1. Cardiac output and Venous Return
Faisal I. Mohammed, MD, PhD

2. 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

3. 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 3 3

4. OXYGEN CONSUMPTION (L/min) CARDIAC OUTPUT (L/min/m)35 5
CARDIAC OUTPUT
OLYMPIC ATHLETE 30 4 O 2
CONSUMPTION 25 20 3
OXYGEN CONSUMPTION (L/min)
CARDIAC OUTPUT (L/min/m) 15 2 10 1 5
COUCH POTATO
WORK OUTPUT DURING EXERCISE (kg*m/min)
Copyright © 2006 by Elsevier, Inc.

5. Magnitude & Distribution of CO at Rest & During Moderate Exercise

6. Variations in Tissue Blood Flow
ml/min/
100 gm
Per cent ml/min
Brain
Heart
Bronchi
Kidneys
Liver
Portal (21) (1050)
Arterial (6) (300)
Muscle (inactive state)
Bone
Skin (cool weather)
Thyroid gland
Adrenal glands
Other tissues
Total

7. Control of Cardiac Output

8. Factors that affect the Cardiac Output

9. Ventricular Stroke Work Output
L.V.
stroke
work
(gram
meters)
R.V.
stroke
work
(gram
meters) 40 4 30 3 20 2 10 1 10 20 10 20
Left Atrial Mean Pressure
(mm Hg)
Right Atrial Mean Pressure
(mm Hg) 9

10. HYPEREFFECTIVE 25
CARDIAC OUTPUT
CURVES 20 15
NORMAL
CARDIAC OUTPUT (L/min) 10
HYPOEFFECTIVE 5
RIGHT ATRIAL PRESSURE (mmHg)

11. Effect of Sympathetic and Parasympathetic Stimulation on Cardiac Output
Maximum
sympathetic stimulation 25 20
Normal
sympathetic stimulation 15
Cardiac Output (L/min)
Zero
sympathetic stimulation 10
(Parasympathetic
stimulation) 5 -4 +4 +8
Right Atrial Pressure (mmHg) 11

12. 15 10 5 -4 0 4 8 12 CARDIAC OUTPUT (L/min)
IPP = INTRAPLEURAL PRESSURE 15
IPP= -4mmHg
IPP= -2mmHg
CARDIAC TAMPONADE 10
CARDIAC OUTPUT (L/min) 5
IPP= -5.5mmHg
IPP= 2mmHg
RIGHT ATRIAL PRESSURE (mmHg)

13. The Cardiac Output Curve
Plateau of CO curve determined by heart strength (contractility + ­HR)
­ Sympathetics Þ ­ plateau
¯ Parasympathetics (HR­) Þ (? plateau)
­ Plateau
Heart hypertrophy Þ­’s plateau
Myocardial infarction Þ (? plateau)
¯ Plateau

14. The Cardiac Output Curve (cont’d)
Valvular disease Þ ¯ plateau (stenosis or regurgitation)
Myocarditis Þ ¯ plateau
Cardiac tamponade Þ (? plateau)
¯ Plateau
Metabolic damage Þ ¯ plateau

15. Factors Affecting Cardiac Output

16. Factors Affecting Stroke Volume
Contractility of
Muscle cells
Cont = ESV

17. A Summary of the Factors Affecting Cardiac Output

18. REGULATION OF STROKE VOLUME: PRELOAD
increased venous pressure
decreased heart rate
increased length of diastole
increased venous return
increased ventricular filling
increased preload
increased ventricular filling
increased ventricular stretch
Frank-Starling mechanism
increased force of contraction
increased stroke volume
increased cardiac output

19. REGULATION OF STROKE VOLUME: CONTRACTILITY
increased sympathetic activity
increased epinephrine
other factors
increased contractility
increased force of contraction
increased stroke volume
increased cardiac output

20. 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. 20

21. REGULATION OF STROKE VOLUME: AFTERLOAD
increased arterial pressure
increased afterload
decreased blood volume ejected into artery
decreased stroke volume
decreased cardiac output

22. Measurement of Cardiac Output
Electromagnetic flowmeter
Indicator dilution (dye such as cardiogreen)
Thermal dilution
Oxygen Fick Method
CO = (O2 consumption / (A-V O2 difference) 22 22

23. Electromagnetic flowmeter23

24. 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}

25. Spirometer 25

26. Swan-Ganz catheter 26

27. O2 Fick Problem If pulmonary vein O2 content = 200 ml O2/L blood
Pulmonary artery O2 content = ml O2 /L blood
Lungs add 400 ml O2 /min
What is cardiac output?
Answer: 400/( ) =10 L/min 27 27

28. Area = Area = C* (t2-t1) (Rectangular) C =Area/(t2-t1)
Cardiac output =

29. Thermodilution Method Curve
AREA = t1 t2

30. 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

31. 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.

32. 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 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.

33. 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

34. Effect of Venous Valves

35. Effect of Venous Valves

36. Venous Valves
Deep vein
Perforating vein
Superficial
vein
Valve

37. Effect Of Gravity on Venous Pressure

38. 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.

39. 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 mmHg.

40. 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

41. Factors that Facilitate Venous Return

42. The Venous Return Curve
MSFP = Mean Systemic Filling Pressure
MSFP= 14 10
MSFP= 7
VENOUS RETURN (L/MIN) 5
MSFP= 4.2
RIGHT ATRIAL PRESSURE (mmHg)

43. 20 15 10 MSFP = 7 5 -4 0 4 8 VENOUS RETURN (L/min/m)
1/2 RESISTANCE
VENOUS RETURN (L/min/m) 10
NORMAL RESISTANCE 5
MSFP = 7
2 X RESISTANCE
RIGHT ATRIAL PRESSURE (mmHg)

44. Venous Return (VR)
Beriberi - thiamine deficiency Þ arteriolar dilatation Þ ¯ RVR
(RVR= resistance to venous return) because VR = (MSFP - RAP) /RVR (good for positive RAP’s)
A-V fistula Þ (? RVR)
¯ RVR
C. Hyperthyroidism Þ (? RVR)

45. Venous Return (VR) (cont’d)
Anemia Þ ¯ RVR (why?)
­ Sympathetics Þ ­ MSFP
­ Blood volume Þ ­ MSFP + small ¯ in RVR
¯ Venous compliance (muscle contraction or venous constriction) Þ (? MSFP)
­ MSFP

46. Factors Causing Venous Return
¯ Blood volume Þ ¯ MSFP
¯ Sympathetics Þ (? v. comp. and MSFP)
­ Venous compliance and ¯MSFP
Obstruction of veins Þ (? RVR)
­ RVR

47. SYMPATHETIC STIMULATION25
MAXIMAL SYMPATHETIC
STIMULATION 20 15
NORMAL CARDIAC
CARDIAC OUTPUT AND VENOUS RETURN (L/min/m)
SYMPATHETIC STIMULATION
MAX
SPINAL ANESTHESIA 10 5
VR CURVE NORMAL
SPINAL
ANESTHESIA
RIGHT ATRIAL PRESSURE (mmHg)

48. Thank You