[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 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.

[Dilated cardiomyopathy and atrio-ventricular block in coeliac disease. Two case reports]. / Cardiomyopathie dilatée et bloc auriculo-ventriculaire dans la maladie coeliaque. A propos de deux observations.

We report two cases of celiac disease (CD) presented as an idiopathic dilated cardiomyopathy in association with a complete heart block in one patient, without digestive manifestation. The diagnosis of CD was obtained by both positivity of antiendomysial antibodies (AEA) and identification of the characteristic duodenal endoscopic and histological findings. Gluten-free diet improved the cardiac function in one patient but it had no effect on atrioventricular conduction in this same patient. These cases highlight the possible cardiac involvement in celiac disease and the relevance of antiendomysial and antigliadin antibodies test in case of rhythm disturbances and cardiomyopathies of unknown etiology. The effect of gluten free diet on cardiac performance was described.

[Comparison of long-term results of the Starr and Saint-Jude mitral valve prostheses]. / Comparaison des résultats à long terme des prothèses de Starr et de Saint-Jude en position mitrale.

Two groups of patients having undergone mitral valve replacement with a Starr-Edwards (Group A = 149 patients) or Saint Jude (Group B = 87 patients) prosthesis between 1981 and 1987 were included in this study. The aim of the study was to evaluate and compare the mortality, the morbidity--especially with respect to thromboembolic events--and echo Doppler haemodynamic profiles of the two types of prosthesis. The two patient groups were comparable with respect to age, aetiology and preoperative haemodynamic status. Late mortality was greater in Group A (13% versus 4.5%) and the 5 year survival was significantly better in Group B (95% versus 89%). Thromboembolic events were significantly more common in Group A (2.6% per patient year versus 0.5% per patient year in Group B, p = 0.01). Five years survival without thromboembolic event was 94% in Group B versus 86% in Group A. The haemodynamic Doppler echocardiography profiles were compared on random samples of 30 cases from each group, the only exclusion criterion being suspected or confirmed prosthetic valve dysfunction.

[Indications and results of surgery of organic involvement of the tricuspid valve]. / Indications et résultats de la chirurgie des atteintes organiques de la valve tricuspide.

In this study the long-term results of 121 repairs for organic lesions of the tricuspid valve are presented, and a attempt is made at selecting the respective indications for valve replacement (VR) and valvoplasty. Tricuspid valve correction was effected by VR in 37 cases (mechanical prosthesis 26, bioprosthesis 11) and by plastic procedures in 84 cases (commissurotomy 62, alone in 12 cases and combined with annuloplasty in 51 cases; annuloplasty alone in 21 cases). The early mortality rate was 9 p. 100. Subsequently, 28 patients (25 p. 100) died and 12 were lost sight of. Deaths related to the tricuspid valve (n = 7) comprised occlusive thrombosis of mechanical prosthesis (MP) in 4 cases and 3 failures of plastic surgery including 2 commissurotomies alone (TC) and 1 commissurotomy combined with annuloplasty (CA). Among the 70 survivors who could be followed up for 36 to 230 months (mean 98 months), there were: --8 failures, 5 of which required reoperation: 3 belonged to the MP group (3 occlusive thromboses) and 5 to the TC group (failure expressed as major tricuspid valve leakage); --4 mediocre results (1 bioprosthesis, 3 plastic operations). The failures of plastic surgery were mostly due to inadequate right ventricular function; --58 successful results, principally with bioprosthesis, CA and annuloplasty alone. Altogether, 93 p. 100 of CA and 92 p. 100 of bioprostheses were free from complications, as against 37 p. 100 of TC and 65 p. 100 of MP. It is concluded that TC completed by annuloplasty ensures satisfactory results, thus allowing the indications conservative tricuspid valve surgery to be enlarged.(ABSTRACT TRUNCATED AT 250 WORDS)

[Outcome more than 10 years later of mechanical mitral valve prostheses in children]. / Evolution au-delà de 10 ans des prothèses valvulaires mécaniques en position mitrale chez l'enfant.

Between 1966 and 1975, fifty-one children aged from 8 to 15 years underwent mitral valve replacement for mitral valve disease of rheumatismal origin. The mechanical prosthesis was a Starr Edwards 6120 N degrees 2 valve in 48 of the children. Late mortality was 20 p. 100; death was due to valve thrombosis in 3 cases, aortic valve regurgitation in 2 cases and left ventricular dysfunction in 2 cases; it was of unknown origin in 3 cases. Four patients were lost sight of, and 36 have survived up to now with a mean follow-up period of 13 years. The life of these 36 patients has been marked by three types of complication. The first complication was thromboembolic accidents which occurred in 10 patients, were virtually always isolated and regressed completely. The incidence of these accidents was highest in patients treated with antivitamin K irregularly. In 23 patients who did not receive antivitamin K the incidence was only 2.27 thromboembolic accidents per 100 patient-years. The second complication, which affected only 4 patients, was functional stenosis of the prosthesis; it developed very late and was always due to periannular fibrosis either isolated or associated with remodelling of the mitral valve left in situ. The third complication was the development, with or without patent rheumatismal activity, of a lesion of the aortic orifice which required reoperation in 5 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fate of Starr-Edwards prostheses in the mitral position. Prognostic factors. Apropos of 309 cases]. / Evolution des prothèses de Starr Edwards en position mitrale. Facteurs de pronostics. A propos de 309 cas.

The authors report the long-term results of 309 patients undergoing isolated mitral valve replacement with a 6120 Starr Edwards mitral valve prosthesis in the great majority of cases, mainly for rheumatic mitral valve disease, with predominant mitral regurgitation. The average age was 26 +/- 14 years with 25% of children. The operative mortality was 9% and late mortality after a mean follow-up period of 4 years was 13,5% mainly due to thromboembolic complications and to myocardial dysfunction. The long-term results with an average 45 month follow-up showed a 10 year survival rate of 70,6% with an excellent clinical result in 71% of cases and an acceptable result in 10%; 20% of patients were considered poor long-term results because of myocardial dysfunction and thromboembolic complications. Endocarditis and perivalvular leaks were rarely observed (9 cases). A study of preoperative parameters which could influence long-term results showed that the quality of long-term survival was significantly correlated to age, the duration of cardiac disease before surgery, cardiomegaly and the presence of preoperative cardiac failure and tricuspid regurgitation. The incidence of thromboembolism was 4,7% patient years and the frequency of these complications was not related to the quality of anti-vitamin-K therapy. Patients under effective anticoagulant therapy had the highest incidence of haemorrhage (10%). This study confirms that the Starr Edwards 6120 prosthesis is a satisfactory choice for mitral valve replacement considering its durability (no cases of abnormal wear) and the 70% ten year survival rate. The problem of myocardial dysfunction could be resolved by earlier surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term results of heterografts in the mitral position]. / Evolution à long terme des hétérogreffes en position mitrale.

The long term results in 43 patients who underwent mitral valve replacement with a bioprosthesis are reported. The average age of the patient was 25, and nearly half of them were under fifteen. The underlying valvular disease was rheumatic in the great majority. Small bioprostheses were used in 40 p. 100 of cases. Hospital mortality was nil. Two patients developed atrioventricular block and needed permanent pacing; this was the principal complication observed in this study. After 34 months, 17 serious complications were recorded including two episodes of thromboembolism. The main problem arose from restenosis of the bioprosthesis, either because of its small size (3 cases) or because of degeneration (6 cases), all in children (33 p. 100 of our paediatric cases). The actuarial survival rate without degeneration shows only 48,2 p. 100 of patients to be without this problem at 5 years. Late mortality reached 29 p. 100 and the five year survival rate showed only 57 p. 100 of patients to be still alive, and only 35 p. 100 with their bioprosthesis. The haemodynamic profile of these prostheses with regards to transvalvular pressure gradient and mitral surface area, was very good for the large size valves, in contrast to the small size. In the absence of degeneration, the gradient was found to be stable. This study has shown that small bioprosthetic valves should be avoided in mitral valve replacement because of the risk of stenosis. Despite the low incidence of thromboembolism, they should not be used in children because of the high incidence of degeneration in paediatric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Reoperations on heart valve prostheses. Apropos of 58 cases]. / Réinterventions sur prothèses valvulaires cardiaques. A propos de 58 cas.

In the period from 1968 to November 1980, 1 023 patients underwent surgery for single or multiple valve replacement. Fifty three patients (6,6% of the follow-up population) had to be reoperated, including 5 patients who had to be reoperated twice, giving a total of 58 reoperations. The average interval before reoperation was 30 months. The incidence was similar in monovalvular (7,5 p. 100 mitral valves, 5 p. 100 aortic valves) and polyvalvular (7 p. 100) cases. On the other hand, the incidence of reoperation of tricuspid prostheses (17 p. 100) was significantly superior to that of mitral valve (5,3 p. 100) or aortic valve (3,8 p. 100) prostheses. In 91 p. 100 of cases, the indication for reoperation was prosthetic valve dysfunction related to endocarditis in over a third of cases (21). In 32 cases, reoperation was required in the absence of any infectious process: 13 spontaneous perivalvular leaks, 10 thromboses, and 9 stenosing prostheses. There were no reoperations for wear of the prosthetic material. Only 9 p. 100 of patients were reoperated for uncorrected valvular disease. The prognosis of these reoperations was poor; hospital mortality being 42,5 p. 100. This high mortality rate is explained by the frequency of reoperation for infective endocarditis (36 p. 100) in our series, the mortality of which was 73,6 p. 100 and even higher when reoperation was an emergency for infectious or hemodynamic reasons. There was also a high mortality rate with reoperation for thrombosis (30 p. 100) because of the severe myocardial dysfunction in thrombosis of tricuspid prostheses and the emergency situation associated with mitral prosthetic valve thrombosis. Excluding these two complications, the average mortality was 21 p. 100. Although the surgical indications are relatively easy for thrombosis, perivalvular leak and stenosing prostheses, they are particularly difficult in infectious endocarditis especially with regards to the timing of reoperation. We believe that, ideally, reoperation should be delayed as long as possible to allow the antibiotic therapy the maximum time to take effect. Surgery can then be performed after controlling the infection and before the installation of severe hemodynamic distress.

[Heart valve prostheses in children with reference to 95 cases]. / Prothèses valvulaires chez l'enfant. A propos de 95 cas.

Over a 10 year period, 95 children aged 15 years and less underwent replacement of one or several of their heart valves, usually by a Starr-Edwards ball prosthesis. The predominant pathology was rheumatic heart disease and the most commonly affected valve was the mitral. Severe symptomatology, heart failure, cardiomegaly and high wedged-capillary and pulmonary arterial pressures were practically constant findings. Operative mortality was low (3.2%) and the long-term mortality was 10 patients. With an average follow-up of 40 months, results were excellent in the great majority of patients, with complete regression of symptoms, cardiomegaly and high capillary and pulmonary arterial pressures. Anticoagulant therapy was not systematic and only half the series were so treated. Thromboembolic complications were rare, 5.5% patients, but only affected those without anticoagulant therapy. The problems of evolving rheumatic disease and, above all, of tricuspid incompetence, the persistence of which after surgery on the mitral valve seems to be a sign of advanced myocardial damage, are discussed.

[Mitral commissurotomy in children. Apropos of 100 cases]. / Commissurotomie mitrale chez l'enfant. a propos de 100 cas.

We report 100 cases of mitral commissurotomy in children, 15-years-old or less, suffering from rheumatic mitral stenosis. Mitral stenosis in children is characterised by the severity of functional impairment and the considerable radiological, electocardiological and haemodynamic changes, with pulmonary arterial hypertension which is always present and often well marked. The early results of mitral commissurotomy are very satisfactory with clinical improvement and a low mortality. But, in the long term, we have seen progressive deterioration in the clinical state of these patients resulting from re-stenosis or from the progression of another valve lesion. Three problems have been discussed. First, the progression of the rheumatic process which seems to account to a large extent for the late failures of mitral commissurotomy in children. Secondly, the problem of tricuspid insufficiency, which is often associated with mitral stenosis in childhood and which usually disappears during the post-operative period. Finally, the problem of pre-capillary pulmonary arterial hypertension which always showed a tendency towards regression.