Impedance cardiography: Pulsatile blood flow and the biophysical and electrodynamic basis for the stroke volume equations

Donald P Bernstein


Impedance cardiography (ICG) is a branch of bioimpedance pimarily concerned with the determination of left ventricular stroke volume (SV). As implemented, using the transthoracic approach, the technique involves applying a current field longitudinally across a segment of thorax by means of a constant magnitude, high frequency, low amplitude alternating current (AC). By Ohm's Law, the voltage difference measured within the current field is proportional to the electrical impedance Z (Ω). Without ventilatory or cardiac activity, Z is known as the transthoracic, static base impedance Z0. Upon ventricular ejection, a characteristic time dependent cardiac-synchronous pulsatile impedance change is obtained, ΔZ(t), which, when placed electrically in parallel with Z0, constitutes the time-variable total transthoracic impedance Z(t). ΔZ(t) represents a dual-element composite waveform, which comprises both the radially-oriented volumetric expansion of and axially-directed forward blood flow within both great thoracic arteries. In its majority, however, ΔZ(t) is known to primarily emanate from the ascending aorta. Conceptually, commonly implemented methods assume a volumetric origin for the peak systolic upslope of ΔZ(t), (i.e. dZ/dtmax), with the presumed units of Ω·s-1. A recently introduced method assumes the rapid ejection of forward flowing blood in earliest systole causes significant changes in the velocity-induced blood resistivity variation (Δρb(t), Ωcm·s-1), and it is the peak rate of change of the blood resistivity variation dρb(t)/dtmax (Ωcm·s-2) that is the origin of dZ/dtmax. As a consequence of dZ/dtmax peaking in the time domain of peak aortic blood acceleration, dv/dtmax (cm·s-2), it is suggested that dZ/dtmax is an ohmic mean acceleration analog (Ω·s-2) and not a mean flow or velocity surrogate as generally assumed. As conceptualized, the normalized value, dZ/dtmax/Z0, is a dimensionless ohmic mean acceleration equivalent (s-2), and more precisely, the electro-dynamic equivalent of peak aortic reduced average blood acceleration (PARABA, d<v>/dtmax/R, s-2). As necessary for stroke volume calculation, dZ/dtmax/Z0 must undergo square root transformation to yield an ohmic mean flow velocity equivalent. To compute SV, the square root of the dimensionless ohmic mean acceleration equivalent ([dZ/dtmax/Z0]0.5, s-1) is multiplied by a volume of electrically participating thoracic tissue (VEPT, mL) and left ventricular ejection time (TLVE, s). To find the bulk volume of the thoracic contents (i.e. VEPT), established methods implement exponential functions of measured thoracic length (L(cm)n) or height-based thoracic length equivalents (0.01×%H(cm)n). The new method conceptualizes VEPT as the intrathoracic blood volume (ITBV, mL), which is approximated through allometric equivalents of body mass (aMb). In contrast to the classical two-element parallel conduction model, the new method comprises a three-compartment model, which incorporates excess extra-vascular lung water (EVLW) as a component of both Z0 and VEPT. To fully appreciate the evolution and analytical justification for impedance-derived SV equations, a review of the basics of pulsatile blood flow is in order.


Impedance cardiography, stroke volume, cardiac output, dZ/dtmax, acceleration, volume conductor, extravascular lung water

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