title: Added value of modified transoesophageal echocardiography in the diagnosis of atherosclerosis of the distal ascending aorta in cardiac surgery patients.
abstract: OBJECTIVE
  Accurate visualization of the distal ascending aorta (DAA) can guide the surgical management and hence prevent dislodgment of atherogenic emboli during cardiac surgery. Conventional transoesophageal echocardiography (TEE) has a poor sensitivity; modified TEE was previously shown to accurately visualize atherosclerosis of the DAA. We studied the added value of modified TEE beyond the patient history and TEE screening.
  
  
  RESULTS
  Included were 421 patients from a previous diagnostic study, which compared the diagnosis of severe atherosclerosis with modified TEE and epiaortic ultrasound (EUS; reference test). We fitted three models, which predicted presence of atherosclerosis Grade ≥3 of the DAA. Model 1 included preoperative patient characteristics; in Model 2 conventional TEE was added; Model 3 additionally included modified TEE results. For each model, the area under the receiver-operating curve (AUC), the 'net reclassification improvement' (NRI) and the 'integrated discrimination improvement' (IDI) were determined. Missing data were imputed. The AUCs of Models 1, 2, and 3 were 0.73 (95% CI: 0.68-0.78), 0.80 (95% CI: 0.76-0.85), and 0.93 (95% CI: 0.90-0.96), respectively. Comparing Model 3 with Model 2, the AUC was significantly higher (P < 0.001), the NRI was 0.60 (95% CI: 0.54-0.66; P < 0.001), and the IDI was 0.30 (95% CI: 0.28-0.32; P < 0.001), indicating that visualization of the DAA with modified TEE significantly improved reclassification.
  
  
  CONCLUSIONS
  Visualization of atherosclerosis of the DAA with modified TEE provided information beyond patient history and conventional TEE screening, which resulted in an improved diagnosis of atherosclerosis.
authors.affiliation: Department of Cardiology, Isala, Dokter van Heesweg 2, Zwolle 8025AB, The Netherlands Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands w.w.jansen.klomp@isala.nl.
authors.forename: Wouter W
authors.initials: WW
authors.lastname: Jansen Klomp
authors.affiliation: Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Peelen
authors.affiliation: Department of (Thoracic) Anaesthesia and Intensive Care, Isala, Zwolle, The Netherlands.
authors.forename: Sander J
authors.initials: SJ
authors.lastname: Spanjersberg
authors.affiliation: Department of Cardiothoracic Surgery, Isala, Zwolle, The Netherlands.
authors.forename: George J
authors.initials: GJ
authors.lastname: Brandon Bravo Bruinsma
authors.affiliation: Departments of Cardiac Anesthesia and Intensive Care, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden 8934 AD, The Netherlands.
authors.forename: Fellery de
authors.initials: Fd
authors.lastname: Lange
authors.affiliation: Department of Cardiology, Isala, Dokter van Heesweg 2, Zwolle 8025AB, The Netherlands.
authors.forename: Arnoud W J
authors.initials: AW
authors.lastname: van't Hof
authors.affiliation: Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
mesh_terms: D000368:Aged; D001011:Aorta / Q000000981:diagnostic imaging* / Q000601:surgery; D019540:Area Under Curve; D050197:Atherosclerosis / Q000000981:diagnostic imaging* / Q000601:surgery; D006348:Cardiac Surgical Procedures / Q000379:methods*; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D011237:Predictive Value of Tests; D011300:Preoperative Care; D012372:ROC Curve; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
keywords: Atherosclerosis; Cardiac surgery; Diagnostic Testing; Transoesophageal echocardiography