Prosthetic heart valves Follow up as important as surgery itself Patients undergoing prosthetic valve surgery need meticulous follow up in the post-operative period. Thorough understanding of the structure of different prostheses, their thrombogenic potential, durability and hemodynamics is imperative for proper management during this period. The treating cardiologist must be familiar with the use of oral anticoagulants (VKAs), their interactions with diet and different drugs to be able to avoid life threatening complications of over or under coagulation. Similarly, thorough knowledge of echocardiography of the prosthetic valves and the interpretation of the various nuances is absolutely essential in the management of these patients.The utility of clinical examination cannot be undermined for it is the astute clinician who picks up the jaundice arising out of hemolysis due to a paravalvular leak or an obstructive valve in association with abnormal sounds and murmurs. Proper recording of all the findings and comparison with baseline findings is of paramount importance. Special precautions should be observed for these patients during special situations like surgery or pregnancy. There is limited data in special populations like the elderly (>70 years), pregnant women and with low molecular heparins, novel anticoagulants and with newer generation valves.Stress Echocardiography in Valvular Stenotic Heart DiseaseStress echocardiography is emerging as an important tool in evaluation of valvular stenosis.Â· It aids in clinical decision making.Â· It provides significant non invasive information on dynamic changes in valve function, left ventricular function, hemodynamic response to exercise.Â· Exercise gives important information on exercise capacity and symptomatic responses.Â· It has the advantage of easy availability, low cost, immediate diagnosis and providing complete anatomic and hemodynamic information. Despite the above, more large scale trials are needed for enhancing its applicability in day to day clinical practice for heart diseases.What to do while dealing with typical Angina and normal coronaries?Evaluation of chest pain especially angina like symptoms has always been a challenging task for clinicians at all levels, be it an experienced clinician or a Resident in the Emergency room. The concept that all chest pains be considered as related to coronary artery disease (CAD) can never be ignored inspite of the documentation that coronary arteries have been reported as normal after an angiogram. Coronary artery spasm in normal coronaries, myocardial bridges, arteritis and stenosis of the coronary Ostia may all contribute to chest pain with angina like symptoms. There is no time lag defined between development of new onset CAD and normal coronary arteries. Chest pain like angina may not always be related to CAD but other life threatening conditions like Pulmonary embolism, acute aortic dissection, tension Pneumothorax, may be missed and passed off as non-cardiac conditions.Hypertrophied left ventricle of hypertrophic Cardiomyopathy, Aortic stenosis or hypertrophied right ventricle of pulmonary stenosis, Pulmonary artery hypertension, dilated Pulmonary arteries as in pulmonary hypertension or idiopathic dilatation of Pulmonary arteries may all contribute to chest pain. Other conditions like musculoskeletal syndromes, disorders of abdominal viscera including gastrooesophageal reflux, psychological conditions may have typical angina like symptoms in spite of normal coronaries. Thus, the syndrome of chest pain is a wide spectrum full of pitfalls unless timely measures are taken for diagnosis and management.
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