Cardiac CT Angiography in Diagnosing Patent Foramen Ovale: A Study on Patients with Suspected Patent Foramen Ovale-Associated Stroke

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Suspected patent foramen ovale (PFO)-associated cryptogenic stroke (n=108). Intervention: Moderate to large right-to-left shunt (RLS) on cardiac CT angiography vs. Small right-to-left shunt (RLS) / Transesophageal echocardiography (TEE) reference standard. Primary outcome: Cardiac CTA false-negative result for PFO detection (missed PFO compared to TEE reference standard) (OR 0.113, 95% CI 0.035-0.365, p=<0.001).

Lijie Sun; Chong Zheng; Zhenxing Fan; Jing Gao; Zhi Liu; Jin Si; Keling Xiao; Ming Yi; Haoyu Zhang; Jiayu Sun; Yijin Liu; Yang Hua; Yingqi Xing; Jie Lu; Jing Li

doi:10.3390/jcdd13020075

February 2, 2026Journal of Cardiovascular Development and DiseaseOpen Access

Cardiac CT Angiography in Diagnosing Patent Foramen Ovale: A Study on Patients with Suspected Patent Foramen Ovale-Associated Stroke

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Key Points

Investigate factors influencing the diagnostic accuracy of cardiac computed tomographic angiography in detecting patent foramen ovale among patients with suspected PFO-associated stroke.
Retrospective study of 108 consecutive patients with cryptogenic stroke and positive contrast transcranial Doppler findings enrolled between November 2020 and April 2023.
Each participant underwent transesophageal echocardiography and cardiac CTA, with univariable and multivariable logistic regression analyses performed to determine predictors of false-negative CTA results.
Compared to TEE, cardiac CTA showed a sensitivity of 70% (95% CI 61–79%), a specificity of 100% (95% CI 54–100%), a positive predictive value of 100% (95% CI 95–100%), and a negative predictive value of 16% (95% CI 6–32%).
In patients with moderate to large right-to-left shunts, CTA sensitivity increased to 90.16% (95% CI 82.69–97.64%), with a significantly reduced risk of a false-negative CTA result compared to small shunts (OR 0.113, 95% CI 0.035–0.365, p < 0.001).

Study Design

Type

Observational (n=108)

Blinding

Blinded outcome assessment (radiologists blinded to TEE and cTCD results)

Multicenter

No

PICO

P

Population

108 hospitalized patients with cryptogenic stroke and positive contrast transcranial Doppler findings (mean age 46.7 years, 52.8% female) evaluated retrospectively with both cardiac CTA and transesophageal echocardiography.

E

Exposure / Comparator

Moderate to large right-to-left shunt (RLS) on cardiac CT angiography vs Small right-to-left shunt (RLS) / Transesophageal echocardiography (TEE) reference standard

O

Primary Outcome

Cardiac CTA false-negative result for PFO detection (missed PFO compared to TEE reference standard) — OR 0.113 (0.035-0.365), p=<0.001

Main Result

Odds Ratio: 0.113 (95% CI 0.035–0.365)

Absolute Event Rate: 77.5% vs 22.5%

p-value: p=<0.001

Limitations

Small-scale single-center retrospective analysis with some missing original imaging data
Cardiac CTA images were reconstructed using only mid-diastolic and end-systole phases rather than the entire cardiac cycle
Absence of the Valsalva maneuver during standard cardiac CTA limited the assessment of small shunts
High PFO prevalence (94.4%) due to selection bias limits generalizability and reliable estimation of specificity and negative predictive value
Relatively small number of false-negative events (n = 31) may lead to multivariable model overfitting
Inter-observer variability was not strictly assessed due to consensus-based image reading

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Implication

Retrospective study investigates cardiac CTA performance in detecting PFO in stroke patients, highlighting significant accuracy variations.

Abstract

Background: Cardiac computed tomographic angiography (CTA) detects patent foramen ovale (PFO) with variable accuracy. This study investigated factors affecting CTA detectability for PFO in patients with suspected PFO-associated stroke. Methods: Consecutive patients with cryptogenic stroke and positive findings on contrast transcranial Doppler (cTCD) examinations were enrolled between November 2020 and April 2023 in this retrospective study. Each participant underwent transesophageal echocardiography (TEE) and cardiac CTA. Patients with confirmed PFO on TEE were categorized into two groups based on CTA detectability: the CTA-positive group (PFO identified by CTA) and the CTA-negative group (PFO missed by CTA). Univariate and multivariate logistic regression analyses were performed to identify predictors of CTA false-negative results. Results: Among 108 patients (mean age 46.7 ± 14.9 years, 47.2% male), the prevalence of PFO by TEE was 94.4% (102/108). Compared to TEE, cardiac CTA had a sensitivity of 70% (95%CI 61–79%), a specificity of 100% (95%CI 54–100%), a positive predictive value of 100% (95%CI 95–100%), and a negative predictive value of 16% (95%CI 6–32%). Among patients with PFO confirmed by TEE (n = 102), the incidence of moderate to large right-to-left shunts (RLS) was significantly higher in the CTA-positive group than in the CTA-negative (77.5% vs. 22.5%, p < 0.001). After adjusting for confounders, patients with moderate to large shunts showed a significantly lower likelihood of a CTA false-negative result compared to those with small shunts (OR 0.113, 95%CI 0.035–0.365, p < 0.001). In patients with moderate to large RLS, the sensitivity of cardiac CTA for diagnosing PFO increased to 90.16% (95% CI 82.69–97.64%). Conclusion: Cardiac CTA could be an effective complementary modality for selected patients with suspected PFO-associated stroke. Its diagnostic performance appears more reliable for identifying PFO in patients with moderate-to-large RLS than in those with small RLS.

Discussion

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Cite This Study

Sun et al. (2026) conducted an observational in Suspected patent foramen ovale (PFO)-associated cryptogenic stroke (n=108). Moderate to large right-to-left shunt (RLS) on cardiac CT angiography vs. Small right-to-left shunt (RLS) / Transesophageal echocardiography (TEE) reference standard was evaluated on Cardiac CTA false-negative result for PFO detection (missed PFO compared to TEE reference standard) (OR 0.113, 95% CI 0.035-0.365, p=<0.001).

synapsesocial.com/papers/69843574f1d9ada3c1fb4484 https://doi.org/10.3390/jcdd13020075

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Cardiac CT Angiography in Diagnosing Patent Foramen Ovale: A Study on Patients with Suspected Patent Foramen Ovale-Associated Stroke

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Cardiac CT Angiography in Diagnosing Patent Foramen Ovale: A Study on Patients with Suspected Patent Foramen Ovale-Associated Stroke

Key Points

Study Design

PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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