Background— A proarrhythmic consequence of pulmonary vein (PV) isolation can be a recurrent organized left atrial (LA) tachycardia after ablation. This arrhythmia is frequently referred to as “left atrial flutter,” but the mechanism and best ablation strategy have not been determined. Methods and Results— Isolation of arrhythmogenic PVs was initially performed by segmental ostial PV ablation guided by a circular mapping catheter in 341 patients. Patients whose predominant recurrent arrhythmia was a persistent organized tachycardia returned for mapping and ablation. Recurrent organized LA tachycardias (cycle length 253±33 ms, range 213 to 328 ms) occurred in 10 (2.9%) of 341 patients (age 59±9 years, 1 woman). Mapping was consistent with a focal origin in 8 patients and with macroreentry in 1 patient and was unclear in 1 patient owing to degeneration to atrial fibrillation. Focal tachycardias originated from reconnected segments of prior isolated PVs (6 patients), the posterior LA (1 patient), or the super...

Mechanisms of Organized Left Atrial Tachycardias Occurring After Pulmonary Vein Isolation

Expert consensus guidelines: Anomalous aortic origin of a coronary artery.

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has received much attention due to its association with sudden death in otherwise healthy individuals. AAOCA is relatively common and may have significant public health implications. While our knowledge of its pathophysiology and natural history remains incomplete, an emphasis has been placed on surgical correction. In 2005 we published a review examining the rates of sudden death with AAOCA, as well as complications of surgical management. Evidence now points even more strongly to lower rates of sudden death, while surgical outcomes data now better documents associated risks. Armed with this updated information, we agree with the need for a national registry to better track patients with AAOCA. We submit that the risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery.

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Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk.

Anomalous origination of a coronary artery from the opposite sinus is a congenital heart defect with an uncertain prevalence and prognosis. The authors review the current understanding of the pathophysiology of the condition, the imaging modalities available to diagnose and functionally assess patients, and the medical, interventional, and surgical treatment options. Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2–2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.

Anomalous origination of a coronary artery from the opposite sinus

Tunisia is one of the North African countries, geographically situated in a central position at the crossroad between Africa and Europe. The demographic features of the Tunisian population include among others high rates of consanguinity. We report, here on the spectrum of genetic diseases in Tunisia. The review of the literature, including other available information (gray literature) showed that there are at least 346 genetic disorders for which cases have been identified in the Tunisian population. Among these, 62.9% are autosomal recessive, 23% autosomal dominant, 5.4% X-linked, and the remaining are of Y-linked, mitochondrial, and unknown mode of transmission. Fifty percent of the reported conditions in this study are caused by at least one mutation. For autosomal recessive diseases, most of the mutations were identified at homozygous state among the affected individuals. Part of the mutations was the result of a founder effect; these are the consequences of the high rate of consanguinity. The congenital malformations, diseases of the nervous system and metabolic disorders are the major groups of genetic diseases affecting the Tunisian population. The large spectrum of diseases and their relatively high frequency could be explained by the high degree of inbreeding and the presence of multiple mutations, either allelic or in different genes. This is due to the richness of the genetic background of the studied population. A multidisciplinary approach is essential to develop adequate preventive programmes adapted to the social, cultural, and economic context. © 2010 Wiley-Liss, Inc.

Genetic diseases in the Tunisian population.

Congenital anomalous aortic origins of the coronary arteries in adults: A Tunisian coronary arteriography study

Takayasu arteritis is an inflammatory condition that involves the large cardiac vessels, predominantly the aorta and its main branches. It typically affects young women (age, ≤40 yr), most often Asians and Latin Americans. Herein, we describe a rare manifestation of Takayasu arteritis in a 19-year-old black Tunisian man who presented with acute inferior myocardial infarction and complete atrioventricular block after occlusion from a giant aneurysm in the right coronary artery. The coronary artery disease was associated with aneurysmal dilations in the carotid, vertebral, and right renal arteries. Medical therapy improved Thrombolysis in Myocardial Infarction flow in the area of the giant aneurysm from grade 1 to grade 3. Upon the diagnosis of Takayasu arteritis, intravenous methylprednisolone and oral prednisone therapy was started. After 10 days of hospitalization, the patient was discharged on a medical regimen. Renovascular hypertension due to renal artery stenosis was suspected, so he underwent successful percutaneous transluminal angioplasty of the inferior segmental artery of the right renal artery. During 12 months of close postprocedural monitoring, he experienced lower blood pressure, no chest pain, and no cardiovascular complications.

This association of conditions has not been previously reported. Besides presenting this very rare combination of findings, we discuss the differential diagnosis of Takayasu arteritis in our patient.

Takayasu Arteritis with Coronary Aneurysms Causing Acute Myocardial Infarction in a Young Man

Introduction: Primary cardiac tumors are uncommon during infancy and childhood. Myxomas originating from the right ventricle are even less common in pediatric patients. Case presentation: Here we describe a case of an 11-year-old Tunisian boy who was referred for syncope. Transthoracic echocardiography revealed a large mobile mass attached to his right ventricle, obstructing his right ventricular outflow tract. Complete surgical excision of the mass with preservation of the pulmonary valve was performed. The diagnosis of myxoma was histologically confirmed. Conclusion: Cardiac myxomas located in the right ventricular outflow tract are rare and can present unusual diagnostic and therapeutic challenges.

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Right ventricular myxoma obstructing the right ventricular outflow tract: a case report

B-type natriuretic peptide (BNP) is a biomarker of cardiovascular disease that is common in adults with chronic kidney disease (CKD). However, in children with CKD, the range and predictive power of BNP concentrations are not known. We aimed to determine the effect of HD on BNP, as well as the prognostic impact of BNP, in end-stage renal disease (ESRD) children undergoing hemodialysis (HD). Thirty-five children with chronic renal failure (16 boys age 12.1 ± 3.7 years) on maintenance HD were included. BNP level was measured, and Doppler echocardiography was performed 30 min before (pre-HD BNP) and 30 min after (post-HD BNP) HD in each patient. An adverse event was defined as all-cause death and heart failure hospitalization. The median pre-HD BNP, the post-HD BNP, and the change in BNP were, respectively, 240 pg/ml (72 to 3346), 318 pg/ml (79 to 3788), and 9 pg/ml (−442 to 1889). Pre-HD BNP concentration was negatively correlated with left ventricular (LV) ejection fraction (r = −0.41, P = 0.018). During a mean follow-up of 39 ± 14 months, 6 patients died, and 3 were hospitalized for heart failure. Using univariate analysis, BNP before and after HD as well as Doppler tissue imaging velocities had a strong graded relationship with adverse events. Cox proportional hazards model demonstrated that pre-HD body weight (P = 0.008), pre-HD BNP (P = 0.011), and post-HD BNP (P = 0.038) remained independent predictors of adverse outcome. Even in case of ESRD, BNP still strongly correlated with LV systolic and diastolic dysfunction and was associated with mortality in HD children.

Relationship of Brain Natriuretic Peptide Concentrations to Left Ventricular Function and Adverse Outcomes in Children With End-Stage Renal Disease Undergoing Hemodialysis

Resume Objectif du travail Etudier la correlation du score TIMI avec l’etendue et la severite de l’atteinte coronaire chez des patients explores par coronarographie a la suite d’un syndrome coronarien aigu sans sus-decalage de ST. Patients et methode Etude retrospective des dossiers de 239 patients explores par coronarographie entre 2002 et 2006 a la suite d’un syndrome coronarien aigu sans sus-decalage de ST. Les patients ont ete classes en trois groupes selon la valeur du score TIMI : score TIMI de 0 a 2 (groupe 1 : n = 121), score TIMI de 3 a 4 (groupe 2 : n = 100) et score TIMI de 5 a 7 (groupe 3 : n = 18). Nous avons compare les donnees angiographiques des trois groupes. Resultats Les patients du groupe 1 ont presente plus frequemment des coronaires angiographiquement normales ou une atteinte coronaire non significative que les patients du groupe 2 (36,3 % vs 13 %, p  Conclusion Le score TIMI est parfaitement correle a l’etendue et la severite de l’atteinte coronaire chez les patients victimes d’un syndrome coronarien aigu sans sus-decalage de ST.

Sana Ouali

Papers

Congenital anomalous aortic origins of the coronary arteries in adults: A Tunisian coronary arteriography study

Takayasu Arteritis with Coronary Aneurysms Causing Acute Myocardial Infarction in a Young Man

Right ventricular myxoma obstructing the right ventricular outflow tract: a case report

Relationship of Brain Natriuretic Peptide Concentrations to Left Ventricular Function and Adverse Outcomes in Children With End-Stage Renal Disease Undergoing Hemodialysis

Corrélation du score TIMI avec l’étendue et la sévérité de l’atteinte coronaire dans les syndromes coronariens aigus sans sus-décalage de ST