Comparison of the Valsalva maneuver and cough maneuver in the diagnosis of right-to-left shunt of patent foramen ovale in migraine patients using contrast transthoracic echocardiography

Zhang Huijuan; Fu Jing; Liu Ailing; Shen Xiaomei; Dai Xiang

doi:10.3969/j.issn.1674-4055.2025.05.19

Abstract：Objective To compare the value of Valsalva maneuver and cough maneuver in the diagnosis of right-to-left shunt of patent foramen ovale(PFO)in patients with migraine by contrast transthoracic echocardiography(cTTE),and to provide evidence for clinical diagnosis.Methods A retrospective analysis was performed on 366 patients treated at the Third Affiliated Hospital of Xuzhou Medical University and The People's Hospital of Pizhou for migraine from January 2021 to August 2024.Transthoracic echocardiography(TTE)and cTTE were performed.A total of 117 cases of right-to-left shunt of patent foramen ovale were detected by cTTE,including 27 cases of minor shunt,58 cases of moderate shunt and 32 cases of large volume shunt.The detection rate of Valsalva maneuver and cough maneuver cTTE in the diagnosis of PFO and the diagnostic efficacy of right-to-left shunt of PFO were analyzed.To analyze the correlation between the degree of right-to-left shunt of PFO and the severity of migraine and the size of PFO.The correlation between migraine grade,foramen ovale diameter and right-to-left shunt grade of PFO was analyzed by generalized additive model(GAM),and the causes of right-to-left shunt missed diagnosis under the cough maneuver were analyzed by multivariate logistic regression.Results The detection rate of PFO detected by cTTE under the Valsalva maneuver(83.76％)was higher than that under the cough maneuver(72.65％).The diagnostic efficiency of Valsalva maneuver was better than that of cough maneuver(P＜0.05).The detection rate of microbubbles classified as grade Ⅲ under the Valsalva maneuver was higher than that under the cough maneuver(P＜0.05),whereas the detection rate of grade Ⅰ microbubbles under the cough maneuver was higher than that under the Valsalva maneuver(P＜0.05).There was no significant difference between Valsalva maneuver and cough maneuver when the number of microbubbles was grade Ⅱ(P＞0.05).It was found that VAS score and diameter of foramen ovale showed a curvilinear relationship with right-to-left shunt grade.Patients with obesity,emphysema,thoracic deformity,and cardiomyopathy were independent related factors for diagnosis of right-to-left shunt under the cough maneuver(P＞0.05).Conclusion Compared with the coughing maneuver in the value of transthoracic right heart contrast echocardiography for diagnosing right-to-left shunt through PFO in migraine patients,the Valsalva maneuver has higher diagnostic accuracy.However,the coughing maneuver has higher sensitivity for detecting a small amount of right-to-left shunt through PFO.