Althea Aranda RN,MSN,CCRN From notes by
Laurie Dickenson
Valvular Heart Disease
 Heart contains
 Two atrioventricular valves


Mitral
Tricuspid
 Two semilunar valves

Aortic
Pulmonic

Valvular Disease

Valvular Heart Disease
 Types of valvular heart disease
depend on
 Valve or valves affected
 Two types of functional alterations




Stenosis
Regurgitation
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Pathophysiology
 Stenosis- narrowed valve, increases afterload
 Regurgitation or insufficiency- increases preload.
The heart has to pump same blood
 **Blood volume and pressures are reduced in front
of the affected valve and increased behind the
affected valve.
 This results in heart failure
murmurs
 All valvular diseases have a characteristic murmur
Valvular Heart Disease
 Valvular disorders occur
 in children and adolescents primarily from congenital
conditions
 in adults from degenerative heart disease
 Risk Factors
 Rheumatic Heart Disease MI
 Congenital Heart Defects
 Aging
 CHF
Mitral Valve Stenosis
Pathophysiology
 Decreased blood flow into




LV
LA hypertrophy
Pulmonary pressures
increase
Pulmonary hypertension
Decreased CO
Fig. 37-9
Fish mouth
Mitral Valve Stenosis
Manifestations
 Primary symptom is DOE
 Later get symptoms of R
heart failure
 A fib is common
 MVS murmur
 Usually secondary to
rheumatic fever
Mitral Valve Regurgitation
Pathophysiology
Manifestations
 Regurgitation of blood into
 Thready pulses




LA during systole
LA dilation and hypertrophy
Pulmonary congestion
RV failure
LV dilation and hypertrophyto accommodate increased
preload and decreased CO
 Cool extremities
 Symptoms of LV failure
 Third heart sound (S3)
 MVR murmur
Mitral Valve Prolapse
Pathophysiology
Manifestations
 Abnormality of the mitral
 Usually asymptomatic
valve leaflets, papillary
muscles or chordae
 Etiology unknown
 Most common valvular heart
disease in US
 Female 2x > Male
 Click murmur
 Atypical chest pain does not
respond to NTG
 Tachydysrhythmias may
develop- SVT
 Risk for endocarditis may be
increased
 heart association guidelines
Mitral Valve Prolapse
 May or may not be present
with chest pain
 If pain occurs, episodes tend
to occur in clusters,
especially during stress
 Pain may be accompanied by
dyspnea, palpitations, and
syncope
 Does not respond to
antianginal treatment
 MVP murmur (mid-systolic
click)
 TEE MVP
Aortic Valve Stenosis
Pathophysiology
 Increase in afterload
 Incomplete emptying of LA
 LV hypertrophy
 Reduced CO
 RV strain
 Pulmonary congestion
 Poor prognosis when
experiencing symptoms and
not treated- 10-20%sudden
cardiac death
Aortic Valve Problems

Aortic Valve Stenosis
Manifestations
Syncope
Angina
Dyspnea
 Exertional Syncope, Angina,
DOE are classic symptoms
 This triad reflects LVF
 Later get signs of RHF
 May be asymptomatic for
many years due to
compensation
 AVS murmur
Nitroglycerin is contraindicated
because it reduces preload
Bicuspid Aortic Valve
Congenital Heart
Defect
Most Common
Congenital Heart
Disease
Familial
Male>Female
Aortic Valve Regurgitation
Pathophysiology
 Increased preoad- 60% of SV
can be regurgitated
 Regurgitation of blood into
the LV
 LV dilation and hypertrophy
 Decreased CO
YouTube - Corrigan's sign
Aortic Valve Regurgitation
Manifestations
 Sudden manifestations of
cardiovascular collapse
 Left ventricle exposed to
aortic pressure during
diastole




Weakness
Severe dyspnea
Chest pain
Hypotension
 Constitutes a medical
emergency
 AVR murmur
Chronic Aortic Valve
Regurgitation
 Generally caused by RF, Syphilis, congenital bicuspid
aortic valve, ankylosing spondylitis
 Characteristic Water Hammer pulse
 Remain asymptomatic for many years
 Develop exertional SOB orthopnea,
 Paroxysmal nocturnal dyspnea after considerable
myocardial dysfunction has occurred.
Tricuspid and Pulmonic Valve
Disease
Pathophysiology
Manifestations
 Uncommon
 RHF
 Both conditions cause an
increase in blood volume in R
atrium and R ventricle
 Result in Right sided heart
failure
 Tricuspid- Rheumatic
 Pulmonic- Congenital
Diagnostic Tests
 Echo- assess valve motion and chamber size
 CXR
 EKG
 Cardiac cath- get pressures-especially if think need
surgery
 Patients history
 TEE
Medications
 Like Heart Failure
 ACE inhibitors
 Beta Blockers
 Digoxin
 Diuretics
 Vasodilators
 Anticoagulants
 Prophylactic antibiotics
Mitral Stenosis Therapy
 Surgical
 Mitral Commissurotomy
 Mitral Valve Replacement


Mechanical
Bioprosthetic
 YouTube - Robotic Mitral Valve Repair Surgery Animation
This is a mechanical valve prosthesis of the more modern tilting
disk variety (for the mitral valve). Such mechanical prostheses
will last indefinitely from a structural standpoint, but the patient
requires continuing anticoagulation because of the exposed nonbiologic surfaces.
This is an excised porcine bioprosthesis. The main advantage
of a bioprosthesis is the lack of need for continued
anticoagulation. The drawback of this type of prosthetic heart
valve is the limited lifespan, on average from 10 to 15 years
(but sometimes shorter) because of wear and calcification.
Ross Procedure
Mitral Regurgitation
MitraClip 3D
Animation
Medical Animation. Aortic valve replacement
Medical/ Surgical Treatment
 Percutaneous balloon valvuloplasty
 Surgical therapy for valve repair or replacement:
 Valve repair is typically the surgical procedure of
choice
 Open commissurotomy- open stenotic valves
 Annuloplasty- can be used for both
 Valve replacement may be required for certain
patients Heart valve surgery
 Mechanical-need anticoagulant
 Biologic-only last about 15 years
 Ross Procedure
 MedlinePlus: Interactive Health Tutorials
Nursing Diagnoses
 Activity intolerance
 Excess fluid volume
 Decreased cardiac output
 Ineffective therapeutic regimen management
Cardiomyopathy
 Condition is which a
ventricle has become
enlarged, thickened or
stiffened
 Group of diseases.
 As a result heart’s ability
as a pump is reduced
Cardiomyopathy
 Primary-idiopathic
 Secondary
 Ischemia- from CAD
 infectious disease
 exposure to toxins
-alcohol, cocaine
 Metabolic disorders
 Nutritional deficiencies
 Pregnancy
3 Types
 Dilated
 Hypertrophic
 Restrictive
Dilated Cardiomyopathy
 Most common- heart failure in 25-40%
 Cocaine and alcohol abuse
 Chemotherapy, pregnancy
 Hypertension
 Genetic
 * Heart chamber dilate and contraction is impaired
and get decreased EF%
 *Dysrhythmias are common- SVT Afib and VT
 Prognosis poor-need transplant
This very large heart has a circular shape
because all of the chambers are dilated. It
felt very flabby, and the myocardium was
poorly contractile. This is an example of a
cardiomyopathy.
Normal weight 350 gms now 700 gms
Dialated Cardiomyopathy
 Diagnostics
 Echocardiogram, CXR, ECG, labs
 Treatment-Control HF
 Diuretics
 Nitrates
 Ace inhibitors
 Beta blockers
 Digoxin
 Amiodarone
 Anticoagulants
Other treatments
 VAD
 Heart transplant
Hypertrophic Cardiomyopathy
 Genetic
 HCM -also known as IHSS or HOCM
 Get hypertrophy of the ventricular mass and
impairs ventricular filling and CO
 Symptoms develop during or after physical activity
 Sudden cardiac death may be first symptom
 Symptoms are dyspnea, angina and syncope
 Early id is critical
Hypertrophic Cardiomyopathy
 Massive ventricular
hypertrophy
 Rapid, forceful contraction of
the LV
 Impaired relaxation or
diastole
 Obstruction to aortic outflow
 Primary defect is diastolic
filling
 **HCM most common cause
of SCD in young adulthood
There is marked left ventricular hypertrophy, with asymmetric
bulging of a very large interventricular septum into the left
ventricular chamber. This is hypertrophic cardiomyopathy. About
half of these cases are genetic. Both children and adults can be
affected, and sudden death can occur.
Hypertrophic Cardiomyopathy
 Manifestations
 Dyspnea
 Fatigue-dec CO
 Angina, syncope
 S4 and systolic murmur
 Diagnostics
 Echo- TEE
 Heart cath
 ekg
Hypertrophic Cardiomyopathy
Treatment Goal- improve ventricular filling and
relieve LV outflow obstruction
 Beta blockers
 Calcium channel blockers
 Digoxin- only for A-fib if present
 Antidysrhythmics
 ICD
 AV pacing
Hypertrophic Cardiomyopathy
Ventriculomyotomy and myomectomy- incising
the septum muscle and removing some of the
hypertrophied muscle
PTSMA- alcohol induced percutaneous trans
luminal septal myocardial ablation
- inject alcohol into small branch of LAD which
causes ischemia and MI of septal wall.
 Live Search Videos: cardiomyopathy
Nursing
 Relieve symptoms
 Prevent complications
 Provide pysch and emotional support
 Teaching Avoid strenuous exercise and dehydration
 Avoid anything increasing the SVR (afterload) makes
obstruction worse
 Chest pain


Rest and elevation of feet for venous return
NO vasodilators like nitroglycerine
Restrictive Cardiomyopathy
 Least common
 Rigid ventricular walls that impair filling
 Requires high diastolic filling pressure to maintain CO
 Cannot Increase CO
 Signs of CHF
 Prognosis-poor
 Cause unknown
Restrictive Cardiomyopathy
Diagnostics
Echo-wall motion and
EF
 ECG
 CXR
 Hemodynamics
 Perfusion scan
 Cardiac cath
 Myocardial biopsy
Restrictive Cardiomyopathy
Treatment
No specific Treatment- goal to improve diastolic
filling
Medications
HF and dysrhythmias
Teaching
avoid strenuous activity, dehydration, increases in
SVR
high risk for Infection need prophylactic antibiotic
Restrictive Cardiomyopathy
Treatment
Surgery
 Vad-bridge to transplant
 Heart Transplant
 Myoplasty
 ICD- antiarrhythmics are negative inotropes
 Dual chamber pacemaker
 Hypertrophic
 excision of ventricular septum-myotomy, inject
denatured alcohol in coronary artery that feeds the top
portion of septum.
Nursing Diagnoses
 Decreased Cardiac Output
 Fatigue
 Ineffective Breathing Pattern
 Fear
 Ineffective Role Performance
 Anticipatory grieving
Question #1
Which of the following diagnostics best differentiates the types
of cardiomyopathy?
a. CXR
b. Echocardiography
c. Cardiac cath
d. ABG
Question # 2
 Which type of cardiomyopathy has the poorest
prognosis
 1. dilated cardiomyopathy
 2 Restrictive cardiomyopathy
 3.hypertrophic cardiomyopathy
 4 all of the above
Question # 3
Which of these are more likely to present as SCD
1. Restrictive cardiomyopathy
2. Dilated cardiomyopathy
3. Hypertrophic cardiomyopathy
4. Acute MI
Question # 4
Water Hammer pulse is a sign of
1.Mitral valve stenosis
2acute aortic valve regurgitation
3Chronic aortic valve regurgitation
Aortic valve stenosis
Question #5
 Most cases of Mitral valve stenosis are caused by
 1 congenital birth defects
 2 Rheumatic fever
 Atrial septal defects
 lupus
Aortic Aneurysms
 Aorta
 Largest artery
 Responsible for
supplying oxygenated
blood to
essentially all vital
organs
 Aneurysm Abnormal dilation of a
blood vessel at a site of
weakness or a tear in the
vessel wall.
 Usually secondary to
atherosclerosis
 Most commonly affect
the aorta
 more common in men
than women
Aortic Aneurysms
 Atherosclerotic plaques deposit beneath the intima
 Plaque formation is thought to cause degenerative
changes in the media
 Leading to loss of elasticity, weakening, and aortic
dilation
 May have aneurysm in
more than one location
 Growth rate
unpredictable
 Larger the aneurysm
greater risk of rupture
 May also involve the
aortic arch or the
thoracic aorta,
 Most (3/4) are found in
abdominal aorta below
renal arteries
 ¼ are found in the
thoracic area
 Dilated aortic wall
becomes lined with
thrombi than can embolize
 Leads to acute ischemic
symptoms in distal
branches
 Important to assess
peripheral pulses
Aortic Aneurysms
 Male>female
 Atherosclerosis Risks:
 Risk increases with age
 Studies suggest strong
genetic predisposition
 *Male gender and smoking
stronger risk factors than
hypertension and diabetes
 Age>60
 Male
 White
 Family Hx AAA
 Smoking
 HTN
 CAD
Aortic Aneurysms
 May result from
 Trauma
 Infection
 After peripheral artery
bypass graft surgery at
site of anastomosis
 Arterial leakage after
cannulae removal
 Genetic
 Marfan’s and Ehler
Danlos
Types of
Aneursyms
 2 basic classifications-
True and False
 True aneurysm
 Wall of artery forms the
aneurysm
 At least one vessel layer
still intact
Fusiform-Circumferential,
relatively uniform in
shape
Saccular-Pouchlike with
narrow neck connecting
bulge to one side of
arterial wall
Types of Aneurysms
Fusiform-most are
Saccular
fusiform and 98% are below
the renal artery
Types of aneursyms
 False aneurysm (also called pseudoaneurysm)
 Not an aneurysm
 Disruption of all layers of arterial wall

Results in bleeding contained by surrounding
structures
Causes of false aneurysm
 Trauma
 Infection
 Peripheral artery bypass graft surgery
Ascending Aortic Aneurysm
Aortic Arch
Clinical Manifestations
 Angina
 Swelling
 Hoarseness
 If presses on superior vena cava decreased venous
return can cause distended neck veins edema of head
and arms
Thoracic Aortic Aneurysm
Clinical Manifestations
 Frequently asymptomatic
 Chest pain most common
 Coughing
 Hoarseness
 Difficulty swallowing
 May have substernal, neck, back pain
 Swelling (edema) in the neck or arms
 Myocardial infarction
 Stroke
Abdominal Aortic Aneurysm
Clinical Manifestations
Abdominal aortic aneurysms
 (AAA)
 Often asymptomatic
 Frequently detected


On physical exam
 Pulsatile mass in periumbilical area
 Bruit may be auscultated
Often found when patient examined for unrelated
problem (i.e., CT scan, abdominal x-ray)
Aortic Aneurysm
Clinical Manifestations
 AAA
 May mimic pain associated with abdominal or
back disorders
 Pain correlates to the size
 May spontaneously embolize plaque

Causing “blue toe syndrome” patchy mottling of
feet/toes with presence of palpable pedal pulses
 It can rupture causing shock and death in 50% of
rupture cases

Complications
 Rupture- signs of ecchymosis
 Back pain
 Hypotension
 Pulsating mass
 (rupture triad)
 Thrombi
 Renal Failure
Aortic Aneurysm- Complications
 Rupture- serious complication related to untreated
aneurysm
 Anterior rupture


Massive hemorrhage
Most do not survive long enough to get to the hospital
 Posterior rupture



Bleeding may be tamponaded by surrounding structures,
thus preventing exsanguination and death
Severe pain
May/may not have back/flank ecchymosis(Grey Turners
sign)
Turner’s sign and Cullen’s Sign
 Live Search Videos: aortic aneurysm
 http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurys
m_case_study.htm
Aortic Aneurysm
Diagnostic Studies
 X-rays
 Chest  Abdomen  ECG -to rule out MI
 Echocardiography
 Ultrasound
 CT scan
 MRI
 Angiography
Medical Treatment
 Anti-hypertensives
 Beta blockers,
 Vasodilators
 Calcium channel blockers
 Nipride
 Sedatives
 Niacin, mevocor, statins
 Post-op anti-coagulants
 GOAL PREVENT RUPTURE
Surgery
 Usually repaired if >5cm
 Open procedure- abd incision, cross clamp aorta,aneuysm
opened and plaque removed, then graft sutured in place
 Pre-op assess all peripheral pulses
 Post-op-check urine output and peripheral pulses
hourly for 24 hours- (when to call Dr.)
 Endovascular stents- placed through femoral artery
YouTube - Abdominal
Aortic Aneurysm
Graft Repair
 Endovascular graft
procedure
 New approach is
percutaneous femoral
access
 Advantages
 Shorter operative time
 Shorter anesthesia time
 Reduction in use of general
anesthesia
 Reduced groin complications
within first 6 months
 YouTube - Cook's
modular AAA graft an
"engineering
achievement"
Ruptured AAA’s
 Time is critical
 90% of patients will not
survive
 Immediate surgery
 Patients often have
severe back pain
 May or may not have
back or flank
ecchymosis(grey turner
sign)
Aortic Dissection
 Blood invades or dissects the layers of the vessel wall
Dissecting aneurysms are unique and life threatening. A break or tear in
the tunica intima and media allows blood to invade or dissect the layers
of the vessel wall. The blood is usually contained by the adventitia,
forming a saccular or longitudinal aneurysm.
Aortic dissection occurs when blood enters the wall of
aorta, separating its layers, and creating a blood filled
cavity.
Aortic Dissection
 Often misnamed “dissecting aneurysm”
 Not a type of aneurysm
 Occurs most commonly in thoracic aorta
 Result of a tear in the intimal lining of arterial wall
 Male>Female
 Occurs most frequently between 30’s-60’s
 Acute and life threatening
 Mortality rate 90% if not surgically treated
Aortic Dissection
Etiology and Pathophysiology
 As heart contracts, each systolic pulsation ↑ pressure on
damaged area
 Further ↑ dissection
 May occlude major branches of aorta
 Cutting off blood supply to brain, abdominal organs,
kidneys, spinal cord, and extremities
 People with Marfan’s at risk
Aortic Dissection
Manifestations
 Abrupt severe ripping or
tearing pain
 Mild or marked HTN
early
 Weak or absent pulses
and BP in upper
extremeties
 Syncope
Aortic Dissection
Collaborative Care
 Initial goal
 ↓ BP and myocardial contractility to diminish pulsatile forces
within aorta
 Conservative therapy- only a bridge to surgery
 If no symptoms
Can be treated conservatively for a period of time
 Success of the treatment judged by relief of pain
 Emergency surgery is needed if involves ascending aorta

Aortic Dissection
Collaborative Care
 Drug therapy
 IV Beta- adrenergic blocker
Esmolol (Brevibloc)
 Other antihypertensive agents
 Calcium channel blockers
 Sodium Nitroprusside
 Angiotensin converting enzyme

Aortic Dissection
Collaborative Care
 Surgical therapy
 When drug therapy is ineffective and pt couldn’t
survive surgery
or
 When complications of aortic dissection are present
 Heart failure, leaking dissection, occlusion of an
artery
 Surgery is delayed to allow edema to decrease and
permit clotting of blood
 Even with prompt surgical intervention 30-day
mortality of acute aortic dissections remains high
(10%-28%)
Nursing Diagnoses
 Risk for Ineffective Tissue Perfusion
 Risk for Injury
 Anxiety
 Pain
 Knowledge Deficit
Nursing Management
Acute Intervention- Post-op ICU monitoring
 Arterial line
 Central venous pressure (CVP) or pulmonary artery (PA)







catheter
Continuous ECG monitoring
Oxygen administration/Mechanical ventilation
Pulse oximetry/ Arterial blood gas monitoring
Urinary catheter
Nasogastric tube
Electrolyte monitoring
Antidysrhythmic/pain medications
Nursing Management
 Infection
 Neurologic Status
 Peripheral perfusion status
 Renal perfusion status
 Gastrointestinal status
 Ambulatory /Home care
Prevention





1.Ultrasound
2.Prevent atherosclerosis
3.Treat and control hypertension
4.Diet- low cholesterol, low sodium and no stimulants
5.Careful follow-up if less than 5cm.
Priority Question # 29
 During the initial post-operative assessment of a




patient who has just transferred to the post-anesthesia
care unit after repair of an abdominal aortic aneruysm
all of these data are obtained. Which has the most
immediate implications for the client’s care?
A. The arterial line indicates a blood pressure of 190/112.
B. The monitor shows sinus rhythm with frequent
PAC’s.
C. The client does not respond to verbal stimulation.
D. The client’s urine output is 100ml of amber urine.
Priority Question #30
 It is the manager of a cardiac surgery unit’s job to develop a




standardized care plan for the post-operative care of client having
cardiac surgery. Which of these nursing activities included in the
care plan will need to be done by an RN?
A. Remove chest and leg dressings on the second post-operative
day and clean the incisions with antibacterial swabs.
B. Reinforce patient and family teaching about the need to deep
breathe and cough at least every 2 hours while awake.
C. Develop individual plan for discharge teaching based on
discharge medications and needed lifestyle changes.
D. Administer oral analgesisc medications as needed prior to
assisting patient out of bed on first post-operative day.
Priority Question # 25
 These clients present to the ER complaining of acute abdominal




pain. Prioritize them in order of severity.
A. A 35 year old male complaining of severe, intermittent cramps
with three episodes of watery diarrhea, 2 hours after eating.
B. An 11 year old boy with a low-grade fever, left lower quadrant
tenderness, nausea, and anorexia for the past 2 days.
C. A 40 year old female with moderate left upper quadrant pain,
vomiting small amounts of yellow bile, and worsening symptoms
over the past week.
D. A 56 year old male with a pulsating abdominal mass and sudden
onset of pressure-like pain in the abdomen and flank within the
past hour.