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Lecture 20

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University of Calgary
NURS 201
Marywyatt Sindlinger

Lecture 20 VALVULAR HEART DISEASE  Valvular stenosis refers to a constriction or narrowing of the valve opening.  Valvular regurgitation (also called valvular incompetence or insufficiency) occurs with incomplete closure of the valve leaflets and results in the backward flow of blood. Mitral Valve Stenosis  Adult mitral valve stenosis results from rheumatic heart disease. Less commonly, it can occur congenitally, from rheumatoid arthritis and from systemic lupus erythematosus.  Clinical manifestations of mitral stenosis include exertional dyspnea, fatigue, palpitations from atrial fibrillation, and a loud first heart sound and a low-pitched, rumbling diastolic murmur. Mitral Regurgitation  Mitral regurgitation (MR) is caused by MI, chronic rheumatic heart disease, mitral valve prolapse, ischemic papillary muscle dysfunction, and IE.  In chronic MR, the additional volume load results in atrial enlargement, ventricular dilation, and eventual ventricular hypertrophy.  In acute MR, there is a sudden increase in pressure and volume that is transmitted to the pulmonary bed, resulting in pulmonary edema and life-threatening shock.  Clinical manifestations of acute MR include thready, peripheral pulses and cool, clammy extremities; and a new systolic murmur.  Patients with asymptomatic MR should be monitored carefully, and surgery considered before significant left ventricular failure or pulmonary hypertension develops. Mitral Valve Prolapse  Mitral valve prolapse (MVP) is an abnormality of the mitral valve leaflets and the papillary muscles or chordae that allows the leaflets to prolapse, or buckle, back into the left atrium during systole. The etiology of MVP is unknown but is related to diverse pathogenic mechanisms of the mitral valve apparatus.  In many patients MVP found by echocardiography is not accompanied by any other clinical manifestations of cardiac disease, and the significance of the finding is unclear.  Clinical manifestations of MVP can include a murmur from regurgitation that gets more intense through systole, chest pain, dyspnea, palpitations, and syncope. Aortic Valve Stenosis  In older patients, aortic stenosis is a result of rheumatic fever or senile fibrocalcific degeneration that may have an etiology similar to coronary artery disease.  Aortic stenosis results in left ventricular hypertrophy and increased myocardial oxygen consumption, and eventually, reduced cardiac output leading to pulmonary hypertension and HF.  Clinical manifestations include a systolic, crescendo-decrescendo murmur and the classic triad of angina, syncope, and exertional dyspnea. Aortic Valve Regurgitation  Acute aortic regurgitation (AR) is caused by IE, trauma, or aortic dissection.  Chronic AR is generally the result of rheumatic heart disease, a congenital bicuspid aortic valve, syphilis, or chronic rheumatic conditions.  Clinical manifestations of acute AR include severe dyspnea, chest pain, and hypotension indicating left ventricular failure and shock that constitute a medical emergency.  Clinical manifestations of chronic AR include exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea after considerable myocardial dysfunction has occurred. Tricuspid and Pulmonic Valve Disease  Diseases of the tricuspid and pulmonic valves are uncommon, with stenosis occurring more frequently than regurgitation.  Tricuspid valve stenosis occurs almost exclusively in patients with rheumatic mitral stenosis, in IV drug abusers, or in patients treated with a dopamine agonist.  Pulmonary stenosis is almost always congenital.  Tricuspid and pulmonic stenosis both result in the backward flow of blood to the right atrium and right ventricle, respectively.  Tricuspid stenosis results in right atrial enlargement and elevated systemic venous pressures. Pulmonic stenosis results in right ventricular hypertension and hypertrophy. Collaborative Care of Valvular Heart Disease  Collaborative care of valvular heart disease includes the prevention of recurrent rheumatic fever and IE and the prevention of exacerbations of HF, acute pulmonary edema, and thromboembolism.  Anticoagulant therapy is used to prevent and treat systemic or pulmonary embolization and is used prophylactically in patients with atrial fibrillation.  An alternative treatment for valvular heart disease is percutaneous transluminal balloon valvuloplasty (PTBV) to split open the fused commissures. It is used for mitral, tricuspid, and pulmonic stenosis, and less often for aortic stenosis.  Surgical intervention is based on the clinical state of the patient and depends on the valves involved, the valvular pathology, the severity of the disease, and the patient’s clinical condition.  Valve repair (e.g., mitral commissurotomy [valvulotomy], is typically the surgical procedure of choice.  Open surgical valvuloplasty involves repair of the valve by suturing the torn leaflets, chordae tendineae, or papillary muscles and is used to treat mitral or tricuspid regurgitation.  Annuloplasty entails reconstruction of the annulus, with or without the aid of prosthetic rings (e.g., a Carpentier ring).  Prosthetic mechanical valves are made from manmade materials.  Prosthetic biologic valves are constructed from bovine, porcine, and human cardiac tissue and usually contain some human-made materials.  Mechanical prosthetic valves are more durable and last longer than biologic valves but have an increased risk of thromboembolism, necessitating long-term an
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