Patent foramen ovale echocardiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S. [3]

Overview

Transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and transcranial Doppler (TCD) are the commonly used diagnostic tools for patent foramen ovale. Each method has its own advantage and disadvantages in diagnosing patent foramen ovale. The performance of a bubble study on echocardiography is a simple diagnostic study of choice. Transesophageal echocardiography is more sensitive in visualizing the interatrial septum, than transthoracic echocardiography and is the imaging modality of choice.

Advantage:

Gold standard in diagnosing patent foramen ovale.
It detects other associated lesions like aortic atheroma, left atrial appendage thrombus, or spontaneous left atrial contrast. Thus, helping in finding other occult causes of stroke.

Disadvantage:

The patent foramen ovale patients who have failed to be diagnosed with a doppler or a two-dimensional echo are sent for a bubble test. In bubble test sonicated microbubbles are injected in the antecubital vein. These bubbles first appear in the right atrium. If bubbles appear in the left atrium within three heart beats, then the study is considered diagnostic of a patent foramen ovale. On echocardiography, there may not be any shunting of blood (i.e. bubbles may not appear in the left atrium and ventricle) except when the patient coughs or performs the Valsalva maneuver. Release of Valsalva maneuver increases flow to the right atrium, and increases the transit of bubbles across the patent foramen ovale. In transesophageal echocardiography the bubble test might not show a shunt because of the following: requirement for patient sedation, positioning in the left decubitus position and the inability to perform a complete Valsalva.

Advantage

Bubble test gives better results with transthoracic echocardiography as the patient is in semiupright position and is able to perform the valsalva maneuver.

Disadvantage

Advantage

Disadvantage

Cannot differentiate between different inter-atrial defects like patent foramen ovale (PFO), atrial septal defect (ASD). If transcranial doppler detects a inter-atrial defect then the other details about the site of the shunt, and the presence of associated features such as atrial septal aneurysm etc has to be done by a follow-up transesophageal echocardiography