valvularheartdisease-1223958935203145-9

8/14/2019 valvularheartdisease-1223958935203145-9

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HeartValves


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the valve opening narrowsthe valve leaflets may become fused or thickened that thevalve cannot open freely obstructs the normal flow of blood

EFFECTS: the chamber behind the stenotic valve is subject togreater stress must generate more pressure or workhard to force blood through the narrowed opening

initially, the compensates for the additional workload bygradual hypertrophy and dilation of the myocardium heart failure


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scarring and retraction of valve leaflets or weakening ofsupporting structures incomplete closure of the valve

result to leakage or backflow of blood from the previouschamber

EFFECTS: causes the to pump the same blood twice (as theblood comes back into the chamber)the dilates to accommodate more blood (the usual bloodit needs to pump + regurgitated blood)ventricular dilation and hypertrophy eventually leads to

heart failure


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Congenital heart diseaseRheumatic heart diseaseHeart attack damage to the heart muscle, papillary musclesWeakening of supporting structures of the heartWeakening of the heart muscleInfections bacterial endocarditis


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most common valvular disorderin rheumatic fevermay also be caused by bacterialinfection, thrombusformation, calcificationobstruct blood flow from leftatrium to the left ventricle


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Narrowing of mitral valve

CO

O2/CO2 exchange(fatigue, dyspnea,

orthopnea)

Left ventricularatrophypulmonarycongestion

pulmonarypressure

left atrialpressure

Hypertrophyleft atrium

blood flow toleft ventricle

Right-sidedfailure

Fatigue


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exertional dyspnea and fatigue (most common)orthopnea, paroxysmal nocturnal dyspnea, cough,hemoptysiscyanosis

Right-sided heart failure distended neck veins,peripheral edema, hepatomegaly, abdominal discomfortAuscultation: S1 followed by an opening snap--created by

forceful opening of mitral valve

- rumbling diastolic murmur (apex)CXR- left atrial enlargementECG atrial fibrillation may develop (50-80% of pts.)

- pulses becomes irregular & faint, BPEchocardiogram (2D Echo) most sensitive in diagnosis


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Na+ restriction, diuretics to relieve pulmonary congestionbed rest, sitting positionDigitalis improve cardiac contraction, HR, treat atrialfibrillationAnticoagulants (blood thinners) coumadin, aspirin,ticlopidine (Ticlid), Plavix, dipyridamoleSurgical interventions:

Mitral commissurotomy separation or incision of thestenosed valve leaflets at their borders or commissures

Balloon mitral valvuloplastyMitral valve replacement when stenosis is severe


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Balloonmitralvalvuloplas

ty


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incomplete closure of the mitral valverheumatic disease is the predominant causemay also be due to congenital anomaly, infective endocarditis,rupture of papillary muscle following MI


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a leaking mitral valve - Stroke volume, CO- Left atrial hypertrophy

- Pulmonary congestion


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Incomplete closure ofmitral valve

vol. of blood ejected byleft ventricle Left atrial pressure

Right-sided heart failure

Left atrial hypertrophyCO

Pulmonary pressure

Backflow of blood to theleft atrium

Right ventricular

pressure


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Fatigue & weakness due to CO predominant complaintexertional dyspnea & cough pulmonary congestionpalpitations due to atrial fibrillation (occur in 75% of pts.)Right-sided heart failure distended neck veins, edema,ascites, hepatomegalyAuscultation: blowing, high-pitched systolic murmur (apex)

- S1 is diminished- S3 severe regurgitation


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restrict physical activity to prevent fatigue & dyspnea Na+ intake, diuretics relieve congestion

Digitalis, vasodilators promote adequate ventricularemptying and prevent or decrease regurgitation

ACE inhibitors arterial dilation, afterloadSurgery:

- Valvuloplasty (repair or reconstruction)- Valve replacement


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Mitral Valve Prolapse


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when 1 or both of the valve leaflets bulge into the leftatrium 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 & papillarymuscles regurgitation may occurusually asymptomatic

Extra heart sound (Mitral click) an early sign that a valve

leaflet is ballooning into the left atriumfatigue, shortness of breatharrhythmias may develop dizziness, chest pain, dyspnea,palpitations, syncopehigh-pitched late systolic murmur


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Interventions:antibiotic prophylaxis to prevent endocarditis

If w/ dysrhythmia avoid caffeine, alcohol, stopsmokinganti-arrhythmic drugs

for chest pain nitrates, calcium channel blockers,

beta blockerssurgery not indicated


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may be due to rheumatic heart disease, atherosclerosis,congenital valvular disease or malformationsnarrowing 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 bloodthrough the narrowed opening


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Aortic Stenosis


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Aortic

Stenosis


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Stiffening/Narrowing ofAortic Valve

Incomplete emptying of

left atrium

Left ventricular hypertrophy

Pulmonary congestionCompression of

coronary arteries

Right-sided heart failure

CO

MyocardialO2 needs

Myocardial ischemia(chest pain)

O2 supply


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fatigue & exertional dyspnea 1st symptoms due to CO

and pulmonary congestion chest pain (angina) most common symptom

- occurs during exercise due to inability of the heart toincrease coronary blood flow to cardiac muscle

exertional syncope , vertigo, periods of confusion -- COweakness, 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


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restrict activitydigitalisNa+ restriction, diuretics

Nitroglycerin for chest painSurgical:

Balloon aortic valvuloplastyAortic valve replacement if not done - poor prognosis


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may be due torheumatic fever most common causeother causes:connective tissuedisease (Marfanssyndrome), severehypertension,congenital anomaly


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Incomplete closure of theaortic valve

Backflow of blood to Leftventricle

Left ventricularhypertrophy & dilation

Left atrial pressure

Left-sided heart failure

(late stage)

Left atrium hypertrophy

COPulmonary pressure

Right-sided heart failure Right ventricular

pressure


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pt. may remain asymptomatic for years --- heartcompensates by hypertrophy & dilation 1st s/sx- heightened awareness of the heart beat &

palpitations esp. when pt. lies on left lateral positiontachycardia, PVC assoc. w/ left ventricular dilation

bounding pulse, marked carotid artery pulsation, apicalpulse force and volume of contraction of thehypertrophied left ventricleDecompensation occurs (cardiac muscle fatigue)

exertional dyspneachest pain myocardial ischemialeft-heart failure fatigue, orthopnea,

right-heart failure peripheral edema

Auscultation: soft, blowing diastolic murmur


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antibiotic prophylaxis before any invasive or dentalproceduresavoid physical exertion, competitive sportsvasodilators, calcium channel blockers, ACE inhibitors

Aortic valvuloplasty or valve replacement


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usually occurs together w/ aortic or mitral stenosismay 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


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uncommon, may be caused by RF, bacterial endocarditismay also be caused by enlargement of right ventriclean insufficient tricuspid valve allows blood to flow backinto the right atrium venous congestion & rightventricular output blood flow towards the lungs


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may not produce any symptomsmoderate-to-severe tricuspid regurgitation exist, the ff.may result:

Active pulsing in the neck veins

Swelling of the abdomenSwelling of the feet and anklesFatigue, tirednessWeakness

Decreased urine outputon palpation, there may be a lift (beating of enlarged rightventricle)murmur on auscultation


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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 arteryS/Sx:

harsh systolic murmurfatigue, dyspnea on exertion, cyanosispoor weight gain or failure to thrive in infantshepatomegaly, ascites, edema


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a rare condition caused by infective endocarditis,tumors or RF

blood flows back into Right ventricle Right ventricleand atrium hypertrphy symptoms of Right-sidedheart failure


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Valvuloplasty is repair of cardiac valve pt. does not require continuous anti-coagulant medication usually require cardiopulmonary bypass machine

Commissurotomy to separate the fused leafletsBalloon Valvuloplasty performed in the cardiac cath. lab.

- balloon inflated for 10-30 secs., w/ multipleinflations- 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 thecommissure

Open Commissurotomy done w/ direct visualization ofthe valve, thrombus and calcifications may be identified

and removed


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2. Annuloplasty is repair of valve annulus (junction of the valve leafletsand the muscular heart wall)

- narrows the diameter of the valves orifice, useful forvalvular regurgitation

3. Chordoplasty is repair of chordae tendineae- done for mitral valve regurgitation caused by stretched,

torn or shortened chordae tendineae


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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 yrsviability)- 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 valveLong-term anticoagulant therapyAntibiotic prophylaxis


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valvularheartdisease-1223958935203145-9

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