Valvular Heart Disease

1. Valvular Heart Disease Dr.Isazadehfar

2. Types • Mitral Stenosis • Mitral Regurgitation • Mitral Valve Prolapse • Aortic Stenosis • Aortic regurgitation • Tricuspid valve is affected infrequently • Tricuspid stenosis – causes Rt HF • Tricuspid regurgitation –causes venous overload

4. Rheumatic Heart Disease • Inflammatory process that may affect the myocardium, pericardium and or endocardium • Usually results in distortion and scarring of the valves

5. Subjective symptoms Prior history of rheumatic fever General malaise Pain – may or may not be present Objective symptoms Temperature Murmurs Dyspnea polyarthritis Rheumatic Heart Disease, cont.

6. Rheumatic Heart Disease • Diagnosis • H/P • WBC and ESR • C-reactive protein • Cardiac enzymes • EKG • Chest x-ray • Echo • Cardiac cath • Cardiac output

7. Rheumatic Heart Disease • Nursing Care • Vital signs • Rest and quiet environment • Give antibiotics, digitalis, and diuretics • Provide adequate nutrition • Monitor I/O • Explain treatment and home care

8. Cardiac Physiology Systole AV/PV – opens S1-S2 MV/TV – closes Diastole AV/PV – closes S2-S1 MV/TV – opens

9. Cardiac Physiology

11. Cardiac Physiology Regurg/ Insuff – leaking (backflow) of blood across a closed valve Stenosis – Obstruction of (forward) flow across an openedvalve SystoleAV/PV – opens-------Aortic Stenosis S1-S2 MV/TV – closes------Mitral Regurg DiastoleAV/PV – closes------Aortic Regurg S2-S1MV/TV – opens-------Mitral Stenosis These concepts are set in stone, it can’t occur any other way, It would be anatomically impossible

12. Cardiac Anatomy

13. Mitral Stenosis • Usually results from rheumatic carditis • Is a thickening by fibrosis or calcification • Can be caused by tumors, calcium and thrombus • Valve leaflets fuse and become stiff and the cordae tendineae contract • These narrows the opening and prevents normal blood flow from the LA to the LV • LA pressure increases, left atrium dilates, PAP increases, and the RV hypertrophies • Pulmonary congestion and right sided heart failure occurs • Followed by decreased preload and CO decreases

14. Mitral Stenosis, cont. • Mild – asymptomatic • With progression – dyspnea, orthopneas, dry cough, hemoptysis, and pulmonary edema may appear as hypertension and congestion progresses • Right sided heart failure symptoms occur later • S/S • Pulse may be normal to A-Fib • Apical diastolic murmur is heard

15. Etiology of Mitral Stenosis • Rheumatic heart disease: 77-99% of all cases • Infective endocarditis: 3.3% • Mitral annular calcification: 2.7%

16. Mitral Stenosis

17. MS Pathophysiology • Progressive Dyspnea (70%):LA dilation  pulmonary congestion (reduced emptying) • worse with exercise, fever, tachycardia, and pregnancy • Increased Transmitral Pressures: Leads to left atrial enlargement and atrial fibrillation. • Right heart failure symptoms: due to Pulmonary venous HTN • Hemoptysis: due to rupture of bronchial vessels due to elevated pulmonary pressure

18. Mitral Stenosis

19. Heart Sounds in MS • Diastolic murmur: • Low-pitched diastolic rumble most prominent at the apex. • Heard best with the patient lying on the left side in held expiration • Intensity of the diastolic murmur does not correlate with the severity of the stenosis

20. Heart Sounds in MS • Loud Opening S1 snap: heard at the apex when leaflets are still mobile  • Due to the abrupt halt in leaflet motion in early diastole, after rapid initial rapid opening, due to fusion at the leaflet tips. • A shorter S2 to opening snap interval indicates more severe disease.

21. Management of MS Serial echocardiography: • Mild: 3-5 years • Moderate:1-2 years • Severe: yearly

22. Mitral Regurgitation • Primarily caused by rheumatic heart disease, but may be caused by papillary muscle rupture form congenital, infective endocarditis or ischemic heart disease • Abnormality prevents the valve from closing • Blood flows back into the right atrium during systole • During diastole the regurg output flows into the LV with the normal blood flow and increases the volume into the LV • Progression is slowly – fatigue, chronic weakness, dyspnea, anxiety, palpitations, cough • May have A-fib and changes of LV failure • May develop right sided failure as well

23. Mitral Regurgitation Physical Exam • Holosystolic Apical Blowing Murmur • Laterally displaced apical impulse • Split S2 (but is obscured by the murmur) • S3 Gallop (increased volume during diastole) • Radiation depends on the etiology

24. Mitral Valve Prolapse • Cause is variable and may be associated with congenital defects • More common in women • Valvular leaflets enlarge and prolapse into the LA during systole • Most are asymptomatic • Some may report chest pain, palpitations or exercise intolerance • May have dizziness, syncope and palpitations associated with dysrhythmias • May have audible click and murmur

25. Mitral Regurgitation -MVP

26. Mitral Regurgitation -MVP

27. Mitral Regurgitation -MVP Diagnosis and Treatment • Echo 2D/Color • B-Blockers (hyperadrenergic symptoms, Palpitations) • Aspirin (TIAs without etiology) • SBE Prophylaxis (only if associated with MR) • Severe Symptomatic MR – same as chronic MR

28. Aortic Stenosis • Valve becomes stiff and fibrotic, impeding blood flow with LV contraction • Results in LV hypertrophy, increased O2 demands, and pulmonary congestion • Causes – rheumatic fever, congenital, arthrosclerosis • Atherosclerosis and calcification is primary cause in the elderly • Complications – right sided heart failure, pulmonary edema, and A-fib • S/S – Early: dyspnea, angina, syncope Late: marked fatigue, debilitation, and peripheral cyanosis, crescendo- decrescendo murmur is heard

30. Aortic Stenosis Physical Exam • Harsh Systolic Ejection Murmur – late peaking • S4 gallop (from LVH) • Sustained Bifid LV impulse (from LVH) • Pulsus Parvus et Tardus (Carotid Impulse) • Heart sounds- soft and split second heart sound

31. Presentation of Aortic Stenosis • Syncope: (exertional) • Angina: (increased myocardial oxygen demand; demand/supply mismatch) • Dyspnea: on exertion due to heart failure (systolic and diastolic) • Sudden death

32. Aortic Stenosis

33. Echo Surveillance • Mild: Every 5 years • Moderate: Every 2 years • Severe: Every 6 months to 1 year

34. Summary • Disease of aging • Look for the signs on physical exam • Echocardiogram to assess severity • Asymptomatic: Medical management and surveillance • Symptomatic: AoV replacement (even in elderly and CHF)

35. Aortic Regurgitation • Aortic valve leaflets do not close properly during diastole • The valve ring that attaches to the leaflets may be dilated, loose, or deformed • The ventricle dilates to accommodate the ↑ blood volume and hypertrophies • Causes: infective endocarditis, congenital, hypertension, Marfan’s • May remain asymptomatic for years • Develop dyspnea, orthopnea, palpitations, ,and angina • May have ↑ systolic pressure with bounding pulse • Have a high pitch, blowing, decrescendo diastolic murmur

36. Etiology of Acute AR • Endocarditis • Aortic Dissection • Physical Findings: • Wide pulse pressure • Diastolic murmur • Florid pulmonary edema

37. Aortic Regurg – pathophysiology

38. Aortic Regurgitation

39. Progressive Symptoms include: - Dyspnea: exertional, orthopnea, and paroxsymal nocturnal dyspnea • Nocturnal angina: due to slowing of heart rate and reduction of diastolic blood pressure • Palpitations: due to increased force of contraction

40. Aortic Regurgitation Physical Exam • Diastolic Decrescendo Blowing Murmur at the left sternal border • Hyperdynamic LV apical impulse • Bounding Pulses • S4, S3 Gallop-advanced AI • Apical Rumble – “Austin Flint Murmur” (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate • Systolic ejection murmur: due to increased flow across the aortic valve

41. Assessment for Valve Dysfunction • Subjective symptoms • Fatigue • Weakness • General malaise • Dyspnea on exertion • Dizziness • Chest pain or discomfort • Weight gain • Prior history of rheumatic heart disease

42. Assessment, cont. • Objective symptoms • Orthopnea • Dyspnea, rales • Pink-tinged sputum • Murmurs • Palpitations • Cyanosis, capillary refill • Edema • Dysrhythmias • Restlessness

43. Diagnosis • History and physical findings • EKG • Chest x-ray • Cardiac cath • Echocardiogram

44. Medical Treatment • Nonsurgical management focuses on drug therapy and rest • Diuretic, beta blockers, digoxin, O2, vasodilators, prophylactic antibiotic therapy • Manage A-fib, if develops, with conversion if possible, and use of anticoagulation

45. Interventions • Assess vitals, heart sounds, adventitious breath sounds • O2 as prescribed • Emotional support • Give medications • I/O • Weight • Check for edema • Explain disease process, provide for home care with O2, medications

46. Surgical Management of Valve Disease • Mitral Valve • Commissurotomy • Mitral Valve Replacement • Balloon Valvuloplasty • Aortic Valve Replacement

47. Mechanical Valve

48. Mechanical Valve

49. Porcine Valve

50. Tissue Valve