Understanding Options for the Unmatched Urology Applicant.

PURPOSE OF REVIEW: To evaluate recent literature regarding the pathways and options for unmatched urology applicants. RECENT FINDINGS: Urology remains a competitive surgical sub-specialty with a match process independent of the National Resident Matching Program. Each year a cohort of competitive applicants go unmatched and are faced with the decision to reapply the following cycle while doing a research fellowship or a preliminary internship in the interim or choose a different specialty altogether. In this review, we sought to evaluate the current match process and literature regarding outcomes and options for unmatched applicants as well as to provide future directions for research and improvements to support unmatched urology applicants. Presently, data regarding outcomes for unmatched applicants is relatively limited. Going forward it is imperative for national urology organizations to create centralized resources for applicants to provide the best possible information for applicants and mentors alike.

Computerized Tomography Based Diagnosis of Visceral Obesity and Hepatic Steatosis is Associated with Low Urine pH.

PURPOSE: Uric acid nephrolithiasis is associated with an elevated visceral fat area in kidney stone formers. Hepatic steatosis has also been linked to visceral obesity and nephrolithiasis. We evaluated the association of noncontrast computerized tomography based diagnosis of visceral obesity and hepatic steatosis with 24-hour urine parameters and stone composition in kidney stone formers. MATERIALS AND METHODS: A total of 98 kidney stone formers were included in study who had computerized tomography imaging and 24-hour urine studies available. For each patient a single computerized tomography axial area measurement was obtained of the visceral fat area. Hepatic steatosis was diagnosed by comparing the HU of regions from the liver and spleen. Univariate analysis was performed to compare patients with or without an elevated visceral fat area and hepatic steatosis. Multivariate linear and logistic regression was done to assess for variables associated with 24-hour urine parameters and stone composition. RESULTS: An elevated visceral fat area was associated with higher 24-hour urine sodium (175 vs 157 mg per day, p <0.036) and lower 24-hour urine pH (5.724 vs 6.478, <0.0001). Urine pH less than 6 (OR 2.52) was associated with hepatic steatosis. Low urine pH less than 6 (OR 11.1, p = 0.004) and stone volume greater than 65 mm3 (OR 5.12, p = 0.023) were associated with an elevated visceral fat area. Low urine pH less than 6 (OR 5.87) and visceral fat area greater than 48% (OR 5.33) were associated with uric acid stones. Linear regression demonstrated that the percent of visceral fat area was associated with lower 24-hour urine pH (ß-coefficient -0.438, p <0.0001). CONCLUSIONS: Noncontrast computerized tomography based diagnosis of visceral obesity is associated with low urine pH, high urinary sodium and uric acid stone formation. Hepatic steatosis is associated with low urine pH.

Comparison of retroperitoneal and transperitoneal robotic partial nephrectomy for Pentafecta perioperative and renal functional outcomes.

BACKGROUND: We compared quality outcomes between transperitoneal (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN). METHODS: Two-center retrospective analysis of TRPN and RRPN from 10/2009 to 10/2015. Perioperative/renal function outcomes were analyzed. Primary endpoint was Pentafecta, a composite measure of quality [negative margin, no 30-day complication, ischemia time ≤25 min, return of glomerular filtration rate (eGFR) to >90% from baseline at last follow-up, and no chronic kidney disease upstaging]. Multivariable analysis (MVA) for factors associated with lack of optimal outcome was performed. RESULTS: 404 patients (TRPN 263, RRPN 141) were analyzed. Comparing TRPN vs. RRPN, mean tumor size (3.1 vs. 2.9 cm, p = 0.122) and RENAL score (7.4 vs. 7.2, p = 0.503) were similar. Most TRPN were anterior (65.0%) and most RRPN posterior (65.3%, p < 0.001). Operative time (p = 0.001) was less for RRPN. No significant differences between TRPN vs. RRPN were noted for ischemia time (23.1 vs. 22.8 min, p = 0.313), blood loss (p = 0.772), positive margins (p = 0.590), complications (p = 0.537), length of stay (p = 0.296), ΔeGFR (p = 0.246), eGFR recovery to >90% (55.9 vs. 57.4%, p = 0.833), and lack of CKD upstaging (84.0 vs. 87.2%, p = 0.464). Pentafecta rates were not significantly different (TRPN 33.9 vs. RRPN 43.3%, p = 0.526). MVA revealed increasing RENAL score (OR 1.5, p < 0.001) and decreasing baseline eGFR (OR 2.4, p = 0.017) as predictive for lack of Pentafecta. CONCLUSIONS: TRPN and RRPN have similar quality outcomes, though RRPN may offer modest benefit for operative time and have utility in posterior tumors. Association of increasing RENAL score and decreased baseline eGFR with lack of Pentafecta suggests dominant role of non-modifiable factors.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization.

BACKGROUND: Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions. STUDY DESIGN AND METHODS: We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs. RESULTS: For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization. CONCLUSIONS: Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.

Robotic-assisted simple prostatectomy: is there evidence to go beyond the experimental stage?

Open simple prostatectomy (OSP) is an effective and durable treatment for select patients with symptomatic benign prostatic hyperplasia (BPH) and large-volume prostate glands (>80 cc), yet is associated with clinically significant risk of bleeding, transfusion, prolonged hospital length of stay (LOS), and complications. Robotic-assisted simple prostatectomy (RASP) potentially reduces intraoperative blood loss and improves perioperative outcomes. Thirteen non-comparative series (Level 3 evidence) of RASP have established its safety and efficacy and have demonstrated substantially decreased risk of transfusion, complications, and mean LOS relative to published series of OSP, but with consistently longer operative times. Comparative outcomes data (Level 1 and Level 2 evidence), however, are relatively lacking. Thus, while RASP has advanced beyond the experimental stage, definitive outcomes studies are needed to establish its benefits and costs relative to OSP and transurethral surgery.

Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet obstruction.

Benign prostatic hyperplasia (BPH) is a histological diagnosis associated with unregulated proliferation of connective tissue, smooth muscle and glandular epithelium. BPH may compress the urethra and result in anatomic bladder outlet obstruction (BOO); BOO may present as lower urinary tract symptoms (LUTS), infections, retention and other adverse events. BPH and BOO have a significant impact on the health of older men and health-care costs. As the world population ages, the incidence and prevalence of BPH and LUTS have increased rapidly. Although non-modifiable risk factors - including age, genetics and geography - play significant roles in the etiology of BPH and BOO, recent data have revealed modifiable risk factors that present new opportunities for treatment and prevention, including sex steroid hormones, the metabolic syndrome and cardiovascular disease, obesity, diabetes, diet, physical activity and inflammation. We review the natural history, definitions and key risk factors of BPH and BOO in epidemiological studies.

Valve surgery for infective endocarditis is associated with high hospital charges.

BACKGROUND AND AIM OF THE STUDY: Half of all patients with infective endocarditis (IE) will require early surgical intervention, and another 40% will eventually undergo surgical treatment for their disease. Although the surgical management of IE is effective, the financial impact of the disease has never been assessed. METHODS: All patients who underwent valve surgery for native valve IE at the present authors' institution over a 10-year period (1996-2006) were reviewed retrospectively. Hospital charges were identified and adjusted to reflect US$ in 2006. A logistic regression analysis was performed to identify factors affecting charges and the patients' length of stay (LOS). RESULTS: A total of 369 patients (252 males, 117 females; mean age 53 +/- 15 years) underwent surgery for IE. Of these patients, 121 (33%) had preoperative renal failure and 70 (20%) were intravenous drug users. In addition, 159 patients (43%) had aortic IE, 112 (30%) had mitral IE, and 45 (12%) had both aortic and mitral valve IE. Right- and left-sided IE was identified in 42 patients (11%), and 11 (3%) had isolated right-sided IE. The median hospital charges were US$ 60,072 (interquartile range (IQR) US$ 39,386-103,960), with a median LOS of 15 days (IQR 9-29 days). Both, hospital charges and LOS were higher for patients undergoing emergent operations, or those with active IE (p < 0.001). The 30-day mortality was 2.7%. Regression analyses showed preoperative renal failure (p = 0.007), intraoperative transfusion (p = 0.028) and postoperative gastrointestinal complications (p < 0.001), renal failure (p = 0.012), heart block (p < 0.001), in-hospital mortality (p < 0.001), and patients undergoing emergent procedures (p < 0.001), or with active infection (p < 0.001) to be associated with significantly increased hospital charges. Factors that significantly affected LOS were other non-white race (p = 0.039), postoperative gastrointestinal complications (p = 0.001), stroke (p = 0.014), heart block (p < 0.001), and patients undergoing emergent procedures (p < 0.001) or with active infection (p < 0.001). CONCLUSION: The present series was among the largest to include patients with IE, and the first in which risk factors were assessed for increased hospital charges and resource utilization following surgery for endocarditis. Operations for IE are associated with a significant financial burden to the healthcare system, despite a relatively low percentage of complications. Patients with significant preoperative comorbidities, those with postoperative complications, and those who underwent emergent procedures or who had active IE, were associated with a prolonged LOS and increased hospital charges.

The Fate of the Unmatched Urology Applicant.

OBJECTIVE: To determine the outcomes and eventual career paths for unmatched applicants by evaluating a historical cohort of unmatched applicants in the Urology Match. METHODS: The 2008-2014 AUA Match lists were obtained from the Society of Academic Urologists and 730 unique applicants were identified with at least one unmatched result. Additional information such as preliminary training and eventual specialty choice were obtained from publicly available sources. Comparative analysis with univariable and multivariable analysis was performed between eventual urologists and those who chose alternative career paths. RESULTS: Overall, 43.5% (318/730) of unmatched urology applicants subsequently continued their interest in Urology and 77.4% (246/317) of initially unsuccessful applicants eventually became urologists. Males (80.9%, P = .01), Doctor of Osteopathy (DO) degree (62.5%, P = <.001), and those undergoing a research year compared to a preliminary surgery year (85.2% vs 72.0% respectively, P = .047) had an increased likelihood of successfully becoming a urologist. The most common alternative specialty choices were Internal Medicine (13.8%), General Surgery (12.9%) and Anesthesiology (11.9%). CONCLUSION: Urology is a competitive surgical sub-specialty. Surprisingly, approximately 3 in 4 unmatched urology applicants who continue their interest in urology will eventually obtain a residency position. However, only 33.7% of initially unmatched students ultimately became urologists. Unmatched applicants have several viable pathways to obtain a urological residency position. Male gender, a DO degree, and a research year are associated with successfully obtaining a urology residency position.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Visual cues as a surrogate for tactile feedback during robotic-assisted laparoscopic prostatectomy: posterolateral margin rates in 1340 consecutive patients.

OBJECTIVE: To analyse consecutive cases of robotic-assisted laparoscopic prostatectomy (RALP), present the incidence of nerve-sparing-related positive surgical margins (SM+), include visual cues that might assist in smoothly changing to the robotic platform, and discuss the scientific rationale for 'intersensory integration' which might explain the 'reverse Braille' phenomenon, i.e. the ability to feel when vision is greatly enhanced, as the lack of tactile feedback during RALP is often cited as a disadvantage of robotic surgery, interfering with a surgeon's ability to make intraoperative oncological decisions. PATIENTS AND METHODS: Data from 1340 consecutive patients undergoing RALP from one institution were analysed and trends for positive posterolateral SM+ (PLSM+) were correlated with oncological variables before and after RALP. A sample of patient slides were reviewed by a extramural pathologist. Multivariate regression modelling was used to compare the projected rates of PLSM+ vs the actual rate, given the effect of a conscious effort to use visual cues. Finally, video recordings of the procedure were systematically reviewed and correlated with anatomical and histopathological images in an integrated session involving the surgeon and the pathology team. RESULTS: The incidence of PLSM+ was 2.1%, which gradually declined to 1.0% in the last 100 patients. The reduction in PLSM+ occurred despite an increased rate of high-risk tumours operated on during this period. Forecasting analysis showed that the actual PLSM+ rate declined by half in the most recent 1000 patients, due to an integrated effort involving the use of visual cues during surgery. The following visual cues were considered important; appreciation of periprostatic (lateral prostatic) fascial compartments; colour and texture of the tissue; periprostatic veins as a landmark for athermal dissection; signs of inflammation; and a freely separating bloodless plane showing loose shiny areolar tissue. CONCLUSION: Adapting to the robotic platform is easy and there is no compromise of the oncological safety of this procedure. Experienced surgeons can use visual cues to assist during nerve-sparing RALP and achieve low PLSM+ rates.

Management of the aortic arch in patients with Loeys-Dietz syndrome.

OBJECTIVES: We sought to develop strategies for management of the aortic arch in patients with Loeys-Dietz syndrome (LDS) through a review of our clinical experience with these patients and a comparison with our experience in patients with Marfan syndrome (MFS). METHODS: We reviewed hospital and follow-up records of 79 patients with LDS and compared them with 256 patients with MFS who served as reference controls. RESULTS: In the LDS group, 16% of patients presented initially with acute aortic dissection (AAD) (67% type A, 33% type B) or developed AAD during follow-up, compared with 10% of patients with MFS (95% type A, 5% type B). There was no difference between patients with LDS or MFS in need for subsequent arch interventions after aortic root surgery (46% vs 50%, P = 1.0). Among the patients who never had AAD, the need for arch repair at initial root surgery was greater in patients with LDS (5% vs 0.4%, P = .04), as was the need for any subsequent aortic surgery (12% vs 1.3%, P = .0004). Late mortality in patients with LDS after arch repair was greater than in those patients who had no arch intervention (33% vs 6%, P = .007). CONCLUSIONS: In the absence of dissection, patients with LDS have a greater rate of arch intervention after root surgery than patients with MFS. After a dissection, arch reintervention rates are similar in the 2 groups. Arch intervention portends greater late mortality in LDS.

Impact of donor-to-recipient weight ratio on survival after heart transplantation: analysis of the United Network for Organ Sharing Database.

BACKGROUND: Generally accepted donor criteria for heart transplantation limit allografts from donors within approximately 20% to 30% of the recipient's weight. We analyzed the impact of donor-to-recipient weight ratio on survival after heart transplantation. METHODS AND RESULTS: Adult heart transplant recipients reported to the United Network for Organ Sharing from 1999 to 2007 were divided into 3 groups based on donor-to-recipient weight ratio: <0.8, 0.8 to 1.2, and >1.2. Kaplan-Meier methodology was used to estimate survival. Propensity-adjusted Cox regression modeling was used to analyze predictors of mortality. A total of 15 284 heart transplant recipients were analyzed; 2078 had weight ratio of <0.8, 9684 had 0.8 to 1.2, and 3522 had >1.2. Kaplan-Meier survival was not statistically different between groups at 5 years (P=0.26). Among patients with weight ratio <0.8, 5-year survival was lower for recipients with high pulmonary vascular resistance (>4 Woods units; P=0.02). Among recipients with high pulmonary vascular resistance, 5-year survival was similar for those with weight ratio 0.8 to 1.2 and >1.2 (P=0.44). Furthermore, male recipients with elevated pulmonary vascular resistance who received hearts from female donors had a significantly worse survival than males who received hearts from male donors (P=0.01). Propensity-adjusted multivariable analysis demonstrated that weight ratio <0.8 did not predict mortality (hazard ratio, 1.09; 95% CI, 0.94 to 1.27; P=0.21). Five-year survival after propensity matching was not statistically different between those with weight ratio <0.8 versus >/=0.8 (P=0.37). CONCLUSIONS: Weight ratio did not predict mortality after heart transplantation. However, recipients with elevated pulmonary vascular resistance who received undersized hearts had poor survival. Furthermore, in the setting of high pulmonary vascular resistance, male recipients who received hearts from female donors had worse survival than those who received hearts from male donors. Extending donor criteria to include undersized hearts in select recipients should be considered.

Valve-sparing aortic root replacement in children: Outcomes from 100 consecutive cases.

OBJECTIVE: Valve-sparing root replacement is an attractive alternative to composite mechanical or biologic prostheses for aortic root aneurysms in children. Data on outcomes in pediatric patients are limited. We present our institutional experience with 100 consecutive pediatric valve-sparing aortic root procedures. METHODS: All children who underwent valve-sparing root replacement at our institution from May 1997 to August 2017 were identified, and echocardiographic and clinical data were reviewed. The primary end point was mortality, and secondary end points included complications, further interventions, and subsequent valvular dysfunction. RESULTS: Median age at operation was 13.6 years (interquartile range, 9.42-15.9); 51 patients (51%) had Marfan syndrome, and 39 patients (39%) had Loeys-Dietz syndrome. Mean preoperative maximum sinus diameter was 4.4 ± 0.71 cm (z score 7.3 [5.7-9.3]). Most patients (n = 80, 80%) underwent reimplantation procedures with a Valsalva graft. Four patients (4%) underwent David I reimplantation with a straight-tube graft, 13 patients (13%) underwent a Yacoub remodeling procedure, and 3 patients (3%) underwent a Florida sleeve procedure. Perioperative valve-sparing root replacement mortality was 2% (n = 2). Six patients required late reintervention for development of pseudoaneurysms. Eight patients underwent additional aortic surgery. Average time to reoperation was 7.23 ± 4.56 years. Of the 84 patients undergoing a reimplantation procedure, 5 (5.9%) underwent late valve replacement versus 5 (33.3%) of the 15 patients who received a remodeling procedure (P = .001). CONCLUSIONS: Valve-sparing root replacement is a safe and effective option for children with aortic root aneurysms in children. The reimplantation procedure is preferred. Late aortic insufficiency and pseudoaneurysm formation remain late concerns.

Surgical ventricular restoration versus cardiac transplantation: a comparison of cost, outcomes, and survival.

BACKGROUND: Cardiac transplantation is the accepted standard treatment for end-stage heart disease but is donor limited. Surgical ventricular remodeling is an established treatment for patients with ischemic cardiomyopathy. We sought to compare charges, outcomes, and survival in patients undergoing surgical ventricular restoration (SVR) versus cardiac transplantation (CTx). METHODS AND RESULTS: We retrospectively analyzed hospital charges, length of stay (LOS), and survival for 69 SVR and 53 CTx patients at our institution between January 2002 and June 2005. We also compared New York Heart Association (NYHA) status and Kaplan-Meier survival of our SVR patients with CTx patients with ischemic cardiomyopathy from the International Society of Heart & Lung Transplantation (ISHLT) registry. Median total LOS (12 days vs. 17 days, P = .01) and median postoperative LOS (10 days vs. 15 days, P = .02) were shorter for SVR patients than our CTx patients. Median total hospital charges ($45,506 vs. $137,679, P < .0001) and median total drug charges ($2,625 vs. $15,930, P < .0001) were lower for SVR patients. Significant improvements in ejection fraction were seen after both SVR (27% vs. 37%; P < .0001) and CTx (14% vs. 62%, P < .0001). Furthermore, 91% (49/54) of surviving SVR patients, 98% (44/45) of surviving CTx patients, and 91% of ISHLT CTx patients improved to NYHA Class I/II at follow-up. Survival did not differ between groups. CONCLUSIONS: SVR patients demonstrate cost-effective clinical improvements that lead to good overall survival. SVR is an excellent surgical option for CHF patients who are not transplant candidates, and should be considered for ischemic cardiomyopathy patients who qualify for transplantation. This strategy may help relieve donor shortage and improve allocation of donor organs.

CT-Based Diagnosis of Low Vertebral Bone Mineral Density Is Associated with Hypercalciuria and Hypocitraturia on Opportunistic Imaging.

INTRODUCTION AND OBJECTIVES: Studies have demonstrated associations between nephrolithiasis and systemic conditions, including low bone mineral density (BMD), which may correlate with hypercalciuria in kidney stone formers (KSFs). Traditionally, low BMD is diagnosed with dual-energy X-ray absorptiometry. As a noncontrast CT (NCCT) scan is typically part of a stone evaluation, our objective was to evaluate the association of NCCT-based vertebral BMD with 24-hour urine parameters in KSF. MATERIALS AND METHODS: This is a retrospective analysis of 99 KSFs who had CT imaging and 24-hour urine studies. For each patient, BMD was estimated at the L1 vertebral body and CT attenuation measured in HU. A threshold of 160 HU was chosen to distinguish normal from low BMD. Univariate and multivariate logistic regression analysis was performed to compare patients with low and normal BMD. Multivariate linear regression was performed to assess for variables associated with 24-hour urine parameters. RESULTS: Patients with low BMD had higher 24-hour urine calcium (219 vs 147 mg/day, p < 0.0001) and larger stone volume (259 vs 78.4 mm3, p = 0.009). Multivariate analysis demonstrated age >60 years (odds ratio [OR] 9.3, p < 0.0001) and hypercalciuria (OR 4.34, p = 0.004) correlated with low BMD. Linear regression demonstrated that lower BMD was associated with higher urinary calcium (ß-coefficient -0.268, p = 0.009) and lower urinary citrate (ß-coefficient 0.332, p = 0.01). CONCLUSIONS: CT-based diagnosis of low mineral bone density is associated with derangement in 24-hour urine calcium and citrate in KSFs, as well as larger stone volumes.

Outcomes following surgical ventricular restoration for patients with clinically advanced congestive heart failure (New York Heart Association Class IV).

BACKGROUND: It has been well documented that survival in patients with advanced congestive heart failure (CHF) receiving medical therapy is worse with advancing stages of disease (New York Heart Association [NYHA] IV versus NYHA III). However, such comparisons are rare in the surgical treatments for CHF. Surgical ventricular restoration (SVR) is an accepted therapy for patients with ischemic cardiomyopathy after anterior wall myocardial infarction. We evaluated the impact of advanced stage of CHF (NYHA IV) on survival after SVR. METHODS AND RESULTS: A retrospective review was conducted of SVR patients at our institution between January 2002 and December 2005. Seventy-eight patients underwent SVR during the study period; 34 patients were NYHA IV and 44 patients were NYHA II/III before surgery. NYHA IV patients had significantly worse preoperative ejection fraction (EF), left ventricular end systolic volume index (LVESVI), and stroke volume index (SVI). Both groups demonstrated significant improvement in EF and LVESVI after SVR, and there were no differences between the groups with regard to postoperative EF, LVESVI, or SVI. There were 3 operative deaths in each group (P = 1.00). Sixty-five percent (P < .0001) of NYHA IV patients and 82% (P < .0001) of NYHA II/III patients improved to NYHA class I or II at follow-up. NYHA IV patients trended toward reduced Kaplan-Meier survival at 32 months (68% versus 88%, P = .08), although NYHA IV was not a significant predictor of mortality. CONCLUSIONS: NYHA IV patients demonstrate similar improvements in cardiac function with acceptable, although decreased, survival after SVR when compared with those with less severe clinical disease. These outcomes are superior to those reported for medical management, indicating that patients with clinically advanced CHF who are appropriate candidates should be considered for SVR irrespective of preoperative NYHA class.

Outcomes following surgical ventricular restoration in elderly patients with congestive heart failure.

Despite the well described benefits of surgical ventricular restoration (SVR) for patients with ischemic cardiomyopathy, the effects of advanced age on outcomes following this procedure have not been well documented. The authors compared outcomes in 69 consecutive patients 65 years and older (n=27) and younger than 65 years (n=42) to determine the utility of SVR in an elderly population with end-stage heart failure. Patients 65 years and older demonstrated significant improvements in ejection fraction (P=.01) and left ventricular end-systolic volume index (P=.07) following SVR, which were similar to the improvements seen in patients younger than 65 years. Sixty percent (15 of 25) of patients 65 years and older in preoperative New York Heart Association class III/IV improved to class I/II at follow-up (P<.0001). Actuarial survival was 68.8% at 2.5 years. Like their younger counterparts, elderly patients demonstrate significant improvements in ventricular function and NYHA class with acceptable survival following SVR.

Vascular Disease and Kidney Stones: Abdominal Aortic Calcifications Are Associated with Low Urine pH and Hypocitraturia.

OBJECTIVE: Vascular calcifications are associated with nephrolithiasis. Although studies have demonstrated correlations with vascular disease and calcium stones in kidney stone formers (KSF), an etiologic link has remained elusive. As a noncontrast CT (NCCT) scan is typically part of a stone evaluation, our objective was to evaluate the association of NCCT-based assessment of abdominal aortic calcifications (AACs) with 24-hour urine parameters and stone composition. MATERIALS AND METHODS: Ninety-seven KSF were included with CT imaging and 24-hour urine studies. For each patient, semi-automated CT software was utilized to provide an AAC Agatston score from the celiac axis to the aortic bifurcation. Univariate analysis was performed to compare patients with or without AAC. Multivariate logistic regression was performed to assess for variables associated with 24-hour urine parameters and stone composition. RESULTS: The presence of AAC was associated with hypertension, diabetes, peripheral vascular disease, and coronary artery disease. Patients with any AAC showed lower 24-hour urine citrate (399 vs 593 mg/day, p < 0.001) and lower 24-hour urine pH (5.862 vs 6.328, p = 0.003). When controlling for age, system comorbidities, the presence of AAC was associated with low urine pH <6 (odds ratio [OR] 2.86, p = 0.032) and hypocitraturia <320 mg/day (OR 4.37, p = 0.005). The receiver operating characteristic curve showed that increasing AAC was associated with low urine pH (area under the curve [AUC] 0.683, p = 0.002) and uric acid stone formation (AUC 0.698, p = 0.045). CONCLUSIONS: NCCT-based diagnosis of AAC is associated with low urine pH, hypocitraturia, and uric acid stone formation. The presence of AAC could be considered an additional prognosticator for the utility of alkalinization therapy.

Aortic Root Replacement for Children With Loeys-Dietz Syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). METHODS: We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. RESULTS: Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality. Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1 (3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). CONCLUSIONS: These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention.

Intra-Aortic Missile After Gunshot Wound to Chest: An Interesting Case of Traumatic Cardiac Injury.

Missile embolus to the heart, although uncommon, is one of the most challenging scenarios in trauma. We describe a 36-year-old man who presented with a gunshot wound to the left chest and a chest x-ray revealing a foreign body in the mediastinum. A median sternotomy was performed and an injury to the left ventricle was identified. After intraoperative echocardiography and fluoroscopy confirmed a foreign body in the aortic root, cardiopulmonary bypass was implemented. A bullet was retrieved from the noncoronary sinus of the aortic valve. Injuries to the anterior leaflet of the mitral valve and left ventricle were repaired.