Chapter 29 Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
|Regurgitation||the valve does not close properly and blood backflows through the valve|
|Stenosis||the valve does not open completely and blood flow through the valve is reduced|
|Valve prolapse||the stretching of an atrioventricular valve leaflet into the atrium during diastole|
|mitral valve prolapse|| Often the first and only sign of ________________ is identified|
when a physical examination of the heart reveals an
extra heart sound, referred to as a mitral click. A systolic
click is an early sign that a valve leaflet is ballooning into
the left atrium.
|Mitral regurgitation|| involves blood flowing back from the|
left ventricle into the left atrium during systole. Often the
edges of the mitral valve leaflets do not close during systole.
|how do chronic and acute mitral regurgitation manifest?|| Chronic mitral regurgitation is often asymptomatic, but|
acute mitral regurgitation (eg, that resulting from a myocardial
infarction) usually manifests as severe congestive heart
failure. Dyspnea, fatigue, and weakness are the most common
symptoms. Palpitations, shortness of breath on exertion,
and cough from pulmonary congestion also occur.
|what is assessed with mitral regurgitation||A systolic murmur is heard as a high-pitched, blowing|
sound at the apex. The pulse may be regular and of good
volume, or it may be irregular as a result of extrasystolic
beats or atrial fibrillation. Doppler echocardiography is used
to diagnose and monitor the progression of mitral regurgitation.
Transesophageal echocardiography (TEE) provides
the best images of the mitral valve.
|Mitral stenosis|| is an obstruction of blood flowing from the|
left atrium into the left ventricle.
|Valvuloplasty||The repair, rather than replacement, of a cardiac valve.|
|commissure.|| Each valve has leaflets; the site where the leaflets|
meet is called
|explain the state of a commissure in stenosis and regurgitation|| The leaflets may adhere to one another and close the commissure (ie, stenosis). Less|
commonly, the leaflets fuse in such a way that in addition to
stenosis, the leaflets are also prevented from closing completely, resulting in a backward flow of blood regurgitation
|A commissurotomy|| is the procedure performed to|
separate the fused leaflets.
|difference between a open and closed commissurotomy||Closed commissurotomies do not require cardiopulmonary|
bypass. The valve is not directly visualized. Closed commissurotomies,
in which a surgical technique is used, are performed
in the operating room with the patient under general
anesthesia; a midsternal incision is made, a small hole
is cut into the heart, and the surgeon's finger or a dilator is
used to open the commissure.Open commissurotomies are performed with direct visualization
of the valve. The patient is under general anesthesia.
A midsternal or left thoracic incision is made. Cardiopulmonary
bypass is initiated and an incision is made into the
heart. The valve is exposed and the surgeon uses a scalpel,
finger, balloon, or dilator to open the commissures.
|Annuloplasty. it's a useful treatment for what valve problem?|| is the repair of the valve annulus (ie, junction|
of the valve leaflets and the muscular heart wall). General
anesthesia and cardiopulmonary bypass are required for
all annuloplasties. The procedure narrows the diameter of
the valve's orifice and is useful for the treatment of valvular
|Leaflet repair|| for elongated, ballooning,|
or other excess tissue leaflets is removal of the extra
tissue. The elongated tissue may be folded over onto itself
(ie, tucked) and sutured (ie, leaflet plication). A wedge
of tissue may be cut from the middle of the leaflet and the
gap sutured closed (ie, leaflet resection)
|Chordoplasty||repair of the chordae tendineae. The mitral|
valve is involved with chordoplasty (because it has chordae
tendineae); the tricuspid valve seldom requires chordoplasty.
Stretched, torn, or shortened chordae tendineae may
cause regurgitation. Stretched chordae tendineae can be
shortened, transposed to the other leaflet, or replaced with
|when is valve replacement is performed?|| When valvuloplasty is not a viable alternative (eg, when|
the annulus or leaflets of the valve are immobilized by calcifications,
severe fibrosis or fusion of the chordate
tendineae, papillary muscles, and leaflets below the valve)
|Mechanical||Do not deteriorate or become infected as easily, but are thrombogenic and require life-long anticoagulation therapy.|
|Xenograft (heterograft):||pig or cow valve used for tricuspid valve replacements|
|Homograft (allograft)|| : human valve are obtained|
from cadaver tissue donations and are used for aortic and
pulmonic valve replacement.
|Autograft|| patient's own valve are obtained by excising|
the patient's own pulmonic valve and a portion of the pulmonary artery for use as the aortic valve.
|Cardiomyopathy. what can it lead to?||is a series of progressive events that culminates in impaired cardiac output and can lead to heart failure, sudden death, or dysrhythmias.|
|Dilated cardiomyopathy|| is distinguished by significant dilation of|
the ventricles without simultaneous hypertrophy (ie, increased
muscle wall thickness) and systolic dysfunction
(Fig. 29-8). The ventricles have elevated systolic and diastolic
volumes but a decreased ejection fraction.
|Hypertrophic cardiomyopathy||the heart muscle asymmetrically increases in|
size and mass, especially along the septum (see Fig. 29-8).
HCM often affects nonadjacent areas of the ventricle. The
increased thickness of the heart muscle reduces the size of
the ventricular cavities and causes the ventricles to take a
longer time to relax after systole.
|restrictive cardiomyopathy|| is characterized by diastolic dysfunction caused by|
rigid ventricular walls that impair diastolic filling and ventricular stretch (see Fig. 29-8). Systolic function is usually
normal. may be associated with amyloidosis (amyloid,
a protein substance, is deposited within cells) and
other such infiltrative diseases.
|Arrhythmogenic cardiomyopathy||occurs when the myocardium of the right ventricle|
is progressively infiltrated and replaced by fibrous scar and
adipose tissue. Initially, only localized areas of the right ventricle
are affected, but as the disease progresses, the entire
heart is affected. Eventually, the right ventricle dilates and
develops poor contractility, right ventricular wall abnormalities,
|Unclassified cardiomyopathies|| are different from or have|
characteristics of more than one of the previously described
|how are infections of the heart treated?||Treatment is with appropriate antimicrobial therapy. Patients need to be instructed to complete the course of appropriate antimicrobial therapy, and require teaching about infection prevention and health promotion.|
|how is pain felt according to layer of infections of the heart||the more superficial the infection the more pain.|
|Rheumatic Endocarditis is related to what bacteria? how is the heart injured? is change permanent?what common illness must be treated to prevent progression to this condition?||-Occurs most often in school-age children, after group A beta-hemolytic streptococcal pharyngitis.|
-Injury to heart tissue is caused by inflammatory or sensitivity reaction to the streptococci.
-Myocardial and pericardial tissue is also affected, but endocarditis results in permanent changes in the valves.
-Need to promptly recognize and treat "strep" throat to prevent rheumatic fever.
|Infective Endocarditis. what type of growth occurs?||A microbial infection of the endothelial surface of the heart. Vegetative growths occur and may embolize to tissues throughout the body.|
|infective endocarditis develops in patients with what heart factors? and also occurs in what type of patients?||Usually develops in people with prosthetic heart valves or structural cardiac defects. Also occurs in patients who are IV drug abusers and in those with debilitating diseases, indwelling catheters, or prolonged IV therapy.|
|Pericarditis|| refers to an inflammation of the pericardium, the|
membranous sac enveloping the heart. It may be a primary
illness or it may develop during various medical and surgical
disorders. For example, pericarditis may occur after pericardectomy
(opening of the pericardium) following cardiac
|what are two potential complications of pericarditis?|| Pericardial effusion|
|Antibiotic Prophylaxis||Mechanical valve replacements including annuloplasty or other prosthetic material|
Valvular defects including mitral click and murmur or mitral regurgitation, mitral stenosis, aortic stenosis, and aortic regurgitation
A history of rheumatic heart disease, endocarditis, or myocarditis
Antibiotic prophylaxis is required for dental procedures and surgical interventions, including GU and GI procedures, to prevent endocarditis.