cardiac manuveres in cardiology

1. CARDIAC MANUVERES

2. Maneuvers
• Valsalva Maneuver
• Isometric exercises
• Postural changes
• Respiration
• VPCs
• Vasoactive agents
1. Amyl nitrite
2. Phenylephrine

3. Valsalva maneuver
•Forcible exhalation against a closed airway was originally
described as a method for inflating the Eustachian tube.
• Its diagnostic use has been credited to Antonio Maria Valsalva.
•This maneuver had been used by Arab physicians dating back to
the 11th
century as well as by early Italian anatomists.

4. Manometer method:
Patient blows into the
mercury manometer and
maintains 40 mmHg for
15 seconds.
Valsalva equivalent:
Patient pushes back against
examiner’s hand which is
pressed downward on mid
abdomen.
Should not be performed in pts with IHD because
of the accompanying fall in coronary blood flow.

5. Valsalva Manoeuvre
• 4 phases
– Phase I – Onset of Strain
– Phase II – Continued Strain
– Phase III – Release phase
– Phase IV – Recovery phase

6. Phase I – Onset of straining
– Transient increase in
BP which lasts for a
few seconds.
– HR does not change
much.
– Mechanism: increased
intrathoracic pressure
and mechanical
compression of aorta
due to the act of
blowing.

7. Phase II - Phase of straining
• Reduced venous return to
right atrium
cardiac output and
systolic pressure .
• Carotid baroreceptors
inhibit vagus nerve and
stimulate vasomotor
centre
Reflex tachycardia and
peripheral
vasoconstriction result.

8. Phase III - Release of straining
• Transient decrease in BP
lasting for a few seconds.
• Little change in HR.
• Mechanical displacement
of blood into pulmonary
vascular bed, which was
under increased
intrathoracic pressure 
BP decreases

9. Phase IV – Recovery phase
• Accumulated venous
return reaches left
ventricle and increased
stroke volume is pumped
into constricted systemic
vascular bed causing
overshoot of BP.
• Overshoot detected by
carotid sinuses resulting in
excitatory effect on vagus
nerve leading to reflex
bradycardia.

12. Valsalva Ratio
• Measure of the change of heart rate that takes place during
a brief period of forced expiration against a closed glottis.
• Ratio of longest R-R interval during phase IV to the
shortest R-R interval during phase II
• Average the ratio from 3 attempts.
• Ratio reflects the integrity of entire baroreceptor reflex arc
and of sympathetic efferents to blood vessels.

13. Valsalva Ratio
Longest RR
Valsalva Ratio = -------------------
Shortest RR
≥ 1.4
Values
• more than 1.21  normal
• less than 1.20  abnormal

14. Effects on murmurs
• PHASE1 –as stroke volume fall there is decrease in –
systolic murmur of AS, PS, MR, TR
diastolic murmur of AR PR MS TS
 PHASE2- reduction in LV volume and size leads to-
increase in systolic murmur of HOCM
increase in degree of MVP prolapse resulting in loud and
early occurrence of mid systolic click and systolic
murmur.

15. • PHASE 3- sudden increase in SVR leads to increase in
right side murmurs
• PHASE 4-left side murmur comes to control levels and
may transiently increase.

16. Heart failure patients
• Phase 1 and 3 are normal .
• Absence of decrease in arterial pressure tracing during
phase 2
• Overshoot of BP does not occur in phase 4 that leads to
Square wave response .

17. Heart failure patients
• Absence of decrease in arterial pressure occurs due to
the excess sympathetic tone to which hearts with reduced
ejection fractions are subject.
Therefore, the strain does not stimulate enough further
sympathetic drive to produce an overshoot after release of
the strain.
• Overshoot of BP does not occur in phase 4 that leads to
Square wave response.
This is partly due to the excess lung blood volume in the
congested lungs, which continues to empty into the LV
during the entire 10 s of strain.

20. The Muller Maneuver
• Converse of Valsalva Maneuver
• Less frequently employed
• Forcibly inspires while the nose is held closed
and mouth is firmly sealed for about 10 sec.
• Augments murmur and filling sound originating
in right side of the heart

21. Lancet 2015; 386: 1747–53August 25, 2015

22. • Background The Valsalva manoeuvre is an
internationally recommended treatment for
supraventricular tachycardia, but cardioversion is
rare in practice (5–20%), necessitating the use of
other treatments including adenosine, which
patients often find unpleasant.

23. • Methods: Investigators did a randomised controlled,
parallel-group trial at emergency departments in England.
Randomly allocated adults presenting with
supraventricular tachycardia (excluding atrial fibrillation
and flutter) in a 1:1 ratio to undergo a modified Valsalva
manoeuvre (done semi-recumbent with supine
repositioning and passive leg raise immediately after
the Valsalva strain), or a standard semi-recumbent
Valsalva manoeuvre.
• A 40 mm Hg pressure, 15s standardised strain was used in
both groups.

24. • The primary outcome was return to sinus rhythm at 1 min
after intervention, determined by the treating clinician and
electrocardiogram and confirmed by an investigator
masked to treatment allocation.
• Findings - 433 participants were enrolled between Jan 11,
2013, and Dec 29, 2014. 214 participants in each group
were included in the intention-to-treat analysis. 37 (17%)
of 214 participants assigned to standard Valsalva
manoeuvre achieved sinus rhythm compared with 93
(43%) of 214 in the modified Valsalva manoeuvre group.

25. `

26. Isometric exercise
• Use calibrated handgrip
device or tennis ball or rolled
up BP cuff.
• Patient exerts 70 – 100% of
this maximum for about 30
seconds.
• Simultaneous handgrip using
both hands.
• ECG monitoring is
recommended during
isometric handgrip in pts with
LVD or rhythm disorder.

27. Handgrip
•Handgrip should be sustained for 20-30 secs.
•Increases
– systemic vascular resistance.
– arterial pressure
– heart rate
– cardiac output
– LV filling pressure

28. Handgrip
• LV S 3 S4↑.
• AS ↓.
• AR ↑.
• MR ↑.
• VSD ↑.
• MS ↑(due to increase CO).
• HOCM ↓.
• Click& late systolic murmur of MVP are
delayed because of increase LV volume.

29. Postural changes
Sudden passive elevation of legs
Sudden assumption of lying from standing or
sitting position.
∀↑venous return
∀↑RV stroke volume
• Several cardiac cycles later ↑LV stroke volume

30. Passive elevation of Legs
 Widening of splitting of S2 in all phases of respiration
 ↑RV S3,S4 & several cardiac cycles later LV S3,S4
 PS
 AS
 MR Systolic murmurs ↑
 TR
 VSD
 Functional systolic murmur are ↑ed
 HOCM murmur ↓ , because LVEDV ↑
 Click & systolic murmur of MVP are delayed &
sometimes attenuated

31. Rapid standing or sitting up from
lying position or squatting posture
•Splitting of S 2 is reduced.
•Because of decrease in venous return
AS ↓
PS ↓
MR ↓
TR ↓
HOCM ↑
MVP ↑ in duration

32. Squatting
↑venous return
↑stroke volume
↑systemic vascular resistance
↑arterial pressure→transient reflex bradycardia

33. Squatting
• S 3 & S 4 ↑ from both ventricles.
• PS↑
• AS↑
• TS ↑
• MS↑
because of
increased stroke
volume

34. Squatting
•Because of elevation of arterial pressure
RVOT murmur in TOF ↑
MR ↑
VSD ↑
•Elevated arterial pressure & ↑ venous return →↑LV size
reduces the obstruction to outflow tract.
decreased HOCM systolic murmur intensity.
•Click & late systolic murmur of MVP are delayed.

35. Positional changes
Left lateral decubitus:
• S3,S4 from left side↑
• Opening snap, MS & MR ↑
• Click & late systolic murmur of MVP ↑
• Austin flint murmur ↑
Sitting up &leaning forward:
• AR ↑
• PR ↑

36. Respiraton
• Inspiratory ↑ in systemic
venous return due to fall
in intrathoracic pressure
∀ ↑ RV stroke volume and
duration of RV ejection
∀ ↓ pulmonary vascular
impedance thereby ↑ the
pulmonary hangout
interval (>80ms).
• Inspiratory ↓ in
pulmonary venous return
due to pooling of blood in
pulmonary vasculature
∀ ↓ LV stroke volume and
LV ejection
∀ ↓ hangout interval on
aortic side .

37. Effects on heart sounds
• S2- normal split during inspiration ,while during expiration
heard as a single sound.
• S3,S4 and OS- RV S3 and S4 and right sided OS ↑ due to
↑ RV stroke volume during inspiration and left sided
sounds vice versa.
• Pulmonary ejection sound –best heard during expiration
and intensity ↓ with inspiration.
• Inspiratory ↑ of venous return and RV SV → ↑ of
RVDEP beyond the pulmonary artery diastolic
pressure (PADP) → premature opening of pulmonary
valve in diastole itself and less upward motion of valve
leaflets → ↓ intensity of ejection sound
• Aortic ejection sound – usually doesnot change.

38. Effects on heart murmurs
• Right sided murmurs ↑ during inspiration including TR
murmur (Carvallo sign) due to ↑ stroke volume and vice
versa.
• MVP – louder and early occurrence of midsystolic click
and murmur during systole as a result of ↓LV stroke
volume and ↓ LV size which ↑ degree of valvular
prolapse.
• No change in inspiratory augmentation of heart sounds
and murmurs in patients with right heart failure due to
increased RVEDP.
• MR murmur doesnot vary with inspiration .

39. Phamacological agents
Amyl nitrite :
Ampoule in gauge is held near pt’s nose & then the ampoule is crushed.
The pt is asked to take 3-4 breaths over 10-15 secs.
First 30 sec : marked vasodilation: ↓systemic arterial pressure.
30-60sec : reflex tachycardia
Followed in turn by reflex increase in cardiac output, velocity of
bloodflow & heart rate

40. Amyl nitrite
• S1 ↑
• A2 ↓
• Opening snap of MS & TS↑
• A2-OS interval ↓
• S3 from either ventricle ↑

41. Amyl Nitrite
• AS↑
• PS↑
• HOCM↑
• TR↑
• Funtional systolic murmur ↑

42. Amyl Nitrite in TOF
Reduction in Arterial Pressure
↓
Increase R→L shunt
↓
Decreases blood flow from RV to PA
↓
Diminishes midsystolic murmur

43. Amyl nitrite
The increase in cardiac output
↑MS
↑ TS
↑ TR
↑ PR

44. Amyl nitrite
Fall in systemic arterial pressure
↓ MR
↓ VSD
↓ AR
↓ Austin flint
↓ PDA
↓ Systemic arteriovenous fistula

45. Amyl nitrite
Reduction in cardiac size
↓
Earlier appearance of midsystole click & late
systolic murmur of MVP
Intensity of the systolic murmur exhibits
variable response

46. Amyl nitrite
The response to amyl nitrite is useful in
distinguishing
• AS (↑) from MR (↓)
• TR (↑) from MR (↓)
• Isolated PS (↑) from TOF (↓)
• MS(↑) from austin flint murmur(↓)
• PR(↑) from AR (↓)

47. Phenylephrine
Exert effect opposite to that of amyl nitrite
• Increase systemic arterial pressure
• Reflex bradycardia
• Decrease contractility
• Decrease cardiac output

48. Phenylephrine is preferred because of shorter
duration of action.
0.3-0.5mg IV elevates systolic pressure by 30mm of
Hg for only 3-5 minutes.
Both drugs should not be used in CCF & systemic
HTN
Phenylephrine

49. Phenylephrine
• S1↓
• A2- OS interval prolonged
• AR ↑
• MR ↑
• VSD ↑
• TOF ↑
• PDA ↑
• Systemic A-v fistula↑
• HOCM↓ because of ↑ LV size
• Click & late systolic murmur of MVP are delayed

50. Phenylepherine
Because of reduction in cardiac output
• AS↓
• Functional systolic murmur ↓
• MS ↓

51. Changes in cardiac cycle length
1. Compensatory pause following VPC
2. Longer cycle length in AF
• increase ventricular filling
• increase ventricular contractility of next beat
o This increases intensity of murmurs that are caused by
obstruction to either left or right ventricular ejection .
o Where as regurgitant murmurs of the valves do not
change appreciably.

52. Effects on heart sounds and murmurs
• AS and PS accentuate due to ↑ ventricular filling i.e
prolonging preceding diastole and contractility.
• DM of AR ↑ due to transient elevation in arterial pressure.
• SM of HOCM ↑ due to increased LVOT obstruction as a
result of ventricular contractility and associated with
decreased volume of the pulse (Brokenbrough
Braunwald Morrow Sign)
• Mid systolic click and late SM of MVP delayed - ↓
prolapse due to increase in ventricular filling and LV size.

54. Thank You

55. Valsalva Maneuver-Square Wave Response
I/T Pr = VR =
BP
sympathetic tone
HR
sudden return of peripherally pooled
blood to the vaso-constricted arterial
system (20
to the increased
sympathetic tone)
PHASE
II
PHASE IV
MAXIMAL
SYMPATHETIC
ACTIVATION
FLAT PART OF
STARLING’S CURVE
HEART
FAILUR
E
ASD

56. Isometric handgrip
• Done with calibrated handgrip device &
handball.
• ECG monitoring is recommended during
isometric handgrip in pts with LVD or
rhythm disorder.
Contraindication
• Arterial HTN.
• Recent MI.
• Recent cerebrovascular disease including
vascular malformation.