A theoretical and experimental model of ventricular interdependence

VENTRICULAR INTERACTION AND CARDIAC PATHOLOGIES IN A THICK SHELL MODEL OF CARDIAC CHAMBER DEFORMATION

Ventricular interdependence is an important part of heart function, and hence a key mediator of most pathological consequences of its impairment. It can only be explained by accounting for overall chamber deformation as well as cardiac dimensions and nonlinear material properties. Further, clinically useful interpretation of imaging data about pathological alterations in chamber geometry is hampered by lack of understanding of its significance in cardiac function. A model has been developed which describes the ventricles and septum as portions of ellipsoid shells, allowing structural characterization of diastolic ventricular interaction over arbitrary ranges of chamber pressures and volumes as well as intrathoracic pressures. Chamber configuration is derived as a function of pressure gradients by combining shell element equilibrium equations through static boundary conditions applied at the sulcus. Coupling coefficients between state variables are then calculated by letting the system evolve quasistatically through the solution space. The model is used to simulate a number of cardiac pathologies (constrictive pericarditis, restrictive myocarditis, left/right free wall and septal hypertrophy, left dilatative cardiomyopathy) and quantify their effect on ventricular pressure–pressure coupling as well as diastolic pressure–volume relationships. Results match experimental observations where available. The model can aid in interpreting diagnostic data about chamber geometry in a quantitative manner, and the differential effect of cardiac pathologies with otherwise similar phenomenology on ventricular interaction can serve as a discriminating diagnostic criterion.

Interventricular coupling coefficients in a thick shell model of passive cardiac chamber deformation

Mechanical interplay between the adjacent ventricles is one of the principal modulators of physiopathological heart function, and the underlying mechanisms of interaction are only partially understood, hence hampering clinically useful interpretation of imaging data. In order to characterize the influence of chamber geometry on ventricular coupling, the ventricles and septum are modeled as portions of ellipsoidal shells, and configuration is derived as a function of pressure gradients by combining shell element equilibrium equations through static boundary conditions applied at the sulcus. Diastolic volume (v) surfaces are calculated as a function of pressure (p), contralateral pressure (clp) and intrathoracic pressure (p ( t )) and match literature data where available. Ventricular interaction is characterized in terms of partial derivatives in v-p-clp-p ( t ) space both under physiological and altered (selectively stiffened walls) conditions. The model allows prediction of diastolic ventricular v-p-clp-p ( t ) interplay in a variety of physiopathological circumstances.

Impaired distensibility of the left ventricle after stiffening of the right ventricle

Acute and chronic alterations of right ventricular (RV) wall properties can change left ventricular (LV) performance. We investigated whether and how stiffening of the RV free wall alters LV diastolic distensibility. We used cross-circulated isolated hearts, in which the LV and RV were independently controllable. Stiffness of the RV free wall was altered by intramuscular injections of glutaraldehyde into the RV free wall after right coronary artery ligation. We measured circumferential and longitudinal regional lengths in the septum and LV free wall. During data acquisition, RV volume was held constant. After the RV free wall was stiffened by glutaraldehyde, the LV diastolic pressure-volume relation shifted upward and became steeper. Importantly, stiffening of the RV free wall increased the diastolic regional area in the septum and LV free wall under constant LV volume. The augmented regional dimensions may result in enhanced regional tension under constant LV volume and may be related to the observed increase in LV diastolic intracavitary pressure. The impaired LV diastolic distensibility by stiffening of the RV free wall may be at least partly explained by myocardial stretch, probably due to LV deformation.

Right ventricular function in congenital heart disease: pressure and volume overload lesions

The right ventricle is often subject to both pressure and volume overload in congenital heart disease. Evaluating right ventricular function in both the native lesion and after surgery in light of these loading conditions, presents a unique challenge for investigators studying these misshapen hearts. The purpose of this article is to briefly delineate what is generally known about right ventricular function in congenital heart disease and to touch on some noninvasive imaging modalities which have helped shed some light on this matter.

Ventricular interdependence: significant left ventricular contributions to right ventricular systolic function

This article reviews diastolic and systolic ventricular interaction, and clinical pathophysiological conditions involving ventricular interaction. Diastolic ventricular interdependence is present on a moment-to-moment, beat-to-beat basis, and the interactions are large enough to be of physiological and pathophysiological importance. Although always present, ventricular interdependence is most apparent with sudden postural and respiratory changes in ventricular volume. Left ventricular function significantly affects right ventricular systolic function. Experimental studies have shown that about 20% to 40% of the right ventricular systolic pressure and volume outflow result from left ventricular contraction. This dependency of the right ventricle on the left ventricle helps to explain the right ventricular response to volume overload, pressure overload, and myocardial ischemia. The septum and its position are not the sole mechanism for ventricular interdependence. Ventricular interdependence causes overall ventricular deformation, and is probably best explained by the balance of forces at the interventricular sulcus, the material properties, and cardiac dimensions.

Intraaortic balloon counterpulsation improves right ventricular failure resulting from pressure overload

BACKGROUND

Right ventricular (RV) dysfunction is common after heart transplantation, and myocardial ischemia is considered to be a significant contributor. We studied whether intraaortic balloon counterpulsation would improve cardiac function using a model of acute RV pressure overload.

METHODS

In 10 anesthetized sheep, RV failure was induced using a pulmonary artery constrictor. Baseline measurements included mean systemic blood pressure, RV peak systolic pressure, cardiac index, and RV ejection fraction. Myocardial and organ perfusion were measured using radioactive microspheres.

RESULTS

After pulmonary artery constriction, there was an increase in RV peak systolic pressure (32 +/- 2 to 60 +/- 3 mm Hg; p < 0.01) and a decrease in mean systemic blood pressure (68 +/- 4 to 49 +/- 2 mm Hg; p < 0.01), RV ejection fraction (0.51 +/- 0.04 to 0.16 +/- 0.02; p < 0.01), and cardiac index (2.48 +/- 0.04 to 1.02 +/- 0.11; p < 0.01). Blood flow to the RV did not change significantly, but there was a significant reduction in blood flow to the left ventricle. The initiation of intraaortic balloon counterpulsation (1:1) using a 40-mL intraaortic balloon inserted through the left femoral artery resulted in an increase in mean systemic blood pressure (49 +/- 2 to 61 +/- 3 mm Hg; p < 0.01), cardiac index (1.02 +/- 0.11 to 1.45 +/- 0.14; p < 0.05), RV ejection fraction (0.16 +/- 0.02 to 0.23 +/- 0.02; p < 0.01), and blood flow to the left ventricle.

CONCLUSIONS

In a model of right heart failure, the institution of intraaortic balloon counterpulsation caused a significant improvement in cardiac function. Although RV ischemia was not demonstrated, the augmentation of left coronary artery blood flow by intraaortic balloon counterpulsation and subsequent improvement in left ventricular function suggest that left ventricular ischemia contributes to RV dysfunction, presumably through a ventricular interdependence mechanism. Therefore, study of the safety and efficacy of intraaortic balloon counterpulsation in the management of patients with acute right heart dysfunction is warranted.

Effects of extreme lateral posture on hemodynamics and plasma atrial natriuretic peptide levels in critically ill patients

OBJECTIVE

To quantify the hemodynamic effects of turning critically ill, mechanically ventilated patients to the extreme left and right lateral postures.

DESIGN

Prospective investigation.

SETTING

Eight-bed intensive care unit in a university hospital.

PATIENTS

Twelve consecutive patients presenting with severe respiratory failure and requiring continuous positive inotropic support.

INTERVENTIONS

All patients were mechanically ventilated and placed in a kinetic treatment system. They were positioned in the supine, left dependent, and right dependent postures, resting for 15 min in each position.

MEASUREMENTS AND RESULTS

Hemodynamic measurements, assessments of right ventricular function, and determinations of intrathoracic blood volume were performed in three different positions. Concentrations of atrial natriuretic peptide in plasma were quantified. In three patients, the findings were controlled by transesophageal echocardiography. Cardiac index [median (range) 5.5 (3.2-8.1) vs 4.3 (3.2-7.5) l/min per m2, p < 0.01], intrathoracic blood volume [1125 (820-1394) vs 1037 (821-1267) ml/m2, p < 0.01], and right ventricular end-diastolic volume [130 (83-159) vs 114 (79-155) ml/m2, p < 0.05] increased significantly in the left dependent position compared to supine. Mean arterial pressure did not change. Atrial natriuretic peptide levels rose from 140 to 203 pg/ml. In the right dependent position, we found a marked decrease in the mean arterial pressure [85 mmHg (supine) to 72 mmHg (right dependent), p < 0.01]. Cardiac index and intrathoracic blood volume were unchanged, but right ventricular end-diastolic volume decreased from 114 to 102 ml/m2 (p < 0.05). Additionally, atrial natriuretic peptide levels decreased significantly (median delta value: 37 pg/ml). In echocardiographic controls we found an increase in right ventricular end-diastolic diameters in the left dependent position and shortened diameters in the right dependent position.

CONCLUSIONS

Extreme lateral posture affects the cardiovascular system in critically ill, mechanically ventilated patients: in the left dependent position a "hyperdynamic state" is reinforced, while the right decubitus position impairs right ventricular preload and predisposes to hypotension. Echocardiography and changes in plasma atrial natriuretic peptide values indicate that these findings are due to altered distensibility of the right ventricle caused by regional intrathoracic gravitational changes. We conclude that the duration and the angle of lateral posture should be restricted in hemodynamically unstable patients.

Left ventricular contributions to right ventricular systolic function during LVAD support

BACKGROUND

In patients with postcardiotomy low cardiac output syndromes, right ventricular (RV) failure develops in approximately 25% of patients receiving left ventricular (LV) assist device support. Depressed RV function have been attributed to abnormalities of the RV myocardium, excessive load imposed on the RV during systole or diastole, or obstruction to RV inflow. However, recent studies also suggest that LV function may significantly affect RV function through ventricular interdependence.

METHODS

We reviewed the data showing the importance of systolic ventricular interaction. We then related these observations to the RV response during LV assist device support, and present our ideas regarding the mechanisms responsible for this RV failure.

RESULTS

Using an electrically isolated right heart preparation, Damiano observed double-peaked waveforms for RV pressure, and pulmonary artery blood flow occurred over a wide range (0 to 300 ms) of pacing intervals between the LV and RV. Numeric analysis indicated that RV systolic pressure and pulmonary artery blood flow were composed of both RV and LV components, with the LV component dominating (63.5% versus 36.5%).

CONCLUSIONS

The experimental studies indicate a very consistent RV response during LV assist device support: a decrease in RV afterload, increased compliance, and decreased contractility. In normal hearts, the net effect is an increase or no change in cardiac output. With a preexisting pathologic condition, the RV responses is qualitatively the same, but anatomic ventricular interaction is accentuated, leading to a greater decrease in RV contractility. The net effect is a decrease in cardiac output, which may require inotropic or RV mechanical support.

Acute alterations in systolic ventricular interdependence-mechanical dependence of right ventricle on left ventricle following acute alteration of right ventricular free wall

The purpose of the study was to examine whether systolic ventricular interdependence can be acutely altered by changes in the mechanical properties of the ventricular wall. In eight acute canine studies, we released an aortic constriction during diastole. We measured right ventricular (RV) pressure changes (dPr) caused by sudden changes in left ventricular (LV) pressure (dPl). Measurements were obtained during control, 10 min after right coronary artery occlusion, and then 15 min after injecting glutaraldehyde into the RV free wall. By superimposing the pressure tracings of the beats immediately before and after the aortic release, the instantaneous pressure difference ratio (dPr/dPl) was calculated during systole. Maximal value of the pressure difference ratio decreased from control 0.11 +/- 0.04 to ischemia 0.08 +/- 0.03; (p < 0.05) and increased with glutaraldehyde 0.15 +/- 0.06; (p < 0.05). Thus, acute ischemia in RV free wall decreased the magnitude of systolic ventricular interdependence from LV to RV, while glutaraldehyde, which stiffens the RV free wall, increased the magnitude.

Computer simulation of the effects of ventricular interdependence on indices of left ventricular systolic function

The influence of ventricular interdependence on cardiovascular function has been convincingly demonstrated. In the intact cardiovascular system ventricular interdependence is always present, and thus measures of cardiac function include the contribution of ventricular interdependence (VI). A cardiovascular system model is presented and used to discuss how VI affects selected indices of left ventricular (LV) systolic function. Indices of LV function studied were the ejection fraction, stroke work, peak time derivative of ventricular pressure (dP/dT) and the LV end-systolic pressure-volume relationship. The effects of right ventricular (RV) volume through systolic VI on these indices are conveniently studied by comparing the model responses to pulmonary artery (PA) and vena caval (VC) occlusions; both PA and VC occlusion reduce LV volume, but the RV volume is increased by PA but reduced by VC occlusions. Through systolic VI the increase in RV volume with PA occlusion shifted the LV end-systolic pressure-volume relationship to the left and thus affected measures of LV maximum elastance. The LV ejection fraction, peak dP/dT and stroke work were all augmented by the increase in RV volume associated with the PA occlusion. Experimental studies comparing the responses to PA and VC occlusions are in broad agreement with the results described here. Systolic VI also shifted the cardiac function curve, a global measure of cardiac function, to the left. The results thus suggest that commonly used indices of LV systolic function are dependent on RV function and do not solely reflect LV function.

Left ventricular pressure effects on right ventricular pressure and volume outflow

Massive destruction of the right ventricular free wall has been shown to cause only mild hemodynamic alterations. Further, the derivative of right ventricular (RV) pressure (P) is broad or double peaked, with one peak occurring coincidentally with peak left ventricular (LV) dP/dt. Both observations suggest a direct LV assistance to RV function. Since the ventricles contract nearly simultaneously, the relative contribution of LV to RV pump function has been difficult to determine. This LV assistance was quantified in six canine experiments using a unique electrically isolated RV preparation. While on total cardiopulmonary bypass, the RV free wall was electrically isolated from the remainder of the heart. This preparation allowed for wide variations in the timing interval between RV and LV contractions. Double-peaked waveforms for RVP and pulmonary flow (RVF) occurred over a wide range (0 to 300 ms) of pacing intervals between the RV and LV. One derivative peak always followed RV contraction for RVP and RVF (r = 0.971 +/- .011, P less than 0.01: r = 0.972 +/- .012, p less than 0.01; respectively). The second derivative peak was unrelated to the RA-RV pacing interval (r = 0.297 +/- .191, P greater than 0.5 RVP; 4 = 0.237 +/- .278, P greater than 0.5 RVF), but corresponded to the maximal LVP rise. Additionally, the magnitude of the two derivative peaks was similar when the ventricles contracted synchronously. When RV contraction preceded or followed LV contraction, the derivative peak associated with LV contraction was significantly greater (P less than 0.05, range 2.1 +/- 0.6 to 6.7 +/- 1.6 for RVP; P less than 0.05 range 1.9 +/- 0.4 to 6.7 +/- 1.5 for RVF) than the derivative associated with RV contraction. These data demonstrate a normally present, large LV assistance to RV contraction and may help to explain the RV response to myocardial infarction.

Geometry of the conduit coronary artery in diastole is determined by the volume of the left and right ventricles

In the canine heart placed in a bath the ramus interventricularis anterior (RIA) was perfused under constant pressure. Segment length and diameter of RIA were monitored by ultrasound technique, coronary pressure by electromanometer. Increasing the volume of the left ventricle by up to 150% of the physiological value increased the segment length by 3.73-12.72% and decreased the diameter by 3.14-9.37%. Similar increments of right ventricular volume increased coronary segment length by 4.38-13.02% and decreased diameter by 2.85-16.45%. In concert with the dynamics of heart deformation segment length and diameter changes were larger in the proximal (close to the basis of the heart) than in the distal part of the artery (close to the apex). Implications of this phenomenon in physiological and/or pathophysiological regulation processes are presented. The results have a methodological implication for in situ studies of coronary smooth muscle activity. When the diameter of the coronary artery is taken as an indicator of smooth muscle activity the ventricular volumes should be kept constant.

Effect of left ventricular volume on right ventricular end-systolic pressure-volume relation. Resetting of regional preload in right ventricular free wall

Effect of left ventricular (LV) volume on right ventricular (RV) end-systolic pressure-volume relation (ESPVR) was investigated, and the mechanism was examined from a standpoint of the alteration of RV free wall mean fiber length. Twelve cross-circulated isovolumically contracting canine hearts in which both ventricular volumes were controlled independently were used, and RV-ESPVR was determined at three different LV volume levels. At small (10.2 +/- 0.6 ml), middle (15.3 +/- 1.0 ml), and large (20.5 +/- 1.4 ml) LV volume, the slope of the RV-ESPVR was 2.63 +/- 0.13, 2.74 +/- 0.13, and 2.89 +/- 0.12 mm Hg/ml, respectively, and each value was significantly different from the others (p less than 0.01). The volume intercept (V0) of the relation (RV-V0) was significantly decreased with the increment of LV volume (RV-V0 in small, middle, and large LV volume; 3.92 +/- 0.68, 3.39 +/- 0.67, and 2.87 +/- 0.71 ml, respectively; p less than 0.01). In nine hearts, RV free wall lengths in latitudinal and meridional direction were measured at three LV volume levels when RV volume was held constant (16.1 +/- 1.1 ml). RV latitudinal end-diastolic length was significantly augmented with increasing LV volume (latitudinal length in small, middle, and large LV volume; 9.68 +/- 0.55, 9.81 +/- 0.56, and 9.92 +/- 0.55 mm, respectively). RV meridional end-diastolic length also increased significantly with increasing LV volume.(ABSTRACT TRUNCATED AT 250 WORDS)

Is stiffness increased during ischemia?

Possible sources of increased ventricular stiffness can be more easily appreciated when pressure and volume patterns are considered as a function of time. A discussion on sources of effective or apparent stiffness or stiffness changes includes viscoelastic properties and active behavior at the muscular level. Chamber geometry and coronary vascular pressure and flow are intrinsic ventricular components. Together with the pressure head and crosstalk as extraventricular components, all these properties are integrated to determine intact heart behavior in late relaxation and diastole.

Contribution of each ventricular wall to ventricular interdependence

The influences of pressure and volume changes in one ventricle on the other ventricle may be determined from the relative compliances of the ventricular free walls and the interventricular septum. If this is correct, then disease states which alter regional compliances should influence the diastolic mechanical coupling between the ventricles. To examine this hypothesis, the hearts of 15 canine dogs were removed and placed in cool cardioplegic solution. Balloons were inserted into each ventricle and the right and left ventricular pressure (delta Pr, delta Pl) and volume (delta Vr, delta Vl) changes caused by changing the pressure and volume of the other ventricle were recorded. Acute changes in right ventricular free wall (N = 5), septal (N = 5), and left ventricular free wall (N = 5) compliances were induced by glutaraldehyde injections. After injecting glutaraldehyde into the right coronary artery, delta Pl/delta Vr, delta Vl/delta Vr, delta Pr/delta Pl, and delta Pr/delta Vl increased significantly (P less than 0.05). After septal artery injection, pressure and volume transfer between the ventricles was significantly depressed. After left coronary artery injection, delta Pl/delta Pr, delta Pl/delta Vr, delta Pr/delta Vl, and delta Vr/delta Vl increased significantly (P less than 0.05). Thus, selective alterations in the mechanical coupling between the ventricles occurred following changes in right ventricular, septal, and left ventricular free wall compliances. Such changes may be important in diseases which primarily affect one side of the heart.

Predictive changes in ventricular interdependence

Based on the balance of forces across the interventricular septum, we developed a theoretical analysis to explain how one ventricle can directly influence the filling characteristics of the other ventricle. The analysis indicated that the pressure and volume transfer were related to the relative compliances of the interventricular septum and ventricular free walls. The present study examined whether the theoretical analysis could be used to predict changes in ventricular interdependence caused by altering regional compliance. To examine this hypothesis, hearts were removed from 18 dogs and placed in cool cardioplegic solution. Balloons were inserted into each ventricle, and the left and right pressure (delta P1, delta Pr) and volume (delta V1, delta Vr) changes caused by changing the pressure and volume of the other ventricle were recorded. After the initial measurements, acute changes in left ventricular free wall compliance (n = 6), septal compliance (n = 6), and right ventricular free wall compliance (n = 6) were induced by glutaraldehyde injections. As predicted by the theoretical analysis, decreasing left ventricular free wall compliance increased delta P1/delta Pr, delta P1/delta Vr, delta Pr/delta V1, and delta Vr/delta V1 significantly (P less than 0.05) by 89 +/- 15, 155 +/- 33, 282 +/- 65, and 112 +/- 22% (mean +/- SEM), respectively. Decreasing septal compliance decreases delta P1/delta Pr, delta V1/delta Pr, delta V1/delta Vr, delta Pr/delta P1, delta Vr/delta P1, and delta Vr/delta V1 significantly (P less than 0.05) by 48 +/- 7, 71 +/- 10, 69 +/- 14, 48 +/- 7, 62 +/- 8, and 57 +/- 13%, respectively. Decreasing right ventricular free wall compliance increased delta P1/delta Vr, delta V1/delta Vr, delta Pr/delta P1, and delta Pr/delta V1 significantly (P less than 0.05) by 97 +/- 25, 79 +/- 20, 57 +/- 18, and 59 +/- 23%, respectively. Furthermore, these alterations in ventricular coupling were predictable: The actual and predicted percentage changes in the transfer functions were in close agreement. The results of these studies show predictable alterations in the mechanical coupling between the ventricles following changes in right ventricular, septal, and left ventricular free wall compliances.