Download Cardiac output and Venous Return

Cardiac output and Venous Return
Faisal I. Mohammed, MD, PhD
1
Objectives




Define cardiac output and venous return
Describe the methods of measurement of CO
Outline the factors that regulate cardiac output
Follow up the cardiac output curves at different
physiological states
 Define venous return and describe venous return
curve
 Outline the factors that regulate venous return
curve at different physiological states
 Inter-relate Cardiac output and venous return
curves
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Important Concepts About Cardiac
Output (CO) Control
• Cardiac Output is the sum of all tissue flows
and is affected by their regulation (CO =
5L/min, cardiac index = 3L/min/m2).
• CO is proportional to tissue O2. use.
• CO is proportional to 1/TPR when AP is
constant.
• F=P/R (Ohm’s law)
• CO = (MAP - RAP) / TPR, (RAP=0) then
• CO=MAP/TPR ; MAP=CO*TPR
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5
CARDIAC OUTPUT (L/min/m)
30
4
25
20
3
15
2
10
1
5
COUCH POTATO
0
0
0
200
400
600
800
1000
1200
1400
1600
WORK OUTPUT DURING EXERCISE (kg*m/min)
Copyright © 2006 by Elsevier, Inc.
OXYGEN CONSUMPTION (L/min)
OLYMPIC ATHLETE
Magnitude & Distribution of CO at Rest
& During Moderate Exercise
5
Variations in Tissue Blood Flow
Per cent
Brain
14
Heart
4
Bronchi
2
Kidneys
22
Liver
27
Portal
(21)
Arterial
(6)
Muscle (inactive state)
15
Bone
5
Skin (cool weather)
6
Thyroid gland
1
Adrenal glands
0.5
Other tissues
3.5
Total
100.0
ml/min
700
200
100
1100
1350
(1050)
(300)
750
250
300
50
25
175
5000
ml/min/
100 gm
50
70
25
360
95
4
3
3
160
300
1.3
--6
Control of Cardiac Output
7
Factors that affect the Cardiac Output
8
Ventricular Stroke Work Output
40
30
L.V.
stroke
work
(gram
meters)
4
3
20
2
10
1
0
0
10
20
Left Atrial Mean Pressure
(mm Hg)
R.V.
stroke
work
(gram
meters)
10
20
Right Atrial Mean Pressure
(mm Hg)
25
HYPEREFFECTIVE
CARDIAC OUTPUT (L/min)
CARDIAC OUTPUT
CURVES
20
15
NORMAL
10
5
HYPOEFFECTIVE
0
-4
0
+4
+8
RIGHT ATRIAL PRESSURE (mmHg)
Effect of Sympathetic and Parasympathetic
Stimulation on Cardiac Output
Maximum
sympathetic stimulation
Cardiac Output (L/min)
25
20
Normal
sympathetic stimulation
15
Zero
sympathetic stimulation
10
(Parasympathetic
stimulation)
5
0
-4
0
+4
+8
Right Atrial Pressure (mmHg)
IPP = INTRAPLEURAL PRESSURE
CARDIAC OUTPUT (L/min)
15
10
5
0
-4
0
4
8
RIGHT ATRIAL PRESSURE (mmHg)
12
The Cardiac Output Curve
• Plateau of CO curve determined by
heart strength (contractility + HR)
•
Sympathetics  plateau
•
 Parasympathetics (HR) plateau)
•
Plateau
•
Heart hypertrophy ’s plateau
•
Myocardial infarction plateau)
•
Plateau
13
The Cardiac Output Curve (cont’d)
• Valvular disease   plateau
(stenosis or regurgitation)
• Myocarditis   plateau
• Cardiac tamponade plateau)
• Plateau
• Metabolic damage   plateau
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Factors Affecting Cardiac Output
Factors Affecting Stroke Volume
Contractility of
Muscle cells
Cont = ESV
Cont = ESV
A Summary of the Factors Affecting
Cardiac Output
REGULATION OF STROKE VOLUME: PRELOAD
increased venous pressure
decreased heart rate
increased venous return
increased length of diastole
increased ventricular filling
increased preload
increased ventricular filling
increased ventricular stretch
Frank-Starling mechanism
increased force of contraction
increased stroke volume
increased cardiac output
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REGULATION OF STROKE VOLUME:
CONTRACTILITY
increased sympathetic activity
increased epinephrine
other factors
increased contractility
increased force of contraction
increased stroke volume
increased cardiac output
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Cardiac Contractility

Best is to measure the C.O. curve, but this is
nearly impossible in humans.
 dP/dt is not an accurate measure because this
increases with increasing preload and afterload.
 (dP/dt)/P ventricle is better. P ventricle is
instantaneous ventricular pressure.
 Excess K+ decreases contractility.
 Excess Ca++ causes spastic contraction, and low
Ca++ causes cardiac dilation.
REGULATION OF STROKE VOLUME:
AFTERLOAD
increased arterial pressure
increased afterload
decreased blood volume
ejected into artery
decreased stroke volume
decreased cardiac output
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Measurement of Cardiac Output





Electromagnetic flowmeter
Indicator dilution (dye such as cardiogreen)
Thermal dilution
Oxygen Fick Method
CO = (O2 consumption / (A-V O2 difference)
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Electromagnetic flowmeter
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q1=CO*CVO2
q2=amount of Oxygen uptake by the lungs
q3= CO* CAO2 and equals = CO*C VO2+ O2 uptake
Oxygen uptake = CO{CAO2-C VO2}
CO=Oxygen uptake/{CAO2-C VO2}
Spirometer
25
Swan-Ganz catheter
26
O2 Fick Problem

If pulmonary vein O2 content = 200 ml
O2/L blood
 Pulmonary artery O2 content =
160 ml O2 /L blood
 Lungs add 400 ml O2 /min
 What is cardiac output?
 Answer: 400/(200-160) =10 L/min
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t1
Area =
 dc.dt
t2
Area = C* (t2-t1)
(Rectangular)
C =Area/(t2-t1)
t1
Cardiac output =
t2
Thermodilution Method Curve
t2
AREA =
dT
.
dt

t1
t1
t2
1.Which of the following characteristics is most similar in the systemic and pulmonary
circulations?
A. Preload
B. Afterload
C. Peak systolic pressure
D. Blood volume
E. Stroke work
2. The major electrical axis of a patient is determined to be 115 degrees. This is closest
to the angle of which one of the following standard electrocardiographic limb leads?
A. Lead aVF
B. Lead aVL
C. Lead aVR
D. Lead II
E. Lead III
3. A patient is admitted to the intensive care unit and is found to have a resting heart rate of 110.
A potential cause of this heart rate is
A. Neither sympathetic nor parasympathetic stimulation to S-A or A-V nodes
B. Parasympathetic stimulation to the A-V node
C. Parasympathetic stimulation to the S-A node
D. Sympathetic stimulation to the A-V node
E. Sympathetic stimulation to the S-A node
4. Which of the following conditions at the A-V node will decrease the heart rate?
A. Decreased acetylcholine levels
B. Increased calcium permeability
C. Increased norepinephrine levels
D. Increased potassium permeability
E. Increased sodium permeability
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5.During the reduced ejection phase, which one of the following is true:
A. Left atrial pressure is falling.
B. Aortic pressure is falling below left ventricular pressure.
C. The A-V valves are closed.
D. Left ventricular pressure is constant.
E. The QRS complex terminates just before this phase.
6.The incisura or diacrotic notch in the aortic pressure curve is:
A. Of unknown mechanism.
B. Indicative of cardiovascualr disease.
C. Coincident with the second heart sound.
D. Absent in arteirosclerosis.
E. Felt easily in normal radial pulse.
7. A huge a-wave is observed in the jugular venous pulse curve in:
A. Atrial fibrillation.
B. Very rapid atrial pulsations more that 250/min.
C. Mitral stenosis.
D. Tricuspid stenosis.
E. Tricuspid regurgitation.
8.
All are involved in ventricular isometric contraction phase EXCEPT:
A. The ventricular pressure increases very rapidly.
B. The ventricular volume decreases markedly.
C. The atrial pressure increases due to sudden closure of A-V valves.
D. The first heart sound.
E. Q wave starts just before start of this phase.
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9. Within the jugular venous pulse, the C-wave:
A. Occurs at the onset of expiration.
B. Occurs during atrial systole.
C. Is the result of bulging of mitral and tricuspid valves into the atria.
D. Occurs as a result of bulging of semilunar valves into the aorta and pulmonary artery respectively.
E. None of the above.
10. Which is determined by ECG:
A. Mechanical performance of the heart:
B. Cardiac output.
C. Systolic and diastolic information.
D. Effects due to changes in fluid electrolytes.
E. Venous return to heart.
11. Which of the following is not seen during isovolumetric (isometric) ventricular
contraction:
A. Increase of intraventricular pressure.
B. The semilunar valves remain closed.
C. Ejection of blood from the ventricles.
D. C wave of Jugular venous pressure.
E. Constant ventricular volume.
12. During ventricular ejection ,the smallest pressure difference is between the;
A. Pulmonary artery and left atrium.
B. Right ventricle and right atrium.
C. Left ventricle and aorta.
D. Left ventricle and left atrium.
E. All choices above have the same pressure differences
13. When the bundle of His is completely interrupted,the:
A. Ventricles contract at a rate of 30-40 beats / minutes .
B. Atria beat irregularly
C. QRS complexes vary in shape from beat to beat .
D. P-R interval remains constant from beat to beat
E. S.A node stops discharging.
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VENOUS RETURN
Definition: Volume of blood returns to
either the left side or right side of the
heart per minute
 VR = CO = P/R
 VR = (Venous pressure –Rt. Atrial
pressure)/ resistance to venous return

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Effect of Venous Valves
34
Effect of Venous Valves
35
Venous Valves
Deep vein
Perforating vein
Superficial
vein
Valve
36
Effect Of Gravity on Venous Pressure
37
Venous Pressure in the Body
• Compressional factors tend to
cause resistance to flow in large
peripheral veins.
• Increases in right atrial pressure
causes blood to back up into the
venous system thereby increasing
venous pressures.
• Abdominal pressures tend to
increase venous pressures in the
legs.
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Central Venous Pressure

Pressure in the right atrium is called central venous
pressure.

Right atrial pressure is determined by the balance of
the heart pumping blood out of the right atrium and
flow of blood from the large veins into the right
atrium.

Central venous pressure is normally 0 mmHg, but can
be as high as 20-30 mmHg.
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Factors affecting Central Venous
Pressure
 Right atrial pressure (RAP) is
regulated by a balance between
the ability of the heart to pump
blood out of the atrium and the
rate of blood flowing into the
atrium from peripheral veins.
 Factors that increase RAP:
 -increased blood volume
 -increased venous tone
 - dilation of arterioles
 -decreased cardiac function
40
Factors that Facilitate Venous Return
41
The Venous Return Curve
VENOUS RETURN (L/MIN)
MSFP = Mean Systemic Filling Pressure
10
5
MSFP= 14
MSFP= 7
MSFP= 4.2
0
-4
0
4
8
RIGHT ATRIAL PRESSURE (mmHg)
12
VENOUS RETURN (L/min/m)
20
15
1/2 RESISTANCE
10
NORMAL RESISTANCE
MSFP = 7
5
2 X RESISTANCE
0
-4
0
4
RIGHT ATRIAL PRESSURE (mmHg)
8
Venous Return (VR)
• Beriberi - thiamine deficiency 
arteriolar dilatation   RVR
• (RVR= resistance to venous return)
because VR = (MSFP - RAP) /RVR
(good for positive RAP’s)
•
A-V fistula (? RVR)
•
RVR
•
C. Hyperthyroidism  (? RVR)
•
RVR
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Venous Return (VR) (cont’d)
•
•
•
•
•
Anemia  RVR (why?)
Sympathetics  MSFP
Blood volume  MSFP + small
 in RVR
 Venous compliance (muscle
contraction or venous constriction)
SFP)
MSFP
45
Factors Causing Venous Return
•
•
•
•
•
 Blood volume   MSFP
 Sympathetics (? v. comp. and
MSFP)
Venous compliance and MSFP
Obstruction of veins (? RVR)
RVR
46
CARDIAC OUTPUT AND VENOUS RETURN (L/min/m)
25
MAXIMAL SYMPATHETIC
STIMULATION
20
15
NORMAL CARDIAC
SPINAL ANESTHESIA
MAX
10
5
SPINAL
0
-4
0
4
8
12
RIGHT ATRIAL PRESSURE (mmHg)
16
Thank You