Background and purpose: For investigating right-to-left shunt with transcranial Doppler, the Valsalva maneuver (VM) is recommended to be commenced five seconds after injection of contrast agent. When using transesophageal echocardiography (TEE) for detection of patent foramen ovale (PFO), VM is recommended to be commenced before injection. The aim of this study is to clarify the detection rates of PFO with TEE conducted with different VM timings.
Methods: We enrolled patients who underwent TEE for detecting PFO. We performed VM four times with contrast agent (CA), twice with VM performed prior to CA injection (PreInj-VC) and twice with VM performed after CA injection (PostInj-VC). We diagnosed the presence of PFO and classified as follows: non-PFO, small-PFO (< 30 bubbles), large-PFO (≥ 30 bubbles). We calculated the concordance rate of diagnosis for PFO between PreInj-VC and PostInj-VC.
Results: Of 79 patients (median age 66 years, male 68%), 30 patients (38%) had PFO (10 patients, large PFO; 20 patients, small PFO). PFO was identified in 27 patients on PreInj-VC and in 28 on PostInj-VC. Diagnostic agreement between PreInj-VC and PostInj-VC was found in 71 patients (90%). Regarding the PFO size, the concordance rate for large PFO was 96% (κ = 0.82, ρ ‹ 0.001) and that for small PFO was 92% (κ = 0.80, ρ ‹ 0.001).
Conclusion: Diagnostic agreement of the deference timings of VM, such as PreInj-VC and PostInj-VC, was as high as 90%. Moreover, two timings of VM made diagnosis of PFO more accurate.

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Cardiac papillary fibroelastoma (CPF) is often of valvular origin, but rarely forms in coumadin ridge (CR) and may cause cerebral embolism. We present an unusual 79-year-old man with cerebral embolism caused by CPF in CR. The patient presented with right upper limb paresis and was diagnosed with left centrum ovale infarction. Atrial fibrillation and severe stenosis of the cerebral and carotid artery were not found in various examinations. Although transthoracic echocardiography showed no abnormalities, transesophageal echocardiography (TEE) revealed a mobile string-like structure measuring approximately 11 mm at the tip of the CR. We suspected a thrombus attached to the CR, and anticoagulation therapy was administered, however the structure did not disappear. Therefore, the patient was diagnosed as cardiac tumor and underwent tumor excision and surgical closure of the left atrial appendage. The tumor was confirmed to be CPF on histopathology. Warfarin therapy was continued, and there was no recurrence of tumor or cerebral embolism at 4 months after surgery. CPF should be considered in cryptogenic stroke, especially in embolic stroke of undetermined sources cerebral embolism.

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