Detection of right-to-left atrial communication using agitated saline contrast imaging: experience with 1162 patients and recommendations for echocardiography.

BACKGROUND: Right-to-left shunting via a patent foramen ovale (PFO) has a recognized association with embolic events in younger patients. The use of agitated saline contrast injection (ASCi) for detecting atrial shunting is well documented, but the optimal technique is not well described. The purpose of this study was to assess the efficacy and safety of transthoracic echocardiographic (TTE) ASCi for the assessment of right-to-left atrial communication in a large cohort of patients. METHODS: A retrospective review was undertaken of 1,162 consecutive patients who underwent TTE ASCi, of whom 195 had also undergone clinically indicated transesophageal echocardiography. ASCi shunt results were compared with color flow imaging, and the role of provocative maneuvers (PM) was assessed. RESULTS: Four hundred three TTE studies (35%) had paradoxical shunting seen during ASCi. Of these, 48% were positive with PM only. There was strong agreement between TTE ASCi and reported transesophageal echocardiographic findings (99% sensitivity, 85% specificity), with six false-positive and two false-negative results. In hindsight, the latter were likely due to suboptimal right atrial opacification and the former to transpulmonary shunting. TTE color flow imaging was found to be insensitive (22%) for the detection of a PFO compared with TTE ASCi. CONCLUSIONS: TTE color flow imaging is too insensitive for PFO screening. TTE ASCi, however, is simple and highly accurate for the detection of right-to-left atrial communication, on the proviso that a dedicated protocol, including correctly implemented PM, is followed. It is recommended that TTE ASCi with PM be considered the primary diagnostic tool for the detection of PFO in clinical practice.

Anti-thymocyte globulin as an adjunct to treatment of fulminant lymphocytic myocarditis.

There is much debate over the role of immunosuppression in the treatment of acute and fulminant myocarditis. The low incidence of the condition prevents large numbers of cases for study, and treatment protocols vary greatly between institutions. In this study we add our experience with anti-thymocyte globulin as an adjunct to standard medical therapy for 5 patients presenting with cardiogenic shock due to fulminant myocarditis. All cases were associated with rapid and dramatic improvement in hemodynamic and electrophysiologic abnormalities, returning patients to NYHA Class I and cardiac function to normal or near normal by discharge.

Case report and review: epicardial coronary artery fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) of the epicardial coronary arteries is an uncommon entity. We describe the first published case of this condition presenting as a transient ischaemic attack due to thromboembolism from intracardiac thrombus secondary to silent myocardial infarction. We also present the first published case of epicardial coronary FMD with sparing of the renal arteries. This case provides further evidence that FMD of the epicardial coronary arteries frequently involves the mid to distal segments of the left anterior descending artery. A brief review of the literature on FMD is presented.