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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