AMS Heart Valve DO

Deoxygenated (arteries)

1. SVC and IVC to RA

2. Tricuspid valve to RV

3. RV to pulmonic valve

4. Pulmonic valve to lungs

Oxygenated (veins)

1. Lungs to LA

2. Mitral valve to LV

3. LV to aortic valve

4. Aortic valve to aorta

What is the blood flow of the heart?

1. Tricuspid

2. Pulmonic

3. MITRAL

4. AORTIC

What are the four valves of the heart?

Heart valves

Maintain FORWARD flow through cardiac chambers

Aortic and Mitral

Which valves experience the most dysfunction?

Annulus

Ring like structure that holds the shape and function of valves and prevents leak

• If stretched or stiff → regurgitation, stenosis

Cusps

Flaps or leaflets of heart valve that open and close

Tricuspid and mitral

Which valves are closing when you hear S1?

Aortic and pulmonic

Which valves are closing when you hear S2?

2nd intercostal space, right sternal border

Where is the aortic valve located?

2nd intercostal space, left sternal border

Where is the pulmonic valve located?

5th intercostal space, left sternal border

Where is the tricuspid valve located?

5th intercostal space, mid-clavicular line

Where is the mitral valve located?

Off root of aorta

Where do coronary arteries orginate?

• Right coronary artery → O2 to right side heart

• Left main coronary artery → O2 to left side of heart

Where do each of the coronary arteries supply O2 to?

1. Stenosis

2. Regurgitation

What are the two types of valve disease?

Stenosis

• Narrowing of valve OPENING due to fibrosis or calcification, which obstructs the outflow of the blood

• Can’t move proper amount → leading to backup of blood

• Shortened and contracted chordae tendinea (heart strings)

Regurgitation

Loosening or dilation of valve where valve can’t fully CLOSE AKA insufficency

• Mitral valve prolapse

• Blood leaks backward and increases work on both chambers

• Congenital (most common in children and teens), genetic

• Older age (increased wear and tear)

• Infections: rheumatic fever or blood infections

• Heart disease, myocardial infarction, endocarditis (bacteria)

• HTN

• Autoimmune DO

What are the causes of valve issues?

• Rheumatic fever

• UNTREATED strep infection, strep throat

• Scarlet fever (from bacteria)

• No access to antibiotics

• Upper respiratory infection with Streptococcus

What are the causes of rheumatic carditis?

Lead to body’s immune response causing inflammation throughout the body to include heart, heart valves and can lead to HF

What happens if strep goes UNTREATED?

• Echocardiogram

  • TTE (noninvasive)

  • TEE (invasive)

• Exercise tolerance testing (ETT)

• Cardiac cath

• CXR

• EKG (due to afib)

What are the dx for valve DO?

• In many cases, valve disease is asymptomatic until heart has failed → s/s HF

• Fatigue, weakness → decreased CO

• Murmur

• Afib

What are the common s/s of valve disease?

1. Stenosis

2. Regurgitation

3. Prolapse

What are three complications of the mitral valve?

1. Mitral valve becomes stenosed

2. LA becomes enlarged due to high pressure (blood stays in LA)

3. Increase pressure in pulmonary veins to lungs (s/s pulmonary congestion)

4. Pressure builds from lungs into RV

5. RV HYPERTROPHIES

6. s/s right sided HF

What is the patho of mitral valve stenosis?

No, because LV isn’t failing but is not working due to not recieving enough blood

Is mitral stenosis related to LS HF?

Pulmonary congestion from high pressure in pulmonary arteries

Why do sx of right sided HF happen as a late sign of mitral stenosis?

• Fatigue, weakness

• Respiratory:

  • Dyspnea on exertion

  • Orthopnea

  • Paroxysmal nocturnal dyspnea (sudden SOB that wakes person from sleep)

  • Hemoptysis (congestion)

• Murmur

• Afib

• Enlargement LA on CXR

• s/s RS HF:

  • Pitting edema

  • Neck vein distention (JVD)

  • Hepatomegaly

What are the s/s mitral stenosis?

1. MV does not completely close during systole (contract)

2. Blood backflows into LA when LV contracts

3. During diastole (rest), more blood is collected in the LA (increased volume)

4. LA DILATES and LV HYPERTROPHIES over time as to compensate for increased volume

5. Left and right side failure

What is the patho for mitral valve regurgitation?

• Asymptomatic → symptomatic

• Related to chronic FVO in LV

  • Fatigue, Weakness

  • Dyspnea on exertion

  • Orthopnea (SOB lying flat)

• Eventual symptoms of RV HF

• Afib

• Murmur

• Changes in respiration

• Atypical CP (ischemia or heart change)

What are the s/s of mitral regurgitation?

Same CP protocol

How do you address chest pain in heart valve disease?

Mitral valve prolapse

MV leaflets enlarge and prolapse into left atrium during systole

• Benign at first but can lead to MV regurgitation

• Asymptomatic until MR occurs

• CP in some

• Dizziness

• Syncope (fainting)

• Palpitations

CD SPA

What are the s/s of mitral valve prolapse?

Aortic valve stenosis

What is the most common valve dysfuntion in the US?

Narrowed AV, reduced LV outflow during systole (contract)

1. LV outflow obstruction (less blood can be pumped out of LV)

2. Increased resistance to ejection = LV HYPERTROPHIES

3. Late disease = LV failure → RV failure

What is the patho for aortic valve stenosis?

As aortic stenosis becomes severe, CO becomes fixed because only a limited amount of blood can pass through the narrowed aortic valve. The LV cannot increase output to meet the body’s demands, especially during activity.

• Leads to left sided HF

What happens in people with SEVERE aortic stenosis?

NITRO

1. Blood can’t get through narrowed valve and nitro causes vasodilation

2. Veins become widened and more less blood returns to the heart (more stays in peripheral circulation) (low BP)

3. Decreased preload = decreased CO

Preload and CO is critical for a patient with aortic stenosis

What medication is contradicted in aortic stenosis and why?.

Classic (s/s low CO)

• Syncope with exertion

• Angina

• Dyspnea

SAD

Late (s/s RS HF)

• Fatigue, Weakness

• Peripheral edema

• JVD

• Ascites

• Cyanosis

• Hypotension

What are the s/s aortic stenosis?

Backflow of blood from aorta in LV during diastole

1. AV leaflets do not close properly during diastole (rest)

2. Blood flows from aorta back into LV

3. LV DILATES to accommodate volume and HYPERTROPHIES

4. Left sided HF → right sided HF

What is the patho for aortic valve regurgitation?

Takes many years to develop symptoms

• Dyspnea on exertion

• Orthopnea (SOB lying flat)

• Paroxysmal nocturnal dyspnea

Severe

• Palpitations

• Nocturnal angina with diaphoresis

POD PN

What are the s/s aortic regurgitation?

Medical tx for symptoms of HF and/or Afib

• Diet (low sodium)

• Rest if low CO

• Percutaneous/non-surgical procedures

• Surgical procedures

  • Repair

  • Replacement

What are the nursing interventions for valve disease?

• Balloon valvuloplasty (stenosis)

• Transcatheter valve replacement (stenosis)

• MitraClip (regurg)

• Cardioversion for Afib

• Catheter ablation for Afib/MAZE procedure

What are the percutaneous/non-surgical procedures for valve disease?

• Commissurotomy (stenosis)

• Annuloplasty (regurg)

• Standard valve replacement

What are the surgical procedures to help repair valves?

Manage symptoms and reduce the risk of complications associated with heart valve DO

What is the goal of meds for valve disease?

• ACE/ARBS: widen vessels, HTN

• Antiarrhythmics (digoxin): restore pumping rhythm

• Anticoagulants (blood thinners): low risk blood clot

• Beta blockers: decrease WL and palpitations

• Diuretics: Reduce fluid in tissues and bloodstream, decrease WL

• Antibiotics: prevent infections (pre procedure)

• Vasodilators: decrease WL, open and relax blood vessels

  • NO nitro for aortic stenosis

What are the meds for valve DO?

Balloon valvuloplasty

Balloon is inserted to open a narrowed heart valve (usually through femoral artery; groin)

• For STENOSIS, not long term but can be bridge to valve replacement or end of life (relief)

• Moderate sedation, hx stay

• Post cath care

• Bedrest 2-6 hr

• Maintain SUPINE position for duration of bedrest

• Protect groin site! or radial access site

• Maintain vascular closure device or dressing

• Monitor for complications (bleeding)

• Monitor VS (neuro)

• Assess peripheral pulses on affected extremity

• Skin assessment (color and temp)

• Monitor UOP (contrast dye)

• Home care

What is the care for post heart cath?

Transcatheter valve replacement

Minimally invasive procedure where new valve is placed inside diseased valve using catheter w/ balloon through femoral artery (groin)

• Usually biological valve is used

• For STENOSIS

MitraClip (transcatheter)

Minimally invasive procedure where leaflets of a valve are stapled together

• Femoral artery (groin)

• For MR

• Not long hx stay after

• Cardioversion

• Catheter ablation

What are the two interventions for afib?

Cardioversion for afib

Procedure that delivers a controlled low electrical shock to reset the heart to a normal rhythm

• Monitor pulse and EKG

Catheter ablation for afb/ MAZE procedure

Procedure where the atria is cauterized with heat or cold to create a MAZE of scar tissue to reroute electrical impulses into controlled pathway

Commissuroteomy

Surgical procedure where valve leaflets are cut apart to open a narrowed heart valve

• For STENOSIS

Annuloplasty

Surgical procedure where a ring a sewn around a heart valve to tighten and reshape it. Helps valve leaflets close properly

• For REGURGITATION (leaky valves)

1. Biological (pig or cow tissue)

2. Mechanical (titanum or carbon)

What are the two types of material used for standard valve replacements?

PRO

• Natural tissue

• Usually do not require anticoagulation after placed

• Quieter

CON

• Life expectancy less than mechanical; 7-10 years

What are the pros and cons of biological valve replacement?

PRO

• Lasts a lifetime

CON

• Require anticoagulation lifelong

• Clicking sound

• Can lead to destruction of RBC

• Increased risk of endocarditis

What are the pros and cons of mechnical valve replacement?

Warfarin

What is the gold standard anticoagulant used for mechanical heart valves?

INR

• Normal: 0.8-1.1

• Therapeutic: 2-3

X2 BASELINE INR if mechanical valve

What lab should be monitored for warfarin?

• Post op care (depends on method)

• Chest tube management

• Possible anticoagulation therapy

• High risk for infective endocarditis

• Risk for anemia

• Med alert bracelet

• Assess for signs of HF

• Diet

What is the nursing intervention for post valve intervention?

• Consent

• Assess respiratory status and VS (O2 sat)

• Drainage amount and quality

• HOB 30/ semi-fowler’s, TCDB, amulate

• Keep system upright and BELOW insertion site

• Prevent kinks and loops

• Tidaling = normal

• CONTINOUS BUBBLING = AIR LEAK (look for where!)

• Intermittent bubbling = normal

• Check suction amount

• Check fluid level in water seal chamber

• If obstruction in tubing → DO NOT STRIP or MILK TUBE

• Order needed to clamp tube

• COVER OPENING and CALL for help if dislodged

What are the nursing interventions for chest tube?

These patients must consult HCP for PROPHYLATIC ANTIBIOTICS before INVASIVE PROCEDURES, including DENTAL procedures/cleanings

What MAJOR precaution is needed for patients with valve disease, heart transplant, or hx of infective endocarditis before procedures?