Detection of right-to-left Atrial communication using agitated saline contrast imaging : experience with 1162 patients and recommendations for echocardiography

Marriott, Kate, Manins, Vance, Forshaw, Anthony, Jeremy, Wright, & Pascoe, Roess (2013) Detection of right-to-left Atrial communication using agitated saline contrast imaging : experience with 1162 patients and recommendations for echocardiography. Journal of the American Society of Echocardiography, 26(1), pp. 96-102.

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Right-to-left shunting via a patent foramen ovale (PFO) has a recognized association with embolic events in younger patients. The use of agitated saline contrast imaging (ASCi) for detecting atrial shunting is well documented, however optimal technique is not well described. The purpose of this study is to assess the efficacy and safety of ASCi via TTE for assessment of right-to-left atrial communication in a large cohort of patients.


A retrospective review was undertaken of 1162 consecutive transthoracic (TTE) ASCi studies, of which 195 had also undergone clinically indicated transesophageal (TEE) echo. ASCi shunt results were compared with color flow imaging (CFI) and the role of provocative maneuvers (PM) assessed.


403 TTE studies (35%) had paradoxical shunting seen during ASCi. Of these, 48% were positive with PM only. There was strong agreement between TTE ASCi and reported TEE findings (99% sensitivity, 85% specificity), with six false positive and two false negative results. In hindsight, the latter were likely due to suboptimal right atrial opacification, and the former due to transpulmonary shunting. TTE CFI was found to be insensitive (22%) for the detection of a PFO compared with TTE ASCi.


TTE ASCi is minimally invasive and highly accurate for the detection of right-to-left atrial communication when PM are used. TTE CFI was found to be insensitive for PFO screening. It is recommended that TTE ASCi should be considered the initial diagnostic tool for the detection of PFO in clinical practice. A dedicated protocol should be followed to ensure adequate agitated saline contrast delivery and performance of provocative maneuvers.

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ID Code: 54461
Item Type: Journal Article
Refereed: Yes
Additional URLs:
Keywords: Echocardiography, Agitated saline, PFO, Bubble study, TIA
DOI: 10.1016/j.echo.2012.09.007
ISSN: 0894-7317
Subjects: Australian and New Zealand Standard Research Classification > MEDICAL AND HEALTH SCIENCES (110000) > CARDIOVASCULAR MEDICINE AND HAEMATOLOGY (110200) > Cardiology (incl. Cardiovascular Diseases) (110201)
Divisions: Current > Schools > School of Clinical Sciences
Current > QUT Faculties and Divisions > Faculty of Health
Copyright Owner: Copyright 2012 Elsevier
Copyright Statement: This is the author’s version of a work that was accepted for publication in Journal of American Society of Echocardiography. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Journal of American Society of Echocardiography, 26(1), (2013)] DOI: 10.1016/j.echo.2012.09.007
Deposited On: 02 Nov 2012 03:44
Last Modified: 18 Jun 2015 08:42

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