The Clinical Value Of Simultaneous Detection Combined With CTTE And CTCD/cTCCD To Evaluate Right-to-Left Shunting Through Foramen Ovale/Pulmonary Circulation

Objective:To investigate the clinical value of simultaneous detection combined with contrast Transthoracic Echocardiography(cTTE)and contrast Transcranial Doppler(cTCD)/contrast Transcranial Color Doppler(cTCCD)to evaluate right-to-left shunting through foramen ovale /pulmonary circulation.We compare the accuracy of the results between the simultaneous testing and the single one.We hope to improve the detection rate of right to left shunt,reduce missed diagnosis,misdiagnosis and unnecessary cTEE examination.Methods:The research enrolled 350 patients admitted to our hospital from March 2021 to December 2022 because of migraine(MA),Transient Ischemic Attack(TIA)or suspected to have RLS disease.Among them,there are 141 cases with headache or with dizziness,101 cases with pectoralgia or asthma,29 cases with cerebral infarction,14 cases with apopsychia,9 cases with TIA,56 cases with other disease.All patients underwent simultaneous detection combined with cTTE and cTCD/cTCCD,and confirmed by Contrast Transesophageal Echocardiogram(cTEE).The results were divided into two groups: positive group with RLS and negative group without RLS independently determined by the operators with cTTE and cTCD/cTCCD at both conditions of rest and Valsalva maneuver.It was classified into the positive group when either of the cTTE or cTCD/cTCCD was positive.The receiver operating characteristic(ROC)curve was drawn to analyze the efficacy of cTTE with cTCD/cTCCD in the diagnosis of RLS alone and jointly.Moreover,to compare the semiquantitative grading using these techniques.Results: Among the 350 patients simultaneously evaluated with cTTE combined with cTCD/cTCCD,the total RLS positive rate was 98.0%(343/350),which was higher than that with cTTE 95.3%(334/350)or cTCD/cTCCD 76.57%(268/350).Whether at rest or VM,the area under the curve(AUC),accuracy of cTTE and cTCD/cTCCD combined diagnosis(0.836、87.14%;0.791、97.71%)were higher than those of the cTTE(0.809、81.71%;0.777、94.85%),P<0.05.Whether at rest or VM,the accuracy of cTTE and cTCD/cTCCD combined diagnosis(87.14%;97.71%)were higher than those of the cTCD/cTCCD(52.00%;76.57%),P<0.05.Whether at rest or VM,the area under the curve(AUC)of cTTE and cTCD/cTCCD combined diagnosis(0.836;0.791)were higher than those of the cTCD/cTCCD(0.659;0.783),nonsignificant difference.cTTE showed higher pick-up rate than cTCD/cTCCD(95.43% vs.76.57%;χ 2 =51.685,p < 0.05),cTEE showed higher pick-up rate than cTCD/cTCCD(98.57%vs.76.57%;χ2 = 77.822,p < 0.05)and than cTTE(98.57% vs.95.43%;χ2 = 5.940,p = 0.015 in the diagnosis of RLS.Under VM,the sensitivity and specificity of each inspection method were improved compared with those under rest.Nevertheless,under VM,cTCD,compared with cTTE and cTEE,underestimated the degree of shunt in patients with semi-quantitative shunt grade Ⅱ.The diameter of PFO entrance was significantly greater in patients with a severe shunt compared with a mild shunt(1.78±0.68 mm vs.1.32±0.32 mm,t =-3.209,p < 0.05).There was a nonsignificant difference in tunnel length between patients with mild shunting and severe shunting(9.55±3.43 mm vs.9.75±3.60 mm;t =-0.551,p > 0.05).Conclusions :1.The simultaneous detection combined with contrast Transthoracic Echocardiography(cTTE)and contrast Transcranial Doppler(cTCD)/contrast Transcranial Color Doppler(cTCCD)to evaluate right-to-left shunting can improve the detection rate of right to left shunt,reduce missed diagnosis,misdiagnosis and unnecessary cTEE examination.The results of the semi-quantitative shunt grade of cTTE were suggested to evaluate the severity of the shunt.When PFO closure is planned,cTEE should be performed to assess the morphology and structure of the PFO.2.A cut off value for intracardiac versus intrapulmonary shunting should not suggest to be dogmatically applied without the integration of other clinical and echocardiographic variables.In this study,the diagnostic efficacy of cTTE3 was slightly higher in distinguishing PFO-RLS and P-RLS than other cut off.3.It is suggested that the severity of right-to-left shunt is correlated with the wide diameter of PFO,but not with the long diameter of PFO.The larger the wide diameter of the PFO,the larger the shunt volume.