Safety of Oral Propranolol for Infantile Hemangioma

OBJECTIVES

The safety of oral propranolol for infantile hemangioma has not yet been studied at population level since the pediatric use marketing authorization was obtained in Europe.

METHODS

A survey of a nationwide, claim-based observational cohort of children <3 years old, with at least 1 delivery of oral propranolol between July 2014 and June 2016, was performed by using the database of the French National Health Insurance system. Standardized morbidity ratios (SMRs) were calculated by using, from the same database, a representative random sample of nonexposed subjects. The main outcomes were hospitalizations for cardiovascular (conduction disorders, bradycardia, and hypotension), respiratory (bronchial hyperactivity and bronchospasm), or metabolic events (hypoglycemia and hyperkalaemia), identified through the hospitalization diagnostic codes of the International Classification of Diseases, 10th Revision. The main analysis was conducted separately on "healthy" children (N = 1484), that is, free from of any prespecified underlying disease and on children with 1 of these underlying diseases (N = 269).

RESULTS

In all, 1753 patients <3 years of age had at least 2 deliveries of oral propranolol. In the healthy population, we observed 2 cardiovascular events (SMR = 2.8 [0-6.7]), 51 respiratory events (SMR = 1.7 [1.2-2.1]), and 3 metabolic events (SMR = 5.1 [0-10.9]). In the population with an underlying disease (mainly congenital heart disease), we observed 11 cardiovascular events leading to an SMR of 6.0 (2.5-9.6). SMRs were not significantly raised for respiratory or metabolic events in this "nonhealthy" population.

CONCLUSIONS

In this study on a large continuous nationwide claims database, we confirm the safety profile of oral propranolol in healthy children to be good.

Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke

BACKGROUND

Trials of patent foramen ovale (PFO) closure to prevent recurrent stroke have been inconclusive. We investigated whether patients with cryptogenic stroke and echocardiographic features representing risk of stroke would benefit from PFO closure or anticoagulation, as compared with antiplatelet therapy.

METHODS

In a multicenter, randomized, open-label trial, we assigned, in a 1:1:1 ratio, patients 16 to 60 years of age who had had a recent stroke attributed to PFO, with an associated atrial septal aneurysm or large interatrial shunt, to transcatheter PFO closure plus long-term antiplatelet therapy (PFO closure group), antiplatelet therapy alone (antiplatelet-only group), or oral anticoagulation (anticoagulation group) (randomization group 1). Patients with contraindications to anticoagulants or to PFO closure were randomly assigned to the alternative noncontraindicated treatment or to antiplatelet therapy (randomization groups 2 and 3). The primary outcome was occurrence of stroke. The comparison of PFO closure plus antiplatelet therapy with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 2, and the comparison of oral anticoagulation with antiplatelet therapy alone was performed with combined data from randomization groups 1 and 3.

RESULTS

A total of 663 patients underwent randomization and were followed for a mean (±SD) of 5.3±2.0 years. In the analysis of randomization groups 1 and 2, no stroke occurred among the 238 patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet-only group (hazard ratio, 0.03; 95% confidence interval, 0 to 0.26; P<0.001). Procedural complications from PFO closure occurred in 14 patients (5.9%). The rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet-only group (4.6% vs. 0.9%, P=0.02). The number of serious adverse events did not differ significantly between the treatment groups (P=0.56). In the analysis of randomization groups 1 and 3, stroke occurred in 3 of 187 patients assigned to oral anticoagulants and in 7 of 174 patients assigned to antiplatelet therapy alone.

CONCLUSIONS

Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation. (Funded by the French Ministry of Health; CLOSE ClinicalTrials.gov number, NCT00562289 .).

close: Closure of patent foramen ovale, oral anticoagulants or antiplatelet therapy to prevent stroke recurrence: Study design

Rationale

Currently available data do not provide definitive evidence on the comparative benefits of closure of patent foramen ovale, oral anticoagulants and antiplatelet therapy in patients with patent foramen ovale-associated cryptogenic stroke

Aim

To assess whether transcatheter patent foramen ovale closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy, for secondary stroke prevention in patients aged 16 to 60 years with a large patent foramen ovale or a patent foramen ovale associated with an atrial septal aneurysm, and an otherwise unexplained ischaemic stroke or retinal ischaemia.

Sample size

Six hundred and sixty-four patients were included in the study.

Methods and design

CLOSE is an academic-driven, multicentre, randomized, open-label, three-group, superiority trial with blinded adjudication of outcome events. The trial has been registered with Clinical Trials Register (Clinicaltrials.gov, NCT00562289). Patient recruitment started in December 2007. Patient follow-up will continue until December 2016. Expected mean follow-up = 5.6 years.

Study outcomes

The primary efficacy outcome is the occurrence of fatal or nonfatal stroke. Safety outcomes include fatal, life-threatening or major procedure- or device-related complications and fatal, life-threatening or major haemorrhagic complications.

Discussion

CLOSE is the first specifically designed trial to assess the superiority of patent foramen ovale closure over antiplatelet therapy alone and the superiority of oral anticoagulants over antiplatelet therapy to prevent stroke recurrence in patients with patent foramen ovale-associated cryptogenic stroke.

An overview of cardiac morphogenesis

Accurate knowledge of normal cardiac development is essential for properly understanding the morphogenesis of congenital cardiac malformations that represent the most common congenital anomaly in newborns. The heart is the first organ to function during embryonic development and is fully formed at 8 weeks of gestation. Recent studies stemming from molecular genetics have allowed specification of the role of cellular precursors in the field of heart development. In this article we review the different steps of heart development, focusing on the processes of alignment and septation. We also show, as often as possible, the links between abnormalities of cardiac development and the main congenital heart defects. The development of animal models has permitted the unraveling of many mechanisms that potentially lead to cardiac malformations. A next step towards a better knowledge of cardiac development could be multiscale cardiac modelling.

Epithelial to mesenchymal transition-the roles of cell morphology, labile adhesion and junctional coupling

Epithelial to mesenchymal transition (EMT) is a fundamental process during development and disease, including development of the heart valves and tumour metastases. An extended cellular Potts model was implemented to represent the behaviour emerging from autonomous cell morphology, labile adhesion, junctional coupling and cell motility. Computer simulations normally focus on these functional changes independently whereas this model facilitates exploration of the interplay between cell shape changes, adhesion and migration. The simulation model is fitted to an in vitro model of endocardial EMT, and agrees with the finding that Notch signalling increases cell-matrix adhesion in addition to modulating cell-cell adhesion.

Parental electrocardiographic screening identifies a high degree of inheritance for congenital and childhood nonimmune isolated atrioventricular block

BACKGROUND

The origin of congenital or childhood nonimmune isolated atrioventricular (AV) block remains unknown. We hypothesized that this conduction abnormality in the young may be a heritable disease.

METHODS AND RESULTS

A multicenter retrospective study (13 French referral centers, from 1980-2009) included 141 children with AV block diagnosed in utero, at birth, or before 15 years of age without structural heart abnormalities and without maternal antibodies. Parents and matched control subjects were investigated for family history and for ECG screening. In parents, a family history of sudden death or progressive cardiac conduction defect was found in 1.4% and 11.1%, respectively. Screening ECGs from 130 parents (mean age 42.0 ± 6.8 years, 57 couples) were compared with those of 130 matched healthy control subjects. All parents were asymptomatic and in sinus rhythm, except for 1 with undetected complete AV block. Conduction abnormalities were more frequent in parents than in control subjects, found in 50.8% versus 4.6%, respectively (P<0.001). A long PR interval was found in 18.5% of the parents but never in control subjects (P<0.0001). Complete or incomplete right bundle-branch block was observed in 39.2% of the parents and 1.5% of the control subjects (P<0.0001). Complete or incomplete left bundle-branch block was found in 15.4% of the parents and 3.1% of the control subjects (P<0.0006). Estimated heritability for isolated conduction disturbances was 91% (95% confidence interval, 80%-100%). SCN5A mutation screening identified 2 mutations in 2 patients among 97 children.

CONCLUSIONS

ECG screening in parents of children affected by idiopathic AV block revealed a high prevalence of conduction abnormalities. These results support the hypothesis of an inheritable trait in congenital and childhood nonimmune isolated AV block.

Towards multiscale systems modeling of endocardial to mesenchymal transition

Cell behavior during endocardial to mesenchymal transition (EMT) was simulated using the cellular Potts formalism in Compucell 3D. The processes of loss of endocardial cohesion and invasion into the extracellular matrix (ECM) were stimulated by changing surface energy parameters. The simulations match in vitro results which suggest that endocardial motility on the surface of collagen gel can be induced separately from 3D invasion of the gel, via Notch signaling in the absence of BMP2. A principle by which the rate of mitosis would regulate the monolayer was demonstrated; suggesting a route for Vascular Endothelial Growth Factor (VEGF) control of EMT. A conceptual model of the system of protein interactions during EMT was assembled from multiple studies. A route for subcellular models to be formalized as Systems Biology Markup Language (SBML) differential equations is indicated. Scale linking would be achieved through Compucell 3D periodically integrating the SBML models for each cell during a simulation run, and updating parameters for protein concentrations assigned to individual cells. The surface energy parameters for the cells would be recalculated at each step from their simulated protein concentrations. Such scale linking opens up the potential for complexity to be gradually introduced, while maintaining experimental validation.

Characteristics and long-term outcome of non-immune isolated atrioventricular block diagnosed in utero or early childhood: a multicentre study

AIMS

The natural history of congenital or childhood non-immune, isolated atrioventricular (AV) block is poorly defined.

METHODS AND RESULTS

We retrospectively studied 141 children with isolated, non-immune AV block diagnosed in utero, or up to 15 years of age, at 13 French medical centres, between 1980 and 2009. Patients with structural heart disease or maternal antibodies were excluded. Atrioventricular block was asymptomatic in 119 (84.4%) and complete in 100 (70.9%) patients. There was progression to complete AV block in 29/41 (70.7%) patients with incomplete AV block over 2.8 ± 3.4 years (1-155 months), but all patients with incomplete AV block may not have been included in the study. Narrow QRS complex was present in 18 of 26 patients (69.2%) with congenital, and 106 of 115 (92.2%) with childhood AV block. Pacemakers were implanted in 112 children (79.4%), during the first year of life in 18 (16.1%) and before 10 years of age in 90 (80.4%). The mean interval between diagnosis of AV block and pacemaker implants was 2.6 ± 3.9 years (0-300 months). The pacing indication was prophylactic in 70 children (62.5%). During a mean follow-up of 11.6 ± 6.7 years (1-32 years), no patient died or developed dilated cardiomyopathy (DCM). The long-term follow-up was uncomplicated in 127 children (90.1%).

CONCLUSION

In this large multicentre study, the long-term outcome of congenital or childhood non-immune, isolated AV block was favourable, regardless of the patient's age at the time of diagnosis. No patient died or developed DCM, and pacemaker-related complications were few.

Multiscale systems modeling of the tetralogy of Fallot

This paper provides a first description of a multiscale systems modeling approach applied to the congenital birth defect known as the tetralogy of Fallot. The multiscale approach adopted owes a lot to the effort of the world-wide physiome consortium and the work of research groups within the European Union on the Virtual Physiological Human. Both a spatial scale and time scale are used to establish the systems boundaries of the application. The tetralogy of Fallot includes up to four simultaneously occurring anatomic abnormalities that underpin the defect. The use of finite state machines and cellular automata pave the way to understand the processes in time and space that contribute to the defect.

A new dynamic 3D virtual methodology for teaching the mechanics of atrial septation as seen in the human heart

Learning embryology remains difficult, since it requires understanding of many complex phenomena. The temporal evolution of developmental events has classically been illustrated using cartoons, which create difficulty in linking spatial and temporal aspects, such correlation being the keystone of descriptive embryology. We synthesized the bibliographic data from recent studies of atrial septal development. On the basis of this synthesis, consensus on the stages of atrial septation as seen in the human heart has been reached by a group of experts in cardiac embryology and pediatric cardiology. This has permitted the preparation of three-dimensional (3D) computer graphic objects for the anatomical components involved in the different stages of normal human atrial septation. We have provided a virtual guide to the process of normal atrial septation, the animation providing an appreciation of the temporal and morphologic events necessary to separate the systemic and pulmonary venous returns. We have shown that our animations of normal human atrial septation increase significantly the teaching of the complex developmental processes involved, and provide a new dynamic for the process of learning.

Diagnosis, management, and follow-up of systemic venous drainage via a single left superior caval vein into the left atrium

A 15-month-old boy presented with asymptomatic hypoxaemia due to right-to-left venous shunting via a left superior caval vein emptying into the left atrium, in absence of right superior caval vein. The diagnosis, suspected by contrast echocardiography, was confirmed by computed tomography and angiography. The child underwent surgical correction of the systemic anomalous return by tunnelling the left superior caval vein towards the right atrium. An asymptomatic narrowing inside the intra-atrial baffle developed 6 months later.

Three-dimensional reconstruction and morphologic measurements of human embryonic hearts: a new diagnostic and quantitative method applicable to fetuses younger than 13 weeks of gestation

Improvements in the diagnosis of congenital malformations explain the increasing early termination of pregnancies. Before 13 weeks of gestation, an accurate in vivo anatomic diagnosis cannot currently be made in all fetuses with current imaging instrumentation. Anatomopathologic examinations remain the gold standard to make accurate diagnoses, although they reach limits between 9 and 13 weeks of gestation. We present the first results of a methodology that can be applied routinely, using standard histologic section, thus enabling the reconstruction, visual estimate, and quantitative analysis of 13-week human embryonic cardiac structures. The cardiac blocks were fixed, embedded in paraffin, and entirely sliced by a microtome. One of 10 slices was topographically colored and digitized on an optical microscope. Cardiac volume was recovered by semiautomatic realignment of the sections. Another semiautomatic procedure allowed extracting and labeling of cardiac structures from the volume. Structures were studied with display tools, which disclosed the internal and external cardiac components and enabled determination of size, thickness, and precise positioning of ventricles, atria, and large vessels. This pilot study confirmed that a new 3-dimensional reconstruction and visualization method enables accurate diagnoses, including in embryos younger than 13 weeks. Its implementation at earlier stages of embryogenesis will provide a clearer view of cardiac development.

[Platypnoea-orthodeoxia syndrome. Diagnosis, etiology, treatment]

Platypnoea-orthodeoxia (P.O.) syndrome is the association of dyspnoea and arterial oxygen desaturation aggravated in the erect position and relieved in the supine position. Initially considered very rare (20 cases reported over fifty years) and occurring essentially in patients having undergone pneumonectomy, it in fact occurs much more frequently if only it is looked for (20 extra cases reported in a single year). Some new aetiologies have been described, in particular dilatations or aneurysms of the ascending aorta. Diagnosis is made easier if the oxygen saturation is measured in the supine position when it is normal, and in the erect position when it falls considerably. Another argument is added by the small effect of inspiration of high concentrations of oxygen. Contrast echocardiography confirms the right-left shunt and allows estimation of the site. This is usually situated at the atrial level, via an inter-atrial communication or more often a patent foramen ovale; as a rule the area of dehiscence having been modified by the associated pathology allowing the right-left shunt despite normal right pressures. Exceptionally the shunt is situated at the vascular or pulmonary parenchymal level. Poor tolerance of P.O. syndrome justifies a therapeutic procedure; this is usually closure of the septal fault with an occluder introduced percutaneously; the results are generally highly spectacular.

[Right atrial compressive aneurysm with favorable outcome after surgery at the age of 1 month]

Right atrial aneurysms are uncommon and often revealed by arrhythmia. We report a case of right atrial aneurysm which required an early management and its follow up during one year. The abnormality was detected at 32 weeks gravida during a systematic echography. At birth the newborn was asymptomatic but with the progressive increase of the aneurysm size shifting the heart and vessels and the occurrence of an intra-cardiac thrombus, a surgical management was decided at the age of one month. The resection of the aneurysm was therefore performed and no complication occurred during recovery. After one year the child remains healthy. The surgical indications are difficult to precise as the majority of these aneurysms are detected at an adult age. Surgical management appears to be essential in case of poor tolerance. The prognosis after surgery seems favorable.

[Heparin therapy in pregnant women]

The prescription of heparin during pregnancy is an uncommon situation but a difficult one to manage because there are no reported therapeutic trials. The main indications are thromboembolic disease, valvular or congenital heart disease, cardiac arrhythmias and patients at high risk of thrombosis with blood clotting disorders. Non-fractionated heparin is the commonest form of anticoagulation in these circumstances as it does not cross the placental barrier; there are no teratogenic or haemorrhagic risks to the foetus. However, its dosage is difficult in pregnant women and this may lead to complications such as haemorrhage, heparin-induced thrombocytopaenia and osteoporosis; in addition, the duration of the treatment is often long and it can affect tolerance. Low molecular weight heparins are a promising alternative because of their long half-lives which give a more predictable dose-effect and reduce the number of daily injections. The risk of heparin-induced thrombocytopaenia is lower. At present, their legal prescription is limited to enoxaparin during the 2nd and 3rd terms of pregnancy as prophylactic treatment. The recommendations described in this article are the result of the 6th Consensus of the ACCP on antithrombotic treatment, which cautions the use of low molecular weight heparin during pregnancy. Different therapeutic regimes are presented according to the degree of thromboembolic risk. In patients with mechanical valvular prostheses, the recommendations are variable, with many workers, especially European groups, preferring anticoagulation to heparin from the 12th to the 36th week of pregnancy because of the greater efficacy of this particular indication. Peridural anaesthesia may be carried out with heparin therapy providing the level of anticoagulation is monitored and the procedure is performed under well controlled conditions. In cases presenting formal contra-indications to heparin therapy, heparinoids may be used instead. In future, low molecular weight heparin therapy will probably play a larger role in anticoagulation during pregnancy and in all the potential therapeutic indications.

Long-term Follow-up of Percutaneous Vena Cava Filters: a Prospective Study in 100 Consecutive Patients

OBJECTIVES

the long-term outcome in following insertion of inferior vena cava (IVC) filters remains unclear.

DESIGN

prospective study.

MATERIAL AND METHODS

one hundred consecutive patients received percutaneous vena cava filters between 1988 and 1993. The patients underwent clinical examination, abdominal X-rays and duplex ultrasound of the IVC, right internal jugular vein and legs after a mean follow-up duration of 38+/-11 months.

RESULTS

forty patients died after implantation (median 11.3 months; IQR: 1.8--20.4 months). The cause of death was known in 33 cases, and pulmonary embolism (PE) was suggested in three. Multivariate analysis revealed the mortality rate to be significantly higher in cancer patients (relative risk of 2.13). The 3-year survival was 20% for cancer patients and 71% for patients without cancer. Among the 60 living patients, thrombi were trapped in the filter in 10 cases, the filter tilted in four, was malpositioned in five and migrated in 29. These incidents were recorded as asymptomatic complications, as opposed to seven IVC thromboses and 23 recurrent lower limb thromboses, which were considered as symptomatic complications.

CONCLUSION

long-term major complications are not frequent. As expected, cancer was the only factor predicting mortality. IVC filters seem effective in preventing PE.

Spontaneous closure of congenital coronary artery fistulas

Six cases of full spontaneous closure of congenital coronary artery fistulas, and one case of near closure, as seen by colour Doppler echocardiography, are presented. It is worth reconsidering the classical view that nearly all cases of spontaneous closure are eligible for surgical or percutaneous correction to prevent the development of significant and potentially fatal complications. As the natural course of coronary artery fistulas is still poorly defined, asymptomatic patients, especially those under 7 years old with small shunts, should be periodically followed up by echocardiography rather than be subjected to operative closure, even by catheterisation.

Early prenatal management of a fetal ventricular tachycardia treated in utero by amiodarone with long term follow-up

Fetal cardiac arrhythmias are one of the causes of intra-uterine congestive heart failure and non-immune hydrops fetalis leading to fetal death. As ventricular tachycardia (VT) is rarely diagnosed in utero, it leads to emergency deliveries. We report a prenatal diagnosis of fetal tachycardia at 20 weeks of gestation associated with non-immune hydrops fetalis. The tachycardia seemed to be supraventricular and was initially treated by digoxin and sotalol. The hydrops increased and sotalol was stopped in order to give the mother a high dose of amiodarone by mouth over a long period. Although the tachycardia, which the ECG recorded at birth revealed to be of ventricular origin, persisted but at a lower rate, the new treatment proved successful. The child is three years old now and health, though with persistent VT. In conclusion, fetal tachycardia with similar ventricular and atrial rates can be a VT and the drug of choice in this case seems to be amiodarone.

[Pregnancy and anticoagulant therapy. Indications and strategies]

Anticoagulant therapy is sometimes required during pregnancy either for the prevention of thromboembolic disease, for patients already on long-term antithrombotic treatment (for valvular prostheses) or for the prevention of complications of risk factors such as hereditary or acquired thrombophilia. Pregnancy is in itself a hyper-coagulable condition and the risk of thromboembolic complications is raised. Anticoagulation is a risk to the mother and to the foetus, and the management (heparin or vitamin K antagonists, respective doses) must be adapted to the underlying pathology and the stage of pregnancy. Mechanical valve prostheses are the most difficult problem and different strategies are proposed. The use of low molecular weight heparin may improve the outcome of these patients, but further trials are necessary.

[Preoperative mortality in transposition of the great vessels]

The aim of the study was to report the incidence and causes of preoperative deaths in isolated transposition of the great vessels and to describe the clinical findings in these neonates.

PATIENTS AND METHODS

In five French centers of pediatric cardiology, data of all the neonates with isolated transposition of the great vessels who died before arterial switch operations between January 1986 and June 1996 were obtained from reviewing hospital files, echocardiography records and autopsy reports.

RESULTS

Among 199 neonates with transposition of the great vessels, 20 (9.9%) died before surgery. The death was related to intracranial haemorrhage in one premature neonate, severe and early hypoxemia in 13 full-term patients (group A) and later sudden collapse in six patients (group B). In group A, the symptoms occurred within 20 minutes after the birth and included cyanosis (n = 12), acute respiratory distress (n = 8), and shock (n = 4). Despite assisted ventilation (n = 13), bicarbonate infusion (n = 12), prostaglandin E1 (n = 7), inotropic drugs (n = 5) and balloon atrioseptostomy (n = 7), death occurred at the median age of five hours. The patent foramen ovale was absent or tiny in ten patients, normal in one patient and not specified in two patients. The ductus arteriosus was patent in ten patients and not specified in three patients. In group B, the neonates were initially in a good hemodynamic condition. Unexplained death occurred between two and five days after the birth: one infant with a large patent foramen ovale did not receive prostaglandin E1, four patients died a few hours after an angiographic study or a balloon atrioseptostomy was performed in a catheterization laboratory, and one child suffered from a cerebral anoxia due to a tightened cord.

CONCLUSION

We conclude that the high preoperative mortality rate in isolated transposition of the great vessels is mainly due to absent or small atrial shunt. These findings suggest that only prenatal diagnosis of transposition of the great vessels with immediate balloon atrioseptostomy could avoid a fatal outcome.

Multisensor fusion for atrial and ventricular activity detection in coronary care monitoring

Information management for critical care monitoring is still a very difficult task. Medical staff is often overwhelmed by the amount of data provided by the increased number of specific monitoring devices and instrumentation, and the lack of an effective automated system. Specifically, a basic task such as arrhythmia detection still produce an important amount of undesirable alarms, due in part to the mechanistic approach of current monitoring systems. In this work, multisensor and multisource data fusion schemes to improve atrial and ventricular activity detection in critical care environments are presented. Applications of these schemes are quantitatively evaluated and compared with current methods, showing the potential advantages of data fusion techniques for event detection in noise corrupted signals.

[Comparison of apical and infundabular pacing in patients with primary dilated or ischemic cardiomyopathy]

Dual chamber pacing has been proposed as an alternative treatment to patients with cardiac failure refractory to optimal medical therapy. The influence of the site of ventricular pacing was studied in 15 patients with an average age of 68.7 +/- 8.7 years with dilated cardiomyopathies and an average left ventricular ejection fraction of 22.3 +/- 6.8%. Three temporary USCI electrodes were positioned in the right atrium, the right ventricular outflow tract (RVOT) and the right ventricular apex. The average duration of the QRS complexes and the haemodynamic parameters (PAP, PCP and cardiac index) were measured in sinus rhythm and during DDD apical, RVOT and simultaneous apical and RVOT pacing. The RVOT and simultaneous pacing significantly reduced the QRS duration (135 +/- 14 ms and 137 +/- 17 ms, p < 0.0001 respectively) compared with apical pacing (150 +/- 19 ms). The mean PAP and mean PCP remained unchanged in the different modes of pacing but the cardiac index increased significantly during RVOT pacing (2.99 +/- 0.67 l/min/m2) and simultaneous pacing (3 +/- 0.77 l/min/m2) compared with apical pacing (2.66 +/- 0.62 l/min/m2) (p < 0.001 and p < 0.01 respectively) and compared with sinus rhythm (2.62 +/- 0.7 l/min/m2) (p < 0.001 and p < 0.005 respectively). This study suggests that better results may be obtained with RVOT screw in lead than with the traditional right ventricular apical electrode.

[Fetal echocardiography]

Cardiac malformations are the most frequent and serious fetal malformations. However their prenatal diagnosis is the less easy. Fetal echocardiography is the main diagnostic tool; in addition it is helpful for the therapeutic orientation. Only 30% of fetal heart diseases are detected on account of maternal or fetal indications, most of them being discovered without any known risk factor. In order to improve its diagnostic sensitivity, fetal echocardiography must include a four chambers view and a study of ventricular and arterial connection. Nevertheless, many heart diseases remain undetected, most of them being minor with favorable prognosis. Search of an extracardiac abnormality and karyotype analysis must be performed in order to explicit the prognosis. Fetal arrhythmias can be analyzed by study of the atrial and ventricular contraction using M-mode echocardiogram or Doppler mode; most of them are supraventricular and accessible to maternal therapy. The sustained fetal bradycardia is frequently a complete heart block whose prognosis depends upon its association with a heart defect and/or a ventricular escape. Antibodies SS-A and SS-B are frequently associated with complete heart block without structural heart defects. Hypertrophic cardiomyopathy may be observed in fetus of diabetic mothers needing an accurate evaluation of the thickness of the interventricular septum. Echocardiography is a part of fetal medicine, which includes the different specialties devoted to the fetus.

[Indications of partial interruption of the inferior vena cava in pulmonary embolism]

Forty years after the first implantation of caval filters, there is still no indication for implantation validated by a controlled clinical trial. This fact may be explained by our poor understanding of the evolution of thromboembolic disease, especially in certain groups of patients. The absolute contra-indications to heparin therapy would seem to be a logical indication for a caval filter. In cases of a relative contra-indication to anticoagulants, the physician has to rely on his clinical judgement and the decision will be taken case by case. In patients with suspected pulmonary embolism under anticoagulant therapy, it is also logical to check that anticoagulation is effective, and to request proof of embolism, to assess its risk and that due to thrombosis before considering a caval filter. The prophylactic implantation of a caval filter is a very controversial indication whether the thrombus is proximal in the ilio-caval region, extensive, not uncommon despite treatment, or floating. For groups said to be at high risk of thromboembolism (elderly, malignant disease or multiple injuries), there is no consensus because of the discordant results in the literature. The implantation of a filter would seem to be justified in patients with chronic cor pulmonale after pulmonary embolectomy. The value of a temporary caval filter during thrombolysis has not been demonstrated; there are hopes that temporary filters "of long duration" will provide filtration of the vena cava during vulnerable periods. The results of the first controlled trial (PREPIC) are eagerly awaited and should rationalise the indications of inferior vena cava filters.

[Doppler echocardiography in the evaluation of volume expansion effects in newborn infants]

BACKGROUND

The effects of volume expansion on the cardiac output (CO) of newborns have not been studied, so that the indications for colloid infusion are not well standardized.

POPULATION AND METHODS

Twenty one newborns (14 preterm and seven term babies) were studied before the 7th day of life. Thirteen had patent ductus arteriosus (PDA) and six had ischemic cardiopathy. Hemodynamic data indicated that these babies should be given 20 ml/kg of a 10% albumin solution. Pulsed-wave Doppler echocardiography was performed before and after infusion.

RESULTS

Only 11 newborns had initial low Co (less than 260 ml/kg/min in patients with PDA; less than 200 ml/kg/min in the others). The increases in CO (31 +/- 25% vs 7 +/- 11%, P < 0.01) and of mean aortic flow velocity (MAFV) (34.6 +/- 19.5% vs 7.2 +/- 6.1%, P < 0.01) were significantly greater in this group. The increases in mean arterial pressure (+4 +/- 5 mmHg) and CO (+20 +/- 18%) were significant (P < 0.01) for all patients, both premature and term (with or without PDA and ischemic cardiopathy). The increase in CO was correlated with the initial CO and the cutaneous refilling time but was not correlated with the increase in arterial pressure. The sizes of the ventricles and left atrium grew significantly but that of the right atrium did not. Analysis of the increase in stroke volume in terms of the end diastolic diameter of the left ventricle indicated that the cardiac reserves varied according to the Starling relation.

CONCLUSION

Evaluation of MAFV and CO plus diagnosis of PDA are all needed in order to assess whether volume expansion is accurate or not, since, clinical data obtained during the neonatal period are insufficient to do this.

Short-term follow-up of inferior vena caval filters: comparison of imaging techniques

OBJECTIVE

The aim of this prospective study was to assess the advantages and limitations of various imaging techniques in identifying problems associated with percutaneous placement of filters in the inferior vena cava.

SUBJECTS AND METHODS

One hundred four vena caval filters (65 Filcard, 39 Cardial) were placed in 100 patients (four patients received two filters). Venacavograms, duplex sonograms of the abdomen, abdominal radiographs, perfusion scans of the lung, and impedance plethysmograms were obtained in all patients within 1-2 days and 3 months after filter placement. CT scans of the filter were obtained in 55 patients.

RESULTS

In five patients, thrombosis of the inferior vena cava, with retraction of the filter struts in four patients, was noted on venacavograms, CT scans, duplex sonograms, and impedance plethysmograms. Perforation of the inferior vena cava was noted in 36 patients after comparison of findings on venacavograms and CT scans, with an increase in the filter span in 29 patients (apparent on duplex sonograms in only two patients). Four filter tiltings (> 30 degrees) and 25 migrations (> 5 mm) were noted on abdominal radiographs. Trapped thrombi in the filter were shown on venacavograms in nine cases, but on duplex sonograms and unenhanced CT scans in only two cases.

CONCLUSION

Our study shows that the major complications of inferior vena caval filters can be detected by noninvasive examinations. Only venacavograms consistently show small trapped thrombi that do not extend above the filter, but the importance of such thrombi is unknown.

[Dilatation of critical aortic value stenosis in infants under 3 months of age. Our experience from 15 cases]

Between April 1988 and October 1992, 15 consecutive infants aged less than 3 months (average 17 days) with critical valvular stenosis underwent balloon dilatation. Thirteen were less than 1 month old and all had low output syndromes. The diagnosis and follow-up assessments were made by Doppler echocardiography. Before valvuloplasty the maximum instantaneous gradient was 75 +/- 34 mmHg. The average diameter of the aortic ring was 6.8 +/- 1.3 mm. Seven patients had aortic rings with diameters of less than 7 mm. Ten infants had a right-to-left shunt via a patent ductus arteriosus and pulmonary hypertension. Dilatation was performed after surgical denudation of the left carotid artery: a balloon catheter with a diameter 0.85 times that of the aortic ring was used. After dilatation, the gradient was 26 +/- 18 mmHg (p < 0.001). Grade I aortic regurgitation was observed in 4 cases and Grade II in 2 cases. Eight patients died 1 to 100 days after dilatation (seven of low output and one sudden death). Of these patients, 6 had aortic rings < 7 mm diameter. The average follow-up was 20.6 +/- 15.5 months (range 2 to 48 months). None of the patients had a precordial or carotid diastolic murmur. The gradient increased with improvement in left ventricular function. Two patients had a stable Grade I aortic regurgitation. Carotid Doppler echocardiographic control examinations performed in 4 patients were normal. Poor prognostic factors were: aortic ring diameter < 7 mm (p < 0.025) and a low gradient after dilatation (p < 0.012).(ABSTRACT TRUNCATED AT 250 WORDS)

[Left intraventricular dynamic gradients in the follow-up of aortic valve replacement: an echo-Doppler study]

The possibility of an intraventricular pressure gradient in patients with aortic stenosis is well known: this entity is associated with a high risk of postoperative complications. The authors carried out a Doppler echocardiographic study of flow in the left ventricle in 51 patients who had recently undergone valve replacement for severe aortic stenosis (valve area < 0.75 cm2). Before surgery, only one patient had significant acceleration of intraventricular systolic flow attaining 3.8 m/s (maximum pressure gradient of 60 mmHg). After surgery, maximum intraventricular systolic velocities of over 2.5 m/s with a typical end systolic peak were observed in 8 patients under basal conditions (gradients of 30 to 115 mmHg), and in 7 others after inhalation of amyl nitrite. Pulsed spectral and color Doppler flow mapping showed that the highest velocities were located at the mitral papillary muscle level. In addition, these patients had significant reduction in cavity size. Only one patient had systolic anterior motion of the anterior mitral leaflet with septal contact. Left ventricular dimensions were measured by TM echocardiography. High intraventricular velocities seemed to be significantly related to the smallest ventricular dimensions, the thickest ventricular walls and the smallest preoperative aortic valve surface area. The highest intraventricular pressure gradients-disappeared with betablocker therapy (4 cases), after correction of hypovolemia (1 case), after drainage of large pericardial effusions (2 cases) or spontaneously (1 case). This study confirms the relatively high prevalence of dynamic intraventricular gradients after surgical cure of aortic stenosis and the value of Doppler echocardiography for the avoidance of certain drugs (inotropic agents, vasodilators, diuretics), which could aggravate the hemodynamic abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

[Efficacy and tolerance of 2 new percutaneous vena cava filters. A prospective study in 80 patients]

Eighty consecutive patients with an average age of 66.5 +/- 16 years were reviewed 3 and 9 months after implantation of two new percutaneous vena caval filters (Filcard, Cardial) in order to evaluate their efficacy and tolerance. The indications were: a contra-indication to anticoagulants in 19 cases, recurrent pulmonary embolism under anticoagulant therapy in 22 patients, chronic cor pulmonale in 4 patients; finally, in 35 cases, the filter was implanted prophylactically for a "floating" or extensive ilio-caval thrombosis under anticoagulant therapy or in high risk patients: severe cardio-pulmonary failure, malignant disease, massive pulmonary embolism with a contra-indication to fibrinolytic therapy. All implantations were performed by the jugular approach with no local or general complications apart from one pericaval haematoma with a favourable outcome. Cavography and opacification of the renal veins was carried out systematically during implantation. All patients underwent clinical examination, antero-posterior and lateral X rays of the filter, pulmonary scintigraphy, antero-posterior and lateral cavography, a CT scan of the filter, Doppler ultrasonography and rheoplethysmography of the legs 3 months after implantation. At 9 months, clinical examination, abdominal X rays and rheoplethysmography were repeated. There was 100% follow-up at 3 and 9 months. The complications observed at 3 and 9 months were: 5 cases of malposition (6%), 3 recurrent pulmonary emboli (4%), 9 recurrent venous thromboses (13%), 4 vena caval thromboses (5.7%), 7 thrombi caught in the filter (10%), 27 perforations of the vena cava (38%), 3 over 30 degrees tilts of the filter (4%) and 22 migrations (31%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Permanent junctional reciprocating tachycardia in children and adolescents. Efficacy of medical treatment]

Between 1969 and 1991, 11 patients were followed up for permanent junctional reciprocating tachycardia. The average age at diagnosis was 2 years and 4 months (1 day to 14 years). The tachycardia was diagnosed at routine examination in 5 cases and following an episode of cardiac failure in the other 6. Digitalis was prescribed in all patients with 4 good results, 5 average and 2 poor results. One patient, who remained in mild cardiac failure with digitalis therapy, died suddenly at the age of 9 years. In more recent cases, amiodarone was used from the onset or secondarily with good results in all patients. In 2 patients, in whom amiodarone was withdrawn after 3 months and 3 years' treatment, there was a recurrence of the tachycardia. No side effects of amiodarone therapy were observed in this series. Three patients were prescribed flecainide with 1 good and 2 average results. Propranolol, used in 2 cases, was associated with 1 average and 1 poor result. Disopyramide and Verapamil were ineffective. These results suggest that amiodarone is the drug to choose in permanent junctional reciprocating tachycardia but it must be given long term. The persistence of cardiac failure, poor control of the tachycardia or secondary effects of drug therapy should lead to consideration of non-medical management of the tachycardia.

[Right atrial thrombosis and severe pulmonary embolism]

Two cases of severe pulmonary embolism associated with right atrial thrombosis are reported. In the first case, fibrinolytic therapy was administered and was thought to be a causative factor in the death of the patient due to massive pulmonary embolism. In the second case, the patient was referred for surgery and two enormous thrombi were extracted. Unfortunately, the outcome was fatal. These two cases were confronted with the results of the literature. They strongly suggest that echocardiography should be a first-line investigation in severe pulmonary embolism. The detection of right atrial thrombosis modifies the clinical strategy and orientates treatment towards surgical referral when the patient's condition allows it.

[Stenosis of the branches of the pulmonary artery caused by Hodgkin's lymphadenopathies]

A 22 year old patient was admitted to hospital for dyspnoea and haemoptysis. Cardiac catheterisation showed a pressure gradient between the main pulmonary artery and its branches. Pulmonary angiography showed appearances of extrinsic compression of the branches of the pulmonary artery. This was shown to be caused by lymphadenopathy on CT scan and Hodgkin's disease was diagnosed after surgical biopsy. The pressure gradient between the main pulmonary artery and its distal branches almost completely regressed after chemotherapy and radiotherapy.