Intro to Valvular Disease

Mitral Valve

Valvular Heart DiseaseHeart contains

Two atrioventricular valves Mitral Tricuspid

Two semilunar valvesAorticPulmonic

Valvular Heart DiseaseTypes of valvular heart disease depend on

Valve or valves affectedTwo types of functional alterations

StenosisRegurgitation

Valvular Heart DiseaseValvular disorders occur in children and adolescents primarily from congenital conditions and in adults from degenerative heart disease

Valvular Heart Disease

HeartPoint: Valvular Heart Disease

http://www.heartcenteronline.com/myheartdr/common/articles.cfm?ARTID=187

Flashcards about Ch 19 NETI KQ- on your own

Risk FactorsRheumatic Heart Disease MICongenital Heart DefectsAgingCHF

Valvular surgery

Heart Surgery Innovations - Google Video

11:22 valves

20 beating heart

20 aortic valve

PathophysiologyStenosis- narrowed valve, increases afterloadRegurgitation or insufficiency- increases preload. The heart has to pump same blood**Blood volume and pressures are reduced in front of the affected valve and increased behind the affected valve.This results in heart failureAll valvular diseases have a characteristic murmur murmurs

Mitral Valve Stenosis

Fig. 37-9

Fish mouth

Mitral StenosisDec. flow into LVLA hypertrophyPulmonary pressures increasePulmonary hypertensionDec. CO* early symptom is DOELater get symptoms of R heart failureA fib is common- anticoagulantsUsually secondary to rheumatic fever

Mitral RegurgitationRegurg of blood into LA during systoleLA dilation and hypertrophyPulmonary congestionRV failureLV dilation and hypertrophy-to accommodate inc. preload and dec CO

Mitral Regurgitation

MitraClip Repair

MitraClip 3D Animation

Mitral Valve ProlapseA type of mitral insufficiencyUsually asymptomatic- click murmurMay get atypical chest pain related to fatigueTachydysrhythmias may developRisk for endocarditis may be increased

Mitral Valve Prolapse

Fig. 37-10Fig. 37-10

Mitral Valve ProlapseUsually benign, but serious complications can occur

Mitral valve regurgitation Infective endocarditis Sudden death Cerebral ischemia

Mitral Valve ProlapseClinical manifestations

Most patients asymptomatic for lifeMurmur from insufficiency that gets more intense through systole

Late or holosystolic murmur

Clicks mid to late systole that may be constant or vary beat to beat

Mitral Valve Prolapse

Dysrhythmias Paroxysmal supraventricular tachycardiaVentricular tachycardia

Palpitations LightheadednessDizziness

Mitral Valve ProlapseMay or may not be present with chest pain

If pain occurs, episodes tend to occur in clusters, especially during stressPain may be accompanied by dyspnea, palpitations, and syncope Does not respond to antianginal treatment

A&P 1 Heart part 1

Midsytolic click & late systolic murmur

MVP video

Infections & Injuries of the Heart- on own

Live Search Videos: mitral valve prolapse

Aortic Stenosis

Aortic Stenosis

Minimally Invasive Aortic Heart Valve Replacement

Aortic Stenosis

Aortic StenosisIncrease in afterloadReduced COLV hypertrophyIncomplete emptying of LAPulmonary congestionRV strain

Symptoms

Syncope

Angina

Dyspnea

This triad reflects left ventricular failure

Aortic StenosisMay be asymptomatic for many years due to compensationDOE, angina, and exertional syncope are classic symptomsLater get signs of R heart failureUntreated-poor prognosis- 10-20%sudden cardiac death

Aortic Valve Stenosis

Poor prognosis when experiencing symptoms and valve obstruction is not relievedNitroglycerin is contraindicated because it reduces preload

New Approach- Percutaneous AVR

Aortic Regurgitation

Aortic RegurgitationGet increased preoad- 60% of SV can be regurgitatedCharacteristic water hammer pulseRegurgitation of blood into the LVLV dilation and hypertrophyDec. CO

Echocardiography

Aortic Valve RegurgitationClinical manifestations

Sudden manifestations of cardiovascular collapseLeft ventricle exposed to aortic pressure during diastoleWeakness

Aortic Valve RegurgitationSevere dyspnea Chest painHypotension Constitutes a medical emergency

Water Hammer pulse

Pulse, water hammer: A jerky pulse that is full and then collapses because of aortic insufficiency (when blood ejected into the aorta regurgitates back through the aortic valve into the left ventricle ).

Also called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse.

Austin Flint

Tricuspid and Pulmonic Valve Disorders

Result in R side heart failure

Diagnostic TestsEcho- assess valve motion and chamber sizeCXREKGCardiac cath- get pressures

Collaborative CareDrug therapy

DigitalisDiuretics Antidysrhythmics-Blockers Anticoagulants

MedicationsLike Heart Failure

ACE, DigDiureticsVasodilatorsBeta blockersAnticoagulants*Prophylactic antibiotics

Medical/ Surgical Treatment

Percutaneous balloon valvuloplastySurgery

Open commissurotomy- open stenotic valvesAnnuloplasty- can be used for bothValve Replacement

Mechanical-need anticoagulantBiologic-only last about 15 yearsRoss Procedure

Collaborative TherapySurgical therapy for valve repair or replacement

Valve repair is typically the surgical procedure of choiceValvular replacement may be required for certain patients

Valve Replacement Surgery

MedlinePlus: Interactive Health Tutorials- on own

Ross Procedure

This is an excised porcine bioprosthesis. The main advantage of a bioprosthesis is the lack of need for continued anticoagulation. The drawback of this type of prosthetic heart valve is the limited lifespan, on average from 5 to 10 years (but sometimes shorter) because of wear and calcification.

This is a mechanical valve prosthesis of the more modern tilting disk variety (for the mitral valve). Such mechanical prostheses will last indefinitely from a structural standpoint, but the patient requires continuing anticoagulation because of the exposed non-biologic surfaces.

Nursing DiagnosesActivity intoleranceExcess fluid volumeDecreased cardiac outputIneffective therapeutic regimen management

What Is New?•Surgeons are exploring heart valve replacement without the need for open heart surgery. Typically, diseased or defective valves are replaced with an artificial valve or a tissue valve (from a pig or cow). A new, less invasive procedure, known as percutaneous transcatheter heart valve implantation, involves the use of balloon catheters and large stents introduced through a puncture in the skin (in the groin area, near the femoral vein). The new heart valve is transported via the stent to the site, where the stent is then expanded to implant the valve. For patients not able to undergo open-heart surgery, due to age and/or physical condition, percutaneous heart valve implantation may impact significantly on survival and quality of life.

New Approach to Valvular Surgery

Case study

New Cont.

A number of new technologies are being explored to allow patients who formerly would need an open-heart surgery to have a less-invasive procedure. For instance, the use of a tiny metallic clip is being studied for the treatment of mitral regurgitation to help the valve close properly.

Cont.

Though they may last a lifetime for older patients, younger patients may need several replacement procedures over time. Therefore, one focus of research is to create longer-lasting replacement valves, particularly for patients with congenital heart disease. Two areas of research have shown potential toward this goal: stem cell research and the use of endothelial cells.

CardiomyopathyCondition is which a ventricle has become enlarged, thickened or stiffened. As a result heart’s ability as a pump is reduced

Fig. 37-12

CardiomyopathyPrimary-idiopathicSecondary

Ischemia- from CADinfectious diseaseexposure to toxins -alcohol, cocaineMetabolic disordersNutritional deficienciesPregnancy

3 Types of Cardiomyopathy

DilatedHypertrophicRestrictive

Fig. 37-13

PathophysiologyDilated

Most common- heart failure in 25-40%Cocaine and alcohol abuseChemotherapy, pregnancyHypertensionGenetic* Heart chamber dilate and contraction is impaired and get dec. EF%*Dysrhythmias are common- SVT Afib and VTPrognosis poor-need transplant

This very large heart has a circular shape because all of the chambers are dilated. It felt very flabby, and the myocardium was poorly contractile. This is an example of a cardiomyopathy.

Normal weight 350 gms now 700 gms

Pathophysiology Hypertrophic-HCM

GeneticAlso known as IHSS or HOCMGet hypertrophy of the ventricular mass and impairs ventricular filling and COSymptoms develop during or after physical activitySudden cardiac death may be first symptomSymptoms are dyspnea, angina and syncope

HCM Patho1. Massive ventricular hypertrophy2. Rapid, forceful contraction of the LV3. Impaired relaxation or diastole4. Obstruction to aortic outflow

Primary defect is diastolic filling**HCM most common cause of SCD in young adulthood

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 37-14

There is marked left ventricular hypertrophy, with asymmetric bulging of a very large interventricular septum into the left ventricular chamber. This is hypertrophic cardiomyopathy. About half of these cases are genetic. Both children and adults can be affected, and sudden death can occur.

HCM- SymptomsDyspneaFatigue- dec. COAngina SyncopeS4 and systolic murmur

Hypertrophic DiagnosticsEcho- TEE

Heart Cath

Treatment of HOCM

cardiomyopathy - Live Search Video

PTSMA- alcohol induced percutaneous trans luminal septal myocardial ablation

- inject alcohol into small branch of LAD which causes ischemia and MI of septal wall. (Grey’s Anatomy episode relief of heart failure)

InterventionsGoal- improve vent filling and relieve LV outflow obstruction

Beta blockers- metoprololCalcium channel blockersDig- only for A-fib if present Anti-arrhythmics- amiodorone or sotalolICD- to dec. risk of sudden deathAV pacing

Surgical TreatmentVentriculomyotomy and myomectomy- incising the septum muscle and removing some of the hypertrophied muscle

Nursing

Relieve symptomsPrevent complicationsProvide pysch and emotional supportTeaching-

Avoid strenuous exercise and dehydrationAvoid anything increasing the SVR (afterload) makes obstruction worseIf chest pain- rest and elevation of feet for venous returnAvoid vasodilators like nitroglycerine- decrease venous return to the heart

PathophysiologyRestrictive

Least commonRigid ventricular walls that impair fillingContraction and EF normalSigns of CHFPrognosis-poor

DiagnosticsEcho-wall motion and EFEKGCXRHemodynamicsPerfusion scanCardiac cathMyocardial biopsy

MedicationsSame as for heart failure except for hypertrophic

TreatmentSurgery

Vad-bridge to transplantHeart TransplantMyloplastyICD- antiarrhythmics are negative inotropesDual chamber pacemakerHypertrophic- excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds the top portion of septum.

Heart transplant

 

virtual transplant

Nursing DiagnosesDecreased Cardiac OutputFatigueIneffective Breathing PatternFearIneffective Role PerformanceAnticipatory grieving

Priority Question # 29

During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit after repair of an abdominal aortic aneruysm all of these data are obtained. Which has the most immediate implications for the client’s care?A. The arterial line indicates a blood pressure of 190/112.B. The monitor shows sinus rhythm with frequent PAC’s.C. The client does not respond to verbal stimulation.D. The client’s urine output is 100ml of amber urine.

Priority Question #30

It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for the post-operative care of client having cardiac surgery. Which of these nursing activities included in the care plan will need to be done by an RN?A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs.B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake.C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes.D. Administer oral analgesisc medications as needed prior to assisting patient out of bed on first post-operative day.

Priority Question # 25

These clients present to the ER complaining of acute abdominal pain. Prioritize them in order of severity.A. A 35 year old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating.B. An 11 year old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days.C. A 40 year old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week.D. A 56 year old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour.

Case study 15Ms. C. 81y/o admitted to CCU with SOB. She has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is MSO4 2-4mg IV as needed for chest pain or dyspnea.

As you go to assess her you find her in bed at 60 degree angle. She is pale, has circumoral cyanosis and respirations are rapid and labored.

Question 1

What action should you take first?

1. Listen to breath sounds

2. Ask when the dyspnea started

3. Increase her O2 to 6L minute

4. Raise the HOB to 75-85 degrees

Cont.Upon assessment, you find crackles and she is coughing pink frothy sputum. Her O2 sat is 85% with O2 increased to 6L/min. She has 3-4+ pitting edema in her feet and mid- calf. She has JVD with HOB elevated to 75 degree angle.

Case Study 15- #2Which one of these complications are you most concerned about, based on your assessment?1. Pulmonary edema2. Cor pulmonale3. Myocardial infarction4. Pulmonary embolus

#3Which action will you take next?1. Call the physician about client’s condition.2. Place client on a non-rebreather mask with FiO2 at 95%.3. Assist client to cough and deep breathe.4. Administer ordered morphine sulfate 2mg IV.

#4What additional assessment data are most important to obtain at this time?1. Skin color and capillary refill2. Orientation and pupil reaction to light3. Heart sounds and PMI4. Blood pressure and apical pulse

#5Client’s B/P is 98/52 and AP is 116 and irregular in ST rate 110-120 with frequent multifocal PVC’s. You call the physician and receive these orders. Which one should be done first?1. Obtain serum dig level2. Give furosemide 100mg. IV3. Check blood potassium level4. Insert #16 french foley catheter

#6Which order could be assigned to an LVN?1. Obtain serum digoxin level2. Give furosemide 100mg. IV3. Check blood potassium level4. Insert #16 french foley catheter

#7While you are waiting for the the potassium level, you give morphine sulfate 2mg IV to the the client. A new graduate asks why you are giving her the morphine. What is the best response?1. It will help prevent any chest pain from occurring.2. It will decrease her respiratory rate.3. It will make her more comfortable if she has to be intubated.4. It will decrease venous return to her heart.

#8Her K is 3.1. the physician orders KCL 20meq. IV before giving the furosemide. How will you administer it.1. Utilize a syringe pump to infuse the KCL over 10 minutes.2. Dilute the KCL in 100 ml of D5W and infuse over 1 hour.3. Use a 5ml syringe and push the KCL over at least 1 minute.4. Add the KCL to 1 liter of D5W and administer over 8 hours.

#9After you have infused the KCL, you give the lasix. Which of these nursing actions will be most useful in evaluating whether the lasix is having the desired effect?1. Obtain the client’s daily weight2. Measure the hourly urine output3. Monitor blood pressure4. Assess the lung sounds

#10The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion?1. Lung sounds2. Heart rate3. Blood pressure4. Peripheral edema

#11Which nurse should be assigned care for this client?1. A float RN who has worked on CCU step down for 9 years and has floated before to CCU2. An RN from a staffing agency who has 5 years CCU experience and is orienting to your CCU today3. A CCU RN who is already assigned to care for a newly admitted client with chest trauma4. The new graduate RN who needs more experience in caring for client with left ventricular failure.

A few days later, she is transferred to the step-down unit. Her weight has decreased 4 kg. She denies SOB at rest, has crackles only in the bases. She is receiving O2 at 1L/min. She has a grade III/IV murmur and her pulse is very irregular. The monitor shows atrial fibrillation, rate 80-100. She denies dizziness, but states her vision feels “fuzzy.” She has 2+ ankle edema. VS are B/P 108/62, 86, 24, O2 sat 95%. Medications:Lasix 40mg twice daily KCL 10mEq dailyAspirin 81mg daily Captopril 6.25mg tidDigoxin 0.25mg daily’

#12Which information would be most important to report to the physician?1. Crackles and oxygen saturation2. Atrial fibrillation and fuzzy vision3. Apical murmur and pulse rate4. Peripheral edema and weight

#13All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician?Furosemide 40mg po bidEcotrin 81mg po dailyKCL 10meq three times a dayCaptopril 6.25mg po three times a dayLanoxin .125mg po every other day