Valvular Heart Disease/Myopathy/ Aneurysm

1. Valvular Heart Disease/Myopathy/Aneurysm By Nancy Jenkins

2. 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

3. Bing Video: Abdominal Aortic Aneurysm Surgery

4. Aortic Aneurysms Atherosclerotic plaques deposit beneath the intima Plaque formation is thought to cause degenerative changes in the media Leading 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

5. 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

6. 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

7. Aortic Aneurysms Studies suggest strong genetic predisposition *Male gender and smoking stronger risk factors than hypertension and diabetes 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

8. Risk Factors- Atherosclerosis

10. Fusiform Most AAA are fusiform and 98% are below the renal artery

11. Aortic AneurysmsClassification • False aneurysm • Also called pseudoaneurysm • Not an aneurysm • Disruption of all layers of arterial wall • Results in bleeding contained by surrounding structures • Pseudoaneurysm: an outpouching of a blood vessel, involving a defect in the two innermost layers (the tunica intima and media) with continuity of the outermost layer, the adventitia. Alternatively, all three layers are damaged and bleeding outside of the vessel is contained by a clot or by surrounding tissue.

12. False Aneurysms • May result from • Trauma • Infection • After peripheral artery bypass graft surgery at site of anastomosis • Arterial leakage after cannulae removal

13. 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

14. 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

15. 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

16. 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

17. Clinical Manifestations By Location-Thoracic Aortic Aneurysm • Frequently asymptomatic • May have substernal, neck or back pain • Coughing, due to pressure placed on the windpipe (trachea) • Hoarseness • Difficulty swallowing • Swelling (edema) in the neck or arms • Myocardial infarction, or stroke due to dissection or rupture involving the branches of the aorta

19. Ascending Aortic AneurysmAortic ArchClinical Manifestations ASH • Angina • Hoarseness • If presses on superior vena cava • Decreased venous return can cause • Distended neck veins • Edema of head and arms

20. Abdominal Aortic AneurysmClinical Manifestations • Abdominal aortic aneurysms (AAA) • Often asymptomatic • Frequently detected • On physical exam • Pulsatile mass in periumbilical area (Grey’s Anatomy) • Bruit may be auscultated • When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

21. 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

22. Nursing Diagnoses • Risk for Ineffective Tissue Perfusion • Risk for Injury • Anxiety • Pain • Knowledge Deficit

23. 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

24. ComplicationAortic Dissection • Blood invades or dissects the layers of the vessel wall- most often thoracic Aortic dissection - Wikipedia, the free encyclopedia

25. Dissecting aneurysms are unique and life threatening. A break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall. The blood is usually contained by the adventitia, forming a saccular or longitudinal aneurysm.

26. 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 medically or surgically treated

27. Aortic DissectionEtiology and Pathophysiology • As heart contracts, each systolic pulsation ↑ pressure on damaged area • Further ↑ dissection • 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

29. Aortic DissectionCollaborative 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

30. Aortic Dissection • 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%)

31. 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. Care much like after CABG (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

32. Stent Graft Repair http://www.youtube.com/watch?v=oQazyeFRNaM

33. Aortic Aneurysm • Endovascular graft procedure, con’t • 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

34. Open Repair of AAA • 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

35. Nursing ManagementNursing Implementation • Acute Intervention • Postop, continued • Cardiovascular status • Continuous ECG monitoring • Electrolyte monitoring • Arterial blood gas monitoring • Oxygen administration • Antidysrhythmic/pain medications

36. Nursing ManagementNursing Implementation • Acute Intervention • Postop, continued • Infection • Antibiotic administration • Assessment of body temperature • Monitoring of WBC • Adequate nutrition • Observe surgical incision for signs of infection

37. Nursing ManagementNursing Implementation • 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

38. Nursing ManagementNursing Implementation • 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

39. Nursing ManagementNursing Implementation • Acute Intervention • Postop, continued • Peripheral perfusion status • Pulse assessment • Mark pulse locations with felt-tip pen • Extremity assessment • (5P’s) Temperature, color, capillary refill time, sensation and movement of extremities

40. Nursing ManagementNursing Implementation • Acute Intervention • Postop, continued • Renal perfusion status • Urinary output • Fluid intake • Daily weight • CVP/PA pressure • Blood urea nitrogen/Creatinine

41. 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

42. 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

43. Other Complications • Rupture- signs of ecchymosis (triad) • Back pain • Hypotension • Pulsating mass • Thrombi • Renal Failure

44. Rupture Triad Back pain Pulsating hematoma Hypotension

45. 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 Anterior rupture • Massive hemorrhage • Most do not survive long enough to get to the hospital WHY??

46. Rupture False Aortic Aneurysm with Rupture of the Aorta : Medical Animation http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurysm_case_study.htm

47. Student Case Study