Balancing the circulation

Introduction

• Single ventricle represents complete mixing

of the two circulations
• Aortic and pulmonary saturations are equal
• The cardiac output is divided in two parallel
circulations
• Total cardiac output = addition of
pulmonary and systemic cardiac output
 Physiology : pulmonary flow

Pulmonary flow is determined by :

– anatomic pulmonary outflow obstruction
– pulmonary vascular resistance
– venous pulmonary and left atria pressure :
• amount of pulmonary venous return
• obstruction on the pulmonary venous return
– size of the aorto-pulmonary shunt ( post-
operatively )
 Physiology : systemic flow

Systemic flow is determined by :

– anatomic systemic outflow obstruction
– systemic vascular resistance
Physiology : neonatal adaptations

Neonatal adaptations :
– decrease in pulmonary vascular resistance
– increase in pulmonary blood flow
– hemodynamic adaptations ( stroke volume,
 heart rate )
– increase in Qp/Qs
– single ventricle failure ( overload )
 Single ventricle physiology
Single ventricle :
– left morphology :
• tricuspid valve atresia 1+ 2
• DILV 1+ 2
• CAVC with right ventricle hypoplasia 1+ 2
• pulmonary atresia with intact ventricular septum 1± 2
– right morphology :
• mitral valve atresia 1+ 2
• aortic valve atresia 1± 2
• CAVC with left ventricle hypoplasia 1+ 2

– single ventricle physiology despite biventricular heart :

• tetralogie of Fallot with pulmonary atresia 1± 2
• truncus arteriosus 1
• total pulmonary abnormal venous return 1

1 = pre-operative, 2 = post-operative
 Single ventricle with low Qp/Qs
Qsystémic Qpulmonry

CO
2
O

CaO2
Cv

2
O
Sv
Systemic Ventricle Lungs
Organs
Atria

2
Cp O
C svO 2

v
Systemic Pulmonary
veins veins
 Single ventricle with high Qp/Qs
Qsystemic
Qpulmonary

CO
2
O

CaO2
Cv

2
O
Sv
Systemic Ventricle Lungs
Organs

2
Atria

Cp O
v
C svO 2

Systemic Pulmonary
veins veins
Single ventricle with balanced Qp/Qs
Qsystémique Qpulmonaire

CO
2
O

CaO2
Cv

2
O
Sv
Systemic Ventricle Lungs
Organs

2
Atria

Cp O
C svO 2

v
Systemic Pulmonary
veins veins
 Equation 1

• O2 flow rate in the systemic circulation ( CaO2 x

Qs ) is reduced by the whole body oxygen consumed
( CO2 ), leaving the reduced oxygen flow rate
returning in the right ventricle ( CsvO2 x Qs ) :

CaO2 x Qs - CO2 = CsvO2 x Qs

or
Qs = CO2 / [ CaO2 - CsvO2]
 Equation 2

• O2 flow rate in the pulmonary circulation

( CpaO2 x Qp ) augmented by the oxygen uptake
in the lungs ( SO2 ) gives the oxygen flow rate
returning in the right ventricle ( CpvO2 x Qp ) :

CpaO2 x Qp + SO2 = CpvO2 x Qp

or
Qp = SO2 / [CpvO2 - CpaO2]
 Equation 3

• In steady state conditions, oxygen uptake

( SO2 ) equals oxygen consumption (
CO2 ) :

SO2 = CO2
 Equation 1 + 2 + 3
• Then, 1 + 2 + 3 :

Qp SO2 / [ CpvO2 - CpaO2 ]

=
Qs CO2 / [ CaO2 - CsvO2 ]
Qp [ CaO2 - CsvO2 ]
=
Qs [ CpvO2 - CpaO2 ]
Qp [ SaoO2 - ScvO2 ]
=
Qs [ SpvO2 - SpaO2 ]
 Qp/Qs calculation

Qp [ SaoO2 - ScvO2 ]
=
Qs [ SpvO2 - SpaO2 ]

Where :
• with complete mixing, aortic oxygen
saturation equals pulmonary artery
saturation
• pulmonary veins saturation can be
estimated to be 96 %
Evaluation of cellular well-being
• SaO2
• SvO2
• ΔA-VO2
• Blood lactate
• Qp/Qs
• Ω = oxygen excess factor
 Major causes of mortality after
Norwood operation for HLHS
• Low systemic blood flow due to myocardial
dysfunction
• Low systemic blood flow due to high
pulmonary to systemic blood flow ratio
• Combination of myocardial dysfunction and
high Qp/Qs ratio
 Major causes of mortality after
Norwood operation for HLHS

=> efforts have focused in part on optimizing

Qp/Qs to improve systemic perfusion
 Qp/Qs, SaO2 and SsvO2
Percent oxygen saturation

High cardiac output

Low cardiac output
80

SaO2

60
Limit for SaO2

40

SsvO2
20

0.1 0.2 0.5 1 2 5 10

Qp/Qs
 Qp/Qs and systemic O2 availability
Systemic O2 availability (mlO /min)

High cardiac output

2

Low cardiac output

80

60

40

20

Oxygen deficit

0.1 0.2 0.5 1 2 5 10

Qp/Qs
 O2 delivery and SaO2
High cardiac output
O2 delivery (mlO /min/kg )

Low cardiac output

40
2

30

<1

Qp
s
20 Q
p/

/Q
Q

>1s
10

20 40 60 80 100

Systemic arterial O2 saturation

 O2 delivery and SsvO2
High cardiac output
O2 delivery (mlO /min/kg )

Low cardiac output

40

s >1
/Q
Qp
2

30

Qs <1
20 Qp/

10

20 40 60 80

Systemic venous O2 saturation

 O2 delivery and Qp/Qs
High cardiac output
O2 delivery (mlO /min/kg )

Low cardiac output

40
2

30

20

10

1 2 3 4 5 6

Qp/Qs
 O2 delivery and 
High cardiac output
O2 delivery (mlO /min/kg )

Low cardiac output

40
2

30

20

10

1 2 3 4 5 6
  = DO2/VO2 = CaO2 x Qs / (CaO2-CvO2) x Qs
= SaO2 / (SaO2 - SvO2)
 Limitations

In theory, cellular well-being may be

compromised with Qp/Qs > 1
But infants may have SaO2 in the high 80s
( which means a Qp/Qs  3/1 ) with adequate
systemic perfusion, suggesting a capacity of
increasing CO as Qp/Qs increases
 Limitations

Some patients may have adequate systemic

perfusion, but insufficient regional blood flow,
in particular inadequate coronary perfusion,
leading to myocardial ischemia
 Limitations
Systemic oxygen availability is a complex
function of cardiac output, pulmonary venous
oxygen content, whole-body oxygen demand
and Qp/Qs. Every change in one variable can
affect the body response and some few
equations cannot predict exactly this response.
 Qp/Qs, SaO2 and SsvO2
%
SpvO2 = 96
Percent oxygen saturation

80 SpvO2 = 68 %

SaO2

60

Limit for SaO2

Critical range for Qp/Qs
40
where systemic oxygen

Sp
availability > basal oxygen

vO
Sp

2
=
vO
demands

96
=
SsvO2
2

%
68
20 %

0.1 0.2 0.5 1 2 5 10

Qp/Qs
 Qp/Qs and systemic O2 availability
Systemic O2 availability (mlO /min)
2

80 SpvO2 = 96 %

60

SpvO2 = 68 %

40

20

Oxygen deficit

0.1 0.2 0.5 1 2 5 10

Qp/Qs
Balancing the circulation