Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy

Suwen Kumar, Grace Van Ness, Aron Bender, Mrinal Yadava, Jessica Minnier, Sriram Ravi, Lidija McGrath, Howard Song, Stephen Heitner

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Abstract

Background: The Valsalva maneuver is widely used to provoke left ventricular outflow tract obstruction in hypertrophic cardiomyopathy (HCM). Whereas early experiments used a standardized, goal-directed approach by maintaining an intraoral pressure >40 mm Hg for >10 sec, current practice depends on patients' understanding and effort. The aim of this study was to evaluate the clinical effectiveness of the goal-directed Valsalva maneuver (GDV) in HCM as a method to provoke left ventricular outflow tract obstruction. Methods: In this prospective study, patients blew into a syringe barrel connected to a manometer with rubber tubing and maintained an intraoral pressure of >40 mm Hg for >10 sec (GDV). Using Doppler echocardiography, peak left ventricular outflow tract gradient (pLVOTG) was measured at rest and using the provocative maneuvers of the self-directed Valsalva maneuver (SDV), GDV, and exercise. Results: A total of 52 patients were included. Mean pLVOTG with GDV was higher compared with SDV (48 vs 38 mm Hg, P =.001, n = 52) and was similar to exercise (GDV, 52 mm Hg; exercise, 58 mm Hg; P =.42; n = 43). Reclassification to obstructive HCM (pLVOTG ≥ 30 mm Hg) with GDV was significantly higher than with SDV (38% vs 16.6%, P =.016) and comparable with exercise (50%, P =.51). Reclassification to severe obstruction (pLVOTG ≥ 50 mm Hg) was higher with GDV compared with SDV (28.3% vs 13.5%, P =.045) and was similar to exercise (29.7%). Furthermore, GDV identified two patients with occult severe obstruction in isolation. Conclusions: GDV is an objective, practical, and effective physiologic method of provoking left ventricular outflow tract obstruction. It can significantly alter patient management by reclassifying disease severity and should be incorporated in the routine clinical evaluation of patients with HCM.

Original languageEnglish (US)
JournalJournal of the American Society of Echocardiography
DOIs
StateAccepted/In press - Jan 1 2018

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Ventricular Outflow Obstruction
Valsalva Maneuver
Hypertrophic Cardiomyopathy
Exercise
Pressure
Doppler Echocardiography
Rubber
Syringes
Disease Management

Keywords

  • Cardiomyopathy
  • Goal-directed
  • Hypertrophy
  • Obstruction
  • Standardized
  • Valsalva

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

Cite this

@article{0f0c226715d34fe5a7bc70d719feea5d,
title = "Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy",
abstract = "Background: The Valsalva maneuver is widely used to provoke left ventricular outflow tract obstruction in hypertrophic cardiomyopathy (HCM). Whereas early experiments used a standardized, goal-directed approach by maintaining an intraoral pressure >40 mm Hg for >10 sec, current practice depends on patients' understanding and effort. The aim of this study was to evaluate the clinical effectiveness of the goal-directed Valsalva maneuver (GDV) in HCM as a method to provoke left ventricular outflow tract obstruction. Methods: In this prospective study, patients blew into a syringe barrel connected to a manometer with rubber tubing and maintained an intraoral pressure of >40 mm Hg for >10 sec (GDV). Using Doppler echocardiography, peak left ventricular outflow tract gradient (pLVOTG) was measured at rest and using the provocative maneuvers of the self-directed Valsalva maneuver (SDV), GDV, and exercise. Results: A total of 52 patients were included. Mean pLVOTG with GDV was higher compared with SDV (48 vs 38 mm Hg, P =.001, n = 52) and was similar to exercise (GDV, 52 mm Hg; exercise, 58 mm Hg; P =.42; n = 43). Reclassification to obstructive HCM (pLVOTG ≥ 30 mm Hg) with GDV was significantly higher than with SDV (38{\%} vs 16.6{\%}, P =.016) and comparable with exercise (50{\%}, P =.51). Reclassification to severe obstruction (pLVOTG ≥ 50 mm Hg) was higher with GDV compared with SDV (28.3{\%} vs 13.5{\%}, P =.045) and was similar to exercise (29.7{\%}). Furthermore, GDV identified two patients with occult severe obstruction in isolation. Conclusions: GDV is an objective, practical, and effective physiologic method of provoking left ventricular outflow tract obstruction. It can significantly alter patient management by reclassifying disease severity and should be incorporated in the routine clinical evaluation of patients with HCM.",
keywords = "Cardiomyopathy, Goal-directed, Hypertrophy, Obstruction, Standardized, Valsalva",
author = "Suwen Kumar and {Van Ness}, Grace and Aron Bender and Mrinal Yadava and Jessica Minnier and Sriram Ravi and Lidija McGrath and Howard Song and Stephen Heitner",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.echo.2018.01.022",
language = "English (US)",
journal = "Journal of the American Society of Echocardiography",
issn = "0894-7317",
publisher = "Mosby Inc.",

}

TY - JOUR

T1 - Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy

AU - Kumar, Suwen

AU - Van Ness, Grace

AU - Bender, Aron

AU - Yadava, Mrinal

AU - Minnier, Jessica

AU - Ravi, Sriram

AU - McGrath, Lidija

AU - Song, Howard

AU - Heitner, Stephen

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: The Valsalva maneuver is widely used to provoke left ventricular outflow tract obstruction in hypertrophic cardiomyopathy (HCM). Whereas early experiments used a standardized, goal-directed approach by maintaining an intraoral pressure >40 mm Hg for >10 sec, current practice depends on patients' understanding and effort. The aim of this study was to evaluate the clinical effectiveness of the goal-directed Valsalva maneuver (GDV) in HCM as a method to provoke left ventricular outflow tract obstruction. Methods: In this prospective study, patients blew into a syringe barrel connected to a manometer with rubber tubing and maintained an intraoral pressure of >40 mm Hg for >10 sec (GDV). Using Doppler echocardiography, peak left ventricular outflow tract gradient (pLVOTG) was measured at rest and using the provocative maneuvers of the self-directed Valsalva maneuver (SDV), GDV, and exercise. Results: A total of 52 patients were included. Mean pLVOTG with GDV was higher compared with SDV (48 vs 38 mm Hg, P =.001, n = 52) and was similar to exercise (GDV, 52 mm Hg; exercise, 58 mm Hg; P =.42; n = 43). Reclassification to obstructive HCM (pLVOTG ≥ 30 mm Hg) with GDV was significantly higher than with SDV (38% vs 16.6%, P =.016) and comparable with exercise (50%, P =.51). Reclassification to severe obstruction (pLVOTG ≥ 50 mm Hg) was higher with GDV compared with SDV (28.3% vs 13.5%, P =.045) and was similar to exercise (29.7%). Furthermore, GDV identified two patients with occult severe obstruction in isolation. Conclusions: GDV is an objective, practical, and effective physiologic method of provoking left ventricular outflow tract obstruction. It can significantly alter patient management by reclassifying disease severity and should be incorporated in the routine clinical evaluation of patients with HCM.

AB - Background: The Valsalva maneuver is widely used to provoke left ventricular outflow tract obstruction in hypertrophic cardiomyopathy (HCM). Whereas early experiments used a standardized, goal-directed approach by maintaining an intraoral pressure >40 mm Hg for >10 sec, current practice depends on patients' understanding and effort. The aim of this study was to evaluate the clinical effectiveness of the goal-directed Valsalva maneuver (GDV) in HCM as a method to provoke left ventricular outflow tract obstruction. Methods: In this prospective study, patients blew into a syringe barrel connected to a manometer with rubber tubing and maintained an intraoral pressure of >40 mm Hg for >10 sec (GDV). Using Doppler echocardiography, peak left ventricular outflow tract gradient (pLVOTG) was measured at rest and using the provocative maneuvers of the self-directed Valsalva maneuver (SDV), GDV, and exercise. Results: A total of 52 patients were included. Mean pLVOTG with GDV was higher compared with SDV (48 vs 38 mm Hg, P =.001, n = 52) and was similar to exercise (GDV, 52 mm Hg; exercise, 58 mm Hg; P =.42; n = 43). Reclassification to obstructive HCM (pLVOTG ≥ 30 mm Hg) with GDV was significantly higher than with SDV (38% vs 16.6%, P =.016) and comparable with exercise (50%, P =.51). Reclassification to severe obstruction (pLVOTG ≥ 50 mm Hg) was higher with GDV compared with SDV (28.3% vs 13.5%, P =.045) and was similar to exercise (29.7%). Furthermore, GDV identified two patients with occult severe obstruction in isolation. Conclusions: GDV is an objective, practical, and effective physiologic method of provoking left ventricular outflow tract obstruction. It can significantly alter patient management by reclassifying disease severity and should be incorporated in the routine clinical evaluation of patients with HCM.

KW - Cardiomyopathy

KW - Goal-directed

KW - Hypertrophy

KW - Obstruction

KW - Standardized

KW - Valsalva

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U2 - 10.1016/j.echo.2018.01.022

DO - 10.1016/j.echo.2018.01.022

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JF - Journal of the American Society of Echocardiography

SN - 0894-7317

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