Introduction:

Right to left shunt (RLS) occurs mainly with intracardiac lesions such as patent foramen ovale and, to a lesser extent, through pulmonary arteriovenous malformations. Since the initial report by Gramiak et al., contrast echocardiography has been the method of choice to identify RLS. Being the Transesophageal Echocardiogram with contrast (TEE-c) currently accepted by many authors as the ideal diagnostic method of RLS.

Material and methods:

A systematic review was carried out, with the objective of knowing the diagnostic performance of the contrast doppler ultrasound (DU-c) in its different variants (transcranial, vertebral and carotid) compared to TEE-c for the diagnosis of RLS; the review was carried out in the EBSCO, Elsevier, KoreaMed, Lilacs, PubMed/Medline, OVID/Cochrane Library, Scielo, SCOPUS, Web of Science and EMBASE databases.

Results:

33 publications were obtained that met the inclusion criteria, providing 36 studies with 3,099 participants (average age 47.1; 53% male). Of these, only 1 study on vertebral UD-c and 1 study on carotid UD-c were included, so it was not possible to perform statistical analysis of these 2 diagnostic tests.

Transcranial UD-c was reported in 34 studies, including 2,964 participants (average age 46.8 years, 52% male); for the set of studies, a sensitivity of 95% (95% CI of 0.93-0.97) and specificity of 95% (95% CI of 0.89-0.98) were calculated; likelihood ratio (+) of 8.93 (95% CI of 7.17-11.0), and a Likelihood ratio (-) of 0.08 (95% CI of 0.05-0.12) were also calculated, and when making Bayes’ nomogram, inferring a probability Pre-Test of 30% (prevalence of CDI in general population), a post-test probability is calculated for their respective Likelihood ratio (+) of 79% (CI 0.75-0.82), and a post-test probability for their respective likelihood (-) of 3% (CI 0.02-0.05).

Conclusions:

The transcranial UD-c is a test with an excellent diagnostic performance when compared to ETE-c, it has the disadvantage of not allowing to differentiate the type of communication (intracardiac or pulmonary). There is not enough evidence to recommend the use of vertebral or carotid UD-c for the diagnosis of CDI; however, current evidence points to a superiority of transcranial UD-c over these.

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