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Unit VI Promoting Health in Patients With Circulatory or Perfusion Disorders
with infectious etiology require antimicrobial therapy, whereas advanced valvular diseases require general HF management. That includes the following: z Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), or angiotensin receptor–neprilysin inhibitors (ARNIs) with beta block- ers to reduce heart rate and blood pressure z Diuretics to decrease preload and pulmonary congestion Medication management is also determined by the type of valve utilized in valve replacement, if necessary. Replace- ment valves are generally categorized as mechanical or bio- prosthetic. Patients who undergo valve replacement with a mechanical prosthetic valve will need to be anticoagulated for life to prevent thrombotic events such as strokes (see Medication Safety Alert). Bioprosthetic valves have recom- mended anticoagulation for 3 to 6 months after placement followed by aspirin use for life. These valves have less lon- gevity. They are typically considered in patients who are older or cannot be anticoagulated safely.
catheter that is peripherally inserted and guided to the heart. With recent advances in technology, the TAVR pro- cedure can be used for aortic stenosis patients with all lev- els of surgical risk. Transcatheter mitral valve replacement is an emerging technology that is being studied and may be considered for patients who have severe regurgitation and symptoms with high surgical risk. Overall, there is growing evidence that when possi- ble, valvular repair yields better outcomes than replace- ment. Reparative surgery includes balloon valvuloplasty, commissurotomy, and mitral valve annuloplasty. Balloon valvuloplasty is a transcatheter procedure to repair stenosed valves. It involves inserting a balloon catheter through an appropriate vessel and advancing it to the heart. The bal- loon is inflated in the affected valve to enlarge the opening. Commissurotomy is a surgical procedure done to incise fused leaflets, widening the valve opening. Valve annu- loplasty is a reconstructive procedure to repair the ring (annulus) that attaches and supports the valve leaflets. For patients with severe mitral valve regurgitation, a procedure that partially clips the bulging leaflets together to reduce regurgitation and improve symptoms may be used. Complications Valvular disorders can result in heart failure; cardiogenic shock; thromboembolism, including stroke; bleeding from anticoagulation; endocarditis; and dysrhythmias. Connection Check 30.4 The nurse hears a loud systolic murmur at the second intercostal space right sternal border. What valve problem is the patient likely experiencing? A. Aortic regurgitation B. Aortic stenosis C. Pulmonic regurgitation D. Pulmonic stenosis Murmurs resulting from turbulent blood flow through dis- eased valves are heard with valve disease. Patients may be asymptomatic until valve function becomes significantly impaired, at which time clinical manifestations of HF related to decreased cardiac output and pulmonary con- gestion become prevalent. They include the following: z SOB z Angina z Syncope z Dysrhythmia z Palpitation z Dizziness z Fatigue z Weight gain z Poor color, cool extremities, weak peripheral pulses Nursing Management Assessment and Analysis
Safety Alert
Medication Safety Alert: Anticoagulants
Patients with valve replacements who take anticoagulants for life to prevent thromboembolisms sometimes must stop taking these medications for invasive diagnostic or surgical procedures. Patients should discuss this with their care team before stopping anticoagulants. Bridging therapy with heparin or enoxaparin may need to be started to prevent thromboembolisms until routine anticoagulants can be restarted. Anticoagulants should not be stopped for low risk procedures such as dental cleaning and skin or eye surgery. Surgical Management Surgical intervention to repair or replace diseased valves is often indicated and is based on the degree of valve dys- function, symptom severity, and surgical risk. For patients needing valve replacement, open-heart surgery with a mechanical or bioprosthetic valve remains the standard approach. In these surgeries, patients undergo general anesthesia and are placed on cardiopulmonary bypass, and the diseased valves are replaced through a sternal incision or multiple smaller chest incisions. For patients with comorbidities, this comes with an increased risk of operative mortality; thus, fewer of these patients undergo surgical intervention. Other factors such as valve condi- tion and anatomy are also considered in the decision to perform a surgical replacement. A treatment option for aortic valve replacement that comes with less risk is a tran- scatheter approach to valve replacement with prosthetic valves. In this procedure, called a transcatheter aortic valve replacement(TAVR) or transcatheter aortic valve implantation (TAVI), a new valve is deployed through a
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