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[Low sensitivity of the echocardiograph compared with contrast transcranial Doppler in right-to-left shunt]
P Martínez-Sánchez1, J Medina-Báez, M Lara-Lara
1Laboratorio de Exploración Neurovascular Ultrasonográfica, Servicio de Neurología y Centro de Ictus, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Instituto de Investigación IdiPAZ, Madrid, España. patrindalo@hotmail.com
Insights
Contrast transcranial Doppler (c-TCD) is more sensitive for detecting right-to-left shunts (RLS) than transthoracic (TTE) or transesophageal echocardiography (TEE). Echocardiography methods yield numerous false negatives, making c-TCD the preferred diagnostic tool for suspected paradoxical embolism.
Area of Science:
- Cardiovascular Imaging
- Neurology
- Diagnostic Techniques
Background:
- Contrast transcranial Doppler (c-TCD) demonstrates high sensitivity for detecting right-to-left shunts (RLS).
- Its sensitivity is likely superior to transthoracic echocardiography (TTE) and comparable to transesophageal echocardiography (TEE).
Purpose of the Study:
- To evaluate the diagnostic accuracy of TTE and TEE in detecting RLS.
- To compare the accuracy of echocardiographic methods with c-TCD.
Main Methods:
- An observational study included 115 patients under 55 with cryptogenic cerebral ischemia.
- Patients underwent c-TCD at rest and during Valsalva maneuver (VM), with TTE and TEE performed as per protocol.
- Accuracy was determined by comparing TTE and TEE results against c-TCD findings.
Main Results:
- c-TCD detected RLS in 67.6% of patients, significantly more than TTE (22.5%) or TEE (53.1%).
- TTE after VM showed 31.8% sensitivity and 52.9% accuracy for RLS detection.
- TEE after VM demonstrated 63.4% sensitivity and 67.9% accuracy, with improved performance at rest.
Conclusions:
- TTE and TEE exhibit a significant rate of false negatives in RLS detection.
- c-TCD is recommended as the optimal diagnostic method for RLS when paradoxical embolism is suspected.
Background:
Contrast transcranial Doppler (c-TCD) has a high sensitivity for detecting right-to-left shunt (RLS), and is probably higher than transthoracic echocardiography (TTE) and comparable with transesophageal echocardiography (TEE).
Objective:
To evaluate the accuracy of echocardiography (TTE and TEE) to detect RLS compared to c-TCD.
Material And Methods:
Observational study of patients <55 years old with cerebral ischaemia of undetermined origin (2007-2009). All underwent c-TCD monitoring to detect RLS, at rest and after Valsalva manoeuvre (VM). The TTE and TEE were performed when indicated by our cerebrovascular protocol. The accuracy of TTE and TEE for detecting RLS was calculated by comparing them with c-TCD.
Results:
A total of 115 patients with c-TCD, mean age 43.3 (SD 10.3) years, 51.3% male. The TTE was performed in 102, and TEE in 81, patients. RLS detection was higher with c-TCD than with TTE (67.6% vs. 22.5%, P=.001) or TEE (77.8% vs. 53.1%, P=.001). The TTE, compared with c-TCD after MV showed: sensitivity 31.8%, specificity 96.9%, positive predictive value (PPV) 95.6%, negative predictive value (NPV) 40.5% and accuracy 52.9% to detect RLS. TEE, compared with c-TCD after MV showed: sensitivity 63.4%, specificity 83.3%, PPV 93%, NPV 39.4% and accuracy 67.9%. The accuracy of TTE and TEE improved when they were compared with c-TCD at rest.
Conclusions:
TTE and TEE show a considerable number of false negatives for RLS detection. Clinical studies should consider the c-TCD as the best technique to diagnose RLS when a paradoxical embolism is suspected.
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