Valvular Heart Disease

Valvular Disorders Mitral stenosis Mitral regurgitation Mitral valve prolapse Aortic stenosis Aortic regurgitation

Definition STENOSIS - Occurs when valve leaflets close together and cannot fully open or close REGURGITATION or (Insufficiency) - Heart valves cannot close completely

Acquired Defects Decreasing order of occurrence Mitral stenosis (most common) Mitral regurgitation Mitral valve prolapse Aortic stenosis Aortic regurgitation

Facts 5 million ~ 2/3 to ¾ women ~ 2/3 of women under 45

Mitral Stenosis Most common cause: rheumatic fever Results from rheumatic carditis Causing valve thickening by fibrosis and calcification Non-rheumatic causes Atrial tumor Calcium accumulation Thrombus formation

What Happens Valve leaflets fuse and become stiff Chordae tendineae contract and shorten Valvular orifice narrows

Diagnostics Echocardiogram *( also TEE) Chest Xray EKG Cardiac cath

Clinical Manifestations Mild stenosis Asymptomatic Beginning Dyspnea on exertion (DOE) Orthopnea Paroxysmal nocturnal dyspnea (PND) Dry cough

Clinical Manifestations Later Hemoptysis Pulmonary edema Right-sided heart failure (DD:Cor Pulmonale) Hepatomegaly Neck vein distention (JVD) Pitting edema ? One more ? Apical diastolic murmur

Mitral Regurgitation

Mitral Regurgitation (Insufficiency) Fibrotic and calcific changes prevent the mitral valve from closing completely during systole. End result left atrial and ventricular dilation and hypertrophy.

Causes Rheumatic heart disease Degenerative calcification Left ventricular hypertrophy MI Congenital defects

Clinical Manifestations Progresses slowly Asymptomatic for decades Chief complaints Fatigue Chronic weakness DOE Orthopnea .

Clinical Manifestations …Continued… Normal blood pressure Atrial fibrillation (75% of all clients). Changes in respiratory patterns High pitched systolic murmur at apex Third heart sound (S3 or S4)

Mitral Valve Prolapse

Mitral Valve Prolapse Valvular leaflets enlarge and prolapse into left atrium during systole Usually benign, but may progress to mitral regurgitation Affects 5%-10% of the population (most common in women 14-30).

Clinical Manifestations Chief complaint Atypical chest pain (sharp localized L chest pain) Dizziness Syncope Tachydysrhythmias causing palpitations Systolic murmur at apex

Aortic Stenosis

Aortic Stenosis Aortic valve orifice narrows and obstructs left ventricular outflow during systole Results in left ventricular hypertrophy Cardiac output becomes fixed and symptoms develop Eventually, can lead to right heart failure as well. Most common valvular disorders in elderly 80% occur in males

Causes Congenital Rheumatic heart disease Atherosclerosis Degenerative calcifications

Clinical Manifestations May be asymptomatic for years Classic manifestations: DOE, angina, syncope Other: narrow pulse pressure systolic murmur

Aortic Regurgitation

Aortic Regurgitation (Insufficiency) Aortic leaflets do not close properly during diastole with possible annulus dilation, loosening, or deformity. Allows blood to flow back into left ventricle from aorta during diastole. End result: left ventricular hypertrophy

Clinical Manifestations Asymptomatic (early) Left ventricle has good compensatory mechanisms  Progression Chief complaints DOE Orthopnea PND Palpitations Nocturnal angina with diaphoresis

Clinical Manifestations High pitched diastolic murmur Diminished diastolic pressure Elevate Systolic blood pressure Wide pulse pressure

Causes Mostly results from rheumatic heart disease Non-rheumatic conditions Infective endocarditis Congenital aortic valve problems Hypertension Marfan’s syndrome

Assessment Insidious or acute onset History Rheumatic fever? Recent infections? IV drug usage? Fatigue and activity tolerance? Family Hx?

Care for All Valvular Disorders

Diagnostics Echocardiogram *( also TEE) Chest Xray EKG (atrial fib most common) Cardiac cath

Interventions Non-surgical management Drug therapy Rest Diuretics Digoxin Oxygen Ace Inhibitors Vasodilators (stenosis) Prophylactic antibiotic therapy Anti coagulants for A-Fib Rest

Interventions Treating atrial fibrillation Rate control: digitalis, diltiazem, sotalol, amiodaron etc. Rhythm control: Cardioversion: Pharmacology Electrical Anti thrombo-embolic: Anticoagulant: Coumadin Antiplatelet: Asetosal

Interventions Surgical management Aortic stenosis requires surgical therapy as it is the only definitive treatment Valve replacements Prosthetic Biologic Surgical repairs Balloon valvuloplasty –cath lab Reconstructive or “Valvuloplasty”: a. Open commisurotomy b. Annuloplasty repairs

Pre-Operative Care Similar to CABG surgery Pain Incisional care Prevent pulmonary complications STOP oral anticoagulants 72 hours before procedure

Post-Operative Care Respiratory care Monitor for hemorrhage Cardiac output reduction Discharge teaching

Complications Fluid & Electrolyte imbalances Hypotension Bleeding Cardiac tamponade Fluid ---check I & O –esp. Output showing signs of dec. CO Hemodynamic monitoring will show FVD or FVE . Elytes---Which is MOST important? K+ and Mg+ protocol. Beck’s triad) Hypotension, muffled heart sounds, pulsus paradoxus – FOR cardiac tamponade

Complications Altered cerebral perfusion Hypothermia Hypertension Infection Post pump syndrome –short term memory loss. Normotensive important to prevent graft blowing with hypertension and prevent hypo , it decreases CO

Client Education Disease process Medications Rest and activity plan Anticoagulants Prophylactic antibiotics Rest and activity plan