertensive group compared to controls (7.1 cm/s vs. 5.6 cm/s; P Conclusion Atrial conduction time is significantly longer in hypertensive patients. Impairment of atrial conduction may be predictive of atrial fibrillation and should prompt closer follow-up to detect this arrhythmia in these patients.

Solitary main and/or accessory papillary muscle (PM) hypertrophy may be an uncommon type of hypertrophic cardiomyopathy that does not meet all the usual criteria. The dynamic intraventricular obstruction related to this PM hypertrophy can be deleterious with an important clinical impact on patients. The mechanisms of such obstruction attracted a lot of attention in order to propose an appropriate treatment. We report a case of a 36-year-old man presenting with a chief complaint of progressively worsening exertional dyspnea. He had demonstrated labile systolic murmur for more than 3 years. Rest echocardiography revealed coexistence of a solitary main PM hypertrophy and additional accessory PM with no left ventricular outflow tract or mid ventricle obstructions. The patient underwent exercise stress echocardiography unmasking severe mid-ventricle obstruction (peak systolic gradient at exercise of 100 mmHg). There was no obvious parietal hypertrophy elsewhere. Cardiac magnetic resonance imaging provided us with anatomical arguments that could explain the dynamic process of obstruction. In fact, multimodality imaging has a determinant role in the screening of spatial configuration and structural abnormalities of PMs in order to avoid the misinterpreting of some atypical presentations of hypertrophic cardiomyopathy.

Carcinoid tumors are rare, mainly located in the gastrointestinal tract particularly in the small intestine. Cardiac involvement, fairly frequent and usually affecting right sided heart valves, had a poor prognosis that is improved by an earlier detection and valve surgery. We report the case of a 50-years old woman with neuroendocrine tumor and liver metastases, in whom carcinoid involvement of the right heart was diagnosed following exertional dyspnea. She had dilated right cavities, severe tricuspid regurgitation, mild tricuspid stenosis and a moderate pulmonary stenosis. She underwent a double valve replacement by bioprosthesis with improvement of symptoms and recovery of normal right cavities size.

Right ventricular (RV) involvement in obstructive sleep apnea syndrome (OAS) is controversial. The aim of this study was to determine a correlation between echocardiographic parameters of RV function and severity of OSA assessed by the apnea- hypopnea index (AHI).Sixty patients with suspected OSA were enrolled. All patients had overnight polygraphy and an echocardiographic assessment of RV structure and function. Patients were divided into three groups: a control group (n=20) with an AHI5/h, a group of mild to moderate OSA (n=18) with an AHI=5-30/h and a group of severe OSA (n=22) with AHI≥30/h.There were no differences of age, body mass index and sex among the three groups. There was no difference in systolic pulmonary pressure. RV free wall thickness, end-diastolic surface and right atrium surface were statistically higher in OSA patients compared with controls. The peak systolic myocardial velocity at tricuspid lateral annulus S' were significantly lower in patients compared with controls (14.5±3 vs 12.2±2 cm / s, p0.001; respectively). This decrease was greater in patients with severe OSA compared with mild to moderate OSA (11.4±3 vs 13.0±1 cm/s, p=0.05, respectively). Right ventricular myocardial performance index (MPI) was significantly higher in OSA compared with controls (0.55±0.12 vs 0.46±0.14, p=0.024, respectively) but it was not correlated with the severity of IAH.In OSA patients, there was a significant RV dysfunction independently of pulmonary pressure, although the correlation with the severity of IAH was moderate.

"2-chlorobenzylidene malononitrile" also named CS gas is the most used riot-control agent in the world. Its reputation as the least toxic tear gas explains its large use by different authorities. Early exposure to CS spray commonly induces visual irritation, skin reactions, with increased mucous secretion in order to temporarily incapacitate targeted people. However, there is a large agreement that safety data of this product is limited and further studies need to be performed since serious problems could occur after heavy exposure such as loss of consciousness, laryngospasm, pulmonary edema and hemorrhage... Herein, we report a case of a young man who had acute myocardial infarction with serious cardiac sequelae after exposure to tear gas. To our knowledge, this is the second case since forty years in the literature that directly links documented acute heart infarction to CS gas exposure.

Introduction Acute myocarditis is one of the most challenging diagnoses in cardiology. It is based on both clinical and paraclinical parameters. Myocarditis often presents as an acute coronary syndrome. Methods This is a retrospective study conducted between 2001 and 2017 in the cardiology department at the FSI hospital in La Marsa. Epidemiological, clinical, paraclinical and prognostic parameters were analyzed. Results Twenty six patients were registered including 3 women and 23 men. The average age was 37 (23–68 years). Symptoms were preceded by Influenza-like symptoms in 15 patients. Only 3 patients had fever. The most common symptoms were: angina in 11 patients, atypical chest pain in 9 patients, isolated palpitations in one patient, acute heart failure in 2 patients, and cardiogenic shock in 3 patients. The electrocardiogram (ECG) showed repolarization abnormalities in 17 cases, ventricular arrhythmias in 2 cases, sequelae of necrosis in 3 cases, atrial fibrillation in 2 cases and a normal ECG in 2 cases. The troponin assay was positive in 18 cases. Fourteen patients had a biological inflammatory syndrome. The etiological investigation concluded to a viral cause in 24 patients including a case of Rickettsiosis and a case of CMV infection. Myocarditis was a complication of chemotherapy in 2 cases. Transthoracic echocardiography demonstrated a decreased ejection fraction in 5 patients and segmental kinetic disorders in 12 patients. Associated pericarditis was noted in 2 patients. Twenty patients underwent myocardial MRI confirming the diagnosis of myocarditis. 24 patients have progressed to a restitution ad integrum. Only two patients kept a decreased left-ventricular function with segmental kinetic disorders. Conclusion Acute myocarditis may have different clinical features. It represents a major diagnostic issue, insofar as it simulates a myocardial infarction. In this context, cardiac MRI is of major interest for the differential diagnosis.

Evaluation of left ventricular systolic function, usually based on the assessment of the ejection fraction, is increasingly supplemented by other more sophisticated techniques such as 3D echocardiography and speckle tracking. However these methods require a high technicity and a good echogenicity. As heart failure leads to lengthening of aortic pre-ejectional time (PET) and shortening of left ventricular ejection time (ET), systolic time intervals (STI) were proposed for the evaluation of systolic myocardial performance.to establish a correlation between left ventricular ejection fraction (LVEF) and STI and determine a cut-off value of PET/ET ratio to diagnose a LVEF inferior to 35%.109 consecutive patients referred to two echocardiographic laboratories had measurements of STI and LVEF estimated by Simpson biplane method. Patients included were in sinus rhythm with a heart rate100 beats per minute. Patients with atrial fibrillation, pacemaker or prosthetic valves were excluded.Feasibility of STI measurements was 100%. A significant negative correlation between PET and LVEF was found (r=-0.49, p0.0001). LVEF was also significantly correlated to ET (r=0.44, p0.0001). PET/ET ratio was significantly correlated to LVEF (r=-0.63, p0.0001). Receiver operating curve analyses revealed a cut-off value of PET/ET ratio of 0.33 to diagnose a LVEF35% with a sensitivity of 85% and a specificity of 78%.STI, easy to obtain and useful in case of poor quality echographic window, are an interesting alternative to evaluate systolic left ventricular function and may be used to detect alteration of LVEF.

Hypereosinophilic syndrome (HES) is defined as a prolonged, unexplained peripheral eosinophilia. Endomyocardial fibrosis and mural thrombus formation are common occurrences such that patients are exposed to lethal thromboembolic complications. The valvular damage described is mainly related to iterative valve thromboses that are amenable to surgery. Here, the case is reported of a 39-year-old woman suffering from HES with mitral valve thrombosis and mechanical prosthetic mitral valve replacement, in whom a new thrombosis of the inserted prosthesis occurred one month postoperatively, concomitant with severe hypereosinophilia and despite adequate anticoagulation. The patient had received a new bioprosthetic mitral valve replacement, and her eosinophil count had been normalized after treatment with corticosteroids. Oral anticoagulation with warfarin was maintained. Subsequently, no recurrent thromboembolic events were reported, and echocardiography performed at the one-year follow up showed the bioprosthesis to have a normal hemodynamic profile.

PREREQUIS: Amyloidosis is a rare infiltrative disease characterized by multiple clinical features. Various organs are involved and the cardiovascular system is a common target of amyloidosis. Cardiac involvement may occur with or without clinical manifestations and is considered as a major prognostic factor.To analyze the clinical features of cardiac involvement, to review actual knowledgement concerning echocardiographic diagnostic and to evaluate recent advances in treatment of the disease.An electronic search of the relevant literature was carried out using Medline and Pubmed. Keys words used for the final search were amyloidosis, cardiopathy and echocardiography. We considered for analysis reviews, studies and articles between 1990 and 2007.Amyloidosis represents 5 to 10% of non ischemic cardiomyoparhies. Cardiac involvement is the first cause of restrictive cardiomyopathy witch must be evoked in front of every inexplained cardiopathy after the age of forty. The amyloid nature of cardiopathy is suggered if some manifestations were associated as a peripheric neuropathy, a carpal tunnel sydrome and proteinuria3g/day. Echocardiography shows dilated atria, a granular sparkling appearance of myocardium, diastolic dysfunction and thickened left ventricle contrasting with a low electric voltage. The proof of amyloidosis is brought by an extra-cardiac biopsy, the indications of endomyocardial biopsy are very limited. The identification of the amyloid nature of cardiopathy has an direct therapeutic implication: it indicates the use of digitalis, calcium channel blockers and beta-blockers. Today the treatment of amyloidosis remains very unsatisfactory especially in the cardiac involvement. An early diagnosis before the cardiac damage may facilitate therapy and improve prognosis.

Auricular fibrillation is the most common sustained cardiac arrhythmia, yet the optimal strategy for its management remains unclear. Since the study AFFIRM from which resulted them final were deferred in December 2002, the assumption of responsibility of the fibrillation of the old subject tends to become clarified. 86 patients at least 65 years or more were enrolled in our retrospective study from January 1997 to June 2003. The mean age is 70 years (65 to 82 years) and sex ratio to 0.79. 34% had a history of hypertension and 12% had a coronary artery disease. 2 groups were individualized, according to the year of admission before or after 2002. It comes out from these work 2 points: the restoration of the sinusal rhythm was the first choice. In the event of failure, the option was to maintain fibrillation and this, in the 2 groups. The AVK were founded in the large majority of the cases only after year 2002.

Primary tumors of the heart are uncommon. 75% of these tumors in the adult are benign and 25% are malignant. Angiosarcoma was the most frequent malignant tumour. 75% occurred on the right side, especially in the right atrial. This tumour was generally discovered in post-mortem because the non specificity of functional symptomatology. Echocardiography is the first non invasive tool for diagnosis and evaluation of cardiac mass. Angiosarcoma was associated with an unfavourable outcome. We reported a case of an atrial angiosarcoma revealed by transoesophageal echocardiography in a 42 years old woman.

The high incidence of association between sleep apnea syndrome and cardiac disturbance was widely descripted during the last decade and has been the target of intensive investigation. Our retrospective study included 12 patients with sleep apnea syndrome diagnosed by polysomnography. 7 patients had HTA with left ventricular hypertrophy (5 cases). The CPAP stabilise blood pressure in 6 of them, 3 patients had ventricular or atrial arrhythmia. CPAP resolved 2 of them. 3 other patients had coronaropathy. Another one presented stoke. The sleep apnea syndrome has been descripted in association with heart failure or unstable HTA.

IntroductionThe prevalence of chronic heart failure (CHF) is increasing in the world. Coronary artery disease is its most common cause in Europe. In Tunisia, valvular abnormalities were the leading aetiology of CHF in the eighties. We sought to determine its epidemiologic profile nowadays.Methods99 patients were hospitalized between 2004 and 2008 for chronic heart failure in our center. We analysed their demographic features, clinical caracteristics and their evolution.ResultsThe mean age was 59,1± 15 years (24 women). 42 patients were hypertensive and 42 had diabetes mellitus. 21% had atrial fibrillation. The mean ejection fraction (EF) at the time of diagnosis was 31,9±8%, 33% of patients had EF< 30%. Coronary artery disease was the cause in 54% of CHF. Hypertension was responsible in 16% of cases. A valvulopathy was the aetiology in only 3 cases. At discharge, the ACE were prescribed in 85% of patients, and betablockers in 41%. The mean follow up was 24±12 months, 12% were in class NYHA III or IV. 50% were hospitalized for worsening HF. 53% of hospitalizations occured during the first 12 months. During the follow up, 17 patients died, all of cardiac cause (i.e= 11.5%). LVEF was the only independent predictive factor of morbid-motality.ConclusionThe epidemiologic profile of CHF in Tunisia had underwent a profound change during the late decade. The regression of rhumatic fever is unfortunately opposed by the high prevalence of diabetes mellitus and systemic hypertension in our population which explain this new profile tracing the european one.

IntroductionThe relationship between right ventricular function and severe tricuspid regurgitation is intricate: severe TR can lead to right ventricle dysfunction and changes in right ventricle morphology can aggravate a tricuspid regurgitation.AimEstablish a correlation between regional and global right ventricular (RV) function parameters and TR severity.MethodsForty consecutive patients with TR and left ventricle valve disease were enrolled prospectively (mean age: 54±16 years; 23 males), TR was evaluated according to EACVI recommendations by PISA method. Regional right systolic function assessed by tricuspid annular plane systolic excursion (TAPSE) and systolic tissue Doppler velocity measured at the lateral tricuspid annulus (S’) and global RV function assessed by fractional area change (FAC) were measured for all patients. Patients were divided into two groups according to the severity of TR.ResultsTen patients (25%) had severe TR (G1) and 30 patients (75%) had mild or moderate TR (G2). FAC was lower in G1 compared to G2 (24.7±7.4% vs 40.4±10.1%, p

Objective To determine the impact of obstructive sleep apnea (OSA) on left ventricle (LV) structure and function and to search for a relationship between systolic LV function and severity of OSA. Methods 40 subjects without any cardiac or pulmonary disease, referred for evaluation of OSA had overnight polysomnography and complete echocardiographic assessment with estimation of left ventricular myocardial performance index (MPI) by tissue Doppler method. According to apnea hypopnea index (AHI), subjects were divided into two groups: patients with moderate OSA (AHI=15-30/h, n=18), and patients with severe OSA (AHI ≥30/h, n=22). Results were compared using ANOVA. The correlation between OSA severity and these variables was determined with Pearson's correlation coefficient. Results There was no significant difference between the 2 groups in clinical data. Ventricular septal and posterior wall thicknesses, LV mass index and LV end-diastolic and end-systolic volume index were similar between the groups. Patients with severe OSA had shorter aortic ejection times (288±32 ms vs 267±23 ms; p=0.02, for severe and no severe OSA respectively) and a higher MPI (0.61±0.14 vs 0.50±0.17; p=0.036, respectively). A correlation was found between OSA severity and left MPI (r=0.36, p=0.019), and aortic ejection times (r=–0.28; p=0.046). Conclusions MPI of left ventricle and aortic ejection time are altered in severe OSA and are correlated to AHI severity.