PTR308

CARDIAC DISEASES AND

REHABILITATION
ASST. PROF. BAHA NACİ
2022-2023 SPRING SEMESTER
22.02.2024
LOCATION AND SIZE OF THE HEART

The heart is a blood pump that works from the end of the 3rd week of embryological life
(day 22-23) to the end of life.
The heart is located within the rib cage, slightly to the left of the midline.
It is protected by the sternum in front, the spine in the back, and the lungs and ribs on the
sides.
• The shape of the heart is not in the form of " " as it is thought, but resembles an
inverted cone with the apex down and the base up. The pointed part of this cone is
called the apex. The apex of the heart is directed to the left side of the chest and
anterior-downward.
LAYERS OF THE HEART

The wall of the heart consists of three layers:

Endocardium: It is a thin layer that covers the inner surface of the heart chambers and
valves.
Myocardium: The heart muscle is the middle layer of the heart. A layer is mainly
responsible for the pumping function of the heart. It is the thickest of the three layers.
Muscle fibers attach to the fibrous skeleton of the heart.
 Pericardium: It is the fibro-serous layer that covers the outer surface of the heart.
PERICARD

The deep layer is called tunica serosa, and the superficial layer that covers this layer from
the outside is called tunica fibrosa.
The serous pericardium, like all serous membranes, has visceral and parietal leaves.
The potential space between these leaves is called the pericardial cavity. Here is a thin
layer of fluid that allows the heart to beat and move in a frictionless environment.
The visceral layer is the thin leaf that covers the heart muscle and is also known as the
epicardium (the outermost layer of the heart wall).
The parietal layer, on the other hand, adheres tightly to the inner surface of the fibrous
layer.
 The fibrous pericardium stabilizes the heart and helps prevent the heart from
overexpanding. The pericardium has an important role in protecting the heart and
reducing mechanical friction.
Superiorly, the fibrous pericardium is continuous with the tunica adventitia of the
large vessels entering and exiting the heart and the pretracheal layer of the deep
cervical fascia.
It is anteriorly connected to the posterior surface of the sternum by strenopericardial
ligaments.
It is attached to the structures in the posterior mediastinum through loose connective
tissue in the posterior.
Inferiorly, it is tightly attached to the central tendon of the diaphragm and is partially
mixed into this structure centrally. This continuous region is known as the
pericardiophrenic ligament.
Because of these connections, the heart is partially well seated in the fibrous sac.
 The phrenic nerve (C3-5) provides the innervation of the pericardium and is the
primary source of sensory fibers. The sensation of pain transmitted by
N.phrenicus is usually reflected in the skin of the supraclavicular region (above
the shoulder) on the same side. Truncus symphaticus-vasomotor.
The heart and large vessel roots in the pericardial sac are in contact with the
sternum, cartilaginous ribs anteriorly and the medial ends of the 3rd, 4th, 5th ribs on
the left side.
The heart and pericardial sac are obliquely located and approximately 2/3 of them
are on the left and 1/3 are on the right of the median plane.
A four-sided, three-sided pyramid with apex cordis; its apex is towards the ground
and anterior, its base completely behind it, opposite to the apex; Its three faces:
facies diaphragmatica inferior (the seated part of the pyramid), facies sternocostalis
(anterior) and facies pulmonalis (left).
The apex is located medially at the intersection of the left 5th intercostal space and
the medioclavicular line, or about 9 cm (approximately the width of the person's
hand) from the median plane on the same line, on the left.
 The average adult's heart is about the size of a clenched fist and weighs about
350 grams.
CHAMBERS OF THE HEART

Blood circulation is a continuous process, and the heart, lungs, and other parts of the
body have a constant supply of blood coming and going. Various structures in the heart
regulate this process.
The heart is divided into two sides: right and left. There are 2 chambers on each side, and
thus the heart has a total of 4 chambers.
These four chambers are the right ventricle, the left ventricle, the right atrium and the left
atrium.
 The atria are small spaces behind the ventricles and their walls are thin.
On both the right side and the left side, there is a valve between the atrium and the
ventricle that allows blood to pass only from the atrium to the ventricle in one
direction.
The right and left atrium are separated from each other by the interatrial septum.
The structure that separates the right ventricle and the left ventricle is called the
interventricular septum.
The right side of the heart provides lung circulation, while the left side provides
systemic circulation in the other part of the body.
The muscles of the left ventricle are 3 times thicker than the right ventricle.
 Since the arterial pressure in the systemic circulation is much higher than in the
pulmonary circulation, the left ventricle does more work than the right ventricle.
Due to the fact that it does more work, its papillary muscles are wider than those
of the right ventricle.
In fatal life, there is a hole in this septum that
allows blood to pass from one atrium to
another (foramen ovale).
 Before birth, while still in the uterus, this
opening is normal because oxygenated
blood enters the circulation directly with
the help of this hole without passing
through the lungs. Since the lungs are
activated after birth, such a transition
between the right and left atrium is no
longer needed and closes immediately.
HEART VALVES

Heart valves keep blood flowing in the right direction, and their function is largely similar
to castle gates: they open only when pushed, and they open only in one direction. Once
closed, they prevent blood from escaping back in the opposite direction.
The heart has 4 valves:
Tricuspid valve, which allows blood to pass from the right atrium to the right ventricle
Pulmonary valve, which allows blood to pass from the right ventricle through the
pulmonary artery to the lungs
The mitral valve, which allows blood to pass from the left atrium to the left ventricle
 The aortic valve, which allows blood to pass from the left ventricle to the aorta
Mitral and tricuspid valve "atrioventricular valves"; The aortic and pulmonary valves
are called "semilunar valves".
During systole, the aortic and pulmonary valves are open, but the mitral and tricuspid
valves are closed to prevent the passage of blood from the ventricle into the atrium.
During diastole, the mitral and tricuspid valves are open, and the aortic and
pulmonary valves are closed to prevent arterial blood from escaping during the
isovolumetric relaxation phase.
Semilunar valves close abruptly due to high arterial pressures at the end of systole.
 AV valves close more slowly than semilunar valves. However, the openings of the
semiluner valves are narrower and their launch speed is greater. Therefore,
mechanical abrasion is greater.
The leaflets in the AV valves are attached to fibrous tissue called chordae tendinea,
which in turn attaches to the papillary muscles.
Chorda tendinea attaches to the free ends, and ventricular faces of the valve leaflets,
just like the ropes of a parachute.
With ventricular contraction, when these muscles contract and stretch the chorda
tendinea, the inversion of the leaflets is prevented, that is, the prolapse of the valve
leaflets is prevented from being pushed into the atrium with an increase in ventricular
pressure. (prevents the leaflets from being pushed into the low-pressure atrium).
With the opening of the valves in the atrium systole, relaxation occurs in the papillary
muscles and therefore in the chorda tendinea.
 One-way flow of blood is provided by: (1) Pressure difference (2) Valves.
CIRCULATION AND INNERVATION OF THE HEART

 The heart, which pumps blood to nourish other parts of the body, also needs blood itself. The
aorta is the single main artery through which the left ventricle pumps blood and is the largest
artery in the body. The first two branches of the aorta are the right and left main coronary arteries
that supply the heart.
 The right coronary artery supplies the sino-atrial node, the atrio-ventricular node, the right atrium,
most of the right ventricle and the upper half of the lower and posterior wall of the left ventricle. It
exits the aorta (right sinus aorta) above the right semilunar valve.
 The left main coronary artery divides into two large branches: the "circumflex coronary artery",
which runs around the back of the heart and supplies the inferior, lateral and posterior regions of
the left ventricle and the left atrium, and the "left anterior descending artery", which runs down
the anterior surface of the heart and supplies the anterior surface of both ventricles, the
ventricular apex and the 2/3 anterior septum.
 The left coronary artery is 70% larger in diameter than the right coronary artery. It arises from the
aorta (left sinus aorta) above the left semilunar valve.
The coronary arteries move towards the
surface of the heart and branch into smaller
branches.
The blood flowing from these arteries is
collected in the coronary vein system after
feeding the heart and poured into the right
atrium.
The sacs (sinuses) formed between the
semilunar valves and the inner surface of the
vessel wall are empty in systole; As a result,
the coronary arteries are also empty.
The blood escaping back in the ventricular
diastole fills these sacs and the aortic valve
closes.
 When the sacs are full, the blood passes
through the sacs to the coronary arteries
and thus the heart feeds itself into the
diastole.
Veins of the heart; There are 3 groups: "Sinus Coronarius and the large vein group
opening to it", "Vv. cordis anterior" and "Vv. cordis minimae".
The large veins collect on the posterior surface and drain into the right atrium
through the sinus coronarius.
Small veins (vv. cardiaca anterior and v. cardiaca minimae) drain directly into the
heart cavities without visiting the sinus coronarius.
 The heart works on its own with a special conduction system. But the autonomic
nervous system controls the work of the heart. The innervation of the heart is a
complex system. The cardiac nerves come from the cardiac plexus around the
arcus aorta.
VEINS

 The arterial and venous systems are connected to each other by the capillary system.
Tr. pulmonalis is in the arterial system, as it carries the blood pumped by the heart to
the lungs, but it carries venous blood. On the other hand, v. pulmonalis, on the other
hand, is in the venous system because it carries blood from the lungs to the heart, but
they carry arterial blood.
 The aorta is the main source of the arterial system, distributing arterial blood
throughout the body. It turns to the left, forming a backward arch, and reaches the top
of the lung stem. Then it stretches down the left side of the spine. According to its
course, the aorta is divided into 3 as ascendens, arcus aorta and aortic descendens.
Aorta ascendens; It is the first part of the aorta that remains within the pericardial sac. After
exiting the pericardial sac, it turns backwards and continues as the arcus aorta. The place of
initiation is the ostium aorta at the base of the left ventricle.
Arcus aorta; It is the 2nd part between the ascending and descending aorta.
 Aorta descendens; The arcus extends from the end of the aorta to the L4 body. It is divided
into two parts: Aorta thoracica (between the lower edge of T4 and the lower edge of T12.
The hiatus passes into the abdominal cavity through the aorticus and continues as the aorta
abdominalis) and the aortic abdominalis (between the lower edge of the T12, diaphragm,
and the L4 body).
 Branches of the Arcus aorta; From the convex upper face, 3 large vessels emerge
that feed the head and neck organs and upper extremities.

Truncus brachiocephalicus; It is the common stump of the arteries that feed the right
upper extremity and the right part of the head and neck coming out of the aortic arch.
It travels upwards, backwards, to the right. Behind the right steroclavicular joint, it
branches into a.carotis communis dextra and a.subclavia dextra.
A.carotis communis sinistra; En. To the left and just behind the brachiocephalicus,
the Arcus leaves the aorta.
1. A.subclavia sinistra; It is the branch of the Arcus Aorta, which separates at the
back and on the left.
 The upper margin of the thyroid cartilage
of A.carotis communis dextra and sinistra
is divided into the end branches of the
a.carotis interna and externa. The head
and neck are mainly fed by the carotid
arteries.
 A.subclavia mainly feeds the upper limbs.
It extends laterally to the 1st rib, to the
middle of the clavicle, and after passing
under the clavicle, it receives the name A.
axillaris, with this name it advances to the
lower-outer edge of the M. pectoralis
major in the fossa axillaris and then
continues in the arm, taking the name of
A. brachialis. At the level of the collum
radii it is divided into a.radialis and
a.ulnaris.
There are 3 groups of veins in the venous system: pulmonary, systemic and portal.
The portal system connects to the inferior vena cava through the liver.
Pulmonary veins
The vena cava system (systemic veins) carries venous blood from all structures in
the body, except the lungs and most of the digestive system, to the right atrium.
There are 3 separate systems here: the venous system of the heart, the upper and
lower vena cava systems. In addition, the fetus has a system of umbilical veins.
After passing under the v.axillaris clavicula in the upper extremity, it is called
v.subclavia and extends to the sternal end of the clavicle. Here, v. subclavia and v.
jugularis interna (the thickest neck vein) combine at an angle called the angulus
venosus (Pirogoff's angle) to form v. brachiocephalica.
 The facial veins are branches of the v.jugularis interna and externa. V.jugularis
externa empties into v.subclavia, close to angulus venosus.
V.cava superior collects venous blood from
the head, neck, chest and upper extremities,
that is, the upper half of the body. It is formed
when two brachiocephalic veins join on the
right side of the sternum and open to the
upper wall of the right atrium.
V. azygos is located singularly to the right of
the spine and opens into the posterior wall of
v. cava superior.
V.hemiazygos, on the other hand, joins
v.azygos by diagonally crossing the midline
from left to right at the T6 level.
 If there is an obstruction in the inferior
vena cava, venous blood is transported to
the superior vena cava by the azygos and
hemizygos veins.
TRANSMISSION SYSTEM OF THE HEART

Electrical impulses start from the sino-atrial (SA) node, which is located at the superior
entrance of the v.cava superior in the upper part of the right atrium, that is, the main
generator of the heart is the sinus node.
The SA node is a small nodal tissue accumulation consisting of specialized heart muscle
fibers and fibroelastic connective tissue and is the pacemaker of the heart.
 The stimulus emanating from the sinus node reaches the atrio-ventricular (AV) node
by passing through the conduction paths in the atria, which we can call electrical
cables.
The AV node, located in the lower-posterior part of the interatrial septum, is similar to
substations. It sends the incoming electric current to the right and left ventricles in a
controlled manner. AV node delays the passage of electrical impulses to the
ventricles. The reason for this delay is to allow the atria to completely expel blood
into the ventricles before the ventricles contract.
The His bundle is the main cable coming out of the transformer; Then this main
cable is divided into two branches, right and left, to spread electricity to both
ventricles.
 Each right and left branch proceeds deep into the endocardium on both sides of
the muscular interventricular septum, then separates into Purkinje fibers that lie
inside the walls of the respective ventricles and are transmitted to the ventricular
walls by papillary muscles.
 If the main generator fails to function due
to illness, one of the backup generators
in the AV node and ventricular tissue is
activated and the heart continues to
work.
 The speed of the stimulus starting from
the SA node is 60-100/min, and at the AV
node it is 40-60/min. The conduction
system ensures that electrical impulses
reach all parts of the heart at the right
time, so that the heartbeat occurs in a
coordinated manner and at a normal rate.
https://www.youtube.com/watch?v=qmpd82mpVO4
INNERVATION of the HEART

The heart is innervated by autonomic nerve fibers that emerge from the superficial and
deep cardiac plexuses.
Sympathetic stimulation comes from presynaptic fibers with nerve cells located in the
cornu lateral of the upper 5 or 6 thoracic segments of the medulla spinalis, and from
postsynaptic sympathetic fibers with nerve cells located in the neck and upper thoracic
paravertebral ganglia of the truncus symphaticus.
 Postsynaptic fibers terminate in the coronary arteries in relation to the SA and AV
nodes, the ends of the parasympathetic fibers in the coronary arteries.
Sympathetic stimulation of nodal tissue increases heart rate and severity of
contractions.
Sympathetic stimulation prevents the coronary arteries from narrowing and indirectly
causes the arteries to expand. Thus, more oxygen and nutrients are provided in the
myocardium during increased activity.
 Parasympathetic stimulation is provided by the presynaptic fibers of the n. vagus.
Postsynaptic parasympathetic fibers terminate in the coronary arteries with the SA
and AV nodes. Parasympathetic stimulation reduces the heart rate and the
contraction of the heart and saves energy between periods of increased need by
vasoconstriction in the coronary arteries.
HEART CYCLE

 It begins with a period of ventricular relaxation (diastole) and ends with a period of
ventricular contraction (systole).
1. Ventricular (isovolumetric) relaxation
2. Ventricular filling phase
3. Atrial systole period
4. Ventricular (isovolumetric) contraction
5. Ejection phase
 In the isovolumetric relaxation phase, the pressures of the ventricles fall below the
pressures of the aorta and pulmonary arteries, the closure of the aortic valve is
followed by pulmonary artery closure.
 When the intraventricular pressure drops further and falls below the atrium
pressures, the AV valves open and the ventricles fill.
 Following atrium depolarization, first the right and then the left atrium contracts.
 After a short interval, the work of the ventricles begins. The left ventricle contracts
first, and the right ventricle shortly after. When the increased ventricular pressure
exceeds the pressure of the atrium, the AV valves close. Until the semilunar
valves open, the ventricles contract without a change in volume, this phase is the
isovolumetric contraction phase.
 When the pressure of the left and right ventricle exceeds the pressure of the aorta
and pulmonary artery, the semilunar valves open and ventricular ejection begins.
The pressure exceeds 80 mmHg in the left ventricle and 8 mmHg in the right
ventricle.
 Thus, the cycle is completed.
The ventricles fill rapidly with blood from the atria in the first 1/3 of the diastole, and
the second 1/3 is the slow filling period.
Approximately 75% of the blood passes through the atria and flows directly into the
ventricles during the first 2/3 of the diastole, before the atrium systole, that is, during
the ventricular filling period.
In the last 1/3 of the diastole, the atrium becomes systole and 25% of the blood
passing to the ventricles is pumped during this period.
Therefore, the atria act as primary pumps, which increase the efficiency of the
ventricles as pumps by 25%. However, even without this additional 25% efficiency,
the heart can continue to function adequately under most conditions.
 In the ejection phase, 70% of the blood is discharged into the arteries with the
rapid ejection phase in the first 1/3 period and 30% with the slow ejection phase in
the last 2/3 periods.
The systole time lasts about 0.3 sec and the diastole time lasts 0.62 sec.
Reasons why the duration of diastole is longer than systole:
The heart muscle rests in diastole.
Blood flow to the subendocardial part of the left ventricle reaches only at
diastole.
 Most ventricular filling occurs in diastole.
STROKE VOLUME

 Stroke volume is the volume of blood that the heart pumps at each systole.
 It is the difference between end-diastolic ventricular volume (130 ml) and end-systole
ventricular volume (60 ml)(70 ml).
 Stroke volume is regulated by three variables: end diastolic volume (EDV), total
peripheral resistance (frictional resistance to blood flow in the arteries), contractility
(ventricular contraction strength).
 The increase in EDV (preload) increases the stroke volume and the changes in the
strength of the contraction are directly related to the EDV.
 In order for blood to be expelled from the arterial system, the ventricular pressure must
be higher than the arterial pressure. Therefore, in cases where total peripheral
resistance (afterload) increases, such as hypertension and vasoconstriction, stroke
volume decreases.
CARDIAC OUTPUT

 Cardiac output; It is the amount of blood that the heart pumps into the aorta and
systemic circulation in one minute.
 A person's activity status varies significantly with body metabolism, age, exercise, and
body size.
 It is approximately 4-6 lt/min.
 Cardiac output=stroke volüme x heart rate
 The cardiac output that the heart can reach is limited. This causes a plateau in the
cardiac output curve. This level is 2.5 times the normal cardiac output (approximately
13 lt/min). The heart that pumps blood above this is called the hypereffectual heart,
and the heart that pumps blood below it is called the hypoeffective heart.
 Hypereffective heart:
1. Neural stimulation: Increase in frequency; 120-150 beats/min, increased
contractile force - approximately twice the normal (around 25 L/min)
2. Hypertrophy of the heart muscle: Exposure to increased workloads leads to
hypertrophy, resulting in an increase in the contractile force of the heart muscle.
For example, marathon runners may experience a 50-75% increase in heart
mass - allowing the heart to pump more blood; approximately 30-40 L/min.
 Hypo-effective heart:

1. Significant reduction in the pumping efficiency of the heart: Myocardial infarction

(MI), severe valve disease, myocarditis
2. Abnormalities leading to a significant decrease in venous return: Decreased
blood volume (hemorrhage), acute venous dilation (sudden inactivity of the
sympathetic nervous system), obstruction of large veins.
HEART SOUNDS

 The closure of the valves and the circulation of blood within the heart throughout the cardiac
cycle are involved. The optimal location for hearing heart sounds is not directly over the valves
but where the sound best resonates on the chest wall.

 The first heart sound (Systolic sound, S1, Lub): Occurs at the beginning of ventricular systole
when the AV valves close. It is long (0.14 s) and has a low frequency (pitch) (25-45 Hz). The
best-heard locations are the mitral focus (where the left midclavicular line intersects the 5th
intercostal space) and the tricuspid focus (where the left 4th intercostal space meets the
sternum).

 The second heart sound (Diastolic sound, S2, Dub): Arises from the closure of the semilunar
valves at the beginning of diastole. It is short-lived (0.11 s) and has a high pitch (50 Hz). The
best-heard locations are the aortic focus (where the right 2nd rib meets the sternum) and the
pulmonary focus (where the left 2nd intercostal space meets the sternum). It occurs during the
isovolumetric relaxation period.
 Third sound (ventricular gallop): It is caused by the vortex currents that occur during
the rapid filling of the heart at the start of the diastol and the vibration of the
ventricular wall. Its duration is 0.1 sec, its frequency is low. It is normal to hear it in
children.
 Fourth voice (atrial gallop): It occurs in the atrial systole with vortex currents formed
by the passage of blood into the ventricles. It is normally obscured by the first heart
sound. In heart block, it is clearly heard when the systole of the atrium is not followed
by the systole of the ventricle.
REFERENCES

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& Wilkins.
4. Hebgen, E.U. (2011). Visceral Manipulation in Osteopathy. Stuttgart: Georg Thieme Verlag.
5. İlerigelen B, editör. (2012). Öğrencilerle Kardiyoloji. Nobel Tıp Kitabevleri.
6. Hülya Harutoğlu, editör. (2018). Kardiyak Rehabilitasyon. Hipokrat Kitabevi