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Transmitral doppler: a new transthoracic contrast method for patent foramen ovale detection and quantification
Conclusion: TMD is sensitive and specific for identification of right to left shunt across a PFO as identified by TEE. Perspective: TMD is a relatively simple method for detecting right to left shunt via PFO on a transthoracic echocardiogram. In many institutions, evaluation for cardiac source of embolus is one of the most common reasons for referral for TEE. In a population with a high prevalence of PFO, such as the one reported in this article, TMD may obviate the need for TEE in many of these patients. JK
months post ADO implantation. Three patients underwent surgical ligation after initial diagnostic study because devices large enough to close the PDA were not yet available. In one patient, the device could not be delivered due to kinking of the PDA; the PDA was closed with multiple coils. In three patients, the ADO embolized to the pulmonary artery, two spontaneously immediately and 24 hours after implantation and one due to catheter manipulation after PDA closure was documented, all felt to be due to choice of too small a device. There was acquired narrowing of the descending aorta with a pressure gradient of 15 mm Hg in one 5-kg infant closed with a large device. Conclusions: Moderate to large PDA can be successfully closed percutaneously with the ADO if a large enough device is used especially in infants over 5 kg. Perspective: With the addition of the ADO to the armamentarium of various coil devices available to the interventional cardiologist, most PDA can be closed successfully using a transcatheter approach. Very small and premature infants with symptomatic PDA should undergo surgical closure. JK
Relation Between Directly Detected Patent Foramen Ovale and Ischemic Brain Lesions in Sport Divers Schwerzmann M, Seiler C, Lipp C, et al. Ann Intern Med 2001; 134:21–24. Study Question: What is the prevalence of self-reported decompression illness and ischemic brain lesions on cranial MRI in divers with and without patent foramen ovale (PFO) detected by contrast TEE as compared with healthy controls? Methods: 52 sport divers were screened for history of decompression illness (either classic decompression sickness or the more rapid-onset arterial gas embolism). All divers and 52 healthy controls underwent both cranial MRI and transesophageal echocardiogram with agitated saline contrast and Valsalva maneuver. Results: 13 of 52 divers and 9 of 52 controls had PFO on transesophageal echocardiography (p ⫽ NS). Decompression sickness and arterial gas embolism were reported more frequently in divers than in divers without PFO (4/13 vs. 2/39, p ⫽ 0.03 and 4/13 vs. 2/39, p ⫽ 0.07, respectively). The presence of a PFO increased the risk for decompression illness in divers by 4.5-fold. Ischemic brain lesions on cranial MRI were more common and greater in number in divers (41 lesions in 19 divers) than in controls (7 lesions in 6 controls, p ⫽ 0.003). The number of ischemic brain lesions/person was higher in divers with than in divers without PFO (1.23 ⫾ 2.0 vs. 0.64 ⫾ 1.22 lesions/person, p ⬍ 0.001) and in controls with than in controls without PFO (0.22 ⫾ 0.44 vs. 0.12 ⫾ 0.63 lesions/person, p ⬍ 0.001). Only 2 of 9 divers with decompression illness had ischemic brain lesions on MRI. Conclusions: Diving, more than diving while having a PFO, is associated with ischemic brain lesions on cranial MRI. Divers with a PFO are 4.5 times more likely to report decompression illness than divers without a PFO. A small number of divers who suffered decompression illness have ischemic brain lesions documented on MRI. Perspective: Although the incidence of decompression illness was self-reported and not documented objectively and the frequency of recurrence in the same divers not identified, this study suggests a higher risk of decompression illness in divers with a PFO. Whether a PFO should be closed in divers with a first episode of decompression illness is not known. JK
Transmitral Doppler: A New Transthoracic Contrast Method for Patent Foramen Ovale Detection and Quantification Kerr AJ, Buck T, Chia K, et al. J Am Coll Cardiol 2000;36:1959 – 66. Study Question: Transmitral doppler (TMD) is a new and fairly simple method for the detection of right to left passage of bubbles across the interatrial septum on surface contrast echocardiography. Since Doppler specifically detects moving objects, and, because bubbles are better acoustic reflectors than the red blood cells they travel with, bubbles are easily detected as high-intensity transient signals in the transmitral doppler profile of Doppler sample volume placed at the tips of the mitral valve leaflets. How does TMD with agitated saline contrast compare to two-dimensional transthoracic echocardiography (TTE) with saline contrast and to transesophageal echocardiography (TEE) for the diagnosis of patent foramen ovale (PFO) with right to left shunt? Methods: 44 patients referred for TEE for evaluation for a cardiac source of embolus underwent TMD, TTE and TEE with color doppler and agitated saline contrast injection both without and with Valsalva maneuver. Interatrial shunt by color doppler of the interatrial septum or the appearance of bubbles in the left atrium within three beats of opacification of the right atrium on saline contrast TEE was the gold standard. Results: The sensitivity of TMD for detection of right to left interatrial shunt on TEE was 100% vs. 75% for TTE. Specificity of TMD was 96% vs. 100% for TTE. The presence of ⬎10 bubbles on the transmitral doppler spectrum was 78% sensitive and 100% specific for identification of a maximum resting PFO opening distance of ⬎2 mm, a finding that may correlate with an increased risk of paradoxical embolization.
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months post ADO implantation. Three patients underwent surgical ligation after initial diagnostic study because devices large enough to close the PDA were not yet available. In one patient, the device could not be delivered due to kinking of the PDA; the PDA was closed with multiple coils. In three patients, the ADO embolized to the pulmonary artery, two spontaneously immediately and 24 hours after implantation and one due to catheter manipulation after PDA closure was documented, all felt to be due to choice of too small a device. There was acquired narrowing of the descending aorta with a pressure gradient of 15 mm Hg in one 5-kg infant closed with a large device. Conclusions: Moderate to large PDA can be successfully closed percutaneously with the ADO if a large enough device is used especially in infants over 5 kg. Perspective: With the addition of the ADO to the armamentarium of various coil devices available to the interventional cardiologist, most PDA can be closed successfully using a transcatheter approach. Very small and premature infants with symptomatic PDA should undergo surgical closure. JK
Relation Between Directly Detected Patent Foramen Ovale and Ischemic Brain Lesions in Sport Divers Schwerzmann M, Seiler C, Lipp C, et al. Ann Intern Med 2001; 134:21–24. Study Question: What is the prevalence of self-reported decompression illness and ischemic brain lesions on cranial MRI in divers with and without patent foramen ovale (PFO) detected by contrast TEE as compared with healthy controls? Methods: 52 sport divers were screened for history of decompression illness (either classic decompression sickness or the more rapid-onset arterial gas embolism). All divers and 52 healthy controls underwent both cranial MRI and transesophageal echocardiogram with agitated saline contrast and Valsalva maneuver. Results: 13 of 52 divers and 9 of 52 controls had PFO on transesophageal echocardiography (p ⫽ NS). Decompression sickness and arterial gas embolism were reported more frequently in divers than in divers without PFO (4/13 vs. 2/39, p ⫽ 0.03 and 4/13 vs. 2/39, p ⫽ 0.07, respectively). The presence of a PFO increased the risk for decompression illness in divers by 4.5-fold. Ischemic brain lesions on cranial MRI were more common and greater in number in divers (41 lesions in 19 divers) than in controls (7 lesions in 6 controls, p ⫽ 0.003). The number of ischemic brain lesions/person was higher in divers with than in divers without PFO (1.23 ⫾ 2.0 vs. 0.64 ⫾ 1.22 lesions/person, p ⬍ 0.001) and in controls with than in controls without PFO (0.22 ⫾ 0.44 vs. 0.12 ⫾ 0.63 lesions/person, p ⬍ 0.001). Only 2 of 9 divers with decompression illness had ischemic brain lesions on MRI. Conclusions: Diving, more than diving while having a PFO, is associated with ischemic brain lesions on cranial MRI. Divers with a PFO are 4.5 times more likely to report decompression illness than divers without a PFO. A small number of divers who suffered decompression illness have ischemic brain lesions documented on MRI. Perspective: Although the incidence of decompression illness was self-reported and not documented objectively and the frequency of recurrence in the same divers not identified, this study suggests a higher risk of decompression illness in divers with a PFO. Whether a PFO should be closed in divers with a first episode of decompression illness is not known. JK
Transmitral Doppler: A New Transthoracic Contrast Method for Patent Foramen Ovale Detection and Quantification Kerr AJ, Buck T, Chia K, et al. J Am Coll Cardiol 2000;36:1959 – 66. Study Question: Transmitral doppler (TMD) is a new and fairly simple method for the detection of right to left passage of bubbles across the interatrial septum on surface contrast echocardiography. Since Doppler specifically detects moving objects, and, because bubbles are better acoustic reflectors than the red blood cells they travel with, bubbles are easily detected as high-intensity transient signals in the transmitral doppler profile of Doppler sample volume placed at the tips of the mitral valve leaflets. How does TMD with agitated saline contrast compare to two-dimensional transthoracic echocardiography (TTE) with saline contrast and to transesophageal echocardiography (TEE) for the diagnosis of patent foramen ovale (PFO) with right to left shunt? Methods: 44 patients referred for TEE for evaluation for a cardiac source of embolus underwent TMD, TTE and TEE with color doppler and agitated saline contrast injection both without and with Valsalva maneuver. Interatrial shunt by color doppler of the interatrial septum or the appearance of bubbles in the left atrium within three beats of opacification of the right atrium on saline contrast TEE was the gold standard. Results: The sensitivity of TMD for detection of right to left interatrial shunt on TEE was 100% vs. 75% for TTE. Specificity of TMD was 96% vs. 100% for TTE. The presence of ⬎10 bubbles on the transmitral doppler spectrum was 78% sensitive and 100% specific for identification of a maximum resting PFO opening distance of ⬎2 mm, a finding that may correlate with an increased risk of paradoxical embolization.
ACC CURRENT JOURNAL REVIEW May/Jun 2001
88