Protocol for Optimal Detection and Exclusion of a Patent Foramen Ovale Using Transthoracic Echocardiography with Agitated Saline Microbubbles

Attaran, Robert R.; Ata, Imran; Kudithipudi, Vijayasree; Foster, Laura A.; Sorrell, Vincent L.

doi:10.1111/j.1540-8175.2006.00272.x

Cited by 78 publications

(73 citation statements)

References 25 publications

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“…In the current study, 1 mL of added air was used, but lower volumes of air have become customary in some centres in order to minimise the risk of air embolism. Current guidelines for TTCE still recommend the use of 1 mL of air [28][29][30][31].…”

Section: Discussionmentioning

confidence: 99%

Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study

Gent

Post²,

Luermans³

et al. 2008

Eur Respir J

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Pulmonary arteriovenous malformations (PAVMs) are associated with severe neurological complications in patients with hereditary haemorrhagic telangiectasia (HHT). The objective of the present study was to prospectively establish the diagnostic value of transthoracic contrast echocardiography (TTCE) as a screening technique for PAVM using chest highresolution computed tomography (HRCT) as the gold standard for PAVMs.All consecutive adult patients referred for HHT screening underwent a chest HRCT (n5299), TTCE (n5281), arterial blood gas analysis (n5291), shunt fraction measurement (n5111) and chest radiography (n5296).TTCE was positive in 87 (58.8%), 12 (16.7%) and four (6.7%) patients, and chest HRCT was positive in 54 (36.5%), three (4.2%) and zero (0%) patients with a definite, possible and negative clinical diagnosis of HHT, respectively. Two patients with a negative TTCE were diagnosed with PAVMs after computed tomography; in both cases the PAVMs were too small to be treated by embolotherapy. The sensitivity of TTCE was 97% (95% confidence interval (CI) 93.6-98.3) and negative predictive value 99% (95% CI 96.9-99.8). The other diagnostic tests showed a considerable lower diagnostic value.The present prospective study shows that transthoracic contrast echocardiography has an excellent diagnostic value and can be used as an initial screening procedure for pulmonary arteriovenous malformations. The high false-positive rate of transthoracic contrast echocardiography possibly represents microscopic pulmonary arteriovenous malformations.KEYWORDS: Contrast echocardiography, hereditary haemorrhagic telangiectasia, pulmonary arteriovenous malformations A pulmonary arteriovenous malformation (PAVM) is a direct communication between a pulmonary artery and pulmonary vein. A PAVM results in a right-to-left shunt (RLS) causing hypoxaemia and risk of paradoxal embolism through bypassing the filtering capillary network. Complications occurring in patients with PAVM and hereditary haemorrhagic telangiectasia (HHT) are stroke (10-19%), transient ischaemic attacks (6-37%), cerebral abscess (5-9%), migraine headaches, seizures, massive haemoptysis and (spontaneous) haemothorax [1][2][3]. Antibiotic prophylaxis prior to procedures carrying the risk of bacteraemia is recommended [3][4][5]. At least 80% of PAVMs are associated with HHT [3]. HHT is an autosomal dominant disorder characterised by vascular abnormalities varying from small telangiectases to large arteriovenous malformations. The clinical diagnosis is based on the Curaçao criteria [6]. Based on genetic analysis, HHT is divided into types 1 and 2, corresponding with mutations in the genes ENG and ACVRL1, coding for endoglin and activin A receptor type-like kinase 1, respectively [7,8]. The prevalence of PAVM, as documented by chest high-resolution computed tomography (HRCT), in all HHT patients is 20-45% [4,9]. The PAVM prevalence differs between these two subtypes, in HHT type 1 the prevalence is 48%, whereas the prevalence in HHT type 2 is 5% [10]. PAVMs can...

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Section: Discussionmentioning

confidence: 99%

Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study

Gent

Post²,

Luermans³

et al. 2008

Eur Respir J

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“…Air to saline ratios of 1 cc air to 9 cc saline have been reported in both the HHT [5] and non-HHT [12] echocardiography literature, and are widely used in community echocardiography laboratories.…”

Section: Discussionmentioning

confidence: 99%

Transthoracic contrast echocardiography for detection of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: How can the process be improved for patient safety?

Fan¹,

Choy²,

Shanks³

et al. 2014

IJDI

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Introduction: Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk for pulmonary arteriovenous malformations (PAVMs). Extracardiac right-to-left shunts due to PAVMs can lead to systemic emboli; clinical sequelae including strokes and brain abscesses. Regular screening is required, with appropriate medical/interventional management to alleviate morbidity and mortality from PAVMs. International HHT guidelines recommend standardized transthoracic contrast echocardiogram (TTCE) with agitated saline (in an HHT Foundation-accredited laboratory) as the initial screening test, and, when needed, non-contrast computerized tomography of the chest (CT Chest) to follow up on a positive TTCE.Case presentation: A 40-year-old woman was seen for evaluation of HHT and referred for TTCE as part of her PAVM screen. Following administration of agitated saline, she developed a headache, visual changes in her right eye, and right arm weakness, followed by posturing and stiffness in her right arm. Her symptoms resolved after five minutes, consistent with a transient ischemic attack (TIA).Clinical impact: Protocols at our institution were amended following this index case and echocardiography laboratory protocols were adjusted to use a maximum of 0.1 cc air to 9.9 cc saline for TTCE studies in the HHT population. Only the attending echocardiologist who is familiar with possible systemic air embolism during bubble contrast echocardiography in patients with HHT should perform agitation and infusion of contrast and should directly review the images for appropriate visualization during the exam for this test to be appropriately interpreted. Paradoxical emboli due to right-to-left shunt are important to recognize. Best practice for PAVM screening in HHT patients includes use of standardized protocols for the performance and reporting of TTCE in the evaluation of pulmonary shunts.

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“…Intracardiac shunt requires one cardiac beat or less, whereas intrapulmonary shunt requires a time interval of 4 -6 cardiac beats. 10,11 Portopulmonary venous anastomoses show characteristic contrast echo patterns: an earlier and stronger appearance of echoes in the left cardiac chambers than in the right. These results allow realtime differential diagnosis of portopulmonary venous anastomosis from other causes of intrapulmonary shunt.…”

Section: Discussionmentioning

confidence: 99%

An Unusual Cause of Refractory Hypoxemia in Cirrhosis

Patidar¹,

Kumar

2014

Respir Care

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Pulmonary gas exchange abnormalities and refractory hypoxemia cause myriad difficulties in patients with chronic liver disease. In addition to intrinsic cardiopulmonary diseases and hepatopulmonary syndrome, some unusual pathophysiological mechanisms in patients with portosystemic collaterals might contribute to hypoxemia. We report the clinical presentation of an unusual portosystemic anatomic shunt that permits venous admixture with oxygenated blood, causing hypoxemia that is refractory to the administration of supplemental oxygen, and recurrent hepatic encephalopathy. There has been no such report in the published literature. This case highlights the importance of keeping direct portopulmonary venous anastomosis in the differential diagnosis of oxygen-refractory hypoxemia and recurrent hepatic encephalopathy in patients with cirrhosis in the appropriate clinical context.

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Protocol for Optimal Detection and Exclusion of a Patent Foramen Ovale Using Transthoracic Echocardiography with Agitated Saline Microbubbles

Cited by 78 publications

References 25 publications

Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study

Screening for pulmonary arteriovenous malformations using transthoracic contrast echocardiography: a prospective study

Transthoracic contrast echocardiography for detection of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: How can the process be improved for patient safety?

An Unusual Cause of Refractory Hypoxemia in Cirrhosis

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