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Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS.

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INTRODUCTION: Diabetes Mellitus (DM) is known to be associated with worse outcomes following percutaneous coronary intervention (PCI). AIM: To assess prognostic impact of DM on patients managed by urgent PCI following ST-segment elevation myocardial infarction (STEMI). METHODS: In a retrospective study, STEMI patients admitted to our department from January 2016 to December 2019 and treated with urgent PCI (primary or rescue PCI) were included. They were divided in two groups: Diabetic and non-diabetic patients. They were followed-up for a period of 12 months. Major cardiac adverse event (MACE) was a composite outcome of the following events: myocardial infarction, target vessel revascularization, target lesion revascularization or cardiovascular death. MACEs were collected during follow-up. RESULTS: Our population consisted of 225 patients. DM was observed in 104 STEMI patients (46.2%). Diabetic patients had higher frequency of hypertension (p 1.4mmol/l (p 75 years, hyperglycemia at admission (>10mmol/l), extensive anterior infarction and procedure failure were associated with in-hospital mortality in the non-diabetic group. Factors associated with 12-months mortality and MACEs among diabetic patients were age > 75 years, anemia, CKD and left ventricular systolic dysfunction. CONCLUSIONS: Despite modern era of STEMI treatment, diabetic patients still have a poor prognosis. These results highlight the need for coronary risk factors treatment among these patients.

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Background: Takotsubo syndrome is a transient stunned myocardium that typically involves the apical and mid-ventricular segments. A variant, called Inverted Takotsubo, concerns the basal and mid-ventricular segments. Case summary: We present a ruptured ectopic pregnancy that was responsible for a catecholamine surge, which led to this stress-induced cardiomyopathy. Transthoracic echocardiography showed mid-basal segments akinesia and hypercontractility of the apical segments. Biology has shown mild elevated troponin and NT-pro-BNP levels which led to performing a coronary angiography that showed no angiographic stenosis. A left ventricle angiography evoked the diagnosis of inverted Takotsubo. The patient has received Levosimendan to allow progressive weaning of catecholamine inotropes. The clinical evolution was favorable. Echocardiography performed after 3 weeks, showed ad-integrum restitution of the left ventricular function. Discussion: Takotsubo syndrome should be evoked whenever a context of physical or psychological stress is present. We underline the usefulness of Levosimendan as a nonadrenergic inotrope in this particular context. How to cite this article: Ghariani A, Dhiab L, Ferhi F, Abdessalem MAB, Mahdhaoui A, Jazia KB, et al. Inverted Takotsubo Following a Ruptured Ectopic Pregnancy, Treated with Levosimendan. Indian J Crit Care Med 2022;26(2):228-230.

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BACKGROUND: The incidence of in-stent restenosis (ISR) remains relatively common despite the use of drug-eluting stents. Outcomes and prognostic factors following ISR revascularization are still being investigated. We aimed to describe the outcomes following different ISR treatment strategies in order to identify prognostic factors associated with worse outcomes. RESULTS: In a retrospective cohort study, we included patients who were admitted to our department and treated for ISR, from January 2017 to December 2018. All patients were followed up for a median period of 24 months. Major cardiac adverse event (MACE) was a composite outcome of the following events: myocardial infarction, target vessel revascularization, target lesion revascularization or cardiovascular death. MACEs were collected during follow-up. Our population consisted of 116 patients. Mean age was 60 years old with a sex ratio of 2.8. During follow-up, 44 patients (37.9%) had at least one MACE. Independent factors identified by multivariate logistic regression were ISR of the proximal left anterior descending artery [Odds ratio (OR) = 1.29; 95% confidence interval (95% CI) 1.16-1.81; p = 0.05], diffuse ISR [OR = 2.16; 95% CI 1.1-3.47; p = 0.022], double or triple vessel disease [OR = 2.97; 95% CI 1.2-6.8; p = 0.008], two or more stents per lesion [OR = 1.82; 95% CI 1.14-2.21, p = 0.031] and absence of post-dilatation in the initial angioplasty [OR = 1.32; 95% CI 1-1.35; p = 0.04]. CONCLUSIONS: Our study suggested that ISR is related to poor outcomes. Identifying prognostic factors would play a key role in the refinement of interventional techniques.

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The distal radial approach (DRA) is suggested to have benefits over the conventional radial approach (CRA) in terms of local complications and comfort of both patient and operator. Therefore, we aimed to compare the feasibility and safety of DRA and CRA in a real life population. We conducted a prospective, observational multicentric trial, including all patients undergoing coronary procedures in September 2019. Patients with impalpable proximal or distal radial pulse were excluded. Thus, the choice of the approach is left to the operator discretion. The primary endpoints were cannulation failure and procedure failure. The secondary endpoints were time of puncture, local complications and radial occlusion assessed by Doppler performed one day after the procedure. We enrolled 177 patients divided into two groups: CRA (n = 95) and DRA (n = 82). Percutaneous intervention was achieved in 37% in CRA group and 34% in DRA group (p = 0.7). Cannulation time was not significantly different between the two sets (p = 0.16). Cannulation failure was significantly higher in DRA group (4.8% vs 2%, p < 0.0008). Successful catheterization was achieved in 98% for the CRA group and in 88% for the DRA group (p = 0.008). Radial artery occlusion, detected by ultrasonography, was found in 3 patients in the CRA group (3.1%) and nobody in the DRA group (p = 0.25). The median diameter of the radial artery diameter was higher in the DRA than the CRA group (2.2 mm vs 2.1 mm; p = 0.007). The distal radial approach is feasible and safe for coronary angiography and interventions, but needs a learning curve.

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BACKGROUND: Atrial fibrillation is the most common heart rhythm disorder in the general population. It is associated with increased cardiovascular morbidity and mortality. Given this risk, anticoagulant therapy is vital. AIM: To estimate the incidence of thromboembolic and hemorrhagic events in patients with Atrial fibrillation and treated by oral anticoagulant in a cardiology department. METHODS: We carried out an observational longitudinal study over a period of three years (January 2013 - December 2015) in the external consultation of cardiology of Farhat Hached hospital of Sousse. Pre-established individual records were used as a source and tool for data collection. RESULTS: Overall, 200 patients were eligible. Forty-nine percent had valvular atrial fibrillation. After an average follow-up of 2.6 years, 15 thromboembolic events were noted affecting 13 patients (6.5%), with an incidence of 2.8%. We found a significant association between TTR <50% and the occurrence of stroke and transient ischemic events. Half of the patients had minor bleeding and 9.5% had major bleeding, with an incidence of 3.6%. No significant correlation between these accidents and the TTR was found. In addition, 9.5% of patients were hospitalized for international normalized ratio equilibration. They were mainly patients with valvular atrial fibrillation (72%) (p = 0.002). CONCLUSION: Anticoagulant therapy with anti-vitamin-K remains the most adequate treatment. Thus, a well-conducted treatment ensures a reduction in thromboembolic risk and minimizes the occurrence of hemorrhages inherent to this therapy. Therefore, an assessment of the quality of anticoagulation is essential.

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INTRODUCTION: Sudden death that occurs during sporting activity affects patients with ignored heart disease. Black athlete's ECG has been little studied and the features of this ethnic group have been discussed. This study aims to study the epidemiological profile and the peculiarities of repolarization of black athletes. METHODS: We conducted a descriptive study of black athletes selected among all the athletes followed in the sectoral Center of Sports Science and Medicine in Sousse over a period of 8 months from March to October 2014. Data were collected using a medical questionnaire. RESULTS: Data on 35 athletes were collected, with a male predominance (94,28%), with an average age of 24,34 years. Four athletes had left ventricular hypertrophy on cardiac ultrasound. There were 8 athletes with atrioventricular block degree I and 8 athletes with electrical type of left ventricular hypertrophy (LVH). ST segment changes were more marked at the level of precordial leads. Five athletes (14.2%) had inverted T waves in V2 and V3. These were the same athletes who ST-segment depression in these same leads. Early repolarization was found in 3 athletes. All these cases had notch signaling. CONCLUSION: Black athletes have quite specific electrical modifications which are important to know. However, our sample is not sufficiently large to certify these results. A comparative study of white athletes would be very interesting.

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BACKGROUND: Atrial fibrillation (AF) is an important health problem in Tunisia. A significant change in the epidemiological pattern of heart disease has been seen in the last 3 decades; however, no large prospective multicenter trial reflecting national data has been published so far. Robust data on the contemporary epidemiological profile and management of AF patients in Tunisia are limited. OBJECTIVE: The aim of this study is to analyze, follow, and evaluate patients with AF in a large multicenter nationwide trial. METHODS: A total of 1800 consecutive patients with AF by electrocardiogram, reflecting all populations of all geographical regions of Tunisia, will be included in the study, with the objective of describing the epidemiological pattern of AF. Patients will be officially enrolled in the National Tunisian Registry of Atrial Fibrillation (NATURE-AF) only if an electrocardiogram diagnosis (12-lead, 24-hour Holter, or other electrocardiographic documentation) confirming AF is made. The qualifying episode of AF should have occurred within the last year, and patients do not need to be in AF at the time of enrollment. Patients will be followed for 1 year. Incidence of stroke or transient ischemic attack, thromboembolic events, and cardiovascular death will be recorded as the primary end point, and hemorrhagic accidents, measurement of international normalized ratio, and time in therapeutic range will be recorded as secondary end points. RESULTS: Results will be available at the end of the study; the demographic profile and general risk profile of Tunisian AF patients, frequency of anticoagulation, frequency of effective treatment, and risks of thromboembolism and bleeding will be evaluated according to the current guidelines. Major adverse events will be determined. NATURE-AF will be the largest registry for North African AF patients. CONCLUSIONS: This study would add data and provide a valuable opportunity for real-world clinical epidemiology in North African AF patients with insights into the uptake of contemporary AF management in this developing region. TRIAL REGISTRATION: ClinicalTrials.gov NCT03085576; https://clinicaltrials.gov/ct2/show/NCT03085576 (Archived by WebCite at http://www.webcitation.org/6zN2DN2QX). REGISTERED REPORT IDENTIFIER: RR1-10.2196/8523.

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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.

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BACKGROUND: Acute coronary syndromes (ACS) are complex and polygenic diseases which are a real problem of public health. These syndromes require multidisciplinary studies to understand the pathogenesis mechanisms. Our study aims to evaluate the endothelin-1 (ET-1) serum concentration in Tunisian coronary compared to controls healthy, as well as the study of the impact of an intronic polymorphism A (8002) G of pre-pro-endothelin-1 Gene (inactive precursor of ET-1) on the change in serum endothelin-1 and in the susceptibility to Acute coronary syndrome (SCA). METHODS: Our samples were subdivided into coronary patients (157) and healthy subjects (142). The quantification of the ET-1 concentration was performed by high performance liquid chromatography, the identification of the different genotypes of the polymorphism A(8002)G was made by PCR-RFLP. The association between the ET-1 concentration and identified genotypes was realized by adapted software for descriptive statistics, Statistical Package for the Sociological Sciences (SPSS v 21.0). RESULTS: Our study showed that the concentration of ET-1 was significantly higher in patients compared to controls and that the mutated allele prevails in patients F (G) = 0.78 and there is a minority in controls F (G) = 0.3. Secondly the homozygous genotype GG is associated with higher concentrations of ET-1 in patients and controls, heterozygous genotype AG is associated with intermediaries' values and AA genotype is related to lower values. CONCLUSION: Although the polymorphism studied is an intronic polymorphism, it is involved in the change in serum concentration of ET-1 and is a candidate gene in susceptibility to SCA. Cardiovascular diseases are "polygenic" pathology and do not obey of the law for transmission of Mendel.

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BACKGROUND: The aim of our study was to assess the delay of fibrinolysis in ST elevation myocardial infarction (STEMI) in our region and to identify characteristics associated with prolonged delay. PATIENTS AND METHODS: We analyzed clinical characteristics of a prospective cohort of unselected patients admitted for (STEMI). The study was conducted over three years 2007-2009 and 250 patients were included in a single center without capability of percutaneous coronary intervention. RESULTS: The mean age of our patients was 58±13, 7 years. Ninety percent of our patients consult directly the emergency department and 61, (5%) of them were admitted within first 6 hours of onset of symptoms. Median time to reperfusion was 46 min. Predictor of this long delay to initiate fibrinolysis were inter-department decision OR 6; 95% CI 3,48-10,34, diabetes OR 2,25; 95% CI 1,28-3,96 age >58,4 years OR 1,97; 95% CI 1,19-3,25 and transfer from regional hospital to our center OR 1,78; 95% 1,03-3.07. CONCLUSION: These results suggest that improvement in organization health care system can shorten delay to fibrinolysis in a center without percutaneous coronary intervention capability.

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BACKGROUND: Permanent cardiac pacing remains the only effective treatment for chronic, symptomatic bradycardia. In recent years, the role of implantable pacing devices has expanded substantially. AIM: To compare the situation of patients with critical brady arrhythmias before and after pacing focusing on indication for pacemaker implantation, frequency of re intervention and early and late complications. METHODS: Retrospective study performed over 24 years between 1984 and 2007 at the department of cardiology of Farhat Hached hospital. A total of 234 patients were included, and the database was formed by the patients' files and the protocols of implantation. RESULTS: The mean age of patients was 69.5 years. The most frequently reported signs and symptoms before implantation of pace maker were dizzy spells and syncope respectively in 53% and 29.1% of patients. Among the electrocardiographic alterations leading to an indication of pacemaker implantation, atrio-ventricular blocks were the most numerous at 74.4% followed by sinus node disease at 17.1%. Early complications were represented essentially by haematoma and infection of the pocket of pacemaker respectively at 2.9% for each one. After a mean follow up of 6.8 years, 88 patients (45.3%) still free of symptoms. Late complications include lead dislodgement and pacemaker syndrome at 2% for each one. CONCLUSION: The results of our study demonstrates that even the rate of complications following pacemaker implantation is not high, the follow-up of patients should be fast, complete, safe, and clear, and should include sufficient documentation.

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Acute myocardial infarction (AMI) in persons under the age of 45 years is uncommon. To determine the clinical features in young patients presenting with AMI, we include 38 patients with mean age 35 years who survive from myocardial infarction. This disease is almost associated with cardiovascular risk factors, the most common of which are tobacco abuse (90%) and diabetes (20%). The coronary arteries are most often normal (40%) or single vessel (33%). In hospital complications are the same as in the older adult but the prognosis seems to be better.

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Between March 1979 and December 1998, 38 patients with isolated chronic aortic insufficiency underwent aortic valve replacement. The aim of this study is to determine whether preoperative echocardiography parameters are useful in predicting operative results in patients with aortic valve replacement for chronic aortic insufficiency. The global survival is 92% in one year and 89% in ten years. We conclude that on end systolic left ventricle diameter < 55 mm has good prognosis (p = 0.019) and there is a strong correlation between preoperative end systolic and post operative end systolic diameter an end diastolic left ventricular diameter > 70 mm and a left ventricular fractional shortening < 25% weren't predictive of a poor prognosis.

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UNLABELLED: Cardiac angiosarcoma represents a primary cardiac malignancy tumor whose early diagnosis is difficult because of its non specific clinical presentation. We present the case of a 57 years old patient with medium abundance hemoptysis. The chest X ray film and CT scan showed bilateral pulmonary infiltrate without cardiac anomaly. Abdominal echography showed disseminated hepatic tumoral lesions. A transthoracic echocardiography made after apparition of heart failure symptoms found a right atrium cardiac tumor. The hepatic lesion biopsy showed angiosarcoma. CONCLUSION: In presence of uncommon systemic symptoms like diffuse pulmonary lesions associated with cardiac anomaly, the diagnosis of angiosarcoma should be included.

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We report the case of a 56-year-old woman with a history of rheumatic heart disease. The clinical, electrocardiographic, and radiologic findings suggested mitral stenosis. Left atrial obstructive myxoma simulating a thrombus was found by transthoracic echocardiography (TTE). The diagnosis was established by use of transesophageal echocardiography (TEE), confirmed after surgery and by anatomical investigation. Cardiac myxoma associated with mitral stenosis may be difficult to diagnose accurately using TTE. The advantage of TEE in this case and in patients with mitral stenosis is emphasized.

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The purpose of this study was to demonstrate the utility and feasibility of transesophageal echocardiography during percutaneous balloon mitral valvuloplasty (PBMV). 40 patients were included with symptomatic rheumatic mitral valve stenosis with mean age of 31 years. Transoesophageal echocardiographic monitoring allowed an immediate detection of mitral insufficiency in 10 patients. This latter was moderate in eight cases and severe in two cases indicating to stop the procedure. The addition of on-line TEE during PBMV facilitate and confirm the success of the procedure and detect complications.

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Seven children with suspected Kawasaki disease were studied by echocardiogram. Coronary abnormalities occurred in all patients, associated with: thrombosis (2 patients) small pericardial effusion (2 patients) poor ventricular function (2 patients), moderate mitral regurgitation (2 patients). Patients received treatment with intravenous gamma globulin, aspirin, and anticoagulant. Echocardiogram abnormalities disappeared between 1 and 26 months after the onset of the disease; only persist coronary hyperechogenecity in 6 patients.

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