Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review
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REVIEW ARTICLE/BRIEF REVIEW
Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review L’e´chocardiographie au chevet pour e´valuer les shunts cardiopulmonaires de droite a`-gauche : un compte rendu narratif Tim Montrief, MD, MPH . Stephen Alerhand, MD . Andre´ Denault, MD, PhD Jeffrey Scott, DO
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Received: 26 February 2020 / Revised: 10 June 2020 / Accepted: 10 June 2020 Ó Canadian Anesthesiologists’ Society 2020
Abstract Right-to-left pulmonary and cardiac shunts (RLS) are important causes of refractory hypoxia in the critically-ill perioperative patient. Using a point-of-care ultrasound (POCUS) agitated saline bubble study for an early diagnosis allows patients with clinically significant RLSs to receive expedited therapy. This narrative review discusses the principles of agitated saline ultrasonography as well as the role of POCUS in detecting the most common RLS types seen in the intensive care unit, including patent foramen ovale, atrial septal defects, and pulmonary arterio-venous malformations. An illustrated discussion of the procedure, as well as shunt-enhancing maneuvers (Valsalva or lung recruitment maneuver with subsequent rapid release) is provided. With the wide dissemination of bedside ultrasound within the perioperative and critical care arena, POCUS practitioners should be knowledgeable of the potential pitfalls leading to both false-positive and false-negative studies. False-positive studies may be due to congenital abnormalities, mischaracterization of
T. Montrief, MD, MPH Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA S. Alerhand, MD Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA A. Denault, MD, PhD (&) Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Universite´ de Montre´al, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada e-mail: [email protected] J. Scott, DO Division of Cardiothoracic and Transplant Critical Care, Jackson Health System, Miami Transplant Institute, Miami, FL, USA
intrapulmonary shunts as intracardiac shunts (and vice versa), or evidence of the Valsalva effect. False negatives are typically due to respiratory-phasic variation, performing an inadequate shunt-enhancing maneuver, inadequate injection of agitated saline, or pathophysiologic states of elevated left atrial pressure. Finally, alternative POCUS methods for determining presence of an RLS in patients with poor echocardiographic windows are discussed, with a focus on pulsed-wave Doppler interrogation of arterial signals. Re´sume´ Les shunts pulmonaires et cardiaques de droite a`gauche sont d’importantes causes d’hypoxie re´fractaire chez le patient pe´riope´ratoire en e´tat critique. En re´alisant un test aux bulles sous e´chographie au chevet, un diagnostic rapide de shunt de droite a`-gauche peut eˆtre pose´, favorisant le traitement rapide des patients pre´sentant un shunt de droite a`-gauche significatif d’un point de vue clin
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