Intro to Valvular Disease

1. Intro to Valvular Disease Morris, an 82 year-old man, went to the doctor to get a physical. A few days later, the doctor saw Morris walking down the street with a gorgeous young woman on his arm. A couple of days later, the doctor spoke to Morris and said, 'You're really doing great, aren't you?' Morris replied, 'Just doing what you said, Doc: 'Get a hot mamma and be cheerful.'' The doctor said, 'I didn't say that.. I said, 'You've got a heart murmur; be careful.'

2. Valvular Heart Disease • Heart contains • Two atrioventricular valves • Mitral • Tricuspid • Two semilunar valves • Aortic • Pulmonic • **review areas to listen**

3. Tricuspid

4. Valvular Heart Disease • Types of valvular heart disease depend on • Valve or valves affected • Two types of functional alterations • Stenosis • Regurgitation • Valvular disorders occur in children and adolescents primarily from congenital conditions and in adults from degenerative heart disease Stenosis and Insufficiency

5. Risk Factors • Rheumatic Heart Disease, MI • Congenital Heart Defects-bicuspid valve • Aging • CHF

6. Pathophysiology • Stenosis- narrowed valve, increases afterload • Regurgitation 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 failure • All valvular diseases have a characteristic murmur murmurs

7. Mitral Valve Stenosis Pathophysiology • Decreased blood flow into LV • LA hypertrophy • Pulmonary pressures increase • Pulmonary hypertension • Decreased CO

8. Mitral Valve Stenosis Manifestations Primary symptom is DOE Later get symptoms of R heart failure A fib is common MVS murmur Usually secondary to rheumatic fever

9. Treatment

11. Mitral Valve Regurgitation Pathophysiology Manifestations Thready pulses Cool extremities Symptoms of LV failure Third heart sound (S3) MVR murmur • Regurgitation of blood into LA during systole • LA dilation and hypertrophy • Pulmonary congestion • RV failure • LV dilation and hypertrophy-to accommodate increased preload and decreased CO

12. Mitral Valve Prolapse Pathophysiology Manifestations Usually asymptomatic Click murmur Atypical chest pain does not respond to NTG Tachydysrhythmias may develop- SVT, VT Risk for endocarditis may be increased heart association guidelines • Abnormality of the mitral valve leaflets, papillary muscles or chordae • Type of mitral insufficiency • Etiology unknown • Most common valvular heart disease in US • Female 2x > Male

13. Mitral Valve Prolapse • Usually benign, but serious complications can occur • Mitral valve regurgitation • Infective endocarditis • Sudden death • Cerebral ischemia Mitral Valve Prolapse

14. Mitral Valve Prolapse • May or may not be present with chest pain • If pain occurs, episodes tend to occur in clusters, especially during stress • Pain may be accompanied by dyspnea, palpitations, and syncope • Does not respond to antianginal treatment • MVP murmur (mid-systolic click) • TEE MVP

15. Aortic Valve Stenosis Pathophysiology Aortic Valve Problems • Increase in afterload • Incomplete emptying of LA • LV hypertrophy • Reduced CO • RV strain • Pulmonary congestion • Poor prognosis when experiencing symptoms and not treated- 10-20%sudden cardiac death

16. Aortic Valve Stenosis Manifestations May be asymptomatic for many years due to compensation AVS murmur Nitroglycerin is contraindicated because it reduces preload • Syncope • Angina • Dyspnea • Exertional Syncope, Angina, DOE are classic symptoms • This triad reflects LVF • Later get signs of RHF

17. Aortic Valve Regurgitation Pathophysiology • Bicuspid valve, genetic • Increased preoad- 60% of SV can be regurgitated • Characteristic water hammer pulse • Regurgitation of blood into the LV • LV dilation and hypertrophy • Decreased CO

18. Aortic Valve Regurgitation Manifestations Sudden manifestations of cardiovascular collapse Left ventricle exposed to aortic pressure during diastole Weakness Severe dyspnea Chest pain Hypotension Constitutes a medical emergency AVR murmur

19. 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. YouTube - Corrigan's sign Austin Flint

20. Tricuspid and Pulmonic Valve Disease Pathophysiology Manifestations RHF • Uncommon • Both conditions cause an increase in blood volume in R atrium and R ventricle • Result in Right sided heart failure • Tricuspid- Rheumatic, IV drug abuse • Pulmonic- Congenital

21. Diagnostic Tests • Echo- assess valve motion and chamber size • CXR • EKG • Cardiac cath- get pressures

22. Medications • Like Heart Failure • ACE inhibitors • Digoxin • Diuretics • Vasodilators • Beta blockers • Anticoagulants • *Prophylactic antibiotics • Antiarrhythmics

23. Medical/ Surgical Treatment • Percutaneous balloon valvuloplasty • Surgical therapy for valve repair or replacement: • **Valve repair is typically the surgical procedure of choice • Open commissurotomy- open stenotic valves • Annuloplasty- can be used for both • Valve replacement may be required for certain patients Heart valve surgery • Mechanical-need anticoagulant • Biologic-only last about 15 years • Ross Procedure • MedlinePlus: Interactive Health Tutorials- on own

24. Ross Procedure

25. This is an excised porcine bioprosthesis. The main advantage of a bioprosthesis is the lack of need for continuedanticoagulation. The drawback of this type of prosthetic heart valve is the limited lifespan, on average from 10 to 15 years because of wear and calcification.

26. 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.

27. Nursing Diagnoses Activity intolerance Excess fluid volume Decreased cardiac output Ineffective therapeutic regimen management

28. What is new? Percutaneous Transcatheter Heart Valve Implantation- Metallic clip -for the treatment of mitral regurgitation Longer-lasting replacement valves Stem cell research and the use of endothelial cells

29. Review of Valvular diseases using Prezis • Case 1 • Case 2 • Case 3 • Case 4 • Case 5-overview all • Case 6

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

31. Cardiomyopathy-Causes • Primary-idiopathic • Secondary • Ischemia- from CAD • infectious disease • exposure to toxins -alcohol, cocaine • Metabolic disorders • Nutritional deficiencies • Pregnancy

32. 3 Types of Cardiomyopathy • Dilated • Hypertrophic • Restrictive

33. PathophysiologyDilated • Most common- heart failure in 25-40% • Cocaine and alcohol abuse • Chemotherapy, pregnancy • Hypertension • Genetic • * Heart chamber dilate and contraction is impaired and get dec. EF% • *Dysrhythmias are common- SVT Afib and VT • Prognosis poor-need transplant

34. Dialated Cardiomyopathy • Diagnostics • Echocardiogram, CXR, ECG, labs • Treatment-Control HF • Diuretics • Nitrates • Ace inhibitors • Beta blockers • Digoxin • Amiodarone • Anticoagulants

35. Normal weight 350 gms now 700 gms

36. PathophysiologyHypertrophic-HCM • **Genetic • Also known as IHSS or HOCM • Get hypertrophy of the ventricular mass and impairs ventricular filling and CO • Symptoms develop during or after physical activity (fatigue from dec CO) • Sudden cardiac death may be first symptom • **HCM most common cause of SCD in young adulthood

37. Hypertrophic Cardiomyopathy • Manifestations • Dyspnea • Fatigue-dec CO • Angina, syncope • S4 and systolic murmur • Diagnostics • Echo- TEE • Heart cath

40. Hypertrophic Cardiomyopathy Treatment Goal- improve ventricular filling and relieve LV outflow obstruction • Beta blockers • Calcium channel blockers • Digoxin- only for A-fib if present • Antidysrhythmics • ICD • AV pacing

41. Hypertrophic Cardiomyopathy • Ventriculomyotomy and myomectomy- incising the septum muscle and removing some of the hypertrophied muscle • PTSMA- alcohol induced percutaneous trans luminal septal myocardial ablation • - inject alcohol into small branch of LAD which causes ischemia and MI of septal wall. • Live Search Videos: cardiomyopathy

42. Nursing • Relieve symptoms • Prevent complications • Provide pysch and emotional support • Teaching- • Avoid strenuous exercise and dehydration • Avoid anything increasing the SVR (afterload) makes obstruction worse • If chest pain- rest and elevation of feet for venous return • Avoid vasodilators like nitroglycerine- decrease venous return to the heart

43. PathophysiologyRestrictive Least common Rigid ventricular walls that impair filling Contraction and EF normal Signs of CHF Prognosis-poor

44. Diagnostics for CMP • Echo- • wall motion and EF • EKG • CXR • Hemodynamics • Perfusion scan • Cardiac cath • Myocardial biopsy

45. Treatment Medications Same as for heart failure except for hypertrophic Surgery • Vad-bridge to transplant or destination therapy • Heart Transplant • Myoplasty • ICD- antiarrhythmics are negative inotropes • Dual chamber pacemaker • Hypertrophic- excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds the top portion of septum.

46. Nursing Diagnoses • Decreased Cardiac Output • Fatigue • Ineffective Breathing Pattern • Fear • Ineffective Role Performance • Anticipatory grieving