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Vasovagal syncope is the most likely cause of syncope in the young. Head-up tilt-table test (HUT) provides the ability to provoke vasovagal syncope under controlled laboratory settings. In adult populations, pharmacologic stimulation with intravenous/sublingual isosorbide dinitrate (ISDN) has been shown to be an alternative to isoproterenol for increasing the diagnostic yield of HUT. In this study, 40 patients aged 9-18 years with unexplained syncope and 12 healthy age-matched children were evaluated by HUT to 70 degrees for 45 minutes. If tilting alone did not induce symptoms (syncope and presyncope), 0.1 mg/kg ISDN was given while the patient lay supine. After 5 min, the table was tilted to 70 degrees for 15 min or until the symptoms occurred. The control group consisted of 12 healthy age-matched children studied in a similar manner. Six patients (15%) had a positive basal tilt test. Twenty-five patients (62.5%) lost consciousness following ISDN administration. In the control group, nobody had a syncopal episode during the basal tilt test. However, ISDN administration resulted in 1 positive response (8.3%). The sensitivity of the test was 77.5% and its specificity was 91.6%. It is concluded that sublingual nitroglycerin HUT is suitable for routine clinical practice in children and adolescents with unexplained syncope.

A 3-year-old girl with a continuous murmur on auscultation was found to have left coronary artery to right atrial fistula simulating cor triatriatum sinister on echocardiography. Coronary angiography of the patient was also insufficient to clarify the exact pathologic anatomy. Magnetic resonance imaging showed that the main drainage of the aneurysmal coronary artery was to the left superior vena cava, resulting in a diffuse arteriovenous fistula in the lower lobe of the left lung by compressing its pulmonary vein.

Acute aortic dissection during balloon angioplasty for coarctation of the aorta or aneurysm formation during follow-up are well-known complications of this procedure. Dissecting aneurysm development during long-term follow-up after balloon angioplasty of a native coarctation has not been previously reported. We report a case in which a huge dissecting aneurysm developed 3 years after the native coarctation angioplasty procedure. The aneurysm required surgical repair.

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