Dorra Abid

Native Valve Infective Endocarditis in a Tertiary Care Center in a Developing Country (Tunisia)

The aim of the study was to describe the epidemiological and clinical aspects of native valve infective endocarditis (IE) in a Tunisian high-volume tertiary care center and to identify the predictors of outcome. Demographic, clinical, laboratory, and echocardiographic characteristics were examined in 134 patients who fulfilled the modified Duke criteria for native valve IE between January 1997 and December 2006. Logistic regression analysis was used to identify prognostic factors for death. Mean age was 34.22 years. Diagnosis was definite in 93% of cases. Median time to diagnosis was 21 days. Rheumatic heart disease (RHD) was the predominant (45%) underlying heart condition. One or more vegetations were detected in more than 93% of cases. The median size of vegetation was >15 mm in 28% of cases. In 66 cases (49%), cultures remained negative. Serology was positive in 15 cases, and in 4 cases leaflet culture identified the agent. The infective agent was identified in 87 cases (65%), causative microorganisms were mainly Staphylococci (n = 30, including 6 coagulase-negative Staphylococcus), and Streptococci (n = 32). Overall mortality was 19%. On multivariate analysis, congestive heart failure (hazard ratio = 5.34, 95% confidence interval 1.67 to 17.15, p = 0.005) and large vegetations (>15 mm; hazard ratio = 5.78, 95% confidence interval 1.84 to 18.32, p = 0.002) were predictive of in-hospital mortality but not neurological complications or staphylococcus IE. In conclusion, IE remains a serious disease affecting a young population in Tunisia, with RHD as still the most common underlying heart disease, and it is associated with a high mortality.

Congenital heart disease in 37,294 births in Tunisia: birth prevalence and mortality rate.

AIM To investigate the previously unknown birth incidence, treatment, and mortality of children with congenital heart disease in Tunisia. METHODS We undertook a retrospective review of medical records of all patients who were born in 2010 and 2011, and were diagnosed in Sfax (Tunisia) with congenital heart defect. RESULTS Among 37,294 births, 255 children were detected to have congenital heart disease, yielding a birth incidence of 6.8 per 1000. The most frequently occurring conditions were ventricular septal defects (31%), ostium secundum atrial septal defects (12.9%), and pulmonary valve abnormalities (12%). Coarctation of the aorta, tetralogy of Fallot, univentricular physiology, pulmonary atresia with ventricular septal defect, and transposition of the great arteries were found in 4.3%, 6.2%, 3.4%, 2.7%, and 2.7%, respectively. During the follow-up of 1 year, 23% of the children died. About three-quarters of those deaths happened before surgery. CONCLUSION The present study is in line with the general estimates in the world. It has revealed a high case of mortality among the patients awaiting corrective surgery. These children need more facilities.

Cardiac tamponade and paroxysmal third-degree atrioventricular block revealing a primary cardiac non-Hodgkin large B-cell lymphoma of the right ventricle: a case report

IntroductionPrimary cardiac lymphoma is rare.Case PresentationWe report the case of a 64-year-old non-immunodeficient Caucasian man, with cardiac tamponade and paroxysmal third-degree atrioventricular block. Echocardiography revealed the presence of a large pericardial effusion with signs of tamponade and a right ventricular mass was suspected. Scanner investigations clarified the sites, extension and anatomic details of myocardial and pericardial infiltration. Surgical resection was performed due to the rapid impairment of his cardiac function. Analysis of the pericardial fluid and histology confirmed the diagnosis of non-Hodgkin large B-cell lymphoma. He was treated with chemotherapy.ConclusionThe prognosis remains poor for this type of tumor due to delays in diagnosis and the importance of the site of disease.

A novel TBX1 missense mutation in patients with syndromic congenital heart defects

Congenital heart defects represent a characteristic part of several genetic syndromes associated with chromosomal abnormalities such as 22q11.2 deletion syndrome; many genes located in this locus, mainly TBX1, are candidate genes for congenital heart defects. In our cohort of 27 subjects with congenital heart defect, both karyotype analysis and Fluorescence in situ hybridization (FISH) were performed. The TBX1 gene was sequenced in patients lacking chromosomal abnormalities. FISH analysis showed a de novo 22q11.2 deletion in two patients. The screening of TBX1 coding sequence identified a novel missense mutation c.569C > A (p.P190Q) in six unrelated patients and detected two associated known single nucleotide polymorphisms; the c.664C > T (rs2301558) in three patients and the c.420T > C (p.Phe140 Phe) (rs41298814) in one patient. Bioinformatic tools show that the novel missense mutation c.569C > A could modify the function and the stability of the TBX1 protein. The c.569C > A mutation was not found in 50 healthy controls. Ours results suggest a deleterious role of the c.569C > A mutation and strengthen the hypothesis that this mutation might be responsible for the same phenotype spectrum as the 22q11.2 deletion syndrome.

Clinical features and prognosis of infective endocarditis in children: Insights from a Tunisian multicentre registry

BACKGROUND Infective endocarditis (IE) is a rare condition in the paediatric setting. No data on the epidemiology and prognosis of IE in children are available from North African countries. AIM To investigate the epidemiological profile and prognosis of IE in children in Tunisia. METHODS All patients aged≤18 years presenting with IE in three Tunisian tertiary care centres between January 1997 and September 2013 were included. Clinical features and 30-day and 6-month mortality rates were studied. Factors predictive of death at 6-month follow-up were determined. RESULTS A total of 73 patients were included in the present study. The mean age was 12±4.8 years; 35 (50.7%) patients were male. Rheumatic heart disease (RHD) was the underlying heart disease in 17 (23.3%) cases and IE occurred in a structurally normal heart in 36 (49.3%) cases. Staphylococcus species were isolated in 17 (23.3%) cases. Regarding IE localization, the mitral valve was involved in 28 (38.4%) cases and the aortic valve in 14 (19.2%) cases. Recourse to surgery was reported in 37 (50.7%) cases. Thirty-day and 6-month mortality rates were 13.6% and 19.2%, respectively. Heart failure on admission or during the hospital course, acute renal failure and neurological complications were significantly associated with death at 6-month follow-up in the univariate analysis and after adjustment for age and sex. CONCLUSIONS In the Tunisian context, IE in children is still characterized by the high prevalence of RHD as an underlying heart disease. Short- and long-term mortality rates remain high. Heart failure, acute renal failure and neurological complications are significantly associated with death at 6-month follow-up.

Echocardiographic analysis of the left ventricular function in young athletes: a focus on speckle tracking imaging

Introduction The objectives were to assess the left ventricular (LV) structure and function in regularly trained young athletes, using 2 D conventional echocardiographic (echo) methods and speckle tracking echocardiography (STE). An observational cross-sectional study. Methods Thirty-three footballers and 20 healthy untrained subjects were included in the study. The systolic and diastolic LV functions were evaluated by 2D conventional echo parameters, Doppler method and STE. Results All the found values were within the normal range. The LV End Diastolic Diameter (LVED 37.24±2.08 mm/m2) and the LV Mass index (LVMi 97.93±15.58 g/m2) were significantly higher in young athletes as compared with controls. There was no difference regarding the LV systolic function assessed by conventional echo parameters in the 2 study groups. Regarding the diastolic function, the transmitral inflow velocities ratio was significantly higher in athletes (E/A = 2.10±0.49 versus 1.64±0.26, p< 0.001) but there was no difference in the filling pressure in the 2 groups. The STE demonstrated a different pattern of LV deformation in the different groups. A significant lower LV global longitudinal strain (GLS -20.68±2.05 versus -22.99±2.32 %, p<0.001) and higher radial and circumferential strains have been found in the young athletes as compared with controls. A significant relationship between the GLS values and LVED (r= 0.299, p = 0.03) and LVMi was also reported in athletes. Conclusion While conventional morphological and functional echocardiographic parameters failed to distinguish the adaptations in the athlete’s heart, deformation parameters showed a different pattern of LV mechanics in young footballers versus controls.

0522: Evaluation of the left ventricular function using speckle tracking echocardiography in hemodialysis patients with preserved left ventricular ejection fraction

Objective Patients with end-stage renal disease (ESRD) more frequently develop a wide range of left ventricular (LV) structural and functional abnormalities. The aim of our study is to evaluate the left ventricular function using two-dimensional and three-dimensional speckle tracking echocardiography (STE) in ESRD patients with preserved left ventricular ejection fraction (PLVEF) undergoing haemodialysis (HD) treatment. Methods Thirty patients on maintenance HD were examined before and after HD. All of the patients had normal left ventricular ejection fraction (50% or greater). Using the 2D-STE and 3D-STE methods, values belonging to the LV global longitudinal (GLS), circumferential (GCS) and radial (GRS) peak systolic strain were measured. BNP levels were measured before and after HD. Results While the LVEF values in the ESRD group were found to be lower in 3D measurement than in 2D- echocardiography (58.46±7.14 vs. 61.36±7.87, P=0.03). LV global longitudinal and radial peak systolic strain was decreased in the study group population. No difference was observed in terms of the GCS. Strain values improved in longitudinal and radial directions after HD [pre- vs. post-HD; GLS: –16.43 (1.7) vs. –18.49 (1.9)%, p Conclusion In patients with ESRD, although the longitudinal and radial systolic functions are reduced, the LVEF may remain within normal limits due to the preservation of the circumferential functions. 2D-STE has the potential to detect the severity of uraemic cardiomyopathy in the early stages of the disease and might provide useful information for the risk stratification in ESRD patients with PLVEF.

Midventricular Obstructive Hypertrophic Cardiomyopathy during Pregnancy Complicated by Pulmonary Embolism: A Case Report

Hypertrophic cardiomyopathy (HCM) with midventricular obstruction (MVO) is a rare condition occurring in 1% of HCM patients. It is characterized by asymmetric left ventricular hypertrophy with MVO and elevated intraventricular pressure gradients. Pulmonary embolism has been associated with mid-ventricular obstructive HCM. Briefly, this case presents an unusual clinical scenario where a young pregnant woman suffering from hypertrophic obstructive cardiomyopathy presents with dyspnea hemodynamic compromise related to pulmonary embolism illustrating hemodynamic challenges created by pregnancy and surgery. We concluded that simple measures such as communication between the cardiology and obstetric teams, understanding of the hemodynamic changes, anesthetic planning, and monitoring were paramount for the success in our patient.

Unusual case of ruptured sinus of valsalva aneurysm in a pregnant woman

Sinus of Valsalva aneurysms are extremely rare, and usually of a congenital nature. There are few documented cases of this condition during pregnancy, which renders unclear the therapeutic options. We here report the case of a 26 years old pregnant woman who was referred to our cardiac center for the evaluation of a heart murmur. The two-dimensional transthoracic echocardiography allowed quickly to establishthe diagnosis of a ruptured sinus of Valsalva aneurysm into the right ventricle. A successful surgical correction of the ruptured aneurysm was performed with patch repair.

Cirrhotic cardiomyopathy: is there any correlation between the stage of cardiac impairment and the severity of liver disease?

ABSTRACT Cirrhotic cardiomyopathy is associated with poor prognosis and risk of acute heart failure after liver transplantation or interventional procedures. We aimed to assess the relationship between the severity of cardiac impairment and hepatic disease. Eighty patients and eighty controls underwent echocardiography, tissue Doppler imaging and speckle tracking measures. We assess the correlation between echocardiographic parameters and Child and MELD scores. Systolic parameters function (s wave, p < 0.001) and global longitudinal strain (p < 0.001) as well as diastolic parameters were significantly more impaired in cirrhotic patients compared to controls. There were no differences among the different groups in ‘Child score’ regarding systolic function as well as diastolic function. Paradoxically, the left atrium size correlated positively to both Child (p = 0.01, r = 0.26) and MELD scores (p = 0.02, r = 0.24). Left ventricular ejection fraction was significantly lower in decompensated patients as compared to compensated patients(p = 0.02).. We did not identify any association between severity of liver disease and cardiac dysfunction. Therefore, a transthoracic echocardiography should be performed in all cirrhotic patients before interventional and surgical procedures regardless of the severity of liver disease.