155 Assessment of Valsalva maneuver as a method for evaluation of patients with pseudonormalized left ventricular filling pattern

Abstract

Background: . Valsalva maneuver was used to differentiate normal from pseudonormal mitral flow pattern. Doppler tissue imaging (DTI), differentiates normal from abnormal diastolic function. Aim of the Work: Assessment of Valsalva maneuver as a mean to differentiate pseudonormal from normal mitral flow pattern (MFP), using pulsed-wave DTI Patients and Methods: sixty patients with dilated cardiomyopathy (EF<40%), sinus rhythm and pseudonormalized MFP were selected. Transmitral flow velocity curve (MFVC), before and during Valsalva maneuver was recorded. Peak early mitral filling (Em), peak atrial filling (Am) and Em/Am were measured before and during Valsalva. After Valsalva patients were classified into two groups. Group I included 24 patients with Em/Am <1 and group II, 36 patients with Em/Am >1. Pulsed-wave DTI was recorded at septal, lateral, inferior and anterior aspect of the mitral annulus from apical 4 and 2 chamber views. The mean peak early velocity (Ea), Peak atrial (Aa), and Ea/Aa of the 4 sites were measured from DTI derived velocity curve for each patient. The results were compared with the MFP. Results: Valsalva maneuver was able to detect a hidden relaxation abnormality in 40% of patients where Em/Am became <1 with significantly prolonged deceleration time (DT), and isovolumetric relaxation time (IVRT). However, 60% of patients the Em/Am remained >1 with slightly prolonged DT and IVRT. Pulsed-wave DTI detected relaxation abnormality in all patients. They had Ea/Aa 0.79±0.11, prolonged DT and IVRT. Group 1 had higher EF (36.71% vs. 32.87%), higher Ea (6.1±0.68 vs 5.3±0.1cm/s), lower Aa (7.9±2.012 vs 8.1±1.91 cm/s) and higher Ea/Aa ratio (0.77 vs 0.65) than group II patients. These data may denote that it was a progression of diastolic dysfunction with or without a hemodynamic factor that was responsible for the persistence of pseudonormalized pattern during Valsalva. Conclusion: Patient uncoperation, less sensitivity, and specificity are the major limitations Valsalva maneuver in assessment of patients with pseudonormalized MFP.Doppler tissue imaging is a simple noninvasive bedside technique with less load dependence. it can be used in combination with MFP for better understanding and assessment of diastolic dysfunctionin those patients.