Importance of an adequately performed Valsalva maneuver for detecting a right-to-left shunt indicating foramen ovale reopening.
OBJECTIVE
The purpose of this study was to investigate the importance of an adequately performed Valsalva maneuver for detecting a right-to-left shunt indicating reopening of the functional closure of the foramen ovale.


METHODS
We prospectively analyzed 260 patients (102 women and 158 men; mean age ± SD, 41 ± 19 years; range, 13-83 years) who underwent transesophageal echocardiography and agitated saline injection. Two-dimensional echocardiography, color Doppler imaging, and microbubbles were used to detect right-to-left shunts, and the Valsalva maneuver was performed to determine whether the functional closure of the foramen ovale had reopened.


RESULTS
Transesophageal echocardiography with color Doppler imaging identified a patent foramen ovale in 20 patients: 18 patients with a patent foramen ovale had left-to-right shunts, and 2 patients with atrial septal defects had bidirectional shunts. Both patients with atrial septal defects showed right-to-left shunt microbubbles without and with the Valsalva maneuver, whereas all 18 patients with a patent foramen ovale showed right-to-left shunt microbubbles only after the Valsalva maneuver. Foramen ovale reopening was identified by transesophageal echocardiography in an additional 40 patients with no shunt during rest on agitated saline injection and in whom the right-to-left shunt appeared only after the Valsalva maneuver. The Valsalva maneuver could cause an atrial septal swing, and its sensitivity and specificity were 100%.


CONCLUSIONS
An adequately performed Valsalva maneuver is important for detecting a right-to-left shunt indicating reopening of the functional closure of the foramen ovale.
Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China weidongmei2013@126.com.
Dongmei
D
Wei
Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
Yi
Y
Ju
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004452:Echocardiography / Q000379:methods*; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000000981:diagnostic imaging*; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging* / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014636:Valsalva Maneuver; D055815:Young Adult
Valsalva maneuver; foramen ovale; microbubbles; right-to-left shunt; transesophageal echocardiography; vascular ultrasound