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Objectif: La principale cause à long terme de morbi-mortalité après réimplantation coronaire pour ALCAPA est liée aux complications au niveau de l’ostium et du segment proximal de l’artère. L’évaluation de la perméabilité coronaire après réimplantation est un problème important en pédiatrie. L’angiographie coronarienne conventionnelle est actuellement l’examen de référence dans cette indication, mais cette technique reste invasive et coûteuse. Le but de cette étude est d’établir l’apport du scanner multibarette dans l’évaluation de la perméabilité de la coronaire gauche après réimplantation chez l’enfant. Matériel et Méthode: Entre mai 2005 et décembre 2007, 13 patients consécutifs (âge médian : 3.5 ans, compris entre 11 mois et 11 ans) opérés pour réimplantation coronaire (coronaire gauche : 12, artère infundibulaire : 1) ont bénéficié d’une imagerie par scanner multibarrette (9 synchronisés à l’ECG, 4 non synchronisés). La présence d’une sténose significative était définie par un rétrécissement de plus de 50 % du diamètre du vaisseau. Pour chaque coronaire, les résultats ont été confrontés aux données de l’angiographie, méthode de référence. Résultats: Toutes les coronaires ont été correctement visualisées par scanner. Cette visualisation était excellente dans 8 cas sur 13 et satisfaisante dans les 5 autres cas. Parmi les 13 patients étudiés, 6 ont bénéficié d’un cathétérisme. L’analyse du scanner montrait 12 artères coronaries normales et une sténose significative de la coronaire gauche. Le scanner était concordant avec l’angiographie dans 100 % des cas. L’enfant ayant une sténose significative a bénéficié d’un pontage. Conclusion: Les résultats préliminaires suggèrent que le scanner multibarrette pourrait être une alternative non invasive à l’évaluation de la perméabilité coronaire après réimplantation chez l’enfant. [Copyright &y& Elsevier]

Objectif: Le diagnostic de retour veineux pulmonaire anormal total ou partiel (RPVAT/RPVAP) est un défi diagnostique. Le but de cette étude était d’évaluer l’efficacité du scanner 64 barrettes non synchronisé à l’électro-cardiogramme dans la détection des RPVAT et RPVAP chez l’enfant. Matériel et Méthode: De mai 2005 à Décembre 2007, 8 RPVAT et 42 RPVAP et ont été diagnostiqués dans le service de radiologie pédiatrique de l’Hôpital Necker Enfants Malades (N = 50). L’âge moyen au diagnostic des enfants présentant un RPVAT était de 3,5 jours (compris entre 1 jours et 14 mois), l’âge moyen au diagnostic des enfants présentant un RPVAP était de 3.5 ans (compris entre 6 jour et 17 ans). Les veines pulmonaires ou collecteurs se drainant dans les veines systémiques ou dans l’oreillette droite furent évaluées comme des structures séparées. Résultats: Les résultats scannographiques furent comparés avec les données de l’échographie cardiaque ou du cathétérisme et/ou chirurgie disponibles. RPVAT : le scanner a identifié 10 veines anormales : 4 drainant dans le tronc veineux innominé, 2 dans la veine cave supérieure droite, 1 dans le sinus coronaire, 2 dans la veine cave inférieure, 1 dans la paroi postérieure de l’oreillette droite. 2 veines étaient obstruées. RPVAP: le scanner a identifié 73veines anormales drainait le poumon droit et 9 le poumon gauche (N = 82). Le RPVAP fut retrouvé en association avec : CIV (N = 5), coarctation aortique (N = 11), valve aortique bicuspide (N = 2), veine cave supérieure gauche (N = 11), CIA type sinus venosus (N = 10 patients), CIA type ostium secondum(N = 3), syndrome de la veine cimeterre (N = 8), syndrome hétérotaxique (N patients = 5), malformations conotroncales (N = 3), sténose congénitale de la veine pulmonaire (N = 1) et cœur tri atrial (N = 1). Parmi les 92 anomalies des veines pulmonaires, 69 % (n = 64) ont été reconnues par échocardiographie, 78 % (N = 72) par chirurgie et/ou cathétérisme. Le scanner multibarrette était confirmé par la chirurgie ou le cathétérisme dans 100 % des cas. Conclusion: La veinographie pulmonaire par scanner cardiaque 64 barrettes non synchronisé à l’électrocardiogramme évalue le système veineux pulmonaire de façon plus complète que l’échographie cardiaque. C’est une méthode fiable pour détecter les anomalies de retour veineux pulmonaire chez l’enfant. [Copyright &y& Elsevier]

Objectif: Le syndrome de Williams est une anomalie multisystémique associé à une microdélétion 7q11.23. Il se manifeste par une dysmorphie faciale typique, un retard mental et des anomalies vasculaires congénitales. L’échocardiographie standard qui est l’examen de première ligne dans le diagnostic des anomalies cardiovasculaires reste parfois non exhaustive. L’objectif de l’étude est de décrire les différentes lésions cardiovasculaires détectées par un scanner multibarette chez ces enfants. Matériel et Méthode: De mai 2005 à décembre 2007, 14 enfants atteints de syndrome de Williams (age médian : 8 mois, compris entre 3 mois et 10 ans) ont bénéficié d’un scanner multibarrette. Toutes les acquisitions cardiaques (2 synchronisées à l’électrocardiogramme, 12 non synchronisées) ont été réalisées par un scanner 64 barrettes après injection périphérique de produit de contraste, sans anesthésie générale. Résultats: Tous les examens réalisés en une acquisition et une injection uniques ont permis l’analyse des artères pulmonaires, rénales et de l’aorte. Dans 71 % des cas ont visualisait au moins l’origine des 2 artères coronaires. Dans 29% des cas, l’origine de la coronaire droite n’était pas clairement visible. Des sténoses aortiques supravalvulaires modérées à sévères ont été identifiées dans 79 % des cas. L’hypertrophie du ventricule gauche et un épaississement diffus de la paroi aortique a été notés respectivement dans 64 % et 100 % des cas. Une hypoplasie de l’aorte était retrouvée dans 5 cas sur 14 (3 homogènes, 1 prédominant sur le segment horizontale et 1 sur le segment abdominal de l’aorte). Une sténose pulmonaire supravalvulaire, une hypoplasie homogène des 2 artères pulmonaires, une hypoplasie de l’artère pulmonaire droite, un kinking de l’artère pulmonaire gauche et une sténose de la bifurcation artérielle pulmonaire ont été respectivement diagnostiquées dans 3,7,2,3, et 2 cas. Une sténose distale des artères pulmonaires a été mise en évidence dans 28 % des cas. Un épaississement pariétal était visible pour 12 % des artères coronaires et 38 % des artères rénales, évaluées comme structures séparées. Conclusion: Dans l’exploration des enfants atteints de syndrome de Williams, le scanner multibarrette est une alternative non invasive qui permet un bilan exhaustif des différentes lésions cardiovasculaires. [Copyright &y& Elsevier]

Objectives: Pulmonary artery banding is often required as a first palliative procedure in infants with congenital heart disease and high pulmonary blood flow or to retrain the left ventricle. The purpose of the study was to demonstrate the safety of a gastric banding system as an adjustable pulmonary artery banding in chronic implantation., Methods: Five ewes underwent implantation of the banding system around the main pulmonary artery through a left thoracotomy. All had functional evaluation with progressive occlusion and opening of the device every two weeks for a total period of three months. Invasive pressure measurements in the right ventricle and aorta were carried out each time., Results: Devices could be implanted easily. Progressive occlusion and re-opening were possible in all animals during each time point. All animals survived throughout the protocol. Retrieval of the device was achieved in all animals. In one, it was challenging because of the presence of a fibrotic reaction around the device. It died because of pulmonary artery perforation before the sacrifice. At autopsy, microscopic examination showed no signs of myocardial fibrosis., Conclusions: In animals, gastric banding system is a safe and effective implantable device to adjust pulmonary artery diameter over a prolonged period of time. This new device may be a valuable alternative to the repeated conventional pulmonary artery banding needed for ventricular retraining in humans.

Persistent left superior caval vein draining into the left atrium is responsible for a right-to-left shunt which can be source of desaturation and systemic embolism. We present 2 cases of successful percutaneous treatment in 2 patients in whom no bridging vein existed and systemic desaturation was found after repair of the underlying congenital heart.

The advances of surgical and interventional treatment of congenital heart diseases have allowed a large number of patients with congenital heart disease to reach adult age. This population involves almost 0.3/1000 of total population in West Europe and North America and can be estimated around 200000 patients in France. Patients with operated Tetralogy of Fallot, benign forms of pulmonary atresia with ventricular septal defect, simple or complex transposition of the great arteries usually survive beyond childhood. These patients can need repeated interventions to treat lesions of native or reconstructed pulmonary arteries and/or aortic arch, to occlude residual shunts, to treat pulmonary incompetence. More complex heart diseases such as single ventricle, rarely allow survival until the adult age. The majority of these patients undergo heart transplant, often made difficult by multiple cardiac surgeries, anomalies of pulmonary arteries, chronic cyanosis, aorto-pulmonary shunts. Patients with relatively simple or complex congenital heart diseases need to be followed-up in specialized units, like those created more than twenty years ago in the United States, Canada, and United Kingdom. Interventional cardiac catheterisation play a major role in the management of this population. The results of 3 years of activity in a new centre treating GUCH patients are illustrated.

Introduction: A fenestration is usually surgically created to improve the post-operative course of patients undergoing total cavopulmonary connection. It, however, has a potentially deleterious effect on the long-term period. Closure of these fenestrations is usually performed by interventional catheterization. No device has been specially designed and closure of extracardiac fenestration, in particular, can be challenging. We report our experience in occlusion of such fenestrations using covered stents (Numed Inc)., Methods: From July 2005 to October 2005, we attempted to occlude extracardiac Fontan fenestration using CP covered stents in 4 consecutive patients., Results: All patients had a successful occlusion of the fenestration. The procedure was performed from femoral or jugular vein respectively in three and one patient. Mean central venous pressure did not increase significantly (from 11.25 to 12.75 mmHg) whereas mean oxygen saturation increased significantly from 92% to 99% (p=0.0047). Abolition of shunt was obtained immediately after insertion of the covered stent in all patients. No early complications were observed. All patients were ambulatory the day after the procedure., Conclusion: The insertion of a covered stent inside the extracardiac Fontan conduit allowed the exclusion of the fenestration in all patients without the need of crossing the fenestration and with no early mortality or morbidity. Long-term follow-up are needed before considering the use of such device as the device of choice in that application.

An 11 year-old boy with an Alagille syndrome was referred for an urgent echocardiography because of new onset of febrile hemoptysis. Follow-up in our institution to that point had shown severe hypoplastic pulmonary arteries. The diagnosis of tricuspid endocarditis complicated by pulmonary embolisms and aneurysm of the left pulmonary artery was done. Despite effective antiobiotics, the evolution was marked by rapid progression in size of the left pulmonary aneurysm. Since the surgery was not an option because of high risk of death, this aneurysm was treated by a trans-catheter technique using covered stents (CP stents, Numed Inc). Its exclusion allowed to stop its progression in size and to avoid its rupture.

Introduction: A direct or tubular communication between the systemic venous system and the systemic atrium, generally called fenestration, is surgically created to improve the postoperative period of patients undergoing total cavopulmonary connection. However, a fenestration prompts a potentially deleterious right to left shunt, and is generally closed after the postoperative period. Direct fenestrations can be closed using coils, or devices designed for atrial septal defect closure. However, no devices have been designed for closure of extracardiac fenestrations. We report our experience concerning the closure of extracardiac Fontan fenestration by the Amplatzer duct occluder (ADO)., Methods: From January 2001 to December 2002, we closed extracardiac Fontan fenestrations using the ADO device in 10 consecutive patients. Indications to fenestration closure were: low velocity shunt through the fenestration, mild desaturation, and absence of effusions., Results: All patients had a successful closure of the fenestration. The procedure was performed through the femoral vein in 7 cases and through the right jugular vein in 3. Mean central venous pressure increased not significantly from 12 to 13-mmHg. Mean oxygen saturation increased significantly from 90 to 97% (p<0.001). Immediate shut abolition was obtained in 9 cases. No complications were observed. At a median follow-up of 12 months (range 6-18 months), all patients are free of symptoms and have a normal oxygen saturation at rest as well as at exertion., Conclusion: The ADO device allowed closing the extracardiac Fontan fenestration in all patients with no mortality, no morbidity and a rate of 100% of complete closure at mid-term follow-up.

Introduction: In order to establish the best strategy of treatment and predictors of outcome in infants with pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries, we reviewed our institutional experience concerning 47 infants., Methods: Inclusion criteria included an angiographic diagnosis of pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries with or without central pulmonary arteries and a repair by the same surgeon. Thirty-one patients had confluent (type III) and 16 absent (type IV) central pulmonary arteries. Pulmonary arteries were considered to be adequate when they measured > or = 4 mm., Results: There were 8 deaths (17%). Complete repair was performed in 24 patients (18 in group III and 6 in group IV) with 79.3% had a right/left ventricular pressure <0.5, 16; 5%<1 and 4.2%>1. Eleven patients are waiting for complete repair and 4 will be operated on pulmonary arteries. One stage complete repair was performed in 3 patients, two and third stage repair (after unifocalisation or right ventricle to pulmonary arteries conduit) was attained in 21 patients. Among patients having had a complete repair and showing a right/left ventricular pressure <0.5, 88.9% had a pulmonary atresia with ventricular septal defect type III and 50% a pulmonary atresia with ventricular septal defect type IV. Only 56% of type III patients with a right/left ventricular pressure <0.5 had adequate central pulmonary arteries., Conclusion: In our study, the small size and the absence of central pulmonary arteries do not prevent a positive outcome.

Unlabelled: The use of long-term central venous catheters is a routine in chronic pediatric diseases. Thrombotic complications progressively reduce the central venous capital and hamper the long-term management of these patients., Observation: We report two cases of obstruction of the central upper venous system and discuss of the techniques used to repermeabilize venous axes before the placement of a new central line., Conclusion: The control of the permeability of the central veins should be performed before any withdrawal of central catheters, repermeabilization of the venous axes being simpler when the central catheter is kept in place in the occluded vessel.

The authors report the spontaneous detachment of a coil during embolisation of a coronary fistula in a 34 old year woman with operated tetralogy of Fallot. The fistula originated from an isolated circumflex artery and drained into the infundibulum. By retrograde approach, a microcatheter was successfully advanced into the distal part of the fistula, one coil loop was fixed through the fistula mouth and two in its distal portion. During positioning of the proximal part of the coil, it suddenly detached into the microcatheter. Coaxial snaring of the coil was attempted, however this manoeuvre produced progressive elongation and repeated ruptures of the coil. Finally, the procedure was abandoned; surgical extraction of the coil and suture of the fistula were successfully performed. Percutaneous transcatheter closure of coronary fistulae, although generally feasible is burdened by complications due to tortuous anatomy, poor stabilisation of catheters and lack of specific materials.

Miniaturisation of diagnostic and interventional tools is of main interest for cardiac catheterization of newborns and small infants, due to the limited vascular access of these patients. Since January 2001 to November 2002, we performed 11 diagnostic and 5 interventional procedures in 15 infants, utilising custom-made 3 F sheaths and catheters. The median age and weight of the patients were 7 days (range 1-180) and 2.8 kg (range 2-4), respectively. Diagnostic catheterizations gave the required information in all cases. Angiography was performed following the results of in vitro pressure to volume tests. Blood sampling was possible by using gentle aspiration. Pressure measurement, although showing some dumping, allowed the evaluation of peak to peak gradient through right and left ventricular outflow tracts. It was always possible to perform an interventional procedure, when required. No procedural complications occurred. The price for a diagnostic or interventional procedure performed with 3 F sheath and catheters exceeded of 23 euros that of a procedure performed with material measuring 4 F or more. Patients underwent echographic examination of femoral vessels at a median follow-up of 6.3 months (range 2-10 months). All vessels of the examined patients were patent, without stenosis nor collateral circulation. In conclusion, preliminary results utilising 3 F sheaths and catheters are encouraging, in terms of feasibility of diagnostic and interventional procedures, absence of procedural complications and preservation of vascular access. Financial implications are not of major concern.

Percutaneous closure of interventricular defects is an alternative or adjunct to surgery with the disadvantage of a sometimes prolonged and difficult catheterisation only during which the choice of prosthesis can be determined. Despite the existence of an occlusion prosthesis, the Amplatzer Septal Defect Occluder, specifically conceived for this purpose, an arterial canal occlusion prosthesis such as the Amplatzer Duct Occluder is sometimes better suited for the occlusion of certain interventricular defects. Since 1999, 11 Amplatzer Duct Occluders were used for the closure of interventricular muscular defects, during 10 catheterisations in 9 patients with a median age of 2.5 (0.1 to 43.9) years. In 5 cases there were residual septal defects after failure of initial surgery. 10 were successful with prostheses of 6/4 mm to 12/10 mm while in one patient the interventricular communication had to be closed surgically because the 14/12 mm prosthesis could not be positioned due to a tortuous introduction route. The only complication was a pericardial effusion requiring surgical drainage in one infant. After a median follow up of 2.1 (0.3 to 4.2) years, all of the patients had a satisfactory functional status, with minimal residual shunt on echocardiography in 2 cases. The Amplatzer Duct Occluder therefore seems better adapted for the closure of post-operative residual interventricular communications, with a thickened interventricular septum or even when the tricuspid valve is very close to the right ventricular side of the orifice.

We report our recent experience with the Palmaz Corinthian stent in children. Since 1/10/01 to 1/11/02 we implanted 18 Palmaz Corinthian stents in 12 children. Median age and weight of patients were 5.6 years (range 0.25-13) and 17.9 kg (range 3-36), respectively. Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 7), complex transposition of the great arteries (n = 2) and others (n = 3). Indications to stent implantation were: pulmonary branches stenosis (n = 9), stenosis of the ductus arteriosus (n = 1), stenosis of systemic veins (n = 2). All stents were pre-mounted and co-axially advanced over a standard guidewire across the stenotic site, using a 6F short introducer. Stent deployment was performed by hand inflation of the balloon. Final angiography confirmed correct positioning and ruled out complications. Median fluoroscopy time was 18 minutes (range 12-56). All stents reached their nominal diameter; 2 were post-dilated to 125 and 150%. No procedural complications occurred. Despite the impossibility of distal injection, stent positioning was always correct. In conclusion, due to the availability of pre-mounted stents, and the need of short 6F sheaths, the use of the Palmaz Corinthian stent in children is relatively simple. Primary results are generally good in terms of adequate delivery and absence of complications. However, the impossibility of distal injection makes more difficult the choice of the deployment site. Due to the limited possibility of over-dilation, the use of this stent has to be limited to the stenosis of peripheral pulmonary branches or to lesions that can be surgically treated during further surgical procedures.

Percutaneous pulmonary valve replacement has recently been introduced as an alternative to surgery, pushing back the frontiers of interventional catheterisation. The authors report their experience in this field and focus on the complications of the method. From September 2000 to November 2002, 14 patients with a failing artificial pulmonary outflow tract were included in this protocol of clinical research. The authors attempted pulmonary implantation of a bovine jugular vein valve fitted in a vascular stent under general anaesthesia. The implantation was possible in all patients. Three had dynamic obstruction due to the implanted valve. This was due to infiltration of blood between the valve and the stent. The problem was resolved by: implanting a second valve in one patient: redialating the valve stent in two other patients. However, the last patient had to be reoperated 7 weeks after the implantation because of recurrence of the obstruction. One valve had to be explanted one year after implantation because of severe infectious endocarditis after unprotected dental treatment. Two patients experienced fracture of the stent but without valve dysfunction. Despite these complications, the clinical state of all patients improved during follow-up. The authors conclude that non-surgical pulmonary valve replacement is feasible, thereby increasing the therapeutic arsenal of interventional catheterisation. Simple modifications should result in fewer problems of dynamic obstruction and stent fracture, and lead to proposing this technique for native pulmonary outflow tracts.

We report the early complications of stent implantation. Since 1/1/97 to 1/12/02, we implanted 91 stents in 76 patients. Median age and weight were 15 years (range 0.3-43) and 49 kg (range 3-96). Primary diagnosis were: pulmonary atresia with ventricular septal defect (n = 17), tetralogy of Fallot (n = 13), aortic coarctation (n = 15), transposition of the great arteries (n = 3), truncus arteriosus (n = 6), univentricular heart (n = 7), other anomalies (n = 28). Indications to stent implantation were: stenosis of the pulmonary outflow and/or pulmonary branches (n = 44), aortic recoarctation (n = 14), native aortic coarctation (n = 1), systemic venous channels obstruction (n = 14), other (n = 3). The stents were: Palmaz (n = 57), non premounted CP (n = 8), premounted CP (n = 3), Palmaz Corinthian (n = 19), self-expanding (n = 4). Procedural complications occurred in 24 patients (31%) and included: 11 balloon bursting, 8 stent slipping, 1 stent migration, 4 wall dissections. Five patients (21%) needed urgent surgery. Sixty three percent of complications occurred during pulmonary outflow or pulmonary branches stenting, 25% during stenting of the aortic arch, 12% during other procedures. All but 2 complications were observed with non premounted stents. In conclusion, the use of not premounted stents, although widely diffuse, has a not negligible incidence of complications, leading to longer procedures, to the use of a large variety of materials and needing more than occasionally a surgical solution. A larger use of premounted stents, when possible, is recommended.

Closure of interatrial communications by interventional catheterisation is recommended and effective. The usual approach is via the femoral vein. However, difficulty in positioning the probe and the guide in a stable fashion across the septal defect occurred during closure of the interatrial communication by the percutaneous route in a 71 year old female with severe scoliosis. This deformity most certainly contributed to the failure of the femoral approach. The decision for closure by the internal jugular route was taken and allowed closure of the interatrial communication to be achieved. The internal jugular route can be an alternative for closure of interatrial communications with difficult access.

The authors report a case of percutaneous closure of paravalvular mitral regurgitation in a 9 year old child. This patient had complete atrioventricular canal with levo-isomerism completely repaired with replacement of the left atrioventricular valve by a mechanical prosthesis. One year after an episode of infectious endocarditis, the patient was readmitted because of jaundice due to haemolysis attributed to paravalvular mitral regurgitation. Transoesophageal echocardiography demonstrated a crescent-shaped dehiscence of the prosthesis opposite the left atrial appendage associated with a small paraseptal regurgitation. First of all, a 6 mm Amplatzer Septal Occluder and a 5 x 5 coil were introduced by retrograde catheterisation to treat the regurgitation due to the valve dehiscence. This procedure was completed 3 months later by the implantation of a second 8 mm Amplatzer prosthesis for persistent haemolysis. Closure of the paraseptal regurgitation resulted in a reduction of the patient's transfusional requirements.

We report a series of 9 children with neonatal Marfan syndrome. The diagnosis was made on a striking facial dysmorphia associated with arachnodactyly type skeletal anomalies. They all had cardiovascular anomalies: aortic dilatation 9 times, and mitral and/or tricuspid valve prolapse 8 times. Three children underwent ascending aorta replacement with the Yacoub technique. There was one operative death in a young infant and the two survivors required further surgery for gross mitral insufficiency and an aneurysm of the horizontal aorta. Three children died before the age of 1 year from cardiac insufficiency linked to massive leaks of all the valves. The three youngest children in the series did not undergo any procedure and were followed up for a slowly growing dilatation of the initial aorta. The prognosis of neonatal Marfan syndrome is weighted with a heavy mortality. The timing of surgical intervention in case of excessive dilatation of the aortic root is difficult to determine. It depends not only on the aortic diameter but also on the aortic valve function and the existence of other mitral or tricuspid lesions. Surgical treatment for lesions of the initial aorta and the atrioventricular valves improves the short-term prognosis but the risk of re-intervention is higher.

The atrial septal defects (ASDs) occlusion by cardiac catheterization is an alternative to the surgical technique. The use of stretching by balloon is considered as the gold-standard for the ASDs calibration. Three dimensional transesophageral echocardiography (3D-TEE) brings an imaging of the ASD surface and allows the measurement of its maximal diameter. With the goal of a percutaneous ASD occlusion, seventy patients had a simultaneous calibration of the ASDs by 3D-TEE and the balloon method. The mean maximal diameter measured by 3D-TEE was at 20 + 15 mm (range 10-28 mm) compared to the mean balloon-stretched diameter at 22 + 5 mm (range 9-31 mm). The correlation between both methods is good (y = 3.15 + 0.77x, r = 0.8, p < 0.0001). The mean difference between the diameters measured by both methods was 1.85 + 3.17 mm. The ASD visualized by 3D-TEE was single in 54 cases and multiple in 16 cases. The correlation between both methods was excellent in those with a single ASD (y = 1.74 + 0.84x; r = 0.85. p < 0.0001) but it was poor in those with multiple ASD (y = 12.4 + 0.4x; r = 0.45). The calibration by the balloon method which tests the septum resistance is an additive method to 3D-TEE which measures the anatomic diameter of ASD.