CARDIOVASCULAR
Intraoperative and Postoperative Evaluation of
Cavitation in Mechanical Heart Valve Patients
Tina S. Andersen, MD, Peter Johansen, PhD, Bekka O. Christensen, MD,
Peter K. Paulsen, DMSc, Hans Nygaard, DMSc, and J. Michael Hasenkam, DMSc
Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby Sygehus, Aarhus, Denmark
Background. Cavitation has been claimed partly re-
sponsible for the increased risk of thromboembolic com-
plications, hemolysis, and fatal valve failure seen in
mechanical heart valve patients. In vivo studies have
investigated cavitation using high-pass filtering of the
high-frequency pressure fluctuations with the root mean
square values as an assessment of intensities. In vitro
studies have shown that this well-known method may
not be ideal owing to loss of data as a consequence of
filtering, and because it requires a priori knowledge of
the valve resonance pattern. Therefore, a new method has
been developed, which decomposes the signal into non-
deterministic (cavitation) and deterministic (valve reso-
nance) signal components, and hence decreases data loss.
This study aimed to evaluate cavitation in patients with
mechanical, biological, and native heart valves both intra-
operatively and postoperatively using the new method.
Methods. High-frequency pressure fluctuations were
P atients with mechanical heart valves have greater risk
of thromboembolic complications and anticoagu-
lant-related bleedings than patients with biological coun-
terparts. A possible explanation for this difference could
be cavitation. In vitro studies using high-speed visualiza-
tion techniques in transparent fluids have shown this
phenomenon to occur in the vicinity of the mechanical
valves, but not in biological valves, or native valves [1, 2].
Cavitation bubble implosion release significant amount
of energy that may impinge on the vessel wall [2], nearby
blood cells, or the valve material and cause severe
damage to these structures [3].
Cavitation could explain the microcracking and ero-
sions found at explanted mechanical heart valves [4], and
may also explain some of the clinical reports on valve
failure and leaflet escape [5]. This kind of damage is also
known from ship propellers, dam outlets, and steel
turbines where cavitation is a well-known phenomenon
that has significant damage potential [6]. Therefore, cav-
itation could be a significant contributor to the observed
differences in thrombogenicity between mechanical and
biological prostheses [79]. The destruction of the blood
Accepted for publication June 7, 2005.
Address correspondence to Dr Hasenkam, Department of Cardiothoracic
and Vascular Surgery, Aarhus University Hospital, Skejby Sygehus,
Brendstrupgaardsvej, 8200 Aarhus N, Denmark; e-mail: hasenkam@
ki.au.dk.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
measured by a hydrophone intraoperatively and postop-
eratively in 14 patients with mechanical valves, 10 pa-
tients with normal aortic valves, and 5 patients with
bioprosthesis. The total signal energy was evaluated as
nondeterministic and deterministic energies.
Results. Nondeterministic energies were verified both
intraoperatively and postoperatively in all patients who
had a mechanical valve; this finding confirms the cavita-
tion potential of mechanical valves. None of the data
recorded in patients with bioprosthetic or native valves
contained nondeterministic energy.
Conclusions. The study confirms the presence of cavita-
tion in mechanical heart valve patients using the nondeter-
ministic energy of high-frequency pressure fluctuations as a
quantitative measure of cavitation both intraoperatively
and postoperatively.
(Ann Thorac Surg 2006;81:34 41)
2006 by The Society of Thoracic Surgeons
cells mediated by cavitation bubble implosion can acti-
vate the coagulation cascade where especially the release
of tissue factor has been found to be an important
initiator for thromboembolic complications [10].
The visualization methods used in vitro (for example,
Graf and associates [2]) are obviously not applicable in
vivo. Therefore, Garrison and coworkers [11] developed a
method based on the property that noise generation at
cavitation implosion can be measured acoustically as
high-frequency pressure fluctuations (HFPF). They found
that the acoustic signal was composed of the valve-
closing sound (less than 35 kHz) and transient pressure
spikes (above 35 kHz) that corresponded with cavitation
bubble formation and implosion visualized in vitro.
Therefore, these investigators [11] high-pass (HP) filtered
the signal at 35 kHz to extract the valve-closing sound
from the cavitation signal. They also found a correlation
between the root mean square of the HP-filtered signal
and hemolysis. Their method was subsequently used in
other studies (for example, Paulsen and colleagues [7],
Andersen and colleagues [8], and Zapanta and associates
[12]). However, we recently found that the different valve
designs had different closing-sound characteristics [13],
which for some valve types showed frequencies above
the previously used 35 kHz [11]. Therefore, HP-filtering
of the data requires a valve-dependent cut-off frequency
to ensure that the closing sound is removed completely
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.06.080
Ann Thorac Surg
2006;81:34 41
and to ensure that some of the cavitation signal is not
filtered away. Recently, we developed a signal analysis
method [14] to distinguish between the cavitation signal
components and the closing sound without using a HP
filter. The method is based on the cavitation bubble
implosion creating random or nondeterministic pres-
sure fluctuations [15]. By comparing the previously
used HP-filtered root mean square values [11] to the
nondeterministic energy extraction, we found a high
correlation between the two methods. Hence, using the
nondeterministic energy extraction method, an alter-
native method has been developed where bandwidth
limitation is avoided and knowledge of the valve-
dependant cut-off frequency is not needed. The method
has been tested in animal studies [16], which support the
use of this method as an alternative to the previously
used method.
From a practical clinical point of view, it would be ideal
if cavitation could be assessed by noninvasive means.
Therefore, we have also developed a new transducer
design that enables recordings of HFPF on the precordial
skin.
We hypothesize that the nondeterministic energy can
be used in humans as a quantitative measure of cavita-
tion both intraoperatively and postoperatively.
The aim of this study was to evaluate cavitation inten-
sities in mechanical heart valve patients intraoperatively
and postoperatively using the nondeterministic charac-
teristics of the HFPF generated during valve closure
compared with biological and native heart valves.
Patients and Methods
The study comprised 29 patients (22 men and 7 women;
average age 67 years). The patients were divided into
three subgroups: (1) 14 with aortic St. Jude Medical
valves; (2) 5 with aortic Carpentier-Edwards pericardial
bioprosthesis; and (3) 10 who underwent coronary artery
bypass surgery (CABG). Preoperatively all CABG pa-
tients had normal aortic and mitral valves verified by
echocardiography. Inclusion criteria were age greater
than 18 years, patient scheduled for elective heart valve
surgery or CABG, and patient giving consent (oral and
written). Exclusion criteria were hemodynamic unstabil-
ity, implantation of composite grafts required, implanta-
tion of double valve prostheses, and coronary bypass
surgery performed as a beating-heart procedure.
The HFPF was measured intraoperatively and postop-
eratively using a miniature hydrophone (type 8103; Brel
& Kjr, Nrum, Denmark) with an upper frequency
limit of 150 kHz. The hydrophone was connected to a
preamplifier (type 2635; Brel & Kjr) with a built-in HP
filter at 20 Hz. Data were stored on a computer equipped
with a data acquisition card (AT-MIO16-E2; National
Instruments, Austin, Texas) at a sampling rate of 500 kHz.
Data acquisition and off-line signal analysis were accom-
plished using a custom-made program developed in
LabVIEW 6.0i (National Instruments). The recorded sig-
nals were visualized on-line using an oscilloscope (type
PM 3305; Phillips, Einthoven, Holland).
ANDERSEN ET AL 35
CARDIOVASCULAR
CAVITATION EVALUATION IN VIVO
The intraoperative measurements were performed
when the patient had been hemodynamically stable for at
least 2 minutes after being weaned from cardiopulmo-
nary bypass. The sterilized hydrophone was placed
near the aortic annulus at the low aorticleft atrial junc-
tion, and data were acquired for approximately 30 sec-
onds, while registering blood pressure, heart rate, cardiac
output, blood gases (pO2 and pCO2). Ejection fractions
were registered from the preoperatively performed
echocardiography.
On the fourth postoperative day, the hydrophone was
placed in a custom-made water-filled chamber and
placed on the precordium in the left fourth intercostal
space close to the sternum. This location has previously
been shown to be the optimal position for mechanical
aortic heart valve sound recordings [17]. The measure-
ments were performed with the patients in supine posi-
tion. Arterial blood pressure brachial cuff and pulse were
recorded.
As the aim was primarily to reconfirm the findings
obtained by Paulsen and colleagues [7] and additionally
to investigate whether it was possible to perform nonin-
vasive measurements, a preoperative measurement was
not performed.
The study was approved by the local Ethical Commit-
tee and complied with the Helsinki II declaration.
Data Analysis
The intraoperative data were analyzed for all 29. Postop-
erative data were not obtained for all the included
patients owing to equipment failure (2 for mechanical
and 2 for native valves), and postoperative complications,
namely, confusion and intensive care unit admission (2
for mechanical, 1 for bioprosthetic, and 1 for native
valves). Therefore, postoperative data were analyzed for
only 21 patients (10 mechanical, 4 biological, and 7 native
valves). This group comprised 15 men and 6 women
(average age 66 years). Thirty seconds of continuous
recorded data were analyzed off-line using LabVIEW 6.0i
(National Instruments). Cavitation was quantified based
on recorded pressure signatures and the method devel-
oped by Johansen and associates [14], which entails
separation of the HFPF signal into deterministic and
nondeterministic components. Motivated by the assump-
tion that the acoustic signal from cavitation is stochastic
(random) [15], the nondeterministic component should
primarily contain signal originating from cavitation, and
the deterministic component originating primarily from
the valve-closing sound. The method first calculates the
ensemble averaged component in a time domain of 30
consecutive closing sounds. Because each closing sound
is within a very short time window, it is necessary to
exactly line up the data before averaging. This lining up
is done by cross correlating every heart cycle with a
chosen template. Using the time variable in the cross
correlation enables temporal line up with reference to the
chosen template. When the ensemble averaged time
domain signal is calculated, the energy density spectrum
is deduced to derive the deterministic signal energy,
which originates from the valve-closing sound. The next
 36 ANDERSEN ET AL
CARDIOVASCULAR
CAVITATION EVALUATION IN VIVO
Fig 1. The total energy content in the signal
recorded intraoperatively in a mechanical
heart valve patient with frequencies (Hz) on
the x-axis and signal energy density (Pa2 . s)
on the y-axis. The graph on the left shows
logarithmic scale and the graph on the right
shows linear scale.
step is calculating the mean energy density spectrum
from each single closing event. The energy is calculated
in the same way as for the ensemble averaged signal.
That leads to the total signal energy, which is the sum of
the deterministic and nondeterministic energy. By sub-
tracting the deterministic energy from the total energy,
the nondeterministic (approximate cavitation parameter)
energy can be deduced.
Results
In all the mechanical heart valve measurements, both
intraoperative and postoperative HFPF were found. The
total energy content in the intraoperatively recorded
signal for one mechanical heart valve is shown in Figure 1.
It is seen that the signal contains a considerable amount
of energy within the hydrophones frequency range (20
Hz to 150 kHz). The total energy consists of the nonde-
terministic energy (Fig 2A) and the deterministic energy
(Fig 2B). The Figures show that the signal comprise
nondeterministic energy in the entire frequency range.
The deterministic energy mostly dominates frequencies
below 75 kHz with a gradual decrease in upper frequency
energy and energies with generally lower amplitude
compared with the nondeterministic energy.
In Figure 3, the total energy content for the same
mechanical valve is shown postoperatively. Figure 4
shows the nondeterministic (Fig 4A) and the determinis-
tic (Fig 4B) energies contained in the signal. The signal
contains a greater amount of nondeterministic than de-
terministic energy in the high frequencies. The nonde-
terministic energy representative for cavitation ranges
interoperatively (Fig 5) from approximately 345 Pa2 to
approximately 16,090 Pa2, with a median value of 6720
Pa2. The postoperative nondeterministic (Fig 5) energy
varied between 1.33 Pa2 and 39.3 Pa2, with a median value
of 6.22 Pa2. None of the data obtained from bioprosthetic
or native valves contained HFPF either intraoperatively
Ann Thorac Surg
2006;81:34 41
or postoperatively. The intraoperative noise floor for the
two control groups (Fig 5) was between 0.77 Pa2 and 10.76
Pa2, with a median value of 2.40 Pa2 for bioprosthetic
valves; and between 0.76 Pa2 and 6.92 Pa2, with a median
value of 2.80 Pa2 for native valves. The postoperative (Fig 5)
noise floor was between 0.006 Pa2 and 0.15 Pa2, with a
median value of 0.06 Pa2 for bioprosthetic valves; and
between 0.004 Pa2 and 0.01 Pa2, with a median value of
0.008 Pa2 for native valves.
Hemodynamic parameters (cardiac output, heart rate,
pO2, pCO2, blood pressure, and ejection fraction) are
shown in Tables 1 and 2. No apparent relation was found
between nondeterministic energies and cardiac output,
heart rate, pO2, pCO2, blood pressure, or ejection frac-
tion; blood pressure and heart rate in the postoperative
data collection setting did not show any relation either.
Valve sizes were compared against the intraoperative
nondeterministic and deterministic values for the me-
chanical valves, but no clear relation was found.
Comment
Thromboembolic complications in mechanical heart
valve patients are the most frequent cause of complica-
tions for heart valve replacement. Especially young pa-
tients with a long life expectancy may face significant
additive risk over several years; therefore, cavitation as a
potential contributor to thromboembolism should be
investigated. Samboe and colleagues [10] showed that
thromboembolic complication may be caused by release
of tissue factor. Our own studies have supported these
findings by demonstrating hypercoagulability caused by
cavitation [16]. As cavitation bubble implosion is known
to release high energies, it may be assumed that the
energies will be able to destroy the blood components
and hence activate the coagulation cascade. Therefore,
it seems plausible that thromboembolic complications
Ann Thorac Surg
2006;81:34 41
in mechanical heart valve patients canat least par-
tiallybe attributed to cavitation.
Using the deterministic/nondeterministic decomposi-
tion method to separate the closing sound from cavita-
tion has the advantage that it does not require valve
specific HP filtering, as in the previously used method
[11, 13]. Furthermore, there is no bandwidth limitation
introduced as a consequence of filtering.
The present study verified that the signal recorded in
all mechanical heart valve patients contained nondeter-
ministic energies in the entire frequency range and only
deterministic energies in the lower frequency ranges.
This finding is in accordance with previous studies
where the valve-closing sound has been found to be
present in the lower frequencies; therefore, these find-
ings support that the deterministic energies can be
used as an expression of the valve-closing sound in
vivo, and the nondeterministic energies used for cavi-
tation monitoring. The HP-filtered HFPF and the non-
ANDERSEN ET AL 37
CARDIOVASCULAR
CAVITATION EVALUATION IN VIVO
Fig 2. The (A) nondeterministic and (B) de-
terministic content in the signal recorded in-
traoperatively in a mechanical heart valve
patient with frequencies (Hz) on the x-axis
and signal energy density (Pa2 . s) on the
y-axis. The graph on the left shows logarith-
mic scale and the graph on the right shows
linear scale.
deterministic energy are not a definite proof of ca-
vitation. However, in vitro studies [1] have since
demonstrated that root mean square values of HFPF
are a good assessment of cavitation intensities assessed
by high-speed visualization techniques. They support
our assumption that nondeterministic energies are an
expression of cavitation.
In Figures 1 and 2, it is seen that the intraoperative
measurements appear to pick up signal at higher
frequencies than the postoperative measurements
(Figs 3 and 4), and the difference between the median
values in the two setups indicate a difference in mag-
nitude of the recorded signal. However, it was ex-
pected that an attenuation of the higher frequencies
would take place in the postoperative situation, as
tissue and bone situated between the transducer and
the valve entail low-pass filtering of the signal [19 21].
Anyway, this method still seems capable of detecting
pressure fluctuations with an acceptable signal-to-
 38 ANDERSEN ET AL Ann Thorac Surg
CARDIOVASCULAR

CAVITATION EVALUATION IN VIVO 2006;81:34 41

Fig 3. The total energy content in the signal

recorded postoperatively in a mechanical
heart valve patient with frequencies (Hz) on
the x-axis and signal energy density (Pa2 . s)
on the y-axis. The graph on the left shows
logarithmic scale and the graph on the right
shows linear scale.

Fig 4. The (A) nondeterministic and (B) de-

terministic content in the signal recorded in-
traoperatively in a mechanical heart valve
patient with frequencies (Hz) on the x-axis
and signal energy density (Pa2 . s) on the
y-axis. The graph on the left shows logarith-
mic scale and the graph on the right shows
linear scale.
Ann Thorac Surg ANDERSEN ET AL 39

CARDIOVASCULAR
2006;81:34 41 CAVITATION EVALUATION IN VIVO

groups of patients investigated, and that may support

Fig 5. The nondeterministic energy with intervals for the three
groups in a logarithmic scale is shown. (A) Intraoperative measure-
ments, n 29. (B) Postoperative measurements, n 21. (E-nondet.
nondeterministic energy; St.J St. Jude Medical; C-E Carpen-
tier-Edwards bioprosthesis; Nat native valves.)
noise ratio at frequencies close to 150 kHz in the
postoperative measurements. Furthermore, HFPF in
the two setups seems to correlate across the three
that it is the same energies we measured intraopera-
tively as postoperatively.
This study aimed to evaluate a method capable of
separating the valve-closing sound from the cavitation
signal in HFPF, which as shown in previous studies only
is present at mechanical heart valves. When using the
method on our control data, it should be observed that
the signal comprises no acoustic signal containing the
closing sound component originating from a rigid geo-
metrical structure. Therefore, these data cannot be di-
rectly compared. Using the method on these data may
show a signal with nondeterministic energies due to
turbulence and low-frequency vibration in the tissue.
Looking at the data obtained from our two control
groups, none of the signals contained HFPF; and it is
therefore assumed that these valves produce no cavita-
tion or closing sound, which also is in accordance with
previous findings in studies with bioprosthetic valves [7, 8].
In Tables 1 and 2, all the measurements registered for
all the patients included in the intraoperative group are
shown. When comparing valve sizes, no apparent corre-
lation were found, although it must be expected that the
larger valves generate more cavitation than the smaller
valves as shown in vitro [2224]. The reason for this
discrepancy is most likely that the study material is too
small to illustrate this aspect. Likewise, in vitro studies [1,
25, 26] have previously indicated a correlation between
closing velocity and cavitation intensity, but no apparent
correlation was found in this study. In vitro studies have
shown a relation between the ratio of ventricular pres-
sure change to time change (dp/dt) and cavitation, where
cavitation intensity increases with dp/dt without any
specific cavitation threshold [27]. Experimental animal
studies [28] have shown that during exercise, more ex-
tensive damage had been found at the explanted valves

Table 1. Patient Data for Mechanical Valves

Patient No. Valve Size BP CO EF pO2 pCO2 E-nondet.
(Sex) (mm) (mm Hg) HR (L/min) (%) (kPa) (kPa) (Pa2)

1 (M) 25 114/67 73 3.5 50 54.58 5.19 15200

2 (M) 23 88/48 84 2.9 60 50.31 4.44 2050
3 (M) 21 79/49 109 3.6 28 48.2 5.7 16090
4 (M) 23 117/54 81 5.9 15 55.09 5.1 15160
5 (F) 21 130/57 80 6.5 58 65.04 4.34 5470
6 (M) 21 78/46 71 5.9 60 37.36 4.34 9190
7 (F) 21 79/45 86 4.4 60 39.29 2.32 5980
8 (F) 21 88/59 90 1.9 66 44.9 4.7 345
9 (M) 21 96/51 59 3.3 60 60.8 4.37 1160
10 (M) 21 87/50 79 6.3 60 18.37 5.3 1690
11 (M) 25 84/55 70 60 54.28 5.48 13380
12 (M) 25 108/61 83 5.3 60 18.4 5.9 1980
13 (M) 25 105/56 67 5.0 45 49.59 6.34 5920
14 (M) 25 95/50 70 5.4 15 67.85 6.75 10000

Hemodynamic parameters recorded intraoperatively for mechanical valves.

BP blood pressure; CO cardiac output; EF ejection fraction; E-nondet. nondeterministic energy; F female; HR heart
rate; M male.
 40 ANDERSEN ET AL Ann Thorac Surg
CARDIOVASCULAR

CAVITATION EVALUATION IN VIVO 2006;81:34 41

Table 2. Patient Data for Control Groups

Patient Valve Type and BP CO EF pO2 pCO2
(Sex) Size (mm) (mm Hg) HR (L/min) (%) (kPa) (kPa)

1 (M) C-E 21 88/37 88 2.1 70 71.6 4.6

2 (F) C-E 19 123/60 104 3.5 58 46.72 4.54
3 (M) C-E 21 93/55 84 6.2 66 49.85 5.05
4 (F) C-E 19 122/62 87 2.1 60 12.34 3.81
5 (F) C-E 21 82/40 69 3.8 60 34.9 5.27
6 (M) C-E 21 80/39 122 6.5 40 61.56 5.23
7 (M) CABG 120/67 86 5.9 45 58.2 4.8
8 (M) CABG 104/61 75 5.8 60 35.92 4.59
9 (M) CABG 86/44 46 4.6 55 12.79 4.99
10 (M) CABG 106/54 77 6.4 50 62.79 5.2
11 (F) CABG 102/60 80 6.2 52 59.7 4.55
12 (M) CABG 99/57 91 3.5 63 44.63 4.8
13 (M) CABG 102/46 65 8.0 38 26.11 5.33
14 (M) CABG 101/64 70 4.1 62 13.53 5.02
15 (M) CABG 129/70 80 5.1 60 23.33 4.49
16 (M) CABG 124/57 86 7.4 70 29.11 4.89

Hemodynamic parameters recorded intraoperatively for biological (C-E) and native (CAGB) valves.
BP blood pressure; CABG coronary artery bypass graft surgery; C-E Carpentier-Edwards bioprothesis; CO cardiac output; EF
ejection fraction; E-nondet. nondeterministic energy; F female; HR heart rate; M male.

than in valves not exposed to exercise conditions, so it
may be assumed that there is a possibility for higher
cavitation intensities in patients during exercise. That
might be a particular concern for younger patients with
high exercise levels.
With regard to the remaining hemodynamic parame-
ters, no clear relation was found.
Table 1 shows that there is a 4.5 times spread between
the patient with the highest nondeterministic energy and
the one with the lowest. Since all the patients had the
same valve type implanted, it may be assumed that this
difference could be attributed to the different amount of
cavitation generated. It would have been interesting to be
able to evaluate cavitation intensities under different left
ventricular pressure dp/dt conditions, but this was not
considered feasible either intraoperatively or postopera-
tively. The method most likely has its strength in moni-
toring cavitation intensities in the individual patient and
not as a comparison between patients.
We have earlier carried out in vitro studies showing
that cavitation may generate frequency components
above 150 kHz, which is the upper frequency limit of the
transducer used in this study [14]. Such high-frequency
components could not be detected with the hydrophone
used in the present study.
This study only comprised patients who had the St.
Jude Medical aortic valves implanted; however, the used
methodology could also have been applied to patients
implanted with a mechanical heart valve in the mitral
position, and a study that examines different types of
mechanical heart valves in different positions is needed.
Recently, an in vitro study has shown that some valve
types are more likely to produce cavitation than other
models [14].
Figures 2 and 4 shows that both intraoperative and
postoperative measurements contain nondeterministic
signal components as an indication of cavitation; and
Figure 5 shows the differences between the mechanical,
bioprosthetic, and native valves with respect to energy
contained in the signal. The low values found in the two
control groups express the noise floor. The type of noise
observed is primarily noncorrelated, and therefore con-
tributes to the nondeterministic energy. However, the
energy in the noise is several orders of magnitude lower
than that of the signal of interest.
It is shown (Figs 1 and 2) that the main part of the
signal recorded at mechanical heart valves consists of
nondeterministic energy. It is also seen that the signal
contain both deterministic and nondeterministic energy
in most of the frequency range of the hydrophone,
suggesting that the two components overlap in frequency
range. This finding further supports that parts of the
cavitation signal will be lost if a HP filter is used, and
parts of the closing sound will be included in the cavita-
tion signal using that method.
The nondeterministic energy can not be used as the
irrefutable fingerprint of cavitation, but can be assumed
to be a good indicator of cavitation intensities compared
with the knowledge achieved from previous studies.
Whether the signal contains other components is diffi-
cult to say, but factors such as turbulence could be a
contributor due to its stochastic nature. Owing to the
time window we used and the frequency composition of
turbulence ( 1,000 Hz), it is believed that turbulence is
an insignificant contributor to bias for these
measurements.
It is believed that it is possible to develop this method
of noninvasive assessment of cavitation further and
Ann Thorac Surg
2006;81:34 41
thereby create a standardized postoperative setup that
can be used for routine investigation of mechanical heart
valve patients.
Methods based on detecting and evaluating cavitation
using HFPF seem promising, but they still require further
investigation.
In summary, high-frequency pressure fluctuations re-
corded during valve closure comprised nondeterministic
energy both intraoperatively and postoperatively in me-
chanical heart valve patients, but not in patients with
bioprosthetic or native valves. This finding indicates that
cavitation only occurs at mechanical valves, and there-
fore contributes to the explanation of the differences in
thrombogenicity among mechanical, bioprosthetic, and
native heart valves. This study supports that the nonde-
terministic method can be used as an alternative method
in cavitation research both intraoperatively and postop-
eratively with a minimal loss of information and no need
of a priori knowledge of the valve characteristics [18].
We wish to thank the Danish Heart Foundation (Grant 00-2-3-
45A-22853) for financial support. We also thank the surgeons
and other personnel at the Department of Cardiothoracic and
Vascular Surgery, Skejby Sygehus, for their kind help during
our measurements.
References
1. Chandran KB, Lee CS, Chen LD. Pressure field in the
vicinity of mechanical valve occluders at the instant of valve
closure: correlation with cavitation initiation. J Heart Valve
Dis 1994;3(Suppl 1):6576.
2. Graf T, Fischer H, Reul H, Rau G. Cavitation potential of
mechanical heart valve prostheses. Int J Artif Organs 1991;
14:169 74.
3. Kafesjian R, Howanec M, Ward GD, Diep L, Wagstaff LS,
Rhee R. Cavitation damage of pyrolytic carbon in mechani-
cal heart valves. J Heart Valve Dis 1994;3(Suppl 1):27.
4. Haubold AD, Ely JL, Chahine GL. Effect of cavitation on
pyrolytic carbon in vitro. J Heart Valve Dis 1994;3:318 23.
5. Kumar N, Balasundaram S, Rickard M, al Halees Z, Duran
CM. Leaflet embolisation from Duromedics valves: a report
of two cases. Thorac Cardiovasc Surg 1991;39:3823.
6. Knapp RT, Daily JW, Hammitt FG. Cavitation. New York:
McGraw-Hill, 1970.
7. Paulsen PK, Jensen BK, Hasenkam JM, Nygaard H. High-
frequency pressure fluctuations measured in heart valve
patients. J Heart Valve Dis 1999;8:482 6.
8. Andersen TS, Johansen P, Paulsen PK, Nygaard H, Hasen-
kam JM. Indication of cavitation in mechanical heart valve
patients. J Heart Valve Dis 2003;12:790 6.
9. Dexter EU, Aluri S, Radcliffe RR, et al. In vivo demonstration
of cavitation potential of a mechanical heart valve. ASAIO J
1999;45:436 41.
10. Sambola A, Osende J, Hathcock J, et al. Role of risk factors in
the modulation of tissue factor activity and blood thrombo-
genicity. Circulation 2003;107:9737.
ANDERSEN ET AL 41
CARDIOVASCULAR
CAVITATION EVALUATION IN VIVO
11. Garrison LA, Lamson TC, Deutsch S, Geselowitz DB, Gau-
mond RP, Tarbell JM. An in-vitro investigation of prosthetic
heart valve cavitation in blood. J Heart Valve Dis 1994;
3(Suppl 1):8 22.
12. Zapanta CM, Stinebring DR, Sneckenberger DS, et al. In
vivo observation of cavitation on prosthetic heart valves.
ASAIO J 1996;42:M550 5.
13. Johansen P, Lomholt M, Nygaard H. Spectral characteristics
of mechanical heart valve-closing sounds. J Heart Valve Dis
2002;11:736 44.
14. Johansen P, Fontaine AA, Deutsch S, Manning K, Nygaard H,
Tarbell JM. A new method for evaluation of cavitation near
mechanical heart valves. J Biomech Eng 2003;125:66370.
15. Oba R, Ikohagi T, Ito Y, Miyakura H, Sato K. Stochastic
behavior (randomness) of desinent cavitation. J Fluids Eng
2002;108:438 43.
16. Johansen P. Mechanical heart valve cavitation. Expert Rev
Med Devices 2004;1:89 98.
17. Johansen P, Andersen TS, Hasenkam JM, Nygaard H. In-
vivo prediction of cavitation near a Medtronic Hall valve.
J Heart Valve Dis 2004;13:651 8.
18. Nygaard H, Inderbitzen R, Hasenkam JM, Wieting DW,
Paulsen PK. Measurement of sounds generated by mechan-
ical aortic and mitral heart valve prostheses. IEEE Seventh
Symposium on Computer-Based Medical Systems, June
10 12, 1994:55 60 (abstract).
19. Durand LG, Langlois YE, Lanthier T, et al. Spectral analysis
and acoustic transmission of mitral and aortic valve closure
sounds in dogs. Part 1. Modeling the heart/thorax acoustic
system. Med Biol Eng Comput 1990;28:269 77. [Erratum in
Med Biol Eng Comput 1990;28:612.]
20. Nygaard H, Thuesen L, Terp K, Hasenkam JM, Paulsen PK.
Assessing the severity of aortic valve stenosis by spectral
analysis of cardiac murmurs (spectral vibrocardiography).
Part II: clinical aspects. J Heart Valve Dis 1993;2:468 75.
21. Nygaard H, Thuesen L, Hasenkam JM, Pedersen EM,
Paulsen PK. Assessing the severity of aortic valve stenosis by
spectral analysis of cardiac murmurs (spectral vibrocardio-
graphy). Part I: technical aspects. J Heart Valve Dis 1993;2:
454 67.
22. Chandran KB, Lee CS, Chen LD. Pressure field in the
vicinity of mechanical valve occluders at the instant of valve
closure: correlation with cavitation initiation. J Heart Valve
Dis 1994;3(Suppl 1):6576.
23. Shu MC, Leuer LH, Armitage TL, Schneider TE, Chris-
tiansen DR. In vitro observations of mechanical heart valve
cavitation. J Heart Valve Dis 1994;3(Suppl 1):8592.
24. Richard G, Beavan A, Strzepa P. Cavitation threshold rank-
ing and erosion characteristics of bileaflet heart valve pros-
theses. J Heart Valve Dis 1994;3(Suppl 1):94 101.
25. Lee CS, Chandran KB, Chen LD. Cavitation dynamics of
mechanical heart valve prostheses. Artif Organs 1994;18:
758 67.
26. Lee CS, Chandran KB, Chen LD. Cavitation dynamics of
Medtronic Hall mechanical heart valve prosthesis: fluid
squeezing effect. J Biomech Eng 1996;118:97105.
27. Kingsbury C, Kafesjian R, Guo G, et al. Cavitation threshold
with respect to dP/dt: evaluation in 29 mm bileaflet, pyrolitic
carbon heart valves. Int J Artif Organs 1993;16:51520.
28. Wieting DW, Breznock E, Kafesjian R, Stobie R. Exercising
sheep: an in vivo model for assessing durability of pyrolytic
carbon heart valves. Bologna: Abstracts XVIIth ESAO Con-
gress 1990:608.