Self- and Goal-Directed Valsalva Maneuver vs Exercise in Eliciting Left Ventricular Outflow Tract Obstruction

In symptomatic patients with hypertrophic cardiomyopathy (HCM), eliciting left ventricular outflow tract obstruction (LVOTO) is critical. A self-directed Valsalva (SDV) and exercise (EX) are frequent tools used to unmask obstruction in HCM patients. SDV is often not performed correctly leading to variable results and underestimation of the true provocable LVOT gradient. Alternatively, a standardized, goal-directed Valsalva (GDV) approach by maintaining an intraoral pressure 40 mm Hg for 10 seconds or more provides a more objective, reproducible result. We previously demonstrated the superiority of GDV compared to SDV in eliciting LVOTO both in patients on and off cardiac myosin inhibitor therapy. However, comparison between EX and GDV is limited.

The objective was to compare the efficacy of EX, GDV, and SDV in eliciting LVOTO in patients.

In this prospective study, patients with HCM or suspicion for obstructive physiology performed a same-day rest transthoracic echocardiogram with SDV and GDV and stress echo evaluating LVOT gradients.

A total of 59 patients were included. The mean age was 55 years; 55% of patients were men, and the average wall thickness was 17 mm. Mean peak LVOT gradient was significantly higher with EX (49 mm Hg) compared to GDV (33 mm Hg) or SDV (26 mm Hg); P < 0.01. More patients were reclassified to obstructive physiology with EX (25%) compared to SDV (8%) and severe obstructive HCM (15%) compared to GDV (8%); P < 0.05.

While GDV is superior to SDV, post-EX stress echo remains the gold standard in evaluating symptomatic patients with clinical concern for obstructive physiology.