The Association of IL-6, TNFα and CRP Gene Polymorphisms with Coronary Artery Disease in a Tunisian Population: A Case-Control study.

Coronary artery disease is an inflammatory disease. Systemic markers of inflammation such as Interleukin-6, Tumor Necrosis Factor alpha and C-reactive protein have previously been shown to be associated with increased risk of cardiovascular events. The aim of the present study is to assess the role of variants in the IL-6 (- 174 G/C), TNFα (- 308 A/G) and CRP (+ 1059G/C) genes as susceptibility markers for CAD in a Tunisian population. The investigation was conducted as a case-control study involving 204 patients and 400 age-gender matched controls. Genotyping was performed using polymerase chain reaction and restriction fragment length polymorphism analysis. There are significant differences between CAD patients and the control group with regard to BMI (p < 10-3) and family history of CAD (p < 10-3). The CAD patients are more likely to have a history of smoking (p < 10-3), have a higher value of TC (p = 0.003), LDLc (p = 0.016), hs-CRP (p = 0.01), IL6 (p < 10-3) and TNFα (p = 0.038). Our analysis showed significant differences between cases and controls in genotypic distribution of IL6-174CC (p = 0.003; OR = 7.71 CI (1.58-37.56)), TNFα - 308 AA (p = 0.004; OR = 2.95 (1.57-5.51)) and CRP + 1059 CC (p < 10-3; OR = 5.40 (2.30-12.68)). However, we failed to find an association between the different genotypes and the inflammatory markers levels. Our results suggest that the presence of IL-6 (- 174 G/C), TNFα (-308 A/G) and CRP (+ 1059G/C) polymorphisms, may be considered to be a risk factor for CAD in Tunisian population.

Contribution of cardiac magnetic resonance imaging in the diagnosis of acute coronary syndrome with normal coronary angiography.

Background - Acute coronary syndrome with high level of troponin is a common pattern for emergency consultation. In 10% of cases, coronary angiography concluded that there were no significant coronary lesions. The contribution of cardiac magnetic resonance imaging (MRI) in the etiological investigation is increasing in these conditions. Aim - We analyzed the diagnostic value of cardiac MRI in case of acute coronary syndromes with elevated troponin and normal coronary angiography. Methods - It's a retrospective analytical study including 31 patients presenting with acute coronary syndrome with positive troponins and normal coronary angiography. All these patients underwent cardiac MRI. Results - The average age was 44.94 years. Cardiovascular risk factors were present in 38.70%. The average level of troponin was 4.85 ng/ml. Modification in the ST segment was noted in 87.1% of which 51.6% had ST elevated segment. Cardiac MRI was performed in the average of 8 days. MRI has contributed to the diagnosis in 77.4%: a myocardial infarction (MI) with no significant coronary lesions in 38.7% of cases, myocarditis in 29% of cases, Tako-Tsubo syndrome in 6.5% of cases and apical HCM in 3.2% of cases. MRI was normal in 22.6% of cases. Conclusions - The contribution of cardiac MRI is growing in the diagnostic management of patients with chest pain, elevated level of troponin and normal coronary angiography. The differential diagnoses have discriminating characteristics in MRI, allowing their identification with excellent diagnostic accuracy. The two main etiologies are myocardial necrosis and myocarditis.

Automatic left ventricle volume and mass quantification from 2D cine-MRI: Investigating papillary muscle influence.

OBJECTIVE: Early detection of cardiovascular diseases is based on accurate quantification of the left ventricle (LV) function parameters. In this paper, we propose a fully automatic framework for LV volume and mass quantification from 2D-cine MR images already segmented using U-Net. METHODS: The general framework consists of three main steps: Data preparation including automatic LV localization using a convolution neural network (CNN) and application of morphological operations to exclude papillary muscles from the LV cavity. The second step consists in automatically extracting the LV contours using U-Net architecture. Finally, by integrating temporal information which is manifested by a spatial motion of myocytes as a third dimension, we calculated LV volume, LV ejection fraction (LVEF) and left ventricle mass (LVM). Based on these parameters, we detected and quantified cardiac contraction abnormalities using Python software. RESULTS: CNN was trained with 35 patients and tested on 15 patients from the ACDC database with an accuracy of 99,15 %. U-Net architecture was trained using ACDC database and evaluated using local dataset with a Dice similarity coefficient (DSC) of 99,78 % and a Hausdorff Distance (HD) of 4.468 mm (p < 0,001). Quantification results showed a strong correlation with physiological measures with a Pearson correlation coefficient (PCC) of 0,991 for LV volume, 0.962 for LVEF, 0.98 for stroke volume (SV) and 0.923 for LVM after pillars' elimination. Clinically, our method allows regional and accurate identification of pathological myocardial segments and can serve as a diagnostic aid tool of cardiac contraction abnormalities. CONCLUSION: Experimental results prove the usefulness of the proposed method for LV volume and function quantification and verify its potential clinical applicability.

Uncommon using of the pulmonary homograft in oncological case - three years follow up.

INTRODUCTION: There are enough cases of colorectal cancer with liver metastasis, but inferior vena cava infiltraion with dissemination to the right atrium is an infrequent event. PRESENTATION OF CASE: This is the first case of surgical treatment of recurrent liver metastasis with the infiltration to the inferior vena cava and to the right atrium of the heart, using a cryopreserved pulmonary homograft. DISCUSSION: The choice of a cryopreserved pulmonary homograft was preferred by the need for a radical and wide resection of tissues involved in the metastasis, as well as to potentially reduce the risk of thrombosis in the short- and long-term postoperative period. CONCLUSION: The use of a cryopreserved homograft in operation undergoing cardiopulmonary bypass allowed us to perform the required volume of radical resection and to replace an extended section of the inferior vena cava.

[Acute myocardial infarction in elderly patients]. / Infarctus du myocarde chez le sujet âgé.

BACKGROUND: Age is the most important determinant of outcome for patients with acute coronary syndromes (ACS) and ischemic heart disease is the leading cause of death among elderly patients. AIM: To determine the epidemiologic particularities, the clinical presentation, and the treatment of Acute Myocardial Infarction (AMI) in patients over 65 years. METHODS: One hundred patients >65 years of age with myocardial infarction were hospitalized in intensive care of cardiologic unit of Military Hospital of Tunis between 2000 and 2008. Clinical characteristics, reperfusion therapy and outcomes of in-hospital period and for one year follow-up were seen for every patient. RESULTS: The mean age of our population was 77 years. Sex-ratio was 3/1.Our population was divided into tow groups; patients aged between 65 and 75 years (48 patients) and those aged more than 75 years (52 patients). Only 44 % of our patients had arrived at the hospital within the first 12 hours. STEMI was found in 65 % of our patients. At admission, 40 % had congestive heart failure (³ Killip II), 10 % were in cardiogenic shock. Urgent reperfusion therapy was given to 58 % of our patients; 33% received a thrombolytic therapy and 25 % were allocated to primary PCI. During in-hospital period, 40 % have developed congestive heart failure, 20 % have had a cardiogenic shock and 12 % were died. All these events were more frequent in patients aged over 75 years and reperfusion therapy was associated with best outcome. CONCLUSION: In our study invasive treatment such as fibrinolysis and PCI was associated to better outcome in acute period and at 12 months of follow up in elderly patients treated for AMI.

Is there a latent left ventricular dysfunction in hypertensive patients with preserved ejection fraction?

INTRODUCTION: Early detection of left ventricular (LV) dysfunction may represent a clinical finding that would justify aggressive treatment aimed to reduce cardiovascular morbidity and mortality. AIM: To evaluate longitudinal contractility in patients with essential hypertension and preserved LV ejection fraction (EF), in an attempt to detect latent impairment of LV systolic function. METHODS: Prospective case-control study carried out on 121 (67 male/54 female) hypertensive patients (HTN group) with preserved EF and without any symptoms of heart failure and 39 age- and gender-matched healthy subjects as a control group. Conventional echocardiographic study, as well as 2D Longitudinal strain imaging by 2D-speckle tracking echocardiography (2D-STE), were performed. RESULTS: Mean age of patients was 60,48 ± 10.5 years old. The LV end-diastolic diameter and LVEF were comparable between the two groups. Hypertensive patients had greater septal thickness, left ventricular mass, and maximum left atrium volume (p respectively at 0.02; 0.04; and 0.01). Only 20 patients (16.5%) had left ventricular hypertrophy (LVH). The architecture of LV was normal in 57.8 % (n=70) patients. A statistically significant difference between the two groups was found for all diastolic function parameters except Em /Ea ratio and DTEm. In comparison with normal controls, GLS was significantly attenuated in patients with HTN (-17.69 ± 4.06 % versus -22.70 ± 5.02% in controls (p=0.000) and 67 (55.4%) hypertensive patients had a GLS<-20% (in absolute value). The decrease of GLS was more marked in the hypertensive group with left ventricular hypertrophy. CONCLUSION: The results of our study confirmed that GLS is a sensitive biomarker of subclinical myocardial dysfunction in hypertensive patients, this suggests that identifying patients at higher risk for heart failure and earlier inter¬vention may be beneficial.

[Sirolimus-eluting stent in the prevention of restenosis in small coronary arteries]. / Le Stent A Elution De Sirolimus Dans La Prevention De La Restenose Des Arteres Coronaires De Petit Calibre.

BACKGROUND: Angioplasty of coronary arteries with a small diameter (commonly defined as diameter inferior than 2.75 mm) is associated with a high rate of restenosis and revascularization. Since the use of Drug Eluting Stents (DES) and considering their good results on simple lesions compared to other techniques (balloon dilation and bare metal stents), many studies have also demonstrated the superiority of DES in reducing restenosis and revascularization of complex lesions in particular lesions on coronary arteries with small diameter. AIM: Assessment of this revascularization procedure. METHODS: Our study is a prospective one carried on between june 2002 and august 2006, involving a cohort of 299 patients. Patients are divided into 2 groups: group I: 175 patients with 220 lesions on coronary arteries with small diameter treated by 233 sirolimus DES (Cypher) and group II: 124 patients treated by 136 angioplasty of coronary arteries with diameter superior than 2.75 mm using 179 DES. RESULTS: During hospitalisation, there was no significant difference in MACE between the 2 groups. Nevertheless, 2 patients among the first group had no angioplasty because of unsuccessful progression of the balloon through the lesion and the absence of atherectomy in our center. All patients having acute thrombosis during hospitalization and presenting with ST elevated acute coronary syndrome had successful urgent revascularization with TIMI 3 flow. The mid-term follow-up (12 months) concerned 157/174 patients in group I and 113/123 patients in group II. We observed a higher mortality and non fatal myocardial infarction in group I without statistically significant difference. CONCLUSION: despite the complexity of the lesions on coronary arteries with small diameter and despite the association with several risk factors in particular diabetes, the use of DES reduces the MACE specially secondary revascularisations thus improving early and midterm prognosis.

Cardiac tamponade: an uncommon presenting feature of systemic lupus erythematosus (a case-based review).

Although pericarditis is the most prevalent cardiac involvement in systemic lupus erythematosus (SLE), cardiac tamponade is extremely infrequent notably as the first manifestation of the disease. Here we report the case of a 22-year-old woman presenting with cardiac tamponade as the initial presentation of SLE.

[Infective endocarditis on probe of pacemaker]. / L'endocardite infectieuse sur sonde de stimulateur cardiaque.

Infective endocarditis is an uncommon but potentially lethal complication of permanent cardiac pacing. Infection is mainly caused by local contamination during the implantation procedure. The most frequently detected causative microorganisms were staphylococci. The clinical presentation is often atypical causing prolonged diagnostic delay. Bacteriological data and visualisation of neostructures consistent with vegetations on transoesophageal echocardiography, strongly suggest pacemaker lead infection. Management is based on a combined approach using both prolonged antibiotic treatment and early complete device explantation. Percutaneous techniques are currently the method of choice for lead extraction but it is not without possible complications. Antibiotic prophylaxis in order to reduce infection risk related to pacemaker implantation is widely recommended.

Stent implantation for ostial left anterior descending coronary artery stenosis: clinical particularities, therapeutic strategies, and medium-term outcomes.

BACKGROUND: The stenosis of the ostial left anterior descending artery represents one of the challenges for the interventional cardiologist. The aim of our study was to define the characteristics of this population and to analyze their results in medium term. METHODS: We had undertaken a retrospective study of 76 patients treated in the Cardiology Department of the Military Hospital of Tunis, between January 2014 and March 2017. Percutaneous coronary revascularizations of de novo ostial lesions of the left anterior descending artery were included. RESULTS: The mean age was 59.8 years with a male predominance. Two dilation strategies were adopted: 39% of patients had a "provisional-T-stenting" of the left main coronary artery versus 61% of patients who had a floating stent technic. The main immediate complication was acute occlusion of the circumflex artery ostium. After 12 months, the thrombosis and restenosis rates were 5,2% and 6,5%. Predictors of MACE were: Insulin-requiring diabetes(p=0.05), chronic renal failure(p=0.02), a low-pressure stent deployment(p=0.01), or the presence of signs of left ventricular failure (p<10-3). The predictive factors for stent thrombosis were the alteration of the left ventricular ejection fraction (p<0.01) and the eccentricity of the lesion (p<10-3). Finally, the predictive factors of restenosis were: acute per procedural occlusion of the ostial circumflex artery (p=0.01) or the presence of an associated lesion of distal IVA (p<0,001). CONCLUSION: Ostial lesions of the interventricular artery can be re-vascularized by percutaneous angioplasty with acceptable rates of major cardiovascular events. However, the risk of iterative revascularization remains significant.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus.

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

[Overview on the management of vasovagal syncope]. / Mise au point sur la prise en charge de la syncope vasovagale.

BACKGROUND: Vasovagal syncope (VVS) is the most common type of syncope. Despite its benignity, quality of life may be severely affected in a significant proportion of highly symptomatic patients. AIM: To review achral knowledgement concerning vasovagal syncope, to assess the utility of diagnostic investigation and report the updat therapeutic management. METHODS: An electronic search of the relevant literature was carried out using medline. Key words used for the final search were "Vasovagal syncope" "pathophysiology" "diagnosis" "tilt-table testing", "imlantableloop recoder", "treatment", "tilt training", isometric muscle tensing", "cardic pacing". RESULTS: A typical history of VVS is usually sufficient to make the diagnosis without any additional testing. Further testing is required when the diagnosis remains uncertain. Approaches to treatment are largely empirical and this is due to our lack of understanding of the pathophysiology. The management of VVS is often limited to reassuring and advising how to avoid predisposing factors with behaviour modification. For patients with recurrent episodes of syncope and premonitory symptoms, a conservative nondrug approach such as isometric muscle tensing should be considered. Tilt training can also be considered first-line therapy in motivated patients. Nevertheless, if patients still experience sudden recurrent and unpredictable episodes of syncope, a more aggressive treatment strategy is required with need of a prophylactic pharmacologic therapy. Various forms of medical treatment have been proposed but there are limited data from randomized controlled trials to support their effectiveness. The role of cardiac pacing is controversial and its indication should be restricted to patients over the age of 40 with severe recurrent syncope that is refractory to other therapies and in whom episodes include a substantial bradycardic component.

[Influence of sex on immediate and late results of percutaneous coronary angioplasty]. / Influence du sexe sur les resultats immediats et tardifs de l'angioplastie coronaire percutanee.

Prior studies have reported worse results after percutaneous transluminal coronary angioplasty (PTCA) in women than in men. However, recent data suggest that this difference is less marked. The aim of our study is to evaluate whether the procedural outcome is equal in the two genders. Six hundred and eighty-eight PTCA were studied in 96 consecutive women and 509 men who underwent the procedure in our catheterization laboratory between 1998 and 2004. Women undergoing PTCA were older than men and had a higher incidence of diabetes, hypercholesterolemia and hypertension. Multivessel disease and severe coronary lesions were more frequent in women. The stenting rates, the use of drug eluting stents and of glycoprotein IIbIIIa inhibitors were similar in the two sexes. Procedural success rate was similar in the two groups. No significant differences were found in in-hospital mortality and in the resort to emergency coronary artery bypass grafting (CABG). 14 month after the procedure there were similar rates of death, repeated revascularisation and restenosis have been shown in the two sexes. Even if the baseline characteristics remain worse in women, increased experience of the operators, introduction of new stents and use of glycoprotein IIIbIIa inhibitors have improved the results in patients undergoing PTCA. This improvement has been higher in women than in men leading to the equalization of the outcome in the two sexes.

[Sinus node dysfunction in a "healthy heart" in an infant. A case report]. / Dysfonction sinusale à "coeur sain"chez l'enfant. A propos d'un cas.

Sinus node dysfunction (SND) is a rare cause of bradycardia in children without structural heart disease. However the association between (SND) and abnormality of atrio-ventricular conduction, is more uncommon. We report a case of a child 23 months old, admitted in the cardiology department for a symptomatic bradycardia. Routine ECG and 24-h-Holter monitoring showed atrioventricular junctional rhythms with minimal rates of 24 bpm and episodes of asystole with a maximal duration of 3.7 seconds. The children was implanted with a permanent VVIR mode pacemaker to relieve his symptoms. During a follow-up period of four years, the child developed syncope, the epicardial pacing lead was broken and atrioventricular block was observed. A second pacemaker was inserted by a subclavicular vein, and was programmed in VVIR mode.

[GPIIB/IIIA blockade after high-risk angioplasty: new perspectives]. / Les anti-GPIIB/IIIA, de l'angioplastie a haut risque vers de nouvelles perspectives.

The treatment of acute coronary syndromes knows today revolution, with the clinical use of platelet glycoprotein IIb/IIIa inhibitors. The benefit of these agents as adjunctive treatment for percutaneous coronary intervention has been substantial and consistently proved among trials; however patients undergoing revascularization after drug discontinuation demonstrated a moderate event reduction. In this analysis, including the entire large-scale trial experience of intravenous glycoprotein IIb/IIIa inhibitors, we try to evaluate this therapeutic class in the high risk coronary intervention, in patients with acute coronary syndromes primarily medically managed, and in combination therapy with thrombolytics in the acute myocardial infarction. The purpose was to demonstrate the reduction of cardiac events after administration of this drug in the different indications and to precise their different adverse effects.

[Role of fibrin D-dimer in acute coronary syndrome. Prospective study of 22 cases]. / Intérêt des D-dimères dans les syndromes coronariens aigus. Etude prospective à propos de 22 cas.

Fibrin D-dimer are the consequence of an excess of fibrinolysis. The raise of their level in coronary heart disease seems to be helpful to enhance the diagnosis of coronary ischemia. Prospective study over 4 months, including 22 patients (16 male, 6 female) divided in 2 subgroups: Group I: 10 patients investigated for stable angina Group II: 12 patients investigated for ACS without ST elevation. All patients underwent fibrin D-dimer dosage and coronarography. Fibrin D-dimer levels were higher in group II (924.5 ng/ml vs 703.9 ng/ml; p < 0.0001). In group II, 6 patients had ST depression with a level of fibrin D-dimer 879.5 ng/ml vs 969.6 ng/ml in the other 6 patients. We found a positive correlation between level of fibrin D-dimer and complexity of coronary lesions (1007 ng/ml in type C vs 675 ng/ml in type A lesions; p < 0.0001). Fibrin D-dimer seems highly implicated in coronary disease and if these results are confirmed by larger studies their routine dosage will be helpful in ACS.

Spontaneous multivessel coronary artery dissection associated with cannabis use.

Cannabis is the most widely used illicit drug in the world. It is generally considered to be a drug with low toxicity. Nevertheless, there are several case reports of myocardial infarction following cannabis use in otherwise low-risk individuals. We report the first case of a cannabis user presenting with acute coronary syndrome related to multivessel coronary artery dissection.

Fatal postpartal dissection of all coronary arteries in an in vitro-fertilized woman.

Myocardial infarction complicates approximately 1 in 10,000 pregnancies [1]. Coronary artery dissection is the leading cause of pregnancy-related myocardial infarction during the postpartum period. Proposed etiologies include altered endocrine status, hemodynamic stress, eosinophilic inflammatory infiltrate, and disruption of vasa vasorum. Definitive diagnosis is made by coronary angiography. Treatment has not been well defined. Strategies include medical management, stenting, and coronary artery bypass grafting. Here, we report the postpartal dissection of all 3 coronary arteries and of the left main coronary in an in vitro-fertilized, 40-year-old woman who, after giving birth to a newborn by cesarean section, presented with myocardial infarction and required urgent coronary artery bypass surgery. Spontaneous coronary dissection that predominantly affects young women is rare and is often dramatic. One-third of the cases occur during pregnancy or in the postpartum period. Our case report is unique; postpartum coronary artery dissection in a patient of any age that was fertilized in vitro is very rare.