Contrast Transesophageal Echocardiography Research Articles

Diagnostic value of contrast-enhanced ultrasonography for patent foramen ovale detection.

Patent foramen ovale (PFO) has been associated with migraine, cryptogenic stroke (CS), and hypoxemia. However, which examination method is most reliable remains controversial. This study sought to investigate the diagnostic value of contrast-enhanced ultrasonography (cU), including contrast-enhanced transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE), for PFO; and to determine the best diagnostic strategy. This retrospective observational study included a total of 147 consecutive patients suspected PFO at The First Hospital of Shanxi Medical University between October 2019 and January 2022. The patients also underwent cTCD, cTTE, and cTEE examinations. The standard for the diagnosis of PFO was confirmation of the presence of PFO by color Doppler flow signals or contrast microbubbles (MBs) passing through the foramen ovale. A total of 123 patients were diagnosed with PFO and 24 patients without PFO during the study period. The detectable rates of cTCD, cTTE, and cTEE were 120 (97.56%), 110 (89.43%), and 121 (98.37%), respectively. The sensitivity between cTCD and cTEE for PFO were comparable [97.56%, 95% confidence interval (CI): 92.5% to 99.4% vs. 98.37%, 95% CI: 93.7% to 99.7%; P>0.99], and the sensitivity of both were higher than that of cTTE (89.43%, 95% CI: 82.3% to 94.0%; P=0.02 and P=0.001, respectively). In addition, the specificity of cTEE for PFO was significantly higher than that of cTCD (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001) and cTTE (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001). Further, the semi-quantitative classification ability of cTCD for PFO with right-to-left shunt (RLS) was significantly higher than that of cTTE and cTEE (P=0.02 and P<0.001, respectively), and that of cTTE was significantly higher than that of cTEE (P=0.01). The Spearman analysis showed that the degree of RLS was positively correlated with the inner diameter of the PFO (r=0.695, P<0.001). The combination of cTCD and cTEE may provide a favorable strategy for the diagnosis of PFO.

Een ongebruikelijke oorzaak van acute desaturatie

An unusual cause of acute desaturation A 61-year-old man presented with symptoms of rapidly increasing dyspnea, chest pain and significant hypoxemia for which the initial investigations revealed no clear explanation. There was a remarkable improvement of the saturation in supine position. A contrast transesophageal echocardiography established the presence of a patent foramen ovale (PFO), which was successfully closed via a percutaneous transcatheter. Platypnoea-orthodeoxia syndrome (POS) is a rare entity characterized by the presence of arterial hypoxemia in upright position with resolution of the hypoxemia in supine position. It is most frequently caused by a PFO. A PFO is, however, merely an essential precondition and the development of POS nearly always requires the presence of other (functional) factors.

Retracted: Evaluation of Cardiac Space-Occupying Lesions by Myocardial Contrast Echocardiography and Transesophageal Echocardiography.

[This retracts the article DOI: 10.1155/2022/2066033.].

Detection rate and shunt grading with synchronous testing of contrast transcranial Doppler and contrast transthoracic echocardiography: Preliminary findings.

Patent foramen ovale, a common congenital atrial septal defect, may lead to cardiac right-to-left shunting (RLS), which has been associated with various diseases. Reliable techniques for detecting RLS are essential for diagnosis and assist with treatment decision-making. Contrast transcranial Doppler (c-TCD), contrast transthoracic echocardiography (c-TTE), and contrast transesophageal echocardiography can be used to detect RLS. However, it is still unclear which ultrasound modalities are the most practical and cost-effective. To evaluate the efficacy of synchronous c-TCD and c-TTE in detecting cardiac RLS. We prospectively designed and continuously recruited 100 patients with cryptogenic stroke, migraines, transient ischemic attack, unexplained syncope, or dizziness admitted at the First Affiliated Hospital of Shenzhen University between February 2020 and August 2020. Ninety-five patients underwent synchronous c-TCD and c-TTE (during a single contrast-enhanced ultrasound session). We compared synchronous test results with the results of c-TCD alone and c-TTE alone. Ninety-five patients successfully underwent synchronous c-TCD and c-TTE, with the data analyzed for each individual. The positive detection rates of Grade I, II, and III shunts with synchronous c-TCD and c-TTE were higher than those with c-TTE or c-TCD alone (P = .047, P = .002, and P = .024, respectively). Overall, the positive detection rates of synchronous tests, c-TCD alone, and c-TTE were 69.5%, 51.6%, and 31.6%, respectively (P = .000, and P = .012). Among the 66 patients who were double-RLS-positive (both c-TTE and c-TCD showed positive results), as detected by the synchronous test, 26 (39.3%) patients who underwent c-TTE alone had higher shunt grades detected than those who underwent c-TCD alone. Conversely, 5 (7.6%) patients who underwent c-TCD alone had higher shunt grades detected than those who underwent c-TTE alone (P = .000). Synchronous c-TCD and c-TTE testing can significantly improve the detection rate, accuracy, and test process efficacy for quantifying RLS, and reduce the testing risk, workload, and medical costs.

Neglected intrapulmonary arteriovenous anastomoses: A comparative study of pulmonary right-to-left shunts in patients with patent foramen ovale.

Pulmonary right-to-left shunt (P-RLS) and patent foramen ovale right-to-left shunt (PFO-RLS) often appear in combination, and there are often differences and connections between them. Intrapulmonary arteriovenous anastomoses (IPAVAs), as part of P-RLS, are often overlooked because there are no technologies to detect and identify them. This study aimed to further clarify the incidence and characteristics of P-RLS with the help of contrast transesophageal echocardiography (c-TEE) and contrast transthoracic echocardiography (c-TTE), providing a reference for clinically relevant research and patent foramen ovale (PFO) management disposal decisions. We retrospectively investigated 414 subjects who came to our hospital for c-TEE from October 2021 to July 2022, and all subjects completed c-TTE simultaneously. 7 Patients who were newly diagnosed with an atrial septal defect were excluded. Eventually, 407 patients were included in this study. Among them, 157 patients with PFO (58 patients were treated with PFO closure subsequently) and 250 patients without PFO confirmed by c-TEE were finally enrolled. In the process, we observed and analysed the presence of P-RLS. A total of 407 patients were included in the final analysis and divided into PFO group (N = 157) and non-PFO group (N = 250) according to the results of c-TEE. Whether at rest or after Valsalva maneuver, the incidence of P-RLS was significantly higher under c-TEE than under c-TTE in the two groups (P < 0.001). For both c-TTE and c-TEE, the incidence of P-RLS was slightly higher after Valsalva maneuver than at rest, but the difference was not significant (c-TTE: rest vs. Valsalva maneuver, P = 0.214; c-TEE: rest vs. Valsalva maneuver, P = 0.076). The Valsalva maneuver increased the incidence of P-RLS in the group without PFO, which was more significant in c-TEE (c-TTE: rest vs. Valsalva maneuver, P = 0.591; c-TEE: rest vs. Valsalva maneuver, P = 0.008). In both groups, the P-RLS semiquantitative grading was statistical significance under different states and examinations (P < 0.001). The vast majority of P-RLS are grade 1-2 and are derived from physiological IPAVAs. Even so, attention should be given to the differentiation between P-RLS and PFO-RLS. c-TEE is an effective method to detect P-RLS; however, the recruitments of c-TEE and Valsalva maneuver to P-RLS should be noted.

Significance of transesophageal contrast echocardiography with the agitated saline test for diagnosing pulmonary arteriovenous malformations.

ObjectivesThis study evaluated the diagnostic value of transesophageal contrast echocardiography (TECE) with the agitated saline test for diagnosing pulmonary arteriovenous malformations (PAVMs) in comparison with chest CT or pulmonary angiography.BackgroundAlthough transthoracic contrast echocardiography (TTCE) is the recommended screening test for diagnosing PAVMs, it has low specificity and positive predictive value. TECE is expected to offer improved sensitivity and specificity compared with TTCE, but no studies have reported the diagnostic accuracy and clinical significance of TECE in detecting PAVMs.Methods and resultsIn total, 1,809 patients underwent TECE with the agitated saline test to evaluate symptoms of a suspected right to left shunt. Patients with hereditary hemorrhagic telangiectasia (HHT) were excluded. A total of 387 patients showed transpulmonary bubble passage, indicating a PAVM. Among them, 182 patients had additional chest CT or pulmonary angiography. Those patients were divided into two groups according to the presence of a PAVM in the radiologic imaging. A total of 18 patients (9.8%) were confirmed for the PAVM group. Only 13 patients required embolization for their PAVMs. The TECE with saline test results were divided into four grades according to the number of bubbles: grade 1 (n = 91), grade 2 (n = 47), grade 3 (n = 35), and grade 4 (n = 9). None of the patients in the PAVM group had grade 1 shunts in their TECE results. The positive predictive values for the presence of a PAVM according to the TECE grade scale were 10.6% for grade 2, 22.8% for grade 3, and 55.6% for grade 4.ConclusionTECE with a grade scale is a useful method for initially diagnosing PAVMs in non-HHT patients with a suspected right to left shunt. The findings of this study also suggest that patients with a small grade (<10 bubbles) shunt in their TECE findings should be spared unnecessary radiation exposure from CT scans or pulmonary angiography.

Application of Transesophageal Echocardiography in Amplatzer Atrial Septal Defect Occluder for Percutaneous Closure of Large Patent Foramen Ovale.

Objective The Amplatzer patent foramen ovale (PFO) occluder is the most commonly used device for percutaneous closure of a large PFO. However, its use may predispose the patient to postoperative residual shunting. To reduce the incidence of residual shunting, we investigated the safety and effectiveness of the Amplatzer atrial septal defect (ASD) occluder for percutaneous closure of a large PFO measured by transesophageal echocardiography (TEE) and evaluated the value of TEE in this procedure. Methods Overall, 118 patients who were diagnosed with a large PFO (all with a ≥ 2 mm left atrial side height after the Valsalva maneuver (VM) excluding those with a small ASD) using contrast transthoracic echocardiography (c-TTE) and TEE underwent closure under TEE guidance at The First Affiliated Hospital of Xi'an Jiaotong University. An ASD device was used in 48 patients (group I) and a PFO device in 70 (group II). After the procedure, we verified the safety and efficacy of different devices using c-TTE, TTE, and TEE. Results In both groups, the preoperative TEE results showed a significantly increased left height of the PFO after VM compared with that at rest (all P < 0.01). Compared with the left height of the PFO measured using TEE after VM, the PFO-stretch diameter (SD) measured by TEE after the delivery sheath passed the PFO was higher (all P < 0.01). We selected the ASD occluder size according to this PFO-SD. In group II, most patients underwent the implantation of the larger PFO devices. Interventional treatment was successfully performed on all patients. The effective occlusion rate in group I at 12 months after the procedure was significantly higher than that in group II (93.7% vs. 78.6%, P < 0.05). The TEE results showed that 18 patients with a medium and large residual shunt at 12 months after the procedure exhibited an intradisc tunnel-like shunt. Conclusion The Amplatzer ASD device and Amplatzer PFO device are safe for large PFO closure, but the Amplatzer ASD device has a higher effective occlusion rate. TEE plays a crucial role in the use of the Amplatzer ASD occluder for percutaneous closure of a large PFO.

A Prospective, Single-Center, Phase I Clinical Trial to Evaluate the Value of Transesophageal Echocardiography in the Closure of Patent Foramen Ovale With a Novel Biodegradable Occluder.

ObjectiveTraditional metal alloy occluders for the closure of patent foramen ovale (PFO) may be associated with some potential complications, and may restrict the trans-septal access to the left atrium for future treatment of left-sided heart disease. Increasing attention has been paid to novel biodegradable occluders (NBOs) to achieve PFO closure. We aimed to evaluate the role of transesophageal echocardiography (TEE) in the diagnostic and anatomical evaluation of PFO, as well as in the Post-procedural assessment after transcatheter closure with a NBO.MethodsWe conducted a prospective, single-center clinical study of 44 patients who were diagnosed with PFO by contrast transthoracic echocardiography (c-TTE) and TEE from June 2019 to June 2020. All patients underwent PFO occlusion with NBO under TTE guidance. Follow-up was performed at 2 days and 3 months after the procedure with TTE, and at 6 months and 1 year after the procedure with c-TTE, TTE, and TEE.ResultsInterventional treatment was successfully performed in all patients. The left and right sides of the occluder device disc were significantly reduced at 3, 6, and 12 months compared to 2 days after the procedure (all P < 0.01), and decreased gradually. The thickness was significantly reduced at 12 months compared to the first three time points (all P < 0.01). Thrombus was found on the surface of the occluder device in three patients (6.4%) at 3 and 6 months after occlusion. At 6 months after procedure, there were 3 (6.8%) cases of extensive residual right-to-left shunt (RLS), 2 (4.5%) cases of moderate shunt, and 7 (15.9%) cases of small shunts. One year after procedure, 2 (4.5%) cases had a extensive residual shunt, 6 (13.6%) cases of small shunts were confirmed to originate from pulmonary veins by TEE, and the PFO-RLS occlusion rate reached 95.5%.ConclusionThis study demonstrates the feasibility, safety, and effectiveness of NBO for the closure of PFO in humans, with a high rate of complete shunt closure. Accurate TEE assessment of the PFO anatomy before closure with NBO is important to ensure that the procedure remains safe and effective. Furthermore, TEE plays a crucial role in the Post-procedure follow-up.

Phase contrast cardiac magnetic resonance imaging versus transoesophageal echocardiography for the evaluation of feasibility for transcatheter closure of atrial septal defects

BackgroundThis prospective study was aimed at comparing phase contrast cardiac magnetic resonance imaging (PC-CMR) with 2D transoesophageal echocardiography (TEE) for determining potential candidature for transcatheter closure in ostium secundum ASD (OS-ASD) patients. We included consecutive adult patients with OS-ASD for the evaluation of feasibility for transcatheter closure using 2D-TEE and PC-CMR over a period of 2 years. Patients who fulfilled the conventional criteria for transcatheter closure, i.e. maximum ASD diameter ≤ 34 mm, adequate rims (≥ 5 mm, except for anterosuperior rim), and normal pulmonary venous drainage on both imaging modalities, were taken for device closure. In patients where there was discrepancy in the measurements of ASD diameter or rim size, making them eligible for device closure on one imaging modality and ineligible on the other hand, provisional device closure was attempted. All patients who underwent transcatheter closure were followed up to 6 months to rule out any complications.ResultsA total of 58 patients (mean age 35.93 ± 10.59 years) were enrolled in the study. Overall, there was significant positive correlation between 2D-TEE and CMR measurements of maximal ASD diameter and rim size (p < 0.001). However, TEE significantly underestimated maximal ASD diameter and posteroinferior rim size in comparison with CMR (p = 0.013 and p = 0.023, respectively). 46 (79.3%) patients were suitable for transcatheter closure on CMR, while 44 (75.9%) were eligible on TEE. Transcatheter closure was attempted in 48 patients based on imaging findings and was successful in 46 (95.8%) patients. Device closure was unsuccessful in 2 patients with defect size < 34 mm on TEE but > 34 mm on CMR. Among 7 patients with deficient posteroinferior rim on TEE, 5 had sufficient rim on CMR and underwent successful transcatheter closure. CMR detected anomalous pulmonary venous drainage in one patient which was missed on TEE, hence excluding the patient from transcatheter closure. Mean device size was 28.3 ± 7.4 mm and correlated more strongly with the defect dimensions on PC-CMR (r = 0.85, p < 0.001) compared to TEE (r = 0.71, p = 0.02).ConclusionsPC-CMR may to be superior to 2D-TEE for the preprocedural planning and feasibility assessment for transcatheter closure in adult patients with ostium secundum ASD.

Evaluation of Cardiac Space-Occupying Lesions by Myocardial Contrast Echocardiography and Transesophageal Echocardiography.

Heart space-occupying lesions are a disease that occurs frequently in clinical setting, and therefore, it is important to diagnose and treat this type of pathologies properly. Angiographic echocardiography and transesophageal sonogram are widely used for clinical diagnosis. Their application provides a guarantee for the diagnosis of cardiac space-occupying lesions. In this paper, the application of cardiac contrast echocardiography and transesophageal echocardiography in cardiac space-occupying lesions was studied. Prediction of cardiac lesions can accurately determine the nature of cardiac occupancies and provide a basis for clinical diagnosis and management judgments. The results of pathological analysis and experimental comparison showed that myocardial contrast echocardiography can accurately distinguish tumor and thrombus and make contribution to patients taking appropriate medical measures. At the same time, it can compare conventional transthoracic echocardiography and transesophageal echocardiography. The results showed that TEE could clearly show the cardiac lesions. The experimental data of 76.9% confirmed cases showed that the diagnostic accuracy is greatly improved. TEE can also clearly show small thrombus that TTE cannot, in which 2DTEE can clearly show the boundary between the space-occupying and surrounding tissues, and whether there is a clear boundary between the space-occupying and surrounding tissues is an important distinguishing point of benign and malignant tumors. In addition, the TEE probe can also be used for large angle imaging and multiangle rotation, so as to determine the tumor boundary and the spatial position relationship between the tumor and the surrounding tissue. All in all, myocardial contrast echocardiography and transesophageal echocardiography have better clinical application effect on cardiac space-occupying lesions.

Importance of direct right-to-left shunt as high-risk patent foramen ovale associated with cryptogenic stroke.

Because transcatheter closure of patent foramen ovale (PFO) has become effective for preventing cryptogenic stroke (CS), it is necessary to determine high-risk PFO associated with CS. This study aimed to clarify the importance of direct right-to-left (RL) shunt through the PFO for identifying high-risk PFO. We analyzed 137 patients with and without CS who were confirmed to have PFO. The timing of RL shunt through the PFO was evaluated by cardiac cycles after right atrium (RA) opacification on saline contrast transesophageal echocardiography. Direct RL shunt was defined as microbubbles crossing the PFO before and at the same time of RA opacification. Cardiac cycles of microbubbles crossing the PFO were shorter in patients with CS than in those without CS (2.0 ± 2.2vs .5 ± 1.1, p<0.01). Direct RL shunt was more frequently observed in patients with CS than in those without CS (77%vs 29%, p<0.01), with a sensitivity of 79% and a specificity of 71% for the association with CS. Multivariate analysis revealed that direct RL shunt was related to atrial septal aneurysm and low-angle PFO. Regarding functional features of PFO, the detection rate of CS was 50% for large RL shunt alone, and was increased to 83% when direct RL shunt was added. Direct RL shunt was associated with CS and had the incremental value in detecting PFO associated with CS for large RL shunt. The timing of RL shunt can be valuable for identifying high-risk PFO.

Case report of contrast transesophageal echocardiography to confirm extracorporeal membrane oxygenation (ECMO) catheter position in aortic dissection

Case report of contrast transesophageal echocardiography to confirm extracorporeal membrane oxygenation (ECMO) catheter position in aortic dissection

Echo Rounds: Partial Anomalous Systemic and Pulmonary Venous Return.

Anomalous drainage of a right-sided superior vena cava to the left atrium is a rare variant of systemic venous return anomalies. During the course of investigation for a heart murmur, an asymptomatic child was found to have a superior sinus venosus atrial septal defect with partial anomalous systemic and pulmonary venous drainage. Despite the right superior vena cava overriding the upper end of the atrial septum and draining into the left atrium, the child did not exhibit hypoxemia. Saline contrast transesophageal echocardiography suggested an explanation for the absence of hypoxemia.

A Comparative Study of Invasive Modalities for Evaluation of Pulmonary Arteriovenous Fistula after Bidirectional Glenn Shunt

Development of pulmonary AV fistula (PAVF) after bidirectional glenn shunt (BDG) results in significant cyanosis, impaired exercise performance, and increased morbidity and mortality. We attempted to detect and quantify PAVF in post-BDG patients by saline contrast transesophageal echocardiography (TEE) and compare with pulmonary angiography and pulmonary vein oximetry. This was a prospective study done between 2017 and 2018. Twenty-five children who underwent BDG and planned for cardiac catheterization prior to Fontan completion were included in the study. All patients underwent pulmonary angiography, oximetry, and saline contrast TEE at the time of cardiac catheterization. Twenty-two patients had undergone unilateral BDG surgery and three were palliated by bilateral BDG. The mean oxygen saturation was 80 ± 5.2%. Thirteen patients (52%) had preserved antegrade pulmonary blood flow. Eighteen patients (72%) had PAVF by angiography and oximetry, while 19 (76%) had PAVF identified by contrast echocardiography. There was moderate correlation between the degree of pulmonary venous desaturation and grading of PAVF by contrast echocardiography. PAVF was predominantly located in the lower zones of the lungs. Higher grades of PAVF were not seen in patients with preserved antegrade flow after BDG. Angiographically detected PAVF showed a steady increase with increasing delay to cardiac catheterization from BDG. Significant reduction in systemic saturation was limited to advanced grades of PAVF in patients after BDG. Saline contrast TEE, pulmonary venous oximetry, and pulmonary angiography equally identified PAVF in patients after BDG. Prognostic utility of the same needs to be assessed by long-term follow-up of these subjects.

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.

Which characteristics of patent foramen ovale and associated anatomical structures determine risk of cryptogenic brain ischemia?

Abstract Background Linking of the characteristics of persistent foramen ovale (PFO) and associated septal/atrial structures to a causal role in cryptogenic stroke is not definitely known. Purpose In a prospective study to assess the risk of morphological and functional features of PFO and selected septal/atrial structures for cryptogenic stroke or transient ischemic attack (TIA). Methods A total of 1 270 consecutive patients underwent contrast transesophageal echocardiography – 702 patients with cryptogenic brain ischemia and 568 controls without the history of stroke or TIA. We compared 224 patients with cryptogenic stroke or TIA and PFO (31.9% of all patients with brain ischemia) to 106 controls with PFO (18.7% of the control group) (p&amp;lt;0.001). We analyzed diameter and length of the PFO, presence of the large PFO (diameter ≥4 mm), long PFO (length ≥10 mm), atrial septal aneurysm (excursion ≥15 mm), Eustachian valve or Chiari network, shunt severity (graded with a 1–3 scale) and the right-to-left shunt present under basal conditions. Results All parameters of PFO significantly increased relatíve risk (RR) of cryptogenic stroke/TIA vs population without PFO [RR (95% CI); p]: PFO – 2.04 (1.57; 2.66); &amp;lt;0.001, large PFO – 4.99 (2.67; 9.39); &amp;lt;0.001, PFO with diameter ≥ median 2.4 mm – 3.20 (2.19; 4.68); &amp;lt;0.001, long PFO – 2.25 (1.65; 3.06); &amp;lt;0.001, PFO with length ≥ median 12 mm – 2.26 (1.61; 3.17); &amp;lt;0.001, moderate or large shunt – 2.25 (1.65; 3.08); &amp;lt;0.001, shunt present under basal conditions – 2.47 (1.74; 3.52); &amp;lt;0.001. None of the associated structures (atrial septal aneurysm, atrial septal aneurysm + PFO, Eustachian valve or Chiari network, atrial septal defect) significantly increased RR of cryptogenic stroke/TIA vs population without the respective structure. In a multivariable logistic regression model PFO diameter ≥ median 2.4 mm and long PFO emerged as significant risk factors of stroke or TIA. Patients with brain ischemia had significantly larger PFO diameter and higher prevalence of large PFO compared to controls (3.1±2.0 mm vs 2.3±1.4 mm, p&amp;lt;0.001; 8.8% vs 2.1%, p&amp;lt;0.001). Symptomatic patients had significantly higher prevalence of long tunnel (23.2% vs 12.3%, p&amp;lt;0.001) and of moderate/large shunt (22.2% vs 11.8%, p&amp;lt;0.001). There was no significant difference between patients and controls in prevalence of atrial septal aneurysm, atrial septal aneurysm + PFO, Eustachian valve or Chiari network, atrial septal defect. Conclusions Among the parameters of PFO large diameter was the most powerful risk factor of cryptogenic brain ischemia. Long PFO, moderate/large shunt and shunt present under basal conditions also significantly increased the risk. Associated septal/atrial structures were not found as risk factors. Funding Acknowledgement Type of funding source: None

The Efficacy of Contrast Transthoracic Echocardiography and Contrast Transcranial Doppler for the Detection of Patent Foramen Ovale Related to Cryptogenic Stroke.

Background Patent foramen ovale (PFO) has been linked to the pathophysiology of cryptogenic stroke. Contrast transesophageal echocardiography (cTEE) is the current gold standard for PFO diagnosis, but it has the disadvantage of being semi-invasive and does not exempt from risks. As a diagnostic test, the efficacy of contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) is controversial. This study is aimed at investigating the efficacy of cTTE and cTCD versus cTEE in PFO detection, exploring a more cost-effective and reliable method for the diagnosis of PFO related to cryptogenic stroke. Methods From August 2019 to January 2020, a total of 213 patients with suspected PFO were included in our study. All patients underwent cTEE, cTCD, and cTTE examinations. cTTE3 was named for using a cutoff of 3 beats to detect PFO during cTTE, and cTTE5 represented a cutoff of 5 beats. A cutoff of cTCD grade III was named cTCD III. A cutoff of grade IV was named cTCD IV. cTTE3+cTCD IV was used for the combination of a cutoff of 3 beats during cTTE with grade IV of cTCD. cTTE5+cTCD III combined a cutoff of 5 beats during cTTE with cTCD grade III. Taking cTEE as the gold standard, we compared the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate for PFO detection among the above methods. Results A total of 161 of 213 (76%) patients had PFO confirmed by cTEE. With the spontaneous Valsalva maneuver, the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTTE3 in PFO diagnosis were 60%, 90%, 44%, and 10%, respectively, and those for cTTE5 were 76%, 78%, 31% and 22%, respectively. The sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTCD III were 80%, 71%, 29%, and 29%, respectively, while those for cTCD IV were 55%, 90%, 49%, and 10%, respectively. When cTTE and cTCD were combined to diagnose PFO, the specificity and misdiagnosis rate were significantly improved, especially cTTE3+cTCD IV, with 100% specificity and a misdiagnosis rate of 0. Conclusion cTTE or cTCD can be used for preliminary PFO related to cryptogenic stroke findings. The combination of the two methods can improve the specificity of PFO diagnosis, especially using the cutoff of cTTE3+cTCD IV.

Diagnosis of Patent Foramen Ovale: The Combination of Contrast Transcranial Doppler, Contrast Transthoracic Echocardiography, and Contrast Transesophageal Echocardiography.

Objectives To access the distinct values of contrast transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE) in the diagnosis of right-to-left shunt (RLS) due to patent foramen ovale (PFO) and to define the most practical strategy for the diagnosis of PFO. Methods 102 patients with a high clinical suspicion for PFO had simultaneous cTCD, cTTE, and cTEE performed. The agitated saline mixed with blood was used to detect right-to-left shunt (RLS). Results In all 102 patients, the shunt was detected at rest by cTCD in 60.78% of cases, by cTTE in 42.16%, and by cTEE in 47.06%. The positive results of all 3 techniques with Valsalva maneuver (VM) were significantly improved. cTCD showed higher pick-up rate than cTTE (98.04% vs. 89.22%; χ2 = 12.452, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, Conclusions The best method to diagnose PFO should be the combination of cTCD, cTTE, and cTEE. And cTCD should be applied as the first choice for screening RLS. Then, cTTE should be performed to quantify the severity of the shunt. Last but not least, cTEE should be performed to assess the morphologies of PFO when the closure is planned. The study provides for clinicians the most practical strategy for diagnosing PFO in the future. However, further trials with a large sample size are required to confirm this finding.

Chronic Small Cortical Cerebellar Infarctions on MRI are Associated with Patent Foramen Ovale in Young Cryptogenic Stroke

Background: In acute infarction patients, small cortical cerebellar infarctions (SCCI) on MRI (assessed on diffusion-weighted imaging, with SCCI often chronic and asymptomatic) are associated with acute cardioembolic infarction. In young cryptogenic stroke patients, patent foramen ovale (PFO) is thought to be a potential source of cardioembolic infarction. We hypothesize that SCCI on MRI would be associated with PFO in young cryptogenic stroke patients. Methods: A total of 321 consecutive young (≤50 years) stroke patients admitted between January 2015 and July 2019 were screened. Of these patients, 287 patients had diagnostic work-up including early-phase MRI, intra- and extracranial vessel imaging, contrast transoesophageal or contrast transthoracic echocardiography, and ≥24 h ECG-monitoring. We retrospectively analyzed MRI scans of the 112 patients with cryptogenic stroke, including 63 with and 49 without PFO. Between both groups, we compared baseline characteristics (including cardiovascular risk factors and history of stroke), MRI characteristics of acute symptomatic infarction (cortical/subcortical localization, arterial territory, lesion number, and lesion size in case of subcortical infarction), atrial septum aneurysm (ASA) presence, and acute and chronic SCCI and non-SCCI lesions assessed on diffusion-weighted imaging. Results: Groups with and without PFO were comparable in regard to performed vessel imaging and echocardiography modalities, baseline characteristics, and acute infarction characteristics, except for more frequent current smoking (67 vs. 44%, p = 0.022) and multiterritorial infarction (14 vs. 0%, p = 0.0024) and less frequent ASA (10 vs. 48%, p < 0.001) in the group without PFO. Risk of Paradoxal Embolism score was >6 in 76% of patients with PFO. SCCI was more frequent in patients with than without PFO (33 vs. 10%, p = 0.0061; OR 4.4, 95% CI 1.5–12.7), with chronic and asymptomatic SCCI in the vast majority of cases. No difference was observed for non-SCCI lesions. Conclusions: Chronic SCCI are strongly associated with PFO in young cryptogenic stroke patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04043559.

Risk and significance of venous air embolism at neurosurgical operations in the position of sitting at adults. Article

Background. Currently, the patientʼs sitting position has largely lost popularity among neurosurgeons mainly due to fears of possible complications. This position involves certain risks, the most dangerous of which are venous air embolism and paradoxical air embolism. Materials and methods. We report a retrospective study that included 66 neurosurgical patients operated on in a sitting position in 2 years. Preoperative examination, anesthetic management, and intraoperative monitoring have been standardized. The analysis included data from anesthetic charts and protocols of intaoperative monitoring. Results. Of 66 patients, 24 (36 %) were diagnosed with patent foramen ovale using contrast transesophageal echocardiography with Valsalva breakdown. The anomaly was not considered as a contraindication for surgery in a sitting position. Venous air embolism during surgery was diagnosed in 34 patients (51.5 %). However, clinically significant complications developed in 3 patients (4.5 %). None of the patients had complications requiring therapy in the postoperative period. Conclusion. Our study shows that an anaesthetic support model like ours is effective in preventing major complications associated with the patientʼs sitting position. The fear of fatal complications seems unfounded.