Muratori M, Italiano G, Innocenti E, Fusini L, Mapelli M, Tamborini G, Ghulam Ali S, Gripari P, Maltagliati A, Celeste F, Pepi M
Centro Cardiologico Monzino IRCCS, Milan, Italy.
Eur Heart J Cardiovasc Imaging. 2016 Dec 1;17(suppl_2):ii109-ii113. doi: 10.1093/ehjci/jew248.003.
BACKGROUND.: The presence of patent foramen ovale (PFO) has been linked to many illness, including cryptogenic stroke, transient ischemic attack, migraine, platypnea-orthodeoxia syndrome and decompression sickness in scuba divers. Transesophageal echocardiography is the gold standard technique for the visualization of atrial septal anatomy, but it is a secondary level exam, not always available, with additional associated costs and not completely free from procedural risks. Standard transthoracic echocardiography (TTE) has a too low sensitivity for PFO screening.
PURPOSE.: The aim of the study was to assess the role of TTE associated with agitated saline contrast injection (contrast-TTE) as a gatekeeper for the identification of PFO in a large cohort of patients undergoing selection for percutaneous closure.
METHODS.: A total of 200 patients undergoing a diagnostic work-up for the identification of PFO was imaged by contrast-TTE at rest and after provocative maneuvers (PM: Valsalva in all cases). Contrast TTE was graded from 0 to 4 on the bases of bubbles counting (0: no bubbles; 1: < 10 bubbles; 2: 10-30 bubbles; 3: >30 bubbles; 4: complete LV opacification). PFO closure was performed after a consensual clinical decision by the cardiologist and the neurologist taking into account comprehensive imaging, clinical evaluation and thrombophilia screening. PFO closure was always monitored by intracardiac echocardiography.
RESULTS.: At baseline contrast TTE was positive (≥2) in 34 patients (17%) while contrast TTE with PM was positive in 94 cases (47%). 27 out of 200 patients (14%) had an interatrial septal aneurysms. PFO closure was performed in 34 cases (17%). All of these had severe right-to-left shunting (≥3) at contrast TTE and 9 cases had also an interatrial septal aneurysms. The procedure was aborted in only 1 patient due to a complex defect anatomy.
CONCLUSION.: Contrast TTE with PM may be not only considered an accurate tool for the detection of PFO but may be also inserted in the diagnostic work- up as a primary gatekeeper for percutaneous closure. Severe shunting at contrast TTE influences final decision making in a large cohort of cases undergoing screening for PFO closure.
卵圆孔未闭（PFO）的存在与许多疾病有关，包括不明原因的中风、短暂性脑缺血发作、偏头痛、平卧呼吸-直立性低氧血症综合征以及潜水员的减压病。经食管超声心动图是观察房间隔解剖结构的金标准技术，但它是二级检查，并非总是可用，还会产生额外费用，且并非完全没有操作风险。标准经胸超声心动图（TTE）对PFO筛查的敏感性过低。
本研究的目的是评估TTE联合生理盐水激发试验（对比增强TTE）在大量接受经皮封堵术筛选的患者中作为PFO识别守门人的作用。
共有200例接受PFO诊断检查的患者在静息状态下及激发试验（所有病例均为Valsalva动作）后接受对比增强TTE检查。对比增强TTE根据气泡计数分为0至4级（0：无气泡；1：<10个气泡；2：10 - 30个气泡；3：>30个气泡；4：左心室完全显影）。在心脏病专家和神经科医生综合影像学、临床评估和血栓形成倾向筛查后达成临床共识决定后进行PFO封堵。PFO封堵始终通过心腔内超声心动图监测。
基线时对比增强TTE阳性（≥2级）的患者有34例（17%），而激发试验后对比增强TTE阳性的有94例（47%）。200例患者中有27例（14%）存在房间隔瘤。34例（17%）患者进行了PFO封堵。所有这些患者在对比增强TTE时均有严重的右向左分流（≥3级），9例患者还存在房间隔瘤。仅1例患者因解剖结构复杂的缺损导致手术中止。
激发试验后的对比增强TTE不仅可被视为检测PFO的准确工具，还可作为经皮封堵术的主要守门人纳入诊断检查流程。对比增强TTE时的严重分流会影响大量接受PFO封堵筛查患者的最终决策。
