Habib Gamra

Percutaneous Balloon Versus Surgical Closed and Open Mitral Commissurotomy Seven-Year Follow-up Results of a Randomized Trial

BACKGROUND Percutaneous balloon mitral commissurotomy (BMC) has been proposed as an alternative to surgical closed mitral commissurotomy (CMC) and open mitral commissurotomy (OMC) for the management of rheumatic mitral valve stenosis (MS). METHODS AND RESULTS We conducted a prospective, randomized trial comparing the results of the 3 procedures in 90 patients (30 patients in each group) with severe pliable MS. Cardiac catheterization was performed in all patients before and at 6 months after each procedure. All patients had clinical and echocardiographic evaluation initially and throughout the 7-year follow-up period. Gorlin mitral valve area (MVA) increased much more after BMC (from 0.9+/-0.16 to 2.2+/-0.4 cm2) and OMC (from 0.9+/-0.2 to 2.2+/-0.4 cm2) than after CMC (from 0.9+/-0.2 to 1.6+/-0.4 cm2). Residual MS (MVA <1.5 cm2) was 0% after BMC or OMC and 27% after CMC. There was no early or late mortality or thromboembolism among the three groups. At 7-year follow-up, echocardiographic MVA was similar and greater after BMC and OMC (1.8+/-0.4 cm2) than after CMC (1.3+/-0.3 cm2; P<.00l). Restenosis (MVA <1.5 cm2) rate was 6.6% after BMC or OMC versus 37% after CMC. Residual atrial septal defect was present in 2 patients and severe grade 3 mitral regurgitation was present in 1 patient in the BMC group. Eighty-seven percent of patients after BMC and 90% of patients after OMC were in New York Heart Association functional class I versus 33% (P<.0001) after CMC. Freedom from reintervention was 90% after BMC, 93% after OMC, and 50% after CMC. CONCLUSIONS In contrast to surgical CMC, BMC and OMC produce excellent and comparable early hemodynamic improvement and are associated with a lower rate of residual stenosis and restenosis and need for reintervention. However, the good results, lower cost, and elimination of drawbacks of thoracotomy and cardiopulmonary bypass indicate that BMC should be the treatment of choice for patients with tight pliable rheumatic MS.

Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice: Insight from the RealiseAF International Registry

Background— There is a paucity of international data on the various types of atrial fibrillation (AF) outside the highly selected populations from randomized trials. This study aimed to describe patient characteristics, risk factors, comorbidities, symptoms, management strategy, and control of different types of AF in real-life practice. Methods and Results— Real-life global survey evaluating patients with atrial fibrillation (RealiseAF) was a contemporary, large-scale, cross-sectional international survey of patients with AF who had ≥1 episode in the past 12 months. Investigators were randomly selected to avoid bias. Among 9816 eligible patients from 831 sites in 26 countries, 2606 (26.5%) had paroxysmal, 2341 (23.8%) had persistent, and 4869 (49.6%) had permanent AF. As AF progressed from paroxysmal to persistent and permanent forms, the prevalence of comorbidities, such as heart failure (32.9%, 44.3%, and 55.6%), coronary artery disease (30.0%, 32.9%, and 34.3%), cerebrovascular disease (11.7%, 10.8%, and 17.6%), and valvular disease (16.7%, 21.2%, and 35.8%), increased, and the prevalence of lone AF decreased. Similarly, there was an increase in mean CHADS2 [cardiac failure, hypertension, age, diabetes, stroke (doubled)] score (1.7, 1.8, and 2.2), and more than half of patients (51.0%, 56.7%, and 67.3%) qualified for oral anticoagulants. Almost 90% of patients received ≥1 antiarrhythmic drug, but >60% had European Heart Rhythm Association symptom scores from II to IV. Furthermore, 40.7% of persistent and 49.8% of permanent AF patients were still in AF with a heart rate >80 beats per minute. Conclusions— This survey disclosed high cardiovascular risks and an unmet need in daily practice for patients with any type of AF, especially those with the permanent form.

Long-term invasive and noninvasive results of percutaneous balloon pulmonary valvuloplasty in children, adolescents, and adults ☆ ☆☆

BACKGROUND Short-term and mid-term results of percutaneous balloon pulmonary valvuloplasty (BPV) are well known. However, data documenting long-term effectiveness of BPV are scarce. METHODS AND RESULTS The long-term results of 62 patients were assessed by catheterization and Doppler echocardiography 1 to 10 years (mean 6.4 +/- 3.4) after BPV. Mean age of the patients was 13.5 +/- 10.5 years (range 9 months to 44 years). Twenty patients were 16 years of age or older. Right ventricular peak systolic pressure was systemic or suprasystemic in 72% of patients. A double-balloon technique was used in 29 patients. The balloon-to-pulmonary valve diameter ratio was 1.4 +/- 0.38 (range 1 to 1.8). Total systolic transpulmonary pressure gradient in excess of 50 mm Hg in all patients before BPV decreased from 98 +/- 40 to 32 +/- 23 immediately after BPV and to 19 +/- 9 mm Hg at follow-up (P <.001). Infundibular gradient increased from 8 +/- 10 to 14 +/- 24 mm Hg after BPV and fell to 1 +/- 4 mm Hg at follow-up (P <.01). In 16 patients it was >/=20 mm Hg and virtually disappeared spontaneously in all at follow-up. The valvar gradient fell from 93 +/- 39 to 19 +/- 11 (P <.001) and was 18 +/- 9 mm Hg at follow-up. It remained unchanged in 3 patients (range 36 to 45 mm Hg). In 3 (4.8%) other patients, a new gradient >35 mm Hg developed that was >/=50 mm Hg in all 3. Among 5 patients having dysplastic valves, 3 had a gradient >35 mm Hg. There were no predictors of a gradient >35 mm Hg at long-term follow-up by univariate or multivariate Cox proportional hazards analysis. Mild to moderate pulmonary regurgitation was present in 39% of patients. On electrocardiography, right ventricular hypertrophy decreased significantly in 90% of patients. CONCLUSIONS BPV as a treatment of typical pulmonic valve stenosis produces excellent long-term results. Restenosis is rare (4.8%) and occurs more frequently in patients with dysplastic valves. There is a constant spontaneous regression of associated infundibular obstruction.

Eighteen-year experience with echinococcosus of the heart: clinical and echocardiographic features in 14 patients

We present a retrospective analysis of clinical symptoms and echocardiographic features in 14 patients having cardiac hydatic cysts and screened during the 18 last years, with surgical correlations in 13. The heart was the sole location of the cyst in six patients. The revealing symptoms were precordial pain (six patients), dyspnea (two patients). A systolic murmur of false pulmonic stenosis was present in three patients. In 13 patients, two-dimensional echocardiographic images of hydatic cysts were those of masses of liquid content with a well-contrasted capsule, which was single in eight patients and multiple in five, one of which had a honeycomb appearance. The mass was solid and calcified in one patient. The outlines of the cysts were particularly sharp on transesophageal echocardiograms (six patients). The cyst size ranged from 1.8 to 11 cm in diameter. Cysts were located in the intramyocardium in 10 patients (left ventricle in four patients, interventricular septum in four patients, right ventricle in two patients), the pericardium in three and the mediatinum in one. There were a Doppler pulmonary valve gradient in three patients. Computed tomography (eight patients) and coronary arteriography (seven patients) have no additional diagnosis value than echocardiography. Nuclear magnetic resonance imaging (three patients) was helpful in determining extracardiac extension of the cysts. Transthoracic and transesophageal two-dimensional echocardiography have a central role in diagnosing cardiac hydatic cysts.

Intracardiac thrombus in Behçet's disease: Two case reports

Intracardiac thrombus in Behçets disease is an extremely rare manifestation. We report two such cases. A 20-year-old man presented with dyspnoea, cough and haemoptysis. Right heart thrombus associated with pulmonary artery aneurysm and thromboembolism was identified by helical CT and transoesophageal echocardiography. The second case was a 29-year-old male admitted for fever and chest pain. A diagnosis of right atrial thrombosis associated with pulmonary embolism and hyperhomocysteinemia was made. Due to the absence of haemodynamic compromise, medical management consisting of immunosupressive and anticoagulation therapy was adopted which resulted in complete dissolution of the thrombus with dramatic clinical improvement in both cases of clinical status.Conclusionintracardiac thrombus is a rare complication of Behçets disease. As shown in our patients, medical treatment should be considered as the first line.

Inappropriate use of antiarrhythmic drugs in paroxysmal and persistent atrial fibrillation in a large contemporary international survey: insights from RealiseAF.

AIMS International atrial fibrillation (AF) guidelines have defined optimal drugs for patients with various underlying diseases, but the extent to which real-life practice complies with these guidelines is unknown. This study aimed to evaluate the appropriate use of antiarrhythmic drugs (AADs) in patients with paroxysmal and persistent AF from the RealiseAF survey, according to the 2006 American College of Cardiology/American Heart Association/European Society of Cardiology AF guidelines. METHODS AND RESULTS RealiseAF was an international cross-sectional, observational survey of 10 523 eligible patients from 26 countries on 4 continents, with ≥1 AF episode documented by standard electrocardiogram or by Holter monitoring in the last 12 months. Participating physicians were randomly selected during 2009-10 from lists of office-based or hospital-based cardiologists and internists. Overall, 4947 patients with paroxysmal (n = 2606) or persistent AF (n = 2341) were included; mean (standard deviation) age was 64.7 (12.4) and 66.0 (11.8) years, respectively. Class Ic drugs were prescribed in 589 patients (11.9%); however, in 20.0% of these patients, the indication was not consistent with published guidelines. Similarly, for the 219 patients prescribed sotalol (4.4%), 16.0% received treatment for an indication that deviated from the published guidelines. Amiodarone was prescribed as first-line therapy in 1268 patients (25.6%), but 49.9% of these did not have heart failure or hypertension with significant left ventricular hypertrophy. CONCLUSION The use of AADs for persistent or paroxysmal AF in this large contemporary international survey showed some deviations from international guidelines. The highest discordance came with the use of amiodarone in first line. Clearly, there is a large discrepancy between published guidelines and current practice.

The GPIIIa PlA polymorphism and the platelet hyperactivity in Tunisian patients with stable coronary artery disease treated with aspirin

BACKGROUND Various genetic polymorphisms have been proposed to explain the persistent platelet hyperactivity (HPR) under aspirin treatment. PlA polymorphism of platelet GPIIIa receptor has been largely studied. However, its influence on platelet sensitivity to aspirin remains controversial. OBJECTIVES The aim of this prospective study is to investigate whether this PlA polymorphism is associated with a greater prevalence of HPR in stable coronary artery disease patients Material and Methods: 188 stable coronary artery disease patients were included. Platelet aspirin inhibitory effect was determined with PFA-100 using Collagen/Epinephrine closure time (CEPI-CT). A CEPI-CT<160sec was defining the HPR status. GPIIIa PlA polymorphism was established using polymerase chain reaction and classical restriction fragments length polymorphism. RESULTS The observed frequencies of different genotypes were not different from those predicted by the Hardy-Weinberg equilibrium: PlA1/lA1 (55.3%), PlA1/PlA2 (39.4%) and PlA2/PlA2 (5.3%). HPR patients with inadequate aspirin inhibition were significantly more often homozygous PlA1/A1 (65.4% vs. 47.7%, p=0.015). After multivariate analysis, PlA1/A1 genotype was the only independent risk factor for persistent HPR (OR: 2.07; 95% CI [1.14 to 3.76; p=0.016). CONCLUSION In CAD patients receiving daily low dose of aspirin, there is a significant and independent association between the expression of GPIIIa PlA1 allele and the occurrence of persistent HPR detected with PFA-100.

Platelet glycoprotein IIIa (platelet antigen 1/platelet antigen 2) polymorphism and 1-year outcome in patients with stable coronary artery disease.

Platelet glycoprotein IIb/IIIa is a membrane receptor which plays a key role in coronary artery disease and thrombotic events. However, there is a considerable controversy regarding the clinical impact of glycoprotein IIIa platelet antigen 1 (PlA1)/platelet antigen 2 (PlA2) polymorphism as a risk factor for myocardial infarction. To evaluate the association between glycoprotein IIIa PlA1/PlA2 polymorphism and 1-year cardiovascular events occurrence in aspirin-treated patients with stable coronary artery disease. We prospectively included 188 postacute coronary syndrome patients (183 men) aged 59 ± 10 years and receiving aspirin (250 mg/day). The clinical outcome at 1 year was the composite end point of nonfatal myocardial infarction, stroke, recurrent unstable angina or cardiac death. Genotyping for PlA1/PlA2 polymorphism was conducted using PCR and restriction fragment length polymorphism analysis. The genotype distribution of glycoprotein IIIa PlA1/PlA2 polymorphism was PlA1/PlA1, 55.3%; PlA1/PlA2, 39.3% and PlA2/PlA2, 4%. Incidence of composite end point in homozygous PlA1/PlA1 carriers was significantly higher than in PlA2/PlA2 and PlA1/PlA2 patients [14.4 vs. 3.6% odds ratio 4.5 (1.2–16.6, 95% confidence interval); P = 0.012]. Multivariate analysis identified three strong predictive factors of cardiac death: age more than 65 years [odds ratio = 6.8, (1.4–34, 95% confidence interval); P = 0.018], ventricular ejection fraction less than 50% [odds ratio = 8.6, (1.7–42.6, 95% confidence interval); P = 0.008] and homozygous PlA1/PlA1 genotype [odds ratio = 8.8, (1.0–78.6, 95% confidence interval); P = 0.014]. Our results demonstrated that glycoprotein IIIa PlA1/PlA1 genotype carriers have a significantly increased risks of acute vascular ischemic events associated with a poor prognosis at 1 year. These postacute coronary syndrome patients might require an optimized secondary antithrombotic prophylaxis strategy.

Recurrent miscarriages as an indication for percutaneous tricuspid valvuloplasty during pregnancy

Isolated balloon tricuspid valvuloplasty was successfully performed in a pregnant woman with a history of recurrent miscarriages. The course of pregnancy was uneventful, and a healthy baby was delivered. This report highlights the unusual indication for the procedure, which was recurrent miscarriage, and outlines some technical aspects of tricuspid valvuloplasty.

The Cyclooxygenase-1 C50T Polymorphism Is Not Associated with Aspirin Responsiveness Status in Stable Coronary Artery Disease in Tunisian Patients

In this study, we evaluate the relationships between aspirin nonresponsiveness and the cyclooxygenase-1 (Cox-1) gene C50T polymorphism in stable coronary artery disease (CAD) in Tunisian patients. One hundred twenty-five stable CAD patients were included. The Cox-1 gene C50T polymorphism was determined by the polymerase chain reaction/restriction fragment length polymorphism method. Aspirin response was evaluated by measuring the collagen epinephrine closer time and the urinary dehydro-thromboxane B2 excretion. According to the collagen epinephrine closer time values, the frequency of the -50T allele was not significantly different in bad responders when compared with good responders (36.8% vs. 15.7%; p=0.1). Similarly, the presence of the -50T mutant allele was not statistically different comparing bad and good responders according to the urinary 11-dehydro-thromboxane B2 excretion concentration (60% vs. 40%; p=0.43). Our study did not demonstrate any association between the Cox-1 gene C50T polymorphism and aspirin nonresponsiveness status in stable CAD patients.