Feasibility, Accuracy, and Reproducibility of Aortic Valve Sizing for Transcatheter Aortic Valve Implantation Using Virtual Reality.

BACKGROUND: Detailed visualization and precise measurements of aortic valve dimensions are critical for the success of transcatheter aortic valve implantation and for the prevention of complications. Currently, multislice computed tomography is the gold standard for assessment of the aortic annulus and surrounding structures to determine the prosthesis size. New technologies such as virtual reality (VR) not only enable 3-dimensional (3D) visualization with the potential to improve understanding of anatomy and pathology but also allow measurements in 3D. This study aims to investigate the feasibility, accuracy, and reproducibility of VR for the visualization of the aortic valve, the surrounding structures, and its role in preprocedural sizing for transcatheter aortic valve implantation. METHODS AND RESULTS: Based on the preprocedural multislice computed tomography data, 3mensio measurements and 3D visualizations and measurements using VR software were performed retrospectively on 60 consecutive patients who underwent transcatheter aortic valve implantation at our heart center. There were no significant differences but strong correlations between the VR measurements compared with those performed with the 3mensio software. Furthermore, excellent or good intra- and interobserver reliability could be demonstrated for all values. In a structured questionnaire, users reported that VR simplified anatomical understanding, improved 3D comprehension of adjacent structures, and was associated with very good self-perceived depth perception. CONCLUSIONS: The use of VR for preprocedural transcatheter aortic valve implantation sizing is feasible and has precise and reproducible measurements. In addition, 3D visualization improves anatomical understanding and orientation. To evaluate the potential benefits of 3D visualization for planning further cardiovascular interventions, research in this field is needed.

Outcome of Patients Managed by Percutaneous Left Ventricular Assist Device Implantation During On-Hours and Off-Hours.

Percutaneous left ventricular assist devices (pVADs) may be used in patients with cardiogenic shock (CS) to stabilize hemodynamics and maintain sufficient end-organ perfusion. Vascular complications are commonly observed in patients with pVAD support. We aimed to assess the relationship between pVAD implantation time and access-site complication rates. This retrospective observational study included all patients who underwent pVAD insertion for the treatment of CS at our university hospital between 2014 and 2021 (n = 224). Depending on the pVAD insertion time, the patients were assigned to the on-hours (n = 120) or off-hours group (n = 104). Both groups had comparable baseline characteristics and comorbidities. The rate of access-site-related complications was higher in the off-hours group than in the on-hours group (26% vs. 10%, p = 0.002). Premature discontinuation of pVAD support to prevent limb ischemia or manage access-site bleeding was required more often in the off-hours group than in the on-hours group (14% vs. 5%, p = 0.016). Pre-existing peripheral artery disease and implantation time off-hours were independent predictors for access-siterelated vascular complications. In conclusion, patients with CS in whom pVAD was inserted during off-hours had higher rates of access-site-related complications and premature discontinuation of pVAD support than those in whom pVAD was inserted during on-hours.

Comparison of costs associated with transcatheter mitral valve repair: PASCAL vs MitraClip in a real-world setting.

AIMS: We aimed to conduct a clinical process cost analysis to evaluate all upcoming costs of mitral valve transcatheter edge-to-edge repair (M-TEER) treatment using the MitraClip and the PASCAL repair system. METHODS: First, we prospectively enrolled 107 M-TEER patients treated with either the PASCAL or MitraClip system and compared all upcoming costs during the M-TEER procedure and the associated in-hospital stay. Second, we retrospectively analysed 716 M-TEER procedures with regard to the occurrence of complications and their associated costs. All materials used in the catheterization laboratory for the procedures were evaluated. The cost analysis considered various expenses, such as general in-hospital costs, device costs, catheter laboratory and material costs. RESULTS: In the prospective study, 51 patients were treated using the PASCAL system, and 56 were treated using the MitraClip system. The two groups had comparable baseline characteristics and comorbidities. The total in-hospital costs were 25 414 (Interquartile range (IQR) 24 631, 27 697) € in the PASCAL group and 25 633 (IQR 24 752, 28 256) € in the MitraClip group (p = 0.515). The major cost driver was initial material expenditure, mostly triggered by device costs, which were similar to the PASCAL and MitraClip systems. Overall intensive care unit and general ward costs did not differ between the PASCAL and MitraClip groups. In the retrospective analysis, M-TEER-related complications were rare but were associated with higher costs, mainly due to prolonged hospitalisation. CONCLUSION: The major cost driver of M-TEER was the material expenditure, which was mostly triggered by high device costs. The costs of treating patients were similar for the PASCAL and MitraClip systems. M-TEER-related complications are associated with higher costs, mainly due to prolonged hospitalisation. This analysis provides valuable insights into reducing expenses by modifying the process of M-TEER.

Early Postoperative Neurologic Events Are Associated With Worse Outcome and Fatal Midterm Survival After Adult Heart Transplantation.

Background Neurologic events during primary stay in heart transplant (HTx) recipients may be associated with reduced outcome and survival, which we aim to explore with the current study. Methods and Results We screened and included all patients undergoing HTx in our center between September 2010 and December 2022 (n=268) and checked for the occurrence of neurologic events within their index stay. Neurologic events were defined as ischemic stroke, hemorrhage, hypoxic ischemic injury, or acute symptomatic neurologic dysfunction without central nervous system injury. The cohort was then divided into recipients with (n=33) and without (n=235) neurologic events after HTx. Using a multivariable Cox regression model, the association of neurologic events after HTx and survival was assessed. Recipients with neurologic events displayed a longer intensive care unit stay (30 versus 16 days; P=0.009), longer mechanical ventilation (192 versus 48 hours; P<0.001), and higher need for blood transfusion, and need for hemodialysis after HTx was substantially higher (81% versus 55%; P=0.01). Resternotomy (36% versus 26%; P=0.05) and mechanical life support (extracorporeal life support) after HTx (46% versus 24%; P=0.02) were also significantly higher in patients with neurologic events. Covariable-adjusted multivariable Cox regression analysis revealed a significant independent association of neurologic events and increased 30-day (hazard ratio [HR], 2.5 [95% CI, 1.0-6.0]; P=0.049), 1-year (HR, 2.2 [95% CI, 1.1-4.3]; P=0.019), and overall (HR, 2.5 [95% CI, 1.5-4.2]; P<0.001) mortality after HTx and reduced Kaplan-Meier survival up to 5 years after HTx (P<0.001). Conclusions Neurologic events after HTx were strongly and independently associated with worse postoperative outcome and reduced survival up to 5 years after HTx.

Reply to Thet et al. Comment on "Oehler et al. Outcome and Midterm Survival after Heart Transplantation Is Independent from Donor Length of Stay in the Intensive Care Unit. Life 2022, 12, 1053".

Myat Soe Thet et al. published a letter [...].

Lactate to Albumin Ratio for Predicting Clinical Outcomes after In-Hospital Cardiac Arrest.

In-hospital cardiac arrest (IHCA) is associated with high mortality and poor neurological outcomes. Our objective was to assess whether the lactate-to-albumin ratio (LAR) can predict the outcomes in patients after IHCA. We retrospectively screened 75,987 hospitalised patients at a university hospital between 2015 and 2019. The primary endpoint was survival at 30-days. Neurological outcomes were assessed at 30 days using the cerebral performance category scale. 244 patients with IHCA and return of spontaneous circulation (ROSC) were included in this study and divided into quartiles of LAR. Overall, there were no differences in key baseline characteristics or rates of pre-existing comorbidities among the LAR quartiles. Patients with higher LAR had poorer survival after IHCA compared to patients with lower LAR: Q1, 70.4% of the patients; Q2, 50.8% of the patients; Q3, 26.2% of the patients; Q4, 6.6% of the patients (p = 0.001). Across increasing quartiles, the probability of a favourable neurological outcome in patients with ROSC after IHCA decreased: Q1: 49.2% of the patients; Q2: 32.8% of the patients; Q3: 14.7% of the patients; Q4: 3.2% of the patients (p = 0.001). The AUCs for predicting 30-days survival using the LAR were higher as compared to using a single measurement of lactate or albumin. The prognostic performance of LAR was superior to that of a single measurement of lactate or albumin for predicting survival after IHCA.

Donor Noradrenaline Support Is Not Associated with Decreased Survival in Heart Transplant Recipients.

Objective: Although the application of higher doses of norepinephrine (NE) in potential organ donors is a frequent reason for heart decline, its associations with outcomes after heart transplantation (HTx) are discussed controversially. Therefore, we aimed to explore donor NE support's potential impact on outcomes in our single-center heart transplant cohort. Methods: All patients who had undergone HTx in our center between September 2010 and April 2022 (n = 241) were screened for eligibility. From those, all patients with complete data on donor NE support (n = 238) were included. Recipients were divided into three groups according to their donor NE support: without support (n = 26), with low support of 0.01−0.2 µg/kg/min (n = 132), and with high support of > 0.2 µg/kg/min (n = 80). Receiver operating characteristics (ROC) and Kaplan Meier analysis was used to investigate the association of donor NE support and mortality after heart transplantation. Recipient and donor variables, including peri- and postoperative characteristics, were reviewed and compared. Results: NE support in donors ranged between 0 and 2.94 µg/kg/min (median 0.13 µg/kg/min, IQR 0.05−0.26 µg/kg/min). No association between donor NE support and mortality after HTx was observed (AUC for overall survival 0.494). Neither Kaplan-Meier analysis in survival up to 5 years after transplantation (Log Rank p = 0.284) nor group comparisons showed significant differences between the groups. With few exceptions, baseline characteristics in recipients and donors were comparable between the groups. Regarding peri- and postoperative parameters, increasing donor NE support was associated with a longer duration of mechanical ventilation (68 h and 95 h vs. 47 h), longer postoperative IMC/ICU stay (14 vs. 15 vs. 19 days), and a higher need for mechanical life support post-HTx (26% and 39% vs. 12%). Conclusion: In this retrospective analysis, NE support in donors prior to heart transplantation was unrelated to differing survival after heart transplantation. However, higher doses of donor NE were associated with prolonged ventilation, longer duration on IMC/ICU, and a higher need for extracorporeal life support in recipients post-HTx.

Case report: Transcatheter edge-to-edge repair after prior surgical tricuspid annuloplasty.

Residual and recurrent tricuspid regurgitation may occur frequently after surgical tricuspid valve repair. However, reoperation for tricuspid regurgitation is rare, although many patients are again highly symptomatic. Tricuspid transcatheter edge-to-edge repair (TEER) is a promising therapy for severe tricuspid regurgitation. Herein, we report a 77-year-old woman with recurrent symptomatic massive tricuspid regurgitation 2 years after sutured annuloplasty of the tricuspid valve. TEER was successfully performed using the TriClip® device and tricuspid regurgitation was reduced to a mild degree. In conclusion, tricuspid TEER is feasible following surgical suture annuloplasty. TEER is an alternative option for patients with a failed previous annuloplasty repair for tricuspid regurgitation to undergo a less invasive treatment rather than a potentially higher-risk reoperation.

Donor hypernatremia is associated with increased mortality after heart transplantation: A retrospective study.

BACKGROUND AND AIMS: Donor hypernatremia has been associated with primary graft dysfunction in heart transplantation (HTx) and is correlated with impaired outcome following liver and renal transplantation. However, controversial data exist regarding the impact of sodium dysregulation on survival. This study aims to investigate the impact of donor sodium levels on early morbidity and short- and midterm survival following HTx. METHODS: Between September 2010 and June 2021, a total of n = 218 patients underwent HTx in our center. From those, 214 could be included retrospectively in our study. For each donor, sodium levels were collected and different cut-off levels from 145 to 159 mmol/L were investigated by Kaplan-Meier-analysis. Then, recipients were divided in three groups regarding donor sodium: Normonatremia (133-145 mmol/L, n = 73), mild hypernatremia (146-156 mmol/L, n = 105) and severe hypernatremia (>156 mmol/L, n = 35). Recipient and donor variables were reviewed and compared, including peri- and postoperative characteristics and recipient survival after up to 5 years after transplantation. RESULTS: All patients were comparable regarding baseline characteristics and perioperative parameters. Regarding early mortality, 90-day survival was significantly reduced only in patients with severe donor hypernatremia in comparison to normonatremia (90% vs. 71%, p = .02), but not in mild hypernatremia (89%, p = .89). One-year survival was comparable in all groups (p > .28). CONCLUSION: Severe donor hypernatremia was associated with reduced short-term survival, while the correlation weakens > 1 year after HTx. As our study is limited due to the nature of its retrospective, single-center approach, future prospective studies are needed to evaluate the importance of donor management with regard to hypernatremia.

Outcome and Midterm Survival after Heart Transplantation Is Independent from Donor Length of Stay in the Intensive Care Unit.

Prolonged treatment of organ donors in the intensive care unit (ICU) may be associated with complications influencing the outcome after heart transplantation (HTx). We therefore aim to explore the potential impact of the donor length of stay (LOS) in the ICU on outcomes in our cohort. We included all patients undergoing HTx in our center between September 2010 and April 2022 (n = 241). Recipients were divided around the median into three groups regarding their donor LOS in the ICU: 0 to 3 days (≤50th percentile, n = 92), 4 to 7 days (50th-75th percentile, n = 80), and ≥8 days (≥75th percentile, n = 69). Donor LOS in the ICU ranged between 0 and 155 days (median 4, IQR 3-8 days). No association between the LOS in the ICU and survival after HTx was observed (AUC for overall survival 0.514). Neither the Kaplan-Meier survival analysis up to 5 years after HTx (Log-Rank p = 0.789) nor group comparisons showed significant differences. Baseline recipient characteristics were comparable between the groups, while the donor baselines differed in some parameters, such as less cardiopulmonary resuscitation prior to HTx in those with a prolonged LOS. However, regarding the recipients' peri- and postoperative parameters, the groups did not differ in all of the assessed parameters. Thus, in this retrospective analysis, although the donors differed in baseline parameters, the donor LOS in the ICU was not associated with altered recipient survival or outcome after HTx.

Fatal outcome of isolated patients who suffered an in-hospital cardiac arrest.

AIM: Isolation of patients in single-patient rooms for infection control precautions leads to less contact with medical staff. Our objective was to assess whether isolated patients who suffer an in-hospital cardiac arrest (IHCA) have lower survival as non-isolated IHCA patients. METHODS: We screened for IHCA occurrence and the isolation state in 75.987 patients that had been hospitalized from 2016 to 2019 at the university hospital. Primary endpoint was survival to discharge. Neurological outcome was assessed using the cerebral performance category scale. RESULTS: In five consecutive years, 4,249 out of 75,987 patients (5.6%) had to be isolated for infection control precautions. In-hospital cardiac arrest occurred in 32 (0.8%) of these isolated patients and in 410 out of 71,738 non-isolated patients (0.6%) (p = 0.130). Propensity score matching yielded 30 isolated and 30 non-isolated patients who suffered an IHCA, without a difference in baseline characteristics and characteristics of cardiac arrests between the groups. Only one out of 30 isolated patients (3.3%) survived to discharge after IHCA compared to 11 non-isolated patients (36.6%) (risk difference, 33.3% [95% CI, 14.9%-51.7%]. None of the 30 isolated patients were discharged with good neurological outcomes compared to nine out of 30 non-isolated IHCA patients (30%) (risk difference, 30% [95% CI, 13.6%-46.4%]). In the multivariate analysis, patient isolation was an independent predictor of poor survival after IHCA (OR, 18.99; 95% CI, 2.467-133.743). CONCLUSIONS: Isolation of patients for infection control precautions is associated with considerable poorer survival and neurological outcome in case these patients are suffering an IHCA.

Comparison of two strategies for managing in-hospital cardiac arrest.

In-hospital cardiac arrest (IHCA) is associated with poor outcomes. There are currently no standards for cardiac arrest teams in terms of member composition and task allocation. Here we aimed to compare two different cardiac arrest team concepts to cover IHCA management in terms of survival and neurological outcomes. This prospective study enrolled 412 patients with IHCA from general medical wards. From May 2014 to April 2016, 228 patients were directly transferred to the intensive care unit (ICU) for ongoing resuscitation. In the ICU, resuscitation was extended to advanced cardiac life support (ACLS) (Load-and-Go [LaG] group). By May 2016, a dedicated cardiac arrest team provided by the ICU provided ACLS in the ward. After return of spontaneous circulation (ROSC), the patients (n = 184) were transferred to the ICU (Stay-and-Treat [SaT] group). Overall, baseline characteristics, aetiologies, and characteristics of cardiac arrest were similar between groups. The time to endotracheal intubation was longer in the LaG group than in the SaT group (6 [5, 8] min versus 4 [2, 5] min, p = 0.001). In the LaG group, 96% of the patients were transferred to the ICU regardless of ROSC achievement. In the SaT group, 83% of patients were transferred to the ICU (p = 0.001). Survival to discharge did not differ between the LaG (33%) and the SaT (35%) groups (p = 0.758). Ultimately, 22% of patients in the LaG group versus 21% in the SaT group were discharged with good neurological outcomes (p = 0.857). In conclusion, we demonstrated that the cardiac arrest team concepts for the management of IHCA did not differ in terms of survival and neurological outcomes. However, a dedicated (intensive care) cardiac arrest team could take some load off the ICU.

Outcome of patients with non-ischaemic cardiogenic shock supported by percutaneous left ventricular assist device.

AIMS: Percutaneous left ventricular assist devices (pVADs) are used to haemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI). One out of every two patients has a non-ischaemic cause of CS, and these patients differ profoundly from patients with AMI-related CS. We assessed the usefulness of pVAD support for patients with non-ischaemic CS. METHODS AND RESULTS: We analysed 106 patients with CS and Impella® support between 2015 and 2018. CS was non-ischaemic in 36 patients and AMI-related in 70 patients. Compared with the AMI group, those in the non-ischaemic group were significantly younger [median age 62 (50.8, 70.8) years vs. 68 (58.0, 75.5) years, P = 0.007] and had more patients with severely reduced left ventricular function (94% vs. 79%, P = 0.035) and worse glomerular filtration rate [45 (27, 57) mL/min vs. 60 (44, 78) mL/min]. Propensity score matching yielded 31 patients with non-ischaemic CS and 31 patients with AMI-related CS, without a difference in baseline laboratory values or comorbidities. In both groups, pVAD support was performed along with haemodynamic stabilization, reduction of catecholamines and normalization of lactate levels. In 7 days, systolic blood pressure increased from 91 (80, 101) mmHg at baseline to 100 (100, 120) mmHg in the non-ischaemic CS group (P = 0.001) and 89 (80, 100) mmHg at baseline to 112 (100, 128) mmHg in the AMI-related CS group (P = 0.001). Moreover, in 7 days, the need of catecholamines (calculated as vasoactive-inotropic score) decreased from 32.0 (11.1, 47.0) at baseline to 5.3 (0, 16.1) in the non-ischaemic group (P = 0.001) and from 35.2 (18.11, 67.0) to zero (0, 0) in the AMI-related CS group (P = 0.001). Lactate level decreased from 3.8 (2.8, 5.9) mmol/L at baseline to 1.0 (0.8, 2.1) mmol/L (P = 0.001) in the non-ischaemic CS group and from 3.8 (2.6, 6.5) mmol/L to 1.2 (1.0, 2.0) mmol/L in the AMI-related group (P = 0.001). In the non-ischaemic CS group, eight patients (25.8%) were upgraded to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or long-term mechanical circulatory support. Two of these upgraded patients received heart transplantation. In the AMI group, eight patients (25.8%) were upgraded to VA-ECMO or long-term mechanical circulatory support. Ninety-day survival did not significantly differ between the groups (non-ischaemic CS group 48.4%, AMI-related CS group 45.2%, P = 0.799). CONCLUSIONS: pVAD support is useful for haemodynamic stabilization of patients with non-ischaemic CS and is valuable as a bridge to patients' recovery or long-term left ventricular support and heart transplantation.

Two year outcome in nonagenarians undergoing percutaneous mitral valve repair.

AIMS: Percutaneous mitral valve repair (PMVR) has emerged as standard treatment in selected patients with clinically relevant mitral regurgitation (MR) and increased surgical risk. We aimed to evaluate the safety and clinical outcomes in nonagenarians undergoing PMVR. METHODS AND RESULTS: Altogether, 493 patients with severe MR who were treated with PMVR were included in this open-label prospective study and followed up for 2 years. We treated 25 patients with PMVR aged 90 years or above, 185 patients aged 80-89 years, and 283 patients aged <80 years. PMVR in nonagenarians was safe and did not differ from PMVR in younger patients in terms of safety endpoints. Device success did not differ among the groups (100% in nonagenarians, 95.7% in octogenarians, and 95.1% in septuagenarians, P = 0.100). Unadjusted 2 year mortality was 28% in nonagenarians, 32.4% in octogenarians, and 19.8% in septuagenarians (P = 0.008). Kaplan-Meier curves confirmed similar 2 year survival in the nonagenarian and octogenarian groups (P = 0.657). In the multivariate analysis, age [hazard ratio (HR) 1.031, 95% confidence interval (CI) 1.002-1.060, P = 0.034], higher post-procedural transmitral valve gradients (HR 1.187, 95% CI 1.104-1.277, P = 0.001), and post-procedural acute kidney injury (HR 2.360, 95% CI 1.431-3.893, P = 0.001) were independent predictors of 2 year mortality. Altogether, 89.4% of the nonagenarians, 85.9% of the octogenarians, and 86.4% of the septuagenarians had MR grade of 2+ or less at 1 year after PMVR (P = 0.910). New York Heart Association functional class improved in the vast majority of patients, irrespective of age (P = 0.129). After 1 year, 9.5% of the nonagenarians, 22.3% of the octogenarians, and 25.2% of the septuagenarians (each P = 0.001 compared with baseline) suffered from New York Heart Association Functional Class III or IV. The rate of heart failure rehospitalization in the first 12 months after PMVR did not differ among the groups (16% in the nonagenarians, 16.7% in the octogenarians, and 17.7% in the septuagenarians) (P = 0.954). Quality of life assessed by the Minnesota Living with Heart Failure Questionnaire before and at 1 year after PMVR improved in all age groups (P = 0.001). CONCLUSIONS: Percutaneous mitral valve repair in carefully selected nonagenarians is feasible and safe with intermediate-term beneficial effects comparable with those in younger patients.

Nanodiscs Incorporating Native ß1 Adrenergic Receptor as a Novel Approach for the Detection of Pathological Autoantibodies in Patients with Dilated Cardiomyopathy.

BACKGROUND: Dilated cardiomyopathy (DCM) is a common cause of heart failure with high morbidity and mortality rates. The association of anti-ß1 adrenergic receptor (ß1AR) autoantibodies with disease progression was shown by various studies and in vivo animal experiments. The prevalence of these disease-driving autoantibodies was estimated as 25% to 75% in DCM. The removal of autoantibodies or the interruption of their action leads to a prolonged improvement of heart function. However, presence and impact of the autoimmune aspect in DCM patients must be examined for targeted treatment. METHODS: We developed a heterogeneous immunoassay to support the diagnosis of anti-ß1AR autoantibody-induced DCM. The presentation of the native conformational epitope was enabled by reconstitution of human ß1AR into lipid bilayer nanodiscs, which stabilize the incorporated receptor in aqueous solution for measurements with standard immunological techniques. RESULTS: The incorporation of ß1AR into nanodiscs was verified by chromatographic, spectroscopic, and immunological methods. The functionality was shown by interaction assays with appropriate binding partners. Furthermore, ß1AR nanodiscs were applied to immunoassays for the detection of anti-ß1AR in human sera. Surface plasmon resonance spectroscopy and ELISA were developed, optimized, and validated. The optimized ß1AR nanodisc ELISA enabled a simultaneous measurement of 40 samples in duplicate. An interassay variance of 24% and an intraassay variance of 5% were determined. The limit of detection and the limit of quantification were determined as 0.64 ng/mL and 1.26 ng/mL, respectively (related to a monoclonal anti-ß1AR). CONCLUSIONS: Nanodisc technology is suitable as a novel biomimetic membrane system to stabilize and present ß1AR for detection of autoantibodies with immunological methods in DCM patients.

G-EYE advanced colonoscopy for improved polyp detection rates - a randomized tandem pilot study with different endoscopists.

BACKGROUND AND AIMS: The most commonly missed polyps in colonoscopy are those located behind haustral folds. The G-EYE system is a standard colonoscope consisting of re-processable balloon at its distal tip. The G-EYE balloon improves the detection of polyps by straightening the haustral folds. In our back-to-back tandem study, we aimed to determine whether and to what extent the G-EYE system could reduce adenoma miss rates in screening colonoscopy. METHODS: Patients referred to colonoscopy were randomized into 2 groups. Group A underwent a standard colonoscopy (SC) followed by balloon colonoscopy (BC), and Group B underwent BC followed by SC. In this randomized tandem study, the investigator's level of training and the endoscopists themselves were changed after each withdrawal. Each endoscopist was blinded to the results of the first withdrawal. RESULTS: Fifty-eight patients were enrolled and randomized into 2 groups with similar baseline characteristics. Nine patients were excluded from the study. Twenty-five patients underwent SC followed by BC while 24 underwent BC followed by SC. The adenoma miss rate for SC was 41 %, with an additional detection rate of 69 % for BC (ratio 1.69). The overall miss rate for polyps was 60 % for SC, with an additional detection rate of 150 % for BC (ratio 2.5). Experienced investigators who used BC were able to identify an additional 7 polyps while inexperienced investigators. CONCLUSIONS: Although our results could not clearly confirm that BC improves adenoma detection, the investigator's experience appears to be a major determinant of the adenoma detection rate.