Valsalva maneuver: A maneuver in which a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air

exits through the mouth ornose as, for example, in strenuous coughing, straining during a bowel movement, or lifting a heavy weight. The Valsalva maneuver impedes the return of venous blood to the heart. Named for Antonio Maria Valsalva, a renowned Italian anatomist, pathologist, physician, and surgeon (1666-1723) who first described the maneuver.

Physiological response

Blood pressure (systolic) and pulse rate during a normal response to Valsalvas maneuver. Forty millimeter mercury pressure is applied at 5 seconds and relieved at 20 seconds.

The normal physiological response consists of 4 phases, which are marked on the figure at right:[2] 1. Initial pressure rise: On application of expiratory force, pressure rises inside the chest forcing blood out of the pulmonary circulation into the left atrium. This causes a mild rise in stroke volume. 2. Reduced venous return and compensation: Return of systemic blood to the heart is impeded by the pressure inside the chest. The output of the heart is reduced and stroke volume falls. This occurs from 5 to about 14 seconds in the illustration. The fall in stroke volume reflexively causes blood vessels to constrict with some rise in

pressure (15 to 20 seconds). This compensation can be quite marked with pressure returning to near or even above normal, but the cardiac output and blood flow to the body remains low. During this time the pulse rate increases. 3. Pressure release: The pressure on the chest is released, allowing the pulmonary vessels and the aorta to re-expand causing a further initial slight fall in stroke volume (20 to 23 seconds) due to decreased left ventricular return and increased aortic volume, respectively. Venous blood can once more enter the chest and the heart, cardiac output begins to increase. 4. Return of cardiac output: Blood return to the heart is enhanced by the effect of entry of blood which had been dammed back, causing a rapid increase in cardiac output (24 seconds on). The stroke volume usually rises above normal before returning to a normal level. With return of blood pressure, the pulse rate returns towards normal. Deviation from this response pattern signifies either abnormal heart function or abnormal autonomic nervous control of the heart. Valsalva is also used by dentists following extraction of a maxillary molartooth. The maneuver is performed to determine if a perforation or antral communication exists.

Definition
The Valsalva maneuver is performed by attempting to forcibly exhale while keeping the mouth and nose closed. It is used as a diagnostic tool to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain.

Purpose
The Valsalva maneuver is used with patients who have suspected heart abnormalities, often in conjunction withechocardiography. The maneuver is based on the fact that when a patient forcibly exhales against a closed nose and mouth while bearing down, as if having a bowel movement, specific changes occur in blood pressure and the rate and volume of blood returning to the heart. Comparing the changes in a diseased heart to those expected in a normal heart gives clues to the type and location of heart damage. In addition, when a doctor listens to the chest with a stethoscope during the Valsalva maneuver, characteristic heart sounds are heard. Variations in these sounds can indicate the type of abnormality present in the heart. A 2004 study found that blood pressure response to the Valsalva maneuver could predict mortality in elderly patients with congestive heart failure. This could prove to be a new noninvasive

way to help determine how long elderly patients with congestive heart failure are expected to live. The Valsalva maneuver also corrects some rapid heartbeats originating in the atria. When the maneuver is done correctly, blood pressure rises. This forces the heart to respond by correcting its rhythm and beating more slowly. On rare occasions, the Valsalva maneuver can be used to diminish chest pain in patients with mild coronary disease. Unrelated to any evaluation of the heart, the Valsalva maneuver also is taught to patients with multiple sclerosis who are unable to fully empty the bladder (flaccid bladder). It sometimes is used in sexual therapy to help men avoid premature ejaculation.

Precautions
The Valsalva maneuver should not be performed by patients who have severe coronary artery disease, have experienced recent heart attack, or have a moderate to severe reduction in blood volume.

Description
When performed formally, the patient is asked to blow against an aneroid pressure measuring device (manometer) and maintain a pressure of 40 millimeters of mercury (mm Hg) for 30 seconds. Or, less formally, the patient may be asked to bear down, as if having a bowel movement. During this 30 second period, a recording is made of the changes in blood pressure and murmurs of the heart.

Preparation
The patient may be connected to a heart monitor and echocardiograph or the physician may simply use a stethoscope to monitor the heart. Sometimes an indwelling needle is inserted for accurate pressure measurements, depending on whether the procedure is being done for corrective or diagnostic purposes.

Aftercare
When this procedure is done to regulate irregular heart rhythms, the patient usually remains on a heart monitor to evaluate heartbeat.

Risks
The patient may feel dizzy or faint during the procedure, but serious consequences are rare. There is a risk that the Valsalva maneuver can cause blood clots to detach, bleeding, and abnormal rhythms originating in the ventricle. It can also cause cardiac arrest. Consequently, the procedure is usually performed in a setting where emergency equipment is accessible.

Normal results
There are four characteristic changes or phases in a normal heart's response to the Valsalva maneuver. An abnormality in any of these phases indicates a cardiovascular abnormality.

Resources
Periodicals Jancin, Bruce. "New Mortality Predictor Found for Heart Failure." Family Practice News March 15, 2004: 48-49.

Key terms
Atria The heart has four chambers. The right and left atria are at the top of the heart and receive returning blood from the veins. The right and left ventricles are at the bottom of the heart and act as the body's main pumps. Echocardiography An ultrasound test that shows the size, shape, and movement of the heart.