Valvular heart disease

Valvular heart disease

1. VALVULAR HEART DISEASE RATHEESH R.L

2. Defined according to the valve or valves affected and the type of functional alteration Includes - stenosis - regurgitation

3. stenosis Valve orifice is smaller, impending the forward flow of blood and creating a pressure gradient difference across an open valve

4. regurgitation Incomplete closure of the valve leaflets results in the backward flow of blood

5. MITRAL STENOSIS most common valvular disorder in rheumatic fever may also be caused by bacterial infection, thrombus formation, calcification obstruct blood flow from left atrium to the left ventricle

6. Pathophysiology Narrowing of mitral valve  CO O2/CO2 exchange (fatigue, dyspnea , orthopnea ) Left ventricular atrophy pulmonary congestion  pulmonary pressure  left atrial pressure Hypertrophy left atrium  blood flow to left ventricle Right-sided failure Fatigue

7. Clinical manifestations Exertional dyspnea Fatigue and palpitations Loud first heart sound Low pitched diastolic murmur Hoarseness of voice Hemoptysis Chest pain Seizures or a stroke

8. Mitral Regurgitation incomplete closure of the mitral valve rheumatic disease is the predominant cause may also be due to congenital anomaly, infective endocarditis, rupture of papillary muscle following MI

9. Etiology Myocardial infarction Chronic rheumatic heart disease Mitral valve prolapse Ischemic papilary muscle dysfunction Infective endocarditis

10. Clinical Manifestations Fatigue & weakness – due to  CO – predominant complaint exertional dyspnea & cough – pulmonary congestion palpitations – due to atrial fibrillation (occur in 75% of pts.) Right-sided heart failure – distended neck veins, edema, ascites, hepatomegaly Auscultation: blowing, high-pitched systolic murmur (apex) - S1 is diminished - S3 –severe regurgitation

11. Mitral Valve Prolapse

12. Cause : due to an inherited connective tissue disorder  enlargement of one or both valve leaflets

13. Clinical manifestations Palpitations May or may not have chest pain Dyspnea , palpitations and syncope accompany the chest pain and do not respond to antianginal treatment

14. Aortic Stenosis may be due to rheumatic heart disease, atherosclerosis, congenital valvular disease or malformations narrowing of the aortic valve   flow of blood from the left ventricle to the aorta   blood volume and pressure in the left ventricle Left ventricle hypertrophy develops as a compensatory mechanism to continue pumping blood through the narrowed opening.

15. Aortic Stenosis

16. Etiology Congenital aortic valve stenosis Rheumatic fever

17. Pathophysiology Stiffening/Narrowing of Aortic Valve Incomplete emptying of left atrium Left ventricular hypertrophy Pulmonary congestion Compression of coronary arteries Right-sided heart failure  CO  Myocardial O2 needs Myocardial ischemia (chest pain)  O2 supply

18. Clinical Manifestations fatigue & exertional dyspnea – 1 st symptoms – due to  CO and pulmonary congestion chest pain (angina) – most common symptom - occurs during exercise – due to inability of the heart to increase coronary blood flow to cardiac muscle exertional syncope , vertigo, periods of confusion --  CO weakness, orthopnea, PND, pulmonary edema (severe cases) signs of right-sided heart failure –- end-stage symptoms - if untreated, survival rate: 1.5-3 years Auscultation: harsh, rough, mid-systolic murmur

19. Aortic Regurgitation may be due to rheumatic fever – most common cause other causes: connective tissue disease (Marfan’s syndrome), severe hypertension, congenital anomaly

20. Pathophysiology Incomplete closure of the aortic valve Backflow of blood to Left ventricle Left ventricular hypertrophy & dilation  Left atrial pressure Left-sided heart failure (late stage) Left atrium hypertrophy  CO  Pulmonary pressure Right-sided heart failure  Right ventricular pressure

21. Clinical Manifestations pt. may remain asymptomatic for years --- heart compensates by hypertrophy & dilation 1st s/ sx - heightened awareness of the heart beat & palpitations esp. when pt. lies on left lateral position tachycardia, PVC  assoc. w/ left ventricular dilation bounding pulse , marked carotid artery pulsation ,  apical pulse   force and volume of contraction of the hypertrophied left ventricle Decompensation occurs (cardiac muscle fatigue) exertional dyspnea chest pain – myocardial ischemia left-heart failure – fatigue, orthopnea , PND right-heart failure – peripheral edema Auscultation : soft, blowing diastolic murmur

22. Tricuspid Stenosis usually occurs together w/ aortic or mitral stenosis may be due to rheumatic heart disease  blood flow from right atrium to right ventricle   right ventricular output   left ventricular filling   CO blood accumulates in systemic circulation  systemic pressure S/Sx: symptoms of right-sided heart failure - hepatomegaly - peripheral edema - neck vein engorgement -  CO – fatigue, hypotension

23. Tricuspid Regurgitation uncommon, may be caused by RF, bacterial endocarditis may also be caused by enlargement of right ventricle an insufficient tricuspid valve allows blood to flow back into the right atrium  venous congestion &  right ventricular output   blood flow towards the lungs

24. Clinical Manifestations may not produce any symptoms  moderate-to-severe tricuspid regurgitation exist, the ff. may result: Active pulsing in the neck veins Swelling of the abdomen Swelling of the feet and ankles Fatigue, tiredness Weakness Decreased urine output on palpation, there may be a lift (beating of enlarged right ventricle) murmur on auscultation

25. Pulmonic Valve Stenosis rare, usually congenital in origin  flow of blood to the pulmonary artery due to narrowing  blood flows back to right ventricle and right atrium  right ventricle hypertrophy to compensate for  blood volume and force blood to the pulmonary artery S/ Sx : harsh systolic murmur fatigue, dyspnea on exertion, cyanosis poor weight gain or failure to thrive in infants hepatomegaly, ascites, edema

26. Diagnostic studies History and physical examination Echocardiogram Cardiac catheterization Electrocardiogram Chest X ray

27. MANAGEMENT

28. Prophylactic antibiotic therapy( rheumatic fever, infective endocarditis ) if the patient is having the signs of heart failure it should be treated first vasodialators , beta blockers and diuretics. Low sodium diet should be prescribed to the patient Anticoagulant therapy is used to treat pulmonary embolization.

29. Percutaneous trans luminal balloon valvoloplasty : - splits open the fused commissures - threading a balloon tipped catheter from the femoral artery or vein to the stenotic valve so that the balloon may be inflated in an attempt to separate the valve leaflets

30. SURGICAL MANAGEMENT 1. Valvuloplasty is repair of cardiac valve pt. does not require continuous anti-coagulant medication usually require cardiopulmonary bypass machine. 2. Annuloplasty is repair of valve annulus (junction of the valve leaflet and the muscular heart wall) - narrows the diameter of the valve’s orifice, useful for valvular regurgitation

31. 3 . Chordoplasty is repair of chordae tendineae - done for mitral valve regurgitation – caused by stretched or shortened chordae tendineae 4.valvulotomy( commissurotomy ) it is an old surgical method for pure mitral stenosis

32. Annuloplasty

33. Annuloplasty (cont.)

34. 5. Prosthetic valves Mechanical valves Biologic valves

35. Difference between mechanical and biologic valve Mechanical valve Biologic valve Manufactured from man made materials and consists of combinations of metal alloys, pyrolite carbon and dacron Constructed from porine and human cardiac tissue and usually contain some man made materials More durable Less durable Increased risk of thromboembolism Low thrombogenicity Need long term anticoagulation therapy No need of anticoagulation therapy

36. Types of mechanical valves Caged ball valve Tilting disk valve Bi- laeflet valve

37. Types of biologic valve Porcine heterograft Pericardial heterograft homograft

38. NURSING MANAGEMENT Assess the high risk patients Monitor ECG of the patient Assess the family history of heart disease Assess the history of smoking and alcoholism Monitor lab values frequently especially serum cholesterol levels. Assess for CAD Monitor vital signs Instruct to avoid high fat and oil rich diet

39. Nursing diagnosis Activity intolerance related to insufficient oxygenation as evidenced by weakness, fatigue, shortness of breath, BP changes Excess fluid volume related to heart failure as evidenced by peripheral edema, weight gain, adventitious breath sounds, neck vein distention

40. Nursing diagnosis Decreased cardiac output related to valvular incompetence as evidenced by murmurs, dyspnea , peripheral edema Deficient knowledge related to lack of experience and exposure to information about disease and treatment process as evidenced by verbalization of misconception about measures to prevent complications