Page 733 - Cardiac Nursing

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C HAPTER 2 9 / Acquired Valvular Heart Disease 709
atrial enlargement, elevation of the left mainstem bronchus caused Interventional and Surgical
by distention of the left atrium, and distribution of blood flow Management
from the lower to upper lobes. Although heart size remains nor-
mal, central pulmonary arteries become prominent. Kerley B lines Percutaneous Mitral Catheter
and interstitial edema are often present. Balloon Valvuloplasty
Percutaneous mitral catheter balloon valvuloplasty is an alterna-
tive, less invasive procedure than surgical treatment for mitral
Medical Management
stenosis. Balloon valvuloplasty is performed in the cardiac
Medical therapy for mitral stenosis is aimed at preventing the catheterization laboratory by a cardiologist experienced with inva-
complications of systemic embolization and bacterial endocarditis sive techniques. A small balloon valvuloplasty catheter is intro-
9
as well as atrial fibrillation if it occurs. Patients who have asymp- duced percutaneously at the femoral vein and passed into the right
tomatic mitral stenosis require only antibiotic prophylaxis. atrium. The catheter is then directed transseptally and positioned
Patients with mild pulmonary congestion can be managed with across the mitral valve. Mitral balloon valvuloplasty is recom-
diuretics alone. -Blockers can be used to reduce heart rate and mended in patients with moderate-to-severe mitral stenosis that is
improve diastolic filling time. When patients have atrial fibrilla- symptomatic with favorable valve morphology. 10
tion, digoxin, -blockers, or calcium channel blockers can be used Inflation of either one large balloon (23 to 25 mm) or two
for ventricular response rate control. Patients with atrial fibrilla- smaller balloons (12 to 18 mm) stretches the valve leaflets
tion require anticoagulation to prevent thrombus formation in the (Fig. 29-3). Inflation of the balloon separates the fused commis-
atrium. Once the patient has symptoms of NYHA functional class sures thus improving valve mobility. The best results from this
III or IV despite adequate medical management, mechanical cor- technique to date have been in patients with rheumatic mitral
rection of mitral stenosis by balloon valvuloplasty or surgery stenosis with commissural fusion. An echocardiographic scoring
should be performed. system rates leaflet thickening, leaflet mobility, calcification, and
A B
■ Figure 29-3 Mitral valvuloplasty: Inoue’s technique. (A) Inflation of distal portion of balloon, which is
then pulled back and anchored at the mitral valve. (B) Inflation of proximal and middle portions of balloon.
At full inflation, the narrowed “waist” of the balloon has disappeared. (From Vahanian, A. S. [1998]. Valvulo-
plasty. In E. J. Topol, R. M. Califf, J. M. Isner, et al. [Eds.], Textbook of cardiovascular medicine [p. 2157].
Philadelphia: Lippincott-Raven.)