Cardiac valvular diseases Flashcards
How is a valvular disease defined?
by the valve that is affected and the functional alteration
What is stenosis and what impact does it have on the blood flow and pressure?
Stenosis is narrowing of the valve orifice. It impedes blow flow through the valve which causes an increased pressure on the side of the valve that blood is flowing into and decreased pressure on the other side of the valve
What is regurgitation and what impact does it have on blood flow?
The valve does not close completely so blood flows backwards
What are the AV valves?
Mitral and tricuspid valves
What are the semilunar valves?
aortic and pulmonary valves
What are the valves doing during systole?
- AV valves are closed during systole
- Semilunar valves are open during systole
This allows blood flow out of the ventricles and into the rest of the body
What are the valves doing during diastole?
- AV valves are open during diastole
- Semilunar valves are closed during diastole
This allows blood flow into the ventricles
What is the mitral valve located?
between the left atrium and the left ventricle
Where does the majority of the SV come from?
the left ventricle
Mitral valve stenosis overview
Mitral valve is unable to open efficiently d/t mitral valve stenosis during left atrial systole
This means blood can’t get out of the left atria to fill the left ventricle d/t the small opening and pressure build in left atrium
What is mitral valve stenosis caused by?
- Most cases causes by rheumatic heart disease
- Congenital heart disease
What is going on with the mitral valve during mitral valve stenosis?
There is scarring of the valve leading to adhesion
The valve becomes thickened and shorter
What does the mitral valve look like with mitral valve stenosis?
fish eye appearance
Mitral valve stenosis manifestations
- Exertional dyspnea
- Heart sounds - loud S1, low pitched diastolic (after S2) murmur
- Atrial fibrillation
- Embolization from Afib –> stroke
- Decreased CO
Why is there Exertional dyspnea with mitral valve stenosis? How does the patient present?
- There is increased pressure in the pulmonary valve –> decreased lung compliance d/t backing up into pulmonary vessels
- SOB while walking
What can Exertional dyspnea lead to? What does it manifest as?
Exertional dyspnea can increase to the point of pulmonary hypertension
Manifests as spitting up blood (hemoptysis)
What is making the sound. of a murmur?
sound of blood going where it is not supposed to
Where is the heart sounds for mitral valve stenosis best heard?
you can best hear the loud S1, and low pitched diastolic murmur at the apex of the heart
Why is there decreased CO with a mitral valve stenosis
Because there left ventricle is not filling
What is the difference between a diastolic and a systolic heart murmur?
- Diastolic - heard after S2
- Systolic - heard after S1
Rheumatic heart disease `
- Causes from strep A bacteria that is not treated and progresses into rheumatic fever
- RF leads to rheumatic heart failure
- Causes scarring and deformity of heart valves- mitral valve is the most common valve to be affected
What increased the risk for rheumatic heart disease?
- Children who are frequently reinfected with strep A and don’t get treated
- Third world countries that do not have access to antibiotics
Mitral valve prolapse is the..
most common valvular disease in the United States
What is mitral valve prolapse disease?What is it caused by?
Leaflets buckle into the left atrium during systole
Causes by abnormality in the leaflet, chord tenineae or papillary muscles
Do patients with mitral valve prolapse disease have symptoms?
They can be asymptomatic or symptomatic
Asymptomatic - common and pt. is monitored for progression into mitral valve regurgitation
Symptomatic: need a valve replacement right away
What is mitral valve prolapse characterized by
systolic murmur
innocent murmur because it is very common for people to have
Just monitor for a period of time once found with ECHO
What does mitral valve prolapse lead to?
Leading cause of mitral valve regurgitation
What is mitral valve regurgitation?
Mitral valve does not completely close during ventricular systole therefore when left ventricle is contracting to get blood out to the body –> blood is regurgitating into the left atrium
Blood flow and pressures r/t mitral valve regurgitation
- increased pressure in left atrium
- Volume deficit of blood going out to the body
- Volume overload in LV d/t both normal SV and regurgitated volume going into LV
What happens to the left ventricle and left atria r/t mitral valve regurgitation?
- Both have to work harder to maintain CO
- Left ventricle hypertrophy
- LV dilates d/t increase preload
What is mitral valve regurgitation caused by?
Deficit in mitral valve or other cardiac structures that relate to blood flow
MI
Rheumatic heart disease
Mitral valve prolapse,
Papillary muscle dysfunction
Endocarditis
What should patients with a mitral valve prolapse avoid?
Any stimulants like coffee or any exacerbation of symptoms
Goal - remain generally healthy
What are the clinical manifestations of an acute onset of mitral valve regurgitation?
- Thready peripheral pulse
- Cool, clammy extremities
- Pulmonary edema
- New systolic murmur
Dangerous and poorly tolerated
What is an acute onset of mitral valve regurgitation usually a result of?
Heart failure post MI
What does an acute onset of mitral valve regurgitation lead to?
left ventricular failure –> cariogenic shock
Chronic mitral vavle regurgitation clinical manifestations are (6)
- Fatigued
- Palpitations
- SOB
- Peripheral edema
- Audible 3rd heart sound - holosystolic murmur
- Left atrial enlargement
Pts. may be asymptomatic for years
What is a holosystolic murmur?
Regurgitant murmur and occurs when blood flows from a chamber in which pressure throughout systole is higher than pressure in the chamber that is receiving the flow
Where is the holosystolic murmur best heard?
apex of heart or axilla around the heart
What is the end results of all valvular diseases?
Heart failure
What is aortic stenosis?
Aortic valve is stiff and narrowed so the blood is not getting to the body –> decreased SV and CO
What does the aortic valve do?
Valve that gets blood to the body
Gatekeeper of all SV that the body receives with every heart beat
What happens to the left ventricle with aortic valve stenosis?
It has to work harder to pump the blood through such a small opening –> hypertrophy
What does aortic stenosis lead to? What do the s/s look like?
Decreased CO and heart failure.. therefore the s/s look like decreased CO and HF
What are the causes of aortic stenosis?
- # 1 cause is age over 65 - sometimes the body just ages this way
- Congenital
- Acquired - result of rheumatic heart disease
When do you start seeing symptoms with aortic stenosis?
when the valve becomes 1/3 of its normal size –> decreased SV enough to cause systemic s/s
What are the signs of aortic stenosis?
- signs of left ventricular heart failure –> decreased cardiac output) - angina, syncope, Exertional dyspnea
- Systolic murmur with absent S2 - hear S1 then loud whoosh
Is there a poor prognosis with aortic stenosis?
Yes, it the problem is not fixed
What normally happens to the aortic valve during ventricular diastole?
it is normally closed to allow for ventricular filling
What happens when aortic valve is not closed curing ventricular diastole?
The blood will flow backwards from the aorta and leak back into the ventricle instead of going to the body –> decrease stroke volume
What happens to the left ventricle during aortic regurgitation?
hypertrophy d/t volume overload
What does the blood go when it backs up during aortic regurgitation?
backs up into the left atrium and pulmonary vessels
What is aortic regurgitation caused by?
disease of the aortic valve
trauma
aortic dissection
endocarditis
What can exist in cases of rheumatic heart disease?
chronic aortic regurgitation
What are the manifestations for acute aortic regurgitation?
- life-threatening d/t sudden cardiovascular collapse
- Severe chest pain
- Dyspnea
- Profound and immediate hypotension
- Can lead to cariogenic shock
What are the manifestations for chronic aortic regurgitation?
- Asymptomatic for years
- Water hammer pulse
- Early diastolic (after S2) murmur
- Fatigue
What is a water hammer pulse?
strong, quick beat that immediately collapses
If taking central pulse, it quickly kicks you and then goes away so you don’t feel the entire pulse
Valvular disease - assessment of history includes? (7)
- Rheumatic heart disease
- Infective endocarditis
- Congenital defects
- MI
- Cardiomyopathy
- Strep infections
- May be asymptomatic for years
Assessment of valvular disease physical exam includes
- S/S of HF
- S/S of a-fib
- Cardiac S/S: S3 or murmur and dysrhythmias
S/S of HF are..
Left
1. Crackles
2. Wheezing
3. Orthopnea
4. Dyspnea
5. Hemopytosis
6. Fatigue
Right
1. Hepatomegaly d/t back up of blood in the liver –> increased liver enzymes
2. Peripheral edema
What are the s/s of a-fib?
D/t pressure in the left atrium
1. Pulse irregularly irregular
2. s/s of stroke
3. Palpitations
4. ECG changes
Diagnostics: ECHO to TEE
Regular ECHO first.
TEE ordered when looking for something specific and it reveals valve structures, function, and size of atria and ventricles
Diagnostics: Cardiac cath
Looks at pressure changes in the heart chambers, measures the pressure changes across the valves and measures the valve openings
Diagnostics: ECG
Changes in rhythm, show chamber enlargement, ischemic changes, a-fib
Diagnostics: CXR
pulmonary congestion, enlargement of pulmonary arteries(from pulmonary back up), enlarged heart chambers
Diagnostics: CT scan
evaluates for aortic disorders
Treatment for a valvular disease depends on..
valve involved and severity
Acute and chronic are treated differently.
In acute, valve replacement immediately because it is needed to survive
Can the heart compensate for a valve disorder?
yes the heart can compensate but patient may eventually become symptomatic
Treatment options include..
- Medical management - 1st line to treat s/s
- Surgical may be required
How do you treat a patient with chronic valvular disease?
- Prevent exacerbations of HF
- Pulmonary edema
- Thromboembolism
- Infective endocarditis
- Prevent recurrence of rheumatic heart disease and infective endocarditis
What is the end of the line for all valvular diseases?
All end with a valvular replacement
Medical management includes
- Treat HF w/ vasodilators, beta-blocker, diuretics (decrease fluid and pressure in LV and rest heart as much as possible), low NA diet, inotropic drugs
- Anticoags for presence of a-fib
- Dysrhythmias are common and need treatment so treat w/ antidysrhythmic medications, cardioversion(meds before this), meds to control vent rate with a-fib
What is the most common reason for ongoing medical care?
HF
When do you need to give a patient a valve replacement?
Once they develop s/s of HF, when heart size increases, EF decreases, angina, syncope
What do you use to monitor patients heart size and ejection fraction?
ECHO
Percutaneous transluminal balloon Valuloplasty (PTBV)
Alternative to valve replacement
Used for mitral or aortic stenosis
Preformed in cardiac cath lab where they stick a catheter with a balloon on the tip and inflate/deflate over and over to decrease stiffness and loosen the leaflets
Works for a short time - bandaid for replacement
Transcutaneous aortic valve replacement (TAVR)
done in the cath lab
Fed though femoral or radial artery and replace valve w/o opening the heart
W/ acute aortic valve problem- most have an emergency TAVR
Prosthetic valve
Most pts. are required to take anticoags for the rest of their lives and will require regular coag labs (INR)
Thromboembolism form easy on artificial valve
At risk for infection
