Sensitivity of transcranial Doppler versus intracardiac echocardiography in the detection of right-to-left shunt.

OBJECTIVES: The purpose of this study was to understand the reason for variation in the sensitivity of different methods of detecting right-to-left shunts (RLS). BACKGROUND: Patent foramen ovale (PFO) is implicated in the pathogenesis of cryptogenic stroke, decompression illness, and migraine headaches. Intravenous agitated saline injections with tomographic imaging (transthoracic, transesophageal, and intracardiac echocardiography) has been used for detecting intracardiac shunts. Some patients with a high clinical suspicion of PFO have inconclusive echocardiographic study results. Transcranial Doppler (TCD) is an alternative method for detecting RLS that is not dependent on tomographic imaging. METHODS: Thirty-eight consecutive patients who were undergoing PFO closure had simultaneous transcranial Doppler and intracardiac echocardiography performed. Agitated saline injections were performed at rest, with Valsalva maneuver, and with forced expiration into a manometer to 40 mm Hg before and after closure, as well as 3 or more months after closure. Right atrial pressures were measured in the periprocedural period, and RLS were graded according to standard methods during these maneuvers. RESULTS: Right atrial pressures were significantly higher with Valsalva maneuver compared with rest (before closure 21.6 +/- 11.9 mm Hg vs. 6.6 +/- 2.6 mm Hg, p < 0.001; after closure 28.4 +/- 13.9 mm Hg vs. 6.8 +/- 2.6 mm Hg, p < 0.001) and with manometer compared with Valsalva maneuver (before closure 38.7 +/- 6.6 mm Hg vs. 21.6 +/- 11.9 mm Hg, p < 0.001; after closure 44.0 +/- 9.5 mm Hg vs. 28.4 +/- 13.9 mm Hg, p < 0.001). Intracardiac echocardiography underestimated shunting in 34% of patients with Valsalva maneuver or manometer after closure compared with TCD. CONCLUSIONS: Transcranial Doppler with immediate feedback provided by forced expiration against a manometer to 40 mm Hg is more sensitive than echocardiographic imaging for the detection of RLS. These observations have significant implications for determining the incidence of RLS in patients with stroke or migraine.

Use of a low-profile, compliant balloon for percutaneous aortic valvuloplasty.

OBJECTIVES: To determine the safety and immediate efficacy after balloon aortic valvuloplasty (BAV) with a new, low-profile balloon. BACKGROUND: BAV has a continuing role in the management of high-risk patients with severe aortic stenosis (AS). BAV with traditional noncompliant balloons requires a large femoral arteriotomy and is associated with high rates of access site complications. METHODS: We retrospectively reviewed medical records of 20 consecutive patients undergoing BAV for severe AS. Retrograde transfemoral BAV was performed with a low-profile, compliant valvuloplasty balloon. Before and after BAV, transaortic gradients were measured invasively and by echocardiography, and aortic valve area (AVA) calculated. Access site complications, functional class and survival were recorded. RESULTS: Patients were 79 +/- 12 years old and had an estimated mortality from open aortic valve replacement of (12.5 +/- 9.6)%. By catheterization, mean aortic gradient fell from 44 +/- 15 to 29 +/- 10 mm Hg (P < 0.001) and AVA increased from 0.63 +/- 0.22 to 0.89 +/- 0.33 cm(2) (P < 0.001). New York Heart Association functional class improved from 3.5 +/- 0.7 to 2.7 +/- 0.8. Procedural mortality was 0%. There were no vascular complications or significant worsening of aortic regurgitation. CONCLUSION: Transfemoral BAV using a low-profile compliant balloon is feasible with acceptable immediate results and safety.