Patent foramen ovale echocardiography and ultrasound: Difference between revisions
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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 | Tranesophageal [[echocardiography]] (TEE) is the procedure of choice for the [[diagnosis]] of [[patent foramen ovale]] although [[transthoracic echocardiography]] and [[Transcranial doppler|transcranial ultradound]] can also be used. The [[diagnostic]] process requires injecting a [[Saline (medicine)|saline]] [[contrast medium]] into a [[peripheral vein]] while the patient performs the [[valsalva maneuver]]. Appearance of micro-bubbles are seen across the [[interatrial septum]] into the [[left atrium]]. The size of the [[Shunt (medical)|shunt]] is determined by the number of micro-bubbles that pass through the [[interatrial septum]] within three [[Cardiac cycle|cardiac cycles]]. Further investigation is not required after a negative [[transthoracic echocardiography]] or [[Transcranial doppler|transcranial ultrasound]] except there is a high suspicion for a [[right-to-left shunt]] or the images are inadequate. | ||
==Echocardiography/Ultrasound== | ==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.<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> | *When diagnosing [[patent foramen ovale]], several [[Echocardiography|echocardiographic]] techniques can be used, including [[Transthoracic echocardiography|transthoracic echocardiography (TTE)]], transesophageal [[echocardiography]] (TEE), and [[Transcranial doppler|transcranial doppler ultrasonography]]. They all require the use of a [[contrast medium]], commonly agitated [[Saline (medicine)|saline]] [[contrast medium]].<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> | ||
*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, | *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, [[Saline (medicine)|saline]] [[contrast medium]] is injected into a [[peripheral vein]] and the [[atrial septum]] is visualized during the release phase of the maneuver.<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> | ||
*Findings on an echocardiography suggestive of/diagnostic of a right-to-left shunt include:<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="MasArquizan2001">{{cite journal|last1=Mas|first1=Jean-Louis|last2=Arquizan|first2=Caroline|last3=Lamy|first3=Catherine|last4=Zuber|first4=Mathieu|last5=Cabanes|first5=Laure|last6=Derumeaux|first6=Geneviève|last7=Coste|first7=Joël|title=Recurrent Cerebrovascular Events Associated with Patent Foramen Ovale, Atrial Septal Aneurysm, or Both|journal=New England Journal of Medicine|volume=345|issue=24|year=2001|pages=1740–1746|issn=0028-4793|doi=10.1056/NEJMoa011503}}</ref><ref name="YuanKasner2018">{{cite journal|last1=Yuan|first1=Kristy|last2=Kasner|first2=Scott Eric|title=Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention|journal=Stroke and Vascular Neurology|volume=3|issue=2|year=2018|pages=84–91|issn=2059-8688|doi=10.1136/svn-2018-000173}}</ref> | *Findings on an [[echocardiography]] suggestive of/diagnostic of a [[right-to-left shunt]] include:<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="MasArquizan2001">{{cite journal|last1=Mas|first1=Jean-Louis|last2=Arquizan|first2=Caroline|last3=Lamy|first3=Catherine|last4=Zuber|first4=Mathieu|last5=Cabanes|first5=Laure|last6=Derumeaux|first6=Geneviève|last7=Coste|first7=Joël|title=Recurrent Cerebrovascular Events Associated with Patent Foramen Ovale, Atrial Septal Aneurysm, or Both|journal=New England Journal of Medicine|volume=345|issue=24|year=2001|pages=1740–1746|issn=0028-4793|doi=10.1056/NEJMoa011503}}</ref><ref name="YuanKasner2018">{{cite journal|last1=Yuan|first1=Kristy|last2=Kasner|first2=Scott Eric|title=Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention|journal=Stroke and Vascular Neurology|volume=3|issue=2|year=2018|pages=84–91|issn=2059-8688|doi=10.1136/svn-2018-000173}}</ref> | ||
:*Presence of bubbles across the | |||
:*3 - 10 bubbles: Small shunt | :*Presence of bubbles across the [[interatrial septum]] into the [[left atrium]]: A [[diagnosis]] is made with the appearance of at least three micro-bubbles within three [[Cardiac cycle|cardiac cycles]] after the complete opacification of the [[right atrium]]. | ||
:*10 - 20 bubbles: Medium shunt | :*3 - 10 bubbles: Small [[Shunt (medical)|shunt]] | ||
:*>20 bubbles: Large shunt | :*10 - 20 bubbles: Medium [[Shunt (medical)|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.<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> | :*>20 bubbles: Large [[Shunt (medical)|shunt]] | ||
*Injecting the [[Contrast medium|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 test result|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 (TEE)=== | ===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 emboli|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> | ||
*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.<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> | *A transesophageal [[echocardiogram]] can be performed to search for the precise [[anatomy]] of a [[patent foramen ovale]] after positive [[Transthoracic echocardiography|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 echocardiography|transthoracic echocardiogram]] and/or [[transcranial doppler]].<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> | *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-positive test result|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 (TTE)=== | ===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 (tests)|sensitivity]] of 46% and a [[Specificity (tests)|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> | ||
:*Hypermobility of the | |||
:*Color flow Doppler findings of | :*Hypermobility of the [[interatrial septum]] (atrial septal aneurysm). | ||
*A standard TTE should precede a contrast-enhanced TEE in a workup for cryptogenic | :*Color flow [[Doppler sonography|Doppler]] findings of left to right or bi-directional flow across the [[atrial septum]]. | ||
*It is a very specific technique that has the ability to detect a large right-to-left shunt.<ref name="pmid19452605">{{cite journal| author=Zito C, Dattilo G, Oreto G, Di Bella G, Lamari A, Iudicello R et al.| title=Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine. | journal=Echocardiography | year= 2009 | volume= 26 | issue= 5 | pages= 495-503 | pmid=19452605 | doi=10.1111/j.1540-8175.2008.00852.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19452605 }} </ref> | *A standard [[TTE]] should precede a contrast-enhanced [[TEE]] in a workup for [[cryptogenic stroke]]. It is limited in its ability to reveal information about aortic sources of [[emboli]] and it has a low [[Sensitivity (tests)|sensitivity]] in small [[Shunt (medical)|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]] [[Mass|masses]], [[aortic]] [[atheroma]], and [[Vegetation (pathology)|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 (medical)|shunt]] is due to a [[patent foramen ovale]].<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 a very specific technique that has the ability to detect a large [[right-to-left shunt]].<ref name="pmid19452605">{{cite journal| author=Zito C, Dattilo G, Oreto G, Di Bella G, Lamari A, Iudicello R et al.| title=Patent foramen ovale: comparison among diagnostic strategies in cryptogenic stroke and migraine. | journal=Echocardiography | year= 2009 | volume= 26 | issue= 5 | pages= 495-503 | pmid=19452605 | doi=10.1111/j.1540-8175.2008.00852.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19452605 }} </ref> | |||
===Transcranial Doppler Ultrasonography=== | ===Transcranial Doppler Ultrasonography=== | ||
*It is a reliable and non-invasive test useful for cryptogenic stroke work-up and consideration for 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 a reliable and [[Non-invasive (medical)|non-invasive]] test useful for [[cryptogenic stroke]] work-up and consideration for [[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 can be used as an alternative to contrast enhanced transesophageal echocardiography in recognizing a right-to-left shunt because of its excellent diagnostic | *It can be used as an alternative to [[Contrast medium|contrast]] enhanced transesophageal [[echocardiography]] in recognizing a [[right-to-left shunt]] because of its excellent diagnostic accuracy.<ref name="pmid24560213">{{cite journal| author=Mojadidi MK, Roberts SC, Winoker JS, Romero J, Goodman-Meza D, Gevorgyan R et al.| title=Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: a bivariate meta-analysis of prospective studies. | journal=JACC Cardiovasc Imaging | year= 2014 | volume= 7 | issue= 3 | pages= 236-50 | pmid=24560213 | doi=10.1016/j.jcmg.2013.12.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24560213 }} </ref> | ||
*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.<ref name="YuanKasner2018">{{cite journal|last1=Yuan|first1=Kristy|last2=Kasner|first2=Scott Eric|title=Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention|journal=Stroke and Vascular Neurology|volume=3|issue=2|year=2018|pages=84–91|issn=2059-8688|doi=10.1136/svn-2018-000173}}</ref> | *It is more [[Sensitivity (tests)|sensitive]] than [[TEE]] but it is limited in the ability to detect structural features and features that affect the characterization of [[Shunt (medical)|shunts]].<ref name="YuanKasner2018">{{cite journal|last1=Yuan|first1=Kristy|last2=Kasner|first2=Scott Eric|title=Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention|journal=Stroke and Vascular Neurology|volume=3|issue=2|year=2018|pages=84–91|issn=2059-8688|doi=10.1136/svn-2018-000173}}</ref> | ||
*From a meta-analysis, transcranial doppler had a mean sensitivity and specificity of 97% and 93%, respectively.<ref name="pmid24560213">{{cite journal| author=Mojadidi MK, Roberts SC, Winoker JS, Romero J, Goodman-Meza D, Gevorgyan R et al.| title=Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: a bivariate meta-analysis of prospective studies. | journal=JACC Cardiovasc Imaging | year= 2014 | volume= 7 | issue= 3 | pages= 236-50 | pmid=24560213 | doi=10.1016/j.jcmg.2013.12.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24560213 }} </ref> | *From a [[meta-analysis]], [[transcranial doppler]] had a mean [[Sensitivity (tests)|sensitivity]] and [[Specificity (tests)|specificity]] of 97% and 93%, respectively.<ref name="pmid24560213">{{cite journal| author=Mojadidi MK, Roberts SC, Winoker JS, Romero J, Goodman-Meza D, Gevorgyan R et al.| title=Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: a bivariate meta-analysis of prospective studies. | journal=JACC Cardiovasc Imaging | year= 2014 | volume= 7 | issue= 3 | pages= 236-50 | pmid=24560213 | doi=10.1016/j.jcmg.2013.12.011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24560213 }} </ref> | ||
*The overlap in time that occurs when | *The overlap in time that occurs when micro-bubbles are detected in the [[middle cerebral artery]] makes it difficult to discriminate between [[Atrium (heart)|atrial]] and [[pulmonary]] [[Shunt (medical)|shunts]].<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> | ||
==References== | ==References== | ||
Revision as of 20:44, 14 February 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];
Overview
Tranesophageal echocardiography (TEE) 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 interatrial septum into the left atrium. The size of the shunt is determined by the number of micro-bubbles that pass through the interatrial 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 medium, 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, saline contrast 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 interatrial 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 interatrial septum (atrial septal aneurysm).
- Color flow Doppler findings of left to right or bi-directional flow across the atrial septum.
- A standard TTE should precede a contrast-enhanced TEE in a workup for cryptogenic stroke. 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 foramen 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 accuracy.[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 micro-bubbles are detected in the middle cerebral artery makes it difficult to discriminate between atrial and pulmonary shunts.[1]
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ 3.0 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.
- ↑ 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.
- ↑ 5.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 10.0 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.