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Original Research: ECHOCARDIOGRAPHY |

Small- and Moderate-Size Right-to-Left Shunts Identified by Saline Contrast Echocardiography Are Normal and Unrelated to Migraine Headache

Timothy D. Woods, MD, FCCP; Leanne Harmann, BA; Traci Purath, MD; Suresh Ramamurthy, MD; Sharath Subramanian, MD; Scott Jackson, MS; Sergey Tarima, PhD
Author and Funding Information

From the Department of Internal Medicine (Drs Woods, Ramamurthy, and Subramanian and Ms Harmann), and Department of Biostatistics (Mr Jackson and Dr Tarima), Medical College of Wisconsin, Milwaukee; and the Department of Neurology (Dr Purath), Wheaton-Franciscan Health Care, Racine WI.

Correspondence to: Timothy Woods, MD, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226; e-mail: twoods@mcw.edu


Funding/Support: This research was supported by the Department of Internal Medicine, Medical College of Wisconsin.

For editorial comment see page 246

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;138(2):264-269. doi:10.1378/chest.09-2797
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Background:  We suspected, based on clinical experience, that the prevalence of both intracardiac and pulmonary arteriovenous malformations (PAVMs) is higher than previously reported in a healthy population when using modern ultrasound technology combined with a rigorous saline contrast echocardiogram (SCE) protocol. We hypothesized the prevalence of right-to-left shunts (RLSs) would be so high when using this sensitive technique that there would be no significant association of RLS with migraine headache.

Methods:  We recruited 104 healthy volunteers to undergo an SCE followed by completion of a migraine questionnaire. The SCEs were meticulously graded for shunt size and location based on left-sided heart contrast quantity and timing. The migraine headache questionnaire was graded by a neurologist blinded to SCE results.

Results:  One hundred four subjects underwent the study protocol. We found 71% of subjects exhibited evidence of RLS. Patent foramen ovale (PFO) was identified in 40 (38%), PAVM was identified in 29 (28%), and five subjects had evidence of both (5%). Based on questionnaires, 42 (40%) of the subjects had migraine headache (29% with aura). There was no significant association of migraine headache with PFO (OR, 0.59; 95% CI, 0.16-2.12; P = .54) or PAVM (OR, 0.8; 95% CI, 0.34-1.9; P = .67), although only 13 (13%) of the subjects had evidence of large RLS.

Conclusions:  When using modern ultrasound technology combined with a rigorous SCE technique, the majority of healthy subjects demonstrate some degree of RLS. PAVM in an otherwise healthy population is common. Small- and moderate-size RLSs do not appear to be significantly associated with migraine headache.

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