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.

中文翻译：

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用于评估肥厚型心肌病中可诱导的左心室流出道梗阻的标准化目标定向Valsalva动作

背景

Valsalva动作被广泛用于引起肥厚型心肌病（HCM）的左心室流出道梗阻。早期的实验采用标准化的，目标导向的方法，将口内压力> 40 mm Hg维持超过10秒钟，而当前的实践取决于患者的理解和努力。这项研究的目的是评估以目标为导向的Valsalva手术（GDV）在HCM中作为引起左心室流出道梗阻的方法的临床效果。

方法

在这项前瞻性研究中，患者从装有橡胶管的压力计连接到的注射器针筒中吹气，并保持口内压力> 40 mm Hg持续10秒钟以上（GDV）。使用多普勒超声心动图，在休息时使用自我指导的Valsalva动作（SDV），GDV和运动的刺激性动作，测量左心室流出道峰值（pLVOTG）。

结果

总共包括52名患者。GDV的平均pLVOTG高于SDV（48 vs 38 mm Hg，P  = .001，n  = 52），与运动相似（GDV，52 mm Hg;运动，58 mm Hg; P  = 0.42; n  = 43）。GDV重分类为阻塞性HCM（pLVOTG≥30 mm Hg）显着高于SDV（38％vs 16.6％，P  = .016），与运动相当（50％，P  = .51）。与SDV相比，GDV对重度阻塞的重分类（pLVOTG≥50 mm Hg）更高（28.3％vs 13.5％，P  = .045），与运动相似（29.7％）。此外，GDV单独查出了两名隐匿性严重梗阻患者。

结论

GDV是一种引起左心室流出道梗阻的客观，实用和有效的生理方法。通过对疾病的严重程度进行重新分类，它可以显着改变患者的管理方式，应将其纳入HCM患者的常规临床评估中。