ArticleEcho research and practice2026
High-density contrast echocardiography for patent foramen ovale assessment: sensitivity and relationship with invasively measured shunt severity and atrial septum morphology.
Article in Echo research and practice, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundTransthoracic contrast echocardiography (cTTE) is a first-line method for patent foramen ovale (PFO) assessment, but its sensitivity is reported as low and inconsistent. We aimed to investigate the sensitivity of high-density cTTE for PFO detection, and the relationship between left-heart contrast opacification grade, invasively measured shunt severity and atrial septum/PFO morphology.
methodsFifty-five consecutive patients with proven PFO on contrast transoesophageal echocardiography (cTOE) underwent cTTE with high density contrast (colloid, mannitol) and invasive quantification of right-to-left shunt severity using the thermodilution method. Echocardiographic shunt severity was classified according to the degree of left atrial (cTOE) or left atrial/ventricular (cTTE) opacification as grade 0 (no bubbles), grade 1(mild), grade 2 (moderate) grade 3 (significant opacification).
resultsFor PFO detection, the sensitivity of rest + Valsalva cTOE was 100%. Compared with this reference, sensitivity of rest + Valsalva cTTE was 98.2%, Valsalva cTTE 97.7%, rest cTTE, 83.9% and rest cTOE, 77.3%. No significant association was observed between left-heart opacification grade on rest or Valsalva cTTE/cTOE and invasively measured right-to-left shunt severity categorized as < 10%, 10-19%, or ≥ 20% (p = 0.10-0.26). A moderate association only was identified between rest + Valsalva cTOE left atrium opacification grade and < 10% and ≥ 10% right-to-left shunt severity (p = 0.024, Cramér's coefficient = 0.368). No significant relationship was found between left-heart opacification grade and the presence of atrial septal aneurysm, Eustachian valve/Chiari's network, or PFO channel width and length (p = 0.45-0.77). Compared with rest cTOE, rest cTTE demonstrated equal contrast opacification grade in 56% and higher in 40%. Valsalva cTTE showed equal contrast opacification grade in 29% and higher in 46% of studies vs. Valsalva cTOE.
conclusionsIn studies using high-density contrast, cTOE and cTTE with Valsalva, but not rest studies, are highly sensitive for PFO assessment. There is no clinically relevant relationship between the left-heart bubble opacification grade and invasively measured right-to-left shunt severity or atrial septum morphology. The left-heart contrast opacification grade is equal to or higher in cTTE than in cTOE, especially in rest studies.
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