Transcranial Doppler: Does Addition of Blood to Agitated Saline Affect Sensitivity for Detecting Cardiac Right-to-Left Shunt?
BACKGROUND
Transcranial Doppler (TCD) with agitated saline has been shown to be an alternative for the detection of right-to-left shunts (RLS) with similar diagnostic accuracies as transesophageal echocardiography (TEE). It is hypothesized that the addition of blood to agitated saline increases the sensitivity of TCD for the detection of RLS. The aim of this meta-analysis was to determine whether agitated saline with blood increases the sensitivity of TCD for the detection of RLS compared to agitated saline alone and other contrast agents.


METHODS
A systematic review of Medline, Cochrane, and Embase was performed to look for all prospective studies assessing intracardiac RLS using TCD compared with TEE as the reference; both tests were performed with a contrast agent and a maneuver to provoke RLS in all studies.


RESULTS
A total of 27 studies (29 comparisons) with 1,968 patients met the inclusion criteria. Of 29 comparisons, 10 (35%) used echovist contrast during TCD, 4 (14%) used a gelatin-based solution, 12 (41%) used agitated saline, and 3 (10%) utilized 2 different contrast agents. The addition of blood to agitated saline improved the sensitivity of TCD to 100% compared to agitated saline alone (96% sensitivity, P = 0.161), echovist (94% sensitivity, P = 0.044), and gelatin-based solutions (93% sensitivity, P = 0.041).


CONCLUSIONS
The addition of blood to agitated saline improves the sensitivity of TCD for the detection of RLS to 100% when compared to other conventional contrast agents; these findings support the addition of blood to agitated saline during TCD bubble studies.
Division of Cardiology, University of Florida, Gainesville, Florida.
Mohammad Khalid
MK
Mojadidi
Division of Cardiology, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York.
Lili
L
Zhang
Division of Cardiology, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York.
Yashasvi
Y
Chugh
Division of Cardiology, Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, Atlanta, Georgia.
Parham
P
Eshtehardi
Division of Cardiology, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York.
Ninel
N
Hovnanians
Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
Rubine
R
Gevorgyan
Division of Cardiology, University of Florida, Gainesville, Florida.
Sanaullah
S
Mojaddedi
Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut.
Nariman
N
Nezami
Department of Medicine, Crozer-Chester Medical Center, Chester, Pennsylvania.
Muhammad Omer
MO
Zaman
Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
Asim
A
Rafique
Division of Cardiology, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York.
Pedro A
PA
Villablanca
Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
Jonathan M
JM
Tobis
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001774:Blood Chemical Analysis; D003287:Contrast Media / Q000008:administration & dosage / Q000737:chemistry; D005260:Female; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging*; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012965:Sodium Chloride / Q000008:administration & dosage / Q000737:chemistry*; D017585:Ultrasonography, Doppler, Transcranial / Q000187:drug effects / Q000379:methods*; D055815:Young Adult
D003287:Contrast Media; D012965:Sodium Chloride
patent foramen ovale; right-to-left shunt; transcranial Doppler; transesophageal echocardiogram