Majed Hassine

Drug-Eluting vs. Bare-Metal Stents: Is it a Matter of Vessel Size?

Background: Although drug-eluting stents (DES) for percutaneous coronary intervention have dramatically reduced the incidence of in-stent restenosis, their deployment for large-size coronary lesions is still controversial because of problems such as prolonged dual antiplatelet therapy, late in-stent thrombosis and costs. Aim: This study sought to evaluate the safety and effectiveness of drug-eluting stents (DES) compared to baremetal stents (BMS) for patients with large coronary vessels ≥ 3.5 mm. Methods: This is a retrospective case-control comparative study conducted in the cardiology A department of the university hospital Fattouma Bourguiba in Monastir. A total of 77 consecutive patients (80 lesions) who underwent, between October 2003 and March 2014, successfully DES implantation were compared to 73 consecutive patients (84 lesions) who were treated with BMS in large coronary vessels ≥ 3.5 mm. Results: The average age in our population was 59.7 ± 11.3 years with a male majority without any significant difference between the two groups. The DES group contained significantly more patients with diabetes (67.5% vs. 38.1%; p<0.0001) and a history of coronary heart disease (40% vs. 16.7%; p=0.001). The BMS group had significantly more procedures in the aftermath of MI (18.8% vs. 40.5%; p=0.002) including more primary angioplasty (6.7% against 47.1%; p=0.006). About two-thirds of the study patients had multi-vessel disease with equal distribution in both groups. The average duration of dual antiplatelet therapy was significantly prolonged in the DES group: 13.01 ± 8.31 months vs. 7.59 ± 8.19 months; p<0.0001. A mean follow of 27.87 ± 14.82 months was obtained. At 12 months, DES led to a significant reduction in the combined rate of major cardiac events by about 70% (OR=0.32; 95% CI: 0.119 to 0.858; p=0.019) without allowing a significant reduction in the rates of in-stent restenosis, in-stent thrombosis, target vessel revascularization or non-combined major cardiac events. During longterm follow-up, the benefit of DES in terms of MACE was maintained by allowing a 60% reduction in the combined rate of major cardiac events (OR=0.406; 95% CI: 0.172 to 0.955; p=0.035). Multivariate analysis identified the BMS as an independent predictor of major cardiac events and death. However, the type of stent does not appear as a factor influencing the ISR and target lesion revascularization rates. Conclusion: The results of our study demonstrate a clear clinical benefit of drug-eluting stents during angioplasty of large coronary arteries in reducing major cardiac events and death without having any effect on in-stent restenosis, in-stent thrombosis nor target lesion revascularization.

0521: Infective endocarditis complicated by heart failure: characteristics and prognosis

Introduction Despite progress in the field of antibiotic prophylaxis, infective endocarditis (IE) remains a common and serious disease. Heart failure (HF) represents the most common cause of death in this pathology. Objective We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by HF and to evaluate the impact of early surgery on 1 year outcome. Patients and methods It is about a single-center observational study that included 241 patients admitted for definite left-sided native valve IE according to the Duke criteria. We are interested in the subgroup of 85 patients with heart failure. Results The average age of our patients was 42±18 years. When compared with patients without CHF (n = 156), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in HF patients. Aortic valve IE, elderly patients were more frequent in HF patients. Congestive HF was independently predictive of in-hospital mortality [OR=3.1, IC 95% (1.9-8.2); p = 0.007]. Early surgery was performed in 51% of HF patients with a peri-operative mortality of 19%. In the HF group, anemia [OR=4, IC 95% (0.9-17); p = 0.05), uncontrolled infection [OR=4, IC 95% (0.9-16.2);p= 0.05), and major neurological events (OR=9, IC 95% (1.4-21.6); p= 0.019) were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR=0.41 (0.17-0.73); p = 0.02]. Conclusion Native valve IE complicated by HF is more frequent in aortic IE and is associated with severe regurgitation. Congestive HF is an independent predictor of in-hospital and 1 year mortality. In HF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

0277: Risk assessment for the management of STEMI: which score fits best for the Tunisian context?

Background Risk assessment after ACS is essential. Risk scores have been mainly used in Non-STEMI patients; nevertheless, patients with STEMI should also be screened according to their risk. Scores have been validated in European and American populations but have not been tested in African populations. Purpose to compare the short term prognosis according to the GRACE and TIMI scores for STEMI Methods GRACE and TIMI scores for STEMI were calculated for patients who were admitted for STEMI between January 2000 and June 2012. All variables included in each score were tested by univariate analysis then included in multivariate model. ROC curve was assessed for each score. Results 1162 patients were included in our analysis. 132 deaths occurred during the study period. All variables included in both scores were tested by univariate analysis and were significantly correlated to intra-hospital mortality except time delay to reperfusion >4hours (p=0.38). By multivariate analysis, the model provided 88.6% power to predict mortality and explained 35.1% of the outcome. Mean GRACE and TIMI scores were significantly higher in the mortality Group (respectively: 198 vs 149 and 7.46 vs 5.88; p Conclusion In the North African context, GRACE score seems to be more powerful in predicting intra-hospital mortality after STEMI and therefore it should be calculated in every patient.

0279: Wilkins score for severe mitral stenosis: what is beyond the procedural considerations?

Background Percutaneous transvenous mitral balloon valvotomy (PTMV) optimal results are usually achieved when echocardiographic Wilkins score (WS) is ≤8. WS from 9 to 11 represent a gray zone in which only some patients have good results. Aim The aim of this study was to determine the early and long term results of this procedure in patients with WS 8 or less and at the gray WS zone. Methods Retrospective review of clinical records of patients with rheumatic MS submitted to PTMV from January 1990 to December 2010. Follow-up was obtained by clinical records when available. Procedure was considered unsuccessful when post-procedure MV area (MVA) was Results We analyzed data for 378 patients with a WS ≤11, 80.5% were women. Mean age at the time of repair was 33 years [10 to 76 years] and the mean follow up time was 74 months. Before the procedure, 33.9% had a WS in the gray zone. They were older (36 years vs. 31 years, p PTMV was safe in the two groups with same rates of success but a lower mitral surface gain in the gray zone group (0.88cm2 vs. 1.05cm2, p During follow up, patients in the gray zone had significantly lower event free survival (freedom from death, systemic embolism and restenosis) (58.6% vs. 69.2%, p Conclusion PTMV was a safe procedure in both WS groups. Optimal results patients with a WS≤8 zone. Patients with a WS 9-11 experienced worse outcomes during follow up.

0276: Balloon mitral valvotomy for patients with mitral stenosis in atrial fibrillation: immediate and long term prognosis

Background Atrial fibrillation (AF) is a common finding in patients with severe mitral stenosis requiring Balloon Mitral Valvotomy (BMV). Its immediate and long term prognosis remains controversial. Objectives We sought to evaluate the effect of AF on the immediate and long-term (23 years) outcome of patients undergoing BMV. Methods The immediate procedural and the long-term clinical outcome after BMV of 139 patients with AF were collected and compared with those of 381 patients in normal sinus rhythm (NSR). Results Patients with AF were older (43.3 vs. 29.7 years; p 0.001) and of mitral commissurotomy (28.1% vs. 19.4%, p=0.035). Patients with AF had more frequently a Wilkins score > 8 (51.4% vs. 30.9%, p BMV was equally successful in the two groups (90.6% vs. 94%, p=0.187) but resulted in a smaller post BMV area (2cm2 vs. 2.15cm2, p=0.012) with a lower mitral valve area gain (0.9cm2 vs. 1 C, p=0.015). BMV was not associated with a higher risk of complications (4.3% vs. 4.7%, p= 0.844). After a mean follow-up of 74 months, patients with AF had the same rate of restenosis (28.3% vs. 25.6%, p=0.96) but required more frequently a mitral valve replacement (16.3% vs. 7.7%, p= 0.012). They also experienced higher rates of systemic embolism (3.8% vs. 0.6%, p=0.018) and had a lower rate of event free survival (52.2% vs 68.8%, p= 0.047). In the group of patients in AF, predictive factors for combined adverse events including death, restenosis, and systemic embolism. Predictive factors of mitral valve replacement are: post BMV area Conclusion Our data support the fact that patients with AF have worse immediate and long term outcomes after BMV. Post BMV area

0409: Selection and timing for invasive therapy in non ST segment elevation acute coronary syndrome: Impact in the real world

Introduction The optimal timing of coronary intervention in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) is a matter of debate. Purpose We proposed through this work to study the optimal time to coronary angiography in patients admitted for acute coronary syndrome without ST-segment elevation in the Tunisian context and its prognostic impact on inhospital mortality. Materials and methods It is about an observational study from MIRACOS registry that included 407 patients admitted for NSTE-ACS. We were interested to find general characteristics, the time to coronary angiography, mortality and in-hospital complications. Results A total of 407 patients were included in our study. Nearly half of our patients (49.5%) were considered at high cardiovascular risk. The average to coronary angiography was 5.09 days. Patients who underwent early coronary angiography were significantly younger (p=0.01), had a lower incidence of diabetes (p=0.01), left heart failure (p=0.0001) and electrical changes suggestive of ischemia (p=0.009). Patients who have undergone an invasive strategy had significantly lower levels of creatinine (p Conclusion Despite the fact that our work has showed that invasive strategy is associated with a better prognosis in ACS ST (-) patients, the use of this strategy remains insufficient.