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http://emedicine.medscape.com/article/1948510overview#showall 1/13
11/7/2016 CardiovascularSystemAnatomy:Overview,GrossAnatomy,NaturalVariants
http://emedicine.medscape.com/article/1948510overview#showall 2/13
11/7/2016 CardiovascularSystemAnatomy:Overview,GrossAnatomy,NaturalVariants
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11/7/2016 CardiovascularSystemAnatomy:Overview,GrossAnatomy,NaturalVariants
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CardiovascularSystemAnatomy
Author:PraveenBuddiga,MDChiefEditor:ThomasRGest,PhDmore...
Updated:Aug20,2014
Overview
Thecardiovascularsystemconsistsoftheheart,whichisananatomicalpump,with
itsintricateconduits(arteries,veins,andcapillaries)thattraversethewholehuman
bodycarryingblood.Thebloodcontainsoxygen,nutrients,wastes,andimmune
andotherfunctionalcellsthathelpprovideforhomeostasisandbasicfunctionsof
humancellsandorgans. [1,2]
Thepumpingactionoftheheartusuallymaintainsabalancebetweencardiac
outputandvenousreturn.Cardiacoutput(CO)istheamountofbloodpumpedout
byeachventricleinoneminute.Thenormaladultbloodvolumeis5liters(alittle
over1gallon)anditusuallypassesthroughtheheartonceaminute.Notethat
cardiacoutputvarieswiththedemandsofthebody. [3]
Thecardiaccyclereferstoeventsthatoccurduringoneheartbeatandissplitinto
ventricularsystole(contraction/ejectionphase)anddiastole(relaxation/fillingphase).
Anormalheartrateisapproximately72beats/minute,andthecardiaccycle
spreadsover0.8seconds.Theheartsoundstransmittedareduetoclosingofheart
valves,andabnormalheartsounds,calledmurmurs,usuallyrepresentvalve
incompetencyorabnormalities. [4]
Bloodistransportedthroughthewholebodybyacontinuumofbloodvessels.
Arteriesarebloodvesselsthattransportbloodawayfromtheheart,andveins
transportthebloodbacktotheheart.Capillariescarrybloodtotissuecellsandare
theexchangesitesofnutrients,gases,wastes,etc. [5]
GrossAnatomy
Heart
Theheartisamuscularorganweighingbetween250350gramslocatedobliquely
inthemediastinum.Itfunctionsasapumpsupplyingbloodtothebodyand
acceptingitinreturnfortransmissiontothepulmonarycircuitforgasexchange.
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Theheartcontains4chambersthatessentiallymakeup2sidesof2chamber
(atriumandventricle)circuitstheleftsidechamberssupplythesystemiccirculation,
andtherightsidechamberssupplythepulmonarycirculation.Thechambersof
eachsideareseparatedbyanatrioventricularvalve(AVvalve).Theleftsided
chambersareseparatedbythemitral(bicuspid)valve,andrightsidedchambersare
dividedbythetricuspidvalve.Bloodflowsthroughtheheartinonlyonedirection
enforcedbyavalvularsystemthatregulatesopeningandclosureofvalvesbased
onpressuregradients(seeimagebelow).
Heartanatomy.
Uniquepropertiesofcardiacmuscle
Cardiacmusclecellsarebranchingstriated,uninucleate(singlenucleus)cellsthat
containmyofibrils.
Adjacentcardiaccellsareconnectedbyintercalateddiscscontainingdesmosomes
andgapjunctions.Themyocardiumbehavesasafunctionalsyncytiumbecauseof
electricalcouplingactionprovidedbygapjunctions.
Cardiacmusclehasabundantmitochondriathatdependonaerobicrespiration
primarilytogenerateadenosinetriphosphate(ATP),themoleculethatprovides
energyforcellularfunction(seetheimagesbelow).
Cardiacmusclecells.
Myocardialgapjunctions.
SystemicCirculation
Thesystemiccircuitoriginatesintheleftsideoftheheartandfunctionsbyreceiving
oxygenladenbloodintotheleftatriumfromthelungsandflowsonewaydowninto
theleftventricleviathemitralvalve.Fromtheleftventricle,oxygenrichbloodis
pumpedtoallorgansofthehumanbodythroughtheaorticsemilunarvalve(seethe
imagebelow). [6,7]
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Systemicandpulmonarycirculation.
PulmonaryCirculation
Thepulmonarycircuitisontherightsideoftheheartandservesthefunctionofgas
exchange.Oxygenpoorsystemicbloodreachestherightatriumvia3majorvenous
structures:thesuperiorvenacava,inferiorvenacava,andcoronarysinus.This
bloodispumpeddowntotherightventricleviathetricuspidvalveandeventually
throughthepulmonicvalve,leadingtothepulmonarytrunkthattakestheoxygen
deprivedbloodtothelungsforgasexchange.Oncegasexchangeoccursinthe
lungtissue,theoxygenladenbloodiscarriedtotheleftatriumviathepulmonary
veins,hencecompletingthepulmonarycircuit(seetheimageabove).
CoronaryCirculation
Coronarycirculationisthecirculationtotheheartorganitself.Therightandleft
coronaryarteriesbranchfromtheascendingaortaand,throughtheirbranches
(anteriorandposteriorinterventricular,marginalandcircumflexarteries),supplythe
heartmuscle(myocardial)tissue.Venousbloodcollectedbythecardiacveins
(great,middle,small,andanterior)flowsintothecoronarysinus.Deliveryof
oxygenrichbloodtothemyocardialtissueoccursduringtheheartrelaxationphase
(seetheimagebelow).
Coronarycirculation.
VesselAnatomy
Anarteryisabloodvesselthatcarriesbloodawayfromthehearttoperipheral
organs(seetheimagebelow).Theyaresubdividedintolargerconductingarteries,
smallerdistributingarteries,andthesmallestarteries,knownasarterioles,that
supplythecapillarybed(thesiteofactivetissuecellsgasexchange).
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Arterialcrosssection.
Capillariesarevesselsthataremicroscopicinsizeandprovideasiteofgas,ion,
nutrient,andcellularexchangebetweenbloodandinterstitialfluid.Theyhave
fenestrationsthatallowforandenhancepermeabilityforexchangeofgas,ion,
nutrient,andcellularelements(seetheimagebelow).
Capillarystructure.
Aveinisabloodvesselthathasalargerlumen,andsometimesveinsserveas
bloodreservoirsorcapacitancevessels,containingvalvesthatpreventbackflow.
Thissystemofvesselsingeneralreturnsbloodtotheheartfromtheperiphery(see
theimagebelow).
Veins:bloodflowandvalvestructure.
NaturalVariants
CongenitalheartanomaliesCongenitalheartdefectscausestructuralproblemsof
theheartandleadtoabnormalorincompletedevelopmentofitsmajorchambers
andvalves,resultinginpoorflowandcirculation.
Atrialseptaldefectisaholeinthewallbetweentherightandleftatriathat
promotesmixingofoxygenatedandunoxygenatedblood.Seetheimagebelow.
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Atrialseptaldefect.
Coarctationoftheaortaisanarrowingoftheaortathatcausesthehearttoneedto
pumphardertoforcebloodthroughthenarrowpartoftheaorta.
Hypoplasticleftheartsyndromeiswhentheleftsideoftheheartdoesnotdevelop
completely,leadingtoadefectiveandunderdevelopedleftventricle,mitralvalve,
aorticvalve,andaorta.
Atrioventricularcanaldefectisalsoknownasaendocardialcushiondefectand
occurswhenaholeexistsbetweenthechambersoftheheartandirregularitieswith
thevalvesoftheheartexisthence,defectsinflowandbloodcirculation.
Ventricularseptaldefectisaholeintheseptalwallbetweentherightandleft
ventriclesthatcontributestothemixingofoxygenatedandunoxygenatedblood.
Patentductusarteriosusisadefectinwhichtheconnectionbetweentheaortaand
thepulmonarytrunkremainsopen.
TetralogyofFallotisarareandveryseriouscongenitalheartdefectinvolvingthe
heartthatincludesastenoticpulmonaryvalve,anaortathatarisesfromboth
ventricles,aninterventricularseptalopening(ie,ventricularseptaldefect),and
enlargedrightventricle.Babiesbornwiththisdefectarecyanoticwithinminutesof
birthandrequireimmediatesurgicalrepair.Seetheimagebelow.
TetralogyofFallot.
PathophysiologicalVariants
CongestiveHeartFailure
Thisisaclinicalsyndromethatresultsfromtheinabilityofthehearttopump
effectivelytoachievethecardiacoutputcapableofsupplyingsufficientoxygento
theperipheralorgansforbasicmetabolicfunctionaswellasmetabolicdemand.
Heartfailuremaybefurtherclassifiedintorightventricularfailure,leftventricular
failure,orbiventricularfailure.Someofthemainetiologiesofcongestiveheart
failureareasfollows:
Cardiomyopathies
Valvularheartdisease
Systemichypertension
Pericardialdisease
Pulmonaryarterialhypertension
Highoutputstatessuchasthyrotoxicosis,anemiaorAVfistula.
Cardiomyopathy
Dilatedcardiomyopathy(congestive)
Themaincharacteristicofthisconditionisadecreasedheartcontractilefunction
withbiventriculardilatation.
Thecausesmaybeidiopathic,inflammatoryinfectiousetiologythatmayhavebeen
causedbypostviralmyocarditis(coxsackieBorEchovirus),noninfectiousetiologies
(collagenvasculardisease[Lupus,rheumatoidarthritis,polyarteritis]),peripartum,or
sarcoidosis.
Toxininduced
Alcohol,chemotherapyagentssuchasdoxorubicinandAdriamycin,drugssuchas
cocaine,heroin,ororganicsolventscancausecardiomyopathy.
Metabolicreasons
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Metabolicreasonsincludehypothyroidism,chronichypocalcemia,or
hypophosphatemia(seetheimagebelow).
Dilatedcardiomyopathy.
Hypertrophiccardiomyopathy
Thisconditioniscausedbyafamilialautosomaldominanttraitresultinginmarked
hypertrophyofthemyocardiumandadisproportionategreaterthickeningofthe
interventricularseptum.Thishypertrophiedseptumcancausenarrowingofthesub
aorticareaduetoitsoppositiontotheanteriormitralleafletresultinginleft
ventricularoutflowobstructionduringmidsystole.Seetheimagebelow.
Hypertrophiccardiomyopathy.
Restrictivecardiomyopathy
Thisischaracterizedbyabnormallyrigidventriclesthatimpairdiastolicheartfilling
buttheheartretainsanormalsizeandanormalsystolicfunction.Areduced
ventricularcomplianceduetofibrosisorinfiltrationresultsinanabnormalhigh
diastolicpressureleadingtohighsystemicandpulmonaryvenouspressures.
Myocardialfibrosis
Myocardialfibrosisiscausedbyscarringorinfiltrationcausedbyamyloidosisor
sarcoidosisnoninfiltrativemyocardialfibrosisiscausedbyscleroderma.Other
storagediseasessuchasglycogenstoragediseaseorhemochromatosismaycause
thiscondition.
Endomyocardialfibrosis
Endomyocardialfibrosisiscausedbyscarringorinfiltrationcausedby
hypereosinophilicsyndromeandradiationtherapymetastatictumorsmayalsobe
consideredasotheretiologies.
Rheumaticheartdisease
Rheumaticheartdiseaseisaseriouscomplicationofrheumaticfever.Acute
rheumaticfeverfollows0.3%ofcasesofgroupAbetahemolyticstreptococcal
pharyngitis(athroatinfection)inchildren.Patientswithacuterheumaticfevermay
developvaryingdegreesofassociatedvalveinsufficiency,heartfailure,pericarditis,
andevendeath.Withchronicrheumaticheartdisease,patientsdevelopvalve
stenosiswithvaryingdegreesofregurgitation,atrialdilation,arrhythmias,and
ventriculardysfunction.Chronicrheumaticheartdiseaseremainstheleadingcause
ofmitralvalvestenosisandvalvereplacementinadultsintheUnitedStates.Acute
rheumaticfeverandrheumaticheartdiseasearethoughttoresultfroman
autoimmuneresponse,buttheexactpathogenesisremainsunclear.
Valveconditions
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Alterationsinthenormalfunctioningofheartvalvesleadtoalterationsinthe
normalcardiovascularphysiology.Avalvedefectmaybestenoticorregurgitant.
Whenitisstenoticitrepresentsavalvularopeningthatisnarrowed,thusrestricting
bloodflowthroughthevalve.Aregurgitantvalveisusuallyincompetentresultingin
backflowthroughapartiallyopenvalve.Theatrioventricularvalves,mitralvalve,
andtricuspidvalve,preventbackflowintotheatriawhentheventriclesare
contracting.Thepulmonaryandaorticsemilunarvalvespreventbackflowintothe
ventriclesduringtherelaxationphase.
Mitralstenosis
Mitralstenosisisusuallyaconsequenceofrheumaticheartdisease.Approximately
50%ofthosewithmitralstenosisusuallyhaveahistoryofrheumaticfever.Thiscan
bedistinguishedbyamurmurthatislocalizedneartheapexoftheheart.Seethe
imagebelow.
Mitralvalvestenosis.
Mitralregurgitation
Mitralregurgitationmayresultfromrheumaticheartdisease,mitralprolapse,or
rupturedchordaetendineaeorpapillarymuscledysfunctionafteramyocardial
infarction.Seetheimagebelow.
Mitralregurgitation.
Valvedefectssuchasabovemaybeseenclinicallyasdyspneaonexertionand
fatiguelikesymptoms.
Aorticstenosis
Thisconditionmayresultfromcongenitallesions,suchasbicuspidaorticvalve,
rheumaticheartdisease,andcalcifiedaorticvalve.Thiscanbedistinguishedbya
systolicejectionmurmur. [8]Seetheimagebelow.
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Aorticstenosis.
Aorticregurgitation
Thisconditionmaybearesultofrheumaticheartdisease,endocarditis,valvular
congenitalstructuralheartdefects,syphilisoraneurysms.Aorticvalvedefectsmay
beseenclinicallypresentingwithsignsorsymptomsofcongestiveheartfailure,
angina,syncopeordecreasesinexercisetolerance.Seetheimagebelow.
Aorticregurgitation.
Pericarditis
Theheartissurroundedbyasacoftissueknownasthepericardiumthatfunctions
asaprotectivelayertotheheartandalsoreducesfrictionwithadjacentorgans.
Inflammationofthislayerisknownaspericarditis.Theclinicalmanifestationsof
acutepericarditisareduetotheinflammationofthepericardiumtreatmentis
targetedwithantiinflammatoriessuchasaspirinorNSAIDs,whiletheclinical
manifestationsofchronicpericarditisareusuallyduetotheconstrictionof
pericardiumaroundthemyocardium.Becausetherightventricleoperatesunder
lowerpressuresthantheleftventricle,therightventricleisprimarilyaffectedbythe
constrictedpericardium.Constrictivepericarditisusuallypresentswithrightsided
symptomsbecausetherightventricledoesnotfillwithnormalcapacityduetothe
anatomicbottleneckcausedbytheconstrictedpericardium,hencecausingvenous
congestion,preloadreduction,andareductionincardiacoutput.Pericarditishas
multiplecauses,asfollows:
Infectiousetiologiesincludeviral(coxsackieB),bacterial,tuberculosis,
fungal,amoebic,andprotozoan.
Rheumatologicetiologiesincludesystemiclupuserythematosus,rheumatoid
arthritis,mixedconnectivetissuedisorder,andscleroderma.
Postmediastinalradiationsecondarytoradiationtherapyformalignancy,
suchasbreastcancer,lymphoma,andlungcancer.
Uremia:Kidneyfailuremaybeacauseforametabolicabnormalityleading
topericarditis.
Trauma:Eitherbluntforsharpinjurytothechest,cardiacproceduresthat
areinvasive,orpostmyocardialinfarctionarepossiblecauses.
Medications:Anumberofdrugsmaycausepericarditis,suchaspenicillin,
cromolynsodium,doxorubicin,cyclophosphamide,procainamide,
hydralazine,methyldopa,isoniazid,mesalazine,reserpine,methysergide,
dantrolene,minoxidil,andphenytoin.
Gastrointestinal:PatientswithinflammatoryboweldiseasesuchasCrohn
diseaseorulcerativecolitismaydeveloppericarditisasaconsequence.
Undeterminedoridiopathic:Treatmentistargetedatthecauseaswellas
towardanycomplicationsuchaspericardialeffusion(seeimagebelow)
whereaneffusionatthepericardialsaccausesanatomicpressurearound
theheart,restrictingitsabilitytorelaxandpumpwithadequatepressures.
Thetreatmentforpericardialeffusionispericardiocentesis,inwhichaneedle
isinsertedtodraintheexcesspericardialfluid,thusrelievingtheexternal
pressure.
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Pericardialeffusion.
SystemicHypertension
Bloodpressureisinfluencedbycardiacoutput,peripheralresistanceofvessels,and
bloodvolume.Vesseldiameteristhemostimportantofthesefactors,andsmall
changesinvesseldiametersignificantlyaffectbloodpressure.Bloodpressurevaries
directlywithbothcardiacoutputandbloodvolumeitvariesinverselywithvessel
diameter.Bloodpressureisregulatedbyautonomicneuralreflexesinvolving
baroreceptors,chemoreceptors,thevasomotorcenter,andvasomotorfibersacting
onvascularsmoothmuscleinputsfromhighercentralnervoussystemcenters,
chemicalssuchashormonesandrenalcompensatorypathways.Bloodpressure
abovethenormalrangesof120mmHgsystolicand80mmHgdiastolicare
consideredprehypertensive(120139/8089)mmHg.Stage1hypertensionis
definedasbloodpressureof140159/9099mmHg.Stage2hypertensionisdefined
asbloodpressuregreaterthan160/greaterthan100mmHg.Themostcommon
typeofhypertensionisessentialhypertension,forwhichthecauseisunknown.This
accountsforupto98%ofpatients.Theremaining2%havesecondarycauses,such
asrenaldisease,pheochromocytoma,mineralocorticoidexcess,aorticcoarctation,
orpreeclampsiaduringpregnancy.Malignanthypertensioniswhentheblood
pressureisgreaterthan200systolicand140diastolicwithevidenceofpapilledema.
Thisisamedicalemergency,andthebloodpressuremustbecontrolledadequately
andpromptly.
OtherCommonAbnormalCardiovascularConditions
Anginapectoris
Thisistheclinicalsyndromethatoccurswhenheartoxygendemandexceedsblood
supplyresultinginpainordiscomfortinthechestandadjacentareas.Anginamay
beclassifiedasstableorunstable.Thisconditionmayresultfrommyocardial
ischemiathatisaresultofareductionincoronarybloodflowcausedbyafixedor
dynamiccoronaryarteryblockage,anabnormalconstrictionordecreasedrelaxation
ofthecoronarymicrocirculation,orareductionintheoxygencarryingcapacityof
theblood.
Myocardialinfarction
Myocardialinfarctionisaconditioninwhichtheheartmuscleisdamageddueto
lackofbloodsupplyorischemiainthecoronaryvesselsand,thus,theheartis
unabletopumpbloodeffectivelytotheperipheralorgans.Atherosclerosisisthe
mostcommoncauseofcoronaryarterystenosisresultinginmyocardialischemia.
Theinfarctionareaorareaofischemiaisisolatedtothemuscularareaofblood
supplyresultinginpoororlackoffunctionofthatregionalareaofheartmuscle.For
example,ablockageintheleftcircumflexarterymayresultindamagetotheleft
ventricularmusclelikewise,arightcoronaryarterydefectorischemiamayresultin
rightheartventriculardysfunction.Seetheimagebelowandtheareaofheartblood
supplyversusregionalinfarctedarea.
Myocardialinfarctionandregionalaffectedcardiacarea.
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ContributorInformationandDisclosures
Author
PraveenBuddiga,MDPhysician,Allergy,AsthmaandImmunology,BazAllergy,AsthmaandSinusCenter
PraveenBuddiga,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofAllergyAsthmaand
Immunology,AmericanCollegeofAllergy,AsthmaandImmunology
Disclosure:Serve(d)asaspeakeroramemberofaspeakersbureaufor:MYLAN,TEVA.
Coauthor(s)
ArchanaBangaloreResearchCoordinatorandVolunteer,AltaFamilyHealthClinicVolunteer,FresnoWomen's
Care
Disclosure:Nothingtodisclose.
ChiefEditor
ThomasRGest,PhDProfessorofAnatomy,DepartmentofMedicalEducation,TexasTechUniversityHealth
SciencesCenter,PaulLFosterSchoolofMedicine
Disclosure:Nothingtodisclose.
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