Premature closure of prosthetic mitral valves as a consequence of gravity

To determine the influence of gravity on premature closure of prosthetic mitral valves, we studied 17 patients in whom this phenomenon had been observed during routine examination. All patients were in atrial fibrillation and none had aortic incompetence. Patients were studied in multiple positions by means of simultaneous echocardiography, phonocardiography, and cinefluoroscopy. In all patients premature closure was observed when the atrial side of the prosthesis was below the ventricular side, resulting in a downward motion of the occluder inside the valve cage. When patients were studied in positions in which the atrial side of the valve was higher that the ventricular side, premature closure never occurred, even during extremely prolonged diastolic periods. Since minor positional changes, which were found to determine whether premature closure occurred or not, are unlikely to produce significant alterations in pressure and flow across the mitral orifice during diastole, we conclude that position-dependent premature closure of prosthetic mitral valves in patients with atrial fibrillation is best explained by the effect of gravity on the prosthetic occluder. Examination of such patients in multiple positions should be helpful in distinguishing premature valve closure caused by aortic regurgitation from gravity-related presystolic closure. Inability to produce premature closure in patients in whom it had previously been demonstrated in the presence of similar R-R intervals may even prove useful in diagnosing new orifice obstruction.