VALVULAR HEART DISORDERS

Valvular Heart Disease

• Valvular heart disease can affect any of the valves in the

heart.
• Diseased valves may have an altered structure, which
changes the blood flow.
• Disorders of the endocardium, the innermost lining of the
heart and valves, damage heart valves.
Valvular Heart Disease
Valvular heart diseases include:
• Mitral stenosis.
• Mitral regurgitation.
• Mitral valve prolapse.
• Aortic stenosis.
• Aortic regurgitation.
REVIEW OF VALVES
MITRAL VALVE PROLAPSE

• The valve cusps bulge into the left atrium when the left
ventricle contracts, allowing leakage of blood into the atrium
MITRAL VALVE PROLAPSE
Causes

• Connective tissue disorders : the chordae tendineae can

become elongated, which allows the mitral valve leaflets to
open backward into the atrium during systole.

Remember:
backflow equals heart failure
Causes

• Congenital heart disease

• Acquired heart disease-CAD
• Rheumatic heart disease: causes valve bulge due to
inflammation
Assessment

Extra heart sound:

• MITRAL CLICK (Mid-to-late systolic click)
• Systolic click is an early sign that a valve leaflet is ballooning
into the left atrium
• Late systolic murmur: blood backing up into left atrium

*Palpitations
Assessment if MR exists
• Fatigue; weakness: during ventricular systole, blood backs up
into left atrium.
• Angina: decreased coronary artery circulation
• Migraine headaches
• Dizziness
• Orthostatic hypotension
Diagnostics
• Auscultation: reveals clicking sound; murmur when left
ventricle contracts
• Echocardiography
• Electrocardiography (ECG): may reveal atrial or ventricular
arrhythmia
• Holter monitor for 24 hours: may show arrhythmia
Treatments
• Decreased caffeine, alcohol, tobacco, stimulant intake:
decreases palpitations
• Fluid intake: maintains hydration
• Beta-blocker
• Anticoagulants: prevent thrombus formation
• Antiarrhythmics: prevent arrhythmias
Complications

• Arrhythmias
• Infective endocarditis
• Mitral insufficiency from chordal rupture
Mitral Insufficiency/ Regurgitation

• The mitral valve does not close properly during ventricular

systole, causing backward flow of blood during systole.
• This backward flow can cause heart failure
Mitral Insufficiency/ Regurgitation
Causes

• Infective endocarditis or rheumatic heart disease

• Coronary artery disease
• Aging: over time, degenerative changes can weaken the
valve
Assessment
• Fatigue; weakness
• Pansystolic murmur
• If S1 and S2 are audible, the murmur will be heard between
these two sounds: lub, “whoosh,” dub
• Angina: decreased coronary artery circulation
• Palpitations
Assessment
• Late signs include signs and symptoms of left-sided heart
failure
• nocturnal dyspnea;
• S3;
• pink, frothy sputum; cough; crackles; orthopnea; tachycardia;
restlessness
Diagnostics
• Auscultation: presence of heart murmur
• Electrocardiography
• Chest x-ray
• Echocardiography
Treatment
• Anticoagulants: prevent clots
• ACE inhibitors: treat mild heart failure
• Valvuloplasty: repairs the faulty valve
• Valve replacement: with a prosthetic valve
Complications
• Severe pulmonary edema
• Embolitic stroke
• Heart failure
• Infection, especially with valve replacement surgery
• Pulmonary embolism
Mitral Stenosis
• Mitral stenosis is narrowing of the mitral valve. The left
atrium meets resistance as it attempts to move blood
forward into left ventricle.
• Eventually the left atrium dilates and contractility decreases.
Forward flow is decreased and fluid backs up into lungs.
Increased volume in the lungs increases pressure in lungs.
• Remember: more volume, more pressure.
• Pulmonary hypertension in turn can lead to right-sided heart
failure
Mitral Stenosis
Causes
• Acute rheumatic fever or infective endocarditis
• Congenital abnormality
• Myxoma
• Blood clot reduces blood flow through the mitral valve
Signs and symptoms
• Exertional dyspnea: the narrowed mitral valve decreases
• Orthopnea: fluid accumulates in the lungs and the client sits
up to breathe better
• Nocturnal dyspnea
• Atrial fibrillation: the enlarged left atrium interferes with
normal conduction pathways.
Signs and symptoms
• Diastolic murmur:
turbulent flow occurs at the narrowed valve
• Murmur is heard after S2. You will hear:
lub (S1) dub (S2), whoosh . . . lub dub, whoosh
• JVD, hepatomegaly, peripheral edema, weight gain, ascites,
epigastric discomfort, tachycardia, crackles, pulmonary
edema
Diagnostic test
• Echocardiography
• Electrocardiography
• Chest x-ray
• Cardiac catheterization
Treatment
• Prevention of rheumatic fever
• Digoxin,
• diuretics,
• vasodilators,
• ACE inhibitors: treat left-sided heart failure
• Oxygen: increases oxygenation
Treatment
• Anticoagulants:
• Nitrates: relieve angina
• Beta-adrenergic blockers or digoxin
• Cardioversion
• Balloon valvuloplasty: enlarges orifice of stenotic mitral valve
• Prosthetic valve: replaces damaged valve that can’t be
repaired
Complications
• Embolitic stroke
• Heart failure
• Infection, especially with valve replacement surgery
• Pulmonary embolism
Aortic Stenosis

• Narrowing of the aortic valve opening that increases

resistance to blood flow from the left ventricle to the aorta.
• The left ventricle hypertrophies and weakens, leading to left-
sided heart failure
Aortic Stenosis
Causes
• Age: degenerative changes causing scarring and calcium
accumulation in the valve cusps
• Rheumatic fever: causes inflammation of the cusps that leads
to scarring; usually accompanied by mitral stenosis and
leakage
Causes
• Birth defect: valve with two cusps instead of usual three;
valve with abnormal funnel shape;
• calcium accumulates, causing the valve to become stiff and
narrow
• Atherosclerosis: lipids can increase calcium accumulation of
the valves
Signs and Symptoms
• Exertional dyspnea: decreased blood supply to the enlarged
heart leads to decreased CO
• Angina: decreased blood supply to the enlarged heart is
inadequate
Signs and Symptoms
• Syncope
• Pulmonary congestion: left-sided heart failure
• Harsh, rasping, crescendo-decrescendo systolic murmur:
forced blood flow across stenotic valve
Diagnostics
• Chest x-ray
• Echocardiography
• Cardiac catheterization: increased pressure across aortic
valve; increased left ventricular pressures; presence of
coronary artery disease
Treatments
• Low-sodium, low-fat, low-cholesterol diet
• Diuretics
• Cardiac glycosides: control atrial fibrillation
• Percutaneous balloon aortic valvuloplasty: reduces degree of stenosis
• Aortic valve replacement: replaces diseased valve
Aortic Insufficiency/ Regurgitation
• Leakage of the aortic valve.
• Each time the left ventricle relaxes, blood leaks back into it.
(Atria are contracting while ventricles are relaxing)
Aortic Insufficiency/ Regurgitation
Causes
• Bacterial endocarditis, rheumatic fever
• Connective tissue diseases: direct damage of the heart
valves can occur, causing valvular regurgitation or valvular
stenosis
Signs and Symptoms
• Left-sided heart failure such as nocturnal dyspnea, S3, pink
fothy sputum, cough, crackles, orthopnea, tachycardia,
restlessness
• Diastolic murmur: blood is backing up into left ventricle from
aorta during diastole.
• You will hear S1, S2, then the murmur:
“lub, dub, whoosh”
Tests
• Chest x-ray
• Echocardiography
• Electrocardiography
• Cardiac catheterization: shows coronary artery disease
Treatments
• Oxygen: increases oxygenation
• Vasodilators: reduce systolic load and regurgitant volume
• Valve replacement with prosthetic valve: removes diseased
aortic valve
• Low-sodium diet
• Diuretics
• Nitroglycerin: relieves angina
Complications
• Left-sided heart failure
• Pulmonary edema
• Myocardial ischemia
Surgical Management: Valve Repair and
Replacement Procedures
Valvuloplasty: repair of a stenosed or regurgitant cardiac valve

Repair may be made to the:

• commissures (between the leaflets)--commissurotomy,
• annulus of the valves---- annuloplasty
• leaflets or to the chordae---- chordoplasty
Valvuloplasty
• Require general anesthesia
• Often require cardiac catheterization laboratory
Suffix -otomy

-otomy means
cutting into a part of the body or
to make an incision or cut into
Commissurotomy
• most common valvuloplasty procedure is commissurotomy.
Commissure
• Each valve has leaflets; the site where the leaflets meet
• The leaflets may adhere to one another and close the
commissure
• Less commonly, the leaflets fuse in such a way that, in
addition to stenosis, the leaflets are also prevented from
closing completely, resulting in a backward flow of blood.
Commissurotomy

splitting or separating
fused cardiac valve
leaflets
Closed Commissurotomy/Balloon Valvuloplasty
Closed Commissurotomy/Balloon Valvuloplasty

Mitral valvuloplasty is contraindicated for patients with:

• Left atrial or ventricular thrombus, severe aortic root
dilation, significant mitral valve regurgitation
OPEN COMMISSUROTOMY
• Open commissurotomies are performed with direct
visualization of the valve.
• general anesthesia
• median sternotomy or left thoracic incision is made.
• Cardiopulmonary bypass is initiated, and an incision is made
into the heart.
• A finger, scalpel, balloon, or dilator may be used to open the
commissures.
Annuloplasty
• Annuloplasty is the repair of the valve annulus (junction of
the valve leaflets and the muscular heart wall).
• General anesthesia and cardiopulmonary bypass are
required for all annuloplasties.
• The procedure narrows the diameter of the valve’s orifice
and is useful for the treatment of valvular regurgitation.
Annuloplasty
• To annuloplasty techniques:
1. annuloplasty ring
2. tacking the valve leaflets
Leaflet Repair
• Leaflet repair for elongated, ballooning, or other excess
tissue leaflets is removal of the extra tissue.
• The elongated tissue may be folded over onto itself (tucked)
and sutured (leaflet plication). A wedge of tissue may be cut
from the middle of the leaflet and the gap sutured closed
(leaflet resection).
Chordoplasty
• Chordoplasty is the repair of the chordae tendineae.
• The mitral valve is involved with chordoplasty (because it has
the chordae tendineae); seldom is chordoplasty required for
the tricuspid valve.
Valve replacement
• Prosthetic valve replacement began in the 1960s.
• When valvuloplasty or valve repair is not a viable alternative,
such as when the annulus or leaflets of the valve are
immobilized by calcifications, valve replacement is
performed.
Valve replacement
• MECHANICAL VALVES
• The mechanical valves are of the ball-and-cage or disk design.
• Mechanical valves are used if the patient has renal failure,
hypercalcemia, endocarditis, or sepsis and requires valve
replacement.
Valve replacement
• MECHANICAL VALVES
• The mechanical valves do not deteriorate or become infected as
easily as the tissue valves used for patients with these conditions.
• Thromboemboli are significant complications
• anticoagulation with warfarin is required.
Valve replacement

• TISSUE OR BIOLOGIC VALVES

• Tissue valves are of three types:
(1) xenografts, (2) homografts, and (3) autografts.
• Tissue valves are less likely to generate thromboemboli, and
long-term anticoagulation is not required.
• Tissue valves are not as durable as mechanical valves and
require replacement more frequently.
Bioprostheses: Xenografts or heterografts

• most are from pigs (porcine) and from cows (bovine

• Viability is 7 to 10 years.
• They do not generate thrombi, thereby eliminating the need
for longterm anticoagulation.
Bioprostheses: Homografts, or allografts

• human valves are obtained from cadaver tissue donations

• harvested and stored cryogenically.
• last for about 10 to 15 years
• Not thrombogenic and are resistant to subacute bacterial
endocarditis.
• They are used for aortic and pulmonic valve replacement.
Bioprostheses: Autografts
• Autografts (autologous valves) are obtained by excising the
patient’s own pulmonic valve and a portion of the pulmonary
artery for use as the aortic valve.
• Anticoagulation is unnecessary because the valve is the
patient’s own tissue and is not thrombogenic.
Cardiomyopathies
Cardiomyopathy is a heart muscle disease associated with
cardiac dysfunction.

It is classified according to the structural and functional

abnormalities of the heart muscle
Cardiomyopathies
There are three types of cardiomyopathy:
• Restrictive: ventricles are stiff and cannot fill properly.
• Hypertrophic: walls of the ventricles thicken and become
stiff.
• Dilated: ventricles enlarge but are not able to pump enough
blood for the body’s needs.
• Ischemic cardiomyopathy is a term frequently used to
describe an enlarged heart caused by coronary artery
disease, which is usually accompanied by heart failure
DILATED CARDIOMYOPATHY (DCMP)
• most common form of cardiomyopathy
• formerly named congestive cardiomyopathy, but DCM may
exist without signs and symptoms of congestion.
DILATED CARDIOMYOPATHY (DCMP)
• Microscopic examination of the muscle tissue shows
diminished contractile elements of the muscle fibers and
diffuse necrosis of myocardial cells. The result is poor systolic
function.
• Embolic events caused by ventricular and atrial thrombi as a
result of the poor blood flow through the ventricle may also
occur.
Causes
• Chemotherapy
• Alcohol and drugs
• Coronary heart disease
• Viral or bacterial infections
• Pregnancy-induced
Signs and Symptoms

• Shortness of breath and orthopnea,

• Left-sided heart failure
• Right-sided heart failure
Signs and Symptoms

• Peripheral cyanosis, tachycardia Low cardiac output

• Murmur Leaking heart valves
• Arrhythmia: Stretching of the heart muscle leads
tocabnormal heart rhythms
• Chest pain; palpitations Arrhythmias may be felt as pain or
palpitations
• Syncope Decreased cardiac output
HYPERTROPHIC CARDIOMYOPATHY
(HCM)
• Heart muscle increases in size and mass, especially along the
septum
• The increased thickness of the heart muscle reduces the size
of the ventricular cavities and causes the ventricles to take a
longer time to relax, making it more difficult for the
ventricles to fill with blood during the first part of diastole
and making them more dependent on atrial contraction for
filling.
Obstructive or non obstructive
HYPERTROPHIC CARDIOMYOPATHY
(HCM)
• Uncontrolled hypertension
• Inherited gene
• Acromegaly: Excessive growth of the heart muscle due to
overproduction of growth hormone
Signs and symptoms

• Fatigue; weakness
• Late signs include signs and symptoms of left-sided heart
failure
• Arrhythmias
• Chest pain
• Palpitations
• Faintness; dizziness
• Sudden cardiac death:Lethal arrhythmias leading to death
Surgical management
• Left ventricular outflow tract surgery
• Heart Transplantation
• Mechanical assist device and Total heart transplant
RESTRICTIVE CARDIOMYOPATHY
• Restrictive cardiomyopathy (RCM) is characterized by
diastolic dysfunction caused by rigid ventricular walls that
impair ventricular stretch and diastolic filling
• Diseases that change the composition of the heart muscle,
making it stiff and noncompliant.
RESTRICTIVE CARDIOMYOPATHY
• Amyloidosis is a condition where glycoproteins are deposited
within the myocardium
• Accumulation of these glycoproteins in the heart alters heart
function.
• The heart becomes stiff and rigid, resulting in a decreased
volume in the ventricles and ultimately a decrease in CO
Signs and symptoms
• Signs and symptoms of heart failure: bradycardia, neck vein
distension, peripheral edema, liver congestion, abdominal
ascites
• Fatigue; weakness
• Late signs include nocturnal dyspnea, S3, pink frothy
sputum, cough, crackles, orthopnea, tachycardia,
restlessness
Diagnostics
• ECG
• Echocardiography
• Magnetic resonance imaging
• Cardiac catheterization
• *Biopsy
Treatments:
• 70% of patients die within 5 years of symptom development.
• Medications not helpful.
• Removal of blood at regular intervals: reduces amount of
stored iron in clients with iron overload.
• Heart transplant.
Infectious Diseases of the Heart
• Among the most common infections of the heart are
infective endocarditis, myocarditis, and pericarditis.
• The ideal management is prevention.
RHEUMATIC ENDOCARDITIS
• Acute rheumatic fever-- school-age children
• group A beta-hemolytic streptococcal pharyngitis (strep
throat)
• Treatment: antibiotics
• The Streptococcus is spread by direct contact with oral or
respiratory secretions.
Recognizing and Preventing Rheumatic
Fever
• Rheumatic fever is a preventable disease.
• Eradicating rheumatic fever would eliminate rheumatic heart
disease.
• Penicillin therapy: can prevent almost all primary attacks of
rheumatic fever.
• throat culture is the only method by which an accurate
diagnosis of strep throat can be determined
Recognizing and Preventing Rheumatic
Fever
The signs and symptoms of streptococcal pharyngitis are the
following:
• Fever
• Chills
• Sore throat (sudden in onset)
• Diffuse redness of throat with exudate on oropharynx
• Enlarged and tender lymph nodes
• Acute sinusitis and acute otitis media (if due to streptococci)
Infective endocarditis
• Infective endocarditis is an infection of the endocardium,
heart valves, or cardiac prosthesis
Origin

• Bacteria: When they attack the heart, they attack the valves.
*“vegetation”
Origin

• Bacteria: When they attack the heart, they attack the valves.
*“vegetation”
• Fungi can proliferate on heart valves
• Prosthetic valves: Bacteria easily stick to the foreign device
• Recent cardiac surgery: Contamination of the area during
surgery
Origin
• Rheumatic heart disease
• Systemic lupus erythematosus
• Congenital heart defects: Malformed heart valves are more
susceptible to colonization
• Valvular dysfunction
• IV drug abuse: IV drug abusers who do not follow aseptic
technique can “inject” bacteria into the blood.
Signs and symptoms
• Fever
• Splenomegaly
• Petechia
• Hematuria
• Cardiac murmurs
• Vegetation on the valve
• Pleuritic pain
• Fatigue; weakness
Signs and symptoms
• Late signs include signs and symptoms of left-sided Infection
and/or clot formation on the mitral or aortic valves heart
failure
Prevention

• primary prevention in high-risk patients

• Antibiotic prophylaxis:
• Dental procedures
• Tonsillectomy or adenoidectomy
• Surgical procedures that involve intestinal or respiratory
mucosa
Prevention
• Bronchoscopy with a rigid bronchoscope
• Sclerotherapy for esophageal varices
• Esophageal dilation
• Gallbladder surgery
• Cystoscopy
• Urethral dilation
Prevention
• Urethral catheterization if urinary tract infection is present
• Urinary tract surgery if urinary tract infection is present
• Prostatic surgery
• Incision and drainage of infected tissue
• Vaginal hysterectomy
• Vaginal delivery
Nursing Management

• monitors the patient’s temperature

• Heart sounds are assessed
• Monitors for signs and symptoms of systemic embolization
• Assesses for signs and symptoms of organ damage such as
stroke (CVA), meningitis, heart failure, myocardial infarction,
glomerulonephritis, and splenomegaly.
• Patient care is directed toward management of infection.
Diagnostics
• Blood cultures
• White blood cell with differential count: elevated.
• Complete blood count and anemia panel
• Erythrocyte sedimentation rate: elevated.
• Creatinine level: elevated.
• Urinalysis: proteinuria, hematuria.
• Echocardiography: shows valvular damage.
• Electrocardiogram: atrial fibrillation.
Treatments

• Antibiotics: given for 2 to 6 weeks IV in high doses.

• Surgery: repair or replace damaged valve and remove
vegetations.
Complications

• Microemboli or septic emboli traveling to other organs

• Stroke
• Heart failure
• Infection
• Valve stenosis or regurgitation
• Myocardial erosion
MYOCARDITIS
• Myocarditis is an inflammatory process involving the
myocardium.
• Myocarditis can cause heart dilation, thrombi on the heart
wall (mural thrombi), infiltration of circulating blood cells
around the coronary vessels and between the muscle
fibers, and degeneration of the muscle fibers themselves.
Pathophysiology
• Myocarditis usually results from a viral, bacterial, mycotic,
parasitic, protozoal, or spirochetal infection
• Myocarditis may result from an allergic reaction to
pharmacologic agents
Clinical Manifestations

• The patient with mild to moderate symptoms often

complains of:
• fatigue and dyspnea,
• palpitations, and
• occasional discomfort in the chest and upper abdomen.
Prevention

• Prevention: appropriate immunizations (eg, influenza,

hepatitis) and
• early treatment
Nursing Management
NURSING ALERT

Patients with myocarditis are sensitive to digitalis.

• They must be closely monitored for digitalis toxicity, which is
evidenced by dysrhythmia, anorexia, nausea, vomiting, headache, and
malaise and BLURRED OR DOUBLE VISION and GREENISH-YELLOW
HALOS AROUND IMAGES.
Nursing Management

• Assesses the patient’s temperature

• continuous cardiac monitoring with personnel and
equipment readily available to treat life-threatening
dysrhythmias.
• Elastic compression stockings and passive and active
exercises should be used, because embolization from venous
thrombosis and mural thrombi can occur.
PERICARDITIS

• Pericarditis refers to an inflammation of the pericardium, the

membranous sac enveloping the heart.
Pathophysiology
• Infection
• Disorders of connective tissue
• Hypersensitivity states
• Disorders of adjacent structures: myocardial infarction, dissecting
aneurysm, pleural and pulmonary disease
• Neoplastic disease
Pathophysiology

• Radiation therapy
• Trauma
• Tuberculosis
• Pericarditis can lead to: pericardial effusion and cardiac
tamponade
Signs and Symptoms
• Pericardial friction rub
• Dysphagia (difficulty swallowing)
• Chest pain: worsens with inspiration and decreases when the
client leans forward; can radiate to neck, shoulders, chest
and arms
Diagnostics
• White blood cell count: elevated.
• Erythrocyte sedimentation rate: elevated.
• Serum creatinine: elevated.
• Pericardial fluid culture: identifies causative organism in
bacterial or fungal pericarditis.
• Blood urea nitrogen: elevated.
• Echocardiography: shows pericardial effusion.
• Electrocardiography: shows elevated ST segment.
Treatments
• Bed rest as long as fever and pain persist
• NSAIDs: relieves pain and reduces inflammation.
• Antibacterial, antifungal, antiviral therapy: if infectious cause.
• Pericardiocentesis: removes excess fluid from pericardial
space.
Nursing Interventions

• RELIEVING PAIN
• patient rest; restrict activity until the pain subsides
• Because sitting upright and leaning forward is the posture
that tends to relieve pain, chair rest may be more
comfortable.
MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
• Cardiac tamponade.
• Pericardial effusion.
• Infection.