Prenatally diagnosed periventricular nodular heterotopia: Further delineation of the imaging phenotype and outcome

OBJECTIVES

Periventricular nodular heterotopia (PNH) is a malformation of cortical development which presents with heterogeneous imaging, neurological phenotype and outcome. There is a paucity of comprehensive description detailing the prenatal diagnosis of PNH. The aim of this study is to report neuroimaging features and correlated outcomes in order to delineate the spectrum of prenatally diagnosed PNH.

METHODS

It was a retrospective study over 15 years in five tertiary centers. All fetuses with prenatally diagnosed PNH were collected. Fetal ultrasound and MRI were reviewed and genetic screening collected. Prenatal findings were analyzed in correlation to fetopathological analyses and post-natal follow up.

RESULTS

Thirty fetuses (22 females and 8 males) with PNH were identified. The two major ultrasound signs were ventriculomegaly associated with dysmorphic frontal horns (60%) and posterior fossa anomalies (73.3%). On MRI, two groups of PNH were identified: the contiguous and diffuse PNH (n = 15, 50%), often associated with megacisterna magna, and the non-diffuse, either anterior, posterior or unilateral PNH. FLNA mutations were found in 6/11 cases with diffuse PNH. Additional cortical malformations were exclusively observed in non diffuse PNH (9/15; 60%). Twenty-four pregnancies (80%) were terminated. Six children aged 6 months to 5 years are alive. Five have normal neurodevelopment (all had diffuse PNH) whereas one case with non diffuse PNH has developmental delay and epilepsy.

CONCLUSION

PNH is heterogeneous but patients with diffuse PNH are a common subgroup with specific findings on prenatal imaging and implications for prenatal counseling.

Systematic molecular and cytogenetic screening of 100 patients with marfanoid syndromes and intellectual disability

The association of marfanoid habitus (MH) and intellectual disability (ID) has been reported in the literature, with overlapping presentations and genetic heterogeneity. A hundred patients (71 males and 29 females) with a MH and ID were recruited. Custom-designed 244K array-CGH (Agilent®; Agilent Technologies Inc., Santa Clara, CA) and MED12, ZDHHC9, UPF3B, FBN1, TGFBR1 and TGFBR2 sequencing analyses were performed. Eighty patients could be classified as isolated MH and ID: 12 chromosomal imbalances, 1 FBN1 mutation and 1 possibly pathogenic MED12 mutation were found (17%). Twenty patients could be classified as ID with other extra-skeletal features of the Marfan syndrome (MFS) spectrum: 4 pathogenic FBN1 mutations and 4 chromosomal imbalances were found (2 patients with both FBN1 mutation and chromosomal rearrangement) (29%). These results suggest either that there are more loci with genes yet to be discovered or that MH can also be a relatively non-specific feature of patients with ID. The search for aortic complications is mandatory even if MH is associated with ID since FBN1 mutations or rearrangements were found in some patients. The excess of males is in favour of the involvement of other X-linked genes. Although it was impossible to make a diagnosis in 80% of patients, these results will improve genetic counselling in families.

Brachytelephalangic chondrodysplasia punctata: prenatal diagnosis and postnatal outcome

We report the prenatal management of a brachytelephalangic chondrodysplasia punctata (CDPX1) case and how postnatal findings confirmed the diagnosis. The mother was initially referred after ultrasound revealed an abnormal fetal mid-face and punctuation of upper femoral epiphyses. Chondrodysplasia punctata (CP) with Binder anomaly was suspected. 3D-HCT revealed brachytelephalangy suggesting CDPX1. At birth, mid-face hypoplasia was marked. Postnatal imaging and genetic analysis confirmed the initial diagnosis. Binder anomaly is probably always associated with CP. The newly revised CP classification facilitates the diagnosis. The main etiologies are metabolic and chromosomal abnormalities, and arylsulfatase E enzyme dysfunction. Thus, screening for arylsulfatase E mutation is mandatory for an accurate diagnosis and can lead to better delineation among CP etiologies associated with a Binder phenotype.

Rare diseases in disabled children: an epidemiological survey

AIM

To estimate the contribution of rare diseases (RD) to severe impairment in 7-year-old children.

METHODS

Data from a morbidity register of childhood impairments in a single French region were used. Impairments were classified as a mental, sensorial, neuromuscular (skeletal or movement-related) impairment (MSN_I) according to the International Classification of Functioning. Details of children born from 1980 to 1994 and resident in the county under study when they were 7 years old were recorded. A rare disease was defined as a prevalence rate of <1 per 2000 general population.

RESULTS

26% of children with severe MSN_I had a rare disease; in 36% the MSN_I was of unknown origin. The proportion of impairments that were due to a rare disease varied according to the type of impairment: 3.3% for severe psychiatric disorders; 16.0% for intellectual impairment; 37.2% for hearing impairment; 41.2% for neuromuscular, skeletal and movement impairment; and 81.1% for visual impairment. The overall prevalence rate of rare diseases was 2.1 per 1000 (459/218 283), and it increased significantly over time (p = 0.003). The latter increase was not associated with a decrease in the proportion of impairments of unknown origin, indicating an improvement in the survival of the children with a rare disease.

CONCLUSIONS

In this study, a rare disease was at the origin of 26% of cases of severe MSN_I. This proportion remained stable over time, whereas the prevalence rate, as well as the prevalence rate of MSN_I disability, increased over time.

Trends in elective terminations of pregnancy between 1989 and 2000 in a French county (the Isère)

OBJECTIVES

This study was performed in order to provide a description of indications for induced elective terminations of pregnancy (ETOP), their characteristics (e.g. gestational age), and their evolution over time.

DESIGN OF THE STUDY

This is an epidemiological study. The geographic area covered is the French county of 'Isère', which represents a mean of 14 000 births per year over the study period.

MATERIALS AND METHODS

Data on ETOPs were collected actively from medical records by a register of childhood deficiencies and adverse perinatal events in this county. Between 1989 and 2000, 996 ETOPs were notified.

RESULTS

Four main grounds for ETOPs were identified: (1) morphological anomalies with normal karyotype (39%), (2) chromosomal anomalies (35%), (3) other fetal grounds (16%), and (4) maternal indications (10%). Prevalence rates for the first two grounds increased significantly over the study period respectively from 2.0 to 2.9 and from 1.4 to 2.7 per 1000. Among the ETOPs carried out because of fetal indications, the percentage of late ETOPs (from 24 weeks of gestation) was 34.6%, and remained stable over the studied period. In some cases, a medical consensus was not reached with respect to indications for termination (sex chromosome anomalies, limb defects). We estimated the percentage of these cases as being 2.7% of the figure for fetal indications, without any variation in prevalence over the whole period (p = 0.59). The increasing number of ETOPs that occurred in the chromosomal aberrations group during the study period is thought to be due to an increase in diagnostic sensitivity. The increase that occurred in the morphological anomalies group is thought to be due both to an increase in sensitivity and to a widening of the field with respect to indications, some of which have an uncertain prognosis (e.g. agenesis of the corpus callosum).

CONCLUSION

This study provides useful data for monitoring medical practice consistency within the field of prenatal diagnosis, and for the drive to keep medical practice within ethically acceptable limits.

Disabilities and trends over time in a French county, 1980-91

AIM

To describe trends over time and types of disability for children born in a French county from 1980 to 1991.

METHODS

Data were collected from medical records of a morbidity register; disabled children with at least one severe deficiency have been included. Prevalence rates are given per 1000 resident children, over four three-year periods.

RESULTS

Overall, 7.73 per 1000 children (that is, 1360 children), had a severe childhood disability, and the prevalence rate had increased significantly since 1980. This increase was mainly owing to an increase in cerebral palsy and psychiatric disorder prevalence rates.

CONCLUSION

Future research aimed to explain these trends over time can be based on such data. The present knowledge is useful for planning purposes.

[Congenital long QT syndrome in newborns]

The perinatal manifestations of the long QT syndrome are rare, but early diagnosis and therapy are necessary to prevent sudden death.

CASE REPORTS

A long QT syndrome was diagnosed in two neonates who presented with foetal bradycardia. In one case, a mutation in the gene KCNQ1 was identified, and a long QT syndrome was diagnosed in the mother and two brothers of the neonate. On beta-blocker therapy, one infant became free of long QT syndrome related symptoms, but a sudden death of the second infant occurred.

CONCLUSION

The long QT syndrome should be considered in the differential diagnosis of foetal bradycardia. Early treatment of the neonate and his family may prevent ventricular arrhythmias and sudden death.

So-called 'cryptogenic' partial seizures resulting from a subtle cortical dysgenesis due to a doublecortin gene mutation

We report the case of a female suffering from resistant partial seizures, which were related to 'cryptogenic' epilepsy, as the cerebral cortex was considered normal on the initial MRI images. As her son is mentally retarded and has a pachygyria, the doublecortin gene, usually involved in band heterotopia or lissencephaly, was screened for mutations. A missense mutation was identified, shared by both the son and his mother, and a subtle discontinuous subcortical heterotopia was subsequently detected on the mother's MRI. The pathophysiology of epilepsy in this woman is discussed in the light of the role of doublecortin, not only in neuronal migration, but also in axonal growth and dendritic connectivity.

[Congenital toxoplasmosis: prevention in the pregnant woman and management of the neonate]

The management of a pregnant women or a child infected by Toxoplasma gondii rests on the screening of pregnant women at risk of infection. Treatment is prescribed if an infection occurs. A prenatal diagnosis (detection of T. gondii in amniotic fluid) may be performed, a positive result leading to a reinforcement of the treatment. After birth, the follow-up of the child is needed in order to prevent and detect the sequellae, mainly ocular. For all these steps, the biological methods used to diagnose T. gondii infection are of paramount importance.

Three-dimensional cartography of the pattern of the myofibres in the second trimester fetal human heart

The aim of the present study was to describe the fibre architecture of the fetal heart at mid gestation, and to clarify some persistent controversies concerning the architecture of the myofibres in the right ventricular wall and the muscular ventricular septum. We used quantitative polarized light microscopy to obtain information about the orientation of myocardial cells in the ventricular mass. These cells, joined into a network by anastomoses, have at any point in the ventricular mass a principal direction--the fibre direction. We have quantitated this information in the form of maps of the azimuth and elevation angles, in 18 midgestation fetal hearts. Our findings show that the fibre architecture of the heart can be conceptualised as myocardial fibres running like geodesics on a nested set of warped "pretzels". This model is an extension to the whole ventricular mass of Krehl's Triebwerk, and Streeter's model which was restricted to the left ventricle. A "pretzel" itself can be considered as two doughnuts joined side-by-side, with the tunnel at the center of each doughnut corresponding to the ventricular cavity. Over and above the excellence of the fit between the data and the geodesic representation, three strong arguments support this model. First, it is the only existing model that explains the observed rolling over of fibres around the atrioventricular valvar orifices. Second, it explains the trajectory of the fibres from the epicardium to the endocardium at the basal parts of both ventricles and at the apical part of the left ventricle. Third, the predicted topological singularities of the model are systematically observed in each of the 18 hearts studied.

Vaginal delivery in a woman with limb-girdle muscular dystrophy. A case report

BACKGROUND

Limb-girdle muscular dystrophy is a muscular disease determined genetically. Few papers have been published on this disorder in pregnancy. Several authors reported on delivery by cesarean section because of the risk of dystocia.

CASE

A woman with limb-girdle muscular dystrophy had two pregnancies with normal vaginal delivery and follow-up. No obstetric complications related to the disease occurred.

CONCLUSION

A trial of labor is possible in patients with limb-girdle muscular dystrophy if no obstetric contraindications exist.

[Angelman syndrome and severe vagal hypertonia. Three pediatric case reports]

Angelman's syndrome is an association of severe mental retardation with absence of language, ataxia, convulsions and hyperactive, joyful behaviour with frequent bouts of laughing. Genetic diagnosis is possible in about 80% of cases. No cardiovascular abnormalities have been described in this syndrome to date. The authors report the cases of three children with Angelman's syndrome who presented with severe malaise due to increased vagal tone. The age of onset of symptoms was between 20 months and 8 years. One of the children had malaises triggered by bouts of laughing. The diagnosis was confirmed in all three cases by the results of Holter 24 hour ECG recording and oculo-cardiac reflex. The treatment chosen was Diphemanil (Prantal) in the two patients under 2 years of age (after failure of a trial of betablockers in one case) and Disopyramide for the oldest child with excellent results in all cases. However, one child died suddenly at the age of 6, two years after stopping diphemanil. Based on these observations, the authors suggest that all malaises in patients with Angelman's syndrome should be investigated by Holter ECG and oculo-cardiac reflex (or tilt test). In view of the potential gravity of the syncopal attacks, long-term medical treatment seems to be justified.

[Combined use of nuchal translucency, gestational age and maternal age for evaluation of the risk of trisomy 21]

PURPOSE

Despite the definition of new screening policies for fetal trisomies, based on nuchal translucency thickness (NT) or maternal serum, the prevalence of trisomy 21 remains high. We propose a strategy based on a combination of maternal age, gestational age and NT, measured at the first trimester ultrasound examination, for the assessment of risk.

METHODS

We present, in this paper, a characterisation of the physiological increase of fetal NT between the 10th and the 14th week of gestation, in a preliminary study of 266 echographic examinations. Next we propose a calculation of the simultaneous risk of trisomy 21 based on marginal risks for maternal age and increased NT values available in the literature.

RESULTS AND CONCLUSION

We propose to define a high-risk group associated to the NT marker by using a cut-off risk of 1/250 for the simultaneous risk. This criteria may, as well, be expressed by a pathological threshold of NT varying with maternal age and gestational age. Without questioning that women aged of 38 years or older are a high-risk group, this approach should allow an improvement of the prenatal screening for trisomy 21.

Characterization of a germline mosaicism in families with Lowe syndrome, and identification of seven novel mutations in the OCRL1 gene

The oculocerebrorenal syndrome of Lowe (OCRL) is an X-linked disorder characterized by major abnormalities of eyes, nervous system, and kidneys. Mutations in the OCRL1 gene have been associated with the disease. OCRL1 encodes a phosphatidylinositol 4, 5-biphosphate (PtdIns[4,5]P2) 5-phosphatase. We have examined the OCRL1 gene in eight unrelated patients with OCRL and have found seven new mutations and one recurrent in-frame deletion. Among the new mutations, two nonsense mutations (R317X and E558X) and three other frameshift mutations caused premature termination of the protein. A missense mutation, R483G, was located in the highly conserved PtdIns(4,5)P2 5-phosphatase domain. Finally, one frameshift mutation, 2799delC, modifies the C-terminal part of OCRL1, with an extension of six amino acids. Altogether, 70% of missense mutations are located in exon 15, and 52% of all mutations cluster in exons 11-15. We also identified two new microsatellite markers for the OCRL1 locus, and we detected a germline mosaicism in one family. This observation has direct implications for genetic counseling of Lowe syndrome families.

Efficacy of routine fetal ultrasound screening for congenital heart disease in Isère County, France

Recent literature has revealed different percentages of prenatal detection of congenital heart disease. Therefore we chose to analyse the sensitivity of this screening in Isère county and to scrutinize to which extent factors like severity of the anomaly, extracardiac anomalies and maternal age influence the sensitivity. This retrospective study covers the period from 1989 to 1995. All the pregnancies with congenital heart disease in Isère county in France were reviewed and analysed, which was possible thanks to our registry of congenital anomalies. In this period, 316 cases were registered in the central database. We obtained an overall sensitivity of 34.8 per cent. By splitting the different malformations into two groups we got a detection rate of 53.7 per cent for major malformations and 26.7 per cent for other abnormalities. This difference is significant. Nevertheless, the sensitivity remains quite low. This result stresses the need for better education of investigators in primary care units, particularly because the prenatal diagnosis of congenital heart disease has a major impact on the outcome of pregnancy, which can be seen in the increased number of abortions in this group.

Population screening for aneuploidy using maternal age and ultrasound

The coexistence of an epidemiological register and a multidisciplinary centre for prenatal diagnosis promoted us to report data collected during six years (1990-1995) in Isère county on prenatally detected chromosomal aberrations. During the whole study period prenatal diagnosis strategy towards chromosome aberrations was based solely on maternal age and ultrasound examination. Results showed a respective contribution of one-third/two-thirds for the two detection modes (maternal age/ultrasound signs). From 1990 to 1995 a significant increase in the proportion of prenatally detected autosomal aneuploidy was observed, from 52 per cent to 75 per cent (P < 0.001). This significant variation was mainly due to an increase in the proportion of prenatally detected trisomy 21 cases, and to an increase in the proportion of aberrations which were detected through first trimester ultrasound examination. The highest positive predictive values were observed for polymalformation, cardiac anomalies and cystic hygroma ultrasound signs (51 per cent, 21 per cent and 26 per cent, respectively). Our results for trisomy 21 are close to those obtained in other studies, even when prenatal strategies are different. Their interest lies in the fact that they can be considered as a reference level of prenatal diagnosis efficiency due to a strategy based on maternal age and ultrasound signs, a level which has to be taken into account when evaluating the benefits of additional serum screening policies in other studies.

[Cytomegalovirus infection in pregnant women. Seroepidemiological prospective study in 1,018 women in Isere]

Cytomegalovirus (CMV) is the leading cause of viral congenital infections. In children, the consequences may be severe, especially in case of maternal primary infection during pregnancy. A prospective study was carried out in the department of Isère, in 1,018 pregnant women, in order to establish the seroprevalence of CMV, the frequency of primary infections during pregnancy and the associated risk factors. The overall seroprevalence was 51.5%; it increased significantly with age, parity, and low socioeconomic status. It was higher in women born in the South of France (51.6%) than in those born in the North (37.4%). Among a total of 878 women with serological follow-up, 7 primary infection cases (0.8%) were observed. Seventeen women (1.9%) presented border IgM values in the first serum, and these values were not related to recent infection. Extrapolation of the results to the whole department of Isère, suggests that each year about 100 pregnant women would be concerned by CMV primary infection, with 2 or 3 cases of death or severe sequelae in children. In light of these results, the interest of serological screening is discussed.

Cytomegalovirus seroprevalence in French pregnant women: parity and place of birth as major predictive factors

In this study we present data on cytomegalovirus (CMV) seroprevalence in pregnant women in France. One thousand and eighteen women were enrolled in a prospective study carried out in Grenoble. The overall rate of seropositivity, using a specific IgG ELISA test, was 51.5 % (95 % CI: 48.5-54.5). Among a homogeneous population of 873 women born in France with high or middle socioeconomic status, CMV seropositivity increased with age and parity. The seroprevalence according to age was found to depend on parity. It increased with age in women with no children or with only one; it was higher but no more age-dependent in women with two children or more. In addition, CMV seroprevalence was significantly higher in women born in southern France (51.6%) than in those born in northern France (37.4%), these findings being consistent with the existence, within France, of a gradient in seroprevalence rate, increasing from the North to the South. A logistic regression analysis reveals the place of birth in France as a major predictive factor of CMV antibody status (OR: 3.5) followed by age (OR: 2) and parity (OR: 1.7). In this study, we show an independent effect of parity on CMV seroprevalence, arguing for the importance of child-to-mother transmission; nevertheless, the latitude of the place of birth, even within a size-limited country such as France, appears to be a major predictive factor of CMV seroprevalence.

[Infant mortality trends compared with trends in handicapped children in Isere, 1976-1985]

Since 1960 progress in obstetric and neonatology modified the survival chance of babies and the pattern of mortality causes. With the information available in the death certificates the aim was to analyse the trends in infant mortality for all 0-1 year children deaths occurring from 1976 to 1991, and to look at its influence on disabled children prevalence rates. The study was conducted in Isere (France) and include 1702 infant deaths. A part from death groups with perinatal disease and/or with congenital defects, a group of deaths with risk factor of disability was identified. This group represented 43% of all the infantile deaths and showed a significant decreasing trend, very similar to the decrease of the early neonatal mortality component (until 1983). However, during the same period, for the disabled children prevalence and for the other infant mortality components, no significant variation was found. The decrease of the deaths with risk factor of disability suggests some influence on the disabled children prevalence.

[An unusual site of cardiac myxoma. Apropos of a case in an 11-year old child]

Cardiac myxoma, a relatively common condition in adults, is exceptionally rare in childhood. It is usually observed in the left atrium. The condition may be latent and a chance echocardiographic finding or present with arrhythmias, intermittent mitral obstruction or embolic phenomena. The authors report the case of an 11-year old child with no previous medical history, admitted to hospital after sudden right hemiplegia due to an ischaemic cerebrovascular accident. The investigation of a cardiac embolic abnormality led to the finding of a very large left ventricular tumour inserted into the mitral annulus and prolapsing into the left ventricular outflow tract, the histological examination of which confirmed the diagnosis of myxoma. Cardiac myxomas in children seem to have a much more variable site of implantation than in adults, especially in the right heart in infancy. Treatment is always surgical. Echocardiography should be requested early in children presenting with a murmur of recent origin, malaises, or unexplained inflammatory syndromes, and would seem to be the only means of avoiding the severe embolic complications of these histologically benign tumours.

Mapping of the orientation of myocardial cells by means of polarized light and confocal scanning laser microscopy

The study of the topological organisation of myocardial cells is a basic requirement for the understanding of the mechanical design of the normal and pathological heart. We developed a technique based on multiparametric image analysis of transmitted polarized light to generate maps of the azimuth and the elevation angles of the myocardial cells. The properties of birefringence of the myocardium embedded in methylmetacrylate were measured in papillary muscles with monitored 3D orientation. This birefringence is positive uniaxial with a 0 degree extinction angle when the axis of the fiber is parallel to the axis of the polarizer or the analyzer. Thick sections were studied between crossed polars, and four images of each section were digitized for an angle of the polarizer with the section varying from 0-67.5 degrees in steps of 22.5 degrees. The amounts of transmitted light for each setup of the polarizer were combined in order to extract the values of the azimuth angle (modulo 90 degrees) and the elevation angle of the myocardial cells, according to the Johannsen equation. The respective maps of these angles were calculated and then assessed with confocal scanning laser microscopy. This method provides an efficient and accurate tool for the study of the histological architecture of the fetal and neonatal heart.

[How to measure disability in children? Different methodologies, values and applications]

Infantile mortality data are insufficient for perinatal care evaluation. Long-term morbidity, particularly child impairment prevalence, needs to be assessed regularly. In this paper different surveys on child impairment registration published in the literature are examined: cohort studies, follow-up studies on "at risk" children, cross sectional surveys and morbidity registers. Study designs and case ascertainment are analysed as well as case validation and reference population. The consistency of the results is discussed. In France, most of the studies on childhood impairment are follow-up studies of at risk children, not concerning a geographically defined population, and there is a need for larger epidemiological studies in order to better assess perinatal morbidity and the quality of perinatal cares.

Method for the study of the three-dimensional orientation of the nuclei of myocardial cells in fetal human heart by means of confocal scanning laser microscopy

A series of three-dimensional image analysis tools are used to measure the three-dimensional orientation of nuclei of myocardial cells. Confocal scanning laser microscopy makes it possible to acquire series of sections up to 100 microns inside thick tissue sections. A mean orientation vector of unit length is calculated for each segmented nucleus. The global orientation statistics are obtained by calculating the vectorial sum of the nuclear unit vectors. The final orientation is expressed by a mean azimuth angle, an elevation angle and a measure of the angular homogeneity. The method is illustrated for two different regions of the myocardium (interventricular septum and papillary muscle) of a normal human fetal heart. This quantitative method will be used to assess and calibrate the information provided by polarized light microscopy.

[Prenatal diagnosis of mucoviscidosis: indication of enzyme determination and molecular biology techniques]

Prenatal diagnosis of cystic fibrosis established by study of RFLPs flanking the gene and, since 1989, by direct detection of the major mutation delta F508 is now widely used. However, there are still some indications of prenatal diagnosis by microvillar intestinal enzymes analysis. We propose a prenatal diagnosis strategy which combines both methods. This diagnosis strategy is applied to families with a 1/4 to 1/200 risk. Screening of delta F508 in the general population is discussed.

Abnormal direct entry of the umbilical vein into the right atrium: antenatal detection, embryologic aspects

Abnormal direct umbilical venous return into the right atrium was detected at obstetric ultrasonography in a 23 week fetus. This was an isolated anomaly; the growth of the fetus and size of the liver were normal, and the child was normal on examination at birth. Exclusion of the umbilico-placental circulation brought about closure of the umbilical vein. Growth and development of the child were normal 6 months after birth. Five other cases of abnormal umbilical venous entry into the right atrium have been reported in the literature, but associated with severe malformations, with situs ambiguous and heterotaxy. These cases have been grouped under the heading: persistence of the right umbilical vein. In view of recent findings relating to the organogenesis of the veins of the human liver, it seems preferable to label this anomaly: direct umbilical venous return into the right atrium.

Prediction of outcome by prenatal Doppler analysis in a patient with aortic stenosis

Stenosis of the aortic valve (pressure drop 50 mm Hg) was diagnosed prenatally by Doppler echocardiography in a 33 week old fetus. Measurement of time-velocity integrals through the tricuspid and mitral valves indicated a significantly higher flow in the right heart. The pressure drop across the aortic valve in the 3 hour old infant was 80 mm Hg. The findings in this patient suggest that the usually accepted theory that prenatally the ventricles function in parallel should take into account the chronology of filling and ejection. In this patient the ability of a ventricle to generate a prenatal transvalvar pressure gradient was evidence that the size, compliance, and contractility of the ventricle were sufficient to maintain good function.

[Left pulmonary artery sling associated with right pulmonary hypoplasia and ventricular septal defect]

The pulmonary artery sling is a congenital malformation where the left pulmonary artery forms a vascular sling that bends around the right border of the lower trachea. Its clinical manifestations are signs of tracheal compression in the first months of life. The diagnosis of this rare anomaly is suspected on radiological and echocardiographic grounds and confirmed by oesophagography, tracheoscopy and angiocardiography. Diagnostic problems may be encountered when the condition is associated with tracheobronchial (50% of the cases) or cardiovascular malformations. In the case reported here respiratory symptoms and heart failure were present in a 1-month hypotrophic infant who also had ventricular septal defect and dextrocardia due to right lung hypoplasia. The pulmonary artery sling was diagnosed by angiography. The severity of the clinical signs precluded all attempts at surgical repair of the cardiovascular anomalies. The child died at the age of 2 1/2 months.

[Mitral atresia. Anatomical aspects]

This study is devoted to a series of 30 anatomical cases of mitral atresia. The left atrium was dilated in 5 cases and hypoplastic in 25. The interatrial ostium was small in 50% of the hearts. Left atrio-ventricular concordance was present in 29 cases, as against 1 case of discordance. There was no atrio-ventricular connection in 29 cases, and the mitral valve was imperforate in 1 case. Connections between the tricuspid valve and the main ventricle were normal in 26 hearts. The tricuspid valve straddled the septum in 4 cases. Five hearts had two ventricles, 25 had a single ventricle. Nine hearts showed no ventriculo-atrial atresia. The main vessels were normally located in 1 case, transposed in 2 and originated in the right ventricle in 2 cases; in the 5 hearts with single ventricle the two main vessels arose from the main cavity. Seventeen hearts had an atresic aortic valve and a hypoplastic ascending aorta; the pulmonary artery arose from the right ventricle in 1 case and from the main chamber of a single ventricle heart in 15 cases. The pulmonary valve was atresic and the aorta arose from the main chamber of a single ventricle heart in 4 cases.

[Atheromatous lesions of the proximal aorta. Severe complications of homozygous type IIa hypercholesterolemia in children]

Coronary lesions with atheromatous deposits occurring in later childhood characterize homozygous type IIa hypercholesterolaemia and condition the somber prognosis of a disease which affects one subject in a million. However, aortic lesions are constantly found, as shown by routine ultrasonographic and angiographic studies in these children. The walls of the proximal aorta are cardboard-like and thick, the origin of the aorta is narrow and the semilunar aortic valves are thickened. The valvular or supravalvular aortic gradient may be considerable; it is often progressive, but is sometimes stabilized or made regressive by medical treatments combined with plasmapheresis or porto-caval shunt. Aortoplasty or aortic valve replacement being difficult to perform in these patients, more aggressive therapeutic procedures, such as liver or heart transplantation, have been suggested. The last generation cholesterol-lowering drugs seem to offer some hope of success.

[Restrictive ostium secundum: a new fetal malformation syndrome]

Echocardiographic examination of a 23 weeks' hydropic fetus disclosed abnormal kinetics of the valve of the foramen ovale. This valve was constantly bulging out, dome-like, into the left atrium, and on TM-mode tracings in transatrial projection the alpha and beta peaks which occur respectively during the opening and closure of the atrioventricular valves throughout fetal life were missing. This anomaly suggested that the ostium secundum was restrictive; the foramen ovale itself was not restrictive. Such abnormal kinetics have not been encountered among 16 other cases of hydrops fetalis of cardiac or other origin, or in a control series of 81 normal fetuses, which clearly shows that the restriction was primitive. At birth, the child presented with aneurysm of the foramen ovale, probably due to the restrictive ostium secundum.

[Digitalis poisoning in children. Treatment with anti-digoxin Fab antibody fragments. Apropos of a case and a discussion of therapeutic indications]

We report one case of Digoxin intoxication in a child treated with Fab Fragments of Digoxin-Specific antibodies (Fabad), although there was no evidence of early life threatening complications. The efficacy of this treatment, which prevents further complications as well as its safety, represent strong arguments to treat children at the early stage of the intoxication in order to avoid temporary cardiac pacing.

[Bourneville's tuberous sclerosis of neonatal disclosure. Apropos of 2 cases]

A cardiac murmur was found in a newborn, after 12 hours of life. It was related to an intracardiac tumor, and we made the diagnosis of tuberous sclerosis. The same diagnosis was made in another patient, with a tumor diagnosed by obstetrical echography. In these two cases, seizures occurred rapidly during the evolution. In one case, the heredity was dominant, in the other one, it was a "de novo" mutation. It is unusual to diagnose tuberous sclerosis during the neonatal period, so we report these two cases.

[Diagnosis and treatment of fetal tachycardia. Apropos of 2 cases]

Fetal echocardiographic studies were performed in 2 patients referred for evaluation of cardiac dysrythmias. Supra-ventricular tachycardia were diagnosed in the 2 patients. Appropriate prenatal treatment can not avoid premature deliveries in one case. Evaluation of in utero cardiac arrhythmias and monitoring of in utero therapy are discussed.

[Extrinsic allergic alveolitis in children. Apropos of 4 cases]

Four cases of extrinsic allergic alveolitis are reported. About them, we discuss: The difficulties of diagnosis that we can only affirm on the association of several clinical, biological, and radiological arguments. The physiopathology: association of immune complex hypersensitivity type III and immediate hypersensitivity type I. It's important to always search for a probable starting infectious factor (mycoplasma). The therapy: antigenic exclusion is the only way to avoid a lung fibrosis.