Sensitivity for Detection of Patent Foramen Ovale Increased with Increasing Number of Contrast Injections: A Descriptive Study with Contrast Transesophageal Echocardiography

Johansson, Magnus C.; Helgason, Hróðmar; Dellborg, Mikael; Eriksson, Peter

doi:10.1016/j.echo.2007.08.030

Cited by 58 publications

(38 citation statements)

References 34 publications

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“…Whether using TTE or TEE, the accuracy of the test will be improved by the use of a standardized protocol that includes multiple injections of agitated saline with provocative maneuvers to transiently increase the RA pressure. 50,106,107 An example of a protocol used by many laboratories is presented:…”

Section: Techniques Standards and Characterization Visualization Ofmentioning

confidence: 99%

Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions

Silvestry

Cohen

Armsby

et al. 2015

Journal of the American Society of Echocardiography

425

436

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Section: Techniques Standards and Characterization Visualization Ofmentioning

confidence: 99%

Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions

Silvestry

Cohen

Armsby

et al. 2015

Journal of the American Society of Echocardiography

425

436

View full text Add to dashboard Cite

“…If initially negative, this can be repeated with multiple injections, which has been shown to improve the sensitivity. 44 In contrast to TTE and TCD, direct visual assessment of the pulmonary veins can often be used to better of PFOs in the general population when TTE is used is approximately 15% as compared with 24% with TEE. 2, 26 TCD is a noninvasive and reproducible assessment of cerebral blood flow that when coupled with use of aerated-saline injection is also often used in the initial evaluation for PFO.…”

Section: Cryptogenic Stroke and Pfomentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp coalesce into a single orifice that becomes the foramen secundum. The septum secundum then forms via involution of the ventrocranial wall and overlaps with the foramen secundum. The septum secundum does not close fully and an oval-shaped opening remains, which becomes the foramen ovale. 17 Prior to birth, the fetus is dependent on the maternal circulation for oxygenation, as the immature fetal lungs do not yet participate in oxygen exchange. As such, the foramen ovale (as well as the ductus arteriosus), enables shunting of blood away from the pulmonary circulation. At birth, when the neonate's lungs begin to participate in oxygen exchange, there is a precipitous drop in the pulmonary vascular resistance and there is reversal of flow through both the foramen ovale and ductus arteriosus. 18 In approximately 75% of individuals, the foramen ovale closes within a few years while in the remaining others, it stays open permanently as a PFO. EpidemiologyThe prevalence of PFO in the healthy adult population ranges from 15% to 25% on echocardiography and 15-35% on autopsy studies. 1,2,19,20 Observational and autopsy studies have showed that the prevalence of detected PFOs is lower in older patients and that detected PFOs in older individuals tend to be larger. 1,19,20 Those studies, however, may be confounded by selection and detection bias because none of the longitudinal studies have demonstrated that individual PFOs change in size. The prevalence of PFOs is equal among men and women, though there may be race-ethnic differences. 1,19,21 he foramen ovale is an important fetal structure that closes after birth in most individuals and remains open as a patent foramen ovale (PFO) in approximately 25% of the healthy population. 1-3 In these individuals, bypass of the pulmonary circulation via shunting from the right-sided venous circulation to the left-sided arterial circulation is possible. Although most patients with PFOs are completely asymptomatic, reports from the late 1800 s by Cohnheim and Litten described cases of patients who were found to have the triad of deep venous thrombosis (DVT), PFO and systemic embolization. They hypothesized that the PFO enabled bypass of a venous thrombosis to the systemic arterial circulation, a process now termed paradoxical embolization. 4,5 Since those initial observations, additional studies have demonstrated a strong association between the presence of PFO and cryptogenic stroke in young patients. 6-11 In addition to its association with stroke, PFO has also been implicated in platypneaorthodeoxia, 12 decompression illness, 13 myocardial infarction, 14 obstructive sleep apnea, 15 and migraine headaches. 16 This review will focus on the relationship between PFO and stroke, discussing the embryology, epidemiology, association, mechanisms, diagnostic methods, associated anatomic factors and management strategies. EmbryologyThe right and left atria begin as a single chamber and separation b...

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“…2 Because some bubbles often also pass through the lungs in patients without pathological intrapulmonary connection, this is probably a common cause of false-positive examinations, especially when 5 and not 3 beats are used to define PFO. 3,4 Modern harmonic imaging is also highly sensitive and makes the appearance of these bubbles brighter. 3,5 Second, moderate to large residual shunting was detected in 4 of 69 cases, as determined by the interventionist who performed the PFO procedure.…”

mentioning

confidence: 99%

“…3,4 Modern harmonic imaging is also highly sensitive and makes the appearance of these bubbles brighter. 3,5 Second, moderate to large residual shunting was detected in 4 of 69 cases, as determined by the interventionist who performed the PFO procedure. The total number of cases with residual shunting was not reported, and, more importantly, neither was it reported how many injections were made to actually discover residual shunting.…”

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confidence: 99%

Letter by Johansson et al Regarding Article, “Migraine Intervention With STARFlex Technology (MIST) Trial”

2009

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We read with interest the report of the MIST trial, 1 designed to answer the intriguing question, "Can elimination of an interatrial shunt mitigate migraine symptoms?" Patent foramen ovale (PFO) closure might be a remedy for thousands of people suffering from migraine. The final report gave a negative answer. Two potential explanations exist for this: Either the PFOs were not closed, or a causal relationship between PFO and migraine with aura does not exist. In our opinion, several procedural issues make it difficult to interpret the results.First, the authors report a 7% rate of false positives for detection of PFO. The MIST protocol specified transthoracic echocardiography with saline contrast to be used and defined PFO as visible bubbles in the left atrium within 5 beats from bubble appearance in the right atrium. The timing of contrast appearance in the right atrium might, however, be obscured by low image quality during the Valsalva maneuver. Moreover, the sole reliance on a number of beats of delay until contrast appearance can be insufficient for differentiating intrapulmonary from interatrial shunting. 2 Because some bubbles often also pass through the lungs in patients without pathological intrapulmonary connection, this is probably a common cause of false-positive examinations, especially when 5 and not 3 beats are used to define PFO. 3,4 Modern harmonic imaging is also highly sensitive and makes the appearance of these bubbles brighter. 3,5 Second, moderate to large residual shunting was detected in 4 of 69 cases, as determined by the interventionist who performed the PFO procedure. The total number of cases with residual shunting was not reported, and, more importantly, neither was it reported how many injections were made to actually discover residual shunting. Repetition of contrast injections at least up to 5 times will increase the sensitivity for PFO detection. 3 False-negative results are frequently caused by absent leftward bulging of the interatrial septum due to a short and insufficient Valsalva maneuver. Another cause is deficient contrast filling of the inferior part of the right atrium due to a prominent Eustachian valve and the inflow of contrast-free blood from the inferior vena cava on release of the Valsalva maneuver.In our opinion, the MIST trial should be considered inconclusive. The hypothesis linking PFO and migraine should be evaluated within future randomized, properly conducted clinical trials using modern, adequate echocardiographic techniques, including a core laboratory facility. Until then, the indications for PFO closure should remain strict to avoid the explosive increase in the off-label use of occluders reported recently. DisclosuresDr Johansson receives honoraria from AGA Medical; Dr Eriksson receives honoraria from Gore, St Jude Medical, AGA Medical, and NMT Medical; and Dr Dellborg receives honoraria from Gore and General Electric. Magnus

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Sensitivity for Detection of Patent Foramen Ovale Increased with Increasing Number of Contrast Injections: A Descriptive Study with Contrast Transesophageal Echocardiography

Cited by 58 publications

References 34 publications

Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions

Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions

Patent Foramen Ovale and Stroke

Letter by Johansson et al Regarding Article, “Migraine Intervention With STARFlex Technology (MIST) Trial”

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