How do you document the sound of an aortic valve replacement?

Documenting the Sound of an Aortic Valve Replacement

The mechanical clicks of an aortic valve replacement should be documented by noting their presence, intensity, and timing (opening and closing clicks), as these are critical diagnostic indicators of proper valve function.

Normal Valve Sounds and Their Documentation

Mechanical Valves

• Document the presence of both opening and closing clicks
• Note the intensity of clicks (clear, muffled, or absent)
• Record timing in relation to the cardiac cycle:
  • Opening click: early systole for aortic valves
  • Closing click: early diastole for aortic valves
• Document any changes from previous examinations

Bioprosthetic Valves

• Document the presence or absence of clicks (typically softer than mechanical valves)
• Note any abnormal sounds (murmurs) that may indicate valve dysfunction
• Document the quality of the first and second heart sounds

Echocardiographic Correlation

When documenting valve sounds, correlate with echocardiographic findings 1:

• On spectral Doppler: Document clicks as brief, intense signals
  • Use continuous wave Doppler (CWD) for aortic valve clicks
  • Use pulsed wave Doppler (PWD) for mitral valve clicks
• On M-mode: Document normal opening and closure of valve leaflets
• For mechanical valves: Document the opening angle (approximately 85° for St. Jude valves) and closing angle (25-30° depending on valve size) 2

Comprehensive Documentation Format

A complete documentation of aortic valve replacement sounds should include:

1. Valve type and position:

   • "St. Jude mechanical aortic valve replacement" or "Magna Ease bioprosthetic aortic valve"

2. Click characteristics:

   • "Normal, crisp opening and closing clicks heard at the right upper sternal border"
   • "Muffled closing click with normal opening click"
   • "Absent opening click, concerning for valve dysfunction"

3. Associated findings:

   • "No murmurs or abnormal sounds"
   • "Early diastolic murmur consistent with paravalvular leak"
   • "Mid-systolic murmur suggesting valve stenosis"

4. Correlation with imaging:

   • "Clicks correlate with normal leaflet motion on echocardiography"
   • "Reduced intensity of clicks corresponds with limited leaflet excursion on echo"

Special Considerations

Mechanical vs. Bioprosthetic Valves

• Mechanical valves (like St. Jude) produce louder, more distinct clicks than bioprosthetic valves 3
• The intensity of mechanical valve sounds varies by valve type - St. Jude valves (44.1 ± 4.4 dB) are typically quieter than Björk-Shiley valves (55.4 ± 1.2 dB) 3

Warning Signs to Document

• Absence or muffling of previously documented clicks may indicate valve thrombosis, pannus formation, or other dysfunction 2
• New murmurs should be carefully documented with timing, location, radiation, and intensity
• Changes in click intensity or timing compared to previous examinations

Pitfalls to Avoid

1. Failure to document baseline sounds - Always document valve sounds at the first post-operative visit to establish a baseline for future comparison

2. Inadequate description - Simply noting "normal valve sounds" is insufficient; document specific characteristics of clicks

3. Missing paravalvular leaks - Document any diastolic murmurs that may indicate paravalvular regurgitation, which occurs in up to 17% of TAVR cases 1

4. Overlooking changes - Compare current findings with previous documentation to detect subtle changes in valve function

By following this structured approach to documenting aortic valve replacement sounds, clinicians can effectively monitor valve function and detect early signs of valve dysfunction, which is critical for preventing morbidity and mortality related to prosthetic valve complications.