The Heart

Editor :

Haryo Aribowo
Surgeon, Cardio Thorax Vascular Consultant

Department of Surgery

Sardjito General Hospital

Jogjakarta

2007
 The HEART

Pemahaman anatomi morfologi jantung normal merupakan dasar untuk

menegakkan diagnosis penyakit jantung, terutama kelainan jantung kongenital. Salah

satu dari masalah penegakan diagnostik adalah bahwa setiap ruang jantung, katub dan

pembuluh darah dari dan ke jantung dapat mengalami kelainan.

Berat jantung berkisar diantara 200 – 425 gram. Bila dibandingkan dengan

ukuran kepalan tangan, sedikit lebih besar. Dibanding organ tubuh yang lain jantung

merupakan organ tubuh yang paling keras bekerjanya . Sepanjang hidup manusia

jantung berdenyut 3,5 milyar kali. Setiap hari jantung berdenyut lebih dari 100.000

kali dan memompa darah 7.500 liter.

Heart Development

The cardiovascular system begins to develop in the third week of gestation. Blood

islands (angiocysts) develop in the newly formed mesoderm, and consist of (a) a

central group of haemoblasts, the embryonic precursors of blood cells; (b) endothelial

cells.

haemoblasts
endothelial cells

Blood islands coalesce to form a vascular plexus. Preferential channels form arteries

and veins .

Day 17 - Blood islands form first in the extra-embryonic mesoderm

Day 18 - Blood islands form next in the intra-embryonic mesoderm

Day 19 - Blood islands form in the cardiogenic mesoderm and coalesce to form a pair

of endothelial heart tubes

cranial end
(arterial)

caudal end
(venous)

The endothelial heart tubes fuse to form a single primitive heart tube with a cranial

(arterial) end and a caudal (venous) end. The heart tubes are derived from the

cardiogenic esoderm situated next to the pericardial cavity, the cranial-most end of the

intra-embryonic coelom. Initially, at 18 days, the cardiogenic mesoderm lies at the

most cranial end of the trilaminar embryo. After the formation of the head fold (at 20

days) the cardiogenic mesoderm is shifted ventrally and comes to lie ventral to the

primitive pharynx.

21 days. The primitive heart tube is divided into a number of primitive chambers

separated by grooves.The truncus arteriosus divides into a pair of aortic arches.The

sinus venosus consists of right and left horns.

 truncus arteriosus

bulbus cordis

ventricle

atrium

sinus venosus

Development of a circulation

A circulation is established during the 4th week after the myocardium is

differentiated.The cranial end communicates with the paired branchial arches that

open into paired dorsal aortae. These fuse into a single dorsal aorta. At this stage

three main pairs of arteries are present (i) to the head, (ii) vitelline arteries to the yolk

sac and (iii) paired umbilical arteries to the placenta . Three corresponding veins

drain into the sinus venosus.

Dorsal aorta

Vitelline artery and vein

Artery and vein

to the head
Umbilical artery and vein
 Folding of the heart tube

Folding of the heart tube occurs on days 23-28 at two sites: (i) the bulboventricular

sulcus (bv), and (ii) the atrio-ventricular groove (av). As a result the heart tube

becomes S-shaped. Cardiac Asymmetry. Folding occurs because of elongation of the

heart tube, which causes it to become asymmetrical. As a result of folding of the heart

tube:

1. The atrium lies dorsal to the ventricle, bulbus cordis and truncus arteriosus, and

bulges on either side of the truncus

2. The bulbus cordis lies to the right of the ventricle

3. The ventricular septum lies between the bulbus cordis and ventricle

4. The A-V opening overhangs both chambers

Formation of the transverse sinus of the pericardium

truncus arteriosus The heart is suspended in the pericardial cavity by a
atrium
A-V opening mesocardium, a double fold of coelomic epithelium situated in
ventricular septum
the midline.

bulbus bulbus
cordis
ventricle
cordis
ventricle The mesocardium breaks down forming the transverse sinus of

the pericardium. The heart tube remains attached to the

pericardium at its cranial (arterial) and caudal (venous) ends. The transverse sinus lies

dorsal to the heart tube between the arterial and venous ends, and communicates the

two sides of the pericardial cavity. It maintains the same relationship in the adult

heart.

Development of the Sinus venosus

Initially the veins entering the sinus venosus are symmetrical. During the fourth week

the venous system becomes asymmetrical causing extensive remodelling of the sinus

venosus.

Initially three sets of paired veins enter the sinus venosus:

1. The common cardical veins enter the sinus venosus laterally. They receive:

a. the anterior cardinal veins from the cranial half of the body (head, neck and

upper limbs)

b. the posterior cardinal veins from the caudal half of the body (abdomen and

lower limbs)

2. The umbilical veins receiving oxygenated blood from the placenta

3. The vitelline veins drasining the gut and yolk sac.

These veins all pass through the septum transversum before entering the sinus

venosus. At the same time the liver begins to develop within the septum transversum

from cells derived from the foregut. A venous plexus of sinusoids develops between

the liver cells and communicates with the umbilical and vitelline veins.

Venous symmetry is radically altered by:

1. establishment of left to right shunts in the venous system, and

2. obliteration of some veins draining into the sinus venosus

Three left to right shunts are formed:

1. A left to right shunt between the two anterior cardinal veins. This will form the

left brachiocephalic vein.

On the left, the common cardinal, the posterior cardinal and most of the anterior

cardinal veins are largely obliterated.

2. The ductus venosus - a preferential channel from the left umbilical to the right

vitelline veins, bypassing the liver sinusoids.

The left umbilical vein loses its direct communication with the sinus venosus and the

right umbilical vein is obliterated

3. The vitelline veins communicate by three anastomoses.

Fetal Circulation

In the fetal circulatory system, the umbilical vein transports blood rich in O2 and

nutrients from the placenta to the fetal body. The umbilical vein enters the body

through the umbilical ring and travels along the anterior abdominal wall to the liver.

About 1/2 the blood it carries passes into the liver. The other 1/2 of the blood enters a

vessel called the ductus venosus which bypasses the liver.

The ductus venosus travels a short distance and joins the inferior vena cava. There,

the oxygenated blood from the placenta is mixed with the deoxygenated blood from

the lower parts of the body. This mixture continues through the vena cava to the right
atrium. In the adult heart, blood flows from the right atrium to the right ventricle then

through the pulmonary arteries to the lungs. In the fetus however, the lungs are

nonfunctional and the blood largely bypasses them.

As the blood from the inferior vena cava enters the right atrium, a large proportion of

it is shunted directly into the left atrium through an opening called the foramen ovale.

A small valve, septum primum is located on the left side of the atrial septum overlies

the foramen ovale and helps prevent blood from moving in the reverse direction. The

rest of the fetal blood entering the right atrium, including a large proportion of the

deoxygenated blood entering from the superior vena cava passes into the right

ventricle and out through the pulmonary trunk. Only a small volume of blood enters

the pulmonary circuit, because the lungs are collapsed, and their blood vessels have a

high resistance to flow.

Enough blood reaches the lung tissue to sustain them. Most of the blood in the

pulmonary trunk bypasses the lungs by entering a fetal vessel called the ductus

arteriosus which connects the pulmonary trunk to the descending portion of the aortic

arch. As a result of this connection, the blood with a relatively low O 2 concentration

which is returning to the heart through the superior vena cava, bypasses the lungs.

At the same time, the blood is prevented from entering the portion of the aorta that

provides branches leading to the brain. The more highly oxygenated blood that enters

the left atrium through the foramen ovale is mixed with a small amount of

deoxygenated blood returning from the pulmonary veins. This mixture moves into the

left ventricle and is pumped into the aorta.

Some of it reaches the myocardium through the coronary arteries and some reaches

the brain through the carotid arteries. The blood carried by the descending aorta is

partially oxygenated and partially deoxygenated. Some of it is carries into the

branches of the aorta that lead to various parts of the lower regions of the body. The

rest passes into the umbilical arteries, which branch from the internal iliac arteries and

lead to the placenta. There the blood is reoxygenated.

Topography

Your heart is located between your lungs in the middle of your chest, behind and

slightly to the left of your breastbone (sternum). A double-layered membrane called

the pericardium surrounds your heart like a sac. The outer layer of the pericardium

surrounds the roots of your heart's major blood vessels and is attached by ligaments to

your spinal column, diaphragm, and other parts of your body. The inner layer of the

pericardium is attached to the heart muscle. A coating of fluid separates the two layers

of membrane, letting the heart move as it beats, yet still be attached to your body.
The parts of the heart

1. Right Coronary 9. Pulmonary Vein Right Atrium

2. Left Anterior Descending 10. Right Ventricle

3. Left Circumflex 11. Left Atrium

4. Superior Vena Cava 12. Left Ventricle

5. Inferior Vena Cava 13. Papillary Muscles

6. Aorta 14. Chordae Tendineae

7. Pulmonary Artery 15. Tricuspid Valve

8. Pulmonary Valve 16. Mitral Valve

Aortic Valve (Not pictured)

Coronary Arteries
The heart muscle, like every other organ or tissue in your body, needs oxygen-rich

blood to survive. Blood is supplied to the heart by its own vascular system, called

coronary circulation.

The aorta (the main blood supplier to the body) branches off into two main coronary

blood vessels (also called arteries). These coronary arteries branch off into smaller

arteries, which supply oxygen-rich blood to the entire heart muscle.

The left coronary artery, which branches into the left anterior descending artery and

the circumflex artery, supplies blood to the left side of the heart. The left side

of the heart is larger and more muscular because it pumps blood to the rest of

the body. The initial segment of the left coronary artery is called the left main

coronary. This blood vessel is approximately the width of a soda straw and is

less than an inch long. It branches into two slightly smaller arteries: the left

anterior descending coronary artery and the left circumflex coronary artery.

The left anterior descending coronary artery is embedded in the surface of the

front side of the heart. The left circumflex coronary artery circles around the

left side of the heart and is embedded in the surface of the back of the heart.
The right coronary artery supplies blood mainly to the right side of the heart. The

right side of the heart is smaller because it pumps blood only to the lungs.

Coronary Circulation

Because the heart is composed primarily of cardiac muscle tissue that continuously

contracts and relaxes, it must have a constant supply of oxygen and nutrients. The

coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich

blood to the cardiac muscle tissue.

Just like branches on a tree, the coronary arteries branch into progressively smaller

vessels. The larger vessels travel along the surface of the heart; however, the smaller

branches penetrate the heart muscle. The smallest branches, called capillaries, are so

narrow that the red blood cells must travel in single file. In the capillaries, the red

blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with

carbon dioxide and other metabolic waste products, taking them away from the heart

for disposal through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood

through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond

the point of the blockage is deprived of oxygen and nutrients. This area of cardiac

muscle tissue ceases to function properly. The condition when a coronary artery

becomes blocked causing damage to the cardiac muscle tissue it serves is called a

myocardial infarction or heart attack.

Great Vessels

Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood

from the body to the heart. Veins from the head and upper body feed into the superior

vena cava, which empties into the right atrium of the heart.

Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood

from the body to the heart. Veins from the legs and lower torso feed into the inferior

vena cava, which empties into the right atrium of the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the

diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle

to the various parts of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right

ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich

blood. It is more appropriate to classify arteries as vessels carrying blood away from

the heart.

Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the

left atrium. A common misconception is that all veins carry de-oxygenated blood. It is

more appropriate to classify veins as vessels carrying blood to the heart.

The Chambers
Atrium.

Atrium atau sering disebut sebagai serambi dibedakan atas atrium kanan dan kiri.

Keduanya mempunyai fungsi yang sama yaitu menampung darah yang masuk ke

dalam jantung. Namun keduanya mempunyai perbedaan yabng mendasar yang harus

diketahui yaitu :

Perbedaan Atrium kanan Atrium kiri

Inlet VCS, VCI, sinus coronaries Vena pulmonalis
Apendage Lebar, segitiga Sempit, jari-jari
M pectinati Banyak Sedikit
Krista terminalis Ada Tidak
Permuikaan Septum sekundum Septum primum
septum
Konduksi SA node, AV node Tidak ada
Outlet Ventrikel kanan Ventrikel kiri

Ventrikel

Ventrikel atau sering disebut sebagai bilik dibedakan atas ventrikel kanan dan

ventrikel kiri. Seperti atrium keduanya juga mempunyai fungsi yang sama yaitu

memompa darah keluar jantung. Keduanya juga mempunyai perbedaan yang

mendasar yaitu :

Perbedaan Ventrikel kanan Ventrikel kiri

 Trabekula karnae Kasar, sedikit Halus, banyak
M papilaris Banyak, kecil Dua, besar
Daun katub AV Tiga (Tricuspid) Dua (mitral)
Infundibulum Berkembang baik Tidak ada
A coronaria Satu, RCA Dua, LAD, Cx
Konduksi Satu Dua
Inlet Atrium kanan Atrium kiri
Outlet A pulmonalis aorta

Cardiac muscles

Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles.

They connect to the chordae tendineae, which attach to the tricuspid valve in the right

ventricle and the mitral valve in the left ventricle. The contraction of the papillary

muscles opens these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae
The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve

in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles

contract and relax, the chordae tendineae transmit the resulting increase and decrease

in tension to the respective valves, causing them to open and close. The chordae

tendineae are string-like in appearance and are sometimes referred to as "heart

strings."

The Valves

Didalam rongga jantung terdapat 4 katub yaitu katub tricuspid, katub mitral, katub

pulmonal dan katub aorta.

Katub tricuspid. Jumlah katub bervariasi mulai dari 2 katub sampai dengan 4 katub.

Namun terbanyak sesuai namanya adalah 3 katub, yaitu katub anterior, katub posterior

dan katub septalis. Katub tricuspid merupakan katub searah menyebabkan aliran darah

menuju ventrikel kanan dan mencegah kembalinya darah ke atrium kanan.

Katub mitral. Mempunyai jumlah katub 2 buah yaitu katub anterior (anterior mitral

leaflet) dan katub posterior (posterior mitral leaflet). Katub ini merupakan katub

searah yang menyebabkan aliran darah dari atrium kiri menuju ventrikel kiri dan

mencegah kembalinya darah ke atrium kiri.

Katub pulmonal. Mempunyai jumlah katub 2 buah yaitu katub. Sesuai dengan

namanya, katub ini merupakan katub searah yang menyebabkan aliran darah dari

ventrikel kanan menuju ke pulmo (paru-paru) dan mencegah kembalinya darah dari

arteri pulmonali ke dalam ventrikel kanan.

Katub aorta. Mempunyai jumlah katub 3 buah.. Katub ini merupakan katub searah

yang menyebabkan aliran darah dari ventrikel kiri menuju ke sistemik dan mencegah

kembalinya darah dari aorta menuju ventrikel kanan. Fungsi lain yang terutama

adalah akibat bendungan katub pada waktu diastole maka darah dapat mengalir

menuju ke arteri coronaria.

The Conduction System

The heart is composed primarily of muscle tissue. A network of nerve fibers

coordinates the contraction and relaxation of the cardiac muscle tissue to obtain an

efficient, wave-like pumping action of the heart.

The Sinoatrial Node (often called the SA node or sinus node) serves as the natural

pacemaker for the heart. Nestled in the upper area of the right atrium, it sends the

electrical impulse that triggers each heartbeat. The impulse spreads through the atria,

prompting the cardiac muscle tissue to contract in a coordinated wave-like manner.

The impulse that originates from the sinoatrial node strikes the Atrioventricular node

(or AV node) which is situated in the lower portion of the right atrium. The

atrioventricular node in turn sends an impulse through the nerve network to the

ventricles, initiating the same wave-like contraction of the ventricles.

The electrical network serving the ventricles leaves the atrioventricular node through

the Right and Left Bundle Branches. These nerve fibers send impulses that cause the

cardiac muscle tissue to contract.

Electrical impulses from your heart muscle (the myocardium) cause your heart to

contract. This electrical signal begins in the sinoatrial (SA) node, located at the top of

the right atrium. The SA node is sometimes called the heart's "natural pacemaker." An

electrical impulse from this natural pacemaker travels through the muscle fibers of the

atria and ventricles, causing them to contract. Although the SA node sends electrical

impulses at a certain rate, your heart rate may still change depending on physical

demands, stress, or hormonal factors.

Electrical impulses from your heart muscle (the myocardium) cause your heart to beat

(contract). This electrical signal begins in the sinoatrial (SA) node, located at the top

of the right atrium. The SA node is sometimes called the heart's "natural pacemaker."

When an electrical impulse is released from this natural pacemaker, it causes the atria

to contract. The signal then passes through the atrioventricular (AV) node. The AV

node checks the signal and sends it through the muscle fibers of the ventricles,

causing them to contract. The SA node sends electrical impulses at a certain rate, but

your heart rate may still change depending on physical demands, stress, or hormonal

factors.

The Circulatory System

Your heart and circulatory system make up your cardiovascular system. Your heart

works as a pump that pushes blood to the organs, tissues, and cells of your body.

Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and

waste products made by those cells. Blood is carried from your heart to the rest of
your body through a complex network of arteries, arterioles, and capillaries. Blood is

returned to your heart through venules and veins. If all the vessels of this network in

your body were laid end-to-end, they would extend for about 60,000 miles (more than

96,500 kilometers), which is far enough to circle the earth more than twice!

The heart is the muscular organ of the circulatory system that constantly pumps blood

throughout the body. Approximately the size of a clenched fist, the heart is composed

of cardiac muscle tissue that is very strong and able to contract and relax rhythmically

throughout a person's lifetime.

The heart has four separate compartments or chambers. The upper chamber on each

side of the heart, which is called an atrium, receives and collects the blood coming to

the heart. The atrium then delivers blood to the powerful lower chamber, called a

ventricle, which pumps blood away from the heart through powerful, rhythmic

contractions.

The human heart is actually two pumps in one. The right side receives oxygen-poor

blood from the various regions of the body and delivers it to the lungs. In the lungs,
oxygen is absorbed in the blood. The left side of the heartreceives the oxygen-rich

blood from the lungs and delivers it to the rest of the body.

Systole

The contraction of the cardiac muscle tissue in the ventricles is called systole. When

the ventricles contract, they force the blood from their chambers into the arteries

leaving the heart. The left ventricle empties into the aorta and the right ventricle into

the pulmonary artery. The increased pressure due to the contraction of the ventricles is

called systolic pressure.

Diastole

The relaxation of the cardiac muscle tissue in the ventricles is called diastole. When

the ventricles relax, they make room to accept the blood from the atria. The decreased

pressure due to the relaxation of the ventricles is called diastolic pressure.

The Heartbeat
A heartbeat is a two-part pumping action that takes about a second. As blood collects

in the upper chambers (the right and left atria), the heart's natural pacemaker (the SA

node) sends out an electrical signal that causes the atria to contract. This contraction

pushes blood through the tricuspid and mitral valves into the resting lower chambers

(the right and left ventricles). This part of the two-part pumping phase (the longer of

the two) is called diastole.

The second part of the pumping phase begins when the ventricles are full of blood.

The electrical signals from the SA node travel along a pathway of cells to the

ventricles, causing them to contract. This is called systole. As the tricuspid and mitral

valves shut tight to prevent a back flow of blood, the pulmonary and aortic valves are

pushed open. While blood is pushed from the right ventricle into the lungs to pick up

oxygen, oxygen-rich blood flows from the left ventricle to the heart and other parts of

the body.

After blood moves into the pulmonary artery and the aorta, the ventricles relax, and

the pulmonary and aortic valves close. The lower pressure in the ventricles causes the

tricuspid and mitral valves to open, and the cycle begins again. This series of

contractions is repeated over and over again, increasing during times of exertion and

decreasing while you are at rest. The heart normally beats about 60 to 80 times a

minute when you are at rest, but this can vary. As you get older, your resting heart rate

rises. Also, it is usually lower in people who are physically fit.

Your heart does not work alone, though. Your brain tracks the conditions around you

—climate, stress, and your level of physical activity—and adjusts your cardiovascular

system to meet those needs.

The human heart is a muscle designed to remain strong and reliable for a hundred

years or longer. By reducing your risk factors for cardiovascular disease, you may

help your heart stay healthy longer.