Assessment of mitral inflow during standardized Valsalva maneuver in stratification of diastolic function

Abstract

Background: We assessed the changes of mitral inflow during Valsalva maneuver (VM) in patients with different stages of left ventricular dysfunction and evaluated their value for the differentiation between normal and pseudonormal filling pattern.

Methods: A total of 190 patients (120 with coronary artery disease, and 70 healthy subjects) were examined by transthoracic echocardiography. Mitral E/A ratio, early wave deceleration time (Edt), and pulmonary vein flow (especially atrial reversal parameters (Ar)), were used for the initial stratification to normal, delayed relaxation, pseudonormal, and restrictive profiles. Changes of mitral inflow during VM were compared between 54 normal (N) and 15 pseudonormal (PN).

Results: During VM, a similar decrease in early wave peak velocity (-30 +/- 18 vs -35 +/- 17 cm/sec), peak velocity of atrial wave (-6 +/- 16 vs -8 +/- 17 cm/sec), and E/A ratio (-0.4 +/- 0.4 vs -0.4 +/- 0.4) was observed in both groups. Only two filling variables, related to atrial phase of inflow, changed in the opposite direction. In normal pattern, the duration and velocity-time integral of atrial wave diminished during VM as opposed to pseudonormal subjects (DeltaAt -7 +/- 39 vs 20 +/- 44 msec; P < 0.05 and DeltaA vti -0.7+/-1.8 vs 0.4+/-2 cm; P < 0.05). Increase in peak atrial velocity and marked decrease in E/A ratio during VM were specific for the restrictive group.

Conclusions: Changes of mitral inflow during VM have a moderate diagnostic value for the differentiation of normal and pseudonormal pattern. Increased duration of atrial phase but not increase in atrial velocity allowed the diagnosis of pseudonormalization.