[Value of the association of D-dimer measurement and the evaluation of clinical probability in a non-invasive diagnostic strategy of pulmonary embolism]. / Intérêt de l'association du dosage des D-dimères et de l'évaluation de la probabilité clinique dans une stratégie diagnostique non invasive de l'embolie pulmonaire.

New diagnostic tools in suspected pulmonary embolism complete the classical diagnostic strategy of pulmonary scintigraphy and pulmonary angiography to limit the indications of these two invasive investigations. In a prospective series of 204 consecutive patients with suspected pulmonary embolism the association of D-dimer measurement and clinical probability was assessed for the exclusion of the diagnosis of pulmonary embolism. The D-DI Liatest is a new generation, unitary, rapid and quantitative latex test with a comparative diagnostic performance to that of the reference ELISA test, and well adapted to emergency situations.The clinical probability was assessed by a quantitative score based on past history, clinical symptoms and signs. The positive diagnosis of pulmonary embolism was made by spiral CT scanner and/or pulmonary angiography, associated with Duplex ultrasonography of the leg veins in nondiagnostic results. The prevalence of pulmonary embolism was 42.6% and the absence of anticoagulation in patients considered not to have pulmonary embolism was associated with a thrombo-embolic incidence of 0.9% at 3 months. Fifty-six patients had D-dimer concentrations equal or inferior to the threshold of 500 microg/L; the sensitivity was 99% and the specificity 47% with a negative predictive value of 98% to 100% in cases with a low clinical probability. D-dimer measurement is reliable and has a high cost-benefit value in ambulatory patients with suspected of pulmonary embolism and is even more valuable when the clinical probability of this diagnosis is low.

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.