Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale

Gin, Kenneth; Huckell, Victor F.; Pollick, Charles

doi:10.1016/0735-1097(93)90789-4

Cited by 106 publications

(53 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Conventional protocols have used upper extremity injection of agitated saline contrast, but blood flowing into the right atrium from the superior vena cava is directed towards the body of the right atrium, away from the inter-atrial septum by the crista interveniens, potentially decreasing the sensitivity of this approach. This has been supported by recent echocardiographic studies that have demonstrated that femoral venous delivery of contrast increases the detection rate of patent foramen ovale to 33% by taking advantage of the preferential direction of inferior vena cava flow towards the inter-atrial septum [5,6].…”

Section: Discussionsupporting

confidence: 58%

See 1 more Smart Citation

Paradoxical embolism through a patent foramen ovale: an unexpected complication of tracheal extubation

Turley¹,

Thambyrajah²,

Clarke³

et al. 2005

Anaesthesia

View full text Add to dashboard Cite

A 41-year-old male with insulin-dependent diabetes mellitus was admitted for an elective arthroscopic release of adhesive capsulitis of his left shoulder. At the end of the surgical procedure, he appeared to regain consciousness but then became unresponsive at the time of tracheal extubation after a violent bout of coughing, developing bilateral up-going plantar responses, decorticate posturing and abnormal pupillary reflexes. He was transferred to the intensive care unit. The following day, the patient made a full neurological recovery. Contrast echocardiography, performed using agitated saline delivered through a femoral venous line, revealed a large patent foramen ovale with evidence of right to left shunting. In the absence of risk factors for air embolism, the clinical diagnosis was one of paradoxical embolism of venous thrombus resulting in brain stem ischaemia. The patient was commenced on life-long aspirin to minimise future embolic risk. A patent foramen ovale is necessary in the fetal circulation to sustain intrauterine life. In utero, placental oxygenated blood enters the right atrium via the inferior vena cava and is directed towards the flap valve of the foramen ovale by the eustachian valve, thus enabling blood to enter the systemic circulation. At birth, the decrease in right-sided cardiac pressures and pulmonary vascular resistance reverses the right to left atrial pressure gradient and causes the flap of the foramen ovale to close against the atrial septum. Fusion is normally complete by the age of 2 years. In cases of incomplete fusion, the foramen ovale is kept sealed by the left atrial to right atrial pressure gradient but may be pushed open if right atrial pressure increases and exceeds that of the left atrium [1,2]. A patent foramen ovale is thus a potential route for emboli arising from the venous system to enter the systemic arterial circulation, resulting in the syndrome of 'paradoxical embolism'. We describe the case of a patient who experienced a paradoxical embolism induced by coughing during tracheal extubation. Case ReportA 41-year-old male with known microvascular complications secondary to insulin-dependent diabetes mellitus was admitted for an elective arthroscopic release of adhesive capsulitis of his left shoulder that had failed to respond to extensive physiotherapy. His past medical history included treated hypertension, micro-albuminuria, bilateral proliferative diabetic retinopathy and left exudative maculopathy with previous extensive panretinal photocoagulation. He had dyslipidaemia, drank alcohol occasionally and was a life-long non-smoker. Overall glycaemic control was good, but he had had several hospital admissions with symptomatic hypoglycaemia. Current medication included insulin, ramipril and over-the-counter analgesics.Six months previously, he had successfully undergone an elective arthroscopic release of his right shoulder with an excellent functional result. On this occasion, the general anaesthetic technique included fentanyl, propofol, atracurium and morphine...

show abstract

Section: Discussionsupporting

confidence: 58%

“…2). This effect is more pronounced with the Valsalva manoeuvre compared to cough provocation [5]. The use of provocation testing in conjunction with femoral contrast delivery increases the detection rate of patent foramen ovale to 50% in selected patients with a history of stroke [5,6].…”

Section: Discussionmentioning

confidence: 94%

Paradoxical embolism through a patent foramen ovale: an unexpected complication of tracheal extubation

Turley¹,

Thambyrajah²,

Clarke³

et al. 2005

Anaesthesia

View full text Add to dashboard Cite

show abstract

“…Because blood flow from the inferior vena cava is directed against the fossa ovalis 8 and blood from the superior vena cava is directed primarily through the tricuspid valve, contrast agent entering the right atrium from the superior vena cava can bypass the interatrial septum or a PFO, thus causing a false-negative or weak contrast study. 8 However, the methods we used (2D TEE and balloon sizing) also have their limitations. The patent foramen is a flaplike valve that is formed by overlapping of the relatively thick septum secundum and the relatively thin, mobile, and compliant septum primum.…”

Section: Discussionmentioning

confidence: 99%

“…However, in addition to the size of a PFO, the magnitude of the contrast shunt is influenced by the position of the patient; the choice, dosage, and route of administration of the contrast agent; the provocative maneuvers used; and patient compliance in performing provocative maneuvers. [7][8][9][10] Furthermore, anatomic and functional variations of the right atrial inflow area 8 and pathological conditions influence the amount of contrast shunting through a PFO. 11 Nonetheless, semiquantitative grading systems of PFO size are used for diagnosis, clinical decision making, and treatment recommendations.…”

mentioning

confidence: 99%

Transesophageal Echocardiography for Quantifying Size of Patent Foramen Ovale in Patients With Cryptogenic Cerebrovascular Events

Schuchlenz¹,

Weihs²,

Beitzke³

et al. 2002

Stroke

View full text Add to dashboard Cite

Background and Purpose-Patent foramen ovale (PFO) is a risk factor for paradoxical embolism, and severe shunting and wide opening of PFO are risk factors for severe and recurrent cerebrovascular events. Neither contrast echocardiography nor 2-dimensional (2D) measurement of PFO size have been validated or compared with invasive balloon sizing. Methods-We performed transesophageal echocardiography (TEE) in 100 patients with cryptogenic stroke and catheter closure of PFO. The amount of contrast shunting through the PFO during cubital and femoral contrast delivery and the PFO size measured by 2D TEE were compared with balloon sizing. Results-There was a significant correlation (r 2 ϭ0.8; PϽ0.0001) between 2D TEE measurement and invasive balloon sizing. Mean balloon-sized PFO diameter was significantly larger than mean PFO diameter measured by 2D TEE (8.3Ϯ2.6 versus 5.2Ϯ1.7 mm). Semiquantitative contrast TEE correlated with PFO size (r 2 ϭ0.7; PϽ0.0001) only if the contrast agent was administered through a femoral vein. Correlation was poor when the contrast agent was administered via a cubital vein. Conclusions-We conclude that 2D TEE measurement of a PFO size is more accurate than the traditionally used contrast technique. (Stroke. 2002;33:293-296.)

show abstract

“…(16)(17)(18) Furthermore, superior caval flow, which is directed towards the tricuspid valve may be prevented from crossing a PFO due to the effect of Eustachian valve streaming which influences the reliability of detection of a PFO's shunting and the injection of echocardiographic contrast into a lower limb vein may prove more accurate. (19,20) Also, since patients are commonly sedated to perform TEE, the Valsalva manoeuvre may be difficult to perform. The classification of atrial septal aneurysm also varies, but tissue movement in excess of 10mm from the septal plane is helpful in the diagnosis.…”

mentioning

confidence: 99%

Percutaneous closure of the patent foramen ovale: A cardiological perspective

Brown

2017

SAHJ

View full text Add to dashboard Cite

Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale

Abstract: Femoral vein contrast delivery significantly enhances the ability of precordial contrast echocardiography to diagnose patent foramen ovale. Physiologic patency of the foramen ovale is more common (prevalence 33%) than previously documented.

Cited by 106 publications

References 21 publications

Paradoxical embolism through a patent foramen ovale: an unexpected complication of tracheal extubation

Paradoxical embolism through a patent foramen ovale: an unexpected complication of tracheal extubation

Transesophageal Echocardiography for Quantifying Size of Patent Foramen Ovale in Patients With Cryptogenic Cerebrovascular Events

Percutaneous closure of the patent foramen ovale: A cardiological perspective

Contact Info

Product

Resources

About