Role of Contrast‐Enhanced Transesophageal Echocardiography for Detection of and Scoring Intrapulmonary Vascular Dilatation

Fischer, Cláudio Henrique; Campos, Orlando; Fernandes, Walnei Barbosa; Kondo, Mário; Souza, Francival Leite de; Andrade, José L.; Carvalho, Antônio Carlos

doi:10.1111/j.1540-8175.2010.01228.x

Cited by 16 publications

(9 citation statements)

References 33 publications

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“…These scoring systems generally range from no contrast or “bubbles” to complete opacification of the left ventricle. Again, the scoring systems are only qualitative, but recent work has demonstrated that there is a significant relationship between the scoring systems and PFO size measured with intracardiac echocardiography, as well as with the AaDO 2 in patients with PAVM . Our recent work and the work of others also support the physiological meaningfulness of bubble scores by demonstrating a relationship between bubble scores and calculated venous admixture during intravenous catecholamine infusion at rest.…”

Section: Methods For Detecting and Quantifying Blood Flow Through Ipavasupporting

confidence: 59%

“…Again, the scoring systems are only qualitative, but recent work has demonstrated that there is a significant relationship between the scoring systems and PFO size measured with intracardiac echocardiography, 48 as well as with the AaDO 2 in patients with PAVM. 49 Our recent work 5 and the work of others 30 also support the physiological meaningfulness of bubble scores by demonstrating a relationship between bubble scores and calculated venous admixture during intravenous catecholamine infusion at rest. Of note, Nomoto et al 17 using radioactive microspheres, reported a shunt fraction of 1.9% of Q T in anesthetized dogs infused with 4 lg/kg per min of epinephrine, which is comparable to what we have calculated with arterial blood gases during intravenous epinephrine infusion (320 ng/kg per min) in healthy humans without a PFO.…”

Section: Saline Contrast Echocardiographysupporting

confidence: 54%

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Clinical Consideration for Techniques to Detect and Quantify Blood Flow through Intrapulmonary Arteriovenous Anastomoses: Lessons from Physiological Studies

2015

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Intrapulmonary arteriovenous anastomoses (IPAVA) are large diameter (>50 μm) vascular conduits, present in >95% of healthy humans. Because IPAVA are large diameter pathways that allow blood flow to bypass the pulmonary capillary network, blood flow through IPAVA (QIPAVA) can permit the transpulmonary passage of particles larger than pulmonary capillaries. IPAVA have been known to exist for over 50 years, but their physiological and clinical significance are still being established; although, currently suggested roles for QIPAVA include allowing emboli to reach the systemic circulation and providing a source of shunt. Studying QIPAVA is an important area of research and as the suggested roles become better established, detecting and quantifying QIPAVA may become significantly more important in the clinic. Several techniques that can be used to quantify and/or detect QIPAVA in animals, ex vivo human/animal lungs, and intact healthy humans; microspheres, radiolabeled macroaggregated albumin particles, and saline contrast echocardiography, are reviewed with limitations and advantages to each. The current body of literature using these techniques to study QIPAVA in animals, ex vivo lungs, and healthy humans has established conditions when QIPAVA is present, such as during exercise or with arterial hypoxemia and conditions when QIPAVA is absent, such as at rest or during exercise breathing 100% O2 . Many of these physiological studies have direct application to patient populations and we discuss each of these findings in the context of their potential to influence the clinical utility, and interpretation, of the results from these techniques highlighted in this review.

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Section: Methods For Detecting and Quantifying Blood Flow Through Ipavasupporting

confidence: 59%

Section: Saline Contrast Echocardiographysupporting

confidence: 54%

Clinical Consideration for Techniques to Detect and Quantify Blood Flow through Intrapulmonary Arteriovenous Anastomoses: Lessons from Physiological Studies

2015

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“…Although quantitative measures of blood flow cannot be determined from bubble scores, greater degrees of left heart contrast (i.e. increased bubble scores) appear to correspond well with an increase in the volume of blood flow through pulmonary arteriovenous malformations (PAVM) and impairments in pulmonary gas exchange efficiency (Fischer et al 2010). Bubble grades/scores also correlate with the size of PFO determined using intracardiac echocardiography (Fenster et al 2014).…”

Section: Techniques and Their Limitations For Detecting And Quantifmentioning

confidence: 99%

Intrapulmonary arteriovenous anastomoses in humans – response to exercise and the environment

Lovering

Duke

Elliott

2015

The Journal of Physiology

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Intrapulmonary arteriovenous anastomoses (IPAVA) have been known to exist in human lungs for over 60 years. The majority of the work in this area has largely focused on characterizing the conditions in which IPAVA blood flow (Q IPAVA ) is either increased, e.g. during exercise, acute normobaric hypoxia, and the intravenous infusion of catecholamines, or absent/decreased, e.g. at rest and in all conditions with alveolar hyperoxia (F IO 2 = 1.0). Additionally,Q IPAVA is present in utero and shortly after birth, but is reduced in older (>50 years) adults during exercise and with alveolar hypoxia, suggesting potential developmental origins and an effect of age. The physiological and pathophysiological roles ofQ IPAVA are only beginning to be understood and therefore these data remain controversial. Although evidence is accumulating in support of important roles in both health and disease, including associations with pulmonary arterial pressure, and adverse neurological sequelae, there is much work that remains to be done to fully understand the physiological and pathophysiological roles of IPAVA. The development of novel approaches to studying these pathways that can overcome the limitations of the currently employed techniques will greatly help to better quantifyQ IPAVA and identify the consequences ofQ IPAVA on physiological and pathophysiological processes. Nevertheless, based on currently published data, our proposed working model is thatQ IPAVA occurs due to passive recruitment under conditions of exercise and supine body posture, but can be further modified by active redistribution of pulmonary blood flow under hypoxic and hyperoxic conditions. AbbreviationsA − aD O2 , alveolar-to-arterial partial pressure of O 2 difference; C aO2 , arterial O 2 content; F IO2 , fraction of inspired oxygen; HHT, hereditary haemorrhagic telangiectasia; HPV, hypoxic pulmonary vasoconstriction; IPAVA, intrapulmonary arteriovenous anastomoses; MAA, macroaggregates of albumin; MIGET, multiple inert gas elimination technique; Pv O2 , mixed venous partial pressure of O 2 ; P aO2 , arterial partial pressure of O 2 ; PASP, pulmonary artery systolic pressure; PAVM, pulmonary arteriovenous malformation; PFO, patent foramen ovale; S aO2 , arterial O 2 saturation; S pO2 , peripheral estimate of arterial O 2 saturation; 99m Tc-MAA, technetium-99m-labelled MAA; TIA, transient ischaemic attack; TTSCE, transthoracic saline contrast echocardiography;Q T , cardiac output;Q IPAVA , blood flow through IPAVA;Q S /Q T , shunt fraction;V O2 , O 2 consumption, ventilation to perfusion ratio (V/Q ).Andrew Lovering, PhD, is an integrative physiologist who has investigated a wide range of respiratory system questions from understanding how medullary respiratory neurons reconfigure their activity during hypoxia-induced periodic breathing in sleeping cats to understanding the roles of intracardiac and intrapulmonary shunt on the regulation of pulmonary gas exchange efficiency in humans exercising above 5000 m; he thinks that the patent foramen ov...

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“…The diagnosis of HPS in patients with intracardiac shunt and inadequate echocardiographic window presents a challenge because MAA lung perfusion scan, the only established alternative to CEE for detecting IPVD, does not distinguish intracardiac shunting from intrapulmonary shunting and is less sensitive, particularly for mild and moderate HPS . Therefore, the exploration of novel alternatives to CEE for detection of IPVD has been a topic of continued interest . The present study evaluated the role of PTT derived from pulmonary angiography in the diagnosis of HPS and found that it (i) is useful for diagnosing HPS, (ii) is more sensitive than MAA lung perfusion scan and (iii) may be able to quantify the degree of intrapulmonary shunting.…”

Section: Discussionmentioning

confidence: 96%

Pulmonary transit time derived from pulmonary angiography for the diagnosis of hepatopulmonary syndrome

Zhao

Tsauo

Zhang

et al. 2018

Liver International

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Role of Contrast‐Enhanced Transesophageal Echocardiography for Detection of and Scoring Intrapulmonary Vascular Dilatation

Abstract: cTEE enabled diagnosis of IVD in a greater number of patients with gasometric changes compared to cTTE. The contrast effect grade by cTEE seems to be proportional to IVD magnitude.

Cited by 16 publications

References 33 publications

Clinical Consideration for Techniques to Detect and Quantify Blood Flow through Intrapulmonary Arteriovenous Anastomoses: Lessons from Physiological Studies

Clinical Consideration for Techniques to Detect and Quantify Blood Flow through Intrapulmonary Arteriovenous Anastomoses: Lessons from Physiological Studies

Intrapulmonary arteriovenous anastomoses in humans – response to exercise and the environment

Pulmonary transit time derived from pulmonary angiography for the diagnosis of hepatopulmonary syndrome

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