Cardiology

The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia?

a b s t r a c t

Supraventricular tachycardia is a common cardiac arrhytmia with recurrent episodes. The rapid resolu- tion of supraventricular tachycardia remains a challenge. Vagal manoeuvres are simple and non- invasive but yield positive results in less than half the cases. Currently, the modified Valsalva manoeu- vre appears to be the most effective technique. We have tested the effectiveness of the reverse Valsalva manoeuvre without swallowing as new vagal manoeuvre for the treatment of supraventricular tachy- cardia. This new technique is easy to perform and can be carried out alone by the patient. We report in this series 11 cases of supraventricular tachycardia, 10 of which were effectively reduced after the completion of the reverse Valsava manoeuvre. The very encouraging results of this series of cases will have to be quickly evaluated by a randomised controlled trial. This new technique, which is simple to learn and carry out, could be easily taught throughout the world, including in regions with few health-care resources.

(C) 2020

  1. Introduction

supraventricular tachycardia is a frequent reason for re- course to emergency medicine. Often, patients experience recurrent episodes of SVT and have a history of this Rhythm disorder. The rapid resolution of SVT remains a challenge. It can require the use of vagal manoeuvres or, in the event of failure, the administration of pharmacological agents and, more rarely, recourse to cardiover- sion [1]. Vagal manoeuvres are simple and non-invasive but yield positive results in only 40% of cases [2]. carotid sinus massage , the standard Valsalva manoeuvre (sVM) and the modified Valsalva manoeuvre (mVM) are the three main techniques used to resolve SVT. To date, the mVM appears to be the most effective [3]. We have tested the effectiveness of a new vagal manoeuvre for the treatment of SVT (excluding flutter and atrial fibrillation). This is the reverse Valsalva manoeuvre (rVM) (or Toynbee manoeuvre) without swallowing. Here, we describe the reverse Valsalva ma-

* Corresponding author at: Bataillon de Marins-Pompiers de Marseille, Groupement Sante, Service Medical d’Urgence, 9 boulevard de Strasbourg, 13233 MARSEILLE cedex 20, France.

E-mail address: [email protected] (N. Cazes).

noeuvre and summarise the performance of this technique in 11 patients between February 2019 and May 2020.

  1. Reverse Valsalva manoeuvre description

In the first step, the patient must be in a sitting position and ex- hale without force. The patient then attempts to inhale against resis- tance for 10 s, pinching their nose and closing their mouth tightly (Fig. 1). The resolution of SVT is accomplished within the next 10 to 15 s if effective. This manoeuvre is responsible for both an increase in vagal tone and a decrease in Sympathetic activity responsible for bradycardia and arterial hypotension (the Bezold-Jarich reflex) [4], leading to SVT resolution.

  1. Cases (See Table 1.)
    1. Case 1

A 55-year-old patient, an emergency physician, with SVT as his only antecedent arrested his SVT by carrying out the rVM himself. In total, three of his last four SVT episodes (over a period of 2 years) were arrested by performing rVM. The rVM was carried out at the onset of SVT. Only one episode of SVT had to be treated by the intravenous

https://doi.org/10.1016/j.ajem.2020.12.061

0735-6757/(C) 2020

1

2

3

4

      1. : exhale without forcing in a sitting position
      2. : pinch the nose and close the mouth (tightly)
      3. : inhale against resistance for ten seconds
      4. : it’s getting better

Fig. 1. Illustration of the reverse Valsalva Manoeuvre without swalling.

administration of calcium channel blockers after the failure of various vagal manoeuvres (mVM and rVM).

    1. Case 2

An emergency medical system (EMS) staffed by physician responded to a 57-year-old patient who had been presenting with palpitations, dys- pnoea and Chest tightness for 1 h. The patient had no previous “SVT his- tory” or treatment. The initial electrocardiogram (ECG) showed regular

tachycardia with fine QRS at 210 bpm, suggesting SVT (Fig. 2). The emer- gency physician performed the classic vagal manoeuvres (sVM and mVM) but without effect. The patient then performed the rVM, which re- sulted in a return to a sinus rhythm (Fig. 3).

    1. Case 3

A 51-year-old patient who underwent a heart transplant 5 years previously presented a first episode of palpitations. A physician-staffed

Image of Fig. 2

Fig. 2. Supraventricular tachycardia recorded at the arrival of the physician-staffed EMS in the case 2.

EMS was sent to his home and made the diagnosis of SVT. The various vagal manoeuvres (sVM, mVM and rVM) were not effective in arresting the tachycardia, nor was the administration of intravenous adenosine. The patient was then transported to a cardiac intensive care unit due to the history of Heart transplantation. The tachycardia spontaneously resolved within a few hours (See Table 1.)

    1. Cases 4 and 8

Two patients (70 and 48 years old) with a known history of SVT experienced new episodes of paroxysmal tachycardia, which were successfully arrested by the rVM after failure of the sVM and mVM. A medical dispatcher from the call processing centre guided the patients in conducting the various manoeuvres.

    1. Case 5

A 32-year-old pregnant woman presented with SVT. A medical dis- patcher from the call processing centre suggested that she carry out the rVM technique to treat the SVT. The physician-staffed EMS that was on-call noted a return in sinus rhythm on the ECG conducted at the patient’s home.

    1. Case 6

A 42-year-old patient with a known history of SVT called the ambu- lance service owing to a new episode of SVT. Knowing that vagal ma- noeuvres usually have no effect, the patient did not perform them

before calling. The medical dispatcher suggested that the patient per- form the mVM after it was explained over the phone. The resolution of SVT after performing the rVM allowed the patient to stay at home.

    1. Case 7

A physician-staffed EMS called the processing centre before transfer- ring a 50-year-old patient to the emergency department. The patient had a history of SVT and was experiencing a 180 bpm episode of SVT that did not resolve after performing the vagal manoeuvres (sVM and mVM) or after intravenous adenosine administration. The medical dis- patcher suggested that the patient should perform the rVM before transfer to the emergency department. This proved to be effective and allowed the patient to remain at home.

    1. Case 9

A 43-year-old patient with a history of SVT called the call processing centre due to a new attack of paroxysmal tachycardia in the context of acute otitis media. The patient refused to perform the sVM and mVM because of his otitis media. The medical dispatcher then suggested that the patient perform the rVM, which then resolved the SVT episode.

    1. Case 10

A 27-year-old patient with hereditary chronic renal failure who underwent dialysis the day before presented with SVT at 225 bpm. The physician-staffed EMS sent to the patient’s home helped him

Image of Fig. 3

Fig. 3. Return to a sinus rhythm after the reverse Valsalva manoeuvre without swallowing.

Table 1

Demographic data, clinical characteristics and different treatments used for each supraventricular tachycardia case.

Characteristics

Sex

Age

Medical history

Current medical particularity

mVM/sVM before rVM

Pharmacological agents before rVM

Reversion success with rVM

Patient 1

Male

55

SVT

None

No

No

Yes

Patient 2

Male

57

None

None

Yes

No

Yes

Patient 3

Male

51

Heart transplantation

None

Yes

Yes

No

Patient 4

Female

70

SVT

None

Yes

No

Yes

Patient 5

Female

32

SVT

Pregnant

No

No

Yes

Patient 6

Female

42

SVT

None

No

No

Yes

Patient 7

Male

50

SVT

None

Yes

Yes

Yes

Patient 8

Male

48

SVT

None

Yes

No

Yes

Patient 9

Male

43

SVT

Otitis

No

No

Yes

Patient 10

Male

27

Chronic renal failure dialysis

None

No

No

Yes

Patient 11

Male

62

SVT

None

No

No

Yes

SVT: supraventricular tachycardia. sVM: standard Valsalva manoeuvre. mVM: modified Valsalva manoeuvre. rVM: reverse Valsalva manoeuvre.

perform the rVM, which arrested the tachycardia and allowed a return to sinus rhythm.

    1. Case 11

A 62-year-old patient with a history of SVT called because of an acute episode of palpitations. The medical dispatcher helped the patient per- form the rVM, which resolved the crisis. When the physician-staffed EMS arrived at the patient’s home, they observed the patient’s return to sinus rhythm.

  1. Discussion

SVT is a common and recurrent pathology in emergency medicine. In the majority of cases, SVT is a recurrent episode of a known supra- ventricular rhythm disorder. SVT is very rarely associated with severe episodes that require hospitalisation. It is resolved by the immediate disappearance of all symptoms, thus allowing the patient to remain at home. Unfortunately, its resolution is rarely spontaneous. Vagal ma- noeuvres have long been known as a non-invasive and potentially ef- fective treatment for SVT (apart from flutter and atrial fibrillation)

(1). Two recent studies [2,3] have shown that the mVM is more effec-

tive than the sVM for resolving SVT (43% versus 20%, respectively). A primary goal is to increase the non-invasive therapeutic arsenal of emergency physicians so that they can rapidly arrest SVT episodes and avoid patient hospitalisation. The scientific literature on this sub- ject is not as abundant as hoped, apart from reviews and case reports, which today tend to advocate that these patients no longer be sys- tematically hospitalised [5].

Here, we describe a new vagal manoeuvre that is simple to perform, “administrable” by telephone and which can be carried out alone by the patient, an aspect that was not possible with the mVM. The pathophys- iology of the vagal mechanism of the reverse Valsalva method (without swallowing), described in the literature as the Toynbee manoeuvre, is identical to that of the sVM. The patient increases the intrathoracic pres- sure during inspiration against resistance, which leads to the barorecep- tors stimulating the vagus nerve and inhibiting the sympathetic system responsible for bradycardia and hypotension. This case series describes the effectiveness of this technique. Its ease of use and ability to be per- formed autonomously by the patient are also important elements given the significant prevalence of this pathology in the population (2.25 cases per 1000 people) [6]. A randomised controlled trial is now

necessary to evaluate the effectiveness of this new therapeutic tech- nique for the non-invasive management of SVT.

  1. Conclusion

The reverse Valsalva manoeuvre without swallowing is described here for the first time as a vagal manoeuvre in the context of arresting SVT. This manoeuvre holds much research interest. The rVM should be compared with the currently used vagal manoeuvres for treating SVT to determine whether it can be an alternative method or whether, be- cause of its greater effectiveness and simplicity of teaching and execu- tion, it should become the method of choice in the First-line treatment of SVT.

CRediT authorship contribution statement

Philippe Gaudart: conceptualization; data curation; Validation; Writing: review & editing. Nicolas Cazes: writing – original draft; For- mal analysis; Methodology; Writing: review & editing. Kimberley Simon: Investigation; Writing – original draft. Denis Larger: Resources; Software; Visualization. Jean-Claude Deharo: conceptualization; Su- pervision; Validation; Writing – review & editing.

Declarations of interest

None.

References

  1. Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva ma- noeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev. 2015 Feb;2015(2):CD009502.
  2. Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, et al. Postural modifica- tion to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015;386(10005): 1747-53.
  3. Ceylan E, Ozpolat C, Onur O, Akoglu H, Denizbasi A. Initial and sustained response ef- fects of 3 Vagal maneuvers in supraventricular tachycardia: a randomized. Clin Trial J Emerg Med. 2019;57(3):299-305.
  4. Mark AL. The Bezold-Jarisch reflex revisited: clinical implications of inhibitory re-

flexes originating in the heart. J Am Coll Cardiol. 1983 Jan;1(1):90-102.

  1. Arnold C, Martinez Martinez CJ. Paroxysmal supraventricular tachycardia. Cureus. 2019;11 (p. e4883).
  2. Medi C, Kalman JM, Freedman SB. Supraventricular tachycardia. Med J Aust. 2009 Mar;190(5):255-60.

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