1. Adult Medical-Surgical Nursing
Cardiovascular Module:
Cardiac Valvular Disorders

2. Cardiac Valvular Disorders: Description
The cardiac valves are:
Aortic
Pulmonary
Mitral
Tricuspid
Disorders lead to poor blood flow through the heart, and may lead to ↓ cardiac output

3. Cardiac Valvular Disorders: Classification
Stenosis
Incompetence

4. Cardiac Valve Stenosis
Narrowing of the valve
Increases demand on the myocardium to pump blood through the valve

5. Cardiac Valve Incompetence
Incompetence/ regurgitation:
A damaged valve which leaks and does not close properly
Leads to:
Backflow of blood during systole and increased back pressure
↓ cardiac output

6. Cardiac Valvular Disorder: Aetiology
Congenital
Ageing: wear and tear
Rheumatic heart disease or bacterial endocarditis:
An auto-immune response following Rheumatic fever (less common now) or streptococcal throat infection
→ endocarditis and chronic bacterial vegetation around valve/ valves

7. Cardiac Valvular Disorder: Diagnosis
History and clinical findings
Chest Xray
ECG
Echocardiography
Cardiac catheterisation: reveals degree of closure / incompetence

8. Prevalent Conditions Mitral stenosis Mitral incompetence
Aortic stenosis
Aortic incompetence

9. Mitral Stenosis

10. Mitral Stenosis: Pathophysiology
Narrowing of mitral valve:
This causes left atrium to force blood to left ventricle
→ dilatation/ hypertrophy of left atrium
Atrial fibrillation: risk of thrombus/ emboli
Backflow/ congestion in pulmonary circulation leads to:
Increased workload of right ventricle →
Right heart failure

11. Mitral Stenosis: Clinical Manifestations
Fatigue/ dizziness (low cardiac output)
Respiratory problems:
Dyspnoea, cough, frequent chest infections, haemoptysis
Atrial fibrillation (dysrythmia): weak often irregular pulse (risk of emboli)
Diastolic murmur on auscultation

12. Mitral Stenosis: Medical Management
Treat congestive heart failure:
Diuretics, Digoxin, vasodilators (reduce afterload)
Anti-dysrythmics
Anticoagulants (longterm to prevent emboli)
Antibiotics prior to dental or surgical procedures (to prevent endocarditis)

13. Mitral Stenosis: Surgery
Valvotomy
Valve replacement:
An animal or human valve
An artificial valve (prosthesis)*
*With an artificial valve long-term anticoagulants required (risk of thrombus)

14. Mitral Incompetence

15. Mitral Incompetence: Pathophysiology
The mitral valve does not close and leaks causing:
Backflow of blood during systole from left ventricle to left atrium
→ cardiac output is reduced
→ increased pressure, dilatation and hypertrophy of left atrium
Pulmonary congestion →
Right heart failure

16. Mitral Incompetence: Clinical Manifestations
Maybe symptomless
Fatigue and weakness
Palpitations on exertion
Dyspnoea and cough
Systolic murmur at apex on auscultation

17. Mitral Incompetence: Surgery
Surgical intervention is necessary as progressively cardiac output is reduced and pulmonary congestion increased:
Valvuloplasty (repair)
Valve replacement
Medical management of symptoms

18. Aortic Stenosis

19. Aortic Stenosis: Pathophysiology
Narrowing of the aortic valve
Causes increased filling and effort of the left ventricle (forcing blood through) →
Left ventricular hypertrophy
Left ventricular failure (maybe acute pulmonary oedema)

20. Aortic Stenosis: Clinical Manifestations
Faintness/ dizziness (low cardiac output)
Angina:
O2 demand of hypertrophied left ventricle
Slow forceful systole reduces diastole and filling time for coronary circulation
Dyspnoea:
If LVF:
Copious blood-stained frothy sputum

21. Aortic Stenosis: Auscultation
Loud systolic murmur over aortic area and vibration of turbulent blood felt by a hand over the apex

22. Aortic Stenosis: Management
Medical:
Treat angina and symptoms of LVF:
Vasodilators, Digoxin, diuretics, anticoagulants
Antibiotics prior to dental work or surgery to prevent endocarditis
Surgery:
Valvotomy
Valve replacement

23. Aortic Incompetence

24. Aortic Incompetence: Pathophysiology
Aortic valve is damaged and leaking
Blood regurgitates from aorta during diastole into left ventricle → dilatation
Left ventricle hypertrophies to force emptying into the aorta
→ increased systolic BP
Arterial vasodilatation to compensate
(↓ peripheral resistance): ↓ diastolic BP
(↑ pulse pressure) → LVF

25. Aortic Incompetence: Clinical Manifestations
Forceful heartbeat
Dyspnoea on exertion and fatigue
Paroxysmal nocturnal dyspnoea and orthopnoea (may lead to LVF)
↑ pulse pressure, “water-hammer” pulse (rapid strong pulse which then collapses)
Diastolic murmur on auscultation

26. Aortic Incompetence: Management
Medical management of LVF
Antibiotic cover for dental or surgery to prevent endocarditis
Surgery: Aortic valve replacement
(This is the preferred management)
Anticoagulants long-term if artificial valve

27. Nursing Responsibilities
Physical examination
ECG monitoring
Weight, vital signs, fluid balance
ICU nursing post-surgery
Patient education on diet, degree of exercise and rest, medications
Psychological/ emotional support