The use of contrast echo to detect shunts at atrial level in a Mustard or Senning repair for transposition of the great arteries: you can teach an old dog new tricks

<span class="paragraphSection">With a simple, but heavily under-used imaging technique—contrast echocardiography—de Pasquale <span style="font-style:italic;">et al</span><span style="font-style:italic;">.</span><a href="#jew302-B1" class="reflinks">¹</a> show that a very high percentage of unselected patients with transposition of the great arteries (TGA), operated upon with the use of an atrial switch technique, have leaks in the intra-atrial baffles. Baffle leaks are described before and were typically found in patients who developed a cerebral vascular accident (CVA).<a href="#jew302-B2" class="reflinks">²</a> In a normal heart, standard transthoracic echo (TTE), even with the use of intravenous contrast, is not very sensitive in finding small shunts through a patent foramen ovale (PFO).<a href="#jew302-B3" class="reflinks">³</a> TTE combined with a bubble study seems to be more reliable in detecting shunts in patients with a Mustard or Senning.<a href="#jew302-B4" class="reflinks">⁴</a> This may seem surprising, since mere understanding of anatomy of these tunnels and imaging their course from caval veins, superior and inferior, towards the anterior part of the left atrium in which they drain, is already quite a challenge. However, irrespective of this complex anatomy, if bubbles appear on the functional left side of the heart, there is a baffle leak. Although the numbers are too small to say something sensible about sensitivity, the fact that a shunt could be demonstrated in 3 out of three patients with documented neurological events, may hint at a better sensitivity than of contrast echo in Mustard and Senning patients. A very important risk factor for development of neurological events is unmasked in this specific patient population, especially in the setting in which risk of venous thrombosis is elevated, like patients with pacemakers, which is q substantial subset in this patient population. </span>

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