dr.

Ihsan Rasyid Yuldi

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Pompa & Pipa
 Jantung, 2 pompa berhimpit
jadi 1
 Jantung kanan & kiri
 Dipisahkan sekat jantung
 Pipa: Sistemik & Pulmonal
 Jantung kiri
 Pulmonal  sistemik
 Pipa: Arteri
 Kaya O2
 Jantung kanan
 Sistemik  pulmonal
 Pipa : Vena
 Kaya CO2

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% Bloodflow
Saat istirahat

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Sites for Auscultation
CIRCULATORY CIRCUIT

CV

RA RV LV
LA

PARU

Kanan Kiri

Aorta
The Cardiac Cycle
 Electrical events of the heart
(measured by ECG)
 Mechanical Events
(contraction & relaxation of the heart)
 Refers to period from the start of one heart
beat → next heart beat.

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Myocardial Action Potential
The Steps of the cardiac cycle

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13
Siklus Jantung : Sistolik-Diastolik

 Fase sistolik (kontraksi dan pengosongan) :

 Ventrikel kontraksi
 Darah keluar dari ventrikel ke sistemik
 Terjadi antara sound 1-sound 2 (lub-dub)
 Katup atrioventrikular menutup, semilunar membuka
 Gelombang EKG : antara QRS - T
 Fase diastolik (relaksasi dan pengisian) :
 Ventrikel relaksasi
 Darah dari atrium masuk ke ventrikel
 Terjadi antara sound 2-sound 1 (dub-lub)
 Katup atrioventrikular membuka, semilunar menutup
 Gelombang EKG : antara T-QRS

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1. Ventricular filling
2. Isovolumetric contraction
3. Ventricular ejection
4. Isovolumetric relaxation
5. Mitral valve opens
6. Mitral valve closes
7. Aortic valve opens
8. Aortic valve closes

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Cardiac Cycle
Phases:
1. Isovolumetric contraction-
period between mitral valve
closure and aortic valve
opening; period of highest
oxygen consumption
2. Systolic ejection-period between
aortic valve opening and closing
3. Isovolumetric relaxation-period
between aortic valve closing
and mitral valve opening
4. Rapid filling-period just after
mitral valve opening
5. Slow filling-period just before
mitral valve closure.
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Cardiac Cycle

Sounds:
S1 – mitral and tricuspid valve
closure.
S2 – aortic and pulmonary valve
closure.
S3 – at end of rapid ventricular
filling.
S4 – high atrial pressure/ stiff
ventricle.

S3 is associated with dilated CHF.

S4 (“atrial kick”) is associated with
a hypertrophic ventricle.

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 HEART SOUNDS
Sound Cause of Events
Sound
S1 Closure of AV • Just after onset of ventricular contraction.
valves. • Signals onset of ventricular systole.
S2 Closure of • Signals end of systole and onset of ventricular diastole.
semilunar valves. • Normal splitting: during inspiration, increased venous
return causes prolongation of right ventricular EF and an
increased separation between aortic valve closure (A2)
and pulmonic valve closure (P2).
• Aortic valve closes first because ejection rate from left
ventricle is higher than that from right ventricle.
• Paradoxical splitting occurs if splitting of S2 decreases
during inspiration, indicating P2 precedes A2.
• Delayed aortic valve closure indicates a disease process
affecting left ventricle (LBBB, aortic stenosis).

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 HEART SOUNDS
Sound Cause of Events
Sound
S3 Rapid, passive • At start of ventricular diastole.
ventricular filling. • Heard best at apex.
• Usually not heard in adults but may be heard in children
or patients with LVE
S4 Forcing of • Atrial contraction.
additional blood • Occasionally heard in healthy individuals.
into distended • Individuals with CHF have triple sound called gallop
ventricle. rhythm.

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Cardiac Cycle

a wave – atrial contraction

c wave – RV contraction
(tricuspid valve bulging
into atrium)
v wave – increased atrial
pressure due to filling
against closed tricuspid
valve.

Jugular venous distention is

seen in right heart failure.

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An example of a normal jugular venous pulse tracing

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 ATRIAL PRESSURE CHANGES
VIA JUGULAR VENOUS TRACING
Wave Timing of Wave
a Atrial contraction at end of
ventricular diastole.
c Isovolumetric contraction
v Ventricular diastole
Cause of Wave
• Small amount of blood regurgitates into great
veins.
• Venous inflow stops, causing rise in venous
pressure
• Rise in atrial pressure produced by bulging of
AV valves into atria.
• Rise in atrial pressure before AV valves open
during diastole

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23
 Diagram of normal blood pressures
within heart chambers and great vessels

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The major features of a left ventricular pressure-
volume loop

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 SUMMARY OF THE CARDIAC CYCLE

Step
Step Mechanism Important Points
No.
Ventricular Contraction (Systole)
AV Valve 1 Ventricular contraction causes  Normal aortic systolic
Closure increased ventricular pressure: 120 mm Hg.
pressure.  Normal pulmonary artery
2 When ventricular pressure systolic pressure: 15-18 mm
exceeds atrial pressure, AV Hg.
valves close.
Iso- 3 Closed AV valves isolate  Arterial diastolic pressure is
volumetric ventricles from atria the lowest arterial pressure.
Contraction  It occurs just before onset of
4 Ventricular volume stays
constant while ventricular ventricular ejection.
pressure rises.

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SUMMARY OF THE CARDIAC CYCLE
Step Step No. Mechanism Important Points
Ventricular Contraction (Systole)
Ventricular 5 When ventricular pressure  Arterial systolic pressure is
Ejection exceeds arterial pressure the peak arterial pressure.
semilunar valves open.  It occurs at the end of rapid
6 Ejection starts, and arterial ejection.
volume and pressure begin to  Right ventricular ejection
increase. occurs before left because
7 Rapid ejection: two thirds of pressure in pulmonary artery
stroke volume ejected during is low compared to that in
first third of systole (ventricular aorta.
pressure > aortic pressure).
8 Reduced ejection: one third of
stroke volume ejected during
last two thirds of systole
(ventricular pressure < aortic
pressure).
9 Ventricles relax.

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SUMMARY OF THE CARDIAC CYCLE

Step
Step Mechanism Important Points
No.
Ventricular Contraction (Systole)
Semilunar 10 Closure of aortic and Incisura: notch on descending
Valve pulmonic valves prevents flow limb of aortic pressure curve
Closure of blood back into ventricles. produced by closure of aortic
valve, indicates end of
ventricular systole.
Ventricular Relaxation (Diastole)
Iso- 11 Ventricles relax and Systemic arterial pressure
volumetric ventricular pressure rapidly declines as blood continues to
Relaxation falls without change in flow.
ventricular volume.

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 Ste
Step p Mechanism
No.
Ventricular Relaxation (Diastole)
AV Valve 12 Rapid filling: high atrial pressure
Opening (due to continued venous return
during ventricular systole) causes
initial rapid passive ventricular
filling (80% of blood volume).
13 Pressure in atria and ventricles
decreases and ventricular
relaxation continues during rapid
filling.
14 Slow filling or diastasis: as blood
continues to return to heart,atrial
and ventricular pressures slowly
rise.
15 Ventricular filling of blood stops
shen ventricles reach their volume
limit.
16 Atrial contraction forces blood into
ventricles to complete ventricular
filling.
Important Points
 Normal diastolic pressure in
aorta: 80 mm Hg.
 Normal diastolic pressure
pulmonary artery: 8-10 mmHg.
 Tachycardia (>180 bpm) results
in decreased CO; ventricular
filling time is markedly reduced,
which lowers VEDV and SV.
 Atrial contraction is not
essential for ventricular filling,
as evidenced by adequate
ventricular filling in patients
without atrial contraction (eg,
atrial fibrillation or heart block).
 Contribution of atrial
contraction to ventricular
volume is more important when
HR is rapid and duration of
diastasis is short (eg, mitral
stenosis).
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 II. The Heart As A Pump

A. The Cardiac Cycle

1. Diastole constitudes 2/3 of the cycle
(filling and isovolumetric contraction).
Aortic pressure is higher than
ventricular (aortic valve closed).
2. Systole accounts for 1/3 of the
cardiac cycle (ejection and
isovolumetric relaxation)

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 Calculations of Stroke Volume,
Cardiac Output & Ejection Fraction

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32
 Responses to Hemodynamic Overload
Pressure overload Volume overload

Systolic wall stress Diastolic wall stress

Mechanical transducers

Intracellular signals

Ventricular remodeling

Paralel sarcomeres Series sarcomeres

Concentric hypertrophy Normal Eccentric hypertrophy

 Cardiac Output Variables
 Stroke volume affected by SV CAP.
Contractility, Afterload, and
Preload. Increased SV when
Stroke volume in anxiety,
preload, afterload, or exercise, and
contractility. pregnancy.
 Contractility (and SV) with : A failing heart has stroke
1. Catecholamines ( activity of volume.
Ca2+ pump in sarcoplasmic
reticulum)
2. intracellular calcium
3. extracellular sodium
4. Digitalis ( intracellular Na+,
resulting in Ca2+)
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 Cardiac Output Variables

Contractility (and SV)

with: Myocardial O2 demand is
by:
1. β1 blockade
1. afterload ( diastolic
2. Heart failure
BP)
3. Acidosis
2. contractility
4. Hypoxia/ hypercapnea
3. heart rate
4. heart size ( wall
tension)

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Cardiac Function Curve
(Frank Starling Curve)

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THANK YOU
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