Standardized Valsalva Maneuver Research Articles

Effectiveness of the modified valsalva maneuver in the emergency management of supraventricular tachycardia

Background: The return rate of supraventricular tachycardia (SVT) to sinus rhythm by the standard Valsalva maneuver (SVM) is as low as 5%–20%. Despite the limited available data in the literature, the modified Valsalva maneuver (MVM) is promising. We tested the effectiveness of the MVM for the emergency treatment of patients with SVT. Materials and Methods: In this cohort prospective study, 93 confirmed SVT cases with mean age of 47.88 ± 15.66 years and female: male ratio (1.73) across multiple centers underwent MVM. The reversion to sinus rhythm after 1 min of the maneuver, in the first or second attempt, was considered to be a success, and other conditions were considered to be a failure. Alternative therapies were administered for nonresponders. Results: The overall success rate of the reversion of SVT to sinus rhythm by using MVM in this study is 47.3%. In addition, the rate was not affected by medical and drug histories, and the rate was not substantially different among the patients having different sociodemographics, blood pressures, and pulse rate statuses. MVM has a high cardioversion rate when used for patients with SVT. We recommend using it instead of the SVM as the first-line nonpharmacologic therapy for SVT. Conclusion: The MVM has a very reasonable cardioversion rate in the setting of emergency treatment of SVT regardless of the associated sociodemographic and medical histories of patients.

Effects of aerobic or resistance exercise training on cardiovascular autonomic function of subjects with type 2 diabetes: A pilot study

Background and aimsBoth aerobic (AER) and resistance (RES) training improve metabolic control in patients with type 2 diabetes (T2DM). However, information on the effects of these training modalities on cardiovascular autonomic control is limited. Our aim was to compare the effects of AER and RES training on cardiovascular autonomic function in these subjects. Methods and resultsCardiovascular autonomic control was assessed by Power Spectral Analysis (PSA) of Heart Rate Variability (HRV) and baroreceptors function indexes in 30 subjects with T2DM, randomly assigned to aerobic or resistance training for 4 months. In particular, PSA of HRV measured the Low Frequency (LF) and High Frequency (HF) bands of RR variations, expression of prevalent sympathetic and parasympathetic drive, respectively. Furthermore, we measured the correlation occurring between systolic blood pressure and heart rate during a standardized Valsalva maneuver using two indexes, b2 and b4, considered an expression of baroreceptor sensitivity and peripheral vasoactive adaptations during predominant sympathetic and parasympathetic drive, respectively.After training, the LF/HF ratio, which summarizes the sympatho-vagal balance in HRV control, was similarly decreased in the AER and RES groups. After AER, b2 and b4 significantly improved. After RES, changes of b2 were of borderline significance, whereas changes of b4 did not reach statistical significance. However, comparison of changes in baroreceptor sensitivity indexes between groups did not show statistically significant differences. ConclusionBoth aerobic and resistance training improve several indices of the autonomic control of the cardiovascular system in patients with T2DM. Although these improvements seem to occur to a similar extent in both training modalities, some differences cannot be ruled out. Clinical trial registration numberNCT01182948, clinicaltrials.gov.

Upside-down position for the out of hospital management of children with supraventricular tachycardia.

The upside-down position is a little known modified Valsalva manoeuvre (VM). The aim of this study was to investigate the safety and the efficacy of the upside-down position for the treatment of paroxysmal SVT in children. Twenty-four paediatric patients followed for SVT were enrolled. The patients were assigned (1:1) to a standard VM or to an upside-down position at the first episode of SVT at home. If no cardioversion occurred, a second attempt was undertaken with the other VM. At the patient's first relapse, the intervention protocol was applied in the opposite order at home. The upside-down position compared to standard VM reached 67% vs 33% rate of cardioversion at a first attempt, followed by 50% vs 0% rate of cardioversion in patients who had failed the first attempt. After having reversed the order of intervention in case of SVT recurrence, we recorded 67% vs 25% and 71% vs 42% success rates in favour of the upside-down position. There were no adverse events. The upside-down position was safe and tended to be more effective than standard VM for out of hospital SVT treatment. Doctors and parents should be more aware of this effective but overlooked manoeuvre.

Usefulness of Pulse Amplitude Changes During the Valsalva Maneuver Measured Using Finger Photoplethysmography to Identify Elevated Pulmonary Capillary Wedge Pressure in Patients With Heart Failure

The pulse amplitude ratio, the ratio of pulse pressure at the end of a Valsalva maneuver to before the onset of Valsalva, correlates with filling pressure. This study aimed to noninvasively estimate cardiac filling pressure in patients with heart failure. We developed a noninvasive handheld device to measure pulse amplitude ratio using finger photoplethysmography. In 69 patients who underwent right heart catheterization, photoplethysmography waveforms were recorded during a standardized Valsalva maneuver, and in 60 of these patients, pulse amplitude ratio was able to be calculated. Pulse amplitude ratio correlated with pulmonary capillary wedge pressure (PCWP) (r = 0.58, p <0.0001), particularly among those subjects with reduced ejection fraction (r = 0.60, p = 0.002, n = 25). A multivariable linear regression model for PCWP including pulse amplitude ratio, age, body mass index, systolic blood pressure, diastolic blood pressure, and heart rate yielded an R2 of 0.54. Difference in mean pulse amplitude ratio for subjects with a PCWP ≤15 mm Hg versus >15 mm Hg was statistically significant (p <0.0001, area under receiver operating characteristics curve 0.79 [0.66, 0.92]). Pulse amplitude ratio ≥0.55 predicted PCWP >15 mm Hg with 73% sensitivity and 77% specificity. Pulse amplitude ratio also increased by an average of 0.03 with a leg raise maneuver (p = 0.05, n = 36). In conclusion, we demonstrate that noninvasively measured response to the Valsalva maneuver in patients with HF can estimate PCWP and also detect changes within a single patient.

Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial

PurposeThe study aimed to detect whether modified Valsalva maneuver (VM) is more effective than the standard VM in terminating paroxysmal supraventricular tachycardia (PSVT). MethodologyThis randomized controlled trial was conducted in the emergency department of a training and research hospital between Dec. 1, 2015 and Dec. 31, 2016. Participants were divided into two groups, randomly assigned standard VM or modified VM, as the first treatment with two-dimensional permutation blocks; in the order of arrival of the patients. In both groups; the determined procedure for standard or modified VM was repeated up to three times in patients whose PSVT did not convert to sinus rhythm. In both groups; if the maneuver was unsuccessful after three attempts, anti-arrhythmic medication was administered. The primary outcome was defined to compare the success rate of achieving sinus rhythm after standard VM or modified VM. ResultsFifty-six patients were randomized to modified or standard VM with 28 patients in each treatment arm. Three of 28 patients (10.7%) in VM group and 12 of 28 patients (42.9%) in modified VM group were returned to sinus rhythm after intervention (p=0.007). The number of patients who needed rescue treatment was lower in the modified VM group - 16 (57.1%) of 28 versus 25 (89.3%) of 28 in the standard VM group (p=0.007). ConclusionThis study suggests that modified VM therapy was more effective than standard VM for terminating PSVT. The modified VM therapy also indirectly reduced the need for anti-arrhythmic medication and indirectly caused fewer side effects.

Leg Lift Valsalva Maneuver for Treatment of Supraventricular Tachycardias.

Clinical question Can conversion to sinus rhythm for a supraventricular tachycardia be enhanced by a postural modification to the Valsalva maneuver? Article chosen Appelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015;386(10005):1747-53. 1 OBJECTIVE: To determine effectiveness of a postural modification of the Valsalva involving leg elevation and supine positioning.

Abstract 10905: Pulse Amplitude Changes During the Valsalva Maneuver Measured Using Finger Photoplethysmography Identify Elevated Pulmonary Capillary Wedge Pressure in Heart Failure Patients

Introduction: Pulse amplitude ratio (PAR) (ratio of pulse pressure at end of Valsalva maneuver (VM) to before onset) correlates with filling pressure. We developed a noninvasive device to measure PAR using finger photoplethysmography (PPG). Hypothesis: PAR reflects PCWP in heart failure (HF) patients and can detect a change in volume status. Methods: Patients referred for right heart catheterization (RHC) or admitted for HF performed three 10-second trials of a standardized VM (at 20 mmH measured via a pressure transducer) while PPG waveforms were recorded. Results: Amongst 60 patients undergoing RHC (Table 1), PAR correlated with PCWP (Pearson correlation coefficient = 0.53, p&lt;0.0001; Fig 1A), particularly in the 25 patients with systolic HF (Pearson correlation coefficient = 0.60, p=0.002; Fig 1B). A multivariable linear model for PCWP including PAR, age, BMI, blood pressure and heart rate improved ability to predict PCWP (r2=0.54). Difference in mean PAR for patients with a PCWP &lt; 15 mmHg versus ≥ 15 mmHg was statistically significant (p=0.0001; Fig 1C). PAR ≥ 0.515 predicted PCWP ≥ 15 mmHg with 83% sensitivity and 80% specificity (85% PPV). Presence of a positive Kussmaul’s sign did not alter the correlation between PAR and PCWP (p=0.897 for interaction). In 8 patients admitted with HF, PAR decreased by a mean of 0.10 from admission to discharge (p=0.023, effect size=0.85). Conclusions: We demonstrate that the response of a finger PPG waveform to a standardized VM in HF patients can estimate PCWP and also detect changes after diuresis. The ability to detect elevated filling pressures noninvasively prior to development of symptomatic congestion could reduce HF hospitalizations.

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial

The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5-20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness. We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027). We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3-5·8; p<0·0001). We recorded no serious adverse events. In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients. National Institute for Health Research.

Valsalva maneuver and strain-related ECG changes

Background:During the four steps of the Valsalva maneuver (VM), opposite changes can be observed in some physiologic parameters. Manifestations of the VM in the electrocardiogram (ECG) have been studied in detail, but there have been few reports comparing VM-related biochemical and hemodynamic changes with a focus on the strain phase of the VM.Objectives:We studied strain-related ECG changes during the VM.Patients and Methods:This self-control descriptive study was conducted in 20 healthy male college students aged 20.12 ± 2.23 years. They were well trained to perform the standard VM: maintenance of a 15-second expiratory pressure at 40 mmHg with open glottis. An ECG was continuously recorded in the supine position at (a) rest (before the VM) and at (b) the start and (c) end of strain maintenance in the second phase of the VM. The averages of four successive beats were computed for each set of (a), (b), and (c). Means ± standard errors of the mean were used for comparison.Results:Following the VM, the RR and PR intervals, corrected QT interval (QTc), P wave duration and amplitude, T wave amplitude, and the ratio of T/R amplitudes showed significant changes. The QRS duration and R wave amplitude did not show significant changes.Conclusions:The VM caused time and voltage changes in some ECG waves during the strain phase. Alterations in heart or lung volume, electrode-related alterations, and autonomic tone may cause these changes.

PD29-06 ADDITION OF A DEFECOGRAPHY PHASE TO DYNAMIC PELVIC MRI ENHANCES DETECTION AND VISUALIZATION OF PELVIC ORGAN PROLAPSE

INTRODUCTION AND OBJECTIVES: Dynamic Pelvic MRI (DPMRI) remains an emerging diagnostic modality in the evaluation of Pelvic Organ Prolapse (POP), but study quality remains variable, and is typically dependent upon performance of a proper valsalva maneuver during the dynamic phase of the procedure. We sought to determine whether the addition of a defecography phase (DP) to routine DPMRI would increase its clinical utility over standard valsalva maneuver (VM) in the evaluation of POP. METHODS: Fifty-six female patients undergoing preoperative evaluation for surgical correction of symptomatic POP were evaluated by DPMRI utilizing a protocol incorporating both VM and DP. Ultrasound gel was injected into the vagina and rectum followed by (1) steady state free precession images in the sagittal plane, (2) dynamic cine acquisitions during VM, and (3) dynamic cine acquisitions during DP. All images were separately reviewed in a blinded fashion by two radiologists experienced in DPMRI. The HMO system was used for quantification of pelvic floor descent. Inferior descent of the ano-rectal junction, bladder base and vaginal vault was recorded in all patients, utilizing the pubococcygeal line (PCL) as a fixed landmark. IRB approval was obtained for the study. RESULTS: DP produced a greater degree of pelvic organ descent compared to VM for all recorded measures in all 56 patients. 100%(56/56) demonstrated rectocele, 71% (40/56) cystocele and 71% (40/56) vaginal vault descent on DP, compared with 86% (48/56), 14% (8/56) and 43% (24/56) on VM, respectively. The average descent of the bladder base was 3.4 cm with DP, compared to 0.4 cm with VM (p<0.01). Average descent of the vaginal vault was 5.1 cm with DP, compared to 3.5 cm with VM (p<0.01). Average rectal descent was 5.5cm with DP, compared to 4.6cm with VM (p<0.01). CONCLUSIONS: DPMRI utilizing a defecography phase demonstrates pelvic organ prolapse better than DPMRI utilizing valsalva maneuver alone. Pelvic organs may show mild prolapse or even appear normal with valsalva maneuver alone, but may demonstrate marked prolapse during the defecography phase.

Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study

IntroductionThe Valsalva manoeuvre (VM) is a recommended first-line physical treatment for patients with re-entrant supraventricular tachycardia (SVT), but is often ineffective in standard practice. A failed VM is typically followed...

Peripheral baroreflex and chemoreflex function after eversion carotid endarterectomy

This study assessed the long-term effect of the eversion technique for carotid endarterectomy (e-CEA) on arterial baroreflex and peripheral chemoreflex function. The study included 13 patients who underwent, between 2001 and 2006, bilateral e-CEA and 16 who underwent bilateral standard CEA (s-CEA) to eliminate the complicating effects of intact contralateral carotid sinus function. Exclusion criteria were age >70 years, diabetes mellitus, chronic pulmonary disease, ischemic cardiac disease or medical therapy with β-blockers, cardiac arrhythmia, neurologic deficits, carotid restenosis, and previous neck or chest surgery or irradiation. Young and aged-matched healthy individuals were recruited as controls. All patients underwent standard cardiovascular reflex tests, including lying-to-standing, orthostatic hypotension, deep breathing, and Valsalva maneuver. Autonomic cardiovascular modulation was indirectly evaluated by spectral analysis of heart rate variability and systolic arterial pressure variability. The chemoreflex sensitivity to hypoxia was obtained during classic rebreathing tests from the slopes of the linear regression of minute ventilation (VE) vs arterial oxygen saturation measured by pulse oximetry (SpO2%) and partial pressure of end-tidal oxygen (PetO2). Patients (16 men; age, 62.4 ± 8.0 years) were enrolled after a mean interval of 24 ± 17 months from the last CEA. All were asymptomatic, and results of standard tests were negative. Residual baroreflex performance was documented in both patient groups, although reduced, compared with young controls. Notably, baroreflex sensitivity (msec/mm Hg) was better maintained after e-CEA than after s-CEA at rest (young controls, 19.93 ± 9.50; age-matched controls, 7.75 ± 5.68; e-CEA, 13.85 ± 14.54; and s-CEA, 3.83 ± 1.15; analysis of variance [ANOVA], P = .001); and at standing (young controls, 7.83 ± 2.55; age-matched controls, 3.71 ± 1.59; e-CEA, 7.04 ± 5.62; and s-CEA 3.57 ± 3.80; ANOVA, P = .001). Similarly, chemoreflex sensitivity to hypoxia was maintained in both patient groups, which did not differ from each other, and was reduced compared with controls (controls vs patient groups ΔVE/ΔSpO2: -1.37 ± 0.33 vs -0.33 ± 0.08 and SpO2% -0.29 ± 0.13 L/min; P = .002; ΔVE/ΔPetO2: -0.20 ± 0.1 vs -0.01 ± 0.0 and -0.07 ± 0.02 L/min/mm Hg; P = .04, ANOVA with least significant difference correction for multiple comparisons). Our data show that e-CEA, even when performed on both sides, preserves baroreflexes and chemoreflexes and, therefore, does not confer permanent carotid sinus denervation. Also, e-CEA does not increase long-term arterial pressure variability, and this suggests that perioperative hemodynamic derangements can be attributed to the temporary effects of surgical trauma.

Comment to: Volume displacements from an incompetent great saphenous vein during a standardised Valsalva manoeuvre, by Lattimer CR, Kalodiki E, Azzam M, Geroulakos G. Acta Phlebologica 2012;13:25-30.

Reflux duration longer than 0.5 s is the cut-off point for the diagnosis of valvular incompetence. It is induced by a calf compression/release maneuvre (CCRM) in a weight-loaded position, with a full venous reservoir. CCRM is a pre-valve challenge test; reflux stops when the reservoir is full. In contrast, a Valsalva maneuvre (VM) is a post-valve challenge test and also a validated technique to induce reflux. It is performed in a supine position, when the venous reservoir is only partially filled. The Authors measured the volume of blood displaced during a standardized VM within an incompetent GSV (18 patients C2, reflux until the popliteal crease). A standard VM was performed by taking a deep breath during 3 s, a strain during the next 3 s, and then a relaxation during the final 3 s. GSV diameters during stain and relaxation were measured just distal to the SFJ. Volume flow in cc/min (time average mean velocity x diameter) multiplied by 3/60 gave volume displacement in 3 s. A median of 25 mL blood was displaced into the GSV over 3 s during straining with only 9 mL blood out of the GSV during the following 3 s of relaxation. As far as the volume is concerned, the different physical properties of foam must be referred to and the displaced foam volumes are likely to be lower. During ultrasound guided foam sclerotherapy (UGFS), VM is unavoidable (leg movements, cough, head lifting, strains, stocking application) and bolus displacement of foam into deep veins, and blood/foam mixing may cause concern over safety and efficacy. Protocols should be formulated to minimize the VM risks (stocking application, avoid standing, talking and coughing soon after the injection). Putting on a below-the-knee stocking before the procedure may be of benefit. This study has also shown that reflux duration following a VM can be determined by the physician and not by the pathology of the disease.

Abstract 17313: Bedside Ultrasound for Serial Assessment of Central Venous Pressure in Patients with Volume Overload

Background: Using bedside ultrasound, we have previously shown that a greater than 17% increase in internal jugular vein (IJ) cross sectional area (CSA) during Valsalva rules out elevated right atrial pressure (RAP &gt; 12mmHg, NPV 94%). This occurs because venous compliance increases nonlinearly with increasing pressure. Here, we sought to validate this US test in the first longitudinal study of patients undergoing acute volume removal during hemodialysis (HD) as well as patients undergoing diuresis for acute decompensated heart failure (ADHF). Methods: Images of the right IJ were captured using portable bedside US before and during the strain phase of a standardized Valsalva maneuver (Fig 1) on hospitalized patients who were either admitted for ADHF or undergoing HD. For HD patients (n=11), percent change in IJ CSA with Valsalva (ΔCSA) was assessed both before and after HD treatment. For ADHF patients (n=37), ΔCSA was measured both at admission and discharge. Results: For HD patients, analysis of US images detected elevated filling pressures (ΔCSA &lt;17%) in 11 of the patients studied. In these subjects, a mean fluid volume of 1.8L was removed and 10 subjects demonstrated an increased ΔCSA after HD (ΔCSA increase of 45 ± 40%, p17% indicating restoration of normal filling pressures. Of the 37 ADHF patients studied with elevated filling pressures at admission (ΔCSA &lt;17%), 27 demonstrated euvolemia after diuresis (ΔCSA increase of 57 ± 157%, p&lt;0.01) and an average length of stay of 7.8 days. Conclusion: US of the IJ can be used to examine intravascular volume status in response to fluid changes that occur over the course of hours (HD) or days (ADHF). This simple bedside technique could be utilized for monitoring volume changes, both acutely and longer term, to guide volume management and overcome some of the difficulties associated with traditional visual assessment of jugular venous pulsations.

Grundelemente der sonographischen Venenabklärung beim offenen Bein

Venous hypertension due to venous insufficiency causes venous ulcers. Duplexsonography is a widely accepted non invasive method to assess venous insufficiency with venous reflux measurements. Retrograde venous flow is defined as venous reflux. The testing of venous reflux is reliable if transvalvular pressure is sufficiently high and transvalvular flow velocity exceeds 30 cm/s. Reflux testing in the proximal leg veins (V. femoralis communis, V. femoralis, V. saphena magna) is done using a standardised Valsalva Manoeuvre (exspiration into a tube up to a pressure of 30 mmHg, pressure established within 0.5 seconds, pressure hold for 3 seconds). Distal leg vein testing (V. poplitea, V. tibialis posterior, V. saphena parva) is recommended with a two handed - compression distally to the tested veins. The most important parameter is venous reflux time, a cut off of > 2 seconds is recommended.

Venous Reflux and Venous Distensibility in Varicose and Healthy Veins

Objectives The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins. Methods Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre. Results Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 – 0.81) p<0.0001, Mann-Whitney). Conclusion Relative venous diameter - changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.

Venous Reflux and Venous Distensibility in Varicose and Healthy Veins

The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins. Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre. Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 - 0.81) p<0.0001, Mann-Whitney). Relative venous diameter--changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.

Assessment of Mitral Inflow During Standardized Valsalva Maneuver in Stratification of Diastolic Function

We assessed the changes of mitral inflow during Valsalva maneuver (VM) in patients with different stages of left ventricular dysfunction and evaluated their value for the differentiation between normal and pseudonormal filling pattern. A total of 190 patients (120 with coronary artery disease, and 70 healthy subjects) were examined by transthoracic echocardiography. Mitral E/A ratio, early wave deceleration time (Edt), and pulmonary vein flow (especially atrial reversal parameters (Ar)), were used for the initial stratification to normal, delayed relaxation, pseudonormal, and restrictive profiles. Changes of mitral inflow during VM were compared between 54 normal (N) and 15 pseudonormal (PN). During VM, a similar decrease in early wave peak velocity (-30 +/- 18 vs -35 +/- 17 cm/sec), peak velocity of atrial wave (-6 +/- 16 vs -8 +/- 17 cm/sec), and E/A ratio (-0.4 +/- 0.4 vs -0.4 +/- 0.4) was observed in both groups. Only two filling variables, related to atrial phase of inflow, changed in the opposite direction. In normal pattern, the duration and velocity-time integral of atrial wave diminished during VM as opposed to pseudonormal subjects (DeltaAt -7 +/- 39 vs 20 +/- 44 msec; P < 0.05 and DeltaA vti -0.7+/-1.8 vs 0.4+/-2 cm; P < 0.05). Increase in peak atrial velocity and marked decrease in E/A ratio during VM were specific for the restrictive group. Changes of mitral inflow during VM have a moderate diagnostic value for the differentiation of normal and pseudonormal pattern. Increased duration of atrial phase but not increase in atrial velocity allowed the diagnosis of pseudonormalization.

Effects of thoracic blood volume on Valsalva maneuver.

The Valsalva maneuver (VM) is frequently used to test autonomic function. However, the VM is also affected by changes in blood volume and blood volume redistribution. We hypothesized that even a standardized VM may produce a wide range of thoracic blood volume shifts. Larger blood volume shifts in some normovolemic individuals may be sufficient to induce decreases in blood pressure (BP) that preclude autonomic restoration of BP in phase II of the VM. To test this hypothesis, we studied 17 healthy volunteers aged 15-22 yr. All had similar vasoconstrictor responses when supine and upright and normal blood volume measurements. We assessed changes in thoracic blood volume by impedance plethysmography before and during the VM performed while subjects were supine. In some subjects, large decreases in BP were produced by thoracic hypovolemia. The maximum fractional decrease in BP correlated well (r(2) = 0.64; P < 0.001) with thoracic hypovolemia and with systolic BP at the end of phase II of the VM (r(2) = 0.67; P < 0.001). The BP overshoot in phase IV of the VM was uncorrelated to phase II changes, which suggests intact autonomic vasoconstriction. We conclude that the BP decrease during the VM is related to a variable decrease in thoracic blood volume that may be sufficient to preclude pressure recovery during phase II even with normal resting peripheral vasoconstriction. The VM depends on vascular as well as autonomic activation, which broadens its utility but complicates its analysis.

Uterine contractility in women whose fetus is delivered in the occipitoposterior position

Objective: Most fetuses in the occipitoposterior position rotate spontaneously after striking the pelvic floor. The increased prevalence of prolonged labor, operative delivery, and oxytocin augmentation in women with an occipitoposterior fetal position seems consistent with decreased uterine contractility. We sought to test the hypothesis that women with a persistent occipitoposterior fetal position have inadequate intrauterine pressure. Study Design: Intrauterine pressure was measured prospectively electronically in 94 women whose labor pain was controlled by patient-requested epidural analgesia. Eleven women (12%) were delivered as a persistent occipitoposterior fetal position. In a nested case-control study, these women were compared with 22 women who were delivered as an occipitoanterior fetal position who were matched for age, parity, gestational age, cervical examination at study enrollment, and body mass index. The intrauterine pressure measurements were initiated during the first stage of labor and continued throughout the entire labor process. Women were encouraged in the second stage of labor, after a period of recording baseline contractility, to push using a standardized Valsalva maneuver once the vertex reached the +2 station. The area under the intrauterine pressure curve (integral) was used to estimate uterine contractility and expulsive performances. Results: Five women (45%) in the occipitoposterior group required operative delivery. The average duration of the second stage of labor in the occipitoposterior group was 91.4 ± 23.2 minutes compared with 51.7 ± 6.6 minutes in the occipitoanterior fetal position (P =.04). Ninety percent of women in the occipitoposterior group required oxytocin, compared with 59% of the women in the occipitoanterior group (P =.11). There were no differences in uterine contractility between occipitoposterior and occipitoanterior groups during either the first stage of labor (integral mean ± SEM: occipitoposterior [1685.3 ± 194.6 mm Hg · s] vs occipitoanterior fetal position [1700.8 ± 128.9 mm Hg · s, P =.98]) or second stages of labor (occipitoposterior [1952.6 ± 186.5 mm Hg · s] vs occipitoanterior fetal position [1740.8 ± 104.3 mm Hg · s, P =.46]). Further, there were no significant differences in pushing performances between the occipitoposterior and occipitoanterior groups (Valsalva maneuver: occipitoposterior 2864.9 ± 328.8 mm Hg · s] vs occipitoanterior [2898.6 ± 222.2 mm Hg · s, P =.90]). Conclusion: Women who were delivered as a persistent occipitoposterior fetal position do not have lower intrauterine pressure levels immediately before or during the second stage of labor. (Am J Obstet Gynecol 2003;188:734-9.)