The Heart

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Dr. Elita Partosoedarso

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 The Heart
Basics
• Location, external and internal
anatomy

Cardiac conduction
• Pathway, intrinsic rhythm, ECG

Cardiac cycle
• Coordination of relaxation and
contraction of the atria and ventricles

Heart sounds
• Auscultation

2
 • In the mediastinum within the thoracic cavity, medially
between the lungs behind the body of the sternum between
the points of attachment of ribs two through six
• 2/3 of heart is left of the midline of the body, 1/3 to the right Sternum

• Boundaries of the heart: clinically important; a marked Apex

Basics of the Heart

increase in size indicates certain types of disease Vertebral

bodies
○ Apex (lower border) rests on the diaphragm
○ Base (upper border) at third costal cartilage: point of
attachment of great vessels
○ Dorsal surface near vertebral bodies
○ Anterior surface sits deep to sternum and costal cartilages.
• Fist size: 12 cm (5 in) x 8 cm (3.5 in) x 6 cm (2.5 in)
• Weight: 250–300 grams (9-11 ounces) for female, 300–350
grams (11-12 ounces) for males.

3
 Wall of the Heart
8

1
3 distinct layers present in the walls of the heart 4
2
7
11. Endocardium: simple squamous epithelium
○continuous with endothelium of blood vessels 6
○Protects myocardium from direct contact with blood
2 Myocardium: Thick, contractile middle layer
2.
Pericardium 3
○Compresses heart cavities and blood with great force
3.
3 Pericardium: Tough, loose-fitting, inextensible sac: Acts like loose fitting jacket
○Provides protection against friction
4
4.Fibrous pericardium: outer layer
5.Serous pericardium
6.Epicardial
6 (visceral) layer: inner layer, fused to heart, part of heart wall
7.Parietal
7 layer: outer layer, fused to fibrous pericardium
8.Pericardial
8 space, or cavity: Located between visceral and parietal layers & contains 10-15 ml fluid
4
 Septa of the Heart
The foramen ovale allows blood in the fetal heart to pass directly from the
right atrium to the left atrium, bypassing the pulmonary circuit. Within
seconds after birth, the septum primum that previously acted as a valve
closes the foramen ovale to become the fossa ovalis and establish the
typical cardiac circulation pattern.

1. Overview: physical extensions of myocardium lined with endocardium that divide the heart into chambers.

2. Interatrial septum: located between the two atria

○contains oval-shaped depression (fossa ovalis), a remnant of opening in fetal heart
(foramen ovale)

3. Interventricular septum: located between the two ventricles

4. Atrioventricular septum: located between the atria and ventricles

○Contains four openings with one-way valves that allow blood to move from the atria
into the ventricles (atrioventricular valves) and from the ventricles into the 5
pulmonary trunk and aorta (semilunar valves)
 Chambers of the Heart

1 Atria, left and right: upper receiving chamber which passively receive venous
1.
Interventricular
septum

blood on a nearly continuous basis to push blood into lower chambers, prevents
venous flow from stopping while the ventricles are contracting
2 Ventricles, left and right: lower pumping chambers which pump blood to lungs or
2.
to rest of body
3 Auricle: superficial leaf-like extension of atria near superior surface: thin-walled
3.
structures that can fill with blood and empty into the atria
4.
4 Sulcus: series of fat-filled grooves along the superior surfaces of heart containing
major coronary blood vessels
5 Septa: myocardium separating chambers of the heart
5.

• The myocardium of the atria is ______ than that of the ventricles.

• The myocardium of the right ventricle is ______ than that of the left ventricle

6
Sulcus
 Anatomy of Heart Valves
A
B
RA: right atrium
LA: left atrium
RV: right ventricle
LV: left ventricle
D C
B
A
Heart valves direct the flow of blood C D

1. Atrioventricular (AV) valves: Between atria and ventricles

○composed of flaps of endocardium
A.
A Tricuspid valve: controls blood flow between RA and RV
B.
B Bicuspid (mitral) valve: controls blood flow between LA and LV

A B
2. Semilunar (SL) valves: Between ventricles and great vessels
○half-moon-shaped flaps formed from lining of great vessels
C.
C Aortic valve: controls blood flow between LV and aorta
D Pulmonary valve: controls blood flow between RV and
D.
pulmonary trunk D7 C
 Physiology of Heart Valves
The heart valves are mechanical structures which permit one-way flow of blood.

○ Heart valves open when pressure in the 1st compartment is higher than that of the 2nd.
This _____________________________________________

○ Heart valves close when pressure in the 1st compartment is lower than that of the 2nd.
This _____________________________________________

• For AV valves, the 1st compartment is _________ and the 2nd compartment is ________
• AV valves open when atrial P > vent P and closes when atrial P < vent P
• For SL valves, the 1st compartment is _________ and the 2nd compartment is __________
• SL valves open when vent P > great vessel P and closes when vent P < great vessel P
• When both atria and ventricles are relaxed and the AV valves are open, blood passively
moves from veins to the atria and straight to the ventricles

During atrial contraction (and ventricular relaxation)

• AV valves are open and SL valves are closed
• An extra 20% of blood moves from atria to ventricles (RA to RV and LA to LV)

During ventricular contraction (and atrial relaxation)

• AV valves are closed and SL valves are open
• Blood moves from RV to pulmonary trunk and from LV to aorta
8
Internal features of the ventricles
1.
1 Trabeculae carneae
○Anatomy: beamlike projections of myocardial muscle tissue
○Physiology: increases force of ventricular contraction to maximize volume of blood leaving the ventricles
2.2 Chordae tendinae
○Anatomy: tendinous cord containing collagenous fibers
○Physiology: anchors papillary muscles to flaps (cusps) of AV valves
3
3. Papillary muscle
○Anatomy: muscles attached to edges of cusps (flaps) of AV valves via the chordae tendineae
○Physiology: contracts when ventricles contracts to help close AV valves to stop backflow of blood into
atria, regardless of how strong ventricle contraction is

2
3
1
2 3
1
Coronary Circulation and nerve supply to the heart
1. Coronary arteries
• First branches of aorta, with most going to cardiomyocytes in LV
• Left coronary artery supplies LA, LV and interventricular septum,
branching into circumflex artery and anterior interventricular artery (left
anterior descending artery (LAD))
• Right coronary artery supplies RA, portions of both ventricles, and heart
conduction system, branching into marginal arteries and posterior
interventricular artery (posterior descending artery)
• Anastomosis: area where vessels unite to form interconnections that
normally allow blood to circulate to a region even if there may be partial
blockage in another branch. The anastomoses in the heart are very small.
Therefore, this ability is somewhat restricted in the heart so a coronary
artery blockage often results in death of the cells (myocardial infarction)
supplied by the particular vessel.

2. Coronary veins
• Veins normally follow a parallel path to coronary arteries
• Blood goes from cardiac veins to coronary sinus to RA
• Great cardiac vein collects blood from posterior cardiac vein, middle
cardiac vein, and small cardiac vein. 10
 Comparison of cardiac vs skeletal muscle anatomy
• Similarities
• Both are striated: alternating pattern of dark A bands and light I bands
• T (transverse) tubules aid in the spread of action potential

• Differences
• Cardiac muscles are smaller in diameter and shorter than skeletal muscles.
• Cardiac muscle cells branch freely,
• intercalated discs form junctions between adjoining cells, containing
desmosomes and tight junctions (which form strong bonds between
cells) and gap junctions (to synchronize contraction)

Skeletal muscle

Cardiac muscle

11
Comparison of cardiac vs skeletal muscle physiology

Skeletal muscle

Cardiac muscle 12
Types of cardiac muscle cells
Major types of cardiac muscle cells
1. Myocardial contractile cells, cardiomyocytes (99% of cells):
responsible for contractions that pump blood through the
body
2. Myocardial conducting cells (1% of cells): form conduction
system of heart by initiating and propagating action potential
that travels throughout the heart and triggers contractions

Unique property of cardiac muscle: autorhythmicity, ie ability

to initiate an electrical potential at a fixed rate (heart rate) that
spreads rapidly from cell to cell to trigger cardiac contraction,
modulated by endocrine and nervous systems.

13
Cardiac conduction pathway

Myocardial conducting cells (1% of cells): form conduction system of heart by initiating and
propagating action potential that travels throughout the heart and triggers contractions

Intrinsic firing rates (without any input from nervous or endocrine systems)
1.
1 SA node: 80–100 beats per minute (bpm)
2.
2 AV node: 40–60 bpm
3.
3 AV bundle: 30–40 bpm
4.
4 Bundle branches: 20–30 bpm
5.
5 Purkinje fibers: 15–20 bpm 14
 Cardiac Conduction 2

1
3

Conduction system is at rest 1

Pacemaker cells in sinoatrial (SA) node initiates action

potential (AP)
2
Intrinsic rhythm set at 80-100 AP travels across atria to
beats/min at rest atrioventricular (AV) node 6 4

100 ms delay for both atria to complete simultaneous 3

contraction
5
AP travels to AV bundle (bundle of His)→ bundle branches 4
→Purkinje fibers → right papillary muscle

AP spreads to contractile fibers of ventricles 5

Ventricular contraction begins 6 15

 Autorhythmicity of Cardiac Conductive Cells in SA node
3

Normal and slow Na+ channels open: Na+ enters

1
1 2 spontaneous (prepotential) MP depolarizes from
depolarization −60 mV to –40mV

Cycle starts again

Ca2+ channels open
2 MP further depolarizes
Ca2+ enters cell quickly
to +15 mV
Unlike skeletal muscles and neurons, cardiac
conductive cells do not have a stable resting potential
3 Ca2+ channels close & K+ channels open
MP repolarizes to−60
K+ leaves cell
mV

4
K+ channels close and Na+ channels open

MP: Membrane potential

16
Electrical Activity in Cardiomyocytes

2 3
1

Skeletal muscle

Cardiomyocyte • Cardiomyocytes have a more stable resting phase

than cardiac conductive cells: −80 mV for atrial
1 Rapid depolarization: from -90 to +30 mV (3–5 ms) cardiomyocytes & −90 mV for ventricular ones
VG Na+ channels open →Na+ enter cardiomyocytes • Long refractory period (250ms) needed to pump
blood effectively before firing again
• Absolute refractory period: 200 ms
2 Plateau phase (175 ms): slow decline to 0 mV • Relative refractory period: 50 ms
VG Na+ channels close, slow Ca2+ channels open, few • Ca2+ influx needed
K channels open: Ca2+ enter while K+ exit cardiomyocytes
+
• To maintain plateau phase
• To bind to troponin to move troponin-
Repolarization (75 ms): return from 0 to -90mV tropomyosin complex away from binding sites
3
Ca2+ channels close as more K+ channels open→ K+ exit cell
VG: voltage gated 17
 Electrocardiogram (ECG)
• Graphic record of the heart’s electrical activity, its conduction of impulses;
a record of the electrical events that precede the contractions of the heart
• Production of an electrocardiogram (ECG)
○ Electrodes are attached to the subject
○ Voltage changes that represent the heart’s electrical activity are sensed
by electrodes and recorded on paper

18
 1

Normal ECG
Small P wave 1
Atrial depolarization Atria contraction starts after P wave starts

Large QRS complex 2

2
Ventricular depolarization & Ventricular contraction starts at
atrial repolarization peak of R wave, atria relax
3
T wave
3
Ventricular repolarization Ventricles relax 19

1 3
Various intervals and segments are clinically relevant
• Can detect delay in conduction
• Can be indicative of various heart conditions
Cardiac Cycle

Definitions
1. Cardiac Cycle: Period that begins with atrial contraction and ends with
ventricular relaxation
2. Diastole: period of relaxation which passively fill chambers with blood
3. Systole: period of contraction which actively pumps blood from one
compartment into the next

• Both atria will contract and relax synchronously.

• Both ventricles will contract and relax synchronously.
• The atria and ventricles undergo systole and diastole at different times:
careful regulation and coordination ensures efficiency.
• Blood moves from an area of higher pressure to one with lower pressure.
Contraction (systole) increases pressure within compartments to open 20
valves and pump blood to the next compartment
 Start Atrial systole Ventricular systole (& atrial diastole) Ventricular diastole

Location

Atria contract (systole) relaxed (diastole) relaxed (diastole)

Ventricles Continuation of relaxed (diastole) contract (systole) relaxed (diastole)

ventricular
Right heart diastole Blood is actively Blood is actively pumped from RV to Blood moves passively from vena cava &
pumped from RA to RV pulmonary trunk during vent ejection coronary sinus to RA to RV
Left heart Blood is actively Blood is actively pumped from LV to aorta Blood moves passively from 4 pulmonary veins to
pumped from LA to LV during vent ejection LA to LV
Open as atrial P Open as atrial P > vent Closed: atrial P < vent P stops backflow of Closed when atrial
AV valves > vent P P blood from ventricles to atria P<vent P: isovolumetric Opens when atrial
P>vent P
relaxation
Closed: vent P < great vessel P. No Closed when vent P < Opens when vent P >
SL valves blood moves between great vessels and great vessel P:
isovolumetric great vessel P: Closed: vent P < great vessel P. No blood moves
between great vessels and ventricles
ventricles contraction vent ejection

20-30% blood moves to No movement of blood ∙70–80

leaves
mL blood
each ventricle 70-80% of final ventricular volume moves into
Continuation
Blood flow vent diastole of ventricles: each
ventricle contains 130 between
between
RA and RV or (SV) actively
LA and LV ∙50–60 mL blood left ventricles
ml (EDV or preload) (ESV)
ECG Nothing Begins with P wave QRS complex End of T wave
Starts at AV valves open At start of atrial systole At start of ventricular systole At end of ventricular systole

Atrial systole At start of ventricular At end of ventricular systole and SL valves

Ends at starts systole and atrial close At end of start
diastole
Some animations
Cardiac conduction is coordinated with contraction and relaxation
 1 2
Heart Sounds

• One of the simplest, yet effective, diagnostic techniques applied to assess the state of a patient’s
heart is auscultation using a stethoscope.
• Only two audible heart sounds: S1 and S2 in a normal, healthy heart
1 S “lub” sound caused by AV valves closing before ventricular contraction
1. 1
2 S “dub” sound caused by SL valves closing before ventricular diastole
2. 2

S3 and S4 sounds are rare in healthy individuals and may indicate heart failure
• S3 sound: sound of blood flowing into atria, or sloshing back and forth in ventricles, or tensing of
chordae tendineae.
• S4 occurs before S1: caused when atrial contraction pushes blood into a stiff or hypertrophic
ventricle. 24