Unconventional Cardiovascular Risk Factors and Systematic Coronary Risk Estimation (SCORE) in the Lebanese Rural Population: The Forgotten Factors.

Purpose: To evaluate the correlation between unconventional risk factors and the Systematic Coronary Risk Estimation (SCORE), and estimate the prevalence of conventional and unconventional cardiovascular (CV) risk factors in the rural Lebanese population in order to assess their CV risk. Methods: This is a retrospective descriptive study conducted between November 2017 and June 2019 among the Lebanese rural population. The risk factors were analyzed from the files of the patients who presented for the CV disease screening days organized by a non governmental organization. The CV risk estimation tool is the SCORE. The classification of socio-economic level ranges from zero (low level) to 3 (high level). Results: A total of 433 patients were included. The prevalence of hypertension, diabetes, dyslipidemia, smoking, and metabolic syndrome was 45.1%, 31.2%, 39.2%, 50% and 42.9% respectively. Only 13.6% of hypertensive patients and 6.7% of diabetics were controlled. A total of 0 or 1 point for the classification of socio-economic status was found in 62.6% of cases. A family history of CV diseases was present in 87.3% of participants. The SCORE was correlated with diabetes and metabolic syndrome (p = 0.000), without being correlated to socio-economic status (HR = -0.104; p = 0.059) or to family history (p = 0.834). Conclusion: The socio-economic status and the family history of CV disease must be evaluated in addition to the classical risk calculation of the SCORE to better pinpoint the actual risk of the targeted population. The risk factors are prevalent but poorly controlled, hence the need for a national effort to ensure better care for the rural Lebanese population.

Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial.

BACKGROUND: Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive. METHODS: Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial. PARTICIPANTS: 195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1. MEASUREMENTS: hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay. RESULTS: At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported. CONCLUSION: In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30. CLINICAL TRIAL REGISTRY NUMBER: NCT03759964.

Preoperative oral magnesium loading to prevent postoperative atrial fibrillation following coronary surgery: a prospective randomized controlled trial.

OBJECTIVES: Postoperative atrial fibrillation (POAF) is common following coronary artery bypass grafting (CABG) surgery. Hypomagnesemia is frequent after CABG surgery. No previous trials have assessed the effect of preoperative magnesium (Mg) loading on POAF incidence. METHODS: This was a single-centre, double-blind, placebo-controlled, parallel-group trial, with balanced randomization [1:1]. The participants were recruited from November 2018 until May 2019. Patients received either 3.2 g of Mg daily (4 tablets of 0.4 g each twice daily) for 72 h preoperatively and 1.6 g of Mg (4 tablets) on the day of surgery or placebo tablets. RESULTS: The primary outcome was the incidence of POAF. Secondary outcomes included time to extubation, transfusion rate, critical care unit and hospital length of stay. Of the 210 randomized participants, 200 (100 in each group) completed the study. A total of 10 (10%) and 22 (22%) subjects developed POAF in the Mg and placebo groups, respectively (RR = 0.45, 95% confidence interval: 0.23-0.91). Hospital and critical care unit length of stay were comparable between the 2 groups. No side effects related to Mg administration were documented. CONCLUSIONS: In this randomized controlled trial, preoperative loading with oral administration of Mg for 3 days in patients admitted for CABG surgery decreases the incidence of POAF compared to placebo. CLINICAL TRIAL REGISTRATION NUMBER: NCT03703349.

First reported case of Cladosporium para-aortic abscess.

Cladosporium species are ubiquitous dematiaceous fungi, widely found in the indoor and outdoor environments. They are considered a frequent source of contamination in laboratory settings. In human pathology, Cladosporium is a main agent of phaeohyphomycosis, known to cause subcutaneous and brain abscess, especially in immunocompromised hosts. The route of disseminated infections is mainly hematogenous after inhalation of the spores. However, a direct inoculation could be possible. We report the first case of a para-aortic abscess with thrombus formation, caused by Cladosporium spp., after a valvular replacement surgery, in an immunocompetent patient. This raises the alarm about the rapid identification of the source of contamination in the operating room, in order to prevent the emergence of further fatal infections.

"You only live twice": multidisciplinary management of catastrophic case in placenta Accreta Spectrum-a case report.

BACKGROUND: Placenta percreta is associated with high hemorrhagic risk and can be complicated with fatal thromboembolic events. Involving a multidisciplinary team in the treatment of these patients is mandatory to reduce morbidity and mortality. CASE PRESENTATION: This paper reports the case of a 22-year-old patient with placenta percreta who was referred to our tertiary care center for delivery. Few hours after undergoing a successful cesarean hysterectomy, the patient developed a pulmonary embolism and cardiac arrest. A transthoracic echocardiogram done in the intensive care unit (ICU) showed a thrombus in the right ventricle. After cardiac resuscitation, the patient underwent an urgent thoracotomy and a pulmonary artery thrombectomy; many clots were retrieved from the pulmonary artery. After weaning from extracorporeal circulation, an intraoperative transesophageal cardiac ultrasound enabled the medical team to detect a new free-floating thrombus in the right atrium and right ventricle, and consequently to perform an embolectomy and prevent the patient's death. CONCLUSION: This case emphasizes the role of multidisciplinary team in treating high-risk obstetric cases that could be complicated with massive and fatal thromboembolic events. The use of intraoperative transthoracic echocardiography helps in detecting a new thrombus and guides the anesthesiologist in the intra-operative monitoring.

Transient Receptor Potential Canonical 3 and Nuclear Factor of Activated T Cells C3 Signaling Pathway Critically Regulates Myocardial Fibrosis.

AIMS: Cardiac fibroblasts (CFs) are emerging as major contributors to myocardial fibrosis (MF), a final common pathway of many etiologies of heart disease. Here, we studied the functional relevance of transient receptor potential canonical 3 (TRPC3) channels and nuclear factor of activated T cells c3 (NFATc3) signaling in rodent and human ventricular CFs, and whether their modulation would limit MF. RESULTS: A positive feedback loop between TRPC3 and NFATc3 drove a rat ventricular CF fibrotic phenotype. In these cells, polyphenols (extract of grape pomace polyphenol [P.E.]) decreased basal and angiotensin II-mediated Ca2+ entries through a direct modulation of TRPC3 channels and subsequently NFATc3 signaling, abrogating myofibroblast differentiation, fibrosis and inflammation, as well as an oxidative stress-associated phenotype. N(ω)-nitro-l-arginine methyl ester (l-NAME) hypertensive rats developed coronary perivascular, sub-epicardial, and interstitial fibrosis with induction of embryonic epicardial progenitor transcription factors in activated CFs. P.E. treatment reduced ventricular CF activation by modulating the TRPC3-NFATc3 pathway, and it ameliorated echocardiographic parameters, cardiac stress markers, and MF in l-NAME hypertensive rats independently of blood pressure regulation. Further, genetic deletion (TRPC3-/-) and pharmacological channel blockade with N-[4-[3,5-Bis(trifluoromethyl)-1H-pyrazol-1-yl]phenyl]-4-methyl-benzenesulfonamide (Pyr10) blunted ventricular CF activation and MF in l-NAME hypertensive mice. Finally, TRPC3 was present in human ventricular CFs and upregulated in MF, whereas pharmacological modulation of TRPC3-NFATc3 decreased proliferation and collagen secretion. Innovation and Conclusion: We demonstrate that TRPC3-NFATc3 signaling is modulated by P.E. and critically regulates ventricular CF phenotype and MF. These findings strongly argue for P.E., through TRPC3 targeting, as potential and interesting therapeutics for MF management.

Successful Operation for Thoracoabdominal Aortic Aneurysm in a 5-Year-Old Boy With Tuberous Sclerosis.

The association of abdominal aortic aneurysm (AAA) and tuberous sclerosis (TS) is rare. A 5-year-old boy was diagnosed with a 7-cm calcified thoracoabdominal aortic aneurysm (TAAA), and the clinical evaluation revealed TS. The patient underwent an open repair with a 14-mm polyester tube graft prosthesis. The pathologic examination showed nonspecific dystrophic changes with loss of elastin fibers in the media of the aorta. The graft was patent on computed tomographic angiography performed 1 month after the operation. Because of the high risk of rupture, early elective repair is suggested.

Myocardial extraction of intracellular magnesium and atrial fibrillation after coronary surgery.

BACKGROUND: The effects of magnesium loading on the incidence of atrial fibrillation following coronary artery bypass graft surgery (CAGB) are equivocal. None of the previous studies assessed the influence of myocardial extraction of magnesium in these settings. The current trial aims to elucidate whether the incidence of atrial fibrillation following CABG is affected by the preoperative rate of myocardial extraction of magnesium. METHODS: The ethical committee approved the study protocol. 113 patients (94 male, mean age 63 ± 11 years) planned for elective CABG surgery under normothermic cardiopulmonary bypass were prospectively included. Preoperative independent variables included preoperative treatment, electrocardiographic abnormalities, left ventricular ejection fraction estimation, left atrial size, creatinine clearance and assays of plasma and intracellular magnesium, calcium, albumin, potassium and ionized calcium, drawn preoperatively from the coronary sinus and the aortic root. The covariates - including the rate of myocardial extraction of magnesium - were entered in a logistic regression model to predict the odds of atrial fibrillation. RESULTS: The incidence of post operative atrial fibrillation was 16%. A rate of myocardial extraction of intracellular magnesium ≥ 7% increases fivefold the multivariate risk of postoperative atrial fibrillation (p < .01). Advanced age was also significantly associated to postoperative atrial fibrillation. CONCLUSIONS: This study suggests that a preoperative rate of myocardial extraction of intracellular magnesium ≥ 7% could be a new and a potent predictive factor for postoperative atrial fibrillation.

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 78 ob/ob and db/db mice fed either a standard or high-calorie (HC) diet, for one or three months. 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 one month 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 three months, fibrosis was aggravated while steatosis, necroinflammation and apoptosis tended to alleviate. This was associated with increased plasma ß-hydroxybutyrate suggesting an adaptive stimulation of hepatic mitochondrial fatty acid oxidation (FAO). Nevertheless, one-third of these db/db mice had steatohepatitis (NAS ≥ 5), 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.

Fatal cardiac atherosclerosis in a child 10 years after liver transplantation: a case report and a review.

We hereby review liver transplantation for homozygous familial hypercholesterolemia and report the case of a 14-year-old girl presenting with severe bilateral coronary ostial stenosis and tight supra-valvular aortic narrowing 10 years after liver transplantation. Despite normalization of the lipids after liver transplantation, the patient showed evidence of severe cardiac atherosclerosis 10 years later and died of apparent sepsis.

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.

Treatment of Heyde's Syndrome by Aortic Valve Replacement.

Heyde's syndrome is the association between calcific aortic stenosis and gastrointestinal bleeding due to angiodysplasia. Alterations in von Willebrand factor due to turbulence across the diseased aortic valve have been incriminated in the pathophysiology of this syndrome. Replacement of the aortic valve has been reported to stop the bleeding, but this is debatable. Along with a review of the relevant medical literature, we hereby report a 68 year old patient with aortic stenosis and severe recurrent gastrointestinal bleeding that completely subsided following aortic valve replacement.

Unusual complication of apicoaortic conduit: left main coronary artery thrombosis.

We report a case of left main coronary artery thrombosis 7 days after aortic valve replacement for native aortic valve regurgitation. The patient had undergone apicoaortic conduit implantation 3 years earlier. The thrombosis resulted from deviation of the cardiac output through the apicoaortic conduit and consequent turbulence of flow in the ascending aorta. Despite thrombus aspiration from the left main coronary artery, the patient never recovered and died 2 days later from multiple organ failure.

Acute thrombosis of abdominal aortic aneurysm during cardiac surgery.

Aortic thrombosis has been described in the medical literature as a rare and catastrophic complication of abdominal aortic aneurysms. However, it has only been reported once in cardiac surgical settings. We report a unique case of thrombosis of an abdominal aortic aneurysms during the course of cardiac surgery, in a fully anticoagulated patient on cardiopulmonary bypass. Prompt diagnosis and immediate surgical management were critical for a successful outcome.

The Amplatzer Duct Occluder II: a new device for percutaneous ductus arteriosus closure.

OBJECTIVE: Study the new Amplatzer Duct Occluder II (ADO II). Limitations were encountered with the preexisting devices in nonconical ducts, large ducts, or in small infants. These include failure, residual shunts, protrusion, migration, and vascular damage. METHODS: Between June 2008 and March 2009, 20 consecutive patients were enrolled. In cases where different devices were applicable, we favored the use of the ADO II to maximize our experience with this device and prove its superiority. No coils were required in these 20 patients. RESULTS: There were 15 females and 5 males (median age 2 years). ADO II group (n = 16): Immediate complete closure in 75% of the patients, rising to 93.7% at 24 hours. A residual shunt persisted at 3 months in one child. Aortic narrowing from device protrusion was noted in two type E ducts, without any significant gradient, however. ADO I group (n = 4): In two adolescents and in one adult patient, the duct was successfully closed. In a 2-year-old patient with a 6.6 mm type B duct, the ADO I totally obstructed the aortic flow and was retrieved before releasing. The child was sent for surgery. CONCLUSION: Even though we did not compare the ADO II to other devices, we feel that it has the capacity to substitute most of the coils, and some of the original ADO I indications. Arterial access was sufficient in most patients, but venous delivery is advised in small infants with large or long ducts, to avoid aortic protrusion and residual shunts.

Apico-aortic valved conduit as an alternative for aortic valve re-replacement in severe prosthesis-patient mismatch.

Off-pump implantation of an apico-aortic bioprothesis-valved conduit in a 75-year-old female symptomatic patient with severe prosthesis-patient mismatch secondary to a previous aortic valve replacement, calcified ascending aorta, tight adhesion with the sternum, was successfully conducted to relieve the left ventricle from severe aortic stenosis.