[Cardiac tamponade by right atrial laceration due to blunt chest trauma in a 3-year-old child]. / Tamponnade cardiaque par plaie de l'oreillette droite liée à un traumatisme fermé du thorax chez une enfant de trois ans.

The case of 3-year-old girl severely injured, as restrained car passenger in a road crash, is reported. She presented with isolated circulatory failure, without specific clinical signs except skin contusions corresponding to seat belt. Because of mediastinum enlargement on systematic chest X-ray, a pericardial effusion was suspected, which was confirmed by echography, rapidly complicated by an acute tamponade without visible cause on CT-scan. The radiological assessment showed a moderate peritoneal haemorrhage related to a splenic injury. A persistent haemodynamic instability required a pericardial puncture, after rapid sequence tracheal intubation of the child, but without clinical improvement, despite fluid bolus, red-blood cell transfusion and epinephrine infusion. The child was rapidly transferred to the cardiac operating room for sternotomy, which showed a right atrial laceration. The injury was repaired, allowing the child to survive without disability. Tamponade due to traumatic cardiac injury is extremely rare in children. The clinical diagnosis is particularly difficult to establish in the context of polytrauma. The classical symptoms of cardiac tamponade are rarely complete. The association of chest injury, isolated circulatory failure and enlargement of mediastinum at chest X-ray should alert the physician. As the severity of these injuries is high, a rapid and multidisciplinary management is required, as well as specific anaesthetics precautions.

[End-stage heart failure: quantity or quality of life?]. / Insuffisance cardiaque terminale: quantité ou qualité de vie ?

Several clinical trials testing the safety and efficacy of different positive inotropic agents in patients suffering form end-stage heart failure have confirmed that these drugs increase mortality. We nevertheless, use these agents regularly because of the presumption that they improve quality of life. However, this presumption, sound a priori, is not firmly anchored. When we prescribe these drugs, do we inform our patients? Do the patients ultimately decide whether to be treated with inotropic agents? What is the role of palliative care in the end-stage heart failure patient? We review the literature and reflect on these issues, long completely ignored, though beginning to elicit specific articles.

[Adrenal vein catheterization in primary hyperaldosteronism: aid in surgical decision making?]. / Cathétérisme des veines surrénales dans l'hyperaldostéronisme primaire: aide à la décision chirurgicale?

UNLABELLED: The localisation of aldosterone-producing adenomas (APA's) remains difficult. Indeed, CT scan may not detect small APA's while CT detected tumours do not necessarily produce aldosterone. OBJECTIVE: To evaluate the value of adrenal vein catheterization (AVC) for the diagnosis of APA's and also the rates of unsuccessful procedures and complications. PATIENTS: One-hundred-and-nine hypertensives with biological features of primary hyperaldosteronism were included. Plasma sodium, potassium, aldosterone and renin levels were obtained after one night in lying position. Aldosterone and renin levels were also measured after a one-hour walking period and after a sodium expansion with saline. All patients underwent a CT scan and AVC. For adrenal samples, the ratio of aldosterone to cortisol concentrations was calculated for both sides. Both ratios were divided by the opposite one and the higher was retained as an index of laterization (IL). For lack of a golden standard variable, we have taken as a working hypothesis that operated patients had an APA (n = 38) and the non operated ones bilateral hypereplasia (n = 71). RESULTS: Operated patients had a shorter history of hypertension, more frequently a left ventricular hypertrophy on ECG, and lower serum creatinine and potassium levels, along with a higher sodium level. None of these features appeared discriminant, however. Presence of a 10-mm tumour on CT scan was not significantly different between the 2 groups. Operated patients had more than a five-fold higher IL compared with that of non-operated patients. Analysis using a ROC curve showed that the value of 12 for "IL" was an acceptable operational criterium of lateralization, producing a specificity of 90%, while maintaining a sensitivity of 62%. AVC appeared most useful in case of middle-range pre-test probability of an APA being present, that is when when clinical, biological, or radiological features are not fully concordant. The rate of unsuccessful procedure and the rate of complications were low (1.8% and 3.6%, respectively). CONCLUSION: With a low iatrogenicity, AVC appears helpful in indicating surgery mostly when clinical, biological, and CT scan features are not fully concordant. A value of 12 for IL appears to allow a high specificity while retaining an acceptable sensitivity.

Primary aldosteronism and adrenal incidentaloma.

Adrenal incidentaloma are usually found during the assessment of non adrenal disease. In this paper we report the association between a bilateral adrenal hyperplasia and a macronodule of adrenal cortex (adrenal incidentaloma) which is a rare and misleading cause of primary aldosteronism. In the light of this association even if it is likely to remain rare and of those previously published, its existence is an additional reason for suggesting surgical treatment of primary aldosteronism only to patients who satisfy the following criteria: 1) satisfactory control with spironolactone; 2) poor spironolactone tolerance and poor control with other drugs; 3) accept to be operated on and the risk of a possible error.

[Double outlet left ventricle: a rare and unusual cardiopathy. Apropos of 7 new cases]. / Le ventricule gauche à double issue:une cardiopathie rare et étonnante de diversité.

Double outlet left ventricle is a very rare condition due to an abnormality of conotruncal morphogenesis. The authors report 7 new cases to the 119 already published, one with an anatomical variation not previously described. Three of the cases reported were of the most usual type similating tetralogy of Fallot. Two of these cases underwent complete correction with excellent results 13 months and 2 years after surgery. The third patient aged 6 months is well after initial palliative neonatal surgery. A case with an L-malposition pedicle with subpulmonary ventricular septal defect and pulmonary outflow tract obstruction died after early palliative surgery (Blalock-Taussig). A case with subaortic ventricular septal defect, pulmonary stenosis, and tricuspid atresia, underwent physiopathological correction (Fontan procedure) after a Waterston shunt and is well at 19 years of age. The other two cases presented more unusual anatomical forms aortic outflow obstruction: one had hypoplasia of the aortic arch with an isthmic coarctation requiring a Crafoord procedure in the neonatal period associating with banding followed by complete correction at 19 months of age. After 3 years, the patient is asymptomatic. The last case with atresia of the aortic valve and severe hypoplasia of the ascending aorta died after corrective surgery of first intent. Other cases have been described in the literature with different clinical presentations: absence of pulmonary or aortic obstruction; intact interventricular septum. The anatomical variability is due to the complex embryogenesis of the conotruncal region and explains the clinical diversity of this congenital cardiac malformation.

New meta-analysis of treatment trials of hypertension: improving the estimate of therapeutic benefit.

The objectives of this sub group meta-analysis on the treatment of hypertension was to: (1) high-light specific results of well-designed trials; (2) group trials according to their specific clinical context; (3) express results of the meta-analysis in absolute reduction terms; and (4) estimate the bias of withdrawal because of blood pressure increase. This meta-analysis is based on summarised published results from randomised controlled trials, comparing a drug treatment versus placebo or no treatment, with morbi-mortality as the principle outcome. The following data were analysed: (1) total mortality; (2) cardiovascular mortality; (3) stroke; (4) major coronary events; and (5) congestive heart failure. The treatment significantly reduced the incidence of all outcomes in trials involving older patients, avoiding up to nine strokes (OR = 0.66, 95% Cl: 0.56-0.77) and four major coronary events (OR = 0.79, 95% Cl: 0.68-0.92) every 1000 patient-years when the bias of withdrawal was taken into account. The only outcome significantly influenced by treatment in younger patients with mild-to-moderate hypertension was stroke, with one stroke avoided every 1000 patient-years (OR = 0.51, 95% Cl: 0.39-0.66). There was insufficient statistical power in the trials which enrolled patients with non-moderate hypertension to reach clinical significance, except for the reduction in the incidence of congestive heart failure. However, the results indicated a trend towards greater absolute benefit under treatment. Trials enrolling patients with post-stroke hypertension also had insufficient power, but suggested benefit by the reduction of the incidence of stroke recurrence and congestive heart failure under treatment. In conclusion, the most constant treatment benefit concerned stroke, although the absolute reduction was very modest in younger patients with mild-to-moderate hypertension. Only the results from trials in older patients showed a significant reduction of major coronary events. Such results need further analyses, ideally based on individual patient data.

[Acute infectious myocarditis in children. Apropos of 2 series from Lyon]. / Les myocardites aiguës infectieuses de l'enfant. A propos de deux séries lyonnaises.

Acute infectious myocarditis in childhood has a very poor initial outcome, but the long-term outlook is relatively good for the survivors. This retrospective study was based on cases of acute myocarditis admitted to two hospital departments with different modes of recruitment. Firstly, a polyvalent paediatric intensive care unit where 12 children (mean age 12 months) were admitted during the acute phase of myocarditis. The initial symptoms were non-specific and misleading, the diagnosis being established at autopsy in 9 cases. Only 4 children presented with typical cardiac failure. The clinical signs were hepatomegaly, sinus tachycardia, cardiomegaly, ECG ST-T wave changes and biological signs of multiple organ failure. Left ventricular function was very poor with a fractional shortening of only 17%. The causal agent was usually viral. The clinical course was marked by a high early mortality (11/26, 42%) within 23 hours of hospital admission. Secondly, a paediatric cardiology unit where 81 children (mean age 15 months) were followed up after acute infectious myocarditis. Thirteen cases were taken from our first series and were included for long-term follow-up; 76.5% had premonitory signs of infection and 71% were in cardiac failure, Classes III or IV, during the hospital admission. The causal agent was identified in 30 cases (37%) and was usually a virus (22 cases). Treatment was classical (association of digitalis, diuretics, angiotensin converting enzyme inhibitors, anticoagulants and beta-sympathomimetics when necessary).(ABSTRACT TRUNCATED AT 250 WORDS)

[Hypothyroidism, hypocholesteremic agents and rhabdomyolysis]. / Hypothyroïdie, hypocholestérolémiants et rhabdomyolyse.

The author report two cases of patients treated for several years for essential hypercholesterolaemia, in whom clinical and biological signs of rhabdomyolosis led to the diagnosis of hypothyroidism. Hormone replacement therapy corrected thyroid function, the muscle enzyme levels and serum cholesterol without associated lipid lowering drugs. All lipid lowering drugs, apart from cholestyramine, can cause rhabdomyolysis, usually by overdosage, renal failure or hypoalbuminaemia. Hypothyroidism is a common cause of rhabomyolysis and hyper-cholesterolaemia and its association with lipid lowering drugs is an additional risk factor for rhabdomyolysis. The cause of rhabdomyolysis may be determined from simple biological tests and this is particularly important because it allows appropriate therapy.

[Primary prevention of hypertension in the general population. The Lyon Action for the Prevention of Hypertension and Atherosclerosis]. / Prévention primaire de l'hypertension artérielle dans la population. L'action lyonnaise de prévention de l'hypertension et de l'athérosclérose.

UNLABELLED: The aim of ALPHA (1976-1982) was to realize an action of cardiovascular prevention in a professional population, by combining a) an education of the general population and b) an individual managing of the high risk people. The "Study" (S) population originated from Lyon; the "Reference" (R) population originated from two smaller cities. There was no randomization. The plan of the study included: A baseline cross study, dealing respectively with 9,598 and 9,558 subjects in S and R; The educational intervention, aiming chiefly at reducing caloric and sodium intakes, and at increasing the potassium intake; The evaluation was done after five years, by re-examining the subjects seen at the baseline study and still present in the enterprises. Mainly because of the economic crisis, the re-examination rates were only about 45%. RESULTS: at the baseline, BP's were not significantly different: 137/77 S vs 132/75 R for men, and 129/74 S vs 126/73 R for women. The final comparisons about primary prevention of hypertension were computed after adjustment for age and sex, after exclusion of the subjects who were hypertensive at baseline. The knowledges about hygiene were significantly but moderately better in S. The urinary Na/K and Na/Creatinine ratios did not differ significantly. The alcohol intake was lower in S (p less than 0.001). The incidence of HT was greater in S (p less than 0.001). The means of the individual variations of systolic and diastolic BP were computed: the adjusted differences S-R were respectively + 1.53 and 2.19 mmHg for systolic and diastolic (p less than 0.001 for both). CONCLUSION: the feasibility of the intervention was moderate. The failure to demonstrate any prevention of HT might indicate that the hypothesis was wrong, and/or that the methodology was inadequate.

[Against routine coronary angiography after myocardial infarction]. / Contre la pratique systématique de la coronarographie après l'infarctus du myocarde.

Various arguments have been put forward to justify routine coronary arteriography after myocardial infarction. This investigation has been said to be essential to: 1) evaluate prognosis--while it has now been shown that combined data based upon coronary history, the initial clinical and electrocardiographic course and stress tests (electrocardiographic and/or isotope) carried out 10 to 20 days after the infarction have a predictive value superior to that of coronary arteriography regarding post-infarct mortality and the remaining functional capacity of the patient; 2) guide therapeutic indications--while patients evaluated as low risk on the basis of the above data, i.e. 50% of all infarction victims, would derive no benefit from myocardial revascularisation procedures; 3) obtain the best cost/efficacy ratio--while it has been shown that approaches based upon stress tests best fulfil this criterion. The authors plead for a reasoned approach in terms of the indication for post-infarction coronary arteriography, with the risk level of patients after the infarct being taken into account overall, and with case by case discussion of the usefulness of the investigation in terms of the patient's age (rarely indicated in the elderly, but also in the younger patient when free of ischemia during exercise), the coronary history (broad indications in recurrent infarctions), the initial clinical course (coronary arteriography indispensable where there is early recurrence of angina and/or severe left ventricular dysfunction with ejection fraction less than 0.45) and the results of stress tests performed 10 to 20 days after the infarct.