How does the Valsalva (forced exhalation) maneuver affect mitral regurgitation seen on echocardiogram (echo)?

From the Guidelines

The Valsalva maneuver typically decreases the severity of mitral regurgitation seen on echocardiogram. This is because during the strain phase of the Valsalva maneuver, increased intrathoracic pressure reduces venous return to the heart, resulting in a smaller left ventricular volume and reduced regurgitant flow across the mitral valve 1. The effect is most pronounced in patients with functional or secondary mitral regurgitation, where the regurgitation is due to left ventricular dilation or papillary muscle displacement rather than primary valve leaflet abnormalities.

Some key points to consider when using the Valsalva maneuver to assess mitral regurgitation include:

• The maneuver is performed by having the patient take a deep breath and bear down as if straining during a bowel movement for 10-15 seconds while imaging continues
• After release of the strain, there is typically a transient increase in regurgitation as venous return suddenly increases, before returning to baseline
• Echocardiographers often use the Valsalva maneuver as a dynamic assessment tool to differentiate between functional and organic mitral regurgitation or to unmask dynamic left ventricular outflow tract obstruction
• The Valsalva maneuver may reflect a change from the pseudonormal to the impaired relaxation pattern, suggesting high LV filling pressures, as indicated by a decrease in E/A ratio >0.5 1

In clinical practice, the Valsalva maneuver is a useful tool for assessing mitral regurgitation and guiding treatment decisions, particularly in patients with functional or secondary mitral regurgitation. By reducing the severity of mitral regurgitation, the Valsalva maneuver can help improve cardiac function and reduce symptoms in these patients.

From the Research

Effect of Valsalva Maneuver on Mitral Regurgitation

• The Valsalva maneuver, which involves forced exhalation, can affect the severity of mitral regurgitation seen on echocardiogram 2.
• During the strain phase of the Valsalva maneuver, the intensity of the murmur of mitral regurgitation decreases 2.
• This decrease in murmur intensity is due to the increased intrathoracic pressure, which reduces the left ventricular preload and subsequently decreases the regurgitant volume 2.
• Echocardiography is a useful non-invasive technique for evaluating patients with mitral regurgitation and can be used to assess the effect of the Valsalva maneuver on mitral regurgitation 2.

Mechanism of Mitral Regurgitation

• Mitral regurgitation occurs when the mitral valve does not close properly, allowing blood to flow backward from the left ventricle into the left atrium 3, 4.
• The severity of mitral regurgitation can be quantified using Doppler-echocardiographic methods 3.
• Mitral regurgitation can be caused by various factors, including degenerative valve disease, ischemic heart disease, and rheumatic heart disease 3, 4.

Treatment of Mitral Regurgitation

• Medical treatment for mitral regurgitation includes digitalis, diuretics, and vasodilators, but surgery is the only treatment proven to improve symptoms and prevent heart failure 3, 2.
• Valve repair is preferred over valve replacement, as it improves outcome and reduces mortality in patients with severe organic mitral regurgitation 3.
• The Valsalva maneuver can be used as a diagnostic tool to assess the severity of mitral regurgitation, but it is not a treatment for the condition itself 2.