A Comparison of Methods to Detect and Quantitate PFO: TCD, TTE, ICE and TEE

  • M. Khalid Mojadidi
  • Rubine Gevorgyan
  • Jonathan M. TobisEmail author


At the present time, the diagnosis of a patent foramen ovale (PFO) is based on either imaging of the interatrial septal anatomy that allows direct visualization of the septal defect transesophageal echo [TEE], transthoracic echo [TTE], intracardiac echo [ICE], or by physiologic quantification of the right-to-left shunt (RLS) through the PFO using transcranial Doppler [TCD]. Contrast TEE is currently the standard technique for identifying a PFO and visualization of the atrial septal anatomy. TEE permits an assessment of PFO size, RLS severity and differentiation between an intracardiac and intrapulmonary RLS. A TTE bubble study is the most commonly used imaging modality for the detection of PFO. Though cost-effective and readily available, TTE has a low sensitivity with poor differentiating ability between cardiac and pulmonary RLS. ICE allows detailed visualization of the inter-atrial septum at a resolution comparable to that of TEE. TCD is a highly sensitive test for indirectly assessing the presence of a RLS; some studies report a sensitivity higher than that of TEE but a lower specificity due to TCD’s inability to differentiate between cardiac and pulmonary shunts. This chapter will compare the different techniques and describe the benefits and drawbacks of the various imaging options.


Transesophageal echo Transthoracic echo Transcranial Doppler Intracardiac echo right-to-left shunt 

Supplementary material

Video 7.1

Positive bubble study in a patient with pulmonary shunt (X-plane) (AVI 7474 kb)

Video 7.2

Positive bubble study in a patient with pulmonary shunt (LA view) (AVI 15840 kb)

Video 7.3

Negative bubble study, bicaval view (AVI 13328 kb)

Video 7.4

Hypermobile septum on TEE (X plane) (AVI 2328 kb)

Video 7.5

PFO closure device image in 3-D (AVI 2360 kb)

Video 7.6

Transthoracic echocardiography in a 33-year old patient suffering from severe migraine with visual aura (apical four-chamber view) (AVI 3510 kb)


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Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • M. Khalid Mojadidi
    • 1
    • 2
  • Rubine Gevorgyan
    • 2
    • 3
  • Jonathan M. Tobis
    • 4
    Email author
  1. 1.Department of MedicineMontefiore Medical Center and Jacobi Medical Center, Albert Einstein College of MedicineBronxUSA
  2. 2.Division of CardiologyUniversity of California, Los AngelesLos AngelesUSA
  3. 3.Department of Medicine, CardiologyDavid Geffen School of Medicine at UCLALos AngelesUSA
  4. 4.Interventional CardiologyUniversity of California, Los Angeles (UCLA)Los AngelesUSA

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