Key result
Combining contrast-enhanced TCD and TTE achieves 100% sensitivity for detecting PFO.
Why the study?
The diagnostic performance of c-TCD versus c-TTE under resting and Valsalva conditions and the utility of an integrated diagnostic model combining both modalities for detecting PFO needed evaluation.
Does an integrated diagnostic model combining c-TCD and c-TTE improve the noninvasive detection of patent foramen ovale in patients with suspected PFO?
Observational (n=146)
No
Does an integrated diagnostic model combining c-TCD and c-TTE improve the noninvasive detection of patent foramen ovale in patients with suspected PFO?
Effect estimate: AUC 0.97 (95% CI 0.93-1.00)
An integrated diagnostic model combining c-TCD and c-TTE with Valsalva maneuver provides high sensitivity and diagnostic accuracy for PFO detection, potentially reducing the need for invasive c-TEE.
Objective: To compare the diagnostic performance of contrast-enhanced transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) under resting and Valsalva conditions for detecting patent foramen ovale (PFO), and to evaluate the clinical utility of an integrated diagnostic model combining both modalities. Materials and methods: In this retrospective study, a total of 146 patients with suspected PFO underwent both c-TCD and c-TTE at rest and during the Valsalva maneuver. Among them, 40 patients also received contrast-enhanced transesophageal echocardiography (c-TEE), which served as the reference standard. Detection rates, shunt grading, and inter-modality agreement were analyzed. A logistic regression model integrating c-TCD and c-TTE findings was developed and assessed using receiver operating characteristic (ROC) curves and decision curve analysis (DCA). Results: = 0.030), supporting its use as a sensitive initial screening tool. Inter-modality agreement improved markedly during Valsalva (weighted Kappa = 0.782). The combined model achieved 100% sensitivity and negative predictive value in the TEE subgroup, with an area under the ROC curve of 0.97 and no false negatives. DCA confirmed the superior net clinical benefit of the integrated approach across a broad range of decision thresholds. Conclusion: Valsalva maneuver significantly enhances the diagnostic yield of both c-TCD and c-TTE. While c-TCD may serve as an effective first-line screening tool, its combination with c-TTE ensures improved diagnostic accuracy and clinical decision-making value. The integrated model demonstrates strong potential for clinical implementation as a noninvasive, efficient strategy to reduce unnecessary c-TEE procedures.
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Yu et al. (2026) conducted an observational in Suspected patent foramen ovale (PFO) (n=146). Combined c-TCD and c-TTE diagnostic model vs. Individual c-TCD or c-TTE modalities was evaluated on Area under the ROC curve (AUC) for predicting PFO (AUC 0.97, 95% CI 0.93-1.00). A combined diagnostic model integrating contrast-enhanced transcranial Doppler and transthoracic echocardiography achieved 100% sensitivity and an AUC of 0.97 for detecting patent foramen ovale.
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