Calculation order & shared state

1. Construct the reference

Selected diseases are deduplicated and assigned independent valve severities. The mixed-state builder chooses a dominant morphology, combines filling and flow constraints, and retains the names of all active lesions. Shunt baseline loading, successful decompression and the baseline flow/filling controls feed the treatment context.

• The cardiac-output control sets reference forward flow; the filling control changes the reference wedge target and associated preload. Manual BP, rate, PVR and SVR can then change the coupled circulation.
• Successful pericardial or pleural decompression removes that obstructive component; valve procedures modify the selected valve. Neither removes unrelated diseases.

2. Apply treatments in order

Within the shared intervention pipeline, valve correction is evaluated first. NSVT suppression, rate drugs, stimulants, sedation-related rate effects and temporary pacing determine the effective rhythm/rate. The supported-state calculation applies rate, BP/resistance loading and IABP.

• Vasoactive and volume interventions → retained antiarrhythmic myocardial/vascular effects → loading maneuver → sedation.
• Ventilator mechanics and CO₂/alveolar oxygen loading → PEEP effects on preload, RV load and LV afterload.
• Mechanical circulatory support → shunt network → transmitted end-expiratory pressure added once to reported pressures.
• Oxygenation, pulse reliability, respiratory timing and display models consume the resulting circulation. This order is intentional and means controls are not independent additive pressure offsets.

3. Sample a shared result

Pressure functions receive the resulting scenario, rate, rhythm, respiratory description and support state. Telemetry, pressure contours, Wiggers, PV and imaging share these inputs. Displayed measurements are sampled from those signals or explicitly labeled calculated values.

The untreated comparison removes interventions while retaining the appropriate disease and user context, including ventilation and manual vitals where applicable. It is a counterfactual teaching reference, not a stored recording from before treatment.

What is and is not coupled

A setting can change a displayed quantity indirectly: PVR changes RV load and forward flow; flow changes systemic pressure at fixed SVR; ventilation changes filling and pulmonary load; valve leaks change chamber volume excursion. Not every biological feedback has an equation. Renal, neurohormonal, metabolic, coronary and long-term remodeling feedbacks are limited to explicitly selected examples.