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European Journal of Echocardiography 2005 6(1):75-78; doi:10.1016/j.euje.2004.06.010
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Copyright © 2005, The European Society of Cardiology

Traditional contrast echocardiography may fail to demonstrate a patent foramen ovale: negative contrast in the right atrium may be a clue

J.E. Lindebooma,*, M.J. van Deudekoma and C.A. Visserb

aDepartment of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
bDepartment of Cardiology, VU Medical Centre, Amsterdam, The Netherlands

Received 25 May 2004; received in revised form 16 June 2004; accepted after revision 18 June 2004.

* Corresponding author. Department of Cardiology, Rijnstate Hospital, PO box 9555, 6800 Arnhem, The Netherlands. Tel.: +31 26 3515199; fax: +31 26 3515163. j.e.lindeboom{at}12move.nl


   Abstract
Top
 Abstract
Case presentation
 Discussion
 References
 
We describe a patient who suffered a stroke of unknown origin and presented a patent foramen ovale (PFO) at contrast echocardiography. This PFO was clearly detectable after contrast delivery in the femoral vein, while repeated contrast delivery in an antecubital vein only showed a negative contrast effect, which suggests that the blood crossing the PFO originated from the vena cava inferior.

However, enhanced detection of a PFO by femoral contrast delivery, compared to antecubital injection has been published many years ago, this mode is not widely implemented yet.

With this case report we would like to illustrate that the negative contrast effect may be used as an indicator that a PFO cannot be excluded and a switch to femoral contrast injection is then mandatory.

Keywords: Patent foramen ovale; Contrast echocardiography; Negative contrast; Femoral vein


   Case presentation
Top
 Abstract
 Case presentation
Discussion
 References
 
A previously healthy 30-year-old man suffered a moderate to large stroke.

Routine neurological, internal, haematological and vascular screening revealed no abnormalities. He did not smoke, his blood pressure was 140/80 and he had stable sinus rhythm without evidence for paroxysmal atrial fibrillation.

Transthoracic 2D echo and Doppler investigation, with several quick injections of 15–20cc contrast (shaken dextran plasma-expander/1cc air), delivered via an antecubital vein, with and without Valsalva maneuver, were attempted to demonstrate a PFO. The best result is shown in Fig. 1. Some contrast was present in the left side of the heart, suggesting a PFO. Furthermore, there was an area of negative contrast (see *).


Figure 1
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  		Figure 1 Transthoracic 2D Echo, apical view. Antecubital delivered contrast fills the right atrium except for the part with "negative contrast (*)". Slight contrast is present in the left heart side.

 
Once contrast was delivered via an indwelling catheter in the right femoral vein, the PFO was easily demonstrated (Figs. 2 and 3Goa, b).


Figure 2
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  		Figure 2 Transthoracic 2D Echo, apical view. Femoral delivered contrast fills the right atrium and clearly shunts to the left heart side.

 


Figure 3
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  		Figure 3 (a) Transesophageal 2D Echo, plane at 63 degrees. Femoral delivered contrast shunts through a patent foramen ovale. (b) Transesophageal 2D Echo, plane at 106 degrees. Femoral delivered contrast shunts through a patent foramen ovale. The inflow from the vena cava superior (negative contrast) is directed away from the foramen ovale.

 

   Discussion
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 Abstract
 Case presentation
 Discussion
References
 
The incidence of a PFO is reported to be ±20% in a healthy population and ±50% in a high-risk group of patients suffering from cryptogenic stroke.1,2

Enhanced detection of a PFO has been demonstrated by femoral contrast delivery, compared to antecubital injection. The sensitivity improved from ±35% to almost 100%.3–5 Notwithstanding this, the femoral approach has not gained wide acceptance.

Obviously, this procedure is more demanding for both patient and doctor.

With this case report, we would like to illustrate that an area of negative contrast sometimes may remain after several antecubital contrast injections, and this may be a warning sign that a PFO cannot be excluded. The area of negative contrast is caused by inflow from the vena cava inferior. This blood flow is directed towards the foramen ovale, as a heritage from the fetal circulation, where oxygen and nutrient rich blood is shunted from the placenta to the left sided fetal circulation.6 This blood flow hampers the contrast filled blood from the vena cava superior to cross the PFO. Fig. 3b shows the inflow from the inferior vena cava directed to the PFO, as well as the flow from the superior vena cava, directed away from the intraatrial septum.

Another cause of negative contrast may be left-to-right shunting through a large PFO or atrial septal defect of the secundum type. Normally the 2D echo image already shows this defect and the shunt can easily be shown with Doppler.

In conclusion, we suggest that in clinical practice, when antecubital delivered contrast fails to demonstrate a PFO, or fails to completely fill the right atrium (negative contrast effect), this may indicate inflow from the inferior vena cava, which may cross and thereby mask a PFO. Such a finding justifies a switch to femoral contrast injection.


   References
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 Abstract
 Case presentation
 Discussion
 References
 

  1. Lynch J.J., Schuchard G.H., Gross C.M., Wann L.S. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol (1984) 53:1478–1480.[CrossRef][Web of Science][Medline]
  2. Lechat P., Mas J.L., Lascault G., Loron P., Theard M., Klimczac M., et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med (1988) 318:1148–1152.[Abstract]
  3. Gin K.G., Huckell V.F., Pollick C. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol (1993) 22:1994–2000.[Abstract]
  4. Hamann G.F., Schätzer-Klotz D., Fröhlig G., Strittmatter M., Jost V., Berg G., et al. Femoral injection of echo contrast medium may increase the sensitivity of testing for a patent foramen ovale. Neurology (1998) 50:1423–1428.[Abstract/Free Full Text]
  5. Di Tullio M., Sacco R.L., Venketasubramanian N., Sherman D., Mohr J.P., Homma S. Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients. Stroke (1993) 24:1020–1024.[Abstract/Free Full Text]
  6. Falk R.H. PFO or UFO? The role of a patent foramen ovale in cryptogenic stroke. Am Heart J (1991) 121:1264–1266.[CrossRef][Web of Science][Medline]

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