National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study

BACKGROUND

In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics.

OBJECTIVE

The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention.

METHODS

The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite).

RESULTS

The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation.

CONCLUSIONS

This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/47525.

Design and Rationale of the National Observational Multicentric Tunisian Registry of Hypertension: Protocol for Evaluating Hypertensive Patient Care in Clinical Practice

Background

This study was designed to evaluate the care of hypertensive patients in daily clinical practice in public and private centers in all Tunisian regions.

Objective

This study will provide us an overview of hypertension (HTN) management in Tunisia and the degree of adherence of practitioners to international recommendations.

Methods

This is a national observational cross-sectional multicenter study that will include patients older than 18 years with HTN for a duration of 4 weeks, managed in the public sector from primary and secondary care centers as well as patients managed in the private sector. Every participating patient signed a consent form. The study will exclude patients undergoing dialysis. The parameters that will be evaluated are demographic and anthropometric data, lifestyle habits, blood pressure levels, lipid profiles, treatment, and adherence to treatment. The data are collected via the web interface in the Dacima Clinical Suite.

Results

The study began on April 15, 2019 and ended on May 15, 2019. During this period, we included 25,890 patients with HTN. Data collection involved 321 investigators from 24 Tunisian districts. The investigators were doctors working in the private and public sectors.

Conclusions

Observational studies are extremely useful in improving the management of HTN in developing countries.

Trial Registration

ClinicalTrials.gov NCT04013503; https://clinicaltrials.gov/ct2/show/NCT04013503

International Registered Report Identifier (IRRID)

DERR1-10.2196/21878

Design and Rationale of the National Tunisian Registry of Percutaneous Coronary Intervention: Protocol for a Prospective Multicenter Observational Study

Background

Coronary artery diseases remain the leading cause of death in the world. The management of this condition has improved remarkably in the recent years owing to the development of new technical tools and multicentric registries.

Objective

The aim of this study is to investigate the in-hospital and 1-year clinical outcomes of patients treated with percutaneous coronary intervention (PCI) in Tunisia.

Methods

We will conduct a prospective multicentric observational study with patients older than 18 years who underwent PCI between January 31, 2020 and June 30, 2020. The primary end point is the occurrence of a major adverse cardiovascular event, defined as cardiovascular death, myocardial infarction, cerebrovascular accident, or target vessel revascularization with either repeat PCI or coronary artery bypass grafting (CABG). The secondary end points are procedural success rate, stent thrombosis, and the rate of redo PCI/CABG for in-stent restenosis.

Results

In this study, the demographic profile and the general risk profile of Tunisian patients who underwent PCI and their end points will be analyzed. The complexity level of the procedures and the left main occlusion, bifurcation occlusion, and chronic total occlusion PCI will be analyzed, and immediate as well as long-term results will be determined. The National Tunisian Registry of PCI (NATURE-PCI) will be the first national multicentric registry of angioplasty in Africa. For this study, the institutional ethical committee approval was obtained (0223/2020). This trial consists of 97 cardiologists and 2498 patients who have undergone PCI with a 1-year follow-up period. Twenty-eight catheterization laboratories from both public (15 laboratories) and private (13 laboratories) sectors will enroll patients after receiving informed consent. Of the 2498 patients, 1897 (75.9%) are managed in the public sector and 601 (24.1%) are managed in the private sector. The COVID-19 pandemic started in Tunisia in March 2020; 719 patients (31.9%) were included before the COVID-19 pandemic and 1779 (60.1%) during the pandemic. The inclusion of patients has been finished, and we expect to publish the results by the end of 2022.

Conclusions

This study would add data and provide a valuable opportunity for real-world clinical epidemiology and practice in the field of interventional cardiology in Tunisia with insights into the uptake of PCI in this limited-income region.

Trial Registration

Clinicaltrials.gov NCT04219761; https://clinicaltrials.gov/ct2/show/NCT04219761

International Registered Report Identifier (IRRID)

RR1-10.2196/24595

Management of patients with cardiovascular diseases during Ramadan

During the month of Ramadan, over one billion Muslims observe a water and food fast from sunrise to sunset. The practice of this religious duty causes marked changes in eating and sleeping habits. With the increasing incidence of cardiovascular (CV) risk factors, the number of patients with CV pathologies who wish to fast is increasing worldwide, and in Tunisia, which is ranked as a high CV risk country. If fasting has been shown to be beneficial for the improvement of some metabolic parameters, its practice in patients with CV pathology remains debated. The Tunisian Society of Cardiology and Cardiovascular Surgery (STCCCV) in consultation with the National Instance of Evaluation and Accreditation in Health (INEAS) has established this document in the form of a consensus after having analysed the literature with the aim of addressing these questions: -What is the impact of fasting in patients with CV pathologies? -How to stratify the risk of fasting according to CV pathology and comorbidities? -How to plan fasting in patients with CV diseases? -What are the hygienic and dietary measures to be recommended during fasting in patients with CV pathologies? -How to manage medication during the month of Ramadan in patients with CV diseases?

Trans-Catheter Closure of Patent Ductus Arteriosus, which device should we use?

Despite the operational experience in the percutaneous closure of Patent ductus arteriosus (PDA), complications can arise during the procedure. To overcome these complications the choice of the device must be adapted to each patient.

AIM

To report the experience of the cardiology department in the transcatheter device closure of PDA and to determine the influencing factors of choice of the device.

METHODS

Our study included patients with patent ductus arteriosus that are admitted for transcatheter closure, between September 2003 and June 2016.

RESULT

One hundred and fifty-three patients were included in our study. Transcatheter closure was not done in 9 cases. The transcatheter closure was successful in 140 patients. The complications were observed in 11 patients that includes device embolization in 3 cases, aortic protrusion in four cases pulmonary protrusion in three cases and inguinal hematoma in one another. Three predictive factors of complications were: age < 2 years, tubular PDA type C and ratio duct diameter/weight > 0.95. A mild residual shunt was observed at the end of the procedure in 22.85 % of the patients. The risk of residual shunt was significantly increased when the age < 2 years, the large PDA, the presence of pulmonary hypertension and the tubular C PDA.

CONCLUSION

The choice of the device depends essentially on age, the weight and the duct anatomy.

Neonatal cardiogenic shock revealing obstructive cardiac Hibernoma: case report

Background

Cardiac Hibernomas are very rare benign tumors and usually remain asymptomatic. Neonatal cardiogenic shock due to cardiac tumors is extremely very rare. Until this date a few cases of cardiac hibernoma have been reported in the literature.

Transthoracic echocardiography help in the differential diagnosis, but the definitive diagnosis is histological. The management strategy is not clearly codified.

The Aim is to report and discuss the clinical features of a cardiac Hibernoma and review the relevant literature.

Case presentation

We describe a case of a 2-day-old Caucasian full-term male neonate admitted in neonate intensive care with cardiogenic shock, having fluid resuscitation and inotropic drugs. Ventilatory support was started immediately with the subsequent reestablishment of normal blood pressure. Then he was transferred to the echocardiography laboratory.

Transthoracic echocardiography showed two echogenic masses in the right atrium and right ventricle.

The masses were extended to the pulmonary trunk. Pulmonary artery flow measurements showed the presence of pulmonary and tricuspid obstruction.

Surgery was rapidly considered since the baby was hemodynamically unstable.

Intraoperative evaluation showed a mass embedded in the interventricular septum that occupy the right ventricular cavity and the right atrium. The tumor involved also the chordae of the tricuspid. Partial resection was done. Tricuspid valve repair was performed by construction of new chordae from the autologous pericardium. The specimen was sent for histopathological analysis. The baby died immediately after surgery.

Histological examination of the surgical specimen revealed clear multivacuolated cells filled with lipid droplets and granular intense eosinophilic cytoplasm which confirms the diagnosis of Hibernoma.

Conclusion

Cardiac Hibernomas are rare benign tumors. The prognosis and treatment strategy is closely dependent on the location, initial clinical presentation and possible complications. The prognosis can be unfavorable if the tumor was obstructive and infiltrate the myocardium.

Conservative Management of Cardiac Hemangioma for 11 Years

Cardiac hemangiomas are benign tumors with an unpredictable natural history. Surgical resection is the treatment of choice; however, conservative management can be an alternative in some patients. We report a case of a left-sided cardiac hemangioma that we managed conservatively for 11 years without obvious major complications in the patient, an adult woman.

Short, midterm and late results of percutaneous coronary interventions for left main coronary artery disease

BACKGROUND

Left main coronary artery disease is found in 4-6% of patients undergoing diagnostic coronary angiography. Coronary artery bypass graft is the gold standard. However, percutaneous coronary intervention is a continuously evolving substitution for surgery in such patients.

METHODS

We report a retrospective study of 32 patients with relevant left main coronary artery disease treated by angioplasty in our faculty, between January 2005 and March 2011.

RESULTS

The mean age of the population on the study was 59.7±10.9 years. The sex-ratio was 3.57. The rate of angiographic success was 97%. The in-hospital stay was uneventful in 94%¨of our patients. Only one patient died of cardiogenic shock complicating an acute anterior myocardial infarction. After a mean follow up of 18.5 ± 15.4 months, the in-stent restenosis rate was 16.12%. The rate of major adverse cardiac events (MACE) was 29%. Independent predictive factors of MACE were: cardiogenic shock on admission (p=0.022), emergency procedures (p=0.033), Euroscore > 6 (p=0.001), Parsonnet score > 20 (p=0.036), High C réactive protein levels on admission (p=0.007),le taux de créatinine (p=0.008), un diamètre de référence du TCCG < 3.5 mm (p =0.036) et l'utilisation de stents  (p=0.036) and the use of bare metal stents (p=0.036). Independent predictive factors of in-stent restenosis were: use of bare metal stents (p=0.004) and Paclitaxel drug eluting stents (p=0.037).

CONCLUSION

Percutaneous coronary intervention is safe and a validated alternative to coronary artery bypass graft for left main coronary artery disease. However, it should be reserved to selected patients and limited to experienced centers.

Anomalous origin of the left coronary artery from the pulmonary artery presenting as dilated cardiomyopathy: a case report

Introduction

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly and one of the causes of myocardial ischemia. The usual clinical course is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life.

Case presentation

We report the case of a 6-month-old Tunisian girl who presented with dilated cardiomyopathy. Echocardiography suspected anomalous origin of the left coronary artery. The definitive diagnosis of anomalous origin of the left coronary artery from the pulmonary artery was reached by multislice computed tomography and coronary angiography.

Conclusion

In cases of dilated cardiomyopathy, anomalous origin of the left coronary artery from the pulmonary artery syndrome has to be kept in mind as a surgically correctable cause.

[Correlation of TIMI risk score with angiographic extent and severity of coronary artery disease in non-ST-elevation acute coronary syndromes]

AIM OF STUDY

To determine whether the TIMI risk score correlates with the angiographic extent and severity of coronary artery disease in patients with non-ST-elevation acute coronary syndrome undergoing cardiac catheterization.

PATIENTS AND METHOD

We conducted a retrospective review of 239 medical records of patients who underwent coronary angiography secondary to non-ST-elevation acute coronary syndrome between 2002 and 2006. Patients were classified into three groups according to TIMI risk score: TIMI scores 0 to 2 (group 1: n=121), 3 to 4 (group 2: n=100), and 5 to 7 (group 3: n=18). We compared the coronary angiography findings of the three groups.

RESULTS

Patients of group 1 had a greater likelihood of normal or non significant CAD than patients of group 2 (36.3 % vs 13 %, P<0.001) and than patients of group 3 (36.3 % vs 0 %, P=0.002). One-vessel disease was found more often in patients with TIMI score 0 to 2 than in patients with TIMI score 5 to 7 (28.9 % vs 0 %; P=0.01), and in patients with TIMI score 3 to 4 than in those with score 5 to 7 (35 % vs 0 %, P=0.006). However, 1-vessel disease was found in patients of group 1 as often as in patients of group 2. The frequency of two-vessel disease was similar whatever the level of TIMI score was low, intermediate or high. Three-vessel or left main disease was more likely found in patients of group 3 than in patients of group 2 (66.7 % vs 26 %; P=0.01), and than patients of group 1 (66.7 % vs 13.2 %; P<0.001). Chronic coronary occlusions and coronary calcifications were also more likely found in patients with TIMI score 5 to 7.

CONCLUSION

In patients with non-ST-elevation acute coronary syndrome undergoing cardiac catheterization, the TIMI risk score correlated with the extent and severity of coronary artery disease.

[Influence of diabetes mellitus on the prognosis of non-ST-elevation acute coronary syndromes]

AIM OF STUDY

Analyze the influence of diabetes mellitus on the prognosis, at short and middle term of patients with non-ST-segment-elevation acute coronary syndrome.

PATIENTS AND METHOD

We conducted a retrospective review of 308 consecutive medical records of patients admitted to the care unit of our department with a non-ST-segment-elevation acute coronary syndrome. One hundred and fifty-six patients were diabetics (group 1) and 152 were not (group 2). We compared the demographic, clinical, angiographic and therapeutic characteristics of the two groups and we analyzed the prognosis of diabetic and non-diabetic patients at short term (30 days) and at middle term (average: 28 months; extreme: 12 months, 72 months).

RESULTS

The mean age was similar into both groups (60.8 years). Diabetic patients were more often women (42.1% vs 23.1%) and presented a higher prevalence of systemic hypertension, dyslipidemia and family history of coronary artery disease. Smoking was more frequent in group 2. The rates of coronary angiography, percutaneous transluminal coronary angioplasty, and coronary bypass surgery were similar in the two groups. At 30 days, diabetic patients were at increased risk for acute heart failure (19.1% vs 6.4%) and for major cardiac events (12.5% vs 6.4%). A pejorative prognosis was also observed at middle term among diabetic patients. They were at greater risk for readmissions for non-ST-segment-elevation acute coronary syndrome (42% vs 25%), for major cardiac events (49.3% vs 31.6%) and for new revascularizations (17.3% vs 7.2%). In a Cox multivariate analysis, diabetes mellitus remains an independent risk factor for major cardiac events at middle term.

CONCLUSION

Our study confirms the pejorative prognosis of acute coronary syndromes without ST elevation at short and middle term in diabetic patients.

[Percutaneous mitral commisurotomy in patients aged 60 years and more]

Of 745 patients treated by balloon mitral commissurotomy (BMC) between February 1988 and December 2002, 45 were > or = 60-years old. Immediate and late outcomes in this group (group 1) were compared with those in the patients aged < 60-years (group 2). Baseline hemodynamic parameters were comparable in the two groups. Mitral surface area and hemodynamic parameters improved significantly after BMC in group 1: mean left atrial pressure fell from 18.76 +/- 6.18 to 10.65 +/- 4.38 mmHg (P < 0.001), mean transmitral gradient from 11.03 +/- 4.70 to 4.63 +/- 2.05 mmHg (p < 0.001) and mitral valve area from 0.99 +/- 0.22 to 1.88 +/- 0.41 cm2 (p < 0.001). Similar significant improvements were seen in group 2. The hemodynamic result was good in 69% of group 1 patients. Tamponade occurred in one patient. Mitral regurgitation grade I or II developed in 8 patients and remained stable in 13 patients. These complication rates were comparable to those seen in group 2. In the group 1, a good result was maintained in 60% of patients after 43 +/- 23 months of follow-up. Although restenosis was observed in 40% of patients, functional amelioration was obtained in most of cases. In the group 2, restenosis was observed in 25% of patients. The data from this study suggest that BMC is effective first therapy in patients aged > or = 60-years with symptomatic mitral stenosis.

[Breast self-examination practice in Tunisia based on a survey of first-line patients]

As the first phase of a breast cancer screening campaign in central Tunisia, a survey aimed at evaluating the frequency of self-examination of the breasts (SEB) and identifying factors which might influence this practice took place in the Kalâa Kbira region of Tunisia, involving 300 first-line out-patients. Women answered a questionnaire presented by a resident in medicine during the course of the visit. The survey showed that the use of SEB remains slight (28%). Discriminant analysis enabled identification of parameters influencing this practice. Thus age of the patient, educational level of the woman and/or spouse and the source of information were the most significant parameters, in increasing order of importance. The results of this survey should enable definition of the content and form of information to be given to women in order to obtain their participation in a breast cancer screening campaign in central Tunisia.