MIDCAB �proximal anastomosis(an enigma)- coronary web mastering a solution

Rajendra Vasaiya, MCh, Vihar Shah,MD, Sunil Vyas,M.sc.PGDPT

BACKGROUND: Distal anastomosis to the coronary arteries may not cause that much problem due to relatively easy accessibility. Method of Exposing aorta and if due to anatomical and hemodynamic limitation aorta can not be expose what other alternatives site are available is explained.


METHOD: once coronary artery is exposed and stabilized distal anastomosis is a relatively easy task. When question of proximal anastomosis arises, through minithoracotomy(from 4th ICS) , where is the aorta? Aorta is no where in the picture. Due to our traditional mind set we look forward to proximal ascending aorta for proximal anastomosis. Technique of exposing proximal ascending aorta is explained. What are the other alternative site and how to carry out proximal anastomosis with alternative site is also explained. A new concept called coronary web mastering along with arterial loop technique is also shown in detailed.

REASULT: with different technique explained above, we have complete and satisfactory proximal anastomosis. Because of not finding suitable site for proximal anastomosis we have never converted our MIDCAB procedure to conventional sternotomy procedure

CONCLUSION: In MIDCAB CABG proximal anastomosis are real challenging compare to distal anastomosis. Over the last 10 yrs we have gradually evolved various alternative site for proximal anastomosis . Though technically challenging these methods are effective for complete triple vessel revascularization through sternal sparing minimally invasive minithoracotomy approach.

Healthy Greens is the sogan which is heard everywhere because we know this green by absobing noxious carbondioxide excreted by all living animals of world and by giving oxygen to breathe, bringing rains,wood,forest,fetilising our soil, conserving soil,forest and human Eco atmoshphere preserve us and our Earth by keeping intact our Glaciers and ozone layers save us from ultra violet radiation of this Universe leaving no hazard of its decomposition like of man made plastic materials.
In this article,we shall like to discuss the importance of a beverage in the form of "TEA" which is most prevalent in our country as well as almost in every part of world where it is consumed by almost every family twice a day or being offered to every guest coming to home/business centre or any other interaction in our day to day personal or social gathering.
Green Tea which is directly plucked as fresh upcoming triplet Leaf from a Tea Bush or plant (First Flush,i.e.,First sesonable tea in month of April May every year from a Plant after a rest of 03-4 months shrugging off its old leaves completely form Hilly tops of darjeeling or Assam Valleys) are very rich source of Many Anti Oxidants which burns fat of our body reduce bad Cholesterol,Open or dilate our blood vessels ,prevent ,Prostate cancer(Prooved by study in Mice from Dr.Chan in USA)Lung cancer reduce recurrence of Breast,Stomach,Colorectal Cancer prevent Strok,Heart Attack and Diabetes Mellitus.This Green Tea leaves like Black tea leaves are not crushed or withered,steamed and fermented and powdered to form Blak tea or Oolong tea but here leaves are dried and preserved for making tea.
For drinking this tea we have to boil one or two or three cups of Water as per our requirement but small preparation is good and then put some Green leaves inside it (or 3/4 tsf or one tsf Green Tea )as per concentration needed and then allowed to get these leaves shocked into this water for few minutes and then we can add sugar or sugar free tablets and lemon inside it (Not MILK AS IT HAS BEEN PROOVED THAT MILK DILUTES THE BENEFICIARY AFFECT OF THIS GREEN TEA OXIDANTS) and allow it to cool for few minutes and then drink it slowly taking few minutes not very hot and not in just few seconds.the Top variety of Tea Garden,More HILLY terrain where water is less logged and stayed but comes and go under cold temperature with high humidity or tea organic where not fertiliser used to produce it are of best variety but their cost some time is very high thousand rupees per kg .Usually Black Tea should be taken twice a day or two cups a day ,it should be used as food supplement not as Drug .It has been prooved that Caffienated Black Tea is more important as it burns our fat and reduce bad cholesterol LDL markedly.
Tea beside containing "Tanins" which are not very useful contain "CATECHINS" OR EGCG(Epigallo catechins 3 gallate ) compond and Antioxidant which is responsible for dilating Blood Vessels,burning Fat (reducing Atherosclerosis,Reducing Cholesterol thus preventing Hear attack,Strok and Prevent cancers ) like other good Anti oxidant substance like red wine,Grapes,Berries,and Dark Chocolate. But out of all these Tea is more consumed in almost every household of our Human world so this should be more included as our foos supplement.

Green tea was first brewed in China, where it was known as a 'miracle medicine'. In her book, Green Tea: The Natural Secret for a Healthier Life, Nadine Taylor states that green tea has been used as a medicine in China for at least 4,000 years.

Today, research shows us how true that ancient claim was. Green tea, with its medicinal properties, is a boon for the health-conscious and a wonder, even to modern science. The benefits of green tea are many as told earlier above but again summarised below:-------------------------
Inhibits Cancer:----------------
The main ingredient in green tea, Epigallocatechingallate (EGCG) inhibits the growth of cancer. The latest good news about green tea comes from a study done at the Karolinska Institute in Stockholm. A team of researchers headed by Dr Yihai Cao found that green tea can block angiogenesis, the development of new blood vessels that tumors need, in order to grow. In an interview, Dr Caoexplained that the polyphenols in green tea prevent angiogenesis, which also explains why green tea is effective in preventing cancer. According to Dr Hasan Mukhtar, professor and research director of Case Western University, Cleveland, studies have shownthat the risk of stomach cancer goes down as consumption of green tea goes up.
Prevents High Blood Pressure and Heart Disease:----

With the chaos of our daily lives, we can do without the added tension of high blood pressure, which can result in heart problems. Scientific studies show that daily consumption of green tea can prevent high blood pressure. 3 to 4 cups of green tea a day, can substantially reduce an individual's risk of heart disease and stroke.
Restricts Buildup of Cholesterol:---------------

We all know that fat and cholesterol are bad for our health. Bur that doesn't stop us from drooling over a sinfully creamy dessert, does it? Now green tea brings along some great news for food freaks. Experiments demonstrate that green tea restricts the excessive buildup of blood cholesteroJ. It reduces the bad cholesterol (LDL) in the blood and increases the levels of positive cholesterol (HDL), thus reducing the chances of heart disease. For years, researchers were puzzled by what they called the 'French Paradox' � the fact that, despite consuming a diet rich in fat, the French had a very low incidence of heart disease. The answer was found to lie in red wine, which contains resveratrol, a polyphenol that limits the negative effects of smoking and fatty diets. In a 1997 study, researchers from the Universiry of Kansas determined that EGCG, strongly present in green tea, is twice as powerful as resveratrol. Which explains why the rate of heart disease among the Japanese, who are regular drinkers of green tea, is quite low, even though approximately 75 % are smokers.
Lowers the Blood Sugar Level:---------------
Let green tea take care of health worries like blood sugar levels. The extract of green tea has the ability to actually lower blood sugar. It is believed that both the EGCG and polysaccharides in green tea are factors in lowering blood sugar.
Strengthens Immune System:------------------
Today, we live life right in the midst of the madding crowd ... with deadlines and schedules that leave no time for ourselves. With its share of ups and downs, our body needs to be strong enough to fight common diseases like the flu and other infections. Green tea helps to strengthen a weak immune system, guarding us from illnesses and infections that take a long time to heal.
Prevents Ageing:========
Oxygen is very important to us, but it can also be a very harmful agent in the form of active or free radical oxygen. One way to slow the ageing process is to prevent the accumulation of active oxygen in our body. This can be done by antioxidants, which are strongly present in green tea.
Oral Hygiene and Dental Care:------------------
Now you can flash that charming smile without worrying about bacteria and bad breath. Fluoride in green tea protects tooth enamel and EGCG reduces the development of bacteria growing in the plaque. Green tea can also kill other oral bacteria, which cause bad breath. It also stimulates the production of saliva and reduces the harmful acids that form in the mouth.
Boon for Dieters:-----------------
Get yourself in shape with a new slimming potion. Yes, green tea can actually help burn fat. In November 1999, the American Journal of Clinical Nutrition published the results of a study at the University of Geneva, in Switzerland. Researchers found that men who were given a green tea extract burned more calories, since green tea helped to excrete more fat.
So Drink To Your Health:--------------------
People who drink green tea daily, have lower rates of heart disease and cancer and a higher life expectancy. Unlike other antioxidants, those found in green tea cause no toxic side effects. Sounds good enough to put the kettle to boil and give green tea a try?Many more good compounds are found in Green Tea but not seen in same quantity and concentration in Black or White Tea (which is powdered or steamed or fermented tea)are found but their direct contribution on organs and tissue Human health system is yet to be discovered .
Dr.D.R.Nakipuria
Ambika Multi speciality Hospital
29 Agrasen road
P.O.Siliguri-734005
Dist:Darjeeling(W.B.)
09434143550,

When Your body Screams No! or you can say when your protective force (Immune System) is unable to protect you became less or no caring for you or
When your immune system turn on itself, there is a war within the body.it means the proteins in the form of B and T Lyphocytes of your body or mixture of Antigen Antibody complex with complement complex becomes allergent to you ,a protein or an organ is no more tolerated by our body or Immune system and it cecomes hyperactive to it itself or on provocation of some external allergens ,it causes Autoimmune Disease and as it mostly involves connective tissue like muscles,joints,Blood vessels etc it is also called as Connective tissue diorder.
As we know this protective Immune system by making either B lymphocytes or Tlymphocytes protects us when ever an acute (Viral fever,Bacterial infection-skin ulcer,pharyngitis, diarrhoea,jaundice)or Chronic infection (TB,Leprosy)invade or attacks us ,they self contain the offending agent either by killing it immediately or converting a protective Antigen Antibody complex making it is totally unharmful for our body.But here this immune sytem which is broken by HIV infections or make less reactive using Immunusupressants like Steroid,Mycopholate,,Tacrolimus,Cycloserine,like medicine in Asthma,Transplant surgery or treating patients with anti cancer drugs which kill Blood cells or lymphocytes the Sanik of our Immune system or Diabetes or any other chronic infection or old age or child age where our Immune system is less reactive leads to somany opputunistic infections to us or our Body cannot control the infections and infections turns into septicaemia leading to more morbidity and mortality.
But in this order this system or its complex antigen antibody becomes injurious to us and produce a variety of diseases,few of them has been enumerated below.Just like a Police officer attacks you instead of protecting you? Or if, instead of getting the bad guys behind bar to protect you, he decides to put you behind bars?
This is exactly what happens when your body's immune system mistakenly turns on your own healthy organs and attacks them, resulting in autoimmune disorders. When the attack is on a single organ system such diseases are called 'organ-specific' autoimmune diseases (e.g., type 1 diabetes), whereas when the attack is more widespread and affects many organs the diseases are termed as 'systemic' autoimmune diseases (e.g. rheumatoid arthritis). Your immune system may also react to a foreign substance that it normally would ignore (akin to a cop arresting an infant) resulting in an immune reaction commonly termed as an 'allergy'. Here are some major autoimmune disorders and how to cope with them.
LUPUS
Diagnosing this disorder can be complicated as Systemic Lupus Erythematosus (SLE) symptoms tend to vary from patient to patient, are unpredictable, and follow an up and down course.
THE DISORDER
Lupus is a chronic inflammatory disease wherein your body's immune system attacks various organs including the joints, skin, kidneys, blood cells, heart and lungs, making it a potentially life-threatening illness. "While lupus is quite rare (affects 1 in 40,000 people), it is a dramatic disease..
WHO�S AT RISK
�Lupus affects young women between 13 and 40 years. "Environmental factors, family history, exposure to oestrogen and smoking, and viral infections are other common risk factors.�
THE SYMPTOMS
These include arthritis, kidney problems, low platelet and WBC counts, psychosis (manic episodes), rashes on face, especially after-sun exposure, mouth sores, and swelling of the lung and heart lining.Rash bilaterl on cheek is diagnostic when localised to this area is also called DLE otherwise SLE when other organs like muscle ,Joints,Lung, Liver, Kidneys and Blood vessels are affected.
RULE IT OUT
This is difficult to diagnose. Doctors will order blood tests to measure your blood cell count, ESR, kidney and liver functions, and the presence of anti-nuclear antibodies (indicative of an autoimmune disease) as well as urine tests to detect increased protein or red blood cells. A false-positive syphilis test may also be indicative of lupus.
HOW TO GET WELL
�About 10 to 15 years ago, the 5-year mortality rates were 80% . But with improved treatment options, 90% of patients survive for 20 years,.Treatment includes immunosuppresants and immunomodulating agents like steroids. "There are many side effects of steroid use, so it is a matter of balancing the side effects of the drug and the disease symptoms,�.
RHEUMATOID ARTHRITIS
Although joint pain and inflammation are the most visible symptoms, this disorder affects every organ in the body; treating it early and aggressively is the best way to tackle the disease.
THE DISORDER
"The name is a misnomer," . Although classified as an autoimmune musculo-skeletal disorder with most visible symptoms like joint pain/inflammation, rheumatoid arthritis (RA) affects every organ in the body. 'We have outstanding medication to treat RA nowadays." low-dose methotrexate (LDMTX) is the 'central anchor drug' for the treatment of RA.
WHO�S AT RISK
Although the cause is unknown, RA is more common in women. Among the confirmed risk factors are gum disease (periodonitis) and smoking.it affects children too and Juvenile Rheumatoid arthritis is a seriuos as adult one.
THE SYMPTOMS
Early diagnosis is very crucial. "Symptoms to watch out for include: joint pain and swelling, long-lasting early morning stiffness, fever, weight loss and fatigue.�
RULE IT OUT
Diagnosis is arrived at after clinical examination of the patients and blood tests to detect
presence of rheumatoid factor and anti-cyclic citrullinated peptide (anti- CCP) antibodies. A negative result for rheumatoid factor is not indicative of lack of the disease as this factor is detectable in only 75 to 80% patients.
HOW TO GET WELL
There has been a �quiet revolution" in treating RA, a. Besides LDMTX, other drugs prescribed may include non- steroidal anti-inflammatory drugs (NSAIDS), steroids, disease modifying anti-rheumatic drugs (DMARDS), and immunosuppresants.
EXPART SPEAK
�An exciting new discovery is that smoking is a trigger for autoimmune genes to become active�
MULTIPLE SCLEROSIS
This condition is characterised by relapses (when new symptoms appear) and remissions (when symptoms improve on their own).
THE DISORDER
Multiple sclerosis (MS) is a disease in which your body's immune system destroys the protective covering on your nerves. This interferes with the communication between your brain and the rest of your body. This ultimately causes irreversible damage to the nerves themselves, which interferes with the functions that are controlled by the nervous system vision, speech, walking etc.
WHO�S AT RISK
�Women are 1.5 to 2 times more likely to get the disease.it manifests itself in younger people between 20 and 30 years of age.�Asian people are less at risk; it typically affects North Europeans." Genetics, infections, and the presence of other autoimmune conditions are also risk factors.
THE SYMPTOMS
These include loss of vision in one eye, weakness/paralysis of legs, arms, head and neck muscles weakness, tremors, fatigue, and difficulty in swallowing or speaking.
RULE IT OUT
The availability of the MRI has revolutionised diagnosis and treatment. "You can spot lesions in the brain very early in the disease" . Other tests include electrical tests that document the velocity of impulses from various parts of the body to the brain and a spinal tap.
HOW TO GET WELL
In many cases, minor symptoms resolve themselves without any treatment. Treatments to control symptoms include immuno-modulating drugs like interferon and glatiramer which slow down the appearance of symptoms and steroids and mitoxantrone to suppress the immune system. However, interferons are very expensive (Rs 25,000 to 30,000 a month) and therefore not accessible to many. Currently, many drugs are in trial and the outlook is optimistic.
TYPE 1 DIABETES
Although most common in children, this form of diabetes (also known as juvenile onset diabetes) is not easily recognised.
THE DISORDER
Type 1 diabetes is a condition where your pancreas produces very little or no insulin, the hormone needed to process sugar to produce energy.
WHO�S AT RISK
Risk factors include family history, genetics, geographical location, exposure to certain viruses, as well as dietary factors like low Vitamin D levels. This disorder is commonly seen in young children (peak age of onset is 12 or 13 years) and in women.
THE SYMPTOMS
�Onset is more dramatic, and if not diagnosed, this condition can potentially be fatal.In a lot of cases, the diagnosis is made when the child presents acute complications. Stay vigilant for symptoms like weight loss, excessive urination, hunger, blurred vision, fatigue, etc.
RULE IT OUT
Diagnosis is primarily done based on patient history and age. Abnormal blood sugar levels show up in a random blood sugar test and a glycated haemoglobin (A1C) test. Specific blood tests to confirm diagnosis include checking for the presence of GAD antibody, islet cell antibody, and insulin auto-antibodies.
HOW TO GET WELL
Life-long treatment with insulin is the only option available currently. Patients are also advised to eat right, exercise, and diligently monitor their blood glucose levels.
THYROIDITIS
This autoimmune disorder is characterised by chronic inflammation of the thyroid gland leading to either hypothyroidism or hyperthyroidism.
THE DISORDER
Thyroiditis is a condition wherein the immune cells attack the thyroid gland causing inflammation. This chronic inflammation leads to thyroid cell damage. Depending on the rapidity of the damage, a patient can develop hypothyroidism or hyperthyroidism.
WHO�S AT RISK
Various factors including heredity, gender (women are more susceptible), age (middleaged women), and viral infections playa role. "There is a 50% concurrence in
identical twins indicating that the trigger is 50% genetic and 50% environmental.
THE SYMPTOMS
Generalised symptoms may include fever, weight loss, puffiness and joint pain. Typical hypothyroidism symptoms include constipation, weight gain, lethargy and dry skin. Typical hyperthyroidism symptoms include cardiac problems, weight loss, diarrhoea and tremors.
RULE IT OUT
Thyroid function tests and blood tests are normally done.
HOW TO GET WELL
Hypothyroidism is treated with synthetic thyroid hormones. Treatment for hyperthyroidism includes drugs to reduce the effect of excessive thyroid hormones. For example, beta blockers may be prescribed to reduce the impact on the heart. Surgery or radiotherapy to destroy the thyroid gland is also an option.
What are allergies?
Allergies are another form of immune system error which occur when your immune system reacts to a foreign substance (allergen) such as pollen, dust, food, or any other allergen that it would otherwise typically ignore. The resulting symptoms can range from minor irritation to a potentially life-threateninq emergency.
Common allergens
� Dust, pollen, mould
� Penicllin-based antibiotics
� Insect bites (bees, wasps)
� Eggs, nuts, dairy products, wheat
RULE IT OUT
� Skin test
� Blood tests
HOW TO GET WELL
Avoid the allergen
Take steroids, antihistamines, decongestants to relieve symptoms
Purified allergen shots
Epinephrine shots in emergencies
CATARACT
HERE LENS PROTEIN OF OUR EYE IN OLD AGE BECOMES REATIVE LEADING TO OPACITY OF lENS LEADING TO LOSS OF NEAR AND DISTANT VISION AND GRADUALLY COMPLETE LOSS OF VISION REQUIRING REMOVAL OF LENS BY CUTTING OR IN PIECEMEAL BY PHACOSURGERYAND PUTTING EXTERNAL GLASSES OR INTRAOCCULAR LENS IMPLANT .
ANKYLOSING ARTHRITIS
Backed with HLAB 27 gene in blood here both Sacroiliac joints gets stiff and rigid and gradually whole spine like a bamboo,affects more male than female ,anti steoid analgesic and physiotherapy is only help.
Psoriatic Arthritis
here a skin infection leading to multiple presentation starting from a bullae to keratineous hypersclrosis with most debilitating incurable skin disease needing stroid and immunosupressants for control with joint and muscleinvolvements need physiotherapy.
Sjogren's syndrome
here all saliva producing glands and lacrimal glands are involved ,patient doesnot have tear or salive in mouth leading to dryness of eye demanding repeated infections and severe xerostomia where digestion of food and deglutation becomes very problematic.
SCLREDEMA
Here mouth and skin of patients becomes thickened as antigen antibody comples settles at subcutaneous tissue leading to a very small stoma of mouth and skins become dry,unstrchable producing ulcers and gradually lung,oesophagus is involved leading to sever respiratory distress and severe dysphagia.
INFLAMMATORY BOWEL DISEASE
here multiple ulcers develops in large colon and lower part of small gut producing severe diarrhoea with pus and mucus in early stage which becomes fatal gradually and can develop internal fistulae or cancer too.
Good pasture Syndrome
here antigen antibody comples settles at nephrons and damaging them leading to renal failure.
therefore these are few Autoimmune Diorders enlisted beside this now a days Antiphospholod Syndrome where Cardiolipin Antibodies appear agains Phoshpholipid of cell wall and produce arteritis,still birth and miscarriage in pregant mother and involves Liver,Kidey,Muscles and joints in adult leading to Heart and lung failure.
More and more research will establish new and new facts more diseases likeAlzehmier and Psychosomatic diseases are also previewd in this category as more research will define Immune system more clearly and its complex agents and factors will be discovered more and more our understanding of Immune system will establish when we shall see that many cancers too will be attributed due to its falacy,so this subject is very vast and this century will establish its more clearly to us and more treatment inform of Gene and Stem cell therapy will come beside good immunosupressants medicines.