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Background: Low socioeconomic status predicts inferior clinical outcomes in many patient populations. The effects of patient insurance status and hospital safety-net status on readmission rates following acute myocardial infarction are unclear. Materials & methods: A retrospective review of State Inpatient Databases for New York, California, Florida and Maryland, 2007–2014. Results: A total of 1,055,162 patients were included. Medicaid status was associated with 37.7 and 44.0% increases in risk-adjusted readmission odds at 30 and 90 days (p Conclusion: Insurance status and hospital safety-net burden affect readmission odds following acute myocardial infarction.

Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.), Graphical abstract

This study evaluated whether the pulmonary artery pulsatility index (PAPi) collected before and after cardiopulmonary bypass (CPB) is predictive and diagnostic of new onset right ventricular (RV) failure in the elective cardiac surgical population.This was a prospective observational study of patients who underwent cardiac surgery between 2017 and 2019.Weill Cornell Medicine, a single large academic medical center.The study comprised 119 patients undergoing elective cardiac surgery.Cardiopulmonary bypass, transesophageal echocardiography, pulmonary artery catheter, and elective cardiac surgery.Echocardiographic and hemodynamic data were collected at 2 time points: pre-CPB and post-chest closure/post-CPB. Patients with and without post-CPB RV dysfunction fractional area of change (35%) were compared, and receiver operating characteristic curves were constructed. One hundred and nineteen patients undergoing elective surgery-coronary artery bypass grafting (23%), aortic valve replacement (21%), aortic surgery (19%), and combined surgery (37%)-were evaluated. Post-CPB RV dysfunction was associated with lower pre-CPB PAPi values (2.0 ± 1.0 v 2.5 ± 1.2; p = 0.001 and p = 0.03) and higher pre-CPB central venous pressure (8.3 ± 3.6 and 6.9 ± 2.7; p = 0.003 and p = 0.02, respectively). Pre-CPB PAPi (0.98 [95% confidence interval {CI} 0.96-0.99]), end systolic area (0.99 [95% CI 0.98-0.99]), and end diastolic area (1.01 [95% CI 1.001-1.02]) were independently associated with RV dysfunction in multivariable modeling, with a lower PAPi and end systolic area and higher end diastolic area demonstrating a greater risk of RV dysfunction post-CPB (post-CPB area under the curve for PAPi 0.80 [95% CI 0.71-0.88; sensitivity = 0.68, specificity = 0.93, optimal cutoff = 1.9]).PAPi measured pre-CPB is a potential predictor and marker of post-CPB RV dysfunction and may have diagnostic utility in cardiac surgery. Additional, large-scale studies are needed to confirm this finding.

Objective To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery. Methods Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use—defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS. Results In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naive. Nearly 1 in 16 (6.2%) opioid-naive patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03). Conclusion Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.

This chapter studies left ventricular assist device (LVAD) implantation. A thorough preoperative evaluation of a patient undergoing LVAD implantation is of utmost importance because of the confluence of associated medical problems patients can have secondary to heart failure. Knowledge of the indications and contraindications for LVAD implantation is needed to provide proper consultation. Indications for LVAD implantation include bridge to transplantation, destination therapy, bridge to decision, and bridge to recovery. Contraindications to LVAD implantation include neurological changes following implantation, pulmonary dysfunction, renal dysfunction, and hepatic dysfunction. Intraoperative management of LVAD implantation involves monitoring, anesthetic induction/maintenance, and device management. Echocardiography is an invaluable tool in the perioperative monitoring and diagnostic assessment of LVAD implantation. The chapter then looks at early complications such as hypovolemia, vasoplegia, and right ventricular failure.

This chapter describes robotic or minimally invasive mitral valve surgery, which was pioneered in 1998 to be the less invasive approach to sternotomy-based mitral valve operations. Patients undergoing robotic valve surgery carry a similar risk of complications that may occur with traditional median sternotomy surgery, but minimally invasive valve surgery has its own inherent complications associated with cardiac access, perfusion, and ventilation methods used in robotic surgeries. Unilateral pulmonary edema (UPE) is an uncommon but potentially life-threatening complication of robotic mitral valve surgery. The incidence of unilateral lung injury, which commonly manifests as UPE, has been reported to be quite variable. The variation in incidence could be related to the difference in patient populations, diagnostic criteria, as well as management. Moreover, the pathophysiology of UPE associated with robotic mitral valve repair remains unclear. The current literature suggests that UPE can be prevented by shorter cardiopulmonary bypass times, avoiding barotrauma, limiting blood product transfusion, and minimizing lung isolation times. Lung preventive ventilation, such as low-level positive pressure and frequent alveolar recruitment, while on cardiopulmonary bypass may be beneficial. Meanwhile, treatment for UPE is dependent on the severity of symptoms.

Introduction: As many as 12.5% of patients who undergo ureteral stent placement fail to have their stent removed in a timely manner. Because retained stents can be a source of substantial morbidity...

Introduction The novel coronavirus 2019 (COVID-19) and ensuing pandemic placed significant pressure on the care of critically ill patients. We present a case of a patient presenting with acute onset left ventricular systolic failure with acute right ventricular dysfunction and unremitting supraventricular tachycardia. Methods A 69 year-old male presented with severe shortness of breath and fever to the emergency department in March of 2020 to a major city hospital in the midst of the resource-limited height of the COVID-19 pandemic. After a thorough history, physical exam, laboratory evaluation, and preliminary point-of-care ultrasonographic examination he was found to be have COVID-19 and mild acute respiratory distress syndrome (ARDS). He was managed initially with non-invasive ventilation, but on hospital day #6, was found to be profoundly hypoxic, confused, and tachycardic. On further evaluation, his vital signs demonstrated a fever of 38.2 C, tachycardia at 140 bpm, blood pressure 125/70 and SpO2 92% on 100% FiO2. Bedside transthoracic echocardiography demonstrated globally severely reduced left ventricular systolic function and a dilated right ventricle with severely reduced systolic function. An electrocardiogram demonstrated monomorphic supraventricular tachycardia. Results We describe the patient's prolonged hospital course extending forty-five days with nearly half requiring critical care. The patient eventually improved and was discharged from the hospital. Discussion We discuss the implications of resource-limited pandemic conditions in the care of critically ill patients. We incorporate the international experience of developed countries in facing a once-in-a-lifetime global medical emergency. In addition, we comment on the proposed ethical considerations when allocating patients to a significantly high level-of-care and the implications of this decision for other patients requiring care.

This annual article summarizes key findings from notable studies published in 2019 relevant to the practice of cardiothoracic critical care medicine. This year’s article encompasses updates to the literature on enhanced recovery after cardiac surgery, extracorporeal membranous oxygenation, delirium, and primary graft dysfunction after heart transplant.

Objective To determine the effect of preoperative opioid use disorder (OUD) on postoperative outcomes in patients undergoing coronary artery bypass grafting (CABG) and heart valve surgery. Design Retrospective, observational study using data from the State Inpatient Database and the Healthcare Cost and Utilization Project. Setting Inpatient data from Florida, California, New York, Maryland, and Kentucky between 2007 and 2014. Participants A total of 377,771 CABG patients and 194,469 valve surgery patients age ≥18 years. Interventions None. Measurements and Main Results The prevalence of OUD was 2,136 (0.57%) in the CABG group and 2,020 (1.04%) in the valve surgery group. There was no significant difference in mortality between the OUD and non-OUD groups in both surgical cohorts (both p > 0.05). On adjusted analyses, preoperative OUD was significantly associated with increased adjusted odds ratios (aORs) of 30-day hospital readmission (CABG aOR 1.47 [95% confidence interval {CI} 1.30-1.66]; valve surgery aOR 1.41 [95% CI 1.27-1.56]) and 90-day hospital readmission (CABG aOR 1.47 [95% CI 1.31-1.64]; valve surgery aOR 1.33 [95% CI 1.23-1.43]). Preoperative OUD was significantly associated with increased adjusted risk ratios (aRRs) of hospital length of stay (CABG aRR 1.13 [95% CI 1.10-1.16]; valve surgery aRR 1.63 [95% CI 1.54-1.72]) and total hospitalization charges (CABG aRR 1.05 [95% CI 1.03-1.07]; valve surgery aRR 1.28 [95% CI 1.24-1.32]). Conclusion Preoperative OUD is significantly associated with poorer outcomes after cardiac surgery, including increased 30- and 90-day readmissions, hospital length of stay, and total hospitalization charges. Opioid use should be considered a modifiable risk factor in cardiac surgery, and interventions should be attempted preoperatively.

To characterize the effects markers of socioeconomic status (SES), including race and ethnicity, health insurance status, and median household income by zip code on in-patient mortality after cardiac valve surgery.Retrospective cohort study of adult valve surgery patients included in the State Inpatient Databases and Healthcare Cost and Utilization Project. The primary outcome was mortality during the index admission. Bivariate analyses and multivariate regression models were used to assess the independent effects of race and ethnicity, payer status, and median income by patient zip code on in-hospital mortality.Multistate database of hospitalizations from 2007 to 2014 from New York, Florida, Kentucky, California, and Maryland.In total, 181,305 patients ≥18 years old underwent mitral or aortic valve repair or replacement and met the inclusion criteria.None.Mortality rates were higher among black (5.59%) than white patients (4.28%, p0.001) and among Medicaid (4.66%), Medicare (5.22%), and uninsured (4.58%) patients compared with private insurance (2.45%, p0.001). After controlling for age, sex, presenting comorbidities, urgent or emergent operative status, and hospital case volume, mortality odds remained significantly elevated for black (odds ratio [OR] 1.127, confidence interval [CI] 1.038-1.223), uninsured (OR 1.213, CI 1.020-1.444), Medicaid (OR 1.270, 95% CI 1.116-1.449) and Medicare (OR 1.316, 95% CI 1.216-1.415) patients.Markers of low SES, including race/ethnicity, insurance status, and household income, are associated with increased risk of in-hospital mortality following cardiac valve surgery. Further research is warranted to understand and help decrease mortality risk in underinsured, less-wealthy and non-white patients undergoing cardiac valve surgery.

The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.

Introduction Pregnancy-induced hypercoagulable states present an anticoagulation management challenge in patients with mechanical prosthetic valves (PHV). In pregnant patients a thrombosed mechanical PHV presents a high risk of morbidity and mortality for both mother and fetus. We present a complex case of a pregnant patient with a thrombosed PHV. Methods N/A Results N/A Discussion A 32 y.o. female at 17 weeks gestation with rheumatic heart disease, s/p mechanical mitral (MVR) and aortic (AVR) valve replacement in 2002, was transferred for management of her thrombosed mitral PHV. The patient had been switched from warfarin to therapeutic low molecular weight heparin (LMWH) pre-partum. She first noticed increased shortness of breath at 10-11 weeks gestation and serial TTE revealed progressively increasing MV pressure gradients due to an immobile mitral PHV disk. Based on concerns that continued pregnancy would complicate maternal outcome and fetal age, a multi-specialty suggestion was made and pregnancy was terminated at our institution. The patient underwent a reoperation aimed at replacing the thrombosed mitral PHV. Intraoperatively, TEE showed that the mitral PHV disks had unrestricted motion and gradients decreased (from 9 mmHg to 3 mmHg). Subsequently, the patient underwent a thrombectomy of the mechanical mitral PHV. The anticoagulation management of pregnant women with mechanical PHV is challenging. The hypercoagulable state in pregnancy should be balanced by anticoagulation with its associated risks of teratogenicity and bleeding. The treatment options include thrombolysis, thrombectomy and valve replacement. The 2014 ACC/AHA guidelines provide guidance, based on class B or Class C evidence. The decision to switch the patient from warfarin to LMWH is controversial due to current ACC/AHA guidelines to continue warfarin up to 5 mg during pregnancy. Pregnancy termination is questionable due to multiple case reports showing the ability to continue pregnancy with thrombolysis, as long as the patient does not develop CHF. At the end, this patient's thrombosis resolved with heparin, and surgical thrombectomy and pregnancy termination could have been avoided. On the other hand, surgical thrombectomy, exposure to CPB and stress of cardiac surgery leads to ∼50% risk of miscarriage.

Purpose: Subjective measures of success after urethroplasty have become increasingly valuable in postoperative monitoring. We examined patient reported satisfaction following anterior urethroplasty using objective measures as a proxy for success.Materials and Methods: Men 18 years old or older with urethral strictures undergoing urethroplasty were prospectively enrolled in a longitudinal, multi-institutional urethroplasty outcomes database. Preoperative and postoperative assessment included questionnaires to assess lower urinary tract symptoms, pain, satisfaction and sexual health. Analyses controlling for stricture recurrence (defined as the inability to traverse the reconstructed urethra with a flexible cystoscope) were performed to determine independent predictors of dissatisfaction.Results: At a mean followup of 14 months we found a high 89.4% rate of overall postoperative satisfaction in 433 patients and a high 82.8% rate in those who would have chosen the operation again. Men with cystoscopic recurr...

Uroflowmetry (UF) is a simple, noninvasive method to evaluate voiding function in patients experiencing lower urinary tract symptoms.1,2 It is often combined with other metrics, including the International Prostate Symptom Score, in the initial diagnosis and follow-up of benign prostatic hyperplasia (BPH), and other causes of obstruction.3 In patients with urethral stricture disease (USD) who have undergone urethroplasty, UF is one of the most frequently used tests to monitor for stricture recurrence.4 However, UF’s use as a stand-alone tool to screen for recurrence following urethroplasty has never been rigorously validated. It has been well established that the maximum flow rate (Qm) in patients with USD is significantly diminished relative to age-matched normal controls.5,6 This knowledge has been extrapolated to the post-urethroplasty setting, where commonly used cutpoints of a postoperative Qm of less than 10 mL/s or a postoperative Qm of less than 15 mL/s are used as indicators of urethral stricture recurrence.5–7 Similarly, when UF data are available both pre- and postoperatively, a change in Qm following surgery of less than 10 mL/s has also been suggested as a predictor of recurrence.8 The goal for each of these UF parameters is to minimize the invasiveness of postoperative screening while maximizing the ability to find recurrences. The purpose of this study is to rigorously evaluate the capability of individual UF parameters, such as Qm and average flow rate (Qa), as well as a novel hybrid measure (Qm-Qa) to monitor for urethral stricture recurrence. Use of Qm-Qa has not been described in prior literature and attempts to provide a simple method to quantify the shape of the voiding curve. The study tested two hypotheses: (1) when compared to the gold-standard cystoscopy, UF parameters will have high test (screening) sensitivity and specificity, and (2) the sensitivity and specificity of UF to screen for stricture recurrence will be diminished in older patients.

INTRODUCTION AND OBJECTIVE:Ureteroscopy (URS) and shockwave lithotripsy (SWL) are standard treatments for patients presenting with proximal ureteral stones. Contemporary data comparing Emergency De...

The noise of a F18E aircraft is studied and analyzed. The main objective is to find out whether the noise has the same dominant noise components as those of a laboratory supersonic jet. The noise spectra at 3 power settings were studied. It is found that at low power, the dominant noise componets are very similar to those of a laboratory jet. But at hight power, there are significant differences.

ORTIC VALVE REPLACEMENT secondary to calcified aortic stenosis is the most common valvular replacement surgery in the United States, constituting nearly 50,000 cases per year. 1 Historically, aortic valve replacement required open heart surgery, which had a 4% to 18% risk of mortality, until 2002 when transcatheter aortic valve replacement (TAVR) was first described. 2 TAVR is an alternative for patients who are at high risk for perioperative complications for an open valve replacement. Maintaining adequate anticoagulation during a TAVR procedure is an integral component, with unfractionated heparin (UFH) being the anticoagulant of choice. Alternative agents for patients with contraindications to heparin undergoing TAVR have not been well-described in the literature. The authors present a case report of a patient with heparin-induced thrombocytopenia (HIT) type II who successfully underwent TAVR with bivalirudin anticoagulation. To the best of their knowledge, this is the first case report of utilizing an alternative anticoagulant, bivalirudin, during a TAVR procedure. CASE PRESENTATION

To characterize the associations between diabetes mellitus (DM) and lower urinary tract symptoms (LUTS). This study focuses on the relationships between specific diabetic characteristics (eg, severity, biomarkers) and the prevalence of LUTS.The 2005-2008 cycles of the National Health and Nutrition Examination Survey were queried for men who completed both a DM and a kidney/prostate questionnaire. Men with LUTS were defined as those experiencing at least 1 out of 3 of the following: nocturia, hesitancy, or incomplete emptying. Men with DM were defined as having been diagnosed by a physician and being actively treated. Multivariate logistic regression with sample weighting was performed to assess effects of biomarker levels (HgbA1c, fasting glucose), medication use, and surrogates of disease progression on the presence of LUTS.Of the 2127 male participants, those with DM (n = 405) were more likely to experience at least 1 urinary symptom (adjusted odds ratio 1.63, P .0001). Men under the age of 70 with long-standing (5 years) DM were more likely to report LUTS than those with a shorter duration of the disease (5 years). Diabetes-specific biomarkers (HgbA1c, fasting glucose) were not predictors of LUTS in men with DM.DM was confirmed to be strongly associated with patient-reported LUTS in men. Younger men and those with longer-standing disease appear to be most susceptible. In actively treated patients with DM, DM biomarkers were not helpful in predicting individual LUTS. Instead, biomarkers that indirectly reflect DM disease progression were most useful.

Objective To validate the use of the International Prostate Symptom Score (IPSS) as a stand-alone tool to detect urethral stricture recurrence following urethroplasty. Materials and Methods This study included 393 men who had undergone anterior urethroplasty and were enrolled in a multi-institutional outcomes study. Data analyzed included pre- and post-operative answers to the IPSS in addition to findings from a same- day cystoscopy. IPSS from men found to have cystoscopic recurrence were then compared to scores from those with successful repairs, and receiver operating characteristic curves were plotted to illustrate the predictive ability of these questions to screen for cystoscopic recurrence. Results Mean postoperative scores were lower (fewer symptoms) in successful repairs; IPSS improved from preoperative values regardless of recurrence. Successful repairs had significantly better degree of improvement in question #5 (assessing weak stream) compared to recurrences. Receiver operating characteristic curves demonstrated the highest area under the curve for the IPSS quality of life question (0.66) that alone outperformed the complete IPSS questionnaire (0.56). Conclusion The IPSS had inadequate sensitivity and specificity to be used as a stand-alone screening tool for stricture recurrence in this large cohort of men, highlighting the need to continue development of a disease-specific, validated patient-reported outcome measure.

Lichen sclerosus is a chronic, inflammatory skin condition of the genitalia of unknown origin that accounts for nearly 10% of urethral stricture disease. In this study we determine systemic comorbidities associated with lichen sclerosus in men.We analyzed data from 1,151 men who were enrolled in a multi-institutional prospective urethroplasty outcomes database. Individuals were grouped by stricture etiology, and baseline demographics, medical histories and patient reported outcome measures were retrospectively compared across groups.Of the 1,151 men in the database 81 (7.0%) were noted to have lichen sclerosus related urethral stricture disease. Average patient age was 46.06 ± 16.52 years, with those with lichen sclerosus being significantly older than those without lichen sclerosus (51.26 ± 13.84 vs 45.68 ± 16.64, p = 0.0011). Men with lichen sclerosus were more likely to have hypertension, hyperlipidemia and diabetes, and to use tobacco products. Controlling for age, men with lichen sclerosus related urethral stricture disease had a higher body mass index (aOR 1.089, 95% CI 1.050-1.130), and were more likely to have hypertension (aOR 2.028, 1.21-3.41) and be active tobacco users (aOR 2.0, 1.36-3.40). Mean preoperative patient reported outcome measures scores for urinary and sexual function were similar. Controlling for stricture length and location, the adjusted odds of surgical failure were higher for lichen sclerosus related urethral stricture disease (aOR 1.9, 95% CI 0.9-4.2).Lichen sclerosus related urethral stricture disease is associated with chronic systemic diseases. This association may implicate a systemic inflammatory and/or autoimmune pathophysiology. A 2-hit mechanism implicating local and systemic factors for lichen sclerosus related urethral stricture disease development and progression is hypothesized.

Objective To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. Materials and Methods We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. Results A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P = .0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P = .0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P = .0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P = .0014). Complications decreased with time (P = .0053). Conclusion This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.