[Utility of stress cardiography to identify myocardial ischemia]. / Apport de l'echographie de stress dans la recherche de l'ischemie myocardique.

BACKGROUND: The dobutamine echocardiography takes more and more an important place in diagnosis, prognosis and therapeutics strategies of the coronary disease. AIM: We prospectively enrolled 130 consecutive patients followed for a coronary insufficiency METHODS: the aim of determinating the diagnostic value of the dobutamine echocardiography in the myocardial ischemia compared with the classic means as the exercise test and the myocardial scintigraphy. RESULTS: Our results are comparable to the data of the literature, the dobutamine echocardiography is more specific than the exercise test and the myocardial scintigraphy (96 %, 61% and 53 %), more sensitive than exercise test (75 % versus 47 %) but less sensitive than the myocardial scintigraphy (75 % versus 96 %). The stress echocardiography has the best diagnosis precision 87% against 72 % for the scintigraphy and 56 % for the exercise test. The dobutamine echocardiography is a very feasible, tolerated well exam and especially very reliable in term of detection of the coronary disease in the feminine population, with a sensibility at 66,7 %, a specificity at 100 % and a diagnostic precision at 92 %, also in patient with hypertension the stress echocardiography is much more specific and reliable than the exercise test (100 % vs 22 % and 93 % vs 54 %, respectively),and it's superior to the exercise test in the presence of electric signs of systolic excess load and to the myocardial scintigraphy in case of left ventricular hypertrophy. The dobutamine echocardiography can be considered as safety and reliable means of investigation of the coronary insufficiency .

[Double chamber right ventricle. About 3 cases]. / Ventricule droit a double chambre. A propos de trois observations.

The double chambered right ventricle is a rare congenital abnormality. It creates an obstacle for the right ventricular ejection. The cardiac ultra sonography examination allows the diagnosis in most majority of cases. The angiography is performed in difficult cases. We report 3 cases of infundibular stenosis with normal interventricular septum. The diagnosis was suspected for the 3 cases by the constellation of clinical findings pointing to systolic murmur over the precordium, and the electrocardiography showing right ventricular hypertrophy. It is confirmed by the echocardiogram and the hemodynamic exploration with a trans stenotic gradient evaluated at 72,80 and 80mmHg. The 3 patients underwent surgery and had all good post operative follow up. These 3 observations allow us to recall the epidemiological, embryological, clinical and echocardiographic particularities of pure infundibular stenosis and to determin the adequate treatment and the prognosis.

[Screening and management of coronary artery disease in diabetic patients]. / Dépistage et prise en charge de la maladie coronarienne chez le diabétique.

Diabetes represents as independent risk factor for coronary artery disease (CAD) and the prognosis in term of survival rates is worse for diabetic patients who have CAD with report to those with CAD but no diabetes. The coronary artery disease in diabetes has specificities and, in particular, more extensive atherosclerosis. Diabetic patients are also more frequently asymptomatic. Due to the extreme complexity of ischemic vascular disease in patients with diabetes, an optimal therapeutic strategy is based on the correction of elevated blood glucose and lipid levels, of blood pressure, of platelet and coagulation abnormalities. Diabetic patients benefit from secondary prevention by drug therapy(aspirin, lipid lowering with statines, beta blocker and ACE inhibitors) to the same extent as, or more than, non-diabetic patients. Both percutaneous and surgical myocardial revascularization have been proved equally effective for CAD treatment in diabetes. A recent randomized trial has shown a significantly improved outcome after surgical revascularization. But, the effects of drug-eluting stents, which dramatically decrease the incidence of re-stenosis, seem promising.

[Predictive factors of significant coronary stenosis in women. Review of 230 patients]. / Les facteurs predictifs d'une atteinte coronaire significative chez la femme. Etude de 230 patientes.

To evaluate the predictive factors of significant coronary stenosis in women, we have studied retrospectively data from 230 women explored by coronary angiography. The population has been divided in 2 groups: one (G1) without significant coronary lesions; the second (G2) having at least one significant coronary stenosis (> 50%). The prevalence of the significant disease was 54.3%. Coronary risk factors associated with a significant disease were : age > 55 years, diabetes mellitus, menopause, high lipid levels, and the association of at least 3 risk factors. Typical angina and history of myocardial infarction were significantly more prevalent in the G2 as like as Q necrosis wave, ST segment modifications percritically and premature ventricular beats. A regional abnormal wall motion at rest echocardiography was independently associated with significant coronary artery lesions (OR = 7.35). Using these data we have established a score of prediction of significant disease in women. This score aided to classify our female patients into different levels of risk and to better indicate subsequent explorations. Thus. with a good evaluation of the clinical and at rest data in women, we could obtain a more accurate degree of suspicion of a significant coronary artery disease before the indication of a coronary angiography.

[Hypertrophic cardiomyopathy in Freidreich ataxia: about two cases]. / Cardiomyopathie hypertrophique dans le cadre d'une maladie de Freidreich: a propos de deux cas.

Freidreich ataxia is the most frequent ataxia of early onset and of autosomal recessive transmission. It is associated with hypertrophic cardiomyopathy in 34 to 77% of cases. The purpose of this article is to describe the cardiac manifestations of two patients affected by this disease. The first case report is about a 34-years-old, bedridden male patient having muscular hypotony and osteotendinous areflexia of the lower limbs. Chest x-ray findings showed a cardiac silhouette distorted by scoliokyphosis. ECG revealed frequent auricular extrasystoles. Cardiac US examination disclosed a pattern of concentric hypertrophic cardiomyopathy with systolic and diastolic dysfonction.

[Acute myocardial infarction with normal coronary angiography: a 46-cases descriptive study]. / Infarctus du myocarde sur coronaires angiographiquement saines: etude descriptive de 46 cas.

This a retrospective study on 46 patients conducted over a 9-year period. These patients had an acute myocardial infarctus (AMI) confirmed wilth changes on the electrocardiogram and raised cardiac enzymes. However, the subsequent coronary angiography showed normal in all these patients. The purpose of our study is to assess epidemiologic, clinical, pronostic and therapeutic features of AMI with angiographically normal coronary arteries and compare the results obtained with those of AMI with coronary artery disease. AMI with angiographically normal coronary arteries is a first coronary event in young patients (mean age 47.7 years) having few coronary risk factors (54.3% have only one risk factor) mainly smoking (73.9%). The anterior location is prevalent. The patients with AMI and angiographically normal coronary arteries have a better prognosis than those with coronary artery stenosis. Indeed, their left ventricular function is unaltered (mean ejection fraction 48.7%). Hypokinesis is the most frequent abnormality of wall motion noticed. The patients' post infarction course is bengin when the coronary arteries are angiographically normal. The incidence of hemodynamic complications and ischemic recurrences are lower than in AMI with coronary stenosis. The choice treatment remains fibrinolysis.

[Introduction to myocardial doppler imaging]. / Introduction au Doppler tissulaire myocardique: principes physiques et applications cliniques.

Introduced in 1989, the myocardial doppler tissue imaging has now many clinical applications. Doppler tissue imaging explores the proper systolic and diastolic regional function of myocardial fibers. We can measure myocardial velocities by recording signals of low velocitiy and high magnitude, the strain and the strain rate are then derived from velocities. Specific software is therefore necessary. There are many ways of recording and representing myocardial doppler tissue parameters. Diagnostic and prognostic value of myocardial doppler tissue imaging is now proved and this method has many applications in ischemic cardiopathy and in cardiomyopathies. The development of powerful software is promising for the applications of the strain in the future.

[Epidemiological transition and health impact of cardiovascular disease in Tunisia]. / La transition epidémiologique ses determinants et son impact sur les systemes de sante a travers l'analyse de la tendance des maladies cardiovasculaires en Tunisie.

OBJECTIVE: We aim at analysing the increase of CVDs in the Tunisian hospitals in order to assess the burden of NCDs in the transitional context. METHODS: Data are recorded through the Tunisian National Morbidity and Mortality Survey (TNMMS). In order to assess the CVDs (CHDs vs RHDs) trend, two representative samples of Cardiology Departements patients were compared one is selected from the TNMMS and the second from the hospitalisations recorded in 1992. Causes, stay duration, status at the end of the hospitalisation, transfer to another hospital and patients socio-demographic characteristics are recorded and compared for the two periods. All the diagnosis are coded referring to the DMC 10. To analyze the determinant of the epidemiological transition, we have elaborated the CVD causal pattern and we have documented all their determinants. RESULTS: CHD rate has dramatically increased, while RHD has decreased especially on men. In 1992, 39.2% of men and 11.8% of women were admitted for CHD. In 2002, these rate are respectivly 58.8% and 38.2% while RHD rates were, in 1992, 11.8% on men and 25.3% on women vs 4.4% and 11.7% respectively. CONCLUSION: This study has confirmed that so far controlling transmitted diseases seems to be successful, Tunisian people are about to face a new problems as hypertension, obesity, diabetes and tobacco smoking. The new challenge with the burden of diseases requires the implementation of a national strategy relevant to the epidemiological, social and economical transition. Population needs and cost effectiveness of interventions assessment is crucial to set the national priorities.

[Delays in acute myocardial infarction treatment: results of a multicenter study in the district of Tunis (Tunisia)]. / Delai de prise en charge et acces aux soins de l'infarctus du myocarde dans les structures hospitalieres. Résultats d'une étude multicentrique.

OBJECTIVE: We aimed to assess the acute myocardial infarction management in Tunis public hospitals during one year (from March 2000 to February 2001). METHOD: A standard questionnaire was designed to record prospective data on 740 patients with a follow up during 28 days. Multivariate analysis was performed using the logistic regression model with all-factors as well as age, gender, CHD risk factors as predictors of the delay and fatality. 54% of patients were admitted during the first 6 hours after the onset of symptoms. In multivariate analysis, the delay of consultation is significantly correlated with gender (OR = 2.3, p < 0.001), age (OR = 1.02, p < 0.01) and health insurance (OR = 1.5, p < 0.01). 90% of patients consulted in emergency wards. The emergency ambulance transported 19.6% of patients. 48% of patients underwent early revascularisation of thrombolysis, 51% on men vs 31% on women (p < 0.01). The fatality rate was higher on women 14% vs 6.4% on men (p < 0.01) at 5 days and 27.2% vs 13.6% at 28 days. In multivariate analysis, the principal fatality predictive factor was age (RR = 1.08, p < 0.001) and delay (2.56 p < 0.001) and tobacco smoking (RR = 2.83, p < 0.0001). CONCLUSION: This study highlighted the problem of acute myocardial infarction management in public hospitals in Tunisia and it constitutes a baseline to assess different interventions focusing on cardiovascular diseases control and surveillance.

[The dual chamber cardiac pacing. A multicenter study apropos of 353 pacemakers]. / La stimulation cardiaque double chambre. Etude multicentrique à propos de 353 stimulateurs.

11 cardiac units, among which 5 experienced cardiac pacing are involved in the study. A retrospective analysis of the operated patient is performed. Authors paid particular attention to the following items: indications, etiologies, per operative parameters, complications and programmatic features of the inserted devices. Demographic date: 176 M, 177 F. The mean age of the sample: 58.4 +/- 16.25 years. The post operative complications occurred in 14% of the patients and were favourable evolution, but the presence of an atrial lead generated the half of the reoperations of which incidence was around 4%. (2%) have led to leave the DDD mode. The favorable results, as well at the technical levels as the evaluating level, witness that the tunisian centers have acquired a sufficient knowledge in the field of the conventional pacing and could now born on other problems, out passing the field of the bradycardias.

[Cellular transplantation: a new alternative treatment in ischemic cardiomyopathy]. / Transplantation cellulaire: nouvelle alternative du traitement de la cardiopathie ischémique.

The cellular transplantation in the myocardium or cellular cardiomyoplasty has been tested extensively among the animal. It showed very encouraging results concerning improval of the contractile function in cardiac failure. This work is going to review the set of the experimentations in the animal and the beginnings of the therapeutic tests. It is going to expose the different technical modes that have been proposed, the conditions of their realization, the problems to which they are exposed as well as the perspectives of future.

[Indications for the implantable cardiac defibrillator]. / Les indications du defibrillateur automatique implantable.

The indications of the implantable cardiac defibrillator (ICD) have enlarged over the time. This has been facilitated by the technological progress which permit the device to be more effective and its implantation to be more simple. So, the implantation rate has increased all over the world but especially in the United States. The ICD was initially proposed in case of recurrent cardiac arrests due to ventricular fibrillation. Later, indications have enlarged. They concern at the present time not only the secondary but also the primary prevention of the sudden cardiac death. Indications in secondary prevention are based on the results of randomized studies which have clearly demonstrated the superiority of the device if compared to the antiarrhythmic drugs. The first indication of the ICD in the primary prevention has been defined by the MADIT study. Since, other studies have tried to define high risk population in whom a prophylactic implantation of an ICD should be justified. However, other clinical trials are still necessary to precise the indications of the ICD in some disease states (hypertrophic cardiomyopathy, long QT syndrome, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, Brugada syndrome) which can be complicated by arrhythmic sudden death. Indeed, indications in these diseases are still based on small studies and in the opinion of experts.

[Aortic stenosis: interest in echocardiography with dobutamine]. / Retrecissement aortique: interet de l'echocardiographie sous dobutamine.

The stress echocardiography with dobutamine confirms her increasing value for the patients with severe aortic stenosis and left ventricular dysfunction in a diagnosis concept by selecting the true severe stenoses and revealing stenoses overestimated by the low fow, and especially prognosis by means of the stratification of the operatory risk and the search for a contractile reserve which represent the guarantee of a survival per and postoperatoire satisfactory. As regards asymptomatic aortic stenosis the times of intervention are in reevaluation, the compliance valvulaire represent reliable means which needs confirmation for a prophylactic indication for surgery.

[Doppler echocardiography and arhythmogenic right ventricular dysplasia]. / Echocardiographie-Doppler et dysplasie arythmogène du ventricule droit.

The aim of this study is to evaluate new echocardiographic modes in diagnosis of arrhythmogenic right ventricular dysplasia (ARVD). Our study is prospective, including ten patients with ARVD and a control group of ten healthy subjects. Transthoracic echocardiography included evaluation of classical criteria's, cross sectional measurements of the right ventricular. M mode and pulsed tissue Doppler techniques were used for quantitative measurement of tricuspid annular motion at the lateral and septal positions. Assessed by M mode, the total amplitude of the tricuspid annular motion was decreased in the lateral and septal positions in the patients compared with the controls. The tissue Doppler velocity pattern showed decreased early diastolic peak annular (Ea) velocity and an accompanying decrease in early (Ea) to late diastolic(Aa) velocity ratio in all positions; the systolic annular velocity was decreased only in the lateral position. Tricuspid annular measurement are valuable, easy to obtain and allow quantitative assessment of right ventricular function. ARVC patients showed an abnormal velocity pattern that may be an early but non specific sign of disease.

[non-Q wave myocardial infarction: study of 31 cases]. / Infarctus sans onde Q: etude descriptive de 31 cas.

The frequency of non-Q wave myocardial infarction is permanently increasing. In this retrospective study, we have tried to establish the clinical features, the prognosis and the therapeutic possibilities in this entity. We have studied the clinical history, the physical examination data, the results of the different explorations and the short and long term general course in 31 patients with a non Q wave myocardial infarction. The main feature of this acute coronary syndrome is the preservation of the myocardial function (normal in 64% of the patients). Concerning the angiographic finding, we note a high prevalence of severe coronary damages particularly of the stenosis of the left main coronary artery (13.5%); but also an important proportion of normal coronary angiographies (20%). In addition to the known factors associated with a poor prognosis in coronary artery disease, we insist on the severity of the initial depression of the ST-segment. The prognosis of the non Q wave myocardial infarction is better at the initial phase than that of the "transmural infarction". However, it becomes similar or worse at the long term general course. The important progress in the prognosis markers and in the anti-thrombotic and interventional therapies may maintain at the long term course the good initial prognosis.

[Myocardial infarction revealed by ischemic stroke]. / Infarctus du myocarde révélé par un accident vasculaire cérébral.

Ischemic cerebral infarction associated with myocardial infarction is yet a real diagnosis challenge. If during the acute myocardial phase the mechanism is mostly embolic, at long-term, the mechanism is not clearant and other causes should be searched. We report a 50 year old man with ischaemic stroke with strong evidence of myocardial infarction in the late phase with wall-motion abnormality and mural clot revealed by echocardiography and Q waves. Atrial fibrillation was suspected and no other abnormalities could be found. The diagnosis of cardio-embolic ischaemic stroke could not be made with certainly.

[Chronic-contained ruptured aortic aneurysm: un unusual cause of back pain]. / Rupture chronique cloisonnée d'un anévrysme de l'aorte abdominale: une cause inhabituelle de dorsalgies.

Chronic contained rupture of abdominal aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as a chronic back pain and the delayed diagnosis and delayed surgical repair may compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repair. We report a case of contained rupture of a small abdominal aortic aneurysm with delayed diagnosis, evaluated by computed tomography showing a beginning erosion of the lumbar vertebral body. The patient was operated on within 24 hours on admission with uneventful surgical outcome.

[Prognostic value of echocardiographic parameters in chronic cardiac insufficiency]. / Valeur pronostique des parameters echographiques chez l'insuffisant cardiaque chronique.

This work was interested in 72 patients (81% males) with chronic heart insufficiency. Ail these patients had a sinusal rythme. The etiology was mainly idiopathic (36%) but also ischemic (64%). 15% of patients were at stage I of NYHA, 37.5% at NYHA II, 40.5% at NYHA III and 7% at NYHA IV. All patients had taken a medical treatment (in 85% of cases, this treatment was based on diuretics and IEC). Transthoracic echocardiography was performed in these patients to determine the telediastolic diameter (TDD = 69 mm), the telesystolic diameter (TSD = 57), the velocity of E wave (0.66 mis) and A wave (0.55 mis) and the E wave deceleration time (DT = 0.196 s), 11 from ali patients were dead after a period of observation 21 months. The factors of pejorative prognostic were: the stages III and IV of NYHA, the cardiothoracic ratio > 0.60 and the echocardiographic parameters: TDD, TSD and DT (p = 0.03, p = 0.02 and p = 0.0001 respectively). But the E and A velocity seems don't influence the prognostic.

[Congenital auriculo-ventricular block in the adult]. / Le bloc auriculo-ventriculaire congenital en milieu adulte.

In this work we report a consecutive series of ten patients having auriculoventricular block "presumed" congenital which is seen in adulthood between 1990 and 2001 to determine their clinical profile and forecast, and to deduct the therapeutic consequences. Our criteria of inclusion requires the existence of patients with a second or third degree heart block, who are less than 40 years old at the time of diagnosis, which is not totally regressive in the effort test and the atropine injection, and whose congenital origin was strongly suspected because of the notion of slow pulse during their youth and the absence of acquired affect which enables us to explain this disease. The population contains ten patients whose average age in hospitalization is 23 years old with the range of 11 to 39, while the average age of the discovery of the disease was 20 years old with the range of 8 to 34. Our patients were referred to us because of cardiac symptoms such as syncope or an equivalent, effort intolerance, asthenia, thoracic pain (like angina), or palpitations. The clinical exam, the electrocardiogram, and additional exams (holter, effort test, echocardiography, electrophysiological investigation) allowed us to retain six indications for the definitive cardiac stimulation, associating to different degrees the existence of worrying symptoms such as a syncope, a congenital heart disorder, a low heart frequency, the association in a sinus dysfunction. Short-term and long-term evolution is favorable for patients of the stimulated group as well as the non-stimulated group.

[Coronary disease in hypothyroidism. 10 case reports]. / L'atteinte coronaire au cours de l'hypothyroidie. A propos de 10 cas.

The hypothyroidism and coronary disease are tightly related. Our retrospective study, based upon the data from ten patients with hypothyroidism and coronary disease, aimed to assess the diagnosis, the prognosis and the therapeutic measures in these patients. Our population aged in average 60 years and was almost composed with women. Acute Coronary syndrome was a circumstance to discover hypothyroidism three patients. Bi and tritruncular stenosis were found in seven of the patients. The mean number of coronary lesion by patient is 2, 1. Myocardial reperfusion was proposed in seven of the patients. The three remainders were treated medically. Among the six operated patients, three were insufficiently prepared by the opotherapy. One of these patients died in preoperative period. The only patient who underwent angioplasty presented an uneventful period. At short and long term follow-up the evolution of all survivors patients was satisfactory on the both coronary and thyroidal sides. During the course of hypothyroidism coronary lesions are more extended, complex and severe. The management of such patients is difficult because of destabilisation of affection by the treatment of the other one. Preventive measures seams to warrant the best result.