Standardized Valsalva Maneuver Research Articles

Valsalva Maneuver Versus Carotid Sinus Massage for Supraventricular Tachycardia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Supraventricular tachycardia (SVT) is one of the most common cardiac arrhythmias, characterized by a sudden increase in heart rate. Initial management often involves vagal maneuvers, including the Valsalva maneuver (VM) and carotid sinus massage (CSM). VM can be categorized into standard VM (sVM) and modified VM (mVM). This study aimed to synthesize the first evidence from published randomized controlled trials (RCTs) comparing the efficacy of VM versus CSM. A comprehensive search across databases, including PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, was conducted up to July 29, 2024. The primary endpoint was the success rate of converting SVT to sinus rhythm. The dichotomous outcome was analyzed using a fixed-effect model to calculate the risk ratio (RR) and 95% confidence intervals (CI). The Risk of Bias (RoB) tool, version 2, was employed to assess bias in the included RCTs. In total, three RCTs with 346 cases were analyzed. Concerns were noted regarding potential bias related to the randomization process in all three studies. The meta-analysis of these RCTs (comprising four arms) revealed that VM had a higher success rate than CSM for treating SVT, with an RR of 1.82 (95% CI: 1.29-2.57, p<0.001). Subgroup analysis showed that the rate of conversion to sinus rhythm was significantly higher in the sVM compared to CSM (RR=1.61, 95% CI (1.13-2.29), p=0.01). Additionally, subgroup analysis of one study indicated that mVM was associated with a higher rate of SVT conversion to sinus rhythm compared to CSM (RR=9.28, 95% CI (1.25-69.13), p=0.03). In conclusion, VM demonstrated a higher success rate compared to CSM in treating SVT. Specifically, mVM was more effective than CSM in both terminating SVT and restoring sinus rhythm, though this evidence was based on a single RCT; hence, the related conclusion should be interpreted with caution and requires validation using additional RCTs. Further research in diverse patient populations and clinical settings is necessary to validate these findings and potentially support the broader use of mVM in practice. Additional well-designed, multi-center studies with diverse populations are needed to confirm these observations and provide more comprehensive guidance on SVT management. This is important to enhance the generalizability of results across different demographics and clinical settings. This approach helps ensure that treatment effectiveness is applicable to a broader range of patients, accounting for variations in age, gender, comorbidities, and regional practices.

Efficacy and safety of modified Valsalva maneuver for treatment of paroxysmal supraventricular tachycardia: a meta-analysis.

To compare the efficacy and safety of the modified versus standard Valsalva maneuver in the treatment of paroxysmal supraventricular tachycardia (PSVT). The PubMed, Embase, Web of Science, CNKI, WanFang Data, and VIP electronic databases were searched to identify studies comparing the modified and standard Valsalva maneuvers in the treatment of PSVT from database inception to 1 May 2023. Two reviewers independently screened the literature, extracted the data, and assessed the risk of bias of all included studies. Nineteen randomized controlled trials involving 2527 patients with PSVT were included. The overall rate of cardioversion was higher in the modified than standard Valsalva group (risk ratio [RR] = 1.80, 95% confidence interval [CI] = 1.61-2.01), as was the success rate of cardioversion after a single Valsalva maneuver (RR = 2.05, 95% CI = 1.74-2.41). There was no statistically significant difference in adverse reactions between the two groups (RR = 1.07, 95% CI = 0.82-1.38). Current evidence suggests that the modified Valsalva maneuver can significantly improve the success rate of cardioversion in patients with PSVT without increasing adverse reactions. The modified Valsalva maneuver is therefore worth promoting and should be considered as a routine first treatment.INPLASY registration number: 2023100092.

Noninvasive Point of Care Device for Assessing Cardiac Response to Acute Volume Changes.

The change in the amplitude of a peripheral pulse in response to a Valsalva maneuver has diagnostic utility for assessing volume status at the bedside. We have developed a device to automatically quantify the Valsalva pulse response (VPR) to a standardized Valsalva maneuver that the device guides a user to perform. In this study, we sought to determine whether VPR by the device, Indicor, is sensitive enough to detect the acute increase in central pressure and volume load that occurs with a passive leg raise (PLR) in healthy volunteers. Healthy volunteers were tested semirecumbently at 45 degrees, then again after being leaned back on a pivoted wedge with legs raised at 45 degrees and torso and head flat, and then again in the semirecumbent position. The device recorded a finger photoplethysmography (PPG) signal during a 10-second expiratory effort of 20 mmHg as guided by the device. VPR was automatically calculated as the ratio of the end-Valsalva pulse amplitude to the baseline pulse amplitude. In the 30 participants who completed testing, VPR increased from baseline to PLR in every participant, from 0.34 ± 0.13 to 0.60 ± 0.14 (p < 0.0001). Back upright, VPR decreased back to 0.33 ± 0.10 (p < 0.0001 versus PLR; NS versus baseline position). In this proof-of-concept study of healthy participants, the Indicor device, a noninvasive, convenient device that automatically calculates VPR from a finger photoplethysmography signal during a standardized Valsalva maneuver, was sensitive enough to detect the increase in VPR that occurred with an acute central volume load from a PLR. Future studies should examine whether VPR responds differently to a PLR in heart failure patients with abnormal cardiac performance and/or congestion.

Evaluation of the prehospital use of a Valsalva assist device in the emergency treatment of supraventricular tachycardia (EVADE SVT): study protocol for a stepped wedge cluster randomised controlled trial

IntroductionPatients with episodes of supraventricular tachycardia (SVT), a common heart arrhythmia, are often attended by ambulance services. International guidelines advocate treatment with the Valsalva manoeuvre (VM), but this simple physical...

Comparing Efficacy of Standard Vs Modified Valsalva Maneuver in Terminating Paroxysmal Supraventricular Tachycardia

Aim: To know whether valsalva maneuver is more effective compared to modified valsalva in terminating paroxysmal supraventricular tachycardia or vice versa. Method: The study design was randomized controlled trial. This research was conducted in accident &amp; emergency department of Mayo hospital, Lahore. Duration of this study was nine months. Participants were divided in two groups, half were assigned in Standard VM group (Group A), and other half in Modified VM group (Group B). In both groups, assigned valsalva maneuver was repeated up to two times, only when paroxysmal supraventricular tachycardia did not revert to sinus rhythm on first time. In those patients, VM failed even after three attempts, antiarrhythmic medications were used. Primary outcome was defined on the basis of successful return of sinus rhythm after either by standard or modified valsalva maneuver. Results: Sixty two patients were included in this study, thirty one in each group. Out of thirty one patients in group A, two patients (3.2%) rhythm reverted to sinus, while in group B, seven patients (11.3%) rhythm reverted to sinus. The number of patients who needed rescue treatment was lower in group B -21 (77.4%) as compared to group A- 29(93.5%). Conclusion: The results of this study showed that modified VM was more effective in terminating PSVT as compared to standard VM. So, number of patients who required pharmacological cardioversion was lower in group B. Keywords: Supraventricular tachycardia (SVT), Standard valsalva maneuver (SVM), Modified valsalva maneuver (MVM)

Effectiveness of modified Valsalva maneuver by using wide bore syringe for emergency treatment of supraventricular tachycardias: Findings from Pakistan.

The Valsalva maneuver (VM) is the most effective measure that can be carried out to treat supraventricular tachycardia (SVT). Our objective was to compare the efficacy of postural modified VM with 20 ml syringe to standard VM for the emergency treatment of SVT. This randomized control trial study was conducted at the Accident and Emergency Department, Pakistan ordinance factories hospital, Wah Cantt from July 2019 to September 2020. In the standard Valsalva group, fifty patients were placed at an angle of 45 with continuous monitoring of vitals and electrocardiogram. Patients blew into a 20ml syringe to generate 40 mmHg pressure for 15 seconds and remained in the same position for 45 seconds before a reassessment of cardiac rhythm at one-minute and three-minute intervals. In the modified Valsalva group same procedure was repeated with the other fifty patients, but immediately at the end of the strain, they were laid flat with their legs raised to 45° for 15 seconds. Participants returned to semi-recumbent position and cardiac rhythm was reassessed after 45 seconds and then at one and three minutes. In the standard Valsalva maneuver (SVM)20.0% of participants versus 58% of participants in the modified Valsalva maneuvers group(MVM) reverted to sinus rhythm at one min (odds ratio or 5.52, 95% CI 2.26-13.47; p<0.001) and time of stay in the emergency room was (odds ratio or 2.39, 95% CI 1.45- 3.93; p<0.0001). Modified Valsalva by using a wide-bore syringe is more effective method than standard Valsalva in terminating SVT.

EFFICACY OF MODIFIED VERSUS STANDARD VALSALVA MANOEUVRE FOR TREATING SUPRAVENTRICULAR TACHYCARDIA IN AN EMERGENCY DEPARTMENT: A QUASI-EXPERIMENT

Objective: To assess efficacy of modified Valsalva manoeuvre in comparison to standard Valsalva manoeuvre in treating Supraventricular tachycardia in an emergency department. Methods: It was a quasi–experiment conducted in Azra Naheed Medical College Lahore including 132 patients presented with supraventricular tachycardia (SVT) in an emergency department. Patients were equally divided and randomly assigned to receive standard Valsalva manoeuvre and modified Valsalva manoeuvre. ECG was recorded before and after the Manoeuvre. Subjects reverted back to sinus rhythm within one minute of allocated manoeuvre were considered successful. SPSS version 21 was used to manage and analyze data. Results: Mean age of participants was 40±11 years with 33% male and 66% were females. Mean duration of paroxysmal SVT in participants was 5 ± 4 years. The mean systolic and diastolic blood pressure was 112±15 and 72±10 mmHg respectively. The range of pulse rate per minute was from 136 to 240 with a mean of 184 ± 24. SVT was reverted by Valsalva Manoeuvre in 89 (67.4%) patients and did not revert by these Manoeuvers in 43 (32.6%) patients. Out of 89 reverted, 38 were reverted by performing Standard Valsalva method and 51 were reverted by performing modified Valsalva methods (p=0.025). There was no association between age, sex, duration of SVT, presence of Diabetes Mellitus, Hypertension or Ischemic Heart Disease with the effectiveness of Vagal Manoeuvre for termination to sinus rhythm. Conclusion: Modified Valsalva manoeuvre is significantly effective than the standard manoeuvre in terminating SVT without increasing adverse effects or time spent in the emergency department.

Valsalva Maneuver Decreases Liver and Spleen Stiffness Measured by Time-Harmonic Ultrasound Elastography

Ultrasound elastography quantitatively measures tissue stiffness and is widely used in clinical practice to diagnose various diseases including liver fibrosis and portal hypertension. The stiffness of soft organs has been shown to be sensitive to blood flow and pressure-related diseases such as portal hypertension. Because of the intricate coupling between tissue stiffness of abdominal organs and perfusion-related factors such as vascular stiffness or blood volume, simple breathing maneuvers have altered the results of liver elastography, while other organs such as the spleen are understudied. Therefore, we investigated the effect of a standardized Valsalva maneuver on liver stiffness and, for the first time, on spleen stiffness using time-harmonic elastography (THE). THE acquires full-field-of-view stiffness maps based on shear wave speed (SWS), covers deep tissues, and is potentially sensitive to SWS changes induced by altered abdominal pressure in the hepatosplenic system. SWS of the liver and the spleen was measured in 17 healthy volunteers under baseline conditions and during the Valsalva maneuver. With the Valsalva maneuver, SWS in the liver decreased by 2.2% (from a median of 1.36 m/s to 1.32 m/s; p = 0.021), while SWS in the spleen decreased by 5.2% (from a median of 1.63 m/s to 1.51 m/s; p = 0.00059). Furthermore, we observed that the decrease was more pronounced the higher the baseline SWS values were. In conclusion, the results confirm our hypothesis that the Valsalva maneuver decreases liver and spleen stiffness, showing that THE is sensitive to perfusion pressure-related changes in tissue stiffness. With its extensive organ coverage and high penetration depth, THE may facilitate translation of pressure-sensitive ultrasound elastography into clinical routine.

Modified Valsalva maneuver for treatment of supraventricular tachycardias: A Meta-analysis.

Valsalva maneuver (VM) is a simple and easy method for acute termination of supraventricular tachycardia (SVT), while a postural modification to the VM has been suggested to be superior to the standard VM (SVM). The objective of this meta-analysis is to explore the efficacy and safety of the modified VM (MVM) to terminate SVT compared with the SVM. Extensive literature was conducted using the database such as PubMed, Embase, Web of Science, Cochrane library and included randomized controlled trials (RCTs) assessing the efficacy and safety of the MVM and SVM for SVT. Meta-analysis was performed using mean difference (MD), relative risk (RR) and 95% confidence interval (CI). Statistical analysis was performed using Review Manager 5.4.1 software. The quality of the published studies was evaluated using the Oxford quality scoring system (Jadad scale). Six RCTs involving 1208 patients were reviewed, including 603 patients in the MVM group and 605 patients in the SVM group. The results of the meta-analysis showed that MVM was found to significantly increase the success rate of the sinus rhythm after single VM (RR=2.83; 95% CI=2.19 to 3.66; P < 0.00001), sinus rhythm after multiple VM (RR=3.83; 95% CI=2.26 to 6.50; P < 0.00001), and single and multiple VM (RR=2.85, 95% CI=2.35 to 3.45; P < 0.00001). MVM also decreased the emergency anti-arrhythmic treatments (RR=0.70; 95% CI=0.62 to 0.79; P < 0.00001), and use of adenosine and verapamil (RR=0.69; 95% CI=0.61 to 0.78; P < 0.00001). There was no significant difference in adverse events (RR=1.48; 95% CI=0.91 to 2.42; P=0.11) and time in emergency department (ED) (RR=0.03; 95% CI=-0.17 to 0.23, P=0.79) between MVM and SVM. Compared with MVM, the conversion rate of SVT to sinus rhythm was more effective than SVM. MVM also reduced the use of anti-arrhythmic measures and drugs, and had no increased time in ED and adverse events.

Reliance on vascular responses for the maintenance of blood pressure in healthy older adults - Insights from the Valsalva maneuver.

Effective baroreflex-mediated cardiac and vascular resistance responses are crucial for homeostatic blood pressure control. We investigated the impacts of age and sex on arterial blood pressure regulation during a standard supine Valsalva maneuver (40mmHg, 20s) in 46 healthy young and 25 healthy older adults. Noninvasive, continuous cardiovascular parameters were recorded. In older adults, cardiac output (older: -58.4±2.4%; young: -40.8±1.4%; p<0.001) and stroke volume (older: -63.6±2.6%; young: -48.7±1.9%; p<0.001) fell more than in young adults and was compensated by augmented vascular resistance responses (older: +189.8±17.6%; young: +105.8±6.7; p<0.001); heart rate responses were attenuated in older adults. Male and female responses were comparable in their respective age groups.

Comparison of the Modified Valsalva Maneuver and the Standard Valsalva Maneuver for Treatment of Supraventricular Tachycardia in Emergency Department

Comparison of the Modified Valsalva Maneuver and the Standard Valsalva Maneuver for Treatment of Supraventricular Tachycardia in Emergency Department

Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis.

Cardiac arrhythmia, specifically paroxysmal supraventricular tachycardia (SVT), accounts for a substantial proportion of emergency medical services resources utilisation. Reconversion requires increasing the atrioventricular node's refractoriness, which can be achieved by vagal manoeuvres, pharmacological agents or electrical cardioversion. There are multiple variants of vagal manoeuvres, including the Valsalva manoeuvre (VM). While the effectiveness of the standard VM has already been systematically reviewed, there has been no such analysis for the modified VM. Compare the effectiveness of the modified VM versus the standard VM in restoring the normal sinus rhythm in adult patients with supraventricular tachycardia. Systematic review with meta-analysis of published randomised controlled trials. The primary outcome was the reconversion to a sinus rhythm. Secondary outcomes included: medication use, adverse events, length of stay in the emergency department and hospital admission. Five randomised controlled trials were included, with a combined total of 1181 participants. The meta-analysis demonstrated a significantly higher success rate for reconversion to sinus rhythm when using the modified VM compared to the standard VM in patients with an SVT (odds ratio = 4.36; 95% confidence interval, 3.30-5.76; P < 0.001). More adverse events were reported in the modified VM group, although this difference is NS (risk ratio = 1.48; 95% confidence interval, 0.91-2.42; P = 0.11). The available evidence suggests that medication use was lower in the modified VM group than the standard VM group. However, medication use could not be generalised across the different studies. None of the included studies showed a significant difference in length of stay in the emergency department. Only one study reported on hospital admission, with no significant difference between the two groups. The available evidence is highly suggestive to support the use of the modified VM compared to the standard VM in the treatment of adult patients with SVT. Meta-analysis showed a higher success rate, required less medication use, and resulted in an equal number of adverse events. However, these results cannot be regarded as definitive in the absence of higher-quality studies.

The Feasibility of a Novel Index From a Wireless Doppler Ultrasound Patch to Detect Decreasing Cardiac Output in Healthy Volunteers.

ABSTRACTIntroductionEarly hemorrhage is often missed by traditional vital signs because of physiological reserve, especially in the young and healthy. We have developed a novel, wearable, wireless Doppler ultrasound patch that tracks real-time blood velocity in the common carotid artery.Materials and MethodsWe studied eight healthy volunteers who decreased their cardiac output using a standardized Valsalva maneuver. In all eight, we simultaneously monitored the velocity time integral (VTI) of the common carotid artery (using the ultrasound patch) as well as the descending aorta (using a traditional pulsed wave duplex imaging system); the descending aortic VTI was used as a surrogate for left ventricular stroke volume (SV). Additionally, in a subset of four, we simultaneously measured SV using a noninvasive pulse contour analysis device.ResultsFrom baseline to peak effect of Valsalva, there was a statistically significant fall in descending aortic and common carotid VTI of 37% (P = 0.0005) and 23% (P < 0.0001), respectively. Both values returned to baseline on recovery. Additionally, a novel index from the carotid ultrasound patch (i.e., the heart rate divided by the carotid artery VTI) detected a 10% fall in aortic VTI with high sensitivity and specificity (100% and 100%, respectively); this novel index also accurately detected a 10% decrease in SV as measured by the noninvasive SV monitor. The mean arterial pressure, measured by the noninvasive pulse contour device, did not correctly detect the fall in SV.ConclusionIn summary, a novel index from a wireless Doppler ultrasound patch may be more sensitive and specific for detecting decreased cardiac output than standard vital signs in healthy volunteers.

Valsalva and modified valsalva maneuver

Valsalva maneuver is a diagnostic and adjunctive method in non-medical treatment of supraventricular tachycardia, in physical examination, differential diagnosis and imaging-guided evaluation of congenital heart defects and valvular diseases and also to show the presence of autonomic neuropathy caused by diabetes, chronic renal failure, certain cardiomyopathies and neurological disorders. The modified Valsalva maneuver is more effective and less complicated variant of the standard Valsalva maneuver.

Observation of the effect of postural modified Valsalva manoeuvre in terminating paroxysmal supraventricular tachycardia

Objective To observe the efficacy and safety of postural modified Valsalval manoeuvre in terminating paroxysmal supraventricular tachycardia (PSVT). Methods From January 2017 to June 2018, a total of 98 patients with PSVT were selected in the Affiliated Hospital of Xuzhou Medical University.They were randomly allocated to standard Valsalval manoeuvre group(48 cases) and postural modified Valsalval manoeuvre group(50 cases) according to sealed envelope method.The patients in standard Valsalval manoeuvre group carried out standard semi-recumbent Valsalva manoeuvre, while the other group received semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain.The general clinical data, total cardioversion success rate, first-time cardioversion success rate and the incidence of adverse reactions were compared between the two groups. Results There were no statistically significant differences in male proportion, age, history of PSVT or coronary heart disease, incidence of hypertension, diabetes and heart rate, systolic and diastolic blood pressure at attack between the two groups(all P>0.05). The total cardioversion success rate [40.0%(20/50)], first-time cardioversion success rate [28.0%(14/50)] in the modified group were significantly higher than those in the standard group [16.7%(8/48), 12.5%(6/48)](χ2=27.924, 16.308, all P 0.05). Conclusion Postural modified Valsalval manoeuvre can effectively improve the cardioversion success rate of PSVT, and has high safety, which is worthy of clinical promotion. Key words: Tachycardia, supraventricular; Valsalval manoeuvre; Syringe; Mechanical stimulation; Vagus nerve; Treatment outcome; Comparative effectiveness research

P1748 Left atrial diastolic and systolic functions modulate the response to the standardised Valsalva maneuver in normal subjects

Abstract Background Although the Valsalva maneuver (VM) is being advocated by current guidelines to identify with echocardiography patients with increased left ventricular (LV) filling pressures using a decrease in mitral E/A velocity &amp;gt; 0.5 as cutoff, there are limited published data for both patients and the normal response to the maneuver in healthy subjects. Purpose To assess LV and left atrial (LA) physiology during a standardized VM (VMs) in normal subjects. Methods The VMs was performed in 50 healthy subjects (M:F 38:12; age 40 ± 12 y.; HR 70 ± 11 bpm; BSA 1.81 ± 11 m2), instructed to forcefully exhale for 20 seconds without an initial deep breath into a tube connected to a sphygmomanometer, maintaining a 25-35 mmHg pressure. The VM was repeated 2 times at 5 minute intervals to record sequentially in the apical 4-chamber view: 1. LV and LA volumes; 2. Transmitral flow velocities. LA diastolic reservoir function (LAres) was calculated as: (maximum – minimum volume) / minimum volume x 100. Results. During the VMs, in all subjects LV indexed end-diastolic (-14 ± 7 ml/m2, -31 ± 15 %) and end-systolic (-6 ± 4 ml/m2, -31 ± 18 %) volumes, and stroke volume index (-9 ± 5 ml/m2, -30 ± 15 %) decreased similarly with unchanged LV ejection fraction %, and LA maximum and minimum volume indices both decreased (respectively -8 ± 6 ml/m2, -3 ± 3 ml/m2;-32 ± 25 %) with high variability. Mitral peak E velocity also decreased (-22 ± 13 cm/s, -27 ± 14 %) in all subjects, whereas peak A velocity change varied, such that a "pseudo-abnormal" decrease of E/A &amp;gt; 0.5 was seen in 18 subjects (37 %). At baseline, this subgroup had lower heart rate (66 ± 11 vs 73 ± 10 bpm, p= .026), higher LAres (193 ± 67 vs 145 ± 47 %, p= .006), lower peak A velocity (50 ± 12 vs 58 ± 12 cm/s, p= .04) and higher E/A (1.8±.6 vs 1.4±.3, p= .004). During VMs, LV and LA volumes decreased similarly in all subjects, but increase in heart rate was higher (12 ± 8 vs 6 ± 5 bpm, p= .023), and peak A wave increased instead of decreasing (20 ± 20 % vs -8 ± 18 %, p&amp;lt; .001) in the subjects with "pseudo-abnormal" decrease of E/A. During VMs, decrease in E/A was mainly determined (regression analysis, r: .76, p= .029) by baseline LAres (B= -.71) and change in LAres during VMs (B= -.47), whereas an increase in peak A velocity (r: .46, p= .031) was mainly determined by degree of HR increase (B= .41) and baseline LV EF (B= .3). Conclusions During VMs, a "pseudo-abnormal" decrease of the E/A velocity ratio is present in almost 40 % of normal subjects, and is determined by the interplay of the baseline diastolic compliance and the increase in systolic function of the LA during VM. These results may influence the accuracy of the VMs in the detection of increased LV filling pressures in patients.

Usefulness of Noninvasively Measured Pulse Amplitude Changes During the Valsalva Maneuver to Identify Hospitalized Heart Failure Patients at Risk of 30-Day Heart Failure Events (from the PRESSURE-HF Study)

The pulse amplitude ratio (PAR), the ratio of pulse pressure at the end of the Valsalva maneuver to before the onset, correlates with cardiac filling pressure. We have developed a handheld device that uses finger photoplethysmography to measure PAR and estimate left ventricular end diastolic pressure (LVEDP). Patients hospitalized with heart failure (HF) performed three 10-second trials of a standardized Valsalva maneuver (at 20 mm Hg measured via pressure transducer), while photoplethysmography waveforms were recorded, at admission and discharge. Combined primary outcome was 30-day HF hospitalization, intravenous diuresis, or death. Fifty-two subjects had discharge PAR testing; 12 met the primary outcome. Median PAR on admission was 0.55 (interquartile range: 0.40 to 0.70, n = 48) and on discharge was 0.50 (interquartile range: 0.36 to 0.69). Mean PAR-estimated LVEDP was significantly higher in subjects that had an event (20.2 vs 16.9 mm Hg, p = 0.043). Subjects with PAR-estimated LVEDP >19.5 mm Hg had an event rate hazard ratio of 4.57 (95% confidence interval 1.37, 15.19, p = 0.013) compared with patients with LVEDP 19.5 mm Hg or below, with significantly lower 30-day event-free survival (log-rank p = 0.006). In conclusion, noninvasively estimated LVEDP using the pulse amplitude response to a Valsalva maneuver in patients hospitalized for HF changes with diuresis and identifies patients at high risk for 30-day HF events. Detection of elevated filling pressures before hospital discharge may be useful in guiding HF management to reduce HF events.

Initial and Sustained Response Effects of 3 Vagal Maneuvers in Supraventricular Tachycardia: A Randomized, Clinical Trial.

For acute termination of supraventricular tachycardia (SVT), vagal maneuvers, including the standard Valsalva maneuver (sVM), modified Valsalva (mVM) maneuver, and carotid sinus massage (CSM), are first-line interventions. There is no criterion standard technique. This prospective, randomized study was aimed at analyzing the success rates of these 3 vagal maneuvers as measured by sustaining sinus rhythm at the fifth minute and SVT termination. We conducted this prospective, randomized controlled study in an emergency department (ED). We enrolled all the patients who were admitted to the ED and diagnosed with SVT. We randomly assigned them to 3 groups receiving sVM, mVM, and CSM and recorded the patients' responses to the vagal maneuvers and SVT recurrence after vagal maneuvers. The study was completed with 98 patients. A total of 25 (25.5%) instances of SVT were initially treated successfully with vagal maneuvers. The success rate was 43.7% (14/32 cases) from mVM, 24.2% (8/33) for sVM, and 9.1 % (3/33) for CSM (p<0.05). At the end of the fifth minute, only 12.2% (12/98) of all patients had sinus rhythm. Sinus rhythm persisted in 28.1% (9/32) of patients in the mVM group, 6.1% (2/33) of patients in the sVM group, and 3% (1/33) in the CSM group at the fifth minute (p<0.05). mVM is superior to the CSM maneuver in terminating SVT and maintaining rhythm. We conclude that it is beneficial to use mVM, which is more effective and lacks side effects.

A multicenter randomized controlled trial of a modified Valsalva maneuver for cardioversion of supraventricular tachycardias

Clinical questionValsalva maneuver is a recognized treatment for supraventricular tachycardia, but in clinical setting it has a low chance to achieve successful cardioversion. Studies suggested that the postural modification of valsalva maneuver may improve the rate of cardioversion. We further modified the maneuver and conduct a multicenter randomized controlled trial to test its efficacy. Research in contextAppelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva maneuver for emergency treatment for supraventricular tachycardias (REVERT): a randomized controlled trial. Lancet 2015; 386 (10005):1747–53 [1].Allison Michaud, PhD, Eddy Lang. Leg lift Valsalva maneuver for treatment of supraventricular tachycardias. CJEM 2017; 19(3):235–237 [2]. ObjectiveTo verify the efficacy of the modified Valsalva maneuver in SVT in Chinese population and simplify the operation process further.

Age-Dependent Variation of Lamina Cribrosa Displacement During the Standardized Valsalva Maneuver

Based on biomechanical theory, lamina cribrosa (LC) displacement, the key component of progressive glaucomatous change, is presumed to be dependent on intraocular pressure (IOP) as well as tissue stiffness of LC. In the performance of the Valsalva maneuver, both IOP and cerebrospinal fluid pressure can increase. The present study investigated the age-dependent variation of LC displacement during the standardized Valsalva maneuver in healthy subjects. Sixty-three (63) eyes (age range: 20–76 years) were prospectively underwent IOP measurement and Cirrus HD-OCT optic disc scans before and during the standardized Valsalva maneuver. During the standardized Valsalva maneuver, the IOP significantly increased from 13.2 ± 2.9 mmHg to 18.6 ± 5.2 mmHg (P < 0.001). The maximal LC depth significantly decreased in the younger age groups (age: 20 s to 40 s) but not in the older age groups (age: over 50). The BMO distance did not change significantly. Younger age (P = 0.009), a smaller increase of IOP during the Valsalva maneuver (P = 0.002), and greater baseline maximal LC depth (P = 0.013) were associated with more anterior displacement of the LC during the standardized Valsalva maneuver. Taken together, age as well as translaminar pressure dynamics seems to play a crucial role in LC biomechanics.