MANAGEMENT OF PATIENTS WITH

STRUCTURAL, INFECTIOUS AND

INFLAMMATORY CARDIAC DISORDERS

PREPARED BY:
ANTHONY C. BARRERA, RN
 VALVULAR DISORDERS
• Involves valves of the heart (tricuspid, mitral, pulmonic, and
aortic valves)
• Examples are:
Mitral Valve Prolapse
Mitral Regurgitation
Mitral Stenosis
Aortic Regurgitation
Aortic Stenosis
MITRAL VALVE PROLAPSE
• Usually produces no symptoms.
• Rarely, it progresses and can result in sudden death
• No clear cause, but associated with inherited connective tissue
disorders
• One or both mitral valve leaflets balloons back into the atrium
during systole
• Can result in mitral regurgitation
CLINICAL MANIFESTATIONS
• Most people may never have symptoms
• Small number of patients will have fatigue, shortness of breath,
lightheadedness, dizziness, syncope, palpitations, chest pain, or
anxiety
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Extra heart sound (a mitral click)
• A murmur of mitral regurgitation may be heard
• Diagnostic procedure is echocardiography
MEDICAL MANAGEMENT
• Symptomatic management only
• Most patients do not require medication, but some are
prescribed antiarrhythmic medications
• For severe, mitral valve repair or replacement may be required
MITRAL REGURGITATION
• Blood flows from the left ventricle back into the left atrium
during systole.
• Edges of mitral valve leaflets do not close completely during
systole.
• May be chronic or, less commonly, acute
• Common causes are degenerative changes of the mitral valve,
ischemia of the left ventricle, rheumatic heart disease
CLINICAL MANIFESTATIONS
• Chronic mitral regurgitation is often asymptomatic
• Acute mitral regurgitation manifests as severe and sudden
congestive heart failure
• Common symptoms: dyspnea, fatigue, and weakness
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Systolic murmur
• Pulse may be regular or irregular
• Diagnostic procedure is echocardiography
MEDICAL MANAGEMENT
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Beta-blockers
• Surgical intervention: mitral valvuloplasty, valve replacement,
MitraClip (for degenerative form of regurgitation)
MITRAL STENOSIS
• Reduced blood flow from the left atrium into the left ventricle
due to narrowed mitral valve orifice
• Usually caused by rheumatic endocarditis
CLINICAL MANIFESTATIONS
• First symptom: dyspnea on exertion (DOE)
• progressive fatigue
• decreased exercise tolerance
• dry cough or wheezing
• For severe: hemoptysis, palpitations, orthopnea, paroxysmal
nocturnal dyspnea, atrial arrhythmias
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Low-pitched, rumbling diastolic murmur
• Weak and irregular pulse
• Echocardiography used to diagnose and quantify the severity
MEDICAL MANAGEMENT
• Anticoagulant medications
• If atrial fibrillation develops, cardioversion may be attempted
• Surgical intervention: valvuloplasty, commissurotomy,
percutaneous transluminal valvuloplasty
AORTIC REGURGITATION
• Also called aortic insufficiency
• Backward flow of blood into the left ventricle from the aorta
during diastole
• Causes: congenital valve abnormality, inflammatory lesions at
the aortic valve leaflets, rheumatic endocarditis, blunt chest
trauma
CLINICAL MANIFESTATIONS
• Pounding or forceful 2121 heartbeat, especially in the head or
neck
• visible or palpable arterial pulsations at the carotid or temporal
arteries
• Dyspnea on exertion (DOE), SOB
• Fatigue, orthopnea
ASSESSMENT AND DIAGNOSTIC FINDINGS
• High-pitched, blowing diastolic murmur is heard at the third or
fourth intercostal space at the left sternal border
• Water hammer (Corrigan’s) pulse
• Diagnostic procedure: echocardiography, cardiac magnetic
resonance imaging (MRI), cardiac catheterization
MEDICAL MANAGEMENT
• If atrial fibrillation develops, cardioversion may be attempted
• ACE inhibitors
• Dihydropyridine calcium channel blockers
• Surgical intervention: aortic valve replacement or valvuloplasty
AORTIC STENOSIS
• Narrowing of the orifice between the left ventricle and aorta
• Caused by degenerative calcification, congenital leaflet
malformations, Rheumatic endocarditis
CLINICAL MANIFESTATIONS
• Often asymptomatic
• first symptom to appear is dyspnea on exertion (DOE)
• Other symptoms: orthopnea, pulmonary edema, paroxysmal
nocturnal dyspnea (PND), syncope, angina pectoris,
• low pulse pressure (30 mm Hg or less)
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Loud, harsh systolic murmur is heard over the aortic area and
may radiate to the carotid arteries and apex of the left ventricle
• S4 sound may be heard
• Palpable vibration
• Diagnostic procedure: echocardiography, cardiac MRI, or
computed tomography (CT) scanning, left-sided heart
catheterization, graded exercise studies (stress tests)
MEDICAL MANAGEMENT
• Anti-arrhythmia medications
• Transcatheter aortic valve replacement (TAVR)
• Balloon percutaneous valvuloplasty
NURSING MANAGEMENT
• Instruct patient to report new symptoms or changes in
symptoms
• educate the patient about how to minimize the risk of
developing infective endocarditis
• advised to avoid strenuous activities, physical exertion,
competitive sports, and pregnancy
• restrict sodium intake
NURSING MANAGEMENT
• Monitor vital signs and note ant changes
• Assess patient for signs and symptoms of heart failure: fatigue,
DOE, decreased activity tolerance, coughing, hemoptysis
• Monitor for any arrhythmias
• Collaborate with the patient to develop a medication schedule
• Educate the patient about the diagnosis, progressive nature of
the disease including the infectious pathogen, and treatment
plan
SURGICAL MANAGEMENT
• Valvuloplasty = repair of cardiac valve
• Types of valvuloplasty:
1. Commissurotomy
2. Annuloplasty
• Transesophageal Echocardiogram (TEE)
COMMISSUROTOMY
Types of commissurotomy:
1. Closed Commissurotomy/Balloon Valvuloplasty
 Most often used for mitral and aortic stenosis
 Non-surgical or percutaneous technique
 Contraindicated for patients with left atrial or ventricular
thrombus, severe aortic root dilatation, significant mitral valve
regurgitation, and severe valvular calcification
 Performed in a cardiac catheterization laboratory
Mitral Balloon Valvuloplasty
• The Inoue-Balloon inflates in three
stages:
 1st below the valve,
 2nd above the valve
 3rd in the valve orifice
Types of commissurotomy:
II. Open Commissurotomy
 Involves open heart surgery
 Less commonly used
 Advantage: removal of thrombus or calcification, if present
SURGICAL MANAGEMENT CONT…

ANNULOPLASTY
 Refers to repair of the valve annulus, resulting to narrowing of
the valve orifice
 Used for valvular regurgitation.
Involves 2 techniques:
1. With the use of annuloplasty ring
2. Tightening the annulus
Annuloplasty Ring Insertion
LEAFLET REPAIR
 Achieved by removing the extra tissue
 Elongated tissue may be tucked or sutured, a technique called
plication, with the use of pericardial or synthetic patch
SURGICAL MANAGEMENT CONT…

CHORDOPLASTY
 Repair of the chordae tendineae
SURGICAL MANAGEMENT CONT…

VALVE REPLACEMENT
 Preferred procedure for patient with less chance of success
with repair
 Indicated for valves with extensive calcification, severely
fibrotic or fused leaflets, chordae tendineae, or papillary
muscles
 Involves open heart surgery
 Cardiopulmonary bypass or sternotomy is needed
VALVE REPLACEMENT
MECHANICAL AND TISSUE VALVES
MECHANICAL VALVES
• Examples are bileaflet, tilting disc, caged ball
• More durable than tissue prosthetic valves
• Often used for younger patients
TISSUE VALVES
• Has three (3) types:
1. Bioprosthesis = made from animal tissue (heterography) and used
for aortic, mitral, and tricuspid valve replacement
2. Homografts (allografts) = obtained from cadaver tissue donations
(human valves) and used for aortic and pulmonic valve
replacement
3. Autografts (autologous valves) = obtained from patients own
pulmonic valve and a portion of pulmonary artery for use as the
aortic valve
NURSING MANAGEMENT FOR SURGICAL PATIENT
• Assesses for signs and symptoms of heart failure and emboli
• Auscultate the chest for changes in heart sounds at least every 4
hours
• Vital signs are assessed every 5 to 15 minutes and as needed
until the patient recovers from anesthesia or sedation, and then
are assessed according to unit protocol.
• Intravenous (IV) medications may be used to increase or
decrease blood pressure, to treat arrhythmias, to increase or
decrease heart rate
NURSING MANAGEMENT FOR SURGICAL PATIENT
• Health teaching about wound care and patient education
regarding diet, activity, medications, and self-care
• Educate the patient about anticoagulant therapy, explaining the
need for frequent follow-up appointments and blood laboratory
studies.
• Provide education about all prescribed medications, including
the name of medication, dosage, actions, prescribed schedule,
potential adverse effects, and any drug-drug or drug-food
interactions
NURSING MANAGEMENT FOR SURGICAL PATIENT
• Educate patient about how to minimize the risk of developing
infective endocarditis
• Inform patient that an echocardiogram may be performed 3 to 4
weeks after hospital discharge
CARDIOMYOPATHY
• Disease of the heart muscle that is associated with cardiac
dysfunction
• Classified according to the structural and functional
abnormalities of the heart muscle
• Ischemic cardiomyopathy = used to describe an enlarged heart
caused by coronary artery disease, which is usually
accompanied by heart failure
Two Major Groups of Cardiomyopathy
1. Primary Cardiomyopathy
 Focused primarily on the heart muscle
2. Secondary Cardiomyopathy
 Myocardial involvement secondary to the influence of a
vast list of disease processes
Examples of Cardiomyopathy
1. Dilated Cardiomyopathy
 Most common
 Distinguished by significant dilation of the ventricles
without simultaneous hypertrophy and systolic dysfunction
2. Hypertrophic Cardiomyopathy
An autosomal dominant genetic disorder that leads to
increased heart muscle size and mass
 Leading cause of sudden death in adolescents and young
adults, particularly in athletes
Examples of Cardiomyopathy
3. Restrictive Cardiomyopathy
 Least common
 Characterized by diastolic dysfunction caused by rigid ventricular
walls that impair diastolic filling and ventricular stretch
 Can be inherited or acquired disease
4. Unclassified Cardiomyopathy
Different from or have characteristics of more than one of the
previously described types and are caused by fibroelastosis,
noncompacted myocardium, systolic dysfunction with minimal
dilation, and mitochondrial diseases
HEART TRANSPLANT
 Therapeutic option for patients with end-stage heart disease
 Orthotopic transplantation = the most common surgical
procedure for cardiac transplantation
 Bicaval technique = removal of the recipient’s heart, and the
implantation of the donor heart with intact atria at the vena cava
and pulmonary veins
Orthotopic Method of Heart Transplantation
INFECTIOUS DISEASE OF THE HEART
 Heart’s layers may be affected by an infectious process
 Infections are named for the layer of the heart most involved in
the infectious process: infective endocarditis (endocardium),
myocarditis (myocardium), and pericarditis (pericardium)
 Ideal management for all infectious diseases is prevention.
 IV antibiotics usually are necessary once an infection has
developed in the heart.
INFECTIOUS DISEASE OF THE HEART

Infective Endocarditis
 Microbial infection of the endothelial surface usually by Staphylococci or
Streptococci
 Rare, but it has a high mortality rate
 Onset is insidious
 Risk factors: implanted cardiac devices, congenital heart disease, cardiac
transplant
 Primary presenting symptoms are fever and a heart murmur.
 Heart failure is the most frequent complication
INFECTIOUS DISEASE OF THE HEART

Pericarditis
 Inflammation of the pericardium
 Etiology can be infectious (viral, bacterial, fungal, parasitic) or
noninfectious (autoimmune disorders)
INFECTIOUS DISEASE OF THE HEART

Pericarditis cont…
 Inflammatory process may lead to an accumulation of fluid in
the pericardial sac (pericardial effusion) and increased pressure
on the heart, leading to cardiac tamponade
 The most characteristic symptom of pericarditis is chest pain
 Clinical manifestation of is a creaky or scratchy friction rub
heard
INFECTIOUS DISEASE OF THE HEART

Sample Nursing Dx
 Acute pain associated with inflammation of the pericardium
 Lack of knowledge of diagnosis and therapeutic self-care
management
INFECTIOUS DISEASE OF THE HEART

Planning and Goals

 Major goals include relief of pain and absence of
complications
 Performs activities of daily living without pain, fatigue, or
shortness of breath
 Exhibits no pericardial friction rub
 Absence of complications
 Absence of jugular vein distention
INFECTIOUS DISEASE OF THE HEART

Nursing Intervention
 Provide rest periods
 Position patient in sitting upright and leaning forward, chair
rest may be more comfortable
Gradually resume patient’s ADL
 Educate the patient about the causes
 Monitor potential of complications
HEART FAILURE
 Structural or functional cardiac disorders that make heart is
unable to pump enough blood
 Impaired contraction of the heart (systolic dysfunction) or
filling of the heart (diastolic dysfunction)
 Chronic, progressive condition that is managed with lifestyle
changes and medications
 Morbid consequence of another disease or disorder. Primary
cause is atherosclerosis of the coronary arteries
Goal: prevention of decompensated heart failure episodes
Heart Failure cont….
 Most common type of HF is systolic HF
 Goal: prevention of decompensated heart failure episodes
PATHOPHYSIOLOGY
Clinical Manifestation
 The cardinal manifestations are dyspnea, fatigue, fluid retention
S/S are related to the affected ventricle:
1. Right-sided heart failure
• Dependent edema, hepatomegaly, ascites, and weight gain
2. Left-sided heart failure
• Pulmonary interstitial edema
• Dyspnea, cough, pulmonary crackles, low oxygen saturation
levels, and extra heart sound may be heard
Clinical Manifestation cont…
 Two main types left-sided heart failure, with a third emerging
category:
1. Heart failure with reduced ejection fraction (HFrEF)
 also known as systolic heart failure
2. Heart failure with preserved ejection fraction (HFpEF)
also known as diastolic heart failure
3. Heart failure with midrange ejection fraction (HFmrEF)
Emerging classification category
Congestive Heart Failure
 Failure of dual mechanisms, in which right-sided heart failure
occurs as a result of left-sided failure
 When the left ventricle fails, fluid pressure is transferred back
through the lungs, damaging the right side of the heart. The
right side of the heart loses its pumping power, the blood backs
up in the body’s venous system causing swelling or congestion
in the legs, ankles, and swelling within the abdomen
Pulmonary Edema
 Breakdown of physiologic compensatory mechanisms
 Sometimes referred to as acute decompensated heart failure
 Occur following acute MI or as an exacerbation of chronic HF
 When the left ventricle cannot handle the volume overload, and blood
volume and pressure build up in the left atrium. The rapid increase in
atrial pressure results in an acute increase in pulmonary venous pressure,
which produces an increase in hydrostatic pressure that forces fluid out
of the pulmonary capillaries and into the interstitial spaces and alveoli
 Clinical Manifestation of Pulmonary Edema
Onset of breathlessness Sense of suffocation
Restless Tachypnea and tachycardia
Tachypnea and tachycardia Skin is pale to cyanotic
Hands may be cool and clammy Jugular Vein Distention
Incessant coughing Foamy sputum
Anxious and confused Crackles
HEART FAILURE

Sample Nursing Dx
 Ineffective tissue perfusion related to pulmonary congestion
 Activity intolerance related to low level of oxygen in the blood
 Hypervolemia related to breakdown of physiologic
compensatory mechanisms
• Anxiety related to disease progressive condition
HEART FAILURE

Planning and Goals

• Major goals include promoting activity and reducing fatigue,
relieving fluid overload symptoms, decreasing anxiety or
increasing the patient’s ability to manage anxiety
HEART FAILURE

Nursing Intervention
 Provide rest periods
 Position patient in sitting upright and leaning forward, chair
rest may be more comfortable
Gradually resume patient’s ADL
 Limit physical activities to only 3–5 min at a time, one to four
times per day
HEART FAILURE

Nursing Intervention
 Educate the patient regarding fluid and diet restrictions (low
sodium)
Assess the patient’s anxiety level
 Oxygen therapy may be necessary
 Continuous positive airway pressure (CPAP) might be
recommended
Monitor potential of complications
HEART FAILURE

Pharmacologic Therapy for Heart Failure

Loop diuretic
Angiotensin system blocker
Beta-blocker
HEART FAILURE

Pharmacologic Therapy cont…

HEART FAILURE

Pharmacologic Therapy cont…

HEART FAILURE

Pharmacologic Therapy cont…

CARDIOGENIC SHOCK
 Occurs when decreased CO leads to inadequate tissue
perfusion and initiation of the shock syndrome
Most commonly occurs following acute MI, but can also occur
as a result of end-stage HF, cardiac tamponade, pulmonary
embolism (PE), cardiomyopathy, and arrhythmias
 Life-threatening condition with a high mortality rate.
THROMBOEMBOLISM
 Clots formation within the cardiac chambers
 Can form in patients with atrial fibrillation (intracardiac
thrombi)
 Can also form on ventricular walls when contractility is poor
(mural thrombi)
 Emboli may dislodge in brain which causes stroke, and may
dislodge in the lower extremities causing deep vein thrombosis
(DVT)
Pharmacologic Therapy for Thromboembolism
• Anticoagulant agents (heparin and warfarin)
PERICARDIAL EFFUSION AND
CARDIAC TAMPONADE
 Accumulation of fluid in the pericardial sac
 May accompany advanced HF, pericarditis, metastatic
carcinoma, cardiac surgery, or trauma
 This has the following effects:
1. Elevated pressure in all cardiac chambers
2. Decreased venous return due to atrial compression
3. Inability of the ventricles to distend and fill adequately
 Clinical Manifestation of Pericardial Effusion
and Cardiac Tamponade
Chest pain Hypotension
Tachypnea Tachycardia
Dyspnea Pulsus paradoxus
Jugular Vein Distention
Diagnostic Examination
 Echocardiogram
 Chest X-ray
 ECG
Medical Management
 Pericardiocentesis

 Pericardiotomy (pericardial window)

CARDIAC ARREST
 Unable to pump and circulate blood to the body’s organs and
tissues
 Caused by an arrhythmia such as ventricular fibrillation,
progressive bradycardia, or asystole
 Electrical activity is present on the ECG but cardiac
contractions are ineffective (PEA)
 Clinical Manifestation of Cardiac Arrest
Unconsciousness, Pulseless
No blood pressure Breathing usually ceases
Gasping may occur Dilated pupil
Seizure may occur Cyanosis
Management of Cardiac Arrest
 Cardiopulmonary resuscitation (CPR)
• Chest is compressed 2 inches (approximately 5 cm) at a
rate of 100 compressions/min
• Complete chest recoil must be observed between
compressions
• Recommended to switch roles every 2 minutes
 Defibrillation (defibrillator or AED)
• First defibrillation is recommended to occur within 2
minutes of the first documented pulseless rhythm
Medications Used in Cardiopulmonary Resuscitation
Medications Used in Cardiopulmonary Resuscitation
Follow-up Monitoring and Care
• Continuous ECG monitoring and frequent blood pressure
assessments are essential until hemodynamic stability is established
and blood pressure is kept in a range to support adequate perfusion
References