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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 shunt (RLS) remains unknown. In this meta-analysis we evaluated 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 that were 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 analyzed. 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% confidence interval [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 in 2000 or later compared with 51% (95% CI, 36%-65%) in those published before 2000. In studies that used harmonic imaging, TTE-C sensitivity was 82% (95% CI, 77%-87%) and specificity was 95% (95% CI, 93%-97%). Among those with patent foramen ovale closure indications, TTE-C sensitivity was 74% (95% CI, 59%-89%) and specificity was 98% (95% CI, 95%-100%). In patients in whom 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 manoeuvres increased sensitivity by approximately 40%.

      Conclusions

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

      Résumé

      Contexte

      L’utilité clinique de l’échocardiographie transthoracique avec contraste (ETT-C) dans la détection du shunt gauche-droit demeure inconnue. Dans cette méta-analyse, nous avons évalué l’exactitude du diagnostic par ETT-C du shunt gauche-droit comparativement à l’échocardiographie transoesophagienne (ETO), l’outil diagnostique de référence.

      Méthodologie

      Un examen systématique et une méta-analyse ont été réalisés à partir des bases de données MEDLINE, EMBASE, PubMed et Cochrane Library. Les études incluses fournissaient des données permettant d’évaluer la sensibilité et la spécificité de l’ETT-C comparativement à l’ETO pour la détection du shunt gauche-droit.

      Résultats

      Au total, 35 études menées auprès de 4 209 patients ont été analysées. L’âge moyen des patients était de 49,1 ± 11,2 ans, et 53,9 % des patients étaient des hommes. Pour la détection du shunt gauche-droit dans toute la cohorte, la sensibilité de l’ETT-C était de 73 % (intervalle de confiance [IC] à 95 % : de 66 à 80 %) et la spécificité était de 94 % (IC à 95 % : de 92 à 96 %). La sensibilité de l’ETT-C était de 80 % (IC à 95 % : de 74 à 86 %) pour les études publiées en 2000 ou après, et de 51 % (IC à 95 % : de 36 à 65 %) dans les études publiées avant 2000. Dans les études utilisant l’imagerie harmonique, la sensibilité de l’ETT-C était de 82 % (IC à 95 % : de 77 à 87 %) et la spécificité, de 95 % (IC à 95 % : de 93 à 97 %). Chez les patients pour qui la fermeture de la persistance du foramen ovale était indiquée, la sensibilité de l’ETT-C était de 74 % (IC à 95 % : de 59 à 89 %) et la spécificité de 98 % (IC à 95 % : de 95 à 100 %). Chez les patients dont le shunt gauche-droit a été diagnostiqué à l’aide de trois moments précis du cycle cardiaque, conformément aux lignes directrices, la sensibilité de l’ETT-C était de 75 % (IC à 95 % : de 66 à 83 %) et la spécificité, de 94 % (IC à 95 % : de 92 à 97 %). Les manœuvres de provocation augmentaient la sensibilité d’environ 40 %.

      Conclusions

      L’ETT-C a une excellente spécificité et une sensibilité modérée dans le diagnostic du shunt gauche-droit comparativement à l’ETO. Il pourrait donc servir d’outil de dépistage initial pour certains patients chez qui un shunt gauche-droit est très probable et chez qui le traitement est indiqué.
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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-side paradoxic emboli, platypnea-orthodeoxia syndrome, left-side carcinoid valve disease, decompression illness in scuba divers, and migraine headaches.1 Of these, cryptogenic stroke is the most researched, with 4 recent large randomised 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 those conditions with favourable results.
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