10/13/2008

Rhythm Of The Heart

The Heart is Like an Orchestra.
It has a conducting system that is
directed by a conductor.

This conductor is the “Natural

Pacemaker” of the Heart

Conducting System:
Abnormalities of the Conduction System -SA node (Primary Pacemaker)
-AV node
Elizabeth Dugan - edugan@hmc.psu.edu
-Bundle of His
Olamide Odubogun - oodubogun@hmc.psu.edu -Purkinje Fibers

Conducting System Electrical Signal

•Sino-Atrial node (SA Node)
-Origination and dissemination of
electrical signals to BOTH atria
-Causes BOTH atria to contract

•Atrioventricular Node (AV Node)

-Transmits signal to ventricles by going
through interventricular septum
-Causes intentional delay, to allow atria
to complete pumping
•His Purkinje System
-Electrical signal flows through the
His-Purkinje system and causes the
ventricles to contract SIMULTANEOUSLY
SA node fires  electrical
signal spreads through the
Right and left atria  Right and
Left atria contract (blood moves from
atria to ventricles)
AV Node fires  electrical signal
spreads through His-Purkinje
System  Right & Left Ventricles
Contract (blood moves from
ventricles into aorta and pulmonary
a.)

The Electrocardiogram
(EKG or ECG)
EKG Mechanics
WHAT does an EKG measure?
•Measures electrical signals from heart.
This consists of:
•Atrial contraction - P Wave
•Ventricular contraction – QRS complex
•Ventricular Relaxation – T Wave
HOLD ON!!!!!
What about Atrial Relaxation?

HOW does it do this?

Your body is a conductor of electricity
•The electrical signal generated in the heart is
detected by the leads placed on the surface
of the body

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Main EKG Waves Normal EKG

P T P T P T P T P

QRS QRS QRS QRS

Atria contract Ventricles contract
QRS complex Normal EKG:
P Wave
1. Regular Rate –heart rate of 60-100 bpm
2. Regular Rhythm – P – QRS – T – P – QRS – T – P – QRS – T - etc
Ventricles Relax
T Wave 3. The height of the wave – related to the mass of the muscle generating the wave
- the ventricles have more mass than the atria: P wave is smaller than QRS complex

- large ventricles (ventricular hypertrophy)  more muscle creating a stronger

signal when the ventricles contract: taller QRS complex

Ventricular Hypertrophy (Large Ventricle) ARRHYTHMIA

NOTICE the very large
QRS complex in the EKG Ventricular Fibrillation
Causes of a Large QRS Complex

Increased mass in:

1. One ventricle
2. Both ventricles
3. Portion of the ventricle
QRS
1. Ventricular Fibrillation – disordered electrical activity

Normal EKG The ventricles "flutter" rather than beat and pump little or no blood.
2. In minutes, collapse and sudden cardiac death will follow
 Medical help is needed immediately
3. Treatment - defibrillator

Hypertrophic Cardiomyopathy

-Disease of the myocardium

-Portion of the myocardium is thickened

(hypertrophied, aka, the opposite of
atrophy)

-Individual muscle fibers are disorganized

 abnormal conduction + arrhythmias
The ventricle is hypertrophied
Hypertrophy is asymmetric What happens to the following:
The interventricular septum (muscle b/w Relaxation? ALL
the 2 ventricles) is usually enlarged much Filling? ARE
more than the rest of the ventricle Pressure? DECREASED!
Forward Flow?
What does all this cause?
Difficulty breathing!

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Outflow tract
obstruction – (the

Outflow Obstruction outflow tract is the path

from the LV into the
aorta)

Increased
velocity!

Normal Flow Outflow Obstruction

Normal Velocity, Low Pressure Fast Velocity, High Pressure

When flow is obstructed, you need to build more muscle so that you can
pump harder! This equals hypertrophy!

Mitral Regurgitation HCM Symptoms

- Narrowed outflow tract = Aortic • Average age presentation : mid 20s
faster flow Valve Regurgitation
• Wide range symptoms/severity
- Faster flow of blood pulls
• Difficulty breathing (dyspnea)
the mitral valve open Mitral
Valve –WHY?
- Blood goes back into the
• Angina
atria from the ventricle
during systole mitral –WHAT DOES ANGINA MEAN?
regurgitation Left
Ventricle • Syncope (fainting)
SHOW VIDEO –FROM WHAT?
HOW WE FIX MITRAL REGURG? –WHY WOULD FAINTING BE BENEFICIAL?

Interesting Facts Physical Exam

– What is the most common cause of cardiac death in
athletes?
• Hypertrophic Cardiomyopathy • Often are normal
– How many people does this affect? • Extra heart sounds
• 1/500 – Fourth heart sound – this is heard before the “Lub” 
instead of “lub-dub” you here “da-lub-dub”
– Is everyone at risk for this?
• Inherited (genetic) disorder: autosomal dominant,
know your genetics and be careful if you are a possible • Systolic Murmur
carrier! – Due to Turbulent (noisy) flow through the outflow tract (LV to Aorta)

– Does everyone with HCM have the same symptoms and

outlook? • Systolic Murmur
• There are different forms of the disease and some are – Due to regurgitation of blood through the mitral valve
more severe than others  incomplete penetrance

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HCM and Arrhythmias

MYOCARDIAL DISARRAY

During Vfib
-The ventricles are like
bowl of jelly

Normal Myocardium : HCM: Disarray! - Inefficient pump

Linear arrangement Physiology 101: Structure = Function -Muscle cells malaligned

Thus, Abnormal Structure=… “Myocardial Disarray”

Implantable Cardioverter Defibrillator (ICD)

HHOW DO YOU SOLVE
An ICD is used in patients at risk for:
THIS PROBLEM?? 1. Ventricular tachycardia (>100 bpm)
2. Ventricular fibrillation
3. Sudden cardiac death caused by
arrhythmias
An ICD is made up of two parts:
1. Pulse generator – battery plus circuits
1) Defribillators 2. One or two leads (wires)
How the ICD Works:
e.g. ICD 1. Leads monitor your heart rate
2. ventricular tachycardia or fibrillation
detected  controlled burst of impulses
2) Pacemakers (called "overdrive" pacing)
3. If that does not work, the ICD "shocks"
(artificial) the heart to restore a normal rhythm.
Newer ICD devices can also work like a
pacemaker if a slow heart rate
(bradycardia) occurs.

What does it Look Like??? Pacemaker

Pacemakers are used to treat:

1. Abnormal rates
Bradycardia/ Tachycardia
2. Abnormal rhythms
Arrhythmia
Atrial fibrillation

Goals:
1. Coordinate the electrical signaling between
the upper and lower chambers of the heart
2. Coordinate the electrical signaling between
the ventricles
An ICD is like a pacemaker in some ways, but it
can use higher energy electrical pulses to treat
certain dangerous types of arrhythmia.

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The End