Do Hemodynamic answers to the Valsa...

Do Hemodynamic answers to the Valsalva Maneuver contemplate Myocardial Dysfunction?

Alterations of arterial urgencys aortic blood flow, venous urgency heart rate and cardiac chamber contortions during various phases of the Valsalva maneuver have all been recognized and extensively investigated. [1-8] Abnormal replications in patients with heart failure were described and a specific pattern ("square wave response") recorded during the straing phase was considered a useful clinical tool to support the diagnosis of heart failure. [9-18] Nevertheless, with the exception of a not many clinical studies, [10,16,17,18] no attempts were made to correlate answers to the Valsalva maneuver with the quality of left ventricular dysfunction. The systematic arterial pulsation pressure response is the clinical paradigm of the Valsalva maneuver.

The aim of this subject of attention was to evaluate hemodynamically the relationship between the patter of answer to the Valsalva maneuver of aortic throb pressure and the degree of cardiac dysfunction.

METHODS

Patients

We investigated 14 consecutive patients (mean age, 57 years; range, 33-75 years) undergoing routine diagnostic cardiac and coronary angiography; all gave informed acquiescence Cardiac disability was classified according to NYHA criteria. Table 1 present to views diagnoses, graded functional disability, and generally received medications.

Catheterization Technique

A Swan-Ganz thermodilution catheter (Edwards Lab 93A-131-7F) and standard coronary angiography catheters were inserted, using the Seldinger technique in the femoral vein and artery, respectively. The fluid-filled catheters were flushed and coupl [i]or[/i] part of to the other transducers (Hewlett-Packard model 1280) to a recording scheme (Hewlett-Packard model 4568). The press monitoring system was calibrated and balanced in acordance with routine catheterization performance The Swan-Ganz catheter was coupl to an Edwards Laboratory cardiac output computer (model 9520) for measurement of cardiac output by the agency of thermodilution. Left heart angiography was performed on high speed dye injection technique. Cineventriculography was obtained in the single-plane right anterior oblique projection. Right atrial pulmonary artery, pulmonary wedge, left ventricular and aortic urgencys and cardiac output were measured before and after angiographic injection.

Valsalva Maneuver

Approximately ten minutes after left ventricular angiographic injection controls performed a standard Valsalva maneuver while lying supine, by means of blowing into a mouthpiece coupleed to a manometer and maintaining a hurry of 40 mm Hg for ten others The procedures were repeated, at least three times, until a satisfactory Valsalva maneuver was obtained subject to direct observation. Signals were recorded continuously for ten others before, during and up to 30 s after release of the maneuver ie, including the Valsalva overshoot phase. [911] Continuous right atrial, pulmonary artery and aortic constraining force were simultaneously recorded.

Hemodynamic Measurements

The following measurements were obtained: (1) mean right atrial pressure; (2) mean pulmonary artery pressure; (3) PCWP; (4) left ventricular end-diastolic pressure; (5) systolic and diastolic aortic pressure; (6) thermodilution cardiac output; (7) cardiac index; (8) ejection fraction, comput by means of planimetry of the end-systolic and end-diastolic cineangiograms.

Quantitative Evaluation of the Valsalva Maneuver

Aortic legumes pressure amplitude was computed for each beat during strain and release phases of the Valsalva maneuver. pair ratios were evaluated from the vibrations during the strain phase to quantitate throb amplitude decay: (A) last beat/first beat percent beating [i]or[/i] throbbing of an artery amplitude ratio and (B) minimum/maximum percent pulsation amplitude ratio. The legumes amplitudes obtained during the strain phase were also fitted to a linear archetype The slope of the regression line was then considered as an index of the aortic pulsation pressure decay during Valsalva strain.

In addition, the "Valsalva ratio"--longest RR during the overshoot phase/shortest RR during the strain phase [14]--was computed

Statistical Analysis

Statistical analysis was performed by way of using the linear regression and the linear correlation coefficients to criterion the relationships between measurements obtained during the Valsalva maneuver and resting hemodynamic conditions. In addition, since all four indices used to characterize the Valsalva maneuver identified barely a single aspect of the hemodynamic pattern of answer multiple regression analsis was performed to assess whether these indices together were able to better predict any of the resting hemodynamic parameters. Significance was assessed from means to F ratio of multiple regression analysis of variance. [19]

RESULTS

Resting Hemodynamic Parameters

Table 2 indicates resting hemodynamic parameters in all controls Right atrial pressure ranged from 0 to 9 mm Hg; mean PAP, from 7 to 80 mm Hg; PCWP from 5 to 30 mm Hg; left ventricular end-diastolic urgency from 3 to 23 mm Hg; systolic aortic constraining force from 105 to 155 mm Hg; diastolic aortic crushing from 55 to 85 mm Hg Cardiac output ranged from 35 to 55 L/min; cardiac index, from 20 to 26 [L/min/m.sup.2]; and ejection fraction, from 40 to 69 percent