Valvular Surgery PDF

Valvular Dysfunction Dr. Deb Jacques DNP AGNP-c Student Learning Outcomes Explain the treatment and nursing management of clients with inflammatory heart diseases and valvular problems Identify appropriate pre and post operative nursing care measures used in caring for clients having cardiac surgery...

Valvular Dysfunction Dr. Deb Jacques DNP AGNP-c Student Learning Outcomes Explain the treatment and nursing management of clients with inflammatory heart diseases and valvular problems Identify appropriate pre and post operative nursing care measures used in caring for clients having cardiac surgery Distinguish the pathophysiology and clinical manifestations of shock Create a nursing care plan for patient with the tree different types of shock, inflammatory diseases and valvular dysfunctions Valves in the Heart The heart contains four different valves -2 Atrioventricular valves -Tricuspid (has three cusps or leaflets) and lies between the right atrium and right ventricle) -Mitral (also called the Bicuspid ) (has two cusps or leaflets) and lies between the left atrium and left ventricle) –2 Semilunar valves -Pulmonic (shaped like a half moon)- lies between the right ventricle and pulmonary artery -Aortic (shaped like a half moon) - lies between the left ventricle and aorta Valvular Dysfunction Heart valves may become stenosed (and obstruct normal blood flow ) OR insufficient (and regurgitate blood) Valvular Dysfunction Stenosis - valve opening becomes narrowed or obstructed so that the valve does not open completely which impedes the forward blood flow Valvular Dysfunction Regurgitation: also called “insufficiency”or “incompetence”; happens when the valve does not close completely, allowing blood to flow backward or “regurgitate” through the valve’s opening Patients can have pure stenosis, pure regurgitation or a combination of both. Normal and Stenosed and Regurgitant Valve Mitral Valve Stenosis Etiology and Pathophysiology Major precipitating cause is Rheumatic heart disease. Other factors (less common) Congenital mitral stenosis, rheumatoid arthritis, radiation exposure and systemic lupus erythematosus Usually involves more than one valve and can present as a mixture of stenosis and regurgitation. Take on a “fish mouth” shape Mitral Valve Stenosis Deformities block the blood flow and create a pressure difference between the atrium and left ventricle-causing high pulmonary vasculature pressure Mitral Valve Stenosis Clinical Manifestations Primary symptoms Dyspnea on exertion Loud, accentuated S1 Low-pitched, rumbling diastolic murmur Less common symptoms Hoarseness Hemoptysis Chest pain Fatigue and palpitation- Atrial fibrillation- stroke Mitral Valve Regurgitation Etiology and Pathophysiology Defect in mitral leaflets, mitral annulus, chordae tendineae, papillary muscles, left atrium or left ventricle Myocardial infarct, chronic rheumatic heart disease, mitral valve prolapse, ischemic papillary muscle dysfunction and infective endocarditis Blood flows backwards from left ventricle to left atrium Increase in pressure and volume Pulmonary edema and cardiogenic shock Mitral Valve Regurgitation Clinical Manifestations Acute Thready peripheral pulses, cool, clammy extremities and new systolic murmur Heart catherization-valve repair or replacement are critical Chronic- may be asymptomatic for years Early symptoms: weakness, fatigue, exertional dyspnea Later symptoms: palpitations, S3 gallop, holosystolic or pan systolic murmur Monitor carefully-HF therapy Mitral Valve Prolapse Etiology and Pathophysiology Abnormality of mitral valve leaflets and papillary muscles (chordae) which the leaflets prolapse into the left atrium during systole. Unknown etiology Some patients there is an increased familial history Most common form of valvular heart disease in U.S. Usually benign, but complications can be Mitral Regurgitation , infective endocarditis, sudden cardiac death, heart failure and cerebral ischemia Mitral Valve Prolapse Clinical manifestations Most patients are asymptomatic Murmur from regurgitation that is louder during systole Dysrhythmias Light-headedness & syncope Chest pain & palpitations Dyspnea Treatments Beta-blockers, hydration, exercise regularly, avoid caffeine Aortic Valve Stenosis Etiology and Pathophysiology Congenital-found in children, adolescence or young adult Older adults-result of rheumatic fever and/or degeneration of the valve d/t aging 3% of people of 65 years of age Causes obstruction of flow from the left ventricle to the aorta during systole Left ventricular hypertrophy Increased myocardial oxygen consumption due to increased myocardial mass Reduced CO leads to decreased tissue perfusion, pulmonary hypertension and heart failure Aortic Valve Stenosis Clinical Manifestations Classic triad: angina, syncope and dyspnea on exertion Left ventricular heart failure-can also see afib Normal or soft S1, a diminished or absent S2, a murmur, and a prominent S4 Prognosis is poor for patients who exhibit manifestations and those whose valve obstruction is not fixed ***Drug alert: Nitroglycerin (Nitrobid) Use cautiously with these patients as drastic reduction of BP may occur Chest pain can worsen due to a decrease in preload and drop in blood pressure Aortic Valve Regurgitation Etiology and Pathophysiology Primary disease of the aortic valve leaflets, the aortic root or both-life threatening Trauma Infective endocarditis Aortic dissection Chronic Aortic regurgitation Rheumatic heart disease Congenital bicuspid aortic valve Syphilis or chronic rheumatic conditions Causes retrograde blood flow from the ascending aorta into the left ventricle during diastole Volume overload Myocardial contractility declines and blood volume increases in the left atrium and pulmonary bed-pulmonary hypertension and right ventricular failure Aortic Valve Regurgitation- Clinical Manifestations Acute Severe dyspnea Chest pain Hypotension Left ventricular failure-Cardiogenic shock Chronic Asymptomatic for years Water hammer pulse (strong, quick beat that collapses immediately) Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnea Tricuspid and Pulmonic Valve Disease Etiology, Pathophysiology and Clinical manifestations Tricuspid Stenosis Rheumatic fever, IV drug users Results in right atrial enlargement and elevated systemic venous pressure Peripheral edema, ascites, hepatomegaly, diastolic low-pitched murmur with increased intensity during inspiration Pulmonary Stenosis Congenital Results in right ventricular hypertension and hypertrophy Asymptomatic-syncope, dyspnea angina Valvular Heart Disease Diagnostic Studies Patient’s history Physical examination CBC Echocardiogram Transesophageal Doppler color flow imaging Chest x-ray ECG Heart catheterization-pp 673, 675-676 Pre and post procedure-complications Valvular Heart Disease Conservative Therapy antibiotic therapy Rheumatic fever & Infective endocarditis Sodium restriction Medications to treat/control heart failure Vasodilators (nitrates, ACE inhibitors) Positive inotropes (digoxin) Diuretics B-blockers Calcium channel blockers Anticoagulation therapy for patient with Afib-Coumadin INR- 2.5-3.5 for mechanical valves-2-3 for tissue) Anti-dysrhythmia drugs Percutaneous transluminal balloon valvuloplasty Percutaneous valve replacement (PT/ Valvular Heart Disease Percutaneous transluminal balloon valvuloplasy Valvular Heart Disease- Valvuloplasy Valvular Heart Disease Surgical Intervention Valve repair Commissurotomy (valvulotomy) Valvuloplasty Annuloplasty Valvular Heart Disease Valvular Replacement Cardiac Surgery Goal - improve functional capacity of the heart Used to treat acquired and congenital heart disorders Used to repair, reconstruct, or replace valves that are diseased Used to revascularize the myocardium for patients at risk for myocardial infarction Cardiac Surgery Postoperative: 24 hour critical care unit Hemodynamic monitoring (PA line, A line) Ventilator (maintain patent airway) Continuous monitoring Watch temp Most tubes/lines are removed within 48 hours Patients with valve replacements -anticoagulants are begun within 72 hours (depending on the valve type) Care of the incision Cardiac rehab - counseling Valve Replacement-options Transcatheter therapies Transcatheter pulmonary valve replacement Approved for pediatric and adult pulmonary valve diseases caused by congenital heart disease Transcatheter aortic valve replacement Patients with severe, symptomatic AS Transfemoral Valvular Heart Disease Nursing Management Nursing Assessment Nursing Diagnoses Decreased cardiac output Excess fluid volume Activity intolerance Planning Valvular Heart Disease Nursing Implementation Health Promotion Acute Intervention, Ambulatory and Home care Restrict activities Discourage use of tobacco Rest periods Vocational counselor Teaching-condition, medication (prophylaxis antibiotics), follow-up