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Non-invasive muscle pump accessory muscles of respiration pressure support ventilation improved PaO /FiO cheap tenormin 100 mg fast delivery arteria networks corp, 2 2 active tenormin 100mg arrhythmia institute newtown. Noninvasive mechanical ventilation in clinical practice: a 2-year experience in a medical intensive care unit generic 50 mg tenormin with mastercard arrhythmia questionnaire. Hoffmann B order tenormin 100 mg visa arteria pudenda interna, Jepsen M, Hachenberg T, Huth C, Welte Introduction of full-face masks and respiratory T. Mechanical ventilation: invasive versus invasive ventilation for recurrent acidotic exacerbations noninvasive. Examples include asthma, recurrence of exacerbations by preserving optimal chest wall disease, cystic fibrosis, bronchiectasis, lung function. Optimizing medical therapy including investigations, which assess functional abnormality • Pharmacotherapy • Improving oxygenation by home oxygen therapy like pulmonary function tests including spirometry, • Noninvasive ventilation arterial blood gas assessment, measurements of 2. Assessment and treatment of complications like the severity of cardiorespiratory impairment. Nutritional assessment and intervention essential in formulating the exercise training 6. Psychosocial and behavioral intervention prescription and evaluating for hypoxemia during 7. The assessment of exercise capacity may be • Exercise training program • Breathing exercises and chest physiotherapy performed using either incremental exercise testing or a timed 6-minute walk test. Management of Advanced Chronic Respiratory Disorders: Pulmonary Rehabilitation 385 Other assessments that may be performed pulmonary hemodynamics. Several such instruments are than 55 mm Hg or oxygen saturation of less than available. Nutritional assessment is important, since 90 percent or a PaO2 of less than 59 mm Hg with changes in body weight, body composition, or evidence of polycythemia or cor pulmonale. Oxygen is delivered by nasal cannula in performed in inpatient, outpatient, or home settings stable hypoxemic patient. The idiopathic scoliosis, old tuberculosis lung, previous rehabilitation team includes a physician specialised polio, chest wall disease, thoracoplasty, muscular in cardiorespiratory care, physical therapist, dystrophies and myopathies. Mechanisms for occupational therapist, respiratory therapist, social improvement are due to relief in respiratory muscle worker and psychologist. However, an experienced fatigue, improvement in chest wall compliance, physician can contribute significantly to most aspects control of nocturnal hypoventilation, which is an of management. The practice administration of influenza vaccine substantially of delivering smoking cessation support should decreases mortality, hospitalization for influenza follow the principles of the “five A’s” listed in and pneumonia, exacerbation of chronic lung Table 23. The vaccine presently is Nicotine replacement therapies after smoking recommended for patients at risk of pneumococcal cessation reduce withdrawal symptoms. A smoker infection, which include patients with chronic who requires his or her first cigarette within 30 pulmonary disease. Vaccine is administered minutes of waking up is most likely to be highly intramuscularly as one 0. A second dose addicted and could benefit from nicotine may be administered, rarely, 5 years later. Nicotine better understanding of the physical and psycho- replacement therapy chewing pieces are marketed logical changes that occur with chronic illness. An individual who education, patients can become more skilled at smokes 1 pack per day should use 4-mg pieces. The collaborative self-management and have improved 2-mg pieces are to be used by individuals who compliance. Instruct patients to The following simple measures form an chew hourly, as well as at the time of their initial important part of a comprehensive pulmonary cravings for 2 weeks. The amount chewed can be rehabilitation program: reduced gradually over the next 3 months. Several studies have sion/Cor pulmonale (chapter 16) sleep disordered found that in patients with chronic lung disease, breathing (chapter 18) and osteoporosis is vital. Immunosuppressants like postmenopausal women but appears to be valid in azathioprine and cyclophosphamide used for men as well (Table 23. With progressive loss of bone mass, the patient is at high risk for vertebral or hip fractures. Majority of them are fragility fractures, more commonly seen in the thoracic spine. Hip fractures have significant morbidity, often resulting in decreased mobility and loss of independence for the patient and financial impact on society and nation. In a dyspneic patient, further loss of mobility after a hip fracture may lead to increased dependence on the caretaker, hospitalization cost and medical complications like pulmonary embolism. Vertebral fractures can be asymptomatic but may present with pain, deformity and paraplegia. They can cause significant morbidity due to back pain and thus decreased functional performance. All the three treatment regimens have similar profiles of side effects and efficacy, but once weekly Note: • “T-score” is the number of standard deviations above regimen has better tolerability and compliance. The increased fat mass increases the work of the compromised respiratory system and may be detrimental to respiratory function. The onset of weight loss in a patient with chronic respiratory disease is a poor prognostic indicator. Progressive weight loss occurs from inadequate dietary intake, increased resting energy expenditure, and poor appetite. The usual intervention for a malnourished patient with chronic respiratory disorder results in weight gain or loss as required with an adequate provision of calories. Nutrition counseling to address the planning the risk factors, weight bearing exercises, improving and preparation of a nutritionally adequate meal diet and nutrition along with calcium and vitamin plan, the adequacy of food supply, the use of D supplementation should be prescribed to patients nutritional supplements, and other details is who have osteoporosis or who are at risk. Psychosocial and behavioral strength training is a rational component of exercise interventions in the form of regular patient training during pulmonary rehabilitation. The most education sessions or support groups focusing on frequently reported form of general exercise specific problems are very helpful. Instructions in training is aerobic brisk walking or static cycling progressive muscle relaxation, stress reduction, and although, theoretically, any mode of exercise, which panic control may help reduce dyspnea and anxiety. As a general principle, the exercise should be Sertraline, are considered first-line treatment for precisely prescribed for the individual and the comorbid depressive or anxiety disorders in intensity increased as the programe progresses. Even low-intensity leg and arm muscle conditioning These agents are associated with a relatively low has led to reduced ventilatory equivalent for oxygen incidence of anticholinergic and other side effects and carbon dioxide. Since the performance of many and minimum interactions with other drugs day-to-day activities involve use of the arms, commonly used by the patients. Supported arm which involves the correction of unrealistic and exercises are prescribed with ergometry or harmful thought patterns through techniques such unsupported arm exercises by lifting free weights as guided imagery and relaxation may be effective or stretching armbands. If facilities for supervised exercise training Support groups increase social interaction and offer programes are not available, the physician should a chance to discuss disease-related medical, encourage the patient to be active and undergo psychological, and social issues with other patients. Therefore, efforts at improving long-term adherence Comprehensive physical rehabilitation programs with exercise training at home are necessary for the have three major components: Exercise training, long-term effectiveness of physical rehabilitation.
Medially order tenormin on line arrhythmia can occur when, the transversalis fascia separates the transversus muscle from the peritoneal cavity 100mg tenormin mastercard prehypertension systolic. The longest running course of the nerve is between the internal oblique and transversus muscles purchase 100 mg tenormin visa blood pressure chart cdc. The iliohypogastric nerve has a parallel course to the ilioinguinal nerve order tenormin 50mg online blood pressure chart throughout the day, running cephalad (supe- rior) and medial. Of the three abdominal wall muscles (external oblique, internal oblique, 2 and transversus), the internal oblique is usually the thickest. The deep (medial) circumfex artery is a recurrent branch of the external iliac artery. The deep circumfex artery pierces the transversus as it ascends the abdominal wall. Branches of the deep circumfex iliac artery often accompany the ilioinguinal nerves. Suggested Technique 3 Nerve and muscle visibility are best cephalad to the pelvic brim. In the classic location for ilioinguinal block (2 cm medial and 2 cm superior to the anterior-superior iliac spine), the external oblique muscle is often aponeurotic, and therefore it is diffcult to visualize this layer over the nerves. The frst step is to obtain a view of the three abdominal wall muscles (external oblique, internal oblique, and transversus) to identify the ilioinguinal nerves between the internal oblique and transversus. Alternatively, the deep circumfex artery can be followed up from the external iliac artery until it meets the ilioinguinal nerves. The block needle approaches in-plane from medial to lateral to aim away from the abdominal cavity. The needle tip should be positioned between the internal oblique and transversus muscles. Because the in-plane approach has a shallow angle, the block needle has a tendency to skim over the fascia rather than pierce it. Positioning Supine Operator Standing at the side of the patient (either side) Display Across the table Transducer High-frequency linear, 38- to 50-mm footprint Initial depth setting 25 to 30 mm Needle 20 to 21 gauge, 70 mm in length Anatomic location Begin by placing the transducer above the iliac crest. In contrast to the artery, the nerves will not have color encoding with appropriate adjustment of the Doppler gain. The injection can be performed where the artery lies between the internal oblique and transversus muscle layers or as proximal as possible. In this location the two nerves consistently lie between 2 the internal oblique and transversus muscles. If the needle tip is suffciently lateral, the iliacus or quadratus lumbo- rum muscle, rather than peritoneum, will lie under the transversus. Improved analgesia with the ilioinguinal block compared to the transversus abdominis plane block after pediatric inguinal surgery: a prospective randomized trial. Ultrasound-guided blocks of the ilioinguinal and iliohypo- gastric nerve: accuracy of a selective new technique confrmed by anatomical dissection. External oblique abdominal muscle: a new look on its blood supply and innervation. Sonogram showing the neurovascular bundle between the internal oblique and transversus muscles adjacent to the iliac bone. During in-plane approach, the needle tip compresses the soft tissue substantially before puncturing the muscle layer. In some patients, both the ilioinguinal and iliohypogastric nerves can be identifed between the internal oblique and transversus muscles. In rare patients, three nerves (here collectively referred to as ilioinguinal nerves) can be identifed between the internal oblique and transversus muscles (A). Examples include the Pfannenstiel (transverse) incision for cesarean delivery or hysterectomy, and surgeries that use a lower midline incision. Although somatic nerves of the abdominal wall are anesthetized, visceral pain following surgery is still an issue. These blocks therefore do not always provide defnitive pain relief and multimodal analgesia is often necessary. The external oblique is usually the most echogenic muscle of the anterolateral abdominal wall. The external oblique and internal oblique muscles typically extend farther posteriorly than the transversus abdominis muscle. Retroperitoneal fat (hypoechoic appearance on ultrasound scans) lies under the posterior aspect of the transversus abdominis muscle. The layers underneath the transversus abdominis muscle are (in order) the transversalis fascia, extraperitoneal fat, and peritoneum. The qua- dratus lumborum muscle is hypoechoic and therefore diffcult to visualize on ultrasound scans (as is the retroperitoneal fat). In this location they are relatively large and shallow with the surrounding muscles providing con- trast. The iliohypogastric and ilioinguinal 2 nerves cross over the anterior surface of the quadratus lumborum muscle but are diffcult to visualize in this anatomic location. The lateral approach is the best way to provide access beyond the posterior border of the transversus abdominis muscle. Ultrasound-guided continuous oblique subcostal transversus abdominis plane blockade: description of anatomy and clinical technique. Displaced retroperitoneal fat: sonographic guide to right upper quadrant mass localization. The quadratus lumborum muscle: a possible source of confusion in sonographic evaluation of the retroperitoneum. The lateral position is more intuitive for the operator and retracts soft tissue away from the transducer by gravity. To do this the transducer is placed between the costal margin and iliac crest in the midaxillary line at the level of the umbilicus. Slowly inject as the needle is withdrawn so that local anesthetic layers over the surface of the muscle. Because the success of this block depends on extensive distribution of local anesthetic to many nerves of the abdominal wall, most practitioners inject a high volume (20 mL per side) of dilute, long-acting local anesthetic. Some therefore consider the optimal plane for infltration of anesthetic to be 3 between this fascial layer and the transversus abdominis muscle. Injections within the transversus abdominis muscle itself often result in successful block of nerves of the lower 4 abdominal wall. The abdominal wall receives motor branches in a segmental fashion from the intercostal nerves. Positioning Supine or lateral Operator Standing at the side of the patient Display transducer Across the table High- to medium-frequency linear, 38- to 50-mm footprint Initial depth setting 35 to 40 mm Needle 21 gauge, 70 to 90 mm in length Anatomic location Begin by placing the transducer between the costal margin and iliac crest at the midaxillary line. The transversus abdominis plane block: a valuable option for postoperative analgesia? Refning the course of the thoracolumbar nerves: a new understand- ing of the innervation of the anterior abdominal wall.
Depending on disease severity and lesion location purchase tenormin 100 mg without a prescription blood pressure chart wiki, claudication may also occur in the thigh and buttock regions buy tenormin 100 mg free shipping prehypertension at 25 years old. A standardized motorized treadmill protocol should be used to ensure reproducibility of pain free maximal walking time (63) purchase cheap tenormin heart attack vol 1 pt 3. Claudication pain perception may be monitored using a numerical rating scale (see Figure 5 cheap tenormin 100mg without a prescription prehypertension in 30s. The exercise test should begin with a slow speed and have gradual increments in grade (12) (see Chapter 5). Following the completion of the exercise test, patients should recover in the seated position. Increases in pain-free walking time and distance of 106%–177% and in absolute walking ability of 64%–85% have occurred following exercise training programs (30). Some patients may need to begin the program by accumulating only 15 min · −1 −1 d , gradually increasing time by 5 min · d biweekly. Weight-bearing exercise may be supplemented with non–weight-bearing exercise, such as arm and leg ergometry. Cycling or other non–weight-bearing exercise modalities may be used as a warm-up but should not be the primary type of activity. A cold environment may aggravate the symptoms of intermittent claudication; therefore, a longer warm-up may be necessary (34). This can result in motor (functional), sensory, emotional, and cognitive impairments, the extent of which are greatly influenced by the size and location of the affected area and presence or absence of collateral blood flow. The etiology of a stroke is most often ischemic (87%, due to either thrombosis or embolism) or hemorrhagic. Loss of physical stamina, mood disturbance, and adoption of sedentary behaviors are common in stroke survivors. Although the Ex R is often adapted to the functional abilities of thex patients, exercise training improves exercise capacity (10%–20%, as measured by O2peak) and quality of life, and helps manage risk for a secondary event (95). Exercise Testing Compared to those who have not suffered a stroke, oxygen uptake is higher at a fixed submaximal level and reduced at peak effort among stroke survivors. During exercise testing, both chronotropic incompetence and early-onset fatigue are common. Exercise testing should employ a mode of testing that accommodates a patient’s physical impairment. All comorbidities should be considered when prescribing exercise as well as any effects the medications used to treat the comorbidities have on exercise responses or exercise programming. Subsequently, and often in tandem, aerobic, neuromuscular, and muscle-strengthening exercises can be engaged to further improve function, facilitate secondary prevention, and improve fitness. Other Considerations Be attentive to affective issues such as mood, motivation, frustration, and confusion. Correctly managing affective issues can favorably influence how a patient conducts, adheres to, and responds to a prescribed exercise regimen. Strategies aimed at minimizing negative influences due to these issues are helpful and include close supervision, individualized instruction until independence is established, involvement of family members, repetition of instructions, and alternate teaching methods. Early-onset local muscle and general fatigue are common and should be considered when setting work rates and rate of progression. Specificity of training can be employed for both aerobic and resistance training in an attempt to provide an individual with the strength and endurance needed to return to his or her previous occupation. Exercise training leads to an improved ability to perform physical work, an enhanced self-efficacy, and a greater desire and comfort level for returning to work following the illness (79,112). A list of respiratory diseases in which exercise is of potential benefit is shown in Box 9. Bronchiectasis — abnormal chronic enlargement of the airways with impaired mucus clearance Restrictive lung diseases — extrapulmonary respiratory diseases that interfere with normal lung expansion. Examples include the following: Interstitial lung disease/pulmonary fibrosis — scarring and thickening of the parenchyma of the lungs Pneumoconiosis — long-term exposure to dusts, especially asbestos Restrictive chest wall disease, (e. The conclusive evidence for exercise training as an effective therapy for asthma is lacking, and at present, there are no specific evidence-based guidelines for exercise training in these individuals. Some (32,47,101) but not all (94) systematic reviews and meta-analyses have suggested that exercise training can be beneficial for individuals with asthma. The data examined from these reviews are limited by small numbers of randomized controlled trials and heterogeneity of trial methods and subjects. Significant improvements in days without asthma symptoms, aerobic capacity, maximal work rate, exercise endurance, and pulmonary minute ventilation ( E) have been noted. Overall, exercise training is well tolerated and should be encouraged in people with stable asthma (32,39,84). Exercise Testing Assessment of physiologic function should include evaluations of cardiopulmonary capacity, pulmonary function (before and after exercise), and oxyhemoglobin saturation via noninvasive methods. Exercise testing is typically performed on a motor-driven treadmill or an electronically braked cycle ergometer. Immediate administration of nebulized bronchodilators with oxygen is usually successful for relief of bronchoconstriction (40). These tests should be administered by appropriately trained individuals with medical supervision. Evidence of oxyhemoglobin desaturation ≤80% should be used as test termination criteria in addition to standard criteria (9). Exercise Prescription Specific evidence-based exercise training guidelines for people with asthma are not available at this time. However, exercise training is generally well tolerated in individuals successfully managed with pharmacotherapy and when triggers to bronchoconstriction (e. Position statements on exercise in asthma (84) and systematic reviews (32) support this recommendation. Individuals experiencing exacerbations of their asthma should not exercise until symptoms and airway function have improved. Individuals on prolonged treatment with oral corticosteroids may experience peripheral muscle wasting and may benefit from resistance training. Exercise in cold environments or those with airborne allergens or pollutants should be limited to avoid triggering bronchoconstriction in susceptible individuals. Use of a nonchlorinated pool is preferable because this will be less likely to trigger an asthma event. Be aware of the possibility of asthma exacerbation shortly after exercise particularly in a high-allergen environment. This contributes to the loss of muscle strength, power, and endurance and decrements in the performance of everyday functional activities. The beneficial effects of exercise occur mainly through adaptations in the musculoskeletal and cardiovascular systems that in turn reduce stress on the pulmonary system during exercise (114).
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If tachycardia results from anoxia purchase 100mg tenormin amex narrow pulse pressure uk, then the causes can be developed on the basis of the causes for anoxia 50 mg tenormin sale arrhythmia nursing diagnosis, which may result from a decreased intake of oxygen purchase tenormin with a visa hypertension 24, a decreased absorption of oxygen tenormin 50mg low price heart attack i was made for loving you, and inadequate transport of oxygen to the tissues. In addition, anything that stimulates the heart directly, such as drugs, electrolyte imbalances, or disturbances in the cardiac conduction system, will cause tachycardia. Decreased intake of oxygen: Anything that obstructs the airway and prevents oxygen from getting to the alveoli should be recalled in this category. Bronchial asthma, laryngotracheitis, chronic bronchitis, and emphysema are most important to recall. In addition, if the “respiratory” pump (thoracic cage, intercostal and diaphragmatic muscles, and respiratory centers in the brainstem) is affected by disease, especially acutely, there will be tachycardia. Finally, the intake of oxygen may decrease if there is a low atmospheric oxygen tension. High altitude is an obvious cause, but hazardous working conditions must also be considered. Diminished perfusion of the pulmonary capillaries in pulmonary emboli and pulmonary and cardiovascular arteriovenous shunts. Disturbed ventilation/perfusion ratio in which alveoli are 783 perfused but not well ventilated, in alveoli that are not well ventilated, or in alveoli that are ventilated but not well perfused. This is typical of pulmonary emphysema, atelectasis, and many chronic pulmonary diseases. Increased tissue oxygen demands: Fever, hyperthyroidism, leukemia, metastatic malignancies, polycythemia, and certain physical or emotional demands fall into this category. Peripheral arteriovenous shunts: These shunts may occur in the popliteal fossa following a gunshot wound, in the sellar area following the rupture of a carotid aneurysm into the cavernous sinus, and in Paget disease. Disorders that directly affect the heart: Stimulants of the heart such as caffeine, adrenalin (pheochromocytomas), thyroid hormone (hyperthyroidism), amphetamines, theophylline, and other drugs fall into this category. Electrolyte disturbances such as hypocalcemia and hypokalemia may precipitate ventricular tachycardia. Excessive amounts of digitalis may also provoke atrial or ventricular tachycardia. Tachycardia of various types may occur from disturbances in the conducting system of the heart. Digitalis has already been mentioned, but the Wolff–Parkinson–White syndrome, focal myocardial anoxia from emboli or infarction, and distention of various chambers of the heart (atria in mitral stenosis, ventricles in essential hypertension and cor pulmonale) are also etiologies of this mechanism. Anticholinergic drugs such as atropine block the ability of the vagus to slow the heart and may cause or contribute to tachycardia. All of the above categories are outlined in Table 56 where a few diseases that are more specific are mentioned. Approach to the Diagnosis The association of other clinical signs and symptoms will often help to pinpoint the diagnosis. If the blood pressure is low, the workup will proceed as that of shock (see page 253). In contrast, tachycardia with a normal blood 784 pressure should prompt thyroid function studies, pulmonary function studies, arterial blood gases, and a venous pressure and circulation time. Electrolyte determinations, a drug screen, and 24-hour urine for catecholamine determinations may be indicated if there is hypertension as well. Tongue—Glossitis, stomatitis Nose—Rhinitis, sinusitis, and hay fever Throat—Tonsillitis and pharyngitis Teeth—Dental cases, alveolar abscess Gums—Gingivitis Joints—Temporomandibular joint syndrome Nerves—Bell palsy, brainstem lesions, uncinate fits (epilepsy) Unfortunately, this method would fail to help recall the drugs and poisons that cause taste abnormalities such as penicillamine, bismuth, iodine, bromide, and mercury. Approach to the Diagnosis Careful examination of the nose and throat ought to reveal most of the above conditions. A psychiatrist should be consulted if there are no objective findings and these studies are negative. V—Vascular conditions bring to mind varicoceles, which cause atrophy on the side of the dilated veins. I—Inflammation recalls the atrophy following mumps, orchitis, and other causes of epididymo-orchitis. N—Neoplasms suggest the atrophy that occurs in the estrogen treatment of prostatic carcinoma. I—Intoxication should remind one of the atrophy resulting from chronic alcoholism, Laennec cirrhosis, and hemochromatosis. T—Trauma reminds one of the atrophy following vasectomy and accidental ligation of the blood supply during hernia repair. E—Endocrine disorders suggest the atrophy of hypopituitarism, Klinefelter syndrome, and other eunuchoidal states. The skin may be involved by many inflammatory conditions leading to swelling, including carbuncles, cellulitis, and dermatitis of various types. The tunica vaginalis is involved with hernias and hydroceles, which may be differentiated by using transillumination. The venous plexus of the scrotum and testes is involved by varicoceles and phlebitis (usually of the left venous plexus), and a varicocele may be the sign of a carcinoma of the kidney when the left spermatic vein is 789 obstructed. Thus, one readily sees how frequently obstruction is a pathophysiologic mechanism in tumors here or elsewhere. The epididymis is frequently inflamed and swollen when there is orchitis and only rarely is inflamed by itself. It may also be enlarged from a spermatocele or from a vas deferens obstruction caused by prostatic disease (inflammation or neoplasm). Finally, arterial occlusion caused by torsion of the testicle may cause a testicular mass. Approach to the Diagnosis Testicular masses may be differentiated by transillumination (hydroceles and spermatoceles transilluminate, whereas hernias and tumors do not). Hernias may also be differentiated by reducing them (some will not reduce, however, if they are incarcerated), and auscultation may reveal bowel sounds. In noncommunicating hydroceles and testicular tumors, one may get above the swelling, whereas in torsion and hernias one cannot. In torsion, the tenderness is decreased by elevation of the testicle, whereas in orchitis the tenderness is not relieved unless elevation is done for an hour or more. Ultrasonography will easily distinguish between torsion and orchitis because of the significant decrease in blood supply to the testicle in torsion. N—Neoplasms of the testicles may be virtually painless, but the mass will give them away. Approach to the Diagnosis The approach to the diagnosis of testicular pain involves searching for a mass; if it is present, certain questions must be answered. A search for prostatic hypertrophy or prostatitis should be made, particularly in older men. An exploration for torsion or hernia may be the only way to establish these diagnoses. N—Neoplasms that may be associated with thrombocytopenia include leukemia, lymphoma, and myeloma; however, any tumor that may invade the bone marrow can cause thrombocytopenia.
Late prosthetic valve endocarditis has a microbiology similar to community-acquired native valve endocarditis discount 100mg tenormin free shipping blood pressure chart for children. Medical cure for prosthetic valve endocarditis caused by staphylococci buy tenormin with a visa blood pressure medication drowsiness, gram-negative organisms buy tenormin now blood pressure regular, or fungi is rare discount 100 mg tenormin free shipping blood pressure medication parkinson's. Streptococcal prosthetic valve endocarditis responds to medical therapy alone in 50% of cases. A high index of suspicion should be maintained for the presence of residual infection, and surgical reevaluation should be considered if medical treatment fails. Subclinical hemolysis is present in many patients with mechanical valves but rarely results in significant anemia. Clinical hemolysis occurs in 6% to 15% of patients with caged ball valves but is uncommon with normal bioprosthetic or tilting disk valves. Clinical hemolysis is also associated with multiple prosthetic valves, small prostheses, periprosthetic leaks, and prosthetic valve endocarditis. Mechanisms involved in the generation of hemolysis include high shear stress or turbulence across the prosthesis, interaction with foreign surfaces such as cloth, and rapid deceleration of erythrocytes following collision with adjoining structures (e. Diagnosis is made by elevated lactate dehydrogenase, reticulocyte count, unconjugated bilirubin, urinary haptoglobin, and presence of schistocytes on blood smear. Echocardiographic findings consistent with mechanical hemolysis include abnormal rocking of the prosthesis or regurgitant jets of high shear stress (e. Mild hemolytic anemia can be managed with iron, folic acid supplement, and if needed, blood transfusion. Paradoxically, treatment of the anemia may reduce the degree of hemolysis by limiting the need for high flow through the defective valve. Repair of perivalvular leaks or valve replacement is indicated in patients with severe hemolysis requiring repeated transfusions or in those with congestive heart failure. Percutaneous approaches can also be considered, but are not feasible with extensive dehiscence or when there is active infection. The incidence is highest in the tricuspid position, followed by the mitral and then the aortic position. Thrombus is suspected in patients with an acute onset of symptoms, an embolic event, or inadequate anticoagulation. Echocardiographic features suggestive of thrombus include an irregular and mobile mass. Fibrinolytic therapy has an initial success rate of 82%, overall thromboembolism rate of 12%, and a 5% incidence of major bleeding episodes. For left-sided valves, there is a similarly high success rate (82%) with fibrinolytic therapy; however, the associated risks of death (10%) or systemic embolism (12. Thrombolysis should be considered for left-sided valves in patients with contraindications to surgery. Thrombolysis may be a reasonable alternative to surgery for mitral or aortic prosthetic valve thrombosis in patients with a small thrombus burden. A: Layering thrombi on the nonflow side of stented bioprosthesis; B: A ring of pannus on the flow side (subvalvular) of a stented bioprosthesis; C: Nodular cuspal calcifications of a stented bioprosthesis; D: Leaflet teat of a stented bioprosthesis; E: Thrombosed bileaflet mechanical valve; F: Subvalvular pannus ingrowth of a bileaflet mechanical valve. The risk profile of the individual patient must be balanced against the expertise and experience at each center. Detachment of the sewing ring from the annulus may occur in the early postoperative period because of poor surgical techniques, excessive annular calcification, chronic steroid use, fragility of the annular tissue (particularly following prior valve operations), or infection. Abnormal rocking of the prosthesis on echocardiography is an indication for urgent surgery. All prosthetic valves, with the exception of stentless aortic homografts, have effective orifices that are smaller than those of native valves. There is an inherent pressure gradient and relative stenosis with each prosthesis. Depending on the definition and surgical series used, this mismatch may occur between 20% and 70% of cases after aortic valve replacement. In a patient with a small annulus, a hemodynamically favorable prosthesis like a stentless bioprosthesis, aortic homograft, or a tilting disk valve is preferred. Alternatively, the aortic annulus may be enlarged surgically in order to accommodate a prosthesis of acceptable size. Aortic prostheses <21 mm in diameter are not recommended for a large or physically active patient. Valve thrombosis and pannus formation are responsible for the majority of mechanical prosthesis obstructions. Little is known about the causes of fibroblastic proliferation in pannus formation. Foreign body reactions to the prosthesis, inadequate anticoagulation, and endocarditis have been implicated as potential causes. Pannus formation begins around the annulus of the valve and is more common in aortic than at mitral valve prostheses. A subacute presentation of fatigue or dyspnea in a patient who is well anticoagulated can suggest pannus formation. Following an embolic stroke, the risk of recurrent stroke is approximately 1% per day for the first 2 weeks. Maintaining anticoagulation reduces the risk of recurrent stroke to one-third but carries an increased risk of hemorrhagic transformation of 8% to 24%, particularly during the first 48 hours. In patients with larger infarcts, anticoagulation is generally withheld for 5 to 7 days. Anticoagulation is withheld for 1 to 2 weeks in the setting of hemorrhagic transformation based on recommendations from neurosurgical and neurology consultants. Reoperation with placement of a tissue valve may be needed for recurrent embolization. However, leaflet tears may produce a sudden clinical deterioration with the onset of severe regurgitation. Indications for reintervention are similar to those for native valve lesions, although repeat intervention is reasonable in asymptomatic patients with severe regurgitation given that further dysfunction could result in rapid clinical deterioration. Failure of the current generation of mechanical prostheses is rare but may precipitate sudden hemodynamic compromise. Catastrophic failure occurs when a strut holding the occluder breaks, allowing the occluder to embolize, resulting in overwhelming regurgitation. Strut failure has been reported most commonly with the Björk-Shiley valve and results from fatigue of a metal weld. In older ball-in-cage prostheses, ball variance, a structural deterioration of the occluder, can occur, giving rise to impaired occluder motion, sticking, and thromboembolism. Multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves. Bioprosthetic versus mechanical prosthesis for aortic valve replacement in the elderly. Recommendations for the imaging assessment of prosthetic valves: a reports from the European Association of Cardiovascular Imaging. Mechanisms of recurrent aortic regurgitation after aortic valve repair: predictive value of intraoperative transesophageal echocardiography.