MioAtlas
G3: Prosthetic valves

Aortic bioprosthesis

Aortic valve surgically replaced by a normally functioning bioprosthesis (bovine pericardial or porcine biological tissue mounted on a rigid three-strut frame or stentless).

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Definition

Aortic valve surgically replaced by a normally functioning bioprosthesis (bovine pericardial or porcine biological tissue mounted on a rigid three-strut frame or stentless), characterized by silent biological opening and closure without metallic clicks and a physiological systolic transprosthetic gradient inherent to the prosthetic orifice [V1] [V5] [G23-05] [G23-06].

Severity criteria

  • Severity grade: Single normally functioning grade (Single).
  • According to the recommendations of the ASE 2024 Guideline [V5, Tabla 5] and ASE 2009 [G23-05, Tabla 6]:
    • Peak velocity (Vmax) < 3.0 m/s (typically 2.0–2.6 m/s depending on model and prosthetic size) [V5] [G23-05].
    • Mean transprosthetic aortic gradient < 20 mmHg (frequently 10–18 mmHg) [V5] [G23-05].
    • Doppler velocity index (DVI = VTI lvot / VTIpr) ≥ 0.30 [V5] [G23-05].
    • Normal effective orifice area (EOA) (typically > 1.2 cm²) [V5] [G23-05].
    • Without significant bioprosthetic or periprosthetic regurgitation [V5].

Findings by layer

Hemodynamics

  • Baseline mean systolic transvalvular gradient < 20 mmHg [V5] [G23-05].
  • Normalization of left ventricular afterload and preserved systolic function [V1] [V5].

Rhythm

  • Normal sinus rhythm [V1].

ECG

  • Normal sinus tracing or progressive regression of prior left ventricular hypertrophy [E1].

Heart sounds and murmurs

  • Absence of metallic clicks: Natural muffled biological opening and closure (without mechanical metallic prosthetic opening or closing clicks) [G23-06] [G23-07].
  • Second heart sound (S2): Present and crisp biological-quality aortic component (A2) generated by tissue leaflet coaptation [G23-06] [G1-11].
  • Systolic ejection / flow murmur: Soft mid-systolic ejection murmur of normal prosthetic flow (grade 1–2/6), diamond-shaped, auscultated at the 2nd right intercostal space (aortic area) [G23-06] [G1-14].
  • Normal first heart sound (S1) [G1-10].

Arterial pulse

  • Normal carotid pulse, with adequate upstroke [B4].

Jugular venous pulse

  • Normal jugular venous pulse [B3].

Maneuvers

  • Hemodynamic maneuvers (Valsalva / squatting): Normal physiological response with concordant variation of cardiac output and ejection murmur [B1].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Normal Sinus Rhythm

Also known as: Aortic valve bioprosthesis · Bioprosthetic aortic valve · Biological aortic valve prosthesis · Tissue aortic valve replacement · Aortic bioprosthesis

Other pathologies in this group

Sources

  1. [B1] Bedside diagnosis of systolic murmurs . N Engl J Med (1988) . DOI: 10.1056/NEJM198806163182404 PubMed: 2897627
  2. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  3. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  4. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  5. [G1-10] The First Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250175
  6. [G1-11] The Second Heart Sound . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250183
  7. [G1-14] Systolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250186
  8. [G23-05] Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography . J Am Soc Echocardiogr (2009) . DOI: 10.1016/j.echo.2009.07.013 PubMed: 19733789
  9. [G23-06] Auscultation of the normally functioning prosthetic valve . Ann Intern Med (1981) . DOI: 10.7326/0003-4819-95-5-594 PubMed: 7294551
  10. [G23-07] Valve Academic Research Consortium 3: Updated Endpoint Definitions for Aortic Valve Clinical Research . J Am Coll Cardiol (2021) . DOI: 10.1016/j.jacc.2021.02.038 PubMed: 33888385
  11. [V1] 2025 ESC/EACTS Guidelines for the management of valvular heart disease . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf194 PubMed: 40878295
  12. [V5] Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography . J Am Soc Echocardiogr (2024) . DOI: 10.1016/j.echo.2023.10.004 PubMed: 38182282