LABORATORY INVESTIGATION

VENTRICULAR PERFORMANCE

Effects of supine and lateral positions on cardiac

output and intracardiac pressures: an experimental
study
SHOICHIRO NAKAO, M.D.,* PATRICIA C. COME, M.D., MICHAEL J. MILLER, M.D.,
SHIN-ICHI MOMOMURA, M.D., PETER SAHAGIAN, B.A., BERNARD J. RANSIL, M.D., AND
WILLIAM GROSSMAN, M.D.

ABSTRACT Hemodynamic measurements in human subjects and in experimental animals are gener-
ally made in the supine position; not much attention is paid to potential beneficial or harmful effects of
right or left lateral positions on cardiac output or other hemodynamic variables. To evaluate the
potential influence of such positional changes on cardiac performance, we measured cardiac output and
left and right ventricular pressures (with micromanometer catheters) in anesthetized experimental
animals (eight dogs and nine pigs) in the supine, right lateral, and left lateral positions. Cardiac output
increased from supine to left lateral (mean SD, 2.6 +- 0.9 to 3.1 1.0 liters/min; p < .001) and
±

from supine to right lateral positions (2.6 0.9 to 3.1

± 1.1 liters/min; p < .001). There was an
±

associated decrease in arteriovenous oxygen saturation difference from supine to left lateral position
(31 + 8% to 24 4%; p < .001) and from supine to right lateral position (32 9% to 25 6%; p <
± ± ±

.001). Left ventricular systolic and end-diastolic pressures increased from supine to left lateral (128
17/9 ± 2 to 147 19/16 4 mm Hg; both p < .001) and from supine to right lateral positions (128 +
±

19/9 2 to 141 16/16 7 mm Hg; p < .01 and p < .001, respectively). Similarly, right ventricular
± ±

systolic and end-diastolic pressures also increased from supine to left lateral (30 7/3 + 2 to 38 +
±
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7/8 2 mm Hg; both p < .001) and from supine to right lateral positions (31 8/3 + 2 to 43 + 8/11
± ±

+ 4 mm Hg; both p < .001). Systolic and end-diastolic right ventricular pressures were significantly

higher in the right lateral position than in the left (both p < .001). Heart rate did not change with
positional maneuvers. Neither the sequence of positional changes nor the species of animal (dog vs pig)
had any apparent influence on the results. Roentgenographic analysis of the differences in height of the
right ventricle relative to the inferior vena cava suggests that changes in hydrostatic pressure may be
entirely responsible for the increases in right ventricular end-diastolic pressure when animals are
changed from the supine to the left or right lateral positions. We conclude that a change from supine to
lateral position significantly increases intracardiac pressures and cardiac output in experimental ani-
mals. If confirmed in humans, these findings may have significant implications for the assessment of
hemodynamic status of patients in intensive care unit and catheterization laboratory settings and for the
treatment of patients in low-cardiac output states.
Circulation 73, No. 3, 579-585, 1986.
IN INTENSIVE CARE UNITS, catheterization labo- beneficial or harmful effects of right or left lateral
ratories, and animal research facilities, cardiac output positions on cardiac output or other hemodynamic va-
is usually measured with the patient or animal in the riables. Indeed, there are few data concerning the in-
supine position; not much attention is paid to potential fluence of supine and lateral positions on cardiac out-
put in experimental animals or human beings. In
From the Charles A. Dana Research Institute and the Harvard-Thorn- pregnant women in the third trimester, cardiac output
dike Laboratory of the Beth Israel Hospital, Department of Medicine,
Beth Israel Hospital and Harvard Medical School, Boston. increases by a mean of up to 27% with a change from
Supported in part by grant RR-01032 from the General Clinical Re- supine to lateral positions.' In nonpregnant human
search Centers Program of the Division of Research Resources, Nation-
al Institutes of Health. Data analysis was performed on the Clinical subjects, contradictory results have been reported.1' 4
Center Core Lab Facilities. Some investigators have described a higher cardiac
Address for correspondence: Patricia C. Come, M.D., Department of
Medicine, Cardiology Division, Beth Israel Hospital, 330 Brookline output in the supine position as compared with right
Ave., Boston, MA 02215. and left lateral positions.4' 6 However, Whitman et al.'
Received June 12, 1985; revision accepted Nov. 29, 1985. found cardiac output to be higher in the left lateral
*Present address: First Department of Internal Medicine, Faculty of
Medicine, Kagoshima University, Kagoshima City 890, Japan. position than in supine and right lateral positions,
Vol. 73, No. 3, March 1986 579
 NAKAO et al.
while Ueland et al. could not demonstrate any differ-
1 tially in the supine position. After left and right ventricular
ence. The effect of supine and lateral positions on
intracardiac pressures measured by micromanometer
has not been reported to our knowledge.
The purpose of this study was to evaluate the effects
of supine and left and right lateral positions on cardiac
output and intracardiac pressures under controlled con-
ditions in anesthetized animals. Subsequent studies are
planned to evaluate hemodynamic changes with posi-
tional maneuvers in human subjects.
Methods
Eight mongrel dogs weighing 18 to 28 kg and nine young pigs
weighing 29 to 37 kg were studied. The use of two species
enabled assessment of whether findings were species specific.
The animals were anesthetized with sodium pentobarbital intra-
venously (25 mg/kg) and were ventilated by a Harvard pump
with a tidal volume of 15 cc/kg room air and a respiratory rate of
15/min. High-fidelity micromanometer catheters (PC 470, Mil-
lar Instruments, Houston, TX) were inserted into the left and
right ventricles via the left carotid artery and the left internal
jugular vein, respectively. The zero reference point of pressures
was taken at mid chest with each animal supine, and high-
fidelity micromanometer pressure signals were matched with
pressures measured through the fluid-filled lumen of each cath-
eter, during each supine recording. With the high-fidelity pres-
sure signals, right and left ventricular systolic pressures were
measured as the peak pressures during systole, and ventricular
end-diastolic pressures were measured after the "a" wave, just
before the rapid systolic rise in ventricular pressure. The pres-
sures reported represent data averaged from at least 3 beats
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recorded during end-expiration. A No. 7F Swan-Ganz catheter
was inserted into the pulmonary artery via the right femoral vein
in each animal. Cardiac output was measured by the thermodilu-
tion method (Edwards 9520A cardiac output computer, Santa
Ana, CA). The injectate was 10 ml of normal saline at a tem-
perature of 00 to 10 C. Each cardiac output value was the mean
of at least three consecutive determinations having variation of
less than 10%. Oxygen saturations of systemic arterial and
mixed venous blood, drawn from the left ventricle and the
pulmonary artery, respectively, were measured by the reflec-
tance oximeter method (Reflection Oximeter, American Optical
Corporation, Buffalo, NY).
Experimental protocol. All 17 animals were evaluated ini-
TABLE 1
Effects of change from supine to lateral positions on hemodynamic variables (mean ± SD)
n Supine
HR (bpm) 17 117+20
CO (l/min) 16 2.6+0.9
AVO7SD(%) 11 31 +8
LVSP (mm Hg) 12 128 17
LVEDP (mm Hg) 12 9+2
RVSP (mm Hg) 17 30 7
RVEDP (mm Hg) 17 3+2
HR = heart rate; CO = cardiac output; AVO2SD = arteriovenous oxygen saturation difference; LVSP = left ventricular
systolic pressure; LVEDP = left ventricular end-diastolic pressure; RVSP = right ventricular systolic pressure; RVEDP = right
ventricular end-diastolic pressure.
Ap < .01, right or left lateral vs supine.
Bp < .01, right vs left lateral.
580
pressures had been stable for at least 30 min, cardiac output,
blood oxygen saturations, and left and right ventricular systolic
and end-diastolic pressures were measured. The positions of the
animals were then changed from supine to left lateral (three
dogs, three pigs) or from supine to right lateral (five dogs, six
pigs). Lateral positions were maintained for 20 min, with con-
tinuous recordings of left and right ventricular pressures to
assess time course and stability of pressure changes. Measure-
ments of cardiac output, blood oxygen saturations, and left and
right ventricular systolic and end-diastolic pressures were re-
peated between 10 and 20 min after change to the lateral posi-
tion. The animals were then returned to the supine position,
micromanometer pressures were rematched with fluid-filled
pressures as necessary, and measurements were repeated be-
tween 10 and 20 min later. Positions were then changed to the
alternate lateral position (left lateral in five dogs and six pigs and
right lateral in three dogs and three pigs), with continuous re-
cording of left and right ventricular pressure again to assess time
course and stability of pressure changes. All measurements
were repeated between 10 and 20 min after the change in posi-
tion. Because of technical factors, not all measurements could
be obtained in each animal.
Additional studies. To define the potential influence of
changes in height of the inferior vena cava (venous filling reser-
voir) relative to the right ventricle in supine, right lateral, and
left lateral positions, two additional dogs and two additional
pigs were studied. Catheters were inserted into the right femoral
vein and advanced into the right ventricle. Catheter position in
the right ventricle was confirmed by pressure recording. Radio-
graphs were taken in the supine, right lateral, and left lateral
positions. The height of the inferior vena cava relative to the
right ventricle was measured in centimeters. The measurement
was corrected for magnification and was converted into equiv-
alent millimeters of mercury by dividing the number of centi-
meters by the conversion factor of 1.36. Changes in height of
the inferior vena cava relative to the right ventricle with alter-
ations in position from supine to left lateral and from supine to
right lateral were then computed.
To assess the possibility of position-related compression of
the inferior vena cava, seven additional pigs were studied. A
Swan-Ganz catheter was inserted into the right femoral vein and
advanced into the right atrium, where the position of the tip was
confirmed by pressure recording. With the fluid-filled catheter
system, simultaneous pressures were then recorded in supine,
right lateral, and left lateral positions both from the catheter tip
in the right atrium and from the side-hole in the inferior vena
Left lateral Supine Right lateral
115+18 116+21 115+19
3.1+t .OA 2.6+0.9 3.1 + .A
24 4A 32 9 25 6A
147 19A 128 19 141 16A
16+4A 9+2 16±7A
38 7A 31+ 8 43 + 8AB
8 2A 3+2 11 ±4A.B
CIRCULAT1[ON
 LABORATORY INVESTIGATION-VENTRICULAR PERFORMANCE
cava located 30 cm from the catheter tip. The zero reference NS NS
I I 1 i p .
point of pressures was taken at mid chest in the supine position. / -
Statistical analysis. Measurements for all variables were 160r
determined to be normally distributed by the Wilkes-Shapiro
test, permitting use of parametric comparison methods. Var-
iances for each species (obtained from two-way analysis of 150 k
variance) were demonstrated equivalent by F test and the data
were therefore pooled. Resulting distributions were normal by
the Wilkes-Shapiro test, with homogeneous variances (Le- 140k
vene's test). Data were then analyzed for statistical significance
with an appropriate multiple-sample comparison test (two-way -
4

analysis of variance, followed by blocked Newman-Keuls test). 130 k

Data were considered significant at the p < .05 level. Measure- 0
ments are reported as mean -+- SD.
;1- \ --
\
c
(U 120 -
Results
a)CO
.0
Hemodynamic data in supine and lateral positions
are summarized in table 1. There was no significant -0 1 10H
change in any of the hemodynamic measurements be- I.. 0=
-1
tween both supine positions. Heart rate, measured in 100k
all 17 animals, did not change significantly with rota- -.9 i_
9-- _ _

tion into right or left lateral positions (figure 1). Cardi-

ac output, measured in 16 of 17 animals, increased 90k
after a change from supine to left lateral position (p <
.001) and from supine to right lateral position (p <
.001) (figure 2). Arteriovenous oxygen saturation dif- 801 9- --_
_ 9

ference, measured in 1 1 of 17 animals, decreased from -r

supine to left lateral position (p < .001) and from S L S R
supine to right lateral position (p < .001) (figure 3). In FIGURE 1. Changes in heart rate (HR) from supine (S) to left lateral
Downloaded from http://ahajournals.org by on August 6, 2021

each of the 11 animals with measurements of both (L) and right lateral (R) positions in 17 animals. Values in dogs and pigs
cardiac output and oxygen saturations, the increase in are shown by solid and dashed lines, respectively. Mean values are
cardiac output observed with a change in position from represented by the horizontal bars.
supine to right or left lateral was associated with a
p<O.OO 1 p<O.OO 1
corresponding decrease in arteriovenous oxygen satu- r

ration difference. 5.0 ,p

Left and right ventricular pressures, measured in 12 /
/
/ / /
A
and 17 animals, respectively, changed within 1 min of /
/
/
_
-
I

/
4.0 /
alteration in position in each animal, reached a stable /- -----

state by 1 to 5 min, and then remained stable through- 9-1 ,- *

out the subsequent recording period. The recorded

0
E 9v,--
--4
-=/ -4

pressures are those obtained 10 min after change of 3.0 h

position. Left ventricular systolic pressure rose from 0aJ)
supine to left and right lateral positions (p < .001 and
p < .01, respectively) (figure 4). Left ventricular end- 0
2.0h
diastolic pressure also increased from supine to left and 9-

right lateral positions (both p < .001) (figure 5). Both

right ventricular systolic and end-diastolic pressures
increased from supine to left and right lateral positions
(all p < .001) (figures 6 and 7). Systolic and end-
diastolic right ventricular pressures were both higher in
the right lateral position than in the left lateral position
(both p < .001).
When percent changes from supine to left and right
lateral positions were compared, they were found to be
equivalent for all except three variables. The percent
1.0 F
fl L
S L S R
FIGURE 2. Changes in cardiac output (CO) from supine (S) to left
lateral (L) and right lateral (R) positions in 16 animals. Values in dogs
and pigs are shown by solid and dashed lines, respectively. Mean values
are represented by the horizontal bars.

Vol. 73, No. 3, March 1986 581

 NAKAO et al.

p (0.00 1 p 40.001 P(0.00 1 p<0.00

F , t

50 r 30

40F

1-

0 30t
I 20
E
CO E
cnJ
0
C0 *..I -.,m
I1
_ _

201
W
_>
10k io1
wU- -4

0 1 1 A
S L S R
FIGURE 3. Changes in arteriovenous oxygen saturation difference
(AVO2SD), given as differences in percent saturations, from supine (S) 1) 1

to left lateral (L) and right lateral (R) positions in 1 1 animals. Values in
dogs and pigs are shown by solid and dashed lines, respectively. Mean
values are represented by the horizontal bars.
Downloaded from http://ahajournals.org by on August 6, 2021
S L S R
FIGURE 5. Changes in left ventricular end-diastolic pressure (LVEDP)
from supine (S) to left lateral (L) and right lateral (R) positions in 12
animals. Values in dogs and pigs are shown by solid and dashed lines,
respectively. Mean values are represented by the horizontal bars.

190 P<0.00 1 P<.0 1

'I

60 pC0.001 p< 0.00 1

180 I_ lI

170 A,?
50
160 -

150 _ 40 _
0)
I
0) 140 _ E
E E
E
a- 130h 0- 30F
0c
CO 120 _ cc)
_i 20-
110!_

100 _
101
90 -

T
S L S R
n
S L
.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
S R
FIGURE 4. Changes in left ventricular systolic pressure (LVSP) from FIGURE 6. Changes in right ventricular systolic pressure (RVSP) from
supine (S) to left lateral (L) and right lateral (R) positions in 12 animals. supine (S) to left lateral (L) and right lateral (R) positions in 17 animals.
Values in dogs and pigs are shown by solid and dashed lines, respective- Values in dogs and pigs are shown by solid and dashed lines, respective-
ly. Mean values are represented by the horizontal bars. ly. Mean values are represented by the horizontal bars.
582 CIRCULATION
 LABORATORY INVESTIGATION-VENTRICULAR PERFORMANCE

20 p'0.Oo 1 p<0.001 there was an 1 1.3 cm difference, equivalent to an 8.3

mm Hg difference in hydrostatic pressure. From su-
pine to right lateral position, the changes in height of
W)
the right ventricle relative to the inferior vena cava
I ,p were 11.2 and 1 1.4 cm for dogs and pigs, respectively,
E equivalent to 8.2 and 8.4 mm Hg differences in hydro-
0-
II
static pressure. In the seven pigs that underwent simul-
0 10 _ taneous measurements of mean right atrial and inferior
W
C] ,-m vena caval pressures with fluid-filled catheters, the
//
pressure gradients between inferior vena cava and right
.0/4< / / atrium were 3.8 + 0.8 mm Hg (mean ± SD) in the
supine position, 3.1 ± 0.6 mm Hg in the right lateral
- /~~~~~~~~~~~~~~~~~~~~~~~ position, and 5.4 + 0.9 mm Hg in the left lateral
0 dc position (figure 9). Each of the three gradients was
S L S R significantly different from the other two at the p <
FIGURE 7. Changes in right ventricular end-diastolic pressure .001 level.
(RVEDP) from supine (S) to left lateral (L) and right lateral (R) posi-
tions in 17 animals. Values in dogs and pigs are shown by solid and Discussion
dashed lines, respectively. Mean values are represented by the horizon- It is well known that certain positional changes may
tal bars. significantly affect cardiovascular performance. Car-
diac output, for example, decreases by approximately
increase in left ventricular systolic pressure was great- 15% to 30% when normal human subjects change from
er in the left lateral position (p < .05), and increases in a supine position to a 70 to 75 degree head-up tilt.7 8
right ventricular systolic and end-diastolic pressures This decrease has been attributed to a reduction in
were greater in the right lateral position (p < .01 and venous return, resulting from venous pooling in the
p < .05, respectively). lower extremities. In normal pregnant women in the
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The results of roentgenographic analysis of catheter third trimester, a change from supine to lateral posi-
position are shown in figure 8. In the two dogs studied, tions has been shown to increase cardiac output by a
the height of the right ventricle relative to the inferior mean of up to 27%. l-3 Compression of the inferior vena
vena cava differed by 8.4 cm with a change from cava by the gravid uterus in the supine position and
supine to left lateral position, equivalent to a difference relief of this compression upon changing to the lateral
in hydrostatic pressure of 6.2 mm Hg. In the two pigs, position are thought to be the physiologic basis of this
Dogs Pigs
S L R S L R
RV
RV RV IVC
lVC &--~ =1
T oVC _-
RV~~Iv lvc
IvC
.

1R

Height of RV Dog A 8.2 0 -3.7 Pig A 13.0 1.5 1.2

relative to IVC Dog B 7.7 -0.7 -2.7 Pig B 12.7 1.6 1.8
(cm)
mean 8.0 -0.4 -3.2 mean 12.9 1.6 1.5

Change in height of RV S-eL S-*R S-eL S-eR

relative to IVC
(cm) 8.4 11.2 11.3 11.4
(Equivalent mmHg) 6.2 8.2 8.3 8.4
FIGURE 8. The height of the catheter tip in the right ventricle (RV) relative to the height of the catheter in the inferior vena cava
(IVC) was assessed roentgenographically with animals in the supine (S), left lateral (L), and right lateral (R) positions.
Measurements (in cm) have been corrected for magnification of the x-ray film. The changes in height of the right ventricle
relative to the inferior vena cava with changes from supine to lateral positions were computed in centimeters and then converted
into equivalent millimeters of mercury hydrostatic pressure.

Vol. 73, No. 3, March 1986 583

 NAKAO et al.

p 0.001 Our experimental study in anesthetized animals

1-~ yielded results different from those obtained in some
p<0.001 p(0.001
7r previous human studies.1 4,6 Cardiac output, measured
by the thermodilution method, rose significantly from
supine to both lateral positions. Changes in arteriove-
cm nous oxygen saturation differences support the validity
I _0
E of the thermodilution measurements. In the studies of
E 0
Ueland et al.' and others4 6 in awake human beings,
c 5F 0
reflex changes may have blunted or otherwise altered
U1) cc 0 the cardiac output response to lateral position, thereby
40
: 0 preventing expression of the hemodynamic changes
a,
C)
CO 4F seen in our study.
L-
V 0 The effects of supine and lateral positions on ven-
0) E 0@
3 tricular pressures have not, to our knowledge, been
U) 0- S determined previously. However, several reports do
0 6 describe the effects of positional changes on aortic or
2k 0
pulmonary arterial pressures in human beings. New-
COa) ton9 and Eggers et al.'0 found no significant differences
0 among aortic pressures recorded in the supine and left
1 and right lateral positions, and Kennedy et al.'1 ob-
served no significant positional differences in pulmo-
nary arterial systolic pressure. Again, the differences
0 between these findings and our own may reflect reflex
Right Supine Left changes in the conscious human subject to maintain
lateral lateral constant arterial pressure. In addition, however, in
FIGURE 9. Differences between mean inferior vena caval pressure these previous studies, pressures were measured with
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(IVCP) and mean right atrial pressure (RA) in supine and lateral posi-
tions. The pressures were measured simultaneously in seven pigs by
means of fluid-filled catheters.
observation. In one study of women in the last trimes-
ter of pregnancy, however, cardiac output was not
increased by a change from supine to left lateral posi-
tion, and it was lower in the right lateral than in the
supine and left lateral positions.'
In nonpregnant subjects, previous studies have pro-
vided conflicting data regarding the effects of supine
and lateral positions on cardiac output. Ueland et al.'
reported no change in cardiac output, measured by dye
dilution techniques, with changes from supine to later-
al (side not defined) positions in women who were 6 to
8 weeks postpartum. Atkins et al.4 also observed no
significant differences in cardiac output, estimated by
impedance plethysmography, in supine and left and
right lateral positions in 19 women. Newman et al.'
however, reported higher cardiac output, estimated by
transcutaneous Doppler flowmeter, in the supine than
in left and right lateral positions in 30 women. And
Whitman et al.,5 measuring cardiac output by thermo-
dilution technique in 50 adult patients after cardiac
surgery, observed a slightly higher cardiac output in
left lateral than in right lateral or supine positions.
584
fluid-filled catheters. When such catheters are used,
the zero reference point should optimally be changed
whenever a patient's position is altered during the
course of a study.'2 Since identification of the proper
zero reference point in each position may be difficult,
actual changes in intravascular pressures may not be
detected. To exclude the potential for such error, we
used high-fidelity micromanometers that do not re-
quire that the zero reference point be changed in each
position. In our experimental study, both systolic and
end-diastolic left and right ventricular pressures were
significantly higher in lateral positions than in the su-
pine position.
The differences in height of the right ventricle rela-
tive to the inferior vena cava, as determined from
roentgenographic studies, suggest that changes in hy-
drostatic pressure may be entirely responsible for the
increases in right ventricular end-diastolic pressure
when animals are changed from the supine to the left
lateral position and from the supine to the right lateral
position. The increase in hydrostatic pressure would be
expected to increase right ventricular diastolic filling
and stroke volume, accounting for the increases in
cardiac output and left ventricular filling pressure in
the lateral positions. The hydrostatic pressure differ-
ences, however, are somewhat larger than the changes
CIRCULATION
 LABORATORY INVESTIGATION-VENTRICULAR PERFORMANCE
in right ventricular end-diastolic pressure observed in
the 17 animals studied with micromanometer-tipped
catheters. This would raise the possibility of variable
compression of the inferior vena cava, perhaps by the
liver, in the three positions. Indeed, the pressure gradi-
ents recorded between the inferior vena cava and right
atrium with fluid-filled catheters, which are insensitive
to changes in hydrostatic pressure, support the possi-
bility of compression and suggest that compression
may be greatest in the left lateral position.
Several limitations of this study should be empha-
sized. First, there are no data with regard to chamber
volumes. Although thermodilution cardiac output
measurements and changes in arteriovenous oxygen
saturation differences suggest that increases in preload
are responsible for increases in left and right ventricu-
lar end-diastolic pressures in the lateral positions, oth-
er contributing factors, such as changes in ventricular
compliance, variable compression of the right ventri-
cle by the left, and alterations in right or left ventricular
afterload, cannot be excluded. Second, inferior vena
caval flows were not measured. Therefore the possibil-
ity of variable, position-related compression of the
inferior vena cava cannot be assessed further. Third,
although we can conclude that positional changes in
two animal species significantly affect intracardiac
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pressures and cardiac output, it has not been deter-
mined that similar changes occur in other animal spe-
cies. In particular, whether and under what circum-
stances positional changes affect cardiac performance
in human beings must be clarified. If similar hemody-
namic changes are confirmed for man, they may help
to explain several clinical observations, including the
preference of some patients with congestive heart fail-
ure or angina for certain positions (trepopnea) and the
Vol. 73, No. 3, March 1986
deterioration in arterial oxygen saturation that often
occurs when patients with bilateral pulmonary disease
assume the left lateral position.13-15
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