Mourad Hentati

Left main coronary thrombosis: unusual complication after radiofrequency ablation of left accessory atrioventricular pathway

Radiofrequency ablation (RFA) has established itself as a first-line therapy for the curative treatment of many patients with supraventricular or atrioventricular tachycardias and has exhibited a generally low incidence of serious sequelae (N Engl J Med. 1991;324:1612; Lancet. 1991;337:1557). Coronary artery injury is a rare complication. We present a patient with an acute thrombotic total occlusion of the left main coronary artery immediately after the end of RFA who was successfully treated with emergency percutaneous transluminal coronary angioplasty. This case illustrates an unusual coronary complication of RFA and serves as an exceptional example of survival with a good short-term prognosis after this unusual etiology of myocardial infarction.

Prosthetic valve endocarditis: management strategies and prognosis: A ten-year analysis in a tertiary care centre in Tunisia.

Background Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement; its optimal management strategy, though, still needs to be defined.Objective To study the clinical, microbiological and echocardiographic characteristics of PVE and to analyse the influence of the adopted therapeutic strategy (medical or surgical) on short- and midterm outcome in a tertiary care centre in a developing country (Tunisia).Methods All cases of PVE treated in our institution between 1997 and 2006 were retrospectively analysed according to the modified DUKE criteria.Results A total of 48 PVE episodes were diagnosed (30 men and 18 women), mean age was 37.93 years. Twenty-eight patients (58.33%) were exclusively medically treated, whereas 20 (41.66%) were treated by a combined surgical and medical strategy. Indications for surgery were haemodynamic deterioration in eight patients (40%), annular abscess in six (30%) and persisting sepsis in six (30%). In comparison with those from the medical group, operated patients had a longer delay to diagnosis (p=0.025), were more frequently in heart failure (p=0.04) and experienced more early complications (p=0.011); they also more frequently had prosthetic dehiscence (p=0.015), annular abscesses (p=0.039) and vegetations >10 mm (p=0.008). Conversely, no differences were found between the groups in terms of age, sex, or nature of involved organisms. In-hospital mortality for the medical group was 14.28% and for the surgical group 35% (p=0.09).Conclusion PVE is a very serious condition carrying high mortality rates regardless of the adopted strategy. Our study demonstrates that, in selected patients, medical treatment could be a successful and acceptable approach. (Neth Heart J 2009;17: 56-60.)

Total absence of ST-segment resolution after failed thrombolysis is correlated with unfavorable short- and long-term outcomes despite successful rescue angioplasty

INTRODUCTION ST-segment resolution (STR) is a well-established and simple tool for assessing the efficacy of reperfusion therapy in myocardial infarction. An incomplete (<50%) STR is a recognized marker of failed thrombolysis and a suitable recruitment criterion for rescue angioplasty. OBJECTIVE We sought to determine the predictive value of the total absence of STR after thrombolysis in rescue angioplasty (percutaneous coronary intervention [PCI]). METHODS Eighty-one consecutive patients who underwent a rescue angioplasty for failed thrombolysis in our institution from 2001 to 2007 were included. Two groups of patients were defined according to their STR extent, 90 minutes after lysis: partial resolution group 1 (10%-50% STR) vs absence of resolution group 2 (<10% STR) and compared in terms of in-hospital and long-term outcomes. RESULTS Patients of group 2 were more likely to experience hemodynamic deterioration (50% vs 24%; odds ratio [OR] = 3.17; P = .017), to have a Thrombolysis in Myocardial Infarction 0 flow on the culprit artery (62.3% vs 42%; OR = 2.24; P = .045), to have a multivessel disease (66.7% vs 40%; OR = 3; P = .018), and to die during index hospitalization (26.7% vs 6%; OR = 5.69; P = .013) despite statistically similar rates of PCI failure in both groups (10% vs 7%; P = .402) and similar post-PCI STR (72% +/- 18.25% vs 75% +/- 11.62%; P = .36). In multivariate analysis, total absence of STR proved to be an independent predictor of in-hospital mortality (HR = 7.02; P = .032; 95% confidence interval, 1.18-41.58). Long-term major adverse cardiac events occurred more frequently in group 2 (log rank, P = .004) and were (on the Cox regression model) independently predicted by total absence of STR (HR = 6.21; P = .023; 95% confidence interval, 1.28-29.1). CONCLUSIONS The STR assessment before rescue PCI proved to be a good and simple means to predict the short- and long-term prognosis in these patients.

Unusual cause of syncope in a 17 year-old young woman: Left ventricular hydatid cyst

Cardiac involvement in echinococcosis remains a singular finding, possibly associated with confusing symptomatology. We report the original case of a 17 year-old young woman, referred to our cardiology department for repeated exertion syncopes, and ultimately, proven through echocardiography, serologies and magnetic resonance imaging to have a massive hydatid cyst developing inside the left ventricular cavity towards the outflow tract. The cyst has been surgically completely removed with excellent results.

Short- and long-term outcomes of surgery for active infective endocarditis: a Tunisian experience

From January 1997 to December 2006, all patients with a Duke criteria-based definite diagnosis of infective endocarditis (IE) operated on during the active phase in a Tunisian high volume tertiary-care centre were included. Among the 186 patients with IE identified during the study period, 88 (48.35%) required surgery in the active phase. Mean age was 34.9 years, 54 (61.4%) were men. The infected valve was native in 70 cases (79.5%) and prosthetic in 18 (20.5%). Streptococcus sp. were the most common causative microorganisms. The most frequent indication for operation was congestive heart failure. There were 24 in-hospital deaths (27.27% early mortality). By multivariate analysis, severe congestive heart failure (HR=13.82, 95% CI [3.38-38.15], P<0.001) and large >15 mm vegetations (HR=6.02, 95% CI [1.48-18.52], P=0.03) were predictive of in-hospital mortality. Survivors were followed-up from 3 to 120 months, mean of 28.6. Actuarial 5- and 10-year survivals free from the combined endpoint of recurrent IE, cardiovascular death and late surgery in survivors were 69+/-5% and 63+/-7%, respectively. In conclusion, despite medical progress, surgery for endocarditis in Tunisia remains challenging and yields high mortality rates. Severe heart failure is the most powerful predictor of mortality. Long-term outcome is, however, satisfactory.

A Neovascularized Left Atrial Mass

Background. The discovery of a large left atrial mass through echocardiography obliges the clinician to perform a differential diagnosis to distinguish tumor from thrombus. The neovascularization of the mass could be helpful to predict the type of the malformation and whether it is in favour of a vacular tumour rather than a thrombus . Observation. A 43-years-old man who had no cardiac antecedent reported that he have had dyspnea and palpitation since 10 months. The cardiac auscultation, revealed an irregular rhythm with diastolic murmur at the apex. The electrocardiogram showed an atrial fibrillation. The transthoracic echocardiography revealed a severe mitral stenosis with a huge left atrial mass, confirmed through transesophageal echocardiography. After 4 weeks of an efficient anticoagulant treatment, the mass was still persistent in the echocardiography. So we decided to resect the mass and to achieve a mitral valve replacement. The preoperative coronarography showed neovascularization among the mass and fistula from the circumflex artery. Considering the characteristic of the mass (neovascularization and resistance to anticoagulant), we strongly suspected a vascular tumor especially myxoma, but the histological exam revealed an organized thrombus. Conclusion. Coronary neovascularization is a specific sign for left atrial thrombus in mitral stenosis, but surgery is the best way to confirm diagnosis.

Rapid Occurrence of Giant Left Ventricular Pseudoaneurysm after Mitral Valve Replacement

Left ventricular pseudoaneurysms are an uncommon and frightening complication after mitral valve replacement. We report the case of a 54‐year old woman, having undergone a mitral valve replacement with uneventful postoperative course and normal echocardiographic predischarge control, who was readmitted to hospital, only 16 days later, for rapidly progressing dyspnea, and finally echocardiographically diagnosed to have a massive 8‐cm long pseudoaneurysm communicating with the left ventricle through a narrow communication. The patient was proposed for emergency surgery but unfortunately died preoperatively.

Potential danger of ocular compression in paroxysmal supraventricular tachycardia in patients with latent preexcitation

The vagal maneuver is the first line of therapeutic available for patients with paroxysmal supraventricular tachycardia. It increases vagal tone and includes the traditional ocular compression, carotid sinus massage, and Valsalva maneuver. A 40-year-old man was admitted because of 180 beats/min regular narrow QRS-complex tachycardia. The physician in the emergency department had performed an ocular compression, and at its ending, the tachycardia degenerated into unstable hemodynamically high ventricular rate atrial fibrillation. It was reverted to sinus rhythm by electrical shock. The electrophysiologic study documented a latent posterolateral bypass tract, with an anterograde refractory period of 210 milliseconds, which was successfully ablated.

QT Prolongation Complicated with Torsades de Pointes in Prosthetic Mitral Valve Endocarditis: A Case Report

We present the case of a 49-year-old male patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. He was asymptomatic until the end of January 2012, when he was admitted to our hospital emergency unit because of syncope, fever, and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. All cultures were positive for methicillin-sensitive Staphylococcus aureus. The corrected QT (QTc) interval was markedly prolonged upon admission (QTc 540 ms). He experienced torsades de pointes (TdP) several times and he was recovered after bystander cardiopulmonary resuscitation. The clinical course and the long QTc interval with deep inverted T wave were completely normalized 4 weeks after. He continued on triple antibiotic therapy for 45 days with a good revolution. The clinical features and the possible mechanisms of QT prolongation (inflammation, infection) of this patient are discussed.

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.