The Valsalva Maneuver in the Diagnosis of Left Ventricular Aneuryem

ONE OF THE most common and serious complications of myocardial infarction is the development of a ventricular aneurysm. Within three to five years, 76 to 88 percent of patients with this complication die (1, 14). Although infrequently diagnosed before death, ventricular aneurysm is now recognized as a significant cause of refractory heart failure in patients with arteriosclerotic heart disease (10). Cardiac aneurysm may be defined as an abnormal bulge of the ventricular wall secondary to increases in intraluminal pressure (4). This bulge may be seen throughout the cardiac cycle or only during systole and, according to Gorlin, may occur in an area varying in thickness from a paperthin scar to full thickness muscle (3). The radiological diagnosis of ventricular aneurysm depends upon the demonstration of such a bulge along one of the margins of the left ventricle. Unfortunately, this can be done in only 10 to 20 percent of the cases in which conventional radiologic technic is employed (3, 13). The Valsalva maneuver has been an effective means of demonstrating diseased left atrial appendages, not otherwise visible, in patients with rheumatic heart disease (5). As a result of our experience with these patients, the maneuver has become a part of the routine cardiac examination at the Los Angeles County-University of Southern California Medical Center. This paper describes the application of the same principle to the examination of the left ventricle as a means of detecting ventricular aneurysms in patients with arteriosclerotic heart disease. Normal Response to the Val Salva Maneuver The Valsalva maneuver is defined asforceful expiration against the closed glottis. It causes increased intrathoracic pressure, resulting in diminished venous return to the heart. On release of the Valsalva there is a sudden increase in pulmonar; venous flow to the left heart. The physiologic changes resulting from this maneuver are reflected in the brachial artery curve (Fig. 1) 1. Immediately after institution of the Valsalva maneuver, there is a momentary increase in cardiac output, resulting in a slight rise in brachial artery pressure. This is due to expression of blood from the pulmonary vascular bed by increased pressure. 2. The pulmonary veins and great veins are blocked by the increase in intrapulmonary and intrathoracic pressure. Cardiac output falls. The brachial artery pressure drops slightly 3. When the Valsalva is released, the collapsed pulmonary vascular bed expands and momentarily absorbs right ventricular output, furth er decreasing venous return to the left ventricle. A precipitous dropin systemic pressure occurs. 4. The onrushing blood is eject ed from the left ventricle against a constricted peripheral vascular bed and there is a bounding rise in brachial artery pressure.