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

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

35 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 - 1 Jan 2013

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