A 52-year-old woman presents with gradually worsening shortness of breath over 2 years and now requires 2 pillows at night. On examination, she has an apical diastolic murmur. This suggests she has valvular heart disease, likely mitral stenosis given the murmur location and symptoms. Mitral stenosis narrows the opening between the left atrium and ventricle, causing shortness of breath and difficulty sleeping flat. Surgical options may include balloon valvuloplasty or valve replacement depending on severity.

1. CASE SENARIO….
• A 52-year-old woman presents with gradually
increasing dyspnoea on exertion over the past 2 years.
Recently she has required 2 pillows at night to alleviate
dyspnoea. On examination, she has an apical
diastolic murmur.

2. VALVULAR
HEART
DISEASES
MODERATOR: PRESENTER:
MR.L GOPICHANDRAN Esther Mary Mathew
LECTURER M.SC. I YEAR
CON,AIIMS CON,AIIMS

3. • To explain the basic anatomy of valves
• To discuss the epidemiology of valvular problems
• To explain different types of valvular problems
• To describe various causes of valvular problems
• To explain sign and symptom of valvular disorders
• To describe management of patient with valvular
disorders
• To explain about the valve replacement
• To explain the nursing management

4. INTRODUCTION
Valvular heart disease occurs when heart valves fail to
open and/or close properly.
Valvular heart disease is categorized under structural
heart disease .
Associated with malfunctioning of single or more heart
valves.
Left untreated, severe valve disease may lead to
congestive heart failure and premature death.

5. HEART VALVES
•Maintain ‘one- way’ blood flow through the heart.

6. HEART VALVES
The four heart valves make sure that blood always
flows freely in a forward direction and that there is
no backward leakage.

7. Any disease of these valves is called valvular
heart disease!

8. PARTS OF HEART VALVE

9. PARTS OF HEART VALVE
• Annulus: a (fibrous) ring like 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
• 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.

10. EPIDEMIOLOGY
 RHD remains the leading cause of valvular disease in
developing countries. It has been estimated that 79%
of the 15.6 to 19.6 million people alive with RHD today
live in developing countries
Over 2.5 million people in India are suffering from
Rheumatic Heart Disease (RHD) which involves
valvular dysfunction.

11. EPIDEMIOLOGY
Aortic stenosis approximately - 3% of people over age 75,
and 4% percent of people over age 85. It is the most
common valvular heart disease in the developed world.
2% of the population is having mitral regurgitation, common
in elderly.
Mitral stenosis most common valvular
heart disease in pregnancy.

12. CAUSES OF VALVULAR
DISORDERS
 Congenital heart disease
 Rheumatic heart disease
Infections – bacterial endocarditis
 Heart attack – damage to the heart muscle, papillary
muscles
 Weakening of supporting structures of the heart

13. TYPES OF VALVULAR HEART
DISEASE
Classified on the basis of :
1. Duration of dysfunction:
Acute and chronic
2.Nature of valvular dysfunction
Stenosis and regurgitation
3. Degree of dysfunction :
NYHA degree of cardiac dysfunction

14. TYPES OF VALVE DISEASE

15. VALVULAR STENOSIS
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 (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

16. VALVULAR REGURGITATION
LEAKAGE OR BACKFLOW OF BLOOD RESULTS FROM
INCOMPLETE CLOSURE OF THE VALVE
 Due to: scarring and retraction of valve leaflets
Or
- Weakening of supporting structures
Effects:
Causes the to pump the same blood twice (as the blood comes
back into the chamber)
 The dilates to accommodate more blood
 Ventricular dilation and hypertrophy  eventually leads to
heart failure

17. VALVULAR HEART DISEASE
1. Mitral Stenosis
2. Mitral regurgitation
3. Aortic Stenosis
4. Aortic regurgitation
5. Tricuspid Stenosis
6. Tricuspid regurgitation
7. Pulmonary Stenosis
8. Pulmonary regurgitation

18. MOST COMMON TYPES
Stenosis Aortic
Regurgitation Mitral

19. MITRAL STENOSIS
 Most common valvular disorder in Rheumatic endocarditis.
 May also be caused by bacterial infection, thrombus
formation, calcification
 Obstruct blood flow from left atrium to the left ventricle

20. MITRAL STENOSIS
NORMAL MITRAL VALVE
FISH MOUTH MITRAL STENOSIS
Mitral stenosis is a disorder in which the mitral valve does
not fully open. This restricts the flow of blood.

21. MITRAL STENOSIS
NORMAL – 4 to 6 cm2
• Mild :- Valve area of 1.6-2.0 cm2
• Moderate :- Valve area of 1-1.5 cm2
• Severe :- Valve area of 1 cm2 or less

22. PATHOPHYSIOLOGY
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
Right-sided
failure
Fatigue

23. CLINICAL MANIFESTATIONS
SYMPTOMS
• Breathlessness, cough (pulmonary congestion)
• Hemoptysis (pulmonary congestion or pulmonary embolism)
• Fatigue (low cardiac output)
• Edema, ascites (right heart failure)
• Palpitation (atrial fibrillation)
• Thromboembolic complications. (Stagnation of blood in left
atrium)

24. CLINICAL MANIFESTATIONS
SIGNS
• Pulse: Weak and irregular due to Atrial fibrillation.
• Mitral facies :(abnormal flushing of the cheeks that occurs from
cutaneous vasodilation)
• Auscultation:- Mid-diastolic murmur (apex)
• Crepitation, pulmonary edema, effusions (raised pulmonary
capillary pressure)

25. INVESTIGATIONS
ECG : Lt atrium enlargement( p mitrale), Rt ventricular
hypertrophy
ECHO : Reduced valve area
Enlarged LA
Reduced rate of diastolic filling
Echo and cardiac catheterization – determines
severity of stenosis

26. MANAGEMENT
Medically
• Anticoagulant (To reduce
the risk of systemic
embolism)
• Digoxin, beta blockers, or
rate limiting calcium
antagonists (To control
ventricular rate in atrial
fibrillation)
• Diuretic (To control
pulmonary congestion)
Surgically
• Mitral balloon
valvuloplasty***
• Mitral valvotomy
• Valve replacement

27. SURGICAL INTERVENTION
• If the patient is symptomatic or in case of severe MS,
surgery is needed.
• Valvuloplasty – open/ closed mitral commissurotomy
(fused commissures of the mitral valve are opened)
• Percutaneous mitral catheter balloon valvuloplasty

28. MITRAL REGURGITATION
• Incomplete closure of mitral valve
• The margins of the valves are unable to close
completely during ventricular systole leading to back
flow of blood from LV into LA
• Causes
Tear, shortening or elongation of
• Valve leaflets
• Chordae tendinae
• Annulus
• Papillary muscles

29. PATHOPHYSIOLOGY
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

30. • Dyspnea
• Fatigue
• Weakness
• Palpitations
• Cough
• Paroxysmal
nocturnal dyspnea
• Lower extremity
edema
• Syncope
• Atrial fibrillation
• LV enlargement
• Decreased BP
CLINICAL FEATURES

31. MANAGEMENT
Medically
• Vasodilators (e.g. ACE
inhibitors)
• Diuretics
• If atrial fibrillation
presents,
• Anticoagulant
• Digoxin
Surgically
• Mitral valve repair
OR
• Mitral valve
replacement
To treat
mitral valve
prolapse

32. MITRAL VALVE PROLAPSE

33. MITRAL VALVE PROLAPSE
A portion of the mitral valve leaflet balloons back into the
atrium during systole; blood may regurgitate from the left
ventricle to the left atrium.
Many people have no symptoms, others may have
• Fatigue
• Shortness of breath
• Dizziness
• Syncope
• Palpitations
• Chest pain
• Anxiety
• Findings :
• Mitral click – a systolic click
• Murmur indicating mitral regurgitation.

34. AORTIC STENOSIS
• Narrowing of the orifice between the left ventricle and
the aorta.
• Aortic stenosis is one of the most common and most
serious valve disease problems in elderly population.
• Causes
• Congenital leaflet malformations
• Rheumatic endocarditis

36. TYPES
• NORMAL – 3 to 4 cm2
• Mild AS – area >1.5 cm2
• Moderate AS – area 1.0-1.5 cm2
• Severe AS – area <0.8-1.0 cm2

37. PATHOPHYSIOLOGY
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

38. CLINICAL FEATURES
Symptoms;
• Mild or moderate stenosis: usually asymptomatic
• Exertional dyspnea
• Angina (due to demands of
hypertrophied LV)
• Exertional syncope
• Sudden death
• Episodes o acute pulmonary oedema
CARDINAL
SYMPTOMS
CO fails to rise
to meet demand

39. FINDINGS
• Loud, rough systolic crescendo- decrescendo murmur
over the aortic area
• Vibration felt over the base of the heart (caused by
turbulent blood flow)
• ECG and echocardiogram– LV hypertrophy
• Cardiac catheterization – determines severity of
stenosis, traces pressures in the LV and aorta.

40. MANAGEMENT
• Restriction of activities to reduce myocardial O2 demand
• Antibiotic prophylaxis – to prevent endocarditis
• Antiarrhythmics
• Digitalis and diuretics for ventricular failure
• Treat angina – vasodilators
Definitive treatment – surgical replacement of aortic valve
(Ross procedure)
Balloon valvuloplasty (symptomatic patients who are not
surgical candidates)

42. AORTIC REGURGITATION
• Flow of blood back into the LV from the aorta during
diastole.
CAUSES
• Inflammatory lesions of the leaflets
• Endocarditis
• Congenital abnormalities
• A dissecting aneurysm of the aorta

43. PATHOPHYSIOLOGY
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

44. CLINICAL FEATURES
 Signs of LV failure –
 Exertional dyspnea,
 Fatigue,
 orthopnea
 Chest pain, fatigue, head ache
 Feeling of forceful heartbeat in the neck or head
 Arterial pulsations visible or palpable at the carotid or
temporal arteries.

45. SPECIFIC SIGNS IN AR
• Muller’s sign-systolic pulsations of the uvula
• Dancing carotids-prominent carotid pulsations due to
the wide pulse pressure in aortic regurgitation
(corrigan’s sign)
• De- musset’s sign-head nodding sign
• Quincke’s sign- prominent nail bed capillary
pulsations
• Traube’s sign-pistol shots sounds heard over the
femoral arteries and sometimes over the brachial
arteries

46. FINDINGS
High- pitched diastolic murmur at the 2nd/3rd ICS at the
left sternal border
Wide pulse pressure
Water hammer pulse – pulse strikes the finger with a
quick, sharp stroke and then collapses suddenly
Diagnosis – confirmed by ECG, echo, and cardiac
catheterization

47. TRICUSPID VALVE DISEASE
TRICUSPID STENOSIS
• Usually occurs together with aortic or mitral stenosis
• May be due to rheumatic heart disease (<5%)
•  Blood flow from right atrium to right ventricle
  right ventricular output
  Left ventricular filling   co
•  Systemic pressure

48. TRICUSPID STENOSIS
Symptoms :
• symptoms of right-sided heart failure
- Hepatomegaly
- Ascites
- Peripheral edema
- Neck vein engorgement
•  co – fatigue, hypotension

49. Accompanies mitral stenosis and pulmonary
hypertension
• C/F
• Atrial fibrillation
• Hepatic congestion
• Abdominal distention, ascitis
• Generalized edema & weakness
• Low urine out put
• Raised JVP
• Visible veins
• Peripheral edema
TRICUSPID REGURGITATION

50. • Leads to right sided heart failure
• Treatment for CHF
• Surgical management
• Tricuspid valve repair- Annuloplasty
• Tricuspid valve replacement-very rarely done
TRICUSPID REGURGITATION

51. TYPES OF SURGERY
REPAIR :
1. Surgery of choice
2. Mitral and Tricuspid heart disease
3. Lower mortality
4. Don't establish total valve competence.
REPLACEMENT :
1. Mitral ,Aortic and Tricuspid valvular heart disease.
2. Treatment of choice for combined AS and AR.

52. VALVE REPAIR SURGERY
Mitral Commissurotomy (valvulotomy): treatment of
choice for pure MS.
‘Performed to separate the fused leaflets’
• Closed commissurotomy -Does not require CPB
• An open-heart surgery
• Patient is put on a heart-lung bypass machine.
• Calcium deposits and other scar tissue from the valve
leaflets are removed.
• It is used for people where balloon valvotomy is
contraindicated.

53. • Midsternal incision is made, A small hole is cut into
heart, surgeon’s finger or dilator is used to break open
the commissure.
Commissurotomy

54. • Most commonly used for mitral and aortic valve
stenosis.
• Done in patients with high risk for complications with
extensive surgical procedures
• Contraindicated in
• Left atrial or ventricular thrombus
• Severe aortic root dilation
• Significant mitral valve regurgitation

55. • Elongated leaflets
• Leaflet plication
• Leaflet resection
• Holes in the leaflets
• Pericardial patch repair
• Short leaflets
• Most often repaired by chordoplasty

56. • Repair of the chordae tendinae
• Mostly used for mitral valve
• Gore-Tex can be used to create chordae tendinae.

57. • Performed when valvuloplasty is not suitable
• Approached through a median sternotomy or mitral
valve (at times) – right thoracotomy incision

58. • Two types of prosthetic valves :-
• Mechanical valves
• Tissue(biologic) valves

59. • Caged ball valve (Starr-Edwards)
• Tilting disc valve (Medtrionic-Hall)
• Bileaflet valve(St. Jude Medical)
• Trileaflet valve
Caged ball valve Bileaflet valveTilting disc valve

61. • More durable
• Can be used if the patient
has hypercalcemia,
endocarditis or sepsis.
• Do not deteriorate or
become infected as easily
as the tissue valves.
•Life long anticoagulation with
warfarin required.
•Increased risk of thrombo
embolism.
•Not suitable for women of
child bearing age.

62. • These are animal tissue valves: pigs(porcine), cows(bovine).
• Viability is 7-10 yrs.
• Do not generate thrombi. So no need for long term
anticoagulation.
Indications :
• Women of child bearing age
• Others who cannot tolerate long term
anticoagulation.
- patients older than 70yrs
- patients with H/O peptic ulcer disease

63. • Obtained from cadaver tissue donations
• Used for aortic and pulmonic valve replacement
• Aortic valve and a portion of the aorta / pulmonic valve and
a portion of the pulmonary artery are harvested from the
cadaver and stored cryogenically
• Non thrombogenic
• Viability – 10 to 15 years

64. • Patient’s own pulmonic valve and a portion of the
pulmonary artery excised for use as the aortic valve
(aortic valve autograft) –Ross procedure
• Anticoagulation not required as non-thrombogenic
• Viability – more than 20 years
• Most aortic valve auto grafts are double valve replacement
procedures
• Where pulmonic valve is replaced with a homograft

66. • Patients receiving a mechanical heart valve require a
blood thinner, warfarin to prevent blood clots.
• Warfarin works by prolonging clotting time. The drug
must be carefully monitored by taking a blood test
• INR first generation- 2.5-3.5
• The drug is prescribed in a dose to keep the INR within
certain parameters.

70. • A complete assessment of all the systems is
performed & compared with baseline.
• Neurologic status: level of responsiveness, reflexes,
motor & sensory functional status.
• Cardiac status: HR, rhythm, heart sounds,
hemodynamic parameters, chest tube & pacemaker
status.
• Respiratory status: chest movement, breath sounds,
ventilator settings, ABG, O2 saturation.

71. • Peripheral vascular status: peripheral pulses, color of
the skin, mucosa, skin temp, edema.
• Renal function: urine output, specific gravity.
• Fluid-electrolyte: serum electrolyte levels & intake
&output including all drains, and s/s of imbalances.

72. History & physical examination are performed.
Baseline physiologic, psychological & social
information are obtained.
A chest X-ray, ECG, Lab test, Blood typing and cross
matching, & autologous blood donation may be
performed.
Patient’s & family’s learning needs are identified and
addressed as necessary.

73. • Fear R/T surgical procedure, its uncertain outcome, &
threat to well-being.
• Deficient knowledge regarding the surgical procedure
and the post operative course.

74. Reducing fear
• Encourage patient and family to express fears.
• Encourage the patient to describe any concerns
related to surgery.
• Discuss about patient’s fear about pain & post
operative pain management methods.
• Teaching is to be given about post operative exercises.
• Measures are to be taken alleviate undue anxiety

75. Teaching patient self care
• Provide information about hospitalization, surgery-
pre& post operative care, ICU stay, visiting hours,
procedures in critical care unit.
• Patient should also be informed about the expected
duration of stay in hospital, need of follow up,
medications, lifestyle changes needed.

77. IMPAIRED GAS EXCHANGE R/T TRAUMA OF
EXTENSIVE CHEST SURGERY
• Assess the alteration in lung function like hypoxemia,
atelectasis, abnormal lung sounds, work of breathing
etc..
• Monitor ABG
• Position properly for maximum lung expansion.
• Administer O2 therapy.
• Teach deep breathing and coughing.
• Schedule activities to conserve energy.
• Medications for pain to prevent tachypnea

78. Risk for deficient fluid volume and
electrolyte imbalance R/T alteration in
circulating blood volume.
• Carefully assess the intake & output.
• Hemodynamic parameters are compared with I/O & weight
to determine the adequacy of hydration.
• Monitor the serum electrolyte levels and observe for any
s/s of electrolyte imbalance.
• Any imbalances are promptly reported & administer fluids
& electrolytes as prescribed

79. Acute pain R/T chest trauma & pleural
irritation by chest tubes.
• Listen to & observe for the patients verbal & non verbal
cues about pain.
• Accurately record the nature, type, intensity, duration of
pain.
• Administer analgesics as prescribed
• Splint the incision during deep breathing, coughing
exercises.
• Use other non pharmacologic Mx techniques.
• Reassess the pain after interventions.

80. Potential for bleeding R/T
anticoagulant therapy
• Assess s/s of bleeding.
• Assess the patient for high risk for bleeding conditions
like liver disease, kidney disease, severe HTN.
• Obtain coagulation profile-PTT, aPTT, INR etc..
• Institute safety precautions.
• Avoid injury, I/M injections.

81. Knowledge deficit R/T, continuing
care at home and follow up.
Incision site care:
shower daily with warm water and a mild soap & pat dry
the area to keep the incision from becoming infected. Do
not lift anything over 10 pounds for 3 months after
surgery.
Activity :
• patient can return to normal life after a period of 6-8wks.
• Alternate activity with rest periods. Sleep for 8-10 hrs.
• Patient can go for walks (at his own pace), climb steps
slowly. Avoid driving for 6 wks.

82. CONTD…
• Diet- do not take vitamin k rich food(green leafy
vegetables).
• Tell the patients the importance of checking PT and
INR frequently.
• Explain the importance of antibiotic prophylaxis for RF
and also IE.
• Explain the patient the importance of follow up visits.
• Tell the patient to limit activities to prevent exertional
symptoms .

83. CONTD…
• Explain the importance of maintaining personal
hygiene and environmental hygiene.
• Patient should keep distance from people suffering
from URTIs and also from crowded places.
• Patient should report to physician in case of any
recurring symptoms or if any s/s of infection develops.
• Patients with mechanical valves should be told to listen
to the sound produced by the valves and report in
case of any absent sounds or abnormal sounds.

84. HOME CARE
Warfarin diet :
Diet- do not take vitamin k rich food(green leafy vegetables).
The adequate intake level of vitamin K for adult men is 120
micrograms (mcg). For adult women: 90 mcg.
Spinach
Brussels sprouts
Parsley
Green tea
Certain drinks can increase the effect of warfarin, leading to
bleeding problems.
Cranberry juice, Grape juice and green tea
Alcohol

85. SUMMARY
• Basic anatomy of valves
• Epidemiology
• Different types of valvular problems
• Causes
• Pathophysiology
• Sign and symptom
• Management
• Valve replacement
• Nursing management

86. EVALUATION…
• 1. List the causes of valvular heart disease?
• 2. List the signs of aortic regurgitation?
• 3. Explain Ross procedure?

87. CONCLUSION
Valvular heart disease: Assessment of patient is crucial
in imparting care to them. Aortic and mitral valve
associated dysfunctions are common in comparison to
other two valves. surgical repair and replacement of
the valve is the definitive management. Nurses play a
very important role in management of the patient
specially an post –operative period.

88. REFERENCE
1.Brunner,Suddarth.Textbook of medical surgical nursing.13th
ed.New Delhi:Wolters Kluwer India Pvt Ltd,2014,vol 1;p.769-
779.
2.Lewis.Medical surgical nursing.7th ed.New Delhi:Elsevier India
Privated Limited,2011;p.871-878.
3.Vee Pee.A textbook of nursing.6.ed.New Delhi:Vikas medical
publisher,2009;p,867-69.