Valsalva Maneuver - Role in Cardiology

Introduction

The Valsalva maneuver was first described by an Italian physician, Antonio Maria Valsalva. The Valsalva maneuver increases the intrathoracic pressure, reducing preload to the heart. This maneuver quickly returns the abnormal heart rhythm to normal. However, the Valsalva maneuver works for specific heart rhythms and does not always work. This article gives insight into the particulars of the Valsalva maneuver.

What Does the Valsalva Maneuver Mean?

The Valsalva maneuver is a breathing technique in which forced expiration of air is performed against a closed glottis. It is performed by closing the mouth, pinching the nose shut, and forcing the air out like blowing a balloon. This technique can help unclog the ears, restore the heart rhythm, or diagnose an autonomic nervous system disorder. It helps restore a fast heart rhythm called supraventricular tachycardia. It is used for assessing the status of autonomic function, for termination of arrhythmias, and as a marker for cardiac failure, murmur differentiation, and other indications.

What Are the Uses of Valsalva Maneuver?

The Valsalva maneuver can be used to diagnose and treat various conditions. It includes the following:

• The Valsalva maneuver can slow the heart rate and stop an abnormal heart rhythm called supraventricular tachycardia. It terminates the tachycardia by increasing the vagal activity, causing an increase in refractoriness of the atrioventricular node interrupting the re-entry.

• It helps to diagnose the type of heart murmur.

• It helps the healthcare provider to diagnose heart failure. Heart failure patients show an abnormal increase in blood pressure in response to the Valsalva maneuver due to an abnormal ventricular function.

• It helps diagnose other conditions, such as venous disease or a varicocele (a swollen vein in the scrotum).

• It helps diagnose autonomic nervous system disorders, which control the heartbeat, breathing, and other functions. It helps to evaluate cardiac autonomic neuropathy.

• It helps clear clogged ears.

• It helps to diagnose varicocele and bleeding points at the end of thyroid surgery.

• It assists in the radiological study of venous disease, liver hemangiomas, and foramen ovale.

• It helps to confirm the absence of cerebrospinal fluid leaks and the presence of hemostasis after neurological procedures.

• It also helps reduce venipuncture pain in pregnant women.

• The Valsalva maneuver also helps reduce pain during a lumbar puncture.

• It also helps to diagnose the presence of oroantral communication between the oral cavity and the maxillary sinus.

• It helps diagnose intrinsic sphincteric deficiency during urodynamic tests.

• It helps in the diagnosis of Arnold-Chiari malformation, in which headache and pain occur while performing the Valsalva maneuver.

How Is the Valsalva Maneuver Performed?

The patient is asked to breathe after sitting or lying on the back. The patient is then asked to breathe out against the closed mouth and nose against resistance, holding it for 15 to 20 minutes, and then breathe out by opening the nose and mouth. Two versions of the Valsalva maneuver can help control supraventricular tachycardia. It includes the following:

• In the modified version of the Valsalva maneuver, the healthcare provider raises the legs right after the patient stops straining. This works better than the standard version of the Valsalva maneuver because raising the legs helps more blood to return to the heart.

• In the reverse Valsalva maneuver, the patient is asked to sit and inhale for 10 seconds keeping the mouth and nose open.

Phases of the Valsalva Maneuver:

• Phase I corresponds to the onset of strain. It is associated with a temporary rise in blood pressure due to the emptying of blood from the large veins and pulmonary circulation.

• Phase II follows when positive intrathoracic pressure reduces the venous return to the heart. The reduced venous return reduces the preload and stroke volume. The blood pressure then recovers.

• Phase III is a transient phase that involves the release of strain, which causes a sudden fall in blood pressure. This causes an expansion in the pulmonary vascular bed and causes a transient fall in blood pressure.

• Phase IV corresponds to the extreme rise in blood pressure above the baseline. This is due to the resumption of normal venous return to the heart. This rise in blood pressure stimulates bradycardia (reduced heart rate) and returns the blood pressure to baseline.

What Are the Contraindications for the Valsalva Maneuver?

The Valsalva maneuver increases the pressure in the eyes and belly. It should not be performed if retinopathy is present or intraocular lens implants are present after a cataract surgery. It is also contraindicated in coronary artery disease, heart valve disease, and congenital heart diseases. Performing the Valsalva maneuver may cause syncope, chest pain, and arrhythmias in some patients. Hence, the Valsalva maneuver should be performed with caution.

What Are the Effects of the Valsalva Maneuver?

The Valsalva maneuver is an effective method to stop supraventricular tachycardia without medications. If the Valsalva maneuver is successful, the heart rate slows down in a minute. Suppose this does not stop the supraventricular tachycardia after three attempts. In that case, the healthcare provider will proceed with procedures like carotid massage, electric cardioversion, or medications based on the symptoms and the type of tachycardia.

What Are the Complications Associated With Valsalva Maneuver?

The Valsalva maneuver is a safe method, but it can cause the following complications in some individuals:

• Fainting.

• Chest pain.

• Abnormal heart rhythms.

• Stroke.

It also causes side effects like hypotension and a sudden blood pressure decrease. It may cause complications like lightheadedness, syncope, or loss of consciousness. It can cause the eardrum to rupture if exhaling against resistance is done too hard.

Conclusion

The Valsalva maneuver is a breathing technique in which forced expiration of air is performed against a closed glottis. It helps quickly return the abnormal heart rhythm to normal. It restores supraventricular tachycardia and helps in various other functions. The Valsalva maneuver is a noninvasive technique to terminate the abnormal heart rhythm. However, the Valsalva maneuver does not reduce the heart rhythm every time, and it is essential to discuss with the doctor if it does not work.