Subject : MEDICAL AND SURGICAL NURSING

SEMINAR ON: HEART VALVULAR DIS-ORDERS

SUBMITTED TO : MRS ARUNA DEVI

PRINCIPAL

BGS COLLEGE OF NURSING

MYSORE

SUBMITTED BY : MR ANAND .T.O

1st Msc NURSING STUDENT

BGS COLLEGE OF NURSING

MYSORE

SUBMITTED ON:

HEART VALVE DISORDERS

INTRODUCTION

Heart valves are thin flexible flaps of connective tissue. The four heart valves are:

1. The tricuspid valve, located between the right atrium and right ventricle;
2. The pulmonary or pulmonic valve, between the right ventricle and the
pulmonary artery;
3. The mitral valve, between the left atrium and left ventricle; and
4. The aortic valve, between the left ventricle and the aorta.

Blood flow occurs only when there's a difference in pressure across

the valves that cause them to open.

Each valve has a set of flaps (also called leaflets or cusps). The mitral valve has
two leaflets while the other valves have three. The mitral and tricuspid valves are
connected to small muscles (papillary) along the wall of the heart by small string
like tendons (chordeae tendineae). Papillary muscle contraction opens these
valves. The aortic and pulmonic valves are differently shaped do not have cordae
tendineae nor papillary muscles.
 For the heart to function properly, the four heart chambers
must beat in an organized manner. Under normal conditions, the heart valves let blood
to flow in only one direction. Problems with a heart valve (or valves) may occur
because of disease, injury or congenital factors. Two kinds of problems usually occur.

1. Stenosis (Narrowing of valve , the heart may have to work much harder to
pump blood across the valve).

2. Incomplete closure of valve

(A second type of problem occurs when a valve (or valves) does not close
completely, causing some blood to be pumped backwards (regurgitation /
incompetence) instead of forwards in the heart.)

Both types of problems can cause the heart to work too hard and eventually weaken
over time.

Causes of Heart valve disorders

1. Infection
2. Heart diseases
3. Trauma
4. Congenital valvular disorders
Valvular problems may be caused by infection, heart disease, trauma
or congenital valvular conditions and may be isolated to a single valve or effect
multiple valves. Right sided (tricuspid, pulmonary) valvular disease is much
less common than left sided (aortic, mitral) valvular disease. Roughly 90% of
valvular disease is chronic, having developed gradually over many years.
Complications of rheumatic fever, congenital disorders and aging cause the
vast majority of chronic valvular disease. The remaining 10% of valvular
disease that develops acutely (over days to weeks) is often due to complications
of recent heart attack or infections.

Infection

Rheumatic fever- Most valvular heart disease is still caused by

childhood rheumatic fever (a complication of untreated streptococcal infection).
During a streptococcal infection (typically in the throat) the body makes its' own
antibodies to fight the bacterial infection. Antibodies recognize the structure of certain
parts of the bacterial surface, attach to it and destroy it. Unfortunately, the surface
structure of certain body tissues (heart valves, skin, joints, kidneys, etc..) may
resemble that on certain types of streptococcal bacteria. With rheumatic fever
antibodies that normally fight infection may attack the body's own tissues. It is
important to stress that it is not bacteria that directly cause injury.

Rheumatic fever usually occurs 2-6 weeks after untreated strep throat. Symptoms of
rheumatic fever are multiple and may include:

 Fever
 Arthritis (pain, swelling and warmth) that shifts from joint to joint.
Larger joints such as hips and knees tend to be more frequently effected.
 Heart failure, new heart murmurs, fast heart rate or pericardial friction
rub due to inflammation of heart muscle, valves or pericardium. This is
called carditis and occurs during rheumatic fever. Carditis is different
from delayed valvular disease that slowly develops over many years
after rheumatic fever has occurred. The latter is due to slow but
progressive thickening of effected heart valves initially injured during
rheumatic fever..
 Nodules may form under the skin on the backs side of the wrist, elbow,
and knees
 a temporary skin rash lasting several days may occur.
 Injury to brain tissues may cause repetitive involuntary writhing
movement of the head and arms. This is called chorea.

The incidence of rheumatic fever in the USA has decreased greatly in recent years due
to the use of antibiotics to treat strep throat. Delayed symptoms of heart valve disease
may take 10-20 years to appear and gradually worsen over time. Rheumatic fever may
effect a single or multiple valves. Symptoms that occur years later is usually from
injury to the mitral and aortic valves.

Infective Endocarditis is infection of heart valves directly with bacteria or fungi.

Infection may occur after certain dental /surgical procedures or with IV drug use.
Infective Endocarditis can involve any heart valve but most commonly involves the
aortic or mitral valve (left sided heart disease). Infection of only the tricuspid valve
(right sided disease) is usually seen in IV drug users.

During dental or surgical procedures a small amount of bacteria may get into the
blood stream. This is almost never a problem for otherwise healthy persons with
normal heart valves- the body easily takes care of this on its own. Bacteria from these
procedures can infect previously injured heart valves (usually from rheumatic fever).
Therefore, a dose of an antibiotic (prophylactic=preventative) is always recommended
prior to dental work and certain types of surgery for people with heart valve disorders
to prevent Endocarditis.

Vegetations (a mixture of bacteria and blood clots) may form on valves of the left,
right or both sides of the heart. Vegetations can embolize (break loose) and travel to
other parts of the body. Emboli from the left heart valves (mitral or aortic) will travel
via the aorta to the body; those from the right heart valves (tricuspid or pulmonic) will
travel to the lungs. Emboli lodging in the brain can cause a stroke. Emboli may carry
infection to other parts of the body. Emboli lodging in the lungs may cause shortness
of breath and cough.

Endocarditis is divided into several categories

Acute Endocarditis usually occurs on previously normal valves and is most often due
to IV drug use and is due to aggressive types of bacteria associated with contaminated
needles. Rapid destruction of the heart valve(s) can happen, causing severe heart
failure.

Symptoms of acute infective Endocarditis include:

 fever and chills

 weakness
 fast heart rate
 shortness of breath and chest pain.

People are usually quite ill. Heart murmurs may be heard as well. Stroke symptoms
may occur if vegetations break loose and lodge in brain arteries. Severe heart failure
may occur if the aortic or mitral valves rupture.

Sub acute Endocarditis usually occurs on artificial or previously injured valves and
progresses more slowly. Bacteria associated with subacte Endocarditis are not as
virulent as bacteria associated with acute Endocarditis. Symptoms of subacute
infective endocarditis, often not as obvious, may include:

 recurrent fever
 weight loss
 decreased appetite
 feeling very run down

People often think they have recurrent flu or may have been treated with antibiotics
several times with antibiotics for presumed bacterial infections such as bronchitis.
As in the case of acute infective endocarditis bacterial vegetations can break loose and
go to other parts of the body. Physical signs are related to the part of the body they
lodge in:

 small haemorrhages may be seen in finger and toe nail beds;

 retinal haemorrhages may be seen in the eyes;
 tender nodules (Osler nodes) may be felt on finger and toe tips;
 non tender plaques (Janeway lesions) may occur on the palms of the
hands and soles of the feet.

Diagnosis of infective Endocarditis is made if blood cultures are positive for bacteria
or fungi known to cause endocarditis and there is evidence of valvular injury or
vegetations. The heart and valves are imaged using echocardiography.

Treatment generally requires hospitalization and intravenous antibiotic therapy for at

least 4 weeks. Infection is almost never adequately treated with oral antibiotics.
Persons with severe valvular destruction may require valve replacement.

Prevention is extremely important because infective endocarditis is so difficult to treat

and can cause severe disability or death. All persons with evidence of valvular injury
or deformity should take preventative antibiotics before dental or surgical procedures
are performed. If you have a known heart murmur or valvular problem consult your
dentist and doctor prior to dental or surgical procedures.

I. Mitral Valve Disorders

The mitral valve normally allows one way flow of blood from the left atrium to the
left ventricle.

1. Mitral Valve Stenosis

2. Mitral Valve Regurgitation
3. Mitral Valve Prolapse (mitral prolapse syndrome)

1) Mitral Stenosis is narrowing of the mitral valve opening that usually gradually
occurs over time due chronic scarring. Rheumatic fever is still the most
common cause of mitral valve stenosis.
As the mitral opening narrows the left atrium enlarges (dilates) over time because it
must work harder to pump blood into the left ventricle. Many people (up to 50%)
eventually develop atrial fibrillation because of progressive dilatation of the left
atrium. In atrial fibrillation the left atrium quivers instead of effectively pumping
blood to the left ventricle causing a decreased amount of blood to the left ventricle.

Severe stenosis may also cause pressure to built up in the lung blood vessels
(pulmonary veins) that supply blood to the left atrium. The lung blood vessels are
normally under much lower pressure (as is the right side of the heart that pumps blood
to the lungs) than the left ventricle, aorta and its' arterial branches. Increased blood
pressure in the lungs is called pulmonary hypertension.

Clinical manifestations

 Symptoms may not appear for many years but are usually due to congestive
heart failure. The first (and most common) symptom to appear is usually
shortness of breath (beyond normal) during physical activity. Any stimulus
that rapidly increases heart rate or blood flow can cause sudden increase in
lung congestion and cause shortness of breath. Other factors responsible for
shortness of breath in those with mitral stenosis (in additional to physical
activity) include stress, fever, pregnancy, or onset of atrial fibrillation.
 As the disease worsens shortness of breath at rest or while lying down may
occur. Severe disease is common with pulmonary hypertension.
 Low cardiac output
 The second most common symptom to initially appear is coughing up blood
due to rupture of a bronchial (lung) vein. ( Hemoptysis ,cough ,respiratory
infections )

Blood clots are more likely to form in the left atrium during atrial
fibrillation - these blood clots (emboli) may dislodge and travel to other body organs
including the brain, eyes, heart and kidneys. The risk of stroke or heart attack (due to
emboli traveling to the brain or coronary arteries) is higher in persons with atrial
fibrillation.

Diagnosis of mitral stenosis

 is suspected in a person with a history of congestive heart failure, findings of a

specific type of mitral heart murmur
  on physical exam, and suggestive chest x-ray and EKG findings. Definitive
diagnosis is made using ultrasound- The entire valve can be visualized.

Cardiac catheterization (dye is injected into a blood vessel near the heart and movie-
like pictures taken) is performed if surgical repair or replacement of the mitral valve is
considered. Catheterization will detect if there is narrowing of the coronary arteries.
Coronary artery disease increases the risk of heart attack during surgery and may need
to be corrected prior to surgical valve repair or replacement.

Treatment depends on the severity of symptoms, health and age of an individual,

amount of mitral valve narrowing, and whether coexisting aortic valvular disease is
present. Persons requiring treatment for this disorder must be under the care of a
physician!

 Persons without symptoms and mild to moderate stenosis do not need to

restrict physical activity.
 Persons with mild symptoms (shortness of breath) with physical activity
are usually started on a mild diuretic, a low salt diet, advised to avoid
vigorous exercise and extreme stress. ACE inhibitors may be used in
conjunction with diuretics.
 Blood thinning agents (coumadin) are recommended with mitral
stenosis, particularly if atrial fibrillation is present, to decrease the risk
of embolization to other areas of the body.
 Persons with symptoms should be evaluated by a cardiologist. Valvular
repair or replacement should not be delayed until symptoms occur at rest
or with minimal exertion. This is particularly true for younger persons
who are otherwise healthy.

Surgical Management

1. Percutaneous balloon mitral valvulotomy- a balloon tipped catheter is

threaded through an artery into the heart. The balloon is inflated to
expand the mitral valve. This technique has been very effective in
younger patients with valves that are not calcified (excessively stiff).
2. Surgical valvulotomy (commisurotomy) - the natural valve is widened
by making a cut in the mitral valve.
3. Total valve replacement- the mitral valve is replaced by a prosthetic
("artificial")valve. Valves may be either bioprosthetic (pig, cow, or
human) or synthetic (usually metal alloys). Valvular replacement is
usually required in older patients with heavily calcified (stiff) mitral
valves.
Prognosis

Most people have no symptoms the first 10 years, increasing shortness of breath on
exertion the next 10 years followed by worsening symptoms that may begin to occur
at rest during the next decade.

All people having mitral stenosis of any degree require antibiotic prophylaxis to
prevent infective Endocarditis prior to dental or surgical procedures.

Mitral Regurgitation

It occurs when blood flows back into the left atrium from
the left ventricle during left ventricular contraction because of a "leaky" mitral valve.

Causes

 Endocarditis
 rupture of the papillary muscles or chordae tendineae
 problem with one or more leaflets of valve
 shortening or tear of mitral valve leaf let

.clinical manifestations

 Symptoms of severe congestive heart failure ( severe shortness of breath, fast

heart rate, and fluid in the lungs) requiring urgent surgical intervention usually
occur with acute mitral valve rupture.


Rheumatic fever is the most common cause of chronic (gradual over many years)
mitral regurgitation. Chronic regurgitation, even with large regurgitant blood flow, is
often tolerated for years due to compensatory changes in the heart. The left atrium
dilates over time to handle the increased blood volume.

Symptoms are very similar to mitral stenosis. As with mitral stenosis the most
common first symptom is shortness of breath with exertion, atrial fibrillation is
common in later stages and the risk of emboli is as high as 20%. Most emboli travel to
tissues that do not cause symptoms. However, emboli traveling to the brain may cause
stroke and emboli traveling to the coronary arteries may cause heart attack.

Diagnosis

 History of shortness of breath

  Heart murmur suggestive of mitral regurgitation.
 Ultrasonography.
 Persons considered for valvular repair or replacement will have cardiac
catheterization performed.

Treatment is similar to that for mitral stenosis except balloon valvuloplasty is not
performed unless the mitral valve is also stenotic. Most cases of mitral regurgitation
do not involve significant stenosis. Valve replacement or reconstruction is indicated
for most persons with severe symptoms (shortness of breath at rest or with minimal
exertion.

Anticoagulation (blood thinning agents) is recommended for those with mitral

regurgitation, especially persons with atrial fibrillation, due to increased risk of stroke
from emboli.

Prognosis- The time course from the presence of this disease to the first symptoms is
similar to that for mitral stenosis.

All people having mitral regurgitation require antibiotic prophylaxis to prevent

infective Endocarditis prior to dental or surgical procedures.

Mitral valve prolapse (click murmur syndrome)

Mitral valve prolapse (MVP) occurs when one or both of the mitral valve
leaflets push back (bow) into the left atrium during contraction of the left ventricle.
MVP is probably only important if a person has both excess bowing of the mitral
leaflets into the atrium and actual regurgitation of blood from the left ventricle to the
left atrium when the heart contracts.

Clinical manifestations

 Fatigue (regardless of patient activity level)

 Shortness of breath
 Light headedness
 Dizziness
 Syncope
 Palpitations
 Chest pain ,anxiety

Diagnosis

 Echocardiogram (ultra sound of heart )

 Palpitations
 II. AORTIC VALVE DISORDERS

The aortic valve normally allows one way flow of blood from the left ventricle to the
aorta.

Disorders of the aortic valve include

1) Aortic valve stenosis

2) Aortic valve regurgitation.

Aortic Stenosis is narrowing of the aortic valve.

Causes include:

1. Congenital heart disease (bicuspid valve)- most common cause

2. Rheumatic heart disease- second most common
3. Degenerative heart disease (calcific aortic stenosis)- most common in
persons over 70 years of age.

What happens with aortic stenosis?

As the aortic valve narrows the left ventricle must work harder to pump the same
amount of blood through a narrower opening. The left ventricle is the largest and
strongest pumping chamber of the heart- it must pump blood to the entire body. The
left ventricular muscle increases in size (hypertrophies) over time to compensate for
the extra work it must perform. The strength and ability of the left ventricle to
compensate for increased work load may mask the symptoms of aortic stenosis for
many years until the valve becomes extremely narrow. When the aortic valve narrows
past a certain point the left ventricle can no longer fully compensate. Not as much
blood can be pumped across the aortic valve to the body, particularly during activities
requiring increased blood flow to the organs and muscles. At this point symptoms may
appear.

Symptoms include:
 1. Shortness of breath with exertion. This symptom may occur earlier in
very physically active people. This is usually the first symptom but is
not specific for aortic stenosis.
2. Shortness of breath awakening a person from their sleep (second most
common symptom).
3. Passing out (syncope) with exertion, angina, or heart attack are also
common and indicate severe disease.

Who gets aortic stenosis?

Most people do not develop symptoms until late in the course of aortic stenosis. Age
at onset of symptoms (clinically apparent aortic stenosis) usually indicates the cause
of aortic stenosis. Symptoms in people younger than 30 years are almost always due
to congenital causes (usually bicuspid aortic valve). Symptoms in people 30-70 years
may be due to either bicuspid valve or rheumatic heart disease. Aortic stenosis caused
by rheumatic fever occurs 10-15 years later than mitral stenosis caused by rheumatic
fever. Symptoms developing in the elderly are usually due to calcific degenerative
changes of a normal aortic valve (wear and tear of aging).

Diagnosis

 Auscultation (heart murmur)

 Echocardiogram (heart ultrasound)

Atrial fibrillation and travelling emboli are less common in isolated aortic stenosis.

Is aortic stenosis serious?

Once symptoms develop aortic stenosis is very serious. The presence of symptoms
almost always means that the aortic valve is extremely narrow and will not tolerate
further narrowing. Once symptoms occur with aortic stenosis, particularly angina or
shortness of breath with minimal exertion or congestive heart failure, many people die
within several years if not treated.

Sudden death, due to cardiac arrhythmias, may occur in upto 20% of people with
aortic stenosis. The cause of sudden death is speculative (unknown).

Treatment

 Asymptomatic persons with mild stenosis do not have to limit physical activity.
 Periodic monitoring should be done because rapid narrowing can occur over as
little as a few years.
  Persons with more severe stenosis should be evaluated by a cardiologist
whether or not they have symptoms.
 Persons with symptoms of passing out on exertion, angina or congestive heart
failure due to aortic stenosis require immediate evaluation by a cardiologist and
may be considered for valve repair or replacement.
 Your doctor may treat symptoms of either angina or congestive heart failure
with medications as they occur. If these symptoms are caused by aortic stenosis
definitive treatment is valve repair or replacement. Very old age (80's) is not a
contraindication to valve replacement as long heart function and overall health
are reasonable.

Persons requiring treatment for this disorder must be under the care of a
physician!

III. Pulmonary and Tricuspid Valve Disorders

Isolated valvular disorders of the right side of the heart (receiving and pumping
venous blood to the lungs for oxygenation) are much less common than left sided
valvular disease. Combined left (mitral and/or aortic) and right (tricuspid and/or
pulmonic) heart valvular disease is more common.

Tricuspid Valve Disorders - Tricuspid valve normally allows one way blood flow
from the right atrium to the right ventricle.

 Isolated tricuspid disease is most commonly due to endocarditis from IV

drug use.
 Right ventricular failure causing tricuspid regurgitation is usually due to
heart attack effecting the right ventricle
 Tricuspid disease and left sided valvular disease due to rheumatic fever
may occur.

IV. PULMONARY VALVE DISORDERS –

Pulmonic valve normally allows one way blood flow from the right
ventricle to the pulmonary (lung) arteries.

 Pulmonary stenosis most frequently caused by a congenital defect

(Tetralogy of Fallot) that is detected and surgically corrected in infancy.
 Pulmonary regurgitation (incompetence) is most commonly due to
pulmonary hypertension.
Symptoms

 Shortness of breath, particularly while laying flat are the most common
initial symptoms of tricuspid and pulmonary valve disorders. Symptoms
of worsening disease, in addition to shortness of breath, include swelling
of the feet, liver, abdomen or neck veins due to fluid retention.

Heart disease

Papillary muscle dysfunction (papillary muscles do not work properly) may occur
from a heart attack, cardiomyopathy or congestive heart failure. This can cause
regurgitation to occur across the tricuspid or mitral valves. Rupture of a papillary
muscle (usually after a heart attack) may cause sudden regurgitation of blood back
into the lungs. This may cause severe breathing problems due to excess fluid in the
lungs- this is called congestive heart failure.

Mitral valve prolapse (click murmur syndrome)

Mitral valve prolapse (MVP) occurs when one or both

of the mitral valve leaflets push back (bow) into the left atrium during contraction
of the left ventricle. MVP is probably only important if a person has both excess
bowing of the mitral leaflets into the atrium and actual regurgitation of blood from
the left ventricle to the left atrium when the heart contracts.

ARTIFICIAL (PROSTHETIC) VALVES

There are more than six dozen types of valves. Prosthetic valves can be grouped into
two main categories:

1. Mechanical (non tissue models) usually made of metal or composite alloys.

2. Tissue valves(bio prostheses) made from pig, cow or human valves.

What type of problems occurs with prosthetic valves?

(cardiomyopathy, congestive heart failure, and/or arrhythmias) at time of valve

replacement.
  Prosthetic valves may be slightly narrow (stenotic). A small amount of
regurgitation, due to incomplete closing, is common.
 Thrombi (blood clots) can form on prosthetic valves. If thrombi become large
enough they can interfere with blood flow or prevent the valve from closing
properly.
 Thrombi can embolize. This is the most important complication of mechanical
(nontissue) valves. This occurs in about 1% of people per year with mechanical
valves. This is not as common in tissue valves. Those with mechanical valves
almost always need to take blood thinning medications (anticoagulation). Not
all tissue valves require anticoagulation.
 Bio prostheses may gradually deteriorate.
 Mechanical valves often cause anemia due to increased red blood cell
destruction.
 Rarely, mechanical valves can suddenly fail (break). This is often fatal.
 Endocarditis is more likely to occur on artificial valves.

Symptoms occur with prosthetic valve problems

Many patients have ongoing shortness of breath and decreased exercise

tolerance after successful valve replacement. This is more likely in persons
with poorer heart function or atrial fibrillation.

 Persons with a sudden decrease in normal exercise tolerance or new chest pain
should see their doctor.
 In addition to these symptoms people with prosthetic valve problems may
experience symptoms of emboli. Minor episodes (temporary) are common and
can include stroke like symptoms, abdominal pain (emboli blocking intestinal
blood vessels), and arm or leg pain (emboli blocking muscle blood vessels).
Major blockages can cause stroke, heart attack, and permanent intestinal injury.
 Severe hemorrhage can occur during anticoagulation therapy. People on
anticoagulants noticing blood in the urine, feces, saliva or new skin bruising
must see their doctor.
 Those with fever should see their doctor urgently. Fever could indicate
infective endocarditis.

Patients with prosthetic valves should receive antibiotic prophylaxis before dental and
surgical procedures.
Glossary

Atrial fibrillation: Left atrium of heart ineffectively quivers instead of normally

contracting.

Arrhythmia:- Irregular beating of the heart that may cause the heart to beat
too fast or slow. Certain arrhythmias may cause the heart to stop
beating.

Chorea:- Repetitive involuntary writhing movement of the head and arms.

Congenital:- a condition present at birth

Congestive heart The heart can't pump enough blood to meet the needs of the
failure:- body's other organs.

Echocardiography: A technique that views the heart valves using sound waves and a
computer generated image. Also called a heart ultrasound.

Heart murmur: Sound caused by turbulent blood flow across a heart valve(s)
heard by a doctor using a stethoscope.

Heart valves: Are thin flexible flaps of connective tissue normally permitting
one-way blood flow through the heart.

Palpitations: An uncomfortable awareness of the heart beating. May be slow,

normal or fast.

Pericardium: A tough fibrous layer of tissue normally covering the heart.

Pericardial friction: A sound heard with a stethoscope due to rubbing of the heart
rub: against the pericardium that may occur with inflammation of the
pericardium.

Pulmonary Increased pressure in the lung veins and arteries. These vessels
hypertension: are normally under lower blood pressure than arteries arising
from the aorta and its' branches. May contribute to or be caused
by chronic congestive heart failure. Often secondary to
increased left atrial pressure, due to mitral stenosis, causing
blood to back up in the lungs.
Regurgitation: Backward flow of blood through a heart valve. Also called
valvular incompetence.

Stenosis: narrowing of the valve opening

Virulence: The ability of an infection to cause illness / injury to the body.