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Canadian Journal of Cardiology

Diagnostic Accuracy of Transthoracic Echocardiography with Contrast for Detection of Right-to-Left Shunt: A Systematic Review and Meta-analysis

Published:August 19, 2022DOI:https://doi.org/10.1016/j.cjca.2022.08.007

      Abstract

      Background

      The clinical utility of transthoracic echocardiography with contrast (TTE-C) for detection of right-to-left shunting (RLS) remains unknown. This meta-analysis evaluates the accuracy of TTE-C for RLS diagnosis compared with transesophageal echocardiography (TEE) as the reference standard.

      Methods

      A systematic review and meta-analysis was performed using a search of MEDLINE, EMBASE, Pubmed and Cochrane library databases. Studies included provided data to assess sensitivity and specificity of TTE-C compared with TEE for RLS detection.

      Results

      A total of 35 studies, involving 4209 patients, were analysed. The average patient age was 49.1+/-11.2 years and 53.9% were male. For RLS detection in the entire cohort, TTE-C sensitivity was 73% (95% CI 66-80%) and specificity was 94% (95% CI 92-96%). The sensitivity of TTE-C was 80% (95% CI 74-86%) in studies published ≥2000 compared with 51% (95% CI 36-65%) in those published <2000. In studies using harmonic imaging, TTE-C sensitivity was 82% (95% CI 77-87%) and specificity was 95% (95% CI 93-97%). Among those with PFO closure indications, TTE-C sensitivity was 74% (95% CI 59-89%) and specificity was 98% (95% CI 95-100%). In patients where RLS was diagnosed using a guideline-suggested 3 cardiac cycle cutoff, TTE-C sensitivity was 75% (95% CI 66-83%) and specificity was 94% (95% CI 92-97%). Provocative maneuvers increased sensitivity by ∼40%.

      Conclusion

      TTE-C offers excellent specificity and moderate sensitivity for RLS diagnosis compared with TEE, and it may therefore serve as an initial screening modality for selected patients with both a high likelihood of having RLS and indications for treatment.
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      Linked Article

      • Detection of Patent Foramen Ovale: Identifying the “Holes” with Contrast-Enhanced Transthoracic Echocardiography
        Canadian Journal of Cardiology
        • Preview
          The presence of a patent foramen ovale (PFO) has been implicated in the pathogenesis of several clinical phenomena, including cryptogenic stroke, left-sided paradoxical emboli, platypnea-orthodeoxia syndrome, left-sided carcinoid valve disease, decompression illness in SCUBA divers, and migraine headaches.1 Of these, cryptogenic stroke is most researched with 4 recent large randomized clinical trials2–5 demonstrating the benefit of PFO closure to prevent recurrent ischemic strokes. Although the other entities are less well studied, PFO closure has been used to treat many of these conditions with favourable results.
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