Journal of the American Society of Echocardiography
Clinical InvestigationPatent Foramen OvaleImportance of Adequately Performed Valsalva Maneuver to Detect Patent Foramen Ovale during Transesophageal Echocardiography
Section snippets
Patients
The study population consisted of all patients with clinical diagnoses of ischemic CVA at our hospital between December 2009 and January 2011. Specifically, we included patients aged >18 years, of both sexes, referred from the neurology clinic with clinical diagnoses of recent (<7 days) ischemic CVA confirmed by brain computed tomography or magnetic resonance. Exclusion criteria were obvious potential cardioembolic sources (atrial fibrillation, mitral stenosis, and intracardiac thrombus).
Results
Of 117 patients who underwent TEE for the purpose of evaluation of a cardioembolic source of CVA, 108 were included in the protocol. Five patients were not able to perform the Valsalva maneuver because of neurologic disability and were excluded from the study. One patient with left ventricular apical akinesia with a thrombus and three others with atrial fibrillation were also excluded. None of the patients were excluded because of poor transthoracic imaging quality. More contrast injections
Discussion
The prevalence of PFO is relatively common in the general population, at approximately 27% in autopsy studies.11 The clinical significance of PFO in patients with stroke, however, remains unclear, with population-based studies failing to confirm PFO as an independent risk factor for stroke.12 On the other hand, the apparent association between cryptogenic stroke and PFO, mainly in young patients,4, 13 and the association between systemic emboli and PFO14, 15 suggests that paradoxical embolism
Conclusion
The presence of a PFO may be adequately assessed in most patients by contrast TTE, provided that an adequate Valsalva maneuver is performed. TEE improves the diagnosis of PFO in those with suboptimal transthoracic echocardiographic image quality and those with very small shunts. Thus, in the presence of TTE negative for PFO, TEE should be considered in patients with stroke when transthoracic echocardiographic images are suboptimal, suspicion for PFO remains high, or other findings must be
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