{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T01:28:54Z","timestamp":1781659734163,"version":"3.54.5"},"reference-count":13,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:00:00Z","timestamp":1770768000000},"content-version":"vor","delay-in-days":10,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T00:00:00Z","timestamp":1769904000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Echocardiography"],"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Contrast\u2010enhanced transesophageal echocardiography (cTEE) is the gold standard for the detection of patent foramen ovale (PFO). However, the diagnostic yield may vary depending on the venous injection site of the saline contrast medium and the presence of anatomical variants such as the Eustachian valve (EV) or Chiari network (CN), which can alter right atrial flow dynamics. This study aims to evaluate whether the route of injection\u2014an upper\u2010extremity vein vs. a lower\u2010extremity vein\u2014affects PFO detection and whether the presence of EV or CN further influences shunt visualization.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We prospectively enrolled 174 patients referred for cTEE for suspected cardioembolic etiology. Agitated saline contrast was injected via an upper\u2010extremity vein (brachial\/antecubital vein; UEV) and via a lower\u2010extremity vein (saphenous veins; LEV) during standardized Valsalva maneuver. Each route was tested with up to three adequately performed injections irrespective of the alternate\u2010route result. PFO was defined as microbubbles visualized traversing the interatrial septum within the first five cardiac cycles after right atrial opacification and Valsalva release. EV\/CN was recorded. EV length and mobility and atrial septal aneurysm (ASA) were assessed by re\u2010review of archived TEE images.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      PFO was detected in 73\/174 (42.0%) by either route. UEV was positive in 58\/174 (33.3%) and LEV in 64\/174 (36.8%) (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.307). Among PFO\u2010positive patients, 49 (67.1%) were positive with both routes, 9 (12.3%) only with UEV injection, and 15 (20.5%) only with LEV injection. EV was present in 56\/174 (32.2%) and CN in 4\/174 (2.3%); among PFO\u2010positive patients, EV was present in 31\/73 (42.5%) and CN in 2\/73 (2.7%). In EV\u2010positive PFO patients (n = 31), positive LEV injection detected 31\/31 (100%) whereas positive UEV injection detected 17\/31 (54.8%) (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.000122). LEV\u2010only positivity occurred in 9\/11 patients with EV length \u226510 mm versus 5\/20 with EV length &lt;10 mm (OR 13.5,\n                      <jats:italic>p<\/jats:italic>\n                      = 0.0068).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>LEV injection improves detection in EV\u2010positive patients, supporting an anatomy\u2010guided approach in which LEV injection is added when EV is visualized or when UEV injections are inconclusive.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Clinical Trial Number<\/jats:title>\n                    <jats:p>Not applicable.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/echo.70401","type":"journal-article","created":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T07:04:41Z","timestamp":1770879881000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Influence of Venous Access Site and Right Atrial Anatomical Variants on the Detection of Patent Foramen Ovale During Agitated Saline Contrast Transesophageal Echocardiography"],"prefix":"10.1111","volume":"43","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7930-7464","authenticated-orcid":false,"given":"Damla","family":"Raimoglou","sequence":"first","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deniz","family":"Mutlu","sequence":"additional","affiliation":[{"name":"Department of Cardiology SUNY Downstate Medical Center  Brooklyn USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bilgehan","family":"Karadag","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baris","family":"Ikitimur","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arda","family":"\u00c7eviker","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayten","family":"Ozal","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Efekan","family":"Dogramaci","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"A. At\u0131l","family":"Aygun","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Utku","family":"Raimoglu","sequence":"additional","affiliation":[{"name":"Department of Cardiology Yedikule Surp P\u0131rgic Armenian Hospital  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kardelen Ohtaroglu","family":"Tokdil","sequence":"additional","affiliation":[{"name":"Department of Cardiology Koc University  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hasan","family":"Tokdil","sequence":"additional","affiliation":[{"name":"Department of Cardiology Koc University  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eser","family":"Durmaz","sequence":"additional","affiliation":[{"name":"Department of Cardiology Cerrahpasa Medical School Istanbul University\u2010Cerrahpasa  Istanbul Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,2,11]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/s0025\u20106196(12)60336\u2010x"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jstrokecerebrovasdis.2025.108319"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.3389\/fpain.2022.823595"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa011503"},{"key":"e_1_2_10_6_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehab122"},{"key":"e_1_2_10_7_1","doi-asserted-by":"publisher","DOI":"10.1161\/STROKEAHA.120.032453"},{"key":"e_1_2_10_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.echo.2015.05.015"},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/echo.12462"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.echo.2003.12.003"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.1111\/echo.13511"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1007\/s12574\u2010025\u201000685\u2010z"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.37616\/2212\u20105043.1249"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1002\/ccd.25391"}],"container-title":["Echocardiography"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/echo.70401","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/echo.70401","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/echo.70401","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,8]],"date-time":"2026-03-08T16:48:12Z","timestamp":1772988492000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/echo.70401"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2]]},"references-count":13,"journal-issue":{"issue":"2","published-print":{"date-parts":[[2026,2]]}},"alternative-id":["10.1111\/echo.70401"],"URL":"https:\/\/doi.org\/10.1111\/echo.70401","archive":["Portico"],"relation":{},"ISSN":["0742-2822","1540-8175"],"issn-type":[{"value":"0742-2822","type":"print"},{"value":"1540-8175","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2]]},"assertion":[{"value":"2025-11-09","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-01-21","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-02-11","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"e70401"}}