How to do echo for patent foramen ovale: Pre, Intra and Postprocedure: A Consensus Statement of the Italian Society of Echocardiography and Cardiovascular Imaging

Figures

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  Figure 1. Shunt quantification at contrast-enhanced transcranial Doppler. During the microbubble test, the middle cerebral artery (MCA) is sampled through the left and the right temporal windows. After contrast injection, continuous monitoring of the MCA is performed both at rest and after the Valsalva maneuver, in order to detect microbubbles. A 50% reduction of systolic velocity of MCA is suggestive of correctly performed Valsalva Maneuver. The number of microembolic signals detected allows shunt quantification. c-TCD = Contrast-enhanced transcranial doppler, MES = Microembolic signals

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  Flowchart 1. Diagnostic algorithm in patient with cryptogenic stroke and suspected patent foramen ovale (PFO). Contrast-enhanced (c-) transcranial doppler and c-transthoracic echocardiography should both be performed as first-line tool. If both are negative, the probability of paradoxical embolism due to PFO is low. If both are positive and percutaneous closure is planned, it would be necessary to proceed to c-transesophageal echocardiography (c-TEE) in order to confirm the diagnosis of PFO, to characterize the anatomy of the PFO and of the interatrial septum, and exclude other sources of cardiac embolism. If the result is doubtful because one of the two tests is negative, but the clinical suspicion of a causative role of the PFO is high is recommended to proceed to c-TEE as above. PFO = Patent foramen ovale, c- = contrast-enhanced, TCD = Transcranial doppler, TTE = Transthoracic echocardiography, TEE = Transesophageal echocardiography, 3D = Three-dimensional

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  Figure 2. Two-dimensional transesophageal echocardiography for the study of the patent foramen ovale (PFO). (a) Left-to-right shunt at rest through a “stretched” PFO. (b) Atrial septal aneurysm (c) Right-to-left shunt of microbubbles through PFO. (d) PFO amplitude measurement. (e) PFO tunnel-like, measurement of the tunnel length; (f) Measurement of the aortic rim. Transesophageal echocardiography allows anatomical characterization of PFO. PFO is defined as “complex” if at least one of the following features is present: long tunnel length (≥8 mm) (e); multiple openings into the left atrium; atrial septal aneurysm (c); hybrid defect; thick secondary septum (≥10 mm); Eustachian ridge; Eustachian valve or Chiari network

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  Figure 3. Two-dimensional (a-c) and three-dimensional (d and e) transesophageal echocardiography during patent foramen ovale (PFO) percutaneous closure, showing the guide (a) and the catheter (b and d) crossing the PFO, followed by the release of the device (c and e)

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  Figure 4. A case of post-procedure follow-up. At 6-months follow-up, bot contrasted-enhanced transthoracic echocardiography (a) and contrast-enhanced transcranial doppler (b) were mildly positive, while at subsequent control, 12 months after the procedure, no passage of microbubbles was detected (c and d)