MITRAL STENOSIS

Mitral stenosis is an obstruction of blood flowing from the left atrium into the left ventricle. It
is most often caused by rheumatic endocarditis, which progressively thickens the mitral valve
leaflets and chordae tendineae. The leaflets often fuse together. Eventually, the mitral valve
orifice narrows and progressively obstructs blood flow into the ventricle.

Mitral Stenosis Pathophysiology

Mitral stenosis results from thickening of the mitral valve flaps and shortening of the chordae
tendineae, causing narrowing of the valve opening. Older patients with mitral stenosis usually
have calcification an fibrosis of the mitral valve flaps. The narrowed opening obstructs blood
flow from the left atrium into the left ventricle. The left atrium enlarges to hold the extra
blood volume caused by the obstruction. As a result of this increased blood volume, pressure
rises in the left atrium. Pressures then rise in the pulmonary circulation and the right ventricle
as blood volume backs up from the left atrium. The right ventricle dilates to handle the
increased volume. Eventually the right ventricle fails from this excessive workload, reducing
the blood volume delivered to the left ventricle and subsequently decreasing cardiac output.

Etiology
The major cause of mitral stenosis is rheumatic fever, with symptoms often taking two to four
decades to appear after the illness. It is a continuous and progressive disease. Less common
causes include congenital defects of the mitral valve, tumors, rheumatoid arthritis, systemic
lupus erythematosus, calcium deposits, and rheumatic endocarditis.
SIGNS AND SYMPTOMS
 At first, patients may be asymptomatic.
 A click or low-pitched murmur may be heard.
 Then mild symptoms progressing to more severe symptoms develop Pulmonary
symptoms are most commonly seen.
 Dyspnea, cough, and hemoptysis from pulmonary congestion are the major symptoms.
 Fatigue and intolerance to activity result from decreased cardiac output.
 Palpitations from atrial flutter or fibrillation caused by atrial enlargement and chest pain
from decreased cardiac output may be experienced.
 Complications from emboli formed from the stasis of blood in the left atrium include
stroke and seizures.
 If the right ventricle fails, symptoms related to heart failure are seen.

Diagnostic investigation and Findings

 Mitral stenosis is diagnosed with data from the patient history and physical examination
and findings from diagnostic tests.
 Echocardiography is used to diagnose mitral stenosis.
 Electrocardiography (ECG) and cardiac catheterization with angiography are used to
determine the severity of the mitral stenosis
 A chest x-ray examination confirms enlargement of the affected heart chambers.

MEDICAL TREATMENT OF MITRAL STENOSIS

 Individualized prophylactic antibiotic therapy may be given to prevent endocarditis.
 Anticoagulants are given to patients with atrial fibrillation to prevent development of
emboliform stasis of blood in the atrium.
 If heart failure develops, symptoms are treated with medications such as digitalis and
diuretics and other therapies used for heart failure.
 For less severe cases, percutaneous balloon valvuloplasty, which uses a balloon to dilate
the stenosed heart valve, is done in a cardiac catheterization laboratory
 Surgical intervention consists of valvuloplasty, usually a commissurotomy to open or
rupture the fused commissures of the mitral valve. Percutaneous transluminal
valvuloplasty or mitral valve replacement may be performed.

AORTIC STENOSIS
Aortic valve stenosis is narrowing of the orifice between the left ventricle and the aorta. In
adults, the stenosis may involve congenital leaflet malformations or an abnormal number of
leaflets (ie, one or two rather than three), or it may result from rheumatic endocarditis or cusp
calcification of unknown cause. The leaflets of the aortic valve may fuse.
Pathophysiology
There is progressive narrowing of the valve orifice, usually over a period of several years to
several decades. The left ventricle overcomes the obstruction to circulation by contracting
more slowly
but with greater energy than normal, forcibly squeezing the blood through the very small
orifice. The obstruction to left ventricular outflow increases pressure on the left ventricle,
which results in thickening of the muscle wall. The heart muscle hypertrophies. When these
compensatory mechanisms of the heart begin to fail, clinical signs and symptoms develop.

Clinical Manifestations
 Many patients with aortic stenosis are asymptomatic.
 After symptoms develop, patients usually first have exertional dyspnea, caused by left
ventricular failure. Other signs are dizziness and syncope because of reduced blood flow
to the brain.
 Angina pectoris is a frequent symptom that results from the increased oxygen demands of
the hypertrophied left ventricle, the decreased time in diastole for myocardial perfusion,
and the decreased blood flow into the coronary arteries.
 Blood pressure can be low but is usually normal; there may be a low pulse pressure (30
mm Hg or less) because of diminished blood flow.
Assessment and Diagnostic Findings
 On physical examination, a loud, rough systolic murmur may be heard over the aortic
area.
 Echocardiography is used to diagnose and monitor the progression of aortic stenosis.
 A chest x-ray examination confirms hypertrophy of the left ventricle.
 ECG shows enlargement of the left ventricle and left atrium.

 Cardiac catheterization will show elevated left ventricular pressure and decreased cardiac
output.

Medical Management
 Antibiotic prophylaxis to prevent endocarditis is essential for anyone with aortic stenosis.
 After left ventricular failure or dysrhythmias occur, medications are prescribed.
 Definitive treatment for aortic stenosis is surgical replacement of the aortic valve.
 Patients who are symptomatic and are not surgical candidates may benefit from one- or
two-balloon percutaneous valvuloplasty procedures

Nursing Diagnoses
■ Pain related to reduced coronary artery blood flow and increased myocardial oxygen needs
■ Decreased cardiac output related to valvular stenosis or insufficiency or heart failure
■ Activity intolerance related to decreased oxygen delivery from decreased cardiac output
■ Excess fluid volume related to heart failure and the secondary reduction in renal blood flow
for filtration
■ Ineffective therapeutic regimen management related to lack of knowledge about disorder

Nursing Management: Valvular Heart Disorders

 The nurse educates the patient with valvular heart disease about the diagnosis,
progressive nature of the disease, and treatment plan.
 The patient is instructed to report new symptoms or changes in symptoms to the primary
provider.
 The nurse also educates the patient that an infectious agent, usually a bacterium, is able to
adhere to a diseased heart valve more readily than to a normal valve. Once attached to the
valve, the infectious agent multiplies, resulting in endocarditis and further damage to the
valve.
 In addition, the nurse educates the patient about how to minimize the risk of developing
infective endocarditis
 The nurse measures the patient’s heart rate, blood pressure, and respiratory rate, compares
these results with previous data, and notes any changes. Heart and lung sounds are
auscultated and peripheral pulses palpated.
The nurse assesses the patient with valvular heart disease for the following:
 Signs and symptoms of heart failure, such as fatigue, DOE, decreased
activity tolerance, an increase in coughing, hemoptysis, multiple
respiratory infections, orthopnea, and PND
 Dysrhythmias, by palpating the patient’s pulse for strength and
rhythm (i.e., regular or irregular) and asking whether the patient has
experienced palpitations or felt forceful heartbeats (see Chapter 26)
 Symptoms such as dizziness, syncope, increased weakness, or angina
pectoris

 In addition, the nurse educates the patient to take a daily weight and
report sudden weight gain, as defined by the primary provider
 The nurse may assist the patient with planning activity and rest periods to achieve an
acceptable lifestyle
 Patients who experience symptoms of pulmonary congestion are advised to rest and sleep
sitting in a chair or bed with the head elevated.
 The nurse instructs the patient about the importance of attempting to relieve the
symptoms of angina with rest and relaxation before taking nitroglycerin and to anticipate
the potential adverse effects.
PULMONARY VALVE STENOSIS
Pulmonary valve stenosis is a condition in which a deformity on or near the pulmonary valve
narrows the pulmonary valve opening and slows the blood flow. The pulmonary valve is
located between the lower right heart chamber (right ventricle) and the pulmonary arteries.

INCIDENCE
Adults occasionally have pulmonary valve stenosis as a complication of another illness,
but mostly, pulmonary valve stenosis develops before birth as a congenital heart defect.

CAUSES
Pulmonary valve stenosis usually occurs when the pulmonary valve doesn't grow properly
during fetal development.

RISK FACTORS
Because pulmonary valve stenosis usually develops before birth, there aren't many known
risk factors. However, certain conditions and procedures can increase your risk of developing
pulmonary valve stenosis later in life, including:
• Carcinoid syndrome
• Rheumatic fever
• Noonan syndrome
• Pulmonary valve replacement

SYMPTOMS
People with mild pulmonary stenosis usually don't have symptoms. Those with more
significant stenosis often may first notice symptoms while exercising.
Pulmonary valve stenosis signs and symptoms may include:
•Heart murmur — an abnormal whooshing sound heard using a stethoscope, caused by
turbulent blood flow
•Fatigue
•Shortness of breath, especially during exertion
•Chest pain
•Loss of consciousness (fainting)

PATHOPHYSIOLOGY
The pathophysiology of pulmonary valve stenosis consists of the valve leaflets becoming too
thick ,therefore not separate one from another.This can cause high pulmonary pressure, and
pulmonary hypertension. This however, does not mean the cause is always congenital.
The left ventricle can be changed physically, these changes are a direct result of right
ventricular hypertrophy. Once the obstruction is subdued, it can return to normal

DIAGNOSIS
•Echocardiogram;This test is useful for checking the structure of the pulmonary valve, the
location and severity of the narrowing (stenosis), and right ventricle size and function.

•Electrocardiogram;. This test helps determine if the muscular wall of your right ventricle is
thickened (right ventricular hypertrophy).

•Cardiac catheterization;This test is also used to measure the blood pressure in the heart
chambers and blood vessels.
•Other imaging tests;MRI and CT scans are sometimes used to confirm the diagnosis of
pulmonary valve stenosis.

TREATMENT
Depending on the degree of obstruction, more-serious cases may need either a balloon
valvuloplasty or open-heart surgery.

•Balloon valvuloplasty.;an uninflated balloon is placed through the opening of the narrowed
pulmonary valve. It is then inflated,widening the narrowed valve to increase blood flow, and
then removes the balloon.
•Open-heart surgery;During surgery, your doctor either repairs the pulmonary artery or valve
or replaces the valve with an artificial valve.

PREVENTIVE MEASURES
Heart-healthy lifestyle
Adopting a heart-healthy lifestyle decreases your risk of developing other types of heart
disease, which can lead to pulmonary valve stenosis ;
• Quitting smoking
• Eating a heart-healthy diet, such as a variety of fruits and vegetables,
•low-fat dairy products, whole grains, and lean meat
• Maintaining a healthy weight
• Regular physical activity

Reference;
Radiopaedia.org
emedicine.medscape.com
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