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ABSTRACT: Coronary artery disease (CAD) is a complex multifactorial disease due to the interaction of multiple genes variations and environmental factors. Genetic variants of lipoprotein lipase (LPL), a key enzyme in the hydrolysis of triglyceride rich particles, may contribute to CAD. We analysed here the frequency of LPL variants (p.Asp9Asn, p.Asn291Ser and p.Ser447X) in a Tunisian population as well as their association with circulating lipid level and risk of CAD.
LPL variations were investigated by PCR-RFLP and lipid parameters were measured in 135 patients and 109 controls.
The frequency of the p.Asp9Asn variation was 10.37% in CAD patients versus 3.66% in controls. The frequency for the p.Ser447X variation was 8.8% in CAD patients versus 13.7% in controls. There was no significant association between these two variants and CAD. The p.Asn291Ser mutation variation was absent in this population. In healthy subjects, heterozygote carriers of the p.Asp9Asn substitution had a significant increase level of total cholesterol (4.2±0.9mmol/L vs 5.6±1.2mmol/L; P=0.01) and a decreased level of HDL-cholesterol (1.36±0.3mmol/L vs 0.93±0.1mmol/L; P=0.045).
There was no significant association between genetic variants of the LPL gene and CAD in this Tunisian population. The very low frequency of the p.Asn291Ser variation may be an ethnic specificity of Tunisians.
Pathologie Biologie 05/2011; 60(3):180-4. · 1.53 Impact Factor
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F Addad,
Z Dridi,
M Jemmali,
K Mzoughi,
M Hassine,
I Ghrissi,
S Hamdi,
M Mahjoub,
F Betbout,
M Ben Farhat,
H Gamra
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ABSTRACT: Previous studies have shown that smokers with acute myocardial infarction (AMI) treated by thrombolysis have lower mortality rates than nonsmokers, a phenomenon often termed "smoker's paradox". This "smoker's paradox" has been rarely studied in case of primary angioplasty.
To evaluate the impact of smoking status on the early mortality of patients admitted with AMI with regard to the strategy of reperfusion (intravenous thrombolysis versus primary angioplasty).
Study undertaken from the Monsatir registry of ST elevation MI including 688 patients having had either a hospital or a prehospital thrombolysis (n=397) or a primary angioplasty (n=291). Among those patients, 482 (70.1%) were active smokers.
In the thrombolysis group, the prevalence of hypertension, diabetes and anterior location of MI was significantly less among smokers. In the group primary angioplasty, only diabetes and hypertension were less frequent. The immediate mortality was significantly less among smokers in case of thrombolysis comparatively to non-smokers (5.3 vs 13%; p=0.008). By multivariate analysis, cardiogenic shock (p<0.0001), anterior MI (p=0.03) and active smoking (p=0.03) were independent predictive factors of mortality in case of thrombolysis. A trend toward a lower mortality among smokers was observed in the primary angioplasty group (10 vs 17.6%; p=0.07).
"The smoker's paradox" seems to be observed mainly among patients having had thrombolysis.
Annales de cardiologie et d'angeiologie 08/2010; 59(4):183-9. · 0.21 Impact Factor
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I Jguirim-Souissi,
A Jelassi,
Y Hrira,
M Najah,
A Slimani, F Addad,
M Hassine,
K B Hamda,
F Maatouk,
M Rouis,
M N Slimane
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ABSTRACT: Peroxisome proliferator-activated receptor delta (PPAR-delta) is a transcription factor implicated in metabolism and inflammation. The +294T/C polymorphism in the PPAR-delta gene is associated with risk of coronary artery disease (CAD) in dyslipidemic women and hypercholesterolemic men. Whether this polymorphism influences the risk of CAD in the absence of dyslipidemia was not known, so we investigated a possible association of this polymorphism with plasma lipid and lipoprotein levels and with risk and outcome of CAD in a normolipidemic Tunisian population. Genotyping was performed by PCR-RFLP in 112 CAD patients and 113 healthy volunteers. The C-allele was significantly more frequent in patients than in controls (0.320 vs 0.189, P = 0.001). This association remained significant after adjustment for age, gender, body mass index, smoking, hypertension, and high-density lipoprotein cholesterol. Subjects carrying either one or two copies of the C-allele had a 2.7-fold higher risk of CAD than subjects homozygous for the T-allele. PPAR-delta genotypes were not associated with lipoprotein concentrations or outcome of CAD. We conclude that PPAR-delta +294T/C polymorphism is an independent risk factor of CAD in normolipidemic Tunisian subjects. The lack of association with lipoprotein concentrations suggests that the effect of the polymorphism on CAD is not mediated through lipoprotein levels in this population and that it may influence the atherosclerotic process through mechanisms involving inflammation.
Genetics and molecular research: GMR 01/2010; 9(3):1326-33. · 1.18 Impact Factor
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ABSTRACT: Thromboembolic complications were uncommon in mediterranean spotted fever.
We report a case of 55-years- old man who was admitted for mediterranean spotted fever. Two days later, the patient developed chest pain due to a pulmonary thrombosis confirmed by angio-CT. The outcome was good with heparin therapy. The investigation for another cause of thrombosis was negative.
Mediterranean spotted fever is usually a moderately severe self-limited illness. Pulmonary thrombosis was uncommon associated with severe disease.
La Revue de Médecine Interne 01/2007; 27(12):973-5. · 0.61 Impact Factor
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ABSTRACT: Aim: The immediate and long-term results of balloon mitral commissurotomy (BMC) during pregnancy were evaluated in patients and in their babies looking for radiation side effects.Methods and results: Sixty one patients (mean age: 28.5+/-5.0 years) had BMC at a mean age of gestation of 26.8+/-5.5 weeks. The procedure was successful in all patients except in one who had a severe mitral regurgitation and subsequent mitral valve replacement (MVR). All patients delivered at term vaginally in 58 (95.1%) cases. There was only one death in a patient who delivered at home. At a mean follow-up of 66.8+/-36.0 months, 4 patients had MVR, the remaining were in NYHA class I/II. Restenosis was found in 4 (7.2%) patients. The 63 babies (two gemellar pregnancies) had a normal weight of birth except of one case of hypotrophy. At a mean follow-up of 64.5+/-32.5 months, two babies died, 1 had hypotrophy, 2 had microcephaly, 8 had an IQ < 70 but none had a severe mental retardation (IQ <34). None of these events were radiation related.Conclusion: BMC is the procedure of choice in pregnant patients with mitral stenosis. No late radiation side effects were observed in children but longer follow-up is required.
EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 11/2006; 2(3):302-9. · 3.29 Impact Factor
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ABSTRACT: Pulmonary embolism is an unusual complication of Behçet's disease. Our aim study is to analyse epidemiological, physiopathological and evolutive aspects of this condition. Among 153 patients with Behçet's disease according to the criteria of the International Study Group for Behçet's disease, seven (5 men and 2 women mean aged at 26.6 +/- 6 years) were diagnosed as having pulmonary embolism. This was inaugural in 3 cases; for 2 females, pulmonary embolism complicated pregnancy. Cardiac thrombosis was presented in 2 cases and pulmonary aneurysm in 2 patients. Pulmonary infarction has been noted in 4 cases. Protein C, protein S and antithrombin III levels were normal in all cases. One patient was positive for IgG anticardiolipin antibody. The hyperhomocysteinemia has been noted (17 to 30 micromol/) in 5 cases. All our patients were treated successfully by anticoagulation therapy combined with high dose prednisone, colchicine and intravenous cyclophosphamide in 6 patients. Pulmonary embolism is one of the severe and worst prognostic manifestations of the disease. Furthermore, the hyperhomocysteinemia may play an important role in the pathogenesis of such complication. Immunomodulation therapy associated to folate may be beneficial to attenuate this hyperhomocysteinemia especially, when introduced in the early stages.
Archives des maladies du coeur et des vaisseaux 10/2006; 99(9):786-90. · 0.40 Impact Factor
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ABSTRACT: To evaluate the effectiveness of the increase of postmortem cardiac troponin T (cTn T) in acute disease-related deaths.
Peripheral venous blood was sampled from 39 autopsies performed. Thirty nonhemolyzed specimens were considered in the final analysis (n = 30).Only the calculation of the cTn T was performed using the Roche Diagnostics Elecsys 2010 Immunoassay System. The high limit and the cutoff are 25 ng/mL. Deaths were divided into 2 groups, according to sudden cardiac deaths (group 1, n = 15) and non-cardiac-related deaths without resuscitation (group 2, n = 15).
All the cases with visual myocardial infarction had elevated concentrations of cTn T. The difference of the postmortem cTn T concentrations between resuscitated and nonresuscitated is nonsignificant. In the non-cardiac-related deaths, the elevated concentrations of cTn T were only noted in all cases of electrocution.
In clinical practice, several biochemical markers are used for the diagnosis of myocardial infarction. Because of its extreme specificity for myocardial damage, cTn T and cardiac troponin I (cTn I) are frequently used. The results of these assays could then be used to facilitate selection for cases that may be released following histologic examinations.
American Journal of Forensic Medicine & Pathology 07/2006; 27(2):175-7. · 0.88 Impact Factor
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ABSTRACT: A myocardial bridge is usually asymptomatic but can cause myocardial ischemia, myocardial infarction or sudden death. Two occurrences of coronary angioplasty in the acute phase of an anterior myocardial infarction on a myocardial bridge are reported. The first case was first treated only with a balloon, and then with a stent 12 h later after a relapse of angina pectoris and the recurrence of a severe compression. The second case immediately benefited from a stent. A systematic control at six months has shown the absence of restenosis in the first case and an asymptomatic occlusion of the stent in the second case. Its deocclusion has revealed a myocardial bridge downstream of the stent. Myocardial stunning might have caused a decreased systolic compression by the bridge in the first case, and an underestimation of its actual length in the second case. Its regression is held responsible for these two relapses. A long active stent installed at high pressure could be used to treat myocardial bridges during myocardial infarctions.
The Canadian journal of cardiology 12/2005; 21(13):1183-5. · 3.36 Impact Factor
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ABSTRACT: Several studies have reported a biochemical resistance to aspirin in 5 to 10% of coronary patients. However, the stability of the platelet anti-aggregation effect with aspirin over time remains poorly understood.
To study the intra-individual variability at 6 months of the anti-platelet action of aspirin in coronary patients.
Prospective study including 40 consecutive patients with acute coronary syndrome and taking regular aspirin (250 mg a day). The biochemical impact of aspirin was determined by measuring the time to occlusion (TO) on a collagen/epinephrine cartridge with PFA-100. The determination of the TO was performed 2 months (TO1) and then 8 months (TO2) after starting aspirin. In our population, a resistance to aspirin was defined as a TO < or =125 sec.
The median value for TO was generally stable over the two periods, at 158 sec for TO1 and 179 sec for TO2 (p = 0.29). Among the 9 initially resistant patients (22.5%), 4 became sensitive to aspirin without changing the dosage, while only one of the 31 initially sensitive patients became biochemically resistant.
the existence of a medium term intra-individual variability in the antiplatelet response to aspirin in coronary patients underlines the importance of biochemical surveillance in these high vascular risk patients.
Archives des maladies du coeur et des vaisseaux 10/2005; 98(10):979-83. · 0.40 Impact Factor
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ABSTRACT: The mechanisms of thrombosis on plaque erosion are poorly understood. We examined the potential role of endothelial apoptosis in endothelial erosion and vessel thrombosis.
Segments of New Zealand White rabbit femoral arteries were temporarily isolated in vivo. One artery was incubated with staurosporin for 30 minutes, whereas the contralateral artery was incubated with saline and served as control. Three days later, thrombosis was evaluated angiographically and histologically. TUNEL score in the endothelial layer was significantly increased in staurosporin-treated arteries compared with controls (2.43+/-0.30 versus 0.93+/-0.44, respectively; P=0.001). Large areas of endothelial denudation were detectable in staurosporin-treated vessels, whereas endothelium integrity was almost preserved in the saline group. Vessel thrombosis occurred in 58% of staurosporin-treated arteries (7 of 12) but in only 8% of saline-treated segments (P<0.01). Immunoreactivities for tissue factor, platelets, and fibrin were detectable within the thrombus. Addition of ZVAD-fmk (0.1 mmol/L) significantly reduced the occurrence of thrombosis (1 of 7 arteries or 14%, P=0.04). These results were confirmed in balloon-injured atheromatous arteries.
In vivo induction of endothelial apoptosis leads to both vessel thrombosis and endothelial denudation. Endothelial apoptosis may be a critical step in the transition from a stable endothelialized plaque to plaque erosion and thrombosis.
Circulation 07/2004; 109(21):2503-6. · 14.74 Impact Factor
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ABSTRACT: We report a case of 48 years old women with a 8 years history of rheumatoid arthritis and severe articular deformation treated during the last 6 months by prednisone (5 mg daily) and chloroquine (200 mg daily), admitted in the emergency room because of syncope. The electrocardiogram showed a complete atrioventricular block. Transesophageal echocardiography was performed and revealed an hyperechogenic mass (6 x 2.5 mm) in the interventricular septum probably related to a fibrous rheumatoid nodule. This potentially explain the atrioventricular block by infiltration of the conduction pathways. A permanent double chamber pacemaker was inserted. The chloroquine, another factor of conduction disturbances was not incriminated in this case. The conduction disturbances should be systematically detected in case of severe rheumatoid arthritis. Therefore, every patient must be submitted to a transthoracic echocardiography. Transesophageal echocardiography may be helpful to detect rheumatoid nodule.
Annales de Cardiologie et d Angéiologie 04/2004; 53(2):101-4. · 0.28 Impact Factor
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H Gamra,
F Betbout,
K Ben Hamda, F Addad,
F Maatouk,
Z Dridi,
S Hammami,
M Abdellaoui,
H Boughanmi,
T Hendiri,
M Ben Farhat
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ABSTRACT: To evaluate the safety, efficacy and long-term actuarial results of balloon mitral commissurotomy in young patients with severe rheumatic mitral stenosis.
Event-free survival and freedom from restenosis were analyzed in 110 patients 20 years old or younger (group 1) and compared with those of 554 adults (group 2). Young patients were less frequently in atrial fibrillation (6% vs 35%, P<0.001) and had less mitral valve deformities (echo score 5.9+/-2.1 vs 7.5+/-3.0, P<0.0001). Mitral valve area index by 2D-echo was of 0.66+/-0.1cm(2)/m(2)in group 1 and 0.67+/-0.1cm(2)/m(2)in group 2 (P=ns) and was larger in group 1 (1.5 vs 1.3 cm(2)/m(2)) after the procedure (P<0.0001). There were more complications in group 2 (8.4% vs 0%, P=0.01). Procedural success was obtained in 110 (100%) patients of group 1 vs 501 (92%) patients of group 2 (P<0.0001). At follow-up mitral valve area index was 1.34 cm(2)/m(2)in group 1 and 1.16 cm(2)/m(2)in group 2 (P<0.0001). At 10 years, freedom from restenosis was 61% in group 1 vs 71% in group 2 (P=0.35) and event-free survival was 74% and 69% respectively (P=0.15
Balloon mitral commissurotomy is safe and effective in young with rheumatic mitral stenosis and provides better immediate results than in adults. However long-term outcome was similar between the 2 groups: 2/3 of patients were alive and free from clinical events at 10 years.
European Heart Journal 07/2003; 24(14):1349-56. · 10.48 Impact Factor
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ABSTRACT: To study clinical course and prognostic factors of infective endocarditis.
Infective endocarditis was identified in 126 consecutive patients (criteria of DURACK). Of these, 73 were male, mean age was 29.9 + 15 years, 98 (77.7%) had past history of cardiac disease. The evolution has been marked by 38 deaths (30%) in spite of the recourse to surgery (69 patients). The mean follow-up period was 52 months, the event-free survival was 61% at 5 years.
By univariate analysis the predictors of bad prognosis: Large vegetations > 10 mm, delay of apyrexia > 10 days presence of a neurological accident and the absence of surgical treatment. Multivariate analysis: Vegetation > 10 mm (OR 1.97, 1-4.1, p = 0.05), presence of a neurological accident (OR:2.76, 1.32-5.76, p = 0.007) and the absence of surgical treatment (OR: 5.03, 2-11.4, p < 0.001).
Infective endocarditis remains a serious affection, identification of patients with poor prognosis should lead to early surgical referral: this attitude provides good immediate and long-term results.
La Tunisie médicale 01/2003; 80(12):739-50.
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ABSTRACT: Most long-term studies after balloon mitral commissurotomy (BMC) were from industrialized countries. Less is known about the long-term results of BMC from developing countries where patients are younger with fewer mitral valve deformities.
Between December 1987 and December 1998, we performed BMC in 654 patients whose mean age was 33 +/- 13 years. Baseline and postprocedural variables were evaluated to identify predictors of event-free survival (survival without repeat BMC or mitral valve replacement) and of freedom from restenosis defined as a mitral valve area (MVA) >/=1.5 cm(2) after BMC and <1.5 cm(2) at follow-up.
The actuarial survival rates were 98%, 98%, and 97% at 5, 7, and 10 years, respectively. The 5-, 7-, and 10-year event-free survival rates were 85%, 81%, and 72%. Multivariate predictors of a higher 10-year event-free survival rate were lower echocardiographic score (79% for a score </=8, 61% for a score of 9 to 11, 62% for a score >/=12, P <.001) and cardiac sinus rhythm (P =.04) before BMC, lower mean left atrial pressure (P <.001), lower mitral valve gradient (P <.001), and less than or equal to grade 2 mitral regurgitation (P =.036) after BMC. Restenosis occurred in 16% of patients. The restenosis-free rates were 88%, 80%, and 66% at 5, 7, and 10 years, respectively. A higher freedom from restenosis at 10 years was associated with a lower score (77% for a score </=8, 45% for a score of 9-11 and 50% for a score >/=12, P =.03) and a larger MVA before BMC (P =.03), a larger MVA (P <.001), and a lower mitral valve gradient (P =.04) after BMC.
BMC produces excellent 10-year results in patients with pliable mitral stenosis and good results in patients with semipliable or calcified mitral stenosis. BMC is the procedure of choice in patients with pliable valves and it is a reasonable treatment option in young patients with unfavorable mitral valve anatomy.
American heart journal 12/2001; 142(6):1072-9. · 4.65 Impact Factor
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ABSTRACT: The strategy of provisional stenting has been guided by functional evaluation (coronary flow reserve) and anatomic evaluation (quantitative coronary angioplasty). Two trials, FROST and DESTINI, compared provisional and systematic stenting strategies. Interestingly, they showed that 43-52% of patients were not stented on the basis of angiographic and Doppler guidance. Moreover, there was no significant difference in the occurrence of restenosis (FROST) and major cardiac events (DESTINI). In conclusion, although provisional stenting appears safe and efficacious, this strategy is overshadowed by the concept of direct stenting which can shorten and simplify the procedure of angioplasty.
International Journal of Cardiovascular Interventions 07/2001; 4(2):83-85.
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ABSTRACT: Arterial remodelling plays an important part in post-angioplasty restenosis but the physiopathology of this process is not fully understood. Abundant collagen synthesis and endothelial dysfunction have been demonstrated after angioplasty, but their role in restenosis and remodelling has not been studied. The aim of this study was therefore to assess endothelial function and collagen with respect to the severity of restenosis and the type of arterial remodelling. Atherosclerosis was induced by an association of endothelial abrasion and a high cholesterol diet in the femoral arteries of 22 white New Zealand rabbits. Four weeks later, angioplasty was performed. The acetylcholine endothelium-dependant vasomotricity (expressed as % inhibition of contraction to phenylephrine), collagen and morphology were assessed 28 days after angioplasty. The change in acetylcholine endothelium-dependant vasomotricity was greater in severe restenosis (r = 0.61, p = 0.02). Endothelium-dependant relaxation was not significantly altered when remodelling was expansive and very abnormal when it was constrictive (35.5 +/- 13.0 vs 3.7 +/- 7.9%; p = 0.04). Restenosis was associated with an increase in collagen (r = 0.69, p = 0.004). The density of collagen was significantly higher in constrictive remodelling than in expansive remodelling (34.5 +/- 4.5 vs 18.2 +/- 4.7%; p = 0.03). Endothelial dysfunction and collagen accumulation are correlated with the severity of restenosis and with constrictive remodelling after angioplasty in an experimental model.
Archives des maladies du coeur et des vaisseaux 07/2001; 94(6):605-11. · 0.40 Impact Factor
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ABSTRACT: Intracoronary thrombosis and post-angioplasty complications (acute occlusion) are now controlled. Restenosis is the principal obstacle to transluminal coronary revascularisation. The conviction of the multifactorial and focal nature of the process leading to this excessive scarring is acquired. Constrictive remodelling is now established as the main mechanism of restenosis. Failure to prevent restenosis by systemic therapy has led several groups to experiment local treatment for this problem. The object of this article is to review the different systems of local treatment at the site of angioplasty. Even if some results are encouraging, there is no solution as yet to the problem of restenosis. Although local therapy is possible, the agent(s) of choice remain(s) to be defined.
Archives des maladies du coeur et des vaisseaux 12/1999; 92(11 Suppl):1699-706. · 0.40 Impact Factor
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ABSTRACT: Short-term and mid-term results of percutaneous balloon pulmonary valvuloplasty (BPV) are well known. However, data documenting long-term effectiveness of BPV are scarce.
The long-term results of 62 patients were assessed by catheterization and Doppler echocardiography 1 to 10 years (mean 6.4 +/- 3.4) after BPV. Mean age of the patients was 13.5 +/- 10.5 years (range 9 months to 44 years). Twenty patients were 16 years of age or older. Right ventricular peak systolic pressure was systemic or suprasystemic in 72% of patients. A double-balloon technique was used in 29 patients. The balloon-to-pulmonary valve diameter ratio was 1.4 +/- 0.38 (range 1 to 1.8). Total systolic transpulmonary pressure gradient in excess of 50 mm Hg in all patients before BPV decreased from 98 +/- 40 to 32 +/- 23 immediately after BPV and to 19 +/- 9 mm Hg at follow-up (P <.001). Infundibular gradient increased from 8 +/- 10 to 14 +/- 24 mm Hg after BPV and fell to 1 +/- 4 mm Hg at follow-up (P <.01). In 16 patients it was >/=20 mm Hg and virtually disappeared spontaneously in all at follow-up. The valvar gradient fell from 93 +/- 39 to 19 +/- 11 (P <.001) and was 18 +/- 9 mm Hg at follow-up. It remained unchanged in 3 patients (range 36 to 45 mm Hg). In 3 (4.8%) other patients, a new gradient >35 mm Hg developed that was >/=50 mm Hg in all 3. Among 5 patients having dysplastic valves, 3 had a gradient >35 mm Hg. There were no predictors of a gradient >35 mm Hg at long-term follow-up by univariate or multivariate Cox proportional hazards analysis. Mild to moderate pulmonary regurgitation was present in 39% of patients. On electrocardiography, right ventricular hypertrophy decreased significantly in 90% of patients.
BPV as a treatment of typical pulmonic valve stenosis produces excellent long-term results. Restenosis is rare (4.8%) and occurs more frequently in patients with dysplastic valves. There is a constant spontaneous regression of associated infundibular obstruction.
American Heart Journal 12/1999; 138(5 Pt 1):950-4. · 4.65 Impact Factor
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ABSTRACT: Constrictive remodeling plays a prominent role in restenosis after balloon angioplasty, but its regulation remains unclear. Because endothelial dysfunction and changes in extracellular matrix have been reported after angioplasty, this study was designed to simultaneously evaluate endothelial function and collagen and elastin changes after restenosis and arterial remodeling.
Atherosclerosis was induced in femoral arteries of 22 New Zealand White rabbits by air-desiccation and a high-cholesterol diet. One month later, angioplasty was performed. Histomorphometry and in vitro assessment of endothelial function were performed 4 weeks after angioplasty. Restenosis correlated with constrictive remodeling (r=0.60, P=0.01) but not with neointimal growth (r=-0.06, P=0.79). Restenosis correlated with an impaired relaxation to acetylcholine (ACh; r=0.61, P=0.02) but not with the response to the endothelium-independent vasodilator sodium nitroprusside (r=-0.25, P=0.40). Restenosis correlated positively with collagen accumulation (r=0.69, P=0.004) and inversely with elastin density (r=-0.48, P=0.05). Relaxations to ACh were significantly more decreased in arteries with constrictive remodeling than in those with enlargement remodeling (3.7+/-7.9% versus 35.5+/-15.0%, P=0.04). Neointimal collagen density was significantly higher in arteries with constrictive remodeling than in those with enlargement remodeling (34.5+/-4.5% versus 18.2+/-4.7%, P=0.03). Endothelial function and collagen and elastin density were independent predictors of restenosis in the study.
These results demonstrate that the severity of restenosis after angioplasty correlated with both defective endothelium-dependent relaxation and increased collagen density.
Circulation 10/1999; 100(10):1109-15. · 14.74 Impact Factor
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Annales de Cardiologie et d Angéiologie 05/1999; 48(4):273-5. · 0.28 Impact Factor
