Valve Disorders

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 Heart Valves

The valves of the heart control the flow of blood through the heart into the
pulmonary artery and aorta by opening and closing in response to the blood
pressure changes as the heart contracts and relax through the cardiac cycle.

Valve problems can lead to conditions such as valve stenosis (narrowing)

or valve regurgitation (leakage). There are four valves:

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• Mitral valve: This valve is located between the left atrium and left
ventricle. It has two cusps that open to allow blood to flow from the left
atrium into the left ventricle, and close to prevent blood from flowing back
into the left atrium when the left ventricle contracts.

• Aortic valve: This valve is located between the left ventricle and the aorta,
which carries blood to the rest of the body. It has three cusps that open to
allow blood to flow from the left ventricle into the aorta, and close to
prevent blood from flowing back into the left ventricle when the heart
relaxes. 5
Tricuspid valve: This valve is located between the right atrium and right ventricle.
It has three cusps, or flaps, that open to allow blood to flow from the right atrium
into the right ventricle, and close to prevent blood from flowing back into the right
atrium when the right ventricle contracts.

Pulmonary valve: This valve is located between the right ventricle and the
pulmonary artery, which carries blood to the lungs. It has three cusps that open to
allow blood to flow from the right ventricle into the pulmonary artery, and close to
prevent blood from flowing back into the right ventricle when the heart relaxes.

‫ ايمان قاسم‬.‫م‬ 6
‫م‪ .‬ايمان قاسم‬ ‫‪7‬‬
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 Cardiovascular Physical Assessment
Inspection: looking for visible signs of cardiovascular disease such as
cyanosis, pallor, or edema.

Palpation: feeling for pulsations, thrills, or heaves over the chest and
assessing peripheral pulses.

Percussion: tapping the chest to assess the size and borders of the heart.

Auscultation: listening to heart sounds with a stethoscope to detect murmurs,

gallops, or other abnormal sounds
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 Diagnostic Tests and Procedures
Electrocardiogram (ECG or EKG): measures the electrical activity of the heart and

helps diagnose abnormal heart rhythms or damage to the heart muscle.

Echocardiography: This non-invasive test uses sound waves to create images of the

heart and assess the structure, function, and blood flow.

Cardiac stress testing: This test involves exercising on a treadmill or stationary bike

while the heart is monitored to evaluate heart function during physical activity.

Cardiac catheterization: This invasive test involves inserting a thin, flexible tube

through a blood vessel in the groin or arm and guiding it to the heart to measure the

pressure in the heart chambers and arteries, and to assess blood flow. 12
Coronary angiography: This is a type of cardiac catheterization that involves
injecting dye into the coronary arteries to assess for blockages or narrowing.
Holter monitor: This is a portable device that records the heart’s rhythm for 24-48
hours, to detect abnormal heart rhythms.
Blood tests: cholesterol levels, blood sugar levels, and kidney function, which are
important factors in the development and management of cardiovascular disease.
Chest X-ray: provides information about the size and shape of the heart, the
presence of fluid in the lungs, or the presence of any other abnormality.
Transesophageal echocardiography (TEE): This is a type of echocardiogram that
involves inserting a small ultrasound probe into the esophagus to get a better view
of the heart and its structures.
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Terminology
• Ejection fraction: percentage of the end-diastolic blood volume ejected from the ventricle with each
heartbeat

• Prolapse: (of a valve): stretching of an atrioventricular heart valve leaflet into the atrium during systole

• Regurgitation: a backward flow of blood through a heart valve (synonym: insufficiency)

• Stenosis: narrowing or obstruction of a cardiac valve’s orifice

• total artificial heart: mechanical device used to aid a failing heart, replacing the right and left ventricles

• Valve replacement: insertion of either a mechanical prosthetic valve or a bioprosthetic, homograft, or

autograft tissue valve at the site of a malfunctioning heart valve to restore normal blood flow through the
heart.

• Valvuloplasty: repair of a stenosed or regurgitant cardiac valve by commissurotomy, annuloplasty, or

leaflet repair (or a combination of procedures).
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• Chordae tendineae: non-distensible fibrous strands connecting papillary muscles to atrioventricular
(mitral, tricuspid) valve leaflets

• Leaflet repair: repair of a cardiac valve’s movable “flaps” (leaflets)

• Commissurotomy: splitting or separating fused cardiac valve leaflets

• Annuloplasty: repair of a cardiac valve’s outer ring.

• Autograft: heart valve replacement made from the patient’s own heart valve (e.g., pulmonic valve
excised and used as an aortic valve).

• Homograft: heart valve replacement made from a human heart valve (synonym: allograft)

• Bioprosthesis: heart valve replacement made of tissue from an animal heart valve (synonym:
heterograft)

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 Valvular disorders

When any heart valve does not close or open properly, blood flow is
affected. When valves do not close completely, blood flows backward
through the valve, a condition called regurgitation. When valves do

not open completely, a condition called stenosis, blood flow through

the valve is reduced.

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 1-Mitral Regurgitation

o Mitral regurgitation involves blood flowing back from the left

ventricle into the left atrium during systole.

o The leaflets cannot close completely during systole because the leaflets
and chordae tendineae have thickened and fibrosis, resulting in their
contraction

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Classification

 Acute (less common): This type of regurgitation occurs suddenly and is often
caused by a rupture of the mitral valve due to trauma or infection.

 Chronic (common): This type of regurgitation develops gradually over time

and is often caused by degeneration or damage to the mitral valve.

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 Primary Causes:

 Mitral valve prolapse: This occurs when the flaps (or leaflets) of the mitral valve do not
close tightly, causing blood to flow backward into the left atrium.
 Mitral valve leaflet rupture: This occurs when one or more of the leaflets tear, causing
blood to flow backward.
 Congenital heart defects: Some congenital heart defects can affect the structure of the
mitral valve and lead to regurgitation.
 Rheumatic heart disease: This is a complication of untreated strep throat or scarlet
fever that can cause damage to the heart valves, including the mitral valve.
 Endocarditis: This is an infection of the inner lining of the heart that can damage the
mitral valve and cause regurgitation. 21
Secondary Causes:
 Left ventricular dysfunction: When the left ventricle of the heart is enlarged or weakened, it can
affect the function of the mitral valve, leading to regurgitation.
 Coronary artery disease: This can cause damage to the heart muscle and affect the function of the
mitral valve.
 Cardiomyopathy: This is a disease of the heart muscle that can lead to left ventricular dysfunction
and mitral valve regurgitation.
 Aortic valve disease: When the aortic valve is diseased, it can affect the function of the mitral valve
as well.
 Hypertension: Long-standing hypertension can cause left ventricular dysfunction and mitral valve
regurgitation.
 Connective tissue disorders: Some connective tissue disorders, such as Marfans’ syndrome, can
affect the structure of the mitral valve and lead to regurgitation. 22
Causes (summery):
 Rheumatic fever: This is a type of bacterial infection that can cause
inflammation and damage to the mitral valve.
 Degenerative valve disease: This is a condition in which the mitral valve
becomes stiff and thickened over time, which can lead to regurgitation.
 Heart attack: A heart attack can cause damage to the heart muscle, including
the mitral valve, which can lead to regurgitation.
 Infective endocarditis: This is a bacterial infection that can affect the heart
valves, including the mitral valve.

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Risk factors

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 Gender

Non- Family
modifiable Age
history

Congenital
heart disease
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 Hypertension

Coronary artery
Alcohol disease,
Atherosclerosis

Modifiable

Smoking Obesity

Diabetes
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 Maintaining a healthy Eating a heart-healthy
weight diet

Limiting alcohol
Exercising regularly
consumption
Prevention

Managing high blood Avoiding tobacco use

pressure and cholesterol

Treating underlying
medical conditions

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 Pathophysiology
Some of the blood is forced back into the left atrium with each beat of LV

LA to stretch and (in time) hypertrophy and dilate.

Backward blood flow from the LV diminishes the volume of blood flowing into
LA from the lungs.

The lungs become congested, eventually adding extra strain on the right ventricle.
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 Clinical Manifestations

Myocardial infarction
Chronic MR
resulting (AMR)

severe and sudden

Asymptomatic Pulmonary Edema
congestive heart failure.

Dyspnea, fatigue, and weakness Palpitations, shortness of breath

are the most common on exertion, and cough
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 Fatigue: due to decreased cardiac output (CO).

 Shortness of breath: particularly during physical activity or when lying flat.

 Chest discomfort: particularly if the condition is severe and there is a significant

decrease in (CO).

 Palpitations: due to atrial fibrillation or other arrhythmias.

 Edema: in legs, ankles, and feet due to fluid buildup as a result of decreased
cardiac output.

 Cough: persistent cough, particularly at night or when lying flat.

 Dizziness or lightheadedness: As cardiac output decreases, particularly upon

standing. 30
 Assessment and Diagnostic Findings
• The systolic murmur of mitral regurgitation is a blowing sound best heard
at the apex.

• The murmur may radiate to the left axilla.

• The pulse may be regular, or it may be irregular because of extra systolic

beats or atrial fibrillation.

• Echocardiography is used to diagnose and monitor the progression of this

disorder

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 Medical management

• The medical management of mitral valve regurgitation depends on the

severity of the condition and its underlying cause. Mild cases may not
require any treatment, while more severe cases may require medication,
lifestyle modifications, or even surgery.

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 Medications: prescribed to manage the symptoms, such as diuretics to
reduce fluid buildup, ACE inhibitors to lower blood pressure, and beta
blockers to control heart rate.
 Lifestyle modifications: help manage the symptoms and reduce the
risk of complications. This may include (maintaining a healthy weight,
and healthy diet, exercising regularly, limiting alcohol consumption,
managing high blood pressure and cholesterol levels, and avoiding
tobacco use.

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 Monitoring: is important to ensure that the condition is not worsening and
to adjust treatment as needed. This may involve regular echocardiograms.
 Anticoagulation therapy: to reduce the risk of stroke or other
complications.
 Endocarditis prophylaxis: Patients with mitral valve regurgitation are at
increased risk for endocarditis, an infection of the heart lining. Therefore,
they may need to take antibiotics before certain medical procedures to
reduce the risk of infection.

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2- Mitral Stenosis

o results in reduced blood flow from the left atrium into the left ventricle. It
is usually caused by rheumatic endocarditis.
o progressively thickens mitral valve leaflets and chordae tendineae,
causing the leaflets to fuse together.
o The mitral valve orifice narrows and progressively obstructs blood flow
into the ventricle.

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Classification

Mild Stenosis: a mitral valve area greater than 1.5 cm². Patients are usually
asymptomatic, and medical management may be sufficient to control symptoms.
Moderate Stenosis: a mitral valve area between 1.0 and 1.5 cm². Patients may
have symptoms such as shortness of breath, fatigue, and palpitations, and medical
management may be sufficient to control symptoms.
Severe Stenosis: a mitral valve area less than 1.0 cm². Patients may have
significant symptoms such as chest pain, fainting, and heart failure. Treatment
may include medical management, balloon valvuloplasty, or surgical intervention
such as mitral valve replacement 37
 Causes
1. The most common cause of mitral stenosis is rheumatic fever, which is caused by
an infection with Group A Streptococcus bacteria.
2. Other causes of mitral stenosis include:
 Congenital heart defects: Some individuals may be born with a narrowed or deformed
mitral valve.
 Mitral annular calcification: Calcium deposits can build up around the mitral valve,
leading to narrowing and stiffness.
 Infective endocarditis: A bacterial infection of the heart valves can cause scarring and
damage to the mitral valve, leading to stenosis.
 Systemic lupus erythematosus: This autoimmune disorder can cause inflammation and
scarring of the heart valves.
 Radiation therapy: Radiation therapy to the chest can cause scarring and narrowing of
the heart valves, including the mitral valve
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Risk factors

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 Gender

Non-
modifiable Genetics

Age

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 Rheumatic
fever

Modifiable Radiation Infective

therapy endocarditis

Systemic
lupus
erythematosus
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Clinical Manifestations

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Dyspnea on exertion (DOE) is the most common symptom, which occurs due to pulmonary
venous congestion.
Fatigue and decreased exercise tolerance due to low cardiac output.
Palpitations may occur due to atrial fibrillation or other atrial arrhythmias.
Hemoptysis (coughing up blood), may occur in cases of severe mitral stenosis with significant
pulmonary congestion.
Chest pain may occur due to the increased workload on the heart.
Orthopnea (shortness of breath when lying flat).
Paroxysmal nocturnal dyspnea (PND), is a sudden onset of shortness of breath during sleep.
Dry cough or wheezing may occur due to the enlargement of the left atrium and pressure on
the left bronchial tree.
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Rheumatic fever (RF):
Most cases of mitral
stenosis are caused by A
Streptococcus bacteria,
which can lead to RF, that
can cause damage to the
heart valves.
Right heart failure: If
untreated, the continued
increase in pulmonary
pressure and right
ventricular hypertrophy
can eventually lead to
right heart failure.
Thickening of the valve:
Obstruction of blood flow:
the valve become
narrowed valve obstructs blood
thickened and calcified
flow from the LA to the LV,
due to scarring from the
causing increase pressure in the
inflammatory process,
Lam and This lead to atrial
causes the valve to
dilation and hypertrophy.
become stiff and narrow.
Pathophysiology
Pulmonary congestion:
Right ventricular hypertrophy:
increased pressure in the
Over time, the increased
LA can also cause blood
pulmonary pressure can cause the
to back up into the
right ventricle to hypertrophy in
pulmonary circulation,
order to overcome the increased
leading to pulmonary
resistance in the pulmonary
congestion and
circulation.
symptoms such as cough
and shortness of breath.
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 Assessment and Diagnostic Findings
 Physical Assessment:
 A low-pitched, rumbling diastolic murmur is heard best at the apex.
 Weak and irregular pulse in the presence of atrial fibrillation.
 Signs and symptoms of heart failure.

 Diagnostic Tests and Procedures:

 Echocardiography is used to diagnose and quantify the severity of mitral stenosis.
 Electrocardiography (ECG) may be used to help determine the severity of mitral stenosis.
 Exercise testing may be used to assess functional capacity and the severity of symptoms.
 Cardiac catheterization with angiography may be used to assess the severity of mitral stenosis
and to determine the need for intervention.

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 Prevention

• Antibiotic prophylaxis for recurrent rheumatic fever with rheumatic carditis

may require 10 or more years of antibiotic coverage.

• Common antibiotics used for prophylaxis include penicillin G

intramuscularly every 4 weeks, penicillin V orally twice daily, sulfadiazine
orally daily, or erythromycin orally twice daily.

• Proper antibiotic prophylaxis can help reduce the risk of developing mitral
stenosis in individuals with a history of rheumatic fever
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 Medical Management

A. Medications:

Diuretics to reduce fluid buildup and ease breathing difficulties

Beta-blockers, calcium channel blockers, or digoxin to control heart rate

and improve blood flow

Anticoagulants to reduce the risk of blood clots

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B. Lifestyle modifications:
Avoid strenuous activities and competitive sports
Maintain a healthy weight
Quit smoking
Manage stress
Get regular check-ups and follow-up care
C. Cardiac monitoring:
Patients with mitral stenosis should have regular cardiac monitoring to assess
the severity of the condition and monitor for complications.
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Surgical Management: Valve Repair and
Replacement Procedures

‫ ايمان قاسم‬.‫م‬ 49
1. Valvuloplasty: Repair of a cardiac valve, rather than replacement, The
recommended procedure depends on the cause and type of valve dysfunction

 Commisurotomy is an of the repairs commissures between the leaflets.

 Annuloplasty is a repair of the outer ring of the cardiac valve's annulus.

 Leaflet Repair cut a wedge of tissue from the middle of the leaflet and
suture the gap closed.

 A transesophageal echocardiogram (TEE) is performed after valvuloplasty to

evaluate the effectiveness

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Some valvuloplasty procedures are open-heart surgeries, which use
cardiopulmonary bypass and general anesthesia

Nonsurgical, or percutaneous, valvuloplasty procedures do not require general

anesthesia or cardiopulmonary bypass and can be performed in a cardiac
catheterization laboratory or hybrid room

A hybrid room is an operating room with imaging capability and interventional

devices for open, minimally invasive, image-guided, and catheter-based
procedures

Percutaneous partial cardiopulmonary bypass may be used in some cardiac

catheterization laboratories and hybrid rooms.
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Annuloplasty Ring Insertion

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Leaflet Repair

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2. Valve replacements: There are two types:

Mechanical valves are made of durable materials (e.g., titanium, carbon,

pyrolytic carbon) and are long-lasting, but require lifelong
anticoagulation therapy to prevent blood clot formation.

Bioprosthetic valves are made of animal or human tissue (usually from

pig, cow, or human) and do not require anticoagulation therapy, but may
need to be replaced after about 10-15 years due to wear and tear.

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Valve Replacement

‫ ايمان قاسم‬.‫م‬ 56
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Nurse Management

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1. Assessment:


- Obtain a detailed medical history and perform a physical examination,
including auscultation of the heart.
 Assess the patient's signs and symptoms, such as dyspnea, fatigue, chest pain,
palpitations, cough, and edema.
 Assess the patient's medication regimen, including anticoagulants and diuretics.
 Assess the patient's activity level and functional capacity.
 Assess the patient's psychosocial and emotional status.

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2- Nursing Diagnosis:
Impaired Gas Exchange R/T decreased cardiac output and pulmonary congestion

Interventions:
 Monitor vital signs, oxygen saturation, and respiratory rate regularly
 Administer supplemental oxygen as ordered and monitor response
 Assist with positioning to promote optimal lung expansion
 Administer diuretics and other medications as ordered to reduce pulmonary congestion
 Encourage deep breathing and coughing exercises to help clear secretions
 Monitor for signs of respiratory distress and notify the physician as needed
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Impaired Gas Exchange R/T decreased cardiac output and pulmonary congestion

Interventions:
 Monitor vital signs, oxygen saturation, and respiratory rate regularly
 Administer supplemental oxygen as ordered and monitor response
 Assist with positioning to promote optimal lung expansion
 Administer diuretics and other medications as ordered to reduce pulmonary congestion
 Encourage deep breathing and coughing exercises to help clear secretions
 Monitor for signs of respiratory distress and notify the physician as needed

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Activity Intolerance R/T decreased cardiac output and fatigue

Interventions:
 Assess the patient's level of activity tolerance and monitor for signs of fatigue
 Assist with activities of daily living as needed to conserve energy
 Implement a progressive activity plan to gradually increase endurance
 Monitor vital signs and symptoms during activity and adjust the plan as needed
 Encourage rest periods as needed throughout the day
 Administer medications as ordered to manage symptoms of fatigue

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Risk for Infection related to invasive procedures and immunosuppression

Interventions:
 Monitor for signs and symptoms of infection, including fever, and chills.
 Maintain strict hand hygiene and infection control precautions
 Monitor incision sites for signs of infection and report any changes to the physician
 Administer prophylactic antibiotics as ordered
 Educate patient and family on signs and symptoms of infection and when to seek
medical attention
 Encourage the patient to maintain good oral hygiene to reduce the risk of bacterial
endocarditis
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Anxiety R/T diagnosis and treatment

Interventions:
 Assess the patient's level of anxiety and coping mechanisms
 Provide education on the disease process, treatment options, and expected outcomes
 Encourage the patient to express concerns and provide emotional support
 Utilize relaxation techniques, such as deep breathing and guided imagery
 Administer anti-anxiety medications as ordered
 Refer the patient to support groups or counseling services as appropriate

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Any question?

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