Souad Mallek

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.

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.

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.

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.

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.

A huge cardiac hydatid cyst: An unusual cause of chest pain revealing multivisceral hydatidosis in a young woman.

Hydatid disease remains endemic in some parts of the world. Cardiac hydatidosis with multivisceral involvement is uncommon but potentially fatal. We report the case of a 36-year-old Tunisian woman admitted with chest pain and T-wave inversion in the inferior leads on her electrocardiogram. Transthoracic echocardiography revealed a large hydatid cyst in the epicardium throughout the left ventricle. Thoraco-abdominal computerized tomography (CT) scan showed several hydatid cysts in the left lung, the liver, and in both breasts. After one week of albendazole treatment, surgical excision of the cardiac cyst on cardiopulmonary bypass was carried out as well as excision of the pulmonary and breast cysts. The postoperative course was uneventful and albendazole treatment was continued for six months. Though hydatid cardiac involvement is very rare, it should be considered in the differential diagnosis of atypical chest pain in young patients, especially those living in regions where hydatid disease is endemic.

Left-sided congenital heart lesions in mosaic Turner syndrome

In the era of the diseasomes and interactome networks, linking genetics with phenotypic traits in Turner syndrome should be studied thoroughly. As a part of this stratagem, mosaicism of both X and Y chromosome which is a common finding in TS and an evaluation of congenital heart diseases in the different situations of mosaic TS types, can be helpful in the identification of disturbed sex chromosomes, genes and signaling pathway actors. Here we report the case of a mosaic TS associated to four left-sided CHD, including BAV, COA, aortic aneurysms and dissections at an early age. The mosaicism included two cell lines, well-defined at the cytogenetic and molecular levels: a cell line which is monosomic for Xp and Xq genes (45,X) and another which is trisomic for pseudoautosomal genes that are present on the X and Y chromosomes and escape X inactivation: 45,X[8]/46,X,idic(Y)(pter→q11.2::q11.2→pter)[42]. This case generates two hypotheses about the contribution of genes linked to the sex chromosomes and the signaling pathways involving these genes, in left-sided heart diseases. The first hypothesis suggests the interaction between X chromosome and autosomal genes or loci of aortic development, possibly dose-dependent, and which could be in the framework of TGF-β-SMAD signaling pathways. The second implies that left-sided congenital heart lesions involve sex chromosomes loci. The reduced dosage of X chromosome gene(s), escaping X inactivation during development, contributes to this type of CHD. Regarding our case, these X chromosome genes may have homologues at the Y chromosome, but the process of inactivation of the centromeres of the isodicentric Y spreads to the concerned Y chromosome genes. Therefore, this case emerges as an invitation to consider the mosaics of Turner syndrome and to study their phenotypes in correlation with their genotypes to discover the underlying developmental and genetic mechanisms, especially the ones related to sex chromosomes.

A continuous murmur following a nonpenetrating chest trauma

We reported a rare case of non-penetrating chest trauma-induced fistula from the right sinus of Valsalva to the right heart chambers. The ruptured sinus of Valsalva aneurysm was diagnosed preoperatively and operated on successfully. The rarity of this case highlights the need for a precise preoperative diagnosis, the role of transthoracic echocardiography, and the importance of a prompt surgical management.

147: Infective endocarditis in Tunisia: A changing profile?

Background Since the first description of infective endocarditis (IE), the profile of the disease has evolved continuously with stable incidence. Objective To update information gained on the epidemiology profile of IE in a Tunisian high-volume tertiary care center Patients and methods This was a descriptive retrospective study of patients treated for IE from January 2001 to December 2010. The patients were divided in two groups according to the date of diagnosis of IE: group 1 (from January 2001 to June 2006) and group 2 (from June 2006 to December 2011). These groups were compared for epidemiologic factors and microbiological differences. Results A total of 297 patients admitted during the study period met the modified Duke criteria for IE. The comparison of demographic and microbiological characteristics of IE cases over time between the results of the two groups showed that the annual incidence of IE was stable. The sex incidence rates of IE, in particular, incidence among men was relatively stable across the study period and ranged from 60% in 2001-2006 to 58% in 2006-2010, also there was no significant increase in incidence among women (P=ns). Among incident cases, there was a significant increasing age on presentation, with median age increasing from 39.5 years in 2001-2006 to 51.5 years in 2006-2010 (P=0.05). There were no statistically significant decreases in the proportions of cases affecting the aortic valve (P=0.4) and in IE due to oral streptococci (P= ns) over time. Also there was no significant increase in the incidence of Staphylococcus IE. However, the incidence of IE with negative blood culture has remained stable and continues to be high, nearing 50%. The rate of rheumatic heart disease as an underlying heart disease was stable over time. However, the standardized incidence of IE has increased in patients with prosthetic valves (P= ns). Overall in-hospital mortality rate decreased from ((18.6% in 2001-2006 vs 14.6% in 2006-2010. Conclusion This study has shown that the annual incidence of IE is stable in Tunisia. However, profound changes in the epidemiological profile of this disease have not been noted in our population.

035 Analysis of long-term survival after revascularization in patients with chronic kidney disease presenting with ST elevation myocardial infarction

Ischemic heart disease is the most common cause of death in patients with chronic kidney disease (CKD). Patients with CKD who develop an ST elevation myocardial infarction (STEMI) have a poor prognosis, with >70% mortality at 2 years. Despite this heavy burden of disease, the optimal management of ACS in this patient population is unknown. Our goal was to compare the effect of coronary revascularization or medical therapy alone on the long-term survival of patients with CKD presenting with STEMI. From 2005 to 2007, data were prospectively collected on 231 patients admitted to a coronary care unit with the diagnosis of STEMI. Of these, 112 had preserved renal function, and 119 had significant renal dysfunction, as defined by the National Kidney Foundation in the Kidney Disease Outcomes Quality Initiative classification of kidney function as an estimated glomerular filtration rate of Long-term survival was assessed and outcomes were compared according to whether patients were treated with medical therapy alone or if they underwent a percutaneous or surgical revascularization procedure. Follow-up information was available in 68 patients up to 1 year after the index hospitalization. Of the 119 patients with significant renal dysfunction, ten underwent coronary artery bypass surgery, 77 under went percutaneous coronary revascularization, eight underwent a diagnostic cardiac catheterization and were subsequently treated medically. Percutaneous coronary revascularization was associated with superior long-term survival. Surgical revascularization was an independent predictor of MACCE at one tear after index hospitalization ((p = 0.03, HR = 2.760; 95% CI 1.101–6.920). In conclusion, patients with severe CKD and STEMI had improved long-term survival when treated with percutaneous coronary revascularization.