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Normal Heart Function

and
Congestive Heart Failure

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 Basic Concepts:
 The Cardiac Cycle
 Myocardial Filling -- “Diastole”
Compliance
Left ventricular filling curves
 Myocardial Emptying -- “Systole”
Cardiac Output
Frank-Starling Performance Curves
 The relationship of filling and emptying:
Pressure - Volume Loops

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 Basic Definitions
 Cardiac Output is  Blood Pressure is
defined as: defined as:

Stroke Volume Cardiac Output

X X
Heart Rate Systemic Vascular
Resistance
What happens to each of these during:
Exercise?
When LV filling is impaired??
When systolic function is impaired???
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 What happens to the runner
during exercise?
OR
“Why the jogger didn’t blow his top!”

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 Basic Definitions
 Cardiac Output is  Blood Pressure is
defined as: defined as:

Stroke Volume Cardiac Output

X X
Heart Rate Systemic Vascular
Resistance

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 Basic Concepts: #1

The Cardiac Cycle

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 The Normal Cardiac Cycle
 Components of Diastole:
Isovolumic relaxation
Rapid Ventricular filling
Atrial contraction (“kick”)
 Components of Systole
Isovolumic contraction
L.V. Ejection

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 Volume change during LV filling

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 The Normal Cardiac Cycle

 Let’s take a look at the cycle in some

depth............

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 The Cardiac Cycle

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 Basic Concepts: #2
 The Cardiac Cycle
 Myocardial Filling -- “Diastole”
Compliance
Left ventricular filling curves
 Myocardial Contractility -- Systole Frank-
Starling Performance Curves
 The relationship of filling and emptying:
Pressure - Volume Loops

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 Left ventricular filling curves
 Relationship of pressure to
volume defines L.V. “stiffness” or
“non-compliance”
 At low pressures, almost linear
40
Pressure (mm Hg)

30
20
Y

10
0

V o l u m e (m l )
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 Relationships to Remember
 “Compliance” is  “Stiffness” is the
proportional to inverse.
change in volume  Stiffness is
over proportional to
change in pressure change in pressure
over
change in volume

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 Normal vs “non-compliant” LV

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 Basic Concepts: #3
 The Cardiac Cycle
 Myocardial Filling -- “Diastole”

Compliance
Left ventricular filling curves
 Myocardial Emptying -- “Systole”
Cardiac Output
Frank-Starling Performance Curves
Bio-Med 350The relationship of filling and emptying:

 Mediators of Cardiac Output

C A R D IA C O U T P U T

H e a rt R a te S tro k e V o lu m e

P re lo a d A f te rlo a d C o n tra c til i ty

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 Relationships to Remember
 “Preload” and “afterload” are defined as
the wall tension during diastole and
systole, respectively
 Wall tension is defined as:

Pxr
2h (where h = wall thickness)

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 Preload
 Is the wall tension during ventricular
filling
 Is defined as Pxr
2h

during diastole!!!

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 Why is volume the most
important determinant of
ventricular preload??

(Hint: look at the cardiac cycle)

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 The Cardiac Cycle

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 Afterload
 Is the wall tension during ventricular
ejection
 Is defined as: Pxr
2h

during systole!!!

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 Why is systolic pressure the
most important determinant of
ventricular afterload???

(Hint: look again at the cardiac cycle)

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 The Cardiac Cycle

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 How do we relate myocardial
performance to:
 Loading conditions: i.e. preload and
afterload

And how does “myocardial contractility”

relate to all of the above??

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 Frank - Starling Curves
7  L.V. “performance”
6 curves relating:
5
or stroke volume
Cardiac Output

4
1. L.V.E.D.P.
3
2
(i.e." preload”)
1
0 2. L.V. “performance”
L .V . e n d -d i a s t o l i c p r e s s u r e (i.e. cardiac
o r e n d -d i a s t o l i c v o l u m e
output)

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 Frank-Starling Curves in CHF

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 What happens to:
 Heart rate  When:
 Blood pressure
 Cardiac output  LV filling falls
 Vascular resistance  LV systolic function
is impaired
 The LV is non-
compliant
 Afterload increases

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 How do we measure.....

?
 Blood pressure
 Cardiac output
 Stroke volume
 LVEDP
 Systemic vascular resistance

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 The Swan-Ganz Catheter

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 Werner Forssman – 1929

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 Right heart catheterization

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 Right Heart Catheterization

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 Measuring Cardiac Output

 Fick Method --  Thermodilution

method --

O2 consumption
A-V O2 difference “The Black Box”

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 The Fick Principle

Lungs

O2

Body

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 Measuring O2 consumption
The Waters Hood

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 The Thermodilution Method
 Similar in principle to the Fick method
 Uses change in temperature per unit
time, rather than change in O2
saturation
 Requires a thermal probe in the right
side of the heart

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 Construction of Starling Curve for
an individual patient
7
6
5
or stroke volume
Cardiac Output

4
3
2
1
0
L .V . e n d -d i a s t o l i c p r e s s u r e
o r e n d -d i a s t o l i c v o lu m e

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 Pressure - Volume Loops
 Relate L.V. pressure
to L.V. volume in a
single cardiac cycle
Pressure
(mm Hg)
 Can be used to
explore the effects of
Vo lume (ml) various therapies on
stroke volume and
L.V.E.D.P.

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 Pressure - Volume Loops
 Holding afterload
and contractility
constant
 Varying “preload”,
measured as end-
diastolic volume

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 Heart Failure
Forward Failure:
Inability to pump blood forward to meet the
body’s demands

Backward Failure:
Ability to meet the body’s demands, at the
cost of abnormally high filling pressures

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 Systolic vs. Diastolic Dysfunction
 Systolic dysfunction
• Decreased stroke volume
• Decreased forward cardiac output
• Almost always associated with diastolic
dysfunction as well
 Diastolic Dysfunction
• One third of patients with clinical heart
failure have normal systolic function – i.e.
“pure” diastolic dysfunction

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 Impa ire d Co ntra c tility Pre s s ure Ove rlo ad

1. Myoc ardial Infarc tio n 1. Aortic S te no s is

2. Tra ns ie nt myo c ardial is c he mia 2. Unc ontrolle d hype rte ns ion
3. Chro nic Volume o ve rlo ad
4. Dila te d Cardio myopathy

L.V. S ys tolic dys func tion

Left Heart Failure

L.V. Dia s to lic dys func tion Obs truc tio n of L.V. filling

1. Le ft ve ntric ula r hype rtrophy 1. Mitra l S te nos is

2. Hype rtrophic c a rdio myopathy 2. Pe ric ardia l c ons tric tio n or
3. Re s tric tive c ardiomyo pathy tamponade
4. Trans ie nt myoc a rdial is c he mia

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 Impaire d Co ntrac tility Pre s s ure Ove rlo ad

1. Myo c ardial Infarc tio n 1. Aortic S te no s is

2. Trans ie nt myo c ardial is c he mia 2. Unc ontrolle d hype rte ns ion
3. Dilate d Cardio myo pathy
4. Chro nic Vo lume o ve rlo ad

L.V. S ys tolic dys func tion

Left Heart Failure

L.V. Dia s to lic dys func tion Obs truc tion of L.V. filling

1. Le ft ve ntric ula r hype rtrophy 1. Mitral S te no s is

2. Hype rtrophic c a rdio myopathy 2. Pe ric a rdial c o ns tric tion or
3. Re s tric tive c ardiomyo pathy tampo nade
4. Trans ie nt myoc a rdial is c he mia

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 Impa ire d Co ntra c tility Pre s s ure Ove rlo ad

1. Myoc ardial Infarc tio n 1 . Ao rtic S te no s is

2. Tra ns ie nt myo c ardial is c he mia 2 . Unc ontrolle d hype rte ns ion
3. Chro nic Volume o ve rlo ad
4. Dila te d Cardio myopathy

L.V. S ys tolic dys func tion

Left Heart Failure

L.V. Dia s to lic dys func tion Obs truc tion of L.V. filling

1. Le ft ve ntric ula r hype rtrophy 1. Mitral S te no s is

2. Hype rtrophic c a rdio myopathy 2. Pe ric a rdial c o ns tric tion or
3. Re s tric tive c ardiomyo pathy tampo nade
4. Trans ie nt myoc a rdial is c he mia

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 Impa ire d Co ntra c tility Pre s s ure Ove rlo ad

1. Myoc ardial Infarc tio n 1 . Ao rtic S te no s is

2. Tra ns ie nt myo c ardial is c he mia 2 . Unc ontrolle d hype rte ns ion
3. Chro nic Volume o ve rlo ad
4. Dila te d Cardio myopathy

L.V. S ys tolic dys func tion L.V. Dias to lic dys func tio n

Left Heart Failure

L.V. Dia s to lic dys func tion Obs truc tion of L.V. filling

1. Le ft ve ntric ula r hype rtrophy 1. Mitral S te no s is

2. Hype rtrophic c a rdio myopathy 2. Pe ric a rdial c o ns tric tion or
3. Re s tric tive c ardiomyo pathy tampo nade
4. Trans ie nt myoc a rdial is c he mia

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 Diastolic Dysfunction
 Impaired early diastolic relaxation
(this is an active, energy dependent process)

 Increased stiffness of the left ventricle

(this is a passive phenomenon)
• LVH
• LV fibrosis
• Restrictive or infiltrative cardiomyopathy

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 Diastolic dysfunction due to LVH

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 Diastolic dysfunction:
Pressure – Volume Loop

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 Impa ire d Co ntra c tility Pre s s ure Ove rlo ad

1. Myoc ardial Infarc tio n 1. Aortic S te no s is

2. Tra ns ie nt myo c ardial is c he mia 2. Unc ontrolle d hype rte ns ion
3. Chro nic Volume o ve rlo ad
4. Dila te d Cardio myopathy

L.V. S ys tolic dys func tion

Left Heart Failure

L.V. Dia s to lic dys func tio n Obs truc tion of L.V. filling

1. Le ft ve ntric ula r hype rtro phy 1. Mitral S te no s is

2. Hype rtrophic c a rdiomyo pa thy 2. Pe ric a rdial c o ns tric tion or
3. Re s tric tive c a rdiomyo pa thy tampo nade
4. Trans ie nt myo c a rdial is c he mia

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 Compensatory Mechanisms for
Heart Failure

 Frank – Starling Mechanism

 Neuro-humoral alterations
 Left ventricular enlargement
• LV Hypertrophy  ↑ contractility
• LV “remodeling”  ↑ stroke volume

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 Frank –Starling mechanism

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 Neuro-humoral mediators

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 Neuro-humoral mediators

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 Left Ventricular enlargement
 Concentric LVH  Eccentric hypertrophy
(cavity dilation and hypertrophy)
• Increased LVEDP
• Seen in volume-overload
• Increased incidence states
of backward failure
• Seen after acute MI
• Decreased wall (post-infarction “remodeling”)
stress at expense of • Increased stroke volume
increased oxygen at the expense of
demand and increased wall stress,
increased LVEDP oxygen demand and
LVEDP

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 End results of “compensatory mechanisms”

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 Impa ire d Co ntra c tility Pre s s ure Ove rlo ad

1. Myoc ardial Infarc tio n 1. Aortic S te no s is

2. Tra ns ie nt myo c ardial is c he mia 2. Unc ontrolle d hype rte ns ion
3. Chro nic Volume o ve rlo ad
4. Dila te d Cardio myopathy

L.V. S ys tolic dys func tion

Left Heart Failure

L.V. Dia s to lic dys func tion Obs truc tio n o f L.V. filling

1. Le ft ve ntric ula r hype rtrophy 1. Mitra l S te nos is

2. Hype rtrophic c a rdio myopathy 2. Pe ric ardia l c ons tric tion or
3. Re s tric tive c ardiomyo pathy tamponade
4. Trans ie nt myoc a rdial is c he mia

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 “Pseudo” Left Heart Failure
Abnormally high filling pressure (PCW pressure)
despite normal LV function and LVEDP

Obs truc tio n o f L.V. filling

Mitral S te no s is

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 Right Heart Failure
 Very commonly a  Cardiac causes
sequela of Left Heart • Pulmonic valve stenosis
Failure • RV infarction

• LVEDP
 Parenchymal pulmonary
causes
• PCW
• COPD
• PA pressure • ILD
• Right heart pressure  Pulmonary vascular disease
overload • Pulmonary embolism
• Primary Pulmonary
hypertension

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 Right heart vs. Left heart failure

Left Heart failure Right Heart failure

• Pulmonary congestion • Neck vein distension
• Reduced forward • Hepatic congestion
cardiac output: • Peripheral edema
• Fatigue • Also may result in
• Renal insufficiency reduced forward cardiac
• Cool extremities output, but with clear
• Decreased mentation lung fields

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