A systematic review and meta-analysis of transthoracic echocardiogram vs. cardiac magnetic resonance imaging for the detection of left ventricular thrombus.

Transthoracic echocardiography (TTE) is the most commonly used imaging modality to diagnose left ventricular thrombus (LVT), however, cardiac magnetic resonance (CMR) remains the gold standard investigation. A comparison of the diagnostic performance between two modalities is needed to inform guidelines on a diagnostic approach towards LVT. We performed a systematic review and meta-analysis to investigate the diagnostic performance of three methods of TTE (non-contrast, contrast, and apical wall motion scoring) for the detection of LVT compared to CMR as a reference test. Studies comprising 2113 patients investigated for LVT using both TTE and CMR were included in the meta-analysis. For non-contrast TTE, pooled sensitivity and specificity were 47% [95% confidence interval (CI): 32-62%], and 98% (95% CI: 96-99%), respectively. In contrast, TTE pooled sensitivity and specificity values were 58% (95% CI: 46-69%), and 98% (95% CI: 96-99%), respectively. Apical wall motion scoring on non-contrast TTE yielded a sensitivity of 100% [95% CI: 93-100%] and a specificity of 54% (95% CI: 42-65%). The area under the curve (AUC) values from our summary receiver operating characteristic curve (SROC) for non-contrast and contrast TTE were 0.87 and 0.86 respectively, with apical wall motion studies having the highest AUC of 0.93. Despite high specificity, routine contrast and non-contrast TTE are likely to miss a significant number of LVT, making it a suboptimal screening tool. The addition of apical wall motion scoring provides a promising method to reliably identify patients requiring further investigations for LVT, whilst excluding others from unnecessary testing.

The formation of left ventricular thrombus (LVT), a blood clot in the left pumping chamber of the heart, can lead to serious complications such as a stroke. Whilst cardiac magnetic resonance (CMR) is the best imaging tool to detect these clots, the most used tool is a transthoracic echocardiogram (TTE), which visualizes the heart by placing an ultrasound on the chest. This is due to the affordability and widespread availability of TTE. Thus, it is important to know how TTE compares to CMR when it comes to detecting LVT. This study pools the results of previous research to compare the diagnostic performance of three different methods of TTE compared to CMR for detecting LVT. Non-contrast TTE.Contrast TTE: The addition of an enhancing dye is thought to improve imaging.Apical wall motion scoring: Evaluating the movement of the heart's walls using TTE. Our results show that current methods of TTE may miss half of the patients with LVT and that the use of contrast did not provide significant improvement. Interestingly, the use of apical wall motion scoring was able to accurately detect all the patients with LVT. This shows promise as a future tool to reliably exclude patients from unnecessary testing, whilst identifying those who need further investigations.

Salvage Versus Primary Robot-assisted Radical Prostatectomy: A Propensity-matched Comparative Effectiveness Study from a High-volume Tertiary Centre.

BACKGROUND: Salvage robot-assisted radical prostatectomy (sRARP) is a potential treatment option for locally recurrent prostate cancer (PCa) after nonsurgical primary treatment. There are minimal data comparing outcomes between propensity-matched sRARP and primary robot-assisted radical prostatectomy (RARP). OBJECTIVE: The primary objective is to compare perioperative, oncological, and functional outcomes of sRARP with primary RARP, and the secondary is to compare outcomes between sRARP after whole and focal gland therapy. DESIGN SETTING AND PARTICIPANTS: A 1:1 propensity-matched comparison was carried out of 135 sRARP cases with primary RARP cases from a cohort of 3852 consecutive patients from a high-volume tertiary centre. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative, oncological, and functional outcomes including complication rates, positive surgical margins, biochemical recurrence (BCR), continence, and erectile dysfunction (ED) were retrospectively collected. RESULTS AND LIMITATIONS: There were no significant differences in patient characteristics between sRARP and primary RARP groups. In the salvage and primary groups, median (interquartile range) follow-up periods were 521 (304-951) and 638 (394-951) d, grade III-V Clavien-Dindo complication rates were 1.5% and 0% (p = 0.310), BCR rates were 31.9% and 14.1% (p < 0.001) at the last follow-up, pad-free continence rates were 78.8% and 84.3% at 2 yr (p = 0.337), and ED rates were 94.8% and 76.3% (p < 0.001), respectively. Comparing the whole and focal gland groups, BCR rates were 36.7% and 29.1% (p = 0.687) at follow-up, pad-free continence rates were 53.1% and 89.3% at 2 yr (p < 0.001), and ED rates were 98% and 93% (p = 0.214), respectively. CONCLUSIONS: Salvage RARP has similar perioperative outcomes to primary RARP with inferior potency rates. Post-focal therapy sRARP has similar recurrence and continence rates to primary RARP. Post-whole gland therapy, complication, and recurrence rates are higher, and there is a higher risk of urinary incontinence. PATIENT SUMMARY: We report the largest propensity-matched comparison of salvage robot-assisted radical prostatectomy (RARP) after focal and whole gland therapy. Salvage RARP is a feasible procedure for the treatment of locally recurrent prostate cancer in high-volume centres; however, patients should be counselled appropriately as to the different outcomes.