Plaque rupture and morphological characteristics of the culprit lesion in acute coronary syndromes without significant angiographic lesion: analysis by intravascular ultrasound.

PURPOSE: To evaluate by intravascular ultrasound (IVUS) the characteristics of the culprit lesion with plaque rupture without significant angiographic stenosis after acute coronary syndromes (ACS). PATIENTS AND METHODS: After ACS, IVUS was performed in 68 patients (46.8 years±11.9) without significant angiographic stenosis (31±15%). Plaque rupture was defined as a cavity within the plaque, communicating with the arterial lumen and having an overlying residual fibrous cap fragment. Qualitative analysis defined the type of plaque, and quantitative analysis evaluated plaque plus media area, plaque volume, plaque burden, and arterial remodeling index. Patients were divided into two groups: Group I with plaque rupture (25 patients) and Group II without plaque rupture (43 patients). RESULTS: All patients with rupture showed soft or mixed plaque but no calcified plaque. In Group I, plaque rupture was associated with a larger plaque burden (49.8±12.3% vs. 39.8±12.1%, P<.0005), a more significant plaque plus media area (7.44±2.9 vs. 5.24±2.4mm(2), P<.001), a greater plaque volume (151.9±103.4 vs. 99.2±81.6mm(3), P<.007), and a higher ratio of plaque volume over length (8.0±3.8 vs. 5.6±3.7mm(3)/mm, P<.003). In Group I, positive remodeling was more frequent than intermediate remodeling (P<.03) or negative remodeling (P<.005). In Group II, there was no significant difference between the three types of remodeling. CONCLUSION: The plaque ruptures responsible for ACS frequently appear on voluminous plaques with a large plaque burden and positive arterial remodeling.

[Assessment of myocardial viability in postinfarction and indications of revascularization]. / Etude de la viabilité myocardique dans le post-infarctus et indications de la revascularisation.

Following myocardial infarction, it is indispensable to investigate the viability of the myocardium when signs of left ventricular dysfunction are predominant, so as to distinguish between permanent ventricular dysfunction and dysfunction that can be improved with treatment. Several imaging techniques are capable of detecting viable hibernating myocardium; each addresses a specific aspect of the problem. Stress echocardiography and nuclear imaging techniques remain the most widely used even though new techniques like MRI may be better for detecting myocardial viability. Remote myocardial revascularization can lead to regression of the remodeling of the left ventricle, which occurs after infarction causing latent or patent cardiac failure, and thus to recovery of left ventricular function. It is therefore indicated, in association with optimal medical treatment, in patients selected by viability explorations. The best revascularization method (angioplasty or surgery) should be proposed according to scientific knowledge, the comorbidities, and the patient's choice.

[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.

[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.

Clinical and angiographic results of angioplasty with a paclitaxel-eluting stent for unprotected left main coronary artery disease (a study of 101 consecutive patients).

BACKGROUND: After coronary stenting with drug eluting stents, long-term clinical outcome of unprotected left main coronary artery disease is unknown, even large scale registries or randomised trials with coronary artery bypass graft are ongoing. AIMS: To report clinical and angiographic results of paclitaxel-eluting stent implantation for left main coronary artery stenosis (a series of 101 consecutive patients). METHODS: This report is a prospective study performed to evaluate the immediate and mid-term clinical and angiographic outcomes of patients undergoing paclitaxel-eluting stent (PES) implantation for unprotected left main coronary artery (LMCA) stenosis. From January 2004 to December 2005, 101 consecutive patients were stented with paclitaxel-eluting stents (the provisional T stenting technique followed by Kissing balloon for distal left main vessel disease). RESULTS: Mean age was 68.9+/-11.07 years. 73.3% of patients were male. Acute coronary syndrome was present in 65% of patients, of whom 22.8% had ST elevation. Distal left main trunk lesions were present in 87.1% of cases. Three-vessel disease represented 7% of cases. Angiographic success was obtained in 97.03% of patients with an acute gain of 2.18+/-0.53mm. GpIIbIIIa inhibitors were used in only 8.9% of cases. Hospital stay was 7.6 +/- 3.7 days. In-hospital complications were present in 7.9%, with a hospital mortality rate of 2%. At six month follow-up, the rate of target lesion revascularization (TLR) was 3%, and the rate for major adverse cardiac events (MACE) was 8.9%. Angiographic control was performed in 88.1% and a late loss of 0.1mm (0.04-0.2mm) was noted. Re-stenosis occurred in 4 patients (4.5% of cases). 4 patients (4%) died, including 2 from cardiac causes. CONCLUSION: Paclitaxel-eluting stent implantation for unprotected left main coronary disease appears to be safe with high procedural success rate and a low re-stenosis rate at six month-follow-up.

[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.

[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.

[Cardiac sequelae of penetrating cardiac wounds]. / Séquelles cardiaques des plaies du coeur.

OBJECTIVE: The aim of our work was to study cardiac sequelae of penetrating cardiac injuries. MATERIAL AND METHODS: It is a retrospective study including nine patients (eight men and one woman with an average age of 26.6 +/- 7.4 years) hospitalised between January 1st, 1988 and December 31, 2002 in cardiovascular surgery department of Tunis Rabta hospital for heart wounds. RESULTS: It was stab wounds in all patients. Heart lesions concerned primarily the right ventricle. In admission, two patients had cardiac tamponade and seven were in shock. Beating heart surgery without cardiopulmonary bypass in all patients performed surgical repair and it consisted in simple suture. Functional symptoms were observed in five patients at late outcome. Five patients had heart sequelae. It consisted of conduction abnormalities (right bundle branch block) in five patients. One patient had a small ventricular septal defect. Finally, partial permanent disability rates were less than 10%. CONCLUSION: Cardiac sequelae of penetrating cardiac wounds have good prognosis with the exception of a small partial permanent disability rate. Their prevention must be based on the fight against the urban violence and on the good initial management.