Difference between revisions of "Patent foramen ovale echocardiography and ultrasound"

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==Overview==
 
==Overview==
Tranesophageal echocardiography is the procedure of choice for the diagnosis of patent foramen ovale although transthoracic echocardiography and transcranial ultradound can also be used. The diagnostic process requires injecting a saline contrast medium into a peripheral vein while the patient performs the valsalva maneuver. Appearance of micro-bubbles are seen across the inter-atrial septum into the left atrium. The size of the shunt is determined by the number of micro-bubbles that pass through the inter-atrial septum within three cardiac cycles.
+
Tranesophageal echocardiography is the procedure of choice for the diagnosis of patent foramen ovale although transthoracic echocardiography and transcranial ultradound can also be used. The diagnostic process requires injecting a saline contrast medium into a peripheral vein while the patient performs the valsalva maneuver. Appearance of micro-bubbles are seen across the inter-atrial septum into the left atrium. The size of the shunt is determined by the number of micro-bubbles that pass through the inter-atrial septum within three cardiac cycles. Further investigation is not required after a negative transthoracic echocardiography or transcranial ultrasound except there is a high suspicion for a right-to-left shunt or the images are inadequate.
  
 
==Echocardiography/Ultrasound==
 
==Echocardiography/Ultrasound==
Line 17: Line 17:
 
*Injecting the contrast through an upper extremity vein may lead to it being washed away by contrast-free blood flow from the inferior vena cava directed by the eustachian valve, thereby creating a false-negative result.<ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="KuttySengupta2012">{{cite journal|last1=Kutty|first1=Shelby|last2=Sengupta|first2=Partho P.|last3=Khandheria|first3=Bijoy K.|title=Patent Foramen Ovale|journal=Journal of the American College of Cardiology|volume=59|issue=19|year=2012|pages=1665–1671|issn=07351097|doi=10.1016/j.jacc.2011.09.085}}</ref>
 
*Injecting the contrast through an upper extremity vein may lead to it being washed away by contrast-free blood flow from the inferior vena cava directed by the eustachian valve, thereby creating a false-negative result.<ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="KuttySengupta2012">{{cite journal|last1=Kutty|first1=Shelby|last2=Sengupta|first2=Partho P.|last3=Khandheria|first3=Bijoy K.|title=Patent Foramen Ovale|journal=Journal of the American College of Cardiology|volume=59|issue=19|year=2012|pages=1665–1671|issn=07351097|doi=10.1016/j.jacc.2011.09.085}}</ref>
  
===Transesophageal Echocardiography===
+
===Transesophageal Echocardiography (TEE)===
 
*Transesophageal echocardiography is the imaging procedure of choice 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.<ref name="pmid1987242">{{cite journal| author=Pearson AC, Labovitz AJ, Tatineni S, Gomez CR| title=Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. | journal=J Am Coll Cardiol | year= 1991 | volume= 17 | issue= 1 | pages= 66-72 | pmid=1987242 | doi=10.1016/0735-1097(91)90705-e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1987242  }} </ref><ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
 
*Transesophageal echocardiography is the imaging procedure of choice 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.<ref name="pmid1987242">{{cite journal| author=Pearson AC, Labovitz AJ, Tatineni S, Gomez CR| title=Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. | journal=J Am Coll Cardiol | year= 1991 | volume= 17 | issue= 1 | pages= 66-72 | pmid=1987242 | doi=10.1016/0735-1097(91)90705-e | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1987242  }} </ref><ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
 
*It is important in monitoring proper percutaneous patent foramen ovale closure.<ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
 
*It is important in monitoring proper percutaneous patent foramen ovale closure.<ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
Line 23: Line 23:
 
*Although tranesopheageal echocardiography is preferred, sedating the patient may cause difficulty in performing the valsalva maneuver which may lead to an increased number of false-positives.<ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
 
*Although tranesopheageal echocardiography is preferred, sedating the patient may cause difficulty in performing the valsalva maneuver which may lead to an increased number of false-positives.<ref name="pmid15772190">{{cite journal| author=Pinto FJ| title=When and how to diagnose patent foramen ovale. | journal=Heart | year= 2005 | volume= 91 | issue= 4 | pages= 438-40 | pmid=15772190 | doi=10.1136/hrt.2004.052233 | pmc=1768819 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15772190  }} </ref><ref name="pmid28465918">{{cite journal| author=Falanga G, Carerj S, Oreto G, Khandheria BK, Zito C| title=How to Understand Patent Foramen Ovale Clinical Significance: Part I. | journal=J Cardiovasc Echogr | year= 2014 | volume= 24 | issue= 4 | pages= 114-121 | pmid=28465918 | doi=10.4103/2211-4122.147202 | pmc=5353567 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28465918  }} </ref>
  
===Transthoracic Echocardiography===
+
===Transthoracic Echocardiography (TTE)===
 
*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%.<ref name="pmid24689727">{{cite journal| author=Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, Gevorgyan R | display-authors=etal| title=Accuracy of conventional transthoracic echocardiography for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies. | journal=Echocardiography | year= 2014 | volume= 31 | issue= 9 | pages= 1036-48 | pmid=24689727 | doi=10.1111/echo.12583 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24689727  }} </ref>
 
*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%.<ref name="pmid24689727">{{cite journal| author=Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, Gevorgyan R | display-authors=etal| title=Accuracy of conventional transthoracic echocardiography for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies. | journal=Echocardiography | year= 2014 | volume= 31 | issue= 9 | pages= 1036-48 | pmid=24689727 | doi=10.1111/echo.12583 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24689727  }} </ref>
 
*Findings on an transthoracic echocardiography suggestive of/diagnostic of patent foramen ovale include:<ref name="GafoorSharma2017">{{cite journal|last1=Gafoor|first1=Sameer|last2=Sharma|first2=Rahul|last3=Zhang|first3=Ming|last4=Casterella|first4=Peter|last5=Atianzar|first5=Kimberly|title=Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review|journal=US Cardiology Review|volume=11|issue=2|year=2017|pages=75|issn=1758-3896|doi=10.15420/usc.2017:18:1}}</ref>
 
*Findings on an transthoracic echocardiography suggestive of/diagnostic of patent foramen ovale include:<ref name="GafoorSharma2017">{{cite journal|last1=Gafoor|first1=Sameer|last2=Sharma|first2=Rahul|last3=Zhang|first3=Ming|last4=Casterella|first4=Peter|last5=Atianzar|first5=Kimberly|title=Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review|journal=US Cardiology Review|volume=11|issue=2|year=2017|pages=75|issn=1758-3896|doi=10.15420/usc.2017:18:1}}</ref>

Revision as of 20:09, 14 February 2020

Patent Foramen Ovale Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];

Overview

Tranesophageal echocardiography is the procedure of choice for the diagnosis of patent foramen ovale although transthoracic echocardiography and transcranial ultradound can also be used. The diagnostic process requires injecting a saline contrast medium into a peripheral vein while the patient performs the valsalva maneuver. Appearance of micro-bubbles are seen across the inter-atrial septum into the left atrium. The size of the shunt is determined by the number of micro-bubbles that pass through the inter-atrial septum within three cardiac cycles. Further investigation is not required after a negative transthoracic echocardiography or transcranial ultrasound except there is a high suspicion for a right-to-left shunt or the images are inadequate.

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 agitated saline contrast medium.[1]
  • The process of detecting a right-to-left shunt across a patent foramen ovale involves the patient performing the valsalva maneuver. During the strain phase of the maneuver, a saline medium is injected into a peripheral vein and the atrial septum is visualized during the release phase of the maneuver.[2][3]
  • Findings on an echocardiography suggestive of/diagnostic of a right-to-left shunt include:[2][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
  • Injecting the contrast through an upper extremity vein may lead to it being washed away by contrast-free blood flow from the inferior vena cava directed by the eustachian valve, thereby creating a false-negative result.[2][3]

Transesophageal Echocardiography (TEE)

  • Transesophageal echocardiography is the imaging procedure of choice 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.[6][2][1]
  • It is important in monitoring proper percutaneous patent foramen ovale closure.[1]
  • A transesophageal echocardiogram can be performed to search for the precise anatomy of a patent foramen ovale after positive transthoracic echocardiogram and/or transcranial doppler. This is particularly useful before scheduling a patient for percutaneous closure. On the other hand, no further studies should be done after a negative transthoracic echocardiogram and/or transcranial doppler.[1]
  • Although tranesopheageal echocardiography is preferred, sedating the patient may cause difficulty in performing the valsalva maneuver which may lead to an increased number of false-positives.[2][1]

Transthoracic Echocardiography (TTE)

  • 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%.[7]
  • Findings on an transthoracic echocardiography suggestive of/diagnostic of patent foramen ovale include:[8]
  • Hypermobility of the inter-atrial septum (atrial septal aneurysm).
  • Color flow Doppler findings of left–right or bi-directional flow across the atrial septum.
  • 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. If TTE study reveals a right-to-left shunt, a TEE is required to expound on the anatomy of the atrial septum, to assess its need for device closure, and to confirm that the shunt is due to a patent forman ovale.[1]
  • It is a very specific technique that has the ability to detect a large right-to-left shunt.[9]

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.[10]
  • It is more sensitive than TEE but it is limited in the ability to detect structural features and features that affect the characterization of shunts.[5]
  • From a meta-analysis, transcranial doppler had a mean sensitivity and specificity of 97% and 93%, respectively.[10]
  • The overlap in time that occurs when microbubbles are detected in the middle cerebral artery makes it difficult to discriminate between atrial and pulmonary shunts.[1]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 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.
  2. 2.0 2.1 2.2 2.3 2.4 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.
  3. 3.0 3.1 Kutty, Shelby; Sengupta, Partho P.; Khandheria, Bijoy K. (2012). "Patent Foramen Ovale". Journal of the American College of Cardiology. 59 (19): 1665–1671. doi:10.1016/j.jacc.2011.09.085. ISSN 0735-1097.
  4. 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.
  5. 5.0 5.1 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.
  6. 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.
  7. Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, Gevorgyan R; et al. (2014). "Accuracy of conventional transthoracic echocardiography for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies". Echocardiography. 31 (9): 1036–48. doi:10.1111/echo.12583. PMID 24689727.
  8. Gafoor, Sameer; Sharma, Rahul; Zhang, Ming; Casterella, Peter; Atianzar, Kimberly (2017). "Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review". US Cardiology Review. 11 (2): 75. doi:10.15420/usc.2017:18:1. ISSN 1758-3896.
  9. 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.
  10. 10.0 10.1 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.

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