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S, is the loudest and longestheart sound and can continue into early ejection. 2. Rapidventricular ejection (100 milliseconds). The aortic valve is open and most of ejection occurs (Figure I-4-9). ('z -- t Figure l-4-9. Rapid ventricular ejection. a. Left ventricular pressure rises above the aortic pressure,opening the aortic valve; in fact, aortic valve opening defines the beginning of ventricular ejection. Left ventricular pressurecontinuesto rise at a slower rate until maximum left ventricular pressure(= 120 mm Hg) is reached.

A reduction in left ventricular compliancedue to hypertrophy or infarction). 40 Physiology lso. Filling Atrial lso. Ejection systole Vol. E - Left ventr'icular presriure Aortic pressure $60 (L 40 Atrial p ressure I " t , " I" f ' f 20 8 4oo-J- c-' . X a 500-1 t t o a i \-V a ! '( Mitral Aortic Tricuspid PulmonaryI 1t ,,i, lntri,:ularoutflow f-:\ l_ 4th i4, \I . a ' \ E soo-l€rzo \ t ( Ar Jtr 2nd I Left ventricular volume Atrial volume '\-- Heart sounds 3rd E Open valves I Closed valves I 0 . 06 0 .

T:'lf: i 3. The Fick method is most accuratewhen the cardiac output is low and the arteriovenous difference in orygen concentration is high. DETERMINANTS OFCARDIAC PERFORMANCE The performance of the heart is determined by three factors: preload, afterload, and inotropic state (contractility). A. Preload. A fundamental property of cardiac muscle is that the force of contraction is determined by the initial stretch on the myocardial fibers, or preload. When applied to the whole heart, this relationship between the force of contraction and preload is referred to as the Starling law of the heart and is best illustrated by plotting ventricular peak systolic pressureas a function of ventricular end-diastolic volume (EDV), to give the peak systolic pressure-volume curve (Figure I-4-12).

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