Pro- and anti-inflammatory cytokines in post-infarction left ventricular remodeling.

OBJECTIVES: Acute myocardial infarction (MI) leads to molecular, structural, geometric and functional changes in the heart during a process known as ventricular remodeling. Myocardial infarction is followed by an inflammatory response in which pro- and anti-inflammatory cytokines play a crucial role, particularly in left ventricular remodeling. This study aimed at evaluating serum concentrations of interleukin-8 (IL8), tumor-necrosis-factor-alpha (TNFα) and interleukin-10 (IL10), pro- and anti-inflammatory cytokines, and at correlating them with left ventricular remodeling as assessed by echocardiographic parameters. METHODS: In a case-control study 30 MI patients were compared with 30 healthy controls. Serum concentrations of IL8, TNFα and IL10 were measured on day 2 and day 30 post-MI by chemiluminescence immunoassay and correlated with echocardiographic parameters. RESULTS: There was an increase of IL8, and TNFα together with a decrease of IL10 at both time points. IL8 was negatively correlated with the left ventricular end-diastolic diameter (LVEDD) and positively with left ventricular systolic volume. IL10 was negatively correlated with LVEDD and left atrial volume 30days post-MI. CONCLUSION: The increase of pro-inflammatory cytokines TNFα and IL8 was accompanied by decreased anti-inflammatory IL10. This imbalance between pro- and anti-inflammatory cytokines might contribute to the progression of left ventricular remodeling and may lead to heart failure.

[Percutaneous mitral commissurotomy associated to sinus venosus atrial septal defect and partially anomalous pulmonary venous connection: a case report]. / Commissurotomie mitrale percutanée associée à une communication interauriculaire type sinus venosus et un retour veineux anormal partiel: à propos d'un cas.

Lutembacher's syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. It is rarely associated to partial anomalous pulmonary venous connection. This condition is treated surgically by mitral commissurotomy or mitral valve operation with concomitant closure of the atrial septal defect with correction of the abnormal pulmonary venous connection. Percutaneous mitral commissurotomy before surgery can be a therapeutic alternative when mitral valve stenosis is severe and valve anatomy is favourable. The authors bring back the case of a 24 years old man having mitral stenosis in sinus rhythm associated to sinus venosus septal defect and partial anomalous pulmonary venous connection. The diagnosis was made for the age of 17 years old on the occasion of dyspnea. He benefited in February 2003 of rescue percutaneous mitral commissurotomy because of pulmonary oedema. Mitral valve area increased from 0.7 cm(2) to 1.6 cm(2). The patient was clinically approved, so that he refused surgery and was lost sight. Seven years later (August 2010) he was taken back for a second rescue percutaneous mitral commissurotomy because of a very severe mitral stenosis (mitral valve area was 0.8cm(2)), in pulmonary oedema with echocardiographic evaluated pulmonary hypertension at 68mmHg. The trans-septal complicated of a false road from the right atrium, towards the pericardic cavity. The patient was operated as the matter of urgency, and benefited from a mitral valve replacement by mechanical prosthesis, of closure of sinus venosus septal defect by PTFE patch and correction of abnormal pulmonary venous connection. Operating suites were simple, and the postoperative echocardiography concludes to a good prosthesis profile, the absence of residual shunt and a decrease of pulmonary artery blood pressure from 68 to 40mmHg. In conclusion, percutaneous mitral commissurotomy may be a waiting procedure for surgery of this disease or emergency treatment of it's valve anomaly, with regular monitoring while awaiting surgery faster and in better conditions.

HLA class II polymorphisms in Tunisian patients with dilated cardiomyopathy.

Cardiomyopathies (CMs) are primary disorders of cardiac muscle. They are a major cause of morbidity and mortality for all ages and, like acquired forms of cardiovascular disease, often result in heart failure. Molecular genetic studies have made remarkable progress in defining the pathogenesis of CM. The present study was the first report to evaluate the relationship between class II major histocompatibility complex (MHC) genes (HLA-DRB1 and HLA-DQB1) and the genetic susceptibility to primary dilated cardiomyopathy (DCM) in Tunisian patients. The human leukocyte antigen (HLA)-DRB1 and -DQB1 alleles were analyzed in 76 patients with primary DCM and 111 ethnically matched healthy controls using polymerase chain reaction-sequence specific primers technique. An increased frequencies of HLA-DRB1*0401 (OR = 2.67, P < 0.001), HLA-DQB1*0302 (OR = 3.28, P = 0.001) and HLA-DQB1*0401 (OR = 6.26, P = 0.005) alleles were found in the patients with primary DCM compared with healthy controls. Individuals with HLA-DRB1*1301 (OR = 0.24, P < 0.001) and HLA-DQB1*0201 (OR = 0.49, P = 0.002) alleles have a protective effect against primary DCM. Two haplotypes were associated with increased risk of primary DCM: DRB1*0401/DQB1*0302 (OR = 4.53, P = 0.002) and DRB1*0401/DQB1*0401 (OR = 9.42, P = 0.004). In conclusion, our data suggest that the variation in class II HLA alleles could be a genetic factor involved in the susceptibility to primary DCM in the Tunisian population.

[Role of transthoracic echocardiography in the diagnosis of acute pulmonary embolism]. / Apport de L'echocardiographie Transthoracique dans le Diagnostic de L'embolie Pulmonaire.

OBJECTIVES: The objective of our work is to determine the value of transthoracic echocardiography (TTE) in the diagnosis of pulmonary embolism (PE) and its place in the diagnostic strategy in a cardiology department in Tunisia. MATERIAL AND METHODS: It is a retrospective study including 43 patients between 1993 and 2003 in the cardiology department of the "Hôpital Militaire Principal d'Instruction de Tunis" for acute pulmonary embolism. RESULTS: Our population had a feminine ascendancy. The average age was 53.9 +/- 17.6 years. In patients with positive pulmonary perfusion scintigram and by taking pulmonary helical CT as diagnostic gold standard, we found that TTE yielded a sensivity of 74 % and a specificity of 25 % for the diagnosis of pulmonary embolism. The most common echocardiographic signs were the right cavities dilation and the increase of right pressures. CONCLUSION: Transthoracic echocardiography is a good test to screen patients for suspected PE because it has an excellent sensitivity. It must be often completed by transesophageal echocardiography and integrated in all diagnostic approach of pulmonary embolism.

Variable cardiac involvement in Tunisian siblings harboring FKRP gene mutations.

Mutations in the gene encoding fukutin-related protein (FKRP) cause limb-girdle muscular dystrophy 2I (LGMD2I) and congenital muscular dystrophy (MDC1C). Cardiac involvement was frequently reported with numerous mutations including C826A and 1364C > A mutations. The original Tunisian family with LGMD2I included 12 patients sharing the LGMD phenotype and homozygous to the 1486T > A mutation but who did not display any cardiac involvement. In this study, we report the clinical data, cardiac assessment and mutation analysis in four sibs belonging to a second Tunisian LGMD2I family. All patients showed the LGMD phenotype, the oldest brother and sister had mild cardiac involvement, whereas two twin sisters displayed severe cardiomyopathy leading to death. The patients shared the compound heterozygous 1486T > A, 1364C > A mutation in the FKRP gene suggesting that the association of a compound heterozygous state of mutation responsible for LGMD2I and the MDC1C phenotype could lead to cardiac involvement.

[Management of acute myocardial infarction: the experience of a Tunisian hospital]. / Prise en charge therapeutique de l'infarctus du myocarde a la phase aigue: Expérience d'un hôpital de Tunis.

UNLABELLED: The aim of this work was to study some aspects of the management of acute myocardial infarction. MATERIAL AND METHODS: Data concerning 153 patients had been collected during one year between July 1st, 2000 and June 30, 2001 from patients' databases. RESULTS: Our population was constituted of 126 men (82.4%) and 27 women (17.6%). The average age was 61 years. 101 patients (66.0%) were treated by thrombolysis with an average delay of 5.3 +/- 2.8 hours. Streptokinase was the thrombolytic agent used in all cases. Percutaneous transluminal coronary angioplasty was performed in thirteen patients (8.5%) (5 primary angioplasties, 4 rescue angioplasties and 4 programmed angioplasties). Stents were implanted in 12 patients. A cardiac surgery was performed in three patients (2 coronary artery bypass graft surgery and 1 closure of ventricular septal defect) in acute phase of their myocardial infarction. The global rate of revascularisation was 71%. CONCLUSION: The thrombolytic therapy remains the most used means of revascularisation in our country because it is available and not expensive. The use of coronary angioplasty in emergency remains exceptional because the technical means were insufficient.

Improved localization of coronary stents based on image enhancement.

Stent thrombosis remains a life threatening complication of percutaneous coronary interventions. The angiographic result of stent implantation is a high predictive factor of stent thrombosis. Nevertheless accurate placement of stents is hindered by the fact that most stents are only slightly radiopaque and hence difficult to see in typical coronary X-ray images. In this work, we propose a simple image guidance approach, making it easier to achieve optimum and complete intracoronary stent deployment. The main idea is to enhance the visibility of stents using an iterative landmark-based registration. After frame averaging over the series of registered frames, the resultant stent image is post processed to increase the contrast visibility. Preliminary simulation results show that despite its low computational cost, our method significantly improves the visibility of stent edge struts.

[Management of pulmonary embolism in a cardiology department]. / Prise en charge de l'embolie pulmonaire en milieu cardiologique: expérience d'un hôpital tunisien.

OBJECTIVES: The objective of our work is to study the clinical features and the management of pulmonary embolism in a cardiology department. MATERIAL AND METHODS: It is a retrospective study including 43 patients between 1993 and 2003 in the cardiology department of a Tunisian hospital for acute pulmonary embolism. RESULTS: The most common clinical signs were dyspnea, pleural pain and deep venous thrombosis. The most common physical signs were tachypnea and tachycardia. Electrocardiographic abnormalities were found in 38 patients (88.4%). Chest X-ray was abnormal in 25 patients (60.5%). The arterial blood gas found hypoxia and\or hypocapnia in 95% of cases. D-dimer was high in almost totality of patients (96%). US doppler of deep leg veins was positive in more than 40% of patients. Transthoracic echocardiography was normal in more than 40% of the patients. Lung scan noted a high or very high probability in 87% of cases. Pulmonary helical CT was positive in majority of cases. Unfractionated heparin was administered to about 75% of patients and low-molecular-weight-heparin was prescribed at only 40% of patients. CONCLUSION: Management of pulmonary embolism in our cardiology department is characterized by the frequent use of non invasive techniques on the diagnostic view and appeal to heparine on the therapeutic view.

[Chemotherapy against polycythemia due to a cyanotic congenital heart disease in adults. One case report]. / Chimiotherapie anti-erythrocytaire dans les cardiopathies congenitales cyanogenes de l'adulte. A propos d'une observation.

BACKGROUND: Hydroxyurea has largely been utilized in the management of primary polycythemia. It is certainly efficient in the short and medium terms side effects are marked by a leukemogenic risk. AIM: In this study we report the case in which hydroxyrea was for the first time used in the reatment of secondary polycythemia due to cyanotic congenital heart disease. CASE: Our patient was a 22-years-old man suffering from pulmonary atresia with ventricular septal defect, and for whom ther was no available surgical option. Because of severe symptomatic and demanding polycythemia requiring frequent phlebotomies, we decided to use hydroxyurea at the dose of Igr a day. Eight months later, ther was obvious clinical improvement with stable hematocrit levels below 60% and with only 3 phlebotomies in 8 months. CONCLUSION: Hydroxyurea seems to be an eddicient there alternative therapy for seconday polycythemia caused by incurable cyantic congenital heart disease.

[Inhospital prognosis of acute myocardial infarction: comparison of two periods to ten years of interval]. / Pronostic hospitalier de l'infarctus du myocarde comparaison de deux périodes a dix ans d'intervalle.

Acute myocardial infarction prognosis depends on many factors relative to the patient, to the disease and to the quality and promptness of the treatment. The interventional revascularisation is superior to pharmacological revascularisation. The aim of the study is to compare acute myocardial infarction inhospital lethality in the coronary care unit before and after use of emergency angioplasty. The retrospective study compared inhospital lethality over two four years periods separated by an interval of ten years: [1991-1994] and [2001-2004]. Lethality had increased from 7.8% to 11.3%. During the second period emergency angioplasty (under 24 hours) primary (4.8%) or rescue (2.5%), not applied in the nineties, was not related to survival and did not allow an improvement of patients' hospital prognosis. The population of the second period was characterized by: a greater average age (60.8 vs. 58.6 years), more female subjects (20.1 vs. 14.6%), less nicotinic subjects (60.2 vs. 78.5%) and less patients receiving fibrinolytic treatment (43.0 vs. 50.4%). These parameters were as many factors related to the risk of hospital death in univariate analysis. The multivariate analysis showed that after adjustment on all the other factors the lack of thrombolysis remains unquestionably related to the hospital overlethality. The time delays for admission in the intensive care unit were relatively long and comparable over the two periods (8.2 vs. 7.5 hours). Within our hospital structure early angioplasty not being able to be realized in the hour, which follows the diagnosis on a large scale, and in a continual way, it would be preferable to always consider thrombolysis first in all cases apart from contraindications without excluding the possibility of a hybrid treatment.

[Homocysteinemia and coronary artery disease: a case-control study in a Tunisian population]. / Homocystéinémie et maladie coronaire: etude cas-témoins dans une population tunisienne.

We have determined the prevalence of hyperhomocysteinemia and tested its relationship with coronary heart disease in Tunisian patients. The study included 70 angiogrphically proven coronary patients and 140 age- and sex-matched healthy subjects. Plasma homocysteine folate and vitamin B12 were analyzed by immunoenzymatic methods. Hyperhomocysteinemia was considered for plasma homocysteine concentration >17 micromol/L. Mean plasma homocysteine concentration and hyperhomocysteinemia prevalence were significantly (p<0.001) higher in patients (16.3 +/- 7.9 micromol/L and 29%) than controls (12.6 +/- 4.0 micromol/L and 10%). The association between hyperhomocysteinemia and coronary heart disease persisted after adjusting on main cardiovascular risk factors (multi adjusted odds ratio, 2.99; 95% CI, 1.18-7.59; p=0.02). No association was observed between hyperhomocysteinemia and coronary disease severity and extent. This study showed an independent association between hyperhomocysteinemia and coronary heart disease, suggesting a role of hyperhomocysteinemia in atherothrombogenesis. However, causal relationship is not yet established. Until results of homocysteine-lowering therapy trials become available, hyperhomocysteinemia should be researched and treated in coronary heart disease patients.

[Cardiac involvement in Emery-Dreifuss muscular dystrophy: a case report]. / L'atteinte cardiaque dans la dystrophie musculaire d'Emery-Dreifuss. A propos d'un cas.

Emery Dreifuss muscular dystrophy (EDMD) is an uncommon hereditary myopathy characterized by 3 symptoms: slow progressive muscular atrophy, muscular contractures and cardiac disease which affect prognosis. We report a 22 year-old patient with EDMD which shows the typical features of the associated dilated cardiomyopathy, ventricular arrhythmia, atrio-ventricular block, atrial standstill then atrial paralysis.

[Distribution of cardiovascular risk factors in a Tunisian cohort of 6901 coronary patients]. / Distribution des facteurs de risque cardiovasculaire chez une cohorte tunisienne de 6901 coronariens.

The Tunisian epidemiological data on cardiovascular disease in the hospital environment are scarce. The aim of this study was to evaluate the frequency of cardiovascular risk factors and their association in patients hospitalised for coronary disease in coronary care units at Rabta, Charles Nicolle, Habib Thameur and Military hospitals, Tunis, over the period 1994-1998. The clinical features of 6901 patients (75.7% men, 3760 myocardial infarction, 3141 unstable angina) on hospital admission were analysed. The prevalence of smoking, dyslipidemia, hypertension, diabetes and obesity was 86; 49.8; 33.9; 40.7 and 15.2% respectively in the men and 12.9; 52.4; 64.6; 53.4 and 29.8% respectively in women. With this risk factor profile Tunisia has to implement a national strategy of primary prevention and heart health promotion in addition to the efforts recently made in secondary prevention of some chronic disease such as hypertension, diabetes and smoking.

[The first Tunisian cardiovascular diseases register: processes and results]. / Le registre des maladies coronaires en Tunisie: organisation et premiers résultats.

BACKGROUND: In Tunisia, cardiovascular diseases are the leading causes of death (30%) and a few studies conducted in the population have demonstrated that the level of their risk factors is increasing. For policy makers, the health system impact of these diseases is currently a crucial issue. The National Public Health Institute has identified the implementation of a morbidity register as a priority. METHODS: A CVD morbidity register is implemented since 2001, in 3 different geographical populations having contrasted levels of health status (Tunis, Ariana and Ben Arous). The 3 regions are covering about 2 millions inhabitants which is the fifth of the overall Tunisian population. All coronary heart events occurring among adults 25 years old and above in the 3 populations are recorded. The diagnosis of events, case fatality and classification are defined according to MONICA criteria. The data are recorded from public and private hospitals, death certificates and autopsies. RESULTS: During the year 2001, the total number of myocardial infarction events was estimated at 942: in men, the age-standardized rates were 163.8/100000 in Tunis population vs. 161.9 in Ariana and 170.5 in Ben Arous. In women, the rates were respectively 43.4, 61.1 and 44.6. Medical causes of death registration was the most crucial problem in spite of the implementation of the death certificate designed according to WHO model. Specific surveys for clinical assessment and surveillance of risk factors were conducted in the register populations. CONCLUSION: It is the first time that data on coronary heart disease incidence and fatality are available in Tunisia through this experience which highlights the practical difficulties experienced in registering and coding coronary events in a developing country. The data source quality should be improved and the register should be integrated in the local health system.

[Congenital Valsalva sinus aneurysm opening into the right ventricle. Two operated cases]. / L'anévrisme congénital du sinus de Valsalva rompu dans le ventricule droit. A propos de deux cas opérés.

Congenital sinus of valsalva aneurysm is a rare cardiac lesion. Once the aneurysm has ruptured, a large left-to-right shunt is created. Prognosis is grave unless operative intervention is undertaken. The authors present 2 cases (2 male) of congenital aneurysm of the right sinus of valsalva ruptured into the right ventricle. The first patient (52 years) have a history of strenuous exertion followed by acute precordial pain and dyspnea. The second patient (25 years) was asymptomatic. The diagnostic was made by 2D and color doppler echocardiography. The defect was closed with a patch with good postoperative course. The authors emphasise the possible rupture of the congenital aneurysm of the sinus of valsalva after 50 years of age. Echocardiography is certainly the best method for diagnosing the condition and for following up these patients. The prognosis after surgical repair has usually been satisfactory.

Cardiopericardial hydatid cysts.

Cardiac hydatic cyst is a rare parasitic disease. We reported 45 patients with cardiac hydatid cysts; 33 of the 45 had a primitive, unique cardiac cyst. Altogether, 18 patients of our series were asymptomatic, and 27 patients complained of symptoms (dyspnea, chest pain, palpitations). In 11 cases the cyst was revealed by an acute complication; 3 of the 11 had pulmonary metastatic hydatidosis. The diagnosis was based on a series of test results in which hydatid serology and imaging (echocardiography, computed tomography, magnetic resonance imaging) played a predominant role. Cystopericystectomy is the gold standard procedure but is sometimes unsuitable for particular sites. In that case, a conservative approach (partial pericystectomy) is mandatory to preserve organ function. The operative mortality rate is 5.5%. Two pericardial recurrences were reported during follow-up.

[Percutaneous mitral commissurotomy: how can it be made simpler and more efficacious?]. / La commissurotomie mitrale percutanée: comment faire plus simple et plus efficace?

The authors report the results of a simplified method of percutaneous mitral dilatation from 936 procedures. This method introduced in our service since 1997 consists in progressively increasing diameters inflation of Inoué balloon, using echographic control and without any arterial procedure. Our population consists on 683 women (73%) and 253 men with a mean age 34 +/- 15 years (extremely 9 and 80 years) with subgroups composed of 26 pregnant women, 32 children less than 17 years, 59 restenosis after closed heart mitral commissurotomy, 14 restenosis after open heart mitral commissurotomy, 74 restenosis after percutaneous mitral commissurotomy, 5 tricuspid and mitral dilatation, 2 coronary and mitral dilatation (with stenting), 2 patients with a history of surgical mitral valvuloplasty for pure mitral regurgitation. The mitral area passed from 1 +/- 0.2 cm2 to 2.1 +/- 0.1 cm2. A surgical mitral regurgitation was observed in 3 cases. The time of fluoroscopy was 6.4 +/- 3.3 min. The hole time procedure was 19 +/- 9 min. The delay of hospitalisation was one day in 97% of patients. The decreased cost was about 20%. The patient comfort and the large diffusion of this method predicts a good future of this simplified technique.

[Percutaneous closure of ostium secundum atrial septal defect using an Amplazter device. Report of the first 5 Tunisian cases]. / Fermeture percutanee des communications interauriculaires ostium secundum par amplatzer. A propos des 5 premieres observations tunisiennes.

We report our initial expérience with percutaneous closure of ostium secundum atrial septal defect using Amplatzer device. Between september 2000 and july 2001, five devices were implanted in 5 patients, 4 female and 1 male. Age ranged from 18 to 66 years. A large atrial septal defect with significant shunting was diagnosed by trans thoracic echocardiography. Procedures were performed under general anesthesia with trans esophageal echocardiography guidance. Stretched diameter of atrial septal defects was determined by balloon sizing, ranged from 21 to 32 mm. Amplatzer devices of 20 to 32 mm were respectively deployed. No complications occurred during the procedure. Total occlusion of interatrial communication, was observed in one patient, immediately after the procedure, and in 3 patients 24 hours later. First 3 patients were controlled at months follow up were free of complications. Closure of atrial septal defect with Amplatzer device appears feasible and safe. However, long term results in comparison to surgery remain to be determined before definite conclusion regarding its use can be made.

[Severe pulmonary hypertension in ostium secundum atrial septal defect]. / L'hypertension artérielle pulmonaire sévère au cours des communications interauriculaires type ostium secundum.

Between 1969 and 1999, 149 patients underwent cardiac catheterization for ostium secundum atrial septal defect, in hemodynamics department. Age average was 21.5 +/- 16 years (2-67). Systolic pulmonary arterial pressure average was 35 +/- 15.6 mm Hg (15-140). The atrial septal defect was closed in 108 patients (by surgery in 107 cases, and by interventional catheterization in one case). Mean follow-up was 8 +/- 7 years (1-20). Overall mortality rate was 2.7%. Severe pulmonary hypertension (systolic pressure > or = to 50 mm Hg) was seen in 13.4% of cases. It was present at all ages, but more frequent above 20 years. Obstructive pulmonary vascular disease was noticed in 2% of patients. Clinical and haemodynamic data analysis showed that, severe pulmonary hypertension is a frequent, and unpredictible complication of secundum atrial septal defect; it might occur at any age and worsen considerably the cardiac disease prognosis. Because of atrial septal defect hemodynamic profile, and current rise of percutaneous closure technics, invasive investigation should be more and more routinely performed, in order to define the best therapeutic option. Early and systematic closure of secundum atrial septal defects, should prevent, or at least minimize pulmonary vascular lesions.