UNIT 2 AND 3 Chapter 32 Mitral and Aortic Valve Stenosis and Regurgitation, Valve Replacement

Question 1

What is Mitral Stenosis

Answer 1

stiffening of the mitral valve disrupts blood flow to the left ventricle

Question 2

What is the cause of Mitral Stenosis?

A. Rheumatic fever
B. e coli
C. h. pylori
D. alteplase

Answer 2

A. Rheumatic fever

Results from Rheumatic Carditis /Endocarditis

Question 3

What are the clinical manifestations of Mitral stenosis

Answer 3

-Pulmonary congestion and right-sided heart failure occur first.
Later, when the left ventricle receives insufficient blood volume, preload is decreased and cardiac output (CO) falls.
-dyspnea on exertion
-orthopnea,
-paroxysmal nocturnal dyspnea (sudden dyspnea at night)
palpitations, and
dry cough.
-Hemoptysis (coughing up blood) -pulmonary edema occurs as pulmonary hypertension and congestion progress.
Thrombi can occur
especially with atrial
fibrillation.
(LEFT SIDE OF CHEST) A rumbling, apical diastolic murmur is noted on auscultation(APICAL LOCATION IS FOUND IN THE MIDCLAVICULAR LINE 5 TH INTERCOASTAL SPACE.

**Right-sided HF hepatomegaly (enlarged liver), neck vein distention, and pi ing dependent edema late in the disorder.

Question 4

What type of dysthymia would you find for a patient with Mitral Stenosis?

A. atrial fibrillation
B. Peak T waves
C. ST elevation
D. Proloned QT intervals

Answer 4

A. atrial fibrillation

Question 5

What is the treatment of choice for atrial fibrillation?

A. Warfarin
B. CPR
C. Cardioversion
D. Thrombolytic

Answer 5

A. Warfarin

calcium channel blockers relax the heart , Verapamil, Nifedepine, Diltiazem

Question 6

What is Mitral Regurgitation?

Answer 6

Incomplete closure of the valve OF THE MITRAL VALVE allows the backflow of blood into the left atrium when the left ventricle contracts. During diastole,

The fibrotic and calcific changes occurring in mitral regurgitation (insufficiency) prevent the mitral valve from closing completely during systole.

Question 7

Cause of Mitral Valve Regurgitation

Answer 7

The causes of primary mitral regurgitation are mitral valve prolapse, rheumatic heart disease, infective endocarditis, myocardial infarction (MI), connective tissue diseases such as Marfan syndrome, and dilated cardiomyopathy.

Question 8

Clinical Manifestations of Mitral Regurgitation

Answer 8

 Initially no s/s
 Fatigue
 Chronic
weakness
 Dyspnea
 Anxiety
 Palpitations
Dyspnea on exertion and orthopnea develop later.
anxiety,
 atypical chest pains,
 Assessment may reveal normal BP,
 atrial fibrillation,
 changes in respirations characteristic of left ventricular failure.
 the neck veins become distended,
 the liver enlarges (hepatomegaly),
 Pitting edema develops.
 A high-pitched systolic murmur at the apex, with radiation to the left axilla, is heard on auscultation.
 Severe regurgitation often exhibits a third heart sound (S3).

Question 9

What is Aortic Stenosis?

Answer 9

Aortic stenosis is the most common cardiac valve dysfunction in the United States and is often considered a disease of “wear and tear.”

aortic valve stiffens and has difficulty ejecting blood to the aorta

Question 10

Which of the following valve surface areas for Aortic Stenosis requires emergency surgery?

A. 3CM
B. 2CM
C. 0.3CM
D. 5CM

Answer 10

C. 0.3CM

Valve surface area
1cm or less – surgery
URGENT

blood is not flowing through the rest of the body , which can cause shock

Question 11

What is the cause of Aortic stenosis?

Answer 11

Congenital bicuspid or unicuspid aortic valves are the primary causes for aortic stenosis in many patients. Rheumatic aortic stenosis occurs with rheumatic disease of the mitral valve and develops in young and middle- age adults. Atherosclerosis and degenerative calcification of the aortic valve are the major causative factors in older adults. Aortic stenosis has become the most common valvular disorder in all countries with aging populations.

Question 12

What are the clinical findings of Aortic Stenonis

Answer 12

• dyspnea,
  angina,
• syncope occurring on exertion. When cardiac output falls in the late stages of the disease, the patient experiences
• marked fatigue,
• debilitation,
  peripheral cyanosis.
  A narrow pulse pressure is noted when the BP is measured.
  A diamond-shaped, systolic crescendo- decrescendo murmur is usually noted on auscultation.

Question 13

What is the #1 tx for Aortic Stenosis

Answer 13

Surgical therapy is the only definitive treatment of aortic stenosis and is recommended when angina, syncope, or dyspnea on exertion develops.

Question 14

What is Aortic Regurgitation

Answer 14

In patients with aortic regurgitation, the aortic valve leaflets do not close properly during diastole; and the annulus (the valve ring that a aches to the leaflets) may be dilated, loose, or deformed. This allows flow of blood from the aorta back into the left ventricle during diastole. The left ventricle, in compensation, dilates to accommodate the greater blood volume and eventually hypertrophies.

Question 15

What is the cause of Aortic Regurgutation

Answer 15

Aortic insufficiency usually results from nonrheumatic conditions such as
-infective endocarditis,
-congenital anatomic aortic valvular abnormalities,
- hypertension, and
-Marfan syndrome (a rare, generalized, systemic connective tissue disease).

Question 16

What are the clinical manifestations ofAortic Regurgitation

Answer 16

left sided failurethe major symptoms are exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

. Palpitations may be noted with severe disease, especially when the patient lies on the left side. Nocturnal angina with diaphoresis often occurs.
On palpation, the nurse notes a “bounding” arterial pulse.

The pulse pressure is usually widened,with an elevated systolic pressure and diminished diastolic pressure.

The classic auscultatory finding is a high- pitched, blowing, decrescendo diastolic murmur.

Question 17

Drug of choice for valuvar disease?

Answer 17

Diuretics, beta blockers, ACE inhibitors, digoxin, and oxygen are often administered to improve the symptoms of HF.
Nitrates are administered cautiously to patients with aortic stenosis because of the potential for syncope associated with a reduction in left ventricular volume (preload).

Vasodilators such as calcium channel blockers may be used to reduce the regurgitant flow for patients with aortic or mitral stenosis.
Verapimil
Nifedepine
Diltiazem

Question 18

Patient teaching - Prophylaxis Antibiotics

Answer 18

Teach pt’s with valve disease the importance of prophylactic antibiotic therapy before any invasive dental or oral procedure.

This includes patients with a previous history of endocarditis and cardiac transplant or valve recipients.

Have patients demonstrate appropriate oral hygiene because optimal oral health is the best intervention to prevent endocarditis.

Prophylactic antibiotics are NOT recommended before GI procedures such as upper GI endoscopy, colonoscopy, or procedures requiring genitourinary instrumentation.

Question 19

What is the best way to prevent endocarditis?
A. brush teeth twice a day and after eating
B. floss teeth
C. Use peroxide oral swish
D. Brush teeth for 5 minutes

Answer 19

A. brush teeth twice a day and after eating

Question 20

Should patients with Endocarditis floss?

Answer 20

• Advise patients to use a soft toothbrush, to brush their teeth at least twice per day, and to rinse the mouth with water after brushing.
  They should NOT use irrigation devices or floss the teeth because bacteremia may result.

Question 21

What does the transcatheter aortic valve replacement (TAVR) do?

Answer 21

bioprosthetic valve placed over stenotic valves.

This procedure is usually performed through a small incision in the groin allowing for bilateral transfemoral access.

. One access is used to place the prosthetic valve while the other is used to place a temporary transvenous pacemaker.

After initial balloon aortic valvuloplasty, the new valve is wrapped around a balloon on a large catheter that is inserted via the femoral artery

The patient is then transvenously paced temporarily at a rate of about 200 beats/min to reduce cardiac output and cardiac motion.

Question 22

Which of the following should the cardiovascular team be prepared to initiate during the transcatheter aortic valve replacement (TAVR)?

A. Heart Transplant
B. Coronary Artery Bypass Graft
C. Kidney replacement
D. surgical aortic valve replacement

Answer 22

D. surgical aortic valve replacement

The team must be prepared to convert to an open or surgical aortic valve replacement (SAVR) if necessary.

If SAVR is required, care of the patient is similar to that of the patient undergoing coronary artery bypass graft (CABG) (

Question 23

Post-op care and teaching for transcatheter aortic valve replacement (TAVR)?

Answer 23

MONITOR FOR BLEEDING

institute postangiogram precautions
-Do not do strenuous exercise
-Do not lift, pull, or push anything heavy

BEDREST FOR 6 HOURS

LIFE LONG ANTIPLATELET THERAPY

Antiplatelet therapy with lifelong daily aspirin

Clopidogrel for the first 6 months

Question 24

Your patient who is a body builder is coming out of the operation room following transcatheter aortic valve replacement. Which of the following statements made by the patient requires further teaching?
A. Since this procedure is minimally invasive I can start lifting weights when I get discharged.
B. I must remain on bedrest for 6 hour after the surgery.
C. I have to be on life long anticoagulant therapy and not lift anything heavy for 6 weeks
D. My provider may prescribe Clopidogre because it l has less side effects than aspirin

Answer 24

A. Since this procedure is minimally invasive I can start lifting weights when I get discharged.

MONITOR FOR BLEEDING

institute postangiogram precautions
-Do not do strenuous exercise
-Do not lift, pull, or push anything heavy
-FOR 6 WEEKS POST OPP

BEDREST FOR 6 HOURS

LIFE LONG ANTIPLATELET THERAPY

ADMINISTRATION OF CLOPIDOGREL AND ASPIRIN FOR THE FIRST 6 MONTHS

antiplatelet therapy with lifelong daily aspirin and clopidogrel for the first 6 months

Question 25

How long does a patient have to wait to resume upper extremities lifting after valve replacement? A. 1 day B. 4 months C. 6 weeks D. 10 days

Answer 25

. Most patients can usually return to normal activity after 6 weeks but should **avoid heavy physical activity involving their upper extremities for 3 to 6 months to allow the incision to heal.**

Question 26

A patient with Valve disorders take a prophylaxis prior to any dental or oral work? A. No B. Yes

Answer 26

B. Yes **Teach patients with valve disease the importance of prophylactic antibiotic therapy before any invasive dental or oral procedure.** **This includes patients with a previous history of endocarditis and cardiac transplant or valve recipients. ** **Have patients demonstrate appropriate oral hygiene because optimal oral health is the best intervention to prevent endocarditis.** Prophylactic antibiotics are NOT recommended before GI procedures such as upper GI endoscopy, colonoscopy, or procedures requiring genitourinary instrumentation.

Question 27

When should surgical procedure be done for a patient with valvular disease?

Answer 27

These procedures are performed after symptoms of** left ventricular failure have developed but before irreversible dysfunction occurs. **

Question 28

What is the only definite treatment for Aortic Stenosis?

Answer 28

Surgical therapy is the only definitive treatment of aortic stenosis and is recommended when angina, syncope, or dyspnea on exertion develops.

Question 29

What are the two types heart valve replacement procedures?

Answer 29

- Biologic -Synthetic The development of a wide variety of prosthetic (synthetic) and biologic (tissue) valves has improved the surgical therapy and prognosis of valvular heart disease. Each type has advantages and disadvantages.

Question 30

Where do biologic valves(xenografts) typically come from?

Answer 30

Biologic valve replacements may be xenograft (from other species), such as a porcine valve (from a pig) (Fig. 32.5) or a bovine valve (from a cow). Because tissue valves are associated with litte risk for clot formation, **long- term anticoagulation is not indicated.**

Question 31

When should xenografts be replaced?

Answer 31

Every 7 to 10 years Xenografts are not as durable as prosthetic valves and usually must be replaced every 7 to 10 years.

Question 32

Do biologic valves require life long anticoagulant therapy? A. No B. Yes

Answer 32

A. No Because tissue valves are associated with lile risk for clot formation, long- term anticoagulation is not indicated

Question 33

Which of the following should be initiated prior to valve replacement surgery? Select all that apply A. Administration of iodine B. administration of metoprolol C. Dental carries removal D. seize anticoagulant medications 72 hrs prior to procedure E. IV potassium

Answer 33

D. seize anticoagulant medications 72 hrs prior to procedure C. Dental carries removal **Patients need to have a preoperative dental examination. If dental caries or periodontal disease is present, these problems must be resolved before valve replacement.** **Teach patients receiving oral anticoagulants to stop taking them before surgery, usually at least 72 hours before the procedure.**

Question 34

How long does mechanical valve replacements last?

Answer 34

20 years

Question 35

What sound is made by mechanical valve

Answer 35

patients may experience an altered self- image as a result of the required lifestyle changes or the visible medial sternotomy incision. In addition, those with prosthetic valves may need to adjust to a soft but audible clicking sound of the valve. Encourage patients to verbalize their feelings about the prosthetic heart valve. They may display a variety of emotions after surgery, especially after hospital discharge.

Question 36

Do mechanical valves require life long anticoagulant therapy? A. No B. Yes

Answer 36

B. Yes When a patient has a mechanical valve, lifelong anticoagulant therapy with warfarin is required. Teach the patient that the international normalized ratio (INR) will need to be monitored frequently.

Question 37

What type of precautions should patients with mechanical valve replacement be on? A. neutropenic B. contact C. bleeding D. airborne

Answer 37

C. bleeding **o use an electric razor to avoid skin cuts. In addition, teach him or her to report any bleeding or excessive bruising to the primary health care provider.**

Question 38

What is the therapeutic INR for a patient who has a **mechanical valve** and is been prescribed **warfarin**? A. 0.9 B. 3.5 C. 2.5 D. 1.2

Answer 38

B. 3.5 **The therapeutic goal for patients with mechanical heart valves is 3.0 to 4.0**

Question 39

Your patient shares that she has needed a root canal for 2 years. She has a past medical history of mechanical valve replacement 4 months ago. Which of the following statements made by the patient is correct? A. I should take an acyclovir before any dental procedure B. I should ask for a prophylaxis antibiotic before any dental procedure. C. I should stop my anticoagulant therapy 12 hours before my pace maker insertion. D. I should take penicillin before my gastrointestinal surgery

Answer 39

**B. I should ask for a prophylaxis antibiotic before any dental procedure.** * Notify all your health care providers that you have a defective heart valve. * Remind the health care provider of your valvular problem when you have any invasive dental work (e.g., extraction). * Request antibiotic prophylaxis before and after these procedures if the health care provider does not offer it. * Notify your primary health care provider immediately if you experience fever, petechiae (pinpoint red dots on your skin), or shortness of breath. **Those who have had valvular surgery should also avoid invasive dental procedures for 6 months because of the potential for endocarditis.**

Question 40

Your patient is 4 months post-op mechanical valve replacements. On assessment, you notice she has petechia on her skin. She has a high fever and also a murmur that changes in location. Which of the following disease processes would you suspect your patient to have? A. Dialated Cardiomyopathy B. Cardiac Tamponade C. Pericarditis D. Ineffective Endocarditis

Answer 40

D. Ineffective Endocarditis * Notify your primary health care provider immediately if you experience fever, petechiae (pinpoint red dots on your skin), or shortness of breath. **Those who have had valvular surgery should also avoid invasive dental procedures for 6 months because of the potential for endocarditis.**

Question 41

Your patient is taking warfarin. Which food items should the patient avaoid eating? A. green leafy vegetables B. rice C. oatmeal D. spaghetti

Answer 41

A. green leafy vegetables Teach patients taking anticoagulants how to manage their drug therapy successfully, including nutritional considerations (if taking warfarin) and the prevention of bleeding. For example, the patient should be taught to avoid foods high in vitamin K, especially dark green leafy vegetables, and to use an electric razor to avoid skin cuts. In addition, teach him or her to report any bleeding or excessive bruising to the primary health care provider.

Question 42

Patient teaching post op

Answer 42

Remind patients to obtain a medical alert bracelet, card, or necklace to indicate that they have a valve replacement and are taking anticoagulants. For example, the patient should be taught to avoid foods high in vitamin K, especially dark green leafy vegetables, and to use an electric razor to avoid skin cuts. In addition, teach him or her to report any bleeding or excessive bruising to the primary health care provider.

Question 43

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. “I need to brush my teeth at least twice daily and rinse with water.” B. “I will eat foods that are low in vitamin K, such as potatoes and iceberg leuce.” C. “I need to take a full course of antibiotics prior to my colonoscopy.” D. “I will take my blood pressure every day and call if it is too high or low.”

Answer 43

C. “I need to take a full course of antibiotics prior to my colonoscopy.”