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1 Zsolt Garami, MD Transcranial Doppler Bubble Test for PFO (Does the saline solution or body position matter?) Methodist DeBakey Heart and Vascular Center, The Methodist Hospital Research Institute, The Methodist Hospital, Houston, TX Disclusure Disclosure Consultation: Rimed, Philips Healthcare Research: Philips Healthcare What is PFO? After birth, right to left atrium blood flow is no longer needed. The two dividers of the right and left atria fuse to form a solid wall (septum). The septum is supposed to be fused by 18 months of age This opening (flap or tunnel) is the Patent Foramen Ovale or PFO 1 Spencer, 2004 TCD is the BEST!!!!!! DIAGNOSTIC TOOLS TRANSESOPHAGEAL ECHO Although surface echo (or TTE) can define most heart structures, the atrial septum ( the site of the PFO) is hard to see. TransEsophageal Echo (or TEE) uses a special ultrasound probe which is placed in the esophagus after giving sedation. The atrial septum and PFO can be clearly seen by this technique. 4
2 DIAGNOSTIC TOOLS EMBOLUS TRACK ON POWER M MODE DOPPLER 7
3 Positive TCD bubble test, Delayed bubble in the L MCA xxxx x
4 1999, Grade 1 SALINE = 0.9 %NaCl 2012 proposal Z score Grade 1 0 G0-0 Grade G Grade 3 > 10 G Grade 4 shower G3 Grade O 0 Grade I 1-10 Grade II Grade III Grade IV Grade V >300 Spencer Grading 0 Grade Grade 3 more than 10 Grade 4 shower Spencer, 2004 Oct, J Neuroim. Grade O 0 Grade I 1-10 Grade II Grade III Grade IV Grade V >300 RED vs. BLACK LABEL
5 BLACK vs. RED LABEL (n=16 patients) 47.5 median age 4M,12F 8 pts category changed 2 negative became + BL BL Spencer RL Spencer consensus RL consensus Sponsored by Scottish Heart Association Category change Inconclusive Conclusion Current Therapeutic Approach Case 1: Blame the Chapstick # cat. change Spencer Consensus Medical therapy Antiplatelet vs. anticoagulant PFO Closure transcatheter/endovascular approach surgery Leave it alone! natural treatment 31 y/o woman with no significant past medical history awoke feeling nauseated and flushed with an unusually severe HA. Later in the day, while leaning over to give her daughter some Chapstick, she had the acute onset of left sided sensory loss, first in her arm, then her leg and face with some mild weakness.
6 Her husband, an EMT, took her to a community ER, where a CT was done and was negative, but the ER MD was concerned and had her transferred to our center for further eval. Dr V s exam showed normal CN, 4/5 strength in the left arm and leg, significantly decreased L F/A/L sensation, normal DTRs and Coord, no bruit or asymmetry of carotid pulses. Work-up Negative CT Negative CUS Artifact obscured MRI/A Possible distal carotid dissection? 4v angioànormal Case 1: Blame the Chapstick TCD Results Definitely negative for PFO Conflicting Results No PFO on TEE Positive RàL shunt on TCD = PFO Called cardiology, reviewed TEE, excellent study, definitely no PFO Spoke to Echo Director who recommended TTE for possibly getting better valsalva Result: Grade 3 RàL shunt with normal respiration & Grade 4 with valsalva TEE TEE vs TCD
7 TTE with TCD TTE with TCD 1st injection cariologist injection negative 2nd injection Zsolt`s injection - positive Definitely positive for PFO Why the change? 1st injection cardiologist injection negative 2nd injection Zsolt`s injection - positive Definitely positive for PFO Better bubbles? On TTE we used bacteriostatic saline with a little blood mixed with the bubbles for more stable bubbles Better valsalva? Patient was wide awake Better position? TTE Repeat TEE Used better bubbles and had patient sitting up, concurrent TCD Same Zsolt`s injection. Positive study Conclusions Combination of PFO with hyper-coaguable state put patient at risk for stroke. TCD bubble test : fast and comfortable vs. TEE, use better saline!!!!! Direct impact on managementà changed from antiplatelet to anticoagulation and patient will consider PFO closure in the long-term based on her tolerance of coumadin. 2 42
8 3
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