The prevalence of hypertrophic cardiomyopathy (HCM) is approximately 1 in 500 (0.2%) based on imaging criteria, though broader definitions including genotype-positive, phenotype-negative individuals suggest a higher prevalence of approximately 1 in 200 (0.5%).[1] This translates to an estimated 750,000 affected individuals in the United States and potentially 15 million people worldwide.[2] The vast majority of HCM cases—approximately 80-90%—remain undiagnosed during a patient’s lifetime. With new treatments available, the condition can be managed much more readily without invasive procedures if patients are diagnosed in a timely fashion.

The Valsalva maneuver is a provocative technique used to unmask left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) when resting gradients are minimal or absent. Provocative maneuvers are essential because resting echocardiography underestimates LVOTO in up to 50% of patients with obstructive physiology.[1] The American College of Cardiology recommends performing provocative maneuvers such as sustained Valsalva or squat-to-stand when the resting gradient is <50 mm Hg, as this may uncover clinically significant obstruction that informs patient management. During echocardiographic assessment, continuous-wave Doppler is used to measure peak LVOT velocities during the Valsalva maneuver, with the gradient calculated using the modified Bernoulli equation. However, the American College of Cardiology notes that Valsalva maneuvers can be variable due to inconsistencies in instruction and patient effort.

To optimize the diagnostic yield of the Valsalva maneuver, a standardized goal-directed approach has been developed that maintains intraoral pressure >40 mm Hg for >10 seconds.[2] This technique uses a syringe barrel connected to a manometer with rubber tubing, allowing patients to visualize and maintain the target pressure, thereby eliminating the variability inherent in self-directed efforts. While this technique seems simple, our team in the Emory Echocardiography lab has found it difficult to replicate and coach our high volumes of hypertrophic cardiomyopathy patients through the correct maneuver. A single use, patient oriented device similar to an incentive spirometer would be extremely useful in standardization within echocardiography labs across the country in unmasking gradients and treating patients across the country – if not world. There is tremendous research and commercialization potential in a product of this caliber. The Emory Echo lab is full of physician, nursing, and sonographer staff interested in collaborating to help this project reach success as several attempts have been carried out and much learned from each though no prototype has been fully developed. We are looking for a motivated team of engineers to bring this important tool to fruition and help unmask obstructive gradients to ultimately diagnose patients and allow for treatment initiation.