by Laurie Dickson

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 HeartPoint: HeartPoint Gallery Flashcards about Ch 19 NETI KQ- on your own

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

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

Mitral Valve Prolapse Pathophysiology Manifestations Abnormality of the mitral valve leaflets, papillary muscles or chordae Etiology unknown Most common valvular heart disease in US Female 2x > Male Usually asymptomatic 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) MVP murmur (mid-systolic click) TEE MVP

Aortic Valve Stenosis Pathophysiology Aortic Valve Problems 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 Stenosis Manifestations May be asymptomatic for many years due to compensation AVS murmur Nitroglycerin is contraindicated because it reduces preload S yncope A ngina D yspnea Exertional Syncope, Angina, DOE are classic symptoms This triad reflects LVF Later get signs of RHF

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 Characteristic water hammer pulse 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

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

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

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

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 non- biologic 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 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 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. 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

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

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

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. cardiomyopathy PTSMA

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

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 IE

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

Case study 15 Ms. C. 81y/o admitted to CCU with SOB. She has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate with occ. PVC’s. The only med ordered is MSO4 2-4mg IV as needed for chest pain or dyspnea. As you go to assess her you find her in bed at 60 degree angle. She is pale, has circumoral cyanosis and respirations are rapid and labored.

Question 1 What action should you take first? 1.Listen to breath sounds 2.Ask when the dyspnea started 3.Increase her O2 to 6L minute 4.Raise the HOB to degrees

#2 Which one of these complications are you most concerned about, based on your assessment? 1. Pulmonary edema 2. Cor pulmonale 3. Myocardial infarction 4. Pulmonary embolus

#3 Which action will you take next? 1. Call the physician about client’s condition. 2. Place client on a non-rebreather mask with FiO2 at 95%. 3. Assist client to cough and deep breathe. 4. Administer ordered morphine sulfate 2mg IV.

#4 What additional assessment data are most important to obtain at this time? 1. Skin color and capillary refill 2. Orientation and pupil reaction to light 3. Heart sounds and PMI 4. Blood pressure and apical pulse

#5 Client’s B/P is 98/52 and AP is 116 and irregular in ST rate with frequent multifocal PVC’s. You call the physician and receive these orders. Which one should be done first? 1. Obtain serum dig level 2. Give furosemide 100mg. IV 3. Check blood potassium level 4. Insert #16 french foley catheter

#6 Which order could be assigned to an LVN? 1. Obtain serum digoxin level 2. Give furosemide 100mg. IV 3. Check blood potassium level 4. Insert #16 french foley catheter

#7 While you are waiting for the the potassium level, you give morphine sulfate 2mg IV to the the client. A new graduate asks why you are giving her the morphine. What is the best response? 1. It will help prevent any chest pain from occurring. 2. It will decrease her respiratory rate. 3. It will make her more comfortable if she has to be intubated. 4. It will decrease venous return to her heart.

#8 Her K is 3.1. the physician orders KCL 20meq. IV. How will you administer it. 1. Utilize a syringe pump to infuse the KCL over 10 minutes. 2. Dilute the KCL in 100 ml of D5W and infuse over 1 hour. 3. Use a 5ml syringe and push the KCL over at least 1 minute. 4. Add the KCL to 1 liter of D5W and administer over 8 hours.

#9 After you have infused the KCL, you give the lasix. Which of these nursing actions will be most useful in evaluating whether the lasix is having the desired effect? 1. Obtain the client’s daily weight 2. Measure the hourly urine output 3. Monitor blood pressure 4. Assess the lung sounds

#10 The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion? 1. Lung sounds 2. Heart rate 3. Blood pressure 4. Peripheral edema

#11 Which nurse should be assigned care for this client? 1. A float RN who has worked on CCU step down for 9 years and has floated before to CCU 2. An RN from a staffing agency who has 5 years CCU experience and is orienting to your CCU today 3. A CCU RN who is already assigned to care for a newly admitted client with chest trauma 4. The new graduate RN who needs more experience in caring for client with left ventricular failure.

#12 Which information would be important to report to the physician? 1. Crackles and oxygen saturation 2. Atrial fibrillation and fuzzy vision 3. Apical murmur and pulse rate 4. Peripheral edema and weight

#13 All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician? Furosemide 40mg po bid Ecotrin 81mg po daily KCL 10meq three times a day Captopril 6.25mg po three times a day Lanoxin.125mg po every other day

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

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 Risk increases with age Studies suggest strong genetic predisposition *Male gender and smoking stronger risk factors than hypertension and diabetes Atherosclerosis Risks: 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

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 Saccular Fusiform-most are 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

Ascending Aortic Aneurysm Aortic Arch Clinical Manifestations ASH 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 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 Death

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

Turner’s sign and Cullen’s Sign

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

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

Abdominal Aortic Aneurysm 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 case study

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 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 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, right lower quadrant tenderness, nausea, and anorexia for the past 2 days. C. A 40 year old female with moderate right 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.