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Werner’s A Massage Therapist’s Guide to Pathology (Fifth Edition)

Lesson Plans

Chapter 5 — Circulatory System Conditions

Goals of the Lesson:

Cognitive: Students will be able to understand the general functionality of the circulatory system, as well as the circulatory system conditions and blood disorders. Motor: N/AAffective: Students will be able to aid in the early detection of circulatory conditions as well as identify the proper modality treatments required.

Learning Objectives:

The lesson plan for each objective starts on the page shown below.

5-1 Name two deficiencies that may cause nutritional anemia...........................................................................................035-2 Name the most likely final destination for loose blood clots on the venous side of the systemic circuit.....................055-3 Name three possible destinations for loose blood clots or other debris on the arterial side of the systemic

circuit.............................................................................................................................................................................085-4 Identify the most likely consequence of untreated hemophilia.....................................................................................105-5 Name two signs or symptoms of deep vein thrombosis................................................................................................135-6 Name the tissue that is damaged first in chronic hypertension.....................................................................................165-7 Name three controllable risk factors for the development of atherosclerosis...............................................................195-8 Name the difference between primary and secondary Raynaud syndrome..................................................................235-9 Name two factors that determine the severity of a heart attack....................................................................................265-10 Describe how right-sided heart failure can develop as a result of left-sided heart failure............................................29

You Will Need:

Gather the following materials and teaching aids for the following lessons:5-5 Freshly cut stalks of celery, glasses half full of water, and dark food coloring.

Copyright © 2013 Wolters Kluwer | Lippincott Williams & Wilkins

Selected Key Terms

Allogenic transplantsAngioplastyAtrial fibrillationAutogenic transplantsBence Jones proteinsBuerger diseaseC-reactive proteinChronic venous insufficiencyDiastoleDysphagiaDyspneaEmbolismEndarterectomyEpistaxisErythropoietinExtramedullary plastocytomaFibrinogenHematomaHematuriaHemoglobinHemolyticHemophiliaHemophilic arthritisHomocysteineInfarctionIntermittent claudicationMalignant hypertensionMonoclonal gammopathyMyelodysplastic anemiaPercutaneous transluminal

coronary angioplasty (PTCA)Peripheral vascular diseasePlastocytomas

Werner’s A Massage Therapist’s Guide to Pathology (Fifth Edition)Chapter 5— Circulatory System Conditions

5-6 Depending on the size of the class, you will need table salt, soda, water, milk, and bowls for each group of students.

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint.


Selected Key Terms (cont.)

Raynaud syndromeRestenosisReticulocytesSplenomegalyTelangiectasiasThrombocytopeniaThrombusTunica intimaTunica mediaStenosisSystoleVirchow triad


Objective 5-1

Name two deficiencies that may cause nutritional anemia. Date:

Lecture OutlineFigures, Tables, and Features

Resources andIn-Class Activities

Outside AssignmentsEvaluation Instructor’s Notes

Content Text page

PPt slide

Circulatory System Conditions Blood Disorders

o Anemiao Embolism,

thrombuso Hematomao Hemophili

ao Leukemiao Malariao Myelomao Sickle cell

diseaseo Thrombop

hlebitis, deep vein thrombosis

Vascular Disorderso Aneurysmo Atheroscle

rosiso Hypertensi

ono Raynaud

syndromeo Varicose

veins Heart Conditions

o Heart attack

o Heart failure

228-232

12-23 FeaturesAnemia p. 229

Figures5.2: Different types of white blood cellsp. 229

5.3: Iron deficiency anemiap. 230

ResourcesAnswer to Chapter Objectives (SR)

Answers to Chapter Review Questions (SR)

In-Class ActivitiesThrough discussion, provide a list of symptoms describing a blood disorder, asking students to identify the appropriate disorder.

Outside AssignmentsCertain kinds of nutritional anemia can be prevented or treated through diet. Have students research iron deficiency anemia, listing foods that counteract, as well as those foods that can continue the deficiency.

EvaluationChapter review questions: Circulatory System Conditions. p. 270



Anemia = Insufficient oxygen-carrying capacity Often a symptom or

complication rather than freestanding problem

Affects about 3.4 million people in USo Most are

women or peoples with chronic disease

Several kinds of anemiao Idiopathic

anemiaso Nutritional

anemiaso Hemorrha

gic anemiaso Hemolytic

anemiaso Aplastic

anemiao Secondary

anemias

Nutritional anemias Some deficiency in diet;

massage won’t have much affect

Cautions for pernicious anemia

Iron deficiency anemiao Needed to

form hemoglobino Most

common in women: need twice as much iron as men; get fewer calories

o Pregnant women especially



Folic acid deficiency anemiao Needed to

form RBCso Water

soluble: any excess can’t be stored

Pernicious anemiao Inadequate

Vitamin B12: not enough in diet (vegans) or poor access in stomach (lack of intrinsic factor)

o Can lead to central nervous system (CNS) damage, anemia

Other nutritional deficiencieso Copper,

protein, others

Legend: IR = instructor’s resource; SR = student resource; PPt = PowerPoint. Objective 5-2

Name the most likely final destination for loose blood clots on the venous side of the systemic circuit. Date:




Content Text page

PPt slide

Embolism: traveling clot Platelets flow through

circulatory system; activated by any rough spot or inflammatory chemicals

Clots form at sites of damage, areas of slow, irregular blood flow

Emboli travel until vessel is

232-235

25-30 FeaturesEmbolism, Thrombusp. 232

Sidebar 5.1 DVT+PE = VTEp. 235

Figures5.4: A thrombus is alodged clot; an embolus is a



In-Class Activities

Outside AssignmentsThe term “embolism” was coined in 1848 by Rudolph Carl Virchow. Ask students to research Virchow and his significance in the study of pathologies.



too small Pulmonary embolism

The lungs are the one and only destination for clots or debris anywhere on the venous side of the systemic circuito Unless the

heart has patent foramen ovale

From a clot that forms on venous side of systemic circuit (Fig. 5.5)

650,000 pulmonary emboli/year

200,000 deaths Often related to deep vein

thrombosis (DVT), complications of trauma, orthopedic surgery

Risk factors for pulmonary embolism Other types of

cardiovascular disease, recent trauma, bed rest, surgery, pregnancy, recent childbirth, overweight, smoking, birth control hormones, hormone replacement therapyo Number 3

cause of death in hospital setting

Signs and symptoms of pulmonary embolism Usually none until after

damage has occurred Dyspnea, chest pain,

coughing with bloody

moving piece of debrisp. 233

5.5: Sites of origin for pulmonary embolip. 233

The signs and symptoms of pulmonary embolism can look like a heart attack. Through discussion, ask students to identify key differentiating factors between the two.




sputum Can look like heart attack

Complications of pulmonary embolism Increased risk of another

event Loss of lung function →

right-sided heart failure

Treatment Thrombolytics,

anticoagulants Surgery if necessary

Prevention Identify risk Low-dose presurgical

anticoagulants Elevation of legs External compression of legs Early ambulation




Objective 5-3

Name three possible destinations for loose blood clots or other debris on the arterial side of the systemic circuit. Date:




Content Text page

PPt slide

Arterial embolism Complication of

atherosclerosiso Could also

be from bacterial infection, atrial fibrillation, rheumatic heart disease

Emboli are usually clotso Can also

be plaque, bone chip, bubble, knot of cancer cells

When septum is intacto All venous

emboli travel to lungs Arterial emboli can

go anywhere except the lungs

Coronary artery (heart attack)

Carotid/ cervical artery (stroke)

Renal artery (renal infarction)

Femoral artery (muscle infarction)

Other

Signs and Symptoms May be silent May involve sharp tingling

234-235

31-36 Figure5.6: Arterial infarction sites



Related ChaptersCerebral aneurysms are discussed in the section onstroke in Chapter 4.

In-Class ActivitiesMost modality recommendations for embolism are contraindicated except PNF/MET/Stretching. Through discussion, ask students to identify why this modality is considered supportive.

Outside AssignmentsThe most commonly used method to predict clinical probability of pulmonary embolism is the Wells score. Ask students to research how this prediction rule has evolved since 1995.



http://en.wikipedia.org/w/index.php?title=Wells_score&action=edit

http://en.wikipedia.org/w/index.php?title=Wells_score&action=edit


pain, tissue damage, and death

Treatment Prophylactic anticoagulants

Massage Rigorous circulatory

massage is contraindicated for clients who tend to form clots

Cautions with anticoagulant medications




Objective 5-4

Identify the most likely consequence of untreated hemophilia. Date:




Content Text page

PPt slide

Hemophilia = Genetic disorder characterized by absence of various clotting factors Affects about 18,000 men in

US About 400 new cases/year

o Carried on X-chromosome: women are carriers who pass it to their sons

About one-third of cases are spontaneous mutations

It is possible but rare for women to have hemophilia

Etiology Hemophilia A (80% of

cases)o Deficiency

in clotting factor VIII Hemophilia B (also called

Christmas disease) (15% of cases)o Deficiency

in clotting factor IX Other: much rarer than A or

B Person with hemophilia has

difficulty forming solid, long-lasting clotso Don’t

235-237

38-46 FeaturesHemophiliap. 235



In-Class ActivitiesThe word hemophilia is formed from the word roots “hemo” and “philia.” Pair students into groups of two. Ask the groups to come up with as many different medical terms as possible using either “hemo” or “philia.”

Outside AssignmentsHemophilia is sometimes called “the royal disease.” Ask students to write a report researching the derivation of this nickname.




bleed faster, do bleed longer than others

Rated as mild, moderate, severeo Severe

hemophilia = 60% of diagnoses; <1% normal clotting factors

Signs and Symptoms Signs at birth: umbilical cord

bleeds excessively Early childhood:

infant/toddler accidents Bruising, hematomas,

nosebleeds, hematuria, joint pain from bleeds into capsule

Complications Leading cause of death in

children with hemophilia is intracranial bleeding

Bleeding into joint capsules with inflammation and extensive damageo Hemophili

ac arthritiso Ankles,

knees, elbows Muscle and nerve damage Infected blood products

o Vaccinate for hepatitis A, B

Resistance, hypersensitivity to synthetic clotting factors

Treatment Supplement clotting factors

o Can be



done at home now, prophylactically or after injury

Careful exercise, weight control

Massage Rigorous mechanical

massage is contraindicated Energetic work appropriate

and helpful for stress, pain relief




Objective 5-5

Name two signs or symptoms of deep vein thrombosis. Date:




Content Text page

PPt slide

Thrombophlebitis, Deep Vein Thrombosis = Veins have become obstructed with clots Usually calves, thighs, pelvis Thrombophlebitis = lesser,

greater saphenous veins DVT = popliteal, femoral,

iliac veins

Etiology Thrombi = stationary clots;

can fragment and travelo Usually to

lung → pulmonary embolism

o Exception with patent foramen ovale; cross over to arterial side

Virchow triado Injury to

endotheliumo Hypercoag

ulabilityo Venous

stasis Possible triggers

o Physical trauma

o Varicose veins

o Local

244-248

77-84 FeaturesThrombophlebitis, Deep Vein Thrombosisp. 245

Case History 5.1 Deep Vein Thrombosisp. 246

Figures5.9 Deep vein thrombosisp. 247



In-Class ActivitiesSimilar to the way our blood flows through our veins and arteries, a piece of celery uses a process called transpiration. Divide the class into small groups. Provide each group with a clear glass, water, dark food coloring, and a stalk of celery. Have the groups add the food coloring to the water, then place the stalk of celery in the water with the leafy side facing up. Throughout the class, have the students check the progress of the colored water throughout the celery’s “vascular bundle.”

MaterialsFreshly cut stalks of celery, glasses half full of water,

Outside AssignmentsDeep vein thrombosis has been nicknamed “economy class syndrome.” Ask students to research and write a report on this nickname.




infection o Reduced

circulation o Immobility o Pregnancy

and childbirth o Certain

types of cancer o Surgery o High-

estrogen birth control pills or hormone replacement therapy

o Other factors: cigarette smoking, hypertension, paralysis, and some genetic conditions

Clot forms; sudden movement or change in position causes debris to break off and travel

Signs and Symptoms May be obvious with signs

of inflammation Sometimes distal edema Chronic problem → skin

rashes, ulcers With infection: fever,

malaise DVT more dangerous,

higher risk of serious damageo May show

pitting edema

Diagnosis Ultrasound: fast,

noninvasive, high chance of false positive

and dark food coloring.



Venography: more accurate, slower, more risk of damage

MRI: fast, noninvasive, accurate, expensive, not available everywhere

Treatment Thrombolytics to break

clots; anticoagulants to prevent future ones

Risk of bleeding Pneumatic compression,

support hose for DVT Superficial

thrombophlebitis: hot packs, analgesics, gentle exercise

Vena cava filter

Massage A client with diagnosed

blood clots is not a good candidate for circulatory massage

Signs may be indistinct, misleading




Objective 5-6

Name the tissue that is damaged first in chronic hypertension. Date:




Content Text page

PPt slide

Hypertension = High blood pressure Persistently above 140/90

Etiology Blood pressure variables

o Pressure inside vessels

o Pressure outside vessels

o Blood volume

o Vessel diameter

Types of high blood pressure Essential: 95% Secondary (temporary

complication) Malignant hypertension:

diastolic rises very quickly—medical emergency

Blood pressure readings Risk of damage to vessels

begins when systolic > 115, diastolic > 75

A measurement is based on two or more readings at different office visits

255-258

114-124

FeaturesHypertensionp. 256

Tables5.1: Blood Pressure Ratingsp. 256

Sidebar 5.4 Heart Disease in the United States: Sobering Statisticsp. 256

ResourcesAnimation (SR)

Answer to Chapter Objectives (SR)


In-Class ActivitiesSalt is a highly absorptive substance. Divide the class into small groups providing each with the materials to conduct an experiment illustrating the absorptive properties of table salt. Each group will need a container of salt, and three different liquids varying in chemical makeup (milk, soda, water). Instruct each group to pour a small amount of each liquid into separate bowls, pouring a mound of salt on top. The groups should document the time differences in the absorption, applying

Outside AssignmentsSodium is an environmental factor of hypertension that relieves a lot of attention. Ask students to research how salt consumption can affect a person’s bloodstream.




Signs and Symptoms Silent killer Shortness of breath;

headache/dizziness; swelling of ankles; sweating, anxiety

Complications Edema Atherosclerosis Stroke Enlarged heart, heart failure Aneurysm Kidney disease Vision problems

Treatment Of 65 million with

hypertension in USo 63.4%

knowo 45.3%

treat it at allo 29.3%

treat it successfully 70% of people with

hypertension don’t control it well enough to prevent complications

DASH diet Exercise Medication

o Diuretics, vasodilators, beta-blockers

o Medication causes side effects; high blood pressure has no symptoms

Massage

theories explaining why they achieved those results.

MaterialsDepending on the size of the class, you will need table salt, soda, water, milk, and bowls for each group of students.

Video: For more information on blood pressure see the animation at thePoint.lww.com/Werner5e



Depends on health, resilience of client

Massage can lower blood pressure and stresso Get

information on kidney, heart problems

o No deep abdominal work




Objective 5-7

Name three controllable risk factors for the development of atherosclerosis. Date:




Content Text page

PPt slide

Atherosclerosis = hardening of the arteries from any cause Subtype of arteriosclerosis Hardening of arteries due to

plaqueo Damage

causes spasm, blood clotso Diameter

is occluded (Fig. 5-9) Coronary artery disease

(CAD) = atherosclerosis at coronary arteries (Fig. 5-14)

Etiology Multifactorial process

o Influenced by gender, age, race, diet, and other factors

Basic progressiono 1.

Endothelial damage Carbon monoxide;

high levels of low-density lipoproteins (LDLs) and triglycerides; high iron.

Occurs most readily at branches or sharp curves

o 2. Monocytes arrive, move

250-254

98-112 FeaturesArtherosclerosisp. 251

Sidebar 5.2 : A Brief Digression on Cholesterolp. 252

Figures5.12: Atherosclerosis.p. 251

5.13: Carotid artery disease. Note the point of stenosis just past the bifurcationp. 254

5.14: Coronary artery diseasep. 254






In-Class ActivitiesPair students in groups of two, asking each group to come up with as many risk factors for arteriolosclerosis as possible. Through discussion, ask the class as a whole to classify each factor as unchangeable or modifiable.

Video: For more

Outside AssignmentsThe terms “arteriosclerosis,” “arteriolosclerosis,” and “atherosclerosis” are very similar, yet distinct, in both spelling and meaning. Ask students to research the differences comparing and contrasting the three.




in, become macrophageso 3.

Macrophages take up LDL. Become foam cells:

beginning of plaqueo 4. Foam

cells infiltrate and damage smooth muscle tissue. Secrete growth

factors that cause smooth muscle cells to proliferate

Release enzymes that damage arterial walls, promote clotting

o 5. Platelets arrive Secrete growth

factors Form clots Cause vascular

spasm

Unchangeable risk factors Heredity, genetics Gender Age Kidney disorders

Modifiable risk factors Smoking High cholesterol levels High blood pressure Sedentary lifestyle Diabetes

Other Risk Factors C-reactive protein Homocysteine Others: BMI, fibrinogen,

information on monocytes see the animation at thePoint.lww.com/Werner5e



lipoproteins, stress management, etc.

Signs and Symptoms None early: 50% occlusion

before dysfunction Angiogenesis, adaptability Later: poor stamina,

shortness of breath, complications

Complications High blood pressure Aneurysm Arrhythmia Thrombus or embolism,

peripheral vascular disease Angina pectoris

o Stable angina pectoris

o Unstable angina pectoris

Heart attack

Diagnosis Angiogram, CT, blood tests,

echocardiogram, ultrasound, ankle-brachial index

Treatment Diet and exercise Drugs

o Lower blood pressure, cholesterol, platelet activity

Surgeryo Bypass,

angioplasty, endarterectomy



Massage Determined by client’s

resilience Adjust for medications as

needed




Objective 5-8

Name the difference between primary and secondary Raynaud syndrome. Date:




Content Text page

PPt slide

Raynaud Syndrome Primary Raynaud disease:

vasoconstriction in extremities (also nose, ears, lips)

Secondary Raynaud phenomenon: complication of underlying disorder

Etiologyo Arterioles

spasmo Temporary

episodes, can become permanent

o Chemical components: tunica intima secretes chemicals that affect vasospasm, viscosity of blood

o May be related to hyperreactivity to cold, stress

Causes (Primary) Stress (sympathetic

response), cold, mechanical irritation

Slow onset, less severe than secondary

Both hands and feet often

258-260

126-134

FeaturesRaynaud Syndromep. 258

Figures5.16: Raynaud syndrome.p. 259



In-Class ActivitiesAll cells involved in inflammation are coordinated by chemical messages. Discuss the chemical interactions throughout each stage of healing.

Outside AssignmentsOne inflammatory indicator, C-reactive protein, has been drawing attention lately. Have students research the substance and discuss its history as well as its current and possible future diagnostic uses.




affected

Causes (Secondary) Arterial diseases: diabetes,

atherosclerosis, Buerger disease

Autoimmune connective tissue diseases: scleroderma, lupus, rheumatoid arthritis

Sensitivity to some drugs: beta-blockers and ergot compounds

Neurovascular compression: carpal tunnel syndrome, thoracic outlet syndrome, crutch use

Signs and Symptoms Usually bilateral Cycle of colors

o Whiteo Blueo Red

Episodes last less than 1minute to several hours

Secondary can be extreme and long lasting: atrophy, ulcerations, skin and nail damage

Treatment Depends on cause

o Quit smoking, avoid vasoconstrictors, soak in warm water, dress for weather, protect hands when working in cold, etc.

o Deal with stress: biofeedback,



massageo Medicatio

n to dilate blood vessels, counteract norepinephrine

o Surgery: sympathectomy

Massage Depends on cause

o Primary indicates massage

o Secondary: be guided by underlying disorder, general health




Objective 5-9

Name two factors that determine the severity of a heart attack. Date:




Content Text page

PPt slide

Heart Attack = damage to cardiac muscle as a result of ischemia CAD Muscle tissue doesn’t repair;

replaced by scar tissue Damaged area = infarct Heart attack = myocardial

infarction

Etiology Usually blockage in

coronary artery impedes blood flowo Could be

clot, debris that travels from elsewhere

o Prolonged coronary spasm (drug overdose)

New plaques more likely to break off than old ones

Cardiac cells die of ischemiao Can’t

contract with coordinationo May

trigger fibrillationso Ventricula

r fibrillation → high risk of sudden death

Seriousness determined by size, location of infarct

262-267

149-156

FeaturesHeart Attackp. 263

Figures5.19 Myocardial infarctionsp. 264

Compare and Contrast 5-2: Chest Pain, Chest Pain, Chest Painp. 265

Case History 5.2: Heart Attackp. 266



In-Class ActivitiesNot all chest pain means heart attack. Read a list of the duration, trigger, activity and causes from Compare and Contrast 5-2, asking students to identify the feature.

Video: For more information on coronary artery disease see the animation at thePoint.lww.com/Werner5e

Outside AssignmentsWHO criteria have classically been used to diagnose myocardial infarction. Ask students to identify the criteria, providing a specific plan for a possible treatment.




o May impair muscle function

o May damage conduction system

Signs and Symptoms Pressure, pain in the chest Spreading pain Light-headedness, nausea,

sweating Others: shortness of breath,

nausea, anxiety, weakness, fainting, palpitations, cold sweat, stomach/abdominal pain

Angina pectoris (chest pain) Stable angina

o 6.5 million have it

o 400,000 diagnoses/year

o Triggered by extra effort

Unstable anginao Sudden

onset of severe chest pain, no trigger

o Reliable predictor

Dynamic processo Blockage

may accrue over hourso Early

intervention can limit damage

Complications Embolism Atrial and ventricular

fibrillations



Aneurysm Heart failure Shock

Diagnosis Hard to identify ahead of

time Angiogram for high-risk

patients Other tests

o High speed CT

o Contrast echocardiogram

o Blood test for C-reactive protein

o MRI for plaque

Treatment Identify location of

blockage, break it up as soon as possibleo Thromboly

tics o Percutaneo

us transluminal coronary angioplasty

o Oxygen, pain management

Later care: anticoagulants, nitroglycerin, observation, evaluation

Lifestyle changes

Massage Depends on resilience,

ability to adapt to changes




Objective 5-10

Describe how right-sided heart failure can develop as a result of left-sided heart failure. Date:




Content Text page

PPt slide

Heart Failure = Progressive loss of heart function Not cardiac arrest

Etiology Heart pumps 2,000 gal/day If resistance develops, heart

compensateso Heart

grows (cardiomegaly)o Ventricles

become stiff, inelastic Stress hormones boost short-

term function, damage in long-term

Heart may fibrillate → circulatory system collapse

Heart failure usually related to other cardiovascular disease

Can be related to congenital weakness with heart muscle or valves

Types of heart failure: systolic v. diastolic Systolic heart failure: left

ventricle is enlarged; can’t push hard enough

Diastolic heart failure: both ventricles are enlarged and

267-268

158-168

FeaturesHeart Failurep. 267

Figures5.20: Left-sided heart failure p. 268

5-21: Right-sided heart failure p. 269




In-Class ActivitiesThrough discussion, provide a list of possible symptoms of heart failure asking the students to identify each as a symptom of left, right, or biventricular heart failure.

Video: For more information on heart failure see the animation at thePoint.lww.com/Werner5e

Outside AssignmentsThere is no gold standard for diagnostic criteria of heart failure, but a few commonly used systems are the "Framingham criteria,” the "Boston criteria," the "Duke criteria," and the "Killip class.” Ask students to compare and contrast 2 of those systems.


Create an exam for Chapter 5 using the Brownstone Test Generator on the IR.

Have students practice for the exam using the interactive quiz bank on the SR.

Chapter 5 crossword puzzle, robotman, and



inelastic

Types of heart failure: left side v. right side Left-sided heart failure (Fig.

5.20)o Resistance

in arteries (atherosclerosis, etc.)

o Back up of fluid in lungs: pulmonary edema, shortness of breath, cough

Right-sided heart (corpulmonale) o Resistance

in lungs (emphysema, pulmonary embolism, pulmonary edema) Often a

complication of pulmonary disease accumulated through left-sided heart failure

o Back up of fluid into legs (Fig. 5.21) or lowest structure

o Can also cause liver, kidney damage

Biventricular heart failure

Signs and symptoms Depends on which side of

heart is dysfunctional Shortness of breath, low

stamina, edema, chest pain, indigestion, arrhythmia, distended vessels in neck, cold sweaty skin

game show (SR and IR).



Diagnosis Observation, auscultation Radiography for

cardiomegaly Electrocardiogram May be rated I–IV or A–D

Treatment Depends on location,

severity Rest, change in diet, modify

physical activity Medication

o Beta-blockers, digitalis, diuretics, vasodilators

Surgery: repair damaged valves, mesh bag, transplant

Massage Heart can’t keep up with

needs; massage shouldn’t challenge any further

Energetic/reflexive work may be helpful



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