1. What is the diagnosis?
Valsalva
1. Tamponade
2. Constriction
3. Restriction
4. Mitral
regurgitation
5. LV dysfunction

2. Valsalva
Figure 1. “square wave sign”
Figure 3. Frank Starling curve in patients with left ventricular dysfunction
and increased ventricular diastolic pressures
Figure 2. Normal Valsalva response
Correct Answer: Left ventricular dysfunction
A normal Valsalva response has 4 phases (Figure 2). In phase 1 a transient increase in blood pressure is observed
due to straining. In phase 2, blood pressure and pulse pressure decrease, while the hear rate increases, due to
decrease in left ventricular filling and decrease in stroke volume. In phase 3, release of straining causes a further
transient decrease in blood pressure. In phase 4, arterial pressure increases and heart rate decreases.
Patients with left ventricular dysfunction and increase in the left ventricular diastolic pressures operate on the
descending limb of the Frank Starling curve (point A, Figure 3). Straining during the Valsalva maneuver decreases
preload, which increases stroke volume (point B, Figure 3) and arterial systolic pressure. This response to the
Valsalva maneuver is called the “square wave sign”.

3. References:
1. Maniu CV, Nishimura RA, Tajik AJ. Tachycardia during the
valsalva maneuver: a sign of normal diastolic filling
pressures. J Am Soc Echocardiogr 2004;17:634-7.
2. Nishimura RA, Tajik AJ. The Valsalva maneuver and
response revisited. Mayo Clin Proc 1986;61:211-7.