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Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography

ABSTRACT: Abstract A patent foramen ovale (PFO) is a common remnant of fetal circulation present in up to 25% of the worldwide adult population. Paradoxical embolism occurs when venous blood crosses the PFO into the arterial system, bypassing the pulmonary circulation. This allows for the direct passage of microemboli into cerebral blood vessels, increasing the risk of cryptogenic stroke. This review investigates the current diagnostic procedures used to detect and grade a PFO, including transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and transcranial Doppler (TCD). Only a few studies have directly compared the use of TTE with TCD for PFO detection but several have compared TTE and TCD independently against the clinical gold standard TOE. Known pitfalls of TTE and TCD are also discussed, including the difficulty of differentiating between intracardiac shunts and intrapulmonary shunts. This review also discusses methods to optimise imaging, such as performing an adequate Valsalva manoeuvre, the role of abdominal compression and the choice of the injection site for the contrast agent and how these may increase the diagnostic success of detecting a right‐to‐left shunt when prompted by a clinician.

SUBMITTER: Van der Giessen H

PROVIDER: S-EPMC8411673 | biostudies-literature |

REPOSITORIES: biostudies-literature

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

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

| S-EPMC6358410 | biostudies-literature

Modified Method of Contrast Transthoracic Echocardiography for the Diagnosis of Patent Foramen Ovale.

Project description:PurposeTo compare the sensitivity and specificity of modified and traditional methods of contrast echocardiography of the right portion of the heart in patients with a suspicion of patent foramen ovale (PFO).MethodsThe study population consisted of 506 patients with high clinical suspicion of PFO. The traditional Valsalva maneuver consists of expiration against a closed glottis after a full inspiration. A modified Valsalva maneuver was performed with a handmade pressure monitoring device, which measured pressure during performance of the Valsalva maneuver. Modified and traditional methods of contrast echocardiography were performed among all patients. Contrast transesophageal echocardiography (TEE) was regarded as the gold standard.ResultsA total of 279 patients with PFO were confirmed by TEE. 259 cases (sensitivity: 92.83%) were detected by a modified method of contrast echocardiography of the right portion of the heart, while 234 cases were detected using the traditional method (sensitivity: 83.87%). The sensitivity of modified contrast echocardiography of the right portion of the heart was significantly higher than that of the traditional method (92.83% vs. 83.87%, P=0.001). However, there was no significant difference in the specificity of the two methods for the diagnosis of PFO (97.35% vs. 96.03%, P=0.431). Additionally, the results of semiquantitative evaluation of PFO using modified method failed to show a more positive rate than shown by the traditional method (Z=-1.782, P=0.075).ConclusionsModified contrast echocardiography of the right portion of the heart yielded a higher sensitivity than the traditional method, which contributed to the diagnosis of cardiac PFO. The research was a part of a register study (https://register.clinicaltrials.gov/ ClinicalTrials ID: NCT02777359).

| S-EPMC6532309 | biostudies-literature

Diagnosis of large, mobile thrombus in transit within a patent foramen ovale by echocardiography.

Project description: Not available

| S-EPMC8015975 | biostudies-literature

Patent foramen ovale diagnosed by real-time three-dimensional contrast transesophageal echocardiography: A case report.

Project description:A 67-year-old man was admitted due to insensitiveness of right upper limb and dysarthria, and treated for suspected lacunar infarction or branch atherosclerotic disease. Carotid ultrasonography showed no abnormalities, and agitated contrast transesophageal echocardiography was performed to detect patent foramen ovale (PFO). Intravenously administered microbubbles did not appear in left atrium by 2-dimensional echocardiography, while contrasts were observed in left atrium using 3-dimensional echocardiography. Real-time 3-dimensional contrast transesophageal echocardiography may be the most useful method for the diagnosis of small PFO. <Learning objective: The presence of patent foramen ovale has been suggested as a potential cause of paradoxical embolism and, in particular, of cerebral emboli in stroke of unknown origin. Transthoracic or transesophageal contrast echocardiography is the method for the detection of the patent foramen ovale, however, real-time 3-dimensional contrast transesophageal echocardiography has an advantage for this purpose.>.

| S-EPMC6275290 | biostudies-literature

Life-threatening paradoxical thromboembolism in a patient with patent foramen ovale

Project description:Background Venous thromboembolism represents the third most frequent acute cardiovascular syndrome worldwide. Its clinical manifestations are deep vein thrombosis and/or pulmonary embolism. Despite a considerable mortality, diagnosis is often missed. Case presentation We report the management of a female patient with high-risk pulmonary thromboembolism treated initially with thromboaspiration, complicated by embolus jailing in a patent foramen ovale. In this situation, left cardiac chambers and systemic circulation were jeopardized by this floating embolus. Conclusions High-risk pulmonary embolism requires reperfusion strategy but sometimes mechanical thromboaspiration may be not fully successful; transesophageal echocardiography led to a prompt diagnosis of this unexpected finding; in this very particular case, open surgery represented a bail-out procedure to avoid cerebral and systemic embolism. Supplementary Information The online version contains supplementary material available at 10.1186/s12947-022-00298-x.

| S-EPMC9703718 | biostudies-literature

The Genetic Landscape of Patent Foramen Ovale: A Systematic Review.

Project description:Patent Foramen Ovale (PFO) is a common postnatal defect of cardiac atrial septation. A certain degree of familial aggregation has been reported. Animal studies suggest the involvement of the Notch pathway and other cardiac transcription factors (GATA4, TBX20, NKX2-5) in Foramen Ovale closure. This review evaluates the contribution of genetic alterations in PFO development. We systematically reviewed studies that assessed rare and common variants in subjects with PFO. The protocol was registered with PROSPERO and followed MOOSE guidelines. We systematically searched English studies reporting rates of variants in PFO subjects until the 30th of June 2021. Among 1231 studies, we included four studies: two of them assessed the NKX2-5 gene, the remaining reported variants of chromosome 4q25 and the GATA4 S377G variant, respectively. We did not find any variant associated with PFO, except for the rs2200733 variant of chromosome 4q25 in atrial fibrillation patients. Despite the scarceness of evidence so far, animal studies and other studies that did not fulfil the criteria to be included in the review indicate a robust genetic background in PFO. More research is needed on the genetic determinants of PFO.

| S-EPMC8700998 | biostudies-literature

First direct evidence of a Patent Foramen Ovale (PFO): a large thrombus straddling the foramen ovale.

Project description: Not available

| S-EPMC4771941 | biostudies-literature

Systematic Review of Treatment for Trapped Thrombus in Patent Foramen Ovale.

Project description:Background and objectivesTrapped thrombus in patent foramen ovale (PFO) is a rare complication of pulmonary embolism that may lead to tragic clinical events. The aim of this study was to identify the optimal treatment for different clinical situations in patients with trapped thrombus in a PFO by conducting a literature review.Subjects and methodsA PubMed database search was conducted from 1991 through 2015, and 194 patients (185 articles) with trapped thrombus in a PFO were identified. Patient characteristics, paradoxical embolic events, and factors affecting 60-day mortality were analyzed retrospectively.ResultsAmong all patients, 112 (57.7%) were treated with surgery, 28 with thrombolysis, and 54 with anticoagulation alone. Dyspnea (79.4%), chest pain (33.0%), and syncope (17.5%) were the most common presenting symptoms. Pretreatment embolism was found in 37.6% of cases, and stroke (24.7%) was the most common event. Surgery was associated with fewer post-treatment embolic events than were other treatment options (p=0.044). In the multivariate analysis, initial shock or arrest, and thrombolysis were independent predictors of 60-day mortality. Thrombolysis was related with higher 60-day mortality compared with surgery in patients who had no initial shock or arrest.ConclusionThis systematic review showed that surgery was associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality in patients with trapped thrombus in a PFO. In patients without initial shock or arrest, thrombolysis was related with a higher 60-day mortality compared with surgery.

| S-EPMC5614954 | biostudies-literature

Role of transoesophageal echocardiography in detecting patent foramen ovale in stroke patients aged ≤60 years: A retrospective study.

Project description:BackgroundThe underlying aetiology of ischaemic strokes is unknown in as many as 50% of cases. Patent foramen ovale (PFO) has become an increasingly recognised cause of ischaemic strokes in young patients. The present study aimed (1) to assess the frequency of transoesophageal echocardiography (TOE) performed and the proportion of PFOs detected in patients aged ≤60 years and (2) examine the effect of PFO closure on reducing stroke reoccurrence.MethodsThis was a retrospective clinical audit based on de-identified, secure medical records of the Canberra Hospital, Australia. A review of records was conducted on discharged patients aged 18-60 years admitted to the stroke unit following an ischaemic stroke episode between January 1, 2015, and December 31, 2018.ResultsA total of 214 acute ischaemic stroke patients were admitted to the stroke unit (mean age, 49.2 ± 9.7 years). Concerning aetiology, 47.2% were cryptogenic in origin, whereas 52.8% had a stroke of a determined cause. 12 patients were diagnosed with a PFO and 7 venous thromboembolic events were identified, 1 in the cryptogenic group and 6 in the determined cause group. 91.7% of PFOs were diagnosed in patients with a cryptogenic stroke. Trans-thoracic echocardiography (TTE) was performed in 37.3% of patients and had detected 4 PFOs (sensitivity 27.3%, specificity 92.5%). TOE was performed in 26.2% of patients and had detected 11 PFOs (sensitivity 90.0%, specificity 100%). The number needed to treat to prevent the occurrence of an ischaemic stroke through PFO closure was estimated at 30.ConclusionsAn inverse association between age and PFO presence was found in patients aged 18-60 years. Additionally, TOE was superior to TTE for detecting PFO, particularly in those with stroke of an undetermined cause. Our results suggest an increased need for TOE as a routine imaging procedure for acute ischaemic stroke patients aged ≤60.

| S-EPMC7703908 | biostudies-literature

Patent foramen ovale closure in a patient with vena cava filter: a case report.

Project description:BackgroundThe presence of a patent foramen ovale (PFO) is associated with several medical conditions, including cryptogenic left circulation thromboembolism. PFO closure was demonstrated to reduce recurrent ischaemic stroke in patients with prior cryptogenic stroke. The presence of an inferior vena cava filter (IVCF), however, may impede a transfemoral PFO closure procedure.Case summaryWe describe the case of a 50-year-old man with a PFO suffering from ischaemic stroke from paradoxical thromboembolism originating from deep vein thrombosis and requiring an IVCF. After deep vein thrombosis resolution, due to the high risk of stroke recurrences, the patient was recommended PFO closure. IVCF retrieval by the interventional radiologist was first attempted but failed. A transfemoral PFO closure procedure was thus endeavoured with the IVCF in place and was successful. The patient was then discharged in good clinical status and no stroke recurrences were reported at 5 months follow-up.DiscussionAlbeit an IVCF provides benefit in patients with recurrent thromboembolic events despite adequate anticoagulation therapy, its presence may hinder interventional procedures necessitating delivery systems to advance through the inferior vena cava. We reported on a successful PFO closure procedure via a femoral venous access in a patient with an IVCF in place, thus demonstrating the feasibility of advancing delivery systems through an IVCF. As interventional procedures requiring the advancement of delivery systems through the inferior vena cava are becoming increasingly common, the feasibility of IVCF crossing with catheters and delivery systems alike paves the way for novel interventional possibilities.

| S-EPMC8343425 | biostudies-literature

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