Care of the Patient with a Cardiac Mechanical Disorder

Nancy E. Stone PhD ACNP ANP CCRN

&
Linda Ethier MSN RN
After completing the assigned readings and attending lecture the student will:
Describe the pathophysiology, clinical manifestations, collaborative care and nursing interventions
of patients with rheumatic heart disease.
Describe the pathophysiology, clinical manifestations, collaborative care and nursing management
of patients with valvular heart disease.
Describe types of cardiac valve repair and replacement procedures used to treat valvular problems
and the care needed by patients who undergo these procedures.
Objectives
Describe the pathophysiology, clinical manifestations, collaborative care and nursing management
of patients with cardiomyopathies.
Compare the pathophysiology of systolic and diastolic dysfunction.
Explain the etiology, clinical manifestations, and compensatory mechanisms involved in heart
failure.
Describe the collaborative care, nursing management, and pharmacological interventions used in
treating the patient with chronic heart failure, acute decompensated heart failure and pulmonary
edema.
Objectives
Describe the management of patients in cardiogenic shock.
Explain why an Intra Aortic Balloon Pump would be used, how it functions and nursing
management of the patient with a balloon pump.
Describe the indications for cardiac transplantation and the nursing management of cardiac
transplant recipients.

Rhematic Heart Disease
An inflammatory process that may affect the endocardium, the valves, or the pericardium
Caused by childhood rheumatic fever, a collagen disease affecting connective tissue & blood vessels
Usually results in distortion, scarring, & stenotic valves, & may lead to adhesions of surrounding tissues
Frequently causes mitral stenosis

Rheumatic Heart Disease
Assessment Subjective: Prior h/o rheumatic fever, feeling of malaise or fatigue, may or may not
experience pain
Objective: Murmurs heard over the affected valves, fever, SOB, polyarthritis, Chorea (St. Vitus Dance:
abrupt, purposeless, involuntary movements)
Diagnostic Test: ASO (antistreptolysin-O) titer shows exposure to streptococcal infections
RHD: Nursing Care
1. Physiological integrity: increase patient comfort & rest; support adequate cardiac comfort
2. Psychosocial integrity: assist with effective coping
3. Health promotion: provide information about disease process & surgery if needed
RHD: Planning & Implementation
4. Administer antibiotics if indicated(PCN is drug of choice), Digoxin or diuretics
5. Monitor I&O, and diet in cases with patients that have Heart Failure


Valvular Heart Disease
Prevents efficient blood flow
Types:
Stenosis: valvular tissue thickens & narrows valve openings
Insufficiency: regurgitation: valve is incompetent; prevents complete valve closure
Mitral Valve Prolapse (MVP): Valve leaflets protrude into left atrium during systole




Valvular Heart Disease
Assessment: personal & family history, H/O rheumatic fever, recent infections, or invasive procedures,
and easily fatigued.
Nursing priorities: Maintaining cardiac output (CO), preventing complications, ie, infection, HF,
dysrhythmias. Controlling sx, ie, pain, SOB, etc. & patient teaching
Nursing Diagnoses: Knowledge Deficit R/T valve surgery; Alt tissue perfusion R/T valve abnormality;
Alt CO, decreased, R/T valvular disease; Activity intolerance R/T decreased cardiac output; Potential
complications R/T valve disorder

Valvular Heart Disease Interventions

Medical:
Prevent disease from worsening
Minimize risk complication
Patient Education

Surgical:
Repair defective valve
Replace valve

Repair Procedures:
Valvuloplasty: repair valve, & suture torn leaflets
Annuloplasty: tightens and sutures malfunctioning valve rings (annulus)
Commissurotomy: Valvotomy: To enlarge opening by mechanical dilitation

Valvular Heart Disease
Valve Replacements:
Mechanical Prosthetic Valves: Durable, but can fail. Thomboembolism a problem, anticoagulation therapy
& patient testing for life. Therapeutic INR 2.5-3.5.
Starr-Edwards Ball Cage: will not be used for Tricuspid valve; it is too large for right ventricle.
St. Jude Bileaflet: hemodynamically efficient, created less resistance to blood flow
Valvular Heart Disease

Valve Replacements
Bioprosthetic valves: Human or animal, less durable, may calcify, DO NOT require prolonged
anticoagulation therapy; but will require anticoagulation for 3 months
Carpenter-Edwards Porcine: Usually does not cause thrombus formation after healing; on anticoagulant
for 3 months
Hancock: Standard & Modified: minimizes risk of leakage

Diagnosis: CXR, EKG, Echocardiogram (transthoracic & transesophogeal)

Right Sided Valve Disease: Tricuspid Valve
Tricuspid Stenosis: S/S: Easily fatigued, c/o fluttering sensations in neck,(obstructed venous flow),
cyanosis, right sided heart failure
Treatment: Low sodium Diet, rarely occurs alone so surgery will be done, commissurotomy or
bioprosthetic valve replacement.
Tricuspid Insufficiency: S/S: Anorexia, N&V, right sided heart failure, seesaw chest movements during
respirations (enlarged right heart)
Treatment: Aggressive medical Rx or if chronic & associated with infective endocarditis & rheumatic fever,
then bioprosthetic valve

Right Sided Heart Disease: Pulmonary Valve
Pulmonary Stenosis: Dyspnea, fatigue, syncope, chest pain, right sided heart failure
Treatment: Usually requires no treatment. If right ventricular failure develops, valvotomy and pulmonic
valve replacement

Pulmonary Insufficiency: Usually asymptomatic unless right sided heart failure develops
Treatment: Depends on cause of underlying primary disease. Surgery if heart failure develops.

Left Sided Valve Disease: Mitral Valve
Mitral Stenosis: S/S: Reflects pulmonary congestion, decreased CO, right ventricular failure, dyspnea,
hemoptysis, orthopnea, and angina.
Treatment: If asymptomatic, then no therapy. Atrial fib & HF, Digoxin, diuretics, low NA diet,
commissurotomy to enlarge valve.

Mitral Insufficiency: S/S:pulmonary HTN, right sided heart failure, dyspnea, fatigue, dizziness, syncope.
Treatment: Medically tx same as mitral stenosis; Surgically tx with annuloplasty ; implant prosthetic
device.

Left Sided Heart Disease: MVP
Mitral Valve Prolapse
Floppy mitral valve; Barlows Syndrome, billowing mitral valve & is quite common
S/S: As the disease progresses fatigue, chest pain, palpitations, and syncope
Treatment: Beta- blockers for tachycardia & PVCs. Valve replacement

Left Sided Valve Disease: Aortic Valve
Aortic Stenosis: S/S: Angina, syncope, left sided heart failure, then right sided heart failure.
Treatment: If not symptomatic, no treatment, or valve replacement (depends on severity). Without
treatment, if symptomatic, death within 3 years

Aortic Insufficiency: S/S: Dyspnea on exertion, left sided heart failure, then right sided heart failure,
visible carotid pulsations, heart beats with unusual force
Treatment: Medically tx with Digoxin & diuretics, surgically replace valve

Valvular Heart Disease
Remember to review the difference between tissue & mechanical heart valves
Remember insufficiency means the same as regurgitation

Cardiomyopathy
A heart disease of the muscle itself
There are 3 categories: based on abnormality in cardiac structure & muscle
Etiologic categories are either considered primary (cause unknown) or secondary (viral or bacterial
infections, metabolic, pregnancy)

Cardiomyopathy
Heart muscle disease unrelated to other cardiovascular causes
Seen in patients with H/O heart failure & cardiac enlargement (cardiomegaly)
Types: Hypertrophic, Congestive (Dilated), Restrictive
DX: EKG, ECHO, Cardiac cath, nuclear studies

Congestive (Dilated) Cardiomyopathy
Large, dilated, flabby ventricular muscle
This leads to ventricular overload & CHF
Myocardial biopsy may lead to a definitve cause
May be caused by ETOH abuse, if so, may reverse damage by cessation of drinking
Congestive (Dilated) Cardiomypathy
S&S: Gradual onset, Left sided HF Sx, dyspnea, fatigue, weakness, emboli, moderate- severe
cardiomegaly, mitral valve regurgitation
Diagnosis: Echo, EKG (PVCs), MUGA, Cardiac cath
Treatment: Steroids & immunosuppresants for inflammation
If CHF: Digoxin, diuretics, vasodilators
Patient may meet requirement for Biventricular pacemaker
Activity limitations
Prognosis: May die within 3-5 years from CHF
Hypertrophic Cardiomyopathy

Hypertrophic Obstructive Cardiomyopathy (Assymetric Septal hypertrophy)
Can be considered obstructive or nonobstructive depending on the presence of LVOT (left ventricular
outflow tract) gradient; either @ rest or with provocative maneuvers.
LVOT is due to systolic anterior motion (SAM) of the anterior leaflet of the mitral valve.
CAN BE GENETIC LINK

Hypertrophic Cardiomyopathy
Pathophysiology: Pronounced ventricular hypertrophy, which leads to fibrosis, finally terminates with
unco-ordinated ventricular construction
S &S: Exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, angina, fatigue, syncope,
palpitations, ankle edema, mild cardiomegaly , murmur
Hypertrophic Cardiomyopathy
Treatment: To prevent sudden death, improve ventricular filling, relieve S & S
Medications: Beta Blockers, Verapamil. Avoid vasodilators, diuretics
Purpose of medications are to decrease HR & contractility, improve myocardial filling, & decrease cardiac
output
May proceed with septal myotomy (LVOT myomectomy), to decrease outflow obstruction; Alcohol
Septal Ablation; Pacemaker; Cardiac Transplant
Diagnosis: EKG, MUGA, Cardiac cath

Restrictive Cardiomyopathy
Least common type
Pathophysiology: Myocardial fibrosis, which leads to decreased compliance. The heart then becomes
stiff, hard to fill, decrease cardiac output, which then leads to pulmonary congestion
S &S: Exercise intolerance, dyspnea, fatigue, R sided HF, mild to moderate cardiomegaly, AV valvular
regurgitation, PND

Restrictive Cardiomyopathy
Treatment: Digoxin, Diuretics, Anticoagulants
Goal is to improve diastolic filling
Prognosis depends on the degree of heart failure & emboli development
Diagnosis: CXR, MUGA, Cardiac cath

Restrictive Cardiomyopathy
ARVC: Arrhythmogenic Ventricular Cardiomyopathy
Occurs when the myocardium of the right ventricle is progressively infiltrated & replaced by fibrous scar
& adipose tissue
SX: Palpitations and syncope
TX: AICD





CHF
Causes 1/3
rd
of all MI deaths. Usually affects left side of heart secondary to left muscle mass
(large)decrease contractility from muscle death
Failure of heart muscle to pump sufficient blood to meet the metabolic need of the body
Pump failure on one side frequently leads to pump failure on another side
Typically, failure begins with the left side
Additionally, patients are medically treated by whether the patient is diagnosed with either systolic or
diastolic dysfunction, or both

Left Ventricular Dysfunction

Compensatory Mechanisms
Frank-Starling Mechanism
the more diastolic stretch, the greater the contractility, and the greater the stroke volume
Compensatory Neurohormonal Stimulation: Summary


CHF: Left sided (Systolic & Diastolic)
Pulmonary S&S
Dyspnea, first noted on exertion, orthopnea, PND
When patient in supine position, increase in venous return, which then leads to increase in fluid load
Patient develops crackles, wheezes, increase BP, hypoxia, cerebral anoxia, cyanosis, pallor, cough, frothy
pink sputum

CHF: right sided (Systolic & Diastolic)
Dependent edema, liver & spleen enlargement, ascites, anorexia, nausea, bloating, abdominal tenderness,
distended neck veins, weakness, fatigue, dizziness & cyanosis

CHF: Treatment
Digoxin (especially with diastolic dysfunction): increase contraction, increase cardiac output, decrease HR
Make sure to check pulse, electrolytes (hypokalemia causes ventricular arrhythmias) & monitor for Dig
toxicity; especially in setting of kidney disease
Diuretics: Most common is Lasix
Ace Inhibitors: Especially with known mitral regurgitation
CHF
Vasodilators: Augment other drugs. They dilate peripheral vessels & decrease blood back to the heart
Inotropic IV agents (in acute care)
Patient may be candidate for biventricular pacemaker


Pulmonary Edema
Emergency, results from failure to effectively reverse effects from left sided CHF
If left untreated, patient will suffocate & die
S&S: severe dyspnea, orthopnea, pallor, tachycardia, diaphoresis, cyanosis, wheezing, bubbling
respirations; ultimately large amounts of frothy blood tinged sputum

Pulmonary Edema
Treatment: To decrease venous return to the heart
Oxygen, diuretics, vasodilators, Morphine Sulfate IV, Natrecor IV (if previous measures are insufficient)
Patient may need Inotropic medication IV support
Intubate & aspirate secretions

Pulmonary Edema
Treatment (continued): Mechanical devices such as IABP (Intra Aortic Balloon Pump)
Intra Aortic Balloon Pump
Temporary mechanical assistive device used when pharmacological attempts fail to improve O2 supply &
demand balance
Inserted via the femoral artery
Decreases the workload of the left ventricle
Increases the coronary perfusion

IABP
The balloon inflates during diastole (relaxation), which then displaces the blood proximally. This increases
coronary perfusion & forces more blood forward into the coronary arteries themselves
The balloon deflates @ the onset of systole which allows the ventricles to eject blood into the aorta @ a
lower systolic pressure
Intra Aortic Balloon Pump

The balloon is driven to inflate and deflate by this device, the console. The helium does the inflation lives
in a small (very small) tank, and the timing of the movements is controlled in careful synch with the rate
and rhythm of the heart. It has to be VERY precise.
http://www.tmc.edu/thi/iabp_console.jpg

IABP
Contraindications: Incompetent aortic valve (because inflation increases aortic regurgitation)
Nursing: Head of bead must be kept 30 degrees or lower. Must monitor for infection or bleeding
IABP augments cardiac output by 15% & provides total support for the heart; which allows the heart to
recover

Ventricular Assist Device (VAD)
Mechanical blood pump used to support a failing ventricle
The pump supports circulation by unloading and replacing the function of the sick, distended heart
Can be isolated Left, Right, or Biventricular support

Ventricular Assist Device
Components of a typical VAD. A continuous-flow left ventricular assist device consists of a pump
connected to the heart and aorta via an inflow and outflow cannula, a driveline that exits the skin on the
right, and a system controller that is typically worn outside the body

Review
CHF & Pulmonary edema may be caused by coronary heart disease
Part of the treatment may include assessment of CAD, hence stress testing or cardiac catheterization
Remember PTCA (when balloon is inflated, it eliminates occlusion by the lesion)
During PTCA, NTG IV (prevents coronary artery spasm) & Heparin IV (prevents thrombus formation)
With decreased cardiac output (less than 2 L/min); Inotropic medications are used. Therfore, these meds
are often used in patients with CHF & MI


Coronary Artery Bypass Graph Surgery (CABG)
Indications for surgery:
Intractable Angina: Anginal pain is often precipitated by emotional or psychosocial situations
A significant Lesion: Especially left main disease or triple vessels disease
Unstable Angina: Recurring episodes of pain & myocardial ischemia
Required if other treatments not working, such as PTCA or medications

Saphenous Vein Graph (SVG) or internal mammary arteries (RIMA or LIMA) are used to bypass an
occlusion or lesion in the coronary artery. They are sutured so as to bypass the occluded coronary artery,
therefore, there is increase in coronary artery perfusion

Pt. undergoes cardiopulmonary bypass CPB; cannulation of inferior & superior vena cavaeblood
from heart to machineblood oxygenatedreturns via ascending aortic arch

Pre-operative: elective vs. emergency
Patient teaching: view CCU, C & DB, sternal incision, foley catheter, IV catheter, chest tubes secondary to
incision

CABG
Patient will be:
pale secondary to CPB
intubated on mechanical respirator, mediastinal tubes, epicardial pacer wires (incision &
grounded & taped to patients chest)
PA & A line
Monitored for dysrhythmias & heart block
Fluid & K replacement
Monitored for ischemia & heart failure
CABG
Sternotomy will take 6-8 weeks to heal
Remember coping mechanisms: anxiety, denial, anger, regression, & depression. Pt. will have an
altered self image

CABG
Operative mortality is largely based on the mechanical functioning of the heart, that is, if the left
ventricular ejection fraction (LVEF) is greater then 55%, then the prognosis is often excellent (barring a
significant co.morbidity such as diabetes)

Future treatments
Laser Therapy
TMLR: Transmyocardial laser revascularization
Sternotomy: drill small holes
Method of working unknown
Angiogenesis may occur
Decrease in pain secondary to denervation
Patient must have no CHF
Patient is not a candidate for CABG






EECP: Enhanced External Counterpulsation
Treatment for intractable angina
G suit is applied & squeezes the legs & hips during diastole creating a positive pressure that increases
coronary perfusion
Collapses during systole
Treatment lasts one hour 5 x week
Pts with CHF, severe valve disease, uncontrolled HTN & H/O phlebitis are Poor candidates

EECP - Enhanced External Counterpulsation
Candidates for treatment include those with documented CAD
Those with coronary ischemia
Those who are poor candidates for PTCA & stents

Gene Therapy
Gene based angiogenesis goal: give growth factors that can stimulate new vessel formation.angioprotein,
fibroblasts growth factor (FGF), & vascular endothelial growth factor (VEGF) by direct cardiac injection
Arteriogenesis should be the goal

Cardiac Transplantation
Treatment of choice for those with Dilated Cardiomyopathy
2300 patients a year in US
LVEF < 25%

Criteria: life expectancy < one year, age < 65 yrs, NYHA class III or IV, nl PVR, no infections, dependence
on Inotropic support for organ perfusion, unresponsive to conventional therapy, no evidence of ETOH/
Drug abuse, stable psycho-social profile, no evidence of DM w/ end organ damage, no severe obesity
Comparable weight, ABO compatibility

Cardiac Transplantation
The transplanted heart is denervated & is unresponsive to vagal stimulation
Isuprel is used to maintain BP; atropine, beta-blockers, digitalis & carotid sinus pressure not used
May cause hypotension in immediate post/op phase
Prevention of rejection: cyclosporine (Sandimmune), azathioprine (Imuran)
Sx of rejection: dyrhythmias, hypotension, weakness, fatigue, & dizziness
Biopsy done to detect if rejection is occuring

Review
Mechanical cardiac problems can take the form of: Valvular disease, Cardiomyopathy, CHF &
pulmonary edema
Very often patients with HF may also have cardiac ischemia
This may then lead to CABG, in addition to other medical treatments & therapies