Diagnosis Of Patent Foramen Ovale 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.

A Case of Forming Test for the Diagnosis of PFO Combined Dynamic Left Ventricular Outflow Tract Stenosis after Occlusion

This patient was diagnosed with Patent Foramen Ovale (PFO) due to recurrent headaches, and her headaches improved significantly after oval foramen occlusion, but a grade 3/6 coarse murmur was heard in the aortic valve auscultation area, and left ventricular outflow tract stenosis was suggested by cardiac ultrasound. This change may be related to a variety of factors, suggesting that we should do a good preoperative assessment of the patient; intraoperative operation as gentle as possible to reduce the damage to the surrounding tissues; postoperative operation should be strengthened to avoid the progression of the inflammatory process, and at the same time to pay attention to the patient's symptoms, signs and dynamics of the relevant examinations to reduce the incidence of complications.

Abstract 14878: Be Aware of False Negative Bubble Study in Diagnosis of Patent Foramen Ovale!

Introduction: Echocardiography plays an important role in diagnosis of Patent Foramen Ovale (PFO). However, there are some anatomic variations which may result in a false negative study. Case presentation: A 55-year-old male was hospitalized for acute right-hemiplegia. The EKG revealed normal sinus rhythm. Brain imaging revealed acute bilateral infarcts. The transthoracic echocardiogram (TTE) showed a normal ejection fraction without significant valve disease and a negative agitated saline Bubble study. A Trans-esophageal echocardiogram (TEE) revealed a negative Bubble study using intravenous access via the left arm. The TEE also revealed an atrial septal aneurysm and large eustachian valve (EV). The Bubble study was then repeated with agitated saline injected from lower extremity. This demonstrated a significant right to left shunt through a PFO. Discussion: EV is a remnant of the valve of the inferior vena cava that directs blood flow through the fossa ovalis during embryonic life. A large or prominent EV may be a risk factor for paradoxical embolism by preventing spontaneous foramen closure. Agitated saline originating from the superior vena cava (SVC) may result in a false-negative study due to the prominent EV preventing microbubbles from the SVC from crossing the interatrial septum. In this case, the patient’s age, clinical presentation and the finding of EV and atrial septal aneurysm raised the suspicion of PFO. Repeating the bubble study using a lower extremity peripheral access was positive. This step played a crucial role in the diagnosis of PFO in this patient and his subsequent management. Conclusion: Cardiologists should be aware that the presence of a prominent EV may result in a false negative bubble study result when the injection is performed via upper limb intravenous access.

Long-term risk of atrial fibrillation or flutter after transcatheter patent foramen ovale closure: a nationwide Danish study.

Transcatheter closure of patent foramen ovale (PFO) is the recommended stroke prevention treatment in patients ≤60 years with cryptogenic ischemic stroke and PFO. Atrial fibrillation or flutter (AF) is a known potential procedure-related complication, but long-term risk of developing AF remains unknown. This paper studied the long-term risk of developing AF following PFO closure. A Danish nationwide cohort study was conducted. During 2008-2020, this study identified a PFO closure cohort, a PFO diagnosis cohort without PFO closure, and a general population comparison cohort matched 10:1 to the PFO closure cohort on age and sex. The outcome was first-time AF diagnosis. Risk of AF and multivariable-adjusted hazard ratio (HR) of the association between PFO closure or PFO diagnosis and AF were calculated. A total of 817 patients with PFO closure, 1224 with PFO diagnosis, and 8170 matched individuals were identified. The 5 year risk of AF was 7.8% [95% confidence interval (CI): 5.5-10] in the PFO closure cohort, 3.1% (95% CI: 2.0-4.2) in the PFO diagnosis cohort, and 1.2% (95% CI: 0.8-1.6) in the matched cohort. The HR of AF comparing PFO closure with PFO diagnosis was 2.3 (95% CI: 1.3-4.0) within the first 3 months and 0.7 (95% CI: 0.3-1.7) thereafter. The HR of AF comparing PFO closure with the matched cohort was 51 (95% CI: 21-125) within the first 3 months and 2.5 (95% CI: 1.2-5.0) thereafter. Patent foramen ovale closure was not associated with any substantial increased long-term risk of developing AF beyond the well-known procedure-related short-term risk.

Agitated saline with 10% blood increases number and stability of microbubbles in detection right-to-left shunt by contrast-enhanced transcranial Doppler: an in vitro and in vivo observational study.

Agitated saline (AS) with blood has been shown to have good tolerance and increased efficacy when used in contrast-enhanced transcranial Doppler (c-TCD) to detect right-to-left shunt (RLS). However, little is known about the effects of blood volume on c-TCD results. Our study investigated the characterization of AS with different blood volumes in vitro and compared the c-TCD results in vivo. In vitro, AS without blood, AS with 5% blood (5% BAS), and AS with 10% blood (10% BAS) were prepared based on previous studies and observed under microscopy. The numbers and sizes of the microbubbles from different contrast agents were compared immediately, 5 min, and 10 min post-agitation. In vivo, 74 patients were recruited. c-TCD was repeated 3 times using AS with different blood volumes in each patient. Signal detection times, positive rates, and classifications of RLS were compared among the 3 groups. In vitro, the AS without blood produced 5.4±2.4/field microbubbles after agitation, the 5% BAS produced 30.4±4.2/field, and the 10% BAS produced 43.9±12.7/field. More microbubbles remained in the 10% BAS than the 5% BAS within 10 min (18.5±6.1 vs. 7.1±2.0/field, P<0.001). The size of the microbubbles from the 5% BAS increased from 9.2±8.2 to 22.1±10.6 µm within 10 min post-agitation (P=0.014), while the 10% BAS changed insignificantly. In vivo, the signal detection times of the 5% BAS (1.1±0.7 s) and 10% BAS (1.0±0.8 s) were significantly shorter than the AS without blood (4.0±1.5 s, P<0.0001). The RLS positive rates were 63.5%, 67.6% and 71.6% in AS without blood, 5% BAS and 10% BAS respectively; however, the differences were not statistically significant. The AS without blood reached 12.2% level III RLS, while the 5% BAS reached 25.7%, and the 10% BAS reached 35.1% (P=0.005). The 10% BAS would be suggested in c-TCD as it addressed larger RLS by increasing the number and stability of microbubbles, and it improves the diagnosis of patent foramen ovale (PFO).

Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography.

The Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver. This study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3-5 s. Overall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017). TENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.

Computed Tomography for Detecting Patent Foramen Ovale: A Meta-Analysis.

Patent foramen ovale (PFO) has been regarded as a potential source of cryptogenic stroke, which was conventionally detected by transesophageal echocardiography. Cardiac computed tomography (CCT) is a promising, noninvasive test for detection of PFO. We sought to conduct a meta-analysis to evaluate the diagnostic performance of CCT in detecting PFO. PubMed, ISI Web of Knowledge, Embase, Cochrane Library, and Wanfang from inception to June 2020 were searched for relevant studies comparing CCT and transesophageal echocardiography as the reference standard in detecting PFO. A bivariate model was used to pool sensitivity and specificity and to construct summary receiver operating characteristic (SROC) curves. A total of seven studies with 483 patients were included in this meta-analysis. For the diagnosis of PFO, CCT had a mean sensitivity and specificity of 0.70 [95% CI:0.58, 0.79] and 0.97 [95% CI: 0.95, 0.99]. The SROC analysis showed an area under the curve of 0.97. CCT shows good diagnostic accuracy in detecting PFO with relatively high sensitivity and specificity. CCT could be considered a noninvasive alternative to transesophageal echocardiography for detecting PFO.

Pitfalls of Using Imaging Technique in the Presence of Eustachian Valve or Chiari Network: Effects on Right-to-Left Shunt and Related Influencing Factors.

When patent foramen ovale (PFO) combines with the prominent Eustachian valve or Chiari network (EV/CN), contrast transthoracic echocardiography (cTTE) may miss the diagnosis of PFO. We sought to determine the characteristics of right-to-left shunt (RLS) in PFO patients with prominent EV/CN on cTTE and identify the causal factors of missed diagnosis. We consecutively enrolled 98 patients who suffered from PFO-related stroke and with prominent EV/CN. All patients were divided into the delayed and non-delayed groups according to the characteristics of RLS on cTTE. The characteristics of RLS were compared with those of 42 intrapulmonary shunt patients. The anatomical characteristics of PFO and EV/CN were analyzed in the 98 PFO patients. Upon cTTE, significantly delayed occurrence and longer duration of the RLS in the delayed group were found both at rest and during the Valsalva maneuver, similar to the intrapulmonary shunt. Multivariate logistic analysis revealed that the length of EV/CN (>19 mm) and the diameter of PFO at the left atrium aspect (<1.2 mm) were high-risk factors for missed diagnosis. In conclusion, RLS showed delayed emergence and disappearance in some of the PFO patients with prominent EV/CN. The length of EV/CN and the diameter of PFO may have been related to the missed diagnosis of PFO.

Risk of Perioperative Stroke in Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis.

Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively, but the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery. Embase, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations. Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06% to 1.4% based on International Classification of Diseases (ICD)-code diagnosis and from 10.4% to 40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0% to 25% of patients with PFO, and 0% to 16.7% without PFO. Studies that used echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes found strong association but were highly heterogeneous. PFO was not associated with a risk of perioperative stroke in cardiac and transplantation surgeries. While the adjusted odds ratios for stroke were substantial for orthopaedic, general, genitourinary, neurologic, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty. In conclusion, PFO is likely a risk factor for perioperative stroke in selected types of surgeries. However, this is based on very low-quality evidence. Rigorous prospective studies are needed to further investigate this relationship.

0829 Workup of Nocturnal Hypoxemia Leads to Diagnosis of Patent Foramen Ovale

Abstract Introduction Patent foramen ovale (PFO) in adults often remains asymptomatic until clinical manifestations such as cryptogenic stroke, migraine headache, air embolism, hypoxemia, or platypnea-orthodeoxia syndrome occur. In this case, prior workup of cryptogenic stroke failed to identify a PFO that was diagnosed after further investigation of polycythemia which revealed nocturnal hypoxemia on polysomnogram. Report of Cases: A 60-year-old male with history of recurrent venous thromboembolic events (VTE), secondary polycythemia, and cryptogenic strokes was referred for a polysomnogram during the evaluation of polycythemia. Over the span of six years, he had multiple cryptogenic strokes and VTEs in the setting of polycythemia and normal hypercoagulability labs. Further evaluation suggested secondary polycythemia after serum erythropoietin and JAK2 mutation testing were negative. The patient was a never smoker without evidence of malignancy or renal disease leading to suspicion that his polycythemia was due to hypoxemia despite normal oxygen saturations during point of care evaluations. He frequently reported shortness of breath during appointments. During a polysomnogram, the patient was found to have a total apnea-hypopnea index of fewer than 5 events per hour but demonstrated hypoxemia with 49.7% of total sleep time spent below an oxygen saturation of 90%. He was referred to pulmonology for further evaluation that showed normal resting oxygen saturation, no desaturation on a six-minute walk test, mild restrictive defect on pulmonary function testing, and a normal chest computed tomography with angiography. Prior transthoracic echocardiogram had demonstrated an atrial septal aneurysm without communication between the atrial chambers. No evidence suggestive of a right-to-left shunt was found on lateral imaging of the brain during a ventilation-perfusion scan. Further evaluation of the aneurysmal atrial septum on transesophageal echocardiogram with an agitated saline bubby study demonstrated a patent foramen ovale with a right-to-left shunt. In the setting of hypoxia leading to secondary polycythemia, the patient was scheduled for PFO closure. Conclusion Hypoxemia out of proportion to sleep-disordered breathing on polysomnogram should prompt further evaluation. Despite multiple prior strokes, our patient’s PFO had gone undiagnosed until polycythemia prompted a polysomnogram that demonstrated isolated nocturnal hypoxemia and prompted a further workup. Clinically significant hypoxemia is an indication for PFO closure. Support (If Any)

Detecting Patent Foramen Ovale after Cryptogenic Stroke - A Single Center Experience in Taiwan.

Cryptogenic strokes related to a patent foramen ovale (PFO) in young patients have been reported. Percutaneous transcatheter occlusion is considered a safe and effective method for achieving PFO closure. Here, we present our experience of PFO closure in a series of young patients diagnosed with cryptogenic stroke. This was a retrospective study of 62 patients who were younger than 60 years of age and previously diagnosed with cryptogenic stroke. They underwent cardiac catheterization for the diagnosis of PFO and/or device closure. Bubble and echocardiography studies, the patients' characteristics, complications, and recurrence of stroke were recorded. The Risk of Paradoxical Embolism (RoPE) score index was also calculated. Patients with a bubble study grade greater than grade I were likely to have PFO (odds ratio: 22.2 [95% confidence interval: 1.2-412.3]). The mean RoPE score in the PFO closure group was 7.18. Two patients (3.9%) developed atrial fibrillation during the procedure. Ischemic stroke recurred in two patients (3.3%). Combining a bubble study with transcranial Doppler ultrasound or transthoracic echocardiography may increase the validity of PFO diagnosis. Because of the low recurrence rate of stroke and low complication rate, it is important to identify PFO patients with a bubble study grade greater than grade I. Closure of PFO may be a good strategy for preventing recurrent stroke among such patients.

Abstract WP169: The Utility Of Transesophageal Echocardiogram In Embolic Strokes Of Undetermined Source Not Associated With Patent Foramen Ovale

Introduction: Transesophageal echocardiography (TEE) is frequently utilized in the diagnosis of embolic stroke of undetermined significance (ESUS), with a patent foramen ovale (PFO) being the most common finding. Transcranial doppler (TCD) is comparable to TEE in diagnosing a right-to-left shunt, while being less invasive. Our aim is to evaluate the diagnostic yield of TEE excluding the diagnosis of PFO, in patients with ischemic stroke satisfying ESUS criteria. Methods: We retrospectively evaluated patients at our institution with acute ischemic stroke fulfilling ESUS criteria who underwent TEE examination during a 50-month period (May 2017 to July 2021). In these patients, we also evaluated whether TCD bubble study was done. We assessed whether non-PFO TEE findings altered management course. Results: We identified 113 patients with ESUS who underwent investigation with TEE (mean age 65 ± 13.5 years, 62% men, 38% women, median NIH Stroke Scale = 4 points [interquartile range: 2-9]). TEE revealed a PFO in 23.4% (95% CI: 19%-28.8%). TCD was performed in 55.6% of the patients with a PFO found on TEE, and revealed a right-to-left shunt in 80% of them. Excluding the finding of PFO, TEE revealed additional findings in 27 (23.9% [95% CI: 15.9%-31.2%]) patients. This changed management (anticoagulation therapy or surgical evaluation) in 3 (2.7% [95% CI: 0%-5.6%]) patients. The surgical evaluation was due to marantic valve endocarditis. No patients required IV antibiotic therapy due to TEE findings. Conclusions: Abnormal TEE findings only rarely affect the management in ESUS. TCD may be sufficient to screen for PFO in ESUS patients.

Assessing patent foramen ovale on coronary computed tomographic angiography: a comparison with transesophageal echocardiography.

This study was undertaken to determine if coronary computed tomographic angiography (CCTA) can help to assess patent foramen ovale (PFO) with high accuracy and reproducibility when compared to transesophageal echocardiography (TEE). In total, 75 suspected PFO cases (31 men, 44 women; mean age, 45 ± 9years) were evaluated by coronary CTA and TEE. PFO tunnel length (TL) and the opening diameter of the left atrial entrance (ODLAE) and right atrial entrance (ODRAE), as well as contrast shunt (if present due to PFO), were measured by both modalities. PFO was detected in 68 patients with TEE. The sensitivity for the detection of PFO with CCTA was 85.3%; specificity, 71.4%; positive predictive value, 96.7%; and negative predictive value, 33.3%. Both modalities demonstrated good agreement in measuring TL and ODLAE of PFO. However, the ODRAE of TEE was different from that of CCTA (1.14 ± 0.4mm and 1.45 ± 0.5mm, respectively, p = 0.04). The intra-observer and inter-observer variability and agreement for TL, ODRAE, and ODLAE of PFO were excellent between the two measurements. CCTA provided a method for detection of PFO with high accuracy and reproducibility compared with TEE. Therefore, CCTA is a practical and efficient alternative to TEE for PFO diagnosis.

Diagnostic Value of Micro-Bubble Transcranial Doppler Combined with Contrast Transthoracic Echocardiography in Cryptogenic Stroke Patients with Patent Foramen Ovale.

In recent years, increasing attention has been paid to cryptogenic stroke (CS) caused by the patent foramen ovale (PFO). This study aims to evaluate the value of microbubble transcranial Doppler (MB-TCD) combined with contrast transthoracic echocardiography (cTTE) in the diagnosis of cryptogenic stroke patients with PFO. From January 2014 to January 2019, patients who suffered from CS were recruited and divided into the cTTE group and MB-TCD combined with cTTE group. All patients were further checked by transesophageal echocardiography (TEE). A total of 130 patients accepted cTTE examination, and 109 patients accepted MB-TCD combined with cTTE. In the group, 52 of the 54 positive patients were finally confirmed by TEE with PFO, and 12 of the 76 negative patients were finally confirmed by TEE with PFO. In combined group, 50 patients were negative on both two examination (Negative group), 54 were positive on both two examination (Positive group) and finally confirmed by TEE indeed with patent foramen ovale (PFO), while remaining five (5) patients were positive only on MB-TCD (Suspected group). After checked by TEE, three (3) of five patients with MB-TCD positive were confirmed by TEE indeed with PFO. The sensitivity, specificity, positive likelihood ratio (+LR), and Youden's index of cTEE in diagnostic of cryptogenic stroke patients with PFO were 81.25%, 96.97%, 26.82 and 0.78, respectively, and these for MB-TCD combined with cTTE were 100%, 96.15%, 25.97 and 0.96, respectively. MB-TCD medium can sensitively discover PFO in cryptogenic stroke patients with 100% sensitivity and a missdiagnosis rate of 0. The combination of MB-TCD and cTTE can improve the sensitivity and specificity of PFO diagnosis in cryptogenic stroke patients. MB-TCD medium also had high sensitivity and specificity.

Case fatality rate and fatal bleeding complication in patients with pulmonary embolism and patent foramen ovale

Abstract Objectives In patients with acute pulmonary embolism (PE), right atrial pressure is elevated, which increases risk for right-to-left shunt when patent foramen ovale (PFO) is present and thus potentially increases risk for paradoxical embolism. Little is known about the clinical outcome of patients with PE and concomitant PFO. Methods We analysed data on patient characteristics, treatments and in-hospital outcomes for all PE patients (ICD-code I26) with concomitant presence of PFO in Germany 2005–2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005–2018, and own calculations). Results Between January 2005 and December 2018, 1,174,235 patients with acute PE (53.5% females) were included in this analysis; of those, 5,486 (0.5%) had a concomitant diagnosis of PFO. Trends analysis demonstrating an increasing frequency of diagnosed PE with additional PFO from 2005 (n=299) to 2018 (n=556; p&amp;lt;0.001). While patients with PE and PFO presented more often with signs of haemodynamic compromise such RV dysfunction (37.6% vs. 28.5%) or shock (7.1% vs. 3.9%) as well as paradox arterial emboli (47.8% vs. 3.2%) or intracerebral bleeding (3.3% vs. 0.6%), PE patients with PFO died less often compared to PE patients without PFO (11.1% vs. 15.8%). Patients with PE and PFO were younger (65 [IQR 52–75] vs. 72 [60–80]; P&amp;lt;0.001) and were more often treated invasively with a reperfusion treatment approach like embolectomy (10.2% vs. 4.2%) or systemic thrombolysis (5.0% vs 0.1%). A multivariate logistic regression analysis revealed a 27.6-fold increased risk for paradox arterial emboli (OR, 27.6 [95% CI 26.1–29.1]; p&amp;lt;0.001) and a 3.9-fold increased risk for intracerebral bleeding events (OR, 3.9 [95% CI 3.3–4.54]; p&amp;lt;0.001) for patients with PE and concomitant PFO. In normotensive patients with RVD and PFO, embolectomy were not associated to affect the rate of intracerebral bleeding events (OR, 0.8 [95% CI 0.2–2.6]; p=0.720) compared to conventional non-reperfusion treatment; instead of systemic thrombolysis, which is associated with a higher risk of intracerebral bleeding (OR, 3.5 [95% CI 1.8–6.59]; p&amp;lt;0.001) compared to conventional non-reperfusion treatment. Conclusion Patients with acute PE and the concomitant presence of PFO are associated with a high risk for paradox arterial emboli and intracranial bleeding events. Especially in normotensive patients, the use of systemic thrombolysis should be considered with cautious. Thus, our findings may improve the clinical management of patients with PE and PFO. Funding Acknowledgement Type of funding sources: None.

The role of cardiac CT throughout the full cardiac cycle in diagnosing patent foramen ovale in patients with acute stroke.

We explored the hypothesis that the diagnostic performance of cardiac computed tomography (CT) throughout the full cardiac cycle would be superior to single-phase CT and comparable to transesophageal echocardiography (TEE) in diagnosing patent foramen ovale (PFO). From May 2011 to April 2015, 978 patients with stroke were diagnosed with PFO by TEE. In patients with stroke, cardiac CT was performed if the patients had more than two cardiovascular risk factors. We prospectively enrolled 70 patients with an indication for cardiac CT. Cardiac CT images were reconstructed at 10% increments of the R-R interval. The sensitivity of cardiac CT throughout the full cardiac cycle in diagnosing PFO was compared to that for TEE and single-phase cardiac CT. To evaluate the specificity of cardiac CT, we analyzed patients without PFO confirmed by TEE who underwent cardiac CT within 1 month of pre-cardiac surgery. Sixty-six patients with cardiac CT and TEE were included in the final analysis. Throughout the full cardiac cycle, cardiac CT had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing PFO, compared to TEE as a reference. PFO was primarily detected in the 60% and 70% intervals in 10-phase reconstructed images. The sensitivity of PFO diagnosis with cardiac CT was 81.8% when analyzing both the 60% and 70% intervals instead of the full cardiac cycle. Cardiac CT throughout the full cardiac cycle outperforms single-phase cardiac CT in detecting PFO. Cardiac CT can be used as an alternative method to TEE for detecting PFO in stroke patients. • Throughout the full cardiac cycle, cardiac computed tomography (CT) had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing patent foramen ovale (PFO), compared to transesophageal echocardiography. • The sensitivity of diagnosing patent foramen ovale with cardiac CT was 81.8% when analyzing 60% and 70% R-R intervals instead of the full cardiac cycle. • Cardiac CT with retrospective electrocardiographic gating throughout the full cardiac cycle can increase the detectability of PFO, compared to single-phase cardiac CT.

The Prevalence of Microembolic Signals in Transcranial Doppler Sonography With Bubble Test in Acute Ischemic Stroke.

Transcranial Doppler ultrasound (TCD) is noninvasive and highly sensitive and specific for the diagnosis of patent foramen ovale (PFO). We evaluated the diagnostic implications of the TCD with a saline agitation test as a routine work-up for ischemic stroke patients. A TCD bubble study was performed in all consecutive ischemic stroke patients as a routine work-up. We evaluated the prevalence of microembolic signals (MES) for each stroke etiology and the optimal number of MES for predicting the PFO-attributable stroke. Subjects (N=499) with acute ischemic stroke were enrolled. A significant fraction of patients had MES during both normal respiration (5.7-44.4%) and the Valsalva maneuver (19.5-55.6%) across all stroke etiology categories. The optimal MES threshold for the diagnosis of PFO-attributable stroke confirmed by transesophageal echocardiography was 46 MES during the Valsalva maneuver (96% sensitivity and 95% specificity). Applying ≥46 MES during the Valsalva maneuver as a threshold effectively increased the ability to differentially diagnose PFO-attributable stroke from other etiologies. The number of MES during the Valsalva maneuver was negatively correlated with increasing age (r=-.108; P=.016). A significant fraction of patients had right to left shunt across all Trial of ORG 10172 in Acute Stroke Treatment etiologies. A threshold number of MES facilitated the differential diagnosis of PFO-attributable stroke from other etiologies, and the optimal threshold was 46 MES during the Valsalva maneuver.

Comparative analysis of the diagnostic value of several methods for the diagnosis of patent foramen ovale.

The aim of this research was to compare the sensitivity and positivepredictive value of contrast transcranial Doppler (c-TCD), contrast transthoracic echocardiography (c-TTE), and contrast transesophageal echocardiography (c-TEE), to determine the best method for diagnosing patent foramen ovale (PFO) and to provide a reference for the further improvement of clinical practice. We investigated 161 patients who suffered from migraines, cryptogenic stroke, TIA, and cerebral infarction of unknown cause. All patients underwent transcatheter examination, and the results of the right heart catheterization(RHC) were considered the gold standard for PFO diagnosis. The present study revealed that c-TTE with the Valsalva maneuver had a higher sensitivity in detecting PFO related right-to-left shunt (PFO-RLS), c-TCD performed similarly to c-TEE but maybe produce more false positives. Moreover, when we observed color shunt from the slit-like channel between the septum primum and the septum secundum on TEE, the positivepredictive value was the highest. Patients with suspectedPFO should be examined with c-TTE and c-TEE for confirmation. When there were a large numberof bubbles in the left heart, especially in the presence of color shunt, the positivepredictive value was the highest. The positive results of c-TCD only point out the presence of right-to-left shunt and cannot exclude extracardiac shunt, so c-TCD should not be used as a screen for PFO, additional measures such as c-TTE and c-TEE should be used.

A review of diving practices and outcomes following the diagnosis of a persistent (patent) foramen ovale in compressed air divers with a documented episode of decompression sickness.

The presence of a persistent (patent) foramen ovale (PFO) increases the risk of decompression sickness (DCS) whilst diving with pressurised air. After the diagnosis of a PFO, divers will be offered a number of options for risk mitigation. The aim of this study was to review the management choices and modifications to diving practices following PFO diagnosis in the era preceding the 2015 joint position statement (JPS) on PFO and diving. A retrospective study was conducted of divers sourced from both the Alfred Hospital, Melbourne and the Divers Alert Network Asia-Pacific during the period 2005-2015. Divers were contacted via a combination of phone, text, mail and email. Data collected included: diving habits (years, style and depths); DCS symptoms, signs and treatment; return to diving and modifications of dive practices; history of migraine and echocardiography (ECHO) pre- and post-intervention; ECHO technique(s) used, and success or failure of PFO closure (PFOC). Analyses were performed to compare the incidence of DCS pre- and post-PFO diagnosis. Seventy-three divers were interviewed. Sixty-eight of these returned to diving following the diagnosis of PFO. Thirty-eight underwent PFOC and chose to adopt conservative diving practices (CDPs); 15 chose PFOC with no modification to practices; 15 adopted CDPs alone; and five have discontinued diving. The incidence of DCS decreased significantly following PFOC and/or adoption of conservative diving practices. Of interest, migraine with aura resolved in almost all those who underwent PFOC. Many divers had already adopted practices consistent with the 2015 JPS permitting the resumption of scuba diving with a lowering of the incidence of DCS to that of the general diving population. These results support the recommendations of the JPS.

Current status of transcatheter closure of patent foramen ovale

A patent foramen ovale (PFO) is a highly prevalent structure among the adult population. It allows the shunt of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, significant right to left shunting resulting in resting and exercise-induced hypoxemia, platypnea orthodeoxia syndrome, and decompression sickness after scuba diving and migraines. Currently, transthoracic and transesophageal echocardiography and transcranial Doppler are the most important diagnostic tools, for the diagnosis of PFO. The sensitivity and specificity of the study depend on the modalities available: transthoracic (TTE), transesophageal (TEE), and transcranial Doppler (TCD), as well as the intravenous use of agitated saline and the site of injection.