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Goal-Directed Versus Self-Directed Valsalva Maneuver in Patients With Hypertrophic Cardiomyopathy on Cardiac Myosin

Aakash Bavishi1, Marybeth Soutar2, Margaret Kurnides2

  • 1Division of Cardiology, University of Illinois-Chicago, Chicago, Illinois, USA.

JACC. Advances
|January 31, 2025
PubMed

Insights

The goal-directed Valsalva (GDV) maneuver provides a more accurate assessment of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy patients than the self-directed Valsalva (SDV). GDV improves management of obstructive HCM on mavacamten by reclassifying severity and reducing follow-up tests.

Area of Science:

  • Cardiology
  • Diagnostic Imaging
  • Pharmacology

Background:

  • The Valsalva maneuver is critical for assessing left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM).
  • Traditional self-directed Valsalva (SDV) instructions are vague, leading to inaccurate LVOT gradient measurements.
  • A standardized goal-directed Valsalva (GDV) maneuver offers objective and reproducible results for LVOT gradient assessment.

Purpose of the Study:

  • To compare the clinical impact of GDV versus SDV in obstructive HCM patients treated with mavacamten.
  • To evaluate how different Valsalva maneuver techniques affect LVOT gradient measurements in patients on cardiac myosin inhibitor therapy.

Main Methods:

  • A prospective study involving patients with obstructive HCM undergoing mavacamten therapy.
  • Patients performed both SDV and GDV maneuvers, with peak LVOT gradient (pLVOTg) measured at rest and during each maneuver.
  • Transthoracic echocardiograms (TTEs) were used to assess pLVOTg.

Main Results:

  • Mean pLVOTg was significantly higher with GDV (31 mm Hg) compared to SDV (24 mm Hg) in initial post-mavacamten TTEs.
  • Fewer patients maintained a pLVOTg ≤20 mm Hg with GDV (43%) versus SDV (63%).
  • GDV was associated with fewer medication dose reductions and reduced TTE follow-up frequency.

Conclusions:

  • GDV significantly alters patient management in obstructive HCM on mavacamten by more accurately reclassifying disease severity.
  • Utilizing GDV can prevent unnecessary medication dose reductions and decrease the need for frequent TTE follow-ups.
  • Standardized GDV improves the precision of LVOT gradient assessment, crucial for optimizing cardiac myosin inhibitor therapy.
Abstract

Keywords:
Valsalvahypertrophic cardiomyopathyobstructiontransthoracic echocardiography

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