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Starship Child HealthCardiologyEchocardiography protocols

Agitated Saline/Bubble study for the detection of an intrapulmonary or intracardiac right to left shunt

Date last published:

To be performed on all patients where the evaluation of an intrapulmonary or intracardiac shunt is required.

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Cardiology

To be performed on all patients where the evaluation of an intrapulmonary or intracardiac shunt is required. Examples include:

  • Stroke (R/o PFO)

  • Pulmonary AVMs

  • Fontan baffle leak

  • Left SVC draining to left atrium

  • Before surgery of RV-PA conduit change

May be performed using Transthoracic (TTE) or Transoesophageal (TOE) imaging .

Cardiologist / Cardiology Fellow to administer agitated saline solution

Setup and Equipment

The patient will require Intravenous access for the bubble study. IV access to be performed by a cardiologist, cardiology fellow, or registered nurse . To evaluate for a Left SVC, the IV access will need to be obtained in the left arm

Two 10-mL syringes and a three-way stopcock are required

It is recommended that the saline mixture be composed of ≥ 8 mL of bacteriostatic normal saline with ≤ 0.5 mL of room air

bubble study image 1

Saline administration

The air-saline mixture is briskly agitated between syringes. The contrast effect is augmented if a small amount of the patient’s blood is pulled into the syringe and included in the agitation process .

Injection should proceed immediately following agitation

At least two agitated saline injections are required; one at rest and one with a Valsalva manoeuvre or abdominal compression

Cough, Valsalva manoeuvre and abdominal compression

  • Transiently increases RA pressure, creating RA-to-LA pressure gradient

  • Abdominal compression is performed by placing the hand on the right side of the epigastrium of the patient and depressing the abdominal wall, and releasing immediately after opacification of the right atrium

  • If the patient is anesthetised and/or ventilated a Valsalva manoeuvre can be undertaken by applying and then releasing positive airway pressure.

Imaging

Image acquisition should begin just before the appearance of saline contrast in the right atrium and continue for at least 10 cardiac cycles and up to 20 cardiac cycles after contrast appearance

Results

Positive Study:

  • Intracardiac: Bubbles visualised in the left heart within 3-5 beats

  • Intrapulmonary: Bubbles visualised in the left heart after at least five beats

Negative Study:

  • No bubbles visualised within the left heart

  • A study should only be considered negative if there is a dense contrast effect in the right side of the heart

 

References

  • Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the American Society of Echocardiography
    JASE August, 2014
    Thomas R. Porter, MD, FASE (Chair), Sahar Abdelmoneim, MD, J. Todd Belcik, BS, RCS, RDCS, FASE, Marti L. McCulloch, MBA, RDCS, FASE, Sharon L. Mulvagh, MD, FASE, Joan J. Olson, BS, RDCS, RVT, FASE, Charlene Porcelli, BS, RDCS, RDMS, FASE, Jeane M. Tsutsui, MD, and Kevin Wei, MD, FASE

  • Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism
    JASE, January 2016
    Muhamed Saric, MD, PhD, FASE, Chair, Alicia C. Armour, MA, BS, RDCS, FASE, M. Samir Arnaout, MD, Farooq A. Chaudhry, MD, FASE, Richard A. Grimm, DO, FASE, Itzhak Kronzon, MD, FASE, Bruce F. Landeck, II, MD, FASE, Kameswari Maganti, MD, FASE, Hector I. Michelena, MD, FASE, and Kirsten Tolstrup, MD, FASE,

  • Importance of Abdominal Compression Valsalva Maneuver and Microbubble Grading in Contrast Transthoracic Echocardiography for Detecting Patent Foramen Ovale
    JASE February 2020
    Yoichi Takaya, MD, Nobuhisa Watanabe, RDCS, Madoka Ikeda, RDCS, Teiji Akagi, MD, Rie Nakayama, MD, Koji Nakagawa, MD, Norihisa Toh, MD, and Hiroshi Ito, MD, Okayama, Japan

 

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Echocardiography protocols
Starship Child Health
2 year(s)
Tom Gentles, Steven Kiyokawa
Tom Gentles

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