title: Diagnostic accuracy of transesophageal echocardiogram for the detection of patent foramen ovale: a meta-analysis.
abstract: BACKGROUND
  Patent foramen ovale (PFO) is a remnant of the fetal circulation present in 20% of the population. Right-to-left shunting (RLS) through a PFO has been linked to the pathophysiology of stroke, migraine with aura, and hypoxemia. While different imaging modalities including transcranial Doppler, intra-cardiac echo, and transthoracic echo (TTE) have often been used to detect RLS, transesophageal echo (TEE) bubble study remains the gold standard for diagnosing PFO. The aim of this study was to determine the relative accuracy of TEE in the detection of PFO.
  
  
  RESULTS
  A systematic review of Medline, using a standard approach for meta-analysis, was performed for all prospective studies assessing accuracy of TEE in the detection of PFO using confirmation by autopsy, cardiac surgery, and/or catheterization as the reference. Search results revealed 3105 studies; 4 met inclusion criteria. A total of 164 patients were included. TEE had a weighted sensitivity of 89.2% (95% CI: 81.1-94.7%) and specificity of 91.4% (95% CI: 82.3-96.8%) to detect PFO. The overall positive likelihood ratio (LR+) was 5.93 (95% CI: 1.30-27.09) and the overall negative likelihood ratio (LR-) was 0.22 (95% CI: 0.08-0.56).
  
  
  CONCLUSIONS
  While TEE bubble study is considered to be the gold standard modality for diagnosing PFO, some PFOs may still be missed or misdiagnosed. It is important to understand the limitations of TEE and perhaps use other highly sensitive screening tests, such as transcranial doppler (TCD), in conjunction with TEE before scheduling a patient for transcatheter PFO closure.
authors.affiliation: Department of Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, Bronx, New York.
authors.forename: Mohammad Khalid
authors.initials: MK
authors.lastname: Mojadidi
authors.forename: Nikolay
authors.initials: N
authors.lastname: Bogush
authors.forename: Jose Diego
authors.initials: JD
authors.lastname: Caceres
authors.forename: Pavlos
authors.initials: P
authors.lastname: Msaouel
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Tobis
mesh_terms: D017548:Echocardiography, Transesophageal / Q000706:statistics & numerical data*; D005260:Female; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D006801:Humans; D008297:Male; D015995:Prevalence; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity
keywords: TEE; echocardiography; patent foramen ovale