RHEUMATIC HEART DISEASE
Heart
Valves
introduction
Rheumatic fever may have complications as a
valvular involvement resulting the disease of
mitral, aortic and tricuspid valves.
The common rheumatic heart disease includes
mitral regurgitation and mitral stenosis.
Aortic valve and tricuspid valvular disease
include mainly aortic and tricuspid regurgitation.
Mitral regurgitation
Mitral regurgitation is the back flow of blood from
the left ventricle into the left atrium resulting from
imperfect closure of the mitral valve.
It is the commonest complication of acute recurrent
rheumatic heart disease.
a leaking mitral valve - Stroke volume, CO
- Left atrial hypertrophy
- Pulmonary congestion
Pathophysiology
Incomplete closure of mitral
valve
Backflow of blood to the left
atrium
vol. of blood ejected by left
Left atrial pressure
ventricle
CO Left atrial hypertrophy
Pulmonary pressure
Right-sided heart failure Right ventricular pressure
Clinical Manifestations
Fatigue & weakness – due to CO – predominant complaint
exertional dyspnea & cough – pulmonary congestion
palpitations – due to atrial fibrillation (occur in 75% of pts.)
Right-sided heart failure – distended neck veins, edema,
ascites, hepatomegaly
Auscultation: blowing, high-pitched systolic murmur (apex)
- S1 is diminished
- S3 –severe regurgitation
Diagnosis evaluation
ECG,
Echocardiography
Chest X-ray
Management
controlling of CCF,
penicillin prophylaxis against future recurrence of
rheumatic fever and prevention against infective
endocarditis.
Surgical management of mitral regurgitation includes
mitral valve repair or replacement of it by prosthetic
valve.
Surgery is indicated more than 55 percent cases with
refractory CCF, pulmonary hypertension and
progressive cardiomegaly.
Interventions
restrict physical activity – to prevent fatigue & dyspnea
Na+ intake, diuretics – relieve congestion
Digitalis, vasodilators – promote adequate ventricular
emptying and prevent or decrease regurgitation
ACE inhibitors – arterial dilation, afterload
Surgery:
- Valvuloplasty (repair or reconstruction)
- Valve replacement
Mitral stenosis
Is the narrowing of the mitral orifice obstructing free
flow of blood from the left atrium to the left
ventricle.
Mitral opening gets tight due to progressive sclerosis
of the base of the mitral ring. It develops relatively
late in children with rheumatic carditis.
It is less common than mitral regurgitation and
commonly found in male children.
MITRAL STENOSIS
most common valvular disorder
in rheumatic fever
may also be caused by bacterial
infection, thrombus
formation, calcification
obstruct blood flow from left
atrium to the left ventricle
MITRAL
STENOSIS
Pathophysiology
Narrowing of mitral valve
left atrial Hypertrophy left blood flow to
pressure atrium left ventricle
pulmonary
CO
pressure
pulmonary Left ventricular
congestion Fatigue
atrophy
O2/CO2 exchange
(fatigue, dyspnea, Right-sided
orthopnea) failure
Clinical Manifestations
exertional dyspnea and fatigue (most common)
orthopnea, paroxysmal nocturnal dyspnea, cough,
hemoptysis
cyanosis
Right-sided heart failure – distended neck veins,
peripheral edema, hepatomegaly, abdominal discomfort
Auscultation: S1 followed by an opening snap--created by
forceful opening of mitral valve
- rumbling diastolic murmur (apex)
CXR- left atrial enlargement
ECG – atrial fibrillation may develop (50-80% of pts.)
- pulses becomes irregular & faint, BP
Interventions
Na+ restriction, diuretics – to relieve pulmonary congestion
bed rest, sitting position
Digitalis – improve cardiac contraction, HR, treat atrial
fibrillation
Anticoagulants (blood thinners) – coumadin, aspirin,
ticlopidine (Ticlid), Plavix, dipyridamole
Surgical interventions:
Mitral commissurotomy – separation or incision of the stenosed valve
leaflets at their borders or commissures
Balloon mitral valvuloplasty
Mitral valve replacement – when stenosis is severe
Balloon mitral
valvuloplasty
Aortic regurgitation or
incompetence
Is the backflow of blood into the left ventricle
due to an incompetent aortic valve. It is less
frequent than mitral regurgitation.
It occurs due to sclerosis of aortic valve
resulting shortening, distortion and retraction
of the casps leading to inadequate closure
AORTIC REGURGITATION
may be due to
rheumatic fever –
most common cause
other causes:
connective tissue
disease (Marfan’s
syndrome), severe
hypertension,
congenital anomaly
AORTIC
REGURGITATION
Pathophysiology
Incomplete closure of the
Incomplete closure of the
aortic valve
aortic valve
Backflow of blood to Left
Backflow of blood to Left
ventricle
ventricle
Left ventricular hypertrophy & Left atrial pressure
Left ventricular hypertrophy &
dilation Left atrial pressure
dilation
Left-sided heart failure Left atrium hypertrophy
Left-sided heart failure Left atrium hypertrophy
(late stage)
(late stage)
Pulmonary pressure
Pulmonary pressure
CO
CO
Right ventricular
Right-sided heart failure Right ventricular
pressure
Right-sided heart failure
pressure
Clinical manifestation
palpitations,
exercise intolerance,
Exertional dyspnea, even paroxysmal nocturnal
dyspnea
angina pain.
rapid water hammer pulse,
wide pulse pressure,
early diastolic murmur and
cardiac enlargement
Management
antibiotic prophylaxis before any invasive or dental
procedures
avoid physical exertion, competitive sports
vasodilators, calcium channel blockers, ACE inhibitors
Aortic valvuloplasty or valve replacement
Salt restriction in diet.
TRICUSPID REGURGITATION
uncommon, may be caused by RF, bacterial endocarditis
may also be caused by enlargement of right ventricle
an insufficient tricuspid valve allows blood to flow back
into the right atrium venous congestion & right
ventricular output blood flow towards the lungs
Clinical Manifestations
may not produce any symptoms
moderate-to-severe tricuspid regurgitation exist, the ff.
may result:
Active pulsing in the neck veins
Swelling of the abdomen
Swelling of the feet and ankles
Fatigue, tiredness
Weakness
Decreased urine output
murmur on auscultation
Endocarditis
is an acute, recurrent inflammatory disease that causes
damage to the heart as a sequel to group A beta-
hemolytic streptococcal infection, particularly the
valves, resulting in valve leakage (insufficiency) and/or
obstruction (narrowing or stenosis).
There are associated compensatory changes in the size
of the heart's chambers and the thickness of chamber
walls.
Pathophysiology
Connective tissue of the heart, blood vessels,
joints, and subcutaneous tissues can be affected.
Lesions in connective tissue are known as Aschoff
bodies, which are localized areas of tissue necrosis
surrounded by immune cells.
Heart valves are affected, resulting in valve leakage
and narrowing.
Cont….
Compensatory changes in the chamber sizes
and thickness of chamber walls occur.
Heart involvement (carditis) also includes
pericarditis, myocarditis, and endocarditis
Clinical Manifestations
Symptoms of streptococcal pharyngitis may
precede rheumatic symptoms
Sudden onset of sore throat; throat reddened with
exudate
Swollen, tender lymph nodes at angle of jaw
Headache and fever 101° to 104° F
Abdominal pain
Some cases of streptococcal throat infection are
relatively asymptomatic
Polyarthritis
Chorea
Erythema marginatum
Subcutaneous nodules
Fever
Prolonged PR interval demonstrated by ECG
Heart murmurs
Diagnostic Evaluation
Throat culture
Sedimentation rate, WBC count and differential
Elevated antistreptolysin-O (ASO) titer
ECG-prolonged PR interval or heart block
Management
penicillin is the drug of choice
Rest to maintain optimal cardiac function
Salicylates or NSAIDs to control fever and pain
Prevention of recurrent episodes through long-
term penicillin therapy for 5 years
Nursing Diagnoses
Hyperthermia related to disease process
Decreased Cardiac Output related to
decreased cardiac contractility
Activity Intolerance related to joint pain and
easy fatigability
Thank you
