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Right-to-Left Shunts and Saline Contrast Echocardiography

Dennis A. Tighe, MD; Gerard P. Aurigemma, MD
Author and Funding Information

From the Department of Medicine, University of Massachusetts Medical School.

Correspondence to: Dennis A. Tighe, MD, Non-invasive Cardiology, Division of Cardiovascular Medicine, Department of Medi­cine, University of Massachusetts Medical School, 55 Lake Ave, N Worcester, MA 01655; e-mail: tighed@ummhc.org.


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Aurigemma is a shareholder for Philips Ultrasound. Dr Tighe has reported that no potential conflicts exist with any companies/organizations whose products or services may be discussed in this article.

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


© 2010 American College of Chest Physicians


Chest. 2010;138(2):246-248. doi:10.1378/chest.10-0420
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Right-to-left shunting, occurring primarily with intracardiac lesions such as patent foramen ovale (PFO) and to a lesser extent via pulmonary arteriovenous malformations (PAVM), has been associated with a variety of common disease processes.1,2 Thus, identification of right-to-left shunting is a frequently requested evaluation in busy echocardiography laboratories. Since the initial report by Gramiak et al,3 saline contrast echocardiography has been the method of choice to identify these shunts. By agitating a small amount of air with solutions such as saline or 5% dextrose/water, microcavitations (“bubbles”) are produced that, when injected into the venous circulation, appear only in the left side of the heart when a permissive right-to-left pathway is present. Even one bubble appearing in the left side of the heart has been proposed as a diagnostic criterion to identify right-to-left shunting.4 Transthoracic echocardiography is the usual starting point; however, some patients may require transesophageal echocardiography (TEE) for detection. Transcranial Doppler can identify right-to-left shunts but cannot specify their location precisely. In general, “early appearance” of microcavitations in the left side of the heart (within three beats of right-sided heart opacification) is considered indicative of atrial level shunting, whereas later-appearing bubbles represent extracardiac shunting.2

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