Valvular

Heart
Diseases
VALVULAR HEART DISEASES
- Refers to alteration in the structure of the valve that
either impedes the blood flow or permits
regurgitation
- Aortic and mitral valves are more often affected than
do pulmonic and tricuspid valves
- Categories:
• Stenosis
• Insufficiency (Incompetence)

Etiology and Risk Factors:

• Myocardial Ischemia/Atherosclerosis
• Inflammation of the Endocardium
• Congenital Abnormalities of the Heart
 MITRAL VALVE DISEASE
1. Mitral Stenosis – narrowing of the mitral valve
that interferes with left ventricular filling and
produces pulmonary hypertension and right
ventricular failure. It is often caused by
rheumatic endocarditis.
Effects:
• Reduced flow into left ventricle
• Left atrial hypertrophy
• Pulmonary hypertension
• Right ventricular hypertrophy and failure
 Pathophysiology
Narrowing of mitral valve

Left atrium has great difficulty moving blood into

the ventricle because of the increased resistance
of the narrowed orifice

it dilates and hypertrophies due to increased

blood volume.

Since there is no valve to protect the pulmonary veins

from the backward flow of blood from the atrium, the
pulmonary circulation becomes congested.

As a result, the right ventricle must contract against an

abnormally high pulmonary arterial pressure and is subjected to
excessive strain. Eventually, the right ventricle fails.
 Signs and Symptoms
• Dyspnea on exertion as a result of
pulmonary venous hypertension.
• Progressive fatigue due to low cardiac
output.
• Hemoptysis
• Cough
• Repeated respiratory infections
 Assessment & Diagnostic
Findings
• The pulse is weak and often irregular
because of atrial fibrillation.
• A low-pitched, rumbling diastolic murmur
is heard at the apex.
 Medical Management
• Prophylactic antibiotics to prevent the
recurrence of infections.
• Anticoagulants such as warfarin (Coumadin)
to decrease the risk of thrombus formation at
the atrium. Make sure to check Prothrombin
Time (PT) and Partial Thromboplastin Time
(PTT) before giving the drug.
• PT – 10-12 seconds
• PTT – 30-45 seconds
• Valvuloplasty – repair of the valve through
surgery
2. Mitral Insufficiency – leaking or regurgitation of
blood back into the left atrium leading to
pulmonary hypertension and right ventricular
failure
Effects:
• Left atrial dilation and
hypertrophy
• Pulmonary
hypertension
• Right ventricular
hypertrophy
 Signs and Symptoms
• Usually asymptomatic, but acute mitral
regurgitation brought about by MI usually
manifests as severe CHF.
• Dyspnea, fatigue, and weakness are
common.
• Palpitations, SOB, and cough from
pulmonary congestion may occur.
 Assessment and Diagnostic
Findings
• A systolic murmur is heard as a high-
pitched, blowing sound at the apex.
• The pulse may be regular and of good
volume, or it may be irregular as a result of
extrasystolic beats or atrial fibrillation.
• Echocardiography is used to diagnose and
monitor the progression of mitral
regurgitation.
 Medical Management
• Same with CHF.
• Surgical intervention consists of mitral
valve replacement or valvuloplasty (ie,
surgical repair of the heart valve).
3. Mitral Valve Prolapse – one or both of the valve
leaflets bulge into the left atrium during ventricular
contractions
 AORTIC VALVE DISEASE
1. Aortic Stenosis – narrowing of the orifice of the
aortic valve which causes a decrease in cardiac
output and an increase pressure in the left
ventricle
Effects:
• Increased blood volume in left ventricle
• Left ventricular dilation and hypertrophy
• Decreased cardiac output
 Pathophysiology
There is progressive narrowing of the valve orifice, usually over a
period of several years to several decades.

The left ventricle overcomes the obstruction to circulation

by contracting more slowly but with greater energy than
normal, forcibly squeezing the blood through the very
small orifice.

The obstruction to left ventricular outflow increases pressure on the

left ventricle, which results in thickening of the muscle wall.

The heart muscle hypertrophies. When these

compensatory mechanisms of the heart begin to fail,
clinical signs and symptoms develop.
 Signs and Symptoms
• Many patients with aortic stenosis are asymptomatic.
• Patients usually first have exertional dyspnea, caused
by left ventricular failure.
• Other signs are dizziness and syncope because of
reduced blood flow to the brain.
• Angina pectoris is a frequent symptom that results
from the increased oxygen demands of the
hypertrophied left ventricle, the decreased time in
diastole for myocardial perfusion, and the decreased
blood flow into the coronary arteries.
• Blood pressure can be low but is usually normal; there
may be a low pulse pressure (30 mm Hg or less)
because of diminished blood flow.
 Assessment and Diagnostic
Findings
• Loud, rough systolic murmur may be heard over
the aortic area. The sound to listen for is a systolic
crescendo-decrescendo murmur, which may
radiate into the carotid arteries and to the apex of
the left ventricle.
• The murmur is low-pitched, rough, rasping, and
vibrating. If the examiner rests a hand over the
base of the heart, a vibration may be felt.
• The vibration is caused by turbulent blood flow
across the narrowed valve orifice.
• Evidence of left ventricular hypertrophy may be
seen on a 12-lead ECG and echocardiogram.
 Continuation…
• Echocardiography is used to diagnose and
monitor the progression of aortic stenosis.
• After the stenosis progresses to the point
that surgical intervention is considered,
left-sided heart catheterization is
necessary to measure the severity of the
valvular abnormality and evaluate the
coronary arteries.
 Medical Management
• Antibiotic prophylaxis to prevent
endocarditis is essential for anyone with
aortic stenosis.
• Definitive treatment for aortic stenosis is
surgical replacement of the aortic valve.
• Patients who are symptomatic and are not
surgical candidates may benefit from one-
or two-balloon percutaneous valvuloplasty
procedures
2. Aortic insufficiency– incomplete closure of the
aortic valve that causes backflow of blood into the
left ventricle from the aorta during diastole.
Effects:
• Increased blood volume in left ventricle
• Left ventricular dilation and hypertrophy
• Decreased cardiac output
 Pathophysiology
Blood from the aorta returns to the left ventricle during diastole in
addition to the blood normally delivered by the left atrium.

The left ventricle dilates, trying to accommodate

the increased volume of blood.

It also hypertrophies, trying to increase muscle strength to expel

more blood with abovenormal force—raising systolic blood
pressure.

The arteries attempt to compensate for the higher

pressures by reflex vasodilation; the peripheral
arterioles relax, reducing peripheral resistance and
diastolic blood pressure.
 Signs and Symptoms
• Asymptomatic in most patients.
• Some patients are aware of a forceful
heartbeat, especially in the head or neck.
• There may be marked arterial pulsations that
are visible or palpable at the carotid or
temporal arteries.
• Exertional dyspnea and fatigue follow.
• Progressive signs and symptoms of left
ventricular failure include breathing difficulties
(eg, orthopnea, paroxysmal nocturnal
dyspnea), especially at night.
 Assessment and Diagnostic
Findings
• A diastolic murmur is heard as a high-pitched, blowing
sound at the third or fourth intercostal space at the left
sternal border.
• The pulse pressure (ie, difference between systolic
and diastolic pressures) is considerably widened in
patients with aortic regurgitation.
• One characteristic sign of the disease is the water-
hammer pulse, in which the pulse strikes the palpating
finger with a quick, sharp stroke and then suddenly
collapses.
• Diagnosis may be confirmed by echocardiogram,
radionuclide imaging, ECG, magnetic resonance
imaging, and cardiac catheterization.
 Medical Management
• Before the patient undergoes invasive or
dental procedures, antibiotic prophylaxis is
needed to prevent endocarditis.
• Heart failure and dysrhythmias are treated.
• Aortic valvuloplasty or valve replacement is
the treatment of choice, preferably performed
before left ventricular failure. Surgery is
recommended for any patient with left
ventricular hypertrophy, regardless of the
presence or absence of symptoms.
 TRICUSPID VALVE DISEASE
1. Tricuspid Stenosis – narrowing of the tricuspid
valve that interferes with the right ventricular filling
and in increases right atrial pressure

1. Tricuspid Insufficiency – leaking of blood back

into the right atrium from the right ventricle

Effects:
• Decreased cardiac output
• Increased right atrial pressure
• Systemic Congestion
 PULMONIC VALVE DISEASE
1. Pulmonic Stenosis – narrowing of the orifice of
the pulmonic valve which causes a decreased
cardiac output and an increased pressure in
right ventricle

1. Pulmonic Insufficiency – incomplete closure

of the pulmonic valve that causes backflow of
blood into the right ventricle from the pulmonary
artery

Effects:
• Decreased cardiac output
• Increased right ventricular pressure
• Right ventricular dilation and hypertrophy
• Narrowing of valve between right ventricle
and pulmonary artery
• Regurgitation of blood from the right
ventricle back into the right atrium
• Valve leaflet bulges into the left atrium during
systole
• Reddish/Bluish discoloration of the face

• (+) Corrigan’s pulse

• (+) Mitral Click
• Decreased left ventricular filling and
increased pressure in the left atrium
• (+) Mitral Facies – rosy cheeks but the rest of
the face is cyanotic
Clinical Manifestation
1. Decreased Cardiac Output
• Fatigue, weakness
• SOB, pallor
• Low BP
• Weak, irregular pulse; Water-hammer pulse

2. Pulmonary Congestion
• Orthopnea, Paroxysmal Nocturnal Dyspnea
• Increased RR, shallow respiration
• Hemoptysis, pink-frothy sputum
• Pulmonary crackles
3. Systemic Congestion
• Peripheral edema, cyanosis
• Jugular vein distention, hepatojugular reflux
• Ascites, Congestive Hepatomegaly

4. Cardiac Manifestation
• Murmurs (sound produced by
abnormal/turbulent blood flow)
• S3 heart sound (ventricular gallop) – occurs
after S2 when the mitral valve opens.
• ECG changes
• Angina pectoris
Jugular vein distention
Ascites
Diagnostic Test
• Cardiac catheterization
• X-ray
• Echocardiography
• Electrocardiography
Management:
Goals: Maintain a normal cardiac output; improve
cardiac function and activity tolerance

✔ Monitor the client’s hemodynamic status (i.e., vs

q1-4 hours; auscultate breathe and heart sounds;
daily weight; check for murmurs, edema)

✔ Oxygen therapy to improve oxygenation and

relieve respiratory distress

✔ Plan rest periods and limit visitors, activity and

noise
✔ Administer the following medications as ordered:
• Digitalis (Digoxin) and other inotropic agents
(Dopamine, dobutamine)
• ACE inhibitors
• Diuretics
• Antibiotics
• Anticoagulants

✔ Monitor patient’s compliance/response to medications

✔ Monitor F&E balance

• I&O
• Daily weight
• Lung sounds
• Presence of Edema
✔ Dietary modifications and activity restrictions if
indicated

✔ Educate patient in possible care for valvular

surgeries

✔ Monitor for complications such as heart failure

SURGICAL MANAGEMENT

Candidates for surgery are those:

- Symptomatic clients
- Clients with progressive impairment of cardiac function
- Gradual enlargement of the heart

1. VALVULOPLASTY – repair or reconstruction of a

cardiac valve
a. Commissurotomy
▪ Open Commissurotomy
▪ Closed Surgical Commissurotomy
▪ Balloon Valvuloplasty
b. Annuloplasty – repair of the valve annulus
c. Chordoplasty – repair of the chordae tendinae
 B

A
C
Annuloplasty
2. VALVE REPLACEMENT – replacement of a
diseased valve by a valve prosthesis
a. Mechanical Valves (e.g., Ball-and-cage or
Disk valve)
b. Tissue Valves
▪ Xenografts – tissue valves from pigs or
cows are used
▪ Homografts/Allografts – obtained from
cadaver tissue donations.
▪ Autografts - are obtained by excising the
patient’s own pulmonic valve and a
portion of the pulmonary artery for use as
the aortic valve.
 Nursing Management Post-
Valvuloplasty and Replacement
• Vital signs are assessed every 5 to 15 minutes and as
needed until the patient recovers from anesthesia or
sedation and then assessed every 2 to 4 hours and as
needed.
• Intravenous medications to increase or decrease
blood pressure and to treat dysrhythmias or altered
heart rates are administered and their effects
monitored. The intravenous medications are gradually
decreased until they are no longer required or the
patient takes needed medication by another route (eg,
oral, topical).
• Patient assessments are conducted every 1 to 4 hours
and as needed, with particular attention to neurologic,
respiratory, and cardiovascular systems
 Continuation…
• The nurse educates the patient about long-term
anticoagulant therapy, explaining the need for
frequent follow-up appointments and blood
laboratory studies, and provides teaching about
any prescribed medication: the name of the
medication, dosage, its actions, prescribed
schedule, potential side effects, and any drug-drug
or drug-food interactions.
• Patients with a mechanical valve prosthesis
require education to prevent bacterial endocarditis
with antibiotic prophylaxis, which is prescribed
before all dental and surgical interventions.