PGI Roselada, Benjune S.

ARMMC Department of Anesthesiology

DLR: Chapter 12 Cardiac Anatomy and Physiology February 20, 2023

Introduction
● In addition to providing its own blood supply, the heart is a phasic, variable speed,
electrically self-activating muscular pump.
● Both the pulmonary and systemic vasculatures receive equal amounts of blood
through the two pairs of atria and ventricles.
● Before (preload) and after (afterload) contraction, the myocardium in the atria and
ventricles responds to stimulation rate and muscle stretch.
● In terms of overall cardiac function, the intrinsic contractile properties of the atria and
ventricles, as well as their ability to fill adequately without excessive pressure, play a
major role.
Gross Anatomy
● Architecture

○ Heart skeleton is a cartilaginous structure made up of the annuli of the cardiac

valves, the roots of the aortic and pulmonary arteries, and the fibrous trigones.
○ Most of the atrial and ventricular muscle originates directly from and inserts
within the adjacent surrounding myocardium. A small portion of superficial
subepicardial muscle also inserts into the cartilaginous skeleton.
○ Two thin orthogonal bands of myocardium comprise the atria, whereas the left
ventricle (LV) and, to a lesser extent, the right ventricle (RV), are composed of
interdigitating deep, superficial, and bulbospiral muscles.
○ As the LV moves from its base (superior in the mediastinum) to its apex, its
myocardial fibers run perpendicularly, obliquely, and helicalt reverses
 direction at approximately the LV’s midpoint, creating an overall fiber
architecture that mimics a flattened “figure of eight.”
■ This fiber orientation facilitates LV chamber shortening along the
heart’s longitudinal axis and produces a distinctive torsional twisting
motion during contraction.
■ The twisting effect substantially enhances the LV’s ability to eject
blood, as loss of this helical–rotational action reduces ejection fraction
in patients with heart failure.
○ Due to the majority of the septum consisting of LV myocardium, the
interventricular septum thickens toward the LV chamber during contraction
under normal conditions.
○ During contraction, the lateral and posterior LV walls move, resulting in the
point of maximum impulse palpable on the left chest wall.
○ An electrically activated LV shortens its long axis, reduces its chamber
diameter, and rotates its apex anterior-right when activated
○ A low-pressure PA vasculature is supplied with venous blood by the RV.
○ There are fewer cardiac myocytes in the RV than in the LV, which is due to its
thinner walls.
○ During contraction, the RV free wall is supported by the interventricular
septum, while the contracting LV also provides RV with additional external
assistance. As a result of these two factors, the RV has a mechanical advantage
over its contractile ability alone, partially compensating for the thinner walls
of the chamber.
● Valve Structure
○ The pulmonic and aortic valves of the normal heart contain two translucent,
macroscopically avascular valves that ensure unidirectional blood flow.
○ As a result of contractions and relaxations, the valves open and close
passively. Pulmonic valve leaflets are named according to their anatomical
location (right, left, and anterior), whereas aortic valve leaflets are named
based on their proximity to coronary artery ostiums (right, left, and non).
○ Each aortic leaflet is immediately superior to the sinuses of Valsalva, which
are dilated segments of aortic root.
■ During diastole, hydraulic flow vortices in the sinuses facilitate valve
closure by preventing valve leaflet adhesion to the aortic wall.
 ○ The mitral valve is located between the LA and the LV and has two leaflets
(the anterior leaflet is oval-shaped and the posterior one is crescent-shaped)
and a three-dimensional prolate ellipsoid shape (saddle-shaped).
○ When LV pressure falls below LA pressure during late LV relaxation, a
positive pressure gradient develops between the LA and LV, allowing blood
from the LA to enter the LV (early ventricular filling).
○ During normal function, the chordae tendinae act as restricting cables between
the apex of the mitral leaflets, facilitating their coaptation.
○ A sphincter-like contraction of the surrounding subepicardium also aids in
mitral valve closure.
○ The mitral valve apparatus is very important for normal LV function for two
major reasons.
■ During LV contraction, the valve apparatus ensures unidirectional
blood flow from the LA to the LV by preventing reflux into the LA and
pulmonary veins.
■ As papillary muscle shortening assists LV apical contraction, the mitral
apparatus also contributes to LV systolic function
○ Tricuspid valves typically consist of anterior, posterior, and septal leaflets and
ensure unidirectional blood flow.
● Coronary Blood Supply
○ The left anterior descending, left circumflex, and right coronary arteries
(LAD, LCCA, and RCA, respectively) supply blood to the LV
○ Based on the known distribution of each coronary artery's blood supply,
critical stenosis or acute occlusion of the LAD, LCCA, or RCA almost always
produces myocardial ischemia or infarction accompanied by regional
contractile dysfunction.
■ Anterior medial LV wall, anterior two-thirds of interventricular
septum, and LV apex are supplied by the LAD and its diagonal
branches.
■ Anterior and posterior aspects of the lateral wall are perfused by the
LCCA and its marginal branches.
■ A large portion of the posterior wall and the posterior third of the
interventricular septum are supplied with blood by the RCA.
 ○ Because aortic pressure most often exceeds the pressure in each of these
chambers unless profound hypotension is present, coronary blood flow to the
RA, LA, and RV occurs both during systole and diastole.
○ RV anterior walls are perfused by blood from the RCA and its branches, as
well as distal diagonal and septal branches of the LAD.
○ In the epicardial surface of the heart, the proximal branches of the RCA,
LCCA, and LAD give rise to intramural vessels that reach deep into the
myocardium perpendicularly or obliquely. There is a thin layer of tissue on the
endocardial surface of each chamber, but the blood supply of the heart is
mostly derived from perforating branches of the three major epicardial
coronary arteries.
○ Due to equal driving pressure across the collateral vessel without
hemodynamically significant stenosis, coronary collateral blood flow is
usually minimal. When a main artery serving one branch of a collateral vessel
is severely stenotic or occluded, a pressure gradient results, diverting blood
from the patent artery into the myocardial distribution of the occluded artery
through the collateral vessel.
○ AV and interventricular grooves retrace the course of the main coronary
venous drainage of the heart. The great cardiac vein runs along the AV groove
and the LAD, the anterior cardiac vein is located adjacent to the RCA, and the
middle cardiac vein is associated with the PDA.
● Impulse Conduction
○ The SA node is the primary cardiac pacemaker.
○ The dominance of SA automaticity may be overridden by decreases in firing
rate, delays in normal conduction, or the presence of secondary pacemakers
(e.g., AV node, bundle of His).
○ RA and AV node depolarization is rapidly transmitted through the anterior,
middle, and posterior internodal pathways (Wenckebach, Thorel).
○ Through the atrial septum, Bachmann's bundle (a branch of the anterior
internodal pathway) transmits depolarization of the SA node across the LA.
Law of Laplace
- Changes in tension and length in cardiac myocytes are translated into alterations in
pressure and volume in intact hearts.
 - Tension development in each myocyte increases LV wall stress (σ; tension exerted
over a cross-sectional area) which is converted into pressure (p) when applied to fluid
(blood).
The Cardiac Cycle
- Depolarization of the RV and LV can be seen on the QRS complex of the
electrocardiogram.
- In response to this electrical activation, contraction occurs (systole) and
pressure increases rapidly in both chambers (LV > RV).
- Tricuspid and mitral valves close when RV and LV pressures exceed RA and LA
pressures, respectively, and produce the first heart sound (S1).
- LV systole consists of three major phases: isovolumic contraction, rapid ejection, and
slower ejection.
- Since both the aortic and mitral valves are closed during LV isovolumic contraction,
LV volume remains constant. However, LV shape becomes more spherical as
longitudinal dimensions decrease.
- Two-thirds of each chamber's end-diastolic volume is rapid ejected when the LV and
RV pressures are greater than the aortic and PA pressures, respectively.
- Ejection stops entirely when the ventricles begin to repolarize once the aortic and PA
pressures reach their maximum values. As this slower ejection phase ends, the aortic
and PA pressures briefly exceed the LV and RV pressures, and the valves close as a
result.
- Second heart sound (S2) occurs when the aortic valve closes slightly after the
pulmonic valve; this signifies end-systole.
- The four phases of LV diastole are isovolumic relaxation, early ventricular filling,
diastasis, and atrial systole.
- Three major deflections are observed in the LA pressure waveform during sinus
rhythm.
- Atrial systole occurs following the "a" wave of LA contraction.
- With the onset of LV contraction, the mitral valve closes, causing a second
small increase in LA pressure.
- As pulmonary venous return enters the LA while the mitral valve is closed, the
final "v" wave is generated during LV systole.
Determinants of Systolic Function
● Heart Rate
 ○ The frequency of stimulation directly affects the contractile state of isolated
cardiac muscle.
○ This phenomenon is known as the Bowditch, “staircase,” or “Treppe” effect,
or the “force-frequency” relationship.
○ The Bowditch effect is most likely caused by improved Ca2+ cycling
efficiency and increased Ca2+ sensitivity in myofilaments.
● Preload
● Afterload
○ The additional load to which cardiac muscle is exposed after contraction has
begun is termed “afterload.”
○ As part of the intact cardiovascular system, four factors determine LV
afterload: the size and mechanical behavior of arterial blood vessels; terminal
arteriolar vasomotor tone, which determines the total arterial resistance; LV
end-systolic wall stress, which is determined by LV pressure development and
changes in LV geometry required to generate it; and blood volume and
physical properties.
● Myocardial contractility
○ Under controlled loading conditions and stimulation rates, myocardial
contractility is an indicator of the force cardiac muscle is capable of producing
during contraction.

Source: Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., Ortega,
R. A., Sharar, S. R., & Holt, N. F. (2017). Clinical anesthesia. Wolters Kluwer.
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In the field of anesthesiology, knowledge of cardiac anatomy and physiology is
crucial for several reasons.
First and foremost, the anesthesiologist is responsible for maintaining the patient's
cardiovascular function. In order to monitor and manage the patient's blood pressure, heart
rate, and cardiac output, one must understand the anatomy and physiology of the heart and
cardiovascular system. The anesthesiologist must be capable of interpreting
electrocardiograms (ECGs), understanding the hemodynamic effects of anesthetics, and
adjusting medication accordingly to ensure that the patient's cardiovascular status is optimal.
 Secondly, anesthesiologists need to be able to diagnose and treat cardiac emergencies
arising during surgery. This includes understanding the signs and symptoms of cardiac
ischemia, arrhythmias, and heart failure, as well as the appropriate interventions required to
stabilize the patient's condition.
Also, anesthesiologists play an essential role in assessing patients with cardiac disease
prior to surgery. In order to develop an effective anesthetic plan and assess the patient's risk
for complications, it is essential to have a thorough understanding of cardiac anatomy and
physiology.
In summary, providing safe and effective care to patients requires knowledge of
cardiac anatomy and physiology by anesthesiologists. During surgery, it allows them to
monitor and manage the patient's cardiovascular function, diagnose and handle cardiac
emergencies, and conduct a comprehensive preoperative evaluation of patients with
underlying cardiac diseases.