Quick PFO ?

[Gidds]

Hopefully this isn't redundent but I searched through the other PFO posts and didn't find the answer to my question:

Is PFO detectable by a standard echocardiogram?

One of my physicians says yes. We were discussing PFO, but not in reference to diving, and he said if I had it they would have seen it on one of the two echos I've already had. From what I've read I didn't think this was the case but I'm not the doctor and now I'm confused :06:

 

[Dr Deco]

Hello Gidds:

Yes, a PFO is diagnosable with an echocardiogram. Larger openings can be found with the color flow Doppler. Small openings can be found with echo contrast. [The later is saline with many small air bubbles in it that is then injected into the vein.]

This system is somewhat on the crude side, however. A better system is the transesophageal echo, but this is a tube inserted into your throat. It is distressing [you choke] to many if they are not properly sedated.

Transcranial Doppler is also good but many do not know how to do this. The advantage here is that it is possible to grade the size and “hemodynamic significance” of the opening. The “spencer” web site referenced on the other recent forum on PFO gives an indication of the grading of the opening. See references below.
The echo studies/tests must really be performed with a Valsalva maneuver. This is important since straining is often a component of real world diving. Within the “Valsalva” category also comes coughing and sneezing. Both of these might be performed by a diver while they would deny having performed a real Valsalva maneuver.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology is September 10 – 11, 2005 :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm


References :book3:

http://www.spencervascular.com/pfoclosure.htm

 

[jiveturkey]

Hehe....now I get it. When I read PFO in the title, I thought you guys were talking about rejection.

 

[Gidds]

So in other words they would have noticed it the last two times they did an echo on me? Or no? They were looking for a mitral valve prolapse (negative) and measuring the diameter of my aorta btw.

 

[perche]

Hello Gidds:

Yes, a PFO is diagnosable with an echocardiogram. Larger openings can be found with the color flow Doppler. Small openings can be found with echo contrast. [The later is saline with many small air bubbles in it that is then injected into the vein.]

This system is somewhat on the crude side, however. A better system is the transesophageal echo, but this is a tube inserted into your throat. It is distressing [you choke] to many if they are not properly sedated.

Transcranial Doppler is also good but many do not know how to do this. The advantage here is that it is possible to grade the size and “hemodynamic significance” of the opening. The “spencer” web site referenced on the other recent forum on PFO gives an indication of the grading of the opening. See references below.
The echo studies/tests must really be performed with a Valsalva maneuver. This is important since straining is often a component of real world diving. Within the “Valsalva” category also comes coughing and sneezing. Both of these might be performed by a diver while they would deny having performed a real Valsalva maneuver.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology is September 10 – 11, 2005 :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm


References :book3:

http://www.spencervascular.com/pfoclosure.htm

Hello Dr Deco,

In terms of specificity and sensitivity could you compare "the standard echocardiogramm", the "transcranial Doppler" and "TEE"?
(not from paper biased by a sponsor like cardioseal or whatever; but from a paper published in peer-review journal; LOL )

Last but not least question: A PFO is diagnosed with " the standard echocardiogramm". How many surgeons or interventional radiologists or cardiologists will treat this so-called PFO based on this exam?

And why any diver with PFO should be treated?

Transcranial Doppler is also good but many do not know how to do this

You're right. Many physicians :11ztongue but radiologist :11ztongue perform ultrasound.

Ten years ago I worked in philadelphia and it seem to me the radiology resident learned someting about Doppler Study. Perhaps I am wrong


Regards

François

 

[perche]

Hopefully this isn't redundent but I searched through the other PFO posts and didn't find the answer to my question:

Is PFO detectable by a standard echocardiogram?

One of my physicians says yes. We were discussing PFO, but not in reference to diving, and he said if I had it they would have seen it on one of the two echos I've already had. From what I've read I didn't think this was the case but I'm not the doctor and now I'm confused :06:

In my opinion there are many false-positive or false-negative results

regards
François

 

[Dr Deco]

Hello perche:

PFO Detection Methods

Papers detailing a comparison of the methods are listed in the REFERENCES below. As you can see, these comparisons have been made for more than a decade.

The comparisons show that transesophageal is equivalent to TCD (but with a grading scale to indicate hemodynamic significance.) Simple echoes are not very sensitive, except for a large opening. The large ones, though, might be significant for a diver.

Treatment

Most divers with a PFO should probably not be treated. The:

• lesion is usually too narrow,
• lesion is usually not in a position to be hemodynamically significant with respect to vein-to-artery passage,
• the diver does not perform dives with significant gas loadings,
• the diver does not produce decompression bubbles (for unclear reasons)
• one dives such that Valsalva-like maneuvers (climbing aboard with full gear, lifting heavy objects) are not performed,
• the breathing patterns are such that left-to-right atrial gradients are always present.

If a diver presents with a history of DCS problems (not joint-pain only ones), then a test might be performed and transcutaneous closure might be considered.

Dr Deco :doctor:

Readers, please note the next class in Decompression Physiology is September 10 – 11, 2005 :1book:
http://wrigley.usc.edu/hyperbaric/advdeco.htm


References :book3:

Albert A, Muller HR, Hetzel A (1997). Optimized transcranial Doppler technique for the diagnosis of cardiac right-to-left shunts. J Neuroimaging; 7(3): 159-63

Droste DW; Kriete JU; Stypmann J; Castrucci M; Wichter T; Tietje R; Weltermann B; Young P; Ringelstein EB (1999). Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts: comparison of different procedures and different contrast agents. Stroke;30(9):1827-32

Droste DW; Reisener M; Kemeny V; Dittrich R; Schulte-Altedorneburg G; Stypmann J; Wichter T; Ringelstein EB. (1999). Contrast transcranial Doppler ultrasound in the detection of right-to-left shunts. Reproducibility, comparison of 2 agents, and distribution of microemboli. Stroke 30(5):1014-8

Horner S; Ni XS; Weihs W; Harb S; Augustin M; Duft M; Niederkorn K (1997). Simultaneous bilateral contrast transcranial Doppler monitoring in patients with intracardiac and intrapulmonary shunts. J Neurol Sci; 150(1):49-57

Jauss M; Kaps M; Keberle M; Haberbosch W; Dorndorf W A comparison of transesophageal echocardiography and transcranial Doppler sonography with contrast medium for detection of patent foramen ovale. Stroke 1994 Jun;25(6):1265-7

Job FP; Ringelstein EB; Grafen Y; Flachskampf FA; Doherty C; Stockmanns A; Hanrath P (1994). Comparison of transcranial contrast Doppler sonography and transesophageal contrast echocardiography for the detection of patent foramen ovale in young stroke patients. Am J Cardiol;74(4):381-4

Klotzsch C; Janssen G; Berlit P (1994). Transesophageal echocardiography and contrast-TCD in the detection of a patent foramen ovale: experiences with 111 patients. Neurology 1994 Sep;44(9):1603-6

Nemec JJ; Marwick TH; Lorig RJ; Davison MB; Chimowitz MI; Litowitz H; Salcedo EE (1991). Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts. Am J Cardiol ;68(15):1498-502

Nygren AT; Jogestrand T (1998). Detection of patent foramen ovale by transcranial Doppler and carotid duplex ultrasonography: a comparison with transoesophageal echocardiography. Clin Physiol; 18(4):327-30

Papadopoulos G; Deppermann KM; Schroder K; Voller H; Kuhly P; Eyrich K (1994). Intraoperative transesophageal versus preoperative transthoracic contrast echocardiography. A method for detection of patent foramen ovale in neurosurgical patients. Anaesthesist, 43(9):582-6

Uzuner N, Horner S, Pichler G, Svetina D, Niederkorn K. Right-to-left shunt assessed by contrast transcranial Doppler sonography: new insights.J Ultrasound Med. 2004 Nov;23(11):1475-82.

Zanette EM; Mancini G; De Castro S; Solaro M; Cartoni D; Chiarotti F (1996). Patent foramen ovale and transcranial Doppler. Comparison of different procedures. Stroke ;27(12):2251-5