The cough test is superior to the Valsalva maneuver in the delineation of right-to-left shunting through a patent foramen ovale during contrast transesophageal echocardiography

Stoddard, Marcus F.; Keedy, David L.; Dawkins, Phillip R.

doi:10.1016/0002-8703(93)90073-i

Cited by 56 publications

(24 citation statements)

References 13 publications

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“…Coughing during injection may increase the sensitivity for detecting PFO over that achieved by the Valsalva maneuver. 16 Use of harmonic imaging with TT echocardiography and contrast injection may also increase the sensitivity of PFO detection. 17,18 Saline contrast injection can be performed while imaging the heart with a TE probe.…”

Section: Contrast Echocardiographymentioning

confidence: 99%

Patent Foramen Ovale and Stroke

2005

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Section: Contrast Echocardiographymentioning

confidence: 99%

Patent Foramen Ovale and Stroke

2005

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“…A review of 9 studies shows TCD has a specificity of 70–100% and a sensitivity of 68–100% when compared to transoesophageal echocardiography (TOE) for shunt detection in patients with stroke or transient ischaemic attack [8]. Provocation manoeuvres, such as coughing or Valsalva, are often used to help unmask a v-aCS by increasing right atrial pressure [9, 10]. Such manoeuvres are easier to standardise during TCD than during TOE under sedation with a large ultrasound probe in the pharynx.…”

Section: Introductionmentioning

confidence: 99%

Is Transcranial Doppler for the Detection of Venous-to-Arterial Circulation Shunts Reproducible?

et al. 2007

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Background: We investigated the reproducibility of contrast transcranial Doppler (TCD), a safe non-invasive test for investigation of venous-to-arterial circulation shunts (v-aCS), usually patent foramen ovale, in young stroke patients. We also investigated whether microbubble contrast was reproducible and whether the addition of blood to agitated saline contrast affected the number of microbubbles produced. Methods: TCD investigation for v-aCS was repeated in 42 patients using a standardised protocol (i) by the same investigator and (ii) by a different investigator. Agitated saline was produced by mixing saline and 1 ml of air between two 10-ml syringes. The effect of adding blood and increasing the number of agitations was evaluated by microscopy examination using a haemocytometer to assess bubble numbers and sizes. Results: TCD: no difference was found in the highest microbubble count for the same investigator and between different investigators (p > 0.05). Reproducibility for the detection of v-aCS consistent with a patent foramen ovale was also good (ĸ values >0.8). Contrast: both the number of contrast mixes before injection and the presence of blood significantly increased the number of bubbles counted. On average, 18 agitations produced 1.86 (95% CI 1.62–2.13) times more bubbles than 6 agitations. Mixtures with blood produced on average 3.8 times more bubbles (3.08–4.69). The size of the bubbles was similar for all mixtures. Conclusions: Contrast TCD is reproducible and reliable for the detection of v-aCS. The addition of blood and 18 mixes rather than 6 significantly increased the number of microbubbles produced and may increase the effectiveness of microbubble contrast.

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“…11,17 (2) Different procedures to enhance right-to-left shunting have been proposed in the literature: a nonstandardized Valsalva maneuver, a standardized Valsalva maneuver, and coughing. 16,18,19 (3) Only 1 direct comparison of saline and Echovist injections has been published thus far, but with different doses of these agents. 17 In the present study, we (1) investigated the effect of different diagnostic time windows on the sensitivity and specificity of the test, (2) systematically compared different provocation maneuvers, and (3) compared identical doses of the 2 contrast agents with respect to sensitivity and specificity.…”

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confidence: 99%

Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts

Droste

Kriete

Stypmann

et al. 1999

Stroke

130

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Background and Purpose-Cardiac right-to-left shunts can be identified by transesophageal echocardiography (TEE) and by transcranial Doppler ultrasound (TCD) with the use of different contrast agents and different provocation procedures. Currently, data on an appropriate time window for the appearance of contrast bubbles in the TCD recording after the injection of the contrast medium and the comparison of different provocation maneuvers to increase right-to-left shunting are insufficient. Methods-Forty-six patients were investigated by both TEE and bilateral TCD of the middle cerebral artery. The following protocol with 6 injection modes was applied in a randomized way: (1) injection of 10 mL of agitated saline without Valsalva maneuver, (2) injection of 10 mL of agitated saline with Valsalva maneuver, (3) injection of 10 mL of a commercial galactose-based contrast agent (Echovist) without Valsalva maneuver, (4) injection of 10 mL of Echovist with Valsalva maneuver, (5) injection of 10 mL of Echovist with standardized Valsalva maneuver, and (6) injection of 10 mL of Echovist with coughing. Results-In 20 patients, a right-to-left shunt was demonstrated by TEE and contrast TCD (shunt-positive). Sixteen patientswere negative in both investigations, no patient was positive on TEE and negative on TCD, and 10 patients were only positive on at least 1 TCD investigation but negative during TEE. The amount of microbubbles detected in the various tests decreased in the following order: Echovist and Valsalva maneuver, Echovist with coughing, Echovist and standardized Valsalva maneuver, saline with Valsalva maneuver, Echovist, and saline. With a time window of 20 to 25 seconds for the bubbles to appear in the TCD recording and with a sequence of first Echovist and Valsalva maneuver and then Echovist with coughing, all shunts were reliably identified with a specificity of 65% compared with TEE as the traditional gold standard. The time of first microbubble appearance was not helpful to distinguish between shunts detected on TEE and other shunts. Conclusions-TCD performed twice with 2 provocation maneuvers using Echovist is a sensitive method to identify cardiac right-to-left shunts also identified by TEE.

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The cough test is superior to the Valsalva maneuver in the delineation of right-to-left shunting through a patent foramen ovale during contrast transesophageal echocardiography

Cited by 56 publications

References 13 publications

Patent Foramen Ovale and Stroke

Patent Foramen Ovale and Stroke

Is Transcranial Doppler for the Detection of Venous-to-Arterial Circulation Shunts Reproducible?

Contrast Transcranial Doppler Ultrasound in the Detection of Right-to-Left Shunts

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