经颅多普勒超声与增强经胸超声心动图诊断卵圆孔未闭与房间隔缺损的对比诊断准确性。

Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect.

机构信息

Division of Cardiology and Coronary Care Unit, San Rocco Clinical Institute, Ome, Brescia, Italy.

Department of Health Promotion, Mother and Child Care, G. D'Alessandro Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy.

出版信息

Panminerva Med. 2024 Jun;66(2):124-130. doi: 10.23736/S0031-0808.24.05123-1. Epub 2024 Apr 2.

DOI:10.23736/S0031-0808.24.05123-1

PMID:38563605

Abstract

BACKGROUND

Recognition of right-to-left shunt is crucial in the work-up of patients with suspected patent foramen ovale (PFO) or atrial septal defect (ASD). While transesophageal echocardiography (TEE) remains the gold standard diagnostic tool for the anatomic assessment of PFO/ASD, transcranial Doppler (TCD) and contrast-enhanced transthoracic echocardiogram (CE-TTE) hold the promise of providing minimally invasive yet accurate clinical details. Their comparative accuracy remains however debated.

METHODS

We conducted a retrospective observational study leveraging our extensive institutional experience with systematic TCD and CE-TTE in patients with suspected PFO/ASD. Several measures of diagnostic test accuracy were computed, with point estimates and 95% confidence intervals, when applicable.

RESULTS

A total of 1358 patients were included, with age 48±14 years and 772 (58%) women. Tests were performed for diagnostic purposes in 797 (58.6%) and during follow-up in 740 (54.5%). A PFO was eventually diagnosed in 1038 (77.9%) patients, and an ASD in 60 (4.5%). Agreement between TCD and CE-TTE occurred in 1309 (85.2%) cases, with TCD yielding worse findings than CE-TTE in 91 (5.9%) patients, and vice versa in 137 (8.9%), yielding a Cohen kappa of 78.6% (95% CI: 76.3-81.1%) and a highly significant P value at McNemar test (P<0.001). After dichotomization, and using TCD as benchmark, CE-TTE yielded sensitivity 96.9%, specificity 95.1%, area under the curve 92.1%, and P=0.249. Similar findings were obtained when focusing only on diagnostic tests or follow-up ones (Cohen kappa respectively 74.0% [70.2-77.1%], P<0.001 and 80.3% [76.4-84.3%], P<0.001). Notably, Valsalva was necessary to disclose the presence of shunt during TCD in 487 (31.7%) patients and during CE-TTE in 482 (31.4%) cases. Finally, performance of TCD and CE-TTE in a subset of patients eventually undergoing TTE was quite similar.

CONCLUSIONS

The diagnostic accuracy of CE-TTE appears favorable, and this imaging test may identify patients who may be missed if only TCD is used to screen patients with suspected PFO/ASD. Accordingly, CE-TTE is recommended as an adjunct diagnostic modality for all patients with a high pre-test probability of PFO/ASD and right-to-left shunt.

摘要

背景

识别右向左分流对于疑似卵圆孔未闭（PFO）或房间隔缺损（ASD）患者的检查至关重要。虽然经食管超声心动图（TEE）仍然是 PFO/ASD 解剖评估的金标准诊断工具，但经颅多普勒（TCD）和对比增强经胸超声心动图（CE-TTE）有望提供微创但准确的临床细节。然而，它们的比较准确性仍存在争议。

方法

我们利用我们在疑似 PFO/ASD 患者中进行系统 TCD 和 CE-TTE 的丰富机构经验进行了回顾性观察研究。计算了几种诊断测试准确性的指标，包括点估计值和 95%置信区间（适用时）。

结果

共纳入 1358 例患者，年龄 48±14 岁，772 例（58%）为女性。797 例（58.6%）为诊断目的进行检查，740 例（54.5%）为随访期间进行检查。最终诊断为 PFO 的患者为 1038 例（77.9%），诊断为 ASD 的患者为 60 例（4.5%）。TCD 和 CE-TTE 之间的一致性发生在 1309 例（85.2%）病例中，TCD 在 91 例（5.9%）患者中比 CE-TTE 产生较差的结果，而在 137 例（8.9%）患者中则相反，Cohen κ 值为 78.6%（95%CI：76.3-81.1%），McNemar 检验的 P 值非常显著（P<0.001）。二分类后，以 TCD 为基准，CE-TTE 的敏感性为 96.9%，特异性为 95.1%，曲线下面积为 92.1%，P=0.249。仅关注诊断性检查或随访性检查时，也得到了类似的发现（Cohen κ 值分别为 74.0%[70.2-77.1%]，P<0.001 和 80.3%[76.4-84.3%]，P<0.001）。值得注意的是，在 487 例（31.7%）患者中，需要进行瓦尔萨尔瓦动作才能在 TCD 期间揭示分流的存在，在 482 例（31.4%）患者中，需要在 CE-TTE 期间进行该动作。最后，在最终接受 TTE 的患者亚组中，TCD 和 CE-TTE 的表现相当相似。