[Risk of deep venous thrombosis during an air flight: prevention and counselling at the counter]. / Le risque de thrombose veineuse profonde lors d'un voyage en avion : prévention et conseil à l'officine.

Worldwide air traffic reaches about 2.3 billion passengers per year. The increasing number of persons at thrombo-embolic risk, together with potentially severe or fatal complications of deep venous thrombosis, suggests community pharmacists can give basic preventive advice to persons identified as at risk.

Electrocardiographic changes and halofantrine plasma level during acute falciparum malaria.

The aim of this study was 1) to assess the incidence of electrocardiographic changes after treatment with halofantrine and 2) to study the relationship between these changes and plasma levels of halofantrine and its main metabolite, N-desbutyl-halofantrine. Thirty-four male patients with uncomplicated falciparum malaria were enrolled in this study. Halofantrine was administered on two separate days at a total oral dosage of 24 mg/kg/day in three doses over a 12-hr period. The interval between the two treatments was seven days. Twelve-lead electrocardiography (ECG) was performed to measure the QT interval (QTc), ambulatory ECG monitoring was done to detect ventricular arrhythmia, signal-averaged ECG was performed to detect late ventricular potentials, and blood tests were performed to determine plasma concentrations of halofantrine and N-desbutyl-halofantrine. Maximum QTc was observed at 12 hr after both the first (P < 0.0002) and second treatments (P < 0.03). Signal-averaged ECG revealed late potentials in four cases (72 hr after the first treatment in one case and 24 hr after the second treatment in three cases). Ventricular arrhythmia was not observed. Significantly higher plasma concentrations of halofantrine were observed 2 hr after the second treatment. At this time, both the time effect and time interaction were significant (P < 0.008 and P < 0.02, respectively). The QTc interval was significantly correlated with the plasma halofantrine level (r = 0.41, P < 0.01) but not with the plasma N-desbutyl-halofantrine level (r = 0.30, not significant). In three cases, late ventricular potentials were associated with a maximum concentration of halofantrine. Our findings indicate that electrocardiographic changes are dose-dependent and that a second treatment at the same dosage may be hazardous.

The effects of antimalarial drugs on ventricular repolarization.

Cardiotoxicity has become a major concern during treatment with antimalarial drugs. Lengthening of the QTc and severe cardiac arrhythmia have been observed, particularly after treatment with halofantrine for chloroquine-resistant Plasmodium falciparum malaria. The purpose of this prospective study was to evaluate whether antimalarial agents alter dispersion of the QTc and ventricular repolarization dynamicity. Sixty patients with uncomplicated falciparum malaria were randomly allocated in four groups of 15 patients and treated with quinine, mefloquine, artemether, or halofantrine at recommended doses. Patients in treatment groups were compared with a group including 15 healthy controls with no history of malaria and/or febrile illness within the last month. QTc dispersion was measured on surface electrocardiograms. Repolarization dynamicity was analyzed from Holter recordings, which allow automatic beat-to-beat measurement of QT and RR intervals. Plasma drug concentration was determined by reversed-phase high-performance liquid chromatography. No change in QTc dispersion was observed after treatment with quinine, mefloquine, or artemether. Treatment with halofantrine was followed by a significant increase in QTc dispersion at 9 hours (P < 0.0001) and 24 hours (P < 0.01). Assessment of QT heart rate variability by QT/RR nychtohemeral regression slope demonstrated no significant difference between the artemether (mean +/- SEM = 0.170 +/- 0.048), mefloquine (0.145 +/- 0.044), and the control groups (0.172 +/- 0.039). A significant decrease in the Q-eT/RR slope was observed in the quinine group compared with the control and artemether groups (0.135 +/- 0.057; P < 0.04). With halofantrine, a significant increase in the QT/RR regression slope (0.289 +/- 0.118) was observed (P < 0.0002). QTc interval, QT dispersion, and QT regression slope were significantly correlated with halofantrine and quinine plasma concentration. Mefloquine and artemether did not alter ventricular repolarization. Quinine induced a significant decrease in QT/RR slope of the same order of magnitude as those previously observed with quinidine. Both QTc dispersion and QT/RR slope were significantly modified by halofantrine. These repolarization changes were related to a class-III antiarrhythmic drug effect and may explain the occurrence of ventricular arrhythmia and/or sudden deaths reported after halofantrine intake.

The comparative efficacy and tolerability of CGP 56697 (artemether + lumefantrine) versus halofantrine in the treatment of uncomplicated falciparum malaria in travellers returning from the Tropics to The Netherlands and France.

CGP 56697 (Riamet) is a new oral anti-malarial drug composed of artemether and lumefantrine (benflumetol) which combines the fast, short-acting artemether for rapid parasite clearance with the prolonged action of lumefantrine for intended radical cure. In this double-blind, comparative trial, the efficacy and tolerability of CGP 56697, given as a course of 4 x 4 tablets over 48 h, was compared to halofantrine, given as 3 x 2 tablets over 12 h with a second course 1 week later. Patients (mostly non-immune) with acute, uncomplicated Plasmodium falciparum infection were randomly assigned to either CGP 56697 (n = 51) or halofantrine (n = 52). CGP 56697 proved superior with respect to parasite clearance time (median 32 vs. 48 h, P < 0.001) and parasite reduction at 24 h (median 99.7 vs. 89.6%, P < 0.001) with a non-significant difference in resolution of fever (median 24 vs. 32 h, P = 0.835). However, a 28-day cure rate of 82% was observed for CGP 56697 and 100% for halofantrine. Significant QTc prolongations (> 30 ms) were seen 6-12 h after halofantrine intake but not after CGP 56697 intake. CGP 56697 is an effective, well-tolerated treatment for uncomplicated falciparum malaria but for this dosing regimen the recrudescence rate is unacceptablyhigh (18%). For travellers contracting malaria abroad, we propose a six-dose regimen of CGP 56697 over 3 days.

Isolated pulmonary valve endocarditis with patent ductus arteriosus. A report of a case.

A case of pulmonary valve endocarditis in a patient with patent ductus arteriosus is reported. The diagnosis was made by echocardiographic examination. The M mode echocardiogram showed "shaggy" echoes on the pulmonic valve and the two dimensional echocardiogram disclosed a big vegetation in the right outflow tract. The patient underwent surgery with complete cardiopulmonary bypass. The ductus arteriosus was closed by endopulmonary approach and the pulmonic vegetation was removed.

[Reconstructive mitral valvuloplasty. Results apropos of 53 cases]. / La valvuloplastie mitrale reconstitutive. Résultats à propos de 53 cas.

In the last three years, 53 patients have undergone a valvuloplasty according to the Carpentier's principles. The patients age ranged from 5 to 35 years, with a mean of 14.3 years. The aetiology was congenital in one case, RHD in 45 cases, and endomyocardial fibrosis (EMF) in 7. The pre-operative condition was severe with 25 patients in class III and 10 patients in class IV. There was a cardiomegaly with a mean CTR of 0.70 (extremes 0.50 and 0.85). The mitral lesions were pure mitral insufficiency in 49 cases, and mixed lesions with predominant insufficiency in 4 cases. There were also 6 aortic and 4 tricuspid significant insufficiencies. The patients have had a valvuloplasty with chordae shortening (n: 46) valvular resection (n: 3), chordae resection (n: 8), annuloplasty without ring (n: 38) or with ring (n: 2). There were associated procedures: endocardectomy (n: 7), aortic valvuloplasty (n: 3), aortic valve replacement (n: 3), tricuspid annuloplasty (n: 4). There were 3 post-operative deaths in children in class IV, with cardiomegaly (CTR 0,80), and systemic pulmonary hypertension. There were 3 mitral valve replacements (MVR) in the first month for failure of the plasty, 2 late MVR for endocarditis and rheumatic evolution. There were 3 mitral valve replacements (MVR) in the first month for failure of the plasty, 2 late MVR for endocarditis and rheumatic evolution. There were 2 late deaths (recurrent mitral insufficiency, serum hepatitis), Among 43 long-term follow-up of patients with a plasty (mean follow-up 18 months), the result has been very good 39 times. There were 4 patients with a significant residual mitral incompetence.(ABSTRACT TRUNCATED AT 250 WORDS)

[Open-heart valvular surgery in children. Apropos of 127 cases]. / La chirurgie valvulaire à coeur ouvert chez l'enfant. A propos de 127 cas.

In view of the frequency and the severity of rheumatic heart disease (RHD) and of endomyocardial fibrosis (EMF) in the african child, the indication of a valvular surgical procedure is frequent in Abidjan. Between 1978 and 1983, 127 open-heart procedures have been performed in 113 patients. The ages ranged from 2 to 15 years, with a mean of 11 years. There were 67 RHD, 37 EMF, 9 bacterial endocarditis. The status of the patients was severe, there was a cardiomegaly (mean CTR of 0.70). 3 patients were in atrial fibrillation. The patients underwent 97 valve replacements (70 mitral, 18 tricuspid, 9 aortic) essentially by a bioprosthesis (n : 87). A mitral valvuloplasty was done in 27 cases. Associate procedures have been employed including : 35 endocardectomies, 11 aortic valvuloplasties, 6 tricuspid annuloplasties. 12 patients have been reoperated for bacterial endocarditis of a mitral prosthesis (n : 4), calcification of a mitral bioprosthesis (n : 5), failure of mitral valvuloplasty (n : 3). There were 13 deaths (10.2 p. 100 mostly in EMF surgery : 7 deaths (5.5 p. 100). No patient with a bioprosthesis received anticoagulants post-operatively. All surviving patients have been improved, with a mean post-operative follow-up of 32 months. There were 11 late deaths (8.6 p. 100). The authors discuss several points including : severity of children valvular diseases in tropical areas; necessity to use the bioprosthesis in this area of the world; increasing tendency to conservative surgery in the mitral and also the aortic position.

[Salmonella aortic valve endocarditis presenting with rupture of a femoral artery mycotic aneurysm]. / Anévrisme mycotique fémoral rompu, révélateur d'une endocardite aortique à salmonelle.

The incidence of Salmonella enteritidis infections has greatly increased over the last few years. Cardiovascular are amongst the most severe extra-digestive complications. The authors report a case of Salmonella enteritidis presenting with rupture of a femoral artery mycotic aneurysm in a chronic alcoholic patient. Salmonella enteritidis was isolated from blood cultures and the operation specimen after the obligatory limb amputation. The outcome was finally favourable after appropriate antibiotic therapy with a residual, stable grade 3 aortic regurgitation. This rare condition is generally observed in immuno-compromised subjects and carries a high mortality (40 to 70% of cases). The initial infectious signs may be masked, and, in these cases, rupture of an aneurysm is often the mode of presentation. Rapid treatment is essential with, ideally, resection of the aneurysm with reestablishment of arterial continuity and adapted, prolonged antibiotic therapy.

[Isolated replacement of the tricuspid valve with a bioprosthesis. Apropos of 22 cases in Abidjan]. / Le remplacement valvulaire tricuspidien isolé par bioprothèse. A propos de 22 cas observés à Abidjan.

The authors reviewed the operative and function results of 24 isolated tricuspid valve replacements with bioprostheses in 22 patients. The patient population was young (average age 15 +/- 8 years). The surgical indication was massive tricuspid regurgitation due to chronic parietal endocarditis in 19 cases and to bacterial endocarditis in 3 cases. Tricuspid valve replacement was associated with 19 right ventricular endocardectomies, 2 direct closures of ventricular septal defects, 2 Wooler mitral valvuloplasties and 1 pericardectomy. The operative mortality was 13.5% and the secondary mortality 13.5%. Of the 16 survivors, 13 are in the NYHA Class I with no regular medical therapy. Their cardiothoracic ratio has slightly decreased. Two patients have permanent atrial fibrillation, and 12 have acquired definitive complete right bundle branch block. Eight of these patients had significant improvement of atrial and right ventricular pressures, of Yu's index and cardiac index at postoperative catheterisation. Three of the 16 patients developed progressive calcific degeneration of their bioprostheses. They are among the 6 patients who have been followed up for more than 3 years. There was no mortality at reoperation. Isolated tricuspid valve replacement by bioprosthesis was chosen despite the young age of these patients because of the disadvantages of mechanical prostheses which are associated with a much higher mortality related to incarceration and thrombosis of the prosthesis. The relatively high operative and secondary mortality in this series of isolated tricuspid valve replacement compared to mitral, aortic or micro-aortic valve replacement, is related to the gravity of the underlying causal pathology.

[Anatomo-clinical forms of left endomyocardial fibrosis. Study of 22 surgically treated cases]. / Les formes anatomo-cliniques de la fibrose endomyocardique gauche. Etude de 22 cas opérés.

The authors studied 22 patients with operated left sided endomyocardial fibrosis (EMF). Twenty patients had pure left sided and 2 bilateral (mainly right sided) EMF. The mean age of the patients was 14 years (range 7-51 years). Three clinico-pathological forms of the disease were identified: obliterating, diffuse and limited. The mechanism of associated mitral regurgitation was papillary muscle and/or posterior leaflet involvement. The anterior mitral leaflet was not affected in any of these cases. Echocardiographic diagnosis was possible in 18 cases by M mode recording showing M-shaped septal wall motion. The diagnosis was made in 5 out of 13 patients by 2D echocardiography. This method was satisfactory in the obliterating form of the disease but direct visualisation of the fibrosis in the diffuse and limited forms was very difficult. Catheter studies showed severe pulmonary hypertension in all cases. The presence of a dip-plateau pressure recording was inconstant and was only observed in the obliterating and diffuse forms of EMF. Angiocardiography was characteristic in the obliterating and diffuse forms and enabled an accurate anatomical diagnosis before surgery. The diagnosis of the limited form was difficult and could only be suspected in cases of mitral regurgitation associated with right ventricular EMF or in the presence of parietal recesses. This surgical series does not include cases of EMF limited to the ventricular apex without mitral regurgitation or adiastole, treated medically.

[Pulmonary artery aneurysms in patent ductus arteriosus]. / Les anévrysmes pulmonaires au cours de la persistance du canal artériel.

Two cases of pulmonary artery aneurysm are reported in patients with persistent ductus arteriosus (PDA). The first was a mycotic aneurysm complicating staphylococcal pneumonia; the other was a calcific aneurysm of the right pulmonary artery. The mycotic origin was confirmed in the first case. The aetiological roles of pulmonary hypertension and previous endocarditis are discussed in the second case. Based on these two observations, the authors analyse the aetiology and evolution of mycotic aneurysms and review the therapeutic problems posed by their association with PDA.

[Acute myocarditis and eosinophilic pneumonia: good outcome after medical treatment and long-term follow-up]. / Myocardite aiguë et pneumopathie à éosinophiles: évolution favorable après traitement médical et suivi à long terme. A propos d'un cas.

The authors report a case of acute eosinophilic myocarditis (AEM) with acute left ventricular failure preceded by an acute hypoxaemic eosinophilic pneumonia. The diagnosis of myocarditis was confirmed histologically. That of the eosinophilic pneumonia was base on the abundance of eosinophilic polynuclear cells in the bronchoalveolar lavage and appearances on computerised tomography. The pulmonary lesions rapidly and definitely regressed and complete recovery of left ventricular function was obtained by long-term steroid therapy. This favourable outcome has been sustained after 11 years of follow-up despite the presence of chronic mild hypereosinophilia. In the absence of specific clinical and paraclinical data, the diagnosis of AEM was based on the demonstration of an inflammatory infiltrate rich in polynuclear eosinophils and necrotic myocardial lesions. This histological signature may be obtained in vivo by endomyocardial biopsy, the indication of which must be rapidly recognised. Only the instauration of early and intensive steroid therapy seems to influence the outcome which is frequently poor. The synthesis of the anatomo-clinical and experimental data suggests a myocardial aggression by cytotoxic effects of granular protein components released during activation of polynuclear eosinophils. The role of AEM is discussed in the different aspects of cardiac hypereosinophilia.

[Echocardiographic, angiographic and hemodynamic development of surgically treated endomyocardial fibrosis]. / Evolution échocardiographique, angiographique et hémodynamique des fibroses endomyocardiques opérées.

The echocardiographic, angiographic and haemodynamic evolution of endomyocardial fibrosis (EMF) was assessed in 19 patients: 8 patients with isolated right sided EMF, 3 with predominantly right-sided EMF, and 8 with isolated left sided EMF with mitral regurgitation. Echocardiographic controls were preformed in 16 patients, on average 11.3 months after surgery; angiographic and haemodynamic controls were preformed in 14 patients, on average 14 months after surgery. In isolated or predominantly right-sided EMF, echocardiographic abnormalities of septal motion (paradoxal) disappeared. Although the volume of the right heart chambers decreased, they remained dilated. The syndrome of adiastole disappeared in patients operated early. In left EMF with mitral regurgitation, the M-shaped motion of the septum regressed in the 4 cases in which this abnormality was observed preoperatively. The size of the left heart chambers decreased on post-operative echo and angiographic studies. Left ventricular function returned to normal after surgery. The author underline the differences between right and left-sided EMF with mitral regurgitation. In right-sided EMF the evolution is that of adiastole and surgery should be preformed early because the right ventricular reserve is small. In left-sided EMF with mitral regurgitation, the evolution is that of a valvular lesion with a good postoperative result.

[Aorto-coronary dysplasia and pseudoxanthoma elastica]. / Dysplasie aorto-coronaire et pseudoxanthome élastique. A propos d'un cas.

The authors report the case of a 50 year old man with pseudowanthoma elastica with a history of myocardial infarction and severe aortic regurgitation. Angiography showed multiple coronary artery aneurysms and aneurysmal dilatation of the aortic annulus. The outcome after triple coronary bypass surgery with aortic valve replacement in a valved Bentall conduit was favourable. Pseudoxanthoma elastica is a rare condition in which the prognosis depends on the degree of vascular involvement. In this context, coronary artery aneurysms and aneurysmal dilatation of the aorta are rare complications.

[Heart rate variability and vagal syncope in the young adult]. / Variabilité sinusale et syncope vagale chez l'adulte jeune.

Heart rate variability is a sign of sympathetic activity. The authors compared two study populations of young males aged 19 to 30 years: population T comprised 15 healthy volunteers who had two negative tilt tests, one under basal conditions and the other after a bolus of isoproterenol; population S comprised 12 patients without cardiac or other disease, who were followed up for malaise and in whom the basal tilt test was positive, confirming the vagal origin of syncope. Temporal and spectral (total power, low frequency 0.04-0.15 Hz, hight frequency 0.16-0.40 Hz) data was obtained concerning heart rate variability from 24 hour Holter monitoring. The main difference between the two study populations was in the temporal data over 24 hours especially with respect to the heart rate (T = 73.5 +/- 6.9; S = 65.4 +/- 6.2/min; p = 0.004) and the percentage of successive R-R intervals varying by more than 50 ms (PNN 50) (T = 20.2 +/- 8.3%; S = 30.7 +/- 10.2%; p = 0.024). At night, the lowest SDANN/5 (standard deviation of RR intervals over periods of 5 minutes) were observed in group S (67.2 +/- 16.7 ms vs 87.3 +/- 24.4 ms; p = 0.026). No statistically significant differences between the two groups was observed in the spectral data. The temporal data of heart rate variability on Holter ECG monitoring over 24 hours could therefore have a good predictive value of the vagal origin of syncope in young adults.

[Buerger's disease and coronary disease]. / Maladie de Buerger et atteinte coronaire.

The authors report the case of a 33 year old man with distal occlusive arterial disease diagnosed as Buerger's disease, with two previous transient ischaemic attacks and coronary disease resulting in myocardial infarction. Coronary angiography showed narrowing of the second segment of the left anterior descending artery, occluded distally and not suitable for revascularisation. The observation of coronary artery disease is very rare in Buerger's disease and data of coronary angiography are very sparse in this context. The occurrence of myocardial infarction and the angiographic appearances of the left anterior descending artery raise the question of coronary involvement of Buerger's disease.

[Contribution of myocardial biopsy and immunohistochemistry to the prognostic evaluation of cardiac amyloidosis]. / Apport de la biopsie myocardique et de l'étude immunohistochimique à l'évaluation pronostique des amyloses cardiaques.

The authors report four cases of cardiac amyloidosis, the diagnosis of which was confirmed by endomyocardial biopsy. They underline the value of immuno-histological studies with labelling of the biopsy fragments with anti-transthyretin and anti-light chain immunoglobulin antibodies. This approach provides a more precise typing of amyloidosis and a more accurate evaluation of the prognosis.

[Bipolar transseptal radiofrequency ablation of posteroseptal bundle of Kent. Apropos of a case]. / Utilisation du mode bipolaire transseptal pour l'ablation par radiofréquence d'un faisceau de Kent postéro-septal. A propos d'un cas.

The posteroseptal localisation of accessory pathways is sometimes responsible for important difficulties for radiofrequency current endocavitary ablation. Some authors have reported the exceptionally rare use of the transseptal bipolar mode for ablation of this type of accessory pathway. The authors report the case of a patient in whom failure of unipolar radiofrequency ablation at the tricuspid and then mitral annulus was followed by immediate success when the bipolar mode was used. The value of recording with the transseptal dipole at the ablation site is emphasised.

[Angiography imaging in pulmonary embolism (author's transl)]. / L'angiographie dans l'embolie pulmonaire.

The principal angiography images found in cases of recent pulmonary embolism include intravascular lacunae, dome-shaped obstructions, a "dead tree" appearance and an avascular region. The first two are specific, but are mainly observed during the few days following the embolism. Highest quality images are obtained by selective angiography of the pulmonary artery, but this technique, which involves transfer of the patient to a specialized unit and catheterization of the pulmonary artery, is not without risk and, more particularly, does not explore the veins of the lower limbs. However, in a series of 110 cases of recent pulmonary embolism, venous thrombosis, usually femoroiliocaval, was present in 102 patients. A new technique is therefore proposed, ascending venous angiopneumography, which has two advantages: --It can be performed in any radiological department as a catheter does not have to be inserted. --It explores both pulmonary and venous systems. Though pulmonary images are less specific (false positives occur more frequently), the simultaneous exploration of the veins allows logical determination of therapy based on the size and site of the embolus and possible associated extension of the venous thrombosis.

[Pulmonary manifestations of malaria]. / Les manifestations pulmonaires du paludisme.

Pulmonary edema is a classic and severe manifestation of falciparum malaria. To evaluate the predictive factors of this severe complication, we studied epidemiological, clinical and biological data of 136 patients with acute malaria. Two groups were individualized according to the presence (group I = 53 patients) or the absence (group II = 83 patients) of pulmonary manifestations. Pulmonary signs incidence was not correlated with impairement consciousness, creatinemia, hypoglycemia, and coagulation abnormalities. However, age, tobacco abused, delay in starting treatment, oliguria, decreased protidemia were significantly increased. These factors, associated with severe malaria, expose to a more important risk of pulmonary edema, often induced by reanimation management.