Potentials and limitations of the Valsalva maneuver as a method of differentiating between normal and pseudonormal left ventricular filling patterns.

Pseudonormalization of the left ventricular (LV) filling pattern complicates the Doppler echocardiographic assessment of LV diastolic function in patients with heart failure. The Valsalva maneuver is recommended as a method of differentiating between normal and pseudonormal LV filling patterns. However, neither a standardized Valsalva maneuver nor a healthy control population has been studied so far. Therefore, we studied changes in mitral flow velocities in response to a standardized Valsolva maneuver in 55 heart failure patients with LV systolic dysfunction and 35 control subjects. The study subjects were instructed to elevate their intrathoracic airway pressure to 40 mm Hg for 10 seconds. Doppler mitral flow velocities were recorded at rest and during the Valsalva maneuver. All study subjects had comparable decreases in early mitral flow velocity, but mitral flow velocity at atrial contraction increased rather than decreased in patients with a restrictive LV filling pattern. This markedly abnormal response might be useful in detecting elevated filling pressures and pseudonormal filling patterns. Furthermore, in all but 2 patients and all control subjects with an E/A ratio between 1 and 2, inversion of the E/A ratio occurred. This proves that, in contrast to previous beliefs, inversion of the E/A ratio does not differentiate between normal and pseudonormal LV filling patterns.

Relation of atrial natriuretic peptides to left ventricular systolic and diastolic function in heart failure.

BACKGROUND: Plasma concentrations of atrial natriuretic peptides are correlated with atrial pressures, as are left ventricular ejection fraction and left ventricular filling abnormalities. AIMS: This study investigated the relation of atrial natriuretic peptides to both left ventricular systolic and diastolic function in heart failure. METHODS: Plasma concentrations of atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide were measured in 63 patients with chronic heart failure and left ventricular systolic dysfunction. According to Doppler transmitral flow measurements, 19 patients had a restrictive and 44 patients had a non-restrictive left ventricular filling pattern. RESULTS: Plasma concentrations of atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide were higher in patients with a restrictive filling pattern than in patients with a non-restrictive filling pattern (197 vs. 75 pmol/l, P<0.0001 and 1.14 vs. 0.45 nmol/l, P<0.0001). In univariate analysis, atrial natriuretic peptide and N-terminal pro-atrial natriuretic peptide correlated with deceleration time, E/A ratio and left ventricular ejection fraction. In multivariate analysis, both peptides appeared independently related to left ventricular ejection fraction and left ventricular filling pattern. CONCLUSION: In patients with chronic heart failure, atrial natriuretic peptides provide information on left ventricular systolic as well as diastolic function.