Mitral Stenosis Typically caused by rheumatic carditis from

rheumatic fever Valve leaflets fuse, stiffen Chordae tendineae contract, shorten Valve opening narrows Compromises blood flow from left atrium to

left ventricle Resulting in rise in L atrial pressure, L atrium

dilitation, increased pulmonary artery pressure, R ventricular hypertrophy

Mitral Regurgitation (Insufficiency) Failure of closure of mitral valve during

systole due to fibrotic and calcific changes Blood leaks from L atrium to L ventricle along

with normal blood flow Results in increased volume to be ejected

during next systole Leading to dilation of L atrium and ventricles

with hypertrophy Rheumatic fever primary cause

Mitral Valve Prolapse Enlargement of valvular leaflets which

prolapse into L atrium during systole. Usually benign in nature but may progress to

pronounced mitral regurgitation. Most are asymptomatic Most common in women between 20 and 54

years of age Genetic Auscultation of midsystolic click with late

systolic murmur audible at apex.

Aortic stenosis Aortic valve orifice narrows and obstructs L

ventricular outflow during systole Leading to increased resistance to efection or

afterload Resulting in ventricular hypertrophy Predominately caused by congenital

malformation/disease Most common valvular disorder in countries

with aging populations Caused by atherosclerosis and degenerative

calcification 80% men

Aortic regurgitations (insufficiency) Aortic valve leaflets do not close properly

during diastole Leads to regurgitation of blood from the aorta

back into L ventricle during diastole L ventricle dilates with eventual hypertrophy Asymptomatic When patient becomes symptomatic,

symptoms due to L ventricular failure Bounding arterial pulse, widened pulse

pressure, high-pitched blowing decrescendo diastolic murmur

Causes: infective endocarditis, congenital anatomic aortic valvular abnormalities, htn, Marfan syndrome

75% are men

NonsurgicalDrug therapy

Diuretics

Beta BlockersDigoxinNitratesCalcium Channel BlockersProphylactic antibiotic therapyAnticoagulantsAntidysrhythmics

Rest

Surgical Management Reparative procedures

Improved function of valve Less problem with complications

Balloon valvuloplasty Patients selected for this are typically older, high

risk for surgical complications or have refused operative treatment

Benefits short lived Postop precautions consistent with those for

cardiac catheterization Direct Commissurotomy

Requires open heart surgery and cardiopulmonary bypass

Removal of thrombi, cutting loose of fused leaflets, debridement of calcium from valve

Mitral Valve Annuloplasty Reconstruction of valve for acquired mitral

insufficiency Valve replacement

Xenograft Porcine or bovine Risk for clot formation minimized No need for long term anticoagulant therapy Typically used for the older patient

Prosthetic valve More durable Used in younger patients Must have long term anticoagulation

See chart 38-9 for patient education

Microbial infection involving endocardium Found in Iv drug abusers, patients having

had valve replacements, bacteremia, structural cardiac defects

Mortality high – early detection key > 90% develop murmurs Heart failure most common complication See chart 38-10 Key features of infective

endocarditis Interventions = antimicrobials, rest

balanced with activity, supportive care for heart failure

Most common procedure = orthotopic transplantation

Donor must be comparable body weight, ABO compatible

Heart must be transplanted within 6 hours of harvesting

See criteria for candidate selection pg 774 Biggest factor to remember is that vagus

nerve will no longer function Atropine, digitalis and carotid sinus pressure

ineffective

Require life long immunosuppressants Long term complications

Coronary artery vasculopathy Organ rejection

See Key Points at end of chapter 38

Acyanotic Do not cause deoxygenation Skin and mucous membrane color is usually pink

Atrial septal defect Left to right shunt Opening between L and R atria Surgical closure or patch of defect

Ventricular septal defect Left to right shunt Increased pulmonary blood flow May have spontaneous closure Surgical patching may be required Prophylactic antibiotics for prevention of endocarditis

Coarctation of the aorta Narrowing of the descending aorta restricting

blood flow leaving heart Progressive, leading to chf BP difference of 20mm between upper and lower

extremities Upper pulses full, lower pulses weak CVA secondary to htn in upper circulation Endocarditis prophylaxis Surgical resection and patch of coarctation

Cyanotic heart defects Heart conditions that couse blood to contain less

oxygen than required Skin and mucous membranes usually pale to blue

Tetrology of Fallot 4 defects that combine to allow blood flow to bypass

lungs and enter L side of heart R to L shunt Unoxygenated blood enters body circulation leading

to cyanosis Defects:

Pulmonic stenosis R ventricular hypertrophy Ventricular septal defect Overriding aorta

Acidosis occurs TET spells: hypercyanosis = transient periods of

increased R to L shunting of blood

Transposition of the great vessels Aorta arises from R ventricle, pulmonary

artery arises from L ventricle This is inconsistent with life

Other anomalies exist that increase mixing of blood between the two separate circulations to promote oxygenation

R to L shunting of blood occurs

Aneurysm – permanent dilation of an artery to at least 2 times its normal diameter Fusiform = affects entire circumference of artery Saccular = outpouching affecting only a distinct portion

of artery True aneurysm = arterial wall weakened by congenital

or acquired problems False aneurysm = occurs as a result of trauma or injury

to all 3 layers of the artery wall Abdominal aortic aneurysms (AAA) account for 75% of

all aneurysms Atherosclerosis is most common cause AAA more common in men than women S/S related to pressure on surrounding structures or

rupture Rupture is life threatening

Interventions Nonsurgical to monitor growth of affected

area and maintain BP at a normal level Surgical management is the excision of the

aneurysm from the area with the placement of a woven Dacron graft Pre and post op care consistent for those

undergoing surgery with general anesthesia