Diagnosis of patent foramen ovale with multiplane transesophageal echocardiography in adult cardiac surgical patients

OBJECTIVE: To evaluate multiplane transesophageal echocardiography (TEE) for detection of patent foramen ovale (PFO) and to compare multiplane TEE with visual inspection (VI) for PFO detection. DESIGN: A prospective observational study. SETTING: University hospital (single institution). PARTICIPANTS: Patients presenting for cardiac surgery requiring TEE. INTERVENTIONS: Multiplane TEE including 2 atrial views with color-flow Doppler (CFD) and contrast echocardiography (CE) with a provocative respiratory maneuver (PRM) and comparison of multiplane TEE and VI with respect to PFO detection. MEASUREMENTS AND MAIN RESULTS: The cohort size was 187. PFO prevalence was 27.3%. CFD with serial decrease of the Nyquist limit detected 51% of all PFO: 41.2% in the bicaval view alone, 27.5% in the 4-chamber view alone, and 9.8% in both views. CE detected 78.4% of all PFO: 72.5% with PRM, 45.1% with no PRM, and 27.4% with/without PRM. PFO detection by multiplane TEE and visual inspection were correlated in 41 subjects. TEE diagnosed 11 PFO (26.8% prevalence, 3 missed by VI). VI diagnosed 12 PFO (29.3% prevalence, 4 missed by TEE). CONCLUSIONS: Multiplane TEE is a gold standard for detection of PFO. Despite advances in TEE technology, 2-dimensional imaging does not detect all PFO. To maximize PFO detection, multiple TEE modalities are required in multiple views, despite a low Nyquist limit for CFD or a PRM for CE. Even though multiplane TEE is equivalent to VI for PFO detection, the discrepancy rate may be an important consideration in the individual case.     

Intraoperative detection of patent foramen ovale by transesophageal echocardiography

This study reports the intraoperative use of contrast and Doppler echocardiography techniques to diagnose patent foramen ovale (PFO). Fifty patients without known atrial septal defects undergoing elective cardiovascular surgery were studied. A 5-MHz esophageal echocardiographic probe was used to image the fossa ovalis (FO) and 10 ml agitated saline was injected into the right atrium during apnea. Echocardiographic contrast was then injected during end-inspiration at 20-cmH2O airway pressure. When opacification of the right atrium was complete, the airway pressure was released. During these maneuvers, color and pulsed-wave Doppler interrogation of the atrial septum were also performed. Right-to-left passage of saline contrast across the interatrial septum was seen in 11 of 50 patients (22%). Doppler echocardiography demonstrated a PFO in 2 patients without contrast evidence of shunting. Thus, the combination of contrast and Doppler echocardiography identified a 26% (13 of 50) prevalence of PFO, approximating the previously reported autopsy rate of 25%. These contrast and Doppler techniques may be useful in detecting patients at risk for paradoxical emboli and in identifying candidates for closure of the PFO.     

Timing of transesophageal echocardiography in diagnosing patent foramen ovale in patients supported with left ventricular assist device

Left ventricular assist devices unload the left ventricle and decrease left atrial pressure. This hemodynamic change may cause a right to left atrial shunt and hypoxemia in patients with patent foramen ovale. We prospectively studied the best time for performing diagnostic transesophageal echocardiography in left ventricular assist device patients. Intraoperative transesophageal echocardiography was performed in 14 patients before cardiopulmonary bypass was initiated and after left ventricular assist device was implanted. No patent foramen ovale was detected when transesophageal echocardiography was done before bypass, but a patent foramen ovale was found in 3 patients when transesophageal echocardiography was performed after left ventricular assist device was activated. Patent foramen ovale was confirmed by inspection in all three patients and surgically closed during the same procedure. There were no patent foramen ovale closure-related complications.     

Thrombus entrapped in a patent foramen ovale of the atrial septum

A 59-year-old women was referred to our hospital due to severe dyspnea and shock status 12 days after intracranial hematoma evacuation for the hypertensive right putaminal hemorrhage. Transthoracic echocardiography revealed right ventricular dilatation and floating structures in the right atrium. Transesophageal echocardiography demonstrated a large, snake-like structure crossing her foramen ovale of the interatrial septum, and impending paradoxical embolism was diagnosed. She did not receive any anticoagulation and surgery due to recent cerebral hemorrhage. Follow-up TEE showed complete disappearance of the thrombus in the atrium two weeks after the onset. Phlebogram of deep vein demonstrated several thrombus in her leg. She underwent placement of inferior vena cava filter and was discharged from our hospital without any symptom of paradoxical embolism.     

Three-dimensional transesophageal echocardiography in the diagnosis of atrial septal aneurysm with patent foramen ovale in a patient with ventricular septal defect

We present a case of a rare combination of ventricular septal defect and atrial septal aneurysm (ASA) with a patent foramen ovale (PFO) in a 57-year-old female. She was referred to our hospital for the treatment of irregular palpitation and exertional shortness of breath. Two-dimensional transesophageal echocardiography (2D-TEE) with color Doppler imaging demonstrated an ASA with two lines of shunt flows. Three-dimensional transesophageal echocardiography (3D-TEE) could clearly visualize the morphology of the PFO in the surgeon??s view and demonstrated a crescent-shaped opening of the PFO. 3D-TEE appears to be a more accurate modality than 2D-TEE for the assessment of PFO.     

经胸超声心动图声学造影评价隐源性脑卒中与卵圆孔未闭的关系

目的应用经胸超声心动图声学造影(cTTE)技术探讨隐源性脑卒中(CS)与卵圆孔未闭(PFO)的关系。方法收集190例CS患者(CS组)及190例年龄、性别相匹配的非卒中对照组患者,并根据年龄分为中青年亚组(≤55岁)及老年亚组(55岁)。应用cTTE技术检查CS组及对照组PFO发生率,对PFO的发生率及缺血性脑卒中危险因素进行组间对照分析,Logistic回归分析PFO与CS的关系。结果中青年CS亚组及老年CS亚组的PFO检出率及PFO合并房间隔瘤(ASA)检出率均高于同年龄段对照组(P0.05)。二元Logistic回归分析PFO是CS的独立危险因素。PFO检出率在中青年CS亚组与老年CS亚组间差异无统计学意义(P0.05)。cTTE检查可显著提高PFO检出率。cTTE检查中CS组右向左分流分级为2、3级的例数较同年龄段对照组明显增多(P0.05)。结论 PFO在不同年龄人群CS的发病中起着重要作用,PFO合并ASA及cTTE检出右向左中到大量的分流能增加脑卒中的风险。经胸超声心动图结合cTTE可作为PFO的常规检查方法。     

The management of patients with patent foramen ovale and stroke

Opinion statement The management of patients with patent foramen ovale (PFO) and stroke remains uncertain. What is known is that PFO is a very common finding in the general population. The risk of initial and recurrent stroke in individuals with PFO is relatively low. With the advent of transesophageal echocardiography, PFO is more commonly being diagnosed. There are insufficient data to support a benefit of warfarin over aspirin in preventing recurrent stroke in most patients with PFO. In those with PFO and a history of a procoagulant state or deep venous thrombosis, anticoagulation may be indicated after weighing the risks of anticoagulation against potential benefits in preventing recurrent stroke. PFO closure does not guarantee the prevention of future stroke and should be addressed case by case, with consideration of patients for entry into ongoing clinical trials of safety, efficacy, and durability.     

TEE引导下外科封堵卵圆孔未闭合并三房心1例

<正>患者男,56岁,3个月前因脑梗死就诊,经颅彩色多普勒发泡实验阳性,TTE明确卵圆孔未闭。拟行TEE引导下卵圆孔封堵术,术中TEE示卵圆孔未闭,直径3 mm;左心房内探及隔膜,一端连接于卵圆窝上缘(图1A),另一端连接于左心耳上方(图1B),中间连接左心房前后壁,将左心房分为副房和真房,副房接受4条肺静脉血流,真房连接卵圆孔未闭、左心耳和二尖瓣口,隔膜孔(真、副房交通口)最大径约28 mm,血流速度150 cm/s;提示:三房心,临床分类     

Contrast echocardiography and transcranial Doppler sonography for detection of a patent foramen ovale

We report the case of a patient, in whom a patent foramen ovale was detected. For the detection of a patent foramen ovale simulation of Valsalva's manoeuvre with a positive airway pressure of 20 cm H2O was applied. Change of ventilation manoeuvre by ventilation with positive airway pressure of 35/30/15 cm H2O at a tidal volume of 1200 ml make a distinct increase in passage of contrast medium from the right to the left atrium. These findings were detected by contrast transesophageal echocardiography and indirectly by transcranial Doppler sonography and were reproducible. This may stress the importance of preoperative screening of patent foramen ovale in patients to be operated on in the sitting position. Contrast echocardiography and the ventilatory manoeuvre with high airway pressure and PEEP might increase the detection rate of patent foramen ovale with a right to left shunt during general anaesthesia.     

Surgical closure of patent foramen ovale in patients with suspected paradoxical embolism: long-term results

OBJECTIVE: It is thought that a patent foramen ovale (PFO) is the crucial mechanism in patients with suspected paradoxical embolism and cryptogenic stroke. It has been hypothesized that closure of the PFO would prevent further cerebrovascular incidents. We describe our early and late experience with surgical closure of the PFO in patients with paradoxical embolism. PATIENTS AND METHODS: Between May 1994 and December 2001, 33 patients (26 men, 7 women; mean age, 55.2 +/- 8.7 years; range, 37-74) underwent surgical closure of a PFO at our institution. All patients had preoperatively suffered from a stroke and/or a transient ischemic attack, after which echocardiography showed a PFO. Mean follow-up at 99 +/- 30 months (range, 10-111 months) was 100% complete. RESULTS: All patients survived the operative procedure. Early complications occurred in four patients (12%). Actuarial survival at 1, 5 and 8 years was 97 +/- 3%, 97 +/- 5% and 94 +/- 8%, respectively. At long-term follow-up all but two patients were alive. The deaths of these two patients were related to malignancy and ischemic heart disease, respectively. Two patients (6%) had suffered a residual cerebrovascular event after successful surgery. CONCLUSION: Surgical closure of PFO in patients with paradoxical embolism can safely be performed with a low risk of early mortality. Residual thromboembolic events were rare and in those few it occurred it did so with the interatrial septum being closed, indicating that in those patients the PFO was not the mechanism of the thromboembolic event in the first place.     

The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients

Transesophageal echocardiography (TEE) is an invaluable intraoperative diagnostic monitor that is considered to be relatively safe and noninvasive. Insertion and manipulation of the TEE probe, however, may cause oropharyngeal, esophageal, or gastric trauma. We report the incidence of intraoperative TEE-associated complications in a single-center series of 7200 adult cardiac surgical patients. Information related to intraoperative TEE-associated complications was obtained retrospectively from the intraoperative TEE data form, routine postoperative visits, and cardiac surgical morbidity and mortality data. The overall incidences of TEE-associated morbidity and mortality in the study population were 0.2% and 0%, respectively. The most common TEE-associated complication was severe odynophagia, which occurred in 0.1% of the study population. Other complications included dental injury (0.03%), endotracheal tube malpositioning (0.03%), upper gastrointestinal hemorrhage (0.03%), and esophageal perforation (0.01%). TEE probe insertion was unsuccessful or contraindicated in 0.18% and 0.5% of the study population, respectively. These data suggest that intraoperative TEE is a relatively safe diagnostic monitor for the management of cardiac surgical patients. IMPLICATIONS: The overall morbidity (0.2%) and mortality (0%) rates of intraoperative transesophageal echocardiography (TEE) were determined in a retrospective case series of 7200 adult, anesthetized cardiac surgical patients. The most common source of TEE-associated morbidity was odynophagia (0.1%), which resolved with conservative management. These results suggest that TEE is a safe diagnostic tool for the management of cardiac surgical patients.