ORIGINAL RESEARCH article
Front. Cardiovasc. Med.
Sec. Cardiovascular Imaging
This article is part of the Research TopicPatent Foramen Ovale: Advances in Mechanisms, Diagnosis, and TherapyView all articles
Diaphragmatic Downward Excursion as a Novel Metric for assessing Valsalva Maneuver efficacy in Patent Foramen Ovale Detection by Contrast Transthoracic Echocardiography
Provisionally accepted
- 1Shaoxing University, Shaoxing, Zhejiang Province, China
- 2Department of Ultrasound, Shaoxing People's Hospital, Shaoxing, China
- 3Republican Specialized Center of Surgery named after acad. V. Vakhidov, Tashkent, Uzbekistan
Select one of your emails
You have multiple emails registered with Frontiers:
Notify me on publication
Please enter your email address:
If you already have an account, please login
You don't have a Frontiers account ? You can register here
Objective: Contrast transthoracic echocardiography (c-TTE) is widely used for the diagnosis of patent foramen ovale (PFO), where the Valsalva maneuver (VM) serves as the standard provocative maneuver to optimize detection. This study aimed to evaluate diaphragmatic downward excursion (DDE) as a novel c-TTE–based parameter for objectively quantifying VM efficacy, thereby establishing a standardized assessment metric. Methods: We studied 145 patients with high clinical suspicion of PFO-related conditions. All participants underwent both c-TTE and contrast transesophageal echocardiography (c-TEE) examinations. Based on intraoral expiratory pressure exceeding 40 mmHg under c-TTE, patients were divided into adequate Valsalva maneuver (AVM) group (n = 90) and non-adequate Valsalva maneuver (non-AVM) group (n = 55). We compared the two groups in terms of DDE at the roof of the right atrium (DDE-RRA) and intracardiac hemodynamic parameters. Results: DDE-RRA was significantly lower in the AVM group than in the non-AVM group (7.3 mm vs. 3.1 mm, P < 0.001). ROC analysis identified 5 mm as the optimal cutoff value for evaluating VM efficacy, with a sensitivity of 77.8%, specificity of 92.7%, and an AUC of 0.90. The kappa test showed good agreement between DDE-RRA and insufflation manometry (kappa = 0.63, P < 0.001). Furthermore, the DeLong test demonstrated that the AUC of DDE-RRA was significantly greater than that of all assessed intracardiac hemodynamic parameters, including mitral and tricuspid peak E and A-wave velocities, as well as mitral and tricuspid velocity time integrals (all P < 0.05). Conclusion: DDE provides a simple and objective method for assessing VM efficacy under c-TTE, showing superior diagnostic performance compared with conventional intracardiac parameters. As this represents an initial attempt, further studies incorporating invasive validation are needed to confirm its clinical value.
Keywords: patent foramen ovale, Diaphragm, Valsalva Maneuver, right-to-left shunt, transthoracic echocardiography, transesophageal echocardiography, saline contrastechocardiography
Received: 22 Apr 2025; Accepted: 02 Dec 2025.
Copyright: © 2025 Li, Chen, Zhu, Zhu, Boburjon, Jiang and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence:
Zhenzhen Jiang
Xiatian Liu
Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.