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Little is known about the incidence of cardiovascular events (CVEs) and their associated risk markers in children with Marfan syndrome (MFS).To assess the incidence of CVEs and determine risk markers in a cohort diagnosed with Marfan syndrome during childhood and followed for several years.From a French multicentre nationwide database, 462 patients with MFS diagnosed during childhood were included prospectively. Patients' files were screened for a period of 20 years (1993-2013). CVEs (e.g. death, aortic dissection, cardiac valve or aortic root surgery) were assessed during the prospective follow-up.Median (interquartile range) age at the end of follow-up was 17.2 (11.1-21.3) years. CVEs were reported for 35 participants (7.6%; 95% confidence interval [CI] 5.3-10.4%). First CVEs were prophylactic aortic root surgery (n=29), aortic dissection (n=4; two aged18 years) and death (n=2). Kaplan-Meier cumulative incidence of CVEs was 5.3% (95% CI 3.3-8.7%) during childhood (aged≤18 years) and 19.4% (95% CI 13.3-27.9%) at 25years of age. The cumulative rate of CVEs was higher in case of Valsalva sinus Z-score increase of≥0.1 per year (P=0.0003), maximal Valsalva sinus diameter growth speed ≥5mm per year (P=0.03), aortic regurgitation≥2 (P=0.0005) and maximal Valsalva sinus Z-score≥3 before 16 years of age (P0.0001). In a multivariable Cox proportional analysis, the Valsalva sinus Z-score remained significantly related to outcome. Considering aortic root evolution, aortic regurgitation, age at diagnosis and beta-blocker therapy were related to Valsalva sinus Z-score evolution during follow-up.CVEs in children with MFS are mainly related to prophylactic aortic root surgery. Aortic dissections are rarely observed in children. The Valsalva sinus Z-score is a strong indicator of subsequent CVEs in children with MFS. Attention to follow-up and beta-blocker observance may be warranted in high-risk children.

Catheter ablation (CA) in children using fluoroscopy carries risks inherent to ionizing radiation exposure.The objective of this study was to demonstrate the feasibility of using low frames rate during ablation in children to maximally decrease radiation dose.Hundred sixty eight successive patients18 years of age undergoing CA performed under a 3.75 frames/second rate were retrospectively included. Demographics, procedural and dosimetry data were analysed. The effective dose (ED) was evaluated in a subgroup of 14 patients.Median age and weight were 15 years and 54kg, 72% had WPW, 10% AV node reentrant tachycardia, 10% ventricular tachycardia (atrial tachycardia, flutter and atrial fibrillation for the other cases). Acute success was achieved in 98.5% without any complication. Median procedure and fluoroscopy duration were 120 and 16minutes. Median Dose Area Product (DAP) and Air Kerma were 2.46Gy.cmLow frame rate fluoroscopy is a highly effective and safe approach in decreasing radiation exposure during CA in children without altering the success rate of the procedure. ED is low, similar to natural/leisure irradiation. This approach can be considered a good alternative to 3D-based procedures in terms of efficiency and radiation issues, at least for WPW ablations.

The aim is to conduct a pilot study to prospectively describe echocardiographic parameters in neonates with pulmonary hypertension (PH) managed according to current recommendations and to identify those parameters that could predict worsening of short-term outcomes. All neonates less than 28 days old with a diagnosis of PH were prospectively enrolled in a tertiary care center for 1 year. Two echocardiograms were performed by a trained neonatologist. The first echocardiogram was performed at the time of diagnosis, whereas the second was performed just after basic therapeutic optimization. The cohort included 27 neonates. Mean gestational age at birth was 36.1 weeks gestational age (WGA) (SD: 4) and mean birth weight was 2658 g (SD: 907). Six neonates (22%) died before day 28, with a median age at death of 48 h (IQR [33; 89]). Although the first echocardiogram showed no difference, the second highlighted a strong link between the persistence of right-to left-shunt and death (p = 0.002). We showed a link between right-to-left shunt and a poor outcome (death or morbidity) after therapeutic optimization among premature and full-term neonates suffering from PH. We recommend repeating echocardiography after basic therapeutic optimization and for prognostic purposes, taking into account only the second examination. Larger cohorts are needed to confirm these results. Supplementary Information The online version contains supplementary material available at 10.1007/s00246-021-02677-z.

Background COVID-19 triggered an unprecedented crisis affecting our society at every level. Clinical research in paediatric and congenital cardiology is currently in full development and may have been disrupted. Aims To determine the impact of COVID-19 in paediatric and congenital cardiology clinical research and to analyse decision-making and adaptation processes, from a panel of on-going academic and industry-sponsored research at the time of the pandemic. Methods This observational study was carried out in April 2020, from a CHD clinical research network involving five tertiary care paediatric and congenital cardiology centres. Investigators and clinical research assistants from each participating research centre filled in an online survey questionnaire, and each principal investigator underwent a one-hour web-based videoconference interview. Results From a total of 34 study questionnaires and 288 enrolled patients at the time of the pandemic, 18 studies were declared as totally suspended. Upon investigator's decision, after discussion on ethical issues and with facilitating support from health authorities, 16 studies were resumed. The rate of study suspension in interventional research (53%) was similar to non-interventional research (56%). Logistical problems were predominantly reported in both continued and suspended trials. Research protocols were adapted, largely thanks to telemedicine, which in some cases even improved the course of the study. Conclusions The impact of the COVID-19 pandemic on clinical research in paediatric and congenital cardiology has been limited by a rapid adaptation of all research structures and an extensive use of telemedicine at all stages of the studies.

Introduction Sickle cell disease (SCD) is characterized by chronic hemolytic anemia and intermittent vaso-occlusive events associated with cardiac abnormalities. Aim To assess 3 dimensional (3D) echocardiographic of right ventricle (RV) volumes and function in a pediatric SCD population. Methods Eighteen patients with SCD aged 4 to 17 years old (mean age: 8.0±4 years, 56% male, body surface area (BSA) 1.0±0.35) and 18 healthy controls matched for age, gender and BSA were prospectively included and compared. Echocardiograms were performed using a commercially available ultrasound Philipps EPIQ 9 system using matrix X5–1 transducer. 3D indexed RV volumes and ejection fraction (3D- RVEF) were obtained using full volume acquisitions. RV free wall strain, tricuspid S-wave, tricuspid annular plane systolic excursion (TAPSE), indexed cardiac output, systolic pulmonary pressure (sPAP) and hemoglobin were assessed. Data were analyzed with TomtecArena© software (v2.3, Germany). Results Cardiac output was significantly higher in SCD children (4.5 vs 3.6 l/min/m2, p=0.025), as sPAP (24.9 vs 21.9 mmHg, p=0.015), 3D-RV diastolic volume (58.1 vs 47.5 ml/m2, p=0.025) and 3D-RV systolic volume (28.8 vs 21.4 ml/m2, p=0.005). 3D-RVEF and RV free wall strain were significantly lower in SCD compared to control population (respectively 51.9 vs 56.3%, p=0.018; −28.6 vs −32, p=0.017). There were no difference regarding TAPSE and doppler S-wave. Mean hemoglobin in SCD population was 9.6±1.7 g/dl. Conclusions Despite normal RV systolic function parameters, 3D-RVEF and RV free wall strain are lower in children with SCD. Chronic anemia generating volume overload and vaso-occlusive events could explain these findings. 3D sickle cell Funding Acknowledgement Type of funding source: None

Highlights • Exercise capacity in patients with CHD is lower than in the general population. • Non-invasive relaxation therapy may be effective in patients with dyspnoea. • Evidence based-medicine on relaxation therapy in the CHD population is poor. • This trial will assess the impact of Sophrology on exercise capacity in CHD patients., Background Recent advances in the field of congenital heart disease (CHD) have significantly improved the overall prognosis. Now more attention is being given to health-related quality of life (HRQoL) and promotion of physical activity. Non-invasive relaxation therapy may be effective in cardiac patients concerned with exercise-induced dyspnoea. The SOPHROCARE randomised trial aims to assess the impact of Caycedian Sophrology on cardiopulmonary fitness in adolescents and young adults with CHD. Methods The SOPHROCARE trial is a nationwide, multicentre, randomised, controlled study in CHD patients aged from 13 to 25 years old. Patients will be randomised into 2 groups (8 Sophrology group sessions vs. no intervention). The primary outcome is the change in percent predicted maximum oxygen uptake (VO2max) between baseline and 12-month follow-up. A total of 94 patients in each group is required to observe a significant increase of 10% in VO2max with a power of 80% and an alpha risk of 5%. The secondary outcomes are: clinical outcomes, cardiopulmonary exercise test parameters (VE/VCO2 slope, ventilatory anaerobic threshold, oxygen pulse, respiratory response to hypercapnia), health-related quality of life score (PedsQL), physical and psychological status. Conclusion After focusing on the survival in CHD, current research is opening on secondary prevention and patient-related outcomes. We sought to assess in the SOPHROCARE trial, if a Sophrology program, could improve exercise capacity and quality of life in youth with CHD. Trial registration Clinicaltrials.gov (NCT03999320).

Background Wolff Parkinson White syndrome is responsible of junctional tachycardia and potentially sudden death in children. Precise location of accessory pathway (AP) is crucial to increase safety and success rate of ablation procedures. Known ECG localization algorithms have limited accuracy in children close to 50%. Objective The aim of study was to evaluate a new ECG algorithm relying on maximal pre-excitation (EMP) in children. Methods ECG with EMP (ventricular activation secondary to AP without His bundle activation), induced by atrial pacing or adenosine test/vagal maneuver, was prospectively recorded during an electrophysiological study in 90 consecutive children under 16, in 3 tertiary centers between 2008 and 2020. 3 blinded investigators (1: expert rythmologist, 2: pediatric cardiologist and 3: pediatric cardiologist in training) tested a new algorithm based on EMP to predict AP location and 2 validated control algorithms, from Arruda and Min Baek, relying on basal pre-excitation. Predicted locations were matched with ablation-verified AP location. Sensibility, specificity, negative/positive predictive values and reproducibility, defined as level of agreement between investigators in determining AP location, were evaluated. Results AP were Left sided in 38%, septal in 47% and right sided in 16%. With the new algorithm, predictive accuracy for the 9 exact locations was 91%, 89% and 90% for investigator 1, 2 and 3, respectively. Sensibility was 80-100% for right sided, 95–100% for left sided and 62-100% for septal AP. Concordance between investigators was excellent (k ≥ 0,86). The accuracy for the reference algorithms remain poor (45% for Arruda and 51% for Min Baek) with less concordance between investigators. Conclusion Our new algorithm based on EMP allows accurate and easy to use localization of AP in children. This algorithm can be employed before cardiac catheterization and can allow better evaluation of the benefit/risk ratio of the intervention.

Background Prevalence of early repolarisation ECG pattern (ER) has been repetitively determined in adults, but has not been reported in large unselected children populations so far. Methods ECG from 1000 successive healthy children from birth to 17years old were prospectively recorded and analyzed. ER was defined by ≥0.1mV J point elevation in at least two contiguous inferior or lateral ECG leads. Correlations with age, gender, ethnic origin, physical activity, Sokolow index and heart rate were performed. Results Prevalence of ER pattern was 23,6% (95% CI 21–26.2%) and increased after 8years of age. ER was independently correlated to a non Caucasian origin and a higher Sokolow index, but not to gender or level of physical activity. ER was independently correlated to an older age in children with heart rate Conclusion ER is present in a quarter of children of various age and is related to ethnic origin, an older age, a slower heart rate and a higher Sokolow index.

Introduction 3D printed models are increasingly used to enhance understanding of complex anatomy in congenital heart disease. We aimed to assess feasibility and accuracy of 3D printed models obtained from cardiac CT scan in small pediatric population with complex congenital heart diseases. Method Patients with conotruncal heart anomalies aged less than 2 years old who had a cardiac CT scan in course of their follow-up were included. Cardiac CT scan datasets were used to generate 3D models. To assess model's accuracy, 4 diameters were compared for each patient between the CT images and the printed models, including the largest diameters (Dmax) of ventricular septal defects (VSD) and aortic annulus (AA) and their minimal diameters (Dmin). Results Images of 14 patients were obtained. Mean age was 5.5 months (1–24 months), mean weight was 6.7 kg (3.4–14.5 kg). 3D models were successfully obtained in all patients. Correlations between measurements obtained from printed models and CT images were excellent (r = 0.90 to 0.98). Mean measurement difference between CT image and 3D model was 0.13 mm for Dmin and 0.12 mm for Dmax for VSD diameters, and was 0.16 mm for Dmin and −0.13 mm for Dmax for AA diameter indicating a non-clinically significant difference ( Fig. 1 ). Conclusion 3D printed models are feasible from cardiac CT scan in small pediatric population with complex congenital heart diseases. This technic is highly accurate and reliably reflects the same structure dimensions when compared to CT source images.

Interventional catheterization in children constantly improved these last decades to reach an extremely high success rate. However, the information given to parents before the intervention may be difficult and anxiety remains high. Aim We questioned about the impact of 3D cardiac printing on understanding, knowledge and anxiety of parents before interventional catheterization of their children. Methods Parents of children undergoing a percutaneous shunt closure were prospectively included. Two questionnaires were provided before and after the consultation: 1/a questionnaire of knowledge and understanding about the disease and the cardiac catheterization; 2/a self-report questionnaire to assess the anxiety (State-Trait Anxiety Inventory (STAI)). During the consultation, the ‘model group’ received an explanation of the children heart defect and the catheterization procedure using the 3D printed model of the cardiac lesion ( Fig. 1 ), while the ‘control group’ had the classical explanation with device and a manual drawing. Results Sixty three parents of 43 children were randomized in ‘control group’ (n = 31) or ‘model group’ (n = 32), including 6 ventricular septal defect, 23 patent ductus arteriosus and 34 atrial septal defect. At baseline, groups were comparable. The level of understanding and knowledge improved after the consultation in ‘control group’ and ‘model group’ (+5.5 ± 0.8 and +10,2 ± 0.8; P Conclusion 3D printed models improve knowledge and information deliverance in consultation for parents of children with CHD, and reduce their level of anxiety before cardiac catheterization

Background Accurate evaluation of the pulmonary valve (PV) is crucial before surgical repair of Tetralogy of Fallot (TOF). Aims To assess PV and pulmonary annulus (PA) morphology using three-dimensional (3D) transthoracic echocardiography (TTE) in infants referred for surgical repair of TOF. Also, to compare PA measurements obtained by 3D TTE with those from other imaging modalities, including two-dimensional (2D) TTE and computed tomography (CT), with reference to surgical measurements. Methods 3D zoom mode was used to assess PV morphology. 2D TTE and CT PA diameters were compared to both vertical and horizontal diameters obtained from 3D datasets. Surgical PA diameters were measured using Hegar's dilators. Results A total of 29 patients with TOF (median [range] age 6 [3–24] months) were included and all successfully underwent 2D and 3D TTE; 22 also underwent CT. The number of pulmonary leaflets could be visualized in 24 patients (82.8%), with complete concordance with surgical findings. Vertical diameter was significantly longer than horizontal diameter (P

A novel formulation of bosentan was evaluated in children with pulmonary arterial hypertension (PAH) in FUTURE-1, which characterized its pharmacokinetic and clinical profile. The subsequent phase III, open-label, long-term extension study, FUTURE-2, aimed to provide long-term tolerability, safety and exploratory efficacy data.Children (≥2 and12 years) with idiopathic or heritable PAH, who completed 12-week treatment in FUTURE-1 and for whom bosentan was considered beneficial were enrolled, and continued to receive bosentan 4 mg/kg twice-daily, which could be down-titrated to 2mg/kg if not tolerated. Safety and tolerability were evaluated via treatment-emergent adverse events (AEs), serious AEs, growth, and laboratory measurements. Exploratory efficacy endpoints included time to PAH worsening and long-term survival. All analyses were conducted on pooled data of both studies.36 patients were enrolled in FUTURE-1 and 33 continued in FUTURE-2. The overall median duration of exposure to bosentan was 27.7 (range 1.9-59.6) months. Treatment-emergent AEs occurred in 32 (88.9%) patients; AEs considered treatment-related in 15 (41.7%) patients. Of 51 serious AEs, three were considered treatment-related: two incidences of reported PAH worsening and one of autoimmune hepatitis. Six deaths occurred; none were considered treatment-related. Kaplan-Meier event-free estimates of PAH worsening were 78.9% and 73.6% at 2 and 4 years, respectively.The pediatric bosentan formulation was generally well tolerated, its safety profile comparable to that of the adult formulation when used in children. The results are in line with the efficacy profile of bosentan in previous pediatric and adult PAH studies of shorter duration.

The fulminant viral myocarditis is associated to a high risk of mortality and heart transplantation in children. Anti-inflammatories and intravenous gamma globulin are used in the majority of studies but the outcome is not always favorable. In this case, we suggest an important role for antiviral therapy in children's fulminant myocarditis.

Introduction Teaching of congenital heart disease (CHD) through 3D printed models is feasible and useful as it improves learning. Medical students are highly satisfied with single defect CHD learning through 3D printing. Aim To evaluate the usefulness and degree of satisfaction with learning through 3D printed models in CHD with several associated defects, compared to a single defect CHD. Methods Students from 5th year of medicine attending a lecture in CoA (n = 118), VSD (n = 50) and TOF (n = 62) were randomised in 6 groups. During the lecture, 3D printed models of each CHD were presented and analysed by the students in the test group, same lecture without 3D models was performed for the control group for each CHD. Knowledge acquisition was obtained by pre and post-lecture test. Student's satisfaction and self-efficacy ratings were evaluated by the subjective post-lecture survey. Satisfaction between CHD groups was compared using Bonferroni method and test results between 3D & control group by t-test. Results Students in the multiple defect (ToF) group were less satisfied of 3D printed models than the students in the single defect (CoA & VSD) groups (P ˂ 0.01). After-lecture test scores for the groups attending the single defect CHD lectures were significantly higher for the students learning through 3D printed models (P = .04 in CoA group; P = 0.03 in VSD group). There was no difference in the post-lecture scores between the 3D learning and control groups attending the ToF lecture. Control ant test groups were comparable by age and sex ( Fig. 1 ). Conclusions Learning of complex CHD is challenging even with the most advanced educational techniques. Visual access to all the defects presented by the 3D model is necessary for correct understanding of the model. Transparent printing materials allow for the students to simulate the flow trajects with probes. In our experience, virtual 3D models can be a great resource and even more when analysed on virtual reality devices.

Background Advances in congenital heart disease (CHD) have transferred the mortality from childhood to adulthood. Exercise capacity in young patients with CHD remains lower than in the general population, resulting in deconditioning and impaired quality of life. Evidence based-medicine in cardiac rehabilitation in this age group with CHD remains limited. We present the QUALI-REHAB study rationale, design and methods. Methods The QUALI-REHAB trial is a nationwide, multicentre, randomised, controlled study, aiming to assess the impact of a combined centre and home-based cardiac rehabilitation program on the quality of life of adolescents and young adults (13 to 25 years old) with CHD. Patients with a maximum oxygen uptake (VO2max) Conclusion After focusing on the survival in CHD, current research is opening on secondary prevention and patient-related outcomes. The QUALI-REHAB trial intends to assess if a combined centre and home-based rehabilitation program, could improve the quality of life and the exercise capacity in youth with CHD. Trial registration: Clinicaltrials.gov ( NCT03690518 ).

Imaging fusion between echocardiography and fluoroscopy was recently developed. The aim of this study was to assess its feasibility and accuracy during pediatric cardiac catheterization.Thirty-one patients (median weight, 26 kg; interquartile range [IQR], 21-37 kg) who underwent percutaneous atrial septal defect closure were prospectively included. The feasibility and accuracy of various imaging fusion modalities (live two-dimensional, live color two-dimensional, live three-dimensional and markers) with EchoNavigator software were assessed. To assess the accuracy of spatial registration of the echocardiogram on the fluoroscopic image, the occluder screw, an object that appeared on each image, was used as a reference tool, and the distance between the two when fused was measured. A distance was measured on the fusion screen between a marker positioned on the screw from the echocardiography screen and from the fluoroscopy screen (distance 1). Another distance was measured on the fusion screen between the screw visualized by three-dimensional echocardiography and by fluoroscopy (distance 2). The two distances were measured on four C-arm orientations in end-systolic and end-diastolic frames.Fusion and marker positioning were feasible in real time in all cases. On the fusion screen, median systolic and diastolic distance 1 were 0.5 mm (IQR, 0.3-1 mm) and 2 mm (IQR, 1.5-2.5 mm; P .0001), respectively. The marker positioned from the echocardiography screen was fixed on the fusion screen and did not follow the movement of the screw. Median systolic and diastolic distance 2 were 0.5 mm (IQR, 0-0.5 mm) and 2 mm (IQR, 1.5-2.5 mm; P .0001), respectively.Echocardiographic fluoroscopic imaging fusion is feasible, safe, and accurate in children weighting20 kg. This technique offers a new method of imaging guidance in the catheterization laboratory for complex procedures and training.

Summary Background Transoesophageal echocardiography (TOE) has become indispensable in the catheterization laboratory in the guidance of some percutaneous interventions, as a complementary imaging technique to fluoroscopy. However, the two imaging modalities are presented separately and differently, making interpretation of the anatomical spatial relationships complicated. EchoNavigator® (Philips Healthcare, Best, the Netherlands) is an innovative software package, enabling fusion of fluoroscopic and echocardiographic images on the same screen. Aims To assess the feasibility of EchoNavigator® in the guidance of interventional procedures, and to present our initial clinical experience with this software. Methods Children with congenital heart disease who underwent interventional catheterization needing guidance with TOE from December 2015 to December 2017 were included. TOE was realized using a X7-2t TOE probe (Philips Healthcare) connected to an echocardiographic system (EPIC™; Philips Healthcare, Andover, MA). Fluoroscopy was realized using the Allura Xper FD/10 system (Philips Healthcare). Image fusion was attempted in all patients using EchoNavigator®. Markers were positioned on the target zone on echocardiographic images, and projected onto the merged screen. Results Fifty-one children were included (mean age, 8 years; mean weight, 25 kg). Thirty-six patients underwent atrial septal defect closure, 10 ventricular septal defect closure, three aortic valve dilatation and two right ventricular outflow tract revalvulation. Image fusion was successfully obtained in all patients during all steps of the procedure. No complication related to the TOE probe was observed. Markers were successfully positioned in the all target zones, and were automatically projected onto the fusion screen. Conclusions The EchoNavigator® system is feasible and safe in the guidance of interventional catheterization in children with congenital heart disease; it enables better appreciation of anatomical relationships and improves the confidence of the interventionist.

Background Pathogenic variants in SMAD3 (type 3 LDS, Marfan-like connective tissue disorder) cause thoracic aortic aneurysms and dissections, along with aneurysms and rupture of other arteries. Generally, these aggressive vascular damages are associated with multisystemic signs including skeletal abnormalities and premature osteoarthritis. Variable expressivity and incomplete penetrance are commonly associated. Methods Aortic status, events, and clinical features were abstracted through retrospective review of medical records 20 new patients (28.8 years-old (6–60)) from 8 families from our Reference Centre. After a complete review of the literature, we collected a total of 49 unique variants of different nature (missense, truncating and splicing variants) from 152 individuals of 58 unrelated families. The aim of this study was to look for genotype-phenotype correlations between the mutations of this gene and the severity of the phenotype. Results Aortic aneurysm and/or dissection are the main vascular findings, affecting respectively 57% and 32% of all type 3 LDS patients described. In our cohort of patients, half presents an aortic dilatation (10/20), 10% an aortic dissection. Three of our patients displays an aortic dilatation during their childhood (at 8 and 7 years old and a surgery for an aortic dilation at 10 years old). Aneurysms and dissections can also be seen in other arteries in 27% (35/138) and particularly intracranial aneurysms found in 20% of patients (21/103), like in two of our patients, one presented an iliac artery dissection. Arterial tortuosity is also frequent, particularly in carotids, representing about a third of the patients (36/117 = 31%), 2 of our 8 patients. Conclusions SMAD3 pathogenic variants cause thoracic aortic aneurysms and dissections in the majority of individuals with variable age of onset and reduced penetrance. We confirmed that there is no correlation between the mutation type and the phenotype severity. Aneurysms-Osteoarthritis syndrome (AOS), genotype-phenotype correlation, heritable thoracic aortic aneurysms and dissections (hTAAD), Loeys-Dietz syndrome, SMAD3, Marfan-like connective tissue disorder, TGFβ pathway.

Introduction Understanding of cardiac structure has been improved by 3D cardiac echocardiography. The anatomy and geometry of the mitral valve annulus (MVA) has been previously described with advanced imaging techniques, allowing for a better comprehension of valve dysfunction and providing significant information for the surgical repair. Aim To apply transthoracic 3D echocardiography (3DTTE) for quantitative and qualitative assessment and comparison of the pathologic MVA in congenital cardiopathies (CC) of the valve with a normal group. Methods Patients with repaired atrioventricular septal defect (AVSD) attending consultation were prospectively included and matched with a control group of healthy children by sex, age and body surface area (BSA). 3DTTE full volume and 3D zoom acquisitions were performed on a Philips EPIQ7. The 3D shape of the annuli was reconstructed and analysed with TOMTEC™ 4D MV-ASSESSMENT© ( Fig. 1 ). The assessed and compared parameters were annular area (2D & 3D), circumference, high-low distances (height), anterolateral-posterolateral (ALPM), and anteroposterior (AP) axes, non-planar angle (NPA), sphericity index, angle between the aortic annulus and AP axe (AAoAP angle). All measurements were indexed by BSA. Results A total of 18 participants were recruited. Both groups were comparable in age (10.67 ± 3.45 years) and BSA (1.13 ± 0.27 m2). All acquisitions could be analysed with need of minimal editing of the annulus after automated detection, leaflets couldn’t be analysed in the AVSD group. Significative differences between both groups were found in the NPA with an increase in the nonplanarity for the patients with a repaired AVSD (144.5 vs. 132.9; P ˂ 0.01) and a more circular shape represented by a higher sphericity index (0.99 vs. 0,85; P = 0.01). No difference was found in indexed height, area and diameters were similar between both groups. Conclusions The specific and exclusive shape of the MVA in patients with repaired AVSD was revealed in the patients studied, resulting in a loss of the saddle shape structure. Those results could help in the comprehension of anatomic changes of the mitral valve annulus occurring after AVSD surgery.

Introduction Multiple studies have demonstrated the feasibility and accuracy of 3D printed models in the field of congenital heart diseases. These models seem enhance conceptual 3D understanding of complex anatomy. Our aim was to evaluate the usefulness of these models as a teaching tool for medical students to improve learning of congenital heart diseases. Methods During the education sessions of left ventricle outflow tract obstruction (LVOTO), students from 5th year of medicine were randomized in two groups. Each group (n = 118) attended a 60-minute lecture of LVOTO. All students answered objective questions for pre- and post-lecture knowledge score evaluation, in addition to a subjective post-lecture survey questions regarding students’ comfort level with the subject. During the lecture, 3D printed models of different types of LVOTO were presented and analyzed by the students in the test group ( Fig. 1 ). Knowledge acquisition was evaluated by comparing pre and post-lecture knowledge score. Student's satisfaction and self-efficacy ratings were evaluated by the subjective post-lecture survey. The datas were analyzed and compared between the two groups using paired t-test. Results There was no difference in pre-lecture objective test score between the two groups (score 8.32/14 vs. 8.35/14). After the lecture, both groups improved their knowledge objective score, but was significantly higher in the test group than that of the control group (score 12.60/14 vs. 11.20/14 respectively P = 0.04). Students in the test group were more satisfied with theirs understanding of the diagnosis (P = 0.03) and treatment (P Conclusions This preliminary study demonstrates the feasibility and the usefulness of 3D printed models as educational tools of congenital heart diseases for medical students.

Summary Background In recent decades, advances in surgery and therapeutic catheterization have steadily increased the life expectancy and prevalence of adults with congenital heart disease (CHD). Aims We assessed medical and psychosocial variables of adults with CHD, according to the disease complexity. Methods We included, from a single-centre observational cohort study, 135 consecutive adults with CHD (median age of 40 years, interquartile range: 28.0–51.0) followed in our cardiology unit, who answered a questionnaire assessing daily activity and psychosocial functioning. Disease complexity was classified according to the Bethesda conference. Results Cardiac malformation complexity was simple in 61 (45.2%), moderate in 50 (37.0%) and complex in 24 (17.8%) patients. Cardiac surgery had been performed in 86.5% of moderate and complex patients. Complications (such as heart failure, arrhythmia and pulmonary hypertension) were mainly observed in the complex group ( P = 0.003). Physical activity was lower in the complex group (no activity in 58.8%, but sport previously contraindicated in 50% of these; P = 0.03). Education level tended to be lower in the complex and moderate groups than in the simple group (respectively, 31.2% and 33.3% vs. 45.7% had passed the Baccalaureate; P = 0.47). The pass rate was lower in patients with complications ( P = 0.037) or more than one cardiac surgery ( P = 0.03). In the complex group, 56.3% of patients were unemployed ( P = 0.048). Conclusions Complexity of heart disease and medical history affect education level and employment of adults with CHD. Academic education of children with a complex defect and career counselling are important to prevent unemployment among adults with CHD.

AIMS: To evaluate the benefit of adding Losartan to baseline therapy in patients with Marfan syndrome (MFS). METHODS AND RESULTS: A double-blind, randomized, multi-centre, placebo-controlled, add on trial comparing Losartan (50 mg when \textless50 kg, 100 mg otherwise) vs. placebo in patients with MFS according to Ghent criteria, age \textgreater10 years old, and receiving standard therapy. 303 patients, mean age 29.9 years old, were randomized. The two groups were similar at baseline, 86% receiving β-blocker therapy. The median follow-up was 3.5 years. The evolution of aortic diameter at the level of the sinuses of Valsalva was not modified by the adjunction of Losartan, with a mean increase in aortic diameter at the level of the sinuses of Valsalva of 0.44 mm/year (s.e. = 0.07) (-0.043 z/year, s.e. = 0.04) in patients receiving Losartan and 0.51 mm/year (s.e. = 0.06) (-0.01 z/year, s.e. = 0.03) in those receiving placebo (P = 0.36 for the comparison on slopes in millimeter per year and P = 0.69 for the comparison on slopes on z-scores). Patients receiving Losartan had a slight but significant decrease in systolic and diastolic blood pressure throughout the study (5 mmHg). During the study period, aortic surgery was performed in 28 patients (15 Losartan, 13 placebo), death occurred in 3 patients [0 Losartan, 3 placebo, sudden death (1) suicide (1) oesophagus cancer (1)]. CONCLUSION: Losartan was able to decrease blood pressure in patients with MFS but not to limit aortic dilatation during a 3-year period in patients \textgreater10 years old. β-Blocker therapy alone should therefore remain the standard first line therapy in these patients

Summary Background Foetal echocardiography has been used to diagnose congenital heart disease. However, conventional echocardiography can only display two-dimensional (2D) structural images of the intricate three-dimensional (3D) foetal heart. Aim The purpose of this study was to report the first use of a new transabdominal xMATRIX array transducer and to describe its ability to perform all 3D modalities: intelligent spatiotemporal image correlation (iSTIC) acquisition, xPlane imaging and 3D surface imaging. Methods Eighty foetuses without congenital heart disease were included consecutively, with a gestational age between 20 and 37 weeks. 2D and 3D scans were performed with a transabdominal xMATRIX array transducer. Cardiac-STIC volume datasets were acquired and postprocessed with new automatic software (the ‘Fetal Heart Navigator’). Results A total of 224 iSTIC acquisitions were performed (mean time for each, 2 seconds). Only 78 iSTIC acquisitions (35%) were able to detect the ductal arch automatically. ‘Fetal Heart Navigator’ feasibility varied according to foetal position, including the descending aorta. Live xPlane imaging had excellent feasibility regardless of foetal position; using rotation, lateral and vertical tilts, all cardiac structures were identified from a unique reference plane. Live 3D surface imaging had variable feasibility depending on the target structure. Only 10% of the volume dataset offered comprehensive imaging of intracardiac views. Conclusion The new xMATRIX transabdominal transducer allows a multimodality approach to the foetal heart. Further studies that include foetuses with cardiac malformations are required.

Background Mutation in the FBN1 gene was common in the Marfan syndrome (MFS), and caused aortic dilatation that could be delayed by beta-blocker therapy. Aims This study evaluated the effect of beta-blockers therapy on aortic dilatation in the MFS patients with subtypes of FBN1 gene mutation. Methods A single center observational prospective study included 53 MFS patients less than 20-years-old with predicting-happlo insufficiency (PTC) or dominant-negative (DN) mutation of FBN1 gene. Among 41 patients used beta-blockers therapy, aortic diameter and aortic dilatation rate were evaluated by echocardiography. Results At the baseline, dimension of aortic sinus of Valsalva of PTC-MFS patients and DN-MFS patients were in the upper bound of normal range (Z-score: 1.76 ± 1.25 vs. 1.69 ± 0.87, P = 0.621, respectively). While, dimension of ascending aorta was in the normal range. After a mean follow-up 1.5 ± 0.71 years with beta-blockers therapy, the dilatation rate at aortic sinus of Valsalva decreased [PTC-MFS: −0.28 ± 0.85 mm/m2.year (95% CI: −0.82; 0.26) vs. DN-MFS: −0.32 ± 1.34 mm/m2.year (95% CI: −0.91; 1.34), P = 0.069]. The dilatation rate at ascending aorta decreased in PTC-MFS patients [−0.18 ± 1.19 mm/m2.year (95% CI: −0.96; 0.61)] and increased in DN-MFS patients [0.4 ± 1.82 mm/m2.year (95% CI: −0.43; 1.23)], P = 0.554. Conclusion Among the FBN1-MFS patients, beta-blockers therapy was effective to reduce the aortic dilatation rate, of which difference between PTC-MFS patients and DN-MFS patients was not significant.

Introduction Sickle cell disease (SCD) is characterized by chronic hemolytic anemia and intermittent vaso-occlusive events associated with cardiac abnormalities. Aim To assess 3-dimensional (3D) echocardiographic of right ventricle (RV) volumes and function in a pediatric SCD population. Methods Eighteen patients with SCD aged 4 to 17 years old (mean age: 8.0 ± 4 years, 56% male, body surface area (BSA) 1.0 ± 0.35) and 18 healthy controls matched for age, gender and BSA were prospectively included and compared. Echocardiograms were performed using a commercially available ultrasound Philipps EPIQ 9 system using matrix X5-1 transducer. 3D indexed RV volumes and ejection fraction (3D-RVEF) were obtained using full volume acquisitions. RV free wall strain, tricuspid S-wave, tricuspid annular plane systolic excursion (TAPSE), indexed cardiac output, systolic pulmonary pressure (sPAP) and hemoglobin were assessed. Data were finally analyzed with TomtecArena© software (v2.3), Germany. Results Cardiac output was significantly higher in SCD children (4.5 vs. 3.6 l/min/m2, P = 0.025), as sPAP (24.9 vs. 21.9 mmhg, P = 0.015), 3D-RV diastolic volume (58.1 vs 47.5 ml/m2, P = 0.0.25) and 3D-RV systolic volume (28.8 vs. 21.4 ml/m2, P = 0.005). 3D-RVEF and RV free wall strain were significantly altered in SCD compared to control population (respectively 51.9 vs. 56.3%, P = 0.018; − 28.6 vs. − 32, P = 0.017). There were no difference regarding TAPSE and Doppler S-wave. Mean hemoglobin in SCD population was 9.6 ± 1.7 g/dl. Conclusion These findings suggest that 3D-RVEF and RV free wall strain are altered and associated to an augmentation of 3D-RV volumes, without alteration of longitudinal traditional RV parameters in this SCD population. Chronic anemia generating volume overload but also elevation of sPAP increasing RV afterload can explain these findings. This data need to be confirmed with cardiac magnetic resonance imaging.

Introduction Imaging fusion between echocardiography and fluoroscopy is now available in the catheterization laboratory. We aim to test the feasibility and accuracy of imaging fusion in a pediatric population. Method Thirty-one patients (26 kgs [21–37]) underwent percutaneous atrial septal defect (ASD) closure were prospectively included. Occluder device's screw, visualized on both echocardiography and fluoroscopy images was used as a reference tool. Bias was measured between a marker positioned on the device screw visualized on echocardiography and the fluoroscopic screw image on the fusion screen (distance 1). Another bias was measured between the screw on 3D echocardiographic image and the screw on fluoroscopic image (distance 2). The 2 distances were measured on 4 orthogonal views in end-systolic and end-diastolic frames. Results Fusion and marker positioning were feasible in real-time in all cases. In 5 cases (16.1%), there was a transient loss of the automatic tracking of the probe during the procedure. Quality of imaging fusion was rated good in all cases. On the fusion screen, systolic and diastolic first distances were 0.5 [0.3–1] and 2 mm [1.5–2.5] (P Conclusion Echocardiographic-fluoroscopic imaging fusion is feasible, safe and accurate in children above 20 kgs. This innovate technic offers a new real-time imaging guiding modality in the catheterization laboratory with potential interest in complex procedures as well as for fellow training.

Introduction Transesophageal echocardiography (TEE) has become indispensable in cat-lab to guide some percutaneous interventions as a complimentary imaging for fluoroscopy. However, the tow imaging modalities are presented separately and differently making the interpretation of the anatomic spatial relationships not easy. Echonavigator® (Philips Healthcare, Best, The Netherlands) is an innovative software enabling fusion between fluoroscopic and echocardiographic image on the same screen. Few data on its feasibility and its clinical applications in children with congenital heart diseases (CHD) are currently available. Aim To assess the feasibility of Echonavigator® system to guide interventional procedure in children with CHD, and to present our initial clinical experience using this software for guidance of percutaneous treatment of children with CHD. Methods We enrolled all children underwent interventional catheterization needing guidance by TEE from December 2015 to December 2017. Patients weighting less than 20 kg or having a contraindication for TEE were excluded. TEE was realized by a pediatric cardiologist using X7-2t TEE probe connected to an echocardiographic system (EPIC). Fluoroscopy was realized by interventional cardiologist using Allura Xper FD/10 system (Philips Healthcare). Image fusion was attempted in all patients using Echnavigator® system. Markers were positioned on the target zone on echocardiographic images and projected to the interventionists on the fusing screen. Results Fifty-one patients with CHD were included, mean age was 8 years old (5.5–14), mean weight was 25 kg (20–36 kg). 36 patients underwent atrial septal defect closure, 10 ventricular septal defect closure, 3 aortic valve dilatation and 2 right ventricular outflow tract revaluation. Image fusions were successfully obtained in all patients in real time during all steps of procedure ( Fig. 1 ). No complication related to TEE probe insertion or manipulation was observed. Markers were successfully positioned in the all target zones and automatically projected to the interventionist on the fusion screen. Conclusion Echonavigator® system is feasible and safe to guide interventional catheterization in children with CHD. It enables better appreciation of anatomical relationships and improves confidence of interventionist to achieve the target zones.

Introduction Transesophageal echocardiography (TEE) has become indispensable in Cat-lab to guide some percutaneous interventions as a complimentary imaging for fluoroscopy. The tow imaging modalities are presented separately and differently making the interpretation of the anatomic spatial relationships not easy. Echonavigator® (Philips) software enables fusion between the two imaging modalities on the same screen. Few data on its feasibility and its clinical applications in children are currently available. Aim Assess the feasibility of Echonavigator system to guide interventional procedure in children with CHD, and to present our initial clinical experience using this software in pediatric Cat-lab. Methods We enrolled all children underwent interventional catheterization needing guidance by TEE from December 2015 to December 2017. Patients weighting less than 20 kg were excluded. TEE was realized using X7-2t TEE probe connected to an echocardiographic system (EPIC). Fluoroscopy was realized using Allura Xper FD/10 system. Image fusion was realized using Echnavigator system. Markers were positioned on the target zone on echocardiographic images and projected to the interventionists on the fusing screen. Results Fifty-one patients with CHD were included, mean age was 8 years old (5.5–14), mean weight was 25 kg (20–36 kg). Thirty-six patients underwent ASD closure, 10 VSD closure, 3 aortic valve dilatation and 2 RVOT revaluations. Image fusions were successfully obtained in all patients during all steps of procedure ( Fig. 1 ). No complication related to TEE probe insertion or manipulation was observed. Markers were successfully positioned in the all target zones and automatically projected to the interventionist on the fusion screen. Conclusion Echonavigator system is feasible and safe to guide interventional catheterization in children with CHD. It enables better appreciation of anatomical relationships and improves confidence of interventionist to achieve the target zones.

New three-dimensional echocardiographic automated software (HeartModel) is now available to quantify the left heart chambers. The aims of this study were to assess the feasibility, reproducibility, and analysis time of this technique and its correlation with manual three-dimensional echocardiography (3DE) and cardiac magnetic resonance (CMR) in children.Ninety-two children (5-17 years of age) were prospectively included in two separate protocols. In protocol 1, 73 healthy children underwent two-dimensional and three-dimensional transthoracic echocardiography. Left ventricular (LV) end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), and left atrial volume at ventricular end-systole (LAV) by automated 3DE were compared with the same measurements obtained using manual 3DE. In protocol 2, automated three-dimensional echocardiographic measurements from 19 children with cardiomyopathy were compared with CMR values.Automated 3DE was feasible in 77% of data sets and significantly reduced the analysis time compared with manual 3DE. In protocol 1, there were excellent correlations for LVEDV, LVESV, and LAV between automated 3DE and manual 3DE (r = 0.89 to 0.99, P .0001 for all) and a weak correlation for LVEF, despite contour adjustment (r = 0.57, P .0001). Automated 3DE overestimated LVEDV, LVEF, and LAV with small biases and underestimated LVESV with wider bias. With contour adjustment, the biases and limits of agreement were reduced (bias: LVEDV, 0.9 mL; LVESV, -1.2 mL; LVEF, 2.2%). In protocol 2, correlations between automated 3DE with contour edit and CMR were good for LV volumes and LAV (r = 0.76 to 0.94, P .0003 for all) but remained weak for LVEF (r = 0.46, P = .05). Automated 3DE slightly underestimated LV volumes (relative bias, -7.2% to -7.8%) and significantly underestimated LAV (relative bias, -31.6%). The limits of agreement were clinically acceptable only for LVEDV. Finally, test-retest, intraobserver, and interobserver variability values were low (12%).HeartModel is feasible, reproducible, faster than manual 3DE, and comparable with manual 3DE for measurements of LV and left atrial volumes in children5 years of age. However, compared with CMR, only LVEDV measured by automated 3DE with contour edit seems applicable for clinical practice.

Background Mutation of the fibrillin 1 (FBN1) gene was common in the Marfan syndrome (MFS) leading to aortic dilatation. Purpose This study aimed to evaluate the effect of beta-blocker therapy on aortic dilatation in the MFS patients with subtypes of FBN1 gene mutation. Methods An observational prospective study included 67 MFS patients with predicting-happloinsufficiency (PTC) or dominant-negative (DN) mutation of FBN1 gene who were followed up at 2.8 ± 1.8 years. Aortic diameters and the rate of aortic dilatation were evaluated by echocardiography. Results At the baseline, dimension of aortic sinus of Valsalva of PTC-MFS patients and DN-MFS patients were in the upper bound of normal-range [Z score: 2.3 ± 1.82 (95% CI: 1.69; 2.91) vs. 2.67 ± 1.58 (95% CI: 2.02; 3.32), respectively, P > 0.05]. While, dimension of ascending aorta of DN-MFS patients were in the upper bound of normal range and was higher than PTC-MFS patients [Z score: 2.8 ± 2.16 (95% CI: 2.05; 3.55) vs. 1.69 ± 2.32 (95% CI: 0.66; 2.72), respectively, P > 0.05]. With the beta-blocker therapy, the rate of aortic dilatation was delayed: at aortic sinus of Valsalva in PTC-MFS patients as 0.27 ± 0.69 mm/m2.year (95% CI: −0.19; 0.73) was higher than in DN-MFS patients as 0.05 ± 2.78 mm/m2.year (95% CI: −1.43; 1.54), P > 0.05; and at ascending aorta in PTC-MFS patients as 0.37 ± 0.93 mm/m2.year (95% CI: −0.35; 1.08) was lower than in DN-MFS patients as 1.65 ± 2.75 mm/m2.year (95% CI: −0.1; 3.4), P > 0.05. Conclusion With beta-blocker therapy, the rate of aortic dilatation for FBN1-MFS patients was delayed and not significantly different between subtypes of FBN1 gene mutation.

Background Accurate evaluation of aortic root geometry is necessary in congenital aortic valve lesions in children, to guide surgical or angiographical intervention. Aim To compare aortic annulus diameters measured by two- and three-dimensional transthoracic echocardiography (2D- and 3D-TTE), to determine the feasibility and reproducibility of 3D imaging and assess the dynamic changes during the cardiac cycle. Methods Thirty children without heart disease were prospectively included. Two orthogonal aortic annulus diameters were measured offline using multiplanar reconstruction in diastole and in systole and were compared with the measurement of the aortic annulus diameter by 2D-TTE. Results Mean age was 11 ± 3.6 years. Feasibility of 3D imaging was 100%. The coefficients of intra- and interobserver variability were 3.5% and 6%, respectively. The 2D mean diameter was significantly smaller than the 3D maximum diameter in systole (1.94 vs. 2.01 mm; p = 0.005). 2D and 3D measurements were well correlated (p

We used three-dimensional printing technology to create an anatomical three-dimensional model of a very rare and complex cyanotic CHD in a newborn, consisting of double-outlet left ventricle, ventricular septal defect, and pulmonary stenosis. This case demonstrates how this new innovative technology allows better understanding of the anatomy in complex CHDs and permits to better plan the surgical repair.

Right ventricular (RV) function is a prognostic marker of cardiac disease in children. Speckle tracking has been developed to assess RV longitudinal shortening, the dominant deformation during systole; little is known about its feasibility in children with congenital heart disease (CHD).To evaluate the feasibility and reproducibility of RV two-dimensional (2D) strain assessed by speckle tracking in infants undergoing CHD surgery compared with conventional markers.In this prospective single-centre study, RV peak systolic strain (RV-PSS) was measured using 2D speckle tracking in 37 consecutive children undergoing CHD surgery. Examinations were performed the day before surgery, a few hours after surgery and before discharge. Relationships with the z score of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TA Sa) were assessed.Median (interquartile range) age was 19 months (5-63); median weight was 9.2 kg (5.3-18.0). RV-PSS analysis was feasible in 92.9% (95% confidence interval [CI]: 86.0-97.1) of examinations. The coefficient of variation was 9.7% (95% CI: 7.4-11.9) for intraobserver variability and 15.1% (95% CI: 12.7-17.6) for interobserver variability. Correlations between RV-PSS and z score of TAPSE and TA Sa were strong (r=0.71, P0.0001 and r=0.70, P0.0001, respectively). RV-PSS was significantly reduced after surgery compared with baseline (-10.5±2.9% vs. -19.5±4.8%; P0.0001) and at discharge (-13.5±4.0% vs. -19.5±4.8%; P0.0001). Similar evolutions were observed with TAPSE and TA Sa (both P0.0001).RV longitudinal strain by speckle tracking is a feasible and reproducible method of assessing perioperative evolution of RV function in children with CHD.

Morphologic description of ventricular septal defect (VSD) is mandatory before performing the newly developed transcatheter closure procedure. Inaccurate estimation of defect size has been reported using conventional two-dimensional (2D) transthoracic echocardiography (TTE). The aim of this study was to assess VSD morphology and size using three-dimensional (3D) TTE compared with 2D TTE and surgery.Forty-eight children aged 21.4 ± 29.3 months with isolated muscular (n = 11 [22.9%]) and membranous (n = 37 [77.1%]) VSDs were prospectively included. Three-dimensional images were acquired using full-volume single-beat mode. Minimal diameter, maximal diameter, and systolic and diastolic VSD areas were measured from 3D data sets using multiplanar reconstruction mode (QLAB 9). Maximal-to-minimal VSD diameter ratio was used to assess VSD geometry. Linear regression analysis and the Bland-Altman method were used to compare 3D measurements with 2D and surgical measurements in a subgroup of 15 patients who underwent surgical VSD closure.VSD 3D diameters and areas were measured in all patients (100%; 95% CI, 92.6%-100%). Maximal diameter was lower on 2D TTE compared with 3D TTE (7.3 vs 11.3 mm, P .0001). Mean bias was 4 mm, with 95% of values ranging from -1.76 to 9.75 mm. Correlation between 3D maximal diameter and surgical diameter was strong (r(2) = 0.97, P .0001), while correlation between maximal 2D diameter and surgical diameter was moderate (r(2) = 0.63, P .0001). VSDs had an oval shape when assessed by 3D TTE. Maximal-to-minimal diameter ratio assessed by 3D TTE was significantly higher in muscular VSDs compared with membranous VSDs (3.20 ± 1.51 vs 2.13 ± 1.28, respectively, P = .01). VSD area variation throughout the cardiac cycle was 32% and was higher in muscular compared with membranous VSDs (49% vs 26%, P = .0001).Three-dimensional TTE allows better VSD morphologic and maximal diameter assessment compared with 2D TTE. VSD shape and its changes during the cardiac cycle can be visually and quantitatively displayed. Three-dimensional echocardiography may thus be particularly useful before and during percutaneous VSD closure.

Background Accurate evaluation of pulmonary valve (PV) morphology and pulmonary annulus (PA) diameter is crucial before surgical correction of tetralogy of Fallot (TOF). Our aim was to assess PV morphology using three-dimensional transthoracic echocardiography (3D-TTE) in infants with TOF before surgical correction. And to compare PA diameter obtained by different imaging modalities. Methods 30 patients with TOF were prospectively included. All patients underwent 2D and 3D-TTE, 23 patients underwent CT-Scan and 7 cardiac catheterization. PA diameter was measured using 2D-TTE in parasternal short axis view as recommended. 3D dataset was acquired using zoom mode at PV. Both vertical (Dv) and horizontal (Dh) diameters of PA were measured. Mean 3D diameter (3DD) was calculated as (Dv+Dh/2). Eccentricity index (EI) of PA was calculated (Dv—Dh/Dv). These measurements were compared to CT-Scan and angiography when available and to perioperative measurements. Results Mean age 7.4 months (3-24 months), mean weight 6.6kg (4.5-13.5kg). PV was described as bicuspid in 15/30 patients by 3D-TTE from en face view, with 75% agreement between 3D-TTE and perioperative finding (20/30 patients). PA geometry was slightly asymmetric by 3D-TTE. Dv was significantly larger than Dh (8.4mm vs 7.4mm, p=0.001), and mean EI of PA was (10%). PA was more asymmetric in bicuspid valves rather than in tricuspid valves (EI 14% vs 7%, p=0.002). PA diameter didn’t differ significantly between 2D-TTE, Dh, CT scan and angiography, and were significantly lower than mean 3DD and Dv. There was a very strong correlation between 3DD and perioperative measurement. PA was conserved in 53.3% without significant residual stenosis immediately and after a 20 month of follow-up (except 1 patient requiring balloon dilatation). Conclusion 3D-TTE in patients with TOF is an accurate method to describe PV, and to measure PA size. Thus could help the surgical repair and the preservation of PV function.

BACKGROUND: Brugada syndrome (BrS) is an arrhythmogenic disease associated with sudden cardiac death (SCD) that seldom manifests or is recognized in childhood. OBJECTIVES: The objectives of this study were to describe the clinical presentation of pediatric BrS to identify prognostic factors for risk stratification and to propose a data-based approach management. METHODS: We studied 106 patients younger than 19 years at diagnosis of BrS enrolled from 16 European hospitals. RESULTS: At diagnosis, BrS was spontaneous (n = 36, 34%) or drug-induced (n = 70, 66%). The mean age was 11.1 ± 5.7 years, and most patients were asymptomatic (family screening, (n = 67, 63%; incidental, n = 13, 12%), while 15 (14%) experienced syncope, 6(6%) aborted SCD or symptomatic ventricular tachycardia, and 5 (5%) other symptoms. During follow-up (median 54 months), 10 (9%) patients had life-threatening arrhythmias (LTA), including 3 (3%) deaths. Six (6%) experienced syncope and 4 (4%) supraventricular tachycardia. Fever triggered 27% of LTA events. An implantable cardioverter-defibrillator was implanted in 22 (21%), with major adverse events in 41%. Of the 11 (10%) patients treated with hydroquinidine, 8 remained asymptomatic. Genetic testing was performed in 75 (71%) patients, and SCN5A rare variants were identified in 58 (55%); 15 of 32 tested probands (47%) were genotype positive. Nine of 10 patients with LTA underwent genetic testing, and all were genotype positive, whereas the 17 SCN5A-negative patients remained asymptomatic. Spontaneous Brugada type 1 electrocardiographic (ECG) pattern (P = .005) and symptoms at diagnosis (P = .001) were predictors of LTA. Time to the first LTA event was shorter in patients with both symptoms at diagnosis and spontaneous Brugada type 1 ECG pattern (P = .006). CONCLUSION: Spontaneous Brugada type 1 ECG pattern and symptoms at diagnosis are predictors of LTA events in the young affected by BrS. The management of BrS should become age-specific, and prevention of SCD may involve genetic testing and aggressive use of antipyretics and quinidine, with risk-specific consideration for the implantable cardioverter-defibrillator.

Because the classification of congenital bicuspid aortic valve (BAV) is of importance to predict a possible valvular dysfunction, we sought to assess the feasibility, the reproducibility, and the accuracy of three-dimensional transthoracic echocardiography (3D-TTE) to accurately depict the morphology of the leaflets in a BAV.Seventy-two consecutive children, who were suspected of having a BAV on two-dimensional transthoracic echocardiography (2D-TTE), were included in this prospective study. 2D-TTE and 3D-TTE views of a BAV were recorded by the same investigator, and then were analysed separately by two confirmed paediatric cardiologists. For each of these two imaging techniques, the spatial position of cusps and raphes was noted for each patient. Intra-observer concordance and inter-observer concordance were evaluated to assess the reproducibility of the techniques. Feasibility of 3D-TTE was 100%. Median acquisition time of 3D-TTE was 117 (98.5-176.8) s. Image quality seemed to be better with 3D-TTE compared with 2D-TTE. When using 3D-TTE, the diagnosis was reconsidered for 12 patients (17%). Only 44.4% of uncertain BAV cases identified by 2D-TTE were confirmed by 3D-TTE. Furthermore, 3D-TTE seems to provide a better visualization of the leaflet morphology, leading to reclassification for 34.4% (95% CI 22.9-47.3) of the patients. Agreement for the BAV classification between 2D-TTE and 3D-TTE was therefore moderate (κ = 0.46). Both inter-observer concordance and intra-observer concordance were good (κ = 0.91 and κ = 0.93, respectively) for 3D-TTE.3D-TTE is feasible and provides accurate description of a BAV in children. Compared with 2D-TTE, 3D-TTE seems to enable a better visualization of the structural geometry of the leaflets.

Invagination of an appendage into the left atrium is a rare complication. It occurs spontaneously or after open-heart surgery. In our case, a postoperative transesophageal echocardiogram, after closure of a ventricular septal defect in a 5-month-old infant, revealed a large mass in the left atrium. A diagnosis of a left appendage inversion was confirmed after external examination of the heart. Herein, we provide echocardiographic images before, during, and after manual reversion of the left appendage. Misdiagnosis of this complication could have led to an additional unnecessary surgical procedure that could have impacted on the patient's morbidity.

RésuméL’échocardiographie 3D transthoracique a longtemps été freinée dans son développement en raison de conditions techniques d’acquisition compliquées et de qualité d’images médiocres. L’avènement des sondes matricielles permet au 3D en devenant temps réel d’entrer dans la pratique clinique courante. Si la voie œsophagienne a permis au 3D de trouver ses lettres de noblesses par ses descriptions anatomiques uniques des valves et des septa, l’échocardiographie transthoracique peut désormais se décliner en modes 2D, Doppler et 3D. Ses applications dans la cardiologie congénitale et pédiatrique sont multiples : description anatomique précise des défauts septaux auriculaires et ventriculaires, classification des bicuspidies aortiques et analyse du mécanisme de sténose. Ainsi, l’échocardiographie 3D permet-elle de sélectionner de façon non invasive les patients, de guider et de juger du résultat d’un cathétérisme interventionnel. L’imagerie 3D est un excellent moyen de communication entre l’imageur et le cardiologue interventionnel mais aussi de délivrer des informations claires au patient et à la famille avant et après un cathétérisme.SummaryThree-dimensional echocardiography has improved dramatically due to technical advances in probe design and computer processing. The introduction of real time 3D echocardiography has led to its use in everyday clinical practice. Congenital heart disease demands a detailed understanding of the spatial relationships of cardiac structures to plan treatment. The introduction of new transthoracic 3D probes has extended the applications to real-time guidance of catheter procedures. Prominent among the cardiac lesions which have been studied are: atrial septal defects, ventricular septal defects and stenotic bicuspid aortic valves. Its values should be decisive in many congenital cardiac lesions requiring interventional catheterisation. 3D echocardiography is an easy way to communicate to the patient and its family about the pathology.

Background A new three-dimensional echocardiographic (3DE) automated software (HeartModel) is now available to quantify left heart chamber. Our aims were to assess the feasibility of this software in children and its correlation with manual 3DE and cardiac magnetic resonance (CMR). Methods Ninety-two children were prospectively included in 2 separate protocols. In protocol 1, 73 healthy children (8.8 ± 3.0 years) underwent 2D and 3D transthoracic echocardiography (EPIQ 7 C). LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LVEF and LA volume at ventricular end-systole (LAV) obtained with automated 3DE were compared with the manual 3DE measurements. In protocol 2, automated 3DE measurements from 19 children with cardiopathy (12.8 ± 2.9 years) were compared with CMR values. Intra and inter-observer variability were assessed. Results Automated 3DE was feasible in 77% of datasets and reduced significantly time required for indices analysis compared with manual 3DE (20 vs. 125 seconds). There was excellent correlation for LVEDV, LVESV and LAV between automated and manual 3DE (R = 0.95) but less for LVEF (R = 0.57). Compared with manual 3DE, automated 3DE slightly overestimated LVEDV, LVEF and LAV and slightly underestimated LVESV. There were excellent correlation for LV volumes between automated 3DE and CMR (R = 0.94) but the correlation for LVEF was moderate (R = 0.46). Compared with CMR, automated 3DE slightly underestimated LVEDV and LVESV (biase-7.5%), underestimated LAV (− 31.6%), and had a negligible bias for LVEF (1.0%). Intraobserver and interobserver variability for automated 3DE measurements were low ( Fig. 1 )). Conclusions HeartModel is promising software for fast assessment of left heart chamber volume and function. Its feasibility in children aged more than 5 years is good, with high reproducibility. The automated 3DE measurements were comparable to manual 3DE. Compared with CMR, LVEDV and LVEF measured by automated 3DE seem interesting in clinical practice.

We extracted L., the newborn of a diabetic mother, for antenatal diagnostic of myocardial hypertrophy and anomaly of foetal heart rate. Post-natal echocardiography showed severe septal myocardial hypertrophy with latero-basal myocardial akinesia. We did not observe a Doppler gradient through the left ventricular outflow. Selective coronary angiography showed an occlusion of the circumflex artery. Myocardial hypertrophy is a classic complication in newborns of diabetic mothers. The mother's diabetes and neonatal infarction remain an exceptional association. We discuss a different hypothesis to explain coronary occlusion and how myocardial infarction avoided septal obstruction.

RésuméL’étude FUTURE 1 a été conçue pour évaluer le profil pharmacocinétique d’une nouvelle formulation pédiatrique du bosentan chez des enfants avec hypertension artérielle pulmonaire (HTAP). Trente six enfants avec HTAP ont été inclus dans une étude multicentrique, prospective, non contrôlée en ouvert et traités 4 semaines par bosentan à 2 mg/kg 2 fois par jour puis 8 semaines avec 4 mg/kg 2 fois par jour. Des échantillons sanguins ont été prélevés pour les études de pharmacocinétique. L’efficacité a été évaluée par le suivi des modifications de la classe fonctionnelle NYHA et l’impression clinique globale des parents et du médecin. Le ratio des moyennes géométriques de l’aire sous la courbe ASCt entre les enfants et les adultes d’une cohorte historique était de 0,54 (intervalle de confiance 90 % : 0,37-0,78) signifiant que l’exposition des enfants au bosentan est d’environ la moitié de celle des adultes. Le profil de concentration de bosentan après administration de 2 et de 4 mg/kg × 2 par jour était comparable suggérant qu’un plateau d’exposition est atteint pour une dose de 2 mg/ kg. Une amélioration de la classe fonctionnelle et de l’impression clinique globale était notée principalement pour les patients sans bosentan avant l’étude alors que les rares aggravations ont été notées pour ceux déjà sous bosentan avant le début de l’étude. L’étude FUTURE-1 et des études préalables suggèrent un rapport bénéfice-risque favorable pour des posologies de 2mg/kg/ × 2 par jour, qui est la posologie à préconiser pour les enfants souffrant d’HTAP. La nouvelle formulation pédiatrique est bien tolérée chez l’enfant avec une forme galénique adaptée qui devrait en favoriser l’observance.SummaryFUTURE-1 study was designed to evaluate pharmacokinetic profile of newly developed paediatric formulation in paediatric patients with pulmonary arterial hypertension (PAH). Thirty-six paediatric PAH patients were enrolled in this multicentre, prospective, open-label, non-controlled study and treated for 4 weeks with bosentan 2 mg/kg b.i.d. and then for 8 weeks with 4 mg/kg b.i.d. Blood samples were taken for pharmacokinetic purposes. Exploratory efficacy measurements included WHO functional class and parent's and clinician's Global Clinical Impression scales. The ratio of the geometric means for the area under the plasma concentration-time curve between paediatric and adult patients was 0.54 (90% CL : 0.37, 0.78), indicating that exposure to bosentan in children in the current study was half the exposure found in adult patients. Plasma concentration-time profiles of bosentan following doses of 2 and 4 mg/kg were similar, suggesting that an exposure plateau was reached at a dose of 2 mg/kg. Improvements in WHO functional class and the Global Clinical Impression scales occurred mainly in bosentan-naive patients whereas the rare worsenings occurred in patients already on bosentan prior to study initiation. FUTURE-1 study and past studies suggest a favourable benefit-risk profile for bosentan at 2 mg/kg b.i.d., this dose is recommended for children with PAH. The new paediatric formulation was well tolerated.