[Trends in the profile of infective endocarditis at a university hospital in Tunis]. / Évolution du profil de l'endocardite infectieuse : expérience d'un centre universitaire à Tunis.

UNLABELLED: Infective endocarditis (IE) is a serious disease for which diagnosis and treatment continue to develop. Purpose of work. To analyze trends in its epidemiologic, clinical, and microbiologic characteristics, as well as its treatment and outcome. METHODS: Retrospective review of data of 135 patients admitted to our adult cardiology department from January 1981 through December 2011. IE was diagnosed according to the modified Duke Criteria. We defined 2 groups of patients according to their date of admission: group A (n = 55), patients admitted before 1995, and group B (n = 80), patients admitted in and after 1995. RESULTS: The entire population was predominantly male, and their mean age was 38.5 ± 16 years, 36 years in group A and 44 years in group B. IE affected mainly native valves (90% group A, 74% group B; p<0.05). Prosthetic IE was more frequent in group B (20% vs 10%, p<0.05), and the portal of entry identified more often (59% vs 22%; p = 0.03). Blood cultures were negative in 78% of patients in group A vs 57.5% in group B (p = 0.04). The principal causative microorganism was streptococcus before 1995 and staphylococcus after 1995, but this difference was not significant. Heart failure was more frequent in group A (p = 0.05). Embolic events affected 27% of the patients in group A vs 32.5% in group B (p = 0.05). The rate of surgery (51% in group A vs 62.5% in group B) did not differ significantly. The in-hospital mortality rate was 53% in group A vs 11% in group B (p<0.001); operative mortality was also higher in group A (p<0.001). CONCLUSION: Our work shows changes in the epidemiologic characteristics of IE that parallel changes in demographic and risk factors. The progress of diagnosis and surgery explains the better prognosis for this pathology today.

Natural history of atrial septal defect in the sixth decade : study of 5 cases.

BACKGROUND: Atrial septal defect (ASD) is one of the most common causes of congenital heart disease manifested in adulthood. AIM: To describe clinical and likelihood picture of adults over 60 years born with an ASD type II. METHODS: We performed a retrospective study of adult'sASD referred toourinstitutionfrom 1985 through 2010. Clinical, electrocardiographic, echocardiographic and hemodynamic data were reviewed. On follow up study, patients were investigated by echocardiography, ECG and assessed for quality of life by a questionnaire RESULTS: Among forty ASD type II manifested in adulthood which were referred to our department of cardiology five cases of ASD manifested in the sixth decades (2 men and 3 women). Complaints were dyspnea and palpitations in 4 cases and chest pain in only one patient. Slight anterior chest deformity was present in the older patient. Systolic murmur was found in the 3rd left intercostals space and the pulmonary second heart sound was accentuated in all patients. Complete right bundle branch block and right ventricular hypertrophy were found in all cases. Three patients presented atrial fibrillation. There was marked cardiomegaly in four patients. The pulmonary arteries were markedly enlarged and the peripheral vascular markings were increased. Echocardiographic data revealed large secundum ASD (mean 20 mm, ranged between 10 and 30mm), severe systolic pulmonary pressure in two cases (>5O mmhg). MeanQP/QS was 2.2 and contrast revealed bidirectional shunt in one patient. All patients were studied by venous cardiac catheterization. They showed a significant increase in the oxygen content of right atrial blood. Three patients underwent surgical atrial septal defect closure under general anesthesia. There were no operative or peri operative deaths. At mean follow up of 50±75 months, there was one late death from heart failure in a patient with advanced preoperative heart failure. The oldest patient is in the medical group and he is 75years old. Most survival patients remain in good clinical condition. Some of them were symptomatic at the last follow up and complained of shortness of breath on effort and palpitations in two cases. Two patients were in chronic atrial fibrillation developed during follow up. However, chest RX showed reduction in cardiothoracic ratio postoperatively. Echocardiographic examination confirmed that there was no residual shunt in across the atrial septum in any patient. Systolic pulmonary pressure felled only in 2 patients in the surgery group. CONCLUSION: To our knowledge, thesepatients havealongue life span, although survivors with ASD described in the world. There is a lack of evidence regarding treatment options for adults with an ASD aged more than 60years. Given the higher risks of surgery in advanced age, the defect should be repaired as early as possible to prevent hemodynamic complications.

[False aneurysm of the right ventricular outflow tract due to infective endocarditis after repair of congenital heart disease]. / Faux anévrisme de la voie d'éjection du ventricule droit compliquant une endocardite infectieuse après réparation d'une cardiopathie congénitale.

A case of an enormous false aneurysm of the right ventricular outflow tract due to infective endocarditis is reported in a 12-year old girl who underwent Rastelli repair of congenital heart disease with reconstruction of the right ventricular outflow tract by bovine jugular vein graft (Contegra). The false aneurysm was associated to desinsertion of the patch of the ventricular septal defect and compresses the right ventricle leading to heart failure and shock. Surgical treatment was performed in emergency but the child died after surgery. Infectious false aneurysm of the right ventricle after surgical reconstruction of the right ventricular outflow tract is very rare. At our knowledge, only three cases have been reported in the literature. We report here another case.

[Microalbuminuria and left ventricular geometry in essential arterial hypertension]. / Microalbuminurie et geometrie ventriculaire gauche dans l'hypertension arterielle essentielle.

The association between left ventricular hypertrophy and microalbuminuria is actually admitted. Recent studies shown that patients with microalbuminuria have higher left ventricular mass index, worst systolic function and often concentric geometric kind of left ventricular hypertrophy. The efficiency of an adapted and early therapeutic on a potential relationship between reduction of microalbuminuria and improvement of target organ injury, principally heart and kidney, is still to evaluate. The aim of our study is to review geometric and hemodynamic aspect of left ventricular hypertrophy in hypertensive micro-albuminuria patients.

[Short- and long-term results of mitral valve replacement by caged-ball and bileaflet mechanical prosthesis (series of 236 consecutive patients with average follow-up of 11 years)]. / Résultats à court et long terme du remplacement valvulaire mitral par prothèse mécanique à bille et à ailettes (à propos d'une série de 236 patients consécutifs avec un suivi moyen de 11 ans).

OBJECTIVES: To study the early and late results of mitral valve replacement (MVR) by Starr-Edwards caged-ball and bileaflet mechanical prosthesis. MATERIAL AND METHODS: We retrospectively analyzed 236 MVR performed in 236 patients: 127 by Starr-Edwards prosthesis (group 1) and 109 by bileaflet prosthesis (group 2). RESULTS: During the early period (30 days), the mortality rate was higher in group 1 (6.3% vs 1.8%; p=0.0001), while hemorrhagic, thromboembolic and infectious complications were comparable in the two groups. In the late period (>30 days) and with an average follow-up of 11.5+/-5.7 years, mortality was higher in group 1 (9.4% vs 4.6%; p<0.0001). The same was true for thromboembolic complications (20.8% vs 6.4%; p<0.0001), hemorrhagic complications (13.4% vs 7.3%; p=0.02), infectious complications (3.1% vs 0.9%; p=0.02) and cardiac complications that were not due to the prosthesis (32.3% vs 14.7 %; p=0.02). The hemodynamic profile of the bileaflet prostheses was better than that of the Starr-Edwards prostheses (average functional prosthetic surface area was 2.37+/-0.44 cm(2) and average pressure gradient was 5.6+/-1.1 mmHg vs 2.04+/-0.52 cm(2) and 7.6+/-4.9 mmHg). CONCLUSION: Our work confirms the superiority of bileaflet mechanical prostheses, with rates of early and late mortality, thromboembolic and hemorrhagic complications lower than those of the Starr-Edwards prostheses in more than 11 years of follow-up. However, one should not forget that the prevention of infective endocarditis, good observance of oral anticoagulant treatment and early surgery before left ventricular dysfunction occurs remain the best guarantee a good result of the MVR.

[Retrospective study on 100 cases of infective endocarditis, Rabta University Hospital, Tunis, from 1980 to 2004]. / Etude retrospective à propos de 100 cas d'endocardite infectieuse, au CHU La Rabta de Tunis de 1980 à 2004.

This retrospective study describes 100 cases of infective endocarditis (IE), collected between 1980 and 2004. Patients were subdivided into 2 groups, according to the use of trans-esophageal echocardiography (TOE) in the institution where the study was performed: group A (GA=55 patients, between 1980 and 1991) and group B (GB=45 patients, between 1992 and 2004). The IE cases of 59 men and 41 women were analyzed. Patients had a mean age of 33 years (range 15-75 years). An underlying heart disease was involved in all cases, mainly rheumatic heart disease (93% of cases). Native valve endocarditis (NVE) was seen in a majority of cases (93%), and the localization of IE was aortic in 36 cases, mitral in 36 cases, mitro-aortic in 26 cases and mitro-aortic-tricuspid in 2 cases. Prosthetic valve endocarditis (PVE) occurred in 12 cases. Blood cultures were positive in 31 cases, with 14 staphylococcal infections (3 in GA and 11 in GB) (p < 0.05), of which 6 were coagulase-negative; 13 were streptococci and 4 were Gram negative bacilli. All patients had a transthoracic echocardiography (TTE), and patients in group B also had a TOE. Seventeen patients had a favorable outcome without need of a surgical intervention. Early surgery was necessary in 71 cases (85.5%), and elective surgery in 12 cases (14.5%). Mortality while awaiting surgery was 27%, and has been decreasing for the past decade (41.8% in GA and 8.9% in GB) [p < 0.05]. Postoperative mortality after early surgery intervention was 13.6% (6 among 44 patients), and it was 8.3% (1 among 12 patients) after elective surgery intervention. Overall mortality was 34%: 27 deaths with NVE (30.7% [27/88]), and 7 deaths with PVE (58.3% [7/12]) [NS]. Predictors of mortality in this observational study were positive blood cultures involving staphylococci, the presence of valve mutilations, unstable prostheses, and heart failure.

[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.

[Intracardiac thrombus in Behçet's disease. A report of three cases]. / Thrombus intracardiaque au cours de la maladie de Behçet. A propos de trois cas.

Intracardiac thrombus formation is exceptional in Behçet's disease (less than 50 cases had been reported). Among 180 patients with Behçet's disease (according to the criteria of the international study group for Behçet's disease), three were diagnosed as having intracardiac thrombus. All were male, the mean age at the time of the diagnosis of the intracardiac thrombus was 27 years and the mean disease duration was 4.8 years. The presenting symptom was hemoptysis in two patients and heart failure in the third. Surgery was the first attempted treatment in two patients but thrombus recurred and resolved after medical treatment. The third patient was given corticosteroids and anticoagulants as the first line treatment. The thrombus did not resolve and the patient declined surgery. Intracardiac thrombus formation should be considered when a young Behçet's disease patient presents with an intracardiac mass. Medical treatment including corticosteroids, immunosuppressive drugs and anticoagulants should be considered as the first line treatment and surgery should be considered when there is no resolution of the thrombus or when it becomes massive and extensive. In certain cases, thrombolytic treatment becomes an interesting alternative to surgery.

[Cardiac hydatid cyst (report of 8 cases)]. / L'hydatidose cardiaque (à propos de 8 observations).

Hydatic cardiac cyst (HCC) is a rare anomaly, characterized by wide spectrum of clinical presentations. Its diagnosis took large benefit from echocardiography progress. We aimed in this study to analyse epidemiologic aspect of HCC, as well as its diagnostic data, with special emphasize on echocardiography. Observations of 8 patients, admitted between 1991 and 2000 has been reviewed. Age average was 30 years (13 to 59). Main symptoms consisted of chest pain (62.5%) and dyspnea (35%). Chest X-Rays showed cardiac silhouette anomaly in 4 cases. Electrocardiogram showed sub-epicardical ischemia in 5 patients. HCC diagnosis was established by transthoracic echocardiography in all cases. It was located inside a cardiac chambers (n = 5), the interventricular septum (n = 2), and the pericardium (n = 1). HCC relation with adjacent cardiac structures was well defined by transoesophageal echocardiography performed in 7 cases. All patients underwent surgery with good immediate results. All patients were events free, with a mean follow-up of 25 months.

[Congenital mitral insufficiency. Diagnosis, prognosis and treatment]. / L'insuffisance mitrale congénitale. Diagnostic, pronostic et traitement.

Between September 1973 and November 1993, 30 children with CMI underwent open-heart surgery. The mean age at operation was 6.63 years with a range of 8 months to 14 years. Twenty patients underwent reconstructive mitral valvuloplasty; 3 immediate failures and 1 case of stenosis of Carpentier's ring, occurring 7 years after the operation, were observed in this group. Among the 10 patients treated by mitral valve replacement, there were 4 deaths, including 3 from specific complications of the prosthesis. Conservative mitral surgery provides better results with far fewer complications that mechanical prostheses and must therefore always be attempted as the first-line procedure.