1. Valvular Heart Disease

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

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

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

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

6. 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

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

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

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

10. 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

11. Mitral Regurgitation

12. 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.

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

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

15. 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)

16. Mitral Valve Prolapse

17. 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).

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

19. Aortic Stenosis

20. 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

21. Causes Congenital Rheumatic heart disease Atherosclerosis
Degenerative calcifications

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

23. Aortic Regurgitation

24. 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

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

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

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

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

29. Care for All Valvular Disorders

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

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

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

33. 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

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

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

36. 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

37. 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

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