Antonio Maria Valsalva, an Italian physician, first described the Valsalva maneuver (VM) in his work De Aure Humana Tractatus in 1704. The maneuver has references in multiple clinical domains ranging from the evaluation of autonomic dysfunction to the treatment of arrhythmias and a marker for heart failure.
Valsalva maneuver is the performance of forced expiration against a closed glottis. Many activities of our daily lives such as straining during defecation or playing the saxophone entail performance of Valsalva maneuver. The key event occurring during the maneuver is increasing intrathoracic pressure leading to the reduction of preload to the heart. The reflex's cardiovascular changes during and post the maneuver are because of reduced preload engaging baroreflex and other compensatory reflex mechanisms.
Based on the characteristic hemodynamic changes, Valsalva maneuver divides into four phases.
Phase I, which corresponds to the onset of strain, is associated with a transient rise in blood pressure because of emptying of some blood from the large veins and pulmonary circulation.
Phase II follows this when positive intrathoracic pressure leads to a reduced venous return to the heart. Because of reduced venous return and thus reduced preload, stroke volume falls; this leads to a fall in blood pressure activating the baroreceptors in the carotid sinus and aortic arch. Vagal withdrawal followed by increased sympathetic discharge ensues, leading to marked tachycardia, increased cardiac output, and vasoconstriction which leads to the recovery of blood pressure to the normal values in healthy individuals.
Phase III is the transient phase involving the release of strain which leads to a sudden dip in blood pressure. The release of positive pressure leads to expansion of the pulmonary vascular bed and reduces left ventricular cross-sectional area resulting in a transient fall in blood pressure.
Phase IV is the overshoot of the blood pressure above the baseline, which is because of resumption of normal venous return to the heart stimulated by the sympathetic nervous system during Phase II. The overshoot of blood pressure leads to stimulation of baroreflex leading to bradycardia and return of blood pressure to the baseline.
Valsalva maneuver is used for assessment of autonomic function status, as a marker for heart failure, for termination of arrhythmias, murmur differentiation, and various other indications.
Valsalva maneuver is relatively safe and can be performed in all patients. Side effects reported are rare. However, since there is a rise in intra-ocular and intra-abdominal pressure, therefore the test must be avoided in patients with retinopathy and intra-ocular lens implantation. Valsalva retinopathy may result in susceptible patients. Also, there are reports of syncope, chest pain, and arrhythmias due to the performance of VM. Therefore, caution is necessary for patients with pre-existing coronary artery disease, valvular disease or congenital heart disease.
The maneuver can be performed in the cardiovascular laboratory or at the bedside by using a disposable syringe/mouthpiece connected to a manometer. A small leak is created in the syringe/mouthpiece to ensure sustained effort throughout the period of forced exhalation. Adequacy of the expiratory effort can be gauged by subjective signs such as visible strain, flushing, and engorgement of the neck veins. Simultaneous acquisition of the ECG signal can help us to assess autonomic indices, such as Valsalva ratio. Measurement of continuous beat to beat blood pressure can help in testing baroreflex sensitivity.
The patient can perform the maneuver in the sitting, supine, or recumbent position. Some reports advocate recumbent position, while others report an increased incidence of abnormal blood pressure responses in the supine position. While different combinations of pressure and duration have been tried, an optimal combination for autonomic function assessment is 40 mm Hg for 15 seconds. Lower pressures may not be sufficient while higher pressures suffer from poor reproducibility.
Valsalva maneuver (VM) is a simple non-invasive test that can be easily performed using a mouthpiece and a manometer. While the maneuver is relatively safe, it is prudent to rule out any pre-existing disease of the retina before performing the maneuver. Therefore, one should consult an ophthalmologist and seek a thorough examination of the fundus in patients with suspected retinopathy. Similarly, the opinion of a cardiologist may assist in patients with pre-existing ischemic or valvular heart disease before the performance of VM.
It can assist the neurologist to identify patients suffering from autonomic neuropathy. Dysautonomia usually manifests as an absence of blood pressure overshoot and reflex bradycardia after the maneuver. Valsalva ratio, assessed using inter-beat intervals during and post the maneuver, is a marker of parasympathetic reactivity. A value of less than 1.21 is considered abnormal,but recently proposed age-specific cutoffs may be more relevant. Also, beat to beat blood pressure and heart rate can be used to evaluate the integrity of the baroreflex arc by computation of baroreflex sensitivity. The maneuver may be useful to the cardiologist as it may help diagnose heart diseases based on the accentuation or diminution of murmur intensity. To sum up, this simple maneuver may give insight into underlying physiological functions as well as serve as a diagnostic and therapeutic modality in the laboratory and clinics.
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