CHAPER SIX

Mechanics of Heart Valves

Introduction

• Four cardiac valves help to direct flow through the heart.

• Heart valves cause blood to flow only in the desired direction.
• If a heart without heart valves were to contract, it would simply
squeeze the blood, causing it to flow both backward and forward
(upstream and downstream).
• Instead, under normal physiological conditions, heart valves act as
check valves to prevent blood from flowing in the reverse direction.
Also, heart valves remain closed until the pressure behind the valve is
large enough to cause blood to move forward.
…continued
• Each human heart has two atrioventricular valves, which are located
between the atria and the ventricles.
• The tricuspid valve is the valve between the right atrium and the right
ventricle.
• The mitral valve is the valve between the left atrium and the left
ventricle.
• The mitral valve prevents blood from flowing backward into the
pulmonary veins.
• The mitral valve is a bicuspid valve having two cusps and the tricuspid
valve has three cusps
…continued
• The two semilunar valves are the aortic valve and the pulmonic
valve.
• The aortic valve is located between the aorta and the left ventricle
and when it closes it prevents blood from flowing backward from the
aorta into the left ventricle.
• The pulmonic valve is located between the right ventricle and the
pulmonary artery, and when it closes it prevents blood from flowing
backward, from the pulmonary artery into the right ventricle.
Heart wall
• Three layers of tissue
• Epicardium: This serous membrane of smooth outer
surface of heart
• Myocardium: Middle layer composed of cardiac muscle
cell and responsibility for heart contracting
• Endocardium: Smooth inner surface of heart chambers
Pressure Gradients across a Stenotic
Heart Valve
• To assess the seriousness of a heart valve stenosis, it would be helpful
to know the area of the stenosed valve when open, or how much of
the valve opening is being blocked by the stenosis.
• Gorlin (1951) developed an equation to empirically predict valve area
based on the pressure drop across the valve and the flow rate through
the valve.
• The published equations that were useful for the prediction of area in
mitral and aortic valves are still used in cardiology today.
The Gorlin equation
• The volume of flow passing through the aortic valve per beat Q is the
cardiac output CO divided by the heart rate HR.
• The average flow rate through the aortic valve is the same amount
divided by the ejection time per beat, TE.
• Next, remember that the mean velocity of the flow V (average flow
velocity across the flow cross section, through the valve) multiplied by
the cross-sectional area AV is equal to the flow rate.
• The Bernoulli equation is an equation based on the principle of
conservation of energy, in the absence of viscous losses.
• In fact, there will be significant viscous losses through the heart valve,
but the Gorlin equation is an empirical equation intended to account
for those losses with an empirically derived valve coefficient.
• The Bernoulli equation is as follows:
…continued
• If point 1 referred to in the equation is a reservoir with a very small
velocity compared to the jet through the valve, the equation could be
rewritten:

• or, in terms of the volume flow rate:

…continued
• The above equation relates flow rate, pressure drop, and valve area in
the ideal case, but in the case of a real valve, two non ideal
characteristics have to be considered. Real blood flow is viscous flow
and therefore V2 uses a valve constant, CV, to represent the actual
velocity through the valve.
• In the second non ideal condition, a jet of blood flowing through the
valve will contract to a smaller area than the total cross-sectional
valve area.
• The area of contraction A depends on the valve design and can be
designated here using the valve coefficient Cc.

A = Cc AV
• Combining the above equation, the Gorlin equation becomes:
…continued
• The coefficients are measured for various orifices and it should be
carefully noted that both the valve coefficient and the contraction
coefficient are empirically derived coefficients which may not be
constant under varying pressure and flow conditions as well as
varying Reynolds numbers.
• In fact, this equation or a modified form of the equation is often used
clinically to estimate the effective area of a stenotic heart valve.
• To further simply its use clinically, the equation is often written in the
following form:
… continued
• where AV is the area of the stenotic valve, CO is the cardiac output in
cc/min, TE is the ejection time or the time per beat during which
blood flows through the valve. HR is the heart rate in beats per
minute, P is the mean pressure gradient over the ejection period in
mmHg, and K is the Gorlin constant.
…continued
• The Gorlin constant is proportional to CC, CV, and 1/ρ and contains all
the conversion factors necessary to account for a mathematically
consistent set of units. The flow rate is equal to:
• Therefore, the Gorlin value of the Gorlin constant K is sometimes
given as 44.3 in aortic valves and 37.7 in mitral valves.
• The units associated with the Gorlin constant are as follows:
Example
• A patient has a cardiac output of 5 L/min. The systolic ejection period
is 358 ms with a heart rate of 70 beats per minute. The mean aortic
gradient as measured by echocardiography is 81 mmHg. Find the
aortic valve area as estimated by the Gorlin equation. What is the
average flow rate across the aortic valve during ejection?
Solution
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