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Pre-Procedural Imaging to Characterize the PFO- TTE, TEE, TCD.pptx
1. Pre-Procedural Imaging to
Characterize the PFO: TTE,
TEE, TCD
Zahid Amin, MD
William B. Strong Endowed Chair
Augusta University; Children’s
Hospital of Georgia, Augusta, GA
2. Disclosure Statement of Financial
Interest
Within the past 12 months, I or my
spouse/partner have had a financial
interest/arrangement or affiliation with the
organization(s) listed below.
Affiliation/Financial Relationship Company
Consulting Fees/Honoraria Abbott Vascular; W.L. Gore &
Associates
3. Characterize the PFO
• Characterize means: to describe the
distinctive nature and features of..
• By using TTE, we can diagnose PFO but
we may not be able to elaborate on it
– Extension
– Tunnel length
– Size
– Aneurysmal nature (we can a little, but it
may not be crisp)
4. PFO
Potential For Opening
• Lack of apposition between septum
secundum and primum that results in PFO
– May be small and slit like
– May be long and lunar in shape
• Potential For Overlap
– Significant overlap = Long tunnel
– No overlap means no tunnel
• Potential For Other issues
– Aneurysmal (redundant septum primum)
– Large defect
– Difficult to cross occasionally
9. PFO
• Defect “anatomic” characteristics
– Size
– Extension
– Location
• Tunnel characteristics
– Type 0, I , II, III
chest
spine
head
feet
10. TTE
• Usually used for initial evaluation of
PFO
– For detection and diagnostic purposes
– Sufficient in pediatric patients
• Images may not be “good enough” to
characterize the atrial septum and
hence the anatomy of PFO
11. TTE
• Good for Detecting PFO:
– Adequate to appreciate lack of apposition
between septum primum and secundum
– Color flow at the atrial level
• Diagnosis
– Demonstration of right to left shunt by
• Color flow
• Saline bubble contrast study that shows right
to left shunt by the first three heart beats
12. TTE Bubble Study-4 chamber
Bubbles in
LA by the
third beat
Bubbles
returning
from lung
after the
4th beat
23. TEE-in summary
• Excellent modality to characterize PFO
diagnosis, it’s morphology, saline
contrast echocardiography
• Excellent modality to help in closing PFO
• Excellent modality to assess for post
procedure complications
– Device edges in relationship to the
transverse sinus, tenting of the atrial free
wall, relationship to the aortic root, etc.
24. TCD
• Doppler ultrasonography measures the velocity of
blood flow through the brain's blood vessels by
measuring the echoes of ultrasound waves
• Sickle Cell
• Ischemic cerebral issues
• Subarachnoid hemorrhage
• AVM
• Perioperative management of infection
• Right to left shunting at atrial level
25. TCD
• Need trained personnel
• Access vein (antecubital)
• Agitated saline contrast mixed with 1 ml blood
• Valsalva
• Once saline is injected, monitor Doppler signal
during Valsalva maneuver
26. TCD
• Four (five)-level visual categorization:
(i) Grade 0: no occurrence of micro-embolic signals
(ii) grade I, 1-10 signals;
(iii) grade II, >10 signals but no curtain pattern
(iv) grade III, curtain pattern.
• Test negative: no microbubble
• Low grade shunt: 1–10 microbubbles
• Medium grade shunt: >10 microbubbles but without
“curtain effect”
• High grade shunt: curtain effect, seen when the
microbubbles are so numerous as to be no longer
distinguishable separately
31. To Summarize
• TCD is not used commonly
• Physicians who use it are strong supporters
• Requires trained personnel
• It does not have higher specificity
• Grade 3 or higher shunts have high
specificity
• Not an absolute requirement to have TCD
but can be useful
