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Diagnostic Accuracy of Transthoracic Echocardiography With Contrast for Detection of Right-to-Left Shunt: A Systematic Review and Meta-analysis. Can J Cardiol 2022; 38:1948-1958. [PMID: 35995285 DOI: 10.1016/j.cjca.2022.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 08/15/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The clinical utility of transthoracic echocardiography with contrast (TTE-C) for detection of right-to-left shunt (RLS) remains unknown. In this meta-analysis we evaluated the accuracy of TTE-C for RLS diagnosis compared with transesophageal echocardiography (TEE) as the reference standard. METHODS A systematic review and meta-analysis was performed using a search of MEDLINE, EMBASE, PubMed, and Cochrane library databases. Studies that were included provided data to assess sensitivity and specificity of TTE-C compared with TEE for RLS detection. RESULTS A total of 35 studies, involving 4209 patients, were analyzed. The average patient age was 49.1 ± 11.2 years and 53.9% were male. For RLS detection in the entire cohort, TTE-C sensitivity was 73% (95% confidence interval [CI], 66%-80%) and specificity was 94% (95% CI, 92%-96%). The sensitivity of TTE-C was 80% (95% CI, 74%-86%) in studies published in 2000 or later compared with 51% (95% CI, 36%-65%) in those published before 2000. In studies that used harmonic imaging, TTE-C sensitivity was 82% (95% CI, 77%-87%) and specificity was 95% (95% CI, 93%-97%). Among those with patent foramen ovale closure indications, TTE-C sensitivity was 74% (95% CI, 59%-89%) and specificity was 98% (95% CI, 95%-100%). In patients in whom RLS was diagnosed using a guideline-suggested 3 cardiac cycle cutoff, TTE-C sensitivity was 75% (95% CI, 66%-83%) and specificity was 94% (95% CI, 92%-97%). Provocative manoeuvres increased sensitivity by approximately 40%. CONCLUSIONS TTE-C offers excellent specificity and moderate sensitivity for RLS diagnosis compared with TEE, and it might therefore serve as an initial screening modality for selected patients with a high likelihood of having RLS and for indications for treatment.
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Cagini L, Cardaioli G, Andolfi M, Savino K, Eusebi P, Corbelli I, Simoni S, Vannucci J, Sacchini E, Ripandelli F, Matricardi A, Puma F. Interatrial Shunting Through an Asymptomatic Patent Foramen Ovale in Thoracic Surgery. Ann Thorac Surg 2019; 107:1040-1045. [DOI: 10.1016/j.athoracsur.2018.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 09/30/2018] [Accepted: 10/17/2018] [Indexed: 10/27/2022]
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Mahmoud AN, Elgendy IY, Agarwal N, Tobis JM, Mojadidi MK. Identification and Quantification of Patent Foramen Ovale-Mediated Shunts: Echocardiography and Transcranial Doppler. Interv Cardiol Clin 2017; 6:495-504. [PMID: 28886841 DOI: 10.1016/j.iccl.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Once deemed benign, patent foramen ovale (PFO)-mediated right-to-left shunting has now been linked to stroke, migraine, and hypoxemia. Contrast transesophageal echocardiography is considered the standard technique for identifying a PFO, allowing visualization of the atrial septal anatomy and differentiation from non-PFO right-to-left shunts. Transthoracic echocardiography is the most common method for PFO imaging, being cost-effective, but has the lowest sensitivity. Transcranial Doppler is highly sensitive but is unable to differentiate cardiac from pulmonary shunts; it is the best method to quantitate shunt severity, being more sensitive than transthoracic or transesophageal echocardiography so is our preferred screening method for PFO.
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Affiliation(s)
- Ahmed N Mahmoud
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Islam Y Elgendy
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Nayan Agarwal
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Jonathan M Tobis
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Factor Building CHS, Room B-976, Los Angeles, CA 90095, USA
| | - Mohammad Khalid Mojadidi
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA.
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Wang Y, Zeng J, Yin L, Zhang M, Hou D. Modified Right Heart Contrast Echocardiography Versus Traditional Method in Diagnosis of Right-to-Left Shunt: A Comparative Study. Pol J Radiol 2016; 81:428-33. [PMID: 27668027 PMCID: PMC5019139 DOI: 10.12659/pjr.897388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 01/29/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the reliability, effectiveness, and safety of modified right heart contrast transthoracic echocardiography (cTTE) in comparison with the traditional method. MATERIAL/METHODS We performed a modified right heart cTTE using saline mixed with a small sample of patient's own blood. Samples were agitated with varying intensity. This study protocol involved microscopic analysis and patient evaluation. 1. Microscopic analysis: After two contrast samples had been agitated 10 or 20 times, they underwent a comparison of bubble size, bubble number, and red blood cell morphology. 2. Patient analysis: 40 patients with suspected RLS (right- to-left shunt) were enrolled. All patients underwent right heart contrast echocardiography. Oxygen saturation, transit time and duration, presence of RLS, change in indirect bilirubin and urobilinogen concentrations were compared afterward. RESULTS Modified method generated more bubbles (P<0.05), but the differences in bubble size were not significant (P>0.05). Twenty-four patients were diagnosed with RLS (60%) using the modified method compared to 16 patients (40%) with the traditional method. The transit time of ASb20 group was the shortest (P<0.05). However, the duration time in this group was much longer (P<0.05). Also, in semi-quantitative analysis mean rank of RLS was higher after injecting the modified contrast agent agitated 20 times (P<0.05). CONCLUSIONS Modified right heart contrast echocardiography is a reliable, effective and safe method of detecting cardiovascular RLS.
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Affiliation(s)
- Yi Wang
- Institute of Ultrasound Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, P.R. China
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Jie Zeng
- Department of Cardiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, P.R. China
| | - Lixue Yin
- Institute of Ultrasound Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, P.R. China
| | - Mei Zhang
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, P.R. China
| | - Dailun Hou
- Department of Medical Image, Shandong Chest Hospital, Jinan, Shandong, P.R. China
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D’Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/22/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called “paradoxical embolism”, most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called “microembolic signal grading score”. In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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D'Andrea A, Conte M, Riegler L, Scarafile R, Cocchia R, Pezzullo E, Cavallaro M, Di Maio M, Natale F, Santoro G, Russo MG, Scherillo M, Calabrò R. Transcranial Doppler Ultrasound: Incremental Diagnostic Role in Cryptogenic Stroke Part II. J Cardiovasc Echogr 2016; 26:71-77. [PMID: 28465966 PMCID: PMC5224669 DOI: 10.4103/2211-4122.187947] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied in both outpatient and inpatient settings. Its main use in current clinical practice is the research for “Paradoxical Embolism,” due to migration of thromboembolic material from systemic venous circulation to the left cardiac chambers and arterial circulation through cardiopulmonary shunts such as patent foramen ovale which represents an important cause of cryptogenic stroke, especially in patients under 55 years of age. In this review, we shall describe the incremental diagnostic role in cryptogenic stroke for this imaging modality. TCD not only can be used to detect right-left cardiopulmonary shunts but it also allows to classify the grade of severity of such shunts using the so-called “Microembolic Signals grading score.”
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Marianna Conte
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Lucia Riegler
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Marco Di Maio
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Francesco Natale
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Giuseppe Santoro
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
| | | | - Raffaele Calabrò
- Department of Cardiology, Second University of Naples, Monadi Hospital, Naples, Italy
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Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Gevorgyan R, Zolty R. Two-dimensional echocardiography using second harmonic imaging for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies. Int J Cardiovasc Imaging 2014; 30:911-23. [PMID: 24740212 DOI: 10.1007/s10554-014-0426-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/11/2014] [Indexed: 01/17/2023]
Abstract
Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients being considered for transcatheter closure. While transesophageal echo (TEE) bubble study is the current standard reference for diagnosing PFO, transthoracic echo with second harmonic imaging (TTE-HI) may be a preferable screening test for RLS due to its high accuracy and non-invasiveness. The aim of this meta-analysis was to determine the accuracy of TTE-HI compared to TEE as the reference. A systematic review of Medline, Cochrane and Embase was done for all the prospective studies assessing for intracardiac RLS using TTE-HI compared to TEE as the reference; both TTE-HI and TEE were performed with a contrast agent and a maneuver to provoke RLS in all studies. A total of 15 studies with 1995 patients fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TTE-HI were 91 and 93 % respectively. Likewise, the positive and negative likelihood ratios were 13.52 and 0.13 respectively. TTE-HI is a reliable, non-invasive test with proficient diagnostic accuracies. The high sensitivity and specificity of TTE-HI make it a useful initial screening test for RLS. If the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.
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Affiliation(s)
- Mohammad Khalid Mojadidi
- Department of Medicine, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Building 1, Rm 3N1, Bronx, NY, USA,
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Li Y, Ya-nan Z, Li-qun W. Which Technique Is Better for Detection of Right-to-Left Shunt in Patients with Patent Foramen Ovale: Comparing Contrast Transthoracic Echocardiography with Contrast Transesophageal Echocardiography. Echocardiography 2014; 31:1050-5. [PMID: 24495142 DOI: 10.1111/echo.12523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Yue Li
- Ultrasound Department of Chinese; PLA General Hospital; Beijing China
| | - Zhai Ya-nan
- Ultrasound Department of Chinese; PLA General Hospital; Beijing China
| | - Wei Li-qun
- Ultrasound Department of Chinese; PLA General Hospital; Beijing China
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Ren P, Li K, Lu X, Xie M. Diagnostic value of transthoracic echocardiography for patent foramen ovale: a meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1743-1750. [PMID: 23820251 DOI: 10.1016/j.ultrasmedbio.2013.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 03/06/2013] [Accepted: 03/08/2013] [Indexed: 06/02/2023]
Abstract
As a non-invasive and convenient modality, transthoracic echocardiography (TTE) has been widely recommended for the diagnosis of patent foramen ovale (PFO). In this study our aim was to systematically review the diagnostic accuracy of TTE in detection of PFO. We conducted comprehensive searches in PubMed, Embase and the Cochrane Library to the end of September 1, 2012. Sixteen studies comprising 1831 patients were included in the meta-analysis. The quality of reported studies was modest. The summary sensitivity and specificity of TTE in diagnosis of PFO were 88% (95% confidence interval [CI], 79-94) and 97% (95% CI, 92-99), respectively. The positive likelihood ratio was 27.1 (95% CI, 11.2-65.1), and the negative likelihood ratio was 0.12 (95% CI, 0.07-0.22). The summary diagnostic odds ratio was 221 (95% CI, 95-518). Subgroup analyses suggested that age and initial disease may affect the accuracy of TTE in detection of PFO. The meta-analysis suggested that TTE is a test with high sensitivity and specificity in detection of PFO, but it may not be appropriate for screening for PFO in all patients, especially patients with a small right-left shunt.
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Affiliation(s)
- Pingping Ren
- Department of Ultrasonography, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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D'Andrea A, Calabrò R. The diagnosis of cryptogenic stroke: is the combined ultrasound approach the right choice? J Cardiovasc Med (Hagerstown) 2011; 12:527-9. [PMID: 21720222 DOI: 10.2459/jcm.0b013e32834976d6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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De Marchis E, Di Legge S, Sallustio F, Stanzione P, Borzi M, Romeo F. Cryptogenic cerebral ischemia. J Cardiovasc Med (Hagerstown) 2011; 12:530-7. [DOI: 10.2459/jcm.0b013e328344e4ed] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Juliard JM, Aubry P, Ducrocq G, Lepage L, Brochet E. Should we close hypoxaemic patent foramen ovale and interatrial shunts on a systematic basis? Arch Cardiovasc Dis 2009; 102:739-41. [DOI: 10.1016/j.acvd.2009.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 10/20/2009] [Indexed: 10/20/2022]
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