; revised mmuseript received June

: Dr. Kenneth 6. Gin, Echwardio$raphy Hm&i, 910 West IQth Avenue, Vancou-

SensitiQity~ with the ability to detect only ap of cases of cath~t~r~~~t~~~u~r~v patent foramc~ ovale (;8,8). fk?QilaUS iflQG%ti#ih.m, dlk cardiac catheterization, demonstrated that the detectio f defects in the atria! septum by the i~d~~a~~~~e green dye-d~~~t~o~ techai markedly enhanced when the contrast agent was d into the inferior versus the superior vena cava (9,10). We

the effecect of femoral vein delivery of contrast the usual method of upper extremity delivery for

en ovnle by transt

s

After acceptance of the protocol by the University of British Columbia Ethics Committee, the study was per- formed in a prospective single-blind manner. Transthoracic contrast echocardiography was performed after informed

injections. Studies were considered positive when three or more microbubbles were visualized in the left heart cham- bers within three cardiac cycles after o~ac~~cat~o~ of the right atr ositive studies were further sem ~titat~ve~y graded ows: + 1 (~~~~~~a~ left ve~t~~c opacika- tion), +2 (moderate left vcntricuiar ~~cat~o~), l-3 (in- tense left ventricular opacification) ventricular opacification with clear eiidocardial (Fig. 1).

Atrial septal integrity was carefully assessed during car- diac catheterization in a randomly selected group of21 of the

Apical four-chamber twa-dimen agent is apparent in the right hea

contrast study showing ffl~l~i~a~ (+ 1) Beft v Left wcntricular cmtrmt agent ia ifl~~~~t~~ cantrast study. Intense (+4) left ventricula ent. LA = left atrium; EV = Scft ventric RV - right venlrick.

tients. The atrial septum was ca woven Dacron (~our~a~~) c

nation. ~athete~zat~om d~c~~eutatio ovale was defined as passage of the septum with confirmation of kft

statistically significant.

I GIN ET AL. FEMORAt VENOUS CONTRAST DELlVERY

No. al

18

10

. w

Valsalva maneuver

embo9ic events) have dc~~n~t~ate# rates of 90% to 98% f3,19). Utilizing matching tcc~~i~ues (precurdial contrast examination, upper extremity contrast delivery), we ob- tained a similar patent fcramen male prevalence of 94%, suggesting that the patimts it-t this study are comparable to

c0ntrast ec~~card~~gr~~~ y 9Ias been sitive than precordial contrast echo-

cardiography for the detection crf patent for n male (92), but tt is a much name invasive procedure. virtue of its increased spatial reso9ution (high frequency transducer, proximity to the atria9 septum), transesop9tagea9 echacardi- egraphy has resulted in higher detection rates than has precordial echmardiography, with a patent foramen ovate prevalence of up to 22% (93). However, other transesopha- gea9 series (14) have demonstrated prevalence rates as low as

JACC Vol. 22. No. 3 December 1W3:W4-2

detect seven of eight surgically created atrial defects 11 to 12 mm in diameter) in mongrel dogs during inferior vena cwvw illjcetion of indocywnine green with densitometric swm- pling in the Femoral artery. In contrast, superior vents cava deliwry of cmmwt medium WBS able to detect only one of

atrial defects. SimiMy, Dwly (II)) d~rno~~~t~~~ed un defect in 4 of lib patients with chronic bronchitis

utilizing the indwyaniae gxccn dye-dilution technique wken wt w&s dclivercd from the ~~f~~~~~ v~na cavil or vein. Delivery of contrM medium from the

CWR OF axilbry vein failed to detecr a patent he 14 ents. These ~nve~ti~~~or~ rior s itivity of inf~r~ur over

Ian by the dye-dilution technique. However, this tk d~$~dv~nt~~ of requiring arterial cnnnula-

bon. ry may improve the detee- use of a “streaming” efkct

Wow being directed into the region of wcross it, if a defect is pmsent. This em, established prenatnlly and neces-

is mainQ3ined in adult lires In

:he normal atrial pressure gradi- rated by transesopha-

on for the enhanced detection of OW& by femoral vein contrast injection is

tie possibibty of inerased right atrial opacification. HOW-

fmimen ovale in embolic stroke is possible di bus. This risk is likely to be extremely low. In two studies that demonstrated a higher prevalence of patent foramen

Clinical ~~~U~~a~~~~s, Although the sensitivity of trans- thoracic and transesophageal echocardiography was not directly compared, we strongly believe t femoral vein delivery of contrast agent increases the sensi- tivity of the ~r~~ord~a~ approach to the level of the conven- tional transesophageal approach. Brecordial e~~o~ard~o~r~- phy in conjunction with femoral vein contrast delivery is sufficient to exclude patent foramen ovale when this is the major concern (as in patients undergoing seated nessrosurgi- cal procedures) and obviates the need for transesophagenl echocardiography with its attendant risks, including tracheal

1. Movsowitz C, Podolsky LA, Meycrawilz CB, Jacobs LE, Kotler MN. Pi&n! foramen ovak: a nonfunclioeal ~rnb~~~~gi~~ r:mnant potential cause of significant palhak#y? J Am kc ~~h~afdi~~~ ‘i 2Yb”m.

2. Loscalzv J. Paradoxical embolism: clinical ymsentali00, diagnostic stratV egies, and therapeutic options. Am Heafl J 1!%6:112: 1416.

3. Lcchat PH, Mas JL, Lascaull G, et al. Prevalence uf in patienls with stroke. N Engl J Med ~~$~;3~~1~4g-~~.

4. Webster MWI. Chancellor AM. Smith HI. Swift DL. Shaf NM. Patent foramen ovalc in yaung stroke paicsrls. kancel

5. Black S, Muzzi DA, Flitihimura RA, Cucchian RF. ~~~~~~~~~v~ and

intraoperative echocardiography IO dekc! ~~~~~~t~~~~f~ shwnt in ~~~~~~~ undergoing neurosurgicai procedures in the silting position. AneHhesiol- agy 199@72:436-8.

h. Rietveld AP, Mermasl C, Essed CE. Trimbus 3 MJ* ~~~~~~~~~~~ F. e&t to left shunt, with severe hypoxemia, at rhc atria! levrl in a patiena wirh hemodynamically important right veafricular infarction. Ji Am C01i CW dial l983:2:776-9.

7. konik 6, Mosslacher W. Posirive contra56 echncaPdiography in patients

GIN ET AL. FEIIQBRAL VENOUS COi%TRAST DELIVERY

with patent foramen ovale and normal right heart hemodynamics. Am J Card01 1982;49:1806-9. Dubourg 0, Bourdarias J-P, Farcot J-C, et al. Contrast visualization of co!~~induced r@ht to let? shunt through a patent foramen ovale. J Am Call Cafdiol 1984;4:587-94. BRIMS JS, Rf&tw SG, Ga;tz-anip AB, O’Connor NE, biaynes FW, Dalen JE. A simg!e technique for detecting small defects of the atrial septum. Am J Cardiol 1971;28:467-71. Daly JJ. Venoartetial shunting in obstructive pulmonary disease. N Engl J Med M&27%:952-3. Lynch JJ, Schucbard GH, Gross CM, Wann LS. Prevalence of right-to- kft rrtpial shutting in a healthy population: detection by Vatsalva maneu-

mups. ‘Am J Cardiol