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Anatomy and Physiology

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Slide 1 :

Anatomy and Physiology Chapter 13 Cardiovascular System

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Introduction to the Cardiovascular System Heart: Pumps 7,000 liters of blood each day Muscular pump contracts 2.5 billion times in an average lifetime Vessels: Arteries, Veins Capillaries: tiniest tubes are sites of nutrient, electrolyte, gas, and waste exchange

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The function of circulation is vital for survival because without it, tissues lack O2 and nutrients. Waste accumulates. Cells soon begin irreversible change leading to death The cardiovascular system transports blood between the body cells and organs such as lungs, intestines, and kidneys that communicate with the external environment.

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Structure of the Heart Hollow cone-shaped muscular pump Size varies with body size. Ave 14 cm long by 9cm wide Located within thoracic cavity, resting on diaphragm Within mediastinum, bordered by lungs, vertebral column, and sternum. Base attaches to several large blood vessels beneath 2nd rib Apex: bottom. Level with 5th intercostal space

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The heart is within the mediastinum and is enclosed by a layered pericardium

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Coverings of the Heart - Pericardium Visceral pericardium: inner delicate layer that covers the heart. Parietal pericardium: dense, fibrous layer that lines the mediastinum

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Pericardial cavity: Spaces between the parietal and visceral layers of pericardium Contains a small volume of serous fluid Reduces friction between pericardial membranes as the heart moves.

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Pericarditis: Inflammation of the pericardium due to viral or bacterial infection. Produces adhesions that attach the layers of pericardium to each other. Painful and interferes with heart movement. Here is a condition often encounter in clinical practice -- acute fibrinous pericarditis. Normally the pericardium is a slick, shiny, serous surface, but here it is covered by rough layer of fibrin.

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A closer view of the pericardium in acute fibrinous pericarditis shows the rough, dry surface that causes the scratchy, rubbing sound heard over the precordium in synchrony with the heart beat. You will often hear this in patients with acute rheumatic fever acute myocardial infarcts and uremia. This is an example of chronic constrictive pericarditis. Here the double layered thin pericardial membranes are turned into a single thick, rigid fibrous capsule, which restricts diastolic filling of the heart and leads to right sided congestive failure. This is usually due to the healing of tuberculosis or purulent bacterial pericarditis.

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Wall of the Heart 3 distinct layers Epicardium Myocardium Endocardium

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Epicardium Outer layer Located below the visceral pericardium Protects heart by reducing friction Serous membrane that consists of connective tissue beneath epithelium. Deeper portions contain adipose tissue along with arteries and veins that carry blood through the myocardium A higher power view. Nerve, blood vessels easily identified.

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Myocardium Middle layer Mostly cardiac muscle tissue Pumps blood out of the heart chambers Muscle fibers organized on planes, separated by connective tissue richly supplied with blood capillaries, lymph capillaries, and nerve fibers.

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Endocardium Inner layer Consists of epithelium and connective tissue with many elastic and collagenous fibers Contains blood vessels and some specialized cardiac muscle fibers called Purkinje fibers. Continuous with inner linings of blood vessels attached to the heart.

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Heart Chambers and Valves 4 hollow chambers – 2 left and 2 right Coronal section of the heart showing the connection between the left ventricle and the aorta as well as the four hollow chambers.

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Atria (atrium) Upper chambers Thin walls Receive blood returning to the heart Auricles: small earlike projections that extend anteriorly from the atria This view, taken looking down on the top of the heart, shows the aorta flanked by the Right Atrium on the left and Left Atrium on the right. The atria have been cut open so that the Tricuspid and Mitral valves are visible. The Pulmonary Artery is serpentine in shape, curling around the aorta. Presumably because it sees lower stresses than the aorta, the pulmonary artery has a thinner wall and is less stiff. (pig heart)

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Ventricles Lower chambers Receive blood from atria and contract to force blood out of the heart into arteries Right ventricle has a thinner muscular wall than left ventricle. Right chamber pumps blood only a short distance to the lungs against low resistance blood flow. Left chamber must force blood to the whole body with great resistance.

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In this view, the heart is completely transected. The left ventricle is easily identifiable by its thick layer of myocardium which appears circular. The part of the myocardium which separates the left and right ventricles is the Septum. Notice the enormous difference in myocardial thickness between the ventricles. The left ventricle has to produce pressures almost ten times higher than those on the right side of the heart, so this is not surprising. Again, the Mitral valve is visible in the left ventricle, on the top half of the heart.

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Septum Solid, wall-like structure that separates the atrium and ventricles Blood from one side never mixes with other side (except in fetus) In this picture, the right ventricle (on the outside) is completely transected, with a large bundle of papillary muscle visible on the bottom half (left side). The leaflets of the Mitral valve appear in the center, surrounded by the bottom and top sections of the Septum. The top of the heart in on the right, and the apex (bottom) of the heart is on the left.

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Atrioventricular Valve (A-V valve) Tricuspid = right; bicuspid = left (Also called mitral valve) Ensures one-way blood flow between the atria and ventricles Prevents backflow by closing passively when ventricle contracts

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Photograph of a transverse section through the heart showing the four valves. (superior view)

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Semilunar valves Pulmonary (tricuspid) and aortic (bicuspid) valves Named for half-moon shapes of their cusps

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Superior vena cava and inferior vena cava 2 large veins that supply the right atrium with blood. Coronary sinus: also drains blood into right atrium

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Chordae tendineae Strong fibrous strings Attach to cusps of tricuspid valve on ventricle side Originate from small mounds of cardiac muscle tissue Papillary muscles: Project inward from walls of ventricle Contract when ventricle contracts Pull on chordae tendineae and prevent the cusps from swinging back into atrium

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Pulmonary trunk Divides to form the left and right pulmonary arteries that lead to the lungs.

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Pulmonary Valves At base of trunk Semilunar valve with 3 cusps Allows blood to leave right ventricle and prevents backflow into ventricular chamber

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Pulmonary Veins Bring blood from lungs to left atrium 4 of them. (2 from right lung and 2 from left lung)

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Bicuspid Valve (Mitral valve) Allows blood to pass from left atrium to left ventricle (A-V valve) Prevents backflow into atrium from ventricle Papillary muscles and chordae prevent the cusps of bicuspid valve from swinging back into left atrium during ventricular contraction.

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The large gaping opening at the bottom is the right ventricle, with the Tricuspid valve visible. Most of the left ventricle has been removed, but the Septum remains. One of the two Mitral leaflets is stretched-out at the top of the picture, and Chordae Tendinae are visible at the forceps. This closeup of the two leaflets of the Mitral Valve shows the chordae tendinae nicely. The chordae are connected to the myocardium of the left ventricle by large muscular bundles called papillary muscle. This chordae/papillary muscle structure helps to maintain valve geometry during ventricular contraction to reduce regurgitation back through the valve. Blood flows out towards the viewer in this picture.

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Aorta Large artery Semilunar valve opens and blood exits through aorta when left ventricle contracts. Bicuspid semilunar valve closes passively and prevents backflow when ventricle relaxes

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Here, the aortic root has been removed from the rest of the heart, and has been cut open longitudinally. Blood flows from the left ventricle, that would be attached below the cusps in the picture, through the valve and on into the aorta, that would continue past the top of the specimen. The three aortic cusps are visible. One of the coronary arteries branches out from an aortic sinus, which is a bulge in the aorta, one sinus for each cusp. There are two coronary arteries, one supplies blood to each side of the heart. The aortic valve is termed a semi-lunar valve, presumably because each cusp looks vaguely like a half moon.

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So, what's all the fuss about? This is a shot of an aortic cusp from the fibrosal (aortic) side. While it has a seemingly simple structure and acts in a passive manner, the failure of this small flap of tissue can mean death. At present, we don't have an adequate replacement for the aortic valve when it becomes diseased. This cusp has been cut along the bottom where it would be attached to the base of an aortic sinus in the aortic root. The top is termed the free edge, and it's the part that 'flaps in the breeze'. Attachment points at the ends of the free edge are called commissures. The more transparent region at the top of the cusp is the coaptation region and is believed to be a redundancy mechanism to reduce regurgitation through the valve during diastole when the ventricles relax. The surface that is visible here is called the fibrosa and is characterized by the large bundles of collagen that run across the cusp. Collagen is a connective tissue protein with a high tensile strength, and as such is believed to be the primary structural component of the cusp.

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This is the other side of the same cusp shown above. The 'bottom' of the cusp is closest to the ventricle and as such is called the ventricularis. It contains collagen and elastin, both connective tissue proteins, in a different ratio than the fibrosa. Because of its less organized structure, the ventricularis is more extensible than the stiffer, stronger fibrosa.

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Mitral Valve Prolapse (MVP) 60% of US population 1 or both cusps of the mitral valve stretches and bulges into the left atrium during ventricular contraction. Valve usually continues to function adequately but blood may regurgitate back into left atrium With stethoscope, sounds like a “click” at end of contraction then murmur as blood backflows through valve Symptoms of MVP – chest pain, palpitations, fatigue

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The mitral valve can be damaged by streptococcus bacteria Endocarditis: inflammation of endocardium due to an infection. Appears as a plant-like growth on the valve. People with MVP are susceptable to endocarditis. Must take antibiotic before undergoing dental work to prevent streptococcus infection in the mouth.

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Skeleton of the Heart Rings of dense connective tissue surround pulmonary trunk and aorta at proximal ends Provide firm attachments for valves and muscle fibers The skeleton of the heart consists of fibrous rings to which the heart valves are attached. (superior view)

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Prevent outlets of atria and ventricles from dilating during contraction Fibrous rings and other masses of dense connective tissue in the portion of the septum between ventricles (intraventricular septum) constitute the “skeleton” of the heart.

Slide 44 :

Path of Blood through the Heart Low O2 / high CO2 enters right atrium through venae cavae and coronary sinus Right atrial wall contracts and blood goes through tricuspid and enters right ventricle When right ventricular wall contracts, tricuspid valve closes and blood moves through pulmonary valve into pulmonary trunk and branches (pulmonary arteries)

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Pulmonary arteries to capillaries associated with alveoli of the lungs. Gas exchange occurs Blood high in O2 / low in CO2 returns to heart through pulmonary veins to left atrium. Left atrial wall contracts and blood moves through bicuspid valve and into left ventricle Left ventricle contracts, bicuspid valve closes and blood moves through aortic valve and into aorta and branches

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Blood Supply to the Heart Coronary arteries First two branches of aorta. Left and right Supply blood to the tissues of the heart Openings lie just beyond aortic valve Openings of the coronary arteries lie just beyond the aortic valve

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Thrombus / Embolus A blood clot or gas bubble that blocks or narrows a coronary artery branch and deprives myocardial cells of O2. Produces ischemia and angina

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Angina Pectoris Causes pain during physical activity when O2 requirements exceed O2 supply Pain lessens with rest Emotional disturbance may also trigger angina May cause sensation of heavy pressure, tightening or squeezing in chest. Pain felt in region behind sternum but it may radiate to neck, jaw, throat, upper limb, shoulder, elbow, back, upper abdomen Other symptoms: diaphoresis (profuse sweating), difficulty breathing (dysphea), nausea, vomiting

Slide 59 :

Myocardial Infarction (MI) A blood clot that completely obstructs a coronary artery or one of the branches (coronary thrombosis) and kills part of the heart “heart attack” The picture on top shows a damaged heart after a heart attack. The damage happens when blood flow through the coronary artery to the heart is blocked and not enough oxygen can get to the heart muscle. Pictured on the bottom is a healthy heart.

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Myocardial Blood Flow (continued) Heart must beat continually to supply blood to body tissues Myocardial cells require constant supply of freshly oxygenated blood. Branches of coronary arteries feed the many capillaries of the myocardium Collateral Circulation Smaller branches of arteries have connections (anastomoses) between vessels that provide alternate pathways for blood Detours in circulation may supply sufficient O2 and nutrients to myocardium when coronary artery is blocked.

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Blood vessels associated with the surface of the heart. (anterior view above/ posterior view on right)

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Cardiac Veins Paths roughly parallel coronary arteries Drain blood that has passed through capillaries Veins join enlarged veins on heart’s posterior surface leading to coronary sinus Coronary sinus empties into right atrium

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Heart Transplantation Recipient’s failing heart is removed (except for posterior walls of right and left atria and connections to venae cavae and pulmonary veins) Donor heart similarly prepared and attached to patients atrial cuffs. Recipient’s aorta and pulmonary arteries connected to donor heart *clinical connection p362 (artificial heart and stem cells) Heart dissection photos

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Heart Action Cardiac Cycle Heart Sounds Cardiac Muscle Fibers Cardiac Conduction System

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Cardiac Cycle Complete heartbeat Pressure within heart chambers rises and falls in repeated cycles Atrial systole(contract) and Ventricular diastole (relaxes) Ventricular systole and atrial diastole Then both relax for a brief moment Pressure difference between the atria and ventricles causes the A-V valves to open or close. (similar with other valves) Animation

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13_10 Atrial Systole and Diastole Slide number: 1 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Pulmonary valve closed Tricuspid and bicuspid valves open Ventricular diastole Atrial systole Aortic valve closed RA LA LV RV Pulmonary valve open Tricuspid and bicuspid valves closed Aortic valve open Ventricular systole Atrial diastole

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13_10 Atrial Systole and Diastole Slide number: 4 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Pulmonary valve closed Tricuspid and bicuspid valves open Ventricular diastole Atrial systole Aortic valve closed RA LA LV RV

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13_10 Atrial Systole and Diastole Slide number: 5 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Pulmonary valve closed Tricuspid and bicuspid valves open Ventricular diastole Atrial systole Aortic valve closed RA LA LV RV

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13_10 Atrial Systole and Diastole Slide number: 6 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Pulmonary valve closed Tricuspid and bicuspid valves open Ventricular diastole Atrial systole Aortic valve closed RA LA LV RV Ventricular systole Atrial diastole

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13_10 Atrial Systole and Diastole Slide number: 7 Copyright © The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Pulmonary valve closed Tricuspid and bicuspid valves open Ventricular diastole Atrial systole Aortic valve closed RA LA LV RV Pulmonary valve open Tricuspid and bicuspid valves closed Aortic valve open Ventricular systole Atrial diastole

Slide 73 :

A graph of some changes that occur in the left ventricle during a cardiac cycle.

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Heart Sounds Heartbeat heard through stethoscope sounds like “lubb-dupp” Sounds due to vibrations in the heart tissues associated with closing of the valves “Lubb”: 1st part. Occurs during ventricular contraction when A-V valves closing “Dupp”: 2nd part. Occurs during ventricular relaxation. Pulmonary and aortic valves closing

Slide 75 :

Provide information concerning the condition of the heart valves. Endocarditis: inflammation of the endocardium, may erode edges of the valvular cusps. Cusps may not close completely and some blood may leak back through valve producing an abnormal sound or murmur. Open heart surgery may repair or replace seriously damaged valves.

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Cardiac Muscle Fibers Function like skeletal muscles but fibers connect in branching networks Stimulation to one part sends impulses throughout heart and it contracts as a unit. Functional syncytium (sin sish’e-um): mass of merging cells that function as a unit. 2 syncytium in the heart: atrial walls and ventricular walls.

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Portions of heart’s fibrous skeleton separates masses of cardiac muscle except for small area in right atrial floor Atrial syncytium and ventricular synctium are connected by fibers of the cardiac conduction system.

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Cardiac Conduction System Clumps and strands of specialized cardiac muscle tissue whose fibers contain only a few myofibrils. These areas initiate and distribute impulses throughout myocardium. Coordinates the events of the cardiac cycle Animation

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The Cardiac Conduction System

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Specialized Cardiac Muscle Tissue Sinoatrial Node Atrioventricular Node A-V bundle Purkinje fibers

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Sinoatrial Node (S-A node) Located in right atrium near opening of superior vena cava. Fibers continuous with atrial syncytium (which stimulates right and left atria) “Pacemaker”: activity is rhythmic. Initiates 70-80 contractions/minute in adult.

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Atroventricular Node (A-V node) Located in inferior portion of septum (separates atria) Provides the only normal conduction pathway between atrial and ventricular synctia Junctional fibers of the conduction system have very small diameters and conduct impulses slowly delaying impulse transmission. Impulse delayed further as it moves through A-V node allowing more time for atria to contract completely and empty all blood into ventricles prior to ventricular contraction

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A-V Bundle (Bundle of His) Distal side of the A-V node Impulse enters upper part of interventricular septum and divides left and right branches and give rise to enlarged Purkinje fibers.

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Purkinje Fibers Spread into papillary muscles and continue around heart Give off small branches continuous with cardiac muscle fibers

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Muscle fibers arranged in irregular whorls. When impulses on Purkinje fibers stimulate muscle fibers, the ventricular walls contract with a twisting motion.

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Electrocardiogram (ECG) A recoding of the electrical changes that occur in the myocardium during a cardiac cycle Because body fluids can conduct electrical currents, changes can be detected on the surface of the body.

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Electrodes placed on skin and connected by wires to an instrument that responds to very weak electrical changes by moving a pen on a moving strip of paper. Up and down movements correspond to electrical changes Paper moves at certain rate, distance between pen deflections indicates time between phases of cardiac cycle

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Normal ECG includes several deflections (waves) during each cycle. Between cycles, muscle fibers remain polarized – no detectable electrical change so pen marks along baseline. P-wave: when S-A node triggers cardiac impulse (atrial fibers depolarize producing electrical change and contract) A normal ECG

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QRS complex: Q wave, R wave, and S wave. Corresponds to depolarization of ventricular fibers just prior to contraction of ventricular walls. Ventricular walls thicker than atria and electrical charge greater so pen deflects more. (record of atrial polarization obscured by QRS complex because it occurs at the same time) T waves:Corresponds to electrical changes occuring as ventricular muscle fibers repolarize slowly ending the ECG pattern. In an ECG pattern, the P wave results from a depolarization of the atria, the QRS complex results from a depolarization of the ventricles, and the T wave results from a repolarization of the ventricles.

Slide 94 :

Physicians use ECG patterns to assess heart’s ability to conduct impulses P-Q interval (or P-R interval if Q is upright): indicates time for the cardiac impulse to travel from S-A node through A-V node. Ischemia or problems affecting fibers of the A-V conduction pathway can increase P-Q interval. Injury to A-V bundle can extend QRS complex. May take longer for impulse to spread throughout ventricular walls. A prolonged QRS complex may result from damage to the A-V bundle fibers.

Slide 95 :

Regulation of the Cardiac Cycle Volume of blood pumped changes to accommodate cellular requirements. Ex. Strenuous exercise: skeletal muscles require more blood and heart rate increases in response. Also responds to changes in body temperature and concentrations of various ions. S-A node normally controls heart rate so changes in rate are a response to factors that affect the S-A node such as motor impulses carried on the parasympathetic and sympathetic nerve fibers.

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Parasympathetic Fibers Fibers that innervate the heart arise from neurons in the medulla oblongata and branch to the S-A and A-v nodes When impulses reach fiber endings they secrete acetylcholine, which decreases S-A and A-V nodal activity. Heart rate decreases. An increase in impulses “breaks” heart action. Slows heart rate A decrease in impulses releases “brake” and heart action increases. Increases heart rate.

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Sympathetic Fibers Join S-A and A-V nodes and other areas of the atria and ventricles. Endings secrete norepinephrine in response to nerve impulses. Increases rate and force of myocardial contractions

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Cardiac Control Center of Medulla Oblongata Maintains the balance between inhibitory effects of parasympathetic fibers and excitatory effects of sympathetic fibers. Receive sensory impulses from throughout cardiovascular system and relays motor impulses to heart in response Example: Baroreceptors / Pressoreceptors: receptors sensitive to stretch are located in aortic arch and in carotid arteries. Can detect changes in blood pressure and signal cardio-inhibitor center in medulla oblongata. (sends parasympathetic impulses to heart via vagus nerve decreasing heart rate, helping to lower blood pressure toward normal.)

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Cerebrum or Hypothalamus Also influence Cardiac Control Center by: Decrease heart rate when a person faints following emotional upset. Increase heart rate during period of anxiety

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Autonomic nerve impulses alter the activities of the S-A and A-V nodes.

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Temperature Rise ? Increases heart action (increases during fever) Abnormally low ? Decrease heart action

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Ions Potassium (K+) Excess K+ / Hyperkalemia: decrease rate and force of contractions Below normal K+ / Hypokalemia: causes arrhythmia, potentially life-threatening abnormal rhythm Calcium (Ca+2) Excess Ca+2 / Hypercalcemia: increase heart actions posing danger that heart will contract for a prolonged time Low Ca+2 / Hypocalcemia: depresses heart action

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Clinical Terms Related to the Heart Blood Mobile Song St. Joseph Aspirin Site Pump, Pump, Pump your Blood Song

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Asystole Condition in which the myocardium fails to contract

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Cardiac tamponade Compression of the heart by fluid accumulating within the pericardial cavity

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Congestive Heart Failure Inability of the left ventricle to pump adequate blood to cells Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. This can result from : narrowed arteries that supply blood to the heart muscle — coronary artery disease. past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work. high blood pressure. heart valve disease due to past rheumatic fever or other causes. primary disease of the heart muscle itself, called cardiomyopathy. heart defects present at birth — congenital heart defects. infection of the heart valves and/or heart muscle itself — endocarditis and/or myocarditis

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The "failing" heart keeps working but not as efficiently as it should. People with heart failure can't exert themselves because they become short of breath and tired. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results. Most often there's swelling in the legs and ankles, but it can happen in other parts of the body, too. Sometimes fluid collects in the lungs and interferes with breathing, causing shortness of breath, especially when a person is lying down. About five million Americans are living with heart failure, and between 400,000 and 700,000 new cases are diagnosed every year. Heart failure is serious and can be life-threatening. About 250,000 people die annually of heart failure.

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Cor Pulmonale Heart-lung disorder characterized by pulmonary hypertension and hypertrophy of the right ventricle

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Palpitation Awareness of a heartbeat that is unusually rapid, strong, or irregular

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Pericardiectomy Excision of the pericardium Endoscopic Pericardiectomy Fluid can build up around the heart as a result of some disease processes. This fluid can adversely affect heart function. The fluid can usually be drained with a needle. However, sometimes the fluid returns, and the sac around the heart should be surgically removed. Most surgeons remove the sac through a sternotomy, some through an incision on the side of the chest called a thoracotomy. A few surgeons use endoscopic surgery to remove the sac around the heart, but by using large endoscopes, the resulting pain is nearly as severe as a thoracotomy. The development of the 5 millimeter endoscope and 3 millimeter instruments has allowed the sac around the heart to be removed more painlessly than before. There is very little pressure on the nerves between the ribs when the small endoscope is used, so the pain is significantly decreased

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Sinus Rhythm The normal cardiac rhythm regulated by the S-A node

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Valvotomy Incision of a valve What causes mitral stenosis?Mitral stenosis most commonly develops many years after a person has had rheumatic fever, although many patients diagnosed with mitral stenosis don't recall ever having the illness. During rheumatic fever, the valve becomes inflamed. Over time, the leaflets of the inflamed valve stick together and become scarred, rigid and thickened, limiting its ability to open completely How is mitral valve stenosis treated?If the symptoms are mild, mitral valve stenosis can sometimes be treated with medications. When medications do not work to control symptoms, balloon mitral valvotomy or surgical valve repair or replacement is performed.

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"PUMP YOUR BLOOD" SONG - VERSE ONE Pump, pump, pumps your Blood. The right atrium’s where the process begins, where the CO2 Blood enters the heart. Through the tricuspid valve, to the right ventricle, the pulmonary artery, and lungs. Once inside the lungs, it dumps its carbon dioxide and picks up its oxygen supply. Then it’s back to the heart through the pulmonary vein, through the atrium and left ventricle. Pump, pump, pumps your Blood. "PUMP YOUR BLOOD" SONG - VERSE TWO Pump, pump, pumps your Blood. The aortic valve’s, where the Blood leaves the heart, then it's channeled to the rest of the bod. The arteries, arterioles, and capillaries too bring the oxygenated Blood to the cells. The tissues and the cells trade off waste and CO2, which is carried through the venules and the veins Through the larger vena cava to the atrium and lungs, and we're back to where we started in the heart. Pump, pump, pumps your Blood

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