Hemodynamic correlates of effective arterial elastance in mitral stenosis before and after balloon valvotomy

Understanding ventriculo-arterial coupling

In the late 19th century, Otto Frank published the first description of a ventricular pressure-volume diagram, thus laid the foundation for modern cardiovascular physiology. Since then, the analysis of the pressure-volume loops became a reference tool for the study of the ventricular pump properties. However, understanding cardiovascular performance requires both the evaluation of ventricular properties and the modulating effects of the arterial system, since the heart and the arterial tree are anatomically and functionally related structures. The study of the coupling between the cardiac function and the properties of the arterial system, or ventriculo-arterial (VA) coupling, provides then a comprehensive characterization of the performance of the cardiovascular system in both health and disease. The assessment of cardiovascular function is an essential element of the hemodynamic evaluation of critically ill patients. Both left and right ventricular dysfunction and arterial system disturbances are frequent in these patients. Since VA coupling ultimately defines de performance and efficiency of the cardiovascular system, the analysis of the interaction between the heart and the arterial system could offer a broader perspective of the hemodynamic disorders associated with common conditions, such as septic shock, heart failure, or right ventricular dysfunction. Moreover, this analysis could also provide valuable information about their pathophysiological mechanisms and may help to determine the best therapeutic strategy to correct them. In this review, we will describe the basic principles of the VA coupling assessment, its limitations, and the most common methods for its estimation at the bedside. Then, we will summarize the current knowledge of the application of VA coupling in critically ill patients and suggest some recommendations for further research.

Reliability of effective arterial elastance using peripheral arterial pressure as surrogate for left ventricular end-systolic pressure

To compare the effective arterial elastance (Ea) obtained from the arterial pressure with Ea calculated from left-ventricular (LV) pressure-volume analysis. Experimental study. LV pressure-volume data was obtained with a conductance catheter and arterial pressures were measured via a fluid-filled catheter placed in the proximal aorta, femoral and radial arteries. Ea was calculated as LV end-systolic pressure (ESP)/stroke volume (SV). Experimental protocol consisted sequentially changing afterload (phenylephrine/nitroprusside), preload (bleeding/fluid), and contractility (esmolol/dobutamine). 90% of systolic pressure (Ea_ao_SYS, Ea_fem_SYS, Ea_rad_SYS), mean arterial pressure (Ea_ao_MAP, Ea_fem_MAP, Ea_rad_MAP), and dicrotic notch pressure (Ea_ao_DIC, Ea_fem_DIC, Ea_rad_DIC) were used as surrogates for LV ESP. SV was calculated from the LV pressure-volume data. When Ea was compared with estimations based on 90% SAP, the relationship was r² = 0.95, 0.94 and 0.92; and the bias and limits of agreement (LOA): - 0.01 ± 0.12, - 0.09 ± 0.12, - 0.05 ± 0.15 mmHg ml^-1, for Ea_ao_SYS, Ea_fem_SYS and Ea_rad_SYS, respectively. For estimates using dicrotic notch, the relationship was r² = 0.94, 0.95 and 0.94 for Ea_ao_DIC, Ea_fem_DIC and Ea_rad_DIC, respectively; with a bias and LOA: 0.05 ± 0.11, 0.06 ± 0.12, 0.10 ± 0.12 mmHg ml^-1, respectively. When Ea was compared with estimates using MAP, the relationship was r² = 0.95, 0.96 and 0.95 for Ea_ao_MAP, Ea_fem_MAP and Ea_rad_MAP, respectively; with a bias and LOA: 0.05 ± 0.11, 0.06 ± 0.11, 0.06 ± 0.11 mmHg ml^-1, respectively. LV ESP can be estimated from the arterial pressure. Provided that the SV measurement is reliable, the ratio MAP/SV provides a robust Ea surrogate over a wide range of hemodynamic conditions and is interchangeably in any peripheral artery, so it should be recommended as an arterial estimate of Ea in further research.

WEB downloadable software for training in cardiovascular hemodynamics in the (3-D) stress echo lab

When a physiological (exercise) stress echo is scheduled, interest focuses on wall motion segmental contraction abnormalities to diagnose ischemic response to stress, and on left ventricular ejection fraction to assess contractile reserve. Echocardiographic evaluation of volumes (plus standard assessment of heart rate and blood pressure) is ideally suited for the quantitative and accurate calculation of a set of parameters allowing a complete characterization of cardiovascular hemodynamics (including cardiac output and systemic vascular resistance), left ventricular elastance (mirroring left ventricular contractility, theoretically independent of preload and afterload changes heavily affecting the ejection fraction), arterial elastance, ventricular arterial coupling (a central determinant of net cardiovascular performance in normal and pathological conditions), and diastolic function (through the diastolic mean filling rate). All these parameters were previously inaccessible, inaccurate or labor-intensive and now become, at least in principle, available in the stress echocardiography laboratory since all of them need an accurate estimation of left ventricular volumes and stroke volume, easily derived from 3 D echo.

Aims of this paper are: 1) to propose a simple method to assess a set of parameters allowing a complete characterization of cardiovascular hemodynamics in the stress echo lab, from basic measurements to calculations 2) to propose a simple, web-based software program, to learn and training calculations as a phantom of the everyday activity in the busy stress echo lab 3) to show examples of software testing in a way that proves its value.

The informatics infrastructure is available on the web, linking to http://cctrainer.ifc.cnr.it

Contribution of systemic vascular resistance and total arterial compliance to effective arterial elastance in humans

The respective contribution of systemic vascular resistance (R) and total arterial compliance (C) to the arterial load remains to be established in humans. Effective arterial elastance (Ea), i.e., the left ventricular end-systolic pressure (LVESP)-over-stroke volume ratio, is a reliable estimate of arterial load. It is widely accepted that Ea mainly relates to mean aortic pressure (MAP) and thus to the R-to-T ratio (R/T ratio), where T is cycle length. We tested the contribution of R/T and 1/C to Ea in 20 normotensive and 46 hypertensive subjects (MAP range: 84-160 mmHg). The multilinear model applied (Ea = 1.00R/T + 0.42/C - 0.04; r2 = 0.97). The sensitivity of Ea to a change in R/T was 2.5 times higher than to a similar change in 1/C in both normotensive and hypertensive adults. The LVESP was more strongly related to systolic aortic pressure (SAP; r2 = 0.94) than to MAP (r2 = 0.83), and LVESP matched 90% SAP (bias = 0 +/- 5mmHg). An alternative model of Ea is proposed, in which Ea is proportional to the heart rate x SAP product-over-cardiac index ratio whatever the MAP.