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Transthoracic echocardiography using second harmonic imaging

Diagnostic alternative to transesophageal echocardiography for the detection of atrial right to left shunt in patients with cerebral embolic events

Harald P. Kühl, MD^a, Rainer Hoffmann, MD^a, Marc W. Merx, MD^a, Andreas Franke, MD^a, Christof Klötzsch, MD^*, Wolfgang Lepper, MD^a, Thorsten Reineke, BSc, Johannes Noth, MD^* and Peter Hanrath, MD, FACC^a

^a Medical Clinic I, University Hospital, Aachen, Germany
^* Department of Neurology, University Hospital, Aachen, Germany
Institute of Biometry, University Hospital, Aachen, Germany

View larger version (27K): [in a new window]   Figure 1 Bar graph showing the number of patients with atrial right to left shunt detected by the three different imaging modalities (FI, SHI, TEE) using venous contrast injections. ALL positives (obliquely hatched bar) = all patients with atrial right to left shunt detected with either imaging modality; FI (black bar) = fundamental imaging mode; SHI (vertically hatched bar) = second harmonic imaging mode; TEE (white bar) = transesophageal echocardiography.

View larger version (20K): [in a new window]   Figure 2 Circle graph showing the number of positive and negative studies using either FI (upper row) or SHI (bottom row) for patients with a positive TEE study (left column) or negative TEE study (right column). In patients with a positive TEE study (n = 51) the number of simultaneously positive studies using SHI (n = 46) was significantly higher as compared to the number of simultaneously positive studies using FI (n = 31; p < 0.01). In patients with a negative TEE study (n = 60) there were six patients who demonstrated a positive study using SHI and one patient with a positive study using FI. This difference did not reach statistical significance. Abbreviations are the same as in Figure 1.

View larger version (75K): [in a new window]   Figure 3 Example of a patient with a PFO and an atrial right to left shunt detected only by SHI. Transthoracic echocardiograms (left and mid-left panel) showing an apical four-chamber view with FI (left panel) and SHI (mid-left panel) as well as transesophageal echocardiograms (mid-right and right panels) showing image planes at 0° and 112° rotation. Intense opacification of the right heart chambers is seen with all imaging modalities. However, contrast bubbles in the left heart chambers are only detected with SHI.

View larger version (15K): [in a new window]   Figure 4 Bar graph showing the severity of atrial right to left shunt (left panel) and the duration of atrial right to left shunt (right panel) using the three different imaging modalities. Abbreviations are the same as in Figure 1.