ECCO: CV Pt.3: Assessing and Managing Patients with Stenosis or Regurgitation of the Aortic and Mitral Valves, ECCO: CV Pt 3. Assessing and Managing Patients with Heart Failure, ECCO: CV Pt 3. Assessing and Managing Patients with Cardiomyopathies

What is aortic regurgitation

When aortic valve leaflets don't close completely resulting in abnormal backflow of blood from aorta to left ventricle during diastole

Causes of aortic regurgitation

infection leading to damage or dilation or trauma to aortic root leading to dilation of aortic valve annulus

Duration of aortic regurgitation

Chronic or acute

Causes of chronic aortic regurgitation

Infections of the aortic valve (ex rheumatic fever)

Trauma

Aneurysms involving the aortic root

What does backflow lead to in chronic aortic regurg

LV dilation and hypertrophy. This is the chronic compensatory stage of the disease. Stroke volume can increase by 2x while meeting CO needs

This stage lasts many years or even decades and patients remain asymptomatic for years

Pathophys of acute aortic regurg

Sudden increase in LV volume which can't be compensated for leading to decreased systemic flow

S/S of chronic aortic regurg and Dx

pulsatile sensation in head that increases when lying down, angina, exertional dyspnea, orthopnea, and pulmonary edema

ECHO: abnormal valve and systolic dysfunction of the LV

What meds for asymptomatic chronic aortic regurgitation

DHP CCBs or ACEI or ARBS

Tx for acute aortic regurg

Surgical Tx is therapy of choice. If cause is infective endocarditis and the patient can be stabilized and tolerate delay, 48 hours of antibiotics is preferred before surgery

If patient is hemodynamically unstable, emergency surgery is indicated

What treatments do you avoid with acute aortic regurg

Beta blockers

Intra-aortic balloon pumps

Arterial vasoconstrictors

What is aortic stenosis

Congenital or acquired disease affecting the opening of the aortic valve and reduces blood flow from the LV into the aorta during ventricular systole

Example of aortic stenosis

Bicuspid aortic valve

Most common cause of acquired aortic stenosis

Degenerative calcilfication and less commonly rheumatic fever

Compensation for aortic stenosis

Causes LV to work harder to eject blood across the stiff, noncompliant valve leading to hypertrophy and diastolic dysfunction

Patient remains asymptomatic for many years to decades

When do symptoms appear in aortic stenosis

1/3 of normal valve opening size

S/S of aortic stenosis

1. Exertional angina

2. Exercise intolerance

3. Palpitations or syncope

4. HF symptoms

Exams for aortic stenosis

1. CV Testing (ECHO, EKG)

2. Cardiac catheterization (if angina occurs or valve replacement is indicated, to evaluate the presence of CAD and inform treatment decisions

3. Auscultation (systolic ejection murmur may be present)

4. Stress test (to assess exercise capacity, may indicate myocardial ischemia, can also identify exercise related symptoms in order to advise appropriate activity levels

When do we start treating aortic stenosis

Not until symptomatic

Tx of aortic stenosis

Valve replacement or balloon valvuloplasty

What is mitral regurgitation

Don't close and seal. Regurg from LV into LA during ventricular systole, decreasing stroke volume and increasing left atrial volume and pressure

Classifications of mitral regurgitation

Chronic

Acute

Etiology and progression of mitral regurgitation

1. Due to infectious (primary) as well as structural changes in the heart such as ventricular dilation (secondary) (ventricular dilation leads to dilation of mitral valve annulus and increased distanced from papillary muscles to fully closed mitral valve)

Pathophys of mitral regurg

increase left atrial pressure and volume leads to dilation until it can no longer manage to volume and pressure increases thus leading to pulmonary HTN

Atrial dilation leads to increased volume to LV during diastole leading to its dilation leading to increased contractility and thus compensation that lasts many years until myocardial fibers eventually develop systolic ventricular dysfunction

S/S of chronic mitral regurg

1. Paroxysmal nocturnal dyspnea

2. Orthopnea

3. Palpitations

4. Atrial fibrillation

Acute mitral regurg pathophys/progression

Immediate mitral regurg to increased left atrial pressure to increased pressure transferred to pulmonary system to pulmonary edema. (Acute cardiac event can come from papillary muscle ischemia, papillary muscle tears, or chordae tendinae rupture. All progresses to LV issues

Body has to compensate for decreased stroke volume by vasoconstricting thus leading to increased afterload, increasing regurg even more

Key assessment finding of acute mitral regurg

Pulmonary edema

Exercise in asymptomatic chronic mitral regurg

normal cardiac structures means they can

Symptomatic with exertion or on a stress test and those with cardiac structural or functional abnormalities should avoid competitive sports or vigorous activity (includes enlarged LV, systolic dysfunction, pulmonary HTN)

Tx of choice for acute mitral regurg

Surgical repair or replacement

Possible medical treatments for acute mitral regurg

1. Intra-aortic balloon pump: may reduce afterload and increase MAP

2. Sodium nitroprusside: may reduce afterload, it should be used in combination with an inotrope, such as dobutamine, in patients with significant hypotension

3. Antibiotics are needed if endocarditis is the cause

Mitral stenosis is what and who gets it

Opening constricted or narrowed

Sixty percent of patients have a history of rheumatic heart disease

Other causes of mitral stenosis

Atrial myxoma (soft tumor made of a gelatinous tissue like that of the umbilical cord)

Calcification

SLE

Pathophys of mitral stenosis

Decreased flow from LA to LV increasing LA pressure/volume leading to increased pulmonary pressure causing pulmonary HTN and RV failure

Which conditions can precipitate mitral stenosis and why

1. Pregnancy

2. Hyperthyroidism

3. Fever

4. Afib

All increase heart rate, leading to s/s

Tx for mitral valve stenosis includes

Control HR

Manage atrial fibrillation

Repair or replace the valve

Mitral stenosis HR Tx

BB

CCB

AFib tx in mitral stenosis

Cardioversion followed by antidysrhythmic, catheter or surgical ablation, canticoag

When is surgery considered for mitral stenosis

When valve area becomes less than 1.5 cm2 they experience symptoms at rest

Surgical treatment of mitral stenosis

1. Percutaneous mitral balloon valvuloplasty

2. Surgical commissurotomy

3. Mitral valve replacement

What is a commissurotomy

Surgical procedure to separate thickened, adherent, stenotic valve leadlets, usually because of mitral stenosis

Interventions for surgical treatmetn

Repair or replace native valve is treatment of choice for valv regurg.

Stenotic valves need surgery if there's a high risk of embolic events of calcification is present on the valve

Percutaneous and catheter-based treatments

Balloon valvuloplasty may be indicated in patients with valve stenosis if there is no regurgitation or calcification

Transcatheter aortic valve replacement (TAVR) is a well established alternative to surgery accomplished through various approaches

What is balloon valvuloplasty

Percutaneous baloon valvuloplasty may be used to temporarily relieve symptoms in patients:

-With severe symptomatic aortic stenosis, until they can receive surgical valve replacement

-As palliative treatment for symptomatic aortic stenosis patients who are too high risk for surgery

-With symptomatic severe mitral stenosis, who do not have left atrial thrombus

Post-procedure nursing care of balloon valvuloplasty and cardiac catheterization procedures

Immobilize affect limb for 4-6 hours after procedure

Monitor groin site

Monitor for neuro changes

HF with reduced EF < or equal to 40%

Systolic heart failure

with preserved EF >50% HF

Diastolic HF

What compensatory mechanisms for systolic HF

SNS, RAAS, dilation of the left ventricle

Mortality of systolic HF

Approximately 40$ die within five years of diagnosis

Presenting symptoms of HF regardless of etiology

1. Intravascular fluid overload

2. Interstitial fluid overload

3. Signs of inadequate tissue perfusion

Meds for systolic HF

1. Angiotensin receptor-neprilysin inhibitor (ARNI)

2. ACEI

3. ARB

4. BB

5. Aldosterone antagonists

6. diuretics

7. vasodilators

8. Inotropes

9. ultrafiltration therapy

10. Anticoagulation

11. Cardiac resynchronization therapy

12. Physical activity

What is an ARNI

Ex sacubitril/valsartan: Sacubitril inhibits breakdown of naturally occuring natriuertic peptides. Results in an increase in circulating endogenous natriuretic peptides that promotes natriuresis, diuresis, and vasodilation.

How do you interrupt neurohormonal responses

1. ARNI, ACEI, or ARB

2. BB

What is used to guide diuretic therapy

Daily weights

How do we improve contractility

Potentially with milrinone or dobutamine. Use with caution to avoid increasing myocardial oxygen consumption, decreasing afterload and resulting in hypotension, and causing v dysrhythmias

What is used to manage decompensated HF

Nesiritide

CRT

Ultrafiltration therapy

Anticoagulation therapy

Nesiritide

Synthetic form of BNP

decreases bnp and afterload, promotes diuresis and vasodilation

What is CRT

Cardiac resynchronization therapy

For moderate to severe HF

For LBBB who are symptomatic, despite optimal medical therapy

Restores synchrony in systole and diastole between the two ventricles, improving overall cardiac function

Physical activity in HF

Should be encouraged in all but those in acute decompensated

What is the best diagnostic tool in differentiating systolic and diastolic hF

Echo

Which two treatments help patients with R-sided HF

Sodium and fluid restrictions and moderate doses of diuretics

What can pressure on the RA that results from right-sided HF lead to

Atrial fibrillation or flutter

Weight change concerns in HF

2 lbs in one day

5 lbs in one week

Definition of dilated CM

EF lessthan 40% with increased left ventricular end-diastolic volume

How does dilated lead to pulmonary and systemic congestion

Weak contractility from stretch and inability to effectively eject leads to decreased CO and backward pressure

In early compensatory stages of dilated, what compensates

RAAS and SNS preserve CO and perfusion

Mortality rate of dilated

50% within 5 years of diagnosis

Most useful test for diagnosing dilated

Echo

S/S of hypertrohpic

Dyspnea

Chest pain

palpitations

Syncope

What is HCM the most common cause of

Sudden cardiac death in young adults

Assymetrical hypertrophy outflow leads to what

hypertrophied septum narrows the left ventricular outflow tract, accelerating the flow of ejecting blood. This rapid flow pulls against the anterior leaflet of the mitral valve, pulling the valve open and further narrowing or blocking the outflow tract

Definition of SCD

Abrupt onset of cardiac symptoms due to an electrical malfunction wihtin the heart, usually ventricular tachycardia or ventricular fibrillation. Resulting dysfunction is profound, and if untreated, results in death within one hour

Meds used for HCM

Beta blockers and CCBs to improve diastolic dysfunction. By decreasing wall tension and HR, they help to increase ventricular filling and optimize stroke volume

What meds do you avoid with HCM

Increase contractility or significantly decrease afterload. Can be life-threatening as they increase outflow obstruction and greatly decrease cardiac output

Cause and effects of stress-induced cardiomyopathy

Sudden temporary dysfunction of myocardium can lead to

Acute HF

Lethal ventricular dysrhtyhmias

Possible ventricular rupture

Takotsubo

Characteristic bulging of the LV apex with preserved function of the base resembling the shape of an octopus pot.

Contractility of apex changes, causing it to balloon out and exhibit dyskinesis or abnormal wall movement. LV base shows hyperkinesia exacerbating the lack of movement at the apex

AKA apical ballooning syndrome or broken heart syndrome

Who gets stress-induced CM

Postmenopausal women with a history of recent and severe emotional or physical stress. Avg age at onset is 58-75 years

How long does stress-induced CM last

2 months

Treatment priorities with takotsubo

1. Optimize fluids

2. Minimize myocardial oxygen demand

3. Decrease afterload

4. Prevent complications

5. Monitor for dysrhythmias

Possible complications of stres-induced CM

hypotension

Cardiogenic shock

Chronic HF

Least common CM

Restrictive

Causes of restrictive

1. Amyloidosis and sarcoidosis usually affecting both ventricles with the ventricular cavity remaining the same size or slightly decreasing in size. Deposits impact the conduction pathway of the heart and can lead to dysrhythmias.

2. Therapeutic radiation: scarring from therapeutic radiation can result in restrictive cardiomyopathy

3. Idiopathic

What is amyloidosis

Waxy protein called amyloid builds up in 1 or more of the organs causing dysfunction. It frequently affects the heart, kidneys, liver, spleen, nervous system, and digestive tract. Severe amyloidosis can lead to life-threatening organ failure

Sarcoidosis

A disease where granulomas formed of inflammatory cells are deposited in various body tissues, most commonly the lungs, lymph nodes, liver, heart, eyes, and skin

Pathophys of restrictive

Ventricles can't accept full volume from atria

Increased atrial volume and pressure

Left-sided HF: backup of blood in lungs

Right-sided HF: backup of blood in venous circulation

Biventricular HF

Mortality of restrictive

Life expectancy is only about two years from diagnosis

Tx priorities in restrictive

1. CO

2. Dysrhythmia

3. Thrombus formation

4. Cardiomyopathy cause