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