c-TCD应用加血生理盐水混合液与生理盐水混合液诊断右向左分流阳性率的比较

目的 比较经颅多普勒超声声学造影（c-TCD)应用加血生理盐水混合液（ASB）与生理盐水混合液（AS)作为对比剂诊断右向左分流(RLS)的阳性检出率（阳性率）。方法 收集不明原因脑卒中和（或）偏头痛患者521例。分别应用生理盐水混合液、加血生理盐水混合液在静息及Valsalva动作（Valsalva maneuver,VM)条件下行c-TCD检查并进行比较。结果 ASB组静息状态下c-TCD 检测RLS阳性率29.9%(156/521),VM后阳性率45.1%(235/521)。AS组RLS阳性率14.2%(74/521),VM后阳性率可达33.0%(172/521)。两组VM后阳性率均明显高于静息状态（P<0.01）。ASB组静息状态或VM后阳性率均显著高于AS组（P<0.05）。ASB组静息状态或VM后RLS程度亦显著高于AS组。结论 加血生理盐水混合液对比剂应用于c-TCD可显著提高诊断RLS的阳性率。     

右心声学造影对卵圆孔未闭右向左分流的检出情况

目的 应用经胸超声心动图(TTE)结合经胸右心声学造影（cTTE）检查评估不明原因脑卒中患者卵圆孔未闭右向左分流发生情况。方法 连续选取不明原因脑梗死患者285例,正常人114例。所有患者均行TTE检查,后用空气加血激活的生理盐水（ASB）行cTTE检查,观察有无右向左分流(right to left shunt,RLS）,并进行分级。结果 不明原因脑梗死组cTTE与正常人群组cTTE比较:RLS总阳性率51% vs. 32%（P<0.01）,少量组14% vs. 10%（P>0.05）,中量组6% vs. 3%（P>0.05）,大量组31% vs. 19%（P<0.01）。结论 cTTE是不明原因脑梗死患者RLS有效的检查手段。     

卵圆孔未闭（右向左分流）与隐源性缺血性脑卒中的关系及筛检评价

目的 探讨卵圆孔未闭（PFO）与隐源性缺血性脑卒中（CS）的相关性,并评价其筛检价值。 方法 回顾性分析2018年6月~2019年12月我科及神经内科门诊因CS而就诊的患者。根据TOAST分型诊断为CS的患者为CS组141例,同期于我科、神经内科门诊就诊并排除脑卒中者为对照组76例。CS组及对照组均根据年龄各自分为两组:中青年组（<55岁）、老年组（≥55岁）。所有患者门诊均行经胸超声心动图声学造影（cTTE）检查初筛PFO,cTTE初筛PFO-RLS阳性后均行经胸超声心动图（TTE）和经食管超声心动图（TEE）证实PFO的诊断。进而分析CS组与对照组PFO-RLS阳性率的比较,以及PFO-RLS在不同年龄段CS组中的比较,采用四格表法计算评价指标。 结果 CS组共141例,其中中青年患者83例,老年患者58例。对照组共76例,其中中青年患者54例,老年患者22例。CS组PFO-RLS阳性发生率为63%,对照组发生率为17%,CS组PFO-RLS阳性率显著高于对照组（P<0.01）。CS中青年组患者PFO-RLS阳性率为65%,CS老年组患者PFO-RLS阳性率为60%,CS两不同年龄组PFO-RLS阳性率的差异无统计学意义。最后将经cTTE初筛后PFO-RLS阳性的102例患者行常规TTE排除其他先天性心脏病,102例PFO-RLS患者均行TEE检查,最终全部证实为PFO,用cTTE初筛PFO-RLS阳性的方法其灵敏度63%,特异度83%,阳性预告值87%。 结论 ①PFO-RLS与CS密切相关;②cTTE简便易行,可作为PFO的初筛手段。     

经颅多普勒超声声学造影与经胸超声心动图造影对卵圆孔未闭右向左分流诊断的比较

目的 比较经颅多普勒超声声学造影(c-TCD)和经胸超声心动图声学造影（c-TTE）对卵圆孔未闭(PFO)右向左分流(RLS)的诊断。方法 选取PFO伴反常栓塞患者195例,均接受c-TTE和c-TCD检查。经肘前静脉注射激活盐水对比剂,观察记录PFO-RLS微泡数量并进行半定量分级。对上述2种检查至少1种结果为阴性的58例患者进一步行经食管超声心动图声学造影（c-TEE）,以c-TEE的结果作为标准,分别对2种检查结果进行对照分析。结果 195例患者c-TCD和c-TTE对PFO- RLS的检出率分别为75.9%（148/195）、88.2%（172/195）,差异有统计学意义（P<0.05）。对2种检查PFO-RLS半定量分级的χ2检验显示,Ⅰ级c-TCD阳性检出率高于c-TTE,差异有统计学意义（P<0.01）;Ⅱ级c-TCD阳性率稍高于c-TTE,但差异未达到显著水平;Ⅲ级和Ⅳ级c-TTE阳性率高于c-TCD,差异有统计学意义（P<0.05）。195例患者中,有58例 c-TCD或c-TTE结果为阴性并进行了c-TEE检查。以c-TEE结果作为标准,对比上述2种检查的准确性,结果显示c-TCD与c-TEE结果有显着差异,差异有统计学意义（P<0.01）,c-TTE与 c-TEE结果较为接近,差异无统计学意义。结论 c-TTE 对 PFO-RLS 的检出阳性率优于 c-TCD,可以作为临床筛查PFO的首选方法。     

cTTE联合TEE诊断卵圆孔未闭右向左分流的临床价值

目的 应用胸超声心动图声学造影（cTTE）联合经食管超声心动图（TEE）检查,诊断卵圆孔未闭（PFO）引发右向左分流（RLS）的临床价值。 方法 对246例临床疑似存反常栓塞的患者先行cTTE 检查观察并对比静息状态及Valsalva动作后RLS情况,并作分流程度的评估;对有RLS的患者再行TEE检查,观察PFO是否存在,测量PFO开放直径、观察PFO形态及其他伴随病变,最终明确PFO-RLS。对PFO-RLS病例组中PFO开放直径与RLS严重程度之间行关联性分析。 结果 cTTE发现不同程度RLS 174例,无RLS 72例。Valsalva动作后比静息状态下RLS的检出率明显增高,差异有统计学意义（P< 0.01）。174例RLS患者TEE检出PFO患者163例,其中129例彩色多普勒存在房水平左向右分流,34例房水平分流不明显。163例PFO-RLS,PFO直径与RLS程度之间存在相关性,但呈低度关联（CP=0.34,P<0.05,）。 结论 cTTE 能快速的发现房水平RLS并半定量判定分流程度,联合TEE可以清晰显示PFO形态及准确测量其开放直径,进而确诊PFO-RLS。PFO直径与RLS严重程度存在低度关联。     

TTE结合cTTE在卵圆孔未闭介入治疗中的应用

目的 探讨经胸超声心动图（TTE）结合经胸超声心动图右心声学造影（cTTE）在卵圆孔未闭（PFO）介入治疗中的应用价值。方法 入选我院90例行介入封堵治疗的PFO患者,年龄（40±15）岁。用TTE、cTTE及食管超声心动图（TEE）评估、检测及随访。结果 90例PFO患者,TTE或TEE检查符合简单型PFO 52例（58%）、复杂型PFO 38例（42%）。术前cTTE检查,38例（42%）于静息状态下检出右向左分流（RLS）,其中少量24例(27%)、中量11例(12%)和大量3例(3%),Valsalva动作除8例（9%）为中量RLS外,余均为大量RLS。Valsalva动作后大量RLS检出率明显高于静息状态（P<0.01）。52例简单型PFO患者均用PFO封堵器,其中18/25 mm、30/30 mm和25/35 mm封堵器各用38例（73%）、6例（12%）和8例（15%）,18/25 mm封堵器使用率明显高于30/30 mm和25/35 mm封堵器（P<0.01）。38例复杂型PFO患者,37例用单封堵器,其中30/30 mm和25/35 mmPFO封堵器分别为16例（42%）和17例（45%）、房间隔缺损（ASD）封堵器4例（11%）。1例PFO并发ASD的患者,孔间距为20 mm,应用18/18 mm和25/35 mm双封堵器。术后cTTE随访:3个月、半年、1年完全堵闭率（无RLS）分别为40%、67%和74%。术后1年残余RLS为23例,其中22例(96%)微泡出现时间超过5个心动周期。结论 TTE结合cTTE在PFO封堵术前病例筛查、术中指导封堵器选择及术后疗效评价中均有着不可或缺的作用,对保证PFO封堵治疗成功具有重要价值。     

经胸超声心动图声学造影与经颅多普勒超声声学造影同步试验对卵圆孔未闭的诊断价值

目的:探讨经胸超声心动图声学造影(cTTE)与经颅多普勒超声声学造影(cTCD)同步试验对卵圆孔未闭(PFO)的诊断价值。方法:选取我院疑似PFO患者769例,其中在静息和Valsalva动作下行cTTE 298例、cTTE与cTCD同步试验471例。以经食道超声心动图(TEE)为PFO的诊断标准,分析cTTE与cTCD同步试验对PFO的诊断价值。结果:共纳入769例患者,其中Valsalva动作下PFO阳性263例(34.2%)。298例患者行cTTE检查,静息时PFO阳性30例(10.1%),Valsalva动作下PFO阳性104例(34.9%),Valsalva动作下PFO阳性率较静息时显著提高(P<0.05)。471例患者行cTTE与cTCD同步试验,静息时PFO阳性50例(10.6%),Valsalva动作下PFO阳性159例(33.7%),Valsalva动作下PFO阳性率较静息时显著提高(P<0.05)。以TEE为PFO确诊标准,Valsalva动作下cTTE诊断PFO的准确性为87.5%(40/44),cTTE与cTCD同步实验诊断PFO的准确性为95.2%(40/42)。结论:cTTE与cTCD同步试验能提高PFO的诊断价值,尤其是Valsalva动作下PFO阳性率明显提高;cTTE与cTCD同步试验较cTTE诊断准确性提高。     

TTE联合右心声学造影筛查PFO的价值及介入封堵治疗中期疗效

目的 应用经胸超声心动图（transthoracic-echocardiography,TTE）及经胸右心声学造影（contrast transthoracic-echocardiography,cTTE）筛查隐源性卒中、不明原因晕厥及偏头痛患者中卵圆孔未闭（patent foramen ovale,PFO）的检出率及经皮介入封堵治疗PFO的中期疗效。 方法 选取167例临床诊断为隐源性卒中、不明原因晕厥及偏头痛的患者,均行TTE检查及cTTE检查,根据微气泡右向左分流（the right-to-left shunt,RLS）数量进行量化分级,分为I级、Ⅱ级和Ⅲ级。选取Ⅲ级RLS患者22例,右心选择性造影证实为PFO并根据形态选择合适封堵器行封堵治疗,术后1、3、6个月门诊及电话随访,术后6个月行cTTE复查。 结果 167例患者行cTTE,静息状态下RLS有67例（40.1%）,Valsalva动作后RLS有85例（50.9%）,其中I级分流23例（13.8%）,Ⅱ级分流12例（7.2%）,Ⅲ级分流50例（29.9%）。在3种不同疾病中,隐源性卒中并发PFO检出率为43.5%;不明原因晕厥并发PFO检出率68.0%;偏头痛并发PFO检出率为47.9%;22例行PFO封堵患者,随访6个月,临床症状改善,无并发症,复查cTTE均未见残余分流。 结论 TTE联合cTTE是筛查PFO重要的无创检查手段;两者结合对隐源性卒中、不明原因晕厥及偏头痛并发PFO有较高的检出率。介入封堵治疗PFO能有效预防隐源性卒中、晕厥再发、明显减轻偏头痛症状。     

经颅多普勒超声造影和经食道超声心动图造影在诊断卵圆孔未闭中的不同价值

目的 比较经颅多普勒超声造影（contrast transcranial doppler，cTCD）和经食管超声心动图造影（contrast transesophageal echocardiography，cTEE）在诊断卵圆孔未闭（patent foramen ovale，PFO）右向左分流（right to left shunt，RLS）中的不同价值。 方法 回顾性分析2018年1月至2019年5月因偏头痛或不明原因脑卒中于我院神经内科就诊并明确诊断为PFO的70例患者cTCD和cTEE检查的影像学资料。 结果 70名患者中，cTCD在静息状态下检出67%存在分流，cTEE检出43%存在分流。在Valsalva动作（Valsalva maneuver，VM）下，两种检查对PFO-RLS的检出率均提高。cTCD对PFO-RLS的检出率高于cTEE，差异有统计学意义(96% vs 83%; x2 = 12.157，P < 0.05)，且cTCD对RLS的半定量分级明显高于cTEE（Z = 40.211，P < 0.05）。cTEE可以准确评估PFO的解剖形态，RLS分流程度与PFO内径呈正相关（r = 0.701，P < 0.05），与PFO隧道长度无相关性（r=0）。 结论 cTCD和cTEE是诊断PFO-RLS互补的检查方法。cTCD由于其高检出率和无创性可用于初步筛查PFO-RLS，对准备进一步行PFO封堵的患者，行cTEE检查观察PFO解剖形态。     

3种不同手振声学造影剂在右心声学造影中应用的对比研究

目的:比较使用手振激活加血生理盐水、手振激活50%葡萄糖溶液与传统手振激活生理盐水进行右心声学造影的稳定性、有效性、敏感性、安全性,为临床选择右心声学造影剂提供参考。方法:选取2015-01-2017-08成都市第三人民医院、成都大学附属医院门诊及住院患者中怀疑有右向左分流(RLS)的患者(不明原因脑卒中、短暂性脑缺血发作、先兆性偏头痛)105例。所有患者均采用振荡20次的3种不同手振声学造影剂进行造影。记录患者右心微泡显影持续时间;观察RLS情况并进行半定量分析;监测患者造影前后的心率、血压、呼吸频率、血氧饱和度。结果:手振加血激活生理盐水、手振激活50%葡萄糖溶液较传统手振激活生理盐水空气微气泡使用时右心微泡显影持续时间长,差异有统计学意义(P0.01),手振加血生理盐水空气微气泡较手振50%葡萄糖溶液空气微气泡右心微泡显影持续时间长,差异有统计学意义(P0.05);手振加血激活生理盐水、手振激活50%葡萄糖溶液较传统手振激活生理盐水对于RLS检出率更高,差异有统计学意义(P0.05),手振加血激活生理盐水与手振激活50%葡萄糖溶液对RLS检出率无统计学差异(P0.05),但手振加血激活生理盐水对于Ⅱ、Ⅲ级分流敏感度更高,差异有统计学意义(P0.05);所有患者造影前后心率、血压、呼吸频率、血氧饱和度差异无统计学意义(P0.05)。结论:手振加血激活生理盐水、手振激活50%葡萄糖溶液是2种经济、安全、有效的右心声学造影剂,尤其是手振加血激活生理盐水,其造影效果较传统手振激活生理盐水更好,制备方便,值得临床推广。     

Harmonic imaging improves sensitivity at the expense of specificity in the detection of patent foramen ovale

Contrast echocardiography using agitated saline is widely employed to detect right to left shunt in patients with suspected patent foramen ovale (PFO). The sensitivity of fundamental transthoracic echocardiography (FTTE) is often limited by poor far-field resolution. The purpose of this study was to evaluate the test characteristics of harmonic imaging during transthoracic echocardiography (HTTE) for the detection of PFO. METHODS: Sixty-four patients referred for transesophageal echo (TEE) for clinical indications underwent FTTE and HTTE during saline contrast injections. RESULTS: TEE identified nine PFOs. For FTTE, the sensitivity was 78% and the specificity was 100%. For HTTE, the sensitivity was 100% and the specificity was 82%. All ten false positives with HTTE occurred after five cardiac cycles, suggesting transpulmonary transit of the bubbles. CONCLUSION: In the detection of PFO, HTTE improves sensitivity at the expense of specificity, particularly if the timing of contrast appearance in the left heart is ignored.     

Overcoming a stubborn patent foramen ovale

Transesophageal echocardiography (TEE) with agitated saline contrast (“bubble study”) is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.     

Platypnea-orthodeoxia of a 69-year old woman with a patent foramen ovale

Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale (PFO) or atrial septal defect. We describe the case of a 69-year-old woman with progressive dyspnea and hypoxia when standing, which was relieved by assuming the recumbent position. After detection of a PFO by transesophageal echocardiography the diagnosis was confirmed by transthoracic echocardiography using saline contrast injection while lying supine and standing upright. This maneuver demonstrated a large right-to-left shunt through a patent foramen ovale while the patient was in a upright position and no significant shunt while being in a recumbent position. The patient showed a rapid improvement after closure of the PFO. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be easily demonstrated by the technique of contrast transthoracic echocardiography and a simple positioning maneuver.     

Transcranial Doppler with contrast injection for the detection of patent foramen ovale in stroke patients

Right-to-left shunt through a patent foramen ovale was searched for in 80 patients with acute ischemic stroke by simultaneously performing transthoracic two-dimensional echocardiography and transcranial Doppler during agitated saline injection. A patent foramen ovale was detected by echocardiography in 14 patients (17.5%). Transcranial Doppler correctly identified all 14 patients, and 7 more patients in whom echocardiographic findings were indeterminate. Prevalence of patent foramen ovale by transcranial Doppler was therefore 26.3% (21 of 80 patients). Concordance between the two tests was 91.3% (73 of 80 patients). The delivery of contrast material to cerebral vessels is therefore demonstrable by transcranial Doppler in all patients diagnosed by contrast echocardiography, suggesting that paradoxical embolization through a patent foramen ovale may be more frequent than previously thought. Transcranial Doppler with contrast injection is a valid alternative in case of poor echocardiographic image quality.     

Patent Foramen Ovale Not So Patent

Transesophageal echocardiography (TEE) with agitated saline contrast is the most sensitive tool for diagnosing patent foramen ovale (PFO), but false positives can result. We report a patient who underwent a TEE during the study of a cryptogenic stroke. Contrast appeared in the left atrium with the Valsalva maneuver. However, the contrast exit site was not identified, and contrast continued to appear with Valsalva once the saline microbubbles had disappeared. Combined with the contrast characteristics, this suggested a spontaneous contrast phenomenon rather than a PFO. This phenomenon must be kept in mind to avoid overdiagnosing PFO .     

Comparison of the degree of right atrial opacification seen on intracardiac echocardiography following femoral or antecubital injection of saline contrast

It is thought that femoral injection of agitated saline contrast is better for detecting patent foramen ovale than antecubital injection mainly because of the nature of intraatrial flow where the venae cavae enter the heart. Our aim was to investigate the effect of the contrast injection site on the degree of right atrial opacification seen on intracardiac echocardiography. The degree of right atrial opacification after each femoral or antecubital injection of saline contrast was scored from 0-4 in 21 patients. It was shown that the degree of right atrial opacification was greater after femoral than antecubital injection (3.76 vs. 1.62; P<.001). Future studies comparing the two routes of saline contrast injection should control for the degree of right atrial opacification.     

Significance of left-sided heart disease for the detection of patent foramen ovale by transesophageal contrast echocardiography.

Detection of patent foramen ovale by contrast echocardiography is based on transient inversion (right atrial pressure higher than left atrial pressure) of the interatrial pressure gradient. Therefore, the presence of left-sided heart disease with potential elevation of left atrial pressure might obscure the diagnosis of patent foramen ovale. Accordingly, 150 patients (88 men, 62 women; mean age 51.7 +/- 15.2 years) were evaluated for a patent foramen ovale by transesophageal contrast echocardiography. Additionally, atrial septal motion during normal respiration and during the Valsalva maneuver was analyzed. Patency of the foramen ovale was observed in 20 (27%) of 74 patients without left-sided heart disease and with previous arterial embolism, in none (0%) of 25 patients with left-sided heart disease and embolism, in 7 (39%) of 18 patients without left-sided heart disease and without embolism and in 3 (9%) of 33 patients with left-sided heart disease and without embolism. The detection rate of patent foramen ovale was lower in patients with than without left-sided heart disease (5% vs. 29%, p = 0.0007) but was similar in patients with and without embolism (20% vs. 19.5%, p = NS). Abnormal atrial septal motion was more frequently observed in patients with left-sided heart disease (p = 0.0003) and was inversely correlated to detection of patent foramen ovale (p = 0.0003). Multivariate analysis revealed an independent association between the absence of left-sided heart disease and the detection of patent foramen ovale (p = 0.0003). These data suggest that in patients with left-sided heart disease, patency of the foramen ovale may be missed even by transesophageal contrast echocardiography.     

When to use femoral vein injection for diagnosis of patent foramen ovale—Effect of a persistent eustachian valve on right atrial flow patterns during contrast transesophageal echocardiography

Contrast echocardiography using agitated saline injected into the antecubital vein is the most common method used for the diagnosis of patent foramen ovale. We describe a case whereby the presence of a persistent eustachian valve and a “negative contrast sign” during contrast transesophageal echocardiography raised suspicion of a false‐negative result. Femoral vein injection of contrast successfully demonstrated a patent foramen ovale. Femoral vein injection should be considered if this scenario is recognized because the eustachian valve directs blood preferentially from the inferior vena cava toward the interatrial septum and this route may prove to be more reliable.