DIAGNOSIS AND TREATMENT

Auscultation of the Normally Functioning Prosthetic Valve

NEALE D. SMITH, M.D.; VEENA RAIZADA, M.D.; and JONATHAN ABRAMS, M.D.; Albuquerque, New
Mexico

Before prosthetic function can be adequately assessed,
physicians must be acquainted with the normal acoustic
events associated with these devices. The auscultatory
findings of the most commonly used devices—ball, disk,
porcine, and bileaflet valves—are reviewed. The
mechanisms of sound production and their timing are
discussed.
PROSTHETIC VALVES are associated with distinct auscul-
tatory events that are caused by component motion or
altered flow patterns. The intensity, timing, and character
of these sounds differ with the type of device and also are
affected by the patient's rhythm and hemodynamic
status. These sounds may obscure normal auscultatory
landmarks. Because auscultation can provide valuable in-
formation on prosthetic valve malfunction—such as
thrombosis, incompetence, or obstruction—it is impor-
tant for physicians to be familiar with the normal acous-
tic phenomena associated with these devices (1-4). Most
published reports of prosthetic valve sounds emphasize
phonocardiographic data, which are not always equiva-
lent to clinical auscultation, are often unavailable to the
clinician, and require special interpretive skills. Because
of the variety of prosthetic valves and their widespread
use, a review of the typical acoustic findings associated
with normally functioning prosthetic valves is needed.
The second heart sound (S2) signals the end of ven-
tricular systole and is associated with deceleration of the
blood mass within the great vessels as the semilunar valve
cusps abruptly close. It consists of two components: an
aortic sound ( A 2 ) that coincides with the incisura of the
central aortic pressure pulse, and a pulmonic component
(P2) that follows A 2 and coincides with the pulmonary
artery incisura. Inspiration increases the interval between
A2 and P2 by increasing pulmonary vascular capacitance
and prolonging right ventricular ejection time ( 7 ) . The
opening of the mitral and tricuspid valves, as with the
semilunar valve opening, is not normally audible.
Acoustic Characteristics of Prosthetic Devices
The characteristics of the four major prosthetic valve
types are listed in Figure 2; these valves are illustrated in
Figure 3.
BALL V A L V E S
Ball valves (Starr-Edwards, Smeloff-Cutter, and
McGovern) have easily audible opening and closing
sounds (Figure 4) that coincide with the maximum ex-

Mechanism of Producing Normal Heart Sounds

For optimal analysis of the auscultatory events associ-
ated with a cardiac prosthesis, reviewing the temporal
relations and hemodynamic accompaniments of normal
heart sounds is helpful (Figure 1). Sudden acceleration
and deceleration of the blood column during the cardiac
cycle produces vibrations within the central vascular
compartment that are appreciated as acoustic events; the
actual pressure crossover responsible for changes in flow
occurs before the associated acoustic events ( 5 ) .
The first heart sound ( S I ) occurs during atrioventricu-
lar valve closure and ends before semilunar valve open-
ing. It is best heard between the lower left sternal border
and apex and precedes the carotid pulse upstroke. The
opening of the semilunar valves is acoustically silent un-
less they are congenitally stenotic or unless the pulmo-
nary artery or aorta is dilated. In such situations, SI may
be followed from 0.04 to 0.10 second by an audible ejec-
tion sound that coincides with maximal doming of the
stenotic valve or anacrotic notch of the carotid or pulmo-
nary artery pulse tracing, respectively ( 6 ) . Figure 1 . Relation between hemodynamic events, acoustic events,
and the apex cardiogram. LV = left ventricle; LA = left atrium;
• From the Department of Medicine, The University of New Mexico; Albuquer- S I = first heart sound; S2 = second heart sound; AO = aortic
que, N e w Mexico. valve opening sound.

594 Annals of Internal Medicine. 1981;95:594-598. © 1981 American College of Physicians

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 Figure 2. Summary of the acoustic characteristics of each valve prosthesis according to type and location. SEM = systolic ejection murmur;
DM = diastolic murmur; S I = first heart sound; S2 = second heart sound; P2 = pulmonic second sound; A2 = aortic second sound;
AO = aortic valve opening sound; AC = aortic valve closure sound; MO = mitral valve opening sound; MC = mitral valve closure sound.

cursion of the ball and its subsequent seating, respective-
ly. These are distinct, high pitched, prominent, and easily
distinguishable from normal cardiac sounds. These
sounds can be quite loud, depending on the prosthetic
model and the composition of the ball.
Mitral Valves: The mitral valve is probably the most
extensively studied prosthetic valve (8-14). A very prom-
inent opening click of the mitral prosthesis follows A2 by
0.07 to 0.11 seconds and occurs at the nadir or 0 point of
the apexcardiogram (8). The interval between A2 and
opening of the valve is similar in duration to the A2
opening snap interval of moderate mitral stenosis. It is
appreciated best at the cardiac apex. The mitral valve
opening transient is typically louder than the mitral clo-
sure sound that coincides with and typically obscures SI.
It is appreciated best at the lower left sternal border. The
interval from A2 to the opening of the mitral valve differs
only minimally from beat to beat even with atrial fibrilla-
tion (9), but a long preceding R-R interval may decrease
the intensity of the prosthetic opening sound (10). Nar-
rowing of this interval to less than 0.05 second suggests
prosthetic obstruction or severe mitral regurgitation,
whereas prolongation to greater than 0.17 second or a
beat-to-beat alteration of the interval suggests abnormal
interference with poppet excursion (11, 12).
The mitral closure sound may diminish in intensity
during first-degree heart block or with long R-R inter-
vals, when the poppet already may have assumed a closed
position before left ventricular isovolumic systole (13). A
single prosthetic closure sound without an opening sound
may be heard when the poppet fails to open after a pre-
mature beat, only to subsequently drift silently open dur-
ing the next diastole and be closed forcibly by the next
ventricular contraction (14). The second heart sound is
unchanged in subjects with a mitral prosthesis that is
functioning normally. A sound may be recorded, but is
not often heard, 0.04 to 0.13 second after mitral opening
that coincides with the rapid filling wave of the apexcar-
diogram and probably represents a ventricular gallop
(8).
An apical early- to mid-systolic murmur is commonly
heard at the lower left sternal border, but the presence of
an apical diastolic murmur is abnormal and suggests
prosthetic dysfunction or obstruction (9, 12). The systol-
ic murmur does not represent mitral regurgitation and
may be caused by turbulence produced by the projection
of the rigid prosthesis cage into the left ventricular out-
flow tract.
Aortic Valves: The aortic ball valve produces a loud
opening click that is distinct from the first component of
SI and separated from it by an average of 0.07 second
(14, 15). At the time of left ventricular and aorta pres-
sure crossover, the ball proceeds to the apex of the cage.
It may remain there or assume a mid-cage position for
the duration of systole, where it may be associated with
the production of multiple systolic clicks (16). Early
ventricular ectopic beats may not open the aortic valve,
whereas a late ventricular ectopic beat may be associated
with both an aortic opening and aortic closure sound. A
low cardiac output may result in a reduction in prosthetic
sound intensity, whereas tachycardia or anemia may in-
crease the intensity of both sounds. The aortic opening
sound is best appreciated at the apex or lower left sternal
border and usually transmits widely. The aortic closure
sound is less prominent but also radiates widely. It pre-
cedes P2 and inspiratory widening of these two sounds is
usually maintained; but paradoxical splitting may occur
with coronary artery disease, poor left ventricular func-
Smith eta/. • Auscultation of Prosthetic Valves 595

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Figure 3. The common prosthetic valve types: ball and cage, disk,
porcine, and bivalve.
tion, or left bundle branch block. The normal amplitude
ratio of aortic opening sound to closing sound by phono-
cardiography is greater than 0.5; a clinically useful sign
of ball valve dysfunction is a reduction of this ratio or
absence of an appreciable aortic opening sound (17).
A grade 2 to 3/6 early descrescendo or systolic ejection
murmur is usually present, which typically radiates to
the carotids where a shudder may be palpated (8). The
systolic murmur can be quite harsh and may increase in
intensity when the stroke volume is augmented, such as
during hemolytic states, anxiety, or tachycardia. It is
probably due to turbulence, a persistent transvalvular
gradient, or both. A diastolic murmur is not normally
present.
interval between A2 and the opening of this valve is
short, 0.05 to 0.09 second (20). A prominent mitral clo-
sure sound is noted at the apex, but after a long R-R
interval. With left ventricular dysfunction or first degree
heart block, the disk may seat early, resulting in a softer
or even absent closing sound. The closure sound may also
decrease in intensity or may be absent if disk movement
is hindered by fibrosis or thrombosis (1, 3, 21). A grade
2/6 early to mid-systolic low frequency ejection murmur
is usually heard, and in one study 14 of 20 patients had a
recordable diastolic murmur (20). Similar to other nor-
mally functioning prosthetic valves, these valves have ori-
fice areas that are one half to one third the area of a
normal orifice. The resulting turbulent blood flow across
the open valve may be responsible for the audible diastol-
ic murmur. Systolic murmurs associated with a mitral
disk prosthesis may be due to mechanisms similar to
those responsible for producing systolic murmurs with
the ball valve prosthesis.
Aortic Valves: In contrast to ball valves, the opening of
a disk valve in the aortic position is not commonly heard
with the stethoscope. It can often be recorded on a pho-
nocardiogram, and it follows Ml by 0.04 second (18).
Disk valves produce distinct, audible closing sounds that
SE AV

DISK V A L V E S
Although the central occluder type of disk valves
(Beall-Surgitool) produce an audible opening sound, the
more commonly used tilting disk valves (Lillihei-Kaster,
Bjork-Shiley) do not (18). As the lightweight disk
swings open in the latter, it does not forcefully strike any
resonant structure: therefore, an opening sound is not
generated. However, both types produce distinct closing
sounds; absence of these sounds during sinus rhythm is
distinctly abnormal (19, 20). The onset of valve closure
coincides with the major component of a tilting disk clos-
ing sound, whereas the disk seating causes this sound in
the nontilting style disk prosthesis (18, 21). Disk valve
sounds tend to be clicking in nature, distinct and of high
frequency. They are less prominent than those produced
by a ball valve.
Mitral Valves: Although phonocardiograms consis-
tently record a prosthetic opening sound at the apex or Figure 4 . Simultaneous carotid pulse tracing, phonocardiogram,
lower left sternal border in patients with a tilting disk and electrocardiogram (ecg) with a ball and cage valve in the aortic
position. M l = mitral valve opening sound; AO = aortic prosthesis
valve, it is rarely heard by auscultation. Because this opening sound; AC = aortic prosthesis closure sound; MA = mitral
sound is associated with the onset of disk motion, the area; and MF = medium frequency.

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 are initiated by disk closing, as shown by echocardiogra-
phy (20). Absence or diminution in the character of the
aortic closure sound may indicate inhibition of disk mo-
tion by a thrombus or can be caused by poor left ventric-
ular function (19). A basal early- to mid-systolic ejection
murmur is commonly heard in patients with an aortic
disk prosthesis. Occasionally, a soft diastolic murmur is
also noted (22), However, significant valvular insufficien-
cy may exist in this or any prosthetic device even in the
absence of an audible murmur.
TISSUE VALVES
The opening of a porcine aortic valve (Hancock, Car-
pentier-Edwards) is associated with an acoustic event
that follows the pressure rise in the downstream cham-
ber. This association suggests that the sound does not
originate from the chamber but from the abrupt halting
of the opening motion of the leaflets (23, 24). Audible
closing sounds occur at the time of leaflet coaptation and
may be due to deceleration of the blood column or to
contact between the leaflets themselves (24). Porcine
opening and closing sounds are crisp and high pitched,
yet typically much less prominent than those produced
by mechanical devices.
Mitral Valves: A mitral opening sound transient is de-
tected by auscultation in approximately one-half of the
patients. The interval from A2 to opening of the valve
ranges from 0.07 to 0.11 second and when heard, it is
appreciated best at the apex (25). The porcine mitral
prosthetic closing sound is audible in most patients at the
lower left sternal border, although it is less prominent
than sounds produced by the metallic valves and blends
with SI. Apical diastolic rumbling murmurs are present
in one half to two thirds of patients and bear no relation
to the patient's functional class, the valve size, or hemo-
dynamic state (26, 27). The subject may have to be
turned to the left lateral decubitus position to appreciate
this murmur. Apical mid-systolic murmurs that increase
with amyl nitrate can be heard in one half to two thirds
of patients with porcine mitral valves (1). Mechanisms
responsible for murmur production include altered reso-
nating properties of the cusps due to gluteraldehyde pres-
ervation (28, 29), plasma coating (30), or structural
change within the leaflets; the presence of a flexible reso-
nating stent; or turbulence in left ventricular outflow
track, aorta, or left ventricle (24). A new diastolic mur-
mur, a change in the character of a murmur, or an in-
crease in the systolic murmur may indicate prosthetic
dysfunction due to tissue degeneration, infection, throm-
bosis, or suture disruption.
Aortic Valves: The aortic closing sounds are audible in
most patients with porcine aortic valves, although an
opening sound is not usually heard (24). The aortic clos-
ing sounds are prominent, discrete, and best heard at the
aortic and pulmonic areas. The aortic opening sound fol-
lows mitral valve closure by 0.03 to 0.09 second (24). A
high frequency, grade 2/6 early to mid-systolic murmur
is located at the lower left sternal border. No diastolic
murmur should be present with this prosthesis in the aor-
tic position.
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BIVALVE PROSTHESIS
Few auscultatory reports have been published about
the acoustic characteristics of the St. Jude's valve (Figure
3). In the aortic position this valve produces a distinct
opening sound after the maximum opening of the valve
leaflets; this suggests that the sound is not produced by
the leaflets themselves but by turbulent flow (30). A
prominent, high pitched, metallic closing sound coincides
with leaflet closure and the dicrotic notch of the carotid
pulse tracing (29). This suggests a leaflet origin of the
sound. No diastolic murmur is audible and only an occa-
sional soft early systolic murmur can be detected in pa-
tients with an aortic prosthesis. We have had insufficient
experience with this valve in the mitral position and no
data have been reported on its acoustic characteristics.
Discussion
All prosthetic valves produce alterations in the normal
laminar pattern of blood flow, and all have a significantly
smaller orifice than normal native valves. These devices
are implanted in patients with abnormal cardiovascular
systems that often possess significant residual abnormali-
ties of function such as pulmonary hypertension, ventric-
ular hypertrophy, and ventricular dysfunction. Also, sig-
nificant abnormalities of cardiac rate and rhythm may be
present. The prosthesis sounds themselves may camou-
flage the appreciation of normal acoustic events. It is in
such settings that prosthetic function must be evaluated.
In addition, significant valvular dysfunction may occur
without audible changes. Nonetheless, familiarity with
the characteristics of normal prostheses and careful aus-
cultation can help the physician make important clinical
assessments on prosthetic function in these complex pa-
tients.
• Requests for reprints should be addressed to Neale D. Smith, M.D.; De-
partment of Medicine, Cardiology Division, The University of New Mexico;
Albuquerque, NM 87131.
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