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Bandyopadhyay A, Puri S, Samra T, Ashok V. Preeclamptic heart failure - perioperative concerns and management: a narrative review. Perioper Med (Lond) 2024; 13:37. [PMID: 38730290 PMCID: PMC11083801 DOI: 10.1186/s13741-024-00391-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.
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Affiliation(s)
- Anjishnujit Bandyopadhyay
- Department of Anaesthesiology, Pain Medicine and Critical Care, JPNATC, All India Institute of Medical Science, New Delhi, India
| | - Sunaakshi Puri
- Department of Paediatric Anaesthesia, Post Graduate Institute of Child Health, Noida, India
| | - Tanvir Samra
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vighnesh Ashok
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Soh MS, Jang JH, Park JS, Shin JH. Effects of high-gravity acceleration forces and anti-gravity maneuver on the cardiac function of fighter pilots. Sci Rep 2024; 14:8749. [PMID: 38627423 PMCID: PMC11021439 DOI: 10.1038/s41598-024-59274-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/09/2024] [Indexed: 04/19/2024] Open
Abstract
The fighter pilots exposed to high gravitational (G) acceleration must perform anti-G maneuvers similar to the Valsalva maneuver. However, the effects of high-G acceleration and anti-G maneuvers on cardiac function have rarely been studied. This study aimed to investigate the effects of high-G forces on cardiac function of fighter pilots. Fighter pilots who underwent regular health check-ups and echocardiography were included (n = 29; 100% men, 41 ± 10 years old; mean flight time, 1821 ± 1186 h). Trainees who had not experienced any flights were included in the control group (n = 16; 100% men, 36 ± 17 years old). Echocardiographic data included left ventricular chamber size, systolic and diastolic functions, right ventricular systolic pressure (RVSP), inferior vena cava (IVC) collapsibility, and tricuspid annular plane systolic excursion (TAPSE). No significant differences in left ventricular ejection fraction, RVSP, or IVC collapsibility were observed between two groups. In the multivariate linear regression analysis with total flight time as an independent continuous variable for fighter pilots, TAPSE was positively correlated with total flight time. The experience of fighter pilots who were exposed to high-G acceleration forces and anti-G maneuvers did not cause cardiac structural changes, but the exposure might be associated with right heart function changes.
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Affiliation(s)
- Moon-Seung Soh
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Hyuk Jang
- Division of Cardiology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Korea
| | - Jin-Sun Park
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea
| | - Joon-Han Shin
- Department of Cardiology, Ajou University School of Medicine, Suwon, Korea.
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Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
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Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Biddix B, Hainstock M, Vergales J, Shorofsky M, Conaway M, Mutters T, McCulloch MA. Standard volume infusion unmasked diastolic dysfunction in pediatric heart transplant recipients during surveillance cardiac catheterization, but without echocardiographic correlates. Pediatr Transplant 2022; 26:e14323. [PMID: 35642670 DOI: 10.1111/petr.14323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/27/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adult experience evaluating left ventricular diastolic function (LVDFx) includes volume administration during catheterization while obtaining pulmonary capillary wedge pressures (PCWP) or left ventricular end diastolic pressures (LVEDP). Catheterization is inherently challenging in pediatric patients, making echocardiographic assessment ideal. Pediatric echocardiographic studies predicting LVDFx have variable hemodynamic and hydration conditions and have produced inconsistent results. We evaluated the association between simultaneous echocardiographic and catheterization assessment of LVDFx, using a fluid bolus for optimal loading conditions. METHODS Prospective cohort study of pediatric heart transplant recipients receiving echocardiogram simultaneous with routine cardiac catheterization. Mitral valve inflow velocities, septal and lateral wall tissue Doppler indices, and PCWP and/or LVEDP were obtained and repeated following a 10 ml/kg bolus. Echocardiographic parameters were evaluated for an association with changes in PCWP or LVEDP following the bolus. Abnormal LVDFx was defined as PCWP or LVEDP ≥12 mm Hg. RESULTS Twenty-nine patients underwent catheterization. Median pre-bolus PCWP and LVEDP were 11.0 mm Hg and 10.0 mm Hg, respectively. After bolus, median PCWP and LVEDP increased to 14.0 mm Hg (p < .001) and 13 mm Hg (p < .001), respectively. Of 21 patients with normal pre-bolus catheterization hemodynamics, 14 (66.7%) increased to abnormal following fluid bolus. Using area under an ROC, no echocardiographic parameter of LVDFx, or their ratios, were associated with predetermined abnormal LVEDP and/or PCWP. CONCLUSION After bolus, our cohort demonstrated significant increases in LVEDP and/or PCWP, unmasking diastolic dysfunction. Fluid challenges should be considered in pediatric patients undergoing cardiac catheterization with suspected diastolic dysfunction. Echocardiographic measurements were unable to discriminate between normal and abnormal LVEDP and/or PCWP.
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Affiliation(s)
- Ben Biddix
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
| | - Michael Hainstock
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
| | - Jeffrey Vergales
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
| | - Michael Shorofsky
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
| | - Mark Conaway
- Divison of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Tracey Mutters
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
| | - Michael A McCulloch
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia Health System, Virginia, USA
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(Physiology of Continuous-flow Left Ventricular Assist Device Therapy. Translation of the document prepared by the Czech Society of Cardiology). COR ET VASA 2022. [DOI: 10.33678/cor.2022.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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6
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Dikshit MB. Cardiovascular Responses to Commonly Used Tests in and Outside of the Laboratory Settings. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2022. [DOI: 10.1055/s-0042-1744391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractSeveral tests are available for assessing cardiovascular response to various interventions which may be given in the laboratory, or outside of it in the field. The tests are meant to excite or deactivate cardiovascular and other sensory receptors which signal the central mechanisms. They have been found useful in generating data to study cardiovascular effects on subjects exposed to specialized physical training (e.g., athletes), in the evaluation of people engaged in special occupations such as pilots, astronauts, and other military personnel, and in training undergraduate and postgraduate students. If the response does not fit into the physiological norm, it may reflect a temporary aberration, or a more serious defect in the cardiovascular control mechanism because of disease. Interpretation of data generated may vary between various operators/observers. Here, an attempt has been made to bring out responses of the cardiovascular system to the commonly used tests, and their applicability in clinical situations.
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Affiliation(s)
- Mohan B. Dikshit
- Formerly Department of Physiology and Clinical Physiology, College of Medicine and Sultan Qaboos Hospital, Sultan Qaboos University, Muscat, Oman
- Formerly Department of Physiology, Maharashtra Institute of Medical Education and Research Medical College, Pune, Maharashtra, India
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Rosenbaum AN, Antaki JF, Behfar A, Villavicencio MA, Stulak J, Kushwaha SS. Physiology of Continuous-Flow Left Ventricular Assist Device Therapy. Compr Physiol 2021; 12:2731-2767. [PMID: 34964115 DOI: 10.1002/cphy.c210016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The expanding use of continuous-flow left ventricular assist devices (CF-LVADs) for end-stage heart failure warrants familiarity with the physiologic interaction of the device with the native circulation. Contemporary devices utilize predominantly centrifugal flow and, to a lesser extent, axial flow rotors that vary with respect to their intrinsic flow characteristics. Flow can be manipulated with adjustments to preload and afterload as in the native heart, and ascertainment of the predicted effects is provided by differential pressure-flow (H-Q) curves or loops. Valvular heart disease, especially aortic regurgitation, may significantly affect adequacy of mechanical support. In contrast, atrioventricular and ventriculoventricular timing is of less certain significance. Although beneficial effects of device therapy are typically seen due to enhanced distal perfusion, unloading of the left ventricle and atrium, and amelioration of secondary pulmonary hypertension, negative effects of CF-LVAD therapy on right ventricular filling and function, through right-sided loading and septal interaction, can make optimization challenging. Additionally, a lack of pulsatile energy provided by CF-LVAD therapy has physiologic consequences for end-organ function and may be responsible for a series of adverse effects. Rheological effects of intravascular pumps, especially shear stress exposure, result in platelet activation and hemolysis, which may result in both thrombotic and hemorrhagic consequences. Development of novel solutions for untoward device-circulatory interactions will facilitate hemodynamic support while mitigating adverse events. © 2021 American Physiological Society. Compr Physiol 12:1-37, 2021.
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Affiliation(s)
- Andrew N Rosenbaum
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
| | - James F Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Atta Behfar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA.,VanCleve Cardiac Regenerative Medicine Program, Center for Regenerative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sudhir S Kushwaha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, Minnesota, USA
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Konecny J, Konecny T. Sleep Apnea, Septal Myectomy, and the Valsalva/Mueller Maneuvers: Who Can Resist Loving Hemodynamic Physiology? Mayo Clin Proc 2021; 96:2298-2300. [PMID: 34481593 DOI: 10.1016/j.mayocp.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Jan Konecny
- First Department of Surgery, St. Anne's Hospital, Masaryk University, Brno, Czech Republic
| | - Thomas Konecny
- Department of Medicine, Division of Cardiovascular Diseases, Malcom Randall Veterans Affairs Medical Center, University of Florida Medical Center, Gainesville, FL.
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Obstetric Anesthesia and Heart Disease: Practical Clinical Considerations. Anesthesiology 2021; 135:164-183. [PMID: 34046669 DOI: 10.1097/aln.0000000000003833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Maternal morbidity and mortality as a result of cardiac disease is increasing in the United States. Safe management of pregnancy in women with heart disease requires appropriate anesthetic, cardiac, and obstetric care. The anesthesiologist should risk stratify pregnant patients based upon cardiac disease etiology and severity in order to determine the appropriate type of hospital and location within the hospital for delivery and anesthetic management. Increased intrapartum hemodynamic monitoring may be necessary and neuraxial analgesia and anesthesia is typically appropriate. The anesthesiologist should anticipate obstetric and cardiac emergencies such as emergency cesarean delivery, postpartum hemorrhage, and peripartum arrhythmias. This clinical review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology.
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Modified Method of Contrast Transthoracic Echocardiography for the Diagnosis of Patent Foramen Ovale. BIOMED RESEARCH INTERNATIONAL 2019; 2019:9828539. [PMID: 31211145 PMCID: PMC6532309 DOI: 10.1155/2019/9828539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/02/2019] [Indexed: 12/23/2022]
Abstract
Purpose To compare the sensitivity and specificity of modified and traditional methods of contrast echocardiography of the right portion of the heart in patients with a suspicion of patent foramen ovale (PFO). Methods The study population consisted of 506 patients with high clinical suspicion of PFO. The traditional Valsalva maneuver consists of expiration against a closed glottis after a full inspiration. A modified Valsalva maneuver was performed with a handmade pressure monitoring device, which measured pressure during performance of the Valsalva maneuver. Modified and traditional methods of contrast echocardiography were performed among all patients. Contrast transesophageal echocardiography (TEE) was regarded as the gold standard. Results A total of 279 patients with PFO were confirmed by TEE. 259 cases (sensitivity: 92.83%) were detected by a modified method of contrast echocardiography of the right portion of the heart, while 234 cases were detected using the traditional method (sensitivity: 83.87%). The sensitivity of modified contrast echocardiography of the right portion of the heart was significantly higher than that of the traditional method (92.83% vs. 83.87%, P=0.001). However, there was no significant difference in the specificity of the two methods for the diagnosis of PFO (97.35% vs. 96.03%, P=0.431). Additionally, the results of semiquantitative evaluation of PFO using modified method failed to show a more positive rate than shown by the traditional method (Z=−1.782, P=0.075). Conclusions Modified contrast echocardiography of the right portion of the heart yielded a higher sensitivity than the traditional method, which contributed to the diagnosis of cardiac PFO. The research was a part of a register study (https://register.clinicaltrials.gov/ ClinicalTrials ID: NCT02777359).
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Thiagaraj AK, Hughes-Doichev R, Biederman RWW. Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature. Echocardiography 2019; 36:783-786. [PMID: 30803022 DOI: 10.1111/echo.14297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/28/2019] [Accepted: 02/02/2019] [Indexed: 01/13/2023] Open
Abstract
Patent foramen ovale (PFO) is the most common type of inter-atrial shunt, with prevalence as high as 30%. Detection of PFO has implications in patients with stroke, peripheral embolism, decompression illness, and other conditions. Transesophageal echo (TEE) with saline contrast injection is the current standard for PFO detection, but even with TEE, PFOs are sometimes missed. With advances in percutaneous PFO closure therapies and proven long-term benefit of closure, accurate PFO detection takes on cardinal importance. Various provocative maneuvers to enhance PFO detection are in clinical use and have been studied. The Valsalva maneuver has long-held position as the ideal provocation to unmask PFO, but other maneuvers such as cough, sniff, Müller's, and more have gained relevance. In this article, we will examine various maneuvers and discuss their utility in PFO detection.
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Affiliation(s)
- Ashwin K Thiagaraj
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Rachel Hughes-Doichev
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Robert W W Biederman
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
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12
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Obstetric anesthesia management of the patient with cardiac disease. Int J Obstet Anesth 2019; 37:73-85. [DOI: 10.1016/j.ijoa.2018.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/09/2018] [Accepted: 09/19/2018] [Indexed: 02/06/2023]
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Kumar S, Van Ness G, Bender A, Yadava M, Minnier J, Ravi S, McGrath L, Song HK, Heitner SB. Standardized Goal-Directed Valsalva Maneuver for Assessment of Inducible Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2018; 31:791-798. [DOI: 10.1016/j.echo.2018.01.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Indexed: 10/17/2022]
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Intraoperative Valsalva maneuver: a narrative review. Can J Anaesth 2018; 65:578-585. [PMID: 29368315 DOI: 10.1007/s12630-018-1074-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 12/08/2017] [Accepted: 12/20/2017] [Indexed: 01/10/2023] Open
Abstract
The Valsalva maneuver (VM) involves expiratory effort against a closed mouth and/or glottis in the sitting or supine position with the increased intraoral and intrathoracic pressure raised to 40 mmHg for 15-20 sec after which the pressure is suddenly released and the breathing restored to normal. Complex cardiovascular and other physiologic changes occur during the VM. The VM has been used for diagnostic and therapeutic reasons as well as intraoperatively during specific surgical procedures. Although the VM is usually safe, rare complications have been reported. This review examines the published literature surrounding the VM and explores the physiologic changes that occur during its performance. Attempts have been made to understand its intraoperative uses and complications and how these can be prevented.
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Affiliation(s)
- E H Jellinek
- 7 Oxgangs Road, Edinburgh EH10 7BG, Scotland, UK
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Bechis MZ, Rubenson DS, Price MJ. Imaging Assessment of the Interatrial Septum for Transcatheter Atrial Septal Defect and Patent Foramen Ovale Closure. Interv Cardiol Clin 2017; 6:505-524. [PMID: 28886842 DOI: 10.1016/j.iccl.2017.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Transcatheter closure of atrial septal defects and patent foramen ovale has become increasingly common with advances in device and imaging technology. The percutaneous approach is now the preferred method of closure when anatomically suitable. Two-dimensional and 3-dimensional echocardiography determines anatomic suitability by characterizing the interatrial defect and its surrounding structures, and is critical for intraprocedural guidance and postprocedure follow-up. This article provides an overview of interatrial anatomy as it pertains to interventional considerations and discusses the transthoracic, transesophageal, and intracardiac echocardiographic modalities used for periprocedural and intraprocedural imaging of the interatrial septum.
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Affiliation(s)
- Mary Z Bechis
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, La Jolla, CA 92037, USA
| | - David S Rubenson
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, La Jolla, CA 92037, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, La Jolla, CA 92037, USA.
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Naoum C, Kritharides L, Gnanenthiran SR, Martin D, Falk GL, Yiannikas J. Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia. Echocardiography 2017; 34:1305-1314. [PMID: 28722185 DOI: 10.1111/echo.13628] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. METHODS LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10 years) and controls (n=22, 67±6 years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). RESULTS In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3 mm/m2 ; HH, 16±5 vs 9±5 mm/m2 ) and LV diameters (22±3 vs 19±3 mm/m2 ; 21±3 vs 17±3 mm/m2 ) and LV volume (38±8 vs 26±10 mL/m2 ; 31±8 vs 19±9 mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). CONCLUSION VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.
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Affiliation(s)
- Christopher Naoum
- Department of Cardiology, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sonali R Gnanenthiran
- Department of Cardiology, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - David Martin
- Department of Upper Gastrointestinal Surgery, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - John Yiannikas
- Department of Cardiology, Concord Hospital, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. Modeling Pathological Hemodynamic Responses to the Valsalva Maneuver. J Biomech Eng 2017; 139:2612938. [PMID: 28303275 DOI: 10.1115/1.4036258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Indexed: 11/08/2022]
Abstract
The Valsalva maneuver (VM) consisting in a forced expiration against closed airways is one of the most popular clinical tests of the autonomic nervous system function. When properly performed by a healthy subject, it features four characteristic phases of arterial blood pressure (BP) and heart rate (HR) variations, based on the magnitude of which the autonomic function may be assessed qualitatively and quantitatively. In patients with some disorders or in healthy patients subject to specific conditions, the pattern of BP and HR changes during the execution of the Valsalva maneuver may, however, differ from the typical sinusoidal-like pattern. Several types of such abnormal responses are well known and correspond to specific physiological conditions. In this paper, we use our earlier mathematical model of the cardiovascular response to the Valsalva maneuver to show that such pathological responses may be simulated by changing individual model parameters with a clear physiological meaning. The simulation results confirm the adaptability of our model and its usefulness for diagnostic or educational purposes.
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Affiliation(s)
- Leszek Pstras
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, Warsaw 02-109, Poland e-mail:
| | - Karl Thomaseth
- Institute of Electronics, Computer and Telecommunication Engineering, National Research Council, c/o University of Padova (DEI), Via G. Gradenigo 6/b, Padova 35131, Italy e-mail:
| | - Jacek Waniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Ks. Trojdena 4, Warsaw 02-109, Poland e-mail:
| | - Italo Balzani
- Department of Medicine, Sant'Antonio Hospital, Via Jacopo Facciolati 71, Padova 35127, Italy e-mail:
| | - Federico Bellavere
- Rizzola Foundation Hospital, Via Gorizia 1, San Donà di Piave (Venezia) 30027, Italy e-mail:
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Zhao E, Zhang Y, Kang C, Niu H, Zhao J, Sun L, Liu B. Influence of the Valsalva maneuver on cardiac hemodynamics and right to left shunt in patients with patent foramen ovale. Sci Rep 2017; 7:44280. [PMID: 28266661 PMCID: PMC5339784 DOI: 10.1038/srep44280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/06/2017] [Indexed: 12/04/2022] Open
Abstract
The purpose of this study was to investigate the influence of the Valsalva maneuver (VM) on cardiac hemodynamics in patients with patent foramen ovale (PFO). Sixty-five patients who were highly suspected to have PFO were included. The changes in E, A, E/A ratio of mitral valve blood flow, E, A, E/A ratio of tricuspid valve blood flow, left ventricular end-diastolic volume, area and right atrial area during the resting state and the strain phase of the Valsalva maneuver were observed by transthoracic echocardiography (TTE). Statistical analyses were performed using SPSS Version18.0. Compared to the resting state, mitral valve diastolic velocity E and A peaks at the strain phase of the Valsalva maneuver significantly decreased (P < 0.05), left ventricular end diastolic volume(LVEDV) and area(LVEDA) decreased significantly (P < 0.05), while E/A ratio of mitral valve, tricuspid valve systolic velocity E and A peaks and E/A ratio remained unchanged (P > 0.05). PFO hemodynamic changes mainly occurred in the left ventricle when the Valsalva maneuver was performed. The Valsalva maneuver increased pressure in the chest, then pulmonary venous return was impeded, which resulted in left ventricular limited filling, and E and A peaks decreased. The pressure of the left ventricle and atrium was lower than that of the right side, which resulted in right-to-left shunt (RLS) through PFO.
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Affiliation(s)
- Enfa Zhao
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yafei Zhang
- Department of General Surgery, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chunmiao Kang
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hua Niu
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jing Zhao
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Lei Sun
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Baomin Liu
- Department of Ultrasound, Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Pstras L, Thomaseth K, Waniewski J, Balzani I, Bellavere F. The Valsalva manoeuvre: physiology and clinical examples. Acta Physiol (Oxf) 2016; 217:103-19. [PMID: 26662857 DOI: 10.1111/apha.12639] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/12/2015] [Accepted: 12/03/2015] [Indexed: 01/30/2023]
Abstract
The Valsalva manoeuvre (VM), a forced expiratory effort against a closed airway, has a wide range of applications in several medical disciplines, including diagnosing heart problems or autonomic nervous system deficiencies. The changes of the intrathoracic and intra-abdominal pressure associated with the manoeuvre result in a complex cardiovascular response with a concomitant action of several regulatory mechanisms. As the main aim of the reflex mechanisms is to control the arterial blood pressure (BP), their action is based primarily on signals from baroreceptors, although they also reflect the activity of pulmonary stretch receptors and, to a lower degree, chemoreceptors, with different mechanisms acting either in synergism or in antagonism depending on the phase of the manoeuvre. A variety of abnormal responses to the VM can be seen in patients with different conditions. Based on the arterial BP and heart rate changes during and after the manoeuvre several dysfunctions can be hence diagnosed or confirmed. The nature of the cardiovascular response to the manoeuvre depends, however, not only on the shape of the cardiovascular system and the autonomic function of the given patient, but also on a number of technical factors related to the execution of the manoeuvre including the duration and level of strain, the body position or breathing pattern. This review of the literature provides a comprehensive analysis of the physiology and pathophysiology of the VM and an overview of its applications. A number of clinical examples of normal and abnormal haemodynamic response to the manoeuvre have been also provided.
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Affiliation(s)
- L. Pstras
- Institute of Biocybernetics and Biomedical Engineering; Polish Academy of Sciences; Warsaw Poland
| | - K. Thomaseth
- Institute of Electronics, Computer and Telecommunication Engineering; National Research Council; Padua Italy
| | - J. Waniewski
- Institute of Biocybernetics and Biomedical Engineering; Polish Academy of Sciences; Warsaw Poland
| | - I. Balzani
- Department of Medicine; Sant'Antonio Hospital; Padua Italy
| | - F. Bellavere
- Provincial Agency for Health Services (APSS); Trento Italy
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ZHANG XIAOYONG, ZHANG XUEMEI, DING YUZENG, LV XIUHUA. BIOMECHANICS OF POSITIVE INTRATHORACIC PRESSURE AND ITS EFFECTS ON LEFT VENTRICULAR FILLING IN HEALTHY SUBJECTS. J MECH MED BIOL 2015. [DOI: 10.1142/s0219519415400576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aims to explore the biomechanics of positive intrathoracic pressure and its effects on left ventricle (LV) filling in healthy subjects. 30 healthy subjects were enlisted to perform a Valsalva maneuver (VM) with a load of 40[Formula: see text]mmHg lasted 10[Formula: see text]s. LV filling parameters were measured by echocardiography at rest and at 10[Formula: see text]s during the VM. Compared with the at rest values, LV early inflow velocity (E) decreased significantly ([Formula: see text]), late inflow velocity (A) decreased insignificantly ([Formula: see text]), while the E/A ratio decreased significantly ([Formula: see text]) after 10[Formula: see text]s of the strain phase of the VM. LV septal early tissue velocity ([Formula: see text]) and lateral early tissue velocity ([Formula: see text]) of the mitral did not change ([Formula: see text]), while the [Formula: see text] ratio and the [Formula: see text] ratio decreased significantly ([Formula: see text] after 10[Formula: see text]s during the VM. Based on these results, biomechanical analysis suggests that the effects of positive intrathoracic pressure on the LV free wall impede LV diastolic motion, which may be one of the factors contributing to a decrease in E and the E/A ratio. Positive intrathoracic pressure also increases the flow resistance of the LV and pulmonary vasculature, which may contribute to a decrease in E, the [Formula: see text] ratio, and the [Formula: see text] ratio.
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Affiliation(s)
- XIAO-YONG ZHANG
- Center of Ultrasound Medicine Shaanxi Provincial People’s Hospital Xi’an 710068, P. R. China
| | - XUE-MEI ZHANG
- Center of Ultrasound Medicine Shaanxi Provincial People’s Hospital Xi’an 710068, P. R. China
| | - YU-ZENG DING
- Center of Ultrasound Medicine Shaanxi Provincial People’s Hospital Xi’an 710068, P. R. China
| | - XIU-HUA LV
- Department of Radiology, Xijing Hospital Fourth Military Medical University Xi’an 710032, P. R. China
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Zhao E, Wei Y, Zhang Y, Zhai N, Zhao P, Liu B. A Comparison of Transthroracic Echocardiograpy and Transcranial Doppler With Contrast Agent for Detection of Patent Foramen Ovale With or Without the Valsalva Maneuver. Medicine (Baltimore) 2015; 94:e1937. [PMID: 26512622 PMCID: PMC4985435 DOI: 10.1097/md.0000000000001937] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patent foramen ovale (PFO) is a remnant of the fetal circulation exist in 20% of the general population. The purpose of our study was to compare of transthoracic echocardiography (TTE) and contrast-transcranial Doppler sonography (c-TCD) in the diagnosis and quantification of PFO with or without the Valsalva maneuver (VM).We studied 106 patients with a high clinical suspicion for PFO prospectively. Simultaneous c-TCD and TTE were conducted using agitated saline solution to detect right to left shunt (RLS). To classify RLS, mainly PFO, we applied a 4-level visual classification for c-TCD test: no occurrence of micro-embolic signals; grade I, 1 to 10 signals; grade II, 10 to 30 signals but not curtain; and grade III, curtain pattern. We used the number of micro-bubbles appeared in left atrium per frame image to define classification for TTE test: no occurrence of micro-bubbles; grade I, 1 to 10 micro-bubbles; grade II, 10 to 30 micro-bubbles; and grade III, more than 30 micro-bubbles or left atrium nearly filled with micro-bubbles or left atrial opacity. Statistical analyses were performed using SPSS Version 18.0.RLS was detected in 36.0% in c-TCD test and in 46% in TTE test at rest (P = 0.158). And during the VM, RLS was detected in 99.0% in c-TCD test and in 83.0% in TTE test (P < 0.001). Compared with the positive results of c-TCD and TTE at rest, the positive results of them with VM is more higher, respectively (all P < 0.001). The VM obviously increased the number of micro-bubbles shunting.Both c-TCD and TTE should used as initial screening tool for PFO. VM increases the size of shunt. VM resulted in detection of more RLS both in c-TCD and TTE tests.
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Affiliation(s)
- Enfa Zhao
- From the Department of Ultrasound, Second Affiliated Hospital of Medical School, Xi'an Jiao Tong University (EZ, YW, BL); Department of General Surgery, Second Affiliated Hospital, School of Medicine, Xi'an Jiaotong University (YZ); and Transcranial Doppler Sonography Laboratory, Second Affiliated Hospital of Medical School, Xi'an Jiao Tong University, Xi'an, Shaanxi, China (NZ, PZ)
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Losi MA, Izzo R, Stabile E, Sannino A, Canciello G, Giamundo A, Musella F, Cirillo P, Prastaro M, Galderisi M, Trimarco B, Esposito G. Diastolic dysfunction reduces stroke volume during daily's life activities in patients with severe aortic stenosis. Int J Cardiol 2015; 195:64-5. [PMID: 26025858 DOI: 10.1016/j.ijcard.2015.05.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Maria Angela Losi
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy.
| | - Raffaele Izzo
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Anna Sannino
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Grazia Canciello
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Alessandra Giamundo
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Francesca Musella
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Maria Prastaro
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Medical Sciences, University Federico II, Naples, Italy
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24
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Wei D, Ju Y. Importance of an adequately performed Valsalva maneuver for detecting a right-to-left shunt indicating foramen ovale reopening. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:879-883. [PMID: 25911721 DOI: 10.7863/ultra.34.5.879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the importance of an adequately performed Valsalva maneuver for detecting a right-to-left shunt indicating reopening of the functional closure of the foramen ovale. METHODS We prospectively analyzed 260 patients (102 women and 158 men; mean age ± SD, 41 ± 19 years; range, 13-83 years) who underwent transesophageal echocardiography and agitated saline injection. Two-dimensional echocardiography, color Doppler imaging, and microbubbles were used to detect right-to-left shunts, and the Valsalva maneuver was performed to determine whether the functional closure of the foramen ovale had reopened. RESULTS Transesophageal echocardiography with color Doppler imaging identified a patent foramen ovale in 20 patients: 18 patients with a patent foramen ovale had left-to-right shunts, and 2 patients with atrial septal defects had bidirectional shunts. Both patients with atrial septal defects showed right-to-left shunt microbubbles without and with the Valsalva maneuver, whereas all 18 patients with a patent foramen ovale showed right-to-left shunt microbubbles only after the Valsalva maneuver. Foramen ovale reopening was identified by transesophageal echocardiography in an additional 40 patients with no shunt during rest on agitated saline injection and in whom the right-to-left shunt appeared only after the Valsalva maneuver. The Valsalva maneuver could cause an atrial septal swing, and its sensitivity and specificity were 100%. CONCLUSIONS An adequately performed Valsalva maneuver is important for detecting a right-to-left shunt indicating reopening of the functional closure of the foramen ovale.
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Affiliation(s)
- Dongmei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases Center of Stroke, Beijing Institute for Brain Disorders, Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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25
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Bishu K, Coylewright M, Nishimura R. The role of hemodynamic catheterization in the evaluation of hypertrophic obstructive cardiomyopathy: A case series. Catheter Cardiovasc Interv 2015; 86:903-12. [PMID: 25620326 DOI: 10.1002/ccd.25856] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Accepted: 01/18/2015] [Indexed: 01/19/2023]
Abstract
Confirmation of the presence and magnitude of left ventricular outflow tract (LVOT) obstruction is a critical component of the evaluation of symptoms in patients with hypertrophic cardiomyopathy (HCM). The presence of LVOT obstruction in patients with severe symptoms refractory to pharmacologic therapy identifies a subgroup of HCM patients who may benefit from septal reduction therapy. Two-dimensional echocardiography with continuous wave Doppler is the main tool for confirming the presence and severity of LVOT obstruction in HCM. However, when uncertainty remains following non-invasive evaluation, invasive hemodynamics studies are required to confirm and quantify LVOT obstruction. In this manuscript we describe a series of 6 cases in which hemodynamic catheterization is instrumental in supplementing non-invasive imaging in the assessment of LVOT obstruction in HCM.
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Affiliation(s)
- Kalkidan Bishu
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan Coylewright
- Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Rick Nishimura
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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26
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Kowallick JT, Joseph AA, Unterberg-Buchwald C, Fasshauer M, van Wijk K, Merboldt KD, Voit D, Frahm J, Lotz J, Sohns JM. Real-time phase-contrast flow MRI of the ascending aorta and superior vena cava as a function of intrathoracic pressure (Valsalva manoeuvre). Br J Radiol 2014; 87:20140401. [PMID: 25074791 DOI: 10.1259/bjr.20140401] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Real-time phase-contrast flow MRI at high spatiotemporal resolution was applied to simultaneously evaluate haemodynamic functions in the ascending aorta (AA) and superior vena cava (SVC) during elevated intrathoracic pressure (Valsalva manoeuvre). METHODS Real-time phase-contrast flow MRI at 3 T was based on highly undersampled radial gradient-echo acquisitions and phase-sensitive image reconstructions by regularized non-linear inversion. Dynamic alterations of flow parameters were obtained for 19 subjects at 40-ms temporal resolution, 1.33-mm in-plane resolution and 6-mm section thickness. Real-time measurements were performed during normal breathing (10 s), increased intrathoracic pressure (10 s) and recovery (20 s). RESULTS Real-time measurements were technically successful in all volunteers. During the Valsalva manoeuvre (late strain) and relative to values during normal breathing, the mean peak flow velocity and flow volume decreased significantly in both vessels (p < 0.001) followed by a return to normal parameters within the first 10 s of recovery in the AA. By contrast, flow in the SVC presented with a brief (1-2 heartbeats) but strong overshoot of both the peak velocity and blood volume immediately after pressure release followed by rapid normalization. CONCLUSION Real-time phase-contrast flow MRI may assess cardiac haemodynamics non-invasively, in multiple vessels, across the entire luminal area and at high temporal and spatial resolution. ADVANCES IN KNOWLEDGE Future clinical applications of this technique promise new insights into haemodynamic alterations associated with pre-clinical congestive heart failure or diastolic dysfunction, especially in cases where echocardiography is technically compromised.
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Affiliation(s)
- J T Kowallick
- 1 Institute for Diagnostic and Interventional Radiology, Heart Center, University Medical Center Göttingen, Göttingen, Germany
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M. Fadel B, Alenazi A, Al-Admawi M, Di Salvo MG, Bech-Hanssen O. Hemodynamics in Reverse: Paradoxical Increase in Left Ventricular Filling Pressure During the Valsalva Maneuver. Echocardiography 2014. [DOI: 10.1111/echo.12429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Bahaa M. Fadel
- King Faisal Specialist Hospital and Research Center; Riyadh Saudi Arabia
| | - Ali Alenazi
- King Faisal Specialist Hospital and Research Center; Riyadh Saudi Arabia
| | - Mohammad Al-Admawi
- King Faisal Specialist Hospital and Research Center; Riyadh Saudi Arabia
| | | | - Odd Bech-Hanssen
- King Faisal Specialist Hospital and Research Center; Riyadh Saudi Arabia
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28
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Lavine SJ. Diastolic Filling Patterns and the Valsalva Maneuver. Cardiology 2014; 128:352-4. [DOI: 10.1159/000360934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 02/27/2014] [Indexed: 11/19/2022]
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29
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The Mechanics of Left Ventricular Filling During the Strain Phase of the Valsalva Maneuver in Healthy Subjects. Am J Med Sci 2013; 346:187-9. [DOI: 10.1097/maj.0b013e31826af7de] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Heart rate, blood pressure, and vascular tone, as well as ventilator drive, respiratory rate, and breathing pattern, are, at least in part, under the control of specific reflexes. These reflexes are mediated by a complex network of baroreceptors and chemoreceptors in the arterial system of the carotids, aorta, and left heart, including receptors in the left atrium, the ventricle, and the coronary arteries; irritants in the upper airways and stretch receptors in the lower airways; juxtacapillary-located nonmyelinated fibers in the alveoli and in the bronchial arterial system; and muscle spindles that evoke changes in the membrane potential upon alteration of sarcolemmal tension. Some of these reflexes, usually named after the first individual to describe them, have spread as eponyms into propaedeutic education and clinical work. Because these euphonic eponyms are enigmatic to most clinicians today, this article is intended to provide a short overview of these reflexes, including the historical context of their describers. As evidenced by their clinical implications, the eponyms discussed are revealed to be more than curiosities taught during undergraduate medical education.
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Affiliation(s)
- Mattia Arrigo
- Cardiosurgical Intensive Care Unit, University Hospital Zurich, Zurich, Switzerland.
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Hu K, Liu D, Niemann M, Hatle L, Herrmann S, Voelker W, Ertl G, Bijnens B, Weidemann F. Failure to Unmask Pseudonormal Diastolic Function by a Valsalva Maneuver. Circ Cardiovasc Imaging 2011; 4:671-7. [DOI: 10.1161/circimaging.111.966457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
For the clinical assessment of patients with dyspnea, the inversion of the early (E) and late (A) transmitral flow during Valsalva maneuver (VM) frequently helps to distinguish pseudonormal from normal filling pattern. However, in an important number of patients, VM fails to reveal the change from dominant early mitral flow velocity toward larger late velocity.
Methods and Results—
From December 2009 to October 2010, we selected consecutive patients with abnormal filling with (n=25) and without E/A inversion (n=25) during VM. Transmitral, tricuspid, and pulmonary Doppler traces were recorded and the degree of insufficiency was estimated. After evaluating all standard echocardiographic morphological, functional, and flow-related parameters, it became evident that the failure to unmask the pseudonormal filling pattern by VM was related to the degree of the tricuspid insufficiency (TI). TI was graded as mild in 24 of 25 patients in the group with E/A inversion during VM, whereas TI was graded as moderate to severe in 24 of the 25 patients with pseudonormal diastolic function without E/A inversion during VM.
Conclusions—
Our data suggest that TI is a major factor to prevent E/A inversion during a VM in patients with pseudonormal diastolic function. This probably is due to a decrease in TI resulting in an increase in forward flow rather than the expected decrease during the VM. Thus, whenever a pseudonormal diastolic filling pattern is suspected, the use of a VM is not an informative discriminator in the presence of moderate or severe TI.
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Affiliation(s)
- Kai Hu
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Dan Liu
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Markus Niemann
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Liv Hatle
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Sebastian Herrmann
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Wolfram Voelker
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Georg Ertl
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Bart Bijnens
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
| | - Frank Weidemann
- From the Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); Comprehensive Heart Failure Center, Würzburg, Germany (K.H., D.L., M.N., S.H., W.V., G.E., F.W.); ICREA, Universitat Pompeu Fabra, Barcelona, Spain, and K.U. Leuven, Belgium (B.B.); and Faculty of Medicine, Norwegian University of Technology and Science, Trondheim, Norway (L.H.)
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Matyal R, Skubas NJ, Shernan SK, Mahmood F. Perioperative assessment of diastolic dysfunction. Anesth Analg 2011; 113:449-72. [PMID: 21813627 DOI: 10.1213/ane.0b013e31822649ac] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Assessment of diastolic function should be a component of a comprehensive perioperative transesophageal echocardiographic examination. Abnormal diastolic function exists in >50% of patients presenting for cardiac and high-risk noncardiac surgery, and has been shown to be an independent predictor of adverse postoperative outcome. Normalcy of systolic function in 50% of patients with congestive heart failure implicates diastolic dysfunction as the probable etiology. Comprehensive evaluation of diastolic function requires the use of various, load-dependent Doppler techniques This is further complicated by the additional effects of dehydration and anesthetic drugs on myocardial relaxation and compliance as assessed by these Doppler measures. The availability of more sophisticated Doppler techniques, e.g., Doppler tissue imaging and flow propagation velocity, makes it possible to interrogate left ventricular diastolic function with greater precision, analyze specific stages of diastole, and to differentiate abnormalities of relaxation from compliance. Additionally, various Doppler-derived ratios can be used to estimate left ventricular filling pressures. The varying hemodynamic environment of the operating room mandates modification of the diagnostic algorithms used for ambulatory cardiac patients when left ventricular diastolic function is evaluated with transesophageal echocardiography in anesthetized surgical patients.
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Affiliation(s)
- Robina Matyal
- Department of Anesthesia and Critical Care Medicine, Beth Israel Deaconess Medical Center, CC-454, 1 Deaconess Rd., Boston, MA 02215, USA.
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Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelisa A. Recommendations for the evaluation of left ventricular diastolic function by echocardiography. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 10:165-93. [PMID: 19270053 DOI: 10.1093/ejechocard/jep007] [Citation(s) in RCA: 1489] [Impact Index Per Article: 106.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Sherif F Nagueh
- Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
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Smith G, Boyle MJ. The 10âmL syringe is useful in generating the recommended standard of 40âmmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas 2009; 21:449-54. [DOI: 10.1111/j.1742-6723.2009.01228.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA, Waggoner AD, Flachskampf FA, Pellikka PA, Evangelista A. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography. J Am Soc Echocardiogr 2009; 22:107-33. [PMID: 19187853 DOI: 10.1016/j.echo.2008.11.023] [Citation(s) in RCA: 2282] [Impact Index Per Article: 152.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Zöllei E, Paprika D, Csillik A, Rudas L. Valsalva maneuver, Müller maneuver: hemodynamic and reflex mechanisms, relevances. Orv Hetil 2007; 148:343-50. [PMID: 17344157 DOI: 10.1556/oh.2007.27899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A Valsalva- és Müller-manőverek az idő próbáját kiállva, ma is gyakran alkalmazott, egyszerű és népszerű vizsgálóeszközök az orvosi gyakorlatban. A manőverek közönséges élethelyzetek és egyes kórállapotok modellezésére egyaránt alkalmasak. A Valsalva-manővert leginkább neuropathiás betegek autonóm reflex tesztjeként használjuk. Folyamatos noninvazív vérnyomásméréssel kiegészítve, a manőver a hagyományos kardiális, vagális paraméterek mérése mellett a vazomotorválaszok értékelését is lehetővé teszi. A Müller- manővert többnyire obstruktív alvási apnoés (OSA) epizódok szimulálására végeztetjük. A manőver kiegészítése folyamatos vérnyomás-monitorozással és a szimpatikus izom idegaktivitásának (MSNA) mérésével az alvási apnoe szindróma és az ahhoz társuló cardiovascularis betegségek kapcsolatára derít fényt.
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Affiliation(s)
- Eva Zöllei
- Szegedi Tudományegyetem, Szent-Györgyi Albert Orvos- és Gyógyszerésztudományi Centrum Aneszteziológiai és Intenzív Terápiás Intézet, Altalános Intenzív Részleg Szeged Korányi Fasor 7, 6720
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37
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Affiliation(s)
- E H Jellinek
- 7 Oxgangs Road, Edinburgh EH10 7BG, Scotland, UK
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