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Diagnosis of Secondary Source of Right-to-Left Shunt With Balloon Occlusion of Patent Foramen Ovale and Power M-Mode Transcranial Doppler

Jill T. Jesurum, PhD^_*,_*, Cindy J. Fuller, PhD^_*, Joshua Renz, RVT, Kimberly A. Krabill, MD^_*, Merrill P. Spencer, MD, Mark Reisman, MD^_*

^_* Swedish Heart and Vascular Institute, Swedish Medical Center, Seattle, Washington
Spencer Vascular, Inc., Seattle, Washington

^_* Reprint requests and correspondence: Dr. Jill T. Jesurum, Scientific Director, Swedish Heart and Vascular Institute, Swedish Medical Center, 550 17th Avenue, Suite 630, Seattle, Washington 98122 (Email: jill.jesurum{at}swedish.org).

Objectives: We sought to assess the prevalence of secondary right-to-left circulatory shunt (RLS) in patients undergoing transcatheter closure of patent foramen ovale (PFO) as detected by power M-mode transcranial Doppler (TCD) and intracardiac echocardiography.

Background: Prevalence of residual RLS in late follow-up after PFO closure may be as high as 34%. Other cardiac and noncardiac sources of RLS may coexist and obscure PFO closure evaluation.

Methods: Eighty-eight patients who underwent transcatheter PFO closure to prevent recurrent paradoxical cerebral embolism between June 2005 and December 2006 were evaluated for a secondary source of RLS. Before device deployment, a sizing balloon was inflated in the PFO tunnel and agitated saline contrast was injected into the inferior vena cava. Clinically significant secondary RLS was defined as >10 embolic tracks on TCD at rest or immediately after calibrated (40 mm Hg), sustained (10 s) respiratory strain, with corresponding negative color-flow Doppler. Late residual RLS was evaluated in all patients with TCD and transthoracic echocardiography (mean: 192 days; 95% confidence interval [CI]: 161 to 223 days).

Results: The sample (n = 84) was 59% female, age 49 ± 14 years. Seventeen patients (20%; 95% CI: 11.7 to 28.8) had secondary RLS during balloon occlusion. At late follow-up (n = 66), 13 of 14 (93%) patients with secondary RLS and 23 of 52 (44%) patients without secondary RLS had residual RLS (p = 0.002).

Conclusions: This is the first report to systematically assess the prevalence of secondary RLS in patients undergoing PFO closure. Residual RLS detected by TCD may be due to secondary RLS, which may have implications for clinical outcomes.

Key Words: patent foramen ovale • transcranial Doppler ultrasound • intracardiac echocardiography • pulmonary arteriovenous malformation

Abbreviations and Acronyms   ASD = atrial septal defect   ET = embolic track(s)   ICE = intracardiac echocardiography   PAVM = pulmonary arteriovenous malformation   PFO = patent foramen ovale   RLS = right-to-left shunt   TCD = power M-mode transcranial Doppler   TTE = transthoracic echocardiography

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