1. Identify five common causes of valvular heart disease. (pp. 480, 482)

2. Differentiate between stenosis and insufficiency (regurgitation). (p. 480)

3. List and briefly describe 6 common diagnostic tests used to identify valvular heart disease (Ch. 30 and p. 484).

4. List 5 clinical signs and symptoms associated with mitral stenosis (p. 483).

5. Name 2 abnormal heart sounds associated with mitral stenosis (p. 484).

6. Contrast venous disease of the extremities with arterial disease with respect to problems involved in each.

7. List and describe the signs and symptoms of peripheral ischemia. (pp. 520, 523-524)

8. Differentiate between thrombosis and embolism (pp. 99, 102, 528-529).

9. List and describe three common diagnostic tests useful in detecting peripheral vascular disease. (pp. 516-519)

10. Know all underlined terms and * questions, including * case study questions.

Be sure to observe all 4 sets of valves in this heart. Note the structure and thinness of the valves. Also note the chordae tendineae and papillary muscles. (Be very careful handling this heart).

Valve replacement - Drawing and photograph of prosthetic (artificial) valves in place. See also the 3 types of prosthetic valves illustrated in Fig. 32-10 (p. 490).

When patients with valvular defects are no longer responsive to medical therapy, replacement of the diseased valve(s) with a prosthetic valve may be performed. See pp. 489-491 in text for details. Like natural valves, these valves work by responding to pressure changes on either side of the valve.

What 2 valves have been replaced in the drawing (St. Jude Medical)?

Arterial grafts

Arterial grafts are commonly used for treating peripheral vascular disease including chronic occlusive disease and aneurysms.

        22. Aorta, atherosclerotic aneurysm, gross

* What is the most common cause of chronic occlusive disease and also a common cause of aneurysms? (pp. 519, 522-523)

Study the synthetic arterial grafts and the various surgical techniques illustrated on the lab demo diagram and in your text (Fig. 34-8, p. 521 & Figs. 34-12 & 34-13, p. 524). Notice that some techniques involve removing and replacing the diseased artery with a graft (Fig. 7 on lab demo and p. 524), whereas in other techniques, the diseased artery is left in place and a bypass graft is made (Fig. 10 on lab demo and p. 521).

Why would blood begin to flow through the bypass graft rather than through the diseased artery after the surgery?

With time the diseased artery will atrophy.

Of the 2 arterial grafts on display, which one would be used as an aortobifemoral graft? (Fig. 34-8)

Brain with Cerebral Atherosclerosis - (if available)

Examine the cerebral arteries (on the inferior surface of the brain) which have been opened to expose atherosclerotic plaques. (The discoloration of the brain is due to fixation).

* What potential complications could occur as a result of these plaques?

Cranial arteriogram

The technique used to produce this arteriogram is similar to that used in coronary angiography. In this case contrast (radiopaque) dye was injected into the carotid artery and flowed from there into the various cerebral arteries.

* What abnormalities could be demonstrated by an arteriogram such as this? (p. 444)

Aneurysm of Aorta

An aneurysm is an outpouching or dilation of the arterial wall. Aneurysms are usually caused by atherosclerosis, syphilis or trauma. (Fig. 34-11, p. 523).

        22. Aorta, atherosclerotic aneurysm, gross

Acute Rheumatic Heart Disease Affecting Mitral Valve

Acute rheumatic fever is a systemic disease potentially involving all layers of the heart. In this valve, note the tiny bead-like fibrous elevations or vegetations deposited along the leaflet borders.

* What organism is responsible for rheumatic fever? (p. 480)

Mitral Stenosis of Rheumatic Heart Disease

Mitral stenosis is characterized by thickening and fusion of the leaflets along the commissures (junction between the leaflets); the chordae tendineae of the AV valves also thicken and fuse.

* What affect do these changes have on the flow of blood between the atria and ventricle? (pp. 482-483)

* What is usually the earliest symptom associated with mitral stenosis? What causes this symptom? (p. 483)

Bacterial Endocarditis on the Aortic Valve

Rheumatic fever has already affected this aortic valve and left it susceptible to infection or endocarditis.

* What organisms commonly cause endocarditis? (p. 482)

* If the aortic valve became stenotic (obstructing blood flow from the left ventricle), how would the ventricle compensate? (p. 485)

* Would you expect to hear a diastolic or a systolic murmur with aortic stenosis? (p. 486)

Congenital Defect in the Ventricular Septum

This defect has been present since birth. There is an abnormal passageway between the right and left ventricles.

* Which way do you think blood would be shunted?

Sometimes infants with this defect are called blue babies.

* What is the physiological rationale for this description?

CASE STUDY I : Chronic Occlusive Disease

John M., a 72 year-old retired postmaster, visited his local clinic complaining of a pain in his right leg occurring after walking one block. After rest, this pain subsided and he could walk another block before the pain returned.

Physical examination revealed thinning of the skin on his foot and ankle, thickening of toenails and loss of hair on the dorsum of the foot and toes. Following arteriography of both legs, John was scheduled for an arterial vascularization procedure - specifically, a femoral-popliteal bypass.

          16. Aorta, lipid streaks, gross
          17. Aorta, lipid streaks, gross
          18. Aortas with mild, moderate, and severe atherosclerosis, gross *
          19. Aorta, atheromatous plaque, medium power microscopic *
          20. Aorta, atheromatous plaque, high power microscopic *
          21. Aorta, atheromatous plaque, high power microscopic *
          Aortic atherosclerosis demonstrated in three aortas, gross.

          Foot with previous healed transmetatarsal amputation and recent ulcer, gross.
          Gangrenous necrosis and ulceration, lower extremity, gross.

          31. Gangrenous necrosis, foot, gross
          32. Gangrenous necrosis, lower extremity, gross
          33. Gangrenous necrosis, low power microscopic *

*1. John's presenting symptom is called what? (p. 520)

*2. John's leg became pale on elevation. When his leg was lowered to a dependent position, it became red and cyanotic. What are the reasons for these color changes? (p. 520)

*3. Diagnostic tests indicated John had significant obstruction due to atherosclerotic plaques at the bifurcation of the femoral and popliteal arteries, yet adequate collateral circulation and a patent artery distal to obstruction. What factors favor the development of adequate collateral circulation? (p. 519)

4. What signs present on physical exam suggest that John has had this condition for a long time (chronic)? (p. 520)

*5. If John experienced an arterial occlusion (secondary to thrombosis) at the site of the atherosclerotic plaque, what signs and symptoms would then occur? (p. 520)

6. John returns home to await his surgery. What can the nurse teach him about maximizing perfusion to his lower leg? (p. 520)

7. Eliciting a Homan's sign on John would indicate severe arterial insufficiency. True or false? (p. 530).

CASE STUDY II - Mitral Stenosis

In 1978, Donna L., age 14, experienced recurring episodes of rheumatic fever. During her acute illness, she remained at home on bed rest, but when she began to feel better, she stopped taking her prescribed prophylactic antibiotics. Today, at the age of 29, Donna has been experiencing increasing dyspnea on exertion, poorly tolerated exercise levels, increasing weakness and fatigue. She has experienced frequent upper respiratory infections and occasional hemoptysis.

Physical examination revealed a diastolic murmur and accentuated first heart sound, EKG findings showed left atrial enlargement ("P mitrale"), right ventricular hypertrophy and atrial fibrillation. Chest x-ray revealed pulmonary venous congestion, interstitial pulmonary edema and vascular redistribution to upper lobes. Cardiac catheterization demonstrated an elevated pressure gradient across the mitral valve and elevated left atrial, pulmonary capillary wedge and pulmonary artery pressures with a low cardiac output.

Donna was found to have mitral stenosis and a mitral valvotomy was scheduled.

*1. The organism thought to be responsible for rheumatic fever and subacute bacterial endocarditis is . (pp. 480, 482)

*2. Mitral valve disease usually produces symptoms earlier in the course of the disease than aortic valve disease. Why is this? (p. 489)

*3. Describe Donna's abnormal heart sounds in relation to mitral stenosis. (pp. 433-434, 484)

*4. What is the reason for Donna's occasional hemoptysis? (p. 483)

5. What is "P mitrale"? What causes it? (p. 484)

6. After reading the results of Donna's cardiac catheterization, describe the approach to the heart utilized to obtain these results. (pp. 443-444)

7. What is meant by a mitral valvotomy? (p. 490)