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Introduction Vital organs functions are related to adequate perfusion of oxygen and nutrients Maintenance of the blood supply to vital organs during postural change is complex and involve several systems (Neuro, Cardiac, Endocrine,

  2. Introduction • Vital organs’ functions are related to adequate perfusion of oxygen and nutrients • Maintenance of the blood supply to vital organs during postural change is complex and involve several systems (Neuro, Cardiac, Endocrine, Renal and vascular) • Upright posture represents a challenge to human vascular system • Cardiac blood output needs a balanced pre load, myocardial muscle contractility and arterial after load

  4. Circulation

  5. Cerebral flow in relation to Systolic Blood Pressure

  6. Gravity effect on Intravascular Plasma distribution

  7. Mechanical and Baroreptors

  8. Renin- Angiotensin- Aldosterone System (RAAS)

  9. Muscular-Venous pumps

  10. Negative Intra thoracic pressure with Inspiration

  11. Neurocardiogenic Syncope Precipitating Events • Standing Stationary • Dehydration • Hot Room • Viral Illness • Urination • Sight of Blood • Pain • Emotional Stress

  12. Types of syncope • reflex (neurally-mediated) syncope • vasovagal • carotid sinus syndrome • orthostatic hypotension • Partial seizures • Psychiatric

  13. Increased Venous Return to the Heart leads to improve Cardiac Output and Blood Pressure

  14. The physiological Hemodynamic Head up Tilt Table Test (HUTT)

  15. Conventional tilt table test started in mid 1980’s

  16. Continuous BP monitor

  17. More physiologic parameters HUTT

  18. Trans- thoracic impedance to measure Stroke volume(SV)

  19. CNsystem Task Force monitor

  20. HUTT in our center

  21. Typical screen display during monitoring

  22. Neurally Mediated Syncope Tilt Test Responses “ Vasopressor ” “ Cardioinhibitory ” “ Vasovagal ” Hypotension w/o Hypotension & Bradycardia Bradycardia Bradycardia Sympathetic Vagal Sympathetic Vagal Vasodilation HR Vasodilation HR HR AV Block

  23. Vasodepressor response

  24. Postural Orthostatic Tachycardia Syndrome (POTS)

  25. Mixed POTS and Vasodepressor Sutton and Bloomfield Am J Cardiol 84, 1999

  26. Cardio-inhibitory Response

  27. POTS with decreased Stroke Volume

  28. Cardiac asystole during HUTT

  29. Near Infra Red Regional Saturation (NIRS)

  30. NIRS of the Bilateral Head, upper muscles (Deltoid) and lower muscles (Calf)

  31. Cerebral Perfusion in Normal subject depicted by NIRS Channel 1: NIRS of right cerebral hemisphere Channel 1: NIRS of left cerebral hemisphere

  32. Cerebral Perfusion in “Syncope” subject depicted by NIRS Channel 1: NIRS of right cerebral hemisphere Channel 1: NIRS of left cerebral hemisphere

  33. Brain NIRS in two different patients with more severe symptoms during HUTT

  34. Heart rate variability during HUTT

  35. Sympathetic and parasympathetic tones during different stages of HUTT Patient 1 Patient 2

  36. EEG Recording in Neurocardiogenic Syncope E. Vicenzini a S. Pro a S. Strano b P. Pulitano a M. Altieri a V. Di Piero a G.L. Lenzi a N. Accornero a O. Mecarelli More abundant and pronounced delta-theta activities and alpha slowing were found in patients than in control subjects

  37. Summary • Adequate blood perfusion of vital organs is necessary to maintain their functions • Blood/Plasma volume significantly affected by gravitational forces • Circulation and perfusion is tightly controlled by neuro-hormonal mechanisms involved sympathetic/parasympathetic tone, Renin- Angiotensin-Aldosterone system, Baro and mechanical receptors, negative chest pressure and musculoskeletal pumps. • Derangement of this tight control can involve one system or multiple systems. • In evaluating these derangements, it is important to study the hemodynamic and autonomic nervous system. • Treatment of these derangements should be directed towards the defected physiology

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