Heart

Valves
 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 or 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
 scarring and retraction of valve leaflets or weakening of
supporting structures  incomplete closure of the valve
 result to leakage or backflow of blood from the previous
chamber

EFFECTS: causes the to pump the same blood twice (as the
blood comes back into the chamber)
 the dilates to accommodate more blood (the usual blood
it needs to pump + regurgitated blood)
 ventricular dilation and hypertrophy  eventually leads to
heart failure
 Congenital heart disease
 Rheumatic heart disease
 Heart attack – damage to the heart muscle, papillary muscles
 Weakening of supporting structures of the heart
 Weakening of the heart muscle
 Infections – bacterial endocarditis
 most common valvular disorder
in rheumatic fever
 may also be caused by bacterial
infection, thrombus
formation, calcification
 obstruct blood flow from left
atrium to the left ventricle
 Narrowing of mitral valve

 left atrial Hypertrophy  blood flow to

pressure left atrium left ventricle

 pulmonary
 CO
pressure

pulmonary Left ventricular

congestion Fatigue
atrophy

O2/CO2 exchange
(fatigue, dyspnea, Right-sided
orthopnea) failure
 exertional dyspnea and fatigue (most common)
 orthopnea, paroxysmal nocturnal dyspnea, cough,
hemoptysis
 cyanosis
 Right-sided heart failure – distended neck veins,
peripheral edema, hepatomegaly, abdominal discomfort
 Auscultation: S1 followed by an opening snap--created by
forceful opening of mitral valve
- rumbling diastolic murmur (apex)
 CXR- left atrial enlargement
 ECG – atrial fibrillation may develop (50-80% of pts.)
- pulses becomes irregular & faint,  BP
 Echocardiogram (2D Echo) – most sensitive in diagnosis
 Na+ restriction, diuretics – to relieve pulmonary congestion
 bed rest, sitting position
 Digitalis – improve cardiac contraction,  HR, treat atrial
fibrillation
 Anticoagulants (blood thinners) – coumadin, aspirin,
ticlopidine (Ticlid), Plavix, dipyridamole
 Surgical interventions:
 Mitral commissurotomy – separation or incision of the
stenosed valve leaflets at their borders or commissures
 Balloon mitral valvuloplasty
 Mitral valve replacement – when stenosis is severe
Balloon
mitral
valvuloplas
ty
 incomplete closure of the mitral valve
 rheumatic disease is the predominant cause
 may also be due to congenital anomaly, infective endocarditis,
rupture of papillary muscle following MI
 a leaking mitral valve -  Stroke volume,  CO
- Left atrial hypertrophy
- Pulmonary congestion
 Incomplete closure of
mitral valve

Backflow of blood to the

left atrium

 vol. of blood ejected by

 Left atrial pressure
left ventricle

 CO Left atrial hypertrophy

 Pulmonary pressure

 Right ventricular
Right-sided heart failure
pressure
 Fatigue & weakness – due to  CO – predominant complaint
 exertional dyspnea & cough – pulmonary congestion
 palpitations – due to atrial fibrillation (occur in 75% of pts.)
 Right-sided heart failure – distended neck veins, edema,
ascites, hepatomegaly
 Auscultation: blowing, high-pitched systolic murmur (apex)
- S1 is diminished
- S3 –severe regurgitation
 restrict physical activity – to prevent fatigue & dyspnea
  Na+ intake, diuretics – relieve congestion
 Digitalis, vasodilators – promote adequate ventricular
emptying and prevent or decrease regurgitation
 ACE inhibitors – arterial dilation,  afterload
 Surgery:
- Valvuloplasty (repair or reconstruction)
- Valve replacement
Mitral Valve Prolapse
 when 1 or both of the valve leaflets bulge into the left
atrium 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 & papillary
muscles  regurgitation may occur
 usually asymptomatic
 Extra heart sound (Mitral click) – an early sign that a valve
leaflet is ballooning into the left atrium
 fatigue, shortness of breath
 arrhythmias may develop – dizziness, chest pain, dyspnea,
palpitations, syncope
 high-pitched late systolic murmur
Interventions:
 antibiotic prophylaxis to prevent endocarditis
 If w/ dysrhythmia – avoid caffeine, alcohol, stop
smoking
 anti-arrhythmic drugs
 for chest pain – nitrates, calcium channel blockers,
beta blockers
 surgery not indicated
 may be due to rheumatic heart disease, atherosclerosis,
congenital valvular disease or malformations
 narrowing 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 blood
through the narrowed opening
Aortic Stenosis
Aortic
Stenosis
 Stiffening/Narrowing of
Aortic Valve

Left ventricular hypertrophy Incomplete emptying of

left atrium

Compression of  CO
coronary arteries Pulmonary congestion

 Myocardial Right-sided heart failure

 O2 supply
O2 needs

Myocardial ischemia
(chest pain)
 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 to
increase coronary blood flow to cardiac muscle
 exertional syncope, vertigo, periods of confusion --  CO
 weakness, 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
 restrict activity
 digitalis
 Na+ restriction, diuretics
 Nitroglycerin – for chest pain
 Surgical:
 Balloon aortic valvuloplasty
 Aortic valve replacement – if not done –- poor prognosis
 may be due to
rheumatic fever –
most common cause
 other causes:
connective tissue
disease (Marfan’s
syndrome), severe
hypertension,
congenital anomaly
 Incomplete closure of the
aortic valve

Backflow of blood to Left

ventricle

Left ventricular  Left atrial pressure

hypertrophy & dilation

Left-sided heart failure Left atrium hypertrophy

(late stage)

 Pulmonary pressure
 CO

 Right ventricular
Right-sided heart failure
pressure
 pt. may remain asymptomatic for years --- heart
compensates by hypertrophy & dilation
 1st s/sx- heightened awareness of the heart beat &
palpitations esp. when pt. lies on left lateral position
 tachycardia, PVC  assoc. w/ left ventricular dilation
 bounding pulse, marked carotid artery pulsation,  apical
pulse   force and volume of contraction of the
hypertrophied left ventricle
 Decompensation occurs (cardiac muscle fatigue)
 exertional dyspnea
 chest pain – myocardial ischemia
 left-heart failure – fatigue, orthopnea,
 right-heart failure – peripheral edema
 Auscultation: soft, blowing diastolic murmur
 antibiotic prophylaxis before any invasive or dental
procedures
 avoid physical exertion, competitive sports
 vasodilators, calcium channel blockers, ACE inhibitors
Aortic valvuloplasty or valve replacement
 usually occurs together w/ aortic or mitral stenosis
 may 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
 uncommon, may be caused by RF, bacterial endocarditis
 may also be caused by enlargement of right ventricle
 an insufficient tricuspid valve allows blood to flow back
into the right atrium  venous congestion &  right
ventricular output   blood flow towards the lungs
 may not produce any symptoms 
 moderate-to-severe tricuspid regurgitation exist, the ff.
may result:
 Active pulsing in the neck veins
 Swelling of the abdomen
 Swelling of the feet and ankles
 Fatigue, tiredness
 Weakness
 Decreased urine output
 on palpation, there may be a lift (beating of enlarged right
ventricle)
 murmur on auscultation
 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 artery
S/Sx:
 harsh systolic murmur
 fatigue, dyspnea on exertion, cyanosis
 poor weight gain or failure to thrive in infants
 hepatomegaly, ascites, edema
 a rare condition caused by infective endocarditis,
tumors or RF

 blood flows back into Right ventricle  Right ventricle

and atrium hypertrphy  symptoms of Right-sided
heart failure
 Valvuloplasty is repair of cardiac valve
• pt. does not require continuous anti-coagulant medication
• usually require cardiopulmonary bypass machine
Commissurotomy – to separate the fused leaflets
 Balloon Valvuloplasty – performed in the cardiac cath. lab.
- balloon inflated for 10-30 secs., w/ multiple
inflations
- 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 the
commissure
 Open Commissurotomy – done w/ direct visualization of
the valve, thrombus and calcifications may be identified
and removed
2. Annuloplasty is repair of valve annulus (junction of the valve leaflets
and the muscular heart wall)
- narrows the diameter of the valve’s orifice, useful for
valvular regurgitation

3. Chordoplasty is repair of chordae tendineae

- done for mitral valve regurgitation – caused by stretched,
torn or shortened chordae tendineae
 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 yrs
viability)
- 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 valve
 Long-term anticoagulant therapy
 Antibiotic prophylaxis