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[007]

Principles of
Cardiac Function
A Reminder: Systemic and Pulmonary Circulations

Systemic Circulation

Pulmonary circulation

Thorax

LV
RV
Key Concepts in Cardiac Function

•  Automaticity
•  Rhythmicity
•  Electrical activity (depolarization and
repolarization) drives mechanical
activity (contraction and relaxation) of
cardiac muscle
•  Two pumps, coordinated
•  Variable function (rate, force)
Basic Anatomy of the Heart

BASE

Auricle of
Left atrium

Right
atrium

Left
APEX ventricle
Right Ventricle

Anterior view
Basic Anatomy of the Heart

Superior
vena cava
(SVC)
Left pulmonary
artery
Ascending
aorta Left pulmonary
veins

Right BASE
pulmonary
veins Auricle of
Left atrium

Right
atrium

Inferior Left
vena cava ventricle
APEX
(IVC) Right Ventricle

Anterior view
As Well As Pumping Blood,
The Heart Receives Its Own Blood Supply

Left
coronary
Artery (LCA)

Right
coronary
Artery
(RCA)

Anterior view
The Four Heart Valves:
Ensure unidirectional flow of blood; open and close passively

Left atrium

Mitral
valve
Pulmonary
Valve Aortic
valve
Right
atrium
Left
Tricuspid ventricle
valve

Right
Ventricle
Anterior view
The Four Heart Valves:
Ensure unidirectional flow of blood; open and close passively
Pulmonary
valve (closed)
Mitral
Valve Aortic
(open) valve (closed)

Tricuspid
Valve (open)

Posterior view, Diastole


Pulmonary orifice & valve

Left A-V orifice Aortic orifice & valve


& mitral valve
Right A-V orifice
& tricuspid valve

Left Ventricle

Right
Ventricle

Posterioinferior view

Posterior view, Systole


Pacemaker and Specialized Conducting Pathways

SVC

LA
Sinoatrial
(SA) node
RA

RV LV

Interventricular
septum
Pacemaker and Specialized Conducting Pathways

SVC

Atrioventricular
(AV) node
LA
Sinoatrial
(SA) node
Bundle
RA
of His

Bundle
branches
RV LV

Purkinje
fibers
Interventricular
septum
Spread of Depolarization (Excitation) and Repolarization

SA node fires, and


depolarization of
atria begins

ECG Recording

Time
Spread of Depolarization (Excitation) and Repolarization

SA node fires, and Depolarization of


depolarization of atria – complete;
atria begins Delay at AV node

ECG Recording

Time
Spread of Depolarization (Excitation) and Repolarization

SA node fires, and Depolarization of


depolarization of atria – complete; Depolarization of
atria begins Delay at AV node ventricles - begins

ECG Recording

Time
Spread of Depolarization (Excitation) and Repolarization

SA node fires, and Depolarization of


depolarization of atria – complete; Depolarization of Depolarization of
atria begins Delay at AV node ventricles - begins ventricles - complete

ECG Recording QRS

Time
Spread of Depolarization (Excitation) and Repolarization

SA node fires, and Depolarization of


depolarization of atria – complete; Depolarization of Depolarization of Repolarization of
atria begins Delay at AV node ventricles - begins ventricles - complete ventricles

ECG Recording QRS


T
P

800 msec

Time
At 75 bpm, 1 cycle (e.g., time between one R and the next R, the R-R interval) = 0.8 sec (60/75)
The Cardiac Cycle - We’ll Discuss the Left Side of the Heart

Aorta – pressure

Left atrium – pressure

Mitral valve – opening and closing;


heart sounds

Aortic valve – opening and closing;


heart sounds

Left ventricle – pressure;


volume of blood

ECG – timing, relationship to


other events
QRS
T
P
The Cardiac Cycle - We’ll Discuss the Left Side of the Heart

Aorta – pressure

Left atrium – pressure

Mitral valve – opening and closing;


heart sounds

Aortic valve – opening and closing;


heart sounds

Left ventricle – pressure;


volume of blood

ECG – timing, relationship to


Right side: other events
QRS
•  timing ≈ left P
T
•  absolute pressures R << L
Diastole Systole
120
100
Aortic Pressure
Pressure (mm Hg)

80

60
Left Intraventricular Pressure
40

20 Left Atrial Pressure


0

130
Ventricular Volume
Vol. (ml)

90

50
0.5 sec 0.3 sec

1 cycle = 0.8 sec at 75 bpm (60/75)


Time
Aortic Pressure: Very similar to arterial BP immediately downstream…

Remember, the LV “creates” the arterial BP by pumping blood on each heart


beat…

Diastole Systole
120
100
Aortic Pressure
Pressure (mm Hg)

80

60
Left Intraventricular Pressure
40

20 Left Atrial Pressure


0

130
Ventricular Volume
Vol. (ml)

90

50
0.5 sec 0.3 sec

1 cycle = 0.8 sec at 75 bpm (60/75)


Time
Aorta
LA

LV

Diastole Systole
120
100
Aortic Pressure
Pressure (mm Hg)

80

60
Left Intraventricular Pressure
40

20 Left Atrial Pressure


0
Mitral valve
130
opens
Ventricular Volume
Vol. (ml)

90

50

Time
Aorta
LA

LV

Diastole Systole
120
100
Aortic Pressure
Pressure (mm Hg)

80

60
Left Intraventricular Pressure
40

20 Left Atrial Pressure


0
Mitral valve
130
opens
Ventricular Volume
Vol. (ml)

90

50

Passive Atrial
filling contraction

Time
Aorta
LA

LV

Diastole Systole
120
100
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0

130 EDV
Ventricular Volume
Vol. (ml)

90

50

Time
Aorta
LA

LV

Diastole Systole
120
100
Pressure (mm Hg)

80

60 Isovolumic
Mitral valve
40 closes
contraction

20
0

130 EDV
Vol. (ml)

90

50

Time
Aorta
LA

LV

Diastole Systole
120
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80
Ejection
60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0

130 EDV
Ventricular Volume
Vol. (ml)

90

50

Time
Aorta
LA

LV

Diastole Systole Diastole


120 Aortic valve closes
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0

130 EDV
Ventricular Volume
Vol. (ml)

90 SV

ESV
50

Time
Aorta
LA

LV

Diastole Systole Diastole


120 Aortic valve closes
Aortic valve
100 opens
Pressure (mm Hg)

80

60 Isovolumic
Mitral valve relaxation
40 closes
20
0

130 EDV
Vol. (ml)

90 SV

ESV
50

Time
Aorta
LA

LV

Diastole Systole Diastole


120 Aortic valve closes
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0
Mitral valve
130 EDV
opens
Ventricular Volume
Vol. (ml)

90 SV

ESV
50

Time SOUNDS
Aorta
LA

LV

Diastole Systole Diastole


120 Aortic valve closes
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0
Mitral valve Mitral valve
opens opens

S2 S1 S2
Heart Sounds
S1 (“Lub”) = closing of Mitral S2 (“Dub”) = closing of Aortic
AND Tricuspid valves AND Pulmonic valves; often “split”
split
S2 is often widened or “split” with inspiration

S1 S2

Deep Inspiration
S2 is often widened or “split” with inspiration

S1 S2

Deep Inspiration

S1 S2

A2 P2

Why ?

You tell me…


Thorax

Aortic
Pulmonary valve
LV
valve
RV
Diastole Systole Diastole
120 Aortic valve closes
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0
Mitral valve Mitral valve
130 EDV
opens opens
Ventricular Volume
Vol. (ml)

90 SV

ESV
50
S2 S1 S2
Heart Sounds

Where’s the ECG ??


Diastole Systole Diastole
120 Aortic valve closes
Aortic valve
100 opens
Aortic Pressure
Pressure (mm Hg)

80

60
Mitral valve Left Intraventricular Pressure
40 closes
20 Left Atrial Pressure
0
Mitral valve Mitral valve
130 EDV
opens opens
Ventricular Volume
Vol. (ml)

90 SV

ESV
50
S2 S1 S2
Heart Sounds

P QRS T
ECG

Excitation (depolarization) precedes, and drives, contraction


What happens when the heart rate increases ?
Diastole Systole
120
100
Pressure (mm Hg)

80

60
40

20
0
0.5 sec 0.3 sec
75 bpm, cycle = 0.8 sec
Diastole Systole
120
100
Pressure (mm Hg)

80

60
40

20 120 bpm, cycle = 0.5 sec


0
0.27 sec 0.23 sec
Learning Objectives
In the list below, the Learning Objectives are annotated with the slide number(s) that deal most closely with the material. Please
note that the list of slides is not absolute, and that a full understanding of the learning objectives requires the relevant readings
and review of the concepts we discussed during the lecture – the PowerPoint slides are not intended to live in isolation.

[007.1] Describe the position of the heart within the thorax and identify the areas where the normal heart sounds are best
heard and the PMI is palpated. Describe the major vessels entering and leaving the heart and their relationship to
the pulmonary and systemic circulations. Slides 4 to 8, and readings. Refer also to session # 021,Thorax Prosection
lab and, regarding where heart sounds are best heard and PMI best palpated, session # 009 The Cardiac Exam PE
Lab.
[007.2] Describe the structure of the heart, including the four chambers, the location of the septa and the valves, the
specialized conduction pathways, and the direction of blood flow through the heart. Slides 4 to 17
[007.3] Describe the origin, time course, and spread of excitation through the heart in a person with normal sinus rhythm, and
relate the spread of depolarization and repolarization to the major waves seen in a standard Lead II ECG recording.
Slides 9 to 15
[007.4] Explain the mechanisms that generate the normal heart sounds heard in a physical exam, and diagram these events
together with changes in left ventricular pressure and volume, left atrial pressure, aortic pressure and ECG versus
time, during a normal cardiac cycle. Describe how the cardiac cycle changes when the heart rate increases. Slides
18 to 31, 33 and 34
[007.5] Compare and contrast the timing and magnitude of changes in pressure, electrical activity, opening and closing of
valves, and heart sounds in the left and right sides of the heart and in the aorta and pulmonary trunk (pulmonary
artery) during a normal cardiac cycle. Explain how these parameters are affected (if at all) on a deep inspiration and
how this relates to the splitting of S2. Slides 18 to 28 (left side of the heart), 29 to 31and the detailed Q and A and
discussion in the lecture (not shown on the PPT), and readings(left vs. right and effects of inspiration).