Congenital & Acquired valvular Heart diseases

Nursing

1. CONGENITAL AND ACQUIRED VALVULAR DISEASES By: Abhishek Yadav M Sc Nursing 1 st Year

2. OUTLINES Introduction. Definition. Incidence. Congenital Valvular Diseases. Acquired Valvular Diseases. Combined Congenital & Acquired Valvular Diseases. Nursing Responsibilities.

3. INTRODUCTION The movement of blood through the heart is crucial for human life. But in addition to perfusion , blood must flow through the heart in an efficient and orderly manner. So here we will focus on the cardiac disorders that affect the structure of heart and impair the efficiency of the heart as a pump.

4. DEFINITION Valvular heart disease can be defined as the damage to or a defect in one of the four heart valves : tricuspid, bicuspid (mitral), pulmonary, and aortic.

5. Some important terms :- Regurgitation - The valve’s tissues flaps (leaflets ) do not fully close or the edges do not fully meet, which causes blood to leak back into the heart. Stenosis - The leaflets can not have an opening for blood to flow through. Atresia - The heart valves do not have an opening for blood to flow through.

6. INCIDENCE Valvular heart diseases remain fairly common in United States even through the incidence is steadily decreasing as the incidence of rheumatic fever decreases Mitral valve prolapse syndrome is one of the most common cardiac abnormalities; as much as 5% of the population is affected , and females are affected more often than males.

7. CONGENITAL VALVULAR DISEASES These occur when a valve does not form correctly in the developing fetus, although it can be diagnosed at any age. Mostly affected valves are pulmonary and aortic. It is of four types: 1- Pulmonary atresia 2- Pulmonary stenosis 3- Tricuspid atresia 4- Bicuspid aortic valve disease

8. 1) PULMONARY ATRESIA Pulmonary atresia is a congenital birth defect, in which pulmonary valve does not form properly. In this, a solid sheet of tissues form at place of valve opening , so valve stays closed. So due to this blood can not go to lungs from right ventricle to pick up oxygen.

9. Its Causes:- Idiopathic. It can be linked with another type of congenital heart defect (Patent Ductus Arteriosus ). It can occur with or without ‘Ventricular septal defect’

10. Symptoms:- Usually occur in the first few hours of life , although it may take up to few days . Bluish colourd skin (cyanosis). Fast breathing. Fatigue. Poor feeding habits. Shortness of breath.

11. Investigations:- Chest X ray. Echocardiogram. Electrocardiogram. Heart catheterization. Pulse oximetry .

12. Treatment: Prostaglandin E1 this medicine keeps blood vessel (PDA) open b/w pulmonary artery and aorta. Heart Catheterization. Open heart surgery: - to repair or replace valve - to place a tube b/w right ventricle and pulmonary artery. Reconstriction of heart as a single ventricle (for temporary period). Heart transplant.

13. Complications:- Delayed growth and development. Seizures. Stroke. Infectious endocarditis . Heart Failure. Death.

14. 2) PULMONARY STENOSIS Pulmonary stenosis or narrowing occurs when the valve can not open wide enough leading to obstructed blood flow from right ventricle to pulmonary artery.

15. Its Causes:- Idiopathic. Congenital. Due to problems during Intra uterine life. Defect occur alone or with other heart defects.

16. Symptoms:- Most cases are mild with no symptoms. Presence of heart murmur sound in infants during routine examination. When the valve stenosis is moderate to severe , the symptoms are: - Abdominal distension. - Cyanosis in some clients. - Poor appetite. - Chest pain. - Fainting. - Poor weight gain or Failure to thrive in infants with a severe blockage. - Sudden Death.

17. Investigations :- Physical Examination ( presenting heart murmur sound) . Other tests are: - Cardiac catheterization, - Chest X-ray, - ECG , - Echocardiogram, - MRI of Heart.

18. Treatment:- No need of treatment for mild cases. In Case of other associated heart defects, the drugs may be used : - prostaglandin. - blood thinners. - diuretics. - antiarrythmic drugs. Vulvoplasty ( percutaneous balloon pulmonary dilation) may be performed in absence of other heart disease. Valve repair or replacement.

19. Complications :- Abnormal heart beats ( arrythmias ). Heart failure & right sided heart enlargement. After repair the chances of pulmonary regurgitation. Death.

20. 3) TRICUSPID ATRESIA In this condition the tricuspid valve is missing or abnormally developed . This defect blocks the blood flow from right atrium to right ventricle.

21. Its causes:- Idiopathic. Heredity. Risk factors are down’s syndrome.

22. Symptoms:- Cyanosis. Tacypnea . Fatigue. Poor growth. Shortness of breath.

23. Investigations:- By routine pre natal Ultrasound imaging or by post natal examination (signs of cyanosis). Physical examination often showing the presence of heart murmur sound at birth and may increase in loudness over several months.. Tests are: ECG , Echocardiogram, Chest X-ray , Cardiac catheterization and MRI of heart.

24. Treatment :- Prostaglandin E1 is administered to keep ductus arteriosus open (so that blood can circulate to lungs). This condition always require surgery an artificial shunt is inserted to keep blood flowing to lungs (in some cases it is not needed). Glenn-shunt or hemi- fontan procedure (in this half of veins carrying blue blood from upper half of body directly to pulmonary artery),( at age of 4-6 months).

25. CONTINUED…… ( during first & second stage child may still look cyanotic ) this is final step also called Fontan procedure ( in this the rest of veins carrying blue blood from body are connected directly to pulmonary artery leading to lungs. The left ventricle is now only has to pump to body, not to lungs),(at the age of 18 months to 3 years). (after thisfinal step the baby is no longer cyanotic)

26. Complications:- Arrythmias . Heart failure. Ascites (fluid in abdomen) ,and Pleural effusion (fluid in lungs). Blockage of artificial shunt. Stroke or other neural disease. Sudden death.

27. 4) BICUSPID AORTIC VALVE DISEASE In this condition the aortic valve has only two cusps or leaflets instead of three. Bicuspid aortic valve works normally for years without any signs of problem, but the valve does not function well.

28. Its causes:- Idiopathic. Latest studies suggest that BAV is caused by a connective tissue disorder that also causes other circulatory problems. Often associated with coarction of aorta (narrowing of aorta).

29. Symptoms:- Most of time symptoms are absent in infants and children, however abnormal valve can leak or narrow overtime the symptoms are: - tiredness - chest pain - difficulty in breathing - palpitations - loss of consciousness - pale skin.

30. Investigations:- Physical examination presenting: - enlarged heart - heart murmur - weak pulse in wrist and ankles. MRI of heart. Echocardiogram. If complications or additional heart defects are suspected ,tests adviced are: - chest X-ray, ECG , Cardiac catheterization.

31. Treatment:- In severe conditions the surgery to repair or replace a leaky or narrowed valve. Vulvoplasty (a catheter with a balloon attached at its tip is inserted in groin and directed to heart , the balloon is inflated to make aortic valve larger). Medicines may be needed to relieve symptoms : - Beta blockers, ACE inhibitors (to lower workload on heart) - Water pills.

32. Complications:- Heart failure. Leakage of blood through valve back in to heart. Narrowing of valve’s opening. Aortic valve or cardiac muscle infection.

33. ACQUIRED VALVULAR DISEASE The valves that are formed properly at birth can still develop problems related to aging, infection ,heart attack or heart damage and other events that cause wear and tear to valves. Valve function can also be affected by a build up of calcium deposits on the valve leaflets , making them stiff and inflexible. ( mostly affected valves are aortic and mitral) AVD consists of 3 types:- 1- Aortic stenosis . 2- Mitral regurgitation. 3- Mitral valve prolapse

34. 1) AORTIC STENOSIS It consists of narrowing of aortic valve , which leads to decreased blood flow from heart.

35. Its causes:- Acquired (develops later in life). Due to build up of calcium deposits that narrow the valve ,called calcific aortic stenosis . (Mostly olders are affected). - Calcium build up of valve happens sooner in people who are born with abnormal aortic or bicuspid valves - Calcium build up can also develop more quickly when a person has received chest radiation. (in rare cases). Rheumatic fever ( leading to fibrosis of valve ) Aging (> 65years of age), more in males .

36. Symptoms:- Symptoms are not developed till the disease becomes advanced. Chest discomfort (chest pain may get worse with activity and reach into arm, neck, or jaw. Chest may feel tight or squeezed). Cough (possibly haemoptysis ) Breathing problems (during exercise). Becoming easily tired. Palpitation (feeling the heart beat). In infants: - becoming easily tired - failure to gain weight, poor feeding - risk of bacterial endocarditis .

37. Investigations:- Physical examination presenting: - Heart murmur - Feeling vibration or movements during palpation over heart Transthoracic echocardiogram( TTE ), which gives a moving images of basic structure of heaart . (it detects most oftenly ) Other tests are: ECG , exercise stress testing, left cardiac catheterization, MRI.

38. Treatment:- Proper check-ups regularly for early detection. Clients with confirmed aortic stenosis are adviced not to play sports even if they have no symptoms. Drugs are used to treat symptoms of heart failure or arrythmias : Diuretics Nitrates Beta blockers Anti- hypertensives Surgery to repair the valve (balloon vulvoplasty ) and valve replacement.

39. Complications:- If left uncheked : Chest pain (angina) Fainting (syncope) Heart failure Arrythmias Cardiac arrest

40. 2) MITRAL REGURGITATION It is the leakage of blood backward through mitral valve each time the left ventricle contracts

41. Its causes:- It may begin suddenly, often occurs after heart attack. Due to weakening or damaging of valve or heart tissue arround the valve. Risk factors are: CAD and hypertension Valvular infections Mitral valve prolapse Untreated syphilis (rarely) Rheumatic heart diseases (rarely)

42. Symptoms:- Symptoms may begin suddenly if Heart attack damages the muscles arround mitral valve. The cord that attach the muscle to valve is broken. Infection of valve destroys parts of valve. The symptoms may or may not include:- Cough Fatigue Tachypnea Palpitation shortness of breath.

43. Investigations:- Physical examination may reveal: a thrill (vibration) sound over the heart. a heart murmur sound Crackles in lungs (if fluid backs up into lungs) hepatomegaly Some tests may be done CT scan of chest Echocardiogram ( transthoracic or transesophageal ) MRI.

44. Treatment:- Symptomatic treatment. When the symptoms get worse , the following antihypertensive drugs may be prescribed by physician : Beta blockers ( labetalol ), ACE inhibitors ( captopril ), calcium channel blockers ( amlodipine ). Blood thinners(anticoagulants) Antiarrythmic drugs Water pills (diuretics) (to remove excess fluid in lungs) Client may need surgery if conditions are not treated by drugs (repair or replacement of valve).

45. Complications :- Arrythmias Valvular infection Heart failure.

46. 3) MITRAL VALVE PROLAPSE It is also called: - Barlow syndrome. - Myxomatous valve syndrome. - Click murmurs syndrome. MVP is a condition in which the two valve flaps of mitral valve do not close smoothly, but insteatd bulge ( prolapse ) upward in left atrium that may cause heart murmur.

47. Its causes:- Abnormally stretched valve leaflets (myxomatous degeneration) Genetic risk of developing MVP Can be due to other connective tissue disease. Other causes include: Ethlers- danlos syndrome (a group of connective tissue disorders). Marfan syndrome (a genetic disorder of connective tissue). Rheumatic heart disease Ischemic papillary muscle dysfunction.

48. Symptoms:- Initially no symptoms seen. But in later stages symptoms may be: Palpitation Shortness of breath Cough Fatigue (tiredness) Anxiety Chest discomfort.

49. Investigations:- Physical examination may reveal: Heart murmur Client may need other tests to diagnose MVP: Echocardiography Doppler USG Chest X-ray ECG .

50. Treatment:- Goals of treatment may include:- Correcting underlying mitral valve problem. Preventing infective endocarditis , arrythmias , etc. Relieving symptoms. Drugs including : Beta blockers ( labetalol ) to treat palpitation and chest discomfort. Blood thinners (to treat atrial fibrillation). Diuretics. Antiarrhythmics ( flecainide and procainamide ). Vasodilators ( isosorbide dinitrate and hydralazine ). Surgery including valve repair and replacement.

51. CONGENITAL OR ACQUIRED VALVULAR DISEASE The valve disease which can be acquired or congenital or both. These are of two types :- 1- Mitral valve stenosis . 2- Aortic regurgitation.

52. 1) MITRAL VALVE STENOSIS In this condition the the valve does not open fully due to its narrowing, that restricts the flow of blood.

53. Its causes:- Rheumatic fever (causes fibrosis or thickening of mitral valve). Severe mitral leaflet calcification. Congenital absence of one of the papillary muscles. Endocardial vegetation (may cause ulceration and perforation of heart valve cusps). Congenital mitral valve defect. Tumors. Rheumatoid arthritis. Systemic lupus erythematosus (a chronic autoimmune disease) Rheumatic endocarditis .

54. Symptoms:- Adults may have no symptoms. However symptoms get worse with exercise or other activity. Mostly between 20-50 yrs of age. Symptoms are: Chest discomfort (extended to arm , neck, jaw, etc.) Cough, dyspnea , fatigue. Respiratory infections. In infants and children within 2 yrs of life: Cough. Poor feeding. Sweating while feeding. Poor growth, shortness of breath.

55. Investigations:- Physical examination may reveal: Heart murmur sound or other abnormal sound. Arrythmias . Other test may include: Chest X-ray. CT scan of heart. Echocardiogram. ECG . MRI of heart. Transesophageal echocardiogram (TEE).

56. Treatment:- Initially symptomatic management. Drugs to treat symptoms of heart failure , hypertension and arrythmia include: Diuretics Nitrites Beta blockers Calcium channel blockers ACE inhibitors. Anticoagulants (blood thinners). Antibiotics (penicillin). Surgeries needed: Percutaneous mitral balloon valvotomy ( vulvoplasty ). Valve replacement.

57. Complications:- Atrial fibrillation and atrial flutter. Stroke. Congestive heart failure. Pulmonary edema. Pulmonary hypertension.

58. 2) AORTIC REGURGITATION Also called aortic insufficiency. It is the failure of aortc valve leding to back flow of blood into left vetricle from aorta during diastole.

59. Its causes:- In past , the rheumatic fever was the main cause for this but the use of antibiotics to treat strep infections made rheumatic fever less common. Other causes are: Ankylating spondylitis (arthritis of spine). Aortic dissection (its tearing) . Congenital valve problems. Syphilis. Systemic lupus erythematosus . Chest trauma.

60. Symptoms:- Most common in men (between 30-60 yrs). Bounding pulse (strong pulse). Chest pain similar to angina. Fainting. Fatigue. Palpitations Shortness of breath. Swelling of feet , leg, or abdomen. Weakness with activity.

61. Investigations:- Physical examination reveal: Heart murmur. Palpitation. Hard pulses in arms and legs. Low diastolic B.P. Signs of fluid in lungs. Aortic insufficiency may be seen on tests : Aortic angiography. Echocardiogram. Left cardiac catheterization. MRI of heart. Transthoracic echocardiogram ( TTE ), or Transesophageal echocardiogram (TEE). Chest X-ray may show swelling of left ventricle.

62. Treatment:- No treatment needed in case of no or mild symptoms (but proper checkup is needed). Anti- hypertensives . Diuretics. Limiting activity needed. Surgery to repair or replace the aortic valve is to be done.

63. Complications:- Arrythmia . Heart failure. Infection in heart.

64. NURSING RESPONSIBILITIES History taking . Physical examination (timely). Administer drugs as prescribed by physician. Monitor for adverse and side effects of drugs administered. Teach the client about the complications and treatment plan. As doctors prescription the antibiotic therapy is provided before any invasive procedures.

65. The nurse teaches the client and his family members about the complication after infections. The nurse teaches the patients about to weigh daily and report to doctor if there is a weight gain of more than 2.3 kg in one week. Assist the patient to adopt life style modifications. If the patient have vulvoplasty or valve replacement, teach them about the procedures , anticipated recovery time and complications.

66. SUMMARY Introduction. Definition. Incidence. Congenital Valvular Diseases. Acquired Valvular Diseases. Combined Congenital & Acquired Valvular Diseases. Nursing Responsibilities

67. CONCLUSION Heart valves are essential for proper circulation because they regulate the direction that your blood flows . Defects in the valves can lead to severe problems. So we should all have to be aware about cardiac problems.

68. REFFERENCES Hariprasath P., A Textbook of Cardiovscular & thoracic Nursing, 1 st Edition, 1 st Volume,2016 , Published by Jaaypee Brothers Medical Publishers (P) Ltd. Joyce M. Black, A Textbook of Medical Surgical Nursing, 8 th Edition, 2 nd Volume, Published by Saunders Elsevier Publication. http://medlineplus.gov/ency/articles ..

69. Thankyou