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Second harmonic transthoracic echocardiography: the new reference screening method for the detection of patent
Cathy Daniëls1, Caroline Weytjens, Bernard Cosyns
1Department of Cardiology, AZ VUB, Laarbeeklaan 101, 1090 Brussels, Belgium. cdaniels@az.vub.ac.be
Insights
Transthoracic echocardiography with second harmonic imaging (TTE) accurately detects patent foramen ovale (PFO), matching transesophageal echocardiography (TEE) performance. TTE (SH) can replace TEE for PFO detection, saving time and resources.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Techniques
Background:
- Transesophageal echocardiography (TEE) is the gold standard for detecting right-to-left shunts, often to rule out patent foramen ovale (PFO).
- Routine TEE for PFO exclusion is time-consuming and costly.
- Transthoracic echocardiography with second harmonic imaging (TTE-SH) offers a potential alternative.
Purpose of the Study:
- To evaluate the diagnostic accuracy of TTE-SH compared to TEE for detecting PFO.
- To assess the utility of TTE-SH in identifying other right-to-left shunts.
Main Methods:
- 256 consecutive patients underwent both TEE and TTE-SH.
- Agitated saline contrast was injected intravenously before Valsalva maneuver release.
- Semi-quantification and timing of contrast passage were analyzed in both modalities.
Main Results:
- TTE-SH demonstrated high sensitivity (90.5%) and specificity (96.5%) for PFO detection versus TEE.
- Similar accuracy was observed for detecting important shunts and arteriovenous pulmonary malformations.
- No significant difference (p>0.05) in diagnostic performance between TEE and TTE-SH.
Conclusions:
- TTE-SH is a reliable and accurate alternative to TEE for PFO detection.
- TTE-SH can replace TEE when the primary goal is PFO identification, particularly in specific patient groups like young stroke patients and divers.
- This approach can lead to significant time and cost savings in echocardiographic laboratories.
Aim:
Transesophageal echocardiography (TEE) is still considered as the reference method for the non-invasive detection of right-to-left shunts. Echocardiographic laboratories are spending most of their time performing TEE studies to exclude a thromboembolic cardiac disease. In a considerable proportion of these patients the question can be simplified to exclude a PFO. Replacing these TEE studies by TTE would result in a considerable gain in time and money. We evaluated the value of transthoracic echocardiography with second harmonic imaging (TTE) (SH) and peripheral intravenous agitated saline solutions in the detection of patent foramen ovale (PFO) in a large cohort of patients.
Methods:
In 256 consecutive patients, TEE and TTE (SH) with the consecutive administration of three intravenous contrast injections of agitated saline injections before the release phase of the Valsalva manoeuvre were performed. Semi-quantification and timing of contrast passage were assessed during both imaging modalities. A shunt was present if at least one imaging modality showed microbubbles appearing in the left atrium. PFO was defined when these bubbles appeared early and arteriovenous pulmonary malformations were suspected if bubbles appeared late after the opacification of the right atrium. Shunts were considered important when >20 bubbles were present in one frame in the left atrium or left ventricle.
Results:
From the 256 patients, 60 presented a passage of contrast from the right to the left atrium in at least one imaging modality. PFO was detected by TEE in 53 patients and by TTE in 55 patients (sensitivity: 90.5% and specificity: 96.5% if TEE is accepted as the golden standard) (p>0.05). Considering only the important shunts TEE detected 39 important shunts and TTE 46 important shunts (sensitivity: 89.7% and specificity: 94.6%) (p>0.05). AV pulmonary malformations were detected by TEE in 7 patients and by TTE in 10 patients (sensitivity: 85.7% and specificity: 98.3%) (p>0.05).
Conclusions:
In this large cohort of patients TTE (SH) is as accurate as TEE for the detection of PFO and late right-to-left shunts. If the only purpose of TEE is the detection of PFO such as in young cryptogenic stroke patients and in divers, TEE can be replaced by TTE (SH).
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