1
|
Aoun J, Hatab T, Volpi J, Lin CH. Patent Foramen Ovale and Atrial Septal Defect. Cardiol Clin 2024; 42:417-431. [PMID: 38910025 DOI: 10.1016/j.ccl.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.
Collapse
Affiliation(s)
- Joe Aoun
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
| | - Taha Hatab
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - John Volpi
- Neurology Department, Houston Methodist Hospital, Houston, TX, USA
| | - Chun Huie Lin
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| |
Collapse
|
2
|
Diagnostic Accuracy of Transthoracic Echocardiography With Contrast for Detection of Right-to-Left Shunt: A Systematic Review and Meta-analysis. Can J Cardiol 2022; 38:1948-1958. [PMID: 35995285 DOI: 10.1016/j.cjca.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The clinical utility of transthoracic echocardiography with contrast (TTE-C) for detection of right-to-left shunt (RLS) remains unknown. In this meta-analysis we evaluated the accuracy of TTE-C for RLS diagnosis compared with transesophageal echocardiography (TEE) as the reference standard. METHODS A systematic review and meta-analysis was performed using a search of MEDLINE, EMBASE, PubMed, and Cochrane library databases. Studies that were included provided data to assess sensitivity and specificity of TTE-C compared with TEE for RLS detection. RESULTS A total of 35 studies, involving 4209 patients, were analyzed. The average patient age was 49.1 ± 11.2 years and 53.9% were male. For RLS detection in the entire cohort, TTE-C sensitivity was 73% (95% confidence interval [CI], 66%-80%) and specificity was 94% (95% CI, 92%-96%). The sensitivity of TTE-C was 80% (95% CI, 74%-86%) in studies published in 2000 or later compared with 51% (95% CI, 36%-65%) in those published before 2000. In studies that used harmonic imaging, TTE-C sensitivity was 82% (95% CI, 77%-87%) and specificity was 95% (95% CI, 93%-97%). Among those with patent foramen ovale closure indications, TTE-C sensitivity was 74% (95% CI, 59%-89%) and specificity was 98% (95% CI, 95%-100%). In patients in whom RLS was diagnosed using a guideline-suggested 3 cardiac cycle cutoff, TTE-C sensitivity was 75% (95% CI, 66%-83%) and specificity was 94% (95% CI, 92%-97%). Provocative manoeuvres increased sensitivity by approximately 40%. CONCLUSIONS TTE-C offers excellent specificity and moderate sensitivity for RLS diagnosis compared with TEE, and it might therefore serve as an initial screening modality for selected patients with a high likelihood of having RLS and for indications for treatment.
Collapse
|
3
|
Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
|
4
|
Garg L, Haleem A, Varade S, Sivakumar K, Shah M, Patel B, Agarwal M, Agrawal S, Leary M, Kluck B. Patent Foramen Ovale Closure in the Setting of Cryptogenic Stroke: A Meta-Analysis of Five Randomized Trials. J Stroke Cerebrovasc Dis 2018; 27:2484-2493. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/05/2018] [Accepted: 05/04/2018] [Indexed: 11/30/2022] Open
|
5
|
Comparison of Different Contrast Agents in Detecting Cardiac Right-to-Left Shunt in Patients with a Patent Foramen Ovale during Contrast-Transthoracic Echocardiography. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6086094. [PMID: 29333447 PMCID: PMC5733159 DOI: 10.1155/2017/6086094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 11/08/2017] [Indexed: 12/17/2022]
Abstract
The aim of this study is to evaluate the ability of two different contrast agents to detect cardiac right-to-left shunting in patients with a patent foramen ovale during contrast transthoracic echocardiography and transesophageal echocardiography. Eighty-four patients who had migraines or experienced cryptogenic stroke were prospectively enrolled. Contrast echocardiography of the right portion of the heart was performed using an injection of either (i) 8 ml of agitated saline, 1 ml of blood, and 1 ml of air (ASB) or (ii) 4 ml of vitamin B6 and 6 ml of sodium bicarbonate solution (VSBS). All patients underwent contrast echocardiography with different contrast agents successively before undergoing transesophageal echocardiography. The diagnostic sensitivity of VSBS and ASB for cardiac shunting diagnosis was 94.23% and 78.85%, respectively. The diagnostic sensitivity in the VSBS group was significantly higher than that in the ASB group (χ2 = 5.283, P = 0.022). The observed semiquantitative shunt grading suggests that the positive rate in the VSBS group was higher than that in the ASB group (Z = −1.998, P = 0.046). The use of vitamin B6 and sodium bicarbonate solution as a TTE contrast agent yielded a high sensitivity compared with ASB. However, further trials with large sample size are required to confirm this finding.
Collapse
|
6
|
Patent Foramen Ovale and the Risk of Cerebral Infarcts in Acute Pulmonary Embolism-A Prospective Observational Study. J Stroke Cerebrovasc Dis 2017; 27:357-364. [PMID: 29031497 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/12/2017] [Accepted: 09/07/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is associated with a risk of consecutive paradoxical embolism with brain infarction through a patent foramen ovale (PFO). The aims of this study were to assess the rate of new ischemic brain lesions (IBLs) using magnetic resonance imaging (MRI) during a 12-month follow-up period with anticoagulation and to evaluate the potential relationship with the presence of PFO on transesophageal echocardiography (TEE). SUBJECTS AND METHODS Seventy-eight patients with acute PE underwent baseline contrast TEE with brain MRI. After the 12-month follow-up, 58 underwent brain MRI. The rates of MRI documenting new IBLs were measured based on the presence of PFO. RESULTS PFO was detected in 31 patients (39.7%). At baseline MRI, IBL was present in 39 of 78 patients (50%). The presence of IBL was not significantly higher in patients with PFO than in patients without PFO (20 [64.5% patients with PFO] versus 19 [40.4% without PFO] of 39 patients with baseline IBL, P = .063). At the follow-up MRI, in the group with new IBL (9 of 58 patients, 15.5%), the number of patients with PFO was significantly higher than that without PFO (7 [33.3%] versus 2 [5.4%], P = .008). PFO was identified as an independent predictor of new IBL (odds ratio 4.6 [1.6-47.4], P = .008). CONCLUSIONS The presence of PFO was associated with new IBL in patients with PE. These patients are at a higher risk of ischemic stroke despite effective anticoagulation therapy.
Collapse
|
7
|
Silvestry FE, Cohen MS, Armsby LB, Burkule NJ, Fleishman CE, Hijazi ZM, Lang RM, Rome JJ, Wang Y. 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. J Am Soc Echocardiogr 2016; 28:910-58. [PMID: 26239900 DOI: 10.1016/j.echo.2015.05.015] [Citation(s) in RCA: 298] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Frank E Silvestry
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meryl S Cohen
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laurie B Armsby
- Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, Oregon
| | | | - Craig E Fleishman
- Arnold Palmer Hospital for Children, University of Central Florida College of Medicine, Orlando, Florida
| | | | - Roberto M Lang
- University of Chicago Hospital, University of Chicago School of Medicine, Chicago, Illinois
| | - Jonathan J Rome
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Yan Wang
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | |
Collapse
|
8
|
Katsanos AH, Psaltopoulou T, Sergentanis TN, Frogoudaki A, Vrettou AR, Ikonomidis I, Paraskevaidis I, Parissis J, Bogiatzi C, Zompola C, Ellul J, Triantafyllou N, Voumvourakis K, Kyritsis AP, Giannopoulos S, Alexandrov AW, Alexandrov AV, Tsivgoulis G. Transcranial Doppler versus transthoracic echocardiography for the detection of patent foramen ovale in patients with cryptogenic cerebral ischemia: A systematic review and diagnostic test accuracy meta-analysis. Ann Neurol 2016; 79:625-35. [PMID: 26833864 DOI: 10.1002/ana.24609] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Patent foramen ovale (PFO) can be detected in up to 43% of patients with cryptogenic cerebral ischemia undergoing investigation with transesophageal echocardiography (TEE). The diagnostic value of transthoracic echocardiography (TTE) in the detection of PFO in patients with cryptogenic ischemic stroke or transient ischemic attack has not been compared with that of transcranial Doppler (TCD) using a comprehensive meta-analytical approach. METHODS We performed a systematic literature review to identify all prospective observational studies of patients with cryptogenic cerebral ischemia that provided both sensitivity and specificity measures of TTE, TCD, or both compared to the gold standard of TEE. RESULTS Our literature search identified 35 eligible studies including 3,067 patients. The pooled sensitivity and specificity for TCD was 96.1% (95% confidence interval [CI] = 93.0-97.8%) and 92.4% (95% CI = 85.5-96.1%), whereas the respective measures for TTE were 45.1% (95% CI = 30.8-60.3%) and 99.6% (95% CI = 96.5-99.9%). TTE was superior in terms of higher positive likelihood ratio values (LR+ = 106.61, 95% CI = 15.09-753.30 for TTE vs LR+ = 12.62, 95% CI = 6.52-24.43 for TCD; p = 0.043), whereas TCD demonstrated lower negative likelihood values (LR- = 0.04, 95% CI = 0.02-0.08) compared to TTE (LR- = 0.55, 95% CI = 0.42-0.72; p < 0.001). Finally, the area under the summary receiver operating curve (AUC) was significantly greater (p < 0.001) in TCD (AUC = 0.98, 95% CI = 0.97-0.99) compared to TTE studies (AUC = 0.86, 95% CI = 0.82-0.89). INTERPRETATION TCD is more sensitive but less specific compared to TTE for the detection of PFO in patients with cryptogenic cerebral ischemia. The overall diagnostic yield of TCD appears to outweigh that of TTE.
Collapse
Affiliation(s)
- Aristeidis H Katsanos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece.,Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Theodoros N Sergentanis
- Department of Hygiene, Epidemiology, and Medical Statistics, School of Medicine, University of Athens, Athens, Greece
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Agathi-Rosa Vrettou
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ioannis Paraskevaidis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - John Parissis
- Second Department of Cardiology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Chrysa Bogiatzi
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Christina Zompola
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - John Ellul
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Nikolaos Triantafyllou
- First Department of Neurology, Eginition Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece
| | | | - Sotirios Giannopoulos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN.,School of Nursing, Australian Catholic University, Sydney, Australia
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN.,International Clinical Research Center, Department of Neurology, St Anne's University Hospital Brno, Brno, Czech Republic
| |
Collapse
|
9
|
Schueler R, Hammerstingl C. Reply. JACC Cardiovasc Interv 2015; 8:1271-1272. [DOI: 10.1016/j.jcin.2015.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 06/29/2015] [Indexed: 11/16/2022]
|
10
|
MUGNAI GIACOMO, SIEIRA JUAN, CICONTE GIUSEPPE, HERVAS MARTASORIANO, IRFAN GHAZALA, SAITOH YUKIO, HÜNÜK BURAK, Ströker ERWIN, VELAGIC VEDRAN, WAUTERS KRISTEL, TONDO CLAUDIO, MOLON GIULIO, ASMUNDIS CARLODE, BRUGADA PEDRO, CHIERCHIA GIANBATTISTA. One Year Incidence of Atrial Septal Defect after PV Isolation: A Comparison Between Conventional Radiofrequency and Cryoballoon Ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1049-57. [DOI: 10.1111/pace.12663] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/09/2015] [Accepted: 05/06/2015] [Indexed: 11/28/2022]
Affiliation(s)
- GIACOMO MUGNAI
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - JUAN SIEIRA
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - GIUSEPPE CICONTE
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | | | - GHAZALA IRFAN
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - YUKIO SAITOH
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - BURAK HÜNÜK
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - ERWIN Ströker
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - VEDRAN VELAGIC
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - KRISTEL WAUTERS
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | - CLAUDIO TONDO
- Cardiac Arrhythmia Research Centre; Centro Cardiologico Monzino IRCCS; Milan Italy
| | - GIULIO MOLON
- Department of Cardiology; Sacro Cuore Hospital; Negrar Verona Italy
| | | | - PEDRO BRUGADA
- Heart Rhythm Management Centre; UZ Brussel-VUB; Brussels Belgium
| | | |
Collapse
|
11
|
Luani B, Markovic S, Krumsdorf U, Rottbauer W, Wöhrle J. Efficacy of different devices for transcatheter closure of patent foramen ovale assessed by serial transoesophageal echocardiography and rates of recurrent cerebrovascular events in a long-term follow-up. EUROINTERVENTION 2015; 11:85-91. [DOI: 10.4244/eijy15m01_02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
12
|
Emerging Role of Cardiovascular CT and MRI in the Evaluation of Stroke. AJR Am J Roentgenol 2015; 204:269-80. [DOI: 10.2214/ajr.14.13051] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
13
|
Lunetta M, Costa F, Gattuta ML, Novo S. Transesophageal Contrast Echocardiography is Not Always the Gold Standard Method in the Identification of a Patent Foramen Ovale: A Clinical Case. J Cardiovasc Echogr 2015; 25:86-89. [PMID: 28465942 PMCID: PMC5353415 DOI: 10.4103/2211-4122.166084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the embryo, Eustachian valve is a crescent-shaped membrane extending from the lower margin of the inferior vena cava and the ostium of the coronary sinus into the right atrium toward fossa ovalis and tricuspid valve. At birth, after the functional closure of the foramen ovale, the Eustachian valve loses its function, reducing to an embryo remnant. According to growing evidence, a persistent Eustachian valve is a frequent finding in patients with a patent foramen ovale (PFO). By directing the blood from the inferior cava to the interatrial septum, it may prevent the spontaneous closure of PFO after birth and indirectly predispose to paradoxical embolism. Transesophageal contrast enhanced echocardiography (cTEE) is considered the gold standard to diagnose a PFO in postnatal life, but its accuracy maybe is not so high in the presence of a persistent Eustachian valve. In these cases, color Doppler TEE is more sensitive and simplifies the diagnostic process, reducing the duration of TEE and improving the patient compliance.
Collapse
Affiliation(s)
- Monica Lunetta
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, Messina, Italy
| | - Marcello La Gattuta
- Department of Radiology, DIBIMEF, University Hospital "P Giaccone", University of Palermo, Palermo, Italy
| | - Salvatore Novo
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
| |
Collapse
|
14
|
Komar M, Olszowska M, Przewłocki T, Podolec J, Stępniewski J, Sobień B, Badacz R, Kabłak-Ziembicka A, Tomkiewicz-Pająk L, Podolec P. Transcranial Doppler ultrasonography should it be the first choice for persistent foramen ovale screening? Cardiovasc Ultrasound 2014; 12:16. [PMID: 24884981 PMCID: PMC4046065 DOI: 10.1186/1476-7120-12-16] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 05/02/2014] [Indexed: 02/06/2023] Open
Abstract
Background Persistent foramen ovale (PFO) is considered a cause of cryptogenic stroke and a risk factor for neurological events in young patients. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (TEE). The goal of this study was to evaluate the feasibility of transcranial color Doppler (TCD) and its diagnostic sensitivity compared with TEE. Methods We investigated 420 patients admitted to our department with cryptogenic stroke, transient ischemic attacks or other neurological symptoms. All patients underwent TCD and TEE evaluation. TCD and TEE examinations were performed according to a standardized procedure: air-mixed saline was injected into the right antecubital vein three times, while the Doppler signal was recorded during the Valsalva maneuver. During TCD the passage of contrast into the right-middle cerebral artery was recorded 25 seconds following the Valsalva maneuver. Results We detected a right-to-left shunt in 220 patients (52.3%) and no-shunts in 159 patients (37.9%) with both TCD and TEE. In 20 (4.8%) patients TEE did not reveal contrast passage which was then detected by TCD. In 21 (5.0%) patients only TEE revealed a PFO. The feasibility of both methods was 100%. TCD had a sensitivity of 95% and a specificity of 92% in the diagnosis of PFO. Conclusions TCD has a relatively good sensitivity and specificity. TCD and TEE are complementary diagnostic tests for PFO, but TCD should be recommended as the first choice for screening because of its simplicity, non-invasive character, low cost and high feasibility.
Collapse
Affiliation(s)
- Monika Komar
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Institute of Cardiology, Collegium Medicum, Jagiellonian University, Krakow, Poland.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Zaman MO, Gevorgyan R, Tobis JM. Accuracy of Conventional Transthoracic Echocardiography for the Diagnosis of Intracardiac Right-to-Left Shunt: A Meta-Analysis of Prospective Studies. Echocardiography 2014; 31:1036-48. [DOI: 10.1111/echo.12583] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Mohammad Khalid Mojadidi
- Department of Medicine; Jacobi Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Jared S. Winoker
- Department of Medicine; Jacobi Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Scott C. Roberts
- Department of Medicine; Jacobi Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Pavlos Msaouel
- Department of Medicine; Jacobi Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Muhammad Omer Zaman
- Department of Family Medicine; William Beaumont Hospital; Grosse Point Michigan
| | - Rubine Gevorgyan
- Program in Interventional Cardiology; Division of Cardiology; David Geffen School of Medicine; University of California at Los Angeles; Los Angeles California
| | - Jonathan M. Tobis
- Program in Interventional Cardiology; Division of Cardiology; David Geffen School of Medicine; University of California at Los Angeles; Los Angeles California
| |
Collapse
|
16
|
SIEIRA JUAN, CHIERCHIA GIANBATTISTA, DI GIOVANNI GIACOMO, CONTE GIULIO, DE ASMUNDIS CARLO, SARKOZY ANDREA, DROOGMANS STEVEN, BALTOGIANNIS GIANNIS, SAITOH YUKIO, CICONTE GIUSEPPE, LEVINSTEIN MOISES, BRUGADA PEDRO. One Year Incidence of Iatrogenic Atrial Septal Defect After Cryoballoon Ablation for Atrial Fibrillation. J Cardiovasc Electrophysiol 2013; 25:11-5. [DOI: 10.1111/jce.12279] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Revised: 08/12/2013] [Accepted: 08/19/2013] [Indexed: 11/29/2022]
Affiliation(s)
- JUAN SIEIRA
- Heart Rhythm Management Center; UZ Brussel-VUB; Brussels Belgium
| | | | | | - GIULIO CONTE
- Heart Rhythm Management Center; UZ Brussel-VUB; Brussels Belgium
| | | | | | | | | | - YUKIO SAITOH
- Heart Rhythm Management Center; UZ Brussel-VUB; Brussels Belgium
| | - GIUSEPPE CICONTE
- Heart Rhythm Management Center; UZ Brussel-VUB; Brussels Belgium
| | | | - PEDRO BRUGADA
- Heart Rhythm Management Center; UZ Brussel-VUB; Brussels Belgium
| |
Collapse
|
17
|
Ren P, Li K, Lu X, Xie M. Diagnostic value of transthoracic echocardiography for patent foramen ovale: a meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1743-1750. [PMID: 23820251 DOI: 10.1016/j.ultrasmedbio.2013.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 03/06/2013] [Accepted: 03/08/2013] [Indexed: 06/02/2023]
Abstract
As a non-invasive and convenient modality, transthoracic echocardiography (TTE) has been widely recommended for the diagnosis of patent foramen ovale (PFO). In this study our aim was to systematically review the diagnostic accuracy of TTE in detection of PFO. We conducted comprehensive searches in PubMed, Embase and the Cochrane Library to the end of September 1, 2012. Sixteen studies comprising 1831 patients were included in the meta-analysis. The quality of reported studies was modest. The summary sensitivity and specificity of TTE in diagnosis of PFO were 88% (95% confidence interval [CI], 79-94) and 97% (95% CI, 92-99), respectively. The positive likelihood ratio was 27.1 (95% CI, 11.2-65.1), and the negative likelihood ratio was 0.12 (95% CI, 0.07-0.22). The summary diagnostic odds ratio was 221 (95% CI, 95-518). Subgroup analyses suggested that age and initial disease may affect the accuracy of TTE in detection of PFO. The meta-analysis suggested that TTE is a test with high sensitivity and specificity in detection of PFO, but it may not be appropriate for screening for PFO in all patients, especially patients with a small right-left shunt.
Collapse
Affiliation(s)
- Pingping Ren
- Department of Ultrasonography, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | | | | |
Collapse
|
18
|
Bhatia N, Abushora MY, Donneyong MM, Stoddard MF. Determination of the optimum number of cardiac cycles to differentiate intra-pulmonary shunt and patent foramen ovale by saline contrast two- and three-dimensional echocardiography. Echocardiography 2013; 31:293-301. [PMID: 24028319 DOI: 10.1111/echo.12360] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) and intra-pulmonary shunt (IPS) are potential causes of stroke. The most optimum cardiac cycle cutoff for bubbles to appear in the left heart on saline contrast transthoracic echocardiography (TTE) as criteria to differentiate the 2 entities is unknown. METHODS Ninety-five adult patients had saline contrast transesophageal echocardiography (TEE), two-dimensional (2D) and 3DTTE. Sensitivity and specificity of each cardiac cycle as cutoff to differentiate a PFO and IPS were obtained. RESULTS Transesophageal echocardiography showed IPS in 28 and PFO in 15 patients. If bubbles appeared in the left heart within the first 4 cardiac cycles (the 4th cardiac cycle rule) as compared to alternate cutoffs, a PFO was most accurately diagnosed by both 2D and 3DTTE. Bubbles appearing at or after the 5th cardiac cycle most accurately determined an IPS. 3D versus 2DTTE had a trend for a higher sensitivity (61% vs. 36%, P = 0.06), but similar specificity (94% vs. 91%) for IPS. Accuracy of 3DTTE was 84% and 2DTTE was 75% (P = 0.08) for IPS. For PFO, 2DTTE sensitivity (87%) and specificity (98%) did not differ (P = NS) from that of 3DTTE sensitivity (73%) and specificity (100%). CONCLUSIONS This study demonstrates for the first time that the 4th cardiac cycle rule differentiates PFO and IPS most optimally by 2D and 3DTTE. 3DTTE appears to have higher sensitivity for diagnosing IPS. These data suggest that 3DTTE is preferable when IPS is to be diagnosed. Both methods are similar for diagnosing PFO.
Collapse
Affiliation(s)
- Nirmanmoh Bhatia
- Department of Medicine, Division of Cardiovascular Medicine, University of Louisville, Louisville, Kentucky
| | | | | | | |
Collapse
|
19
|
Ning M, Lo EH, Ning PC, Xu SY, McMullin D, Demirjian Z, Inglessis I, Dec GW, Palacios I, Buonanno FS. The brain's heart - therapeutic opportunities for patent foramen ovale (PFO) and neurovascular disease. Pharmacol Ther 2013; 139:111-23. [PMID: 23528225 PMCID: PMC3740210 DOI: 10.1016/j.pharmthera.2013.03.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 01/18/2023]
Abstract
Patent foramen ovale (PFO), a common congenital cardiac abnormality, is a connection between the right and left atria in the heart. As a "back door to the brain", PFO can serve as a conduit for paradoxical embolism, allowing venous thrombi to enter the arterial circulation, avoiding filtration by the lungs, and causing ischemic stroke. PFO-related strokes affect more than 150,000 people per year in the US, and PFO is present in up to 60% of migraine patients with aura, and in one out of four normal individuals. So, in such a highly prevalent condition, what are the best treatment and prevention strategies? Emerging studies show PFO-related neurovascular disease to be a multi-organ condition with varying individual risk factors that may require individualized therapeutic approaches - opening the field for new pharmacologic and therapeutic targets. The anatomy of PFO suggests that, in addition to thrombi, it can also allow harmful circulatory factors to travel directly from the venous to the arterial circulation, a concept important in finding novel therapeutic targets for PFO-related neurovascular injury. Here, we: 1) review emerging data on PFO-related injuries and clinical trials; 2) discuss potential mechanisms of PFO-related neurovascular disease in the context of multi-organ interaction and heart-brain signaling; and 3) discuss novel therapeutic targets and research frontiers. Clinical studies and molecular mapping of the circulatory landscape of this multi-organ disease will both be necessary in order to better individualize clinical treatment for a condition affecting more than a quarter of the world's population.
Collapse
Affiliation(s)
- Mingming Ning
- Cardio-Neurology Clinic, Massachusetts General Hospital, Harvard Medical School, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Kanaganayagam GS, Malik IS. Modern management of a patent foramen ovale. JRSM Cardiovasc Dis 2012; 1:10.1258_cvd.2012.012017. [PMID: 24175077 PMCID: PMC3738369 DOI: 10.1258/cvd.2012.012017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A patent foramen ovale (PFO) has been associated with medical conditions such as cryptogenic stroke, migraine with aura, and decompression illness. Whether closure of the PFO has clinical benefit has been suggested from registry studies, but not yet confirmed in multiple randomized trials. Methods of diagnosis of a PFO and a summary of the current evidence for treatment is presented and discussed as a guide to patient-centred decision-making.
Collapse
Affiliation(s)
- G S Kanaganayagam
- Hammersmith Hospital, Cardiovascular Sciences and the Renal Institute, Imperial College London and Imperial College Healthcare NHS Trust , London , UK
| | | |
Collapse
|
21
|
Esposito R, Raia R, De Palma D, Santoro C, Galderisi M. The role of echocardiography in the management of the sources of embolism. Future Cardiol 2012; 8:101-14. [PMID: 22185449 DOI: 10.2217/fca.11.72] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The echocardiographic diagnosis of cardiac thrombi, vegetations and tumors as well as the identification of predisposing conditions such as patent foramen ovale, aortic atherosclerosis and other minor causes (e.g., mitral valve prolapse, mitral and aortic valve calcification) have crucial clinical relevance, affecting the choice of surgery and/or of pharmaceutical therapy in the setting of patients presenting embolism. The echocardiographic assessment helps not only for the retrospective diagnosis of sources of embolism but also for the prevention of events in asymptomatic patients. Echocardiography can also distinguish normal variants and artifacts from cardiac masses and tumors. Echocardiographic characterization/typology of cardiac sources of embolism is currently below par when compared with cardiac MRI, the current gold standard. Nevertheless, echocardiography remains the 'first-line' imaging tool, because of its low cost and the possibility to add easily available, functional and structural information at the patient's bedside.
Collapse
Affiliation(s)
- Roberta Esposito
- Laboratory of Echocardiography, Cardioangiology with CCU, Department of Clinical & Experimental Medicine, Federico II University Hospital, Naples, Italy
| | | | | | | | | |
Collapse
|
22
|
Badano LP, Boccalini F, Muraru D, Bianco LD, Peluso D, Bellu R, Zoppellaro G, Iliceto S. Current clinical applications of transthoracic three-dimensional echocardiography. J Cardiovasc Ultrasound 2012; 20:1-22. [PMID: 22509433 PMCID: PMC3324722 DOI: 10.4250/jcu.2012.20.1.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 03/15/2012] [Accepted: 03/15/2012] [Indexed: 02/04/2023] Open
Abstract
The advent of three-dimensional echocardiography (3DE) has significantly improved the impact of non-invasive imaging on our understanding and management of cardiac diseases in clinical practice. Transthoracic 3DE enables an easier, more accurate and reproducible interpretation of the complex cardiac anatomy, overcoming the intrinsic limitations of conventional echocardiography. The availability of unprecedented views of cardiac structures from any perspective in the beating heart provides valuable clinical information and new levels of confidence in diagnosing heart disease. One major advantage of the third dimension is the improvement in the accuracy and reproducibility of chamber volume measurement by eliminating geometric assumptions and errors caused by foreshortened views. Another benefit of 3DE is the realistic en face views of heart valves, enabling a better appreciation of the severity and mechanisms of valve diseases in a unique, noninvasive manner. The purpose of this review is to provide readers with an update on the current clinical applications of transthoracic 3DE, emphasizing the incremental benefits of 3DE over conventional two-dimensional echocardiography.
Collapse
Affiliation(s)
- Luigi P Badano
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Roushdy A, Fiky AE, Din DEE. Visualization of patent ductus arteriosus using real-time three-dimensional echocardiogram: Comparative study with 2D echocardiogram and angiography. J Saudi Heart Assoc 2012; 24:177-86. [PMID: 23960692 DOI: 10.1016/j.jsha.2012.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/27/2012] [Accepted: 02/04/2012] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To determine the feasibility and accuracy of real time 3D echocardiography (RT3DE) in determining the dimensions and anatomical type of the patent ductus arteriosus (PDA). METHODS The study included 42 pediatric patients with a mean age of 3.6 years (ranging from 2 months to 14 years) who were referred for elective percutaneous PDA closure. All patients underwent full 2D echocardiogram as well as RT3DE with off line analysis using Q lab software within 6 h from their angiograms. The PDA was studied as regard the anatomical type, length of the duct as well as the ampulla and the pulmonary end of the PDA. Data obtained by RT3DE was compared against 2D echocardiogram and the gold standard angiography. RESULTS Offline analysis of the PDA was feasible in 97.6% of the cases while determination of the anatomical type using gated color flow 3D acquisitions was achieved in 78.5% of the cases. The pulmonary end of the duct was rather elliptical using 3D echocardiogram. There was significant difference between the pulmonary end measured by 3D echocardiogram and angiography (P < 0.001). There was no significant difference between either the length or the ampulla of the PDA measured by 3D echocardiogram and that measured by angiography (P value = 0.325 and 0.611, respectively). There was a good agreement between both 2D or 3D echocardiogram and angiography in determining the anatomical type of the PDA (K = 0.744 and 0.773, respectively). However 3D echocardiogram could more accurately determine type A and type E ductus compared to 2D echocardiogram. CONCLUSION 3D echocardiogram was more accurate than 2D echocardiogram in determining the length and the ampulla of the PDA. The morphologic assessment of the PDA using gated 3D color flow was achieved in 78.5% of the patients. Nevertheless the use of 3D echocardiogram in assessment of small vascular structures like PDA in children with rapid heart rates is still of limited clinical value.
Collapse
Affiliation(s)
- Alaa Roushdy
- Cardiology Department, Ain Shams University Hospital, Cairo
| | | | | |
Collapse
|
24
|
Abstract
Ischemic stroke in younger people is common, and often remains unexplained. There is a well-documented association between unexplained stroke in younger people, and the presence of a patent foramen ovale. Therefore, in the absence of a clear cause of stroke, the heart is often assessed in detail for such lower risk causes of stroke. This usually involves imaging with a transesophageal echo, and investigation for a right-to-left shunt. An understanding of the anatomy of the atrial septum, and its associated abnormalities, is important for the stroke neurologist charged with decision making regarding appropriate secondary prevention. In this paper, we review the development and anatomy of the right heart with a focus on patent foramen ovale, and other associated abnormalities. We discuss how the heart can be imaged in the case of unexplained stroke, and provide examples. Finally, we suggest a method of investigation, in light of the recent European Association of Echocardiography guidance. Our aim is to provide the neurologist with an understanding on how the heart can be investigated in unexplained stroke, and the significance of abnormalities detected.
Collapse
Affiliation(s)
- Paul E Cotter
- Department of Medicine, University of Cambridge, Cambridge, UK.
| | | | | |
Collapse
|
25
|
Diagnosis and quantification of patent foramen ovale. Which is the reference technique? Simultaneous study with transcranial Doppler, transthoracic and transesophageal echocardiography. Rev Esp Cardiol 2011; 64:133-9. [PMID: 21277667 DOI: 10.1016/j.recesp.2010.10.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 10/12/2010] [Indexed: 01/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Patent foramen ovale (PFO) is the most common cause of cryptogenic stroke in patients younger than 55. Transesophageal echocardiography (TEE) has been accepted as the reference diagnostic technique. The purpose of this study was to compare the accuracy of transthoracic echocardiography (TTE), TEE and transcranial Doppler (TCD) in the diagnosis and quantification of patent foramen ovale. METHODS We studied 134 patients prospectively. Simultaneous TTE with TCD and TEE with TCD were performed, using agitated saline solution to detect right to left shunt. RESULTS In 93 patients diagnosed with PFO, the shunt was visualized at baseline by TCD in 69% of cases, by TTE in 74% and by TEE in 58%. The Valsalva maneuver produced a similar improvement in shunt diagnosis with all 3 techniques (26%-28%). TTE and TCD showed higher sensitivity (100% vs 97%; non significant difference) than TEE in the diagnosis of PFO (86%; P<.001). TCD performed during TEE did not diagnose 12 (13%) shunts previously diagnosed during TTE. Similarly, TEE underestimated shunt severity. CONCLUSIONS TTE enables adequate diagnosis and quantification of PFO. TEE is less sensitive and tends to underestimate the severity of the shunt.
Collapse
|
26
|
González-Alujas T, Evangelista A, Santamarina E, Rubiera M, Gómez-Bosch Z, Rodríguez-Palomares JF, Avegliano G, Molina C, Álvarez-Sabín J, García-Dorado D. Diagnosis and Quantification of Patent Foramen Ovale. Which Is the Reference Technique? Simultaneous Study With Transcranial Doppler, Transthoracic and Transesophageal Echocardiography. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.rec.2010.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
27
|
Davison P, Clift PF, Steeds RP. The role of echocardiography in diagnosis, monitoring closure and post-procedural assessment of patent foramen ovale. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 11:i27-34. [DOI: 10.1093/ejechocard/jeq120] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
28
|
Usefulness of intravenously administered fluid replenishment for detection of patent foramen ovale by transesophageal echocardiography. Am J Cardiol 2010; 106:1054-8. [PMID: 20854974 DOI: 10.1016/j.amjcard.2010.05.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2010] [Revised: 05/16/2010] [Accepted: 05/18/2010] [Indexed: 01/11/2023]
Abstract
Patent foramen ovale (PFO) is associated with cryptogenic stroke, migraine headache, decompression sickness, and platypnea-orthodeoxia syndrome. Patients undergoing transesophageal echocardiography are often hypovolemic from preprocedural fasting and might not demonstrate right to left shunting owing to insufficient right atrial pressure generation, despite provocative maneuvers. We hypothesized that volume replenishment with saline loading could potentially unmask a PFO by favorably modulating the interatrial pressure gradient. Our study sought to examine the role of pre- or intraprocedural intravenous fluid replenishment on PFO detection during transesophageal echocardiography. A total of 103 patients were enrolled. An initial series of bubble injections was performed unprovoked and then with provocative maneuvers such as the Valsalva maneuver and coughing. The patients were then given a rapid 500 ml saline bolus, and the same sequence of bubble injections was repeated. The presence, type, and magnitude of the right to left shunts were noted before and after the saline bolus. The detection rate of PFO increased from 10.6% to 26.2% after saline loading without any provocative maneuvers. When combined with provocative maneuvers (Valsalva or cough), saline loading improved the detection rate from 17.4% to 32.0%. Overall, from amongst the 103 enrolled patients, saline bolusing resulted in a de novo diagnosis of PFO in 15 patients, atrial septal aneurysm in 15, PFO coexisting with an atrial septal aneurysm in 10, and pulmonary arteriovenous fistula in 5 patients. In conclusion, saline infusion in appropriately selected patients during transesophageal echocardiography significantly enhances the detection of PFOs and pulmonary arteriovenous fistulas.
Collapse
|
29
|
Cianciulli TF, Rubinetti ER, Saccheri MC, Llanos Dethinne SD, Prezioso HA. Contrast echocardiography in the non-invasive diagnosis of giant aneurysm of the right atrial appendage. ACTA ACUST UNITED AC 2010; 11:E26. [DOI: 10.1093/ejechocard/jeq065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|