Diagnosis Of Patent Foramen Ovale Research Articles

Setting Up a Multidisciplinary Program for Management of Patent Foramen Ovale‐Mediated Syndromes

These days no codified multidisciplinary protocol has been reported to manage all the different patent foramen ovale (PFO)-mediated syndromes. We sought to propose a multidisciplinary program of diagnosis, treatment, and follow-up of all PFO-mediated syndromes based on an in-hospital multidisciplinary task force and to review the activities during the first year. From September 2004, we organized in our hospital, a 600-bed tertiary hospital, a management program for PFO-mediated syndromes based on a task force composed of cardiologists, neurologists, and internists. Different levels of protocols were created in order to cover diagnosis, treatment, and follow-up of PFO-mediated syndromes. We reviewed the activity of our program in the first year up to September 2005. Thirty-five patients (23 female, mean age 65 +/- 24 years) were evaluated for suspected PFO-mediated syndromes: 20 for cryptogenic stroke, 2 for peripheral and coronary embolisms, 3 for platypnea-orthodeoxia, 9 for emicrania with aura, and 1 with hypoxiemia during neurosurgical intervention in the posterior cranial fossa. Diagnosis of PFO was confirmed in 25 patients. According to the multidisciplinary protocols, 15 patients failed to meet the requirements for transcatheter closure and were left in medical therapy whereas 11 patients (7 patients with PFO, 2 with multiperforated ASD, and 2 with a secundum ASD) underwent transcatheter closure. After a mean follow-up of 10.8 +/- 4.9 months, no recurrent PFO syndromes were noted in patients treated with devices. The first year of our multidisciplinary program allowed a reasonable and potentially successful approach for correctly identifying patients with PFO-mediated syndromes until randomized studies are completed.

Diagnosis of patent foramen ovale by transnasal transoesophageal echocardiography

Campolongo, G.; Chiavari, P. A.; Mollo, P.; Placanica, A.; Tritapepe, L. Author Information

Response to Letter by Magrini et al

Response: Magrini and associates argue that particular working conditions entailing frequent Valsalva maneuvers may represent a risk factor for the development of migraine in subjects with right-to-left shunt. This is a clever and intriguing observation that, besides being biologically plausible, raises the hypothesis, never considered so far, that the beneficial effect of atrial septal repair on migraine in stroke patients might result not so much from the correction of the shunt but mainly from changes in lifestyle that reduce the number or the strength of Valsalva strains. This variable will have to be taken into account in future studies. However, …

Paradoxical embolism with a patent foramen ovale and atrial septal aneurysm

Patent foramen ovale (PFO) and atrial septal aneurysm have been cited as potential risk factors for cryptogenic stroke. We present two cases which we propose to directly illustrate paradoxical embolisation as a mechanism of cerebrovascular accident. The diagnosis of PFO is discussed and the literature reviewed.

A large Eustachian valve is a confounder of contrast but not of color Doppler transesophageal echocardiography in detecting a right-to-left shunt across a patent foramen ovale

Background Transesophageal contrast echocardiography (cTEE) is considered to be the method of choice for diagnosing patent foramen ovale (PFO), but its diagnostic accuracy compared with color Doppler guided TEE in the presence of an Eustachian valve (EV) has not been evaluated. The main aim of this study was to assess the diagnostic accuracy for PFO diagnosis of color Doppler TEE at low pulse repetition frequency. Methods We ascertained the presence of PFO and EV using cTEE and transthoracic contrast echocardiography (cTTE) in 292 consecutive patients (age 42 ± 12 years) with cryptogenic stroke. A diagnosis of PFO was based on the observation of right-to-left shunting of contrast bubbles or by color Doppler with pulse repetition frequency of 20–30 cm/s. An EV with a diameter of > 1.5 cm in the bicaval view was considered large. Results Overall 204 patients (70%) had evidence of a right-to-left shunt by either contrast echo method. Shunting was demonstrated more frequently by color Doppler than by cTEE, either spontaneously (133 vs. 92; p = 0.01) or during provocative maneuvers (166 vs. 184; p = 0.01). The sensitivity of color Doppler was significantly higher than that of cTEE (90% vs. 81%; p = 0.01). A large EV was found in 37 patients, 31 (84%) of whom had a PFO. The presence of a large EV did not significantly influence the sensitivity of color Doppler for detecting shunting through a PFO, but the sensitivity of cTTE and cTEE was significantly reduced (from 88% to 42%, p < 0.001). Conclusions Color Doppler TEE is more accurate than traditional cTEE for PFO diagnosis and is not negatively influenced by the presence of an EV, provided that a low pulse repetition frequency is used.

PFO management: Neurologists vs cardiologists

Patent foramen ovale (PFO) is associated with stroke, particularly in younger patients without another identifiable etiology. Therapeutic options available include antiplatelet medications, warfarin, surgical closure, or percutaneous closure, yet there have been no adequate head-to-head trials to guide management decisions.1 We conducted a survey of cardiologists and neurologists to determine current management strategies for patients with PFO. In April 2004, a 17-item questionnaire (see the survey on the Neurology Web site at www.neurology.org) was sent to all neurologists and cardiologists participating as local principal investigators in the CLOSURE-I PFO closure trial (NMT medical), a study comparing PFO closure to medical management. The survey addressed practice patterns prior to participation in the trial focusing on PFO diagnosis, high risk characteristics, treatment choices, and alternative indications for PFO closure. Results were analyzed in aggregate and by specialty. Neurologists and cardiologists were compared using t tests or χ2 tests as appropriate. A total of 108 neurologists and 129 cardiologists were surveyed. After two mailings, we received a response from 39% (44% of neurologists, 36% of …

Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients

The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt. One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests. This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.

Transcranial power M-mode Doppler ultrasound for diagnosis of patent foramen ovale

Patent foramen ovale (PFO) is a right-to-left shunt (RLS) which communicates blood from the right to left atrium of the heart. PFO has been associated with stroke and, more recently, with migraine headache. Diagnosis of RLS can be accomplished effectively with transcranial power M-mode Doppler ultrasound (PMD). PMD is a modality which can be performed without the sedation required by the more invasive diagnostic technique using transesophageal echocardiography. PMD for this application consists of 2 MHz pulse Doppler ultrasound with placement of sample gates at 2 mm intervals along the single-transducer beam axis, and 8 kHz pulse repetition rate (PMD100M, Spencer Technologies). Doppler power versus depth is constructed every 4ms, using 33 sample gates. Bubble microemboli injected in the venous system and moving across a PFO present as high intensity tracks on a PMD image, as emboli transit from the heart to the brain and through the observed cerebral vasculature. Use of PMD in this context has been reported in the clinical literature [M. P. Spencer, M. A. Moehring, J. Jesurum et al, J. Neuroimaging 14, 342–349 (2004)]. This talk surveys the basic technical features of PMD for sensing PFO-related showers of bubble microemboli, and how these features provide clues to the severity of PFO.

Patent Foramen Ovale: The Missing Link between Deep Venous Thrombotic Disease and Embolic Stroke

El proyecto denominado «Compromiso por la calidad de las sociedades científicas» impulsado desde el año 2013 por el Ministerio de Sanidad, Servicios Sociales e Igualdad tiene como objetivo disminuir las intervenciones sanitarias innecesarias que no han demostrado eficacia, tienen escasa o dudosa efectividad o no son eficientes. El objetivo de este trabajo es elaborar las recomendaciones de «qué no hacer» seleccionadas para el tratamiento de los pacientes críticos. Se designó un panel de expertos de los 13 grupos de trabajo (GT) de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC), elegido por su experiencia clínica o científica para la realización de las recomendaciones. Se analizó la literatura publicada entre los años 2000 y 2017 sobre diferentes cuestiones asociadas a los pacientes críticos. En reuniones de cada GT, los expertos debatieron las propuestas y sintetizaron las conclusiones, que fueron finalmente aprobadas por los GT después de un amplio proceso de revisión interna, realizado durante el primer semestre de 2017. Finalmente, se elaboraron un total de 65 recomendaciones, 5 por cada uno de los 13 GT. Estas recomendaciones se basan en la opinión de expertos y en el conocimiento científico, y pretenden reducir aquellos tratamientos o procedimientos que no aporten valor al proceso asistencial, evitar la exposición de los pacientes críticos a potenciales riesgos y mejorar la adecuación de los recursos sanitarios.The project “Commitment to Quality of Scientific Societies”, promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the “do not do” recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.

Diagnosis of Patent Foramen Ovale Using Contrast-Enhanced Dynamic MRI: A Pilot Study

The aim of this study was to evaluate the feasibility of dynamic contrast-enhanced MRI for detection of patent foramen ovale. Fifteen patients with and five patients without patent foramen ovale underwent transesophageal echocardiography and MRI, which were performed during the Valsalva maneuver. Grading results (grade 0, no patent foramen ovale and grades 1-3, minor to major enhancement due to intracardiac shunt) were assessed visually. Signal-intensity curves in the left atrium and in a pulmonary vein served to underline the diagnosis. The diagnoses of all patients with (15/15) and without patent foramen ovale (5/5) were correct compared with the findings of the reference transesophageal echocardiography. In 12 (60%) of 20 patients, the grading scores were identical, and in four (20%) of 20 patients, the scores differed by more than one grade. Overall, there was a good correlation of grading scores (r = 0.7, p < 0.05). Using signal-intensity curves, we found that the patients with patent foramen ovale showed an additional signal peak in the left atrium before the enhancement of the pulmonary vein because of an intracardiac shunt. In three of 15 patients with patent foramen ovale, an atrial septal aneurysm was correctly diagnosed. This pilot study shows that MRI is a new noninvasive method to detect patent foramen ovale and atrial septal aneurysm. A grading is possible but warrants further investigation regarding its predictive value and impact on treatment strategies.

Diagnosis of patent foramen ovale with multiplane transesophageal echocardiography in adult cardiac surgical patients

Objective: To evaluate multiplane transesophageal echocardiography (TEE) for detection of patent foramen ovale (PFO) and to compare multiplane TEE with visual inspection (VI) for PFO detection. Design: A prospective observational study. Setting: University hospital (single institution). Participants: Patients presenting for cardiac surgery requiring TEE. Interventions: Multiplane TEE including 2 atrial views with color-flow Doppler (CFD) and contrast echocardiography (CE) with a provocative respiratory maneuver (PRM) and comparison of multiplane TEE and VI with respect to PFO detection. Measurements and Main Results: The cohort size was 187. PFO prevalence was 27.3%. CFD with serial decrease of the Nyquist limit detected 51% of all PFO: 41.2% in the bicaval view alone, 27.5% in the 4-chamber view alone, and 9.8% in both views. CE detected 78.4% of all PFO: 72.5% with PRM, 45.1% with no PRM, and 27.4% with/without PRM. PFO detection by multiplane TEE and visual inspection were correlated in 41 subjects. TEE diagnosed 11 PFO (26.8% prevalence, 3 missed by VI). VI diagnosed 12 PFO (29.3% prevalence, 4 missed by TEE). Conclusions: Multiplane TEE is a gold standard for detection of PFO. Despite advances in TEE technology, 2-dimensional imaging does not detect all PFO. To maximize PFO detection, multiple TEE modalities are required in multiple views, despite a low Nyquist limit for CFD or a PRM for CE. Even though multiplane TEE is equivalent to VI for PFO detection, the discrepancy rate may be an important consideration in the individual case.

Power m-mode transcranial Doppler for diagnosis of patent foramen ovale and assessing transcatheter closure.

Transcatheter closure of patent foramen ovale (PFO) can benefit from a less invasive diagnostic method than transesophageal echocardiography (TEE). Thirty-three gate power m-mode transcranial Doppler (pmTCD) was evaluated for its accuracy in diagnosis of PFO and utility in evaluating residual intracardiac right-to-left shunt (RLS) following transcatheter closure. The sensitivity of pmTCD and single-gate TCD (sgTCD) to detect contrast bubble emboli through RLS was compared during transcatheter PFO closure. During 100 preclosure diagnostic evaluations and in 81 postclosure assessments, embolic tracks on pmTCD were counted following intravenous contrast injections and were graded using a 6-level logarithmic scale. The accuracy of TEE and pmTCD was separately compared to PFO anatomical findings during transcatheter closures. There were significantly more microemboli detectable on pmTCD (322 +/- 166; 95% confidence interval [CI], 388-257) than on sgTCD (186 +/- 109; 95% CI, 229-143; P < .001). McNemar change tests suggest that the diagnostic capabilities of pmTCD and TEE for detecting PFO are comparable and correspond to the anatomical findings determined during cardiac catheterization (P = .69 and .45, respectively). During 6-month postclosure evaluation (mean = 185 days), 66% of the patients demonstrated successful closure without significant RLS (ie, grades 0, I, or II), and 34% were found to have incomplete closure with significant RLS (ie, grades III, IV, or V). pmTCD provides greater sensitivity to contrast bubble emboli than does sgTCD. Among candidates for transcatheter closure, pmTCD provides an improved noninvasive method for diagnosing PFO and evaluating transcatheter closure.

Power M‐Mode Transcranial Doppler for Diagnosis of Patent Foramen Ovale and Assessing Transcatheter Closure

ABSTRACT Background and Purpose. Transcatheter closure of patent fora men ovale (PFO) can benefit from a less invasive diagnostic method than transesophageal echocardiography (TEE). Thirty‐three gate power m‐mode transcranial Doppler (pmTCD) was evaluated for its accuracy in diagnosis of PFO and utility in evalu ating residual intracardiac right‐to‐left shunt (RLS) following transcatheter closure. Methods. The sensitivity of pmTCD and single‐gate TCD (sgTCD) to detect contrast bubble emboli through RLS was compared during transcatheter PFO closure. During 100 preclosure diagnostic evaluations and in 81 postclosure assessments, embolic tracks on pmTCD were counted following intravenous contrast injections and were graded using a 6‐level logarithmic scale. The accuracy of TEE and pmTCD was separately compared to PFO anatomical find ings during transcatheter closures. Results. There were signifi cantly more microemboli detectable on pmTCD (322 ± 166; 95% confidence interval [CI], 388–257) than on sgTCD (186 ± 109; 95% CI, 229‐143; P &lt; .001). McNemar change tests sug gest that the diagnostic capabilities of pmTCD and TEE for detecting PFO are comparable and correspond to the anatomi cal findings determined during cardiac catheterization (P= .69 and .45, respectively). During 6‐month postclosure evaluation (mean = 185 days), 66% of the patients demonstrated success ful closure without significant RLS (ie, grades 0, I, or II), and 34% were found to have incomplete closure with significant RLS (ie, grades III, IV, or V). Conclusions. pmTCD provides greater sensitivity to contrast bubble emboli than does sgTCD. Among candidates for transcatheter closure, pmTCD provides an improved noninvasive method for diagnosing PFO and evaluating transcatheter closure.

CASE 1—2004 Intraoperative diagnosis of a patent foramen ovale in a patient undergoing coronary artery bypass graft surgery

Patent foramen ovale (PFO) is found in approximately one quarter of postmortem examinations. 1 Hagen P.T. Scholz D.G. Edwards W.D. Incidence and size of patent foramen ovale during first 10 decade of life An autopsy study of 965 normal hearts. Mayo Clin Proc. 1984; 59: 17-20 Abstract Full Text Full Text PDF PubMed Scopus (2039) Google Scholar Transesophageal echocardiography (TEE) is able to detect PFO with almost the same frequency in the clinical setting. 2 Schneider B. Zienkiewicz T. Jansen V. et al. Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings. Am J Cardiol. 1996; 77: 1202-1209 Abstract Full Text PDF PubMed Scopus (196) Google Scholar The intraoperative utilization of TEE presents a dilemma to clinicians if PFO is diagnosed at the time of coronary artery bypass graft (CABG) surgery. Acute alterations in preload and afterload, which often occur intraoperatively, make it more difficult to evaluate the clinical significance of a PFO. Also, patients are unconscious (general anesthesia) at the time of detection of the PFO and hence cannot participate in the decision to close or not to close the PFO. It is unclear whether closure of a PFO should be performed in this context, which would require opening of the right atrium for access and performing bicaval cannulation to establish total cardiopulmonary bypass (likely increasing risk for the patient). There has been a recent trend toward an increased use of the off-pump approach to CABG surgery. 3 Roy A. Stanbridge R.D. O’Regan D. et al. Progression to 100% off-pump coronary artery bypass with the Octopus 1 dual holder. Heart Surg Forum. 2001; 4: 174-178 PubMed Google Scholar The decision to close a PFO diagnosed intraoperatively in a patient scheduled for elective off-pump CABG requires a radical change in management; that is, from no cardiopulmonary bypass for off-pump CABG to initiation of total cardiopulmonary bypass. Currently, there are no clinical data available to guide clinicians presented with this scenario. The authors present a patient who was diagnosed with a PFO intraoperatively, underwent CABG surgery without closure of the PFO, and subsequently developed a possible postoperative paradoxical embolism.

The Positions of the Patients in the Diagnosis of Patent Foramen Ovale by Transcranial Doppler

Background and Purpose. There is no information about the optimal position of a patient for the performance of a transcranial Doppler (TCD) examination to detect patent foramen ovale (PFO). Such information is important to improving the sensitivity of the test in comparison to the gold standard of transesophageal echocardiography (TEE). Methods. Thirty-four patients with TEE-proved PFO were examined by contrast TCD. Examinations were done in both the sitting and supine positions in random order. Results. Eight hundred ninety-two microemboli were recorded. Patients'positions and the sequence of testing did not affect the number of microemboli detected. Yet for each individual, 1 of the 2 positions was more sensitive. Conclusions. To improve the sensitivity of TCD in the detection of PFO, it is recommended, in the case of a first negative test, to change the patient's position for a repeated TCD examination.

The Positions of the Patients in the Diagnosis of Patent Foramen Ovale by Transcranial Doppler

There is no information about the optimal position of a patient for the performance of a transcranial Doppler (TCD) examination to detect patent foramen ovale (PFO). Such information is important to improving the sensitivity of the test in comparison to the gold standard of transesophageal echocardiography (TEE). Thirty-four patients with TEE-proved PFO were examined by contrast TCD. Examinations were done in both the sitting and supine positions in random order. Eight hundred ninety-two microemboli were recorded. Patients' positions and the sequence of testing did not affect the number of microemboli detected. Yet for each individual, 1 of the 2 positions was more sensitive. To improve the sensitivity of TCD in the detection of PFO, it is recommended, in the case of a first negative test, to change the patient's position for a repeated TCD examination.

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Transcranial Doppler (TCD) ultrasound with the intravenous injection of agitated saline as contrast (cTCD) is an effective method for detecting right-to-left intracardiac and extracardiac shunt (RLS); however, the sensitivity of cTCD in the diagnosis of RLS remains slightly less than that of transesophageal echocardiography, even in patients with adequate transtemporal ultrasonic bone windows. The authors present a case with cTCD underestimating RLS because of jugular valve incompetence in a 42-year-old man presenting with an episode of transient aphasia. Three weeks after transcatheter closure of a patent foramen ovale associated with an atrial septal aneurysm, he experienced 2 episodes of amaurosis fugax. Following a negative 45-minute embolus detection study with power M-mode TCD, the patient underwent a cTCD study with monitoring of the left middle cerebral artery (MCA), the anterior cerebral artery, and the submandibular extracranial internal carotid artery. A single microbubble (MB) was detected in the left MCA in only 1 of 5 studies; the remaining runs all failed to detect an RLS. Significant MB reflux was noted in the left internal jugular vein because of jugular valve incompetence. The authors conclude that incompetence of the jugular vein valve can result in a false negative cTCD study for RLS detection.

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Importance of Jugular Valve Incompetence in Contrast Transcranial Doppler Ultrasonography for the Diagnosis of Patent Foramen Ovale

Patent Foramen Ovale in Pulmonary Medicine

Patent foramen ovale (PFO) is a common embryologic remnant that is usually clinically occult. Yet, a PFO may manifest clinically in two important ways, including serving as a conduit for emboli (bland, septic, or gas) and as a pathway for venous admixture or right-to-left shunt (as following pulmonary embolization or due to streaming of blood). The diagnosis of PFO is made by contrast-enhanced transesophageal echocardiography, usually using agitated saline injectate. Treatment involves closure of the PFO, which is indicated when clinical sequelae (e.g., paradoxic embolization and/or refractory hypoxemia due to right-to-left shunt) prompt correction. Options include surgical closure and deployment of a device from a catheter (e.g., a clam shelllike device that straddles the PFO).

Patent Foramen Ovale and Recurrent Stroke

Clinical management of patients with acute stroke and the approach used for secondary prevention depends upon clarification of pathogenesis. Although most strokes are a consequence of cerebrovascular disease, ≈15% to 20% of ischemic (nonhemorrhagic) strokes have been attributed to cardiogenic embolism.1 In practice, determination of the stroke mechanism is fraught with uncertainty, particularly when the possibility of thromboembolism emanating from atherosclerotic lesions in the aorta or cervical arteries is considered. When cardiogenic embolism is suspected, cardiac ultrasound is the principal method used to identify the potential source. The finding of left atrial enlargement has been shown to bear a significant relationship to the risk of stroke in a multivariate analysis of population-based data from the Framingham Heart Study2. The most frequent confounding variable is atrial fibrillation, occurring in >2 million patients in North America and in over half of all patients with cardiogenic embolism. Criteria for selection of patients with acute ischemic stroke for transesophageal echocardiography (TEE) to search for a potential cardiac source of embolism are controversial, particularly because cardiogenic embolism is often an uncertain diagnosis that is inferred merely on the basis of the finding of potential cardiac source. Even after extensive investigation, ≈40% of ischemic stroke patients have no clearly identifiable pathogenesis (cryptogenic stroke).3 In one study, 62% of patients younger than 60 years of age without an obvious source of cerebral infarction and 23% of those with arterial lesions had potential sources of cardiogenic embolism identified by TEE ( P =0.0007 for the difference).4 See p 2625 Among the cardiac anomalies detected by TEE that have been implicated as risk factors for stroke are patent foramen ovale (PFO) and atrial septal aneurysm (ASA).5,6⇓ The foramen ovale, a remnant of the fetal circulation, remains patent through adulthood in ≈1 in 4 …