Valvular Heart Disease
Valves
• What is the main job of our valves?
• 4 valves
• 2 Atrioventricular
• What are the 2 AV valves?
• When do they close?
• When do they open?
• What prevents the valves from opening during systole?
• 2 semilunar
• What are the 2 SL valves?
• When do they close?
• When do they open?
Valvular Heart Disease
• Valves open and close due to pressure gradients
• AV valves (mitral and tricuspid) - prevent backflow of
blood from ventricles into atria during systole
• SL valves (aortic and pulmonic) - prevent backflow of
blood from aorta and pulmonary artery
into ventricles during diastole
Valvular Heart Disease
• Regurgitation- Blood flows backward through the valve.
• Stenosis-Narrowing of the valve opening
• Flow of blood through the valve is reduced
• Caused by thickening of valvular tissue
• Hypertrophies the chamber preceding
• Increased work to pump past the narrow opening
• Murmur heard when valve is opened
Valvular Heart Disease
• Prolapse- stretching of the valve back into the preceding
chamber
• Insufficiency-Inability of valve to close completely
 Allows blood to flow back into the preceding structure
 Stretches it out
 Dilates the chamber preceding
 Murmur heard when valve is closed
 Heart works harder
• Has to pump the blood again
• Decrease CO
Valvular Heart Disease
• Etiology:
 Rheumatic fever
 Congenital malformations
 Calcium accumulation on valve leaflets
• Syphilis
• Aging
 Atrial myxomas (tumors)
 Blunt chest trauma
 Chronic hypertension
 Papillary muscle dysfunction
• Tricuspid/ Pulmonic Dysfunctions
 Rare in adults usually d/t congenital anomalies
Valvular Heart Disease
• Diagnosed by:
 Chest x-ray
 Echo
 Cardiac catheterization
 Stress test
 EKG
 Murmur
• Consequence of turbulent blood flow that produce vibrations
• Blowing/swishing sounds
• Note timing in cycle (“lub” or “dub”)
• Note location on chest where it is best heard
• Check for thrill associated with murmur
Subjective Assessment
• Palpitations
 Rapid, forceful or irregular heart beat
• Syncope
 Remind me of what this is…..
 Can be caused by aortic stenosis and/or aortic
insufficiency
• Personal/Family History
 Childhood diseases: Rheumatic fever
Mitral Stenosis
Acquired Valvular Dysfunctions
Mitral Stenosis
 Left atrium hypertrophies and dilates
 Blood backs up in the lungs
• Symptoms
 Dyspnea on exertion is usually first sign
 Diastolic murmur – Apex
 Fatigue, chest pain, activity intolerance
 Atrial fibrillation-20% develop systemic emboli
 Decreased pulse pressure
• Heart Sounds
Acquired Valvular Dysfunctions
Mitral Stenosis
 Diagnosis
 Symptoms
 CXR
 Echocardiogram
 Cardiac catheterization
 Treatment
 Valvular surgery
 Dig, diuretics, diet, sitting up, activity
restrictions, anticoagulants
 Prophylactic antibiotics
Acquired Valvular Dysfunctions
Mitral Regurgitation (Insufficiency)
• Mitral valve doesn’t close completely during systole Blood
regurgitates into left atrium
 Dilation and hypertrophy of left atrium & ventricles
 Left sided failure  pulmonary congestion
Acquired Valvular Dysfunctions
Mitral Regurgitation (Insufficiency)
 Signs and Symptoms
 Chronic is often asymptomatic
 Fatigue, dyspnea, chest pain, activity intolerance
 Atrial fibrillation-risk of emboli
 Systolic murmur-Apex
 Syncope
Acquired Valvular Dysfunctions
Mitral Regurgitation (Insufficiency)
• Treatment
 Valve repair/replace
 Digoxin, Diuretics, Diet, sitting up, activity restriction
 Nitrates, ACE Inhibitors
 Anticoagulants
Acquired Valvular Dysfunctions
Mitral Valve Prolapse
• One or both valve leaflets bulge into the left atrium during systole
• Signs and Symptoms
 Many asymptomatic-w/o regurgitation
 Vague symptoms usually with stress
• Tachycardia
• lightheadedness
• weakness
• fatigue
• palpitations
• chest pain
• exercise intolerance
Acquired Valvular Dysfunctions
Mitral Valve Prolapse
• Diagnosis
 Often the first and only sign is an extra heart sound called the mitral
click (systolic click)
• Treatment
 Depends upon symptoms
 Beta-Blockers: help control heart rate and B/P if needed
 Diuretics: help with fluid volume if overloaded
 Stress management
 Patients are at risk for infections from bacteria
adhering to abnormal valve structures
• Heart - Systolic click
Acquired Valvular Dysfunctions
Aortic Stenosis
• Obstruction of blood flow across aortic valve during systole
 Increased pressure in the left ventricle leads to left ventricular
hypertrophy
 Insufficient O2 supply to heart and brain
Acquired Valvular Dysfunctions
Aortic Stenosis
• Signs and Symptoms
 Systolic murmur that is low pitched, rough, rasping, and vibrating Occurs
gradually
 Dyspnea
 Vertigo & syncope
 Angina
 Pulse pressure may be low
• Diagnosis:
 EKG,
 CXR,
 ECHO
• Heart - Murmur
Acquired Valvular Dysfunctions
Aortic Stenosis
• Treatment
 Digoxin, diuretics, diet, sitting up, activity restrictions
 Antibiotics - before invasive medical or dental procedure
 Valve replacement is only definitive treatment
*Nitro is contraindicated!
Aortic Regurgitation
Acquired Valvular Dysfunctions
Aortic Regurgitation (Insufficiency)
• Blood forward regurgitates backward into the left ventricle left
ventricular hypertrophies then dilates
• Diastolic murmur
 2nd ICS right
 High-pitched, blowing sound
• Diagnosis
 EKG
 CXR
 ECHO
Acquired Valvular Dysfunctions
Aortic Regurgitation (Insufficiency)
• Signs and Symptoms
 May have long period of no symptoms
 May feel “forceful” heartbeat
 Dyspnea
 Palpitations
 Increased pulse pressure (low diastolic)
• Treatment
 Dig, diuretics, diet, activity restrictions
 Valve replacement
Acquired Valvular Dysfunctions
• Nursing Care: Valvular Heart Disease
 May remain asymptomatic for many years
 Initial indication of problem – murmur
 Teaching
• Disease
• Diet
• Medications
• Exercise
• Prescriptions
Acquired Valvular Dysfunctions
• Nursing Care: Valvular Heart Disease
 Assess
• Vital signs
• Complications CHF
 Prophylactic – antibiotics
 Surgical repair/replacement
• Replace with biologic - durability problems
• Replace with artificial - lifelong anticoagulants
Acquired Valvular Dysfunctions
• Repair:
 Commissurotomy
• Valve reconstruction - excision of parts of leaflets to enlarge opening
 Valvuloplasty: repair rather than replace
• Catheter with balloon
• Dilate valve
 Chordoplasty
• Repair of the chordae tendineae
 Annuloplasty
• Rebuild leaflets and annulus
Commissurotomy
Acquired Valvular Dysfunctions
Valve Replacement:
• Homografts – human cadaver valves (seldom used – not readily available)
• Heterograft – valve from pig or cow
 Last approximately 10-15 years
*Do not need lifetime anticoagulants
New on the Horizon
Transcatheter Aortic Valve Replacement (TAVR)
 Heterograft (cow’s pericardium)
 Used for severe aortic stenosis
 Valve is reached via a catheter introduced through the femoral artery
 Recently approved by the FDA
Acquired Valvular Dysfunctions
Mechanical Valves
• Do not deteriorate or become infected as easily as the tissue
valves
 Clots tend to form on them
 Can be used up to 25 years
 Clicks
 Lifetime anticoagulants
Acquired Valvular Dysfunctions
Valve Replacement:
• Disadvantages
 Risk of infection with procedures
 Noisy
 Thrombus
 Anemia-breakdown of RBC
Acquired Valvular Dysfunctions
• Complications
 Valve regurgitation
 Restenosis
 Perforation of the myocardium
 Rarely, systemic embolization
Tissue & Mechanical Valves
Inflammatory Heart Disease
Heart and heart wall layers
• Let’s review!!!
 What is the outermost layer of the heart?
 What is the middle layer?
 What is the inner layer?
Pericardial Sac
• Tell me what you know about the pericardial sac…
 What are the 2 layers?
 What is the pericardial space?
 What is the purpose of the fluid inside the pericardial space?
Inflammatory Cardiac Disorders
• Pericarditis:
 Syndrome caused by inflammation of pericardium
 Constrictive Pericarditis
• Chronic problem
• Fuse pericardium's
• Ask me about pericardial windows
Pericardial Window
Pericarditis
• Etiology
 Infection
• Viral, bacterial - staph, strep, fungal, TB
 Myocardial injury
• Cardiac trauma
• Dressler’s syndrome post MI
 Auto immune
• collagen disease - rheumatic fever- scleroderma
 Metabolic disorders - uremia
 Cancer
 Radiation and Chemotherapy
Pericarditis
• Signs and Symptoms:
 Chest pain - more severe on inspiration, coughing, and swallowing,
abrupt onset
• Relieved by position change (leaning forward)
 Dyspnea, tachycardia
 Chills, fever
 Pericardial friction rub
• Heard best at apex and left sternal border – scratchy,
grating, rasping
 Elevated ESR (Erythrocyte Sed Rate)
• Indicates inflammation – measures speed of RBC’s
settling
 Elevated WBC
 Blood cultures
 EKG- shows ST elevation, atrial fibrillation
Pericarditis – 12 lead EKG
Pericarditis
AMI
Pericarditis
• Diagnostics
 Chest x-ray
 Echocardiogram
 CT: best at determining size, shape, and location of any
effusions
Pericarditis
• Treatment:
 Treat underlying causes
 Anti-inflammatory
 Analgesics, antibiotics
 Pericardiocentesis
• Aspiration of fluid from pericardial sac
Pericardiocentesis
Nursing Care with Pericarditis
• Pain management
• Activity restrictions till pain and fever resolve
• Assess for complications:
 CHF
 Cardiac Tamponade: compression of the heart
Cardiac Tamponade
• Life threatening
• Complication of pericarditis or chest trauma
• Fluid accumulates in the pericardial cavity
• Restricts diastolic filling
• Compresses the heart  blood cannot
flow into the heart
Cardiac Tamponade
• Signs and Symptoms:
 Decreased B/P, elevated pulse, jugular vein distention
 Cyanosis of the lips, nails, dyspnea
 Muffled heart sounds, diaphoresis
 Paradoxical pulse - weak pulse on inspiration
 Pulsus Paradoxus – drop in B/P 10 mm Hg during inspiration
• Cause by altered filling pressures in R&L ventricles
– Can be seen with constrictive pericarditis
and pulmonary hypertension
http://www.youtube.com/watch?v=jTsjCZ9QxW8
Cardiac Tamponade
• Treatment
 Pericardiocentesis
Medical Emergency!!!
Pericardiocentesis
More Inflammatory Cardiac
Disorders
• Endocarditis:
 Inflammatory/Infective process
• Colonize valves-especially damaged ones
• Vegetation breaks off and embolizes through body
Brain, joints, kidney, lungs
Cause petechiae in periphery
 Rheumatic Fever is considered an endocarditis
 Acute bacterial endocarditis
• Develops days to weeks
 Subacute bacterial endocarditis
• Develops weeks to months
More Inflammatory Cardiac
Disorders
• Endocarditis: An infection of the inner lining of the heart
• Etiology
 Following invasive procedure-including dental procedures
 IV drug users
 Previously damaged valves
 Piercings
• Signs and Symptoms
 Malaise, fever, fatigue, weakness, cough
 HA with musculoskeletal complaints
 Murmur, dyspnea, splenomegaly
 Increased pulse, night sweats, emboli  brain,
kidney, lungs
Endocarditis
Endocarditis
• Signs and Symptoms:
 Splinter hemorrhages – reddish/brown lines and streaks seen under
nail beds
 Osler’s nodes - painful, red, pea sized, nodules in the skin of the
extremities (usually fingertips)
 Janeway lesions - flat, small, non-tender red spots
on palms of hands and soles of feet
 Ocular - conjunctional petechiae, Roth’s spots fundus is white or yellow center surrounded by red,
irregular halo
Splinter Hemorrhages
Osler’s Nodes
Janeway Lesions
Roth Spots
Endocarditis
• Diagnosis
– Blood cultures
– Elevated WBC,ESR
– EKG, Echo
• Treatment
– Antibiotic - 4 to 6 weeks
• Prophylactic for procedures
– Restricted activity - depending on condition
– Valve replacement
– Anticoagulants
Endocarditis
• Prevention
– Education of clients at high risk is essential
– Antibiotics before high risk procedures
– Could IV therapy and blood draws be high risk procedures
– Good dental hygiene - regular dental check ups
– Avoid people with URI
– May be on anticoagulant therapy
• Medication action, administration, SE
– Educate on S/S of heart failure
• # 1 complication and cause of death in endocarditis
Heart Transplants
• End stage heart disease
• Must meet transplant candidate requirements
• Life long immunosuppressants
– Protect from infection
• Monitor for rejection
– Pain
– Fever
– Dyspnea
– Malaise
– Fatigue
– New onset dysrhythmia
–Complications
– Hypertension and CHF