Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature

Thiagaraj, Ashwin; Hughes-Doichev, Rachel; Biederman, Robert W

doi:10.1111/echo.14297

Cited by 13 publications

(7 citation statements)

References 24 publications

(46 reference statements)

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“…Some practitioners advocate for abdominal compression to improve the Valsalva response and this has been shown to increase the sensitivity of the technique. 54,55 Furthermore, it is not unusual for patients to undertake an exaggerated inspiration immediately prior to the Valsalva and the echo image becomes obscured by inflated lungs. For this reason, it is ideal to instruct the patient to perform the Valsalva after a normal inspiration.…”

Section: Optimisation Of the Imagingmentioning

confidence: 99%

“…Using a calibrated device that the patients blows against is ideal, 53 but not always practical. Some practitioners advocate for abdominal compression to improve the Valsalva response and this has been shown to increase the sensitivity of the technique 54,55 . Furthermore, it is not unusual for patients to undertake an exaggerated inspiration immediately prior to the Valsalva and the echo image becomes obscured by inflated lungs.…”

Section: Optimisation Of the Imagingmentioning

confidence: 99%

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Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

Giessen

Wilson

Coffey

et al. 2020

Australas J Ultrason Med

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A patent foramen ovale (PFO) is a common remnant of fetal circulation present in up to 25% of the worldwide adult population. Paradoxical embolism occurs when venous blood crosses the PFO into the arterial system, bypassing the pulmonary circulation. This allows for the direct passage of microemboli into cerebral blood vessels, increasing the risk of cryptogenic stroke. This review investigates the current diagnostic procedures used to detect and grade a PFO, including transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and transcranial Doppler (TCD). Only a few studies have directly compared the use of TTE with TCD for PFO detection but several have compared TTE and TCD independently against the clinical gold standard TOE. Known pitfalls of TTE and TCD are also discussed, including the difficulty of differentiating between intracardiac shunts and intrapulmonary shunts. This review also discusses methods to optimise imaging, such as performing an adequate Valsalva manoeuvre, the role of abdominal compression and the choice of the injection site for the contrast agent and how these may increase the diagnostic success of detecting a right-to-left shunt when prompted by a clinician.

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Section: Optimisation Of the Imagingmentioning

confidence: 99%

Section: Optimisation Of the Imagingmentioning

confidence: 99%

Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

Giessen

Wilson

Coffey

et al. 2020

Australas J Ultrason Med

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“…Various studies have shown that other provocative maneuvers, such as abdominal compression, inferior vena cava compression, cough, deep inspiration, and the Müller maneuver, have good results as new provocative maneuvers ( 28 ) ( Table 2 ). At present, the Valsalva maneuver and cough are commonly used in clinical practice, but it can be difficult for patients to cooperate during TEE examination, resulting in difficulty in reaching the standard.…”

Section: Discussionmentioning

confidence: 99%

Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography

Zhu¹,

Chen²,

Zhu³

et al. 2023

Front. Neurol.

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ObjectiveThe Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver.MethodsThis study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3–5 s.ResultsOverall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017).ConclusionTENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.

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“…1). In PFO patients, TEE identifies the shunt, spontaneous or under Valsalva maneuver as small, moderate and severe on the basis of an old but still valid classification (Mojadidi et al 2014a;Saver et al 2017;Silvestry et al 2015;Thiagaraj et al 2019;Vitarelli et al 2014 ). The effectiveness of the maneuver can be assessed echocardiographically by the presence of a leftward shift of the primary atrial septum with the release phase, denoting the attainment of RA pressure greater than LA pressure.…”

Section: Diagnostic Methodsmentioning

confidence: 99%

Patent Foramen Ovale: Pivotal Role of Transesophageal Echocardiography in the Indications for Closure, Assessment of Varying Anatomies and Post-procedure Follow-up

Vitarelli

2019

Ultrasound in Medicine & Biology

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Patent foramen ovale (PFO) is present in 15%À30% of the general population and has been associated with various pathologic states, including cryptogenic stroke, platypneaÀorthodeoxia syndrome, decompression sickness and migraine with auras. Transesophageal echocardiography (TEE) has a major role in the diagnostic evaluation of PFO, as well as in the post-procedural assessment after transcatheter closure. The goals of this article were to synthesize the echocardiographic transesophageal techniques required for accurate PFO diagnosis and careful anatomic assessment of its anatomic variants, to focus TEE indications for device closure as complementary to clinical indications and to assess the role of TEE in the post-procedure follow-up.

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Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature

Cited by 13 publications

References 24 publications

Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography

Patent Foramen Ovale: Pivotal Role of Transesophageal Echocardiography in the Indications for Closure, Assessment of Varying Anatomies and Post-procedure Follow-up

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