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Comparison of transthoracic echocardiography with second harmonic imaging with transesophageal echocardiography in the detection of right to left shunts

      Defects in the interatrial septum as well as abnormalities in the pulmonary vascular bed may result in a right to left shunt. Patent foramen ovale can be responsible for cryptogenic stroke in young patients.
      • Lechat P
      • Mas J.L
      • Lascault G
      • Loron P.H
      • Theard M
      • Klimczac M
      • Drobinski G
      • Thoms D
      • Grosgogeat Y
      Prevalence of patent foramen ovale in patients with stroke.
      ,
      • de Belder M.A
      • Tourikis L
      • Leech G
      • Camm A.J
      Risk of patent foramen ovale for thromboembolic events in all age groups.
      ,
      • Van Camp G
      • Schulze D
      • Cosyns B
      • Vandenbossche J.L
      Relation between patent foramen ovale and stroke.
      A possible cause of unexplained hypoxemia is the presence of abnormal arteriovenous communications in the pulmonary circulation.
      • Barzilai B
      • Waggoner A.D
      • Spessert C
      • Picus D
      • Goodenberger D
      Two-dimensional contrast echocardiography in the detection and follow-up of congenital pulmonary arteriovenous malformations.
      Contrast echocardiography has been shown to be effective in detecting right to left shunts.
      • Lechat P
      • Mas J.L
      • Lascault G
      • Loron P.H
      • Theard M
      • Klimczac M
      • Drobinski G
      • Thoms D
      • Grosgogeat Y
      Prevalence of patent foramen ovale in patients with stroke.
      ,
      • de Belder M.A
      • Tourikis L
      • Leech G
      • Camm A.J
      Risk of patent foramen ovale for thromboembolic events in all age groups.
      ,
      • Van Camp G
      • Schulze D
      • Cosyns B
      • Vandenbossche J.L
      Relation between patent foramen ovale and stroke.
      ,
      • Barzilai B
      • Waggoner A.D
      • Spessert C
      • Picus D
      • Goodenberger D
      Two-dimensional contrast echocardiography in the detection and follow-up of congenital pulmonary arteriovenous malformations.
      ,
      • Vedrinne J.M
      • Duperret S
      • Bizollon T
      • Magnin C
      • Motin J
      • Trepo C
      • Ducerf C
      Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease.
      ,
      • Pearson A.C
      • Labovitz A.J
      • Tatineni S
      • Gomez C.R
      Superiority of transesophageal echocardiography in detecting cardiac sources of embolism in patients with cerebral ischemia of uncertain etiology.
      ,
      • de Belder M.A
      • Tourikis L
      • Griffith M
      Transesophageal contrast echocardiography and color flow mapping methods of choice for the detection of shunts at the atrial level?.
      ,
      • Lee R.J
      • Bartzokis T
      • Yeoh T.K
      • Grogin H.R
      • Choi D
      • Schnittner I
      Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography.
      ,
      • Devuyst G
      • Despland P.A
      • Bogousslavsky J
      • Jeanrenaud X
      Complementarity of contrast transcranial Doppler and contrast transesophageal echocardiography for the detection of patent foramen ovale in stroke patients.
      ,
      • Sun J.P
      • Stewart W.J
      • Hanna J
      • Thomas J.D
      Diagnosis of patent foramen ovale by contrast versus color Doppler by transesophageal echocardiography relation to atrial size.
      ,
      • Nemec J.J
      • Marwick T.H
      • Lorig R.J
      • Davison M.B
      • Chimowitz M.I
      • Litowitz H
      • Salcedo E.E
      Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts.
      ,
      • Wilmshurst P.T
      • Byrne J.C
      • Webb-Peploe M.M
      Relation between interatrial shunts and decompression sickness in divers.
      Because transesophageal echocardiography (TEE) provides more accurate diagnostic information on posterior localized structures of the heart than transthoracic echocardiography (TTE), this technique combined with color Doppler or contrast administration is now considered as the method of choice in the diagnosis of patent foramen ovale.
      • Van Camp G
      • Schulze D
      • Cosyns B
      • Vandenbossche J.L
      Relation between patent foramen ovale and stroke.
      ,
      • de Belder M.A
      • Tourikis L
      • Griffith M
      Transesophageal contrast echocardiography and color flow mapping methods of choice for the detection of shunts at the atrial level?.
      ,
      • Lee R.J
      • Bartzokis T
      • Yeoh T.K
      • Grogin H.R
      • Choi D
      • Schnittner I
      Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography.
      ,
      • Devuyst G
      • Despland P.A
      • Bogousslavsky J
      • Jeanrenaud X
      Complementarity of contrast transcranial Doppler and contrast transesophageal echocardiography for the detection of patent foramen ovale in stroke patients.
      ,
      • Sun J.P
      • Stewart W.J
      • Hanna J
      • Thomas J.D
      Diagnosis of patent foramen ovale by contrast versus color Doppler by transesophageal echocardiography relation to atrial size.
      ,
      • Nemec J.J
      • Marwick T.H
      • Lorig R.J
      • Davison M.B
      • Chimowitz M.I
      • Litowitz H
      • Salcedo E.E
      Comparison of transcranial Doppler ultrasound and transesophageal contrast echocardiography in the detection of interatrial right-to-left shunts.
      ,
      • Wilmshurst P.T
      • Byrne J.C
      • Webb-Peploe M.M
      Relation between interatrial shunts and decompression sickness in divers.
      Recently, second harmonic imaging was developed to visualize first- and second-generation contrast agents more selectively than the surrounding tissue.
      • Burns P.N
      • Powers J.E
      • Fritzsch T
      Harmonic imaging a new imaging and Doppler method for contrast enhanced ultrasound (abstr).
      Harmonic imaging without the use of contrast also enhances the differentiation between the blood pool in the left ventricle and the surrounding tissue due to the partial clearing of artifacts as reverberations.
      • Thomas J.D
      • Rubin D.N
      Tissue harmonic imaging why does it works?.
      ,
      • Senior R
      • Soman P
      • Khattar R.S
      • Lahiri A
      Improved endocardial visualization with second harmonic imaging compared with fundamental two-dimensional echocardiographic imaging.
      ,
      • Pyles J.M
      • Sawada S.G
      • Feigenbaum H
      • Segar D.S
      Enhanced endocardial visualization using harmonic imaging without contrast.
      We tested the hypothesis that second harmonic imaging during TTE is as accurate as TEE for detecting right to left shunts in a nonselected population using a simple saline-agitated solution.
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