Valvular Heart Disease/Myopathy/Aneurysm

By Nancy Jenkins

Definition

• Abnormal dilation of a blood vessel at a site of weakness or a tear in the vessel wall.

• Usually secondary to atherosclerosis.

• Most commonly affect the aorta

Aorta

• Largest artery• Responsible for supplying oxygenated

blood to essentially all vital organs

• **Aneurysm can occur in any artery but the aorta is most common

• Growth rate unpredictable– **Larger the aneurysm greater risk of rupture

May also involve the aortic arch or the thoracic aorta,

Most (3/4) are found in abdominal aorta below renal arteries

¼ are found in the thoracic area

Aortic Aneurysms

– Studies suggest strong genetic predisposition

•Abdominal aortic aneurysms (AAA)– Occur in 4.1% to 14.2% of men– 0.35% to 6.2% of women over 60– Cause of 16,000 deaths per year

Risk Factors- Atherosclerosis

*Male gender and smoking stronger risk factors than hypertension and DM

Aortic Aneurysm Pathophysiology

• Atherosclerotic plaques deposit beneath the intima– This is thought to cause degenerative changes in the media– Leads to loss of elasticity, weakening, and aortic dilation

• Dilated aortic wall can become lined with thrombi than can embolize– Leads to acute ischemic symptoms in distal branches

– Important to assess peripheral pulses

Types of Aneursyms

• 2 basic classifications- True and False

• True aneurysm– Wall of artery forms the

aneurysm

– At least one vessel layer still intact

Fusiform-Circumferential, relatively uniform in shape

Saccular-Pouchlike with narrow neck connecting bulge to one side of arterial wall

Aortic AneurysmsClassification

• True aneurysm– Further subdivided to fusiform and saccular

• Fusiform- most are fusiform and 98 below the renal artery

– Circumferential, relatively uniform in shape

• Saccular– Pouchlike with narrow neck connecting bulge to one side

of arterial wall

False Aneurysms

– Also called pseudoaneurysm– Not an aneurysm– Disruption of all layers of arterial wall

• Results in bleeding contained by surrounding structures

• May result from– Trauma

– Infection

– After peripheral artery bypass graft surgery at site of anastomosis

Arterial leakage after cannula removal- heart cath

Aortic AneurysmDiagnostic Studies

• X-rays- Most are diagnosed without symptoms on routine X-ray– Chest - Demonstrate mediastinal silhouette and any

abnormal widening of thoracic aorta

– Abdomen -May show calcification within wall of AAA

• ECG -to rule out MI

Aortic AneurysmDiagnostic Studies

• Echocardiography– Assists in diagnosis of aortic valve

insufficiency• Related to ascending aortic dilation

• Ultrasonography– Useful in screening for aneurysms– Monitor aneurysm size

Aortic AneurysmDiagnostic Studies

• CT scan– Most accurate test to determine

• Anterior to posterior length

• Cross-sectional diameter

• Presence of thrombus in aneurysm

• MRI– Diagnose and assess the location and severity

Aortic AneurysmDiagnostic Studies

• Angiography– Anatomic mapping of aortic system using

contrast– Not reliable method of determining diameter or

length– Can provide accurate info about involvement of

intestinal, renal or distal vessels

Thoracic Aortic Aneurysm ClinicalManifestations

Frequently asymptomatic

Coughing Hoarseness Difficulty swallowingMay have substernal, neck, back pain Swelling (edema) in the neck or arms Myocardial infarctionStroke

Ascending Aortic AneurysmAortic Arch Clinical Manifestations

ASH– Angina – Swelling– Hoarseness

– If presses on superior vena cava decreased venous return can cause distended neck veins edema of head and arms

Abdominal Aortic AneurysmClinical Manifestations

Abdominal aortic aneurysms

• (AAA)– Often asymptomatic– Frequently detected

• On physical exam

– Pulsatile mass in periumbilical area

– Bruit may be auscultated

• Often found when patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

Aortic AneurysmClinical Manifestations

• AAA, con’t– May mimic pain associated with abdominal or back

disorders– Pain correlates to the size- can be excrutiating– May spontaneously embolize plaque

• Causing “blue toe syndrome” patchy mottling of feet/toes with presence of palpable pedal pulses

• It can rupture, causing shock and death in 50% of rupture cases

–

Nursing Diagnoses

• Risk for Ineffective Tissue Perfusion

• Risk for Injury

• Anxiety

• Pain

• Knowledge Deficit

Medical Treatment of Aneurysms- if less than 5cm

• Anti-hypertensives– Beta blockers, – Vasodilators– Calcium channel blockers– Nipride

• Sedatives• Niacin, mevocor, statins

Post-op anti-coagulants

ComplicationAortic Dissection

• Most occur in thoracic aorta

• Blood invades or dissects the layers of the vessel wall

Aortic dissection - Wikipedia, the free encyclopedia

Aortic Dissection• Affects men more often than women

• Occurs most frequently between fourth and seventh decades of life

• Acute and life threatening

• Mortality rate 90% if not surgically treated– May occlude major branches of aorta

• Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities

• People with Marfan’s at risk

Manifestations of Aortic D issection Aneurysm

Abrupt, severe, ripping or tearing pain in area of aneurysm

Mild or marked hypertens ion early

Weak or absent pulses and blood pressure in upper extremities

S yncopeC omplications: hemorrhage,

ischemic kidneys (renal failure), MI, heart failure, cardiac tamponade, seps is , weakness or paralys is of lower extremities .

Aortic Dissection Collaborative Care

• Initial goal – ↓ BP and myocardial contractility to diminish

pulsatile forces within aorta

• Drug therapy– IV β-adrenergic blocker

• Esmolol (Brevibloc)

– Other hypertensive agents • Calcium channel blockers• Sodium Nitroprusside• Angiotensin-converting enzyme

Aortic DissectionCollaborative Care

• Conservative therapy– If no symptoms

• Can be treated conservatively for a period of time

– Success of the treatment judged by relief of pain

– Emergency surgery is needed if involves ascending aorta

Aortic DissectionCollaborative Care

• Surgical therapy– When drug therapy is ineffective or– When complications of aortic dissection are present

• Heart failure, leaking dissection, occlusion of an artery

– Surgery may be delayed to allow edema to decrease and permit clotting of blood

– Even with prompt surgical intervention• 30-day mortality of acute aortic dissections remains high

(10%-28%)

AAA-Medical Treatment - Surgery or Stent• Usually repaired if >5cm• Open procedure- abd incision, cross clamp

aorta,aneuysm opened and plaque removed, then graft sutured in place. (Not done as much anymore unless a rupture)– Pre-op assess all peripheral pulses– Post-op-check urine output and peripheral pulses

hourly for 24 hours- (when to call Dr.)

• Endovascular stents- placed through femoral artery

YouTube - Endovascular Repair for Abdominal Aortic Aneurysm

Endovascular graft procedure, Approach is percutaneous femoral access

Advantages:Shorter operative time

Shorter anesthesia time

Reduction in use of general anesthesia

Reduced groin complications within first 6 months

Surgery- Open Method• Acute Intervention

– Post-op (similar to CABG)• ICU monitoring

– Arterial line

– Central venous pressure (CVP) or pulmonary artery (PA) catheter

– Mechanical ventilation

– Urinary catheter– Nasogastric tube– ECG– Pulse oximetry– Pain medication

Cont.

• Acute Intervention– Postop, continued

• Cardiovascular status– Continuous ECG monitoring

– Electrolyte monitoring

– Arterial blood gas monitoring

– Oxygen administration

– Antidysrhythmic/pain medications

Cont.

• Acute Intervention– Postop, continued

• Infection– Antibiotic administration- 30 minutes before incision-

Core Measure

– Assessment of body temperature

– Monitoring of WBC

– Adequate nutrition

– Observe surgical incision for signs of infection

Cont.

• Acute Intervention– Postop, continued

• Gastrointestinal status– Nasogastric tube

– Abdominal assessment

– Passing of flatus is key sign of returning bowel function

– Watch for manifestations of bowel ischemia

Post-Op• Acute Intervention

– Postop, continued• Neurologic status

– Level of consciousness– Pupil size and response to light– Facial symmetry– Speech– Ability to move upper extremities– Quality of hand grasps

• Peripheral perfusion status– Pulse assessment

• Mark pulse locations with felt-tip pen– Extremity assessment

• Temperature, color, capillary refill time, sensation and movement of extremities (5 P’s)

Nursing ManagementNursing Implementation

• Acute Intervention– Postop, continued

• Renal perfusion status– Urinary output

– Fluid intake

– Daily weight

– CVP/PA pressure

– Blood urea nitrogen/Creatinine

Nursing Management

• Ambulatory and Home Care• Encourage patient to express concerns

• Patient instructed to gradually increase activities

• No heavy lifting

• Educate on signs and symptoms of complications• Infection

• Neurovascular changes

Prevention• 1.Ultrasound is extremely effective at

detecting AAAs.The U.S. Preventive Services Task Force (USPSTF) recommends that anyone aged 65 to 75 who has ever smoked undergo a one-time ultrasound screening for AAA

• 2.Prevent atherosclerosis• 3.Treat and control hypertension• 4.Diet- low cholesterol, low sodium and no

stimulants• 5.Careful follow-up if less than 5cm. It can

grow .5cm /year

Other Complications

• Rupture- signs of ecchymosis (triad)– Back pain– Hypotension– Pulsating mass

• Thrombi

• Renal Failure

Aortic Aneurysm Rupture

• Rupture- serious complication related to untreated aneurysm– Posterior rupture

• Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death

• Severe pain

• May/may not have back/flank ecchymosis

Turner’s sign and Cullen’s sign

Anterior ruptureMassive hemorrhage Most do not survive long enough to get to the hospital WHY??

Student Case StudyPatient History

27 year old male Full Code African AmericanLives alone in apartmentFamily hx DMMorbid obesity (314.6 lbs)Height: 5’11Ambulates with walker

Medical History:ETOH abuseSmokerHypertensionDOE

Sleep apneaTrach (8/30)Ejection Fraction 50%Hemodialysis (M-W-F)Mitral insufficiency, Mild regurgitation(mitrial, tricuspid)Pressure ulcer on coccyxRespiratory failure with trach , pneumonia, delirium

(8/13) P t appeared in E R w c/o flank and abd pain

B /P 270/159 (C ardene drip which decreased pressure to 185/73)

Na 138 K 4.4 C h108 B UN 24 C reat 3.0 G lucose 147 C a 8.5 Hgb 12.5

Admiss ion diagnos is : Malignant hypertens ionT ype B Aortic D issectionR enal insufficiencyMorbid obes ity

P t teaching:S moking cessationC ontrol HTNL ifestyle changesDiet controlUse of s tool softeners (increase fluid and fiber in diet)

• E X T R A DX DE VE L O P E D DUR ING HO S P IT AL S T AY :

• Myopathy• Acute respiratory failure• C hronic kidney disease• P neumonia due to S taph

and Hemophilus Influenze

• HT N encephalopathy acute renal dis eas e with les ion of tubular necros is

• Delirium• Uns pec d/o of kidney and

ureter

S urgery

• S urgery is done when an aneurysm is 6 cm in diameter, expanding fast or symptomatic. T ype B diss ections are surgically repaired depending on extent of involvement and risk for rupture.

• Aneurysm excised and replaced with s ynthetic fabric graft.

Nsg Dx:• R isk for Ineffective tissue

perfus ion.• Anxiety

Med i ca ti on s Al lergy:PCN

T reated with long term beta blocker therapy and antihypertens ive drugs as needed to control heart rate and blood pressure. Initially treated with I.V beta blockers such as propranolol (Inderal),metoprolol (L opressor), Normodyne or B revibloc to reduce heart rate to 60 bpm. Niprideinfus ion to reduce systolic to 120mmHg. C alcium channel blockers may also be used. Direct vasodilators are avoided because they may worsen the dissection. After surgery anticoagulants may be initiated; used indefinitely and maybe even lifelong.

P t meds: Albuterol 2.5mg IH q8hHeparin 5000u S Q q8hF lonase nas al spray 2 sprays each nose q12hAmphojel 1020mg q8hC atapress 0.2mg q4hMinoxidil 10mg P O q12hE ns ure supp 240ml P O T IDP rotonix 40mg po dMultivitamin 1 tab P O dL exapro 20mg P O d R enal D ietP rocrit 10000u S Q MWF R P ermacath, R AC , S L