Patent foramen ovale echocardiography and ultrasound
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];
Overview
Echocardiography/Ultrasound
When diagnosing patent foramen ovale, several echocardiographic techniques can be used, including transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and transcranial doppler ultrasonography. They all require the use of a contrast, commonly saline solution.[1]
Transesophageal Echocardiography
- Transesophageal echocardiography is the gold standard for diagnosis. It has a superior image resolution and the ability to identify the origin of a right-to-left shunt. It is the study of choice in patients suspected to have a paradoxical embolus.[2][3][1]
- The process of detecting a right-to-left shunt across a PFO involves the patient performing the valsalva maneuver while injected with a saline contrast medium. During the strain phase of the maneuver, the saline medium is injected into a peripheral vein and the atrial septum is visualized during the release phase of the maneuver.[3]
- Findings on an echocardiography suggestive of/diagnostic of a right-to-left shunt include:[3][4][5]
- Presence of bubbles across the inter-atrial septum into the left atrium: A diagnosis is made with the appearance of at least three micro-bubbles within three cardiac cycles after the complete opacification of the right atrium.
- 3 - 10 bubbles: Small shunt
- 10 - 20 bubbles: Medium shunt
- >20 bubbles: Large shunt
- Although tranesopheageal echocardiography is preferred, sedating the patient may cause difficulty in performing the valsalva maneuver.[3]
Transthoracic Echocardiography
- It is the most commonly used screening test for diagnosing a right-to-left shunt. It has a sensitivity of 46% and a specificity of 99%.
- A standard TTE should precede a contrast-enhanced TEE in a workup for cryptogenic shock. It is limited in its ability to reveal information about aortic sources of emboli and it has a low sensitivity in small shunts. Therefore, if the suspicion is high after a negative study result or inadequate images, a contrast-enhanced TEE should be done to check for the presence of a thrombus in the the atrial appendage, cardiac masses, aortic atheroma, and vegetations that the TTE may have missed. [1]
- It is a very specific technique that has the ability to detect a large right-to-left shunt.[6]
Transcranial Doppler Ultrasonography
- It is a reliable and non-invasive test useful for cryptogenic stroke work-up and consideration for patent foramen ovale closure.[1]
- It can be used as an alternative to contrast enhanced transesophageal echocardiography in recognizing a right-to-left shunt because of its excellent diagnostic accuracies.[7]
- From a meta-analysis, transcranial doppler had a mean sensitivity and specificity of 97% and 93%, respectively.[7]
References
- ↑ 1.0 1.1 1.2 1.3 Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C (2014). "How to Understand Patent Foramen Ovale Clinical Significance: Part I." J Cardiovasc Echogr. 24 (4): 114–121. doi:10.4103/2211-4122.147202. PMC 5353567. PMID 28465918.
- ↑ Pearson AC, Labovitz AJ, Tatineni S, Gomez CR (1991). "Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology". J Am Coll Cardiol. 17 (1): 66–72. doi:10.1016/0735-1097(91)90705-e. PMID 1987242.
- ↑ 3.0 3.1 3.2 3.3 Pinto FJ (2005). "When and how to diagnose patent foramen ovale". Heart. 91 (4): 438–40. doi:10.1136/hrt.2004.052233. PMC 1768819. PMID 15772190.
- ↑ Mas, Jean-Louis; Arquizan, Caroline; Lamy, Catherine; Zuber, Mathieu; Cabanes, Laure; Derumeaux, Geneviève; Coste, Joël (2001). "Recurrent Cerebrovascular Events Associated with Patent Foramen Ovale, Atrial Septal Aneurysm, or Both". New England Journal of Medicine. 345 (24): 1740–1746. doi:10.1056/NEJMoa011503. ISSN 0028-4793.
- ↑ Yuan, Kristy; Kasner, Scott Eric (2018). "Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention". Stroke and Vascular Neurology. 3 (2): 84–91. doi:10.1136/svn-2018-000173. ISSN 2059-8688.
- ↑ Zito C, Dattilo G, Oreto G, Di Bella G, Lamari A, Iudicello R; et al. (2009). "Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine". Echocardiography. 26 (5): 495–503. doi:10.1111/j.1540-8175.2008.00852.x. PMID 19452605.
- ↑ 7.0 7.1 Mojadidi MK, Roberts SC, Winoker JS, Romero J, Goodman-Meza D, Gevorgyan R; et al. (2014). "Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: a bivariate meta-analysis of prospective studies". JACC Cardiovasc Imaging. 7 (3): 236–50. doi:10.1016/j.jcmg.2013.12.011. PMID 24560213.