Valvular Heart Disease Valvular Disorders Mitral stenosis l

Valvular Heart Disease

Valvular Disorders Mitral stenosis l Mitral regurgitation l Mitral valve prolapse l Aortic stenosis l Aortic regurgitation l

Definition STENOSIS - Occurs when valve leaflets close together and cannot fully open or close REGURGITATION or (Insufficiency) Heart valves cannot close completely

Acquired Defects ¢ Decreasing order of occurrence Mitral stenosis (most common) l Mitral regurgitation l Mitral valve prolapse l Aortic stenosis l Aortic regurgitation l

Facts ¢ 5 million ¢ ~ 2/3 to ¾ women ¢ ~ 2/3 of women under 45

Mitral Stenosis Most common cause: rheumatic fever ¢ Results from rheumatic carditis ¢ l ¢ Causing valve thickening by fibrosis and calcification Non-rheumatic causes Atrial tumor l Calcium accumulation l Thrombus formation l

What Happens Valve leaflets fuse and become stiff ¢ Chordae tendineae contract and shorten ¢ Valvular orifice narrows ¢

Diagnostics Echocardiogram ¢ Chest Xray ¢ EKG ¢ Cardiac cath ¢ *( also TEE)

Clinical Manifestations ¢ Mild stenosis l ¢ Asymptomatic Beginning Dyspnea on exertion (DOE) l Orthopnea l Paroxysmal nocturnal dyspnea (PND) l Dry cough l

Clinical Manifestations ¢ Later l l l Hemoptysis Pulmonary edema Right-sided heart failure (DD: Cor Pulmonale) • • l Hepatomegaly Neck vein distention (JVD) Pitting edema ? One more ? Apical diastolic murmur

Mitral Regurgitation

Mitral Regurgitation (Insufficiency) Fibrotic and calcific changes prevent the mitral valve from closing completely during systole. ¢ End result left atrial and ventricular dilation and hypertrophy. ¢

Causes Rheumatic heart disease ¢ Degenerative calcification ¢ Left ventricular hypertrophy ¢ MI ¢ Congenital defects ¢

Clinical Manifestations ¢ Progresses slowly l ¢ Asymptomatic for decades Chief complaints Fatigue l Chronic weakness l DOE l Orthopnea. l

Clinical Manifestations …Continued… Normal blood pressure ¢ Atrial fibrillation (75% of all clients). ¢ Changes in respiratory patterns ¢ High pitched systolic murmur at apex ¢ Third heart sound (S 3 or S 4) ¢

Mitral Valve Prolapse

Mitral Valve Prolapse Valvular leaflets enlarge and prolapse into left atrium during systole ¢ Usually benign, but may progress to mitral regurgitation ¢ Affects 5%-10% of the population (most common in women 14 -30). ¢

Clinical Manifestations ¢ Chief complaint Atypical chest pain (sharp localized L chest pain) l Dizziness l Syncope l Tachydysrhythmias causing palpitations l Systolic murmur at apex l

Aortic Stenosis

Aortic Stenosis Aortic valve orifice narrows and obstructs left ventricular outflow during systole ¢ Results in left ventricular hypertrophy ¢ Cardiac output becomes fixed and symptoms develop l Eventually, can lead to right heart failure as well. l

Causes Congenital ¢ Rheumatic heart disease ¢ Atherosclerosis ¢ Degenerative calcifications ¢

Clinical Manifestations May be asymptomatic for years ¢ Classic manifestations: DOE, angina, syncope Other: narrow pulse pressure systolic murmur ¢

Aortic Regurgitation

Aortic Regurgitation (Insufficiency) Aortic leaflets do not close properly during diastole with possible annulus dilation, loosening, or deformity. ¢ Allows blood to flow back into left ventricle from aorta during diastole. ¢ End result: left ventricular hypertrophy ¢

Clinical Manifestations ¢ Asymptomatic (early) l ¢ Left ventricle has good compensatory mechanisms Progression l Chief complaints • • • DOE Orthopnea PND Palpitations Nocturnal angina with diaphoresis

Clinical Manifestations • • High pitched diastolic murmur Diminished diastolic pressure Elevate Systolic blood pressure Wide pulse pressure

Causes Mostly results from rheumatic heart disease ¢ Non-rheumatic conditions ¢ Infective endocarditis l Congenital aortic valve problems l Hypertension l Marfan’s syndrome l

Assessment ¢ Insidious or acute onset ¢ History Rheumatic fever? l Recent infections? l IV drug usage? l Fatigue and activity tolerance? l Family Hx? l

Care for All Valvular Disorders

Diagnostics Echocardiogram *( also TEE) ¢ Chest Xray ¢ EKG (atrial fib most common) ¢ Cardiac cath ¢

Interventions ¢ Non-surgical management l Drug therapy • • l Diuretics Digoxin Oxygen Ace Inhibitors Vasodilators (stenosis) Prophylactic antibiotic therapy Anti coagulants for A-Fib Rest

Interventions ¢ Treating atrial fibrillation l l Rate control: digitalis, diltiazem, sotalol, amiodaron etc. Rhythm control: • Cardioversion: • Pharmacology • Electrical l Anti thrombo-embolic: • Anticoagulant: Coumadin • Antiplatelet: Asetosal

Interventions ¢ Surgical management l l Aortic stenosis requires surgical therapy as it is the only definitive treatment Valve replacements • Prosthetic • Biologic l Surgical repairs • Balloon valvuloplasty –cath lab • Reconstructive or “Valvuloplasty”: • a. Open commisurotomy • b. Annuloplasty repairs

Pre-Operative Care ¢ Similar to CABG surgery Pain l Incisional care l Prevent pulmonary complications l STOP oral anticoagulants 72 hours before procedure l

Post-Operative Care Respiratory care ¢ Monitor for hemorrhage ¢ Cardiac output reduction ¢ Discharge teaching ¢

Complications ¢ Fluid & Electrolyte imbalances ¢ Hypotension ¢ Bleeding ¢ Cardiac tamponade

Complications ¢ Altered cerebral perfusion ¢ Hypothermia ¢ Hypertension ¢ Infection

Client Education Disease process ¢ Medications ¢ Anticoagulants l Prophylactic antibiotics l ¢ Rest and activity plan