Have Heart

USA is fattest country in the world!!

2011-02-07T07:06:00.000-08:00

New study:USA has highest average BMI meeting definition of over overweight in the world!! No wonder healthcare costs are rising. http://bit.ly/eOitjX

Chocolate and cardiovascular disease

2011-01-16T19:19:00.000-08:00

Study of 19,000 people in Germany shows 7.5 g (1 sml square) of dark chocolate daily decreases blood pressure, risk of heart attack and stroke.

Another study:eating chocolate cut risk of heart failure by a third! More cocoa content (ie dark) is better http://bit.ly/cJ7fT6

HeartMate for Christmas

2010-12-25T05:07:00.000-08:00

Activity

2010-12-18T15:55:00.000-08:00

Since I have been less than effusive in my posting I will add twitter, fb posts here as well.....

Experts warn of epidemic of "worn out" heart valves. http://bbc.in/gL9qgu

Vice President Cheney, Heart Failure and Heart Pumps

2010-07-15T02:35:00.000-07:00

The news is awash with reports that former Vice President Dick Cheney had a "heart pump" implanted last week as treatment for his congestive heart failure. Although the details are not available, multiple reports consistently state that he has had heart problems through out most of his adult life, sustaining his first heart attack at age 37. He is quoted in the recent release as stating the he was "entering a new phase of the disease when I began to experience increasing congestive heart failure" and it is further stated that he had a 'heart pump' implanted.
Congestive heart failure is a condition in which the heart muscle is severely weakened reducing its ability to adequately pump blood. It is a very common condition and affects almost 5 million people in the U.S. Heart failure is the single most common reason people are admitted to the hospital. Some heart failure statistics:
-4,8000,000 people with heart failure in US, 2% of population in their 50's, 5% in their 60's, and 10% of population over 70
-875,000 hospital admissions every year in US for heart failure (2400/day). Number one admitting diagnosis
-400,000 newly diagnosed cases of heart failure annually in US (1100/day)
-55,000 people in US die every year due to heart failure (139/day)
-66% of heart failure patients die within 5 years of their diagnosis (worse then most cancers)
-2 people died of heart failure while you were reading this blog post.
Obviously there is considerable room for improvements in the treatment of this condition. Common symptoms of heart failure are shortness of breath, initially with significant exertion, but as it progresses this occurs with less activity. In it's more severe extent, New York Heart Association classification 3B or 4, these patients cannot walk undertake normal activities of daily living without having to stop due to shortness of breath. Other symptoms include swelling of the legs, waking up at night short of breath, having to sleep with the head elevated to facilitate breathing, having to urinate multiple times at night, palpitations and generalized fatigue.
The most common causes of heart failure include coronary artery disease, heart valve problems, and viral cardiomyopathy. Treatment includes dealing with the underlying etiology, which may totally alleviate the heart failure, and/or medicines. As heart failure progresses, in situations where the underlying cause was not reversible, it becomes harder to treat and the symptoms interfere with normal daily activities.
Heart Pumps
In severe cases of heart failure, when medications are no longer effective, and a patients symptoms progress to the point of interfering with normal activities of daily living, a heart pump or left ventricular assist device may be recommended. These bits of ingenious technology have progressed significantly in recent years. The HeartMate II system is the most advanced system currently approved by the FDA. Although not confirmed, this is the device VP Cheney has been purported to have received.
The HeartMate II is a continuous flow device, with a single moving part, a propeller, of sorts, that spins at around 10,000 rpms to aid in the emptying of the heart and restoring normal circulation. Since this device moves the blood at a constant, consistent rate, rather then the rhythmic squeezing type of pumping, these patients usually do not have a palpable pulse.
The indications for implantation of a left ventricular assist device, or LVAD, are for bridging to transplantation, or destination therapy. Bridge to transplant is just what it sounds like, maintaining adequate circulation and restoring the ability to resume full activities while awaiting availability of an appropriate donor organ. Destination therapy is for patients who are not candidates for transplantation and the LVAD serves as the permanent treatment for heart failure in these patients.
In recent studies, the HeartMate II has proven to be very reliable, with 2 year patient survival at about 90% and overall complication rates significantly lower than previous generation devices. Additionally most patient are able to resume full activities. A number of the early recipients of this device are now over 5 years out from their initial implant.
Considering almost 5 million heart failure patients and only 2500 LVAD implants in the US, there is room for much improvement in the lives of many people with this remarkable new technology. I wish Mr. Cheney, and all patients in similar circumstances, a speedy recovery and best wishes for a bright and fulfilling future.
See http://www.youtube.com/watch?v=2auyZ54x2uA for an interview with a recent HeartMate II recipient.

Barbara Walters and Aortic Stenosis

2010-05-15T06:13:00.000-07:00

Celebrities deserve the same rights to privacy, with respect to their medical conditions, as everyone else. However, when they chose to go public with details about their health, it can raise the public awareness of medical conditions and aid in education. Such was the case this week with Barbara Walters revelation that she has aortic stenosis and was scheduled to undergo valve replacement surgery.
Aortic stenosis affects approximately 6% of the US population or about 3.5 million people. The incidence increases with age. About 2% of 60 year olds, 3% of 70's and 4% of 80 year olds are affected.
The aortic valve is between the left ventricle (main pumping chamber of the heart) and the aorta (the main artery leaving the heart to the rest of the body). Normally it is comprised of 3 very thin leaflets. When the ventricle squeezes, the force of the blood ejecting opens the valve completely allowing the blood to pass into the aorta. The valve then closes so the blood does not leak back into the heart but continues its forward movement. The gradient, or pressure difference across the valve is normally essentially zero.
Aortic stenosis is a condition in which the leaflets of the valve thicken and stiffen. This then reduces their mobility and the heart is now pumping against a partially closed door. As this process continues the stiffness of the valve progresses and the opening shrinks leading to a significant gradient across the valve. About 15% of the population is born with an aortic valve that has 2 leaflets instead of 3. These valves are more prone to developing aortic stenosis, though usually not until later in life. Some however are tight from birth and require surgery in childhood.
A mean gradient of 40 mm of mercury is generally considered significant. With a gradient of 40 across the valve if the blood pressure measured in your arm is 120/ the pressure within the ventricle would then be 160/. If the gradient was 80 a BP of 120/ would mean the intra-cardiac pressure is 200, and so on. This is not a good situation for the heart.
Another measurement of the valve involves estimating the cross sectional area of the opening. Echocardiography is a good way to view this and an area of less than one centimeter is considered severe aortic stenosis.
As you would expect, the heart has to pump harder to push the blood thru this smaller opening. It causes the muscle to strain and thicken. The jet going thru the narrow opening is like putting your finger over the end of an open water hose. The resulting increased blood velocity can cause the aorta to enlarge. Also the straining of the heart to pump against this resistance can lead to chest pain, rhythm problems, fainting spells and heart failure. When fainting spells or heart failure develop from aortic stenosis there is a 50% risk of dying within 3 years.
For patients with symptomatic or severe aortic stenosis surgery to replace the valve is recommended. This is a mechanical problem and there are no medications to reverse it. There is also no good evidence that diet is implicated in its development or treatment.
Surgery to replace the aortic valve is typically performed thru a sternotomy (splitting the breastbone), however in many cases minimally invasive options are available (see previous post). A procedure to implant aortic valves via a needle stick in the groin is currently under investigation in the US.
There are a number of choices of valve type for replacing the aortic valve. Bioprosthetic or tissue valves are the most common choice in the US. These valves are either the aortic valves from pig hearts or are constructed from the pericardium (sac the heart lives in) of cows or horses. These are mounted on a covered stent and are available in a range of sizes. The advantage of tissue valves is that no medication is required following their implantation. The disadvantage is that they wear out. Current generations of valves have improved durability and their longevity is said to be over 90% at 12 years following implant.
The second most common type of valve is a mechanical valve. These are manufactured from pyrolytic carbon and have a bi-leaflet design. They look like a disc split in half that pivots open and closed with the blood flow. The advantage of this type of valve is that it can last virtually indefinitely. The disadvantage is that a blood thinner (warfarin or Coumadin) is required indefinitely.
These two valve types account for the vast majority of valve replacements.
Other options include homograft (cadaver human) valves and autografts. Autografts involve a procedure known as the Ross procedure in which a patients own pulmonary valve is removed and placed in the aortic position, then a homograft in used to replace the pulmonary valve.
How is a decision made as to which type of valve to implant? In the absence of any mitigating factors, age is a reasonable guideline for deciding. It is generally recommended that individuals less than 65 receive mechanical valves and over 65 lean toward tissue valves. This is NOT a hard and fast rule but a guide, and either valve type can be reasonably placed in either population. Obviously if a patient is unwilling or unable to take a blood thinner and have his blood routinely checked, then a mechanical valve is not for him.
Bottom line is that there are many good options. A thorough discussion of options, pros and cons with your surgeon is imperative prior to proceeding with your surgery

Dietary/Nutritional education

2010-02-27T12:43:00.000-08:00

Jamie Oliver gets it. Juvenile obesity and diabetes are on the rise. Most of the "diseases of affluence" start during youth. To make a real lifelong impact, nutritional education must start in school or before. Check out his talk at TED http://www.ted.com/talks/jamie_oliver.html

Forks over Knives

2010-02-22T03:57:00.000-08:00

New film being made about Drs. Campbell and Esselstyn and their research. Trailer looks great, check out the website and view the trailer: http://forksoverknives.com/

Richmond Times Dispatch

2010-02-10T17:53:00.000-08:00

Amazed at number of positive responses to newspaper article today. http://bit.ly/913XmP

Working on setting up seminars, support groups. Many have questions about the study, we have a grant proposal pending on; it will be for those with documented coronary artery disease to measure the impact of diet on the disease. For others, stay tuned working on more options.

The China Study

2009-03-29T17:35:00.000-07:00

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

2009-03-10T05:25:00.000-07:00

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

2009-02-19T18:41:00.001-08:00

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.

Minimally Invasive Heart Surgery

2008-11-23T19:07:00.000-08:00

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

2008-11-08T17:45:00.000-08:00

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

2008-09-23T03:23:00.000-07:00

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)

2008-09-17T19:17:00.000-07:00

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.

Have Heart (havhrt)

2008-09-15T19:14:00.000-07:00

Welcome. In this blog I will try to decipher some of the confusion and controversy in the world of heart care. I will attempt to explain, in layman's terms, what some common conditions are and review some of the available treatments. In addition I will try to pass on some relevant cardiac medical news updates. I will be glad to answer some factual questions but, for obvious reasons, cannot dispense personal medical advice in a forum such as this. In that line, nothing in this blog should be considered as medical advice simply an adjunct to understanding the often confusing world of medical care.

Some times I will give you an insight to the world of my cardiac surgical practice, obviously without compromising any specific patient confidentialities. And from time to time may share some of my other passions, such as photography.