5 years ago

Comparison of Valsalva Maneuver, Amyl Nitrite, and Exercise Echocardiography to Demonstrate Latent Left Ventricular Outflow Obstruction in Hypertrophic Cardiomyopathy

Guidelines recommend exercise stress echocardiogram (ESE) for patients with hypertrophic cardiomyopathy (HC) if a 50 mmHg gradient is not present at rest or provoked with Valsalva or amyl nitrite, in order to direct medical and surgical management. However, no study has directly compared all 3 methods. We sought to evaluate efficacy and degree of provocation of left ventricular outflow gradients by ESE, and compare with Valsalva and amyl nitrite. In patients with HC between 2002-2015, resting echocardiograms and ESEs within one year were retrospectively reviewed. Gradients elicited by each provocation method were compared. Rest and ESE were available in 97 patients (mean age 54±18 years, 57% male); 78 underwent Valsalva maneuver and 41 amyl nitrite provocation. Median gradients (IQR) were 10 mmHg (7,19) at rest, 16 mmHg (9,34) with Valsalva, 23 mmHg (13,49) with amyl nitrite and 26 mmHg (13,58) with ESE. ESE and Amyl nitrite were able to provoke obstruction (≥30 mmHg) and severe obstruction (≥50 mmHg) more frequently than Valsalva. In patients with resting gradient <30 mmHg (n=83), provocation maneuvers demonstrated dynamic obstruction in 51%; in those with Valsalva gradient <30 mmHg (n=57), ESE or amyl nitrite provoked a gradient in 44%; and in those with amyl nitrite gradient <30 mmHg (n=20), ESE provoked a gradient in 29%. No demographic or baseline echocardiographic parameter predicted provocable obstruction. In conclusion, ESE is clinically useful, however different provocation maneuvers may be effective in different patients with HC, and all maneuvers may be required to provoke dynamic obstruction in symptomatic patients.

Publisher URL: www.sciencedirect.com/science

DOI: S0002914917314704

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