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Antonio Maria Valsalva (1666 – 1723)

Steven H. Yale, MD, Department of Internal Medicine, Marshfield Clinic, and Clinical Research Center, Marshfield Clinic Research Foundation, 1000 North Oak Avenue, Marshfield, WI 54449

Reprint Requests: Steven H. Yale, MD, Department of Internal Medicine, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, Telephone: 715-387-5436, Fax: 715-389-3808, Email: yale.steven{at}mcrf.mfldclin.edu

Received: December 13, 2004.

Accepted: January 13, 2005.

Key Words: Valsalva maneuver • Heart function tests • Heart sounds • Heart murmurs

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 11^th 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

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).

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).

View larger version (23K): [in this window] [in a new window]   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 when Korotkoff’s sounds are heard. (BP = blood pressure). (© 2000 David Klemm. Reprinted with permission from Am Fam Physician 2000;61:1319–1328[Medline].)

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.

References

1. Fransson S, Rubboli A. Antonio Maria Valsalva. Clin Cardiol 2003;26:102–103.[Medline]
2. Antonio Maria Valsalva (1666–1723), Valsalva maneuver. JAMA 1970;211:655.[Abstract/Free Full Text]
3. Canalis RF. Valsalva’s contribution to otology. Am J Otolaryngol 1990;11:420–427.[Medline]
4. Zema MJ, Restivo B, Sos T, Sniderman KW, Kline S. Left ventricular dysfunction—bedside Valsalva manoeuvre. Br Heart J 1980;44:560–569.[Abstract/Free Full Text]
5. Zema MJ, Masters AP, Margouleff D. Dyspnea: the heart or the lungs? Differentiation at bedside by use of the simple Valsalva maneuver. Chest 1984;85:59–64.[Abstract/Free Full Text]
6. Lembo NJ, Dell’Italia LJ, Crawford MH, O’Rourke RA. Bedside diagnosis of systolic murmurs. N Engl J Med 1988;318:1572–1578.[Abstract]
7. Sapira JD. The vital signs. In: Mitchell CW, ed. The art and science of bedside diagnosis. 1^st ed. Baltimore, MD: Urban and Schwarzenberg; 1990. 444–446.
8. Shamsham F, Mitchell J. Essentials of the diagnosis of heart failure. Am Fam Physician 2000;61:1319–1328.
9. Antonio Maria Valsalva. http://www.whonamedit.com/doctor.cfm/2053.html. Accessed December 14, 2004.

This article has been cited by other articles:

				G Smith, A Morgans, and M Boyle Use of the Valsalva manoeuvre in the prehospital setting: a review of the literature Emerg. Med. J., January 1, 2009; 26(1): 8 - 10. [Abstract] [Full Text] [PDF]

				B. C. Hiner Valsalva Maneuver Clin. Med. Res., May 1, 2005; 3(2): 55 - 55. [Full Text] [PDF]

				S. Yale Author's Reply Clin. Med. Res., May 1, 2005; 3(2): 55 - 56. [Full Text] [PDF]

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