• Humans
• Foramen Ovale, Patent/therapy
• Foramen Ovale, Patent/diagnosis
• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/surgery
• Septal Occluder Device
• Cardiac Catheterization/instrumentation
• Cardiac Catheterization/adverse effects
• Cardiac Catheterization/methods
• Stroke/prevention & control
• Stroke/etiology
• Treatment Outcome

• PFO closure
• Patent foramen ovale
• anticoagulation
• antiplatelets
• atrial fibrillation
• stroke

• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/therapy
• Humans
• Ischemic Stroke/etiology
• Ischemic Stroke/diagnosis
• Ischemic Stroke/therapy
• Stroke/etiology
• Stroke/diagnosis
• Europe

• European Stroke Organisation

• PFO-associated stroke
• hypermobile septum
• intracardiac echocardiogram
• patent foramen ovale
• right-to-left shunt

• Humans
• Female
• Adolescent
• Adult
• Middle Aged
• Male
• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/diagnostic imaging
• Foramen Ovale, Patent/therapy
• Retrospective Studies
• Treatment Outcome
• Echocardiography
• Echocardiography, Transesophageal
• Stroke/etiology

• Lindegaard ratio
• acute subarachnoid hemorrhage
• cerebral vasospasm
• cryptogenic stroke
• micro-embolic signals
• middle cerebral artery
• paradoxical embolism
• patent foramen ovale
• transcranial Doppler ultrasonography

• Cerebrovascular Circulation/physiology
• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/diagnostic imaging
• Humans
• Subarachnoid Hemorrhage/diagnosis
• Ultrasonography, Doppler, Transcranial/methods
• Vasospasm, Intracranial/diagnosis

Percutaneous patent foramen ovale (PFO) closure by traditional, double disc occluder devices was shown to be safe for patients with PFO, and more effective than prolonged medical therapy in preventing recurrent thromboembolic events. The novel suture-mediated “deviceless” PFO closure system overcomes most of the risks and limitations associated with the traditional PFO occluders, appearing to be feasible in most interatrial septum anatomies, even if data about its long-term effectiveness and safety are still lacking. The aim of the present review was to provide to the reader the state of the art about the traditional and newer techniques of PFO closure, focusing both on the procedural aspects and on the pivotal role of transesophageal echocardiography (TEE) in patient’s selection, peri-procedural guidance, and post-interventional follow-up.

Introduction: Divers with a patent Foramen Ovale (PFO) have an increased risk for decompression sickness (DCS) when diving with compressed breathing gas. The relative risk increase, however, is difficult to establish as the PFO status of divers is usually only determined after a DCS occurrence.

Methods: This prospective, single-blinded, observational study was designed to collect DCS data from volunteer divers after screening for right-to-left shunt (RLS) using a Carotid Doppler test. Divers were blinded to the result of the test, but all received a standardized briefing on current scientific knowledge of diving physiology and “low-bubble” diving techniques; they were then allowed to dive without restrictions. After a mean interval of 8 years, a questionnaire was sent collecting data on their dives and cases of DCS (if any occurred).

Results: Data was collected on 148 divers totaling 66,859 dives. There was no significant difference in diving data between divers with or without RLS. Divers with RLS had a 3.02 times higher incidence of (confirmed) DCS than divers without RLS (p = 0.04). When all cases of (confirmed or possible DCS) were considered, the Relative Risk was 1.42 (p = 0.46). DCS occurred mainly in divers who did not dive according to “low-bubble” diving techniques, in both groups.

Conclusion: This prospective study confirms that DCS is more frequent in divers with RLS (such as a PFO), with a Relative Risk of 1.42 (all DCS) to 3.02 (confirmed DCS). It appears this risk is linked to diving behavior, more specifically diving to the limits of the adopted decompression procedures.

• SCUBA dive
• adverse effects
• decompression sickness
• diving
• patent foramen ovale (PFO)
• prospective study
• relative risk
• right-to-left shunt (RLS)

• Decompression Sickness/diagnosis
• Decompression Sickness/epidemiology
• Decompression Sickness/therapy
• Foramen Ovale, Patent/diagnosis
• Foramen Ovale, Patent/diagnostic imaging
• Humans
• Migraine Disorders
• Risk Assessment
• Syndrome

• CS/15/7/31679 British Heart Foundation

• cryptogenic stroke
• patent foramen ovale
• transoesophageal echocardiography/transcranial Doppler/survey/EACVI

• Atrial Fibrillation
• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/diagnostic imaging
• Foramen Ovale, Patent/epidemiology
• Humans
• Ischemic Stroke
• Risk Factors
• Stroke/diagnostic imaging
• Stroke/epidemiology
• Stroke/etiology

• Boehringer Ingelheim
• German Research Council
• German Ministry of Education and Research
• European Union
• NIH
• Bertelsmann Foundation
• Heinz-Nixdorf Foundation

• echocardiography
• patent foramen ovale
• right to left shunt
• stroke
• transcranial Doppler

• bubble study
• echocardiography
• patent foramen ovale
• point-of-care ultrasound
• pulmonary arterio-venous malformation

• Aneurysms
• Echocardiography
• Factor analysis
• Hyperlipidemia
• Hypertension
• Ischemic stroke
• Longitudinal studies
• Medical risk factors
• Stroke
• Transient ischemic attacks

To access the distinct values of contrast transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE) in the diagnosis of right-to-left shunt (RLS) due to patent foramen ovale (PFO) and to define the most practical strategy for the diagnosis of PFO.

102 patients with a high clinical suspicion for PFO had simultaneous cTCD, cTTE, and cTEE performed. The agitated saline mixed with blood was used to detect right-to-left shunt (RLS).

In all 102 patients, the shunt was detected at rest by cTCD in 60.78% of cases, by cTTE in 42.16%, and by cTEE in 47.06%. The positive results of all 3 techniques with Valsalva maneuver (VM) were significantly improved. cTCD showed higher pick-up rate than cTTE (98.04% vs. 89.22%; χ² = 12.452, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm,

The best method to diagnose PFO should be the combination of cTCD, cTTE, and cTEE. And cTCD should be applied as the first choice for screening RLS. Then, cTTE should be performed to quantify the severity of the shunt. Last but not least, cTEE should be performed to assess the morphologies of PFO when the closure is planned. The study provides for clinicians the most practical strategy for diagnosing PFO in the future. However, further trials with a large sample size are required to confirm this finding.

• Foramen Ovale, Patent
• Heart Septal Defects, Atrial
• Humans
• Thromboembolism

Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation.

A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke.

The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.

• Atrial septum defect
• atrial fibrillation
• cryptogenic stroke
• paradoxical embolism
• stroke
• transesophageal echocardiography

Transthoracic contrast echocardiography (TTCE) is recommended for screening of pulmonary arteriovenous malformations (PAVMs) in hereditary haemorrhagic telangiectasia. Shunt quantification is used to find treatable PAVMs. So far, there has been no study investigating the reproducibility of this diagnostic test. Therefore, this study aimed to describe inter-observer and inter-injection variability of TTCE.

We conducted a prospective single centre study. We included all consecutive persons screened for presence of PAVMs in association with hereditary haemorrhagic telangiectasia in 2015. The videos of two contrast injections per patient were divided and reviewed by two cardiologists blinded for patient data. Pulmonary right-to-left shunts were graded using a three-grade scale. Inter-observer and inter-injection agreement was calculated with κ statistics for the presence and grade of pulmonary right-to-left shunts.

We included 107 persons (accounting for 214 injections) (49.5% male, mean age 45.0 ± 16.6 years). A pulmonary right-to-left shunt was present in 136 (63.6%) and 131 (61.2%) injections for observer 1 and 2, respectively. Inter-injection agreement for the presence of pulmonary right-to-left shunts was 0.96 (95% confidence interval (CI) 0.9–1.0) and 0.98 (95% CI 0.94–1.00) for observer 1 and 2, respectively. Inter-injection agreement for pulmonary right-to-left shunt grade was 0.96 (95% CI 0.93–0.99) and 0.95 (95% CI 0.92–0.98) respectively. There was disagreement in right-to-left shunt grade between the contrast injections in 11 patients (10.3%). Inter-observer variability for presence and grade of the pulmonary right-to-left shunt was 0.95 (95% CI 0.91–0.99) and 0.97 (95% CI 0.95–0.99) respectively.

TTCE has an excellent inter-injection and inter-observer agreement for both the presence and grade of pulmonary right-to-left shunts.

The online version of this article (10.1007/s12471-018-1094-4) contains supplementary material, which is available to authorized users.

• Hereditary haemorrhagic telangiectasia
• Pulmonary arteriovenous malformation
• Pulmonary right-to-left shunt
• Transthoracic contrast echocardiography

• Bubble study
• Echocardiography
• Patent foramen ovale
• Right-to-left shunt
• Transcranial Doppler

• Echocardiography, Transesophageal/methods
• Foramen Ovale, Patent/complications
• Foramen Ovale, Patent/diagnosis
• Humans
• Stroke/diagnosis
• Stroke/etiology
• Ultrasonography, Doppler, Transcranial/methods

• Echocardiography
• Echocardiography, Transesophageal
• Foramen Ovale, Patent
• Heart Septal Defects, Atrial
• Humans
• Vena Cava, Inferior

• Acute subarachnoid hemorrhage
• Cryptogenic STroke
• Ischemic stroke
• Lindegaard ratio
• Microembolic signals
• Middle cerebral artery
• Paradoxical embolism
• Patent foramen ovale
• Transcranial Doppler ultrasonography
• Vasospasm

• atrial septal defect
• coronary sinus catheter
• retrograde cardioplegia catheter
• sinus venous defect
• transesophageal echocardiography

SCUBA diving exposes divers to decompression sickness (DCS). There has been considerable debate whether divers with a Patent Foramen Ovale of the heart have a higher risk of DCS because of the possible right-to-left shunt of venous decompression bubbles into the arterial circulation. Symptomatic neurological DCS has been shown to cause permanent damage to brain and spinal cord tissue; it has been suggested that divers with PFO may be at higher risk of developing subclinical brain lesions because of repeated asymptomatic embolization of decompression-induced nitrogen bubbles. These studies however suffer from several methodological flaws, including self-selection bias. We recruited 200 volunteer divers from a recreational diving population who had never suffered from DCS; we then randomly selected 50 of those for further investigation. The selected divers underwent brain Magnetic Resonance Imaging to detect asymptomatic brain lesions, contrast trans-oesophageal echocardiography for PFO, and extensive neuro-psychometric testing. Neuro-psychometry results were compared with a control group of normal subjects and a separate control group for subjects exposed to neurotoxic solvents. Forty two divers underwent all the tests and are included in this report. Grade 2 Patent Foramen Ovale was found in 16 (38%) of the divers; brain Unidentified Bright Objects (UBO's) were found in 5 (11.9%). There was no association between PFO and the presence of UBO's (P = 0.693) or their size (p = 0.5) in divers. Neuropsychometric testing in divers was significantly worse from controls in two tests, Digit Span Backwards (DSB; p < 0.05) and Symbol-Digit-Substitution (SDS; p < 0.01). Compared to subjects exposed to neurotoxic solvents, divers scored similar on DSB and SDS tests, but significantly better on the Simple Reaction Time (REA) and Hand-Eye Coordination (EYE) tests. There was no correlation between PFO, number of UBO's and any of the neuro-psychometric tests. We conclude that for uneventful recreational diving, PFO does not appear to influence the presence of UBO's. Diving by itself seems to cause some decrease of short-term memory and higher cognitive function, including visual-motor skills; this resembles some of the effects of nitrogen narcosis and we suggest that this may be a prolonged effect of diving.

• PFO
• SCUBA diving
• adverse effects
• embolism
• long term effects

Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied in both outpatient and inpatient settings. Its main use in current clinical practice is the research for “Paradoxical Embolism,” due to migration of thromboembolic material from systemic venous circulation to the left cardiac chambers and arterial circulation through cardiopulmonary shunts such as patent foramen ovale which represents an important cause of cryptogenic stroke, especially in patients under 55 years of age. In this review, we shall describe the incremental diagnostic role in cryptogenic stroke for this imaging modality. TCD not only can be used to detect right-left cardiopulmonary shunts but it also allows to classify the grade of severity of such shunts using the so-called “Microembolic Signals grading score.”

• Cryptogenic stroke
• paradoxical embolism
• patent foramen ovale
• transcranial Doppler ultrasonography

• cardiac source
• critical care
• neurological emergency
• stroke

• Atrial device
• Intracardiac shunt
• Patent foramen ovale
• Percutaneous transcatheter closure
• Transesophageal echocardiography

It has been suggested that there is an increase in aortic regurgitation (AR) in the short and medium term after percutaneous closure of patent foramen ovale (PFO). The aim of this study is to determine the long-term effect of percutaneous closure of PFO on the prevalence of AR.

Patients with cryptogenic stroke or transient ischemic attack who had undergone percutaneous closure of PFO more than five years before the study were invited to an echocardiographic examination.

Out of 83 invited patients, 64 accepted the invitation and were examined with echocardiography. Mild AR was found in one patient (2%), but this was already evident in the patient's echocardiographic result before PFO closure. Trace AR was detected in 11 patients (17%). No case of moderate or severe AR was detected. Patients with AR were more often hypertensive (six out of 12 patients with AR, compared to nine of the 52 without AR, p = 0.025), and the indexed sinus of Valsalva was larger in patients with AR (18.6 mm/m², SD 1.6, as compared to 17.3 mm/m², SD 1.6, p = 0.02).

In this long-term study with a minimum follow-up of 5.6 years and a mean of 7.1 years, we found negligible levels of AR. Where present, AR was associated with hypertension and mild dilatation of the aortic root, but there was no indication that device closure per se increased the risk of developing AR.

• Adverse effect
• Aortic valve insufficiency
• Echocardiography
• Endovascular procedure
• Patent foramen ovale

• Anti-Bacterial Agents/chemistry
• Anti-Bacterial Agents/pharmacology
• Benzyl Alcohol/chemistry
• Benzyl Alcohol/pharmacology
• Contrast Media/chemistry
• Drug Contamination/prevention & control
• Echocardiography, Transesophageal/methods
• Humans
• Michigan
• Microbubbles
• Predictive Value of Tests
• Preservatives, Pharmaceutical/chemistry
• Preservatives, Pharmaceutical/pharmacology
• Rheology
• Sodium Chloride/chemistry
• Time Factors
• Video Recording

• Diastolic function
• Echocardiography
• Nitroglycerin
• Patent foramen ovale
• Septum primum motion

• Diagnostic accuracy
• Meta-analysis
• Patent foramen ovale
• Sensitivity
• Specificity
• Transthoracic echocardiography

• Adult
• Age Distribution
• Aged
• Echocardiography/statistics & numerical data
• Female
• Foramen Ovale, Patent/diagnostic imaging
• Foramen Ovale, Patent/epidemiology
• Humans
• Male
• Middle Aged
• Observer Variation
• Prevalence
• Reproducibility of Results
• Risk Factors
• Sensitivity and Specificity