Valvular Heart disease
1. 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 reduced
2- 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 “regurgitate
flow.”
Types
1- Mitral stenosis: Progressive
thickening and contracture
of valve cusps wit
narrowing of the orifice and
progressive obstruction to
blood flow
an obstruction of blood flowing
from the left atrium into the left
ventricle.
most common cause:
 rheumatic valvulitis
 rheumatic endocarditis
S/S
Dyspnea on exertion:
 first symptom
 due to pulmonary venous
hypertension
 progressive fatigue
 as a result of low CO
 Hemoptysis
 cough
 repeated respiratory
infections
2- Aortic Stenosis: is
narrowing of the orifice
between the LV and the
aorta. ▪ leaflets of aortic
valve may fuse.
Causes:
 congenital leaflet
malformations
 abnormal number of
leaflets
 rheumatic endocarditis
 RF
 cusp calcification of
unknown cause
3- Aortic regurgitation
S/S
 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 flow
backward (leak) into the right
 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.
Causes
 Endocarditis
 rheumatic heart disease
congenital abnormalities (e.
marfan syndrome)
 Syphilis may produce
aortitis
 dissecting aneurysm
 causes dilation or tearing of
the ascending aorta
 deterioration of an aortic
valve replacement
S/S
 Usually asymptomatic
 Progressive s/s of LVF
 Exertional dyspnea and
fatigue
 breathing difficulties (e.g.,
orthopnea, PND)
4- tricuspid regurgitation
a disorder in which the heart's
tricuspid valve does not close
properly, causing blood to flow
causes stretching of the
upper heart chamber (atrium) leaflets and chordae
when the right lower heart tendinous
chamber contracts.  Chronic RHDCAD
Etiology Infective endocarditis
 Infective endocarditis drug  Meds and penetrating
abusers and non-penetrating
 RVF/LVF trauma
 Rheumatic Heart disease
 RV infarction
 Ebstein's anomaly
S/S
 Holosystolic / Pansystolic
murmur in tricuspid area
 High pitched
 increases with inspiration
 At parasternal region at 4 th
ICS
 RHF
 Hepatic congestion, RUQ
pain, jaundice
 Pulsatile liver
S/S
 Right ventricular lift
 Chronic mitral
 Jugular venous pulsation regurgitation often
5- Tricuspid Stenosis
asymptomatic
Narrowing of tricuspid valve
 Acute mitral
orifice due to commissural regurgitation (e.g., that
fusion and fibrosis
resulting from a
Causes
myocardial infarction)
 Usually follows RF
 manifests as severe CHF
 Commonly assoc with
 Dyspnea, fatigue, and
diseases of mitral valve
weakness
S/S
 Palpitations, SOBon
Rumbling or blowing mid
exertion, and cough
diastolic murmur along L sternal
from pulmonary
border
6- Mitral regurgitation
congestion also occur.
 Holosystolic or
 involves blood flowing back
pansystolic murmur
from the left ventricle into
Pulse
the left atrium during
systole.
 Often, the margins of the
mitral valve cannot close
during systole.
Causes
 Due to myxomatous
degeneration, which
1- Mitral stenosis:
Assessment:
 pulse weak irregular
 Increase intensity of S1
 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 dysrhythmias
Diagnostic:
 Echocardiography
 used to diagnose mitral
stenosis
 used to determine the
severity
 Electrocardiography
 cardiac catheterization with
angiography
Medical Mgmt
 Antibiotic prophylaxis
therapy
 to prevent recurrence of
infections
 Treat CHF
 Anticoagulants
 to decrease the risk
developing atrial thrombus
 Treat anemia
Surgical intervention
 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 replacement
2- Mitral regurgitation:
Diagnosis:
 Echocardiography
 used to diagnose
 monitor the progression
Medical Mgmt
 CHF MGMT
 Digitalis
 Diuretics
 Vasodilators
 Diet
 Anticoagulants
 SURGICAL INTERVENTION
 Mitral valve replacement
 Valvuloplasty annuloplasty
3- Aortic Stenosis:
Assessment:
 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
LV
 Thrill/ Vibration
 Palpated over base of
heart/ 2 nd 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 regurgitation
Diagnosis
 12 lead ECG and
echocardiogram
 Evidence of LV hypertrophy
may be seen
 Echocardiography
 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.
4- Aortic regurgitation:
Assessment
 Diastolic murmur
 high pitched, blowing sound
at the third or 4 th 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.
 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
 Hill’s sign
 systolic blood pressure is
higher in the legs than in
the arms (> 20mmHg)
 Pistol shot femoral pulse
(Traube's sign)
 short, loud, snapping
sounds with each pulse
with auscultation over the
femoral, brachial, or radial
pulse.
 a pulse that sounds like a
pistol shot
 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.
 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;
Diagnosis
 Echocardiogram
 radionuclide imaging
 ECG
 Magnetic resonance
imaging
 cardiac catheterization
Mgmnt Aortic both
 antibiotic prophylaxis
 Before the patient
undergoes invasive or
dental procedures
 to prevent endocarditis
 Treat HF and dysrhythmias
 Aortic valve replacement
 treatment of choice
 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.
5- Tricuspid regurgitation
Diagnostic
 ECG RV and RA
enlargement
 CXR RV enlargement with
obliteration of the
retrosternal space on
lateral view
6- Tricuspid Stenosis
Mgmnt tricuspid both
 Treat left sided HF
 Valvuloplasty
 Valve replacement
NURSING MGMNT
 Educate about
 Diagnosis
 progressive nature of
valvular heart disease
 treatment plan
 report any new symptoms
or changes in symptoms
 Emphasize need for
prophylactic antibiotic
therapy before any invasive
procedure that may
introduce infectious agents
to the patient’s
bloodstream.
 Teach that infectious agent
is able to effect
endocarditis and further
damage to the valve.
 Collaborate with patient
 develop a meds schedule
 teach about name, dosage,
actions, side effects, and
any drug drug or drug food
interactions
 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.
 VS : HR, BP RR measured
and compared with
previous data for any
changes.
 Auscultate heart and lung
sounds
 Assess s/s HF
 Assess dysrhythmias
 Assess for dizziness,
syncope, increased
weakness, or angina
pectoris
 Palpate peripheral pulses
 Periop care surgical valve
replacement or
valvuloplasty
1- Acute Pericarditis
 Acute inflammation of the
pericardium
 Originin: fectious, systemic
diseases, malignancy,
radiation, drug toxicity,
hemopericardium, other
inflammatory processes in
the myocardium or lung
 Pathologic process often
involves both the
pericardium and the
myocardium
S/S
 chest pain
(pleuritic/postural)
 dyspnea
 pericardial friction rub (with
or w/o evidence of fluid
accumulation or
constriction)
 Fever & leukocytosis
Diagnostic
 Chest x ray
 may show cardiac
enlargement or pleural dx
 ECG
 generalized ST and T wave
changes
 characteristic progression
(ST elevation, return to
baseline, T wave inversion)
 Echocardiogram
 often normal in
inflammatory pericarditis
 may show pericardial
effusions
Causes
 viral infection
(coxsackie virus, & echovirus
HIV, influenza, Epstein Bar,
varicella, hepatitis, mumps)
 bacterial infection
(staphylococcus, Strep
pneumonia, B hemolytic
streptococci) Mycobacterium
tuberculosis, lyme dz
 Fungal infection
 Malignancy
Viral Pericarditis
 caused by coxsackie virus, &
echovirus HIV, influenza,
Epstein Bar, varicella,
hepatitis, mumps
 Most commonly affects
males < age 50
 Diagnosis usually clinical
 rising viral titers in paired
sera may be obtained for
confirmation of diagnosis
 cardiac enzymes may be
slightly elevated indicating
myocarditis component
Bacterial Pericarditis
Tuberculous Pericarditis
Uremic Pericarditis
Neoplastic pericarditis
Radiation Pericarditis
Constrictive Pericarditis
2- Endocarditis
 Native valve (acute and
subacute) endocarditis
 Prosthetic valve (early and
late) endocarditis
 Endocarditis related to
intravenous drug use
S/S
 fever (90% of cases) and
chills
 Anorexia, weight loss,
malaise, headache, myalgia,
night sweats, shortness of
breath, cough, or joint pains
are common complaints
 Dyspnea, cough, and chest
pain are common
complaints of intravenous
drug users who have
infective endocarditis
 Petechial Common but
nonspecific finding
 Splinter hemorrhages Dark
red linear lesions in the
nailbeds
 Osler nodes Tender VALVULOPLASTY
subcutaneous nodules Types
usually found on the distal  Commissurotomy
pads of the digits Repair to commissures between
 Janeway lesions Nontender leaflets
maculae on the palms and Type
soles  CLOSED
 Roth spots Retinal COMMISSUROTOMY
hemorrhages with small,  Balloon Valvuloplasty
clear centers; rare and (OPEN
observed in only 5% of COMMISSUROTOMY)
patients.  Annuloplasty
3- Myocarditis Repair to annulus of the valve
 Inflammation of the by Leaflet repair
myocardium  Chordoplasty
 May be the result of Repair to the chordae
systemic disorder or
infectious agent ...usually
follows an upper resp
infection
 Pericarditis frequently
accompanies myocarditis
 Drug induced, cytotoxic
agents, cocaine
 Bacterial cases include;
Coryne bacterium
diphtheria, Neisseria
meningitides, Mycoplasma
pneumonia, and B
hemolytic streptococci
 Viral etiologies include;
coxsackie B, echovirus,
influenza, parainfluenza,
Epstein Barr, and HIV
S/S
 Systemic signs/symptoms
(fever, tachycardia, myalgia,
headache, and rigors)
 chest pain due to coexisting
pericarditis
 pericardial friction rub in
cases of concomitant
pericarditis
 In severe cases symptoms
of progressive heart failure
1- Acute Pericarditis
Diagnosis
 Chest x ray
 ECG
 Echocardiogram
 ST segment elevation
 Pericarditis w/o other
underlying cardiac
disease does not
typically produce
dysrhythmias
Other Tests
 CBC w/diff
 BUN
 Creatinine
 streptococcal serology
 appropriate vial
serology
 thyroid function studies
 Sed rate, creatinine
kinase levels w/
isoenzymes
Treatment
 Generally symptomatic Tx
 aspirin or NSAIDs
 Corticosteroids --
(unresponsive
 Symptoms generally
subside over several days to
weeks
 May be recurrences during
first few weeks’ months
 Rarely, patients suffer from
chronic recurrences
resulting in constrictive
pericarditis
 Major early complication
tamponade
Physical Exam
 Pedal edema
 hepatomegaly
 ascites
 JVD
 Kussmaul’s sign
 pericardial knock heard at
the apex
Nursing Management
 Physical assessment
 Vital signs
 Assess patient in various
positions to detect if pain is
alleviated/aggravated by
respiratory movements,
coughing and swallowing
Diagnosis
 Ineffective breathing
pattern related to chest
pain
 Altered comfort pain
related to the inflammation
of the pericardium
 Ineffective tissue perfusion
related to decrease blood
flow
2- Endocarditis
Management:
 Explain procedures to the
patients to comfort anxiety
 Position patient is semi
fowlers to relieve pain and
allow expansion of chest for
effective breathing
 Encourage gradual increase
activity
 Monitor V/S
 Administer analgesics as
prescribed
 Drainage of pericardial
fluids as ordered
Nursing assessment
It includes history taking
like: – Subjective data:
– past medical history:
patient asked of signs of the
disease and the onset of
the disease and review with
patient history of risk
factors like cardiac failure,
shock
– Medication history: has
the pt ever taken any
medication, what happened
afterwards
– Family history : asked of
any case at home of the
similar conditions
- Social history: social
behaviours that can trigger
the problem
- – Surgical history: if ever
operated on
- – Objective data: assess for
temperature elevations,
heart mummer,
Diagnosis
 Infective breathing pattern
related to inflammation of
heart muscle as evidenced
by use of accessory muscle,
dyspnea.
 Impaired gaseous exchange
related to fluid
accumulation in the lungs
as evidenced by shortness
of breath
 Decreased cardiac output
related to valvular
dysfunction as evidenced by
poor tissue perfusion
 Imbalanced nutrition less
than body requirement
related to anorexia as
evidenced by loss of weight.
 Altered thermoregulation
related to infection as
evidenced by increased
body temperature (fever).
 Impaired physical mobility
related to fatigue
 Ineffective tissue perfusion
related to embolization
 Anxiety related to hypoxia
or life threatening situation
as evidenced by patient
verbalization
 Altered comfort pain
related to use of accessory
muscle as evidenced by
patient verbalization
Nursing management
 Position the patient at semi
fowlers position to help in
infective breathing through
providing enough room for
lung expansion as
abdominal contents goes
down
 Administer oxygen therapy
4 6 l/min to help pt in
breathing effectively
through supplementing
oxygen
 Monitor arterial blood gas,
carbon dioxide, oxygen
saturation hourly and
document to monitor signs
of respiratory acidosis
 Encourage and provide
small frequent meals reach
in proteins helping in
repairing worn out tissues
 Monitor vital signs, heart
and lung sound, level of
consciousness to evaluate
how effectively the organs
like the heart and the lungs
are working
 Schedule nursing activities
to allow rest
 Encourage and assist pt to
cough and deep breath to
promote chest expansion
 P rovide tepid sponging to
reduce raised body
temperature by
evaporation and conduction
 Encourage patient on
exercises in order to
improve patient’s mobility
through making the body
physically fit
 Make yourself available to
the patient and nurse with
love and respond well to
his/her questions to array
pain and anxiety
 Educate the patient on  Myocardial biopsy may
disease process to make pt reveal inflammatory
cope up with therapy and pattern
the condition  Many cases spontaneously
3- Myocarditis resolve others progress to
Diagnosis dilated cardiomyopathy
 Nonspecific ECG changes, Nursing management
atrioventricular block,  The nurse assesses the
prolonged QRS duration, or patient’s temperature to
ST segment elevation (in determine whether the
cases of accompanying disease is subsiding
pericarditis)  The cardiovascular
 normal chest x ray assessment focuses on
 cardiac enzymes may be signs and symptoms of
elevated heart failure and
 Differential diagnosis dysrhythmia
includes cardiac ischemia or  Elastic compression
infarction, valvular disease stockings and passive and
and sepsis active exercises should be
Treatment used
 Supportive care
 If bacterial cause suspected,
antibiotics are appropriate
 Myocardial biopsy may
reveal inflammatory
pattern
 Many cases spontaneously
resolve others progress to
dilated cardiomyopathy
Diagnosis
 Nonspecific ECG changes,
atrioventricular block,
prolonged QRS duration, or
ST segment elevation (in
cases of accompanying
pericarditis)
 normal chest x ray
 cardiac enzymes may be
elevated
 Differential diagnosis
includes cardiac ischemia or
infarction, valvular disease
and sepsis
Treatment
 Supportive care
 If bacterial cause suspected,
antibiotics are appropriate