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Self- and Goal-Directed Valsalva Maneuver vs Exercise in Eliciting Left Ventricular Outflow Tract Obstruction
Aakash Bavishi1, John Fritzlen2, Kutaiba Nazif3
1Department of Cardiology, University of Illinois-Chicago, Chicago, Illinois, USA.
Insights
Exercise stress echo is the gold standard for unmasking left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) patients. While goal-directed Valsalva (GDV) is better than self-directed Valsalva (SDV), neither matches exercise stress echo for diagnosing obstructive HCM.
Area of Science:
- Cardiology
- Echocardiography
- Cardiovascular Imaging
Background:
- Eliciting left ventricular outflow tract obstruction (LVOTO) is critical in symptomatic hypertrophic cardiomyopathy (HCM) patients.
- Self-directed Valsalva (SDV) often yields variable results due to incorrect performance.
- Goal-directed Valsalva (GDV) offers a more objective and reproducible method for unmasking LVOTO.
Purpose of the Study:
- To compare the efficacy of exercise stress echo (EX), goal-directed Valsalva (GDV), and self-directed Valsalva (SDV) in eliciting LVOTO in HCM patients.
Main Methods:
- Prospective study involving 59 HCM patients or those with suspected obstructive physiology.
- Same-day rest transthoracic echocardiogram with SDV and GDV.
- Stress echocardiogram to evaluate LVOT gradients.
Main Results:
- Mean peak LVOT gradient was significantly higher with EX (49 mm Hg) compared to GDV (33 mm Hg) and SDV (26 mm Hg).
- EX reclassified more patients to obstructive physiology (25%) than SDV (8%).
- EX identified severe obstructive HCM in 15% of patients, compared to 8% with GDV.
Conclusions:
- Goal-directed Valsalva (GDV) is superior to self-directed Valsalva (SDV) in eliciting LVOTO.
- Post-exercise stress echo remains the gold standard for evaluating symptomatic patients with suspected obstructive physiology.
- EX is most effective in unmasking LVOTO in HCM patients.
Background:
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.
Objectives:
The objective was to compare the efficacy of EX, GDV, and SDV in eliciting LVOTO in patients.
Methods:
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.
Results:
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.
Conclusions:
While GDV is superior to SDV, post-EX stress echo remains the gold standard in evaluating symptomatic patients with clinical concern for obstructive physiology.
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