Valvular Heart Disease Presented by Mary Ann Degges
Valvular Heart Disease Presented by: Mary Ann Degges, MSN, RN, CCNS Clinical Nurse Specialist Cardiovascular Services University Hospital
Definition • Structural and/or functional abnormality of the cardiac valve(s) • Results in altered blood flow across the valve(s) • Two types of valvular lesions: – stenotic – regurgitant
Valve Anatomy
Etiology • • • Rheumatic fever Infective endocarditis Idiopathic Congenital malformations Aging valve tissue Rupture/dysfunction of the papillary muscles Collagen vascular disease Aortic dissection Syphilis
Aortic Valve Stenosis • Pathophysiology: – LVH – Failure of ventricular emptying – Pulmonary congestion – Failure of right side of heart – Sudden cardiac death
Aortic Valve Stenosis • Symptoms – Heart failure – Angina – Syncope – Fatigue – Visual defects • Signs – Aortic dilatation – LVH – Systolic ejection murmur – Pressure gradient – Increased LVEDP
Aortic Valve Regurgitation • Pathophysiology: – Increased volume load in left ventricle – LV dilatation and hypertrophy
Aortic Valve Regurgitation • Symptoms – Awareness of pulsation in neck or precordium – Fatigue – Dyspnea on exertion – Palpitations • Signs – Increased pulse pressure – High-pitched early diastolic murmur – LVH
Mitral Valve Stenosis • LA must generate higher pressure to move blood into LV • Increase in LAP and volume results in backflow to PA • RVH • RVF
Mitral Valve Stenosis • Symptoms – Dyspnea on exertion – Fatigue/weakness – Pronounced respiratory symptoms – Mild hemoptysis – Susceptibility to pulmonary infections • Signs – Pulmonary congestion – Atrial fibrillation – Diastolic murmur – Pressure gradient – Increased LAP, PCWP, PAP – Low CO
Mitral Valve Regurgitation • LV dilation and hypertrophy • LA dilation and hypertrophy
Mitral Valve Regurgitation • Symptoms – Weakness/fatigue – Exertional dyspnea – Palpitations • Signs – LA/LV enlargement – P-mitrale – Atrial fibrillation – Holosystolic murmur – Elevated PAP
Mitral Valve Regurgitation Acute Vs. Chronic • Acute symptoms: – severe LVF – low CO – PCWP • V wave – Pulmonary HTN • Medical emergency that generally requires prompt surgical therapy
Medical Therapy • Consists of: – Pharmacological therapy – Balloon dilatation – Fluid/Na+ restriction – Patient/family education • Exception: Aortic stenosis
Medical Management • Medications – Digoxin, Diuretics, Antibiotics, Anticoagulants, Vasodilators/ACE Inhibitors • Optimizing Fluid Balance – Na+ Restriction, Fluid Restriction • Maintenance of Cardiac Output – Contractility, Hemodynamics, Heart Rate • Patient and Family Education – Planning Activities, Observe for Palpitations, Medications, Fluid Restriction, Infection Control, Weight
Surgical Therapy
Valvular Surgery • Indicated when the patient’s symptoms can no longer be medically managed • Indicated in aortic stenosis when symptoms begin – after onset of symptoms average survival is <2 -3 years!
Valve Repair Vs Replacement · lower operative risk · better preservation of ventricular function · lower risk of thromboembolic complications · less need for anticoagulation · improved hemodynamic performance · lower risk for endocarditis · better long-term survival · lower costs
Valve Replacement Vs Repair • Mechanical valves: – Extremely low rate of structural deterioration – Better survival rate in patients <65 years old after AVR and in patients 50 years old after MVR • Bioprosthetic valves: – Lack of need for antithrombotic therapy
Valve Replacement with Mechanical Prosthesis • Patients with expected long life spans • Patients with a mechanical valve already in place in a different position than the valve to be replaced • Patients in renal failure, on hemodialysis, or with hypercalcemia • Patients already on warfarin for other reasons • Patients 65 years for AVR and 70 years for MVR • Valve rereplacement for thrombosed biological valve
Valve Replacement with Bioprosthesis • Patients who cannot or will not take warfarin • Patients 65 years needing AVR who do not need warfarin for other reasons • Patients considered to have possible compliance problems with warfarin • Patients >70 years needing MVR who do not need warfarin for other reasons • Valve rereplacement for thrombosed mechanical valve
Valve Repair or Valve Replacement? • Aortic Valve surgery is typically aortic valve replacement (AVR), although some are repairable • Mitral valve surgery includes 3 choices: – Commissurotomy – Valve Repair – Valve Replacement • Tricuspid and Pulmonic Valves – rarely require surgery due to lower pressures on right side of heart
COMMISSUROTOMY
VALVE REPAIR-Annuloplasty Ring
VALVE REPAIR
Ross Procedure • 2 -step procedure • aortic valve is replaced with native pulmonary valve • native pulmonary valve is replaced with a homograft valve • neo-aorta can grow
Classification of Prosthetic Cardiac Valves MECHANICAL VALVES • Tilting-disk: a free-floating, lens-shaped disk mounted on a circular sewing ring – Björk-Shiley – Omniscience (Lillehei-Kaster) – Medtronic-Hall (Hall-Kaster) • Caged-ball: a ball moves freely within a –three-or four sided metallic cage mounted on a circular sewing ring – Starr-Edwards • Bileaflet: two semicircular leaflets, mounted on a circular sewing ring, that open centrally – St. Jude Medical
Classification of Prosthetic Cardiac Valves BIOLOGIC (TISSUE) VALVES (BIOPROSTHESES) • Porcine heterograft: a porcine aortic valve mounted on a semiflexible stent and preserved with glutaraldehyde – Hancock – Carpenter-Edwards • Bovine pericardial heterograft: bovine pericardium fashioned into three identical cusps that are then mounted on a clothcovered frame – Carpenter-Edwards – Ionescu-Shiley • Homograft: a human heart valve (aortic or pulmonic) harvested from a donated heart and cryopreserved; may or may not be mounted on a supported ring.
Cardiac Valves
Caged-Ball Valve
Bileaflet Valve
Porcine Valve • Carpentier-Edwards Bioprosthesis Aortic Model 2625
Bovine Valve • Carpentier-Edwards PERIMOUNT Pericardial Bioprosthesis Aortic Model 2700 Carpentier-Edwards
Medtronic Mosaic Valves • Porcine tissue • Can be used for aortic or mitral position
Anticoagulation for Prosthetic Valve Replacement 1 • Bileaflet valve in aortic position: INR 2. 0 -3. 0 • All tilting disk valves and bileaflet valves in mitral position: INR 2. 5 -3. 5 • All caged ball or caged disk valves: INR 2. 5 -3. 5 in combination with ASA 75 -100 mg/day • All bioprosthetic valves: INR 2. 0 -3. 0 for first 3 months after valve insertion (mitral and aortic) • All bioprosthetic valves (without AF): long-term therapy with ASA 75 -100 mg/day 17 th ACCP Conference on Antithrombotic and Thrombolytic Therapy (2004)
Anticoagulation for Prosthetic Valve Replacement in Pregnancy • No clinical trials available to guide therapy • Conception to completion of 1 st trimester: – unfractionated or LMWH • After completion of 1 st trimester: – warfarin therapy, wk 12 -36 (target INR 2. 0 -3. 0) • Week 36: – discontinue warfarin – change to unfractionated or LMWH • Delivery: – restart heparin 4 -6 hours after delivery if no contraindications – resume warfarin night after delivery if no bleeding complications
Complications • Valve failure • Prosthetic valve endocarditis Figure: This artificial heart valve was removed owing to prosthetic valve endocarditis. The bacterial colonies which have grown over the side of the valve and into the valve itself can clearly be seen.
Endocarditis Prophylaxis • High risk: – all prosthetic cardiac valves – previous bacterial endocarditis • Moderate risk: – acquired valve dysfunction (RHD) – mitral valve prolapse with regurgitation or thickened leaflets
CASE STUDY • Mr. S was a 47 YOM with cardiac hx of: – rheumatic valve disease – previous AVR with Starr-Edwards – mitral regurgitation – ascending aortic aneurysm • Underwent aortic root replacement, MV replacement with bileaflet valve, and ascending aortic replacement
CASE STUDY
CASE STUDY • Required placement of permanent pacemaker • Target INR 2. 5 -3. 5 • Endocarditis prophylaxis
Percutaneous Transcatheter Implantation for AS • Clinical trials currently underway-Percutaneous Valve Technologies • 3 equine pericardial leaflets mounted within a balloon expandable stent • Implanted in aortic valve position under mild sedation and local anesthesia
THANK YOU!
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