- An echocardiogram 6 weeks to 3 months after valve implantation allows assessment of surgery results and serves as a baseline.
- Asymptomatic patients with mechanical valves usually need annual exams unless complications arise.
- Echocardiograms evaluate leaflet motion, pannus/thrombus formation, gradients, and regurgitation to assess prosthetic function.
- Doppler indices like DVI help determine stenosis while features like mobile echoes indicate pannus or thrombus.
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
A heart coping with a dysfunctional prosthetic valveescardio
A heart coping with a dysfunctional prosthetic valve (at least once in every few beats…)
http://www.escardio.org/communities/Working-Groups/valvular/Pages/welcome.aspx
An artificial heart valve is a device implanted into the heart of a patient to replace a dysfunctional native heart valve. The human heart contains four valves: tricuspid valve, pulmonic valve, mitral valve and aortic valve.
The 10 commandments of prosthetic valve - ESC 2014
1. Mechanical heart valve- life-long OA. Antiplatelet medications does not provide adequate protection against thromboembolic risk. The combination of low-dose aspirin and vitamin K antagonists (VKAs) is recommended for all patients with mechanical valve prostheses by the ACC)/AHA & selective aspirin – ACCP/ESC/EACTS .
2. Bioprosthetic - avoid the need for life-long anticoagulation.
3.INR- 2.5 for aortic without additional risk factors for thromboembolism (e.g., Afib, prior thromboembolism, left ventricular dysfunction, and hypercoagulable states). INR range of 3.0 (or 3.5) for mitral and any aortic valve prosthesis associated with thromboembolic risk factors.
4. INR variability - increased mortality . INR variability is dictated by genetic polymorphisms of cytochrome P450 2C9, genotyping of patients treated with VKA is not currently recommended.
5. INR (>6.0) but no severe bleeding, management includes transient withdrawal of the OA and administration of oral vitamin K according to the actual and target INR values. Patients with severe bleeding should be treated with immediate anticoagulant reversal (usually prothrombin concentrates or fresh frozen plasma) and vitamin K.
6. PTCA- 3-6 months of triple antithrombotic therapy (VKA, aspirin, and a P2Y12 inhibitor) are recommended. The combination of clopidogrel and VKA without aspirin should be considered because it may decrease the risk of bleeding without a significantly increased risk of thromboembolism.
7.DOA (dabigatran, rivaroxaban, apixaban, and edoxaban) –NOT to use
8. Thromboembolism risk x10 s higher in the first month following valve replacement surgery. Use of heparin 12-24 hours following surgery is recommended. Use of either UFH or LMWH is reasonable. Use of low-dose aspirin can lower the thromboembolic risk while increasing the bleeding risk postoperatively. Anticoagulation with VKA is recommended for the first 3 months in most patients receiving a bioprosthetic valve. ESC/EACTS/ ACCP - aspirin therapy in the first 3 months following a bioprosthetic aortic valve replacement. ACC/AHA/ACCP aspirin beyond 3 months in all patients with bioprosthetic valves.
9. Noncardiac surgery- can often be performed safely without interruption of VKA therapy if they are at low risk for bleeding (e.g., dental care, ophthalmologic and demographic surgery, many gastrointestinal endoscopic procedures). Major surgery- INR should be <1.5 and heparin bridging is advised for high-risk patients only (mitral valve prostheses or patients with aortic valve prostheses and thromboembolic risk factors). Heparin bridging is not required for aortic valve prostheses without thromboembolic risk factors. Use of either UFH or LMWH is reasonable when bridging is indicated.
10. TAVR- indefinite low-dose aspirin long-term and aspirin plus clopidogrel (or another thienopyridine) for the first 1-3 months.
A heart coping with a dysfunctional prosthetic valveescardio
A heart coping with a dysfunctional prosthetic valve (at least once in every few beats…)
http://www.escardio.org/communities/Working-Groups/valvular/Pages/welcome.aspx
An artificial heart valve is a device implanted into the heart of a patient to replace a dysfunctional native heart valve. The human heart contains four valves: tricuspid valve, pulmonic valve, mitral valve and aortic valve.
The 10 commandments of prosthetic valve - ESC 2014
1. Mechanical heart valve- life-long OA. Antiplatelet medications does not provide adequate protection against thromboembolic risk. The combination of low-dose aspirin and vitamin K antagonists (VKAs) is recommended for all patients with mechanical valve prostheses by the ACC)/AHA & selective aspirin – ACCP/ESC/EACTS .
2. Bioprosthetic - avoid the need for life-long anticoagulation.
3.INR- 2.5 for aortic without additional risk factors for thromboembolism (e.g., Afib, prior thromboembolism, left ventricular dysfunction, and hypercoagulable states). INR range of 3.0 (or 3.5) for mitral and any aortic valve prosthesis associated with thromboembolic risk factors.
4. INR variability - increased mortality . INR variability is dictated by genetic polymorphisms of cytochrome P450 2C9, genotyping of patients treated with VKA is not currently recommended.
5. INR (>6.0) but no severe bleeding, management includes transient withdrawal of the OA and administration of oral vitamin K according to the actual and target INR values. Patients with severe bleeding should be treated with immediate anticoagulant reversal (usually prothrombin concentrates or fresh frozen plasma) and vitamin K.
6. PTCA- 3-6 months of triple antithrombotic therapy (VKA, aspirin, and a P2Y12 inhibitor) are recommended. The combination of clopidogrel and VKA without aspirin should be considered because it may decrease the risk of bleeding without a significantly increased risk of thromboembolism.
7.DOA (dabigatran, rivaroxaban, apixaban, and edoxaban) –NOT to use
8. Thromboembolism risk x10 s higher in the first month following valve replacement surgery. Use of heparin 12-24 hours following surgery is recommended. Use of either UFH or LMWH is reasonable. Use of low-dose aspirin can lower the thromboembolic risk while increasing the bleeding risk postoperatively. Anticoagulation with VKA is recommended for the first 3 months in most patients receiving a bioprosthetic valve. ESC/EACTS/ ACCP - aspirin therapy in the first 3 months following a bioprosthetic aortic valve replacement. ACC/AHA/ACCP aspirin beyond 3 months in all patients with bioprosthetic valves.
9. Noncardiac surgery- can often be performed safely without interruption of VKA therapy if they are at low risk for bleeding (e.g., dental care, ophthalmologic and demographic surgery, many gastrointestinal endoscopic procedures). Major surgery- INR should be <1.5 and heparin bridging is advised for high-risk patients only (mitral valve prostheses or patients with aortic valve prostheses and thromboembolic risk factors). Heparin bridging is not required for aortic valve prostheses without thromboembolic risk factors. Use of either UFH or LMWH is reasonable when bridging is indicated.
10. TAVR- indefinite low-dose aspirin long-term and aspirin plus clopidogrel (or another thienopyridine) for the first 1-3 months.
Evaluation of prosthetic valve function and clinical utility.Ramachandra Barik
Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.
Valular heart disease is very common in most of Afro Asian counteries mainly due to Rheumatic heart disease..Definitive treatment is surgery.which may be valve replacement or reapir. In this ppp I have discussed this subject in a simple way
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
Imaging for Predicting and Assessing Patient Prosthesis Mismatch after AVRJunhao Koh
Echocardiographic evaluation to prevent, detect and intervene on patient prosthesis mismatch in aortic valve replacement, including TAVR / TAVI and valve-in-valve cases.
Long-Term Durability of Transcatheter Aortic Valve ProsthesesShadab Ahmad
Assessments of valve function in the early randomized trial cohorts and registries have consistently shown preserved valve function up to 5 years after TAVR. However, it is well recognized that structural valve degeneration (SVD) with surgical aortic valve bioprostheses is usually not seen until 5 to 10 years post-procedure, and data in this time frame following TAVR are very sparse
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. •Thanks …………
Echocardiographic Evaluation Of
Prosthetic Cardiac Valves
Dr Gaurav Kumar Chaudhary MD,DM( Cardiology)
Assistant Professor
Department of Cardiology
King George Medical University ,Lucknow
Cardiology
Department K.G.M.U
2. Outline
• When we should asses Prosthetic valve function ?
• What are parameters that need to be assessed?
• How should we assess?
• ECHO images of assessment of patients with prosthetic
valve
Learning Points in Presentation
Cardiology Department
K.G.M.U
3. • An echocardiographic examination performed 6 weeks to 3 months
after valve implantation
• It allows for an assessment of the effects and results of surgery
• Serves as a baseline for comparison should complications or
deterioration occur later
Timing of assessment of prosthetic valve
Cardiology Department
K.G.M.U
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart
Disease A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
4. • Asymptomatic uncomplicated patient is usually seen at 1–year intervals
for a cardiac history and physical examination
• No further echocardiographic testing is required after the initial postoperative
evaluation in patients with mechanical valves
Who are stable
Who have no symptoms
No clinical evidence of prosthetic valve or ventricular dysfunction or
dysfunction of other heart valves.
Cardiology Department
K.G.M.U
Timing of assessment of prosthetic valve
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart
Disease A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
5. Cardiology Department
K.G.M.U
Timing of assessment of prosthetic valve
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart
Disease A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines
6. • Motion of leaflets or occluder
• Presence of calcification on the leaflets
• Any abnormal densities on the various components
of the prosthesis
• Valve sewing ring integrity and motion
Cardiology Department
K.G.M.U
Imaging of valve
Recommendations for Evaluation of Prosthetic Valves With
Echocardiography and Doppler Ultrasound, JASE 2009
7. • Contour of jet velocity signal
• Peak velocity and gradient
• Mean pressure gradient
• VTI of the jet
• DVI
• Pressure half time in MV and TV
• EOA
• Presence, location and severity of regurgitation
Doppler Study of Prosthetic valve
Recommendations for Evaluation of Prosthetic Valves With
Echocardiography and Doppler Ultrasound, JASE 2009
Cardiology Department
K.G.M.U
8. Case 1
• 27 yr female ,Post MVR (SJM ) 1 yr back
Cardiology Department
K.G.M.U
Case 1
17. • Fibrous pannus, is usually annular in location
• Pannus formation is more frequent on aortic than on mitral
prostheses
• On mitral prosthetic valves, they most often occur on the atrial side of
the prosthesis
• Typically presenting as a very dense immobile echo, pannus are
typically seen in patients with
Normal anticoagulation profile
Subacute or chronic symptoms
Pannus versus Thrombus
Cardiology Department
K.G.M.U
28. DVI (Doppler velocity index)
DVI is a dimensionless ratio of the proximal velocity in
the LVO tract to that of flow velocity through the
prosthesis:
DVI = VLVO/VPrAV
Normal prosthetic valve function
Mean DVI, 0.39; range - 0.28-0.55
A DVI < 0.25 is highly suggestive of significant valve
obstruction
Cardiology Department
K.G.M.U
DVI (Doppler velocity index )
37. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart
Disease A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines Cardiology Department
K.G.M.U
Prosthetic valve stenosis/regurgitation …..
38. Case 4
• 35 yr male ,Post MVR (TTK 29 Chitra ) in oct
2008
Cardiology Department
K.G.M.U
Case 4
44. TTK chitra valve
• Tilting disc valve
Metallic housing (cobalt based wrought alloy)
Circular disc high molecular weight polyethylene
Polyester suture ring
• Hemodynamically comparable to other mechanical
valves
• Valve related complications are similar
Cardiology Department
K.G.M.U
45. Case 5
• 65 yr male Post CABG (LIMA –LAD,SVG-RCA)
+ AVR ( 21 A –SJM ) in may 2014
Cardiology Department
K.G.M.U
Case 5
47. Trivial AR, No significant gradient
across Prosthetic valve
48. Patient-prosthesis mismatch (PPM)
It is Nonstructural dysfunction, a composite category that includes any
abnormality that results in stenosis or regurgitation of the operated
valve that is not intrinsic to the valve itself, exclusive of thrombosis and
infection
This includes inappropriate sizing, which is called valve prosthesis–
patient mismatch (VP-PM)
When the effective prosthetic valve area, after insertion into the
patient less than that of a normal valve
Patients with aortic PHV have obstruction to left ventricular outflow
(similar to aortic stenosis), and patients with mitral PHV have
obstruction to left atrial emptying (similar to mitral stenosis)
Cardiology Department
K.G.M.U