What is the difference between Left Ventricular (LV) mild dilatation and Valsalva maneuver?

From the Guidelines

For assessing left ventricular (LV) function, particularly in the context of diastolic dysfunction, the Valsalva maneuver is a valuable adjunct to standard echocardiography, as it can help unmask 'pseudonormal' mitral inflow patterns, indicating high LV filling pressures 1. When evaluating LV cavity size and function, it's crucial to consider the clinical implications of various echocardiographic measurements. The Valsalva maneuver can change the mitral inflow pattern from 'pseudonormal' to 'impaired relaxation', suggesting high LV filling pressures, which is a critical aspect of diagnosing and managing heart failure 1. Some key points to consider in the assessment of LV function include:

• The E/e' ratio, where high values (>15) indicate high LV filling pressures, and low values (<8) suggest normal LV filling pressures 1.
• The mitral inflow E/A ratio, which can be 'restrictive' (>2), indicating high LV filling pressure and volume overload, or 'impaired relaxation' (<1), suggesting delayed LV relaxation with normal LV filling pressure 1.
• The response of mitral inflow to the Valsalva maneuver, where a change from 'pseudonormal' to 'impaired relaxation' pattern (with a decrease in E/A ratio ≥0.5) indicates high LV filling pressure 1. Given the information from the European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure 1, the Valsalva maneuver provides additional diagnostic value in assessing LV diastolic function, especially when standard measurements are inconclusive or suggest 'pseudonormal' patterns.

From the Research

Comparison of LV Mild Cavity Test and Valsalva Maneuver

• The Valsalva maneuver is a technique used to aid in the diagnosis of various heart conditions, including left ventricular outflow tract obstruction and diastolic dysfunction 2, 3.
• In patients with hypertrophic cardiomyopathy, the Valsalva maneuver and exercise echocardiography can be used to induce latent left ventricular outflow tract gradients, with similar degrees of gradient induction 4.
• The Valsalva maneuver has been shown to be a useful tool in evaluating filling pressures in patients with heart failure, with a significant correlation between the cardiovascular response to the maneuver and invasively measured ventricular filling pressures 3.
• Echocardiographic evaluation of the Valsalva maneuver has been used to assess left ventricular function in healthy subjects and patients with and without heart failure, with differences in left ventricular internal dimensions and calculated stroke volume observed between groups 5.

Clinical Applications

• The Valsalva maneuver can be used to decrease preload and provoke left ventricular outflow tract gradient in dynamic left ventricular outflow tract obstruction 2.
• A decrease in E/A ratio in mitral inflow >50% with Valsalva correlates with increased left ventricular filling pressure and diastolic dysfunction 2.
• The Valsalva maneuver can also be used to unmask a patent foramen ovale with the use of saline contrast 2.

Limitations and Considerations

• Correct and adequate performance of the Valsalva maneuver is often missed, highlighting the need for proper technique and interpretation 2.
• The Valsalva maneuver may not be suitable for all patients, and exercise echocardiography may be necessary for clinical management in certain cases 4.