Modified Valsalva manoeuvre to treat recurrent supraventricular tachycardia: description of the technique and its successful use in a patient with a previous near fatal complication of DC cardioversion

Effectiveness of modified Valsalva maneuver by using wide bore syringe for emergency treatment of supraventricular tachycardias: Findings from Pakistan

Background and Objectives

The Valsalva maneuver (VM) is the most effective measure that can be carried out to treat supraventricular tachycardia (SVT). Our objective was to compare the efficacy of postural modified VM with 20 ml syringe to standard VM for the emergency treatment of SVT.

Methods

This randomized control trial study was conducted at the Accident and Emergency Department, Pakistan ordinance factories hospital, Wah Cantt from July 2019 to September 2020. In the standard Valsalva group, fifty patients were placed at an angle of 45 with continuous monitoring of vitals and electrocardiogram. Patients blew into a 20ml syringe to generate 40 mmHg pressure for 15 seconds and remained in the same position for 45 seconds before a reassessment of cardiac rhythm at one-minute and three-minute intervals. In the modified Valsalva group same procedure was repeated with the other fifty patients, but immediately at the end of the strain, they were laid flat with their legs raised to 45° for 15 seconds. Participants returned to semi-recumbent position and cardiac rhythm was reassessed after 45 seconds and then at one and three minutes.

Results

In the standard Valsalva maneuver (SVM)20.0% of participants versus 58% of participants in the modified Valsalva maneuvers group(MVM) reverted to sinus rhythm at one min (odds ratio or 5.52, 95% CI 2.26-13.47; p<0.001) and time of stay in the emergency room was (odds ratio or 2.39, 95% CI 1.45- 3.93; p<0.0001).

Conclusion

Modified Valsalva by using a wide-bore syringe is more effective method than standard Valsalva in terminating SVT.

Effectiveness of the modified Valsalva manoeuvre in adults with supraventricular tachycardia: a systematic review and meta-analysis

BACKGROUND AND IMPORTANCE

Cardiac arrhythmia, specifically paroxysmal supraventricular tachycardia (SVT), accounts for a substantial proportion of emergency medical services resources utilisation. Reconversion requires increasing the atrioventricular node's refractoriness, which can be achieved by vagal manoeuvres, pharmacological agents or electrical cardioversion. There are multiple variants of vagal manoeuvres, including the Valsalva manoeuvre (VM). While the effectiveness of the standard VM has already been systematically reviewed, there has been no such analysis for the modified VM.

OBJECTIVES

Compare the effectiveness of the modified VM versus the standard VM in restoring the normal sinus rhythm in adult patients with supraventricular tachycardia.

DESIGN

Systematic review with meta-analysis of published randomised controlled trials.

OUTCOME MEASURES

The primary outcome was the reconversion to a sinus rhythm. Secondary outcomes included: medication use, adverse events, length of stay in the emergency department and hospital admission.

MAIN RESULTS

Five randomised controlled trials were included, with a combined total of 1181 participants. The meta-analysis demonstrated a significantly higher success rate for reconversion to sinus rhythm when using the modified VM compared to the standard VM in patients with an SVT (odds ratio = 4.36; 95% confidence interval, 3.30-5.76; P < 0.001). More adverse events were reported in the modified VM group, although this difference is NS (risk ratio = 1.48; 95% confidence interval, 0.91-2.42; P = 0.11). The available evidence suggests that medication use was lower in the modified VM group than the standard VM group. However, medication use could not be generalised across the different studies. None of the included studies showed a significant difference in length of stay in the emergency department. Only one study reported on hospital admission, with no significant difference between the two groups.

CONCLUSIONS

The available evidence is highly suggestive to support the use of the modified VM compared to the standard VM in the treatment of adult patients with SVT. Meta-analysis showed a higher success rate, required less medication use, and resulted in an equal number of adverse events. However, these results cannot be regarded as definitive in the absence of higher-quality studies.

Modified valsalva versus standard valsalva for cardioversion of supraventricular tachycardia: systematic review and meta-analysis

Background

Supraventricular tachycardia (SVT) is a major cause of emergency room visits where vagal maneuver is used as first-line therapy. The valsalva maneuver (VM) is proven to be safe and, to some extent, effective in terminating SVT episodes. We aimed to compare the standard VM (SVM) to the modified valsalva maneuver (MVM). We hypothesized that MVM is more effective in terminating SVT episodes and reducing the time spent in the emergency department.

Methods

In this systematic review and meta-analysis, we searched Medline/PubMed, Ovid, Web of Science, and Cochrane Central Register of Controlled trials. We included only randomized controlled trials (RCTs) that compared the modified valsalva to the standard valsalva maneuver in treating SVT. Our main outcome was the termination of SVT within 1 min.

Results

Four articles met the eligibility criteria of our review. Sinus rhythm was achieved 2.5 times more in the MVM group compared to the SVM group (risk ratio (RR) = 2.54, CI 1.98–3.24, P < 0.001) and thus lowered the need of intravenous SVT termination medication without any significant increase in adverse events or time spent in the emergency department.

Conclusion

Our review found MVM to be more effective than the SVM in terminating SVT. This should encourage broader adoption of the MVM as a first-line vagal maneuver in subjects presenting with SVT in the emergency room.

Prehospital conversion of paroxysmal supraventricular tachycardia using the modified Valsalva maneuver: A case report

The modified Valsalva maneuver (MVM) has never before been performed in the prehospital setting by the Hamad Medical Corporation Ambulance Service (HMCAS) clinicians in the State of Qatar. Currently, their clinical practice guidelines (CPG) prescribe the vagal maneuver (VM) using a 10 cc syringe as first-line therapy for patients presenting with symptomatic paroxysmal supraventricular tachycardia (pSVT). The effectiveness of the MVM in terminating pSVT compared to the traditional VM is well documented, although prehospital studies in this area are lacking. In this case, a generally healthy, 47-year-old male migrant worker presented with new-onset symptomatic pSVT, which was successfully terminated by a MVM after initial failed attempts of the traditional VM. The MVM is a postural technique performed by initially placing the patient in a semirecumbent position. The patient is then encouraged to blow into a manometer to achieve a 40 mmHg intrathoracic pressure for 15 seconds. Once the 40 mmHg intrathoracic pressure is achieved, the patient is repositioned supine, and their legs are raised passively to 45 degrees for 15 seconds. The patient is then returned to the semirecumbent position for 45 seconds before cardiac rhythm reassessment. The MVM has shown to have an increased termination rate of pSVT with no documented serious adverse events. The MVM can be performed in a time-effective manner and is cost effective as intravenous (IV) cannulation is not required. The prevention of adenosine-associated transient asystole is prevented. It is recommended that ambulance services consider the inclusion of the MVM in their CPGs for the treatment of new-onset pSVT.

A Case Report of Acupuncture at Neiguan Point (P6) for Paroxysmal Supraventricular Tachycardia

Paroxysmal supraventricular tachycardia (PSVT) is a common medical emergency, and this case report describes an acupuncture treatment of traditional Chinese medicine terminating PSVT. In this case report, a 67-year-old female patient diagnosed with PSVT had a recurrence in the ward; accompanying symptoms were heart palpitations and shortness of breath. Modified Valsalva maneuver, the first-line treatment, failed to convert paroxysmal supraventricular tachycardia. However, acupuncture at Neiguan point (P6) for about 1 min on her right hand successfully treated the patient. This case indicates that the application of acupuncture in the clinic may serve as an alternative and complementary treatment for PSVT.

A multicenter randomized controlled trial of a modified Valsalva maneuver for cardioversion of supraventricular tachycardias

CLINICAL QUESTION

Valsalva maneuver is a recognized treatment for supraventricular tachycardia, but in clinical setting it has a low chance to achieve successful cardioversion. Studies suggested that the postural modification of valsalva maneuver may improve the rate of cardioversion. We further modified the maneuver and conduct a multicenter randomized controlled trial to test its efficacy.

RESEARCH IN CONTEXT

Appelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva maneuver for emergency treatment for supraventricular tachycardias (REVERT): a randomized controlled trial. Lancet 2015; 386 (10005):1747-53 [1]. Allison Michaud, PhD, Eddy Lang. Leg lift Valsalva maneuver for treatment of supraventricular tachycardias. CJEM 2017; 19(3):235-237 [2].

OBJECTIVE

To verify the efficacy of the modified Valsalva maneuver in SVT in Chinese population and simplify the operation process further.

Leg Lift Valsalva Maneuver for Treatment of Supraventricular Tachycardias

Clinical question Can conversion to sinus rhythm for a supraventricular tachycardia be enhanced by a postural modification to the Valsalva maneuver? Article chosen Appelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015;386(10005):1747-53. 1 OBJECTIVE: To determine effectiveness of a postural modification of the Valsalva involving leg elevation and supine positioning.

Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial

BACKGROUND

The Valsalva manoeuvre is an internationally recommended treatment for supraventricular tachycardia, but cardioversion is rare in practice (5-20%), necessitating the use of other treatments including adenosine, which patients often find unpleasant. We assessed whether a postural modification to the Valsalva manoeuvre could improve its effectiveness.

METHODS

We did a randomised controlled, parallel-group trial at emergency departments in England. We randomly allocated adults presenting with supraventricular tachycardia (excluding atrial fibrillation and flutter) in a 1:1 ratio to undergo a modified Valsalva manoeuvre (done semi-recumbent with supine repositioning and passive leg raise immediately after the Valsalva strain), or a standard semi-recumbent Valsalva manoeuvre. A 40 mm Hg pressure, 15 s standardised strain was used in both groups. Randomisation, stratified by centre, was done centrally and independently, with allocation with serially numbered, opaque, sealed, tamper-evident envelopes. Patients and treating clinicians were not masked to allocation. The primary outcome was return to sinus rhythm at 1 min after intervention, determined by the treating clinician and electrocardiogram and confirmed by an investigator masked to treatment allocation. This study is registered with Current Controlled Trials (ISRCTN67937027).

FINDINGS

We enrolled 433 participants between Jan 11, 2013, and Dec 29, 2014. Excluding second attendance by five participants, 214 participants in each group were included in the intention-to-treat analysis. 37 (17%) of 214 participants assigned to standard Valsalva manoeuvre achieved sinus rhythm compared with 93 (43%) of 214 in the modified Valsalva manoeuvre group (adjusted odds ratio 3·7 (95% CI 2·3-5·8; p<0·0001). We recorded no serious adverse events.

INTERPRETATION

In patients with supraventricular tachycardia, a modified Valsalva manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.

FUNDING

National Institute for Health Research.

Randomised Evaluation of modified Valsalva Effectiveness in Re-entrant Tachycardias (REVERT) study

INTRODUCTION

The Valsalva manoeuvre (VM) is a recommended first-line physical treatment for patients with re-entrant supraventricular tachycardia (SVT), but is often ineffective in standard practice. A failed VM is typically followed by treatment with intravenous adenosine, which patients often find unpleasant. VM effectiveness might be improved by a modification to posture which exaggerates the manoeuvre's vagal response and reduces the need for further emergency treatment.

METHODS AND ANALYSIS

This is a multicentre randomised controlled clinical trial in 10 UK emergency departments (EDs). It compares a standard VM with a modified VM incorporating leg elevation and a supine posture after a standardised strain in stable adult patients presenting to the ED with SVT. The primary outcome measure is return to sinus rhythm on a 12-lead ECG. Secondary outcome measures include the need for treatment with adenosine or other antiarrhythmic treatments and the time patients spend in the ED. We plan to recruit approximately 372 patients, with 80% power to demonstrate an absolute improvement in cardioversion rate of 12%. An improvement of this magnitude through the use of a modified VM would be of significant benefit to patients and healthcare providers, and justify a change to standard practice.

ETHICS AND DISSEMINATION

The study has been approved by the South West-Exeter Research Ethics Committee (REC reference 12/SW/0281). The trial will be published in an international peer reviewed journal. Study findings will be sent to the European and International resuscitation councils to inform future revisions of arrhythmia management guidelines.

RESULTS

The trial will also be disseminated at international conferences and to patients through the Arrhythmia Alliance, a patient support charity.

REGISTRATION

The study is registered with Current Controlled Trials (ISRCTN67937027) and has been adopted by the National Institute for Health Research (NIHR) Clinical Research Network.