Page 734 - Cardiac Nursing

LWBK340-c29_p705-721.qxd 6/30/09 12:04 AM Page 710 Aptara Inc.

710 PA R T IV / Pathophysiology and Management of Heart Disease

subvalvular deformity, with a maximum score of 4 in each division. thetic valve of choice in mitral stenosis is a mechanical prosthesis,
Patients with a total echo score of 8 respond most favorably. 13 because patients already require life-long anticoagulation because
Balloon valvuloplasty has been associated with complications in- of atrial fibrillation. For young women who wish to become preg-
cluding systemic embolization (1% to 3%), severe mitral regur- nant, a bioprosthesis may be recommended.
gitation (3% to 5%), and death (0% to 1%). 14 An atrial septal
defect also may occur in as many as 10% of patients undergoing
balloon valvuloplasty as a result of the transseptal approach, but TRICUSPID VALVE DISEASE
the defect closes or decreases in most patients. 15 Results have
been promising, with the average gradient reduction being ap-
proximately 18 to 6 mm Hg and, on the average, an increase in Tricuspid regurgitation is primarily “functional” rather than struc-
calculated valve area of 50% to 100%. Mitral balloon valvulo- tural and occurs secondary to dilation of the right ventricle and the
plasty is reserved for patients who continue to be symptomatic annulus of the tricuspid valve. Functional tricuspid regurgitation
despite adequate medical therapy. Mitral balloon valvuloplasty frequently accompanies mitral stenosis and pulmonary hyperten-
may be used in women who experience hemodynamic decom- sion because of the increased pressure and volume load on the right
pensation during pregnancy due to mitral stenosis as it offers less ventricle. Symptoms include signs of right-sided heart failure, large
risk to the fetus than mitral valve replacement and cardiopul- V waves in their right atrial or central venous pressure trace, and
monary bypass. pulsatile neck veins. Other causes of tricuspid regurgitation include
trauma, infective endocarditis, right atrial tumor, and tricuspid
Surgical Treatment valve prolapse. The murmur of tricuspid regurgitation is a holosys-
Surgical replacement of the mitral valve is required when there is tolic murmur heard along the left sternal border and may extend
severe mitral regurgitation coexisting with mitral stenosis or if the over the precordium, sounding like the murmurs of mitral regur-
mitral stenosis is not amenable to percutaneous balloon valvulo- gitation and ventricular septal defect (Table 29-3). Patients with
plasty. Although some valves with mitral stenosis may be repaired mild tricuspid regurgitation normally do not require treatment.
by open commissurotomy and reconstruction, heavily calcified Medical treatment is aimed at reducing pulmonary artery pressures
rheumatic mitral valves are often beyond the point of repair. For and right heart afterload. If tricuspid regurgitation in severe and
patients with coexistent tricuspid regurgitation, combined mitral symptomatic, tricuspid valve repair may be performed. Tricuspid
valve surgery with tricuspid repair is related to better clinical out- valve replacement is uncommon and is done only if a satisfactory
comes than mitral balloon valvuloplasty alone. 16 The usual pros- tricuspid repair cannot be accomplished.

Table 29-3 ■ SYSTOLIC MURMURS RELATED TO ACQUIRED VALVULAR HEART DISEASE
Auscultatory Location Quality and
Origin of Murmur and Radiation Configuration Frequency Maneuvers That Alter Intensity

Aortic stenosis Right second intercostal Harsh Increases with squatting, amyl nitrate
space decrescendo High pitched Decreases with standing, Valsalva maneuver,
Radiates to carotid Diamond and isometric exercise
arteries and apex shaped”

S 1 S 2
Mitral regurgitation Apex y Harsh or Increases with expiration, squatting, and
Radiates to axilla blowing isometric exercise
and back S S S High pitched Decreases with Valsalva maneuver,
standing, and amyl nitrate
Mitral valve prolapse Apex Mid to late Harsh Increases with Valsalva maneuver, amyl
Radiates to axilla systolic, with High pitched nitrate, and inspiration
and back systolic click Decreases with squatting, standing, and
isometric exercise
S 1 Click S 2
Tricuspid regurgitation Fourth and fifth left Holosystolic Harsh Increases with amyl nitrate and inspiration
intercostal spaces High pitched Decreases with Valsalva maneuver
Radiates to right and standing
parasternal border S 1 S 2
Pulmonic stenosis Second left intercostal Harsh Increases with amyl nitrate, squatting,
space decrescendo High pitched and inspiration
Radiates to back Diamond Decreases with Valsalva maneuver
shaped” and standing

S 1 S S 2