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1 Author(s): Louis D Alecy, D.M.D., Ph.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Non-commercial Share Alike 3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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3 M2 Mini Review! Summer 2008! Chapter 9 Lilly! With flash backs to Mohrman and Heller! Pathophysiology of Heart Failure! Congestive HF = CO = Demand! =! CO &/or " Demand! Louis G. D Alecy, Professor of Physiology! 3!
4 Heart Failure Outline! 1) Normal Control of Stroke Volume! a) Contractility! b) Preload! c) Afterload! 2) Pathophysiology! a) Systolic Dysfunction! b) Diastolic Dysfunction! c) Right-Sided Heart Failure! d) Compensatory Mechanisms! 4!
5 ! Requirements for Effective Cardiac Pumping!! 1 Synchronized!!!not arrhythmic!! 2 Valves open fully!!not stenotic!! 3 Valves don't leak!!not insufficient!!!!!!or regurgitant!!! 4 Forceful!!!!not failing!! 5 Must fill!!!!not "dry"!! 5!
6 Fig. 3.14! 2-10! Lilly p 61! CVP! 2-8! 2-8! 2-10! PCWP! 2 Pumps! - in series! - Interact! - Preload! - Afterload! 2-8! 2-10! 2-8! 3/10/11! 6! Lilly Pg. 61
7 Interaction RV & LV (e.g.)! If RV in failure inadequate blood!!gets to LV for adequate!!lv preload & LV output goes!.! If LV in failure inadequate blood!!gets removed from lungs and!!rv and excess afterload to RV!!! output & " pulmonary edema.! 7!
8 Lilly Table 9.1 Definitions! Preload - The ventricular wall tension!!at the end of diastole.!! Afterload -- The ventricular wall tension!!during contraction; the resistance that!!must be overcome for the ventricle to!!eject its contents. Approximated by!!systolic ventricular or arterial pressure.!! Contractility -- Property of heart muscle that!!accounts for changes in strength of!!contraction independent of preload!!and afterload.! 8!
9 Inotropic! state! End-diastolic! pressure! Arterial! pressure! Ejection! Fraction! ~ 55%! 3/10/11! 9!
10 + inotropic! Normal response:! increased! contractility! increases! stroke volume! Fig 9.5! 3/10/11! 10!
11 Decreased SV with Systolic Dysfunction! Fig 9.7! **Abnormal**! Even! with! ESV! Because! "EDV!!SV! 11!
12 Normally:! Increased preload increases! stroke volume! Fig 9.5! (Preload)! 3/10/11! 12!
13 Frank-Starling Decompensation! 13!
14 Increased! contractility! Normal! Heart Failure! Fig 9.3 3/10/11! 14!
15 Arterial! pressure! Increased afterload! decreases! stroke volume! 3/10/11! 15!
16 Same for 1, 2, 3! Fig 9.5! 3! 2 1! Increased afterload! decreases stroke volume! Same for 1, 2, 3! (Preload)! 3/10/11! 16!
17 Inotropic state! or! End-diastolic! Pressure! or! Arterial! Pressure or! LV stress! LaPlace! Relationship! 3/10/11! 17!
18 stress! Pressure X radius! 2 X thickness! Lilly Pg. 229 Page 229 Lilly! Hypertrophy:! not beat to beat.! 18!
19 From Surgery: Scientific Principles and Practice! Ed. By Greenfield, Mulholland, Oldham, Zelenock,and Lillemoe! 3/10/11! 19! Surgery: Scientific Principles and Practice Ed.,Greenfield, Mulholland, Oldham, Zelenock,and Lillemoe
20 T = P x r! Tension = Press X radius! COST! LaPlace! Relationship! 50T= 50P x r! 2T = P x 2r! 50T = 25P x 2r! 3/10/11! 20!
21 T = P x r! Tension = Press X radius! COST! 1T = P x 1r! PCWP! or! LVEDP! 2T = P x 2r! As ventricle fills during diastole! the volume increases, tension doubles, with little increase in pressure! 21!
22 Isovolumetric contraction! Increases T and P! T = P x r! Tension = Press X radius! COST! 2T = P x 2r! iso 50T = 25P x 2r! 22!
23 T = P x r! Tension = Press X radius! COST! 50T= 50P x r! 2T = P x 2r! 3/10/11! 23! 50T = 25P x 2r!
24 Left ventricle pressure-volume loop! e! 50P (Systolic)! LaPlace! 25P (Diastolic)! Fig. 9.4! 24!
25 Pathophysiology of HF! CO fails to meet demand because:! 1) SYSTOLIC DYSFUNCTION! a) Impaired ventricular contractile function! b) Increased afterload! 2) DIAST a) Impaired ventricular filling! 3) COMPENSATORY MECHANISMS! a) Frank-Starling! b) Hypertrophy! c) Neurohumoral!! 25!
26 Contractile function! Reflexes! Fig 9.6! Top! 3/10/11! 26!
27 Contractile! function! 2/3! Fig /3! 27!
28 Fig 9.6! Bottom! " Stiffness! Chronic! Acute 28!
29 Decreased SV with Diastolic Dysfunction! Increased stiffness! Decreased Compliance!! SV! Fig 9.7 B! # EDV! 29!
30 Right-Sided Heart Failure! 30!
31 **limited! **limited! 3/10/11! 31!
32 Heart Failure COMPENSATORY MECHANISMS or failing compensatory mechanisms!!frank-starling!hypertrophy!neurohumoral! 32!
33 Initial compensation! Fig. 9.8! 33!
34 Really BP! Fig. 9.9! 3/10/11! 34!
35 Decreased CO..decreased MAP Baroreceptor Reflex!!!! 35!
36 Baroreceptor Reflex! + Ino! + Chron! VC +! Veno C! Fluid! retention! 36!
37 Really BP! Fig. 9.9 Ven Press! +/or! PCWP! 3/10/11! 37!
38 38!
39 Things that require an }increase in cardiac output.! 39!
40 e.g.! Beta blk.! Isoflurane! Thiopental! 40!
41 Coming Attractions: what to do!! Fig 9.10! 41!
42 HF-Evidence Based Therapies! 1) ACE inhibitors! 2) ARB s (angiotensin receptor blockers)! 3) Beta-blockers! 4) Aldosterone antagonists! 5) Anticoagulants for Atrial fibrillation! 6) Implantable cardioverter (ICD)! 7) Cardiac resynchronization (CRT)! 42!
43 Additional Source Information for more information see: Slide 6: Lilly Pg. 61 Slide 9: Slide 10: Slide 11: Slide 12: Slide 13: Slide 14: Slide 15: Slide 16: Slide 17: Slide 18: Lilly Pg. 229 Slide 19: Surgery: Scientific Principles and Practice Ed.,Greenfield, Mulholland, Oldham, Zelenock,and Lillemoe Slide 20: Slide 21: Slide 22: Slide 23: Slide 24: Slide 26: Slide 27: Slide 28: Slide 29: Slide 30: Slide 31: Slide 33: Slide 34: Slide 35: Slide 36: Slide 37: Slide 38: Slide 39: Slide 40: Slide 41:
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