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STROKE

VOLUME

AND

CARDIAC

OUTPUT

BY

NO.

744

(C-5)

ECHOCARDIOGRAPHY

by
Benedict
Kingsley,
M.Sc.
Research
Associate
Professor
of Medicine
Hahnemann
Medical
College
& Hospital
Philadelphia,
Pennsylvania

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1970

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STROKE

VOLUME

AND

CARDIAC

OUTPUT

BY

ECHOCARDIOGRAPHY

B Y

Research

Benedict
Kingsley,
M. Sc.
Associate
Professor
of Medicine

Hahnemann

Medical

Philadelphia,

College

& Ilospital

Pennsylvania

19102

INTRODUCTION
The

advent

of

open-heart

surgery

has

accentuated

the

need

for

more

accurate

evaluation

of the ability
of the heart to provide
adequate
blood flow.
The single most important
factor
in evaluating
the performance
of the heart is the cardiac
output measured
in liters per
minute.
Cardiac
output
is a significant
clinical
entity
in evaluating
the performance
of
p_osthetic
cardiac
valves,
in monitoring
the restoration
of myocardial
attach patients
and in identifying
the hyperkinetic
(high-flow
state)
youngsters

cardiac

in innocent

murmurs.

The diagnosis
of low
output
rather than

cardiac
output usually
its direct measurement.

the estimation
of cardiac
output,
but most
are not applicable
to bedside
monitoring.
indirect
technique

estimations
contains

Presently,
conjunction
with

function
in heart
heart
syndrome
in

based
inherent

on various
errors

physical

which

rests on recognition
of the
Many
techniques
have been

of these
(1) All

must

the Fick principle

and the
intracardiac
catheterization

and
be

involve
cardiac

venous
output

mathematical

determined

and

indicator-dilution
are the accepted

effects
of low
developed
for

and arterial
measurement

assumptions.

punctures
techniques
Therefore,

and
are
each

minimized.
techniques
standards

utilized
in
for measuring

the

cardiac
output.
The Fick principle
is based on the fact that during its passage
through
the
peripheral
tissues,
a certain
amount
of oxygen
is taken up from the blood.
The limitations
of this

method

are

the

sampling
of pulmonary
oxygen
concentrations.
of an indicator
into
This

technique

tion

and pulsatile

difficulty

of

obtaining

accurate

samples

of expired

air,

the need

for

artery blood,
and the time-consuming
analysis
of expired
air and blood
The indicator
or dye-dilution
technique
involves
the rapid
injection
the circulation,
with down stream
analysis
of its dilution
concentration.

assumes
flow

perfect

mixing

of

the

dye

in its

dilution

volume

and

neglects

effects.

Echocardiography
is a simple,
non-invasive
bedside
technique
based
ultrasonic
waves for measuring
and monitoring
cardiac
output.
(2)

on

reflected

recircula-

MEASUREMENT

AND

Prior
measurement

APPARATUS

to the

clinical

of cardiac

application

output,

in the laboratory
to demonstrate
the
non-invasive
technique
of ultrasound.
Figure

1 shows

the

Starr-Edwards
prosthetic
means
for measuring
the
head-on

to the

analog

Figure
gate.

valve

remains

the
the

valve

in vitro

feasibility
(3)

apparatus

in order

to insure

open

and

the pump

used

steady

flow

rate.

that

the total

flow

through

the

Assuming

conditions

for

(Figure

to the
1) was

of measuring

the

flow

velocity

set up

flow

of water

of the

each

ball

by

the

through

is being

Actual

the

ball

moves

stroke

of the

pump,

AVToR
1000

hydraulic area in cm 2

linear

To

time valve

pump rate

valve

in

Flow

at the

same

the entire
time the valve
as described
below.

recorded.

flow

velocity

remains

in

open

the

velocity

remains

as

open,

equation

cm/sec.

in sec.

liters/minute.
by ultrasound
The percentage

TABLE
p/min

that

Table 1 compares
the flow measured
the stop watch and graduated
cylinder.
satisfactory
for in vive
applications.

rate

accuracy

to measure

flow conditions
exist for
from the direct recording

where

Pump

and

technique

system

cardiac
valve.
The graduated
cylinder
and stop watch
provide
a
actual
flow.
The transducer
of the ultrasonoscope
is positioned

fluid and that steady

flow can be determined

the

echocardiographic

cardiovascular

2 shows the waveform

representing
the motion
of the ball as recorded
through
an
This direct
recording
supplies
the opening
velocity
of the ball,
the time the

Assuming

gives

of the

a simulated

l/min

with the actual

flow measured
with
error falls within
+
10% which is

Flow

by

Ultrasound

1/min

Percent

Error

32.2

0.87

0.83

-4.60

37,9
43.4

1.03
1,19

1.02
1.19

-0.97
0.00

49.5
54,5

1.39
1.52

1.41
1.54

+1.44
+1.32

59.6
66.0

1,68
1.90

1.66
1.72

-1.19
-9.46

79.0

2,58

2.80

+8.54

99.1

3.22

2.90

-9.94

-2-

CLINICAL

APPLICATIONS

Eehocardiography
when
for measuring
stroke volume
basic
hydraulic
equation

applied
to man provides
a non-invasive
reproducible
and cardiac
output.
Stroke volume
is computed
by

where

AVT

mitral valve cross-sectional

blood

velocity

duration
o

This
ventricle
velocity
the left

formula

assumes

is equal

of opening
of
ventricle
and

remains
open.
is assumed
to

elapsed

from

Cardiac

point
output

D
is

flow

of

of blood

normal
(4)

echocardiogram

opening
velocity
of the
to V and is measured
in

flow across

blood

ejected

mitral

valve

of mitral

valve

anterior
cm/sec.

mitral valve
The duration

(beginning

of mitral

computed

the mitral

(diastolic filling

the

across
into

aorta

in

area

is

valve

in most

shown

liters/min,

opening)

from

the

left

that

the

blood filling
time the valve

3.

textbooks

(5)

Tile

by slope of DE corresponds
corresponds
to time

to point

stroke

the

beat,

physiology

in Figure

leaflet
as represented
of mitral
valve
opening

valve

into

for each

as that of the
for the entire

as stated

motion

valve

time) in seconds

the mitral
the

area _n cm 2

cm/sec.

the mitral
valve leaflets
is the same
that a steady flow condition
prevails

The average
be
5 cm 2.

A typical

that

to the volume

of

in

technique
utilizing
the

volume,

(mitral
F,

valve

utilizing

closure).
the

formula

C. O.
assuming
In
cardiac

a regular
case of
output.

In vivo,
cardiac
measured

heart

the

cardiac

lmmo-dialysis.
In these
were within
10%.

BEATS
MIN.

stroke

volumes

rate.

arrhythmia

catheterization.
by dye dilution

F
1000

addition

output

of

of 100

all

patients

Typical
results
are
studies
in 7 patients
7 patients,

the

read

shown
with

cardiac

-3-

in

within

in Table
implanted

outputs

done

one

15%

minute

will

of outputs

also

yield

measured

at

II.
Cardiac
output was also
arterio-venous
shunts
for
simultaneously

by ultrasound

CARDIAC

Ultrasonic Output

OUTPUT

_AS_E_NTS

Dye Dilution Output

Difference

(L/min)

(L/min)

7.5
6.7

7.8
6.5

-3.9
+3.0

5.7
5.7

6.2
5.4

+8.0
+5.5

5.4
4.9

5.0
5.2

4-8.0
-5.8

4.8
4.6

4.5
4.0

-6.6
+15.0

4.7
4.6

4.3
4.5

+9.3
+2.2

4.6
4.4

4.5
4.9

+ 2,2
-14.3

4.2
3.7

4.2
3.4

0.0
+9.1

3.4

3.4

3.3
7,7
8.7

3.7
7.5
8.5

-10.8
+2.6
+2.3

8.1

8.3

-2.4

7,5
3.4
4.2

7.8
3.4
4.9

-3.8
0.0
-14.3

11.2

0.0

1]..5

- 2.6

SUMbiARY

the

Echocardiography
is a non-invasive,
diagnostic
technique
of proven
value
output of the heart.
1N VITRO,
the validity
of this ultrasonic
technique

firmedemployingapulsatilepump,

rubbertubingandaSTARR-EDW_DSprostheticvalve.

in estimating
has been conIN

IVO, the cardiac

output read within
]5% of outputs
measured
at cardiac
catheterization.
This
bedside
technique
may also be valuable
in monitoring
the restoration
of myocardial
function
in heart
attack patients
and in evaluating
the performance
of prosthetic
cardiac
valves
eliminating

the

need

for

cardiac

catheterization

-4-

in many

cases.

REFERENCES

1.

Berne, R.M. and Levy, M.N.:

Cardiovascular
The C.V. Mosby Company,
Saint Louis, 1967,

Physiology.
pp.80-81;
170-174.

2.

Bell, D.S. and Kingsley, B.:

Ultrasonic Measurement
of Flow
Through A Prosthetic Mitral Valve .
Proceedings
of the 8th
International
Conference
on Medical
and Biological
Engineering,
Chicago,
Illinois.
July, 1969.

3.

Bell, D.S.:
Mitral Valve
School, Penn

4.

Gorlin, R. and Gorlin,

S.G.:
Ilydraulic Formula For Calculation
Of The Area Of The Stenotic Mitral Valve, Other Cardiac Valves,
and Central Circulatory
Shunts.
American Heart Journal, 41: 1-27,
January,
1951.

5.

Kingsley, B., Flint, G., Jr., Raber, G., and Segal, Bo: Another
Look at Echocardiography
(Concepts
in Biomedical
Engineering).
Am. J. Cardiol., January,
1967.

Evaluation
of the Performance
of the Starr-Edwards
by Ultrasound.
Master's
Degree Thesis, The Graduate
State University,
March,
1969.

SYSTEM FOR DETERMINING FLOW BY ULTRASOUND

MEASURING FILLING TIME OFA KNOWN VOLUME

AND BY

Transducer

Ball Valve

__UltraI
/ sonoscopeJ

FIGURE

i_i

FIGURE

rE
_.---Diastolic
/

Filling

Period (To)---_

Upstroke

ECHO
I11O

t
CLOSED

INITIAL
OPENING

FIGURE

FULL
OPENING

CLOSED