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Valvular Heart Disease- Cardiovascular Nursing
This is a review of the information that nursing students will need to know about valvular heart disease. In this review we will cover mitral stenosis, mitral regurgitation, mitral valve prolapse, atrial stenosis, and atrial regurgitation. Then, the management options for these valvular heart diseases will be explored.
If you want some more cardiac study material, then you can also check out these posts:
Once you are done reading this post, be sure to download this FREE PDF cheat sheet/study guide that highlights all the important information in this post.
Before you begin, be sure to review the flow through the heart if you are a little rusty on the concept. It is imperative to understand this basic information so that you can fully understand the problems that occur when the heart valves are dysfunctional.
You can watch this detailed video from Khan Academy for a refresher!
*Also, a quick note about the drawings in this post. The drawings are not anatomically correct and are a gross oversimplification of what is occurring in the body. I simplify the drawings in order to illustrate certain points in an easy to understand way (also, I could not draw them anatomically correct even if I tried lmao). I hope the drawings are useful to you and do not distract from your learning*
Mitral Stenosis
Stenosis=narrowing or restriction
Usually results from rheumatic carditis after rheumatic fever
Causes valve thickening by fibrosis and calcification
Characteristics of mitral stenosis:
- Valve leaflets fuse and become stiff
- Chordae tendinae contract and shorten
- Valve opening narrows and prevents normal blood flow from the left atrium to the left ventricle
- Increased left atrial pressure
- Left atrium dilates
- Increased pulmonary artery pressure
- Right ventricle hypertrophies
Pulmonary congestion and right sided heart failure occur and decreased cardiac output will result over time
Signs/symptoms:
- Dyspnea on exertion
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Palpitations
- Dry cough
- Hemoptysis
- Pulmonary edema
- Right sided heart failure– hepatomegaly, neck vein distention, pitting edema
Let’s break this down in an easy to understand way.
We know that blood flows from the left atrium through the left ventricle through the mitral valve. If the mitral valve is stenosed, then the blood will not be able to flow through normally. This causes increased pressure in the left atrium and causes the left atrium to dilate.
So, if the blood cannot flow normally through the left atrium to left ventricle, the blood has to go somewhere, right? It will inevitably backflow. And if we think of the anatomy of the heart, then we know it will backflow into the pulmonary system through the pulmonary veins . And this is why we see pulmonary congestion and the associated pulmonary symptoms like dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, dry cough, and hemoptysis.
Pulmonary hypertension and congestion then causes the right ventricle of the heart to have to work harder (the right ventricle is having to overcome a greater amount of pressure), so the right ventricle then hypertrophies.
This right ventricle hypertrophy then leads to right sided heart failure, which is why we can see s/s such as hepatomegaly, neck vein distention, and pitting edema.
Mitral regurgitation (insufficiency)
Prevents mitral valve from closing all the way during systole. This results from fibrotic and calcific changes in the mitral valve.
This causes backflow into the left atrium during systole. During diastole, the blood flows into the left ventricle which increases the amount of volume needing to be ejected. This increased volume and pressure cause the left atrium and ventricle to dilate and hypertrophy.
Causes:
- Degenerative due to aging
- Infective endocarditis
- Rheumatic heart disease
Signs/symptoms:
Symptoms begin to develop when the left ventricle fails because of chronic fluid volume overload
- Fatigue, weakness- due to decreased cardiac output
- Dyspnea on exertion
- Orthopnea
- Anxiety
- Chest pain
- Palpitations
- Right sided heart failure- hepatomegaly, pitting edema, neck vein distention
Just as with mitral stenosis the pulmonary congestion (caused by the failing left ventricle) causes the pulmonary symptoms dyspnea upon exertion and orthopnea. Decreased cardiac output from the failing left ventricle also causes fatigue, weakness, and chest pain.
The left ventricular failure can then lead to right sided heart failure which can result in hepatomegaly, pitting edema, and neck vein distention.
Mitral Valve Prolapse
Mitral valve prolapse occurs because valvular leaflets enlarge and prolapse into the left atrium during systole. This can eventually lead to mitral regurgitation.
Most patients are asymptomatic but can experience chest pain, palpitations, and exercise intolerance.
Aortic Stenosis
Aortic stenosis is the most common valve dysfunction.
The aortic valve narrows and obstructs left ventricular output during systole. This eventually results in ventricular hypertrophy. This then causes the left ventricle to fail which leads to blood backing up in the atrium causing pulmonary congestion. Right sided heart failure can develop as a result.
Causes:
- Congenital abnormalities
- Rheumatic disease
- Atherosclerosis
Signs/symptoms:
- Dyspnea
- Angina
- Syncope
- Peripheral cyanosis
- Fatigue
- Crescendo-decrescendo murmur
Aortic Regurgitation (insufficiency)
Aortic valve leaflets do not close properly during diastole. This allows blood to backflow into the left ventricle during diastole.
This eventually results in left ventricular hypertrophy as the left ventricle dilates to compensate for the increase blood volume.
Causes:
- Infective endocarditis
- Congenital anomalies
- Hypertension
- Marfan Syndrome
Signs/symptoms:
Asymptomatic for many years
- Exertional dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Palpitations
- Nocturnal angina
Diagnostics for Valvular Heart Disease
Echocardiography- to visualize the structure and movement of the heart
Transesophageal echocardiography (TEE)- to assess for valve problems
Cardiac catheterization may be needed to asses severity
ECG- to assess for abnormalities. May see Atrial Fibrillation in mitral stenosis, mitral regurgitation, and atrial stenosis.
Nonsurgical Management of Valvular Heart Disease
Medication therapy:
Diuretics, beta-blockers, digoxin, and oxygen to improve symptoms of heart failure
Calcium channel blockers to decrease regurgitant flow with aortic and mitral stenosis
**Antibiotic prophylaxis before invasive procedures is imperative for patients with valve disorders**
If Atrial Fibrillation develops, then the patient will be at increased risk of thrombi formation. If A. Fib occurs, patients will need to be started on an anticoagulant such as warfarin to prevent thrombi formation. Cardioversion may be needed for patients who develop A. Fib. If a patient remains in A. Fib, then amiodarone can be used.
Noninvasive Repair of Valvular Heart Disease
Balloon valvuloplasty- for mitral or aortic stenosis. Rarely lasts longer than 6 months.
- Mitral valvuloplasty- balloon is inserted through femoral vein and fed to the atrial septum and then the mitral valve. The balloon is then inflated to enlarge the mitral orifice.
- Aortic valvuloplasty- balloon is inserted through the femoral artery and fed to the aortic valve. The balloon is then inflated to enlarge the aortic orifice.
*Utilize post-angiogram precautions for patients who undergo balloon valvuloplasty*
- Monitor for bleeding at insertion site
- Observe for signs of a systemic emboli
Surgical Management
Direct commissurotomy- cardiopulmonary bypass during open heart surgery. Surgeon removes thrombi from the atria, incises the fused leaflets, and debrides calcium from the leaflets
Mitral valve annuloplasty- regurgitation is eliminated or reduced by making the annulus smaller; leaflet repair is also done concurrently
Heart valve replacement:
Heart valve replacement is achieved by either using a biological/tissue valve replacement or a prosthetic/mechanical valve replacement
Biological/tissue valve
- Biological valves cannot be used for aortic stenosis
- Little risk associated with clot formation so long-term anticoagulation therapy is not indicated
- Must be replaced every 7-10 years
- Infections are easier to treat
Prosthetic/mechanical valves
- Requires lifelong anticoagulation therapy
- Subject to mechanical failure
- Infections are harder to treat
A preoperative dental examination will need to be completed before surgery. All periodontal disease and dental caries will need to be resolved.
Patients should stop taking anticoagulants at least 72 hours before the procedure.
Post-operative nursing interventions for heart valve replacement:
(Similar to those for a CABG)
- Monitor cardiac output and assess for signs of heart failure
- Monitor hemodynamic status for signs of compromise
- Monitor ECG continuously for disturbances in heart rate and rhythm
- Maintain patient’s Mean Arterial Pressure (MAP) between 70-100 mmHg
- Check ABGs every 2-4 hours and adjust the ventilator settings as needed
- Assess chest tubes for signs of hemorrhage, excessive drainage, and a sudden decrease or cessation of drainage
- Administer analgesics for pain as prescribed and indicated
- Monitor for fluid and electrolyte imbalances, especially hypokalemia
- Teach patients how to care for their sternal incision and how to monitor for s/s of infection
- Teach patients to avoid heavy physical activity for 3-6 months
- Teach patient that they should wear a medical alert bracelet indicating they have had a valve replacement
- Teach patients they are at an increased risk of infective endocarditis
- Teach patients who have prosthetic valves that they will be on prophylactic anticoagulants. Teach them s/s to report to their provider such as excessive bleeding, excessive bruising, etc.
- Teach patients they should avoid dental procedures for 6 months after surgery
That wraps up this information! I hope you find this useful when you are studying for you cardiac exam in nursing school.
As always, feel free to reach out to me if you have any questions or just want to chat.
Happy Nursing!