Transthoracic Contrast Echocardiography Research Articles

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.

Positive Relationship Between Paroxysmal Vertigo and Right-to-Left Shunt: A Large Observational Study.

BackgroundThe association between paroxysmal vertigo and right-to-left shunt (RLS) is rarely reported. This study investigates the prevalence and correlation of RLS in patients with different paroxysmal vertigo diseases.MethodsPatients with paroxysmal vertigo from seven hospitals in China were included in this observational study between 2017 and 2021. Migraine patients within the same period were included for comparison. Demographic data and medical history were collected; contrast transthoracic echocardiography was performed; and the clinical features, Dizziness Handicap Inventory, and incidence of RLS in each group were recorded.ResultsA total of 2,751 patients were enrolled. This study's results demonstrated that the proportion of RLS in patients with benign recurrent vertigo (BRV) and vestibular migraine (VM) was significantly higher than that in patients with benign paroxysmal positional vertigo, Meniere's disease, and vestibular paroxysmia (P < 0.05). No statistical difference was shown between the frequency of RLS in patients with BRV and those with migraine and VM. A positive correlation was shown between the RLS grade and Dizziness Handicap Inventory scores of patients with VM and BRV (P < 0.01) after effectively controlleding the effect of confounding variables.ConclusionsRLS was significantly associated with BRV and VM. RLS may be involved in the pathogeneses of BRV and VM and may serve as a differential reference index for the paroxysmal vertigo.Trial RegistrationCHRS, NCT04939922, registered 14 June 2021- retrospectively registered, https://register.clinicaltrials.gov.

Abstract No. 390 Comparison of graded transthoracic contrast echocardiography and high resolution chest CT for pulmonary arteriovenous malformation follow-up in the early post-embolization period

Pulmonary arteriovenous malformations (PAVMs) treated with embolotherapy are typically followed using high-resolution chest CT (HRCT) to assess for PAVM persistence requiring retreatment. A prior study demonstrated that graded transthoracic contrast echocardiography (TTCE) can reliably predict the need for retreatment when compared with HRCT, potentially offering a radiation-free follow-up modality. However, many TTCEs performed in that study were compared with HRCTs performed at 5- and 10- year post-embolotherapy follow-up visits and those TTCEs and HRCTs were not always performed concurrently.

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.

Impact of the Birth Transition on Striated Muscle Function in Normal Development

Considerable changes are expected in the regulation of myocardial and limb skeletal muscle perfusion from the pre‐ to post‐natal condition based on changes in gravitational force, work load, and arterial O2 content. Yet the impact of birth on the growth and function of microvasculature in striated muscle is poorly understood. Our objective was to assess resting and maximal microvascular flow in the cardiac left ventricle (LV; with high workload before and after birth), and biceps femoris (BF; hindlimb muscle with little workload before birth). We hypothesized that resting flow in the fetus exceeds that in the neonate because of low fetal arterial O2 content, but that flow reserve is greater in the neonate in order to support ambulation. We expected this increase in reserve to be greater in skeletal than myocardial muscle.Fetuses (N=8) were instrumented at 130 d gestational age (dGA, birth is at 146 d) and studied exteriorized from the uterus at 135 dGA. Lambs (N=8) were instrumented 2 d after birth and studied at 5 d. Instrumentation included arterial, venous, and left atrial catheters for systemic pressure monitoring, arterial blood sampling, and drug delivery; and an inflatable occluder around the descending thoracic aorta. Myocardial perfusion (Q) in mL/min/g of tissue was assessed by transthoracic contrast echocardiography at rest, during adenosine‐induced hyperemia, and during combined hyperemia and increased perfusion pressure produced by transient constriction of the postductal aorta. Work was determined by the product of heart rate and perfusion pressure. Hindlimb BF muscle Q was assessed at rest, and during contractile work produced by electrostimulation (2 Hz, 10 mA). Differences were assessed by the Mann‐Whitney U‐test. One fetus and one lamb were excluded from analysis because of abnormal blood gasses at the time of study.At rest, LV myocardial Q was 2‐fold higher in fetuses than neonates (Fig 1A), as was Q normalized to work; whereas, O2 delivery was similar between groups (Fig 1B). Maximal flow during hyperemia followed a similar pattern, with fetal Q, as well as Q per work, exceeding that in the neonate by a factor of 7, whereas maximal O2 delivery per work was similar between age groups. Skeletal muscle (BF) flow in the fetus was highly variable both at rest and during exercise. Median resting Q, resting O2 delivery, and exercised flow were all at least 5‐fold higher in the fetus than neonate, however the difference only reached statistical significance for resting flow (Fig 1A,B). Exercise O2 delivery was similar between ages. Flow reserve was similar between the fetus and neonate in both myocardium and skeletal muscle (Fig 1C).At rest, elevated flow in the fetal LV supported similar levels of O2 delivery per work as found in the newborn. Surprisingly, there was a tendency for increased O2 delivery in the fetal skeletal muscle compared to the newborn; we speculate that this reflects differences in regulation of non‐nutritive flow between the ages studied. Overall, the results of this study suggest that despite the dramatically different physiological circumstances between the fetus and newborn, microvascular growth is regulated to preserve similar levels of flow reserve in both.

High prevalence of patent foramen ovale in recreational to elite breath hold divers

ObjectivesDuring apnea diving, a patent foramen ovale may function as a pressure relief valve under conditions of high pulmonary pressure, preserving left-ventricular output. Patent foramen ovale prevalence in apneic divers has not been previously reported. We aimed to determine the prevalence of patent foramen ovale in apneic divers compared to non-divers. DesignCross sectional. MethodsApnea divers were recruited from a training camp in Cavtat, Croatia and the diving community of Split, Croatia. Controls were recruited from the population of Split, Croatia and Eugene, Oregon, USA. Participants were instrumented with an intravenous catheter and underwent patent foramen ovale screening utilizing transthoracic saline contrast echocardiography. Appearance of microbubbles in the left heart within 3 cardiac cycles indicated the presence of patent foramen ovale. Lung function was measured with spirometry. Comparison of patent foramen ovale prevalence was conducted using chi-square analysis, p < .05. ResultsApnea divers had a significantly higher prevalence of patent foramen ovale (19 of 36, 53%) compared to controls (9 of 36, 25%) (X2 (1, N = 72) = 5.844, p = .0156). ConclusionsWhy patent foramen ovale prevalence is greater in apnea divers remains unknown, though hyperbaria during an apnea dive results in a translocation of blood volume centrally with a concomitant reduction in lung volume and alveolar hypoxia during ascent results in hypoxic pulmonary vasoconstriction. These conditions increase pulmonary arterial pressure, increasing right-atrial pressure allowing for right-to-left blood flow through a patent foramen ovale which may be beneficial for preserving cardiac output and reducing capillary hydrostatic forces.

Diffuse large B-cell lymphoma presenting as reversible intrapulmonary arteriovenous shunts with hypoxia, fever and progressive jaundice: a case report and literature review

BackgroundIntrapulmonary arteriovenous shunts is rare seen in a patient without lung involvement.Case presentationThis is the first report of reversible intrapulmonary arteriovenous shunts secondary to extrapulmonary lymphoma as one initial symptom. The patient presented as fever of unknown origin and dyspnea, and examinations of infection were negative. Diagnosis of DLBCL was finally confirmed through bone marrow and splenic biopsies. Intrapulmonary arteriovenous shunts were diagnosed through 100% oxygen inhalation test and transthoracic contrast echocardiography (TTCE). After the treatment of lymphoma, his respiratory failure was relieved. We rechecked the 100% oxygen inhalation test and TTCE, which both indicated that his intrapulmonary arteriovenous shunts had resolved.ConclusionsWe speculated the prominent inflammation from active DLBCL was the most possible mechanism associated with the reversible intrapulmonary shunt in this patient. These findings will assist us to better understand the mechanism of intrapulmonary shunts.

Association between patent foramen ovale and migraine without aura: a community-based cross-sectional study in China

ObjectivesTo assess the influence of patent foramen ovale (PFO) on the prevalence of migraine without aura based on propensity score-matched samples in Southwest China.DesignPropensity-matched cross-sectional study.ParticipantsResidents over 20 years of...

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.

Unmasking Hypoxia in Cirrhosis Patients: Six-Minute Walk Test as a Screening Tool for Hepatopulmonary Syndrome.

Background:Hepatopulmonary syndrome (HPS) is one of the complications of advanced cirrhosis which has a serious impact on prognosis of patient. Finding arterial deoxygenation early and initiating higher-level treatment is one of the most critical strategies in the therapy of HPS. In this study, we aimed to assess the utility of six-minute walk test (6MWT) in the diagnosis of HPS.Materials and Methods:We have enrolled 100 consecutive cirrhosis patients referred to the Liver Clinic of a tertiary care centre of India for >1 year. The Child-Pugh score and the MELD score were used to determine the severity of cirrhosis. All the patients underwent transthoracic contrast echocardiography, arterial blood gas measurements on room air, 6MWT, and chest imaging.Results:A total of 100 patients were included in the study after fulfilling the inclusion criteria. HPS was present in 21 out of 100 patients (21%). Median (twenty fifth to seventy fifth percentile) MELD score in patients with HPS was 29 (26–33), which was significantly higher as compared to patients without HPS 22 (14.5–26); P <.0001. The 6MWT was positive in 20 (95.23%) HPS patients, while only 1 patient (4.77%) of HPS had negative 6MWT. If 6MWT is positive, then there was 76.92% probability of HPS and if 6MWT is negative, then 98.65% chances of no HPS.Conclusion:The 6MWT is a simple and effective screening test for HPS, it helps in identifying the patients early who have a potential to deteriorate. This simple intervention would help in prioritizing patients for liver transplantation as liver transplant is the only effective treatment for HPS.

Party Balloon Inflation Maneuver During Saline Contrast Transthoracic Echocardiography to Detect Patent Foramen Ovale

Saline contrast echocardiography requires an adequate provocation method for the detection of patent foramen ovale. The party balloon inflation maneuver during saline contrast transthoracic echocardiography is easy to explain to patients and objectively assesses the performance of provocative maneuvers by a clinician by watching balloon inflation. (Level of Difficulty: Intermediate.)

A Machine Learning Approach Based on Spatio-Temporal Informations in the Detection of Patent Foramen Ovale from Contrast Transthoracic Echocardiography Images: A Primary Study

A Machine Learning Approach Based on Spatio-Temporal Informations in the Detection of Patent Foramen Ovale from Contrast Transthoracic Echocardiography Images: A Primary Study

Cyanosis in a Previously Well Child.

Cyanosis in a Previously Well Child.

Multimodal echocardiography in the diagnosis of masses localized to the proximal portions of pulmonary arteries.

Proximal pulmonary artery masses are exceedingly rare, and their diagnosis and therapy are important and challenging for clinicians. This study reviews our experience exploring the value of a combination of transthoracic echocardiography and contrast echocardiography for the differential diagnosis of proximal pulmonary artery masses. Between January 2018 and June 2021, 44 patients diagnosed with a mass attached to the major pulmonary artery and straddling the bilateral pulmonary arteries or pulmonary valve on transthoracic echocardiography were referred to this study. Contrast echocardiography was performed in 17 patients. Masses were diagnosed based on their site of attachment, shape, size, mobility, hemodynamic consequences on transthoracic echocardiography, and tissue perfusion on contrast echocardiographic perfusion imaging. Pathological data were collected from medical records and analyzed. The most frequent location of proximal pulmonary artery masses was the major pulmonary artery trunk. Twelve patients underwent complete mass resection, whereas nine patients underwent percutaneous pulmonary artery biopsy puncture and had a pathological diagnosis. Another 24 patients were confirmed with the validation methods. Contrast echocardiography has good sensitivity and specificity for differentiating thrombi from pulmonary artery sarcomas (PAS). The mass types were distributed as follows: thrombi (19, 43%), PAS (15, 34%), metastatic tumors (6, 14%), vegetations (3, 7%), and primary benign lesions (1, 2%). The majority of proximal pulmonary artery masses were thrombi or PAS. A combination of transthoracic echocardiography and contrast echocardiography offers advantages in the early identification of proximal pulmonary masses and provides clinically important information about the characteristics of masses, especially for differentiating thrombi from PAS.

Importance of saline contrast transthoracic echocardiography for evaluating large right-to-left shunt in patent foramen ovale associated with cryptogenic stroke

Transcatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing recurrent stroke in very specific patient cohorts, such as cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of saline contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. We enrolled 119 patients with or without CS who were confirmed to have PFO by transesophageal echocardiography (TEE) or catheterization. The severity of RL shunt evaluated by TTE and TEE was classified as follows: small (< 10 microbubbles), moderate (10–20 microbubbles), and large (> 20 microbubbles). With TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With TEE, large RL shunt was observed in 33 (28 %) patients, including 26 with CS and 7 without CS. TTE showed large RL shunt more frequently than TEE (p < 0.01). Large RL shunt evaluated by TTE had a sensitivity of 89 % and an accuracy of 70 % for the association with CS, whereas large RL shunt evaluated by TEE had a sensitivity of 35% and an accuracy of 56 %. Accuracy was significantly greater in TTE than in TEE (p = 0.02). In conclusion, TTE identified large RL shunt associated with CS with higher sensitivity and accuracy compared to TEE. Our findings suggest that the decision for device closure should be made based on the severity of RL shunt by TTE.

Applicability of Transthoracic Contrast Echocardiography for the Diagnosis and Treatment of Idiopathic Pulmonary Arteriovenous Malformations.

Objective: To explore the preferred test to screen for pulmonary arteriovenous malformations (PAVMs) and to predict the probability of interventional embolization.Methods: We performed a retrospective observational study evaluating patients with idiopathic PAVMs from 2009 to 2019. After clinical evaluation, a total of 105 patients were studied, including 71 patients with positive digital subtraction pulmonary angiography (DSPA) findings and 34 with negative DSPA findings. The following patient data were assessed: blood test, chest radiograph, transthoracic contrast echocardiography (TTCE), and DSPA findings.Results: The majority of patients with idiopathic PAVMs were female (66.2% with positive DSPA findings). We found a good κ-coefficient of 0.77 with strong consistency for inter observer agreement concerning the pulmonary right-to-left shunt (RLS) grade on TTCE, which was superior to conventional chest radiographs. The positive predictive value (PPV) of the radiographic features for PAVMs on DSPA was 0.83 (95% CI 0.64–1.0) and 0.44 for the possibility of embolization (95% CI 0.19–0.70). The PPV of the shunt grade of PAVMs on DSPA was 0.14 (95% CI 0.01–0.29) for grade 1, 0.74 (95% CI 0.60–0.88) for grade 2, and 0.97 (95% CI 0.92–1.0) for grade 3. The PPVs of pulmonary shunt grades 2 and 3 on TTCE for the possibility of embolization for PAVMs were 0.21 (95% CI, 0.05–0.36) and 0.87 (95% CI, 0.79–0.99), respectively.Conclusion: TTCE is the preferred screening test for PAVMs. The pulmonary RLS grade on TTCE not only identifies the likelihood of PAVMs but also predicts the probability for embolization.

Reduction in Pulmonary Arterial Pressure at Rest and During Exercise and Improvement in Gas Exchange Efficiency Following Percutaneous Closure of Patent Foramen Ovale

PURPOSE The patent foramen ovale (PFO) is a source of intracardiac right-to-left shunt and is present in ~1/3rd of the adult population. Deficits in pulmonary gas exchange efficiency associated with PFO have been well-documented (Lovering et al, J Appl Physiol 2016). However, changes in pulmonary artery pressure and total pulmonary resistance (TPR) following closure have not previously been reported. METHODS Four candidates (3F, 1M) for closure of PFO were identified by local cardiologists and referred to our laboratory as subjects. 3 subjects (3F) received physician clearance to participate in the exercise trials. 1 subject (1M) was not cleared for exercise so only resting measures were taken. Presence and size of PFO was confirmed utilizing transthoracic saline contrast echocardiography (TTSCE). A radial arterial catheter was placed utilizing aseptic technique. Subjects exercised at 4 sub-maximal workloads (25%, 50%, 75% and 90% of pre-closure VO2Max), with arterial blood drawn anaerobically during the last 30 seconds of each workload and immediately analyzed in duplicate for gas content. Transthoracic ultrasound measures of cardiac output (QT) and pulmonary arterial systolic pressure (PASP) were taken prior to exercise and during the final minute of each workload. TPR was calculated as PASP/ QT. Subjects then underwent percutaneous closure of PFO utilizing a commercially available closure device (Amplatzer PFO Occluder, Abbott, Illinois; Cardioform Septal Occluder, GORE, Arizona). All measures were repeated in the laboratory 3-6 months after closure of PFO following confirmation of endothelialization of the closure device with TTSCE. RESULTS Data were analyzed by a 2-way (Closure x Workload) RMANOVA. There was a main effect of closure on PASP F(1, 11) = 21.05, p = 0.0008, and a main effect of closure on TPR F(1, 11) = 9.899, p = 0.0093, with reductions in both following closure. There was a main effect of workload, but not closure, on cardiac output F(4, 11) = 60.18, p < 0.0001. There were main effects of both workload F(4,11) = 73665, p = .0033 and closure F(1,11) = 28.31, p = .0002 on pulmonary gas exchange efficiency. CONCLUSION Improvements in pulmonary gas exchange efficiency are expected with removal of the intracardiac right-to-left shunt. However, our results demonstrating a significantly reduced pulmonary artery pressure, due to a significantly reduced TPR, are intriguing and deserve more attention to better understand the contributing factors of a PFO to exercise-induced pulmonary hypertension.

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.

Non diagnosed PAPVC induce large reverse venovenous shunt after modified Fontan surgery: A case report of a rare anomaly and embolization therapy

Fontan operation is a reliable palliative surgery for patients with single ventricle physiology. Still, the development of complication is common; one of these complications that need to interventional approach is veno-venous collaterals between systemic and pulmonary veins. A 16-yearoldgirl with a history of modified Fontan operation at 9 years ago was referred with progressive cyanosis and dyspnea on exertion. In contrast trans-thoracic echocardiography (TTE), no fenestration was seen in Fontan circulation. Cardiac magnetic resonance revealed partial anomalous pulmonary vein connection (PAPVC) from left upper pulmonary vein to vertical vein and then into the in nominate vein and SVC with the reverse flow from superior vena cava (SVC) to left upper pulmonary vein(LUPV). This anomalous vein became severe engorged and tortuous. Possibly, LUPV and the verticalvein was dilated gradually as a result of increased pressure in the Fontan circuit. Finally, she underwent successful coil embolization in the midpart of the vertical vein. The oxygen saturation increased from80% to 93%.

Impact of Patent Foramen Ovale Anatomic Features on Right-to-Left Shunt in Patients with Cryptogenic Stroke

The purpose of this study was to investigate the impact of the morphologic characteristics of patent foramen ovale (PFO) on right-to-left shunt (RLS) in patients with PFO and cryptogenic stroke using transesophageal echocardiography and saline contrast transthoracic echocardiography (c-TTE). Of the 165 patients with PFO stroke, both the height and the length of PFO in the provoked RLS group were smaller than those in the constant RLS group. PFO height, interatrial septum mobility and proportion of atrial septal aneurysms were greater in the severe RLS group than in the mild and moderate RLS groups. Multivariate analysis revealed that PFO height and interatrial septum mobility were independent predictors of severe RLS. Multiple territorial ischemic lesions were more common in the severe RLS or constant RLS group. Our findings indicated that the severity of RLS was related to the anatomic features in PFO, inducing different cerebral ischemia lesion patterns in cryptogenic stroke patients with PFO.