Saline contrast echocardiography for the detection of patent foramen ovale in hypoxia: a validation study using intracardiac echocardiography

Echocardiography. 2014 Apr;31(4):420-7. doi: 10.1111/echo.12403. Epub 2013 Oct 18.


Although the "3 beat rule" is widely utiized to discriminate patent foramen ovale (PFO)-mediated right-to-left shunt (RTLS) from intrapulmonary RTLS using saline contrast transthoracic echocardiography (SCE), SCE diagnostic performance has yet to be validated using an invasive intracardiac standard. Percutaneous PFO occluder placement was recently shown to ameliorate hypoxia in patients with suspected PFO-mediated RTLS. We evaluated the ability of SCE to predict PFO presence and size using intracardiac echocardiography (ICE) as a gold standard in a hypoxic cohort. Sixty-three hypoxic patients with suspected PFO-mediated RTLS who underwent SCE at rest, with Valsalva maneuver, and with cough prior to ICE were evaluated retrospectively. PFO RTLS was defined by ICE findings including PFO anatomy, RTLS by saline contrast and color Doppler, and probe patency. SCE shunt severity and timing of left heart saline target appearance were compared to the presence of ICE-defined PFO RTLS. Forty-seven patients (75%) met criteria for PFO-mediated RTLS. A 4 beat cutoff for resting SCE provided optimal diagnostic performance for detection of PFO-mediated RTLS with a 71% sensitivity, 94% specificity, and 97% positive predictive value (PPV). Valsalva and cough maneuvers improved sensitivity compared to rest SCE (89% and 80%, respectively). Valsalva SCE shunt severity more accurately predicted PFO size than resting SCE. In contrast to the widely accepted "3 beat rule," resting SCE for the detection of PFO RTLS in a hypoxic population performs optimally using a 4-cycle cutoff with both excellent specificity and PPV.

Keywords: intra-cardiac echocardiography; patent foramen ovale; right-to-left shunt; saline contrast.

Publication types

  • Validation Study

MeSH terms

  • Aged
  • Cardiac Catheterization
  • Cardiac Catheters
  • Cohort Studies
  • Echocardiography, Doppler, Color / methods*
  • Echocardiography, Transesophageal / methods
  • Female
  • Foramen Ovale, Patent / diagnosis
  • Foramen Ovale, Patent / diagnostic imaging*
  • Humans
  • Hypoxia / diagnosis
  • Hypoxia / diagnostic imaging
  • Image Enhancement / methods*
  • Male
  • Middle Aged
  • Retrospective Studies
  • Sensitivity and Specificity
  • Sodium Chloride*
  • Ultrasonography, Interventional / methods*


  • Sodium Chloride