A trans-catheter closure of an atrial septal defect (ASD) is efficient. Balloon sizing (BS) during the catheterization leads to an overestimation of ASD size. Three-dimensional transoesophageal echocardiography (3D-TEE) allows the ASD morphology to be assessed comprehensively. The aim of this study was to assess the relationships between the shape and the measurements of ASDs by 2D-, 3D-TEE, and BS in children. Methods and resultsThirty children who underwent percutaneous closures of a single ASD were enrolled. ASD diameters were measured by 2D-transthoracic echocardiography (TTE), 2D-TEE, 3D-TEE and compared with BS. The ASD area was measured on 3D-TEE images after multi-planar reconstruction. ASD was estimated as round or oval on 3D-TEE 'en-face' view. 2D-TTE, 2D-TEE, and 3D-TEE max ASD diameters were well correlated with BS (r ¼ 0.75; 0.80, and 0.85, respectively). Mean diameters were all significantly smaller than the mean BS. The mean difference between the balloon area and 3D-TEE area was 1.6 + 1.4 cm 2 (P , 0.0001). The mean difference between BS and 3D-TEE max diameters was higher in round ASDs than in oval ASDs (4.0 + 3.3 vs. 1.1 + 3.3, P ¼ 0.02). With multivariate linear regression analysis, two formulas were built to predict BS. The first model was BS ¼ 1.07 × 3D-TEE max 2 3.1 × ASDshape + 3. The ASD shape was 0 for round and 1 for oval ASDs. A second model was BS ¼ 4.5 × ASDarea + 11.5. ConclusionThe ASD shape is accurately estimated by 3D-TEE and influences the relationship between echocardiographic measurements and BS. The ASD shape, its maximal diameter and the area assessed by 3D-TEE may be sufficient to determine the device size without BS in children.--

Ventriculoatrial shunt (VAS) is an accepted treatment for hydrocephalus, submitting intra-cranial pressure to right atrial pressure. Several pathological situations can increase right atrial pressure, frequently as a consequence of pulmonary hypertension, and lead to the recurrence of intra-cranial hypertension. We report an unusual aetiology of invalidating headaches in a 26-year-old woman with history of Dandy-Walker syndrome treated initially by multiple ventriculoperitoneal shunts (VPS) switch 2 years ago by a VAS. Congenital heart disease was excluded during the childhood. She was current smoker, obese (body mass index 32.5 kg/m 2 ) and took combined oral contraceptive pill. She also reported a stage II NYHA class dyspnoea aggravated for 2 weeks. On physical examination, the heart rate was 95 beats per minute and the blood pressure 120/70 mmHg. She had an elevated jugular venous pressure and an accentuated pulmonary component of the second heart sound. Cerebral computed tomography (CT) showed a DandyWalker cyst in the posterior fossa (Fig. 1a). ECG reported a sinus rhythm with tachycardia, S1Q3 pattern and negative T waves in the right precordium (Fig. 1b). Arterial blood gas showed hypoxemia (PaO 2 70 mmHg) and hypocapnia (PaCO 2 32 mmHg; pH 7.43). CT pulmonary angiogram confirmed lingular pulmonary emboli with chronic pulmonary embolism signs as pulmonary artery enlargement and pulmonary vascular thickening (Fig. 1c). There was no abnormality of VAS catheter confirmed by transesophageal echocardiography but there was an interauricular septum curve inversion with a right ventricle dilatation (Fig. 1d), and transthoracic echocardiography confirmed a pulmonary hypertension with 65 mmHg systolic pulmonary arterial pressure. There was no intra-cardiac thrombosis. Bilateral leg venogram ultrasound was normal. The final diagnosis was pulmonary emboli with chronic pulmonary heart complicated by exacerbation of intracranial hypertension because of right atrium pressure overload. Search of thrombophilia was negative. Finally, the VAS was replaced by a ventriculoperitoneal shunt, permitting the retrocession of the pain. Retrospective test of the device didnÕt shown dysfunction. Two years later, she is still alive. She takes an oral anticoagulation and reports a NYHA stage 2 dyspnoea. Transthoracic echocardiography follow-up shows pulmonary hypertension stability. DiscussionVentriculoatrial shunt became accepted treatment for hydrocephalus in the late 1950s [1]. Previous studies reported development of severe pulmonary hypertension after placement of a VAS [2][3][4]. In patients with a VAS, pulmonary embolism and pulmonary hypertension were recognized clinically in 0.4% and 0.3%, respectively, whereas, at necropsy the frequency of these complications was 59.7% and 6.3% respectively [2]. Several hypotheses could explain this phenomenon: latent shunt infection could induce a persistent activation of clotting factors, which leads to recurrent pulmonary embolism [5]; other hypothesis suggests a possible role for cerebrosp...

Myocarditis can lead to acute heart failure, cardiogenic shock, or sudden death and later, dilated cardiomyopathy (DCM) with chronic heart failure. We report the cases of two DCM induced by acute and past myocarditis in the same family and expressed by its two main complications within few weeks: an hemodynamic presentation as a fulminant myocarditis rapidly leading to cardiac tranplantation and a rythmologic presentation as an electrical storm leading to catheter ablation of ventricular tachycardia. These cases ask the question of the family predisposition to viral myocarditis leading to DCM.

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