1. Valvular Heart Disease Cardiomyopathy and Aneursyms
Althea Aranda RN,MSN,CCRN From notes by
Laurie Dickenson

2. Valvular Heart Disease
Heart contains
Two atrioventricular valves
Mitral
Tricuspid
Two semilunar valves
Aortic
Pulmonic
Valvular Disease

3. Valvular Heart Disease
Types of valvular heart disease depend on
Valve or valves affected
Two types of functional alterations
Stenosis
Regurgitation
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4. 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

5. 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

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

7. Fig. 37-9
Fish mouth

8. 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

9. 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

11. 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

12. 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

14. 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 %sudden cardiac death

15. 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

16. Bicuspid Aortic Valve Congenital Heart Defect
Most Common Congenital Heart Disease
Familial
Male>Female

17. 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

18. 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

19. 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.

20. 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

21. Diagnostic Tests Echo- assess valve motion and chamber size CXR EKG
Cardiac cath- get pressures-especially if think need surgery
Patients history
TEE

22. Medications Like Heart Failure ACE inhibitors Beta Blockers Digoxin
Diuretics
Vasodilators
Anticoagulants
Prophylactic antibiotics

27. Mitral Stenosis Therapy
Surgical
Mitral Commissurotomy
Mitral Valve Replacement
Mechanical
Bioprosthetic

28. YouTube - Robotic Mitral Valve Repair Surgery Animation

30. 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.

31. 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.

32. Ross Procedure

33. Mitral Regurgitation
MitraClip 3D Animation

34. Medical Animation. Aortic valve replacement

35. 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
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36. Nursing Diagnoses Activity intolerance Excess fluid volume
Decreased cardiac output
Ineffective therapeutic regimen management

37. 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

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

39. 3 Types
Dilated
Hypertrophic
Restrictive

40. 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

41. 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.

42. Normal weight 350 gms now 700 gms

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

44. Other treatments
VAD
Heart transplant

46. 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

47. 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

51. 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.

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

53. 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

54. 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

55. 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

56. 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

57. Restrictive Cardiomyopathy
Diagnostics
Echo-wall motion and EF
ECG
CXR
Hemodynamics
Perfusion scan
Cardiac cath
Myocardial biopsy

58. 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

59. 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.

62. Nursing Diagnoses Decreased Cardiac Output Fatigue
Ineffective Breathing Pattern
Fear
Ineffective Role Performance
Anticipatory grieving

63. Question #1
Which of the following diagnostics best differentiates the types of cardiomyopathy?
CXR
Echocardiography
Cardiac cath
ABG

64. Question # 2 Which type of cardiomyopathy has the poorest prognosis
1. dilated cardiomyopathy
2 Restrictive cardiomyopathy
3.hypertrophic cardiomyopathy
4 all of the above

65. Question # 3 Which of these are more likely to present as SCD
Restrictive cardiomyopathy
Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Acute MI

66. Question # 4
Water Hammer pulse is a sign of 1.Mitral valve stenosis 2acute aortic valve regurgitation 3Chronic aortic valve regurgitation Aortic valve stenosis

67. Question #5 Most cases of Mitral valve stenosis are caused by
1 congenital birth defects
2 Rheumatic fever
Atrial septal defects
lupus

68. 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

69. 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

70. 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

71. Dilated aortic wall becomes lined with thrombi than can embolize
Leads to acute ischemic symptoms in distal branches
Important to assess peripheral pulses

72. 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

73. 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

74. 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

75. Types of Aneurysms
Saccular
Fusiform-most are fusiform and 98% are below the renal artery

76. 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

77. Causes of false aneurysm
Trauma
Infection
Peripheral artery bypass graft surgery

78. 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

79. 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

80. 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)

81. 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

82. Complications Rupture- signs of ecchymosis Thrombi Renal Failure
Back pain
Hypotension
Pulsating mass
(rupture triad)
Thrombi
Renal Failure

83. 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)

84. Turner’s sign and Cullen’s Sign
Live Search Videos: aortic aneurysm

85. Aortic Aneurysm Diagnostic Studies
X-rays
Chest -
Abdomen -
ECG -to rule out MI
Echocardiography
Ultrasound
CT scan
MRI
Angiography

86. Medical Treatment Anti-hypertensives Sedatives
Beta blockers,
Vasodilators
Calcium channel blockers
Nipride
Sedatives
Niacin, mevocor, statins
Post-op anti-coagulants
GOAL PREVENT RUPTURE

87. 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.)

88. Endovascular stents- placed through femoral artery

89. YouTube - Abdominal Aortic Aneurysm Graft Repair

90. 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"

91. 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)

92. Aortic Dissection
Blood invades or dissects the layers of the vessel wall

93. 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.

94. Aortic dissection occurs when blood enters the wall of aorta, separating its layers, and creating a blood filled cavity.

95. 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

96. 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

97. Aortic Dissection Manifestations
Abrupt severe ripping or tearing pain
Mild or marked HTN early
Weak or absent pulses and BP in upper extremeties
Syncope

98. 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

99. Aortic Dissection Collaborative Care
Drug therapy
IV Beta- adrenergic blocker
Esmolol (Brevibloc)
Other antihypertensive agents
Calcium channel blockers
Sodium Nitroprusside
Angiotensin converting enzyme

100. 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%)

101. Nursing Diagnoses Risk for Ineffective Tissue Perfusion
Risk for Injury
Anxiety
Pain
Knowledge Deficit

102. 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

103. Nursing Management Infection Neurologic Status
Peripheral perfusion status
Renal perfusion status
Gastrointestinal status
Ambulatory /Home care

104. 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.

105. 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.

106. 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.

107. 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.