Cardiac Anatomy

Outside to Inside
Pleura:
- Parietal plerua
- Right pleural cavity
- Visceral pleura

Pericardium: fuses with diaphragm central tendon (moves heart)

- Fibrous pericardium
- Parietal pericardium
- Pericardial cavity
- Visceral pericardium

Heart: surrounded by pericardium in the mediastinum (region between two pleura)

Heart base = top Heart apex = bottom

SVC: upper limb, head, neck regions

IVC: rest of body

Arch of Aorta splits into 3, supplies upper limb, head, neck

Descending Aorta supplies rest of body

Middle Mediastinum
- Ascending aorta (base of heart)
- Pulmonary trunk (outflow tract to right ventricle)
- Phrenic nerves innervating diaphragm run through pericardium. Phrenic n. C3/4/5
Anterior Mediastinum
- Thymus gland (educating t cells in adaptive immune)
Posterior Mediastinum
- Descending aorta
- Esophagus (oral cavity to stomach)
- Lymph nodes (immune cell home)
- Vagus n. 10 follows esophagus to abdomen
- Thoracic duct
Superior Mediastinum
- Aortic arch
- Esophagus
- Trachea (becomes lungs at this point)

Anterior Heart
- Right ventricle most visible
- Auricle: associated ear to each atrium. flap look like dog ear
Sulci (Grooves): BV sit in grooves to be protected. Fat around BVs
- Coronary Sulcus: between atria and ventricles
- Interventricular Sulcus: between left right ventricle
Aortic Arch splits into two coronary arteries L/R to supply blood to heart

LCA: Comes past pulmonary trunk, bifurcates, through coronary sulcus, becomes circumflex
artery, through interventricular artery, left anterior descending artery LAD

RCA: Stars in coronary sulcus, between right atrium and ventricle. Goes to back to posterior
interventricular Sulcus

LCA/RCA form anastamoses. Not well developed

Heart blood flow is affected (blood clot): Infarct

Many coronary veins drain directly into coronary sinus

Coronary Veins:
- Great Cardiac Vein: starts ant. interventricular sulcus, goes up through coronary
sulcus (LA/LV), goes to back drains into coronary sinus.
- Small Cardiac Vein; right side between coronary sulcus. Around back to C.Sinus
- Anterior Cardiac Vein: Prominent at front, drains into right atrium
- Coronary Sinus: drains into right atrium

Posterior Heart;
Left atrium; most prominent posterior feature. All pulmonary veins bringing O2 blood back to
heart

Pericardium: fuses with diaphragm central tendon (moves heart)

- Fibrous pericardium: dense irregular connective tissue. protects and anchors
- Parietal pericardium: secretes serous fluid
- Pericardial cavity: can accommodate other fluids, consequences
- Visceral pericardium: secretes serous fluid

Heart Wall Layers

- Epicardium
- MyoCardium
- Endocardium
Left side is more thicker for more force to get it to the whole body
- Left ventricle is circular. Right ventricle is half-moon

Inflammation
Pericarditis: fluid, pus accumulation
Myocarditis: viral infection, rheumatic fever (strep), radiation, meds
Endocarditis; Often bacterial, heart valves affected, potentially fatal

Blood Flow: Vena cava - Right atrium - Atrioventricular valve - Right ventricle - Pulmonary
trunk - lungs - pulmonary veins - left atrium - left ventricle - aorta
These valves work on pressure. If atrium has higher pressure it opens and closes if ventricle
has higher pressure. Cordae tendinae and papillary contract a little to prevent opposite valve
opening.

Pulmonary Semilunar valve: right ventricle to pulmonary trunk valve

Aortic Semilunar valve: left ventricle to aorta valve
- Coronary arteries are at the valve, they are covered when pushing out blood, opened
when heart is relaxed and blood flows into heart
Tricuspid Valve: Right atrium to ventricle
Bicuspid Valve: Left atrium to ventricle
Fibrous Rings:
- Provide structural foundation for heart valves
- Maintains valve diameter
- Attachment site for muscle fibres
- Electrically separates atria and ventricles.

Subvalvular apparatus. Heart Valve. Arrangement vvv

Cordae Tendinae are attached to the above heart valves
Papillary muscles are attached to above Chordae Tendineae. Ventricle below
Ventricle.

SVC/IVC holes become smaller when atrium contracts to prevent backflow

Pulmonary veins to left atrium follows same procedure

Heart Sounds
- Aortic valve = 2nd right intercostal space (2-3 rib)
- Pulmonary valve = 2nd left intercostal space (2-3 rib)
- Bicuspid valve = 5th left intercostal space (5-6 rib)
- Tricuspid valve = Left lower sternal border.

Heart Disorders
- Stenosis (Narrowing)
common Aortic / infants Pulmonary / left side pressure Mitral
Valve damage healing. Scar tissue make gap smaller. Binds leaflets

- Prolapse (Eversion) .
Mitral valve prolapse,. Blow open in backwards direction. Left side high pressure
Cardiac Development

Adult Circulatory System

- Pulmonary circuit (Right side)

- Blood to lungs Oxygenation
- Removal of CO2

- Systemic circuit (Left side)

- Delivery system. nutrients and O2
- Waste transport

Pressure is always higher on left side / systemic

Fetal Circulation

- Bypasses shunts: alternative routes for blood flow around developing organs
- Higher pressure on the right than left
- Fetus attached to placenta to umbilical cord to umbilicus with umbilical vein

Ductus Venousus: bypass for the liver, little waste extraction or nutrient processing
Goes to IVC. Mother's oxygenated blood gets mixed into fetus deoxygenated. Mixed purple
blood bypasses through...

Foramen Ovale: bypass from right atrium to left atrium to get oxygen out asap

Ductus Arteriosus: bypass from Pulmonary trunk to aorta. 90% of blood from Pulmonary
trunk is diverted away

- Near the iliacs, there are two umbilical arteries to send blood to placenta and one
umbilical vein bringing the oxygenated blood back

Foramen Ovale - Fossa Ovalis

Ductus Arteriosus - Ligamentum Arteriosum
Ductus Venousus - Ligamentum Venousum
Umbilical Arteries - Medial Umbilical Ligaments
Umbilical Vein - Ligamentum Teres
Fetal vs Adult
Site of oxygen exchange
- Fetal Placenta
- Adult Lungs
Circulations
- Fetal Parallel Open circuit
- Adult Series Closed circuit. Specific flow pathway
Bypasses
- Fetal Open
- Adult Closed
Oxygenation of blood in heart
- Fetal R L sides mix de/oxygenated blood (purple)
- Adult R deoxygen L oxygen
Pressure
- Fetal Higher on right
- Adult higher on left

Fetal Heart
- Starts as 2 tubes
- Fuse into one tube
- Develops sacculations/bulges (future parts)
- Elongates. Folds infront of fetus

Sacculations
- Sinus Venosus: Right atrium, SA node, Coronary sinus
- Truncus Arteriosus: Aorta, Pulmonary trunk
- Bulbis cordis: Right ventricle
- Ventricle: Left ventricle
- Atrium: R/L atriums R/L auricles
Truncus Arteriosus Aorta/Pulmonary trunk

- Bulbar Ridges grow towards each other

- Create Aorticopulmonary septum (spiral).
- Divides Aorta from Pulmonary trunk
- Spiral septum causes aorta, pulmonary to wrap around each other

Valve Stenosis: Spiral septum but towards one side. One stenosed (thin) one side expanded
- PT often the stenosed valve
- Obstructed ventricular flow. Reduced flow into PT to lungs
- Stenoses valve requires more pressure to push through
- The extent of stenosis determines a/cyanotic (blue skin)
Stenosis Treatment
- Short term: drug to dilate smooth muscle, more open flow
- Permanent fix: balloon catheter inserted femoral v., RA, RV, Pulm V. Balloon stretches PT

Persistent Truncus: Truncus Arteriosus doesn’t change into aorta / pulmonary trunk
Septum fails to form
R and L blood mixes where aorta / pulmonary trunk should be

Transposition of the Great Vessels: septum forms, but does not spiral 180°
- Right side heart - Aorta - body - SVC/IVC
- Left side heart - PT - Lungs - PV
- Fatal without bypasses or shunts

Patent Ductus Arteriousus: Ductus Arteriosus remains open

- Can lead to volume overload in pulmonary circuit.
- Increased pulmonary blood flow can lead to pulmonary edema
- “Gas exchange under water”
Shunt, Blood flows from aorta to PT, blood volume issue, depends on extent (pulm edema)

Formation of interatrial septum (prev foramen ovale)

- Septum Primum; First wall from top of atriums to center of heart (endocardial cushion)
- Foramen Primum: First hole closer to endocardial cushion than atriums
- Foramen secundum: Hole near top after there is a wall from atrium to ventricle.
- Septum Secundum: second wall with hole behind first wall
- Foramen ovale: Hole in second wall, first wall covers over as valve
- Foreman Ovale valve: made out of septum primum closer to cushion

Higher Pressure Side switches after birth (R to L)

- Increased systemic resistance with loss of placenta
- Decreased pulmonary vascular resistance with breathing

Atrial Septal Defect; Foramen Ovale fails to close

- Hole in wall between atria
- Wall never develops into the valve
Shunt, Blood flow from LA to RA, Volume more blood through pulm circuit, Asymptomatic
Formation of Interventricular Septum
- Starts at Apex of heart
- Muscular tissue; cardiomyocytes. bottom part 80%
- Membraneous portion touches valves. top part thin
- Valves formed by stem cells found within tissue cushions/swelling around fibrous
- 3 Cushions around tricuspid right valve. 2 Cushions around bicuspid left valve

Tetralogy of Fallot
- Stenosed pulmonary valve
- Interventricular septal defect
- Overriding Aorta emerges from both ventricles
- Enlarged/Hypertrophy Right ventricle
Cardiac Physiology

MyoCardium
- 95% of heart
- Responsible for pumping
- Striated, involuntary muscle
- Fibers swirl diagonally around heart in bundles. The heart wrings blood out of the
ventricles and atria

Cardiac Muscle Tissue

- Myocytes form a functional syncytium. Work as one coordinated unit. Electrically
connected.
Intercalated Disc; part where cells connect to other cells
- Contain desmosomes which glue myocytes together
- When one cell contracts the next cell will contract
- Contain gap junctions. Half on one cell half on other
- Allows sodium potassium, calcium to move freely between cells to electrically
connect those cells

Cardiac Conduction System

- Sinoatrial SA Node on back of right atrium near SVC.

- SA Node = Pacemaker cells = depolarize, create action potential recover and
depolarize again. Stimulating resting heart rate of heart on it's own.
- SA nodes send action potentials through myocytes connected by gap junctions,
Sends it out to both sides of heart

- Atrioventricular AV Node on base of right atrium.

- Pacemaker cells but depolarize at a slower rate. Doesnt set the heart rate
- Signal slows down at AV node. Allows atria to contract then ventricles

- Atrioventricular Bundle (Bundle of HIS)

- Only structure passing fibrous skeleton. Only way electrical signals to be passed
from atria to ventricle
- Fibrous skeleton electrically separates at the level of the valves. Atria-Ventricle

- Right/Left Bundle Branches

- Brings down the signal to the apex because ventricles need to contract upwards

- Purkinje dense fibers at the apex of heart

- Spread out action potential evenly brought down by bundle branches
- Makes the Left Right ventricle contract at the same time
AP in a Ventricular Myocyte

Depolarization
- Excitable cell, very negative resting membrane potential,
- Pacemaker cell generates AP, stimulates myocyte to the threshold
- At threshold, voltage gated sodium channels open, sodium flows into the cell
(inside cell becomes less - more +)
Plateau
- Voltage gated potassium channels start to open to drive membrane potential to
resting. Voltage gated calcium channels opening as well. Calcium higher outside
- Potassium is leaving the cell but calcium is entering the cell
- Calcium required for simulating/regulating contraction in skeletal muscle
- Positive in Positive out membrane potential stays straight
Repolarization
- Calcium channels close and 2nd longer activating potassium channel opens too
- Potassium channels still open and they leak out until at resting membrane potential

Sodium Potassium ATP always working in the back to fix the positive negative differences
Refractory Period: Time required before being able to generate another action potential. Always
longer than the contraction time as heart needs time to relax and refill with blood

Inotropes: Substance that influence strength of heart contractions by altering movement of

calcium through channels
- eg Epinephrine increases contraction by enhancing calcium influx. Positive inotrope

Electrocardiogram (ECG / EKG)

Record of all action potentials produced by all heart muscle fibers

Detected at the body's surface. 3 WAVES are detected: P, QRS, and T

P wave
- Depolarization of atrial contractile fibers. Action potentials being sent out
P-Q Segment
- Contraction occurs. Delayed because action potential takes a minute
QRS wave
- Depolarization of the ventricles. Much larger because ventricle muscles are strong
- Atria repolarize at the same time
S-T segment
- Ventricular systole/contraction
T wave
- Repolarization of ventricles
After T
- Ventricular diastole (relaxation)
Left sided pressure related to ECG
- Pressure in aorta is at 80 and valve is closed because it is higher in aorta than left
ventricle
- Left atrium fills. Low pressure. Contracts and stays low pressure since bicuspid valve
closed
- Ventricle contracts and pressure goes above 80 opening the aorta valve and up to
120 until ventricular pressure drops below 80 and doors close again.

Heart sounds : S1 and S2 represent closing of AV and SEMILUNAR valves

- S1 = ventricle contraction, shuts AV valve
- S2 = Ventricular relaxation, aortic pressure closes SEMILUNAR valve

Isovolumetric contraction; Iso same Volume

Volume in ventricle is the same but both valves are closed
which builds up enough pressure to open semilunar valve

Isovolumetric relaxation
When aortic valve closes the pressure in ventricle has to
drop before the Atrioventricular valve can open

End diastolic volume; Volume when filled with blood. 120 ml

End systolic volume; Remaining blood leftover in heart 50 ml
Stroke volume: Amount of blood moved forward per heartbeat 70ml
- LV to aorta / RV to PT. They eject same amount of blood per beat

Cardiac Output CO: Volume of blood moved forward per minute

SV x HR = CO

Factors regulating Stroke Volume.

Preload
- Degree of stretch on heart before contraction
- Heart muscle stretched during diastolic filling
- Increases force of contraction and volume of blood ejected
- Too much stretch causes heart failure, actin and myosin can't function
Slow heart rate = more time to fill and stretch = increased SV
Increase in venous return (excersizes) = Increased SV

Contractility
- Forcefulness if contraction of individual fibers
- Due to changes in cytosolic calcium levels
- Influx from extracellular fluid. Release from sarcoplasmic reticulum
- Positive inotropes increase contractility and SV. Negatives decrease SV
After load
- Pressure ventricles have to overcome to open Semilunar valves
- Pressure in aorta usually 80 mmHg. Pulm trunk value 20 mmHg.
Elevated BP and narrowing of arteries increase afterload and decrease SV
Blood loss and vasodilation decreases afterload and increases SV

Factors affecting Heart Rate

Increasing factors
- Sympathetic Nervous System
- Chemical Hormones (epinephrine)
- Infants have higher resting HR
- Increased body temp

Decreasing factors
- Parasympathetic Nervous System (talk to SA nodes)
- Hypoxia (lower O2 level)
- Acidosis/Alkalosis
- Older age have lower HR
- Decreased body temp

How does the nervous system affect the heart.

Cardiovascular Center located in medulla oblongata

Input
- Higher brain centers: cerebral cortex, limbic system, hypothalamus
- From sensory receptors: proprio,chemo,baro receptors. motion blood chemistry BP

Output To Heart
- Cardiac accelerator nerves (sympathetic) : Increase rate of SA node Depolarization,
increases HR. Cardiac accelerator nerves increase atria and Ventricular contractions.
Increases SV
- Vagus nerve Parasympathetic; Decreases rate of SA node Depolarization decreases
HR
Vasculature

Principal Divisions of the Aorta

Ascending Aorta. base of heart

- R&L coronary arteries

Arch of Aorta
- Brachiocephalic trunk; ---->>> R. common carotid , R. Subclavian
- L subclavian
- L common carotid

Thoracic / Descending Aorta

- Pericardium, Esophagus, Bronchi, Diaphragm, Intercostal and chest muscles,
mammary gland, skin, vertebrae and spinal cord

Abdominal Aorta
- Abdominal and pelvic viscera & lower extremities. What each artery supplies

Unpaired Arteries:
- Celiac trunk, supplies; Liver, Stomach, Pancreas, Duodenum, Spleen
- Superior Mesenteric A., Small intestine, Ascending large intestine
- Inferior Mesenteric A. Descending large intestine towards rectum

Paired arteries. Supply pair of organs

- Suprarenal A. Adrenal gland
- Renal A. Kidneys
- Gonadal A. Gonads way down there but they dragged artery
- Veins are similar to Arteries

Veins:
- SVC: head neck chest upper limbs
- Coronary circulation: Great Middle Small Cardiac Vein, Coronary sinus
- IVC: Abdomen Pelvis Lower Limbs

Portal System: capillary bed turns into a vein into another capillary bed somewhere else
- Hepatic portal system, Bed on large intestine, vein, Bed inside liver

Every cell is no more than 2 cells away from a capillary

Artery - Arterioles - Capillaries
- Site of gas exchange and nutrient exchange
- Waste Removal
Capillaries - Venules - Veins
Arteries

Lumen: inside the artery

Tunica Intima
- Endothelium
- Basement membrane
- Internal Elastic Lamina

Tunica Media
- Smooth muscle cells
- Elastic Fibers
- External Elastic Lamina

Tunica Externa / Adventita

- Elastic and collagen fibers
- Vasa vasorum (blood vessels for the blood vessels)

Veins : ⅔ blood volume, less pressure, no need for elastic lamina

Lumen: inside of vein

Valves inside veins

Tunica Intima
- Endothelium
- Basement Membrane

Tunica Media
- Smooth muscle cells

Tunica Externa
- Elastic and Collagen fibers
- Vasa Vasorum (BV OF BV)

Anatomic
Veins have much thinner muscular layer and Tunica Externa
Veins have no elastic layers but have valves to prevent gravity backflow

Physiological
Veins have very little BP so their wall can be thinner and weaker
Valves are necessary to prevent backflow and assist venous return.
.
Elastic Vs Muscular Arteries

Elastic/Conducting Artery
- Conducting blood away from the heart
- Diameter 15mm Thickness 1mm

Muscular/Distributing Artery
- Distributes blood to all the muscles / tissues
- D 6mm T 1mm

Both are mostly smooth muscle

Elastic more Elastic
Muscular more fibrous

Elastic Artery: Aorta

- Conduct blood to Muscular Arteries
- Must handle pressure from heart contractions (systole)
- Provide pressure between heartbeats (diastole)
- Tunica media full of elastic fibers
- Stretch when BP increases and recoil when BP decreases to even it out

Muscular Arteries
- Medium sized more muscle than elastic in Tunica Media
- Capable of greater vasoconstriction or vasodilation to adjust BP
- Wall are relatively thick. Multiple branching
- Brachial a. arm, Radial a. forearm. / femoral a. thigh, tibial a. leg

Arterioles & Capilaries

Arteriole / resistance via contraction

- D 37 um, T 6um
- mostly smooth muscle

Capillary
- D 9um, T 0.5um
- mostly endothelium
- Allows for exchange

Microvascular Bed
- Throughfare channel: connect terminal arterioles to postcapillary venule (main road)
- Being cold. blood is only going through throughfare channel

Capillaries
- Continuous
- Sinusoid
- Fenestrated
Continuous. Most prominent.
- eg brain lungs muscle
- Abundant tight junctions between endothelial cells. Prevent leaking

Fenestrated. (Pores)
- eg kidney, choroid plexus
- Plasma can leak through it
- Nutrient exchange and filtration. Kidneys remove waste

Sinusoid (Many Big Holes)

- eg red bone marrow, liver
- Huge spaces incomplete basement membrane
- Cells can come in and out

Capillary Exchange

Arterial end - Hydrostatic pressure > Oncotic pressure resulting in a net filtration out of the
vessel

Venous end - Oncotic pressure > Hydrostatic pressure resulting in net reabsorption into the
vessel

Not everything get reabsorbed tho, 15% lost. Picked up by lymphatics

Veins & Venules

Venule
- D 20 um , T 1um
Vein
- 5mm , T 0.5mm.
Mostly fibrous tissues

Aiding venous return

Skeletal muscle pump

- Contraction of muscles
- Compresses deep veins
- Milks blood to heart

Respiratory Pump
- Inhale diaphragm moves down increasing abdomen pressure
- Compresses Abdominal veins
- Blood forced back to heart