INDIVIDUAL REQUIREMENTS

MECHANICAL AND TISSUE (BIOLOGICAL) VALVE REPLACEMENT:

Mechanical Valve Replacement:

• Ball-and-cage or disk design
• More durable than tissue prosthetic
• Often used for younger patients
• Used for patients with renal failure, hypercalcaemia, endocarditis or sepsis who require
valve replacement.
• Do not deteriorate or become infected as the tissue valves used for patients with this
condition (renal failure, hypercalcemia, endocarditis or sepsis)
• Significant complication associated with mechanical valve replacement:
 Thromboemboli requiring long-term use of anticoagulants
 Some amount of hemolysis also occurs with mechanical valves (usually it is not
clinically significant)

Tissue (biological) Valve Replacement:

• 3 types;
 Xenografts (e.g bioprosthesis, heterografts)
– used for all tricuspid valve replacement.
- They are used for women of childbearing age because the potential
complications of long-term anticoagulation associated with menses,
placental transfer to a fetus, and delivery of a child do not exist.
- Used also for patients with a history of peptic ulcer disease, and others
who cannot tolerate long-term anticoagulation.
- Most xenografts are from pigs (porcine), but valves from cows
(bovine) may also be used.
- Viability is 7 to 10 years.
- Xenografts do not generate thrombi, thereby eliminating the need for
long-term anticoagulation.
 Homogratfs or Allografts (e.g human valves)
- Obtain from cadaver tissue donations
- Used for aortic and pulmonic valve and a portion of the pulmonary
artery are harvested and are stored cryogenically.
- Always available and are very expensive
- Last about 10 to 15 years, somewhat longer than xenogratfs
- Not thrombogenic and are resistant to sub-acute bacterial endocarditis.
 Autografts (e.g autologous valves)
- Obtain by excising the patient’s own pulmonic valve and a portion of
the pulmonary artery for use as aortic valve.
- Anti-coagulation is unnecessary because the valve is the patient’s own
tissue and it is not thrombogenic
 - Alternative for children , women of childbearing age, young adults,
patient with history of peptic ulcer disease, and people who cannot
tolerate anticoagulation.
- Aortic valve autografts have remained viable for more than 20 years
- Most aortic valve autograft procedures are double valve procedures; a
homograft also is performed for pulmonic valve replacement.
- If the pulmonary vascular pressures are normal, some surgeons elect
not to replace the pulmonic valve
- Patients can recover without a valve between the right ventricle and
the pulmonic artery

Your choices are:

• Get a mechanical replacement valve.

• Get a tissue replacement valve.

The decision about whether to get a mechanical or tissue valve takes into account your personal
feelings and the medical facts.

Deciding about a mechanical valve or tissue valve

Reasons to get a mechanical valve Reasons to get a tissue valve

• A mechanical valve lasts 20 to 30 • You are older than 65 or have a health

years.
• The durability of a mechanical valve
makes it less likely that you will need
another replacement valve in your
lifetime.
• You are younger than 60 and are
likely to outlive a tissue valve and
require another valve replacement.
• You already are taking anticoagulants
for another condition.
Are there other reasons you might want to
get a mechanical replacement valve?
problem that makes it unlikely that
you will outlive a tissue valve.
• You are less likely to develop blood
clots.
• You do not want to take
anticoagulants permanently.
• You are worried about the increased
risks of bleeding associated with
anticoagulants.
• Tissue valves tend to last longer in
older people.
Are there other reasons you might want to get
a tissue valve?

NURSING DIAGNOSIS AND INTERVENTIONS AFTER CARDIAC SURGERY:

1. Decrease cardiac output R/T blood loss, compromised myocardial function, and
dysrhytmias
  Monitor cardiovascular status. Serial readings of blood pressure (arterial,
pulmonary artery wedge pressure [PAWP], central venous pressure [CVP],
cardiac output/index, systemic and pulmonary vascular resistance, and cardiac
rhythm and rate are obtained, recorded, and tolerated with the patient’s condition
 Observe for persistent bleeding; steady, continuous drainage of blood;
hypotension, low CVP; tachycardia. Prepare to administer blood products, IV
solutions
 Observe for cardiac tamponade: hypotension; rising PAWP, PAD, CVP, or pulsus
paradoxus; muffled heart sounds; weak thready pulse; jugular vein distention,
decreasing urinary output. Check for diminished amount of blood in chest
drainage collection system. Prepare reoperation.
 Observe for cardiac failure; hypotension, rising PAWP, PAD, CVP, tachycardia,
restlessness, agitation, cyanosis, venous distention, dyspnea, moist crackles,
ascites. Prepare to administer diuretics, digoxin, IV inotropic agents
 Observe for myocardial infarction: ST-segment elevations, T-wave changes,
decreased cardiac output in the presence of normal circulating volume and filling
pressures. Monitor serial ECGs and cardiac biomarkers. Differentiate myocardial
pain from incisional pain.

2. Impaired gas exchanged R/T the trauma of the chest surgery

 Maintain mechanical ventilation until the patient is able to breathe independently
 Monitor arterial blood gases, tidal volume, peak inspiratory pressure and
extubation parameters.
 Auscultate chest for breath sounds
 Sedate patient adequately, as prescribed, and monitor respiratory rate and depth if
ventilations are not “controlled” by ventilator.
 Assist in weaning and endotracheal tube removal
 After extubation, promote deep breathing, coughing, and turning. Encourage use
of the incentives spirometer and compliance with breathing treatments. Teach
incisional splinting with a “cough pillow” to decrease discomfort.

3. Risk for imbalanced fluid volume (and electrolyte imbalance) R/T alteration in
circulating blood volume
 Maintain fluid and electrolyte balance
 Be alert to changes in serum electrolyte levels

4. Disturbed sensory perception (visual or auditory) R/T excessive environmental stimuli

(critical care environment, surgical experience), insufficient sleep, psychological stress,
altered sensory integration, and electrolyte imbalances
 Use measures to prevent postcardiotomy delirium
o Explain all procedures and the need for patient cooperation
o Plan nursing care to provide for periods of uninterrupted sleep with
patient’s normal day-night pattern
o Decrease sleep-preventing environmental stimuli as much as possible
o Promote continuity of care
 oOrient to time and place frequently. Encourage family to visit
oAssess for medications that may contribute to delirium
oTeach relaxation techniques and diversions
oEncourage self-care as much as tolerated to enhance self-control. Assess
support systems and coping mechanisms
 Observe for perceptual distortions, hallucinations, disorientation, and paranoid
delusions

5. Acute pain R/T surgical trauma and pleural irritation caused by chest tubes
 Record nature, type, location, intensity and duration of pain
 Assist patient to differentiate between surgical pain and angina pain
 Encourage routine pain medication dosing for the first 24 to 72 hours and observe
for side effects of lethargy, hypotension, tachycardia, respiratory depression.

6. Ineffective tissue perfusion (renal, cerebral, cardiopulmonary, gastrointestinal, peripheral)

R/T decreased cardiac output, hemolysis, vasopressor, drug therapy, embolizaiton,
underlying atherosclerotic disease, or coagulation problems
 Assess renal function
 Prepare to administer rapid-acting diuretics or inotropic drugs (i.e dobutamine)
 Prepare patient for dialysis or continuous renal replacement therapy if indicated

7. Ineffective thermoregulation R/T infection or postpericardiotomy syndrome

 Assess temperature every hour
 Use aseptic technique when changing dressings, suctioning endotracheal tube;
maintain closed systems for all intravenous and arterial lines and for indwelling
urinary catheter
 Observe for symptoms of postcardiotomy syndrome; fever, malaise, pericardial
friction rub, arthralgia
 Obtain cultures and other lab work (CBC, ESR); administer antibiotics as
prescribed
 Administer anti-inflammatory agents as directed

8. Deficient knowledge about self-care activities.

 Develop teaching plan for patient and family. Provide specific instructions for the
following:
o Diet and daily weighs
o Activity progression
o Exercise
o Deep breathing, coughing, lung expansion exercises
o Temperature monitoring
o Medication regimen
o Pulse taking
o Access to the emergency medical system
o Need for medic alert identification
  Provide verbal and written instructions; provide several teaching sessions for
reinforcement and answering questions
 Involve family in teaching sessions
 Provide contact information for surgeon and cardiologist and instructions about
follow check-up visit with the surgeon
 Make appropriate referrals; home care agency, cardiac rehabilitation program,
community support groups, mended hearts club.
CAUSE AND SIGNIFICANCE OF ‘GALLOP SOUNDS”
• If the blood filling the ventricle is impeded during diastole, as occurs in certain disease
states, then a temporary vibrations may occur in diastole that is similar to, although
usually softer than, S1 and S2. The heart sounds then come in triplets and have the acoustic
effect of a galloping horse; they are called GALLOPS. This may occur early in diastole,
during the rapid-filling phase of the cardiac cycle, or later at the time of arterial
contraction.
• Gallop sounds are very low-frequency sounds and may be heard only with the bell of the
stethoscope placed against the chest.
• Best heard at the apex, although occasionally, when emanating from the right ventricle,
they may be heard to the left of the sternum
• A gallop sound that occurs during rapid ventricular filling is called a THIRD HEART
SOUND (S3). Normal finding in children and young adults.
• Such a sounds is heard in patients who have myocardial disease or in those who have HF
and whose ventricles fail to eject all of their blood during diastole.
• An S3 gallop – BEST HEARD WITH THE PATIENT LYING ON THE LEFT SIDE
• Gallop sound that occurs during arterial contraction is called FOURTH HEART SOUND
(S4) – often heard when the ventricle is enlarged or hypertrophied and therefore resistant
to filling.
• Such circumstances may associated with CAD, HTN, or stenosis of the aortic valve.
• On rare occasions, all four heart sounds are heard within single period of cardiac
contraction, ejection refilling, and resting, referred to as cardiac cycle, giving rise to what
is called a QUADRUPLE RHYTHM

ATHEROSCLEROSIS AS DAMAGING PROCESS

Atherosclerosis is a disease in which plaque builds up on the insides of your arteries. Arteries
are blood vessels that carry oxygen-rich blood to your heart and other parts of your body.

Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over
time, plaque hardens and narrows your arteries. The flow of oxygen-rich blood to your organs
and other parts of your body is reduced. This can lead to serious problems, including heart
attack, stroke, or even death.

WEB ASSIGNMENT:

CARDIOMYOPATHY
 Cardiomyopathy is a weakening of the heart muscle or a change in heart muscle
structure. It is often associated with inadequate heart pumping or other heart
function problems.
 TYPES:
1. Dilated Cardiomyopathy
o Most common form of cardiomyopathy
o 5 to 8 case per 100,000 people per year and increasing
o Occurs most often in men and AfricansAmericans
o Distinguished by significant dilation of the ventricles without
simultaneous hypertrophy
o Ventricles have elevated fraction
o Formerly name Congestive Cadiomyopathy, but it may exist without signs
and symptoms of congestion
2. Hypertropic Cardiomyopathy
o Rare autosomal dominant condition, occurring in men, women , and
children (often detected after puberty)
o The heart muscle asymmetrically increases in size and mass, especially
along the septum.
o Often affects nonadjacent areas of the ventricle.
o May be non-obstructive or obstructive
o Has been called idiopathic hypertrophic sub-aortic stenosis and
asymmetric septal hypertrophy.
3. Restrictive Cardiomyopathy
o Characterized by diastolic dysfunction caused by rigid ventricular walls
that impair diastolic filling and ventricular stretch.
o Least common cardiomyopathy
o 5% of cases of pediatric cardiomyopathies, is pathogenesis is the least
understood.
o May be associated with amyloidosis and other infiltrative diseases.
4. Arrythmogenic Right Ventricular Cardiomyopathy
o Occurs when the myocardium of the right ventricle is progressively
infiltrated and replaced by fibrous scar and adipose tissue.
o Initially, only localized areas of the right ventricle are affected, but as the
disease progresses, the entire heart is affected. Eventually, the right
ventricular dilates and develops poorly contractility, right ventricular wall
abnormalities and dysrythmias.
o Prevalence is unknown because many causes are not recognized.
o Palpitations or syncope may develop between 15 and 40 years of age
5. Unclassified Cardiomyopahties
o Different from or have characteristics of more than one of the previously
described types.
o Examples include fibroelastosis, noncompacted myocardium, systolic
dysfunction with minimal dilation, and mitochondrial involvement.

TREATMENT STRATEGIES:
While all types of cardiomyopathy can cause heart failure, each case requires specific
strategies for recovery.

Treatment involves a combination of patient education, dietary changes, and medications.

Possible medications include:

• ACE-inhibitors and angiotensin receptor blockers (ARBs): These drugs have been
shown to improve survival and reduce heart-related complications.
• Aldosterone blockers: These drugs help balance electrolytes in the body. Studies have
shown that aldosterone blockers can improve survival in patients who have a heart
attacked complicated by cardiomyopathy.
• Beta blockers: Beta blockers are widely used for congestive heart failure. They
improve survival in patients with cardiomyopathy and are important parts of therapy.
Beta blockers slow the heart rate.
• Diuretics: Often called "water pills," diuretics help relieve the fluid overloads in heart
failure.
• Positive inotropic medications: These medicines help the heart contract. They include
dopamine, dobutamine, and milrinone.
• Vasodilators: These drugs dilate blood vessels at several levels in the body, reducing
the workload for the heart.

Other drugs that correct irregular heart rhythms and blood thinners may also be used.

Certain individuals with severely weak pumping function of the heart and severe heart
failure may need a biventricular pacemaker. It works on the right and left chambers
(ventricles) of the heart and keeps them pumping together. In very specific cases, this
special pacemaker may also have a defibrillation function, which means it can quickly
detect a life-threatening, rapid heartbeat and convert it back to normal. See:
Defibrillation.

In severe cases, surgery may be performed to help the patient live longer until a donated
heart is available. However, surgery does not cure the disease. Surgical procedures
include:

• Left ventricular assist device (LVAD): LVADs are the most common type of heart
pump. They help the left side of the heart push blood to the aorta, the body’s main
blood vessel.
• Dynamic cardiomyoplasty: A procedure in which a flap created from a patient's chest
muscle is trained to contract often and "wrapped around" the heart to help it contract.

Patients with advanced, severe heart failure need a heart transplant.