Noise disturbance arising from the valve is a rare event of ventriculoperitoneal shunts. We queried and investigated shunt patients for occurrence and evaluated the possible factors related to noise development.
Fifty ambulatory patients with implanted proGAV valve were investigated consecutively. Patients were asked for any noise arising from the shunt. In all cases, the valve was auscultated in sitting and upright position. The position of the gravitational unit (GU) was determined in respect to the Frankfurt horizontal plane (FHP) and in head reclination. Ten valves were perfused in vitro at different settings. One valve was opened for video documentation, and a frequency analysis of the noise was performed in nine valves.
Eight percent (4/50) of the patients reported a noise arising from the valve only in upright position in combination with maximum head reclination, and immediately stopped when performing Vasalva’s maneuver. In three out of four of these patients, the noise was also audible for the investigator (FS) with a prepared stethoscope. Patients complaining about a noise had a larger GU deviation from vertical during head reclination (median: −80 vs −43°, p = 0.0007, t-test). A deviations threshold of less than −58.4° excluding audible noise by a negative predictive value of 1 (95 % confidence interval [CI] 0.9 to 1.0). In an experimental setting, the noise came from vibrations of the ball in the cone of the adjustable unit and was restricted to a flow of at least 220 ml/h. The noise frequencies tended to be higher at higher opening pressures.
Valve-related noise development may occur in patients with proGAV valves. This event could be prevented during shunt placement by avoiding posterior tilt of the gravitational unit, especially in patients with a good cervical mobility. The noise might indicate transient peak flows and was not associated with clinical or radiological signs of overdrainage.
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Thank to Florian Freimann for providing additional clinical data.
Conflicts of interest
FS, VR and CS received speaker fees, CM is director and TK is an employee of the Miethke Inc. partner of B.Braun Inc., Melsungen, Germany. None of the authors declares a conflict of interests.
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Electronic supplementary material
Below is the link to the electronic supplementary material.ESM 1
Audio_or1.mpg recording from the adusting unit of a female 30-year-old patient. The noise starts in terms of a crescendo after the patient performed a maximum head inclination. (MPG 988 kb)
Video_or2.mpg adjustable unit of a proGAV valve after removal of the titanium lid at 0 cm H2O opening pressure perfused with saline at 220 ml/h. Note the sapphire ball vibrating in the cone from where the saline enters the valve. (MPG 11794 kb)
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Stockhammer, F., Miethke, C., Knitter, T. et al. Flow-related noise in patients with ventriculoperitoneal shunt using gravitational adjustable valves. Acta Neurochir 156, 761–765 (2014). https://doi.org/10.1007/s00701-013-1876-9
- Gravitational valve
- Side effect
- Ventriculoperitoneal shunt