Download Valvular Heart Disease

Valvular Heart Disease
Dr.Isazadehfar
Types
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Mitral Stenosis
Mitral Regurgitation
Mitral Valve Prolapse
Aortic Stenosis
Aortic regurgitation
Tricuspid valve is affected infrequently
– Tricuspid stenosis – causes Rt HF
– Tricuspid regurgitation –causes venous overload
Rheumatic Heart Disease
• Inflammatory process that may affect
the myocardium, pericardium and or
endocardium
• Usually results in distortion and scarring
of the valves
Rheumatic Heart Disease,
cont.
• Subjective
symptoms
– Prior history of
rheumatic fever
– General malaise
– Pain – may or may
not be present
• Objective
symptoms
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Temperature
Murmurs
Dyspnea
polyarthritis
Rheumatic Heart Disease
• Diagnosis
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H/P
WBC and ESR
C-reactive protein
Cardiac enzymes
EKG
Chest x-ray
Echo
Cardiac cath
Cardiac output
Rheumatic Heart Disease
• Nursing Care
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Vital signs
Rest and quiet environment
Give antibiotics, digitalis, and diuretics
Provide adequate nutrition
Monitor I/O
Explain treatment and home care
Cardiac Physiology
Systole
S1-S2
AV/PV – opens
MV/TV – closes
Diastole
S2-S1
AV/PV – closes
MV/TV – opens
Cardiac Physiology
Cardiac Physiology
Regurg/ Insuff – leaking (backflow) of blood across a closed valve
Stenosis – Obstruction of (forward) flow across an opened valve
Systole
S1-S2
Diastole
S2-S1
AV/PV – opens-------Aortic Stenosis
MV/TV – closes------Mitral Regurg
AV/PV – closes------Aortic Regurg
MV/TV – opens-------Mitral Stenosis
These concepts are set in stone, it can’t occur any other way,
It would be anatomically impossible
Cardiac Anatomy
Mitral Stenosis
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Usually results from rheumatic carditis
Is a thickening by fibrosis or calcification
Can be caused by tumors, calcium and thrombus
Valve leaflets fuse and become stiff and the
cordae tendineae contract
These narrows the opening and prevents normal
blood flow from the LA to the LV
LA pressure increases, left atrium dilates, PAP
increases, and the RV hypertrophies
Pulmonary congestion and right sided heart failure
occurs
Followed by decreased preload and CO decreases
Mitral Stenosis, cont.
• Mild – asymptomatic
• With progression – dyspnea, orthopneas, dry
cough, hemoptysis, and pulmonary edema
may appear as hypertension and
congestion progresses
• Right sided heart failure symptoms occur
later
• S/S
– Pulse may be normal to A-Fib
– Apical diastolic murmur is heard
Etiology of Mitral Stenosis
• Rheumatic heart disease: 77-99% of all
cases
• Infective endocarditis: 3.3%
• Mitral annular calcification: 2.7%
Mitral Stenosis
MS Pathophysiology
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Progressive Dyspnea (70%): LA dilation 
pulmonary congestion (reduced emptying)
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worse with exercise, fever, tachycardia, and
pregnancy
Increased Transmitral Pressures: Leads to left
atrial enlargement and atrial fibrillation.
Right heart failure symptoms: due to
Pulmonary venous HTN
Hemoptysis: due to rupture of bronchial
vessels due to elevated pulmonary pressure
Mitral Stenosis
Heart Sounds in MS
• Diastolic murmur:
– Low-pitched diastolic rumble most
prominent at the apex.
– Heard best with the patient lying on the
left side in held expiration
– Intensity of the diastolic murmur does not
correlate with the severity of the stenosis
Heart Sounds in MS
• Loud Opening S1 snap: heard at the apex
when leaflets are still mobile
– Due to the abrupt halt in leaflet motion in
early diastole, after rapid initial rapid
opening, due to fusion at the leaflet tips.
– A shorter S2 to opening snap interval
indicates more severe disease.
Management of MS
Serial echocardiography:
– Mild: 3-5 years
– Moderate:1-2 years
– Severe: yearly
Mitral Regurgitation
• Primarily caused by rheumatic heart disease, but
may be caused by papillary muscle rupture form
congenital, infective endocarditis or ischemic heart
disease
• Abnormality prevents the valve from closing
• Blood flows back into the right atrium during systole
• During diastole the regurg output flows into the LV
with the normal blood flow and increases the
volume into the LV
• Progression is slowly – fatigue, chronic weakness,
dyspnea, anxiety, palpitations, cough
• May have A-fib and changes of LV failure
• May develop right sided failure as well
Mitral Regurgitation
Physical Exam
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Holosystolic Apical Blowing Murmur
Laterally displaced apical impulse
Split S2 (but is obscured by the murmur)
S3 Gallop (increased volume during diastole)
Radiation depends on the etiology
Mitral Valve Prolapse
• Cause is variable and may be associated
with congenital defects
• More common in women
• Valvular leaflets enlarge and prolapse into
the LA during systole
• Most are asymptomatic
• Some may report chest pain, palpitations or
exercise intolerance
• May have dizziness, syncope and palpitations
associated with dysrhythmias
• May have audible click and murmur
Mitral Regurgitation -MVP
Mitral Regurgitation -MVP
Mitral Regurgitation -MVP
Diagnosis and Treatment
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Echo 2D/Color
B-Blockers (hyperadrenergic symptoms, Palpitations)
Aspirin (TIAs without etiology)
SBE Prophylaxis (only if associated with MR)
Severe Symptomatic MR – same as chronic MR
Aortic Stenosis
• Valve becomes stiff and fibrotic, impeding blood flow with LV
contraction
• Results in LV hypertrophy, increased O2 demands, and
pulmonary congestion
• Causes – rheumatic fever, congenital, arthrosclerosis
• Atherosclerosis and calcification is primary cause in the
elderly
• Complications – right sided heart failure, pulmonary edema,
and A-fib
• S/S – Early: dyspnea, angina, syncope
Late: marked fatigue, debilitation, and
peripheral cyanosis, crescendodecrescendo murmur is heard
Aortic Stenosis
Physical Exam
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Harsh Systolic Ejection Murmur – late peaking
S4 gallop (from LVH)
Sustained Bifid LV impulse (from LVH)
Pulsus Parvus et Tardus (Carotid Impulse)
Heart sounds- soft and split second heart sound
Presentation of Aortic Stenosis
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Syncope: (exertional)
Angina: (increased myocardial
oxygen demand; demand/supply
mismatch)
Dyspnea: on exertion due to heart
failure (systolic and diastolic)
Sudden death
Aortic Stenosis
Echo Surveillance
• Mild: Every 5 years
• Moderate: Every 2 years
• Severe: Every 6 months to 1 year
Summary
• Disease of aging
• Look for the signs on physical exam
• Echocardiogram to assess severity
• Asymptomatic: Medical
management and surveillance
• Symptomatic: AoV replacement
(even in elderly and CHF)
Aortic Regurgitation
• Aortic valve leaflets do not close properly during
diastole
• The valve ring that attaches to the leaflets may be
dilated, loose, or deformed
• The ventricle dilates to accommodate the ↑ blood
volume and hypertrophies
• Causes: infective endocarditis, congenital,
hypertension, Marfan’s
• May remain asymptomatic for years
• Develop dyspnea, orthopnea, palpitations, ,and
angina
• May have ↑ systolic pressure with bounding pulse
• Have a high pitch, blowing, decrescendo diastolic
murmur
Etiology of Acute AR
• Endocarditis
• Aortic Dissection
• Physical Findings:
– Wide pulse pressure
– Diastolic murmur
– Florid pulmonary edema
Aortic Regurg – pathophysiology
Aortic Regurgitation
• Progressive Symptoms include:
- Dyspnea: exertional, orthopnea, and
paroxsymal nocturnal dyspnea
- Nocturnal angina: due to slowing of heart
rate and reduction of diastolic blood
pressure
- Palpitations: due to increased force of
contraction
Aortic Regurgitation
Physical Exam
• Diastolic Decrescendo Blowing Murmur at the left
sternal border
• Hyperdynamic LV apical impulse
• Bounding Pulses
• S4, S3 Gallop-advanced AI
• Apical Rumble – “Austin Flint Murmur” (apex):
Regurgitant jet impinges on anterior MVL causing it
to vibrate
• Systolic ejection murmur: due to increased
flow across the aortic valve
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Assessment for Valve
Dysfunction
• Subjective symptoms
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Fatigue
Weakness
General malaise
Dyspnea on exertion
Dizziness
Chest pain or discomfort
Weight gain
Prior history of rheumatic heart disease
Assessment, cont.
• Objective symptoms
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Orthopnea
Dyspnea, rales
Pink-tinged sputum
Murmurs
Palpitations
Cyanosis, capillary refill
Edema
Dysrhythmias
Restlessness
Diagnosis
• History and physical findings
• EKG
• Chest x-ray
• Cardiac cath
• Echocardiogram
Medical Treatment
• Nonsurgical management focuses on
drug therapy and rest
• Diuretic, beta blockers, digoxin, O2,
vasodilators, prophylactic antibiotic
therapy
• Manage A-fib, if develops, with
conversion if possible, and use of
anticoagulation
Interventions
• Assess vitals, heart sounds, adventitious breath
sounds
• O2 as prescribed
• Emotional support
• Give medications
• I/O
• Weight
• Check for edema
• Explain disease process, provide for home care with
O2, medications
Surgical Management of Valve
Disease
• Mitral Valve
– Commissurotomy
– Mitral Valve Replacement
– Balloon Valvuloplasty
• Aortic Valve Replacement
Mechanical Valve
Mechanical Valve
Porcine Valve
Tissue Valve
Tissue Valve
Common Murmurs and
Timing (click on murmur to play)
Systolic Murmurs
• Aortic stenosis
• Mitral insufficiency
• Mitral valve prolapse
• Tricuspid insufficiency
Diastolic Murmurs
• Aortic insufficiency
• Mitral stenosis
S1
S2
S1