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Virendra S. Shekhawat Medical Surgical Nursing Date: 18 feb 2012 CKRDM Nursing College
Heart Valves
Mitral stenosis is a valvular heart disease characterized by the narrowing of the orifice of the mitral valve of the heart.
Etiology
Most cases of adult mitral valve stenosis result from rheumatic heart disease Less common cause are conginital mitral stenosis Rheumatoid arthritis Systemic lupus erythematosus
Systemic lupus erythematosus or lupus, is a systemic autoimmune disease (or autoimmune connective tissue disease) that can affect any part of the body. As occurs in other autoimmune diseases, the immune system attacks the body's cells and tissue, resulting in inflammation and tissue damage. It is a Type III hypersensitivity reaction
Rheumatic fever is an inflammatory disease that occurs following a Streptococcus pyogenes infection, such as streptococcal pharyngitis or scarlet fever. Believed to be caused by antibody crossreactivity that can involve the heart, joints, skin, and brain,[1] the illness typically develops two to three weeks after a streptococcal infection.
Pathophysiology
Rheumatic endocarditis causes scarring of the valve leaflets and the chordae tendineae Contractures and adhesions develop between the commissures. Thickening and shortening of valve Strectural defomities cause obstruction of blood flow Pressure difference between left atrium and the left ventricle during diastole Increase pulmonary vascular pressureand subsequent hypertrophy of the pulmonary vessels.
Clinical manifestation
Primary symptoms - exertional dyspnea - Fatigue - Palpitation from atrial fibrillation diastolic murmur Less frequently - Hoarseness - Hemoptysis - Chest pain - Seizures or sroke
Mitral regurgitation (MR), mi tral insufficiency or mitral incompetence is a disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood.
Etiology
Mitral valve function depends on intact mitral leaflets, mitral annulus, chordae tendineae, papillary muscles, left atrium and left ventricle. Any defect in any of these structures can result in regurgitation Chronic rheumatic heart disease Mitral valve prolapse Ischemic papillary muscle dysfunction Infective endocarditis MI
Pathophysiology
Mitral regurgitation allows blood to flow backward from the left ventricle to the left atrium the left ventricle to the left atrium work harder to preserve an adequate CO The sudden increase in pressure and volume is transmitted to the pulmonary bed Pulmonary edema and shock
Clinical manifestation
Thready, peripheral pulse and cool, clammy extremities. exertional dyspnea Fatigue Palpitation Peripheral edema S3 heart sound
Mitral valve prolapse is an abnomality of the mitral leaflets and the papillary muscles or chordae that allow the leaflets to prolapse or back into the left atrium during
Mitral valve prolapse (MVP) is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole
Etiology
The etiology of MVP is unknown but is related to pathogenic mechanisms of the mitral valve.
Clinical manifestation
Patients may asymptomatic and remain so for their entire lives. Murmur One or more clicks usually heard in midsystole to late systole. MVP does not alter S1 S2 heart sounds Chest pain may or may not Dyspnea, palpitation and syncope
Aortic valve stenosis (AS) is a disease of the heart valves in which the opening of the aortic valve is narrowed. The aortic valve is the valve between the left ventricle of the heart and the aorta, which is the largest artery in the body and carries the entire output of blood.
Etiology
Pathophysiology
Rheumatic valvular diseases Fusion of the commissures Resulting in calcification cause the valvular leaflets to stiffen and retract Resuts in stenosis.
Clinical manifestation
Symptoms appear when orifice becomes about one third of its normal size Angina Syncope Exertional dyspnea
Auscultation S1 a diminished or absent S2 a systolic, crescendo-decrescendo murmur that ends before S2 a prominent fourth heart sound *(S4)
Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. Aortic valve regurgitation may be result of primary disease of aortic valve leaflets, the aortic root or both.
Etioloy
Acute aortic regurgitation caused by infective, trauma or aortic dissection. Chronic AR is generally the result of rheumatic heart disease, a congenital bicuspid aortic valve, syphilis, or chronic rheumatic condition.
Pathophysiology
Aortic regurgitation causes retrograde blood flow from the ascending aorta into LV during diastole Resulting in volume overload Dilation and hypertrophy of LV Decline in myocardial contraction Blood volume increase in LA and pulmonary bed Results in pulmonary hypertension and right ventricular failure
Clinical Manifestations
Patient with acute AR sudden manifestations of cardiovascular collapse. Severe dyspnea Chest pain Hypotension Shock Water- hammer pulse
auscultation
Disease of the tricuspid and pulmonic valve are uncommon with stenosis occurring more frequently then regurgitation. Tricuspid valve stenosis occur almost exclusively in patient with rheumatic fever, in IV drug abuser, in patient treated with a dopamine. Pulmonary stenosis is almost always congenital.
Tricuspid and pulmonic stenosis both result in an increase in blood volume in the right atrium and right ventricle Tricuspid stenosis results in the right atrial enlargement and elevated pulmonic stenosis results in right ventricular hypertension and hypertrophy
History Physical examination Chest X-ray reveals the heart size, alteration in pulmonary circulation and calcification Echocardiogram reveals valve structure, function and chamber size
Cardiac catheterization detect pressure changes in cardiac chambers, measure gradient across the valve and quantifies the size of valve openings ECG shows heart rate and rhythm and provides information about any ischemia or chamber enlargement.
Medical management
Treatment depends on the valve involved and the severity of the disease. It focuses on preventing of HF, acute pulmonary edema, thromboembolism and recurrent endocarditis If manifestation of HF develop, vasodilators intropes, -adrenergic blocker, diuretics, a low- sodium diet and anticoagulant therapy are recommended.
Percutaneous transluminal ballon valvoplasty PTBV procedure , which splits open the fused commissures it can used in stenosis of valves. This procedure involves a balloon tipped catheter from femoral artery or vein to the stenotic valve so that the balloon may be inflated in an attempt to separate the valve leaflets.
Surgical therapy
Commissurotomy
Commissurotomy of cardiac valves is called valvulotomy and consists of making one or more incisions at the edges of the commissure formed between two or three valves, in order to relieve constriction such as occurs in valvular stenosis, specially mitral valve stenosis
Annuloplasty
Mitral valve annuloplasty is a surgical technique for the repair of leaking mitral valves. Due to various factors, the two leaflets normally involved in sealing the mitral valve to retrograde flow may not coat properly. Surgical repair typically involves the implantation of a device surrounding the mitral valve, called an annuloplasty device, which pulls the leaflets together to facilitate coatation and aids to re-establish mitral valve function.
Valve replacement
Valve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis (homograft from human tissue or xenograft e.g. from pig). It is an alternative to valve repair. There are four procedures: Aortic valve replacement Mitral valve replacement Tricuspid valve replacement Pulmonary valve replacement
Nursing management
Nursing Assessment
Important health information Past health history: rheumatic fever, infective endocarditis, congenital defects, myocardial infection, chest trauma, cardiomyopathy, streptococcal infection. Clinical manifestation Fever ,cyanosis, clubbing, peripheral edema, crackles, wheezes, hoarseness, S3 and S4 tachycardia, water- hammer pulses.
Nursing diagnosis
Activity intolerance related to insufficient oxygenation secondary to decease cardiac out put as evidenced by weakness, fatigue Excess fluid volume related to heart failure secondary to incompetent valves as evidenced by peripheral edema, weight Decreased cardiac output related to valvular incompetence as evidenced by murmur dyspnea
Deficient knowledge related to lack of experience and exposure to information as evidenced by verbalization of misconceptions.