Can the extent of change of the left ventricular Doppler inflow pattern during the Valsalva maneuver predict an elevated left ventricular end-diastolic pressure?

Background: The objective of this study was to determine whether analysis of changes in the transmitral filling pattern during the Valsalva maneuver improves the diagnostic accuracy to noninvasively detect an elevated left ventricular end-diastolic pressure (LVEDP). Methods: We prospectively compared the diagnostic accuracy of the mitral flow velocity indexes at baseline with those obtained during the Valsalva maneuver to detect an elevated LVEDP in 50 patients with coronary artery disease. Results: Moderate correlations were found between LVEDP (mean, 11.8 +/- 6.2 mmHg) and deceleration time (r=0.49), isovolumetric relaxation time (r=0.52), and the E/A ratio (r=0.48). There was a strong correlation (r=0.73) between LVEDP and the percentile decrease in the E/A ratio during the Valsalva maneuver. Discriminant analysis showed that a decrease in E/A ratio during the Valsalva maneuver by greater than or equal to 40% detected an elevated LVEDP with a sensitivity of 77% and a specificity of 94%, resulting in a diagnostic accuracy of 88%. In 11 patients, the constellation of pseudonormalization (normal E/A ratio and elevated LVEDP) was present. This could be identified in 73% with a diagnostic accuracy of 87%. Conclusions: For a comprehensive assessment of diastolic dysfunction by Doppler echocardiography, combined analysis of the E/A ratio at baseline and during the Valsalva maneuver should be performed routinely as an easy method of increasing diagnostic accuracy and uncovering pseudonormalization.