title: Failure to unmask pseudonormal diastolic function by a valsalva maneuver: tricuspid insufficiency is a major factor.
abstract: BACKGROUND
  For the clinical assessment of patients with dyspnea, the inversion of the early (E) and late (A) transmitral flow during Valsalva maneuver (VM) frequently helps to distinguish pseudonormal from normal filling pattern. However, in an important number of patients, VM fails to reveal the change from dominant early mitral flow velocity toward larger late velocity.
  
  
  RESULTS
  From December 2009 to October 2010, we selected consecutive patients with abnormal filling with (n=25) and without E/A inversion (n=25) during VM. Transmitral, tricuspid, and pulmonary Doppler traces were recorded and the degree of insufficiency was estimated. After evaluating all standard echocardiographic morphological, functional, and flow-related parameters, it became evident that the failure to unmask the pseudonormal filling pattern by VM was related to the degree of the tricuspid insufficiency (TI). TI was graded as mild in 24 of 25 patients in the group with E/A inversion during VM, whereas TI was graded as moderate to severe in 24 of the 25 patients with pseudonormal diastolic function without E/A inversion during VM.
  
  
  CONCLUSIONS
  Our data suggest that TI is a major factor to prevent E/A inversion during a VM in patients with pseudonormal diastolic function. This probably is due to a decrease in TI resulting in an increase in forward flow rather than the expected decrease during the VM. Thus, whenever a pseudonormal diastolic filling pattern is suspected, the use of a VM is not an informative discriminator in the presence of moderate or severe TI.
authors.affiliation: Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany.
authors.forename: Kai
authors.initials: K
authors.lastname: Hu
authors.forename: Dan
authors.initials: D
authors.lastname: Liu
authors.forename: Markus
authors.initials: M
authors.lastname: Niemann
authors.forename: Liv
authors.initials: L
authors.lastname: Hatle
authors.forename: Sebastian
authors.initials: S
authors.lastname: Herrmann
authors.forename: Wolfram
authors.initials: W
authors.lastname: Voelker
authors.forename: Georg
authors.initials: G
authors.lastname: Ertl
authors.forename: Bart
authors.initials: B
authors.lastname: Bijnens
authors.forename: Frank
authors.initials: F
authors.lastname: Weidemann
mesh_terms: D000368:Aged; D001783:Blood Flow Velocity; D015331:Cohort Studies; D018618:Echocardiography, Doppler, Color / Q000379:methods*; D005260:Female; D054144:Heart Failure, Diastolic / Q000000981:diagnostic imaging* / Q000503:physiopathology; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging* / Q000503:physiopathology; D014636:Valsalva Maneuver