TheHeart

Chapter18

Introduction

Theheartisthepumpofourcirculatory
system
Thecardiovascularsystemprovidesthe
transportsystemofthebody
Usingbloodasthetransportmedium,the
heartcontinuallypropelsoxygen,
nutrients,wastes,andmanyother
substancesintotheinterconnectingblood
vesselsthatmovepastthebodycells

Introduction

Theheartisamusculardoublepump
withtwofunctions
Itsrightsidereceivesoxygenpoorblood
fromthebodytissuesandthenpumpsitto
thelungs
Itsleftsidereceivesoxygenatedbloodfrom
thelungsandthenpumpsittothebody

Introduction

Thebloodvessels
thatcarryblood
fromthelungs
formthe
pulmonarycircuit
Thevesselsthat
carrybloodtoall
thebodytissues
formthesystemic
circuit

HeartSize,LocationandPosition

Theheartisaboutthesize
ofafist
Itweighsbetween250
350grams(lessthana
pound)
Locatedinthemedial
cavityofthethorax,the
mediastinum
Itextendsfromthe2nd
ribto5thintercostalspace
Restsonthesuperior
surfaceofdiaphram

HeartSize,LocationandPosition

Thelungsflanktheheartlaterallyandpartially
obscureit

HeartSize,LocationandPosition

Theheartliesanteriorto
thevertebralcolumnand
posteriortothesternum
Twothirdsoftheheart
liestotheleftofthemid
sternalline;thebalance
projectstotheright
Itsbroadflatbase,or
posteriorsurface,points
torightshoulder
Theapexpointstoward
thelefthip

Location4Corners

Theheartishasfour
cornersprojectedonto
theanteriorthoracic
wall
Superiorrightwhere
thecostalcartilage
joinsthe3rdrib
Superiorleftcostal
cartilageof2ndriba
fingersbreadthlateral
tothesternum

Location4Corners

Theinferiorrightlies
atthecostalcartilage
ofthesixthrib,a
fingersbreathlateral
tothesternum
Theinferiorleft(apex)
liesinthefifth
intercostalspaceatthe
midclavicularline
Thesepointsdepictthe
normalheartsizeand
placement

CoveringsoftheHeart

Theheartisenclosedinatriplewalledsaccalledthe
pericardium
Theloosefittingouterlayerofthesacisthefibrous
pericardium
Thistough,denseconnectivetissuelayer1)protectstheheart;
2)anchorstheheart;and3)preventsoverfilling

CoveringsoftheHeart

Deeptothefibrouspericardiumisthedoublelayered
serouspericardium,aclosedsacsandwichedbetween
thefibrouspericardiumandtheheart
Thetwolayersare
Parietallayer
Viscerallayer

CoveringsoftheHeart

Theouterparietallayeradherestotheinternal
surfaceofthefibrouspericardium
Atthesuperiorreflectionoftheheart,theparietal
layeriscontinuouswiththeviscerallayerofthe
serouspericardiumorepicardium

CoveringsoftheHeart

Theviscerallayer,alsocalledtheepicardium,isan
integralpartoftheheartwall
Thetwolayermembraneconformsaroundtheheart
muchlikepushingyourfistintoadoublelayer
membranewithanairpocketinbetween

CoveringsoftheHeart

Betweenthetwolayersofserouspericardiumistheslitlike
pericardialcavity
Thecavitycontainpericardialfluid
Theserousmembranes,lubricatedbyfluid,glidesmoothly
againstoneanotherduringheartactivity,creatinga
relativelyfrictionfreeenvironment

Inflammation

Inflammationoftheheartcanleadto
seriousproblems
Pericarditis/hindersproductionofserous
fluidproductioncausingthehearttorub
Cardiactamponade/inflammatoryfluid
seepintothepericardialcavity,compressing
theheartandlimitingitsabilitytopump
blood

LayersoftheHeartWall

Theheartwalliscomposedofthreelayers
Superficiallayerofepicardium
Middlelayerofmyocardium
Deeplayerofendocardium

Allthreelayersarerichlysuppliedwithbloodvessels

LayersoftheHeartWall

Theepicardiumistheviscerallayeroftheserous
pericardium
Theepicardiumisofteninfiltratedwithfat,especially
inolderpeople

LayersoftheHeartWall

Themyocardiumisthelayerofcardiacmusclethat
formsthebulkoftheheart
Itisthelayerthatactuallycontracts
Themyocardiumselongatedcircularlyspirally
arrangedmusclecellssqueezethebloodthoughthe
heart

LayersoftheHeartWall

Withinthemyocardium,thebranching
cardiacmusclecellsaretetheredtoeach
otherbycrisscrossingconnectivetissue
fibersalsoarrangedinspiralorcircular
bundles
Theseinterlacingbundleseffectivelylink
allpartsofthehearttogether

LayersoftheHeartWall

Theconnectivetissue
formsadensenetwork
calledtheinternal
skeletonoftheheart
Itreinforcesthe
myocardiuminternally
andanchorsthecardiac
muscle
Thisnetworkoffibersis
thickerinsomeareas
thaninotherstorein
forcevalvesandwhere
themajorvesselsexit

LayersoftheHeartWall

Theinternalskeleton
preventsoverdilationof
vesselsduetothe
continualstressofblood
pressure
Additionally,since
connectivetissueisnot
electricallyexcitable,it
limitsactionpotentials
acrosstheheartto
specificpathways

LayersoftheHeartWall

Theendocardiumisaglisteningwhitesheetof
endothelium(squamousepithelium)restingonathin
layerofconnectivetissue

LayersoftheHeartWall

Locatedontheinnermyocardialsurface,it
linestheheartchambersandcoversthe
connectivetissueskeletonofthevalves
Theendocardiumiscontinuouswiththe
endothelialliningsofthebloodvessels
leavingandenteringtheheart

HeartChambers

Thehearthasfour
chambers

Atria

Twosuperioratria
Twoinferiorventricles

Thelongitudinalwall
separatingthe
chambersiscalledthe
Interartialseptum
Betweenatria

Interventricular
septum

Septum

Betweenventricles

Ventricles

HeartChambers

Therightventricle
formsmostofthe
anteriorsurfaceofthe
heart
Theleftventricle
dominatestheinferio
posterioraspectofthe
heartandformsthe
heartapex

Left
Ventricle

RightVentricle

HeartChambers

Twogroovesvisible
onthesurfaceofthe
heartindicatethe
boundariesofitsfour
chambersandcarry
thebloodvesselsthat
supplymyocardium
TheAtrioventricular
grooveorcoronary
sulcusencirclesthe
junctionoftheatria
andventricles

Coronary
Sulcus

HeartChambers

Theanteriorinter
ventricularsulcus,
separatestheright
andleftventricles
Itcontinuesasthe
posteriorinter
ventricularsulcus
whichprovidesa
similarlandmarkon
theheartsposterio
inferiorsurface
Posterior

Interventricular
Sulcus

Anterior
Interventricular
Sulcus

HeartChambers

Exceptforthesmall,
wrinkled,protruding
appendagescalled
auricles,theatriaare
freeofdistinguishing
surfacefeatures
Theauriclesincrease
theatrialvolume
slightly

Atria

Auricles

HeartChambers

Internally,the
posteriorwallsare
smooth,butthe
anteriorwallsare
ridgedbybundlesof
muscletissue
Thesemusclebundles
arecalledpectinate
muscles

Pectinate
Muscle

HeartChambers

Theinteratrial
septumbearsa
shallowdepression,
thefoveaovalis
Thislandmarkmarks
thespotwherean
opening,theforamen
ovale,existedinthe
fetalheart

Fovea
Ovalis

HeartChambers

Functionally,theatriaarereceiving
chambersforbloodreturningtothe
heartfromthecirculation
Becausetheyneedtocontractonly
minimallytopushbloodintothe
ventricles,theatriaarerelativelysmall,
thinwalledchambers
Asaruletheycontributelittletothe
propulsivepumpingoftheheart

Atria:TheReceivingChambers

Bloodenterstheright
atriumviathreeveins

Superior
vena
cava

Superiorvenacava
Returnsbloodfrom
bodyregionssuperior
todiaphragm

Inferiornvenacava
Returnsbloodfrom
bodyareasbelowthe
diaphragm
Coronary

Coronarysinus

sinus

Collectsblooddraining
fromthemyocardium
itself

Inferior
venacava

Atria:TheReceivingChambers

Bloodenterstheleft
atriumviafourveins
Rightandleft
pulmonaryveins

Thepulmonaryveins
transportbloodfrom
thelungsbacktothe
heart

Right
Pulmonary
veins

Left
pulmonary
veins

Posterior
view

Ventricles:DischargingChambers

Markingtheinternal
wallsoftheventricle
chambersareirregular
ridgesofmusclecalled
trabeculaecarneae
Thepapillarymuscles
projectintothecavity
andplayaroleinvalve
function

Papillary
muscles

Trabeculae
carneae

Ventricles:DischargingChambers

Theventriclesare
thedischarging
chambersofthe
heart
Notethedifference
inthicknessofthe
wall
Whentheventricles
contractbloodis
propelledoutofthe
heartandinto
circulation

Atrial
Wall
Ventricular
Wall

Ventricles:DischargingChambers

Therightventricle
pumpsbloodinto
thepulmonary
trunk,whichroutes
bloodtothelungs
forgasexchange
Theleftventricle
pumpsbloodinto
theaorta,the
largestarteryinthe
systemiccirculation

Aorta
Left
ventricle

Right
ventricle

Pulmonary
trunk

PathwayofBlood:Heart

Theheartisactually
twopumps,each
servingaseparate
bloodcircuit
Bloodvesselsthat
carrybloodtothe
lungformthe
pulmonarycircuit
(gasexchange)
Vesselscarrying
bloodtothebody
formthesystemic
circuit

PathwayofBlood:Heart

Therightsideofthe
heartformsthe
pulmonarycircuit
Bloodreturningfrom
thebodyentersthe
rightatriumand
passesintotheright
ventricle
Theventriclepumps
thebloodtothelungs
viathepulmonary
trunk

PathwayofBlood:Heart

Bloodinthe
pulmonarycircuitis
oxygenpoorand
carbondioxiderich
Onceinthelungsthe
bloodunloadscarbon
dioxideandpicksup
oxygen
Freshlyoxygenatedis
carriedbacktothe
heartbythe
pulmonaryveins

PathwayofBlood:Heart

Notethatthecirculationofthepulmonary
circuitisunique
Typicallyveinscarryoxygenpoorbloodto
theheartandarteriescarryoxygenrich
blood
Thepatternisreversedinthepulmonary
circuitwiththepulmonaryarteries
carryingoxygenpoorbloodtothelungs
andthepulmonaryveinscarryingoxygen
richbloodbacktotheheart

PathwayofBlood:Heart

Theleftsideofthe
heartisthesystemic
systempump
Freshlyoxygenated
bloodleavingthe
lungsenterstheleft
atriumandpasses
intotheleftventricle
Theleftventricle
pumpsbloodintothe
aortaandfromthere
intomany
distributingarteries

PathwayofBlood:Heart

Smallerdistributing
arteriescarrythe
bloodtoallpartsof
thebody
Gases,wastesand
nutrientsare
exchangedacross
capillarywalls
Bloodthenreturnsto
therightatriumof
theheartviasystemic
veinsandthecycle
continues

PathwayofBlood:Heart

Althoughequalvolumesofbloodare
flowinginthepulmonaryandsystemic
circuitsatanyonemomentthetwo
ventricleshaveveryunequalworkloads
Thepulmonarycircuit,servedbytheright
ventricle,isalowpressurecirculation
Thesystemiccircuit,servedbytheleft
ventricle,circulatesthroughtheentire
bodyandencountersaboutfivetimesas
muchresistancetobloodflow

PathwayofBlood:Heart

Thefactthatbloodpassesthroughheart
chamberssequentiallydoesnotmean
thatthefourchamberscontractinthat
order
Ratherthetwoatriacontracttogether,
followedbythesimultaneouscontraction
ofthetwoventicles

PathwayofBlood:Heart

Asinglesequenceofatrialcontraction
followedbytheventricularcontractionis
acalledaheartbeat
Theheartoftheaverageadultpersonat
restbeats7080timesaminute

PathwayofBlood:Heart

Thecontractionofaheartchamberis
calledasystole
Thetimeduringwhichaheartchamber
isrelaxingandfillingwithbloodis
termeddiastole
Althoughbothatrialandventricular
chambersexperiencesystoleanddiastole
thetermsusuallyreferencetheventricles
whicharethedominantheartchambers

Ventricles:DischargingChambers

Thedifferencein
systemworkloadis
revealedinthe
comparative
anatomyofthetwo
ventricles
Thewallsoftheleft
ventriclearethree
timesasthickas
thoseoftheright
ventricle

Left
ventricle

Ventricles:DischargingChambers

Thecavityoftheleft
ventricleiscircular
Therightventricle
wrapsaroundthe
leftandiscrescent
shaped
Theleftcan
generatemuchmore
pressurethanthe
rightandisafar
morepowerful
pump

Left
ventricle

PathwayofBlood:System

Bloodflowsthroughtheheartandother
partsofthecirculatorysysteminone
direction
Rightatriumrightventriclepulmonary
arterieslungs
Lungspulmonaryveinsleftatriumleft
ventriclebody

Thisonewayflowofbloodiscontrolledby
fourheartvalves

HeartValves

Heartvalvesare
positionedbetween
theatriaandthe
ventriclesand
betweenthe
ventriclesandthe
largearteriesthat
leavetheheart
Valvesopenand
closeinresponseto
differencesinblood
pressure
Tricuspid

valve

Bicuspid
(mitral)
valve

Aortic
valve
Pulmonary
valve

HeartValves

Thevalvesofthe
heartallowforthe
bloodtoflowin
onlyonedirection
Note:Viewofthe
heartwiththe
superioratria
removed

Atrioventricular(AV)Valves

TheAVvalvesare
locatedateachatrial
ventricularjunction
Thevalvesare
positionedtoprevent
abackflowofblood
intotheatriawhen
theventriclesare
contracting
Thevalvesarethe
Tricuspidvalve
Bicuspidvalve

Tricuspid
valve

Bicuspid
(mitral)
valve

Atrioventricular(AV)Valves

TherightAVvalve,
thetricuspid,has
threeflexiblecusps
TheleftAVvalve,
thebicuspid,hastwo
flexiblecusps
Thecuspsareflaps
ofendocardium
reinforcedby
connectivetissue

Tricuspid
valve

Bicuspid
(mitral)
valve

Atrioventricular(AV)Valves

Attachedtoeachof
theAVvalveflaps
aretinycollagen
cordscalledchordae
tendoneae
Thecordsanchorthe
cuspstothepapillary
musclesprotruding
fromtheventricular
walls

Papillary
muscles

Chordae
tendoneae

Atrioventricular(AV)Valves

Whentheheartis
completedrelaxed,the
AVvalveflapshang
limplyintothe
ventricularchambers
Bloodflowsintothe
atriaandthenthrough
theopenAVvalves
intotheventricles
Atriacontract,forcing
additionalbloodinto
ventricles

Atrioventricular(AV)Valves

Whentheventricles
begintocontract,
compressingtheblood
inthechambers,intra
ventricularpressure
risesforcingblood
superiorlyagainstthe
valveflaps
Thechordaetendoneae
andthepapillary
musclesanchorthe
flapsintheirclosed
position

Semilunar(SL)Valves

Theaorticand
pulmonary
semilunarvalvesare
locatedatthebases
ofthelargearteries
exitingtheventricles
Thevalvesprevent
backflowofblood
fromtheaortaand
pulmonarytrunk
intotheassociated
ventricles

Aortic
valve

Pulmonary
valve

Semilunar(SL)Valves

Eachsemilunarvalve
ismadeupofthree
pocketlikecusps
Theirmechanismof
closurediffersfrom
thatoftheAVvalves
Whentheventricles
contractintra
ventricularpressure
exceedstheblood
pressureintheaorta
andpulmonarytrunk

Semilunar(SL)Valves

Bloodpressurefrom
theventricleforces
thesemilunarvalves
openandbloodis
forcedpastthevalve
andintotheartery
Whentheventricles
relax,andtheblood
flowsbackward
towardtheheartit
fillsthecuspswhich
closesthevalves

HeartSounds

Theclosingoftheheartvalvescauses
vibrationsintheadjacentbloodand
heartwallsthataccountforthefamiliar
lubdupsoundsoftheheartbeat
Thelubisproducedbytheclosingof
theAVvalvesatthestartofventricular
systole
Thedupisproducedbytheclosingof
thesemilunarvalvesattheendof
ventricularsystole

FibrousSkeleton

Thefibrous
skeletonofthe
heartliesinthe
planebetweenthe
atriaandthe
ventricles
Itsurroundsthe
fourvalves
Itiscomposedof
denseconnective
tissue

FibrousSkeleton

Thefibrousskeletonhasfourfunctions
Itanchorsthevalvecusps
Itpreventsoverdilationofthevalveopenings
asbloodpulsesthroughthem
Itisthepointofinsertionforthebundlesof
cardiacmuscleintheatriaandventricles
Itblocksthedirectspreadofelectrical
impulsesfromtheatriatotheventricles

ConductingSystem

Cardiacmusclecellshaveanintrinsic
abilitytogenerateandconductimpulses
thatsignalthesesamecellstocontract
rhythmically
Thesepropertiesareintrinsictotheheart
muscleitselfanddonotdependon
extrinsicnerveimpulses
Evenifallnerveconnectionstotheheart
aresevered,theheartcontinuestobeat
rhythmically

ConductingSystem

Theconductingsystemoftheheartisa
seriesofspecializedcardiacmusclecells
thatcarriesimpulsesthroughoutthe
heartmusculature,signalingtheheart
chamberstocontractinpropersequence

ConductingSystem

Thecomponentsof
theconducting
systemare:
Sinoatrialnode
Internodalfibers
Atrioventricular
node
Atrioventricular
bundle
Rightanleft
branches
Purkinjefibers

ConductingSystem

Theimpulsethat
signalseach
heartbeatbeginsat
thesinoatrial(SA)
node
Thisisacrescent
shapedmassof
musclecellsthat
liesinthewallof
therightatrium,
belowtheentrance
ofthesuperior
venacava

ConductingSystem

Thesinoatrial
node,thehearts
ownpacemaker,
setsthebasicheart
ratebygenerating
7080impulsesper
minute

ConductingSystem

Thesequencethatcontrolseach
heartbeatatrialcontractionfollowedby
ventricularcontractionisspecific

ConductingSystem

Impulsesfromthe
SAnodespreadin
awavealongthe
cardiacmuscle
fibersoftheatria
signalingtheatria
tocontract

ConductingSystem

Someofthese
impulsestravel
alongtheintranodal
pathwaytothe
atrioventricular
(AV)nodeinthe
inferiorpartofthe
interatrialseptum,
wheretheyare
delayedfora
fractionofasecond

ConductingSystem

Afterthisdelay,
theimpulsesrace
throughtheatrio
ventricularbundle
whichentersthe
interventricular
septumand
dividesintoright
andleftbundle
branches

ConductingSystem

Abouthalfway
downtheseptum,
theBundlefibers,
(crura),become
bundlesof
Purkinjefibers
whichapproach
theapexofthe
heart,thenturn
superiorlyintothe
ventricularwalls

ConductingSystem

Thisarrangementofconductingstructures
ensuresthatthecontractionofthe
ventriclesbeginsattheapexoftheheart
andtravelssuperiorly,sothatthe
ventricularbloodisejectedsuperiorlyinto
thegreatarteries
Thebriefdelayofthecontraction
signalingimpulsesattheAVnodeenables
theventriclestofillcompletelybeforethey
starttocontract

ConductingSystem

Becausethefibrousskeletonbetweenthe
atriaandventriclesisnonconducting,it
preventsimpulsesintheatrialwallfrom
proceedingdirectlyontotheventricular
wall
Asaresult,onlythosesignalsthatgo
throughtheAVnodecancontinueon

ConductingSystem

Examinationofthemicroscopicanatomy
oftheheartsconductingsystemreveals
thatthecellsofthenodesandAVbundle
aresmall,butotherwisetypicalcardiac
musclecells
EachPurkinjefiber,bycontrast,isa
longrowofspecial,largediametercells
calledPurkinjemyocytes

ConductingSystem

Purkinjemyocytesarecardiacmuscle
cellscontainingrelativelyfew
myofilamentsbecausetheyareadapted
moreforconductionthancontraction
Theirlargediametermaximizesthe
speedofimpulseconduction
Purkinjefibersarelocatedinthedeepest
partoftheventricularendocardium,
betweentheendocardiumand
myocardiumlayers

Innervation

Althoughthehearts
inherentrateof
contractionissetbythe
SAnode,thisratecan
bealteredbyextrinsic
neuralcontrols

Innervation

Thenervestotheheart
consistofvisceral
sensoryfibers
Parasympatheticfibers
thatslowheartrate
Sympatheticfibersthat
increasetherateand
forceofheart
contractions

Innervation

Parasympathetic
nervefibersarise
asbranchesofthe
Vagusnerveinthe
neckandthorax

Innervation

Sympatheticnerves
traveltotheheart
fromthecervical
andupperthoracic
chainganglia
Allnervesserving
theheartpass
throughthe
cardiacplexuson
thetracheabefore
enteringtheheart

Innervation

Althoughautonomic
fibersprojecttocardiac
musculature
throughouttheheart,
theyprojectmost
heavilytotheSAand
VAnodesandthe
coronaryarteries

Innervation

Theautonomicinputto
theheartiscontrolledby
cardiaccentersinthe
reticularformationof
themedullaofthebrain
Inthemedulla,the
cardioinhibitorycenter
influences
parasympathetic
neurons,whereasthe
cardioacceleratory
centerinfluences

sympatheticneurons

Innervation

Thesemedullary
cardiaccenters,inturn,
areinfluencedbysuch
higherbrainregionsas
thehypothalamus,
periaqueductalgray
matter,amygdala,and
insularcortex

CoronaryCirculation

Thecoronary
circulation,the
functionalblood
supplyoftheheart,
istheshortest
circulationinthe
body
Thearterialsupply
ofthecoronary
circulationis
providedbythe
rightandleft
coronaryarteries

CoronaryCirculation

Theleftcoronary
arteryrunstoward
theleftsideofthe
heartandthen
dividesintoitsmajor
branches
Anterior
interventricular
arteryfollowsthe
sulcusandsupplies
bloodtotheinter
ventricularseptum
andwallsofventricle

CoronaryCirculation

Therightcoronary
arterycoursestothe
rightsideoftheheart
whereitdivides
Themarginalartery
servesthemyo
cardiumofthelateral
partoftherightsideof
theheart
Theposteriorinter
ventriculararteryruns
totheapexoftheheart

CoronaryCirculation

Therearemanymergingbloodvessels
thatdeliverybloodtotheheartmuscle
Thisexplainshowtheheartcanreceive
anadequatesupplywhenoneofits
coronaryarteriesisalmostentirely
occluded

CoronaryCirculation

Thecoronaryarteriesprovideaninter
mittentpulsatingflowtothemyocardium
Thesevesselsandtheirmainbrancheslie
intheepicardiumandsendbranches
inwardtonourishthemyocardium
Althoughtheheartrepresentsonlyabout
1/200ofbodyweight,itrequires1/20of
thebodysbloodsupply
Theleftventriclereceivesthelargest
proportionofthebloodsupply

CoronaryCirculation

Afterpassing
throughthemyo
cardium,thevenous
bloodiscollectedby
thecardiacveins
Theveinsjoin
togethertoforman
enlargedvessel
calledthecoronary
sinuswhichempties
intotherightatrium

EndofMaterial
Chapter18