title: The detection of interatrial flow patency in awake and anesthetized patients: a comparative study using transnasal transesophageal echocardiography.
abstract: The Valsalva maneuver in the awake patient and the ventilation maneuver in the tracheally intubated anesthetized patient are two provocation methods to detect a patent foramen ovale (PFO) by means of contrast transesophageal echocardiography. In 60 patients undergoing posterior fossa surgery, a contrast agent was administered via a peripheral vein during a Valsalva maneuver immediately before anesthesia induction, followed by central venous administration during a ventilation maneuver in the same patients when anesthetized and endotracheally intubated. We evaluated both maneuvers with a 32-element monoplane transnasal transesophageal echocardiography probe to trace the atrial flow of the contrast agent in a 90 degrees bicaval view. A maneuver was rated positive when more than four bubbles appeared in the left atrium during the first three cardiac cycles after intrathoracic pressure release. The right atrial cross-sectional area before pressure release, and the peak septal excursion during atrial contrast opacification, were measured. McNemar's test was used to assess a paired dichotomous response on the two maneuvers for a significant difference. In 56 patients, the ventilation maneuver was significantly (P < 0.037) more often positive for PFO (n = 14) than the Valsalva maneuver (n = 7). Although there was no difference in the methods regarding the peak septal excursion, the mean right atrial area before pressure release was significantly smaller during the ventilation maneuver than during the Valsalva maneuver (11.2 +/- 3.1 cm(2) vs 14.4 +/- 3.3 cm(2), n = 42, P < 0.05). In the patients with a positive ventilation, but a negative Valsalva maneuver, the discrepancy was even larger (10.9 +/- 4.4 cm(2) vs 16.3 +/- 4.2 cm(2), n = 7, P < 0.001). We conclude that the ventilation maneuver is superior to the Valsalva maneuver in detecting PFO. Our data suggest that a peak pressure of 30 cm H(2)O during the ventilation maneuver achieves a more pronounced reduction in right atrial load and allows right atrial pressure to exceed left atrial pressure when intrathoracic pressure is released.
  
  
  CONCLUSIONS
  A controlled ventilation maneuver in anesthetized patients immediately before posterior fossa surgery may be superior to the preoperative Valsalva maneuver in detecting a patent foramen ovale by contrast transesophageal echocardiography. This approach identifies patients at high risk for paradoxic embolism, but it is not practical for preoperative identification of patients who might benefit from patent foramen ovale closure before surgery.
authors.affiliation: Department of Anesthesiology, University Hospital Würzburg, Josef-Schneider-Str. 2, 97080 Würzburg, Germany. cgreim@anaesthesie.uni-wuerzburg.de
authors.forename: C A
authors.initials: CA
authors.lastname: Greim
authors.forename: H
authors.initials: H
authors.lastname: Trautner
authors.forename: K
authors.initials: K
authors.lastname: Krämer
authors.forename: P
authors.initials: P
authors.lastname: Zimmermann
authors.forename: C C
authors.initials: CC
authors.lastname: Apfel
authors.forename: N
authors.initials: N
authors.lastname: Roewer
mesh_terms: D000758:Anesthesia; D003287:Contrast Media; D003388:Cranial Fossa, Posterior / Q000601:surgery; D017548:Echocardiography, Transesophageal / Q000379:methods; D005260:Female; D006323:Heart Arrest / Q000000981:diagnostic imaging; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011134:Polysaccharides; D011187:Posture; D012121:Respiration, Artificial; D014636:Valsalva Maneuver; D014851:Wakefulness
chemical_list: D003287:Contrast Media; D011134:Polysaccharides; C040642:SHU 454