Available online 15 May 2023

Large randomized controlled trials have shown the benefits of percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke and PFO. Recent studies have highlighted the clinical significance and prognostic implication of various anatomical features of PFO and the adjacent atrial septum, such as atrial septal aneurysm (ASA), PFO size, large shunt, and hypermobility. Transthoracic echocardiography with contrast study is used for the indirect diagnosis of PFO, as it reveals the passage of the contrast into the left atrium. In contrast, transesophageal echocardiography (TEE) offers a direct demonstration of PFO by measuring its size using the maximum separation distance between the septum primum and septum secundum. Furthermore, TEE enables the acquisition of detailed anatomical features of the adjacent atrial septum including ASA, hypermobility, and PFO tunnel length, which carry significant prognostic implications. TEE also facilitates the diagnosis of pulmonary arteriovenous malformation, a relatively rare cause of paradoxical embolism. This review provides evidence for supporting TEE as a useful screening test for patients with cryptogenic stroke to identify suitable candidates for percutaneous device closure of PFO. Additionally, cardiac imaging specialists with proficiency in comprehensive TEE examination should be part of the heart-brain team for proper evaluation of and decision-making in patients with cryptogenic stroke.

Central Illustration. Algorithm for the echocardiographic diagnosis of the patent foramen ovale (PFO) during evaluation of patients with embolic stroke of unknown source (ESUS). TTE, transthoracic echocardiography; TEE, transesophageal echocardiography; DDx, differential diagnosis; PAVM, pulmonary arteriovenous malformation; TCD, transcranial Doppler; (+), positive test for the presence of right-to-left shunt; (-), negative test for the presence of right-to-left shunt.Download : Download high-res image (226KB)Download : Download full-size image

2023 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.