Valsalva Maneuver and Echocardiography

There are four phases during the Valsalva maneuver.

Phase one is the onset of straining with increased intrathoracic pressure. The heart rate does not change but blood pressure rises.

Phase two is marked by the decreased venous return and consequent reduction of stroke volume and pulse pressure as straining continues. The heart rate increases and blood pressure drops.

Phase three is the release of straining with decreased intrathoracic pressure and normalization of pulmonary blood flow.

Phase four marks the blood pressure overshoot (in the normal heart) with return of the heart rate to baseline.

Dynamic cardiac auscultation includes the Valsalva maneuver:

Phase two can be used to distinguish fixed left ventricular outflow obstruction (valvular aortic stenosis) from dynamic obstruction. During phase two the murmurs of hypertophic obstructive cardiomyopathy and mitral valve prolapse may increase as a result of the decreased stroke volume. Most other murmurs (including valvular aortic stenosis) decrease in intensity.

It is important to continue listening after Valsalva release. Phase four auscultation is useful in distinguishing left-sided from right-sided murmurs. Right-sided murmurs (such as pulmonic stenosis) that decrease in intensity during phase two will return to baseline intensity almost immediately after Valsalva release. Left-sided murmurs (such as aortic stenosis) require five to ten cardiac cycles to return to baseline.

Echocardiographic References

J Am Soc Echocardiogr 1995 Jul-Aug;8(4):536-42
Ventricular interdependence during Valsalva maneuver as seen by two-dimensional echocardiography: new insights about an old method.
Aebischer N, Malhotra R, Connors L, Kappenberger L, Parisi AF.
Department of Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne University Medical School, Lausanne, Switzerland.

Two-dimensional echocardiography was used in 15 normal volunteers to assess left (LV) and right ventricular (RV) responses, as well as their interdependence, during the Valsalva maneuver. During the strain phase, LV and RV areas decreased progressively, the RV area decreasing more than the LV area. Immediately after strain release, the RV end-diastolic area increased suddenly and dramatically to 143.3% +/- 9.4% of its baseline value, whereas the LV end-diastolic area decreased further. This transiently overloaded right ventricle and associated septal shift changed LV shape and further reduced the LV cross-sectional area. Thus the resulting momentary drop in the stroke LV area may contribute, along with pulmonary blood pooling, to the abrupt systemic blood pressure drop characteristic of phase III seen in normal subjects. Real-time imaging with echocardiography during respiratory maneuvers is feasible for clinical use. Its application in patients with congestive heart failure might bring further understanding of LV and RV interrelationships in the failing heart.

Am Heart J 1993 Nov;126(5):1182-6
Abnormal Valsalva blood pressure response in dilated cardiomyopathy: association with "pseudonormalization" of echocardiographic Doppler transmitral filling velocity pattern.
Schwengel RH, Hawke MW, Fisher ML, Gottlieb SS, Plotnick GD.
University of Maryland School of Medicine, Baltimore 21201.

In patients with dilated cardiomyopathies, the presence of an abnormal blood pressure response to the Valsalva maneuver has been shown to correlate well with increased left-sided filling pressures. The presence of a "pseudonormalized" early peak to late peak velocity (E/A) ratio on echocardiographic Doppler transmitral filling pattern has also been correlated with increased left ventricular end-diastolic pressures in these patients. Since both abnormal blood pressure response to the Valsalva maneuver and a "pseudonormalized" Doppler transmitral E/A ratio probably represent elevated left ventricular filling pressure, we postulated that there would be a positive correlation between the two in a group of patients with dilated cardiomyopathy and abnormal systolic function. Twenty-five consecutive male patients with New York Heart Association (NYHA) class II to IV heart failure and dilated cardiomyopathy were included. Patients with abnormal blood pressure responses to Valsalva had significantly larger peak early (E) velocities, smaller peak late (A) velocities, and larger E/A ratios compared with patients with normal responses. E/A ratio < 1.0 was present in eight (100%) of the eight patients with a normal blood pressure response to the Valsalva maneuver and E/A ratio > 1.0 was present in 12 (71%) of 17 patients with an abnormal response (p < 0.01). This correlation supports the hypotheses of the physiologic mechanisms of these phenomena and also provides two noninvasive methods of evaluating left-sided filling pressures useful in the diagnosis and treatment of congestive heart failure caused by dilated cardiomyopathy.

Am J Cardiol 1991 Aug 15;68(5):515-9
Use of Valsalva maneuver to unmask left ventricular diastolic function abnormalities by Doppler echocardiography in patients with coronary artery disease or systemic hypertension.
Dumesnil JG, Gaudreault G, Honos GN, Kingma JG Jr.
Quebec Heart Institute, Laval University, Sainte-Foy, Canada.

It has been suggested that changes in left atrial pressure may mask or mimic left ventricular diastolic function abnormalities detected by Doppler echocardiography. The effect of the Valsalva maneuver on the transmitral flow velocity profile was therefore studied in 28 patients without evidence of coronary artery disease (group 1, mean age +/- standard deviation 50 +/- 8 years) and in 94 patients with evidence of coronary artery disease or systemic hypertension (group 2, mean age 54 +/- 10 years). At baseline, group 2 patients had higher peak late diastolic filling velocity (A), lower peak early (E) to late diastolic filling velocity (E/A) ratio and longer isovolumic relaxation time than group 1, whereas heart rate, E velocity and E deceleration time were similar in both groups. During Valsalva, both groups had similar increases in heart rate and similar decreases in E velocity but E/A ratio decreased significantly only in group 2 because of a lesser decrease in A velocity. The E/A ratio was greater than or equal to 1.0 both before and during Valsalva in all but 1 patient in group 1, whereas in group 2, 32 patients had E/A greater than or equal to 1.0 at rest and during Valsalva, 33 patients had E/A greater than or equal to 1.0 at rest but less than 1.0 both at rest and during Valsalva. Using group 1 as controls, prevalence, specificity and positive predictive value of E/A less than 1.0 in group 2 were 31, 100 and 100% at rest and 66, 96 and 98% during Valsalva. (Abstract truncated....)

Chest 1990 Nov;98(5):1175-8
Abnormal hemodynamic response to Valsalva maneuver in patients with atrial septal defect evaluated by Doppler echocardiography.
Tsai LM, Chen JH.
Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of China.

Hemodynamic responses to the Valsalva maneuver were studied in eight healthy subjects (group 1) and eight patients with ASD (group 2) using Doppler echocardiography. The acute changes of aortic blood flow profiles during the Valsalva maneuver were investigated on a basis of beat-to-beat estimation. During the active strain phase (phase 2), group 1 showed a significant decrease in systolic blood pressure, SV and CO with reflex tachycardia; in group 2, there was a significant decrease in SV and CO with reflex tachycardia, but not systolic blood pressure. The percentage decreases in SV and CO in group 2 were significantly less than those in group 1 (23 +/- 16 percent vs 48 +/- 10 percent for SV, p less than 0.01; 17 +/- 12 percent vs 40 +/- 13 percent for CO, p less than 0.05). After release of strain phase (phase 4), group 1 showed significant reversed changes in systolic blood pressure, SV and heart rate, indicating an overshoot effect which was, however, not observed in group 2. Thus, patients with ASD presented abnormal Valsalva response which was characterized by the absence of phase 4 overshoot and a less marked phase 2 change. The findings suggest that the decremental effect of impaired venous return on stroke output during active strain may be attenuated by the increased pulmonary blood volume due to left-to-right shunt. In patients with ASD, the lesser decrement of CO during phase 2 may not provoke sufficient sympathetic activity to induce overshoot response in phase 4.

Am J Cardiol 1990 Jun 1;65(20):1387-91
Doppler echocardiographic flow velocity measurements in the superior vena cava during the Valsalva maneuver in normal subjects.
Gindea AJ, Slater J, Kronzon I.
Department of Medicine, New York University Medical Center, New York.

The hemodynamic manifestations of the Valsalva maneuver are in part the result of changes in the venous return accompanying changes in intrathoracic pressure. Doppler echocardiography was performed during Valsalva maneuver in 13 normal subjects. Superior vena cava flow velocities and flow velocity integrals were measured in all 13 subjects. In the 5 subjects in whom the superior vena cava was clearly visualized throughout the maneuver, vena cava diameter was also analyzed. The superior vena cava flow velocity integral at rest was 17 +/- 2 cm. It diminished significantly, disappeared or reversed (-13 +/- 6 cm, p less than 0.001) with phase I of the maneuver. During the maintenance phase (phase II), the flow velocity integral increased significantly (31 +/- 2 cm, p = 0.05 vs baseline and phase I) and was associated with a decrease in superior vena cava lumen diameter at the time of Valsalva and continuing throughout the strain. With release of the maneuver (phase III), there was a sudden significant increase in flow velocity integral (61 +/- 2 cm, p = 0.005 vs phase II) and superior vena cava lumen diameter. Subsequently, superior vena cava flow velocity integral returned to baseline values. This study suggests that one of the ways in which the Valsalva maneuver leads to decreased venous return may be by direct external compression of the superior vena cava.

J Cardiogr 1981 Jun;11(2):477-84
The effect of the Valsalva and Muller maneuvers on right and left atrial dimensions in man studied by esophageal echocardiography
Toma Y, Matsuzaki M, Sasaki T, Anno Y, Takahashi Y, Uchida T, Sada K, Takahashi T, Hiroyama N, Kusukawa R, Tada T, Nakashima A.

The effect of the Valsalva (V) and Muller maneuvers (M) on the right and left atrial dimensions was evaluated by esophageal echocardiography in 8 normal male subjects. During V and M, the right atrial free wall (RAW), interatrial septum (IAS) and left atrial posterior wall were recorded by esophageal echocardiography simultaneously with intraairway pressure (Paw). Right (RAD) and left atrial dimensions (LAD) at atrial end-diastolic were measured at various phases during each maneuver. Mean expiratory effort of +40 mmHg Paw in V and mean inspiratory effort of -40 mmHg Paw in M were maintained for about 10 sec. Both atrial dimensions changed significantly during each maneuver. RAD began to decrease just after the onset of V, while LAD changed little during this phase, after which began to decrease progressively. The leftward displacement of IAS with the simultaneous outward displacement of RAW resulted in an increase of RAD and a decrease of LAD just after the onset of M and the release of V. LAD remained higher than resting value from the second (2--4 sec after the onset) to late phase (just before the release) during M. RAD decreased just after the release of M. Thus, esophageal echocardiography was useful to evaluate both atrial dimensions during V and M.

Acta Med Austriaca 1978;5(4-5):124-5
Echocardiographic determination of left ventricular function during isometric muscle exertion and the Valsalva maneuver
Aigner A, Muss N.

Left ventricular dimensions and function were estimated in 11 healthy volunteers by means of echocardiography during isometric exercise and the Valsalva manoeuvre. Isometric exercise induces a rise of heart rate and Vcf by 14% and of cardiac output as well as of the cardiac index by 12%. Stroke volume remains unchanged. During Valsalva's manoeuvre a marked decrease in left ventricular dimensions is observed. A reduction of the stroke volume by 29% was not compensated by increasing heart rate. However, cardiac output and cardiac index is found 10% below control values.

Circulation 1977 Apr;55(4):596-62
The effect of the Valsalva maneuver on echocardiographic dimensions in man.
Robertson D, Stevens RM, Friesinger GC, Oates JA.

Physiologic changes in the circulatory system caused by performing the Valsalva maneuver are blunted or absent in patients with congestive heart failure. Previously there has been no non-invasive method for examining cardiac chamber size during this maneuver. M-mode echocardiography was used to evaluate possible changes in cardiac chamber dimensions in 12 normal subjects (group I) and 15 patients with cardiovascular disease (group II). In group I, the left ventricular end-diastolic dimension decreased 11.2% (+/- 1.5%) and the end-systolic dimension 9.5% (+/- 1.32%), with a fall in stroke volume of 29%. The left atrial (LA) dimension decreased 30%. In group II, only the response of the LA dimension is reported. There was a diminished response to Valsalva related to the severity of congestive heart failure. Patients in NYHA classes III and IV decreased LA dimension by only 3.8%, significantly less (P less than 0.001) than those in classes I and II who had essentially normal responses. Echocardiographically-determined changes in left atrial size in response to the Valsalva maneuver may provide an objective, noninvasive means of evaluating and following patients with suspected or proven congestive heart failure. Possible mechanisms for the changes observed are discussed.

Circulation 1976 Dec;54(6):921-7
Echocardiographic evaluation of the Valsalva Maneuver in healthy subjects and patients with and without heart failure.
Parisi AF, Harrington JJ, Askenazi J, Pratt RC, McIntyre KM.

The Valsalva maneuver was evaluated by echocardiography in three groups: A) 10 normal volunteers, B) 10 patients with no history of heart failure and normal ejection fractions, and C) 10 patients with heart failure and depressed ejection fractions. Groups A and B had a significant fall in left ventricular internal dimensions and calculated stroke volume by end strain which returned rapidly to baseline in recovery without significant overshoot. Arterial pressure showed a sigmoidal strain pattern with a normal overshoot in early recovery in all group B patients. In group C ventricular dimensions did not diminish during strain; arterial pressures showed a "square wave" pressure elevation during strain without an overshoot in recovery. Echocardiography allows a new approach to evaluate further the left ventricular response to the Valsalva maneuver. Patients with severely depressed ejection fractions, unlike those with normal ventricular function, are unable to alter stroke output in response to acutely increased intrathoracic pressure. A square wave pressure response is a likely consequence of a fixed stroke output during the strain maneuver.

Anaesthesia 2000 Feb;55(2):113-7
A new method of predicting pulmonary capillary wedge pressure: the arterial pressure ratio.
Uehara H, Takenaka I, Aoyama K, Kadoya T, Sata T, Shigematsu A.
Department of Anaesthesiology, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka Yahatanishi-ku Kitakyushu 807-8555, Japan.

The response of arterial blood pressure to an increase in intrathoracic pressure has been shown to be predictive of pulmonary capillary wedge pressure. We devised a new method, which we termed the arterial pressure ratio. We defined arterial pressure ratio as the ratio of systolic blood pressure of the final beat during the strain phase of the Valsalva manoeuvre to that during apnoea before the manoeuvre, and tested the accuracy of arterial pressure ratio in predicting pulmonary capillary wedge pressure. In 30 patients scheduled for elective abdominal aortic reconstruction, following induction of general anaesthesia and tracheal intubation, a 20-G catheter and pulmonary artery catheter were inserted through the radial artery and right internal jugular vein, respectively. Pulmonary capillary wedge pressure was then measured during a brief period of apnoea and the Valsalva manoeuvre was performed by application of pressure to the reservoir bag. Airway pressure was maintained at 30 cmH2O for 10 s and then released. Radial arterial pressure and airway pressure were recorded simultaneously, and arterial pressure ratio was calculated. There was a close linear correlation between arterial pressure ratio and pulmonary capillary wedge pressure (r = 0.88, p < 0.0001).

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