The China Study

     Dr. T. Colin Campbell, Professor of Nutritional Biochemistry at Cornell University lead a study of 65 counties across 24 provinces in rural China.  It involved 6500 adults aged 35-64.  Dietary questionnaires, blood and urine samples were analyzed yielding over 347 data points for interpretation.

     Some key findings:

Fat intake:rural China 14% of total caloric intake vs US >35%

Protein intake: rural China 10% of calories from animal protein, US 70%

Total caloric intake of rural Chinese diet was 20-30% more that in US

     The diet consumed in rural China is plant based nutrition compared with the typical American diet based upon animal protein.

     The study analysis showed a tremendous difference in the incidence of "Diseases of Affluence", specifically cancer, heart disease and diabetes.  These diseases exist in very low rates in rural China compared to the US.  What's more, rural Chinese who emigrated to the US, adopting the local diet then developed these diseases at the same rate as native born Americans.  One finding I found to be particularly amazing involved a 3 county area in China with a population of over 400,000 in which, during the 3 years of the study, not a single person died from a heart attack.  In a comparable sized US region the rate of death from heart attacks is about 80 per year, so 240 over a 3 year period compared to zero.  I find that astounding.

     The effects of these dietary differences were also noted to impact other disease states i.e. kidney stones, osteoporosis, and autoimmune diseases.  The implications are broad.  Adopting a plant based diet can significantly impact the incidence and prevalence of the leading causes of death and disability in the U.S.  It will, however, take a tremendous change in our dietary habits.  

     Reading the China Study, as well as Dr. Esselstyn's Prevent and Reverse Heart Disease, has totally changed my perspective on diet and health.  I am now 2 months into my adoption of these dietary changes and feel great.  Join me, it's not as daunting a task as it first appears.   In fact it is quite simple.  Read the China Study, it is eye opening.

Cholesterol - It's not just bad for your heart

     It is widely publicized that high cholesterol levels are linked to coronary artery disease.  But.... did you know that the single biological factor associated with 'diseases of affluence' (diabetes, coronary artery disease and cancers of the brain, breast, colon, liver, stomach and leukemia) is..... you guessed it......Cholesterol.

     In the China Study,  Dr. T. Colin Campbell found that in rural China, where a plant based diet is followed the incidence of these diseases of affluence was extremely low.  In this region the average total cholesterol was 127! (The average in the US is ~200)

    More on this comprehensive study to come.

Prevent and Reverse Heart Disease

    I have recently finished reading 'Prevent and Reverse Heart Disease' by Dr. Caldwell Esselstyn.  It is more than interesting.  His general message is very powerful.  Western diets based on animal protein lead to significant vascular inflammation and development of plaque (blockages).  Additionally the inflamed lining of these vessels also makes "vulnerable" plaques at higher risk of rupture.  People with a total cholesterol of less than 150 and LDL of less than 80 are at extremely low risk for coronary events.  His study spanning more than 15 years showed solid evidence of stabilization and even reversal of coronary artery disease.  This is remarkable.

    To achieve these results the study patients followed a strict change in diet.  A no fat vegan dietary plan.  "Nothing with a face or a mother" is allowed to be eaten.  This includes no fish, dairy, nuts (except a few walnuts in low risk people), no avocados, no oils, and no soy milk (except non fat).  This may sound spartan at first blush but he goes on to describe many food ideas and the last half of the book contains many recipes and meal plans.  I have been following this diet for the last 2 weeks and have been very pleasantly surprised.  No hunger, no cravings and many options.  It does take more work, both mental and physical, as most prepared foods are off limits.

     Now, as a cardiac surgeon, how is this new information to be integrated into my practice? First, I still believe that patients with tight lesions and unstable symptoms need urgent revascularization to relieve symptoms and ideally avoid muscle damage.  Next, I will be informing my patients about these findings, the potential impact on their long term health and encourage them to read this book and adopt the dietary changes. I am continuing my research in the exciting area.  

    Congratulations to Dr. Esselstyn for an amazing study over a long period, breaking with standard conventions and achieving stunning results.

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Minimally Invasive Heart Surgery

      Most heart surgery is performed via an incision known as a 'median sternotomy'.  This incision splits the breast bone (sternum) longitudinally.  The main advantage is exposure.  The heart is entirely visible and the surgeon can literally get both hands around it.  A disadvantage is that the resulting two long strips of bone must, at the end of the procedure, be wired back together.  Bone is slow to heal and significant upper body activity must be strictly curtailed during the healing time, about 3 months.  This means no heavy lifting, pushing, pulling or reaching.  Therefore, no golf, tennis or swimming.  More importantly no work if your job entails lifting, painting, digging or hauling.  Thus, a manual laborer is out of work for about 3 months.  Now, considering that heart surgery is only done for serious, frequently life threatening, conditions, it is a price that must often be paid for the multiple and significant benefits.  Most patients do very well with this incision and it remains the standard approach today.

      

      But.............what if we could achieve the same life saving, heart improving benefits via an approach that does not require the physical limitations post operatively?  This is the goal of minimally invasive approaches to heart repair.  The same work done on the inside, with, at least, equivalent results and safety, but with a mode of entry and exit that heals faster, with less pain and little to no physical activity restriction.

     

       A variety of approaches to heart surgery can be considered minimally invasive:

Mini sternotomy: this can entail an incision thru just the top or bottom of the breast bone, sometimes with a 'T' off to the right or left.  Advantage: smaller incision, half sternum remains intact.  Disadvantage: still requires bone healing, smaller field of vision.

Mini thoracotomy: an incision into the chest thru the space between two ribs. Advantage:much more rapid healing, minimal or no activity limitation, lower infection risk.  Disadvantage: smaller field of vision, limited access.

Endoscopic or thoracoscopic approach: utilizes small ports, usually 5-8mm incisions between the ribs, thru which a scope and a variety of instruments are passed. Advantage: scope increases field of view and magnification, very small incisions, rapid healing with minimally or no restriction, shorter hospital stay and recovery. Disadvantage: 2D vision, visual motor misalignment as surgeon is looking a scope away from operative field, instruments are long and not suited to very fine work.

Robotically assisted endoscopic approach: adds a powerful computer interface to enable introduction of wristed instruments, 3D vision magnified 10-15x, tremor elimination (tremor is exacerbated by long endoscopic instruments), motion scaling and hand eye alignment is restored compared to traditional endoscopic approach.  A variety of instruments and fine motion control make this amenable to fine reconstructive techniques.  Disadvantage: not available everywhere, longer procedure time.  Advantages: small port incisions, rapid healing, shorter hospital stay, rapid return to full activity, less infection risk.

      Each approach has advantages and disadvantages.  Some lend themselves to specific procedures more than others.  Aortic valve replacement surgery, for example, is not currently approachable via endoscopic or robotic approaches, but in many instances can be well suited for a small thoracotomy incision instead of the standard sternotomy.  Mitral valve repairs, atrial septal defect closure, maze procedures for atrial fibrillation and removal of left atrial myxomas can often be done via an endoscopic or robotic approach.  Some coronary bypass surgeries can be performed robotically or via a small thoracotomy.  The bottom line is, if you are in an elective situation and have the opportunity to do some research before a planned procedure, ask about all of your options.  A minimally invasive approach might be possible which could cut your hospital stay in half and allow you to return to full activity in as little as a week or two.

  

                                

           

   

Atrial Fibrillation

  Atrial fibrillation is the most common sustained heart rhythm disturbance.  During this rhythm the atrial (upper chambers of the heart) are quivering instead of contracting (beating).  Roughly 6 million people are affected by this problem.  Patients with this rhythm have twice the risk of death and 7 times the risk of stroke compared to people in normal sinus rhythm. Since the atria are responsible for about 10% of the heart's output many people notice a significant drop in their energy levels when this occurs.  One key risk of this rhythm is that since the atrial are not beating,  the blood flow thru these chambers can be sluggish allowing clots to form.  These can then be ejected into the circulation causing occlusion of vessels to the brain (with subsequent stroke) or other organs.  Atrial fibrillation can be intermittent or continuous.  

      Initial treatment is aimed at controlling the heart rate (since it can commonly reach 150 or higher) and thinning the blood to avoid clot formation.  In situations where patients are either intolerant of medical therapy, the medicines are not effective or they continue to be symptomatic, invasive treatment to reverse this rhythm may be indicated.

     Dr James Cox developed an operation known as the Cox Maze procedure.  This ingenious operation was carefully designed to form a series of scars in the heart to re-route the electrical signals into a more controlled and regular pattern.  Although quite complex in its original design a modified method has been successful in treating many patients with intermittent atrial fibrillation.  Additionally the full Cox Maze III procedure can now be performed thru minimally invasive approaches for many patients.

New device study

 Starting a new study using an automated anastomotic device, the Cardica C Port Flex A (www.cardica.com), in robotically assisted coronary artery bypass operations. The C Port device produces a precise, consistent, compliant connection between two vessels.  In previous studies it has been shown to have results (graft patency) superior to hand sewn anastomoses.

We have been using these devices in both open coronary bypass procedures (mainly in off pump procedures) and some robotically assisted closed chest coronary bypasses for over a year now with good results (they have already gained FDA approval).  The purpose of the study is to document the results of using this technology in a closed chest setting.  So, although the basic procedure will not change from our current practice the follow up will include a cardiac CT scan at 2 weeks, then again at 9 months to document the result of using this technology.

Angina (Chest pain)

Angina: officially Angina Pectoris, from latin and greek meaning 'squeezing of the chest'.  Chest pain characteristic of ischemia (lack of blood and oxygen) to the heart muscle.  Frequently described as a tightness in the mid chest with radiation to the arm or neck.  The actual symptoms can vary  widely, and in fact many people (especially diabetics) can have 'silent' angina and have ischemia or even a heart attack and just feel 'bad', with no specific chest discomfort.  Angina is most often caused by a narrowing in one or more of the coronary arteries.  These vessels supply the blood to the heart muscle itself.  Prolonged lack of blood and oxygen to an area of heart muscle leads to the death of muscle cells (think permanent irreversible damage) = Heart Attack.

    Angina itself is not a heart attack.  The pain is usually relatively short in duration and with cessation of the inciting activity will subside and adequate perfusion to the involved heart muscle cells return.  Stable angina is characterized by a repeatable set of symptoms, typically chest discomfort that occurs with physical exertion and will be relievable with rest.  It may progress to occurring with less activity and in severe cases may even occur at rest or wake one from sleep.  Symptoms that are progressive are then referred to as "Unstable" angina.  Rest and especially nocturnal angina are most concerning since they frequently are characteristic of severe coronary artery disease.

      The important 'take away' is that any chest pain should not be ignored.  In the case of a heart attack "time is muscle' and the sooner attention is sought and perfusion restored to the heart muscle in jeopardy (via drugs or mechanical treatments) the less permanent damage occurs.