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Regulation of Cardiac Output

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The Heart and Circulation

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Abstract

Models are used to simplify a group of observable events into readily understandable concepts. Over the years, numerous models of circulation have been developed in an effort to elucidate fundamental hemodynamic principles. They attest to the ingenuity on the part of the investigators but also point to the complexity of the subject at hand. Because the heart is the organ which is thought to provide the total hydraulic energy to the blood, the idea of the heart as a pressure-generating pump is implicit in most commonly used models. Just how much of a role the heart plays in blood propulsion and the relative contribution of the peripheral circulation in the regulation of cardiac output is a matter of ongoing debate. Because of the multitude of factors which contribute to the regulation of cardiac output, the subject will be approached from the two commonly used perspectives: that of the heart and of the peripheral circulation. The left ventricular (LV) view purports that the heart is the sole source of blood propulsion and hence the principal controller of cardiac output. Guyton’s “venous return” (VR) model posits, on the contrary, that the peripheral circulation is the main determinant of cardiac output and the heart plays a secondary role. LV and VR views are reviewed and critiqued for their conceptual and methodological inconsistencies. Trends in the pharmacologic therapy of heart failure and the declining use of intra-aortic balloon pumps speak in favor of the peripheral circulation as the principal determinant of cardiac output.

The subject of cardiac output regulation is so important that all possible analytical approaches to its understanding deserve widespread support and exploration.

Arthur Guyton (1979)

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Notes

  1. 1.

    Like Aristotle, Galileo still considered that circular motion is primary. Descartes and later Newton challenged this idea and held that linear motion was primary. For contemporary discussion on the problem of circular motion, see [14].

  2. 2.

    According to the prevailing theory, venous blood was manufactured from the nutrients in the liver and flowed to the periphery where part of it “coagulated” into organs and tissues (see Fig. 15.4). Harvey proposed the existence of the capillaries which were first observed by Malphigi in 1660, 3 years after Harvey’s death.

  3. 3.

    It is implicit in Descartes’ inductive method that the external world we experience and perceive by the senses is simply an extension, “res extensa” of pure mathematical and geometrical concepts. Descartes’ miraculous mathematical science, scientia mirabilis, opened up new avenues for scientific exploration and technological inventions, but proved detrimental to large areas of scientific inquiry that cannot be captured by mathematics [18]. For further discussion on the significance of the method of science in cardiovascular physiology see Chap. 25.

  4. 4.

    Pascal set out to solve the problem originally raised by Galileo Galilei (1564–1642) in 1638 on the limits of performance of suction pumps that could raise water only about 10 m. Galileo believed that this experiment contradicts Aristotle’s theory of the non-existence of vacuum in nature, i.e., “nature abhors vacuum”. Three years (1641) later Evangelista Torricelli (1608–1648) demonstrated the rise of mercury in evacuated tube and discovered the barometer (Torricellian vacuum). Torricelli ascribed the difference of height between mercury and water column to vacuum and to weight of air pressing on the liquid. Lacking theoretical proof, however, the experiment went unnoticed until Pascal demonstrated in 1647, in a series of ingenious experiments, that fluids rise in evacuated tubes because of the surrounding air, worked out the mathematics of atmospheric pressure and confirmed the existence of vacuum. Twice, on September 23 and 24, 1647 Pascal discussed the existence of vacuum and the concept of fluid pressure with Descartes [20].

  5. 5.

    Well known is Pascal’s reflection that, “the heart has its reasons that reason knows not of…Do you love by reason?” A further consequence of this paradigm was a denial of feeling life to animals and sanctioning of vivisection in animal experimentation.

  6. 6.

    It is noteworthy that over the last 50 years the traditional (positivistic) interpretation of Harvey’s research has been revised by a number of scholars that have adopted a more nuanced approach toward Harvey’s scientific works (see [14,15,16]). It appears that some of the better-known Harvey biographers of the nineteenth and twentieth centuries regarded Harvey’s “forays into cosmic philosophy as the lesser side of his genius,” while seeking to present him as a rational man, whose empirical research proceeded in a logical manner toward the “great” truth, i.e., the discovery of the circulation.

  7. 7.

    The assumption of a linear relation between pressure and flow (as predicted by Ohm’s law) is likewise employed in the mathematical analysis of the arterial pressure and flow waveforms. In place of peripheral resistance (used in steady flow), the concept of (arterial) input impedance is used in oscillatory flow. In analogy with the oscillating (electrical) current, sinusoidal signals of arterial pressure (power spectrum) and flow can be directly related through Fourier transformation [29]. See also Sect. 22.2.

  8. 8.

    Personal note to C. Wiggers, book inscription, photocopy with the author.

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  1. Professor of Anesthesiology, Albany Medical College, Albany, NY, USA

    Branko Furst MD, FFARCSI

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Furst, B. (2020). Regulation of Cardiac Output. In: The Heart and Circulation. Springer, Cham. https://doi.org/10.1007/978-3-030-25062-1_14

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