MODULE II

THE CARDIOVASCULAR SYSTEM

 Heart attack! - Many deaths Instrumentation Reduced death from heart disease Blood pressure, flow, volume m/m available The ECG, echocardiogram, phonocardiogram: recorded with electronic instruments IntensiveCU & CoronaryCU available Cardiac assist devices: Pacemaker, defibrillator

THE HEART & CARDIOVASCULAR SYSTEM

 Pulmonary circulation: blood flow through lungs Systemic circulation: Supplies O2 & nutrients to cells of the body

 Systemic circulation high resistance circuit with large pressure diff. b/w arteries & veins considered as Pressure pump Pulmonary circulation Pressure diff. is small Low resistance to flow Volume pump. Muscle contraction of left heart is larger & stronger than right heart due to great pressure requirement for systemic circ.

 Pumping action contraction of heart muscles Muscles receive blood coronary artery that surround heart Arteries & veins flexible

Cardiovascular System

Cardiovascular circulation

 Hearts pumping cycle is divided into two parts:

Systole Diastole

 Systole Period of contraction of heart muscles the ventricular muscle at which time blood is pumped into the pulmonary artery & the aorta. Diastole Period of dilation of the heart cavities as they fill with blood.

 After blood pumps to arteries Heart relaxes pressure in chamber outlet valve closes inlet valve opens to restart diastole & new cycle of heart

 Heart beat 75 bpm when stands up & when sits down range 60 85 Higher in women Decreases with age Infant 140 bpm normal Heart rate with heat exposure, physiological & psychological factors

Heart pumps 5 liters of blood per minute Circulation rate increases with exercise About 75-80 % blood volume veins About 20 % blood volume arteries Rest Capillaries

 Systolic BP (Maximum) 95 to 140 mm Hg 120 avg varies with climate, age, eating habits etc.. Diastolic BP (Lowest pressure b/w beats) 60 to 90 mm Hg 80 avg

ELECTRO-CONDUCTION SYSTEM OF THE HEART

Pericardium Septum AV Node Right Atrium SA Node Right Ventricle Bundle of His

Tricuspid valve Left atrium Mitral valve Left ventricle Purkinje fibers

HEART SOUNDS

 Sounds & vibrations diagnosis of heart disorders Auscultation Technique of listening to sounds produced by organs & vessels of body Auscultation depends on skill, experience, hearing ability of physician Heart sounds Vibrations set up in the blood inside the heart by sudden closure of valves

 With each heart beat, heart produces 2 sounds that are audible in stethescope Lub-Dub Lub Closure of atrioventricular valves (?) Called as first heart sound Occurs at the time of QRS of ECG & just before ventricular systole

 Dub Caused by closing of semilunar valves at the end of systole just before AV valve reopens Called as second heart sound Occurs at end of T wave of ECG Third heart sound sometimes heard in young adults 0.1 to 0.2 sec after 2nd sound Rush of blood from atria to ventricles occurs before atrial contraction

 An Atrial heart sound that is not audible but visible on graphic recording occurs as atria contracts causing blood to ventricles Inaudibility due to low amplitude & freq. of vibrations

 In abnormal hearts Murmurs heard b/w heart sounds Caused by improper opening of valves or regurgitation ( Results when valve do not close completely & allows some backward flow) Sound due to high velocity through small opening Small opening in septum also cause sounds

 Normal sound short duration one tenth of second Murmurs extend b/w normal sounds Stenosis Abnormal narrowing of blood vessel or tubular organ

Difference in frequency range b/w normal & abnormal sounds

First heart sound Sound energy in 30 45 Hz Second sound Higher in pitch 50 70 Hz range Third sound weak vibration below 30 Hz Murmurs Higher pitch sound e.g., Regurgitation causes a murmur in 100 600 Hz range

 Other than auscultation, for detecting & analyzing heart sounds graphic recording of sounds :Phonocardiogram Like ECG but higher frequency range Vibrocardiogram Vibrations of side of heart towards chest wall Apex cardiogram Tip of heart hitting ribs

 Sounds & pulsations measured at various locations Pulse can be felt at finger tips at certain points on arteries Artery occlusion velocity through it increases sounds heard through stethescope Korotkoff sounds Ballistocardiogram beating produces some forces blood ejection measured & recorded

CARDIOVASCULAR MEASUREMENTS

ELECTROCARDIOGRAPHY
ECG OR EKG P, QRS, T Rhythmic electrical depolarization & repolarization of myocardium contractions of atria & ventricles ECG Diseases & conditions of heart Timing reference for other m/m

 ECG waveform depends on lead configuration Normal values of amplitude & durations of ECG parameters:
Amplitude P wave R wave Q wave T wave 0.25mV 1.60mV 25% of R wave 0.1 to 0.5mV

 Duration

P-R interval Q-T interval S-T interval P interval QRS interval

0.12 to 0.20 sec 0.35 to 0.44 sec 0.05 to 0.15 sec 0.11 sec 0.09 sec

 For diagnosis, cardiologist heart rate 60 to 100 bpm Bradycardia slow heart Tachycardia fast heart Cycles Evenly spaced if not, Arrhythmia (irregular heart beat) If P-R interval > 0.2sec Blockage

 Healthy ECG remains constant even though heart rate changes Position of heart within thoracic region & position of body influences electrical axis Electrical axis of heart the resultant of the electromotive forces within the heart at any instant shifts continually through a repeated pattern during every cardiac cycle

 Changes in ECG under pathological conditions:

Altered path of excitation of heart Changed origin of waves Altered relationships of features Changed magnitude of one or more features Differing durations of waves or intervals

 Electrocardiograph Instrument Disorders From ECG some disorders cannot be diagnosed Other diagnostic techniques Angiography, Echocardiography

History
Contracting of heart muscles electrical voltages Capillary electrometer Lippman in 1875 Mercury- filled glass capillary immersed in dilute sulphuric acid Meniscus changed when voltage applied b/w mercury & acid Movement Small Magnified Cumbersome, limited frequency range

 String Galvanometer Einthoven in 1903 Thin Pt wire or gold plated quartz fiber suspended in air gap of strong electromagnet Current through string movement of string perpendicular to mag. Field Magnitude Small Magnified

 ECG using immersion electrodes String galvanometer with electronic amplification Recording techniques many disadvantages Direct writing recorders (1946) ink transfer from ribbon to record ECG on paper strip

 ECG measured from electrodes dependent on placement Electrode placement Some disappear ECG recorded from different leads 12 No details missing Placement, name & configuration Standardized

Electrodes
Placement, color code Earlier ECG m/m 3 electrodes 2 used at a time Introduction of electronic amplifier additional connection reqd. ground reference right leg Chest or precordial electrodes Plate electrodes used at extremities chest electrode Suction type

Leads
ECG leads
Bipolar leads Unipolar leads

Bipolar leads
ECG measured using 2 electrodes Referred to as Einthoven leads LeadI : Electrodes placed at RA & LA LeadII : RA & LL Lead III : LA & LL Potential difference measured b/w electrodes & ref point: RL

Einthoven triangle
At any instant of cardiac cycle : electrical axis of heart 2D vector ECG measured from any of 3 limb leads Single dimensional component of vector Electric field represented by triangle heart at centre Triangle Einthoven Triangle

 Instantaneous voltage from one of three limb lead position = algebraic sum of other two Or vector sum of projections on 3 lines = 0 QRS : greatest in lead II LeadII produces greatest R wave potential When amplitude of 3 limb leads measured, R wave amp. of lead II = Sum of R waves of lead I & III

Unipolar Leads (V leads)

ECG recorded b/w exploratory electrode & central terminal ( potential corresponding to centre of body) Central terminal combination of several electrodes tied at single point Two types
Limb leads Pericordial or chest leads

 Limb Leads ( Augmented unipolar limb leads) AVR Right arm recorded w.r.t. LA & LL electrodes AVL LA w.r.t RA & LL AVF LL w.r.t RA & LA

 Unipolar chest leads Single chest electrode exploratory electrode Six predesignated points on the chest Chest positions called as precordial unipolar leads, v1 through v6 All three active limb electrodes used to obtain central terminal

ECG RECORDER PRINCIPLES

Connecting wires patient cable & ECG recorder

 Wires from electrode to Lead selector switch resistors necessary for unipolar leads PB standardization voltage of 1mv calibrate or standardize recorder Changing setting of Lead selector artifacts A special contact turns off amplifier Turns on after passage of artifact

 From LSS ECG moves to preamplifier differential amp with high CMRR provides switch to select gain Goes to pen amplifier dc amplifier that provides power to drive pen motor that records ECG trace position control in PA to center the pen on recording paper

 ECG recorders use heat sensitive paper and pen is electrically heated stylus temperature adjusted by stylus heat control A marker stylus actuated by PB mark coded indication of lead at margin of ECG Paper speed 25mm/sec, Faster speed 50mm/sec for better resolution

 Power switch 3 positions ON, OFF, RUN ON power to amp is ON but paper drive not running RUN will start paper drive Polarity switch In older ECG, polarity check necessary to prevent shock hazard to patients Now, have grounding pins Not necessary

 Buffer amplifier To increase i/p impedence & reduce effect of variations in electrode impedence Transistors in these protected by a n/w of resistors & neon lamp from overvoltages during surgery During defibrillation over voltages present Methods adopted to prevent device burnout

 Some modern devices utilize driven right leg lead summing n/w to get sum of voltages from all other electrodes & a driving amplifier Voltage at right leg = sum of voltages of other leads This inc. CMRR & dec. interference

ECG MACHINE BLOCK DIAGRAM

 Potentials from patient Lead selector switch By capacitive coupling s/l differential preamplifier Preamplifier 3 or 4 stage differential amplifier -ve current feedback from end stage to first stage stabilizing effect Then given to power amplifier push-pull differential type

 Base of one transistor driven by preamplified unsymmetrical s/l Another by feedback s/l from pen position by frequency selective n/w O/p of power amplifier is single ended pen motor deflection on paper Auxiliary circuit 1mv calibration & automatic blocking of amplifier during change of LSS Speed control for chart drive motor

 Standby mode provided on machine Stylus moves in response to input but paper is stationary Allows operator to adjust gain

TYPES OF RECORDERS

Single Channel Recorders Three- Channel Recorders Vector Electrocardiographs Electrocardiograph systems for stress testing Electrocardiographs for computer processing Continuous ECG recording

SINGLE CHANNEL RECORDERS

 Portable In hospital, mounted on cart wheeled to bedside of patient Ease

THREE CHANNEL RECORDER

 Record 3 leads simultaneously Automatically switches to next group of three leads An ECG with 12 leads recorded as sequence of 4 groups with 3 leads Code marking at margin which lead combination Total ECG time less More time to apply electrodes Separate electrodes for each chest position

VECTOR ELECTROCARDIOGRAPH (VECTORCARDIOGRAPH)

 Voltage generated by heart Vector whose magnitude & spatial orientation change with time Vector Cardiography presents an image of magnitude & spatial orientation of heart vector Special lead placement to pick ECG signals for vector cardiogram Displayed on CRT as in patient monitors Machines that uses computers to slow ECG s/ls available

ELECTROCARDIOGRAPH FOR STRESS TESTING

 Stress test performed- consists of following parts

Patients walk at different speed on tread mill ECG is recorded while on tread mill ECG monitor with CRT display & heart rate meter ECG recorder Automatic or semiautomatic sphygmomanometer for indirect m/m of BP

As stress involve risks, dc defibrillator kept while test is performed

ELECTROCARDIOGRAPH FOR COMPUTER PROCESSING

Automatic analysis of ECG ECG s/l transmitted sequentially to computer with additional information on patient ECG s/l recorded & later entry to computer Information regarding patient entered & transmitted along with ECG During transmission ECG recorded to verify transmitted s/ls are free of artifacts

CONTINUOUS ECG RECORDING (HOLTER RECORDING)

 Normal ECG brief sample of cardiac activity Arrhythmias under certain conditions like emotional stress Missed Continuous ECG recording Capture arrhythmias ECG recorded during daily activity by special magnetic tape recorder

 Smallest device of this type worn inside pocket - Allows recording for 4 hours Other recorders Size of camera case worn over shoulder & can record for 24 hours Recorded tape analyzed using special scanning device plays back at a faster rate 24 hour to 12 minutes Slowed down to obtain normal ECG strip

ECG READOUT DEVICES

 Two forms of ECG readout devices

Oscilloscopes Strip chart recorders

 Medical oscilloscopes like CRO Horizontal sweep speed 25mm/s, some 50 mm/s & 100 mm/s Medical strip chart recorders also offer same speeds, 25mm/s standard Standard ECG paper has grid pattern 50mm wide Small grid divisions 1mm apart while large grid divisions 5mm apart

 Vertical scale calibrated at 0.1 mV/mm Heart rate in BPM can be measured from ECG paper Some ECG paper have 3 or 6 sec marks at top margin By counting no. of R waves heart rate Count no. of R waves in 3 s & multiply by 20

 Eg:

MEASUREMENT OF BLOOD PRESSURE

 Blood pressure - Good indicator of status of heart High BP - Hypertension BP m/ m - indirect by Sphygmomanometer easy to use & automated Disadvantages: No continuous monitoring of pressure variations- Systolic & Diastolic readings No details of pressure waveform

 Fails when pressure very low Direct BP m/m : Continuous recording of BP waveform More accurate Blood vessel punctured to place sensor

INDIRECT MEASUREMENT
Or Non-invasive Sphygmomanometer & Stethoscope Sphygmomanometer- inflatable pressure cuff & mercury or aneroid manometer to measure pressure in cuff Cuff rubber bladder inside inelastic fabric covering wrapped around upper arm

 Cuff inflated manually with rubber bulb & deflated slowly through a needle valve

 Working pple: When cuff placed on upper arm & inflated, arterial blood flow when arterial pressure> cuff pressure When cuff is inflated that partially occludes artery, turbulence generated & Korotkoff sounds produced heard through Steth placed down cuff

 To obtain BP using Sphygmomanometer & stethoscope,

Pressure cuff on upper arm inflated to pressure above systolic pressure No sounds can be heard through steth placed over brachial artery Cuff pressure reduced below systolic pressure Small amounts of blood gush out & sounds can be heard through steth Pressure indicated on manometer when first korotkoff sound is heard systolic blood pressure

 As pressure in cuff drops, Korotkoff sounds continue until cuff pressure is no longer sufficient to occlude the vessel Below this pressure sounds disappear diastolic pressure Method of locating sys. & dias. Pressure by listening to Korotkoff sounds- auscultatory method of sphygmomanometry Alternative method Palpatory method

 Identifies flow of blood by feeling pulse Systolic pressure can be identified but diastolic pressure difficult Auscultatory method- commonly used

DIRECT MEASUREMENT
Three methods
PERCUTANEOUS INSERTION CATHETERIZATION ( VESSEL CUTDOWN) IMPLANTATION OF A TRANSDUCER IN A VESSEL OR IN THE HEART

 In percutaneous insertion, local anesthetic is injected near site of invasion Hollow needle is inserted at a slight angle towards the vessel When needle is in place, a catheter is fed through needle with some guide After catheter is in place in vessel, needle & guide is withdrawn

 For some other m/m, needle is attached to airtight tube & BP is sensed directly attaching transducer to the tube Other types- transducer built in tip of catheter

 Catheterization Diagnostic technique for analyzing heart & other components of cardiovascular system Not only m/m of BP used to obtain blood samples from heart for oxygen content analysis & location of abnormal blood flow path Catheters also for injection of dyes for x-ray studies, drugs directly to heart & vessels

 M/m of BP with catheter achieved in 2 ways First method Introduce saline solution into catheter fluid pressure transmitted to transducer outside the body A complete fluid pressure s/m is set up with provision for checking against atm. pressure Second method Transducer introduced into catheter or mounted at tip of catheter

 Implantation involve major surgery Research experiments Transducer fixed in a place in appropriate vessel for long periods of time

OSCILLOMETRIC METHOD
Advantage over auscultatory m/m Sound not used -environmental noise do not hamper m/m Pple- When occluding cuff deflates from level above systolic pressure artery walls vibrate Vibrations sensed in transducer s/m As cuff pressure dec., oscillations inc. max dec. until normal blood flow

 Max. oscillations- mean arterial pressure Oscillometric method oscillometric pulses or pressure pulses generated in cuff during inflation & deflation

ULTRASONIC DOPPLER SHIFT METHOD

Due to back scattering of moving blood particles frequency shift Occlusive cuff placed with ultrasonic transducer on the arm over brachial artery Cuff inflated above systolic pressure deflated Ultrasonic beam transmitted to arm Ultrasound reflected freq shift when artery wall moves

 Above systolic vessel closed- monitor s/l not received When cuff pressure falls just below arterial pressure- artery wall open First korotkoff sound doppler shift & is interpreted by logic in instrument systolic Similar shifts produced until diastolic pressure artery not occluded

 Motion disappears & doppler shift small Instrument notes sudden change in doppler shift & cuff pressure displayed as diastolic pressure

 + also used in noisy environment + Used with infants and hypotensive individuals - Subjects movements change the path from sensor to vessel - Special electronic circuit detect motion artifact

MEASUREMENT OF HEART SOUNDS

 Stethoscope Greek; Stethos : Chest Skopein : to examine Carry sound energy from chest to ear through air column, 2 ear piece connected to chest piece Only small portion of energy in heart sound is in audible frequency range If amplified, greater portion of sound spectrum heard

 High fidelity equipment would be able to reproduce entire frequency range that is missed by steth. Electronic steth. : never found favor with physician: any change was confusing Graphic record of heart sound Phonocardiogram Phonocardiograph

 Transducer used for phonocardiogram : Microphone Frequency response range from below 5 Hz to above 1000 Hz An amplifier with similar response required: Offer selective low pass filter to allow high frequency cutoff for noise Pen recorder is inadequate for high frequencies integrator employed

 Read out of phonocardiograph: High frequency chart recorder or oscilloscope Normal heart sound in the range of Pen recorders : But high freq. murmurs require photographic recorders/ device Presence of high frequencies in phonocardiogram : heart disorder

 Spectral analysis of heart sound : tool for discriminating b/w normal & abnormal hearts: requires digital computer with ADC & FT software Microphones placed over chest over heart Special microphone transducers placed at tip of catheters : sounds from chambers of heart/ from major blood vessels near heart

 Vibrocardiograph? Apex cardiograph? Use microphones as transducers : displacement or force For recording korotkoff sounds from occluded artery : microphone placed beneath cuff

MEASUREMENT OF BLOOD FLOW & CARDIAC OUTPUT

 Impaired blood supply disease M/m of blood flow diagnosis Industrial methods fluid flow flow meters, rotameters not suitable
Damage to blood cells (cutting) Blood clot formation (sharp edges)

 Methods for blood flow m/m

Electromagnetic induction Ultrasound transmission on reflection Thermal convection Radiographic principles Indicator ( dye or thermal ) dilution

Magnetic blood flow meters

Pple of magnetic induction- electric conductor moved through mag. Field, voltage induced in conductor prop. to velocity of motion Magnet around blood vessel voltage measured by electrodes Mean blood velocity measured Magnetic blood flow transducers catheter tip electromagnet inside catheter & electrodes outside

 O/p voltage small few micro volts Early blood flow meters constant mag. Field used difficulties with electrode polarization & amplifier drift Electromagnets driven by alternating currentsproblem- Induces error voltage exceed s/l level Different waveforms for magnet current used

Block diagram

 Oscillator- Drives magnet & provides control signal for gate Operating frequency b/w 60 & 400 Hz Gated detector When flow direction reverses, polarity of o/p signal reversed Frequency response of s/m- recording of flow pulses Mean or avg. flow low pass filter

ULTRASONIC BLOOD FLOW METERS

Beam of ultrasonic energy used to measure velocity of flowing blood Transit time ultrasonic flow meter pulsed beam through blood vessel transit time measured When blood flows in direction of energy transmission transit time short Opposite direction transit time long

 Ultrasonic flow meter- doppler pple more common Oscillator excites piezoelectric transducer Transducer coupled to wall of exposed blood vessel sends ultrasonic beam, freq. F, to flowing blood Small part scattered received by second transducer opposite to first transducer

 Scattering due to moving blood reflected s/l has diff. freq. F + FD or F-FD FD prop to flowing velocity A fraction of transmitted s/l reaches with freq. unchanged Amplification of composite s/l, doppler freq. at o/p of detector diff b/w direct & scattered s/l

 Doppler s/l low audio freq. range Can be heard from loud speaker or ear phone

BLOOD FLOW M/M BY THERMAL CONVECTION

Hot object in colder flowing medium- cooled by thermal convection Rate of cooling prop. Rate of flow of medium Used- m/m of blood velocity One method- thermistor in blood stream at constant temp. by servo system Electrical energy required to maintain this temp measure of flow rate

 Another method electric heater b/w 2 thermocouples or thermistors at a distance apart along vessel Temp. difference b/w upstream & downstream sensor measure of blood velocity Device of this typethermostromuhr

BLOOD FLOW DETERMINATION BY RADIOGRAPHIC METHOD

Blood not visible on x-ray Same radio density as surrounding tissue By injection of contrast medium (iodated organic compound) to blood vessel circulation pattern visible Obstructions detected & blood flow in vessels estimated Cine or video angiography -Damage after stroke or heart attack detected

 Another method- Injection of radioactive isotope into blood circulation detection of vascular obstructions with device like scanner Vascular obstructions also measured by temperature difference

M/M BY INDICATOR DILUTION METHOD

Indicator or dye dilution method blood flow not blood velocity Any substance indicator if it mixes with blood concentration in blood determined after mixing Substance must be stable- no toxic side effects

 Indocyanine dye, cardiogreen used in solution as indicator Its conc. Determined measuring light absorption with densitometer that measures degree of darkness Radioactive isotopes radioiodited serum albumen Isotonic saline - mostly used Injected at a temperature lower than body temperature Conc. Of saline water after mixing determined

 Pple of dilution method when blood not recirculated Indicator injected at t at constant infusion rate I (grams/minute)- detector checks conc. After certain time indicator appear- conc inc. & reaches const. value Co Flow F (liters/ minute) = I (mg/minute) Co (mg/liter)

 When indicator is dye or isotope conc. Inc when recirculated( R in fig.) Indicator injected as bolus instead a constant rate. Fig (c ) open s/m - conc inc , reaches P & exp. Dec. Spread of bolus To calculate flow, area under curve reqd.

 Area under conc. curve =

 Method was complicated & time consuming to determine area under curve Use of cold saline as indicator solution to problem

 To determine cardiac output (CO) : Earliest method used- Fick method Indicator used Oxygen of inhaled airinjected to blood in lungs Infusion rate measured Oxygen content of exhaled air & subtracting from known inhaled content (room air)

 Oxygen metabolism resembles open circulation A part of O2 consumed in systemic circulation Returning venous blood some O2 O2 conc. from venous blood subtracted from O2 conc. in arterial blood leaving lungs Automated s/m for m/m of O2 conc (Calorimetry) & O2 consumption & CO from these m/m

 Calorimetry m/m of heat of chemical reactions A bolus injection increases the concentration of a drug in the blood stream so the drug can start working quickly

PLETHYSMOGRAPHY

 m/m of volume changes during heart beat Instruments- plethysmographs Chamber or rigid cup placed over limb or digit Any changes of volume in limb pressure changes inside chamber

 If cuff not inflated- o/p s/l sequence of pulsations prop. Individual volume changes with each heart beat By inflating cuff above venous pressure arterial blood flow but venous blood cannot. Limb or digit volume increases with each heart beat

Capacitance plethysmograph
Use either arm or leg Limb in which the volume is measured one plate of capacitor Other plate is fixed screen kept at a distance by an insulating layer Pulsations of blood in arm or leg- capacitance change- distance b/w limb & screen changes

Mercury Strain gauge Plethysmograph

Several plethysmographs measure variable related to volume Pseudo plethysmographs changes in diameter of finger, toe, arm, leg etc Diameter m/m Mercury strain gauge- small diameter elastic tubing wrap around digit or limb With each pulsation of blood diameter of limb or digit inc.- elongation of SG change in resistance

Photoelectric Plethysmograph
Volume changes in limb or digit change optical density Light source in chamber illuminates finger scattered & transmitted to photo cell As capillaries fill with blood blood density inc. amount of light reaching photocell dec. Change in resistance in photocell wheatstone bridge

Impedence plethysmograph
Volume changes- change in impedence Two electrode or four electrode system Electrodes wrapped around limb or digit Two electrode- current forced through tissue Resulting voltage change is measured Four electrode constant current through two outer electrodes voltage b/w 2 inner electrode measured Rheoencephalography- imp. Changes b/w electrodes in scalp cerebral blood flow & circulatory diff b/w 2 sides of head

Oculo Pneumo Plethysmograph

Volume changes in the eye with each arterial circulation Eye cup placed Site for non invasive access to cerebral circulation system

THANK YOU