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Valvular Disease & Cardiacitis Handout

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Valvular Disease & Cardiacitis Handout 7/23/2016 A. Acute Coronary Syndrome B. Dysrhythmias C. Heart Failure D. Other Cardiac Issues ◦ Papillary Muscle Rupture ◦ Ventricular Septal Rupture ◦ Ventricular Aneurysm Cheryl Herrmann, APN, CCRN, CCNS-CSC-CMC ◦ Valvular Heart Disease ◦ Acute Inflammatory Disease E. Vascular Issues CMC CSC Located in the ventricles Three papillary muscles in RV ◦ Anterior -- largest ◦ Posterior ◦ Septal Two papillary muscles in LV ◦ Anterior -- largest ◦ Posterior Attached to the AV valves (mitral & tricuspid) Contact to prevent inversion or prolapse of the mitral or triscuspid valves Prevents regurgitation www.online-nursing-dot.com Cause Clinical Manifestations Complication of AMI ↑ RAP, PAP, PAOP Hypotension Occurs within first Large v waves on Tachycardia week PAOP waveform Dyspnea ↓ More with inferior MI CO/CI Crackles ↓ or subendocardial MI SpO 2, SvO 2 S3 New holosystolic at the apex Symptoms of Acute Cardiogenic Shock & Pulmonary Congestion New holosystolic at the apex 1 7/23/2016 Cause Treatment Complication AMI Prepare for emergency mitral valve replacement Occurs 3 and 5 – 7 Treat the symptoms of the mitral regurgitation, days post AMI cardiogenic shock and pulmonary congestion Complication of ◦ Supportive management until surgery endocarditis ◦ Afterload reduction with nitrates and nitroprusside ◦ Diuretics ◦ IABP ◦ Oxygen/ventilator Treatment Hypotension ↑ RAP, PAP Tachycardia Large v on PAOP Emergent surgical repair Tachypnea waveform Supportive care of cardiogenic shock while ↑ SvO New holosystolic 2 ↑ preparing for surgery murmur at lower left oxygen gradient (left to right shunt) ◦ Vasodilators sternal border ◦ Inotropes Inaccurate ↑ CO/CI Thrill ◦ Diuretics ◦ IABP Pulmonary congestion Syncope Sudden hemodynamic compromise and pulmonary congestion New holosystolic murmur at lower left sternal border Opening of the septum between the right and left Clinical features ventricle Oxygenated blood in the Harsh and loud holoystolic LV returns to the RV murmur rather than the Left atrial dilation Left ventricular enlargement oxygenated blood Pulmonary artery dilation continuing forward to Left to right shunt deliver oxygen to the Normal Heart & Heart with VSD cells. Normal Heart & Heart with VSD Results in an increase in ventricular workload Leads to heart failure Holosystolic murmur 2 7/23/2016 Clinical Presentation A ballooning, dyskinetic area of infarcted myocardium Diffuse PMI – spread over more than one ICS Left ventricular heave May be a complication Atrial Fibrillation or ventricular arrhythmias of AMI Persistent ST segment elevation Prone to dysrhythmias, CXR= left ventricular dilation intraventricular Echo = dyskinesia and left ventricular dilation thrombus formation, Signs of LVF may be present and rupture Systemic emboli symptoms may be present ◦ Cerebral emboli ◦ Peripheral emboli with acute arterial occlusion Treatment Mitral Aortic Medical Antiarrhythmic medications Possible ablation for ventricular arrhythmias Anticoagulation medications Treatment of HF with ACEI, beta blockers, diuretics, inotropes, and vasodilators Surgical Excision of the weakened area of the myocardium, Patch is sewn in the edges of the remaining viable myocardium An acquired or congenital disorder of a cardiac Common Causes of Acquired valve Valvular heart disease Characterized by ◦ Stenosis (obstruction) Rheumatic heart disease ◦ Regurgitation (backward flow) Degenerative diseases Can occur acutely Infective endocarditis Typically is a chronic progressive disorder Causes a significant impact on quality of life Medical management delays the inevitable surgery for replacement/repair Prosthetic valve creates new problems 3 7/23/2016 Clinical Management Large anterior leaflet Cardiac compensatory mechanisms can maintain Small posterior stability for years before symptoms occur. leaflet Key is early diagnosis to prevent the long-term consequences Chordae tendineae ◦ Pulmonary hypertension and papillary ◦ Heart Failure muscles prevent the ◦ Atrial fibrillation ◦ Thromboembolism prolapse of valve Important to understand leaflets into left ◦ The structure and function of the valves atrium during ◦ The causes and treatments of each disorder systole Mitral valve will not Cause Pathophysiology open completely ◦ Mostly rheumatic fever 1. Small opening causes Restricts flow of ↓ ↓ ◦ Some calcified blood flow and CO ↑ blood from left degenerative disease 2. workload in Left Atrium atrium to LV 3. ↑ pressure in LA Continuous, slow 4. LA dilation & hypertrophy progressive disease 5. May lead to A fib with symptoms 6. LA blood flow stagnant appearing 20-40 7. May cause clot formation & thromboembolism years after 8. ↑ in LA pressure backflow into pulmonary artery rheumatic fever 9. Leads to pulmonary hypertension, congestion, right ventricular hypertrophy and right sided heart failure LV size and contractility = normal in MS Ruddy face (mitral facies) Clinical Presentation Heart Sounds Nx LV function ◦ Loud first heart sound S1 (closing snap) Pulmonary Hypertension Mild MS ◦ Mid-diastolic murmur/rumble ◦ Dyspnea on exertion from at apex RV failure pulmonary congestion ◦ Opening snap ◦ Right sided S3 & S4 Tricuspid insufficiency Moderate MS ◦ Right ventricular heave at ◦ Fatigue sternum High left atrial pressures and pulmonary CXR ◦ Paroxysmal nocturnal ◦ Left atrial and RV enlargement pressures dyspnea ◦ Pulmonary congestion ◦ Atrial fib EKG Low CO and pulmonary congestion ◦ LA enlargement: Notched P Severe MS waves P Mitrale ◦ Dyspnea on mild exertion ◦ Right ventricular hypertrophy or at rest – tall R waves V 1 & V2 Pulmonary congestion & right sided failure signs 4 7/23/2016 Causes Assess for pulmonary hypertension Mitral valve fails to ◦ Anything that affects any Increased PVR leads to RV failure close completely part of the MV Increased CVP = possible RV decompression Mitral annulus TEE to assess for RV and LV function Blood is propelled Valve leaflets Dobutamine, Milrinone, Norepinephrine to increase backward into the LA Chord tendineae Papillary muscle contractility of RV and $ PVR during systole Fluid administration ◦ Mitral Valve Prolapse PAD does not reflect LA filling pressures related to pulmonary ◦ Rheumatic heart disease hypertension – Wedge more accurate ◦ Infective endocarditis PA catheter may be placed farther in related to dilated ◦ Cardiomyopathy pulmonary arteries ◦ Ischemic heart disease IABP usually not indicated as no LV dysfunction but RV ◦ dysfunction Pathophysiology Heart Sounds Clinical Presentation ◦ Holosystolic murmur – high pitched, blowing at apex ◦ S2 – widely split 1. During systole, a portion of blood is ejected May be asymptomatic ◦ Displaced PMI laterally back into the LA for years ◦ Maybe right sided S3 & S4 ↓ ↓ CXR 2. blood in LV CO Initial symptoms ◦ Cardiomegaly 3. ↑ blood in LA ↑ LA pressures pulmonary ◦ Left sided failure ◦ LA enlargement ↑ ◦ LV hypertrophy congestion and pulmonary pressures RV ◦ Dyspnea on exertion ◦ Possible pulmonary hypertrophy Cough congestion EKG 4. During diastole, blood continues to flow into Peripheral Edema ◦ LA enlargement P mitrale ↑ LV LV volume Palpitations from new ◦ Left and/or right ventricular hypertrophy 5. LV hypertrophy onset of A fib Large QRS complexes MR = LA enlargement, Left or Ventricular Failure Endocarditis risk is RARE Mitral valve leaflets Cause: myxomatous Immediate # SVR due to no backflow of blood prolapse back into degeneration of valve in LA leaflets causes the left atrium during Pulmonary hypertension & Myocardial leaflets to enlarge systole hibernation take time to reverse and prolapse Inotropes (Milrinone, Dobutamine) Frequently asymptomatic & no IABP treatment needed Monitor for RV failure Midsystolic click Late systolic murmur 5 7/23/2016 Repair preserves native valve Has three leaflets or Repair is favored due to disadvantages of cusps prosthetic valves Cusps close as the ◦ No anticoagulation needed for repair pressure in the aorta Technically more difficult becomes greater ◦ Depends on degree of regurgitation, than the pressure in ◦ Pathophysiology of the regurgitation the left ventricle. ◦ LV function, ◦ Ability of surgeon Aortic valve will not Most common valve Clinical Presentation open completely lesion in USA ◦ Echocardiogram: Restricts flow of Gradual progressive disease – usually Grades: blood from left Normal AVA > 2.5 – 3.5 ventricle to aorta remain cm2 asymptomatic for Mild AVA > 1.5 cm2 Moderate AVA = 1.0 – 1.5 decades. cm2 Severe AVA < 1.0 cm2 Critical AVA < 0.75 cm2 Mean gradients: > 40-45 mmHg Peak velocity over 4 m/s Syncope --- Systolic ejection harsh murmur Pathophysiology Clinical Presentation Heart Sounds ◦ Systolic ejection murmur (harsh) at the right 1. Small opening causes ↓ blood flow and ↓ CO Syncope, Dyspnea, sternal border radiating to neck 2. ↑ Afterload Angina, – especially CXR 3. ↑ workload in Left ventricle with exertion ◦ May be normal 4. ↑ pressure in LV Angina more common EKG 5. LV hypertrophy if CAD as comorbidity ◦ Left ventricular 6. LV becomes stiff HF with severe AS hypertrophy with severe 7. High LV pressures leads to LV failure AS and left atrial enlargement ◦ Left Atrial enlargement, 8. High pressures transmitted to the Left axis deviation, Left lungs leads to pulmonary BBB hypertension, pulmonary edema and right sided failure LV size and contractility = abnormal in AS Syncope --- Systolic ejection harsh murmur 6 7/23/2016 Causes Inotropes rarely
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