New “Reverse” Valsalva for SVT

Written by Sam Parnell

Spoon Feed
The reverse Valsalva maneuver is a novel technique to terminate supraventricular tachycardia (SVT). Based on a small case series, this simple maneuver appears to be safe, effective, and can be performed by patients alone at home. However, additional studies are needed to establish the actual efficacy of this technique.

Why does this matter?
SVT is a common reason for acute care presentation, and many patients have recurrent episodes of SVT. The REVERT trial (covered by REBEL EM) crowned the modified Valsalva technique as the current champion with more than double the efficacy compared to the standard Valsalva maneuver (43% vs 17%, NNT=3). However, this maneuver requires assistance from another individual to reposition the patient as well as a manometer or 10 mL syringe. What if there was another technique that was easier, more effective, and didn’t require any assistance or equipment? Enter the reverse Valsalva maneuver.

SVT to the left. SVT to the right. Reverse! Reverse! Cardiovert now y’all!
This was a case series of 11 patients from France with SVT treated with the reverse Valsalva technique. Approximately 91% of patients (10/11) were successfully cardioverted back to sinus rhythm with the reverse Valsalva technique, including 4 patients who had previous unsuccessful attempts with the modified Valsalva maneuver.

The reverse Valsalva technique increases vagal tone and decreases sympathetic activity to restore sinus rhythm. It is comprised of four main steps as shown in the figure from the article below. This technique, if successful, usually allows for restoration of sinus rhythm within 10-15 seconds after completion of the maneuver.  

Overall, this seems like a very promising technique that is simple, safe, and most importantly can be performed autonomously by patients at home. However, with only limited evidence from case reports and small case series like this one, we still don’t know its true efficacy. Nevertheless, the reverse Valsalva maneuver is an additional tool to add to your clinical toolbelt and is a viable alternative to the current first-line modified Valsalva approach.

Source
The reverse vagal manoeuvre: A new tool for treatment of supraventricular tachycardia? Am J Emerg Med. 2021 Mar;41:66-69. doi: 10.1016/j.ajem.2020.12.061. Epub 2020 Dec 26.