{"id":6647,"date":"2024-01-22T05:25:00","date_gmt":"2024-01-22T10:25:00","guid":{"rendered":"https:\/\/cardioserv.net\/fiverr\/?p=6647"},"modified":"2024-02-05T14:24:44","modified_gmt":"2024-02-05T19:24:44","slug":"patent-foramen-ovale-pfo","status":"publish","type":"post","link":"https:\/\/www.cardioserv.net\/fiverr\/patent-foramen-ovale-pfo\/","title":{"rendered":"4 Things Needed To Rule Out a Patent Foramen Ovale (PFO)"},"content":{"rendered":"<p>A Patent Foramen Ovale (<strong>PFO<\/strong>) is a slit-like defect resulting from an incomplete fusion of the foramen ovale within the atrial septum. Studies show that 20-25% of the population have a PFO and echocardiography is often used to diagnosis it. This week we will review the 4 things needed to rule out a PFO during an echo bubble study.<\/p><h3 class=\"wp-block-heading\" id=\"h-patent-foramen-ovale-pfo\">PATENT FORAMEN OVALE (PFO)<\/h3><ul class=\"wp-block-list\"><li>Incomplete fusion of the foramen ovale<\/li>\n\n<li>Not a true deficiency (separation) of the atrial septal tissue<\/li>\n\n<li>Slit-like defect<\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-pfo-risks-symptoms\">PFO:&nbsp;<strong>Risks &amp; Symptoms<\/strong><\/h4><ul class=\"wp-block-list\"><li>Migraine headaches<\/li>\n\n<li>TIA, CVA<\/li><\/ul><h3 class=\"wp-block-heading\" id=\"h-echo-bubble-study\">ECHO BUBBLE STUDY<\/h3><p>We have written extensively on the correct techniques to perform an echo bubble study. Please review our past blogs here:<\/p><ul class=\"wp-block-list\"><li><a href=\"https:\/\/www.cardioserv.net\/indications-echo-bubble-study\/\" target=\"_blank\" rel=\"noreferrer noopener\">7 Indications for an Echo Bubble Study<\/a><\/li>\n\n<li><a href=\"https:\/\/www.cardioserv.net\/9-steps-to-perform-an-echo-bubble-study\/\" target=\"_blank\" rel=\"noreferrer noopener\">9 Steps to Perform an Echo Bubble Study<\/a><\/li>\n\n<li><a href=\"https:\/\/www.cardioserv.net\/6-tips-to-improve-an-echo-bubble-study\/\" target=\"_blank\" rel=\"noreferrer noopener\">6 Tips to Improve an Echo Bubble Study!<\/a><\/li><\/ul><h3 class=\"wp-block-heading\" id=\"h-patent-foramen-ovale-pfo-and-echo-bubble-studies\"><strong>PATENT FORAMEN OVALE (PFO) AND ECHO BUBBLE STUDIES<\/strong><\/h3><ul class=\"wp-block-list\"><li>Echo bubble studies are the principal means of diagnosis<\/li>\n\n<li>Potential for misinterpretation (false positive and\/false negative)<\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-positive-pfo-shunt\"><strong>Positive PFO Shunt<\/strong><\/h4><ul class=\"wp-block-list\"><li>Appearance of micro-bubbles on the left side of the heart after their appearance in the right heart chambers<\/li>\n\n<li>First, inject saline without Valsalva to look for a resting shunt<\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-resting-pfo-shunt\"><strong>Resting PFO Shunt<\/strong><\/h4><ul class=\"wp-block-list\"><li>Resting study: &nbsp;Bubble study without Valsalva<\/li>\n\n<li>Resting&nbsp;shunt: Agitated saline crosses from right-left without Valsalva<\/li>\n\n<li><strong>A resting shunt has:<\/strong><ul class=\"wp-block-list\"><li>Worse outcomes<\/li>\n\n<li>Predictor for stroke recurrence\u00a0<\/li><\/ul><\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-valsalva-pfo-shunt\"><strong>Valsalva<\/strong>&nbsp;PFO Shunt<\/h4><ul class=\"wp-block-list\"><li>If the first injection of agitated saline produces a positive result then there is no need for further imaging<\/li>\n\n<li>If the first injection is negative: Repeat with Valsalva<\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-valsalva-timing\"><strong>Valsalva Timing<\/strong><\/h4><ul class=\"wp-block-list\"><li>Injection:\u00a0Performed while the patient is bearing down<\/li>\n\n<li>Valsalva Release: As contrast enters the RA<\/li>\n\n<li>Complete opacification of the RA occurs at the&nbsp;<em>end of<\/em>&nbsp;Valsalva<\/li><\/ul><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/s3.amazonaws.com\/thinkific\/file_uploads\/105730\/images\/e57\/b03\/5a5\/1608765993764.jpg\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - correct valsalva technique\" style=\"width:650px\"\/><\/figure><h4 class=\"wp-block-heading\" id=\"h-valsalva-mechanism\"><strong>Valsalva Mechanism<\/strong><\/h4><ul class=\"wp-block-list\"><li>Valsalva momentarily alters the pressure gradient between the left and right atria<\/li>\n\n<li>This causes the septum primum, on the left side of the atrial septum, to transiently lift up and open the septum \u2013 like a door jam<\/li><\/ul><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-22.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - Interatrial septum anatomy\" class=\"wp-image-7074\" style=\"width:500px\"\/><\/figure><h4 class=\"wp-block-heading\" id=\"h-acceptable-valsalva\"><strong>Acceptable Valsalva<\/strong><\/h4><ul class=\"wp-block-list\"><li>The interatrial septum shifts to the left<\/li>\n\n<li>An incorrect technique results in a lower detection rate of PFOs in echo<\/li><\/ul><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-23.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - IAS shift right to left\" class=\"wp-image-7075\" style=\"width:350px\"\/><\/figure><h4 class=\"wp-block-heading\" id=\"h-valsalva-tips\"><strong>Valsalva Tips<\/strong><\/h4><ul class=\"wp-block-list\"><li>The patient bears down for 5\u201310 seconds<\/li>\n\n<li>Press on the patients\u2019 abdomen and ask the patient to use their abdominal muscles to push back against your hand<\/li>\n\n<li>The patient may need several practice attempts<\/li>\n\n<li><strong>Valsalva TEE<\/strong><ul class=\"wp-block-list\"><li>Valsalva during TEE is dependent on the level of sedation<\/li>\n\n<li>Ask the patient to cough forcefully several times<\/li>\n\n<li>Perform the agitated bubble study toward the end of the TEE (patient less sedated)<\/li><\/ul><\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-timing\"><strong>Timing<\/strong><\/h4><ul class=\"wp-block-list\"><li>The common viewpoint is that bubbles must appear in the left atrium&nbsp;<strong>within 3 cardiac cycles<\/strong>&nbsp;of their appearance in the right atrium to diagnose a PFO and that bubbles appearing in the LA beyond five cycles suggest transpulmonary shunting<\/li><\/ul><h4 class=\"wp-block-heading\" id=\"h-exceptions\"><strong>Exceptions&nbsp;<\/strong><\/h4><ul class=\"wp-block-list\"><li>PFO &gt; 3-5 seconds\u2013 dilated fibrillating atria&nbsp;<\/li>\n\n<li>Pulmonary shunt &lt; 3-5 seconds \u2013 large pulmonary shunt may allow bubbles to get to the LA within the 3\u20135 cycles<\/li><\/ul><h3 class=\"wp-block-heading\" id=\"h-false-negative-pfo-echo-bubble-study\">FALSE NEGATIVE PFO: ECHO BUBBLE STUDY<\/h3><p>The main reason for a false negative study is because of inadequate technique. In order to feel confident in your diagnosis to rule out a PFO with an Echo Bubble Study there are 4 things to keep in mind:<\/p><h3 class=\"wp-block-heading\" id=\"h-echo-bubble-study-4-things-needed-to-rule-out-a-pfo\">ECHO BUBBLE STUDY:&nbsp;<strong>4 THINGS NEEDED TO RULE OUT A PFO<\/strong><\/h3><p><strong>#1<\/strong>. Dense opacification. It is important to make sure the agitated saline was prepared correctly and administered in such a way as to densely opacify the right heart.<\/p><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-25-1024x403.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - 1. Dense opacification\" class=\"wp-image-7077\" style=\"width:750px\"\/><\/figure><p><strong>#2<\/strong>. IAS Shift. The interatrial septum should visibly shift from right to left ensuring the Valsalva was correctly performed.<\/p><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-26-1024x429.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - 2. Left shift of IAS\" class=\"wp-image-7078\" style=\"width:750px\"\/><\/figure><p><strong>#3<\/strong>. No bubbles in the LA. If there is dense opacification of the right heart and an IAS shift (R-L) and no bubbles in the right atrium within 3 cardiac cycles you can rule out PFO<\/p><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-27-1024x439.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - 3. No bubbles in the LA\" class=\"wp-image-7079\" style=\"width:750px\"\/><\/figure><p><strong>#4<\/strong>. Late Bubbles. If bubbles appear in the left atrium after 3 cardiac cycles (3-8 cycles) this represents a pulmonary arteriovenous malformation (PAVM) and usually rules out PFOs.<\/p><figure class=\"wp-block-image is-resized\"><img decoding=\"async\" src=\"https:\/\/www.cardioserv.net\/wp-content\/uploads\/2020\/12\/image-28-1024x429.png\" alt=\"4 things to rule out Patent Foramen Ovale (PFO) - 4. late bubbles PAVM\" class=\"wp-image-7080\" style=\"width:750px\"\/><\/figure><h3 class=\"wp-block-heading\" id=\"h-echo-bubble-study-v-color-doppler\">ECHO BUBBLE STUDY V. COLOR DOPPLER<\/h3><p>In a study by Marriott (2013):<\/p><ul class=\"wp-block-list\"><li>1162 patients who underwent TTE agitated saline bubble studies<\/li>\n\n<li>Agitated bubble and Valsalva maneuver was compared with color flow<\/li>\n\n<li>403 studies had shunting but 48% were only positive with Valsalva<\/li>\n\n<li>Strong agreement with TEE findings<\/li>\n\n<li>TTE color was insensitive (22% accurate) for detection of PFO compared with agitated saline bubble study<\/li><\/ul><p>Transthoracic color flow imaging is too insensitive for PFO screening. An agitated saline bubble study is simple and highly accurate for the detection of right-to-left atrial communication with correctly performed Valsalva<\/p><h3 class=\"wp-block-heading\" id=\"h-conclusion\">CONCLUSION<\/h3><p>It is recommended to use an echo-bubble study&nbsp;<strong>with Valsalva as the primary diagnostic tool for the detection of PFO in clinical practice<\/strong>.<\/p><h3 class=\"wp-block-heading\" id=\"h-learn-more-about-echo-bubble-studies-and-earn-cmes\">LEARN MORE ABOUT ECHO BUBBLE STUDIES AND EARN CMES<\/h3><p><a href=\"https:\/\/cme.cardioserv.net\/courses\/echo-bubble-study\" target=\"_blank\" rel=\"noreferrer noopener\">2.5 CME The Why and How of Echo Bubble Studies<\/a><\/p><ul class=\"wp-block-list\"><li>Preparation and administration of agitated saline<\/li>\n\n<li>Tips for improving imaging<\/li>\n\n<li>PFOs<\/li>\n\n<li>Persistent Left Superior Vena Cava<\/li>\n\n<li>Pulmonary Arteriovenous Malformation<\/li>\n\n<li>Guided procedures bubble studies<\/li><\/ul><p><strong>References<\/strong><\/p><ul class=\"wp-block-list\"><li>Gupta, S. K., Shetkar, S. S., &amp; Ramakrishnan, S. (2015). Saline Contrast Echocardiography in the Era of Multimodality Imaging \u2014 Importance of \u201c Bubbling It Right .\u201d Echocardiography, 1707\u20131719.&nbsp;<a href=\"https:\/\/doi.org\/10.1111\/echo.13035\">https:\/\/doi.org\/10.1111\/echo.13035<\/a><\/li>\n\n<li>Marriott, K., Ultrasound, M. C., Manins, V., Forshaw, A., Ultrasound, M. C., Wright, J., &amp; Pascoe, R. (2013). Detection of Right-to-Left Atrial Communication Using Agitated Saline Contrast Imaging\u202f: Experience with 1162 Patients and Recommendations for Echocardiography. Journal of the American Society of Echocardiography, 26(1), 96\u2013102.&nbsp;<a href=\"https:\/\/doi.org\/10.1016\/j.echo.2012.09.007\">https:\/\/doi.org\/10.1016\/j.echo.2012.09.007<\/a><\/li>\n\n<li>Porter, T. R., Abdelmoneim, S., Belcik, J. T., Mcculloch, M. L., Mulvagh, S. L., Olson, J. J., \u2026 Wei, K. (2014). Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography\u202f: A Focused Update from the American Society of Echocardiography. Journal of the American Society of Echocardiography, 27(8), 797\u2013810.&nbsp;<a href=\"https:\/\/doi.org\/10.1016\/j.echo.2014.05.011\">https:\/\/doi.org\/10.1016\/j.echo.2014.05.011<\/a><\/li>\n\n<li>Puledda, F., Toscano, M., Pieroni, A., Veneroso, G., Piero, V. Di, &amp; Vicenzini, E. (2016). Right-to-left shunt detection sensitivity with air \u2013 saline and air \u2013 succinil gelatin transcranial Doppler. International Journal of Stroke, 11(2), 229\u2013238.&nbsp;<a href=\"https:\/\/doi.org\/10.1177\/1747493015609938\">https:\/\/doi.org\/10.1177\/1747493015609938<\/a><\/li>\n\n<li>Superiority of the Combination of Blood and Agitated Saline for Routine Contrast Enhancement<br>Fan, Sandra et al. Journal of the American Society of Echocardiography, Volume 12, Issue 2, 94 \u2013 98<\/li>\n\n<li>Romero, R., Frey, J. L., Schwamm, L. H., Demaerschalk, B. M., Chaliki, H. P., Parikh, G., \u2026 Babikian, V. L. (2009). Cerebral Ischemic Events Associated With \u2018 Bubble Study \u2019 for Identification of Right to Left Shunts. Stroke, 2342\u20132348.&nbsp;<a href=\"https:\/\/doi.org\/10.1161\/STROKEAHA.109.549683\">https:\/\/doi.org\/10.1161\/STROKEAHA.109.549683<\/a><\/li><\/ul>","protected":false},"excerpt":{"rendered":"<p>A Patent Foramen Ovale (PFO)\u00a0It is a slit-like defect resulting from an incomplete fusion of the foramen ovale within the atrial septum. 20-25% of the population have a PFO and echocardiography is often used to diagnosis it. This week we will review the 4 things needed to rule out a PFO during an echo bubble- study.<\/p>\n","protected":false},"author":7,"featured_media":6648,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"footnotes":""},"categories":[440],"tags":[19,21,22],"class_list":["post-6647","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-echocardiography","tag-agitated-saline","tag-contrast-echo","tag-pfo"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>4 Things Needed To Rule Out a Patent Foramen Ovale (PFO) - Cardioserv<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.cardioserv.net\/fiverr\/patent-foramen-ovale-pfo\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"4 Things Needed To Rule Out a Patent Foramen Ovale (PFO) - Cardioserv\" \/>\n<meta property=\"og:description\" content=\"A Patent Foramen Ovale (PFO)\u00a0It is a slit-like defect resulting from an incomplete fusion of the foramen ovale within the atrial septum. 20-25% of the population have a PFO and echocardiography is often used to diagnosis it. 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