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Cardiac Case StudyLisa Sharp-GomezAndrews UniversityFall, 2015Introduction:JL is a 6’1”, 217 lb., 72 year old white male. He had been experiencing SOB and fatigue and was referred to Atrium Medical Center (AMC) by Veterans Administration Hospital (VA) to confirm a diagnosis of severe aortic stenosis. He has a history of hypertension and herpetic eye infections. He smoked a pack of cigarettes a day for 50 years, finally quitting in August 2012. He current uses chewing tobacco. A transesophageal echocardiogram (TEE) was performed at AMC, which confirmed the diagnosis of severe aortic stenosis, severe aortic insufficiency and mild to moderate mitral regurgitation. It was determined that JL had a mean valve area of .8cm2. An area of less than 1.0cm2 is considered severe aortic stenosis. (Spaccarotella, Mongiardo & Indolfi, p. 14) With this diagnosis, it was felt that JL would benefit from aortic valve replacement.JL was given the option to receive treatment at the VA hospital in Cleveland, however, as he is the primary caregiver for his wife, who suffers from Parkinson’s disease and it was his opinion that she was unable to travel that far. He declined treatment in Cleveland. JL was chosen for this study because of the severity of the condition, the opportunity to research the procedure and post procedure nutritional support to aid in healing. This study began on 9/28/15 and ended on 10/2/15.Social History:JL is married with 2 grown children. He does not drink or use drugs. He has smoked a pack of cigarettes a day for 50 years, but quit in 2012. He now uses smokeless tobacco. He is the sole caretaker for his wife, who has Parkinson’s disease. JL will be discharged to his home with home health care vs. being discharged to a rehabilitation facility. His children will assist him during his recuperation and with the care his wife.Explanation of the disease process:Normal cardiac function moves the blood from the body into the right atrium and through the tricuspid valve into the right ventricle. It is then pumped through the pulmonary valve to the lungs and oxygenated blood returns to the left atrium. This oxygenated blood moves through the mitral valve, into the left ventricle and is pushed forward through the aortic valve out to the body. Aortic stenosis occurs when the aortic valve becomes calcified and hardened. This prevents the proper opening and closing of the valve and thus the blood does is not pushed forward freely during ventricular contraction. This stenosis of the valve also prevents the valve from closing properly, thus allowing blood to flow backwards into the ventricle. Because the valve is functioning poorly, left ventricle hypertrophy results from the increased pressure required to move the blood forward. This increased pressure can result in a lower cardiac output and thus, less oxygenated blood is available for the cardiac muscles and the rest of the body. (American Heart Association, 2013). Manifestations of this lack of oxygen are angina, syncope, left heart failure and shortness of breath. Aortic stenosis can be the result of a congenital abnormality, can be rheumatic in origin (rare) and can be the result of age related calcification. (Vahanian, et al., p. 2463) Recent research from the Canadian Journal of Cardiology (2014, p. 985) points to associations between high LDL levels, hypertension and aortic stenosis. Higher LDL levels appear to lead to inflammation which, in turn, leads to neovascularization of valve tissue. This risk appears to be lower in older individuals. (Rajamannan, et al., p.1787) . Inflammation can also lead to the expression of metalloproteinases. These “produce peptide fragments which might directly promote the mineralization of the aortic valve” and “produce elastin-derived peptide fragments with osteogenic properties”. (Mathieu and Boulanger, 2014, p. 985). In the later stages of the disease, “lamellar bone, microfractures and hemopoetic tissues can be found in the valve tissue”.(Dweck, Boone & Newby, 2012, p.1857)JL does not have a congenital abnormality, did not report any rheumatic disease and does not appear to have an issue with hyperlipidemia. He does have hypertension and was a long time smoker. These have also been singled out as risk factors (Rajamannan, et al., p.1787). Past Medical History: JL appears to have had relatively good health throughout his life. There are no hospital admissions currently listed in his records, but it should be noted that JL does receive healthcare from the VA hospital and therefore, his health information is not in the AMC system. It is noted that he smoked 1 pack of cigarettes per day for fifty years, quitting in 2012. He has suffered or suffers from unspecified essential hypertension, asbestosis, anxiety and herpes (in the eye). JL did undergo a cardiac catheterization at the VA hospital. Findings included mild coronary artery disease and aortic stenosis.Present medical status and treatment:Presently, JL is suffering from weakness and fatigue. His medical records reveal that he has an irregular heartbeat, heart murmur and a heart valve problem. He also suffers from shortness of breath. He is slightly anemic and has a below normal hematocrit. He does not appear to have any issues with hyperlipidemia.Theoretical discussion of disease condition:Aortic valve stenosis is defined as “an obstacle to the flow of blood through the aortic valve during left ventricular ejection”. As the functional area of the valve declines, pressure in the left ventricle increases in an attempt to move the blood forward. This results in a hypertrophy and stiffening of the left ventricle. (Spaccorotella et al., p. 13)As blood is not moving out of the left ventricle efficiently, there is increased pressure in the left atrium as it attempts to push the blood through. This, in turn, causes pressure in the pulmonary arteries to increase, causing increased pressure in the right ventricle which in turn, causes increased pressure in the right atrium. This cycle results in increased systemic venous blood pressure. (Spaccarotella et al., p. 13). As the blood flow through the aortic valve is decreased with each ventricular contraction, there is less efficient blood flow through the entire circulatory system. This also results in a smaller quantity of blood moving through the lungs and thus, lower O2 concentrations in the blood. These lower O2 levels are the cause of the symptoms frequently associated with aortic stenosis - angina, syncope, dyspnea and left HF. (Stump, p. 365).Aortic stenosis in older adults is typically caused by calcification of the valves. It affects between 2 and 7% of the population who are older than 65 years of age. Once symptoms appear, the survival rate without treatment is 15-50% after 5 years. (Vahanian, et al., p. 2463). Usual treatment of the condition:The usual treatment of this condition is the replacement of the stenotic aortic valve. The surgeon and patient can choose from different types of prosthetic valves. Each valve replacement has its advantages and disadvantages. Replacement valves can be mechanical. These are durable and may last the remainder of the patient's life. The disadvantage is that the recipient will need continuous anticoagulation therapy, as the blood cells can stick to the mechanical valves leading to clot formation.Replacement valves can be bioprosthetic and are be made from animal valves or other flexible tissues. These do not carry the risk of clotting, but may last between 10-20 years. Therefore, if a younger person is being given this type of prosthetic valve, there will very likely be another surgery in the future to replace it. Both of these surgical interventions require open-heart surgery and the transfer of the patient onto and off of a heart/lung bypass. The patient must also be ventilated during the surgery and for a period of time after. These procedures carry some risk and the patient must be deemed a good surgical candidate. (American Heart Association, 2014)For those patients who would benefit from valve replacement but are older (>85) or have other risk factors which would prevent a surgical replacement, a procedure to deliver a new valve to the heart via catheter has been developed. It delivers this new valve, enclosed in a stent-like cage to the heart without the need for open heart surgery, heart/lung bypass or ventilation. The stent is inserted into the malfunctioning valve and when the stent is expanded, collapsing the stenotic valve against the walls of the aorta. The expanded stent seals the annulus and contains the new valve which works immediately to regulate the blood flow from the left ventricle of the heart. (Spaccarotella, et al., p.16)Patients symptoms upon admission leading to present diagnosis: JL presented initially to the VA with fatigue and shortness of breath. There he underwent a cardiac catheterization. This indicated that he had mild atherosclerotic heart disease. A transesophageal echocardiogram (TEE) was performed at AMC which indicated severe aortic stenosis and severe aortic regurgitation. These new diagnoses are the underlying cause of JL’s fatigue and shortness of breath.Laboratory findings and interpretation (compared with normal values).Prior to surgery/preadmission testing:TestResultsNormal values (Marshall University, n.d.)Cl11495-105 mEq/LBilirubin, total1.1.1 - 1.0GFR57>60RBC3.464.7 - 6.1Hemoglobin10.913.5 -17.5 Hematocrit32.242% - 52%Platelet count*118150-400*It was felt that this lower platelet count was due to the chronic use of antivirals that JL had been taking for a herpetic eye infection and that if it dropped too low, a transfusion would be arranged.Medications: DrugUse / purposedrug/food interactionsside effectsHeparinanticoagulant maintain consistent intake of Vit K containing foodsbleeding risk with long term useNitroglycerinAntianginaavoid alcoholheadache, dizziness, hypotensionCardeneshort term antihypertensive (intended for IV use only)None notedheadache, nausea/vomitingMetoprololantihhypertensiveTake with food, monitor Na and decrease kcal in diet with long term usedry mouth, nausea, dyspepsia, flatulence, diarrhea, constipation, decreased blood pressureNorvascantihypertensiveTake with food, avoid natural licoriceswelling of ankles or feet, flushing, fatigueCoumadinanticoagulantMaintain consistent intake of Vit K containing foods. Avoid foods with affect coagulation(garlic, ginger, ginkgo, ginseng, saw palmetto or horse chestnut. Avoid St Johns Wort and avocado. Do not exceed UL for Vit AIncreased risk of bleeding, Increased P/INT, decreased clotting factorsLasixdiuretic (in this case used to aid antihypertensives)monitor vit K, Na, Cl, Mgincreased thirst, cramps, nausea/vomiting, constipationInsulinantihyperglycemic Typically, monitor carbohydrate intake to match insulin amountWeight gain, hypoglycemia, MorphineAnalgesicInsure adequate fluid intake to avoid constipationdry mouth, constipationPercosetAnalgesicDo not take with grapefruit, do not take with high fat mealAnorexia, dry mouth, nausea and vomiting, dry mouth, constipation, drowsiness, fatigue, dizziness Diprivansedative / anesthesiaIf used more than 72 hours, use low fat enteral feeding, low fat TPN or low fat diet Increased triglycerides, increased cholesterol, hypotensionColacestool softenerEat a high fiber diet with adequate liquid to prevent constipationCramps, diarrheaMiralaxstool softenerEat a high fiber diet with 1500-2000ml fluids per day to prevent constipationBloating, cramps, flatulence ( Pronsky and Crowe, 2012)Treatment Surgical procedures, findings and results:JL had open heart surgery to replace a calcified aortic valve. He was placed on a heart/lung bypass during the procedure. After the chest was opened, the heart was stopped and cooled to minimize damage during the procedure. The valve was accessed and the old valve was removed. It was replaced with a #21 Carpentier-Edwards Perimount Magna pericardial bioprothesis which was sewn into place. After successful replacement of the valve, the heart was restarted and the chest was closed. JL was transferred to ICU in stable, but critical condition. He remained on a ventilator under sedation. The goal was to remove the JL from the ventilator within 24 hours after surgery. He was extubated at 2040L on 9/28, 13 hours after surgery. Prognosis for a complete recovery is good.MNTNutrition history:JL visually appears in general good health. He has a BMI of 28.57 and states that he eats a varied diet, but usually only eats two meals a day, breakfast and dinner. He has a piece of fruit in the middle of the day. After surgery and extubation, a Cardiac clear liquid diet was ordered for JL. Contrary to what one might think – that any clear liquids would be allowed and could include reduced sodium or sodium free broths, clear fruit juices and clear sodas - the Cardiac clear liquid diet contains no sodium as well as no sugar. Essentially, it provides hydration, but no nutrition and is intended for short term use only. Two days after surgery, JL was placed on a Cardiac 3-4 mg Sodium diet. The Cardiac 3-4 mg Sodium diet is designed to meet the DRIs, carbohydrate, protein and fat needs of most patients. This meal plan limits fat intake to 25-35% of total calories, less than 200mg of cholesterol per day and 3-4mg of sodium per day. It is most often used for those patients who need cholesterol and triglyceride control, management of essential hypertension and cardiovascular disease and those who have had cardiac surgery. (Premier Health Diet Manual, 2014)The first visit with JL, on 9/29, his nurse advised that she had just given him pain meds and he was sleeping. She stated that he had not been interested in eating, but that she would encourage him when he woke up. An assessment of his height, weight, BMI, physical health and reason for admission placed him to a low risk category, providing that his diet advanced. He was on a clear liquid cardiac diet at this time.On the second attempt to visit with JL on 9/30, he was out for physical therapy. He had been advanced to a Cardiac 3-4mg Sodium diet. It was noted in his charts that he was eating less than 50% of his meals. This, combined with no intake for two days prior, place him at moderate nutritional risk. On the third attempt, 9/31, JL was with his doctor. His doctor allowed an interruption. JL stated that he was hungry, but that he had not ordered breakfast. After a few more questions, it was clear that he was unaware that he could order his own breakfast. Instructions about ordering were provided. Apparently that was all that was needed. It was to be noted that all subsequent meals were consumed at 75-100%.Kcal/protein guidelines:At the time of admission, JL was 6’ (182cm) and 216 lbs (98.2kg) with a BMI of 28.57. His energy needs could be met with 25-30 kcal/kg 2455 – 2946 kcal. His protein needs were calculate at 1 – 1.2 g/kg or 98 – 117g per day. This higher protein range was chosen to meet his needs for two reasons: his age and the additional requirement for healing due to his recent surgery. JL should resume his normal diet once he returns home, but should take a few things into consideration. The cardiac catheterization done at the VA showed some mild coronary artery disease. Because of this, JL should monitor his consumption of cholesterol, saturated fats and sodium. The DASH diet (Dietary Approach to Stop Hypertension) would be beneficial for him to follow. JL should aim to limit his sodium to 2300mg/day, while limiting his fat intake to between 25-30% of his total calories. He should aim to limit his saturated fats to less than 7%. (Stump, p. 317)JL does still use tobacco, albeit smokeless. If he cannot quit, he should consider increasing his consumption of Vit C by 35 mg per day in addition to the DRI of 90mg per day. Tobacco use can reduce the amount of Vitamin C that is absorbed. There is evidence that can also reduce the risk of developing the oral cancers which are seen in smokeless tobacco users. (Oral Cancer Foundation, 2015)Prognosis:According to the journal Circulation, “the median survival in patients 65 to 69, 70 to 79, and ≥ 80 years of age undergoing isolated AVR was 13, 9, and 6 years, respectively.” JL is 72 and thus has an estimated life expectancy of at least another 9 years. (Brennan et al., p.1621)JL was very motivated to return to his usual routine after surgery. He was weaned from the vent earlier than planned and was sitting up in his chair the day after surgery. Two days after surgery, he was involved in physical therapy and was walking the halls. JL stated prior to surgery that he was the sole caregiver to his wife and that he would be returning home, not to an extended care facility as was desired by his doctor and his children. JL was discharged on Oct 2, on the 4th post surgical day. He went home with the following medications: Norvasc (a calcium channel blocker, for hypertension), Lipitor (for hyperlipidemia), Norco (for pain control), Lopressor (a beta blocker, for hypertension), Lasix (a diuretic, for hypertension) and Coumadin (an anticoagulant).JL was prescribed 3 medications to control his hypertension – a calcium channel blocker, a beta blocker and a diuretic. Each of them has a different mechanism to control hypertension. Calcium channel blockers block the flow of calcium into veins and arteries, causing relaxation of the blood vessels and a lowering of blood pressure. Beta blockers decrease the force and rate of heart contractions, thereby decreasing blood pressure. Diuretics cause excretion of excess fluids, thus reducing the total blood volume and decreasing blood pressure. (Stump, p. 371). A low calorie, low sodium diet is recommended when taking the beta blockers and calcium channel blockers. (Stump, p. 371) Diuretics can cause potassium depletion, so JL was also prescribed K-Dur, a potassium supplement. JL should also avoid products which contain natural licorice. Natural licorice contains glycyrrhizin which can reduce the effectiveness of anti-hypertensives and diuretics. (Webb, pg. 26)Summary and conclusion:The study of JL allowed me to learn a great deal more about the anatomy and function of the heart. I watched a YouTube video of a valve replacement and was very impressed, although I cringed at the first cut into the aorta. I researched the different medications used in this procedure and learned why JL, who was not diabetic, was given insulin and why he was given Lasix when he did not have excessive fluid buildup. I learned that Diprivan is given in a 10% lipid formula and that any tube feeds should be low fat and any TPN should be given without the lipid piggyback while Diprivan is being administered.Bibliography:Brennan, J.M., Edwards, F.H., Zhao, Y., O'Brien, S.M., Douglas, P.S., Peterson, E.D., (2012). Long-term survival after aortic valve replacement among high-risk elderly patients in the United States: insights from the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 1991 to 2007. Circulation, 126(13),1621-29. Retrieved Oct 11, 2015 from , M., Boon, N., Newby, D., (2012). Calcific aortic stenosis. Journal of the American College of Cardiology. 60(19),1854-1863.Marshall University, (n.d.). Normal lab values. retrieved Oct 12 , 2015 from Clinic, (2015). Aortic valve stenosis: basics and risk-factors. retrieved Oct 11, 2015, from., Boulanger, M., (2014). Basic mechanisms of calcific aortic valve disease. Canadian Journal of Cardiology, 30, 983-993.Premier Health Network. (2014). Premier health diet manual. Franklin, OH:Pronsky, Z., Crowe, J., (2012). Food and medication interactions. Birchrunville, PA: Stump, S.E., (2012). Nutrition and diagnosis-related care. Baltimore, MD: Lippincott, Williams &WilkinsRajamannan, N., Evans, F., Aikawa, E., Grande-Allen, K.J., Demer, L., Heistad, D., Simmons, C., Masters, K., Mathieu, P., O’Brien, K., Schoen, F., Towler, D., Yoganathan, A., Otto, C. (2011). Calcific aortic valve disease: not simply a degenerative process. Circulation.124,1783 – 1791.Spaccarotella, C., Mongiardo, A., Indolfi, C., (2011). Pathophysiology of aortic stenosis and approach to treatment with percutaneous valve implantation. Official Journal of the Japanese Circulation Society. 75, 11-19.The American Heart Association, (2013). Aortic valve stenosis. retrieved Oct 11, 2015, from American Heart Association, (2014). Types of heart valve replacements. retrieved Oct 11, 2015 from Oral Cancer Foundation, (2014). Risk factors. retrieved Oct 13, 2015 from Society of Thoracic Surgeons, (2015). Minimally invasive aortic valve replacement advantageous for some very elderly patients. retrieved Oct 11, 2015 from, A., Alfieri, O., Andreotti, F., Antunes, M., Baro-Esquivias, G., Baumgartner, H., Borger, M.A., Carrel, T., DeBonis, M., Evangelista, A., Falk, V., Iung, B., Lancellotti, P., Pierard, L., Price, S., Schafers, H.J., Schuler, G., Stepinska, J., Swedberg, K., Takkenberg, J., Von Oppell, O., Windecker, S., Zamorano, J.L., Zembala, M. (2012). Guidelines on the management of valvular heart disease. European Heart Journal, 33, 2463 – 2469.Webb, D., (2010). When foods and drugs collide – studies expose interactions between certain foods and medications. Today’s Dietitian. 12(12), 26.Other ResourcesBlitz, A. (2011, June 16). Aortic valve replacement: operative technique. retrieved from HYPERLINK "" \h Academy. (2014, Oct 21). Aortic stenosis and aortic regurgitation. retrieved from, R. (2013, June 4). Aortic stenosis explained clearly [ video file]. retrieved from ................
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