Effect of ureteric access sheath on outcomes of retrograde intrarenal surgery for renal stone disease: a randomized controlled trial.

BACKGROUND: The need of ureteric access sheath (UAS) in retrograde intrarenal surgery (RIRS) has been controversial for gaining high success in terms of stone free rate (SFR), reducing operative times and complications. There has been lack of high level of evidence in the literature on this topic. MATERIALS AND METHODS: This prospective randomized controlled trial (RCT) was conducted in the Department of Urology, PGIMER, Chandigarh from July 2019 to Dec 2021. The effect of UAS on the outcome of RIRS (SFR, operative time and complications) for renal stone disease was assessed. Ninety patients were randomized into two groups: 41 patients in Group 1 (RIRS with UAS) and 40 patients in Group 2(RIRS without UAS) were finally analyzed after exclusion. All the patients underwent preoperative double J stent placement at least 10 days prior to the definitive procedure. Operative time was recorded and postoperative pain was assessed by visual analogue scale(VAS) at 6 and 24 h postoperatively. Complications and emergency visits were recorded up to one month post procedure. SFR was assessed at 1 month using noncontrast CT KUB. Success was defined as absence of any residual fragment more than 3 mm in maximum diameter. RESULTS: Demographic parameters (age, body mass index, and comorbidities) and preoperative parameters (stone burden, proportion of recurrent stone formers and proportion of patients with inferior calyceal stones) were comparable between the two groups. Operative times (45.49 vs 48.38 min; p - 0.484) and VAS scores at 6 and 24 h post-op (p - 0.577) were also comparable between Group 1 and Group 2. SFR was comparable in Group 1 and Group 2 (78.05% vs 80%, p - 0.829). Postoperative complications were higher in the UAS group, but not statistically significant (4.88% vs 0%; p - 0.157). CONCLUSION: The use of UAS during RIRS is not associated with improved SFR. RIRS can be performed safely without the use of UAS and without increasing postoperative complications.

TAVR explant with aortic root replacement using a homograft for an aortic rupture.

This case report describes the explantation of an Evolut PRO valve 9 months after implantation in a 69-year-old male presenting with an aortic rupture adjacent to the stent frame of the prosthesis. Imaging was consistent with aortic sinus pseudoaneurysm and a large haemopericardium. Degeneration of the aortic root compounded by the transcatheter prosthesis in addition to the aortic rupture required replacement of the aortic root. The complexity of the procedure also required a modified Cabrol extension of the left coronary button and reconstruction of the left coronary button with bovine pericardium. We describe the technical challenges posed by the self-expanding transcatheter aortic valve prosthesis and tips and tricks to circumvent these challenges.

Direct relationship between transvalvular velocity and cardiac dysfunction, morbidity, and mortality in patients with aortic stenosis.

OBJECTIVE: Current guidelines recommend intervention in subjects with severe symptomatic aortic stenosis (AS), even though any degree of AS is associated with a higher risk of mortality. We investigated the association between the degree of AS, delineated by transvalvular flow velocity, and patient morbidity and mortality. METHODS: Medically managed patients aged 40-95 years with maximum flow velocity (Vmax ) by echocardiography between 2013 and 2018 were stratified into five groups (A-E) based on the 75th, 90th, 97.5th, and the 99th percentiles of Vmax distribution. Patient characteristics, cardiac structural changes, and end-organ disease were compared using Kruskal-Wallis and Cochran-Armitage tests. Mortality over a median of 2.8 (1.52-4.8) years was compared using Kaplan-Meier curves and risk estimates were derived from the Cox model. RESULTS: The Vmax was reported in 37,131 patients. There was a steady increase (from Group A towards E) in age, Caucasian race, structural cardiac changes, end-organ morbidities, and all-cause mortality. In reference to Group A, there as an increased risk of mortality in Groups B (hazard ratio [HR] = 1.3; confidence interval [CI]: 1.2-1.35; p < .0001), C (HR = 1.5; CI: 1.4-1.6; p < .0001), and D (HR = 1.8; CI: 1.6-2; p < .0001), with an exponential increase in Group E (HR = 2.5; CI: 2.2-2.8; p < .0001). CONCLUSIONS: A direct, strong correlation exists between the degree of AS and cardiac structural changes and mortality. Patients with Vmax ≥ 97.5th percentile (≥3.2 m/s) might benefit from early intervention.

Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience.

Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.

Comparison of efficacy of three commonly used alpha-blockers as medical expulsive therapy for distal ureter stones: A systematic review and network meta-analysis

ABSTRACT Introduction: The efficacy of alpha-blockers as medical expulsive therapy (MET) is well established. However, it is not known which of the three most commonly used alpha-blockers (tamsulosin, alfuzosin and silodosin) is the most efficacious. With this study we aimed to assess the efficacy of the three commonly used alpha-blockers as MET for distal ureter stones. Materials and Methods: For this review, we searched multiple databases such as PubMed/Medline, Scopus, Embase, OviD SP, CINAHL, and web of science to identify all the relevant randomized studies comparing the efficacy of tamsulosin, alfuzosin, and silodosin. Preferred reporting items for systematic reviews for network meta-analysis (PRISMA-NMA) were followed while conducting this review and the study protocol was registered with PROSPERO (CRD42020175706). Results: In this review, 31 studies with 7077 patients were included. Compared to placebo all the treatment groups were more effective for both stone expulsion rate (SER) and stone expulsion time (SET). For both SER and SET, silodosin had the highest SUCRA (94.8 and 90.4) values followed by alfuzosin (58.8 and 64.9) and tamsulosin (46.2 and 44.5). The incidence of postural hypotension was similar with all the drugs, whereas, the incidence of retrograde ejaculation was significantly higher for silodosin. Overall confidence for each comparison group in this review ranged from "very low" to "moderate" according to the CINeMA approach. Conclusion: Among the three commonly used alpha-blockers silodosin is the most efficacious drug as MET for lower ureter stones followed by alfuzosin and tamsulosin.

One and Five-Year Mortality Risk Prediction in Patients with Moderate and Severe Aortic Stenosis.

(1) Background: Our goal was to develop a risk prediction model for mortality in patients with moderate and severe aortic stenosis (AS). (2) Methods: All patients aged 40−95 years, with echocardiographic evidence of moderate and severe AS at a single institution, were studied over a median of 2.8 (1.5−4.8) years, between 2013−2018. Patient characteristics and mortality were compared using Chi-squares, t-tests, and Kaplan−Meier (KM) curves, as appropriate. The risk calculation for mortality was derived using the Cox proportional hazards model. A risk score was calculated for each parameter, and the total sum of scores predicted the individualized risks of 1-and 5-year mortality. (3) Results: A total of 1991 patients with severe and 2212 with moderate AS were included. Severe AS patients were older, had a lower ejection fraction %, were more likely to be Caucasian, and had lower rates of obesity and smoking, but had higher rates of cardiac comorbidities and AVR (49.3% vs. 2.8%, p < 0.0001). The unadjusted overall mortality was 41.7% vs. 41%, p = 0.6530, and was not different using KM curves (log rank, p = 0.0853). The models included only patients with complete follow-up (3966 in the 1-year, and 816 in the 5-year model) and included 13 variables related to patient characteristics, degree of AS, and AVR. The C-statistic was 0.75 and 0.72 for the 1-year and the 5-year models, respectively. (4) Conclusions: Patients with moderate and severe AS experience high morbidity and mortality. The usage of a risk prediction model may provide guidance for clinical decision making in complex patients.

Atrophic Kidney-Like Lesion - Case Report of A Provisional Entity with Brief Review of Literature.

Atrophic kidney-like lesion is a recently recognized entity, post 2016 World Health Organization Classification of tumors of the urinary system. The behavior of this tumor is not fully known as only a handful of cases with limited follow-up are available. This entity closely mimics thyroid-like follicular carcinoma of the kidney, which has different prognosis. We report a case of incidentally detected atrophic kidney-like lesion in an elderly gentleman who had urothelial carcinoma of the urinary bladder with a brief review of literature. Atrophic kidney-like lesion and urothelial carcinoma of the urinary bladder association has not been reported in the literature.

Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis.

BACKGROUND: When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. METHODS: Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. RESULTS: Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31-1.94; OR 1.79, 95% CI 1.21-2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64-1.95; OR 1.23, 95% CI 0.67-2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18-1.45; IRR 1.41, 95% CI 1.11-1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70-1.47; IRR 1.16, 95% CI 0.82-1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15-7.87); TF access ranked as the best strategy followed by TAo. CONCLUSION: TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.

Relationship of surgeon experience and outcomes of surgery for degenerative mitral valve disease.

OBJECTIVE: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. METHODS: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011 and 2016. Experienced surgeon was defined as performing ≥ 25 mitral valve operations/year. Patient characteristics and outcomes were compared. Competing risk analysis was performed to identify factors associated with mitral regurgitation (MR) recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional hazard method. RESULTS: There were 575 patients treated by 9 surgeons for severe MR caused by degenerative mitral valve disease between 2011 and 2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (p = .001). Experienced surgeons were more likely to attempt repair (p = .024), to succeed in repair (94.7% vs. 87%; p = .001), had shorter cross-clamp times (p = .001), and achieved higher repair rate (81.3% vs. 69.7%; p = .005). Experienced surgeons were more likely to use neochordae (p = .001) and less likely to use chordae transfer (p = .001). Surgeon experience was not associated with recurrence of moderate or higher degree of MR after repair but was an independent risk factor for mortality (HR = 2.64; p = .002). CONCLUSIONS: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Variants of the aortic arch in adult general population and their association with thoracic aortic aneurysm disease.

BACKGROUND: Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. METHODS: CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm (TAA). RESULTS: Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n = 354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p < .001), non-Caucasian(p < .001), and hypertensive (p < .001). Prevalence of TAA in arch anomalies group was 10.8% (n = 65) compared to 4.1% (n = 844) in the nonarch anomaly cohort (p < .001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR = 2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease. CONCLUSIONS: Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is approximately 3%, with high association of TAA (OR = 2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.

Intraoperative retrograde TEVAR to control endoleak after emergent total arch replacement and frozen elephant trunk repair for ruptured Kommerell's diverticulum.

We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.

Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer.

Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.

Optimal perioperative medical management of the vascular surgery patient.

Perioperative medical management of patients undergoing vascular surgery can be challenging because they represent the surgical population at highest risk. ß-Blockers should be continued perioperatively in patients already taking them preoperatively. Statins may be used in the perioperative period in patients who are not on statin therapy preoperatively. Institutional guidelines should be used to guide insulin replacement. Recent research suggests that measurement of troponins may provide some risk stratification in clinically stable patients following vascular surgery. Multimodal pain therapy including nonopioid strategies is necessary to improve the efficacy of pain relief and decrease the risk of side effects and complications.

Cerebral near-infrared spectroscopy in perioperative management of left ventricular assist device and extracorporeal membrane oxygenation patients.

PURPOSE OF REVIEW: Neurologic injury remains a common complication in patients undergoing mechanical support for cardiac and respiratory failure with either left ventricular assist devices (LVAD) or extracorporeal membrane oxygenation (ECMO). Cerebral near-infrared spectroscopy (NIRS) has been recognized clinically as a valid, continuous, and practical monitor of cerebral perfusion in cardiac surgery. Recently, interest in utilizing this technology to monitor patients while undergoing LVAD and ECMO placement and their resultant care has expanded. The purpose of this review is to discuss the practical approaches to using cerebral NIRS for LVAD and ECMO implantation. RECENT FINDINGS: Recent studies suggest that implementation of cerebral NIRS monitoring during LVAD and ECMO implantation may reduce the perioperative neurological complications. In addition, cerebral NIRS can function as a first-alert monitor to warn of problems with oxygenation, ventilation, mixed venous oxygen saturation, and cardiac output. SUMMARY: Despite an overall small body of literature, early evidence suggests a possible beneficial effect of utilizing cerebral NIRS during LVAD and ECMO implantation. Prospective randomized studies are needed to develop algorithm-based therapies centered on NIRS monitoring. On the basis of potential benefits and minimal risks in relation to cerebral NIRS, it is recommended that it be utilized during the operative and immediate postoperative period in the LVAD and ECMO patient population.

An unusual case of sudden collapse in the immediate postoperative period in a young healthy female with myxofibroma of the maxilla.

Benign myxofibromas of heart are well known to cause systemic inflammatory mediator release causing multiple complications ranging from fever and widespread effusions to DIC and shock. We report that in a particular case of maxillary myxofibroma, a shock-like state and widespread serous cavities effusion presented in the immediate postoperative period. The occurrence was possibly due to release of inflammatory mediators by the tumour, disseminated during tumour resection causing diffuse capillary leak, precipitated by fluid resuscitation, leading to decrease in plasma oncotic pressure.

Surgical repair of a submitral aneurysm in a three-year-old child.

Submitral aneurysm (SMA) is a rare anomaly occurring adjacent to the posterior leaflet of the mitral valve. It usually presents in young adults and it is uncommon in the pediatric age group. We report one case of SMA in a three-year-old child and its successful surgical management.