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Valvular Heart Disease
 

Valvular Heart Disease

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    Valvular Heart Disease Valvular Heart Disease Presentation Transcript

    •  
    • Heart Valves
    •  
      • the valve opening narrows
      • the valve leaflets may become fused or thickened that the
      • valve cannot open freely  obstructs the normal flow of blood
      • EFFECTS: the chamber behind the stenotic valve is subject to
      • greater stress  must generate more pressure or work
      • hard to force blood through the narrowed opening
        • initially, the compensates for the additional workload by
        • gradual hypertrophy and dilation of the myocardium  heart failure
      • scarring and retraction of valve leaflets or weakening of
      • supporting structures  incomplete closure of the valve
      • result to leakage or backflow of blood from the previous
      • chamber
      • EFFECTS: causes the to pump the same blood twice (as the
      • blood comes back into the chamber)
        • the dilates to accommodate more blood (the usual blood
        • it needs to pump + regurgitated blood)
        • ventricular dilation and hypertrophy  eventually leads to
        • heart failure
      • Congenital heart disease
      • Rheumatic heart disease
      • Heart attack – damage to the heart muscle, papillary muscles
      • Weakening of supporting structures of the heart
      • Weakening of the heart muscle
      • Infections – bacterial endocarditis
      • most common valvular disorder
      • in rheumatic fever
      • may also be caused by bacterial
      • infection, thrombus
      • formation, calcification
      • obstruct blood flow from left
      • atrium to the left ventricle
    •  
    • Narrowing of mitral valve  CO
      • O2/CO2 exchange
      • (fatigue, dyspnea, orthopnea)
      Left ventricular atrophy pulmonary congestion  pulmonary pressure  left atrial pressure Hypertrophy left atrium  blood flow to left ventricle Fatigue Right-sided failure
      • exertional dyspnea and fatigue (most common)
      • orthopnea, paroxysmal nocturnal dyspnea, cough,
      • hemoptysis
      • cyanosis
      • Right-sided heart failure – distended neck veins,
      • peripheral edema, hepatomegaly, abdominal discomfort
      • Auscultation: S1 followed by an opening snap--created by
      • forceful opening of mitral valve
      • - rumbling diastolic murmur (apex)
      • CXR- left atrial enlargement
      • ECG – atrial fibrillation may develop (50-80% of pts.)
      • - pulses becomes irregular & faint,  BP
      • Echocardiogram (2D Echo) – most sensitive in diagnosis
      • Na+ restriction, diuretics – to relieve pulmonary congestion
      • bed rest, sitting position
      • Digitalis – improve cardiac contraction,  HR, treat atrial
      • fibrillation
      • Anticoagulants (blood thinners) – coumadin, aspirin,
      • ticlopidine (Ticlid), Plavix, dipyridamole
      • Surgical interventions:
        • Mitral commissurotomy – separation or incision of the stenosed valve leaflets at their borders or commissures
        • Balloon mitral valvuloplasty
        • Mitral valve replacement – when stenosis is severe
    • Balloon mitral valvuloplasty
      • incomplete closure of the mitral valve
      • rheumatic disease is the predominant cause
      • may also be due to congenital anomaly, infective endocarditis,
      • rupture of papillary muscle following MI
      • a leaking mitral valve -  Stroke volume,  CO
      • - Left atrial hypertrophy
      • - Pulmonary congestion
    •  
    • Incomplete closure of mitral valve  vol. of blood ejected by left ventricle  Left atrial pressure Right-sided heart failure Left atrial hypertrophy  CO  Pulmonary pressure Backflow of blood to the left atrium  Right ventricular pressure
      • Fatigue & weakness – due to  CO – predominant complaint
      • exertional dyspnea & cough – pulmonary congestion
      • palpitations – due to atrial fibrillation (occur in 75% of pts.)
      • Right-sided heart failure – distended neck veins, edema,
      • ascites, hepatomegaly
      • Auscultation: blowing, high-pitched systolic murmur (apex)
      • - S1 is diminished
      • - S3 –severe regurgitation
      • restrict physical activity – to prevent fatigue & dyspnea
      •  Na+ intake, diuretics – relieve congestion
      • Digitalis, vasodilators – promote adequate ventricular
      • emptying and prevent or decrease regurgitation
      • ACE inhibitors – arterial dilation,  afterload
      • Surgery:
      • - Valvuloplasty (repair or reconstruction)
      • - Valve replacement
    • Mitral Valve Prolapse
      • when 1 or both of the valve leaflets bulge into the left
      • atrium during ventricular contraction
      • more common in women
      • Cause : due to an inherited connective tissue disorder 
      • enlargement of one or both valve leaflets
      • Elongates/stretches the chordae tendinae & papillary
      • muscles  regurgitation may occur
      • usually asymptomatic
      • Extra heart sound (Mitral click) – an early sign that a valve
      • leaflet is ballooning into the left atrium
      • fatigue, shortness of breath
      • arrhythmias may develop – dizziness, chest pain, dyspnea,
      • palpitations, syncope
      • high-pitched late systolic murmur
      • Interventions:
      • antibiotic prophylaxis to prevent endocarditis
      • If w/ dysrhythmia – avoid caffeine, alcohol, stop
      • smoking
      • anti-arrhythmic drugs
      • for chest pain – nitrates, calcium channel blockers,
      • beta blockers
      • surgery not indicated
      • may be due to rheumatic heart disease, atherosclerosis,
      • congenital valvular disease or malformations
      • narrowing of the aortic valve
      •   flow of blood from the left ventricle to the aorta
      •   blood volume and pressure in the left ventricle
      • Left ventricle hypertrophy develops as a
      • compensatory mechanism to continue pumping blood
      • through the narrowed opening
    • Aortic Stenosis
    • Aortic Stenosis
    • Stiffening/Narrowing of Aortic Valve Incomplete emptying of left atrium Left ventricular hypertrophy Pulmonary congestion Compression of coronary arteries Right-sided heart failure  CO  Myocardial O2 needs Myocardial ischemia (chest pain)  O2 supply
      • fatigue & exertional dyspnea – 1 st symptoms – due to  CO
      • and pulmonary congestion
      • chest pain (angina) – most common symptom
      • - occurs during exercise – due to inability of the heart to
      • increase coronary blood flow to cardiac muscle
      • exertional syncope , vertigo, periods of confusion --  CO
      • weakness, orthopnea, PND, pulmonary edema (severe cases)
      • signs of right-sided heart failure –- end-stage symptoms
      • - if untreated, survival rate: 1.5-3 years
      • Auscultation: harsh, rough, mid-systolic murmur
      • restrict activity
      • digitalis
      • Na+ restriction, diuretics
      • Nitroglycerin – for chest pain
      • Surgical:
        • Balloon aortic valvuloplasty
        • Aortic valve replacement – if not done –- poor prognosis
      • may be due to
      • rheumatic fever –
      • most common cause
      • other causes:
      • connective tissue
      • disease (Marfan’s
      • syndrome), severe
      • hypertension,
      • congenital anomaly
    •  
    • Incomplete closure of the aortic valve Backflow of blood to Left ventricle Left ventricular hypertrophy & dilation  Left atrial pressure Left-sided heart failure (late stage) Left atrium hypertrophy  CO  Pulmonary pressure Right-sided heart failure  Right ventricular pressure
      • pt. may remain asymptomatic for years --- heart
      • compensates by hypertrophy & dilation
      • 1st s/sx- heightened awareness of the heart beat &
      • palpitations esp. when pt. lies on left lateral position
      • tachycardia, PVC  assoc. w/ left ventricular dilation
      • bounding pulse , marked carotid artery pulsation ,  apical
      • pulse   force and volume of contraction of the
      • hypertrophied left ventricle
      • Decompensation occurs (cardiac muscle fatigue)
        • exertional dyspnea
        • chest pain – myocardial ischemia
        • left-heart failure – fatigue, orthopnea, PND
        • right-heart failure – peripheral edema
      • Auscultation : soft, blowing diastolic murmur
      • antibiotic prophylaxis before any invasive or dental
      • procedures
      • avoid physical exertion, competitive sports
      • vasodilators, calcium channel blockers, ACE inhibitors
      • Aortic valvuloplasty or valve replacement
      • usually occurs together w/ aortic or mitral stenosis
      • may be due to rheumatic heart disease
      •  blood flow from right atrium to right ventricle
      •   right ventricular output
      •   left ventricular filling   CO
      • blood accumulates in systemic circulation
      •  systemic pressure
      • S/Sx: symptoms of right-sided heart failure
      • - hepatomegaly
      • - peripheral edema
      • - neck vein engorgement
      • -  CO – fatigue, hypotension
      • uncommon, may be caused by RF, bacterial endocarditis
      • may also be caused by enlargement of right ventricle
      • an insufficient tricuspid valve allows blood to flow back
      • into the right atrium  venous congestion &  right
      • ventricular output   blood flow towards the lungs
      • may not produce any symptoms 
      • moderate-to-severe tricuspid regurgitation exist, the ff.
      • may result:
        • Active pulsing in the neck veins
        • Swelling of the abdomen
        • Swelling of the feet and ankles
        • Fatigue, tiredness
        • Weakness
        • Decreased urine output
      • on palpation, there may be a lift (beating of enlarged right
      • ventricle)
      • murmur on auscultation
      • rare, usually congenital in origin
      •  flow of blood to the pulmonary artery due to narrowing
      • blood flows back to right ventricle and right atrium
      • right ventricle hypertrophy to compensate for
      •  blood volume and force blood to the pulmonary artery
      • S/Sx:
        • harsh systolic murmur
        • fatigue, dyspnea on exertion, cyanosis
        • poor weight gain or failure to thrive in infants
        • hepatomegaly, ascites, edema
      • a rare condition caused by infective endocarditis,
      • tumors or RF
      • blood flows back into Right ventricle  Right ventricle
      • and atrium hypertrphy  symptoms of Right-sided
      • heart failure
      • Valvuloplasty is repair of cardiac valve
        • pt. does not require continuous anti-coagulant medication
        • usually require cardiopulmonary bypass machine
      • Commissurotomy – to separate the fused leaflets
          • Balloon Valvuloplasty – performed in the cardiac cath. lab.
      • - balloon inflated for 10-30 secs., w/ multiple inflations
      • - common used for mitral and aortic stenosis
          • Closed surgical valvuloplasty – done in the OR under GA
      • - midsternal incision, a small hole is cut into the heart,
      • the surgeons finger or a dilator is used to open the
      • commissure
          • Open Commissurotomy – done w/ direct visualization of
          • the valve, thrombus and calcifications may be identified
          • and removed
    • 2. Annuloplasty is repair of valve annulus (junction of the valve leaflets and the muscular heart wall) - narrows the diameter of the valve’s orifice, useful for valvular regurgitation 3. Chordoplasty is repair of chordae tendineae - done for mitral valve regurgitation – caused by stretched, torn or shortened chordae tendineae
    •  
    •  
      • Mechanical valves – Ex. Caged ball valve, Tilting-disk valve
      • - more durable, used for younger pts.
      • - risk of thromboembolism – long-term use of anti-coagulants
      • Tissue or biological valves:
      • - xenografts – porcine or bovine heterografts (7-10 yrs
      • viability)
      • - homografts – from cadaver tissue donations (10-15 yrs)
      • - autografts – excising the pts.’s own pulmonic valve and
      • portion of pulmonary artery for use as the artic valve
      • Long-term anticoagulant therapy
      • Antibiotic prophylaxis
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