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Echocardiography. 2016 Aug;33(8):1219-27. doi: 10.1111/echo.13231. Epub 2016 Apr 20.

Transcranial Doppler: Does Addition of Blood to Agitated Saline Affect Sensitivity for Detecting Cardiac Right-to-Left Shunt?

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Division of Cardiology, University of Florida, Gainesville, Florida.
Division of Cardiology, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York.
Division of Cardiology, Emory Clinical Cardiovascular Research Institute (ECCRI), Emory University School of Medicine, Atlanta, Georgia.
Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut.
Department of Medicine, Crozer-Chester Medical Center, Chester, Pennsylvania.



Transcranial Doppler (TCD) with agitated saline has been shown to be an alternative for the detection of right-to-left shunts (RLS) with similar diagnostic accuracies as transesophageal echocardiography (TEE). It is hypothesized that the addition of blood to agitated saline increases the sensitivity of TCD for the detection of RLS. The aim of this meta-analysis was to determine whether agitated saline with blood increases the sensitivity of TCD for the detection of RLS compared to agitated saline alone and other contrast agents.


A systematic review of Medline, Cochrane, and Embase was performed to look for all prospective studies assessing intracardiac RLS using TCD compared with TEE as the reference; both tests were performed with a contrast agent and a maneuver to provoke RLS in all studies.


A total of 27 studies (29 comparisons) with 1,968 patients met the inclusion criteria. Of 29 comparisons, 10 (35%) used echovist contrast during TCD, 4 (14%) used a gelatin-based solution, 12 (41%) used agitated saline, and 3 (10%) utilized 2 different contrast agents. The addition of blood to agitated saline improved the sensitivity of TCD to 100% compared to agitated saline alone (96% sensitivity, P = 0.161), echovist (94% sensitivity, P = 0.044), and gelatin-based solutions (93% sensitivity, P = 0.041).


The addition of blood to agitated saline improves the sensitivity of TCD for the detection of RLS to 100% when compared to other conventional contrast agents; these findings support the addition of blood to agitated saline during TCD bubble studies.


patent foramen ovale; right-to-left shunt; transcranial Doppler; transesophageal echocardiogram

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