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Maria Carmela L. Domocmat, RN, MSN
Instructor, School of Nursing
Northern Luzon Adventist College
valves of the heart control the flow of blood
     through the heart into the pulmonary artery
     and aorta
     by opening and closing in response to the BP
     changes as the heart contracts and relaxes.

     atrioventricular valves and semilunar valves


8/23/2012      Maria Carmela L. Domocmat
separate the atria from the ventricles
     tricuspid valve
            separates the right atrium from the right ventricle
            has three leaflets
     mitral valve
            separates the left atrium from the left ventricle
            has Two leaflets
     both valves have chordae tendineae that anchor
     the valve leaflets to the papillary muscles and
     ventricular wall.
8/23/2012              Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
located between the ventricles and their
     corresponding arteries.
     pulmonic valve
            lies between right ventricle and pulmonary artery;
     aortic valve
            Lies between the left ventricle and the aorta




8/23/2012             Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Annulus: a (fibrous) ringlike structure, or any
          body part that is shaped like a ring
          Commissure: a site of union of corresponding
          parts; specifically, the sites of junction
          between adjacent cusps of the heart valves.




http://medical-dictionary.thefreedictionary.com/commissure
    8/23/2012                          Maria Carmela L. Domocmat
Chordae tendineae: thread-like bands of
          fibrous tissue that attach on one end to the
          edges of the tricuspid and mitral valves of the
          heart and on the other end to the papillary
          muscles.
          Papillary muscles: small muscle within the
          heart that anchors the heart valves.


http://medical-dictionary.thefreedictionary.com/commissure
    8/23/2012                          Maria Carmela L. Domocmat
1 Heart Valves, ana phy.flv


8/23/2012   Maria Carmela L. Domocmat
DISORDERS OF THE MITRAL                          DISORDERS OF THE AORTIC
 VALVE                                            VALVE
     mitral valve prolapse                          aortic regurgitation
     mitral regurgitation                           aortic stenosis
     mitral stenosis



Tricuspid and pulmonic valve disorders
     usually with fewer symptoms and
     complications.




8/23/2012             Maria Carmela L. Domocmat
lead to various symptoms that, depending on
     their severity, may require surgical repair or
     replacement of the valve to correct the
     problem
     Regurgitation and stenosis may occur at the
     same time in the same or different valves.



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Valvular stenosis
   Valvular insufficiency




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Valvular stenosis
            impedance of blood flow
            the tissues forming the valve leaflets become
            stiffer, narrowing the valve opening and reducing
            the amount of blood that can flow through it. If
            the narrowing is mild, the overall functioning of
            the heart may not be reduced



8/23/2012            Maria Carmela L. Domocmat
Valvular insufficiency
            Aka: regurgitation, incompetence, "leaky valve"
            occurs when the leaflets do not close completely,
            letting blood leak backward across the valve.
            This backward flow is referred to as “regurgitant
            flow.”




8/23/2012            Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Mitral Valve Prolapse
     Mitral Regurgitation
     Mitral Valve Stenosis
     Aortic Regurgitation
     Aortic Stenosis
     Tricuspid Regurgitation



8/23/2012      Maria Carmela L. Domocmat
Mitral stenosis
            Progressive thickening and contracture of valve
            cusps wit narrowing of the orifice and progressive
            obstruction to blood flow
     Aortic stenosis
            Narrowing of orifice between LV and aorta
     Tricuspid stenosis
            Narrowing of tricuspid valve orifice due to
            commissual fusion and fibrosis
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Mitral insufficiency (regurgitation)
            Incomplete closure of the mitral valve during
            systole, allowing blood to flow back into LA
     Aortic insufficiency (regurgitation)
            Valve flaps fail to completely seal the aortic orifice
            during diastole and thus permit backflow of blood
            from aorta into LV
     Tricuspid insufficiency (regurgitation)
            Allows regurgitation of blood from RV into the RA
            during systole
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8/23/2012   Maria Carmela L. Domocmat
an obstruction of blood flowing from the left
     atrium into the left ventricle.




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8/23/2012   Maria Carmela L. Domocmat
most common cause
            rheumatic valvulitis
            rheumatic endocarditis

     other causes
            malignant carcinoid, SLE, RA




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causes
     progressively thickens the mitral valve
     leaflets and chordae tendineae.
     The leaflets often fuse (glued) together.
     Eventually, the mitral valve orifice narrows
     and progressively obstructs blood flow into
     the ventricle.


8/23/2012      Maria Carmela L. Domocmat
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.
     LA - great difficulty moving blood into the ventricle
            Bcoz of increased resistance of the narrowed orifice;
            it dilates (stretches) and hypertrophies (thickens) bcoz of
            increased blood volume it holds
     no valve to protect the pulmonary veins from the
     backward flow of blood from the atrium, the pulmonary
     circulation becomes congested.
     RV - must contract against abnormally high pulmonary
     arterial pressure (PAP) and is subjected to excessive strain.
            right ventricle fails

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Rheumatic Fever or infective
                             Endocarditis


                       Inflammation of valve leaflets


                          Fibrosis and retraction of
                                    leaflets


                     Shortening of chordae tendinae


                        Narrowing of valvular orifice
                               (n=4-
                               (n=4-6 cm2)
                              Mild stenosis-2 cm2
                                   stenosis-
                            Severe stenosis-1 cm2
                                   stenosis-
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Decrease blood flow from left atrium to
                                          left ventricle
            Rupture of
               small                                                      Stagnation
                                      Increase LA pressure                of blood in
             bronchial
              vessels                                                       the left
                                                                            atrium
                                     Left atrial enlargement
       Hemoptysis
                                                                          Thrombus
                              Increase pulmonary venous pressure

                                                                          Embolism
             Impinges on       Increase right ventricular pressure
            left recurrent
              laryngeal
                 nerve           Right ventricular Enlargement            Pulmonary
                                                                            edema

            Hoarseness                                                    Orthopnea
                                    Right Ventricular Failure
                                                                             PND
8/23/2012            Edema Carmela L. Domocmat Anorexia
                        Maria  Ascites                          Fatigue      NVE
HF s/s
            Dyspnea on exertion
            ▪ first symptom
            ▪ due to pulmonary venous hypertension
            progressive fatigue
            ▪ as a result of low CO
            Hemoptysis
            cough
            repeated respiratory infections
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pulse - weak , irregular
     Increase intensity of S1                            Listen
     diastolic rumble/ diastolic murmur
            low-pitched, rumbling, heard at the apex
            Opening snap after S2- apex
            heart murmurs heard during diastole.
            start at or after S2 and end before or at S1.
            result of the increased blood volume and pressure,
            the atrium dilates, hypertrophies, and becomes
            electrically unstable
     atrial dysrhythmias

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Echocardiography
            used to diagnose mitral stenosis
     used to determine the severity
            Electrocardiography (ECG)
            cardiac catheterization with angiography




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Antibiotic prophylaxis therapy
            to prevent recurrence of infections
     Treat CHF
     Anticoagulants
            to decrease the risk developing atrial thrombus
     Treat anemia



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Valvuloplasty
            Closed Mitral commissurotomy or valvotomy
            Open mitral commissurotomy or valvotomy
            ▪ to open or rupture the fused commissures of the mitral
              valve.
     Percutaneous transluminal valvuloplasty /
     Balloon valvuloplasty
     Mitral valve replacement

8/23/2012              Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
involves blood flowing back from the left
     ventricle into the left atrium during systole.
     Often, the margins of the mitral valve cannot
     close during systole.




8/23/2012      Maria Carmela L. Domocmat
may be caused by problems with
            one or more of the leaflets : shorten or tear
            chordae tendineae : elongate, shorten, or tear
            Annulus : stretched by heart enlargement or
            deformed by calcification




8/23/2012            Maria Carmela L. Domocmat
may be caused by problems with
            papillary muscles: rupture, stretch, or be pulled
            out of position by changes in the ventricular wall
            (e.g., scar from a myocardial infarction or
            ventricular dilation). papillary muscle may be
            unable to contract because of ischemia.




8/23/2012             Maria Carmela L. Domocmat
Regardless of the cause
     blood regurgitates back into the atrium during systole.
     With each beat of LV , some of blood is forced back into
     LA
     Because this blood is added to the blood that is beginning
     to flow in from the lungs, LA must stretch. It eventually
     hypertrophies and dilates.
     The backward flow of blood from the ventricle diminishes
     the volume of blood flowing into the atrium from the
     lungs.
      As a result, the lungs become congested, eventually
     adding extra strain on the right ventricle.
     Mitral regurgitation ultimately involves the lungs and RV

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Due to myxomatous degeneration, which
cuases stretching of the leaflets and chordae
tendineae
       Chronic RHD
       CAD
       Infective endocarditis
 Meds and penetrating and nonpenetrating
trauma

8/23/2012         Maria Carmela L. Domocmat
Mitral Valve Regurgitation ana phy.flv




8/23/2012   Maria Carmela L. Domocmat
Pathophysiology
                                            Increase left ventricular
                                                   pressure


                                                       Systole           Small amount to
                                                                          blood pump to
            Increase backflow of                                              aorta
            blood to left ventricle
            through incompetent
                     MV                                                  Increase LV work
                                                                        load to pump more
                                                                               blood
                     LAH

                                                                              LVH
              Inc. LA pressure
                                          RVH             RVF
                                                                              LVH
               Inc. pulmonary
                  pressure                       Ascites /edema
8/23/2012                  Maria Carmela L. Domocmat             Orthopnea   PND    Dyspnea
Chronic mitral regurgitation - often
     asymptomatic
     Acute mitral regurgitation (e.g., that resulting
     from a myocardial infarction)
            manifests as severe CHF
            Dyspnea, fatigue, and weakness
            Palpitations, SOBon exertion, and cough from
            pulmonary congestion also occur.

8/23/2012            Maria Carmela L. Domocmat
Holosystolic or pansystolic murmur       5 Holosystolic Murmur.flv


   a high-pitched, blowing sound at the apex.
   heard best at the apex and radiates to the axilla and
usually accompanied by a thrill
   a heart murmur occurring throughout systole.

  Pulse - regular and of good volume, or it may
be irregular as a result of extrasystolic beats or
atrial fibrillation.
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Echocardiography
            used to diagnose
            monitor the progression




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CHF MGMT                                      SURGICAL INTERVENTION

      Digitalis                                 Mitral valve
                                                replacement
      Diuretics
                                                Valvuloplasty
      Vasodilators                              (annuloplasty)
      Diet
                                                 Mitral Valve Regurgitation treatment.flv
      Anticoagulants


8/23/2012         Maria Carmela L. Domocmat
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is narrowing of the orifice between the LV
     and the aorta.
     leaflets of aortic valve may fuse.




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8/23/2012   Maria Carmela L. Domocmat
congenital leaflet malformations
     abnormal number of leaflets (i.e., one or two
     rather than three)
     rheumatic endocarditis
     RF
     cusp calcification of unknown cause



8/23/2012      Maria Carmela L. Domocmat
progressive narrowing of the valve orifice,
            usually over a period of several years to several decades.
     LV overcomes the obstruction to circulation by
     contracting more slowly but with greater energy than
     normal, forcibly squeezing the blood through the very
     small orifice.
     obstruction to LV outflow increases pressure on the
     left ventricle, which results in thickening of the muscle
     wall.
     heart muscle hypertrophies.
     When these compensatory mechanisms of the heart
     begin to fail, clinical signs and symptoms develop.
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Aortic Stenosis
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Pathophysiology
                             Narrowed aortic orifice

                                                                   Decreased
                             Increased back flow of               blood flow to
                              blood to left ventricle                 aorta
                                  during systole

                                                                  Decrease CO
                             Increased LV pressure
                                                        Syncope
                                                                   Decreased
                                        LVH                         coronary
                                                                   blood flow

                             Increased LA pressure
                                                                     Angina

                                        LAH

8/23/2012   Maria Carmela L. Domocmat
Increased pulmonary pressure

                                                                Pulmonary
                                    Increased RV pressure       edema
                                                                Orthopnea
                                                                dyspnea
                                                  RVH


                                                  RVF


            Edema      Ascites                  Anorexia    Fatigue   NVE




8/23/2012           Maria Carmela L. Domocmat
Many asymptomatic
     exertional dyspnea
            caused by LVF
            Other signs are dizziness and syncope because of reduced blood
            flow to the brain.
     Angina pectoris
            a frequent symptom
            results from the increased oxygen demands of the
            hypertrophied left ventricle, the decreased time in diastole for
            myocardial perfusion, and the decreased blood flow into the
            coronary arteries.
     BP - can be low but usually normal
     low pulse pressure (30 mm Hg or less)
            because of diminished blood flow

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systolic murmur
            loud, rough systolic murmur
            low-pitched, rough, rasping, and vibrating
            heard over the aortic area (R upper sternal border)
            may radiate into the carotid arteries and to the
            apex of LV




8/23/2012             Maria Carmela L. Domocmat
Thrill/ Vibration
            Palpated over base of heart/ 2nd RICS
            caused by turbulent blood flow across the
            narrowed valve orifice.
     Gallavardin phenomenon
            murmur also reflected to mitral area which may give a
            false impression of a mitral regurgitation



8/23/2012             Maria Carmela L. Domocmat
12-leadECG and echocardiogram
            Evidence of LV hypertrophy may be seen
     Echocardiography (2D echo)
            used to diagnose and monitor the progression of
            aortic stenosis.
     left-sided heart catheterization
            measure the severity of the aortic stenosis and
            evaluate the coronary arteries.
            Pressure tracings are taken from LV and base of aorta.
            systolic pressure in LV is considerably higher than that
            in the aorta during systole.
8/23/2012              Maria Carmela L. Domocmat
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is the flow of blood back into the left ventricle
     from the aorta during diastole.
     may be caused by inflammatory lesions that
     deform the leaflets of the aortic valve,
     preventing them from completely closing the
     aortic valve orifice.



8/23/2012       Maria Carmela L. Domocmat
endocarditis
     rheumatic heart disease (RHD)
     congenital abnormalities (e.g., marfan
     syndrome)
     Syphilis - may produce aortitis
     dissecting aneurysm
            causes dilation or tearing of the ascending aorta
     deterioration of an aortic valve replacement

8/23/2012             Maria Carmela L. Domocmat
blood from the aorta returns to the LV during diastole
     in addition to the blood normally delivered by the LA
      LV dilates
            trying to accommodate the increased volume of blood.
     LV hypertrophies
            trying to increase muscle strength to expel more blood
            with above normal force—raising systolic BP.
     reflex vasodilation
            arteries attempt to compensate for the higher pressures
     peripheral arterioles relax
            reducing peripheral resistance and diastolic BP.

8/23/2012              Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Pathophysiology
                                   Etiologic factors


                             Incompetent aortic valve


                    Regurgitation of blood from systemic
                    circulation + blood form LA increases
                                 LV pressure


                                         LVH


                                         LVF


                                         RVF
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Usually asymptomatic
     Progressive s/s of LVF
            Exertional dyspnea and fatigue
            breathing difficulties (e.g., orthopnea, PND)




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Diastolic murmur
     Austin flint murmur
     Watson's water hammer pulse
     Corrigan’s pulse
     Widened pulse pressure
     Hill’s sign



8/23/2012    Maria Carmela L. Domocmat
Diastolic murmur                              3 Austin Flint Murmur.avi.flv

            high-pitched, blowing sound at the third or 4th ICS L
            sternal border
            sitting up and leaning forward
     Austin flint murmur
            low pitched diastolic rumble similar to mitral stenosis;
            indicates moderate to severe insufficiency
            a mid-diastolic or presystolic murmur low-pitched
            rumbling murmur which is best heard at the cardiac apex.
            A murmur due to aortic regurgitation, originating at the
            mitral valve when blood enters simultaneously from both
            the aorta and the left atrium.
8/23/2012              Maria Carmela L. Domocmat
Watson's water hammer pulse
             AKA: collapsing pulse, cannonball pulse
             is the medical sign which describes a pulse that is
             bounding and forceful, as if it were the hitting of a
             water hammer that was causing the pulse.
             PA: radial pulse of a supine patient with arm at
             side is firmly palpated with slight pressure until
             the pulse is obscured. The arm is then raised over
             the patient's head, with the arm perpendicular to
             the supine patient.
http://depts.washington.edu/physdx/heart/physical.html
    8/23/2012                       Maria Carmela L. Domocmat
Corrigan’s pulse
            marked arterial pulsations
            forceful heartbeat visible or palpable at the carotid or
            temporal arteries.
            result of the increased force and volume of the blood
            ejected from the hypertrophied LV.
     De Musset’s sign
            Rhythmic nodding or bobbing of the head in synchrony
            with the heart beat
     Increased pulse pressure
            Refers to the difference between the systolic pressure and
            the diastolic pressure.
            Normal - 50-60.
                                      http://depts.washington.edu/physdx/heart/physical.html

8/23/2012               Maria Carmela L. Domocmat
Hill’s sign
            systolic blood pressure is higher in the legs than in
            the arms(> 20mmHg) .
     Pistol shot femoral pulse (Traube's sign)
            short, loud, snapping sounds with each pulse with
            auscultation over the femoral, brachial, or radial
            pulse.
            a pulse that sounds like a pistol shot


8/23/2012             Maria Carmela L. Domocmat
Duroziez’s sign
            to-and-fro murmur over the lightly compressed
            femoral arteries
            a double murmur over the femoral or other large
            peripheral artery; due to aortic insufficiency.




8/23/2012            Maria Carmela L. Domocmat
Quincke’s pulse
            systolic blushing and diastolic blanching of the
            nail bed when gentle pressure is place on the nail
            alternate blanching and flushing of the nail bed
            due to pulsation of subpapillary arteriolar and
            venous plexuses;
                                                  QUINCKE'S PULSE.wmv




                                                  4 Quincke's pulse.avi.flv




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Diagnosis may be confirmed
            Echocardiogram
            radionuclide imaging
            ECG
            Magnetic resonance imaging
            cardiac catheterization




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antibiotic prophylaxis
            Before the patient undergoes invasive or dental
            procedures
            to prevent endocarditis
     Treat HF and dysrhythmias




8/23/2012            Maria Carmela L. Domocmat
Aortic Valve Replacement.mp4
     Aortic valve replacement
            treatment of choice                  Aortic Valve replacement- OR.flv


     One- or two-balloon percutaneous aortic
     valvuloplasty
            For symptomatic and not surgical candidates
     Note: surgery is recommended for any
     patient with left ventricular hypertrophy,
     regardless of the presence or absence of
     symptoms.
8/23/2012            Maria Carmela L. Domocmat
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a disorder in which the heart's tricuspid valve
     does not close properly, causing blood to flow
     backward (leak) into the right upper heart
     chamber (atrium) when the right lower heart
     chamber (ventricle) contracts.



http://www.ncbi.nlm.nih.gov/pubmedhealth/P
MH0001222/
8/23/2012            Maria Carmela L. Domocmat
Infective endocarditis- drug abusers
      RVF/LVF
      Rheumatic Heart disease
      RV infarction
      Ebstein's anomaly




8/23/2012      Maria Carmela L. Domocmat
Ebstein's anomaly
            rare heart defect in which parts of the tricuspid valve
            are abnormal.
            leaflets are unusually deep in the RV ; often larger
            than normal.
            Congenital defect
            exact cause is unknown
            although the use of certain drugs (such as lithium or
            benzodiazepines) during pregnancy may play a role.
            condition is rare

8/23/2012              Maria Carmela L. Domocmat
Holosystolic / Pansystolic murmur in tricuspid area
            High-pitched
            increases with inspiration
            At parasternal region at 4th ICS
      s/s RHF
            Hepatic congestion, RUQ pain, jaundice
            Pulsatile liver
            Right ventricular lift
            Jugular venous pulsation

8/23/2012               Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Tricuspid regurgitation is a disorder involving backflow of blood from RV to RA during
contraction of RV . The most common cause of tricuspid regurgitation is not damage to
the valve itself but enlargement of the RV, which may be a complication of any disorder
that causes RVHF.
 8/23/2012              Maria Carmela L. Domocmat
ECG- RV and RA enlargement
     CXR- RV enlargement with obliteration of the
     retrosternal space on lateral view




8/23/2012      Maria Carmela L. Domocmat
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Narrowing of tricuspid valve orifice due to
     commissual fusion and fibrosis




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Usually follows RF
     Commonly assoc with diseases of mitral valve




8/23/2012      Maria Carmela L. Domocmat
Rumbling or blowing mid-diastolic murmur
     along L sternal border




8/23/2012     Maria Carmela L. Domocmat
Treat left sided HF
     Valvuloplasty
     Valve replacement




8/23/2012      Maria Carmela L. Domocmat
Nursing Care of Clients with Valvular Disorders
Educate about
            Diagnosis
            progressive nature of valvular heart disease
            treatment plan
            report any new symptoms or changes in
            symptoms




8/23/2012             Maria Carmela L. Domocmat
Emphasize need for prophylactic antibiotic
     therapy before any invasive procedure that may
     introduce infectious agents to the patient’s
     bloodstream.
       (e.g., dental work, genitourinary or
       gastrointestinal procedure)




8/23/2012       Maria Carmela L. Domocmat
Teach that infectious agent (usually a
     bacterium) is able to adhere to the diseased
     heart valve more readily than to a normal
     valve. Once attached to the valve, the
     infectious agent multiplies, resulting in
     endocarditis and further damage to the
     valve.


8/23/2012      Maria Carmela L. Domocmat
Collaborate with patient
            develop a meds schedule
            teach about name, dosage, actions, side effects,
            and any drug-drug or drug-food interactions of
            the prescribed meds for HF , dysrhythmias,
            angina pectoris, or other symptoms




8/23/2012            Maria Carmela L. Domocmat
Teach to weigh daily
     report weight gain of 2 pounds in 1 day or 5
     pounds in 1 week
     assist patient with planning activity and rest
     periods to achieve a lifestyle acceptable to
     the patient.



8/23/2012      Maria Carmela L. Domocmat
VS : HR, BP RR measured and compared with
     previous data for any changes.
     Auscultate heart and lung sounds
     Palpate peripheral pulses




8/23/2012     Maria Carmela L. Domocmat
Assess s/s HF
            fatigue, dyspnea with exertion, increase in
            coughing, hemoptysis, multiple respiratory
            infections, orthopnea, or PND




8/23/2012            Maria Carmela L. Domocmat
Assess dysrhythmias
            by palpating the patient’s pulse for strength and
            rhythm (ie, regular or irregular) and asks if the
            patient has experienced palpitations or felt
            forceful heartbeats
     Assess for dizziness, syncope, increased
     weakness, or angina pectoris



8/23/2012             Maria Carmela L. Domocmat
Peiop care - surgical valve replacement or
     valvuloplasty




8/23/2012      Maria Carmela L. Domocmat
Nursing Care of Clients with Valvular Disorders
VALVULOPLASTY




8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Repair of a cardiac valve
     Types
            Commissurotomy
            Annuloplasty
            Chordoplasty




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depends on the cause and type of valve
     dysfunction.
     Commissurotomy
            Repair to commissures between leaflets
     Annuloplasty
            Repair to annulus of the valve by
     Leaflet repair
     Chordoplasty
            Repair to the chordae
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Most require
            general anesthesia
            cardiopulmonary bypass
     Some can be performed in the cath lab
            Percutaneous partial cardiopulmonary bypass




8/23/2012            Maria Carmela L. Domocmat
CCU - first 24 to 72 hrs post op
     PACU/ CCU care
            focus hemodynamic stabilization & recovery from
            anesthesia
            VS q 5 to 15 min and as needed until recovers from
            anesthesia or sedation
            ▪ then q 2 to 4 hrs and as needed
            IV meds
            ▪ blood pressure; dysrhythmias
            Patient assessments
            ▪ q 1 to 4 hrs and PRN
            ▪ Esp neuro, respi, cardio

8/23/2012               Maria Carmela L. Domocmat
Patient transferred to a telemetry or surgical unit
            after recovery fr anes & sedation
            hemodynamically stable without IV meds
            assessments are stable
     Surgical area care
            wound care
            patient teaching regarding diet, activity, medications, and self-
            care.
     Patients are discharged from the hospital in 1 to 7 days.

     In general, valves that have undergone valvuloplasty function longer
     than replacement valves, and the patients do not require continuous
     anticoagulation.

8/23/2012                Maria Carmela L. Domocmat
most common valvuloplasty
     the procedure performed to separate the
     fused leaflets.




8/23/2012     Maria Carmela L. Domocmat
Commissurotomy is a special form of valvuloplasty. Commissurotomy is used when the
leaflets of the valve become stiff and actually fuse together at the base, which is the ring
portion (or annulus) of the valve. Sometimes a scalpel is used to cut the fused leaflets
(commissures) near the ring, which may help them open and close better. In other cases,
a balloon catheter, similar to a catheter used during angioplasty, is inserted into the valve.
The balloon is inflated, splitting the commissures and freeing the leaflets to open and
shut fully.
  8/23/2012     http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php
                               Maria Carmela L. Domocmat
each valve has leaflets;
     the site where the leaflets meet is called the
     commissure.
     The leaflets may adhere to one another and
     close the commissure (i.e., stenosis).
     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 (i.e., regurgitation).

8/23/2012       Maria Carmela L. Domocmat
CLOSED COMMISSUROTOMY
            Balloon Valvuloplasty
     OPEN COMMISSUROTOMY




8/23/2012            Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
do not require cardiopulmonary bypass
     The valve is not directly visualized.
     general anesthetic
     midsternal incision
     a small hole is cut into the heart
     surgeon’s finger or a dilator is used to break
     open the commissure.
     for mitral, aortic, tricuspid, and pulmonary
     valve disease.
8/23/2012       Maria Carmela L. Domocmat
Another type of closed commissurotomy
     Indications
            For mitral and aortic valve stenosis
            younger patients
            for aortic valve stenosis in elderly patients
            patients with complex medical conditions that
            place them at high risk for the complications of
            more extensive surgical procedures.
            also has been used for tricuspid and pulmonic
            valve stenosis
8/23/2012             Maria Carmela L. Domocmat
in cath lab
     local anesthetic
     remain in hospital 24 to 48 hours postop




8/23/2012      Maria Carmela L. Domocmat
C/I
            Left atrial or ventricular thrombus
            severe aortic root dilation
            Significant mitral valve regurgitation
            thoracolumbar scoliosis,
            Rotation of the great vessels
            and other cardiac conditions that require open
            heart surgery

8/23/2012            Maria Carmela L. Domocmat
Types
            Mitral balloon valvuloplasty
            Aortic balloon valvuloplasty




8/23/2012            Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
A balloon-tipped catheter is percutaneously
     inserted, threaded to affected valve, and
     positioned across narrowed orifice
     Balloon is inflated and deflated, causing a
     crack of the calcified commissures and
     enlargement of the valve orifice



8/23/2012      Maria Carmela L. Domocmat
Complications
            some degree of mitral regurgitation
            bleeding from catheter insertion sites
            emboli resulting in complications such as strokes
            left-to-right atrial shunts through an atrial septal
            defect caused by the procedure.




8/23/2012             Maria Carmela L. Domocmat
introduce catheter thru aorta, across AV, and
     into LV .
     The one-balloon or the two-balloon
     technique can be used for treating aortic
     stenosis.
     not as effective as procedure for mitral valve,
            rate of restenosis - nearly 50% in first 12 to 15
            mos post op


8/23/2012             Maria Carmela L. Domocmat
complications
            aortic regurgitation                       Let’s
            emboli                                    watch
                                                      baby
            ventricular perforation                  sophie

            rupture of the aortic valve annulus
            Ventricular dysrhythmias
            mitral valve damage
            bleeding from the catheter insertion sites

8/23/2012             Maria Carmela L. Domocmat
CLOSED COMMISSUROTOMY
            Balloon Valvuloplasty
     OPEN COMMISSUROTOMY




8/23/2012            Maria Carmela L. Domocmat
performed with direct visualization of valve
     general anesthesia
     Median sternotomy or left thoracic incision
     Cardiopulmonary bypass
     incision is made into the heart
     A finger, scalpel, balloon, or dilator may be used
     to open the commissures
     direct visualization of valve
            Advantages: thrombus ID and removed, calcifications
            can be seen, and if valve has chordae or papillary
            muscles, they may be surgically repaired
8/23/2012             Maria Carmela L. Domocmat
Repair of a cardiac valve
     Types
            Commissurotomy
            Annuloplasty
            Chordoplasty




8/23/2012          Maria Carmela L. Domocmat
repair of the valve annulus (i.e., junction of
     the valve leaflets and the muscular heart wall)
     Or retailoring of the valve ring
     narrows the diameter of the valve’s orifice
     and is useful for the treatment of valvular
     regurgitation.



8/23/2012      Maria Carmela L. Domocmat
General anesthesia & cardiopulmonary bypass
     2 techniques
     (1) use annuloplasty ring
            The leaflets of the valve are sutured to a ring, creating an
            annulus of the desired size. When the ring is in place, the
            tension created by the moving blood and contracting
            heart is borne by ring rather than by valve or a suture line,
            and progressive regurgitation is prevented by the repair.
     (2) tacking the valve leaflets to atrium with sutures or
     taking tucks to tighten the annulus.
            may degenerate more quickly than with the annuloplasty
            ring technique
            ▪ Because valve’s leaflets and suture lines are subjected to the direct
              forces of the blood and heart muscle movement,

8/23/2012                Maria Carmela L. Domocmat
Annuloplasty ring




8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Damage to cardiac valve leaflets may result
     from stretching, shortening, or tearing.
     Types:
            removal of the extra tissue
            tucked
            leaflet plication
            leaflet resection



8/23/2012             Maria Carmela L. Domocmat
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 (i.e., tucked) and sutured (i.e.,
     leaflet plication).



8/23/2012      Maria Carmela L. Domocmat
Image of the aortic leaflets after correction of the prolapse using free edge plication
with prolene 6/0 sutures.
 8/23/2012              Maria Carmela L. Domocmat
leaflet resection
            A wedge of tissue cut from middle of leaflet and gap
            sutured closed
     Short leaflets are most often repaired by
     chordoplasty.
      After the short chordae are released, the leaflets
     often unfurl and can resume their normal
     function of closing the valve during systole. A
     piece of pericardium may also be sutured to
     extend the leaflet.
     A pericardial patch may be used to repair holes
     in the leaflets.
8/23/2012             Maria Carmela L. Domocmat
Repair of a cardiac valve
     Types
            Commissurotomy
            Annuloplasty
            Chordoplasty




8/23/2012          Maria Carmela L. Domocmat
is the repair of the chordae tendineae.
     mitral valve is involved with chordoplasty
     (because it has the chordae tendineae);
     seldom is chordoplasty required for the
     tricuspid valve.




8/23/2012      Maria Carmela L. Domocmat
Regurgitation may be caused by stretched,
     torn, or shortened chordae tendineae.
     Stretched chordae tendineae can be
     shortened, torn ones can be reattached to
     the leaflet, and shortened ones can be
     elongated. Regurgitation may also be caused
     by stretched papillary muscles, which can be
     shortened.

8/23/2012      Maria Carmela L. Domocmat
Artificial chordoplasty. A, residual prolapse of A2 is
                                                 evident on saline testing. B, a Gore-Tex suture is passed
                                                 through the fibrous tip of the papillary muscle and the
                                                 margin of the prolapsing segment. C, optimal artificial
                                                 chordae height is determined by intermittently testing
                                                 valve competency by injecting saline into the ventricle. D,
http://www.mitralvalverepair.org/content/view/67/
                                                 a final saline test confirms correction of prolapse.*
     8/23/2012                        Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
Prosthetic valve replacement
     annulus or leaflets of the valve are
     immobilized by calcifications, valve
     replacement is performed.
     General anesthesia and cardiopulmonary
     bypass
     median sternotomy or right thoracotomy


8/23/2012     Maria Carmela L. Domocmat
valve is visualized
     leaflets and other valve structures, such as the chordae and
     papillary muscles, are removed
     Some surgeons leave the posterior mitral valve leaflet, its
     chordae, and papillary muscles in place to help maintain the shape
     and function of the left ventricle after mitral valve replacement.
     Sutures are placed around the annulus and then into the valve
     prosthesis.
     replacement valve is slid down the suture into position and tied
     into place
     incision is closed, and surgeon evaluates the function of the heart
     and the quality of the prosthetic repair.
     patient is weaned from cardiopulmonary bypass, and surgery is
     completed.

                              Heart valve surgery - operation for replacement heart valves.flv

8/23/2012           Maria Carmela L. Domocmat
Complications
            unique to valve replacement are related to the sudden changes in
            intracardiac blood pressures.
            All prosthetic valve replacements create a degree of stenosis when
            they are implanted in the heart. Usually, the stenosis is mild and does
            not effect heart function. If valve replacement was for a stenotic
            valve,blood flow through the heart is often improved.
            The signs and symptoms of the backward heart failure resolve in a few
            hours or days. If valve replacement was for a regurgitant valve, it may
            take months for the chamber into which blood had been regurgitat
            ing to achieve its optimal postoperative function. The signs and
            symptoms of heart failure resolve gradually as the heart function
            improves. The patient is at risk for many postoperative complications,
            such as bleeding, thromboembolism, infection, congestive heart
            failure, hypertension, dysrhythmias, hemolysis, and mechanical
            obstruction of the valve.


8/23/2012                Maria Carmela L. Domocmat
Two types of valve prostheses may be used:
            mechanical valves
            Tissue (i.e., biologic) valves




8/23/2012             Maria Carmela L. Domocmat
Designs: ball-and-cage or disk
     thought to be more durable than tissue
     prosthetic valves
     Indications:
            younger patients
            if the patient has renal failure, hypercalcemia,
            endocarditis, or sepsis and requires valve
            replacement.
            do not deteriorate or become infected as easily as the
            tissue valves used for patients with these conditions.
8/23/2012             Maria Carmela L. Domocmat
MECHANICAL VALVES
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
long-term anticoagulation with warfarin is
     required
            Thromboemboli are significant complications
            associated with mechanical valves




8/23/2012            Maria Carmela L. Domocmat
three types: xenografts, homografts, and
     autografts.
     less likely to generate thromboemboli, and
     long-term nticoagulation is not required.
     are not as durable as mechanical valves and
     require replacement more frequently.



8/23/2012      Maria Carmela L. Domocmat
are tissue valves (eg, bioprostheses,
     heterografts);
     most are from pigs (porcine), but valves from
     cows (bovine) may also be used.
     Durability - 7 to 10 yrs
     don’t require anticoagulation therapy
            do not generate thrombi



8/23/2012            Maria Carmela L. Domocmat
Indications
            for women of childbearing age
            because the potential complications of long-term
            anticoagulation associated with menses, placental
            transfer to a fetus, and delivery of a child do not exist
            patients older than 70 years of age
            patients with a history of peptic ulcer disease
            and others who cannot tolerate long-term
            anticoagulation.
            for all tricuspid valve replacements

8/23/2012              Maria Carmela L. Domocmat
or allografts (i.e., human valves)
     obtained from cadaver tissue donations.
     The aortic valve and a portion of the aorta or the
     pulmonic valve and a portion of the pulmonary artery
     are harvested and stored cryogenically.
     limited availability
            not always available and are very expensive.
     last for about 10 to 15 years
     don’t require anticoagulation
            not thrombogenic and are resistant to subacute bacterial
            endocarditis.
     used for aortic and pulmonic valve replacement.
     excellent hemodynamic flow pattern
8/23/2012              Maria Carmela L. Domocmat
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.



8/23/2012             Maria Carmela L. Domocmat
Indications:
            alternative for children (it may grow as the child
            grows),
            women of childbearing age
             young adults
            patients with a history of peptic ulcer disease
            those who cannot tolerate anticoagulation.
     Aortic valve autografts have remained viable
     for more than 20 years.
8/23/2012             Maria Carmela L. Domocmat
Most aortic valve autograft procedures -
     double valve replacement procedures
            because a homograft also is performed for
            pulmonic valve replacement.
            If pulmonary vascular pressures are normal, some
            surgeons elect not to replace the pulmonic valve.
            The patient can recover without a valve between
            the right ventricle and the pulmonary artery.


8/23/2012            Maria Carmela L. Domocmat
MARBLE-IN-A-CAGE (Starr-Edwards ball-and-cage valve)
developed by Miles "Lowell" Edwards and cardiothoracic surgeon Albert Starr
 first used in 1960.
When resting against the ring, the caged ball prevents backward blood flow into the heart.
When the heart beats, the outflow of blood pushes the ball forward and the blood can flow
around the ball. However, the ball slows blood flow to below a normal rate, and people with
these valves could not perform strenuous activity.
   8/23/2012             Maria Carmela L. Domocmat
•    The marble-in-a-cage
      valve took up a lot of
      space, pressing on other
      body parts, so valve-
      makers sought a flatter
      design.
 •    invented in 1977
 •    still in use today, rely on
      a disc that flips open
      "like a toilet seat,"
 •    When open, it also
      allows more blood
      through than the ball
      design did.                              http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves


8/23/2012          Maria Carmela L. Domocmat
The most common mechanical
      valve in use today is this double-
      door design
      first implanted in the 1970s,
      made of carbon-based material
      with two flaps that open and
      close with the pumping of
      blood.
      Mechanical valves are durable
      and long-lasting, but because
      they can cause dangerous blood
      clots to form, patients must take
      blood thinners such as warfarin
      for the rest of their lives. That, in
      turn, increases the risk of stroke.

                                                    http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves



8/23/2012               Maria Carmela L. Domocmat
To avoid the risk of blood
      clots, Parisian doctor
      Alain Carpentier
      developed pig valves,
      first implanted in 1965.
      Valve-makers use the
      chemical
      glutaraldehyde, a
      common tissue stabilizer
      used in laboratories and
      embalming, to sterilize
      and inactivate the tissue
      so the patient's immune
      system won't attack it.                 http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves

8/23/2012         Maria Carmela L. Domocmat
Today, many valves are
                                                  made from cows, with
                                                  tissue mounted in a wire
                                                  frame covered with Dacron
                                                  fabric, a design around
                                                  since the 1980s. Cutting
                                                  leaflets out of the sac that
                                                  surrounds a cow's heart,
                                                  valve-makers can make
                                                  any required shape or size;
                                                  they can also use chemicals
                                                  to make the tissue less
                                                  likely to attract the calcium
                                                  that can harden a valve.
                                        http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves


8/23/2012   Maria Carmela L. Domocmat
Open-heart surgery is not an
                                                                   option for many patients of
                                                                   fragile health, so researchers
                                                                   designed this collapsible
                                                                   valve—available since 2007 in
                                                                   Europe, but not yet approved
                                                                   in the U.S.—that can be
                                                                   slipped into an artery without
                                                                   cutting open the chest.
                                                                   It scrunches down to pencil-
                                                                   width so a surgeon can thread
                                                                   it from a blood vessel in the
                                                                   leg up to the heart, then use a
                                                                   balloon to inflate it, pushing
                                                                   the old valve out of the way.
      Fluoroscopy and TAVI Procedure.flv
                                                         http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves


8/23/2012                    Maria Carmela L. Domocmat
Sometimes a whole new
      valve is unnecessary, and a
      surgeon can use a ring like
      this to restructure the faulty
      valve. "Repair is definitely a
      lot better," Yoganathan says.
      "You still maintain a lot of the
      natural function." According
      to the Mayo Clinic, the
      original valve better resists
      infection, does not require
      blood thinners and generally
      means a longer life
      expectancy. Yoganathan
      predicts more repair devices
      will be available in the future.            http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves



8/23/2012             Maria Carmela L. Domocmat
8/23/2012   Maria Carmela L. Domocmat
MITRAL STENOSIS                 MITRAL REGURGITATION

  HF s/s                          Chronic mitral
  pulse - weak , irregular        regurgitation - often
  Increase intensity of S1        asymptomatic
  diastolic rumble/ diastolic     Acute mitral regurgitation
  murmur                            severe CHF
  atrial dysrhythmias               Holosystolic or pansystolic
                                    murmur
                                    Pulse - regular or irregular
AORTIC STENOSIS                  AORTIC REGURGITATION

  asymptomatic                     s/s of LVF
  s/s LVF                          Diastolic murmur
  Angina pectoris                  Austin flint murmur
  low pulse pressure (30 mm Hg     Watson's water hammer pulse
                                   Corrigan’s pulse
  or less)
                                   De Musset’s sign
  systolic murmur                  Increased pulse pressure
  Thrill/ Vibration                Hill’s sign
  Gallavardin phenomenon           Pistol shot femoral pulse
                                   (Traube's sign)
                                   Duroziez’s sign
                                   Quincke’s pulse
TRICUSPID REGURGITATION        TRICUSPID STENOSIS

  Holosystolic / Pansystolic     Rumbling or blowing mid-
  murmur in tricuspid area       diastolic murmur along L
                                 sternal border
  s/s RHF
Echocardiography (2D echo)
Electrocardiography (ECG)
cardiac catheterization with angiography
CXR- RV
STENOSIS                     REGURGITATION

  Treat CHF                    Treat CHF
  Mitral valve replacement     Mitral valve replacement
  Valvuloplasty (balloon)      Valvuloplasty
  Antibiotic prophylaxis       (annuloplasty)
  therapy
  Anticoagulants
  Treat anemia
Antibiotic prophylaxis
     Treat HF and dysrhythmias
     Aortic valve replacement
     One- or two-balloon percutaneous aortic
     valvuloplasty




8/23/2012     Maria Carmela L. Domocmat
Treat left sided HF
     Valvuloplasty
     Valve replacement




8/23/2012      Maria Carmela L. Domocmat

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Nursing Care of Clients with Valvular Disorders

  • 1. Maria Carmela L. Domocmat, RN, MSN Instructor, School of Nursing Northern Luzon Adventist College
  • 2. valves of the heart control the flow of blood through the heart into the pulmonary artery and aorta by opening and closing in response to the BP changes as the heart contracts and relaxes. atrioventricular valves and semilunar valves 8/23/2012 Maria Carmela L. Domocmat
  • 3. separate the atria from the ventricles tricuspid valve separates the right atrium from the right ventricle has three leaflets mitral valve separates the left atrium from the left ventricle has Two leaflets both valves have chordae tendineae that anchor the valve leaflets to the papillary muscles and ventricular wall. 8/23/2012 Maria Carmela L. Domocmat
  • 4. 8/23/2012 Maria Carmela L. Domocmat
  • 5. located between the ventricles and their corresponding arteries. pulmonic valve lies between right ventricle and pulmonary artery; aortic valve Lies between the left ventricle and the aorta 8/23/2012 Maria Carmela L. Domocmat
  • 6. 8/23/2012 Maria Carmela L. Domocmat
  • 7. 8/23/2012 Maria Carmela L. Domocmat
  • 8. Annulus: a (fibrous) ringlike structure, or any body part that is shaped like a ring Commissure: a site of union of corresponding parts; specifically, the sites of junction between adjacent cusps of the heart valves. http://medical-dictionary.thefreedictionary.com/commissure 8/23/2012 Maria Carmela L. Domocmat
  • 9. Chordae tendineae: thread-like bands of fibrous tissue that attach on one end to the edges of the tricuspid and mitral valves of the heart and on the other end to the papillary muscles. Papillary muscles: small muscle within the heart that anchors the heart valves. http://medical-dictionary.thefreedictionary.com/commissure 8/23/2012 Maria Carmela L. Domocmat
  • 10. 1 Heart Valves, ana phy.flv 8/23/2012 Maria Carmela L. Domocmat
  • 11. DISORDERS OF THE MITRAL DISORDERS OF THE AORTIC VALVE VALVE mitral valve prolapse aortic regurgitation mitral regurgitation aortic stenosis mitral stenosis Tricuspid and pulmonic valve disorders usually with fewer symptoms and complications. 8/23/2012 Maria Carmela L. Domocmat
  • 12. lead to various symptoms that, depending on their severity, may require surgical repair or replacement of the valve to correct the problem Regurgitation and stenosis may occur at the same time in the same or different valves. 8/23/2012 Maria Carmela L. Domocmat
  • 13. 8/23/2012 Maria Carmela L. Domocmat
  • 14. Valvular stenosis Valvular insufficiency 8/23/2012 Maria Carmela L. Domocmat
  • 15. Valvular stenosis impedance of blood flow the tissues forming the valve leaflets become stiffer, narrowing the valve opening and reducing the amount of blood that can flow through it. If the narrowing is mild, the overall functioning of the heart may not be reduced 8/23/2012 Maria Carmela L. Domocmat
  • 16. Valvular insufficiency Aka: regurgitation, incompetence, "leaky valve" occurs when the leaflets do not close completely, letting blood leak backward across the valve. This backward flow is referred to as “regurgitant flow.” 8/23/2012 Maria Carmela L. Domocmat
  • 17. 8/23/2012 Maria Carmela L. Domocmat
  • 18. Mitral Valve Prolapse Mitral Regurgitation Mitral Valve Stenosis Aortic Regurgitation Aortic Stenosis Tricuspid Regurgitation 8/23/2012 Maria Carmela L. Domocmat
  • 19. Mitral stenosis Progressive thickening and contracture of valve cusps wit narrowing of the orifice and progressive obstruction to blood flow Aortic stenosis Narrowing of orifice between LV and aorta Tricuspid stenosis Narrowing of tricuspid valve orifice due to commissual fusion and fibrosis 8/23/2012 Maria Carmela L. Domocmat
  • 20. Mitral insufficiency (regurgitation) Incomplete closure of the mitral valve during systole, allowing blood to flow back into LA Aortic insufficiency (regurgitation) Valve flaps fail to completely seal the aortic orifice during diastole and thus permit backflow of blood from aorta into LV Tricuspid insufficiency (regurgitation) Allows regurgitation of blood from RV into the RA during systole 8/23/2012 Maria Carmela L. Domocmat
  • 21. 8/23/2012 Maria Carmela L. Domocmat
  • 22. an obstruction of blood flowing from the left atrium into the left ventricle. 8/23/2012 Maria Carmela L. Domocmat
  • 23. 8/23/2012 Maria Carmela L. Domocmat
  • 24. 8/23/2012 Maria Carmela L. Domocmat
  • 25. most common cause rheumatic valvulitis rheumatic endocarditis other causes malignant carcinoid, SLE, RA 8/23/2012 Maria Carmela L. Domocmat
  • 26. causes progressively thickens the mitral valve leaflets and chordae tendineae. The leaflets often fuse (glued) together. Eventually, the mitral valve orifice narrows and progressively obstructs blood flow into the ventricle. 8/23/2012 Maria Carmela L. Domocmat
  • 27. 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. LA - great difficulty moving blood into the ventricle Bcoz of increased resistance of the narrowed orifice; it dilates (stretches) and hypertrophies (thickens) bcoz of increased blood volume it holds no valve to protect the pulmonary veins from the backward flow of blood from the atrium, the pulmonary circulation becomes congested. RV - must contract against abnormally high pulmonary arterial pressure (PAP) and is subjected to excessive strain. right ventricle fails 8/23/2012 Maria Carmela L. Domocmat
  • 28. Rheumatic Fever or infective Endocarditis Inflammation of valve leaflets Fibrosis and retraction of leaflets Shortening of chordae tendinae Narrowing of valvular orifice (n=4- (n=4-6 cm2) Mild stenosis-2 cm2 stenosis- Severe stenosis-1 cm2 stenosis- 8/23/2012 Maria Carmela L. Domocmat
  • 29. Decrease blood flow from left atrium to left ventricle Rupture of small Stagnation Increase LA pressure of blood in bronchial vessels the left atrium Left atrial enlargement Hemoptysis Thrombus Increase pulmonary venous pressure Embolism Impinges on Increase right ventricular pressure left recurrent laryngeal nerve Right ventricular Enlargement Pulmonary edema Hoarseness Orthopnea Right Ventricular Failure PND 8/23/2012 Edema Carmela L. Domocmat Anorexia Maria Ascites Fatigue NVE
  • 30. HF s/s Dyspnea on exertion ▪ first symptom ▪ due to pulmonary venous hypertension progressive fatigue ▪ as a result of low CO Hemoptysis cough repeated respiratory infections 8/23/2012 Maria Carmela L. Domocmat
  • 31. pulse - weak , irregular Increase intensity of S1 Listen diastolic rumble/ diastolic murmur low-pitched, rumbling, heard at the apex Opening snap after S2- apex heart murmurs heard during diastole. start at or after S2 and end before or at S1. result of the increased blood volume and pressure, the atrium dilates, hypertrophies, and becomes electrically unstable atrial dysrhythmias 8/23/2012 Maria Carmela L. Domocmat
  • 32. Echocardiography used to diagnose mitral stenosis used to determine the severity Electrocardiography (ECG) cardiac catheterization with angiography 8/23/2012 Maria Carmela L. Domocmat
  • 33. Antibiotic prophylaxis therapy to prevent recurrence of infections Treat CHF Anticoagulants to decrease the risk developing atrial thrombus Treat anemia 8/23/2012 Maria Carmela L. Domocmat
  • 34. Valvuloplasty Closed Mitral commissurotomy or valvotomy Open mitral commissurotomy or valvotomy ▪ to open or rupture the fused commissures of the mitral valve. Percutaneous transluminal valvuloplasty / Balloon valvuloplasty Mitral valve replacement 8/23/2012 Maria Carmela L. Domocmat
  • 35. 8/23/2012 Maria Carmela L. Domocmat
  • 36. involves blood flowing back from the left ventricle into the left atrium during systole. Often, the margins of the mitral valve cannot close during systole. 8/23/2012 Maria Carmela L. Domocmat
  • 37. may be caused by problems with one or more of the leaflets : shorten or tear chordae tendineae : elongate, shorten, or tear Annulus : stretched by heart enlargement or deformed by calcification 8/23/2012 Maria Carmela L. Domocmat
  • 38. may be caused by problems with papillary muscles: rupture, stretch, or be pulled out of position by changes in the ventricular wall (e.g., scar from a myocardial infarction or ventricular dilation). papillary muscle may be unable to contract because of ischemia. 8/23/2012 Maria Carmela L. Domocmat
  • 39. Regardless of the cause blood regurgitates back into the atrium during systole. With each beat of LV , some of blood is forced back into LA Because this blood is added to the blood that is beginning to flow in from the lungs, LA must stretch. It eventually hypertrophies and dilates. The backward flow of blood from the ventricle diminishes the volume of blood flowing into the atrium from the lungs. As a result, the lungs become congested, eventually adding extra strain on the right ventricle. Mitral regurgitation ultimately involves the lungs and RV 8/23/2012 Maria Carmela L. Domocmat
  • 40. Due to myxomatous degeneration, which cuases stretching of the leaflets and chordae tendineae Chronic RHD CAD Infective endocarditis Meds and penetrating and nonpenetrating trauma 8/23/2012 Maria Carmela L. Domocmat
  • 41. Mitral Valve Regurgitation ana phy.flv 8/23/2012 Maria Carmela L. Domocmat
  • 42. Pathophysiology Increase left ventricular pressure Systole Small amount to blood pump to Increase backflow of aorta blood to left ventricle through incompetent MV Increase LV work load to pump more blood LAH LVH Inc. LA pressure RVH RVF LVH Inc. pulmonary pressure Ascites /edema 8/23/2012 Maria Carmela L. Domocmat Orthopnea PND Dyspnea
  • 43. Chronic mitral regurgitation - often asymptomatic Acute mitral regurgitation (e.g., that resulting from a myocardial infarction) manifests as severe CHF Dyspnea, fatigue, and weakness Palpitations, SOBon exertion, and cough from pulmonary congestion also occur. 8/23/2012 Maria Carmela L. Domocmat
  • 44. Holosystolic or pansystolic murmur 5 Holosystolic Murmur.flv a high-pitched, blowing sound at the apex. heard best at the apex and radiates to the axilla and usually accompanied by a thrill a heart murmur occurring throughout systole. Pulse - regular and of good volume, or it may be irregular as a result of extrasystolic beats or atrial fibrillation. 8/23/2012 Maria Carmela L. Domocmat
  • 45. Echocardiography used to diagnose monitor the progression 8/23/2012 Maria Carmela L. Domocmat
  • 46. CHF MGMT SURGICAL INTERVENTION Digitalis Mitral valve replacement Diuretics Valvuloplasty Vasodilators (annuloplasty) Diet Mitral Valve Regurgitation treatment.flv Anticoagulants 8/23/2012 Maria Carmela L. Domocmat
  • 47. 8/23/2012 Maria Carmela L. Domocmat
  • 48. is narrowing of the orifice between the LV and the aorta. leaflets of aortic valve may fuse. 8/23/2012 Maria Carmela L. Domocmat
  • 49. 8/23/2012 Maria Carmela L. Domocmat
  • 50. 8/23/2012 Maria Carmela L. Domocmat
  • 51. congenital leaflet malformations abnormal number of leaflets (i.e., one or two rather than three) rheumatic endocarditis RF cusp calcification of unknown cause 8/23/2012 Maria Carmela L. Domocmat
  • 52. progressive narrowing of the valve orifice, usually over a period of several years to several decades. LV overcomes the obstruction to circulation by contracting more slowly but with greater energy than normal, forcibly squeezing the blood through the very small orifice. obstruction to LV outflow increases pressure on the left ventricle, which results in thickening of the muscle wall. heart muscle hypertrophies. When these compensatory mechanisms of the heart begin to fail, clinical signs and symptoms develop. 8/23/2012 Maria Carmela L. Domocmat
  • 53. Aortic Stenosis 8/23/2012 Maria Carmela L. Domocmat
  • 54. Pathophysiology Narrowed aortic orifice Decreased Increased back flow of blood flow to blood to left ventricle aorta during systole Decrease CO Increased LV pressure Syncope Decreased LVH coronary blood flow Increased LA pressure Angina LAH 8/23/2012 Maria Carmela L. Domocmat
  • 55. Increased pulmonary pressure Pulmonary Increased RV pressure edema Orthopnea dyspnea RVH RVF Edema Ascites Anorexia Fatigue NVE 8/23/2012 Maria Carmela L. Domocmat
  • 56. Many asymptomatic exertional dyspnea caused by LVF Other signs are dizziness and syncope because of reduced blood flow to the brain. Angina pectoris a frequent symptom results from the increased oxygen demands of the hypertrophied left ventricle, the decreased time in diastole for myocardial perfusion, and the decreased blood flow into the coronary arteries. BP - can be low but usually normal low pulse pressure (30 mm Hg or less) because of diminished blood flow 8/23/2012 Maria Carmela L. Domocmat
  • 57. systolic murmur loud, rough systolic murmur low-pitched, rough, rasping, and vibrating heard over the aortic area (R upper sternal border) may radiate into the carotid arteries and to the apex of LV 8/23/2012 Maria Carmela L. Domocmat
  • 58. Thrill/ Vibration Palpated over base of heart/ 2nd RICS caused by turbulent blood flow across the narrowed valve orifice. Gallavardin phenomenon murmur also reflected to mitral area which may give a false impression of a mitral regurgitation 8/23/2012 Maria Carmela L. Domocmat
  • 59. 12-leadECG and echocardiogram Evidence of LV hypertrophy may be seen Echocardiography (2D echo) used to diagnose and monitor the progression of aortic stenosis. left-sided heart catheterization measure the severity of the aortic stenosis and evaluate the coronary arteries. Pressure tracings are taken from LV and base of aorta. systolic pressure in LV is considerably higher than that in the aorta during systole. 8/23/2012 Maria Carmela L. Domocmat
  • 60. 8/23/2012 Maria Carmela L. Domocmat
  • 61. is the flow of blood back into the left ventricle from the aorta during diastole. may be caused by inflammatory lesions that deform the leaflets of the aortic valve, preventing them from completely closing the aortic valve orifice. 8/23/2012 Maria Carmela L. Domocmat
  • 62. endocarditis rheumatic heart disease (RHD) congenital abnormalities (e.g., marfan syndrome) Syphilis - may produce aortitis dissecting aneurysm causes dilation or tearing of the ascending aorta deterioration of an aortic valve replacement 8/23/2012 Maria Carmela L. Domocmat
  • 63. blood from the aorta returns to the LV during diastole in addition to the blood normally delivered by the LA LV dilates trying to accommodate the increased volume of blood. LV hypertrophies trying to increase muscle strength to expel more blood with above normal force—raising systolic BP. reflex vasodilation arteries attempt to compensate for the higher pressures peripheral arterioles relax reducing peripheral resistance and diastolic BP. 8/23/2012 Maria Carmela L. Domocmat
  • 64. 8/23/2012 Maria Carmela L. Domocmat
  • 65. 8/23/2012 Maria Carmela L. Domocmat
  • 66. 8/23/2012 Maria Carmela L. Domocmat
  • 67. Pathophysiology Etiologic factors Incompetent aortic valve Regurgitation of blood from systemic circulation + blood form LA increases LV pressure LVH LVF RVF 8/23/2012 Maria Carmela L. Domocmat
  • 68. Usually asymptomatic Progressive s/s of LVF Exertional dyspnea and fatigue breathing difficulties (e.g., orthopnea, PND) 8/23/2012 Maria Carmela L. Domocmat
  • 69. Diastolic murmur Austin flint murmur Watson's water hammer pulse Corrigan’s pulse Widened pulse pressure Hill’s sign 8/23/2012 Maria Carmela L. Domocmat
  • 70. Diastolic murmur 3 Austin Flint Murmur.avi.flv high-pitched, blowing sound at the third or 4th ICS L sternal border sitting up and leaning forward Austin flint murmur low pitched diastolic rumble similar to mitral stenosis; indicates moderate to severe insufficiency a mid-diastolic or presystolic murmur low-pitched rumbling murmur which is best heard at the cardiac apex. A murmur due to aortic regurgitation, originating at the mitral valve when blood enters simultaneously from both the aorta and the left atrium. 8/23/2012 Maria Carmela L. Domocmat
  • 71. Watson's water hammer pulse AKA: collapsing pulse, cannonball pulse is the medical sign which describes a pulse that is bounding and forceful, as if it were the hitting of a water hammer that was causing the pulse. PA: radial pulse of a supine patient with arm at side is firmly palpated with slight pressure until the pulse is obscured. The arm is then raised over the patient's head, with the arm perpendicular to the supine patient. http://depts.washington.edu/physdx/heart/physical.html 8/23/2012 Maria Carmela L. Domocmat
  • 72. Corrigan’s pulse marked arterial pulsations forceful heartbeat visible or palpable at the carotid or temporal arteries. result of the increased force and volume of the blood ejected from the hypertrophied LV. De Musset’s sign Rhythmic nodding or bobbing of the head in synchrony with the heart beat Increased pulse pressure Refers to the difference between the systolic pressure and the diastolic pressure. Normal - 50-60. http://depts.washington.edu/physdx/heart/physical.html 8/23/2012 Maria Carmela L. Domocmat
  • 73. Hill’s sign systolic blood pressure is higher in the legs than in the arms(> 20mmHg) . Pistol shot femoral pulse (Traube's sign) short, loud, snapping sounds with each pulse with auscultation over the femoral, brachial, or radial pulse. a pulse that sounds like a pistol shot 8/23/2012 Maria Carmela L. Domocmat
  • 74. Duroziez’s sign to-and-fro murmur over the lightly compressed femoral arteries a double murmur over the femoral or other large peripheral artery; due to aortic insufficiency. 8/23/2012 Maria Carmela L. Domocmat
  • 75. Quincke’s pulse systolic blushing and diastolic blanching of the nail bed when gentle pressure is place on the nail alternate blanching and flushing of the nail bed due to pulsation of subpapillary arteriolar and venous plexuses; QUINCKE'S PULSE.wmv 4 Quincke's pulse.avi.flv 8/23/2012 Maria Carmela L. Domocmat
  • 76. Diagnosis may be confirmed Echocardiogram radionuclide imaging ECG Magnetic resonance imaging cardiac catheterization 8/23/2012 Maria Carmela L. Domocmat
  • 77. antibiotic prophylaxis Before the patient undergoes invasive or dental procedures to prevent endocarditis Treat HF and dysrhythmias 8/23/2012 Maria Carmela L. Domocmat
  • 78. Aortic Valve Replacement.mp4 Aortic valve replacement treatment of choice Aortic Valve replacement- OR.flv One- or two-balloon percutaneous aortic valvuloplasty For symptomatic and not surgical candidates Note: surgery is recommended for any patient with left ventricular hypertrophy, regardless of the presence or absence of symptoms. 8/23/2012 Maria Carmela L. Domocmat
  • 79. 8/23/2012 Maria Carmela L. Domocmat
  • 80. a disorder in which the heart's tricuspid valve does not close properly, causing blood to flow backward (leak) into the right upper heart chamber (atrium) when the right lower heart chamber (ventricle) contracts. http://www.ncbi.nlm.nih.gov/pubmedhealth/P MH0001222/ 8/23/2012 Maria Carmela L. Domocmat
  • 81. Infective endocarditis- drug abusers RVF/LVF Rheumatic Heart disease RV infarction Ebstein's anomaly 8/23/2012 Maria Carmela L. Domocmat
  • 82. Ebstein's anomaly rare heart defect in which parts of the tricuspid valve are abnormal. leaflets are unusually deep in the RV ; often larger than normal. Congenital defect exact cause is unknown although the use of certain drugs (such as lithium or benzodiazepines) during pregnancy may play a role. condition is rare 8/23/2012 Maria Carmela L. Domocmat
  • 83. Holosystolic / Pansystolic murmur in tricuspid area High-pitched increases with inspiration At parasternal region at 4th ICS s/s RHF Hepatic congestion, RUQ pain, jaundice Pulsatile liver Right ventricular lift Jugular venous pulsation 8/23/2012 Maria Carmela L. Domocmat
  • 84. 8/23/2012 Maria Carmela L. Domocmat
  • 85. Tricuspid regurgitation is a disorder involving backflow of blood from RV to RA during contraction of RV . The most common cause of tricuspid regurgitation is not damage to the valve itself but enlargement of the RV, which may be a complication of any disorder that causes RVHF. 8/23/2012 Maria Carmela L. Domocmat
  • 86. ECG- RV and RA enlargement CXR- RV enlargement with obliteration of the retrosternal space on lateral view 8/23/2012 Maria Carmela L. Domocmat
  • 87. 8/23/2012 Maria Carmela L. Domocmat
  • 88. Narrowing of tricuspid valve orifice due to commissual fusion and fibrosis 8/23/2012 Maria Carmela L. Domocmat
  • 89. Usually follows RF Commonly assoc with diseases of mitral valve 8/23/2012 Maria Carmela L. Domocmat
  • 90. Rumbling or blowing mid-diastolic murmur along L sternal border 8/23/2012 Maria Carmela L. Domocmat
  • 91. Treat left sided HF Valvuloplasty Valve replacement 8/23/2012 Maria Carmela L. Domocmat
  • 93. Educate about Diagnosis progressive nature of valvular heart disease treatment plan report any new symptoms or changes in symptoms 8/23/2012 Maria Carmela L. Domocmat
  • 94. Emphasize need for prophylactic antibiotic therapy before any invasive procedure that may introduce infectious agents to the patient’s bloodstream. (e.g., dental work, genitourinary or gastrointestinal procedure) 8/23/2012 Maria Carmela L. Domocmat
  • 95. Teach that infectious agent (usually a bacterium) is able to adhere to the diseased heart valve more readily than to a normal valve. Once attached to the valve, the infectious agent multiplies, resulting in endocarditis and further damage to the valve. 8/23/2012 Maria Carmela L. Domocmat
  • 96. Collaborate with patient develop a meds schedule teach about name, dosage, actions, side effects, and any drug-drug or drug-food interactions of the prescribed meds for HF , dysrhythmias, angina pectoris, or other symptoms 8/23/2012 Maria Carmela L. Domocmat
  • 97. Teach to weigh daily report weight gain of 2 pounds in 1 day or 5 pounds in 1 week assist patient with planning activity and rest periods to achieve a lifestyle acceptable to the patient. 8/23/2012 Maria Carmela L. Domocmat
  • 98. VS : HR, BP RR measured and compared with previous data for any changes. Auscultate heart and lung sounds Palpate peripheral pulses 8/23/2012 Maria Carmela L. Domocmat
  • 99. Assess s/s HF fatigue, dyspnea with exertion, increase in coughing, hemoptysis, multiple respiratory infections, orthopnea, or PND 8/23/2012 Maria Carmela L. Domocmat
  • 100. Assess dysrhythmias by palpating the patient’s pulse for strength and rhythm (ie, regular or irregular) and asks if the patient has experienced palpitations or felt forceful heartbeats Assess for dizziness, syncope, increased weakness, or angina pectoris 8/23/2012 Maria Carmela L. Domocmat
  • 101. Peiop care - surgical valve replacement or valvuloplasty 8/23/2012 Maria Carmela L. Domocmat
  • 103. VALVULOPLASTY 8/23/2012 Maria Carmela L. Domocmat
  • 104. 8/23/2012 Maria Carmela L. Domocmat
  • 105. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty 8/23/2012 Maria Carmela L. Domocmat
  • 106. depends on the cause and type of valve dysfunction. Commissurotomy Repair to commissures between leaflets Annuloplasty Repair to annulus of the valve by Leaflet repair Chordoplasty Repair to the chordae 8/23/2012 Maria Carmela L. Domocmat
  • 107. Most require general anesthesia cardiopulmonary bypass Some can be performed in the cath lab Percutaneous partial cardiopulmonary bypass 8/23/2012 Maria Carmela L. Domocmat
  • 108. CCU - first 24 to 72 hrs post op PACU/ CCU care focus hemodynamic stabilization & recovery from anesthesia VS q 5 to 15 min and as needed until recovers from anesthesia or sedation ▪ then q 2 to 4 hrs and as needed IV meds ▪ blood pressure; dysrhythmias Patient assessments ▪ q 1 to 4 hrs and PRN ▪ Esp neuro, respi, cardio 8/23/2012 Maria Carmela L. Domocmat
  • 109. Patient transferred to a telemetry or surgical unit after recovery fr anes & sedation hemodynamically stable without IV meds assessments are stable Surgical area care wound care patient teaching regarding diet, activity, medications, and self- care. Patients are discharged from the hospital in 1 to 7 days. In general, valves that have undergone valvuloplasty function longer than replacement valves, and the patients do not require continuous anticoagulation. 8/23/2012 Maria Carmela L. Domocmat
  • 110. most common valvuloplasty the procedure performed to separate the fused leaflets. 8/23/2012 Maria Carmela L. Domocmat
  • 111. Commissurotomy is a special form of valvuloplasty. Commissurotomy is used when the leaflets of the valve become stiff and actually fuse together at the base, which is the ring portion (or annulus) of the valve. Sometimes a scalpel is used to cut the fused leaflets (commissures) near the ring, which may help them open and close better. In other cases, a balloon catheter, similar to a catheter used during angioplasty, is inserted into the valve. The balloon is inflated, splitting the commissures and freeing the leaflets to open and shut fully. 8/23/2012 http://www.heart-valve-surgery.com/heart-valve-repair-valvuloplasty-annuloplasty.php Maria Carmela L. Domocmat
  • 112. each valve has leaflets; the site where the leaflets meet is called the commissure. The leaflets may adhere to one another and close the commissure (i.e., stenosis). 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 (i.e., regurgitation). 8/23/2012 Maria Carmela L. Domocmat
  • 113. CLOSED COMMISSUROTOMY Balloon Valvuloplasty OPEN COMMISSUROTOMY 8/23/2012 Maria Carmela L. Domocmat
  • 114. 8/23/2012 Maria Carmela L. Domocmat
  • 115. do not require cardiopulmonary bypass The valve is not directly visualized. general anesthetic midsternal incision a small hole is cut into the heart surgeon’s finger or a dilator is used to break open the commissure. for mitral, aortic, tricuspid, and pulmonary valve disease. 8/23/2012 Maria Carmela L. Domocmat
  • 116. Another type of closed commissurotomy Indications For mitral and aortic valve stenosis younger patients for aortic valve stenosis in elderly patients patients with complex medical conditions that place them at high risk for the complications of more extensive surgical procedures. also has been used for tricuspid and pulmonic valve stenosis 8/23/2012 Maria Carmela L. Domocmat
  • 117. in cath lab local anesthetic remain in hospital 24 to 48 hours postop 8/23/2012 Maria Carmela L. Domocmat
  • 118. C/I Left atrial or ventricular thrombus severe aortic root dilation Significant mitral valve regurgitation thoracolumbar scoliosis, Rotation of the great vessels and other cardiac conditions that require open heart surgery 8/23/2012 Maria Carmela L. Domocmat
  • 119. Types Mitral balloon valvuloplasty Aortic balloon valvuloplasty 8/23/2012 Maria Carmela L. Domocmat
  • 120. 8/23/2012 Maria Carmela L. Domocmat
  • 121. 8/23/2012 Maria Carmela L. Domocmat
  • 122. A balloon-tipped catheter is percutaneously inserted, threaded to affected valve, and positioned across narrowed orifice Balloon is inflated and deflated, causing a crack of the calcified commissures and enlargement of the valve orifice 8/23/2012 Maria Carmela L. Domocmat
  • 123. Complications some degree of mitral regurgitation bleeding from catheter insertion sites emboli resulting in complications such as strokes left-to-right atrial shunts through an atrial septal defect caused by the procedure. 8/23/2012 Maria Carmela L. Domocmat
  • 124. introduce catheter thru aorta, across AV, and into LV . The one-balloon or the two-balloon technique can be used for treating aortic stenosis. not as effective as procedure for mitral valve, rate of restenosis - nearly 50% in first 12 to 15 mos post op 8/23/2012 Maria Carmela L. Domocmat
  • 125. complications aortic regurgitation Let’s emboli watch baby ventricular perforation sophie rupture of the aortic valve annulus Ventricular dysrhythmias mitral valve damage bleeding from the catheter insertion sites 8/23/2012 Maria Carmela L. Domocmat
  • 126. CLOSED COMMISSUROTOMY Balloon Valvuloplasty OPEN COMMISSUROTOMY 8/23/2012 Maria Carmela L. Domocmat
  • 127. performed with direct visualization of valve general anesthesia Median sternotomy or left thoracic incision Cardiopulmonary bypass incision is made into the heart A finger, scalpel, balloon, or dilator may be used to open the commissures direct visualization of valve Advantages: thrombus ID and removed, calcifications can be seen, and if valve has chordae or papillary muscles, they may be surgically repaired 8/23/2012 Maria Carmela L. Domocmat
  • 128. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty 8/23/2012 Maria Carmela L. Domocmat
  • 129. repair of the valve annulus (i.e., junction of the valve leaflets and the muscular heart wall) Or retailoring of the valve ring narrows the diameter of the valve’s orifice and is useful for the treatment of valvular regurgitation. 8/23/2012 Maria Carmela L. Domocmat
  • 130. General anesthesia & cardiopulmonary bypass 2 techniques (1) use annuloplasty ring The leaflets of the valve are sutured to a ring, creating an annulus of the desired size. When the ring is in place, the tension created by the moving blood and contracting heart is borne by ring rather than by valve or a suture line, and progressive regurgitation is prevented by the repair. (2) tacking the valve leaflets to atrium with sutures or taking tucks to tighten the annulus. may degenerate more quickly than with the annuloplasty ring technique ▪ Because valve’s leaflets and suture lines are subjected to the direct forces of the blood and heart muscle movement, 8/23/2012 Maria Carmela L. Domocmat
  • 131. Annuloplasty ring 8/23/2012 Maria Carmela L. Domocmat
  • 132. 8/23/2012 Maria Carmela L. Domocmat
  • 133. 8/23/2012 Maria Carmela L. Domocmat
  • 134. 8/23/2012 Maria Carmela L. Domocmat
  • 135. Damage to cardiac valve leaflets may result from stretching, shortening, or tearing. Types: removal of the extra tissue tucked leaflet plication leaflet resection 8/23/2012 Maria Carmela L. Domocmat
  • 136. 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 (i.e., tucked) and sutured (i.e., leaflet plication). 8/23/2012 Maria Carmela L. Domocmat
  • 137. Image of the aortic leaflets after correction of the prolapse using free edge plication with prolene 6/0 sutures. 8/23/2012 Maria Carmela L. Domocmat
  • 138. leaflet resection A wedge of tissue cut from middle of leaflet and gap sutured closed Short leaflets are most often repaired by chordoplasty. After the short chordae are released, the leaflets often unfurl and can resume their normal function of closing the valve during systole. A piece of pericardium may also be sutured to extend the leaflet. A pericardial patch may be used to repair holes in the leaflets. 8/23/2012 Maria Carmela L. Domocmat
  • 139. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty 8/23/2012 Maria Carmela L. Domocmat
  • 140. is the repair of the chordae tendineae. mitral valve is involved with chordoplasty (because it has the chordae tendineae); seldom is chordoplasty required for the tricuspid valve. 8/23/2012 Maria Carmela L. Domocmat
  • 141. Regurgitation may be caused by stretched, torn, or shortened chordae tendineae. Stretched chordae tendineae can be shortened, torn ones can be reattached to the leaflet, and shortened ones can be elongated. Regurgitation may also be caused by stretched papillary muscles, which can be shortened. 8/23/2012 Maria Carmela L. Domocmat
  • 142. Artificial chordoplasty. A, residual prolapse of A2 is evident on saline testing. B, a Gore-Tex suture is passed through the fibrous tip of the papillary muscle and the margin of the prolapsing segment. C, optimal artificial chordae height is determined by intermittently testing valve competency by injecting saline into the ventricle. D, http://www.mitralvalverepair.org/content/view/67/ a final saline test confirms correction of prolapse.* 8/23/2012 Maria Carmela L. Domocmat
  • 143. 8/23/2012 Maria Carmela L. Domocmat
  • 144. Prosthetic valve replacement annulus or leaflets of the valve are immobilized by calcifications, valve replacement is performed. General anesthesia and cardiopulmonary bypass median sternotomy or right thoracotomy 8/23/2012 Maria Carmela L. Domocmat
  • 145. valve is visualized leaflets and other valve structures, such as the chordae and papillary muscles, are removed Some surgeons leave the posterior mitral valve leaflet, its chordae, and papillary muscles in place to help maintain the shape and function of the left ventricle after mitral valve replacement. Sutures are placed around the annulus and then into the valve prosthesis. replacement valve is slid down the suture into position and tied into place incision is closed, and surgeon evaluates the function of the heart and the quality of the prosthetic repair. patient is weaned from cardiopulmonary bypass, and surgery is completed. Heart valve surgery - operation for replacement heart valves.flv 8/23/2012 Maria Carmela L. Domocmat
  • 146. Complications unique to valve replacement are related to the sudden changes in intracardiac blood pressures. All prosthetic valve replacements create a degree of stenosis when they are implanted in the heart. Usually, the stenosis is mild and does not effect heart function. If valve replacement was for a stenotic valve,blood flow through the heart is often improved. The signs and symptoms of the backward heart failure resolve in a few hours or days. If valve replacement was for a regurgitant valve, it may take months for the chamber into which blood had been regurgitat ing to achieve its optimal postoperative function. The signs and symptoms of heart failure resolve gradually as the heart function improves. The patient is at risk for many postoperative complications, such as bleeding, thromboembolism, infection, congestive heart failure, hypertension, dysrhythmias, hemolysis, and mechanical obstruction of the valve. 8/23/2012 Maria Carmela L. Domocmat
  • 147. Two types of valve prostheses may be used: mechanical valves Tissue (i.e., biologic) valves 8/23/2012 Maria Carmela L. Domocmat
  • 148. Designs: ball-and-cage or disk thought to be more durable than tissue prosthetic valves Indications: younger patients if the patient has renal failure, hypercalcemia, endocarditis, or sepsis and requires valve replacement. do not deteriorate or become infected as easily as the tissue valves used for patients with these conditions. 8/23/2012 Maria Carmela L. Domocmat
  • 149. MECHANICAL VALVES 8/23/2012 Maria Carmela L. Domocmat
  • 150. 8/23/2012 Maria Carmela L. Domocmat
  • 151. 8/23/2012 Maria Carmela L. Domocmat
  • 152. long-term anticoagulation with warfarin is required Thromboemboli are significant complications associated with mechanical valves 8/23/2012 Maria Carmela L. Domocmat
  • 153. three types: xenografts, homografts, and autografts. less likely to generate thromboemboli, and long-term nticoagulation is not required. are not as durable as mechanical valves and require replacement more frequently. 8/23/2012 Maria Carmela L. Domocmat
  • 154. are tissue valves (eg, bioprostheses, heterografts); most are from pigs (porcine), but valves from cows (bovine) may also be used. Durability - 7 to 10 yrs don’t require anticoagulation therapy do not generate thrombi 8/23/2012 Maria Carmela L. Domocmat
  • 155. Indications for women of childbearing age because the potential complications of long-term anticoagulation associated with menses, placental transfer to a fetus, and delivery of a child do not exist patients older than 70 years of age patients with a history of peptic ulcer disease and others who cannot tolerate long-term anticoagulation. for all tricuspid valve replacements 8/23/2012 Maria Carmela L. Domocmat
  • 156. or allografts (i.e., human valves) obtained from cadaver tissue donations. The aortic valve and a portion of the aorta or the pulmonic valve and a portion of the pulmonary artery are harvested and stored cryogenically. limited availability not always available and are very expensive. last for about 10 to 15 years don’t require anticoagulation not thrombogenic and are resistant to subacute bacterial endocarditis. used for aortic and pulmonic valve replacement. excellent hemodynamic flow pattern 8/23/2012 Maria Carmela L. Domocmat
  • 157. 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. 8/23/2012 Maria Carmela L. Domocmat
  • 158. Indications: alternative for children (it may grow as the child grows), women of childbearing age young adults patients with a history of peptic ulcer disease those who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years. 8/23/2012 Maria Carmela L. Domocmat
  • 159. Most aortic valve autograft procedures - double valve replacement procedures because a homograft also is performed for pulmonic valve replacement. If pulmonary vascular pressures are normal, some surgeons elect not to replace the pulmonic valve. The patient can recover without a valve between the right ventricle and the pulmonary artery. 8/23/2012 Maria Carmela L. Domocmat
  • 160. MARBLE-IN-A-CAGE (Starr-Edwards ball-and-cage valve) developed by Miles "Lowell" Edwards and cardiothoracic surgeon Albert Starr first used in 1960. When resting against the ring, the caged ball prevents backward blood flow into the heart. When the heart beats, the outflow of blood pushes the ball forward and the blood can flow around the ball. However, the ball slows blood flow to below a normal rate, and people with these valves could not perform strenuous activity. 8/23/2012 Maria Carmela L. Domocmat
  • 161. The marble-in-a-cage valve took up a lot of space, pressing on other body parts, so valve- makers sought a flatter design. • invented in 1977 • still in use today, rely on a disc that flips open "like a toilet seat," • When open, it also allows more blood through than the ball design did. http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 162. The most common mechanical valve in use today is this double- door design first implanted in the 1970s, made of carbon-based material with two flaps that open and close with the pumping of blood. Mechanical valves are durable and long-lasting, but because they can cause dangerous blood clots to form, patients must take blood thinners such as warfarin for the rest of their lives. That, in turn, increases the risk of stroke. http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 163. To avoid the risk of blood clots, Parisian doctor Alain Carpentier developed pig valves, first implanted in 1965. Valve-makers use the chemical glutaraldehyde, a common tissue stabilizer used in laboratories and embalming, to sterilize and inactivate the tissue so the patient's immune system won't attack it. http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 164. Today, many valves are made from cows, with tissue mounted in a wire frame covered with Dacron fabric, a design around since the 1980s. Cutting leaflets out of the sac that surrounds a cow's heart, valve-makers can make any required shape or size; they can also use chemicals to make the tissue less likely to attract the calcium that can harden a valve. http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 165. Open-heart surgery is not an option for many patients of fragile health, so researchers designed this collapsible valve—available since 2007 in Europe, but not yet approved in the U.S.—that can be slipped into an artery without cutting open the chest. It scrunches down to pencil- width so a surgeon can thread it from a blood vessel in the leg up to the heart, then use a balloon to inflate it, pushing the old valve out of the way. Fluoroscopy and TAVI Procedure.flv http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 166. Sometimes a whole new valve is unnecessary, and a surgeon can use a ring like this to restructure the faulty valve. "Repair is definitely a lot better," Yoganathan says. "You still maintain a lot of the natural function." According to the Mayo Clinic, the original valve better resists infection, does not require blood thinners and generally means a longer life expectancy. Yoganathan predicts more repair devices will be available in the future. http://www.scientificamerican.com/article.cfm?id=artificial-heart-valves 8/23/2012 Maria Carmela L. Domocmat
  • 167. 8/23/2012 Maria Carmela L. Domocmat
  • 168. MITRAL STENOSIS MITRAL REGURGITATION HF s/s Chronic mitral pulse - weak , irregular regurgitation - often Increase intensity of S1 asymptomatic diastolic rumble/ diastolic Acute mitral regurgitation murmur severe CHF atrial dysrhythmias Holosystolic or pansystolic murmur Pulse - regular or irregular
  • 169. AORTIC STENOSIS AORTIC REGURGITATION asymptomatic s/s of LVF s/s LVF Diastolic murmur Angina pectoris Austin flint murmur low pulse pressure (30 mm Hg Watson's water hammer pulse Corrigan’s pulse or less) De Musset’s sign systolic murmur Increased pulse pressure Thrill/ Vibration Hill’s sign Gallavardin phenomenon Pistol shot femoral pulse (Traube's sign) Duroziez’s sign Quincke’s pulse
  • 170. TRICUSPID REGURGITATION TRICUSPID STENOSIS Holosystolic / Pansystolic Rumbling or blowing mid- murmur in tricuspid area diastolic murmur along L sternal border s/s RHF
  • 171. Echocardiography (2D echo) Electrocardiography (ECG) cardiac catheterization with angiography CXR- RV
  • 172. STENOSIS REGURGITATION Treat CHF Treat CHF Mitral valve replacement Mitral valve replacement Valvuloplasty (balloon) Valvuloplasty Antibiotic prophylaxis (annuloplasty) therapy Anticoagulants Treat anemia
  • 173. Antibiotic prophylaxis Treat HF and dysrhythmias Aortic valve replacement One- or two-balloon percutaneous aortic valvuloplasty 8/23/2012 Maria Carmela L. Domocmat
  • 174. Treat left sided HF Valvuloplasty Valve replacement 8/23/2012 Maria Carmela L. Domocmat