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The percutaneous aortic valve replacement (TAVI) is the most recent and promising procedure in the area of interventional cardiology with a rapidly growing number of interventions worldwide. The transfemoral approach being less invasive, it has become the predominant access for the device delivery. The prevention of vascular complications by an optimal risk stratification using appropriate imaging techniques (vascular CT scan and angiography), optimised techniques for femoral puncture (active control of the arterial punction, crossover...) and skilled teams for peripheral angioplasty and percutaneous arterial closure devices (Prostar) has become mandatory given the fragile target population for TAVI. Vascular complications remain indeed one of the most frequent complication although the trend toward reduced sheeths size led to significant reduction This is mandatory regarding the needed size of the vascular arterial access - itself with constant improvement by minimising the initial 24 French with mandatory real chirurgical closure to the actual 18-19 French and soon 16 French. The improvement of the implanted devices is due to the recent evidence of the promising future of this technique and the important technological effort realised by the industry not only on the implanted aortic prosthesis but also on their delivering catheters.

The impact of accidental injury on childhood morbidity and mortality in Africa is underestimated. The frequency and severity of accidents is high. This retrospective study includes 381 children (3% of admission) between the ages of 0 and 15 years hospitalized for accidental injury at the Principal Hospital in Dakar, Senegal, between January 1, 1997 and December 31, 2000. The annual incidence of childhood injury doubled over the 4-year study period. Mean age was 48 months and the M/F sex ratio was 1.7. The causes were trauma (n = 184) due to domestic accidents (n = 109 including 91 falls) or road accidents (n = 75), poisoning (n = 129 including 38 caustic soda burns), foreign body aspiration or ingestion (n = 30), burns (n = 18), and miscellaneous accidents (n = 20). Most fatalities (9%) were due to road accidents and falls. Rapid uncontrolled urbanization and problems of displaced rural populations in adapting to city living may account for the high frequency of falls from high buildings and road accidents. As in industrialized countries road accidents, though not the most frequent, are the most lethal. Lack of emergency services accounts for severity. Vigorous information campaigns and prevention action will be needed to lower the high morbidity and mortality of childhood injury in developing countries.

Childhood cancer has often been considered as a problem mainly affecting industrialized countries. In reality more than half of cases occur in developing countries where management and diagnosis are major issues. This retrospective study includes 130 children (0.3% of admissions) between the ages of 0 and 15 years hospitalized for malignant disease at the Principal Hospital in Dakar, Senegal between January 1, 1990 and December 31, 2000. Mean age was 97 months and M/F sex ratio was 1.2. Mean delay for admission was 3 months. The five most frequent cancers, accounting for 75% of cases, were leukemia (n = 28), lymphoma (n = 21), nephroblastoma (n = 21), retinoblastoma (n = 16) and osteochondrosarcoma (n = 10). Treatment was completed in 18% of cases. Half of patient were lost from follow-up. The cure rate was 10% overall and 50% for patients receiving complete treatment. The highest cure rate was achieved for nephroblastoma, i.e., 58% of cases treated. Management of childhood cancer in Africa is confronted with numerous problems, namely, paucity of specialized staff, absence of expert centers, shortage of anticancer drugs, lack of financial resources, and delay in treatment. These factors associated with frequent malnutrition and recurrent infectious diseases, greatly lower cure rates in comparison with industrialized countries.

The authors report a new case of isolated spontaneous nephrocutaneous fistula revealed by a persisting draining sinus in the left groin. Their present causative factors are identified. The computed tomography and magnetic resonance imaging actually may resolve the diagnostic dilemma and are helpful in the surgical treatment.

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

Congenital syphilis is responsible for a variety of clinical symptoms, from subclinical attacks to septicemic forms that may be fatal. The most frequently encountered forms typically involve low birth weight, heptosplenomegaly and jaundice. Premature birth, anemia, cutaneous lesions, coryza, anasarca and pseudoparalysis may also occur. Neonatal X rays generally show characteristic but nonspecific osteochondrocyte lesions and periosteous dystrophy. A clinical form partly associated with growing tissues may be detected late. Diagnosis of fetal syphilis depends on the detection by immunofluorescence of specific IgM immunoglobulins in the newborn. Parenteral antibiotic treatment with 100,000 IU penicillin/kg.day for 15 days is given to newborns with symptoms. The classification and treatment of asymptomatic forms is unclear. A single injection of benzathine-penicillin is a good compromise between simple surveillance and admission to hospital for 10 days of intravenous treatment. In any case, serological surveillance is required to check that IgM disappears from the blood or that the titer of IgG decreases. Reinfection is always possible, even in a newborn treated correctly. In developing countries, pediatricians must be aware of the various clinical forms of congenital syphilis. In addition, national programs to combat sexually transmitted diseases should be supported and developed by international aid agencies. In economically advanced countries, attention is currently focused on the restricted nature of medical treatment. Improvements in the management of congenital syphilis depend above all on dealing with the social and cultural problems of populations affected by syphilis.

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.

The authors report the case of a 34 year old woman, admitted to hospital because of myocardial infarction two months after delivery of her fifth child. The infarction was caused by spontaneous dissection of the left main coronary and left anterior descending arteries. Twenty-three months later, the patient was well with medical therapy. This case is an example of spontaneous post-partum coronary dissection which is the commonest cause of infarction occurring in that period. The physiopathology of this complication is not fully understood. The prognosis is poor, lethal in two thirds of cases. However, it must be emphasised that coronary dissection may regress spontaneously. Patients were previously referred systematically for surgery, but now it is usually reserved for cases with persistent myocardial ischaemia despite medical therapy. Angioplasty may be preferred despite the risks and may be successful in some cases.

The authors report the case of a 31 year old woman at 30 weeks' gestation who developed a non-Q wave postero-lateral myocardial infarction during treatment with salbutamol. There were no complications and delivery took place at term normally. Coronary angiography was performed 3 months post-partum and was normal: the Methergin test was negative. Myocardial ischaemia occurring during treatment with a beta-2 mimetic in pregnancy is rare and hardly ever progresses to myocardial infarction. The usual mechanism of ischaemia is an imbalance of myocardial oxygen demand and supply. Myocardial oxygen consumption is naturally increased during pregnancy and excess intracellular calcium secondary to the beta-1 stimulation occurring with the use of beta-2 mimetic drugs further aggravates matters. This hypothesis raises the question of the value of calcium inhibitors in these forms of myocardial ischaemia.

One case of repeated incisional hernia is reported. This hernia was initially repaired but repeated infection occurred. This hernia was then successfully treated with a fasciocutaneous tensor fasciae latae island flap. The patient was reexamined two years after surgery and presented a functional abdominal wall. Other different reconstructive possibilities of regional myocutaneous flaps are described.

BETTER THAN ANGIOPLASTY: Prolonging inflation with a perfusion balloon decreases the risk of acute coronary occlusion after angioplasty. The longer the artery remains patent, the greater the chances of 0% residual stenosis. This is what the sent allows. Stent act on both mechanisms of stenosis: elastic recoil and fibrous remodeling of the arterial plaque. TARGETTED ACTION: Stents improve angioplasty prevention of acute stenosis. They have a real action on preventing degeneration of the saphenous graft and lead to a significant reduction in the rate of restenosis of the dilated site. There are however two specific complications: subacute occlusion and greater incidence of vascular events. Stents are particularly indicated for the treatment of restenosis and chronic occlusions. TWO IMPROVEMENTS: Risks related to the implantation of a foreign body in the vascular system have been reduced with the use of ticlopidine and high-pressure stent implantation. POSITIVE RESULTS: Stents have produced better angiographic results. They limit restenosis and the number of revascularizations required in treated patients. Several questions concerning indications remain open.

GENERAL CHARACTERISTICS: Several criteria are used for coronary stent design: biocompatibility, i.e. the capacity to resist thrombotic events and corrosion, flexibility, radial force sufficient to resist elastic recoil, percentage of the lesion covered, radio-opacity, minimal shortening at opening, absence of effect on collateral branches, possibility to use small calibre probe guides, and cost. TWO CATEGORIES: Both tubular stents (self-expanding stents and balloon stents) and filamentary stents (made of stainless steel or tantalum) are used, THE IDEAL STENT: There is no one ideal stent. Choice is dictated by the characteristics of the lesion and by the status of the artery to treat.

RATIONALE FOR ANTITHROMBOSIS THERAPY: Introducing a foreign body into the coronaries raises the risk of thrombosis in the acute phase and for the 4 following weeks. The objective of antithrombotic therapy is to inhibit platelet adhesion and aggregation or to induce hypocoagulability. AT IMPLANTATION: High-dose heparin is given in a bolus following pretreatment with aspirin. ASPIRIN-TICLOPIDINE COMBINATION: The risk of subacute thrombosis is low, about 1%, and the rate of vascular complications is minimal. Treatment is simple and compatible with short hospitalization.

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR wasor = 150 ms and the ratio of the minimal velocity to the maximal velocity wasor = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

Neurocysticercosis is the most frequent parasitosis of the central nervous system in the world. Due to the extension of the pandemy, and the importance of the migrations from endemic countries, this parasitosis is being diagnosed with increasing frequency in France. Epilepsy is the main revealing symptom. However, in endemic countries, neurocysticercosis should be suspected in patients with any neurological sign. Diagnosis is based upon imaging procedures (computed tomography and magnetic resonance imaging) and serology (Elisa and Western blot). The evolution is highly variable, from complete latency to severe encephalopathy with psychomotor regression. Praziquantel and albendazole are the main therapeutic agents. Although corticosteroids are usually very effective on symptoms of the acute phase of the disease, their place in the treatment remains to be clarified. Racemic and ventricular forms of the disease usually need neurosurgery. In endemic regions, the diminution of the frequency of the disease relies upon prevention through health education compaigns, pending the achievement of an efficient vaccine.

The authors report the case of a patient undergoing coronary angiography for angina who had an anomalous origin of the septal perforator artery from a separate ostium. Anomalies of the coronary arteries may consist not only of anomalous trajectories and coronary fistulae but also of anomalous origins of the main coronary arteries. The anomalous origin of a septal artery from a separate ostium is very rare accounting for 0.5% of cases in the medical literature. In some cases, this artery provides a collateral circulation for occluded main coronary vessels, thereby preserving left ventricular contractility.

Rarely seen in industrialised countries, ileo-caecal tuberculosis does not require surgery unless complications or diagnosis uncertainly occur. When laparotomy is contre indicated in presence of chronical respiratory disease, laparo-assisted ileo-caecal resection is an interesting alternative to classical surgery as it has less effect on ventilation. This laparo-assisted ileo-caecal resection appears to the first reported in presence of intestinal tuberculosis.

Unique physiological and immunological features of the brain, as previously presented, explain the limitation of local inflammatory reactions and the existence of intrathecal specific IgG production. In addition, some parasitic factors of recent knowledge are induced during neurocysticercosis, which could be involved in vivo in a modulation of the immune response by larval products (a soluble RNA-peptide, some metacestode surface sphingoglycolipids). These recent findings lead us to make a critical review of the antigenic profiles obtained by enzyme-linked immunoelectrotransfer blot (EITB) on samples collected from patients suffering from simple or multiple neurocysticercosis.

The authors report two cases of spontaneous paroxysmal atrial fibrillation closely followed by syncopal ventricular tachycardia resulting in cardiac arrest requiring defibrillation. Both patients, men aged 62 and 64 years, had a past history of myocardial infarction without arrhythmias; atrial fibrillation occurred during severe myocardial ischaemia; coronary arteriography showed tight stenoses of the left main coronary artery with normal left ventricular function. Ventricular tachycardia (or fibrillation) during spontaneous paroxysmal atrial fibrillation is a rare occurrence. This sequence of events has been described in patients with accessory conduction pathways or in hypertrophic cardiomyopathy. It is an exceptionally rare complication of ischemic heart disease with only a very few previously reported cases. Myocardial ischaemia is probably the cause of the arrhythmia in together with irregularity of the ventricular contractions responsible for long cycle-short cycle sequences which are particularly arrhythmogenic and changes in sympathetic tone.

Coronary by-pass surgery and percutaneous transluminal angioplasty (PTCA) have changed the prognosis and life quality of patients with stable angina. Medical treatment and myocardial revascularisation are both useful and most often complementary. Coronary by-pass surgery is indicated in the treatment of coronary left main disease and three-vessel disease with poor left ventricular function. PTCA is the best choice in patient with one-vessel disease resulting in myocardial ischaemia. Discussion remains open in other cases mainly in stenosis of proximal left anterior descending artery. Often the ultimate choice results from the limits of each technique: sapheneous by-pass occlusion or coronary artery restenosis after PTCA. New techniques and devices in revascularization are expected to improve prognosis:use of arterial by-pass grafts, gene transfer, local drug delivery.