Heart

Overview:

 Located in the middle mediastinum

 Has two ventricles and two atria that connect the two major circulatory systems of the body:
the pulmonary circulation with the systemic circulation
 Has valves to ensure blood flow only in one direction
 Surrounded by pericardium (fibroserous, fluid-filled sac)
 About the size of a fist and weighs ∼ 300–500 g

Gross anatomy:
Heart chambers

The heart has:

Two atria
 Right atrium
 Receives deoxygenated blood from the upper and lower body via the superior vena
cava (SVC), inferior vena cava (IVC), and the coronary veins
 Pumps deoxygenated blood into the right ventricle
 Left atrium
 Receives oxygenated blood from the four pulmonary veins
 Pumps oxygenated blood into the left ventricle to enter the systemic circulation
Two ventricles of the heart
 Right ventricle
 Receives deoxygenated blood from the right atrium
 Pumps deoxygenated blood into the pulmonary trunk as part of the pulmonary circulation
 Left ventricle
 Receives oxygenated blood from the left atrium
 Pumps oxygenated blood into the aorta as part of the systemic circulation

Atrioventricular valves

Consist of leaflets that are supported by the attachment of fibrous cords (chordae tendineae) and papillary
muscles. The papillary muscles contract during systole and prevent prolapse of the valve leaflets into the atria.

 Tricuspid valve: consists of three leaflets located between the right atrium and right ventricle
 Bicuspid valve (mitral valve) consists of two leaflets located between the left atrium and the left
ventricle

Semilunar valves

Consist of three crescent-shaped cusps (semilunar valves) without chordae tendineae or papillary
muscles involvement.

 Pulmonary valve: between right ventricle and pulmonary trunk

 Aortic valve: between left ventricle and aorta

Circulatory system

 Pulmonary circulation:
 Deoxygenated blood in the right heart flows into the lungs, where it is oxygenated, and delivered
back to the left atrium.
  Right atrium → tricuspid valve → right ventricle → pulmonary valve → pulmonary
trunk → pulmonary arteries → lungs → four pulmonary veins → left atrium
 Systemic circulation:
 Oxygenated blood flows from the left ventricle into the systemic circulation and, after passing
through the capillary bed, flows back in a deoxygenated state to the right atrium of the heart to
restart the process.
 Left atrium→ mitral valve → left ventricle→ aortic valve → aorta→ systemic
circulation (capillary beds) → SVC and IVC → right atrium

Cardiac skeleton

 Definition:
 A layer of connective tissue that separates the atria from the ventricles and anchors the valves
with fibrous rings (annuli fibrosi cordis)surrounding the atrioventricular and arterial orifices.
 Functions
 Electrical insulation layer between atria and ventricles
 Does not conduct electricity (stimuli can only be conducted by the specialized conduction
system of the heart as described below)
 Anchors the valves

Internal structure of the heart

Structures of cardiac conduction system

Collection of nodes and specialized conduction cells that initiate and coordinate contraction of the heart muscle.

Consists of:

 Sinoatrial node (SA node)

 Atrioventricular node (AV node)
 Atrioventricular bundle (bundle of His)
 Purkinje fibers (modified myocytes)

Normal course of electrical conduction: SA node (pacemaker) creates an action potential → signal spreads
across atria and causes their contraction (The SA node excites the right atrium and then travels
through Bachmann bundle to excite the left atrium) → signal reaches AV node and is slowed down → AV
node conducts the signal to bundle of His down the interventricular septum to Purkinje fibers in myocardium →
they spread the signal across the ventricles → the ventricles contract
Vasculature
Coronary arteries
 The left and right coronary artery arise from the ascending aorta and supply arterial blood to the heart
muscle.
 Coronary blood flow peaks during early diastole at a point when the pressure differential between the
aorta and the ventricle is the greatest

Right coronary artery (RCA)

 Course: arises from right aortic sinus of the ascending aorta

 Supplies:
 Right atrium and right ventricle
 Inferior margin of the right ventricle (via right marginal artery)
 Parts of the left ventricle and ⅓ of the interventricular septum (via posterior descending artery)
 Sinus node and AV node (via sinoatrial nodal artery and AV node artery)

Left coronary artery (LCA)

 Course:
 arises from left aortic sinus of the ascending aorta and anastomoses with the RCA
 Supplies:
 Anterior aspects of the right and left ventricles
 Cardiac apex and ⅔ of interventricular septum
 Left atrium and left ventricle (via left circumflex artery)

Venous drainage
 The venous blood from the heart is drained into the right atrium by the coronary sinus.
 Left side drains into great cardiac vein → coronary sinus → right atrium
 Right side drains into middle and small cardiac veins → coronary sinus → right atrium
Innervation

 Sympathetic fibers
 Present throughout the heart
 Increase heart rate (positive chronotropy), contractility (positive inotropy), conduction velocity
(positive dromotropy), dilate coronary arteries
 Parasympathetic fibers (from the vagal nerve)
 Primarily innervates the atria (SA node and AV node)
  Decrease heart rate (negative chronotropy), contractility (negative inotropy), and conduction
velocity (negative dromotropy)
 Phrenic nerve: sensory innervation of the pericardium

Lymphatics
 Lymph of the heart drains into anterior mediastinal nodes and tracheobronchial nodes.

Microscopic anatomy:

Heart tissue consists of four layers.

Endocardium: inner layer with three sublayers
1. Endothelium (innermost): simple squamous epithelium
2. Smooth muscle and connective tissue
3. Subendocardium (outermost) - loose connective tissue
o Site of Purkinje fibers: consist of modified cardiac muscle cells with more glycogen, extensive gap
junctions, and fewer myofibrils, specialized for conduction

Myocardium: thick myocardial layer

 Cross-striated muscle cells (cardiomyocytes) with single centrally located nucleus
o Each cell contains myofibrils organized into sarcomeres (smallest functional contractile unit
of cardiac muscle).
o Contain many mitochondria to produce ATP for contraction
o Atrial cardiomyocytes release atrial natriuretic peptide (ANP) when stretched to lower BP→ ↑
water and sodium excretion by the kidneys.
o Cardiomyocytes are joined together by intercalated discs to form long fibers.
 Intercalated discs connect the single cardiomyocytes to a functional syncytium and force
transmission during muscle contraction.
 Contain adherent junctions (transmit mechanical stimuli) and gap junctions (transmit
electrical stimuli)
 Appear as dark-staining lines between cardiac muscle cells under light microscopy
 Cardiac Purkinje cells: Specialized/modified cardiomyocytes of the heart conduction system with fewer
contractile myofibrils and more mitochondria and glycogen
 Fibroblasts (turn into myofibroblasts after injury)
 Extracellular matrix: collagen, elastin, and glycosaminoglycans

Epicardium: a connective tissue layer where the visceral layer of the serous pericardium comes into contact with
the heart
 Contains blood vessels, lymphatics, and adipose tissue

Pericardium: a fibroserous sac enclosing the heart that consists of a 2-layered inner serous pericardium and an
outer fibrous pericardium
1. Visceral layer of serous pericardium (innermost)
2. Pericardial cavity: space between the visceral and parietal layers of the serous pericardium that
contains serous, pericardial fluid
3. Parietal layer of serous pericardium
4. Fibrous pericardium (outermost)

Heart valves: composed of connective tissue and endocardium

 Mostly vessel-free derive nutrition from the surrounding blood