Are there good and bad responders to prehospital thrombolysis in the acute phase of myocardial infarction? OPTIMAL study rationale.

The effectiveness of thrombolytics has been clearly demonstrated in more than half the cases in the large cohorts of patients selected for trials during the acute phase of myocardial infarction. At individual level, thrombolysis will clinically either succeed or fail so, for the medical team managing the patient, choice of treatment may be likened to a gamble which in the best of cases (most often) leads to an uncomplicated success and, in the worst of cases, failure worsened by a severe complication. OPTIMAL is a multidisciplinary and multicentre, prospective cohort study associating mobile medical teams and interventional cardiology units to test the hypothesis that the outcome of prehospital thrombolysis does not depend on chance alone but also varies according to demographic, etiological, clinical and logistic factors involved in the occurrence and management of myocardial infarction. The primary objective of this French study, conducted over one year on more than 800 subjects, is to identify the predictors of the results of prehospital thrombolysis from a very early angiographic evaluation. The results for this cohort may be useful for setting up appropriate management strategies for acute myocardial infarction, from the prehospital phase (thrombolysis or not) up to in-hospital orientation of the patients (angiography room or Intensive Care Unit) and to determine the most judicious time for coronary angiography. OPTIMAL is to date the largest prospective serie of prehospital thrombolysis evaluated by an early angiographic control.

[Unusual diagnosis of partial left abnormal pulmonary venous return in neonate]. / Découverte inhabituelle d'un retour veineux anormal partiel du poumon gauche chez un nouveau-né.

The authors report on a case of a newborn with partial anomalous pulmonary venous return of the lower left pulmonary vein. Diagnosis was performed during the introduction of a central venous catheter. The complications of partial anomalous pulmonary venous rely principally in the risk of endothelium damage and subsequent pulmonary arterial hypertension.

[Real time 3D echocardiography in congenital heart disease]. / Echocardiographie 3D temps réel des cardiopathies congénitales.

The introduction of the 3D mode in echocardiography has led to its use in everyday clinical practice. One hundred and fifty real time 3D echocardiographic examinations were performed in 20 foetus, 110 children and 20 adults with various congenital heart lesions (shunts, valvular lesions, aortic diseases). The 4x matricial probe enables the instantaneous acquisition of transthoracic volumes. Four modes of 3D imaging were used: real time, total volume, colour Doppler and biplane. Quantitative measurements were performed at an outlying station. The feasibility of the method in the foetus, the child and the adult was respectively 90%, 99% and 85%. Real time 3D echocardiography did not affect the diagnoses made by standard echocardiography. The 3D imaging gave a more accurate description of atrial septal defects and congenital valvular lesions. Biplane imaging was decisive in the quantitative approach to aortic dilatation of Marfan's syndrome and in segmental analysis of the foetal heart. 3D colour Doppler imaging has been disappointing but the possibilities of volumic quantification of blood flow are very promising. The present limitations of the method are the inadequate resolution in the small child and the absence of quantitative measurement on the echograph. The facility of utilisation of the matricial probe should lead to routine usage of 3D echocardiography as with 2D and the Doppler modes. Its value should be decisive in many congenital cardiac lesions requiring surgery or interventional catheterisation.

[Slow ventricular tachycardia presenting in the antenatal period]. / Tachycardie ventriculaire lente de révélation anténatale.

The authors report two cases of slow ventricular tachycardia presenting in the antenatal period. One foetus had anasarca at 38 weeks' gestation. After birth, improved myocardial function contributed to the rapid resorption of the effusions. The other case was well tolerated in the foetal and neonatal periods. In both cases, Holter ECG recorded an intermittent ventricular arrhythmia with salvos of sustained ventricular tachycardia with a maximum rate of 185/min, only 10% higher than the underlying sinus rhythm, disappearing on acceleration of the sinus rhythm. The aetiological investigation was negative. Therapeutic abstention was supported by the spontaneously favourable outcome after 3 and 5 months. Slow ventricular tachycardia or accelerated idioventricular rhythms are usually considered to be benign but the case with foetal anasarca suggests that they should be carefully followed up in the neonatal period. In the absence of a consensus on management, therapeutic abstention implies regular cardiological examination until the arrhythmia has disappeared.