VALVULAR DISORDERSReported By: Charlene Dorothy S. Tabigne

REVIEW

VALVULAR DISORDERS2 Main Categories of Valvular Disorders:

•Stenosis – problem: valves cannot open completely.

•Regurgitation – problem: valves doesn’t close properly.

CAUSES:• Heart valve tissue may degenerate with age.• Rheumatic fever• Bacterial endocarditis - an infection of the inner lining of the heart muscle • High blood pressure and atherosclerosis • A heart attack • Calcifications (cholesterol and fats).• Annulus Dilation• Ventricular Attachment Chords (chordae tendineae & papillary muscles)

*Left sided valvular disorders are more common than right sided due to the effort exerted by the left side of the heart to pump blood out of the heart to the body.

ASSESSMENT AND DIAGNOSIS:

History• JVD• S3 or S4

heart sounds / murmurs

• Pulse Changes

• Edema• BP

Physical Assessment:

EKG

CXR

Echocardiogram

MITRAL VALVE PROLAPSE• Portion of one or both leaflet balloons back into the atrium.

CLINICAL MANIFESTATIONS

Palpitations Fatigue

Chest Pain SOB

Mitral Click

MANAGEMENT:Goal: to control symptoms•Avoid caffeine and alcohol•Anti-arrhythmic meds•Calcium channel Blockers / Beta-Blockers •Surgery: Mitral valve replacement / repair

NURSING MANAGEMENT:• Instruct patients about the need for prophylactic antibiotic therapy before undergoing invasive procedures that may introduce infectious agents systemically. • Encourage patients to read product labels, particularly in over-the-counter products such as cough medicine.• Advise patient to avoid alcohol and caffeine.

MITRAL REGURGITATION• Blood flowing back from the left ventricle into the left atrium during

systole. Often, the leaflets of the valve cannot close due to thickening or fibrosis of leaflets or chordae tendineae.

CLINICAL MANIFESTATIONS

Cough

Fatigue

Dyspnea

Palpitations

Sytolic Murmur

MANAGEMENT:• Same as congestive Heart Failure• Restrict activity level once heart failure develops• Antibiotic prophylaxis to prevent infectious endocarditis• Afterload reduction:• ACE inhibitors (-pril)

•Mitral valvuloplasty (repair or replacement)

MITRAL STENOSIS• An obstruction of blood flowing from the left atrium into the left ventricle.

Often caused by rheumatic endocarditis which progressively thickens the mitral valve leaflets and chordae tendineae. Eventually, the mitral valve orifice narrows and progressively obstructs blood flow.

• Normally, the mitral valve opening is as wide as the diameter of three fingers. In cases of marked stenosis, the opening narrows to the width of a pencil. The left atrium has great difficulty moving blood into the ventricle because of the increased resistance of the narrowed orifice; it dilates (stretches) and hypertrophies (thickens) because of the increased blood volume it holds. Because there is no valve to protect the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. As a result, the right ventricle must contract against an abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right ventricle fails.

CLINICAL MANIFESTATIONSDifficulty of Breathing on exertion (as a result of pulmonary venous hypertension)

Fatigue (low cardiac output)

Cough and repeated respiratory infections

ASSESSMENT FINDINGS AND DX:

pulse is weak and often irregular

• because of atrial fibrillation (caused by the strain on the atrium).

Diastolic Murmur Diagnostic Tests:

• Echocardiography is used to diagnose mitral stenosis.

• Electrocardiography (ECG) and cardiac catheterization to determine severity.

TREATMENT:• Congestive heart failure treatment• Anticoagulants to avoid thrombus formation• Prophylaxis antibiotic to prevent endocarditis• Avoid strenuous activities – increased heart rate decreases cardiac output and increases pulmonary pressures with the backup of blood from the left atrium to the pulmonary veins.• Valvuloplasty

AORTIC REGURGITATION• Backflow of the blood into the left ventricle from the aorta during

diastole.

CAUSES:• Inflammatory lesions that deforms leaflets of the aortic valve, preventing them from completely closing. • Infective endocarditis• Congenital abnormalities• Blunt chest trauma• Idiopathic

PATHOPHYSIOLOGY:• In aortic regurgitation, blood from the aorta returns to the left ventricle

during diastole in addition to the blood normally delivered by the left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. It also hypertrophies, trying to increase muscle strength to expel more blood with abovenormal force—raising systolic blood pressure. The arteries attempt to compensate for the higher pressures by reflex vasodilation; the peripheral arterioles relax, reducing peripheral resistance and diastolic blood pressure.

CLINICAL MANIFESTATIONS & ASSESSMENT FINDINGS:

Marked arterial

pulsations

visible or palpable

at the carotid

or temporal arteries

Exertional dyspnea

and fatigue

Breathing

difficulties

Widened pulse

pressureWater – hammer pulse

MANAGEMENT:•Prophylaxis antibiotic before invasive / dental procedures to prevent endocarditis•ACE Inhibitors•Ca Channel Blockers•Aortic Valvuloplasty

AORTIC STENOSIS

Narrowing of the orifice between left ventricle and the aorta. Causes:1. Congenital Leaflet

malfunction2. Rheumatic

Endocarditis3. Cusp Calcification

PATHOPHYSIOLOGY• There is progressive narrowing of the valve orifice, usually

over a period of several years to several decades. The left ventricle overcomes the obstruction to circulation by contracting more slowly but with greater energy than normal, forcibly squeezing the blood through the very small orifice. The obstruction to left ventricular outflow increases pressure on the left ventricle, which results in thickening of the muscle wall. The heart muscle hypertrophies. When these compensatory mechanisms of the heart begin to fail, clinical signs and symptoms develop.

CLINICAL MANIFESTATIONS:

Dizziness / syncope Angina Pectoris

Low to Normal BP

Systolic crescendo-

decrescendo murmur

VALVULOPLASTY• The repair of cardiac valve. Types of valvuloplasty depends on the cause

and type of valve dysfunction.

KINDS OF VALVULOPLASTY:Commissurotomy – performed to separate the fused leaflets.

a. Closed Commissurotomy:a1. Balloon valvuloplasty:

• for mitral valve stenosis of younger patients• for aortic valve stenosis of elderly patients

CONTRAINDICATED for patients with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation.

b. Open Commissurotomy – performed with direct visualization, under general anesthesia.

Annuloplasty – repair of the annulus; the procedure narrows the diameter of the valve’s orifice and is useful for the treatment of valvular regurgitation.

CHORDOPLASTYRepair of the chordae tendineae.

VALVE REPLACEMENT

TYPES OF VALVE REPLACEMENT:Mechanical Valves

• Ball and cage design or disk design• More durable than tissue

prosthetics• Used for younger patients or

patients with renal failure, sepsis, endocarditis who need valve replacement.

• Complications: thromboemboli; requires long term use of anticoagulants.

Biologic/Tissue Valve• Not as durable as mechanical

prosthetics• Thromboemboli is less likely to

generate; not requiring long term use of anticoagulant.

MECHANICAL VALVES:

NURSING RESPONSIBILITIES• Assessment for sign and symptoms of heart failure and emboli.• IV meds to increase or decrease BP and treat disrhythmias.•Health Education about long term use of anticoagulants; pervetion of infection for patients with mechanical valve.