HEART LUNG INTERACTION

Eka Seprianti Widiastuti

Anesthesiologist Intensivist
Siloam Hospitals Balikpapan

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 OUTLINE

• Introduction
• Basic physiology
• Clinical Implication
• Summary

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Introduction

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 Heart AND Lung
• Share the same intrathoracic space à “to pump
within a pump”
• Intrathoracic pressure (ITP) and volume changes
during respiratory cycle affect the performance of
the heart

• Heart lung interaction : effects of pressure variations

of the respiratory system on the circulatory system

Kochhar G, et al. J Card Crit Care, 2018.

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Basic physiology

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 Factors Governing Stroke Volume
• Stroke volume (SV) = amount of blood ejected
by a ventricle on each heartbeat.
• Depends on preload, contractility and
afterload.
• Under the limit, preload and contractility have
positive effect while afterload has negative
effect on SV.

Kochhar G, et al. J Card Crit Care, 2018.

Grubler MR, et al. Swiss Medical Weekly, 2017.
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 Right Ventricular Preload
Preload = EDV, depends on venous return (VR)
- VR depends on gradient for VR and resistance to VR
- Gradient for VR = MSFP - RAP

Spontaneous breathing :
VENOUS RETURN AND CARDIAC

-Inspiration : ITP ê à gradient é

à preload é
liters/m2/min

- Expiration : ITP é à gradient ê

OUTPUT

à preload ê

Opposite happens during

mechanical breathing

0
RIGHT ARTERIAL PRESSURE
mmHg

Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.

Kochhar G, et al. J Card Crit Care, 2018.
Left Ventricular Preload

Kochhar G, et al. J Card Crit Care, 2018.

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 Contractility and Starling’s Law
flat

Preload-Independence

steep
Will increase the stroke volume
Stroke Volume

Preload-dependence

Every increasing preload by volume loading

Preload
Kochhar G, et al. J Card Crit Care, 2018.
 Afterload
• Pressure against which heart must work to
eject blood during systole
• Increases by increase in transmural pressure
and vascular resistance

Kochhar G, et al. J Card Crit Care, 2018.

Grubler MR, et al. Swiss Medical Weekly, 2017.
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Concept of Transmural Pressure (1)
• Heart is situated in fossa surrounded by lungs
• Pressure surrounding the heart : pericardial
pressure à if no pericardial disease = pleural
pressure
• Pleural pressure varies as per phase of
respiration, affected by type of respiration
• Transmural pressure = intracavitary pressure
minus surrounding pressure
Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.
Kochhar G, et al. J Card Crit Care, 2018.
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 Concept of Transmural Pressure (2)
Transmural pressure of the heart = actual “working pressure”
of the cardiac chamber against pressure of wall chamber
ü Surrounding pressure of the heart is negative à ventricle has to
overcome the extra load
ü If positive à compress ventricles from outside, aiding in systole

Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.

Kochhar G, et al. J Card Crit Care, 2018.
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 Left Ventricular Afterload
• SVR does not fluctuate remarkably during
respiratory cycle, transmural pressure does
• Spontaneous breathing :
üInspiration : ITP ↓ à transmural pressure ↑
à LV afterload ↑
üExpiration : ITP ↑ à transmural pressure ↓
à LV afterload ↓
• Opposite happens during mechanical
breathing
Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.
Kochhar G, et al. J Card Crit Care, 2018.
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Physical effect of lung volume on
pulmonary vasculature diameter

Kochhar G, et al. J Card Crit Care, 2018.

Magder S. Ann of Transl Med, 2018
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Effect of Lung Volume on PVR
Spontaneous breathing :
-Inspiration : ITP ê à high volume à alveolar vessels
compressed à PVR ê
- Expiration : ITP é àlow volume à extraalveolar
pressure compressed à PVR é
Opposite happens during mechanical breathing

Kochhar G, et al. J Card Crit Care, 2018.

Magder S. Ann of Transl Med, 2018
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 Right Ventricular Afterload

• Both RV and pulmonary vasculature are

exposed to similar swings to ITP, but variations
in PVR that plays a more dominant role in
deciding afterload.
• Spontaneous breathing :
üInspiration : ITP ↓ à PVR ↓ à RV afterload ↓
üExpiration : ITP ↑ à PVR ↑ à RV afterload ↑

Kochhar G, et al. J Card Crit Care, 2018.

Magder S. Ann of Transl Med, 2018
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 Ventricular Interdependence
• Both ventricles share fixed space within pericardium and a
common septum à diastolic pressure of one ventricle
directly affects the diastolic filling of the other.
• When RV volume is increased, LV filling declines.

Kochhar G, et al. J Card Crit Care, 2018.

Magder S. Ann of Transl Med, 2018
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 Acute Cor Pulmonale
• RV is adapted to low-resistance pulmonary
vasculature and does not work efficiently at high
pressure.
• Acute rise in afterload is poorly tolerated by the RV
as compared with the LV (which possesses much
higher contractile reserves).
• Such acute rise : air trapping, ARDS, pulmonary
embolism, even mechanical ventilation àRV EDV
increased à (ventricular interdependence
phenomenon) à LV EDV decreased.
Kochhar G, et al. J Card Crit Care, 2018.
Magder S. Ann of Transl Med, 2018
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Consolidated Effect of Spontaneous Breathing

Cheifetz IR. Resp Care, 2014.

Kochhar G, et al. J Card Crit Care, 2018.
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Consolidated Effect of Mechanical Ventilation

Cheifetz IR. Resp Care, 2014.

Kochhar G, et al. J Card Crit Care, 2018.
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VR AND Cardiac Function Curve

Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.

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VR AND Cardiac Function Curve

Mahmood SS, Pinsky MR. Ann of Transl Med, 2018.

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Clinical Implication

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Dynamic Hemodynamic Indices (PPV, SVV)
• Mechanical breathing à ITP changes cyclically
and causes similar changes in RAP (rises
during inspiration and falls with expiration).
• This variation RV SV causes with time delay
(pulmonary transit time) à variation in LV
preload and SV
• SVV maximally seen if the heart works on the
steep portion of Starling Curve à responsive
to fluid administration.
Outtara A, et al. Ann Franc Anest Rean, 2014.
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 Obstructive sleep apneu
• Patients exhibit inspiratory muscular efforts against a
closed upper airway creating a strongly negative
pleural pressure :
ü ITP ↓↓ à VR ↑↑ à dilation of RV à LV preload
and SV ↓ (pulsus paradoxus)
ü LV afterload ↑↑
• Arterial desaturation occurs during these negative
pleural pressure swings, paralleled by hypoxic
pulmonary vasoconstriction
• CPAP therapy helps keeping the airway open so
reduced negative swings
Grubler MR, et al. Swiss Medical Weekly, 2017.
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 Acute cardiogenic pulmonary edema

• LV EDP ↑, PAOP ↑ and fluid extravasation from

pulmonary vasculature to interstitium and alveoli
• Mechanical ventilation :
ü LV preload ↓ (due to VR ↓)
ü LV afterload ↓
ü Warning : RV afterload may ↑

Grubler MR, et al. Swiss Medical Weekly, 2017.

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Summary

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 Summary
• Heart lung interaction : effects of pressure
variations of the respiratory system on the
circulatory system
• Spontaneous VS mechanical breathing
• Usefull in managing critically ill patients as
well as perioperative setting

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 Thank You
dr_echa@yahoo.com
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