The valsalva maneuver as a test of cardiac function: Pathologic physiology and clinical significance

Eighty-eight observations were made in seventy-eight subjects: seven normal persons and seventy-one patients with various forms of heart and lung disease. Directly recorded and ausculted arterial pressure measurements were obtained during the Valsalva maneuver. Other tests of circulatory and pulmonary function were performed as indicated, including cardiac catheterization in forty-two subjects. The clinical and physiologic results were correlated. A normal arterial pressure response during forced expiration (falling arterial pressure) was observed in normal subjects, in pregnancy and in heart disease without heart failure or vascular stenosis. An abnormal arterial pressure response (unchanged arterial pressure) was observed in twenty-three patients with left or right ventricular failure or tight aortic or mitral stenosis (0.5 to 1.0 cm. 2). Most patients in this group were in class iii or iv. There was good correlation with abnormalities in other tests of cardiac function including elevated pulmonary capillary wedge and/or right atrial pressures. Twenty-six patients showed an intermediate response; in these an abnormal test either could be elicited by alterations in body position or was inconstant in degree and frequency. These cardiac patients were usually in class ii, with either mild left ventricular failure or mild to moderately severe mitral stenosis (0.8 to 1.5 cm. 2) or tight aortic stenosis; there was one patient with chronic cor pulmonale. Correlations with tests of cardiac function other than elevated pulmonary wedge pressure were not striking. The difference between the normal and the abnormal Valsalva response was believed to depend on a flattened ventricular function curve or a flattened valvular pressure-flow curve. The simplicity and reliability of the Valsalva maneuver as a clinical test utilizing an ordinary blood pressure cuff is emphasized. Its greatest clinical value lay in the fact that, in the absence of severe right ventricular failure, the test can detect early left ventricular failure, tight mitral stenosis or tight aortic stenosis.