1. Valvular Heart Disease
Dr.Isazadehfar

2. Types Mitral Stenosis Mitral Regurgitation Mitral Valve Prolapse
Aortic Stenosis
Aortic regurgitation
Tricuspid valve is affected infrequently
Tricuspid stenosis – causes Rt HF
Tricuspid regurgitation –causes venous overload

4. Rheumatic Heart Disease
Inflammatory process that may affect the myocardium, pericardium and or endocardium
Usually results in distortion and scarring of the valves

5. Rheumatic Heart Disease, cont.
Subjective symptoms
Prior history of rheumatic fever
General malaise
Pain – may or may not be present
Objective symptoms
Temperature
Murmurs
Dyspnea
polyarthritis

6. Rheumatic Heart Disease
Diagnosis
H/P
WBC and ESR
C-reactive protein
Cardiac enzymes
EKG
Chest x-ray
Echo
Cardiac cath
Cardiac output

7. Rheumatic Heart Disease
Nursing Care
Vital signs
Rest and quiet environment
Give antibiotics, digitalis, and diuretics
Provide adequate nutrition
Monitor I/O
Explain treatment and home care

8. Cardiac Physiology Systole AV/PV – opens S1-S2 MV/TV – closes
Diastole AV/PV – closes
S2-S1 MV/TV – opens

9. Cardiac Physiology

11. Cardiac Physiology Systole AV/PV – opens-------Aortic Stenosis
Regurg/ Insuff – leaking (backflow) of blood across a closed valve
Stenosis – Obstruction of (forward) flow across an opened valve
Systole AV/PV – opens Aortic Stenosis
S1-S2 MV/TV – closes------Mitral Regurg
Diastole AV/PV – closes------Aortic Regurg
S2-S1 MV/TV – opens Mitral Stenosis
These concepts are set in stone, it can’t occur any other way,
It would be anatomically impossible

12. Cardiac Anatomy

13. Mitral Stenosis Usually results from rheumatic carditis
Is a thickening by fibrosis or calcification
Can be caused by tumors, calcium and thrombus
Valve leaflets fuse and become stiff and the cordae tendineae contract
These narrows the opening and prevents normal blood flow from the LA to the LV
LA pressure increases, left atrium dilates, PAP increases, and the RV hypertrophies
Pulmonary congestion and right sided heart failure occurs
Followed by decreased preload and CO decreases

14. Mitral Stenosis, cont. Mild – asymptomatic
With progression – dyspnea, orthopneas, dry cough, hemoptysis, and pulmonary edema may appear as hypertension and congestion progresses
Right sided heart failure symptoms occur later
S/S
Pulse may be normal to A-Fib
Apical diastolic murmur is heard

15. Etiology of Mitral Stenosis
Rheumatic heart disease: 77-99% of all cases
Infective endocarditis: 3.3%
Mitral annular calcification: 2.7%

16. Mitral Stenosis

17. MS Pathophysiology
Progressive Dyspnea (70%): LA dilation  pulmonary congestion (reduced emptying)
worse with exercise, fever, tachycardia, and pregnancy
Increased Transmitral Pressures: Leads to left atrial enlargement and atrial fibrillation.
Right heart failure symptoms: due to Pulmonary venous HTN
Hemoptysis: due to rupture of bronchial vessels due to elevated pulmonary pressure

18. Mitral Stenosis

19. Heart Sounds in MS Diastolic murmur:
Low-pitched diastolic rumble most prominent at the apex.
Heard best with the patient lying on the left side in held expiration
Intensity of the diastolic murmur does not correlate with the severity of the stenosis

20. Heart Sounds in MS
Loud Opening S1 snap: heard at the apex when leaflets are still mobile 
Due to the abrupt halt in leaflet motion in early diastole, after rapid initial rapid opening, due to fusion at the leaflet tips.
A shorter S2 to opening snap interval indicates more severe disease.

21. Management of MS Serial echocardiography: Mild: 3-5 years
Moderate:1-2 years
Severe: yearly

22. Mitral Regurgitation
Primarily caused by rheumatic heart disease, but may be caused by papillary muscle rupture form congenital, infective endocarditis or ischemic heart disease
Abnormality prevents the valve from closing
Blood flows back into the right atrium during systole
During diastole the regurg output flows into the LV with the normal blood flow and increases the volume into the LV
Progression is slowly – fatigue, chronic weakness, dyspnea, anxiety, palpitations, cough
May have A-fib and changes of LV failure
May develop right sided failure as well

23. Mitral Regurgitation Physical Exam Holosystolic Apical Blowing Murmur
Laterally displaced apical impulse
Split S2 (but is obscured by the murmur)
S3 Gallop (increased volume during diastole)
Radiation depends on the etiology

24. Mitral Valve Prolapse
Cause is variable and may be associated with congenital defects
More common in women
Valvular leaflets enlarge and prolapse into the LA during systole
Most are asymptomatic
Some may report chest pain, palpitations or exercise intolerance
May have dizziness, syncope and palpitations associated with dysrhythmias
May have audible click and murmur

25. Mitral Regurgitation -MVP

26. Mitral Regurgitation -MVP

27. Mitral Regurgitation -MVP
Diagnosis and Treatment
Echo 2D/Color
B-Blockers (hyperadrenergic symptoms, Palpitations)
Aspirin (TIAs without etiology)
SBE Prophylaxis (only if associated with MR)
Severe Symptomatic MR – same as chronic MR

28. Aortic Stenosis
Valve becomes stiff and fibrotic, impeding blood flow with LV contraction
Results in LV hypertrophy, increased O2 demands, and pulmonary congestion
Causes – rheumatic fever, congenital, arthrosclerosis
Atherosclerosis and calcification is primary cause in the elderly
Complications – right sided heart failure, pulmonary edema, and A-fib
S/S – Early: dyspnea, angina, syncope
Late: marked fatigue, debilitation, and peripheral cyanosis, crescendo- decrescendo murmur is heard

30. Aortic Stenosis Physical Exam
Harsh Systolic Ejection Murmur – late peaking
S4 gallop (from LVH)
Sustained Bifid LV impulse (from LVH)
Pulsus Parvus et Tardus (Carotid Impulse)
Heart sounds- soft and split second heart sound

31. Presentation of Aortic Stenosis
Syncope: (exertional)
Angina: (increased myocardial oxygen demand; demand/supply mismatch)
Dyspnea: on exertion due to heart failure (systolic and diastolic)
Sudden death

32. Aortic Stenosis

33. Echo Surveillance Mild: Every 5 years Moderate: Every 2 years
Severe: Every 6 months to 1 year

34. Summary Disease of aging Look for the signs on physical exam
Echocardiogram to assess severity
Asymptomatic: Medical management and surveillance
Symptomatic: AoV replacement (even in elderly and CHF)

35. Aortic Regurgitation
Aortic valve leaflets do not close properly during diastole
The valve ring that attaches to the leaflets may be dilated, loose, or deformed
The ventricle dilates to accommodate the ↑ blood volume and hypertrophies
Causes: infective endocarditis, congenital, hypertension, Marfan’s
May remain asymptomatic for years
Develop dyspnea, orthopnea, palpitations, ,and angina
May have ↑ systolic pressure with bounding pulse
Have a high pitch, blowing, decrescendo diastolic murmur

36. Etiology of Acute AR Endocarditis Aortic Dissection Physical Findings:
Wide pulse pressure
Diastolic murmur
Florid pulmonary edema

37. Aortic Regurg – pathophysiology

38. Aortic Regurgitation

39. Progressive Symptoms include:
- Dyspnea: exertional, orthopnea, and paroxsymal nocturnal dyspnea
Nocturnal angina: due to slowing of heart rate and reduction of diastolic blood pressure
Palpitations: due to increased force of contraction

40. Aortic Regurgitation Physical Exam
Diastolic Decrescendo Blowing Murmur at the left sternal border
Hyperdynamic LV apical impulse
Bounding Pulses
S4, S3 Gallop-advanced AI
Apical Rumble – “Austin Flint Murmur” (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate
Systolic ejection murmur: due to increased flow across the aortic valve

41. Assessment for Valve Dysfunction
Subjective symptoms
Fatigue
Weakness
General malaise
Dyspnea on exertion
Dizziness
Chest pain or discomfort
Weight gain
Prior history of rheumatic heart disease

42. Assessment, cont. Objective symptoms Orthopnea Dyspnea, rales
Pink-tinged sputum
Murmurs
Palpitations
Cyanosis, capillary refill
Edema
Dysrhythmias
Restlessness

43. Diagnosis History and physical findings EKG Chest x-ray Cardiac cath
Echocardiogram

44. Medical Treatment
Nonsurgical management focuses on drug therapy and rest
Diuretic, beta blockers, digoxin, O2, vasodilators, prophylactic antibiotic therapy
Manage A-fib, if develops, with conversion if possible, and use of anticoagulation

45. Interventions Assess vitals, heart sounds, adventitious breath sounds
O2 as prescribed
Emotional support
Give medications
I/O
Weight
Check for edema
Explain disease process, provide for home care with O2, medications

46. Surgical Management of Valve Disease
Mitral Valve
Commissurotomy
Mitral Valve Replacement
Balloon Valvuloplasty
Aortic Valve Replacement
Commissurotomy – excision of parts of the valve leaflets to enlarge the opening
Replacement – tissue or mechanical
Balloon – done in the cath lab to enlarge the opening

47. Mechanical Valve

48. Mechanical Valve

49. Porcine Valve

50. Tissue Valve

51. Tissue Valve

52. Common Murmurs and Timing (click on murmur to play)
Systolic Murmurs
Aortic stenosis
Mitral insufficiency
Mitral valve prolapse
Tricuspid insufficiency
Diastolic Murmurs
Aortic insufficiency
Mitral stenosis
S S S1