Afef Ben Halima

Cardiac hydatid cyst revealed by ventricular tachycardia

Hydatid disease is a human parasitic infestation caused by the larval stage of Echinococcus Granulosus. The liver and the lungs are the most common locations. Cardiac involvement is rare and accounts for 0.5-2% of all hydatid disease. We report an unusual presentation of cardiac hydatid cyst revealed by ventricular tachycardia in a patient with a history of cerebral hydatid cyst.

Clinical and Genetic Investigation of Atrial Septal Defect with Atrioventricular Conduction Defect in a Large Consanguineous Tunisian Family

BACKGROUND Atrial septal defect (ASD) is an autosomal dominant disease characterized by left-to-right shunting and increased right ventricular output. Approximately 5-10% of congenital heart diseases (CHD) are due to ASD, which is one of the most frequent CHD found in adults. The gene responsible for ASD was mapped to chromosome 5q35 encoding the transcription factor NKX2-5 that plays an important role for the regulation of septation during cardiac morphogenesis. METHODS A Tunisian family including four affected members was investigated. Individuals were genotyped using the polymorphic microsatellite markers D5S394 and D5S2069 overlapping the NKX2-5 gene. RESULTS We report here clinical and molecular investigation of a Tunisian consanguineous family with four affected members. Two presented with ASD associated with prolonged PR interval, whereas the other two presented only a prolonged PR interval. We also identified five asymptomatic individuals in the same family with ventricular preexcitation. Although the patients were products of a consanguineous marriage, no other abnormalities were observed in this family. Genotyping and linkage analysis showed exclusion of linkage between the gene responsible for ASD in this family and NKX2.5 gene. CONCLUSIONS Our results further confirm the genetic heterogeneity of ASD.

256: Ramadan fasting and high sensitive CRP in patients with stable coronary artery disease: a pilot study

Introduction Ramadan fasting is one of the five pillars observed by Muslim adults worldwide. Data on incidence of acute coronary syndrome during fasting Ramadan are scarce and conflicting. Inflammation plays a major role in atherothrombosis, and measurement of cardiac biomarkers such as High sensitive C-reactive protein (hs-CRP) may provide a strong independent predictor of future cardiac events. Aim of this study was to evaluate the effect of fasting during Ramadan on hs-CRP in patients with stable coronary artery disease (CAD). Patients and Methods it was a prospective pilot study among 27 patients with stable CAD (within the last 6 months) who were observed before and at the end of Ramadan fasting. Patients were recruited from outpatients department. Twenty one were males and 6 were females with a mean age of 59±8.2 years (52-75 y). Fifteen patients had hypertension, 10 were smokers and 7 were diabetics. Blood was analyzed at the first visit was a week before the onset of Ramadan and the second visit at the third week of Ramadan. The assay of hs-CRP was done with the collected sera by Demeditec Diagnostics Systems Laboratories (Germany). Results Six patients were excluded for the second visit due to various reasons (break voluntary of fasting in two cases, 4 patients with concurrent inflammatory disorders e.g. rheumatoid disease in 2 cases and intercurrent infections in two others). A total of 21 subjects were screened during this period. There was a significant reduction in hs-CRP during Ramadan compared before this period: 6.6±8.7 vs 3.8±5.5 (p Conclusion The practice of fasting during the month of Ramadan by the people with stable CAD might be cardio-protective as it resulted in the lowering of hs-CRP.

Design and Rationale of the National Tunisian Registry of Atrial Fibrillation: Protocol for a Prospective, Multicenter Trial

Background Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiological pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiological profile and management of AF patients in Tunisia are limited. Objective The aim of this study is to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. Methods A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective of describing the epidemiological pattern of AF. Patients will be officially enrolled in the National Tunisian Registry of Atrial Fibrillation (NATURE-AF) only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point, and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. Results Results will be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. Conclusions This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. Trial Registration ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX) Registered Report Identifier RR1-10.2196/8523

Left ventricular non-compaction and hypertrophic cardiomyopathy: two overlapping diseases or two manifestations of the same cardiomyopathy? Response to the letter concerning the article: “Left ventricular non-compaction associated with hypertrophic…

We thank Dr. Finsterer and Dr. Stollberger for their valuable comments on our paper [1]. First, we agree that both left ventricular non compaction (LVNC) and hypertrophic cardiomyopathy (HCM) can be associated with neuromuscular disorders [2]. Our patient did not report any symptoms suggestive of myopathy. He was also referred to a neurologist, who did not find any abnormality. Of note, creatine kinase serum level was normal. Second, LVNC and HCM have been accepted as distinct cardiomyopathies and classified as genetic cardiomyopathies by the American Heart Association [3]. We concur that since LVNC was reported to disappear and was even inducible in animal models, its genetic origin could be conflictual and debatable. Recently, Lorca et al. [4] studied three families with both LVNC and HCM diseases, with different common mutations in each family and autosomal dominant inheritance. Within one family, the investigators found the coexistence of both diseases in two patients, with a possible pathogenic candidate described: mutation of sarcomere cardiac b-myosin heavy chain gene (MYH7 L620P). In the two other families, the same mutation was described (MYBPC G263NX) with phenotype variability, and only one case associating both LVNC and HCM in each family [4]. Further genetic studies should be performed to try to answer to the following question: are HCM and LVNC two overlapping diseases or two different manifestations of the same cardiomyopathy spectrum? Unfortunately, we did not perform genetic analysis because the patient’s family refused it. Finally, regarding complications, our patient showed heart failure symptoms and signs with mildly impaired left ventricular ejection fraction, in addition to episodes of non-sustained ventricular tachycardia on 24-h Holter electrocardiography recording. According to sudden cardiac death score related to HCM, implantable cardiac defibrillator was indicated and thus implanted. Although the left atrium was dilated (area 27 cm2), no atrial fibrillation was found on 24-h Holter electrocardiogram recordings or on different telemetries; therefore, anti-coagulation was not indicated. To conclude, LVNC can be either primary (congenital) or secondary. When it is primary, LVNC genetic determination is close to that of HCM. Further genetic studies are needed to better elucidate this relationship and to better identify the pathogenic mutations.

Left ventricular non-compaction associated with hypertrophic cardiomyopathy in the same patient

Address for correspondence: Dr. Lobna Laaroussi, Université Tunis El Manar, Faculté de Médecine de Tunis, Service de Cardiologie Hopital Abderrahmen Mami, 2008 Ariana, Tunisia, e-mail: lobna_laroussi@hotmail.com Conflict of interest: none declared Kardiologia Polska Copyright

Giant left main coronary artery aneurysm revealed by a myocardial infarction

A 73-year-old woman was admitted for acute chest pain lasting for 2 h. She had no cardiovascular risk factor except her age. Her previous medical history was unremarkable. On admission, her heart rate was 90 bpm and blood pressure was 120/70 mm Hg. An electrocardiogram revealed ST-segment elevation in anteroseptal leads. No acute heart failure was found on examination. Fibrinolysis was successfully performed with ST-segment regression. Transthoracic echocardiogram showed impaired left ventricular systolic function (ejection fraction: 40%). Coronary angiography revealed a large, partially thrombosed left main aneurysm; no other coronary significant stenosis was observed (Fig. 1). Hence, we concluded a diagnosis of embolic myocardial infarction originating from the left main aneurysm. Syphilis serology tests and immunological investigations were negative. A computed tomography scan was performed showing a 5 × 3-cm partially thrombosed aneurysm of the left main coronary artery (LMCA) (Figs. 2, 3). Surgical exclusion of the aneurysm was indicated; however, it was rejected by the patient. Double anti-aggregation (aspirin + clopidogrel) associated with oral anticoagulation for six months were prescribed, followed by the association of aspirin and oral anticoagulation. At the time of writing, the patient is asymptomatic after an uneventful three-year follow-up. In 1761, Morgagni published the first pathologic description of aneurysmal coronary artery disease [Morgagni JB. De sedibus et causis morborum. Tom 1. Venetus: 1761: Epis 27, Art 28]. Coronary artery aneurysms are defined as dilated segments larger than 1.5 times the diameter of adjacent coronary arteries. The LMCA location is extremely rare. Common causes are atherosclerosis, autoimmune diseases (Kawasaki disease, systemic lupus erythematous, Behçet’s disease, Takayasu disease), dissection, and trauma. In our case, the most probable aetiology was atherosclerosis. The clinical presentations of coronary artery aneurysms are extremely variable. Our patient presented with acute myocardial infarction, probably due to distal embolisation originating from the left main aneurysm thrombus. Rupture is the other severe life threatening complication that may occur. Although invasive coronary angiography is still the gold standard for aneurysm assessment, computed tomography and magnetic resonance imaging can adequately evaluate these aneurysms. Echocardiography has also been shown to be useful, especially in children. The management of coronary aneurysm is controversial: both conservative and surgical treatments can be used. Medical treatment is based on antiplatelet agents alone or associated with anti-coagulants. Successful percutaneous obliteration of left main aneurysm using a covered stent was described, with good short-term outcome. Nonetheless, surgical revascularisation, either by aneurysm repair using a pericardial patch or by resection associated with coronary artery bypass, remains the recommended gold standard therapy.

0538: Rheumatic valvular detected during the medical examination of non-counter-indications to the practice of the high level sport: result of a systematic evaluation

Introduction The cardiovascular assessment during the first medical examination of of noncounter-indications to the practice of the high level sport has systematically a heart Doppler ultrasound according to the consensus of National Center for Sport’s Medicine and Science (NCSMS). Objective To study the prevalence of rheumatic valve disease detected during the systematice echocardiographic assessment of Tunisian elite athletes. Materials and Methods We retrospectively studied the data of all the TTE carried out in the NCSMS from 1998 to 2009 (4254 heart Doppler ultrasound performed). The study population was composed of 2253 sportsmen including 586 girls (26.1%) and 1667 boys (73.9%). They are of average age of 20.58±4. 2 years. It is composed of national team’s members (31.5%), professional players (9.23%), sporting pupils (50.19%) and arbitrators (9.23%). Results We report 628 cardiac anomalies with good left ventricular function, consistent with the practice of competitive sports, mainly 173 cases of rheumatic valvular disease (27.5%) representing 94% of all valvular abnormalities observed.Rheumatic mitral leak was found in 122 cases (70.5%) with the combination of a moderate dilatation of the LV in 7 cases only. 40 athletes (32.7%) received only their routine annual echocardiographic controls whose data were similar to initial results, with the exception of three cases with valvular heart disease has evolved on a LV moderately dilated. We detected 34 rheumatic aortic insufficiency (19.6%), grade 1 to 2 (mild to moderate).Mitral and aortic valve disease (rheumatic mitral insufficiency grade I and rheumatic aortic insufficiency grade I) were observed in 17 athletes (9.9%). Six of them have benefited from echocardiographic control that was similar to the initial one. Conclusion Our study therefore to an echo-cardiographic description of the various rheumatic valve disease that can be observed in the athlete population and is compatible with the sport.

0218: Influence of gender on the distribution of anatomic anomalies of the pulmonary veins (PVs) in a cohort of 38 patients with atrial fibrillation (AF)

Introduction Obstructive sleep apnea (OSA) is associated with oxidative stress, risk factors including hypertension, and with binary presence of coronary artery disease (CAD). However, whether OSA contributes to the severity of CAD and to future adverse events in patients with CAD remains unknown. Aim The aim of this study was to investigate the association between severe OSA and multivessel CAD. Methods We examined the apnea hypopnea index (AHI) using polygraphy (PG) in 60 consecutive patients with ACS who underwent coronary angiography. OSA was defined by AHI≥5 events per hour and was considered severe if the AHI≥30 events per hour. The Friesinger score was calculated for each patient from the coronary angiography to evaluate the severity of CAD. Results The average age of patients was 59.73 years±10.1 years. The sex ratio was 1, 5. 61, 7% of patients had an AHI≥5 and 21,7% had severe OSA with AHI≥30. The Friesinger score was significantly greater in the group with multivessel CAD (11, 28±4, 17 versus 5, 35±3, 96, p=0,0001). There were no differences between patients having multivessel CAD and those with single-vessel CAD regarding clinical characteristics. Table summarizes these results. Abstract 0218 – Table: Comparison of patients with multivessel CAD and with single vessel CAD. Multivessel CAD (n=33) Single vessel CAD (n=27) P Age 59,3±9,1 60,26±11,47 0,72 Male 35% 25% 0,51 Bmi 27,75±3,43 28,27±4,61 0,62 Smoking 31,7% 20% 0,31 Hypertension 33,3% 28,3% 0,85 Diabetes 35% 23,3% 0,35 Severe OSA 11,7% 10% 0,83 Conclusion In summary, these data suggest a high occurrence of obstructive sleep apnoea in patients with CAD, which should be taken into account when considering risk factors for CAD. However, severe OSA is not more frequent in the group of multivessel CAD. Further studies are needed to evaluate the impact of the presence of severe OSA on short and long term prognosis.

0419: Comparison of clinical and angiographic features of acute coronary syndromes with and without obstructive sleep syndrome detected by the Berlin questionnaire

Introduction obstructive sleep apnea sundromeObstructive sleep apnea syndrome (OSA) is a common and often underdiagnosed disease. It is involved in the progression of atherosclerosis and could be considered as a factor of cardiovascular risk. Objective The aim of this study was to compare the clinical and angiographic characteristics of patients admitted for acute coronary syndrome with high risk and low risk of OSA detected by the Berlin questionnaire Materials and methods 150 patients with an average age 61.6 years with a sex ratio of 3.65 were admitted for acute coronary syndrome over a period of 3 months. Patients already paired with OSA were excluded. All patients responded to the questionnaire Berlin. 50.6% were considered at high risk for OSA and 49.4% were considered low risk of OSA. The evaluation of the distribution of coronary lesions was studied by the modified score Friesinger. Results cf Table Abstract 0419 – Table: results High risk OSA N= 76 Low risk OSA N =74 p Age 63±11 60±11 0,5 Male 34,2% 44,3% 0,048 Female 15,2% 6,3% Hypertension 36.7% 24,1% 0,015 Diabetes 62,9% 37,1% 0,042 Tobacco 26,6% 37,6% 0,085 Dyslipidemia 22,8% 3,8% 0,001 ACS ST + 19% 24,1% 0,41 ACSST – 28,2% 25,6% 0,65 One vessel 26,5% 20,6% NS Multivessel 26,5% 26,4% NS Coronary Score 7,6±4,4 8,47±5,5 0,09 Conclusion The presence of cardiovascular risk factors including hypertension, diabetes and dyslipidemia was significantly associated with a high probability of OSA according to the Berlin questionnaire. However, the distribution of coronary lesions was similar and independent of the probability of OSA.