In vitro performance of six combinations of adjustable differential pressure valves and fixed anti-siphon devices with and without vertical motion

Objective Adjustable differential pressure (DP) valves in combination with fixed anti-siphon devices are currently a popular combination in counteracting the effects of cerebrospinal fluid overdrainage following implantation of a ventriculoperitoneal shunt system. The study examined the flow performance of three DP valves in successive combination with an anti-siphon device in an in vitro shunt laboratory with and without vertical motion. Methods We analyzed three DP valves (Codman Hakim Medos programmable valve [HM], Codman CertasPlus [CP], and Miethke proGAV [PG], in combination with either Codman SiphonGuard [SG] or Miethke ShuntAssistant [SA]), resulting in the evaluation of six different valve combinations. Defined DP conditions between 4 and 40 cm H2O within a simulated shunt system were generated and the specific flow characteristics were measured. In addition, combinations with SA, which is a gravity-dependent valve, were measured in defined spatial positions (90 degrees, 60 degrees). All device combinations were tested during vertical motion with movement frequencies of 2, 3, and 4 Hz. Results All valve combinations effectively counteracted the siphon effect in relation to the chosen DP. Angulation-related flow changes were similar in the three combinations of DP valve and SA in the 60 degrees and 90 degrees position. In CP-SA and PG-SA, repeated vertical movement at 2, 3, and 4 Hz led to significant increase in flow, whereas in HM-SA, constant increase was seen at 4 Hz only (flow change at 4Hz, DP 40 cm H2O: PG (opening pressure 4 cm H2O) 90 degrees: 0.95 ml/min, 60 degrees: 0.71 ml/min; HM (opening pressure 4 cm H2O) 90 degrees: 0.66 ml/min, 60 degrees: 0.41 ml/min; CP (PL 2) 90 degrees: 0.94 ml/min, 60 degrees: 0.79 ml/min;p< 0.01); however, HM-SA showed relevant motion-induced flow already at low DPs (0.85 ml/min, DP 4 cm H2O). In combinations of DP valve with SG, increase of flow was far less pronounced and even led to significant reduction of flow in certain constellations. Maximum overall flow increase was 0.46 +/- 0.04 ml/min with a HM (opening pressure 12 cm H2O) at 2 Hz and a DP of 10 cm H2O, whereas maximum flow decrease was 1.12 +/- 0.08 with a PG (opening pressure 4 cm H2O) at 3 Hz and a DP of 10 cmH(2)O. Conclusion In an experimental setup, all valve combinations effectively counteracted the siphon effect in the vertical position according to their added resistance. Motion-induced increased flow was consistently demonstrated in combinations of DP valve and SA. The combination of HM and SA especially showed relevant motion-induced flow already at low DPs. In combinations of DP and SG, the pattern of the motion induced flow was more inconsistent and motion even led to significant flow reduction, predominantly at DPs of 10 and 20 cmH(2)O.