Antonio Maria Valsalva (1666 – 1723)

An otherwise healthy 32-year-old man presents to the clinic for evaluation of palpitations. Physical examination reveals normal vital signs. Cardiac examination shows a pre-systolic thrust at the apex and an ejection systolic murmur at the left sternal border. A loud fourth heart sound is present. The murmur decreases in intensity in the supine position or in a squatting position. It is accentuated when the patient stands or forcibly expires against a closed airway. Forcible exhalation against a closed airway was originally described as a method for inflating the Eustachian tube, and its diagnostic use has been credited to Antonio Maria Valsalva. The Valsalva maneuver is performed by having the patient forcibly exhale while keeping the mouth and nose closed, and thus resulting in increased pressure transmitted to the tympanic membrane. This maneuver was used to remove suppuration and foreign bodies from the ear and, interestingly, had been used by Arab physicians dating back to the 11th century as well as by early Italian anatomists.3 Antonio Maria Valsalva was born in 1666 in Imola, Italy. The surname, Valsalva, was adopted by his father from the castle owned by the family.1 Antonio received his doctorates of medicine and philosophy in Bologna in 1687, and was appointed Professor of Anatomy at the University of Bologna in 1705. He later was also appointed President of the Academy of Sciences.1,2 Although he will best be remembered for the maneuver that bears his name, his most substantial contribution to the field of medicine was his detailed illustrative work of the anatomy, physiology, and pathology of the ear published in 1704 under the title De aure humana tractatus. For decades this textbook was considered to be the standard reference work on the ear.2 He is credited for identifying the function of and for the naming of a number of structures in the ear, cranium, and aorta including the Eustachian tube and the aortic sinus (table 1). Valsalva is also recognized in the field of psychiatry as being one of the first physicians to address and implement humanitarian treatment for the mentally ill.3 The Valsalva maneuver has been adapted in modern cardiovascular medicine as a method to assess left-sided heart failure and to evaluate heart murmurs. The constellation of findings in the physical examination described above is consistent with the diagnosis of hypertrophic obstructive cardiomyopathy. While the advent of echocardiography has caused this diagnostic method to be less frequently used, it remains a practical tool for preliminary office examinations.4–6 Table 1. Eponyms attributed to Valsalva.9 There are 4 physiological phases in the Valsalva maneuver: (I) onset of strain, (II) continued strain, (III) release, and (IV) recovery (table 2).7 Normally, exhaling against an obstructed airway (closed glottis) causes increased intrathoracic pressure and a rise in systolic blood pressure due to compression of the aorta (phase I). This is followed by a decrease in venous return and a decline in systolic blood pressure to below baseline as positive intrathoracic pressure is maintained (phase II). The release and recovery phases represent compensations for normal physiologic mechanisms that are activated due to the decline in intrathoracic pressure. These compensations include a decrease in systolic blood pressure during phase III caused by initial pooling of blood in the pulmonary vasculature followed by an overshoot in systolic blood pressure (phase IV) resulting from increased cardiac output and vasoconstriction from sympathetic overactivity. The Korotkoff sounds, which correspond to the periods in which there is a rise in systolic blood pressure, are normally heard while auscultating over the brachial artery during phases II and IV in response to the changes in systolic arterial pressure (i.e., normal sinusoidal pattern). Table 2. Phases and physiologic changes of Valsalva maneuver. To perform this test, a blood pressure cuff is insufflated to 15 mm Hg above the patient?s systolic blood pressure.4 While auscultating over the brachial artery for Korotkoff sounds, the patient is asked to forcibly expire against a closed airway for 10 to 25 seconds following a normal inspiratory effort.7 Two abnormal patterns have been found in heart failure patients during assessment with the Valsalva maneuver and have been demonstrated to be highly sensitive and specific for diagnosing left ventricular systolic dysfunction.5 These abnormal patterns are found during phase II and phase IV of the maneuver. The abnormality in phase II is seen as a square root pattern recognized by the maintenance of systolic blood pressure, and in phase IV as the absence of the normal overshoot of systolic blood pressure (figure 1). Figure 1. Arterial blood pressure response and Korotkoff's sounds during Valsalva's maneuver. (A) Sinusoidal response in normal patient. (B) Absent overshoot in patient with heart failure. (C) Square wave response in patient with heart failure. The red lines indicate ... The decrease in left ventricular end diastolic volume resulting from diminished venous return during phase II of the Valsalva maneuver is a bedside physiologic technique applied during auscultation of the heart that can be helpful in distinguishing between different types of systolic heart murmurs. The increase in intensity of murmurs during performance of the Valsalva maneuver in patients with hypertrophic obstructive cardiomyopathy distinguishes this type of murmur from other types of systolic murmurs (65% sensitivity, 95% specificity).6 Moreover, during the maneuver, the murmur and click of mitral valve prolapses occur earlier during systole. Although the Valsalva maneuver is not 100% sensitive or specific in identifying the etiology of systolic heart murmurs, it does indeed assist in distinguishing between different types of murmurs. Antonio Maria Valsalva was a surgeon, anatomist, pathologist, teacher, scientist and humanitarian who contributed greatly to medicine not only by furthering our understanding of the ear, but also by indirectly enabling modern practitioners to adapt his clinical procedures to produce a unique method for identifying abnormal heart sounds to help diagnose left ventricular heart failure and heart murmurs.