Abstract
Ultrasound technology have made available many non-invasive techniques for diagnosing a right-to-left shunting (RLS), such as transthoracic echocardiography, transesophageal echocardiography and transcranial Doppler ultrasound.
Echocardiographic examination defines patent foramen ovale(PFO) as flap-like opening in the atrial septum secundum, with the septum primum serving as a one-way valve allowing for permanent or transient right-to-left shunt.
Transthoracic (TTE) and transesophageal (TEE) echocardiography with saline contrast injection in basal conditions and after Valsalva maneuver have been considered sensitive methods to detect PFO.
Although TTE may identify patients with RLS, TEE with saline contrast injection is more sensitive by allowing visualization and microbubbles count in the left atrium that would otherwise be filtered by the lung capillary.
Echocardiographic assessment particularly by TEE is of paramount importance for the morphological evaluation of PFO. Different anatomic characteristics such as long-tunnel PFO, large atrial septum aneurysm, prominent Eustachian valve, multiperforated fossa ovalis or lipomatous rims, often combined with each other, may have an impact on immediate procedural results and outcomes.
On the other hand, transcranial Doppler (TCD) is unable to locate the source of RLS but is likely to represent the most valid alternative to the so called “gold standard” color Doppler TEE for its high sensitivity and specificity, relative ease of execution and little discomfort to the patients; it may even be superior to assess the functional consequences of RLS, especially so in those cases in whom postural variations in the amount of shunted blood may be present and can be easily detected, a task almost impossible with echocardiography.
It has been suggested that it is precisely the amount of shunt as assessed in the cerebral vessels by contrast TCD that may constitute the principal determinant of stroke occurrence and relapse. Therefore, the assessment of RLS by TCD represents a precioustool to help stratify patients according to their risk profile.
Furthermore, contrast TCD isideal for follow-up studies, because it is easily repeatable and sensitive enough to detect also minor residual shunts.
Disclosures
The authors have nothing to disclose regarding the content of this manuscript.
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References
Belkin RN, Pollack BD, Ruggiero ML, et al. Comparison of transesophageal and transthoracic echocardiography with contrast and color flow Doppler in the detection of patent foramen ovale. Am Heart J. 1994;128:520–5.
Valton L, Larrue V, Pavy leTraon A, et al. Microembolic signals and risk of early recurrence in patients with stroke or transient attack. Stroke. 1998;29:2125–8.
Schwarze JJ, Sander D, Kukla C, et al. Methodological parameters influence the detection of right-to-left shunts by contrast transcranial Doppler ultrasonography. Stroke. 1999;30:1234–9.
Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology. 2000;24:1172–9.
Cabanes L, Mas JL, Cohen A, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age: a study using transesophageal echocardiography. Stroke. 1993;24:1865–73.
Di Tullio M, Sacco RL, Gopal A, et al. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med. 1992;15:461–5.
Cohnheim J. Thrombose und embolie. In: Vorlesungen über allgemeine Pathologie, vol. 1. Berlin: Hirschwald; 1877. p. 134.
Konstadt SN, Louie EK, Black S, et al. Intraoperative detection of patent foramen ovale by transesophageal echocardiography. Anesthesiology. 1991;74:212–6.
Serena J, Segura T, Perez-Ayuso MJ, et al. The need to quantify right-to-left shunt in acute ischemic stroke: a case-control study. Stroke. 1998;29:1322–8.
Steiner MM, Di Tullio MR, Rundek T, et al. Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke. 1998;29:944–8.
Onorato E, Casilli F. Influence of PFO anatomy on successful transcatheter closure. Intervent Cardiol Clin. 2013;2:51–84.
Schneider B, Hanrath P, Vogel P, et al. Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events. J Am Coll Cardiol. 1990;16:1000–9.
Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59:17–20.
Di Tullio MR, Sacco RL, Venketasubramanian N, et al. Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients. Stroke. 1993;24:1020–4.
Braun MU, Fassbender D, Schoen SP, et al. Transcatheter closure of patent foramen ovale in patients with cerebral ischemia. J Am Coll Cardiol. 2002;39:2019–25.
Windecker S, Wahl A, Nedeltchev K, et al. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol. 2004;44:750–8.
Gin KG, Huckell VF, Pollick C. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol. 1993;22:1994–2000.
Movsowitz HD, Movsowitz C, Jacobs LE, et al. Negative air-contrast test does not exclude the presence of patent foramen ovale by transesophageal echocardiography. Am Heart J. 1993;126:1031–2.
Ha JW, Shin MS, Kang S, et al. Enhanced detection of right-to-left shunt through patent foramen ovale by transthoracic contrast echocardiography using harmonic imaging. Am J Cardiol. 2001;87:669–71.
Madala D, Zaroff JG, Hourigan L, et al. Harmonic imaging improves sensitivity at the expense of specificity in the detection of patent foramen ovale. Echocardiography. 2004;21:33–6.
Kerr AJ, Buck T, Chia K, et al. Transmitral Doppler: a new transthoracic contrast method for patent foramen ovale detection and quantification. J Am Coll Cardiol. 2000;36:1959–66.
Daniel WG, Erbel R, Kasper QW, et al. Safety of transesophageal echocardiography. A multicenter survey of 10419 examinations. Circulation. 1991;83:817–21.
Urbanowicz JH, Kernoff RS, Oppenheim G, et al. Transesophageal echocardiography and its potential for esophageal damage. Anesthesiology. 1990;72:40–3.
Tanaka J, Izumo M, Fukuoka Y, et al. Comparison of two-dimensional versus real-time three-dimensional transesophageal echocardiography for evaluation of patent foramen ovale morphology. Am J Cardiol. 2013;111:1052–6.
De Castro S, Caselli S, Papetti F, et al. Feasibility and clinical impact of live three-dimensional echocardiography in the management of congenital heart disease. Echocardiography. 2006;23:553–61.
Tamborini G, Pepi M, Susini F, Trabattoni D, Maltagliati A, Berna G, Onorato E, Bartorelli AL. Comparison of two- and three-dimensional transesophageal echocardiography in patients undergoing atrial septal closure with the Amplatzer septal occluder. Am J Cardiol. 2002;90(9):1025–8.
Stoddard MF, Keedy DL, Dawkins PR. The cough test is superior to the Valsalva maneuver in the delineation of right-to-left shunting through a patent foramen ovale during contrast transesophageal echocardiography. Am Heart J. 1993;125:185–9.
Stone DA, Godard J, Corretti MC, et al. Patent foramen ovale association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J. 1996;131:158–61.
De Castro S, Cartoni D, Fiorelli M, et al. Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke. 2000;31:2407–13.
Jauss M, Zanette E. Detection of right-to-left shunt with ultrasound contrast agent and transcranial Doppler sonography. Cerebrovasc Dis. 2000;10:490–6.
Anzola GP, Zavarise P, Morandi E, et al. Transcranial Doppler and risk of recurrence in patients with stroke and patent foramen ovale. Eur J Neurol. 2003;10:129–35.
Anzola GP, Morandi E, Casilli F, Onorato E. Different degrees of right-to-left shunting predict migraine and stroke: data from 420 patients. Neurology. 2006;66:765–7.
Morandi E, Anzola GP, Casilli F, Onorato E. Silent brain embolism during transcatheter closure of patent foramen ovale: a transcranial Doppler study. Neurol Sci. 2006;27:328–31.
Caputi L, Carriero MR, Parati EA, Onorato E, Casilli F, Berti M, Anzola GP. Postural dependency of right to left shunt: role of contrast-enhanced transcranial Doppler and its potential clinical implications. Stroke. 2008;39(8):2380–1.
Spencer MP, Moehring MA, Jerurum J, Gray WA, Olsen JV, Reisman M. Power M-Mode transcranial Doppler for diagnosis of patent foramen ovale and assessing transcatheter closure. J Neuroimaging. 2004;14:342–9.
Caputi L, Carriero MR, Falcone C, Parati E, Piotti P, Materazzo C, Anzola GP. Transcranial Doppler and transesophageal echocardiography: comparison of both techniques and prospective clinical relevance of transcranial Doppler in patent foramen ovale detection. J Stroke Cerebrovasc Dis. 2009;18(5):343–8.
Anzola GP, Refatti N, Casilli F, Berti M, Onorato E. The impact of patent foramen ovale diagnosis on cryptogenic stroke. Riv Ital Neurobiol. 2008;54(1):3–6.
Desai AJ, Fuller CJ, Jesurum JT, Reisman M. Patent foramen ovale and cerebrovascular diseases. Nat Clin Pract Cardiovasc Med. 2006;3(8):446–55.
Anzola GP, Magoni M, Guindani M, et al. Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology. 1999;12:1622–5.
Sorrentino M, Resnekov L. Patent foramen ovale associated with platypnea and orthodeoxia. Chest. 1991;100:1157–8.
Germonpre P. Patent foramen ovale and diving. Cardiol Clin. 2005;23:97–104.
Stendel R, Gramm HJ, Schroeder K, et al. Transcranial Doppler ultrasonography as a screening technique for detection of a patent foramen ovale before surgery in the sitting position. Anesthesiology. 2000;93:971–5.
Beelke M, Angeli S, Del Sette M, et al. Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study. Sleep Med. 2003;4:219–23.
Wöhrle J, Kochs M, Hombach V, Merkle N. Prevalence of myocardial scar in patients with cryptogenic cerebral ischemic events and patent foramen ovale. JACC Cardiovasc Imaging. 2010;3(8):833–9.
Ilkhanoff L, Naidu SS, Rohatgi S, Ross MJ, Silvestry FE, Herrmann HC. Transcatheter device closure of interatriale septal defects in patients with hypoxia. J Interv Cardiol. 2005;18:227–32.
Klötzsch C, Sliwka U, Berlit P, Noth J. An increased frequency of patent foramen ovale in patients with transient global amnesia. Analysis of 53 consecutive patients. Arch Neurol. 1996;53(6):504–8.
Akkawi NM, Agosti C, Rozzini L, Anzola GP, Padovani A. Transient global amnesia and venous flow patterns. Lancet. 2001;357(9256):639.
Akkawi NM, Agosti C, Rozzini L, Anzola GP, Padovani A. Transient global amnesia and disturbance of venous flow patterns. Lancet. 2001;357(9260):957.
Nemec JJ, Marwick TH, Lorig RJ, Davison MB, Chimowitz MI, Litowitz H, Salcedo EE. Comparison of transcranial Doppler ultrasound and trans esophageal contrast echocardiography in the detection of inter atrial right-to-left shunts. Am J Cardiol 1991;68:1498–1502.
Jauss M, Kaps M, Keberle M et al. A comparison of transesophageal echocardiography and Transcranial Doppler sonography with contrast medium for detection of patent foramen ovale. Stroke 1994;25:1265–7
Anzola GP, Costa A, Magoni M, Guindani M, Cobelli M. Transcranial Doppler monitoring of cerebral embolism in atrial fibrillation and prosthetic valves. Clinical correlations. Eur J Neurol 1995;6:566–9.
Droste DW, Kriete JU, Stypmann J, Castrucci M, Wichter T, Tietje R, Weltermann B, Young P, Ringelstein EB. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of different procedures and different contrast agents. Stroke 1999;9:1827–32.
Droste DW, Silling K, Stypmann J, Grude M, Kemény V, Wichter T, Kühne K, Ringelstein EB. Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: time window and threshold in microbubble numbers. Stroke 2000;7:1640–5.
Mas et al. Recurent cerebrovascualr events associated with PFO, atrial septal ameurysm, or both. N Eng J Med 2001;345(24):1740–6.
Anzola et al. Transcranial Doppler and Risk of recurrence in patients with stoke and PFO. Eur J Neuorl 2003;10(2):129–35.
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Onorato, E.M., Casilli, F., Anzola, G.P. (2015). Echocardiographic Detection and Transcranial Doppler Quantification of Right-to-Left Shunting. In: Amin, Z., Tobis, J., Sievert, H., Carroll, J. (eds) Patent Foramen Ovale. Springer, London. https://doi.org/10.1007/978-1-4471-4987-3_5
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