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In the paediatric section, two papers relating to the upper urinary tract are presented. The first, from Hungary, describes simultaneous bilateral percutaneous nephrolithotomy in 13 patients, where it was deemed feasible; this is the first such report. Authors from London report on unilateral nephrectomy in patients with nephrogenic hypertension, and found that it was successful in normalising blood pressure in patients with renal hypertension with a normal contralateral kidney. OBJECTIVE To evaluate the efficacy of removing bilateral kidney stones simultaneously from children, in one session. PATIENTS AND METHODS Thirteen patients (three girls and 10 boys, 26 kidneys; mean age 8 years, range 3–14) underwent simultaneous bilateral percutaneous nephrolithotomy (PCNL) in the same session, under general anaesthesia, starting with ureteric catheter insertion into both kidneys and using a 26 F adult nephroscope. The mean (range) stone diameter was 2 (1–3.5) cm. Three patients had staghorn stones in one of their kidneys. Ultrasonic disintegration was used; two patients had bilateral and two others unilateral endopylotomy, and one patient had percutaneous suprapubic cystolithotomy in the same session. The mean (range) operative duration was 65 (55–90) min. RESULTS All patients were rendered stone‐free; there was no severe bleeding or any other complication. On one side in one of the patients, a second session was needed because of residual stone. The nephrostomy tubes were removed 3 and 4 days after PCNL and the hospital stay was 6 (1–11) days. CONCLUSION The advantages of simultaneous bilateral PCNL are reduced psychological stress, one cystoscopy and anaesthesia, less medication and a shorter hospital stay and convalescence, with considerable savings in cost. In experienced hands this method can be used not only in adults but also in children. To our knowledge this is the only report of this technique in children.

In patients on left ventricle assist device (LVAD) support, total cardiac output (CO) results from the summation of LVAD flow and native flow through the aortic valve. Our study aims to: 1) quantify discrepancies between LVAD flow and total CO, and 2) test a novel approach to estimate total CO using non-invasive parameters in patients implanted with a Heart-Mate 3 (HM3), a centrifugal pump that features intrinsic pulse technology to prevent stasis within the pump. Methods: Patients implanted with a HM3 between 11/2014 and 12/2017 were retrospectively studied. CO by thermodilution (TD) was measured in triplicate and the average was used for subsequent analyses. A total of 17 concurrently acquired variables were considered as potential predictors of CO: age, gender, weight, BMI, BSA, hemoglobin (Hb), hematocrit, LVEF, LVEDd, SBP, DBP, MAP, HR, LVAD flow, speed, PI and power. A multiple linear regression model was fit with the above predictor variables and CO by TD as the dependent variable to derive the HM3 CO Formula. To assess validity of the HM3 CO Formula against CO by TD, Pearson's correlation coefficients (r), mean absolute difference (MAD) and mean observed difference (MOD) were calculated. Results: 69 HM3 patients (age 60 §11y, 84% male, ischemic 43%, BMI 29 §5.4 kg/m 2 ) were studied. LVAD flow had good correlation but poor agreement with total CO by TD (r= 0.455, p<0.0001; MAD §SE 1.33 § 0.13 l/min, MOD §SE 1.15 §0.15 l/min, Fig A). The HM3 CO formula incorporating SBP, Hb, LVAD Power, and weight (CO = 1.197 + 0.028 x SBP -0.372 x Hb + 0.734 x power + 0.021 x weight) had better correlation and agreement with CO by TD (r= 0.714, p <0 .0001; MAD §SE 0.79 § 0.09 l/min, MOD §SE -0.05 § 0.13 l/min, Fig B). Conclusion:In HM3 patients, LVAD flow does not provide good estimate of total CO. The HM3 CO Formula offers an alternative method to estimate total CO using non-invasive parameters. Validation studies are warranted to confirm these preliminary findings.

Background: Vigorous systematic physical training can result in increased left ventricular wall thickness (LVWT) (i.e., “athlete’s heart”) which can be challenging to differentiate diagnostically from mild non-obstructive hypertrophic cardiomyopathy (HCM). The efficacy of a deconditioning strategy to observe changes in LVWT using cardiovascular magnetic resonance (CMR) that would support a diagnosis of athlete’s heart vs. HCM is not well established. Methods: We identified 9 highly trained patients involved in various organized sports who were referred to the Tufts Medical Center HCM center with a maximal LVWT in a diagnostic “gray area” of 13-15 mm. Maximal LVWT and other clinical and imaging variables were compared at baseline and following > 3 months of deconditioning from athletic training. A clinically relevant change in maximal LVWT at the end of athletic deconditioning was defined as a decrease of ≥2 mm, consistent with “athlete’s heart”. Imaging studies were interpreted blinded to study time period. Results: Among the 9 patients (23.1 ± 12.3 years old; 100% male), 4 demonstrated a ≥ 2 mm decrease in maximal LVWT (range: 2 mm to 3 mm) to ≤ 12 mm in 3 patients and 13 mm in one patient, with an average decrease of 2.3 mm. Among these 4 patients, LV and LA size also decreased (217.3 ± 31.5 ml to 208.9 ± 16.8 ml; and 55.4 ± 10.0 mm to 51.7 ± 9.1 mm, respectively), and there was no late gadolinium enhancement, pathogenic sarcomere mutation, or family history of HCM. Parameters of diastolic function were normal prior to deconditioning. After deconditioning evaluation and significant change in LVWT, these 4 patients were judged to not have a clinical diagnosis of HCM. The remaining 5 patients had a non-significant change in maximal LVWT after deconditioning of 0.2 mm, with maximal LVWT remaining ≥ 13 mm, and no change in LV or LA cavity size (p>0.2 for each). After deconditioning, these 5 patients were judged to have a clinical diagnosis of HCM. In the 9 patients that underwent a period of deconditioning, there was an average heart rate increase of 6.33. Conclusion: In athletes with maximal LVWT within the “gray zone” (13-15 mm) of overlap with HCM, athletic deconditioning using CMR to detect changes in maximal LVWT can aid in the differential diagnosis and inform management decisions.

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