Search

We aim to identify the incidence and timing of dysfunction and failure of stented bioprosthetic valves in the pulmonary position in congenital heart disease patients.A total of 482 congenital heart disease patients underwent 484 stented bioprosthetic pulmonary valve implantations between 2008 and 2018. There were 164 porcine valves (Porcine) and 320 bovine pericardial valves (Pericardial) implanted. Primary endpoints were survival, valve dysfunction, and valve failure.Pericardial valves were implanted in older patients (22.0, interquartile range [IQR] 14-33 vs 16.0, IQR 11-23 years, P0.001). Five-year survival (96.7% vs 97.9%) for the Pericardial and Porcine groups, respectively, were similar, P0.05. Forty-six (34%) Porcine and 75 (27%) Pericardial group patients met criteria for valve dysfunction at a median echocardiographic follow-up time of 7.43 years (IQR 4.1-9.5 years) and 3.26 years (IQR 1.7-4.7 years), respectively. More Pericardial group patients suffered from at least mild late PR while late median peak gradient was higher in the Porcine group, P.001 for both. Risk factors for valve dysfunction included decreasing patient age for the entire cohort (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.00-1.04, P = .015) and lack of anticoagulation at discharge for the Porcine group (HR 3.06, 95% CI 1.03-9.10, P = .044) but not the Pericardial group. Five-year cumulative incidence of dysfunction was 39% for the Pericardial group and 17% for the Porcine group.Porcine stented and bovine pericardial stented valves can be implanted in the pulmonary position in all age groups safely. However, despite similar rates of valve failure, bovine pericardial stented valves have a higher incidence of valve dysfunction at mid-term follow-up.

The ideal aortic valve replacement strategy in young- and middle-aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long-term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients.Data were retrospectively collected for patients 18-50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well-matched pairs from a total of 216 eligible patients.Demographic and preoperative characteristics were similar between the two groups. Median follow-up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population (p .01). Overall survival (p = .93), freedom from reintervention and valve dysfunction free survival (p = .91) were equivalent.In this mid-term propensity score-matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long-term anticoagulation. At specialized centers with sufficient expertize, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.

Objectives To evaluate contemporary clinical presentations of priapism, their association with socioeconomic characteristics, and the role of prescribing providers in priapism episodes in a large cohort of patients managed at 3 major academic health systems. Methods We identified all consecutive patients presenting with ischemic priapism to the emergency departments of three major academic health systems (2014 –2019). Demographic characteristics, priapism etiologies, and clinical management were evaluated. Univariable and multivariable analyses were used to assess the contribution of socioeconomic characteristics and the role of prescribing providers in priapism episodes. Results We identified 102 individuals with a total of 181 priapism encounters. Hispanic race, lower income quartile, sickle-cell disease, and illicit drug use were associated with increased risk of recurrent episodes. Of ICI users, 57% received their prescriptions from non-urological medical professionals (NUMPs); the proportion with recurrent episodes was higher for NUMPs compared to urologists (24% vs 0%, P = 0.06) with no demographic differences identified between patients treated by either group. Conclusion Socioeconomic disparities exist among patients presenting with recurrent episodes of priapism, potentially highlighting systemic issues with access to care and patient education. With most patients who developed ischemic priapism from ICI being prescribed these medications by NUMPs, further investigation is required to elucidate the prescribing and counseling patterns of these providers. Increased awareness of disparities and complications may improve patient safety.

The ideal number of neoadjuvant chemotherapy (NAC) cycles for muscle-invasive bladder cancer is uncertain with 3 to 4 representing the standard of care (SOC). We compared ypT0 rates and survival between patients receiving 4 versus 3 cycles of NAC with evaluation of chemotherapy-related toxicity for correlation with tumor chemosensitivity and pathological response.Patients receiving NAC followed by radical cystectomy for cT2-4N0M0 urothelial carcinoma from 2 institutions were included. Primary study groups included 4 cisplatin-based NAC cycles, 3 cisplatin-based NAC cycles, and nonSOC NAC (1-2 cycles or noncisplatin-based) to compare ypT0/≤ypT1 rates and survival. A cohort of patients not receiving NAC was included for pathological reference.Of 693 total patients, 318 (45.9%) received NAC. ypT0 and ≤ypT1 rates were 42/157 (26.8%) and 86/157 (54.8%) for 4 cycles, 38/114 (33.3%) and 71/114 (62.3%) for 3 cycles, and 6/47 (12.8%) and 13/47 (27.7%) for nonSOC (p=0.03 and p0.01, respectively). Pathological response appeared higher among patients receiving 3 cycles due to toxicity (ypT0: 29/77 [37.7%]; ≤ypT1: 51/77 [66.2%]) but did not reach statistical significance. Toxicities leading to treatment modifications were thrombocytopenia (32.1%), neutropenia (27.2%), renal insufficiency (22.2%), and constitutional symptoms (18.5%). NonSOC patients had lower Kaplan-Meier survival (cT2-cT4N0M0: log-rank p=0.07; cT2N0M0: log-rank p=0.02). There were no statistically significant differences in survival between 4 and 3 cycles (HR 1.00 [95% CI 0.57-1.74], p=0.99).Patients completing 3 cycles of cisplatin-based NAC have similar pathologic response and short-term survival compared to 4 cycles. Further evaluation of patients experiencing toxicity as a potential marker of tumor chemosensitivity is needed.

To characterize post-orchiectomy treatment trends in prepubescent and adolescent patients with nonseminomatous germ cell tumors (NSGCT) and identify patient and hospital factors associated with receiving surveillance or treatment (chemotherapy or RPLND) after orchiectomy.Patients18 years old diagnosed with NSGCT from 2006 to 2016 were extracted from the National Cancer Database. Patients were stratified into prepubescent (12 years old) and adolescent (age 13-17) cohorts. National trends and multivariable logistic regression for odds of undergoing treatment were identified.Documentation of use of post-orchiectomy treatment or surveillance was available for 1006 patients. This population was divided into a prepubescent cohort (≤12 years of age, n = 153) and an adolescent cohort (13-17 years of age, n = 853). 545 (54.4%) patients proceeded with treatment. The proportion of patients undergoing treatment in each cohort remained similar over time, but there was a shift in the adolescent cohort away from RPLND towards chemotherapy. In the prepubescent cohort, pathologic stage group III was associated with undergoing treatment. Older age,50 miles travel to treatment facility, and higher pathologic stage group were associated with treatment in the adolescent cohort. Black race was associated with decreased odds of undergoing treatment among adolescents.National treatment trends regarding NSGCT remained similar over a decade. Higher disease stage in prepubescent patients lead to additional post-orchiectomy treatment. Adolescents with NSGCT were more likely to undergo post-orchiectomy treatment if they were older, traveled farther to a treatment center, and had a higher disease stage.

Purpose:The 2 most common adverse effects of radical prostatectomy are erectile dysfunction and stress urinary incontinence which often require surgical management with penile prosthesis (P...

Keywords extraction, that is the process of extracting the most important and relevant words from a text or a set of texts, is one of the core components of every News Aggregator Service. This paper elaborates how Markov Chain can be used for extracting nouns from a set of news articles, and then ranking them in order to extract the top five. The process involves noun extraction using POS tagger, construction of a graph of extracted nouns, and PageRank algorithm for ranking nouns.

Clinical outcomes of redo surgical aortic valve replacement (redo-SAVR) compared with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) are poorly understood. This study compared short- and midterm outcomes of patients undergoing isolated redo-SAVR vs VIV-TAVR after previous SAVR.A single-institutional review of the initial use of VIV-TAVR from 2012 to 2019 identified 273 patients undergoing VIV-TAVR (n = 187) or redo-SAVR (n = 86) after prior SAVR. Outcomes analysis included a univariate analysis and Kaplan-Meier survival analysis.The Society of Thoracic Surgeons predicted risk of mortality was higher for VIV-TAVR (6.3%; interquartile range [IQR], 3.6%-10.5%) vs redo-SAVR (4.2%; IQR, 2.4%-6.9%; P.01). VIV-TAVR patients (76 years; IQR, 67.5-82.5 years) were older than redo-SAVR patients (64 years; IQR, 54-72; P.01). Redo-SAVR and VIV-TAVR had similar early mortality (1.2% vs 1.6%, P = .92). Two redo-SAVR (2.3%) and 3 VIV-TAVR patients (1.6%) died 4.8 ± 0.5 years and 4.8 ± 1.5 months after discharge, respectively. Redo-SAVR had an increased stroke rate (7.0% vs 1.1%, P = .02). Postoperative mean valve gradients were similar between VIV-TAVR (14 mm Hg; IQR, 9-21 mm Hg) and redo-SAVR patients (12 mm Hg; IQR, 8-20 mm Hg; P = .08). Postprocedure transesophageal echocardiography showed at least mild aortic insufficiency for 24 VIV-TAVR patients (16%) and 2 redo-SAVR patients (2.9%) (P = .01). The cumulative incidence of aortic valve reintervention was 5.2% for the redo-SAVR patients and 28.5% for the VIV-TAVR patients (P = .07).After previous SAVR, redo-SAVR and VIV-TAVR can both be performed with acceptable operative results. Despite treating a high-risk patient population, we found redo-SAVR and VIV-TAVR both carry similar operative outcomes. Improved valve hemodynamics were observed in redo-SAVR patients compared with VIV-TAVR patients.

There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.

Objective: The timing and nature of and risk factors for reoperation after the arterial switch operation in the setting of d-transposition of the great arteries requires further elucidation. Methods: A total of 403 patients who underwent arterial switch operation from 1986 to 2017 were reviewed. Institutional preference was for pulmonary artery reconstruction using a pantaloon patch of fresh autologous pericardium. The targets for coronary artery reimplantation were identified by intermittent root distension. Multivariable analysis was used to identify risk factors for reoperation. Results: Median follow-up was 8.6 years (interquartile range [IQR]: 2-16.9). Pulmonary arterioplasty was the most common reoperation (n = 11, 2.7%) at 3.3 years (IQR: 1.4-11.4) postoperatively. Subvalvar right ventricular outflow tract reconstruction (RVOTR) was required in nine (2.2%) patients at 2.5 years (IQR: 1.1-5.3) postoperatively. Aortic valve repair or replacement (AVR/r) was required in seven (1.7%) patients at 13.6 years (IQR: 10.0-15.8) postoperatively. Aortic root replacement (ARR) and Coronary Artery Bypass Graft/coronary patch arterioplasty were required in five (1.2%) patients each at 13.6 years (IQR: 11.0-15.3) and 11.3 years (IQR: 2.3-13.6) postoperatively, respectively. Taussig-Bing anomaly was a risk factor for any reoperation ( P = .034). Risk factors for specific reoperations included ventricular septal defect for AVR/r ( P = .038), Taussig-Bing anomaly for RVOTR ( P = .004), and pulmonary artery banding for ARR ( P = .028). Conclusions: Pantaloon patch pulmonary artery reconstruction and intermittent neo-aortic root distension during coronary reimplantation have minimized respective outflow tract reoperations. Certain anatomic subsets carry different risks for late reoperation, and pulmonary artery and/or RVOT reinterventions tend to occur sooner than aortic reinterventions. Special attention to these higher risk subpopulations will be critical to optimizing lifelong outcomes.

Introduction:We sought to compare re-treatment rates between shockwave lithotripsy and ureteroscopy to evaluate the effectiveness of these modalities. Additionally, we aimed to compare cost...

To characterize the presentation and management of spermatocytic seminoma (SS) compared to classic seminoma in adults utilizing a large cancer registry.Patients18 years of age in the National Cancer Database from 2006 to 2016 who underwent orchiectomy for testicular tumors were identified. Demographics, oncologic characteristics, and treatment patterns were compared between patients with SS and classic seminoma.Of 53,481 adults receiving orchiectomy, 29,208 were diagnosed with classic seminoma and 299 (1%) with SS. Compared to patients with classic seminoma, SS patients were older (57 vs 39 years) and more likely to be African-American (odds ratio (OR) 1.8) and insured by Medicare (OR 2.0; all P.05). SS patients had larger tumors on presentation (3-6 cm: OR 1.8;6 cm: OR 1.8), but were less likely to have ≥pT2 stage (OR 0.5), regional nodal involvement (Clinical Stage II: OR 0.3), or distant metastatic disease (Clinical Stage III: OR 0.1; all P.01). For postorchiectomy management, 73.6% of SS patients underwent surveillance while 24.5% had active treatment (retroperitoneal lymph node dissection, chemotherapy, radiation, or a combination). When stratified by year, there was an increasing trend toward surveillance compared to active treatment.SS is a rare germ cell tumor that typically presents as a larger tumor in older patients. Although these tumors are less likely to be characterized by advanced disease compared to classic seminoma, many patients have undergone aggressive postorchiectomy treatment in the past. Importantly, treatment trends have shifted toward surveillance in recent years with adjuvant therapy limited primarily to higher stage tumors.

Proton-pump inhibitors (PPIs) may increase the risk of kidney stone formation, but the mechanism has not been elucidated. There is a paucity of literature evaluating the effects of PPIs on urinary metabolites and urine pH. We performed a retrospective review of nephrolithiasis patients treated at our institution and compared patients who were taking PPIs to those who were not at the time of their 24-h urine collections. Hierarchical multivariate linear regression was used to evaluate the independent relationship between PPI use and urinary mineral composition. We identified 301 consecutive patients, 88 (29%) of whom were taking PPIs at the time of their 24-h urine collections. Patients taking PPIs were older and more likely to have medical comorbidities associated with metabolic syndrome such as hypertension, diabetes, and dyslipidemia (p

Introduction Non-pharmacologic alternative therapies for pain have been around for a long time, some for hundreds of years. They have been used throughout history to treat many issues. Recent Findings Currently, alternative medicine is most frequently used to treat musculoskeletal pain, and between 59 and 90% of patients utilizing alternative therapies for chronic pain claimed they were helpful and can serve as an effective adjunctive for the treatment of chronic pain. Some examples of alternative therapies that will be discussed in this review include acupuncture, tai chi, osteopathic manipulation, and chiropractic care. Acupuncture, traditionally a Chinese practice, is becoming more popular across the world to attempt to relieve pain. It involves the placement of thin needles at various points in the body. The efficacy of acupuncture for pain is heavily debated. More research and discussion are necessary to determine the exact role it plays in the treatment of chronic pain. Tai chi is also a traditional Chinese practice that is often used as a form of meditation and for potential health benefits. Tai chi involves a series of complex movements such as squatting combined with deep breathing to achieve relaxation and pain reduction. Osteopathic manipulative treatment (OMT) is a technique used by both osteopathic physicians (DO) as well as other health professionals to manage a wide range of conditions in any given patient. The technique involves utilization and manipulation of the musculoskeletal system to achieve potential health benefits. OMT has been used as therapy for many issues but is commonly used for pain conditions. Summary Alternative therapies may serve as an effective adjunctive treatment modality for the management of chronic pain conditions. There has been a tremendous amount of research dictating the effectiveness of alternative therapies for chronic pain management. The purpose of this review is to provide a comprehensive evidence-based update of alternative therapy used for the management of chronic pain conditions.

This retrospective cohort study evaluates the characteristics of patients who presented to the emergency department with acute urinary retention.Using the Healthcare Cost and Utilization Project State Emergency Department Databases we conducted a retrospective cohort study of patients who presented to emergency departments in Florida between 2005 and 2015. Male patients age 45 years or older who presented with diagnosis codes for acute urinary retention and lower urinary tract symptoms/benign prostatic hyperplasia were considered. Information was collected on age, race/ethnicity, primary insurance and rural-urban commuting area codes.The mean age for males presenting with acute urinary retention was 72.2 years, which was 10.6 years older than those presenting for nonurological complaints (p0.001). Multivariable analysis adjusted for measured confounders found all covariates to be significant. The risk of presenting to the emergency department for acute urinary retention from lower urinary tract symptoms/benign prostatic hyperplasia increased with age, with the 75 to less than 85-year-old age group at the highest risk (OR 15.96, p0.001). Other factors associated acute urinary retention included African American (OR 1.15, p0.001) or Hispanic (OR 1.75, p0.001) race, Medicare (OR 1.27, p0.001) or private (OR 1.33, p0.001) insurance, and urban rural-urban commuting area codes (OR 1.31, p0.001).Male patients who presented to the emergency department for acute urinary retention with benign prostatic hyperplasia were more likely to be older, of nonwhite race, have Medicare or private insurance, and live in more urban areas. These data suggest that African American and Hispanic patients may be untreated or under treated for benign prostatic hyperplasia in the outpatient setting, resulting in an increased risk of presentation to the emergency department with acute urinary retention.

Purpose Despite paucity of data, there exists growing popularity of catheter-based extraction methods for intravascular thrombi and vegetations. We describe a large single center experience with vacuum-assisted extraction techniques (VAET) for right-sided intravascular and cardiac masses. Methods We retrospectively reviewed the perioperative course of patients undergoing VAET between 2014 and 2019. Primary outcomes were survival and freedom from recurrent bacteremia. Procedural success was a composite definition of survival, majority of mass extraction, absence of recurrent bacteremia, and valve function not requiring further intervention during index hospitalization. Results Of the entire cohort (n = 58), 48% and 52% underwent VAET for vegetations and sterile thrombi, respectively. Of those with positive cultures, the most common organism isolated was Staphylococcus aureus (48%). Preoperative active bacteremia was present in 36% (21/58) and of these patients, 76% (16/21) had neither recurrent nor persistent bacteremia post-op. The majority of masses (67%, 38/58) were debulked with an average reduction in size of 42%. Conversion to open surgery occurred in 3.5% (2/58). Intraoperative and 30-day survival were 98% (57/58) and 90% (28/31), respectively. Overall success was 86% (50/58). The prevalence of moderate/severe tricuspid regurgitation was 37% pre-op and 61% post-op. Average length of intensive care unit and overall hospital stay was 5.6 and 16 days, respectively. Conclusions In this single center experience, VAET was conducted safely with a high degree of success and freedom from short-term recurrent bacteremia. This minimally invasive procedure is an attractive alternative to traditional open techniques for removal of right-sided intravascular and cardiac masses.

Occipital neuralgia (ON) is unilateral or bilateral neuralgia in the dermatomal nerve distribution of the greater, lesser or third occipital nerves and is a very common presentation of neuropathic pain. ON, although common and well defined, is still a poorly understood pain syndrome. It often requires invasive treatment for long term and significant pain alleviation; however, the evidence supporting different options is still limited. Several minimally invasive techniques have proven to be efficacious and safe, and the selection depends mostly on response to nerve blocks, patient choice and provider preference. This is a comprehensive review of the latest and seminal literature available about occipital neuralgia and currently available minimally invasive treatment options. It covers the anatomical and physiologic biology at the base of neuralgia, the presentation and diagnostic process. It then reviews the available literature to provide description and comparison of the available methods for alleviation.

Objectives:The Ross procedure involves using the native pulmonary valve for aortic valve replacement then replacing the pulmonary valve with an allograft or xenograft. We aimed to compare our age-matched experience with the bovine jugular vein conduit and the pulmonary homograft for pulmonary valve replacement during the Ross procedure in children.Methods:Between 1998 and 2016, 15 patients Results:The median age of the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft patients were 4.8 years (interquartile range 1.1–6.6) and 3.3 years (interquartile 1.2–7.6), respectively (p = 0.6). The median follow-up time for the Ross-Bovine Jugular Vein Conduit and Ross-Pulmonary Homograft groups were 1.7 years (interquartile range 0.5–4.9) and 6.8 years (interquartile range 1.9–13.4), respectively (p = 0.03). Overall, 5-year survival, freedom from redo aortic valve replacement, and freedom from pulmonary valve replacement were similar between groups.Conclusion:The bovine jugular vein conduit and pulmonary homograft have favourable mid-term durability when used for right ventricular outflow tract reconstruction for the Ross operation. The bovine jugular vein conduit may be a suitable replacement for appropriately sized patients undergoing a Ross aortic valve replacement, though longer follow-up is needed.

Background The ideal aortic valve replacement strategy in young- and middle-aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long-term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients. Methods Data were retrospectively collected for patients 18 to 50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well-matched pairs from a total of 216 eligible patients. Results Demographic and preoperative characteristics were similar between the two groups. Median follow-up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population ( p < 0.01). Overall survival ( p = 0.93), freedom from reintervention and valve dysfunction free survival ( p = 0.91) were equivalent. Conclusions In this mid-term propensity score-matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long-term anticoagulation. At specialized centers with sufficient expertise, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement.

INTRODUCTION AND OBJECTIVE:Ideal length of neoadjuvant chemotherapy (NAC) before cystectomy for muscle-invasive bladder cancer (MIBC) is uncertain. Trials initially studied 3 cycles, but 4 cycles a...

PURPOSE OF REVIEW: This is a review of elagolix use for pain related to endometriosis. It summarizes the background and recent data available about the pathogenesis of endometriosis and pain that is secondary to this syndrome. It then reviews the evidence to support the use of elagolix and the indications for use. RECENT FINDINGS: Endometriosis occurs in 10% of reproductive-age women and is a common source of chronic pelvic pain, infertility, and co-morbid disorders. It usually presents with some combination of dysmenorrhea, dyspareunia, chronic pelvic pain, and infertility. Treatment options may be surgical or hormonal. Traditional treatment is divided into medical and surgical. The latter, though effective, is reserved for surgical emergencies and patients failing medical management. Medical management with NSAIDs is usually limited in efficacy. It is generally based on hormonal suppression leading to atrophy of endometrial lesions. Elagolix (Orlissa) is a GnRH antagonist that suppressed the entire hypophysis-gonadal axis. Reduced levels of estrogen and progesterone lead to involution of the endometrial lesions and improvement in symptoms. Clinical trials showed that elagolix is effective in treating dysmenorrhea and non-menstrual pain that is secondary to endometriosis. It is well tolerated and has a relatively safe usage profile. Studies up to 12 months long showed continued efficacy and reduction in dysmenorrhea of up to 75%, with 50%–60% reduction in non-menstrual pain. Elagolix was found effective when compared to both placebo and alternative treatments. SUMMARY: Endometriosis is a common syndrome that causes significant pain, morbidity, and disability, as well as financial loss. Elagolix is an effective drug in treating the symptoms of endometriosis and is a relatively safe option. Phase 4 studies will be required to evaluate the safety and efficacy of long term chronic use.

Introduction: There has been a recent trend towards the increased use of biologic valves at the time of surgical aortic valve replacement (SAVR) with an understanding there may be a potential need for future valve intervention. In this study, we compared the clinical outcomes of Redo-SAVR with valve-in-valve transcatheter aortic valve replacement (VIVTAVR) in patients with a prior history of SAVR. Methods: From 2012 to 2019, 263 patients underwent isolated aortic valve reintervention after prior SAVR: VIV-TAVR (n=187) or redo-SAVR (n=86). Multivariable analysis was performed to identify risk factors mortality and aortic reintervention. Sub-analyses were performed to compare VIV-TAVR patients to Redo-SAVR patients undergoing biologic valve explant and implant (Biologic) as well as VIV-TAVR and Redo-SAVR patients matched by STS Predicted Risk of Mortality (STS PROM). Results: Operative mortality for the Redo-SAVR and VIV-TAVR was 1.2% (1) and 1.6% (3) respectively (p=0.92). Redo-SAVR patients had an increased stroke rate (7.0% vs 1.1%, p=0.02) and longer postoperative length of stay (7 vs 2 days, p Conclusions: Aortic valve reintervention following prior SAVR is associated with outstanding clinical outcomes. Both Redo-SAVR and VIV-TAVR can be performed with lower than expected predicted mortality. Redo-SAVR was associated with increased morbidity compared to VIV-TAVR, but improved valve function and hemodynamics. Differences in long term valve durability and patient survival between these two therapies are yet to be determined.

Proton-pump inhibitors (PPIs) may increase the risk of kidney stone formation, but the mechanism has not been elucidated. There is a paucity of literature evaluating the effects of PPIs on urinary metabolites and urine pH.We performed a retrospective review of nephrolithiasis patients treated at our institution and compared patients who were taking PPIs to those who were not at the time of their 24-h urine collections. Hierarchical multivariate linear regression was used to evaluate the independent relationship between PPI use and urinary mineral composition.We identified 301 consecutive patients, 88 (29%) of whom were taking PPIs at the time of their 24-h urine collections. Patients taking PPIs were older and more likely to have medical comorbidities associated with metabolic syndrome such as hypertension, diabetes, and dyslipidemia (p 0.01). Controlling for these factors, patients taking PPIs were found to have 12% lower 24-h urine citrate excretion (β = - 0.12, ΔF = 4.24, p = 0.04). There were no other differences in urinary mineral composition between the groups.Our findings suggest that patients who take PPIs regularly may be at risk for decreased urinary citrate excretion. The consequent decrease in urinary citrate may become clinically significant for patients with other predisposing factors for hypocitraturia.