Bold Wish

The deep grays of winter
are bursting to green
the soft glow of sunshine
starts warming to spring

That cold winter past
Just sad memories
with jumbled new life
exploding new trees

as seasons progress
so do our souls
hardened cold hearts
to rekindled coals

As old love is lost
where twisted branch grew
a space to be filled
with life that's as new

These cycles of seasons
They go ever on
shining sweet face
replaced sad one gone

Hearts seem as seasons
in our history of years
summer to fall
and joy into tears

Pray grant me partner
that blows hot nor cold
but steady she steers
dare I wish this so bold ?

Lumbar Back Sprains and Strains

Most people will experience back pain during their lifetime. Some patients fear the worst, especially when pain is severe. Although back pain can be caused by fracture, disc disorder, or tumor, the most common cause is sprain or strain.

Sprains and strains often result from excessive physical demands on the back. Lifting something too heavy, a sudden fall, car crash, or sports injury can cause soft tissues (ligaments, muscles, tendons) to stretch too much.

Sprains · Strains
The spine includes vertebrae (bones), discs (cartilaginous pads or shock absorbers), the spinal cord and nerve roots (neurological wiring system), and blood vessels (nourishment). Ligaments link bones together, and tendons connect muscles to bones and discs. The ligaments, muscles, and tendons work together to handle the external forces the spine encounters during movement, such as bending forward and lifting.

Sprains and strains are similar disorders affecting different soft tissues in the spine. Sprains are limited to ligaments whereas strains affect muscles, tendons, or muscle-tendon combinations.

Ligaments are strong flexible bands of fibrous tissue. Although ligaments are resistant to being stretched, they do allow some freedom of movement. Muscle is made up of individual and segmental strands of tissue. When back muscles encounter excessive external force, individual strands can stretch or tear while the rest of the muscle is spared injury.

To illustrate a sprain or strain, consider what happens when lifting something heavy. Initially muscles are recruited to manage the load. When the load or force exceeds the muscles' ability to cope, the force is shared with the ligaments. When a ligament is stressed beyond its strength, it can tear.

Local tissues swell when ligaments, muscles, tendons, or combination's become overstretched, overused, or torn. Swelling causes pain, tenderness, and stiffness; swelling serves to protect the injured back by restricting movement - similar to a splint on a broken leg.

Back pain also known "dorsalgia"

Back pain (also known "dorsalgia") is pain felt in the back that usually originates from the ,muscles, nerves, bones, joints or other structures in the spine.

The pain can often be divided into neck pain, upper back pain, lower back pain or tailbone pain. It may have a sudden onset or can be a chronic pain; it can be constant or intermittent, stay in one place or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck (and might radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.

Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year.

The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.

Back pain can be divided anatomically:neck pain, upper back pain, lower back pain or tailbone pain.

Associated conditions

Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause:

• Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs.
• Severe back pain (such as pain that is bad enough to interrupt sleep) that occurs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition.
• Back pain that occurs after a trauma, such as a car accident or fall may indicate a bone fracture or other injury.
• Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention.
• Back pain in individuals with a history of cancer (especially cancers known to spread to the spine like breast, lung and prostate cancer) should be evaluated to rule out metastatic disease of the spine.

Back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months.

A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease may not be more prevalent among those in pain than among the general population, and that the mechanisms by which these conditions might cause pain are not known. Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.

A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.

Treatment

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of back pain patients (most estimates are 1% - 10%) require surgery.

Short-term relief

• Heat therapy is useful for back spasms or other conditions. A meta-analysis of studies by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain. Some patients find that moist heat works best (e.g. a hot bath or whirlpool) or continuous low-level heat (e.g. a heat wrap that stays warm for 4 to 6 hours). Cold compression therapy (e.g. ice or cold pack application) may be effective at relieving back pain in some cases.

• Use of medications, such as muscle relaxants, opioids, non-steroidal anti inflammatory drugs (NSAIDs/NSAIAs) or paracetamol (acetaminophen). A meta-analysis of randomize controlled trials by the Cochrane Collaboration found that injection therapy, usually with corticosteroids, does not appear to help regardless of whether the injection is facet joint, epidural or a local injection. Accordingly, a study of intramuscular corticosteroids found no benefit.

• Massage therapy, especially from an experienced therapist, can provide short term relief. Acupressure or pressure point massage may be more beneficial than classic (Swedish) massage.

Conservative treatments

• Exercise can be an effective approach to reducing pain, but should be done under supervision of a licensed health professional. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, one study found that exercise is also effective for chronic back pain, but not for acute pain. Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.

• Physical therapy consisting of manipulation and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine), often learned with the help of a health professional, such as a physical therapist. Physical therapy may be especially effective when part of a 'work hardening' program, or 'back school'.

• A British edical journa trial found that the The Alexander techniques was shown in to have long term benefits for patients with chronic back pain.. A subsequent review concluded that 'a series of six lessons in Alexander technique combined with an exercise prescription seems the most effective and cost effective option for the treatment of back pain in primary care'.

• Manipulation, as provided by an appropriately trained and qualified chiropractor, osteopath, physical therapist, or a psychiatrist. Studies of the effect of manipulation suggest that this approach has a benefit similar to other therapies and superior to placebo.

• Acupuncture has some proven benefit for back pain; however, a recent randomized controlled trials suggested insignificant difference between real and sham acupuncture

• Education, and attitude adjustment to focus on psychological or emotional causes -respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.

Surgery

Surgery may sometimes be appropriate for patients with:

• Lumbar disc herniation or Disgenerative disc disease
  
• Spinal stenosis from Lumbar disc herniation, degenerative joint disease, or spondilolisthesis
  
• Scoliosis
  
• Compression fracture
  

Emerging treatments

• Vertebroplasty involves the percutaneous injection of surgical cement into vertebral bodies that have collapsed due to compression fractures. This new procedure is far less invasive than surgery, but may be complicated by the entry of cement into Batson's plexus with subsequent spread to the lungs or into the spinal canal. Ideally this procedure can result in rapid pain relief.
• The use of specific biologic inhibitors of the inflammatory cytokine tumor necrosis factor-alpha may result in rapid relief of disc-related back pain.

Treatments with uncertain or doubtful benefit

• Injections, such as epidural steroid injections and facet joint injections, may be effective when the cause of the pain is accurately localized to particular sites. The benefit of prolotherapy has not been well-documented.

• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain"

• Bed rest is rarely recommended as it can exacerbate symptoms, and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.

• Electrotherapy, such as a transcutaneous electrical nerve stimulation (TENS) has been proposed. Two randomized controlled trials found conflicting results. This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS. In addition, spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain.

• Inversion therapy is useful for temporary back relief due to the traction method or spreading of the back vertebres through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang ( 90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.
  

• Body Awareness Therapy such as the Feldenkrais Method has been studied in relation to Fibromyalgia and chronic pain and studies have indicated positive effects. Organized exercise programs using these therapies have been developed.

• Ultrasound has been shown not to be beneficial and has fallen out of favor.

Low-Carb Fruit: Lists of the Best and Worst

Fruit is an area where some of the low-carb diets part company, as some depend more upon glycemic index or glycemic load (South Beach, Zone), while others just look at total carbs (Atkins, Protein Powder). Also, some diets (Atkins, South Beach) don�t allow fruit at all in the first phase. In general, your best bet fruits are the ones near the top of this list, but do check carb counts. These are roughly arranged by sugar content - where the information is available, based on a half-cup serving of fruit.

Good news: the fruits lowest in sugar are some of the highest in nutritional value, including antioxidants and other phytonutrients.

If you are considering using organic vegetables, check out this list of which fruits and vegetables have the most and least pesticides to help you guide your choices.

Fruits Lowest in Sugar

• Small Amounts of Lemon or Lime
  
  
• Rhubarb
  
  
• Raspberries
  
  
• Blackberries
  
  
• Cranberries
  
  

Fruits Low to Medium in Sugar

• Strawberries
  
  
• Casaba Melon
  
  
• Papaya
  
  
• Watermelon
  
  
• Peaches
  
  
• Nectarines
  
  
• Blueberries
  
  
• Cantaloupes
  
  
• Honeydew Melons
  
  
• Apples
  
  
• Guaves - Pineapple Guavas (Feijoa) and Strawberry Guavas are probably similar, but information that directly compares them is not available
  
  
• Apricots
  
  
• Grapefruit
  
  

Fruits Fairly High in Sugar

• Plums
  
  
• Oranges
  
  
• Kiwifruit
  
  
• Pears
  
  
• Pineapple
  
  

Fruits Very High in Sugar

• Tangerines
  
  
• Cherries
  
  
• Grapes
  
  
• Pomegranates
  
  
• Mangos
  
  
• Figs
  
  
• Bananas
  
  
• Dried Fruit, such as
  
  
  
  • Dates
    
    
  • Raisins
    
    
  • Dried Apricots
    
    
  • Prunes
    

How Much Protein Do You Need?

What is protein?

Protein is one of the basic building blocks of the human body, being about 16 percent of our total body weight. Muscle, hair, skin, and connective tissue are mainly made up of protein. However, protein plays a major role in all of the cells and most of the fluids in our bodies. In addition, many of our bodies' important chemicals -- enzymes, hormones, neurotransmitters, and even our DNA -- are at least partially made up of protein. Although our bodies are good at “recycling” protein, we use up protein constantly, so it is important to continually replace it.

Proteins are made up of smaller units called amino acids. Our bodies cannot manufacture nine amino acids, so it is important to include all these amino acids in our diets. Animal proteins such as meat, eggs, and dairy products have all the amino acids, and many plants have some of them.

How much protein do we need?

Our protein needs depend on our age, size, and activity level. The standard method used by nutritionists to estimate our minimum daily protein requirement is to multiply the body weight in kilograms by .8, or weight in pounds by .37. This is the number of grams of protein that should be the daily minimum. According to this method, a person weighing 150 lbs. should eat 55 grams of protein per day, a 200-pound person should get 74 grams, and a 250-pound person, 92 grams.

Do people who exercise need more protein?

Although it is controversial, there is evidence that people engaging in endurance exercise (such as long distance running) or heavy resistive exercise (such as body building) can benefit from additional protein in their diets. One prominent researcher in the field recommends 1.2 to 1.4 grams per kilogram of body weight per day for endurance exercisers and 1.7 to 1.8 grams per kg per day for heavy strength training.

But shouldn’t protein intake be a percentage of total calories?

Quite a few programs and nutritionists quote percentage of calories, usually in the range of 10 percent to 20 percent, as a way to figure out how much protein a person needs to consume daily. This is a rough estimate of a person's minimum protein needs. It works because usually larger and more active people need more calories, so the more calories they need, the more protein they will get.

Where this falls down is when people are eating diets which are lower in calories for any reason, conscious or not. People who are ill or losing weight, for example, do not need less protein just because they are eating fewer calories.

What happens if we don’t eat enough protein?

Unlike fat and glucose, our body has little capacity to store protein. If we were to stop eating protein, our body would start to break down muscle for its needs within a day or so.

Is it OK to eat a lot more protein than the minimum recommendations?

This is the crucial question for people on diets which are higher in protein than usual, as low-carb diets tend to be. In a review of the research, the National Academy of Sciences reported that the only known danger from high protein diets is for individuals with kidney disease. After careful study, they recommend that 10 percent to 35 percent of daily calories come from protein. They point out that increased protein could be helpful in treating obesity. There is also accumulating evidence that extra protein may help prevent osteoporosis.

Extra protein can be broken down into glucose in a process called gluconeogenesis. On low carb diets, this happens continually. One benefit of obtaining glucose from protein is that it is absorbed into the bloodstream very slowly, so it doesn’t cause a rapid blood sugar increase.

What foods have the most protein?

Meat, fish, eggs, dairy products, legumes, and nuts all have substantial amounts of protein.

Migraine

What Makes a Headache a Migraine?

Almost everyone gets headaches. You might feel throbbing in the front of your head during a cold or bout with the flu, for example. Or you might feel pain in your temples or at the back of your head from a tension headache after a busy day. Most regular headaches produce a dull pain around the front, top, and sides of your head, almost like someone stretched a rubber band around it.

A migraine is different. Us doctors define it as a recurrent headache that has additional symptoms. The pain is often throbbing and on one or both sides of the head. People with migraines often feel dizzy or sick to their stomachs. They may be sensitive to light, noise, or smells. Migraines can be disabling, and teens with migraines often need to skip school, sports, work, or other activities until they feel better.

If you have migraines, you are not alone. Experts estimate that up to 10% of teens and young adults in the United States get migraines. Before age 10, an equal number of boys and girls get migraines. But after age 12, during and after puberty, migraines affect girls three times more often than boys.

What Causes a Migraine?

Not all scientists agree about what causes migraines. Many believe that a migraine is caused by narrowing and expanding of the blood vessels in the brain. There are also theories that the level of certain chemicals in the brain may affect the nerve system that regulates pain.

Whatever the cause, experts do agree that different things trigger (set off) migraines in people who have them. For some people, eating certain foods brings on a migraine. Others find that sleeping too long (or too little) provokes a migraine attack.

Some common migraine triggers are:

• stress
• menstruation
  
• skipping meals
• too much caffeine
• certain foods (alcohol, cheese, pizza, chocolate, ice cream, fatty or fried food, lunch meats, hot dogs, yogurt, aspartame, or anything with MSG, a seasoning often used in Asian foods)
• sudden changes in sleep patterns
• changes in hormone levels
• smoking
• weather changes
• travel

Experts believe that the likelihood of getting migraines is inherited. If one of your parents gets migraines, you have a greater chance of having these types of headaches than someone who doesn't have a family history of migraines.

What's a Migraine Attack Like?

Most migraines last from 30 minutes to 6 hours; some can last a couple of days.

Every migraine begins differently. Some people just don't feel right. Light, smell, or sound may bother them or make them feel worse. Sometimes, if they try to continue with their usual routine after the migraine starts, they may become nauseated and vomit. Often the pain begins only on one side of the head. Trying to perform physical activities may worsen the pain.

Some people get auras, a kind of warning that a migraine is on the way. The most common auras include blurred vision and seeing spots, colored balls, jagged lines, or bright or flashing lights or smelling a certain odor. The auras may only be seen in one eye. An aura usually starts about 10 to 30 minutes before the start of a migraine. Some individuals experience a migraine premonition hours to days prior to the actual headache. This is slightly different from auras and may cause cravings for different foods, thirst, irritability, or feelings of intense energy.

Some people with migraines also have muscle weakness, lose their sense of coordination, stumble, or even have trouble talking either just before or while they have a headache.

How Do Doctors Diagnose and Treat Migraines?

Because migraine headaches are different in different people — in some people, for example, they are triggered by hormones; in others, stress and lifestyle influence headaches — how doctors treat someone depends on the type of migraine that person gets.

A doctor may ask someone having migraines to keep a headache diary to help figure out what triggers the headaches. If your doctor has asked you to keep such a diary, the information you record will help the doctor figure out the best treatment. A doctor may also take blood tests or imaging tests, such as a CAT scan or MRI of the brain, to rule out medical problems that might cause a person's migraines.

Part of treatment may involve making certain changes in your lifestyle — like changing your sleep patterns or dietary habits or avoiding certain stress that trigger your migraines. Your doctor may also start you on a pain relief medication or also prescribe medicines that help with nausea and vomiting. Some people need preventive medicines that are taken every day to reduce the number and severity of the migraines.

Some doctors teach a technique called biofeedback to their patients with migraines. This technique helps a person learn to relax and use the brain to gain control over certain body functions (like heart rate and muscle stress) that cause tension and pain. If a migraine begins slowly, many people can use biofeedback to remain calm and stop the attack.

There have also been studies indicating that some alternative methods, such as acupuncture and the use of certain herbs, can help some people. However, it is important to ask your physician about alternative medicines before trying them for yourself. This is especially true of herbal treatments because they can interfere with more traditional methods of treatment.

List of High-Protein Foods and Amount of Protein in Each

Shortcut: An ounce of meat or fish has approximately 7 grams of protein.

Beef

• Hamburger patty, 4 oz – 28 grams protein
• Steak, 6 oz – 42 grams
• Most cuts of beef – 7 grams of protein per ounce

Chicken

• Chicken breast, 3.5 oz - 30 grams protein
• Chicken thigh – 10 grams (for average size)
• Drumstick – 11 grams
• Wing – 6 grams
• Chicken meat, cooked, 4 oz – 35 grams

Fish

• Most fish fillets or steaks are about 22 grams of protein for 3 ½ oz (100 grams) of cooked fish, or 6 grams per ounce
• Tuna, 6 oz can - 40 grams of protein

Pork

• Pork chop, average - 22 grams protein
• Pork loin or tenderloin, 4 oz – 29 grams
• Ham, 3 oz serving – 19 grams
• Ground pork, 1 oz raw – 5 grams; 3 oz cooked – 22 grams
• Bacon, 1 slice – 3 grams
• Canadian-style bacon (back bacon), slice – 5 – 6 grams

Eggs and Dairy

• Egg, large - 6 grams protein
• Milk, 1 cup - 8 grams
• Cottage cheese, ½ cup - 15 grams
• Yogurt, 1 cup – usually 8-12 grams, check label
• Soft cheeses (Mozzarella, Brie, Camembert) – 6 grams per oz
• Medium cheeses (Cheddar, Swiss) – 7 or 8 grams per oz
• Hard cheeses (Parmesan) – 10 grams per oz

Beans (including soy)

• Tofu, ½ cup 20 grams protein
• Tofu, 1 oz, 2.3 grams
• Soy milk, 1 cup - 6 -10 grams
• Most beans (black, pinto, lentils, etc) about 7-10 grams protein per half cup of cooked beans
• Soy beans, ½ cup cooked – 14 grams protein
• Split peas, ½ cup cooked – 8 grams

Nuts and Seeds

• Peanut butter, 2 Tablespoons - 8 grams protein
• Almonds, ¼ cup – 8 grams
• Peanuts, ¼ cup – 9 grams
• Cashews, ¼ cup – 5 grams
• Pecans, ¼ cup – 2.5 grams
• Sunflower seeds, ¼ cup – 6 grams
• Pumpkin seeds, ¼ cup – 19 grams
• Flax seeds – ¼ cup – 8 grams

What is Cord Blood Banking?

Are you pregnant? Is someone you love? If so, then check this out: Your little one could be able to save somebody's life merely by being born.

When you are in labor, you have three options in regards to what to do with the placenta and umbilical cord blood. You will be able to either trash it (what regularly takes place, a loss), store it for possible use by your baby or a family member, or donate it in public storage that it might be provided to research.

Cord blood contains blood forming, hematopoietic cells. Each year tens of thousands of patients become diagnosed with life threatening medical problems that may be treated by rebuilding the patient's hematopoietic system with working, blood creating cells. Umbilical cord blood is presently being studied as a potential source for blood cells.

Giving cord blood is safe. The cord blood is collected from the umbilical cord after your little one is born. Donation doesn't change the normal birth process. Donating cord blood is free to you and confidential.

To find out more regarding cord blood donation the NMDP has plenty of info including Frequently asked questions, guidelines, participating cord blood banks, hospitals and more.

Certain expectant families may be considering storing for private utilization. Some websites will have a quiz that can let you make the choice between private and public storage.

Think about it. Regardless of your decision, remember that there are multiple ways in which you can donate life.

UK Cord Blood Trends

In Britain, over ninety couples have forked out 1,500 pounds just to have their child's umbilical cord blood stored, as it preserves the coveted (cell producing) stem cells that may one day be used in order to cure a range of medical circumstances.

As of today, cord blood has simply been used as a way to assist in curing conditions such as leukaemia along with other blood diseases that would otherwise need "ordinary" stem cell transplants from bone marrow. But researchers will be looking into the deployment of cord blood in stem cell treatments for a range of other diseases.

A few sicknesses that may one day be treated with stem cells are Alzheimer's disease, spinal cord injury, diabetes, arthritis, stroke, heart disease, cancers, and Parkinson's disease. There are various cord blood banks located in the United Kingdom, one in London, Liverpool, Wirral, and Cardiff. However, any cord blood donated to public sector banks is on a similar basis as blood donation and won't be insured for consumption by the family involved.

Curious families therefore have to pay for personalized storing, unless of course the cord blood is expected to be used in a medical treatment for an ill family member. But the personalized service is not cheap. The program usually costs around 1,000 pounds for 21 years worth of storage - a worth which several scientists continue to say is not worth the price.

It is accurate to note however, that to individuals who have moral issues with the most common method of stem cell transfer (fetal extraction), cord blood continues to grow as the only viable alternative to acquire both the perks of cell regrowth, and life protection.

Hypertension

HYPERTENSION = HIGH BLOOD PRESSURE


Blood pressure (BP) as measured by a blood pressure cuff is an estimate of the blood pressure in the large blood vessels in your chest. It is a combination of the force generated by the pumping action of the heart and the resistance provided by the stretch on the blood vessels. In general terms, the more resistance to stretch of these vessels (the stiffer they are) the higher the pressure. Studies have shown that the lower the blood pressure the better but the benefits are less pronounced below 130/80* so that becomes the maximum blood pressure target. Above this number the chance of heart attack and stroke rises steeply. Blood pressure varies from minute to minute and can vary by 50-80 mm with stress or activity. Our goal is to sense what your average blood pressure is and react accordingly.

Who gets HBP? In this country almost everyone! >60% of Americans will have blood pressure >120/80. More than 90% of people over 50 will develop HBP. The usual culprits of stress, lack of exercise, overweight & excess salt account for much of the epidemic but there are some family trends. Offspring of parents with HBP tend to get higher blood pressure earlier in life, occasionally in their teens and twenties.

Why worry? Since, with rare exception having HBP doesn’t make you feel any differently it is sometimes difficult to see the rationale for worrying about a few mm difference in readings. Numerous studies however show a dramatic rise in the incidence of heart attack and stroke with rising blood pressure. In addition HBP is the 2nd leading cause of congestive heart failure and the leading cause of kidney failure. It has also recently been implicated in macular degeneration. HBP damages blood vessels throughout the body on a daily basis and even mild forms need treatment. Fortunately, appropriate therapy reverses most of these risks.

HBP can be prevented and blood pressure significantly reduced by proper diet, including salt restriction, increased fruit and exercise*. Even when HBP is recognized, instituting these changes can be as effective as the most powerful drugs. However once HBP is established, it often requires drug therapy. Fortunately there are now more than 90 drugs approved for treatment and usually drugs can be found that have few or no long term side effects. Often patients eventually require 2 or 3 drug combination therapy for adequate control.

Special Cases: “White Coat Hypertension” in some people even mild stress can raise BP tremendously. Going to the doctors office, getting stuck in traffic or snarling with your boss can cause these changes in moments. It often takes minutes to hours to settle down. Usually stress reduction techniques are more effective than drugs to control these surges.
Renovascular Hypertension. Can be caused by kidney disease or disease of blood vessels leading to the kidney. This can frequently be surgically corrected.
Endocrine (hormonal) related hypertension of several different kinds can lead to intermittent and severe hypertension, especially in young and middle aged individuals. This may require specialized testing to uncover and specific treatment.

*Why report 2 numbers? The blood pressure rises to a maximum during each heartbeat as blood is forced into the arteries by the action of the heart. This is the higher number, the Systolic blood pressure (“systolic” means contraction, as in when the heart contracts. In general terms, the Systolic BP reflects how hard the heart has to squeeze each beat to force the blood along. Between beats, the pressure doesn’t fall to zero but somewhere in between zero and the systolic pressure. This number, the Diastolic BP (diastolic means expansion which the heart does between beats as it fills with blood in preparation for the next ‘systole’) is a reflection of how stiff the blood vessels are. It is reduced with exercise as blood vessels dilate and it rises with age and cholesterol deposition as blood vessels stiffen. It can be thought of as a reflection of the overall ‘health’ of the blood vessels.

High Cholesterol

HIGH CHOLESTEROL


Medically speaking: “Dyslipidemia”, literally abnormal forms and quantities of several kinds of fatty molecules that can be found in your blood stream. The usual determinants include: HDL, LDL and Triglycerides*. But there are actually several more that can be measured, and have clinical significance including, VLDL and VLDL ‘remnants’.

These fats have varying capability of entering the wall of the blood vessels and forming deposits that can eventually become blockages that lead to heart attacks, strokes and vascular disease. Although there is a strong genetic component to these values, they can be heavily influenced by diet and exercise. By example, more than 80% of Americans over age 50 have unhealthy levels of these fats compared to 10% of Japanese with most of the difference accounted for by diet.

Fats enter your system via diet and are converted by your liver into the variety of forms mentioned. Genetic differences account for differences in the rates of absorption from the gut and rates of conversion. Diet and medication can affect both of these processes and picking the right treatment is critical to the outcome. Traditional determinations of these values can miss certain subtle abnormalities, which can lead to under or over treatment. Complete lipid profiles by NMR (Nuclear Magnetic Resonance) can address these shortcomings and lead to more precise treatment. In certain patients, NMR is critical to the correct diagnosis.

Dietary changes and exercise can be as effective as many of the more than 10 drugs available. These changes are more related to the kind of foods eaten than the quantity. Reductions in certain types of fats and carbohydrates can be more effective than caloric restriction. Additionally, dietary supplements such as niacin, fish oil and red yeast can be useful in reducing risk. Occasionally, there needs to be several attempts to get the right combination of therapy that is both well tolerated and effective. Our lipid clinic staff has more than 8 years experience with these measurements and treatments.


*Since blood is mostly water, cholesterol, a long chain fatty alcohol found only in animal products doesn’t mix well and has to be attached to a protein molecule that is miscible (dissolved) in water. The resultant combination is called a Lipo-Protein. The size of the protein molecule determines the density of the combined structure. Large protein molecules result in HIGH Density Lipoproteins (HDL) whereas smaller proteins result in LOW Density Lipoprotein (LDL). Triglycerides are a combination of three fatty acids and represent most of the fats found in plants and animals (the white streaks in the meat). The vast majority of ingested fats are in the form of triglycerides. Your liver converts ingested cholesterol and triglycerides into the various lipoproteins.

HDL is beneficial and acts as a transport mechanism to take cholesterol back from the blood vessel walls to the liver. LDL in its oxidized form tends to deposit in arteries. Either having a LOW HDL or HIGH LDL is likely to cause arterial blockages. Having a low HDL is actually the most common abnormality in patients with vascular disease and puts you at significant risk even if your total cholesterol is in the recommended range.

Abdominal Aortic Aneurysm

Abdominal Aneurysm is a ballooning out of the walls of the aorta, The main blood vessel going from your heart to your abdominal organs and legs and carrying about 80% of all blood flow, the aorta has significant pressure inside it, your blood pressure or 120-150mm of mercury or about 3 or 4 psi, similar to a partially deflated bicycle tire. Even this relatively low pressure by tire standards can, over time, cause ballooning of the walls of the aorta. Just like the bubble you can get on your tire after you hit the sharp granite curbing, weakening of the aorta can occur due to cholesterol deposits in the aortic walls. The combination of the high pressure and weak walls can lead to ballooning and eventual rupture of the aorta. This process takes many years to go from a normal aorta of about 1 inch in diameter to one that is ready to burst at around 2 1/2 to 3 inches. If it blows, you are unlikely to survive due to massive internal bleeding and death within minutes. The trick is to identify early enlargement and act responsibly.
Who is at risk for this? Men (more than women), over 55 years, overweight, smoker or prior smoker with high blood pressure is the highest risk group. Although AAA can be felt with a thorough physical exam, it is notoriously hard to feel a 3 inch bubble under a layer of fat in overweight people. Furthermore, there are rarely symptoms even from large aneurysms although when they are ready to burst, there may be a few days of mid back pain. AAA runs in families with significantly increased incidence in people who have close relatives with aneurysms. Fortunately, ultrasound screening is virtually 100% effective at making a diagnosis and is used to follow small aneurysms to be sure they are not growing dangerously large. See our website for ultrasound availability.

AAA treatment
If you are diagnosed with an aortic aneurysm you should most importantly follow it closely to see if it is enlarging. If the aneurysm is small, less than 1 1/4 inches or about 3 cm it can be followed annually because it is unlikely to grow quickly. It may remain like this for years especially if the underlying problems of high cholesterol and high blood pressure are controlled and smoking ceases. Once the aneurysm gets bigger than 4 cm or about 1 3/4 inches it is increasingly likely to grow more quickly and steadily and should be followed more frequently. Generally repair is considered when the aneurysm reaches about 2 inches or 5 cm. By then the wall is stretched so thin that rupture becomes unpredictable.
Repair can be the tried and true way, to open the abdomen and wrap a Dacron mesh, that looks like fiberglass matting around the aneurysm after cutting it open and removing the weakest segment. This is a big operation with a significant risk of death or disability (1-8% death rate depending on the health of the patient) but is pretty much a permanent fix. The newer alternative is to place a ‘stent-graft’ inside the blood vessel by threading it up into the aneurysm through a blood vessel in the groin. A ‘stent graft’ looks like a slinky with a cloth (again, Dacron) covering. It can be stretched so it is thin enough to go through the smaller groin artery then unfolded in the aorta and attached to the inside of the aorta at the top and bottom. It is a procedure that takes a few hours and people can be out of the hospital the next day. It may be the only way to fix the aorta for those in too sick to undergo the very stressful open procedure. The downsides are that there is a small chance of failure to seal off the aorta at the top and bottom initially and subsequent leaks can occur as the aorta itself continues to weaken over time so close followup indefinitely is needed. All this means you will become very friendly with your vascular surgeon so choose wisely.

I am a Cardiologist Especially interested in treating patients with Heart failure .

Your Heart Pumps about 70 times per minute and 160000 times per day . Imagine IF IT WERE TO STOP! NO IT HAS TO PUMP ON FOR LIFE TO GO ON . ;-)

What this means is basically THE HEART IS A PUMP. When this pump fails due to many reasons it enlarges, the heart muscle becomes flabby , and the Internal pressure rises.
Since the Left side of the Heart is connected to the Lungs - This high pressure Distends the Lung blood vessels making it difficult to breathe.

Picture this like a Flooded Room - after a certain stage it floods the adjoining rooms.

HEART FAILURE CAN BE SILENT : Doctors Diagnose this by tests like Chest X-ray, Doppler Echo cardiogram and Radionuclide scans

What do we do to reverse this >?

Traditionally Doctors Pump Intravenous injections to Drive the fluid out- Out through the Urine and We also give a Few drug injections using Pumps. But nothing seems to work on the long term

All these options are TEMPORARY . The patient remains weak , loses weight Or Becomes
" puffy" due to fluid swelling under the skin and is in grave DANGER !

CAN WE DO ANYTHING RADICALLY DIFFERENT ? WOULD YOU LIKE TO OFFER SOMETHING MORE PERMANENT FOR YOUR NEAR AND DEAR ONES

NEW TREATMENT OPTIONS:

1.ARTIFICIAL HEARTS : We use devices like TANDEM HEART or HEART MATE in case of long standing Heart Failure. These are Artificial Mechanical support devices which take over function of the Heart. In Sudden heart failure we use what we called ECMO (extracorporeal membrane oxygenation).

2. STEM CELLS THERAPY " A new evolving mode of therapy which involves separating Stem cells from Bone marrow and injecting on to the Heart Muscle or into the Cardiac arteries.

3. HEART TRANSPLANT : Established option - but NOBODY ALIVE IS READY TO DONATE HIS/HER HEART ! We need to find Brain dead patients to donate their Hearts - Quite a difficult task!

Endoscopic Vein Harvesting

Endoscopic Vein Harvesting

Also called: EVH, Minimally Invasive Vein Harvesting

Summary

During coronary artery bypass graft surgery, a surgeon takes a segment of a healthy blood vessel (an artery or vein) from another part of the body and uses it to create a detour or bypass around the blocked portion of the coronary artery. That process is called vein harvesting. Traditionally, vein harvesting is accomplished through a lengthy surgical incision in the leg. However, a less invasive method called endoscopic vein harvesting (EVH) is becoming more common and is the preferred method of vein harvesting among centers that are properly equipped. Traditional vein harvesting requires an incision to remove the blood vessel being used for the bypass graft, leaving the patient with a long scar. By contrast, EVH requires one to three small incisions, each less than 1 inch in length. A special video camera (called an endoscope) is then used to allow the physician to clearly view the vein harvesting. In addition to avoiding a scar, patients undergoing EVH are also less likely to experience complications and usually have shorter recovery times. Because of these advantages, more bypass procedures are being performed using endoscopic vein harvesting. Most people who require a bypass operation are candidates for EVH.

About endoscopic vein harvesting

Endoscopic vein harvesting (EVH) is a minimally invasive procedure performed to extract the saphenous vein from the leg – a blood vessel commonly chosen for a bypass graft. The procedure is part of conorary artery bypass graft (CABG) surgery, which is performed to bypass one or more blocked coronary arteries and restore oxygen-rich blood flow to the heart. In CABG, a segment of blood vessel is harvested (taken from another part of the body) and used to create a detour around the blocked artery. The most commonly used conduits include an artery from behind the sternum (the internal mammary artery) and a vein from the leg (the saphenous vein, which runs along the inner leg from the groin to the ankle). Traditional harvesting of the saphenous vein requires a long incision down the entire leg to remove the blood vessel. This leaves patients with a scar that runs the full length of their leg. By contrast, endoscopic vein harvesting eliminates the need for such a large incision. With this less invasive technique, the surgeon removes the vein through one to three small incisions, each less than 1 inch in length, with the aid of a special video camera, or endoscope. The endoscope is a thin instrument with a tiny camera at the end that allows the surgeon to clearly view the removal of the segment of saphenous vein. Once the vein is removed, the incision(s) are closed. After surgery, other veins take over for the missing saphenous vein to maintain the health of the leg. The advantages of endoscopic vein harvesting go beyond avoiding a long leg scar. Patients undergoing EVH are also less likely to experience events that can prolong hospital stay or require re-admission for another surgery (e.g., wound complications, swelling, leg pain, infection). This is particularly true for patients at greater risk for leg wound complications, such as those with obesity, diabetes or peripheral vascular disease. Patients can therefore have a shorter recovery time and be back on their feet sooner than with traditional vein harvesting. Because of these advantages, more CABG procedures are being performed using endoscopic saphenous vein harvesting. Most people who require a bypass operation are candidates for EVH. Those who may not be candidates for EVH include patients who have pre-existing conditions (e.g., varicose veins, thrombophlebitis, peripheral venous disorders) or are too thin. In some cases, the surgeon may begin an EVH and then need to switch to traditional vein harvesting in mid-procedure.

EVH and alternative forms of bypass surgery

Besides traditional conorary artery bypass graft (CABG) surgery, there is a newer type of bypass surgery called off-pump bypass, or beating heart bypass surgery. Off-pump bypass allows the surgeon to sew the bypass graft into place without stopping the heart or using a heart-lung machine, both of which are required for traditional bypass. With “beating heart” revascularization, the movement of the heart is minimized using heart stabilizers and positioners. These devices keep the targeted regions of the heart virtually motionless while the physician performs the bypass. This off-pump method eliminates any risk of complications from use of the heart-lung machine (e.g., stroke, memory problems after surgery, or postpump syndrome). However, because most off-pump operations still use the traditional incision in the middle of the chest, patients may still require a longer recovery period than with less-invasive surgical approaches. Endoscopic vein harvesting (EVH) may also be used with a less-invasive form of conorary artery surgery known as minimally invasive direct coronary artery bypass, or MIDCAB. During a MIDCAB procedure, the physician gains access to the patient’s heart through a smaller incision in the side of the chest. This form of surgery is limited to patients with fewer blockages. It may be performed with or without the heart-lung machine.

Postpump Syndrome

Postpump Syndrome

Also called: Systemic Inflammatory Response Syndrome, Adult Respiratory Distress Syndrome, Acute Lung Injury, ARDS, Pump Syndrome Summary Postpump syndrome (PPS) is a condition that can occur in people who have been supported by a heart-lung machine (cardiopulmonary bypass) during open-heart surgery. PPS is used to describe a variety of complications that may occur in people who have had surgeries to correct cardiac defects. During many open heart surgeries, the lungs and heart must be stopped for surgeons to operate on the heart. While these organs are stopped, a lung-bypass machine takes over for the heart and lungs, maintaining blood flow and delivering oxygen and nutrients to the body. Cardiopulmonary bypass is used in surgeries such as conorary artery bypass graft (CABG) or heart valve surgery. About post pump syndrome Post pump syndrome (PPS) is a condition that can occur in people who have been supported by a heart-lung machine (cardiopulmonary bypass) during open-heart surgery. PPS is used to describe a variety of complications that may occur in people who have had surgeries to correct cardiac defects. During many open heart surgeries, the lungs and heart must be stopped for surgeons to operate on the heart. While these organs are stopped, a lung-bypass machine takes over for the heart and lungs, maintaining blood flow and delivering oxygen and nutrients to the body. Cardiopulmonary bypass is used in surgeries such as conorary artery bypass graft (CABG) or heart valve surgery. A very small percentage of patients (1 to 2 percent by some estimates) experience serious complications after use of the heart-lung machine. These complications may develop in the lungs, kidneys, brain or other areas of the body. In the lungs, postpump syndrome can damage the tiny blood vessels where oxygen exchange takes place. It has also been associated with pulmonary edema and other signs of adult respiratory distress syndrome. In the brain, postpump syndrome is associated with confusion and memory loss in some patients. There are several theories to explain this confusion and memory loss, including the presence of tiny air bubbles (micro-emboli) that are released into the bloodstream during surgery. As the technology behind the heart-lung machine has improved, there is some evidence that the rate of postpump syndrome is declining. Modern heart-lung machines are equipped with sophisticated filters to prevent embolism and advanced bubblers to properly oxygenate the blood. Another theory behind postpump syndrome is concerned with unstable molecules called free radicals. Free radicals are typically produced as byproducts of metabolism. Free radicals do have a beneficial role. For example, they enable some cells to destroy foreign substances. However, in other situations the release of free radicals can cause cell and tissue damage. In postpump syndrome, it is felt that free radicals impair heart function and initiate a widespread inflammatory response. The inflammatory response can also be triggered by anesthetics, or even by the physical trauma of the surgery itself. To address the apparent connection between free radicals and postpump syndrome, certain medications and vitamins have been used. Some physicians think that vitamin E and coenzyme Q10, for example, can help to prevent or reduce the severity of the inflammatory response associated with postpump syndrome. Other studies are testing the safety and effectiveness of certain antibiotics in the treatment of postpump syndrome. Recent advances in technology and techniques have allowed surgeons to perform some types of open-heart surgery without use of the pump. These operations are called off-pump surgeries (or beating-heart surgeries). The surgeon isolates the area of the heart to be worked on using stabilizers and positioners. This type of surgery is most common with CABG. Minimally invasive bypass surgery (MIDCAB) is another type of bypass surgery that can be performed without cardiopulmonary bypass. In this operation, the surgeon operates on the heart through two incisions made in the chest.

Bypass surgery - Off Pump Bypass Surgery

Off Pump Bypass Surgery

Also called: OPCAB, Off Pump Coronary Artery Bypass

Summary

Off-pump coronary artery bypass surgery (OPCAB) is an operation that treats blocked coronary arteries. By dramatically improving the flow of oxygen-rich blood to the heart (a process called revascularization), an off-pump bypass greatly reduces the risk of angina and heart attack. Off-pump bypass involves the same two procedures that are performed during traditional bypass surgery. In the first, the surgeon removes (harvests) one of the patient’s blood vessels – usually the saphenous vein in the leg or the mammary artery. In the second procedure, the surgeon uses the blood vessel to create a detour (bypass graft) around the blockages in the coronary arteries. About off-pump bypass surgery Like conventional bypass surgery, off-pump coronary artery bypass surgery (OPCAB) is an operation that treats patients with blocked coronary arteries. The coronary arteries lie on the surface of the heart and supply the heart muscle with oxygen-rich blood. They may become clogged with deposits of plaque, thus reducing the amount of oxygen-rich blood that can flow to the heart. By dramatically improving the flow of oxygen-rich blood to the heart (a process called revascularization), an off-pump bypass greatly reduces the risk of angina and heart attack. Off-pump bypass involves the same two procedures that are performed during traditional bypass surgery. In the first, the surgeon removes (harvests) one of the patient’s blood vessels – usually either the saphenous vein in the leg or the mammary artery. In the second procedure, the surgeon uses the blood vessel to create a detour (bypass graft) around the blockages in the coronary arteries. However, off-pump bypass differs from traditional bypass surgery because the surgeon is able to operate on the heart while it is still beating, rather than stopping the heart and using the heart-lung machine. Thus, off-pump surgery is sometimes nicknamed “beating heart” surgery. By forgoing use of the heart-lung machine, the risk of complications associated with the machine is avoided. These complications include depression and/or mood swings that are common after use of the heart-lung machine. Other side effects of the machine include possible stroke and memory problems after the surgery (post-pump syndrome). In addition, bleeding is greatly reduced, so patients are less likely to need a blood transfusion. Off-pump surgery may be performed with a traditional chest incision, or by using newer minimally invasive techniques. About 25 percent of the bypass operations performed in the United States are off-pump surgeries using a traditional chest incision. During this procedure, the surgeon makes an incision in the chest, cutting through the breastbone (sternum), after harvesting the vessel for the bypass graft. The two halves of the breastbone are divided (median sternotomy), and a retractor will be used to pull back the two halves of the breastbone to give the surgeon plenty of room to work. The ribs are not divided, thereby reducing discomfort during recovery. The surgeon will then use certain heart stabilizers and positioners to keep the targeted region of the heart virtually motionless while working on a particular coronary artery. The heart maintains its own rhythm throughout the procedure. The next step is to sew the bypass graft into place in the chest. For each blockage, the surgeon will graft one end of the harvested vein to a larger artery (e.g., the aorta) and will sew the other end into place beyond the blockage in the coronary artery. Once this is finished, blood can flow freely through the bypass graft, around the blockage and into the coronary artery, restoring healthy blood flow to the heart muscle. When the surgeon is satisfied that complete blood circulation has been restored to the heart, the surgical site will be carefully closed layer by layer. The sternum will be closed, usually with wire, and the surface incision will be closed with staples or sutures, depending on the surgeon’s preference. The entire surgery takes approximately two to five hours. Recovery from OPCAB is similar to traditional bypass surgery because of the surgical incision. Because off-pump bypass surgery is still a new procedure, studies on the long-term effect of OPCAB are still emerging. It appears that the results of OPCAB are similar to conventional surgery, and it is effective in treating patients with single- or multi-vessel coronary artery disease. OPCAB may also be recommended for patients who cannot tolerate having their heart stopped, including those who are elderly with widespread disease. Patients who may undergo bypass operation should discuss all the possible benefits and disadvantages of each procedure with their physician. Off pump surgery is not suitable for patients who, in addition to the coronary bypass, require surgery to repair/replace their heart valves or to close a defect within the heart.

Bypass Surgery - Coronary Artery Bypass Surgery

Also called: Coronary Bypass Surgery, Heart Bypass Surgery, Coronary Artery Bypass Grafting, CABG, Coronary Artery Bypass

Summary

The conorary artery bypass graft (CABG) is the gold-standard surgical treatment for coronary artery disease (CAD). It is a relatively safe procedure that is performed thousands of times every year for treating CAD. CAD is characterized by the hardening and narrowing (atherosclerosis) of the coronary arteries, which supply oxygen-rich blood to the heart. If left untreated, CAD may lead to a heart attack.

During CABG, a surgeon harvests a segment of a healthy blood vessel (either an artery or vein) from another part of the body and uses it to create a detour or bypass around the blocked portion of the coronary artery. As a result, oxygen-rich blood can flow more freely to nourish the heart muscle. Depending on the number of blocked coronary arteries, a patient may need one, two, three or more bypasses.

For various medical reasons, only about one-tenth of CAD patients even need this type of heart surgery. Those who have the surgery need to stay in the hospital for at least three to five days afterward while recovering. After returning home, further recovery time will be necessary.

The CABG is one of the most commonly performed surgeries in the United States. According to the American Heart Association, more than 467,000 CABGs were performed in 2003. Also increasing is the age at which the procedure can be safely performed, as individuals 80 years of age and older have benefited from CABG. Although there are risks associated with any surgery, the potential life-saving benefits of a CABG usually outweigh the risks.

Conorary artery bypass surgery is often known simply as a “bypass” and is referred to as such in this article. Surgeons also perform other types of bypass surgery to treat diseases in other parts of the body, including peripheral vascular disease.

About coronary bypass

The goal of conorary artery bypass graft surgery (CABG) is not to repair or remove any blocked arteries, but to detour blood around a blockage in a coronary artery and reestablish the flow of oxygen-rich blood to the heart. To create the detour, a segment of a blood vessel is taken from another part of the body. The segment may be taken from one of the following: The saphenous vein from the leg is commonly used. The internal mammary artery from the chest is usually preferred for key artery branches because it tends to remain open longer. Some call it the internal thoracic artery. The radial artery from the arm and sometimes arteries from the stomach (gastroepiploic artery) may also be used as bypass grafts. Depending on which blood vessel is used, one end is either sewn to the aorta or may remain connected to the larger artery where it originated. The other end is attached (grafted) beyond the blockage in the coronary artery. As a result, blood can flow around the blocked area, increasing the supply of oxygen and nutrients to the heart muscle. Bypass surgery may be recommended for individuals with a history of any of the following: Narrowing in several coronary artery branches (common in people with diabetes) Severe narrowing in the left main coronary artery Blockage in the coronary artery or another condition that may not or has not responded to other treatments (e.g., angioplasty) Severe angina Bypass surgery carries some risks, including a less than 5 percent chance of heart damage and a less than 2 percent chance of death. Studies show that women have a slightly higher risk during or immediately after bypass surgery. This may relate to the fact that women who undergo the surgery are generally older and in poorer health, and their smaller body size makes the surgery technically more difficult. However, the overall risks are relatively low when compared to the fact that many of these bypass operations significantly lengthen and improve the quality of the patient’s life. In some cases, the grafted arteries may also become blocked and require a second bypass surgery. Second bypass has slightly higher risks than the initial surgery, because patients are older and other, less optimal blood vessels must be used for the new grafts. However, bypassed arteries can remain functioning for many years, especially when the patient makes diet and exercise adjustments for cardiac health. Therefore, bypass surgery remains a popular choice for physicians treating severe coronary artery disease During coronary bypass surgery For several weeks before bypass surgery, patients who smoke will be advised to stop smoking. Many surgeons also advise their patients to stop taking aspirin to minimize the risks of excessive bleeding during and immediately after surgery. Patients will also be asked not to eat or drink anything after midnight before surgery. Certain medications, especially those that affect blood clotting, may be reduced or stopped. Patients should discuss their medication schedules with their physician. The patient is usually admitted the morning of surgery. A few days before surgery, the patient undergoes a number of tests, which include an x-ray, blood tests, urinalysis and an electrocardiogram (EKG). The patient’s blood is typed and cross–matched with units of donor blood, according to the surgeon’s wishes. Blood transfusions may not be needed. Patients should know, however, that blood banks test blood to screen donor blood for most major diseases, such as hepatitis or AIDS. The patient will be given specific pre-operative medications and is then prepared for surgery. The chest, groin and leg areas are shaved, and a bacteria-killing (bactericidal) solution is applied to the operative site and surrounding area. The patient is then sedated with medication given through an intravenous (I.V.) line in the arm or hand. As soon as the patient is asleep, an anesthetic inhalation gas (general anesthesia) is continuously administered through an endotracheal tube (breathing tube) and constantly monitored by the anesthesiologist. After the patient is asleep, a device called a Swan-Ganz catheter is often inserted through a needle stick into the jugular vein (in the neck) and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter is used to measure heart function, measure the pressures in both the heart and lungs, and to give any necessary medications. The endotracheal tube, which was inserted into the mouth and down the windpipe (trachea), is used to maintain an airway. A urinary catheter is also inserted and connected to a collection bag to measure the patient’s urine output. An incision is then made in the chest, through the breastbone (sternum), and the two halves of the breastbone are divided (median sternotomy). A medical device called a retractor is used to pull back the two halves of the breastbone to give the surgeon plenty of room to work. The ribs are not divided, reducing discomfort during recovery. The functions of the heart, including blood flow and oxygenation, are rerouted through a heart-lung machine. While the machine takes care of the heart’s functions, the heartbeat can be carefully stopped by administering a cardioplegic solution. In total, the heart will remain stopped for about 30 to 90 minutes during the four to five hours (on average) of surgery. Before the heart is stopped, the blood vessel(s) to be used as grafts are removed from their source location. If they are located in the chest, one end of the blood vessel(s) may remain connected to the larger artery it originated from, or it will be sewn to the aorta, depending on which blood vessel is used for the graft. The other end is sewn into place below the blockage in the conorary artery. After the graft(s) are completed, and blood is successfully flowing around the blockage, the heart is restarted and the patient is removed from the heart-lung machine. Finally, when normal blood flow and heartbeat are re-established, the surgical site is carefully closed layer by layer. The sternum is usually closed with wire and the surface incision is closed with staples or sutures, depending on the surgeon’s preference. Although coronary bypass is a relatively safe surgery with an extensive history in patients, researchers are still looking for ways to improve it. For instance, studies are underway to investigate new ways of grafting blood vessels. One method involves a “sewing” device consisting of two sets of hooks. One set holds the graft; the other makes the attachment to the aorta. In the small group of individuals having undergone the procedure, the graft was connected in less than two minutes (versus up to seven minutes with current methods). Researchers also noted a better quality of connection. Moreover, it resulted in less time required on the heart-lung machine. Another technique, still in the animal testing stages, involves connecting grafts with an adhesive. Researchers think that either procedure may someday find use in minimally invasive bypass surgery and may make the heart-lung machine unnecessary in standard coronary bypass surgery. Coronary artery bypass surgery can also be performed in conjunction with other cardiac surgical procedures to treat other conditions that may have occurred at the same time (e.g., stenosis, leakage of cardiac valves). A transesophageal echocardiogram is often required during surgery to detect these abnormalities and document the success of the surgery. After coronary bypass surgery After surgery, the patient is moved to a hospital bed in the cardiac surgical intensive care unit. Heart rate and blood pressure monitoring devices continuously monitor the patient for 12 to 24 hours. Family will be able to visit periodically. Medications that regulate circulation and blood pressure may be administered through the intravenous tube. A breathing tube (endotracheal tube) will remain in place until the physicians are confident that the patient is awake and ready to breathe comfortably without assistance. The patient may feel groggy and disoriented, and sites of incisions – both the chest and the leg, if a segment of blood vessel was taken from the leg – may be sore. Painkillers are given as necessary. Patients usually stay in the hospital at least three to five days and sometimes longer. During this time, tests will be conducted to assess and monitor the patient’s condition. After release from the hospital, the patient may experience side effects, such as: Loss of appetite Swelling in the area from which the segment of blood vessel was removed Difficulty sleeping Constipation Mood swings and feelings of depression Muscle pain or tightness in the shoulders and upper back Mild disorientation Some temporary memory loss Poor concentration Fatigue Many of these side effects usually disappear over the course of four to six weeks, although a full recovery may take a few months or more. When the patient is ready, he or she may be enrolled in a physician-supervised program of cardiac rehabilitation. This program teaches stress management techniques and other important lessons (e.g., about diet and exercise) and helps people to rebuild their strength and confidence. Potential risks with coronary bypass A successful surgery results in a dramatic increase in blood flow to the heart muscle. This increase in blood flow, in turn, reduces the pain, pressure or discomfort (angina) associated with cardiac ischemia. Abnormal heart rhythms (arrhythmias) may develop just after the surgery and may last three to four days, but these abnormal heart rhythms are usually only temporary. In addition, the chest and leg area where incisions were made will likely be slightly sore for at least a few weeks. However, severe pain should be reported to a physician. Complications that may arise from bypass surgery include: Bleeding Difficulty breathing Infection High blood pressure (hypertension) Abnormal heart rhythm (arrhythmia), particularly atrial fibrillation Most of these complications are short-term and are not serious, though advanced age and poor overall health may increase their risk and severity. More serious complications that may arise, usually due to the use of the heart-lung machine, include kidney failure, heart attack, stroke or even death. These risks are higher for older patients, people with diabetes and patients with other major health problems. However, it's also important to note that in recent years, the risk of serious complications due to cardiopulmonary bypass has been dramatically reduced due to improved surgical techniques. In one study, researchers found that the rate of serious complications fell by half in the period from the early 1980s to the mid 1990s. In addition, physicians have a number of tools at their disposal to further reduce the risk of post-operative complications. This includes the use of medications, such as aspirin and beta blockers, and very strict blood sugar control. One area of complication occurs when grafted arteries become blocked over time and a patient needs a second bypass surgery. This procedure presents greater risks for several reasons. The patient is older and their heart disease has usually worsened. The blood vessels used as grafts in the first surgery are not available to use for the second surgery. In addition, there may be adhesion around the original grafts that make the second surgery more difficult. Patients should discuss all additional risks with their physician

Bypass Surgery - Minimally Invasive Bypass Surgery

Minimally Invasive Bypass Surgery

Also called: Beating Heart Surgery, MIDCAB, Limited Access Coronary Artery Surgery, Minimally Invasive Direct Coronary Artery Bypass

Summary

Minimally invasive direct conorary artery bypass (MIDCAB) is a minimally invasive version of the traditional coronary artery bypass graft (CABG). Like CABG, MIDCAB creates a detour for blood to flow around a blocked coronary artery. Unlike conventional CABG surgery, however, the patient’s chest is not fully opened. Instead, the surgeon works through a smaller incision in the side of the chest. MIDCAB surgery may be performed with or without the use of the heart-lung machine.

MIDCAB surgery is used to treat the symptoms of coronary artery disease. By bypassing blockages in diseased coronary arteries, surgeons are able to reestablish blood flow to the heart. This will relieve such symptoms as angina (chest pain, pressure or discomfort) and lower the risk of heart attack or other potentially fatal events.

MIDCAB was developed as a less-invasive approach toward bypass surgery. Because a smaller incision is used, patients recover more quickly, with less trauma and lost time as compared to conventional CABG. Recovery time after MIDCAB is comparable to the recovery time after balloon angioplasty (3 to 7 days) versus the two weeks that are common after conventional CABG. Within two weeks, many MIDCAB patients can return to normal activities.

However, there are a number of drawbacks to MIDCAB. Because the surgeon is working through a smaller incision, the technique is only available for coronary artery disease that occurs in one artery. Multi-vessel disease cannot usually be treated with MIDCAB alone. This shortcoming has been addressed to some extent by the development of hybrid techniques that use MIDCAB surgery in conjunction with balloon angioplasty. In addition, MIDCAB is more technically demanding.

About MIDCAB

MIDCAB (minimally invasive direct conorary artery bypass) surgery was developed as a less-invasive alternative to conventional coronary artery bypass graft (CABG). During a conventional CABG, the surgeon “cracks” the patient’s chest by making an incision through the breastbone and spreading the ribs. This gives the surgeon excellent access to the heart, but it results in a long recovery for the patient. Also, the incision is more prone to infection and other complications. MIDCAB addresses these concerns by using a smaller incision in the side of the chest. Working through this smaller incision, the surgeon is able to sew bypass grafts onto diseased coronary arteries. This technique reestablishes blood flow to the heart with much less trauma to the patient and a reduced risk of infection at the site of the surgical wound. On average, patients who undergo MIDCAB may be released from the hospital within 3 to 7 days and can often return to normal activities within two weeks. By contrast, patients undergoing CABG often spend two weeks in the hospital and several months in recovery. MIDCAB surgery may be performed with or without use of the heart-lung machine. If it is performed with the heart–lung machine, the surgeon stops the heart through use of cardioplegia solution, then uses a special system of clamps and shunts to redirect blood flow around the heart. This may be called port access surgery, after the device that is used to reroute blood flow. This technique gives the surgeon the ability to work on a still, empty heart, which increases the level of control over the operation. If the surgery is performed without the heart-lung machine, the surgeon uses a special system of clamps and stabilizers to hold the heart still while the bypass grafts are sewn into place. MIDCAB is used to treat the symptoms of conorary artery disease, including angina (chest pain and pressure). By reestablishing blood flow to the heart, the risk of heart attack is also reduced. Compared to conventional CABG, MIDCAB has a number of advantages and disadvantages. It offers the following advantages: It is less costly. The risk of serious complications, including infection, can be minimized because of the smaller incision. It does not require the trauma of “cracking the sternum” and opening the entire chest. Because much smaller surgical incisions are used, there is less pain and trauma to the patient. It usually requires a shorter operation, hospital stay and recovery period. There are also some limitations to the MIDCAB: MIDCAB techniques can only be used in a very small subset of patients. To date, MIDCAB has been performed only in either very high-risk patients who could not withstand balloon angioplasty or conventional CABG, or very low-risk patients whose coronary artery disease was limited to the left anterior descending coronary artery (LAD), which lies on the front of the heart. In some cases, MIDCAB can be used on the right coronary artery or for multiple bypasses, but these procedures are far less common. Several studies have noted that MIDCAB may not be as effective over the long term as the standard CABG. Follow-up data revealed that patients who had undergone MIDCAB were more likely to have blockages in their new grafts than patients who had undergone CABG. It must be noted when interpreting this data that MIDCAB requires greater skill of the surgeon, and these studies were done when MIDCAB was still a new technique. Difficulty in accessing the LAD or an inability to use the mammary artery as the graft may disqualify the use of this procedure in some patients. Efforts have been made to address MIDCAB’s main limitation, which is its limited usefulness in patients with multiple vessel disease. In some cases, it has been used successfully in conjunction with a catheter-based procedure such as balloon angioplasty. In this case, disease of the LAD will be corrected with a MIDCAB graft, while blockages in other arteries may be treated with balloon angioplasty and stenting. Results for these hybrid procedures are comparable to classic CABG for multi-vessel disease. Not all surgeons are qualified to perform minimally invasive techniques, which require greater skill and experience. Patients interested in determining their eligibility for these techniques and/or finding a qualified surgeon to perform the surgery may wish to seek a second opinion. Before the MIDCAB procedure Patients should prepare in advance for a hospital stay of about three days. The patient is usually admitted on the scheduled date of the minimally invasive direct conorary artery bypass (MIDCAB). In the hospital, the patient will undergo a pre-operative assessment that includes: Urine and blood tests. These are done to ensure that the patient is in good overall health for undergoing surgery. Blood tests to assess blood clotting (coagulation tests) include an INR or prothrombin time (PT), partial thromboplastin time (PTT), bleeding and clotting times, and a platelet count. Electrocardiogram (EKG). A recording of the heart’s electrical activity as a graph on a moving strip of paper or video monitor. Echocardiogram. This test uses sound waves to visualize the structures and functions of the heart. A moving image of the patient’s beating heart is played on a video screen, where a physician can study and measure the heart’s thickness, size and function. The image also shows the motion pattern and structure of the four heart valves, revealing any potential leakage (regurgitation) or narrowing (stenosis). Chest x-ray. A radiation-based imaging test that offers the physician a picture of the general size, shape, and structure of the heart and lungs. Eight hours before surgery, all patients are placed on NPO (non per os; nothing by mouth) status. That means that they are not permitted to eat, drink or take anything by mouth until after their surgery. Smokers will have been instructed to completely avoid smoking for at least two weeks before their surgery to prevent problems in breathing, reduce secretions and facilitate necessary coughing. Certain medications may need to be reduced or stopped temporarily, so patients should discuss their medication schedules with their cardiologist before surgery. Immediately before surgery, the patient will be given specific pre-operative medications and then “prepped” for surgery. First, the chest area is shaved. Next, the surgical team creates a sterile environment by swabbing the patient’s chest with an antiseptic solution and covering the operative area with sterile surgical drapes. An intravenous (I.V.) line will also be started, usually in the forearm or back of the hand. The patient is then given a sleep-inducing medication through the I.V. line. Once asleep, the patient will continue to breathe a mixture of oxygen and anesthetic gas (general anesthesia) to make sure that he or she remains asleep throughout the entire surgery. During the MIDCAB procedure After the patient is asleep, a device called the Swan-Ganz catheter is often inserted into the jugular vein (in the neck) and threaded to the pulmonary artery (which goes from the heart to the lungs). The catheter can be used to give medication, to measure the oxygen levels in the blood and to measure pressures in the heart. A breathing tube (endotracheal tube) will also be inserted into the mouth and down the windpipe (trachea) to maintain an airway. The surgeon will then make an incision about 4 to 6 inches long on the left side of the chest. Through this incision, the surgeon can identify the mammary artery (also known as the internal thoracic artery), which will be used for the graft. The artery is located and part of it is retrieved for use (harvested). If the surgeon finds the mammary artery to be unusable for this purpose, or if other complications are revealed (e.g., the LAD shows severe calcification), then the surgeon may proceed with a standard bypass surgery from that point. Whether the heart is stopped or not depends on the particular patient and the surgeon. If the heart is stopped, a cardioplegia solution is administered and special incisions (ports) are made to accommodate the port access system. The ports are held open during surgery with 1.5-centimeter (1-inch) tubes that provide a workspace for tools and scopes to access the heart and coronary arteries. A catheter is inserted through the groin and fed through the femoral vein and/or femoral artery to assist with the diversion of the blood flow to the heart-lung machine. During the surgery, the heart is still and empty of blood. This enables the surgeon to reach more of the heart than during a “beating heart” surgery. If the heart is not stopped, specialized clamps and stabilizers are used to hold the heart in place. To prevent ischemia, or lack of blood flow to the heart, a temporary shunt is put in place. Once this has been accomplished, blood flow to the left anterior descending artery (LAD) is temporarily clamped off. The mammary artery is then attached directly to the LAD beyond the blockage. Once the procedure is finished, blood can flow freely through the LAD beyond the blockage, restoring blood flow to the heart muscle. When the surgeon is satisfied that complete blood circulation has been restored to the heart, the chest incisions are closed (sutured). The procedure takes approximately two hours. After the MIDCAB procedure Following the minimally invasive direct coronary artery bypass (MIDCAB), the patient will spend some time in the recovery room, where simple exercises will be performed to restore normal breathing, circulation and movement. Heart and blood flow will be continuously monitored. Within 24 hours, the patient will be transferred to a regular hospital room. Routine medications and additional pain medications may be administered and food will be given as tolerated by the patient. An average hospital stay after a MIDCAB procedure is approximately three days. After discharge, patients are encouraged to engage in light exercise, such as walking. Strenuous exercise is discouraged.