MIDTERM
abnormalities of single or multiple
CHAPTER 28 Management of Patients with
Structural, Infectious, and Inflammatory
Cardiac Disorders.
How do valves work?
- It maintains one-way blood flow
through your heart
- The four heart valves make sure that
blood always flows freely in a forward
direction and that there is no backflow.
Heart Valves
- AV valves (tricuspid and mitral) and
Semilunar valves (pulmonic and aortic)
- AV valves close during S1 at the
beginning of systole while the
Semilunar valves open
- Semilunar valves close during S2 at the
beginning of diastole while the AV
valves open
- Chordae Tendineae anchors the valves
to the papillary muscles of the
ventricles.
- Interventricular Septum has 2 areas, the
membranous part and the muscular
area.
- The membranous part is the area where
most congenital heart defect occurs.
Such as VSD/ Ventricular Septal Defect
Valvular Heart Disease
- Describes structural and functional
cardiac valves
- Alteration in blood flow across the
valve
TYPES OF VALVULAR LESIONS
 STENOSIS – valves do not open
completely, blood flow through the
valve is reduced. Narrowed
 REGURGITATION – valves do not close
completely, blood flows back through
the valves. Backflow
MURMURS
SYSTOLIC MURMUR
- Aortic stenosis
- Mitral regurgitation
- Tricuspid regurgitation
DIASTOLIC MURMUR
- Aortic regurgitation
- Mitral stenosis
- Tricuspid stenosis
VULVULAR DISORDERS
1. MITRAL VALVE PROLAPSE
- A deformity that produces no
symptoms
- Frequently in women than in men
- “floppy” mitral valve
- Etiology: annulus dilation, leaflet
floppiness, or chordae tendineae
rupture
- Stretchy chordae tendineae
- Mitral regurgitation (from the left
ventricle back to the left atrium)
- Malfunctioning mitral valve allows
backflow of blood into the left atrium,
causing progressive enlargement.
- Causes: idiopathic
- Feature of connective tissue disorders
like Marfan’s Syndrome: pectus
excavatum, arachnodactyly, dilation of
the aorta.
Signs and Sx:
 - Asymptomatic
- MVP syndrome: atypical chest pain,
palpitations, SOB, dizziness/syncope,
mid-systolic click (classical sign)
- Fatigue may occur regardless of activity
level and amount of rest and sleep.
- SOB is not correlated with activity
levels or pulmonary functions.
- Atrial or ventricular dysrhythmias may
produce the sensation of palpitations.
Patho:
- About 15% of patients who develop
murmur eventually experience heart
enlargement, a-fib, pulmonary
hypertension, or heart failure.
Mildest form
- Valves remain competent but bulges
back into the atrium during systole
resulting to a mid-systolic click but no
murmur.
In the presence of regurgitant valve
- Click is followed by a late systolic
murmur, which lengthens as the
regurgitation becomes more severe
Severe form
- Progression elongation of chordae
tendineae leads to increasing
regurgitation resulting to chordal
rupture and severe regurgitation
Assessment and Findings:
- Extra heart sound referred to as the
mitral click or Barlow’s syndrome. It is
an early sign that a valve leaflet is
ballooning into the left atrium.
- Echocardiography is used to diagnose
and monitor progression.
Medical Management:
Focus: control of symptoms
For palpitations/arrhythmias: eliminate
caffeine and alcohol; stop smoking;
antiarrhythmic medication.
For chest pain: nitrates (vasodilator), Calcium
channel) blockers (dipine; amlodipine), beta
blockers (olol; propranolol)
For severe mitral regurgitations and
symptomatic HF: mitral valve repair or
replacement.
Nursing Management:
 Client education – disease may be
hereditary, read product labels. Such as
OTC meds like cough meds may
contain alcohol, caffeine, ephedrine,
and epinephrine.
 Explore client’s diet, activity, sleep, and
other lifestyle factors.
2. MITRAL VALVE REGURGITATION
- Blood flows from the left ventricle back
into the left atrium during systole
- Mitral valve leaflets do not close
completely during systole
- The most common cause is rheumatic
heart disease.
Causes:
 Rheumatic heart disease
- Caused by GABHS/Group a Beta
Hemolytic Streptococcus.
 Mitral valve prolapse
 Dilation of the LV and the mitral ring
- Coronary artery disease
- Cardiomyopathy
 Damage to valve cusps and chordae
- Rheumatic heart disease
- Endocarditis
 Ischemia or infarction of papillary
muscle (post MI)
Patho:
 Incomplete closure of mitral valve
 Backflow of blood to the left atrium
 Decrease volume of blood ejected by
left ventricle
- Decrease CO
 Increase atrial pressure
- Left atrial hypertrophy
 - Increase pulmonary pressure Medical Management:
- Increase right ventricular pressure
 Vasodilators
- Leading to right sided HF
- ACE inhibitors (angiotensin
Clinical manifestation: converting-enzyme; pril)
- Captopril, lisinopril, enapril, ramipril
 Acute
 ARBs (angiotensin receptor blockers;
- Resulting from myocardial infarction
sartan, tan)
- Usually manifests as severe congestive
- Losartan, Valsartan
HF
 Diuretics
- Chordae tendineae/papillary muscle
- Thiazide
rupture
 If A-fib presents
- A medical emergency; flash pulmonary
- Anticoagulants (warfarin)
edema, CHF/congestive HF.
- Digoxin (digitalis/cardiac glycoside)
- Most common symptoms: dyspnea,
 Digoxin
fatigue, and weakness
- + inotropic; increases the strength of
 Chronic
contractility
- Dilated ischemic cardiomyopathy
- - chronotropic; decreases heart rate
 For pulmonary congestion; most
- Therapeutic range: 0.5 to 2.0
common symptoms are SOB,
nanogram/mL
palpitations, and cough.
- Hold medication if: heart rate decreases
Symptoms: beyond 60 bpm, K decreases 3.5.
- Beyond 2.0 ng/mL is a risk for Digitalis
 Fatigue & weakness
Toxicity
- Due to decrease CO (predominant
- Signs: Vision changes and GI
complaint)
disturbances
 Exertional dyspnea & cough
- Antidote: Digibind
- Pulmonary congestion
 Palpitations Surgical Management:
- Due to atrial fibrillation (occur in 75%
 Mitral valve repair to treat mitral valve
of pts)
prolapse
 Edema, ascites
 Mitral valve replacement; an artificial
- Right-sided HF
valve is sewn in place.
Signs:

 A-fib
3. MITRAL STENOSIS
 Cardiomegaly
- Reduced blood flow from the left
 Apical systolic murmur
atrium into the left ventricle
 Signs of pulmonary venous congestion: - Mitral valve does not open completely;
crepitations, pulmonary edema, narrowed pathway.
effusion. - Most often caused by rheumatic
 Signs of pulmonary hypertension and endocarditis, which progressively
right sided HF. thickens mitral valve leaflets and
Diagnostic findings: chordae tendineae.

 Echocardiography Causes:
 ECG  Rheumatic endocarditis (most common
 Chest radiograph cause)
  In older people, it can be caused by  Chest radiograph; pulmonary
calcification of mitral valve congestion congestion, redistribution of blood flow
 In babies, very rare to upper lobes.
 ECG; A-Fib and other atrial
Patho:
dysrhythmias
 Auscultation; diastolic murmur,
accentuated S1, opening snap
 Catheterization; elevated pressure
gradient across valve, increased left
atrial pressure, pulmonary artery
occlusion pressure, and pulmonary
artery pressure; low cardiac output.
Medical Management:

 Anticoagulants
- To reduce the risk of developing atrial
thrombus and systemic embolism
Clinical Manifestation: - Warfarin, aspirin, clopidogrel
 Digoxin, beta blockers, calcium channel
Symptoms:
blockers
 Pulmonary congestion: breathlessness, - To control ventricular rate in A-fib
cough  Diuretics
 Pulmonary hypertension: chest pain, - To control pulmonary congestions
DOE (dyspnea on exertion)
Surgical Management:
 Pulmonary congestion/pulmonary
hypertension: hemoptysis  Mitral balloon valvuloplasty
 Low CO: fatigue  Commissurotomy to open or rupture
 Right sided HF: edema, ascites the fused commissure of the valves.
 A-Fib: palpitations  Valve replacements
 Thromboembolic complications
Client Education:
Signs:
- Avoid strenuous activities, competitive
 A-Fib; pulse is weak and irregular sports, and pregnancy.
caused by a strain on the atrium.
 Mitral facies; abnormal flushing of the
cheeks that occur from cutaneous
vasodilation in the setting of sever
mitral valve stenosis
 Auscultation; loud first heart sound,
opening snap (increased by forceful
opening of mitral valve); Mid-diastolic
murmur (apex) 4. AORTIC REGURGITATION
 Crepitation, pulmonary edema, - Backward flow of blood into the left
effusions (raised pulmonary capillary ventricle from the aorta during diastole
pressure) - May be caused by inflammatory lesions
that deform aortic valve leaflets or
Diagnostic Findings:
dilation of the aorta, preventing
complete closure of the aortic valve.
 - May also result from infective or - Usually asymptomatic; because
rheumatic endocarditis, congenital compensatory ventricular dilatation
abnormalities, diseases such as syphilis, and hypertrophy occurs)
blunt chest trauma. - Awareness of heartbeat, palpitations;
particularly when lying on the left side,
Causes:
which results from increased in stroke
 Congenital volume.
- Bicuspid valve or disproportionate  Severe
cusps - Breathlessness
 Acquired - Angina
- Rheumatic disease
Signs:
- Infective endocarditis
- Trauma  Pulses
- Aortic dilatation (Marfan’s syndrome, - Large volume or collapsing pulse
aneurysm, dissection, syphilis) - Low diastolic and increased pulse
pressure
Patho:
- Bounding peripheral pulse
- Capillary pulsation in nail beds:
Quincke’s sign
- Femoral bruit (pistol shot): Duroziez’s
sign
- Head nodding with pulse: de Musset’s
sign

 Murmurs (characteristic murmur is

best heard at the left sternum during
held expiration)
- Early diastolic murmur
- Systolic murmur (increased stroke
volume)
- Austin Flint murmur (soft mid-
diastolic)

 Other signs:
- Displaced, heaving apex beat (volume
overload)
- Pre-systolic impulse
- 4th heart sound
- Crepitations (pulmonary venous
congestion)
Medical Managements:

Clinical Manifestations:  Patients with aortic regurgitation with

hypertension should be treated with
Symptoms:
calcium channel blockers or ACE
 Mild or moderate inhibitors to provide afterload
reduction.
  Systolic BP should be controlled with
vasodilating drugs, such as nifedipine
or ACE inhibitors (pril)
Surgical Management:

 Aortic valve replacement or

valvuloplasty
- Treatment of choice
- Preferably performed before left
ventricular failure occurs.
- May be combines with aortic root
replacement and coronary bypass
surgery.
Client Education:

 Asymptomatic patients should have

annual follow up with
echocardiography for evidence of
increasing ventricular size.
 Avoid physical exertion, competitive
sports, and isometric exercise.
 Restrict sodium intake.