Pathophysiology of Acquired Valvular Disorders

Backward Heart Failure Aoritc stenosis limits forward flow of blood from the left ventricle Aortic regurgitation permits blood flow back into the left ventricle Increased blood volume and pressure in the left ventricle Left ventricular hypertrophy and dilation; blood from the left atrium cannot get Mitral stenosis limits the forward flow of blood into the left ventricle Mitral regurgitation permits blood flow back into the left atrium Forward Heart Failure Not enough blood flows through the aorta for the bodys needs (decreased cardiac Angina pectoris, postural hypotension, fatigue, dizziness

Increased blood volume and pressure in Left atrium hypertrophy and dilation Increased blood volume and pressure in the Pulmonary congestion (shortness of breath and pulmonary edema), increased pulmonary vascular pressure Increased work for the right ventricle, right Right ventricular failure

MITRAL REGURGITATION

Mitral regurgitation involves blood flowing back from the left ventricle into the left atrium during systole. Clinical Manifestations Chronic mitral regurgitation is often asymptomatic, but acute mitral regurgitations (eg, that resulting from a myocardial infarction) usually manifests as severe congestive heart failure. Dysnpea, fatigue, and weakness are the most common symptoms. Palpitations, shortness of breath on exertion, and cough from pulmonary congestion also 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 Surgical intervention consists of mitral valve replacement or valvuloplasty (ie, surgical repair of the heart valves). MITRAL STENOSIS Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle. It is most often caused by rheumatic endocarditis, which progressively thickens the mitral valve leaflets and chordae tendineae. The leaflets often fuse together. Eventually, the mitral valve orifice narrows and progressively obstructs blood flow into the ventricle. Clinical Manifestations The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a result of low cardiac output. They may expectorate blood (ie, hemoptysis), cough, and experience repeated respiratory infections. Assessment and Diagnostic Findings The pulse is weak and often irregular because of atrial fibrillation (caused by the strain on the atrium). A low-pitched, rumbling diastolic murmur is heard at the apex. As a result of the increased blood volume and pressure, the atrium dilates, hypertrophies, and becomes electrically unstrable, and the patient experience atrial dysrhythmias. Echocardiography is used to diagnose mitral stenosis. Electrocardiography (ECG) and cardiac catheterization with angiography are used to determine the severity of the mitral stenosis.

Medical Management Antibiotic prophylaxis therapy is instituted to prevent recurrence of infections. Patients with mitral stenosis may benefit from anticoagulants to decrease the risk for developing atrial thrombus. They may also require treatment for anemia. Surgical intervention consists of valvuloplasty, usually commissurotomy to open or rupture the fused commussures of the mitral valve. Percutaneous transluminal valvuloplasty or mitral valve replacement may be performed. VALVULAR HEART DISORDERS: NURSING MANAGEMENT Educate the patient regarding the disease: about the diagnosis, the progressive nature, and treatment plan to report any new symptoms or changes in symptoms to the health care provider on emphasis of the need for prophylactic antibiotic therapy before any invasive procedure that may introduce infectious agents to the patients bloodstream infectious agent, usually a bacterium, is able to adhere to the diseased heart valve more readily than to a normal valve. Once attached tot the valve, the infectious agent multiplies, resulting in endocarditis and further damage tot eh valve Assessment: patients vital signs are taken, recorded, and compared with previous data for any changes heart and lung sounds are auscultated and peripheral ppulses palpated. Assess patient for signs and symptoms of heart failure: fatigue, dyspnea with exertion, an increase in coughing, hemoptysis, multiple respiratory infections, orthopnea, or paroxysmal nocturnal dyspnea assess for dysrhythmias by palpating the patients pulse for strength and rhythm (ie, regular or irregular) and asks if the patient has experienced palpitations or felt forceful heartbeats assess for dizziness, syncope, increased weakness, or angina pectoris Collaborative: to develop a medication schedule and teaches about the name, dosage, actions, side effects, and any drug-drug or drug-food interactions of the prescribed medications for heart failure, dysrhythmias, angina pectoris, or other symptoms teach the patient to weigh daily and report the gain of 2 pounds in 1 day or 5 pounds in 1 week to the health care provider assist the patient with planning activity and rest periods to achieve a lifestyle acceptable to the patient

 If the patient is to have surgical valve replacement or valvuloplasty, teaches the patient about the procedure and anticipated recovery.

Valve Repair and Replacement Procedures VALVULOPLASTY The repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty. The type of valvuloplasty depends on the cause and type of valve dysfunction. Repair may be made to the commissures between the leaflets in a procedure known as commissurotomy, to the annulus of the valve by annuloplasty, to the leaflets, or to the chordae by chordoplasty. The patient is usually managed in a critical care unit for the first 24 to 72 hours after surgery. Care focuses on hemodynamic stabilization and recovery from anesthesia. Vital signs are assessed every 5 to 15 minutes and as needed until the patient recovers from anesthesia or sedation and then 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 are 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 assessments. After the patient has recovered from anesthesia and sedation, is hemodynamically stable without intravenous medications, and assessments are stable, the patient is usually transferred to a telemetry or surgical unit for continued postsurgical care and teaching. The nurse provides wound care and patient teaching regarding diet, activity, medications, and self-care. Patients are discharged from the hospital in 1 to 7 days. In general, valves that have undergone valvuloplasty function longer than replacement valves, and the patients do not require continuous anticoagulation. Commissurotomy The most common valvuloplasty procedure is commissurotomy. Each valve has leaflets; the site where the leaflets meet is called the commissure. The leaflets may adhere to one another and close the commissure (ie, stenosis). Less commonly, the leaflets fuse in such a way that, in addition to stenosis, the leaflets are also prevented from closing completely, resulting in a backward flow of blood (ie, regurgitation). A commissurotomy is the procedure performed to separate the fused leaflets. CLOSED COMMISSUROTOMY Closed commissurotomies do not require cardiopulmonary bypass. The valve is not directly visualized. The patient receives a general anesthetic, a midsternal incision is made, a small hole is cut into the heart, and the

surgeons finger or a dilator is used to break open the commissure. This type of commissurotomy has been performed for mitral, aortic, tricuspid, and pulmonary valve disease. Balloon Valvuloplasty. Balloon valvuloplasty is another type of closed commissurotomy beneficial for mitral valve stenosis in younger patients, for aortic valve stenosis in elderly patients, and for patients with complex medical conditions that place them at high risk for the complications of more extensive surgical procedures. Most commonly used for mitral and aortic valve stenosis, balloon valvuloplasty also has been used for tricuspid and pulmonic valve stenosis. The rocedure is performed in the cardiac catheterization laboratory, and the patient may receive a local anesthetic. Patients remain in the hospital 24 to 48 hours after the procedure. Mitral valvuloplasty is contraindicated for patients with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation, thoracolumbar scoliosis, rotation of the great vessels, and other cardiac conditions that require open heart surgery. Mitral balloon valvuloplasty involves advancing one or two catheters into the right atrium, through the atrial septum into the left atrium, across the mitral valve into the left ventricle, and out into the aorta. A guide wire is placed through each catheter, and the original catheter is removed. A large balloon catheter is then placed over the guide wire and positioned with the balloon across the mitral valve. The balloon is then inflated with a dilute angiographic solution. When two balloons are used, they are inflated simultaneously. The advantage of two balloons is that they are each smaller than the one large balloon often used, making smaller atrial septal defects. As the balloons are inflated, they usually do not completely occlude the mitral valve, thereby permitting some forward flow of blood during the inflation period. All patients have some degree of mitral regurgitation after the procedure. Other possible complications include bleeding from the catheter insertion sites, emboli resulting in complications such as strokes, and rarely, left-toright atrial shunts through an atrial septal defect caused by the procedure. Aortic balloon valvuloplasty also may be performed by passing the balloon or balloons through the atrial septum, but it is performed more commonly by introducing a catheter through the aorta, across the aortic valve, and into the left ventricle. The one balloon or the two-balloon technique can be used for treating aortic stenosis. The aortic procedure is not as effective as the procedure for the mitral valve, and the rate of restenosis is nearly 50% in the first 12 to 15 months after the procedure (Braunwald et al., 2001). Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmias, mitral valve damage, and bleeding from the catheter insertion sites. OPEN COMMISSUROTOMY Open commissurotomies are performed with direct visualization of the valve. The patient is under general anesthesia, and a median sternotomy or left

thoracic incision is made. Cardiopulmonary bypass is initiated, and an incision is made into the heart. A finger, scalpel, balloon, or dilator may be used to open the commissures. An added advantage of direct visualization of the valve is that thrombus may be identified and removed, calcifications can be seen, and if the valve has chordae or papillary muscles, they may be surgically repaired. Annuloplasty Annuloplasty is the repair of the valve annulus (ie, junction of the valve leaflets and the muscular heart wall). General anesthesia and cardiopulmonary bypass are required for all annuloplasties. The procedure narrows the diameter of the valves orifice and is useful for the treatment of valvular regurgitation. There are two annuloplasty techniques. One technique uses an annuloplasty ring (Fig. 29-4). The leaflets of the valve are sutured to a ring, creating an annulus of the desired size. When the ring is in place, the tension created by the moving blood and contracting heart is borne by the ring rather than by the valve or a suture line, and progressive regurgitation is prevented by the repair. The other technique involves tacking the valve leaflets to the atrium with sutures or taking tucks to tighten the annulus. Because the valves leaflets and the suture lines are subjected to the direct forces of the blood and heart muscle movement, the repair may degenerate more quickly than with the annuloplasty ring technique. Leaflet Repair Damage to cardiac valve leaflets may result from stretching, shortening, or tearing. Leaflet repair for elongated, ballooning, or other excess tissue leaflets is removal of the extra tissue. The elongated tissue may be folded over onto itself (ie, tucked) and sutured (ie, leaflet plication). A wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed (ie., leaflet resection). Short leaflets are most often repaired by chordoplasty. After the short chordae are released, the leaflets often unfurl and can resume their normal function of closing the valve during systole. A piece of pericardium may also be sutured to extend the leaflet. A pericardial patch may be used to repair holes in the leaflets. Chordoplasty Chordoplasty is the repair of the chordae tendineae. The mitral valve is involved with chordoplasty (because it has the chordae tendineae); seldom is chordoplasty required for the tricuspid valve. Regurgitation may be caused by stretched, torn, or shortened chordae tendineae. Stretched chordae tendineae can be shortened, torn ones can be reattached to the leaflet, and shortened ones can be elongated. Regurgitation may also be caused by stretched papillary muscles, which can be shortened. VALVE REPLACEMENT Prosthetic valve replacement began in the 1960s. When valvuloplasty or valve repair is not a viable alternative, such as when the annulus or leaflets

of the valve are immobilized by calcifications, valve replacement is performed. General anesthesia and cardiopulmonary bypass are used for all valve replacements. Most procedures are performed through a median sternotomy (ie, incision through the sternum), although the mitral valve may be approached through a right thoracotomy incision. Types of Valve Prostheses MECHANICAL VALVES The mechanical valves are of the ball-and-cage or disk design. Mechanical valves are thought to be more durable than tissue prosthetic valves and often are used for younger patients. Mechanical valves are used if the patient has renal failure, hypercalcemia, endocarditis, or sepsis and requires valve replacement. The mechanical valves do not deteriorate or become infected as easily as the tissue valves used for patients with these conditions. Thromboemboli are significant complications associated with mechanical valves, and long-term anticoagulation with warfarin is required. TISSUE OR BIOLOGIC VALVES Tissue (ie, biologic) valves are of three types: xenografts, homografts, and autografts. Tissue valves are less likely to generate thromboemboli, and longterm anticoagulation is not required. Tissue valves are not as durable as mechanical valves and require replacement more frequently. Xenografts. Xenografts are tissue valves (eg, bioprostheses, heterografts); most are from pigs (porcine), but valves from cows (bovine) may also be used. Their viability is 7 to 10 years. They do not generate thrombi, thereby eliminating the need for longterm anticoagulation. They are used for women of childbearing age because the potential complications of long-term anticoagulation associated with menses, placental transfer to a fetus, and delivery of a child do not exist. Xenografts also are used for patients older than 70 years of age, patients with a history of peptic ulcer disease, and others who cannot tolerate long-term anticoagulation. Xenografts are used for all tricuspid valve replacements. Homografts. Homografts, or allografts (ie, human valves), are obtained from cadaver tissue donations. The aortic valve and a portion of the aorta or the pulmonic valve and a portion of the pulmonary artery are harvested and stored cryogenically. Homografts are not always available and are very expensive. Homografts last for about 10 to 15 years, somewhat longer than xenografts. Homografts are not thrombogenic and are resistant to subacute bacterial endocarditis. They are used for aortic and pulmonic valve replacement. Autografts. Autografts (ie, autologous valves) are obtained by excising the patients own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve. Anticoagulation is unnecessary because the valve is the patients own tissue and is not thrombogenic. The autograft is an alternative for children (it may grow as the child grows), women of childbearing age,

young adults, patients with a history of peptic ulcer disease, and those who cannot tolerate anticoagulation. Aortic valve autografts have remained viable for more than 20 years. Most aortic valve autograft procedures are double valvereplacement procedures, because a homograft also is performed for pulmonic valve replacement. If pulmonary vascular pressures are normal, some surgeons elect not to replace the pulmonic valve. The patient can recover without a valve between the right ventricle and the pulmonary artery. VALVULOPLASTY AND REPLACEMENT: NURSING MANAGEMENT Patients who have had valvuloplasty or valve replacements area admitted to the intensive care unit; care focuses on recovery from anesthesia and hemodynamic stability. 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. After the patient has recovered from anesthesia and sedation, is hemodynamically stable without intravenous medications, and assessment values are stable, the patient is usually transferred to a telemetry unit, typically within 24 to 72 hours after surgery. Nursing care continues as for most postoperative patients, including wound care and patient teaching regarding diet, activity, medications, and self-care. 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. Patients are discharged from the hospital in 3 to 7 days. Home care and office or clinic nurses reinforce all new information and self-care instructions with the patient and family for 4 to 8 weeks after the procedure.