National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study.

BACKGROUND: In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics. OBJECTIVE: The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention. METHODS: The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite). RESULTS: The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation. CONCLUSIONS: This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/47525.

Impact of atorvastatin reload on the prevention of contrast-induced nephropathy in patients on chronic statin therapy: A prospective randomized trial.

BACKGROUND: This trial aimed to assess the efficacy of Atorvastatin reloading on the prevention of Contrast-induced nephropathy (CIN) in patients pre-treated with this statin and undergoing coronary catheterization. METHODS: This was a prospective randomized controlled study including patients on chronic atorvastatin therapy. We randomly assigned the population to the Atorvastatin Reloading group (AR group), by reloading patients with 80 mg of atorvastatin one day before and three days after the coronary procedure, and the Non-Reloading group (NR group), including patients who received their usual dose without a reloading dose. The primary endpoints were the incidence of cystatin (Cys)-based CIN and Creatinine (Scr)-based CIN. The secondary endpoints consisted of the changes in renal biomarkers (Δ biomarkers) defined as the difference between the follow-up level and the baseline level. RESULTS: Our population was assigned to the AR group (n = 56 patients) and NR group (n = 54 patients). The baseline characteristics of the 2 groups were similar. Serum creatinine (SCr)-based CIN occurred in 11.1% in the NR group, and in 8.9% in the AR group without any significant difference. Cys-based CIN occurred in 37% in the NR group and 26.8% in the AR group without any significant difference. The subgroup analysis showed that high dose reloading had significantly reduced the CYC-based CIN risk in patients with type 2 diabetes (43.5% vs 18.8%, RR = 0.43. CI 95% [0.18-0.99])). The comparison of "Δ Cystatin" and Δ eGFR between the AR and NR groups didn't show any significant difference. However, cystatin C had significantly increased between baseline and at 24 hours in the NR group (0.96 vs 1.05, p = 0.001), but not in the AR group (0.94 vs 1.03, p = 0.206). CONCLUSIONS: Our study did not find a benefit of systematic atorvastatin reloading in patients on chronic atorvastatin therapy in preventing CIN. However, it suggested that this strategy could reduce the risk of CyC-based CIN in diabetic type 2 patients.

Thromboembolic events in COVID-19 ambulatory patients: An observational study about incidence, and thromboprophylaxis outcomes.

INTRODUCTION: There are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life. PATIENTS AND METHODS: This is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients. RESULTS: We included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%). CONCLUSIONS: Our study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

[Epidemiological, clinical and echographic profile of patients operated for subvalvular aortic stenosis in the region of Sfax (Tunisia) and factors associated with postoperative recurrence: an observational study]. / Profil épidémiologique, clinique et échographique des patients opérés pour un rétrécissement aortique sous-valvulaire dans la région de Sfax (Tunisie) et facteurs associés à la récidive post-opératoire: étude observationnelle.

Subvalvular aortic stenosis is difficult to manage due to the evolutionary unpredictability of stenosis and a high recurrence rate after surgical treatment. The purpose of this study is to describe the profile of patients undergoing surgery for the treatment of aortic subvalvular stenosis and to investigate factors associated with post-operative recurrence of the subaortic obstacle. We conducted an observational study of all patients operated for subvalvular aortic stenosis, whose data were collected in the Department of Cardiology of the Sfax University Hospital between January 2010 and December 2020. The study involved 28 patients, with predominance of male sex (64.29%, n=18). At diagnosis, the mean age was 6.82 (±4.84) years and 19 patients (67.85%) had symptoms. On echocardiography, maximal subaortic gradient ≥50 mmHg was found in 23 patients (82.14%). Cardiovascular malformations associated with subvalvular stenosis were found in 16 patients (57.14%). The average age of patients at the time of surgery was 10.43 (±7.08) years. Subaortic membrane resection was the most commonly used technique (46.4%, n=13). It was associated with septal myomectomy in 8 patients (28.6%). Postoperative mortality rate was zero. Residual gradient ≥30 mmHg was reported in 8 patients (28.6%) after surgery. Recurrences were observed in 7 patients (25%) of whom 6 underwent reintervention. In multivariate analysis, only postoperative residual gradient was significantly associated with recurrence (p=0.030, OR=33.785, 95% CI: 1.398-816.754). Despite old age at diagnosis and surgery, favorable short-term outcomes were reported, but recurrences were frequent in the long term. This highlights the role of regular, perioperative and postoperative, clinical and echographic monitoring of these patients.

[Masked arterial hypertension in patients with type2 diabetes mellitus: Prevalence, associated factors and cardiovascular impact]. / L'hypertension artérielle masquée chez les diabétiques de type 2 : Prévalence, facteurs associés et retentissement cardiovasculaire.

PROBLEMATIC AND OBJECTIVE: Masked arterial hypertension (MHTN) is a recently described entity that is associated with the same cardiovascular risk as permanent hypertension. Its prevalence is more frequent in patients with diabetes. The objective of this study is to assess the value of systematic screening for MHTN by 24-hour blood pressure monitoring in a population of type 2 diabetic patients by estimating its prevalence and looking for predictive factors of MHTN in this population. METHODS: Through a prospective study, we recruited normotensive type 2 diabetics for clinical measurement, in whom we systematically searched for MHTN by performing an ambulatory blood pressure measurement (ABPM). The diagnosis of MHTN is established if: mean daytime BP ≥ 135/85 mmHg and / or, mean nighttime BP ≥ 120/70 mmHg and / or, mean 24 hour BP ≥ 130/80 mmHg. We then compared the two populations of MHTN (G1) and normotensive (G2) on clinical and laboratory parameters and we assessed end-organ damage in order to identify the predictive factors of MHTN. RESULTS: We recruited 53 patients whose mean age was 55.3 ± 8.4 years (range 35-72 years) with a female predominance (53%). The duration of diabetes was on average 8.7 ± 3.9 years with extremes between 2 and 17 years. The average BMI of our patients was 28.2 ± 5.3 Kg/m2. Overweight was found in almost half of our patients (47.2%). Obesity was found in 32.1% of cases. Metabolic syndrome was found in 64.2% of patients. In our study, the prevalence of HTAM in type 2 diabetics was 64%. We also found that MHTN was more often nocturnal (58.5%) and occurred mainly in non-dipper patients. Left ventricular hypertrophy, microalbuminuria and arterial stiffness evidenced by pulse pressure greater than 60mmHg were more common in the MHTN group. For the predictive factors of MHTN, we were able to collect in univariate analysis the following factors: duration of diabetes, fasting blood sugar, weight and microalbuminuria. In multivariate analysis, the predictive factors that emerged in our study are poor glycemic control (HbA1c ≥7%), high BMI and duration of diabetes. CONCLUSION: MHTN should be sought in diabetics because it allows a better assessment of the cardiovascular risk, in particular by identifying end-organ damage.

[Maladies cardiaques et Ramadan : revue de la littérature]. / Cardiovascular disease and Ramadan. A literature review.

We review the literature on the safety of fasting in cardiac patients. We examined the changes of blood pressure among hypertensive patients and the incidence of cardiac events during Ramadan in patients with coronary disease and heart failure. We also assess the modifications of INR levels in cardiac patients who take oral anticoagulant. We found that Ramadan fasting is safe in stable cardiac patients, even under several drugs. Fasting does not affect blood pressure. There is no difference in regards to cardiac event incidence between Ramadan and the non-fasting-months. The level of INR is slightly higher when fasting, it is thus recommended to monitor patients with high bleeding risk during Ramadan.

Long COVID 19 Syndrome: Is It Related to Microcirculation and Endothelial Dysfunction? Insights From TUN-EndCOV Study.

The COVID-19 disease is a multisystem disease due in part to the vascular endothelium injury. Lasting effects and long-term sequelae could persist after the infection and may be due to persistent endothelial dysfunction. Our study focused on the evaluation of endothelial quality index (EQI) by finger thermal monitoring with E4 diagnosis Polymath in a large cohort of long COVID-19 patients to determine whether long-covid 19 symptoms are associated with endothelial dysfunction. This is a cross-sectional multicenter observational study with prospective recruitment of patients. A total of 798 patients were included in this study. A total of 618 patients (77.4%) had long COVID-19 symptoms. The mean EQI was 2.02 ± 0.99 IC95% [1.95-2.08]. A total of 397 (49.7%) patients had impaired EQI. Fatigue, chest pain, and neuro-cognitive difficulties were significantly associated with endothelium dysfunction with an EQI <2 after adjustment for age, sex, diabetes, hypertension, dyslipidemia, coronary heart disease, and the severity of acute COVID-19 infection. In multivariate analysis, endothelial dysfunction (EQI <2), female gender, and severe clinical status at acute COVID-19 infection with a need for oxygen supplementation were independent risk factors of long COVID-19 syndrome. Long COVID-19 symptoms, specifically non-respiratory symptoms, are due to persistent endothelial dysfunction. These findings allow for better care of patients with long COVID-19 symptoms.

Predictors of maternal and neonatal complications in women with severe valvular heart disease during pregnancy in Tunisia: a retrospective cohort study.

BACKGROUND: Severe valvular heart disease, especially stenosis, is a contraindication for conception according to the World Health Organization. This is still encountered in countries with a high rheumatic fever prevalence. The objective of this study was to determine predictors of maternal cardiac, obstetric and neonatal complications in pregnant women with severe valve disease. METHODS: This is an observational retrospective cohort study of all pregnant women with severe heart valvulopathy who gave birth between 2010 and 2017. RESULTS: We included 60 pregnancies in 54 women. Cardiac complications occurred during 37 pregnancies (61%). In multivariate analysis, parity (aOR =2.41, 95% CI[1.12-5.16]), revelation of valvulopathy during pregnancy (aOR = 6.34; 95% CI[1.26-31.77]), severe mitral stenosis (aOR = 6.98, 95% CI[1.14-41.05],) and systolic pulmonary arterial pressure (aOR =1.08, 95% CI[1.01-1.14]) were associated with cardiac complications. Obstetrical complications were noted during 19 pregnancies (31.8%). These complications were associated with nulliparity (aOR = 5.22; 95% CI[1.15-23.6]), multiple valve disease (aOR = 5.26, 95% CI[1.19-23.2]), systolic pulmonary arterial pressure (aOR =1.04, 95% CI[1.002-1.09]), and treatment with vitamin K antagonists (aOR = 8.71, 95% CI[1.98-38.2]). Neonatal complications were noted in 39.3% of newborns (n = 61) and these were associated with occurrence of obstetric complications (aOR = 16.47, 95% CI[3.2-84.3]) and revelation of valvulopathy during pregnancy (aOR = 7.33, 95% CI[1.4-36.1]). CONCLUSIONS: Revelation of valvular heart disease during pregnancy is a predictor of not only cardiac but also neonatal complications. Valvular heart disease screening during pre-conceptional counseling is thus crucial.

Epidemiological and clinical profile of hypertensive octogenarian patients and factors associated with uncontrolled hypertension: observational study of 346 patients.

INTRODUCTION: hypertension (HTN) is the main risk factor for most morbidities of elderly subjects. The objective of this study was to identify the epidemiological and clinical characteristics of hypertension in octogenarians and to identify the factors associated with uncontrolled hypertension in this population. METHODS: we used data collected in the outpatient cardiology department of the University Hospital of Sfax between 15th April 2019 and 15th May 2019 as part of the National Tunisian Registry of Hypertension. We included in our study patients aged 80 years or more with hypertension. We described the epidemiological and clinical profile of this population, and we studied the associations between uncontrolled hypertension and socio-demographic, lifestyle, clinical and therapeutic factors using logistic regression models. RESULTS: we included 346 subjects (45.1% (n=156) male and 54.9% (n=190) female), with a mean age of 84.36 (SD 4.01) years. More than half of them had uncontrolled hypertension. Dyslipidemia was the most common cardiovascular risk factor found in 43.6 % (n=151) of patients followed by diabetes (35.5%, n=122). One-third of patients had a history of coronary artery disease and/or stroke. Renal failure and kalemia disorders were observed, respectively, in 12.1% (n=42) and 25.2% (n=40) of patients. In multivariate analysis, factors associated with uncontrolled hypertension (HTN) were male sex (adjusted odds ratio (aOR): 1.663, 95% confidence interval (CI): 1.045-2.647; p=0.032), diabetes (aOR: 1.66, 95%CI: 1.031-2.688; p=0.037,) and poor adherence to blood pressure (BP) medications (aOR: 1.960, 95%CI: 1.195-3.214; p=0.008). CONCLUSION: our results showed that more than half of octogenarian hypertensive patients did not reach the BP target and that poor adherence to BP medications was the main factor of uncontrolled HTN. In this population, the presence of other comorbidities and poor adherence to BP medications are very common. Systematic research for behaviors suggesting poor medication adherence should be a priority for physicians caring for these patients.

Giant Left Atrial Myxoma with Mitral Valve Obstruction.

Cardiac myxomas are the most common primary intracardiac tumors in adults. Although benign from a histopathological point of view, they can be life-threatening for the patient. We present a case of an unusually giant left atrial myxoma causing mitral valve obstruction and pulmonary hypertension successfully treated with surgical resection. Our patient was a 54-year-old woman who presented to our emergency complaining of progressive dyspnea of about 1 month duration. On cardiovascular examination, we found crackling rales at both lung bases and a diastolic murmur in the mitral focus. Transthoracic echocardiography revealed a giant mass in the left atrium connected to the interatrial septum and extended into the left ventricle during diastole which caused obstruction of the left ventricular inflow tract and a pulmonary hypertension. The patient underwent a median sternotomy with the removal of left atrial mass and patch closure of the interatrial septum. Histopathological examination confirmed the diagnosis of myxoma. One week later, the patient was discharged without any complications. Giant left atrial myxoma although a benign mass, can induce dramatic symptoms and be life-threatening. In case of suspicion, it must be diagnosed early by transthoracic echocardiography and urgently managed by surgical removal.

Acute myocardial infarction in a child with nephrotic syndrome.

Myocardial infarction is very rare in children. It can have different etiologies such as thromboembolism caused by nephrotic syndrome (NS). We report the case of a 15 year old boy with NS, diagnosed at the age of 7 year, admitted for prolonged chest pain. The final diagnosis was ST-elevation myocardial infarction with thromboembolism in the left anterior descending artery due to hypercoagulability of NS. This association is very uncommon and the management of both conditions presents a challenge.

[Assessment of the practices and knowledge among cardiologists regarding radiation protection in Tunisia]. / Évaluation des pratiques et connaissances en radioprotection des cardiologues en Tunisie.

INTRODUCTION: interventional cardiology procedures have become complex and expensive in time with a higher risk of exposure to ionizing radiations. The purpose of our study was to assess radiation protection knowledge and practices among Tunisian cardiologists exposed to X-rays. METHODS: we conducted a descriptive, analytical study in October 2019. An anonymous survey on the knowledge and practices regarding radiation protection was sent to all Tunisian cardiologists exposed to X-rays. RESULTS: among 126 cardiologists exposed to X-rays and having received the survey, 58 physicians responded to the survey (48%), with a male predominance (72%, n=42). Thirty-eight physicians (65%) were public sector workers. Average years of working experience were 12.02 years (SD 6.88 years). Half of doctors had a knowledge score of less than 50%. The average practice score was 43.83 (SD 13.95%). Wearing a lead apron, thyroid shield, dosimeter, lead glasses, lead cap accounted for 100% (n=58), 86.2% (n=50), 30.7% (n=18), 12.1% (n=7) and 1.7% (n=1) respectively. There was no correlation between scores and doctor's age as well as the length of working experience. There was no statistical differences between knowledge scores of males and females (p=0.06) or between public sector and private sector (p=0.9). Practice score was significantly higher among men (0.007) and interventional cardiologists compared to rhythmologists and pediatric cardiologists (p<0.001). CONCLUSION: the level of knowledge and practices among Tunisian cardiologists regarding radiation protection is generally insufficient. Then, health authorities should implement regular training programs.

An exceptional complication of transesophageal ultrasound in a patient with Coronavirus disease.

EP after TEE represents a medico-surgical emergency. Given the high rate of asymptomatic patients with COVID 19, the risk of contamination and the frailty of esophageal tissues, we should check coronavirus infection in every patient before TEE.

Left ventricular myocardial function in hemodialysis patients: the effects of preload decrease in conventional, Doppler and speckle tracking echocardiography parameters.

INTRODUCTION: our aim was to investigate the value of conventional echocardiography, pulsed Doppler and speckle tracking imaging (STI) analysis in the assessment of the left ventricular (LV) myocardial function in hemodialysis (HD) patients with preserved LV ejection fraction and to evaluate the effect of a single HD session on the LV systolic and diastolic functions. METHODS: the study population consisted of 30 chronic HD patients. Echocardiography and Doppler studies were performed before and after HD. The LV global longitudinal, circumferential and radial strains were measured with two and three-dimensional STI. RESULTS: after HD, LV dimensions, left atrium (LA) area, systolic pulmonary arterial pressure and inferior vena cava diameter decreased significantly. The peak mitral E velocity, the E/A ratio of the mitral inflow and the lateral E/E´ ratio decreased also significantly. The LV and LA volumes index and LV mass index (LVMi) decreased remarkably after HD. The 3D- LV and LA ejection fractions were unchanged after HD. Although, 3D-estimated LVEF seemed to be preserved in the HD patients, the 2D and 3D- strain rates were decreased in all directions. The global strain values improved in all directions after a single HD session. Inverse correlations were found between the LVMi, serum BNP and LV global longitudinal strain. CONCLUSION: in HD patients with preserved LV ejection fraction, the STI analysis may add important information concerning the subclinical LV dysfunction.

Myocardial performance after coronary re-implantation in pediatric patients assessed with conventional echocardiographic and 2D-speckle tracking analysis: a case-control study.

INTRODUCTION: reduced exercise capacity, coronary artery abnormalities and reversible myocardial ischemia have been demonstrated after arterial switch operation (ASO) and coronary reimplantation. Despite this, indices of systolic function, assessed by standard and Doppler echocardiography, are within the normal range. The aim of this study was to highlight the long-term changes in myocardial function following coronary reimplantation using Doppler and speckle-tracking imaging (STI) echocardiography. METHODS: this observational case control study included 36 patients and 20 gender and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2015 and May 2016. Systolic and diastolic parameters, left ventricle (LV) and right ventricle (RV) myocardial performance were assessed in each group. RESULTS: the LV global peak strain parameters revealed a significant decrease in the longitudinal and circumferential strain components. The LV global longitudinal strain (GLS) values were lower in both groups of operated patients than controls (-19.9 ± 2.2% (group 1) versus -20.9 ± 1.6% (group 2) versus -22.9 ± 2.3% (group 3), p<0.001). The patients with coronary reimplantation had the lowest values. The LV global circumferential strain was also decreased in the group 1 patients as compared with the 2 other groups (-16.6 ± 4.1% (group 1) versus -19.4 ± 3.9% (group 2) versus -19.8 ± 4.0% (group 3), p<0.001). CONCLUSION: although global LV function, assessed with conventional echocardiographic parameters, was normal, the 2D-STI analysis showed slight but significant decrease in the global and segmental longitudinal and circumferential LV strain during the long-term follow-up after coronary arteries reimplantation.

[Observational study of the prevalence of non-valvular atrial fibrillation and ischemic stroke and the factors associated with non-valvular atrial fibrillation in hypertensive patients: about 2887 cases]. / Prévalence de la fibrillation atriale non valvulaire et de l´accident vasculaire cérébral ischémique et facteurs associés à la fibrillation atriale non valvulaire chez les patients hypertendus: étude observationnelle à propos de 2887 patients.

INTRODUCTION: high blood pressure (HBP), atrial fibrillation (AF) and ischemic stroke are three public health problems. The purpose of this study was to determine the prevalence of AF and ischemic stroke in hypertensive patients and the factors associated with the occurrence of non-valvular AF in these patients. METHODS: we used data collected in the Department of Cardiology at the University Hospital of Sfax as a part of National Tunisian Registry of Hypertension. We examined the associations between different socio-demographic, clinical, paraclinical, and therapeutic variables and AF in hypertensive patients using logistic regression models. RESULTS: our sample consisted of 2887 patients with a sex ratio of 0.95. The average age of patients was 65 years (±11). AF was found in 230 patients (8%), while ischemic stroke was found in 152 patients (5.3%). Multivariate analysis highlighted that independent factors associated with an increase in the prevalence of AF were: advanced age (p = 0,001, Odds Ratio (OR) = 1,647, 95% confidence interval ( CI): 1,1227-2,213), the detection of left ventricular hypertrophy (LVH) on cardiac ultrasound (p= 0,004, OR= 2,140, 5%CI 9: 1,281-3,576), and left ventricular ejection fraction (LVEF) < 50% (p<0,001, OR=4,677, 95% CI: 2,715 and 8.057). CONCLUSION: this study confirms that there is a direct and independent relationship between high blood pressure, advanced age, LVH and AF. AF in patients with high blood pressure is a disease progression leading to an increased risk of ischemic stroke. Optimal high blood pressure control is a priority in hypertensive patients, especially in the elderly, aiming at preventing the risk of AF and ischemic stroke.

Q fever presenting as myocarditis.

We report the case of a 19-year-old healthy adolescent, living in an urban area, admitted because of acute chest pain and extensive anterior ST elevation. Coronary arteries were normal on coronary angiography; troponins were very high, echocardiography revealed a preserved global systolic function but an alteration of the longitudinal strain in the inferolateral wall. Cardiac MRI confirmed the diagnosis of acute myocarditis. As part of the etiological workup, Coxiella burnetii serology showed an acute infection. The diagnosis of Coxiella burnetii myocarditis was retained and the patient was treated with doxycycline and corticosteroid therapy. The myocardial localization of this germ is unusual but can be serious, hence the interest of a Coxiella serology in endemic countries face to any acute myocarditis.

Angioplasty of Anomalous Coronaries Arising from the Opposite Sinus with an Interarterial Course, is it Safe?

BACKGROUND: The coronary artery with an interarterial course CAIAC is the most threatening coronary anomaly, especially if it concerns the left coronary. Percutaneous coronary intervention PCI is scarcely described given its low prevalence and lack of long-term outcome data. Therefore, we assessed through this case series the feasibility and safety of PCI in this population. METHODS: This is an observational multicentric study including patients with CAIAC arising from the opposite sinus of Valsalva. The primary endpoints were immediate angiographic success and target lesion revascularization. RESULTS: During the period of the study, we performed 27235 PCI in six Cath labs, 26 procedures concerning abnormal coronaries including 12 with CAIAC. The median age was 57 years extremes: 43-78 with male predominance 1:11. Anomalous coronary artery was Right coronary artery RCA in eight patients, Left main LM in three patients, and left anterior descending LAD in one patient. The stenosis was located in all cases in proximal segments beyond the inter-arterial course proximal LAD, the superior genius of the RCA, or the proximal segment of mid-RCA. Five patients showed slit-like ostium and all have an angle take-off <45° on CT scan. After a median follow-up of 24 months, four subjects presented target lesion revascularization TLR, all were initially treated with either a bare-metal stent or with balloons. CONCLUSIONS: PCI of patients with CAIAC is feasible and appears safe. The operator should carefully analyze the angiogram before PCI to choose the appropriate guiding catheter and should be acquainted with the different techniques for improving backup.

Distal radial approach versus conventional radial approach: a comparative study of feasibility and safety.

The distal radial approach (DRA) is suggested to have benefits over the conventional radial approach (CRA) in terms of local complications and comfort of both patient and operator. Therefore, we aimed to compare the feasibility and safety of DRA and CRA in a real life population. We conducted a prospective, observational multicentric trial, including all patients undergoing coronary procedures in September 2019. Patients with impalpable proximal or distal radial pulse were excluded. Thus, the choice of the approach is left to the operator discretion. The primary endpoints were cannulation failure and procedure failure. The secondary endpoints were time of puncture, local complications and radial occlusion assessed by Doppler performed one day after the procedure. We enrolled 177 patients divided into two groups: CRA (n = 95) and DRA (n = 82). Percutaneous intervention was achieved in 37% in CRA group and 34% in DRA group (p = 0.7). Cannulation time was not significantly different between the two sets (p = 0.16). Cannulation failure was significantly higher in DRA group (4.8% vs 2%, p < 0.0008). Successful catheterization was achieved in 98% for the CRA group and in 88% for the DRA group (p = 0.008). Radial artery occlusion, detected by ultrasonography, was found in 3 patients in the CRA group (3.1%) and nobody in the DRA group (p = 0.25). The median diameter of the radial artery diameter was higher in the DRA than the CRA group (2.2 mm vs 2.1 mm; p = 0.007). The distal radial approach is feasible and safe for coronary angiography and interventions, but needs a learning curve.

A Prospective Study About Trastuzumab-induced Cardiotoxicity in HER2-positive Breast Cancer.

BACKGROUND: Trastuzumab improves therapeutic outcomes among patients with human epidermal growth factor receptor 2-positive breast cancer (BC). However, it is associated with a risk of treatment-induced cardiotoxicity. The aims of this study were to determine the frequency of trastuzumab-induced cardiotoxicity (TIC) in Tunisian patients, to study the effects of trastuzumab on cardiac biomarkers and echocardiographic parameters using the speckle tracking technique and to identify risk factors of occurrence of TIC. PATIENTS AND METHODS: Fifty women with newly diagnosed human epidermal growth factor receptor 2-positive BC treated with or without anthracycline followed by taxane and trastuzumab were enrolled, from November 2016 to December 2018, to be evaluated every 3 months during trastuzumab treatment (total of 15 mo) using echocardiograms and blood samples. Left ventricular ejection fraction (LVEF) and peak systolic left ventricular longitudinal myocardial strain were calculated. Ultrasensitive troponin I (TNI) and N-terminal pro-B-type natriuretic peptide (NT pro-BNP) were also measured. RESULTS: LVEF decreased from 62±3.12% to 59±3.3% (P=0.005) over 15 months. Seven patients (14%) developed cardiotoxicity, as defined by the European Society of Cardiology; of these patients, 2 (4%) had symptoms of heart failure. Hypertension, left ventricular longitudinal myocardial strain, Log TNI, and NT pro-BNP measured at the completion of anthracyclines were significantly correlated to TIC occurrence. At multivariate analysis, the degree of LVEF decline was the only independent factor correlated to TIC (hazard ratio=2.4; 95% confidence interval=1.2-6.03; P=0.049). This TIC was reversible in 86% of cases. CONCLUSION: In patients with BC treated with trastuzumab, in addition to the evaluation of the LVEF, systolic longitudinal strain, TNI, and NT pro-BNP measured at the completion of anthracyclines are useful in the prediction of subsequent TIC.