Heart

The heart is a four-chambered organ, supplied by the coronary circulation that pumps
oxygen-poor blood to the lungs and oxygen-rich blood to the rest of the body.
Location of the heart: The heart is located close to the anterior chest wall, directly posterior to
the sternum. The heart sits in the mediastinum, a region between two pleural cavities.
The heart can be visualized as a cone lying on its side. The inferior, pointed tip of the heart is the
apex which is formed by the tip of the left ventricle whereas the superior part of the heart is
base which is formed by the atria (upper chambers) of the heart. The base sits posterior to the
sternum at the level of the third costal cartilage, whereas, the apex reaches the fifth intercostal
space approximately 7.5 cm (3 in.) to the left of the midline.
A midsagittal section through the trunk does not divide the heart into two halves. Approximately
a third of the heart is to the right of the midline of the sternum and the remainder (two-thirds) is
to the left of the midline.
Note that (1) the center of the base lies slightly to the left of the midline, (2) a line drawn
between the center of the base and the apex points further to the left, and (3) the entire heart is
rotated to the left around this line so that the right atrium and right ventricle dominate an anterior
view of the heart.
Size of the heart: For all its might, the heart is relatively small, roughly the same size (but not the
same shape) as your closed fist. It is about 12 cm (5 in.) long, 9 cm (3.5 in.) wide at its broadest
point, and 6 cm (2.5 in.) thick, with an average mass of 250 g (8 oz) in adult females and 300 g
(10 oz) in adult males.

In a superficial view, the heart consists of four chambers. The two atria have relatively thin
muscular walls and are highly expandable. When not filled with blood, the outer portion of each
atrium deflates and becomes a lumpy, wrinkled flap. This expandable extension of an atrium is
called an atrial appendage, or an auricle, because it reminded early anatomists of the external
ear.
The coronary sulcus, a deep groove, marks the border between the atria and the ventricles.
The anterior interventricular sulcus and the posterior interventricular sulcus are shallower
depressions that mark the boundary between the left and right ventricles.
Substantial amounts of fat generally lie in the coronary and interventricular sulci. In fresh or
preserved hearts, this fat must be stripped away to expose the underlying grooves. These sulci
also contain the arteries and veins that carry blood to and from the cardiac muscle.

Pericardium:
Pericardium consists of two parts: a pericardial sac and a pericardial membrane.
The pericardial sac, or tough/fibrous pericardium, surrounds the heart. The pericardial sac
consists of a dense network of collagen fibers. It stabilizes the position of the heart and
associated vessels within the mediastinum.
Pericardial membrane: The inner side of the pericardial sac is line with a delicate serous
membrane, called a pericardial membrane. The pericardial membrane can be subdivided into
two portions. The visceral pericardium, or epicardium, covers and adheres closely to the outer
surface of the heart. The parietal pericardium lines the inner surface of the tough pericardial
sac surrounding the heart.
The potential space between the parietal and visceral surfaces is the pericardial cavity. It
normally contains 15–50 ml of pericardial fluid, secreted by the pericardial membranes. This
fluid acts as a lubricant, reducing friction between the opposing surfaces as the heart beats.
Pathogens can infect the pericardium, producing inflammation and the condition pericarditis.
Cardiac tamponade or pericardial effusion is a clinical syndrome caused by the accumulation
of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent
hemodynamic compromise.
The Heart Wall:
A section through the wall of the heart reveals three distinct layers: an outer epicardium, a
middle myocardium, and an inner endocardium.
1. The epicardium is the visceral pericardium that covers the outer surface of the heart.
This serous membrane consists of, an exposed mesothelium and an underlying layer of
loose areolar connective tissue that is attached to the myocardium.
2. The myocardium, or muscular wall of the heart, forms the atria and ventricles. This layer
contains cardiac muscle tissue, blood vessels, and nerves. The myocardium consists of
concentric layers of cardiac muscle tissue. The atrial myocardium contains muscle
bundles that wrap around the atria and form figure eights that encircle the great vessels.
Superficial ventricular muscles wrap around both ventricles, and deeper muscle layers
spiral around and between the ventricles toward the apex in a figure-eight pattern.
3. The endocardium covers the inner surfaces of the heart, including those of the heart
valves. This simple squamous epithelium is continuous with the endothelium of the
attached great vessels.
Cardiac Muscle Tissue:
Cardiac muscle cells are interconnected by intercalated discs. At an intercalated disc, the
interlocking membranes of adjacent cells are held together by desmosomes and linked by gap
junctions. Intercalated discs transfer the force of contraction from cell to cell and propagate
action potentials.
Histological characteristics that distinguish cardiac muscle cells from skeletal muscle fibers
include
(1) small size;
(2) a single, centrally located nucleus;
(3) branching interconnections between cells; and
(4) the presence of intercalated discs.

Intercalated
disc
Nucleus

Cardiac muscle
cells

Internal Anatomy and organization of heart:

In heart, right atrium communicates with the right ventricle, and the left atrium with the left
ventricle the atria are separated by the interatrial septum (septum, wall), and the ventricles are
separated by the much thicker interventricular septum. Each septum is a muscular partition.
Atrioventricular (AV) valves are folds of fibrous tissues that extend into the openings between
the atria and ventricles. These valves permit blood to flow only in one direction: from the atria to
the ventricles.
The Right Atrium
The right atrium receives blood from the systemic circuit through the two great veins: the
superior vena cava and the inferior vena cava. The superior vena cava opens into the
posterior and superior portion of the right atrium. It delivers blood to the right atrium from
the head, neck, upper limbs, and chest. The inferior vena cava opens into the posterior and
inferior portion of the right atrium. It carries blood to the right atrium from the rest of the trunk,
the viscera, and the lower limbs. The cardiac veins draining the myocardium return blood to the
coronary sinus, a large, thin-walled vein that opens into the right atrium inferior to the
connection with the superior vena cava.
The opening of the coronary sinus lies near the posterior edge of the interatrial septum. From the
fifth week of embryonic development until birth, an oval opening called the foramen ovale
penetrates the interatrial septum and connects the two atria of the fetal heart. Before birth, the
foramen ovale permits blood to flow from the right atrium to the left atrium while the lungs are
developing. At birth, the foramen ovale closes, and the opening is permanently sealed off
within three months of delivery. A small, shallow depression called the fossa ovalis remains at
this site in the adult heart.
The posterior walls of the right atrium and the interatrial septum have smooth surfaces. In
contrast, the anterior atrial wall and the inner surface of the auricle contain prominent
muscular ridges called the pectinate muscles (pectin, comb), or musculi pectinate.
The Right Ventricle
Blood travels from the right atrium into the right ventricle through a broad opening bordered by
three fibrous flaps. These flaps, called cusps, are part of the right atrioventricular (AV) valve,
also known as the tricuspid valve. The free edge of each cusp is attached to connective tissue
fibers called the chordae tendineae (tendinous cords). The fibers originate at the papillary
muscles, conical muscular projections that arise from that inner surface of the right ventricle.
The right AV valve closes when the right ventricle contracts, preventing the backflow of blood
into the right atrium. Without the chordae tendineae to anchor their free edges, the cusps would
be like swinging doors that permit blood flow in both directions.
The internal surface of the ventricle also contains a series of muscular ridges: the trabeculae
carneae. The superior end of the right ventricle tapers to the conus arteriosus, a cone-shaped
pouch that ends at the pulmonary valve, or pulmonary semilunar valve. The pulmonary valve
consists of three semilunar (half-moon-shaped) cusps of thick connective tissue. Blood flowing
from the right ventricle passes through this valve into the pulmonary trunk, the start of the
pulmonary circuit. The cusps prevent backflow as the right ventricle relaxes. Once in the
pulmonary trunk, blood flows into the left pulmonary arteries and the right pulmonary arteries.
These vessels branch repeatedly within the lungs before supplying the capillaries, where gas
exchange occurs.
The Left Atrium
From the respiratory capillaries, blood collects into small veins that ultimately unite to form the
four pulmonary veins. The posterior wall of the left atrium receives blood from two left and two
right pulmonary veins. Like the right atrium, the left atrium has an auricle. A valve, the left
atrioventricular (AV) valve, or bicuspid valve, guards the entrance to the left ventricle. As the
name bicuspid implies, the left AV valve contains two cusps. Clinicians often call this valve the
mitral (mitre, a bishop’s hat) valve. The left AV valve permits blood to flow from the left atrium
into the left ventricle, but it prevents backflow when the left ventricle contracts.
Even though the two ventricles hold and pump equal amounts of blood, the left ventricle is much
larger than the right ventricle. It has thicker walls. These thick, muscular walls enable the left
ventricle to push blood through the large systemic circuit. In contrast, the right ventricle needs to
pump blood, at lower pressure, only about 15 cm (6 in.) to and from the lungs.
The internal organization of the left ventricle resembles that of the right ventricle. The trabeculae
carneae are prominent. A pair of large papillary muscles tenses the chordae tendineae that
anchor the cusps of the AV valve and prevent blood from flowing back into the left atrium.

The Left Ventricle

Blood leaves the left ventricle through the aortic valve, or aortic semilunar valve, and
goes into the ascending aorta. The arrangement of cusps in the aortic valve is the same as that in
the pulmonary valve. Once the blood has been pumped out of the heart and into the systemic
circuit, the aortic valve prevents backflow into the left ventricle. From the ascending aorta, blood
flows through the aortic arch and into the descending aorta. The pulmonary trunk is attached to
the aortic arch by the ligamentum arteriosum, a fibrous band left over from an important fetal
blood vessel that once linked the pulmonary and systemic circuits.
Difference between Left and Right Ventricle:
Anatomical differences between the left and right ventricles are easiest to see in a three-
dimensional view.
The muscular wall of the right ventricle is relatively thin. This is because the right ventricle
normally does not need to work very hard to push blood through the pulmonary circuit as the
lungs are close to the heart, and the pulmonary blood vessels are relatively short and wide. In
sectional view, the right ventricle resembles a pouch attached to the massive wall of the left
ventricle. When the right ventricle contracts, it acts like a bellows, squeezing the blood against
the thick wall of the left ventricle. This action moves blood very efficiently with minimal effort,
but it develops relatively low
pressures.

However, four to six times as much pressure must be exerted

to push blood through the systemic circuit as compare to the
pulmonary circuit. Therefore, the left ventricle has an
extremely thick muscular wall, and is round in cross section.
When this ventricle contracts, it shortens and narrows. In
other words, (1) the distance between the base and apex
decreases, and (2) the diameter of the ventricular chamber
decreases. The effect is similar to simultaneously squeezing and rolling up the end of a
toothpaste tube. The pressure generated is more than enough to open the aortic valve and eject
blood into the ascending aorta. As the powerful left ventricle contracts, it bulges into the right
ventricular cavity. This action makes the right ventricle more efficient. Individuals with severe
damage to the right ventricle may survive, because the contraction of the left ventricle helps push
blood into the pulmonary circuit.
The Heart Valves:
The heart has two pairs of one-way valves that prevent the backflow of blood as the chambers
contract.
The Atrioventricular Valves
The atrioventricular (AV) valves prevent the backflow of blood from the ventricles to the atria
when the ventricles are contracting. The chordae tendineae and papillary muscles play important
roles in the normal function of the AV valves.
When the ventricles are relaxed, the chordae tendineae are loose, and the AV valves offer no
resistance as blood flows from the atria into the ventricles. When the ventricles contract, blood
moving back toward the atria swings the cusps together, closing the valves. At the same time,
the contraction of the papillary muscles tenses the chordae tendineae, stopping the cusps before
they swing into the atria. If the chordae tendineae were cut or the papillary muscles were
damaged, backflow, called regurgitation, of blood into the atria would occur each time the
ventricles contracted.

The heart has two pairs of one-way valves that prevent the backflow of blood as the chambers
contract.
The Semilunar Valves
The pulmonary and aortic valves prevent the backflow of blood from the pulmonary trunk and
aorta into the right and left ventricles, respectively. Unlike the AV valves, the semilunar valves
do not need muscular braces, because the arterial walls do not contract and the relative positions
of the cusps are stable. When the semilunar valves close, the three symmetrical cusps support
one another like the legs of a tripod.
Adjacent to each cusp of the aortic valve are saclike expansions of the base of the ascending
aorta. These sacs, called aortic sinuses, prevent the individual cusps from sticking to the wall of
the aorta when the valve opens. The right and left coronary arteries, which deliver blood to the
myocardium, originate at the right and left aortic sinuses.
Serious valve problems can interfere with the working of the heart. If valve function deteriorates
to the point at which the heart cannot maintain adequate circulatory flow, symptoms of valvular
heart disease (VHD) appear. Congenital malformations may be responsible, but in many cases
the condition develops after carditis, an inflammation of the heart, occurs. One important cause
of carditis is rheumatic fever, an inflammatory autoimmune response to an infection by
streptococcal bacteria. It most often occurs in children.
The Blood Supply to Heart
A great volume of blood flows through the chambers of the heart, but the myocardium has its
own, separate blood supply to meet oxygen and nutrient demand. The coronary circulation
supplies blood to the muscle tissue of the heart. During maximum exertion, the heart’s demand
for oxygen rises considerably. The blood flow to the myocardium may then increase to nine
times that of resting levels. The coronary circulation includes an extensive network of coronary
blood vessels.
The Coronary Arteries:
The left and right coronary arteries originate at the base of the ascending aorta, at the aortic
sinuses. Myocardial blood flow is not steady. It peaks while the heart muscle is relaxed, and
almost ceases while it contracts. These phasic changes in blood flow through cardiac muscle are
more prominent in left ventricle muscle. In the left ventricle muscle, the coronary blood flow
falls to a low value during systole. The reason for this is strong compression of the left
ventricular muscle around the intramuscular vessels during systolic contraction. During diastole,
the cardiac muscle relaxes and no longer obstructs blood flow through the left ventricular muscle
capillaries, so that blood flows rapidly during all of diastole.
Blood flow through the coronary capillaries of the right ventricle also undergoes phasic changes
- only partial.
Arterial Blood Supply
Right coronary artery (RCA)
It supplies blood to (1) the right atrium, (2) portions of both ventricles
Course and branches of RCA
The right coronary artery supplies small branches (atrial branches) to the right atrium.
It continues inferior to the right atrium and follows the coronary sulcus around the heart and
ultimately divides into the posterior interventricular and marginal branches.
The posterior interventricular branch follows the posterior interventricular sulcus and supplies
the walls of the two ventricles with oxygenated blood.
The marginal branch beyond the coronary sulcus runs along the right margin of the heart and
transports oxygenated blood to the myocardium of the right ventricle.

Left coronary artery

It supplies blood to the left ventricle, left atrium, and interventricular septum.
Course and branches of LCA
The left coronary artery passes inferior to the left auricle and divides into the anterior
interventricular and circumflex branches.
The anterior interventricular branch or left anterior descending (LAD) artery is in the anterior
interventricular sulcus and supplies oxygenated blood to the walls of both ventricles.
The circumflex branch lies in the coronary sulcus and distributes oxygenated blood to the walls
of the left ventricle and left atrium.
Anastomoses/ collateral circulation
Most parts of the body receive blood from branches of
more than one artery, and where two or more arteries
supply the same region, they usually connect through their
branches. These connections, called anastomoses, provide
alternate routes, called collateral circulation, for blood to
reach a particular organ or tissue. The myocardium
contains many anastomoses that connect branches of a
given coronary artery or extend between branches of
different coronary arteries. They provide detours for
arterial blood if a main route becomes obstructed. Thus,
heart muscle may receive sufficient oxygen even if one of
its coronary arteries is partially blocked.
The Cardiac Veins
After passing through the arteries of the coronary circulation, blood flows into capillaries, where
it delivers oxygen and nutrients to the heart muscle and collects carbon dioxide and waste, and
then moves into coronary veins.
Most of the deoxygenated blood from the myocardium drains into a large vascular sinus in the
coronary sulcus on the posterior surface of the heart, called the coronary sinus (A vascular sinus
is a thin walled vein that has no smooth muscle to alter its diameter.) The deoxygenated blood in
the coronary sinus empties into the right atrium.
The principal tributaries carrying blood into the coronary sinus are the following:
 Great cardiac vein in the anterior interventricular sulcus, which drains the areas of the
heart supplied by the left coronary artery (left and right ventricles and left atrium)
 Middle cardiac vein in the posterior interventricular sulcus, which drains the areas
supplied by the posterior interventricular branch of the right coronary artery (left and
right ventricles).
 Small cardiac vein in the coronary sulcus, which drains the right atrium and right
ventricle
 Posterior cardiac vein, which drains the areas supplied by circumflex artery
 Anterior cardiac veins, which drain the right ventricle and open directly into the right
atrium

The Conducting System:

Unlike skeletal muscle, cardiac muscle tissue contracts on its own, without neural or hormonal
stimulation. This property is called automaticity, or auto rhythmicity. The conducting system of
heart, also known as the nodal system is responsible to initiate and distribute the stimulus. This
system is a network of specialized cardiac muscle cells that can initiate and distribute electrical
impulses.
The conducting system includes the following elements:
The sinoatrial (SA) node, located in the posterior wall of the right atrium, near the entrance of
the superior vena cava. The SA node contains pacemaker cells, which establish the heart rate. As
a result, the SA node is also known as the cardiac pacemaker or the natural pacemaker
The atrioventricular (AV) node, located at the junction between the atria and ventricles with in
the floor of the right atrium near opening of coronary sinus.
Internodal pathways:
In atria, the internodal pathways, made up of
conducting cells, distribute the contractile stimulus
initiated at SA node to atrial muscle cells as this
electrical impulse travels from the SA node to the
AV node. However, the impulse can also spread
from contractile cell to contractile cell of atria,
reaching the AV node at about the same time as an
impulse that travels an internodal pathway.)
AV bundle. Bundle branches and Purkinje
fibres: In the ventricles, conducting cells include
those in the AV bundle and the bundle branches, as
well as the Purkinje fibers.
The AV bundle, also called the bundle of His (hiss), is normally the only electrical connection
between the atria and the ventricles. Once an impulse enters the AV bundle, it travels to the
interventricular septum and enters the right and left bundle branches. The left bundle branch,
which supplies the massive left ventricle, is much larger than the right bundle branch. The
bundle branches extend through the interventricular septum toward the apex of the heart. Finally,
the large-diameter Purkinje fibers rapidly conduct the action potential from the apex of the heart
upward to the remainder of the ventricular myocardium.
Most of the cells of the conducting system are smaller than the contractile cells of the
myocardium and contain very few myofibrils. Purkinje cells, however, are much larger in
diameter than the contractile cells. As a result, they conduct action potentials more quickly than
other conducting cells.