Contrast-enhanced Transthoracic Echocardiography Research Articles

Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect.

Recognition of right-to-left shunt is crucial in the work-up of patients with suspected patent foramen ovale (PFO) or atrial septal defect (ASD). While transesophageal echocardiography (TEE) remains the gold standard diagnostic tool for the anatomic assessment of PFO/ASD, transcranial Doppler (TCD) and contrast-enhanced transthoracic echocardiogram (CE-TTE) hold the promise of providing minimally invasive yet accurate clinical details. Their comparative accuracy remains however debated. We conducted a retrospective observational study leveraging our extensive institutional experience with systematic TCD and CE-TTE in patients with suspected PFO/ASD. Several measures of diagnostic test accuracy were computed, with point estimates and 95% confidence intervals, when applicable. A total of 1358 patients were included, with age 48±14 years and 772 (58%) women. Tests were performed for diagnostic purposes in 797 (58.6%) and during follow-up in 740 (54.5%). A PFO was eventually diagnosed in 1038 (77.9%) patients, and an ASD in 60 (4.5%). Agreement between TCD and CE-TTE occurred in 1309 (85.2%) cases, with TCD yielding worse findings than CE-TTE in 91 (5.9%) patients, and vice versa in 137 (8.9%), yielding a Cohen kappa of 78.6% (95% CI: 76.3-81.1%) and a highly significant P value at McNemar test (P<0.001). After dichotomization, and using TCD as benchmark, CE-TTE yielded sensitivity 96.9%, specificity 95.1%, area under the curve 92.1%, and P=0.249. Similar findings were obtained when focusing only on diagnostic tests or follow-up ones (Cohen kappa respectively 74.0% [70.2-77.1%], P<0.001 and 80.3% [76.4-84.3%], P<0.001). Notably, Valsalva was necessary to disclose the presence of shunt during TCD in 487 (31.7%) patients and during CE-TTE in 482 (31.4%) cases. Finally, performance of TCD and CE-TTE in a subset of patients eventually undergoing TTE was quite similar. The diagnostic accuracy of CE-TTE appears favorable, and this imaging test may identify patients who may be missed if only TCD is used to screen patients with suspected PFO/ASD. Accordingly, CE-TTE is recommended as an adjunct diagnostic modality for all patients with a high pre-test probability of PFO/ASD and right-to-left shunt.

Dyspnoea in liver cirrhosis: beyond the ordinary cardiopulmonary cause

BackgroundDyspnoea is a common presentation to the casualties, attributed mostly to cardiopulmonary diseases. Approach to dyspnoea consists of initial acute management to ensure airway patency, respiratory support, and hemodynamic stability, followed by identification of the underlying disease for a definite management to reduce short-term inpatient morbidity and mortality, and rehospitalization in long term. Awareness of the patient’s pre-existing medical conditions is a crucial clue to guide the attending doctor to the primary cause. Dyspnea in chronic liver disease can be due to concomitant cardiopulmonary diseases as well as pulmonary vascular congestion or abnormality associated with portal hypertension such as hepatopulmonary syndrome.Case presentationA 59-year-old man presented with a syncopal attack associated with breathlessness after physical exertion. He had alcohol associated liver cirrhosis for 2 years with a 6-month duration of platypnea and reduced effort tolerance. His physical examination revealed a cyanosed man with normal blood pressure and heart rate, without evidence of systemic and pulmonary fluid congestions. Chest radiography and computed tomography showed no evidence of pulmonary embolism and parenchymal disease and a normal echocardiography ruled out any cardiogenic cause. A diagnosis of hepatopulmonary syndrome was made after the appearance of microbubbles over left atrium at fourth to fifth cardiac cycle demonstrated by a transthoracic contrast-enhanced echocardiography to suggest an extracardiac intrapulmonary shunt.ConclusionsHPS is not an uncommon complication of chronic liver disease. Usual manifestation of HPS is platypnea which needs to be differentiated from orthopnoea associated with cardiopulmonary disease. Nevertheless, there is no effective therapeutic approach of HPS besides liver transplantation.

Relationship between Migraine and Patent Foramen Ovale Observed by Contrast-enhanced Transthoracic Echocardiography.

To observe the association between migraine and patent foramen ovale (PFO) using contrast-enhanced transthoracic echocardiography (cTTE). Eighty-five migraine with aura (MA) patients and 85 migraine without aura (MO) patients from January 2020 to February 2022 were divided into group A and group B, respectively. Sixty-five healthy people were included in normal control group. Difference of PFO positive rate among group A, group B, and normal control group was significant (p=0.002). Difference of PFO related right-to-left shunt (PFO-RLS), Grade 2 shunt, and Grade 3 shunt among group A, group B, and normal control group was significant (p=0.043 and p=0.013 respectively). PFO-RLS Grade 2 and 3 shunts may play an important role in MA patients and MO patients, and the size of PFO-RLS shunt may be associated with migraine. Key Words: Migraine, Patent foramen ovale (PFO), Right-to-left shunt (RLS), Contrast-enhanced transthoracic echocardiography (cTTE).

Adjunct Methods for the Detection of Patent Foramen Ovale: The Contribution of Transcranial Doppler and the Valsalva Manoeuvre.

A patent foramen ovale (PFO) is present in 25% of the population. In some patients, especially those without traditional stroke risk factors and with no immediately apparent cause, a cryptogenic stroke may be caused by an embolus passing through the PFO to the systemic circulation. The identification, or indeed exclusion, of a PFO is sought in these patients, most commonly using contrast-enhanced transthoracic or transoesophageal echocardiography. Another method for detecting a PFO is transcranial Doppler, which allows the detection of PFO possibly without the need for an echo laboratory, and with arguably improved sensitivity. This review will focus on transcranial Doppler detection of PFO, with a brief summary of echocardiographic techniques and the use of ultrasound contrast agents, and the role of provocations to increase diagnostic accuracy, specifically the Valsalva manoeuvre. We discuss the phases alongside the direct and indirect signs of an adequate Valsalva manoeuvre.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BackgroundTo assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.MethodsA prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.ResultsAs per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.ConclusionsThe concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Aortic Root Downward Movement as a Novel Method for Identification of an Adequately Performed Valsalva Maneuver to Detect Patent Foramen Ovale during Transesophageal Echocardiograph.

The Valsalva maneuver (VM) is the most sensitive auxiliary method for the detection of patent foramen ovale (PFO), but it is difficult to assess whether the maneuver is adequately performed during transesophageal echocardiography (TEE). In this study, we tried to use aortic root downward movement as a novel method for judging whether VM was adequate or not, and to evaluate whether this novel method can increase the sensitivity of detecting PFO. A total of 224 patients with clinically suspected PFO were enrolled in this study. These patients were injected with activated normal saline to detect the right-to-left shunt (RLS), in the following three conditions: contrast-enhanced transthoracic echocardiography under adequate VM (AVM cTTE), contrast-enhanced TEE under non-adequate VM (non-AVM cTEE), and cTEE under adequate VM (AVM cTEE). A novel method in which the aorta root moves downward (movement range ≥16 mm) in the cTEE judged whether AVM was performed. The PFO detection rate and sensitivity of AVM cTEE were better than that of non-AVM cTEE (detection rate: 108 PFOs [48.2%] vs. 86 PFOs [38.4%], p = 0.036; sensitivity: 100% vs. 79.6%). Among AVM cTTE, non-AVM cTEE, and AVM cTEE, the RLS grade evaluation results were inconsistent, with significant differences (p < 0.05). Non-AVM cTEE had RLS underestimation or false negatives. Compared with non-AVM cTEE, AVM cTEE and AVM cTTE had better consistency in evaluating PFO RLS (kappa value = 0.675). Aortic root downward movement could be used as a novel method for judging the effectiveness of VM, which is critical for the detection of PFO in cTEE. Concerning effectiveness and convenience, this method should be promoted during the clinical detection of PFO.

CT Appearance of Pulmonary Arteriovenous Malformations and Mimics.

A pulmonary arteriovenous malformation (PAVM) is a fistulous connection between a pulmonary artery and a pulmonary vein that bypasses the normal pulmonary capillary bed resulting in a right-to-left shunt. Because of the potential for paradoxical emboli, PAVMs are treated when their feeding arteries exceed 3 mm or patients are symptomatic. PAVMs are often encountered in patients with suspected hereditary hemorrhagic telangiectasia (HHT). Sporadic cases are uncommon. The radiologist may be called on to diagnose a PAVM after positive transthoracic contrast-enhanced echocardiography in a patient with suspected HHT to direct patient management and avoid potential complications. The radiologist may also be required to evaluate a potential PAVM detected at CT performed for other reasons. Through the authors' experiences at an HHT Center of Excellence in an area endemic with histoplasmosis, the authors have gained a unique perspective on the diagnosis of PAVMs and differentiation of PAVMs from their mimics. Understanding the CT appearance of PAVMs limits misdiagnosis, directs appropriate treatment, and allows subsequent family screening for HHT (and avoidance of unnecessary screening when a PAVM mimic is encountered). Both vascular and nonvascular pulmonary lesions can mimic PAVMs. Vascular mimics include fibrosing mediastinitis, venovenous collaterals, arterial collaterals, pulmonary artery pseudoaneurysms, hepatopulmonary vessels, Sheehan vessels, meandering pulmonary veins, and pulmonary vein varices. Nonvascular mimics include granulomas, nodules, mucoceles, bronchoceles, ground-glass opacities, and atelectasis. The authors review the CT technique for evaluating PAVMs and the appearance of PAVMs and their mimics. ©RSNA, 2022.

Impact of hepatopulmonary syndrome in liver transplantation candidates and the role of angiogenesis.

Hepatopulmonary syndrome affects 10-30% of patients with cirrhosis and portal hypertension. We evaluated the serum angiogenic profile of hepatopulmonary syndrome and assessed the clinical impact of hepatopulmonary syndrome in patients evaluated for liver transplantation. The Pulmonary Vascular Complications of Liver Disease 2 study was a multicentre, prospective cohort study of adults undergoing their first liver transplantation evaluation. Hepatopulmonary syndrome was defined as an alveolar-arterial oxygen gradient ≥15 mmHg (≥20 mmHg if age >64 years), positive contrast-enhanced transthoracic echocardiography and absence of lung disease. We included 85 patients with hepatopulmonary syndrome and 146 patients without hepatopulmonary syndrome. Patients with hepatopulmonary syndrome had more complications of portal hypertension and slightly higher Model for End-Stage Liver Disease-Na score compared to those without hepatopulmonary syndrome (median (interquartile range) 15 (12-19) versus 14 (10-17), p=0.006). Hepatopulmonary syndrome patients had significantly lower 6-min walk distance and worse functional class. Hepatopulmonary syndrome patients had higher circulating angiopoietin 2, Tie2, tenascin C, tyrosine protein kinase Kit (c-Kit), vascular cell adhesion molecule 1 and von Willebrand factor levels, and lower E-selectin levels. Patients with hepatopulmonary syndrome had an increased risk of death (hazard ratio 1.80, 95% CI 1.03-3.16, p=0.04), which persisted despite adjustment for covariates (hazard ratio 1.79, 95% CI 1.02-3.15, p=0.04). This association did not vary based on levels of oxygenation, reflecting the severity of hepatopulmonary syndrome. Hepatopulmonary syndrome was associated with a profile of abnormal systemic angiogenesis, worse exercise and functional capacity, and an overall increased risk of death.

Diagnosis, significance, and management of ventricular thrombi in patients referred for VT ablation.

In patients with structural heart disease presenting with ventricular tachycardia (VT), detection of ventricular thrombi and subsequent management can be challenging. This study aimed to assess the value of multimodality imaging with cardiac magnetic resonance imaging (CMR), contrast-enhanced transthoracic echocardiography (TTE), and computed tomography (CT) for thrombus detection as well as a management algorithm geared towards anticoagulation and deferred ablation for patients referred for VT ablation. A total of 154 consecutive patients referred for VT ablation underwent preprocedural multimodality imaging with CMR, CT, and TTE. In 9 patients (6%) a new ventricular thrombus was detected and anticoagulation was initiated. Thrombi were detected by CMR in nine patients, by CT in seven patients, and by TTE in two patients. Five patients eventually underwent endocardial VT ablation procedures 6.0 ± 2.0 months after initiation of anticoagulation with one patient also requiring an epicardial approach. Two patients died while on anticoagulation, unrelated to ventricular arrhythmia. Four of five patients were rendered non-inducible and no testing was performed in 1/5 patients. Areas containing left ventricular thrombi were non-excitable with pacing. Six of thirty-two inducible VTs were mapped in close vicinity of ventricular thrombi. No clinical embolic events occurred during the ablation procedures. Ventricular thrombus was detected in 6% of consecutive patients with structural heart disease undergoing VT ablation. CMR was the most sensitive modality, while contrast-enhanced TTE failed to detect the majority of thrombi. Anticoagulation followed by ablation can be safely and successfully performed in patients with ventricular thrombi.

Pure SARS-CoV-2 related AVDS (Acute Vascular Distress Syndrome)

BackgroundSARS-CoV-2 virus which targets the pulmonary vasculature is supposed to induce an intrapulmonary right to left shunt with an increased pulmonary blood flow. Such vascular injury is difficult to observe because it is hidden by the concomitant lung injury. We report here what may be, to the best of our knowledge, the first case of a pure Covid-19 related Acute Vascular Distress Syndrome (AVDS).Case presentationA 43-year-old physician, tested positive for Covid-19, was addressed to the emergency unit for severe dyspnoea and dizziness. Explorations were non informative with only a doubt regarding a sub-segmental pulmonary embolism (no ground-glass lesions or consolidations related to Covid-19 disease). Dyspnoea persisted despite anticoagulation therapy and normal pulmonary function tests. Contrast-enhanced transthoracic echocardiography was performed which revealed a moderate late right-to-left shunt.ConclusionsThis case report highlights the crucial importance of the vascular component of the viral disease. The intrapulmonary shunt induced by Covid-19 which remains unrecognized because generally hidden by the concomitant lung injury, can persist for a long time. Contrast-enhanced transthoracic echocardiography is the most appropriate test to propose in case of persistent dyspnoea in Covid-19 patients.

Cardiovascular disorders in patients with congenital portosystemic shunts: 23 years of experience in a tertiary referral centre

Congenital portosystemic shunts are rare vascular malformations that may have an impact on the heart-lung system. Associated congenital and/or acquired heart diseases are poorly reported. To analyse cardiovascular disorders within a large congenital portosystemic shunt population, and develop a diagnostic strategy. Among the 168 consecutive fetuses and children referred for congenital portosystemic shunt (1996-2019), patients presenting with at least one cardiovascular disorder, including congenital heart disease, heart failure, portopulmonary hypertension and/or hepatopulmonary syndrome, were reviewed retrospectively. Cardiovascular disorders were detected using echocardiography and one or more of the following: right-sided heart catheterization; contrast-enhanced transthoracic echocardiography; or lung perfusion radionuclide scan. Overall, 46/168 patients with a congenital portosystemic shunt (27.4%) had one or more clinically significant cardiovascular disorders. Congenital heart disease was present in 28 patients, including six with left heterotaxy. Heart failure was present in six fetuses and 21 neonates (eight without congenital heart disease, and 13 with congenital heart disease). In neonates without congenital heart disease, heart function recovered by the age of 3years. Portopulmonary hypertension was identified in 11 patients (mean age at diagnosis: 9years); it was fatal in one patient, and remained stable in five of six patients after congenital portosystemic shunt closure. In six patients, hepatopulmonary syndrome presented as hypoxia (mean age at diagnosis: 5.3years), which reversed after congenital portosystemic shunt closure. Evaluation and monitoring of the cardiopulmonary status of patients with a congenital portosystemic shunt is mandatory to detect and prevent cardiovascular complications. Furthermore, congenital portosystemic shunts must be sought in patients with unexplained cardiovascular disorders, especially when malformations are present.

Diagnosis of Hepatopulmonary Syndrome in a Large Integrated Health System

Data on the accuracy of the diagnosis of hepatopulmonary syndrome (HPS) in cirrhosis is limited. We evaluated the clinical characteristics of patients with International Classification of Diseases (ICD) codes for hepatopulmonary syndrome (HPS) in a large integrated health system. A retrospective review of encounters was performed of all patients with ICD-9-CM and/or ICD-10-CM diagnosis of cirrhosis and HPS from 2014-2019 in a multi-state health system. Demographics and cardiopulmonary testing closest to the time of HPS diagnosis were recorded. HPS was defined using standard criteria. A total of 42,749 unique individuals with cirrhosis were identified. An ICD diagnosis of HPS was found in 194 patients (0.45%), of which 182 had clinically confirmed cirrhosis. 143 (78.5%) underwent contrast-enhanced transthoracic echocardiography, and 98 (54%) had delayed shunting. Among them, 61 patients had a documented arterial blood gas, with 53 showing abnormal oxygenation (A-a gradient of >15 mm Hg). 12 were excluded due to significant pulmonary function test abnormalities and abnormal oxygenation from other cardiopulmonary diseases. Ultimately, 41 (22.5%) fulfilled the criteria for HPS. When stratifying those with an ICD code diagnosis of HPS into HPS, no HPS and indeterminate HPS groups, based on standard diagnostic criteria for HPS, we found that the confirmed HPS patients had similar complications except for less portopulmonary hypertension, worse gas exchange, less cardiopulmonary disease and were more often diagnosed in transplant centers. The diagnosis of HPS by ICD code is made in an extremely small subset of a sizeable cirrhotic cohort. When made, only a minority of these patients meet diagnostic criteria. Our findings highlight the need for improved education and more effective screening algorithms.

CT Angiography Findings of Pulmonary Arteriovenous Malformations in Children and Young Adults With Hereditary Hemorrhagic Telangiectasia.

OBJECTIVE. The purpose of this study was to evaluate the CT angiography (CTA) findings of pulmonary arteriovenous malformation (PAVMs) in patients with hereditary hemorrhagic telangiectasia and to correlate these findings with those of graded contrast-enhanced transthoracic echocardiography (CE-TTE). MATERIALS AND METHODS. A retrospective review was conducted of PAVMs visualized at CTA of patients with abnormal CE-TTE findings (3-point scale). Location, distribution, size, number, volume, grade, and relative attenuation (attenuation of PAVM divided by attenuation of aorta) of PAVMs were recorded. PAVMs were graded as follows on conventional and maximum-intensity-projection (MIP) images: 0, nodule, unlikely PAVM; 1, ground-glass opacity (GGO); 2, GGO with increased vascular network; 3, GGO or nodule with single vessel; 4, GGO or nodule with two or more vessels; 5, GGO or nodule with afferent and larger efferent vessels; 6, mature arteriovenous malformation. Correlation between PAVM grade and relative attenuation and between CTA variables and CE-TTE grades was assessed. RESULTS. Forty patients (median age, 14.9 years; range, 0.6-27.9 years) had 117 PAVMs at CTA: 107 peripheral, eight central, and two both peripheral and central. None of the PAVMs was diffuse. Median size and volume were 0.4 cm (range, 0.1-4.4 cm) and 0.031 mL (range, 0.0009-10.019 mL). At CTA, seven PAVMs were grade 1, five grade 2, 28 grade 3, 62 grade 4, two grade 5, and 13 grade 6. MIP images showed 39 of 117 PAVMs were higher grade. Statistically significant correlation was found between relative attenuation and PAVM grade (p < 0.001, r = 0.58) in 40 patients and between all CTA variables and CE-TTE (p < 0.05, strongest correlation with highest grades [p < 0.0001, r = 0.81]) in 32 patients. CONCLUSION. In children and young adults with hereditary hemorrhagic telangiectasia, grade 4 PAVMs were most common. Higher-grade PAVMs more often have right-to-left shunts.

Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke: single center experience in 132 consecutive patients

BackgroundPercutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE.MethodsWe reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12–68 years old) and 65.42 ± 9.70 kg (40–95 kg), respectively. All patients only received aspirin (3–5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure.ResultsAll (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients.ConclusionTEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.

Experimental study of right ventricular structure and function by contrast-enhanced transthoracic echocardiography

Objective To investigate the accuracy and repeatability of contrast-enhanced transthoracic echocardiography for measurements of right ventricular structure and function. Methods The apical four-chamber views and the three-dimensional full-volume images of the right heart were collected from 12 beagles with unenhanced and contrast-enhanced transthoracic echocardiography. The intimal display rate of the right ventricular segments, right ventricular end diastolic longitudinal dimension (RVLD), right ventricular end diastolic area (RVEDA), right ventricular end systolic area (RVESA) and right ventricular fractional area change (RVFAC) were evaluated respectively with two-dimensional unenhanced and contrast-enhanced echocardiography. Right ventricular three-dimensional full-volume images were processed and analyzed by TomTec software, and right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV) and right ventricular ejection fraction (RVEF) were measured respectively with three-dimensional unenhanced and contrast-enhanced echocardiography. The measurements of pathological specimen were taken as the gold standard, the accuracies of measuring RVEDVand RVLD by different methods were evaluated. All indexes were measured repeatedly by the same observer and different observers to assess the intraobserver and interobserver reproducibilities of different methods. Results ①The intimal display rate of the right ventricular segments was higher with contrast-enhanced echocardiography than that with unenhanced echocardiography (P<0.05). ②The measurements of RVEDV by three-dimensional contrast-enhanced echocardiography correlated well with the measurements by anatomical specimens. And the correlation was higher (0.916 vs 0.843), the consistency was better than that by unenhanced echocardiography. The measurements of RVLD by two-dimensional contrast-enhanced echocardiography correlated well with the measurements by anatomical specimens. And the correlation was higher (0.928 vs 0.850), the consistency was better than that by unenhanced echocardiography. ③For inter- and intraobservers reproducibilities, the interclass correlation coefficients of RVLD, RVEDV, RVESV, RVEF, RVEDA, RVESA, RVFAC with contrast-enhanced echocardiography were higher and 95% confidence interval ranges were smaller than those with unenhanced echocardiography. Conclusions Contrast-enhanced transthoracic echocardiography can improve the accuracy and repeatability for measurements of right ventricular structure and function, providing a new evaluation method for patients with poor image quality of the right ventricle in clinical practice. Key words: Echocardiography; Ventricular function, right; Ultrasound enhancing agents

P3721Clinical and echocardiographic outcomes after treatment of patent foramen ovale with two transcatheter occlusion devices: mononcenter observational study

Abstract Background Percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) is strongly recommended in the current guidelines. Most available evidence has been obtained from randomized studies in which Amplatzer PFO occluder device or Groe occluder device were implanted. Several occluder devices are used off-label for percutaneous treatment of PFO. Rate of recurrent CS and rate of residual shunting after percutaneously occlusion of PFO varies between different occlusion devices. To date, there are no randomized clinical studies that compare the effectivity and safety of several devices in patients with CS. Aim The aim of this study was to compare rate of residual shunting and recurrent CS after percutaneus treatment of PFO with the most common used PFO occluder devises. Methods This was a retrospective, non-randomized, monocenter study. Between 2008 and 2014, all patients with CS or transient ischemic attack (TIA) treated with transcatheter occlusion of PFO with Amplatzer PFO occlusion device or Occlutech occlusion device were included. Patients were followed up at 1 and 6 months with contrast-enhanced transesophageal echocardiography (TEE), and at 3 months with contrast-enhanced transthoracic echocardiography. Primary endpoint was residual shunting at 6 months. Secondary endpoint was recurrent CS or TIA at 6 months after the procedure. Results 220 consecutive patients (57±12 year, 131 men) were treated with Amplanz PFO occlusion device (140 patients) or Occlutech PFO occlusion device (80 patients) after CS or TIA. Procedural success was 100% in both groups. Residual shunting was observed directly after the procedure in 26 patients in the Amplatzer group and 22 patients in the Occlutech group (19% and 27%, respectively; p=0.003), at 1 months follow (15% and 25%, respectively; p=0.064) and at 6 months (9% and 16%, respectively; p=0.024). There was no significant difference between both groups according recurrent CS (0.7% and 0%, respectively; p=0.449). At 6 months follow up atrial fibrillation was detected in 2 patients from Amplatzer group and 5 patients from Occlutech group (1.4% and 6.0%, respectively; p=0.050). Death, aortic erosion and pericardial effusion was not observed in both groups. Clinical and echocardiographic outcome Variable Amplatzer occluder device (N=140) Occlutech occluder device (N=80) p-value Clinical outcome at 6 months follow up Death, n (%) 0 (0%) 0 (0%) 1.000 Stroke, n (%) 1 (1%) 0 (0%) 0.449 Transient ischemic attack, n (%) 0 (0%) 0 (0%) 1.000 Atrial fibrillation, n (%) 2 (1.4%) 5 (6%) 0.050 Aortic erosion, n (%) 0 (0%) 0 (0%) 1.000 Pericardial effusion, n (%) 0 (0%) 0 (0%) 1.000 Echocardiographic Outcome at 6 months follow up Residual shunting after Implantation directly, n (%) 26 (19%) 22 (27%) 0.003 Residual shunting at one month, n (%) 21 (15%) 20 (25%) 0.064 Residual shunting at 6 months, n (%) 13 (9%) 16 (20%) 0.024 Conclusion Percutaneous treatment of PFO after CS or TIA with Amplatzer PFO occluder device was associated with lower rate of residual shunting and lower rate of atrial fibrillation at 6 months follow up, whereas rate of recurrent CS and TIA was comparable between both groups.

Prevalence and characteristics of hepatopulmonary syndrome in children with cirrhosis in southern Brazil.

Hepatopulmonary syndrome (HPS) is defined as a triad characterized by arterial deoxygenation, intrapulmonary vascular dilatations (IPVDs), and liver disorder. The aims of this study were to assess the prevalence of HPS in children with cirrhosis, the clinical characteristics of patients with HPS, and the tests used for the diagnosis of IPVD. This was a prospective, cross-sectional study of 40 children with cirrhosis (median age: 44 months). Investigations of HPS included arterial blood gas analysis, contrast-enhanced transthoracic echocardiography (CE-TTE), and perfusion lung scanning using technetium-99m-labeled macroaggregated albumin (Tc-MMA). Patients' clinical characteristics (age, etiology of cirrhosis, and severity of hepatopathy) were assessed. HPS was defined as liver disease; alveolar-arterial oxygen gradient of at least 15 mmHg and/or partial pressure of arterial oxygen less than 80 mmHg; and detection of IPVD by CE-TTE or Tc-MMA scanning. Statistical significance was indicated by a P value less than 0.05. The prevalence of HPS was 42.5% (17/40). Eight patients had moderate HPS (47%) and two patients had severe HPS (12%). In bivariate analysis, biliary atresia (P=0.033) and median age (10 months; P=0.005) were associated with HPS. In multivariate analysis, only age remained statistically significant (prevalence ratio=0.99; 95% confidence interval=0.98-0.99; P=0.010). Sixteen patients with HPS had IPVD detected by CE-TTE (94.1%) and six patients had IPVD detected by Tc-MMA scanning (35.3%), with no significant agreement between these methods (κ=-0.12; P=0.163). HPS is a common complication of cirrhosis in children. A combination of clinical and imaging criteria should be used to diagnose HPS.

Sensitivity of contrast-enhanced transthoracic echocardiography for the detection of residual shunts after percutaneous patent foramen ovale closure.

The objective of this study is to investigate the sensitivity of contrast-enhanced transthoracic echocardiography (c-TTE) versus transesophageal echocardiography (TEE) to detect a residual right-to-left shunt (RLS) following a transcatheter patent foramen ovale (PFO) closure.A self-controlled study was conducted in a tertiary referral hospital. 57 patients with PFO who had experienced migraines underwent percutaneous PFO closure. c-TTE, TEE, and contrast-enhanced transcranial Doppler (c-TCD) at resting and Valsalva maneuver were performed during the 3-month follow-up after the closure.The closure devices were successfully implanted in all patients without complications. Three months after closure, TEE did not detect residual Valsalva shunts in any of the 57 patients; residual valsalva shunts were found via c-TTE in 15 of the 57 patients and were also observed via c-TCD. When c-TTE and/or c-TCD were used, the rate of residual RLSs detected in patients who underwent PFO closure was 26.32%, which was significantly different than the rate detected using TEE (P < .05)c-TTE and c-TCD showed equivalent sensitivity in evaluating transcatheter closure of a PFO. c-TTE could be a more cost-effective and reliable method to detect the residual shunt after PFO closure.

Influence of High-Velocity Blood Flow on Right-to-Left Shunt in Patients with Patent Foramen Ovale during the Valsalva Maneuver

In this study, we investigated the changes in the right-to-left shunt (RLS) of the patent foramen ovale (PFO) at different phases of the Valsalva maneuver and analyzed the possible mechanisms. The study population consisted of 57 patients with symptoms highly suggestive of a PFO. These patients had been diagnosed with apsychia, migraine with aura, cerebral infarction, transient ischemic attack (TIA), and cerebral ischemia with unknown cause. Routine echocardiography was performed in all patients to rule out a cardiac malformation. Contrast-transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) were used to visualize and quantify the RLS. The standard apical four chamber view was used to observe the changes of E peak, A peak, and velocity-time integral (VTI) ratio of tricuspid blood flow during the strain phase and release phase of the Valsalva maneuver. Paired t-test was used to compare E peak, A peak, and VTI ratio of tricuspid blood flow during the different phases. The right-to-left shunt across the PFO (PFO-RLS) was graded in the two phases and compared by Kruskal-Wallis test. Compared with the strain phase of the Valsalva maneuver, the parameters of E, A, and VTI in diastolic period in patients with PFO-RLS at the release phase were significantly increased [54.30 ± 13.65 cm/s vs 100.35 ± 21.11 cm/s, 42.21 ± 12.32 cm/s vs 57.30 ± 18.88 cm/s, 10.34 ± 3.27 cm/s vs 19.58 ± 4.56 cm/s, respectively], and the difference was statistically significant. The positive consequence of PFO-RLS, as diagnosed by c-TTE with the Valsalva maneuver at the release phase of the Valsalva maneuver, was significantly higher than that at the strain phase of the Valsalva maneuver. At the beginning of release phase of the Valsalva maneuver, decreased intrathoracic pressure led to increased venous backflow into the right atrium. Thus, high-velocity blood flow rapidly pushed the PFO open, which resulted in a significant increase in the PFO-RLS. Therefore, the increase of the PFO-RLS during the Valsalva maneuver is caused by the impact of high-velocity blood flow the PFO.

Hepatopulmonary syndrome

Hepatopulmonary syndrome