Accuracy of Transcranial Doppler for the Diagnosis of Intracardiac Right-to-Left Shunt A Bivariate Meta-Analysis of Prospective Studies

作者：Mojadidi M Khalid^*; Roberts Scott C; Winoker Jared S; Romero Jorge; Goodman Meza David; Gevorgyan Rubine; Tobis Jonathan M

来源：JACC: Cardiovascular Imaging , 2014, 7(3): 236-250.

DOI：10.1016/j.jcmg.2013.12.011

• patent foramen ovale
• right-to-left shunt
• transcranial Doppler

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.

• 出版日期2014-3