Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt: A bivariate meta-analysis of prospective studies

M. Khalid Mojadidi, Scott C. Roberts, Jared S. Winoker, Jorge E. Romero, David Goodman-Meza, Rubine Gevorgyan, Jonathan M. Tobis

Research output: Contribution to journalArticle

65 Citations (Scopus)

Abstract

Objectives: The aim of this meta-analysis was to determine the accuracy of transcranial Doppler (TCD) compared with transesophageal echocardiography (TEE) as the reference. Background: Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke, and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients with these conditions, and those being considered for transcatheter closure. Although a TEE bubble study is the current standard reference for diagnosing PFO, the TCD bubble study may be a preferable alternative test for RLS because of its high sensitivity and specificity, noninvasive nature, and low cost. Methods: A systematic review of Medline, the Cochrane Library, and Embase was done to look for all the 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 (mean age 47.8 ± 5.7 years; 51% male) fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TCD were 97% and 93%, respectively. Likewise, the positive and negative likelihood ratios were 13.51 and 0.04, respectively. When 10 microbubbles was used as the embolic cutoff for a positive TCD study, TCD produced a higher specificity compared with when 1 microbubble was used as the cutoff (p = 0.04); there was, however, no significant change in sensitivity (p = 0.29). Conclusions: TCD is a reliable, noninvasive test with excellent diagnostic accuracies, making it a proficient test for detecting RLS. TCD can be used as a part of the stroke workup and for patients being considered for PFO closure. If knowledge of the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.

Original languageEnglish (US)
Pages (from-to)236-250
Number of pages15
JournalJACC: Cardiovascular Imaging
Volume7
Issue number3
DOIs
StatePublished - 2014

Fingerprint

Patent Foramen Ovale
Meta-Analysis
Transesophageal Echocardiography
Prospective Studies
Microbubbles
Stroke
Sensitivity and Specificity
Migraine Disorders
Contrast Media
Libraries
Observational Studies
Anatomy
Clinical Trials
Costs and Cost Analysis

Keywords

  • patent foramen ovale
  • right-to-left shunt
  • transcranial Doppler

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging
  • Medicine(all)

Cite this

Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt : A bivariate meta-analysis of prospective studies. / Mojadidi, M. Khalid; Roberts, Scott C.; Winoker, Jared S.; Romero, Jorge E.; Goodman-Meza, David; Gevorgyan, Rubine; Tobis, Jonathan M.

In: JACC: Cardiovascular Imaging, Vol. 7, No. 3, 2014, p. 236-250.

Research output: Contribution to journalArticle

Mojadidi, M. Khalid ; Roberts, Scott C. ; Winoker, Jared S. ; Romero, Jorge E. ; Goodman-Meza, David ; Gevorgyan, Rubine ; Tobis, Jonathan M. / Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt : A bivariate meta-analysis of prospective studies. In: JACC: Cardiovascular Imaging. 2014 ; Vol. 7, No. 3. pp. 236-250.
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AU - Romero, Jorge E.

AU - Goodman-Meza, David

AU - Gevorgyan, Rubine

AU - Tobis, Jonathan M.

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N2 - Objectives: The aim of this meta-analysis was to determine the accuracy of transcranial Doppler (TCD) compared with transesophageal echocardiography (TEE) as the reference. Background: Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke, and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients with these conditions, and those being considered for transcatheter closure. Although a TEE bubble study is the current standard reference for diagnosing PFO, the TCD bubble study may be a preferable alternative test for RLS because of its high sensitivity and specificity, noninvasive nature, and low cost. Methods: A systematic review of Medline, the Cochrane Library, and Embase was done to look for all the 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 (mean age 47.8 ± 5.7 years; 51% male) fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TCD were 97% and 93%, respectively. Likewise, the positive and negative likelihood ratios were 13.51 and 0.04, respectively. When 10 microbubbles was used as the embolic cutoff for a positive TCD study, TCD produced a higher specificity compared with when 1 microbubble was used as the cutoff (p = 0.04); there was, however, no significant change in sensitivity (p = 0.29). Conclusions: TCD is a reliable, noninvasive test with excellent diagnostic accuracies, making it a proficient test for detecting RLS. TCD can be used as a part of the stroke workup and for patients being considered for PFO closure. If knowledge of the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.

AB - Objectives: The aim of this meta-analysis was to determine the accuracy of transcranial Doppler (TCD) compared with transesophageal echocardiography (TEE) as the reference. Background: Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke, and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients with these conditions, and those being considered for transcatheter closure. Although a TEE bubble study is the current standard reference for diagnosing PFO, the TCD bubble study may be a preferable alternative test for RLS because of its high sensitivity and specificity, noninvasive nature, and low cost. Methods: A systematic review of Medline, the Cochrane Library, and Embase was done to look for all the 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 (mean age 47.8 ± 5.7 years; 51% male) fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TCD were 97% and 93%, respectively. Likewise, the positive and negative likelihood ratios were 13.51 and 0.04, respectively. When 10 microbubbles was used as the embolic cutoff for a positive TCD study, TCD produced a higher specificity compared with when 1 microbubble was used as the cutoff (p = 0.04); there was, however, no significant change in sensitivity (p = 0.29). Conclusions: TCD is a reliable, noninvasive test with excellent diagnostic accuracies, making it a proficient test for detecting RLS. TCD can be used as a part of the stroke workup and for patients being considered for PFO closure. If knowledge of the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.

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