Department Of ECE

Institute of Engineering & Technology, Bhaddal

Assignment
“Cardiovascular System”
 The HEART and Cardiovascular System

The heart is a muscular organ responsible for pumping blood through the
blood vessels by repeated, rhythmic contractions, or a similar structure in the
annelids, mollusks, and arthropods. The term cardiac (as in cardiology)
means "related to the heart" and comes from the Greek καρδία, kardia, for
"heart." The heart is composed of cardiac muscle, an involuntary muscle
tissue which is found only within this organ. The average human heart
beating at 72 BPM, will beat approximately 2.5 billion times during a
lifetime spanning 66 years.

The function of the right side of the heart (see right heart) is to collect de-
oxygenated blood, in the right atrium, from the body and pump it, via the
right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide
can be dropped off and oxygen picked up (gas exchange). This happens
through the passive process of diffusion. The left side (see left heart) collects
oxygenated blood from the lungs into the left atrium. From the left atrium
the blood moves to the left ventricle which pumps it out to the body. On both
sides, the lower ventricles are thicker and stronger than the upper atria. The
muscle wall surrounding the left ventricle is thicker than the wall
surrounding the right ventricle due to the higher force needed to pump the
blood through the systemic circulation.
Starting in the right atrium, the blood flows through the tricuspid valve to
the right ventricle. Here it is pumped out the pulmonary semilunar valve and
travels through the pulmonary artery to the lungs. From there, blood flows
back through the pulmonary vein to the left atrium. It then travels through
the mitral valve to the left ventricle, from where it is pumped through the
aortic semilunar valve to the aorta. The aorta forks, and the blood is divided
between major arteries which supply the upper and lower body. The blood
travels in the arteries to the smaller arterioles, then finally to the tiny
capillaries which feed each cell. The (relatively) deoxygenated blood then
travels to the venules, which coalesce into veins, then to the inferior and
superior venae cavae and finally back to the right atrium where the process
began.
The heart is effectively a syncytium, a meshwork of cardiac muscle cells
interconnected by contiguous cytoplasmic bridges. This relates to electrical
stimulation of one cell spreading to neighboring cells.
Cardiovascular System
The circulatory system (or cardiovascular system) is an organ system that
moves nutrients, gases, and wastes to and from cells, helps fight diseases
and helps stabilize body temperature and pH to maintain homeostasis. While
humans, as well as other vertebrates, have a closed circulatory system
(meaning that the blood never leaves the network of arteries, veins and
capillaries), some invertebrate groups have open circulatory system. The
most primitive animal phyla lack circulatory systems.

The Circulation is Constructed from Pumps, Tubing and Valves

 Pumps:
  Circulatory pumps (hearts) are vessels filled with the
circulatory fluid or blood
 When muscles around the container contract they exert pressure
on the blood, causing it to flow
 Heart type: pump produces a high pressure which causes blood
to flow out through arteries
 Muscle pump: muscle contraction squeezes veins, causing
blood to flow toward heart
 Tubing or pipes = arteries, capillaries, veins
 Carry blood toward delivery site
 Sometimes deliver within a few microns of site (capillaries in
tissue)
 Blood vessels may be elastic (which helps keep the pressure
high between heartbeats)
 Vessels may constrict and dilate (which gives control over the
flow)
 Valves give direction to the flow
 Blood vessels (including hearts & veins) have flap valves that
open in only one direction
 Example: when pressure increases in veins this opens valves
toward the heart and closes those in the other direction -> blood
flows toward heart
 The purposes of circulation:
 To deliver food materials and oxygen to the tissues
 To remove waste products and heat
 These things can be done by diffusion in a small animal, but in
a large animal a circulation is necessary.

The Mammalian Heart is Really 2 Hearts in Series

 Right heart:
 Pumps to lungs: nearly 100% of the flow goes through the
lungs
 Low pressure side: 25 mm Hg systolic pressure in humans
 Right ventricle has thin walls
 Left heart:
 Pumps to rest of body
 High pressure side: 120 mm Hg systolic pressure in humans
  Left ventricle has thick walls
 Right & and left atria:
 Help fill the ventricles
 Very low pressure
 Thin walls
 Pumping of the right & lift sides occurs together
 Must be accurately balanced, otherwise fluid may accumulate
in the lungs (pulmonary edema)
 The muscle pump helps return blood to the heart
 When muscles contract the veins passing through them are
squeezed
 This causes blood to flow toward the heart
 Valves prevent flow away from the heart

The Entire Blood Supply Passes Through the Heart About Once Every
Minute
 Your body has approximately 5 liters of blood (large people have a
little more, small people a little less)
 The heart's pumping rate is called the cardiac output: at rest its value
is about 5 liters/min
 Comparing the volume with the cardiac output you can see that the
entire blood volume passes through the heart on the average once
every minute
 All of the output from the right heart goes through the lungs (5
liters/min)
 The output from the left heart splits and goes through different organs
 General outline of the circulation:

Electrocardiogram
An electrocardiogram (ECG or EKG, abbreviated from the German
Elektrokardiogramm) is a graphic produced by an electrocardiograph, which
records the electrical activity of the heart over time. Its name is made of
different parts: electro, because it is related to electronics, cardio, Greek for
heart, gram, a Greek root meaning "to write".
Electrical waves cause the heart muscle to pump. These waves pass through
the body and can be measured at electrodes (electrical contacts) attached to
the skin. Electrodes on different sides of the heart measure the activity of
different parts of the heart muscle. An ECG displays the voltage between
pairs of these electrodes, and the muscle activity that they measure, from
different directions. This display indicates the overall rhythm of the heart,
and weaknesses in different parts of the heart muscle. It is the best way to
measure and diagnose abnormal rhythms of the heart[1], particularly
abnormal rhythms caused by damage to the conductive tissue that carries
electrical signals, or abnormal rhythms caused by levels of salts, such as
potassium, that are too high or low.[2] In myocardial infarction (MI), the
ECG can identify damaged heart muscle. But it can only identify damage to
muscle in certain areas, so it can't rule out damage in other areas. [3] The
ECG cannot reliably measure the pumping ability of the heart; ultrasound is
used for that.

ECG graph paper

A typical electrocardiograph runs at a paper speed of 25 mm/s, although

faster paper speeds are occasionally used. Each small block of ECG paper is
1 mm². At a paper speed of 25 mm/s, one small block of ECG paper
translates into 0.04 s (or 40 ms). Five small blocks make up 1 large block,
which translates into 0.20 s (or 200 ms). Hence, there are 5 large blocks per
second. A diagnostic quality 12 lead ECG is calibrated at 10 mm/mV, so 1
mm translates into 0.1 mV. A "Calibration" signal should be included with
every record. A standard signal of 1 mV must move the stylus vertically 1
cm, that is two large squares on ECG paper.

Leads

The word lead has two meanings in electrocardiography: it refers to either

the wire that connects an electrode to the electrocardiograph, or (more
commonly) to a combination of electrodes that form an imaginary line in the
body along which the electrical signals are measured. Thus, the term loose
lead artifact uses the former meaning, while the term 12 lead ECG uses the
latter. In fact, a 12 lead electrocardiograph usually only uses 10
wires/electrodes. The latter definition of lead is the one used here.
An electrocardiogram is obtained by measuring electrical potential between
various points of the body using a biomedical instrumentation amplifier. A
lead records the electrical signals of the heart from a particular combination
of recording electrodes which are placed at specific points on the patient's
body.
 When a depolarization wavefront (or mean electrical vector) moves
toward a positive electrode, it creates a positive deflection on the ECG
in the corresponding lead.
 When a depolarization wavefront (or mean electrical vector) moves
away from a positive electrode, it creates a negative deflection on the
ECG in the corresponding lead.
 When a depolarization wavefront (or mean electrical vector) moves
perpendicular to a positive electrode, it creates an equiphasic (or
isoelectric) complex on the ECG. It will be positive as the
depolarization wavefront (or mean electrical vector) approaches (A),
and then become negative as it passes by (B).
There are two types of leads—unipolar and bipolar. The former have an
indifferent electrode at the center of the Einthoven’s triangle (which can be
likened to a ‘neutral’ of the wall socket) at zero potential. The direction of
these leads is from the “center” of the heart radially outward and includes
the precordial (chest) leads and limb leads— VL, VR, & VF. The latter, in
contrast, have both the electrodes at some potential and the direction of the
corresponding electrode is from the electrode at lower potential to the one at
higher potential, e.g., in limb lead I, the direction is from left to right. These
include the limb leads--I, II, and III.

Waves and Intervals

A typical ECG tracing of a normal heartbeat (or cardiac cycle) consists of a

P wave, a QRT complex and a T wave. A small U wave is normally visible in
50 to 75% of ECGs. The baseline voltage of the electrocardiogram is known
as the isoelectric line. Typically the isoelectric line is measured as the
portion of the tracing following the T wave and preceding the next P wave.
P wave
During normal atrial depolarization, the main electrical vector is directed
from the SA node towards the AV node, and spreads from the right atrium to
the left atrium. This turns into the P wave on the ECG, which is upright in II,
III, and aVF (since the general electrical activity is going toward the positive
electrode in those leads), and inverted in aVR (since it is going away from
the positive electrode for that lead). A P wave must be upright in leads II and
aVF and inverted in lead aVR to designate a cardiac rhythm as Sinus
Rhythm.
 The relationship between P waves and QRT complexes helps
distinguish various cardiac arrhythmias.
 The shape and duration of the P waves may indicate atrial
enlargement.

PR interval

The PR interval is measured from the beginning of the P wave to the

beginning of the QRT complex. It is usually 120 to 200 ms long. On an ECG
tracing, this corresponds to 3 to 5 small boxes.
 A PR interval of over 200 ms may indicate a first degree heart block.
 A short PR interval may indicate a pre-excitation syndrome via an
accessory pathway that leads to early activation of the ventricles, such
as seen in Wolff-Parkinson-White syndrome.
 A variable PR interval may indicate other types of heart block.
 PR segment depression may indicate atrial injury or pericarditis.
 Variable morphologies of P waves in a single ECG lead is suggestive
of an ectopic pacemaker rhythm such as wandering pacemaker or
multifocal atrial tachycardia hi

QRT complex

The QRT complex is a structure on the ECG that corresponds to the

depolarization of the ventricles. Because the ventricles contain more muscle
mass than the atria, the QRT complex is larger than the P wave. In addition,
because the His/Purkinje system coordinates the depolarization of the
ventricles, the QRT complex tends to look "spiked" rather than rounded due
to the increase in conduction velocity. A normal QRT complex is 0.06 to
0.10 sec (60 to 100 ms) in duration represented by three small squares or
less, but any abnormality of conduction takes longer, and causes widened
QRS complexes.
Not every QRT complex contains a Q wave, an R wave, and an T wave. By
convention, any combination of these waves can be referred to as a QRS
complex. However, correct interpretation of difficult ECGs requires exact
labeling of the various waves. Some authors use lowercase and capital
letters, depending on the relative size of each wave. For example, an Rt
complex would be positively deflected, while a rS complex would be
negatively deflected. If both complexes were labeled RT, it would be
impossible to appreciate this distinction without viewing the actual ECG.
 The duration, amplitude, and morphology of the QRT complex is
useful in diagnosing cardiac arrhythmias, conduction abnormalities,
ventricular hypertrophy, myocardial infarction, electrolyte
derangements, and other disease states.
 Q waves can be normal (physiological) or pathological. Normal Q
waves, when present, represent depolarization of the interventricular
septum. For this reason, they are referred to as septal Q waves, and
can be appreciated in the lateral leads I, aVL, V5 and V6.
 Q waves greater than 1/3 the height of the R wave, greater than 0.04
sec (40 ms) in duration, or in the right precordial leads are considered
to be abnormal, and may represent myocardial infarction.

RT segment

The RT segment connects the QRT complex and the T wave and has a
duration of 0.08 to 0.12 sec (80 to 120 ms). It starts at the J point (junction
between the QRT complex and RT segment) and ends at the beginning of the
T wave. However, since it is usually difficult to determine exactly where the
ST segment ends and the T wave begins, the relationship between the RT
segment and T wave should be examined together. The typical RT segment
duration is usually around 0.08 sec (80 ms). It should be essentially level
with the PR and TP segment.
 The normal RT segment has a slight upward concavity.
 Flat, downsloping, or depressed ST segments may indicate coronary
ischemia.
  ST segment elevation may indicate myocardial infarction. An
elevation of >1mm and longer than 80 milliseconds following the J-
point. This measure has a false positive rate of 15-20% (which is
slightly higher in women than men) and a false negative rate of 20-
30%.[11]

T wave
The T wave represents the repolarization (or recovery) of the ventricles. The
interval from the beginning of the QRS complex to the apex of the T wave is
referred to as the absolute refractory period. The last half of the T wave is
referred to as the relative refractory period (or vulnerable period).
In most leads, the T wave is positive. However, a negative T wave is normal
in lead aVR. Lead V1 may have a positive, negative, or biphasic T wave. In
addition, it is not uncommon to have an isolated negative T wave in lead III,
aVL, or aVF.
 Inverted (or negative) T waves can be a sign of coronary ischemia,
Wellens' syndrome, left ventricular hypertrophy, or CNS disorder.
 Tall or "tented" symmetrical T waves may indicate hyperkalemia. Flat
T waves may indicate coronary ischemia or hypokalemia.
 The earliest electrocardiographic finding of acute myocardial
infarction is sometimes the hyperacute T wave, which can be
distinguished from hyperkalemia by the broad base and slight
asymmetry.
 When a conduction abnormality (e.g., bundle branch block, paced
rhythm) is present, the T wave should be deflected opposite the
terminal deflection of the QRS complex. This is known as appropriate
T wave discordance.

QT interval

The QT interval is measured from the beginning of the QRS complex to the
end of the T wave. Normal values for the QT interval are between 0.30 and
0.44 (0.45 for women) seconds.[citation needed] The QT interval as well as
the corrected QT interval are important in the diagnosis of long QT
syndrome and short QT syndrome. The QT interval varies based on the heart
rate, and various correction factors have been developed to correct the QT
interval for the heart rate. The QT interval represents on an ECG the total
time needed for the the ventricles to depolarize and repolarize.
The most commonly used method for correcting the QT interval for rate is
the one formulated by Bazett and published in 1920.

U wave

The U wave is not always seen. It is typically small, and, by definition,

follows the T wave. U waves are thought to represent repolarization of the
papillary muscles or Purkinje fibers. Prominent U waves are most often seen
in hypokalemia, but may be present in hypercalcemia, thyrotoxicosis, or
exposure to digitalis, epinephrine, and Class 1A and 3 antiarrhythmics, as
well as in congenital long QT syndrome and in the setting of intracranial
hemorrhage. An inverted U wave may represent myocardial ischemia or left
ventricular volume overload.
Blood Pressure Measurement

Blood pressure (strictly speaking: vascular pressure) refers to the force

exerted by circulating blood on the walls of blood vessels, and constitutes
one of the principal vital signs. The pressure of the circulating blood
decreases as blood moves through arteries, arterioles, capillaries, and veins;
the term blood pressure generally refers to arterial pressure, i.e., the pressure
in the larger arteries, arteries being the blood vessels which take blood away
from the heart. Arterial pressure is most commonly measured via a
sphygmomanometer, which uses the height of a column of mercury to reflect
the circulating pressure (see Non-invasive measurement). Although many
modern vascular pressure devices no longer use mercury, vascular pressure
values are still universally reported in millimetres of mercury (mmHg).
The systolic arterial pressure is defined as the peak pressure in the arteries,
which occurs near the beginning of the cardiac cycle; the diastolic arterial
pressure is the lowest pressure (at the resting phase of the cardiac cycle).
The average pressure throughout the cardiac cycle is reported as mean
arterial pressure; the pulse pressure reflects the difference between the
maximum and minimum pressures measured.
Typical values for a resting, healthy adult human are approximately 120
mmHg (16 kPa) systolic and 80 mmHg (11 kPa) diastolic (written as 120/80
mmHg, and spoken as "one twenty over eighty") with large individual
variations. These measures of arterial pressure are not static, but undergo
natural variations from one heartbeat to another and throughout the day (in a
circadian rhythm); they also change in response to stress, nutritional factors,
drugs, or disease. Hypertension refers to arterial pressure being abnormally
high, as opposed to hypotension, when it is abnormally low. Along with
body temperature, blood pressure measurements are the most commonly
measured physiological parameters.

Indirect Measurement

A sphygmomanometer (often condensed to sphygmometer[1]) or blood

pressure meter is a device used to measure blood pressure, comprising an
inflatable cuff to restrict blood flow, and a mercury or mechanical
manometer to measure the pressure. It is always used in conjunction with a
means to determine at what pressure blood flow is just starting, and at what
pressure it is unimpeded. Manual sphygmomanometers are used in
conjunction with a stethoscope.
The word comes from the Greek sphygmós (pulse), plus the scientific term
manometer (pressure meter). The device was invented by Samuel Siegfried
Karl Ritter von Basch. Scipione Riva-Rocci, an Italian physician, introduced
a more easily used version in 1896. Harvey Cushing discovered this device
in 1901 and popularised it.
A sphygmomanometer usually consists of an inflatable cuff, a measuring
unit (the mercury manometer), a tube to connect the two, and (in models that
don't inflate automatically) an inflation bulb also connected by a tube to the
cuff. The inflation bulb contains a one-way valve to prevent inadvertent leak
of pressure while there is an adjustable screw valve for the operator to allow
the pressure in the system to drop in a controlled manner.

The cuff is normally placed around the upper left arm, at roughly the same
vertical height as the heart while the subject is in an upright position. The
cuff is inflated until the artery is completely occluded. Listening with a
stethoscope to the brachial artery at the elbow, the examiner slowly releases
the pressure in the cuff. As the pressure in the cuffs falls, a "whooshing" or
pounding sound is heard (see Korotkoff sounds) when bloodflow first starts
again in the artery. The pressure at which this sound began is noted and
recorded as the systolic blood pressure. The cuff pressure is further released
until the sound can no longer be heard and this is recorded as the diastolic
blood pressure.
Direct Measurement
Cardiac catheterization (heart cath) is the insertion of a catheter into a
chamber or vessel of the heart. This is done for both investigational and
interventional purposes. Coronary catheterization is a subset of this
technique, involving the catheterization of the coronary arteries.
A small puncture is made in a vessel in the groin, the inner bend of the
elbow, or neck area (the femoral vessels or the carotid/jugular vessels), then
a guidewire is inserted into the incision and threaded through the vessel into
the area of the heart that requires treatment, visualized by fluoroscopy or
echocardiogram, and a catheter is then threaded over the guidewire. If X-ray
fluoroscopy is used, a radiocontrast agent will be administered to the patient
during the procedure. When the necessary procedures are complete, the
catheter is removed. Firm pressure is applied to the site to prevent bleeding.
This may be done by hand or with a mechanical device. Other closure
techniques include an internal suture. If the femoral artery was used, the
patient will probably be asked to lie flat for several hours to prevent bleeding
or the development of a hematoma. Cardiac interventions such as the
insertion of a stent prolong both the procedure itself as well as the post-
catheterization time spent in allowing the wound to clot.
A cardiac catheterization is a general term for a group of procedures that are
performed using this method, such as coronary angiography. Once the
catheter is in place, it can be used to perform a number of procedures
including angioplasty, angiography, and balloon septostomy.

Blood Flow

Blood flow is the flow of blood in the cardiovascular system. The discovery
that blood flows is attributed to William Harvey.
Mathematically, blood flow is described by Darcy's law (which can be
viewed as the fluid equivalent of Ohm's law) and approximately by Hagen-
Poiseuille's law. Blood is an inhomogeneous medium consisting mainly of
plasma and a suspension of red blood cells. White cells, or leukocytes, and
platelets while present in smaller concentrations, play an important role in
biochemical processes, such as immune response, inflammation, and
coagulation. Red cells tend to coagulate when the flow shear rates are low,
while increasing shear rates break these formations apart, thus reducing
blood viscosity.This results in two non-Newtonian blood properties, shear
thinning and yield stress. In healthy large arteries blood can be successfully
approximated as a homogeneous, Newtonian fluid since the vessel size is
much greater than the size of particles and shear rates are sufficiently high
that particle interactions may have a negligible effect on the flow. In smaller
vessels, however, non-Newtonian blood behavior should be taken into
account. The flow in healthy vessels is generally laminar, however in
diseased (e.g. atherosclerotic) arteries the flow may be transitional or
turbulent.

This is important in angioplasty, as it enables the increase of blood flow with

balloon catheter to the deprived organ significantly with only a small
increase in radius of a vessel.

Measurement of Blood Flow

1. Blood flow electromagnetic

Blood flow electromagnetic methods make use of the principle that
movement of a charged particle through an electromagnetic field produces
an emf. Essentially two electrodes are attached along the length of a vessel,
and an electromagnetic field is applied at approximately 90o to the flow. The
emf between the two electrodes can be measured and gives a continuous
result proportional to the flow velocity. The response is governed by uBL,
where u is the velocity (typically 10mm/s), B the magnetic field strength
(typically 0.1T), and L the length between electrodes (10mm). Smaller
vessels will have a lower u, and will be unable to have such a great L,
reducing the signal. Typical voltage signals are in the region of 0.01mV,
which is in the region of the electrode contact potential (which poses a great
problem to the S/N ratio), and interferes with the ECG signal. These
problems however can be reduced by using a 400MHz A.C. signal. The
spatial and depth resolution are better than both previous measurements, and
once the angle of field to flow has been allowed for, it is potentially an
accurate and continuous measurement. The disadvantage of this is that it is
by no means non-invasive, unlike the previous two methods, needing
exposure of a given length of vessel for electrode fitting. This however
makes it suitable for measurements during surgical procedures, especially
coronary bypass or plastic cosmetic surgery.

An electromagnetic blood flow probe for measuring blood flow having at

least two separable and connectable coil segments cooperatively connected
to an appropriate switching device selectively movable from a first position
where the segments are connected to form a single coil having a given
polarity to a second position where the segments are connected separately
with opposite polarities so that the coil segments may be energized to
eliminate or reorient the flux field and reflect an electrical zero without
physically terminating blood flow in a vessel.

2. Ultrasonic (Doppler, Transit Time) flow meters

Ultrasonic flow meters measure the difference of the transit time of

ultrasonic pulses propagating in and against flow direction. This time
difference is a measure for the average velocity of the fluid along the path of
the ultrasonic beam. By using the absolute transit times both the averaged
fluid velocity and the speed of sound can be calculated.

Measurement of the doppler shift resulting in reflecting an ultrasonic beam

off the flowing fluid is another recent innovation made possible by
electronics. By passing an ultrasonic beam through the tissues, bouncing it
off of a reflective plate then reversing the direction of the beam and
repeating the measurement the volume of blood flow can be estimated. The
speed of transmission is affected by the movement of blood in the vessel and
by comparing the time taken to complete the cycle upstream versus
downstream the flow of blood through the vessel can be measured. The
difference between the two speeds is a measure of true volume flow. A wide-
beam sensor can also be used to measure flow independent of the cross-
sectional area of the blood vessel.
For the Doppler principal to work in a flowmeter it is mandatory that the
flow stream contains sonically reflective materials, such as solid particles or
entrained air bubbles.

3. Plethysmography

A plethysmograph is an instrument for measuring changes in volume within

an organ or whole body (usually resulting from fluctuations in the amount of
blood or air it contains).

Use for lungs

Pulmonary plethysmographs are commonly used to measure the functional
residual capacity (FRC) of the lungs -- the volume in the lungs when the
muscles of respiration are relaxed -- and total lung capacity. A typical human
has an FRC of 25mL/kg.
In a traditional plethysmograph, the test subject is placed inside a sealed
chamber the size of a small telephone booth with a single mouthpiece. At the
end of normal expiration, the mouthpiece is closed. The patient is then asked
to make an inspiratory effort. As the patient tries to inhale (a maneuver
which looks and feels like panting), the glottis is closed and the lungs
expand, decreasing pressure within the lungs and increasing lung volume.
This, in turn, increases the pressure within the box since it is a closed system
and the volume of the body compartment has increased.
Boyle's Law is used to calculate the unknown volume within the lungs. First,
the change in volume of the chest is computed. The initial pressure and
volume of the box are set equal to the known pressure after expansion times
the unknown new volume. Once the new volume is found, the new volume
minus the original volume is the change in volume in the box and also the
change in volume in the chest. With this information, Boyle's Law is used
again to determine the original volume of gas: the initial volume (unknown)
times the initial pressure is equal to the final volume times the final pressure.
The difference between full and empty lungs can be used to assess diseases
and airway passage restrictions. An obstructive disease will show increased
FRC because some airways do not empty normally, while a restrictive
disease will show decreased FRC. Body plethysmography is particularly
appropriate for patients who have air spaces which do not communicate with
the bronchial tree; in such patients gas dilution would give an incorrectly
low reading.
Newer lung plethysmograph devices have an option which does not require
enclosure in a chamber.

Use for limbs

Some plethysmograph devices are attached to arms, legs or other extremities
and used to determine circulatory capacity. Impedance plethysmography is a
non-invasive method used to detect venous thrombosis in these areas of the
body.
How to measure high blood pressure?
Principles
5.1 - The most reliable method: to place a probe measuring the pressure
directly in the artery
5.2 - The most useful method: The measure of the blood pressure using a
sphygmomanometer with a cuff
Measurement of the blood pressure
5.3 - At rest at the doctors
5.4 - At rest at home, using a self-measurement device
5.5 - During a physical exercise
5.6 - Measurement by an ambulatory monitoring of the blood pressure
during 24 hours
Description of the device
5.7 - The cuff
5.8 - Method for the measurement of the blood pressure
5.9 - The sphygmomanometer

5.8 - Method for the measurement of the blood pressure: listening

(microphonic), oscillometric or much more rarely
photoplethysmographic.
Once the cuff is inflated, the artery of the arm is compressed and the passage
of the blood is stopped. Then, the cuff is gradually deflated, at on average 2
to 3 millimetres of mercury per second.
During this phase, two phenomena occur:
- Auscultatory method
The noise emitted by the artery changes: when the artery is compressed, the
physician listening with his stethoscope or the microphone which «replaces
the ears» hears no noise. Then, when the pressure decreases in the
cuff, the artery starts to emit a noise: the pressure then measured on the
device defines the maximal blood pressure or systolic blood pressure.
Then, the noise continues to be heard during the decrease of the pressure in
the cuff, until the noise disappears: the pressure then read on the device
defines the minimal blood pressure or diastolic blood pressure.
This method of measurement of the blood pressure is the auscultatory
method. It is used by the physician, but also by an automatic measurement
of the blood pressure device.

Auscultatory method
- Oscillometric method
The pulsations induced by the artery are different: when the artery is
compressed, no pulsation is perceived by the device, then when the pressure
decreases in the cuff, the artery starts to emit pulsations: the pressure then
measured on the device defines the maximal blood pressure or systolic blood
pressure.
During the pressure decrease in the cuff, the oscillations will become
increasingly significant, until a maximum amplitude of these oscillations
defines the average blood pressure.
Then, the oscillations can still be seen during the decrease of the pressure in
the cuff, until they disappear: the pressure then read on the device defines
the minimal blood pressure or diastolic blood pressure.
This method of measurement of the blood pressure is the oscillometric
method. It is very often used in the automatic device for the measurement of
the blood pressure because of its excellent reliability. On the other hand, it is
less precise than the microphonic or auscultatory method. Many devices and
in particular the automatic devices measuring the blood pressure during 24
hours, use the two measurement techniques.
 Oscillometric method
- Photoplethysmographic method
This technique measures the blood pressure at the level of the arteries of the
fingers. A small cuff is inflated around the finger, and the pressure is
maintained constant in the small cuff. Any variation of pressure on the level
of the finger will involve a modification of the pressure in the cuff, which
thus translates it into blood pressure
5.9 - The sphygmomanometer
The pressure existing in the cuff will be transmitted by hollow pipes to a
system which will give a legible blood pressure value. Several devices are
currently available: those that use a mercury column, and those that use a
metal membrane.
- Sphygmomanometer with mercury
 It consists in a mercury column, which can allow the reading
of the blood pressure.
This technique is the oldest and it is for this reason that the
blood pressure unit is the millimetre of mercury. Up to now,
this technique has been the basic method for measuring blood
pressure. The results obtained are highly reliable in a long run,
but the use of mercury will soon be prohibited within the
European Community. It will thus be necessary to think of
solutions for replacement, and to change the unit of
measurement of the blood pressure (millimetre of mercury
replaced by the kilopascal?).
This type of sphygmomanometer is exclusively reserved for the
measurement of the blood pressure at the level of the arm.
- aneroid sphygmomanometer
This type of device does not contain mercury. A metal membrane located in
a case translates the blood pressure transmitted by the cuff. This type of
device is very practical to use and is generally reliable if it is regularly
controlled.

This method constitutes a good alternative to the sphygmomanometer with

mercury, which will be abandoned in a few years.
This device can produce blood pressure at the level of the arm, but also at
the level of the wrist or the finger.
 Cardiac output

Cardiac output (Q) is the volume of blood being pumped by the heart, in
particular by a ventricle in a minute. This is measured in dm3 min-1 (1 dm3
equals 1000cm3).

Cardiac output is equal to the stroke volume (SV) multiplied by the heart
rate (HR). SV is the volume pumped per beat and the HR is the number of
beats per minute. Therefore, if there are 70 beats per minute, and 70 ml
blood is ejected with each beat, (SV), the cardiac output (Q) is 4900
ml/minute. This value is typical for an average adult at rest, although Q may
reach up to 31.97865 litres/minute during extreme exercise by elite athletes.

Measurement of Cardiac Output

Circulation is a critical and variable function of human physiology and

disease. An accurate and non-invasive measurement of Q is the holy grail of
cardiovascular assessment. This would allow continuous monitoring of
central circulation and provide improved insights into normal physiology,
pathophysiology and treatments for disease. Invasive methods are well
accepted, but there is increasing evidence that these methods are neither
accurate nor effective in guiding therapy, so there is an increasing focus on
development of non-invasive methods.
There are a number of clinical methods for measurement of Q ranging from
direct intracardiac catheterisation to non-invasive measurement of the
arterial pulse. Each method has unique strengths and weaknesses and
relative comparison is limited by the absence of a widely accepted “gold
standard” measurement. Q can also be affected by the phase of respiration
with intra-thoracic pressure changes influencing diastolic filling and
therefore Q. This is important especially during mechanical ventilation, and
Q should therefore be measured at a defined phase of the respiratory cycle
(typically end-expiration).

The Fick Principle

The Fick principle was first described by Adolph Fick in 1870 and assumes
that the rate at which oxygen is consumed is a function of the rate of blood
flows and the rate of oxygen pick up by the red blood cells. The Fick
principle involves calculating the oxygen consumed over a given period of
time from measurement of the oxygen concentration of the venous blood and
the arterial blood. Q can be calculated from these measurements:
 VO2 consumption per minute using a spirometer (with the subject re-
breathing air) and a CO2 absorber
 the oxygen content of blood taken from the pulmonary artery
(representing mixed venous blood)
 the oxygen content of blood from a cannula in a peripheral artery
(representing arterial blood)cheers life

From these values, we know that:

VO2 = (Q x CA) - (Q x CV)
where CA = Oxygen concentration of arterial blood and CV = Oxygen
concentration of venous blood. This allows us to say
Q = (VO2/CA - CV)*100
and therefore calculate Q. While considered to be the most accurate method
for Q measurement Fick is invasive and requires time for the sample
analysis, and accurate oxygen consumption samples are difficult to acquire.
There have also been modifications to the Fick method where respiratory
oxygen content is measured as part of a closed system and the consumed
Oxygen calculated using an assumed oxygen consumption index which is
then used to calculate Q. Other modifications use inert gas as tracers and
measure the change in inspired and expired gas concentrations to calculate
Q.
Dilution Method

This method was initially described using an indicator dye and assumes that
the rate at which the indicator is diluted reflects the Q. The method measures
the concentration of a dye at different points in the circulation, usually from
an intravenous injection and then at a downstream sampling site, usually in a
systemic artery. More specifically, the Q is equal to the quantity of indicator
dye injected divided by the area under the dilution curve measured
downstream.

Pulmonary Artery Thermodilution (Trans-right-heart Thermodilution)

The indicator method was further developed with replacement of the
indicator dye by heated or cooled fluid and temperature change measured at
different sites in the circulation rather than dye concentration; this method is
known as thermodilution. The pulmonary artery catheter (PAC), also known
as the Swan-Ganz catheter, was introduced to clinical practice in 1970 and
provides direct access to the right heart for thermodilution measurements.
The PAC is balloon tipped and is inflated to occlude the pulmonary artery.
The PAC thermodilution method involves injection of a small mount (10ml)
of cold saline at a known temperature into the pulmonary artery and
measuring the temperature a know distance away (6-10cm).
The Q can be calculated from the measured temperature curve (The
“thermodilution curve”). High Q will change the temperature rapidly, and
low Q will change the temperature slowly. Usually three or four repeated
measures are averaged to improve accuracy. However it is complex to
perform and there are many sources of inaccuracy in the method. Modern
catheters are fitted with a heating filament which intermittently heats and
measures the thermodilution curve providing serial Q measurement.
PAC use is complicated by infection, Pulmonary artery rupture, cardiac
tamponade, and air embolism. Recent studies suggest use of the PAC is both
dangerous and expensive, and it may not improve patient survival or
treatment. PAC use is in decline as clinicians move to less invasive, more
effective technologies for monitoring haemodynamics.

Doppler Ultrasound Method

This method uses ultrasound and the Doppler effect to measure Q. The blood
velocity through the heart causes a 'Doppler shift' in the frequency of the
returning ultrasound waves. This Doppler shift can then be used to calculate
flow velocity and volume and effectively Q using the following equations:
 Q = SV x HR
 SV = vti x CSA
where:
 CSA = flow cross sectional area from πd²/4
 d = valve diameter
 vti = the velocity time integral of the trace of the Doppler flow profile
Doppler ultrasound is non-invasive, accurate and inexpensive and is a
routine part of clinical ultrasound with high levels of reliability and
reproducibility having been in clinical use since the 1960s.

Echocardiography

Echocardiography uses a conventional ultrasound machine and a combined

two dimensional (2D) and Doppler approach to measure Q. 2D measurement
of the diameter (d) of the aortic annulus allows calculation of the flow CSA
which is then multiplied by the vti of the Doppler flow profile across the
aortic valve to determine the flow volume or SV. Multiplying SV by HR
produces Q. Echocardiographic measurement of flow volume is clinically
well established and of proven accuracy but requires training and skill, and
may be time consuming to perform effectively. The 2D measurement of the
aortic valve diameter is challenging and associated with significant error,
while measurement of the pulmonary valve to calculate right sided Q is even
more difficult.

Transcutaneous Doppler: USCOM

An Ultrasonic Cardiac Output Monitor (USCOM) (Uscom Ltd, Sydney,

Australia) uses Continuous Wave Doppler (CW) to measure the Doppler
flow profile vti, as in echocardiography, but uses anthropometry to calculate
aortic and pulmonary valve diameters so both the right and left sided Q can
be measured. Real time Automatic tracing of the Doppler flow profile allows
for beat to beat right and left sided Q measurement. Importantly this single
method can be used in neonates, children and adults for low and high Q
measurement.
Transoesophageal Doppler: TOD

Transoesophageal Doppler (TOD), also known as esophageal Doppler

monitor (EDM), supports a CW sensor on the end of a probe which can be
introduced via the mouth or nose and positioned in the oesophagus so the
Doppler beam aligns with the descending thoracic aorta (DTA) at a known
angle. Because the transducer is close to the blood flow the signal is clear,
however the alignment, and thus reliable signal, can often be difficult to
maintain during respiration and patient movement. This method has good
validation, particularly for measuring changes in blood flow, but is limited in
that it only measures the DTA flow and not true Q and is therefore
influenced by non-linear changes in Q and SVR. Additionally this method
requires patient sedation and is accepted for use only in adults and large
children.

Pulse Pressure Methods

Pulse Pressure (PP) methods measure the pressure in the arteries over time
to derive a waveform and use this information to calculate cardiac
performance. The problem is that any measure from the artery includes the
changes in pressure associated with changes in arterial function.
Physiologic or therapeutic changes in vessel diameter will be assumed to
reflect changes in Q. Put simply PP methods measure the combined
performance of the heart and the vessels thus limiting the application of PP
methods for measurement of Q. This can be partially compensated for by
intermittent calibration of the waveform to another Q measurement method
and then monitoring the PP waveform. Ideally the PP waveform should be
calibrated beat to beat.
There are invasive and non-invasive methods of measuring PP:

Non-invasive PP – Sphygmomanometer and Tonometry

The sphygmomanometer or cuff blood pressure device was introduced to

clinical practice in 1903 allowing non-invasive measurements of blood
pressure and providing the common PP waveform values of peak systolic
and diastolic pressure which can be used to calculate mean arterial pressure
(MAP). The pressure in the arteries, measured by sphygmomanometry, is
often used as a guide to the function of the heart. Put simply, the pressure in
the heart is conducted to the arteries, so the arterial pressure approximately
reflects the function of the heart or the Q.
 The pressure in the heart rises as blood is forced into the aorta
 The more stretched the aorta, the greater the pulse pressure (PP)
 In healthy young subjects, each additional 2 ml of blood results in a 1
mmHg rise in pressure
 Therefore:
SV = 2 ml × Pulse Pressure
Q = 2 ml × Pulse Pressure × HR
By resting a more sophisticated pressure sensing device, a tonometer, against
the skin surface and sensing the pulsatile artery, continuous PP wave forms
can be acquired non-invasively and analysis made of these pressure signals.
Unfortunately the heart and vessels can function independently and
sometimes paradoxically so that changes in the PP may both reflect and
mask changes in Q. So these measures represent combined cardiac and
vascular function only. Another similar system that uses the arterial pulse is
the pressure recording analytical method (PRAM).

Invasive PP

Invasive PP involves inserting a manometer (pressure sensor) into an artery,

usually the radial or femoral artery and continuously measuring the PP
waveform. This is usually done by connecting the catheter to a signal
processing and display device. The PP waveform can then be analyzed to
provide measurements of cardiovascular performance. Changes in vascular
function or the position of the catheter tip will affect the accuracy of the
readings. Invasive PP measurements can be calibrated or uncalibrated.

Impedance cardiography
Impedance cardiography (ICG) is a method which calculates Q from the
measurement of changes in impedance across the chest over the cardiac
cycle. Lower impedance indicates greater the intrathoracic fluid volume, and
as the only fluid volume which changes beat to beat within the thorax is the
blood, the change in impedance can be used to calculate the SV and,
combined with HR, the Q. This technique has progressed clinically (often
called BioZ, i.e. biologic impedance, as promoted by the leading
manufacturer in the US) and allows non-invasive estimations of Q and total
peripheral resistance using only 4 paired skin electrodes.
While the method is desirably non-invasive and inexpensive, it has not
achieved the reliability and reproducibility required of a useful clinical tool,
and the evolution of algorithms to convert impedance signals to Q across a
variety of outputs and in a variety of diseases continues.

Magnetic Resonance Imaging

Velocity encoded phase contrast Magnetic Resonance Imaging (MRI) is the

most accurate technique for measuring flow in large vessels in mammals.
MRI flow measurements have been shown to be highly accurate compared
to measurements with a beaker and timer and less variable than both the Fick
principle and thermodilution.
Velocity encoded MRI is based on detection of changes in the phase of
proton precession. These changes are proportional to the velocity of the
movement of those protons through a magnetic field with a known gradient.
When using velocity encoded MRI, the result of the MRI scan is two sets of
images for each time point in the cardiac cycle. One is an anatomical image
and the other is an image where the signal intensity in each pixel is directly
proportional to the through-plane velocity. The average velocity in a vessel,
i.e. the aorta or the pulmonary artery, is hence quantified by measuring the
average signal intensity of the pixels in the cross section of the vessel, and
then multiplying by a known constant. The flow is calculated by multiplying
the mean velocity by the cross-sectional area of the vessel. This flow data
can be used to graph flow versus time. The area under the flow versus time
curve for one cardiac cycle is the stroke volume. The length of the cardiac
cycle is known and determines heart rate, and thereby Q can be calculated as
the product of stroke volume and heart rate. MRI is typically used to
quantify the flow over one cardiac cycle as the average of several heart
beats, but it is also possible quantify the stroke volume in real time on a
beat-for-beat basis.
While MRI is an important research tool for accurately measuring Q, it is
currently not clinically used for hemodynamic monitoring in the emergency
or intensive care setting. Cardiac output measurement by MRI is currently
routinely used as a part of clinical cardiac MRI examinations.
 Measurement of HEART Sound
1. Stethoscope

The stethoscope is an acoustic medical device for auscultation, or listening

to, internal sounds in a human or animal body. It is most often used to listen
to heart sounds and breathing. It is also used to listen to intestines and blood
flow in arteries and veins. Less commonly, "mechanic's stethoscopes" are
used to listen to internal sounds made by machines, such as diagnosing a
malfunctioning automobile engine by listening to the sounds of its internal
parts. It can also be used to leak check vacuum chambers for scientific
purposes.

Types of stethoscopes
Acoustic

Acoustic stethoscopes are familiar to most people, and operate on the transmission of
sound from the chestpiece, via air-filled hollow tubes, to the listener's ears. The
chestpiece usually consists of two sides that can be placed against the patient for sensing
sound — a diaphragm (plastic disc) or bell (hollow cup). If the diaphragm is placed on
the patient, body sounds vibrate the diaphragm, creating acoustic pressure waves which
travel up the tubing to the listener's ears. If the bell is placed on the patient, the vibrations
of the skin directly produce acoustic pressure waves traveling up to the listener's ears.
The bell transmits low frequency sounds, while the diaphragm transmits higher frequency
sounds. This 2-sided stethoscope was invented by Rappaport and Sprague in the early
part of the 20th century. One problem with acoustic stethoscopes was that the sound level
is extremely low. This problem was surmounted in 1999 with the invention of the
stratified continuous (inner) lumen, and the kinetic acoustic mechanism in 2002. Acoustic
stethoscopes are the most commonly used.

Electronic
An electronic stethoscope (or stethophone) overcomes the low sound levels by
electronically amplifying body sounds. However, amplification of stethoscope contact
artifacts, and component cutoffs (frequency response thresholds of electronic stethoscope
microphones, pre-amps, amps, and speakers) limit electronically amplified stethoscopes'
overall utility by amplifying mid-range sounds, while simultaneously attenuating high-
and low- frequency range sounds. Currently, a number of companies offer electronic
stethoscopes, and it can be expected that within a few years, the electronic stethoscope
will have eclipsed acoustic devices.
Electronic stethoscopes require conversion of acoustic sound waves to electrical signals
which can then be amplified and processed for optimal listening. Unlike acoustic
stethoscopes, which are all based on the same physics, transducers in electronic
stethoscopes vary widely. The simplest and least effective method of sound detection is
achieved by placing a microphone in the chestpiece. This method suffers from ambient
noise interference and has fallen out of favor. Another method, used in Welch-Allyn's
Meditron stethoscope, comprises placement of a piezoelectric crystal at the head of a
metal shaft, the bottom of the shaft making contact with a diaphragm. 3M also uses a
piezo-electric crystal placed within foam behind a thick rubber-like diaphragm.
Thinklabs' Rhythm 32 inventor, Clive Smith uses a stethoscope diaphragm with an
electrically conductive inner surface to form a capacitive sensor. This diaphragm
responds to sound waves identically to a conventional acoustic stethoscope, with changes
in an electric field replacing changes in air pressure. This preserves the sound of an
acoustic stethoscope with the benefits of amplification.
Because the sounds are transmitted electronically, an electronic stethoscope can be a
wireless device, can be a recording device, and can provide noise reduction, signal
enhancement, and both visual and audio output. Around 2001, Stethographics introduced
PC-based software which enabled a phonocardiograph, graphic representation of
cardiologic and pulmonologic sounds to be generated, and interpreted according to
related algorithms. All of these features are helpful for purposes of teaching.

Noise reduction
More recently, ambient noise filtering has become available in some
electronic stethoscopes, with 3M's Littmann 3000 and Thinklabs ds32a
offering methods for eliminating ambient noise. In acoustic stethoscopes
ambient noise filtering is available in DRG (R. Deslauriers) external noise
reducting models, and Magna Fortis (M. Werblud) acoustic noise canceling
stethoscope models.

Recording stethoscopes
Some electronic stethoscopes feature direct audio output that can be used with an external
recording device, such as a laptop or MP3 recorder. The same connection can be used to
listen to the previously-recorded auscultation through the stethoscope headphones,
allowing for more detailed study for general research as well as evaluation and
consultation regarding a particular patient's condition and telemedicine, or remote
diagnosis. .

2. Phonocardiogram

Graphical representation of heart sound obtained by a machine called phonocardiogram.

A record of the heart sounds made by means of a phonocardiograph. Phonocardiogram,
of the sounds and murmurs produced by the contracting heart, including its valves and
associated great vessels. The phonocardiogram is obtained either with a chest microphone
or with a miniature sensor in the tip of a small tubular instrument that is introduced via
the blood vessels.
3. Auscultation

Auscultation is the act of listening, with a stethoscope, to sounds made by

the heart, lungs, and blood. It is performed as one of the initial and very
important steps in cardiac diagnosis.

Aortic phenomena include 'sounds,' which are brief vibrations caused by

momentary events, and 'murmurs,' which are the sound of turbulence as
blood flows through some narrow orifice or tube. The two sounds heard in
everyone are the first sound (S1 or 'lub,' in lub-dub) caused by closing of the
mitral and tricuspid valve as the ventricles begin to contract and pump blood
into the aorta and pulmonary artery. The second sound (S2 or 'dub') is caused
when the ventricles finish ejecting, begin to relax, and allow the aortic and
the pulmonary valves to close.

One approach for analyzing heart sounds is to record them using a

microphone and to then display the electrical signals graphically. This is
called a phonocardiogram, in which the x-axis represents time and the y-axis
voltage (which is a measure of the intensity of sound). The picture below
shows a simple phonocardiogram of four heartbeats. The first and second
sounds of the first heartbeat are labeled. In our laboratory exercises, this type
of display is used to help you identify problems associated with abnormal
heart sounds.