Main structures and pathway of the conduction system.

1. Definition: A network of specialized cardiac muscle cells that initiate and transmit the electrical
impulses responsible for cardiac contraction and heart rate.
2. Cardiac Conduction system = The electrical pathway of the heart.
3. SA Node
4. Internodal Pathways and Bachmann’s Bundle
5. AV Node
6. Bundle of His
7. Right and Left Bundle Branches
8. Purkinje Fibers

The cardiac conduction system is the electrical pathway of the heart that leads to atrial and
ventricular contraction.

The conduction system consists of pacemaker cells that generate spontaneous action potential
and then deliver those impulses throughout the heart.

The cardiac conduction system comprises the following structures in order: SA Node, Internodal
Pathway and Bachmann’s Bundle, AV Node, bundle of His, bundle branches, and Purkinje Fibers.

Pacemaker Cells
The heart has the innate ability to generate its own spontaneous action potentials without any
external stimuli, a phenomenon known as automaticity.

It does this by using pacemaker cells, which are specialized cardiac myocytes (muscle cells)
within the myocardium that have the ability to generate action potentials.

The pacemaker cells are located in structures that make up the electrical pathway of the heart,
known as the conduction system, and they generate and transmit electrical impulses throughout
the myocardium.

As the action potential travels through the conduction system and myocardium, it will lead to
atrial and ventricular depolarization and contraction.

The rate at which the pacemaker cells fire is the heart rate.

The pacemaker cells do not have a true “resting phase” in their action potential cycle.

Once a pacemaker cell repolarizes, the voltage across the cell membrane slowly becomes more
positive until the action potential threshold is met and rapid depolarization occurs again.

The pacemaker cells are located within the SA Node, AV Node, bundle of His, right and left
bundle branches, and Purkinje Fibers.

Contractile Cells

The contractile cells are the second type of cardiac myocytes, found within the myocardium.

The contractile cells make up the bulk of the myocardium (99%) and they are the cardiac
myocytes (muscle cells) responsible for contraction of the heart.

They mainly rely on the above conduction system to become depolarized, which will lead to
cardiac contraction and movement of blood forward.

SA Node

In a normal functioning heart, the SA Node is the primary pacemaker of the heart that produces
spontaneous action potentials that will determine the heart rate.

The SA Node is composed of many pacemaker cells, and it is located at the back of the right
atrium near the superior vena cava entry.

The conduction system of the heart can be influenced by the sympathetic nervous system to
speed up the heart rate by activating cardiac beta cells.
The pacemaker cells within the SA Node generate action potentials at 70-100 beats per minute.

The action potential travels from the SA Node through the right atrium via the internodal
pathway, and to the left atrium via Bachmann’s Bundle.

There are 3 internodal tracts: Anterior, Middle, and Posterior.

The action potential will also travel from the right atrium to the left atrium via Bachmann’s
Bundle, a branch of the anterior nodal tract.

As the action potential travels through the atria, the atria depolarize and contract to further
push blood into the ventricles during diastole.

Atrial depolarization is represented by the P wave on an EKG.

AV Node

After the action potential travels through the atria, it will converge onto another node called the
AV Node.

The AV Node is located at the base of the right atrium near the interventricular septum.

It is the gatekeeper that sends the action potential from the atria to the ventricles.

Similar to the SA Node, the AV Node consists of many pacemaker cells that have the ability to
generate their own spontaneous action potentials.

The key difference between them are that the pacemaker cells within the AV Node generate
their action potentials at a slower rate than the SA Node.

The rate at which the AV Node produces spontaneous action potentials is approximately 40-60
beats per minute.

Since the SA Node produces action potentials at a much faster rate than the AV Node, the SA
Node depolarizes the pacemaker cells within the AV Node before they have time to
spontaneously depolarize.

The AV Node slows down the conduction velocity of the action potential to allow time for the
atria to contract before depolarizing the ventricles.

Therefore, the AV Node is the transition from the end of diastole to the start of systole in the
cardiac cycle.
Right and Left Bundle Branches

The action potential then travels from the bundle of His to the right and left bundle branches,
also known as the atrioventricular bundle branches.

The Right bundle branch mainly supplies the right ventricle and the left bundle branch mainly
supplies the left ventricle.

The bundle branches consist of pacemaker cells that can generate spontaneous action potential
at a rate of 20-40 beats per minute.

Purkinje Fibers

Lastly, the action potential travels from the right and left bundle branches to the Purkinje Fibers.

The Purkinje Fibers conduct the impulse throughout the right and left ventricles.

As the action potential travels through the bundle of his, the bundle branches, and the Purkinje
Fibers, the ventricular contractile myocytes depolarize and contract.

The heart is now in systole.

Ventricular depolarization is represented by the QRS complex on an EKG.

The pacemaker cells within the Purkinje Fibers have the ability to generate spontaneous action
potential at a rate of 20-40 beats per minute.

Bradycardia : slow heart rate

Tachycardia: fast heart rate (100BPM+)

Anatomy of the heart:

Great Vessels

The main pulmonary artery, also known as the pulmonary trunk, emerges from the right
ventricle and delivers deoxygenated blood to the pulmonary circulation and lungs.

The aorta emerges from the left ventricle and delivers oxygenated blood to the rest of the body.

The superior vena cava and inferior vena cava are the main veins that deliver oxygenated venous
blood from the rest of the body back to the heart, specifically the right atrium.

The pulmonary veins are the main veins that deliver oxygenated blood from the lungs back to
the heart.

Valves

There are 4 valves in the heart: the tricuspid valve, mitral valve, pulmonic valve, and aortic valve.

The tricuspid and mitral valves are positioned between the atria and ventricles.

Specifically, the tricuspid valve is located between the right atrium and right ventricles, and the
mitral valve is positioned between the left atrium and left ventricles.
Then pulmonic and aortic valves are located between the ventricles and great vessels.

Specifically, the pulmonic valve is positioned between the right ventricle and pulmonary truck,
and the aortic valve is located between the left ventricle and aorta.

Blood Flow

All blood enters the right side of the heart through two veins. The superior vena cava and the
inferior vena cava.

The SVC collects blood from the upper half of the body. The IVC collects blood from the lower
half of the body. Blood leaves the SVC and the IVC and enters the right atrium.

When the RA contracts, the blood goes through the tricuspid valve and into the right ventricle .
When the RV contracts, blood is pumped through the pulmonary valve, and into the pulmonary
artery and into the lungs where it picks up oxygen.

Why does it happen this way? Because blood returning from the body is relatively poor in
oxygen. It needs to be full of oxygen before being returned to the body. So the right side of the
heart pumps blood into the lungs first to pick up oxygen before going to the left.

Blood now returns to the heart from the lungs by way of the pulmonary veins, and goes into the
left atrium. When the LA contracts, blood travels through the mitral valve and into the left
ventricle. The LV is a very important chamber that pumps blood through the aortic valve and
into the aorta. The aorta is the main artery of the body. It receives all the blood that the heart
has pumped out and distributes it to the rest of the body. The LV has a thicker muscles than any
other heart chamber because it must pump blood to the rest of the body against much higher
pressure in the general circulation.

Left atrium = oxygenated blood

Right atrium = deoxygenated blood
Left ventricle = oxygenated blood
Right ventricle = deoxygenated blood

Blood flow (breakdown)

1. To the superior and inferior vena cava
2. Then to the right atrium
3. Through the tricuspid valve
4. To the right ventricle
5. Through the pulmonic valve
6. To the pulmonary artery
7. To the lungs.

The blood picks up oxygen in the lungs and then flows from the lungs:
 1. To the pulmonary veins
2. To the left atrium
3. Through the mitral valve
4. To the left ventricle
5. Through the aortic valve
6. To the aorta

Membranes of the Heart

The membrane that directly surrounds the heart and defines the pericardial cavity is called the
pericardium or pericardial sac. It also surrounds the roots of the major vessels, or the areas of closest
proximity to the heart. The pericardium, which literally translates as “around the heart,” consists of two
distinct sublayers: the sturdy outer fibrous pericardium and the inner serous pericardium. The fibrous
pericardium is made of tough, dense connective tissue that protects the heart and maintains its position
in the thorax. The more delicate serous pericardium consists of two layers: the parietal pericardium,
which is fused to the fibrous pericardium, and an inner visceral pericardium, or epicardium, which is
fused to the heart and is part of the heart wall. The pericardial cavity, filled with lubricating serous fluid,
lies between the epicardium and the pericardium.
In most organs of the human body, visceral serous membranes are usually microscopic. However in the
case of the heart, it is not a microscopic layer but a macroscopic layer, consisting of a simple squamous
epithelium called a mesothelium, reinforced with loose, irregular, or areolar connective tissue that
attaches to the pericardium. This mesothelium secretes the lubricating serous fluid that fills the
pericardial cavity and reduces friction as the heart contracts.

Surface Features of the Heart

Inside the pericardium, the surface features of the heart are visible, including the four chambers. There
is a superficial leaf-like extension of the atria near the superior surface of the heart, one on each side,
called an auricle, which means “ear-like.” Auricles are relatively thin-walled structures that can fill with
blood and empty into the atria or upper chambers of the heart. They may also be referred to as atrial
appendages. Also prominent is a series of fat-filled grooves, each of which is known as a sulcus (plural=
sulci), along the superior surfaces of the heart. Major coronary blood vessels are located in these sulci.
The deep coronary sulcus is located between the atria and ventricles. Located between the left and right
ventricles are two addition sulci that are not as deep as the coronary sulcus. The anterior
interventricular sulcus is visible on the anterior surface of the heart, whereas the posterior
interventricular sulcus is visible on the on the posterior surface of the heart.

Skeleton of the Heart

 The fibrous skeleton of the heart, also called the cardiac skeleton, consists of four fibrous rings
(annuli fibrosi, singular: annulus fibrosis) and the membranous portions of the septa of the heart. This
skeleton is located at the base of the ventricles, between the atria and the ventricles.

The rings of the fibrous skeleton are compose of dense, fibrous connective tissue that encircle the
orifices of the heart valves. These fibrous rings are interconnected by connective tissue called the right
and left trigones and form the structural support for the heart on which the valvular leaflets and cardiac
muscle fibers are anchored.

This complex structure is located between the atria and the ventricles. These are the four fibrous rings,
right and left fibrous trigones and the membranous aspects of the interatrial, interventricular and
atrioventricular septa.

These four fibrous rings surround the orifices of the pulmonary, aortic and atrioventricular valves, giving
attachments to their leaflets and resisting excessive distention. The left fibrous ring encircles the left
atrioventricular valve (mitral valve), and the right fibrous ring encircles the left atrioventricular valve
(tricuspid valve.) The pulmonary ring corresponds to the pulmonary valve as does the aortic ring to the
aortic valve.

The left and right trigones are interconnections between the fibrous rings, and the strongest parts of the
skeleton. A thickened connective tissue connection between the aortic ring and right atrioventricular
ring forms the right trigone, while the left trigone is formed by a similar connective tissue bridge
between the aortic ring and the left atrioventricular ring.
The fibrous skeleton of the heart performs several important functions and plays a vital role in
supporting both the structure and function of the heart.

It helps keep the orifices of the valves it surrounds patent, and serves as points of attachment for the
leaflets and cusps of these valves.

The fibrous skeleton separate the atrial musculature from that of the ventricles. It serves as the
framework for the attachment of myocardial fibers, with atrial fibers arising from the upper border of
the rings and ventricular fibers originating from the lower border of the rings.

The fibrous skeleton serves as an electrical insulator, partitioning electrical impulses conducted through
the musculature of the atria and ventricles, allow them to contract independently. In line with this, the
fibrous skeleton provides passage for the atrioventricular bundle, which serves as the only electrical
connection between the atria and ventricles.

The Cardiac Cycle

Each cardiac cycle has a diastolic phase (diastole) where the heart chamber is in a state of relaxation and
fills with blood that receives from the veins and systolic phase (systole) where the heart chambers are
contracting and pumps the blood towards the periphery via the arteries. Both the atria and the
ventricles undergo alternating states of systole and diastole. In other words, when the atria are in
diastole, the ventricles are in systole and vice versa.

Atrial diastole: Atria passively filling, atrioventricular valves open.

Atrial systole: Action potential from the sinoatrial node, synchronous atrial contraction, active filling of
ventricles.

Ventricular diastole: First third of the diastolic phase (early ventricular diastole): ventricular rapid inflow,
middle third of the diastolic phase (late ventricular diastole): passive inflow or diastasis, last third of the
diastolic phase (atrial diastole): ventricular filling due to atrial contraction

Ventricular systole: Isovolumetric contraction – atrioventricular and semilunar valves are closed,
semilunar valve opens, emptying of ventricle, end systolic volume.

The events of the cardiac cycle start with a spontaneous action potential in the sinus node. This stimulus
causes a series of events in the atria and ventricles. These events are organized into two phases:

Diastole: when the heart fills with blood

Systole: when the heart pumps the blood.

Effects of potassium and calcium on the heart

Potassium and calcium are two important electrolytes that play a crucial role in the function of the
myocardium, the muscular tissue of the heart. Movement of the ions across the semi-permeable
myocardial cell membrane causes the voltage across the membrane to exceed a threshold and generate an
action potential, resulting in muscle contraction.
Potassium is crucial for normal cell function in the body, including heart muscle cells. The right level of
potassium is key. An above normal level of potassium can interfere with proper electrical signals in that
muscle layer and lead to different types of heart arrythmias.
Calcium is also important for heart function. Calcium ions are involved in the initiation of muscle
contraction in the heart.

The effect of sympathetic stimulation on arteries and arterial walls

In blood vessels, sympathetic activation constricts arteries and arterioles, which increases vascular
resistance and decreases distal blood flow. When this occurs throughout the body, the increased
vascular resistance causes arterial pressure to increase. Sympathetic induced constriction of veins
decreases venous compliance and blood volume increases, and increases venous pressure. The effect of
sympathetic activations is to increase cardiac output, systemic vascular resistance and arterial blood
pressure. This is important during exercise, emotional stress and during hemorrhagic shock.