British Hert Journl, I97I, 33, 494-499. Reltions between pressure in pulmonry rtery, left trium, nd left ventricle with specil reference to events t end distole S. A. Forsberg' From the Medicl Deprtment I, Shlgren's Hospitl, University of Gdteborg, Sweden Results were extrcted from I58 ptients who hve undergone dignostic hert ctheteriztion t rest. Seventeen were considered norml. Simultneous pressure records from the pulmonry rtery nd left trium were lwys mde nd often lso from the left trium nd ventricle. Some of the min conclusions re s follows. I) There is normlly t rest left trioventriculr distolic pressure congruence. 2) The z point, tht is thefoot of the left tril c wve, is normlly identicl with the end-distolic ventriculr pressure. 3) Normlly the pulmonry rteril distolic pressure is pproximtely identicl with the enddistolic pressure of the left ventricle. 4) At the end of distole, the flow nd pressure grdient cross the pulmonry vsculr bed seem to be in phse nd both re close to zero. _5) Ptients with different crdiovsculr diseses, the mjority with mitrl vlvulr disese, were compred with the norml group. With moderte mitrl stenosis without much rised pulmonry vsculr resistnce, the reltion between pulmonry rteril distolic pressure nd enddistolic pressure in the left trium is similr to tht in norml ptients. Pulmonry rteril distolic pressure hs received reltively less ttention thn other mesured entities in the pulmonry circultion such s the rteril systolic or men pressure or pulmonry cpillry venous pressure. The min purpose of the present study ws to investigte fctors determining the pulmonry distolic pressure nd its reltion to events in the left ventricle nd left trium. Methods nd mteril Results were extrcted from the mteril of 158 ptients who hve undergone dignostic right nd left hert ctheteriztion with mesurement of the pulmonry blood volume. Detils of the methods were described by Forsberg (1964). Ctheters were plced in the pulmonry rtery nd left trium, nd pressures were simultneously recorded. In bout one-third of the mteril the two pressures were recorded with the sme zero nd clibrtion pressure on congruent levels on the recording pper, giving direct visul picture of the instntneous pressure difference during the hert cycles. A similr technique ws routinely used when left tril nd ventriculr pressures were simultneously recorded. Received 23 September I970. 1 Present ddress: Medicinsk kliniken, Bors lsrett, 50i I5 Boris, Sweden. The undmped nturl frequency of the whole mesuring system is of the order of I5-40 Herz, the pulmonry rteril ctheter usully giving vlues in the lower hlf of the rnge nd the left tril or left ventriculr ctheter rther more in the upper hlf. The degree of dmping is round Oi. An empiricl comprison of the two recording systems is seen in Fig. x. In ll figures the time between two thick lines equls OI sec. Clcultions of verge pressures were mde out of I0 hert cycles. The end-distolic pressure in the left trium ws mesured from the z point which is the foot of the c wve. In bsence of the c wve it ws judged on the left trium curve, from the left ventriculr curve, or from the R wve in the electrocrdiogrm. All results refer to investigtions of ptients t rest in the supine position. The dignoses in the totl mteril were s follows: norml hemodynmics without hert or lung vsculr disese (I5); obstructive lung disese with norml hemodynmics (2); left tril myxom (2); mitrl vlvulr disese (8i); mitrl nd ortic vlvulr disese (I3); ortic vlvulr disese (23); ortic corcttion (6); systemic hypertensive disese (i); crdiomyopthy (5); pulmonry stenosis (2); primry pulmonry hypertension (7); hyperkinetic hert syndrome (i). Absence of hert disese mostly implies ptients with systolic murmur where no pthology could be found.
Reltions between pressure in pulmonry rtery, left trium, nd left ventricle 495 FIG. I () Two ctheters in the left ventricle: dignosis, physiologicl murmur. (b) Two ctheters in the right trium: dignosis, mitrl stenosis. Results Reltions between left tril nd left ventriculr pressure during distole nd round end-distolic point The trioventriculr grdient could be visully inspected in 8 ptients without mitrl obstruction: 7 hd sinus rhythm (2 with norml herts nd 5 with some hert disese) nd one hd tril fibrilltion. With due regrd to minor rtefcts there ws distolic congruence in ll ptients (Fig. 2). As the shpe of the left tril pressure curves generlly grees with tht previously reported, only some points of interest should be stressed. The upstroke of the c wve is consistently congruent with the upstroke of ventriculr systole in ptients with sinus rhythm nd norml hemodynmics or some ventriculr or ortic disese (Fig. 2). This fct serves s test of vlidity of our recordings nd verifies the tril z point s n indictor of the end-distolic ventriculr pressure. The c wve is, however, not consistent. In I7 hemodynmiclly norml ptients without hert disese, 6 lcked c wve nd 2 hd c wve in one recording but not in nother (Fig. 2b). In ptients with mitrl vlvulr disese nd tril fibrilltion c wve is lwys present, beginning t the point of equilibrtion of left tril nd ventriculr pressure during the isovolumetric ventriculr contrction phse (Fig. 3). Reltions between pulmonry rteril distolic nd left tril pressure The I7 ptients with norml hemodynmics without signs of hert disese were studied seprtely. The men left tril pressure vried from 3 to... I2 mmhg with men of 6-4 mm. The difference between pulmonry rteril distolic nd men left tril pressure is 14 ± 2-0 mmhg. Pulmonry rteril distolic pressure minus left tril end-distolic pressure is -04 ± PI5 mmhg. The pulmonry rteril pressure decreses during distole nd reches its minimum t level equl to the pek of the left tril wve or slightly below this pek, constituting pressure grdient from the trium to the pulmonry rtery for moment (Fig. 4). A selection ws mde of ptients hving hert disese, tril fibrilltion, nd men left tril pressure t rest of I2 mm or less nd pulmonry vsculr resistnce less thn 2 units. It hppened tht ll i5 such ptients hd mitrl vlvulr disese. Pulmonry rteril distolic pressure minus left tril men pressure is i o ± 2-o mmhg. Pulmonry rteril distolic pressure minus left tril end-distolic pressure is 2-5 ± i.5 mmhg. These results re close to those in the norml ptients (Fig. 5). During long systolic intervls, the pulmonry rteril pressure cn become congruent with the left tril pressure (Fig. 5b), but the left tril pressure ws never highest t the end of distole with tril fibrilltion. The Tble shows the difference between pulmonry rteril distolic pressure nd left tril men pressure relted to the pulmonry vsculr resistnce in ll ptients with sinus rhythm or tril fibrilltion. These two groups behved similrly nd were therefore combined. For ech increment of pulmonry vsculr resistnce the verge pressure difference incresed but not more thn 4 mmhg with b...
496 S. A. Forsberg C FIG. 2 Simultneous records from the left trium nd left ventricle in 2 norml ptients ( nd b) nd ptients with crdiovsculr disese but norml mitrl orifice (c, d, nd e). TABLE r55 ptients with sinus rhythm or tril fibrilltion (i7 without nd I38 with some crdiovsculr disese) Puilm. vsc. No. of Pulm. rt. dist. - resist. (units)* ptients left tril men (mmhg) 00-09 27 ±0 (-4; +4) 10I-19 83 +2 (-3; +9) 2-0-29 22 +4(-I; +I6) 30-39 8 +4(-I; +8) 40-49 4 +5 (+I; +8) 5 0-59 I +7 ((-) 6-o-69 2 + 27 (+ 26; + 27) 70-7 9 2 +9(0; +I8) >8-o 6 +36 (+I9; +63) * Pulmonry vsculr resistnce expressed in units (pressure difference mmhg, crdic output in l./min). Within brckets re the extreme vlues in ech group, nd outside re the men vlues. resistnce s high s 4 units. Individul vritions exist mong those with hert disese, some with low resistnce nd lrge pressure grdient, others with high resistnce nd smll grdient. In the 24 ptients with pulmonry vsculr resistnce between I-o nd I19 units, those I2 with the lrgest pressure grdient (pulmonry distolic minus left tril men pressure) were compred with those I2 with the lowest grdient. On n verge the lrgest difference ws ssocited with higher hert rte nd lower men left tril pressure, wheres the stroke volume nd pulmonry distolic pressure were similr in the two groups.
-0*s-----4-w Reltions between pressure in pulmonry rtery, left trium, nd left ventricle 497 0 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~....;.. ;i!^ 1t* *......,.....,.., +.,..,,.....-..-.-.-..5... t.j..-...+.r...-.--...-.j.-s... ::'':::':':ti<:':::0:::00::;1':::' ve.. -$. r.. t wf..r----.. >\-t *- -- JA \* ;u-, t------- n-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.. t--- ----- +-... _W 2t i.e -... Y* L,4.,...... -....................... @ + e D FIG. 3 Simultneous records from the left trium nd left ventricle in ptients with mitrl stenosis nd tril fibrilltion. Discussion whole of distole between the left tril nd A review of norml pressure curves from the ventriculr pressure. In mitrl vlvulr disese pulmonry rtery, left trium, nd left ventricle, nd their interreltions nd connexions to congruence if the grdient disppers with moderte or slight stenosis it lso comes to hemodynmic events ws presented by before the end of distole. Brecher nd Glletti (I963). Left trioventriculr pressure events in mitrl vlvulr ventriculr pressure normlly is the fctor Our results show tht the end-distolic left disese hve been repetedly reported (Brunwld et l., I955; Gordon, Kirschner nd pressure t rest. In bout 95 per cent the which sets the pulmonry rteril distolic Moscovits, I96I; Wooley et l., I968). Our pressure difference should be less thn 3 recordings in ptients with norml s well s mmhg. Recently, Bouchrd, Gult, nd Ross bnorml hemodynmics gree with those (I969) presented similr dt t meeting. previously described. Pertinent to this study In our ptients with mitrl vlvulr disese is the conclusion tht in the resting condition nd norml to slightly incresed pulmonry there is normlly congruence during the vsculr resistnce the figures were close to FIG. 4 Records from ptients with norml herts. Only the trcings from the pulmonry rtery nd left trium should be considered. 1...i. --IS@-I<l l<s i-@ir-sil0 l^tsix-sied:~~... i!!!! 1! I S+w.,,, v ~~~~~4 \ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ ~ ~~~~~~~ rw r+ ~~ ~~~~~~~~~~~~~~~~~~~~~~~~~~ -q-to~~~~so+o*s+r - ~~~~~~.. r ~~~~.... + -t ^- - s; r+-> t~~~~~~... 4^ *...... 4. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~.. I - Iṟ -:-- - V V b...... -...-...-... b c ; K -,-ia s < 0~~~~., J: T vxt se i;;;;~~~~~~~~~~~~~~~~... '~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... -.!.<<i<.!!.,.t * * ; Xt~~~~~~~* *w~~~~~~~~~~* P_+SX+4 W< X N ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~S >~~...
498 S. A. Forsberg I-.le.!.:::::..~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... At...A FIG. 5 Records from ptients with mitrl stenosis nd tril fibrilltion. Only the trcings from the pulmonry rtery nd left trium should be considered. those in norml ptients. From our dt on the norml ptients, it cn be clculted tht the difference between men nd end-distolic left tril pressure is i -8 mm. Brunwld et l. (I96I) found o-3 mm nd Smet et l. (I965) I *0 These fcts mm. hve importnt implictions for ptients where the pulmonry rteril pressure is continully monitored in order to disclose left ventriculr insufficiency nd the wedged pressure cnnot be esily recorded. This is now becoming more common in coronry cre units. It is necessry to do future studies similr to the present one nd to include ptients with reltively norml vsculr bed fflicted by cute ventriculr filure. Our unpublished observtions hve filed to show ny significnt phse shift of the pressure curve, withdrwing the ctheter from the peripherl lung vessels to the pulmonry rteril stem or to the left trium by the trnsseptl route. Identity of pressure in the pulmonry rtery nd left trium mens bsence of flow-driving force cross the pulmonry vsculr bed t the end of distole nd the momentry reversed pressure difference found in some norml ptients t the pek of the wve mens force driving blood bckwrds. Presumbly no wterfll effect is present in the lungs of norml ptients t rest in the supine position (Permutt nd Riley, I963). The pulmonry venous pressure is then supposedly higher thn the lveolr pressure. Wht norml flow pttern there is in the pulmonry cpillries does not seem to be settled yet. From Fishmn's review (I963), it is evident tht some plethysmogrphic studies nd investigtions including direct inspection of the pulmonry microcircultion in vivo support n intermittent type of flow wheres..., other plethysmogrphic studies support continuous but pulstile flow. Cinerdiogrphic observtions of rdiopque droplets in the pulmonry veins nd left trium of dogs hve demonstrted flow with smll momentry bckwrd component occurring close to the end-distolic point (Ferrrio, Nordenstrom, nd Pulin, I968). Direct flow mesurements from the pulmonry vein nd left trium re in ccordnce with these results (Morkin et l., i965). The sum of evidence is consistent with the ide tht the flow through the pulmonry veins nd the pressure grdient cross the whole pulmonry vsculr bed re in pproximte phse t the end of distole. Both re miniml nd t lest sometimes momentrily reversed. Our ptients with pulmonry vsculr resistnce between i nd 2 units hd norml s well s bnorml pulmonry vsculr beds. The end-distolic pulmonry rteril to left tril men pressure difference ws positively correlted to hert rte nd negtively to men left tril pressure. High hert rte implies short time for equilibrtion of pressures, nd low left tril pressure mens tht the pulmonry rteril pressure hs to fll deeper for equilibrtion with the left trium. References Bouchrd, R. J., Gult, J. H., nd Ross, J., Jr. (I969). Comprison of pulmonry rteril end-distolic pressures in ptients with nd without left ventriculr disese. Circultion, 40, Suppi. 3, p. 49. Brunwld, E., Brockenbrough, E. C., Frhm, C. J., nd Ross, J. (I96I). Left tril nd left ventriculr pressures in subjects without crdiovsculr disese. Circultion, 24, 267. b
Reltions between pressure in pulmonry rtery, left trium, nd left ventricle 499 Brunwld, E., Moscovitz, H. L., Amrm, S. S., Lsser, R. P., Spin, S. O., Himmelstein, A., Rvitch, M. M., nd Gordon, A. J. (I955). The hemodynmics of the left side of the hert s studied by simultneous left tril, left ventriculr, nd ortic pressures; prticulr reference to mitrl stenosis. Circultion, I2, 69. Brecher, G. A., nd Glletti, P. M. (I963). Functionl ntomy of crdic pumping. In Hndbook of Physiology, Section 2: Circultion, Vol. 2, pp. 759-798. Americn Physiology Society, Wshington, D.C. Ferrrio, C. M., Nordenstrom, B., nd Pulin, S. (I968). Flow velocity vritions in the pulmonry veins of the dog. Investigtive Rdiology, 3, 73. Fishmn, A. P. (I963). Dynmics of the pulmonry circultion. In Hndbook of Physiology, Section 2: Circultion, Vol. 2, pp. I667-I743. Americn Physiology Society, Wshington, D.C. Forsberg, S. A. (I964). Pulmonry blood volume in mn. Act Medic Scndinvic, 175, Suppl. 4I0. Gordon, A. J., Kirschner, P. A., nd Moscovits, H. L. (I96I). Hemodynmics of Aortic nd Mitrl Vlve Disese. Grune nd Strtton, New York. Morkin, E., Collins, J. A., Goldmn, H. S., nd Fishmn, A. P. (I965). Pttern of blood flow in the pulmonry veins of the dog. Journl of Applied Physiology, 20, iii8. Permutt, S., nd Riley, R. L. (1963). Hemodynmics of collpsible vessels with tone: the vsculr wterfll. Journl of Applied Physiology, I8, 924. Smet, P., Bernstein, W. H., Medow, A., nd Levine, S. (I965). Trnsseptl left hert dynmics in thirtytwo norml subjects. Diseses of the Chest, 47, 632. Wooley, C. F., Klssen, K. P., Leighton, R. F., Goodwin, R. S., nd Ryn, J. M. (I968). Left tril nd left ventriculr sound nd pressure in mitrl stenosis. Circultion, 38,'295. Br Hert J: first published s 10.1136/hrt.33.4.494 on 1 July 1971. Downloded from http://hert.bmj.com/ on 5 October 2018 by guest. Protected by copyright.