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

AIMS: 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. 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. CONCLUSION: 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.