Intro to Valvular Disease Morris, an 82 year-old man, went to the doctor to get a physical. A few days later, the doctor saw Morris walking down the street with a gorgeous young woman on his arm. A couple of days later, the doctor spoke to Morris and said, 'You're really doing great, aren't you?' Morris replied, 'Just doing what you said, Doc: 'Get a hot mamma and be cheerful.'' The doctor said, 'I didn't say that.. I said, 'You've got a heart murmur; be careful.'

Valvular Heart Disease Heart contains Two atrioventricular valves Mitral Tricuspid Two semilunar valves Aortic Pulmonic **review areas to listen**

Tricuspid

Valvular Heart Disease Types of valvular heart disease depend on Valve or valves affected Two types of functional alterations Stenosis Regurgitation Valvular disorders occur in children and adolescents primarily from congenital conditions and in adults from degenerative heart disease Stenosis and Insufficiency

Risk Factors Rheumatic Heart Disease, MI Congenital Heart Defects-bicuspid valve Aging CHF

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 All valvular diseases have a characteristic murmur murmurs

Mitral Valve Stenosis Pathophysiology Decreased blood flow into LV LA hypertrophy Pulmonary pressures increase Pulmonary hypertension Decreased CO

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

Treatment

Mitral Valve Regurgitation Pathophysiology Regurgitation of blood into LA during systole LA dilation and hypertrophy Pulmonary congestion RV failure LV dilation and hypertrophy-to accommodate increased preload and decreased CO Manifestations Thready pulses Cool extremities Symptoms of LV failure Third heart sound (S3) MVR murmur

Mitral Valve Prolapse Pathophysiology Abnormality of the mitral valve leaflets, papillary muscles or chordae Type of mitral insufficiency Etiology unknown Most common valvular heart disease in US Female 2x > Male Manifestations Usually asymptomatic Click murmur Atypical chest pain does not respond to NTG Tachydysrhythmias may develop- SVT, VT Risk for endocarditis may be increased – heart association guidelines heart association guidelines

Mitral Valve Prolapse Usually benign, but serious complications can occur Mitral valve regurgitation Infective endocarditis Sudden death Cerebral ischemia 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) 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 %sudden cardiac death Aortic Valve Problems

Aortic Valve Stenosis Manifestations S yncope A ngina D yspnea 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

Aortic Valve Regurgitation Bicuspid valve, genetic Increased preoad- 60% of SV can be regurgitated Characteristic water hammer pulse Regurgitation of blood into the LV LV dilation and hypertrophy Decreased CO Pathophysiology

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

Water Hammer pulse Pulse, water hammer: A jerky pulse that is full and then collapses because of aortic insufficiency (when blood ejected into the aorta regurgitates back through the aortic valve into the left ventricle ). Also called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse. YouTube - Corrigan's sign YouTube - Corrigan's sign Austin Flint

Tricuspid and Pulmonic Valve Disease Pathophysiology Uncommon Both conditions cause an increase in blood volume in R atrium and R ventricle Result in Right sided heart failure Tricuspid- Rheumatic, IV drug abuse Pulmonic- Congenital Manifestations RHF

Diagnostic Tests Echo- assess valve motion and chamber size CXR EKG Cardiac cath- get pressures

Medications Like Heart Failure ACE inhibitors Digoxin Diuretics Vasodilators Beta blockers Anticoagulants *Prophylactic antibiotics Antiarrhythmics

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 Heart valve surgery Mechanical-need anticoagulant Biologic-only last about 15 years Ross Procedure MedlinePlus: Interactive Health TutorialsMedlinePlus: Interactive Health Tutorials- on own

Ross Procedure

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 because of wear and calcification.

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 non- biologic surfaces.

Nursing Diagnoses Activity intolerance Excess fluid volume Decreased cardiac output Ineffective therapeutic regimen management

What is new? Percutaneous Transcatheter Heart Valve Implantation- Metallic clip -for the treatment of mitral regurgitation Longer-lasting replacement valves Stem cell research and the use of endothelial cells

Review of Valvular diseases using Prezis Case 1 Case 2 Case 3 Case 4 Case 5Case 5-overview all Case 6

Cardiomyopathy Condition is which a ventricle has become enlarged, thickened or stiffened. As a result heart’s ability as a pump is reduced

Cardiomyopathy-Causes Primary-idiopathic Secondary Ischemia- from CAD infectious disease exposure to toxins-alcohol, cocaine Metabolic disorders Nutritional deficiencies Pregnancy

3 Types of Cardiomyopathy Dilated Hypertrophic Restrictive

Pathophysiology Dilated Most common- heart failure in 25-40% Cocaine and alcohol abuse Chemotherapy, pregnancy Hypertension Genetic * Heart chamber dilate and contraction is impaired and get dec. EF% *Dysrhythmias are common- SVT Afib and VT Prognosis poor-need transplant

Dialated Cardiomyopathy Diagnostics – Echocardiogram, CXR, ECG, labs Treatment-Control HF – Diuretics – Nitrates – Ace inhibitors – Beta blockers – Digoxin – Amiodarone – Anticoagulants

Normal weight 350 gms now 700 gms

Pathophysiology Hypertrophic-HCMHypertrophic-HCM **Genetic 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(fatigue from dec CO) Sudden cardiac death may be first symptom **HCM most common cause of SCD in young adulthood

Hypertrophic Cardiomyopathy Manifestations Dyspnea Fatigue-dec CO Angina, syncope S4 and systolic murmur Diagnostics Echo- TEE Heart cath

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 If chest pain- rest and elevation of feet for venous return Avoid vasodilators like nitroglycerine- decrease venous return to the heart

Pathophysiology Restrictive Least common Rigid ventricular walls that impair filling Contraction and EF normal Signs of CHF Prognosis-poor

Diagnostics for CMP Echo- wall motion and EF EKG CXR Hemodynamics Perfusion scan Cardiac cath Myocardial biopsy

Treatment Medications Same as for heart failure except for hypertrophic Surgery Vad-bridge to transplant or destination therapy 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