Chapter 19 The Circulatory System: The Heart

1. Define cardiovascular system and distinguish between the pulmonary and systemic circuits. The cardiovascular system consists of the heart and the blood vessels that carry the blood to and from the bodys organs. The system has two major divisions: a pulmonary circuit and a systemic circuit. Pulmonary circuit carries the blood to the lungs for gas exchange and returns it to the heart. Systemic circuit supplies blood to every organ of the body, including other parts of the lungs and the walls of the heart itself. 2. Describe the general location, size and shape of the heart. The human heart is a four-chambered muscular organ, about the size and shaped roughly like a persons closed fist. It lies in the mediastinum, or middle region of thorax, just behind the body of the sternum. Its about 310g is average for a male and 255g for a female. 3. Define pericardium, pericardial sac (parietal pericardium), epicardium (visceral pericardium), pericardial cavity and pericardial fluid. Pericardium- a double walled loose fitting inextensible sac that encloses the heart and isolates it from other thoracic organs. Ligaments and fibrous connective tissue anchor it. Pericardial sac (parietal peracardium)- forms the outer wall of the pericardium. it is composed of 2 layers; the outer wall is a tough superficial fibrous layer of dense irregular connective tissue, and a deep thin serous layer. Epicardium (visceral peracardium)- The serous inner layer of the pericardium, a conical sac of fibrous tissue that surrounds the heart and the roots of the great blood vessels. Pericardial cavity- space between the parietal and visceral membranes filled with 5 to 30 mL of pericardial fluid. Pericardial fluid It is the serous visceral pericardium that secretes the pericardial fluid into the pericardial cavity, (the space between the two pericardial layers). It is similar to the serous fluid that is found in the brain for cushioning and ability to move semifreely. 1

The pericardial fluid reduces friction within the pericardium by lubricating the epicardial surface allowing the membranes to glide over each other with each heart beat 4. Describe the three layers of the heart wall. Define fibrous skeleton The heart wall consists of three layers: a thin epicardium covering its external surface, a thick myocardium in the middle, and a thin endocardium lining the interior of the chambers. Epicardium (visceral pericardium) This is a serous membrane on the heart surface. It consist mainly of a simple squamous epithelium overlying a thin layer of areolar tissue. Endocardium This layer lines the interior of the heart chambers. It is a simple squamous enthothelium overlying a thin areolar tissue layer; it has no adipose tissue. The endocardium covers the valve surfaces and is continuous with the endothelium of the blood vessels. Myocardium This is the middle layer it is composed of cardiac muscle. This is the thickest layer and performs the work of the heart. Fibrous skeleton This is a meshwork of collagenous and elastic fibers in the heart. It is concentrated in the walls between the heart chambers, in fibrous rings around the openings of the heart valves and in the sheets of tissue that interconnect these rings. 5. Describe the four chambers of the heart including the external and internal anatomy of the chambers. The heart has four chambers. The two ventricles (right and left) are muscular chambers that propel the blood out of the heart (the right ventricle to the lungs, and the left ventricle to all other organs). The two atria (right and left) hold the blood returning to the heart, and at just the right moment empty into the right and left ventricles. The four chambers are the right atria, left atria, right ventricle, and the left ventricle. The surface boundaries of the four are marked by 3 sulci (grooves). The right and left atria are at the superior pole of the heart. They are thin walled receiving chambers for blood RETURNING to the heart by way of the great

veins. Most of their mass is located in the posterior side of the heart. The right and left ventricles are the inferior chambers. They are pumps that EJECT blood into the arteries and keep it flowing around the body. The left ventricle bears the greatest workload of all 4 chambers, pumping blood through the entire body. 6. Define cusps (leaflets) and describe the valves of the heart. Define tendinous cords (chordate tendineae) and papillary muscles and identify their function. Cusps this is a fibrous flap of tissue covered with endocardium on the valves of the heart. The cusps of the heart valves serve to seal the heart valves when closed. There are three cusps for each valve except for the mitral valve, which has only two (hence its alternate name, "bicuspid valve") Tendinous cords- Stringlike, reminiscent of the shroud lines of a parachute, connect the valve cusps to conical PAPILLARY MUSCLES (nipple shaped) on the floor of the ventricle. They prevent the AV valves from flipping inside out or bulging into the atria when the ventricles contract. There are 2 main types of valves. The atrioventricular valves and the semilunar valves. The atrioventricular valves consist of a left and a right AV, they regulate the opening between the atria and ventricles. The right AV (tricuspid) has 3 cusps. The left AV (bicuspid) has 2, and is also known as the MITRAL valve. The semilunar valves (pulmonary and aortic valves) regulate the flow of blood from the ventricles into the great arteries. The pulmonary valve controls the opening from the right ventricle into the pulmonary trunk, and the aortic valve controls the opening from the left ventricle into the aorta. The valves do NOT open and close by any muscular effort of their own, they are simply pushed open and closed by changes in blood pressure that occur as the heart chambers contract and relax. 7. Trace the flow of blood through the 4 chambers and valves of the heart as well as the adjacent blood vessels. Describe the level of oxygen and carbon dioxide in each location. There are 11 steps to the flow of blood. 1. Blood enters right atrium from superior and inferior venae cavae. Oxygen level- poor. Carbon dioxide level- rich.

2. Blood in right atrium flows through right AV valve into right ventricle. Oxygen level- poor. Carbon dioxide level- rich.

3. Contraction of right ventricle forces pulmonary valve open. Oxygen level- poor. Carbon dioxide level- rich.

4. Blood flows through pulmonary valve into pulmonary trunk. Oxygen level- poor. Carbon dioxide level- rich.

5. Blood is distributed by right and left pulmonary arteries to the lungs, where it unloads carbon dioxide and loads oxygen. Oxygen level- poor. Carbon dioxide level- rich.

6. Blood returns from lungs via pulmonary veins to left atrium. Oxygen level- rich. Carbon dioxide level- poor.

7. Blood in left atrium flows through left AV valve into left ventricle. Oxygen level- rich. Carbon dioxide level- poor.

8. Contraction of left ventricle (simultaneous with step 3) forces aortic valve open. Oxygen level- rich. Carbon dioxide level- poor.

9. Blood flows through aortic valve into ascending aorta. Oxygen level- rich. Carbon dioxide level- poor.

10. Blood in aorta is distributed to every organ in the body, where it unloads oxygen and loads carbon dioxide. Oxygen level- rich. Carbon dioxide level- poor.

11. Blood returns to heart via venae cavae. Oxygen level- poor. Carbon dioxide level- rich.

8. Define coronary circulation. Describe the arteries that nourish the myocardium and the veins that drain it. Define anastomoses and collateral circulation. Coronary circulation is a system of blood vessels that serve the wall of the heart. Anastomoses- A point where 2 arteries come together and combine their blood flow to points farther downstream Collateral circulation- an alternate route provided by arterial anastomoses that can supply the heart tissue with blood if the primary route becomes obstructed. Arterial Supply Left Coronary Artery (LCA) - travels through the coronary sulcus under the left auricle and divides into two branches the Anterior Interventicular Branch and the Circumflex Branch Anterior Interventicular Branch (left anterior descending (LAD) branch supplies blood to both ventricles and the anterior two-thirds of the interventricular septum. Circumflex Branch - supplies blood to the left atrium and posterior wall of the left ventricle. Gives off the left marginal branch, which furnishes blood to the left ventricle. Right Coronary Artery (RCA) - supplies the right atrium and senatorial node (pacemaker), continues along the coronary sulcus under the right auricle and gives off two branches the Right Marginal Branch and Posterior Interventricular Branch Right Marginal Branch - supplies the lateral aspect of the right atrium and ventricle.

Posterior Interventricular Branch - supplies the posterior walls of both ventricles as well as the posterior portion of the interventricular septum. It ends by joining the anterior interventricular branch of the LCA. Venous Drainage Great Cardiac Vein - collects blood from the anterior aspect of the heart and carries it from the apex to empty into the coronary sinus. Posterior Interventricular (middle cardiac) Vein - collects blood from the posterior aspect of the heart and it too, carries it from the apex to empty into the coronary sinus. Left Marginal Vein - travels from a point near the apex up the left margin, and empties into the coronary sinus. Coronary Sinus - large transverse vein on the posterior side of the heart that collects blood from the three previous veins (and smaller ones) to empty into the right atrium. 9. Define myogenic and autorhythmic. Describe the structure and metabolism of cardiac muscle cells. Myogenic- A vertebrate heartbeat where the signal originates within the heart itself. Autorhythmic- self-rhythmic pulses, not dependent on the nervous system. It has its own pacemaker and electrical system to continue its pulsations. Cardiac muscle cells (cardiocytes) are short, thick, branched cells like a log with deep notches in the end. Cardiac muscle does NOT contain satellite cells, so damage is repaired almost entirely by fibrosis. It depends almost exclusively on aerobic respiration to make ATP and is not prone to fatigue. 10. Describe the cardiac conduction system of the heart beginning with the SA node. Cardiac conduction system: The electrical conduction system that controls the heart rate. This system generates electrical impulses and conducts them throughout the muscle of the heart, stimulating the heart to contract and pump blood. Among the major elements in the cardiac conduction system are the sinus node, atrioventricular node, and the autonomic nervous system. The SA Node is the hearts natural pacemaker-it is a cluster of cells in the 6

upper right atrium. The normal electrical conduction of the heart allows electrical propagation to be transmitted from the Sinoatrial Node through both atria and forward to the Atrioventricular Node. The AV node is a cluster of cells situated in the center of the heart between atria and ventricles. It serves as a gate that slows electrical current before it is permitted to pass down through ventricles. Normal/baseline physiology allows further propagation from the AV node to the Ventricle or Purkinje Fibers and respective bundle branches and subdivisions/fascicles. Both the SA and AV nodes stimulate the Myocardium. Time ordered stimulation of the myocardium allows efficient contraction of all four chambers of the heart, thereby allowing selective blood perfusion through both the lungs and systemic circulation. The autonomic nervous system controls the firing of the sinus node to trigger the start of the cardiac cycle 11. Describe the nerve supply to the heart and explain its role. The heart receives signals from both the sympathetic and parasympathetic nerves, which modify the heart rate and contraction strength. The sympathetic nerves arise from the cervical ganglia and supply mainly the ventricular myocardium. Stimulation of the sympathetic nerves (sympathetic) will: Increase in coronary blood flow by vasodilating the coronary arteries Decreases the length of diastole Stimulates the SA node Increases the force and speed of contraction of cardiac muscle Increases the oxygen consumption of the heart

The parasympathetic or vagus nerves supply the SA and AV nodes. The branches from the vagus nerve, keeps the heart beating at a slow, regular rate Stimulation of the vagus nerve (parasympathetic) will: Slow the heart Reduce the blood pressure Constrict the coronary arteries

These nerves do not make the heart beat they are only involved in the modification of the heartbeat. 7

12. Define systole, diastole, sinus rhythm, ectopic focus and nodal rhythm Systole: The time period when the heart is contracting. The period specifically during which the left ventricle of the heart contracts. Diastole: The time period when the heart is in a state of relaxation and dilatation (expansion). Sinus rhythm: The normal regular rhythm of the heart set by the natural pacemaker of the heart called the sinoatrial (or sinus) node. It is located in the wall of the right atrium (the right upper chamber of the heart). Normal cardiac impulses start there and are transmitted to the atria and down to the ventricles (the lower chambers of the heart). An ectopic focus or ectopic pacemaker is an excitable group of cells that causes a premature heartbeat outside the normally functioning SA node of the human heart. If the SA node is damaged an ectopic focus may take over governance of the heart rhythm Nodal rhythm: A cardiac rhythm characterized by pacemaker function originating in the atrioventricular node, with a heart rate of 40-70 per minute. 13. Explain why the SA node (pacemaker) fires spontaneously and rhythmically Not completed 14. Explain how the SA node excites the myocardium and how the excitation continues throughout the myocardium. Include the rate at which each component of the conduction system fires. SA node: The SA node (SA stands for sinoatrial) is one of the major elements in the cardiac conduction system, the system that controls the heart rate. This system generates electrical impulses and conducts them throughout the muscle of the heart, stimulating the heart to contract and pump blood. The SA node is the heart's natural pacemaker. The SA node consists of a cluster of cells that are situated in the upper part of the wall of the right atrium (the right upper chamber of the heart). The electrical impulses are generated there. The SA node is also called the sinus node. The electrical signal generated by the SA node moves from cell to cell down through the heart until it reaches the atrioventricular node (AV node), a cluster of cells situated in the center of the heart between the atria and ventricles.

The AV node serves as a gate that slows the electrical current before the signal is permitted to pass down through to the ventricles. This delay ensures that the atria have a chance to fully contract before the ventricles are stimulated. The ventricular myocardium has a conduction speed of 0.3-0.5 m/sec. After passing the AV node, the electrical current travels to the ventricles along special fibers embedded in the walls of the lower part of the heart. The autonomic nervous system, the same part of the nervous system as controls the blood pressure, controls the firing of the SA node to trigger the start of the cardiac cycle. Firing of the SA node excites atrial cardiocytes and stimulates the two atria to contract almost simultaneously. The signal travels at a speed of 1m/sec through the myocardium and reaches AV node in about 50 msec. Once in the AV node signal slows down to 0.05 m/sec because cardiocytes are thinner.

15. Describe how the action potentials of cardiac muscle differ from neurons and skeletal muscles. In skeletal muscle and neurons, and action potential falls back to the resting potential with in 2 msec. In cardiac muscle the depolarization is prolonged for 200 to 250 msec (heart rate of 70-80 bpm), producing a long plateau in the action potential. Rather than showing a brief twitch like skeletal muscle, cardiac muscle has a more sustained contraction necessary for expulsion of blood from the heart chambers. Cardiac muscle has an absolute refractory period of 250 msec, compared with 1 to 2 msec in skeletal muscle. 16. Define electrocardiogram. List and describe the deflections shown on an electrocardiogram and interpret a normal electrocardiogram. Electrocardiogram- An instrument that detects and records electrical currents in the heart by means of electrodes applied to the skin, usually on a moving paper chart. A typical ECG shows three principal defections above and below the baseline: The P wave, QRS complex, and T wave. The P wave represents depolarization of the atria. That is the P wave is the deflection caused by the passage of an electrical impulse from the SA node through the musculature of the atria. The QRS complex consists of a small downward defection (Q), a tall sharp peak (R), and a final downward deflection (S). The QRS complex represents the entire process of ventricular depolarization. At the same time the ventricle are depolarizing the atria are repolarizing. However the massive ventricular depolarization overshadows the voltage fluctuation caused by atrial 9

repolarization. The T wave is generated by ventricular repolarization immediately before diastole. Ventricles take longer to repolarize than depolarize; T wave is therefore smaller and more spread out than QRS complex, and has rounder peak, it can be recognized by its relatively rounded peak. 17. Define cardiac cycle. Briefly describe how changes in blood pressure operate the heart valves and explain what causes the sounds of the heartbeat. Cardiac cycle is the term referring to all or any of the events related to the flow or blood pressure that occurs from the beginning of one heartbeat to the beginning of the next. It consists of one complete contraction and relaxation of all the four heart chambers. It means a complete heartbeat or pumping cycle, consisting of contraction (systole) and relaxation (diastole) of both atria and ventricles. The opening and closing of the heart valves are governed by pressure changes. The valves are just soft flaps of connective tissue with no muscle. They do not exert any force of their own, but are passively pushed open and closed by the changes in blood pressure on the upstream and downstream sides of the valve. When the ventricles are relaxed and their pressure is low, the AV valve cusps hang down limply and both valves are open Blood flows freely from the artria into the ventricles even before the atria contract. As the ventricles fill with blood, the cusps the cusps float upward toward the closed position. When the ventricles contract, their internal pressure rises sharply and blood surges against the AV valves from below. This pushes the cusps together, seals the openings, and prevents blood from flowing back into the atria. The papillary muscles contract slightly before the rest of the ventricular myocardium and tug on the tendinous cords, preventing the valves from bulging excessively (prolapsing) into the atria or turning inside out like windblown umbrellas The rising pressure in the ventricles also acts on the aortic and pulmonary valves. Up to a point, pressure in the aorta and pulmonary trunk opposes their opening, but when the ventricular pressure rises above the arterial pressure, the valves open and blood is ejected from the heart.

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Then, as the ventricles relax again and their pressure falls below that in the arteries, arterial blood briefly flows backward and fills the pocketlike cusps of the semilunar valves. The three cusps meet in the middle of the orifice and seal it, thereby preventing arterial blood from reentering the heart. Heart Sound The sounds of the heart "LUBB-DUPP" are produced due to the sharp closure of the valves of the heart. The first, or systolic sound is caused primarily by the contraction of the ventricles and also by the vibrations of the closing atrioventricular, bicuspid and tricuspid valve valves. It is longer and lower than the second or diastolic sound, which is short and sharp and is caused by the closure of the semilunar (pulmonary and aortic valves) valves.

18. Describe in detail one complete cycle of heart contraction and relaxation. Include a definition of stroke volume and ejection fraction. The cycle can be divided into four phases Ventricle filling Isovolumetric contraction Ventricular ejection. Isovolumetric relaxation 1. Ventricle filling. Here the ventricles expand, the AV valves open, blood flows into the ventricles, rapidly at first and then more slowly. The P wave occurs and then the atria contracts and contribute the last one-third of the blood to the ventricles. At the end of this phase each ventricle contains an end-diastolic volume (EDV) of about 130mL 2. Isovolumetric contraction. In this phase isovolumetric contraction, the QRS wave occurs, the atria repolarize and relax, and the ventricles begin contracting. The AV valve closes and the heart sound S1 occurs. The semilunar valves remain closed and no blood is expelled yet. 3. Ventricular ejection. In ventricular ejection, the semilunar valves open and blood is ejected, rapidly at first and then more slowly. Each ventricle ejects a stroke volume of about 70 mL, which is an ejection fraction of about 54% of the end systolic volume (ESV). The T wave begins about the middle of this phase. 4. Isovolumetric relaxation. Here the ventricles repolarize and relax. The

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semilunar valves close and the heart sound S2 occurs. The AV valves remain closed and no blood enters the ventricles until the next phase of ventricle filling where they cycle starts over again. Note each ventricle ejects the same amount of blood. If they ejected unequal amounts, fluid would accumulate in the tissues of either the pulmonary or systemic circuit. Stroke volume (SV) is the volume of blood pumped from one ventricle of the heart with each beat. Stroke volume is an important determinant of cardiac output, which is the product of stroke volume and heart rate, and is also used to calculate ejection fraction, which is stroke volume divided by end-diastolic volume. Because stroke volume decreases in certain conditions and disease states, stroke volume itself correlates with cardiac function. Ejection fraction (Ef) is the fraction of blood pumped out of ventricles with each heartbeat. The term ejection fraction applies to both the right and left ventricles. 19. Relate the events of the cardiac cycle to the volume of blood entering and leaving the heart. Blood Volume Blood volume is directly related to blood pressure. If the blood volume is increased, then venous return of blood to the heart will increase. An increase in venous return will, by Starling's Law, cause stroke volume to increase. As stroke volume goes up the cardiac output goes up and the blood pressure rises. Thus one way to control blood pressure over the long term is to control blood volume. The first, "late diastole", is when the semilunar valves close, the atrioventricular (AV) valves open, and the whole heart is relaxed. The second, "atrial systole", is when the atrium contracts, the AV valves open, and blood flows from atrium to the ventricle. The third, "isovolumic ventricular contraction", is when the ventricles begin to contract, the AV and semilunar valves close, and there is no change in volume. The fourth, "ventricular ejection", is when the ventricles are empty and contracting, and the semilunar valves are open. During the fifth stage, "Isovolumic ventricular relaxation", pressure decreases, no blood enters the ventricles, the ventricles stop contracting and begin to relax, and the semilunar valves close due to the pressure of blood in the aorta.

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An additional perspective on the cardiac cycle can be gained if we review the volume changes that occur. This balance sheet is from the standpoint of one ventricle; both ventricles have equal volumes. The volumes vary somewhat from person to person and depend on a persons state of activity. End-systolic volum (ESV, left from previous heartbeat) Passively added to the ventricle during atrial diastole Added by atrail systole 60mL +30mL +40 mL

Total: End-diastolic volume (EDV) Stroke volume (SV) ejected by ventricular systole Leaves: End systole volume (ESV)

130 mL -70 mL 60 mL

Notice that the ventricle pumps out as much blood as it received during diastole: 70 mL in this example Both ventricles eject the same amount of blood even though the pressure in the right ventricle is only about one-fifth of the pressure in the left. Blood pressure in the pulmonary trunk is relatively low, so the right ventricle does not need to generate much pressure to overcome it. It is essential that both ventricles have the same output.

20. Define cardiac output and cardiac reserve. Identify and describe in detail the two factors that govern cardiac output. Include in the description definitions of preload, contractility, and afterload. Cardiac Output (CO) - the amount of blood pumped by each ventricle of the heart in one minute. Cardiac Reserve - the difference between the maximum and resting cardiac output. Cardiac output, is the product of stroke volume and heart rate, CO = HR x SV Heart rate is the number of heartbeats per unit of time - typically expressed as beats per minute (bpm) - which can vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep. It is most easily measured by taking a persons pulse. This can be done either with the brachial artery in the wrist or the common carotid artery in the neck. Each beat produces a surge of pressure that can be felt by the fingertips.

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It can be obtained by counting the number of pulses in 15 secs and multiplying by 4 to get the beats per minute. Stroke Volume - volume of blood ejected by one ventricle of the heart in one contraction. This is governed by three variables. Increased preload or contractility increases stroke volume, increased after load opposes the emptying of the ventricles and reduces stroke volume. Preload - the amount of tension in the ventricular myocardium immediately before it begins to contract. The degree of stretching of cardiac muscle cells before contraction which is determined primarily by the amount of venous return of blood to the atria and any circumstances that would alter venous return (the length-tension relationship) Contractility - refers to how hard the myocardium contracts for a given preload. Factors that increase this are positive isotropic agents, and those that reduce it are negative isotropic agents. Afterload - the blood pressure in the aorta and pulmonary trunk immediately distal to the semi lunar valves; it opposes the opening of these valves, thus limiting the stroke volume. It is the pressure that must be overcome the ventricles to eject blood from the heart; usually this is the arterial blood pressure which is influenced by blood volume and the various forces that influence resistance to flow

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