Inflammatory and Structural Disorders

Infective Endocarditis (IE)-Definition

Disease of the endocardium, innermost layer of the heart, and the heart valves

IE is associated with a poor prognosis and a decreased life expectancy

Increase in the number of cases of IE largely related to an increase in IV drug use

Infective Endocarditis (IE)-Classifications

By cause: IV drug use (IVDA IE), fungal IE

By site of involvement: Prosthetic valve endocarditis (PVE)

Subacute form affects those with preexisting valve disease

Acute form affects those with healthy valves

Infective Endocarditis (IE)-Causative Organisms

Bacterial most common

• Staphylococcus aureus (about 50%)

• Streptococcus viridans

• Coagulase Negative Staphylococci

Colonizers of the oropharynx

• HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Infective Endocarditis (IE)-Risk Factors

Categories of high, moderate, and low risk of developing IE

History of IE

IV drug use

Prosthetic valve

Health care–associated infection from use of an intravascular device

Methicillin-resistant S. aureus (MRSA)

Renal dialysis

Infective Endocarditis (IE)-Stages

1. Bacteremia

2. Adhesion

3. Vegetation

Vegetation

• Fibrin, leukocytes, platelets, and microbes

• Stick to the valve or endocardium

• Parts break off and enter circulation (embolization)

• Left-sided vegetation can move to brain, kidneys, spleen, and extremities

• Right-sided vegetation can move to lungs (PE)

Infective Endocarditis (IE)-Manifestations Nonspecific

Fever

Chills

Weakness

Malaise

Fatigue

Anorexia

Infective Endocarditis (IE)-Manifestations Subacute

Arthralgias

Myalgias

Back pain

Abdominal discomfort

Weight loss

Headache

Clubbing of fingers

Infective Endocarditis (IE)-Manifestations General

New or worsening systolic murmur in most patients

Heart failure

Manifestations secondary to septic embolism

• Central nervous system

• Extremities

• Spleen

• Kidneys

Infective Endocarditis (IE)-Diagnostics

Health history

Laboratory tests: Blood cultures, CBC with differential, ESR, C-reactive protein (CRP)

Echocardiography

Duke criteria

Echocardiogram-Care

Prophylactic antibiotic treatment for select patients having

Certain dental procedures

Respiratory tract incisions

Tonsillectomy and adenoidectomy

Surgical procedures involving infected skin, skin structures, or musculoskeletal tissue

Rheumatic Heart Disease

Starts as a sore throat from bacterium Streptococcus pyrogenes (group A streptococcus)

Can pass from person to person as an upper respiratory infraction

Most common in childhood.

RF symptoms can include: fever, painful joints, fatigue, jerky uncontrollable body movements called chorea, heart murmur

Symptoms of heart valve damage associated with RF include: chest pain, SOB, rapid or irregular heartbeat

Valvular Heart Disease-Types

Stenosis (constriction/narrowing)

• Valve opening is smaller

• Forward blood flow is impeded

• Pressure differences on the two sides of the valve reflect degree of stenosis

Regurgitation (incompetence or insufficiency)

• Incomplete closure of valve leaflets

• Results in backward flow of blood

Mitral Valve Stenosis-Definition

Most common cause is rheumatic heart disease
Scarring of valve leaflets and chordae tendineae
Contractures develop with adhesions between commissures of the leaflets

Results in decreased blood flow from left atrium to left ventricle

Increased left atrial pressure and volume

Increased pulmonary vasculature pressure

Risk for atrial fibrillation

Mitral Valve Stenosis-Manifestations

Exertional dyspnea

Loud S1

Diastolic murmur

Fatigue

Palpitations

Hoarseness, hemoptysis

Atrial fibrillation with risk for stroke

Mitral Valve Regurgitation-Mechanics

Normal valve function depends on intact:

• Mitral leaflets

• Mitral annulus

• Chordae tendineae

• Papillary muscles

Damage caused by:

• MI

• Chronic rheumatic heart disease

• Mitral valve prolapse

• Ischemic papillary muscle dysfunction

• IE

Mitral Valve Regurgitation-Definition

Incomplete valve closure

Backward flow of blood

Acute MR
Pulmonary edema
Untreated- cardiogenic shock

Chronic MR
Left atrial enlargement, ventricular dilation, eventual ventricular hypertrophy, decreased CO

Mitral Valve Regurgitation-Acute Manifestations

Thready peripheral pulses

Cool, clammy extremities

Mitral Valve Regurgitation-Chronic Manifestations

Asymptomatic for years

Weakness, fatigue, palpitations, dyspnea

Progress to orthopnea, paroxysmal nocturnal dyspnea

Peripheral edema

Audible S3, murmur

Mitral Valve-Prolapse

Abnormality of mitral valve leaflets and the papillary muscle or chordae
Leaflets prolapse back into left atrium during systole

Usually benign with valve closing effectively

Potential complications

Unknown cause but genetic link in some

Mitral Valve-Diagnostics

Echocardiography
M-mode or 2-D

Mitral Valve-Manifestations

Most patients asymptomatic for life

Only 10% with symptoms

Murmur d/t regurgitation

Severe MR uncommon

Dysrhythmias can cause palpitations, light- headedness, and syncope
Infective endocarditis
Chest pain unresponsive to nitrates

Treat symptoms with β-blockers

Valve surgery for MR

Mitral Valve-Teaching

Antibiotic prophylaxis if MR present

Take drugs as prescribed

Healthy diet; avoid caffeine

Avoid OTC stimulants

Exercise

When to call HCP or EMS

Aortic Valve Stenosis-Definition

Congenital aortic stenosis (AS) generally found in childhood, adolescence, or young adulthood

In adults, can be degenerative or caused by rheumatic fever

Obstruction of blood flow from left ventricle to aorta

Left ventricular hypertrophy and increased myocardial oxygen consumption

Decreased CO leads to decreased tissue perfusion, pulmonary hypertension, and HF
Poor prognosis if left untreated

Aortic Valve Stenosis-Manifestations

Angina

Syncope

Exertional dyspnea

Use nitroglycerin cautiously: Reduces preload and BP; Can worsen chest pain

Aortic Valve Regurgitation-Types

Acute AR

• Infective endocarditis, trauma, or aortic dissection

• Life-threatening emergency

Chronic AR

• Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, connective tissue problem, or post-surgical cause

Aortic Valve Regurgitation-Definition

Backward blood flow from ascending aorta into left ventricle

With chronic AR, left ventricular dilation and hypertrophy

Decrease in myocardial contractility

Pulmonary hypertension and right ventricular failure

Aortic Valve Regurgitation-Acute Manifestations

Severe dyspnea

Chest pain

Hypotension

Cardiogenic shock

Life-threatening emergency

Aortic Valve Regurgitation-Chronic Manifestations

May be asymptomatic for years

Exertional dyspnea, orthopnea, paroxysmal dyspnea

Angina

Water-hammer pulse if severe

Soft or absent S1

S3 or S4

Murmur

Tricuspid Valve Stenosis-Definition

Almost usually caused by rheumatic fever

Tricuspid Valve Stenosis-Manifestations

Fluttering discomfort in neck

Fatigue

Right upper quadrant pain

Pulmonary Regurgitation-Definition

Often symptomatic

Crescendo-decrescendo murmur

Can cause RV dilation.

Pulmonary Regurgitation-Causes

Pulmonary hypertension

Surgical repair of tetralogy of Fallot (TOF)

Congenital valve disease

Pulmonic Valve Stenosis-Definition

Almost always congenital

Causes right ventricular hypertension and hypertrophy

Pulmonic Valve Stenosis-Manifestations

Syncope

Dyspnea

Angina

Valvular Heart Disease-Diagnosis

History and physical assessment

Real-time 3-D echocardiography

TEE

Doppler color flow

Chest x-ray

ECG

Heart catheterization

Valvular Heart Disease-Conservative Therapy

Dependent on valve involved and disease severity

Prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent RF and IE

Prophylactic antibiotic therapy to prevent recurrent RF and IE

Valvular Heart Disease-Conservative Management

Drugs to treat/control HF:

• Vasodilators (e.g., nitrates, ACE inhibitors)

• Positive inotropes (e.g., digoxin)

• Diuretics

• β-blockers

• Low sodium diet

For atrial dysrhythmias:

• Calcium channel blockers, β-blockers

• Anti-dysrhythmic drugs

• Anticoagulation therapy for A-fib

Valvular Heart Disease-Percutaneous Transluminal Balloon Valvuloplasty (PTBV)

Split open fused commissures

Treats mitral, tricuspid, and pulmonic, and AS

Balloon-tipped catheter inserted via femoral artery

Inflated to separate valve leaflets

Valvular Heart Disease-Surgical Therapy

Valve repair

• Preferred surgical procedure

• Lower operative mortality rate than replacement

• May not restore total valve function

Valve replacement

Valvular Heart Disease-Valve Repair

Commissurotomy (valvulotomy)

• Closed

• Open (more common)

Valvuloplasty

• Open

• Minimally invasive

Annuloplasty

Valvular Heart Disease-Valve Replacement

Mechanical (artificial)

• More durable, last longer

• Risk of thromboembolism

• Require long-term anticoagulation

Biologic (tissue)

• Bovine, porcine, and human

• More natural blood flow

• No anticoagulation required

• Less durable

Valvular Heart Disease-Transcatheter Aortic Valve Replacement (TAVR)

For severe AS

Transfemoral approach

2 types: Edwards Sapien 3 valve, CoreValve transcatheter aortic valve