{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,20]],"date-time":"2026-10-20T15:58:43Z","timestamp":1792511923038,"version":"4.5.0"},"reference-count":16,"publisher":"Wiley","issue":"8","license":[{"start":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:00:00Z","timestamp":1785283200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:00:00Z","timestamp":1785283200000},"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":[[2026,8]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Growing evidence associates patent foramen ovale right\u2010to\u2010left shunt (PFO\u2010RLS) with conditions including migraine, cryptogenic stroke (CS), and transient ischemic attack (TIA). However, the potential role of pulmonary right\u2010to\u2010left shunt (P\u2010RLS) remains unclear. This study aimed to characterize PFO\u2010RLS and P\u2010RLS using contrast transesophageal echocardiography (cTEE) and analyze their distinct features and intrinsic associations with migraine and CS\/TIA.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>302 patients with clinically suspected right\u2010to\u2010left shunt (RLS) contrast transesophageal echocardiography (cTEE) between October 2019 and January 2025 were retrospectively analyzed. Target Symptom Group\u00a0included patients presenting with migraine, cryptogenic stroke (CS), and\/or transient ischemic attack (TIA); all other patients comprised the\u00a0Comparison Group. cTEE was performed to detect and quantitatively evaluate both patent foramen ovale right\u2010to\u2010left shunt (PFO\u2010RLS) and pulmonary right\u2010to\u2010left shunt (P\u2010RLS). We conducted stratified analyses to assess the relationships of PFO\u2010RLS and P\u2010RLS individually with the presence of target symptoms. Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with the Target Symptom Group.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      All 302 patients were successfully examined using TTE and cTEE. cTEE revealed 165 cases of PFO\u2010RLS and 217 cases of P\u2010RLS. Stratified analyses showed no statistical significance of P\u2010RLS among patients with varying degrees of PFO\u2010RLS between the positive symptom and other symptoms group. PFO\u2010RLS was statistically significant between the two groups in patients with varying degrees of P\u2010RLS. Pulmonary vein shunt and PFO shunt were significantly associated with positive symptoms (\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.05) in the univariate analysis; however, only PFO shunt was an independent risk factor in the multivariate analysis (OR 1.363,\n                      <jats:italic>p<\/jats:italic>\n                      &lt; 0.05). Patients with moderate\u2010to\u2010severe dual shunts had the highest proportion(76.5%) of positive symptoms. Further analysis showed no significant interaction (\n                      <jats:italic>p<\/jats:italic>\n                      &gt; 0.05).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>cTEE has a good diagnostic value for determining the source of RLS microvesicles. PFO\u2010RLS causes migraine and CS\/TIA; the more shunts there are, the more severe the symptoms. Current grading system for right\u2010to\u2010left shunt does not take microbubble size into consideration, although P\u2010RLS is more common, it does not cause severe symptoms. A PFO shunt alone is an independent risk factor for migraine and CS\/TIA.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/echo.70576","type":"journal-article","created":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T16:19:32Z","timestamp":1785341972000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Quantitative Analysis of Pulmonary Right\u2010to\u2010Left Shunts and Patent Foramen Ovale via Agitated Saline Contrast Transesophageal Echocardiography: Associations With Migraine, Cryptogenic Stroke, and Transient Ischemic Attack"],"prefix":"10.1111","volume":"43","author":[{"given":"Jian","family":"Chen","sequence":"first","affiliation":[{"name":"Department of Ultrasound Shenzhen Second People's Hospital The First Affiliated Hospital of Shenzhen University Health Science Center  Shenzhen China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lang","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Ultrasound Southern University of Science and Technology Hospital  Shenzhen China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yihua","family":"He","sequence":"additional","affiliation":[{"name":"Maternal\u2010Fetal Consultation Center of Congenital Heart Disease Department of Echocardiography Beijing Anzhen Hospital Capital Medical University  Beijing China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhengyi","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Ultrasound Shenzhen Second People's Hospital The First Affiliated Hospital of Shenzhen University Health Science Center  Shenzhen China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shanshan","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Ultrasound Shenzhen Second People's Hospital The First Affiliated Hospital of Shenzhen University Health Science Center  Shenzhen China"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hong","family":"Li","sequence":"additional","affiliation":[{"name":"Department of Ultrasound The Fourth Clinical Medical College of Guangzhou University of Chinese Medicine (Shenzhen Traditional Chinese Medicine Hospital)  Shenzhen China"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,29]]},"reference":[{"key":"e_1_2_13_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcin.2009.04.006"},{"key":"e_1_2_13_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jstrokecerebrovasdis.2023.107344"},{"key":"e_1_2_13_4_1","doi-asserted-by":"publisher","DOI":"10.1155\/2020\/8845652"},{"key":"e_1_2_13_5_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.echo.2014.12.008"},{"key":"e_1_2_13_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1526-4610.2006.00374.x"},{"key":"e_1_2_13_7_1","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehae150"},{"key":"e_1_2_13_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2005.10.044"},{"key":"e_1_2_13_9_1","article-title":"Agitated Saline Contrast Echocardiography in the Identification of Intra\u2010 and Extracardiac Shunts: Connecting the Dots","author":"Bernard 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