Acynotic Disease

ACYANOTIC HEART DISEASE

COARCTATION OF THE AORTA(COA)

• DEFINITION

• COA is a narrowing of part of the aorta ,it is a type of birth defect

Localized narrowing near the insertion of ductus arteriosus,resulting in increased pressure proximal to the defect and decreased pressure distal to the obstruction

• It is third most common congenital heart defect.

• Coarction occurs more than twice as often in males as in females.

CAUSES

• Genetic disorders-turner syndrome – is a genetic condition in which female does not have the usual fair of two X chromosomes

• Congenital heart condition such as;

• Aortic stenosis

• P.D.A

• Defect in which only one ventricle is present

• Ventricular septal defect.

PATHOPHYSIOLOGY

• The effect of a narrowing within the aorta is increased pressure proximal to the defect and decreased pressure distal to it

• Blood pressure increased in the heart and upper portions of the body& decreased in lower part of body

• Left ventricular after load is increased& leads to heart failure

• Collateral circulation developes,increase BP

• Risk for aortic rupture ,aneurysm &CVA

TYPES

1.Preductal coarctation-The narrowing is proximal to the ductus arteriosus.Blood flow to the aorta that is distal to the narrowing is dependent on the ductus arteriosus,this is the type seen in approximately 5% of infants with Turner Syndrome.

2. Ductal coarction-Narrowing occurs at the insertion of the ductus arteriosus.This kind usully appears when the ductus arteriosus closes.

3.Postductal coarctation –Narrowing is distal to the insertion of the ductus arteriosus. Open ductus arteriosus blood flow to the lower body can be impaired.This type is most common in adults.

CLINICAL MANIFESTATION

• High blood pressure• Bounding pulses in the arm• Weak &delayed femoral pulse(radio femoral delay)• Signs of CHF in infants• In adolescence symptoms include,• Dizziness or fainting• Shortness of breath• Chest pain • Cold feet or legs • Nose bleed • Leg cramps

• Prominent pulsations in the neck

• Suzman’s sign is dilated, tortuous, pulsatile arteries seen around the scapulae and intercostal regions in the back. It is better seen with the patient bent forwards and hands hanging down

• Cork – screw – shaped retinal arteries

Diagnostic test

• History and physical examination

• Echocardiogram

• Chest x-ray

• ‘rib notching’ or dock’s sign is the notching of the undersurface of posterior ribs extending from 3rd to 9th ribs seen in after 6 years

• E.C.G

• C.T.OR MRI

Complications

• Aortic aneurysm

• Aortic rupture

• Bleeding in the brain

• Endocarditis

• Heart failure

• Impaired kidney function

• Hypertension

SURGICAL TREATMENT

• Resection of coarcted portion with end-to end anastomosis of the aorta

• Percutaneous balloon angioplasty

AORTIC STENOSIS

• Aortic valve stenosis is narrowing of the orifice between the left ventricle and the aorta.

Pathophysiology

Clinical features• Exertional dyspnea

• PND

• Syncope

• Angina, palpitations

• Pulmonary congestion: Left sided heart failure

• Decreased cardiac output

• Systolic murmur

Diagnostic measures

• History

• Physical examination: a loud, rough systolic crescendo-decrescendo murmur is heard over the aortic area. If the examiner rests a hand over the base of the heart, a vibration may be felt. The vibration is caused by turbulent blood flow across the narrowed valve orifice

• Chest x-ray: shows valvular calcification, left ventricle enlargement, pulmonary vein congestion.

• Echocardiography: shows decreased valve area, increased left ventricular wall thickness

• Cardiac catheterization: increased pressure across aortic valve; increased left ventricular pressures; presence of coronary artery disease.

• ECG: LVH

Medical Management

• Low-sodium, low-fat, low-cholesterol diet: treats left-sided heart failure

• Diuretics: treat left sided heart failure

• Periodic noninvasive evaluation: monitors severity of valve narrowing

• Cardiac glycosides: control atrial fibrillation

• Antibiotics before medical, dental, surgical procedures: prevent endocarditis

• Oxygen, NTG – relieves angina

Surgical solutions

• Percutaneous balloon aortic valvuloplasty: reduces degree of stenosis.

• Aortic valve replacement: replaces diseased valve

Nursing Assessment of patient with valvular disoders

• Past health history: rhematic fever, congenital defects, MI, chest truma, cardiomyopathy, endocarditis, Marfan syndome.

• Ask for palpitations, activity intolerance, orthopnea, PND, cough, hemoptysis.

• Ask patient about symptoms of fever or throat or joint pain.

• Ask patient about chest pain, dyspnea, fatigue.

• Observe for skin lesions or rash on trunk and extremities.

• Palpate for firm, non tender movable nodules near tendons or joints.

• Auscultate heart sounds for murmurs and/or rubs.

Decreased Cardiac Output related to valvular incompetence

• Assess frequently for change in existing murmur or new murmur.

• Assess for signs of left- or right-sided heart failure.

• Assess vital signs, cardiovascular status.

• Monitor and treat dysarrhythmias as ordered.

• Administer inotropic medications to increase myocardial contractility

• Prepare the patient for surgical intervention

Activity Intolerance related to reduced oxygen supply

• Maintain bed rest while symptoms of heart failure are present.

• Allow patient to rest between interventions.

• Encourage patient to choose activities that gradually build endurance to increase cardiac tolerance.

• Begin activities gradually (e.g. chair sitting for brief periods).

• Assist with or perform hygiene needs for patient to reserve strength for ambulation.

Ineffective Tissue Perfusion (renal, cerebral, cardiopulmonary, GI, and peripheral) related to interruption of blood flow

• Observe patient for altered mentation, hemoptysis, aphasia, loss of muscle strength, complaints of pain.

• Observe for splinter hemorrhages of nail beds, Osler's nodes, and Janeway's lesions.

• Notify health care provider of observed changes in the patient's status.

• Reposition patient frequently to prevent skin breakdown and pulmonary complications associated with bed rest.

Imbalanced Nutrition: Less Than Body Requirements related to anorexia

• Assess patient's daily caloric intake.

• Discuss food preferences with patient.

• Consult with a dietitian about nutritional needs of patient and food preferences.

• Encourage small meals and snacks throughout the day.

• Record daily caloric intake and weight.

• Educate family about the patient's caloric needs.

• Encourage family to assist the patient with meals and bring in patient's favorite foods.