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Chest. 2013 Aug;144(2):542-548. doi: 10.1378/chest.12-1599.

Grade of pulmonary right-to-left shunt on contrast echocardiography and cerebral complications: a striking association.

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Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands. Electronic address:
Department of Gastroenterology, Maggiore Hospital, Crema, Italy.
Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Department of Cardiology, Maggiore Hospital, Crema, Italy.
Genetic Institute, University of Pavia, Pavia, Italy.
Department of Neurology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Department of Pulmonology, St. Antonius Hospital, Nieuwegein, The Netherlands.



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).


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 opacification of the left ventricle. Cerebral complications were defined as ischemic stroke, transient ischemic attack, or brain abscess diagnosed by a neurologist and confirmed by appropriate imaging techniques.


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 = 51) differed significantly 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.


The pulmonary RLS grade on TTCE is strongly associated with the prevalence of cerebral complications in patients screened for HHT.

[Indexed for MEDLINE]

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