Victor Jebara

Pathology of the liver in obese and diabetic ob/ob and db/db mice fed a standard or high-calorie diet

Non‐alcoholic fatty liver disease (NAFLD) is one of the commonest liver diseases in Western countries. Although leptin deficient ob/ob and db/db mice are frequently used as murine models of NAFLD, an exhaustive characterization of their hepatic lesions has not been reported to date, particularly under calorie overconsumption. Thus, liver lesions were characterized in 78u2003ob/ob and db/db mice fed either a standard or high‐calorie (HC) diet, for one or threeu2003months. Steatosis, necroinflammation, apoptosis and fibrosis were assessed and the NAFLD activity score (NAS) was calculated. Steatosis was milder in db/db mice compared to ob/ob mice and was more frequently microvesicular. Although necroinflammation was usually mild in both genotypes, it was aggravated in db/db mice after oneu2003month of calorie overconsumption. Apoptosis was observed in db/db mice whereas it was only detected in ob/ob mice after HC feeding. Increased apoptosis was frequently associated with microvesicular steatosis. In db/db mice fed the HC diet for threeu2003months, fibrosis was aggravated while steatosis, necroinflammation and apoptosis tended to alleviate. This was associated with increased plasma β‐hydroxybutyrate suggesting an adaptive stimulation of hepatic mitochondrial fatty acid oxidation (FAO). Nevertheless, one‐third of these db/db mice had steatohepatitis (NASu2003≥u20035), whereas none of the ob/ob mice developed non‐alcoholic steatohepatitis under the same conditions. Steatosis, necroinflammation, apoptosis and fibrosis are modulated by calorie overconsumption in the context of leptin deficiency. Association between apoptosis and microvesicular steatosis in obese mice suggests common mitochondrial abnormalities. Enhanced hepatic FAO in db/db mice is associated with fibrosis aggravation.

Dynamic cardiomyoplasty for long-term cardiac assist.

The principle of cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the failing heart. Technically, this procedure consists of placing the left LDM flap around the heart via a window created by partial resection of the 2nd or 3rd rib, and subsequent muscle electrostimulation in synchrony with ventricular systole. The aim of cardiomyoplasty is to support ventricular function in ischemic or dilated cardiomyopathies, or to partially replace the ventricular myocardium after large aneurysm or tumor resections. Our clinical experience at Broussais Hospital involves 44 patients. The functional class and quality of life improved after cardiomyoplasty. Improvement of the ventricular performance and limitation of cardiac dilatation were demonstrated over the long-term. The actuarial survival at 6 years was 71%. Risk factors influencing perioperative mortality were: age > 65 years, associated surgical procedures, pulmonary vascular hypertension, and patients hemodynamically unstable or on inotropic drug support. Preoperative risk factors influencing the long-term mortality were: permanent NYHA functional class 4, cardiothoracic ratio > 0.60, LV ejection fraction < 15%, bi-ventricular heart failure, and atrial fibrillation. Cardiomyoplasty does not preclude the use of future orthotopic heart transplantation.

Traumatic mitral insufficiency following percutaneous mitral dilation: anatomic lesions and surgical implications

Percutaneous mitral dilation is a widely accepted technique for treating pure mitral stenosis. Traumatic mitral insufficiency may occur secondary to this technique raising the problem of the feasibility of mitral valve repair. Twenty patients were operated on for traumatic mitral insufficiency following percutaneous mitral dilation. Three patients required emergency operations (within 6 h). In the other cases, surgery was carried out within the following days or weeks. Operative analysis of the mitral valves showed the following lesions: tear of the anterior leaflet (n = 4), tear of the posterior leaflet (n = 2), anterior (n = 4) or posterior (n = 9) paracommissural tear and papillary muscle rupture (n = 1). Associated chordal rupture was found in 3 patients. Septal perforation secondary to transseptal puncture was found in all cases. A septal tear of more than 10 mm was present in 4 patients. Surgery consisted of mitral valve reconstruction (n = 12) or mitral valve replacement (n = 8). Anatomic lesions following percutaneous mitral dilation may affect all the elements of the mitral valve apparatus. The possibility of repair depends more on the degree of calcification of the valve than on the extent of the leaflet tear.

Aberrant Right Subclavian Artery Aneurysm: Report of a Case and Review of the Literature

Aneurysms of an aberrant subclavian artery are rare. They are usually secondary to atherosclerosis. Dysphagia is the most common presenting symptom. The diagnosis of these lesions is most easily established by CT scan. Biplane arteriography is necessary in order to clearly analyze the aortic arch and its branches. Surgical resection is usually indicated. Numerous procedures have been proposed to treat these lesions and controversy exists concerning the best surgical technique. We treated a patient who suffered from an aneurysm of an aberrant subclavian artery. The surgical technique is detailed as well as a review of all the cases of the literature.

Is prompt exploratory laparotomy the best attitude for mesenteric ischemia after cardiac surgery

Mesenteric ischemia following cardiac surgery is a life-threatening complication. Early identification of patients may help optimizing management and improving outcome. Between January 2000 and July 2007, surgical exploration was realized when mesenteric ischemia was suspected after coronary-artery bypass grafts (CABG). Patients were divided in two groups according to diagnosis confirmation upon laparotomy. Peri-operative predictors of complication and death were analyzed. Of 1634 consecutive patients, 13 (0.8%) developed acute abdomen with suspicion of mesenteric ischemia. Seven (0.4%) underwent resection for ischemic lesions (group 1), of whom two were during a second look laparotomy. The other six patients had normal bowel (group 2). Both groups were comparable according to preoperative status, clinical signs, biological and radiological findings. Delays to laparotomy were 13.7+/-19.0 and 51.4+/-29.0 h in group 1 and 2, respectively (P=0.02). Mortality rates were 46.1% (6/13) overall, 42.8% for group 1 and 50% for group 2. All deaths occurred within the first nine postoperative days. Mesenteric ischemia following CABG is a fatal complication in almost half the cases. Diagnostic tools and timely laparotomy still need to be optimized. Low threshold-based strategy for prompt surgical intervention is efficient for both diagnosis and treatment.

Interventions in heart and thyroid surgery: can they be safely combined?

OBJECTIVEnThyroid diseases are relatively common problems in patients with cardiac disease. The aim of this study was to evaluate the feasibility of combined interventions in heart and thyroid surgery.nnnMETHODSnA retrospective study of 2530 cardiac operations yielded six patients who underwent thyroid intervention combined with cardiac surgery (coronary artery bypass grafting, valvular surgery or both) between 1996 and 2003. All patients were examined for age, gender, cardiac problems, thyroid pathology and related symptoms.nnnRESULTSnfour males and two females were operated for coronary artery disease, valvular disease or both and for thyroid pathologies. All patients had anticoagulation with intravenous heparin peroperatively and then postoperatively. No patient suffered from bleeding at the neck neither per- or postoperatively. No hemodynamic or cardiovascular compromises were noted.nnnCONCLUSIONnThe combined staged thyroid and cardiac surgery was feasible with a little risk for the both operations.

Development of catheter-based treatment of patent ductus arteriosus: a medium-sized centre experience.

BACKGROUNDnDespite the availability of effective devices, percutaneous closure of patent ductus arteriosus (PDA) can be challenging in some situations.nnnAIMnTo describe our initial experience of percutaneous PDA closure.nnnMETHODSnBetween 2001 and 2007, 73 consecutive patients aged 3 months to 70 years underwent transcatheter PDA closure. An Amplatzer duct occluder (ADO) was chosen for ducts greater than 2 mm (n=50) and a Detachable coil (DC) for smaller ducts (n=23).nnnRESULTSnThe diameter of the ducts ranged from 1 to 7.2 (mean 2.9+/-1.3) mm. The prostheses were implanted successfully in all patients. The complete closure rate reached 98% in the ADO group and 100% in the DC group at 12 months. Four (5.4%) patients showed asymptomatic device protrusion: three patients (5, 6 and 10 kg) into the aortic isthmus and one patient (7 kg) into the pulmonary artery (PA). One patient (7 kg) experienced transient severe bradycardia due to pulmonary air embolism. Another patient (3.3 kg) had a permanent asymptomatic occlusion of the femoral artery. In a third patient (17 kg), the ADO migrated asymptomatically into the descending aorta and was discovered 12 months later.nnnCONCLUSIONnEven during the learning curve, percutaneous PDA closure can give excellent results. Strict adherence to protocols and careful follow-up assessments are mandatory. In small infants, the use of the ADO may lead to obstruction in the aorta or PA, or to device migration. Cautious surveillance for untoward events is essential, especially in small infants with large ducts.

Extracardiac Unruptured Sinus of Valsalva, Coronary, and Intracranial Aneurysms

A 65-year-old woman presented for chronic cough and dyspnea with an aortic diastolic murmur. Transesophageal echocardiogram revealed a large, 57-mm nonruptured extracardiac aneurysm of the noncoronary sinus of Valsalva with mild aortic regurgitation. Coronary angiogram showed further multiple aneurysms of the entire coronary arteries (Figure 1). Cardiac MRI (Figure 2) elucidated the anatomy of the aneurysm. Cerebral angiography demonstrated large saccular aneurysms of the left anterior choroidal artery and the …

Recurrent Lower Limb Abscesses as the Primary Manifestation of Aorto-Femoral Graft Paraprosthetic Fistula

A 62-year-old man was presented to our facility with recurrent right lower limb abscesses. He had an aortobifemoral graft for an aortoiliac occlusive disease. The diagnosis of paraprosthetic fistula was confirmed by performing a high-resolution contrast-enhanced computed tomography, whereas labeled leukocyte imaging provided a negative result. The graft present in the right limb was removed and extra-anatomical femoro-femoral bypass was performed along with segmental ileal resection of the affected loop and a side-to-side anastomosis. Recovery was unremarkable, with no recurrence of abscess 18 months after surgery. To our knowledge, this is the first report in published data on a paraprosthetic fistula presenting as recurrent lower limb abscesses. In this article, we have discussed the clinical features, principal diagnostic findings, and therapeutic options.