Added value of modified transoesophageal echocardiography in the diagnosis of atherosclerosis of the distal ascending aorta in cardiac surgery patients

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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.

Methods and 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.

Methods and results

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.


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.

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