MioAtlas
G3: Prosthetic valves

Mechanical mitral valve prosthesis

Mitral valve replaced by a normally functioning mechanical prosthesis (pyrolytic bileaflet).

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Definition

Mitral valve replaced by a normally functioning mechanical prosthesis (pyrolytic bileaflet), characterized by a loud, metallic mechanical first heart sound (closing click), a metallic opening click following the second heart sound, and a laminar transprosthetic mean diastolic gradient within physiological limits [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 6] and ASE 2009 [G23-05, Tabla 8]:
    • Peak velocity (Vmax) < 1.9–2.0 m/s [V5] [G23-05].
    • Mean mitral transprosthetic gradient ≤ 5–6 mmHg (frequently 3–5 mmHg at normal baseline rate) [V5] [G23-05].
    • Doppler velocity index ratio (DVI = VTIpr / VTI lvot) < 2.2 [V5] [G23-05].
    • Pressure half-time (PHT) < 130 ms [V5] [G23-05].
    • Normal effective orifice area (EOA) (typically ≥ 1.7–2.0 cm²) [V5] [G23-05].
    • Without pathological transvalvular or paravalvular regurgitation [V5].

Findings by layer

Hemodynamics

  • Mean diastolic transprosthetic gradient ≤ 5 mmHg [V5] [G23-05].
  • Mean pulmonary capillary wedge pressure and left cavitary pressures normal or mildly elevated if previous atrial stiffness persists [V5] [G23-05].

Rhythm

  • Normal sinus rhythm or atrial fibrillation frequent as sequela of prior left atrial remodeling [V1] [G23-05].

ECG

  • Sinus rhythm or atrial fibrillation; possible signs of residual left atrial enlargement [E1].

Heart sounds and murmurs

  • Mechanical closing click (S1): First heart sound replaced by a very loud, sharp, crisp, high-frequency metallic click, auscultated with maximum intensity at the apex and radiating to the entire precordium [G23-06] [G23-07].
  • Mechanical opening click: High-frequency metallic opening click auscultated immediately after the A2 component of the second heart sound (at the moment pyrolytic discs tilt open into the LV cavity) [G23-06] [G23-07].
  • Diastolic flow murmur / rumble: Possible minimal, soft diastolic rumble (grade 1/6) produced by laminar flow across the prosthetic orifice [G23-06] [G1-15].
  • Second heart sound (S2): Preserved native biological A2 and P2 components [G1-11].

Arterial pulse

  • Normal peripheral arterial pulse [B4].

Jugular venous pulse

  • Normal jugular venous pulse [B3].

Maneuvers

  • Exercise / Increased heart rate: Moderately increases mean transprosthetic gradient due to reduction in diastolic filling time, while clicks remain sharp [G23-05].

Simulator severity grades

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

Also known as: Mechanical mitral valve prosthesis · Mechanical mitral valve · Mitral valve mechanical replacement · Bileaflet mechanical mitral valve · Mitral mechanical prosthesis

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. [G1-15] Diastolic Murmurs . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250187
  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