TY - JOUR
T1 - Accuracy of transcranial Doppler for the diagnosis of intracardiac right-to-left shunt
T2 - A bivariate meta-analysis of prospective studies
AU - Mojadidi, M. Khalid
AU - Roberts, Scott C.
AU - Winoker, Jared S.
AU - Romero, Jorge
AU - Goodman-Meza, David
AU - Gevorgyan, Rubine
AU - Tobis, Jonathan M.
PY - 2014/3
Y1 - 2014/3
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.
KW - patent foramen ovale
KW - right-to-left shunt
KW - transcranial Doppler
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U2 - 10.1016/j.jcmg.2013.12.011
DO - 10.1016/j.jcmg.2013.12.011
M3 - Article
C2 - 24560213
AN - SCOPUS:84896539242
SN - 1936-878X
VL - 7
SP - 236
EP - 250
JO - JACC: Cardiovascular Imaging
JF - JACC: Cardiovascular Imaging
IS - 3
ER -