CV Valvular & Structural

Disorders
Pattie Schrader, MSN, RN

Cardiac Valves
Open & close passively
Respond to pressure &
volume changes
Supported by chordae
tendineae
2 Types of Valves
Atrioventricular (AV)
Semilunar

Atrioventricular (AV) Valves

Facilitate blood flow during ventricular
diastole
Prevent backflow of blood during systole
Tricuspid valve has ___ leaflets and
separates the ___ atrium from the ___
ventricle
Mitral valve has ___ leaflets and separates
the ___ atrium from the ____ ventricle

Semilunar Valves
Consist of 3 cuplike cusps
Prevent backflow of blood during ventricular
diastole
Permit blood blow during ventricular systole.
Pulmonic valve separates ___ ventricle from the
_______
Aortic valve separates ___ ventricle from the
_______

Valvular Disorders
Regurgitation: the valve does not close
properly and blood flows backwards through
the valve
Stenosis: the valve does not open
completely and blood flow through the valve
is reduced
Valve prolapse: the stretching of an
atrioventricular valve leaflet into the atrium
during diastole

Valvular Heart Disease

Valvular Heart Disease

Occurs when the heart valves cannot:
Open fully Valvular stenosis
Close completely
Valvular insufficiency
Valvular regurgitation

Prevents efficient blood flow through the heart

Acquired valvular dysfunction involves the left
side of the heart most, especially the mitral valve

Specific Valvular Disorders

Mitral valve prolapse

Mitral regurgitation
Mitral stenosis
Aortic regurgitation
Aortic stenosis

Mitral Stenosis
Thickening of the mitral valve by fibrosis
and calcification
Valve leaflets fuse together, becoming stiff
Chordae tendineae contract and shorten
Valvular orifice narrows
Thromboemboli may form on calcified
leaflets
Chronic and progressive

Mitral Valve Prolapse

Mitral valve leaflets are enlarged and
prolapse into the ____ atrium during
systole
Usually benign but may progress to
pronounced mitral regurgitation
Affects 5-10% of people
Most common in women 20-54 years of
age

Mitral Valve Prolapse

Causes often unclear & variable
Usually no other cardiac abnormality is found
Familial occurrence is well established
Acute or chronic rheumatic damage
Ischemic heart disease
Other cardiac disorders
Marfans syndrome
Other congenital cardiac defects

Mitral Valve Prolapse

Mitral Valve Prolapse

13

Mitral Valve Prolapse

Assessment Findings most asymptomatic
Chest pain atypical with sharp pain localized to
the left of the chest
Palpitations
Dizziness
Syncope
Exercise intolerance
Midsystolic click at the apex

Mitral
Regurgitation/Insufficiency
Fibrotic changes and calcification in the
mitral valve preventing complete
closure
Incomplete closure allows backflow of
blood from the left ventricle into the left
atrium during ventricular systole

Mitral Regurgitation/Insufficiency
Causes
Rheumatic heart disease more in women
Degenerative calcification of the mitral opening
in older women
Processes that dilate the mitral open or affect
the support structures, papillary muscles, or the
chordae tendineae (left ventricular hypertrophy
and MI)
Infective endocarditis
Congenital anomaly

Mitral Regurgitation

Mitral
Regurgitation/Insufficiency
Assessment Findings
Fatigue & weakness
DOE
Orthopnea
Anxiety
Atypical CP
Palpitations
Atrial fibrillation
Neck vein distention
Pitting edema
High-pitched, holosystolic murmur

Mitral Stenosis
Causes
Rheumatic fever
Bacterial endocarditis
Atrial myxoma, calcium accumulation, &
thrombus formation
Congenital defects
Females > Males

Mitral Stenosis
Prevents normal blood
flow from the ____ to
the _____ which
increases the
pressure in the
______ causing the
_____ ______ to
dilate increasing the
pressure in the _____
so the ____ _____
hypertrophies.

Valvular Dysfunction

21

Mitral Stenosis
Signs/symptoms - asymptomatic to severe

Fatigue
DOE - earliest manifestation
Cough
Hemoptysis
Frequent pulmonary infections
Paroxysmal nocturnal dyspnea
Orthopnea
Weakness
Palpitations

Mitral Stenosis
Assessment findings will worsen and ___
heart failure appears
JVD
Hepatomegaly
Ascites
Pitting peripheral edema
Crackles in lung bases

Mitral Stenosis
Assessment findings if severe
Cyanosis of face & extremities
CP is rare but may occur
Rumbling, _____ diastolic murmur
Atrial dysrhythmias
Thrombi

Aortic
Regurgitation/Insufficiency
Aortic valve leaflets do not close properly
during diastole (incompetent)
Leaflets are dilated, loose, or deformed
Allows regurgitation of blood from the
aorta back into the ____ ventricle
Left ventricle dilates to accommodate
larger blood volume
Left ventricle hypertrophies

Aortic
Regurgitation/Insufficiency
Causes
Nonrheumatic conditions
Infective endocarditis
Congenital anatomic abnormalities
Hypertension
Marfans syndrome

75% Men

Aortic
Regurgitation/Insufficiency

Aortic
Regurgitation/Insufficiency
Assessment Findings asymptomatic for many years
until left ventricular failure develops
DOE
Orthopnea
Paroxysmal noctural dyspnea
Palpitation especially when lying on left
Nocturnal angina with diaphoresis
Bounding arterial pulse
Wide pulse pressure elevated SBP& diminished DBP
High-pitched, blowing, decrescendo diastolic murmur

Aortic Stenosis
Aortic valve narrows & valvular tissue thickens
Obstructs left ventricular outflow during systole
Increased resistance to ejection or afterload
results in ventricular hypertrophy
CO becomes fixed and unable to meet demands
Left ventricle fails backs up in left atrium and
pulmonary system becomes congested right
heart failure

Aortic Stenosis
Causes
Congenital defects - predominantly
Bicuspid or unicuspid aortic valves

Rheumatic disease
Atherosclerosis
Degenerative calcification
Most common valvular disorder with aged populations
80% Men

Aortic Stenosis

Aortic Stenosis
Assessment Findings
Classic symptoms resulting from fixed CO
dyspnea, angina & syncope on exertion
As the CO falls marked fatigue,
debilitation and peripheral cyanosis
Narrow pulse pressure
A diamond-shaped, systolic crescendodecrescendo murmur is auscultated

Valvular Heart Disease

Murmur
Mitral
Stenosis

Cardiac
Cycle
Diastole

Auscultation
Site

Configuration
of Sound

Continuity

Apical

Rumble,
continuous

Mitral
Systole
Regurgitation

Apex

Holosystolic,
continuous

Mitral Valve
Prolapse

Systole

Apex

Click

Aortic
Stenosis

Systole

2nd ICS, RSB

Crescendodecrescendo,
continuous

3rd ICS, LSB

Decrescendo,
continuous

Aortic
Diastole
Regurgitation

Question
Which statement is correct about regurgitation?
A.Valve does not close properly and blood
backflows through the valve
B.Valve does not open properly and blood flow
through the valve is reduced
C.Stretching of an atrioventricular valve leaflet into
the atrium diastole
D.Repair of a cardiac valves outer ring

Pathophysiology: Left Heart Failure

as a Result of Aortic and Mitral
Valvular Heart Disease

Treatment Interventions
Nonsurgical management
Surgical management
Reparative Procedures
Replacement Procedures

Nonsurgical Management
Focuses on drug therapy and rest
Diuretics
Digoxin
Oxygen
Nitrates
Vasodilators (Adalat, Procardia)
EBP No longer need prophylactic antibiotics
before invasive procedures

Nonsurgical Management
Focuses on cardiac output
Monitor cardiac output & tissue perfusion
Monitor for any irregularly irregular rhythm
Prone to atrial fibrillation
Notify MD
Tx with drugs (IV diltiazem) or cardioversion

Nonsurgical Management
Other medications
Quinidine gluconate
Procainamide
Beta-blocking agents (propranolol
hydrochloride)
Calcium channel blocker (verapamil
Anticoagulants (Coumadine)

Valve Repair and Replacement

Procedures
Valvuloplasty
Commissurotomy: open or closed
Balloon valvuloplasty: open or closed
Annuloplasty
Leaflet repair
Chordoplasty

Valve replacement

Surgical Management
Reparative
Balloon Valvuloplasty
An invasive, nonsurgical procedure
Involves the passage of a balloon catheter
from the femoral vein through the atrial
septum to the mitral valve, or through the
femoral artery to the aortic valve
Balloon is inflated to enlarge the orifice

Valvular Heart Disease

Balloon Valvuloplasty
Institute precautions for arterial puncture if
appropriate
Monitor for bleeding from the catheter
insertion site
Monitor for signs of systemic emboli
Monitor cardiac rhythm, heart sounds and
cardiac ouptut

Balloon Valvuloplasty

Surgical Management
Reparative
Mitral annuloplasty tightening & suturing
the malfunctioning valve annulus to
eliminate or markedly reduce regurgitation

Surgical Management
Reparative
Commissurotomy/valvotomy
Accomplished with cardiopulmonary bypass
during open heart surgery
Valve is visualized, thrombi are removed from
the atria, fused leaflets are incised and
calcium is debrided from the leaflets thus
opening the orifice

Valve Leaflet Resection and

Repair with Ring Annuloplasty

Surgical Management
Replacement
Valve replacement procedures
Biological valves (xenograft)
Mechanical prosthetic valves
Pulmonary autographs

Valve Replacement

Types of Replacement Valves

Mechanical valves
Do not deteriorate or become infected as easily,
but are thrombogenic and require life-long
anticoagulation therapy.

Tissue (biologic) valves

Xenograft (heterograft): pig or cow valve
Homograft (allograft): human valve
Autograft: patients own valve

Mechanical Heart Valves

Prosthetic heart valves are mechanical
valves which are durable but can fail
Thromboembolism is a problem so lifetime
anticoagulation therapy is required
Usually replaced every 10 years

Mechanical Valves

Prosthetic Heart Valves

Biological Heart Valves

Biological grafts are xenografts (valves from
other species)
Porcine valves pigs
Bovine valves cow
Homografts human cadavers

Little risk of clot formation so long-term

anticoagulation is not indicated long-term
Durability is limited so may need replacing

Biological Heart Valves

Pulmonary Autographs
Relocation of the clients pulmonary valve
to the aortic position
Especially useful for younger clients

Valvular Heart Disease

Surgical Management
Preoperative Care
Ideally surgery is elective and planned
Consult with MD regarding anticoagulation
therapy 72 hours prior to surgery
Assist in educating client/significant others about
the management of

Postoperative pain
Incision care
Strategies to prevent respiratory complications
Oral anticoagulants .

Valvular Heart Disease

Surgical Management
Postoperative Care
Monitor closely postoperatively
Monitor cardiac output watch for signs of heart
failure
Monitor closely for signs of bleeding
Aortic stenosis higher risk

Monitor ECG tx dysrhythmias

Monitor respiratory status
Mitral Stenosis difficult to wean from ventilator

Valvular Heart Disease

Community-Based Care
Health Teaching
Home Care Management
Health Care Resources

Valvular Heart Disease

Community-Based Care
Health Teaching
Disease process
Medications diuretics, vasodilators, cardiac
glycosides, antibiotics, and anticoagulants
Prophylactic use of antibiotics ???
Conversation of energy work, activity & rest
Surgical intervention

Valvular Heart Disease

Home Care Management
Home care nurse helps client with adherence
to:
Medications
Activity schedules
Detection of problems
Anticoagulants

Incision care if post op

Home care aide to assist with activities of daily
living

Valvular Heart Disease

Health Care Resources
American Heart Association
Wallet sized care identifying client as
needing prophylactic antibiotics
Bracelet stating anticoagulant

Question
Is the following statement True or False?
The mitral valve is a semilunar valve located
between the right ventricle and the
pulmonary artery.

Question
Is the following statement True or False?
Xenograft is a heart valve replacement
made of tissue from an animal heart valve.