Nursing Care of Clients with Valvular Disorders


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Presentation of Nursing Care for Clients with Valvular heart disorders: Mitral stenosis, mitral regurgitation/ insufficiency, Mitral valve prolapseAortic stenosis, aortic regurgitation/ insufficiency, Tricuspid stenosis, tricuspid regurgitation

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Nursing Care of Clients with Valvular Disorders

  1. 1. Maria Carmela L. Domocmat, RN, MSNInstructor, School of NursingNorthern Luzon Adventist College
  2. 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 valves8/23/2012 Maria Carmela L. Domocmat
  3. 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. 4. 8/23/2012 Maria Carmela L. Domocmat
  5. 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 aorta8/23/2012 Maria Carmela L. Domocmat
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  7. 7. 8/23/2012 Maria Carmela L. Domocmat
  8. 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. 8/23/2012 Maria Carmela L. Domocmat
  9. 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. 8/23/2012 Maria Carmela L. Domocmat
  10. 10. 1 Heart Valves, ana phy.flv8/23/2012 Maria Carmela L. Domocmat
  11. 11. DISORDERS OF THE MITRAL DISORDERS OF THE AORTIC VALVE VALVE mitral valve prolapse aortic regurgitation mitral regurgitation aortic stenosis mitral stenosisTricuspid and pulmonic valve disorders usually with fewer symptoms and complications.8/23/2012 Maria Carmela L. Domocmat
  12. 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. 13. 8/23/2012 Maria Carmela L. Domocmat
  14. 14. Valvular stenosis Valvular insufficiency8/23/2012 Maria Carmela L. Domocmat
  15. 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 reduced8/23/2012 Maria Carmela L. Domocmat
  16. 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. 17. 8/23/2012 Maria Carmela L. Domocmat
  18. 18. Mitral Valve Prolapse Mitral Regurgitation Mitral Valve Stenosis Aortic Regurgitation Aortic Stenosis Tricuspid Regurgitation8/23/2012 Maria Carmela L. Domocmat
  19. 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 fibrosis8/23/2012 Maria Carmela L. Domocmat
  20. 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 systole8/23/2012 Maria Carmela L. Domocmat
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  22. 22. an obstruction of blood flowing from the left atrium into the left ventricle.8/23/2012 Maria Carmela L. Domocmat
  23. 23. 8/23/2012 Maria Carmela L. Domocmat
  24. 24. 8/23/2012 Maria Carmela L. Domocmat
  25. 25. most common cause rheumatic valvulitis rheumatic endocarditis other causes malignant carcinoid, SLE, RA8/23/2012 Maria Carmela L. Domocmat
  26. 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. 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 fails8/23/2012 Maria Carmela L. Domocmat
  28. 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. 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 PND8/23/2012 Edema Carmela L. Domocmat Anorexia Maria Ascites Fatigue NVE
  30. 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 infections8/23/2012 Maria Carmela L. Domocmat
  31. 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 dysrhythmias8/23/2012 Maria Carmela L. Domocmat
  32. 32. Echocardiography used to diagnose mitral stenosis used to determine the severity Electrocardiography (ECG) cardiac catheterization with angiography8/23/2012 Maria Carmela L. Domocmat
  33. 33. Antibiotic prophylaxis therapy to prevent recurrence of infections Treat CHF Anticoagulants to decrease the risk developing atrial thrombus Treat anemia8/23/2012 Maria Carmela L. Domocmat
  34. 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 replacement8/23/2012 Maria Carmela L. Domocmat
  35. 35. 8/23/2012 Maria Carmela L. Domocmat
  36. 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. 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 calcification8/23/2012 Maria Carmela L. Domocmat
  38. 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. 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 RV8/23/2012 Maria Carmela L. Domocmat
  40. 40. Due to myxomatous degeneration, whichcuases stretching of the leaflets and chordaetendineae Chronic RHD CAD Infective endocarditis Meds and penetrating and nonpenetratingtrauma8/23/2012 Maria Carmela L. Domocmat
  41. 41. Mitral Valve Regurgitation ana phy.flv8/23/2012 Maria Carmela L. Domocmat
  42. 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 /edema8/23/2012 Maria Carmela L. Domocmat Orthopnea PND Dyspnea
  43. 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. 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 andusually accompanied by a thrill a heart murmur occurring throughout systole. Pulse - regular and of good volume, or it maybe irregular as a result of extrasystolic beats oratrial fibrillation.8/23/2012 Maria Carmela L. Domocmat
  45. 45. Echocardiography used to diagnose monitor the progression8/23/2012 Maria Carmela L. Domocmat
  46. 46. CHF MGMT SURGICAL INTERVENTION Digitalis Mitral valve replacement Diuretics Valvuloplasty Vasodilators (annuloplasty) Diet Mitral Valve Regurgitation treatment.flv Anticoagulants8/23/2012 Maria Carmela L. Domocmat
  47. 47. 8/23/2012 Maria Carmela L. Domocmat
  48. 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
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  51. 51. congenital leaflet malformations abnormal number of leaflets (i.e., one or two rather than three) rheumatic endocarditis RF cusp calcification of unknown cause8/23/2012 Maria Carmela L. Domocmat
  52. 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. 53. Aortic Stenosis8/23/2012 Maria Carmela L. Domocmat
  54. 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 LAH8/23/2012 Maria Carmela L. Domocmat
  55. 55. Increased pulmonary pressure Pulmonary Increased RV pressure edema Orthopnea dyspnea RVH RVF Edema Ascites Anorexia Fatigue NVE8/23/2012 Maria Carmela L. Domocmat
  56. 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 flow8/23/2012 Maria Carmela L. Domocmat
  57. 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 LV8/23/2012 Maria Carmela L. Domocmat
  58. 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 regurgitation8/23/2012 Maria Carmela L. Domocmat
  59. 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. 60. 8/23/2012 Maria Carmela L. Domocmat
  61. 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. 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 replacement8/23/2012 Maria Carmela L. Domocmat
  63. 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. 64. 8/23/2012 Maria Carmela L. Domocmat
  65. 65. 8/23/2012 Maria Carmela L. Domocmat
  66. 66. 8/23/2012 Maria Carmela L. Domocmat
  67. 67. Pathophysiology Etiologic factors Incompetent aortic valve Regurgitation of blood from systemic circulation + blood form LA increases LV pressure LVH LVF RVF8/23/2012 Maria Carmela L. Domocmat
  68. 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. 69. Diastolic murmur Austin flint murmur Watsons water hammer pulse Corrigan’s pulse Widened pulse pressure Hill’s sign8/23/2012 Maria Carmela L. Domocmat
  70. 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. 71. Watsons 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 patients head, with the arm perpendicular to the supine patient. 8/23/2012 Maria Carmela L. Domocmat
  72. 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. Maria Carmela L. Domocmat
  73. 73. Hill’s sign systolic blood pressure is higher in the legs than in the arms(> 20mmHg) . Pistol shot femoral pulse (Traubes sign) short, loud, snapping sounds with each pulse with auscultation over the femoral, brachial, or radial pulse. a pulse that sounds like a pistol shot8/23/2012 Maria Carmela L. Domocmat
  74. 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. 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; QUINCKES PULSE.wmv 4 Quinckes pulse.avi.flv8/23/2012 Maria Carmela L. Domocmat
  76. 76. Diagnosis may be confirmed Echocardiogram radionuclide imaging ECG Magnetic resonance imaging cardiac catheterization8/23/2012 Maria Carmela L. Domocmat
  77. 77. antibiotic prophylaxis Before the patient undergoes invasive or dental procedures to prevent endocarditis Treat HF and dysrhythmias8/23/2012 Maria Carmela L. Domocmat
  78. 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. 79. 8/23/2012 Maria Carmela L. Domocmat
  80. 80. a disorder in which the hearts 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. Maria Carmela L. Domocmat
  81. 81. Infective endocarditis- drug abusers RVF/LVF Rheumatic Heart disease RV infarction Ebsteins anomaly8/23/2012 Maria Carmela L. Domocmat
  82. 82. Ebsteins 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 rare8/23/2012 Maria Carmela L. Domocmat
  83. 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 pulsation8/23/2012 Maria Carmela L. Domocmat
  84. 84. 8/23/2012 Maria Carmela L. Domocmat
  85. 85. Tricuspid regurgitation is a disorder involving backflow of blood from RV to RA duringcontraction of RV . The most common cause of tricuspid regurgitation is not damage tothe valve itself but enlargement of the RV, which may be a complication of any disorderthat causes RVHF. 8/23/2012 Maria Carmela L. Domocmat
  86. 86. ECG- RV and RA enlargement CXR- RV enlargement with obliteration of the retrosternal space on lateral view8/23/2012 Maria Carmela L. Domocmat
  87. 87. 8/23/2012 Maria Carmela L. Domocmat
  88. 88. Narrowing of tricuspid valve orifice due to commissual fusion and fibrosis8/23/2012 Maria Carmela L. Domocmat
  89. 89. Usually follows RF Commonly assoc with diseases of mitral valve8/23/2012 Maria Carmela L. Domocmat
  90. 90. Rumbling or blowing mid-diastolic murmur along L sternal border8/23/2012 Maria Carmela L. Domocmat
  91. 91. Treat left sided HF Valvuloplasty Valve replacement8/23/2012 Maria Carmela L. Domocmat
  92. 92. Educate about Diagnosis progressive nature of valvular heart disease treatment plan report any new symptoms or changes in symptoms8/23/2012 Maria Carmela L. Domocmat
  93. 93. 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
  94. 94. 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
  95. 95. 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 symptoms8/23/2012 Maria Carmela L. Domocmat
  96. 96. 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
  97. 97. VS : HR, BP RR measured and compared with previous data for any changes. Auscultate heart and lung sounds Palpate peripheral pulses8/23/2012 Maria Carmela L. Domocmat
  98. 98. Assess s/s HF fatigue, dyspnea with exertion, increase in coughing, hemoptysis, multiple respiratory infections, orthopnea, or PND8/23/2012 Maria Carmela L. Domocmat
  99. 99. 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 pectoris8/23/2012 Maria Carmela L. Domocmat
  100. 100. Peiop care - surgical valve replacement or valvuloplasty8/23/2012 Maria Carmela L. Domocmat
  101. 101. VALVULOPLASTY8/23/2012 Maria Carmela L. Domocmat
  102. 102. 8/23/2012 Maria Carmela L. Domocmat
  103. 103. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty8/23/2012 Maria Carmela L. Domocmat
  104. 104. 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 chordae8/23/2012 Maria Carmela L. Domocmat
  105. 105. Most require general anesthesia cardiopulmonary bypass Some can be performed in the cath lab Percutaneous partial cardiopulmonary bypass8/23/2012 Maria Carmela L. Domocmat
  106. 106. 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, cardio8/23/2012 Maria Carmela L. Domocmat
  107. 107. 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
  108. 108. most common valvuloplasty the procedure performed to separate the fused leaflets.8/23/2012 Maria Carmela L. Domocmat
  109. 109. Commissurotomy is a special form of valvuloplasty. Commissurotomy is used when theleaflets of the valve become stiff and actually fuse together at the base, which is the ringportion (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 andshut fully. 8/23/2012 Maria Carmela L. Domocmat
  110. 110. 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
  111. 111. CLOSED COMMISSUROTOMY Balloon Valvuloplasty OPEN COMMISSUROTOMY8/23/2012 Maria Carmela L. Domocmat
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  113. 113. 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
  114. 114. 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 stenosis8/23/2012 Maria Carmela L. Domocmat
  115. 115. in cath lab local anesthetic remain in hospital 24 to 48 hours postop8/23/2012 Maria Carmela L. Domocmat
  116. 116. 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 surgery8/23/2012 Maria Carmela L. Domocmat
  117. 117. Types Mitral balloon valvuloplasty Aortic balloon valvuloplasty8/23/2012 Maria Carmela L. Domocmat
  118. 118. 8/23/2012 Maria Carmela L. Domocmat
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  120. 120. 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 orifice8/23/2012 Maria Carmela L. Domocmat
  121. 121. 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
  122. 122. 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 op8/23/2012 Maria Carmela L. Domocmat
  123. 123. 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 sites8/23/2012 Maria Carmela L. Domocmat
  124. 124. CLOSED COMMISSUROTOMY Balloon Valvuloplasty OPEN COMMISSUROTOMY8/23/2012 Maria Carmela L. Domocmat
  125. 125. 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 repaired8/23/2012 Maria Carmela L. Domocmat
  126. 126. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty8/23/2012 Maria Carmela L. Domocmat
  127. 127. 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
  128. 128. 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
  129. 129. Annuloplasty ring8/23/2012 Maria Carmela L. Domocmat
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  133. 133. Damage to cardiac valve leaflets may result from stretching, shortening, or tearing. Types: removal of the extra tissue tucked leaflet plication leaflet resection8/23/2012 Maria Carmela L. Domocmat
  134. 134. 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
  135. 135. Image of the aortic leaflets after correction of the prolapse using free edge plicationwith prolene 6/0 sutures. 8/23/2012 Maria Carmela L. Domocmat
  136. 136. 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
  137. 137. Repair of a cardiac valve Types Commissurotomy Annuloplasty Chordoplasty8/23/2012 Maria Carmela L. Domocmat
  138. 138. 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
  139. 139. 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
  140. 140. 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, a final saline test confirms correction of prolapse.* 8/23/2012 Maria Carmela L. Domocmat
  141. 141. 8/23/2012 Maria Carmela L. Domocmat
  142. 142. 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 thoracotomy8/23/2012 Maria Carmela L. Domocmat
  143. 143. 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.flv8/23/2012 Maria Carmela L. Domocmat
  144. 144. 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
  145. 145. Two types of valve prostheses may be used: mechanical valves Tissue (i.e., biologic) valves8/23/2012 Maria Carmela L. Domocmat
  146. 146. 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
  147. 147. MECHANICAL VALVES8/23/2012 Maria Carmela L. Domocmat
  148. 148. 8/23/2012 Maria Carmela L. Domocmat
  149. 149. 8/23/2012 Maria Carmela L. Domocmat
  150. 150. long-term anticoagulation with warfarin is required Thromboemboli are significant complications associated with mechanical valves8/23/2012 Maria Carmela L. Domocmat
  151. 151. 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
  152. 152. 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 thrombi8/23/2012 Maria Carmela L. Domocmat
  153. 153. 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 replacements8/23/2012 Maria Carmela L. Domocmat
  154. 154. 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 pattern8/23/2012 Maria Carmela L. Domocmat
  155. 155. 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
  156. 156. 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
  157. 157. 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
  158. 158. 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 flowaround the ball. However, the ball slows blood flow to below a normal rate, and people withthese valves could not perform strenuous activity. 8/23/2012 Maria Carmela L. Domocmat
  159. 159. • 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. Maria Carmela L. Domocmat
  160. 160. 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. Maria Carmela L. Domocmat
  161. 161. 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 patients immune system wont attack it. Maria Carmela L. Domocmat
  162. 162. 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 cows 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. Maria Carmela L. Domocmat
  163. 163. 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 Maria Carmela L. Domocmat
  164. 164. 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. Maria Carmela L. Domocmat
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  166. 166. 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
  167. 167. 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 Watsons 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 (Traubes sign) Duroziez’s sign Quincke’s pulse
  168. 168. TRICUSPID REGURGITATION TRICUSPID STENOSIS Holosystolic / Pansystolic Rumbling or blowing mid- murmur in tricuspid area diastolic murmur along L sternal border s/s RHF
  169. 169. Echocardiography (2D echo)Electrocardiography (ECG)cardiac catheterization with angiographyCXR- RV
  170. 170. STENOSIS REGURGITATION Treat CHF Treat CHF Mitral valve replacement Mitral valve replacement Valvuloplasty (balloon) Valvuloplasty Antibiotic prophylaxis (annuloplasty) therapy Anticoagulants Treat anemia
  171. 171. Antibiotic prophylaxis Treat HF and dysrhythmias Aortic valve replacement One- or two-balloon percutaneous aortic valvuloplasty8/23/2012 Maria Carmela L. Domocmat
  172. 172. Treat left sided HF Valvuloplasty Valve replacement8/23/2012 Maria Carmela L. Domocmat