Valvular Heart Disease Cardiomyopathy and Aneursyms 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 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. 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 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 TEE MVP 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 Aortic Valve Problems 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 Stenosis Syncope Angina Dyspnea Manifestations 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 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-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 non-biologic surfaces.

This is an excised porcine bioprosthesis 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? CXR Echocardiography Cardiac cath 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 Restrictive cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy 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 Aneurysm- 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 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 Genetic 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 Aneursyms

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

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 Thrombi Renal Failure 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/aneurysm_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 Sedatives 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 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.