Overcoming a stubborn patent foramen ovale

Transesophageal echocardiography (TEE) with agitated saline contrast (bubble study) is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.

Automated summary

Transesophageal echocardiography (TEE) is the gold standard for detecting patent foramen ovale (PFO), and the bubble study with agitated saline contrast helps diagnose PFO. However, standard maneuvers may be challenging during TEE, and hypovolemia due to preprocedural fasting can affect PFO detection. Additional optimization measures, such as fluid replenishment with passive leg raise (PLR), can enhance PFO detection.