Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications

A striking association

Sebastiaan Velthuis, Elisabetta Buscarini, Marco W F Van Gent, Pietro Gazzaniga, Guido Manfredi, Cesare Danesino, Wouter J. Schonewille, Cornelis J J Westermann, Repke J. Snijder, Johannes J. Mager, Martijn C. Post

Research output: Contribution to journalArticle

36 Citations (Scopus)

Abstract

Background: A pulmonary right-to-left shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). Methods: We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary shunt grading on TTCE (grade 0, no microbubbles; grade 1, <30 microbubbles; grade 2, 30-100 microbubbles; grade 3, > 100 microbubbles) was performed according to contrast opacifi cation of the left ventricle. Cerebral complications were defi ned as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confi rmed by appropriate imaging techniques. Results: A pulmonary RLS was present in 530 out of 1,038 patients (51.1%; mean age, 44.3 ± 15.6 years; 58.6% women). The presence of a cerebral manifestation (n 5 51) differed signifi cantly among pulmonary shunt grades on TTCE: 1.4%, 0.4%, 6.5%, and 20.9% for grades 0, 1, 2 and 3, respectively. A pulmonary shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95% CI, 0.05-4.13; P = .47), whereas pulmonary shunt grade 2 (OR, 4.78; 95% CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95% CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. Conclusions: The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.

Original languageEnglish
Pages (from-to)542-548
Number of pages7
JournalChest
Volume144
Issue number2
DOIs
Publication statusPublished - Aug 2013

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Echocardiography
Lung
Hereditary Hemorrhagic Telangiectasia
Microbubbles
Brain Abscess
Transient Ischemic Attack
Nervous System
Heart Ventricles
Cations
Cross-Sectional Studies
Stroke

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Critical Care and Intensive Care Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Velthuis, S., Buscarini, E., Van Gent, M. W. F., Gazzaniga, P., Manfredi, G., Danesino, C., ... Post, M. C. (2013). Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: A striking association. Chest, 144(2), 542-548. https://doi.org/10.1378/chest.12-1599

Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications : A striking association. / Velthuis, Sebastiaan; Buscarini, Elisabetta; Van Gent, Marco W F; Gazzaniga, Pietro; Manfredi, Guido; Danesino, Cesare; Schonewille, Wouter J.; Westermann, Cornelis J J; Snijder, Repke J.; Mager, Johannes J.; Post, Martijn C.

In: Chest, Vol. 144, No. 2, 08.2013, p. 542-548.

Research output: Contribution to journalArticle

Velthuis, S, Buscarini, E, Van Gent, MWF, Gazzaniga, P, Manfredi, G, Danesino, C, Schonewille, WJ, Westermann, CJJ, Snijder, RJ, Mager, JJ & Post, MC 2013, 'Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: A striking association', Chest, vol. 144, no. 2, pp. 542-548. https://doi.org/10.1378/chest.12-1599
Velthuis, Sebastiaan ; Buscarini, Elisabetta ; Van Gent, Marco W F ; Gazzaniga, Pietro ; Manfredi, Guido ; Danesino, Cesare ; Schonewille, Wouter J. ; Westermann, Cornelis J J ; Snijder, Repke J. ; Mager, Johannes J. ; Post, Martijn C. / Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications : A striking association. In: Chest. 2013 ; Vol. 144, No. 2. pp. 542-548.
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abstract = "Background: A pulmonary right-to-left shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). Methods: We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary shunt grading on TTCE (grade 0, no microbubbles; grade 1, <30 microbubbles; grade 2, 30-100 microbubbles; grade 3, > 100 microbubbles) was performed according to contrast opacifi cation of the left ventricle. Cerebral complications were defi ned as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confi rmed by appropriate imaging techniques. Results: A pulmonary RLS was present in 530 out of 1,038 patients (51.1{\%}; mean age, 44.3 ± 15.6 years; 58.6{\%} women). The presence of a cerebral manifestation (n 5 51) differed signifi cantly among pulmonary shunt grades on TTCE: 1.4{\%}, 0.4{\%}, 6.5{\%}, and 20.9{\%} for grades 0, 1, 2 and 3, respectively. A pulmonary shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95{\%} CI, 0.05-4.13; P = .47), whereas pulmonary shunt grade 2 (OR, 4.78; 95{\%} CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95{\%} CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. Conclusions: The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.",
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T2 - A striking association

AU - Velthuis, Sebastiaan

AU - Buscarini, Elisabetta

AU - Van Gent, Marco W F

AU - Gazzaniga, Pietro

AU - Manfredi, Guido

AU - Danesino, Cesare

AU - Schonewille, Wouter J.

AU - Westermann, Cornelis J J

AU - Snijder, Repke J.

AU - Mager, Johannes J.

AU - Post, Martijn C.

PY - 2013/8

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N2 - Background: A pulmonary right-to-left shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). Methods: We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary shunt grading on TTCE (grade 0, no microbubbles; grade 1, <30 microbubbles; grade 2, 30-100 microbubbles; grade 3, > 100 microbubbles) was performed according to contrast opacifi cation of the left ventricle. Cerebral complications were defi ned as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confi rmed by appropriate imaging techniques. Results: A pulmonary RLS was present in 530 out of 1,038 patients (51.1%; mean age, 44.3 ± 15.6 years; 58.6% women). The presence of a cerebral manifestation (n 5 51) differed signifi cantly among pulmonary shunt grades on TTCE: 1.4%, 0.4%, 6.5%, and 20.9% for grades 0, 1, 2 and 3, respectively. A pulmonary shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95% CI, 0.05-4.13; P = .47), whereas pulmonary shunt grade 2 (OR, 4.78; 95% CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95% CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. Conclusions: The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.

AB - Background: A pulmonary right-to-left shunt (RLS) carries the risk of cerebral paradoxical embolization and severe neurologic complications. Recognizing patients at risk is important to facilitate appropriate management strategies, but a direct relation between pulmonary shunt size and risk of complications remains controversial. This study evaluated the potential relation between pulmonary shunt grade on transthoracic contrast echocardiography (TTCE) and prevalence of cerebral manifestations in patients screened for hereditary hemorrhagic telangiectasia (HHT). Methods: We conducted a two-center, cross-sectional study of all consecutive patients screened for HHT between 2004 and 2011. Pulmonary shunt grading on TTCE (grade 0, no microbubbles; grade 1, <30 microbubbles; grade 2, 30-100 microbubbles; grade 3, > 100 microbubbles) was performed according to contrast opacifi cation of the left ventricle. Cerebral complications were defi ned as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confi rmed by appropriate imaging techniques. Results: A pulmonary RLS was present in 530 out of 1,038 patients (51.1%; mean age, 44.3 ± 15.6 years; 58.6% women). The presence of a cerebral manifestation (n 5 51) differed signifi cantly among pulmonary shunt grades on TTCE: 1.4%, 0.4%, 6.5%, and 20.9% for grades 0, 1, 2 and 3, respectively. A pulmonary shunt grade 1 was not associated with an increased prevalence of cerebral manifestations (OR, 0.44; 95% CI, 0.05-4.13; P = .47), whereas pulmonary shunt grade 2 (OR, 4.78; 95% CI, 1.14-20.0; P = .03) and grade 3 (OR, 10.4; 95% CI, 2.4-45.3; P = .002) were both independent predictors for the prevalence of a cerebral ischemic event or brain abscess. Conclusions: The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.

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