Effects of the Mueller maneuver on global and regional left ventricular function in angina pectoris with or without previous myocardial infarction

In patients with coronary artery disease, left ventricular (LV) regional wall akinesia can develop during the Mueller maneuver.15 The present study determines if the presence of myocardial ischemic disease with no infarction is a sufficient condition for this to occur, or if the presence of prior acute myocardial infarction (MI) is necessary. In men, first-pass radionuclide ventriculography was performed in the 30 ° left anterior oblique supine position to measure LV ejection fraction, end-diastolic and end-systolic volumes and heart rate, and to obtain an image of the LV cavitary perimeter. This procedure was performed in 4 subject groups: 13 normal volunteers, 25 patients with coronary artery disease but no prior MI, 13 patients with coronary artery disease and prior nontransmural MI, and 36 patients with coronary artery disease and prior transmural MI. All patients had angina and underwent routine contrast coronary angiography; 60 also underwent contrast LV angiography. Ejection fraction decreased during the Mueller maneuver in each of all the coronary artery disease groups (p < 0.01), but not in the normal subjects. Heart rate increased in groups 1, 2 and 4 (p < 0.01), and end-diastolic volume decreased in all 4 groups (p < 0.01), whereas end-systolic volume did not change. Only in group 4 did regional wall akinesia develop (17 patients) during the Mueller maneuver. Among patients who had akinesia during the Mueller maneuver and also underwent routine contrast ventriculography, half of the akinetic segments were not seen on routine contrast study, but were seen only on radionuclide ventriculography during the Mueller maneuver. Thus, the appearance of regional LV wall akinesia on the radionuclide ventriculogram during the Mueller maneuver signifies the presence of prior transmural MI. The Mueller maneuver enhances the sensitivity of the radionuclide ventriculogram for detecting poorly functioning or nonfunctioning myocardium. The decrease in ejection fraction occurring in the patient groups, even in the absence of prior MI, may indicate that subtle abnormalities are present, which are exaggerated and detected during the performance of the Mueller maneuver.