The motivation behind early studies of ventricular function curves was the desire to identify intrinsic ventricular contractile function. Classic Starling function curves shift down with increased afterload [
3] without a change in contractility of the heart [
4]. Therefore, modifications to ventricular function curves were considered. In some versions “output” was changed to stroke work or stroke work per minute (stroke power) [
5]. Stroke work incorporates afterload since it is pressure afterload × stroke volume. In some versions “input” was changed to end-diastolic volume [
6]. This addressed the issue of non-linear diastolic compliance [
5]. Probably the zenith of modifications to ventricular function curves is the concept of preload recruitable stroke work [
7]. When stroke work is plotted against end-diastolic volume the relationship is highly linear and fairly insensitive to loading conditions. The slope of this relationship is a measure of ventricular contractility [
7]. These modified ventricular function curves are more specific for intrinsic ventricular contractile function but fall short of perfect. Because of different strengths and weaknesses, different variants of ventricular pump function inputs and outputs can be chosen strategically to address specific questions. In a clinical context central venous pressure (right ventricular end-diastolic pressure) and cardiac output are readily measurable and are often most appropriate.
Alternative approaches to measurement on intrinsic myocardial contractility included consideration of the rate of change of ventricular chamber pressure during isovolumic systole—before “afterload” is seen by the contracting ventricle. The maximum rate of change of ventricular pressure, dP/dt
max, occurs late in isovolumic systole and increases when contractility is increased [
8] (for example, by addition of adrenergic agents or calcium). While dP/dt
max avoids the problem of afterload effect, dP/dt
max is sensitive to changes in preload. Not surprisingly, when isovolumic contraction starts at a greater end-diastolic volume (V
ED) then dP/dt
max is greater. Therefore, empirical corrections have been applied. (dP/dt
max)/V
ED is another adjusted measure of ventricular contractile function [
9]. An interesting extension relates these isovolumic pressure measurements to sarcomere shortening. Vmax [
6], the maximum rate of sarcomere shortening, was calculated by considering units of cardiac muscle (sarcomeres) to be made up of a contractile element and a linear series elastic element—the series elastic element converting contractile element shortening into pressure. In analogy to cardiac muscle velocity–length relationships [
10], the maximum velocity of shortening can be extrapolated from a plot of dP/dt (representing velocity of contractile element shortening) versus ventricular pressure (representing contractile element length). This approach appeared to circumvent afterload sensitivity and incorporated preload. However, these and related computed indices all remain sensitive to changes in preload, afterload, and heart rate to varying degrees.
“Curve-fitting” approaches to modifying ventricular function curves did not conceptually connect easily with underlying mechanism—Hill’s sliding filament model of muscle contraction. While isovolumic phase measurements were linked to underlying mechanism, they required many debatable assumptions. Consideration of ventricular pressure–volume relationships made the connection to underlying mechanism and incorporated the concepts of preload, afterload, diastolic compliance, and contractility [
11].