Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale.

Objectives: We postulated that femoral vein delivery of contrast medium because of streaming, might enhance precordial echocardiographic detection of patent foramen ovale.

Background: Although precordial contrast echocardiography is widely used to diagnose patent foramen ovale, this method is limited by poor sensitivity. Previous investigators have demonstrated enhanced detection of atrial defects by the dye-dilution technique after delivery of contrast medium into the inferior rather than the superior vena cava.

Methods: Transthoracic contrast examinations were performed in a randomly selected group of 70 patients (without previous history of cerebral or systemic embolus) undergoing cardiac catheterization. Paired contrast agent injections (10 ml dextrose in water/0.25 ml air) were administered from an upper extremity vein and femoral vein in each patient during spontaneous respiration, cough and Valsalva maneuvers. Studies were interpreted by an experienced echocardiographer unaware of the sequence and site of injections. Positive studies were semiquantitatively graded from +1 (minimal left ventricular opacification) to +4 (intense left ventricular opacification). Catheterization and echocardiographic assessment of patent foramen ovale were compared in 21 subjects.

Results: Patent foramen ovale was detected significantly more often during femoral vein versus upper extremity contrast delivery (23 of 70 patients [prevalence 33%] vs. 9 of 70 patients [prevalence 13%], p < 0.001). The intensity of left ventricular opacification was also greater during femoral vein contrast injection. Precordial echocardiography combined with femoral contrast delivery was significantly more sensitive than cardiac catheterization for assessment of patent foramen ovale (8 of 21 patients vs. 2 of 21 patients, p < 0.05).

Conclusions: Femoral vein contrast delivery significantly enhances the ability of precordial contrast echocardiography to diagnose patent foramen ovale. Physiologic patency of the foramen ovale is more common (prevalence 33%) than previously documented.