Agitated Saline Contrast Injection Research Articles

Agitated Saline Contrast Injection in Patients with Severe Hypoxemia.

The use of agitated saline contrast (ASC) during echocardiographic examinations is a well-established practice, most commonly performed to identify atrial septal abnormalities in the context of stroke. In the intensive care unit, this technique may be employed to identify anatomic right-to-left shunts (either intracardiac or transpulmonary) that may be contributing to hypoxemic respiratory failure. This narrative review will describe the technique of ASC injection, summarize clinical scenarios where it may be useful, and review the strengths and limitations of the tool.

Relation of Patent Foramen Ovale to Acute Mountain Sickness

Over 50% of patients who rapidly ascend to extreme altitudes develop various symptoms known as acute mountain sickness (AMS), which rarely can be life threatening. It is unclear why some patients are more susceptible to AMS than others. Our objective was to determine whether patent foramen ovale (PFO) is a risk factor for AMS. Subjects who had hiked to altitudes above 10,000' (∼3,000 meters) on the John Muir Trail in California were recruited. Participants completed a questionnaire and 2-physician adjudication was performed in regard to AMS status. A transcranial Doppler with agitated saline contrast injection was performed to evaluate the presence or absence of PFO. The primary outcome was the development of AMS. From 2016 to 2018, 137 hikers were recruited into the study. There was a higher prevalence of PFO in hikers with AMS 15 of 24 (63%) compared with hikers without AMS 44 of 113 (39%); p = 0.034. In the multivariate model, the presence of a PFO significantly increased the risk for developing AMS: odds ratio 4.15, 95% confidence intervals 1.14 to 15.05; p = 0.030. In conclusion, hikers with a PFO had significantly higher risk of developing AMS relative to hikers without a PFO. Clinicians should consider PFO a risk factor in patients who plan to hike to high altitudes.

Incidence and Outcomes of Positive Bubble Contrast Study Results After Transcatheter Closure of a Patent Foramen Ovale

ObjectivesThe aim of this study was to assess the incidence of persistently positive results on agitated saline contrast injection after patent foramen ovale (PFO) closure, the underlying mechanism, and management. BackgroundTranscatheter intervention to close a PFO is reasonable in highly selected patients younger than 60 years, after a thorough cardioneurological investigation following a cryptogenic stroke, particularly in the presence of thromboembolic disease or in patients at high risk for venous thrombosis. The U.S. Food and Drug Administration approved the Amplatzer PFO Occluder in October 2016 for such an indication. Confirmation of PFO closure is usually verified by an agitated saline contrast injection during an echocardiographic examination. The appearance of bubbles in the left atrium raises the concern of incomplete closure or other sources of shunting. MethodsThe medical records and echocardiograms of patients who were treated with transcatheter closure of a PFO for cryptogenic stroke were reviewed. ResultsFrom January 1998 through December 2015, 880 patients were taken to the catheter laboratory for PFO closure, of whom 568 patients, 320 men (56.3%), underwent transcatheter closure of a PFO using an Amplatzer PFO Occluder, at a mean age of 48.1 ± 12.9 years. The incidence of right-to-left shunting (RLS) was 19.5% at a mean of 4 months’ follow-up, which reduced to 8.4% at 11 ± 2 months. Sources of RLS were identified in 10 (1.8%); pulmonary arteriovenous malformation (n = 4) was the most common etiology, followed by leak through the device (n = 3). All patients with additional sources of RLS were treated percutaneously. At 2-year follow-up, 16 patients (2.8%) persisted with only mildly positive results on agitated saline contrast injection, without an apparent additional source of shunting. ConclusionsCoexistence of a PFO and an additional lesion responsible for RLS is uncommon, but not rare; the majority are amenable to transcatheter or surgical intervention.

P594Contrast transthoracic echocardiography as a gatekeeper for patent foramen ovale closure.

The presence of patent foramen ovale (PFO) has been linked to many illness, including cryptogenic stroke, transient ischemic attack, migraine, platypnea-orthodeoxia syndrome and decompression sickness in scuba divers. Transesophageal echocardiography is the gold standard technique for the visualization of atrial septal anatomy, but it is a secondary level exam, not always available, with additional associated costs and not completely free from procedural risks. Standard transthoracic echocardiography (TTE) has a too low sensitivity for PFO screening. The aim of the study was to assess the role of TTE associated with agitated saline contrast injection (contrast-TTE) as a gatekeeper for the identification of PFO in a large cohort of patients undergoing selection for percutaneous closure. A total of 200 patients undergoing a diagnostic work-up for the identification of PFO was imaged by contrast-TTE at rest and after provocative maneuvers (PM: Valsalva in all cases). Contrast TTE was graded from 0 to 4 on the bases of bubbles counting (0: no bubbles; 1: < 10 bubbles; 2: 10-30 bubbles; 3: >30 bubbles; 4: complete LV opacification). PFO closure was performed after a consensual clinical decision by the cardiologist and the neurologist taking into account comprehensive imaging, clinical evaluation and thrombophilia screening. PFO closure was always monitored by intracardiac echocardiography. At baseline contrast TTE was positive (≥2) in 34 patients (17%) while contrast TTE with PM was positive in 94 cases (47%). 27 out of 200 patients (14%) had an interatrial septal aneurysms. PFO closure was performed in 34 cases (17%). All of these had severe right-to-left shunting (≥3) at contrast TTE and 9 cases had also an interatrial septal aneurysms. The procedure was aborted in only 1 patient due to a complex defect anatomy. Contrast TTE with PM may be not only considered an accurate tool for the detection of PFO but may be also inserted in the diagnostic work- up as a primary gatekeeper for percutaneous closure. Severe shunting at contrast TTE influences final decision making in a large cohort of cases undergoing screening for PFO closure.

A Rare Association of Sinus Venosus-Type Atrial Septal Defect and Persistent Left Superior Vena Cava Detected by Transthoracic Echocardiography and Cardiac Magnetic Resonance Imaging

Patient: Male, 60Final Diagnosis: Persistent left superior vena cavaSymptoms: —Medication: —Clinical Procedure: Transthoracic echocardiogram and cardiac magnetic resonance imagingSpecialty: CardiologyObjective:Congenital defects/diseasesBackground:Association of persistent left superior vena cava (PLSVC) and sinus venosus-type atrial septal defect (SVASD) is rare. We describe a patient with dilated coronary sinus (CS) found to have PLSVC and SVASD.Case Report:The patient is a 60-year-old man with history of stroke who underwent a transthoracic echocardiogram (TTE) for evaluation of shortness of breath. TTE demonstrated a markedly dilated CS. Agitated saline was injected into the left antecubital vein to further assess CS. The parasternal long axis view demonstrated immediate filling of the CS and confirmed the presence of a PLSVC. Apical 4-chamber view with injection of agitated saline into the right antecubital vein demonstrated immediate contrast opacification of both atria, consistent with a right to left cardiac shunt. Cardiac magnetic resonance (CMR) was performed, which confirmed the TTE findings of PLSVC and defined the cardiac shunt as SVASD.Conclusions:PLSVC should be suspected in a patient with an abnormally dilated CS. In this case we identified a rare association of PLSVC with a SVASD. TTE with agitated saline contrast injection and CMR are useful diagnostic tools for PLSVC and associated cardiac congenital anomalies, respectively.

Detection of Right-to-Left Atrial Communication Using Agitated Saline Contrast Imaging: Experience with 1162 Patients and Recommendations for Echocardiography

Right-to-left shunting via a patent foramen ovale (PFO) has a recognized association with embolic events in younger patients. The use of agitated saline contrast injection (ASCi) for detecting atrial shunting is well documented, but the optimal technique is not well described. The purpose of this study was to assess the efficacy and safety of transthoracic echocardiographic (TTE) ASCi for the assessment of right-to-left atrial communication in a large cohort of patients. A retrospective review was undertaken of 1,162 consecutive patients who underwent TTE ASCi, of whom 195 had also undergone clinically indicated transesophageal echocardiography. ASCi shunt results were compared with color flow imaging, and the role of provocative maneuvers (PM) was assessed. Four hundred three TTE studies (35%) had paradoxical shunting seen during ASCi. Of these, 48% were positive with PM only. There was strong agreement between TTE ASCi and reported transesophageal echocardiographic findings (99% sensitivity, 85% specificity), with six false-positive and two false-negative results. In hindsight, the latter were likely due to suboptimal right atrial opacification and the former to transpulmonary shunting. TTE color flow imaging was found to be insensitive (22%) for the detection of a PFO compared with TTE ASCi. TTE color flow imaging is too insensitive for PFO screening. TTE ASCi, however, is simple and highly accurate for the detection of right-to-left atrial communication, on the proviso that a dedicated protocol, including correctly implemented PM, is followed. It is recommended that TTE ASCi with PM be considered the primary diagnostic tool for the detection of PFO in clinical practice.

Diagnosis of pulmonary arteriovenous malformation using a transesophageal echocardiography bubble study

A 42-year-old woman underwent transthoracic echocardiography with agitated saline contrast injection after an ischaemic stroke; a right-to-left shunt was observed ( Figure A ). Transesophageal echocardiography with agitated saline contrast injection (‘bubble study’) was then performed; bubbles were apparent in the left atrium after four …

Double trouble

A 18-year-old boy presented for cardiological evaluation for a previous pleuritic chest pain. Physical exam was normal and ECG showed an early repolarization pattern. Transthoracic echocardiogram revealed an ondulating structure on the left side of the interatrial septum (IAS), without other abnormalities. Transoesophageal study was performed in order to define better the IAS anatomy and assess for other anomalies. It showed a high mobile membrane adjacent and parallel to the IAS with flow into its chamber. Intravenous agitated saline contrast injection excluded the presence of patent foramen ovale (PFO) or interatrial septum defect. We review literature about atrial septal malformations.

Prevalence of Intracardiac Shunting in Children with Sickle Cell Disease and Stroke

To determine the prevalence of potential intracardiac shunts, including patent foramen ovale (PFO), in children with sickle cell disease (SCD) and stroke. We performed a transthoracic echocardiogram (TTE) on 40 children with SCD (39 with hemoglobin SS and 1 with sickle-beta0 thalassemia) and earlier stroke (overt stroke in 30, silent infarction in 10). We compared 3 TTE techniques: conventional 2-dimensional imaging, color Doppler ultrasound, and intravenous agitated saline contrast injection for the detection of intracardiac shunts. We also evaluated the clinical, laboratory, and radiographic findings of the children with and without shunts. We identified PFO or other potential intracardiac shunts in 10 of 40 children with SCD and earlier stroke (25%; 95% CI, 11.6-38.4). With contrasted TTE, we failed to detect potential shunts in 2 children. In a comparison group of 60 children with stroke but without SCD, retrospective review of clinical echocardiograms identified PFO in 7 of 60 (11.7%; 95% CI, 3.6-19.8). Clinical features significantly associated with the presence of intracardiac shunts were stroke in the setting of vaso-occlusive crisis (P = .026) and headache at stroke onset (P = .014). One-quarter of children with SCD and stroke have potential intracardiac shunts. A combination of echocardiographic techniques is required for optimal shunt detection. Intracardiac shunting could be a risk factor for stroke in children with SCD because they are predisposed to thrombosis and elevations of right heart pressure, which could promote paradoxical embolization across an intracardiac shunt.

Echocardiographic Assessment of Percutaneous Patent Foramen Ovale and Atrial Septal Defect Closure Complications

Atrial septal defect (ASD) is a common congenital defect (1 in 1000 live births) and accounts for up to 40% of clinically relevant acyanotic shunts in adults.1 Patent foramen ovale (PFO) is much more common and is present in more than 25% of adults.2,3 The clinical syndromes associated with ASD/PFO represent a significant health burden. Surgical closure is the most common therapy for these defects, and it is associated with low morbidity and mortality. However, it remains a surgical procedure requiring cardiopulmonary bypass, a significant postoperative recovery, and a sternotomy scar that may be undesirable to young patients. Catheter-based techniques for the treatment of ASD/PFO were pioneered by King and Mills in 1975.4 Since then, significant device development and modifications have been made (Table 1). Percutaneous therapy is now the preferred strategy for ASD/PFO closure, by patients and physicians alike, in the absence of complicated anatomy or another indication for traditional cardiac surgery, because it is technically simple and associated with negligible morbidity and mortality.5 Longer-term follow-up, however, remains necessary to more completely evaluate the safety and efficacy of such devices. View this table: Table 1. Summary of Devices Most Frequently Used for Percutaneous Closure of ASD or PFO The role of 2-dimensional (2D) transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) during the assessment and management of ASD/PFO has been demonstrated.6–8 Although universal practice standards, in the form of consensus committee guidelines or professional society recommendations, still have to be established for the use of echocardiography in this context, it is used by a majority of groups who perform these procedures. In our institution, TTE with color Doppler and/or agitated saline contrast injection is most frequently the method used to diagnose interatrial communication. Once the diagnosis has been made and percutaneous closure is deemed clinically appropriate, a careful …

A case of platypnea-orthodeoxia syndrome caused by the interaction between the presence of corrected transposition of the great arteries and patent foramen ovale

A 42-year-old was admitted to our institution for recurrent episodic dyspnea on exertion. The patient had also a history of recurrent transient ischemic attacks. Careful history taking revealed that she developed dyspnea in an upright position, whereas the symptoms were relieved in a supine position (platypnea). The patient was given the diagnosis of platypnea-orthodeoxia syndrome. Transthoracic echocardiography showed cardiac situs solitus levocardia with great artery transposition with intact interventricular septum, patent foramen ovale (PFO) and moderate right atrial dilatation. Agitated saline contrast injection demonstrated the presence of spontaneous right-to-left shunt. The patient underwent transcatheter closure of PFO. After percutaneous closure of PFO patient became asymptomatic and hypoxemia induced by orthostatic conditions did not appear again. A transthoracic echocardiography performed after two months, showed the complete closure of PFO, without residual shunt.

Simultaneous release of interdigitating atrial septal defect and patent foramen ovale Amplatzer devices

In the absence of an alternative cause of breathlessness, a 73-year-old patient with an atrial septal defect and right volume overload on echocardiography was referred for transcatheter device closure under general anesthesia. After balloon sizing under fluoroscopy, a 22 mm Amplatzer (AGA Medical Corporation, USA) septal occluder device was partially deployed. However, transesophageal echocardiography revealed a large patent foramen ovale (PFO) (Figure 1A). Figure 1 Transesophageal, bicaval echo view of the interatrial septum. A Central ostium secundum atrial septal defect (ASD) and patent foramen ovale (PFO). B The ASD device is deployed but not released. The rim of the larger left atrial disc fails to cover neck ... Multiple defects in the atrial septum may be occluded by one large device (1), but the 22 mm device with a 7 mm left atrial disc rim failed to close the neck of the PFO (Figure 1B). Agitated saline contrast injection via the inferior vena cava revealed dense puffs of contrast moving across the PFO (Figure 1C). For dual ASD device closures, deployment of the smallest device followed by the larger is advocated (2). Our need for a large 34 mm Amplatzer PFO occluder posed a technical challenge, addressed in Figure 2. Figure 2 A Left atrial (LA) disc of atrial septal defect (ASD) device deployed with gentle traction into the defect within centre of fossa ovalis. The LA disc of the Amplatzer (AGA Medical Corporation, USA) patent foramen ovale (PFO) occluder overlapped the ASD ...

Traumatic right ventricular rupture

Fig. 1. Transthoracic echocardiogram demonstrating an echolucent area (arrow) adjacent to the apical right ventricular free wall in the standard apical four-chamber view (top). Prior to contrast injection (middle), a serpiginous echolucent tract (arrow) appears to originate from the right ventricular free wall. Following an intravenous agitated saline contrast injection (bottom), the tract becomes hyperechoic as it fills with agitated saline (dashed line), confirming a right ventricular free wall rupture4 (LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle). Fig. 2. Computed tomography of the thorax with contrast demonstrating right ventricular rupture with extravasation of contrast into the anterior mediastinum (arrow).

Intrapulmonary arteriovenous shunt: Diagnosis by saline contrast bubbles in the pulmonary veins

A 54-year-old man with end-stage cirrhosis of the liver presented for evaluation of dyspnea. Intrapulmonary arteriovenous shunting was suspected. Transthoracic echocardiography with agitated saline contrast injection from the right antecubital vein was performed. Late arrival of saline contrast bubbles in the left atrium by pulmonary veins leading to complete left heart opacification confirmed the diagnosis of significant intrapulmonary shunting. This case and images illustrate the use of agitated saline contrast in combination with transthoracic echocardiography for the diagnosis of intrapulmonary arteriovenous fistula. (J Am Soc Echocardiogr 2002;15:1012-4.)

Vascular distribution of paradoxical emboli by transcranial Doppler.

Paradoxical embolism through a patent foramen ovale is a contributory mechanism to stroke and may be diagnosed by contrast echocardiography. The intracranial distribution of these emboli has not been previously reported. We used transcranial Doppler combined with agitated saline contrast injection to determine whether there was a preferential distribution of the contrast into the anterior or posterior intracranial circulation of patients with an acute stroke or transient ischemic attack. Forty-nine patients were studied--27 men and 22 women, with a mean age of 62.7 +/- 13.3 years (range, 29 to 85 years). Microcavitations were detected in the proximal right middle cerebral artery in 12 of 49 patients (24%). A patent foramen ovale was confirmed in all cases by simultaneous transesophageal echocardiography. Of the 12 patients, microcavitations were also detected in the proximal basilar artery in nine (75%). While paradoxical embolism appears to occur more frequently in the anterior circulation, the high rate of detection of microcavitations in the basilar artery suggests that paradoxical embolism to the posterior intracranial circulation may be more frequent than generally believed.