Valvular Heart Disease

Prepared by Urmila Prajapati

MN 2nd year
Roll no 12
Anatomy of valve

• The heart contain two atrioventricular valves:

• Mitral valve

• Tricuspid valve

Two semilunar valve

• Aortic valve
•  Pulmonary valve
 Types of Valvular heart disease

Types of Valvular heart disease are defined according to the valve defect. 

• Stenosis – constriction or narrowing

• Regurgitation – incomplete closure of the valve leaflets results in the backward

flow of blood.
 Types of valvular heart disease

• Mitral stenosis

• Mitral regurgitation

• Mitral prolapse

• Aortic stenosis

• Aortic regurgitation

• Tricuspid stenosis

• Tricuspid regurgitation

• Pulmonary stenosis

• Pulmonary regurgitation
 Common Causes

• Rheumatic disease

• Endocarditis

• Congenital heart valve disease

• Heart failure

• Artheisclerotic/aging

• Myocardial infraction

• Marfan’s syndrome.
 Epidemiology

• In developed countries, degenerative valve disease has replaced rheumatic heart

disease (RHD) as the leading cause of valvular heart disease.

• Mitral regurgitation and aortic stenosis are the most common VHD in the community
and hospital settings.

• RHD remains the most common cause of VHD in developing countries and affects

33.4 million people worldwide(Geoffrey et al, 2019) .

 Epidemiology

In Nepal
• Rheumatic heart disease is most common cause of Valvular heart disease.

• Mitral valve was the most commonly affected valve (98.2%) and mitral regurgitation was
the most common Valvular lesion

• Mitral Stenosis was statistically significant in female patients while aortic regurgitation as
well as aortic stenosis were significant in male patients (Koirala, Sah, & Sharma, 2018).

• In elderly population MS is less common as primary / degenerative but AS, AR and MR is

most common as senile calcifie degeneration (Kodali, Velagapudi, Hahn, Abbott, & Leon,
2018)
Mitral valve stenosis 

• Mitral valve is typically 4 to 6 square centimeters (0.62 to 0.93 sq in) in area.

• Because of narrowing of mitral valve orifice, an obstruction of blood flowing from

the left atrium into the left ventricle

• Patient will not experience valve related symptoms until the valve area is 2-2.5 cm 2
or less,
Pathophysiology
 Clinical manifestation

• Exertional dyspnea: reduce lung compliance

• Hemoptysis: pulmonary hypertension

• Fatigue and palpitation: reduce cardiac output

• Chest pain: decreased CO and coronary perfusion

• Less often hoarness: from arterial enlargement pressing on the laryngeal nerve.

• Heart sound include loud first heart sound and low pitched, diastolic murmur

• Arterial fibrillation in ECG

• Emboli can form in the left atriums secondary to arterial fibrillation and cause a stroke.
 Mitral Valve Regurgitation
• Blood flowing back from the left ventricle into
the left atrium during systole because valve
doesn’t close properly

• Mitral valve function depend on intact mitral

leaflet, mitral annulus, chordae tendineae,
papillary muscles, left atrium and left ventricle.

• A defect in any of these structure can result in

regurgitation
Cause

• Myocardial infraction

• Chronic rheumatic heart disease

• Mitral valve prolapse

• Ischemic papillary muscle dysfunction

• Infective endocarditis
Pathophysiology
Regurgitation mitral orifice 

Volume overload on the LV

LV is decompressed into the LA during diastole

Backward flow of blood in the LA

Volume overload in LA

LA enlargement

 Raised left atrium pressure

 Rise pressure in pulmonary vasculature

Pulmonary edema
Clinical manifestation

Acute MR Chronic MR
May remain asymptomatic for many
• Thready peripheral pulse yrs until the development of some
degree of right ventricular failure
• Cool clammy extremities
• Weakness
• Low cardiac output may mask new • fatigue
systolic murmur • Palpitation
• Dyspnea
• orthopnea,
• paroxysmal nocturnal dyspnea
peripheral edema
 Mitral prolapse

Mitral valve prolapse is an

abnormality of the mitral valve
leaflets and the papillary muscle
or chordae that allow the leaflet
to prolapse, or buckle, back into
the left atrium during systole
 Clinical manifestation

• Most patients are asymptomatic.

• Patient may or may not have chest pain: abnormal tension of papillary muscle,
during emotional stress.

• Dyspnea

• palpitation

• Syncope
 Aortic valve stenosis

• Aortic valve stenosis is a narrowing of the

orifice between the left ventricle and aorta.

• A normal aortic valve area is 3 square

centimeter

• Symptoms usually occur when the aortic

valve area narrows to less than 1 square
centimeter

• Critical aortic stenosis is present when the

valve area is less than 0.7 square centimeters.
 Etiology

• Congenital aortic stenosis is generally found in childhood, adolescence, or young

adulthood

• Rheumatic fever

• Senile calcific aortic stenosis

• Bicuspid aortic valve.

 ,
Pathophysiology
n
o
Progressive narrowing of
n aortic valve orifice
-

Increase pressure
c on LV
o
Worsening LVH tom p
minimum stroke volume
l
Stiff, non- compliant
i ventricle
a
n
Elevated end t
diastolic pressure

v
More pressure on LA Blood
e
backflow into LA and pulmonary vasculature
n
t
Various clinical
r manifestations
i
c
l
e
 Clinical manifestation

• Exertional dyspnea

• Orthopnea

• Dizziness

• Syncope attack

• Angina

• Pulmonary edema

• Pulse pressure may be low (30 mmHg or less)

• Normal or soft s1, diminished or soften s2 and systolic murmur, prominent s4

 Aortic valve regurgitation

• Aortic regurgitation is a condition due to inadequate

closure of aortic valve leaflet leading to the flow of
blood back into the left ventricular from ascending
aorta during cardiac diastole
 Etiology

• The result of primary disease of aortic valve leaflets, the aortic root or both.

• Congenital: bicuspid aortic valve

• Rheumatic heart disease

• Syphilis

• Chronic rheumatic condition eg ankylosing spondylitis

• Reactive arteritis eg Takayasu arteritis

• Aortic dissection
Pathophysiology
 Clinical manifestation

• Fatigue

• Exertional dyspnea

• Paroxysmal nocturnal dyspnea

• Chest pain : angina less frequently than in AS

• Water hammer pulse: strong, quick beat that collapse immediately

• Heart sound: soft or absent S1, S3 or S4 and a soft high pitched diastolic murmur
Tricuspid and Pulmonic valve disease

• Disease of the tricuspid and pulmonic valves are uncommon

• Stenosis occurring more frequently than regurgitation

• Tricuspid stenosis result in right arterial enlargement and elevated systemic venous
pressure rather than pulmonary venous pressure.

• Pulmonic stenosis is almost always congenital and result in right ventricular

hypertension and hypertrophy.

• The low cardiac output state causes fatigue; abdominal discomfort may occur due
to hepatomegaly and ascites.
Clinical manifestation

• Peripheral edema

• Ascites

• Hepatomegaly

• Diastolic pitched murmur with increased intensity during inspiration

 Diagnostic assessment for valvular dysfunction

• History and physical examination

• Chest x-ray: heart size, altered pulmonary circulation

• Complete blood count

• ECG: heart rate, rhythm, any ischemia or ventricular hypertrophy

• ECHO: valve structure, function and heart chamber size

• Heart catheterization: pressure change in heart chamber, measure the size of valve
opening, measure pressure difference across the valve.
Complication

• Heart failure

• Stroke

• Blood clots

• Heart rhythm abnormalities

 Medical management

• Medical management is directed at controlling symptoms, heart failure

• Prevent beta hemolytic streptococcal infection as treatment to RH fever/ infective

endocarditis.

• Digitalis is prescribed for arterial fibrillation

• Beta blocker are given to decrease heart rate there by increasing exercise tolerance.

• Anticoagulant are prescribed to reduce risk of embolus.

• Nitrate, angiotensin converting enzyme (ACE) inhibitor are used for symptomatic relief.

• Diuretic and low sodium diet are prescribed to control pulmonary congestion.
Medical management

• Arterial dysrhythmia are common and treated with calcium channel blocker, beta
blocker, antidysrhythemic drugs.

• Prophylactically antibiotic can be used before invasive procedure (dental

procedure)

• Avoid strenuous activities and competitive sport both of which increase heart rate.
Surgical management

Valve repair
Valve replacement
• Mitral commissurotomy (valvulotomy) • Mechanical valve
• Open procedure
• Biological (tissue) valve
• Closed procedure
• Xenograft
• Open surgical valvuplasty
• Homograft
• Minimally invasive valvuplasty
• Autograft
• Annuloplasty
 Nursing management

Subjective symptoms Objective symptoms

• Fever
• Fatigue
• Orthopnea
• Weakness
• Dyspnea, rales crackles
• General malaise
• Pink-tinged sputum
• Dyspnea on exertion, paroxynal nocturnal
• Murmurs
dyspnea
• Palpitations
• Dizziness
• Cyanosis, capillary refill
• Chest pain or discomfort • Edema
• Weight gain • Dysrhythmias
• Prior history of rheumatic heart disease • Restlessness
Nursing diagnosis

• Decreased tissue perfusion related to decrease cardiac output related to Valvular

incompetence

• Excess fluid volume related to fluid retention secondary to Valvular heart disease
induced heart failure

• Activity intolerance related to insufficient oxygenation secondary to decreased

cardiac output and pulmonary congestion.

• Knowledge deficit related to the complexity of treatment.

 Maintain Tissue perfusion
1. Assess for sign of decreased tissue perfusion eg blood pressure, pulse pressure, pulse,
dyspnea, peripheral skin color

2. Use pulse oximetry to monitor oxygen saturation and pulse rate to detect change in
oxygenation.

3. Monitor urine output. Kidney respond to reduce cardiac output by retaining water and
sodium. Urine output is usually decreased during day.

4. Provide rest during symptomatic episode to improve cardiac output

5. Assist with position change in supine to sitting position to reduce the risk of orthostatic
BP changes
Maintain Tissue perfusion cont:

6. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. It

assist to alleviate sign of hypoxia and subsequent activity intolerance.

7. Avoid any strenuous activity that can cause fatigue and dyspnea because damage
valve may not handle the increase CO demand.

8. Develop care plan to emphasize conserving energy, setting priorities and taking
planned rest period.

9. Instruct the patient to get adequate rest and sleep to promote relaxation to the
body.
 Maintain fluid volume

1. Monitor weight regularly using the same scale and same time (prefer morning) of day
wearing same amount of cloth to make consistency.

2. Assess weight in relation to nutritional status because poor nutrition and decrease
appetite over time result in decrease in weight which may accompanied by fluid
retention even though the net weight remain unchanged.

3. Monitor blood pressure and heart rate. Sinus tachycardia and increased BP are evident in
early stage

4. Monitor input and output closely because decrease cardiac output also decrease renal
perfusion.

5. Assess urine output in response to diuretic therapy.

 Maintain fluid volume cont

6. Assess for crackle in lungs, change in respiratory pattern, shortness of breath and
orthopnea. These are sign of accumulation of fluid in the lung.

7. Assess for bounding pulse and S3. These finding are sign of fluid overload.

8. Limit sodium intake as prescribed to decrease fluid retention.

9. Monitor fluid intake. It enhance compliance with the regimen.

10. Aid with repositioning every 2 hours to prevent fluid accumulation in dependent
area.
Activity intolerance

1. Assess the physical activity level, baseline cardiopulmonary status and mobility of the patient. Discontinue the
activity if patient respond with chest pain dizziness, BP, increase pulse rate.

2. Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing.
Gradual progression of the activity prevents overexertion.

3. Administer oxygen to meet sufficient oxygenation.

4. Encourage physical activity consistent with the patient’s energy level to promote sense of autonomy while being
realistic about capabilities.

5. Teach patient to recognize sign of physical overexertion to promote awareness to prevent the complication of
overexertion.

6. Teach energy conservation technique, sitting to do task, frequent position task, pushing rather than lifting, sliding
rather than lifting, resting for at least 1 hour meals before starting new activity to reduce oxygen consumption,
allowing a more prolong activity.
 Knowledge deficit

1. Assess ability to learn or perform desired health related care to outline appropriate teaching plan

2. Grant a calm and peaceful environment without interruption to allow the patient to concentrate
and focus more completely.

3. Provide and ensure that patient have prophylaxis antibiotic before any invasive intervention
(dental gastrointestinal, genitourinary procedure) to prevent infective endocarditis.

4. Monitor side effect of medicine. Eg decreased pulse rate as digitalis toxicity and beta blocker use,
hypokalemia and sign of dehydration if patient is using diuretic, sign of hypernatremia in ACE
inhibitor user , peripheral edema in calcium channel blocker, hypotension.

5. Provide necessary care, If patient is undergoing surgery such as valve repair and replacement,
provide preoperative and postoperative care.
 Knowledge deficit

6. Teach patient about importance of continuous fallow up and need to compliance with treatment regimen
(correct dose and time, life style modification).

7. Patient having prosthetic valve replacement should take anticoagulant for long time and regular blood test
for INR ,precautions to prevent bleeding observe sign of overdose eg ecchymosis.

8. Provide appropriate information about disease, drug and treatment to the patient which help to reduce
anxiety and promote psychological support,

9. Advice not to get pregnant in severe stenosis.

10. Educate the patient when to seek medical care, any sign of infection, heart failure, bleeding and any planned
invasive or dental work.

11. Educate ongoing cardiac assessment is necessary to monitor effectiveness of drug and prevent complication.
Evaluation

• Maintains adequate tissue and organ perfusion

• Achieves fluid and electrolyte balance

• Achieves optimal level of activity

• Describes disease process recognize need for medication, understand treatment

and appropriate measure to prevent complication
 References

• Kodali, S. K., Velagapudi, P., Hahn, R., Abbott, D., & Leon, M. B. (2018). Valvular Heart
Disease in Patients ≥80 Years of Age. Journal of the American College of Cardiology,
71(18), 2058-2072.
• Koirala, P. C., Sah, R. K., & Sharma, D. (2018). Pattern of rheumatic heart disease in
patients admitted at tertiary care centre of Nepal. Neplese Heart Journal, 15(1), 29-33.
• Lewis, Bucher, Heitkemper, Kwong, Harding, & Robert. (n.d.). Lewis's Medical Surgical
Nursing assessment and management of clinical problems (3rd south Asia edition ed., Vol.
1). Elsevier.
• sharma, M., Paudel, K., & Gautam, R. (2017). Essential testbook of Medical Surgical
Nursing (2nd edition ed.). Samikha.
• Smeltzer, S., Bara, B., Hinkle, J., & Cheever, K. (n.d.). Brunner & Suddarth's Texbook of
Medical Surgical Nursing (11th edition ed., Vol. 1).
• https://emedicine.medscape.com/article/155724-overview#a5
• https://www.researchgate.net/figure/Pathophysiology-of-mitral-stenosis_fig2_27